neurological management ksu

8/3/2019 Neurological Management KSU

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Pathology

The pathology involving the CNS arises from

injuries, vascular insufficiency, tumors,infections and disorders from other diseases.Neurological medical problems are due tointerference with normal functioning of the

affected cells


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Nervous SystemAnatomy and Physiology

Review

The nervous system acts as a coordinatedunit both structurally and functionally

Communication network responsible forcoordinating and organizing the functions ofall body parts

The bodys link to the environment

Works with the endocrine system to maintainhomeostasis

Reacts in a split second


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Functions

1.Regulates system

2. Controls communication 3. Coordinates Activities of body system


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Divisions

Central nervous system ( CNS) : brain and

spinal cordinterprets incoming sensoryinformation and sends out instruction based onpast experiences

Peripheral nervous system ( PNS) : Cranial

and spinal nerves extending out from brain andspinal cord---carry impulses to and from brainand spinal cord


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Neurological Terms

Anesthesia- complete loss of sensation

Aphasia-loss of ability to use language

Auditory/receptive aphasia- loss of ability tounderstand

Expressive aphasia- loss of ability to use spoken orwritten word

Ataxia- uncoordinated movements Coma- state of profound unconsciousness

Convulsion- involuntary contractions and relaxation ofmuscles


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Neurological terms

Delirium- mental state characterized by

restlessness and disorientation Diplopia- double vision

Dyskeinesia- difficulty in voluntary movement

Flaccidd- without tone- limp

Neuralgia- intermittent, intense pain, along thecourse of a nerve


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Neurological terms

Neuritis- inflammation of a nerve or nerves

Nystagmus- involuntary, rapid movements ofthe eyeball

Paresthesia- abnormal sensation withoutobvious cause, with numbness and tingling

Stupor- state of impaired consciousness withbrief response only to vigorous and repeatedstimulation

Vertigo- dizziness


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Preparing a patient for a diagnostic

test

Answer question that thepatient may need clarification

Diet ordersNPO??? Special room or equipment

used

Special medications requiredfor test

An informed patient will bemore cooperative

Nursing assessment

Baseline vital signs and neurocks

Know level education todevelop an individualizedteaching plan

Determine awareness ofactual or potential medical

diagnosis Determine previous

experence with Dx test


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Diagnostic test/ methods

A. Computerized Tomography- CT or CAT scan

computer analysis of tissues as x-rays passthrough them; has replaced many of the usualtests: no special preparation or care after test


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CT scan

Nursing Interventions

Explain procedure will be enclosed tunel

Written consent

Assess allergies to iodine

Remove wigs hair pins or clips, partial denture plates

Assess for pacemakers

NPO 4 hours before if oral contrast is administered Encourage patient to drink fluids to avoid renal complications

and to promote excretion of the dye


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B. lumbar puncture- spinal tap

Done under local anesthesia a puncture is made atthe junction of the third and fourth lumbar vertebraeto obtain a specimen of cerebrospinal fluid (CSF)

CSF pressure measured

Used to inject medications- spinal anesthesia Used to inject diagnostic materialsair or dye-

myelogram


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Lumbar puncture

Nursing interventions Written consent

Monitor vital signs Have patient empty bowel and bladder

Position the patient

Label and number specimens

Keep patient supine 4-8 hours

Observe for headache and nuchal rigidity

Observe for mobility of extremities, pain, ability to void

Monitor site for leakage


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Cerebral Angiography- intraarterial injection of

radiopaque dye to obtain an xray film of thecerebrovascular circulation


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Cerebral angiography


Assess for allergy to iodine NPO past midnight

Administer preprocedure medications

Observe arterial puncture site

Monitor extremity for adequate circulation- pain tenderness

bleeding temperature and color Pedal pulses and vital signs q 1 hour

Provide ice pack to puncture site

Bedrest 12- 24 hours

Force fluids- to increase excretion of dye


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Electroencephalography (EEG)- electrodes are

placed on unshaven scalp with tiny needlesand electrode jelly


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EEG

Nursing Inventions Anticipate patients fears about electrocutions

Explain procedure Written consent

Hair should be clean

Do not give stimulants/ depressants before test /consult withM.D. about meds

Administer sedatives or hypnotics if ordered No smoking or caffeinated beverages before the test

Eat full meal before the testhypoglycemia may alter brainwaves

Stress need for restful sleep before the test sleep deprivation

may cause abnormal brain waves Wash hair and scal after test


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Brain Scan-after injection of a radioisotope,

abnormal brain tissue will absorb more rapidlythan normal tissue: this can be detected with aGeiger counter to diagnose brain tumors


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Brain Scan

Nursing interventions

NPO 4 hours before test Remove wigs, hair clips or pins,

Assess for iodine allergies

If ordered give sedation

Encourage fluids after test to increase excretion ofdye


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Magnetic Resonance Imaging- ( MRI)

uses combination of radio waves and a strongmagnetic field to view soft tissue ( does Notuse x-rays or dyes) ; produces a computerizedpicture that depicts soft tissues in high

contrast color


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MRI


Written consent Explain procedure- will have to remain perfectly still

in the narrow cylinder-shaped machine . No pain ordiscomfort but no room for movement

Assess for any metal contraindications-pacemaker,surgical clips, hair clips, belts

Empty bladder before test


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Myelogram- injection of a radiopaque dye into thesubarachnoidd space via a lumbar puncture:

performed to locate lesions of the spinal column orruptured vertebral disk


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Myleogram


Prepare for LP NPO for 4 hours before test

Positioning for LP

Vital signs

Observe for photophobia, fever stiff neck, occipital headaches,

nausea , dizziness, and possibly seizures Force fluids to promote dye excretion dehydration will result in

severe headache

Check with M.D. when withheld medications prior to test maybe restarted

Observe site for leakage of CSF Bedrest


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Nursing Diagnosis and

Interventions

Identify the patients needs

Neuro checks Assessment of history from family

Patient history

Nursing observations


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Impaired Physical Mobility

Neuro checks q2-4h

Explain the need for regular

exercise program ROM to all joints q2-4h

foundations pg 243-244

Use assistive devices

Protect the affect side from

injury

Protection from falling

Turn q2h


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Ineffective breathing pattern relatedto neuromuscular impairment

Maintain patent airway

Suction as needed

Elevate HOB 30-60-degrees

Have trach set ready

Provide O2 with humidity

V/S with neuro cks q2h Oral hygiene q2h

Lubricate lips

Maintain bed rest

Keep unconscious pt in

lateral position to allowsecretion drainage

Monitor for S/Spulmonary emboli Chest pain, SOB,

Monitor ability to swallow


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Risk for alteration in body

temperature

Asses rectal temp q2h

Use external heating orcooling blankets


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Risk for aspiration

Maintain NPO

Position Pt on side: turnq2h

Provide N/G feedings

Monitor IV fluid


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Altered patterns of urinary

elimination

1. Oligura-urinaryretention

Provide indwellingcatheter

Monitor I&O qh

2. Incontinence

Wash dry and inspect

skin Implement measures to

prevent decubitus ulcers

Implement bladdertraining


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Bowel incontinence/constipation

Incontinence

wash dry and inspectskin

Implement measures toprevent decubitus ulcers

Implement bowel training

Constipation

-Record bowel movements

-Provide stool softners,laxatives and enemas

-Check for impaction

-Increase fluid intake

-Increase Fiber in diet

-Increase activity


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Altered Nutrition: less than bodyrequirements related to dysphagia

and fatigue

Prepare for N/G

feedings Check gag reflex

Provide mouth care,clean and care for

dentures Place food in patients

visual field do patientcan see food

Diet low salt low

cholesterol consult dietary

Wt daily


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Impaired Communication

Assess communicationpatterns

Provide calm environmentwith minimal distraction

Use touch to increaseattention

Use familiar music to

enhance recall

Simple verbal commands

Communication boards

Pen and paper

Gestures eye blinks


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Fluid Volume deficit


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Inability to meet needs:Coma

COMA-Unconscious state in which the Pt isunresponsive to verbal or painful stimuli: thisoccurs with many primary diseases: the Ptdepends on the nurse for maintenance of allbasic human needs, nourishment, bathing,

elimination, respiration, prevention ofcomplications and assessment and provision ofcare for problems


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Coma : nursing interventions

Include family in nursing care and planning

Note LOC q15 minutes

Nero Ck q 15 minutes

Demonstrate respect for Pt presence

Provide quite restful environment

Speak to Pt, use proper name, introduce self,explain all care

Provide privacy


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Patient with paralysis

Paraplegia-paralysis of the lower extremities

There may be no motion or sensory function or reflexes

There may be uncontrollable muscle spasms

Perspiration ceases then becomes profuse

Loss of bowel and bladder control

Anxiety, fear, depression, anger, and embarrassment May be totally dependant


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Patient with paralysis

Quadriplegia- paralysis of all four extremities

Same problems as paraplegia


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Nursing interventions : Paralysis

Take measures to prevent complications of immobility

Bowel and bladder training

Prevent deformity: maintain joint mobility: correctalignment

Increase fluid intake

Provide high protein diet

Teach independence according to ability Work with health care team for rehabilitation

Include family in planning and care


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Increased intracranial pressure

( ICP)

Fluid accumulation or a lesion takes up spacein the cranial cavity, producing ICP: the brain isgradually compressed, or life-sustainingfunctions cease: may be sudden or progressslowly


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ICP

Causes

Tumors

Hematoma Edema from trauma

Abscesses from infection


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ICP

signs and symptoms

Headache, restless, anxiety

Vomiting,recurrent, projectile,

and not related to nausea ormeds

Change in pupil response tolight

Seizures

Respiratory difficulty;irregular, Cheyne-Stokes orKussmaul

BP elevates ,with wide pulsepressure

Pulse Increases at first thenslows to 40- 60

Alter LOC,lethargic, speechslows, confused, decreaselevel of response

Visual disturbances,diplopia

and blurred vision Progressive weakness or

paralysis

Loss of consciousness,comadeath


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ICP

Treatment

Depends on cause

Craniotomy Meds

Steroids

Anticonvulsants

Mannitol

dexamethasone


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ICP


Elevate HOB to semi-Fowlers

Never place in Trendelenburg

V/S and neuro cks q15 minutes Prevent aspiration

Place Pt on Side

Maintain airway- O2

Observe pupillary response ( usually unequal and maynot react to light)

Report changes in LOC immediately

Seizure precations

Provide care for Coma Pt


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Convulsive disorders

Frequently a convulsion or seizure is not adisease but a symptom of a neurologicdisorder:

Epilepsy is a disease characterized by adisposition for seizures;


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Types of seizures

Generalized or grand mal

Aura- There may be a premonition or sign

The Pt cries out Loss of consciousness

Enters tonic phase- the body is rigid and the jaw isclenched

Then the clonic phase- jerking movements ofmuscles

Cessation of respiration

Fecal and urinary incontinence

Lasts 1-2 minutes


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Types of seizures

Partial or petit Mal

Loss of consciousness that last 5- 30seconds

Normal activities may or may not ceas

There may be amnesia concerning the time


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Types of seizures

Jacksonian or Motor

A focal seizure that may precede a grand malseizure


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Convulsive Disorders

Causes

May be secondary to another condition

CVA, head injury, brain tumor, elevated temp,toxins, electrolyte imbalance

Epilepsy may have no known cause

Onset is usually during childhood or before age 30


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Diagnostic test

EEG

CT scan MRI


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Treatment

Treat and remove cause

Anticonvulsant drugs Surgery sterotactic- electrical stimulation to

locate and reset ( destroy) epileptogenic focus


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Provide accurate observation and documentation

Aura

Time of onset Whether seizure is generalized or focal

Specific parts of body involved

Progression of seizure

Eye movements Loss of consciousness

Loss of bowel or bladder

Condition after seizure

Memory loss


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Encourage Pt to wear medical alert tag

Have suction available

During seizure maintain airway Prevent head injury

Place pt on side

Protect extremities from injury

Do not restrain Loosen clothing

Remove pillows

Maintain safety until fully conscious


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Transient Ischemic Attacks

TIA

Altered cerebral tissue perfusion related to atemporary neurologic disturbance

Manifested by sudden loss of motor or sensoryfunction

Lasts for a few minutes to a few hours

Caused by temporarily diminished blood supplyto an area of the brain

High risk for stroke


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TIA

Treatment

Control hypertension

Low sodium diet Possible anticoagulant therapy

Stop smoking


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Cerebrovascular Accident

CVA Stroke

Decreased blood supply to a part of the brain

caused by rupture , occlusion, or stenosis of the blood

vessels Onset may be sudden or gradual

Symptoms and patient problems depend on locationand size of area of brain with reduced or absent blood

supply right CVA results in Left side involvement often

associated with safety/ judgment

Left CVA results in Right side involvement oftenassociated with speech problems


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Cerebrovascular Accident

CVA Stroke

Symptoms related to location and size of brain areaaffected

Approximately 50% of survivors permanently disabled

High proportion experiencing recurrence within weeksto years

Chances for complete recovery depending an

circulation returning to normal soon after the initialstroke

Third most common cause of neurological disability


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Predisposing factors-CVA

History TIAs

Hypertension

Arrhythmias

Atherosclerosis

Rheumatic HeartDisease

MI

DM

High serum triglyceridelevels

Lack of exercise

Cigarette smoking

Family history


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CVA

Causes

Incidence increased with aging

Atherosclerosis Embolism

Thrombosis

Hemorrhage from ruptured cerebral aneurysm

hypertension


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CVA

Signs and Symptoms

Altered LOC

Change in mental status

Decreased attention span Decreased ability to think and reason

Difficulty following simple directions

Communication; motor and sensory aphasia difficulty

with reading ,writing, speaking, or understanding Bowel and bladder dysfunction retention impaction or

incontinence


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CVA

Signs and Symptoms

Seizures

Limited motor function; paralysis, dysphgia, weakness ,

hemiplegia, loss of function Loss of sensation/ perception

Headaches and syncope

Loss of temp regulation elevated TPR and BP

Absent of gag reflex ( aspiration) Unusual emotional responses; depression, anxiety,

anger, verbal outburst, and crying: emotional lability

Problems related with immobility


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CVA

Diagnostic test

Physical assessment

Pt and family history EEG

CT scan

Lunbar puncture

Cerebral angiogram

Carotid ultrasonogram


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CVA

Treatments

Remove cause, prevent complications, and maintainfunction, rehabilitation to restore function

Meds Antihypertensives

Anticoagulants

Stool softners

Surgical removal of clot, repair of aneurysm, carotidendarterectomy or balloon agioplasty


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CVA


Patent airway

Maintain bedrest

Provide complete care Use turn sheet

Footboard

Firm mattress

Pillow and torchanter rolls

Maintain proper bodyalignment

Place items within reach

Reposition q2h

ROM passive and active

Place in chair

Flotation mattress orsheepskin

Skin assessment


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CVA


O2 with humidity

C,T, DB q2h

Suction PRN

Keep head turned toside

Place in semi- fowlers

Assess nutrition daily withI&O, WT, %diet, calorie count

Provide N/G feedings ifneeded

Maintain IV fluids

Progress to soft diet prn

TPN as ordered

Aspiration precautions

Dietary consult & Speech forswallowing


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CVA


Establish means ofcommunication

Nonverbal gestures

Speak slowly

Explain all care

Speech therapy

Encourage familyparticipation


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CVA


Assess LOC

Maintain safety

Use side rails

Restrain only asnecessary

Observe for ICP

V/S & Neuro CKS q 4 h

Seizure precations

Ensure elimination

Assess bowel sounds

Monitor bowelmovements

I & O

Indwelling catheter prn

Bowel and bladdertraining


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CVA


Family support

Begin discharge

teaching early

Physical therapy

Speech therapy


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Brain Tumor

A benign or malignant growth that grows a ndexerts pressure on vital centers of the braindecreasing function and causing increasedintracranial pressure

Cause is unknown


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Brain Tumor

Signs and Symptoms

Personality changes, fear and anxiety

H/A , dizziness and visual disturbances

Seizures

Pituitary dysfunction

ICP

Local paralysis or anesthia Aphsia

Problems with coordination


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Brain tumor

Diagnostic test

History

Physical exam

Neurologic assessment

EEG

CT

Angiogram

MRI


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Brain tumor

treatment

Surgical removalcraniotomy

Combination of radiation or chemotherapy


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Brain tumor

nursing interventions

Neuro cks q 1-4 hoursdepending on pt status

Safety

Seizure precautions

express fears andfeelings

POST OP care

Maintain airway

Seizure precautions Regulate body temp

Position on unoperated side

Elevate HOB ONLY underMD orders

Inspect dressing q30min V/S neuro cks q 15 min

progress to q4h

Coma care


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Head injuries

Trauma to scalp, skull, or brain. A fracture toskull may result either a simple break in the

bone or bone fragmentation that penetrates thebrain tissue, can also cause hemorrhage,concussion, or contusion


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Head injuries

Cerebral concussion- injury to the head, patientmay be dazed; or unconscious for a few

minutes: some function(memory) may beimpaired for as long as several weeks

Cerebral contusion- head injury causing

bruising of brain tissue> person experiencesstupor, confusion or loss of consciousness: ifsevere may go into coma


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Head injuries

Cerebral laceration- a break in continuity ofbrain tissue

Causes

Blow to head MVA

Fall

Head injuries


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Head injuriesSigns and Symptoms and

diagnostic test

Nausea & vomiting

Lethargic: increasing

loss of consciousness toimpending coma

Disorientation

Drainage of CSF from

ear or nose ICP

History and physicalexam

X-ray of head Angiogram, doppler

studies

CT head, MRI

PET


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Head injuries

Treatment

Anticonvulsulants

Corticosteriods

Mannitol

Maintain fluid balance

surgery


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Head injuries


Care for ICP

COMA care

Neuro cks & V/S q 15min to q1h

Maintain airway

Seizure precations

Observe ears and nosefor CSF


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Multiple Sclerosis

A chronic progressive disease of the brainandspinal cord: lesions cause degeneration of the

myelin sheath and interfere with conduction ofmotor nerve impulses: there are periods ofremissions and exacerbations: onset occuresin young adult: it has an unpredictableprogression

Cause: unknown< exacerbates with stress


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Multiple Sclerosis

Signs ands symptoms

Ataxia

Paresthesia

Weakness and loss ofmuscle tone

Loss of sense of position

Vertigo

Blurred visionprogressto blindness

Inappropriate emotions

Euphoria, apathy,

depression Dysphagia

Slurred speech

Bowel and bladder

dysfunction Sexual dysfunction

spasticity


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Multiple Sclerosis

Diagnostic test and treatments

History Physical exam

Neuro Cks

Ct

MRI

Exam of CSF

Treatment issymptomatic

Corticosteriods duringacute excerbation


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Multiple Sclerosis

Nursing interventions Prevent Complications of

immobility

Encourage independence Patient should participate in

plan of care

High calorie, vitamin, proteindiet

Family education

Bowel and bladder training

Safety

Express feelings regardingdependence and disabilities

Avoid precipitating factors forexacerbations

Fatigue, cold, heat, infections,stress


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Parkinsons Disease

A progressive , degenerative disease causingdestruction of nerve cells in the basal ganglia of the

brain caused by a deficiency of dopamine: limbsbecome rigid, fingers have characteristic pill rollingmovement, and head has to and for movement: thepatient has a bent position and walks in short, shufflingsteps: facial expressions become blank with wide openeyes and infrequent blinking ( parkinsons Mask)

Intelligence is NOT affected


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Parkinsons Disease

Signs and symptoms Tremor

Voluntary movement is slowand difficult

Coordination is poor- ataxia

Impaired chewing and eating

Excessive salivation anddrooling

Speech is slow

Patient is soft spoken

Written communication isdifficult

Excessive sweating

Emotional changes

Depression , confusion

dependency


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Parkinsons Disease

Dx test and treatments

History

Physical exam

Neuro cks

Many pt s respond todrug therapy and the

disease is controlled withmeds for the reminder oftheir lives

Others have no

response to meds -invalidism


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Parkinsons Disease


Foster independenceADLs

Avoid social withdrawalinvolve in work, socialand diversional activities

Aviod embarrassmentwhile eating Use straws, wipe drool,

use bib, keep clothingclesn, use large handlegrips

Soft diet

Daily walkingsafety

Avoid fatigue Physical, Speech and

Occupational therapy

Avoid constipation-stool

softner


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Parkinsons Disease


Bowel and bladdertraining

Be patient when patientis slow and clumsy

Establish a means ofcommunication

Reorientation Prevent pneumonia

Mouth care q4h

Family participation


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Spinal Cord Impairment

The vertebral column houses the spinal cord.A small cartilage disk acts as a cushion

between the vertebrae. All sensory and motornerves to the neck, trunk, and extremitiesbranch out from the spinal cord. The degree ofdisability and patient problems is related thepart of the body controlled by the injured ordisease nerves


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Spinal Cord Injuries

Trauma to spinal cord may cause complete orpartial severing of the spinal cord

If severing is complete there is permanentparalysis of body parts below site of injury

When there is partial damage edema may

cause a temporary paralysis


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Cause : accident ,MVA diving, shooting

S&S individual to site, respiratiory distress,paralysis

DX test: physical exam

Treatment: immobilization

Crutchfield tongs.halo traction.brace.body cast

Surgery corticosteroids, mannitol


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Care for paralysis patient

Observe for complications of spinal shock

Maintain airway and respiratory function

neurological management ksu

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