BGallatin 2007

Medical Surgical Nursing A

Care of the Patient

With a Neurological

Disorder

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Anatomy and Physiology

Central nervous system (CNS) Brain Spinal cord

Peripheral nervous system Somatic (voluntary) Autonomic

(involuntary)

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Anatomy and Physiology

Neurons Transmitter cells Carry messages to and

from brain and spinal cord

Glial cells Support and protect

neurons Produce cerebral spinal

fluid

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Anatomy and Physiology

CNS: brain Cerebrum – lobe functions Diencephalon – thalamus, hypothalamus Cerebellum – balance, coordination Brain stem – midbrain, pons, medulla oblongata

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Anatomy and Physiology

PNS: Somatic (voluntary) 31 pairs of spinal nerves 12 pair of cranial nerves

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Anatomy and Physiology

PNS: Autonomic (involuntary) Controls:

Smooth MusclesCardiac MusclesGlands

Check and balance system:Sympathetic nervous systemParasympathetic nervous system

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Neurological Assessment

History Headaches Loss of function Visual acuity Seizures Numbness

Pain Personality change Mood swing Fatigue

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Neuro Assessment

Mental Status Orientation Mood and behavior General knowledge Short term memory Long term memory

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Neuro Assessment

Level of consciousness

Glasgow Coma Scale Eye opening Verbal response Motor response

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Neuro Assessment

Language and Speech Aphasia

SensoryExpressiveGlobal

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Cranial Nerves

I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens

VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal

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Neuro Assessment

Motor Function Paralysis Paresis

Flaccid Spastic

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Neuro Assessment

Sensory and Perceptual Status Pain Touch Temperature Proprioception Unilateral neglect Hemianopia

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Neuro Assessment

Blood and urine ABG Lumbar puncture Imaging EEG EMG Carotid Duplex

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Neurological Problems

Headache Vascular – migraine, cluster, hypertensive Tension – stress Traction-inflammatory – infection, occlusion

vessels

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Neurological Problems

Increased Intracranial Pressure (IIP)

Occurs slowly or rapidly

May lead to brain stem herniation and death

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Assessment of IIP

Subjective Diplopia Personality change Thought processes change Headache Nausea

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Assessment of IIP

Objective Decreasing LOC Hyperthermia Weakness Vomiting Seizures Papilledema

Posturing Wide pulse pressure Bradycardia Altered respirations Pupils fixed & dilated

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Assessment of IIP

Diagnostic tests: CT scan, MRI Close observation Craig’s screw

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Medical Management of IIP

Craniotomy Craniectomy Tumor removal Drainage of ventricles Drainage of hematoma Intubation

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Medical Management of IIP

Medications Osmotic diuretics - Mannitol Corticosteroids - Decadron Anticonvulsants - Dilantin

Internal monitoring

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Nursing Care of the Patient With IIP

Elevate HOB Neck in neutral

position Avoid flexion hips,

waist and neck Avoid isometric

activity or Valsalva

Restrict fluids Foley Suctioning O2 Hypothermia blanket

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Neurological Disorders-Seizures

Seizures Disorderly neuron discharges in brain Transitory Different types affect body differently Involuntary movement usually

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Seizures

Generalized: Tonic-clonic –

grand mal Absence - Petit mal Myoclonic Atonic or akinetic

Localized: (Focal) Partial (Jacksonian) Psychomotor

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Seizures

Causes: Hypoglycemia Infection Electrolyte imbalance Trauma IIP Toxins

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Seizure Medications

Dilantin (Phenytoin) Phenobarbital Mysoline Tridione Valium (Diazepam) Depakene

Clonopin Mesantoin Neurontin Lamictal Felbatol Cerebyx

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Seizure Medications

Nursing: Medications Continue meds Medic alert ID Avoid alcohol, avoid driving, get adequate rest If on Dilantin, instruct on oral hygiene

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Seizures: Nursing Care

Protect Lower to the floor; pad side rails; pillow under

head; don’t restrain No bite block or padded tongue blade Allow for post-ictal rest

Prevent aspiration (airway) Turn side; loosen clothing around neck

Document everything

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Degenerative Neuro Diseases

Multiple Sclerosis

Parkinson’s Disease

Alzheimer’s Disease

Myasthenia Gravis

Amyotrophic Lateral Sclerosis (ALS)

Huntington’s Disease (chorea)

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Multiple Sclerosis

Common degenerative neurological disease. Myelin sheath is destroyed. Symptoms vary. Relapsing/remitting. Usually ages 20-40.

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Multiple Sclerosis - Symptoms

Subjective: Shakiness, difficulty walking Fatigue, muscle weakness Numbness, tingling Tinnitus Visual problems Difficulty chewing and speaking Incontinent; impotent

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Multiple Sclerosis - Symptoms

Objective: Ataxia Changes in behavior & emotions Nystagmus Spasticity, tremors, dysphagia, facial palsy,

speech impaired, fatigue Incontinence Impaired judgment

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Multiple Sclerosis - Tests

CSF CT scan MRI

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Multiple Sclerosis-Treatment

Meds: Anti inflammatory

ACTH, Solu Medrol, Prednisone Immuno Modifiers

Avonex, Betaseron, Capoxone Muscle Relaxants

Valium

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Multiple Sclerosis-Nursing Interventions

Nutrition Skin Care Activity Control of environment Emotional support Patient teaching

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Parkinson’s Disease

Unknown cause Lack of dopamine. Parkinsonism: encephalitis, toxic chemicals,

meds, drugs

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Parkinson’s

Symptoms include: Muscular tremors and rigidity Emotional instability Judgment defects Heat intolerance Mask-like facial appearance Dysphagia and drooling

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Parkinson’s Testing

No specific test to diagnose Parkinson’s

Diagnosis based on symptoms

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Parkinson’s – Medical Treatment

Medications Sinemet, Symmetrol, Levodopa or Cogentin Less effective over time

Surgery Experimental

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Parkinson’s – Nursing Care

Prevent injury (fall or aspiration) Prevent urinary retention and constipation Patient teaching about medication Patient and family support

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Alzheimer’s

Unknown cause, but genetic link Very common; risk increases with age Brain changes:

plaques tangled neurons blood vessel degeneration chemical changes

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Alzheimer’s - Symptoms

1st– memory lapses, difficult word finding, decreased attention span

2nd – increased memory problems, disoriented to time, loses things, confabulates

3rd – total disorientation, apraxia, wanders 4th – severe impairment

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Alzheimer’s - Testing

No definitive test

Family history

Diagnosis: autopsy

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Alzheimer’s – Medical Management

Medication to treat symptoms Memory:Cognex, Aricept Agitation: Mellaril, Haldol

Supplements Folic Acid & Vitamin B12 Low fat diet NSAIDS

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Alzheimer’s – Nursing Care

2 key points for all care: Prevent overstimulation Provide structured, orderly environment

Other concerns Communication Family support and education

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Myasthenia Gravis

Autoimmune disorder Myoneural junction problem Symptoms:

ptosis, diplopia, weakness, dysarthria, dysphagia, difficulty

sitting up, respiratory distress

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Myasthenia Gravis - Treatment

Medication to improve impulse transmission (Mestinon) to suppress immune system (steroids, Cytoxan)

Plasmapheresis Respiratory support Safety

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Amyotrophic Lateral SclerosisALS – Lou Gehrig’s disease

Motor neurons in brain stem and spinal cord degenerate

Brain’s messages don’t reach the muscles Symptoms – weakness, dysarthria, dysphagia No loss of cognitive function No cure, death occurs in 2-6 years

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Huntington’s DiseaseChorea

Genetic Onset at age 35-45 Excessive involuntary movements Death in 10-20 years No cure

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Huntington’s Disease

Nursing interventions are palliative Give meds Provide for safety Provide adequate diet

Emotional support Genetic counseling

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Cerebrovascular Accident (CVA)

Ischemia of brain tissue Hemorrhage Thrombus Embolus

3rd leading cause of death in the US

All ages, but usually elderly

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CVA – Contributing Factors

Atherosclerosis Heart disease Kidney disease

Hypertension Obesity

High cholesterol Cigarette smoking Stress Sedentary Diabetes Oral contraceptives Cocaine

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Cerebral Thrombosis

Most common cause of CVA

Most often:Atheroclerosis

↓

Thrombus ↓

CVA

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Cerebral Embolism

2nd most common cause of CVA Most often:

Heart disease↓

Thrombus↓

Embolus↓

CVA

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Cerebral Hemorrhage

3rd most common cause of CVA Most often:

Hypertension↓

Ruptured cerebral blood vessel↓

CVA

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Transient Ischemic Attack

Cerebrovascular insufficiency

Causes – same as CVA

Warning sign of impending CVA

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CVA - Assessment

Motor changes Opposite side Balance, coordination, gait, proprioception Glasgow Coma Scale

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CVA Assessment

Sensory Changes Aphasia =can’t speak or write Agnosia =can’t recognize familiar objects/people Apraxia =can’t perform purposeful acts or use

objects properly Neglect Syndrome Visual problems, including hemianopsia

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CVA Assessment

Cognitive changes denial impaired memory, judgment can’t concentrate disoriented slow and cautious versus impulsive depressed, anxious versus euphoric angers quickly versus constantly smiling

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CVA - Testing

CT or MRI Cerebral angiogram CBC, PT, PTT, electrolytes

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CVA – Medical Management

Thrombolytic (“clot buster”) Anticoagulants Antiplatelet drugs Aneurysm repair Carotid endarterectomy

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CVA-Nursing Care

Assess LOC IV, NG, Foley, Vent. Nutrition Encourage perform ADLs Bladder and bowel training ROM Teaching and emotional support

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Trigeminal NeuralgiaTic Douloureux

Trigeminal nerve – degeneration, pressure Facial pain Medication, surgery Avoid triggers

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Bell’s Palsy

Facial nerve inflammation

Unilateral weakness of facial muscles

Steroids, Zovirax, warm moist cloth, massage, facial exercises

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Infection and Inflammation

Meningitis Encephalitis Brain abscessGuillain-Barré

Neurosyphilis Poliomyelitis Herpes zosterAIDS

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Guillain-Barré - Polyneuritis

Peripheral nerve disease Prior infection; autoimmune response

Weakness and paralysis, begins in extremities and works up

Respiratory failure may occur

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Meningitis

Acute infection of the meninges Viral or bacterial

Severe headache, irritable, fever, delirium, N/V, neck stiffness Kernig’s sign Brudzinski’s sign

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Meningitis-Medical Management

Diagnosed by LP Medications Respiratory isolation Cool, dark quiet room Maintain hydration Prevent injury

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Acquired Immunodeficiency Syndrome - AIDS

AIDS dementia complex Infection of CNS

Dementia

Treatment depends on infection Treat symptoms, maintain safety

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Spinal Cord Trauma

Complete cord injury – all voluntary movement below level of trauma is lost

Autonomic hyperreflexia stimulus sympathetic nervous system response