Care of the Patient With a Neurological Disorder

LEARNING OBJECTIVE
At the end of this lesson student should be able to:

1. Explain the causes, pathophysiology and sign/symptom of neurological disorder. 2. Explain the Surgical and Nursing management of

common Neurological Disorders:

Cerebrovascular disease, Cerebro-Vascular Accident, Seizure disorders, GuilleinBarreSyndrome, Myasthenia Gravis, Head injury, Spinal cord injury, meningitis and altered level of consciousness.

Anatomy and Physiology

Central nervous system (CNS)

Peripheral nervous system

Brain Spinal cord

Somatic (voluntary) Autonomic (involuntary)

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

Anatomy and Physiology

CNS: brain

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

Anatomy and Physiology

PNS: Somatic (voluntary)

31 pairs of spinal nerves 12 pair of cranial nerves

Anatomy and Physiology

PNS: Autonomic (involuntary)

Controls:
Smooth Muscles Cardiac Muscles Glands

Check and balance system:

Sympathetic nervous system Parasympathetic nervous system

Neurological Assessment
History Headaches Loss of function Visual acuity Seizures Numbness

Pain Personality change Mood swing Fatigue

Neuro Assessment
Mental Status

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

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 Craigs 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: Tonic-clonic grand mal Absence - Petit mal Myoclonic Atonic or akinetic Localized: (Focal) 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; dont restrain No bite block or padded tongue blade Allow for post-ictal rest

Prevent aspiration (airway)

Turn side; loosen clothing around neck

Document everything
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Degenerative Neuro Diseases

Multiple Sclerosis Parkinsons Disease Alzheimers Disease Huntingtons 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 Avonex, Betaseron, Capoxone Valium

Immuno Modifiers

Muscle Relaxants

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Multiple Sclerosis-Nursing Interventions

Nutrition Skin Care Activity Control of environment Emotional support Patient teaching
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Parkinsons Disease
Unknown cause Lack of dopamine. Parkinsonism: encephalitis, toxic chemicals, meds, drugs

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Parkinsons
Symptoms include:

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

No specific test to diagnose Parkinsons Diagnosis based on symptoms

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Parkinsons Medical Treatment

Medications

Sinemet, Symmetrol, Levodopa or Cogentin Less effective over time

Surgery

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Parkinsons Nursing Care

Prevent injury (fall or aspiration) Prevent urinary retention and constipation Patient teaching about medication Patient and family support

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Alzheimers
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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Alzheimers - 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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Alzheimers - Testing
No definitive test Family history Diagnosis: autopsy

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Alzheimers 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

Alzheimers 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 Gehrigs disease

Motor neurons in brain stem and spinal cord degenerate Brains messages dont reach the muscles Symptoms weakness, dysarthria, dysphagia No loss of cognitive function No cure, death occurs in 2-6 years

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Huntingtons Disease Chorea

Genetic Onset at age 35-45 Excessive involuntary movements Death in 10-20 years No cure

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Huntingtons 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 Hypertension Obesity High cholesterol Cigarette smoking Stress Sedentary Diabetes Oral contraceptives Cocaine
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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 =cant speak or write Agnosia =cant recognize familiar objects/people Apraxia =cant 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 cant 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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Infection and Inflammation

Meningitis Encephalitis Brain abscess Guillain-Barr Neurosyphilis Poliomyelitis Herpes zoster AIDS

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Guillain-Barr - 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

Kernigs sign Brudzinskis 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 Injury (SCI)

Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain.
It also damages gray matter in the central part of the spinal, causing segmental losses of interneurons and motoneurons.
Sapiah R 2012

Spinal Cord Injury (SCI)

Complete cord injury all voluntary movement below level of trauma is lost

Autonomic hyperreflexia

stimulus sympathetic nervous system response

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Pathophysiology: Damage to the spinal cord ranges from transient concussion to contusion, laceration and compression of the cord substance, to complete transaction of the cord. Separated into 2 categories: Primary injuries - are the result of the initial insult or trauma and are usually permanent. Secondary injuries - are usually the result of a contusion or tear injury, in which the nerve fibers begin to swell and disintegrate.

Causes:
Trauma - such as automobile accidents, falls, gunshots, diving accidents, war injuries, etc. Tumor - such as meningiomas and metastatic cancer. Ischemia - resulting from occlusion of spinal blood vessels, including dissecting aortic aneurisms, emboli, arteriosclerosis. Developmental disorders - such as spina bifida & meningomyolcoele Others examples: Neurodegenerative diseases, Multiple Sclerosis, aneurysm and etc.

Treatment:
Acute Traumatic Spinal Cord Injuries : high dose methylprednisolone if the injury occurred within 8 hours.
Stem Cell Transplants - to help or cure paralysis caused by spinal injury.

HEAD INJURIES

Sapiah R 2012

HEAD INJURY
CLASSIFICATION: LACERATION OF THE SCALP SKULL INJURY BRAIN INJURY

INTRACRANIAL HEMORRHAGE
CONCUSSION CONTUSION LACERATION COMPRESSION

EPIDURAL SUBDURAL INTRACEREBRAL OR SUBARACHNOID

Pathophysiology
Brain suffers from traumatic injury Brain swelling or bleeding increases intracranial volume Rigid cranium allows no room for expansion of contents so ICP increases Cerebral blood flow decreases Intracranial pressure continues to rise. Brain may herniate Cerebral hypoxia and ischemia occurs

Pressure on blood vessels within the brain causes blood flow to the brain slowly

Scalp Injuries
They bleed profusely because of the abundance of blood vessels in the scalp. Infection is of major concern.

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Skull Injuries
May occur with or without brain injury, Fracture usually caused by extreme force, Skull fractures considered closed if dura mater is intact; open if dura mater is torn.

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Types of Skull Fractures

Linear (nondisplaced cracks in the bone). Comminuted (bone broken into fragments). Depressed (bone fragments pressing into intracranial cavity). Basiliar (fractures of the bones in the base of the skull).

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Brain Injuries: Causes

Acceleration-deceleration force (acceleration injuries caused by moving objects striking the head; e.g. baseball bat. Deceleration injuries result when head is moving and strikes object, e.g. dashboard). Rotational (twisting of the cerebrum on the brain stem, e.g. whiplash). Penetrating missile (direct penetration of an object, e.g. bullet, into brain tissue).
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Brain Injuries: Open

Brain injuries resulting from skull fractures and penetrating injuries are referred to as open head injuries. Hemorrhaging from the nose, pharynx, or ears; ecchymosis over the mastoid area (Battles sign) or blood in the conjunctiva may occur in conjunction with open head injuries.
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Brain Injuries: Closed

Caused by blunt force to the head. Types of closed head injuries include concussion, contusion, and laceration.

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Concussion
Transient neurological deficits caused by the shaking of the brain. Clinical manifestations may include immediate loss of consciousness lasting from minutes to hours, momentary loss of reflexes, respiratory arrest for several seconds, an amnesia afterwards.
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Contusions
Surface bruises of the brain. Skin is cool and pale. Pulse, blood pressure, and respirations are below normal. Cerebral edema may occur in conjunction with widespread injury.

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Cerebral Lacerations
Tearing of cortical tissue. Symptoms include deep coma from time of impact, decerebate posturing, autonomic dysfunction, nonreactive pupils, respiratory difficulty.

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Clinical Manifestations:
Depend on the severity and the distribution of the brain injury. Persistent localized pain usually suggest that a fracture is present. Fractures of the cranial vault may or may not produced swelling in the region of the fracture Battles Sign - an area of ecchymosis (bruising) which is

seen over the mastoid. CSF Otorrhea - cerebrospinal fluid leaking through the ears. CSF Rhinorrhea - cerebrospinal fluid leaking through the nose. Halo Sign - it is a blood stain surrounded by a yellowish stain (CSF) which is usually seen on bed linens or pillows.

Back to topic

Hemorrhage
Intracranial hemorrhage is common complication of any head injury. Treatment is surgery to evacuate the hematoma, stop the bleeding, and relieve pressure on the brain.

Sapiah R 2012

HEAD INJURY
Nursing Care:
Emergency Care: airway supine straight, then turned to lateral or semi-prone possible cervical collar: no neck flexion & hyperextension keep pt covered, quiet & undisturbed

General Care:

airway prevent aspiration check cardiovascular complications search evidence of spinal injury check skull & scalp injuries

prophylactic tetanus observe csf leakage: otorrhea, rhinorrhea battles sign observe for s/sx of increased ICP control restlessness & pain: NO NARCOTICS maintain fluid &electrolyte, acid-base balance
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Thanks For Listening