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Timby/Smith: Introductory
Medical-Surgical Nursing, 11/e
Chapter 37: Caring for Clients With Central
and Peripheral Nervous System Disorders
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Increased Intracranial Pressure
• Pathophysiology and Etiology
– Dilation or constriction of cerebral blood vessels in
response to changes in blood pressure, blood
oxygen levels, and blood pH maintains constant
and consistent tissue perfusion.
– Causes
• Brain tumors
• Swelling or bleeding from head trauma
• Infectious and inflammatory disorders of the
brain (meningitis, encephalitis)
– Consequences: impaired cellular activity,
temporary or permanent neurologic dysfunction,
death
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Increased Intracranial Pressure—(cont.)
• Assessment Findings
– Decreasing level of consciousness (LOC)
– Stuporous, semicomatose, comatose; confusion,
restlessness, periodic disorientation
– Headache—more severe in the morning
– Cushing’s triad: a pulse rate that increases initially
but then decreases, systolic BP that rises with a
widening pulse pressure, and a respiratory rate
that is irregular
– Cheyne-Stokes respirations
– Other: vomiting, papilledema, decorticate or
decerebrate posturing
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Increased Intracranial Pressure—(cont.)
• Diagnostic Findings: skull radiography, computed
tomography (CT), magnetic resonance imaging (MRI),
lumbar puncture, cerebral angiography
• Medical Management
– Goals: maintain BP, prevent hypoxia, and ensure
cerebral perfusion
• Isotonic normal saline, lactated Ringer’s,
hypertonic (3%) saline solutions: avoid
hypotonic solutions and solutions containing
glucose because they increase ICP
• Supplemental oxygen: keep SaO2 at 95%
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Increased Intracranial Pressure—(cont.)
• Medical Management—(cont.)
– Maintain head in midline at 30° of elevation.
– Avoid hypothermia.
– Control seizures; administer diazepam (Valium)
– Sedate agitated clients: midazolam (Versed)
hyperactivity contributes to transient rises in ICP
– Indwelling catheter, nasogastric tube, stool
softener, histamine antagonist; famotidine
(Pepcid)
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Question
Which of the following nursing interventions will help
prevent further increase in ICP?
A) Encourage fluids.
B) Elevate the head of bed.
C) Provide physical therapy.
D) Reposition client frequently.
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Answer
B) Elevate the head of bed.
Rationale: Elevation of head of the bed reduces increased
cranial pressure. All of other options will increase ICP.
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Infectious and Inflammatory Disorders
of the Nervous System
Meningitis
• Pathophysiology and Etiology: inflammation of the
meninges
– Causes
• Infectious microorganisms such as bacteria
meningococci (Neisseria meningitidis) and
streptococci (Streptococcus pneumoniae)
• Viruses: herpes simplex virus, mumps virus,
enteroviruses; viral meningitis is more common
in children and older adults
• Other: fungi, parasites
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Meningitis—(cont.)
• Assessment Findings
– Headache, fever, nuchal rigidity, nausea, vomiting,
photophobia, restlessness, irritability, seizures,
opisthotonos, positive Brudzinski’s sign
• Diagnostic Tests: lumbar puncture, C&S, CT scan, blood
culture, complete blood count
• Medical Management
– Intravenous (IV) fluids and antimicrobial therapy
– Anticonvulsants: seizures
– Immunization: meningococcal meningitis (Menomune)
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Encephalitis
• Pathophysiology and Etiology: swelling of the brain
and pathologic changes in both the white and gray
matter and surrounding meninges
– Causes: vector-borne viral infections, rubeola
(measles), neurotoxic effects associated with
childhood vaccination
• Examples: St. Louis, western equine, eastern
equine, West Nile viruses
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Encephalitis—(cont.)
• Assessment Findings
– Sudden fever, severe headache, stiff neck,
vomiting, drowsiness, tremors, seizures, spastic or
flaccid paralysis, irritability, muscle weakness,
lethargy, delirium, coma, incontinence, visual
disturbances
• Diagnostic Findings
– Lumbar puncture: CSF pressure is elevated, but
fluid is clear.
– MRI and CT scan
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Encephalitis—(cont.)
• Medical Management
– Supportive; symptoms are managed with
antipyretics, anticonvulsants, anti-inflammatory
drugs, analgesics
• Nursing Management
– Monitor vital signs
– LOC
– I&O
– Bowel function
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Guillain-Barré Syndrome
• Pathophysiology and Etiology: antibodies attack the
Schwann cells that make up the insulating myelin
sheath; the affected nerves become inflamed and
edematous
– Causes: unknown, autoimmune reaction,
influenza, lupus erythematosus
• Assessment Findings: weakness, numbness, tingling in
the arms and legs, progressive weakness, paralysis
– Other: difficulty chewing, talking, and swallowing
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Guillain-Barré Syndrome—(cont.)
• Diagnostic Findings
– Lumbar puncture, electrophysiologic testings
• Medical Management
– Plasmapheresis, immune globulin (Gamimune N)
• Nursing Management
– Assess signs of respiratory distress, spirometer,
skin care, change position every 2 hours, ROM
exercises to prevent muscle atrophy
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Brain Abscess
• Pathophysiology and Etiology: infection in nearby
structures such as the middle ear, sinuses, or teeth
– Causes: intracranial surgery or head trauma;
bacterial endocarditis, bacteremia, pulmonary or
abdominal infections
• Assessment Findings: increased ICP, fever, headache,
paralysis, seizures, muscle weakness, lethargy
• Diagnostic Findings
– Laboratory tests: WBC count, lumbar puncture, CT
scan, MRI, skull radiographs
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Infectious and Inflammatory Disorders
of the Nervous System—(cont.)
Brain Abscess—(cont.)
• Medical Management
– Antimicrobial therapy, control of fever, mechanical
ventilation, IV fluids, nutritional support
– Surgical Management: craniotomy
• Nursing Management
– Assessment for altered LOC
– Assess changes in sensory and motor functions
– Signs of increased ICP; monitor vital signs
– I&O
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Neuromuscular Disorders
Multiple Sclerosis
• Pathophysiology and
Etiology
– Demyelinating
disease; causes
permanent
degeneration and
destruction of myelin
sheath
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Neuromuscular Disorders—(cont.)
Multiple Sclerosis—(cont.)
• Assessment Findings
– Blurred vision, diplopia, nystagmus, weakness,
clumsiness, and numbness and tingling of an arm or
leg; an intention tremor and slurred, hesitant speech
(scanning speech); mood swings
– Others: motor incoordination, bowel and bladder
incontinence, loss of memory, difficulty concentrating,
impaired judgment
• Diagnostic Findings
– Lumbar puncture and CSF analysis
– Electrophoresis of CSF
– CT scan and MRI
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Nursing Care Plan: Neuromuscular
Disorders
• Nursing Diagnosis: Risk for Ineffective Breathing
Pattern related to weakening of muscles for respiration
– Encourage client to deep breathe several times.
– Place client in a Fowler’s position and support the
arms.
• Nursing Diagnosis: Impaired Physical Mobility related
to diminished muscle strength and inactivity
– Provide rest between bathing, eating, and
ambulating.
– Baclofen (Lioresal) and dantrolene (Dantrium) for
muscle spasticity and rigidity
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Neuromuscular Disorders—(cont.)
Myasthenia Gravis
• Pathophysiology and Etiology
– neuromuscular disorder characterized by severe
weakness of one or more groups of skeletal
muscles; antibodies bind to and degrade
acetylcholine receptors on the surface of skeletal
muscles
• Assessment Findings
– Muscle weakness—ptosis of the eyelids, difficulty
chewing and swallowing, diplopia, voice weakness,
masklike facial expression, weakness of
extremities, respiratory system
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Neuromuscular Disorders—(cont.)
Myasthenia Gravis—(cont.)
• Diagnostic Findings
– Diagnostic confirmation is made by IV administration of
edrophonium (Tensilon)
• Relieves muscular weakness in a few seconds; the
restored muscle strength dissipates in minutes
– Acetylcholine receptor antibody titer
– Chest radiography may show an enlargement of the
thymus (thymoma).
– Electromyography: measures the electrical potential of
muscles
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Neuromuscular Disorders—(cont.)
Myasthenia Gravis—(cont.)
• Medical Management
– Administration of anticholinesterase drug;
pyridostigmine bromide (Mestinon)
– Prednisone, immunosuppressant, plasmapheresis
• Surgical management: removal of the thymus gland
• Nursing Management
– Provide periods of rest; elevate head of bed; suction
secretions; demonstrate patience and empathy to help
the client deal with his or her changes in appearance,
function, and lifestyle
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Neuromuscular Disorders—(cont.)
Amyotrophic Lateral Sclerosis (ALS)
– Also known as Lou Gehrig’s disease; a progressive
and fatal neurologic disorder
• Pathophysiology and Etiology
– Degeneration of the motor neurons of the spinal
cord and brain stem; results in muscle weakness
and wasting
• Cause: The cause of ALS is unknown.
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Neuromuscular Disorders—(cont.)
Amyotrophic Lateral Sclerosis (ALS)—(cont.)
• Assessment Findings
– Progressive muscle weakness; wasting of the
arms, legs, and trunk develop; client experiences
episodes of muscle fasciculations (twitching)
– If ALS affects the brain stem—difficulty speaking
and swallowing, periods of inappropriate laughter
and crying, respiratory failure and total paralysis
• Diagnostic Findings
– No specific diagnostic tests are available.
• Electromyography: validates weakness in
affected muscles
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Neuromuscular Disorders—(cont.)
Amyotrophic Lateral Sclerosis (ALS)—(cont.)
• Medical Management
– No specific treatment and death occurs several
years after diagnosis
– Treated with riluzole (Rilutek), which slows the
progression of ALS and delays the need for a
tracheostomy
• Nursing Management
– Assistance with ADLs in beginning stages and total
dependence on staff and family for ADLs in later
stages
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Cranial Nerve Disorders
Trigeminal Neuralgia (Tic Douloureux)
• Pathophysiology and Etiology
– Involves the fifth (V) cranial nerve (the trigeminal
nerve), which has three major branches:
mandibular, maxillary, ophthalmic
– This sensory and motor nerve is important to
chewing, facial movement, and sensation.
• Cause: unknown; related to compression of the
trigeminal nerve root
• Assessment Findings: sudden, severe, and burning
pain
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Cranial Nerve Disorders—(cont.)
Trigeminal Neuralgia (Tic Douloureux)—(cont.)
• Diagnostic Findings
– Skull radiography, MRI, CT scan
• Surgical Management
– If medical management is unsatisfactory, surgical
division of the sensory root of the trigeminal nerve
provides permanent relief.
• Nursing Management
– Identify the location, pattern, and events
associated with pain.
– Inspect the oral cavity for signs of injury.
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Cranial Nerve Disorders—(cont.)
Bell’s Palsy
• Pathophysiology and Etiology
– Inflammation occurs around one of the paired
facial nerves, blocking motor impulses to muscles
on one side of the face
– Cause: unknown; viral link is suspected
• Assessment Findings: facial pain, pain behind the ear,
numbness, diminished blink reflex, ptosis of the
eyelid, tearing on the affected side occur
• Diagnostic Findings
– Based on symptoms and visual examination of the
face
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Cranial Nerve Disorders—(cont.)
Bell’s Palsy—(cont.)
• Medical Management
– Corticosteroid therapy combined with an antiviral
acyclovir (Zovirax) to inhibit viral replication and
shorten the duration of symptoms
– Analgesics prescribed for pain
• Nursing Management
– Obtain the client’s history; viral infection
– Perform a physical examination to determine which side
of the face is involved.
– Assess for speech impairment and observe the client's
ability to chew and swallow food.
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Extrapyramidal Disorders
Parkinson’s Disease
• Pathophysiology and Etiology
– Deficiency of the neurotransmitter dopamine
• Causes: unknown; exposure to environmental
toxins such as insecticides, herbicides, selfadministration of an illegal synthetic form of
heroin known as MPTP
• Others: sequelae of head injuries and
encephalitis
• Phenothiazines (category of antipsychotic
drugs)
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Extrapyramidal Disorders—(cont.)
Parkinson’s Disease—(cont.)
• Assessment Findings
– Stiffness (rigidity)
– Tremors: pill rolling
– Bradykinesia
– Masklike expression
– Stooped posture
– Hypophonia (low volume
of speech)
– Shuffling gait; difficulty
redirecting forward
motion
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Extrapyramidal Disorders—(cont.)
Parkinson’s Disease—(cont.)
• Diagnostic Findings: based on typical symptoms and
neurologic examination; no specific tests
• Medical Management
– Drug therapy goal: prolong independence;
selegiline (Eldepryl), levodopa (Larodopa)
– Physical therapy, occupational therapy, client and
family education; nutritional counseling
• Surgical Management
– Stereotaxic pallidotomy, deep brain stimulation
(DBS), gene therapy, glial cell–derived
neurotrophic factor (GDNF)
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Nursing Care Plan: Extrapyramidal
Disorders
• Nursing Diagnosis: Impaired Physical Mobility and SelfCare Deficit related to muscular rigidity, tremors, and
dementia
– Assist with ambulation.
– Minimize fatigue; provide rest periods.
• Nursing Diagnosis: Impaired Verbal Communication
related to inability to articulate words
– Anticipate client needs.
– Reduce environmental noise.
– Ask client to speak slowly.
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Question
Which nursing interventions can help prevent fall in a client
with Parkinson’s disease? Select all that apply.
A) Keep the client’s call light within reach.
B) Apply a soft vest restraint when the client is in bed.
C) Avoid use of throw rugs.
D) Maintain the client’s bed in a low position.
E) Provide a cane or walker for ambulation.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
A) Keep the client’s call light within reach.
C) Avoid use of throw rugs.
D) Maintain the client’s bed in a low position.
E) Provide a cane or walker for ambulation.
Rationale: All are actions to prevent falls.
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Extrapyramidal Disorders—(cont.)
Huntington’s Disease
• Pathophysiology and Etiology
– Basal ganglia and portions of the cerebral cortex
degenerate
– Cause: transmitted genetically and inherited by
people of both genders
• Assessment Findings
– Mental apathy and emotional disturbances,
choreiform movements, grimacing
– Other: difficulty chewing and swallowing, speech
difficulty, intellectual decline, loss of bowel and
bladder control; severe depression can lead to
suicide
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Extrapyramidal Disorders—(cont.)
Huntington’s Disease—(cont.)
• Diagnostic Findings: positron emission tomography (PET);
genetic testing can predict which family members will
develop the disease
• Medical Management
– Tranquilizers and antiparkinson drugs relieve the
choreiform movements
– Genetic counseling before a pregnancy is advised
• Nursing Management
– Client eventually becomes totally dependent on others;
pneumonia, contractures, infections, aspiration of food
or fluids, falls, pressure ulcers are complications
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Extrapyramidal Disorders—(cont.)
Huntington’s Disease—(cont.)
• Pathophysiology and Etiology
– Brief episode of abnormal electrical activity in the brain
• Causes: high fever, electrolyte imbalances, uremia,
hypoglemia, hypoxia, brain tumor, drug abuse,
alcohol withdrawal
– Seizure Classifications
• Partial: focal seizures, complex partial seizures
• Generalized seizures: absence, myoclonic, tonicclonic
• Preictal phase, aura, status epilepticus
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Seizure Disorders
• Assessment Findings
– Client’s motor, sensory, neurologic functions are
normal except at the time of a seizure.
• Absence seizure: stares blankly, eyelids flutter,
lack of prominent movements
• Myoclonic seizure: sudden, excessive jerking
• Tonic-clonic seizure: muscle alternate between
contraction and relaxation; jerking movements
• Diagnostic Findings
– EEG, CT scan, MRI, serology, serum electrolyte
levels, EEGs
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Seizure Disorders—(cont.)
• Medical Management
– Anticonvulsant drugs: phenytoin (Dilantin),
phenobarbital, carbamazepine (Tegretol), IV
barbiturates or diazepam (Valium)
• Nursing Management
– Position client on his or her side; loosens
restrictive clothing; airway kept patent; client is
suctioned and oxygen is administered
– Documentation of the situation that proceeded the
seizure to assist in identifying any precipitating
factors or aura, duration of seizure, parts of the
body involved
– Vital signs, oxygen saturation, capillary blood
glucose level
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Brain Tumors
– Classified according to whether they are benign or
malignant, type of cells involved, and the site of
tumor
– Causes: viral infection, exposure to radiation,
head trauma, immunosuppression
• Assessment Findings: headache (most common in the
morning, becoming increasingly severe and occurs
more frequently as the tumor grows), vomiting occurs
without nausea or warning, papilledema, seizures,
speech difficulty, paralysis, double vision
• Diagnostic Findings
– CT scan, MRI, brain scan, cerebral angiography
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Brain Tumors—(cont.)
• Medical Management
– Treated by surgery, radiation therapy, chemotherapy
– Intra-arterial or intrathecal administration,
corticosteroids, osmotic diuretics, analgesics,
anticonvulsants, antibiotics
• Surgical Management: craniotomy, craniectomy,
radioisotopes, gamma-knife radiosurgery
• Nursing Management
– Support adverse effects of chemotherapy and radiation
– Teaching plan: medication regimen, appointments,
nutritional support, home care, rehabilitation, referrals
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