Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 25

NURSING CARE OF THE CLIENT: NEUROLOGICAL SYSTEM

The Human Nervous System

Its purpose is to control motor, sensory, and autonomic functions of the body.

This is accomplished by coordination and initiation of cellular activity through the transmission of electrical impulses and various hormones.

The Nervous System: Structure The nervous system is divided into:

The central nervous system, consisting of the brain and spinal cord.

The peripheral nervous system, which consists of the cranial nerves and spinal nerves.

The autonomic nervous system, which is part of the peripheral nervous system and consists of sympathetic and para-sympathetic systems.

The Brain

Composed of gray matter and white matter, the brain controls, initiates, and integrates body functions through the use of electrical impulses and complex molecules.

Physiology of the Brain

The brain is contained within the skull, or cranium.

Three coverings of the brain, called the meninges. They are the dura mater, arachnoid mater, and pia mater.

The Brain Hemispheres The right side receives information from

and controls the left side of the body. Specializes in perception of physical environment, art, music, nonverbal communication, spiritual aspects.

The left receives information from and controls the right side of the body. Specializes in analysis, calculation, problem solving, verbal communication, interpretation, language, reading, and writing.

The Spinal Cord

A continuation of the brain stem. Exits the skull through the foramen

magnum, an opening in the base of the skull.

Cerebrospinal Fluid

Provides for shock absorption and bathes the brain and spinal cord.

Peripheral Nervous System:

Cranial Nerves Twelve pairs of cranial nerves have

sensory, motor, or mixed functions.

Peripheral Nervous System:

Cranial Nerves Twelve pairs of cranial nerves have

sensory, motor, or mixed functions.

Cranial NervesOlfactorySensory;smell

OpticSensory;Vision

OculomotorMotor; PupilConstriction

TrochlearMotor;upper eyelid elevation

Trigeminalcornea, nose,

oral mucosa; mastication

AbducensMotor; Extraocular eye movement

FacialMotor (facial muscles); Sensory (taste)

AcousticSensory;Hearing; Equilibrium

Glosso-

PharyngealTaste; Swallowing

VagusMotor and Sensory

Spinal AccessoryMotor

HypoglossalTongue Movement

Peripheral Nervous System:

Spinal Nerves

Cervical 8 Thoracic 12 Lumbar 5 Sacral 5 Coccyx 1

NERVES NUMBER OF PAIRS

Peripheral Nervous System:

Autonomic Nervous System Main function is to maintain internal

homeostasis. Two subdivisions of ANS:

The sympathetic system (activated by stress, prepares body for “fight or flight” response).

The parasympathetic system (conserves, restores, and maintains vital body functions, slowing heart rate, increasing gastrointestinal activity, and activating bowel and bladder evacuation).

Cerebral Function: Assessment

Emotional StatusObsevation of client's affect

(emotional repsonse or mood)

OrientationAwareness of self in

relation to person, place, and time

Pupil ReactionSize, equality, and roundness of pupils

Mental StatusObservation of client's

appearance, behavior, posture,mood, gestures, facial expressions

CommunicationBoth written and oral communications

are assessed

Intellectual Functionability of brain to perform thought processes

Level of ConsciousnessResponsiveness; Glasgow Coma Scale (objective tool)

Cranial Nerve Function Assessment:

Motor Function

Posturing

Balance

Coordination

Muscle Strength

Muscle ToneType Title Here

Muscle Size and SymmetryType Title Here

Cranial Nerve Function Assessment:

Sensory Function

Integration of Sensation

GraphesthesiaAbility to identify letters, numbers, or shapes drawn on the skin

StereognosisAbility to recognize an object by feel

ProprioceptionSense of joint position in space

Vibration

Pain and Temperature

Tactile Sensation

Cranial Nerve Function Assessment:

Reflexes

Abnormal Reflexes

Description or Grading of Response

ExaminationUse of reflex hammer

Common Diagnostic Tests for Nervous System Disorders

Lumbar puncture (LP). Electroencephalogram (EEG). Electromyogram (EMG). Imaging Procedures. Cerebral Angiography. Brain scan. Myelogram.

Head Injuries

Scalp. Skull. Brain.

Head injuries involve trauma to the:

Scalp Injuries

They bleed profusely because of the abundance of blood vessels in the scalp.

Infection is of major concern.

Skull Injuries

May occur with or without brain injury, Fracture usually caused by extreme force, Skull fractures considered closed if dura

mater is intact; open if dura mater is torn.

Types of Skull Fractures Linear (nondisplaced cracks in the bone). Comminuted (bone broken into

fragments). Depressed (bone fragments pressing into

intracranial cavity). Basiliar (fractures of the bones in the

base of the skull).

Brain Injuries: Causes Acceleration-deceleration force (acceleration

injuries caused by moving objects striking the head; e.g. baseball bat. Deceleration injuries result when head is moving and strikes object, e.g. dashboard).

Rotational (twisting of the cerebrum on the brain stem, e.g. whiplash).

Penetrating missile (direct penetration of an object, e.g. bullet, into brain tissue).

Brain Injuries: Open

Brain injuries resulting from skull fractures and penetrating injuries are referred to as open head injuries.

Hemorrhaging from the nose, pharynx, or ears; ecchymosis over the mastoid area (Battle’s sign) or blood in the conjunctiva may occur in conjunction with open head injuries.

Brain Injuries: Closed

Caused by blunt force to the head. Types of closed head injuries include

concussion, contusion, and laceration.

Concussion

Transient neurological deficits caused by the shaking of the brain.

Clinical manifestations may include immediate loss of consciousness lasting from minutes to hours, momentary loss of reflexes, respiratory arrest for several seconds, an amnesia afterwards.

Contusions

Surface bruises of the brain. Skin is cool and pale. Pulse, blood pressure, and respirations

are below normal. Cerebral edema may occur in conjunction

with widespread injury.

Cerebral Lacerations

Tearing of cortical tissue. Symptoms include deep coma from time

of impact, decerebate posturing, autonomic dysfunction, nonreactive pupils, respiratory difficulty.

Hemorrhage

Intracranial hemorrhage is common complication of any head injury.

Treatment is surgery to evacuate the hematoma, stop the bleeding, and relieve pressure on the brain.

Brain Tumor Space-occupying intracranial lesions,

either benign or malignant. Clinical manifestations differ according to

area of lesion and rate of growth, but commonly include alterations in consciousness, decreased mental functioning, headaches, seizures, or vomiting (sometimes sudden and projectile),

Cerebrovascular Accident (CVA)

Also known as stroke, CVA is a sudden loss of brain function accompanied by neurological deficit.

Third highest cause of death in U.S. Strokes are caused by ischemia (oxygen

deprivation) resulting from a thrombus, embolus, severe vasospasm, or cerebral hemorrhage.

Transient Ischemic Attacks (TIAs)

Frequently preceding CVAs, TIAs are temporary or transient episodes of neurological dysfunction caused by temporary impairment of blood flow to the brain.

Classic symptom is fleeting blindness in one eye.

Epilepsy/Seizure Disorder

Epilepsy is a disorder of cerebral function in which the client experiences sudden attacks of altered consciousness, motor activity, or sensory phenomenon.

Most clinicians use the term seizure disorder for epilepsy or seizures

Seizures are classified as generalized or partial.

Herniated Intervertebral Disk

A major cause of chronic back pain. Majority of herniated disks occur in

lumbar or cervical spine. This can occur either suddenly from trauma, lifting, or twisting, or gradually from aging, osteoporosis, or degenerative changes.

Spinal Cord Injury (SCI)

Occurs from trauma to the spinal cord or from compression of the spinal cord due to injury to the supporting structures.

Each year, almost 10,000 new spinal cord injuries occur.

Leading causes are motor vehicle accidents, acts of violence, falls, and sporting accidents.

Parkinson’s Disease

A chronic, progressive, degenerative disease affecting the area of the brain controlling movement.

Typical symptoms include muscular rigidity, bradykinesia (slowness of voluntary movement and speech), resting tremors, muscular weakness, and loss of postural reflexes.

Multiple Sclerosis (MS)

A chronic, progressive, degenerative disease wherein scattered nerve cells of the brain and spinal cord are demyelinated.

Symptoms include visual disturbance, numbness, paresthesia, pain, decreased sense of temperature, decreased muscle strength, spasticity, paralysis, bowel and bladder incontinence or retention.

Amyotrophic Lateral Sclerosis (ASL) (Lou Gehrig’s Disease)

A progressive, fatal disease characterized by the degeneration of motor neurons in the cortex, medulla, and spinal cord.

Alzheimer’s Disease (AD)

A progressive, degenerative neurological disease wherein brain cells are destroyed and the cerebral cortex atrophies.

Risk factors include advanced age, female gender, head injury, history of thyroid disorders, and chromosomal abnormalities.

Stages of Alzheimer’s Disease

Stage 3: LateInability to communicate; Inability to eat; Incontinence; Confinement to bed;

Inability to recognize family and friends ;Total dependence relative to care

Stage 2: MiddleProgressing forgetfulness; confusion; tendency to lose things; fearfulness; easily induced frustration;

inability to follow simple directions; paranoia; changes in eating and sleep patterns; pacing; wandering

Stage 1: EarlyForgetfulness, often subtle and masked by client;slowed reaction time;Increasing self-centeredness; difficulty in learning new information;beginning of compromised performance at home and work

Guillain-Barré Syndrome

An acute inflammatory process primarily involving the motor neurons of the peripheral nervous system.

Clinical manifestations include motor weakness and absence of reflexes (areflexia).

Headache

Also known as cephalagia, headache is the condition of pain in the head, caused by stimulation of pain-sensitive structures in the cranium, head, or neck.

Types of Headache: Primary

Tension-Type Migraine. Cluster Headaches.

Types of Headache: Secondary

Secondary headaches are the result of pathological conditions such as aneurysm, brain tumor, or inflamed cranial nerves.

The headache is caused by compression, inflammation, or hypoxia of pain-sensitive structures.

Client Teaching: Headaches

Advise clients to: Keep a diary of headache history to

ascertain pattern. Avoid foods that trigger headaches. Reduce salt intake. Practice relaxation techniques.

Trigeminal Neuralgia(Tic Douloureux)

A condition of cranial nerve V that is characterized by abrupt paroxysms of pain and facial muscle contractions.

Encephalitis/Meningitis Encephalitis is inflammation of the brain. Meningitis is inflammation of the

meninges. Most common cause of both is a virus. Cerebral edema, hemorrhage, and

necrosis of brain tissue can occur. Fever, headache, nuchal rigidity,

photophobia, irritability, lethargy, nausea, and vomiting are typical symptoms.

Huntington’s Disease or Chorea

A chronic, progressive hereditary disease of the nervous system characterized by chorea, abnormal involuntary, purposeless movements of all musculature of the body.

Gilles de la Tourette’s Syndrome

A neurological movement disorder that also has prominent behavioral manifestations.