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Chapter 54
Care of the Patient with a
Neurologic Disorder
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Overview of Anatomy and Physiology
• Structural divisions – 2 main
– Central nervous system (CNS)
• Brain and spinal cord
– Peripheral nervous system – 2 main
• Somatic nervous system
– Sends messages from the CNS to the skeletal muscles;
voluntary
• Autonomic nervous system
– Sends messages from the CNS to the smooth muscle, cardiac
muscle, and certain glands; involuntary
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Slide 2
Overview of Anatomy and Physiology
• Cells of the nervous system – 2 broad categories
– Category one:
• neurons – transmitter cells
– Space between each
neuron is called a synapse
– Category two:
• neuroglial or glial cells – support cells
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Slide 3
Overview of Anatomy and Physiology
– Neuron (nerve cell) : 3 Main structures
• Cell Body: contains a nucleus surrounded by
cytoplasm
• Axon: cylindric extension of the nerve cell
that conducts impulses away from the
neuron cell body
• Dendrites: branching structures that extend
from a cell body and receive impulses
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Slide 4
Overview of Anatomy and Physiology
– Neuromuscular junction: is the area of
contact between the ends of a large myelinated
nerve fiber and a fiber of skeletal muscle. The
neurotransmitters act to make sure that the
neurological impulse passes from the nerve to
the muscle.
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Slide 5
Overview of Anatomy and Physiology
Neurotransmitters: chemicals that modify or result in
the transmission of impulses between synapses
• Acetylcholine: role in nerve impulse transmission; spills into the
synapses area and speeds up transmission of the impulse. Enzyme
cholinesterase is then released to deactivate the acetylcholine once
the message or impulse has been sent.
• Norepinephrine: has an effect on maintaining arousal (awakening
from a deep sleep), dreaming, and regulation of mood (happiness or
sadness).
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Slide 6
Overview of Anatomy and Physiology
• Neurotransmitters: cont.
• Dopamine: affects motor function (gross subconscious movements
of the skeletal muscles), also plays a role in emotional response.
Parkinson’s disease there is a decrease in dopamine levels. This causes
the tremors, or involuntary, trembling muscles
• Serotonin: induces sleep, affects sensory perception, controls
temperature, and helps regulate mood
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Slide 7
Overview of Anatomy and Physiology
• Neuron coverings:
– Myelin – white, waxy, fatty material covering many nerve fibers
(axons and dendrites). Increases rate of transmission of impulses and
protects and insulates the fibers.
• Axons leaving the CNS are wrapped in layers of myelin with indentations
called Nodes of Ranvier; which further increase the rate of transmission,
because the impulse can jump from node to node.
• In the Peripheral nervous system the myelin is produced by
Schwann cells. Outer membrane of the Schwann cells gives rise to
another layer called the neurilemma. Neurilemma is a very
important layer, because it helps regenerate injured axons. This
only occurs in the peripheral nervous system. Cells damaged in
the CNS result in permanent damage (paralysis), because they do
not have neurilemma and are not able to regenerate.
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Slide 8
Figure 54-1
(A, B, from Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby. )
A, Diagram of a typical neuron. B, Myelinated axon.
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Slide 9
Overview of Anatomy and Physiology
• Central nervous system:
One of two main divisions of the
nervous system and composed of the brain and spinal cord. Cranium
protects the brain. Vertebral column protects the spinal cord
– Brain: specialized cells in the brain’s
mass of convoluted, soft, gray or white
tissue coordinate and regulate the
functions of the CNS. One of largest
organs weighing approximately 3 pounds
(6.6 kg). Divided into 4 principal parts: the
cerebrum, diencephalon, cerebellum, and
the brainstem.
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Slide 10
Overview of Anatomy and Physiology
• Cerebrum
• Largest part of the brain. Divided into Right and Left
hemispheres. Outer portion of brain
composed of gray matter and is called the
cerebral cortex. Arranged in folds call gyri,
grooves are sulci (fissures). Connecting
structure is the corpus callosum,
divides the two hemispheres into
4 lobes. Controls initiation of movement
on the opposite side of the body.
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Slide 11
Overview of Anatomy and Physiology
• Diencephalon: often called the interbrain, it lies beneath the
cerebrum. It contains the thalamus and the hypothalamus.
– Thalamus serves as a relay station for some sensory impulses while
interpreting other sensory messages such as pain, light touch, and
pressure.
– Hypothalamus lies beneath the thalamus, plays vital role in control of body
temperature, fluid balance, appetite, and certain emotions, such as fear,
pleasure, and pain.
» Both the sympathetic and
parasympathetic divisions are under
the control of the hypothalamus. The
hypothalamus influences heartbeat,
contraction and relaxation of the walls
of the blood vessels, hormone secretion,
and other vital body functions.
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Slide 12
Overview of Anatomy and Physiology
• Cerebellum: lies posterior and inferior to the cerebrum and is the
second largest portion of the brain. Contains 2 hemispheres.
Responsible for coordination of voluntary movement and
maintenance of balance, equilibrium, and muscle tone.
– Sensory messages form the semicircular
canals in the inner ear send their
messages to the cerebellum
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Slide 13
Overview of Anatomy and Physiology
– Brain stem: located at the base of the brain and contains the midbrain,
pons, and medulla oblongata
– Midbrain: forms the superior portion of the brainstem. Responsible for
motor movement, relay of impulses, and auditory and visual reflexes.
Is the origin of cranial nerves III and IV.
– Pons: connects the midbrain
to the medulla oblongata. Is the
origin of cranial nerves V through
VIII. Composed of myelinated nerve
fibers and responsible for sending
impulses to the structures that are
inferior and superior to it. Also
contains the respiratory center and
compliments the respiratory center
in the medulla.
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Slide 14
Overview of Anatomy and Physiology
• Brain Stem cont.
– Medulla oblongata: distal portion of the brainstem. Origin of cranial nerves
IX and XII. Controls heartbeat, rhythm of breathing, swallowing, coughing,
sneezing, vomiting, and hiccups (singultus). A vasomotor center regulates
the diameter of the blood vessels, which aids in the control of the blood
pressure
– Coverings of the brain and spinal cord: Brain and spinal cord are
surrounded by three protective coverings called the meninges:
1) the dura mater (the outer layer)
2) arachnoid membrane (second layer)
3) pia mater (the inner most layer) which provides oxygen and
nourishment to the nervous tissue. These layers also bathe the spinal cord and
brain in CSF
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Slide 15
Overview of Anatomy and
Physiology
• Ventricles:
4 in all, are spaces
located in the brain. The CSF, which
is clear and resembles plasma, flows
into the subarachnoid spaces around
the brain and the spinal cord and
cushions them. Contains proteins,
glucose, urea, and salts; it also
contains certain substances that
form a protective barrier that
prevents harmful substances from
entering the brain and spinal cord.
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Slide 16
Overview of Anatomy and Physiology
• Spinal cord:
is a 17”-18” cord that extends from the brainstem to
the second lumbar vertebra. 2 main functions: conducting impulses to
and from the brain and serving as a center for reflex actions. Responsible for
reflex activities, such as knee jerks. Sensory neuron sends information to the cord,
a central neuron interprets the impulse, and motoneuron sends the message back
to the
muscle or organ involved.
Thus message is sent,
interpreted, and acted
upon without traveling
to the brain
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Slide 17
Figure 54-2
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Sagittal section of the brain (note position of midbrain).
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Slide 18
Overview of Anatomy and Physiology
• Peripheral nervous system: comprises the motor nerves, sensory nerves,
and ganglia outside the brain and spinal cord.
– Spinal nerves: 31 pairs, all mixed nerves. This means
that they transmit sensory information to the spinal cord through afferent neurons and
motor information from the CNS to the various areas of the body through efferent
neurons. Spinal nerves are named according to the corresponding vertebra (e.g. C1,
C2).
– Cranial nerves: 12 pairs,
attach to the posterior surface of
the brain, mainly the brainstem.
Conduct impulses between the
head, neck, and brain, excluding
the vagus nerve (X), also serves
organs in the thoracic and
abdominal cavaties.
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Slide 19
Overview of Anatomy and Physiology
• Autonomic nervous system: controls the activities of the smooth muscle,
cardiac muscle, and all glands. Is a subdivision of the peripheral nervous system. Primary
function is to maintain internal homeostasis; EX. Maintain a normal heartbeat, constant body
temperature, and a normal respiratory rate. Has 2 divisions that are antagonistic. One slows
and one accelerates the action.
• Sympathetic nervous
system: prepares the body
for “fight or flight”
Parasympathetic
nervous system: Calms the
•
body after a crisis
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Slide 20
Figure 54-4
(From Thibodeau, G. A., Patton, K. T. Anthony’s textbook of anatomy and physiology. [18th ed.]. St. Louis: Mosby.)
Neural pathway involved in the patellar reflex.
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Slide 21
Overview of Anatomy and Physiology
• Effects of normal aging on the nervous system
– Loss of brain weight
– Loss of neurons (1% a year after age 50)
– Reduction in cerebral blood flow
– Decrease in brain metabolism and oxygen
utilization
– Decreased blood supply to spinal cord causes
decreased reflexes
– Older Adult Considerations: Neurological
Disorders List
p 1933 (5th ed) p1892 (6th ed)
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Slide 22
Overview of Anatomy and Physiology
• Prevention of neurological problems
– Avoid drug and alcohol use
– Safe use of motor vehicles
– Safe swimming practices
– Safe handling and storage of firearms
– Use of hardhats in dangerous construction areas
– Use of protective padding as needed for sports
– Preventing neurological Injuries List
p1933 (5th ed) p1892 (6th ed)
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Slide 23
Assessment of the Neurological
System
• History:
Comprehensive history essential for diagnosing neurological
disease. Be specific about symptoms experienced as well as pt. understanding.
Information from family may also be helpful.
– Symptoms/Subjective data that may be significant include:
• A) Headaches – especially those that first occur after middle age or those that
change in character; headaches that are worse in the morning or awaken a person
from a sleep are especially significant.
• B) Clumsiness or loss of function in an extremity
• C) Change in visual acuity
• D) Any new or worsened seizure activity
• E) Numbness or tingling in one or more extremities
• F) Pain in an extremity or other part of the body
• G) Personality changes or mood swings
• H) Extreme fatigue or tiredness
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Slide 24
Assessment of the Neurological
System
• Mental status: Assessment of the neurological pt’s mental
status is important and is done with every assessment. It generally
includes:
–
–
–
–
–
–
Orientation to person, place, time, and purpose
Mood and behavior
General knowledge (such as names of presidents)
Short and long term memory
Attention span
Ability to concentrate
• DOCUMENTATION: is key to determining a change.
– Nurse should vary orientation questions so pt doesn’t
memorize answers through repetition.
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Slide 25
Assessment of the Neurological
System
• Level of consciousness (LOC): is the earliest and most sensitive
indicator that something is changing. A decrease in LOC is the earliest sign of
increased intracranial pressure. LOC has 2 components, arousal and awareness.
– Wakefulness is controlled by the brainstem and most fundamental part of LOC. If pt
can open eyes to voice or to pain the wakefulness center in the brainstem is still
functioning.
– Awareness, a higher function controlled by the reticular activating system in the
brainstem, is the ability to interact with others. Has 4 parts:
• 1. Orientation – person, place, time, and purpose
• 2. Memory: Assess short-term memory; do not ask yes or no question
• 3. Calculation: example, “If you had $2 and your apple costs $1.25, how many quarters
would you get back?”
• 4. Fund a knowledge: Ask the patient to name the president and to tell you what’s on the
national news
• Restlessness, disorientation, and lethargy may be seen first.
• Table 54-2 LOC (p1934 5th ed) p1894 (6th ed)
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Slide 26
Assessment of the Neurological
System
• Glasgow coma scale: quick, practical and standardized system for
assessing the degree of consciousness impairment in the critically ill and
for predicting the duration and ultimate outcome of coma, particularly
with head injuries.
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Slide 27
Assessment of the Neurological
System
• Language and speech
– Speech is a function of the dominant hemisphere, on the left side of the brain
for all right-handed people and most left-handed people.
– Aphasia is an abnormal neurological condition in which the language function
is defective or absent due to injury of certain areas of the cerebral cortex .
– Broca’s area in
the frontal lobe responsible
for speech production
– Wernicke’s area in the
posterior part of the
temporal lobe responsible
for understanding speech
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Slide 28
Assessment of the Neurological
System
• Language and speech
– Aphasia includes all areas of language, including speech, reading,
writing, and understanding. Aphasia has been subdivided as follows:
• 1. Sensory aphasia or receptive aphasia: inability to comprehend the
spoken word or written word
• 2. Motor aphasia: inability to use symbols of speech (aka expressive
aphasia)
• 3. Global aphasia: inability to understand the spoken word or to speak
• Anomia is a form of aphasia characterized by inability to name objects.
• Dysarthria is defined as difficult, poorly articulated speech that usually
results from interference in the control over the muscles of speech caused
by damage to a central or peripheral nerve.
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Slide 29
Assessment of the Neurological
System
• Cranial nerve function:
12 pairs of nerves emerge from
the cranial cavity through openings in the skull (Table 54-1 p1932
(5th ed) p1896 (6th ed))
• Motor Function: will detect abnormalities in the
normal functioning of nerves and muscles.
– Motor status exam includes:
•
•
•
•
•
Gait and stance
Muscle tone
Coordination
Involuntary movements
Muscle stretch reflexes (push-pull)
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Slide 30
Assessment of the Neurological
System
• Motor function cont.
– Paralysis – a loss of function
– Paresis – a lesser degree of movement deficit from
partial or incomplete paralysis
– Flaccid – weak, soft, and flabby and lacking normal
muscle with absent deep tendon reflexes
– Spastic – involuntary, sudden movement or muscular
contraction with increased reflexes.
– Fasciculations – small, localized, spontaneous, and
involuntary contractions
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Slide 31
Assessment of the Neurological
System
• Sensory and perceptual status:
most difficult part
of the neurological exam. Alterations in sensation should be
assessed include: Pain, touch, temperature, and
proprioception (the sensation pertaining to spatial-position
and muscular-activity stimuli originating from within the body
or to the sensory receptors that those stimuli activate.
• Unilateral neglect – condition in which an individual is
perceptually unaware of and inattentive to oneside of the
body
• Hemianopia – characterized by defective vision or blindness
in half of the visual field.
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Slide 32
Assessment of the Neurological
System
• Blood and urine
– Culture- may rule out infection
– Drug screens – rule out use of drugs w/ lethargy or to identify specific drugs ingested.
– Arterial blood gases - used in monitoring O2 levels of the blood. Gases may be altered with
neurological diseases such as Guillain-Barre’ syndrome, in which breathing patterns are altered.
• Cerebrospinal fluid: Normally up to 10 lymphocytes/ml of spinal fluid. An increase of the
number of lymphocytes can indicate infection such as tuberculosis, meningitis or a viral
infection.
– Bacterial infections often lower the glucose level as well as the chloride levels. A culture is done to
determine the causative organism for meningitis.
– Spinal-fluid protein is elevated when degenerative diseases or a brain tumor is present.
– Blood in the spinal-fluid indicates hemorrhage from somewhere in the ventricle system.
– Protein electrophoresis eval may give evident of neurological diseases such as multiple sclerosis
(MS)
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Slide 33
Assessment of the Neurological
System
• Computed tomography (CT [aka.cat scan]): detect pathologic conditions of the
cerebrum and spinal cord using a technique of scanning without radioisotopes.
Takes 20-30 minutes w/o contrast and up to 60 minutes w/ contrast and is painless
(except with some discomfort with the injection of dye) NOTE: check allergies to
shellfish, seafood, and/or iodine.
• Brain scan: detecting pathologic conditions of the cerebrum. Uses radioactive
isotopes and a scanner. Takes about 45 - 60 minutes. (If mercury is used as the
isotope indicator, a mercurial diuretic Meralluride (aka..Mercuhydrin) is
administered several hrs before the procedure to allow a greater concentration of
the mercury to circulate to brain tissue because meralluride minimizes the uptake
of mercury by the kidneys.
– Used less often because CT’s and MRI’s give excellent results
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Slide 34
Assessment of the Neurological
System
• MRI scan: Magnetic resonance imaging
– Uses magnetic forces to image body structures
– Relevance in the nervous system as a way to detect pathologic conditions
of the cerebrum and spinal cord
– Used to detect Stroke, multiple sclerosis, tumors, trauma, herniation, and
seizure.
– Greater contrast of soft-tissue vs CT scan
– Diagnostic choice for neurological diseases
– Caution: remove watches, credit cards, and any metal from clothing and
body before entering the scanning room
– Takes about 30-60 minutes
• PET scan: Positron Emission Tomography Scan
– Uses injection of deoxyglucose with radioactive fluorine
– Gives color composite of questioned area. Shades of color give an
indication of the level of glucose metabolism
– Used for patients w/ stroke, Alzheimer’s disease, tumors, epilepsy, and
Parkinson’s disease
– Takes about 45 – 60 minutes
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Slide 35
Assessment of the Neurological
System
• Lumbar puncture
– To obtain CSF for examination, to relieve pressure, or introduce dye or
medication
– Takes about 10-15 minutes at the bedside
– Caution: sharp shooting pain down one leg may occur, caused by the needle
coming close to a nerve.
– Usually done between L4-L5 or L5-S1
– Post procedure pt lays flat for several hours. Headache may occur (opioids are
usually not helpful).
• MRA: Magnetic Resonance Angiography
– Differential signal characteristic of flowing blood to evaluate extracranial
and intracranial blood vessels.
– Provides anatomic and hemodynamic information
– With or without contrast
– Rapidly replacing cerebral angiography for use in dx CVA
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Slide 36
Laboratory and Diagnostic
Examinations
•
•
•
•
•
•
•
Electroencephalogram
Myelogram
Angiogram
Carotid duplex
Digital subtraction angiography
Electromyogram
Echoencephalogram
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Slide 37
Assessment of the Neurological
System
• Electroencephalogram (EEG)
– To provide function by measuring the electrical activity of the brain.
– Disease assessed by EEG: epilepsy, mass lesions (tumors, abscess,
hematoma), cerebrovascular lesions, and brain injury.
• Myelogram
– Used to identify lesions in the intradural or extradural compartments
of the spinal canal by observing the flow of radiopaque dye through
the subarachnoid space
– Most common use is dx of herniated or protruding intervertebral disk.
Other lesions include spinal tumors, adhesions, bony deformations,
and arteriovenous malformations.
– Water soluble iodine dyes are more often used because they are
absorbed into the bloodstream and excreted by the kidneys
– Site of puncture to be monitored for leakage of CSF
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Slide 38
Assessment of the Neurological
System
• Angiogram
– Used to visualize the cerbral arterial system by injecting radiopaque
material. For detection of arterial aneurysms, vessel anomalies,
ruptured vessels and displacement of vessels by tumors or masses
– Takes about 2-3 hours
• Carotid Duplex
– Uses ultrasound and pulsed doppler technology
– Noninvasive procedure that evaluates carotid occlusive disease
• Electromyogram
– Used to measure the contraction of a muscle in response to electrical
stimulation
– Takes about 45-60 minutes for one muscle study
• Echoencephalogram
– Uses ultrasound to depict the intracranial structures of the brain.
– Helpful in detecting ventricular dilation and major shift of midline
structures in the brain as a result of an expanding lesion.
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Slide 39
Figure 54-6
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [4th ed.]. St. Louis: Mosby.)
Position and angle of the needle when lumbar puncture is
performed.
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Slide 40
Common Disorders of the
Neurological System
• Headaches
– Common neurological complaint; has many different causes
– Etiology/pathophysiology
• Skull and brain tissues are not able to feel sensory pain
• Vascular headaches
– Migraine
» Pre-Migraine: visual field defects, unusual smells or sounds, disorientation,
paresthesias
» During Migraine: nausea, vomiting, sensitivity to light, chills, fatigue, irritability,
diaphoresis, edema
» Cause includes abnormal metabolism of serotonin, a vasoactive neurotransmitter
found in platelets and cells of the brain, plays a major role.
– Cluster
» Aka alarm clock headache : known to wake up pt in the middle of the night with
intense pain in or around the eye on one side of your head
» Pain is described as sharp, penetrating or burning.
» A cluster period generally lasts from six to 12 weeks
» Risk factors include: Gender (men) Age (late 20’s) Smoking/Alcohol use, family
history
– Hypertensive
» Elevated blood pressure cause increased pressure
• Tension headaches – caused by tension, stress, or cervical arthritis
• Traction-inflammation headaches – caused by an infection, intracranial causes,
occlusive vascular structures and temporal arthritis
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Slide 41
Common Disorders of the
Neurological System
• Headaches (continued)
– Clinical manifestations/assessment
• Head pain
• Migraine headaches
– Prodromal (early sign/symptom)
» Visual field defects, unusual smells or sounds,
disorientation, paresthesias
– During headache
» Nausea, vomiting, light sensitivity, chilliness, fatigue,
irritability, diaphoresis, edema
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Slide 42
Common Disorders of the
Neurological System
• Headaches (continued)
– Medical management/nursing interventions
• Pharmacological management
– Migraine headaches
» Aspirin, acetaminophen, ibuprofen
» Ergotamine tartrate
» Codeine; Inderal
• Dietary recommendations
– Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or
marinated foods, ripened cheese, cured sandwich meat,
caffeine, and pork
• Psychotherapy
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Slide 43
Common Disorders of the
Neurological System
• Headaches (continued)
– Medical management/nursing interventions
• Cluster headaches
– Narcotic analgesics
• Tension headaches
– Non-narcotic analgesics
• Traction-inflammatory headaches
– Treat cause
• Comfort measures
– Cold packs to forehead or base of skull
– Pressure to temporal arteries
– Dark room; limit auditory stimulation
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Slide 44
Common Disorders of the
Neurological System
• Neuropathic pain
– Etiology and pathophysiology
• May arise from several occurrences
• The pain transmission is not fully understood
– Clinical manifestations
• Ranges from mild to excruciating
• Changes in ability to carry out ADLs
– Medical management/nursing implications
• Pharmacological management
– Anticonvulsants; nonopioid analgesics; antidepressants
• Comfort measures
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Slide 45
Common Disorders of the
Neurological System
• Increased intracranial pressure
– Etiology/pathophysiology
• Increase in any content of the cranium
• Space-occupying lesions, cerebrospinal problems,
cerebral edema
– Clinical manifestations/assessment
•
•
•
•
Diplopia
Headache
Decreased level of consciousness
Pupillary signs
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Slide 46
Common Disorders of the
Neurological System
• Increased intracranial pressure (continued)
– Clinical manifestations/assessment (continued)
•
•
•
•
•
•
•
•
•
Widening pulse pressure (increased systolic/decreased diastolic)
Bradycardia (pulse less than 60)
Respiratory problems (poss. Cheyne stoking)
High, uncontrolled temperatures
Positive Babinski’s reflex (extension of the big toe while fanning the
other toes.)
Seizures
Posturing (Decorticate, Decerebrate, or both)
Vomiting
Singultus (ordinary hiccup)
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 47
Common Disorders of the
Neurological System
• Increased intracranial pressure (continued)
– Medical management/nursing interventions
• Treat cause if possible
• Pharmacological management
–
–
–
–
Corticosteroids (dexmethasone)
Antacids; histamine-receptor blockers
Anticonvulsants (dilantin, cerebyx(short-term IV or IM use))
AVOID opioids and other drugs that cause respiratory depression
• Mechanical decompression
– Craniotomy (surgical operation in which a bone flap is temporarily removed from the
skull to access the brain)
– Craniectomy (Surgical removal of a portion of the cranium)
• Internal monitoring devices
– Ventricular pressure monitoring – catheter inserted through a burr hole into the lateral
ventricle and attached to a transducer and oscilloscope to monitor ICP
– Subarachnoid screw – inserted through a burr hole in skull and attached to a transducer
and oscilloscope for continuous monitoring
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 48
Common Disorders of the
Neurological System
• Disturbances in muscle tone and motor
function
– Etiology/pathophysiology
• Damage to the nervous system causes serious problems
in mobility
– Clinical manifestations/assessment
• Flaccid or hyperreflexic muscle tone
• Clumsiness or incoordination
• Abnormal gait
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Slide 49
Common Disorders of the
Neurological System
• Disturbances in muscle tone and motor
function (continued)
– Medical management/nursing interventions
•
•
•
•
•
•
•
Muscle relaxants
Protect from falls
Assess skin integrity
Positioning
Sit up and tuck chin when eating
Encourage patient to assist with ADLs
Emotional support
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 50
Other Disorders of the Neurological
System
• Epilepsy or seizures
– Etiology/pathophysiology
• Transitory disturbance in consciousness or in motor,
sensory, or autonomic function due to sudden,
excessive, and disorderly discharges in the neurons of
the brain; results in sudden, violent, involuntary
contraction of a group of muscles
• Types: grand mal; petit mal; psychomotor;
Jacksonian-focal; myoclonic; akinetic
• Status epilepticus
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Slide 51
Other Disorders of the Neurological
System
• Epilepsy or seizures (continued)
– Clinical manifestations/assessment
• Depends on type of seizure
• Aura
• Postictal period
– Medical management/nursing interventions
• During seizure: Protect from aspiration and injury
• Anticonvulsant medications
• Surgery
– Removal of brain tissue where seizure occurs
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Slide 52
Other Disorders of the Neurological
System
• Epilepsy or seizures (continued)
– Medical management/nursing interventions
(continued)
•
•
•
•
Adequate rest
Good nutrition
Avoid alcohol
Avoid driving, operating machinery, and swimming until
seizures are controlled
• Good oral hygiene
• Medic Alert tag
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 53
Degenerative Diseases
• Multiple sclerosis
– Etiology/pathophysiology
• Degenerative neurological disorder with demyelination
of the brain stem, spinal cord, optic nerves, and
cerebrum
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Slide 54
Figure 54-13
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Pathogenesis of multiple sclerosis.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 55
Degenerative Diseases
• Multiple sclerosis (continued)
– Clinical manifestations/assessment
•
•
•
•
•
•
•
Visual problems
Urinary incontinence
Fatigue
Weakness
Incoordination
Sexual problems
Swallowing difficulties
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 56
Degenerative Diseases
• Multiple sclerosis (continued)
– Medical management/nursing interventions
• No specific treatment
• Pharmacological management
–
–
–
–
–
–
–
Adrenocorticotropic hormone (ACTH)
Steroids
Valium
Betaseron (interferon beta-1b)
Avonex (interferon beta-1a)
Pro-banthine; urecholine
Bactrim, Septra, and Macrodantin
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Slide 57
Degenerative Diseases
• Multiple sclerosis (continued)
– Medical management/nursing interventions
•
•
•
•
•
Nutrition
Skin care
Activity
Environmental controls
Patient teaching
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 58
Degenerative Diseases
• Parkinson’s disease
– Etiology/pathophysiology
• Deficiency of dopamine
– Clinical manifestations/assessment
• Muscular tremors; bradykinesia (slow movement)
• Rigidity; propulsive gait (a stooped, stiff posture with
the head and neck bent forward)
• Emotional instability
• Heat intolerance
• Decreased blinking
• “Pill-rolling” motions of fingers
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 59
Figure 54-14
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Nigrostriatal disorders produce parkinsonism.
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Slide 60
Degenerative Diseases
• Parkinson’s disease (continued)
– Medical management/nursing interventions
• Pharmacological management
–
–
–
–
–
Levodopa
Sinemet
Artane
Cogentin
Symmetrol
• Surgery – ablation of affected area vs deep brain stimulator
• Activity – posture is important, best to not use a pillow
– Should walk with hands behind back to maintain erect spine and decrease
incidence of falling
• Nutrition – malnutrition and constipation can be severe
– Need foods that are appetizing and easily chewed and swallowed
– Encourage 5-6 small meals a day
• Elimination may feel urgency and hesitancy in voiding
– Should be on a high fiber diet to help prevent chronic constipation
– Encourage fluids and take a stool softener, suppositories, prune juice, or milk
of magnesia
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Slide 61
Degenerative Diseases
• Nursing Diagnosis:
– Impaired physical mobility, related to rigidity, bradykineia, and
akinesia
– Risk for aspiration related to disease process
• Patient Teaching:
–
–
–
–
Important to take medication as prescribed
Good skin care
Proper ambulation and positioning
Proper feeding and eating technique to reduce risk of aspiration
• Prognosis
– Chronic degenerative disorder with no acute exacerbations
– If pt compliant with treatment, signs and symptoms can be managed
for a long period of time.
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Slide 62
Degenerative Diseases
• Alzheimer’s disease (AD)
– Etiology/pathophysiology
• Is a chronic, progressive, degenerative disorder
• Impaired intellectual functioning
– Common cause of dementia in the older person and affects men
and women equally.
• Chronic, progressive degeneration of the cells of the brain
• Brain changes include plaques in the cortex, neurofibrillary
tangles, and the loss of connections between cells and cell
death. Decrease in brain size
• 10% age 65 or older and 50% age 85 and older have AD
• Genetic link
• Increased plasma levels of homocysteine are associated
with a significantly increased risk of AD or dementia
• Blood homocysteine levels can be lowered by eating foods
rich in folic acid, such as fruits and green leafy vegetables.
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Slide 63
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
http://alz.org/research/video/alzheimers_videos_and_
media_identifying.asp
• Stage 1
–
–
–
–
Mild memory lapses; decreased attention span
Difficulty in using the correct word
Disinterest in surroundings and possibly depression
No impairment (normal function)
The person does not experience any memory problems. An
interview with a medical professional does not show any evidence
of symptoms of dementia.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 64
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
• Stage 2
–
–
–
–
Obvious memory lapses, especially short-term memory
Disoriented to time
Loss of personal objects
Loss of impulse control , behavioral manifestations of AD result
from changes in brain (agitation)
– Some pts develop psychotic manifestations
– Decrease in sleep
– Very mild cognitive decline (may be normal age-related changes
or earliest signs of Alzheimer's disease)
The person may feel as if he or she is having memory lapses —
forgetting familiar words or the location of everyday objects. But
no symptoms of dementia can be detected during a medical
examination or by friends, family or co-workers.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 65
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
• Stage 3
•
•
•
•
•
– Total disorientation to person, place, and time
– Apraxia ( impairment in the ability to perform purposeful acts or to
use objects properly ); visual agnosia (inability to recognize objects
by sight); dysgraphia (difficulty communicating via writing);
wandering
– Awake most of the night
Mild cognitive decline (early-stage Alzheimer's can be diagnosed in
some, but not all, individuals with these symptoms)
Friends, family or co-workers begin to notice difficulties. During a detailed
medical interview, doctors may be able to detect problems in memory or
concentration. Common stage 3 difficulties include: Noticeable problems
coming up with the right word or name
Trouble remembering names when introduced to new people
Having noticeably greater difficulty performing tasks in social or work
settings Forgetting material that one has just read
Losing or misplacing a valuable object
Increasing trouble with planning or organizing
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 66
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
– Stage 4
• Moderate cognitive decline
(Mild or early-stage Alzheimer's disease)
At this point, a careful medical interview should be able to
detect clear-cut symptoms in several areas: Forgetfulness of
recent events
• Impaired ability to perform challenging mental arithmetic —
for example, counting backward from 100 by 7s
• Greater difficulty performing complex tasks, such as planning
dinner for guests, paying bills or managing finances
• Forgetfulness about one's own personal history
• Becoming moody or withdrawn, especially in socially or
mentally challenging situations
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 67
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
– Stage 5
• Moderately severe cognitive decline
(Moderate or mid-stage Alzheimer's disease)
Gaps in memory and thinking are noticeable, and individuals begin
to need help with day-to-day activities. At this stage, those with
Alzheimer's may: Be unable to recall their own address or
telephone number or the high school or college from which they
graduated
• Become confused about where they are or what day it is
• Have trouble with less challenging mental arithmetic; such as
counting backward from 40 by subtracting 4s or from 20 by 2s
• Need help choosing proper clothing for the season or the occasion
• Still remember significant details about themselves and their
family
• Still require no assistance with eating or using the toilet
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 68
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
– Stage 6
• Severe cognitive decline
(Moderately severe or mid-stage Alzheimer's disease)
Memory continues to worsen, personality changes may take place
and individuals need extensive help with daily activities. At this
stage, individuals may:
• Lose awareness of recent experiences as well as of their
surroundings
• Remember their own name but have difficulty with their personal
history
• Distinguish familiar and unfamiliar faces but have trouble
remembering the name of a spouse or caregiver
• Need help dressing properly and may, without supervision, make
mistakes such as putting pajamas over daytime clothes or shoes
on the wrong feet
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Slide 69
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
– Stage 6 (cont)
• Experience major changes in sleep patterns — sleeping
during the day and becoming restless at night
• Need help handling details of toileting (for example, flushing
the toilet, wiping or disposing of tissue properly)
• Have increasingly frequent trouble controlling their bladder
or bowels
• Experience major personality and behavioral changes,
including suspiciousness and delusions (such as believing
that their caregiver is an impostor)or compulsive, repetitive
behavior like hand-wringing or tissue shredding
• Tend to wander or become lost
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Slide 70
Degenerative Diseases
• Alzheimer’s disease (continued)
– Clinical manifestations/assessment = 7 stages
• Stage 7 (Terminal stage)
– Severe mental and physical deterioration
– Hospice appropriate
• Very severe cognitive decline
(Severe or late-stage Alzheimer's disease)
In the final stage of this disease, individuals lose the ability
to respond to their environment, to carry on a conversation
and, eventually, to control movement. They may still say
words or phrases.
• At this stage, individuals need help with much of their daily
personal care, including eating or using the toilet. They may
also lose the ability to smile, to sit without support and to
hold their heads up. Reflexes become abnormal. Muscles
grow rigid. Swallowing impaired.
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Slide 71
Degenerative Diseases
• Alzheimer’s disease (continued)
– Assessment
• Memory loss initial sign combined w/ inability to carry
out normal activities.
• Diagnostic Tests
– No specific test for AD
• CT, EEG, MRI, and PET may be used to rule out other
pathologic conditions
• At times only confirmation is at autopsy
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Slide 72
Degenerative Diseases
• Alzheimer’s disease (continued)
– Medical management/nursing interventions
• Pharmacological management
– Agitation: Lorazepam; Haldol
– Dementia: Cognex ; Aricept (short-term benefit for mild cognitive impairment
(MCI) , slows progression by up to 3 yrs)
– Namenda used for moderate to sever (only slows symptoms not MCI)
• Nutrition
– Finger foods; frequent feedings; encourage fluids (2000 ml/day)
– Increase foods high in folic acid and vitamin B to reduce homocysteine levels
12
• Safety
– Remove burner controls at night
– Double-lock all doors and windows
– Constant supervision
– Prognosis
• NO effective treatment to stop progression
• Lifespan w/ disease 5-20 yrs; cost is approximately $19,000 annually
• Most pt die from complications related to the disease such as
pneumonia, malnutrition, or dehydration
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Slide 73
Degenerative Diseases
• Myasthenia gravis
– Etiology/pathophysiology
• Autoimmune disease of the neuromuscular junction
• Neuromuscular disorder; nerve impulses fail to pass at the myoneural
junction; causes muscular weakness
• Can occur at any age but common between ages 10 to 65. Peak in women
age 20 – 30. Women more affected than men in young but equals out at
older age
• Infants of mothers with MG may be symptomatic at birth
• 25% patient have Thymoma (cancer of the thymus)
• 80% have cellular structure of the thymus gland
– Clinical manifestations/assessment
• Ptosis (eyelid drooping); diplopia (double vision); 15% of cases confined to
the eye muscles
• Skeletal weakness; ataxia (lack of voluntary coordination of muscle
movements)
• Dysarthria (difficulty w/ speech); dysphagia (difficulty swallowing)
• Bowel and bladder incontinence
• Exacerbations may be initiated by upper respiratory infections, emotional
tension, and menstuation
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Slide 74
Degenerative Diseases
• Myasthenia gravis (continued)
– Medical management/nursing interventions
• Pharmacological management
– Anticholinesterase drugs (promote nerve impulse transmission and quite
effective of alleviating symptoms)
» Prostigmin
» Mestinon
– Corticosteroids (adjunct therapy d/t immune component)
» Imuran
» Cyclosporine
– Caution with certain drugs:
» Anesthetics, antidysrhythimics, antibiotics, quinine, antipsychotics,
barbituates, sedatives, hypnotics, opioids, tranquilizers, and thyroid
prep
– Plasmapheresis removes antibodies produced by the autoimmune
response…short term fix
– Thymectomy if thymoma is present
– Intravenous immune globulin to reduce production of acetylcholine
antibodies used only in severe relapse of MG
• May require mechanical ventilation
• Prognosis: chronic disease
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 75
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS)
– Etiology/pathophysiology
• Motor neurons in the brain stem and spinal cord
gradually degenerate
• Electrical and chemical messages originating in the
brain do not reach the muscles to activate them
• Lou Gehrig’s disease famous baseball player stricken in
early 1940’s
• Onset between ages 40-70 (2:1 men:women)
• 10% of cases is genetic defect
• Effects 5 out of every 100,000 people worldwide
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 76
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS) (continued)
– Clinical manifestations/assessment
• Weakness of the upper extremities
• Head drop due to weak neck muscles
• Muscle cramps
– Muscle contractions called fasciculations
• Dysarthria (speech difficulty)
• Dysphagia (difficulty swallowing)
– Choking easily
– Drooling
– Gagging
• Muscle wasting
– paralysis
• Compromised respiratory function
– Difficulty breathing
• Weight loss
• DOES NOT AFFECT THE SENSES (sight, smell, taste, hearing, touch)
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Slide 77
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS) (continued)
– Medical management/nursing interventions
• Diagnostics
– Medical Hx. w/ strength and endurance eval (muscle tremors ,
spasms, twitching, or loss of muscle tissue (atrophy), twitching of tongue is
common)
– Abnormal reflexes, stiffness and clumsiness
– Emotional incontinence
– Tests may be done to rule out other causes (i.e. blood, CT or MRI,
Electromyography, spinal tap, swallow studies, nerve conduction)
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Slide 78
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS) (continued)
– Medical management/nursing interventions
• NO CURE
• Rilutec (Riluzole): slows the progression of ALS and prolongs life. Helps protect
motoneurons damaged by the disease
• Baclofen or diazepam: used to control spasticity that interferes with daily activities
• Trihexyphenidyl or amitriptyline: used for people w/ problems of swallowing their
own saliva
• G-Tube placement due to choking
• Complications:
–
–
–
–
–
–
Aspiration
Loss of abilty to care for self
Lung failure (ARDS)
Pneumonia
Pressure sores
Weight loss
• Multidisciplinary ALS teams; emotional support;
– Part of the Muscular Dystrophy Foundation
» http://www.als-mda.org/?gclid=CPma4oi2vq8CFWkQNAodKC31xg
– ALS Associan
» http://www.alsa.org/
• Prognosis
– Death. Lifespan post diagnosis typically ranges 2-6 years. Approximately 25% patients live for
more than 5 years (up to 7 years)
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Slide 79
Degenerative Diseases
• Huntington’s disease
– Etiology/pathophysiology
• Like Parkinson’s disease involves the basal ganglia and the
extrapyramidal motor system
• Overactivity of the dopamine pathways
• Genetically transmitted autosomal dominant disorder that
affects both men and women of all races. Defect on
chromosome 4
– Offspring of person w/ disease has 50% chance of developing
disease
– Two forms:
• Adult-onset (most common) symptoms in mid 30s-40s
• Early-onset symptoms occur during childhood or
adolescence
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Slide 80
Degenerative Diseases
• Huntington’s disease (continued)
– Clinical manifestations/assessment
• Behavioral
–
–
–
–
–
–
Hallucinations
Irritability
Moodiness
Restlessness or fidgeting
Paranoia
psychosis
• Abnormal and excessive involuntary movements (chorea)
–
–
–
–
–
–
Facial movements, including grimaces
Head turning to shift eye position
Wild jerking of extremities face and other body parts
Slow, uncontrolled movement
Abnormal reflexes
Hesitant speech or poor enunciation
• Ataxia to immobility
– Unsteady gait
– “Prancing” and wide walk
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Slide 81
Degenerative Diseases
• Huntington’s disease (continued)
– Clinical manifestations/assessment
• Deterioration in mental functions
–
–
–
–
–
–
Dementia
Disorientation or confusion
Loss of judgment
Loss of memory
Personality changes
Speech changes
– Symptoms in children
• Rigidity
• Slow movements
• Tremors
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 82
Degenerative Diseases
• Huntington’s disease (continued)
– Medical management/nursing interventions
• Diagnostics
– CT of head may show loss of brain tissue
– MRI or PET of brain
– Genetic tests
• Treatment
– NO CURE; palliative care (treat the symptoms)
• Pharmacological management
– Antipsychotics: Dopamine blockers may reduce abnormal
behaviors (Azilect, Clozaril, Reglan, Haloperidol)
– Antidepressants (Depression and suicide common (assess for
S&S))
– Antichoreas (Amantadine & tetrabenzine: used to control extra
movements)
– Co-enzyme Q10: help slow down the course of the disease (but
not conclusive)
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Slide 83
Degenerative Diseases
• Huntington’s disease (continued)
– Medical management/nursing interventions
• Safe environment
• Emotional support
– Huntington’s Disease Society of America
» www.hdsa.org
• High-calorie diet
– As much as 4000-5000 kcal/day to maintain body weight due to involuntary
body movements
• Complications
–
–
–
–
–
–
Loss of ability to care for self
Loss of ability to interact
Injury to self or others
Increased risk for infection
Depression
death
• Prognosis
– Causes disability that gets worse overtime
– Average lifespan from onset of symptoms is 15-20 years.
– Cause of death is often infection or suicide
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Slide 84
Vascular Problems
• Stroke (cerebrovascular accident [CVA])
– Etiology/pathophysiology: Blood flow to a part of the brain stops.
Aka.. Brain attack
• Abnormal condition of the blood vessels of the brain: 2 types
– 85% thrombosis & embolism = ischemic stroke
– 15% hemorrhage = hemorrhagic stroke (weak and bursts open,
aneurysm, arteriovenous malformation)
• Results in ischemia of the brain tissue
• Most common disease of nervous system (estimated 700,000
suffer strokes each yr. and the cause of 158,000 deaths annually)
• All ages affected
– Greatest number between ages 75-85
• Residual effects vary from mild deficits to severe disabilities
– Hemiparesis (weakness or paralysis of one side of the body), inability
to walk, complete or partial dependence with ADL’s and aphasia
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 85
Figure 54-17
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Three types of stroke.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 86
Vascular Problems
• Stroke (cerebrovascular accident [CVA]) cont.
– Risk Factors
•
•
•
•
•
•
•
Atrial Fibrillation
Diabetes
Family Hx of stroke
High Cholesterol
Increasing age >65
Race (black people are more likely to die of a stroke)
Unhealthy lifestyle
–
–
–
–
–
Overweight or obese
Drinking heavily
To much fat or salt in diet
Smoking
Illegal drugs (cocaine)
• Birth control pills
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 87
Vascular Problems
• Stroke (cerebrovascular accident [CVA]) cont.
– Clinical manifestations/assessment
•
•
•
•
•
Headache
Sensory deficit
Hemiparesis; hemiplegia
Dysphasia or aphasia
*See handout page 2 Symptoms
– Diagnostics
• CT – primary test for diagnosis. Used to differentiate between
ischemic vs hemmorhagic
• CT angiography (CTA) provides visualization of vasculature
• MRI or PET used to determine extent of damage
• Doppler, CTA, or MRA may be done to assess cartoids
• post TIA may result in cerebral angiogram
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 88
Vascular Problems
• Stroke (cerebrovascular accident) (continued)
– Medical management/nursing interventions
• Hemorrhagic
– Surgery to repair damage
– May cause vasospasm (narrowing of blood vessel, decreasing perfusion)
» Occurring in 30-60% of cases post-operatively (between days 4-12).
» Mortality rate as high as 50%
» If not tx rapidly can cause cerebral ischemia or cerebral anoxia which leads to severe
mental and physical deficits or death.
• Thrombosis or embolism
– Thrombolytics (plasmnogen activator t-PA, alteplase) causes lyses of clot
» Must be administered within 3 hours of the onset of symptoms. The longer the wait
the less effective. TIME IS A FACTOR
– Heparin, Lovenox, and Coumadin (platelet inhibitors and anticoagulants
– PATIENTS MUST BE SCREENED CAREFULLY BEFORE TX BEGINS
» Recent hx. Of GI bleed, CT or MRI to rule out hemorrahagic stroke
•
•
•
•
Decadron to reduce ICP
Neurological checks at regular intervals Q8 hrs
Nutritional interventions: tube feeding may be necessary or TPN
Physical, occupational, and/or speech therapy
– Bobath approach: designed to normalize muscle tone by providing as many sensations of
normal muscle tone, posture, and movement as possible
• Support Groups
– American Stroke Association www.strokeassociation.org
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Slide 89
Vascular Problems
• Stroke (cerebrovascular accident) (continued)
– Complications
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•
•
•
•
•
•
•
•
•
Aspiration
Dementia
Falls
Loss of mobility
Loss of movement or feeling in one or more parts of the
body
Muscle spasticity
Poor nutrition
Pressure ulcers
Problems speaking and understanding (effects on Broca or
Wernike’s area of brain)
Problems thinking and/or focusing
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Slide 90
Cranial and Peripheral Nerve Disorders
• Trigeminal neuralgia
– Etiology/pathophysiology
• Degeneration of or pressure on the trigeminal nerve;
tic douloureux
• Occurs at any age
• Caused by
– Multiple Scleroisis
– Pressure on the trigeminal nerve from a swollen blood vessel or tumor
– Clinical manifestations/assessment
• Excruciating, burning facial pain, electric-like spasms that last a
few seconds or minutes
• Pain usually one side of face
• May be triggered by touch or sounds
• Can be triggered by
– Brushing teeth, chewing, drinking, eating, lightly touching the face,
shavingl
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Slide 91
Cranial and Peripheral Nerve Disorders
• Trigeminal neuralgia
– Medical management/nursing interventions
• Diagnostics:
– Blood tests
– MRI of the head
– Trigeminal reflex testing: electrical stimulation of the divisions of the trigeminal
nerve and measurement of the response with standard electromyography
apparatus. This testing is not readily available to most physicians, and its indications
and clinical utility are still unclear
• Pharmacological Management
– Anti-seizure drugs (carbamazepine (Tegratol), gabapentin, phenytoin,
valproate, and pregabalin)
– Muscle relaxants (baclofen, clonazepam)
– Tricyclic antidepressants (amitriptyline, nortriptyline)
• Surgical resection of the trigeminal nerve
– Within 24 hrs of resection of 5th nerve pt develops herpes simplex of
the lips (cold sores) heals in about a week (5-14 days)
• Avoid stimulation of face on affected side
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 92
Cranial and Peripheral Nerve Disorders
• Trigeminal neuralgia
– Medical management/nursing interventions
• Comfort measures
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–
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–
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–
–
Keep room free of drafts
Avoid walking briskly to bedside of patient
Place bed out of traffic area to prevent jarring of bed
avoid touching the patients face
Don’t urge pts to wash or shave the affected area or to comb the hair
Avoid hot or cold liquids, may trigger pain
Puree food and ensure that it is lukewarm. Suggest food be taken
through a straw
• Prognosis
– Depends on cause. Pain varies and permanent relief of pain is obtained
only by surgery
– Pain can be disruptive to lifestyle. Can be total physical and
psychological dysfunction or even suicide.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 93
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis)
– Etiology/pathophysiology
• Inflammatory process involving the facial nerve VII from the nucleus in
the brain to the periphery
• Damage to this nerve causes weakness or paralysis of these muscles
• Evidence the reactivated herpes simplex (HSV) may be involved.
Causing inflammation, edema, ischemia, and demyelination of the facial
nerve.
• Can be unilateral (one side) or bilateral (both sides)
– Causes, Incidence, and risk factors
• Affects 30,000-40,000 people in the USA
• Cause is not clear. But may be caused by other disease processes such
as:
–
–
–
–
Herpes simplex
HIV infection
Middle ear infection
Sarcoidosis - inflammation occurs in the lymph nodes, lungs, liver, eyes, skin, or
other tissues
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 94
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis)
– Clinical manifestations/assessment
• Facial numbness or stiffness
– Hard to close one eye
– Problems w/ smiling, grimacing, or making facial expressions
• Drawing sensation of the face
– Twitching
• Unilateral weakness of facial muscles
– Drooping of face
• Reduction of saliva
– Drooling
• Pain behind the ear
• Ringing in ear or other hearing loss
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 95
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis)
(continued)
– Medical management/nursing interventions
• Diagnostics
– CT scan or MRI of the head
– Electromyography (EMG) or Nerve conduction test to check nerves
that supply the muscles of the face
• Treatment
– Often no tx needed. Begins to resolve immediately but may take up
to months to get full muscle strength
– Eye drops to lubricate if needed or an eye patch when sleeping
• Pharmacological management
– Corticosteroids may reduce swelling around the facial nerve
– Antiviral medications in an attempt to fight off virus that may be
causing bell’s palsy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 96
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis) (continued)
– Medical management/nursing interventions
•
•
•
•
Electrical stimulation
Moist heat
Massage of the affected area
Facial exercises
– Prognosis
•
•
•
•
Usually resolve on own
Long term changes in taste
Spasms of muscles or eyelids
Weakness that remains in facial muscles
– Complications
• Excess drying of the eye surface, leading to eye ulcer or infections
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 97
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome
– Etiology/pathophysiology
• Inflammation and demyelination of the peripheral nervous
system
• Possibly viral or autoimmune reaction
• Most common in people of both sexes between the ages of
30-50
• Often follows a minor infection, such as lung or GI infection
• Nerve damage causes tingling, muscle weakness, and
paralysis. Guillian-Barre syndrome most often affects the
nerves’ covering (myelin sheath) and causes nerve signals to
move more slowly or not at all.
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Slide 98
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome (continued)
– Clinical manifestations/assessment
• Symptoms are progressive
• Paralysis usually starts in the lower extremities and moves
upward; may stop at any point
• Respiratory failure if intercostal muscles are affected
• May have difficulty swallowing, breathing, and speaking
• Diagnostics
–
–
–
–
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Lumbar puncture
ECG
Electroyography (EMG)
Nerve conduction velocity test
Pulmonary function tests
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 99
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome (continued)
– Medical management/nursing interventions
•
•
•
•
•
•
•
Adrenocortical steroids
Apheresis
Mechanical ventilation
Gastrostomy tube
Meticulous skin care
Range-of-motion exercises
Complications:
–
–
–
–
–
–
–
–
Respiratory failure
DVT
Increased risk of infections
Low or unstable bp
Paralysis that is permanent
Pneumonia
Skin damage
aspiration
• Prognosis: Most recover completely but can take weeks, months, or years.
30% of cases will have some residual effects
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Meningitis
– Etiology/pathophysiology
• Acute infection of the meninges
• Bacterial or aseptic
• Increased incidence in winter and fall months
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Meningitis (continued)
– Clinical manifestations/assessment
•
•
•
•
•
•
•
Headache; stiff neck
Irritability; restlessness
Malaise
Nausea and vomiting
Delirium
Elevated temperature, pulse, and respirations
Kernig’s and Brudzinski’s signs
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Meningitis (continued)
– Medical management/nursing interventions
• Pharmacological management
– Antibiotics
» Massive doses
» Multiple types
» IV or intrathecal
– Corticosteroids
– Anticonvulsants
– Antipyretics
• Dark, quiet room
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Encephalitis
– Etiology and pathophysiology
• Acute inflammation of the brain caused by a virus
– Clinical manifestations
•
•
•
•
Headache
Fever
Seizures
Change in LOC
– Medical management and nursing interventions
• Primarily supportive
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• West Nile virus
– Etiology and pathophysiology
• Principal route of infection through the bite of an
infected mosquito
– Clinical manifestations
•
•
•
•
Fever
Headache
Back pain
Myalgia
– Prevention
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Brain abscess
– Etiology and pathophysiology
• Accumulation of pus within the brain tissue
– Clinical manifestations
•
•
•
•
Headache
Fever
Drowsiness, changes in LOC
Seizures
– Medical management/nursing interventions
• Antimicrobial therapy
• Supportive care
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Acquired immunodeficiency syndrome
– Etiology and pathophysiology
• Symptoms may develop from the infection with HIV or as a
result of an associated infection
– Clinical manifestations
• AIDS dementia complex (ADC)
• Memory loss
• Global cognitive dysfunction
– Medical management/nursing interventions
• Antiviral, antifungal, antibacterial agents
• Anticonvulsants
• Safety
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Brain tumors
– Etiology/pathophysiology
• Benign or malignant
• Primary or metastatic
• May affect any area of the brain
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Brain tumors (continued)
– Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Headache
Hearing loss
Motor weakness
Ataxia
Decreased alertness and consciousness
Abnormal pupil response and/or unequal size
Seizures
Speech abnormalities
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Cranial and Peripheral Nerve Disorders
• Brain tumors (continued)
– Medical management/nursing interventions
• Surgical removal of tumor
– Craniotomy
– Intracranial endoscopy
• Radiation
• Chemotherapy
• Combination of above
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Craniocerebral trauma
– Etiology/pathophysiology
• Motor vehicle and motorcycle accidents, falls, industrial
accidents, assaults, and sports trauma
• Direct trauma: Head is directly injured
• Indirect trauma: Tension strains and shearing forces
• Open head injuries
• Closed head injuries
• Hematomas
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Craniocerebral trauma
– Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Headache
Nausea
Vomiting
Abnormal sensations
Loss of consciousness
Bleeding from ears or nose
Abnormal pupil size and/or reaction
Battle’s sign
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Craniocerebral trauma (continued)
– Medical management/nursing interventions
•
•
•
•
•
Maintain airway
Oxygen
Mannitol and dexamethasone
Analgesics
Anticonvulsants
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Spinal cord trauma
– Etiology/pathophysiology
• Automobile, motorcycle, diving, surfing, other athletic
accidents, and gunshot wounds
• Fracture of vertebra
• Complete cord injury
• Incomplete cord injury
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Figure 54-24
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and
management of clinical problems. [7th ed.]. St. Louis: Mosby.)
Mechanisms of spinal injury.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Spinal cord trauma (continued)
– Clinical manifestations/assessment
•
•
•
•
Loss of muscle function depends on level of injury
Spinal shock
Autonomic dysreflexia
Sexual dysfunction
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Trauma
• Spinal cord trauma (continued)
– Medical management/nursing interventions
• Realignment of bony column for fractures or
dislocations: Immobilization; skeletal traction
– Surgery for spinal decompression
• Methylprednisolone
• Mobility: Slowly increase sitting up
• Urinary function: Foley catheter; bladder training
– Intermittent catheterization
• Bowel program
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Nursing Process
• Nursing diagnoses
– Autonomic dysreflexia
– Communication, impaired
– Coping, compromised family
– Disuse syndrome, risk for
– Grieving
– Infection, risk for
– Knowledge, deficient
– Memory, impaired
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide
Nursing Process
• Nursing diagnoses (continued)
– Mobility, impaired physical
– Nutrition, imbalanced: less than body
requirements
– Pain, acute, chronic
– Self-care deficit
– Swallowing, impaired
– Thought process, disturbed
– Tissue perfusion (cerebral), ineffective
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide