Medical Surgical Nursing A

Care of the Patient

With a Neurological
Disorder

BGallatin 2007
 Anatomy and Physiology

 Central nervous system  Peripheral nervous

(CNS) system
 Brain  Somatic (voluntary)
 Spinal cord  Autonomic
(involuntary)

BGallatin 2007
 Anatomy and Physiology

 Neurons  Glial cells

 Transmitter cells  Support and protect
 Carry messages to and neurons
from brain and spinal  Produce cerebral spinal
cord fluid

BGallatin 2007
 Anatomy and Physiology

 CNS: brain
 Cerebrum – lobe functions
 Diencephalon – thalamus, hypothalamus
 Cerebellum – balance, coordination
 Brain stem – midbrain, pons, medulla oblongata

BGallatin 2007
 Anatomy and Physiology

 PNS: Somatic (voluntary)

 31 pairs of spinal nerves
 12 pair of cranial nerves

BGallatin 2007
 Anatomy and Physiology

 PNS: Autonomic (involuntary)

 Controls:
 Smooth Muscles
 Cardiac Muscles

 Glands

 Check and balance system:

 Sympatheticnervous system
 Parasympathetic nervous system

BGallatin 2007
 Neurological Assessment

 History
 Headaches  Pain
 Loss of function  Personality change
 Visual acuity  Mood swing
 Seizures  Fatigue
 Numbness

BGallatin 2007
 Neuro Assessment

 Mental Status
 Orientation
 Mood and behavior
 General knowledge
 Short term memory
 Long term memory

BGallatin 2007
 Neuro Assessment

 Level of consciousness

 Glasgow Coma Scale

 Eye opening
 Verbal response
 Motor response

BGallatin 2007
 Neuro Assessment

 Language and Speech

 Aphasia
 Sensory

 Expressive

 Global

BGallatin 2007
 Cranial Nerves

 I. Olfactory  VII. Facial

 II. Optic
 III. Oculomotor
 IV. Trochlear
 V. Trigeminal
 VI. Abducens
 VIII. Acoustic
 IX. Glossopharyngeal
 X. Vagus
 XI. Spinal Accessory
 XII. Hypoglossal

BGallatin 2007
 Neuro Assessment

 Motor Function
 Paralysis
 Paresis

 Flaccid
 Spastic

BGallatin 2007
 Neuro Assessment

 Sensory and Perceptual Status

 Pain
 Touch
 Temperature
 Proprioception
 Unilateral neglect
 Hemianopia

BGallatin 2007
 Neuro Assessment

 Blood and urine

 ABG
 Lumbar puncture
 Imaging
 EEG
 EMG
 Carotid Duplex
BGallatin 2007
 Neurological Problems

 Headache
 Vascular – migraine, cluster, hypertensive
 Tension – stress
 Traction-inflammatory – infection, occlusion
vessels

BGallatin 2007
 Neurological Problems

 Increased Intracranial Pressure (IIP)

 Occurs slowly or rapidly

 May lead to brain stem herniation and death

BGallatin 2007
 Assessment of IIP

 Subjective
 Diplopia
 Personality change
 Thought processes change
 Headache
 Nausea

BGallatin 2007
 Assessment of IIP

 Objective
 Decreasing LOC

 Hyperthermia  Posturing
 Weakness  Wide pulse pressure
 Vomiting  Bradycardia
 Seizures  Altered respirations
 Papilledema  Pupils fixed & dilated

BGallatin 2007
 Assessment of IIP

 Diagnostic tests:
 CT scan, MRI
 Close observation
 Craig’s screw

BGallatin 2007
 Medical Management of IIP

 Craniotomy
 Craniectomy
 Tumor removal
 Drainage of ventricles
 Drainage of hematoma
 Intubation

BGallatin 2007
 Medical Management of IIP

 Medications
 Osmotic diuretics - Mannitol
 Corticosteroids - Decadron
 Anticonvulsants - Dilantin

 Internal monitoring

BGallatin 2007
 Nursing Care of the Patient
With IIP
 Elevate HOB  Restrict fluids
 Neck in neutral  Foley
position  Suctioning
 Avoid flexion hips,  O2
waist and neck  Hypothermia blanket
 Avoid isometric
activity or Valsalva

BGallatin 2007
 Neurological Disorders-
Seizures
 Seizures
 Disorderly neuron discharges in brain
 Transitory
 Different types affect body differently
 Involuntary movement usually

BGallatin 2007
 Seizures

 Generalized:  Localized: (Focal)

 Tonic-clonic –  Partial (Jacksonian)
grand mal  Psychomotor
 Absence - Petit mal
 Myoclonic
 Atonic or akinetic

BGallatin 2007
 Seizures

 Causes:
 Hypoglycemia
 Infection
 Electrolyte imbalance
 Trauma
 IIP
 Toxins

BGallatin 2007
 Seizure Medications

 Dilantin (Phenytoin)  Clonopin

 Phenobarbital  Mesantoin
 Mysoline  Neurontin
 Tridione  Lamictal
 Valium (Diazepam)  Felbatol
 Depakene  Cerebyx

BGallatin 2007
 Seizure Medications

 Nursing:
 Medications
 Continue meds
 Medic alert ID
 Avoid alcohol, avoid driving, get adequate rest
 If on Dilantin, instruct on oral hygiene

BGallatin 2007
 Seizures: Nursing Care

 Protect
 Lower to the floor; pad side rails; pillow under
head; don’t restrain
 No bite block or padded tongue blade
 Allow for post-ictal rest
 Prevent aspiration (airway)
 Turn side; loosen clothing around neck
 Document everything

BGallatin 2007
 Degenerative Neuro Diseases

 Multiple Sclerosis  Myasthenia Gravis

 Parkinson’s Disease  Amyotrophic Lateral

Sclerosis (ALS)
 Alzheimer’s Disease
 Huntington’s Disease
(chorea)

BGallatin 2007
 Multiple Sclerosis

 Common degenerative neurological disease.

 Myelin sheath is destroyed.
 Symptoms vary.
 Relapsing/remitting.
 Usually ages 20-40.

BGallatin 2007
 Multiple Sclerosis - Symptoms

 Subjective:
 Shakiness, difficulty walking
 Fatigue, muscle weakness
 Numbness, tingling
 Tinnitus
 Visual problems
 Difficulty chewing and speaking
 Incontinent; impotent

BGallatin 2007
 Multiple Sclerosis - Symptoms

 Objective:
 Ataxia
 Changes in behavior & emotions
 Nystagmus
 Spasticity, tremors, dysphagia, facial palsy,
speech impaired, fatigue
 Incontinence
 Impaired judgment

BGallatin 2007
 Multiple Sclerosis - Tests

 CSF
 CT scan
 MRI

BGallatin 2007
 Multiple Sclerosis-Treatment

 Meds:
 Anti inflammatory
 ACTH, Solu Medrol, Prednisone
 Immuno Modifiers
 Avonex, Betaseron, Capoxone
 Muscle Relaxants
 Valium

BGallatin 2007
 Multiple Sclerosis-Nursing
Interventions
 Nutrition
 Skin Care
 Activity
 Control of environment
 Emotional support
 Patient teaching

BGallatin 2007
 Parkinson’s Disease

 Unknown cause
 Lack of dopamine.
 Parkinsonism: encephalitis, toxic chemicals,
meds, drugs

BGallatin 2007
 Parkinson’s

 Symptoms include:
 Muscular tremors and rigidity
 Emotional instability
 Judgment defects
 Heat intolerance
 Mask-like facial appearance
 Dysphagia and drooling

BGallatin 2007
 Parkinson’s Testing

 No specific test to diagnose Parkinson’s

 Diagnosis based on symptoms

BGallatin 2007
 Parkinson’s – Medical
Treatment
 Medications
 Sinemet, Symmetrol, Levodopa or Cogentin
 Less effective over time
 Surgery
 Experimental

BGallatin 2007
 Parkinson’s – Nursing Care

 Prevent injury (fall or aspiration)

 Prevent urinary retention and constipation
 Patient teaching about medication
 Patient and family support

BGallatin 2007
 Alzheimer’s

 Unknown cause, but genetic link

 Very common; risk increases with age
 Brain changes:
 plaques
 tangled neurons
 blood vessel degeneration
 chemical changes

BGallatin 2007
 Alzheimer’s - Symptoms

 1st– memory lapses, difficult word finding,

decreased attention span
 2nd – increased memory problems,
disoriented to time, loses things,
confabulates
 3rd – total disorientation, apraxia, wanders
 4th – severe impairment

BGallatin 2007
 Alzheimer’s - Testing

 No definitive test

 Family history

 Diagnosis: autopsy

BGallatin 2007
 Alzheimer’s – Medical
Management
 Medication to treat symptoms
 Memory:Cognex, Aricept
 Agitation: Mellaril, Haldol
 Supplements
 Folic Acid & Vitamin B12
 Low fat diet
 NSAIDS

BGallatin 2007
 Alzheimer’s – Nursing Care

 2 key points for all care:

 Prevent overstimulation
 Provide structured, orderly environment

 Other concerns
 Communication
 Family support and education

BGallatin 2007
 Myasthenia Gravis

 Autoimmune disorder
 Myoneural junction problem
 Symptoms:
 ptosis, diplopia,
 weakness, dysarthria, dysphagia, difficulty
sitting up, respiratory distress

BGallatin 2007
 Myasthenia Gravis - Treatment

 Medication
 to improve impulse transmission (Mestinon)
 to suppress immune system (steroids, Cytoxan)
 Plasmapheresis
 Respiratory support
 Safety

BGallatin 2007
 Amyotrophic Lateral Sclerosis
ALS – Lou Gehrig’s disease
 Motor neurons in brain stem and spinal cord
degenerate
 Brain’s messages don’t reach the muscles
 Symptoms – weakness, dysarthria, dysphagia
 No loss of cognitive function
 No cure, death occurs in 2-6 years

BGallatin 2007
 Huntington’s Disease
Chorea
 Genetic
 Onset at age 35-45
 Excessive involuntary movements
 Death in 10-20 years
 No cure

BGallatin 2007
 Huntington’s Disease

 Nursing interventions are palliative

 Give meds
 Provide for safety
 Provide adequate diet
 Emotional support
 Genetic counseling

BGallatin 2007
 Cerebrovascular Accident
(CVA)
 Ischemia of brain tissue
 Hemorrhage
 Thrombus
 Embolus

 3rd leading cause of death in the US

 All ages, but usually elderly

BGallatin 2007
 CVA – Contributing Factors

 Atherosclerosis  High cholesterol

 Heart disease  Cigarette smoking
 Kidney disease  Stress
 Sedentary
 Diabetes
 Hypertension  Oral contraceptives
 Obesity  Cocaine

BGallatin 2007
 Cerebral Thrombosis

 Most common cause of CVA

 Most often:
 Atheroclerosis

↓
 Thrombus

↓
 CVA

BGallatin 2007
 Cerebral Embolism

 2nd most common cause of CVA

 Most often:
 Heart disease
↓
 Thrombus
↓
 Embolus
↓
 CVA

BGallatin 2007
 Cerebral Hemorrhage

 3rd most common cause of CVA

 Most often:
 Hypertension
↓
 Ruptured cerebral blood vessel
↓
 CVA

BGallatin 2007
 Transient Ischemic Attack

 Cerebrovascular insufficiency

 Causes – same as CVA

 Warning sign of impending CVA

BGallatin 2007
 CVA - Assessment

 Motor changes
 Opposite side
 Balance, coordination, gait, proprioception
 Glasgow Coma Scale

BGallatin 2007
 CVA Assessment

 Sensory Changes
 Aphasia =can’t speak or write
 Agnosia =can’t recognize familiar objects/people
 Apraxia =can’t perform purposeful acts or use
objects properly
 Neglect Syndrome
 Visual problems, including hemianopsia

BGallatin 2007
 CVA Assessment

 Cognitive changes
 denial
 impaired memory, judgment
 can’t concentrate
 disoriented
 slow and cautious versus impulsive
 depressed, anxious versus euphoric
 angers quickly versus constantly smiling
BGallatin 2007
 CVA - Testing

 CT or MRI
 Cerebral angiogram
 CBC, PT, PTT, electrolytes

BGallatin 2007
 CVA – Medical Management

 Thrombolytic (“clot buster”)

 Anticoagulants
 Antiplatelet drugs
 Aneurysm repair
 Carotid endarterectomy

BGallatin 2007
 CVA-Nursing Care

 Assess LOC
 IV, NG, Foley, Vent.
 Nutrition
 Encourage perform ADLs
 Bladder and bowel training
 ROM
 Teaching and emotional support

BGallatin 2007
 Trigeminal Neuralgia
Tic Douloureux
 Trigeminal nerve – degeneration, pressure
 Facial pain
 Medication, surgery
 Avoid triggers

BGallatin 2007
 Bell’s Palsy

 Facial nerve inflammation

 Unilateral weakness of facial muscles

 Steroids, Zovirax, warm moist cloth,

massage, facial exercises

BGallatin 2007
 Infection and Inflammation

Meningitis  Neurosyphilis
 Encephalitis  Poliomyelitis
 Brain abscess  Herpes zoster
Guillain-Barré AIDS

BGallatin 2007
 Guillain-Barré - Polyneuritis

 Peripheral nerve disease

 Prior infection; autoimmune response

 Weakness and paralysis, begins in

extremities and works up
 Respiratory failure may occur

BGallatin 2007
 Meningitis

 Acute infection of the meninges

 Viral or bacterial

 Severe headache, irritable, fever, delirium,

N/V, neck stiffness
 Kernig’s sign
 Brudzinski’s sign

BGallatin 2007
 Meningitis-Medical
Management
 Diagnosed by LP
 Medications
 Respiratory isolation
 Cool, dark quiet room
 Maintain hydration
 Prevent injury

BGallatin 2007
 Acquired Immunodeficiency
Syndrome - AIDS
 AIDS dementia complex
 Infection of CNS

 Dementia

 Treatment depends on infection

 Treat symptoms, maintain safety

BGallatin 2007
 Spinal Cord Trauma

 Complete cord injury – all voluntary

movement below level of trauma is lost

 Autonomic hyperreflexia
 stimulus
 sympathetic nervous system response

BGallatin 2007