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Chapter 38
Care of the Patient with a
Neurological Disorder
Christensen
Kockrow, White, Broyles
5th ed
Leslie Lehmkuhl, RN 2009
1
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Slide 1
Key Terms
•
•
•
•
Agnosia: inability to recognize
familiar objects or persons. Can
be partial or total
Aneurysm: dilation of the wall of a
blood vessel usually caused by
artheriosclerosis and HTN
Aphasia: absence or impairment
of the ability to communicate
through speech, writing, or signs
because of a brain dysfunction
(damage to the cerebral cortex)
Apraxia: inability to perform
purposeful acts or to use objects
properly.
•
Ataxia: Defective muscular
coordination (e.g. balance)
•
Aura: sensation (e.g. light touch)
precedes migraine or epileptic sz.
•
Bradykinesia: extreme slowness
of movement
•
Diplopia: double vision
•
Dysarthria: Difficulty articulating
speech
•
Dysphagia: severe swallowing
difficulty
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Slide 2
Key Terms
•
Flaccid: weak soft and flabby.
Lacking normal muscle tone.
•
Nystagmus: involuntary movements of
the eye (back and forth or cyclical)
•
Glasgow Coma Scale: Assessment of
impaired consciousness (eye, motor
and verbal)
•
Paresis: partial or incomplete
paralysis
•
Global Cognitive Dysfunction :
generalized impairment of cognitive
function (e.g. intellect, awareness,
judgment)
Postictal Period: rest period that
occurs after sz
•
Proprioception: spatial positioning
(e.g. muscle, posture, position, weight)
•
Hemianopia: defective vision in ½ of
the visual field
•
•
Spastic: involuntary, sudden
movement (spasm like) or muscular
contraction
Hemiplegia: unilateral paralysis
•
Unilateral Neglect: perceptually
unaware of an inattentive to one side
of the body
•
•
Hyperreflexia: increased reflex action
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Slide 3
Structural divisions
Central nervous system (CNS)
• Brain and spinal cord
(body’s control center)
Peripheral nervous system
(PNS)
• 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
*note: a & i are vowels
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Slide 4
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Slide 6
Overview of Anatomy and
Physiology
• Cells of the nervous
system
– Neuron (fundamental
unit of the nervous
system)
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Slide 7
CELLS OF THE NERVOUS
SYSTEM
• Neurons
– Consist of three main
parts—dendrites; cell
body of neuron; and
axon
• Dendrites conduct
impulses to cell body of
neuron
• Axons conduct
impulses away from cell
body of neuron
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– Neurons classified
according to function
• Sensory (afferent)
neurons: conduct
impulses to the spinal
cord and brain
• Motor (efferent)
neurons: conduct
impulses away from
brain and spinal cord to
muscles and glands
• Interneurons: conduct
impulses from sensory
neurons to motor
neurons
Slide 8
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Slide 9
(A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby.
B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.)
A, Diagram of a typical neuron. B, Scanning electron micrograph of
a neuron. C, Myelinated axon.
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Slide 10
Myelin and nerve structure
Myelin is the layer that forms around nerves. Its purpose
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Slide 11
Cells of the Nervous System
– Neuromuscular
junction
– Neurotransmitters
– Neuron coverings
• Myelin sheath
• Schwann Cell (PNS
only)
• Acetylcholine;
norepinephrine;
dopamine; serotonin
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Slide 12
(A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby.
B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.)
A, Diagram of a typical neuron. B, Scanning electron micrograph of
a neuron. C, Myelinated axon.
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Slide 13
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Slide 14
Central Nervous System
Brain:
• Cerebrum interprets
sensory messages (e.g.
pain, light touch, pressure).
Plays a vital role in temp
regulation, fluid balance,
appetite and some
emotions. Influences the
HR & hormone secretions
• Brainstem carries all nerve
fibers between the spinal
cord and the cerebrum.
Contains the midbrain and
pons, aka bridge that
connects midbrain and
medulla
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• Cerebellum is
responsible for
coordination of
voluntary muscles,
maintenance of
balance, equilibrium,
and muscle tone.
• Spinal cord conducts
impulses to and from
the brain, serves as a
center for reflex
action
Slide 15
Brain Stem/Cranial Nerves
• Brain stem (base of the brain) contains:
– Midbrain (CN III-IV)
– pons (CN V-VIII)
– medulla oblongata (CN IX-XII)
– coverings of the brain and spinal cord;
ventricles
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Slide 16
Spinal Cord
• Spinal cord (17 to 18 inches long) is a 2 way
conductor pathway between the brain and
peripheral nervous system.
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Slide 17
Brain
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Slide 18
Figure 14-2
(From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.)
Sagittal section of the brain (note position of midbrain).
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Slide 19
Figure 14-3
(From Thibodeau, G. A., Patton, K. T. [1990]. Anthony’s textbook of anatomy and physiology. [13th ed.]. St. Louis: Mosby.)
Neural pathway involved in the patellar reflex.
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Slide 20
Peripheral Nervous System
– Spinal nerves (31)
– Cranial nerves (12)- all
CN transport impulses
between the head,
neck and brain except
the Vagus nerve which
serves organs in the
thoracic and abd
cavities.
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– Autonomic nervous
system
• Sympathetic nervous
system “flight or fight”
(face threat or run from
threat)
• Parasympathetic
nervous system
“vegetative activities”
(e.g. digestion,
defecation, urination)
Slide 21
Effects of Normal Aging on the
Nervous System
– Loss of brain weight
(1% per year p 50 y/o)
– Loss of neurons
(substantial loss p 50
y/o)
– Reduction in cerebral
blood flow
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– Decrease in brain
metabolism and
oxygen utilization
– Decreased blood
supply to spinal cord
causes decreased
reflexes
Slide 22
Aged Nervous Tissue
Aged nervous tissue
Aged nervous tissue is less able to rapidly communicate
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Slide 23
Prevention of neurological
problems
– Avoid drug and alcohol
use
– Safe use of motor
vehicles
– Safe swimming
practices
– Safe handling and
storage of firearms
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– Use of hardhats in
dangerous
construction areas
– Use of protective
padding as needed for
sports
– Cigarette smoking
decreases lung cancer
which frequently will
metabolize to the brain
Slide 24
Assessment of the Neurological
System
• History of patients
subjective C/O (do
not use leading
questions)
• Mental status
• Level of
consciousness
• Language and
speech (sensory,
motor, global aphasia)
• Cranial nerve function
• Motor function
• Sensory and
perceptual status
– Glasgow coma scale
*note a decreased LOC
is the earliest sign of
increases ICP
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Slide 30
Laboratory, Diagnostic &
Nursing Considerations
• Blood and urine
– Culture, r/o infection
– Drug screens-ingested
– Arterial blood gases
Guillain-barre
• Cerebrospinal fluidcontents see table 14-3
• Computed
tomography (CT)check for allergies to
seafood and iodine
• MRI scan- no metal
• PET scan-Alz, tumor,
Park. Non -invasive
• Lumbar puncture- lay
flat the first 8 hrs p
obtaining CSF
sample. Assess for
leakage, give
analgesic/ice for HA
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Slide 31
Intracerebellar Hemorrhage - CT
Scan
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Slide 32
MRI
MRI of the brain
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Slide 33
Lumbar Puncture (spinal tap)
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Slide 34
Figure 14-5
(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)
Position and angle of the needle when lumbar puncture is
performed.
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Slide 35
Laboratory and Diagnostic
Examinations
• Electroencephalogram
• Electromyogram (EMG)(EEG)- clean hair
muscle contraction
measurement in
• Myelogram- lay flat for 4
response to electrical
hrs+check for allergies
stimulus. No special prep
• Angiogram-allergies
• Echoencephalogram-U/S
• Carotid duplex- non
to view intracranial
invasive. U/s and doppler
structures, no spec prep
technology combined used
for TIA’s
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Slide 36
Headaches
– Etiology/pathophysiology
• Skull and brain tissues are not
able to feel sensory pain
• Vascular headaches
– Migraine
– Hypertensive
• Tension headaches
• Traction-inflammation
headaches
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– Clinical
manifestations/assessment
• Head pain
• Prescience of sinus
drainage
• Migraine headaches
– Prodromal (early
sign/symptom)
» Visual field defects,
unusual smells
(aura) or sounds,
disorientation,
paresthesias
– During headache
» Nausea, vomiting,
light sensitivity,
chilliness, fatigue,
irritability,
diaphoresis, edema
Slide 37
Headaches (cont)
– Medical
management/nursing
interventions
• Diet: limit MSG,
vinegar, chocolate,
yogurt, alcohol,
fermented or marinated
foods, ripened cheese,
cured sandwich meat,
caffeine, and pork
• Psychotherapy to help
identify areas of stress
• Medications
– Migraine headaches
» Aspirin, acetaminophen,
ibuprofen
» Ergotamine tartrate
(constricts cerebral
blood vessels thus
reducing cerebral blood
flow. Cause a decrease
in inflammation and may
reduce pain
transmission)
» Codeine; Inderal
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Slide 38
Headache
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Slide 39
Headaches (continued)
– Medical
management/nursing
interventions
• Tension headaches
– Non-narcotic
analgesics
• Cluster headaches
• Comfort measures
– Cold packs to
forehead or base of
skull
– Pressure to temporal
arteries
– Dark room; limit
auditory stimulation
– Narcotics during
attacks
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Slide 40
Headache
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Slide 41
Tension-type headache
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Slide 42
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Slide 43
Subdural hematoma
ICP
– Etiology/pathophysiology
• Increase in any content of
the cranium
• Space-occupying lesions,
cerebrospinal problems,
cerebral edema
• Usually effects one side of
the brain which eventually
effects both sides
-DX
• Usually ICP is an emergency
situation lending little time for
diagnostic tests (CT or MR
scan is sometimes used)
• Note: Lumbar puncture is
not used D/T extraction of
CSF can cause pressure
changes and poss. lead to
brain hemorrhage
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Slide 44
ICP
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Slide 45
Increased Intracranial Pressure
– S/S
• Diplopia (double vision)
• Headache
• Changes in level of
consciousness is the
earliest sign
• Monitor Glasgow Coma
Scale and be ready to
intervene, contact MD and
use measures to
decreases ICP..
• Pupillary signs change on
the same side as the
lesion and later may
become dilated and fixed.
• Widening pulse pressure
• Bradycardia
• Respiratory problems (lumbar
puncture is not used d/t poss
brain stem hernia ion)
cheynestokes.
• High, uncontrolled
temperatures
• Positive Babinski’s reflex
(great toe extends and outer
toes fan out)
• Seizures
• Posturing
• Vomiting
• Singultus (hiccup)
• Blown pupil (fixed and dilated)
unilateral eventually Bilateral
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Slide 46
Intracranial Pressure
• Pupillary changes
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Slide 47
Increased Intracranial Pressure
(continued)
– Treatment
• Treat cause if possible
• Mechanical
decompression
– Craniotomy (bone
flap removed and
later replaced)
– Craniectomy (bone
flap removed and
not replaced)
• Internal monitoring
devices
•
Elevate HOB 30-45 degrees to
promote venous return
•
Place neck in neutral position
(non-flexed or extended) to
promote venous return
• No nasal suctioning for head
injuries D/T possible CSF
leakage..
• Corticosteroids (Decadron)
reduces cerebral edema..
• Osmotic diuretics (Mannitol)
reduce fluid in brain tissue..
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Slide 48
ICP Monitoring
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Slide 49
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 50
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
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Slide 51
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
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• Status epilepticus is when
recurrent generalized
seizures occur at such
frequency that full
consciousness is not
regained between
seizures
• Generalized seizures are
tonic clonic (grand mal)or
absence(petit mal)
• Partial Seizures are
psychomotor (temporal
lobe) Jacksonian or
myoclonic
Slide 52
Grand Mal Seizure
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Slide 53
Epilepsy or seizures (continued)
– Clinical
manifestations/assessment
• Aura (grand mal,
psychomotor,
Jacksonian-focal)
• Postictal period (grand
mal, psychomotor,
Jacksonian-focal)
– Treatment/interventions
• During seizure: protect
from aspiration and injury
(turn on side to maintain
airway)
• Note onset and duration
• Remove all items which
can cause injury
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• Lower to floor if standing
• Pad side rails
• Anticonvulsant
medications (valium
common for tonic-clonic),
Dilantin, Tegretol
• If benzodiazepines are
used… monitor for vertigo,
dizziness, oversedation.
The elderly most likely
experience SE’s.
Depressed and suicidal
clients should be
monitored closely
(Broyles)
Slide 54
Treatment of Epilepsy
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Slide 55
Epilepsy or seizures (continued)
– Medical
management/nursing
interventions
(continued)
•
•
•
•
Adequate rest
Good nutrition
Avoid alcohol
Pharm. methods are
primary means of
controlling sz activity..
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• Avoid driving, operating
machinery, and
swimming until seizures
are controlled
• Good oral hygiene
(gingivitis Dailantin)
• Medical alert tag
Slide 56
HERNIATED
INTERVERTEBRAL DISK
• Major cause of chronic
back pain.
• The intervertebral disk is
cartilage cushion
between vertebrae bodies
• When the herniate or
rupture pressure on SC
or SN cause symptoms
• Symptoms include pain,
motor changes, sensory
changes, and alterations
in reflexes.
• Treatment includes bed
rest,, stress reduction and
immobility of the spine,
physical therapy, pain
relief, and surgery.
• Positioning for comfort is
lying on back with knees
flexed and a small pillow
under head, or lying on
unaffected side with
affected knee flexed..
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Slide 57
Degenerative Diseases
•
•
•
•
•
•
Multiple sclerosis
Parkinson’s
Alzheimer’s
Myasthenia Gravis
Amyotrophic Lateral Sclerosis
Huntington’s Disease
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Slide 58
Multiple Sclerosis (MS)
• Etiology/Patho
• Degenerative
neurological disorder
with demyelination of
nerve sheath disrupting
neural transmission.
• The occurance of
sclerotic (hardend)
patches replaces
myelin and disorupt
conduction of impulses.
• Onset 20-50 y/o
• Affects women more
than men
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– S/S
• Visual problemsdiplopia, scotomata
(spots before the eyes),
nystagmus (involuntary
eye movement)
• Urinary incontinence
• Fatigue
• Weakness
• Incoordination (ataxia)
• Sexual problems
(impotence in men)
• Swallowing difficulties
Slide 59
Multiple sclerosis (continued)
– Treatments
• No specific treatment
• Adrenocorticotropic
hormone (ACTH),
steroids, Valium,
Betaseron (interferon
beta-1b), Avonex
(interferon beta-1a),
Pro-banthine;
urecholine, Bactrim,
Septra, and
Macrodantin
• Condition may be exacerbated
by insomnia, infection, illness,
stress, pregnancy, trauma or
fatigue..
• Encourage pt to remain active
(avoid fatigue) with frequent
rest periods
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Slide 60
Multiple sclerosis
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Slide 61
Figure 14-13
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Pathogenesis of multiple sclerosis.
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Slide 62
Nerve supply to the pelvis
(MS)
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Slide 63
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Slide 64
Parkinson’s
Disease
– Etiology/patho
• Deficiency of dopamine
• Effects the area of the brain
that controls movement
– S/S
• Muscular tremors;
bradykinesia (beginning stages
, only mild tremor, handwriting
changes, a slight limp, or
decreased arm swing may be
evident, slow speech)
• Rigidity; propulsive gait, fall
risk
• Emotional instability
• Heat intolerance
• Decreased blinking
• “Pill-rolling” motions of fingers
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• Dysphagia (teach to tuck chin
and sit upright when eating and
thickened liquids)
• Do not rush pts with treatments,
meals or PO meds (Broyles)
• Rise slowly from bed or chair for
pts on levadopa to prevent falls..
Slide 65
Parkinsons
– Treatment (cont)
• Medications
– Levodopa
– Sinemet is a combo
drug
carbidopa/levadopa
. The carbidopa
prevents levadopa
breakdown in
peripheral
circulation.
Thereby, requiring
less levadopa
(Broyles)
– Artane
– Cogentin
– Symmetrol
Surgery
– Pallidotomy is
not a treatment.
However, it
interupts
transmission
impulses that
cause tremors.
• Therapeutic (Rx) effectiveness
can be determined by the
patients ability to ambulate,
speak, and provide self care
(Broyles)
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Slide 66
Parkinson’s (Cont)
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Slide 67
Substantia nigra and Parkinson's
disease
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Slide 68
Figure 14-14
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Nigrostriatal disorders produce parkinsonism.
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Slide 69
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Slide 70
Alzheimer’s Disease
• Alzheimer’s disease
– Etiology/pathophysiology
• Impaired intellectual
functioning
• Degeneration of the cells of
the brain
• The cells most affected are
the neurons that use the
neurotransmitter acytecholine
• Both brain size and
acytecholine decrease
• Definitive diagnosis is
determined on autopsy that
shows an increased
aluminum in the brain biopsy..
– S/S
• Early stage (do reality
orientation)
– Mild memory lapses;
decreased attention
span
• Second stage
– Obvious memory lapses
• Third stage
– Total disorientation to
person, place, and time
– Apraxia; wandering
• Terminal stage (validation
therapy)
– Severe mental and
physical deterioration
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Slide 71
Alzheimer’s disease (cont)
– Treatment:
• Medications
– Agitation: lorazepam;
Haldol
– Dementia: Cognex;
Aricept
– Nutrition
» Finger foods;
frequent
feedings;
encourage fluids:
folic acid, Vit B12
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• Safety
– Remove burner
controls at night
– Double-lock all doors
and windows
– Constant supervision
Slide 72
Myasthenia gravis
– Etiology/pathophysiology
• Acetylcholine deficiency @
the neuromuscular junction
where impulses fail to pass
which causes muscular
weakness.
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0
– S/S
• Ptosis (drooping of
eyelid); diplopia (double
vision)
• Skeletal weakness;
ataxia
• Dysarthria; dysphagia
• Bowel and bladder
incontinence
– DX
• Tensolin Test
• Ptosis
Slide 73
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Slide 74
MG (tensilon test)
Muscle fatigue
Holding your arms above your shoulders until they drop is one
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Slide 75
Myasthenia gravis (continued)
0
– Treatment
• Anticholinesterase
drugs
– Prostigmin
– Mestinon
• Corticosteroids
• May require
mechanical
ventilation
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Slide 76
Amyotrophic lateral sclerosis (ALS)
Lou Gehrig’s disease
0
– Etiology/patho
• Progressive fatal disease
caused by degeneration of
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
• Unknown etiology possibly
d/t viral immune response
or hereditary defect
• Dx made 40-70 yo
• Men affected more than
women
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– S/S
• Weakness of the upper
extremities end stages
become totally dependent
on nurse)
• Dysarthria; dysphagia
• Muscle wasting
• Compromised respiratory
function
– Treatment/interventions
• No cure
• Rilutec (Riluzole)
• Multidisciplinary ALS
teams; emotional support
• Nx Dx Self Care Deficit
R/T?
Slide 77
ALS Muscle Wasting
Muscular atrophy
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Slide 78
Huntington’s Disease
– Etiology/pathophys
• Overactivity of the
dopamine pathways
• Chronic, progressive
heredity disease..
– S/S
• Abnormal and
excessive involuntary
movements (chorea)..
• Ataxia to immobility
• Deterioration in mental
functions (dementia)..
– Treatment
• No cure; palliative
treatment
• Antipsychotics
• Antidepressants
• Antichoreas
• Safe environment
• Emotional support
• High-calorie diet
• Genetic counseling..
– Dx
fam hx,,s/s,,Dna
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Slide 79
GILLES DE LA TOURETTE’S
SYNDROME
2
• Neurological movement
disorder that also has
prominent behavioral
manifestations..
• Symptoms may include
motor tics, involuntary
repetitive movements of
the mouth, face, head, or
neck, involuntary
swearing, echolalia, or
involuntary repetition of
person’s own speech..
vocal tics or repetitive
involuntary vocalizations
that may take the form of
sniffing, grunting, throat
clearing, or coprolalia
(involuntary and
inappropriate swearing)..
• Treatment includes
medications,
psychotherapy, family
counseling, and a great
deal of emotional support.
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Slide 80
Vascular Problems
• CVA (stroke)- Usually caused by
thrombus, embolism, or hemorrhage
• TIA’s- intermittent with spontaneous
resolution of neurological deficit (unlike
strokes)
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Slide 81
Stroke (cerebrovascular accident)
– Etiology/pathophysiology
• Abnormal condition of the
blood vessels of the brain:
thrombosis; embolism;
hemorrhage
• Results in ischemia of the
brain tissue
• Note- TIA’s are
intermittent (tiny clots)
reduced blood flow to the
brain with self resolution.
Temporary interruption in
blood flow can result in
motor or sensory loss from
seconds, minutes or hours
(<24 hr)
– S/S
•
•
•
•
•
Headache
Sensory deficit
Hemiparesis; hemiplegia
Dysphasia or aphasia
Proprioception (unable to
discern position of body
part w/o looking)
• Aphasia (sensory, motor,
or global)
• Agnosia (total or partial
loss ability to recognize
familiar objects or people)
- Dx
• CT scan, MRI, LP (may show
blood which is not normal) &
PET scan
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Slide 82
Figure 14-16
HOB Flat
HOB flat
HOB elevated to decrease cerebral perfusion
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Three types of stroke.
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Slide 83
Transient Ischemic Attack (TIA)
Transient Ischemic attack (TIA)
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Slide 84
Stroke (cerebrovascular accident)
(continued)
– Treatment
• Thrombosis or embolism
– Thrombolytics
– Heparin and
Coumadin
• Decadron
• Neurological checks
• Feeding tube, or teach
chin tuck and swallow
• Physical, occupational,
and/or speech therapy
• Plan care with aphasia by
first determining the type.
Then, adapt
communication
accordingly
• Teach safety to pt and family
members
• If hemioptic approach from
unaffected side
• Teach pt to scan area affected
and check and/or prevent
injury
• Stroke preventionteach to check B/P annually,
No smoking, check cholesterol
level, reduce Na+ and fat in
diet..
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Slide 85
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 86
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 87
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 88
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Slide 89
Cranial and Peripheral Nerve
Disorders
• Trigeminal Neuralgia
• Bells Palsy
• Infection and
Inflammation
• Guillian- Barre’
Syndrome
• Meningitis
• Encephalitis
• West Nile Virus
•
•
•
•
Brain Abscess
AIDS
Intracranial Tumors
Craniocerebral
Trauma
• Spinal Cord Trauma
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Slide 90
Trigeminal Neuralgia
0
– Etiology/pathophys
• Degeneration of or
pressure on the trigeminal
nerve; tic douloureux
• CN V
• Neuroligia (nerve pain)
follows three branches
mandibular, maxuillary
and ophthalmic
• Remission and
exaserbations
– S/S
• Excruciating, burning
facial pain
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– Medical
management/nursing
interventions
• Tegretol
• Surgical resection of
the trigeminal nerve
• Avoid stimulation of
face on affected side
(e.g. drafts, shaving,
solid food, washing
face)
Slide 91
Bell’s Palsy (peripheral facial
paralysis)
0
– Etiology/pathophysiology
• Inflammatory process involving
the facial nerve VII
• No known cause however
herpes simplex has been
involved
– S/S
• Facial numbness or stiffness
• Drawing sensation of the face
• Unilateral weakness of facial
muscles
• Reduction of saliva
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
• Pain behind the ear
• Ringing in ear or other
hearing loss
– Treatment
•
•
•
•
Electrical stimulation
Moist heat
Steroids
Massage of the affected
area
• Facial exercises
Slide 92
Facial drooping
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Slide 93
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 94
Guillain-Barré Syndrome
(Polyneuritis)
– Etiology/pathophys
• Inflammation and
demyelination of the
peripheral nervous
system
• Possibly viral or
autoimmune reaction
• Antibodies attack the
schwann cells causing
breakdown of myelin
sheath
• Interrupts nerve
conduction
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– S/S
• 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
(monitor closely), and
speaking
Slide 95
Guillain-Barré Syndrome
(Polyneuritis)
– Treatment
• Adrenocortical steroids
• Apheresis (blood is withdrawn, 1 or more
components are removed, then re-infused into the
donor)
• Mechanical ventilation
• Gastrostomy tube
• Meticulous skin care
• Range-of-motion exercises
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Slide 96
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Slide 97
Meningitis
– Etiology/pathophysiology
• Acute infection of the
meninges caused by
inflammation
• Bacterial or aseptic or viral
• Dx lumbar puncture to test
CSF for causative agent..
– S/S
• Headache; stiff neck (nucchal
rigidy)
• Irritability; restlessness
• Malaise
• Nausea and vomiting
• Delirium
• Elevated temperature, pulse,
and respirations
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• Kernig’s (inability to
extend legs without pain)
and Brudzinski’s signs
– Treatment/ interventions
• Antibiotics
– Massive doses
– Multiple types
(Pcn.ampicillin)
– IV or intrathecal (2wks
followed by Po atb)
• Steroids
• Anticonvulsants
• Dark, quiet room w/
minim,al clt activity..
• Hib prevention (respiratory
isolation)
Slide 98
Meninges of the spine
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Slide 99
Haemophilus influenza organism
This is a gram stain of spinal fluid from a person
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Slide 100
Kernig's sign of meningitis
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Slide 101
Brudzinski's sign of meningitis
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Slide 102
Intracranial tumors
– Etiology/pathophysiology
• Benign or malignant
• Primary (neoplasms) or
metastatic (named where
tumor appears)
• May affect any area of the
brain
– S/S
• Headache
• Hearing loss
• Motor weakness (unable
to perform ADL’s)
• Ataxia
• Decreased alertness and
consciousness
• Abnormal pupil response
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– Treatment/ interventions
• Surgical removal of tumor
– Craniotomy (skull bone
removed, tumor
extracted, bone
replaced)
– Intracranial endoscopy
(newer method)
• Radiation
• Chemotherapy
• Combination of above
Slide 103
Trauma
• Craniocerebral Trauma
• Spinal Cord Trauma
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Slide 104
Craniocerebral Trauma
– Etiology/patho
• 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 (swelling,
containing blood)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– S/S
•
•
•
•
•
•
•
•
HA/Nausea/Vomiting
Abnormal sensations
Loss of consciousness
Bleeding from ears or
nose (CSF + Glu)
Abnormal pupil size and\or
reaction
Battle’s sign (fig. 14-21)
Decorticate: flexion of
arms, wrists and fingers w/
adduction BUE, extension,
internal rotation and
plantar flexion
Decebrate: all 4
extremities in rigid
extension, hyperpronation
of forearms and plantar
flexion
Slide 105
Craniocerebral Trauma (continued)
– Treatment/interventions
• Maintain airway
• Monitor for signs of ICP
• Teach- no coughing,
sneezing, blowing nose or
cleaning area. Allow to
wipe nose or ears gently
• Monitor ears, nose for
blood or serous drainage
(CSF + glu)
• Oxygen
• Mannitol and
dexamethasone
• Analgesics
• Anticonvulsants
• Note: craniocerebral
trauma S/S may not
occur until several days p
trauma
• Remember ABC’s in
priority care
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Slide 106
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Slide 107
Concussion
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Slide 108
Head injury
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Slide 109
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Slide 110
Spinal cord trauma
Trauma
– Etiology/pathophysiolo
gy
• Automobile, motorcycle,
diving, surfing, other
athletic accidents, and
gunshot wounds
• Fracture of vertebra
• Complete cord injury
• Incomplete cord injury
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
– S/S
• Loss of muscle function
depends on level of
injury
• Spinal shock
• Autonomic dysreflexia
(injury T6 or above,
usually caused by a
distended bladder or
fecal impaction) reflux
CV response causing
bradycardia,
diaphoresis, severe HA,
nasal stuffiness.
• Sexual dysfunction
Slide 111
Figure 14-22
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Mechanisms of spinal injury.
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Slide 112
Spinal cord injury
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Slide 113
Spinal Cord Trauma (continued)
– Treatment/ 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
• Any injury involving C1-C7
may require mechanical
ventilation
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Slide 114
Nursing Process
• Nursing diagnoses
– Autonomic dysreflexia
– Communication, impaired
– Coping, compromised family
– Disuse syndrome, risk for
– Grieving
– Infection, risk for
– Knowledge, deficient
– Memory, impaired
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Slide 115
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
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Slide 116
Glasgow Coma Scale
Eyes open
Spontaneously
(4)
To speech
(3)
To pain (2)
None (1)
Best verbal
response
Orientated (5)
Confused (4)
Inappropriate
words (3)
Incomprehensible
sounds (2)
None (1)
Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc.
Best motor response*
Obeys commands (6)
Localizes pain (5)
Withdraws to pain
(4)
Flexion (abnormal)
to pain (3)
Extension to pain (2)
none(1)
Slide 117
Brain Tumor
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Slide 118