Neuro System

CARE OF CLIENTS WITH PROBLEMS RELATED TO NEUROLOGICAL SYSTEM Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Nursing Assessment ♦ Behavioral changes ♦ Loss of consciousness ♦ Memory loss ♦ Headache

Neurological Examination ♦ Level of Consciousness (LOC) – arousal;

awareness of self or environment

– Alert – fully awake; appropriate responses to external and internal stimuli; oriented to person, place and time – Lethargic – somnolent, drowsy, listless, indifferent to surroundings, very sleepy, can be aroused from sleep but when stimulation ceases, falls back to sleep; may be oriented or confused

Neurological Examination – Stuporous – unconscious most of the time but makes spontaneous movements and response is evoked only by a strong, continuous, noxious stimuli; loud noises or sounds, bright light, pressure to sternum, response is usually a purposeful attempt to remove the stimulus – Comatose – absence of voluntary response to stimuli including painful stimuli; no response, no eye opening – score of 7 or less on GCS

Glascow Coma Scale EYE OPENING RESPONSE SPONTANEOUS TO VOICE TO PAIN NONE

4 3 2 1

BEST VERBAL RESPONSE

ORIENTED CONFUSED INAPPROPRIATE WORDS INAPPROPRIATE SOUNDS NONE

5 4 3 2 1

BEST MOTOR RESPONSE

OBEYS COMMANDS LOCALIZES PAIN WITHDRAWS (PAIN) FLEXION (PAIN) EXTENSION (PAIN) NONE

6 5 4 3 2 1

TOTAL

15

Neurological Examination ♦ Memory – Recent – ability to recall immediate events – Remote – ability to remember past events ♦ Speech – Aphasia – impairment of language function – Dysarthria – indistinctness of word articulation or enunciation resulting from inference with peripheral speech mechanisms

Neurological Examination – Expressive (Non-fluent) aphasia – loss of ability to express one’s thoughts in speech and writing – Receptive (Fluent) aphasia – impairment of ability to comprehend spoken or written language – Global aphasia – expressive + receptive aphasia

Neurological Examination ♦ Motor – Decerebrate rigidity – arms stiffly extended and abducted with hyperpronation of arms – Decorticate rigidity – arms, wrisht and fingers are flexed; arms are adducted; in both, legs fully extended and internally rotated with plantar flexion of feet – Paresis – impaired strength or power – Paralysis – loss of strength

Neurological Examination – Hemiplegia – paralysis of lateral half – Paraplegia – paralysis of the legs – Apraxia – inability to carry out a learned movement on command without weakness paralysis

♦ Sensory – Paresthesia – abnormal sensation; distortion of sensory stimuli; numbness, tingling sensation – Anesthesia – absence of sensation or touch

Neurological Examination – Hyperesthesia – pathologic over-perception of touch – Hypoesthesia – reduced sense of touch – Analgesic – absence of pain

♦ Reflexes – involuntary response which

tends to be specific or fixed pattern for a given stimuli – Deep tendon reflexes (DTR’s) – muscle stretch reflex; uses percussion hammer to check knee jerk

Neurological Examination – Patellar reflex – knee jerk • N = contraction of quardriceps femoris muscle; extension of the leg

– Corneal reflex (blinking) • N = eyes blink when hand is passed across eyes

– Pupillary reaction; functioning of brainstem; observing the size of pupil in relation to light reflex • N = pupil constricts when light is flashed • Normal size of pupil 3-4 mm; <2 mm miosis; >5mm mydriasis

Neurological Examination • Anisocoria – unequal pupils • Ptosis – drooping of eyelids • Nystagmus – involuntary trembling or oscillation of eyeball

– Oculocephalic response or doll’s eyes • Normal if with eyes, open, turn head to right and eyes deviate to left (conjugate or dysconjugate)

– Babinski • Extension of great toe and fanning of other toes in response to stroking of sole of foot; (-) plantar flexion; (+) dorsiflexion

Neurological Examination – Brudzinski sign • Forward flexion of pt’s head by examiner; abn = flexion of ankle knee or thigh

– Cremasteric = stroke medial surface of upper thigh = elevation of scrotum and testicle

Diagnostic Procedures or Tests ♦ Cranial nerve testing – Olfactory – smell • Anosmia – loss of smell • Hyposmia – impairment of smell

– Optic – vision • Retina to brain link • Papilledema – choked disc – swelling of optic nerve; increased intraocular pressure

– Oculomotor – movements of eyeball and eyelids; constriction or dilation of pupils

Diagnostic Procedures or Tests – Trochlear – movement of eyeball – oblique – Trigeminal – mastication, sensations of face, nose, teeth and mouth – Abducens – movement of eyeball – lateral rectus – Facial – contraction of facial and scalpmuscles; taste – Vestibulocochlear (auditory) • Vestibular – equilibrium; cochlear – hearing

Diagnostic Procedures or Tests – Glossopharyngeal – swallowing, blood pressure, taste, oral and pharyngeal – Vagus – pharynx, larynx, thoracic and abdominal viscera – Accessory – shoulder and head; sternocleidomastoid – Hypoglossal – tongue

♦ Lumbar puncture, spinal tap – Subarachnoid space of spinal canal (L3-L5)

Diagnostic Procedures or Tests – Normal opening pressure 60-180 mm H2O – – – – –

WBC 0-5 cells/mm Cl = 720-750 mg/ 100 ml Protein = 15-45 mgs/100 ml Glucose = 40-80 mgs/100 ml Xanthochromia (bleeding) – yellow color of CSF from blood or RBC – Pleocytosis – increased

Diagnostic Procedures or Tests ♦ Romberg test – stand with feet together,

eyes open or close; (+) if unable to maintain erect posture ♦ X-rays CNS – spine or skull x-rays, CT

Diagnostic Procedures or Tests ♦ Cerebral angiography,

pneumoencephalography, ventriculography contrast studies – Cerebral Angiography – visualization of brain’s vascular system by injection contrast dye into the circulation blood – Pneumoencephalography – visualization of ventricles and subarachnoid spaces by withdrawal of CSF and injection of air or oxygen into subarachnoidal space through lumbar puncture

Diagnostic Procedures or Tests – Ventriculography – visualization of ventricles by removal of CSF and injection of air or oxygen directly into the ventricles through burr holes in skull – Myelography – x-ray examination of spinal cord and vertebral canal following introduction of contrast media into subarachnoid space ♦ Electroencephalography (EEG) – – record of electrical activity of the brain – Prep – no stimulant within 24 hrs before the procedure – Post – hair shampoo to remove collodia (paste)

Common neurological disorders ♦ Unconsciousness – State of depressed cerebral function in which reaction to stimuli is lost and any response, if present is on the reflex level – Causes • • • • •

A Alcohol E Epilepsy I Insulin O Opiates U Urates

Unconsciousness – Causes • • • • •

T I P P S

Trauma Infection Psychological Poison Shock

– Basic mechanism – interruption of oxygen supply and glucose supply

Unconsciousness – Objectives of care: • A. assess for and maintain patent airway • B. monitor VS and neurological status • C. maintain integrity of skin – Bedsores class: – Grade 1 – erythema – 2 – dermis – 3 – subcutaneous – 4 – muscle – 5 – joints and body cavities

Unconsciousness • • • • •

D. maintain joint mobility E. maintain sensory function F. maintain fluid and nutritional status G. maintain bladder or bowel function H. maintain psychosocial function

Common neurological disorders ♦ Increased intracranial pressure – intracranial

hypertension; cerebral edema – – – – – –

Causes: A. increased inracranial blood volume B. increased CSF volume C. increased in bulk of brain tissue D. intracranial tumors E. increased production of CSF or blockage of ventricles; – F. decrease in absorption of CSF

Increased intracranial pressure ♦ Nursing Assessment – A. swelling of optic disk – B. headache, vomiting projectile – C. decreasing level of consciousness – D. pupillary signs – ipsilateral pupil – affected is dilated – E. blood pressure – increased systolic and decreased diastolic (widening pulse pressure) – F. decreased PR and RR – G. respiration – cheyne-stokes – H. temperature regulation – increased temperature

Increased intracranial pressure ♦ Nursing management: – A. positioning – HOB elevated 15-30o – B. activites: no coughing, sneezing or straining at stool valsalva maneuver – C. avoid hip, waist, neck flexion; avoid rotation of head especialy to right – D. space out nursing activities – E. perform suctioning only PRN

Increased intracranial pressure – F. IV mannitol and dexamethasone • • • •

Monitor fluid balance Restrict fluids Urinary output Watch for hypotension

– G. Craniectomy to provide room for expansion

Common Neurological Disorders ♦ Seizures (Convulsions) – Brief cerebral storms associated with sudden excessive and disorderly electrical discharges from the brain. – Nursing observations: • A. Aura – symptoms that occur during the prodome of seizure (numbness, dizziness, yawning, smells).

Seizures • B. During – Never leave alone – If standing, lower to floor to prevent injury – Loosen constrictive clothing – Do not restrain – Do not pry jaw open to place padded tongue blade – Pad side rails; no pillows

• C. Postictal phase – normally groggy and confused; deep sleep also follows

Common Neurological Disorders ♦ CVA or stroke or apoplexy – Disruption in cerebral circulation resulting in motor or sensory deficit – Risk factors: • A. hypertension • B. heart disease • C. DM • D. hypercolesterolemia • E. oral contraception • F. obesity • G. family history

CVA or stroke or apoplexy ♦ Etiology: – A. Thrombosis – most common cause of cerebral infarct (atherosclerosis) – B. Embolism – increased incidence after 40 years

Common Neurological Disorders ♦ Intracerebral hemorrhage – Within brain substance most common cause – rupture of arteriosclerotic hypertensive vessels – most common cause of death in CVA – Middle cerebral artery – most common site – Extra or epidural – outside dura mater – Subdural – beneath dura mater – Subarachnoid – in subarachnoid space

Intracerebral Hemorrhage ♦ Nursing Assesment: – A. mental confusion, drowsiness, headache, transient loss of speech, TIA, hemiplegia or paresthesias to paralysis – B. typical headache, vomiting, seizures, coma, nuchal rigidity, fever, hpn, confusion disorientation – C. Focal symptoms – weakness, paralysis, sensory loss, language disorders, reflex changes – D. Fatal – increased temperature, PR and RR; increased depth of coma and collapse of vasomotor and heat regulating centers

Intracerebral Hemorrhage ♦ Nursing management: – A. Decrease salt diet, oxygen therapy – B. intubation and mechanical ventilation – C. GI decomopression, NGT – D. Semi-fowler’s position – E. Antacid, anticoagulants, antihpn – F. Anticonvulsants

Intracerebral Hemorrhage – G. intracranial surgery • Craniectomy – portion of cranium is permanently removed to relieve pressure on brain structures to provide space for expansion • Craniotomy – surgical opening into skull – Position – not in operative site – Superatentorial – HOB elevated at 30o – Infratentorial – flat without head elevation to prevent pressure on brain stem structures

Neurologic Degenerative Diseases ♦ Parkinson’s disease – Degeneration and destruction of nerve cells of the basal ganglia throughout the brain (loss of dopamine – neurotransmitter with anticholinergic effect) – Incidence: men and women (50-60 y/o) – Cause: unknown – Signs and symptoms: cogwheel rigidity; pill rolling or resting tremor; masklike appearance of face; slow monotonous speech

Parkinson’s Disease – Nursing management: • Levo-dopa to increase dopamine • Sinemet to prevent breakdown of dopamine

Neurologic Degenerative Diseases ♦ Multiple Sclerosis – Multiple patches of demyelination or nerve degeneration throughout the brain and spinal cord – Cause: unknown – Incidence: women – Signs and symptoms: Charcot’s triad – nystagmus, intention tremor, scanning speech, muscular and gait incoordination

Multiple Sclerosis – Nursing management: • Baclofen – to decrease spasms • Symptomatic

Neurologic Degenerative Diseases ♦ Myasthenia Gravis – Decreased secretion of acetylcholine or increase in cholinesterase at the myoneural junction leading to transmission failure – Etiology: autoimmunity – Incidence: young adults (women)

Myasthenia Gravis – Signs and Symptoms: • Muscular weakness • Fatigue • Ptosis • Weight loss • Muscle atrophy – Diagnostic assessment: Tensilon test – injection of Tensilon or Prostigmin and muscle weakness disappears but comes back when medication wears off

Myasthenia Gravis – Nursing Management: • Anticholinesterase – prostigmin; mestimon to be taken at specified time; before meals – Myasthenic crisis – due to undermedication (management – anticholenesterase) – Cholinergic crisis – due to overmedication (management – atropine sulfate – Brittle crisis – receptors at neuromuscular junciton becomes insensitive to anticholinesterase

Myasthenia Gravis • Avoid muscle relaxants, barbiturates, morphine, tranquilizers and neomycin • Avoid stress, colds and infection • Never rush, provide rest periods • Avoid unnecessary muscle activity