Managing Problems in Perception and Coordination

Seizure Disturbances

Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a
combination of these) that result from sudden excessive discharge from cerebral neurons
(Hickey, 2009). A part or all the brain may be involved.

Classification of Seizures (Three Main Seizure Types)

Generalized Seizures

Occur in and rapidly engage bilaterally distributed networks (Berg, Berkovic,

Brodie et al., 2010).

Tonic-Clonic (in any combination) Myoclonic

Absence Myoclonic Atonic

Typical Myoclonic Tonic

Atypical Tonic

Absence with special features Clonic

Myoclonic Absence Atonic

Eyelid Myoclonia

Focal Seizures

Are thought to originate within one hemisphere in the brain.

Unknown

Unclassified seizures are so termed because of incomplete data but are not
considered a classification.

Epileptic Spasms

Causes:
Electrical Disturbances (Dysrhythmia) in the nerve cells in one section of the brain; these
cells emit abnormal, recurring, uncontrolled electrical discharges. Associated loss of
consciousness, excess movement or loss of muscle tone or movement, and disturbances
of behavior, mood, sensation, and perception may also occur.

Causes of Seizure

Cerebrovascular Accident Metabolic and toxic conditions (e.g.,

renal failure, hyponatremia,
Hypoxemia of any cause, including
hypocalcemia, hypoglycemia, pesticide
vascular insufficiency
exposure)
Fever
Brain tumor
Head Injury
Drug and alcohol withdrawal
Hypertension
Allergies
CNS Infection

Clinical Manifestations

Depending on the location of the discharging neurons, seizures may range from a simple
staring episode (absence seizure) to prolonged convulsive movements with loss of
consciousness.

Only a finger or hand may shake, or the mouth may jerk uncontrollably. The person may
talk unintelligibly; may be dizzy; and may experience unusual or unpleasant sights,
sounds, odors, or tastes, but without loss of consciousness (Hickey, 2009)

Generalized seizures often involve both hemispheres of the brain, causing both sides of
the body to react (Berg et al., 2010). Intense rigidity of the entire body may occur, followed
by alternating muscle relaxation and contraction (generalized tonic-clonic contraction).
The simultaneous contractions of the diaphragm and chest muscles may produce a
characteristic epileptic cry. The tongue is often chewed, and the patient is incontinent of
urine and feces. After 1 to 2 minutes, the convulsive movements begin to subside; the
patient relaxes and lies in deep coma, breathing noisily. The respirations at this point are
chiefly abdominal. In the postictal state (after the seizure), the patient if often confused
and hard to arouse and may sleep for hours. Many patients report headache, sore
muscles, fatigue, and depression. (AANN, 2009).

Assessment and Diagnostic Findings

The diagnostic assessment is aimed at determining the type of seizures, their frequency
and severity, and the factors that precipitate them. Developmental history is taken,
including events of pregnancy and childbirth, to seek evidence of preexisting injury. The
patient is questioned about illnesses or head injuries that may have affected the brain.

Diagnostic Findings

MRI – Is used to detect structural lesions such as focal abnormalities, cerebrovascular

abnormalities, and cerebral degenerative changes (AANN, 2019).

EEG – Assists in classifying the type of seizure (Karpoff & Labus, 2008).

Nursing Management

During a Seizure

A major responsibility of the nurse is to observe and record the sequence of signs.
Before and during a seizure.

 Circumstances before the seizure (Visual, auditory, or olfactory stimuli; tactile

stimuli; emotional or psychological disturbances; sleep; hyperventilation)
 Occurrence of an aura (a premonitory or warning sensation, which can be visual,
auditory, or olfactory)
 First thing the patient does in the seizure – where the movements or the stiffness
begins, conjugate gaze position, and the position of the head at the beginning of
the seizure. This information gives clues to the location of the seizure origin in the
brain. (In recording, it is important to state whether the beginning of the seizure
was observed.)
 Type of movements in the part of the body involved.
 Areas of the body involved (turn back bedding to expose patient)
 Size of both pupils and whether the eyes are open
  Whether the eyes or head are turned to one side
 Presence or absence of automatisms (involuntary motor activity, such as lip
smacking or repeated swallowing)
 Incontinence of urine or stool
 Duration of each phase of the seizure
 Unconsciousness, if present, and its duration
 Any obvious paralysis or weakness of arms and legs after the seizure
 Inability to speak after the seizure
 Movements at the end of the seizure
 Whether or not the patient sleeps afterward
 Cognitive status (confused or not confused) after the seizure

Nursing care is directed at preventing injury and supporting the patient, not only
physically but also psychologically. Consequences such as anxiety, embarrassment,
fatigue, and depression can be devastating to the patient.

After a Seizure

The nurse’s role is to document the events leading to and occurring during and after
the seizure and to prevent complications (e.g., aspiration, injury). The patient is at risk
of hypoxia, vomiting and pulmonary aspiration. To prevent complications, the patient
is placed in the side-lying position to facilitate drainage of oral secretions, and
suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.
Seizure precautions are maintained, including having available functioning suction
equipment with a suction catheter and oral airway. The bed is places in a low a position
with two to three side rails up and padded, if necessary, to prevent injury to the patient.
The patient may be drowsy and may wish to sleep after the seizure; he or she may
not remember events leading up to the seizure and for a short time thereafter.

Nursing Care During a Seizure

 Provide privacy, and protect the patient from curious onlookers. (The patient
who has an aura [warning of an impending seizure] may have time to seek a
safe, private place.)
  Ease the patient to the floor, if possible.
 Protect the head with a pad to prevent injury (from striking a hard surface)
 Loosen constrictive clothing.
 Push aside any furniture that may injure the patient during the seizure.
 If the patient is in bed, remove pillows and raise side rails.
 If an aura precedes the seizure, insert an oral airway to reduce the possibility
of the patient biting the tongue or cheek.
 Do not attempt to pry open jaws that are clenched in a spasm or attempt to
insert anything Broken teeth and injury to the lips and tongue may result from
such an action.
 No attempt should be made to restrain the patient during seizure, because
muscular contractions are strong and restraint can produce injury.
 If possible, place the patient on one side with head flexed forward, which allows
the tongue to fall forward and facilitates drainage of saliva and mucus. If suction
is available, use it if necessary, to clear secretions.

Nursing Care After the Seizure

 Keep the patient on one side to prevent aspiration. Make sure the airway is patent.
 There I usually a period of confusion after a grand mal seizure.
 A short apneic period may occur during or immediately after a generalized seizure.
 The patient, on awakening, should be reoriented to the environment.
 If the patient becomes agitated after the seizure (postictal), use persuasion and
gentle restraint to assist him or her to stay calm.
 Vascular Disturbances

Vascular System

A system of flexible tubes - some big, some very tiny - move fluids throughout your body. If
they were stretched end-to-end, there would be enough to circle the Earth multiple times.

Some of them move blood. As your heart beats, it pumps blood with oxygen and nutrients to
feed your tissues and carry off waste. Arteries move blood away from the heart. Veins return
it.

Lymph vessels and lymph nodes are part of a cleaning system that removes damaged cells
from your body. They also help protect your body from infections and cancer. The vessels
pick up fluid from tissues throughout your body. That fluid eventually drains back into veins
under your collarbones.

This whole network of vessels is known as your vascular or circulatory system. "Vascular"
comes from a Latin word for hollow container. Any condition that affects this system is
considered vascular disease. The diseases range from problems with your arteries, veins,
and vessels that carry lymph to disorders that affect how blood flows. A disease can lead to
your tissues not getting enough blood, a condition called ischemia, as well as other serious,
even life-threatening, problems.

Arterial Disorders
Atherosclerosis and Peripheral Artery Disease

Coronary arteries supply blood to your heart muscle. Peripheral arteries carry blood to other
tissues and organs throughout your body. Both can have deposits of fat, cholesterol, and
other substances on their inside walls. These deposits are known as plaque. Over time,
plaque can build up, narrowing the vessel and making it hard for blood to flow.

Eventually, the artery will be so narrow that your body's tissues don't get enough blood.
Depending on where it happens, you can have different symptoms and problems. For
example:

 Blockage in coronary arteries can cause chest pain (angina) or a heart attack.
 If it's in the carotid arteries that supply your brain, it can lead to a stroke or mini stroke,
which is called a transient ischemic attack or TIA.
 Blockage in the kidneys can lead to trouble with how they work, uncontrolled high
blood pressure, and heart failure.
 A blockage in a leg can lead to leg pain or cramps when you're active -- a condition
called claudication -- skin color change, sores or ulcers, and your legs feeling tired.

When you don't have any blood flow to a part of your body, the tissues could die. If that
happens, you may lose a limb or an organ.

Risk Factors

Nicotine use (i.e., tobacco smoking) Hyperlipidemia

Diet (contributing to hyperlipidemia) Stress

Hypertension Sedentary lifestyle

Diabetes (speeds the atherosclerotic Elevated C-reactive protein

process by thickening the basement
Hyperhomocysteinemia
membranes of both large and small
vessels)

Nonmodifiable Risk Factor

Increasing age

Female gender

Familial predisposition/genetics

Nursing Management

Arterial blood supply to a body part can be enhanced by positioning the part below the level
of the heart. For the lower extremities, this is accomplished by elevating the head of the
patient’s bed or by having the patient use a reclining chair or sit with the feet resting on the
floor.

The nurse can assist the patient with walking or other moderate or graded isometric exercises
that may be prescribed to promote blood flow and encourage the development of collateral
circulation. The nurse instructs the patient to walk to the point of pain, rest until the pain
subsides, and then resume walking so that endurance can be increased as collateral
circulation develops. Pain can serve as a guide in determining the appropriate amount of
exercise. The onset of pain indicates that the tissues are not receiving adequate oxygen,
signaling the patient to rest before continuing activity. A regular exercise program can result
in increased walking distance before the onset of claudication.

Not all patients with peripheral vascular disease should exercise. Before recommending any
exercise program, the patient’s primary provider should be consulted. Conditions that worsen
with exercise include leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions.

Nursing interventions may involve applications of warmth to promote arterial flow and
instructions to the patient to avoid exposure to cold temperatures, which causes
vasoconstriction.

Nursing Diagnosis: Ineffective peripheral tissue perfusion related to compromised

circulation

Goal: Increased arterial blood supply to extremities

Nursing Intervention Rationale Expected Outcomes

 1. Lower the extremities 1. Dependency of lower  Has extremities
below the level of the extremities enhances warm to touch
heart (if condition is arterial blood supply.  Has extremities with
arterial in nature). 2. Muscular exercise improved color
2. Encourage moderate promotes blood flow  Experiences
amount of walking or and the development decreased muscle
graded extremity of collateral pain with exercise
exercises if no circulation.
contraindications
exist.

Decreased in venous congestion

Nursing Intervention Rationale Expected Outcomes

1. Elevate extremities 1. Elevation of  Elevates lower

above heart level (if extremities extremities as
condition is venous in counteracts gravity, prescribed
nature) promotes venous  Has decreased
2. Discourage standing return, and prevents edema of extremities
still or sitting for venous stasis.  Avoids prolonged
prolonged periods 2. Prolonged standing standing still or sitting
3. Encourage walking still or sitting  Gradually increases
promotes venous walking time daily
stasis.
3. Walking promotes
venous return by
activating the
“muscle pump.”

Promotion of vasodilation and prevention of vascular compression

Nursing Intervention Rationale Expected Outcomes

1. Maintain warm 1. Warmth promotes  Protects extremities

temperature and arterial flow by from exposure to
avoid chilling. preventing the cold.
2. Discourage use of vasoconstriction  Avoids all tobacco
tobacco products. effects of chilling. products
3. Counsel in ways to 2. Nicotine in all  Uses stress
avoid emotional tobacco products management
upsets; stress causes vasospasm, program to minimize
management. which impedes emotional upset
4. Encourage peripheral circulation.  Avoids constricting
avoidance of 3. Emotional stress clothing and
constrictive clothing causes peripheral accessories
and accessories. vasoconstriction by  Avoids crossing legs
5. Encourage stimulating the  Takes medication as
avoidance of sympathetic nervous prescribed
crossing the legs. system.
6. Administer 4. Constrictive clothing
vasodilation and accessories
medications and impede circulation
adrenergic blocking and promote venous
agents as prescribed, stasis.
with appropriate 5. Crossing the legs
nursing causes compression
considerations. of vessels with
subsequent
impediment of
circulation, resulting
in venous stasis.
 6. Vasodilators relax
smooth muscle;
adrenergic blocking
agents block the
response to
sympathetic nerve
impulses or
circulating
catecholamines.

Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen

Goal: Relief of pain

Nursing Intervention Rationale Expected Outcomes

1. Promote 1. Enhancement of  Uses measures to

increased peripheral circulation increase arterial
circulation increases the oxygen blood supply to
through exercise supplied to the extremities
(e.g., walking muscle and  Uses analgesic
program, upper decreases the agents as prescribed
extremities accumulation of
exercises, using metabolites that
stationary cause muscle
bicycle). spasms.
2. Administer 2. Analgesic agents
analgesic agents help reduce pain and
as prescribed, allow the patient to
with appropriate participate in
nursing activities and
considerations.
 exercises that
promote circulation.

Aneurysm

An aneurysm is a bulge in the wall of any blood vessel. It's most often seen in the aorta,
the main blood vessel leaving the heart. You can get an aortic aneurysm in your chest,
where it's called thoracic, or your belly, where it's called abdominal.

Small aneurysms generally pose no threat. But they do put you at risk for other problems:

 Plaque deposits may build up where the aneurysm is.

 A clot may form there then break off and get stuck somewhere else, which could
be very dangerous.
 The aneurysm might get bigger and press on other organs, which causes pain.

Because the artery wall is stretched and thinner at the spot of an aneurysm, it's fragile
and could burst under stress, like a balloon. The sudden rupture of an aortic aneurysm
can be deadly.

Medical Management

If the aneurysm is stable in size based on serial duplex ultrasound scans, the blood
pressure is closely monitored over time, because there is an association between
increased blood pressure and aneurysm rupture (Cronenwett & Johnson, 2010)

An expanding or enlarging abdominal aortic aneurysm is likely to rupture. Surgery is the

treatment of choice for abdominal aortic aneurysms more than 5.5 cm (2 inches) wide or
those that are enlarging.

Nursing Management

Before surgery, nursing assessment is guided by anticipating a rupture and by

recognizing that the patient may have cardiovascular, cerebral, pulmonary, and renal
impairment from atherosclerosis. The functional capacity of all organ systems should be
assessed.

Signs of impending rupture include severe back or abdominal pain, which may be
persistent or intermittent. Abdominal pain is often localized in the middle or lower
abdomen to the left of the midline. Low back pain may be present because of pressure of
the aneurysm on the lumbar nerves. Indications of a rupturing abdominal aortic aneurysm
include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
Rupture into the peritoneal cavity is rapidly fatal.

Post-operative care requires frequent monitoring of pulmonary, cardiovascular, renal, and

neurologic status.

Raynaud's Phenomenon (Raynaud's Disease or Raynaud's Syndrome)

When you're cold or excited, the small arteries of your fingers and sometimes your toes
may twitch or cramp. This can temporarily shut down blood supply to the area, making
your skin look white or bluish and feel cold or numb.

The working conditions of some jobs bring on Raynaud's. Or the symptoms might be
related to underlying diseases, including lupus, rheumatoid arthritis, and scleroderma.

Medical Management

Avoiding the particular stimuli (e.g., cold, tobacco) that provoke vasoconstriction is a
primary factor in controlling Raynaud’s Phenomenon. Avoidance of exposure to cold and
trauma and implementing measures to improve local circulation are the primary focus of
treatment for acrocyanosis.

Nursing Management

The nurse instructs the patient to avoid situations that may be stressful or unsafe. Stress
management classes may be helpful. Exposure to cold must be minimized, and in areas
where the fall and winter months are cold. The patient should wear layers of clothing when
outdoors. Patients should be cautioned to handle sharp objects carefully to avoid injuring
their fingers.
Venous Thromboembolism

Blood Clots in Veins (VTE)

A blood clot in a vein inside a muscle, usually in your lower leg, thigh, or pelvis, is a deep
vein thrombosis (DVT). If it breaks loose and travels to your lungs, it becomes a
pulmonary embolism (PE). These clots in your veins are called venous
thromboembolisms, or VTE.

They're usually caused by:

 Conditions that slow blood flow or make blood thicker, such as congestive heart failure
and certain tumors
 Damaged valves in a vein
 Damaged veins from injury or infection
 Genetic disorders that make your blood more likely to clot
 Hormones, such as estrogen from pregnancy and birth control pills
 Long bed rest or not being able to move much
 Surgery, especially some operations on your hips and legs

Damaged vein valves or a DVT can cause long-term blood pooling and swelling in your legs,
too. That's called chronic venous insufficiency. If you don't do anything about it, fluid will leak
into the tissues in your ankles and feet. It may eventually make your skin break down and
wear away.

Deep vein thrombosis (DVT) and pulmonary embolism collectively make up the condition
called venous thromboembolism. VTE is frequently not diagnosed, however, because
DVT and PE are often clinically silent. It is estimated that as many as 30% of patients
hospitalized with VTE develop long-term post-thrombotic complications. Hospital lengths
of stay are shorter, which means that the majority of symptomatic thromboembolic
complications in surgical patients occur after hospital discharge.

Prevention
Patients with a prior history of VTE are at increased risk a new episode. VTE can be
prevented, especially if patients who are considered at high risk are identified and
preventive measures are instituted without delay. Preventive measures include the
application of graduated compression stockings, the use of the intermittent pneumatic
compression devices, and encouragement of early mobilization and leg exercises.

Medical Management

Anticoagulant therapy (administration of a medication to delay the clotting time of blood,

prevent the formation of a thrombus in postoperative patients, and forestall the extension
of a thrombus after it has formed) can meet these objectives.

Nursing Management

If the patient is receiving anticoagulant therapy, the nurse must frequently monitor the
APTT, PT, INR, ACT, hemoglobin and hematocrit values, platelet count and fibrinogen
level, depending on which medication is being given. Close observation is also required
to detect bleeding; if bleeding occurs, it must be reported immediately and anticoagulant
therapy discontinued.

Elevation of the affected extremity, graduated compression stockings, and analgesic

agents for pain relief are adjuncts to therapy. They help improve circulation and increase
comfort. Warm, moist packs applied to the affected extremity reduce the discomfort
associated with DVT. The patient is encouraged to walk once coagulation therapy has
been initiated. The nurse should instruct the patient that walking is better than standing
or sitting for long periods. Bed exercises, such as repetitive dorsiflexion of the foot, are
also recommended. Graduated compression stockings are prescribed for patients with
venous insufficiency. The amount of pressure gradient is determined by the amount and
severity of venous disease.

20-30 mmHG – for asymptomatic varicose veins

30-40 mmHG for patients with venous stasis ulceration

Anti-embolic stockings should not be confused with graduated compression stockings.

Anti-embolic stockings provide lesser compression at 12 to 20 mmHG.
When the patient is on bed rest, the feet and lower legs should be elevated periodically
above the level of the heart. This position allows the superficial and tibial veins to empty
rapidly and to remain collapsed. Active and passive exercises, particularly those involving
calf muscles, should be performed to increase venous flow.

Early ambulation

Deep Breathing Exercises – produce increased negative pressure in the thorax that
assists in emptying the large veins.

Buerger's Disease

This rare disease most often affects the small and medium sized arteries and veins in
your arms and legs. They swell up and may get blocked by clots, cutting off blood supply
to your fingers, hands, toes, or feet. These body parts will hurt, even when you're resting.
If it's severe, you might need to amputate fingers or toes that have died.

People with Buerger's disease may also have Raynaud's phenomenon.

Although the cause is unknown, there's a strong association with tobacco use --
including cigars and chewing tobacco -- and secondhand smoke.

Peripheral Venous Disease and Varicose Veins

Unlike arteries, veins have flaps inside called valves. When your muscles contract, the valves
open and blood moves through the tubes. When your muscles relax, the valves close so the
blood only flows in one direction.

Damaged valves may not close completely as your muscles relax. This allows blood to flow
in both directions, and it can pool.

Varicose veins are an example of this. They may bulge like purple ropes under your skin.
They can also look like small red or purple bursts on your knees, calves, or thighs. These
spider veins are caused by swollen small blood vessels called capillaries. At the end of
the day, your legs might ache, sting, or swell.
More women than men get varicose veins, and they often run in families. Pregnancy,
being very overweight, or standing for long times can cause them.

Because the blood is moving more slowly, it may stick to the sides of the veins, and clots
can form.

Blood Clotting Disorders

Some illnesses make your blood more likely to form clots. You could be born with one, or
something may happen to you. These disorders can cause:

 Higher-than-normal levels of clot-forming substances, including fibrinogen, factor 8,

and prothrombin
 Not enough blood-thinning (anticoagulant) proteins, including antithrombin, protein C,
and protein S
 Trouble breaking down fibrin, the protein mesh that holds clots together
 Damage to the endothelium, the lining of the blood vessel

Lymphedema

Your lymphatic system doesn't have a pump like your blood circulation system does. It relies
on valves in the vessels and muscle contractions to keep the lymph moving.

When vessels or nodes are missing or don't work right, fluid can build up and cause swelling,
most often in your arms or legs. This is called lymphedema.

Primary lymphedema is rare. It happens when you're born without certain lymph vessels or
when you have a problem with the tubes themselves.

A blockage or interruption of the lymphatic system is called secondary lymphedema. It can

happen because of:

 Cancer and cancer treatments, including radiation

 Deep vein thrombosis (DVT)
 Infection
 Scar tissue formation
  Serious injury
 Surgery

Degenerative Disorders

Parkinson’s Disease

Parkinson’s Disease is a slowly progressing neurologic movement disorder that eventually

leads to disability. It is the fourth most common neurodegenerative disease, and 50,000 new
cases are reported each year in the United States. (Chen & Fernandez, 2007; Thomure,
2006). The disease affects men more often than women. Symptoms usually first appear in
the fifth decade of life; however, cases have been diagnosed as early as 30 years of age.
Parkinson’s disease is associated with decrease levels of dopamine resulting from
destruction of pigmental neuronal cells in the substantia nigra in the basal ganglia region of
the brain.

Medical Management

Treatment is directed at controlling symptoms and maintaining functional independence,

because no medical or surgical approaches in current use prevent disease progression. Care
is individualized for each patient based on presenting symptoms and social, occupational,
and emotional needs. Patient are usually cared for at home and are admitted to the hospital
only for complications or to initiate new treatments.

Nursing Management

The goals for the patient may include improving functional mobility, maintaining
independence in ADL’s, achieving adequate bowel elimination, attaining and maintaining
acceptable nutritional status, achieving effective communication, and developing positive
coping mechanisms.

Improving Mobility – A progressive program of daily exercises will increase muscle strength,
improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that
occur when muscles are not used.
Enhancing Self-Care Activities - Encouraging, teaching and supporting the patient during
ADLs promote self-care (Stewart et al., 2005). Environmental modifications are necessary to
compensate for functional disabilities. Patients may have severe mobility problems that make
normal activities impossible. Adaptive or assistive devices may be useful. A hospital bed at
home with bedside rails, an overbed frame with a trapeze, in pulling up without help.

Improving Bowel Elimination – The patient may have severe problems with constipation.
Among the factors causing constipation are weakness of the muscles used in defecation,
lack of exercise, inadequate fluid intake, and decreased autonomic nervous system activity.
The medications used for the treatment of the disease also inhibit normal intestinal
secretions. A regular bowel routine may be established by encouraging the patient to follow
a regular time pattern, consciously increase fluid intake, and eat foods with moderate fiber
content.

Improving Nutrition - Patients may have difficulty maintaining their weight. Eating becomes
a very slow process, requiring concentration due to a dry mouth from medications and
difficulty chewing and swallowing. They are at risk for aspiration because of impaired
swallowing and the accumulation of saliva. They may be unaware that they are aspirating,
and subsequently bronchopneumonia may develop.

Enhancing Swallowing - Swallowing disorders can be due to poor head control, tongue
tremor, hesitancy in initiating swallowing, difficulty in shaping food into a bolus, and
disturbances in pharyngeal motility. To offset these problems, the patient should sit in an
upright position during mealtime. A semisolid diet with thick liquids is easier to swallow
than solids; thin liquids should be avoided. It is helpful for patients to think through the
swallowing sequence.

Encouraging the Use of Assistive Devices - An electric warming tray keeps food hot and
permits the patient to rest during the prolonged time that it takes to eat. Special utensils
also assist at mealtime. A plate that is stabilized, a no spill cup, and eating utensils with
built-up handles are useful self-help devices. The occupational therapist can assist in
identifying appropriate adaptive devices.
Improving Communication - Speech disorders are present in most patients with
Parkinson’s disease. Their low-pitched, monotonous, soft speech requires that they make
a conscious effort to speak slowly, with deliberate attention to what they are saying.
Patients are reminded to face the listener, exaggerate the pronunciation of words, speak
in short sentences, and take a few deep breaths before speaking.

Supporting Coping Abilities - Support can be given by encouraging the patient and
pointing out that activities are being maintained through active participation. A
combination of physiotherapy, psychotherapy, medication therapy, and support group
participation may help reduce the depression that often occurs.

Huntington Disease

Huntington’s disease is a chronic, progressive, hereditary disease of the nervous system

that results in progressive involuntary choreiform movement and dementia. It affects men
and women of all races. Because it is transmitted as an autosomal dominant genetic
disorder, each child of a parent with Huntington’s disease has a 50% risk of inheriting the
illness (Bradley et al., 2000). Involves premature death of cells in the striatum (caudate
and putamen) of the basal ganglia, the region deep within the brain involved in the control
of movement. The most prominent clinical features of the disease are abnormal
involuntary movements (chorea), intellectual decline, and, often, emotional disturbance.

Management

Although no treatment halts or reverses the underlying process, several methods of

management have fairly good palliative. Thiothixene hydrochloride (Navane) and
haloperidol decanoate (Haldol), which predominantly block dopamine receptors, improve
the chorea in many patients. Chorea also is lessened by reserpine (depletes presynaptic
dopamine) and tetrabenazine (reduces dopaminergic transmission). Motor signs must be
assessed and evaluated on an ongoing basis so that optimal therapeutic drug levels can
be reached. Akathisia (motor restlessness) in the overmedicated patient is dangerous
because it may be mistaken for the restless fidgeting of the illness and consequently can
be overlooked.
Promoting Home and Community-Based Care Teaching Patients Self-Care - The needs
of the patient and family for education depend on the nature and severity of physical,
cognitive, and psychological changes experienced by the patient. Patients and family
members are taught about the medications prescribed and about signs indicating a need
for change in medication or dosage. The teaching plan addresses strategies to manage
symptoms such as chorea, swallowing problems, limitations in ambulation, and loss of
bowel and bladder function. Consultation with a speech therapist may be indicated to
assist in identifying alternative communication strategies if speech is affected.

Muscular Dystrophies

The muscular dystrophies are a group of chronic muscle disorders characterized by

progressive weakening and wasting of the skeletal or voluntary muscles. Most of these
diseases are inherited. The pathologic features include degeneration and loss of muscle
fibers, variation in muscle fiber size, phagocytosis and regeneration, and replacement of
muscle tissue by connective tissue.

Medical Management

Treatment of the muscular dystrophies at this time focuses on supportive care and
preventing complications in the absence of a cure or specific pharmacologic interventions
(Bach, 1999; Carson & Hieber, 2001). Supportive management aims to keep the patient
active and functioning as normally as possible and to minimize functional deterioration.
An individualized therapeutic exercise program is prescribed to prevent muscle tightness,
contractures, and disuse atrophy.

Nursing Management

The goals of the patient and the nurse are to maintain function at optimal levels and to
enhance the quality of life. Therefore, the patient’s physical requirements, which are
considerable, are addressed without losing sight of emotional and developmental needs
(Carson & Hieber, 2001).

Degenerative Disk Disease

Degenerative disc disease is an age-related condition that happens when one or more of
the discs between the vertebrae of the spinal column deteriorates or breaks down, leading
to pain. There may be weakness, numbness, and pain that radiates down the leg. Despite
its name, degenerative disc disease is not a disease, but a natural occurrence that comes
with aging. The rubbery discs between the vertebrae normally allow for flexing and
bending of the back, like shock absorbers. In time, they become worn, and they no longer
offer as much protection as before.

Medical Management

Herniations of the cervical and the lumbar disks occur most commonly and are usually
managed conservatively with bed rest and medication.

Surgical Management

In general, surgical excision of a herniated disk is performed when there is evidence of a

progressing neurologic deficit (muscle weakness and atrophy, loss of sensory and motor
function, loss of sphincter control) and continuing pain and sciatica (leg pain resulting
from sciatic nerve involvement) that are unresponsive to conservative management.

VISUAL DISTURBANCES

Glaucoma

Glaucoma is a group of ocular conditions characterized by optic nerve damage. The optic
nerve damage is related to the IOP caused by congestion of aqueous humor in the eye.
There is a range of pressures that have been considered “normal” but that may be
associated with vision loss in some patients. Glaucoma is one of the leading causes of
irreversible blindness in the world and is the leading cause of blindness among adults in
the United States. Glaucoma is more prevalent among people older than 40 years of age,
and the incidence increases with age.

Classification of Glaucoma

There are several types of glaucoma. Whether glaucoma is known as open-angle or

angle-closure glaucoma depends on which mechanisms cause impaired aqueous
outflow. Glaucoma can be primary or secondary, depending on whether associated
factors contribute to the rise in IOP. Although glaucoma classification is changing as
knowledge increases, current clinical forms of glaucoma are open-angle glaucomas,
angle-closure glaucomas (also called pupillary block), congenital glaucomas, and
glaucomas associated with other conditions, such as developmental anomalies,
corticosteroid use, and other ocular conditions. The two common clinical forms of
glaucoma encountered in adults are open-angle and angle-closure glaucoma.

Medical Management

The aim of all glaucoma treatment is prevention of optic nerve damage through medical
therapy, laser or nonlaser surgery, or a combination of these approaches. Lifelong
therapy is almost always necessary because glaucoma cannot be cured. Although
treatment cannot reverse optic nerve damage, further damage can be controlled. The
treatment goal is to maintain an IOP within a range unlikely to cause further damage.

Surgical Management

In laser trabeculoplasty for glaucoma, laser burns are applied to the inner surface of the
trabecular meshwork to open the intratrabecular spaces and widen the canal of Schlemm,
thereby promoting outflow of aqueous humor and decreasing IOP.

Nursing Management

Teaching Patients About Glaucoma Care - The medical and surgical management of
glaucoma slows the progression of glaucoma but does not cure it. The lifelong therapeutic
regimen mandates patient education. The nature of the disease and the importance of
strict adherence to the medication regimen must be explained to help ensure compliance.

Cataracts

A cataract is a lens opacity or cloudiness. Cataracts rank only behind arthritis and heart
disease as a leading cause of disability in older adults. Cataracts affect nearly 20.5 million
Americans who are 40 years of age or older, or about one in every six people in this age
range. By age 80, more than half of all Americans have cataracts. According to the World
Health Organization, cataract is the leading cause of blindness in the world (Preshel &
Prevent Blindness America, 2002). Cataracts can develop in one or both eyes at any age
for a variety of causes. Visual impairment normally progresses at the same rate in both
eyes over many years or in a matter of months.

Medical Management

Ongoing studies are investigating ways to slow cataract progression, such as intake of
antioxidants (eg, vitamin C, beta-carotene, vitamin E) (Age-Related Eye Disease
Research Study Group, 2001). In the early stages of cataract development, glasses,
contact lenses, strong bifocals, or magnifying lenses may improve vision. Reducing glare
with proper light and appropriate lighting can facilitate reading. Mydriatics can be used as
short-term treatment to dilate the pupil and allow more light to reach the retina, although
this increases glare.

Retinal Detachment

Retinal detachment describes an emergency situation in which a thin layer of tissue (the
retina) at the back of the eye pulls away from its normal position. Retinal detachment
separates the retinal cells from the layer of blood vessels that provides oxygen and
nourishment. The longer retinal detachment goes untreated, the greater your risk of
permanent vision loss in the affected eye. Retinal detachment itself is painless. But
warning signs almost always appear before it occurs or has advanced, such as: The
sudden appearance of many floaters — tiny specks that seem to drift through your field
of vision.

Nursing Management

For the most part, nursing interventions consist of educating the patient and providing
supportive care.

Promoting Comfort - If gas tamponade is used to flatten the retina, the patient may have
to be specially positioned to make the gas bubble float into the best position. Some
patients must lie face down or on their side for days. Patients and family members should
be made aware of these special needs beforehand, so that the patient can be made as
comfortable as possible.

Macular Degeneration

Macular degeneration is the most common cause of visual loss in people older than age
60 (Margolis et al., 2002). Commonly called age-related macular degeneration (AMD), it
is characterized by tiny, yellowish spots called drusen beneath the retina. Most people
older than 60 years of age have at least a few small drusen. There is a wide range of
visual loss in patients with macular degeneration, but most patients do not experience
total blindness. Central vision is generally the most affected, with most patients retaining
peripheral vision. There is no cure for macular degeneration, but it can be treated with
vitamins, laser therapy, medications, and vision aids.

Conjunctivitis

Conjunctivitis (inflammation of the conjunctiva) is the most common ocular disease

worldwide. It is characterized by a pink appearance (hence the common term pink eye)
because of subconjunctival blood vessel hemorrhages. General symptoms include
foreign body sensation, scratching or burning sensation, itching, and photophobia.
Conjunctivitis may be unilateral or bilateral, but the infection usually starts in one eye and
then spreads to the other eye by hand contact.
Management

The management of conjunctivitis depends on the type. Most types of mild and viral
conjunctivitis are self-limiting, benign conditions that may not require treatment and
laboratory procedures. For more severe cases, topical antibiotics, eye drops, or ointment
are prescribed.

Diabetic Retinopathy

Of all of the medical disorders that the nurse encounters, diabetes mellitus is one of the
most common and one that can have devastating effects on the patient. Diabetes affects
every system of the body in a deleterious way and consequently affects the patient’s
family and society in general. Diabetes is the leading cause of new cases of blindness in
people between 20 and 74 years of age in the United States today. Over time, too much
sugar in your blood can lead to the blockage of the tiny blood vessels that nourish the
retina, cutting off its blood supply. As a result, the eye attempts to grow new blood vessels.
But these new blood vessels don't develop properly and can leak easily.

Dry Eye Syndrome

Dry eye syndrome, or keratoconjunctivitis sicca, is a deficiency in the production of any

of the aqueous, mucin, or lipid tear film components; lid surface abnormalities; or
epithelial abnormalities related to systemic diseases (thyroid disorders, Parkinson’s
disease), infection, injury, or complications of medications (antihistamines, oral
contraceptives, phenothiazines).

Clinical Manifestations

The most common complaint in dry eye syndrome is a scratchy or foreign body sensation.
Other symptoms include itching, excessive mucus secretion, inability to produce tears, a
burning sensation, redness, pain, and difficulty moving the lids. Chronic dry eyes may
result in chronic conjunctival and corneal irritation that can lead to corneal erosion,
scarring, ulceration, thinning, or perforation that can seriously threaten vision. Secondary
bacterial infection can occur.

Management

Management of dry eye syndrome requires the complete cooperation of the patient with
a regimen that needs to be followed at home for a long period, or complete relief of
symptoms is unlikely. Instillation of artificial tears during the day and an ointment at night
is the usual regimen to hydrate and lubricate the eye through stimulating tears and
preserving a moist ocular surface. Anti-inflammatory medications are also used, and
moisture chambers (moisture chamber spectacles, swim goggles) may provide additional
relief.

Auditory Disturbances

Hearing Loss

Hearing loss that occurs gradually as you age (presbycusis) is common. About one-third
of people between the ages of 65 and 75 have some degree of hearing loss. For those
older than 75, that number is approximately 1 in 2. Aging and chronic exposure to loud
noises both contribute to hearing loss. Other factors, such as excessive earwax, can
temporarily reduce how well your ears conduct sounds.

Hearing loss is defined as one of three types:

• Conductive (involves outer or middle ear)

• Sensorineural (involves inner ear)
• Mixed (combination of the two)

Early manifestations of hearing impairment and loss may include tinnitus, increasing
inability to hear in groups, and a need to turn up the volume of the television. Hearing
impairment can also trigger changes in attitude, the ability to communicate, the
awareness of surroundings, and even the ability to protect oneself, affecting the person’s
quality of life. In a classroom, a student with impaired hearing may be disinterested and
inattentive and have failing grades. A person at home may feel isolated because of an
inability to hear the clock chime, the refrigerator hum, the birds sing, or the traffic pass.

Medical Management

If a hearing loss is permanent or untreatable with medical or surgical intervention or if the

patient elects not to have surgery, aural rehabilitation may be beneficial.

Nursing Management

The nurse who understands the different types of hearing loss will be more successful in
adopting a communication style to fit the patient’s needs. Trying to speak in a loud voice
to a person who cannot hear high-frequency sounds only makes understanding more
difficult. However, strategies such as talking into the less impaired ear and using gestures
and facial expressions can help. A major issue for many deaf and hearing-impaired
people is that they have other health problems that often do not receive attention, in large
part because of communication problems with their health care practitioners. To
effectively meet the health care needs of these patients, practitioners are legally obligated
to make accommodations for the patient’s inability to hear. Providing the services of
interpreters or those who can communicate through sign language is essential in many
situations so that the practitioner can effectively communicate with the patient.

External Otitis (Otitis Externa)

External otitis, or otitis externa, refers to an inflammation of the external auditory canal.
Causes include water in the ear canal (swimmer’s ear); trauma to the skin of the ear canal,
permitting entrance of organisms into the tissues; and systemic conditions, such as
vitamin deficiency and endocrine disorders. Bacterial or fungal infections are most
frequently encountered. The most common bacterial pathogens associated with external
otitis are Staphylococcus aureus and Pseudomonas species. The patient usually reports
pain, discharge from the external auditory canal, aural tenderness (usually not present in
middle ear infections), and occasionally fever, cellulitis, and lymphadenopathy. Other
symptoms may include pruritus and hearing loss or a feeling of fullness. On otoscopic
examination, the ear canal is erythematous and edematous. Discharge may be yellow or
green and foul smelling. In fungal infections, the hair like black spores may even be
visible.

Medical Management

The principles of therapy are aimed at relieving the discomfort, reducing the swelling of
the ear canal, and eradicating the infection. Patients may require analgesics for the first
48 to 92 hours. If the tissues of the external canal are edematous, a wick should be
inserted to keep the canal open so that liquid medications (Burow’s solution, antibiotic
otic preparations) can be introduced.

Nursing Management

Nurses need to teach patients not to clean the external auditory canal with cotton-tipped
applicators, to avoid swimming, and not to allow water to enter the ear when shampooing
or showering. A cotton ball can be covered in a water-insoluble gel such as petroleum
jelly and placed in the ear as a barrier to water contamination. Infection can be prevented
by using antiseptic otic preparations after swimming (Swim Ear, Ear Dry), unless there is
a history of tympanic membrane perforation or a current ear infection.

Acute Otitis Media

Acute otitis media is an acute infection of the middle ear, usually lasting less than 6 weeks.
The primary cause of acute otitis media is usually Streptococcus pneumoniae,
Haemophilus influenzae, and Moraxella catarrhalis, which enter the middle ear after
eustachian tube dysfunction caused by obstruction related to upper respiratory infections,
inflammation of surrounding structures (sinusitis, adenoid hypertrophy), or allergic
reactions (allergic rhinitis). Bacteria can enter the eustachian tube from contaminated
secretions in the nasopharynx and the middle ear from a tympanic membrane perforation.
A purulent exudate is usually present in the middle ear, resulting in a conductive hearing
loss. The symptoms of otitis media vary with the severity of the infection. The condition,
usually unilateral in adults, may be accompanied by otalgia. The pain is relieved after
spontaneous perforation or therapeutic incision of the tympanic membrane. Other
symptoms may include drainage from the ear, fever, and hearing loss.

Medical Management

The outcome of acute otitis media depends on the efficacy of therapy (ie, the prescribed
dose of an oral antibiotic and the duration of therapy), the virulence of the bacteria, and
the physical status of the patient. With early and appropriate broad-spectrum antibiotic
therapy, otitis media may resolve with no serious sequelae.

Serous Otitis Media

Serous otitis media (middle ear effusion) implies fluid, without evidence of active infection,
in the middle ear. In theory, this fluid results from a negative pressure in the middle ear
caused by eustachian tube obstruction. This condition is found primarily in children.
Patients may complain of hearing loss, fullness in the ear or a sensation of congestion,
and perhaps even popping and crackling noises, which occur as the eustachian tube
attempts to open. The tympanic membrane appears dull on otoscopy, and air bubbles
may be visualized in the middle ear. Usually, the audiogram shows a conductive hearing
loss.

Management

Serous otitis media need not be treated medically unless infection occurs (ie, acute otitis
media). If the hearing loss associated with middle ear effusion is a problem for the patient,
a myringotomy can be performed, and a tube may be placed to keep the middle ear
ventilated. Corticosteroids in small doses sometimes decrease the edema of the
eustachian tube in cases of barotrauma. Decongestants have not proved effective. A
Valsalva maneuver, which forcibly opens the eustachian tube by increasing
nasopharyngeal pressure, may be cautiously performed. Performing the Valsalva
maneuver may cause worsening pain or perforation of the tympanic membrane.

Chronic Otitis Media

Chronic otitis media is the result of repeated episodes of acute otitis media causing
irreversible tissue pathology and persistent perforation of the tympanic membrane.
Chronic infections of the middle ear damage the tympanic membrane, destroy the
ossicles, and involve the mastoid. Before the discovery of antibiotics, infections of the
mastoid were life-threatening. The use of medications in acute otitis media has made
acute mastoiditis a rare condition in developed countries. Symptoms may be minimal,
with varying degrees of hearing loss and the presence of a persistent or intermittent, foul-
smelling otorrhea. Pain is not usually experienced, except in cases of acute mastoiditis,
when the postauricular area is tender to the touch and may be erythematous and
edematous.

Medical Management

Local treatment of chronic otitis media consists of careful suctioning of the ear under
microscopic guidance. Instillation of antibiotic drops or application of antibiotic powder is
used to treat a purulent discharge. Systemic antibiotics are usually not prescribed except
in cases of acute infection.

Motion Sickness

Motion sickness is a disturbance of equilibrium caused by constant motion. For example,

it can occur aboard a ship, while riding on a merry-go-round or swing, or in the back seat
of a car. Clinical Manifestations The syndrome manifests itself in sweating, pallor, nausea,
and vomiting caused by vestibular overstimulation. These manifestations may persist for
several hours after the stimulation stops.

Management

Over-the-counter antihistamines used to treat vertigo, such as dimenhydrinate

(Dramamine) or meclizine hydrochloride (Bonine), provide some relief. Anticholinergic
medications, such as scopolamine patches, may be helpful. These must be replaced
every few days. Side effects such as dry mouth and drowsiness occur with these
medications, which may prove to be more troublesome than helpful. Potentially
hazardous activities such as driving a car or operating heavy machinery should be
avoided if the patient experiences drowsiness.

Ménière’s Disease

Ménière’s disease is an abnormal inner ear fluid balance caused by a malabsorption in

the endolymphatic sac. Evidence indicates that many people with Ménière’s disease may
have a blockage in the endolymphatic duct. Regardless of the cause, endolymphatic
hydrops, a dilation in the endolymphatic space, develops. Either increased pressure in
the system or rupture of the inner ear membranes occurs, producing symptoms of
Ménière’s disease. Ménière’s disease involves the following symptoms: fluctuating,
progressive sensorineural hearing loss; tinnitus or a roaring sound; a feeling of pressure
or fullness in the ear; and episodic, incapacitating vertigo, often accompanied by nausea
and vomiting.

Medical Management

Most patients with Ménière’s disease can be successfully treated with diet and medication
therapy. Many patients can control their symptoms by adhering to a low-sodium (2,000
mg/day) diet. The amount of sodium is one of many factors that regulate the balance of
fluid within the body. Sodium and fluid retention disrupt the delicate balance between
endolymph and perilymph in the inner ear. Psychological evaluation may be indicated if
the patient is anxious, uncertain, fearful, or depressed.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is a brief period of incapacitating vertigo

that occurs when the position of the patient’s head is changed with respect to gravity,
typically by placing the head back with the affected ear turned down. The onset is sudden
and followed by a predisposition for positional vertigo, usually for hours to weeks but
occasionally for months or years. Bed rest is recommended for patients with acute
symptoms. Patients with acute vertigo may be medicated with meclizine for 1 to 2 weeks.
After this time, the meclizine is stopped and the patient is reassessed. A physical therapist
prescribes balance exercises that help the brain compensate for the impairment to the
balance system.