WHAT YOU MUST KNOW ABOUT NEUROLOGICAL DISORDERS

by: Chulou H. Penales, R.N., M.A.N.

ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM

CHULOU H. PENALES, RN

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Central nervous system Brain Spinal cord *Autonomic vs. Somatic Peripheral nervous system Spinal nerves Cranial nerves
CHULOU H. PENALES, RN

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Impulse transmission Acetylcholine Serotonin Dopamine GABA Sodium-potassium pump

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Myelin sheath Oligodendrocytes Schwann cells Nodes of Ranvier Neurilemma

CHULOU H. PENALES, RN

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

The Human Intel Core Duo

3 major divisions Weight Basic structures

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

I. Cerebral Hemispheres

4 Lobes
I m aware

I can talk/understand I can move and sense I can remember I can reason out

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Cerebral Hemispheres
Broca s Area

Other structures
Basal ganglia

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

II. Diencephalon/ Interbrain

III. Brainstem

Midbrain
Thalamus

Medulla Oblongata Pons RAS

Epithalamus Hypothalamus

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

IV: Cerebellum

Meninges

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Cerebrospinal fluid Source Purpose Contents Volume/ specific gravity Blood brain barrier Assessment

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Spinal Cord (***C1-L2) Roots/ Horns

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Brain blood supply

R/L internal carotids Circle of Willis R/L vertebral arteries
CHULOU H. PENALES, RN

ANATOMY & PHYSIOLOGY

Sample Question:
An example of integration by the nervous system is: a. The feeling of a cold breeze b. The shivering and goose bumps that result c. The sound of rain d. The decision to go back for an umbrella

CHULOU H. PENALES, RN

ANATOMY & PHYSIOLOGY

Sample Question:
What makes up the blood-brain barrier? a. Large Arteries b. Small Veins c. Least permeable capillaries d. semi-soft bones

CHULOU H. PENALES, RN

ASSESSING PEOPLE WITH NEUROLOGICAL DISORDERS

CHULOU H. PENALES, RN

COMPUTED TOMOGRAPHY SCAN Need for consent Position/instructions Phobia/dye assessment Sound expectations Post-procedure Fluids
Use of narrow x-ray beams to scan the head in successive layers

Injection site

POSITRON EMISSION TOMOGRAPHY

Similarity and differences with CT scan Radioactive substance administration

Computer-based nuclear imaging technique that produces images of actual organ functioning

MAGNETIC RESONANCE IMAGING

Metal assessment Main risks

Use of a powerful magnetic field to obtain images of different body areas

LUMBAR PUNCTURE Position/instructions ICP assessment Bladder instructions Post-procedure positions

Insertion of a needle into the lumbar subarachnoid space to withdraw CSF

MYELOGRAM Purpose Position/instructions Meds/dye assessment Dye types and positions Post-procedure X-ray of the Spinal Subarachnoid Space after injection of a contrast agent into the SSS thru a lumbar puncture Fluids Possible complications

ELECTROENCEPHALOGRAPHY Types and duration Pre-procedure care Patient assurance Meds/diet/sleep Intra-procedure actions Post-procedure care
EEG represents a record of electrical brain activity

ELECTROMYOGRAPHY What to expect Post-procedure care

Introduction of a needle into skeletal muscles to measure changes in the electrical potential of the muscles & the nerves leading to them.

CRANIAL NERVES ASSESSMENT

Graphestesia Stereognosis Two-point stimulation Extinction phenomenon

GLASSGOW COMA SCALE

Vital facts: Motor response Verbal response Eye response
Which brain part is likely to be affected if the patient is in a decerebrate position? Decorticate?

Significance of results

GRADING DEEP TENDON REFLEXES (DTR) Vital facts: 0 to plus 4 Physiologic vs. pathologic clonus DOLL·S EYE TEST

Procedure Significance of results

ASSESSMENT PROCEDURES

Sample Question:
Which of the following GCS scores indicates a coma? a. 9 and above b. 8 and below c. 2 d. 9 and below

CHULOU H. PENALES, RN

ASSESSMENT PROCEDURES

Sample Question:
Which of the following is the most important indicator of neurologic function? a. Eye opening b. Verbal response c. Motor response d. All are equally important indicators

CHULOU H. PENALES, RN

ASSESSMENT PROCEDURES

Sample Question:
If increased ICP is suspected in this patient, which of the following diagnostic tests would most likely be contraindicated? a. Intracranial computed tomography scan b. Skull radiography c. Lumbar puncture d. EEG

CHULOU H. PENALES, RN

NURSING PEOPLE WITH NEUROLOGICAL DISORDERS
(AUTOIMMUNE PROCESSES, INFECTIONS & DEGENERATIVE DISORDERS)

CHULOU H. PENALES, RN

MULTIPLE SCLEROSIS Vital facts: Risk factors Pathophysiology Dx test of choice Charcot s triad:SIN Lhermitte s sign Prognosis

MULTIPLE SCLEROSIS Types/ Mgt: Relapsing-remitting Primary progressive Secondary progressive Progressive relapsing
Medications: ABC&R, Steroids, Muscle relaxants

Symptoms & Tx: Optic nerves Cerebrum Brain stem/cranial nerves Cerebellum Spinal cord (Muscle,Elimination, Sensation)

MULTIPLE SCLEROSIS Questions:
What bowel problems can you anticipate? Is there a cure for M.S.? How do you elicit Lhermitte s sign? What are three cardinal findings of patients with MS? What emotional state do MS patients usually display?

CHULOU H. PENALES, RN

GUILLAIN- BARRE SYNDROME Vital facts: Risk factors Pathophysiology Pattern of paralysis Sx: Respi, Vagus,Optic Dangers Prognosis (2 years) Management/ Corticosteroids

GUILLAIN- BARRE SYNDROME Sample Question:
Ms. May Lasse, 37 years old, complains of numbness/tingling in the legs that has recently progressed to the arms. She is suspected to have GBS. Which of the following questions is important to include when assessing Ms. May? a. Has anyone in your family ever had GBS? b. Did you have an upper respiratory tract infection lately? c. Do you bruise easily? d. Have you been out of the country for the past 4 CHULOU H. PENALES, RN months?

AMYOTROPHIC LATERAL SCLEROSIS Vital facts: Risk factors Pathophysiology Pattern of paralysis Sx: Respi, Vagus, Spasms Dangers Long-term mgt./ meds. Prognosis (3 years)

MYASTHENIA GRAVIS Vital facts: Risk factors Pathophysiology Dx test of choice Crisis management Cholinergic medications Timing and antidote Other treatments/ diet

MYASTHENIA GRAVIS Sample Question:
The teaching plan for a client with Myasthenia Gravis should include which of the following as a priority instruction? a. Exercise to increase peripheral circulation b. Plan important activities for late afternoon c. Identify signs and actions during crisis d. Eat three well-balanced meals per day

CHULOU H. PENALES, RN

TRIGEMINAL NEURALGIA (TIC DOULOREUX) Vital facts: Greatest risk factor Pathophysiology/triggers Characteristics of attacks Medications and its s/e Bone marrow Dietary instructions Alternative meds: B-P

BELL·S PALSY Vital facts: Risk factors: I H.A.V.E
Ischemia, Herpes, Autoimmune, Viral & Ear infections

Symptoms Nursing care/ teachings Diet, muscle tone, speech Prognosis

BELL·S PALSY Questi s:

Can you consider bell s palsy a minor stroke? How long does Bell s palsy usually last? What pharmacological therapy is usually prescribed for Bell s Palsy? What do you mean by T.E.N.S. and what purpose does it serve in Bell s Palsy cases? Who does T.E.N.S.?

CHULOU H. PENALES, RN

PARKINSON·S DISEASE (a.k.a. PARALYSIS AGITANS) Vital facts: Risk factors Pathophysiology Triad Sx: R-A-T Medications: Anticholinergics, Antiviral & Dopaminergic Nursing care Prognosis

Nursing care Safety: Levodopa s/e Patience Diet & lifestyle OLOF promotion

PARKINSON·S DISEASE

Sample Question:
The nurse should instruct the patient with Parkinson s disease to avoid which of the following? a. Walking in an indoor shopping mall b. Sitting on the deck on a cool summer evening c. Walking to the car on a cold, windy day d. Sitting in the beach in the sun on a summer day

CHULOU H. PENALES, RN

HUNTINGTON·S DISEASE

Vital facts: Genetic transmission (AD) Probable cause Pathophysiology Main Symptom; Sensory vs. motor deficits Affected structures (Cerebrum, Cerebellum, BG) Medications Nursing care: SAFETY

ALZHEIMER·S DISEASE Vital facts: Risk factors Pathophysiology Confirmatory dx Medications Nursing care Prognosis

ALZHEIMER·S DISEASE Stages: Stage 1: DePART Decline in Personal Appearance Recent memory loss Time disorientation Nursing care

ALZHEIMER·S DISEASE Stages: Stage 2: CACA PHEW

Catastrophic reactions Agnosia (V-A-T) Confabulation Agraphia Perseveration Hyperorality (Eat), Wandering

ALZHEIMER·S DISEASE Stages: Stage 3: SHAK Sensorimotor deterioration Hyperetamorphosis Absence of speech Kluver-Bucy Syndrome

Open-ended questions are encouraged for patients with Alzheimer s. A patient s question may actually be a personal statement from the patient Calendars and clocks help the person keep oriented The patient should be discouraged from talking about his/her past. The patient may be restrained if he/she wanders. Liver enzymes should be monitored when the patient is on Tacrine therapy With Alzheimer s disease, there is an excess Ach.
CHULOU H. LES,

ALZHEIMER·S DISEASE (T or F)

ALZHEIMER·S DISEASE Sample Question:
Mrs. Lee Mott, a 65- years old Alzheimer s patient, becomes very restless. The nurse is concerned that she may harm herself. Which of the following nursing interventions would best protect the patient? a. Applying a waist restraint under her gown b. Placing the patient in a special geriatric chair c. Distracting the patient with loud music d. Taking the patient for frequent walks
CHULOU H. PENALES, RN

NURSING PEOPLE WITH NEUROLOGICAL DISORDERS
(CNS INJURIES, INFECTIONS and OTHER CONDITIONS)

CHULOU H. PENALES, RN

MIGRAINE HEADACHES Vital facts: Risk factors: Type A Personality Vascular theory Types of headaches Aura and time of onset Symptoms & Location Possible treatments
CHULOU H. PENALES, RN

MIGRAINE HEADACHES Scheme of treatment: Mild migraine Migraine headache worsens Arterial walls have become rigid Medication facts

HEADACHES (IDENTIFICATION)
Excruciatingly painful yet of short duration. Preceded by an aura. Hunger, fatigue, excitement or alcohol may serve as its trigger. Anxiety and depression may serve as triggers. Bright spots or diplopia may be experienced by the client. Believed to be cause by sensitivity to Histamine. Throbbing, steady pain occurring mostly at night.
CHULOU H. PENALES, RN

HEADACHES (IDENTIFICATION)
Interventions may be ineffective due to shortness of episodes. Relaxation techniques and rest may be enough to treat the headache. Crescendo quality headache. Preventive treatment is possible with Methysergide.

CHULOU H. PENALES, RN

SEIZURES Vital facts: Generalized S.: T-A-M-A Tonic/clonic, Absence, Myoclonic, Akinetic Partial S.: Simple, Complex Priority of care Medications Sensations post-seizure (LOC, speech, aches)

SEIZURES Nursing care: Airway Injury prevention/ restraints Privacy Importance of documentation

SEIZURES Sample Question:
Mr. Kerr Rogg is at risk for developing further seizures. Knowing this, the nurse should: a. Keep all side rails of the bed down b. Keep the height of the bed at the highest level possible c. Observe the patient frequently d. Keep a padded tongue blade at the bedside

CHULOU H. PENALES, RN

INCREASED INTRACRANIAL PRESSURE Vital facts: Possible causes: H-I-T-M-A-N Hemorrhage,Infection,Trauma, Meningitis, Accidents, Neoplasia Monroe-Kellie hypothesis; Early Sx Cerebral Perfusion Pressure (MAP-ICP) Normal and abnormal values Cushing sBradypnea, Bradycardia,triad response vs. BP, Widened Increased SystolicCushing s Pulse Pressure, Bradycardia HPN

INCREASED INTRACRANIAL PRESSURE Nursing care: ABC priorities Bed position/ neck position Environment (Avoid chills) Medications Things to avoid, inc Morphine

INCREASED ICP: HEAD INJURIES

Vital facts: Coup vs. counter coup injuries Concussion vs. contusion Epidural vs. subdural hematoma Ideal position: Modified trendelenburg Nursing care

INCREASED ICP: HEAD INJURIES

Surgical interventions: Infratentorial Supratentorial Posterior fossa

INCREASED ICP: PITUITARY TUMORS

Hypophysectomy care: Possible complications CSF leak: Avoidance Incision care Toothbrushing, straw, oral hygiene, nasal packing Post-op meds

INCREASED INTRACRANIAL PRESSURE Sample Question:
The nurse is teaching the family of a patient with a concussion about early signs of increased ICP. Which of the following would she cite as an early sign of increased ICP? a. Decreased systolic blood pressure b. Headache and vomiting c. Inability to wake patient with a noxious stimuli d. Dilated pupils that don t react to light
CHULOU H. PENALES, RN

INCREASED ICP: PITUITARY TUMORS

Sample Question:
After Transsphenoidal surgery, which of the following statements by the patient would need further teaching? a. I can expect the packing to be removed in 3-4 days b. I need to perform deep breathing and coughing exercises to prevent pulmonary complications c. I need to sleep in an elevated position for at least 2 weeks d. I can drink juice thru a cup or glass
CHULOU H. PENALES, RN

SPINAL CORD INJURIES Vital facts:
Types: Anterior,Posterior,Central,B-S,Conus/Cauda

Symptoms
Touch, pos n, vibration Motor function, pain,temp B-S: Motor--- pain temp

Spinal shock and Autonomic dysreflexia Symptoms: Flushed and drenched

SPINAL CORD INJURIES Vital facts: Nursing care for spinal cord injuries: ABC Safety Nursing care for autonomic dysreflexia: R-S-V-P

SPINAL CORD INJURIES Cervical traction devices:

Skull tongs

Halo Traction
CHULOU H. PENALES, RN

SPINAL CORD INJURIES True or False:
Sterile pin site care is needed for both halo traction & skull tongs. I can pull on the halo traction device to move the patient. The Halo vest must be snugly fitted and must not allow even one finger under it. I can insert fleece or foams to relieve pressure points in the vest/jacket. Redness, swelling and a slight discharge under the jacket do not need to be reported. My patient may have a shower but not a tub bath.

SPINAL CORD INJURIES True or False:
The patient may roll onto the side & push with the arms to get up. I need to keep a correct-sized wrench available at the bedside. I need to use a flashlight in assessing the skin under the jacket. If CPR is required, I need not take off the jacket .

CHULOU H. PENALES, RN

SPINAL CORD INJURIES Sample Question:
Mr. Pee. Ang, age 25, suffered a cervical fracture requiring immobilization with a halo traction. When caring for the patient with a halo traction, the nurse must: a. Keep a wrench taped to the halo vest for quick removal if CPR is necessary b. Remove the brace once a day to allow the patient to rest c. Encourage the patient to use a pillow under the ring. d. Remove the brace so that the patient can shower
CHULOU H. PENALES, RN

SPINAL CORD INJURIES Sample Question:
Although Ms. Kirsten Dunst has a spinal cord injury, she can still have sexual intercourse. Discharge teaching should make her aware that: a. She must remove her indwelling urinary catheter prior to intercourse b. She can no longer achieve orgasm c. Positioning may be awkward d. She can still get pregnant
CHULOU H. PENALES, RN

CEREBROVASCULAR ACCIDENT Vital facts: Types Significance of TIA Brain death occurrence Expressive vs. receptive aphasia Nursing care Warning signs in HPN people

CEREBROVASCULAR ACCIDENT Manifestations and related care: Neglect syndrome
Homonymous hemianopsia

Agnosia Apraxia Right brain vs. left brain CVA
Judgment, speech, performance, awareness

ANEURYSM PRECAUTIONS
Bed rest in a private, dark room Elevate HOB upto 30 degrees Perform enemas to prevent straining Administer prescribed stool softeners Bed rest in a private, bright room Elevate HOB upto 45 degrees Avoid enemas

Avoid prescribed stool softeners due to possible laxative abuse Take rectal temperatures for Avoid rectal temperatures accurate measurements Mild fluid restriction to No fluid restricition minimize ICP Limit visitors Encourage visitors

CEREBROVASCULAR ACCIDENT

Sample Question:
Which of the following nursing diagnoses would be most appropriate for Mr. Friendster (A patient with a CVA in the right hemisphere)? a. Impaired verbal communication r/t aphasia b. Impaired physical mobility r/t right hemiparesis c. Risk for injury r/t denial of deficits & impulsiveness d. Decreased cardiac output r/t atrial arrhtyhmias

CHULOU H. PENALES, RN

CEREBROVASCULAR ACCIDENT Sample Question:
Immediately following a cerebral aneurysm rupture, the patient usually complains of: a. Photophobia b. Explosive headache c. Seizures d. Hemiparesis

CHULOU H. PENALES, RN

MENINGITIS Vital facts: Possible causes Signs and symptoms Usual drug of choice CSF changes Nursing care

MENINGITIS

Sample Question:
Mel Enjay was diagnosed with pneumococcal meningitis. What response by the patient indicates that he understands the precautions necessary with this diagnosis? a. I can t have visitors for 1 week. b. Thank goodness, I ll only be in isolation for 1 day c. The nurse told me my urine and stool are also sources of the meningitis bacteria d. The doctor is a good friend of mine and won t keep me in isolation CHULOU H. PENALES, RN

You have just completed the lecture on Neurological disorders. THANK YOU VERY MUCH for your attention!

CHULOU H. PENALES, RN

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