Download Nursing Management of the Adult Patient with Neurological Alterations

Nursing Management of the
Adult Patient with
Neurological Alterations
Prepared by:
Hikmet Qubeilat. RN,MSC.
Brain Needs…
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Blood flow
Glucose
Oxygen
Diagnostic Studies
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Skull and Spinal Radiology
CT (Computerized Tomography)
MRI (Magnetic Resonance Imaging)
PET (Positron Emission Tomography)
EEG (Electroencephalogram)
EMG (Electromyelogram)
Cerebral Blood Flow Studies
Neurological Assessment
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Level of Consciousness (LOC)
Pupils
Vital Signs (VS)
Neuromuscular status
Response to stimuli
Posturing
Glasgow Coma Scale (GCS)
I. Neurological Disorders
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The normal functioning of the CNS can be
affected by a number of disorders, the most
common of which are headaches, tumors,
vascular problems, infections, epilepsy, head
trauma, demyelinating diseases, and
metabolic & nutritional diseases.
Headaches
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Not always
chronic…be
careful
Classified based on characteristics of the
headache
Functional vs. Organic type
May have more than one type of headache
History & neurologic exam diagnostic keys
Pattern Tension
Migraine
Cluster
Site
Bilateral,
basilar, bandlike
Unilateral,
anterior
Unilateral,
occular
Quality
Squeezing,
constant
Throbbing
Severe
Pattern
Cycles, years
Periodic, years
Remitting,
relapsing
Duration Days, weeks,
months
Hours, days
30-90 min
Onset
Anytime
Prodrome,
starts in AM
Nocturnal
Assoc.
S&S
Stiff neck
N&V,
photo/phonophobia
ONSET: Not reliable or diagnostic
Horner
syndrome
HA: Essential History
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Onset this particular headache
Character of pain, severity and duration
Associated symptoms
Prior history, pattern
Original onset: prior testing, treatment
Other therapeutic regimens
Physical Exam
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Neurologic examination
Inspect for local infections, nuchal rigidity
Palpation for tenderness, bony swellings
Auscultation for bruits over major arteries
Organic vs. Traumatic vs. Functional:
Diagnostics
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CBC: underlying illness, anemia
Chem panel: if associated vomiting, dehydrated
CT scan: for focal neurological signs, sinus
No LP for suspected ICP; ↑ association with brain
herniation
Don’t Miss It
1. Caused by subarachnoid hemorrhage from an aneurysm or head
injury
2.“Worse headache of my life”
3. Changes in LOC, focal neurological signs
4. Highly correlated with CVA
5. Untreated, 50 % mortality
Headache Teaching Guide
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Keep a calendar/diary
Avoid triggers
Medications (purpose, side effects)
Stress reduction
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Dark quiet room, exercise, relaxation
Regular exercise
Intracranial Pressure (ICP)
Brain Components
 Skull is a rigid vault that does not expand
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It contains 3 volume components:
 Brain tissue: (80%) or 2% of TBW
 Intravascualr blood: (10%)
 CSF: (10%)
Intracranial Pressure (ICP)
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Intracranial Pressure (ICP) is the pressure exerted by
brain tissue, blood volume & cerebral spinal fluid
(CSF) within the skull.
ICV = Vbrain + Vblood + Vcsf
Normal ICP – 10 to 15 mmHg
Cerebral Perfusion Pressure (CPP)
 CPP = MAP – ICP
 Normal CPP – 70 to 100 mmHg
Normal CSF – 5 to 13 mmHg
Increased Intracranial Pressure (IICP)
fluid pressure > 15 mm Hg
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IICP is a life threatening situation that
results from an  in any or all 3 components
within the skull
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> volume of brain tissue, blood, and / or CSF
Cerebral edema: > H2O content of tissue as a result
of trauma, hemorrhage, tumor, abscess, or ischemia
Acute Coma
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Levels of consciousness diminish in stages:
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Confusion: can’t think rapidly and clearly‫التشويش‬
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Disorientation: begin to loose consciousness
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Time, place, self
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Lethargy: spontaneous speech and movement limited
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Obtundation: arousal (awakeness) is reduced
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Stupor: deep sleep or unresponsiveness
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Open eyes to vigorous or repeated stimuli
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Coma: respond to noxious stimuli only
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Light (purposeful), full coma (non-purposeful),
deep coma (no response)
Multiple Sclerosis
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is a chronic autoimmune disorder affecting
movement, sensation, and bodily functions. It is
caused by destruction of the myelin sheath
covering nerve fibres in the central nervous
system (brain and spinal cord).
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Causes:
1. Autoimmune destruction.
2. Heredity.
3. Viruses.
4. Environmental factors.
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Diagnostic Test:
1. MRI.
2. Physical examination.
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Clinical Manifestations:
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* Early:
1. Muscle weakness causing difficulty walking
2. loss of coordination or balance
3. numbness or other abnormal sensations
4. visual disturbances, including blurred or double
vision
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* Late:
1. Fatigue .
2. Muscle spasticity and stiffness
3. Tremors.
4. Paralysis .
5. pain .
6. Vertigo.
7. Speech or swallowing difficulty .
8. Loss of bowel and bladder control.
9. Sexual dysfunction .
10. Changes in cognitive ability
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Treatment:
1. Immunosuppressant drugs . These drugs include
corticosteroids such as prednisone and
methylprednisolone, the hormone
adrenocorticotropic hormone (ACTH), and
azathioprine.
2. Physiotherapy.
3. Occupational therapy.
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Parkinson's Disease
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is a progressive movement disorder marked by tremors,
rigidity, slow movements (bradykinesia), and postural
instability. It occurs when, for unknown reasons, cells in one
of the movement-control centers of the brain begin to die.
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Causes:
1. Degeneration of brain cells in the area known as the
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substantia nigra, one of the movement control centers of the
brain.
2. Drugs given for psychosis, such as haloperidol (Haldol) or
chlorpromazine (Thorazine), may cause parkinsonism.
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Clinical Manifestations
1. Tremors
2. Slow movements (bradykinesia), freezing in place during movements
(akinesia).
3. Muscle rigidity or stiffness, occurring with jerky movements
4. Postural instability or balance difficulty occurs.
5. Masked face.
6. Depression
7. Speech changes
8. Problems with sleep
9. Emotional changes10. Incontinence.
11. Constipation.
12. Handwriting changes,
13. (dementia)
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Treatment:
1. Maintain regular exercise (physical therapy, occupational therapy)
2. Provide good nutrition to maintain health.
3. Drugs that replace dopamine (levodopa)
4. If the patient is unresponsive or intolerant to pharmacotherapy, Electro
convulsive therapy is indicated.
Nursing Management
* Observe the patient's mood, cognition; organization and general well being
* Observe for features of depression,
*Suicidal precautions to be followed, if the patient exhibits any suicidal ideas
*Instruct the patients to speak slowly and clearly, and to pause and take a deep
breath at appropriate levels.
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Parkinson's Disease (cont’d)
*In dementia, environmental modification is followed
*Avoid frequent change in the environment to minimise confusion if the
memory deficit is very severe, name boards and signboards by the side of
the rooms and things will be very helpful.
*Sedatives are used if sleep related problems are noticed, when sleep hygiene
is unsuccessfully.
* Patients should not be forced into situations in which they feel ashamed of
their appearance.
*Encourage the patient to participate in moderate exercises, free-moving sports
like swimming.
*Advise the patient to organize thoughts before speaking and encourage the
client to use facial expression and gestures if possible to assist with
communication.
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Seizure Disorders & Epilepsy
Seizure:
 paroxysmal, uncontrolled electrical discharge of neurons
in the brain that interrupts normal function
Epilepsy:
 spontaneously recurring seizures caused by a chronic
underlying condition
Two major classes:
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Generalized
Partial
Depending on type, phases may include:
 Prodromal phase- signs & activity preceeding seizure
 Aural phase- sensory warning
 Ictal phase- full seizure
 Postictal phase- recovery
Aura Phase
I’m
seeing
spots
I feel very
angry!
I taste
metal!
I smell
bananas!
I’m
dizzy
!
Seizure Disorders & Epilepsy
Drug Therapy for Tonic-Clonic and Partial Seizures
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Carbamezepine/ Tegretol
Divalproex/ Depakote
Gabapentin/ Neurontin
Lamotrigine/ Lamictal
Levetiracetam/ Keppra
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Phenytoin/ Dilantin
Tiagabine/ Gabitril
Topiramate/ Topamax
Valproic Acid/ Depakene
Felbamate/ Felbatol *
Phenobarbitol**
*Felbatol has been associated with aplastic anemia
**Phenobarbitol is a barbituate
Seizure Disorders & Epilepsy:
Nursing Care
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Assure oxygen and suction equipment at bedside
Safety precautions in active stage
 Support/ protect head
 Turn to side
 Lossen constricted clothing
 Ease to floor
Time seizure, record details of seizure and postictal phase
Seizure Disorders & Epilepsy:
Nursing Care
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Patient teaching:
 importance of good seizure control using
medication as ordered
 Medical alert bracelet
 Avoid decreased sleep, increased fatigue
 Regular meals/ snacks
Seizure Disorders & Epilepsy:
Status Epilepticus
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Medical emergency
Seizure repeated continuously
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Tonic clonic: hypoxia could develop if muscle
contraction is lengthened. Also: hypoglycemia,
acidosis, hypothermia, brain damage, death
 IV administration of antiepileptics
 Maintain airway patency
Intracranial surgery
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Craniotomy:
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Opening the skull surgically to gain access to
intracranial structures
Intracranial surgery
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Burr hole
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Circular opening made in the skull by a drill
Intracranial surgery
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Craniectomy
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An excision of a portion of the skull
Intracranial surgery
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Cranioplasty
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Repair of a cranial defect by means of a plastic or
metal plate
Intracranial surgery
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Transsphenoidal
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Through the nasal sinuses to gain access to the
pituitary gland
Types of Stroke
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Ischemic: embolic or thrombotic
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blocked blood flow to the brain
Hemorrhagic: ICH, SAH, ruptured cerebral
aneurysm
TIA: This is a stroke, although symptoms
resolve within an hour
Signs and Symptoms of Stroke
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Sudden numbness or weakness of the face, arm or leg,
especially on one side of the body
Sudden confusion, trouble speaking or understanding
Sudden trouble seeing in one or both eyes
Sudden dizziness, loss of balance or coordination or
trouble walking
Sudden severe headache with no known cause
Risk Factors
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High blood pressure
Carotid artery disease
Physical inactivity
Excess alcohol intake
Atrial fibrillation
Diabetes
Heart disease
Smoking
Family history
Prior stroke/TIA
High cholesterol
Obesity
Treatment for Ischemic Stroke
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tPA=Thrombolytic agent
Document time of symptom
onset. (If awoke with
symptoms, must go by time
when last seen normal)
Immediate head CT (check
for blood)
Evaluate for tPA
administration (review
exclusion/inclusion criteria)
Treatment Cont…
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If not a tPA candidate, ASA in ED. Rectal ASA
if fails swallow eval. or if swallow eval. not
complete.
Keep NPO, until a formal swallow eval. is done.
Admit as Inpatient and perform diagnostic
testing: Carotid US, Echo, TEE, ECG
monitoring for a-fib, MRI, fasting Lipid,
Clotting disorder blood work (Antiphospholipid,
Factor V, Antithrombin III)
Rehabilitation
Hemorrhagic Stroke Treatment
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Do not give antithrombotics or
anticoagulants
Monitor and treat blood
pressure greater than 150/105
(Table 6, 2005 Guidelines
update)
NPO, until swallow eval is
completed
Anticipate Neurosurgical
consult
Possible administration of
blood products
Meningitis
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An inflammation of the meninges of the brain and spinal cord
 Bacterial
Causes:Meningococcus and pneumococcus
,Haemophilus-influenza
Organisms enter brain by:
 Blood stream
 Respiratory tract
 Pentrating wonds of skull
It is secondary to another infections such as otitismedia,
upper respiratory infection,pneumonia
 Viral (aseptic): less severe than bacterial
Clinical Presentations
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High fever, tachycardia, chills, petechial rash
headache, photophobia, stiff neck
Nausea, vomiting
papilledema (> ICP),confusion, altered LOC
Restlessness and irritability
Seizures
Brudzinski’s: passive flexion of the neck produces pain &
increased rigidity
Kernig’s: Flex hip and knee and then straighten the
knee…pain or resistance?
complication of Meningitis
Seizures
Sepsis
Cranial nerve dysfunctions
Cerebral infarction
Coma
Death
Collaborative care
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Bacterial menigitis is a medical emergency
Treatment focus on rapid diagnosis and starting IV antibiotic
therapy immediately(7-21 days)
Isolation
Antipyretics
Analgesics
Anticonvulsants
Osmotic diuretics
IV fluids
Diagnosis
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lumbar puncture :collect samples of CSF
Bacterial:
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Cloudy csf
Elevated protein level
Increased WBC
Decreased glucose level
Elevated CSF pressure
C&S OF CSF
CBC
Cultures from Blood, urine, throat, nose