Neurological Nursing

Ronnie V. Mayo, MD, RN, MSN

NERVOUS SYSTEM
A. Central Nervous System B. Peripheral Nervous System C. Autonomic Nervous System

Central Nervous System

A. Brain - Cerebral Hemispheres and Diencephalon - Brainstem - Cerebellum B. Spinal Cord

Peripheral Nervous System

A. Cranial Nerves
12 pairs

B. Peripheral Nerves
31 pairs ( cervical, thoracic, lumbar, sacral, coccygeal)

Autonomic Nervous System

Sympathetic Parasympathetic

Neurons
Dendrites

Cell body

Axon

Nerve Structure

Skull
Frontal View
Location for placement of ICP catheters Anterior to coronal suture & off midline (Saggital sinus underneath)

Midline
Frontal

Skull
Lateral View
Frontal Temporal Parietal Occipital
Coronal suture
Frontal Parietal

Sutures
Separation between bones Underlying coronal suture is motor strip

Temporal Occipital

Dura Mater
Tough outer layer, inelastic, fibrous membrane Double layered Attaches to
skull - periosteum brain - meningeal forms compartments

Dura Mater
Compartments
Right & left side Supratentorial (contains cerebral hemispheres) Infratentorial (posterior fossa contains brain stem & cerebellum)

Arachnoid Membrane
Middle layer Delicate avascular membrane Forms the subarachnoid space and cisterns

Arachnoid Membrane
Contains CSF (cerebral spinal fluid) in space below Arachnoid granulations project into venous sinus Clinical relevance
Subarachnoid hemorrhage (SAH)

Pia Mater
Innermost layer adherent to brain Mesh-like, vascular

Spaces between the coverings

Epidural
Potential space between the dura and skull Bleeding occurs from the middle meningeal artery

Spaces between the coverings

Subdural
Potential space between the dura and arachnoid Bleeding occurs from injury to bridging veins Placement of subdural catheters

Spaces between the coverings

Subarachnoid
Space between the arachnoid and pia mater Contains major arterial vessels Bleeding may be due to rupture of a vessel

Cerebral Circulation - Arterial

Brain uses 15-20% of cardiac output Blood supply into brain Anterior circulation Carotid arteries
Common to internal

Posterior circulation Vertebral arteries

Internal carotid Common carotid

Cerebral Circulation - Arterial

Carotid Stenosis (narrowing)
Treated by carotid endarterectomy Use carotid shunt

Arterial Circulation
Circle of Willis
Interconnection of arteries that supply blood to cerebral hemispheres

Posterior circulation
Supplies blood to brainstem

Venous Drainage
Occurs through the bridging veins Brain - through arachnoid - dural sinus

Venous Drainage
Clinical Observations
About 80% blood volume is venous Avoid sagittal sinus with placement of Monitoring (ICP, Licox) Obstruction of venous pathways - ICP

Brain

Cerebral Lobes
Frontal Parietal Temporal Occipital
Parietal Occipital

Frontal

Temporal

Frontal Lobe
Motor function
Contraction and synchronization

Cognitive functions
Judgment Uniqueness of personality Reasoning

Brocas speech center ability to

talk

Long term memory

Parietal Lobe
Sensory interpretation
Touch Temperature Taste

Occipital Lobe
Visual brain Appreciation of size, shape, and color

Temporal Lobe
Sensation and interpretation of sounds Interpret sense of smell Control behavior patterns

Ventricular System
Fluid filled cavities deep in cerebrum filled with Cerebrospinal Fluid (CSF)

Ventricular System
Four ventricles
2 Lateral
Location for ventricular catheters

Third Fourth

Connected by
Foramen of Monro
Landmark used to zero transducers & EDVs

Ventricular System
Lateral View AP View

Ventricular System
Choroid Plexus
Very vascular Found throughout ventricular system but mostly in lateral 500cc CSF produced daily Approx 20cc produced hourly 150cc in the system at any time

CSF Flow-path
Lateral ventricles thru Foramen of Monro to 3rd ventricle thru aqueduct of Sylvius to 4th ventricle. Exits through Foramen of Magendie & Foramen of Luschke. Travels around spinal cord & exits thru Arachnoid Granulations.

Hydrocephalus excess CSF

Communicating
Flows thru system Usually a decrease reabsorption of CSF
(blockage in arachnoid villi due trauma or

SAH) Ventriculostomy, lumbar drain, shunt (VP or LP)

Hydrocephalus
Non-communicating
CSF unable to flow thru the system Congenital Obstruction Cysts

VP shunt

Diencephalon, Midbrain, Brainstem and Cerebellum

Diencephalon
Thalamus
Process incoming sensory information before distribution to the somatosensory cortex Process motor information from the cerebral cortex and cerebellum and projects its analysis back to the motor cortex Contributes to the concentrating ability by filtering out distracting sensory input Contributes to emotional component of sensations (pleasant or unpleasant)

Diencephalon
Hypothalamus
forms a crucial part of the neural path by which emotions and other cerebral functions can alter vital, automatic functions. (heartbeat, BP, peristalsis, and gland secretions) Secretes neuropeptides (TRH and LH-RH) Produces ADH and oxytocin Contains appetite center, satiety center and temperature regulating center Maintains waking state (arousal or alerting neural pathway)

Midbrain
Located between pons, diencephalon and cerebrum Integrates and analyzes sensory input from the ears, eyes, and various regions of the cerebral cortex Reflex centers for cranial nerves III and IV Pineal body

Brainstem
Medulla
Conducts impulses between the cord and brain Contains important reflex centers for heart, blood vessel diameter, respiratory reflexes, vomiting, coughing, and swallowing

Brainstem
Pons
Conducts impulses between the cord and various parts of the brain Contains reflex centers for cranial nerves V, VI, VII, and VIII. Contains pneumotaxic center

Cerebellum
Exerts synergic control over the skeletal muscles producing smooth, steady, and precise movements Coordinates skeletal muscle contractions and play an essential part in producing normal postures and maintaining equilibrium

Spinal Cord
Cervical

Thoracic

Lumbar

Sacral

Spinal cord

Spinal Cord
From foramen of magnum to the 1st lumbar vertebra Inner core consist of gray matter, shaped like a three dimensional H Long columns of white matter surround the cords inner core of gray matter (composed of numerous sensory and motor tracts).
Right and left anterior columns Lateral and posterior columns

Spinal cord

Spinal Cord Functions

Sensory tracts conduct impulses up cord to brain Motor tracts conduct impulses down cord from brain Gray matter of cord contains reflex centers for all spinal cord reflexes

Peripheral Nervous System

A. Cranial Nerves
12 pairs

B. Peripheral Nerves
31 pairs ( cervical, thoracic, lumbar, sacral, coccygeal)

Cranial Nerves
Cranial I and II direct extensions of receptor organ Cranial Nerve III, IV midbrain Cranial Nerve V, VI, VII, VIII pons Cranial Nerve IX, X, XI, XII - medulla

Autonomic Nervous System

Conducts impulses from the brainstem or cord out to visceral effectors: cardiac muscles, smooth muscles, and glandular tissues Consist of 2 divisions: Sympathetic nervous system and Parasympathetic nervous system

Autonomic Nervous System

Sympathetic Nervous System
Adrenergic fibers secrete norepinephrine Influences smooth muscle of blood vessels and hairs and sweat glands Under conditions of stress, sympathetic impulses to the visceral effectors usually increase greatly and dominate over parasympathetic impulses.

Autonomic Nervous System

Parasympathetic Nervous System
Cholinergic fibers secrete acetylcholine Influences digestive tract and smooth muscles to promote digestive gland secretion, peristalsis, and defecation Influences heart to decrease rate and strengthen contractility Vagus nerve is the most significant parasympathetic nerve

Diseases of the Nervous System

Head Injury
Includes
Scalp injury Skull Brain

Traumatic Brain Injury

Most serious form of head injury Motor vehicles, violence, falls 15 to 24 years of age, under 5, over 75 Best approach is prevention

Pathophysiology
Two Forms
Primary
Initial damage to the brain

Secondary
Evolves over the ensuing hours and days after the initial injury Due to brain swelling and ongoing bleeding

SCALP INJURY
Scalp trauma bleeds profusely when injured Abrasion, contusion, laceration, or hematoma beneath the layers of the scalp (subgaleal hematoma) Diagnosis: physical exam, inspection, palpation. Potential portals for organisms Irrigate before suturing

SKULL FRACTURES
Break in the continuity of the skull With or without damage to the brain Linear, comminuted, depressed, or basilar. May be open scalp laceration, tear in the dura May be closed dura is intact

SKULL FRACTURE DIAGNOSIS

Skull Series Cranial CT-Scan Cranial MRI

MEDICAL MANAGEMENT
Conservative Management
For non-depressed skull fracture

Surgical Management
Contaminated or deforming fractures If significant cerebral edema is present, surgery may be delayed for 3 to 6 months Penetrating wounds require surgical debridement Antibiotic treatment

TRAUMATIC BRAIN INJURY (TBI)

Rigid close compartment Do not allow expansion Any bleeding or swelling increases volume increases ICP Increase ICP downward and lateral displacement of the brain Displacement restriction of blood flow oxygen delivery Brain becomes anoxic irreversible brain damage

TBI: CLINICAL MANIFESTATIONS

Altered level of consciousness Confusion Pupillary abnormalities Altered or absent gag Absent corneal reflex Sudden onset of neurologic deficits Vision or hearing impairment Sensory dysfunction Headache Vertigo Seizures Spasticity

TRAUMATIC BRAIN INJURY

Assessing Injury Severity: GCS

Ranges:
3 - 8 Severe TBI 9 -12 Moderate TBI 13 -15 Mild TBI

Glasgow Coma Scale

Eye-opening ability: Spontaneous (4) To speech (3) To pain (2) No response (1) Motor response: Obeys commands (6) Localizes pain (5) Withdraws (4) Abnormal flexing (3) Abnormal extension (2) No response (1)

Verbal response: Oriented (5) Confused (4) Inappropriate words (3) Incomprehensible sounds (2) No response (1)

CONCUSSION
Temporary loss of neurologic function with no apparent structural damage Involves a period of unconsciousness for a few seconds to minutes May be hospitalized for observation

CONCUSSION
OBSERVE FOR
headache Dizziness Lethargy Irritability Anxiety Post concussion syndrome

CONCUSSION
Advise to resume normal activities slowly Instruct family to observe the following
Difficulty in awakening Difficulty in speaking Confusion Severe headache Vomiting Weakness on one side of the body

CONTUSION
More severe injury Brain is bruised Unconscious for few secs to mins Symptoms depend on the size, and amount of edema

HEMATOMAS
EPIDURAL SUBDURAL INTRACEREBRAL

EPIDURAL HEMATOMA
Lucid interval -- loss of consciousness followed by an interval of apparent recovery Considered an extreme emergency Treatment: Surgery: Burr holes / craniotomy Drain usually inserted

SUBDURAL HEMATOMA
Mainly due to rupture of bridging veins in the subdural space May also be caused by coagulopathy May be acute, subacute, or chronic

 Acute
Symptoms develop over 24 to 48 hours Requires immediate intervention

Subacute
Appear between 48 hours to 2 weeks

 Chronic Subdural hematomas

From minor injuries Most frequently in the elderly There may be severe headache, alternating focal signs, personality changes, mental deterioration Treatment: Surgical Evacuation

INTRACEREBRAL HEMATOMA
Bleeding into the substance of the brain Onset may be insidious from neurologic deficit to headache

MANAGEMENT OF BRAIN INJURIES

All head injured patient is presumed to have a cervical spine injury until proven otherwise. Preventing secondary injury

NURSING DIAGNOSIS AND INTERVENTIONS

Ineffective airway clearance Ineffective cerebral tissue perfusion Deficient fluid volume Imbalanced nutrition Risk of injury Impaired skin integrity Disturbed thought process Disturbed sleep pattern Compromised family coping Deficient knowledge

Potential Complications
Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolytes, and nutritional balance Risk of post-traumatic seizures

Brain Tumors
Etiology and pathophysiology Either benign or malignant Classified according to tissue of origin Meningioma: occurs outside brain from covering meninges; usually benign

Brain Tumors
Acoustic neuroma and optic nerve spongloblastoma; occur from the cranial nerves Gliomas; originate in neural tissue; usually malignant and include astrocytoma; glioblastoma, oligodendroglioma Hemangioblastomas and angiomas; occur from within blood vessels

Brain Tumors
Metastatic tumors; originate elsewhere in the body, most commonly the lung and breast

Clinical findings
Subjective: headache that increases when supine or stooping; lethargy Objective: signs of increased intracranial pressure; abnormal CT scan, MRI, EEG Symptoms may vary depending on location of tumor

Brain Tumors
Frontal lobe: personality changes, focal seizures, blurred vision, hemiparesis, altered thought processes Temporal lobe: seizures, headache, papilledema, receptive aphasia, tinnitus Parietal lobe: visual loss, motor and sensory focal seizures Occipital region: focal seizures, visual hallucinations, homonymous hemianopsia

Brain Tumors
Cerebellar region: loss of coordination, tremors, nystagmus

Therapeutic interventions
Radiation therapy and/or chemotherapy Surgery for partial or complete removal of the lesion

Craniotomy with removal of lesion and invaded tissue

Brain Tumors
Stereotactic radiosurgery; employs computer-directed radiation to eradicate tissue Steroids, anticonvulsives, and osmotic diuretics to control symptoms

Nursing Care of Clients with Brain Tumors

ASSESSMENT History from client and family to identify behavioral changes, coping skills, and neurologic deficits

Brain Tumors
Neurologic status Unilateral nonreactive and/or dilated pupil progressing to bilateral as intracranial pressure increases Signs of increased intracranial pressure Decreased level of consciousness Rapid rise in body temperature; decreased pulse rate; changes in respiratory pattern

Brain Tumors
Increased systolic pressure; widening pulse pressure Restlessness Headache Weakness or paralysis Visual and other sensory disturbances;papilledema Vomiting Seizures

Brain Tumors
Analysis/Nursing Diagnoses
Ineffective breathing pattern related to compromised neurologic function Decreased adaptive capacity: intracranial, related to increased ICP Anxiety related to uncertain prognosis

Planning/Implementation
Perform routine neurologic assessments

 Provide emotional support for the client and family; refer to additional resources such as clergy and support groups Administer analgesics and antiemetics as ordered Provide small, frequent feedings, supplements, and oral hygiene Provide care for the client requiring brain surgery Obtain consent for surgery and removal of hair After surgery keep the client`s head elevated 30 degrees

Support respiratory function by encouraging deep breathing, appropriate positioning, and suctioning to maintain the airway Use strict aseptic technique with ICP monitoring Observe dressings for cerebrospinal fluid leakage or hemorrhage Maintain intake and output Use hypothermia as ordered if the client is febrile; fever increases metabolic needs of the brain

Brain Tumors
Assist client to focus on abilities rather than disabilities Emphasize need for continued health care supervision

Evaluation/Outcomes
Maintains adequate respiratory function Oriented to person, place, and time Establishes effective communication

Management of Patients With Cerebrovascular Disorders

Stroke
Is a brain attack
Needing emergency management, including specific treatments and secondary and tertiary prevention.

Is an emergency
No allowances for worsening are tolerated

Is treatable
Through proven, affordable, acceptable means

Is preventable
In implementable ways across all levels of society

CEREBROVASCULAR DISEASE STROKE DEFINITION

Sudden onset of focal neurological deficit lasting more than 24 hours due to an underlying vascular pathology. Refers to any functional abnormality of the central nervous system that occurs when the normal blood supply to the brain is interrupted.

STROKE
3rd leading cause of death in the U.S. 2nd leading cause of death in the Philippines

STROKE
Two Major Categories
Ischemic Vascular occlusion and significant hypoperfusion occur Hemorrhagic Extravasation of blood into the brain

STROKE
Ischemic Large artery thrombosis Lacunar Cardiogenic embolic Cryptogenic Other Hemorrhagic Intracerebral Hemorrhage Subarachnoid Hemorrhage Cerebral Aneurysm Arteriovenous malformation

Large Artery Thrombosis

Cardiogenic Emboli

Pathophysiology

The Stroke Continuum

Transient Ischemic Attack
Sudden focal neurologic deficit lasting not more than 24-hours

Stroke in Evolution
Worsening of neurologic signs and symptoms over several minutes. Progressing stroke.

Completed Stroke
Stabilization of the neurologic signs and symptoms

Stroke Risk Factors

Well-Established Hypertension Transient Ischemic Attack Valvular Heart Disease Atrial Fibrillation Coronary Artery Disease / Myocardial Infarct Carotid Stenosis Diabetes Mellitus Cigarette Smoking Dyslipidemia

Stroke Risk Factors

Less Well Established
Alcohol Physical Inactivity Lifestyle Factor: Diet

Clinical Manifestations
Visual Field Deficits Motor Deficits Sensory Deficits Verbal Deficits Cognitive Deficits Emotional Deficits

Visual Field Defects Homonymous Hemianopia

Place objects within intact field of vision. Approach patient from side of intact field of vision. Instruct/Remind patient to turn head in direction of visual field loss

Loss of peripheral field of vision

Avoid night driving, or risky activities in the darkness Place objects in center of patients intact visual field Encourage use of cane

Motor Deficits
Hemiparesis
Place objects within patients reach on the non-affected side Instruct patient to exercise and increase strength on non-affected side

Motor Deficit
Hemiplegia
Provide ROM exercises Maintain body alignment Exercise unaffected limb to increase immobility

 Ataxia
Support patient during initial ambulation Provide supportive device Instruct patient not to walk without assistance

 Dysarthria
Provide patient with alternative methods of communicating Allow the patient sufficient time to respond Support patient and family to alleviate frustration

 Dysphagia
Test the patients pharyngeal reflexes before offering food or fluids Assist the patient with meals Place food on the unaffected side of the mouth Allow ample time to eat

Sensory Defictis
Paresthesias
Instruct patient to avoid using this extremity as the dominant limb Provide range of motion to affected areas

 Expressive aphasia
Encourage patient to repeat sounds of the alphabet

Receptive aphasia
Speak slowly and clearly to assist patient in forming the sounds

Global aphasia
Use simple sentences Use gestures or pictures when able Establish alternative means of communication

Cognitive Deficits
Short and Long term memory loss
Reorient patient to time, place, and situation frequently

Decreased attention span

Use verbal and auditory cues to orient patient

Impaired ability to concentrate

Provide familiar objects

 Poor abstract reasoning

Use non-complicated language

Altered Judgement
Minimize distracting noises Repeat and reinforce instructions frequently

 Emotional deficits
Support patient during uncontrollable outbursts

Emotional lability
Discuss with patient and family that the outburst are due to disease process

Decrease tolerance to stressful situations

Encourage patient to participate in group activity

 Depression
Provide stimulation for the patient

Withdrawal Fear, Anger

Provide safe environment

Feelings of Isolation
Encourage patient to express feelings and frustrations

Medical Assessment and Diagnostic Findings

Complete history, physical and neurologic examination. Initial Diagnostic Test: Cranial CT scan. Other work-ups:
12 L ECG 2D Echocardiography Electrolytes Carotid Ultrasound Cerebral Angiography Cranial MRI

Medical Management
Warfarin : INR target 2.5 ASA, clopidogrel, ticlopidine, dipyridamole Heparin: PTT

THROMBOLYTIC THERAPY
Used to treat ischemic stroke by dissolving the blood clot Recombinant t-PA (rt-PA) must be given within 3 hours of stroke onset. Leads to an overall improvement in functional outcome after 3 months

Eligibility Criteria
Age 18 years or older NIHSS under 22 Within 3 hours or less BP systolic < 185 diastolic < 110 No seizure at onset Not taking warfarin PROTHROMBIN TIME < 15 sec INR < 1.7

Eligibility Criteria
Not receiving heparin during the past 48 hours w/o elevated PTT Platelet count > 100,000 CBG 50 to 400 No MI No Intracranial hemorrhage, neoplasm, AV mal, aneurysm

Eligibility Criteria
No major surgical procedures within14 days No stroke or head injury within 14 days No gastrointestinal or urinary bleeding within last 21 days

THROMBOLYTIC THERAPY
Community Education directed at:
Recognizing symptoms of stroke Obtaining appropriate emergency care Ensure rapid transport to a hospital and initiate therapy within a 3 hour time frame Delays make the patient ineligible for thrombolytic therapy

Rt-PA Dosage and Administration

Minimum dose is 0.9mg/kg. Maximum dose is 90 mg. Loading dose is 10% of the calculated dose. Loading dose is infused over 1 minute. Remaining dose is administered over 1 hour via an infusion pump.

Monitoring After Thrombolysis

ICU / Acute Stroke Unit Admission VS q15 for 2 hours, q30 for next 6 hours, then every 16 hours. BP should be maintained at 180 mmHg systolic, and 100 mmHg diastolic. Side Effect: Bleeding.

Other treatments
Reduce ICP with osmotic diuretics Maintaining pCO2 to 30 to 35 mmHg Elevation of the head Intubation if necessary Maintaining cerebral perfusion: MAP Avoiding precipitous drop in blood pressure Neurologic exam to determine if stroke is evolving or complications of treatment develop.

Endarterectomy for prevention of Ischemic Stroke

Carotid Endarterectomy
Removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral artery Indicated for patients with symptoms of TIA or mild stroke due to SEVERE or 70% to 99% carotid artery stenosis.

Nursing Management: Carotid Endarterectomy

Maintain adequate blood pressure in the immediate postoperative period Monitor Neurologic status. Baseline neurologic exam. Difficulty in swallowing, hoarseness, or other signs of cranial nerve dysfunction

COMPLICATIONS OF CAROTID ENDARTERECTOMY

Complication Incision Hematoma Nursing intervention Monitor neck discomfor and wound expansion Check blood pressure frequently Monitor BP and signs and symptoms of hypotension Severe unilateral headache improved by sitting, standing Monitor neurologic status and report changes in mental status

Hypertension
Postoperative hypotension Hyperperfusion syndrome Intracerebral hemorrahage

Nursing Diagnosis: Interventions

Impaired physical mobility Shoulder pain Self-care deficits Disturbed sensory perception Impaired swallowing Incontinence Disturbed thought process Impaired verbal communication Impaired skin integrity Interrupted family processes Sexual dysfunction

Nursing Diagnoses: Interventions

Impaired physical mobility Correct positioning Prevent contractures Body alignment Preventing shoulder adduction Changing positions Establishing an exercise program Preparing for ambulation

Nursing Diagnoses: Interventions Self-Care / Hygiene

Eating Devices
Non-skid mats to stabilize plates Wide-grip utensils

Bathing and Grooming Devices

Grab-bars, shower and tub seats

Toileting Aids Dressing Aids Mobility Aids

Canes, walkers, wheelchairs, transfer devices

Nursing Diagnosis: Interventions Managing Dysphagia

Must be observed for paroxysms of coughing, food, dribbling, or pooling on one side of the mouth, food retained for long periods in the mouth, nasal regurgitation. Smaller boluses of food. Thick liquids ------ thin liquids. Sit upright, chin towards chest

Nursing Diagnosis : Interventions Attaining bowel and bladder control

Bladder becomes atonic, with impaired sensation in response to bladder filling, or control of external urinary sphincter is lost.
Intermittent catheterization

Constipation / Bowel Control

High Fiber diet, adequate fluid intake

Nursing Diagnosis: Interventions Aphasic Patient

Face the patient and establish eye contact Speak in normal manner and tone Use short phrases and pause between phrases Limit conversation to practical and concrete matters Use gestures, pictures, and objects

Nursing Diagnosis : Interventions Aphasic Patient

Consistent in using same words and gestures Keep extraneous noises and sounds to minimum.

Hemorrhagic Stroke
15% of cerebrovascular disease Two types:
Subarachnoid Hemorrhage
Aneurysms

Intracerebral Hemorrhage
AVM Hypertensive Bleeds

Pathophysiology: ICH
Bleeding into the brain substance or parenchyma Most common in patients with hypertension, and cerebral atherosclerosis May also be due to AVM, brain tumors, and medications.

Pathophysiology: AVM: Arteriovenous Malformation

Abnormality in embryonal development Tangle of arteries and veins in the brain without capillaries dilation of arteries and veins rupture. Common cause of hemorrhage in young people.

Pathophysiology: SAH
Secondary to intracranial aneurysms Aneurysms is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall May be due atherosclerosis May congenital Head trauma most common cause of SAH

CLINICAL MANIFESTATIONS
Are similar to patients with ischemic stroke. Would depend the site or area of the brain involved

ASSESSMENT AND DIAGNOSTIC FINDINGS

Cranial CT scan more sensitive than an MRI in detecting blood. Lumbar puncture can confirm presence of SAH Toxicology drug screen if patient is less than 40 years of age.

Prevention
Managing hypertension Control of other risk factors Smoking Alcohol Intake High cholesterol level

Hunt-Hess Classification of Subarachnoid Hemorrhages

I Asymptomatic, Mild HA, Slight Nuchal rigidity II Cranial nerve palsy (III, VI), Mod to severe headache III Mild focal deficit, lethargy, confusion IV Stupor, Mod to sev. Hemiparesis, early decerebrate rigidity V Deep coma, decerebrate rigidity

Medical Management
Allow brain to recover Prevent, minimize risk of rebleeding Prevent, treat complications Bed rest with sedation Analgesics Compression stockings

Complications
Rebleeding Cerebral vasospasm Acute hydrocephalus Seizures

Cerebral Hypoxia, Dec. cerebral blood flow

Provide adequate oxygenation Maintain hemoglobin and hematocrit Adequate hydration Avoid extreme hypo/hypertension Controlling seizures

Managing Increase ICP

Osmotic diuretics Managing complications secondary to osmotic diuretics

Systemic Hypertension
Preventing sudden systemic hypertension If elevated, may be given labetalol, nicardipine, nitroprusside Stool softeners are used

Surgical Management
ICH: Most frequently via craniotomy SAH: Clipping of aneurysm ASAP
Newer endovascular procedures such as Coiling is now available.

Complications: Hydrocephalus
Can occur within the first 24 hours, or days to several weeks later. Sudden onset of stupor or coma Managed with ventriculostomy drain to decrease ICP VP shunt for chronic hydrocephalus

Nursing Diagnosis: Interventions

Ineffective cerebral tissue perfusion Monitor closely for neurologic deterioration Pupillary response Motor function Respiration Implementing aneurysm precaustions

Nursing Diagnosis: Interventions

Aneurysm precautions Provide non-stimulating environment Bedrest w/o BRPs Restrict visitors No strenuous activity including straining Administers all nursing care

Nursing Diagnosis: Interventions

Disturbed sensory perception due to medically imposed restrictions Explanation of the restrictions to reduce anxiety Family requires information and support

SEIZURE DISORDERS

SEIZURES
Are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from excessive discharge from cerebral neurons. A part or all of the brain may be involved. Most seizures are sudden and transient. Specific causes of seizures are varied and can be idiopathic or acquired.

 Acquired Seizures Hypoxemia Fever (childhood) Head injury Hypertension CNS infections Metabolic renal failure, hyponatremia, hypoglycemia, hypocalcemia Toxic - pesticides Brain tumor Drug and alcohol withdrawal CVD leading cause of seizures in the elderly.

EPILEPSY
Group of syndromes characterized by recurring seizures Classified by specific patterns of clinical features, including age of onset, family history, and seizure type. Can be primary or secondary when the cause is known and the seizures is a symptom of an underlying condition. In most cases, the cause is unknown or idiopathic.

Clinical Manifestations
Depends on the location of the discharging neurons May range from simple starting episode to prolonged convulsive movements with loss of consciousness Partial seizures are focal in origin Generalized are nonspecific in origin Initial pattern of the seizures indicates the region of the brain in which the seizure originates

International Classification of Epileptic Seizures

Generalized Seizures - Involve both
hemispheres of the brain Tonic-clonic (grand mal) aura, loss of consciousness, rigidity followed by tonic and clonic movements, interruption of respirations, loss of bladder/bowel control. In post-ictal state, patient is often confused and hard to arouse and may sleep for hours.

 Absence (petit mal) brief transient loss of consciousness ( 3-5 secs) with or without minor motor movements of eyes, head or extremities Myoclonic brief, transient rigidity or jerking of extremities, singly or in groups Status epilepticus prolonged repetitive seizure without recovery between attacks; may result in complete exhaustion and lead to death Febrile seizure associated with hyperpyrexia. Occurs only once

International Classification of Epileptic Seizures

Partial, or Focal Seizures
SIMPLE
With focal motor, sensory, or autonomic symptoms Without loss of consciousness

COMPLEX

Begins as simple partial and progress to impairment of consciousness. Cognitive, psychosensory, psychomotor, or affective effect Person does not remember the episode when it is over

Medical Management
PHARMACOLOGIC THERAPY Objective is to achieve seizure control with minimal side effects. Anticonvulsant therapy continued throughout life; diazepam (Valium) given IV to treat status epilepticus Sedatives used to reduce emotional stress

Surgical Management
Indicated for patients whose epilepsy results from intracranial tumors, abscess, or vascular anomalies. Seizures that do not respond to medications.

Nursing Process: ASSESSMENT

Determining the type of seizures, their frequency and severity, factors that precipitate them. Developmental history including pregnancy and childbirth Head injury history Imaging: MRI seizure protocol EEG, Video EEG

Nursing Process: Assessment

Observe and record the sequence of symptoms. The following are assessed and documented.
Circumstances Occurrence of aura First thing patient does in a seizure Type of movements Areas of the body involved Size of both pupils Automatisms Incontinence Duration Unconsciousness Paralysis Inability to speak Movements at the end Sleep at the end of the seizure Cognitive status

Nursing Process: Assessment

Ask the following questions:
Effect of epilepsy on the patients lifestyle Limitations imposed by the seizure disorder Recreational program Social contacts Occupation Coping mechanism

Nursing Care During a Seizure

Provide privacy Ease the patient to the floor Protect the head with a pad to prevent injury Loosen constrictive clothing If in bed, remove pillows, and raise side rails If an aura precedes the seizure, insert oral airway DO NOT attempt to pry open jaws that are clenched in a spasm to insert anything DO NOT attempt to restrain patient during the seizure. Place patient on one side with head flexed forward. Clear secretions

Nursing Care After the Seizure

Keep the patient on one side to prevent aspiration. Make sure airway is present. Usually a period of confusion after a grand mal seizure, patient should be reoriented to the environment upon awakening. If patient becomes agitated, use calm persuasion or gentle restraint.

Nursing Diagnosis and Interventions

DIAGNOSES
Risk of injury Fear related to possibility of seizures Ineffective coping mechanisms Deficient knowledge related to epilepsy Complications: STATUS EPILEPTICUS Risk of aspiration related to lowered level of consciousness

INTERVENTIONS
Preventing Injury Reducing fear of seizures

Improving coping mechanisms Providing patient and family education Monitoring and managing complications

HOME CARE CHECKLIST

Take medications as prescribed Keep a medication and seizure chart Have antiseizure medication check regularly Avoid activities that require alertness and coordination Report signs of toxicity Avoid over the counter medications Avoid seizure triggers Take showers instead of tub baths Regular sleep patterns
Alcoholic bev, stress, caffeine, fever, hypoglycemia

Bell`s Palsy (Facial Paralysis)

Etiology and pathophysiology
Paralysis that occurs on one side of the face as a result of an inflamed seventh cranial (facial) nerve; generally lasts only 2 to 8 weeks but may last longer in older clients Cause unknown; possible viral link Most common between ages 20 to 50 years

Bell`s Palsy
Clinical findings
Subjective: facial pain; altered taste; impaired ability to chew and swallow Objective: distortion of face; drooping of mouth on affected side; difficulty with articulation; diminished blink reflex; upward movement of eyeball when closing eye; increased lacrimation

Bell`s Palsy
Therapeutic interventions
Prednisone therapy Heat, massage, and electric stimulation to maintain circulation and muscle tone Prevention of corneal irritation with eyedrops and use of protective eye shield

Bell`s Palsy
Nursing Care of Clients with Bell`s Palsy
Assessment Presence or absence of blink reflex and ability to close the eye Facial pain; extent of facial paralysis Nutritional intake and the ability to chew and swallow

Bell`s Palsy
Analysis/Nursing Diagnoses
Pain related to inflammation or compression of facial nerve Risk for injury related to absent or diminished blink reflex Body image disturbance related to change in facial appearance

Planning/Implementation
Teach prevention of corneal irritation by using artificial tears, manually closing the eye, and applying an eye shield Teach importance of keeping face warm

Bell`s Palsy
Teach gentle massage of face; simple exercises such as blowing; institute only when acute phase is over Encourage ventilation of feelings Support nutritional status by providing privacy, small, frequent feedings, and encourage favoring the unaffected side while eating

Bell`s Palsy
Evaluation/Outcomes
Maintains corneal integrity Expresses a positive body image States pain is reduced

Trigeminal Neuralgia (TIC Douloureux)

Etiology and pathophysiology
Incidence higher in women of middle and older age Disorder of the fifth cranial (trigeminal) nerve characterized by intense knifelike pain along the branches of the nerve

Clinical findings
Subjective: burning or knifelike pain lasting 1 to 15 minutes, usually in lip, chin, or teeth; pain precipitated by brushing hair, eating, cold drafs Objective: sudden closure of an eye; twitching of mouth and cheek

Therapeutic interventions
Anticonvulsants to relieve and prevent acute attacks Injection of alcohol into the ganglion to relieve pain for several months or years until nerve regenerates

Trigeminal Neuralgia
Surgical intervention
Severing of the sensory root of the nerve, which will cause loss of all sensation in the area supplied by the nerve Microscopic relocation of arterial loop that may cause vascular compression of trigeminal nerve

Percutaneous radio frequency trigeminal gangliolysis: thermal lesion destroys nerve, providing permanent relief for most clients

Trigeminal Neuralgia
Nursing Care of Clients with Trigeminal Neuralgia Assessment
Descriptions of pain and factors that precipitates attacks Effect on activities (e.g., eating, shaving, washing the face, brushing the teeth) because of fear of precipitating an attack

Trigeminal Neuralgia
Analysis/Nursing Diagnoses
Fear related to triggering an attack Pain related to irritation of the trigeminal nerve Altered nutrition: less than body requirements related to reluctance to chew

Planning/Implementation
Teach factors to limit triggering an attack which can result in exhaustion

Trigeminal Neuralgia
Avoid foods that are too cold or too hot Chew foods on unaffected side Use cotton pads to gently wash face and for oral hygiene Keep the room free of drafts; avoid jarring Provide teaching to clients who have sensory loss as a result of treatment Inspection of the eye several times a day for foreign bodies, which the client will not be able to feel

Trigeminal Neuralgia
Warm normal saline irrigation of the affected eye two or three times a day is helpful in preventing a corneal infection Dental checkups every 6 months, because caries will not produce pain

Teach about anticonvulsants and the need for continued medical supervision

Trigeminal Neuralgia
Evaluation/Outcomes Reports decreased severity of attacks Consumes nutritionally balanced diet Develops mechanisms to cope with fear

Parkinson`s Disease (Paralysis Agitans)

Etiology and pathophysiology
Progressive disorder in which there is a destruction of nerve cells in the basal ganglia and substantia nigra of the brain, which results in dopamine deficiency and subsequent generalized degeneration of muscular function Incidence highest in elderly; suspected causes include neurotransmitter imbalance (dopamine and acetylcholine), unknown virus, cerebral vascular disease, and chemical or physical trauma

 Clinical findings
Subjective: mild, diffuse, muscular pain; stiffness and rigidity, particularly of large joints; depression; emotional lability may be present, but intelligence is usually not impaired Objective Increased difficulty in performing usual activities such as writing, dressing, and eating Generalized tremor commonly accompanied by pill-rolling movements of the thumb against the fingers; nonintention tremors usually reduced by purposeful movements

Parkinson`s Disease
Various disorders of locomotion (e.g., bent posture, difficulty in rising from sitting position, shuffling propulsive gait, loss of rhythmic arm swing when walking, bradykinesia) Masklike facial expression with unblinking eyes Low-pitched, slow,poorly modulated, poorly articulated speech Drooling; difficulty in swallowing saliva Various autonomic symptoms (e.g., lacrimation, constipation, incontinence, decreased sexual capacity, excessive perspiration)

 Dementia and confusion in 15% to 20% of individuals, especially the elderly Therapeutic interventions Medical regimen is palliative rather than curative Pharmacologic intervention (see Antiparkinson Agents in Pharmacology) Physiotherapy to reduce rigidity of muscles and prevent contractures The role of surgical intervention is limited Destruction of thalamus or globus pallidus for intractable tremor and rigidity Transplantation of tissue of adrenal medulla into brain to produce dopamine and transplantation of fetal tissue has been tried

Parkinson`s Disease
Nursing Care of Clients with Parkinson`s Disease
Assessment
History of onset and progression of symptoms Observations of tremors, gait, facial expression,and bradykinesia Nutritional status Elimination status Horizontal and vertical blood pressures to identify postural hypotension

Parkinson`s Disease
Analysis/Nursing Diagnoses
Impaired physical mobility related to neuromuscular degeneration Risk for injury related to postural changes and bradykinesia Self-esteem disturbance related to loss of independence Risk for aspiration related to dysphagia

Parkinson`s Disease
Planning/Implementation
Provide a safe environment Teach client or family to cut food into small bitesized pieces or alter the consistency to prevent chocking; encourage diet rich in nutrient-dense foods such as fruits, vegetables; whole grains, and legumes to improve and maintain nutritional status and prevent possible drug-induced nutrient deficiencies Suction to maintain an adequate airway (usually advanced stages)

Parkinson`s Disease
Encourage an adequate intake of roughage and fluids to avoid constipation Teach activities to limit postural deformities (e.g., use firm mattress without a pillow, periodically lie prone, keep head and neck as erect as possible, think about posture when walking) Teach activities to maintain gait as normal as possible; utilize cane or walker as necessary

 Teach and encourage daily physical therapy to limit rigidity and prevent contractures (e.g., warms baths, passive and active exercises) Avoid rushing as stress intensifies symptoms Encourage continuation of medications even though results may be minimal Teach client and family about antiparkinson agents Assist in setting achievable goals to improve self-esteem

Parkinson`s Disease
Evaluation/Outcomes
Maintains patent airway Participates in daily exercise program Complies with prescribed medical therapy Remains free from injuries

Multiple Sclerosis (Disseminated Sclerosis)

Etiology and pathophysiology
Randomly scattered patches of demyelination in brainstem, cerebrum, cerebellum, and spinal cord Chronic debilitating, progressive disease with periods of remission and exacerbation Cause unknown; viral and immunologic causes have been implicated Onset in early adult life (20 to 40 years); higher occurrence in females Greater incidence in Caucasians and those living in cold climates Fatigue, stress, and heat tend to increase symptoms

Multiple Sclerosis
Clinical findings
Subjective Paresthesia; altered position sense; ataxia Dysphagia Weakness; fatigue Blurred vision; diplopia Altered emotional affect (depression, apathy, or euphoria) Objective Charcot`s triad: intention tremor, nystagmus, scanning (clipped) speech Shuffling gait; increased deep tendon reflexes; spastic paralysis

Multiple Sclerosis
Impaired bowel and bladder function Impotence Cognitive loss (advanced stage) Pallor of optic discs; blindness Increased immunoglobulin G (IgG) levels in the CSF MRI indicates demyelination

Multiple Sclerosis
Therapeutic interventions
Generally palliative Corticosteroids or ACTH Baclofen is used to control spasticity Interferon beta-1b (Betaseron) Physiotherapy and psychotherapy Carbamazepine for paresthesias and trigeminal neuralgia Immunosuppressive drugs (e.g., cyclophosphamide, azathioprine)

Multiple Sclerosis
Nursing Care of Clients with Multiple Sclerosis
Assessment History of onset and progression of motor and sensory loss Factors that intensify symptoms Neurologic status Analysis/Nursing Diagnoses Risk for aspiration related to impaired swallowing Impaired physical mobility related to spasticity and muscle fatigue

Multiple Sclerosis
Risk for injury related to unsteady gait, altered sensations, and impaired vision Constipation related to immobility and neuromuscular impairment Urinary retention related to spasticity Hopelessness related to progression of the disease

Multiple Sclerosis
Planning/Implementation
Incorporate frequent rest periods Avoid hot baths, which can increase symptoms Teach use of assistive devices when carrying out activities of daily living Assist family to understand why client should be encouraged to be active

Multiple Sclerosis
Assist client and family to plan and implement a bowel and bladder regimen Explain the disease process to both client and family in understanding terms Do not encourage false hopes during periods of remission Spend time listening to both client and family; encourage ventilation of feelings

Multiple Sclerosis
Refer client and family to the National Multiple Sclerosis Society Encourage counseling and rehabilitation Explain to client and family that mood swings and emotional alterations are part of the disease process Help client maintain self-esteem Teach how to compensate for problems with gait: walk with feet farther apart to broaden base of support; use low-heeled shoes; use assistive devices when necessary (tripod cane, walker, wheelchair)

Multiple Sclerosis
Teach how to compensate for loss of sensation: use a thermometer to test water temperature; avoid constricting stockings; use protective clothing in cold weather; change position frequently Teach how to compensate for difficulty in swallowing; take small bites; chew well; use a straw with liquids; eat foods of more solid consistency

Multiple Sclerosis
Provide a diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status and compensate for nutrient interactions of corticosteroid medications Provide skin care to prevent formation of pressure ulcers; turn frequently Prevent dysfunctional contractures; provide range-of-motion exercises; splints

Multiple Sclerosis
Evaluation/Outcomes
Maintains a patent airway Remains free from injury Establishes exercise/activity and rest/sleep routine that avoids fatigue Maintains bowel and bladder function Copes with changes in physical abilities and life-style changes

Myasthenia Gravis
Etiology and pathophysiology
Chronic, progressive, neuromuscular disorder with remissions and exacerbations; there is a disturbance in the transmission of impulses at the myoneural junction resulting in profound weakness Dysfunction thought to be caused by a reduced number of acetylcholine receptors (AChR) and an alteration of the postsynaptic membrane of the muscle end-plate

Myasthenia Gravis
Autoimmune theory: it is believed that complement and antibodies to AChR cause accelerated destruction and blockage of the AChR Highest incidence in young adult females Myasthenic crisis refers to sudden inability to swallow or maintain respirations because of the weakness of the muscles of respiration

Myasthenia Gravis
Clinical findings
Subjective: Extreme muscle weakness; becomes progressively worse with use, but disappears with rest; dyspnea, dysphagia (difficulty chewing and swallowing); dysarthria (difficulty speaking); diplopia Objective
Physical: ptosis of the eyelid; strabismus; weak voice (dysphonia); myasthenic smile (snarling, nasal smile)

Myasthenia Gravis
Diagnostic measures: spontaneous relief of symptoms with administration of subcutaneous neostigmine (Prostigmin) or IV administration of edrophonium (Tensilon); edrophonium used to distinguish myasthenic crisis from cholinergic crisis (toxic effects of excessive neostigmine)

Therapeutic interventions
Medications that block the action of cholinesterase at the myoneural junction

Myasthenia Gravis
X-ray therapy or surgical removal of the thymus may cause partial remission Corticosteroids or ACTH Tracheostomy with mechanical ventilation as necessary in myasthenic crisis Plasmapheresis and immunosuppressives to reduce circulating antibody titer

Myasthenia Gravis
Nursing Care of Clients with Myasthenia Gravis
Assessment
History of onset and progression of motor and sensory loss; factors that intensify symptoms Neurologic status (see Neurologic Assessment)

Analysis/Nursing Diagnoses
Fatigue related to profound muscle weakness Ineffective airway clearance related to inability to cough or swallow

Myasthenia Gravis
Planning/Implementation
Administer medications on strict time schedule to prevent onset of symptoms Observe for signs of dyspnea, dysphagia, and dysarthria; may be caused by worsening of myasthenia (myasthenic crisis) or overdose of anticholinergic drugs (cholinergic crisis) Have an emergency tracheostomy set at bedside Plan activity to avoid fatigue based on the individual`s tolerance

Myasthenia Gravis
Teach to avoid people with upper respiratory tract infections, because pneumonia may develop as a result of fatigued respiratory muscles Encourage use of a medical alert card Avoid administering morphine to clients receiving cholinesterase inhibitors; these drugs potentiate effects of morphine and may cause respiratory depression

Myasthenia Gravis
Provide emotional support and close client contact to allay anxiety Administer tube feedings to avoid aspiration if client has difficulty swallowing Administer artificial tears to keep cornea moist if client has difficulty closing eyes Encourage client and family to participate in planning care Ensure that client understands the signs and symptoms of myasthenic and cholinergic crises

Myasthenia Gravis
Refer client and family to Myasthenia Gravis Foundation and local self-help groups In severe instances anticipate all needs, because the client is too weak to turn, drink, or even request assistance Maintain a patent airway; suction as necessary; provide tracheostomy care; maintain mechanical ventilation as ordered

Myasthenia Gravis
Evaluation/Outcomes
Maintains a balance between activity and rest Maintains effective respiratory function Identifies signs and symptoms of crises

Guillain-Barr Syndrome (Polyradiculoneuritis)

Etiology and pathophysiology
Changes in motor cells of spinal cord and medulla with areas of demyelination Cause unknown; thought to be linked to immunologic status; often follows respiratory or gastrointestinal infection After initial and plateau periods, recovery may take up to a year; although most recover, some experience residual deficits or die of complications

Guillain-Barr Syndrome
Clinical findings
Subjective:generalized weakness; paresthesia; muscle pain; diplopia Objective Paralysis begins in lower extremities; ascends within the body; maximal deficit usually by 4 weeks Respiratory paralysis Autonomic neuropathy (e.g., hypertension, tachycardia, diaphoresis) Abnormal CSF and electrophysiologic studies

Guillain-Barr Syndrome
Therapeutic interventions
Intravenous therapy with IgG Plasmapheresis Support of vital functions

Nursing Care of Clients with GuillainBarre Syndrome

Assessment
Respiratory function including airway, respiratory rate, breath sounds, and arterial blood gases Neurologic status (see Neurologic Assessment)

Guillain-Barr Syndrome
History of any recent illness (particularly viral infections) Onset and progression of symptoms

Analysis/Nursing Diagnoses
Inability to sustain spontaneous ventilation related to muscle weakness Altered role performance related to lengthy recovery period Impaired physical mobility related to impaired neuromuscular function

Guillain-Barr Syndrome
Planning/Implementation
Monitor vital signs, breath sounds, and arterial blood gases Maintain airway and keep tracheostomy set at the bedside Monitor functioning of the respirator and suction as necessary Provide emotional support for the client and family because of the severity of adaptations and lengthy convalescent period

Guillain-Barr Syndrome
Prevent complications of immobility: skin care; range-of-emotion exercises; position changes; coughing and deep breathing; antiembolism stockings Refer client and family to Guillain-Barre Foundation for additional information and community resources Maintains effective respiratory function Remains free from complications of immobility Discusses feelings with family and other health-team members

Evaluation/Outcomes

Amyotrophic Lateral Sclerosis (ALS)

Etiology and pathophysiology
Progressive, degenerative process involving the corticospinal and anterior horn neurons, with subsequent upper and lower motor neuron effects Occurs more frequently in men than women in the fourth and fifth decades Cause unknown; autoimmune diseases and genetic causes are implicated

Amyotrophic Lateral Sclerosis

Death from respiratory complications frequently occurs within 3 to 5 years

Clinical findings
Subjective: muscular weakness; malaise; fatigue Objective Fasciculations (irregular spasmodic twitching of small muscle groups); spasticity; atrophy Difficulty in breathing, chewing, swallowing, speaking Outbursts of laughter or crying Abnormal electromyography

Amyotrophic Lateral Sclerosis

Therapeutic interventions
Physiotherapy to relieve spasticity Supportive respiratory functions Riluzole (Rilutek) to inhibit glutamate accumulation, possibly preventing injury or death of neurons

Amyotrophic Lateral Sclerosis

Nursing Care of clients with Amyotrophic Lateral Sclerosis
Assessment History of onset and progression of symptoms Neurologic status Respiratory status including rate, depth, and effort

Amyotrophic Lateral Sclerosis

Analysis/Nursing Diagnoses
Inability to sustain spontaneous ventilation related to neuromuscular impairment Anticipatory grieving related to progressive nature of illness Impaired physical mobility related to neuromuscular impairment

Planning/Implementation
Encourage client to remain active as long as possible, employing supportive devices as needed

Amyotrophic Lateral Sclerosis

Encourage range-of-motion exercises Monitor swallowing ability; positioning and consistency of diet to prevent aspiration Provide alternate means of communication as speech declines Allow client to discuss feelings about life support while still able to speak Monitor respiratory function; increased fluids, positioning, chest physiotherapy, coughing and deep breathing exercises, and suctioning help prevent complications

Amyotrophic Lateral Sclerosis

Support natural defense mechanisms; encourage a diet consisting of nutrientdense foods, especially those rich in the immune-stimulating nutrients selenium and vitamins A, C, and E Teach the avoidance of situations that may contribute to infection Provide emotional support for the client and family Refer client and family to ALS Association

Amyotrophic Lateral Sclerosis

Evaluation/Outcomes
Maintains effective respiratory function Discusses feelings with family and other health team members

Low Back Pain

Low Back Pain

Low Back Pain

Pain may be a result of acute or repeated stress on the lower back over a period of years Pain occurs because of degeneration and/or acute injury to the tissue of the lower back Caused by sprain or strain of ligaments and muscles Pain may be felt at the site of the injury or referred Overall health of muscles of the lower back determines the degree of risk for injury as

Low Back Pain

Etiology and pathophysiology
Low back pain occurs because of repeated injury and progressive degeneration of the spine The two most common causes of low back pain are mechanical strain (irritation or injury to the disc causing degeneration) and herniation of the nucleus pulposus (putting pressure on the nerve roots)

Low Back Pain

Low Back Pain

Assessment
Risk factors include but are not limited to: degenerative disc disease, poor muscle tone of the lower back, sedentary lifestyle, obesity, poor body mechanics, smoking, and stress Client will report pain caused by a shift of one vertebra on another or pinching and irritation of the nerve root Muscle spasms are a common symptom

Low Back Pain

Pain does not appear at the time of injury but is related to the gradual increase of muscle spasms of the paravertebral tissue The straight leg raise test may not be positive with acute injury but pain is present with radiation to the buttock and leg along the path of the sciatic nerve with chronic injury

Low Back Pain

Planning and implementation
The goal of treatment is to improve symptoms and slow progression of the degenerative process Include client and family in plan of care Provide emotional support

Low Back Pain

Medication therapy
Medication therapy includes but is not limited to analgesics, NSAIDs, and muscle relaxants Epidural corticosteroid injections may be used if conservative treatment is ineffective

Low Back Pain

Client education
Teach client about expected therapeutic effects, side/adverse effects, and contraindications with medication use Teach client about the pain rating scale Teach client the importance of adhering to activity restrictions such as bed rest as indicated Teach client the importance of adhering to gradual to activity restrictions such as adherence with exercise plan

Low Back Pain

Teach client the importance of maintaining ideal body weight Inform client that physical therapy will be part of the rehabilitation process to assist in maintaining muscle strength and flexibility as well as improving muscle tone Teach client the use of heat/cold for comfort

Low Back Pain

Teach client about the importance of adhering to the principles of body mechanics to avoid excessive strain on the lower back Encourage client to sleep on a firm mattress Have client demonstrate correct sleeping position using the principles of body mechanics (side lying or supine with knees and hips flexed) Encourage client to avoid or stop smoking Teach client about use of prescribed brace or corset (if needed) to prevent flexion and extension motions of lower back

Low Back Pain

THANK YOU!

Clotting (Helitene)

Helitene

Why monitor ICP?

Monro-Kellie Hypothesis
closed box essentially non-compressible components brain, blood, CSF

Autoregulation
vascular resistance maintains constant pressure

Volume pressure curve

Concepts of ICP

Closed Box Concept

Volume Pressure Curve

30

I C 20 P
10 0

Volume

Causes of Increased ICP

Brain
trauma, tumor, infection, edema
Cerebral contusion Cerebral edema with slit ventricles Middle cerebral artery stroke

Blood
vasodilatation, cerebrovascular disease, intracerebral bleeding

CSF
hydrocephalus

hydrocephalus

 Normal ICP ~ 0 15
Moderate elevation > 20 mmHg

Cerebral Perfusion Pressure

Cerebral perfusion calculated
CPP = MAP (mean arterial pressure) - ICP

CPP > 60 - 70 mmHg

Necessary for carrying oxygen to brain to prevent ischemia

Herniation (displacement of brain

from normal position)

Who should we monitor?

Guidelines for the Management of Severe Head Injury
Bullock, Chesnut et al (2000)

All patient GCS <8 Who are these patients?

Trauma, edema, tumors, aneurysms Sometimes hydrocephalus Infectious diseases

The END
Time for the Test