Neurological Disorders

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NEUROLOGICAL NEUROLOGICAL DISORDERSDISORDERS

Presented by: Dave Jay S. Presented by: Dave Jay S. Manriquez, RNManriquez, RN

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Diagnostic TestsDiagnostic Tests


Skull and spinal x-ray

reveal the size and shape of the skull bones, suture separation in infants, fractures or bony defects, erosion, or calcification

identify fractures, dislocation, compression, curvature, erosion, narrowed spinal cord, and degenerative processes


Implementation preprocedure

immobilization of the neck if a spinal fracture is suspected

Remove metal items from body parts

If the client has thick and heavy hair, this should be documented, because it may affect interpretation of the x-ray film


Computed Tomography (CT) scanComputed Tomography (CT) scan

a type of brain scanning that may a type of brain scanning that may or may not require an injection of a or may not require an injection of a dyedye

used to detect intracranial bleeding, used to detect intracranial bleeding, space-occupying lesions, cerebral space-occupying lesions, cerebral edema, infarctions, hydrocephalus, edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain cerebral atrophy, and shifts of brain structuresstructures




Obtain a consent if a dye is used Assess for allergies to iodine, contrast

dyes, or shellfish if a dye is used Instruct the client in the need to lie still

and flat during the test Remove objects from the head, such as

wigs, barrettes, earrings, and hairpins Assess for claustrophobia



Inform the client if possible mechanical noises as the scanning occurs

Inform the client that there may be a hot, flushed sensation and a metallic taste in the mouth when the dye is injected

Note that some clients may be given the dye even if they report an allergy, and are treated with an antihistamine and corticosteroids prior to the injection, to reduce the severity of a reaction


Implementation postprocedure

• Provide replacement fluids because diuresis from the dye is expected

• Monitor for an allergic reaction to dye

• Assess dye injection site for bleeding or hematoma, and monitor extremity for color, warmth, and the presence of distal pulses


Magnetic resonance imaging Magnetic resonance imaging (MRI)(MRI)

a noninvasive procedure that a noninvasive procedure that identifies types of tissues, tumors, identifies types of tissues, tumors, and vascular abnormalitiesand vascular abnormalities

Similar to the CT scan but provides Similar to the CT scan but provides more detailed pictures and does not more detailed pictures and does not expose the client to ionizing expose the client to ionizing radiationradiation



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Implementation Implementation preprocedurepreprocedure

1.1. Remove all metal objects from the clientRemove all metal objects from the client

2.2. Determine if the client has a pacemaker, Determine if the client has a pacemaker, implanted defibrillator, or metal implants such as a implanted defibrillator, or metal implants such as a hip prosthesis or vascular clips because these hip prosthesis or vascular clips because these clients cannot have this test performedclients cannot have this test performed

3.3. Instruct the client that he or she will need to Instruct the client that he or she will need to remain still during the procedureremain still during the procedure

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Implementation postprocedureImplementation postprocedure

1. client may resume normal activities

2. expect diuresis if a contrast agent was used

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Lumbar punctureLumbar puncture

• Insertion of a spinal needle through L3-L4 Insertion of a spinal needle through L3-L4 interspace into the lumbar subarachnoid interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or instill measure CSF fluid or pressure, or instill air, dye or medicationsair, dye or medications

• Contraindicated in clients with increased Contraindicated in clients with increased intracranial pressure, because the intracranial pressure, because the procedure will cause a rapid decrease in procedure will cause a rapid decrease in pressure within the CSF around the spinal pressure within the CSF around the spinal cord, leading to brain herniationcord, leading to brain herniation

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Implementation preprocedureImplementation preprocedure

obtain a consentobtain a consent have the client empty the bladderhave the client empty the bladder


Implementation during the procedure

position the client in a lateral recumbent position and have the client draw knees up to the abdomen and chin onto the chest

Assist with the collection of specimens (label the specimens in sequence)

Maintain strict asepsis



Monitor vital signs and Monitor vital signs and neurological signsneurological signs

Position the client flat as Position the client flat as prescribedprescribed

Force fluidsForce fluids Monitor I & OMonitor I & O


MyelogramMyelogram

Injection of dye or air into the Injection of dye or air into the subarachnoid space to detect subarachnoid space to detect abnormalities of the spinal cord and abnormalities of the spinal cord and vertebraevertebrae



Obtain a consentObtain a consent Provide hydration for at least 12 Provide hydration for at least 12

hours before the testhours before the test Assess for allergies to iodineAssess for allergies to iodine Premedicate for sedation as Premedicate for sedation as

prescribedprescribed



• if a water-based dye is used, elevate the head 15 to 30 degrees for 8 hours as prescribed

• If an oil-based dye is used, keep the client flat 6 to 8 hours as prescribed

• If air is used, keep the head lower than the trunk as prescribed

• Assess for bladder distention and voiding


Cerebral angiographyCerebral angiography

Injection of contrast through the femoral Injection of contrast through the femoral artery into the carotid arteries to artery into the carotid arteries to visualize the cerebral arteries and visualize the cerebral arteries and assess for lesionsassess for lesions





obtain a consent Assess the client for allergies to iodine

and shellfish Encourage hydration for 2 days before

the test NPO 4 to 6 hours prior to the test as

prescribed Mark the peripheral pulses Remove metal items from the hair


Implementation Implementation postprocedurepostprocedure

Monitor for swelling in the neck and for difficulty Monitor for swelling in the neck and for difficulty swallowing and notify the physician if these symptoms swallowing and notify the physician if these symptoms occuroccur

Elevate the head of the bed 15 to 30 degrees only if Elevate the head of the bed 15 to 30 degrees only if prescribedprescribed

Keep the bed flat if the femoral artery is used, as Keep the bed flat if the femoral artery is used, as prescribedprescribed

Assess peripheral pulsesAssess peripheral pulses Immobilize the puncture site for 12 hours as prescribedImmobilize the puncture site for 12 hours as prescribed Apply sandbags and a pressure dressing to the Apply sandbags and a pressure dressing to the

injection site as prescribedinjection site as prescribed Force fluidsForce fluids


ElectroencephalographyElectroencephalography

A graphic recording of the electrical A graphic recording of the electrical activity of the superficial layers of activity of the superficial layers of the cerebral cortexthe cerebral cortex





Wash the client’s hairWash the client’s hair Inform the client that electrodes are Inform the client that electrodes are

attached to the head and that attached to the head and that electricity does not enter the headelectricity does not enter the head

Withhold stimulants, Withhold stimulants, antidepressants, tranquilizers, and antidepressants, tranquilizers, and anticonvulsants for 24 to48 hours anticonvulsants for 24 to48 hours prior to the test as prescribedprior to the test as prescribed



• Wash the client’s hairWash the client’s hair

• Maintain side rails and safety Maintain side rails and safety precautions if the client was precautions if the client was sedated sedated


Caloric Testing (oculovestibular testing)

Provides information about the function of the vestibular portion of the eighth cranial nerve and aids in the diagnosis of cerebellum and brainstem lesions




Procedure

Patency of the external canal is confirmed

Cold or warm water is introduced into the external auditory canal

Stimulation of the auditory canal with warm water produces a horizontal nystagmus toward the side of the irrigated ear when the vestibular eighth cranial nerve is normal

Stimulation of the auditory canal with cold water produces a horizontal nystagmus away from the side of the irrigated ear if the brainstem is intact

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The Unconscious ClientThe Unconscious Client

A state of depressed cerebral A state of depressed cerebral functioning with unresponsiveness functioning with unresponsiveness to sensory and motor functionto sensory and motor function

Some of the cause include head Some of the cause include head trauma, cerebral toxins, shock, trauma, cerebral toxins, shock, hemorrhage, tumor, and infectionhemorrhage, tumor, and infection


AssessmentAssessment

UnarousableUnarousable

Primitive or no response to painful stimuliPrimitive or no response to painful stimuli

Altered respirationsAltered respirations

Decreased cranial nerve and reflex activityDecreased cranial nerve and reflex activity


Implementation Assess patency of airway and keep an airway

and emergency equipment at the bedside Maintain a patent airway and ventilation

because a high CO2 level increases intracranial pressure

Suction PRN Assess neurological status, including LOC,

papillary reactions, motor and sensory function Place the client in semi-Fowler’s position Change the position of the client every 2

hours, avoiding injury when turning


ImplementationImplementation

Use side rails at all timesUse side rails at all times Assess for edemaAssess for edema Maintain NPO status until Maintain NPO status until

consciousness returnsconsciousness returns Check the gag and swallowing Check the gag and swallowing

reflex before resuming diet, and reflex before resuming diet, and begin with ice chips and fluidsbegin with ice chips and fluids



Monitor for constipation, impaction, and paralytic Monitor for constipation, impaction, and paralytic ileusileus

maintain urinary output to prevent stasis, infection, maintain urinary output to prevent stasis, infection, and calculus formationand calculus formation

Remove dentures and contact lensesRemove dentures and contact lenses Assume that the unconscious client can hearAssume that the unconscious client can hear Avoid restraintsAvoid restraints Do not leave the client unattended if unstableDo not leave the client unattended if unstable Initiate seizure precautions if necessaryInitiate seizure precautions if necessary Provide range-of-motion exercises to prevent Provide range-of-motion exercises to prevent

contracturescontractures


Increased Intracranial Increased Intracranial Pressure Pressure

An increase in ICP caused by trauma, An increase in ICP caused by trauma, hemorrhage, growths or tumors, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammationhydrocephalus, edema, or inflammation

Can impede circulation to the brain, Can impede circulation to the brain, impede the absorption of CSF, affect the impede the absorption of CSF, affect the functioning of nerve cells, and lead to functioning of nerve cells, and lead to brainstem compression and deathbrainstem compression and death




Assessment Assessment

Assess level of consciousness (LOC), Assess level of consciousness (LOC), which is the most sensitive and which is the most sensitive and earliest indication of increasing earliest indication of increasing intracranial pressureintracranial pressure

HeadacheHeadache Abnormal respirationsAbnormal respirations Rise in blood pressure with widening Rise in blood pressure with widening

pulse pressurepulse pressure VomitingVomiting


Assessment

Pupil changes Changes in motor function from weakness to

hemiplegia, a positive Babinski reflex, decorticate or decerebrate posturing, and seizures

Late signs of increased ICP include increased systolic blood pressure, widened pulse pressure, and slowed heart rate


Implementation

Elevate the head of the bed 30 to 40 degrees as prescribed

Avoid Trendelenburg position Prevent flexion of the neck and hips Monitor respiratory status and prevent hypoxia Prevent shivering, which can raise ICP Decrease environmental stimuli avoid straining activities such as coughing and

sneezing Instruct the client to avoid Valsalva maneuver


Surgical Intervention for ICP

Ventriculoperitoneal Shunt Shunts CSF from ventricles into the

peritoneum

Implementation Postprocedure Position the client supine and turn

from back to non-operative side Monitor for signs of increasing ICP

resulting form shunt failure Monitor for signs of infection



HyperthermiaHyperthermia

A temperature of 106 degrees F, which A temperature of 106 degrees F, which increases the cerebral metabolism and increases the cerebral metabolism and increases the risk of hypoxiaincreases the risk of hypoxia

The causes include infection, heat stroke, The causes include infection, heat stroke, exposure to high environmental exposure to high environmental temperatures, and dysfunction of the temperatures, and dysfunction of the thermoregulatory centerthermoregulatory center


AssessmentAssessment

Temperature of 106 degrees FTemperature of 106 degrees F ShiveringShivering Nausea and vomitingNausea and vomiting



• Maintain a patent airway

• Initiate seizure precautions

• Monitor lung sounds

• Monitor for dysrhytmias

• Assess peripheral pulses for systemic blood flow

• Induce normothermia with fluids, cool baths, fans, or hypothermia blanket


Inducing normothermiaInducing normothermia

• Prevent shivering, which will increase Prevent shivering, which will increase CSF pressure and oxygen consumptionCSF pressure and oxygen consumption

• Administer medications as prescribed Administer medications as prescribed to prevent shiveringto prevent shivering

• Monitor I & OMonitor I & O

• Prevent trauma to the skin and tissuesPrevent trauma to the skin and tissues

• Apply lotion to the skin frequentlyApply lotion to the skin frequently


Head InjuryHead Injury

usually caused by car accidents, usually caused by car accidents, falls, assaults falls, assaults

Types:Types: ConcussionConcussion ContusionContusion HemorrhageHemorrhage

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Concussion

severe blow to the head jostles brain causing it to strike the skull; results in temporary neural dysfunction




Contusion Contusion

results from more severe blow results from more severe blow that bruises the brain and that bruises the brain and disrupts neural function disrupts neural function


Hemorrhage

epidural hematoma accumulation of blood between the dura

mater and skull; commonly results from laceration of middle meningeal artery during skull fracture; blood accumulates rapidly

subdural hematoma accumulation of blood between the dura

and arachnoid; venous bleeding that forms slowly; may be acute, subacute, or chronic


HemorrhageHemorrhage

subarachnoid hematoma subarachnoid hematoma

– – bleeding in the subarachnoid spacebleeding in the subarachnoid space

intracerebral hematoma intracerebral hematoma

– – accumulation of blood within the cerebrumaccumulation of blood within the cerebrum


Assessment findingsAssessment findings

• Concussion – headache, transient loss of consciousness, retrograde or posttraumatic amnesia, nausea, dizziness, irritability

• Contusion – neurologic deficits depend on the site and extent of damage; include decreased LOC, aphasia, hemiplagia, sensory deficits



HemorrhagesHemorrhages

a. a. epidural hematomaepidural hematoma

- brief loss of consciousness followed - brief loss of consciousness followed by lucid interval; progresses to by lucid interval; progresses to severe headache, vomiting, rapidly severe headache, vomiting, rapidly deteriorating LOC, possible seizure, deteriorating LOC, possible seizure, ipsilateral papillary dilationipsilateral papillary dilation


Assessment findings

b. subdural hematoma - alterations in LOC, headache, focal

neurologic deficits, personality changes, ipsilateral papillary dilation

c. intracerbral hematoma- headache, decreased LOC,

hemiplegia, ipsilateral papillary dilation


Nursing InterventionsNursing Interventions

Maintain a patent airway an adequate Maintain a patent airway an adequate ventilationventilation

Observe for CSF leakageObserve for CSF leakagea. bloody spot encircled by watery, pale a. bloody spot encircled by watery, pale ring on pillowcase or sheetring on pillowcase or sheet

b. never attempt to clean the ears or b. never attempt to clean the ears or nose of a head-injured client or use nasal nose of a head-injured client or use nasal suction unless cleared by physiciansuction unless cleared by physician



4. If a CSF leak is present4. If a CSF leak is present

a. instruct client not to blow nosea. instruct client not to blow nose

b. elevate head of bed 30 degrees as orderedb. elevate head of bed 30 degrees as ordered

d. place a cottonball in the ear to absorb d. place a cottonball in the ear to absorb otorrhea; replace frequentlyotorrhea; replace frequently


Spinal Cord InjuriesSpinal Cord Injuries

- occurs most commonly in young - occurs most commonly in young adults male between ages 15 and 25adults male between ages 15 and 25

-causes – motor vehicle accidents, -causes – motor vehicle accidents, diving in shallow water, falls, diving in shallow water, falls, industrial accidents, sports injuries, industrial accidents, sports injuries, gunshot or stab woundsgunshot or stab wounds

- nontraumatic causes – tumors, - nontraumatic causes – tumors, hematomas, aneurysms, congenital hematomas, aneurysms, congenital defects (spina bifida)defects (spina bifida)




Pathophysiology

Hemorrhage and edema cause ischemia, leading to necrosis and destruction of the cord


Medical Management

1. Horizontal turning frames

2. Skeletal traction:a. Cervical tongs

– inserted through burr holes; traction is provided by a rope extended from the center of tongs over a pulley with weights attached at the end


Cervical tongs



Medical Management

b. Halo traction1) stainless steel halo ring fits

around the head and is attached to the skull with four pins; halo is attached to plastic body cast or plastic vest

2) permits early mobilization, decreased period of hospitalization and reduces complications of immobility



Assessment findings

1. Spinal shock- characterized by absence of reflexes below the level

of the lesion, flaccid paralysis, lack of temperature control in affected parts, hypotension with bradycardia, retention of urine and feces

quadriplegia – cervical injuries (C1-C8) cause paralysis of all four extremities; respiratory paralysis occurs in lesions above C4 due to lack of innervation to the diaphragm

paraplegia – thoraco/lumbar injuries (T1-L4) cause paralysis of the lower half of the body involving both legs



1) complete cord transaction1) complete cord transactiona) loss of all voluntary movement and sensation a) loss of all voluntary movement and sensation

below the level of the injury; reflex activity below below the level of the injury; reflex activity below the level of the lesion may return after spinal the level of the lesion may return after spinal shock resolvesshock resolves

b) lesions in the conus medullaris or cauda equine b) lesions in the conus medullaris or cauda equine result in permanent flaccid paralysis and areflexiaresult in permanent flaccid paralysis and areflexia

2) incomplete lesions – varying degrees of motor or 2) incomplete lesions – varying degrees of motor or sensory loss below the level of the lesion sensory loss below the level of the lesion depending on which neurologic tracts are depending on which neurologic tracts are damaged and which are spareddamaged and which are spared


Nursing Interventions: Nursing Interventions: emergency careemergency care

1. assess airway, breathing, circulation1. assess airway, breathing, circulationa. do not move the client during assessmenta. do not move the client during assessmentb. if airway obstruction or inadequate ventilation b. if airway obstruction or inadequate ventilation

exists: do not hyperextend neck to open exists: do not hyperextend neck to open airway, use jaw thrust insteadairway, use jaw thrust instead

2. perform a quick head-to-toe assessment: 2. perform a quick head-to-toe assessment: check for LOC, signs of trauma to the head or check for LOC, signs of trauma to the head or neck, leakage of clear liquid from ears or nose, neck, leakage of clear liquid from ears or nose, signs of motor or sensory impairmentsigns of motor or sensory impairment

3. immobilize the client in the position found until 3. immobilize the client in the position found until help arriveshelp arrives


Nursing Interventions : acute careNursing Interventions : acute care

• Maintain optimum respiratory function• Maintain optimal cardiovascular function• change position slowly and gradually elevate the

had of bed to prevent postural hypotension • . Maintain immobilization and spinal alignment

always

a. turn every hour on turning frame

b. maintain cervical traction at all times if indicated


Nursing Interventions : acute Nursing Interventions : acute carecare

• Maintain urinary eliminationMaintain urinary elimination

• maintain bowel elimination: administer maintain bowel elimination: administer stool softeners and suppositories to prevent stool softeners and suppositories to prevent impaction as orderedimpaction as ordered

• Monitor temperature controlMonitor temperature control

• Observe for and prevent infectionObserve for and prevent infection


Nursing Interventions : acute Nursing Interventions : acute carecare

10. Observe for and prevent stress 10. Observe for and prevent stress ulcersulcers

a. assess for epigastric or shoulder paina. assess for epigastric or shoulder pain b. if corticosteroids are ordered, give b. if corticosteroids are ordered, give

with food or antacids; administer with food or antacids; administer cimetadine (Tagamet) as orderedcimetadine (Tagamet) as ordered

c. Check nasogastric tube contents and c. Check nasogastric tube contents and stools for bloodstools for blood


Nursing Interventions – chronic care

1. Neurogenic bladderreflex or upper motor neuron bladder; reflex activity of the bladder may occur after spinal shock resolves; the bladder is unable to store urine very long and empties involuntarily

nonreflexive or lower motor neuron bladder: reflex arc is disrupted and no reflex activity of the bladder occurs, resulting in urine retention with overflow


Nursing Interventions – chronic Nursing Interventions – chronic carecare

c. management of reflexive bladderc. management of reflexive bladder► intermittent catheterization every 4 hours intermittent catheterization every 4 hours

and gradually progress to every 6 hoursand gradually progress to every 6 hours

► regulate fluid intake to 1800- 2000 cc/dayregulate fluid intake to 1800- 2000 cc/day

► bladder taps or stimulating trigger points to bladder taps or stimulating trigger points to cause reflex emptying of the bladdercause reflex emptying of the bladder


Nursing Interventions – chronic careNursing Interventions – chronic care

d. Management of nonreflexive bladderd. Management of nonreflexive bladder intermittent catheterization every 6 hoursintermittent catheterization every 6 hours

Crede maneuver or rectal stretchCrede maneuver or rectal stretch

regulate intake to 1800- 2000 cc/day to regulate intake to 1800- 2000 cc/day to prevent overdistention of bladderprevent overdistention of bladder


Nursing Interventions – Nursing Interventions – chronic carechronic care

2. Spasticity2. Spasticity drug therapy : baclofen (Lioresal), drug therapy : baclofen (Lioresal),

dantrolene (Dantrium), diazepam dantrolene (Dantrium), diazepam (Valium)(Valium)

physical therapy – stretching exercises, physical therapy – stretching exercises, warm tub baths, whirlpoolwarm tub baths, whirlpool

surgery – chordotomysurgery – chordotomy



Autonomic dysreflexia

rise in blood pressure, sometimes to fatal levels

occurs in clients with cord lesions above T6 and most commonly in clients with cervical injuries

stimulus may be overdistended bladder or bowel, decubitus ulcer, chilling, pressure from bedclothes


SymptomsSymptoms

severe headachesevere headachehypertensionhypertensionbradycardia, sweatingbradycardia, sweatinggoosebumpsgoosebumpsnasal congestionnasal congestion blurred visionblurred visionconvulsionconvulsion


InterventionsInterventions

raise client to sitting position to raise client to sitting position to decrease BPdecrease BP

check for source of stimulus (bladder, check for source of stimulus (bladder, bowel, skin)bowel, skin)

remove offending stimulus remove offending stimulus (catheterize client, digitally remove (catheterize client, digitally remove impacted feces, reposition clientimpacted feces, reposition client

monitor blood pressuremonitor blood pressure


Intracranial Surgery

1. Craniotiomy – surgical opening of skull to gain access to intracranial structures; used to remove a tumor, evacuate blood clot, control hemorrhage, relieve increased ICP

2. Craniectomy – excision of a portion of the skull; sometimes used for decompression

3. Cranioplasty – repair of a cranial defect with a metal or plastic plate


Craniotiomy



Nursing Interventions – preoperative Routine pre-op care Shampoo the scalp and check for signs of infection Shave hair Evaluate and record baseline vital signs and neuro

checks Avoid enemas unless directed (straining increase

ICP) Give pre-op steroids as ordered to decrease brain

swelling Insert Foley catheter as ordered


Nursing Interventions: Nursing Interventions: postoperativepostoperative

Supratentorial incision – elevate head of bed Supratentorial incision – elevate head of bed 15-45 degrees as ordered; position on back (if 15-45 degrees as ordered; position on back (if intubated or conscious) or on unaffected side; intubated or conscious) or on unaffected side; turn every 2hours to facilitate breathing and turn every 2hours to facilitate breathing and venous returnvenous return

Infratentorial incision – keep of head flat or Infratentorial incision – keep of head flat or elevate 20-30 degrees as ordered; do not flex elevate 20-30 degrees as ordered; do not flex head on chest; turn side to side every 2 hours head on chest; turn side to side every 2 hours using a turning sheet; check respirations using a turning sheet; check respirations closely and report any signs of respiratory closely and report any signs of respiratory distressdistress


Nursing Interventions: Nursing Interventions: postoperativepostoperative

• watch for signs of diabetes insipidus (severe thirst, polyuria, dehydration) and inappropriate ADH secretion (decreased urine output, hunger, thirst, irritability, decreased LOC, muscle weakness)

• For infratentorial surgery – may be NPO for 24 hours due to possible impaired swallowing and gag reflexes


Nursing Interventions: Nursing Interventions: postoperativepostoperative• check dressings for excessive drainage, CSF, check dressings for excessive drainage, CSF,

infection, displacement, and report to physicianinfection, displacement, and report to physician• if surgical drain is in place, note color, amount, if surgical drain is in place, note color, amount,

and odor of drainageand odor of drainage• Administer medications as orderedAdminister medications as ordereda. Corticosteroids – to decrease cerebral edemaa. Corticosteroids – to decrease cerebral edemab. anticonvulsants – to prevent seizuresb. anticonvulsants – to prevent seizuresc. stool softeners – to prevent strainingc. stool softeners – to prevent strainingd. mild analgesicsd. mild analgesics• Apply ice to swollen eyelids; lubricate lids and Apply ice to swollen eyelids; lubricate lids and

areas around eyes with petrolatum jellyareas around eyes with petrolatum jelly


Seizure DisordersSeizure Disorders

Seizures – recurrent sudden changes Seizures – recurrent sudden changes in consciousness, behavior, in consciousness, behavior, sensations, and/or muscular sensations, and/or muscular activities beyond voluntary control activities beyond voluntary control that are produced by excess that are produced by excess neuronal dischargeneuronal discharge

Epilepsy – chronic recurrent seizures Epilepsy – chronic recurrent seizures


Causes

structural or space-occupying lesion

metabolic abnormalities

infection

encephalopathy

Degenerative diseases (Tay-Sachs)

Congenital CNS defects (hydrocephalus)

Vascular problems (intracranial hemorrhage)


PathophysiologyPathophysiology

with seizures, many more neurons than with seizures, many more neurons than normal fire in a synchronous fashion in a normal fire in a synchronous fashion in a particular area of the brain; the energy particular area of the brain; the energy generated overcomes the inhibitory generated overcomes the inhibitory feedback mechanismfeedback mechanism


Classification

Generalized – initial onset in both hemispheres, usually involves loss of consciousness and bilateral motor activity


ClassificationClassification

1.major motor seizures (grand mal)1.major motor seizures (grand mal) Maybe preceded by aura; tonic and clonic phasesMaybe preceded by aura; tonic and clonic phases

Tonic phase - limbs contract or stiffen; pupils Tonic phase - limbs contract or stiffen; pupils dilate and eyes roll up and to one side; glottis dilate and eyes roll up and to one side; glottis closes, causing noise on exhalation; may be closes, causing noise on exhalation; may be incontinent; occurs at same time as loss of incontinent; occurs at same time as loss of consciousness; lasts 20-40 secondsconsciousness; lasts 20-40 seconds

Clonic phase – repetitive movements, increased Clonic phase – repetitive movements, increased mucus production; slowly tapersmucus production; slowly tapers seizure ends with postictal period of confusion, seizure ends with postictal period of confusion,

drowsinessdrowsiness


Classification

2. Absence seizures (petit mal)- usually non-organic brain damage

present; must be differentiated from daydreaming

- sudden onset, with twitching or rolling of eyes; lasts a few seconds


Classification

3. Myoclonic seizures

– associated with brain damage, may be precipitated by tactile or visual sensations

- may be generalized or local

- brief flexor muscle spasm; may have arm extension, trunk flexion

- single group of muscle affected; involuntary muscle contractions; myoclonic jerks


Classification

4. Akinetic seizure

– related to organic brain damage

- sudden brief loss of postural tone, and temporary loss of consciousness



5. Febrile seizure5. Febrile seizure- common in 5% of population - common in 5% of population

under 5, familial, under 5, familial, nonprogressive; does not nonprogressive; does not generally result in brain damagegenerally result in brain damage

- seizure occurs only when fever - seizure occurs only when fever is risingis rising

-EEG is normal 2 weeks after -EEG is normal 2 weeks after seizuresseizures



Partial seizures Partial seizures

– – begins in focal area of brain and begins in focal area of brain and symptoms are appropriate to a symptoms are appropriate to a dysfunction of that area; may dysfunction of that area; may progress into a generalized seizure, progress into a generalized seizure, further subdivided into simple partial further subdivided into simple partial or complex partialor complex partial



1. Psychomotor seizure1. Psychomotor seizure- may follow trauma, hypoxia, drug use- may follow trauma, hypoxia, drug use-purposeful but inappropriate, repetitive -purposeful but inappropriate, repetitive

motor actsmotor acts- aura present; dreamlike state- aura present; dreamlike state2. Simple partial seizure2. Simple partial seizure- seizure confined to one hemisphere of brain- seizure confined to one hemisphere of brain- no loss of consciousness- no loss of consciousness- may be motor, sensory, or autonomic - may be motor, sensory, or autonomic

symptomssymptoms


Classification

3. Complex partial seizure- begins in focal area but spreads to both hemispheres- impairs consciousness- may be preceded by an aura4. status epilepticus- seizure is prolonged (or there are repeated seizures

without regaining consciousness) and unresponsive to treatment

- can result in decreased oxygen supply and possible cardiac arrest


Medical management

Phenytoin inhibits spread of electrical discharge

Phenobarbital

– elevates the seizure threshold and inhibits the spread of electrical discharge

Surgery

– to remove the tumor, hematoma, or epileptic focus


Assessment findings

blood studies to rule out lead poisoning, hypoglycemia, infection, or electrolyte imbalances

lumbar puncture to rule out infection or trauma

skull x-rays, CT scan, or ultrasound of the head, brain scan, arteriogram, or pneumoencephalogram to detect any pathologic defects



EEG may detect abnormal wave patterns EEG may detect abnormal wave patterns characteristic of different types of seizurescharacteristic of different types of seizures

1) children may be awake or asleep; 1) children may be awake or asleep; sedation is ordered and child may be sleep sedation is ordered and child may be sleep deprived the night before the testdeprived the night before the test

2) evocative stimulation – flashing stobe 2) evocative stimulation – flashing stobe light, clicking sounds, hyperventilationlight, clicking sounds, hyperventilation



• prevent falling, gently support headprevent falling, gently support head

• decrease external stimuli; do not restraindecrease external stimuli; do not restrain

• loosen tight clothingloosen tight clothing

• keep airway openkeep airway open

• observe and record seizureobserve and record seizure


Cerebrovascular Accident (CVA)Cerebrovascular Accident (CVA)

- destruction (infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen

- caused by thrombosis, embolism, hemorrhage


Risk factorsRisk factors

• hypertension, diabetes mellitus, hypertension, diabetes mellitus, arteriosclerosis/atherosclerosis, arteriosclerosis/atherosclerosis, cardiac disease (valvular disease/ cardiac disease (valvular disease/ replacement, chronic atrial replacement, chronic atrial fibrillation, myocardial infarction)fibrillation, myocardial infarction)

• obesity, smoking, inactivity, stress, obesity, smoking, inactivity, stress, use of oral contraceptivesuse of oral contraceptives


PathophysiologyPathophysiology

interruption of cerebral blood flow for interruption of cerebral blood flow for 5 minutes or more causes death of 5 minutes or more causes death of neurons in affected area with neurons in affected area with irreversible loss of functionirreversible loss of function


Modifying factors

1) cerebral edema – develops around affected area causing further impairment

2) vasopasm – constriction of cerebral blood vessel may occur, causing further decrease in blood flow

3) collateral circulation – may help to maintain cerebral blood flow when there is compromise of main blood supply


Stages of developmentStages of development

a. Transient ischemic attack (TIA)a. Transient ischemic attack (TIA)- warning sign of impending CVA- warning sign of impending CVA- brief period of neurologic deficit - brief period of neurologic deficit

– visual loss, hemiparesis, – visual loss, hemiparesis, slurred speech, aphasia, vertigoslurred speech, aphasia, vertigo

- may last less than 30 seconds, - may last less than 30 seconds, but no more than 24 hours with but no more than 24 hours with complete resolution of complete resolution of symptomssymptoms


Stages of developmentStages of development

b. Stroke in evolutionb. Stroke in evolution- progressive development of stroke progressive development of stroke

symptoms over a period of hours to symptoms over a period of hours to daysdays

c. completed strokec. completed stroke

- neurologic deficit remains unchanged - neurologic deficit remains unchanged for a 2-to-3-day periodfor a 2-to-3-day period


Assessment findings Headache Generalized signs – vomiting,

seizures, confusion, disorientation, decreased LOC, nuchal rigidity, fever, hypertension, slow bounding pulse, Cheyne-Stokes respirations

Focal signs ( related to site of infarction) – hemiplegia, sensory loss, aphasia, homonymous hemianopsia


Assessment findings

CT and brain scan reveal lesion

EEG – abnormal changes

Cerebral arteriography – may show occlusion or malformation of blood vessels


Nursing Interventions acute Nursing Interventions acute stagestage

Maintain patent airway and adequate Maintain patent airway and adequate ventilationventilation

Provide complete bed rest as orderedProvide complete bed rest as ordered nasogastric tube feedings if client nasogastric tube feedings if client

unable to swallowunable to swallow c. fluid restriction as ordered to c. fluid restriction as ordered to

decrease cerebral edemadecrease cerebral edema


Nursing Interventions acute stageNursing Interventions acute stage

head of bed may be elevated 30- 45 degrees to head of bed may be elevated 30- 45 degrees to decrease ICPdecrease ICP

turn and reposition every 2 hours (only 20 minutes on turn and reposition every 2 hours (only 20 minutes on the affected side)the affected side)

passive ROM exercises every 4 hourspassive ROM exercises every 4 hours administer stool softeners and suppositories as administer stool softeners and suppositories as

ordered to prevent constipation and fecal impactionordered to prevent constipation and fecal impaction Establish a means of communicating with the clientEstablish a means of communicating with the client


Nursing Interventions acute stage

Administer medications as ordered

a. hyperosmotic agents, corticosteroids to decrease cerebral edema

b. anticonvulsants to prevent or treat seizures

c. anticoagulants for stroke in evolution or embolic stroke


Nursing Interventions Nursing Interventions acute stageacute stage

HeparinHeparin

warfarin (Coumadin) for long-term therapywarfarin (Coumadin) for long-term therapy

aspirin and dipyrimadole (Persantine) to aspirin and dipyrimadole (Persantine) to inhibit platelet aggregation in treating TIAsinhibit platelet aggregation in treating TIAs

Antihypertensives if indicated for elevated Antihypertensives if indicated for elevated blood pressureblood pressure


Nursing Interventions – Nursing Interventions – rehabilitationrehabilitation

Hemiplegia Hemiplegia

– – results form injury to cells in the results form injury to cells in the cerebral motor cortex or to cerebral motor cortex or to corticospinal tracts (causes corticospinal tracts (causes contralateral hemiplegia since tracts contralateral hemiplegia since tracts cross in medulla)cross in medulla)


Hemiplegia Hemiplegia

turn every two hours turn every two hours use proper positioning and use proper positioning and

repositioning to prevent deformities repositioning to prevent deformities support paralyzed arm on pillow or support paralyzed arm on pillow or

use sling while out of bed to prevent use sling while out of bed to prevent subluxation of shouldersubluxation of shoulder

elevate extremities to prevent elevate extremities to prevent dependent edemadependent edema

provide active and passive ROM provide active and passive ROM exercises every 4 hoursexercises every 4 hours


Susceptibility to hazardsSusceptibility to hazards

keep side rails up at all timeskeep side rails up at all times

institute safety measuresinstitute safety measures

inspect body parts frequently for inspect body parts frequently for signs of injurysigns of injury


DysphagiaDysphagia

check gag reflex before feeding check gag reflex before feeding clientclient

place food in unaffected side of place food in unaffected side of mouthmouth

offer soft foodsoffer soft foods


Homonymous hemianopsiaHomonymous hemianopsia

– – loss of half of each visual fieldloss of half of each visual field

approach client on unaffected sideapproach client on unaffected side place personal belongings, food, etc., place personal belongings, food, etc.,

on unaffected sideon unaffected side gradually teach client ,top compensate gradually teach client ,top compensate

by scanning ( turning the head to see by scanning ( turning the head to see things on affected side)things on affected side)


Emotional lability

create a quiet, restful environment with a reduction in excessive sensory stimuli

maintain a calm, nonthreatening manner

explain to family that the client’s behavior is not purposeful


Aphasia

a. receptive aphasia 1) give simple, slow directions 2) give one command at a time; gradually shift

topics 3) use nonverbal techniques of communication

(pantomime, demonstration) b. expressive aphasia 1) listen and watch very carefully when the client

attempts to speak 2) anticipate client’s needs to decrease frustration

and feelings of helplessness 3) allow sufficient time for client to answer


Sensory/ perceptual deficits characterized by impulsiveness, unawareness

of disabilities, visual neglect (neglect of affected side and visual space on affected side)

a. assist with self-careb. provide safety measuresc. initially arrange objects in environment on

unaffected sided. gradually teach client to take care of the

affected side and to turn frequently and look at affected side


ApraxiaApraxia

loss of ability to perform purposeful, loss of ability to perform purposeful, skilled actsskilled acts

a.a. guide client through intended guide client through intended movement (take object such as movement (take object such as washcloth and guide client through washcloth and guide client through movement of washing)movement of washing)

b. keep repeating the movementb. keep repeating the movement


Left Hemiplegia Versus Left Hemiplegia Versus Right HemiplegiaRight Hemiplegia

a. Left hemiplegiaa. Left hemiplegia1) perceptual, sensory deficits; quick and 1) perceptual, sensory deficits; quick and

impulsive behaviorimpulsive behavior2) use safety measures, verbal cues, simplicity in 2) use safety measures, verbal cues, simplicity in

all areas of careall areas of care

b. Right hemiplegiab. Right hemiplegia1) speech- language deficits; slow and cautious 1) speech- language deficits; slow and cautious

behaviorbehavior2) use pantomime and demonstration2) use pantomime and demonstration


Multiple SclerosisMultiple Sclerosis

- chronic, intermittently progressive disease of the CNS, characterized by scattered patches of demyelination within the brain and spinal cord

AMERICAN DREAM REVIEW INSTIAMERICAN DREAM REVIEW INSTITUTETUTEAMERICAN DREAM REVIEW INSTITUTE



• visual disturbances: visual disturbances:

• impaired sensation impaired sensation

• euphoria or mood swingseuphoria or mood swings

• impaired motor function:impaired motor function:

• impaired cerebellar function impaired cerebellar function

• nystagmus, dysarthria, intention tremornystagmus, dysarthria, intention tremor

• bladder : retention or incontinencebladder : retention or incontinence



constipationconstipation sexual impotence in malesexual impotence in male CSF studies – increased protein and Ig CSF studies – increased protein and Ig

(immunoglobulin)(immunoglobulin) Visual evoked response (VER) determined Visual evoked response (VER) determined

by EEG – may be delayedby EEG – may be delayed CT scan – increased density of white matterCT scan – increased density of white matter MRI – shows areas of demyelinationMRI – shows areas of demyelination


Nursing InterventionsNursing Interventions muscle-stretching and strengthening exercisesmuscle-stretching and strengthening exercises assistive devices : canes, walker, rails, assistive devices : canes, walker, rails,

wheelchair as necessarywheelchair as necessary Administer medicationsAdminister medications a. for acute exacerbations : a. for acute exacerbations :

corticosteroids (ACTH [IV], prednisone) to corticosteroids (ACTH [IV], prednisone) to reduce edema at sites of demyelinizationreduce edema at sites of demyelinization

b. for spasticity : baclofen (Lioresal), b. for spasticity : baclofen (Lioresal), dantrolene (Dantrium), diazepam (Valium)dantrolene (Dantrium), diazepam (Valium)

Encourage independence in self-care activitiesEncourage independence in self-care activities



perform intermittent catheterization as perform intermittent catheterization as orderedordered

Force fluids to 3000 cc/dayForce fluids to 3000 cc/day test bath water with thermometertest bath water with thermometer avoid heating pads, hot-water bottlesavoid heating pads, hot-water bottles inspect body parts frequently for injuryinspect body parts frequently for injury make frequent position changesmake frequent position changes


Myasthenia Gravis Myasthenia Gravis

- a neuromuscular disorder in which there is a - a neuromuscular disorder in which there is a disturbance in the transmission of impulses from disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction, nerve to muscle cells at the neuromuscular junction, causing extreme muscle weaknesscausing extreme muscle weakness

- thought to be autoimmune disorder whereby - thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular postsynaptic membrane of the neuromuscular junctionjunction

- voluntary muscles are affected, especially those - voluntary muscles are affected, especially those muscles innervated by the cranial nervesmuscles innervated by the cranial nerves


Surgery (thymectomy)Surgery (thymectomy)

surgical removal of the thymus surgical removal of the thymus gland (thought to be involved in gland (thought to be involved in the production of acetylcholine the production of acetylcholine receptor antibodies)receptor antibodies)


Plasma exchange

removes circulating acetylcholine receptor antibodies

use in clients who do not respond to other types of therapy



Diplopia, dysphagiaDiplopia, dysphagia Extreme muscle weakness, Extreme muscle weakness,

increased with activity and reduced increased with activity and reduced with restwith rest

Ptosis, masklike facial expressionPtosis, masklike facial expression Weak voice, hoarsenessWeak voice, hoarseness




• Tensilon test – IV injection of Tensilon Tensilon test – IV injection of Tensilon provides spontaneous relief of provides spontaneous relief of symptoms (lasts 5-10 minutes)symptoms (lasts 5-10 minutes)

• Electromyography (EMG) – amplitude Electromyography (EMG) – amplitude of evoked potentials decrease rapidlyof evoked potentials decrease rapidly

• Presence of antiacetylcholine Presence of antiacetylcholine receptor antibodies in the serum receptor antibodies in the serum



Administer anticholinesterase drugs Administer anticholinesterase drugs as orderedas ordered

check gag reflex and swallowing check gag reflex and swallowing ability before feedingability before feeding

Monitor respiratory status Monitor respiratory status frequently : rate, depth; vital frequently : rate, depth; vital capacity; ability to deep breathe and capacity; ability to deep breathe and coughcough



Observe for signs of myathenic or cholinergic Observe for signs of myathenic or cholinergic crisiscrisis

a. Myasthenic crisisa. Myasthenic crisis1) abrupt onset of severe, generalized muscle 1) abrupt onset of severe, generalized muscle

weakness with inability to swallow, speak, or weakness with inability to swallow, speak, or maintain respirationsmaintain respirations

2) caused by undermedication, physical or 2) caused by undermedication, physical or emotional stress, infectionemotional stress, infection



b. Cholinergic crisisb. Cholinergic crisis-excessive salivation and sweating, abdominal -excessive salivation and sweating, abdominal

cramps, nausea and vomiting, diarrhea, cramps, nausea and vomiting, diarrhea, fasciculationsfasciculations

2) caused by overmedication with the 2) caused by overmedication with the cholinergic (anticholinesterase) drugscholinergic (anticholinesterase) drugs

3) symptoms worsen with Tensilon test; keep 3) symptoms worsen with Tensilon test; keep atropine sulfate and emergency equipment on atropine sulfate and emergency equipment on handhand


Nursing Care in CrisisNursing Care in Crisis maintain tracheostomy or endotracheal tube maintain tracheostomy or endotracheal tube

with mechanical ventilation as indicatedwith mechanical ventilation as indicated

administer medications as orderedadminister medications as ordereda) myasthenic crisis – increases doses of a) myasthenic crisis – increases doses of

anticholinesterase drugs as orderedanticholinesterase drugs as orderedb) cholinergic crisis – discontinue b) cholinergic crisis – discontinue

anticholinesterase drugs as ordered until the anticholinesterase drugs as ordered until the client recoversclient recovers

establish a method of communicationestablish a method of communication


Parkinson’s Disease

a progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular function; disorder of the extrapyramidal system

usually occurs in the older population


Pathophysiology

disorder causes degeneration of the dopamine-producing neurons in the substantia nigra in the midbrain

dopamine influences purposeful movement

depletion of dopamine results in degeneration of the basal ganglia






Assessment findings tremor – mainly of the upper limbs,

“pill rolling”, resting tremor; most common initial symptom

rigidity : cogwheel type bradykinesia – slowness of movement fatigue stooped posture; shuffling, propulsive

gait difficulty rising form sitting position


Assessment findings

masklike face with decreased blinking of eyes quiet, monotone speech emotional lability, depression increased salivation, drooling cramped, small handwriting autonomic symptoms – excessive sweating,

seborrhea, lacrimation, constipation; decreased sexual capacity


Nursing Interventions

1. Administer medications as ordered Levodopa (L-dopa) Carbidopa- levodopa (Sinemet) Amantadine (Symmetrel) Anticholenergic drugs Antihistamines: diphenhydramine (Benadryl) Bromocriptine (Parlodel)



Side rails on bed; rails and Side rails on bed; rails and handlebars in toilet, bathtub, handlebars in toilet, bathtub, and hallways; no scatter rugsand hallways; no scatter rugs

Hard-back or spring-loaded Hard-back or spring-loaded chair to make getting up easierchair to make getting up easier


Nursing Interventions Improve communication abilities:

instruct client to practice reading aloud, to listen to own voice, and enunciate each syllable clearly

cut food into bite-sized pieces

provide, small, frequent feedings


Trigeminal Neuralgia (Tic Douloureux)

• - disorder of cranial nerve V causing disabling and recurring attacks of severe pain along the sensory distribution of one or more branches of the trigeminal nerve



Medical management

1. anticonvulsant drugs : carbamazepine (Tegretol), phenytoin (Dilantin)

2. Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve; temporary effect, lasts 6-18 months

3. Surgery a. peripheral – avulsion of peripheral

branches of trigeminal nerve


Medical managementMedical management

1)retrogasserian rhizotomy 1)retrogasserian rhizotomy – – total severance of the trigeminal nerve total severance of the trigeminal nerve

intracranially; results in permanent intracranially; results in permanent anesthesia, numbness, heaviness, and anesthesia, numbness, heaviness, and stiffness in affected part; loss of corneal stiffness in affected part; loss of corneal reflexreflex

2) microsurgery 2) microsurgery – – uses more precise cutting and may uses more precise cutting and may

preserve facial sensation and corneal preserve facial sensation and corneal reflexreflex


Medical managementMedical management

3) percutaneous radio-frequency 3) percutaneous radio-frequency rhizotomy –thermally destroys the rhizotomy –thermally destroys the trigeminal nerve in the area of the trigeminal nerve in the area of the ganglionganglion

4) microvascular decompression of 4) microvascular decompression of trigeminal nerve trigeminal nerve

- decompresses the trigeminal nerve; - decompresses the trigeminal nerve;



sudden paroxysms of extremely sever sudden paroxysms of extremely sever shooting pain in one side of the faceshooting pain in one side of the face

attacks may be triggered by a cold breeze, attacks may be triggered by a cold breeze, foods/fluids of extreme temperature, foods/fluids of extreme temperature, toothbrushing, chewing, talking, or toothbrushing, chewing, talking, or touching the facetouching the face

During attack: twitching, grimacing, and During attack: twitching, grimacing, and frequent blinking/tearing of the eyefrequent blinking/tearing of the eye

poor eating and hygiene habitspoor eating and hygiene habits withdrawal from interactions with otherswithdrawal from interactions with others


Nursing Interventions assess characteristics of the pain including triggering factors,

trigger points, and pain management techniques administer medications as ordered; monitor response maintain room at an even, moderate temperature, free from

drafts provide small, frequent feedings of lukewarm, semiliquid, or soft

foods that are easily chewed provide the client with a soft washcloth and lukewarm water and

perform hygiene during periods when pain is decreased prepare the client for surgery if indicated


Bells’ Palsy

- disorder of cranial nerve VII resulting in the loss of ability to move the muscles on one side of the face

- complete recovery in 3-4 months in majority of clients



Assessment findings

loss of taste over anterior two-thirds of tongue on affected side

complete paralysis of one side of face loss of expression, displacement of mouth

toward unaffected side, and inability to close eyelid (all on affected side)

pain behind the ear


Nursing Interventions Nursing Interventions

• Assess facial nerve function regularlyAssess facial nerve function regularly• provide soft diet with supplementary feedings as provide soft diet with supplementary feedings as

indicatedindicated• instruct to chew on unaffected side, avoid hot instruct to chew on unaffected side, avoid hot

fluids/foods, and perform mouth care after each fluids/foods, and perform mouth care after each mealmeal

• provide special eye care to protect the corneaprovide special eye care to protect the cornea• dark glasses (cosmetic and protective reasons) or dark glasses (cosmetic and protective reasons) or

eyeshieldeyeshield• artificial tears to prevent drying of the corneaartificial tears to prevent drying of the cornea• ointment and eye patch at nightointment and eye patch at night


Guillain- Barre SyndromeGuillain- Barre Syndrome

- symmetrical, bilateral, peripheral symmetrical, bilateral, peripheral polyneuritis characterized by polyneuritis characterized by ascending paralysisascending paralysis

- cause unknown; may be an cause unknown; may be an autoimmune processautoimmune process

- precipitating factors – antecedent viral - precipitating factors – antecedent viral infection, immunizationinfection, immunization






mild sensory changes; in some clients mild sensory changes; in some clients severe misinterpretation of sensory stimuli severe misinterpretation of sensory stimuli resulting in extreme discomfortresulting in extreme discomfort

clumsiness : usually first symptomclumsiness : usually first symptom progressive motor weakness in more than progressive motor weakness in more than

one limb (classically is ascending and one limb (classically is ascending and symmetrical)symmetrical)

cranial nerve involvement (dysphagia)cranial nerve involvement (dysphagia)



• ventilatory insufficiency if paralysis ascends to respiratory muscles

• absence of deep tendon reflexes

• autonomic dysfunction

• CSF studies- increased protein

• EMG – slowed nerve conduction


Nursing Interventions Maintain adequate ventilation Check individual muscle groups every 2 hours

in acute phase to check for progression of muscle weakness

Assess cranial nerve function : check gag reflex and swallowing ability; ability to handle secretions; voice

monitor vital signs and observe for signs of autonomic dysfunction such as acute periods of hypertension fluctuating with hypotension, tachycardia, arrythmias

administer corticosteroids to suppress immune reaction as ordered


Encephalitis

– inflammation of the brain caused by virus, e.g. herpes simplex (type I) or abovirus (transmitted by mosquito or tick)

– may occur as a sequela of other diseases such as measles, mumps, chicken pox




headacheheadache fever, chills, vomitingfever, chills, vomiting signs of meningeal irritationsigns of meningeal irritation possibly seizurespossibly seizures alteration in LOCalteration in LOC



• monitor vital signs and neuro checks frequently

• provide nursing measures for increased ICP, seizures, hyperthermia if they occur

• provide nursing care for confused or unconscious client as needed


MeningitisMeningitis

- inflammation of the meninges of the brain - inflammation of the meninges of the brain and spinal cordand spinal cord

- caused by bacteria, viruses, or other - caused by bacteria, viruses, or other microorganismsmicroorganisms

- may reach CNS- may reach CNSa. via the blood, CSF, lympha. via the blood, CSF, lymphb. by direct extension from adjacent cranial b. by direct extension from adjacent cranial

structures (nasal sinuses, mastoid bone, structures (nasal sinuses, mastoid bone, ear, skull fracture)ear, skull fracture)

c. by oral or nasopharyngeal routec. by oral or nasopharyngeal route




Assessment findings

headache, photophobia, malaise, irritability chills and fever signs of meningeal irritation

a. Nuchal rigidity – stiff neck

b. Kernig’s sign – contraction or pain in the harmstring muscle when attempting to extend the leg when the hip is flexed

c. Brudzinski’s sign – flexion at the hip and knee in response to forward flexion of the neck


Assessment findings

Vomiting Possible seizures and decreasing LOC Lumbar puncture – measurement and

analysis of CSF shows increased pressure, elevated WBC and protein, decreased glucose and culture positive for specific microorganism


Nursing Interventions

Administer large doses of antibiotics IV as ordered

Provide bed rest; keep room quiet and dark if client has headache or photophobia

Monitor vital signs and neuro checks frequently


NEUROLOGICAL NEUROLOGICAL MEDICATIONSMEDICATIONS


Antimyasthenic Medications

Relieve muscle weakness associated with myasthenia gravis by blocking acetylcholine breakdown at the neuromuscular junction

Used to treat or diagnose myasthenia gravis or to distinguish cholinergic crisis


Antimyasthenic Medications

Edrophonium chloride (Tensilon, Enlon) Neostigmine bromide (Prostigmin Bromide)


Side effects: Cholinergic CrisisSide effects: Cholinergic Crisis

GI disturbancesGI disturbances Abdominal crampsAbdominal cramps Nausea, vomiting, diarrheaNausea, vomiting, diarrhea Increased salivation and tearingIncreased salivation and tearing Increased bronchial secretionsIncreased bronchial secretions SweatingSweating MiosisMiosis HypertensionHypertension



Monitor the client for signs and symptoms of Monitor the client for signs and symptoms of medication overdose (cholinergic crisis) and medication overdose (cholinergic crisis) and underdose (myasthenic crisis)underdose (myasthenic crisis)

Instruct the client to take medications on Instruct the client to take medications on time to prevent weakness, because weakness time to prevent weakness, because weakness can impair the client’s ability to breath and can impair the client’s ability to breath and swallowswallow

Instruct the client to take the medication Instruct the client to take the medication before meals for best absorptionbefore meals for best absorption


Tensilon testTensilon test

tensilon is injected by IVtensilon is injected by IV The Tensilon test can cause ventricular The Tensilon test can cause ventricular

fibrillation and cardiac arrestfibrillation and cardiac arrest Atropine sulfate is the antidote for Atropine sulfate is the antidote for

overdoseoverdose Diagnosis of myasthenia gravis: Most Diagnosis of myasthenia gravis: Most

myasthenic clients will show a marked myasthenic clients will show a marked improvement in muscle tome within 30 to improvement in muscle tome within 30 to 60 seconds after injection, and the muscle 60 seconds after injection, and the muscle improvement lasts for 4 to 5 minutesimprovement lasts for 4 to 5 minutes

Diagnosis of cholinergic crisis (overdose Diagnosis of cholinergic crisis (overdose with anticholinesterase) or myasthenic with anticholinesterase) or myasthenic crisis (undermedication)crisis (undermedication)


Tensilon testTensilon test

In cholinergic crisis, muscle tone does not In cholinergic crisis, muscle tone does not improve after the administration of improve after the administration of Tensilon, and muscle twitching may be Tensilon, and muscle twitching may be noted around the eyes and facenoted around the eyes and face

A Tensilon injection makes the client in A Tensilon injection makes the client in cholinergic crisis temporarily worse cholinergic crisis temporarily worse (negative Tensilon test)(negative Tensilon test)

A tensilon injection temporarily improves A tensilon injection temporarily improves the condition when the client is in the condition when the client is in myasthenic crisis (positive Tensilon test)myasthenic crisis (positive Tensilon test)


Antiparkinsonian Medications Antiparkinsonian Medications

restore the balance of the restore the balance of the neurotransmitters acetylcholine and neurotransmitters acetylcholine and dopamine in the central nervous system dopamine in the central nervous system (CNS), decreasing the signs and (CNS), decreasing the signs and symptoms of Parkinson’s diseasesymptoms of Parkinson’s disease


Dopaminergic medications

stimulate the dopamine receptors increase the amount of dopamine available

in the CNS or enhance neurotransmission of dopamine

Contraindicated in cardiac, renal, or psychiatric disorders

Levodopa taken with a monoamine oxidase inhibitor (MAOI) antidepressant can cause a hypertensive crisis


Medications to treat Parkinson’s Disease

Medications affecting the amount of Dopamine Amantadine (Symmetrel) Bromocriptine (Parlodel) Carbidopa-levodopa (Sinemet)Anticholinergics Benztropine mesylate (Cogentin) Biperiden hydrochloride (Akineton) Trihexyphenidyl hydrochloride (Artane)Antihistamine Diphenhydramine hydrochloride (Benadryl)


Side effects

Dyskinesia Involuntary body movements Nausea and vomiting Urinary retention Constipation Dizziness Orthostatic hypotension Confusion Mood changes Hallucinations


Implementation

Instruct the client to take the medication with food if nausea and vomiting occur

Assess for signs and symptoms of parkinsonism, such as rigidity, tremors, akinesia, and bradykinesia; a stooped forward posture; shuffling gait; and masked facies

Monitor for signs of dyskinesia Instruct the client to change positions slowly to

minimize orthostatic hypotension


Implementation

Instruct the client to avoid alcohol Inform the client that urine or perspiration

may be discolored and that this is harmless, but it may stain the clothing

When administering levodopa, instruct the client to avoid excessive vitamin B6 intake to prevent medication reactions


Anticholinergic Anticholinergic medications medications

block the cholinergic receptors in the block the cholinergic receptors in the CNS, thereby suppressing acetylcholine CNS, thereby suppressing acetylcholine activityactivity

reduce the rigidity an some of the reduce the rigidity an some of the tremors but have a minimal effect on tremors but have a minimal effect on the bradykinesiathe bradykinesia

Contraindicated in clients with Contraindicated in clients with glaucomaglaucoma


Side effectsSide effects

Blurred visionBlurred vision Dry mouth and dry secretionsDry mouth and dry secretions Increased pulse rateIncreased pulse rate ConstipationConstipation Urinary retentionUrinary retention Restlessness and confusionRestlessness and confusion PhotophobiaPhotophobia



• Assess for risk of injury• Encourage the client to avoid alcohol, smoking,

caffeine, and aspirin to decrease gastric acidity• Instruct the client to minimize dry mouth by

increasing fluid intake and by using ice chips, hard candy, or gum

• Instruct the client to use sunglasses in direct sun because of possible photophobia


Anticonvulsant MedicationsAnticonvulsant Medications

Used to depress abnormal neuronal Used to depress abnormal neuronal discharges and prevent the spread of discharges and prevent the spread of seizuresseizures


Anticonvulsant MedicationsAnticonvulsant Medications

• Phenytoin (Dilantin)Phenytoin (Dilantin)

• Carbamazepine (Tegretol)Carbamazepine (Tegretol)

• Lorazepam (Ativan)Lorazepam (Ativan)

• Valproic acid (Depakene)Valproic acid (Depakene)


Implementation for Implementation for clients on clients on anticonvulsants anticonvulsants

Initiate seizure precautionsInitiate seizure precautions Monitor urinary outputMonitor urinary output Take anticonvulsant with food to decrease GI irritation, Take anticonvulsant with food to decrease GI irritation,

but avoid milk and antacids, which impair absorptionbut avoid milk and antacids, which impair absorption Do not discontinue medicationDo not discontinue medication Urine may be a harmless pink-red pr red-brown colorUrine may be a harmless pink-red pr red-brown color Report symptoms of sore throat, bruising, and Report symptoms of sore throat, bruising, and

nosebleeds, which may indicate a blood dyscrasianosebleeds, which may indicate a blood dyscrasia


Side effectsSide effects Gingival hyperplasiaGingival hyperplasia Reddened gums that bleed easilyReddened gums that bleed easily Slurred speechSlurred speech ConfusionConfusion DepressionDepression Nausea and vomitingNausea and vomiting ConstipationConstipation HeadachesHeadaches Blood dyscrasias: decreased platelet count and decreased Blood dyscrasias: decreased platelet count and decreased

white blood cell count (WBC) countwhite blood cell count (WBC) count Elevated blood glucoseElevated blood glucose AlopeciaAlopecia HirsutismHirsutism


Implementation

When administering phenytoin, dilute in normal saline, because dextrose causes the medication to precipitate

Instruct the client about the importance of good oral hygiene and regular dental examination


Barbiturates

used for tonic-clonic seizures and acute episodes of seizures resulting from status epilepticus

Barbiturates Phenobarbital



drowsinessdizzinesshypotensionrespiratory depressiontolerance to medication


Benzodiazepines- to treat absence seizures

Diazepam (Valium) – used to treat status epilepticus, anxiety, and skeletal muscle

spasms

Clorazepate (Tranxene) – is used as adjunctive therapy for partial seizures

Side effects ataxia respiratory and cardiac depression medication tolerance and drug dependency


Benzodiazepine

Diazepam (Valium) Lorazepam (Ativan)


Central Nervous System Central Nervous System StimulantsStimulants

used to treat narcolepsy and used to treat narcolepsy and attention deficit hyperactivity attention deficit hyperactivity disordersdisorders

used to treat respiratory used to treat respiratory depressiondepression

used as adjunctive therapy for used as adjunctive therapy for exogenous obesityexogenous obesity



• irritabilityirritability• restlessnessrestlessness• tremorstremors• insomniainsomnia• heart palpitationsheart palpitations• tachycardiatachycardia• hypertensionhypertension• dry mouthdry mouth• anorexiaanorexia• weight lossweight loss• diarrhea or constipationdiarrhea or constipation• impotence impotence • dependence and tolerancedependence and tolerance



1. Monitor vital signs1. Monitor vital signs

2. Assess mental status2. Assess mental status

3. Instruct the client to take the medication 3. Instruct the client to take the medication before mealsbefore meals

4. Instruct the client to avoid foods and 4. Instruct the client to avoid foods and beverages containing caffeine to prevent beverages containing caffeine to prevent additional stimulationadditional stimulation



5. Instruct the client not to discontinue 5. Instruct the client not to discontinue the medication abruptlythe medication abruptly

6. Instruct the client to take the last 6. Instruct the client to take the last daily dose of the CNS stimulant at daily dose of the CNS stimulant at least 6 hours before bedtime to least 6 hours before bedtime to prevent insomniaprevent insomnia


Narcotic analgesics Narcotic analgesics

suppress pain impulses but can suppress suppress pain impulses but can suppress respiration and coughing by acting on the respiration and coughing by acting on the respiratory and cough center in the medulla of respiratory and cough center in the medulla of the brainstemthe brainstem


Narcotic analgesics

Codeine sulfate

effective cough suppressant at low doses

can cause constipation

Hydromorphone hydrochloride (Dilaudid)

can decrease respiration

can cause hypotension


Narcotic analgesicsNarcotic analgesics

Meperidine hydrochloride (Demerol)Meperidine hydrochloride (Demerol) used for acute pain and as a preoperative used for acute pain and as a preoperative

medicationmedication contraindicated in head injuries and contraindicated in head injuries and

increased intracranial pressure, respiratory increased intracranial pressure, respiratory disorders, hypotension, shock, severe disorders, hypotension, shock, severe hepatic and renal disease, and in clients hepatic and renal disease, and in clients taking monoamine oxidase inhibitorstaking monoamine oxidase inhibitors

should not be taken with alcohol or should not be taken with alcohol or sedative hypnotics because it may sedative hypnotics because it may increase the CNS depressionincrease the CNS depression


Meperidine Hydrochloride Meperidine Hydrochloride (Demerol)(Demerol)

Side effectsSide effects Respiratory depressionRespiratory depression HypotensionHypotension TachycardiaTachycardia DrowsinessDrowsiness ConstipationConstipation Urinary retentionUrinary retention NauseaNausea VomitingVomiting TremorsTremors


Narcotic analgesics Morphine sulfate

used for acute pain resulting from myocardial infarction (MI) or cancer, for dyspnea resulting from pulmonary edema, and as a preoperative medication

contraindicated in severe respiratory disorders, head injuries, increased intracranial pressure, severe renal disease, or seizure activity

Nalbuphine hydrochloride (Nubain) preferable for treating the pain of an MI because

it reduces the oxygen needs of the heart without reducing blood pressure


Morphine sulfate

Side effects Respiratory depression Orthostatic hypotension Urinary retention Nausea Vomiting Constipation Cough suppression Reduction in papillary size Miosis


Implementation for narcotic analgesics

Administer medications 30 to 60 minutes before painful activities

Monitor respiratory rate, and if the rate is less than 12 breaths per minute in an adult, withhold the medication unless ventilatory support is being provided

Auscultate breath sounds because narcotic analgesics suppress the cough reflex


Implementations

Have naloxone (Narcan) available for overdose

Monitor for pupil changes because pinpoint pupils indicate morphine overdose

Note rate and depth of respirations Avoid alcohol or CNS depressants because

they can cause respiratory depression


Narcotic Antagonists

used to treat respiratory depression from narcotic overdose

Implementation Auscultate breath sounds Have resuscitation equipment available do not leave the client unattended Monitor the client closely for several hours because

when the effects of the antagonist wears off, the client may again display signs of narcotic overdose


Narcotic AntagonistsNarcotic Antagonists

Naloxone hydrochloride (Narcan)Naloxone hydrochloride (Narcan)

Naltrexone (ReVia)Naltrexone (ReVia)


Osmotic Diuretics

increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water and electrolytes

used for oliguria and to prevent renal failure

used to decrease intraocular pressure in narrow-angle glaucoma

used to decrease intracranial pressure


Osmotic DiureticsOsmotic Diuretics

Mannitol (Osmitrol)Mannitol (Osmitrol)


Side effects

fluid and electrolyte imbalances pulmonary edema from the rapid shifts of

fluid nausea and vomiting tachycardia from the rapid fluid loss hyponatremia and dehydration



Monitor lungs and heart sounds for Monitor lungs and heart sounds for signs of pulmonary edemasigns of pulmonary edema

Change the client’s position slowly Change the client’s position slowly to prevent orthostatic hypotensionto prevent orthostatic hypotension

Monitor for crystallization in the Monitor for crystallization in the vial of mannitol prior to vial of mannitol prior to administering the medication; if administering the medication; if crystallization is noted, do not crystallization is noted, do not administer the medicationadminister the medication


Neurological Disorders

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