care of the patient with neuro disorders
TRANSCRIPT
BGallatin 2007
Medical Surgical Nursing A
Care of the Patient
With a Neurological
Disorder
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Anatomy and Physiology
Central nervous system (CNS) Brain Spinal cord
Peripheral nervous system Somatic (voluntary) Autonomic
(involuntary)
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Anatomy and Physiology
Neurons Transmitter cells Carry messages to and
from brain and spinal cord
Glial cells Support and protect
neurons Produce cerebral spinal
fluid
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Anatomy and Physiology
CNS: brain Cerebrum – lobe functions Diencephalon – thalamus, hypothalamus Cerebellum – balance, coordination Brain stem – midbrain, pons, medulla oblongata
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Anatomy and Physiology
PNS: Somatic (voluntary) 31 pairs of spinal nerves 12 pair of cranial nerves
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Anatomy and Physiology
PNS: Autonomic (involuntary) Controls:
Smooth MusclesCardiac MusclesGlands
Check and balance system:Sympathetic nervous systemParasympathetic nervous system
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Neurological Assessment
History Headaches Loss of function Visual acuity Seizures Numbness
Pain Personality change Mood swing Fatigue
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Neuro Assessment
Mental Status Orientation Mood and behavior General knowledge Short term memory Long term memory
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Neuro Assessment
Level of consciousness
Glasgow Coma Scale Eye opening Verbal response Motor response
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Neuro Assessment
Language and Speech Aphasia
SensoryExpressiveGlobal
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Cranial Nerves
I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens
VII. Facial VIII. Acoustic IX. Glossopharyngeal X. Vagus XI. Spinal Accessory XII. Hypoglossal
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Neuro Assessment
Motor Function Paralysis Paresis
Flaccid Spastic
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Neuro Assessment
Sensory and Perceptual Status Pain Touch Temperature Proprioception Unilateral neglect Hemianopia
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Neuro Assessment
Blood and urine ABG Lumbar puncture Imaging EEG EMG Carotid Duplex
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Neurological Problems
Headache Vascular – migraine, cluster, hypertensive Tension – stress Traction-inflammatory – infection, occlusion
vessels
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Neurological Problems
Increased Intracranial Pressure (IIP)
Occurs slowly or rapidly
May lead to brain stem herniation and death
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Assessment of IIP
Subjective Diplopia Personality change Thought processes change Headache Nausea
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Assessment of IIP
Objective Decreasing LOC Hyperthermia Weakness Vomiting Seizures Papilledema
Posturing Wide pulse pressure Bradycardia Altered respirations Pupils fixed & dilated
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Assessment of IIP
Diagnostic tests: CT scan, MRI Close observation Craig’s screw
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Medical Management of IIP
Craniotomy Craniectomy Tumor removal Drainage of ventricles Drainage of hematoma Intubation
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Medical Management of IIP
Medications Osmotic diuretics - Mannitol Corticosteroids - Decadron Anticonvulsants - Dilantin
Internal monitoring
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Nursing Care of the Patient With IIP
Elevate HOB Neck in neutral
position Avoid flexion hips,
waist and neck Avoid isometric
activity or Valsalva
Restrict fluids Foley Suctioning O2 Hypothermia blanket
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Neurological Disorders-Seizures
Seizures Disorderly neuron discharges in brain Transitory Different types affect body differently Involuntary movement usually
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Seizures
Generalized: Tonic-clonic –
grand mal Absence - Petit mal Myoclonic Atonic or akinetic
Localized: (Focal) Partial (Jacksonian) Psychomotor
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Seizures
Causes: Hypoglycemia Infection Electrolyte imbalance Trauma IIP Toxins
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Seizure Medications
Dilantin (Phenytoin) Phenobarbital Mysoline Tridione Valium (Diazepam) Depakene
Clonopin Mesantoin Neurontin Lamictal Felbatol Cerebyx
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Seizure Medications
Nursing: Medications Continue meds Medic alert ID Avoid alcohol, avoid driving, get adequate rest If on Dilantin, instruct on oral hygiene
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Seizures: Nursing Care
Protect Lower to the floor; pad side rails; pillow under
head; don’t restrain No bite block or padded tongue blade Allow for post-ictal rest
Prevent aspiration (airway) Turn side; loosen clothing around neck
Document everything
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Degenerative Neuro Diseases
Multiple Sclerosis
Parkinson’s Disease
Alzheimer’s Disease
Myasthenia Gravis
Amyotrophic Lateral Sclerosis (ALS)
Huntington’s Disease (chorea)
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Multiple Sclerosis
Common degenerative neurological disease. Myelin sheath is destroyed. Symptoms vary. Relapsing/remitting. Usually ages 20-40.
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Multiple Sclerosis - Symptoms
Subjective: Shakiness, difficulty walking Fatigue, muscle weakness Numbness, tingling Tinnitus Visual problems Difficulty chewing and speaking Incontinent; impotent
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Multiple Sclerosis - Symptoms
Objective: Ataxia Changes in behavior & emotions Nystagmus Spasticity, tremors, dysphagia, facial palsy,
speech impaired, fatigue Incontinence Impaired judgment
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Multiple Sclerosis - Tests
CSF CT scan MRI
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Multiple Sclerosis-Treatment
Meds: Anti inflammatory
ACTH, Solu Medrol, Prednisone Immuno Modifiers
Avonex, Betaseron, Capoxone Muscle Relaxants
Valium
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Multiple Sclerosis-Nursing Interventions
Nutrition Skin Care Activity Control of environment Emotional support Patient teaching
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Parkinson’s Disease
Unknown cause Lack of dopamine. Parkinsonism: encephalitis, toxic chemicals,
meds, drugs
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Parkinson’s
Symptoms include: Muscular tremors and rigidity Emotional instability Judgment defects Heat intolerance Mask-like facial appearance Dysphagia and drooling
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Parkinson’s Testing
No specific test to diagnose Parkinson’s
Diagnosis based on symptoms
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Parkinson’s – Medical Treatment
Medications Sinemet, Symmetrol, Levodopa or Cogentin Less effective over time
Surgery Experimental
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Parkinson’s – Nursing Care
Prevent injury (fall or aspiration) Prevent urinary retention and constipation Patient teaching about medication Patient and family support
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Alzheimer’s
Unknown cause, but genetic link Very common; risk increases with age Brain changes:
plaques tangled neurons blood vessel degeneration chemical changes
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Alzheimer’s - Symptoms
1st– memory lapses, difficult word finding, decreased attention span
2nd – increased memory problems, disoriented to time, loses things, confabulates
3rd – total disorientation, apraxia, wanders 4th – severe impairment
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Alzheimer’s - Testing
No definitive test
Family history
Diagnosis: autopsy
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Alzheimer’s – Medical Management
Medication to treat symptoms Memory:Cognex, Aricept Agitation: Mellaril, Haldol
Supplements Folic Acid & Vitamin B12 Low fat diet NSAIDS
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Alzheimer’s – Nursing Care
2 key points for all care: Prevent overstimulation Provide structured, orderly environment
Other concerns Communication Family support and education
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Myasthenia Gravis
Autoimmune disorder Myoneural junction problem Symptoms:
ptosis, diplopia, weakness, dysarthria, dysphagia, difficulty
sitting up, respiratory distress
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Myasthenia Gravis - Treatment
Medication to improve impulse transmission (Mestinon) to suppress immune system (steroids, Cytoxan)
Plasmapheresis Respiratory support Safety
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Amyotrophic Lateral SclerosisALS – Lou Gehrig’s disease
Motor neurons in brain stem and spinal cord degenerate
Brain’s messages don’t reach the muscles Symptoms – weakness, dysarthria, dysphagia No loss of cognitive function No cure, death occurs in 2-6 years
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Huntington’s DiseaseChorea
Genetic Onset at age 35-45 Excessive involuntary movements Death in 10-20 years No cure
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Huntington’s Disease
Nursing interventions are palliative Give meds Provide for safety Provide adequate diet
Emotional support Genetic counseling
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Cerebrovascular Accident (CVA)
Ischemia of brain tissue Hemorrhage Thrombus Embolus
3rd leading cause of death in the US
All ages, but usually elderly
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CVA – Contributing Factors
Atherosclerosis Heart disease Kidney disease
Hypertension Obesity
High cholesterol Cigarette smoking Stress Sedentary Diabetes Oral contraceptives Cocaine
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Cerebral Thrombosis
Most common cause of CVA
Most often:Atheroclerosis
↓
Thrombus ↓
CVA
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Cerebral Embolism
2nd most common cause of CVA Most often:
Heart disease↓
Thrombus↓
Embolus↓
CVA
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Cerebral Hemorrhage
3rd most common cause of CVA Most often:
Hypertension↓
Ruptured cerebral blood vessel↓
CVA
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Transient Ischemic Attack
Cerebrovascular insufficiency
Causes – same as CVA
Warning sign of impending CVA
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CVA - Assessment
Motor changes Opposite side Balance, coordination, gait, proprioception Glasgow Coma Scale
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CVA Assessment
Sensory Changes Aphasia =can’t speak or write Agnosia =can’t recognize familiar objects/people Apraxia =can’t perform purposeful acts or use
objects properly Neglect Syndrome Visual problems, including hemianopsia
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CVA Assessment
Cognitive changes denial impaired memory, judgment can’t concentrate disoriented slow and cautious versus impulsive depressed, anxious versus euphoric angers quickly versus constantly smiling
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CVA - Testing
CT or MRI Cerebral angiogram CBC, PT, PTT, electrolytes
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CVA – Medical Management
Thrombolytic (“clot buster”) Anticoagulants Antiplatelet drugs Aneurysm repair Carotid endarterectomy
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CVA-Nursing Care
Assess LOC IV, NG, Foley, Vent. Nutrition Encourage perform ADLs Bladder and bowel training ROM Teaching and emotional support
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Trigeminal NeuralgiaTic Douloureux
Trigeminal nerve – degeneration, pressure Facial pain Medication, surgery Avoid triggers
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Bell’s Palsy
Facial nerve inflammation
Unilateral weakness of facial muscles
Steroids, Zovirax, warm moist cloth, massage, facial exercises
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Infection and Inflammation
Meningitis Encephalitis Brain abscessGuillain-Barré
Neurosyphilis Poliomyelitis Herpes zosterAIDS
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Guillain-Barré - Polyneuritis
Peripheral nerve disease Prior infection; autoimmune response
Weakness and paralysis, begins in extremities and works up
Respiratory failure may occur
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Meningitis
Acute infection of the meninges Viral or bacterial
Severe headache, irritable, fever, delirium, N/V, neck stiffness Kernig’s sign Brudzinski’s sign
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Meningitis-Medical Management
Diagnosed by LP Medications Respiratory isolation Cool, dark quiet room Maintain hydration Prevent injury
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Acquired Immunodeficiency Syndrome - AIDS
AIDS dementia complex Infection of CNS
Dementia
Treatment depends on infection Treat symptoms, maintain safety
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Spinal Cord Trauma
Complete cord injury – all voluntary movement below level of trauma is lost
Autonomic hyperreflexia stimulus sympathetic nervous system response