Medical Surgical Nursing A

Care of the Patient With a Neurological Disorder

BGallatin 2007

Anatomy and Physiology
 Central nervous system (CNS)
 

 Peripheral nervous system
 

Brain Spinal cord

Somatic (voluntary) Autonomic (involuntary)

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Anatomy and Physiology
 Neurons
 

 Glial cells

Transmitter cells Carry messages to and from brain and spinal cord

Support and protect neurons Produce cerebral spinal fluid

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Anatomy and Physiology
 CNS: brain
   

Cerebrum – lobe functions Diencephalon – thalamus, hypothalamus Cerebellum – balance, coordination Brain stem – midbrain, pons, medulla oblongata

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Anatomy and Physiology
 PNS: Somatic (voluntary)
 

31 pairs of spinal nerves 12 pair of cranial nerves

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Anatomy and Physiology
 PNS: Autonomic (involuntary)

Controls:
 Smooth

Muscles  Cardiac Muscles  Glands

Check and balance system:
 Sympathetic

nervous system  Parasympathetic nervous system
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Neurological Assessment
 History
    

Headaches Loss of function Visual acuity Seizures Numbness

   

Pain Personality change Mood swing Fatigue

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Neuro Assessment
 Mental Status
    

Orientation Mood and behavior General knowledge Short term memory Long term memory

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Neuro Assessment
 Level of consciousness  Glasgow Coma Scale
  

Eye opening Verbal response Motor response

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Neuro Assessment
 Language and Speech

Aphasia
 Sensory  Expressive  Global

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Cranial Nerves
      I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens       VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal

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Neuro Assessment
 Motor Function
 

Paralysis Paresis Flaccid Spastic

 

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Neuro Assessment
 Sensory and Perceptual Status
     

Pain Touch Temperature Proprioception Unilateral neglect Hemianopia
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Neuro Assessment
 Blood and urine  ABG  Lumbar puncture  Imaging  EEG  EMG  Carotid Duplex
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Neurological Problems
 Headache
  

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

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Neurological Problems
 Increased Intracranial Pressure (IIP)  Occurs slowly or rapidly  May lead to brain stem herniation and death

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Assessment of IIP
 Subjective
    

Diplopia Personality change Thought processes change Headache Nausea

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Assessment of IIP
 Objective  Decreasing LOC
    

Hyperthermia Weakness Vomiting Seizures Papilledema

    

Posturing Wide pulse pressure Bradycardia Altered respirations Pupils fixed & dilated

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Assessment of IIP
 Diagnostic tests:
  

CT scan, MRI Close observation Craig’s screw

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Medical Management of IIP
 Craniotomy  Craniectomy  Tumor removal  Drainage of ventricles  Drainage of hematoma  Intubation
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Medical Management of IIP
 Medications
  

Osmotic diuretics - Mannitol Corticosteroids - Decadron Anticonvulsants - Dilantin

 Internal monitoring

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

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Neurological DisordersSeizures
 Seizures
   

Disorderly neuron discharges in brain Transitory Different types affect body differently Involuntary movement usually

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Seizures
 Generalized:

 Localized: (Focal)
 

  

Tonic-clonic – grand mal Absence - Petit mal Myoclonic Atonic or akinetic

Partial (Jacksonian) Psychomotor

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Seizures
 Causes:
     

Hypoglycemia Infection Electrolyte imbalance Trauma IIP Toxins
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Seizure Medications
      Dilantin (Phenytoin) Phenobarbital Mysoline Tridione Valium (Diazepam) Depakene       Clonopin Mesantoin Neurontin Lamictal Felbatol Cerebyx

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Seizure Medications
 Nursing:
    

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

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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 Turn side; loosen clothing around neck

 Prevent aspiration (airway)

 Document everything
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Degenerative Neuro Diseases
 Multiple Sclerosis  Parkinson’s Disease  Alzheimer’s Disease  Huntington’s Disease (chorea)  Myasthenia Gravis  Amyotrophic Lateral Sclerosis (ALS)

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Multiple Sclerosis
 Common degenerative neurological disease.  Myelin sheath is destroyed.  Symptoms vary.  Relapsing/remitting.  Usually ages 20-40.

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Multiple Sclerosis - Symptoms
 Subjective:
      

Shakiness, difficulty walking Fatigue, muscle weakness Numbness, tingling Tinnitus Visual problems Difficulty chewing and speaking Incontinent; impotent
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Multiple Sclerosis - Symptoms
 Objective:
   

 

Ataxia Changes in behavior & emotions Nystagmus Spasticity, tremors, dysphagia, facial palsy, speech impaired, fatigue Incontinence Impaired judgment
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Multiple Sclerosis - Tests
 CSF  CT scan  MRI

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Multiple Sclerosis-Treatment
 Meds:

Anti inflammatory
 ACTH,

Solu Medrol, Prednisone Betaseron, Capoxone

Immuno Modifiers
 Avonex,

Muscle Relaxants
 Valium

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Multiple Sclerosis-Nursing Interventions
 Nutrition  Skin Care  Activity  Control of environment  Emotional support  Patient teaching
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Parkinson’s Disease
 Unknown cause  Lack of dopamine.  Parkinsonism: encephalitis, toxic chemicals, meds, drugs

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Parkinson’s
 Symptoms include:
     

Muscular tremors and rigidity Emotional instability Judgment defects Heat intolerance Mask-like facial appearance Dysphagia and drooling
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Parkinson’s Testing

No specific test to diagnose Parkinson’s Diagnosis based on symptoms

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Parkinson’s – Medical Treatment
 Medications
 

Sinemet, Symmetrol, Levodopa or Cogentin Less effective over time

 Surgery  Experimental

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Parkinson’s – Nursing Care
 Prevent injury (fall or aspiration)  Prevent urinary retention and constipation  Patient teaching about medication  Patient and family support

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Alzheimer’s
 Unknown cause, but genetic link  Very common; risk increases with age  Brain changes:
   

plaques tangled neurons blood vessel degeneration chemical changes
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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
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Alzheimer’s - Testing
 No definitive test  Family history  Diagnosis: autopsy

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Alzheimer’s – Medical Management
 Medication to treat symptoms
 

Memory:Cognex, Aricept Agitation: Mellaril, Haldol Folic Acid & Vitamin B12 Low fat diet NSAIDS
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 Supplements
  

Alzheimer’s – Nursing Care
 2 key points for all care:
 

Prevent overstimulation Provide structured, orderly environment

 Other concerns
 

Communication Family support and education

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Myasthenia Gravis
 Autoimmune disorder  Myoneural junction problem  Symptoms:
 

ptosis, diplopia, weakness, dysarthria, dysphagia, difficulty sitting up, respiratory distress

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Myasthenia Gravis - Treatment
 Medication
 

to improve impulse transmission (Mestinon) to suppress immune system (steroids, Cytoxan)

 Plasmapheresis  Respiratory support  Safety

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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

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

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Huntington’s Disease
 Nursing interventions are palliative
  

Give meds Provide for safety Provide adequate diet

 Emotional support  Genetic counseling

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Cerebrovascular Accident (CVA)
 Ischemia of brain tissue
  

Hemorrhage Thrombus Embolus

 3rd leading cause of death in the US  All ages, but usually elderly
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CVA – Contributing Factors
 Atherosclerosis  Heart disease  Kidney disease       
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 Hypertension  Obesity

High cholesterol Cigarette smoking Stress Sedentary Diabetes Oral contraceptives Cocaine

Cerebral Thrombosis
 Most common cause of CVA  Most often:
 Atheroclerosis


 Thrombus


 CVA

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Cerebral Embolism
 2nd most common cause of CVA  Most often:

Heart disease

Thrombus

Embolus

CVA
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Cerebral Hemorrhage
 3rd most common cause of CVA  Most often:

Hypertension

Ruptured cerebral blood vessel

CVA
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Transient Ischemic Attack
 Cerebrovascular insufficiency  Causes – same as CVA  Warning sign of impending CVA

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CVA - Assessment
 Motor changes
  

Opposite side Balance, coordination, gait, proprioception Glasgow Coma Scale

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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
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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
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CVA - Testing

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

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CVA – Medical Management
 Thrombolytic (“clot buster”)  Anticoagulants  Antiplatelet drugs  Aneurysm repair  Carotid endarterectomy

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CVA-Nursing Care
 Assess LOC  IV, NG, Foley, Vent.  Nutrition  Encourage perform ADLs  Bladder and bowel training  ROM  Teaching and emotional support
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Trigeminal Neuralgia Tic Douloureux
 Trigeminal nerve – degeneration, pressure  Facial pain  Medication, surgery  Avoid triggers

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Bell’s Palsy
 Facial nerve inflammation  Unilateral weakness of facial muscles  Steroids, Zovirax, warm moist cloth, massage, facial exercises
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Infection and Inflammation
Meningitis  Encephalitis  Brain abscess Guillain-Barré  Neurosyphilis  Poliomyelitis  Herpes zoster AIDS

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Guillain-Barré - Polyneuritis
 Peripheral nerve disease  Prior infection; autoimmune response  Weakness and paralysis, begins in extremities and works up  Respiratory failure may occur

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Meningitis
 Acute infection of the meninges  Viral or bacterial  Severe headache, irritable, fever, delirium, N/V, neck stiffness
 

Kernig’s sign Brudzinski’s sign
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Meningitis-Medical Management
 Diagnosed by LP  Medications  Respiratory isolation  Cool, dark quiet room  Maintain hydration  Prevent injury
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Acquired Immunodeficiency Syndrome - AIDS
 AIDS dementia complex  Infection of CNS  Dementia  Treatment depends on infection  Treat symptoms, maintain safety
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Spinal Cord Trauma
 Complete cord injury – all voluntary movement below level of trauma is lost  Autonomic hyperreflexia
 

stimulus sympathetic nervous system response

BGallatin 2007

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