Care of the Patient with a Neurological Disorder

Care of the Patient with a Neurological Disorder
Chapter 54 Care of the Patient with a Neurological Disorder - Complete Slides

Overview of Anatomy and Physiology
Nervous System Responsible for communication and control within the body Interprets and processes information received and sends in to the appropriate area of brain and spinal cord where response is generated Body’s link to the environment Works with endocrine to maintain homeostasis NS reacts in a split second Endocrine works more slowly to secrete hormones

Structural divisions 2 Main Structural division: Central nervous system (CNS) Brain and spinal cord Occupies a medial position in the body Responsible for interpreting incoming sensory information and issuing instructions based on past experiences The nervous system functions as a switchboard for the body. It receives messages from the environment and transfers them to the brain for interpretation and action.

2 main structural divisions – cont’d Peripheral nervous system (Lies Outside the CNS), divided into 2 main divisions: Somatic nervous system Sends messages from the CNS to the skeletal muscles Voluntary muscles Sensory (Afferent) and Motor (Efferent) Neuron Autonomic nervous system Transmits messages from the CNS to the smooth muscle, cardiac muscle and certain glands Involuntary Known as involuntary nervous system Actions takes place without conscious control

Overview of Anatomy and Physiology -cells of the nervous system
2 Broad Category: Neurons, transmitter cells as they carry messages to and from the brain and spinal cord. Neuroglial or glial cells, support and protect the neurons while producing cerebrospinal fluid (CSF), which continuously bathes the structures of the CNS. Neuron (nerve cell) Basic nerve cell of nervous system Separate unit compose of: Cell body, the axon and the dendrites Cell body Contains a nucleus surrounded by cytoplasm Axon Cylindrical extension of a nerve cell Conducts impulses away from the neuron cell body Dendrites Branching structures that extend from a cell body and receive impulses The basic nerve cell in the body is known as a neuron. Neurons act under the “all or none law.” Explain this phenomenon.

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neuron (nerve cell) – cont’d Synapse A gap (space) between each neuron Defined as region surrounding the point of contact between two neurons Between a neuron and an effectors organ, across which nerve impulses are transmitted through the action of a neurotransmitter Governed by “all or none” law Never a partial transmission of a message Impulse is either strong enough to elicit a response or too weak to generate the message

Overview of Anatomy and Physiology -cells of the nervous system (cont’d)

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neuromuscular junction Area of contact between ends of a large myelinated nerve fiber and a fiber of skeletal muscle Necessary for functioning of the body Neurotransmitters act to make sure the neurological impulse passes from nerve to muscle

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neurotransmitters It modify or result in transmission of impulses between synapses Best known neurotransmitter are: Acetylcholine, Norepinephrine, dopamine and serotonin. Acetylcholine (Ach) Role in nerve impulse transmission Spills into synapse area and speed transmission of impulse Cholinesterase (enzyme) Deactivate Ach once message or impulse has been sent Happens rapidly and continuously as each impulse is relayed Norepinephrine Effects on maintaining arousal (awakening from deep sleep) and dreaming Regulation of mood (i.e. happiness and sadness)

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neurotransmitters Dopamine Primarily affects motor function Involved in gross subconscious movements of skeletal muscles Role in emotional responses In Parkinson’s disease There is a decrease in dopamine, that’s why the person suffers from tremors or involuntary, trembling muscle movements Serotonin Induces sleep Affects sensory perception Controls temperature Role in control of mood

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neuron coverings Myelin White, waxy, fatty material Increases rate of transmission of impulses Protects and insulate fibers nodes of Ranvier Wraps the axon leaving the CNS in layers of myelin with indentation Further increase rate of transmission, because impulse can jump from node to node

Overview of Anatomy and Physiology -cells of the nervous system (cont’d) Neuron coverings Peripheral nervous system Myelin is produced by Schwann cells Outer membrane gives rise to another layer which is very important in regeneration of cells called neurilemma, functions of neurilemma: Helps to regenerate injured axons Regeneration of nerve cell occurs only in peripheral nervous system Cells damaged in CNS results permanently (paralysis) Do not have neurilemma, so no regeneration occurs.

Overview of Anatomy and Physiology -cells of the nervous system (cont’d)

Figure 54-1 The neuron is composed of three main structures. These structures are the cell body, the axon, and the dendrites. What roles are played by each of the parts? (A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby. B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.) A, Diagram of a typical neuron. B, Scanning electron micrograph of a neuron. C, Myelinated axon.

Overview of Anatomy and Physiology -Central Nervous System (CNS)
One of two main divisions of nervous system Composed of brain and spinal cord Functions somewhat like a computer but is much more complex Cranium protects the brain Vertebral column protects the spinal cord The central nervous system is one of the divisions of the nervous system. The brain is one of the body’s largest organs. What are the functions of each of the structures identified? What is the impact on the body if the key areas identified are injured or unable to adequately function?

Brain Specialized cells in the brain’s mass of convoluted, soft, gray or white tissue coordinate and regulate the functions of CNS Largest organ weighing about 3 pounds Divided into four parts Cerebrum Diencephalon Cerebellum Brain stem Midbrain; pons; medulla oblongata; coverings of the brain and spinal cord; ventricles

Brain Cerebrum Largest part of the brain Divided into left and right hemispheres Outer portion is gray matter Called - Cerebral cortex Arrange into folds called gyri (convolutions) Grooves are called sulci (fissures Corpus callosum Connecting structure or bridge Divides two hemispheres into for lobes Frontal lobe, parietal lobe, temporal lobe, occipital lobe

Brain Cerebrum Fissure is a natural division between the left and right hemispheres Controls initiation of movement on opposite side of body Specific areas of cerebral cortex are associated with specific functions: Frontal Lobe Written speech (ability to write) Motor speech (ability to speak) Motor ability – directs movements of body; left side controls the right side of the body and the right side of the brain controls the left side of the body. Intellectualization – the ability to form concepts Judgment formation

Brain.. cont Cerebrum.. cont Specific areas of cerebral cortex are associated with specific functions.. cont: Parietal Lobe Interpretation of sensory impulses from the skin such as touch, pain, and temperature Recognition of body parts Determination of left from right Determination of shapes, sizes and distances Temporal Lobe Memory storage Integration of auditory stimuli Occipital Lobe Interpretation of visual impulses from the retina Understanding of the written word

Brain Diencephalon Called interbrain It lies beneath the cerebrum Contains: thalamus and hypothalamus Thalamus Relay station for some sensory impulses while interpreting other sensory messages (i.e. pain, touch, pressure) Hypothalamus Lies beneath the thalamus Role in control of body temperature, fluid balance, appetite, emotions (i.e. fear, pleasure, pain) Controls sympathetic and parasympathetic divisions of autonomic system as is the pituitary glands Influences heartbeat, contraction and relaxation of walls of blood vessels, hormone secretion, and other vital body functions

Brain Cerebellum Lies posterior and inferior to cerebrum Second largest portion of brain Contains two hemispheres with convoluted surface much like cerebrum Responsible for coordination of voluntary movement and maintenance of balance, equilibrium, and muscle tone Sensory messages from semicircular canals in inner ear sends messages to cerebellum Brain stem Located at the base of the brain Consist of: Midbrain; pons; medulla oblongata; Connect spinal cord and cerebrum Carries all nerve fibers between spinal cord and cerebrum

Brainstem..cont Midbrain Superior portion of brain stem Responsible for motor movement, relay of impulses, auditory and visual reflexes Origin of Cranial Nerves (CN) III and IV Pons Connects midbrain to medulla oblongata “Pons” means “bridge” Origin of CN V through VIII Composed of myelinated nerve fibers and is responsible for sending impulses to structures that are inferior and superior to it Contains a respiratory center that compliments respiratory centers located in medulla

Brainstem.. cont Medulla oblongata Distal portion of brainstem Origin of CN IX and XII Controls heart beat, rhythm of breathing, swallowing, coughing, sneezing, vomiting, and hiccups (singultus) Vasomotor center regulates diameter of blood vessels, helps aid in BP control

Sagittal section of the brain (note position of midbrain).
Figure 54-2 (From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.) Sagittal section of the brain (note position of midbrain).

Coverings of brain and spinal cord Three protective coverings called meninges 1. Dura mater Outer most layer 2. Arachnoid membrane Second layer 3. Pia mater Inner most layer Provides oxygen and nourishment to nervous tissue These layers also bathe Spinal Cord and brain in cerebrospinal fluid (CSF)

Ventricles Four in all: 3rd, 4th, left and right lateral ventricle Spaces or cavities located in brain CSF Clear and resembles plasma Flows into subarachnoid spaces around brain and spinal cord and cushions them Contains protein, glucose, urea, and salts Contains substances that forms a protective barrier (the Blood-Brain Barrier) Prevents harmful substances to enter the Brain and SC

Spinal Cord 17 to 18 inch cord extending from brainstem to second lumbar vertebra Two main functions: Conducting impulses to and from the brain Serving as a center for reflex actions Responsible for certain reflex activity such as knee jerk Sensory neuron sends information to cord, a central neuron (within the cord) interprets impulse, and a motorneuron sends message back to muscle or organ involved Message is sent, interpreted, and acted upon without traveling to brain

Neural pathway involved in the patellar reflex.
Figure 54-3 (From Thibodeau, G. A., Patton, K. T. [1990]. Anthony’s textbook of anatomy and physiology. [13th ed.]. St. Louis: Mosby.) Neural pathway involved in the patellar reflex.

Another example

Overview of Anatomy and Physiology - Peripheral nervous system
Comprise motor nerves, sensory nerves, and ganglia outside brain and SC 31 pairs of spinal nerves 12 pairs of cranial nerves Autonomic nervous system Sympathetic nervous system Parasympathetic nervous system

Spinal Nerves 31 pairs and all are mixed nerves Transmit sensory information to SC through afferent neurons and motor information from CNS to areas of body through efferent neurons Named according to the corresponding vertebra (e.g C1, C2) See next figure

Cranial Nerves 12 pairs Attach to posterior surface of brain, mainly brainstem Conduct impulses between head, neck, and brain, excluding vagus nerve (CN X), which also serves organs in thoracic and abdominal cavities List of CN, impulses sent and functions: CN I, Olfactory – nose to brain – sense of smell CN II, Optic – eye to brain – vision CN III, Oculomotor – brain to eye muscles – eye movements, pupillary control CN IV, Trochlear – brain to external eye muscles – eye movements CN V, Trigeminal (opthalmic, maxillary, mandibular branch) – skin & mucus membrane of head to brain; teeth to brain; brain to chewing muscles – sensation of face, scalp and teeth; chewing movements CN VI, Abducens – brain to external eye muscles – turning eyes outward CN VII, Facial – taste buds of tongue to brain; brain to facial muscles – sense of taste; contraction of muscles of facial expression CN VIII, Acoustic (vestibulocochlear) – ear to brain – hearing; sense of balance

Cranial Nerves.. cont List of CN, impulses sent and functions..cont: CN IX, Glossopharyngeal – throat and taste buds of tongue to brain; brain to throat muscle and salivary glands – sensations of throat, taste, swallowing, movements, secretion of saliva CN X, Vagus – throat, larynx & organs in thoracic & abdominal cavities to brain; brain to muscles of throat & to organs in thoracic & abdominal cavities – sensation of throat, larynx & of thoracic & abdominal organs; swallowing, voice production, slowing heartbeat, acceleration of peristalsis CN XI, Spinal accessory – brain to certain shoulder & neck muscles – shoulder movements & turning movements of head CN XII, Hypoglossal – brain to muscles of tongue – tongue movements

Autonomic Nervous System Controls activities of smooth muscle, cardiac muscle, and all glands Subdivision of peripheral nervous system Primary function is to maintain internal homeostasis Strives to maintain a normal heartbeat, constant body temperature, and normal respiratory pattern Two divisions: Sympathetic nervous system Parasympathetic nervous system

Autonomic Nervous System Two divisions Antagonistic One slows an action, and the other accelerates the action Note: function simultaneously, but have the ability to dominate each other as the need arises Stress Sympathetic takes over to prepare body for “fight or flight” Heartbeat accelerates, BP increases, adrenal glands increase secretions To calm the body Parasympathetic dominates Slowing heartbeat and decreasing BP and adrenal hormones

Effects of Normal Aging on the Nervous System Loss of brain weight Loss of neurons (1% a year after age 50) Cortex losing cells faster than the brainstem Remaining cells undergo structural changes General decline in interconnections of dendrites Reduction in cerebral blood flow Decrease in brain metabolism and oxygen utilization Neurons may contain senile plaques, neurofibrillary tangles & age pigment lifofuscin Altered sleep/ wakefulness ratio Decrease in ability to regulate body temperature Decrease in velocity of nerve impulses Decreased blood supply to spinal cord causes decreased reflexes As the body ages, there is a gradual reduction in the effectiveness of neurological functioning. An estimated 1% loss of neurons occurs after age 50. Outline the implications when factoring in this loss for an adult at age 65. Ask those who have grandparents to estimate their ages and discuss the implication of a 1% loss in neurons for them. What safety implications arise when considering the neurological changes in an older adult?

Overview of Anatomy and Physiology Older Adult Consideration Box
Neurological Disorder As neuron are lost with aging, there is a deterioration in neurological function, resulting in slowed reflex and reaction time Tremors that increase with fatigue are commonly observed in adults The sense of touch & the ability for fine motor coordination diminish with aging Most older people possess the ability to learn, but the speed of learning is slowed. Short-term memory is more affected by aging than long-term memory The incidence of physiologic dementia or organic brain syndrome-including Alzheimer’s disease, Pick’s disease & multiinfarct dementia-increases with aging Incidence of stroke increases with age. Prognosis is affected by the location & extent of the cerebral damage. Rehab potential after a stroke is often reduced by advanced age & coexisting medical problem Nerve irritation resulting from arthritis, joint injuries or spinal-cord compression can cause chronic pain or weakness Dementia is not a normal consequence of aging but may be result of may reversible conditions, including anemia, fluid & electrolyte imbalance, malnutrition, hypothyroidism, metabolic disturbances, drug toxicity, a drug reaction/idiosyncrasy & hypotension.

Prevention of neurological problems Avoid drug and alcohol use Smoking increases lung cancer and lung CA metastasizes to the brain Safe use of motor vehicles Safe swimming practices Safe handling and storage of firearms Use of hardhats in dangerous construction areas Use of protective padding as needed for sports Some of the disorders in the neurological system are the result of a disease process. Other illnesses occur in response to an injury or are the impact of a chosen lifestyle. What populations are associated with unhealthy neurological behaviors? What opportunities exist for health teaching in these populations?

Assessment of the Neurological System
History Essential for diagnosing neurological disease Includes specifics about symptoms experienced Asses patient understanding & perception of what is happening. Obtain info from family members/ significant others may be helpful Make sure information is complete For patients with suspected neurological conditions presence of many symptoms of subjective data may be significant. These include the following: Headaches, especially those that first occur after middle age or those that change in character; headaches that are worse in the morning or awaken a person from sleep are especially significant

History..cont For patients with suspected neurological conditions presence of many symptoms of subjective data may be significant. These include the following..cont: Clumsiness or loss of function in an extremity Change in visual acuity Any new or worsened seizure activity Numbness or tingling in one or more extremities Pain in an extremity or other part of the body Personality changes or mood swings Extreme fatigue or tiredness

Mental Status Assessment of patient neurological mental status is important Examination generaly includes orientation (person, place, time, and purpose), mood and behavior, general knowledge (such as names of U.S. presidents), and short- and long-term memory. The patient’s attention span and ability to concentrate may also be assessed Note actual patient statement & note actual level of orientation (name, date, time & purpose), always try different approach cause patient my learn the correct answer through repetition

Level of consciousness Level of consciousness (LOC) is the earliest and most sensitive indicator that something is changing. A decreasing level of consciousness is the earliest sign of increased intracranial pressure. LOC has two components Arousal (or wakefulness) and Awareness. Wakefulness is the most fundamental part of LOC. If the patient can open the eyes spontaneously to voice or to pain, it says that the wakefulness center in the brainstem is still functioning. Awareness, a higher function controlled by the reticular activating system in the brainstem.

Level of consciousness Awareness has four components: Orientation: person, place, time, purpose Memory: assess short-term memory; do not ask yes or no questions. Calculation: example, “If you have $2 and your apple costs $1.25, how many quarters would you get back?” Fund of knowledge: Ask the patient to name the president and to tell you what’s on the national news (Lower, 2002). Restlessness, disorientation, and lethargy may be seen first.

LEVELS OF CONSCIOUSNESS Alert, Disorientation, Stupor, Semicomatose, Comatose, level & description below: Alert: Responds appropriately to auditory, tactile, and visual stimuli Disorientation: Disoriented; unable to follow simple commands, thinking slowed, inattentive, flat affect. Stupor: Responds to verbal commands with moaning or groaning, if at all Semicomatose: Impaired state of consciousness characterized by obtundation and stupor, from which a patient can be aroused only by energetic stimulation Comatose: Unable to respond to painful stimuli; cornea and papillary reflexes are absent. The patient cannot swallow or cough. The patient is incontinent of urine and feces. The EEG pattern demonstrates decreased or absent neuronal activity.

Glasgow Coma Scale Quick, practical & standardized system for assessing the degree of consciousness impairment in the critically ill and for predicting the duration and ultimate outcome of coma, particularly head injury. Neurologic evaluation uses the Glasgow Coma scale as an indicator of the severity of brain injury. The highest possible number of 15 indicates that the individual has no impairment, while a score of 3 indicates brain death. A score of 6 – 8 is associated with a coma state

Glasgow Coma Scale E: Eye opening Spontaneous = 4 To verbal stimuli = 3 To pain stimuli = 2 None = 1 M: motor response Obeys commands = 6 Localizes pain = 5 Normal withdrawal flexion = 4 Decorticate flexion = 3 Decerebrate extension = 2 Flaccid = 1 V: verbal response Oriented = 5 Confused conversation = 4 Inappropriate words = 3 Incomprehensible sounds = 2

LANGUAGE AND SPEECH Speech is a function of the dominant hemisphere, which is on the left side of the brain for all right-handed people and most left-handed people. Aphasia An abnormal neurological condition in which the language function is defective or absent because of an injury to certain areas of the cerebral cortex-Broca’s area in the frontal lobe and Wernicke’s area in the posterior part of the temporal lobe. Aphasia includes all areas of language, including speech, reading, writing, and understanding. Aphasia has been subdivided as follows: Sensory aphasia or receptive aphasia: inability to comprehend the spoken word or written word. Motor aphasia: inability to use symbols of speech (also called expressive aphasia). Global aphasia: inability to understand the spoken word or to speak.

LANGUAGE AND SPEECH Anomia A form of aphasia characterized by the inability to name objects. Dysarthria Defined as difficult, poorly articulated speech that usually results from interference in the control over the muscles of speech. The general cause is damage to a central or peripheral nerve.

The cranial nerves classification I (olfactory) - Identification of common odors II (optic) - Testing of visual acuity and visual fields III (oculomotor) - Testing of ability of eyes to move together in all directions, testing pupillary response IV (trochlear) - Tested with oculomotor; testing eye movements V (trigeminal) - Jaw strength and sensation of face corneal reflex VI (abducens) - Tested with oculomotor; testing eye movements VII (facial) - Ability of face to move in symmetry, identification of tastes VIII (acoustic, or vestibulocochlear) - Testing of hearing through whisper or other means and checking equilibrium and balance. IX (glossopharyngeal) - Identification of taste X (vagus) - Gag reflex, movement of uvula and soft palate XI (spinal accessory) - Shoulder and neck movement XII (hypoglossal) - Tongue motion

MOTOR FUNCTION Motor function disturbances are the most commonly encountered neurological symptom In general, the parts of the motor status examination include gait and stance, muscle tone, coordination, involuntary movements, and the muscle stretch reflexes. Reflexes that are usually tested include the biceps, triceps, brachioradialis, quadriceps, gastrocnemius, and soleus muscles. The examiner taps briskly over the muscle with a reflex hammer. The response is noted and graded on a scale, usually from 0 to 4+, with 4+ being hyperreflexic The most important feature of any reflex pattern is not the absolute value on the scale, but the comparison of one side of the body with the other. Stick figures are commonly used to record the bilateral values. Damage to the nervous system often causes a serious problem in mobility. A loss of function is called paralysis; a lesser degree of movement deficit from partial or incomplete paralysis is called paresis.

MOTOR FUNCTION..cont Muscles may be flaccid (weak, soft, and flabby and lacking normal muscle tone), with absent deep tendon reflexes, or spastic (involuntary, sudden movement or muscular contraction), with increased reflexes. With some muscle problems, the affected muscle shows small, localized, spontaneous, and involuntary contractions called fasciculations. With other problems, clonus (a forced series of alternating contractions and partial relaxation of a muscle) may occur.

SENSORY AND PERCEPTUAL STATUS The sensory examination is the most common difficult part of the neurological evaluation. Specific alterations in sensation that should be assessed include pain; touch; temperature; and proprioception, the sensation pertaining to spatial-position and muscular-activity stimuli originating from within the body or to the sensory receptors that those stimuli activate. This sensation gives one the ability to know the position of the body without looking at it and the ability to know objects by the sense of touch.

SENSORY AND PERCEPTUAL STATUS..cont Unilateral neglect, a condition in which an individual is perceptually unaware of and inattentive to one side of the body Another perceptual problem is hemianopia or hemianopsia, which is characterized by defective vision or blindness in half of the visual field of one or both eyes.

SENSORY AND PERCEPTUAL STATUS..cont It is usually not feasible or necessary to complete the total neurological examination during shift-to-shift assessments of the patient. In intensive care units, the neurological checks may be done as frequently as every 15 minutes. Factors that are the most important include orientation, level of consciousness, bilateral muscle strength, speech ability, involuntary movements, ability to follow commands, and any abnormal posturing.

Laboratory and Diagnostic Exam
BLOOD AND URINE TESTS Urine culture may rule out infection involving the urinary tract. Other urine testing may indicate the presence of diabetes insipidus Urine drug screens may be done to rule out drug use as a cause of lethargy or to identify specific drugs ingested Arterial blood gas values may be an important diagnostic tool in monitoring the oxygen content of the blood Gases may be altered with neurological diseases suc as Guillain-Barre syndrome where breathing pattern were altered Blood test that are routinely done may help narrow the Dx of neurological disorder

CEREBROSPINAL FLUID Normally there are up to 10 lymphocytes per milliliter of spinal fluid. An increase in the number of cells may indicate an infection. Infections such as Tuberculosis meningitis often lower the CSF glucose level Bacterial infection such as TB meningitis often lower the CSF glucose level as well as the chloride levels (culture or smear exam is done to determine the causative organism in meningitis) Spinal-fluid protein is elevated when degenerative disease or a brain tumor is present Blood in the spinal fluid indicates hemorrhage from somewhere in the ventricular system A protein electrophoresis eval may give evidence of neurological diseases such as Multiple Sclerosis (MS)

CEREBROSPINAL FLUID..cont Normal Characteristic of CSF Spec Gravity pH Chloride mEq/L Glucose mg/dl Pressure mm water Total vol ml (15ml in ventricle) Total protein mg/dl – lumbar 10-25 mg/dl – cisternal 5-15 mg/dl – ventricular Gamma globulin 6-13% of total protein count Cell count RBC None WBC cells (all lymphocytes n monocytes) Culture & sensitivity No organism present Serology for syphilis Negative

Other Tests Routine skull radiographs of the head and vertebral column, used in ruling out fractures of the skull and cervical vertebrae. Since the development of the computed tomography (CT) scan, skull radiographs are not used as extensively as before.

Computed Tomography (CT) Scan The purpose of the CT scan, also called the CAT scan, is to detect pathologic conditions of the cerebrum and spinal cord using a technique of scanning without radioisotopes If contrast medium is used, it is important for the nurse to document and report to the physician any history of allergy to iodine and seafood because iodine is present in the contrast medium No special physical preparation on the patient, takes about min without contrast medium and 60 min with contrast medium. Painless except discomfort when IV is started for contrast medium and claustrophobic feeling as head will be placed on a holder while laying still Each image appears specific brain tissue, computer will display areas of increased densities (e.g tumors or thrombi)

Brain Scan The brain scan’s purpose is detecting pathologic conditions of the cerebrum. It uses radioactive isotopes and a scanner. No special physical preparation, patient lay still as the scanner passes over the brain area Procedure takes 45 min for the scanning The patient is injected with radioisotope, minimal discomfort may occur when IV is started for radioisotope If mercury is used as isotope, meralluride (mercuhydrin) is administered several hours before to allow greater concentration of mercury to circulate the brain tissue, coz it minimizes uptake of mercury by kidney Brain scan is being used less frequently than in the past because of the excellent results obtained from CT scan and magnetic resonance imaging (MRI)

Magnetic Resonance Imaging (MRI) Scan MRI uses magnetic forces to image body structures. Used to detect pathologic conditions of the cerebrum and spinal cord, as in detection of stroke, multiple sclerosis, tumors, trauma, herniation & seizures MRI is the diagnostic test of choice for many neurological diseases because it yields greater contrast in the images of soft-tissue structures than does the CT scan The scan involves a magnetic force, hence, the patient is cautioned to remove watches and any metal from body or clothing before entering the scanning room. Painless procedure takes about 45-60min, minimal discomfort for lying still and claustrophobia feeling, patient must be warned that machine may makes loud noises during procedure New advanced in MRI techniques include diffusion weighted imaging and magnetic resonance spectroscopy

Magnetic Resonance Angiography (MRA) Magnetic resonance angiography (MRA) uses differential signal characteristic of flowing blood to evaluate extracranial and intracranial blood vessels. It provides both anatomic and hemodynamic information. MRA is rapidly replacing cerebral angiography for use in diagnosing cerebrovascular disease Also called cMRA (contrast enhanced MRA) if used in conjuction with contrast media

Positron Emission Tomography (PET) Scan In this procedure the patient receives an injection of deoxyglucose with radioactive fluorine. The area in question is scanned, and a color composite picture is obtained. Shades of color give an indication of the level of glucose metabolism; this then can be translated into indications of a pathologic state. PET scan provide non invasive means of determining biochemical processes that occur in the brain There is increased clinical use of PET scan to monitor select patients following stroke, Alzheimer’s disease, tumors, epilepsy, and Parkinson’s disease Discomfort is minimal, patient must be aware the need to lie still during scanning, approx 45 min.

The gray outer surface is the surface of the brain from MRI and the inner colored structure is cingulate gyrus, part of the brain's emotional system visualized with PET. Photo by Monte S. Buchsbaum, M.D.

Lumbar Puncture Performed as part of the Dx workup of the patient who may have a neurological problem A lumbar puncture is done to obtain CSF for examination, to relieve pressure, or to introduce dye or medication It is contraindicated in patients with increased intracranial pressure, because the withdrawal of fluid may cause the medulla oblongata to herniate downward into the foramen magnum Procedure takes 10-15min, commonly done in patient’s room or the imaging department, slight pain & pressure may be felt as the dura is entered, sharp shooting pain down one leg may occur, caused by needle coming close to a nerve Done in side positioned with knee and head flexed at acute angle allowing lumber flexion & separation of the interespinous spaces. Anesthetized the area with local aesthesis then needle inserted at L4-L5 or L5-s1 interspace. Removed inner needle for drainage & measure the spinal fluid. Manometer is used to measure the pressure After the procedure the patient lies flat in bed for several hours. Headache is fairly common and is thought to be caused by the loss of spinal fluid. If a headache develops, bed rest, analgesics, and ice to the head may help. Opioids are usually not helpful

LUMBAR PUNCTURE (BETWEEN L3–L4) Position and angle of the needle when lumbar puncture is performed.

Electroencephalogram The electroencephalogram (EEG) is used to provide evidence of focal or generalized disturbances of brain function by measuring the electrical activity of the brain. Among the cerebral diseases assessed by the EEG are epilepsy, mass lesions (e.g, tumors, abscess, hematoma), cerebrovascular lesions, and brain injury. No special preparation, only rest & quite surrounding before procedure. Usually done first thing in the morning, takes about 1hr to complete After procedure patient must rest and assisted to wash the patient hair to remove the collodion from scalp.

Myelogram The myelogram is commonly used to identify lesions in the intradural or extradural compartments of the spinal canal by observing the flow of radioppaque dye through the subarachnoid space. The most common lesion for which this test is used is a herniated or protruding intervertebral disk. Other lesions include spinal tumors, adhesions, bony deformations, and arteriovenous malformations. Procedure takes about 2 hrs, will be slight discomfort as dura entered and may be asked to assume variety position during procedure Preparation are the same as the lumbar puncture aside from the injection of dye (ask patient for allergic reaction) Patient usually undergoes CT scan 4-6hrs after myelogram Headaches are common after the procedure, might be accompanied by N&V. Patient must lay flat for few hours.

Angiograms The angiograms (cerebral arteriography) is a procedure used to visualize the cerebral arterial system by injecting to visualize the cerebral system by injecting radiopaque material. It allows the detection of arterial aneurysms, vessel anomalies, ruptured vessels, and displacement of vessels by tumors or masses. Clear liquid only before procedure, some other facility require NPO Asses allergic reaction to iodine Takes about 2-3hrs, may experience discomfort lying still for that time period. Supine position on radiograph table When dye injected may experience feeling or extremely hot and seeing flashes of light. After procedure bed rest is ordered for 4-6hrs, VS checked every 15mins, neurological assesment every VS check, asses puncture site for hematoma Patient may be at risk for cerebral vascular accident as well as increase in intracranial pressure. Any changes in LOC must be reported promptly MRA is replacing cerebral ateriography in some facility

CAROTID DUPLEX Combined ultrasound & Doppler technology Amplified response & graphic record & sound registers blood flow velocity indicating stenosis of a vessel Non invasive studies that evaluates carotid occlusive disease Usually ordered on Transient Ischemic Attack patient to determine the pathology of the carotid

ELECTROMYOGRAM Used to measure the contraction of a muscle in response to electrical stimulation Provide evidence of lowere motoneuron disease; primary muscle disease; defects in transmission of electrical impulses at NMJ, such as in Myasthenia gravis Takes 45min for muscle study, there will be discomfort when electrode inserted into muscle & when electrical current is used. Muscle may ache afterwards Asses signs of bleeding after procedure at the injection sites. May need analgesic for discomfort & rest period

Echoencephalogram Uses ultrasound to depict the intracranial structures of the brain Helpful in detecting ventricular dilation & major shift of midline structures in the brain as result of expanding lesion Procedure is similar to brain scan

Common Disorders of the Neurological System
Headaches Etiology/pathophysiology The exact mechanism of head pain is not known. Although the skull and brain tissues are not able to feel sensory pain, pain arises from the scalp, its blood vessels and muscles, and from the dura mater and its venous sinuses. Pain also arises from the blood vessels at the base of the brain and from cervical cranial nerves. Blood vessels may dilate and become congested with blood Headaches can be classified as vascular, tension, and traction-inflammatory Vascular headache, include migraine, cluster, and hypertensive headaches Tension headache, arise from medical problems such as cervical arthritis. Traction-inflammatory headaches include those caused by infection, intracranial or extracranial causes, occlusive vascular structures, and temporal arteritis. Headaches are a frequent complaint in both men and women. They can be caused by a variety of events. Headaches are classified according to their underlying cause. What population is most at risk of experiencing each of the headache types?

Headaches (continued) Clinical manifestations Headache pain may be worse by stress or tension. Knowledge of the patient’s perception of the effect of stress on the pain is important in planning effective interventions. Migraine headaches Prodromal (early s/s ofsigns and symptoms that occur before the acute attack. These may include any of the following: Visual field defects Experiencing unusual smells or sounds Disorientation Paresthesias and, In rare cases, paralysis of a part of the body. To diagnose and classify the type of headaches, an accurate accounting of the clinical manifestations is important. What data should be collected from the patient regarding the headache?

Headaches (continued) Clinical manifestations...cont During a migraine headache s/s may include: N&V, sensitivity to light, chilliness, fatigue, irritability, diaphoresis, edema & other signs of autonomic dysfunction Abnormal metabolism of serotonin, a vasoactive neurotransmitter found in platelets & cells of the brain, plays a major role. Assessment Include the patient’s understanding of the headache, possible causes and any precipitating factors Important to determine what measures relieve the symptoms as well as the location, frequency, pattern & character of the pain Includes the site of return f the headache, time of day, intervals between headaches Initial onset of the headache, presence of any symptoms that occur before the headache or associated symptoms, the presence of allergies and any family history of similar headache patterns are also important to asses

Headaches (continued) Assessment..cont Objective date include any behavior indicating stress, anxiety and pain Changes in ADL, as abnormally raised temperature n presence of sinus drainage may be important Document abnormality during physical exam of neurological assessment Diagnostic test Usual testing includes neuro exam, a CT scan (MRI or PET), brain scan, skull radiograph and lumbar pucture Lumbar pucture is contraindicated if increased intracranial pressure exist, or if brain tumor is suspected as it may cause brain herniation. CT scan is the preferable test in this situation.

Headaches (continued) Medical management Diet: limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork Psychotherapy Medications Migraine headaches Aspirin, acetaminophen, ibuprofen Ergotamine tartrate Codeine Inderal Treatment options for headaches can be pharmacological or nonpharmacological. What nondrug interventions can be employed for managing headaches? What is the underlying rationale for each of the interventions? Why are caffeine restrictions recommended in headache sufferers and yet caffeine is one of the leading ingredients in migraine relief medications?

Medical management...cont Acetylsalicylic acid (aspirin) may help relieve migraine pain. Ergotamine tartrate preparations taken early in the attack may prevent progression of the headache. These drugs act by constricting cerebral blood vessel walls and reducing cerebral blood flow. Reduces inflammation and may reduce pain transmission Given orally, sublingually, rectally or by injection Can be combined with caffeine, phenobarbital & belladona Side effects of ergot preparations include nausea, vomiting, numbness and tingling, muscle pain, and changes in heart rate They cannot be taken by pregnant women because they stimulate contractions of the uterine smooth muscle

Medical management…cont Drugs that are Classified as selective serotonin receptor agonists, these drugs are all indicated to treat acute migraine (with or without aura) in adults: Eletriptan (Relpax) Almotriptan (Axert), Frovatriptan (Frova), Naratriptan (Amerge), Rizatriptan (maxalt), Sumatriptan (Imitrex), and Zolmigriptan (Zomig) The Triptan are thought to act on receptors in the extracerebral, intracranial vessels that become dilated during a migraine attack. Stimulating this receptor constricts cranial vessels, inhibit neuropeptide release and reduces nerve impulse transmission along trigeminal pain pathways. Triptans relieve N&V and photphobia assicuated with acute migrane attack

Medical management ..cont Other drugs that maybe used include nonopioid analgesics such as phenacetin, acetaminophen (Darvocet N). Propranolol (Inderal) has been used in the prophylactic treatment of migraine and other vascular headaches. Intranasal lidocaine has been used with some relief. Tension headaches Non-narcotic analgesics Traction-inflammatory headaches Treat cause Comfort measures Cold packs to forehead or base of skull Pressure to temporal arteries Dark room; limit auditory stimulation

Nursing Interventions and Patients Teaching Because stress and emotional upsets may precipitate some headaches and worsen others, relaxation and rest should be facilitated. This includes relaxation techniques, planned sleeping hours, and regular rest periods. Alcohol should not be used to relieve tension because it may become addicting and has been found to be a significant cause of cluster headaches, especially ones caused by tension. Treatment options for headaches can be pharmacological or nonpharmacological. What nondrug interventions can be employed for managing headaches? What is the underlying rationale for each of the interventions? Why are caffeine restrictions recommended in headache sufferers and yet caffeine is one of the leading ingredients in migraine relief medications?

Nursing Interventions and Patients Teaching Comfort measures. Other treatments that may be helpful for a patient with a headache include cold packs applied to the forehead or base of the skull. Pressure applied to the temporal arteries may be helpful. People with migraine headaches, especially, are usually most comfortable lying in a dark room with minimal auditory stimulation.

Education and Teaching: Avoidance of factors that trigger headaches, Relaxation techniques including biofeedback, Importance of maintaining regular sleep patterns, Medications to be used (including dose, actions, and side effects), and The importance of follow-up care. Prognosis With proper treatment the person with headaches can expect to live a normal life. Changes in lifestyle may need to occur, especially during acute episodes of headache pain. The person may have to adjust to periodic headaches and will need to rest until the headache resolves.

Neurological Pain Etiology/pathophysiology Neurological pain other than headache is common. The transmission of pain is not fully understood, but patients may experience disabling pain either caused by a disorder within the nervous system (lesion in nerve roots, thalamus, central pain tract [lateral spinothalamic]) or caused peripherally at a distant part of the body Pain receptor can be activated by cellular damage certain chemicals such as histamine, heat, ischemia, muscle spasm & sensation of cold & pruritus that go beyond specific level of intensity. Pain that is described as unbearable and does not respond to treatment is classified as intractable. It is chronic and often debilitating, and may prevent the patient from functioning in ADLs.

Neurological Pain..cont Assessment Subjective: Perception of pain is highly subjective Asses patient understanding of pain Any precipitating factors Measures to relieve stress, including medication & Usual coping patterns of the patient when under stress Site, quality, frequency & nature of the pain Presence of associated symptoms & measures that makes it worse are important too Objective: Any behavioral signs indicating pain or stress Change in ADLs Muscle weakness or wasting Vasomotor responses (flushing) Abnormalities in spinal reflexes Abnormalities noted during the sensory examination

Neurological Pain..cont Diagnostic Test Diagnostic tests for the patient in pain may include electrical stimulation used to define the pain to a greater degree. Psychological testing may be part of the workup. If back or neck pain is present, a myelogram is usually performed. Medical management Nonsurgical methods of pain control include Transcutaneous electrical nerve stimulation (TENS) Spinal cord stimulation. Both techniques use electrodes applied near the site of pain or on or around the spine. Acupuncture has also been used to treat patients with neurological pain.

Neurological Pain..cont Medical management..cont Nerve block used to control intractable pain By injecting local anesthetic, alcohol or phenol close enough to a nerve to block the conduction of impulses Sources of pain treated include trigeminal neuralgia, cancer, or pheripheral vascular disease Duration of effect is from months to years Epidural catheter is used to control pain & spacticity Continued Meds are given

Neurological Pain..cont Medical management..cont Medications are often used to treat patients with neurological pain. Gabapentin (Neurontin) to control neurological pain Nonopioid analgesics such as acetaminophen, propoxyphene (Darvon), phenacetin, and acetylsalicylic acid. Opioids may be prescribed, as well as muscle relaxants, but these drugs may led to abuse. The emphasis should be on helping the patient learn other measures to control the pain.

Neurological Pain..cont Medical management..cont Surgical methods of pain control In cases of intractable pain that does not respond to more conservative measures, surgery may be necessary to reduce or abolish pain. Neurosurgical procedures that may be done include neurectomy, rhizotomy, cordotomy, and percutaneous cordotomy. Side effects of the procedures (cordotomy) include postural hypotension, inability to feel hot or cold, and possibly motor and bowel dysfunction function.

Neurological Pain..cont Nursing Interventions and Patient Teaching Comfort measures. The patient assumes the most comfortable position. Nurse should help the patient to find a comfortable position and may need to actively assist the patient in turning or moving Straining may intensify pain, so stool softener may be needed. Offer prune juice & high fiber diet with 2000ml/ day fluid or more Promotion of rest and relaxation. As with headache, stress and emotional upsets may precipitate or exacerbate neurological pain. Rest and relaxation should be facilitated, with planned sleeping hours and rest periods as needed. Some patients with pain, especially intractable pain, may respond well to psychotherapy.

Neurological Pain..cont Prognosis As with headache pain, neurological pain can in most cases be treated adequately. Lifestyle changes may be helpful in allowing the person to live a full life.

Increased intracranial pressure Etiology/pathophysiology Complex grouping of events that occurs because of multiple neurological conditions Occurs suddenly, can progress rapidly, often requires surgical intervention Considered as an increase in any content of the cranium Space-occupying lesions, cerebrospinal problems, cerebral edema Since cranial vault is rigid and nonexpandable, buildup pressure may occur in weeks, or rapidly depending on cause. Usually involved one side of the brain, but both will eventually involved The structure of the cranium does not allow for expansion as it is housed within the rigid skull. Any increase in the contents will result in an increase in intracranial pressure. What are normal contents of the cranium? What are some causes of intracranial pressure? Does intracranial pressure occur suddenly with rapid onset or is it slow, taking place over a period of time?

Increased intracranial pressure Etiology/pathophysiology..cont Normal ICP = 4 – 13 mmHg Any sustained increase in ICP is dangerous hence early detection and treatment are vital before complications occur Neuron tissue death will begin within 4 – 6 minutes if oxygen is not supplied

Increased intracranial pressure..cont Etiology/pathophysiology..cont How it happened: Increased pressure in cranial cavity compensated by venous compression & cerebrospinal displacement. As pressure increased the cerebral blood flow decreases causing inadequate perfusion to the brain, starting a vicious cycle that causes PCO2 to increase and PO2 & pH decrease. These causing vasodilation and cerebral edema causing further increased intracranial pressure and even greater increase in pressure as compression of neural tissue increased. When pressure is greater than the ability to compensate, pressure is exerted on surrounding structure where the pressure is lower, this movemenet of pressure is called supratentorial shift, which can result in herniation

Increased intracranial pressure..cont Etiology/pathophysiology..cont How it happened..cont Brainstem is compressed at various levels, which in turn compresses the vasomotor center, posterior cerebral artery, oculomotor nerve, corticospinal nerve pathway and the fibers of the ascending reticular activating system as a result of herniation of the brain Rise in systolic pressure and an unchanged diastolic pressure, resulting in a widening pulse pressure, bradycardia & abnormal respiration are late sign of increased ICP and indicating that brain is about to herniate.

Increased intracranial pressure..cont Assessment Subjective Presence of any visual changes such as diplopoa or double vision Change in patient personality Change in the ability to think Presence of nausea or pain, especially headache is important Headache thought resulting from venous congestion & tension in the intracranial blood vessels as the cerebral pressure rises Increase intensity with coughing, straining at stool or stooping Usually present early mornings and may awaken patient from sleep

Increased intracranial pressure..cont Assessment..cont Objective Change of LOC (earliest sign of increased ICP) Disorientation, restlessness or lethargy It’s important to chart what is seen not what is inferred Pupillary sign may change responsiveness as it’s controlled by cranial nerve III (oculomotor nerve) As the brain herniates, the nerve is being compressed-with the top part of the nerve being affected first. The ipsilateral pupil (when lesion in one hemisphere) remains dilated & incapable of constricting Once both halves of the brain become affected bilateral pupil dilation and fixation occur Pupil that is fixed & dilated is called blown pupil, an ominous sign that must be reported to the MD immediately BP & pulse will increase in increased ICP, causing systolic BP to rise If pressure continues widening pulse pressure will occur

Increased intracranial pressure..cont Assessment..cont Objective..cont Pressure will increased parasympathetic transmission of impulses through the vagus nerve to the heart, causing slowing of the pulse Cushing’s response will exist, it is a widened pulse pressure, increase systolic BP and bradycardia. Cushing’s is considered and important Dx sign of late stage brain herniation Breathing pattern may be deep & stertorous (snorelike) or periodic (Cheyne-Stokes) respiration Ataxic breathing may occur (an irregular & unpredictable breathing pattern with random, shallow, and deep breath & occasional pauses) As Intracranial pressure increases to fatal levels, respiratory paralysis occur Seen in patient with damage to medulla oblongata

Increased intracranial pressure..cont Assessment..cont Objective..cont High, uncontrolled temperature occur due to a failure of the thermoregulatory center Presence of Babinski’s reflex, hyperflexia, rigidity & seizures are additional signs of decreased motor function due to compression of the upper motoneuron pathway (corticospinal tract) interrupting transmission of impulses to the lower motoneuron Herniation of the upper part of the brainstem may produce characteristic posturing when patient is stimulated (see picture left)

Increased intracranial pressure..cont Assessment..cont Objective..cont Vomiting & singultus are two objective sign. Vomiting is often projectile in nature & usually not preceded by nausea (called unexpected vomiting) Singultus is caused by compression of the vagus nerve (CN X) when brainstem herniation occur. Papilledema, can be detected by using ophtalmoscope (done by MD’s) as optic disk becomes edematous, reitna is also compressed, damaged retina cannot detect light rays as blind spot enlarges as visual acuity lessened. Papilledema is also called choked disk Urinary incontinence Bulging fontanelles Leakage of CSF (clear yellow or pinkish fluid) from the nose (rhinorrhea) or ear (otorrhea).

Increased intracranial pressure..cont Herniation of the Brain When Inc. ICP exerts enough pressure to displace a portion of the brain, herniation can occur. The brain would herniate through a large foramen in the occipital bone, which lies between the cranial and spinal cavities. Herniation causes severe injury to the brain because of prolonged hypoxia to parts of the brain that control the vital functions of the body, such as breathing and blood circulation. The result is brain death and death of the patient. When ICP is elevated, lumbar puncture is contraindicated , because it can cause the brain to herniate.

Increased intracranial pressure..cont Diagnostic Test CT or MRI scan, shows structural herniation & shifting of the brain Most of the time acute increased intracranial pressure is an emergency there is little time for Dx test Dx must be based on frequent & careful observation & neurological testing Presence of even subtle changes may be very significant Internal measuring device used to Dx increased intracranial pressure (see right pic) ICP Monitoring

Increased intracranial pressure..cont Medical management Treat cause if possible Mechanical decompression Craniotomy, bone flap is removed then replaced Craniectomy, bone flap is removed & not replaced (often done when pressure is high) Drainage of the ventricles or any subdural hematoma may be beneficial as well Internal monitoring devices Endotracheal intubation may be necessary ABG analysis to guide O2 therapy (to maintain 100mmHg)

Increased intracranial pressure..cont Medical management Three types of medications are usually administered to patients with increased intracranial pressure: Osmotic Diuretics, Corticosteroids & Anticonvulsants. Example of drugs: Osmotic diuretics (mannitol), Loop diuretics (furosemide (Lasix), bumetanide (Bumex), and ethacrynic acid (Edecrin) Midazolam (sedative, hypnotic, antianxiety) and atracurium besylate (neuromuscular blocker) Corticosteroids – Dexamethasone – to control edema surrounding cerebral tumors and abcesses (monitor glucose level). Anticonvulsants - Phenytoin (Dilantin), Fosphenytoin (Cerebyx) through IV for better absorbtion– To prevent seizures

Increased intracranial pressure..cont Nursing Interventions and Patients Teaching Therapeutic measures to reduce venous volume may be implemented. Elevate the head of the bed to 30 to 45 degrees to promote venous return. Place the neck in a neutral position (not flexed or extended) to promote venous drainage. Position the patient to avoid flexion of the hips, waist, and neck as well as rotation of the head, especially to the right. Extreme hip flexion is avoided because this position causes an increase in intraabdominal and intrathoracic pressures, which can produce a rise in ICP. Instruct the patient to avoid isometric or resistive exercises. Restrict fluid intake.

Increased intracranial pressure..cont Nursing Interventions and Patients Teaching Therapeutic measures to reduce venous volume may be implemented. Implement measures to help the patient avoid Valsalva’s maneuever (any forced expiratory effort against a closed airway, such as straining to have a stool). Enemas and laxatives should be avoided if possible. Have a Foley catheter in place if the patient is not alert because of the large amount of urine that is produced Perform suctioning only as necessary and for no longer than 10 seconds with admission of 100% oxygen before and after to prevent decreases in the PaO2. Administer oxygen via mask or cannula to improve cerebral perfusion. Use a hypothermia blanket to control body temperature (increased body temperature increases brain damage).

Increased intracranial pressure..cont Prognosis The prognosis for the patient with increased intracranial pressure depends on the cause and how rapid with which it is treated. The nurse assumes a very important role in monitoring the patient for signs and symptoms of increased pressure. After herniation of the brain has begun as a result of pressure, there is little chance for complete reversal without significant brain damage.

Increased intracranial pressure Clinical manifestations/assessment Diplopia Headache Decreased level of consciousness Pupillary signs

Increased intracranial pressure (continued) Clinical manifestations/assessment (continued) Widening pulse pressure Bradycardia Respiratory problems High, uncontrolled temperatures Positive Babinski’s reflex Seizures Posturing Vomiting Singultus The onset of symptoms associated with intracranial pressure will vary. They will become increasingly evident as the pressure intensifies. Initially the body attempts to compensate for the changes. What actions does the body take into account for the alteration in homeostasis? In what order will the signs and symptoms manifest? Why? At what point do these clinical manifestations become ominous?

Increased intracranial pressure (continued) Medical management/nursing interventions Treat cause if possible Mechanical decompression Craniotomy Craniectomy Internal monitoring devices Once it is identified, there may be limited time to treat intracranial pressure. What diagnostic testing can be utilized for increased intracranial pressure? Why is prompt treatment such a priority? Discuss the use of pharmacological agents in the management of intracranial pressure. What physiological symptoms indicate that the medical interventions have been effective? What is the prognosis for increased intracranial pressure?

Disturbances in muscle tone and motor function Etiology/pathophysiology Damage to the nervous system causes serious problems in mobility Clinical manifestations/assessment Flaccid or hyperreflexic muscle tone Clumsiness or incoordination Abnormal gait Patients experiencing neurological system disorders can present with a variety of signs and symptoms. The assessment will be key in making a determination of the exact problem and developing a plan of care. Review the assessments that will be performed. What types of questions should be asked during the patient interview?

Disturbances in muscle tone and motor function (continued) Medical management/nursing interventions Muscle relaxants Protect from falls Assess skin integrity Positioning Sit up and tuck chin when eating Encourage patient to assist with ADLs Emotional support Safety is a key part of a successful plan of care for the neurologically impaired patient. The risk of injury is great. What are priority safety-related goals for the neurologically impaired patient?

Other Disorders of the Neurological System
Epilepsy or seizures Etiology/pathophysiology Transitory disturbance in consciousness or in motor, sensory, or autonomic function due to sudden, excessive, and disorderly discharges in the neurons of the brain; results in sudden, violent, involuntary contraction of a group of muscles Types: grand mal; petit mal; psychomotor; Jacksonian-focal; myoclonic; akinetic Status epilepticus Seizures affect both men and women of all races and ages. Identify some potential causes of seizures. Recurrent generalized seizures will result in status epilepticus. Sudden withdrawal from the prescribed anticonvulsant therapies is the #1 cause of its occurrence. Status epilepticus is a “9-1-1” event. Emergency intervention is needed to prevent brain damage or death. What events occur during status epilepticus that will result in neurological death?

Epilepsy or seizures (continued) Clinical manifestations/assessment Depends on type of seizure Aura Postictal period Medical management/nursing interventions During seizure: protect from aspiration and injury Anticonvulsant medications Surgery Removal of brain tissue where seizure occurs Seizures have predictable stages. The seizure might begin with an aura (the predictor of the seizure), followed by the ictal phase (seizure), and ending with the postictal period. An estimated 50% of people experience auras. An aura is a sensation which indicates impending seizure activity. Auras are individualized and can include psychic, olfactory, visual, auditory, or taste hallucinations. What is the value of an aura? What should the patient do after experiencing the aura? After the seizure activity ends, a patient might experience a postictal period. The postictal period can be characterized by feelings of fatigue, lethargy, and disorientation.

Epilepsy or seizures (continued) Medical management/nursing interventions (continued) Adequate rest Good nutrition Avoid alcohol Avoid driving, operating machinery, and swimming until seizures are controlled Good oral hygiene Medical alert tag The diagnosis of a seizure disorder is traumatic to the patient and family. What are the long-range implications of a seizure disorder diagnosis? What are the nursing responsibilities when caring for the patient during and after seizure activity has taken place?

Degenerative Diseases
Multiple sclerosis Etiology/pathophysiology Degenerative neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum Multiple sclerosis is a chronic, progressive neurological disease. The disease initially begins between the ages of 15 and 50 years. Women are affected more than men.

Pathogenesis of multiple sclerosis.
Figure 54-13 In multiple sclerosis, the myelin sheath becomes damaged. This loss of myelin integrity results in impaired transmission of nerve impulses. What theories do scientists support regarding the cause of multiple sclerosis? (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Pathogenesis of multiple sclerosis.

Multiple sclerosis (continued) Clinical manifestations/assessment Visual problems Urinary incontinence Fatigue Weakness Incoordination Sexual problems Swallowing difficulties The clinical manifestations are typically vague and gradually increase in severity and regularity. Several body systems are affected as multiple sclerosis progresses. The disease is associated with periods of remissions and exacerbations. What diagnostic procedures can be implemented when multiple sclerosis is suspected?

Multiple sclerosis (continued) Medical management/nursing interventions No specific treatment Adrenocorticotropic hormone (ACTH) Steroids Valium Betaseron (interferon beta-1b) Avonex (interferon beta-1a) Pro-banthine; urecholine Bactrim, Septra, and Macrodantin The prescribed pharmacological treatments will vary among practitioners. Drug therapy will also be affected by the stage and severity of the disease. What are goals of nursing interventions when caring for the patient experiencing an exacerbation of multiple sclerosis? Outline the prognosis associated with multiple sclerosis.

Parkinson’s disease Etiology/pathophysiology Deficiency of dopamine Clinical manifestations/assessment Muscular tremors; bradykinesia Rigidity; propulsive gait Emotional instability Heat intolerance Decreased blinking “Pill-rolling” motions of fingers Parkinson’s disease is a chronic neurological disorder. It occurs most frequently in middle-aged and older adults. Explain the pathology of the disease. There is no known cure.

Nigrostriatal disorders produce parkinsonism.
Figure 54-14 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Nigrostriatal disorders produce parkinsonism.

Parkinson’s disease (continued) Medical management/nursing interventions Medications Levodopa Sinemet Artane Cogentin Symmetrol Surgery Pallidotomy Treatment goals for Parkinson’s disease focus on managing symptoms. Long-term drug therapy for the management of the disease can eventually result in an overabundance of side effects. A “drug holiday” might be indicated. Discuss the purpose of the “drug holiday.” Considering the treatment modalities available, what are the implications of a diagnosis of Parkinson’s disease on patients and families?

Alzheimer’s disease Etiology/pathophysiology Impaired intellectual functioning Degeneration of the cells of the brain Alzheimer’s disease is a chronic, progressive disease that impacts men and women in equal numbers. Review available theories relating to potential causes of Alzheimer’s disease.

Alzheimer’s disease (continued) Clinical manifestations/assessment Early stage Mild memory lapses; decreased attention span Second stage Obvious memory lapses Third stage Total disorientation to person, place, and time Apraxia; wandering Terminal stage Severe mental and physical deterioration A series of four stages is used to outline the progression of Alzheimer’s disease. The stages chronicle the clinical manifestations being experienced by the patient. As the disease progresses, the characteristics of the stages worsen. What are the goals of nursing care for each of the stages?

Alzheimer’s disease (continued) Medical management/nursing interventions Medications Agitation: lorazepam; Haldol Dementia: Cognex; Aricept Nutrition Finger foods; frequent feedings; encourage fluids Safety Remove burner controls at night Double-lock all doors and windows Constant supervision Presently there is no cure for the disease. Pharmacological therapies focus on controlling symptoms. Non-medication therapies seek to promote and prolong functioning for the patient. What are the psychosocial implications of a diagnosis of Alzheimer’s disease?

Myasthenia gravis Etiology/pathophysiology Neuromuscular disorder; nerve impulses fail to pass at the myoneural junction; causes muscular weakness Clinical manifestations/assessment Ptosis; diplopia Skeletal weakness; ataxia Dysarthria; dysphagia Bowel and bladder incontinence Myasthenia gravis is a disorder of the nervous system associated with neuromuscular weakness. It is considered an autoimmune disease. What is meant by the term “autoimmune”? How is an individual affected by an autoimmune disease such as myasthenia gravis?

Myasthenia gravis (continued) Medical management/nursing interventions Anticholinesterase drugs Prostigmin Mestinon Corticosteroids May require mechanical ventilation Myasthenia gravis characteristically has a slow onset, and diagnosis may be difficult or mistaken for other disorders. What tests are employed to assess for myasthenia gravis?

Amyotrophic lateral sclerosis (ALS) Etiology/pathophysiology Motor neurons in the brain stem and spinal cord gradually degenerate Electrical and chemical messages originating in the brain do not reach the muscles to activate them Lou Gehrig’s disease Amyotrophic lateral sclerosis (ALS) involves the destruction of motor neurons in the brain stem and spinal cord. The loss of motor neurons impairs the body’s ability to respond to messages from the brain. The disorder is often referred to as Lou Gehrig’s disease, named after a professional baseball player who developed the disease in the 1940s.

Amyotrophic lateral sclerosis (ALS) (continued) Clinical manifestations/assessment Weakness of the upper extremities Dysarthria; dysphagia Muscle wasting Compromised respiratory function Medical management/nursing interventions No cure Rilutec (Riluzole) Multidisciplinary ALS teams; emotional support The progression of ALS is made increasingly difficult because as the body begins to fail, the patient’s mind remains intact and fully functioning. There is no cure. Therapies seek to manage symptoms and promote functioning. What nursing interventions should be incorporated into the care of the patient experiencing ALS?

Huntington’s disease Etiology/pathophysiology Overactivity of the dopamine pathways Genetically transmitted Clinical manifestations/assessment Abnormal and excessive involuntary movements (chorea) Ataxia to immobility Deterioration in mental functions Huntington’s disease is genetically transmitted. It is an autosomal dominant disorder. The children of an affected parent have a 50% chance of inheriting it. Given the rate of transmission between parents and children, what genetic counseling should be provided to potential carriers?

Huntington’s disease (continued) Medical management/nursing interventions No cure; palliative treatment Antipsychotics Antidepressants Antichoreas Safe environment Emotional support High-calorie diet The disease has no cure. The goals of treatment seek to manage the symptoms and reduce injury. What are the primary needs of the patient? How can the nurse meet these needs?

Vascular Problems Stroke (cerebrovascular accident)
Etiology/pathophysiology Abnormal condition of the blood vessels of the brain: thrombosis; embolism; hemorrhage Results in ischemia of the brain tissue Clinical manifestations/assessment Headache Sensory deficit Hemiparesis; hemiplegia Dysphasia or aphasia Stroke is the most prevalent neurological disorder. It ranks as the third leading cause of death in the United States. The clinical manifestations of a stroke vary by cause and individual. Some of the more common symptoms can include disturbances in motor activity, intellectual functioning, or communication abilities. What factors can determine the types and degree of impairments that will be experienced?

Figure 54-16 Three types of stroke.
Strokes are classified by their underlying cause. Strokes can be ischemic, thrombotic, or embolic. How do the types of strokes differ? (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Three types of stroke.

Vascular Problems Stroke (cerebrovascular accident) (continued)
Medical management/nursing interventions Thrombosis or embolism Thrombolytics Heparin and Coumadin Decadron Neurological checks Feeding tube Physical, occupational, and/or speech therapy The greatest chance for a positive prognosis involves early intervention. Currently there are pharmacological interventions, if provided in the early stages, that can improve the patient’s chances for recovery. These therapies involve the use of thrombolytics. Explain their uses and parameters for successful intervention. What nursing assessments are needed for the patient who has had a stroke?

Cranial and Peripheral Nerve Disorders
Trigeminal neuralgia Etiology/pathophysiology Degeneration of or pressure on the trigeminal nerve; tic douloureux Clinical manifestations/assessment Excruciating, burning facial pain Medical management/nursing interventions Tegretol Surgical resection of the trigeminal nerve Avoid stimulation of face on affected side Trigeminal neuralgia is a disorder of the peripheral nervous system. It is most common in women in middle and late adulthood. Patients having trigeminal neuralgia experience severe pain when trigger points along the trigeminal nerve are activated. What activities can cause this pain?

Bell’s palsy (peripheral facial paralysis) Etiology/pathophysiology Inflammatory process involving the facial nerve Clinical manifestations/assessment Facial numbness or stiffness Drawing sensation of the face Unilateral weakness of facial muscles Reduction of saliva Pain behind the ear Ringing in ear or other hearing loss Bell’s palsy occurs as a result of inflammation of the facial nerve (cranial nerve V). No exact cause has been identified. What theories concerning a cause of this disease have been identified?

Bell’s palsy (peripheral facial paralysis) (continued) Medical management/nursing interventions Electrical stimulation Moist heat Steroids Massage of the affected area Facial exercises There is no exact course of therapy to treat Bell’s palsy. Medical interventions seek to reduce inflammation and manage symptoms. What are the nursing responsibilities in the care of this disorder? What is the prognosis for patients diagnosed with Bell’s palsy?

Guillain-Barré syndrome Etiology/pathophysiology Inflammation and demyelination of the peripheral nervous system Possibly viral or autoimmune reaction Guillain-Barré syndrome involves the loss of myelin sheaths in the peripheral nervous system. Myelin acts as insulation for nerves, and the loss of myelin results in alterations of nerve conduction. Although no exact cause has been pinpointed, commonality has been noted between at least 50% of people diagnosed. Review this “common ground.”

Guillain-Barré syndrome (continued) Clinical manifestations/assessment Symptoms are progressive Paralysis usually starts in the lower extremities and moves upward; may stop at any point Respiratory failure if intercostal muscles are affected May have difficulty swallowing, breathing, and speaking

Guillain-Barré syndrome (continued) Medical management/nursing interventions Adrenocortical steroids Apheresis Mechanical ventilation Gastrostomy tube Meticulous skin care Range-of-motion exercises The vast majority of people diagnosed with Guillain-Barré syndrome will fully recover. What are the goals of treatment during the acute phase of the disease?

Meningitis Etiology/pathophysiology Acute infection of the meninges Bacterial or aseptic

Meningitis (continued) Clinical manifestations/assessment Headache; stiff neck Irritability; restlessness Malaise Nausea and vomiting Delirium Elevated temperature, pulse, and respirations Kernig’s and Brudzinski’s signs The clinical manifestations seen in meningitis largely occur as a result of the impact of the inflammatory process on the meninges. What diagnostic testing can be used to confirm diagnosis?

Meningitis (continued) Medical management/nursing interventions Antibiotics Massive doses Multiple types IV or intrathecal Steroids Anticonvulsants Dark, quiet room Treatment of meningitis uses a variety of different classifications of medications. What is the desired effect/purpose for the use of each of the potential drug classifications?

Intracranial tumors Etiology/pathophysiology Benign or malignant Primary or metastatic May affect any area of the brain Brain tumors can originate in the brain tissue or spread there from some other location of the body. What terminology would be used to describe those tissues originating in the brain? What would tumors that spread to the brain be referred to as?

Intracranial tumors (continued) Clinical manifestations/assessment Headache Hearing loss Motor weakness Ataxia Decreased alertness and consciousness Abnormal pupil response and/or unequal size Seizures Speech abnormalities The clinical manifestations of a brain tumor will vary according to size and location.

Intracranial tumors (continued) Medical management/nursing interventions Surgical removal of tumor Craniotomy Intracranial endoscopy Radiation Chemotherapy Combination of above Management of brain tumors is individualized. The physician and patient chart a path unique to the individual’s degree of involvement and personal wishes. What nursing care will be needed for the patient after surgical intervention for a brain tumor?

Trauma Craniocerebral trauma Etiology/pathophysiology
Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma Direct trauma: head is directly injured Indirect trauma: tension strains and shearing forces Open head injuries Closed head injuries Hematomas Trauma to the brain can result in disability or death. It is a major cause of neurological impairment. How do acceleration and deceleration injuries differ? Provide examples of each type of injury. A hematoma can occur as a result of a brain injury. Compare and contrast an epidural and a subdural hematoma.

Trauma Craniocerebral trauma Clinical manifestations/assessment
Headache Nausea Vomiting Abnormal sensations Loss of consciousness Bleeding from ears or nose Abnormal pupil size and\or reaction Battle’s sign In addition to the assessment of objective and subjective data, diagnostic tools can be employed to assess a craniocerebral injury. What tests can be anticipated?

Trauma Craniocerebral trauma (continued)
Medical management/nursing interventions Maintain airway Oxygen Mannitol and dexamethasone Analgesics Anticonvulsants When a head injury occurs, the priorities employ the ABCs—Airway, Breathing, and Circulation of health care. Once the patient has been stabilized, pain management might be needed. Care must be given to medicate the patient while avoiding medications that reduce respirations or mask neurological changes. What are the preferred analgesic medications when caring for the patient who has experienced a head injury? What analgesics should be avoided? Anticonvulsants can also be administered. What is the rationale for their use?

Trauma Spinal cord trauma Etiology/pathophysiology
Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds Fracture of vertebra Complete cord injury Incomplete cord injury An estimated 10% of traumatic injuries to the nervous system involve the spinal cord. What populations are at greatest risk of spinal cord injury? Compare and contrast a complete spinal cord injury with an incomplete spinal cord injury.

Mechanisms of spinal injury.
Figure 54-22 (From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.) Mechanisms of spinal injury.

Trauma Spinal cord trauma (continued)
Clinical manifestations/assessment Loss of muscle function depends on level of injury Spinal shock Autonomic dysreflexia Sexual dysfunction The level of spinal cord injury will determine the degree of functioning lost. The higher the injury, the greater the loss. Outline the types of impairments that would be associated with injuries to the cervical, thoracic, lumbar, and sacral regions. Spinal shock is a common early occurrence in most spinal cord injuries. What additional needs might the patient have during this period? Autonomic dysreflexia is a serious complication experienced when damage at or above T-6 occurs. Review the signs and symptoms of autonomic dysreflexia. What stimuli can promote this problem?

Trauma Spinal cord trauma (continued)
Medical management/nursing interventions Realignment of bony column for fractures or dislocations: immobilization; skeletal traction Surgery for spinal decompression Methylprednisolone Mobility: slowly increase sitting up Urinary function: Foley catheter; bladder training Intermittent catheterization Bowel program A spinal cord injury is a traumatic event for the patient and family. What psychosocial supports will be indicated? What are the responsibilities of the nurse regarding emotional support?

Nursing Process Nursing diagnoses Autonomic dysreflexia
Communication, impaired Coping, compromised family Disuse syndrome, risk for Grieving Infection, risk for Knowledge, deficient Memory, impaired

Nursing Process Nursing diagnoses (continued)
Mobility, impaired physical Nutrition, imbalanced: less than body requirements Pain, acute, chronic Self-care deficit Swallowing, impaired Thought process, disturbed Tissue perfusion (cerebral), ineffective

Care of the Patient with a Neurological Disorder

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Care of the Patient with a Neurological Disorder

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