Neuro Content

Neuro Content

Pupils

• Equal and react normally

• Reacts to light slowly or briskly

• Dilated pupil = compressed cranial nerve

• Bilateral dilated, fixed pupils = ominous!!

• Pinpoint pupils – pons damage or drugs

GCS

• Eyes open – spontaneous, to name, to pain, etc

• Best Verbal response – appropiate, oriented…..confused, incomprehensible

• Best motor – follows commands, only to pain, etc

Brief Neuro Check

• LOC

• Pupils

• Grips

• MAE

• Speech

• VS

Cranial Nerves

• 12

• Some mixed or some purely sensory or purely motor– Names– Functions– assessment

• Cranial Nerves - Introduction

Increased Intracranial Pressure

• Definition/Pathophysiology – pressure exerted by three components in the brain – brain, CSF, and blood

• Assessment – nl 0-15 mm Hg– Signs and symptoms – assoc with Decreased CPP– Deficits – possible brainstem compression and

herniation– Changes in LOC, posturing, headache, vomiting– Remove CSF, mannitol,

Fig. 57-1

Intracranial Pressure (cont’d)Intracranial Pressure (cont’d)

• Cerebral blood flowCerebral blood flow– Autoregulation of cerebral blood flowAutoregulation of cerebral blood flow– Pressure changesPressure changes– Factors affecting cerebral blood flowFactors affecting cerebral blood flow

Fig. 57-2

Increased Intracranial PressureIncreased Intracranial Pressure

• Cerebral edemaCerebral edema– Vasogenic cerebral edemaVasogenic cerebral edema– Cytotoxic cerebral edemaCytotoxic cerebral edema– Interstitial cerebral edemaInterstitial cerebral edema

• Mechanisms of increased Mechanisms of increased intracranial pressureintracranial pressure

Fig. 57-3

IncreasedIncreasedIntracranial Pressure (cont’d)Intracranial Pressure (cont’d)

• Clinical manifestationsClinical manifestations– Change in level of consciousnessChange in level of consciousness– Changes in vital signsChanges in vital signs– Ocular signsOcular signs– Decrease in motor functionDecrease in motor function– HeadacheHeadache– VomitingVomiting

Fig. 57-5

IncreasedIncreasedIntracranial Pressure (cont’d)Intracranial Pressure (cont’d)

• ComplicationsComplications• Diagnostic studiesDiagnostic studies• Measurement of ICPMeasurement of ICP

– Indications for ICP monitoringIndications for ICP monitoring– Methods of measuring ICPMethods of measuring ICP– CSF drainageCSF drainage

IncreasedIncreasedIntracranial Pressure (cont’d)Intracranial Pressure (cont’d)

• Collaborative careCollaborative care– Drug therapyDrug therapy– Hyperventilation therapyHyperventilation therapy– Nutritional therapyNutritional therapy

Nursing ManagementNursing ManagementIncreased Intracranial PressureIncreased Intracranial Pressure

• Nursing assessmentNursing assessment– Glasgow Coma ScaleGlasgow Coma Scale– Neurologic assessmentNeurologic assessment

• Nursing diagnosesNursing diagnoses

• PlanningPlanning

Fig. 57-11

Fig. 57-12

Nursing ManagementNursing ManagementIncreased Intracranial Pressure (cont’d)Increased Intracranial Pressure (cont’d)• Nursing implementationNursing implementation

– Acute interventionAcute intervention• Respiratory functionRespiratory function• Fluid and electrolyte balanceFluid and electrolyte balance• Monitoring intracranial pressureMonitoring intracranial pressure• Body positionBody position• Protection from injuryProtection from injury• Psychologic considerationsPsychologic considerations

• EvaluationEvaluation

Head InjuryHead Injury

• Types of head injuriesTypes of head injuries– Scalp lacerationsScalp lacerations– Skull fracturesSkull fractures– Minor head traumaMinor head trauma– Major head traumaMajor head trauma

• PathophysiologyPathophysiology

Head InjuryHead Injury

• Types of head injuriesTypes of head injuries– Scalp lacerationsScalp lacerations– Skull fracturesSkull fractures– Minor head traumaMinor head trauma– Major head traumaMajor head trauma

• PathophysiologyPathophysiology

Fig. 57-13

Fig. 57-14

Head Injury (cont’d)Head Injury (cont’d)

• ComplicationsComplications– Epidural hematomaEpidural hematoma– Subdural hematomaSubdural hematoma– Intracerebral hematomaIntracerebral hematoma

• Diagnostic studies andDiagnostic studies andcollaborative carecollaborative care

Fig. 57-15

Fig. 57-16

Nursing Management Nursing Management Head InjuryHead Injury

• Nursing assessmentNursing assessment

• Nursing diagnosesNursing diagnoses

• PlanningPlanning

• Nursing implementationNursing implementation

– Health promotionHealth promotion

– Acute interventionAcute intervention

– Ambulatory and home careAmbulatory and home care

• EvaluationEvaluation

Brain TumorsBrain Tumors

• TypesTypes

• Clinical manifestationsClinical manifestations

• ComplicationsComplications

• Diagnostic studiesDiagnostic studies

• Collaborative careCollaborative care

– Surgical therapySurgical therapy

– Radiation therapy and radiosurgeryRadiation therapy and radiosurgery

– ChemotherapyChemotherapy

Fig. 57-17

Fig. 57-18

Inflammatory ConditionsInflammatory Conditionsof the Brainof the Brain

Bacterial MeningitisBacterial Meningitis

• Etiology and pathophysiologyEtiology and pathophysiology• Clinical manifestationsClinical manifestations• ComplicationsComplications• Diagnostic studiesDiagnostic studies• Collaborative careCollaborative care

Viral MeningitisViral Meningitis

Headaches (anyone have one?)

• Migraines

• Clusters

• Tension

Trigeminal Neuralgia

• Tic Douloureaux• Intermittent INTENSE pain• “Triggers”• Surgeries only reduce pain• Monitor nutrition

Chapter 61Chapter 61

Nursing ManagementNursing ManagementPeripheral Nerve and Spinal Cord Peripheral Nerve and Spinal Cord

ProblemsProblems

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Trigeminal NeuralgiaTrigeminal Neuralgia

• Etiology and pathophysiologyEtiology and pathophysiology• Clinical manifestationsClinical manifestations• Diagnostic studiesDiagnostic studies• Collaborative careCollaborative care

– Drug therapyDrug therapy– Conservative therapyConservative therapy– Surgical therapySurgical therapy

Chapter 61Chapter 61

Nursing ManagementNursing ManagementPeripheral Nerve and Spinal Cord Peripheral Nerve and Spinal Cord

ProblemsProblems

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Fig. 61-1

Bell’s Palsy

• Facial Palsy• Inflammatory /

Unilateral• Cannot close eye,

smile, grimace, whistle, or wrinkle forehead

Multiple Sclerosis

• Chronic Neurological disease• Pathophysiology• Symptoms• Labs/ radiology tests• Treatments• Nursing considerations

Parkinson’s Disease

• Chronic neurological disease• Pathophysiology• Symptoms• Labs/ radiology tests• Treatment• Nursing considerations• “parkinsonism”

Guillian-Barre

• Definition

• Signs and Symptoms

• Medical Treatment

• Nursing Considerations

Myasthenia Gravis

• Definition/Pathophysiology

• Signs and Symptoms

• Treatment

• Nursing Considerations

• Myasthenic/Cholinergic Crisis

Seizure Disorders

• Definition/Pathophysiology

• Types of Seizures– Partial– Generalized

• Treatment/Nursing Considerations

• Status Epilepticus

• Aura

Circulation to the brain

• Carotid arteries

• Vertebral arteries

• Circle of willis

• Perfusion deficit r/t symptoms

TIA

• Transient Ischemic Attack• “Mini-strokes” / “Silent strokes”• Carotid Dopplers• Echocardiogram for mural thrombi

TIA

• Most common symptoms– Contralateral weakness of lower face, fingers,

hands, arms and legs– Transient dysphagia– Some sensory impairment

• Nursing considerations

Carotid Endarterectomy

• Performed on stenotic sites• Nursing Care IMPORTANT 1st 24 hours• Hourly checks; positioning• Horner’s syndrome

CVA

• 3rd Leading Cause of Death• Thrombus / Embolus / Hemorrhage• Circle of Willis• Ischemia vs. hemorrhagic• Clinical Warning Signs• “stroke belt”

CVA – risk factors

• HTN• CVD• DM• Stress• BCP

• Cocaine/drug abuse• Obesity• Increased cholesterol,

triglycerides, LDL• Age• Gender

Right brain vs. Left Brain

• Right brain CVA– Left side paralysis– Left neglect– Spatial-perceptual deficit– Deny problem– Impulsive– Short attn span– Impaired judgement– Impaired time concept

• Left brain CVA– Right paralysis– Impaired speech/language

(left=language– Right/left discrimination– Slow performance– Aware of deficits– Impaired comprehension r/t

language, math

Terminology/management

• Aphasia - expressive, receptive, global• Apraxia• Neglect• Dysphagia• Impulsive• Dysarthria• Ataxia• Homonymous hemianopsia• Hemiplegia vs hemiparesis

Management

• Surgery – selective based on age, area affected, cause of CVA

• Medications: look at source of CVA rt-PA Anti-coagulants / Anti-platelets Calcium Channel Blockers

antihypertensives Anti-convulsants Steroids

Spinal Cord Injury

• Anatomy– Vertebral column

• Vertebrae

– Disks• “cushions”

– Spinal Cord• Brain stem----L2• Meningeal layers

– Dura mater

– Arachnoid

– Pia mater

Spinal cord injury

• Anatomy– Gray matter – control motor/sensory function– White matter

• Myelinated• Tracts that convey info between brain and spinal

cord

– Blood supply• Vertebral arteries• Spinal artery

Spinal Cord InjurySpinal Cord Injury

• Etiology and pathophysiologyEtiology and pathophysiology– Initial injuryInitial injury

• Spinal and neurogenic shockSpinal and neurogenic shock

Spinal Cord Injury (cont’d) Spinal Cord Injury (cont’d)

• Classification of spinal cord injuryClassification of spinal cord injury– Mechanisms of injuryMechanisms of injury– Level of injuryLevel of injury– Degree of injuryDegree of injury

• Central cord syndromeCentral cord syndrome• Anterior cord syndromeAnterior cord syndrome

• Brown-Brown-Séquard Séquard syndromesyndrome

• Posterior cord syndromePosterior cord syndrome• Conus medullaris syndrome and cauda equina syndromeConus medullaris syndrome and cauda equina syndrome

– American Spinal Injury Association (ASIA) Impairment American Spinal Injury Association (ASIA) Impairment ScaleScale

Fig. 61-5

Fig. 61-6

Spinal Cord Function

• Reflexive – stimulus received/ response initiated at level of spinal cord

• Relay – stimulus enters spinal cord and travels up to brain to relay information…processed…response sent back through descending tracts

Major Spinal Cord Tracts

• Spinothalamic – ascending – pain, temp

• Corticospinal – descending – voluntary motor movement

• Spinocerebellar – ascending-coordination of muscle movements

• Posterior columns – ascending – touch, pressure, vibration, position

Major Effects of Spinal Cord Injury

• Respiratory– Phrenic Nerve (above level of C5)– Intercostal/abdominal muscle impairment

• Spinal Shock– Flaccidity– Days to months

Major Effects of spinal cord injuries

• Autonomic dysreflexia– Dangerous – requires immediate attention– Exaggerated response of autonomic nervous

system– Parasympathetic system/regulatory

mechanisms – fail below level of injury– Vagus nerve stimulation

Major effects of spinal cord injury

• Spasticity

• Impaired sensory and motor function

• Bowel and bladder dysfunction

• Temperature regulation

• Sexual dysfunction

• Skin integrity

Medical Treatment

• Medications – corticosteroids, anti-spasmodics, anti-infectives

• Traction – cervical immobility– Roto bed, stryker frame– Halo traction

Assessment

• Airway – always first priority

• VS

• LOC, posture, spontaneous movement

• Spasticity

• Sensory perception

• proprioception

Nursing issues

• Risk for injury• Risk for disuse syndrome• Bowel and bladder programming• Risk for infection• Ineffective thermoregulation• Ineffective coping• Self-care deficit• Ineffective breathing pattern

Fig. 61-7

Fig. 61-8

Fig. 61-9

Spinal Cord Injury (cont’d)Spinal Cord Injury (cont’d)

• Clinical manifestationsClinical manifestations

– Respiratory systemRespiratory system

– Cardiovascular systemCardiovascular system

– Urinary systemUrinary system

– Gastrointestinal systemGastrointestinal system

– Integumentary systemIntegumentary system

– ThermoregulationThermoregulation

– Metabolic needsMetabolic needs

– Peripheral vascular problemsPeripheral vascular problems

Spinal Cord Injury (cont’d)Spinal Cord Injury (cont’d)

• Diagnostic studiesDiagnostic studies

• Collaborative careCollaborative care– Nonoperative stabilizationNonoperative stabilization– Surgical therapySurgical therapy– Drug therapyDrug therapy

Nursing Management: Nursing Management: Spinal Cord Injury (cont’d)Spinal Cord Injury (cont’d)

– Acute interventionAcute intervention• ImmobilizationImmobilization• Respiratory dysfunctionRespiratory dysfunction• Cardiovascular instabilityCardiovascular instability• Fluid and nutritional maintenanceFluid and nutritional maintenance• Bladder and bowel managementBladder and bowel management• Temperature controlTemperature control• Stress ulcersStress ulcers• Sensory deprivationSensory deprivation• ReflexesReflexes• Autonomic dysreflexiaAutonomic dysreflexia

Fig. 61-10

Fig. 61-11

Nursing Management Nursing Management Spinal Cord Injury (cont’d)Spinal Cord Injury (cont’d)

– Rehabilitation and home careRehabilitation and home care• Respiratory rehabilitationRespiratory rehabilitation• Neurogenic bladderNeurogenic bladder• Neurogenic bowelNeurogenic bowel• Neurogenic skinNeurogenic skin• SexualitySexuality• Grief and depressionGrief and depression

• EvaluationEvaluation

Spinal Cord TumorsSpinal Cord Tumors

• Etiology and pathophysiologyEtiology and pathophysiology

• Clinical manifestationsClinical manifestations

• Nursing management: Spinal Nursing management: Spinal cord tumorscord tumors