Nursing Management of the

Adult Patient with

Neurological Alterations

Prepared by:

Hikmet Qubeilat. RN,MSC.

Brain Needs…

� Blood flow

� Glucose

� Oxygen

Diagnostic Studies

� Skull and Spinal Radiology

� CT (Computerized Tomography)

� MRI (Magnetic Resonance Imaging)

� PET (Positron Emission Tomography)

� EEG (Electroencephalogram)

� EMG (Electromyelogram)

� Cerebral Blood Flow Studies

Neurological Assessment

� Level of Consciousness (LOC)

� Pupils

� Vital Signs (VS)

� Neuromuscular status

� Response to stimuli

� Posturing

� Glasgow Coma Scale (GCS)

I. Neurological Disorders

� The normal functioning of the CNS can be

affected by a number of disorders, the most

common of which are headaches, tumors,

vascular problems, infections, epilepsy, head

trauma, demyelinating diseases, and

metabolic & nutritional diseases.

Headaches

� Classified based on characteristics of the

headache

� Functional vs. Organic type

� May have more than one type of headache

� History & neurologic exam diagnostic keys

Not always

chronic�be

careful

Pattern Tension Migraine Cluster

Site Bilateral, basilar, band-like

Unilateral, anterior

Unilateral, occular

Quality Squeezing, constant

Throbbing Severe

Pattern Cycles, years Periodic, years Remitting, relapsing

Duration Days, weeks, months

Hours, days 30-90 min

Onset Anytime Prodrome, starts in AM

Nocturnal

Assoc. S&S

Stiff neck N&V, photo/phono-phobia

Horner syndrome

ONSET: Not reliable or diagnostic

HA: Essential History

� Onset this particular headache

� Character of pain, severity and duration

� Associated symptoms

� Prior history, pattern

� Original onset: prior testing, treatment

� Other therapeutic regimens

Physical Exam

� Neurologic examination

� Inspect for local infections, nuchal rigidity

� Palpation for tenderness, bony swellings

� Auscultation for bruits over major arteries

Organic vs. Traumatic vs. Functional:

Diagnostics

� CBC: underlying illness, anemia

� Chem panel: if associated vomiting, dehydrated

� CT scan: for focal neurological signs, sinus

� No LP for suspected ICP; ↑ association with brain

herniation

Don’t Miss It

1. Caused by subarachnoid hemorrhage from an aneurysm or head

injury

2.“Worse headache of my life”3. Changes in LOC, focal neurological signs

4. Highly correlated with CVA

5. Untreated, 50 % mortality

Headache Teaching Guide

� Keep a calendar/diary

� Avoid triggers

� Medications (purpose, side effects)

� Stress reduction

� Dark quiet room, exercise, relaxation

� Regular exercise

Intracranial Pressure (ICP)

Brain Components

� Skull is a rigid vault that does not expand

� It contains 3 volume components:

� Brain tissue: (80%) or 2% of TBW

� Intravascualr blood: (10%)

� CSF: (10%)

� Intracranial Pressure (ICP) is the pressure exerted by

brain tissue, blood volume & cerebral spinal fluid

(CSF) within the skull.

� ICV = Vbrain + Vblood + Vcsf

� Normal ICP – 10 to 15 mmHg

� Cerebral Perfusion Pressure (CPP)

� CPP = MAP – ICP

� Normal CPP – 70 to 100 mmHg

� Normal CSF – 5 to 13 mmHg

Intracranial Pressure (ICP)

Increased Intracranial Pressure (IICP)

fluid pressure > 15 mm Hg

� IICP is a life threatening situation that results from an ⇑ in any or all 3 components within the skull� > volume of brain tissue, blood, and / or CSF

� Cerebral edema: > H2O content of tissue as a result of trauma, hemorrhage, tumor, abscess, or ischemia

Acute Coma

� Levels of consciousness diminish in stages:

• Confusion: can’t think rapidly and clearly التشويش

• Disorientation: begin to loose consciousness

• Time, place, self

• Lethargy: spontaneous speech and movement limited

• Obtundation: arousal (awakeness) is reduced

• Stupor: deep sleep or unresponsiveness

• Open eyes to vigorous or repeated stimuli

• Coma: respond to noxious stimuli only

• Light (purposeful), full coma (non-purposeful), deep coma (no response)

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Multiple Sclerosis

� is a chronic autoimmune disorder affecting movement, sensation, and bodily functions. It is caused by destruction of the myelin sheath covering nerve fibres in the central nervous system (brain and spinal cord).

� Causes:

1. Autoimmune destruction.

2. Heredity.

3. Viruses.

4. Environmental factors.

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� Diagnostic Test:

1. MRI.

2. Physical examination.

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� * Early:

1. Muscle weakness causing difficulty walking

2. loss of coordination or balance

3. numbness or other abnormal sensations

4. visual disturbances, including blurred or double

vision

Clinical Manifestations:

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* Late:

1. Fatigue .

2. Muscle spasticity and stiffness

3. Tremors.

4. Paralysis .

5. pain .

6. Vertigo.

7. Speech or swallowing difficulty .

8. Loss of bowel and bladder control.

9. Sexual dysfunction .

10. Changes in cognitive ability

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Treatment:

1. Immunosuppressant drugs . These drugs include

corticosteroids such as prednisone and

methylprednisolone, the hormone

adrenocorticotropic hormone (ACTH), and

azathioprine.

2. Physiotherapy.

3. Occupational therapy.

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Parkinson's Disease

� is a progressive movement disorder marked by tremors, rigidity, slow movements (bradykinesia), and postural instability. It occurs when, for unknown reasons, cells in one of the movement-control centers of the brain begin to die.

� Causes:

� 1. Degeneration of brain cells in the area known as the substantia nigra, one of the movement control centers of the brain.

� 2. Drugs given for psychosis, such as haloperidol (Haldol) or chlorpromazine (Thorazine), may cause parkinsonism.

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Clinical Manifestations1. Tremors

2. Slow movements (bradykinesia), freezing in place during movements (akinesia).

3. Muscle rigidity or stiffness, occurring with jerky movements

4. Postural instability or balance difficulty occurs.

5. Masked face.

6. Depression

7. Speech changes

8. Problems with sleep

9. Emotional changes10. Incontinence.

11. Constipation.

12. Handwriting changes,

13. (dementia)

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Treatment:

1. Maintain regular exercise (physical therapy, occupational therapy)

2. Provide good nutrition to maintain health.

3. Drugs that replace dopamine (levodopa)

4. If the patient is unresponsive or intolerant to pharmacotherapy, Electro

convulsive therapy is indicated.

Nursing Management

* Observe the patient's mood, cognition; organization and general well being

* Observe for features of depression,

*Suicidal precautions to be followed, if the patient exhibits any suicidal ideas

*Instruct the patients to speak slowly and clearly, and to pause and take a deep

breath at appropriate levels.

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Parkinson's Disease (cont’d)

*In dementia, environmental modification is followed

*Avoid frequent change in the environment to minimise confusion if the memory deficit is very severe, name boards and signboards by the side of the rooms and things will be very helpful.

*Sedatives are used if sleep related problems are noticed, when sleep hygiene is unsuccessfully.

* Patients should not be forced into situations in which they feel ashamed of their appearance.

*Encourage the patient to participate in moderate exercises, free-moving sports

like swimming. *Advise the patient to organize thoughts before speaking and encourage the

client to use facial expression and gestures if possible to assist with communication.

Seizure Disorders & Epilepsy

Seizure:

� paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function

Epilepsy:

� spontaneously recurring seizures caused by a chronic underlying condition

Two major classes:� Generalized

� Partial

Depending on type, phases may include:

� Prodromal phase- signs & activity preceeding seizure

� Aural phase- sensory warning

� Ictal phase- full seizure

� Postictal phase- recovery

Aura Phase

I’m

dizzy

!

I smell

bananas!I taste

metal!I’m

seeing

spots

I feel very

angry!

Seizure Disorders & EpilepsyDrug Therapy for Tonic-Clonic and Partial Seizures

� Carbamezepine/ Tegretol

� Divalproex/ Depakote

� Gabapentin/ Neurontin

� Lamotrigine/ Lamictal

� Levetiracetam/ Keppra

� Phenytoin/ Dilantin

� Tiagabine/ Gabitril

� Topiramate/ Topamax

� Valproic Acid/ Depakene

� Felbamate/ Felbatol *

� Phenobarbitol**

*Felbatol has been associated with aplastic anemia**Phenobarbitol is a barbituate

Seizure Disorders & Epilepsy:

Nursing Care

� Assure oxygen and suction equipment at bedside

� Safety precautions in active stage

� Support/ protect head

� Turn to side

� Lossen constricted clothing

� Ease to floor

� Time seizure, record details of seizure and post-ictal phase

Seizure Disorders & Epilepsy:

Nursing Care� Patient teaching:

� importance of good seizure control using medication as ordered

� Medical alert bracelet

� Avoid decreased sleep, increased fatigue

� Regular meals/ snacks

Seizure Disorders & Epilepsy:

Status Epilepticus

� Medical emergency

� Seizure repeated continuously

� Tonic clonic: hypoxia could develop if muscle

contraction is lengthened. Also: hypoglycemia,

acidosis, hypothermia, brain damage, death

� IV administration of antiepileptics

� Maintain airway patency

Intracranial surgery

� Craniotomy:

� Opening the skull surgically to gain access to

intracranial structures

Intracranial surgery

� Burr hole

� Circular opening made in the skull by a drill

Intracranial surgery

� Craniectomy

� An excision of a portion of the skull

Intracranial surgery

� Cranioplasty

� Repair of a cranial defect by means of a plastic or

metal plate

Intracranial surgery

� Transsphenoidal

� Through the nasal sinuses to gain access to the

pituitary gland

Types of Stroke

� Ischemic: embolic or thrombotic

� blocked blood flow to the brain

� Hemorrhagic: ICH, SAH, ruptured cerebral

aneurysm

� TIA: This is a stroke, although symptoms

resolve within an hour

Signs and Symptoms of Stroke

� Sudden numbness or weakness of the face, arm or leg,

especially on one side of the body

� Sudden confusion, trouble speaking or understanding

� Sudden trouble seeing in one or both eyes

� Sudden dizziness, loss of balance or coordination or

trouble walking

� Sudden severe headache with no known cause

Risk Factors

� High blood pressure

� Carotid artery disease

� Physical inactivity

� Excess alcohol intake

� Atrial fibrillation

� Diabetes

� Heart disease

� Smoking

� Family history

� Prior stroke/TIA

� High cholesterol

� Obesity

Treatment for Ischemic Stroke

� tPA=Thrombolytic agent

� Document time of symptom onset. (If awoke with symptoms, must go by time when last seen normal)

� Immediate head CT (check for blood)

� Evaluate for tPA administration (reviewexclusion/inclusion criteria)

Treatment Cont…

� If not a tPA candidate, ASA in ED. Rectal ASA if fails swallow eval. or if swallow eval. not complete.

� Keep NPO, until a formal swallow eval. is done.

� Admit as Inpatient and perform diagnostic testing: Carotid US, Echo, TEE, ECG monitoring for a-fib, MRI, fasting Lipid, Clotting disorder blood work (Antiphospholipid, Factor V, Antithrombin III)

� Rehabilitation

Hemorrhagic Stroke Treatment

� Do not give antithrombotics or

anticoagulants

� Monitor and treat blood

pressure greater than 150/105

(Table 6, 2005 Guidelines

update)

� NPO, until swallow eval is

completed

� Anticipate Neurosurgical

consult

� Possible administration of

blood products

Meningitis

� An inflammation of the meninges of the brain and spinal cord

� Bacterial

Causes:Meningococcus and pneumococcus,Haemophilus-influenza

Organisms enter brain by:

� Blood stream

� Respiratory tract

� Pentrating wonds of skull

It is secondary to another infections such as otitismedia, upper respiratory infection,pneumonia

� Viral (aseptic): less severe than bacterial

Clinical Presentations� High fever, tachycardia, chills, petechial rash

� headache, photophobia, stiff neck

� Nausea, vomiting

� papilledema (> ICP),confusion, altered LOC

� Restlessness and irritability

� Seizures

� Brudzinski’s: passive flexion of the neck produces pain & increased rigidity

� Kernig’s: Flex hip and knee and then straighten the knee…pain or resistance?

complication of Meningitis

Seizures

Sepsis

Cranial nerve dysfunctions

Cerebral infarction

Coma

Death

Collaborative care

� Bacterial menigitis is a medical emergency

� Treatment focus on rapid diagnosis and starting IV antibiotic

therapy immediately(7-21 days)

� Isolation

� Antipyretics

� Analgesics

� Anticonvulsants

� Osmotic diuretics

� IV fluids

Diagnosis

� lumbar puncture :collect samples of CSF

� Bacterial:� Cloudy csf

� Elevated protein level

� Increased WBC

� Decreased glucose level

� Elevated CSF pressure

� C&S OF CSF

� CBC

� Cultures from Blood, urine, throat, nose