nurs 1130 adult nursing iii unit i chapters 27, 28, 29 teresa champion, rn, msn 9/2012
TRANSCRIPT
NURS 1130Adult Nursing III
Unit IChapters 27, 28, 29
Teresa Champion, RN, MSN 9/2012
Chapter 27
Neurologic Disorders
Anatomy and Physiology of the Nervous System
Neuron (Nerve Cell)
Functional unit of the nervous system that conducts electrical impulses from one area of the brain to another
Sensory neurons Transmit information from distal parts of the
body or environment toward the central nervous system
Motor neurons Carry motor information from the CNS to the
periphery
Axons and Dendrites
Branch off the main cell body Axons conduct impulses away from
the cell body Dendrites convey impulses toward
the cell body
Myelin Material that covers many axons and
dendrites Enhances conduction along nerve
fibers Gives the axons a white appearance;
cell bodies without myelin are gray
Figure 27-1
Central Nervous System (CNS)
Made up of the brain and spinal cord
Peripheral Nervous System
Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves
Brain
Divided into the cerebrum, cerebellum, and brainstem
Cerebrospinal Fluid (CSF)
Composed of water, glucose, sodium chloride, and protein
Acts as a shock absorber for the brain and spinal cord
Figure 27-2
Spinal Cord
Extends from the border of the first cervical vertebra (C1) to the level of the second lumbar vertebra (L2)
Thirty-one pairs of spinal nerve roots exit the spinal cord, each consisting of a posterior sensory (afferent) root and anterior motor (efferent) root
These roots, along with the 12 cranial nerves, make up the peripheral nervous system
Autonomic Nervous System
Controls the involuntary activities of the viscera, including smooth muscle, cardiac muscle, and glands
Two major subdivisions: sympathetic nervous system and the parasympathetic nervous system
Age-Related Changes
The number of nerve cells decreases Brain weight is reduced; ventricles increase in size Lipofuscin: aging pigment deposited in nerve cells
with amyloid, a type of protein Increased plaques and tangled fibers in nerve tissue Eye pupil often smaller; may respond to light more
slowly Reflexes intact except for Achilles tendon jerk, which
is often absent Reaction time increases, especially complex
reactions Tremors in the head, face, and hands are common Some develop dizziness and problems with balance
Pathophysiology of Neurologic Diseases
Types of Disorders
Developmental and genetic Trauma Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders
Nursing Assessment of Neurologic Function
Health history Note speech, behavior, coordination, alertness,
comprehension Chief complaint and history of present illness
Document what prompted the patient to seek medical attention
Describe any injuries If patient has pain, note the onset, severity, location,
and duration Past medical history
Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer
Record dates and types of immunizations
Nursing Assessment of Neurologic Function
Family history Have immediate family members had heart
disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or Huntington’s disease?
Review of systems Fatigue or weakness, headache, dizziness,
vertigo, changes in vision/hearing, tinnitus, drainage from ears or nose, dysphasia, neck pain or stiffness, vomiting, bladder or bowel function, sexual dysfunction, fainting, blackouts, tremors, paralysis, incoordination, numbness or tingling, memory problems, mood changes
Nursing Assessment of Neurologic Function
Functional assessment Document whether present symptoms interfere
with the patient’s usual activities and occupation Explore sources of stress, usual coping
strategies, and sources of support Physical examination
Level of consciousness, pupillary evaluation, neuromuscular response, and vital signs
Nursing Assessment of Neurologic Function
Level of Consciousness: 1. Anxious, agitated, combative – hyper-stimulated2. Somnolence – unnatural drowsiness or sleepiness3. Lethargy – like Somnolence, is excessive
drowsiness4. Stupor – decreased responsiveness with a lack of
spontaneous motor activity5. Semi-comatose – decreased responsiveness, no
spontaneous motor activity (stuporous) but can be aroused usually with noxious or painful stimuli
6. Comatose (Coma) – not responsive, not spontaneous motor activity and cannot be aroused with even painful stimuli
Diagnostic Tests and Procedures Advanced neurologic examination
Cranial nerves Coordination and balance Neuromuscular function Sensory function
Pain Temperature Light touch Vibration Position Tactile discrimination
Figure 27-5
Figure 27-6
Figure 27-7
BABINSKI REFLEX – B) negative Babinski – normal for adults C) positive Babinski – abnormal for adults
Diagnostic Tests and Procedures
Lumbar puncture Electroencephalography Electromyography Radiologic studies
Brain scan Cerebral angiography and digital subtraction
angiography Computed tomography Magnetic resonance imaging
Figure 27-8
Figure 27-9
Figure 27-10
Figure 27-11
Common Therapeutic Measures Drug therapy
Antimicrobials Analgesics Anti-inflammatory Corticosteroids Anticonvulsants Diuretics Chemotherapeutic agents Dopaminergics Anticholinergics Cholinergics Antihistamines
Common Therapeutic Measures
Surgery Craniotomy
Surgical opening of the skull Craniectomy
Excision of a segment of the skull Cranioplasty
Any procedure done to repair a skull defect
Increased Intracranial Pressure (ICP)
Normal ICP is 0-15 mmHg (averages 10-15) Brain, Blood, Cerebral Spinal Fluid are
factors of ICP All must remain normal, if one factor increases
ICP will rise; unless the other two factors have a decrease.
When ICP increases, blood perfusion to brain decreases.
Assessment for Signs and Symptoms of Increasing ICP
Level of consciousness (most reliable), pulpillary characteristics, motor function, sesnory function, vital signs.
Abnormal motor function called posturing as ICP increases: Decorticate – abnormal flexation Decerebriate – abnormal extension (worse)
Cushing’s Triad – Life threatening signs!
Assessment for Signs and Symptoms of Increasing ICP
Cushing’s Triad - Hypertension with widening pulse pressure
Irregular, shallow respirations Bradycardia
Treating Increasing ICP
Positioning – Head of Bead no more than 30 Hyperventilation Fluid Management Mechanical drainage (ventriculostomy) Drug Therapy – Mannitol drug of choice,
diuretic helps decrease ICP, increases UO
External Ventriculostomy Drain
Disorders of the Nervous System
Migraine Headache
Intracranial vasoconstriction followed by vasodilation Triggered by menstruation, ovulation, alcohol, some
foods, stress Pain usually unilateral, often begins in the temple or
eye area and is very intense Tearing and nausea and vomiting may occur Hypersensitive to light and sound; prefers dark, quiet
environment Mild migraines treated with acetaminophen or aspirin;
severe ones with ergotamine (Cafergot) or sumatriptan (Imitrex) tablet or auto injector for self-injection
Cluster Headache
Occur in a series of episodes followed by a long period with no symptoms
Intensely painful and seem to be related to stress or anxiety
Usually have no warning symptoms Treatment may include cold application,
indomethacin (Indocin), and tricyclic antidepressants
Tension Headache
Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources, such as a brain tumor or an abscessed tooth
Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing
Treatment: correction of known causes, psychotherapy, massage, heat application, and relaxation techniques
Analgesics, usually nonopioid, may be prescribed to reduce anxiety
Seizure Disorder
Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior
Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors
Medical diagnosis Accurate history of the seizure disorder Electroencephalogram (EEG)
Seizure Disorder
Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior
Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors
Medical diagnosis Accurate history of the seizure disorder Electroencephalogram (EEG)
Seizure Disorder: Classification
Partial seizures Simple
Part of one cerebral hemisphere; consciousness not impaired
Complex Consciousness impaired; may exhibit bizarre behavior
Generalized seizures Involve the entire brain from the onset Consciousness lost during the ictal (seizure) period Types: tonic-clonic, absence, myoclonic, and atonic
Seizure Disorder: Phases of generalized tonic-clonic seizure (grand
mal) Tonic phase Loss of consciousness, falling, crying and
generalized stiffness. Clonic phase
Jerking of the limbs Salivary frothing
Postictal phase Deep sleep, extreme tiredness Headaches, confusion, irritability, vomitting
Seizure Disorder
Status epilepticus Medical emergency: continuous seizures or repeated
seizures in rapid succession for 30 minutes or more Aura
Dizziness, numbness, visual or hearing disturbance, noting an offensive odor, or pain may precede a seizure minutes to seconds before a seizure.
Medical treatment Resolution of the underlying condition Anticonvulsant drug therapy
Seizure Disorder
Surgical treatment Removal of seizure foci in the temporal lobe and
pallidotomy or vagal nerve stimulator
Seizure Disorder: Nursing Care
Assessment Describe the seizure episode, including the
postictal period (following the seizure), and document drug therapy
Seizure Disorder: Nursing Care
Risk for Injury Side rails of bed up and padded, suction
machine readily available, bed maintained in the low position
Quickly move objects away from the patient Do not attempt to restrain the patient
Ineffective Coping and Deficient Knowledge Teach family and patient about the seizure
disorder and the therapy Teaching must be directed toward helping the
patient and family adjust to a chronic condition Encourage questions and concerns
Head Injury: Types
Scalp injuries Lacerations, contusions, abrasions, and
hematomas Concussion
Trauma with no visible injury to the skull or brain Contusion
Bruising and bleeding in the brain tissue Hematoma
Subdural hematoma or epidural hematoma Intracerebral hemorrhage
From lesions within the tissue of the brain itself Penetrating injuries
Sharp objects penetrate the skull and brain tissue
Head Injury
Surgical treatment Directed at evacuating hematomas and
débriding damaged tissue
Head Injury: Nursing Care
Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Risk for Injury Risk for Infection Impaired Physical Mobility Disturbed Body Image and Ineffective Role
Performance
Brain Tumors
Etiology and risk factors Some congenital; others may be related to heredity Drug/environmental factors may play a role in development
Signs and symptoms Directly related to area of brain invaded by the tumor Visual disturbances and headache New-onset seizure activity Difficulties with balance and coordination
Medical treatment Surgery often followed by radiation with or without
chemotherapy
Brain Tumors: Nursing Care
Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping
Meningitis
Etiology and risk factors Inflammation of the meningeal coverings of the
brain and spinal cord caused by either viruses or bacteria
Signs and symptoms Headache, nuchal rigidity (stiffness of the back of
the neck), irritability, diminished level of consciousness, photophobia (sensitivity to light), hypersensitivity, and seizure activity
Positive Kernig’s sign and Brudzinski’s sign Medical diagnosis
Lumbar puncture to obtain CSF for lab analysis
Figure 27-16A
KERNIG’S SIGN – when leg is flexed at the knee the patient will not be able to extend the same leg
http://www.youtube.com/watch?v=rJ-5AFuP3YA
Figure 27-16B
BRUDZINSKI REFLEX – bend up head (flex neck) and hip flexes
http://www.youtube.com/watch?v=jO9PAPi-yus&feature=endscreen&NR=1
Meningitis
Medical treatment Bacterial infections usually respond to
antimicrobial therapy, but no specific drugs effective against most viral infections
Anticonvulsants used to control seizure activity if necessary
Meningitis: Nursing Care
Assessment Assess vital signs and neurologic status
frequently to determine further deterioration or onset of complications
Meningitis: Nursing Care
Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Acute Pain Risk for Injury Deficient Fluid Volume
Encephalitis Etiology and risk factors
Inflammation of brain tissue caused by virus Signs and symptoms
Fever, nuchal rigidity (stiff neck), headache, confusion, delirium, agitation, and restlessness commonly seen
Comatose or exhibit aphasia, hemiparesis, facial weakness, and other alterations in motor activity
Medical treatment Enhance patient comfort and increase strength Because seizure activity is a potential problem,
take appropriate safety precautions
Encephalitis: Nursing Care
The nursing plan of care parallels that of the patient with meningitis
Guillain-Barré Syndrome
Etiology and risk factors Although specific cause unknown, it is believed
to be an autoimmune response to a viral infection
Patients often report some recent viral infection or vaccination
Guillain-Barré Syndrome
Initial phase Symmetric muscle weakness: begins in lower
extremities; ascends to trunk and upper extremities
Visual and hearing disturbances, difficulty chewing, and lack of facial expression
Mild paresthesias or anesthesia in feet and hands in a glove or stocking distribution pattern
Hypertension, orthostatic hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention
Guillain-Barré Syndrome
Plateau phase Remains essentially unchanged No further neurologic deterioration, but no
improvement either Recovery phase
Remyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes)
Guillain-Barré Syndrome
Medical diagnosis Characteristic onset and pattern of ascending
motor involvement Elevated protein level in the CSF Nerve conduction velocity studies reveal slowed
conduction speed in the involved nerves
Guillain-Barré Syndrome
Medical treatment Preserve vital function, particularly respiration Respiratory status is closely monitored and
mechanical ventilation initiated if vital capacity falls to 15 mL/kg of body weight
Massive doses of corticosteroids prescribed to suppress the inflammatory process
Plasmapheresis
Guillain-Barré Syndrome: Nursing Care
Assessment Health history describes the progression of
symptoms Note fears, coping strategies, and sources of
support Physical examination focuses on cranial nerve,
motor, respiratory, and cardiovascular function
Guillain-Barré Syndrome: Nursing Care
Interventions Ineffective Breathing Pattern Decreased Cardiac Output Risk for Disuse Syndrome Imbalanced Nutrition: Less Than Body
Requirements Anxiety Deficient Knowledge Rehabilitation
Parkinson’s Syndrome
Etiology and risk factors Progressive degenerative disorder of the basal
ganglia: an eventual loss of coordination and control over involuntary motor movement
Signs and symptoms Tremor, rigidity, and bradykinesia Loss of dexterity and power in affected limbs,
aching, monotone voice, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, reduced blinking, and slumped posture
Depression common; dementia may develop
Figure 27-17
Parkinson’s Syndrome
Medical diagnosis From health history and physical examination MRI to rule out other causes of the symptoms
Medical treatment Control symptoms: physical therapy and drug
therapy Massage, heat, exercise, and gait retraining Dopamine receptor agonists pramipexole (Mirapex) or
ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine); carbidopa/levodopa (Sinemet); anticholinergic drugs such as trihexyphenidyl (Artane) and benztropine (Cogentin)
Parkinson’s Syndrome: Nursing Care Assessment
Weakness, fatigue, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements
Note lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination
Interventions Impaired Physical Mobility Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Deficient Knowledge
Multiple Sclerosis Etiology
Chronic, progressive degenerative disease Attacks the protective myelin sheath around
axons and disrupts the conduction of impulses through the CNS Chronic, progressive MS: progresses steadily Exacerbating-remitting MS: exacerbations and
remissions Relapsing-progressive MS: less stable periods than
exacerbating-remitting Stable MS: stable; no active disease for a year
Exact cause of MS is unknown; viral infections and autoimmune processes have been implicated
Multiple Sclerosis
Signs and symptoms Fatigue, weakness, and tingling in one or more
extremities; visual disturbances; problems with coordination; bowel and bladder dysfunction; spasticity; and depression
Figure 27-18
Multiple Sclerosis
Medical diagnosis Based on the physical examination and history of
cyclic remission-exacerbation periods Magnetic resonance imaging of the brain and
spinal cord may reveal plaques characteristic of MS
Multiple Sclerosis
Medical treatment Corticosteroids (ACTH, prednisone,
methylprednisolone) Interferon 1b (Betaseron) and interferon 1a
(Avonex) Glatiramer acetate (Copaxone) Immunosuppressants: mitoxantrone
(Novantrone) Amantadine (Symmetrel) Urinary retention treated with cholinergics, such
as bethanechol (Urecholine) or neostigmine (Prostigmine)
Multiple Sclerosis: Nursing Care
Assessment Onset and progression of symptoms, especially
those that affect mobility, vision, eating, and elimination
Range of motion and strength, gait abnormalities, tremors, and muscle spasms
Multiple Sclerosis: Nursing Care
Interventions Impaired Physical Mobility Disturbed Sensory Perception Self-Care Deficit Functional Urinary Incontinence Risk for Infection Ineffective Coping Deficient Knowledge
Amyotrophic Lateral Sclerosis (ALS)
Etiology Also known as Lou Gehrig’s disease; a
degenerative neurologic disease Virus suspected, but exact cause unknown
Pathophysiology Degeneration of the anterior horn cells and the
corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms
ALS
Signs and symptoms Weakness of voluntary muscles of the upper
extremities, particularly the hands Difficulty swallowing and speaking Eventually, respirations shallow; difficulty
clearing airway of pulmonary secretions Death results from aspiration, respiratory
infection, or respiratory failure
ALS
Medical diagnosis History and physical examination findings Electromyography
Medical treatment Because no known cure or treatment, therapy is
supportive; focuses on preventing complications and maintaining maximum function
ALS: Nursing Care
Assessment Dyspnea, dysphagia, muscle cramps, weakness,
twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis
ALS: Nursing Care
Interventions Ineffective Airway Clearance Impaired Physical Mobility Imbalanced Nutrition: Less Than Body
Requirements Impaired Verbal Communication Impaired Skin Integrity Anticipatory Grieving Situational Low Self-Esteem Interrupted Family Processes
Huntington’s Disease
Inherited degenerative neurologic disorder Usually begins in middle adulthood with
abnormal movements, emotional disturbance, and intellectual decline
Symptoms progress steadily: increasing disability and death in 15 to 20 years
Medical and nursing care are supportive only; there is no cure
Myasthenia Gravis
Etiology May have an autoimmune basis
Pathophysiology Insufficient receptor sites at the junction of the
motor nerve with the muscle With repeated stimulation, muscle becomes
exhausted; eventually unable to contract at all If respiratory muscles involved, death from
respiratory insufficiency or arrest possible
Myasthenia Gravis
Signs and symptoms Weakness of voluntary muscles, particularly
those of chewing, swallowing, and speaking Partial improvements of strength with rest Dramatic improvement with the use of
anticholinesterase drugs Ptosis and diplopia commonly seen
Myasthenia Gravis
Medical diagnosis Administering edrophonium (Tensilon)
Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes
Medical treatment Anticholinesterase drugs
Neostigmine and pyridostigmine (Mestinon)
Corticosteroids Cytotoxic therapies Thymectomy Plasmapheresis
Myasthenia Gravis: Nursing Care
Assessment Health history describes the onset of symptoms:
muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance
Interventions Ineffective Breathing Pattern Impaired Physical Mobility and Self-Care Deficit Impaired Swallowing Deficient Knowledge
Chapter 28
Cerebrovascular Accident
Cerebrum
Complex functions: initiation of movements, recognition of sensory input, higher-order thinking, regulating emotional behavior and endocrine and autonomic functions
Divided into two halves: hemispheres Each hemisphere controls the opposite side of
the body: the right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body
The cortex of each is divided into the parietal, frontal, temporal, and occipital lobes; each has a different area of function
Figure 28-1
Cerebrum
Brainstem Includes midbrain, pons, medulla, and part of the
reticular activating system Controls vital, basic functions, including
respiration, heart rate, and consciousness
Cerebellum
Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate movement, balance, and posture
Unlike the cerebrum, the right side of the cerebellum controls the right side of the body, and the left side of the cerebellum controls the left side of the body
Circulation
Carotid system Begins as one common artery; later divides into
the external and internal carotid arteries The external carotid arteries divide to supply blood
to the face The internal arteries further divide into the middle
cerebral artery and the anterior cerebral artery to supply blood to the brain
Circulation
Vertebral arteries Originate from the subclavian artery, travel up
the anterior neck to merge and form the basilar artery at the brainstem
Second division forms posterior cerebral artery Internal carotid and vertebrobasilar arteries
unite to form the circle of Willis
Figure 28-2
Risk Factors for Stroke
Nonmodifiable factors Risk factors that cannot be changed
Age, race, gender, and heredity
Modifiable factors Those that can be eliminated or controlled
Transient Ischemic Attack
Temporary neurologic deficit caused by impairment of cerebral blood flow
Blood vessels occluded by spasms, fragments of plaque, or blood clots
Important warning signs for the individual experiencing a full stroke
Transient Ischemic Attack
Signs and symptoms Dizziness, momentary confusion, loss of speech,
loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body
Medical diagnosis Health history, physical examination findings, and
results of brain imaging studies Laboratory studies, electrocardiography (ECG),
duplex ultrasonography, and cerebral angiography
Transient Ischemic Attack
Medical treatment Depends on the location of the narrowed vessel
and the degree of narrowing Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping
Warfarin (Coumadin) and heparin Carotid endarterectomy and transluminal
angioplasty
Figure 28-3
Stroke
An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours
Stroke: Pathophysiology
Hemorrhagic stroke (20%) Blood vessel in brain ruptures; bleeding into the
brain occurs Ischemic stroke (80%) – most common
Obstruction of blood vessel by atherosclerotic plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain
Figure 28-4
Stroke: Pathophysiology
Common locations of Hemorrhagic stroke: Intracerebral - within the cerebrum
Subdural – between dura and skull Subarachnoid – between arachnoid and pia matter Ventricular
Ischemic stroke (80%) – most common Obstruction of blood vessel by atherosclerotic
plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain
Stroke: Signs and Symptoms
Hemorrhagic stroke Occurs suddenly; may include severe
headache described as “the worst headache of my life”
Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures
Ischemic Strokes: Thrombotic – plaque build up causing narrowing Embolic – dislodged thrombi of plaque, blot clot
and occludes cerebral arteries
Stroke: Signs and Symptoms
CARDINAL SIGNS OF STROKE: 1. Numbness or weakness of the face, arm or leg,
especially on one side of the body. visual problems,
2. Sudden confusion, trouble speaking or understanding
3. Sudden trouble seeing in one or both eyes4. Sudden trouble walking, dizziness, loss of balance
or coordination. 5. Sudden severe headache with no known cause.
Strokes:
Some additional terminology: Stroke in evolution – s/s of stroke are still present Stroke completed – s/s of stroke may or not be
present but neurological status is stabilized
Luncar Stroke – Ischemic type stroke from occlusions of small arteries deep in brain. These are less severe strokes and usually have no or less-pronounced neurological changes.
Figure 28-5
Stroke: Signs and Symptoms
Aphasia A defect in the use of language; speech, reading, writing, or
word comprehension Dysarthria
The inability to speak clearly Dysphagia
Swallowing difficulty Dyspraxia
The partial inability to initiate coordinated voluntary motor acts Hemiplegia
Defined as paralysis of one side of the body
Figure 28-8
Perceptual Disturbances in hemiplegia
Stroke: Signs and Symptoms
Sensory impairment Unable to feel touch, pain, or temperature in affected body
parts Unilateral neglect
Do not recognize one side of the body as belonging to them Homonymous hemianopsia
Perceptual problem: involves loss of one side of field of vision Elimination disturbances
Neurogenic bladder Flaccid bladder Bowel incontinence
Medical Diagnosis
Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance imaging, carotid ultrasound studies, cerebral and carotid angiography, electrocardiography, positron-emission tomography, and single-photon emission computed tomography
Complications
Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis, decubitus ulcers, and pneumonia
Sensory losses put patient at risk for traumatic and thermal injuries
Swallowing difficulties place patient at risk for pulmonary complications, such as choking and aspiration pneumonia
Prognosis
Prognosis for TIA or stroke increasingly hopeful Critical variables for recovery: patient’s condition
before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy
Long-term recovery may depend on the care received immediately after the stroke
Most recovery takes place in the first 3-6 months, but progress often continues long after that
Medical Treatment in the Acute Phase
Begins with the onset of signs and symptoms and continues until vital signs, particularly blood pressure and neurologic condition, stabilize
This phase usually lasts 24 to 48 hours Many medical management interventions
are directed at minimizing complications and deterioration of the patient’s condition after a stroke
Medical Treatment in the Acute Phase
Major focus areas Hypertension Oxygenation Hyperthermia Hyperglycemia
Drug therapy Tissue plasminogen activator (rt-PA, alteplase,
Activase) Given to dissolve clots in acute ischemic strokes
Medical Treatment in the Acute Phase
Other medications Mannitol Nimodipine (Nimotop) Phenytoin (Dilantin) and phenobarbital Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)
Medical Treatment in the Acute Phase
Surgical intervention An option for some patients with hemorrhagic
strokes Decisions about surgery are based on patient’s
age, intracranial pressure, and location of the hemorrhage
Medical Treatment in the Acute Phase
Fluids and nutrition Intravenous fluids Dietary order based on patient’s nutritional
requirements and ability to eat Regular, soft, or pureed
Total parenteral nutrition may be ordered for the malnourished patient
Medical Treatment in the Acute Phase
Urine elimination Indwelling catheter to manage urinary
incontinence Intermittent catheterization: controlling
incontinence caused by a flaccid bladder
Doctor Emergency Department
Door to Doctor = 10 minutes
Door to non-contrast CT or MRI
= 25 minutes
Emergency Department Timeline to Suspected Stroke:
Door to non-contrast CT or MRI
completed and read = 45 minutes
Door to Drug/Admission = 60 MIN
Emergency Department Timeline to Suspected Stroke:
60 MIN
<3hours from symptom onset to be a canidate for
drug (tPA). (could go up to 4.5 hours but outcomes are not as good).
o Glasgow Coma Scale or GCS is a neurological scale used for recording the conscious state of a person .
o Score between 3 (indicating deep unconsciousness) or 15 (fully conscious).
o Today, it is the most used scale on both acute medical and trauma patients.
GLASCOW COMA SCALE (GCS) - ADULT
• A tool often used to assess patients who have experienced a stroke, by use of a point system• Addresses: Motor Function, Visual Fields, Ataxia,
Speech, Language, Cognition and Motor and Sensory Abnormalities.
• Most facilities, especially those that have accreditation as a Stroke Center, require those that
administer the NIH Stroke Scale Examination to be Certified to ensure consistency among examiners.
• See page 504, Table 28-4, in your book for a condensed version of the NIH Stroke Scale.
National Institutes of Health (NIH) Stroke Scale
Nursing Care in the Acute Phase
Assessment Evaluate type and extent of the stroke: time of
onset, symptoms, other details Cincinnati Pre-hospital Stroke Scale
Health history Chief complaint and history of present illness Medical history Family history Review of systems Functional assessment
Nursing Care in the Acute Phase
Physical examination Assess patient’s general appearance,
responsiveness, and behavior Record restlessness or agitation Measure vital signs; weight and height if possible Inspect the face for symmetry; mouth for
moisture and drooling Evaluate the alert patient’s ability to swallow Inspect pupils for size, equality, and reaction to
light
Nursing Care in the Acute Phase
Physical examination Conduct a gross vision assessment Inspect skin color and palpate for moisture and
turgor Assess extremities for muscle tone and strength,
sensation, and voluntary movement Record evidence of incontinence or bladder
distention Frequently repeat neurologic checks: evaluating level
of consciousness, pupil appearance and response to light, the patient’s ability to follow commands, and the movement and sensation of extremities
Nursing Care in the Acute Phase
Interventions Ineffective Airway Clearance and Ineffective
Breathing Patterns Risk for Injury Deficient Fluid Volume or Excess Fluid Volume Imbalanced Nutrition Disturbed Sensory Perception Ineffective Thermoregulation Disturbed Thought Processes
Nursing Care in the Acute Phase
Interventions Impaired Verbal Communication Impaired Physical Mobility Total or Functional Urinary Incontinence Constipation and/or Bowel Incontinence Ineffective Coping Interrupted Family Processes
Nursing Care in the Rehabilitation Phase
Assessment Reassess patient’s abilities, expectations,
knowledge, motivation, and resources
Nursing Care in the Rehabilitation Phase
Interventions Self-Care Deficit Risk for Injury Ineffective Coping Impaired Verbal Communication Imbalanced Nutrition Impaired Physical Mobility Constipation Total and Functional Urinary Incontinence
Figure 28-6
Figure 28-7
Figure 28-9
Discharge
Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy
Outpatient therapy is an option for some patients
When able, patients are transitioned back into the home setting
Essential to include family, friends, and significant others in this process
Discharge
During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities
In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible
Chapter 29
Spinal Cord Injury
Anatomy and Physiology of the Spinal Cord
Vertebral Column
Consists of 33 vertebrae 7 cervical (C1 through C7) 12 thoracic (T1 through T12) 5 lumbar (L1 through L5) 5 sacral (S1 through S5) 4 fused coccygeal
Figure 29-1
Vertebral Column
Each vertebra consists of a body and an arch
The spinal cord passes through an opening in the center of each arch
Each arch has articulating surfaces against which adjacent vertebrae smoothly glide with movement
The bony column is supported by muscles and ligaments, which permit mobility and flexibility
Disks
Vertebrae separated by disks which serve as shock absorbers for the vertebral column
Composed of anulus fibrosus and nucleus pulposus anulus fibrosus: ring of tissue; encircles nucleus
pulposus Nucleus pulposus: saclike structure with a
gelatinous filling that has a high water content
As we age, nucleus pulposus loses much of its water; less effective as a shock absorber
Figure 29-2
Spinal Cord
Extends from the brainstem to L2 in pelvic cavity Surrounded by three protective meningeal layers
Dura mater Outermost layer
Arachnoid Middle layer: spaces containing cerebrospinal fluid
(CSF) Pia mater
Innermost layer: directly covers the spinal cord CSF circulates through the brain and spinal column,
bathing and protecting the entire central nervous system
Figure 29-3
Spinal Cord
Gray matter Consists of the bodies of nerve cells that control
motor and sensory activities White matter
Myelinated (surrounded by a sheath); consists of bundles of fibers
Convey information between the brain and the spinal cord
Tracts may be ascending or descending
Figure 29-4
Spinal Cord
Blood supply Major arterial supply to the spinal cord; consists
of the vertebral arteries posteriorly and the anterior spinal artery
Reflexive activity The sensory stimulus is received, and a response
is initiated at the level of the spinal cord
Spinal Cord
Relay activity Stimulus enters spinal cord; travels up ascending
tracts to relay sensory signals to the brain Information processed in the brain; responses
initiated by impulses transmitted to the body by way of descending tracts
Information conveyed to brain and spinal cord via peripheral nervous system
Diagnostic Tests and Procedures
Neurologic examination Initial evaluation of the spinal cord: injured
patient provides the nurse with a baseline assessment of function and problems
Ongoing assessment necessary to monitor the effects of neurologic injury, detect related complications, and determine patient’s need for assistance in activities of daily living
Focuses on the motor and sensory systems
Diagnostic Tests and Procedures
Imaging studies Radiography
Detects vertebral compression, fractures, or problems with alignment
Computed tomography (CT) Noninvasive examination of the specific levels of the
spinal cord to be visualized, bony vertebrae, and the spinal nerves
Magnetic resonance imaging (MRI) Produces precise, clear images of internal structures
Myelogram Visualizes the spinal cord and vertebrae
Pathophysiology of Spinal Cord Injury
Types of Injuries
Location Cervical, thoracic, or lumbar
Open or closed Closed: trauma in which the skin and meningeal
covering that surround the spinal cord remain intact Open: damage to the protective skin and meninges
Extent of damage to the cord Complete spinal cord injury occurs when the cord has
been completely severed, whereas an incomplete injury results from partial cutting of the cord
Effects of Spinal Cord Injury
Factors include extent of cut and level of injury
Sometimes cannot be fully determined because the symptoms of spinal cord edema may mimic partial or complete transection
With incomplete spinal cord injuries some function remains below the level of the injury Specific tracts may be involved, causing particular
patterns of neurologic dysfunction
Figure 29-6
Effects of Spinal Cord Injury
The higher the level of injury, the more encompassing the neurologic dysfunction
Quadriplegia High cervical spine injuries; loss of motor and
sensory function in all four extremities Paraplegia
Injuries at or below T2 may cause paralysis of the lower part of the body
Respiratory Impairment
Injuries at or above the level of C5 may result in instant death because the nerves that control respiration are interrupted
Cervical injuries below the level of C4 spare the diaphragm but can involve impairment of intercostal and abdominal muscles
Spinal Shock
An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases
Autonomic Dysreflexia
Exaggerated response of autonomic nervous system to noxious (painful) stimuli
With injury at or above the level of T6 The sympathetic nervous system is
stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system
Autonomic Dysreflexia
Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes
Spasticity
Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation
Impaired Sensory and Motor Function
Impaired motor function can affect the patient’s mobility and self-care and thus result in complications from immobility
Loss of sensation puts patient at risk for skin breakdown and other injuries because pressure and pain are not perceived
Impaired Bladder Function
During spinal shock, all bladder and bowel function ceases
Once spinal shock resolves, reflex activity returns
Impaired Bowel Function
Most spinal cord–injured patients can maintain bowel function because the large bowel musculature has its own neural center that responds to distention by the fecal mass
Impaired Temperature Regulations
May lose these regulatory mechanisms and be unable to adapt to temperature extremes
Impaired Sexual Function
Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels results in sexual dysfunction
Ability to achieve erection and ejaculation is variable
Impaired Skin Integrity
Because immobile patient can’t change positions, skin in sacral area and across bony prominences may break down
Loss of tone results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores
Altered Self-Concept and Body Image
French and Phillips (1991) describe the effects of spinal cord injury on body image as occurring in four phases: impact, retreat, acknowledgment, and reconstruction
Medical Treatment in the Acute Phase
Saving the Patient’s Life:Establish Airway
Conventional head-tilt–chin-lift: inappropriate with spinal injury; increases risk of cord damage
Risk of additional damage is especially high with cervical injury
Neck flexion, even that caused by a pillow or other support, must be avoided
Jaw-thrust method of opening the airway is preferred for these patients
Saving the Patient’s Life: Establish Airway
Once airway is open, administer 100% oxygen by mask and manual resuscitator
Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation
Any injury that compromises ventilation must be treated immediately
Preventing Further Cord Injury
Traction Immobilization with skeletal traction manages
cervical spinal cord injuries acutely Gardner-Wells tongs
Secured just above the ears; doesn’t actually penetrate skull
Crutchfield tongs Applied directly to the skull just behind the hairline
Halo vest: immobilizes and aligns cervical vertebrae; placed when surgery is done to internally stabilize fractures and relieve the compression of nerve roots
Figure 29-7
Figure 29-8
Preventing Further Cord Injury
Special beds and cushions Kinetic bed, such as the Roto-Rest bed,
continually rotates the patient from side to side Overlay air mattresses: flotation devices placed
on standard hospital beds Air-fluidized and flotation beds may be used after
the spine has been stabilized Wedge-Stryker frame: canvas and metal frame
bed that may be used to help turn the patient Types of cushions include those inflated with air,
flotation devices, and gel pads
Figure 29-9
Preventing Further Cord Injury
Drug therapy Methylprednisolone
Reduces the damage to the cellular membrane Administered within the first 8 hours of injury Completely paralyzed patients often regain about
20% of function Partially paralyzed have regained up to 75% of
function
Preserving Cord Function
Early surgical intervention to repair cord damage Cord compression by bony fragments, compound
vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable
Laminectomy Involves removing all or part of the posterior arch
of the vertebra Spinal fusion
If multiple vertebrae are involved Placing a piece of donor bone into area between
the involved vertebrae
Assessment
Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output
Health History
Present illness Event that brought the patient to the hospital Specific injuries incurred in the incident Describe pain and other symptoms in detail
Past Medical History
Other accidents or injuries and chronic illnesses such as diabetes, hypertension, heart disease, cancer, or seizure disorder
Previous hospitalizations and operations Obstetric history from female patient Identify and record current medications and
allergies
Family History
Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma
Review of Systems
Skin condition, headache or dizziness, vision disturbances, hearing impairment or tinnitus, nasal or ear drainage, dyspnea, nausea and vomiting, constipation or diarrhea, fecal incontinence, bladder dysfunction, sexual dysfunction, and impaired motor and sensory function
Functional Assessment
Patient’s self-care abilities Patient’s roles and responsibilities as a
family member Occupation, hobbies, usual activity pattern,
habits, and diet Emotional response to the spinal injury Usual coping strategies Spiritual beliefs; other sources of support
Physical Examination
Record the patient’s reported height and weight
Take vital signs Take the temperature Level of responsiveness, posture, and
spontaneous movements Inspect the skin for lesions Evaluate tissue turgor Inspect head for lesions and palpate for
masses and swelling
Physical Examination
Examine pupils for size, equality, reaction to light
Respiratory effort and breath sounds Inspect abdomen; auscultate for bowel
sounds Inspect extremities for open fractures or
abnormal positions Range of motion Ability to perceive sharp and dull sensation;
use a dermatome chart
Figure 29-10
Interventions
Ineffective Breathing Pattern Risk for Injury and Disturbed Sensory
Perception Risk for Autonomic Dysreflexia Risk for Disuse Syndrome Bowel Incontinence Impaired Urinary Elimination
Interventions
Risk for Infection Ineffective Thermoregulation Feeding/Dressing/Grooming Self-Care Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen
Management
Rehabilitation
Activities that assist individual to achieve highest possible level of self-care and independence
Well-organized interdisciplinary team that can address all aspects of function Physician, nurse, physical therapist, occupational
therapist, speech therapist, dietitian, social worker, psychologist, and counselor
Patient and family must be emotionally and physically prepared to make adjustments
Rehabilitation
Team helps the patient accomplish activities of daily living and self-care and addresses successful adjustment to social integration and gainful employment in the workplace
Although this phase of treatment may take more than a year, patient, family, and rehabilitation team can take pride in the realization that a life can once again be productive and happy
Nursing Care of the Laminectomy Patient
Preoperatively Assess patient’s vital signs and neurologic status
to establish baselines Patient’s understanding of surgical routines Tell patient what to expect in the immediate
postoperative period Ongoing assessment of neurologic status and on
promoting healing at the operative site
Nursing Care of the Laminectomy Patient
Assessment Vital signs, neurologic status, and breath sounds Frequently assess movement, strength, range of
motion, and ability to localize sensory stimulus Fluid intake and output Abdomen for bowel sounds; palpate bladder Inspect the surgical dressing for bleeding, clear
cerebrospinal fluid drainage, and foul drainage If the patient has pain, obtain a complete
description
Nursing Care of the Laminectomy Patient
Interventions Risk for Injury Ineffective Tissue Perfusion Acute Pain Impaired Urinary Elimination Constipation Impaired Physical Mobility Deficient Knowledge