neuro bsn 3c

8/6/2019 Neuro BSN 3C

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} NEUROLOGICAL DISORDERS

Aka: Cephalgia

Classification:a. PRIMARY

is one for which no organic cause can be identified.b. SECONDARY

Is a symptom associated with an organic cause, such as in braintumor or an aneurysm.

} 2.) CLUSTER HEADACHE} have cyclical pattern of 1-3 short-lived attacks of periorbital pain} occurs more often in men} TRIGGERED BY ROH CONSUMPTION} pain described as deep, boring, intense pain of such severity that the

client has difficulty remaining still3.) MIGRAINE HEADACHE

considered as vascular h/a, vasospasm & ischemia of intracranial vesselbeing the cause of painh/a is most often unilateral, but pain may occur on alternate sides withdifferent attack

} Etiology: Idiopathic

Risk Factors:Menstrual CycleStressDepressionSleep DeprivationFatigueOveruse of MedsTyramine-rich foods

PATHOPHYSIOLOGY:Dysfunction of brainstem pathway

Abnormal metabolism of serotoninIncrease plasma serotonin level

Dilates cerebral blood vessel} 4 Phases of Migraine:

I. ProdromeII. AuraIII. Headache phaseIV. Recovery Phase

Diagnostic Tests:} Detailed History Taking} Complete Physical & Neurological Examination


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} CT-Scan} MRI} Cerebral Angiography} Medical Management} Preventive}

Abortive

Medications:1. Serotonin receptor antagonist

Sumatriptan (Imitrex)Ergotamines

Ergotamine tartrateAnti-epileptics

TopiramateGabapentin

NURSING INTERVENTIONSH-eat application or massage

E-ducate on prevention

A-nti-emetic medications

D-im or dark environment

A-dminister analgesics

C-oach on habit and lifestyle changes

H-ead elevation

E-xercise programs

INCREASED INTRACRANIAL PRESSURE

} Intracranial hypertension associated with altered states of consciousness.} Monroe-Kellie Hypothesis} Causes of Increased ICP} Cerebral edema} Brain swelling} Brain surgery} Mass lesions in the brain} Hydrocephalus} Valsalva maneuver } Clinical manifestations:} Changes in LOC} Projectile vomiting

Cushings Triad:


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} Hyperthermia} Cushings ulcer } Seizure} Papilledema} Brain Herniation

Diagnostic Tests:1. CSF Analysis with manometer 2. ICP Monitoring Device

Management

R- educing CSF & Intracranial Blood volume

E- dema decrement

D- ecrease of metabolic demand

U- pright position

C-ontrolling fever

E-nsure oxygenation

D-rug administration

SEIZURE DISORDER} Is a sudden, abnormal electrical discharge from the brain that results in

changes in sensation, behavior, movements, perception and consciousness} EPILEPSY- is a chronic disorder of recurrent seizure.

Etiology} Pathologically acquired epilepsy} Biochemical Epilepsy} Posttraumatic} Idiopathic

Clinical Findings: TYPES OF SEIZURE

I. PARTIAL SEIZURE

1.) SIMPLE-PARTIAL } Originate in themotor cortex of thefrontal lobe.

} Characterized byJACKSONIANMARCH

2. ) COMPLEX-PARTIAL


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} Originate in thetemporal lobe andlimbic system

} Characterized by AUTOMATISM.

II. Generalized Seizure

1.) GRANDMAL SEIZUREPre-ictal: Begins with an AuraIctal Phase: 2 phases:

TONIC- muscular rigidity/ extension of extremitiesCLONIC- muscular jerking.

Post-ictal Phase: Sleep2.) PETIT-MAL

Occurs to children ages 4- pubertyThe victim appears to be daydreaming.

3.) MYOCLONICInvolve a sudden uncontrollable jerking movements of either a single muscle group.

4.) ATONICAssociated with total loss of muscle tone.

5.) Febrile Seizures

Complication:

STATUS EPILEPTICUS- continuous seizure lasting for more than 30 minutes withoutfull recovery in between.

Diagnostic Tests1. EEG2. MRI3. PET Scan

Medications:} Phenytoin} Phenobarbital} Carbamazepine} Ethosuximide (Zarontin)} Valproic Acid} Diazepam


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Surgical M anagement: Cortical Resection? Corpus CallosotomyTemporal LobectomyHemispherectomyVagal nerve Stimulator Implants

NURSING Management

Seizure precautions:1. Monitor temperature & Respirations2. Note level of consciousness3. Provide a quiet, dimly lighted rooms.4. Prepare plastic airways and suction machine

NURSING Management} Safety

} Side-rails up} Ease the patient to the floor (if sitting on a chair)} Remove pillow (if in bed)} Loosen constrictive clothing} Position patient on one side if possible} Do not restraint

} Airway} Suctioning} Oxygen

Traumatic Head Injury

- a traumatic insult to the brain capable of causing physical, intellectual, emotional,social, and vocational changes

- National Head Injury Foundation

Mechanism of Brain Injury:

a. Acceleration

b. Deceleration

c. Acceleration- Deceleration

d. Rotation

e. Deformation

1. OPEN those that penetrate the skull } SCALP INJUR IES

} Laceration, hematoma, contusion and abrasion to theSKIN.

} SKULL F RACTURES


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} Caused by a force sufficient to fracture the skull} Depressed skull fractures injure the brain by bruising

it or by driving bone fragments into it} TYPES OF SKULL FRACTURE

1. Simple

2. Comminuted3. Depressed4. Basilar

CLINICAL MANIFESTATION} Battles sign} Racoons eye} Subconjunctival hemorrhage} Rhinorrhea} Otorrhea}

H

ALO S

IGN

RISK FACTORS:

2 . CLOSED -caused by blunt trauma } CONCUSS IONS

} A jarring of the brain} temporary LOC (


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} Onset of eye movement paralysis on the same side of the hematoma

} Lapses into coma} INTRACRANIAL HEMMORHAGE

2.) SUBDURAL HEM ATO M A } Rupture of VEINS in the subdural space

} Acute rapidly develop (24-48 hours)} Subacute (48hrs -


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DIAGNOSTIC TESTS1. Skull X-ray2. CT-Scan3. MRI4. Cerebral Angiography

Treatment of Increased ICPSupportive Measures:Mechanical ventilationSeizure PreventionF & E MaintenanceNutritional supportPain Management

} Surgical Management

Goal: Decompression

1.) CRANIECTOMY

- excision of the cranial bone without replacing} Surgical Management

Goal: Decompression

2.) BURR HOLE

- decompression, evacuation of clot & abscess.} Surgical Management

Goal: Decompression

3.) CRANIOTOMY

- opening of the cranium} Surgical

Approach} NURSING MANAGEMENT

Maintain Patent AirwayNeurological assessmentTreatment of ICPSupportive measuresElectrolyte & Fluid BalanceAdequate NutritionPrevention of InjuryMaintaining Skin integrity

result of trauma to the vertebral column.

CAUSES- MECHANISM OF INJURY


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A. Acceleration B. Deceleration C. Hyp erflexion D. Hyp erextension E. Axial Loading

F. Excessive Rotation

G eneral: PoikilothermiaIntegumentar y:

Warm, dry skin below level of injury

Res p irator y: Lesions at C1-C3: apnea, Inability to coughLesions at C4: poor cough, diaphragmatic breathing, hypoventilationLesions at C5-T6: decreased respiratory reserve

Cardiovascular Lesions above T5: bradycardia, hypotension, postural hypotension,absence of vasomotor tone

G astrointestinal Decrease or absent bowel sound (paralytic ileus in lesions above T5)Abdominal distentionConstipationFecal incontinenceFecal impaction

Urinar y Retention for lesions between T1 and L2Flaccid bladder (acute stage). Loss of nerve innervations causes atony of the bladder which causes urine retention.Spasticity with reflex bladder emptying (later stage)

Re p roductive Priapism (prolonged penile erection)Loss of sexual function

Neurologic i. Complete

Flaccid paralysis &anesthesia below level of injuryTetraplegiaParaplegia

ii. incompleteM usculoskeletal

Muscle atony (in flaccid state)Contractures (in spastic state)


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1. SPINAL SHOCK

Characterized by decreased reflexes, loss of sensation andflaccid paralysis below the level of injury

2. NEUROGENIC SHOCK

develops due to the loss of autonomic nervous system function below thelevel of the lesion.

Characterized by:} Bradycardia} hypotension

3. AUTONOMIC DYSREFLEXIAIs a complication with a lesion T4-T6.A hypertensive medical emergency.Caused by:

Overdistended bladder Rectal stimulationImpaction

S/Sx:PiloerectionSevere HPNHeadacheDiaphoresisNasal congestion

MANAGEMENT:1. Elevate head of the bed

2. Check the patency of catheter 3. Administer Hydralazine (Apresoline)

DIAGNOSTIC TESTSSpinal RADIOGRAPHYCT/MRIECG

EMERGENCY MANAGEMENT1. Immobilize on a spinal back board2. Avoid flexion, rotation and extension of patients neck and head3. Transport the patient to spinal injury or trauma centers4. P HARM ACOLO GI C THERAPY

} Dexamethasone (Decadron)} Anti-inflammatory and edema reducing effects

} DEXTRAN} Plasma expander to increase capillary blood flow and treat

hypotension


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} Baclofen (Lioresal)} Control muscle spasticity

1. RESP IRATORY THERAPY 2. SKELETAL TRACT ION and REDUCT ION

3. Promoting adequate breathing & airway4. Improve Mobility5. Promoting adaptation top sensory & Perceptual alterations6. Maintaining skin integrity7. Maintaining urinary elimination8. Improving bowel function9. Providing comfort measures10. Prevention of thrombophlebitis

Aneurysm} An intracranial aneurysm is the weakness in the tunica media, the middle

layer of the blood vessels.} The most common type is saccular or berry aneurysm.} Are found more often in the anterior cerebral circulation

RISK FACTORS:SmokingHypertensionAtherosclerosisAlcohol abuseStimulant drug abuseAging process

Clinical Manifestations} Asymptomatic

Ruptured Aneurysm:} Sudden onset of headache Worst headache of my life} Vomiting} Generalized seizure} Decrease LOC: confused, lethargic, coma} S/sx of Menigeal Irritation( Nuchal rigidity, photophobia)} Focal motor & Sensory Deficits

Hunt-Hess Clinical Grading ScaleI. Alert, minimal headache

II. Alert, moderate to severe headache (cranial nerve palsy allowed)III. Lethargic or confused, mild or focal deficitIV. Stuporous, moderate to severe hemiparesis, possible early decerebrate

rigidityV. Deep coma, decerebrate rigidity, moribund appearance.


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Diagnostic Tests:

} History Taking} Physical Assessment} CT Scan}

MRI} Transcranial Doppler

Medical Management1. Neurologic Assessment2. Maintain a patent Airway3. Continuous hemodynamic monitoring4. Nimodipine administration5. Morphine administration6. I & O monitoring

Surgical Management1. ANEURYSM CLIPPINGSurgical obliteration of the aneurysm with a metal clip toeliminate the risk of rebleeding.

ENDOVASCULAR THERAPY & EMBOLIZATIONInvolves obliteration of the aneurysm by means of platinum coils.

Nursing Management

A-ssess neurologic status

E-levate head at 30 degrees

U- rine output monitoring

R-espi and cardio monitoring

Y-oukeep patient & family members in a quite and comfortable environment

S -urgery preparation

M -edication administrationIs a syndrome of a group of sudden focal neurological deficit resulting frominterruption of cerebral blood flow.

Classification of Brain Attacks:

Ischemic (emboli, Thrombus)Hemorrhagic

INITIAL MANIFESTATIONS

S-evere& sudden headache


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T-trouble in speaking

R-ight or left hemiparesis

O-cular disturbances

K-onfusionE-mpairement in coordination

Changes in LOCSpatial and proprioceptive dysfunctionImpairment in memory, judgment, or problem-solving and decision-makingprocess

Decreased ability to concentrate and attend to taskAphasiaAlexiaAgraphiaAcalcula

Homonymous hemianopiaAgnosiaApraxiaHemiplegiaHemiparesisAtaxiaDysarthria

DysphagiaFlaccidity of the muscles associated with paralysis on the motor neurons.

SpasticityPtosisUnilateral neglect syndromeAmaurosisfugax

CT ScanMRICerebral AngiographyDoppler Flow studies

NSG MGT:Maintenance of a patent airway and optimal oxygenation

Control cerebral edemaControl of fluid and electrolyte balanceMaintenance of adequate cerebral blood flow and cerebral perfusionpressure

} Antihypertensive.} Platelet Aggregant

} Aspirin} Ticlodipine


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} Anticoagulant} Heparin} Warfarin

} Thrombolytics} t-PA} urokinase} streptokinase

} Calcium channel blockers} Mannitol} Dexamethasone

Surgical MGTCarotid EndarterectomyTransluminal AngioplastyStentingExtra-Intracranial (EC-IC) BypassOptimizing cerebral tissue perfusionImproving Mobility and Preventing Joint DeformityEnhancing Self-CareManaging Sensory-Perceptual DifficultiesAssisting with NutritionAttaining Bowel and Bladder ControlImproving CommunicationMaintaining Skin Integrity

Myesthenia Gravis

- an autoimmune neuromascular disorder in which there is chronic, progressivedecreased amplitude of the nerve impulse at the myoneural junction.

RISK FACTORSGender: FemaleAge: 20-40 y.oThymicTumor

} PTOSIS} Diplopia} Dysarthria} Dysphagia} Respiratory muscle weakness} Skeletal muscle weakness

CLASSIFICATIONS A. Ocular FormB. Generalized Form

Stages of generalized FormI. Mild

II. Moderate


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III. Acute FulminatingIV. Late Severe

Tensilon Testing} (+) MG; Myasthenic Crisis

} improvement in muscle strength post injection}

NEOSTIGMINE METHYLSUFATE (Prostigmin) longer duration} (-) MG; Cholinergic Crisis

} no improvement in strength} increase in severity} ATROPINE SULFATE antidote

EMG

MYASTHENIA GRAVIS1. Drug Therapy

Anticholinesterase drugs

CorticosteroidsCytotoxic and Immunosuppressive drugsPlasmapheresis

THYMECTOMY1. Promote Effective breathing pattern2. Improved Airway clearance3. Ensure adequate nutrition4. Increase activity tolerance5. Provision of optimum vision

GBS- Landry GBS, Landry-GBS-Strohl

} Is an autoimmune attack of the p eri p heral nerve m yelin .

RISK FACTORSViral infection- history of upper respiratory and GI infection

} Campylobacter jejuni most common; Gram-negative} Targets myelin sheath} Poultry, pets, raw milk and contaminated water

CMVEBVHepatitisHIVRubella &rubeolaVaricella

Clinical M anifestations } Bilateral weakness in the legs} Respiratory dysfunction} Dysphagia


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} CN VII (facial)} Horners syndrome

} ip silateral p tosis } eno p hthalmos } Anhidrosis

CSF analysis

EMG} Plasmapheresis} Steroids} Immunoglobulin infusion} Ace inhibitors} Medications: 4 AS(ANT IB IOT ICS, ANAL G ES IC, ANT ICOA G ULANTS,

AZAT HR IP INE & CYCLOP HOSP HAMI DE)} Maintaining Respiratory Function

1. Maintaining Respiratory Function2. Enhancing physical mobility3. Providing adequate nutrition4. Improving communication

5. Decreasing fear and anxiety} Progressive, degenerative disease of the CNS.Etiolog y:UNKNOWN

} Abnormalities in T-helper cells, T-suppresosr, B-lymphocytes} Viral: mumps, measles, rubella} Stress} Trauma} Pregnancy} Age: 20-45 y.o} Female

Common initial symptoms:} Tingling sensation} Numbness} Sensory symptoms: Lhermittes sign} Motor Symptoms} Charcots Triad

} Scanning of speech} Nystagmus} Tremors

} DIAGNOSTIC TESTCT-ScanCSF AnalysisMRI

PHARMACOLOGIC THERAPYSPASTICITY

Baclofen; ValiumFATIGUE

SymmetrelRitalin

Urinary frequencyAnticholinergics propantheline

Urinary retention


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Cholinergic prostigmine,bethanecol

ExacerbationsCorticosteroids, novantrone

Promoting physical mobility

1. Prevent Injury2. Enhancing bladder and bowel control3. Enhancing communication4. Manage feeding difficulties5. Improve sensory & cognitive function

BELS PALSY

- a sudden loss of motor control on one side of the face.Age: 20-60 y.oGBSGeneticsViral infection

HerpesEpstein-Barr virus

pain behind the ear 1-2 days prior to paralysis,unable to:

smile,frown,

close eyelids,puff out cheeks,

close the lips.Mouth displaced

Saliva droolsConstant tearingLoss of taste at the anterior 2/3 of the tongue.EMG

Steroids for 7 daysAnalgesicsWarm or moist applicationTENSChew on unaffected sideOral careArtificial tear Soft diet

} Tic douloureux} Idiopathic CN 5 disorder characterized by pain along one or more branches

of the CN 5.

CAUSE: UNKNOWN (compression of cerebellar artery)Age: 50 y.oGender: Female


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Compression:ArteriosclerosisAneurysmAcoustic neuromaMultiple sclerosis

Infection of the jaw and teethDIAGNOSTIC TESTS:

CT-ScanMRI

} Medical managementPharmacologic Therapy

Anti-convulsantsCarbamazepinephenytoin

Muscle relaxantsNerve block

SURGICAL MANAGEMENTPERCUTANEOUS RADIOFREQUENCY RHIZOTOMYMICROVASCULAR DECOMPRESSION/ JanettaALCOHOL/ GLYCEROL INJECTION

NURSING MANAGEMENTProvision of therapeutic environment

Room should be kept at moderate temperature and free of draftsto prevent stimulation on Trigeminal nerve.

Avoid jarring the bed or touching the patients face that cantrigger the onset of pain on the three branches of trigeminalnerve.

} Provide lukewarm water and soft cloths or cotton saturated solutions notrequiring rinsing for cleansing the face.

} Use soft-bristled toothbrush or a warm mouthwash during oral care.} Avoid extensive conversation during the acute phase because it may trigger

paroxysms of pain.} Diet must be high protein and calories and easy to chew.

Meningitis- is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid-filled subarachnoid space.

} ETIOLOGYBacteriaVirus

RISK FACTORS:


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Head traumaOtitis mediaSinusitisMastoiditisImmunosupression

Systemic sepsisMOT:

Blood-streamDirect spread

ASSESSMENTHeadacheFever S/sx of meningeal Irritation:

Nuchal rigidity

(+) Kernigs Sign(+) Brudzinski SignPhotophobia

OpisthotonusSkin Lesions (N.menigitidis)

SeizureIncrease ICPNon-communicating hydrocephalusFriderichsen syndrome

CS F ANALYS IS CT -SCAN SKULL RAD IOG RAP H Y

Pharmacologic TreatmentPenicillinDexamethasone

PhenytoinRespiratory isolation

Im p rove of Cognitive F unction Op timizing Cerebral Tissue p erfusion Promotion of Comfort M aintenance of Normal Bod y Tem p erature Preventing Com p lications

Encephalitis- is an inflammation of the brain parenchyma (brain tissue) and often the

meninges.


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} Etiology: Viral Infection} Mumps} Measles

MOT: Direct InvasionChanges in LOCNuchal RigidityFocal neurologic deficitsMotor DysfunctionS/sx of Increased ICPLumbar PunctureMRIEEGTreatment of Increased ICPIntubation & mechanical ventilation

Pharmacologic ManagementDexamethasone

Acyclovir (Zovirax)Anti-pyreticAnalgesicsAnticonvulsants

Improve Tissue cerebral perfusionAdequate oxygenationPromotion of comfortAttain Normal Body temperature

Parkinsons DSE- Paralysis agitans

} Is a chronic, progressively degenerative disease of the basal ganglia.} Cause: Unknown

Age: >30 y.oGender: MaleGeneticsAtherosclerosisFree radicalsViral infectionsHead traumaChronic use of anti-psychotic medications

3 CARDINAL SIGNS1. Tremors2. Rigidity: Cogwheel3. Bradykinesia

} Micrographia} Masked-like facial expression} Short-shuffling steps.PET SCAN


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CSF ANALYSIS

M ED ICAT IONS:

1.) Anti-Cholinergic} Trihexyphenidyl (Artane)}

BenztropineMesylate (Cogentin)2.) Anti-histamine: Benadryl

3.) Dopaminergic Agent} Carbidopa/Levodopa (Sinemet)} Bromocriptine

4.) Anti-viral: Amantadine

5.) Anti-depressantsImproving mobilityEnhancing self-care activitiesImproving bowel eliminationImproving nutrition

Enhance swallowing 6.) Monoamine oxidase Inhibitors: Selegiline

Improving communicationSupporting coping abilities

neuro bsn 3c

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