Medical-Surgical Nursing: Neurologic Concepts DIAGNOSTIC test

CEREBROVASCULAR DISEASE • 1. CT scan

• 2. MRI
• An umbrella term that refers to any
• 3. Angiography
functional abnormality of the CNS related to
disrupted blood supply

Client with CVA: TWO TYPES

CLINICAL MANIFESTATIONS
1. Numbness or weakness
2. confusion or change of LOC
3. motor and speech difficulties
4. Visual disturbance
5. Severe headache

Motor Loss
• Hemiplegia
• Hemiparesis
Communication loss
• Dysarthria= difficulty in speaking
• Aphasia= Loss of speech
• Apraxia= inability to perform a previously
learned action
Perceptual disturbances
• Hemianopsia
Sensory loss
The stroke continuum • paresthesia
• 1. TIA- transient ischemic attack, temporary NURSING INTERVENTIONS
neurologic loss less than 24 hours duration 1. Improve Mobility and prevent joint deformities
• Correctly position patient to prevent contractures
CEREBROVASCULAR DISEASE: Ischemic Stroke • Place pillow under axilla
• There is disruption of the cerebral blood flow • Hand is placed in slight supination- “C”
due to obstruction by embolus or thrombus • Change position every 2 hours
2. Enhance self-care
RISKS FACTORS • Carry out activities on the unaffected side
• Prevent unilateral neglect
Non-modifiable
• Keep environment organized
• Advanced age
• Gender • Use large mirror
• Race 3. Manage sensory-perceptual difficulties
Modifiable • Approach patient on the Unaffected side
• Hypertension • Encourage to turn the head to the affected side to
• Cardio disease compensate for visual loss
• Obesity 4. Manage dysphagia
• Smoking • Place food on the UNAFFECTED side
• Diabetes mellitus • Provide smaller bolus of food
• hypercholesterolemia • Manage tube feedings if prescribed
5. Help patient attain bowel and bladder control
Pathophysiology of ischemic stroke • Intermittent catheterization is done in the acute
• Disruption of blood supply stage
• Anaerobic metabolism ensues • Offer bedpan on a regular schedule
• Decreased ATP production leads to impaired • High fiber diet and prescribed fluid intake
membrane function 6. Improve thought processes
• Cellular injury and death can occur • Support patient and capitalize on the remaining
strengths
7. Improve communication 3. Decreased CSF production
• Anticipate the needs of the patient Decompensatory mechanisms:
• Offer support 1. Decreased cerebral perfusion
• Provide time to complete the sentence 2. Decreased PO2 leading to brain hypoxia
• Provide a written copy of scheduled activities 3. Cerebral edema
• Use of communication board 4. Brain herniation
• Give one instruction at a time
8. Maintain skin integrity Decreased cerebral blood flow
• Use of specialty bed • Vasomotor reflexes are stimulated initially→
• Regular turning and positioning slow bounding pulses
• Keep skin dry and massage NON-reddened • Increased concentration of carbon dioxide will
areas cause VASODILATION → increased flow→
• Provide adequate nutrition increased ICP
9. Promote continuing care
• Referral to other health care providers Cerebral Edema
10. Improve family coping
• Abnormal accumulation of fluid in the
11. Help patient cope with sexual dysfunction
intracellular space, extracellular space or both.
CVD: Hemorrhagic Stroke Herniation
• Normal brain metabolism is impaired by • Results from an excessive increase in ICP when
interruption of blood supply, compression and the pressure builds up and the brain tissue
increased ICP presses down on the brain stem
• Usually due to rupture of intracranial aneurysm,
Subarachnoid hemorrhage Cerebral response to increased ICP
• Sudden and severe headache 1. Cushing’s response
• Same neurologic deficits as ischemic stroke • Vasomotor center triggers rise in BP to
• Loss of consciousness increase ICP
• Meningeal irritation • Sympathetic response is increased BP
• Visual disturbances but the heart rate is SLOW
• Respiration becomes SLOW
DIAGNOSTIC TESTS
Increased Intracranial pressure
1. CT scan
CLINICAL MANIFESTATIONS
2. MRI
Early manifestations:
3. Lumbar puncture (only if with no increased ICP)
• Changes in the LOC- usually the earliest
• Pupillary changes- fixed, slowed response
NURSING INTERVENTIONS
• Headache
1. Optimize cerebral tissue perfusion
• vomiting
2. relieve Sensory deprivation and anxiety
late manifestations:
3. Monitor and manage potential complications
• Cushing reflex- systolic hypertension,
bradycardia and wide pulse pressure
Increased Intracranial pressure
• bradypnea
Intracranial pressure more than 15 mmHg
• Hyperthermia
Brunner= Normal intracranial pressure 10-20 mmHg
• Abnormal posturing
Causes:
• Head injury
Nursing interventions:
• Stroke
Maintain patent airway
• Inflammatory lesions
1. Elevate the head of the bed 15-30 degrees- to
• Brain tumor
promote venous drainage
• Surgical complications
2. assists in administering 100% oxygen or
controlled hyperventilation- to reduce the CO2 blood
Pathophysiology
levels→constricts blood vessels→reduces edema
• The cranium only contains the brain substance, 3. Administer prescribed medications- usually
the CSF and the blood/blood vessels Mannitol- to produce negative fluid balance
• MONRO-KELLIE hypothesis- an increase in corticosteroid- to reduce edema
any one of the components causes a change in anticonvulsants-p to prevent seizures
the volume of the other 4. Reduce environmental stimuli
• Any increase or alteration in these structures will 5. Avoid activities that can increase ICP like
cause increased ICP valsalva, coughing, shivering, and vigorous
Compensatory mechanisms: suctioning
1. Increased CSF absorption 6. Keep head on a neutral position. AVOID- extreme
2. Blood shunting flexion, Valsalva
7. monitor for secondary complications 9. Promote bowel function
• Diabetes insipidus- output of >200 mL/hr • High fiber diet
• SIADH • Stool softeners and suppository
10. Provide sensory stimulation
Altered level of consciousness • Touch and communication
• It is a function and symptom of multiple • Frequent reorientation
pathophysiologic phenomena
• Causes: head injury, toxicity and metabolic Headache
derangement • Cephalgia
• Disruption in the neuronal transmission results • Primary headache- no organic cause
to improper function • Secondary headache- with organic cause
Assessment • Migraine headache- periodic attacks of headache
• Orientation to time, place and person due to vascular disturbance
• Motor function Migraine
• Decerebrate 1. Aura phase – bright spots or flashing light
• Decorticate 1. Lasts from 5-60 minutes
• Sensory function 2. Initial stage of vasoconstriction
• Patient is not oriented 2. Headache
• Patient does not follow command 1. Cerebral vasodilation
• Patient needs persistent stimuli to be awake 2. Decrease serotonin levels
• COMA= clinical state of unconsciousness where 3. Headache both sides, NV
patient is NOT aware of self and environment 3. Recovery phase – HA area is sensi to touch
Etiologic Factors 1. Feeling of exhaustion
1. Head injury Nursing Interventions
2. Stroke • 1. Avoid precipitating factors
3. Drug overdose • 2. modify lifestyle
4. Alcoholic intoxication • 3. relieve pain by pharmacologic measures
5. Diabetic ketoacidosis • Beta-blockers
6. Hepatic failure • Serotonin antagonists- “triptan"
ASSESSMENT
1. Behavioral changes initially DEMYELINATING DISEASES
2. Pupils are slowly reactive
3. Then , patient becomes unresponsive and pupils MULTIPLE SCLEROSIS
become fixed dilated
Glasgow Coma Scale is utilized • CAUSE- unknown
• Multiple factors- viral infection, genetic
Nursing Intervention predisposition
1. Maintain patent airway • Common in WOMEN ages 20-40
• Elevate the head of the bed to 30 degrees What went wrong?
• Suctioning • Autoimmune
2. Protect the patient • Demyelination of CNS
• Pad side rails (myelin&oligodendrocytes)
• Prevent injury from equipments, restraints. DIAGNOSTIC TESTS
3. Maintain fluid and nutritional balance • 1. MRI- primary diagnostic study
• Input an output monitoring • 2. CSF Immunoglobulin G
• IVF therapy
• Feeding through NGT
4. Provide mouth care
• Cleansing and rinsing of mouth
• Petrolatum on the lips
5. Maintain skin integrity
• Regular turning every 2 hours
• 30 degrees bed elevation
• Maintain correct body alignment by using
trochanter rolls, foot board
6. Preserve corneal integrity
• Use of artificial tears every 2 hours
7. Achieve thermoregulation PATHOPHYSIOLOGY
• Minimum amount of beddings • The most common areas affected are
• Rectal or tympanic temperature • Optic nerves and chiasm
• Administer acetaminophen as prescribed • Cerebrum
8. Prevent urinary retention • Cerebellum
• Use of intermittent catheterization
 • Spinal cord CLINCAL MANIFESTATIONS
• amnesia – loss of memory
Pharmacotherapy
• apraxia – unable to determine
• Interferons
function & purpose of object
• Corticosteroids
• agnosia – unable to recognize
• BACLOFEN for muscle spasms
familiar object
• NSAIDS for pain
• aphasia
- Expressive – brocca’s aphasia – unable to
Nsg Interventions:
speak
• Exercise
• Wheelchair - Receptive – wernickes aphasia – unable to
• Aspiration precaution understand spoken words
• Eye patch
• Warm packs Common to Alzheimer – receptive aphasia
• Stress mgt. LATE CLINICAL MANIFESTATIONS
• Speech therapist
• Difficulty in abstract thinking
Guillian-Barre’ Syndrome • Difficulty communicating
• Severe deterioration in memory, language
• CAUSE: unknown origin commonly follows and motor function
viral infection • personality changes
• What went wrong?
• Demyelination of PNS (myelin only, DIAGNOSTIC TEST
intact Schwann cells thus allowing • No definitive examination
recovery) • Brain scan could help
• Ascending weakness and paralysis Drug therapy
• diminished reflexes of the lower extremities • Aricept
• paresthesia • Cognex
• potential respiratory failure • Alzhemed
Nursing Management Nursing Interventions:
➢ CPT • Use short simple sentences, words and gestures
➢ Prevent complications of immobility • Maintain a calm and consistent approach
➢ Improve communication • Keep bed in low position
MEDICAL MANAGEMENT • Provide adequate lightning
• ICU admission
• Mechanical Ventilation PARKINSON’s Disease
• TPN and IVF
• PLASMAPHERESIS • What went wrong?
• IV IMMUNOGLOBULIN • Destruction of substantia nigra
• Decreased dopamine
ALZHEIMER’S disease • Imbalance of Dopamine &
• What went wrong? Acetylcholine in the corpus striatum
• Chronic, progressive & degenerative thus impaired in controlling complex &
brain disorder fine body movements
• Profound effects on memory, cognition CAUSATIVE FACTORS: unknown
& ability for self care • Genetics
• Due to destruction of neurons by the • Atherosclerosis
Beta Amyloid plaques • viral infection
CAUSES: • head trauma
• Unknown
• Potential factors- Amyloid plaques in the brain
Symptoms MEDICAL THERAPY
• Tremor in hands, arms, legs, jaw or head • Anticholinesterase drugs- pyridostigmine and
• Stiffness of the limbs and trunk neostigmine
• Slowness of movement • Corticosteroids
• Impaired balance and coordination, sometimes • Plasmapheresis
leading to falls • Thymectomy

4 cardinal signs NURSING INTERVENTIONS

1. Administer prescribed medication as scheduled
• Tremor 2. Aspiration precaution
• Bradykinesia 3. Promote respiratory function
• Rigor 4. Prepare for complications like myasthenic crisis and
• Postural instability cholinergic crisis
Nursing management
Client with Bell’s Palsy
• Assess neurological status What went wrong?
• Assess ability to swallow and chew • Inflammation of 7th CN
• Provide high calorie, high protein, high fiber diet Causes
with small frequent meals 1. Autoimmune
• Increase fluid intake to 2LPD if not 2. Local traumatic injury
contraindicated
• Monitor for constipation
• Promote independence along with safety
measures
Medical management
1. Anti-parkinsonian drugs- Levodopa, Carbidopa
2. Anti-cholinergic therapy
Trihexyphenidyl, benztropine, orphenadrine,
biperiden
3. Antiviral therapy- Amantadine
4. Dopamine Agonists- bromocriptine and Pergolide
5. Anti-depressants
Sertraline, fluoxetine, citalopram, MANIFESTATIONS
amitriptyline
6. Antihistamine • Blinking
• Eye Dryness
Myasthenia gravis • Loss of Facial Expressions
• Loss of Taste
ETIOLOGY • Severe Pain
• Autoimmune disease
• Common to women
What went wrong?
antibodies directed at the Acetylcholine receptor
sites myoneural junction, thus impaired transmission of
impulses

Manifestations

• DRooping
• DIplopia
• DYsphonia
• DYsphagia
• DYspnea
Diagnostic tests
• DIstress & Weakness
• EMG
DIAGNOSTIC TESTS
• Medical management
1. EMG
• 1. Prednisone
2. TENSILON TEST
• 2. Artificial tears
3. CT scan
4. Serum anti-AchReceptor antibodies
Nursing Interventions
1. Apply moist heat to reduce pain
2. Massage the face to maintain muscle tone
3. Give frequent mouth care
4. protect the eye with an eye patch. Eyelid can be
taped at night
5. instruct to chew on unaffected side
Trigeminal neuralgia
• What went wrong?
• Uncertain
• Vascular compression & pressure over
the 5th CN
• Some evidence of demyelination
• CAUSES: repetitive pulsation of an artery as it
exits the pons is the usual cause
ASSESSMENT
1. Pain history
2. Burning jabs of pain lasting from 1-15 minutes in
an area innervated by the trigeminal nerve

DIAGNOSTIC TESTS
• Skull x-ray or CT scan
NURSING INTERVENTIONS
• provide adequate nutrition in small frequent
meals at room temperature
• Assessing & managing patients pain (distraction
techniques, relaxation, massage therapy)
• Provide emotional support
Medical management
• Neuropathic pain
o Gabapentin
o pregabalin
• Anticonvulsants
o Carbamazepine
o Lamotrigine
▪ Adjunct to carbamazepine
o phenytoin