Presentation of ALS to the otolaryngologist/head and neck surgeon: getting to the neurologist.

Patients with early symptoms of bulbar amyotrophic lateral sclerosis (ALS) are usually referred to the otolaryngologist without a diagnosis. Careful examination of the speech quality and a physical exam, including the vocal cords, should be undertaken. The emotional state of the patient should be considered, and a diagnosis should not be offered before a neurologic consultation has been obtained. Patients with late symptoms of bulbar ALS almost always present with both significant speech and swallowing abnormalities. Evaluation can be difficult because many abnormalities are found on examination. Advanced progression of symptoms is a clear indication for rapid referral to a neurologist if a diagnosis has not already been made. Supportive and symptomatic care should be offered to the patient immediately. The University of Washington Neuromuscular Clinic for Speech and Swallowing Disorders has seen 600 new neurologic patients since 1986, 211 of whom were ALS patients. The introduction of percutaneous gastrostomy has greatly changed the management of ALS patients, and 75 patients have undergone this procedure (32% because of inadequate swallowing, 68% for declining vital capacity). Medical management to improve symptoms may be indicated before surgery. Surgical options for patients with late salivary presentation are uncommon and include removal of the submaxillary glands, tracheostomy, and laryngeal or salivary diversion procedures. Laryngectomy or laryngeal diversion procedures are only very rarely indicated. Although tracheostomy usually interferes with swallowing and worsens aspiration, it may rarely be indicated in patients with late airway presentation for glottic narrowing or artificial respiratory support. Symptomatic management of patients with bulbar ALS is usually best undertaken by a multidisciplinary clinic that can provide a physically and psychologically supportive environment.

Amyotrophic lateral sclerosis severity scale.

The amyotrophic lateral sclerosis (ALS) severity scale has been developed to provide an ordinal staging system and a means of rapid functional assessment for patients with ALS. The scale allows an examiner to evaluate the symptoms of ALS numerically in four categories that describe speech, swallowing, lower extremity, and upper extremity abilities. These scores, combined with a vital capacity measured on a hand-held respirometer, provide a rapid, accurate assessment of a patient's disease status and can be used for treatment planning. The ALS severity scale has been shown to have an average estimated reliability coefficient of 0.95 between examiners. Speech ratings were correlated greater than 0.80 for objective speech measures. Rates of progression of the total score in a small group of patients ranged from -3.4 to -24.0 points/year with a mean of -11.3 points/year.

Computer-assisted instruction: design and content in neuroscience nursing.

Computer-assisted instruction (CAI) includes games, tutorials, simulations, and drills. Computer simulation exercises can be used to simulate patient care and promote diagnostic reasoning skills in nursing. Computer simulation exercises (CSEs) based on case studies of patients with head injury, spinal cord injury, epilepsy, febrile seizures and meningitis have been developed and implemented at the University of Washington School of Nursing, Department of Physiological Nursing, in conjunction with the Health Sciences Center for Educational Resources. These simulations provide a realistic, constantly changing scenerio in which the nurse-learner collects data, analyzes it, and makes decisions about the patient's nursing care. The patient's condition may change dramatically as a result of the decisions made by the nurse-learner.

Alterations in movement: nursing assessment and implications.

Physical assessment for nursing purposes is necessarily different from that of medicine because the focus of nursing is to diagnose and treat human responses to disease rather than the disease itself. This article will consider nursing assessment, pathophysiology, implications for daily living, and nursing implications for selected functional aspects of movement, namely seeing, eating, expressing (facially), speaking, moving, and walking.

Hysterical seizures or pseudoseizures.

With proper diagnosis and management, the frequency of pseudoseizures can be reduced or eliminated. Emotional factors, whether internal or external, can precipitate pseudoseizures. The goals of therapy are to identify pseudoseizures and resolve the conflicts that manifest them; both psychiatric intervention and hypnosis have produced good results in the treatment of pseudoseizures. Nurses are involved in all aspects of care from observation of seizure activity to assessment and implementation of an appropriate plan of care. The care plan should include helping the patient and his family understand the meaning of the patient's pseudoseizures, recognizing the effect of stigma on the patient and his family, assessing the coping skills of the patient and his family, and setting realistic expectations for the patient regarding prognosis and treatment.