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)

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!

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

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
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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