Nursing of Adults with Medical & Surgical Conditions Neurological Disorders

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

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: RBC None WBC 0-10 cells (lymphocytes and monocytes)

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

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

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

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

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

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

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

Carotid Duplex Electromyogram (EMG) 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

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

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

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

Headache Treatment Diet Psychotherapy Medications 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

Headaches Comfort Measures 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

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

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

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

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

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

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.

Epilepsy or Seizures Types of seizures Grand Mal Petit Mal Psychomotor 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

Epilepsy or Seizures Jacksonian-focal Myoclonic Akinetic 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

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

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

Epilepsy or Seizures Treatment During seizure Medications Surgery 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

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

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

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

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

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

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

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

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

Parkinson’s Disease

Parkinson’s Disease Treatment Medications Surgery Levodopa Sinemet 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

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

Alzheimer’s Disease Signs & Symptoms Early Stage Second 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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”

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

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

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

Bell’s Palsy

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.

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

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

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

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

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

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

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

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

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

Crainiotomy

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

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

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

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

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

Spinal Cord Trauma Signs & Symptoms Loss of muscle function depends on level of injury INJURY LOST FUNCTION Above C4 All, including respiration C5 Arms, chest, all below chest C6-C7 Some arm, fingers, chest, all below chest Thoracic Trunk, all below chest Lumbosacral Legs

Spinal Cord Trauma Spinal Shock Autonomic dysreflexia 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

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

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

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