Care Of The Patient With Neuro Disorders

Medical Surgical Nursing A

Care of the Patient With a Neurological Disorder

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

 Peripheral nervous system

Brain Spinal cord

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Somatic (voluntary) Autonomic (involuntary)

Anatomy and Physiology  Neurons  

 Glial cells

Transmitter cells Carry messages to and from brain and spinal cord

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Support and protect neurons Produce cerebral spinal fluid

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 BGallatin 2007

Neurological Assessment  History     

Headaches Loss of function Visual acuity Seizures Numbness

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Pain Personality change Mood swing Fatigue

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

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VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal

Neuro Assessment  Motor Function  

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Paralysis Paresis Flaccid Spastic

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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

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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

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Posturing Wide pulse pressure Bradycardia Altered respirations Pupils fixed & dilated

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 BGallatin 2007

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

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Restrict fluids Foley Suctioning O2 Hypothermia blanket

Neurological DisordersSeizures  Seizures    

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

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Seizures  Generalized: 

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 Localized: (Focal)

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

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Partial (Jacksonian) Psychomotor

Seizures  Causes:      

Hypoglycemia Infection Electrolyte imbalance Trauma IIP Toxins BGallatin 2007

Seizure Medications      

Dilantin (Phenytoin) Phenobarbital Mysoline Tridione Valium (Diazepam) Depakene

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Clonopin Mesantoin Neurontin Lamictal Felbatol Cerebyx

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 

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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)

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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 BGallatin 2007

Multiple Sclerosis - Symptoms  Objective:    

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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

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Multiple Sclerosis-Treatment  Meds: 

Anti inflammatory  ACTH,

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Solu Medrol, Prednisone

Immuno Modifiers  Avonex,

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Betaseron, Capoxone

Muscle Relaxants  Valium

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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

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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 BGallatin 2007

Parkinson’s Testing 

No specific test to diagnose Parkinson’s

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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 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

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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

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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 BGallatin 2007

CVA – Contributing Factors  Atherosclerosis  Heart disease  Kidney disease

 Hypertension  Obesity

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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 ↓

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Thrombus ↓

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Embolus ↓

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CVA BGallatin 2007

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

Hypertension ↓

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Ruptured cerebral blood vessel ↓

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CVA BGallatin 2007

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   

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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

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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 BGallatin 2007

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 BGallatin 2007

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 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

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