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Nursing Care of Patients with Central Nervous System Disorders
The Nervous System Nursing Care of Patients with Central Nervous System Disorders
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Meningitis Pathophysiology
Infection / Inflammation of Brain & Spinal Cord Viral- flu-like s/s, last 1-2 wks Bacterial- may begin as URI, enters blood and invade CNS, causes meninges to become inflamed and ICP to increase. May cause vessel occulsion and necrosis of brain, may affect cranial nerves.
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Signs & Symptoms Severe Headache Fever Photophobia Petechial Rash
Nuchal Rigidity Positive Kernig’s and Brudzinski’s Signs Nausea and Vomiting Encephalopathy
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Kernig’s & Brudzinski’s
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Complications Seizures Cranial Nerve Damage
Occasional Permanent Neurological Deficits Dx with Lumbar puncture and C&S
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Therapeutic Interventions
Antibiotics Antipyretics Cooling Blanket PRN Dark, Quiet Environment Monitor VS, neuro cks Monitor for s/s of >ICP and seizure activity Analgesics Corticosteroids Antiemetics Isolation if Contagious
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Encephalitis Pathophysiology
Inflammation of Brain Tissue- affects cerebrum, brainstem and cerebellum May cause Nerve Damage, Edema, Necrosis IICP May be viral , bacterial, parasitic, or vaccines
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Signs & Symptoms Headache Fever Nausea and Vomiting Nuchal Rigidity
Confusion Decreased LOC and mental status change are s/s of >ICP Seizures Photophobia Ataxia Tremors Coma Death
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Complications Cognitive Disabilities Personality Changes
Ongoing Seizures Blindness Dx: CT, EEG, LP
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Therapeutic Interventions
Analgesics Anticonvulsants Antipyretics Corticosteroids Antivirals Sedatives Neurological Assessment Symptomatic Care
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Increased Intracranial Pressure
Pathophysiology Pressure exerted within the cranial cavity by increase in brain, blood or CSF Caused by brain tumor, trauma, or intracranial hemorrhage
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Signs & Symptoms Restlessness >Confusion > coma Irritability
Decrease in LOC- earliest s/s Hyperventilation Pupil Changes Cushing’s Response- late s/s
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ICP Monitoring External Ventricular Drain- catheter into the ventricle allows CSF drainage and monitor ICP Subarachnoid Bolt-easy to place, but easily occluded. Intraparenchymal Monitor- placed directly into brain tissue, most accurate but does not drain CSF and can become occluded
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ICP Monitoring
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Nursing Diagnoses: CNS Infections
Pain Hyperthermia Disturbed Thought Processes Self Care Deficit Impaired Physical Mobility Risk for Injury: Seizures
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Headaches Tension-persistent contraction of scalp and facial muscles causing tenderness and HA. Result of stress and sustained muscle contraction of head/neck. May be r/t premenstrual syndrome, anxiety, emotional distress, and depression Use relaxation exercises, massage affected muscles,rest, heat, non-narcotic analgesics
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Migraines Caused by cerebral vasoconstriction followed by vasodilation
May have aura, throbbing, pounding pain usually on one side of head, exacerbated by noise and light Triggers may include specific foods, noise, bright light, alcohol and stress Tx: quiet, dark environment, cold compress,medications (Imitrex, Zomig, Ergot)
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Cluster Headaches Occurs in clusters during time span of days to weeks. Caused by anxiety, stress, and vascular disturbances, worse with use of alcohol. Usually begins suddenly, same time of night, unilateral, throbbing, severe pain Tx: quiet dark environment. Cold compress, meds- NSAIDs and antidepressants
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Nursing Care for Headaches
Assessment WHAT’S UP? (Where, how, Aggravating, timing, severity, other s/s, pt perception) Patient Education Keep HA Diary Record Triggers, Timing, Symptoms Teach Relaxation and Stress Reduction Teach : Medications
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Seizures Sudden, abnormal, and excessive electrical discharges from the brain that can change motor or autonomic function, consciousness, or sensation.
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Classification Partial (Simple) Generalized (complex)
Begin on One Side of Cerbral Cortex Generalized (complex) Both Hemispheres Involved Both may have aura (visual, auditory, olfactory disturbance)
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Signs & Symptoms cont’d
Partial Seizures (Simple) begin on 1 side of brain Automatisms- dream like state Maintain Consciousness Usually < 1 Minute Paresthesias- numbness, tingling Visual Disturbances Generalized (Complex Partial) both hemispheres involved Lose Consciousness, 2 – 15 minutes Two types
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Signs & Symptoms cont’d
Generalized Seizures Absence (Petit Mal) Staring Tonic Clonic May Have Aura Usually Lose Consciousness Rigidity Followed by Muscle Contraction and Relaxation Incontinence Postictal Period Dx: EEG, look for underlying cause Tx: anticonvulsants, surgical resection
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Emergency Care: Seizure
Pad Side Rails Prevent Injury Maintain an open Airway Do Not Restrain Turn on Side to Prevent Aspiration Suction PRN Observe and Document
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Status Epilepticus 30 Minutes of Seizure Activity
Therapeutic Interventions Ensure Airway and Oxygenation Administer IV Diazepam Teach patient – sudden withdrawal of anticonvulsants can lead to status epilepticus
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Traumatic Brain Injury
Hemorrhage Contusion- bruising Laceration Most common cause is MVA, falls, assault, sports-related injury Think immobilize if trauma Can Cause Cerebral Edema Hyperemia Hydrocephalus Brain Herniation Death
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Types of Injury Concussion Contusion Hematoma Subdural Epidural
Dx: CT, MRI
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Therapeutic Interventions
Surgical Removal of Hematoma Control IICP ICP Monitoring Osmotic Diuretic- mannitol Mechanical Hyperventilation Therapeutic Coma
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Complications of TBI Brain Herniation Diabetes Insipidus
Acute Hydrocephalus Labile Vital Signs Posttraumatic Syndrome Cognitive and Personality Changes
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Brain Herniation
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Nursing Diagnoses Ineffective Cerebral Tissue Perfusion- monitor VS, GCS, implement measures to prevent ICP Ineffective Airway Clearance- Monitor airway and BS, Limit suction, >HOB 30, turn pt freq to mobilize secretions Ineffective Breathing Pattern- monitor Bs, resp rate, O2 sat, ABG’s
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Brain Tumor Pathophysiology Neoplastic growth of the Brain or Meninges
Primary or secondary (Metastatic) Compress or Infiltrate Brain Tissue Cause IICP Begin with vague s/s HA, visual changes, seizures, motor and sensory changes Dx: MRI, CT, angiogram Tx: Radiation, Chemo, surgery, symptom control
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Complications/ Nursing Dx
Seizures,HA Aphasia Memory Impairment Cognitive Changes Ataxia, lethargy Coma, then death Disturbed thought process Self-care deficit Pain Impaired physical mobility Risk for injury
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Intracranial Surgery Indicated for Hematomas, tumor, trauma, malformation, and seizures Craniotomy- surgical opening in the skull Craniectomy- removal of part of cranial bone Crainoplasty- repair of bone or replacement with prosthesis
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Preoperative Care Lab work-up and anesthesia evaluation
Patient Education helps control anxiety ICU visit Surgery may last 2 hrs for biopsy to 12 hrs or longer for procedure
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Postoperative Care Nursing Diagnoses
Risk for Ineffective Cerebral Tissue Perfusion Risk for Infection Body Image Disturbance Deficient Knowledge
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Herniated Disk Pathophysiology
Disk moves out of normal position, tough outer ring tears, allows leakage of soft inner portion of disk, compresses nerve roots Dx:MRI, Mylegram
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Signs & Symptoms Pain Muscle Spasm Numbness or Tingling of Extremity
Weakness Atrophy
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Therapeutic Interventions
Rest Physical Therapy Traction- seperates the verebral bodies and allow disk to return to normal position Muscle Relaxants NSAIDS, Analgesics Epidural Anesthetic/Steroid Surgery- diskectomy, spinal fusion Complications are hemorrhage, nerve damage, reherniation
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Pre / Postoperative Care
Preop- teach log rolling, routine teaching Postop- Monitor exts (color, warmth, pulses), pain, monitor surgical site, I & O Nursing Diagnoses Pain Risk for Impaired Urinary Elimination Risk for Impaired Physical Mobility
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Spinal Cord Injury Pathophysiology
Damage to Nerve Fibers, interferes with communication Between Brain and Body. If suspected, avoid flexion or rotation of the spine Damage may be cause by bruising, tearing, cut, edema, or bleeding into the spinal cords. Most common are MVA, Falls, sports injury and assault Dx: x-ray, CT, MRI
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Signs & Symptoms Cervical Injury Paralysis, may be quadriplegia
Paresthesias Impaired Respiration Loss of Bladder and Bowel Control C3 or Above Fatal- muscles for breathing are paralyzed When assessing motor/sensory function, no sensation/movement in all 4 exts, C4-C8 damaged.
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Signs & Symptoms continued
Thoracic/Lumbar Injury Paraplegia- paralyzed from waist down Altered Bowel and Bladder Control Cord below the injury stops functioning completely, urine and feces retention
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Spinal Shock SNS Disruption ( Spinal Neurogenic Shock) cord stops functioning below injury Vasodilation- SNS disrupted, dilation of blood vessels allows more blood flow Hypotension Bradycardia Hypothermia- cooled blood circulates, unable to maintain body temp Urine and Feces Retention
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Complications of Spinal Cord Injury
Infection DVT Orthostatic Hypotension Skin Breakdown Renal Complications Depression and Substance Abuse Autonomic Dysreflexia- life-threatening
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Spinal Cord Injury
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Emergency Management Respiratory-mechanical ventilation, trach
Gastrointestinal- TPN, feeding not started till BS returns Genitourinary- Foley Immobilization- skeletal traction (Crutchfield, Gardner-Wells, Halo)
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Surgical Management Stabilize Spine Halo Brace Rods Corset Brace
Body Cast
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Skeletal Traction
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Nursing Diagnoses Impaired Gas Exchange Ineffective Airway Clearance
Risk for Autonomic Dysreflexia Total Urinary Incontinence/ Skin Integrity Constipation Impaired Physical Mobility Self-Care deficit Anxiety Risk for Sexual Dysfuntion
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Dementia Not a disease, but a s/s of a number of different disorders
Huntington’s Disease Parkinson’s Disease Alzheimer’s Disease Vascular Dementia Chronic Alcoholism Medications
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Signs & Symptoms Recent Memory Affected First
Remote Memory Affected Later Forget How to Perform Simple Tasks Wandering Aphasia Behavioral Problems Total Dependence Dx: MRI, CT, for underlying cause, Depression screening, medication review
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Therapeutic Interventions
Medications Delay Progression Cholinesterase Inhibitors NMDA Agonist End of Life Decision Making Nursing Diagnosis Risk for Injury Disturbed Thought processes Imbalanced nutrition
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Delirium Temporary mental disturbance with rapid or gradual onset, must be treated promptly Underlying Cause Must be Corrected Pain Hypoxia Response to medications Illness, electrolyte imbalance
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Parkinson’s Disease Chronic, degenerative disorder affects basal ganglia and < production of dopamine and excess of Acetylcholine. Loss of dopamine impairs semiautomatic movements because it transmits impulses. Etiology is unknown, may be genetic.
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Signs & Symptoms Muscular Rigidity, posture changes Bradykinesia
Pill-Rolling Tremor Difficulty Initiating Movement Shuffling and Freezing Gait Dx: Hx/physical exam
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Signs & Symptoms
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Therapeutic Interventions
Antiparkinson drugs Anticholinergic Agents Pallidotomy Nursing Diagnosis Impaired physical mobility Self-care deficit Risk for injury
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Huntington’s Disease
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Signs & Symptoms Progressive, genetic, degenerative disease of the brain Dementia Personality Changes Inappropriate Behavior Paranoia Violence Choreiform Movements Dysphagia Depression Death Dx: Family hx, CT, MRI, genetic testing Tx: antipsychotics, antidepressant
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Alzheimer’s Disease S/S
Progressive, degenerative disease with loss of mental functioning Dx: H/P, MRI, autopsy Stage 1 Forgetfulness Last 2-4 yrs Decreased interest in activities Stage 2 Progressive Memory Loss Irritability Depression Aphasia Sleep Disruption Hallucinations Seizures
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Signs & Symptoms cont’d
Stage 3- Constant supervision required Complete Dependency Bowel and Bladder Control Lost Emotional Control Lost Inability to Recognize Significant Others Death
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Therapeutic Interventions
Cholinesterase Inhibitors (Aricept, Exelon) NMDA Antagonists (Namenda, Axura) Antidepressants Antipsychotics Antianxiety Agents
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Nursing Diagnoses: The Patient with Dementia
Self-care deficit Risk for Injury Imbalanced Nutrition Disturbed Thought Processes Caregiver Role Strain
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