The NERVOUS SYSTEM

1. The NERVOUS SYSTEM INCREASED INTRACRANIAL PRESSURE

2. Increased intracranial pressure • The cranial valut contains brain tissues, 1400 g; blood, 75 ml; CSF, 75 ml • The volume and pressure of these components are in a state of equilibrium, producing ICP of 0-10, 15 mm/Hg-upper limit of the normal. • The valut has limited space for expansion; an increase in one affect the volume of other components; diminishing production of CSF or decreasing cerebral blood flow. Without such changes, ICP begins to rise • Under normal conditions, minor changes in blood and CSF volume occur due to alterations in intrathoracic pressure, posture, BP, systemic O2 & CO2

3. ICP • Common precipitating factors: head injuries brain tumors, subarachnoid hemorrhage, viral encephalopathies • Increased ICP -decreases cerebral perfusion, -stimulates edema, -shifting brain tissues; herniation, a fatal condition.

4. ICP- Pathophysiology • Increased ICP--reduced CBF--ischemia and cell death; • In the early stages; Vasmotor centres are stimulated--increased SBP accompanied by bounding pulse, respiratory irregularities • PaCO2 also regulate CBF--increased PaCo2 causes vasodilatation--increased CBF--increased ICP • Decreased venous outflow----increased CB volume----increased ICP

5. ICP Pathophysiology • Cerebral edema is abnormal accumulation of water or fluids in intracellular space, extracellular or both; as brain tissues swell–ICP increased • Compensatory mechanisms: a) decreased production of CSF, • b) autoregulation: change diameter of BVs to maintain a constant blood flow during changes in SBP • Cerebral perfusion is maintained if SBP is 50-150 mm Hg and ICP less than 40 mm Hg • Cerebral perfusion pressure CPP = MAP – ICP; the normal range is 70-100; the CPP must be maintained at 70-80 mm Hg to ensure adequate blood flow

6. ICPHealth assessment • When brains ability to adjust to increased ICP decreased—neural function is impaired • The first clinical manifestation is Altered level of consciousness LOC, slowing of speech, delay in response to verbal stimuli • Any sudden changes: restlessness, drowsiness, confusion—indicate compression of brain • As ICP increases—stuporous; reacting only to loud or painful stimuli—indicating serious impairment of the brain circulation

7. ICP • Further deterioration: comatose and exhibits abnormal motor response, decortication and decerebration • Decortication: abnormal flexion of upper extremities & extension of lower extremities • Decerebration: extreme extension of upper & lower extremities • If coma is profound with dilated fixed pupils and respiratory impaired; death

8. Altered level of consciousness LOC • Is not oriented; does not follow commands; • Altered LOC is evaluated on a continuum alertness-coma • Coma is a clinical state of unarousable unresponsiveness in which there are no purposeful responses to internal or external stimuli • The cause may be neurologic; toxicologic; metabolic • The underlying change is disruptions in the cells of the nervous system; neurotransmitters; brain anatomy • As changes in LOC occur; changes in pupillary response, eye opening, verbal & motor response also occur • Initial alteration in LOC is reflected by subtle behavioral changes: restlessness, increased anxiety

9. Nursing care for patients with altered LOCASSESSMENT • Verbal response: by determining patients’ orientation • Alertness by determining ability to open eye spontaneously, in response to verbal, painful stimuli • Motor response: spontaneous purposeful movement on command; in response to painful stimuli • Posture • Respiratory status; reflexes; • Body’s systems function: circulation; respiration; elimination; fluid & electrolytes balances

10. Nurses diagnoses • Ineffective airway clearance; • Risk for injury • Deficient fluid volume; • Impaired mucous membrane—mouth breathing • Risk for impaired skin integrity • Impaired tissue integrity of cornea • Ineffective thermoregulation-damage to hypothalamic center • Impaired urinary elimination; bowel incontinence • Disturbed sensory perception • Impaired family processes

11. Maintaining airway • Establish an adequate airway—tongue may obstruct oropharynx; • Removal of secretion—to eliminate danger of aspiration • Elevate head 30 degrees; prevent aspiration • Place in lateral position—promote drainage of secretions • Suctioning and oral hygiene—hyperoxygenation—to prevent hypoxia; chest physiotherapy; unless contraindicated • Auscultate chest every 8 hours • Despite all of this; intubation & mechanical ventilation may be needed

12. Protecting the patient • Side rails must be raised and padded • Prevent injury from invasive lines, equipment, straints, tight dressing • Protect patient privacy & dignity; no negative talks • Maintaining fluid balance & nutritional needs -assess hydration status -slow administration of fluids in patients with intracranial conditions -feeding / gastrostomy tube for prolonged coma

13. Providing mouth care • Keep mouth clean / Oral care to prevent parotitis • Clean & rinse mouth to remove secretions, crust & to moist mucus membrane • A thin coating petrolatum on the lips prevent dryness, cracking, encrustation; if intubated—move tube to opposite side daily, routine teeth brushing reduces VAP • Preserving corneal integrity: -clean the cornea with cotton ball moistened with N/S, to remove debris & discharge -instill artificial tears ever 2 hours if prescribed -cold compresses for orbital edema; but be carful not to contact cornea -use eye patch carefully; not in contact with cornea

14. Maintaining skin & joint integrity • Assess skin frequently for breakdown • Regular schedule of turning to avoid pressure • Careful positioning to prevent ischemic necrosis over pressure areas; Avoid dragging or pulling the patient up in the bed • Maintain correct position; use splint to prevent foot drop • Trochanter rolls to support hip joints & legs in proper alignment; assess heals of the feet • Arms in abduction; fingers lightly flexed; fingers in slight supination • Specialty beds: fluidized or low air-loss are used to decrease pressure on bony prominence • Passive exercise

15. Managing body tempreture • Causes of fever in unconscious patients: damage to hypothalamic regulating center; infections; drug interaction • Actions: modifications of the environment; light bedding; cool room to 18 degree C. • In case of very High temperature (damage of hypothalamus; intracranial infection—increased metabolic demand -remove all bedding except light sheet; -acetaminophen as prescribed -cool sponge bath and electric fan -use a hypothermic blanket -frequent monitoring of the TEMP. to prevent excessive decrease in Temp

16. Preventing urinary retention • Assess bladder for urinary retention • If not voiding; urinary catheter connected to a closed drainage system • Then, observe for fever, cloudy urine, drainage around uretheral orifice • After removal; assess bladder • Intermittent catheterization program to ensure complete bladder emptying • In case of spontaneous urination: condom catheter for males; absorbent pads for females • As consciousness regained; bladder training program • Assess & mange skin irritation and breakdown

17. Promoting bowel function • Assess for abdominal distension, auscultation and measuring the girth • Commercial fecal collection bag-if has frequent loose stool • Constipation because of immobility and lack of fiber • Frequent assessment of bowel movement; • Stool softeners; glycerin suppository • The patient may need enema every other day

18. Providing sensory stimulation • Once increased ICP is not a problem; efforts to restore the sense of daily rhythm • Touch & talk to the patient, encourage family to do so • Avoid making any negative comments • Orient the patient to time; place every 8 hours • Family member can read to the patient, a previously favorite topic • After arousal; may experience agitation—a positive sign • In this case minimize stimulation

19. Managing potential complication • Encourage family to participate in care; • Give time to adapt; encourage ventilation of feeling • Monitoring and managing potential complications -monitor vital signs and respiratory function -suctioning & chest physiotherapy -monitor for manifestations of skin injury -strategies to prevent skin breakdown -monitor for signs of DVT; strategies for prevention

20. Seizures • Episodes of abnormal motor, sensory, autonomic, or psychic activities resulting from sudden excessive discharge from cerebral neurons; International classification: • Partial seizure begins in one part of the brain; • Generalized that electrical discharge involve all brain • In a simple partial: consciousness remains intact; • In complex partial seizures: consciousness is impaired • Generalized seizures involve the whole brain • The underlying cause is an electrical disturbance in nerve cells; these cells emit abnormal, recurring, uncontrolled electrical discharges; • Predisposing factors: idiopathic, genetic, • Or acquired—list of health problems, in P. 1881

21. Nursing management assessment & document • Circumstances before seizures, visual, auditory, emotional, sleep, hyperventilation stimuli • Occurrence of aura, warning stimuli • First thing patient does in the seizure; where stiffness begins • Type of movement in the part of the body involved • Part of the body involved; the size of the pupil whether eyes are open; Whether eyes or head turn to one side; • Presence of automatism; involuntary movement-lip, repeated swallowing. Duration, consciousness level, sleep; cognitive changes; Incontinence of urine or stool • After seizure:-effort to prevent injury, aspiration -place patient in side-lying position -Bed in low position with 3 side rails up. Read chart 61-4; P 1883

22. Epilepsies • Is a group of syndromes characterized by unprovoked recurring seizures • Can be partial or generalized; primary (idiopathic) or secondary • During emission of unwanted electrical discharge; Parts of body controlled by errant cells perform erratically—mild to incapacitating; often causing LOC • Epilepsy does not mean mental retardation or reduced intellectual level • In simple partial seizure, only small part, finger, hand, mouth may shake; may talk unintelligibly • In complex partial seizure, may remain motionless or move automatically—inappropriately; may experience excessive emotions, fear, anger, does not remember the episode.

23. Epilepsyhealth assessment • Generalized/ grand mal; involve both hemisphere of the brain: intense rigidity of the entire body may occur, followed by alternating muscle relaxation and contraction (generalized tonic-clonic contraction • Contraction of diaphragmatic and chest muscle produce epileptic cry • The tongue may be chewed, incontinent urine and feces • After 1-2 minutes this stage subside; relaxed in deep coma--breathing noisily, respiration is chiefly abdominal • In postical state, after the episode, the patient is confused and may sleep for hours. • Full history, seeking for a cause • MRI for structural changes; EEG

24. Epilepsymedical management • Medication: many are available, unknown action • The objective is to control seizures with minimal side effects • If properly prescribed and taken—control in 70%-80% of the patients; Start with single medication • Dose and rate is dependent on side effect & serum level • Example: Tegretol, phenobarbital, valproate, phenytoin • Side effects; allergic, acute toxicity; chronic toxicity • Surgical management: • Underlying causes-tumor, abscess • If possible to excise the focal point in the brain • Refractory to treatment in partial seizures---generator under clavicle

25. Nursing management • Nursing diagnoses • Risk for injury • Fear related to possibility of seizures • Ineffective coping with stress • Deficient knowledge • Potential complications: Status epilepticus; Medications side effects • Preventing injury • Safe environment; lowered him gently; padded side rails • Never restrain the patient; not insert any thing in his mouth • Read chart 61-4; P 1883

26. Nursing actions • Reducing fear of seizures • Adherence to prescribed regimen; patient-family cooperation, • Frequent monitoring • Aware of precipitating factors • Follow moderate routine life style; diet—avoiding stimulants • Avoid sleep deprivation • Moderate exercise, avoid excessive • Ketogenic diet, high protein-low carbohydrate-high fat diet is more effective in children • Avoid Photic stimulation, bright flickering light, TV • Wearing dark glasses is preventive; stress management

27. Nursing actions • Improving coping mechanisms • Feeling of stigmatization, alienation, depression and uncertainty • Not being able to drive, other activities, marriage child bearing • Counselling patient and family; support effective coping, expression of concerns; patient and family teaching

28. Ischemic stroke • CVA ,brain attack, is a sudden loss of function resulting from disruption of blood supply to a part of the brain; Thrombolytic treatment window is 3 hours only • Types: • Large artery thrombotic stroke: by atherosclerotic plaques—thrombus—occlusion—ischemia & infarction • Small penetrating artery thrombotic stroke: affect one or more vessels, most common • Cardiogenic embolic stroke: cardiac dysrhythmias—atrial fibrillation or valvular heart disease; can be prevented by anticoagulant therapies • Cryptogenic stroke: unknown cause • Others by drugs, coagulopathies

29. I SPATHOPHYSIOLOGY • Occlusion----disruption of blood flow, • When CBF decreases; neuron switch to anaerobic respiration • ------------increased lactic acid—change Ph; • ------------Less ATP for depolarization processes; membrane pump to maintain electrolytes balance fails, and cells function ceases---Penumbra region: exists around an area of infarction, that may be salvaged with timely intervention; if not, increases intracellular Ca and release of glutamate; destruction of cell membrane. • IS can cause a variety of neurologic deficits depending on location; size affected; collateral circulation;

30. Clinical manifestations • Patients may present with any of the following S & Ss • Numbness, weakness of face, leg, arm especially on one side • Confusion / change mental status • Trouble speaking or understanding speech • Visual disturbances • Difficulty walking, dizziness, loss of balance or coordination • Sudden severe headache • Read table 62-2, P. 1898, and table 62-3,P. 1899.

31. IS: clinical manifestationscontinues • Motor loss: IS-is an upper motor neuron lesion -hemiplegia, hemiparesis; in the early stage, flaccid paralysis, decreased deep tendon reflexes -after 48, when deep tendon reflexes reappear--an increase in muscle tone with increased spasticity: abnormal increase in muscle tone • Communication loss: dysarthria, difficulty speaking; -dysphasia, impaired speech; aphasia, loss of speech—expressive or receptive or global--both; -Apraxia, inability to perform a previously learned action • Perceptual disturbances: inability to interpret sensation -visual-perceptual dysfunction, sensory loss;

32. Clinical manifestations • -homonymous hemianopsia—loss of half of the visual field; could be temporary or permanent • Sensory loss: impairment of touch to loss of proprioception: -decreased ability to perceive position and motion of body parts -difficulty in interpreting visual, tactile & auditory stimuli -Agnosias—inability to recognise previously familiar objects • Cognitive impairment: if frontal lobe is damaged -impairment of learning capacity, memory, higher cortical intellectual function: limited attention span, difficulty in comprehension; these changes may result in frustration & lack of motivation • Depression is common

33. ISPREVENTION • Identify those at increased risk—teaching • Low-dose aspirin • Control modifiable risk factors: HTN, AF, hyperlipidemia, obesity, smoking, diabetes. • In AF administration of warfarin • In carotid stenosis –carotid endarterectomy • Secondary prevention for those having TIA, AF: dose-adjusted warfarin, • Platelet inhibiting medication: aspirin, persantine, clopidogrel, ticlopidine • statins: Simvastatin (Zocor) reduce coronary event & stroke

34. Medical management Thrombolytic agents: t-PA; • binds to fibrin-convert plasminogen to plasmin which stimulates fibrinolysis • Administration within 3 hrs----decreases stroke size and improve functional outcomes • Requires urgent presentation & diagnosis; use the national institute for health stroke scale table 62-4, page 1901. • Eligibility chart 62-2 page 1900 • Dose:0.9 mg/kg; maximum 90 mg; 10% IV bolus in one minute • 90% IV infusion over 1 hr • Side effects: bleeding; a 24-hour delay in placing invasive tubes is recommended -intracranial bleeding, 6.4%, is a major complication

35. Other management approachesnot candidate for t-PA • Low molecular wt heparin-no longer recommended • Maintenance of cerebral perfusion • Measures to reduce ICP: • Osmotic diuretics, Mannitol • Maintain Pa CO2 30-35; • Elevate head of the bed; possible hemicraniectomy • Intubation-patent airway • Continuous hemodynamic monitoring, • Withheld antihypertinsive, unless SBP >220; DBP >120 • Neurologic assessment to detect complications, seizures, bleeding

36. IS NURSING assessment • Acute phase lasts 1-3 days; monitoring is required using a flow sheet; including • Change in LOC / responsiveness, orientation • Voluntary or involuntary movement, body posture position of the head • Stiffness / flaccidity of neck • Eye opening, pupil size, movement; reaction to light • Colour of the face, extremities, temp, moisture of skin • Quality & rate of pulse, respiration, ABGs • Ability to speak • Presence of bleeding; intake & output • Bp within normal

37. NURSING DIAGNOSES • impaired physical mobility, • acute pain/pain shoulder-disuse related to hemiplegia & disuse; • self-care deficits; • disturbed sensory perception; • impaired swallowing; • Impaired urinary elimination related to flaccid bladder • disturbed thought process; • impaired verbal communication; • risk for impaired skin integrity; • sexual dysfunction • Potential complications

38. IS:nursing actionsimproving mobility and preventing joint deformities • Arm tend to adduct and rotate internally; leg tends to rotate externally; • ankle joint supinate and tend toward planter flexion; because flexors stronger than extensors • Preventing shoulder adduction: pillow in the axilla; -pillow under arm-placed in a neutral position, slightly flexed -distal joints higher than proximals to prevent edema • Hand and fingers: fingers barely flexed, hand in slight supination

39. Positioning • Change position every 2 hours: lateral; -pillow between legs before positioning, -upper leg should not acutely flexed to prevent edema; - if sensation is affected limit the time on affected limb; -place in prone position 15-30 minutes several times, with pillow under pelvis, this helps to promote hyper-extension of hip joints & draining of pulmonary secretions • Exercise program: passive exercise, range of motion 4-5 times a day; monitor respiratory and cardiac function • Regularity of exercise is important • Rehabilitation program

40. IS: nursing actionsPreventing shoulder pain • 72% suffer sever pain in the shoulder that may prevent learning new skills • 3 problems may occur: pain, subluxation, shoulder-hand syndrome: • Never lift by a flaccid shoulder, • Position arm on a table while seated • Wear a sling while ambulatory • Range of motion exercise; palm and finger exercises • Medication: Amitriptyline, Lamictal for post stroke pain

41. IS: nursing action Enhancing self-care • Assist in personal hygiene; set realistic goals; • start with unaffected side to perform daily activities; • Vasomotor skills can be learned by repetition • Be sure not to neglect the affected side; assistive devices for help • Assess functional ability, using the Functional Independence Measure • Assist patients in dressing; recommend larger size clothes • perceptual problems: difficulty in matching clothes with body parts • Support to prevent fatigue / painful twisting

42. Managing sensory-perceptual difficulties • With decreased field of vision; approach the side with intact visual perception • Visual stimuli (calendar, TV on the intact side • Encourage patients to move the head to the direction of defective field to compensate, especially in case of homonymous hemianopsia

43. IS: nursing actionAssisting with nutrition • Have swallowing problems, dysphagia: assess paroxysms of coughing, food dribbling, pooling in one side, nasal regurgitation; dysphagia places the patient at risk of aspiration • A speech therapist to assess gag reflexes • Advised to take small boluses, may start with thick liquid, pureed diet • upright position in a chair, tuck chin toward chest prevent aspiration; Enteral, nasogastric nasoenteral (in duodenum) • Elevate head of the bed 30 degree, • check position of tube; slowly tube feeding • Cuff of tracheostomy in place and inflated • Periodic aspiration of the tube; if for long period, gastrostomy

44. IS nursing actionAttaining bowel and bladder control ; Improving thought process • May has urinary incontinence , loss of external urinary sphincter • Intermittent catheterization • Persistent U incontinence may indicate bilateral brain damage • Analyse voiding pattern • May have constipation: High fiber diet, adequate fluid intake • Regular toileting, and Bladder and bowel retraining programs 2-3 L a day-FLUIDS • Cognitive-perceptual retraining, reality orientation; cueing • Provide support, positive feedback, • Convey attitudes of confidence and hope for progress

45. IS: nursing actionImproving communication • The cortical area that is responsible for comprehension and formulation of language called Broca’s area -controls muscular movement needed to speech; -It is close to the left motor area; -SO, Aphasia associates right hemiplegia • A speech therapist to assess communication needs; • identify best communication methods; • The patient may become depressed because of difficulty in communications

46. Communications / continues • Make atmosphere conducive of communication: sensitive to patients’ reactions, responding in an appropriate manner, • Understand anxiety • To complete the patient’s sentence is a pitfall--frustration • Consistent schedule, routine, repetition • A written copy of personal information • Checklist and audiotaped list help improve memory and concentration • Draw patient attention, speak slowly, consistent instructions, use gestures, • Talk to the patient while providing care

47. IS: nursing actionMaintaining skin integrity • Altered sensation and inability to respond to pressure -----skin breakdown • Frequent assessment of skin, bony areas and dependent parts • Low air-loss bed until ambulation • Regular turning schedule, every 2 hours • When turning, minimize shear and friction forces • Keep skin clean and dry • Gentle message of healthy non-reddened skin • Adequate nutrition

48. IS: nursing actionImproving family coping • Encourage family to participate in counselling and use support system for emotional & physical stress of caring • Give information about expected outcomes • Avoid doing activities the patient not able to do • Assure their love and interest are part of therapy • Inform that rehabilitation requires months and progress is slow • Encourage to approach the patient with supportive and optimistic attitudes • Inform that episodes of emotional liability are expected, they improve over time

49. Hemorrhagic strokes • Account for 15-20% of CV disorders; primarily causes are intracranial or subarachnoid haemorrhage • Is a bleeding in brain tissue, ventricles, or subarachnoid space • Primary intracerebral hemorrhage is from a spontaneous rupture of small vessels accounts for 80%--caused by uncontrolled hypertension • Subarachnoid haemorrhage—from ruptured intracranial aneurism • Secondary intrcerebral haemorrhage is from arteriovenous malformation, intracranial aneurysms, neoplasms

50. Pathophysiology / continues • Symptoms are produced when pressure on cranial nerves, or brain tissues increases • Normal brain metabolism is disturbed by: • Brain being exposed to blood • Increase ICP from sudden entry of blood into subarachnoid space compressing and injuring brain tissue • Secondary ischemia of the brain because of reduced perfusion and vasospasm