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Nursing Management of the Adult Patient with Neurological Disorder

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1 Nursing Management of the Adult Patient with Neurological Disorder
Dr. Marietta Mercado

2 Objectives Upon completion of this lesson, the student will be able to
describe how cognitive alterations influence the neurological assessment. list the changes in ICP that affect the cerebral perfusion pressure and cerebral oxygenation. differentiate between the types of brain trauma. state the etiology and course of the inflammation of the CNS and intracranial hemorrhage. explain the different diagnostic studies and surgical approach

3 Brain Needs… Blood flow Glucose Oxygen

4 Diagnostic Studies Skull and Spinal Radiology
CT (Computerized Tomography) MRI (Magnetic Resonance Imaging) PET (Positron Emission Tomography) EEG (Electroencephalogram) EMG (Electromyelogram) Cerebral Angiography

5 Computed Tomography (CT) scan
a type of brain scanning that may or may not require an injection of a dye used to detect intracranial bleeding, space-occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain structures

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7 Magnetic resonance imaging (MRI)
a noninvasive procedure that identifies types of tissues, tumors, and vascular abnormalities Similar to the CT scan but provides more detailed pictures and does not expose the client to ionizing radiation

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9 Electroencephalography
A graphic recording of the electrical activity of the superficial layers of the cerebral cortex

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11 Cerebral angiography Injection of contrast through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions

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13 Neurological Assessment
Level of Consciousness (LOC) Pupils Vital Signs (VS) Neuromuscular status Response to stimuli Posturing Glasgow Coma Scale (GCS)

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15 I. Neurological Disorders
The normal functioning of the CNS can be affected by a number of disorders, the most common of which are headaches, tumors, vascular problems, infections, epilepsy, head trauma, demyelinating diseases, stroke and metabolic & nutritional diseases.

16 Headaches Classified based on characteristics of the headache
Not always chronic…be careful Classified based on characteristics of the headache Functional vs. Organic type May have more than one type of headache History & neurologic exam diagnostic keys

17 Pattern Tension Migraine Cluster Site Bilateral, basilar, band-like
Unilateral, anterior Unilateral, occular Quality Squeezing, constant Throbbing Severe Cycles, years Periodic, years Remitting, relapsing Duration Days, weeks, months Hours, days 30-90 min Onset Anytime Prodrome, starts in AM Nocturnal Assoc. S&S Stiff neck N&V, photo/phono-phobia Horner syndrome ONSET: Not reliable or diagnostic

18 HA: Essential History Onset this particular headache
Character of pain, severity and duration Associated symptoms Prior history, pattern Original onset: prior testing, treatment Other therapeutic regimens

19 Physical Exam Neurologic examination
Inspect for local infections, nuchal rigidity Palpation for tenderness, bony swellings Auscultation for bruits over major arteries

20 Organic vs. Traumatic vs. Functional: Diagnostics
CBC: underlying illness, anemia Chem panel: if associated vomiting, dehydrated CT scan: for focal neurological signs, sinus No LP for suspected ICP; ↑ association with brain herniation

21 Don’t Miss It “Worse headache of my life”
Caused by subarachnoid hemorrhage from an aneurysm or head injury “Worse headache of my life” Changes in LOC, focal neurological signs Highly correlated with CVA Untreated, 50 % mortality

22 Headache Teaching Guide
Keep a calendar/diary Avoid triggers Medications (purpose, side effects) Stress reduction Dark quiet room, exercise, relaxation Regular exercise

23 Intracranial Pressure (ICP)
Brain Components Skull is a rigid vault that does not expand It contains 3 volume components: Brain tissue: (80%) or 2% of TBW Intravascualr blood: (10%) CSF: (10%)

24 Increased Intracranial Pressure
An increase in ICP caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation Can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

25 Intracranial Pressure (ICP)
Intracranial Pressure (ICP) is the pressure exerted by brain tissue, blood volume & cerebral spinal fluid (CSF) within the skull. Normal ICP – 10 to 15 mmHg Cerebral Perfusion Pressure (CPP) Normal CPP – 70 to 100 mmHg Normal CSF – 5 to 13 mmHg

26 Increased Intracranial Pressure (IICP) fluid pressure > 15 mm Hg
IICP is a life threatening situation that results from an  in any or all 3 components within the skull > volume of brain tissue, blood, and / or CSF Cerebral edema: > H2O content of tissue as a result of trauma, hemorrhage, tumor, abscess, or ischemia

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29 Surgical Intervention for ICP
Ventriculoperitoneal Shunt Shunts CSF from ventricles into the peritoneum Implementation Postprocedure Position the client supine and turn from back to non-operative side Monitor for signs of increasing ICP resulting form shunt failure Monitor for signs of infection

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31 Acute Coma Levels of consciousness diminish in stages:
Confusion: can’t think rapidly and clearly التشويش Disorientation: begin to loose consciousness Time, place, self Lethargy: spontaneous speech and movement limited Obtundation: arousal (awakeness) is reduced Stupor: deep sleep or unresponsiveness Open eyes to vigorous or repeated stimuli Coma: respond to noxious stimuli only Light (purposeful), full coma (non-purposeful), deep coma (no response)

32 Multiple Sclerosis Causes:
is a chronic autoimmune disorder affecting movement, sensation, and bodily functions. It is caused by destruction of the myelin sheath covering nerve fibres in the central nervous system (brain and spinal cord). Causes: 1. Autoimmune destruction. 2. Heredity. 3. Viruses. 4. Environmental factors.

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34 Diagnostic Test: 1. MRI. 2. Physical examination.

35 Clinical Manifestations:
* Early: 1. Muscle weakness causing difficulty walking 2. loss of coordination or balance 3. numbness or other abnormal sensations 4. visual disturbances, including blurred or double vision

36 * Late: 1. Fatigue . 2. Muscle spasticity and stiffness 3. Tremors. 4. Paralysis . 5. pain . 6. Vertigo. 7. Speech or swallowing difficulty . 8. Loss of bowel and bladder control. 9. Sexual dysfunction . 10. Changes in cognitive ability

37 Treatment: 1. Immunosuppressant drugs . These drugs include corticosteroids such as prednisone and methylprednisolone, the hormone adrenocorticotropic hormone (ACTH), and azathioprine. 2. Physiotherapy. 3. Occupational therapy.

38 Parkinson's Disease Causes:
is a progressive movement disorder marked by tremors, rigidity, slow movements (bradykinesia), and postural instability. It occurs when, for unknown reasons, cells in one of the movement-control centers of the brain begin to die. Usually occurs in the older population Causes: 1. Degeneration of brain cells in the area known as the substantia nigra, one of the movement control centers of the brain. 2. Drugs given for psychosis, such as haloperidol (Haldol) or chlorpromazine (Thorazine), may cause parkinsonism.

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40 Clinical Manifestations
1. Tremors 2. Slow movements (bradykinesia), freezing in place during movements (akinesia). 3. Muscle rigidity or stiffness, occurring with jerky movements 4. Postural instability or balance difficulty occurs. 5. Masked face. 6. Depression 7. Speech changes 8. Problems with sleep 9. Emotional changes10. Incontinence. 11. Constipation. 12. Handwriting changes, 13. (dementia)

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42 Treatment: Nursing Management
1. Maintain regular exercise (physical therapy, occupational therapy) 2. Provide good nutrition to maintain health. 3. Drugs that replace dopamine (levodopa) 4. If the patient is unresponsive or intolerant to pharmacotherapy, Electro convulsive therapy is indicated. Nursing Management * Observe the patient's mood, cognition; organization and general well being * Observe for features of depression, *Suicidal precautions to be followed, if the patient exhibits any suicidal ideas *Instruct the patients to speak slowly and clearly, and to pause and take a deep breath at appropriate levels.

43 Trigeminal Neuralgia (Tic Douloureux)
- disorder of cranial nerve V causing disabling and recurring attacks of severe pain along the sensory distribution of one or more branches of the trigeminal nerve

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45 Medical management 1. anticonvulsant drugs : carbamazepine (Tegretol), phenytoin (Dilantin) 2. Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve; temporary effect, lasts 6-18 months 3. Surgery a. peripheral – avulsion of peripheral branches of trigeminal nerve

46 Surgical management 1)retrogasserian rhizotomy
– total severance of the trigeminal nerve intracranially; results in permanent anesthesia, numbness, heaviness, and stiffness in affected part; loss of corneal reflex 2) microsurgery – uses more precise cutting and may preserve facial sensation and corneal reflex

47 Seizure Disorders & Epilepsy
paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function Epilepsy: spontaneously recurring seizures caused by a chronic underlying condition Two major classes: Generalized Partial

48 SEIZURE Phases of Generalized Seizure Attack Aura Phase – split second
Tonic Phase -15 – 20 sec unresponsiveness to 15 sec of muscle rigidity Clonic Phase – 1 to 5 minutes of convulsion Post-ictal – 5 mins to 30 mins to hours of deep sleep Status Epilepticus – prolonged seizures or recurrent seizures without the patient completely recovered between episodes.

49 Aura Phase I smell bananas! I taste metal! I’m seeing spots I’m dizzy!
I feel very angry!

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51 Seizure Disorders & Epilepsy Drug Therapy for Tonic-Clonic and Partial Seizures
Carbamezepine/ Tegretol Divalproex/ Depakote Gabapentin/ Neurontin Lamotrigine/ Lamictal Levetiracetam/ Keppra Phenytoin/ Dilantin Tiagabine/ Gabitril Topiramate/ Topamax Valproic Acid/ Depakene Felbamate/ Felbatol * Phenobarbitol** *Felbatol has been associated with aplastic anemia **Phenobarbitol is a barbituate

52 Seizure Disorders & Epilepsy: Nursing Care
Assure oxygen and suction equipment at bedside Safety precautions in active stage Support/ protect head Turn to side Lossen constricted clothing Ease to floor Time seizure, record details of seizure and post-ictal phase

53 Seizure Disorders & Epilepsy: Nursing Care
Patient teaching: importance of good seizure control using medication as ordered Medical alert bracelet Avoid decreased sleep, increased fatigue Regular meals/ snacks

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55 Seizure Disorders & Epilepsy: Status Epilepticus
Medical emergency Seizure repeated continuously Tonic clonic: hypoxia could develop if muscle contraction is lengthened. Also: hypoglycemia, acidosis, hypothermia, brain damage, death IV administration of antiepileptics Maintain airway patency

56 Intracranial surgery Craniotomy:
Opening the skull surgically to gain access to intracranial structures

57 Intracranial surgery Burr hole
Circular opening made in the skull by a drill

58 Intracranial surgery Craniectomy An excision of a portion of the skull

59 Intracranial surgery Cranioplasty
Repair of a cranial defect by means of a plastic or metal plate

60 Intracranial surgery Transsphenoidal
Through the nasal sinuses to gain access to the pituitary gland

61 Cerebrovascular Accident (CVA) or Stroke
destruction (infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen - caused by thrombosis, embolism, hemorrhage

62 Types of Stroke Ischemic: embolic or thrombotic
blocked blood flow to the brain Hemorrhagic: Intracranial Hemorrhage (ICH) , Subarachnoid Hemorrhage(SAH), ruptured cerebral aneurysm TIA ( transient: ischemic attack) : this is a stroke, although symptoms resolve within an hour

63 Signs and Symptoms of Stroke
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden dizziness, loss of balance or coordination or trouble walking Sudden severe headache with no known cause

64 Risk Factors High blood pressure Carotid artery disease
Physical inactivity Excess alcohol intake Atrial fibrillation Diabetes Heart disease Smoking Family history Prior stroke/TIA High cholesterol Obesity

65 Diagnostic Examination
CT and brain scan reveal lesion EEG – abnormal changes Cerebral arteriography – may show occlusion or malformation of blood vessels

66 Treatment for Ischemic Stroke
tPA=Thrombolytic agent Document time of symptom onset. (If awoke with symptoms, must go by time when last seen normal) Immediate head CT (check for blood) Evaluate for tPA administration (review exclusion/inclusion criteria) CT does not show new stroke, need MRI

67 Treatment Cont… Keep NPO, until a formal swallow eval. is done.
Admit patient and perform diagnostic testing: Carotid US, Echocardiography, ECG monitoring for a-fibrillation, MRI, fasting Lipid, Clotting disorder blood work (Antiphospholipid, Factor V, Antithrombin III) Rehabilitation

68 Hemorrhagic Stroke Treatment
Do not give antithrombotics or anticoagulants Monitor and treat blood pressure greater than 150/105 NPO, Anticipate Neurosurgical consult BP treatment - nipride

69 Meningitis An inflammation of the meninges of the brain and spinal cord Bacterial Causes:Meningococcus and pneumococcus ,Haemophilus-influenza Organisms enter brain by: Blood stream Respiratory tract Pentrating wonds of skull It is secondary to another infections such as otitismedia, upper respiratory infection,pneumonia Viral (aseptic): less severe than bacterial

70 Clinical Presentations
High fever, tachycardia, chills, petechial rash headache, photophobia, stiff neck Nausea, vomiting papilledema (> ICP),confusion, altered LOC Restlessness and irritability Seizures Brudzinski’s: passive flexion of the neck produces pain & increased rigidity Kernig’s: Flex hip and knee and then straighten the knee…pain or resistance?

71 complication of Meningitis
Seizures Sepsis Cranial nerve dysfunctions Cerebral infarction Coma Death

72 Collaborative care Bacterial menigitis is a medical emergency
Treatment focus on rapid diagnosis and starting IV antibiotic therapy immediately(7-21 days) Isolation Antipyretics Analgesics Anticonvulsants Osmotic diuretics IV fluids

73 Diagnosis lumbar puncture :collect samples of CSF Bacterial:
Cloudy csf Elevated protein level Increased WBC Decreased glucose level Elevated CSF pressure C&S OF CSF CBC Cultures from Blood, urine, throat, nose

74 Lumbar puncture Insertion of a spinal needle through L3-L4 interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or instill air, dye or medications Contraindicated in clients with increased intracranial pressure, because the procedure will cause a rapid decrease in pressure within the CSF around the spinal cord, leading to brain herniation

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76 Head Injury usually caused by car accidents, falls, assaults Types:
Concussion Contusion Hemorrhage

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79 Concussion severe blow to the head jostles brain causing it to strike the skull; results in temporary neural dysfunction

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81 Contusion results from more severe blow that bruises the brain and disrupts neural function

82 Assessment findings Concussion – headache, transient loss of consciousness, retrograde or posttraumatic amnesia, nausea, dizziness, irritability Contusion – neurologic deficits depend on the site and extent of damage; include decreased LOC, aphasia, hemiplagia, sensory deficits

83 Hemorrhage epidural hematoma
accumulation of blood between the dura mater and skull; commonly results from laceration of middle meningeal artery during skull fracture; blood accumulates rapidly subdural hematoma accumulation of blood between the dura and arachnoid; venous bleeding that forms slowly; may be acute, subacute, or chronic

84 Hemorrhage subarachnoid hematoma – bleeding in the subarachnoid space intracerebral hematoma – accumulation of blood within the cerebrum

85 Assessment findings Hemorrhages a. epidural hematoma
- brief loss of consciousness, progresses to severe headache, vomiting, rapidly deteriorating LOC, possible seizure.

86 Spinal Cord Injuries - occurs most commonly in young adults male between ages 15 and 25 -causes – motor vehicle accidents, diving in shallow water, falls, industrial accidents, sports injuries, gunshot or stab wounds - nontraumatic causes – tumors, hematomas, aneurysms, congenital defects (spina bifida)

87 Management 1. Skeletal traction: a. Cervical tongs – inserted through burr holes; traction is provided by a rope extended from the center of tongs over a pulley with weights attached at the end

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Cervical tongs AMERICAN DREAM REVIEW INSTITUTE

89 Medical Management b. Halo traction
1) stainless steel halo ring fits around the head and is attached to the skull with four pins; halo is attached to plastic body cast or plastic vest 2) permits early mobilization, decreased period of hospitalization and reduces complications of immobility

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91 Assessment Findings quadriplegia – cervical injuries (C1-C8) cause paralysis of all four extremities; respiratory paralysis occurs in lesions above C4 due to lack of innervation to the diaphragm paraplegia – thoraco/lumbar injuries (T1-L4) cause paralysis of the lower half of the body involving both legs

92 QUESTION

93 THANK YOU


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