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 – NURS 6531:Week 9: Evaluation and Management of Neurologic Disorders

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. NURS 6531:Week 9: Evaluation and Management of Neurologic Disorders

ADDITIONAL DETAILS 

Evaluation and Management of Neurologic Disorders

Introduction

The nervous system is a complex and highly interconnected network of neurons. The various parts of the nervous system are responsible for coordinating many functions, including movement, sensation, and consciousness. These parts include the brain (which coordinates thought, perception and learning), spinal cord (which relays information from your body to your brain), nerves (organs that carry messages between tissues in the body) and blood vessels (which transport nutrients throughout your body).

Headaches

Headaches are the most common neurologic symptom. They can be caused by many different things and are not always a sign that you have a serious illness. A headache may also be a symptom of a neurologic disorder, but it is important to remember that headaches occur in many other settings besides neurological disorders:

• Acute head injury

• Occipital neuralgia (pain around your ear)

• Migraine headaches

Dizziness and vertigo

Dizziness is a common symptom of neurological disorders, such as vertigo and vestibular neuritis. The causes of dizziness vary depending on the type of problem being treated.

Vertigo: This is a feeling of spinning or spinning around that’s caused by motion sickness or other factors in the body (such as pregnancy). It may also be related to medications you’re taking or certain illnesses like meningitis. Treatment involves avoiding triggers like strong odors or bright lights while resting until symptoms subside; see your doctor if they don’t improve after two weeks (or sooner if they get worse).

Vestibular neuritis: This condition causes loss of balance due to inflammation in one part (the inner ear) or another part(s) involved with sensing movement relative to gravity; it’s not usually serious but can result in permanent loss of hearing due to nerve damage if left untreated

Seizure disorders

Seizures are abnormal electrical discharges in the brain. They can be focal, general or partial and secondarily generalized seizures.

Focal seizures involve only one part of the brain, while generalized seizures affect both sides of the brain. Simple focal motor events such as shaking (called hemiballismus) or loss of consciousness without other symptoms may simply be classified as simple focal limbic (the limbic system is involved with emotion) seizures.

Syncope, neurally mediated hypotension, and POTS

• Syncope (a temporary loss of consciousness)

• Neurally mediated hypotension: a drop in blood pressure during standing

• POTS (orthostatic intolerance): a condition that causes orthostatic intolerance.

Neuro-infectious diseases

The most common neurological disease is seizures. Seizures are sudden, repeated electrical disturbances of the brain caused by abnormal electrical activity in the neurons. A person may have one seizure or multiple seizures at a time and they may be mild or severe, brief or prolonged; they can also occur without warning (absence seizure).

The causes of seizures include:

• Environmental factors such as toxins and viruses infection

• Medical conditions like meningitis, encephalitis and stroke

• Heredity (genetic predisposition)

Nervous system tumors

• Meningiomas

• Schwannomas

• Primitive neuroectodermal tumors (PNETs)

• Astrocytomas

Neuro-ophthalmology and neuro-otology

Neuro-ophthalmology is the medical specialty that focuses on the diagnosis, treatment and management of diseases affecting the nerves and tissues of the eye. Neuro-otology is a subspecialty within this field that deals with problems related to hearing loss or dysfunction.

Neuro-otology, including Menière disease, vestibular neuronitis, BPPV, and other causes of vertigo

Meniere disease

Meniere’s disease (MD) is a form of inner ear disorder that causes episodes of vertigo and hearing loss. Patients often complain of progressive tinnitus, dizziness, and hearing loss in the high-frequency range. In addition to its otological manifestations, MD is also associated with symptoms involving other body systems including fatigue, nausea/vomiting, visual disturbances (including photophobia and color blindness), headaches/migraines and paresthesias such as numbness or tingling sensations in the limbs. There are no specific tests for diagnosing this condition; however it may be suspected based on your current symptoms if you have experienced one or more of these conditions over several months with no known cause despite having undergone various diagnostic procedures that were unsuccessful at providing an explanation for these symptoms (e.g., vestibular evoked responses).

Visual disturbances including transient visual loss, visual field defects, amaurosis fugax, and visual hallucinations

• Transient visual loss: The patient may experience a temporary loss of vision.

• Visual field defects: These are defects in the size, shape, or position of one or more areas on the retina. They can be caused by disease processes such as glaucoma or tumor growths.

• Amaurosis fugax: This refers to an acute episode of blindness caused by damage to the optic nerve (usually through injury). The blindness is usually transient and lasts only a few hours before recovery; however, some cases have been known to persist for several months following initial injury if left untreated.* Visual hallucinations: Patients with epilepsy often complain about seeing things that aren’t there—things like faces in windows or objects appearing out of nowhere while they’re driving at night.*

Conclusion

The majority of patients presenting to the emergency department with a neurologic disorder are young, healthy individuals. This may help to explain why many of them do not receive necessary care when they first present to the emergency department. The most common cause of neurological emergencies in this group is concussion, followed by seizures and stroke.