NURS 6531: Primary Care of Adults Across the Lifespan | Week 10

In the United States, stroke is the fourth leading cause of death and a leading cause of adult disability (National Stroke Association, 2012). Of all stroke cases, 20% are recurrent strokes in patients (American Heart Association, 2012). This outlines the importance of patient education for stroke prevention and disorder management. Depending on the patient’s medical history, stroke prevention might be as simple as recommendations for changes in behavior and lifestyle. This was the case for Connie Bentley, an avid weightlifter. She exercised often and was healthy, but her blood pressure always rose when she lifted weights, which eventually caused her to suffer a stroke. After receiving treatment for her stroke, Bentley’s provider recommended that she stop lifting weights, as it would increase her risk of recurrent stroke. Instead, her provider suggested alternative activities such as tai chi, swimming, and hiking (Bentley, 2012). Although this change was difficult for Bentley, she understood the risks because of provider-patient collaboration and education. When developing treatment and management plans that include behavior and lifestyle changes, provider-patient collaboration is essential, as this will increase the likelihood of patient adherence to established plans.

This week, as you explore neurologic disorders, you examine stroke prevention methods for select patient populations.

Learning Objectives

By the end of this week, students will:

• Assess differential diagnoses for patients with neurological disorders
• Analyze the role of patient information in differential diagnosis for neurological disorders
• Evaluate the patient treatment options for neurological disorders
• Understand and apply key terms, concepts, and principles related to neurological disorders
• Analyze pattern recognition in patient diagnoses

Learning Resources

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

• • Part 19, “Evaluation and Management of Multisystem Disorders”

• • • Chapter 227, “Sleep Disorders” (pp. 1209-1217)

This chapter differentiates between normal sleep from abnormal sleep and identifies the epidemiology, clinical presentation, and management of sleep disorders.

• •  
  • Part 16, “Evaluation and Management of Neurologic Disorders” (pp. 999-1070)

This part explores the evaluation process of neurologic disorders. It then covers the pathophysiology, clinical presentation, diagnostic criteria, and complications of neurologic disorders.

Lawrence, M., Fraser, H., Woods, C., & McCall, J. (2011). Secondary prevention of stroke and transient ischemic attack. Nursing Standard, 26(9), 41–46.

This article examines risk factors for stroke and explores prevention methods for patients at high risk of suffering from strokes.

Lawrence, M., Kerr, S., Watson, H. E., Jackson, J., & Brownlee, M. G. (2009). A summary of the guidance relating to four lifestyle risk factors for recurrent stroke. British Journal of Neuroscience Nursing, 5(10), 471–476.

This article explores lifestyle and behavioral risk factors for stroke. It also describes the role of nurses in educating patients about stroke prevention.

Perry, M. (2012). Stroke prevention. Practice Nurse, 42(8), 14–18.

This article identifies patient risk factors for strokes. It also explores patient prevention and education methods to lower the prevalence of the disorder.

National Institute of Health. (n.d.). National institute of neurological disorders and stroke. Retrieved November 1, 2012, from http://www.ninds.nih.gov/index.htm

This website provides information about neurological disorders and strokes, as well as potential causes, prevention strategies, diagnosis, and treatment of these disorders.

Discussion: Diagnosing Neurological Disorders

As an advanced practice nurse, you will likely observe patients who experience neurological disorders. Challenging to the diagnosis of neurological disorders is the realization that many manifestations of disease may not be overt physically.

For this Discussion, consider the following three case studies of patients presenting with neurological disorders.

Case Study 1: 80-year-old male Caucasian male brought to the clinic by his wife concerned about his “memory problems”. Per the wife, she has noticed his memory declining but has never interfered with his daily activities until now. He is unable to remember his appointments and heavily relies on written notes for reminder. Just last week, he got lost driving and was not found by his family until 8 hours later. He is unable to use his cell phone or recall his home address or phone number. He has become a “hermit” per his wife. He has withdrawn from participating with church activities and has become less attentive.

PMH: HTN, controlled
Prostate cancer 20 years ago
Dyslipidemia
SH: no alcohol or tobacco use; needs assistance with medications
PE: VS stable, physical exam unremarkable

Case Study 2

A 30-year-old Asian female presents to the clinic with headaches. History of headaches since her teen years. Headaches have become more debilitating recently. Describes the pain as sharp, worsens with light and accompanied by nausea and at times vomiting. Rates the pain as 7/10. Typically takes 2 tabs of OTC Motrin with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache. VS WNL, physical exam unremarkable.

Case Study 3

A 50-year-old African American male presents with complaints of dizziness left arm weakness and fatigue. PMH: poorly controlled diabetes, hypertension, hyperlipidemia
PE: Upon exam, you noted a very mild dysarthria, he understands and follows commands very well. Mild weakness on the left side of the face is noted, and left sided homonymous hemianopsia but no ptosis or nystagmus or uvula deviation.

To Prepare:

• You will either select or be assigned one of the three case studies provided.
• Reflect on the provided patient information including history and physical exams.
• Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.
• Reflect on potential treatment options based on your diagnosis.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study that you selected or were assigned. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days who selected or were assigned a different case study than you did. Respond to questions posed to you during the week.

ADDITIONAL INFORMATION;

Role of patient information in differential diagnosis for neurological disorders

Introduction

The differential diagnosis of neurological injuries can be challenging, especially in children. The most common causes of neurologic injury include falls and motor vehicle accidents (MVA). However, the list of potential causes is long and includes other events such as choking on food or foreign objects, drowning incidents, starvation due to inability to eat due to pain or weakness from other causes (such as a tumor), and many others. The first step in making a diagnosis is determining which symptoms are present at the time of injury or shortly thereafter. This will help determine whether there is any additional information that may be helpful in making a diagnosis including meningeal irritation (inflammation) such as phonophobia and visual disturbances such as diplopia or fluctuating vision caused by head trauma or contusion due to impact with something solid like another person’s head during an accident.

Introduction

Differential diagnosis is the process of identifying a disease or condition that fits a particular set of symptoms. It’s important to understand how to make a differential diagnosis, both in order to understand what you’re looking at and because it can help guide treatment decisions.

Differential diagnoses are often based on the patient history and physical exam findings but sometimes there may be additional clues that need further investigation before arriving at an accurate diagnosis. For example:

• A patient who has been admitted for pneumonia with high fever and shortness of breath should receive antibiotics even if their sputum looks clear (pneumonia bacteria are resistant). But if no bacteria were found during sputum culture, then this would be an indication that another ailment may be responsible for their illness; maybe something like tuberculosis? Or perhaps something more serious like meningitis?

• A woman with sudden-onset vomiting who has not had any recent travel plans should undergo testing for infectious diseases such as hepatitis B infection due to her recent travels abroad (although this does not necessarily mean she has contracted HBV).

These include the following symptoms and findings:

• Headache, emesis and focal neurologic deficits

• Signs of meningeal irritation including neck stiffness, photophobia, or phonophobia

• Place of occurrence/environment where injury occurred (high/low incidence of trauma)

Circumstances leading to injury

• When did the injury occur?

• Where did the injury occur?

• What was the patient doing at the time of injury?

• Who was present when the injury occurred and what were they doing, if anything, which might have increased their risk of getting injured.*

Level of consciousness and cognitive impairment

The level of consciousness is a patient’s ability to make decisions, communicate, and comprehend what is happening around them. A person can be unconscious for many reasons. When a person is unconscious, it may be due to any number of injuries such as head trauma or stroke that causes their brain to be unable to function properly. If you suspect this type of injury in your patient, you should contact their healthcare provider immediately so they can get treatment and get them back on track with their recovery process.

Cognitive impairment refers to an inability on the part of someone who has had brain damage caused by disease or injury (such as Alzheimer’s disease) because they cannot remember where they are or what they did yesterday while awake but still able enough to communicate clearly enough when spoken too closely at close range by another person who understands English well enough not only understand what was said but also understand why it was said without knowing beforehand about how long ago prior knowledge existed before speaking about something specific later down line after further explanation between two strangers talking about topics unrelated territory shared between two individuals sharing common interest

Headache, emesis, and focal neurologic deficits.

Headache, emesis and focal neurologic deficits are common symptoms of neurological disorders. They may precede the onset of other symptoms by hours or days, they may last longer than one week, and they can be recurrent or intermittent. Headache is a common symptom of many neurological disorders including migraine headache, trigeminal neuralgia (tic douloureux), cluster headaches and others.

Emesis describes the passage through vomit or diarrhea; it occurs due to either increased pressure on nerve endings in the esophagus or stomach because these organs protrude through openings called “stomach valves” at their upper ends which open when food enters them; this leads to an increase in pressure within their chambers until just before it escapes out through another opening called “oesophagus”. If you feel like vomiting during your exam then it might be worth mentioning this as something we should look out for!

Signs of meningeal irritation including neck stiffness, photophobia, or phonophobia.

Neck stiffness or neck pain is a common finding in patients with meningitis. Photophobia, or sensitivity to light, is also not uncommon. However, phonophobia a fear of sound is more likely to be found in patients with meningitis. This can be due to raised intracranial pressure from increased fluid in the brain.

In addition to these signs associated with inflammation around your brainstem (meningeal irritation), you may also notice that you have blurry vision or double vision when looking at something far away as well as difficulty concentrating on what’s happening right in front of your face (dysarthria). These symptoms should not be ignored!

Place of occurrence/environment where injury occurred (high/low incidence of trauma).

• The patient’s place of occurrence: A high incidence of trauma is seen in the home. A low incidence of trauma is seen in the workplace or community.

• Incidence of injury: The injury occurs after leaving the home, but before arriving at work or school.

Associated sleep or seizure activity.

The presence of seizure activity may be associated with a variety of neurological disorders, including:

• Epilepsy. Seizures are usually focal and can occur in isolation or as part of a seizure disorder such as temporal lobe epilepsy (TLE). They are characterized by twitching muscles, loss of consciousness, and convulsions that result from abnormal electrical activity in the brain.

• TLE. TLE is an umbrella term for several conditions that cause seizures and brain damage due to excessive firing or overactivity within one side of the brain’s cortex (the outermost layer). This type includes both vestibular neuronitis (VN), which causes inflammation proximal to vestibular ganglion neurons; mesial temporal lobe epilepsy (MTLE), which affects structures within this region; and hippocampal sclerosis/entorhinal cortex syndrome (HSE), which involves abnormal growths on both sides around hippocampal formation but not elsewhere in cerebral cortex.

Posture at onset (sitting, standing) or precipitating activity.

• Posture at onset (sitting, standing) or precipitating activity.

• Location of injury.

• Level of consciousness and cognitive impairment.

Visual disturbance including diplopia, visual field defects, fluctuating vision, or pain with eye movement.

Visual disturbance including diplopia, visual field defects, fluctuating vision, or pain with eye movement.

Visual disturbance is one of the most common presenting symptoms of stroke. It can be caused by a number of mechanisms including lesions in brainstem centers that regulate eye movements (e.g., optokinetic nystagmus), loss of vision from cerebral infarctions (CIV), and other causes such as optic neuritis or multiple sclerosis (MS).

Conclusion

Neurologic examinations are commonly performed in the emergency department (ED) and can be very useful to improve diagnosis of patients with suspected neurologic disorders. The ED provider often uses a combination of clinical findings, the patient’s history, and information obtained from laboratory tests for differential diagnoses for neurological disorders. These include: headache, stroke, seizure activity, focal neurologic deficits such as visual loss, hearing loss or speech difficulty and symptoms that may suggest meningeal irritation such as neck stiffness and photophobia/phonophobia.