NEUROLOGICAL NURSING

Adult II Nursing Neurological Nursing

NEUROLOGICAL NURSING

Introduction:

The care of a neurological patient may be complex. Successful nursing care requires preparation, sound clinical skills, and systematic approach to the nursing process

1. Nervous System: 1. Regulates system

2. Controls communication

3. Coordinates Activities of body system

Divisions

Central nervous system ( CNS) : brain and spinal cord interprets incoming sensory information and sends out instruction based on past experiencesBrain:

Cerebrum-Largest part of brain:outer layer called cerebral cortex composed of dendrites and cell bodies : controls mental processes: highest level of functioning

Cerebellum: controls muscle tone coordination and maintains equilibrium

Diencephalon:Consist of two major structures located between cerebrum and midbrain

Hypothalamus: regulates the autonomic nervous system: controls blood pressure: hepls maintain normal body temperature and appetite: controls water balance and sleep

Thalamus: acts as a relay station for incoming and outgoing nerve impulses:produces emotions o pleasantness and unpleasantness associated with sensations

Brainstem: Connects the cerebrum with the spinal cord

Midbrain- relay center for eye and ear reflexes

Pons- connecting link between cerebellum and rest of nervous system

Medulla oblongata- contains center for respiration, heart rate, and vasomotor activity

Spinal Cord: Inner column composed of gray matter, shaped like a H, made up of dendrites and cell bodies: outer part composed of white matter, made up of bundles of axons called tracts

Functions: sensory tract conducts impulses to brain motor tract conducts impulses from brain: center for all spinal cord reflexes

Protection for CNS: Bone- vertebrae surround cord: skull surrounds the brain

Meninges: three connective tissue membranes that cover the brain and spinal cord

1. Dura mater: white fibrous tissue: outer layer

2. Arachnoid: delicate membranes: middle layer : contains subarachnoid fluid

3. Pia mater: inner layer contains blood vessels

Cerebrospinal Fluid: acts as a shock absorber: acts in exchange of nutrients and waste materials

Peripheral nervous system (PNS): Cranial and spinal nerves extending out from brain and spinal cord---carry impulses to and from brain and spinal cord. Caries voluntary and involuntary impulses

Cranial nerves:

I olfactoryNose to brainSmell

II opticEye to brainVision

III oculomotorBrain to eye and eye musclesContraction of upper eyelid

Maintain position of eyelid

Pupillary reflexes

IV TrochlearBrain to external eye musclesEye movements

V trigeminalFrom skin & mucous membranes of head & teeth to chewing musclesSensations of head & teeth

Muscles of chewing

VI AbducensFrom brain to external eye musclesEye movements

VII FacialFrom taste buds & facial muscles to muscles facial expressionTaste

Facial expressions

VIII AcousticFrom organ of corti to brainHearing

IX GlossopharyngealFrom pharynx & tongue to brain

From brain to throat muscles and salivary glandsSensations of tastes& swallowing

Secretion of salvia

X VagusFrom throat & organs in thoracic & abdominal cavitiesImportant in swallowing, speaking, peristalsis and production of gastric juices

XI AccessoryFrom brain to shoulder and neck musclesRotation of head and raising shoulders

XII HypoglossalFrom brain to tongueMovement of tongue

Spinal nerves: 31 Pairs: conduct impulses necessary for sensation and voluntary movements: each group named for the corresponding part of spinal column

Autonomic nervous system (ANS): functional classification of the PNS---regulates involuntary activities. Part of PNS: controls smooth muscle, cardiac muscle, and glands

It has two divisions;

1. Sympathetic-flight or fight response: increases heart rate and blood pressure; dilates pupils

2. Parasympathetic : dominates control under normal conditions: maintains homeostasis

Somatic nervous system (SNS) : Functional classification of the PNS: --allows conscious or voluntary control of skeletal muscles

Neurons or nerve cells

Respond to a stimulus, connect it into a nerve impulse (irritability), and transmit the impulse to neurons, muscle, or glands (conductivity), consists of three main parts

Neurons main parts

1. Cell body: contains nucleus and one or more fibers or process extending from the cell body

2. Dendrites: conduct impulses toward cell body: neurons has many dendrites

3. Axons: conduct impulses away from cell body: neuron has one axon

Types of neurons

1. Motor (efferent ): conduct impulses from CNS to muscle and glands

2. Sensory (afferent): conduct impulses toward CNS

3. Connecting ( interneuron): Conduct impulses from axon to dendrites

Synapse-chemical transmission of impulses from axon to dendrites

Myelin sheath protects and insulates the axon fibers: increases the rate of transmission of nerve impulses Neurilemma sheath covering the myelin: found in PNS : function is regeneration of nerve fiber

Neuroglia- connective or supporting tissueimportant in reaction of nervous system to injury or infection

Ganglia-clusters of nerve cells outside CNS

White Matter-bundles of myelinated nerve fibers conducts impulses along fibers

Gray matter- clusters of neuron cell bodiesfibers not covered with myelin distributes impulses across selected synapses

Neurological Terms: Anesthesia- complete loss of sensation

Aphasia-loss of ability to use language

Auditory/receptive aphasia- loss of ability to understand

Expressive aphasia- loss of ability to use spoken or written word

Ataxia- uncoordinated movements

Coma- state of profound unconsciousness

Convulsion- involuntary contractions and relaxation of muscles

Delirium- mental state characterized by restlessness and disorientation

Diplopia- double vision

Dyskeinesia- difficulty in voluntary movement

Flaccid- without tone- limp

Neuralgia- intermittent, intense pain, along the course of a nerve

Neuritis- inflammation of a nerve or nerves

Nuchal rigidity-stiff neck

Nystagmus- involuntary, rapid movements of the eyeball

Papilledema- swelling of optic nerve head

Paresthesia- abnormal sensation without obvious cause, with numbness and tingling

Spastic- convulsive muscular contractions

Stupor- state of impaired consciousness with brief response only to vigorous and repeated stimulation

Tic-spasmodic, involuntary twitching of a muscle

Vertigo- dizziness

Transient Ischemic AttacksTIA

Definition:

Altered cerebral tissue perfusion related to a temporary neurologic disturbance. It is manifested by sudden loss of motor or sensory function. It lasts for a few minutes to a few hours, caused by temporarily diminished blood supply to an area of the brain

Treatment: Control hypertension

Low sodium diet

Possible anticoagulant therapy

Stop smoking

Cerebro Vascular Accident

(CVA)(Stroke)

Definition:

It is defined as decreased blood supply to a part of the brain, which caused by rupture, occlusion, or stenosis of the blood vessels. Its onset may be sudden or gradual

Right CVA results in Left side involvement often associated with safety/ judgment

Left CVA results in Right side involvement often associated with speech problems

Approximately 50% of survivors permanently disabled

High proportion experiencing recurrence within weeks to years

Chances for complete recovery depending an circulation returning to normal soon after the initial stroke

Third most common cause of neurological disability Pathophysiology/Etiology: 1. Partial or complete occlusion of a cerebral blood vessel resulting from cerebral thrombosis (due to arteriosclerosis) or embolism. 2. Ischemia related to decreased blood flow to an area of the brain secondary to systemic disease, such as cardiac or metabolic disease. 3. Hemorrhage occurring outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance (intracerebral). 4. Risk factors include hypertension, TIAs, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, cigarette smoking.

Predisposing factors-CVA: Cigarette smoking Family history

Incidence increased with aging

Atherosclerosis

Embolism

Thrombosis

Hemorrhage from ruptured cerebral aneurysm

Hypertension

History TIAs

Hypertension Arrhythmias

Atherosclerosis

Rheumatic Heart Disease

MI

DM

High serum triglyceride levels

Lack of exerciseSigns 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 Seizures

Limited motor function; paralysis, dysphgia, weakness , hemiplegia, loss of function or contractures

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 immobilityDiagnostic test: Physical assessment

Pt and family history

EEG

CT scan

Lumbar puncture

Cerebral angiogram

Carotid ultra sonogram

Treatments: Remove cause, prevent complications, and maintain function, rehabilitation to restore function

Medications

Anti-hypertensive

Anticoagulants

Stool softeners

Surgical removal of clot, repair of aneurysm, carotid endarterectomy or balloon angioplastyNursing Interventions: Patent airway

O2 with humidity

Suction PRN

Keep head turned to side

Place in semi- fowlers

Maintain therapeutic bed rest

Use turn sheet

Footboard

Firm mattress

Pillow and torchanter rolls

Maintain proper body alignment

Place items within reach

Reposition q2h

ROM passive and active

Flotation mattress or sheepskin

Skin assessment Prevent complications of immobility

ADLs Assess nutrition daily with I&O, WT, %diet, calorie count

Provide N/G or PEG feedings if needed

Maintain IV fluids

Progress to soft diet PRN

TPN as ordered

Aspiration precautions

Dietary consult & Speech for swallowing

Establish means of communication

Call bell pad and pencil

Nonverbal gestures

Use simple commands

Speak slowly

Explain all care

Speech therapy

Be nonjudgmental about personality changes

Encourage family participation

Provide diversional activities

Be realistic

Assess LOC Maintain safety

Use side rails

Restrain only as necessary Seizure precautions

Observe for ICP

V/S & Neuro CKS q 4 h

Ensure elimination

Assess bowel sounds

Monitor bowel movements

I & O

Indwelling catheter PRN

Bowel and bladder training

Family support

Begin discharge teaching early

Rehabilitation therapy

Physical therapy (see figures). Speech therapy

Occupational therapyPHYSICAL EXERCISES & RANGE OF MOTION

Dr: Hanan Yossef ( 1