Mr. Wal Kenbad is a 32 year old right handed male who presented with a progressive gait disorder. Three years ago, the patient first noticed difficulty walking ina straight line but did not think much of the problem. Over the next two years, however, this difficulty progressed to the point where he could no longer deny it. By this time, his gait was unsteady and "drunken", causing him to trip frequently especially when turning. He noted marked difficulty negotiating stairs, especially when walking down. At night, in the dark, his unsteadiness worsened. He was diagnosed with a peripheral neuropathy by another neurologist and sent to our center for further investigation and treatment. The patient denied any muscle wasting, weakness, fasciculations, muscle stiffness, tingling, numbness, visual disturbance, dysarthria, dysphagia, diplopia, incontinence, or memory disturbance. He is able to walk up to three miles a day, but his less fatigue easily.
Past Medical History:Unremarkable
Past Surgical History:None
Medications:Tylenol, as needed
Social History:Unmarried tire salesman with no history of alcohol, tobacco, or drug abuse. He denied any HIV risk.
Family History:No neurological disorders; specifically, no gait abnormalities.
Neurologic Disorders-Case Studies
Case studies are from Mosby 2001.
Case Study Number One
D.S. Is a 74-year-old retired social worker who has been on your floor for several days receiving q.o.d. plasmapheresis for myasthenia gravis (MG). She has a PMH of type 2 DM for 3 years and low back pain secondary to spinal stenosis. She received 2 steroid injections into her spine for pain 2 to 3 weeks before her admission, which was followed by progressive, symmetric, weakness in her lower extremities proximal > distal; R foot numbness; poor eye-hand coordination; and significant hand weakness. On admission, D.S. was unable to bear any weight of take fluids through a straw. There have been periods of exacerbation and remission since admission.
1. You are visiting with D.S.s grandson who tells you he is just starting medical school and he would like to know more about MG so that he can discuss it with his grandmother. What do you tell him?
2. He asks you to explain how plasmapheresis works. How would you explain this treatment?
3. He asks what drugs are used to treat MG. You explain although neostigmine (prostigmin) and pyridostigminbe (Mestinin) are often used in combination, drug regimens and doses are highly individualized. Identify the appropriate drug classification and explain the action of these two drugs to D.S.s grandson.
4. D.S. told her grandson that after taking her morning medications, she often experienced nausea, heartburn, slight SOB, sweating, and she felt her heart beating rapidly. What can you tell him about this?
5. Describe a myasthenic crisis.
6. List six nursing problem statements that would be appropriate for D.S.
7. List five factors that could predispose D.S. to an exacerbation of her illness.
8. D.S. Asks you what the doctors meant when they were talking about some kind of a challenge test. You realize they must have been discussing the possibility of performing an edrophonium (Tensilon) challenge. What is a Tensilon challenge, and what information will it yield>
9. What are aminoglycosides, and why are they contraindicated in patients with MG?
10. D.S.s grandson wants to know when shell be able to go home. How do you respond?
11. What supportive measures can you suggest to D.S.s grandson that he can undertake or arrange on behalf of his grandmother?
Case Study Number Two
You have been asked to see D.V. in the neurologic clinic. D.V. has been referred by his internist, who thinks his patient is having symptoms of multiple sclerosis (MS). D.V. is a 20-year-old male who has experienced increasing urinary frequency and urgency over the past 2 months. Because fis female partner was treated for an STD, D.V. also underwent treatment, but the symptoms did not resolve. D.V. has also recently had 2 brief episodes of eye fuzziness associated with diplopia and brightness. He has noticed ascending numbness and weakness of the R arm with inability to hold objects over the past few days. Now he reports rapid progression of weakness in his legs.
1. MS is an inflammatory disorder of the nervous system causing scattered, patchy demyelinization of the CNS. What does myelin do? What is demyelinization?
2. MS is characterized by remission and exacerbations. What happens to the myelin during each of these phases?
3. Isnt D.V. too young to get MS? What is the etiology?
4. What assessment data from the case study causes the physician to suspect a possible diagnosis of MS?
Diagnostic tests are often done to R/O other disorders with similar symptoms. A diagnosis will be made when other disorders have been R/O. when the patient has 2 or more exacerbations, when there is slow, steady progression, and/or when the patient has 2 or more areas of demyelinization or plaque formation.
5. What are four common diagnostic tests you can begin to teach D.V. about?
6. D.V. asks you, if this turns out to be MS, what is the treatment?
7. As part of your teaching plan, you want D.V. to be aware of situations or factors that are known to cause an exacerbation of symptoms. List four.
8. The National Multiple Sclerosis Society, 733 3rd Ave., 6th Flood, New York, NY 10017-3288 (800-344-4867), is a great resource for D.V. List several resources available in the community that D.V. may find helpful.
D.V. Confides in you that he tried to commit suicide at the age of 14 when his parents got a divorce. He tells you that he knows his girlfriend hasnt been faithful, but hes afraid of living alone. He admits that she occasionally hits him, but hes afraid if he tells her about his MS diagnosis, shell leave him for good. You recall seeing yellowish bruises on his arms when you took his admission BP.
9. What are you going to do with this information?
10. In view of his personal history and current diagnosis, what two critical psychosocial issues are you going to monitor for in his follow-up visits?
D.V. takes advantage of his time with the psychiatric nurse specialist, joins a local MS support group, and tells his girlfriend to move out. He later marries a woman from the support group.
Case Study Number Three
T.W. is a 22-year-old man who fell 50 feet from a chairlift while skiing and landed on hard-packed snow. He was found to have a T10-11 fracture with paraplegia. He was initially admitted to the SICU and placed on high-dose steriods for 24 hours. He was taken to surgery 48 hours postaccident for spinal stabilization. He spent 2 additional days in the SICU, 5 days on the neuro unit, and now is ready to be transferred to your rehab unit. He continues to have no movement of his lower extremities.
1. The goal of treatment in the acute phase of spinal cord injury (SCI) is to help T.W. survive the injury and maintain physiologic stability through the period of spinal shock. Once the acute phase is over, T.W. moves into the postacute and early rehab phases. What are the treatment goals for T.W. in these phases?
2. Considering a hierarchy of rehabilitative needs for patients like T.W., number the following from highest (1) to lowest (5) priority.
_____Community integration and employment
_____Accomplishment of self-care and ADLs
_____Stabilization of the physiologic systems
_____Adjustment to living at home
3. T.W. receives high-dose steroid therapy every 24 hours; then he is placed on a smaller maintenance dose. What effect will steroids have on T.W.?
4. List three critical potential infections that T.W. should be monitored for throughout his hospitalization.
A person with an SCI at the T2-12 level should be independent in a wheelchair and able to manage ADLs, including bowel and bladder care.
5. T.W. is taking vitamin C 250 mg PO bid. What is the purpose of this?
You request a consultation with an RD because you realize that T.W. neeeds proteins for healing; however, too much can stress his kidneys. The RD will adjust his diet to ensure adequate amount of protein, carbohydrates, calcium, magnesium, and zinc.
6. Rehabilitation teaching includes teaching T.W. how to manage his urinary drainage system. What would this teaching include?
7. What is the usual amount of time for the return of reflex function of the bladder?
8. The large musculature has its own neural center that can directly respond to distention caused by fecal material. This is what allows most SCI patients to regain bowel control. What dietary instructions are important for T.W.?
9. T.W. should also be taught bowel training techniques. What would this teaching include?
10. What medications can assist with a bowel program?
11. Describe digital stimulation.
12. T.W. asks you whether hell ever be able to have sex again. What do you tell him, and what are some possible referrals?
For patients with lesions at T6 or above, there is the potential for autonomic dysreflexia (AD) in response to noxious stimulation of the sympathetic nervous system. The patient develops severe hypertension (as high as 240-300/150 mm Hg), pounding headache, bradycardia, blurred vision, nausea, nasal congestion, and flushing and sweating above the level of the injury and goose bumps or pallor below the level of the injury. Potential causes include bladder distention, obstruction, infection, spasms, catheterization, and bladder irrigations done too fast or with cold fluid; bowel constipation, impaction, or rectal stimulation; and alterations in skin integrity including pressure, infection, injury and cold or hit. This can cause retinal hemorrhage, CVA, and seizure activity.
Case Study Number Four:
T.S. is a 76-year-old widower being seen in your outpatient clinic for a medication refill for his Parkinsons disease. He is a retired railroad engineer who derives great pleasure from collecting railroad memorabilia and taking daily walks with his dog around his neighborhood. T.S. was diagnosed with moderate (stage lll) Parkinsons disease 2 years ago. He does not smoke cigarettes or drink alcohol. His PMH includes a femur fx at age 22, a cholecystectomy at age 47, and a transurethral resection of the prostate (TURP) at age 72.
1. Because of the interference of normal muscle tone and control of smooth muscle, patients with Parkinsons disease exhibit a classic triad of symptoms. Name them.
2. Parkinsons is primarily a disease affecting older adults with symptoms usually first noted in 60- to 70-year-olds. List two reasons why we are seeing a growing number of people with Parkinsons disease.
3. Symptoms very and are highly individualized. List eight symptoms associated with Parkinsons.
Medical management of the patient with Parkinsons is usually directed toward control of symptoms with drug therapy, supportive therapy, physiotherapy, and possibly pschotherapy. Pharmacotherapy can be fairly complex in these patients because there are several types of antiparkinsonian drugs with different mechanisms of action. The physician works with the patient to achieve the most effective regimen and often involves trial-and-error periods.
4. Why cant we just give oral dopamine as replacement therapy? What medication do we give instead?
5. Levodopa is always given in combination with carbidopa. Why?
6. What are five nursing interventions to decrease the number or severity of side effects of antiparkinsonian medications?
7. What advice will the RD give T.S. about his diet?
8. T.S. asks you to explain Parkinsonian crisis. Describe it in a way he can understand, and describe what someone should do if it occurs.
9. If you were a home health nurse, list six things that you would assess to determine whether T.S.s care can be managed in his home.
10. How might T.S.s PMH affect his symptoms?
For additional information contact:
Parkinsons Disease Foundation, Inc.
710 West 168th St.
New York, NY 10032-9982
Telephone (800) 457-6676
Case Study Number Five:
You are working at a skilled nursing facility that cares for patients with ventilators. G.W. is your first patient with Guillain-Barre syndrome. G.W. Is a divorced, self-supporting 56-year-old woman from a small town who developed a URI after caring for her grandson who had the same. Three weeks later she developed weakness, numbness, and tingling in her feet that progressed up her body. Her physician recognized the seriousness of her condition and transferred her to a tertiary referral center. Within days she became totally paralyzed; she was trached and placed on mechanical ventilation. She spent 1 month in the neuro critical care unit and several months on the floor before being transferred to your facility. Her only in hospital complication was pneumonia, which has totally resolved. The physicians dont know how long the paralysis will last.
1. What adaptions would you or your family have to make if you were paralyzed and unable to perform your normal responsibilities? How would you feel if you were totally dependent on others for your simplest needs? Use a separate sheet of paper for a detailed response, and include daily care; financial issues, such as who would pay the rent/mortgage, groceries, utilities, mounting medical bills; social issues, such as who would care for your children, see to their education, meet their emotional needs; self-perception; emotions; etc.
2. Is G.W.s case typical?
3. Why does potentially fatal respiratory dysfunction occur?
4. Describe a plan for pulmonary hypgiene for G.W.
5. How do you anticipate that G.W.s nutritional needs are being met?
6. Describe nursing interventions to manage bladder and bowel elimination for G.W.
7. What are some things you can do to decrease G.W.s fear and anxiety?
8. You are using your expert nursing skills to avoid complications. List four potential complications.
9. What measures can be taken to prevent pressure ulcers?
An additional 3 weeks have passed. G.W. has recovered gross movement of her arms and some respiratory effort. She is still on a ventilator, but she has gone from controlled to assisted breathing. This morning G.W. receives a letter from her health insurance company informing her that she has exceeded her lifetime limit and has been dropped from their plan. She is crying hysterically and is chocking because of the increased mucous production in her sinuses. Remember that she cannot wipe her eyes or blow her nose to clear it.
10. What can be done for her?
It takes G.W. almost 11 months to recover enough to be discharged to home with assistance of a home health aide.
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