chapter 14 care of the patient with a neurologic disorder mosby items and derived items © 2011,...

Chapter 14Chapter 14

Care of the Patient with a Neurologic Disorder

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.


Woo Family Neurological Issues Woo Family Neurological Issues

Rosa

• Meningitis at 6 months

• Cerebral Palsy diagnosis at 11 months

• Seizure history

Mingzhu

• TIA

• CVA with IICP Broca’s area

• Motor aphasia Hemiparalysis Impaired swallow


Continued Continued

Beatrisa & Pierre

• Alzheimer’s disease

Therese

• Parkinson’s disease

AndresNeuropathy


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Structural divisions Central nervous system (CNS)

• Brain and spinal cord Peripheral nervous system

• Somatic nervous system Sends messages from the CNS to the skeletal muscles;

voluntary

• Autonomic nervous system Sends messages from the CNS to the smooth muscle,

cardiac muscle, and certain glands; involuntary



• Cells of the nervous system Neuron Neuromuscular

junction Neurotransmitters

• Acetylcholine; norepinephrine; dopamine; serotonin

Neuron coverings



• Central nervous system Brain

• Cerebrum

• Diencephalon

• Cerebellum

• Brain stem Midbrain; pons; medulla oblongata; coverings of the brain

and spinal cord; ventricles

• Spinal cord


Figure 14-2Figure 14-2

Sagittal section of the brain (note position of midbrain).

(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)



• Peripheral nervous system Spinal nerves Cranial nerves Autonomic nervous

system• Sympathetic nervous

system• Parasympathetic

nervous system



• Effects of normal aging on the nervous system Loss of brain weight Loss of neurons Reduction in cerebral blood flow Decrease in brain metabolism and oxygen utilization Decreased blood supply to spinal cord causes

decreased reflexes



• Prevention of neurological problems Avoid drug and alcohol use Safe use of motor vehicles Safe swimming practices Safe handling and storage of firearms Use of hardhats in dangerous construction areas Use of protective padding as needed for sports


Assessment of the Neurological SystemAssessment of the Neurological System

• History

• Mental status

• Level of consciousness Glasgow coma scale

• Language and speech

• Cranial nerve function

• Motor function

• Sensory and perceptual status


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Blood and urine Culture Drug screens Arterial blood gases

• Cerebrospinal fluid

• Computed tomography (CT)

• Brain scan

• MRI scan

• PET scan

• Lumbar puncture


Laboratory and Diagnostic ExaminationsLaboratory and Diagnostic Examinations

• Electroencephalogram

• Myelogram

• Angiogram

• Carotid duplex

• Digital subtraction angiography

• Electromyogram

• Echoencephalogram


Common Disorders of the Neurological SystemCommon Disorders of the Neurological System

• Headaches Etiology/pathophysiology

• Skull and brain tissues are not able to feel sensory pain

• Vascular headaches Migraine Cluster Hypertensive

• Tension headaches

• Traction-inflammation headaches



• Headaches (continued) Clinical manifestations/assessment

• Head pain

• Migraine headaches Prodromal (early sign/symptom)

o Visual field defects, unusual smells or sounds, disorientation, paresthesias

During headacheo Nausea, vomiting, light sensitivity, chilliness, fatigue,

irritability, diaphoresis, edema



• Headaches (continued) Medical management/nursing interventions

• Pharmacological management Migraine headaches

o Aspirin, acetaminophen, ibuprofeno Ergotamine tartrateo Codeine; Inderal

• Dietary recommendations Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented

or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork

• Psychotherapy

• What would Svetlana use for her migraines?

Antimigraine Medications Ergotamine Derivatives

Migranal• dihydroergotamine

Ergomar• ergotamine

Cafergot • caffeine & ergotamine

Serotonin Receptor Agonists (-triptans)

Axert almotriptan

Maxalt rizatriptan

Imitrex * sumatriptan

Zomig zolmitriptan

Relpax elatriptan



• Headaches (continued) Medical management/nursing interventions

• Cluster headaches Narcotic analgesics

• Tension headaches Non-narcotic analgesics

• Traction-inflammatory headaches Treat cause

• Comfort measures Cold packs to forehead or base of skull Pressure to temporal arteries Dark room; limit auditory stimulation



• Neuropathic pain Etiology and pathophysiology

• May arise from several occurrences

• The pain transmission is not fully understood Clinical manifestations

• Ranges from mild to excruciating

• Changes in ability to carry out ADLs Medical management/nursing implications

• Pharmacological management Anticonvulsants; nonopioid analgesics; antidepressants What would Andres take for his neuropathy?

• Comfort measures



• Increased intracranial pressure Etiology/pathophysiology

• Increase in any content of the cranium

• Space-occupying lesions, cerebrospinal problems, cerebral edema

• Is this an acute or a chronic problem? Clinical manifestations/assessment

• Diplopia

• Headache

• Decreased level of consciousness

• Pupillary signs



• Increased intracranial pressure (continued) Clinical manifestations/assessment (continued)

• Widening pulse pressure

• Bradycardia

• Respiratory problems

• High, uncontrolled temperatures

• Positive Babinski’s reflex

• Seizures

• Posturing

• Vomiting

• Singultus



• Increased intracranial pressure (continued) Medical management/nursing interventions

• Treat cause if possible

• Pharmacological management Corticosteroids Antacids; histamine-receptor blockers Anticonvulsants

• Mechanical decompression Craniotomy Craniectomy

• Internal monitoring devices



• Disturbances in muscle tone and motor function Etiology/pathophysiology

• Damage to the nervous system causes serious problems in mobility

• What are Mingzhu’s symptoms during the acute phase? Clinical manifestations/assessment

• Flaccid or hyperreflexic muscle tone

• Clumsiness or incoordination

• Abnormal gait



• Disturbances in muscle tone and motor function (continued) Consults: speech therapy, physical therapy & OT Medical management/nursing interventions

• Muscle relaxants

• Protect from falls

• Assess skin integrity

• Positioning

• Sit up and tuck chin when eating (90 degree)

• Encourage patient to assist with ADLs

• Emotional support


Skeletal muscle relaxantsSkeletal muscle relaxants

• Lioresal (baclofen)

• Flexeril (cyclobenzaprine)


Other Disorders of the Neurological SystemOther Disorders of the Neurological System

• Epilepsy or seizures Etiology/pathophysiology

• Transitory disturbance in consciousness or in motor, sensory, or autonomic function due to sudden, excessive, and disorderly discharges in the neurons of the brain; results in sudden, violent, involuntary contraction of a group of muscles

• Types: grand mal; petit mal; psychomotor; Jacksonian-focal; myoclonic; akinetic

• Status epilepticus

• Which type of seizure does Rosa have? What medications might she take?



• Epilepsy or seizures (continued) Clinical manifestations/assessment

• Depends on type of seizure

• Aura

• Postictal period Medical management/nursing interventions

• During seizure: Protect from aspiration and injury

• Anticonvulsant medications

• Surgery Removal of brain tissue where seizure occurs



• Epilepsy or seizures (continued) Medical management/nursing interventions

(continued)• Adequate rest

• Good nutrition

• Avoid alcohol

• Avoid driving, operating machinery, and swimming until seizures are controlled

• Good oral hygiene

• Medic Alert tag

Anticonvulsants or Antiepileptic Drugs

Seizures: sudden muscle contractions that happen without conscious control

Etiology: disease or disorders; head injury; idiopathic

Four major drug classes Drug Table 16-3

29Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Barbiturates

Action Long duration of action and sedative effect on

the brain; action occurs in the brainstemUses Status epilepticus; to prevent and control

grand mal seizures May treat seizures caused by tetanus, fever,

or drugs


Benzodiazepines

Action CNS depressants; suppress electrical

discharge in seizures

Uses Treat minor motor seizures; Lennox-Gastaut

syndrome (petit mal)


Benzodiazepines

End in –lam or –pam Anticonvulsant as well as sedative Valium

diazepam Klonopin

clonazepam Ativan

lorazepam

Hydantoins

Action Work primarily on the motor cortex, where

they stop the spread of seizure activity by increasing or decreasing Na+ ion movement across the motor cortex during the generation of nerve impulses

Uses Grand mal and psychomotor seizures, status

epilepticus, migraines, and trigeminal neuralgia


Hydantoins

Cause gingival hyperplasia Cannot be given NG with feeding. MUST hold

feeding for 2 hours before and after med. Cerebyx (name alert! Not Celebrex)

fosphenytoin Dilantin

phenytoin

Succinimides

Action and Uses Elevation of the seizure threshold in the

cortex and basal ganglia and reduced synaptic response to low-frequency repetitive stimulation; controls petit mal seizures

Adverse Reactions Drug Interactions Other antiseizure agents and bone marrow–

depressing drugs


Succinimides

Action and Uses Elevation of the seizure threshold in the

cortex and basal ganglia and reduced synaptic response to low-frequency repetitive stimulation; controls petit mal seizures

Drug Interactions Other antiseizure agents and bone marrow–

depressing drugs RX: Zarontin (ethosuximide)


Succinimides (cont.)

Nursing Implications and Patient Teaching Assessment Diagnosis Planning Implementation Evaluation Patient Teaching


Other Common Anticonvusants

Diamox acetazolamide

Tegretol carbamazepine

Neurontin gabapentin

Lamictal lamotrigine

Keppra levetiracetam

Mysoline primidone

Topamax topiramate

Depakene / Depakote valproic acid

Trileptal oxcarbazepine

Sedative-Hypnotic Medications

Action and Uses Sedative agent: relaxes the patient and

allows him or her to sleep Hypnotic agent produces sleep in the patient Used to relax patients and induce sleep

before medical testing and surgical procedures; used to treat insomnia caused by mental and physical stress

Drug Tables 16-13, 16-14, 16-15


Sedative-Hypnotic Medications (cont.)

Adverse Reactions Drug Interactions Nursing Implications and Patient Teaching



Degenerative DiseasesDegenerative Diseases

• Multiple sclerosis Etiology -

pathophysiology• Degenerative

neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum



• Multiple sclerosis (continued) Clinical manifestations/assessment

• Visual problems

• Urinary incontinence

• Fatigue

• Weakness

• Incoordination

• Sexual problems

• Swallowing difficulties



• Multiple sclerosis (continued) Medical management/nursing interventions

• No specific treatment

• Pharmacological management Adrenocorticotropic hormone (ACTH) Steroids Valium Betaseron (interferon beta-1b) Avonex (interferon beta-1a) Pro-banthine; urecholine Bactrim, Septra, and Macrodantin



• Multiple sclerosis (continued) Medical management/nursing interventions

• Nutrition

• Skin care

• Activity

• Environmental controls

• Patient teaching



• Parkinson’s disease Etiology/pathophysiology

• Deficiency of dopamine Clinical manifestations/assessment

• Muscular tremors; bradykinesia

• Rigidity; propulsive gait

• Emotional instability

• Heat intolerance

• Decreased blinking

• “Pill-rolling” motions of fingers



Nigrostriatal disorders produce parkinsonism.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2007]. Medical-surgical nursing: assessment and management of clinical problems. [7th ed.]. St. Louis: Mosby.)



• Parkinson’s disease (continued) Medical management/nursing interventions

• Pharmacological management Levodopa Sinemet Artane Cogentin Symmetrol

• Surgery – deep brain stimulator

• Activity

• Nutrition

• Which interventions would Therese choose?

Antiparkinsonian Agents

Actions Change the neurotransmitters produced in the

brain: excessive acetylcholine, deficient dopamine

Block the uptake of acetylcholine and elevate the functional levels of dopamine in the motor regulatory centers

Uses Control of the symptoms of Parkinson disease


Antiparkinsonian Agents (cont.)

Adverse Reactions Dysrhythmias, muscle twitching, GI

symptoms, etc. Anticholinergic agents

Drug Interactions Many; read product information closely



Nursing Implications and Patient Teaching Assessment Diagnosis Planning Implementation Evaluation Patient Teaching

Drug Table 16-5



Adverse Reactions Dysrhythmias, muscle twitching, GI

symptoms, etc. Anticholinergic agents

Drug Interactions Many; read product information closely




• Alzheimer’s disease Etiology/pathophysiology

• Impaired intellectual functioning

• Chronic, progressive degeneration of the cells of the brain

• Brain changes include plaques in the cortex, neurofibrillary tangles, and the loss of connections between cells and cell death

• How has Alzheimer’s disease affected Pierre and Beatrisa?



• Alzheimer’s disease (continued) Clinical manifestations/assessment

• Early stage Mild memory lapses; decreased attention span

• Second stage Obvious memory lapses

• Third stage Total disorientation to person, place, and time Apraxia; wandering

• Terminal stage Severe mental and physical deterioration



• Alzheimer’s disease (continued) Medical management/nursing interventions

• Pharmacological management Agitation: Lorazepam; Haldol Dementia: Cognex; Aricept

• Nutrition Finger foods; frequent feedings; encourage fluids

• Safety Remove burner controls at night Double-lock all doors and windows Constant supervision



• Myasthenia gravis Etiology/pathophysiology

• Neuromuscular disorder; nerve impulses fail to pass at the myoneural junction; causes muscular weakness

Clinical manifestations/assessment• Ptosis; diplopia

• Skeletal weakness; ataxia

• Dysarthria; dysphagia

• Bowel and bladder incontinence



• Myasthenia gravis (continued) Medical management/nursing interventions

• Pharmacological management Anticholinesterase drugs

o Prostigmino Mestinon

Corticosteroids

• May require mechanical ventilation

• Nutrition



• Amyotrophic lateral sclerosis (ALS) Etiology/pathophysiology

• Motor neurons in the brain stem and spinal cord gradually degenerate

• Electrical and chemical messages originating in the brain do not reach the muscles to activate them

• Lou Gehrig’s disease



• Amyotrophic lateral sclerosis (ALS) (continued) Clinical manifestations/assessment

• Weakness of the upper extremities

• Dysarthria; dysphagia

• Muscle wasting

• Compromised respiratory function Medical management/nursing interventions

• No cure

• Rilutec (Riluzole)

• Multidisciplinary ALS teams; emotional support

• Nutrition



• Huntington’s disease Etiology/pathophysiology

• Overactivity of the dopamine pathways

• Genetically transmitted - dominant Clinical manifestations/assessment

• Abnormal and excessive involuntary movements (chorea)

• Ataxia to immobility

• Deterioration in mental functions



• Huntington’s disease (continued) Medical management/nursing interventions

• No cure; palliative treatment

• Pharmacological management Antipsychotics Antidepressants Antichoreas

• Safe environment

• Emotional support

• High-calorie diet

Psychotherapeutic Agents

Antianxiety Medications Antidepressants Antipsychotic Drugs Antimanic Drugs Sedative-Hypnotic Medications


Antianxiety Agents (cont.)

Action Produce a calming effect

Uses Relieve anxiety, tension, and fear

May be used to manage alcohol withdrawal symptoms; used preoperatively; used to relieve muscle spasm

Problematic when it interferes with a person’s ability to perform activities of daily living


Antianxiety Agents (cont.)

Nursing Implications and Patient Teaching Assessment Diagnosis Planning Implementation Evaluation Patient and Family Teaching

Dosing; appointments and follow-up; adverse reactions; safety with storage; drug and alcohol interactions

Habit-forming: should be used for the shortest time possible



Vascular ProblemsVascular Problems

• Stroke (cerebrovascular accident) Now that Mingzhu’s acute phase is over, let’s see how

the CVA will affect her: Etiology/pathophysiology

• Abnormal condition of the blood vessels of the brain: thrombosis; embolism; hemorrhage

• Results in ischemia of the brain tissue Clinical manifestations/assessment

• Headache

• Sensory deficit

• Hemiparesis; hemiplegia

• Dysphasia or aphasia



Three types of stroke.



Vascular ProblemsVascular Problems

• Stroke (cerebrovascular accident) (continued) Medical management/nursing interventions

• Thrombosis or embolism Thrombolytics Heparin and Coumadin

• Decadron

• Neurological checks

• Nutritional interventions

• Physical, occupational, and/or speech therapy


Cranial and Peripheral Nerve DisordersCranial and Peripheral Nerve Disorders

• Trigeminal neuralgia Etiology/pathophysiology

• Degeneration of or pressure on the trigeminal nerve; tic douloureux

Clinical manifestations/assessment• Excruciating, burning facial pain

Medical management/nursing interventions• Tegretol

• Surgical resection of the trigeminal nerve

• Avoid stimulation of face on affected side

• Nutrition



• Bell’s palsy (peripheral facial paralysis) Etiology/pathophysiology

• Inflammatory process involving the facial nerve Clinical manifestations/assessment

• Facial numbness or stiffness

• Drawing sensation of the face

• Unilateral weakness of facial muscles

• Reduction of saliva

• Pain behind the ear

• Ringing in ear or other hearing loss



• Bell’s palsy (peripheral facial paralysis) (continued) Medical management/nursing interventions

• Pharmacological management Corticosteroids Antiviral medications

• Electrical stimulation

• Moist heat

• Massage of the affected area

• Facial exercises

• Nutrition



• Guillain-Barré syndrome Etiology/pathophysiology

• Inflammation and demyelination of the peripheral nervous system

• Possibly viral or autoimmune reaction



• Guillain-Barré syndrome (continued) Clinical manifestations/assessment

• Symptoms are progressive

• Paralysis usually starts in the lower extremities and moves upward; may stop at any point

• Respiratory failure if intercostal muscles are affected

• May have difficulty swallowing, breathing, and speaking



• Guillain-Barré syndrome (continued) Medical management/nursing interventions

• Adrenocortical steroids

• Apheresis

• Mechanical ventilation

• Gastrostomy tube

• Meticulous skin care

• Range-of-motion exercises



• Meningitis How did Rosa contract meningitis? Etiology/pathophysiology

• Acute infection of the meninges

• Bacterial or aseptic

• Increased incidence in winter and fall months



• Meningitis (continued) Clinical manifestations/assessment

• Headache; stiff neck

• Irritability; restlessness

• Malaise

• Nausea and vomiting

• Delirium

• Elevated temperature, pulse, and respirations

• Kernig’s and Brudzinski’s signs



• Meningitis (continued) Medical management/nursing interventions

• Pharmacological management Antibiotics

o Massive doseso Multiple typeso IV or intrathecal

Corticosteroids Anticonvulsants Antipyretics

• Dark, quiet room

• Nutrition



• Encephalitis Etiology and pathophysiology

• Acute inflammation of the brain caused by a virus Clinical manifestations

• Headache

• Fever

• Seizures

• Change in LOC Medical management and nursing interventions

• Primarily supportive

• Nutrition



• West Nile virus Etiology and pathophysiology

• Principal route of infection through the bite of an infected mosquito

Clinical manifestations• Fever

• Headache

• Back pain

• Myalgia Prevention Nutrition



• Brain abscess Etiology and pathophysiology

• Accumulation of pus within the brain tissue Clinical manifestations

• Headache

• Fever

• Drowsiness, changes in LOC

• Seizures Medical management/nursing interventions

• Antimicrobial therapy

• Supportive care and nutrition



• Acquired immunodeficiency syndrome Etiology and pathophysiology

• Symptoms may develop from the infection with HIV or as a result of an associated infection

Clinical manifestations• AIDS dementia complex (ADC)

• Memory loss

• Global cognitive dysfunction Medical management/nursing interventions

• Antiviral, antifungal, antibacterial agents

• Anticonvulsants

• Safety and nutrition



• Brain tumors Etiology/pathophysiology

• Benign or malignant

• Primary or metastatic

• May affect any area of the brain



• Brain tumors (continued) Clinical manifestations/assessment

• Headache

• Hearing loss

• Motor weakness

• Ataxia

• Decreased alertness and consciousness

• Abnormal pupil response and/or unequal size

• Seizures

• Speech abnormalities



• Brain tumors (continued) Medical management/nursing interventions

• Surgical removal of tumor Craniotomy Intracranial endoscopy

• Radiation

• Chemotherapy

• Combination of above

• Nutrition


TraumaTrauma

• Craniocerebral trauma Etiology/pathophysiology

• Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma

• Direct trauma: Head is directly injured

• Indirect trauma: Tension strains and shearing forces

• Open head injuries

• Closed head injuries

• Hematomas


TraumaTrauma

• Craniocerebral trauma Clinical manifestations/assessment

• Headache

• Nausea

• Vomiting

• Abnormal sensations

• Loss of consciousness

• Bleeding from ears or nose

• Abnormal pupil size and/or reaction

• Battle’s sign


TraumaTrauma

• Craniocerebral trauma (continued) Medical management/nursing interventions

• Maintain airway

• Oxygen

• Mannitol and dexamethasone

• Analgesics

• Anticonvulsants

• Nutrition


TraumaTrauma

• Spinal cord trauma

• How did Stefan come to have spinal cord trauma? Etiology/pathophysiology

• Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds

• Fracture of vertebra

• Complete cord injury

• Incomplete cord injury



Mechanisms of spinal injury.



TraumaTrauma

• Spinal cord trauma (continued) Clinical manifestations/assessment

• Loss of muscle function depends on level of injury

• Spinal shock

• Autonomic dysreflexia

• Sexual dysfunction


TraumaTrauma

• Spinal cord trauma (continued) Medical management/nursing interventions

• Realignment of bony column for fractures or dislocations: Immobilization; skeletal traction

Surgery for spinal decompression

• Methylprednisolone

• Mobility: Slowly increase sitting up

• Urinary function: Foley catheter; bladder training Intermittent catheterization

• Nutrition

• Bowel program


Nursing ProcessNursing Process

• Nursing diagnoses Autonomic dysreflexia Communication, impaired Coping, compromised family Disuse syndrome, risk for Grieving Infection, risk for Knowledge, deficient Memory, impaired


Nursing ProcessNursing Process

• Nursing diagnoses (continued) Mobility, impaired physical Nutrition, imbalanced: less than body requirements Pain, acute, chronic Self-care deficit Swallowing, impaired Thought process, disturbed Tissue perfusion (cerebral), ineffective

Central Nervous System


Antiemetic-Antivertigo Agents Action Factors that may provoke nausea and vomiting: some

drugs, metabolic disorders, radiation, motion, gastric irritation, vestibular neuritis, or increases in central trigger zone dopamine levels or vomiting center acetylcholine levels

Agents act to redirect stimulation by stopping or reducing stimulation of the vomiting center

Uses Prevent and treat motion sickness or the nausea and

vomiting that occur with surgery, anesthesia, and cancer treatment

Dramamine Benadryl Antivert


Antiemetic-Antivertigo Agents (cont.)

Adverse Reactions Drowsiness and drug tolerance with long-term

therapy Anticholinergic effects

Drug Interactions CNS depressants


Attention Deficit Hyperactivity Disorder (ADHD)

Ritalin Concerta Straterra Vyvanse Adderall Characteristics

CNS stimulants• Monitoring• Adverse effects• Patient counseling


chapter 14 care of the patient with a neurologic disorder mosby items and derived items © 2011,...

Documents

derived items

sports slide

affiliate of elsevier

overview of anatomy

brain metabolism

physiology cells

cerebral blood flow

blood supply