Neurological Disorders Kizia

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Neurologic

Disorders

Elvin Gene B. Colcol, RN, MN, MAN

UNCONSCIOUS

CLIENT

General Information

State of depressed cerebral

functioning with unresponsiveness tosensory and motor function.

Not oriented, does not followcommands, or needs persistent stimulito achieve a state of alertness.

Terminologies

Coma – clinical state of unconsciousness inwhich the patient is unaware of self or

the environment for prolonged periods

Akinetic mutism – state ofunresponsiveness to the environment inwhich the patient makes no movement orsound but sometimes opens the eyes

Persistent vegetative state – condition inwhich the patient is described as wakeful butdevoid of conscious content, withoutcognitive/affective mental function.

Brain death – irreversible loss of all

functions of the entire brain, including thebrain stem

Causes Neurologic – head injury, stroke

Toxicologic – drug overdose, alcoholintoxication

Metabolic – hepatic/kidney failure, diabetes

ketoacidosis

Assessment Findings

Unarousable No response to painful stimuli Altered respirations Decreased cranial nerve and reflex activity Pupillary changes Decreased GCS Initially – restlessness and anxiety

Laboratory Tests

Blood glucose

Serum electrolytes

Serum ammonia

Clotting time Serum ketones

BUN / serum creatinine

Serum osmolality

Arterial blood gas (ABG)

Serum drug and alcohol level

Complications

Respiratory failure

Pneumonia

Pressure ulcers

Aspiration

Venous stasis / DVT

Musculoskeletal deterioration

Disturbed GI functioning

Medical Management

Maintain a patent airway

Circulation – heart rate and blood pressure

Intravenous access

Nutritional support

Nursing Diagnoses

Ineffective airway clearance

Risk for injury

Deficient fluid volume

Impaired oral mucous membrane

Risk for impaired skin integrity

Nursing Interventions:

Airway, Breathing, Circulation, Disability Place the client in a semi-Fowler’s position Change position of the client every 2 hours

avoiding injury when turning Protect patient at all times (side rails,

restraints) Assess for edema Monitor for fluid and electrolyte imbalances Monitor intake and output and daily weight Maintain NPO status until consciousness returns Provide intravenous or enteral feedings as

prescribed

Continuation on interventions: Assess bowel sounds Maintain urinary output to prevent stasis, infection

and calculus formation Monitor the status of skin integrity Provide frequent mouth care Remove dentures and contact lenses Assess for cerebrospinal fluid leakage Assume that the unconscious client can hear

Initiate seizure precautions Use footboard or high-topped sneakers to prevent

footdrop

Increased ICP

Normal ICP is 10 – 20 mmHg

Brain tissue (1400g); blood (75mL); CSF (75mL)

Impede circulation to the brain, impede theabsorption of CSF, affect the functioning of nerve

cells, and lead to brainstem compression and death

Assessment: Altered LOC

Headache

Abnormal respirations

Increased BP with widening pulse pressure Slowing of pulse

Elevated temperature

Vomiting

Pupil changes

Changes in motor function

Complications:

Brain stem herniation

Diabetes Insipidus

Medical Management

Decrease cerebral edema

Lower volume of CSF

Decrease cerebral blood flow while maintaining

adequate perfusion

Administer osmotic diuretic andcortecosteroids

Restricting fluids Drain CSF

Control fever

Maintain BP and oxygenation Reduce cellular metabolic demand

Nursing Diagnoses Ineffective airway clearance

Impaired breathing pattern

Altered cerebral tissue perfusion

Deficient fluid volume

Risk for infection

Elevate the head of the bed 30 to 40 degrees asprescribed

Avoid the administration of morphine

Maintain mechanical ventilation Maintain body temperature Prevent shivering Decrease environmental stimuli

Monitor intake and output Monitor electrolyte and acid base balance Instruct client to avoid straining activities such as

coughing and sneezing Instruct the client to avoid valsalva’s manuever

Medications:

Anticonvulsants

Antipyretics and muscle relaxants

Blood pressure medication

Corticosteroids

Intravenous fluids

Hyperosmotic agents

Ventriculoperitoneal Shunt

Shunts cerebrospinal fluid from the ventricles

into the peritoneum

Monitor infection

Monitor signs on increasing ICP

Position the client supine

Late signs of increased ICP: Deteriorating LOC

Altered respiratory patterns

Projectile vomiting

Hemiplegia and abnormal posturing

Loss of brain stem reflexes

CEREBRAL

ANEURYSM

Cerebral Aneurysm

Dilation of the walls of a weakened

cerebral artery

Aneurysm can lead to rupture

Assessment findings:

Headache

Irritability

Diplopia Blurred vision

Tinnitus

Hemiparesis

Nuchal rigidity

Seizures

Maintain a patent airway

Administer oxygen as prescribed

Monitor vital signs and for hypertension ordysrhythmias

Avoid taking temperatures via the rectum

Initiate aneurysm precautions

Aneurysm Precautions:

Maintain bed rest on semi-Fowler’s orside lying position

Maintain a darkened room Provide a quiet environment Limit visitors Maintain fluid restrictions

Avoid overstimulants in diet Avoid valsalva’s maneuver Administer care gently

Limit invasive procedures

Maintain normothermia

Prevent hypertension

Provide sedation

Provide pain control

Administer prophylactic anticonvulsant

Provide DVT prophylaxis as prescribed

MENINGITIS

Meningitis: Inflammation of the meninges of the brain

and spinal cord

Caused by bacteria, viruses, or othermicroorganisms

May reach CNS through:

Blood, CSF, lymph Direct extension Oral or nasopharyngeal route

Assessment findings: Headache, photophobia, malaise,

irritability Chills, vomiting and fever

Possible seizure and altered LOC Lumbar puncture result Signs of meningeal irritation

Nuchal rigidity

Kernig’s sign Opisthotonos – body arched forward Brudzinki’s sign

Nursing Interventions: Administer large doses of antibiotics IV as

ordered (penicillin and cephalosporin) Enforce respiratory isolation for 24 hours after

initiation of antibiotic therapy Provide nursing care for increased ICP, seizures,

and hyperthermia Provide nursing care for delirious, or unconscious

client as needed

Provide bed rest Administer analgesic for headache

Maintain fluid and electrolyte balance

Prevent complications of immobility

Monitor vital signs and neuro checksfrequently

Provide client teaching and dischargeplanning concerning

Importance of good diet Rehabilitation program of residual deficits

ENCEPHALITIS

Encephalitis

Inflammation of the brain caused by

a virus

May be associated with other

diseases such as measles, mumps,chickenpox

Assessment findings:

Headache

Fever, chills, vomiting

Signs of meningeal irritation

Possible seizures

Alterations in LOC

Monitor vital signs and neuro checksfrequently

Provide nursing measures for increased ICP,seizures, hyperthermia if they occur

Provide nursing care for confused orunconscious client as needed

Provide client teaching and dischargeplanning

BRAIN TUMOR

Brain Tumor

Tumor within the cranial cavity; maybe benign or malignant

Types: Primary – originates in brain tissue

(glioma, meningioma)

Secondary – metastasizes from tumorelsewhere in the body

Medical Management:

Craniotomy – remove tumor when possible

Radiation therapy and chemotherapy – forinaccessible and metastatic tumors

Drug therapy to manage increased ICP

Assessment findings: Headache Vomiting Papilledema

Seizures Changes in mental status Neurologic deficits– hemiparesis, sensory

problem

Diagnostic tests Skull x-ray, CT scan, MRI EEG and brain biopsy

Nursing Interventions: Monitor vital signs and neuro checks Administer medications as ordered

(corticosteroids, anticonvulsant, analgesic)

Provide supportive care for neurologicdeficit Prepare client for surgery Provide care for effects of radiation

therapy or chemotherapy Provide psychologic support

BRAIN ABSCESS

Brain Abscess

Collection of free or encapsulated puswithin the brain tissue

Usually follows an infectious processelsewhere in the body (ear, sinuses,mastoid bone, trauma)

Assessment findings: Headache, malaise, anorexia

Vomiting

Signs of increased ICP

Hemiparesis

Seizures

Adminitster large doses of antibiotics asordered (penicillin and chloramphenicol)

Monitor vital signs and neuro checks

Provide symptomatic and supportive care Prepare client for surgery if indicated

Corticosteroids and antiseizure drugs

HEADACHE

Headache

Diffuse pain in different parts of the head

Types: Functional / primary

Tension - anxiety Migraine – recurrent throbbing headache Cluster – recurrent with remissions

Organic – secondary to intracranial or systemicdisease

Assessment findings: Tension – pain usually bilateral; occurs at the

back of the neck extending on top of head

Migraine – severe, throbbing pain, often in

temporal or supraorbital area, lasting severalhours to days; N and V, irritability, pallor andsweating

Cluster – intense, throbbing pain, usually affecting

only one side of face and head; abrupt onset,lasts 30-90 minutes, skin reddens, teary eyesdue to pain

Nursing Interventions: Carefully assess details regarding the headache Provide quiet, dark environment Provide nonpharmacologic pain relief measures Administer medication as ordered

Nonnarcotic analgesic Fiorinal Midrin Sumatriptan

Ergotamine tartrate (migraine)

CEREBROVASCULAR

ACCIDENT

Cerebrovascular Accident Destruction or brain cells caused by a

reduction in cerebral blood flow and oxygen

Interruption of cerebral blood flow for 5

minutes or more causes death of neurons inaffected area with irreversible loss offunction

Affects men more than women; incidenceincreases with age

Caused by thrombosis, embolism, hemorrhage

Risk factors:

Hypertension, diabetes mellitus,arteriosclerosis, atherosclerosis, cardiacdisease (valvular disease, atrial fibrillation,MI)

Lifestyle: obesity, smoking, inactivity,stress, use of oral contraceptives

M dif i f t

Modifying factors: Cerebral edema – develops around affected area

causing further impairment

Vasospasm – constriction of cerebral blood vessel

causing further decrease in blood flow

Collateral circulation – help to maintain cerebralblood flow when there is compromise of main

blood supply

St f d l t

Stages of development: Transient ischemic attack

Warning sign of impending stroke Brief period of neurologic deficit Less than 24 hours

Stroke in evolution – progressive symptoms overhours or days

Completed stroke – neurologic deficit remainsunchanged for a 2- to 3-day period

A t fi di

Assessment findings: Headache Generalized signs: vomiting, seizures, confusion,

disorientation, decreased LOC, nuchal rigidity,fever, hypertension, slow bounding pulse, cheyne-

stokes respirations Focal signs: hemiplegia, aphasia, homonymous

hemianopsia Diagnostic tests:

CT scan EEG Cerebral arteriography

N i I t ti

Maintain patent airway and adequateventilation

Monitor vital signs and neuro checks Provide complete bed rest Maintain fluid and electrolyte balance and

ensure adequate nutrition Maintain proper positioning and body alignment Promote optimum skin integrity

Provide a quiet, restful environment Establish a means of communicating with theclient

Rehabilitation care

M di ti

Medications: Hyperosmotic agents

Anticonvulsants

Thrombolytics

Anticoagulant

Antihypertensive

TRIGEMINALNEURALGIA

G l I f ti

General Information Disorder of cranial nerve V causing disabling and

recurring attacks of severe pain along the sensorydistribution of one or more branches of thetrigeminal nerve

A unilateral shooting and stabbing pain

Involuntary contraction of facial muscles causedtwitching of the mouth (tic douloureux)

Incidence increased in elderly women

Cause unknown

M di l M n m nt

Medical Management Anticonvulsant drugs: carbamazepine

(Tegretol), Gabapentin (Neurontin), Baclofen(Lioresal), and phenytoin (Dilantin)

Nerve block: injection of alcohol or phenolinto one or more branches of the trigeminalnerve; temporary effect, lasts 6-18 months

Surgery Peripheral: avulsion of peripheral branches of

trigeminal nerve Intracranial: microvascular decompression

Assessment Findings

Assessment Findings Sudden paroxysms of extremely severe shooting pain in one side of

the face

Attacks may be triggered by a cold breeze, foods/fluids with extremetemperature, toothbrushing, chewing, talking, or touching the face

During attack: twitching, grimacing, and frequent blinking/tearing of the eye

Poor eating and hygiene habits

Withdrawal from interactions with others

Diagnostic tests: X-rays of the skull, teeth, and sinuses may identifydental or sinus infection as an aggravating factor

Nursing Interventions

Assess characteristics of the pain including triggering factors,trigger points, and pain management techniques

Administer medications as ordered; monitor response

Maintain room at an even, moderate temperature, free fromdrafts

Provide small, frequent feedings of lukewarm, semiliquid, orsoft foods that are easily chewed

Provide the client with a soft washcloth and lukewarm waterand perform hygiene during periods when pain is decreased

Prepare the client for surgery of indicated

Provide client teaching and discharge planning concerning

Need to avoid outdoor activities during cold, windy, or rainyweather

Importance of good nutrition and hygiene

Use of medications, side effects, and signs of toxicity

Specific instructions following surgery for residual effects of anesthesia and loss of corneal reflex

BELL’S PALSY

General Information

General Information Disorder of cranial nerve VII resulting in the loss of

ability to move the muscles on one side of the face

Inflamed, edematous nerve becomes compressed to

the point of damage or nutrient vessel is occludedproducing ischemic necrosis

Cause unknown; may be viral or autoimmune

Complete recovery in 3-5 weeks in majority ofclients

Assessment Findings

Assessment Findings Loss of taste over anterior two-thirds of

tongue on affected side

Complete paralysis of one side of face

Loss of expression, displacement of mouthtoward unaffected side, and inability to closeeyelid (all on affected side)

Painful sensations in the face, behind theear, and in the eye

Nursing Interventions Assess facial nerve function regularly

Administer medications as ordered Corticosteroids (prednisone)

Mild analgesics as necessary

Provide soft diet with supplementary feedings as indicated

Instruct to chew on unaffected side, avoid hot fluids/foods, and performmouth care after each meal

Provide special eye care to protect the cornea. Dark glasses or eyeshield

Artificial tears to prevent drying of the cornea

Ointment and eye patch at night to keep eyelid closed

Provide support and reassurance

AMYOTROPHICLATERAL SCLEROSIS

General Information

General Information Progressive motor neuron disease, which usually

leads to death in 2-6 years.

Onset usually between ages 40 and 70; affectsmen more than women

Cause unknown; overexcitation of the nerve cellsby the neurotransmitter glutamate leads to cellinjury and neuronal degeneration

There is no cure or specific treatment; deathusually occurs as a result to respiratory infectionsecondary to respiratory insufficiency; RILUZOLE(RILUTEK) a glutamate antagonists

Assessment Findings

Assessment Findings Progressive weakness and atrophy of the muscles

of the arms, trunk, or legs

Dysarthria, dysphagia

Fasciculations (twitching)

Respiratory insufficiency

Diagnostic tests: EMG and muscle biopsy can ruleout other diseases; MRI (motor neuropathy)

Nursing Interventions Provide nursing measures for muscle weakness and dysphagia

Promote adequate ventilatory function

Encourage diversional activities; spend time with the client

Provide compassion and intensive support to client/significant

others

Provide or refer for physical therapy as indicated

Promote independence for as long as possible

GUILLAIN BARRESYNDROME

General Information

General Information Symmetrical, bilateral, peripheral polyneuritis

characterized by ascending paralysis

Can occur at any age; affects women and men equally

Cause unknown; may be an autoimmune process

Precipitating factors: antecedant viral infection,immunization

Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usuallyfrom 3-6 months; may have residual deficits

Medical Management

Medical Management Mechanical ventilation if respiratory problems present

Plasmapheresis to reduce circulating antibodies

Propanolol to prevent tachycardia

Atropine may be given to prevent episodes of bradycardiaduring endotracheal suctioning and physical therapy

Assessment Findings

Assessment Findings Mild sensory changes; in some clients severe misinterpretation of sensory stimuli resulting in extreme discomfort

Clumsiness: usually the first symptom

Progressive motor weakness in more than one limb (ascending andsymmetrical)

Ventilatory insufficiency if paralysis ascends to respiratory muscles

Absence of deep tendon reflexes

Autonomic dysfunction

Diagnostic tests: CSF studies: increased protein

EMG: slowed nerve conduction

Nu s g te ve t o s Maintain adequate ventilation

Check individual muscle group every 2 hours in acute phase to check for progression of muscle weakness

Assess cranial nerve function: gag reflex

Monitor vital signs and observe for signs of autonomic dysfunction such as acute periods of hypertensionfluctuating with hypotension, tachycardia, arrhythmias

Administer corticosteroids to suppress immune reaction as ordered

Administer antiarrhythmic agents as ordered

Promote comfort

Promote optimum nutrition

Provide psychologic support and encouragement

MULTIPLESCLEROSIS

General Information

Chronic, intermittently progressive disease of the CNS,characterized by scattered patches of demyelination within the brainand spinal cord

Incidence

Affects women more than men Usually occurs from 20-40 years of age

More frequent in cool or temperate climates

Cause unknown; may be a slow-growing virus or possibly of autoimmune origin (sensitized T cells)

Signs and symptoms are varied and multiple, reflecting the locationof demyelination within the CNS

Characterized by remissions and exacerbations

Assessment Findings

Visual disturbances: blurred vision, scotomas (blind spots), diplopia

Impaired sensation: touch, pain, temperature, or position sense;paresthesias such as numbness, tingling

Euphoria or mood swings

Impaired motor function: weakness, paralysis, spasticity

Impaired cerebellar function: scanning speech, ataxic gait, nystagmus,dysarthria, intention tremor

Bladder: retention or incontinence

Constipation

Sexual impotence in the male

Medical Management

MRI – primary diagnostic test for visualizingplaques, documenting disease activity and evaluatingthe effect of treatment

Medications (ABC and R drugs)

Interferon beta-1a (Avonex)

Interferon beta-1b (Betaseron)

Glatiramer acetate (Copaxone)

Corticosteroids

Assess the client for specific deficits related tolocation of demyelinization

Promote optimum mobility

Administer medications as ordered

Encourage independence in self-care activities

Institute bowel program

g Maintain urinary elimination

Prevent injury related to sensory problems

Prepare client for plasma exchange if indicated

Provide psychological support to client and SO

Provide client teaching and discharge planning

MYASTHENIAGRAVIS

General Information

A neuromuscular disorder in which there is a disturbance in thetransmission of impulses from the nerve to muscle cells at theneuromuscular junction, causing extreme muscle weakness

Incidence Highest between ages 15 and 35 for women, over 40 for men

Affects women more than men

Cause: thought to be autoimmune disorder whereby antibodiesdestroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction

Voluntary muscles are affected, especially those muscles innervatedby the cranial nerves

Assessment Findings

Diplopia, dysphagia

Extreme muscle weakness, increased with activity andreduced with rest

Ptosis, masklike facial expression

Weak voice, hoarseness

Diagnostic tests: Tensilon test – IV injection of Tensilon provides spontaneous relief of

symptoms (lasts 5-10 minutes)

EMG – amplitude of evoked potentials decreases rapidly

Presence of antiacetylcholine receptor antibodies in the serum

This is also called the Simpson test in which

fatigue is observed on sustained lid and eye

elevation.

Animated picture of a patient with right Cogan'stwitch sign on rapid up gaze. Note the

overshooting of the lid before settling down to the

original ptotic level.

Medical Management

Drug therapy Anticholinesterase drugs: neostigmine, pyridostigmine (Mestinon)

Block the action of cholinesterase and increase levels of acetylcholine at the neuromuscular junction

Side effects: excessive salivation and sweating, abdominal cramps,nausea and vomiting, diarrhea, fasciculations (muscle twitching)

Corticosteroids: prednisone Used if other drugs are not effective Suppress autoimmune response

Plasma Exchange Removes circulating acetylcholine receptor antibodies

Use in clients who do not respond to other types of therapy

Surgery (thymectomy) – see new neuro pics Surgical removal of the thymus gland (involved in the production

of acetylcholine receptor antibodies)

May cause remission in some clients especially if performed earlyin the disease

Nursing Management

Administer anticholinesterase drugs as ordered

Promote optimal nutrition

Monitor respiratory status frequently: rate, depth, vital capacity,

ability to deep breathe and cough

Assess muscle strength frequently; plan activity to take advantage of energy peaks and provide frequent rest periods

Observe for signs of myasthenic or cholinergic crisis

Provide nursing care for the client with a thymectomy

Provide client teaching and discharge planning

ALZHEIMER’SDISEASE

General Information

In dementia, the elderly client is alert with a

progressive decline in memory and cognition

accompanied by personality and behavioral

changes

Alzheimer’s disease accounts for 60-75% of

all dementias and is the number one reasonfor institutionalization of the elderly

Medical Management

Rule out other conditions that might be causingsymptoms. A definitive diagnosis of Alzheimer’sdisease can only be made upon autopsy

Medications for treatment include tacrine (Cognex),donepezil (Aricept), rivastigmine (Exelon), orgalantamine (Reminyl)

Treatment goals are to minimize behavioralsymptoms and maximize quality of life

Assessment Findings

Early in the diseaseprocess

Depressed or anxious

Increased risk of suicide

Early, mild impairment

Last 2-4 years

Short-term memory loss

Social withdrawal

Decreased interest in

usual activities

Mood swings

Irritability Insight is diminished

Assessment Findings

Middle, moderateimpairment

Last several years

Memory and math

calculations faulty

Disoriented to time and

Can no longer drive

Needs assistance with

complex ADLs

Personality changes

Incontinence begins

Late, severe impairment Assistance with all ADLs

Nonverbal or

communication is

incoherent

Becomes nonambulatory

Requires total support in

all activities

Incontinent in bowel and

bladder

Indifference in food Agitation and aggression

Provide a safe environment

Provide structured environment and simple routines

Enlist caregiver’s assistance in assessing routine andestablishing plan of care

Use touch and a calm, relaxed manner in approaching theclient

Facilitate effective communication

Encourage orientation with use of calendars and clocks

Having family bring items that stimulate memory

Encourage mobility and provide opportunities for exercise

Avoid isolating the client

Provide nutritious, high-fiber foods and adequate fluids tomaintain weight and hydration

Promote bowel and bladder continence by toileting at regularintervals

Provide a simple bedtime routine that facilitates sleep, andencourage daytime activities to avoid excess napping

PARKINSON’S

DISEASE

General Information

A progressive disorder with degeneration of thenerve cells in the basal ganglia resulting ingeneralized decline in muscular function; disorder of the extrapyramidal system

Usually occurs in the older population

Cause unknown, predominantly idiopathic, but

sometimes disorder is postencephalic, toxic,arteriosclerotic, traumatic, or drug induced(reserpine, methyldopa, haloperidol, phenothiazines)

Pathophysiology

Disorder causes degeneration of thedopamine-producing neurons in the substantianigra in the midbrain

Dopamine influences purposeful movement

Depletion of dopamine results in degenerationof the basal ganglia

Assessment Findings

Tremors: at the upper limb, “pill-rolling,” resting tremor;most common initial symptom

Rigidity: cogwheel type

Bradykinesia: slowness of movement

Fatigue

Stooped posture; shuffling, propulsive gait

Difficulty rising from sitting position

Assessment Findings

Masklike face with decreased blinking of eyes

Quiet, monotone speech

Emotional lability, depression

Increased salivation, drooling

Cramped, small handwriting

Autonomic symptoms: excessive sweating, seborrhea,lacrimation, constipation; decreased sexual capacity

Administer medications as ordered

Provide a safe environment

Provide measures to increase mobility

Encourage independence in self-care activities

Improve communication abilities

Refer for speech therapy when indicated

Maintain adequate nutrition

Avoid constipation and maintain adequate bowel elimination

Provide psychological support to client and SO

Neurological Disorders Kizia

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