Topic 2: Neurological, Perceptual, And Cognitive Complexities

Objectives:

Evaluate functions of the neurological, perceptual, and cognitive systems based on findings.
Propose an intervention for a patient with a cognitive complexity.

Assignment 1

Identify a common perceptual, neurological, or cognitive issue and discuss contributing factors. Outline steps for prevention or health promotion for the patient and family.

Assignment 2

Discuss characteristic findings for a stroke and how it affects the lives of patients and their families. Discuss the nurse’s role in supporting the patient’s psychological, emotional, and spiritual needs. Provide an example integrating concepts from the “Statement on the Integration of Faith and Work” located in Class Resources.

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Assignment 3-A

Evidence-Based Practice Project: Intervention Presentation on Diabetes

Identify a research or evidence-based article published within the last 5 years that focuses comprehensively on a specific intervention or new treatment tool for the management of diabetes in adults or children. The article must be relevant to nursing practice.

Submit a reference and a working link to the article as a word document.

Assignment 3-B

Case Study: Mr. M.

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mr. M., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below. Topic 2: Neurological, Perceptual, And Cognitive Complexities

Health History and Medical Information

Health History

Mr. M., a 70-year-old male, has been living at the assisted living facility where you work. He has no known allergies. He is a nonsmoker and does not use alcohol. Limited physical activity related to difficulty ambulating and unsteady gait. Medical history includes hypertension controlled with ACE inhibitors, hypercholesterolemia, status post appendectomy, and tibial fracture status postsurgical repair with no obvious signs of complications. Current medications include Lisinopril 20mg daily, Lipitor 40mg daily, Ambien 10mg PRN, Xanax 0.5 mg PRN, and ibuprofen 400mg PRN.

Case Scenario

Over the past 2 months, Mr. M. seems to be deteriorating quickly. He is having trouble recalling the names of his family members, remembering his room number, and even repeating what he has just read. He is becoming agitated and aggressive quickly. He appears to be afraid and fearful when he gets aggressive. He has been found wandering at night and will frequently become lost, needing help to get back to his room. Mr. M has become dependent with many ADLs, whereas a few months ago he was fully able to dress, bathe, and feed himself. The assisted living facility is concerned with his rapid decline and has decided to order testing.

Objective Data

Temperature: 37.1 degrees C
BP 123/78 HR 93 RR 22 Pox 99%
Denies pain
Height: 69.5 inches; Weight 87 kg

Laboratory Results

WBC: 19.2 (1,000/uL)
Lymphocytes 6700 (cells/uL)
CT Head shows no changes since previous scan
Urinalysis positive for moderate amount of leukocytes and cloudy
Protein: 7.1 g/dL; AST: 32 U/L; ALT 29 U/L

Critical Thinking Essay

In 750-1,000 words, critically evaluate Mr. M.’s situation. Include the following:

Describe the subjective and objective clinical manifestations present in Mr. M.
Based on the information presented in the case scenario, state what primary and secondary medical diagnoses should be considered for Mr. M. Formulate a nursing diagnosis from the medical diagnosis and explain why these should be considered and what data is provided for support.
What abnormalities would you expect to find and why when performing your nursing assessment using the identified primary and secondary medical diagnoses.
Describe the physical, psychological, and emotional effects Mr. M.’s current health status may have on him. Discuss the impact it can have on his family.
Discuss what interventions can be put into place to support Mr. M. and his family.
Given Mr. M.’s current condition, discuss at least four actual or potential problems he faces. Provide a rationale for each.

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. Topic 2: Neurological, Perceptual, And Cognitive Complexities

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Neurological, Perceptual, and Cognitive ComplexitiesBy Angel Falkner and Sue Z. Green

Essential Questions

What are the pathophysiological changes and abnormal findings associated with neurological, perceptual, and cognitive dysfunctions?
Which neurological health conditions are most prevalent?
How does the nurse manage these health conditions to restore the patient to optimal health?
What measures can a nurse use to transition patients toward independence in managing their own care?

Introduction

Diseases of the neurologic system are multifaceted, often affecting every aspect of a patient’s life. Insult or injury to the brain can leave a patient with lifelong effects requiring psychosocial and physical adjustments that necessitate a great deal of support. While the nurse should be knowledgeable regarding the details of neurologic diseases, it is equally imperative for the nurse to anticipate the varying needs of neuro patients and provide resources and education to manage their care.

Neurological, Perceptual, and Cognitive Complexities

The brain controls the ability to think, enables awareness of and movement within the surrounding environment, and makes interaction with others possible. The brain’s cognitive abilities depend on sensory nerve input from the body. The various parts of the brain must be able to learn new information, recognize familiar persons and objects, recall past experiences, and apply all of these to current thoughts and actions. The spinal nerves must be intact to receive and send sensory and motor messages within the body and brain. Understanding the complexities of the organ, nerves, and various functions helps the nurse in determining care for a person experiencing altered health in this area. Awareness of normal function triggers the notation of changes in expected neurological activity. Diagnostic testing may lead to diagnosis of a neurological condition, demonstrate response to treatment, or reveal progression of a disorder.

Pathophysiology

Normal Function

The nervous system (NS) is responsible for the complex network of communication in the body through transmission of nerve impulses, an electrical stimulus. The various portions of the system have a variety of functions. The nervous system is divided into the central nervous system (CNS) and the peripheral nervous system (PNS) (see Figure 2.1). Both the CNS and PNS contain neurons, the smallest component of the NS (see Figure 2.2). The neuron has two extensions: dendrites and axons. Dendrites receive the electrical stimuli and transfer the impulses to the body of the neuron. Axons conduct the impulse away from the neuron body to other cells.

Figure 2.1

Components of the Nervous System

Figure 2.2

Anatomy of a Neuron

The following are examples of NS components with specific corresponding parts and functions:

Components of the brain (see Figure 2.3),
Functions of the brain (see Table 2.1),
Functions of the cranial nerves (see Table 2.2), and
Functions of the spinal nerves (see Figure 2.4).

Figure 2.3

Components of the Brain

Table 2.1

Functions of the Brain

Component of the Brain

Function

Cerebral cortex

· Thought, voluntary movement, reasoning, perception.

· Outer layer of the brain.

Cerebrum consisting of two hemispheres containing the:

· Frontal lobe

· Occipital lobe

· Parietal lobe

· Temporal lobe

· The cerebrum is divided into two hemispheres, which control the activities of the opposite sides of the body. For example, the left side of the frontal lobe controls the right side of the body and vice versa.

· The frontal lobe directs voluntary skeletal actions, influences talking, writing, emotions, intellect, reasoning ability, judgment, and behavior. The Broca’s area within the lobe is responsible for speech. The frontal lobe contains basal ganglia near the lateral ventricles of both cerebral hemispheres. The basal ganglia are responsible for maintenance of balance and movement.

· The occipital lobe is the primary visual receptor center and influences the ability to read and understand the written word.

· The parietal lobe interprets touch, pain, temperature, and shapes.

· The temporal lobe receives and interprets impulses from the ear. The Wernicke’s area within the lobe is responsible for interpreting auditory stimuli.

Diencephalon consisting of:

· Thalamus

· Hypothalamus

· Integration of sensory and motor information.

· The thalamus relays sensory information to the cortex, receives information from the cerebral cortex, and transmits the information to the brain and spinal cord.

· The hypothalamus regulates body temperature, pulse, respiration, blood pressure, emotions, circadian rhythms, pain perception, appetite (hunger), and water balance (thirst).

· The limbic system, located near the hypothalamus:

o Aids in the control of emotions.

o Aids learning and memory.

o Is located near the hypothalamus.

o Includes the amygdala, hippocampus, mammillary bodies, and cingulate gyrus. Topic 2: Neurological, Perceptual, And Cognitive Complexities

Brain stem consisting of:

· Midbrain

· Pons

· Medulla oblongata

· The midbrain is the relay center for ear and eye reflexes and impulses from regions higher and lower in the brain and spinal cord.

· The pons serves as a link of the cerebellum to the cerebrum and the midbrain to the medulla.

· The medulla oblongata controls and regulates respiratory function, heart rate and force, and blood pressure. It contains the nuclei for cranial nerves.

Cerebellum

· Smooths voluntary movement.

· Maintenance of trunk equilibrium.

· Maintenance of muscle tone and posture.

· Receives information from the cerebral cortex, inner ear, muscles, and joints.

Note. Adapted from Medical-Surgical Nursing (10th ed.), by S. L. Lewis, L. Bucher, M. M. Heitkemper, M. M. Harding, J. Kwong, & D. Roberts, 2017; “Function of the Nervous System,” by A. Mandal, 2016; and Health Assessment in Nursing (6th ed.), by J. R. Weber & J. H. Kelley, 2018.

Table 2.2

Function of the Cranial Nerves

Cranial Nerve	Function
Olfactory	Sensory nerve that carries smell impulses from nasal mucous membrane to the brain.
Optic Sight	Sensory nerve that carries sight impulses from the retina to the brain.
Oculomotor	Motor nerve that carries impulses from the midbrain to the brain to control eyeball movement, pupil constriction, and raising of eyelids through contraction of eye muscles.
Trochlear	Motor nerve that carries impulses to the brain to control the eye’s superior oblique muscle for lateral eye movements.
Trigeminal	Sensorimotor nerve that carries impulses of pain, touch, and temperature from the following three areas to the brain: · Ophthalmic nerve carries impulses from the scalp, forehead, and eyes. · Maxillary nerve carries impulses from the upper jaw, upper lip, and cheeks. · Mandibular nerve carries impulses from the lower jaw and chin with the responses of biting, chewing, and clenching.
Abducens	Motor nerve that carries impulses from the lower pons to control lateral eye movements.
Facial	Sensorimotor nerve that carries impulses to and from the pons for tear production and muscle control for the scalp, face, and ears. Carries taste sensation from the anterior two-thirds of the tongue to the brain with response of stimulation of the salivary glands.
Acoustic (Vestibulocochlear)	Sensory nerve that carries impulses from the cochlea and inner ear for hearing and maintenance of balance.
Glossopharyngeal	Sensorimotor nerve that carries taste sensation from the back of the tongue and throat to the medulla with the response of increased secretion of saliva and swallowing.
Vagus	Sensorimotor nerve that carries impulses from the chest and abdominal organs to the medulla to monitor oxygen, carbon dioxide, and pH levels of the blood with the responses related to cardiac action, talking, swallowing, digestive juice production, and gastrointestinal activity.
Spinal Accessory	Motor nerve in the medulla and cervical cord that controls the sternocleidomastoid and trapezius muscles for head rotation and movement of shoulders and larynx.
Hypoglossal	Motor nerve in the medulla that controls muscles of the tongue for talking, swallowing, and movement of food in the mouth.

Note. Adapted from “Function of the Nervous System,” by A. Mandal, 2016; and Health Assessment in Nursing (6th ed.), by J. R. Weber & J. H. Kelley, 2018.

Figure 2.4

Functions of the Spinal Nerves

Note. Adapted from Understanding Pathophysiology (6th ed.), by S. E. Huether, K. L. McCance, V. L. Brashers, & N. S. Rote, 2017.

Central Nervous System

The CNS involves the brain, spinal cord, and olfactory and optic nerves (cranial nerves I and II) (Lewis et al., 2017). The CNS communicates through neurons to take in all sensory information, maintain memory, and control bodily functioning and regulation. A sensory electrical impulse travels from neuron to neuron across synapses until it reaches its destination—the brain or the spinal cord. After the sensory impulse arrives at its destination, a motor impulse is sent in return to illicit skeletal muscle function. The reflex arc within the spinal cord provides for immediate reaction to a potentially harmful stimulus. For example, if something feels too hot to the hand, a message is sent to the spinal cord, instead of forwarding to the brain, so that an immediate response is triggered to remove the hand (see Figure 2.5). The automatic action of blinking is another example of this involuntary response (Mandal, 2016). The CNS, particularly the brain, also controls sleep, thought, language, creativity, expression, emotions, personality, and memory (Huether, McCance, Brashers, & Rote, 2017; Taylor, n.d.).

Figure 2.5

Reflex Arc

Peripheral Nervous System

The PNS includes the cranial and spinal nerves and ganglia (Lewis et al., 2017; Taylor, n.d.). The PNS is further divided into the autonomic nervous system (ANS) and somatic nervous system (Mandal, 2017). The somatic nervous system portion of the PNS controls voluntary skeletal muscle movement. The ANS portion commands the sympathetic nervous system (SNS) and parasympathetic nervous system (PSNS). The SNS triggers the body’s energy mechanisms in response to stress, eliciting either fight or flight when confronted with a stressor (e.g., if faced with a bear in the woods, the reaction is to take flight and run from the impending danger) (Taylor, n.d.). Stressors include danger, excitement, emotions, embarrassment, or exercise (Taylor, n.d.). The sympathetic response increases respirations and heart rate, releases hormones (such as adrenaline), increases glucose production and release, and decreases digestion as a means of coping with the stress (see Figure 2.6) (Taylor, n.d.).

Figure 2.6

Sympathetic System

The PSNS responses are opposite of the SNS. The PSNS triggers the body’s relaxation response mechanisms (Lewis et al., 2017). The PSNS decreases respirations and heart rate and increases digestion (see Figure 2.7) (Taylor, n.d.). For example, after the stimulus is removed for a fight or flight sympathetic response, the PSNS restores the heart rate and breathing to previous normal rates. Topic 2: Neurological, Perceptual, And Cognitive Complexities

Figure 2.7

Parasympathetic System

Abnormal Findings

Disruption of normal NS function can occur through an interruption of nerve impulses. This can occur for a variety of reasons, including trauma, infection, cell death caused by oxygen deprivation, diseases or genetic processes, and inflammatory processes. Signs and symptoms also vary depending on the cause. Various common diagnostic tests are commonly used to determine the cause of the dysfunction or monitoring progress for either deterioration or improvements in function (see Table 2.3). This testing leads to diagnosis of some NS dysfunctions that are among the leading causes of death or disability, such stroke or Alzheimer’s disease. For example, if an infection is suspected, a lumbar puncture may be performed. If a stroke is suspected, the person is likely to undergo radiologic studies, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI).

Table 2.3

Common Neurological Diagnostic Tests

Category of Testing	Diagnostic Test	Abnormal Finding
Electrographic Studies	Electroencephalography (EEG)	Brain death, cerebral disease, CNS effects of systemic diseases, or seizure disorders.
	Electromyography (EMG)	Detection of lower neuron dysfunction, primary muscle disease, or peripheral vessel disease.
	Evoked potentials	Detection of abnormal nerve conduction to diagnose disease, such as multiple sclerosis, or locate nerve damage. May monitor nerve conduction during surgery.
	Magnetoencephalography (MEG) and nerve conduction studies	Pinpoints part of the brain involved in a seizure, stroke, or other disorder or injury.
Lumbar Puncture	Cerebrospinal fluid analysis	Fluid that is cloudy, has odor, abnormal specific gravity or pH, presence of red blood cells or microorganisms, abnormal level of white blood cells, glucose, or protein. Higher or lower than normal pressure reading.
Radiologic Studies	Skull and spinal column x-ray	Abnormal vascularity, bone erosion, calcifications, fractures.
	Cerebral angiography	Vascular lesions or tumors in the brain.
	Computed tomography (CT) scan	Brain atrophy, cysts, edema, hemorrhage, infarction, tumor, or other abnormalities.
	Magnetic resonance angiography (MRA)	Abnormal blood flow in the extracranial or intracranial blood vessels.
	Magnetic resonance imaging (MRI)	Herniation, multiple sclerosis, seizures, stroke, trauma, tumors.
	Myelogram	X-ray with contrast to reveal spinal lesions, such as a herniated or ruptured disc or a spinal tumor.
	Positron emission tomography (PET)	Radioactive materials injected in the scan procedure for diagnosis of Alzheimer’s disease, Parkinson’s disease, seizure disorders, stroke, and tumors.
	Single-photon emission computed tomography (SPECT)	Radioactive materials injected in the scan procedure to visualize blood flow or glucose utilization. Used in the diagnosis of brain tumor, seizure disorder, and stroke.
Ultrasound	Carotid duplex studies	Increased blood flow velocity indicates stenosis of carotid artery.
Ultrasound	Transcranial Doppler	Used to determine intracranial blood flow velocity.

Note. Adapted from Medical-Surgical Nursing (10th ed.), by S. L. Lewis, L. Bucher, M. M. Heitkemper, M. M. Harding, J. Kwong, & D. Roberts, 2017.

Prevalent Problems

Stroke (CVA)

A stroke or brain attack occurs when blood flow to an area of the brain is halted by a rupture (hemorrhagic stroke) or a thrombus (ischemic stroke) in a blood vessel supplying the area. When the blood flow ceases, the area of the brain is deprived of oxygen, and brain cells begin to die, also known as a cerebrovascular accident (CVA). The functions of that area of the brain are diminished or lost because of brain cell death and reduction in NS ability to transmit impulses. A transient ischemic attack (TIA) occurs when there is a temporary interruption of the blood flow. For example, the person may have temporary weakness of an arm, leg, or one side of the body, or lose aspects of memory or ability to speak, depending on the site and severity of the stroke (National Stroke Association, n.d.g). According to the Centers for Disease Control and Prevention (CDC):

every 4 minutes someone dies from a CVA,
CVA is the leading cause of adult disability in the United States, and
up to 80% of CVAs are preventable (CDC, 2017c).

CVA is the fifth leading cause of death in the United States (CDC, 2017a). Strokes usually occur suddenly and require prompt recognition and medical treatment. The sudden signs and symptoms of stroke include:

numbness or weakness in the face, arm, or leg, especially on one side of the body;
confusion, trouble speaking, or difficulty understanding speech;
trouble seeing in one or both eyes;
trouble walking, dizziness, loss of balance, or lack of coordination; and
severe headache with no known cause (CDC, 2018; National Stroke Association, n.d.d).

Diminishing the long-lasting effects of a CVA depends on rapid recognition and quick interventions. The acronym FAST is useful for the awareness of the public and health care professionals that quick intervention is needed, preferably within 3 hours of the first symptoms. The assessment elements included in the FAST test are explained in Figure 2.8.

Figure 2.8

FAST Intervention

Note. Adapted from “Stroke Signs and Symptoms,” by the Centers for Disease Control and Prevention, 2018.

Stroke-like symptoms can occur with a TIA, and rapid intervention should still occur because it is unknown which condition is occurring (National Stroke Association, n.d.a). A TIA left untreated may lead to a major CVA that may lead to permanent lifelong effects or even death.

Once the patient has been identified as a possible CVA victim, the first diagnostic test to be completed upon arrival to a certified stroke hospital is a noncontrast CT scan. This is done to identify whether the CVA is hemorrhagic or ischemic. If the CVA is identified as ischemic there are several lifesaving treatment options that are available. The identification of CVA symptoms and subsequent type of stroke within the 3-hour window enables the practitioner to consider treatment with the intravenous drug tissue plasminogen activator (tPA), which has the capacity to reduce or eliminate life altering symptoms associated with stroke (Cheng & Kim, 2015). This medication is sometimes referred to as the clot buster because its quite literally breaks down the clot that is impeding blood flow to the brain (Cheng & Kim, 2015). Another option for treatment of an ischemic stroke is the endoscopic retrieval of the clot, which may be done in combination with tPA (Mayo Clinic, n.d.).

If the patient is diagnosed with a hemorrhagic stroke, the treatment involves close monitoring of the size of the bleeding within the brain through frequent neurologic assessments and CT scans, as well as discontinuing any medications that may increase risk of bleeding. Treatment also involves tight control of the patient’s blood pressure, treatment with anticonvulsant medications to prevent seizures, and osmotic diuretics to decrease intracranial pressure (Liebeskind, 2017). The patient may be a candidate for surgery, in which the hematoma within the brain is removed and the blood vessels within the area are repaired (Weill Cornell Brain and Spine Center, 2017).

Dementia/Alzheimer’s Disease

Dementia is a non-age-related decline in cognitive abilities caused by damage to the cerebral hemispheres and subcortical areas for memory and learning (Porth, 2014). The damage is caused by direct trauma, stroke, Alzheimer’s disease, or similar permanent conditions. The impaired cognitive function becomes apparent because of memory disorders, personality changes, and impaired reasoning. Alzheimer’s disease causes 60% to 80% of all dementia (Porth, 2014). Alzheimer’s dementia is progressive, with symptoms gradually worsening over a number of years. Initially, mild memory loss occurs, but in the final stage the person loses ability to respond to persons or the environment and leads to death. Alzheimer’s disease is the sixth leading cause of death in the United States (CDC, 2017a). Extracellular amyloid plaques, intracellular neurofibrillary tangles (NFTs), and neuronal death synaptic deterioration, occurs with Alzheimer’s disease (Ulep, Saraon, & McLea, 2017) (see Figure 2.9).

Figure 2.9

Comparison of a Healthy Brain and Alzheimer’s Brain

Clinical signs and symptoms along with neuropsychological testing and biomarkers can lead to diagnosis of Alzheimer’s disease (Ulep et al., 2017). Early signs and symptoms of Alzheimer’s disease include:

Changes in mood, such as depression or other behavior and personality changes;
Confusion with location or passage of time;
Difficulty concentrating, planning, or problem-solving;
Having visual or space difficulties, such as not understanding distance in driving, getting lost, or misplacing items;
Language problems, such as word-finding problems or reduced vocabulary in speech or writing;
Memory impairment, such as difficulty remembering events;
Problems finishing daily tasks at home or at work;
Using poor judgment in decisions;
Withdrawal from work events or social engagements. (Mayo Clinic Staff , 2016, para. 3)

Risk factors for Alzheimer’s disease include head injury, hypertension, genetics, obesity, older age, sedentary lifestyle, smoking, and type 2 diabetes (Ulep et al., 2017). On average, persons with Alzheimer’s disease live 8 years after diagnosis, but the range is from 4 to 20 years (Alzheimer’s Association, n.d.d; Ulep et al., 2017). Three stages are noted for the disease’s progression (see Table 2.4).

Table 2.4

Stages of Alzheimer’s Disease

Stage of Alzheimer’s Disease	Signs and Symptoms of Stage
Mild Alzheimer’s Disease (Early Stage)	· Challenges performing tasks in social or work settings. · Forgetting material that one has just read. · Losing or misplacing a valuable object. · Problems coming up with the right word or name. · Trouble remembering names when introduced to new people. · Increasing trouble with planning or organizing.
Moderate Alzheimer’s Disease (Middle Stage)	· An increased risk of wandering and becoming lost. · Being unable to recall their own address or telephone number or the high school or college from which they graduated. · Changes in sleep patterns, such as sleeping during the day and becoming restless at night. · Confusion about where one is or what day it is. · Feeling moody or withdrawn, especially in socially or mentally challenging situations. · Forgetfulness of events or about one’s own personal history. · Personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like hand wringing or tissue shredding. · The need for help choosing proper clothing for the season or the occasion. · Trouble controlling bladder and bowels in some individuals.
Severe Alzheimer’s Disease (Late Stage)	· Become vulnerable to infections, especially pneumonia. · Experience changes in physical abilities, including the ability to walk, sit, and eventually, swallow. · Have increasing difficulty communicating. · Lose awareness of recent experiences as well as of their surroundings. · Need round-the-clock assistance with daily activities and personal care.

Note. Adapted from “Stages of Alzheimer’s,” by the Alzheimer’s Organization, found at https://www.alz.org/alzheimers-dementia/stages

Currently, there is no cure or reversal for AD. Medications prescribed to treat the cognitive symptoms are memantine, cholinesterase inhibitors, such as donepezil, galantamine, and rivastigmine, or Namzaric, which is a combination of donepezil and memantine (Alzheimer’s Association, n.d.c; Ulep et al., 2017). Treatment is focused on supportive and palliative care of the patient and their caregivers.

Alzheimer’s Disease

Theodore received a call from a police officer when his mother, Aubrey, was found wandering the parking lot of a local grocery store, unable to recall the make, model, or color of her car and other information, such as the day of the week or her address. The officer was able to locate Theodore’s contact information from Aubrey’s wallet. Theodore had noticed that his mother had increasing difficulty with remembering new information or finding objects, but he thought this was a normal part of his mother’s aging. Shortly after this, Aubrey was diagnosed with moderate Alzheimer’s disease and placed on memantine. Theodore explored safer living environments for his mother, eventually moving her to an extended care unit specializing in the care of those with Alzheimer’s disease.

Check for Understanding

What symptoms alert the nurse that a person may be experiencing dementia?
What are priority nursing actions when a person exhibits signs and symptoms of a CVA?

Nursing Management

Restoration of Function

Restoration of function has various implications depending on the disease or condition affecting the NS of the patient. Acute care of a stroke includes stabilization and aggressive treatment if indicated, then initiation of supportive services, such as physical, occupational, and speech therapies, to begin restoration of function to any areas of deficit. Care for a patient with Alzheimer’s disease or dementia attempts to maintain health and functioning as long as possible. Interventions center on improving quality of life and maximizing cognitive and physical functioning. When caring for a patient with dementia, the nurse should be aware that dementia may heighten pain sensitivity (Hadjistavropoulos et al., 2014). A pain assessment tool, such as the Pain Assessment in Advanced Dementia tool (PAINAD), assists the nurse in assessment of the pain and comfort level in a patient with dementia (Cornelius, Herr, Gordon, & Kretzer, 2017; Lopez & Molony, 2018; Schofield, 2017; Warden, Hurley, & Volicer, 2003) (see Table 2.5).

Table 2.5

PAINAD Scale

Behavior	Score of 0	Score of 1	Score of 2	Score
Breathing Normal Independent of Vocalization	Normal	Occasional labored breathing. Short period of hyperventilation.	Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations.
Negative Vocalization	None	Occasional moan or groan. Low-level speech with a negative or disapproving quality.	Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial Expression	Smiling or inexpressive	Sad. Frightened. Frown.	Facial grimacing.
Body Language	Relaxed	Tense. Distressed. Pacing. Fidgeting.	Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.
Consolability	No need to console	Distracted or reassured by voice or touch.	Unable to console, distract or reassure.
Total:
Scoring The total range: 0-10 points. Total score interpretation: 0 = No Pain and 10 = Severe Pain. Range interpretation: Mild Pain = 0-3, Moderate Pain = 4-6, and Severe Pain = 7-10.

Note. Adapted from “Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD) Scale,” by V. Warden, A. C. Hurley, & L. Volicer, 2003, Journal of the American Medical Directors Association, 4, 9-15. Topic 2: Neurological, Perceptual, And Cognitive Complexities

Nutritional Considerations

A healthy nutritional status is a challenge when cognitive changes occur. Maintenance of weight is aided when snack foods are selected that can increase energy and protein intake without increasing volume. These foods may be modified to include butter, cream, grated cheese, milk powder, protein powders, or oral supplements (Lopez & Molony, 2018). Food for snacks and meals should be ones that the person with dementia enjoys and the consistency that they can manage. For example, finger foods are easier for the person to manage than using eating utensils (Lopez & Molony, 2018). The person may have lost the ability to remember how to use a fork or spoon, and finger food encourages the person’s autonomy of self-feeding rather than being spoon-fed. Also, preconceived ideas of what is served should be modified as needed. If the person wants to eat breakfast food at dinnertime, then this is encouraged rather than complying with the societal expectations for food choices based on the time of day. When cognitive functioning deteriorates or is impaired, swallowing may become difficult and ineffective. Impaired swallowing abilities increase the risk for aspiration pneumonia and airway obstruction (Lopez & Molony, 2018). Rather than use an enteral feeding tube, the American Geriatrics Society advocates careful hand feeding of patients with advanced dementia (American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee, 2014). Careful hand feeding is the provision of small amounts of food and drink when patients are no longer able to feed themselves and may have swallowing difficulties. The caregiver should

avoid any distractions during the slow feeding process;
remain focused on the patient and watch for signs of choking;
limit the portion to one teaspoon or less;
use thickeners for liquids;
provide reminders to chew and swallow, perhaps multiple times; and
encourage a gentle cough after each swallow (Luk, Chan, Hui, & Tse, 2017).

Transition to Independence

Psychosocial, Cultural, and Spiritual Support

Spiritual and cultural aspects intertwine with psychosocial elements. The person’s culture, religion, spiritualty, gender, and sexuality can affect how the person views the impact of a temporary or permanently debilitating condition. Patients with NS disorders may question why they have been afflicted with such a debilitating disease process. The concept of hope is important as the patient deals with these life changes (Scammell, 2017). Depression can hinder recovery after a stroke and the maintenance of cognitive and physical functioning with dementia. As many as 30% to 50% of stroke survivors develop depression in the early or later poststroke phases (American Heart Association/American Stroke Association [AHA/ASA], 2013a). Recovery from stoke requires changes in physical, social, and emotional aspects of life (National Stroke Association, n.d.e). The patient and family may fear another stroke will occur and need assistance to make lifestyle changes to decrease the risk of reoccurrence. Concerns include the strain on family relationships, finances, ability to drive and regain other independent activities, diet, smoking cessation, weight loss, and return to work (National Stroke Association, n.d.b). Patients may need to reformulate their perception of self and their role in the family and society. Regaining abilities includes range of motion and motor skill exercises and mobility training. The nurse can offer support by listening, using touch, being present, using silence when appropriate, offering encouragement, and observing the patient for signs of distress (Caldeira & Timmons, 2017). The nurse monitors the care given for signs of respect and dignity toward the patient, considering the patient’s religious, cultural, and spiritual beliefs and gender preferences.

Almost one third of those experiencing a stroke are under the age of 65 and need to return to work (National Stroke Association, n.d.c). The National Stroke Association has information to assist the person decide whether to return to work or seek another source of income (National Stroke Association, n.d.c). The Job Accommodation Network (JAN) is a Department of Labor resource for seeking assistance when navigating a return to work that requires some workplace accommodations (Job Accommodation Network, n.d.).

Families of the person with Alzheimer’s disease experience caregiver strain from watching a family member slowly decline. Caregivers must be encouraged to care for their own health as this is often neglected when the focus becomes the patient. Caregivers may require emotional support and resources regarding psychological care. The Family Caregiver Alliance (n.d.) is one resource that may be of benefit to the family. This organization has information, resources, and support links. Some families find comfort in providing as much care as they can give to the affected family member. For example, careful hand feeding allows the family to continue to express affection through food (Lopez & Molony, 2018). In addition, the sharing of food has cultural and spiritual aspects that are important to some families (Lopez & Molony, 2018).

Contributing Factors

The risks related to the development of neurologic disease such as stroke are numerous. Just as in other diseases, there are often comorbidities that exist together, such as cardiovascular disease (e.g., hypertension), neurologic disease (e.g., stroke) and metabolic disease (e.g., diabetes). Some neurologic diseases, such as AD, have genetic components. Others, such as stroke, are related to modifiable lifestyle choices. Changes in lifestyle, such as smoking cessation, diet, and exercise modification, are imperative for decreasing the risk or reoccurrence of a CVA (Harvard Health Publishing, 2017a). In addition, the person must manage comorbid health conditions, such as hypertension, to decrease CVA risks. For diseases such as AD, research has found that keeping the brain active with activities such as reading may be key to decreasing risk. In addition, important factors such as proper diet, physical activity, and adequate sleep all play an essential role in decreasing the risk of developing this crippling disease (Harvard Health Publishing, 2017b).

Prevention and Health Promotion

Genetic factors are nonmodifiable for stroke and AD, but various modifiable factors exist (Mendiola-Precoma, Berumen, Padilla, & Garcia-Alcocer, 2016). Specially, modifiable risks to consider for prevention of stroke include:

air pollution,
atrial fibrillation,
cigarette smoking,
diabetes,
diet and activity,
depression,
dyslipidemia,
hypertension,
postmenopausal hormone replacement therapy (HRT),
sickle cell disease, and
weight and body fat (Silver, 2018).

Primary modification of these risks occurs through diet modifications, exercise, smoking cessation, weight loss, and use of 3-hydroxy-3-methylgutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), anticoagulants, platelet antiaggregants, and antihypertensive medications, as applicable (Silver, 2018). Secondary prevention after a stroke occurrence is through blood pressure control, smoking cessation, diabetes control, weight loss, regular exercise, and a low-fat diet, such as the Mediterranean diet or dietary approaches to stop hypertension (Silver, 2018). According the National Heart, Lung, and Blood Institute (n.d.), the DASH diet is recommended for persons with hypertension. DASH is an acronym for Dietary Approaches to Stop Hypertension and focuses on a lower sodium intake and more healthy fruits and vegetables than the typical American diet (Mayo Clinic Staff, n.d.; National Heart, Lung, and Blood Institute, n.d.).

Patients may require an angioplasty and stents to treat cardiovascular disease or a carotid endarterectomy to remove a blockage such as fatty plaque from the carotid artery (AHA/ASA, 2013b). The mnemonic, A, B, C, D, E, standing for the aspects needed for secondary prevention, is visualized in Figure 2.10.

Figure 2.10

ABCDE – Secondary Prevention of Stroke

Note. Adapted from “Stroke Prevention,” by B. Silver, 2018, Medscape.

Resources for Nonacute Care

The Internet provides many resources for poststroke care and care for dementia patients. The National Center on Aging has information regarding both conditions (National Institute on Aging, n.d.a.; National Institute on Aging, n.d.b). Information related to strokes and recovery can be found on the websites of the American Stroke Association (AHA/ASA, 2013a), the CDC (2016), the National Institute of Neurological Disorders and Stroke (2018), and the National Stroke Association (n.d.f). The website of the Alzheimer’s Association (n.d.a; n.d.b) addresses a variety of topics and includes a caregiver center. In the interest of public health, the CDC’s Healthy Brain Initiative includes partnerships to promote cognitive functioning and address cognitive impairments (CDC, 2017b).

Coping With a Spouse’s Stroke

When George had a stroke, his wife Lavina, searched various websites suggested by his nurse. On the American Stroke Association site, she found resources for stroke recovery, such as Getting the Most out of Stoke Rehab, Understanding the Needs of the Caregiver Family, and Regaining Independence After Stroke. She also found a link for an online support network for stroke survivors and caregivers. She found similar educational information on the other nurse suggested websites. For example, on the Centers for Disease Control and Prevention site, she located links to educational handouts, including one for herself on Women and Stroke. She found links for the signs and symptoms of and risks for stroke on the National Institute of Neurological Disorders and Stroke’s public education page. Being in touch with these resources provided Lavina a sense of autonomy and hope for her and George’s current situation. She reached out to other survivors and caregivers as her husband recovered.

Check for Understanding

How can the nurse promote recovery after a CVA?
How can the nurse support the patient with Alzheimer’s disease and the family?

Reflective Summary

Patients with neurologic diseases require prevention, management, treatment and multidimensional resources. The nurse is a key proponent of these elements and strives to provide education, support, and resources to the patient from the patient’s initial diagnosis to the chronic management of disease. Nurses are essential in helping to find ways to promote wellness and functioning in spite of the barriers patients may face in coping with the effects of neurologic diseases.

Key Terms

Alzheimer’s Disease: Generalized degeneration of the brain causing progressive mental deterioration; a form of dementia that may onset after age 64, or earlier in the people in their 40s or 50s; cognitive decline that is not a normal aspect of aging.

Anticonvulsant Medications: Medications used to treat and prevent the onset of seizure activity that can be seen with neurologic injury.

Autonomic Nervous System (ANS): The portion of the peripheral nervous system responsible for control of basic bodily functions that are not consciously controlled, such as breathing, heartbeat, and digestion.

Axons: Extensions of the neuron that conduct electrical impulses away from the neuron body to other cells.

Careful Hand Feeding: The cautious hand feeding of small amounts of food and thickened drink to patients who are no longer able to feed themselves and may have swallowing difficulties.

Central Nervous System (CNS): The portion of the nervous system that is composed of the brain and spinal cord.

Cerebrovascular Accident (CVA): The damage that occurs to an area of the brain caused by the occlusion of a blood vessel leading to the affected area; causes brain cell death from oxygen deprivation; can cause permanent effects, such as paralysis and speech deficits.

Certified Stroke Hospital: An acute care hospital certified to care for stroke patients, with CT capability as well as the capability to administer medications such as tPA.

Dementia: Impaired cognitive function evidenced by memory disorders, personality changes, and impaired reasoning caused by brain disease, such as Alzheimer’s disease, or injury, such as a stroke; cognitive decline that is not a normal aspect of aging.

Dendrites: Extensions from the neuron that receive electrical stimuli and transfer the impulses to the neuron body.

Ganglia: A portion of the peripheral nervous system that is composed of a grouping of nerve cell bodies.

Hemorrhagic Stroke: An interruption of blood flow to an area of the brain caused by rupture of a weakened blood vessel or rupture of an aneurysm, resulting in brain cell death from oxygen deprivation.

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Intracranial Pressure: Pressure inside the skull. Increase in this pressure can cause permanent damage to the brain. Pressures may be monitored if there is neurologic trauma or injury. Normal levels are 5-15mmHg; anything above 15mmHg may require prompt treatment to decrease these pressures.

Ischemic Stroke: An interruption of blood flow to an area of the brain caused by a thrombus impeding blood flow to the area, resulting in brain cell death from oxygen deprivation.

Neurons: A type of human body cells that are part of the nervous system; also known as nerve cells.

Osmotic Diuretics: Medication such as Mannitol, used in neurological injuries to aid in decreasing intracranial pressure and thereby increase blood flow within the brain.

Parasympathetic Nervous System (PSNS): The portion of the nervous system controlling the body’s relaxation response mechanisms, such decreasing respirations and heart rate and increasing digestion processes.

Peripheral Nervous System (PNS): The portion of the nervous system that consists of components outside the brain and spinal cord, which are cranial and spinal nerves and ganglia.

Reflex Arc: A nerve pathway that controls a reflex action at a synapse between a sensory nerve and motor nerve in the spinal cord. Topic 2: Neurological, Perceptual, And Cognitive Complexities

Somatic Nervous System: The portion of the peripheral nervous system responsible or voluntary body movements.

Sympathetic Nervous System (SNS): The portion of the peripheral nervous system responsible for mobilization of the body’s energy mechanisms in response to stress—for either fight or flight. In response to a stress, the SNS increases respirations and heart rate, releases hormones, such as adrenaline, increases glucose production and release, and decreases digestion.

Thrombus: A clot in a blood vessel, impeding blood flow.

Tissue Plasminogen Activator (tPA): Intravenous medication that is utilized within the 3-hour window of onset of thrombotic stroke symptoms; its action is to break down the thrombus that is occluding the vessel in the brain.

Transient Ischemic Attack (TIA): The temporary interruption of blood flow in a vessel leading to the brain that causes temporary, stoke-like symptoms; can be a precursor to a major cerebrovascular accident (CVA).

References

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Lopez, R. P., & Molony, S. L. (2018). Dementia: Weight loss and mealtime challenges. Journal for Nurse Practitioners, 14(3), 153-159.

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Mendiola-Precoma, J., Berumen, L. C., Padilla, K., & Garcia-Alcocer, G. (2016). Therapies for prevention and treatment of Alzheimer’s disease. BioMed Research International, 2016, 1-17. doi:10.1155/2016/2589276

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National Institute on Aging. (n.d.a). Alzheimer’s disease and related dementias. Retrieved from https://www.nia.nih.gov/health/alzheimers. Topic 2: Neurological, Perceptual, And Cognitive Complexities

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National Stroke Association. (n.d.d). Signs and symptoms. Retrieved from http://www.stroke.org/understand-stroke/recognizing-stroke/signs-and-symptoms-stroke

National Stroke Association. (n.d.e). Stroke recovery. Retrieved from http://www.stroke.org/we-can-help/survivors/stroke-recovery

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Porth, C. M. (2014). Essentials of pathophysiology (4th ed.). Philadelphia, PA: Wolters Kulwer/Lippincott, Williams, & Wilkins.

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Topic 2: Neurological, Perceptual, And Cognitive Complexities