Friday, February 8, 2019
MANAGE NURSING CARE AT HOME, "Ch. 10 Nervous System"
ELEVEN-SYSTEM MEDICAL ASSESSMENT
The body can be described as being comprised of eleven systems. Each system is made up of organs, and each organ is further broken down into many tissues and innumerable cells. Systems are organized groups of structures classified as to performing a function, as follows:
· Nervous system
· Respiratory system
· Cardiovascular system
· Lymphatic and immune system
· Gastro-intestinal system
· Endocrine system
· Reproductive system
· Urinary system
· Integumentary system
· Skeletal system
· Muscular system
These systems and their disorders are discussed in this and later chapters, with an emphasis on those conditions likely to result in long-term nursing care at home.
The nervous system is comprised of the brain, spinal cord, nerves, and sensory organs such as the eyes and ears. From impulses received from outside the body due to tactile stimulation from the skin, to inside communications via hormones, nerves, sensory organs, blood and lymph transmit these messages to the brain via the spinal cord and integumentary (skin) system. In the brain the impulses are translated into fine or gross motor responses as well as active or reactive actions in response to adverse or pleasurable stimuli. The brain also houses memory, cognition, language and many other sophisticated methods of communication and understanding all by way of nerve impulses.
Some of the various nervous systems conditions and care considerations appear below.
Cerebrovascular Accidents (CVA), commonly referred to as “strokes,” are common, with 800,000 diagnosed yearly. They rank fourth as a leading cause of death after heart disease, cancer, and pulmonary diseases. (Recently, some medical specialists have listed medical errors as the third largest cause.) Loss of neurological function can be sudden or gradual due to a long-term bleeding incident into the brain. Most strokes result from a blood clot that either originated in the brain (thrombosis) or traveled to the brain (embolus). Once the clot occludes a brain vessel, the area no longer receives enough oxygen, causing a cerebral infarction (tissue death). Brain hemorrhages are another main cause of strokes and can occur by a tear in a vessel wall, hypertension, or from an injury. As bleeding continues, pressure is placed on the brain tissues, causing brain tissue damage. Loss of blood flow to the brain results in injury to various parts of the body, causing neurologic deficits. The injury may be temporary and resolve over time or cause long-term or permanent disability. The extent and location of the region of the body that is impaired is solely determined by the area of the brain that was damaged. As all bodily functions are controlled by the brain, the possibilities are endless.
Care Considerations for Cerebrovascular Accidents:
1) Paralysis or decreased function to one side of the body (hemiplegia), to one or both lower, or to one or both upper extremities can occur. Activity difficulties may also be due to loss of sensation, simple weakness, or changes in muscle tone (being spastic or flaccid). Loss of fine or gross motor skills could be apparent. Depending on the injury, various devices could prove helpful, including canes and wheelchairs, as well as many other occupational therapy aids.
2) Elimination patterns may be altered and could encompass voiding and/or defecation. Catheterization, whether intermittent or continual, may be required if bladder retraining is unsuccessful. Bowel evacuation might be accomplished by use of medication, enemas, or laxatives if retraining proves ineffective.
3) Obtaining the proper amount of nutrients and fluids could be problematic due to lack of appetite, nausea or vomiting, dysphagia (inability to swallow), loss of sensation in the mouth and throat, medication side effects, or facial paralysis. If insufficient quantities are consumed, a percutaneous gastric feeding tube could be placed for long-term use. Shorter-term aids include centrally placed venous catheters for total parenteral nutrition (
4) Perception and sensory deficits are often present. These may include vision difficulties such as blurred or double vision (diplopia). Partial loss of vision (monocular blindness) or total blindness could also result. Disturbances to taste and smell are reported. Touch and skin sensations are often not discriminated, and loss of feeling (neuropathy) could lead to unknowingly received injuries. Dysphasia (decreased speech capacity) may take the form of difficulty producing speech (expressive), understanding speech (receptive), or both (global). Aphasia is an inability to communicate via speech, but also includes inability to understand writing and signs or pictures.
5) Cognitive function impairment includes inability to recognize: faces (prosopagnosia), speech versus not speaking sounds (auditory agnosia), objects (visual agnosia), colors (achromatopsia), and visual objects (visual agnosia) to name a few. Apraxia is the inability to use objects properly when there is no muscle deficit.
6) Skin care is essential due to possible incontinence, paralysis, lack of sensation, and inability to ask for assistance.
Alzheimer’s and Dementia
The severity and increasing prevalence of these neurological conditions are evident in these quotes from the Alzheimer’s Association’s alz.org/facts (our emphasis added):
· Alzheimer’s disease is the only cause of death among the top 10 in America that cannot be prevented, cured, or even slowed.
· Today, more than 5 million Americans are living with Alzheimer’s disease, including an estimated 200,000 under the age of 65. By 2050, as many as 16 million will have the disease.
· You can use the free, online Community Resource Finder to easily locate Alzheimer’s and dementia resources, programs, and services in your area. To learn more about this comprehensive resource for people facing Alzheimer’s or other dementias, visit alz.org/crf.
· The Alzheimer’s Association’s 24/7 helpline provides reliable information and support to people living with Alzheimer’s or other dementias, caregivers, health care professionals, and the public. Call toll-free, anytime, day or night, at 800.272.3900.
· Since 1982, the Alzheimer’s Association has committed over $340 million to more than 2250 scientific investigations with the goal of identifying novel approaches to diagnosis, treatment and – one day – a cure.
· Warning Signs of Alzheimer’s (alz.org):
§ Memory loss that disrupts daily life.
§ Challenges in planning or solving problems.
§ Difficulty completing familiar tasks at home, at work, or at leisure.
§ Confusion with time or place.
§ Trouble understanding visual images and spatial relationships.
§ New problems with words in speaking or writing
§ Misplacing things and losing the ability to retrace steps.
§ Decreased or poor judgment.
§ Withdrawal from work or social activities.
§ Changes in mood and personality.
Care Considerations for Alzheimer’s and Dementia:
Gary Joseph LeBlanc (2013) has written a clear and concise little book, Managing Alzheimer’s and Dementia Behaviors: Common Sense Caregiving, which stresses the following:
Early warning signs of Alzheimer’s include regular difficulties in recalling: dates, appointments, familiar names, and information given minutes before. Reading and numeracy may suffer markedly, despite a flood of excuses.
Hospitalization is disruptive and enhances their confusion.
Dementia is a general term for cognitive and memory loss, and Alzheimer’s is one of the possible causes.
Early-onset Alzheimer’s afflicts about a half-million people under the age of 65 and is more heritable than the more prevalent Alzheimer’s.
Such patients benefit greatly from the maintenance of routines.
Early in the progression, patients can have their thoughts readily redirected. Later, this becomes nearly impossible.
Approach these patients slowly, gently, looking to see if they recognize you. Introduce yourself, even to family.
Be prepared not to be recognized or only after long delay.
Go with the flow. “You cannot move them to your world, you have to move into theirs.”
Be prepared for their hallucinations and delusions. Exhibiting your frustration will only exacerbate the situation.
Don’t debate, elude. “I just went out and checked. They must have moved.”
Delusions are false beliefs.
Hallucinations are false perceptions.
Keep the environment well lit, for safety and to reduce “sundowning.”
Allow your patient a full-minute delay in responding to you.
Communicate face-to-face, not on the run or at a distance.
Be alert to pain versus frustration.
Avoid combat. Retreat. Don’t take verbal abuse personally.
Most important asset of a caregiver: patience, patience, patience.
Mr. LeBlanc’s little book is a bargain at amazon.com for those dealing with such patients. See also the excellent book by Scallan (2015), outlined in our Appendix.
Also, very highly regarded is the much longer (384 pages) book, The 36-hour Day: A Family Guide to Caring for People Who have Alzheimer Disease, Related Diseases, and Memory Loss, 5th Edition (2011), by Nancy L. Mace and Peter V. Rabins, originally published in 1981. It is available in ebook, paperback, audio book, and hardcover editions.
On a personal note, this afternoon, when I [DWC] came to check on my wife and give her a kiss, she asked, “What’s your name?” Yesterday, she told me she loved me. Tomorrow? Recently, as I pushed her in the wheelchair along the path through our park-like setting, she said she would like to live to be 100. I commented that would be 29 more years and asked her if she was enjoying her life, and she replied that she was.
Epilepsy (aka Seizure Disorder) is an abnormal electrical discharge of brain neurons which may be hypersensitive and react to unknown chemical or environmental stimuli. Seizures may also occur due to metabolic disorders such as hypoglycemia or hyponatremia (deficits in sugar or salt, respectively), infections such as meningitis, fever, drug and environmental toxins, or trauma. They may be unrelated to any known activities or causes, thereby making it difficult to ascertain origins. Patients may experience brief loss of consciousness and/or whole-body convulsions lasting many minutes.
Care Considerations for Epilepsy:
1) Patient may state he has “aura” which may signal an attack. Precipitating signs may include pungent smells, nausea, dreamy feelings, and visual disturbances as flashing lights.
2) Patient my experience fear and shame during seizures due to lost bodily functions; fear from inability to control or predict seizure.
3) Due to loss of consciousness, orient patient, explain slowly.
4) Anoxia (loss of oxygen) can occur. During and after seizure, monitor oxygen saturation.
5) Inspect body for any injuries.
6) Lasting safely modifications may need to be enacted which may include perceived loss of freedom by patient, such as restricted driving. Expect some loss of “self” and independence.
7) Consider adding padding, removal of rugs, and improving the availability of suction apparatus.
8) A medical alert bracelet, along with wallet medication information, is imperative.
Parkinson’s disease is a neurological impairment leading to a slow decline in muscle function. It leads to progressive muscular rigidity and decrease in movement (akinesia), and involuntary tremors. Often, initiating ambulation is difficult, and the patient is “stuck” and unable to move. This is a hallmark of the disease. Once initiated, the patient’s gait gains momentum that cannot be easily controlled. Tremors are evident and often appear when the extremity is at rest. There is often a unilateral “pill-rolling” tremor. As the disease progresses, it affects the other muscular systems, such as digestion and elimination. Causes of the disease are unknown. This is a disease that affects purposeful muscles versus involuntary muscle movements.
Care Considerations for Parkinson’s Disease:
1) Tremors are prevalent but decrease during purposeful movements. Patients should utilize all muscles in both upper and lower extremities.
2) In many instances, the body is bent forward to initiate movement because it is difficult to get the body in motion. Time and patience are required to initiate motion.
3) While walking, a potential for fall can easily result, due to the bent body position, inability to alter course quickly, and lack of peripheral vision fields due to forward intent. Once in motion, patient cannot quickly react nor avoid obstacles.
4) Other injuries resulting from lack of movement include bedsores and urinary tract infections (
5) Assess for additional deficits, including loss of balance, speech difficulties (dysarthia), and problems with eating and swallowing (dysphagia).
6) Obtain evaluation of level of consciousness.
7) As this is typically a disease of the muscles and not of the mind, psycho-social evaluation is paramount.
Multiple Sclerosis (MS) is an autoimmune disease causing defects in the myelin sheath that insulates the nerves that conduct electrical impulses from the brain and the spinal cord (the central nervous system). Lack of this myelin insulation (demyelination) is similar to a road under construction: impulses may be slowed greatly or blocked completely rather than traveling at a high speed to get to their destination. MS affects the nerves of the eyes and spinal column primarily, but the deficits are not limited to them. However, nerves of the peripheral nervous system are not involved. Often the disease takes years to diagnose due to the characteristic exacerbations and remissions that the disease presents. Signs and symptoms of exacerbations may be transient or last for long periods and may eventually become chronic. The resulting disabilities depend on the location and extent of the demyelination, and on what remyelination occurs after an exacerbation.
Care Considerations for Multiple Sclerosis:
1) During exacerbations, treatment is supportive, depending on the location affected. This typically includes bed rest, prevention of pressure ulcers, along with bowel and bladder management.
2) Monitor ventilation and promote deep breathing and coughing to eliminate stasis of secretions since respiratory muscle can be affected. Monitor oxygen saturation. Provide incentive spirometer for visual reading of deep breathing. Be aware for signs and symptoms of pneumonia.
3) Muscle weakness, spasms and hyper-reflexia (over-reaction to stimuli) may occur. Ensure precautions for fall potential and injuries, difficulties swallowing (dysphagia) and potential for aspiration pneumonia, poor gait (ataxia) and speed.
4) Patient may experience paralysis: monoplegia, hemiplegia, or quadriplegia (paralysis to one extremity, one side, or all extremities, respectively). Patient safety and care issues are paramount. Frequently aid in or provide range of motion exercises to keep joints fluid and prevent contractures. Prevent foot drop by utilizing high-top footwear. Utilize aids, such as canes and other rehabilitating equipment, to encourage self-care.
5) Visual disturbances are frequent. These can range from peripheral vision loss, to blurred vision, to complete blindness. Assess for vision disturbances prior to ambulation or activities of daily living.
6) Promote bowel and bladder elimination, and prevent harm to skin from incontinence by using frequent adult diaper changes, skin barrier creams or ointments, frequent turning and positioning.
7) Reassure patient about loss of function he is experiencing but make no guarantee that function will be restored. Remissions often occur with this disease, but such are not necessarily complete.
Myasthenia Gravis is an autoimmune disease that effect the nervous system and exhibits as a periodic, progressive, and extreme weakness of voluntary muscles, which are the group of muscles which we “choose” to utilize for activities. Primarily affecting muscle of the face, lips, eyes, and the activities of chewing and swallowing (mastication), and speech, this disease can affect any skeletal muscle in the body, including those for ambulation. This disease prohibits the conduction of the nerves to the voluntary (skeletal) muscles, and exacerbations occur during repetitive use of those muscles. A very simplified explanation is that there’s no gas left in the tank to make the car (skeletal muscle) run. It is a disease of exacerbations and remissions; often, symptoms worsen during the day but are improved after resting the affected muscle group. Extreme muscle fatigue that lessens with rest is one of the hallmarks of this disease. There is no cure, but most patients tend to live relatively normal lives, especially when they know their symptoms, recognize them, and can provide the rest that is necessary to abate exacerbations.
Care Considerations for Myasthenia Gravis:
1) As medications are not effective, there is no “fix” for this disease. The patient must understand that knowledge of his body will be the main treatment.
2) Knowing outward symptoms by the patient and family may provide signs of over-exerted muscles caused by the blocked and weakened transmission of nerve impulses to the muscles. For example, a dropping or drooping of the eyelid is often evidence of a potential exacerbation. Prior to the drooping, the patient may be tilting his head back to see better due to the muscle weakness of the eye because the visual field is lessened by the eyelid interference.
3) Attention should be paid to breathing and ventilation, especially during exacerbations. The respiratory muscles can often be compromised, and this could result in hypoventilation. Not breathing deeply and fully due to reduced muscle accessibility, both inhalation (breathing in) and exhalation (breathing out), decreases could potentially lead to dangerously decreased oxygen input and carbon dioxide output. In addition, with prolonged decreases in ventilation, respiratory tract infections could develop, including pneumonia. Assess oxygen saturation; promote use of incentive spirometer to encourage deep breaths and full expansion of lungs, and monitor level of consciousness and awareness.
4) Promote an environment and personal security that allow and encourage rest when needed.
5) Understand that loss of ability due to continued activity, debilitating muscle fatigue, and the losses associated with “wanting to do” but simply “cannot even consider” lead to loss of self-esteem. Encourage patient to schedule down-time.
Traumatic Brain Injuries (TBI) produce a range of disturbances, from short-term and slight trauma resulting in no apparent damage, long-term brain dysfunction leading to life-long impairment, to a vegetative state in the most extreme cases. These are injury-induced conditions which cause neurological damage and do not stem from illness or disease. A variety of accidents can cause TBIs, including sports injuries, playground falls, motor vehicle accidents, lack of oxygen (hypoxia), falling off ladders or down stairs. Recovery from any brain injury varies according to the area of the brain impacted as well as the wellness of the individual and how well the patient reacts to treatment and therapy. Examples of these brain injuries include concussions, skull fractures, and hemorrhages.
Care Considerations for Traumatic Brain Injuries (TBIs):
1) Constant assessment is necessary to determine actual consequences of the injury. Time will indicate acute deficits or chronic conditions.
2) Areas of the injured brain dictate deficits, and these may include motor skills (weakness, loss of balance, unsteady gait or ataxia, paraplegia, and quadriplegia), sensory changes (blurred vision, decreased acuity, blindness, loss of taste or smell, hearing difficulties, and tinnitus), behavior changes, bowel and bladder incontinence, dizziness or fainting (syncope), swallowing difficulties (dysphagia), chronic headaches, increased sensations to or loss of awareness of various body parts, increased or decreased reflexes, speech difficulties (expressive aphasia, receptive aphasia, anomia), or breathing difficulties.
3) Physical and occupational therapy is often necessary. Rest should be provided between care and therapy to promote maximum effectiveness.
4) Slow-talking and short-term therapy can aid in decreasing frustration associated with slow progress of therapy.
5) Ensure airways are protected if gag and swallowing reflexes are impaired.
6) Encourage deep breathing to promote lung expansion and ventilation.
7) Avoid coughing, straining or bearing down which can increase intracranial pressure.
8) Provide skin care and equipment to decrease risk of pressure ulcers. Turn and position body frequently. Provide an air mattress to increase circulation and decreases stasis of blood.
9) Assist with range of motion exercises to avoid deep venous thrombosis.
Guillain-Barre’ Syndrome is thought to be an immune disorder that affects the nervous system. It is hallmarked by acute and rapidly progressing loss of peripheral nerve transmissions to muscles due to demyelination. This results in muscle weakness, immobility, and paralysis beginning in the legs and ascending to the arms, body trunk, and face. Often respiratory muscles are affected which hampers breathing. The disease process takes three distinct phases: The “acute phase” begins when the first symptoms develop and continues until no further deterioration or loss of function is noted. This phase may last anywhere from one to three weeks typically. During the next few days to weeks, the “plateau phase” occurs. No further loss of function is noted but there is also no betterment. The last phase, “recovery phase” can last months to years but recovery is usually complete. This is the time when remyelination occurs and growth of peripheral nervous tissue takes place.
Care Considerations for Guillain-Barre’ Syndrome:
1) As the muscles necessary for respiration may be involved, assessment must be ongoing to determine loss of function. While the patient is recovering, provide use of incentive spirometer to promote lung expansion.
2) Paralysis of any or all extremities is likely. Provide skin care, turn and position, and inspect skin for any breakdown or presence of any deep venous thrombi (DVT, blood clots); check for swelling, reddening, warmth, suddenly visible veins.
3) Provide gentle massage to the extremities. Deep massage is not performed due to the possibility of DVTs.
4) If facial muscles are involved, provide oral care frequently. It is possible that eyelids will not close properly and completely. Instill eye drops to lubricate them.
5) During recovery when physical and/or occupation therapy is provided, ensure rest is given between sessions to promote maximum benefit.
Sensory Deficits can occur with any disease or injury of the nervous system but are not limited to this system solely. Sensory functions include hearing, vision, speech, taste, smell, and tactile sensitivity. While some modifications to the environment or use of tools may minimize the deficit, this is not the case with deficiencies in taste and smell.
Care Consideration for Sensory Deficits:
1) Hearing Difficulties: Deafness, whether partial or complete, is not only disease-induced but also results from age, environmental noise, medications and viruses. Hearing aids may help mitigate the problem, but other useful measures include using subtitles on the television, speaking directly to the patient so visualization of the lips is possible, speaking clearly and slowly, and decreasing background noise.
2) Vision Difficulties: There are many forms of vision deficits; these include decreased acuity, double vision (diplopia), light sensitivity (photophobia), blurred vision and loss of the visual field. There are few measures that can be taken to decrease this state. Utilization of trained professionals can provide teaching to enhance life. However, dependent on the severity, large print face, recorded books, and bright lighting may prove beneficial to some.
3) Speech Difficulties: These could be simply the inability to utter sounds (muteness) or a brain impairment called aphasia, the inability to communicate using speech, writing, or signs. It is almost as if communication is attempted between two people speaking two different and unrelated languages. Aphasia can take the form of being receptive (lack of understanding of words spoken by others) or expressive (inability to speak in meaningful and proper words). Anomia is the inability to recall names of objects. If the patient has some ability such as reading, communication can be maintained via use of written words or signs. Time and continued education may be beneficial. Frustration and anxiety are common.
4) Tactile Sensitivity: Paresthesia is caused by injury to the nerves. If it often painful and unpleasant, and described as a numbness, stinging, tingling, or burning. While there is little that can be done other than medications, running water over the appendage, wax dips, and massage can decrease the discomfort.
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549