Care of Patients with Problems of the Central Nervous System: The Brain Chapter 44 reviews headaches, central nervous

system infections and common neurodegenerative diseases that affect mobility and cognition. The brain is part of the central nervous system that functions as the bodys center for controlling movement, sensation, and cognition. Health problems involving disease damage of the brain can be acute or chronic and often affect the patients level of independence and quality of life. A migraine headache is a chronic, episodic disorder with multiple subtypes classified as a long-duration headache because it usually lasts more than four hours. Migraines tend to be familial and may have a genetic basis, although vascular, genetic, neurologic, chemical, and environmental factors may also be involved. Abortive therapy alleviates pain during the aura phase or soon after the start. Drug therapy is prescribed to manage migraine headaches, but complementary and alternative therapies, such as yoga, meditation, massage, exercise, biofeedback, ice, darkened room, and relaxation techniques may be helpful. Drugs used may include triptans, ergotamine preparations, and anti-epileptic drugs. Teach patients with migraine headaches about triggers that could cause an episode, such as caffeine, wine, and pickled foods. Cluster headaches are manifested by brief intense unilateral pain, often in spring and fall, and classified as the most common chronic short-duration headaches. The pain of cluster headaches is usually accompanied by ipsilateral eye tearing, rhinorrhea, congestion, ptosis, facial sweating, eyelid edema, and miosis. Teach patients with cluster headaches about precipitating factors, such as anger episodes, excitement, and excessive physical activity. Tension headaches are the most common type of chronic long-duration headache, lasting more than 4 hours and are caused by stress and tension. Teach patients to keep a headache diary and to notify their health care provider if the severity, intensity, or nature of the headache increases or changes and report associations with unusual visual changes or ineffective drug therapy. A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons resulting in alteration in consciousness, motor or sensory ability, or behavior. Seizures may be due to a pathologic condition of the brain, such as a tumor. Epilepsy is defined as two or more seizures experienced by a person. The International Classification of Epileptic Seizures recognizes three broad categories of seizure disorders: generalized seizures, partial seizures, and unclassified seizures. Primary or idiopathic epilepsy is not associated with any identifiable cause. Secondary seizures result from an underlying brain lesion, most commonly a tumor, trauma, or metabolic or other disorders. Most seizures can be completely or almost completely controlled through the administration of antiepileptic drugs, referred to as anticonvulsants. Emphasize that the drugs must not be stopped even if the seizures have stopped as the recurrence of seizures or status epilepticus may occur.

 The actions taken during a seizure should be appropriate for the type of seizure, such as observation, timing, turning the patient on the side to prevent aspiration and allow secretions to drain, and removing any objects that might injure the patient. Place patients who have had one or more seizures on seizure precautions, which includes oxygen, suctioning equipment, IV access, and side rails up at all times. Status epilepticus is a medical emergency characterized by prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes. Causes of status epilepticus may include withdrawal from antiepileptic drugs, alcohol or other drugs, head trauma, infections, cerebral edema, and metabolic disturbances. Patients who cannot be managed effectively with medication may be candidates for surgery, including vagal nerve stimulation and conventional surgical procedures. Meningitis is an inflammation of the meninges surrounding the brain and spinal cord. Bacterial and viral organisms are most often responsible for meningitis, although fungal meningitis and protozoal meningitis also occur. Viral meningitis is usually self-limiting and the patient has a complete recovery; but bacterial meningitis is potentially life-threatening. Increased intracranial pressure may occur as a result of blockage of the flow of CSF, change in cerebral blood flow or thrombus formation. Analysis of the cerebrospinal fluid is used to diagnose meningitis. Patients who are older than 60 years of age, immunocompromised, or with signs of increased intracranial pressure (ICP) usually have a CT scan performed before the lumbar puncture. The most important nursing intervention for patients with meningitis is the accurate monitoring and recording of neurologic status, including vital signs and neurovascular checks, and observing for signs and symptoms of increased ICP. Standard precautions are appropriate for most patients with meningitis unless the patient has a bacterial infection that is transmitted by droplets. Encourage people in areas of high population density, such as college dormitories and crowded living areas, to become immunized against meningococcal meningitis. Encephalitis is an inflammation of the brain tissue and often the surrounding meninges, affecting the cerebrum, the brainstem, and the cerebellum. A viral agent elsewhere in the body most often causes the disease, although bacteria, fungi, or parasites may also be involved. Viral encephalitis can be life-threatening or lead to persistent neurological problems such as learning disabilities, epilepsy, memory loss, and fine motor deficits. In severe cases of encephalitis, the patient may exhibit increased ICP resulting from cerebral edema, hemorrhage, and necrosis of brain tissue. Lumbar puncture and diagnostic analysis of CSF may be helpful, depending on the patients condition. Supportive nursing care and prompt recognition and treatment of increased ICP are essential components of management. Teach people who enjoy outdoor activities to avoid areas where mosquitoes and ticks are likely to populate, especially near lakes and wooded areas. Parkinson disease, also referred to as paralysis agitans, is a progressive neurodegenerative disease, which most often is idiopathic in origin.

 It is a debilitating disease affecting motor ability and is characterized by four cardinal symptoms: tremor, rigidity, bradykinesia or akinesia, and postural instability. A few patients have secondary parkinsonian symptoms from conditions such as brain tumors and certain anti-psychotic drugs. Although the cause is not known, it may be due to environmental and genetic factors. Exposure to pesticides, herbicides, industrial chemical and metals as well as well water, age over 40, and reduced estrogen levels are known risk factors. The diagnosis is made based on clinical findings after other disorders have been ruled out. Drug therapy decreases signs and symptoms and allows the patient to provide self-care and have a reasonable quality of life. Surgery, when drugs are not effective, may include stereotactic pallidotomy and thalamotomy, although newer surgical procedures are being tried. Monitor for drug toxicity, especially delirium and decreased drug effectiveness, when patients are taking levodopa combinations for Parkinson disease. Alzheimers disease is a chronic, progressive, degenerative disease accounting for 60% of the dementias occurring in people older than 65 years of age, eventually causing complete disorientation and total dependence on others for care. It is characterized by loss of memory, judgment, and visuospatial perception, and by a change in personality. The most important risk factors are age, female gender, and family history. The primary focus of the neurologic assessment is to identify abnormalities in cognition, including language, personality, and behavior. Physical manifestations of neurologic impairment, such as seizures, tremors, or ataxia, tend to occur late in the disease process. The priority for interdisciplinary care is safety since chronic confusion and physical deficits place the patient at a high risk for injury. Huntington disease is transmitted as an autosomal dominant trait at conception. The triad of dominant inheritance, choreiform movements or rapid, jerky movements, and dementia are hallmarks of the disease There is no known cure or treatment, therefore genetic counseling is important. Collaborate with the health care team in discharge planning and health teaching for patients who have chronic neurodegenerative diseases. Help patients and families identify community resources for chronic brain disorders, including the Alzheimers Association and the National Parkinson Foundation. Teach caregivers of patients with dementia to use validation therapy, rather than reality orientation, to acknowledge the patients feelings and concerns. Involve patients and families in developing a continuing plan of care to meet expected outcomes and maintain quality of life.