Ch 59 Learning objective:

Compare and contrast the etiology, clinical manifestations,

collaborative care, pharmacologic management and nursing
management of tension-type, migraine, and cluster headaches
Primary vs Secondary headache:
*Primary are not caused by a disease or another type of condition
*examples include: Tension-type migraine and cluster headaches
*Secondary caused by another condition or disorder
*Ex: sinus infection, neck injury or stroke
tension-type headache (etiology, clinical manifestations, diagnostic
studies, collaborative care, pharmacologic management and nursing
management).
*also called stress headache
*etiology: it is likely that neurovascular factors similar to those involved
in migraine headaches play a role in the development of these
headaches
*clinical manifestations: Bilateral, frontaloccipital headache, constant
dull pressure, bandlike pressure at the base of the skull, does not
include nausea or vomiting but may involve photophobia (sensitivity to
light) or phonophobia (sensitivity to sound)
*headaches may occur intermittently for weeks, months, or years
*diagnostic studies: take history table 59- 2 and electromyography
(EMG) may show sustained contraction of the neck,scalp, or facial
muscles
*drug therapy: usually involves aspirin, acetaminophen, or NSAIDs
used alone or in comination with a sedative, muscle relaxant, or
tranquilizer, patient may also receive preventative therapy with a
tricylic antidepressant.
Migraine headache (etiology, clinical manifestations, diagnostic
studies, collaborative care, pharmacologic management and nursing
management).
*etiology: Triggering event: food, menstruation, head trauma, physical
exertion, missed meals, weather, stress and drugs.

*patho: etiology is unknown but peopple with migraines have a state of

hyperexcitability
in the cerebral cortex, especially in the occipital cortex
*clinical manifestations: there is a prodome (early manifestation of
impending disease) may be neurological (photophobia) or
psychological (irritability) an aura may be include visual (scotomas),
sensory (voices or sounds that don't exist), and or motor (weakness,
paralysis, feeling that limbs are moving) phenomena duration 4-72
hours
*aura only occur in 10% of migraines
*diagnostic studies: history, labs, CT, angiography, EMG, EEG, MRI,
MRA, lumbar puncture do CT and MRI if you find abnormal neurological
findings
*drug therapy: -mild to moderate can be relieved with NSAIDs, asprin,
or caffeine -containing combination analgesics. -for moderate to severe
triptans are the first line of defense they effect serotonin receptors,
reducing the neurogenic inflammation of the cerebral blood vessels
and producing vasoconstriction -botox may be an effective prophylactic
treatment for patients with chronic migraines or with migraines that
don't
respond to other medications.
Cluster headaches (etiology, clinical manifestations, diagnostic studies,
collaborative care, pharmacologic management and nursing
management)
*involves repeated headaches that typically last 2 weeks to 3 months
and then the patient does into remission for months to years the
clusters usually occur with regularity
during the same time of day during the same seasons of the year
*etiology is unknown: trigeminal nerve has a role in the production of
pain but cluster headaches also involved dysfunction of intracranial
blood vessels
*alcohol is the only dietary trigger, strong odors, weather changes, and
napping are
other triggers
*clinical manifestations: intense pain min to 3 hours, sharp, stabbing
feeling pain is generally located around the eye radiating to the
temple, forehead, cheek, nose, or gums

*diagnostic: based on history patient is asked to keep a diary of

headaches. CT scan, MRI or magnetic resonance angiography (MRA)
may rule out an aneurysm, tumor or infection. a lumbar puncture may
rule out other disorders
*drug therapy:
-prophylactic medications include:
verapamil, lithium, melatonin, or
divalproex
-inhaling oxygen 6-8 L/min may cause vasoconstriction
-methysergide
-Intranasal lidocaine
Nursing management for headaches
Subjective/Objective
Headache diary
Food diary
PLANNING
Reduce pain
Client will understand triggers and treatments
Coping strategies with pain
Maintain a quality of life
IMPLEMENTATION
Teach coping mechanisms
Analgesics
Non pharmacologic therapies
Avoid triggers
EVALUATION
Pain relief
Follow the plan of care.
Differentiate the etiology, clinical manifestations, diagnostic studies,
collaborative care, and nursing managment of seizure disorders,
multiple sclerosis, and Parkinsons disease.
Seizure: Uncontrolled electrical firing of the neurons that interrupt the
normal function of the brain.
Epilepsy: Recurring seizures that are caused by an underlying chronic
condition
Generalized Seizure:
*involves both sides of the brain and are characterized by bilateral
synchronous epileptic discharge in the brain in most cases patient
loses consciousness
*these types include: tonic-clonic, typical absence, and atypical
seizures

Tonic - Clonic Seizure:

*most common
*characterized by a loss of consciousness and falling to the ground if
the patient is standing up, followed by stiffening of the body for 10 to
20 seconds (tonic phase) and then jerking of the extremities for
another 30-40 seconds (clonic phase)
*tongue and cheek biting may occur
*cyanosis may also occur
*patient has no memory of seizure.
Typical absence Seizure:
*happens only in children and rarely into adolescents
*child appears to be daydreaming
*only lasts a few seconds
*when untreated can occur up to 100 times a day
*hyperventilation and flashing lights can cause these seizures.
Atypical Absence Seizure:
*characterized by a staring spell
*lasts longer than a typical seizure
Focal Seizure:
*begin in one hemisphere of the brain in a specific region of the cortex
*they produce signs and symptoms related to the function of the area
of the
brain involved
* in simple focal seizures :person remains conscious
*complex focal seizures : person is unconscious.
Status Epilepticus:
*state of continuous seizure activity or a condition in which seizures
recur in rapid succession without return to consciousness
*it is a neurological emergency.
Diagnostic Study for Seizure:
*CBC, urinalysis, electrolytes, creatinine, fasting blood glucose, lumbar
puncture these rule out metabolic disorders
*CT, MRI, MRA, MRS, Pet Scan rule out structural lesions
* EEG useful only if it shows abnormalities.
Collaborative Care:
Antiseizure drugs, surgery, vagal nerve stimulation, psychosocial
counseling.

Emergency Care for Seizure:

*Ensure patent airway
* Protect from injury ( do not restrain)
* Loosen or remove tight clothing
*Gain IV access
* Stay with patient for the duration of the seizure
* Administer medications ordered by physician
* Suction if needed
* Assist ventilation if client is not breathing.
On going monitoring for Seizure:
*Monitor level of conssciiousness , viital
siigns,, o2 saturation and Glasgow Coma Scale
*Reorient and reassure patient after seizure
*Never force an airway if teeth are clenched
*Administer medications for hypoglycemia as ordered by physician (IV
dextrose).
What is multiple sclerosis ?
*Chronic, progressive, degenerative disorder of the CNS.
*characterized by demyelination of nerve fibers of the brain and spinal
cord.
Etiology of multiple sclerosis ?
*cause is unknown
*some researchers say it's unlikely to be a single cause
*it may develop in a person genetically susceptible as a result of
environmental exposure.
Clinical manifestations of multiple sclerosis ?
*symptoms are gradual and vague and occur over months or years
*Chronic, progressive deterioration in neurological function
* OR Remissions and exacerbations
*symptoms include motor, sensory, and cerebellar, and emotional
problems
*motor symptoms include weakness or paralysis, diplopia (double
vision)
*sensory symptoms include: numbness, tingling, patchy blindness,
vertigo, decreased hearing
*bowel and bladder function can be affected including constipation and
spastic (overactive) bladder.

Diagnostic Studies multiple sclerosis ?

*history and physical examination
*clinical manifestations
*MRI of the brain and spinal cord may show the presence of plaques,
inflammation, atrophy, and tissue breakdown
*CSF analysis may show an increase in IgG
*TO MAKE A DIAGNOSIS OF MS THERE MYST BE EVIDENCE OF AT LEAST
TO INFLAMMATORY DEMYELINATING LESIONS IN AT LEAST 2 DIFFERENT
LOCATIONS WITHIN THE CNS WITH EVIDENCE OF DAMAGE OR AN
ATTACK OCCURRING AT DIFFERENT TIMES
collaborative care of multiple sclerosis ?
*use drugs that slow the disease progression and relive symptoms
* immunomodulator drugs
-fingolimod
-teriflunomide
-dimethly fumarate.
Nursing Management of multiple sclerosis ?
*maximize neuromuscular function
*maintain independence
*managing fatigue
*reduce exacerbations
*psychosocial well-being
*accept the illness
*Teach client regarding triggers
Reassure client during the diagnostic stage
Prevent complications from immobility
Good balance of exercise and rest
Prevent infections
Good nutrition
Bladder and bowel care
Emotional support.
What is Parkinson's disease ?
Chronic, progressive neurodegenerative disorder characterized by
slowness, in the initiation and execution of movement (bradykinesia),
increased muscle tone (rigidity), tremor at rest and gait disturbance.
Etiology of Parkinson's disease
*Associated with decreased levels of dopamine
*Due to destruction of cells in them Substantia Nigra in the basal
ganglia
*This effects the neurotransmission of impulses.

Clinical Manifestations of Parkinson's disease

*triad of tremor, rigidity, and bradykinesia
*tremor: is usually noticed by the patient only at first, more prominent
at rest, and is aggravated with emotional stress and increased
concentration ex: pill rolling
*rigidity: increased resistance to passive motion when limbs are moved
through range of motion
* bradykinesia : slow movement evident in the loss of automatic
movements like blinking, swinging arms while walking, swallowing
saliva, and self expression with face and hand movements.
Diagnostic Studies for Parkinson's disease
*diagnosis is based on history and clinical manifestations
*at least 2 of the three triad must be present.
collaborative care for Parkinson's disease
*drugs are given to either increase the supply of dopamine or decrease
the ACh
*levadopa
*anticholinergic drugs
*selegiline
*entacapone
*surgery is used to relieve symptoms and is usually done in patients
who don't respond to drug therapy
-ablative procedures a electrode is placed on the thalamus to reduce
the increased neuronal activity.
Nursing Management for Parkinson's disease
*Maintain good health, encourage independence
*Physical exercise, physical therapy.
what is myasthenia gravis ?
Autoimmune disease of the neuromuscular junction characterized by
fluctuating weakness of certain skeletal muscle groups.
etiology of myasthenia gravis
*it's caused by an autoimmune process in which antibodies are
produced and attack acetylcholine receptors
* a reduction in ACh receptors prevents ACh molecules from attaching
to receptors and promoting muscle contraction

Clinical manifestations of myasthenia gravis

*Fluctuating weakness of skeletal muscles ( eyes, eyelids, chewing,
swallowing, speaking and breathing).
*usually restored after a period of rest
*Myasthenic crisis: exacerbation of muscle weakness that results in
aspiration, respiratory infection, and respiratory insufficiency.
Diagnostic Testing for myasthenia gravis
*EMG: electromyogram may show decreased response to repeated
stimulation of the hand muscles
*tensilon test: reveals improved muscle contractility after IV injection
of the anticholinesterase agent edrophonium chloride (tensilon)
Collaborative care for myasthenia gravis
drug therapy include:
*anticholinesterase drugs: mestinon alternate day-corticoseroids, :
prednisone and immunosuppressants : imuran, cellcept, sandimmune
*Surgery:
because presence of the thymus gland appearance to enhance the
production of ACh receptor antibodies removal of the thymus results in
improvement of patients
*plasmapheresis and IV IgG can result in short-term improvement in
symptoms and in indicated for patient in crisis or in reparation for
surgery when coriticosteroids must be avoided.
Nursing Management myasthenia gravis
*Return of normal muscle function
*Manage fatigue
* Prevent complications
* Maintain a quality of life
* Maintain adequate ventilation
* Balance diet
* Aspiration precautions
* Administer medications
What is restless legs syndrome? What are the 2 types?
*also known as Willis-Ekbom disease is characterized by unpleasant
sensory (parasthesias) and motor abnormalities of one or both legs
*primary (idiopathic): unknown, but patients in this case have a
positive family history
*secondary: can be seen with metabolic abnormalities associated with
iron deficiency, renal failure, polyneuropathy associated with diabetes
mellitus, RA, or pregnancy

Etiology of restless legs syndrome?

*cause is unknown but it is believed that RLS is related o a dysfunction
in the brain's basal ganglia circuits that use the neurotransmitter
dopamine, which controls movements
*in RLS this causes the urge to move the legs.
clinical manifestations of restless legs syndrome?
*sensory sysmptoms usually appear first and are manifested as an
annoying and uncomfortable but usually painless sensation in the legs
*then you have parasthesias including numbness, tingling, "pins and
needles" to severe pain
*some describe the sensation as bugs crawling on the skin
*leg pain is localized in the calf muscles
*patient can also experience pain in the upper extremities and trunk
during evening or night when patient is sedentary.
Collaborative management of restless legs syndrome?
*goal is to reduce patient discomfort and improve sleep quality
*if RLS is secondary to uremia (urea in the blood) or iron deficiency,
treatment of these conditions will decrease symptoms
*non drug apparoaches include regular sleep patterns, encourage
exercise, eliminating aggravating factors such as alcohol, caffeine,
antipsychotic drugs, lithium, antihistamines, antidepressants
*if non drug approaches don't work then give carbidopa-levadopa
(Sinemet), ropinirole (Requip), pramipexole (Mirapex)
What is amyotrophic lateral sclerosis (ALS)?
*Progressive neurological disorder cause by a loss of motor neurons
*Electrical and chemical messaging that originate in the brain are
unable to transmit the signals to the muscles.
*also called Lou Gehrig's Disease after the baseball player who was
diagnosed
with the disease in 1939.
clinical manifestations of ALS?
*Limb weakness
*dysarthia (difficulty saying words because of problems with the
muscles that help you talk)
*dysphagia (difficulty swallowing)
*muscle wasting results from not using the muscle
*other symptoms include: pain, sleep disorders, drooling, emotional
lability.

nursing and collaborative management of ALS?

*riluzole (Rilutek) slows the progession of ALS this drug works to
decrease the amount of glutamate acid in the brain
*Facilitate communication
* Reduce risk of aspiration
*Identify early signs of respiratory distress (death usually results from
respiratory infection)
* Monitor pain
* Decrease falls
* Diversional activities such as reading and human companionship
support the patients cognitive and emotional functions.
What is Huntington's Disease?
*Genetically transmitted, autosomal dominant disorder
*involves the deficiency of aceteylcholine and GABA
* results in an increase of dopamine so symptoms are opposite of
Parkinson's.
Clinical manifestations of Huntington's Disease?
*Excessive involuntary movements
*writhing and twisting movements of the face, limbs and the body
*the gait deteriorates and ambulation eventually becomes impossible
*depression is common anxiety, agitation, impulsivity, apathy (lack of
interest) , social withdrawal, and obsessiveness
*death usually occurs 10 to 20 years after onset of symptoms most
commonly because of pnuemonia followed by suicide.
Diagnostic studies of Huntington's Disease?
*begins with family history and clinical symptoms
*genetic testing confirms the presences of the disease in a person with
symptoms
* someone who is asymptomatic but as a positive family history faces
the problem of being tested or not . If the test is positive the person
will develop HD but when and to what extent the disease will develop
can't be determined.
Nursing Management of Huntington's Disease?
Maintain a safe environment
Treat physical symptoms
Provide emotional support
*because of constant movement they need 4000 to 5000 cal/day.
Ch 60 Alzheimer, Delirium, Dementia.

Compare and contrast different etiologies of dementia?

Dementia: Characterized by dysfunction or loss of memory,
orientation, attention, language, judgment, and reasoning. It is
confused with depression most of the time. It is not part of aging, but
aging is a risk factor.
60--80% off patients with dementia have Alzheimer's disease ((AD))
and
they are often lumped together.
Dementia usually insidious, Often abrupt. And depression often
coincides with life.
Progression: dementia is slow
Duration: years ( 8 -20)
Most time pt. Feels sense guilt and hopelessness and may not
want to live.
Psychomotor behavior: may pace or hyperactive as disease
progress, may not be able to perform task or movemnet
sleep- wake cycle: sleep during day, frequent awakenings at
night, disturbed with early morning awakening.
What are the two most common causes of dementia?
1. Neurodegenerative disorders
- this is insidious and gradual in onset Alzheimer's disease
Dementia with Lewy bodies (DLB)
Frontotemporal lobar degeneration (FTLD)
Down syndrome
Amyotrophic lateral sclerosis (ALS)
Parkinson's disease
Huntington's disease
2) Vascular diseases
- this is abrupt in onset w/stepwise progression Vascular (multi infarct) dementia
-Vascular dementia can often be prevented through treatment of risk
factors: Hypertension, diabetes, smoking, hypercholesterolemia,
dysrhythmias.
Subarachnoid hemorrhage (potentially reversible)
Chronic subdural hematoma (potentially reversible)
CT and MRI are done to rule out other diseases.
What are other causes of dementia?

Toxic, metabolic,, or nutritional diseases

Immunologic diseases or infections
Systemic diseases
Trauma
Tumors
Ventricular disorders, Drugs

What are the risk factors for dementia?

Age is # 1 risk, Diabetes, Family history of dementia, Head injury, high
cholesterol, smoking, obesity, heart problems, hypertension.
What is Dementia with Lewy bodies (DLB)?
Characterized by presence of Lewy bodies in brainstem and cortex,
Abnormal deposits of the protein -synuclein, Typically have symptoms
of parkinsonism (e.g. hallucinations, short-term memory loss,
unpredictable cognitive shifts, and sleep disturbances)
Indicated by dementia + 2 of the following:
- Extrapyramidal signs (e.g. bradykinesia, rigidity, and postural
instability, but not always a tremor)
- Fluctuating cognitive ability
- Hallucinations
Medications may include
levodopa/carbidopa and
acetylcholinesterase inhibitors
NCLEX Question
Dementia is defined as a: syndrome characterized by cognitive
dysfunction and loss of memory.
What is sundowning?
Sundowning is a specific type of agitation Alzheimer's patients can
experience
Patient becomes more confused and agitated in late afternoon or
evening.
Cause is unclear.
To manage it:
Create a quiet, calm environment. Maximize exposure to daylight.,
Evaluate medications, Limit naps and caffeine, Consult health care
provider on drug therapy.
What is Alzheimer's disease?
Chronic, progressive, degenerative disease of the brain - Most common
form of dementia (60- 80%), age iiss most important risk factor.

Clinical manifestations of Alzheimer's disease

- Personal hygiene
- Concentration and attention
- Unpredictable behavior
- Delusions and hallucinations
- Dysphasia
- Apraxia (difficult or impossible to make certain motor movements)
- Visual agnosia (inability to process visual sensory information)
- Dysgraphia (inability to write, primarily in terms of handwriting, but
also in terms of coherence)
- Some long-term memory loss
- Wandering
Late stage:
Unable to communicate
Cannot perform activities of daily living (ADLs)
Patient becomes unresponsive and incontinent.
What are the 10 early warning signs of Alzheimer's disease?
1) Memory loss that affects job skills
2) Difficulty performing
familiar tasks
3) Problems with language
4) Disorientation to time and
place
5) Poor or decreased judgment
6) Problems with abstract
thinking
7) Misplacing things
8) Changes in mood or
behavior
9) Changes in personality
10) Loss of initiative
Is there a definitive diagnostic test for Alzheimer's disease?
No.
Diagnosed by exclusion once all other possible conditions causing
cognitive
impairment have been ruled out. A definitive diagnosis of AD usually
requires examination of brain tissue and the presence of neurofibrillary
tangles and neuritic plaques at autopsy.

Alzheimer's Disease Diagnostic

History and physical examination, including psychologic evaluation
Neuropsychologic testing, including Mini-Cog, Mini-Mental State
Examination
Brain imaging tests: CT, MRI, MRS, PET (atrophy, disease progression)
Complete blood count
Electrocardiogram
Serum glucose, creatinine, BUN
Serum levels of vitamins B1, B6, B12
Thyroid function tests
Liver function tests
Screening for depression
Collaborative care: Alzheimer's Disease Collaborative therapy
Drug therapy for cognitive problems
Behavioral modification
Moderate exercise
Assistance with functional independence
Assistance and support for caregiver
Drug therapy: Alzheimer's disease
levodopa/carbidopa and
acetylcholinesterase inhibitors
There are too many drugs, but those the two that she mentioned in
class.
What are some major concerns in Alzheimer's patients?
Behavioral problems (sundowning), Safety (falls, burns, ingesting toxic,
substance,, wandering), Pain management (difficult bc can't always
communicate they're in pain)
Eating and swallowing difficulties, (undernutrition), Oral care (inspect
mouth and provide
oral care regularly), Infection prevention (UTI, PNA), Skin care
(Incontinence, immobility, and, undernutrition increased risk of skin
breakdown)
Elimination problems (Urinary and fecal incontinence, constipation),
Caregiver support.
What is Delirium?
Temporary, acute mental confusion
Delirium precipitations:
-Drugs
-History of delirium
-Dementia -Environment
-Decreased oral intake
-Surgery
-Coexisting
medical conditions
-Functional status
Delirium Manifestations

Develops over 2-3 days Inability to concentrate Irritability

Loss of appetite Confusion Agitation Hallucinations

Insomnia

Delirium diagnostic techniques

Review medication, determine whether the delirium is an early sign of
dementia
Delirium intervention
Safety, caregiver support, reorientation, drug therapy.
What is the difference between dementia and delirium?
Delirium is abrupt-you need to get a baseline
Symptoms will develop quickly.
Dementia is slower- there will be first signs then will develop over
longer period of time
Why should you check the patient's treatment when at risk for
delirium?
To see which medications are new- the new medications may be
causing delirium