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1 Community College of Rhode Island
Neurological Systems Mary Roche, RN, MSN, CS Community College of Rhode Island April 22,2003 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

2 Copyright - Mary Roche, RN, MSN, CS
Credits All materials for this presentation are based on: Medical-Surgical Nursing Across the Health Care Continuum by Ignatavicius, Workman, and Mishler - Volume 2 - 3rd Edition - W.B. Saunders Company This presentation was built for and is the copyrighted property of Mary Roche. This presentation is publicly available for viewing under the Web Developments section at 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

3 Copyright - Mary Roche, RN, MSN, CS
Goals of this Course Following attendance at this series of lectures, you should be: Familiar with the nomenclature and functions of the nervous system, In possession of a viable summary of the course textbook, Empowered to find information in a timely fashion, and Prepared to initiate nursing practice in neurological situations. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

4 Anatomy and Physiology Review
The nervous system is the basis for all human function. It is the center of thinking, memory, judgment, sensation, movement, cognition, communication, behavior, and personality. In addition to its direct control over many processes, the nervous system innervates many other body systems. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

5 Anatomy and Physiology Review
The major divisions of the nervous system are the Central Nervous System and the Peripheral Nervous System. The brain and spinal cord are the major components of the Central Nervous System. The Peripheral Nervous System is composed of 12 pairs of cranial nerves, 1 pairs of spinal nerves and the autonomic nervous system. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

6 Anatomy and Physiology Review Neurons
The Neuron Is the Basic Unit of the Nervous System. When a neuron receives an impulse from another neuron, the effect may be excitation or inhibition. Neurons Function to Transmit Impulses. Sensory – facilitate sensation. Motor – facilitate movement. Some process information; some retain information 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

7 Anatomy and Physiology Review Structure
Each neuron has a cell body, a short branching process called a dendrite and a single axon. Each dendrite synapses with another cell body, axon or dendrite. Axons are covered by a myelin sheath. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

8 Anatomy and Physiology Review Pathways
Dendritic process is called afferent pathway. Axonic process is called efferent pathway. Also called white matter. Non-myelinated – gray matter. Nodes of Ranvier – gaps in the myelin. Terminal knob – large distal end of each axon. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

9 Anatomy and Physiology Review Pathways
Within the synaptic knobs are mechanisms for manufacturing, storing, and releasing a transmitter substance. Each neuron produces a specific substance. Either enhances or inhibits impulses. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

10 Anatomy and Physiology Review Nerve Impulse Conduction
Mechanism for nerve impulse conduction – the sodium and chloride ions. Sodium and chloride are heavily concentrated outside the cell. Intracellular concentration of potassium Due to these different concentrations – a neuron is always charged. Via stimulus – polarity changes = depolarization. Proteins function as gates and open to either potassium or sodium (NOT BOTH). Sodium in – potassium out; then repolarization with sodium being actively pumped back out. In the membranes this occurs as an action potential. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

11 Anatomy and Physiology Review Synapse
Neuron to neuron / Muscle to muscle Factors affecting transmission: Strength of the stimulus Inadequate supply of substance Cerebrospinal Fluid (CSF) changes Lack of oxygen Acidosis/alkalosis Drugs 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

12 Anatomy and Physiology Review Transmitters
See Table 43-1, page 993 Anatomy and Physiology Review Transmitters Chemical substances that enhance or inhibit nerve conduction. Amines: Acetylcholine Brain, brain stem, basal ganglia, ANS Nerve and muscle transmission. Parasympathetic and preganglionic systems. Excitatory, but some inhibitory. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

13 Anatomy and Physiology Review Transmitters
Gamma-aminobutyric acid (GABA) Brain, brain stem, Nerve and muscle basal ganglia, spinal cord, cerebellum Possibly one-third of brain neurons. Inhibitory. Histamine / Serotonin Brain, spinal cord, PNS Medial brain stem, hypothalamus, dorsal horn of spinal cord. Possible onset of sleep, mood control, pain pathway inhibitor. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

14 Anatomy and Physiology Review Transmitters
Catecholamines: Dopamine Substantia nigra to basal ganglia. Complex movement, emotional response regulation, attention. Usually inhibitory. Norepinephrine Hypothalamus, brain stem, reticular formation, cerebellum, sympathetic nervous system. Maintenance of arousal, reward system, dreaming sleep, mood regulation. Mainly excitatory. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

15 Anatomy and Physiology Review Transmitters
Amino Acids: Aspartic acid Brain, spinal cord interneurons Sensation Excitatory. Glutamic acid Sensory pathways Sensation Excitatory. Glycine Spinal cord interneurons Muscle control. Inhibitory. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

16 Anatomy and Physiology Review Transmitters
Polypeptides: Substance P Brain, neurons in spinal cord Pain transmission Excitatory Endorphins, enkephalins Brain, neurons in spinal cord Pain transmission Excitatory 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

17 Anatomy and Physiology Review Glial Cells
Glial cells – two main classes: Microglia and Macroglia Microglia cells respond to infections or trauma in CNS. Macroglia Cells are divided into four subsets: Astroglia (star-shaped) cells provide physical support for neurons, regulate chemical environment, nourish. Oligodendrocyte and Schwann cells – form the myelin sheath. Ependymal cells for lining of ventricles of the spinal cord. Also part of blood-brain barrier. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

18 Central Nervous System

19 Central Nervous System Components
Brain - directs regulation and function of the nervous system and other systems of the body. Spinal Cord - initiates reflex activity and transmits impulses to and from the brain. Cranium And Vertebral Column - Brain and spinal cord are encased, respectively, in cranium and vertebral column. Vertebrae - 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, fused coccygeal. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

20 Central Nervous System The Brain
Meninges - form the immediate protective covering of the brain and spinal cord. Pia Mater - thin, delicate and vascular membrane. Adheres to the brain and spinal cord. Arachnoid - the next layer which is thin, delicate and fibrous. CSF fills tissue. Dura Mater - The outer layer which is heavy, fibrous, nonelastic. Subarachnoid - situated between arachnoid and pia mater is subarachnoid space where CSF circulates. Venous sinuses are between two layers of dura. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

21 Central Nervous System Cerebrum
Lobes and Ventricles Two hemispheres. Right and left lobes joined by corpus callosum. Dominant hemisphere for most people is the left hemisphere. Within the cerebrum are the right and left lateral ventricles. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

22 Central Nervous System Cerebrum
Cerebral Cortex Cerebral cortex divided into lobes by sulci and are named the same as the overlying bones. Speech Areas: Wernicke’s and Broca’s areas: higher brain functions 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

23 Central Nervous System Brain Lobe Functions
Table 43-2, Page 994 Central Nervous System Brain Lobe Functions Frontal Lobe Primary motor area. Broca’s speech center. Eye field, access to current sensory data. Access to past info. Affective response. Behavior. Judgment. Ability to develop long-term goals and to weigh pros and cons. Parietal Lobe Understand sensation, texture, size, shape, and spatial relations. Playing musical instruments. Processing nonverbal visual experiences. Perception of body parts and body position awareness. Taste impulses for interpretation. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

24 Central Nervous System Brain Lobe Functions
Table 43-2, Page 994 Central Nervous System Brain Lobe Functions Temporal Lobe Auditory center for sound interpretation. Complicated memory patterns. Wernicke’s area for speech. Occipital Lobe Primary visual center. Limbic Lobe Emotional and visceral patterns connected with survival. Learning and memory. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

25 Central Nervous System Brain
Diencephalon - lies below the cerebrum and includes: Thalamus – the ‘central switchboard’ for the CNS Hypothalamus - intellectual function Epithalamus - controls pineal gland Hypophysis (pituitary gland) – situated in the sella turcica of the ethmoid bone and is connected to the hypothalamus by the hypophyseal stalk. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

26 Central Nervous System Brain Stem
Midbrain Contains the cerebral aqueduct or aqueduct of Sylvius. Location of periaqueductal gray, which, when stimulated, may abolish pain. Cranial nerve nuclei III (oculomotor) and IV (trochlear) located here Pons Cardiac acceleration and vasocontriction centers - pneumotaxic center helps control respiration pattern and rate Four cranial nerves originate from the pons: V (trigeminal), VI (abducens), VII (facial), and VIII (acoustic) 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

27 Central Nervous System Brain Stem
Medulla Cardiac-slowing center - Respiratory center - Cranial nerves IX (glossopharyngeal), X (vagus), XII (spinal accessory), and XII (hypoglossal) and portions of VII (facial) and VIII (acoustic) emerge from the medulla 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

28 Central Nervous System Diencephalon Functions
Table 43-3, Page 995 Central Nervous System Diencephalon Functions Hypothalamus Regulates water metabolism, appetite, sleep-wake cycle, temperature control, and thirst Hormonal activity Posterior pituitary hormones such as vasopressin and oxytocin Anterior pituitary hormone excretion Growth, thyrotropin, and follicle stimulating hormones, prolactin, and corticotropin Emotions and drives basic to self-preservation 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

29 Central Nervous System Diencephalon Functions
Thalamus All sensation except smell Sensation perceived at the thalamic level is crude and cannot be localized or quantified Epithalamus By young adulthood often calcified and is radiopaque. Used as point of reference on an x-ray or a CT scan Subthalamus Contains sensory tracts. Connections to basal ganglia 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

30 Central Nervous System Cerebellum
The Cerebellum receives instantaneous and continuous information about the condition of muscles, joints, and tendons. Cerebellar function enables a person to: Keep a moving part from overshooting intended destination Move in an orderly sequence Predict distance, gauge speed of approaching object Control voluntary movement Maintain equilibrium 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

31 Blood Distribution To The Brain Cerebrospinal Fluid Spinal Cord
Cerebral Circulation Blood Distribution To The Brain Cerebrospinal Fluid Spinal Cord

32 Blood Distribution Cerebral Circulation
Cerebral circulation originates from carotid and vertebral arteries. Anterior, middle, and posterior cerebral arteries are joined together by communicating arteries which for the circle of Willis. Venous drainage occurs through cerebral veins into dural sinuses. Cerebral veins have no valves therefore intracranial pressure can be affected by central venous pressure. Two sinuses are of particular importance: superior saggital sinus and cavernous sinus. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

33 Blood Distribution Internal Carotid Artery Distribution
Hypophyseal Posterior pituitary. Ophthalmic Eye, frontal scalp, frontal and ethmoid sinuses. Anterior chorioidal Choroid plexus (lateral), optic tract, uncus, amygdaloid body, hippocampus, globus pallidus, lateral geniculate nucleus, Internal capsule. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

34 Blood Distribution Internal Carotid Artery Distribution
Letinculostriate Putamen, caudate nucleus, globus pallidus, internal capsule, corona radiata. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

35 Internal Carotid Artery Distribution Basilar Artery Branches
Anterior inferior cerebellar Cortex and inferior surface cerebellum, cerebellar nuclei, upper medulla, lower pons. Internal auditory – Inner ear Pontine – Pons Superior cerebellar Cortex, white matter and nuclei of cerebellum, pons, superior cerebellar peduncle, inferior peduncle, inferior colliculus. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

36 Internal Carotid Artery Distribution Vertebral Artery Branches
Posterior cerebellar Medulla. Posterior cerebellum, inferior vermis, cerebellar nuclei, choroid plexus (fourth ventricle), posterolateral medulla. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

37 Cerebrospinal Fluid Circulation
CSF surrounds and cushions the brain and spinal cord. While circulating through the subarachnoid space, the fluid is continuously reabsorbed by the arachnoid villi and then channeled into the superior sagittal sinus. The spinothalamic tracts begin in the spinal cord and end primarily in the thalamus. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

38 Copyright - Mary Roche, RN, MSN, CS
Spinal Cord Function Controls body movement; regulates visceral function; processes sensory information, and transmits information to and from the brain. It contains gray matter (neuron cell bodies) that is H- shaped and surrounded by white matter (myelinated axions). White matter is divide into posterior, lateral, and anterior columns. Gray matter divisions are posterior, intermediolateral, and anterior. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

39 Spinal Cord Components
Ascending tracts generally begin in the spinal cord and end in the brain. groups of cells in white matter Three ascending tracts are important for understanding neurologic problems: spinothalamic, spinocerebellar and fasciculi gracilis and cuneatus (posterior white columns). The spinothalamic tracts - begin in the spinal cord and end primarily in the thalamus. The posterior and anterior spinocerebellar tracts - begin in the spinal cord and end in the cerebellum. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

40 Spinal Cord Transmissions
Posterior white columns transmit to the thalamus: The sensation of proprioception from muscles, joints, and tendons. Vibratory sense. Light touch from the skin. Discrete localization. Two-point discrimination. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

41 Spinal Cord Descending tracts
Begin in the brain and end in the spinal cord. Pyramidal tract (lateral corticospinal) – of major importance in understanding neurological problems. Originates in the motor cortex of the frontal lobe and portions of the parietal lobe. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

42 Spinal Cord Circulation
Spinal cord circulation – comes from three main arteries: Anterior spinal artery which originates from a branch of the vertebral arteries. The two posterior spinal arteries originate from either the vertebral or posterior inferior cerebellar artery. Additional circulation is supplied by branches of the descending aorta. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

43 Peripheral Nervous System
The peripheral nervous system is composed of the spinal nerves, the twelve cranial nerves, and the autonomic nervous system (ANS).

44 Peripheral Nervous System Spinal Nerves
There are 31 pairs exiting from the spinal cord. (8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal) Each spinal nerve is responsible for the muscle innervation and sensory reception of a given area of the body. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

45 Peripheral Nervous System Sensory Receptors
Monitor and Transmit impulses of pain, temperature, touch, vibration, pressure, visceral sensation, and proprioception, as well as sensations of vision, taste, smell, and hearing. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

46 Peripheral Nervous System Lower Motor Neurons and Plexuses
Each motor neuron that leaves the spinal cord joins other nerves to form plexuses. Plexuses continue as trunks, cords, divisions and finally branch into individual peripheral nerves. The major plexuses are: cervical, brachial, lumbar and sacral. Here are major concentrations of nerves. The nerves of each plexus pass through or are surrounded by bone. Injury to the area or entrapment of a nerve can cause multiple problems. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

47 Peripheral Nervous System Reflexes
Reflexes consist of sensory input from: The muscles, tendons, skin, organs, and special senses. Small cells in the spinal cord lying between the posterior and anterior gray matter (interneurons). Anterior motor neurons, along with the muscles they innervate. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

48 Peripheral Nervous System 12 Cranial Nerves
I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Spinal accessory XII. Hypoglossal The type, origin and function of the cranial nerves are will be explained in the next few slides. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

49 Cranial Nerves I: Olfactory
Assessment With the client’s eyes closed, the nurse tests one of the client’s nostrils at a time; the client occludes the other with a finger. The nurse asks the client to identify familiar odors, such as coffee, tobacco, mint, or soap. Alcohol sponges and ammonia are not used because they stimulate the trigeminal nerve rather than the olfactory nerve. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

50 Cranial Nerves II: Optic
Assessment Each eye is tested individually, with the other eye covered but open. The nurse tests central vision, or visual acuity, using the Snellen chart. Clients are tested with and without glasses. Visual fields or peripheral vision are assessed by asking the client to focus on the nurse’s nose. The nurse wiggles one finger of each hand in the superior field, asking the client where the movement is. The client should see movement on both sides. This is then repeated with the inferior field. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

51 Cranial Nerves III: Oculomotor
Assessment Pupil constriction is tested with the room darkened. The nurse brings the penlight in from the side or from above or below the client’s head and shines the light in the client’s eye. The pupil should constrict and stay constricted. This is direct response. The response in the other eye is consensual and is less than the eye being tested. Pupils should be equal, round, regular, and react to light and accommodation. (PERRLA). 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

52 Cranial Nerves IV: Trochlear
Assessment Eye movement (inferior and medial) is tested with assessment of cranial nerve VI. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

53 Cranial Nerves V: Trigeminal
Assessment The nurse tests all three branches of the trigeminal nerve: ophthalmic branch – forehead maxillary branch – cheek mandibular branch – jaw. Using an object that has sharp and blunt aspects (a safety pin), the nurse asks the client to indicate whether the sensation is sharp or dull and then repeats the process. The motor aspect can be tested with the eyes open. The nurse palpates the jaw muscles for strength and equality. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

54 Cranial Nerves VII: Facial
Assessment Only the motor portion of the facial nerve is tested. Taste on the anterior portion of the tongue is tested with cranial nerve IX. The nurse asks the client to frown, smile puff out cheeks looking for symmetry. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

55 Cranial Nerves VIII: Vestibulocochlear (Acoustic)
Assessment Hearing is tested initially with the client’s eyes closed. The nurse rubs a thumb and finger together next to the client’s ear and asks where sound is heard. The nurse then repeats this maneuver for the other ear. The nurse may use the Weber and Rinne tests (with the client’s eyes open) to check for conductive or sensorineural hearing loss. Conductive hearing loss is caused by external-ear and middle-ear problems, such as excessive cerumen , presence of pus, ossicle fusion, or a damaged eardrum. Sensorineural hearing loss is due to cochlear or nerve damage. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

56 Cranial Nerves IX: Glossopharyngeal
Assessment The motor portion is tested with cranial nerve X assessment. Taste is often not tested unless the client reports loss of taste. .7 Cranial Nerve VII: Facial Only the motor portion of the facial nerve is tested. Taste on the anterior portion of the tongue is tested with cranial nerve IX. The nurse asks the client to frown, smile puff out cheeks looking for symmetry. .8 Cranial Nerve VIII: Vestibulocochlear (Acoustic) Hearing is tested initially with the client’s eyes closed. The nurse rubs a thumb and finger together next to the client’s ear and asks where sound is heard. The nurse then repeats this maneuver for the other ear. The nurse may use the Weber and Rinne tests (with the client’s eyes open) to check for conductive or sensorineural hearing loss. Conductive hearing loss is caused by external-ear and middle-ear problems, such as excessive cerumen , presence of pus, ossicle fusion, or a damaged eardrum. Sensorineural hearing loss is due to cochlear or nerve damage. .9 Cranial Nerve IX: Glossopharyngeal The motor portion is tested with cranial nerve X assessment. Taste is often not tested unless the client reports loss of taste. .10 Cranial Nerve X: Vagus To test the motor portion, the nurse asks the client to say “Ah” when looking into the throat. The uvula and palate should rise bilaterally and equally. .11 Cranial Nerve XI: Spinal Accessory The nurse assesses the strength of the client’s sternocleidomastoid and trapezius muscles by having the client turn the head against resistance. .12 Cranial Nerve XII: Hypoglossal The nurse tests motor innervation to the tongue by asking the client to stick out the tongue. The nurse checks for deviation to one side or the other. The tongue deviates toward the same side where the lesion has occurred in the brain. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

57 Cranial Nerves X: Vagus
Assessment To test the motor portion, the nurse asks the client to say “Ah” when looking into the throat. The uvula and palate should rise bilaterally and equally. .7 Cranial Nerve VII: Facial Only the motor portion of the facial nerve is tested. Taste on the anterior portion of the tongue is tested with cranial nerve IX. The nurse asks the client to frown, smile puff out cheeks looking for symmetry. .8 Cranial Nerve VIII: Vestibulocochlear (Acoustic) Hearing is tested initially with the client’s eyes closed. The nurse rubs a thumb and finger together next to the client’s ear and asks where sound is heard. The nurse then repeats this maneuver for the other ear. The nurse may use the Weber and Rinne tests (with the client’s eyes open) to check for conductive or sensorineural hearing loss. Conductive hearing loss is caused by external-ear and middle-ear problems, such as excessive cerumen , presence of pus, ossicle fusion, or a damaged eardrum. Sensorineural hearing loss is due to cochlear or nerve damage. .9 Cranial Nerve IX: Glossopharyngeal The motor portion is tested with cranial nerve X assessment. Taste is often not tested unless the client reports loss of taste. .10 Cranial Nerve X: Vagus To test the motor portion, the nurse asks the client to say “Ah” when looking into the throat. The uvula and palate should rise bilaterally and equally. .11 Cranial Nerve XI: Spinal Accessory The nurse assesses the strength of the client’s sternocleidomastoid and trapezius muscles by having the client turn the head against resistance. .12 Cranial Nerve XII: Hypoglossal The nurse tests motor innervation to the tongue by asking the client to stick out the tongue. The nurse checks for deviation to one side or the other. The tongue deviates toward the same side where the lesion has occurred in the brain. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

58 Cranial Nerves XI: Spinal Accessory
Assessment The nurse assesses the strength of the client’s sternocleidomastoid and trapezius muscles by having the client turn the head against resistance. .7 Cranial Nerve VII: Facial Only the motor portion of the facial nerve is tested. Taste on the anterior portion of the tongue is tested with cranial nerve IX. The nurse asks the client to frown, smile puff out cheeks looking for symmetry. .8 Cranial Nerve VIII: Vestibulocochlear (Acoustic) Hearing is tested initially with the client’s eyes closed. The nurse rubs a thumb and finger together next to the client’s ear and asks where sound is heard. The nurse then repeats this maneuver for the other ear. The nurse may use the Weber and Rinne tests (with the client’s eyes open) to check for conductive or sensorineural hearing loss. Conductive hearing loss is caused by external-ear and middle-ear problems, such as excessive cerumen , presence of pus, ossicle fusion, or a damaged eardrum. Sensorineural hearing loss is due to cochlear or nerve damage. .9 Cranial Nerve IX: Glossopharyngeal The motor portion is tested with cranial nerve X assessment. Taste is often not tested unless the client reports loss of taste. .10 Cranial Nerve X: Vagus To test the motor portion, the nurse asks the client to say “Ah” when looking into the throat. The uvula and palate should rise bilaterally and equally. .11 Cranial Nerve XI: Spinal Accessory The nurse assesses the strength of the client’s sternocleidomastoid and trapezius muscles by having the client turn the head against resistance. .12 Cranial Nerve XII: Hypoglossal The nurse tests motor innervation to the tongue by asking the client to stick out the tongue. The nurse checks for deviation to one side or the other. The tongue deviates toward the same side where the lesion has occurred in the brain. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

59 Cranial Nerves XII: Hypoglossal
Assessment The nurse tests motor innervation to the tongue by asking the client to stick out the tongue. The nurse checks for deviation to one side or the other. The tongue deviates toward the same side where the lesion has occurred in the brain. .7 Cranial Nerve VII: Facial Only the motor portion of the facial nerve is tested. Taste on the anterior portion of the tongue is tested with cranial nerve IX. The nurse asks the client to frown, smile puff out cheeks looking for symmetry. .8 Cranial Nerve VIII: Vestibulocochlear (Acoustic) Hearing is tested initially with the client’s eyes closed. The nurse rubs a thumb and finger together next to the client’s ear and asks where sound is heard. The nurse then repeats this maneuver for the other ear. The nurse may use the Weber and Rinne tests (with the client’s eyes open) to check for conductive or sensorineural hearing loss. Conductive hearing loss is caused by external-ear and middle-ear problems, such as excessive cerumen , presence of pus, ossicle fusion, or a damaged eardrum. Sensorineural hearing loss is due to cochlear or nerve damage. .9 Cranial Nerve IX: Glossopharyngeal The motor portion is tested with cranial nerve X assessment. Taste is often not tested unless the client reports loss of taste. .10 Cranial Nerve X: Vagus To test the motor portion, the nurse asks the client to say “Ah” when looking into the throat. The uvula and palate should rise bilaterally and equally. .11 Cranial Nerve XI: Spinal Accessory The nurse assesses the strength of the client’s sternocleidomastoid and trapezius muscles by having the client turn the head against resistance. .12 Cranial Nerve XII: Hypoglossal The nurse tests motor innervation to the tongue by asking the client to stick out the tongue. The nurse checks for deviation to one side or the other. The tongue deviates toward the same side where the lesion has occurred in the brain. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

60 Autonomic Nervous System
The Autonomic Nervous System is composed of two parts: Sympathetic Nervous System, and Parasympathetic Nervous System.

61 Autonomic Nervous System Sympathetic vs. Parasympathetic
If almost any portion of the sympathetic nervous system is stimulated, the whole system responds (the fight or flight response). During periods of excessive sympathetic stimulation: Skeletal muscle vessels dilate The heart pumps faster The liver releases extra glucose The thyroid is stimulated Sweating increases 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

62 Autonomic Nervous System Sympathetic vs. Parasympathetic
The PAS nervous system conserves the body’s resources. Parasympathetic fibers to the viscera have some sensory ability in addition to motor function. Sensations of irritation, stretching of an organ, or decrease in tissue oxygen are transmitted to the thalamus through pathways not yet fully understood. Table 43-7 page compares the action of sympathetic and parasympathetic systems in the body. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

63 Neurological Changes Associated with Aging
Motor / Sensory Ability Mental Status Diagnostic Assessment

64 Aging Motor / Sensory Ability
Sensory changes in older people can affect their daily activities. Pupils decrease in size and adapt more slowly. Touch sensation decreases. Vibration sense may be lost in ankles and feet. Hearing also decreases. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

65 Copyright - Mary Roche, RN, MSN, CS
Aging Mental Status Memory is one of the most important criteria for neurologic assessment. Loss of memory (esp. recent) tends to be an early sign of neurologic problems. Anxiety, insomnia, and depression may cause change in mental status. Circadian rhythm disorders may alter normal sleep patterns. Long term memory seems better than recall or immediate memory. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

66 Assessment of Mental Status
Personal And Family History Demographic Data Past Medical History Current History Current symptoms Social History Activities Habits Other Appropriateness Level of Consciousness Lethargic Stuporous Comatose The client is also asked questions to indicate orientation to person, place, and time. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

67 Assessment of Mental Status Abnormal Posturing
Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. The client’s arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs. Decerebration is abnormal posturing and rigidity characterized by extension of the client’s arms and legs, pronation of the arms, plantar flexion, and opisthotonos. It is usually associated with dysfunction in the brain stem area. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

68 Assessment of Mental Status Glasgow Coma Scale*
Eye Opening Spontaneous 4 To sound 3 To pain 2 Never 1 Motor Responses Obeys commands 6 Localizes pain 5 Normal flexion 4 Abnormal flexion 3 Extension 2 Nil 1 Verbal Responses Oriented 5 Confused Conversation 4 Inappropriate words 3 Incomprehensible Sounds 2 None 1 * The highest score is 15. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

69 Assessment of Mental Status Diagnostic Assessment
X-rays of the Skull and Spine x-rays are used to determine bony fractures, curvatures, bone erosion, done dislocation, and possible calcification of soft tissue. Cerebral Angiography illuminates the cerebral circulation. Contrast medium is injected into an artery, and x-rays are taken as the medium flows with the blood. Digital Subtraction Angiography (DSA) is used to evaluate the carotid and other cerebral arteries. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

70 Assessment of Mental Status Diagnostic Assessment
Myelography Myelography enables the vertebral column, intervertebral disks, spinal nerve roots, and blood vessels to be visualized. A contrast medium is inserted into the subarachnoid space of the spine. A lumbar puncture is the usual insertion site. Contrast Media Method A contrast medium is injected and x-rays are taken. Follow-up care requires vital and neuro signs, bed rest for 6 hours, extremity used is checked for adequate circulation demonstrated by skin color and temperature, pulses distal to the injection site and capillary refill. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

71 Assessment of Mental Status Diagnostic Assessment
Computerized Tomography - With the aid of a computer, pictures are taken at many horizontal slices of the brain or spinal cord. The nurse must ascertain if the client is allergic to iodine. The client must be completely still for the procedure which takes 10 minutes or less. Positron Emission Tomography / Single Photon Emission Computed Tomography. PET scanning provides information about the function of the brain. Lumbar Puncture - (spinal tap) is the insertion of a needle into the subarachnoid space between the third and fourth lumbar vertebrae. Used to obtain pressure readings, obtain CSF, inject medium, inject medication, reduce increased ICP. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

72 Manifestations / Classifications/ Symptoms
Spinal Cord Injury Manifestations / Classifications/ Symptoms Nursing Assessment Nursing Diagnoses

73 Spinal Cord Injury Manifestations / Classifications
SCI often result in loss of motor function sensation reflex activity, and bowel and bladder control The client may experience significant behavior and emotional problems as a result of changes in body image, role performance, and self-concept. SCI are classified as complete or incomplete. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

74 Spinal Cord Injury Symptoms
Specific syndromes seen after SCI and damage to the ANS are spinal shock and autonomic dysreflexia. Spinal Shock occurs immediately after injury and is characterized by flaccid paralysis, loss of reflex activity below the level of the lesion, bradycardia, hypotension and occasionally paralytic ileus. Autonomic Dysreflexia is usually seen in injuries above the level of the sixth thoracic vertebra. It generally occurs after the period of spinal shock is completed. Key features are: severe, rapidly occurring HTN, bradycardia, flushing above level of lesion, severe, throbbing headache, nasal stuffiness, sweating, nausea, blurred vision. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

75 Spinal Cord Injury Nursing Assessment
Respiratory Status Assess the client’s respiratory status; monitor for atelectasis, pneumonia, and pulmonary embolus. Vital Signs Take vital signs q1h or more often if clinically indicated; monitor for orthostatic hypotension. Neurologic Status Perform neurologic status checks q1h or more often if clinically indicated. Notify physician immediately of a deterioration of motor status. Watch for and immediately treat autonomic dysreflexia. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

76 Spinal Cord Injury Nursing Assessment
Assess Bladder Function Palpate for distention. Begin retraining as appropriate. Assess intake and output. Assess Bowel Function Auscultate bowel sounds. Palpate for distention. Chart stool frequency. Begin a bowel program as appropriate. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

77 Spinal Cord Injury Nursing Assessment
Medical Give pain medication as ordered; Document the client’s response. Prevent immobility complications. Have the client TCDB q2h. Use pneumatic boots or compression stockings. Check skin for breakdown. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

78 Spinal Cord Injury Nursing Assessment
Monitor Nutritional Status including a calorie count, and collaborate with dietitian to identify an appropriate diet. Assess Psychological Status Communicate with the client. Answer questions honestly; refer questions you can’t answer to someone who can. Assess for signs of depression or anger. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

79 Emergency Care Autonomic Dysreflexia
Positioning Raise the head of the bed to a high Fowler position. Loosen tight clothing on the client. Physical Care Monitor blood pressures every minutes Check the Foley catheter tubing (if present) for kinks or obstruction. If a Foley is not present, check for bladder distention and catheterize immediately. Check the client for fecal impaction; if present, disimpact immediately using anesthetic ointment. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

80 Emergency Care Autonomic Dysreflexia
Notification Call the physician and notify him or her of the emergency. Environment Check the room temperature to ensure that it is not too cool or drafty. Medication Give nitrates or Hydralazine (Apresoline, Novo-Hylazin) as ordered. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

81 Spinal Cord Injury Common Cord Syndromes
Complete Lesion total loss of motor sensory, and reflex activity. Anterior Cord Syndrome Loss of motor function with preservation of position, vibration, and touch senses. Brown-Sequard Syndrome Loss of pain, temperature, and light touch on opposite side. Loss of motor function and vibration, position, and deep touch sensation on same side as the cord damage. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS delay one click

82 Spinal Cord Injury Common Cord Syndromes
Central Cord Syndrome Loss of motor function and incomplete loss of motor function. Conus Medullaris and Cauda Equina Syndromes Loss of motor and/or sensory function in various patterns, with potential for recovery of function with regeneration of peripheral nerves; neurogenic bowel and bladder. Please see text Figure 5-5 for the above common cord syndromes 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS delay one click

83 Spinal Cord Injury Assessment
Respiratory Pattern Initial assessment is respiratory pattern to assure adequate airway. Sensation Motor Ability Cardiovascular GI/GU Muskuloskeletal Psychosocial Laboratory Diagnostic 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

84 Spinal Cord Injury Assessment Of Motor Function
C-5 apply downward pressure while the client shrugs his shoulders upward. C5-6 apply resistance while the client pulls up his arms. C7 apply resistance while the client straightens his flexed arms. C-8 make sure that the client is able to grasp an object and form a fist. L2 apply resistance while the client lifts his legs from the bed. L5 apply resistance while the client dorsiflexes his or her feet. S1 apply resistance while the client plantar flexes his feet. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

85 Spinal Cord Injury Nonsurgical Management
Vital Signs and Neuro Signs Nurse assesses vital signs and neuro signs every hour. In the first 2- hours after injury the client is at risk for neurogenic shock which is manifested by bradycardia and hypotension (most often associated with cervical spine injuries). Fixed Skeletal Traction The client with a cervical spine injury is usually placed in fixed skeletal traction to realign the vertebrae, facilitate bone healing and prevent further injury. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

86 Spinal Cord Injury Nonsurgical Management
Immobilization – Cervical Injuries Most commonly used is the halo fixator and cervical tongs. Halo fixator is a static traction device. Immobilization – thoracic and lumbar/sacral injuries. Bed rest, immobilization with a body cast. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

87 Spinal Cord Injury Use Of A Halo Device
(See page 1070 in text for illustration of these devices). Spinal Cord Injury Use Of A Halo Device Be aware that the weight of the halo device alters balance. Be careful when leaning forward or backward. Wear loose clothing preferably with Velcro fasteners. Bath in the tub or sponge bathe. Wash under lamb’s wool liner to prevent rash; use powders or lotions sparingly under vest. Have someone change liner if it becomes odorous. Support head with small pillow when sleeping. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

88 Copyright - Mary Roche, RN, MSN, CS
(See page 1070 in text for illustration of these devices). Use Of A Halo Device Try to resume activities to the extent possible. Avoid contact sports, swimming. Do not drive, vision is impaired with the device. Use straws to drink fluids. Cut food into small pieces to facilitate chewing and swallowing. Have someone clean pin sites according to hospital protocol. Observe pin sites daily for drainage or redness. Increase fluid and fiber in the diet to prevent constipation. Use a position of comfort during sexual activity. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

89 Spinal Cord Injury Drug Therapy
Solu-Medrol in high dosages within first 8 hours of injury is the first course of treatment. Clients receiving this medication show significant improvement in motor and sensory function. Dextran a plasma expander, may be used to increase capillary blood flow within the spinal cord and to prevent or treat hypotension. Atropine sulfate is used to treat bradycardia. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

90 Spinal Cord Injury Drug Therapy
Dopamine and Isoproterenol used to treat severe hypotension. Dantrium [Bacolfan] may be used to treat spasticity. Didronel may be ordered for patient with heterotopic ossification. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

91 Spinal Cord Injury Surgical Management
Emergency Surgery Emergency surgery may be indicated if there is evidence of spinal cord compression. It may be necessary to remove bone fragments from a vertebral fracture, evacuate a hematoma, or remove penetrating objects. Compressive laminectomy allows for cord expansion from edema. Additional typical procedures include: Harrington rods to stabilize thoracic spinal injuries. Postop the client usually wears a brace or TLSO to keep operative area immobile. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

92 Spinal Cord Injury Surgical Management
Postop Care The nurse assesses the client’s neurological status and vital signs at least every hour. Complications of surgery, such as hematoma and edema, are manifested by a deterioration in neurologic status. The client is at risk for cardiovascular instability because of the loss of sympathetic innervation. Logrolling is used when moving the patient. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

93 Some Nursing Diagnoses Associated With Spinal Cord Injury

94 Copyright - Mary Roche, RN, MSN, CS
Ineffective Airway Clearance; Ineffective Breathing Pattern; Impaired Gas Exchange Expectations The client is expected to maintain a patent airway and not experience respiratory complications, such as pneumonia, atelectasis, and aspiration. Interventions Turn the client every 2 hours. Instruct the client to breathe as deeply as possible. Assist cough. Use incentive spirometer. Possible use of suction. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

95 Impaired Physical Mobility; Self-Care Deficit
Expectations The client is expected to be free from complications of immobility and learn to perform activities of daily living as independently as possible. Interventions The client with an SCI is especially at risk for pressure ulcers, contractures, and deep venous thrombosis or pulmonary emboli. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

96 Impaired Physical Mobility; Self-Care Deficit
Preventing Complications of Immobility Reposition or teach client to reposition every 2 hours. Use of special pressure relief pads. ROM exercises at least once every 8 hours. The nurse collaborates with PT and OT to determine the most appropriate positioning and exercise techniques, to assess need for hand splints, to develop plan for foot drop. Compression stockings or boots are used. Coumadin is used to prevent DVT. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

97 Impaired Physical Mobility; Self-Care Deficit
Preventing Orthostatic Hypotension Clients with cervical cord injuries are especially at high risk for orthostatic (postural) hypotension. If the client moves from a lying to a sitting or a standing position quickly, he may experience hypotension which could result in dizziness and falls because of autonomic innervation in which blood vessels do not respond quickly enough to push blood up to the brain. To help prevent this, the nurse instructs the client to move slowly. Thigh high embolism stockings also help. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

98 Impaired Physical Mobility; Self-Care Deficit
Promoting Self-Care The most important thing is to set realistic goals. The nurse collaborates with PT and OT to do this and maximize self-care. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

99 Altered Urinary Elimination; Constipation
Expectations The client is expected to achieve continence of stool and urine. Interventions Clients with SCIs have reflex or neurogenic loss of bowel and bladder control. Many clients can become continent if they rigorously adhere to an established program. The type program depends on whether the injury involves upper motor neurons or lower motor neurons. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

100 Altered Urinary Elimination; Constipation
Establishing a Bladder Retraining Program - Catheterization Client typically is catheterized every 3 hours and more frequently if output is greater than 500 cc. Over time intervals between catheterizations are increased and adjusted to intake and sleep times. Other techniques may be used. Urecholine may be prescribed. To ascertain effectiveness of these maneuvers, the nurse catheterizes the client for residual urine after voiding. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

101 Altered Urinary Elimination; Constipation
Establishing a Bowel Retraining Program The essential elements of a bowel program are: A consistent time for bowel elimination. A high fluid intake (at least 2000 cc a day). A high fiber diet. Rectal stimulation with or without suppositories. If needed, a stool softener. If the client has sustained an LMN injury, the resulting flaccid large bowel may require the client to perform or to have manual disimpaction. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

102 The Mitrofanoff Procedure
Creates a catheterizable channel between a stoma on the skin of the abdomen (usually the umbilicus) and the bladder Allows patients to intermittently empty their bladder by inserting a disposable catheter into the channel. Also called an appendicovesicostomy because the appendix is used to create the channel. First described in 1980, has become the most widely used alternative to urethral self-catheterization in the world. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

103 The Mitrofanoff Procedure
It is highly successful with continence achieved in more than 90% of patients. Is used for patients who have: a neurogenic bladder or other conditions that interfere with continence and who are unable to easily self-catheterize through the urethra. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

104 The Mitrofanoff Procedure
Typically, this procedure is performed in pediatric specialty institutions or major medical centers. Understanding this procedure is important if you work in med-surg, long-term care, school, or rehab setting. For most patients, the primary reason to undergo the Mitrofanoff procedure is physiological – to maintain a healthy urinary tract and establish urinary continence through intermittent catheterization via an easily accessible stoma. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

105 The Mitrofanoff Procedure
For patients with spinal cord injuries, the procedure can help stem the continued potential for deterioration of renal function. For others, there is improved quality of life. It is essential to make sure that the patient has the physical ability, mental capacity, self-discipline, and psychological readiness to perform the self-catheterizations. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

106 Copyright - Mary Roche, RN, MSN, CS
Screening Candidates The majority of patients who undergo a Mitrofanoff procedure will require a rigid schedule of self-catheterization – typically once every four hours while awake – to achieve dryness and prevent the complications of continued incontinence. There is extensive bowel prep, antibiotic therapy and laboratory work preop. Cystourethrogram and renal ultrasound are needed to assess the patient for any structural abnormalities of the urinary tract. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

107 Using The Appendix to Create a Channel
During the procedure, a channel from the bladder to the abdomen is created to achieve entrance to the bladder. Because the appendix has a constant, reliable blood supply, supple muscular wall, and adequate lumen, it has proven to be the ideal tissue with which to create the channel. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

108 Using The Appendix to Create a Channel
After the mucosa to mucosa anastomy a flap valve is created to prevent reflux and leakage of urine. The stoma is then created and concealed in the umbilicus. Postoperatively, patients generally have a 12F cath placed through their appendicovesicostomy. While undergoing surgery some patients may undergo bladder augmentation with segment of stomach or intestine. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

109 Using The Appendix to Create a Channel
The catheter remains in place about three weeks and the patient goes home with them. After then, the stoma is healed and functional. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

110 Copyright - Mary Roche, RN, MSN, CS
Post Op And Followup Patients are sent home with the appendicovesicostomy and urethral catheters in place, though the appendicovesicostomy catheter is clamped. Approximately three weeks postop, the patient returns to the hospital. Both catheters are removed and the patient is taught how to perform self-cath through the appendicovesicostomy. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

111 Copyright - Mary Roche, RN, MSN, CS
Post Op And Followup Patient must be explained that since the catheter is entering the bladder from above, emptying is like siphoning liquid from a gas tank. The container must be lower than the bladder, and when urine begins to flow, the catheter should be pushed in another one to one-and-one-half inches to insure adequate bladder drainage. Patients should be taught to use sterile technique and report any signs of infection. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

112 Copyright - Mary Roche, RN, MSN, CS
Post Op And Followup Patients must use the conduit regularly to ensure patency. To date, minimal complications have been reported. Stomal stenosis must be watched for and 7% to 24% of patients experience this. Stomal stenosis can occur if the appencovesicostomy is not dilated frequently enough. Repeated self dilation by intermittent self-catheterization can usually remedy this problem. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

113 Copyright - Mary Roche, RN, MSN, CS
Post Op And Followup Stone formation in the bladder or kidney can be a long-term complication. The longer a channel is in place, the greater the chance for stone formation. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

114 Copyright - Mary Roche, RN, MSN, CS
Impaired Adjustment Expectations The client is expected to demonstrate the ability to cope with the changes caused by the injury and verbalize his or her feelings about the injury and changes in lifestyle. Interventions: The nurse encourages the client to discuss his perception of the situation and what coping skills can be used. Referrals to clergy, rabbis, or other spiritual leaders or a psychologist are offered. Support groups are available to family and friends. Social workers can help with insurance status and appropriate social service agencies as necessary. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

115 Spinal Cord Injury Home Care Management
If the client is discharged home or returns home for a weekend visit from the rehab setting, the environment must be assessed to ensure that it is free from hazards and can accommodate the client’s special needs. OT or PT works in collaboration with rehab in the home setting. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

116 Spinal Cord Injury Health Teaching
The teaching plan for the client with an SCI includes: Physical mobility and activity skills ADL skills Bowel and bladder retraining program Skin care Medication regimen Sexuality education The information should be reinforced with handouts. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

117 Spinal Cord Injury Health Teaching
Learning mobility skills is important so that the client can negotiate movement on sidewalks and carpeting and other flooring surfaces. The client must also be able to negotiate sidewalk curbs while walking independently with crutches, cane, or in a wheelchair. Some clients are discharged to home with a halo vest that has a significant physical and psychological impact on clients. Clients find it difficult to perform mobility skills and ADLs independently. ADL training includes a structured exercise program to promote strength and endurance. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

118 Spinal Cord Injury Psychosocial Preparation
Nurse teaches name and purpose of medication and side effects. Client should understand possible interaction of prescribed medication with OTC and illegal drugs and alcohol. Psychosocial adaptation is one of the critical factors in determining the success of rehab. The nurse should prepare the client for reactions of others outside the rehab. For example, the client can practice answering questions about why he is in a wheelchair. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

119 Spinal Cord Injury Health Care Resources
The nurse or case manager refers the client to appropriate organizations. There is a National Spinal Cord Injury Association and hotline. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

120 Key Features Manifestations
Spinal Cord Tumors Key Features Manifestations

121 Spinal Cord Tumors Key Features
Occur most frequently in the thoracic area. Venous occlusion by the tumor may lead to spinal cord congestion and infarction. The appearance of neurologic signs and symptoms is related to the rate of tumor growth. The spinal cord can often accommodate a slow growing tumor. On the other hand, a fast growing tumor quickly leads to spinal cord compression. Anatomically, spinal cord tumors may be extramedullary or intramedullary, i.e. originate within or out of the spinal cord. Spinal cord tumors account for about 1% of all tumors in adults. The majority of tumors are benign. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

122 Spinal Cord Tumors General Symptoms
Pain Sensory loss or impairment Motor loss or impairment Sphincter disturbance (bladder before bowel) Cervical High cervical Respiratory distress Diaphragm paralysis Occipital headache Quadriparesis Stiff neck Nystagmus Cranial nerve dysfunction Low cervical Pain in the arms and shoulders Weakness Paresthesia Motor loss Horner's syndrome 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

123 Spinal Cord Tumors Specific
Thoracic Sensory loss Spastic paralysis Positive Babinski’s sign Bladder and bowel dysfunction Pain in the chest and the back Muscle atrophy Muscle weakness in the legs Foot drop Lumbosacral Low back pain Paresis Spastic paralysis Sensory loss Bladder and bowel dysfunction Sexual dysfunction Decreased-to-absent ankle and knee reflexes See Table 1, p in text for Location and Treatment of Spinal Cord Tumors 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

124 Spinal Cord Tumors Assessment/Clinical Manifestations
Clinical manifestations depend on the location of the tumor and its rate of growth. The nurse assesses for weakness, clumsiness, spasticity, and hyperactive reflexes and compares the responses on both sides of the body. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

125 Problems Of The Peripheral Nervous System

126 Peripheral Nervous System Guillain-Barre Syndrome (GBS)
is an acute inflammatory process characterized by varying degrees of motor weakness and pathology. In GBS the immune system starts to destroy the myelin sheath that surrounds the axons. Etiology cell mediated immunologic reaction. Lab Assessment No single finding confirms diagnosis. Physician does a lumbar puncture to evaluate CSF. Peripheral blood tests may show leukocytosis early in the illness. ESR is typically WNL. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

127 Peripheral Nervous System Myasthenia Gravis (MG)
Myasthenia Gravis means ‘grave muscle weakness’ or weakness of the voluntary or striated muscles. May take many forms, from mild ocular muscle disturbance to severe weakness leading to death from respiratory failure. Clients with MG develop specific antibodies to one or more ACh receptor sites, possibly because of autoimmune injury. Etiology Research suggests that MG is caused by antibodies to ACh receptors. Evidence also suggests a relationship between MG and hyperplasia of the thymus gland. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

128 Myasthenia Gravis (MG) Assessment
Subjective complaints are noted. Inquiry re: eye problems, ability with performing ADLs, respiratory difficulty, presence of paresthesia or aching, weakened muscles. Any history of thymus gland tumor is elicited. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

129 Myasthenia Gravis Clinical Manifestations
Progressive paresis, ocular palsies, ptosis, diplopia, weak or incomplete eye closure.Diagnostic assessment - Response to cholinergic drugs. Thyroid function should be tested. Assessment for thyoma by CT. Tensilon testing - This test can be used to evaluate myasthenic crisis (under medication with cholinesterase inhibitors). EMG – electrical testing to detect defective neuromuscular transmission. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

130 Myasthenia Gravis Interventions
Assistance with activities. Active or passive ROM. Turn q. 2 h. Drug therapy: Three groups of drugs used – anticholinesterases (Prostigmin), Corticosteroids (Prednisone), immunosuppressants (Imuran). Plasmapheresis is a method by which offending autoantibodies are removed from the plasma. Respiratory support. Self-care. Nutritional support. Assistance with communication. Eye protection. Surgical management (thymectomy) . Lifestyle changes. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

131 Myasthenia Gravis Crisis
Sudden increases in weakness and the inability to clear secretions, swallow, or breathe adequately indicate that the client is experiencing crisis. There are two types of crisis: Myasthenic crisis an exacerbation of the myasthenic symptoms caused by under medication with anticholinesterase drugs. Myasthenic crisis is often preceded by some type of infection. Cholinergic crisis an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

132 Characteristics of Crises
Increased pulse and respiration. Rise in blood pressure. Anoxia. Cyanosis. Bowel and bladder incontinence. Decreased urinary output. Absence of cough and swallow reflex. Restlessness. Dyspnea. Dysphagia. Dysarthria. Increased lacrimation. Increased salivation. Diaphoresis. Generalized weakness. Nausea, vomiting, diarrhea. Abdominal cramps. Blurred vision. Pallor. Facial muscle twitching. Pupillary miosis. Hypotension.App rehension. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

133 Myasthenia Gravis Treatment
In either crisis, an adequate airway and artificial respiration must be maintained. Because both have many common characteristics, the type of crisis the client is experiencing must be identified for effective treatment to be provided. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

134 Myasthenia Gravis Improving Nutrition In Clients
Assess the client’s gag reflex and ability to chew and swallow. Provide frequent oral hygiene as needed. Collaborate with the dietitian, speech and language pathologist, to plan and implement a meal the client can enjoy. Offer small, frequent meals. Observe client for choking, nasal regurgitation, and aspiration. Provide high-calorie snacks or supplements such as puddings Keep the head of the bed elevated during meals and for 0 minutes after. Avoid liquids as they can easily cause choking and aspiration. Provide a soft diet. Monitor food intake carefully. Weigh the client daily. Monitor serum transferring and albumin levels. Administer anticholinesterase drugs, as ordered: 0-60 minutes before each meal. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

135 Peripheral Nervous System Polyneuritis and Polyneuropathy
Manifestations Systemic diseases, infections, trauma, vascular or metabolic disturbances, alcohol, medications, heavy metals may damage cranial and peripheral nerves. Although the term polyneuritis implies an inflammatory process, it may denote noninflammatory lesions as well. Hallmarks Terms polyneuritis, polyneuropathy, and peripheral neuropathy may describe syndromes whose clinical hallmarks are muscle weakness with or without atrophy, pains and paresthesia, impaired reflexes, or a combination of these symptoms. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

136 Polyneuritis and Polyneuropathy
Assessment Examination of sensory and motor ability. Position sense, pain, signs of injury of which the client may be unaware. The nurse also assesses the client for: Orthostatic hypotension Abnormal sweating Miosis Sphincter disturbances. Other dysfunctions that may accompany neuropathy. Interventions: Removal of the underlying cause. Supplementation of diet. Client teaching. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

137 Peripheral Nervous System Restless Leg Syndrome
The client complains of intense “crawling-type” sensations in the limbs and subsequently feels the need to move the limbs repeatedly. Diagnosis is made on history and there is no known etiology. Management is symptomatic. Antiembolism stockings may be helpful. Some medications that may help include: Catapres, Tegretol, Clonidine. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

138 Peripheral Nervous System Trigeminal Neuralgia
Also called tic douloureux. Entails a type of facial pain, which occurs in abrupt, intense paroxysms. Usually provoked by minimal stimulation of a trigger zone. Is unilateral and confined to the area innervated by the trigeminal nerve, most often the second and third branches. Usually in persons over 50. Cause is thought to be related to impaired inhibitory mechanisms in the brain stem. Approximately 70% respond to carbamazepine (Tegretol). 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

139 Peripheral Nervous System Facial Paralysis (Bell’s Palsy)
Onset is acute. Cause remains obscure. Management consists of prednisone and analgesics. Nursing care is directed toward managing the major neurologic deficits and providing psychosocial support. 80% of clients recover fully within a few months. Approximately 20% have residual weakness; a few have permanent neurologic deficits. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

140 Interventions For Critically Ill Clients With Neurologic Problems
Some neurologic problems, such as cerebrovascular accident (CVA), head injury, brain tumor, can cause increased intracranial pressure (ICP), a life-threatening complication. Through prompt recognition and aggressive management of this complication, permanent neurologic dysfunction or death may be prevented. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

141 Cerebrovascular Accident
– “stroke”, is a disruption in the normal blood supply to the brain. It often occurs suddenly and produces focal neurologic deficits. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

142 Cerebrovascular Accident Pathophysiology
Through the process of cerebral autoregulation, blood flow to the brain is maintained at a fairly constant rate of 1000mL/min. In the event of a CVA, ischemia occurs in the brain tissue supplied by the affected artery. Ischemia leads to hypoxia or anoxia and hypoglycemia. These processes then cause infarction or death of the neurons, the glia, and the involved area of the brain. In addition, brain metabolism after stroke is affected in the involved area as well as in the contralateral hemisphere. Small lacunar infarcts may also occur. Lacunae are small, deep cavities within the brain that result from occlusion of a small vessel. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

143 Cerebrovascular Accident Classifications
CVAs are generally classified as ischemic (occlusive) or hemorrhagic. Ischemic strokes are further divided into thrombotic strokes and embolic strokes. Ischemic Stroke – caused by occlusion of a cerebral artery by either a thrombus or an embolus. Hemorrhagic Stroke - In this type of stroke, the integrity of the vessel is interrupted. Hemorrhage into the brain tissue generally results from a ruptured saccular (berry) aneurysm, rupture of an AV malformation or, hypertension. A ruptured cerebral aneurysm is another cause of hemorrhagic stroke. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

144 Transient Ischemic Attack
TIA and Reversible Ischemic Neurologic Deficit – RIND. Warning signs or silent strokes. Etiology – Strokes are caused by an occlusion in an artery from a thrombus or an embolus; also from hypertension. Risk factors include: smoking, substance abuse (particularly cocaine), obesity, sedentary lifestyle, high stress levels, elevated cholesterol, lipoprotein, triglycerides, previous CVA or TIA, heavy alcohol use. Sudden discontinuation of antihypertensive medications can cause hemorrhagic stroke. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

145 Transient Ischemic Attack
African-Americans affected more frequently as a result of high frequency of diabetes and HTN in this group. Prevalence – Estimated million stroke survivors in U.S. The number of strokes occurring in the younger population is increasing as a result of IV drug abuse. Those using crack cocaine experience increased incidence of stroke due to changes in clotting mechanism caused by the drugs or sudden increase in systolic BP. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

146 Differential Features of the Types of Strokes
Feature Ischemic thrombotic Ischemic embolic Hemorrhagic Evolution Intermittent improvement between episodes of worsening. Completed stroke. Abrupt development of completed stroke. Steady progression. Usually abrupt onset. Onset Daytime (10a.m. – 12 p.m.) Gradual (minutes to hours). Daytime. Sudden. Daytime. Sudden, may be gradual if caused by hypertension. Level Of Consciousness Preserved (client is awake). Preserved (client is awake). Deepening stupor or coma. Contributing Associated Factors HTN Atherosclerosis. Cardiac disease. HTN Vessel disorders. Prodromal TIAs Neurologic Deficits Deficits during the first few weeks. Slight headache. Speech deficits. Visual problems. Confusion. Maximal deficit at onset. Paralysis. Expressive aphasia. Focal deficits. Severe, frequent. 17 Cerebrospinal Fluid Normal, possibly presence of protein. Normal. Bloody. 18 Seizures No No Usually 19 Duration Improvements during weeks to months. Possibly permanent deficits. Rapid improvements. Variable, possibly permanent neurologic deficits. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

147 Key Features of Transient Ischemic Attack
Visual Deficits Blurred vision Diplopia Blindness in one eye Tunnel vision Motor Deficits Transient weakness (arm, hand, or leg) Gait disturbance Sensory Deficits Transient numbness (face, arm, or hand) Vertigo Speech Deficits Aphasia Dysarthria (slurred speech) 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

148 Monitoring for Increased Intracranial Pressure
Client is at most risk for increased intracranial pressure (ICP) resulting from edema during the first 72-hours after the onset of the stroke. Nurse elevates the HOB to 0-5 degrees and maintains the client’s head in a midline position. Avoid clustering activities and nursing procedures. Hyperoxygenate the client prior to suctioning. Quiet environment in presence of headache. Lights lowered for clients with photophobia. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

149 Key Features of Increased Intracranial Pressure
Decreased LOC (lethargy to coma). Behavior changes; restless, irritable, and confused. Headache. Nausea and vomiting. Change in speech pattern. Aphasia. Slurred speech. Change in sensorimotor status. Pupillary changes; dilated and nonreactive or constricted and nonreactive pupils.Cranial nerve dysfunction. Ataxia. Seizures. Cushing’s triad: increased BP, widening of pulse rate and decreased heart rate. Abnormal posturing: Decerebrate (latest stage) or decorticate (latest stage). 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

150 Copyright - Mary Roche, RN, MSN, CS
Head Injury Craniocerebral Trauma commonly referred to as head trauma, is a traumatic insult to the brain caused by an external physical force that may produce a diminished or altered state of consciousness. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

151 Head Injury Direct vs. Indirect Injury
Various terms are used to describe brain injuries that are produced when a mechanical force is applied either directly or indirectly to the brain. A force produced by a blow to the head is a direct injury. A force applied to another body part with a rebound effect to the brain is an indirect injury. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

152 Head Injury Shearing Injuries
The brain may also rebound or rotate on the brain stem, causing diffuse axonal injury (shearing injuries). This moving brain may be contused or lacerated as it moves over the inner surfaces of the cranium, which is irregularly shaped and sharp. Damage most frequently occurs to the frontal and temporal lobes of the brain, especially the raised surfaces of the summits of the gyri. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

153 Copyright - Mary Roche, RN, MSN, CS
Primary Brain Injury Results from the physical stress (force) within the brain tissue caused by open or closed trauma. Open Head Injury occurs when there is a fracture of the skull or the skull is pierced. The integrity of the brain and the dura is violated and there is exposure to the outside. Damage may occur to underlying vessels, dural sinus, brain, and the cranial nerves. Closed head injury is the result of blunt trauma; the integrity of the skull is not violated. It is the more serious of the two types of injury. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

154 Primary Brain Injury Open Head Injury
Four types of fractures associated with open head injuries. linear fracture - A linear fracture is a simple, clean break in which the impacted area of bone bends inward, whereas the area around it bends outward. Linear fractures account for about 80% of head fractures. depressed fracture - In a depressed fracture the bone is pressed inward into the brain tissue to at least the thickness of the skull. open fracture - In an open fracture, the scalp is lacerated, creating a direct opening to the brain tissue. comminuted fracture - involves fragmentation of the bone, with depression of the bone into the brain tissue. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

155 Primary Brain Injury Unique Fracture
A unique fracture is the basilar skull fracture. It occurs at the base of the skull and results in CSF leakage from the nose or ears. Of significance with this fracture is the potential development of hemorrhage caused by damage to the internal carotid artery; damage to cranial nerves I, II, VII, and VIII; and infection. The majority of penetrating injuries to the skull are caused by gunshot wounds and knife injuries. The degree of injury to the brain tissue depends on the velocity, mass, shape, and direction of impact. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

156 Primary Brain Injury Closed Head Injury
Caused by blunt trauma and lead to concussions, contusions, and lacerations of the brain. Concussion - is characterized by a brief LOC. Damage occurs to the gray matter of the cerebral cortex or possibly to the diencephalon or brain stem. The damage to the axons is functional, not structural, which is why permanent neurologic dysfunction is generally not seen. Contusion - Contusion is bruising of the brain tissue. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

157 Primary Brain Injury Types of force
Acceleration Injury An acceleration injury is caused by the head in motion. Deceleration Injury A deceleration injury occurs when the head is suddenly stopped or hits a stationary object. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

158 Primary Brain Injury Secondary Responses and Insults
The most frequently occurring response is the development of increased Intracranial pressure (ICP) attributable to edema, hemorrhage, hematoma development, impaired cerebral autoregulation, or hydrocephalus. Hypoxemia, hypercapnia, or systemic hypotension may precipitate increased ICP. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

159 Secondary Responses and Insults Increased Intracranial Pressure
The brain is composed of brain tissue, blood, and cerebrospinal fluid encased in a rigid skull. Through the processes of accommodation and compliance, the ICP is maintained at its normal level of mmHg despite transient increases in pressure that occur. Increased ICP is the leading cause of death from head trauma in clients who reach the hospital alive. It occurs when compliance no longer takes place. As the ICP increases, cerebral blood flow decreases, leading to tissue hypoxia, a decrease in serum pH level, and an increase in CO2 levels. This process causes cerebral vasodilation, edema, and a further increase in the ICP, and the cycle continues. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

160 Secondary Responses and Insults Increased Intracranial Pressure
If not treated, the brain herniates downward toward the brain stem, causing irreversible brain damage and possible death. Two types of edema may cause ICP: vasogenic and cytotoxic. A third type (interstitial edema) occurs in the presence of acute brain swelling. Vasogenic edema - is seen most often as a cause of increased ICP in the adult. Fluid accumulates mostly in the white matter. Cytotoxic or cellular, edema - may occur as a result of a hypoxic insult, which causes a disturbance in cellular metabolism, the sodium pump, and active ion transport. This results in an abnormal amount of fluid in the brain cells. Cytotoxic edema may lead to vasogenic edema and further increase in ICP. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

161 Focus on the Elderly: Head Injury
It is the fifth leading cause of death year old group has second highest incidence of head injury of all age groups. Falls and motor vehicle accidents are most common cause. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

162 Focus on the Elderly: Head Injury High Mortality Factors
The following factors contribute to high mortality: Falls causing subdural hematomas – especially CSH. Poorly tolerated systemic stress. Medical complications, such as hypotension, hypertension, and cardiac problems. Decreased protective mechanisms, which make clients susceptible to infections (especially pneumonia). Decreased immunologic competence, further diminished by head injury. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

163 Physical Assessment Clinical Manifestations
The goals of nursing assessment are the establishment of baseline data and the early detection of and prevention of increased ICP, systemic hypotension, hypoxia, or hypercapnia. Because it is estimated that 5% to 20% of clients with head trauma have associated cervical spinal cord injuries, all clients with head trauma are treated as though they have spinal cord injury until radiographic studies prove otherwise. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

164 Copyright - Mary Roche, RN, MSN, CS
Nursing Assessments The nurse makes the following assessments: Airway and breathing pattern Vital signs Neurologic Eye Motor 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

165 Copyright - Mary Roche, RN, MSN, CS
Other Assessments The following assessments are also made: Laboratory – there are no laboratory tests to diagnose primary brain injury; however, several tests are used to prevent secondary damage. ABGs, CBC, serum glucose, electrolytes and osmolality. Radiography. Other – Magnetic Resonance Imaging is particularly useful. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

166 Common Respiratory Patterns in Comatose Clients
PATTERN LOCATION OF LESION Cheyne-Stokes Usually bilateral in cerebral Respiration hemispheres. Cerebellar sometimes. Midbrain. Upper pons Central neurogenic Hyperventilation Low midbrain. Upper pons. Apneustic breathing Mid pons. Low pons. Cluster breathing Low pons. High medulla. Ataxic breathing Medulla. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

167 Copyright - Mary Roche, RN, MSN, CS
Minor Head Injury If the person is sleeping, wake him every - hours for the first two days,asking name, where the client is, and identification of caregiver. Expect the person to complain of headache, nausea, or dizziness for at least 2-hours. If these symptoms are severe or do not improve, contact the physician immediately or take the person back to the ER. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

168 Head Injury Altered Cerebral Tissue Perfusion
Expectations The client is expected to maintain a normal ICP, maintain appropriate vital signs and ABGs, and improve LOC. Interventions Severe head injuries – admitted to CCU or trauma center. Minor head injuries – either admitted to general nursing unit for 2- hour observation or sent home with instructions. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

169 Head Injury Nonsurgical Management
Interventions are directed toward preventing or detecting increased ICP, promoting fluid and electrolyte balance, and monitoring the effects of treatments and medications. Vital signs are assessed q. 1-2 hours. Nurse positions client to avoid extreme flexion or extension of the neck and maintain the head in midline position. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

170 Head Injury Nonsurgical Management
Prophylactic hyperventilation during the first 20 hours after injury is usually avoided as it may produce ischemia. Induction of barbiturate coma: for clients whose ICP cannot be controlled by other means, the client may be given Nembutal to decrease metabolic demands of the brain and cerebral blood flow, thus decreasing edema. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

171 Head Injury Drug Therapy
Mannitol used as an osmotic diuretic. Codeine or Sublimaze may be used with ventilated clients to decrease agitation and control restlessness. Narcan reverses these. Neuromuscular blocking agents such as Pavulon help decrease cerebral metabolic rate and must never be used without sedation. Anticonvulsants such as Dilantin are given for seizures. Tylenol or aspirin are given to reduce fever. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

172 Head Injury Surgical Management
The physician may elect to insert an intracranial pressure monitoring device. Various types are used. Craniotomy In extreme cases where ICP cannot be controlled, the physician may elect to perform a craniotomy. Removal of nonvital brain tissue allows expansion of brain tissue. A craniotomy may also be performed to removed epidural or subdural hematomas. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

173 Brain Tumors Key Features
Cerebral Tumors Headache (most common feature) Vomiting unrelated to food intake Changes in visual acuity and visual fields; diplopia Hemiparesis or hemiplegia Hypokinesia Hyperesthesia, paresthesia, decreased tactile discrimination Seizures Aphasia Changes in personality and/or behavior 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

174 Brain Tumors Brain Stem Tumors
Hearing loss (acoustic neuroma) Facial pain and weakness Dysphagia, decreased gag reflex Nystagmus Hoarseness Ataxia and Dysarthria (cerebellar tumors) 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

175 Brain Tumors Key Features of Brain Tumors
Complications of Tumors Cerebral edema results from changes in capillary endothelial tissue permeability which allows plasma to seep into the extracellular spaces. This leads to increased ICP, and herniation of brain tissue may occur. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

176 Brain Tumors Key Features
A variety of focal neurologic deficits result from edema, infiltration, and compression of surrounding brain tissue. Increased ICP may also result from obstruction of the flow of CSF or displacement of the lateral ventricles by the expanding lesion. Typically, a tumor obstructs the aqueduct of Sylvius or one of the ventricles or encroaches on the subarachnoid space. Posterior fossa tumors may obstruct the flow of CSF from the fourth ventricle to the foramen of Luschka of Magendie. With any brain tumor, the obstruction of normal CSF flow causes hydrocephalus and eventually leads to increased ICP. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

177 Brain Tumors Classifications
Benign Acoustic neuroma Meningioma Pituitary adenoma Astrocytoma (a grade 1 may become malignant) Chondroma Craniopharyngioma Hemangioblastoma Malignant Astrocytoma (grades 2, , ) Oligodendroglioma Ependymoma Medulloblastoma Chondrosarcoma Glioma Lymphoma 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

178 Brain Tumors Incidence / Assessment
Incidence/Prevalence Brain tumors account for % of all cancer deaths. Each year 6,000 primary cases are diagnosed and 18,000 secondary cases are found. Brain tumors in the adult population are seen primarily in clients 0-60 years old. Assessment Clinical manifestations vary. Diagnosis based on history, neuro assessment, clinical exam and testing. Noninvasive diagnostic studies CT and MRI and done first. Additionally EEG and PET may be indicated. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

179 Copyright - Mary Roche, RN, MSN, CS
Interventions Nonsurgical: drug therapy, radiation, chemotherapy, radiosurgical procedures. Surgical: Craniotomy. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

180 Surgical Management after Craniotomy
Focus of Postop care is to monitor the client to detect changes in status and prevent or minimize complications. Positioning based on type of surgery. NPO status for 2-hours. Monitoring the dressing: check for drainage (typical amount is 0-50 cc per shift). Excessive amounts of drainage should be reported to physician immediately. Monitoring lab values: CBC, electrolytes, osmolality, coag studies and ABGs. HCT and HGB Drug therapy: Routinely given meds include anticonvulsants, histamine blockers and corticosteroids. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

181 Continuing Care after Craniotomy
The client with a brain tumor is managed at home if possible. Seizures are a potential complication that can occur at any time for as long as a year or more postoperatively. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

182 Preventing Postoperative Complications
Increased ICP is the major postop complication of cranial surgery. Symptoms include severe headache, deteriorating LOC, restlessness, irritability and dilated or pinpoint pupils. Treatment includes placing the client supine with HOB elevated 0-5 degrees. Osmotic diuretics may be given to decrease edema. Surgery may be necessary. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

183 Preventing Postoperative Complications
Hydrocephalus - caused by obstruction of the normal CSF pathway from edema, an expanding lesion such as a hematoma, or blood in the subarachnoid space. A surgical shunt may be placed for treatment. Respiratory Problems - Complications include atelectasis, pneumonia, and neurogenic pulmonary edema. Frequent deep breaths, movement, incentive spirometry are useful in preventing these complications. Wound infection - Occur more in debilitated clients. If infection occurs the wound will be red and puffy. The nurse may treat a localized infection. For more severe infection, systemic antibiotic treatment is given. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

184 Preventing Postoperative Complications
Meningitis an inflammation of the Meninges and may occur as a result of wound infection, CSF leak or contamination during surgery. Fluid And Electrolyte Imbalance Complications include diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH). Clients are on strict I&O. The nurse assesses the client carefully for indications of fluid overload or dehydration during treatment. Serum electrolyte levels and osmolality are measured daily or more often if indicated clinically. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

185 Copyright - Mary Roche, RN, MSN, CS
Brain Abscess A brain abscess is a prurulent infection of the brain in which pus forms in the extradural, subdural, or intracerebral area of the brain. Organisms enter from the ear, sinus, or the mastoid area. Organisms cause a local infection. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

186 Brain Abscess Physical Assessment/Clinical Manifestations
Clinical manifestations are insidious. Mild lethargy, some confusion. Pupillary response is normal in the early stage. As increased ICP progresses, the pupils dilate and become nonresponsive. 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

187 Key Features of Brain Abscess
Early Manifestations Headache Fever Focal neurologic deficits Lethargy Late Manifestations Confusion Increased intracranial pressure (ICP) Dilated and nonresponsive pupils Visual field deficits Cushing’s triad 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

188 Antibiotics Used To Treat Brain Abscesses
Streptococcus Penicillin Chloramphenicol Anaerobes Staphylococcus Metronidazole Nafcillin Methicillin Vancomycin Enterobacteriaceae Toxoplasma Cefotaxime Pyrimethamine Sulfonamides Trimethoprim- sulfamethoxazole Clindamycin Fluconazole 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

189 Copyright - Mary Roche, RN, MSN, CS
Presentation Credits This presentations was developed for Mary Roche under contact with Peter Martin, dba Stacy House Designs. The presentation is the sole, copyrighted property of Mary Roche. Copies of this and other presentations can be seen on the Internet at Please fill out the guestbook selection when visiting that site. Thank you. Mary Roche & Peter Martin 4/22/2003 version Copyright - Mary Roche, RN, MSN, CS

190 The End Mary Roche, MSN, RN, CS


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