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Nursing of Adults with Medical & Surgical Conditions Neurological Disorders.

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Presentation on theme: "Nursing of Adults with Medical & Surgical Conditions Neurological Disorders."— Presentation transcript:

1 Nursing of Adults with Medical & Surgical Conditions Neurological Disorders

2 Laboratory and Diagnostic Exams Blood and Urine –Culture Urinary tract infection –Drug screens Rule out drugs as cause of symptoms –Arterial Blood Gases Monitor the oxygen content of the blood Low levels indicate altered breathing patterns

3 Cerebrospinal Fluid –Normal Values Specific gravity: 1.007 pH:7.35 to 7.45 Chloride:120 to 130 mEq/L Glucose:50 to 75 mg/dl Pressure:80 to 200 mm water Total Volume:80 to 200 ml Total Protein:5 to 45 mg/dl Gamma globulin:6% to 13% of total protein Cell Count: –RBCNone –WBC0-10 cells (lymphocytes and monocytes)

4 Cerebrospinal Fluid (Cont) –Elevated lymphocytes may indicate infection –Decreased chloride and glucose levels may indicate tuberculosis meningitis –Culture or smear is done to determine the causative organism in meningitis –Protein is elevated with degenerative disease or brain tumors –Blood indicates hemorrhage from somewhere in the ventricular system –Protein electrophoresis may give evidence of MS

5 Computed Tomography (CT) Scan –Detects pathological conditions of the cerebrum and spinal cord –May be done with or without contrast Brain Scan –Uses radioactive isotopes MRI Scan –Uses magnetic forces to image the cerebrum and spinal cord

6 PET Scan –Positron Emission Tomography –Used following stroke, Alzheimer’s, epilepsy and Parkinson’s –Injection of deoxyglucose with radioactive fluorine is given –Color scan is done; different shade can be translated into different pathological conditions

7 Lumbar Puncture –Obtain CSF for examination –Relieve pressure –Inject dye or medication –Contraindicated in patients with increased intracranial pressure

8 Electroencephalogram (EEG) –Used to provide evidence of focal or generalized disturbances of brain function by measuring the electrical activity of the brain –Epilepsy, mass lesions, cerebrovascular lesions and brain injury –Procedure Patient is kept awake the night before Hair and scalp must be clean Electrodes are placed on the scalp

9 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. –Used to diagnose herniated or protruding intervertebral disk. Spinal tumors, adhesions, bony deformations, and arteriovenous malformations –Lumbar puncture is performed, dye injected, and fluoroscopic and radiopaque films are taken

10 Angiogram –Used to visualize the cerebral arterial system by injecting radiopaque material –Allows the detection of arterial aneurysms, vessel anomalies, ruptured vessels, and displacement of vessels by tumors or masses

11 Carotid Duplex –Uses combined ultrasound and pulsed Doppler –Noninvasive study that evaluates carotid occlusive disease Electromyogram (EMG) –Used to measure the contraction of a muscle in response to electrical stimulation –Provides evidence of lower motor neuron disease; primary muscular disease; and defects in the transmission of electrical impulses

12 Echoencephalogram –Uses ultrasound to depict the intracranial structures of the brain –Detects ventricular dilation and a major shift of midline structures in the brain as a result of an expanding lesion

13 Headaches Etiology/Pathophysiology –Skull and brain tissues are not able to feel sensory pain Pain arises from the scalp, blood vessels, muscles, dura mater, and sinuses –Vascular Headaches Migraine –Vessels are dilated Hypertensive –Excessive pressure –Tension Headaches Psychological problems –tension, stress, Cervical arthritis –Traction-Inflammation Headaches Infection, intracranial or extracranial causes, occlusive vascular structures, temporal arteritis

14 Headaches Signs & Symptoms –Head pain –Migraine headaches Prodromal (early s/s) –visual field defects, experiencing unusual smells or sounds, disorientation, paresthesias, and rarely paralysis of a part of the body During headache –nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema

15 Headache Treatment –Diet Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork –Psychotherapy Decrease stress factors –Medications Migraine Headaches –aspirin, acetaminophen, ibuprofen –ergotamine tartrate »Constricts vessels –Codeine –Inderal

16 Headaches Tension Headaches –Nonnarcotic analgesics »acetaminophen, propoxyphene, phenacetin, ibuprofen, and aspirin Traction-inflammatory Headaches –Treat cause –Comfort Measures Cold packs to forehead or base of skull Pressure to temporal arteries Dark room; limit auditory stimulation

17 Increased Intracranial Pressure Etiology/Pathophysiology –Increase in any content of the cranium Cranium is rigid and nonexpandable –Space-occupying lesions, cerebrospinal problems, cerebral edema

18 Increased Intracranial Pressure Signs & Symptoms –Diplopia double vision –Headache increases with coughing, straining, or stooping –Decrease in level of consciousness disorientation, restlessness, lethargy –Pupillary signs ipsilateral pupil dilation –lesion is one hemisphere bilateral pupil dilation –both halves of brain are involved

19 Increased Intracranial Pressure –Widening pulse pressure increased systolic and decreased diastolic B/P –Bradycardia –Respiratory problems vary related to the level of brainstem involvement –High, uncontrolled temperatures –Positive Babinski’s reflex Toes fan out when bottom of foot is stroked –Seizures

20 Increased Intracranial Pressure –Posturing decorticate –flexion of arms, wrists, and fingers with adduction of arms decerebrate –All four extremities in rigid extension, with hyperpronation of forearmsand plantar extension of feet –Vomiting –Singultus

21 Increased Intracranial Pressure Treatment –Treat cause if possible –Mechanical decompression Craniotomy –remove bone flap and replace Craniectomy –remove bone flap and not replaced –Internal Monitoring Devices Diagnose and monitor increased intracranial pressure Ventricular catheter, subarachnoid bolt or screw, and the epidural sensor –produce pressure waves to indicate status of IIP

22 Epilepsy or Seizures Etiology/Pathophysiology –Transitory disturbance in consciousness or in motor, sensory, or autonomic function with or without loss of consciousness –Sudden, excessive, and disorderly discharges in the neurons of the brain –Results in sudden, violent, involuntary contraction of a group of muscles –Hypoglycemia, infection, and electrolyte imbalance.

23 Epilepsy or Seizures –Types of seizures Grand Mal –Generalized –Tonic-clonic movements –Loss of consciousness Petit Mal –Sudden impairment or loss of consciousness –Little or no tonic-clonic movement –Vacant facial expression; eye straight ahead Psychomotor –Sudden change in awareness –Behaves as if partially conscious –May appear intoxicated –Antisocial behavior »exposing self or violence

24 Epilepsy or Seizures Jacksonian-focal –One body part is affected »hand, foot, face –May end in grand mal seizure Myoclonic –Sudden involuntary contraction of muscle group »usually in extremities or trunk –No loss of consciousness Akinetic –Generlaized tonelessness –Falls in flaccid state –Unconsciousness for 1-2 minutes

25 Epilepsy or Seizures Signs & Symptoms –Depends on type of seizure –Aura Sensation that may precede a seizure –flashing lights, smells, numbness, tingling, hallucinations –Postictal Period Rest period of variable length Groggy and disoriented Headache and muscle aches May sleep

26 Epilepsy or Seizures –Status epilepticus recurrent, gernalized seizure activity occurs at such frequency that full consciousness is not regained

27 Epilepsy or Seizures Treatment –During seizure Protect from aspiration and injury –Lower to the floor –Move away from furniture and equipment –Turn the head to the side if possible –Loosen clothing around neck –DO NOT RESTRAIN –DO NOT PUT ANYTHING IN MOUTH –Medications Page 608; table 15-5 –Surgery Removal of brain tissue where seizure occurs

28 Epilepsy or Seizures –Adequate rest –Good nutrition –Avoid alcohol –Avoid driving, operating machinery, & swimming until seizures are controlled –Good oral hygiene esp. if on Dilantin causes gingival hyperplasia –edematous and enlarged gums –Medical alert tag

29 Multiple Sclerosis Etiology/Pathophysiology –Degenerative neurological disorder –Cause unknown –Possibly genetic –Most common in wet cold climates –Demyelination of the brain stem, spinal cord, optic nerves, and cerebrum causes an interruption or distortion of the nerve impulse

30 Multiple Sclerosis Signs & Symptoms –Visual problems diplopia scotomata (spots) blindness nystagmus –Urinary incontinence –Fatigue –Weakness –Incoordination –Sexual problems –Swallowing difficulties

31 Multiple Sclerosis –Remissions may last for a year or more –Exacerbaions precipitated by fatigue chilling emotional disturbances

32 Multiple Sclerosis Treatment –No specific treatment –Adrenocorticotropic hormone (ACTH) –Steroids prednisone –Deltasone or Decadron –Valium –Betaseron (Interferon beta-1b) reduces frequency of exacerbations –Avonex (Interferon beta-1a) reduce neurological attacks and slow progress of physical disability

33 Multiple Sclerosis –Pro-Banthine decrease urinary frequency and urgency –Urecholine antispasmodic for neurogenic bladder –Bactrim, Septra, & Macrodanitn Urinary tract infections

34 Parkinson’s Disease Etiology/Pathophysiology –Deficiency of dopamine necessary for the normal transmission of nerve impulses –Viral, toxic, vascular and genetic causes –May be drug induced Reserpine, phenothiazines, haloperidol, cocaine

35 Parkinson’s Disease Signs & Symptoms –Muscular tremors –Rigidity mask-like facial appearance monotonous speech drooling –Propulsive gait –Emotional instability –Heat intolerance –Decreased blinking –“Pill-rolling” motions of fingers –Bradykinesia slowness of voluntary movements and speech

36 Parkinson’s Disease

37 Treatment –Medications –side effects may be worse than disease Levodopa –converted to dopamine Sinemet Artane Cogentin Symmetrol –Surgery Pallidotomy –Destroying portions of the brain that control the rigidity or tremor Human fetal dopamine cell transplants

38 Alzheimer’s Disease Etiology/Pathophysiology –Impaired intellectual functioning –Degeneration of the cells of the brain –Cause is unknown –Possible genetic link

39 Alzheimer’s Disease Signs & Symptoms –Early Stage Mild memory lapses Decreased attention span –Second Stage Obvious memory lapses –Esp. short term –Disorientation to time –Loss of personal belongings –Third Stage Total disorientation to person, place, & time Apraxia –impaired ability to perform purposeful acts or use objects Wandering –Terminal Stage Severe mental and physical deterioration

40 Alzheimer’s Disease Treatment –Medications Agitation –Lorazepam –Haldol Dementia –Cognex –Aricept –Nutrition Finger foods Frequent feedings Encourage fluids

41 Alzheimer’s Disease –Safety Removing burner controls at night Double-locking all doors and windows Constant supervision

42 Myasthenia Gravis Etiology/Pathophysiology –Neuromuscular disorder –Nerve impulses fail to pass at the myo- neural junction; causes muscular weakness –Possible causes Inadequate production of acetylcholine Excessive quantities of cholinesterase Non-response of the muscle fibers to acetylcholine

43 Myasthenia Gravis Signs & Symptoms –Ocular Ptosis –eyelid drooping Diplopia –double vision –Generalized Skeletal weakness Dysarthria Dysphagia Ataxia Bowel and bladder incontinence

44 Myasthenia Gravis Treatment –Anticholinesterase drugs Prostigmin Mestinon –Corticosteroids –May require mechanical ventilation

45 Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s Disease Etiology/Pathophysiology –Motor neurons in the brainstem and spinal cord gradually degenerate –Electrical and chemical messages originating in the brain do not reach the muscles to activate them

46 Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s Disease Signs & Symptoms –Weakness of the upper extremities –Dysarthria –Dysphagia –Muscle wasting –Compromised respiratory function death usually occurs due to infection

47 Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s Disease Treatment –No cure –Rilutec (riluzole) Helps protect damaged motor neurons –Multidisciplinary ALS Teams experimental drugs physical, occupational, and speech therapy nutritional regimens psychological support –Emotional support Mentally healthy; physically wasting away

48 Huntington’s Disease Etiology/Pathophysiology –Overactivity of the dopamine pathways opposite of Parkinson’s –Genetically transmitted

49 Huntington’s Disease Signs & Symptoms –Abnormal and excessive involuntary movements (chorea) Writhing, twisting movements of the face, limbs, and body Abnormal facial movements –affect speech, chewing, and swallowing –Ataxia to immobility –Deterioration in mental functions

50 Huntington’s Disease Treatment –No cure; pallative treatment –Antipsychotics –Antidepressants –Antichoreas –Safe environment –Emotional support –High calorie diet

51 Cerebral Vascular Accident (CVA) Etiology/Pathophysiology –Abnormal condition of the blood vessels of the brain thrombosis emoblism hemorrhage –Results in ischemia of the brain tissue –Underlying causes atherosclerosis, heart disease, hypertension, kidney disease, PVD, DM –Risk factors obesity, high serum cholesterol, cigarette smoking, stress, cocaine use, and sedentary lifestyle


53 Cerebral Vascular Accident (CVA) Signs & Symptoms –Headache –Sensory deficit numbness or tingling inability to think clearly visual problems –Hemiparesis Weakness on one side of the body –Hemipalegia Paralysis on one side of the body Depends on area of brain affected –Dysphasia or aphasia

54 Cerebral Vascular Accident (CVA) Treatment –Aneurysm Surgery –tie off or clipping of aneurysm –Thrombosis or Embolism Thrombolytics –TPA, activase Heparin and Coumadin –Decadron –Neurological checks –Feeding tube –Physical, occupation, and/or speech therapy

55 Trigeminal Neuralgia (Tic Douloureux) Etiology/Pathophysiology –Degeneration of or pressure on the trigeminal nerve

56 Trigeminal Neuralgia (Tic Douloureux) Signs & Symptoms –Excruciating, burning pain radiates along one or more of the three divisions of the fifth cranial nerve –typically extends only to the midline of the face and head pain may be initiated by stimulation of “trigger points”

57 Trigeminal Neuralgia (Tic Douloureux) Treatment –Tegretol –Surgical resection of the trigeminal nerve –Avoid stimulation of face on affected side touching drafts hot or cold liquids

58 Bell’s Palsy (peripherial facial paralysis) Etiology/Pathophysiology –Inflammatory process involving the facial nerve –Vasoconstriction due to ischemia, edema, or emotional trauma may also be a cause –Unilateral or bilateral

59 Bell’s Palsy (peripherial facial paralysis) Signs & Symptoms –Facial numbness or stiffness –Drawing sensation of the face –Unilateral weakness of facial muscles unable to wrinkle forehead, close eyelid, pucker lips, or retract the mouth Face appears asymmetric –drooping of mouth and cheek –Loss of taste –Reduction of saliva –Pain behind the ear –Ringing in ear or other hearing loss

60 Bell’s Palsy

61 Bell’s Palsy (peripherial facial paralysis) Treatment –Electrical stimulation –Warm moist heat –Steroids –Massage of the affected area –Exercises wrinkling the brow and forehead, closing the eyes, and puffing out the cheeks.

62 Guillain-Barre’ Syndrome Etiology/Pathophysiology –Inflammation and demyelination of the peripheral nervous system –Cause is unknown –Possibly viral or autoimmune reaction

63 Guillain-Barre’ Syndrome Signs & Symptoms –Symptoms are progressive –Progression may stop at any point –Paralysis usually starts in the lower extremities and moves upward –May include the thorax, upper extremities, and face –Respiratory failure if intercostal muscles are affected –May have difficulty swallowing, breathing, and speaking

64 Guillain-Barre’ Syndrome Treatment –Adrenocortical steroids –Apheresis removal of unwanted components from the blood serum by a flow separator –Mechanical ventilation may require tracheostomy –Gastrostomy tube –Meticulous skin care –Range of motion exercises

65 Meningitis Etiology/Pathophysiology –Acute infection of the meninges –Pneumococci, meningococci, staphylococci, streptococci, H. influenzae, and viral –Bacterial or aseptic

66 Meningitis Signs & Symptoms –Headache –Stiff neck –Irritability –Malaise –Restlessness –Nausea & vomiting –Delirium –Elevated temperature, pulse, & respirations –Kernig’s Sign inability to extend the legs completely without extreme pain –Brudzinski’s Sign flexion of the hip and knee when the neck is flexed

67 Meningitis Treatment –Antibiotics massive doses multiple types IV or intrathecal –Steroids –Anticonvulsants –Dark, quiet room stimulation may cause seizure

68 Intracranial Tumors Etiology/Pathophysiology –Benign or malignant –Primary or metastatic –May affect any area of the brain

69 Intracranial Tumors Signs & Symptoms –Headache –Hearing loss –Motor weakness –Ataxia –Decreased alertness and consciousness –Abnormal pupil response and/or unequal size –Seizures –Speech abnormalities

70 Intracranial Tumors Treatment –Surgical removal of tumor craniotomy intracranial endoscopy –Radiation –Chemotherapy –Combination of above

71 Crainiotomy

72 Craniocerebral Trauma (Head Injury) Etiology/Pathophysiology –Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma –Direct trauma head is directly injured acceleration-deceleration injury bruising or contusion of the occipital and frontal lobes and brainstem and cerebellum –Indirect trauma Tension strains and shearing forces transmitted to the head by stretching of the neck





77 Craniocerebral Trauma (Head Injury) –Open head injuries Skull fractures Penetrating wounds –Closed head injuries Concussions –violent jarring of the brain against the skull Contusions Lacerations –Hematomas scalp, epidural, subdural, intracerebral, and intraventricular –epidural and subdural must be monitored carefully

78 Craniocerebral Trauma (Head Injury) Signs & Symptoms –Headache –Nausea –Vomiting –Abnormal sensations –Loss of consciousness –Bleeding from ears or nose –Abnormal pupil size and\or reaction –Battle’s Sign in small hemorrhagic spot behind the ear may indicate a fracture the lower skull

79 Craniocerebral Trauma (Head Injury) Treatment –Maintain airway –Oxygen –Mannitol and dexamethasone reduce cerebral edema and IICP –Analgesics must not suppress respiratory system –Anticonvulsants

80 Spinal Cord Trauma Etiology/Pathophysiology –Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds –Fracture of vertebra simple, compressed, wedged, comminuted or burst fractures dislocation of vertebrae – Complete cord injury total transection of the spinal cord complete loss of spinal cord function –Incomplete cord injury partial transection or injury of spinal cord

81 Spinal Cord Trauma Signs & Symptoms –Loss of muscle function depends on level of injury INJURYLOST FUNCTION Above C4All, including respiration C5Arms, chest, all below chest C6-C7Some arm, fingers, chest, all below chest ThoracicTrunk, all below chest LumbosacralLegs


83 Spinal Cord Trauma –Spinal Shock Vasodilation, increased venous capacity, and hypotension –Autonomic dysreflexia Increased reflex actions –bradycardia, hypertension, diaphoresis, “goose bumps”, severe headache, and nasal stuffiness Occurs in injuries above T6; most common in cervical injuries Result of abnormal cardivascular response to stimulation of the sympathetic division of the autonomic nervous system Occurs as a result of stimulation of the bladder, large intestine or other visceral organs

84 Spinal Cord Trauma –Sexual Dysfunction Male –Impotence –Decreased sensation –Difficulties with ejaculation –Infertility Female –Altered sexual pleasure

85 Spinal Cord Trauma –Treatment Realignment of bony column for fractures or dislocations –Immobilization –Skeletal traction »Crutchfield tongs »Halo traction »Stryker frame –Sugery for spinal decompression Methylprednisolone –high doses

86 Spinal Cord Trauma –Mobility Slowly increase sitting up –may have to use thromboembolism stockings –prevents hypotension Urinary function –Foley catheter, initially –Bladder training –Intermittent catheterization Bowel function –Bowel program »Dulcolax suppositories »Digital stimulation »Adequate fluids »Stool softeners

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