Comprehensive Guide to Neurologic Disorders: Nursing Care and Assessment

1. Chapter 27 Neurologic Disorders

2. Learning Objectives • Identify common neurologic changes in the older person and the implication of these for nursing care. • Describe the diagnostic tests and procedures used to evaluate neurologic function and the nursing responsibilities associated with each. • Identify the uses, side effects, and nursing interventions associated with common drug therapies employed in patients with neurologic disorders. • Describe the signs and symptoms associated with increased intracranial pressure and the medical therapies used in treatment. • List the components of the nursing assessment of the patient with a neurologic disorder. • Describe the pathophysiology, signs and symptoms, complications, and medical or surgical treatment for patients with selected neurologic disorders. • Assist in developing a nursing care plan for the patient with a neurologic disorder.

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

22. Figure 27-5

23. Figure 27-6

24. Figure 27-7

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

26. Figure 27-8

27. Figure 27-9

28. Figure 27-10

29. Figure 27-11

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

31. 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

32. Disorders of the Nervous System

33. 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 autoinjector for self-injection

34. 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

35. 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

36. 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)

37. 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

38. 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 Medical treatment Resolution of the underlying condition Anticonvulsant drug therapy

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

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

41. 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

42. 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

43. Head Injury Surgical treatment Directed at evacuating hematomas and débriding damaged tissue

44. 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

45. 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

46. Brain Tumors: Nursing Care Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping

47. 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

48. Figure 27-16A

49. Figure 27-16B

50. 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