Nursing of Adults with

Medical & Surgical Conditions

Neurological Disorders

Laboratory and Diagnostic Exams

• Blood and Urine– Culture

• Urinary tract infection

– Drug screens• Rule out drugs as cause of symptoms

– Arterial Blood Gases• Monitor the oxygen content of the blood• Low levels indicate altered breathing

patterns

• Cerebrospinal Fluid– Normal Values

• Specific gravity: 1.007• pH: 7.35 to 7.45• Chloride: 120 to 130 mEq/L• Glucose: 50 to 75 mg/dl• Pressure: 80 to 200 mm water• Total Volume: 80 to 200 ml• Total Protein: 5 to 45 mg/dl • Gamma globulin: 6% to 13% of total protein• Cell Count:

– RBC None– WBC 0-10 cells (lymphocytes and monocytes)

• Cerebrospinal Fluid (Cont)– Elevated lymphocytes may indicate infection– Decreased chloride and glucose levels may

indicate tuberculosis meningitis– Culture or smear is done to determine the

causative organism in meningitis– Protein is elevated with degenerative disease or

brain tumors– Blood indicates hemorrhage from somewhere in

the ventricular system– Protein electrophoresis may give evidence of MS

• Computed Tomography (CT) Scan– Detects pathological conditions of the

cerebrum and spinal cord– May be done with or without contrast

• Brain Scan– Uses radioactive isotopes

• MRI Scan– Uses magnetic forces to image the

cerebrum and spinal cord

• PET Scan– Positron Emission Tomography– Used following stroke, Alzheimer’s, epilepsy

and Parkinson’s– Injection of deoxyglucose with radioactive

fluorine is given– Color scan is done; different shade can be

translated into different pathological conditions

• Lumbar Puncture– Obtain CSF for examination– Relieve pressure– Inject dye or medication– Contraindicated in patients with increased

intracranial pressure

• Electroencephalogram (EEG)– Used to provide evidence of focal or

generalized disturbances of brain function by measuring the electrical activity of the brain

– Epilepsy, mass lesions, cerebrovascular lesions and brain injury

– Procedure• Patient is kept awake the night before• Hair and scalp must be clean• Electrodes are placed on the scalp

• Myelogram– Used to identify lesions in the intradural or

extradural compartments of the spinal canal by observing the flow of radiopaque dye through the subarachnoid space.

– Used to diagnose herniated or protruding intervertebral disk. Spinal tumors, adhesions, bony deformations, and arteriovenous malformations

– Lumbar puncture is performed, dye injected, and fluoroscopic and radiopaque films are taken

• Angiogram– Used to visualize the cerebral arterial

system by injecting radiopaque material– Allows the detection of arterial aneurysms,

vessel anomalies, ruptured vessels, and displacement of vessels by tumors or masses

• Carotid Duplex– Uses combined ultrasound and pulsed Doppler – Noninvasive study that evaluates carotid

occlusive disease

• Electromyogram (EMG)– Used to measure the contraction of a muscle

in response to electrical stimulation– Provides evidence of lower motor neuron

disease; primary muscular disease; and defects in the transmission of electrical impulses

• Echoencephalogram– Uses ultrasound to depict the intracranial

structures of the brain– Detects ventricular dilation and a major shift

of midline structures in the brain as a result of an expanding lesion

Headaches• Etiology/Pathophysiology

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

• Pain arises from the scalp, blood vessels, muscles, dura mater, and sinuses

– Vascular Headaches• Migraine

– Vessels are dilated • Hypertensive

– Excessive pressure

– Tension Headaches• Psychological problems

– tension, stress,• Cervical arthritis

– Traction-Inflammation Headaches• Infection, intracranial or extracranial causes, occlusive

vascular structures, temporal arteritis

Headaches

• Signs & Symptoms– Head pain– Migraine headaches

• Prodromal (early s/s)– visual field defects, experiencing unusual

smells or sounds, disorientation, paresthesias, and rarely paralysis of a part of the body

• During headache– nausea, vomiting, light sensitivity, chilliness,

fatigue, irritability, diaphoresis, edema

Headache

• Treatment– Diet

• Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork

– Psychotherapy• Decrease stress factors

– Medications• Migraine Headaches

– aspirin, acetaminophen, ibuprofen– ergotamine tartrate

» Constricts vessels– Codeine– Inderal

Headaches

• Tension Headaches– Nonnarcotic analgesics

» acetaminophen, propoxyphene, phenacetin, ibuprofen, and aspirin

• Traction-inflammatory Headaches– Treat cause

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

Increased Intracranial Pressure

• Etiology/Pathophysiology– Increase in any content of the

cranium• Cranium is rigid and nonexpandable

– Space-occupying lesions, cerebrospinal problems, cerebral edema

Increased Intracranial Pressure• Signs & Symptoms

– Diplopia• double vision

– Headache• increases with coughing, straining, or stooping

– Decrease in level of consciousness• disorientation, restlessness, lethargy

– Pupillary signs• ipsilateral pupil dilation

– lesion is one hemisphere

• bilateral pupil dilation– both halves of brain are involved

Increased Intracranial Pressure

– Widening pulse pressure• increased systolic and decreased diastolic

B/P

– Bradycardia– Respiratory problems

• vary related to the level of brainstem involvement

– High, uncontrolled temperatures– Positive Babinski’s reflex

• Toes fan out when bottom of foot is stroked

– Seizures

Increased Intracranial Pressure

– Posturing• decorticate

– flexion of arms, wrists, and fingers with adduction of arms

• decerebrate– All four extremities in rigid extension, with

hyperpronation of forearmsand plantar extension of feet

– Vomiting– Singultus

Increased Intracranial Pressure

• Treatment– Treat cause if possible– Mechanical decompression

• Craniotomy– remove bone flap and replace

• Craniectomy– remove bone flap and not replaced

– Internal Monitoring Devices• Diagnose and monitor increased intracranial

pressure• Ventricular catheter, subarachnoid bolt or screw,

and the epidural sensor– produce pressure waves to indicate status of IIP

Epilepsy or Seizures

• Etiology/Pathophysiology– Transitory disturbance in consciousness or

in motor, sensory, or autonomic function with or without loss of consciousness

– Sudden, excessive, and disorderly discharges in the neurons of the brain

– Results in sudden, violent, involuntary contraction of a group of muscles

– Hypoglycemia, infection, and electrolyte imbalance.

Epilepsy or Seizures– Types of seizures

• Grand Mal– Generalized– Tonic-clonic movements– Loss of consciousness

• Petit Mal– Sudden impairment or loss of consciousness– Little or no tonic-clonic movement– Vacant facial expression; eye straight ahead

• Psychomotor– Sudden change in awareness– Behaves as if partially conscious– May appear intoxicated– Antisocial behavior

» exposing self or violence

Epilepsy or Seizures

• Jacksonian-focal– One body part is affected

» hand, foot, face– May end in grand mal seizure

• Myoclonic– Sudden involuntary contraction of muscle group

» usually in extremities or trunk– No loss of consciousness

• Akinetic– Generlaized tonelessness– Falls in flaccid state– Unconsciousness for 1-2 minutes

Epilepsy or Seizures

• Signs & Symptoms– Depends on type of seizure– Aura

• Sensation that may precede a seizure– flashing lights, smells, numbness, tingling,

hallucinations

– Postictal Period• Rest period of variable length• Groggy and disoriented• Headache and muscle aches• May sleep

Epilepsy or Seizures

– Status epilepticus• recurrent, gernalized seizure activity

occurs at such frequency that full consciousness is not regained

Epilepsy or Seizures

• Treatment– During seizure

• Protect from aspiration and injury– Lower to the floor– Move away from furniture and equipment– Turn the head to the side if possible– Loosen clothing around neck– DO NOT RESTRAIN– DO NOT PUT ANYTHING IN MOUTH

– Medications• Page 608; table 15-5

– Surgery• Removal of brain tissue where seizure occurs

Epilepsy or Seizures

– Adequate rest– Good nutrition– Avoid alcohol– Avoid driving, operating machinery, &

swimming until seizures are controlled– Good oral hygiene esp. if on Dilantin

• causes gingival hyperplasia– edematous and enlarged gums

– Medical alert tag

Multiple Sclerosis

• Etiology/Pathophysiology– Degenerative neurological disorder– Cause unknown– Possibly genetic– Most common in wet cold climates– Demyelination of the brain stem, spinal

cord, optic nerves, and cerebrum• causes an interruption or distortion of the

nerve impulse

Multiple Sclerosis• Signs & Symptoms

– Visual problems• diplopia• scotomata (spots)• blindness• nystagmus

– Urinary incontinence– Fatigue– Weakness– Incoordination – Sexual problems– Swallowing difficulties

Multiple Sclerosis

– Remissions may last for a year or more

– Exacerbaions precipitated by• fatigue• chilling• emotional disturbances

Multiple Sclerosis

• Treatment– No specific treatment– Adrenocorticotropic hormone (ACTH)– Steroids

• prednisone– Deltasone or Decadron

– Valium– Betaseron (Interferon beta-1b)

• reduces frequency of exacerbations

– Avonex (Interferon beta-1a)• reduce neurological attacks and slow progress of

physical disability

Multiple Sclerosis

– Pro-Banthine• decrease urinary frequency and urgency

– Urecholine• antispasmodic for neurogenic bladder

– Bactrim, Septra, & Macrodanitn• Urinary tract infections

Parkinson’s Disease

• Etiology/Pathophysiology– Deficiency of dopamine

• necessary for the normal transmission of nerve impulses

– Viral, toxic, vascular and genetic causes

– May be drug induced• Reserpine, phenothiazines, haloperidol,

cocaine

Parkinson’s Disease• Signs & Symptoms

– Muscular tremors– Rigidity

• mask-like facial appearance• monotonous speech• drooling

– Propulsive gait– Emotional instability– Heat intolerance– Decreased blinking– “Pill-rolling” motions of fingers– Bradykinesia

• slowness of voluntary movements and speech

Parkinson’s Disease

Parkinson’s Disease• Treatment

– Medications– side effects may be worse than disease

• Levodopa– converted to dopamine

• Sinemet• Artane• Cogentin• Symmetrol

– Surgery• Pallidotomy

– Destroying portions of the brain that control the rigidity or tremor

• Human fetal dopamine cell transplants

Alzheimer’s Disease

• Etiology/Pathophysiology– Impaired intellectual functioning – Degeneration of the cells of the brain– Cause is unknown– Possible genetic link

Alzheimer’s Disease• Signs & Symptoms

– Early Stage• Mild memory lapses• Decreased attention span

– Second Stage• Obvious memory lapses

– Esp. short term– Disorientation to time– Loss of personal belongings

– Third Stage• Total disorientation to person, place, & time• Apraxia

– impaired ability to perform purposeful acts or use objects

• Wandering

– Terminal Stage• Severe mental and physical deterioration

Alzheimer’s Disease

• Treatment– Medications

• Agitation– Lorazepam– Haldol

• Dementia– Cognex– Aricept

– Nutrition• Finger foods• Frequent feedings• Encourage fluids

Alzheimer’s Disease

– Safety• Removing burner controls at night• Double-locking all doors and windows• Constant supervision

Myasthenia Gravis

• Etiology/Pathophysiology– Neuromuscular disorder– Nerve impulses fail to pass at the myo-

neural junction; causes muscular weakness

– Possible causes• Inadequate production of acetylcholine• Excessive quantities of cholinesterase• Non-response of the muscle fibers to

acetylcholine

Myasthenia Gravis

• Signs & Symptoms– Ocular

• Ptosis– eyelid drooping

• Diplopia– double vision

– Generalized• Skeletal weakness• Dysarthria• Dysphagia• Ataxia• Bowel and bladder incontinence

Myasthenia Gravis

• Treatment– Anticholinesterase drugs

• Prostigmin• Mestinon

– Corticosteroids– May require mechanical ventilation

Amyotrophic Lateral Sclerosis (ALS)

Lou Gehrig’s Disease

• Etiology/Pathophysiology– Motor neurons in the brainstem and

spinal cord gradually degenerate– Electrical and chemical messages

originating in the brain do not reach the muscles to activate them

Amyotrophic Lateral Sclerosis (ALS)

Lou Gehrig’s Disease

• Signs & Symptoms– Weakness of the upper extremities– Dysarthria– Dysphagia– Muscle wasting– Compromised respiratory function

• death usually occurs due to infection

Amyotrophic Lateral Sclerosis (ALS)

Lou Gehrig’s Disease• Treatment– No cure– Rilutec (riluzole)

• Helps protect damaged motor neurons

– Multidisciplinary ALS Teams• experimental drugs• physical, occupational, and speech therapy• nutritional regimens• psychological support

– Emotional support• Mentally healthy; physically wasting away

Huntington’s Disease

• Etiology/Pathophysiology– Overactivity of the dopamine

pathways• opposite of Parkinson’s

– Genetically transmitted

Huntington’s Disease

• Signs & Symptoms– Abnormal and excessive involuntary

movements (chorea)• Writhing, twisting movements of the face,

limbs, and body• Abnormal facial movements

– affect speech, chewing, and swallowing

– Ataxia to immobility– Deterioration in mental functions

Huntington’s Disease

• Treatment– No cure; pallative treatment– Antipsychotics– Antidepressants– Antichoreas– Safe environment– Emotional support– High calorie diet

Cerebral Vascular Accident (CVA)• Etiology/Pathophysiology

– Abnormal condition of the blood vessels of the brain• thrombosis• emoblism• hemorrhage

– Results in ischemia of the brain tissue– Underlying causes

• atherosclerosis, heart disease, hypertension, kidney disease, PVD, DM

– Risk factors• obesity, high serum cholesterol, cigarette smoking, stress,

cocaine use, and sedentary lifestyle

Cerebral Vascular Accident (CVA)

• Signs & Symptoms– Headache– Sensory deficit

• numbness or tingling• inability to think clearly• visual problems

– Hemiparesis• Weakness on one side of the body

– Hemipalegia• Paralysis on one side of the body• Depends on area of brain affected

– Dysphasia or aphasia

Cerebral Vascular Accident (CVA)• Treatment

– Aneurysm• Surgery

– tie off or clipping of aneurysm

– Thrombosis or Embolism• Thrombolytics

– TPA, activase

• Heparin and Coumadin

– Decadron– Neurological checks– Feeding tube– Physical, occupation, and/or speech therapy

Trigeminal Neuralgia(Tic Douloureux)

• Etiology/Pathophysiology– Degeneration of or pressure on the

trigeminal nerve

Trigeminal Neuralgia(Tic Douloureux)

• Signs & Symptoms– Excruciating, burning pain

• radiates along one or more of the three divisions of the fifth cranial nerve

– typically extends only to the midline of the face and head

• pain may be initiated by stimulation of “trigger points”

Trigeminal Neuralgia(Tic Douloureux)

• Treatment– Tegretol– Surgical resection of the trigeminal

nerve– Avoid stimulation of face on affected

side• touching• drafts• hot or cold liquids

Bell’s Palsy(peripherial facial paralysis)

• Etiology/Pathophysiology– Inflammatory process involving the

facial nerve– Vasoconstriction due to ischemia,

edema, or emotional trauma may also be a cause

– Unilateral or bilateral

Bell’s Palsy(peripherial facial paralysis)

• Signs & Symptoms– Facial numbness or stiffness– Drawing sensation of the face– Unilateral weakness of facial muscles

• unable to wrinkle forehead, close eyelid, pucker lips, or retract the mouth

• Face appears asymmetric– drooping of mouth and cheek

– Loss of taste– Reduction of saliva– Pain behind the ear– Ringing in ear or other hearing loss

Bell’s Palsy

Bell’s Palsy(peripherial facial paralysis)

• Treatment– Electrical stimulation– Warm moist heat– Steroids– Massage of the affected area– Exercises

• wrinkling the brow and forehead, closing the eyes, and puffing out the cheeks.

Guillain-Barre’ Syndrome

• Etiology/Pathophysiology– Inflammation and demyelination of

the peripheral nervous system– Cause is unknown– Possibly viral or autoimmune reaction

Guillain-Barre’ Syndrome

• Signs & Symptoms– Symptoms are progressive– Progression may stop at any point– Paralysis usually starts in the lower

extremities and moves upward – May include the thorax, upper extremities,

and face– Respiratory failure if intercostal muscles

are affected– May have difficulty swallowing, breathing,

and speaking

Guillain-Barre’ Syndrome

• Treatment– Adrenocortical steroids– Apheresis

• removal of unwanted components from the blood serum by a flow separator

– Mechanical ventilation• may require tracheostomy

– Gastrostomy tube– Meticulous skin care– Range of motion exercises

Meningitis

• Etiology/Pathophysiology– Acute infection of the meninges– Pneumococci, meningococci,

staphylococci, streptococci, H. influenzae, and viral

– Bacterial or aseptic

Meningitis• Signs & Symptoms

– Headache– Stiff neck– Irritability– Malaise– Restlessness– Nausea & vomiting– Delirium– Elevated temperature, pulse, & respirations– Kernig’s Sign

• inability to extend the legs completely without extreme pain

– Brudzinski’s Sign• flexion of the hip and knee when the neck is flexed

Meningitis

• Treatment– Antibiotics

• massive doses• multiple types• IV or intrathecal

– Steroids– Anticonvulsants– Dark, quiet room

• stimulation may cause seizure

Intracranial Tumors

• Etiology/Pathophysiology– Benign or malignant– Primary or metastatic– May affect any area of the brain

Intracranial Tumors

• Signs & Symptoms– Headache– Hearing loss– Motor weakness– Ataxia– Decreased alertness and consciousness– Abnormal pupil response and/or unequal

size– Seizures– Speech abnormalities

Intracranial Tumors

• Treatment– Surgical removal of tumor

• craniotomy• intracranial endoscopy

– Radiation– Chemotherapy– Combination of above

Crainiotomy

Craniocerebral Trauma(Head Injury)

• Etiology/Pathophysiology– Motor vehicle and motorcycle accidents,

falls, industrial accidents, assaults, and sports trauma

– Direct trauma• head is directly injured• acceleration-deceleration injury• bruising or contusion of the occipital and frontal lobes

and brainstem and cerebellum

– Indirect trauma• Tension strains and shearing forces transmitted to the

head by stretching of the neck

Craniocerebral Trauma(Head Injury)

– Open head injuries• Skull fractures• Penetrating wounds

– Closed head injuries• Concussions

– violent jarring of the brain against the skull

• Contusions• Lacerations

– Hematomas• scalp, epidural, subdural, intracerebral, and

intraventricular– epidural and subdural must be monitored carefully

Craniocerebral Trauma(Head Injury)

• Signs & Symptoms– Headache– Nausea– Vomiting– Abnormal sensations– Loss of consciousness– Bleeding from ears or nose– Abnormal pupil size and\or reaction– Battle’s Sign

• in small hemorrhagic spot behind the ear• may indicate a fracture the lower skull

Craniocerebral Trauma(Head Injury)

• Treatment– Maintain airway– Oxygen– Mannitol and dexamethasone

• reduce cerebral edema and IICP

– Analgesics• must not suppress respiratory system

– Anticonvulsants

Spinal Cord Trauma

• Etiology/Pathophysiology– Automobile, motorcycle, diving, surfing,

other athletic accidents, and gunshot wounds

– Fracture of vertebra• simple, compressed, wedged, comminuted or burst

fractures• dislocation of vertebrae

– Complete cord injury• total transection of the spinal cord• complete loss of spinal cord function

– Incomplete cord injury• partial transection or injury of spinal cord

Spinal Cord Trauma

• Signs & Symptoms– Loss of muscle function depends on level of

injury• INJURY LOST FUNCTION• Above C4 All, including respiration• C5 Arms, chest, all below chest• C6-C7 Some arm, fingers, chest, all

below chest• Thoracic Trunk, all below chest• Lumbosacral Legs

Spinal Cord Trauma– Spinal Shock

• Vasodilation, increased venous capacity, and hypotension

– Autonomic dysreflexia• Increased reflex actions

– bradycardia, hypertension, diaphoresis, “goose bumps”, severe headache, and nasal stuffiness

• Occurs in injuries above T6; most common in cervical injuries

• Result of abnormal cardivascular response to stimulation of the sympathetic division of the autonomic nervous system

• Occurs as a result of stimulation of the bladder, large intestine or other visceral organs

Spinal Cord Trauma

– Sexual Dysfunction• Male

– Impotence– Decreased sensation– Difficulties with ejaculation– Infertility

• Female– Altered sexual pleasure

Spinal Cord Trauma

– Treatment• Realignment of bony column for fractures

or dislocations– Immobilization– Skeletal traction

» Crutchfield tongs» Halo traction» Stryker frame

– Sugery for spinal decompression

• Methylprednisolone– high doses

Spinal Cord Trauma

– Mobility• Slowly increase sitting up

– may have to use thromboembolism stockings– prevents hypotension

• Urinary function– Foley catheter, initially– Bladder training– Intermittent catheterization

• Bowel function– Bowel program

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