Comprehensive Overview of Neurologic Disorders and Nursing Assessment

1. NURS 1130 Adult Nursing III Unit I Chapters 27, 28, 29 Teresa Champion, RN, MSN 9/2012

2. Chapter 27 Neurologic Disorders

3. Anatomy and Physiology of the Nervous System

4. 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

5. Axons and Dendrites Branch off the main cell body Axons conduct impulses away from the cell body Dendrites convey impulses toward the cell body

6. 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

7. Figure 27-1

8. Central Nervous System (CNS) Made up of the brain and spinal cord

9. Peripheral Nervous System Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves

10. Brain Divided into the cerebrum, cerebellum, and brainstem

11. Cerebrospinal Fluid (CSF) Composed of water, glucose, sodium chloride, and protein Acts as a shock absorber for the brain and spinal cord

12. Figure 27-2

13. 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

14. 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

15. 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

16. Pathophysiology of Neurologic Diseases

17. Types of Disorders Developmental and genetic Trauma Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders

18. 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

19. 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

20. 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

21. Nursing Assessment of Neurologic Function Level of Consciousness: Anxious, agitated, combative – hyper-stimulated Somnolence – unnatural drowsiness or sleepiness Lethargy – like Somnolence, is excessive drowsiness Stupor – decreased responsiveness with a lack of spontaneous motor activity Semi-comatose – decreased responsiveness, no spontaneous motor activity (stuporous) but can be aroused usually with noxious or painful stimuli Comatose (Coma) – not responsive, not spontaneous motor activity and cannot be aroused with even painful stimuli

22. Diagnostic Tests and Procedures Advanced neurologic examination Cranial nerves Coordination and balance Neuromuscular function Sensory function Pain Temperature Light touch Vibration Position Tactile discrimination

23. Figure 27-5

24. Figure 27-6

25. BABINSKI REFLEX – B) negative Babinski – normal for adults C) positive Babinski – abnormal for adults Figure 27-7

26. Diagnostic Tests and Procedures Lumbar puncture Electroencephalography Electromyography Radiologic studies Brain scan Cerebral angiography and digital subtraction angiography Computed tomography Magnetic resonance imaging

27. Figure 27-8

28. Figure 27-9

29. Figure 27-10

30. Figure 27-11

31. Common Therapeutic Measures Drug therapy Antimicrobials Analgesics Anti-inflammatory Corticosteroids Anticonvulsants Diuretics Chemotherapeutic agents Dopaminergics Anticholinergics Cholinergics Antihistamines

32. 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

33. 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.

34. 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!

36. Assessment for Signs and Symptoms of Increasing ICP Cushing’s Triad - Hypertension with widening pulse pressure Irregular, shallow respirations Bradycardia

37. 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

38. External Ventriculostomy Drain

39. Disorders of the Nervous System

40. 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

41. 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

42. 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

43. 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)

44. 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)

45. 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

46. 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

47. 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

48. Seizure Disorder Surgical treatment Removal of seizure foci in the temporal lobe and pallidotomy or vagal nerve stimulator

49. Seizure Disorder: Nursing Care Assessment Describe the seizure episode, including the postictal period (following the seizure), and document drug therapy

50. 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