Divine Word College of San Jose Nursing Department NURSING CARE MANAGEMENT (NCM 104) Neurological, Neurosurgical Nursing

I. Overview of Neuroanatomy & Neurophysiology A. The Nervous System The functional unit of the nervous system is the nerve cell, or neuron. The nervous system consists of the central nervous system (CNS), which includes the brain and spinal cord, and the peripheral nervous system (PNS), which includes the cranial nerves and the spinal nerves. The autonomic nervous system is a subdivision of the PNS that automatically controls body functions such as breathing and heartbeat. It is further subdivided into the sympathetic and parasympathetic nervous system. Neuron 1. Primary component of the nervous system composed of cell body (gray matter), axon, and dendrites. 2. Axon: elongated process or fiber extending from the cell body, transmits impulses (messages) away from the cell body to dendrites or directly to the cell bodies or other neurons, neuron has usually one axon. 3. Dendrites: short, branching fibers that receive impulses and conduct them toward the nerve cell body. Neurons may have many dendrites. 4. Synapse: junction between neurons where an impulse is transmitted. 5. Neurotransmitters: chemical agents (e.g. acetylcholine, norepinephrine) involved in transmission of impulse toward synapse. 6. Myelin Sheath: a wrapping of myelin (a whitish, fatty material) that protects and insulates nerve fibers and enhances the speed of impulse conduction. 6.1 Both axons and dendrites may or may not have a myelin sheath (myelinated/unmyelinated). 6.2 Most axons leaving the CNS are heavily myelinated by Schwann cells. Functional Classification: 6.11 Afferent (sensory) neurons: transmit impulses from peripheral receptors to the CNS. 6.12 Efferent (motor) neurons: conduct impulses from CNS to muscles and glands. 6.13 Internuncial neurons (interneurons): connecting links between afferent and efferent neurons.

B. Central Nervous System: Brain and Spinal Cord Brain 1. Cerebrum : outermost area (cerebral cortex) is gray matter, deeper area is composed of white matter. 1.1 Two hemispheres: right and left 1.2 Each hemisphere divided into four lobes, many of the functional areas of the cerebrum have been located in these lobes. 1.21 Frontal Lobe 1.211 Personality, behavior 1.212 higher intellectual functioning 1.213 precentral gyrus: motor function 1.214 brocas area: specialized motor speech area 1.22 Parietal lobe 1.221 Postcentral gyrus: registers general sensation (e.g. touch, pressure) 1.222 integrates sensory information 1.23 Temporal Lobe 1.231 hearing, taste, smell

1.232 wernickes area: sensory speech area (understanding/formulation of language). 1.24 Occipital Lobe: vision 1.3 Corpus callosum: large fiber tract that connects the two cerebral hemispheres 1.4 Basal Ganglia: islands of gray matter within white matter of cerebrum 1.41 Regulate and integrate motor activity originating in the cerebral cortex. 1.42 Part of the extrapyramidal system 2. Diencephalon : connecting part of the brain, between the cerebrum and the brain stem. Contains several small structures; the thalamus and hypothalamus are the most important. 1.1 Thalamus 1.11 Relay station for discrimination of sensory signal (e.g. pain, temperature, touch). 1.12 Controls primitive emotional responses (e.g. rage, fear) 1.2 Hypothalamus 1.21 Found immediately beneath the thalamus 1.22 Plays major role in regulation of vital functions such as blood pressure, sleep, food and water intake, and body temperature. 1.23 Acts as a control center for pituitary gland and affects both divisions of the autonomic nervous system. 3. Brain Stem 3.1 Contains midbrain, pons, and medulla oblongata 3.2 Extends from the cerebral hemispheres to the foramen magnum at the base of the skull 3.3 Contains nuclei of the cranial nerves and the long ascending and descending tracts connecting the cerebrum and the spinal cord. 3.4 Contains vital centers of respiratory, vasomotor, and cardiac functions. 4. Cerebellum : coordinates muscle tone and movements and maintains position in space (equilibrium). Spinal Cord 1. Serves as connecting link between the brain and the periphery. 2. Extends from foramen magnum to second lower vertebra. 3. H-shaped gray matter in the center (cell bodies) surrounded by white matter (nerve tracts and fibers). 4. Gray Matter 5. Anterior Horns: contain cell bodies giving rise to efferent (motor) fibers Posterior fibers: contain cell bodies connecting via afferent (sensory) fibers from dorsal root ganglion. Lateral Horns: in thoracic region, contains cells giving rise to autonomic fibers of sympathetic nervous system. 6. White Matter Ascending Tracts (sensory pathways) 5.11 Posterior columns: carry impulses concerned with touch, pressure, vibration and position sense. 5.12 Spinocerebellar: carry impulses concerned with touch, pressure, vibration, and position sense. 5.13 Lateral Spinothalamic: carry impulses resulting in pain and temperature sensations 5.14 Anterior Spinothalamic: carry impulses concerned with crude touch and pressure. 5.2 Descending Tracts (motor pathways) 5.21 Corticospinal (pyramidal, upper motor neuron): conduct motor impulses from motor cortex to anterior horn cells (cross in the medulla). 5.22 Extrapyramidal: help to maintain muscle tone and to control body movement, especially gross automatic movements such as walking. 5.3 Reflex Arc 5.31 Reflex consists of involuntary response to a stimulus occurring over a neural pathway called a reflex arc. 5.32 Not relayed to and from the brain; takes place at cord levels

5.33 Components 5.331 Sensory receptor: receives/reacts to a stimulus 5.332 Afferent pathway: transmits impulses from motor neuron to effectors 5.333 Effector: muscle or organ that responds to stimulus Supporting Structures 1. Skull Rigid, numerous bones fused together Protects and supports the brain 2. Spinal Column Consist of 7 cervical, 12 thoracic, and 5 lumbar vertebrae, as well as sacrum and coccyx. Supports the head and protects the spinal cord. 3. Meninges Membranes between the skull and brain and the vertebral column and spinal cord. Layers 3.21 Dura Matter: outermost layer; tough and leathery 3.22 Arachnoid matter: midlle layer; web-like 3.23 Pia matter: innermost layer, delicate, clings to surface of brain 3.3 Area between arachnoid and pia matter is called subarachnoid space. 4. Ventricles 4.1 Four fluid-filled cavities connecting with one another and the spinal canal 4.2 Produce and circulate cerebrospinal fluid. 5. Cerebrospinal Fluid (CSF) 5.1 Surrounds brain and spinal cord 5.2 Offers protection by functioning as a shock absorber 5.3 Allows fluid shifts from the cranial cavity to the spinal cavity 5.4 Carries nutrients to and waste products away from nerve cells. 6. Vascular Supply 6.1 Two internal carotid arteries anteriorally 6.2 Two vertebral arteries leading to basilar artery posteriorally. 6.3 These arteries communicate at the base of the brain through the circle of willis 6.4 Anterior, middle, and posterior cerebral arteries are the main arteries for disturbing blood to each hemisphere of the brain. 6.5 Brain stem and cerebellum are supplied by branches of the vertebral and basilar arteries. 6.6 Venous blood drains into dural sinuses and then into internal jugular veins. 7. Blood-brain barrier: protective barrier preventing harmful agents from entering the capillaries of the CNS; protects brain and spinal cord. Peripheral Nervous System Spinal Nerves 1. 31 pairs: carry impulses to and from the spinal cord. 2. Each segment of the spinal cord contains a pair of spinal nerves (one of each side of the body. 3. Each nerve is attached to the spinal cord by two roots Dorsal (posterior) root: contains afferent (sensory) nerve whose cell body is in the dorsal root ganglion. Ventral (anterior) root: contains efferent (motor) nerve whose nerve fibers originate in the anterior horn cell of the spinal cord (lower motor neuron). Cranial nerves 1. Twelve (12) pairs: carry impulses to and from brain (see Table 1) 2. May have sensory, motor or mixed functions

Table 1. Cranial Nerves

Name and Number Olfactory: Cranial Nerve I Optic: Cranial Nerve II Oculomotor: Cranial Nerve III

Function

Sensory: carries impulses for sense of smell Sensory: carries impulses for vision Motor: muscles for papillary constriction, elevation of upper eyelid; 4 out of 6 extra ocular movements Trochlea: Cranial Nerve IV Motor: muscles for downward, inward movement of eyes Trigeminal: Cranial Nerve V Mixed: impulses from face, surface of eyes (corneal reflex; muscles controlling mastication Abducens: Cranial Nerve VI Motor: muscles for lateral deviation of eye Facial: Cranial Nerve VII Mixed: impulses for taste from anterior tongue; muscles for facial nerve Acoustic: Cranial Nerve VIII Sensory: impulses for hearing (cochlear division) and balance (vestibular division) Glassopharyngeal: Cranial Nerve Mixed: impulses for sensation to posterior tongue and pharynx IX (elevation) and swallowing Vagus: Cranial Nerve X Mixed: impulses for sensation to lower pharyns and larynx; muscles for movement of soft palate pharynx and larynx Spinal Accessory: Cranial Nerve Motor: movement of sternomastoid muscles and upper part of XI trapezius muscels Hypoglossal: Cranial Nerve XII Motor: movement of tongue Autonomic Nervous System 1. Part of the peripheral nervous system 2. Includes those peripheral nerves (both cranial and spinal) that regulates functions occurring automatically in the body, ANS regulates smooth muscle, cardiac muscle, and glands. 3. Components Sympathetic nervous system: generally accelerates some body functions in response to stress Parasympathetic nervous system: controls normal body functioning 4. Effects of ANS activity (see Table 2) Effector Eye Glands of head, lacrimal, salivary Sypathetic (Adrenergic) Effects Dialates pupils (mydriasis) Noeefect Scanty, thick , viscous Secretions; dry mouth Increases rate and force of contraction Constricts smooth muscles of skin, abdominal vessesls, and cutaneous blood vessels, dilates small muscle of bronchioles, blood vessels of heart and skeletal muscles Bronchodilation Decreases motility Constricts sphincter Possibly inhibits secretion Inhibits activity of gall bladder and ducts Inhibits glycogenolysis in liver Stimulates secretion of epinephrine Parasympathetic (cholinergic) Effects Constricts pupils (miosis) Stimulates secretion Copious thin, watery secretions

Heart Blood vessels

Decreases rate No effect

Lungs GI Tract

Bronchoconstriction Increases motility Relaxes sphincters Stmulates secretion Stimulates activity of gall bladder and ducts No effects

Adrenal Gland

Urinary Tract

and norepinephrine Relaxes dtrusor muscle Contracts detrusor muscle Contracts trigone shpincter (control Relaxes trigone sphincter voiding) (allows voiding)

II. Assessment of Neurological System A. Establishing a Nursing Database 1. Purposes 1.1 Establish a neurological database 1.2 Identify the presence of nervous system dysfunction 1.3 Determine the effects of nervous system dysfunction on ADLs and independent function 1.4 Detect life-threatening situations 1.5 Compare current data to previous assessment data to determine trends and need for change intervention 1.6 Provide a database on which nursing diagnosis and collaborative problems will be based 2. Self-Assessment Questions 2.1 2.2 2.3 2.4 What do I see? What does it mean? How does it relate to previous assessments? How am I going to proceed?

3. Components of the Neurological Assessment 3.1 3.2 3.3 3.4 LOC (Orientation and Cognition) Pupillary Signs Motor Tone and strength (e.g., hand grasps, pronator drift, leg environment, motor strength of extremities) Other areas of neurological assessment (mental status, neuropsychological assessment).

4. Frequency Assessments & Documentation 4.1 4.2 4.3 Always depend on the stability of the patient and the underlying condition. For stable patient, an assessment may be ordered every 4 to 8 hours. For a patient who is unstable, every 5 to 15 minutes.

5. Assessment of conscious, Cooperative Client 5.1 Consciousness: a state of general awareness of oneself and the environment and includes the ability to orient toward new stimuli. It results from a diffuse yet organized neuronal system located in the brain stem, diencephalon, and cerebral hemisphere.

Two Components of Consciousness: 5.11 5.12 Arousal and wakefulness: the appearance of wakefulness; reflects activity of the reticular activating system. Content of consciousness: cognitive mental functions: reflects cerebral cortex activity. change in the

Note: Consciousness is the most sensitive indicator of neurological change; such as, a LOC is usually the first sign to be noted in neurological signs. 5.2 Anatomical and Physiological Basis of Consciousness

5.21

5.22 5.3

A centrally positioned neuronal system located in the brain stem, diencephalon, and cerebral hemisphere (i.e., from spinal cord to cerebral cortex) controls consciousness Ongoing impulses keep a person alert and awake.

Level of Consciousness Assessment 5.31 Auditory stimuli: sound is the stimulus that is applied first; as normal speaking voice is used initially. If the patient responds, then the nurse can talk to him and ask questions to assess orientation and responses to questions. If the patient does not respond, a louder voice or noise may be used, such as the sound produced by clapping the hands. Tactile Stimuli: If there is no response to auditory stimulation, the patients area is gently shaken while calling his or her name. Still, if no response elicit/ apply painful (or noxious) stimuli.

5.32

5.321 Apply firm pressures to the nail beds or web spaces between the fingers or toes observe the motor response. 5.322 Firmly grasp the trapezius or pectoralis major muscle. 5.323 By sternal rub (vertically rubbing the tissue along the sternum) 5.324 By applying supraorbital pressure.

Classification of Motor Response to Painful Stimuli 5.32.1 Purposeful: Withdraws from the painful stimuli and crosses midline; may push the examiners hand away (seen in light coma) 5.32.2 Non-purposeful: the stimulated area moves slightly, without any attempt to withdraw from the source of pain; stimuli to the pectoralis or trapezius may result in a contraction of a muscle or muscle, such as the quadriceps or biceps, but the arm does not (move) cross midline. 5.32.3 Unresponsive: Patient shows no signs of reacting to painful stimuli (seen in deep coma) 5.4 Identifying the levels of consciousness 5.41 There is no internationally accepted taxonomy of definitions with which to label LOC, nor is there agreement on the definitive manifestations of the various stages of consciousness. Consciousness can be viewed as crude continuum, anchored by full consciousness at one end and deep coma on the opposite end.

5.42

Figure 1. Continuum of Consciousness

Full Consciousnes Confusion s

Lethargy

Obtundation

Stupor

Coma

Light Coma

Coma Deep Coma

Table 3. Level of Consciousness TERMS DEFINITIONS COMMENTS Full Consciousness Awake, alert, and oriented to time, place, Demonstrates reliable and person; comprehends the spoken word and responsible and written word and is able to express behavior ideas verbally or in writing Confusion Disoriented in time, place or person; High risk for falls and shortened attention. Span; has difficulty injury. Requires following commands; may have frequent observation & hallucinations supervision Lethargy Oriented to time, place and person; very High risk for falls and slow sluggish in speech, mental processes injury. Pull up side and motor activities; responds appropriately rails. to painful stimuli Needs Complete care

Obtundation

Stupor

Coma

Arousable with stimulation; response High risk for injury verbally with a word or two; can follow simple Needs complete care commands appropriately to painful stimuli Lies quietly with minimal spontaneous High risk for injury movement; generally unresponsive except to Needs complete care vigorous and repeated stimuli; incomprehensible sounds and/or eye opening may be rated; responds appropriately to painful stimuli Appears to be in Sleep, like state with eyes High risk for injury and closed; does not respond appropriately to aspiration. bodily or environmental stimuli; does not Needs standard of make any verbal sounds; differentiation of care. Appropriate for coma level in based on motor response to comatose; completely painful stimuli dependent. Priority care in patent airway

5.43

Glasgow Coma Scale: is used universally to decrease the subjectivity and confusion associated with assessing LOC in acute situations. 5.431 Developed in Glasgow, Scotland in 1974 and is widely used in the US. And internationally for assessment of comatose patients. 5.432 The GCs is especially useful for mentoring changes during the first few days after acute injury or in unstable comatose patients. 5.433 Scale is divided into three subscales: eye opening, best verbal response, and best motor response.

Figure 2. Glasgow Coma Scale BEST EYE OPENING RESPONSE (Record "C" if eyes closed by swelling) BEST MOTOR RESPONSE to painful stimuli (record best upper limb response) Spontaneously to speech to pain No response Obeys verbal command Localizes pain non-purposeful environment Flexion Abnormal * Extension-abnormal+ No response 4 3 2 1 6 5 4 3 2 1

BEST VERBAL RESPONSE (Record "E" if end tracheal tube in place,"T" Oriented x 3 if tracheotomy tube in place Conversation-Confused Speech-inappropriate Sounds-incomprehensible No Response Legend: * Abnormal Flexion-Decorticate rigidity Abnormal Extension + - Decerebrate rigidity 5.434 Guidelines for Scoring Eye opening 4 3 2 1 = = = = Opens eyes spontaneously when the nurse approaches opens eyes in response to speech (normal or shout) Opens eyes only to painful stimuli (e.g., squeezing of nail beds) Does not open eyes to painful stimuli

5 4 3 2 1

Motor Response 6 5 4 3 2 1 = = = = = = Can obey a simple command, such as lift your left hand off the bed Localizes to painful stimuli and attempts to remove source Purposeless movement in response to pain Flexes elbows and wrists while extending lower legs to pain extends upper and lower extremities to pain No motor response to pain or any limb

Verbal Response 5 = Oriented to time, place and person 4 = Converses, although confused 3 = Speaks only in words or phrases that make little or no response 2 = Responds with incomprehensible 1 = No verbal responsible 5.434.1 in interpreting the GCS, the numeric values of each subscale included for a total score 5.434.2 the range of possible scores is 3 to 15 5.435.3 A score of 15 indicates a fully alert, oriented person whereas a score of 3 indicates coma. 5.435.4 A score of 7 or below is considered coma however, patients with a score of 8 are often unconscious. Note: According to Plum and Posner, nearby all comatose patients begin to awaken from their comatose state within 2.4 weeks after injury, regardless of the severity of brain damage, if they survived at all.

Special Status of Altered Consciousness & Brain Death 1. Persistent vegetative state (PUS) is a term used to describe a sub acute or chronic condition that usually occurs following severe cerebral injury. When the condition lasts for a month, it is called persistent vegetative state (PUS). Other terms formerly used were coma vigil and in eversible coma. s/s: no evidence of behavioral responsible responses to visual, auditory, tactile or noxious stimuli, no bowel or bladder control, cannot experience pain, maintain v/s and spontaneous respirations and have open eyes and spontaneous eye movement. Etiology: acute traumatic & non-traumatic brain injuries, degenerative and brain disorders, severe congenital malformations of the brain. Life Expectancy: Substantially reduced; survival ranges from 2-5 year; beyond 10 years very unusual.

2. Locked-in syndrome state in which consciousness and cognition are intact but severe paralysis of the voluntary motor system makes movement and communications impossible. Etiology: interruption of the descending corticobalbular and corticospinal at or below the pins; however breathing is still left intact. May also be seen in CVs, MG and poliomyelitis 3. Brain DeathState of irreversible tons of both cortical and brain-stem activity. It is characterized by irreversible coma and apnea; all brain stem reflexes and cranial nerve function is lost. The diagnosis of brain death is made based on requirement in three areas: Absence of brain stem reflexes Absence of cortical activity Demonstration that this state is irreversible 5.5 Assessment of Cognitive function at the bed side 5.51 5.52 Content: represents the sum of cognitive and effective function and is controlled by cerebral cortex Purpose of cognitive assessment is to determine the effect of neurological disease on the patients ability to function in day-today living Sample of questions that can be asked at the bed side to assess cognitive and motor function: What is the name of this place? What is the date? Show me two fingers Stick out your tongue Wiggle your thumb or toes 5.6 Assessment of the unconscious client The comatose patient appears to be in sleep-line state. With or without eyes closed. The eyelids can gently be raised to inspect the position & movement center in the brain stem is not functioning. 5.62 Assessment of Pupils:The general points to note when assessing the pupils include their size, shape and reaction to light. The findings in one pupil are always compared with the finding in the other pupil, differences between the two are always noted. 5.621 Equal in size measuring about 2-6 min in diameter with average diameter of 3.5 min. 5.622 Two Methods: Millimeter scale (most common) the examiner, using a diagrammatic gauge, estimates the size of pupil by comparing the gauge with patients pupil (see Figure 2). Descriptive method uses the following terms: pinpoint, small, midposition, large and dilated 5.61

5.53

*Mental Status Exam*

Figure 3. Pupil Gauge

Table 4 Common Abnormal Pupillary Responses Findings Most Common Cause/s Nursing Action One pupil is larger than the other (L), Compression of the oculomotor Compare data with previous the dilated pupil does not react to nerve, cerebral edema and uncal assessments. If it is new finding, report light. Ptosis may be seen in the dilated hermiation on the same side of to the physician because the process of pupil the brain rostralcaudal downward pressure most be treated with delay

the pupils appear small but equal in size Bilateral diancephalic damage, Compare findings with previous and both react to direct light, diabetic coma assessments. Review blood chemistry contracting when light is introduced and other data. and dilating when light is withdrawn one pupil (L) is smaller than the other Hypothalamic damage, a lesion Report to the physician if this is a new , both pupils react to light. The eyelid of the lateral medulla or finding on the same side as the smaller pupil ventrolateral cervical spinal (L) droops (Ptosis). Inability to sweat cord, and occlusion of internal (anhidrosis) on the same side of the carotid artery face as the Ptosis is common.

Both Pupils are at midposition and non Midbrain damage reactive to light transtentorial hermiation

or Compare findings with previous assessments. Relate with other neurologic assessments. Report to physician if this is a new finding.

Very small (pinpoint) no reactive pupils Positive damage due to Compare findings with previous are seen hemorrhage or ischemia. assessments & report findings to the Bilateral pinpoint pupils and physician immediately seen in opiate drug overdose Both pupils are dilated and non reactive Severe brain anoxia and death Resuscitate the patient, although (fixed) possibility of reversal is low. Oxygen therapy at high concentration. Maintain patent airway

5.623 Shape: is assessed by looking at the contour of the pupils. Normally, both pupils are round (see table 5 for abnormal pupillary shapes).

10

Table 5. Abnormal Pupillary Shapes. Descriptive Term Definition Round Like a Ovoid Slightly oval; "ovoid" Findings circle Normal Findings almost always indicates intracranial hypertension and represents as intermediate phrase between a normal pupil (round) and a fully dilated fixed pupil; an early sign of transtentorial hermiation Seen in patients who have had an iridectomy (excision of part of the iris an open part of cataract surgery) Seen in Argyll-Robertson pupils and with traumatic orbital injuries.

Keyhole

Like a keyhole

Jagged Irregular

5.623 Inspection of the eyelids: After the eyes are inspected, the
eyelids are released and observations of each eye are compared. Normally, the lid slightly covers the outer margin of the iris. In coma, the lids slowly cover the eyes. Abnormal Findings: Ptosis narrowed palpebral fissure (space between upper and lower eyelid) ; droopy eyelid. Proptosis or exopthalmos protrusion of one or both eyeballs. Opthalmos abnormal recession of or both eyelids.

5.624

Movement of the eyes: Because the patient is unconscious and therefore unable to follow commands, voluntary eye movement cannot be assessed. Although not routinely done by the nurse, the physician may wish to evaluate the eye movement brainstem centers to determine if they are intact For this evaluation, the oculocephalic reflex (dolls eye response) or oculovestibular reflex (cold caloric) can be assessed, provided there are no contraindications (if the eys do not move, the brainstem is involved and the patient most likely will not awaken).

Assessment technique for the oculocephalic reflex: 1. Briskly rotate the head from side to side, or 2. Briskly flex and extend the neck. Findings: 1. When the head is rotated, the eyes should move in the direction opposite to the head movement. If the head is rotated to the left, the eyes appear to move to the right). Alternative method: When the neck is flexed, the eyes appear to look upward; when the neck is extended, the eyes look downward. 2. When the dolls eye reflex is absent, the eys do not move in the sockets and thus follow the direction of passive rotation. Loss of oculocephalic reflex in the comatose patient indicates a lesion at the pontine-midbrain level of the brainstem. Contraindications: 1. Cervical fracture 2. Cervical dislocation Assessment technique for the oculovestibular reflex (cold caloric): Most sensitive test of brainstem function.

11

1.Infuse at least 30-50 ml of cold water (33C) over 30 seconds on the ear of a comatose patient. 2. The ice water infusion can be repeated in the other ear of the comatose patient (wait 5 minutes before testing the other side) to test the integrity of the other side of the brainstem. Findings: 1. Infusion of ice water on the ear of the comatose patient will elicit the oculovestibular reflex generating a slow movement of the eyes to the side of the ice water infusion. 2. This is followed by a rapid corrective movement of the eyes, generated by an intact ipsilateral side of the cerebral hemisphere. No movement toward the side of irrigation suggest lesion of the oculomotor nerve or nucleus (e.g., rostralcaudal hermiation) and downward deviation of one or both eyes is suggestive of sedative drug intoxication. Contraindications: 1. Perforation of the tympanic membrane 2. Impacted cerumen Clinical Implication: The importance of the oculocephalic and oculovestibular reflexes is that their presence or absence provides important information on brainstem function that is useful to determine the depth of coma and to predict patient outcome. Full reflex eye movement in the comatose patient is solid evidence of intact brainstem from the pons to the midbrain level and excludes a mass lesion in the brain stem.

5.625

Frequency of Assessing Eye Movement: The nurse should assess eye movements once during a shift and more often if the patient is unstable.

5.7

Assessment of Selected Reflexes in Unconscious Client: Brainstem reflexes (corneal, gag, and swallowing reflexes) can be assessed in both the conscious and unconscious client and these reflexes are helpful in determining the intactness of the brainstem. 5.71 Corneal reflex assessment: Touch cornea with a wisp of cotton and observe for blinking action. Another way to check the corneal reflex in an unconscious client is to drop a small amount of saline onto the cornea. If the reflex is intact, the eye will blink. Recall that the corneal reflex is mediated by CNs V and VII. 5.72 Gag and Swallowing Reflex: For an unconscious client, gentle tugging on an endotracheal tube will cause gagging if reflex is intact. Alternatively, a cotton-tipped applicator can be used to stimulate each side of the posterior pharynx, there should be an immediate retraction of the pharynx or gagging. Recall that the gag and swallowing reflexes are mediated by cranial nerves IX and X.

B. Assessment of Motor Function: the assessment of motor function is conducted in orderly fashion, beginning with the upper limbs and proceeding to the neck and trunk and, finally to the lower extremities. Limb evaluation proceeds from proximal to distal. Noting motor function helps the nurse to consider the clients functional level, the effect on independence on ADLs, and the need for adaptation activities or assistive devices.

1. Assessment of Motor Function at the Bedside

12

1.1 Conscious patient able to follow commands: A sampling of the strength of key muscles in the extremities will provide an overview of motor function . Upper Extremities Deltoids Biceps Triceps Hand grasps Pronator drift Lower Extremities Hamstrings Quadriceps Dorsiflexion Plantar flexion 1.2 Unconscious client: can exhibit abnormal muscle tone or motor responses that appear as stereotyped postures and are initiated by noxious stimuli. Upper Extremities First observe for spontaneous movement with client lying in bed. Apply noxious stimulus ( centrally rather than peripherally). Ex. Pinching the pectoralis major muscle observe for reaction. Lower Extremities Observe for spontaneous movements. Apply noxious stimuli; observe for motor response.

1.2 Assessment of Muscle Size and Tone : The muscle or muscle group is observed for size (dystrophy, deformities). It is also palpated at rest and then during passive movement for tone. 1.21 Common Abnormalities in Muscle Tone 1.211 Spasticity refers to increase resistance to passive movement, often more pronounced at the extremities at the range of motion and often followed by a gradual release of resistance. Clasp-knife spasticity is increased resistance with a sudden release at the end of extension. 1.212 Rigidity is a state of increase resistance. Cogwheel rigidity is a series of ratchel-like, small, regula jerks that are perceived in passive flexion or extension. Lead-pipe rigidity is resistance that persists throughout extension and flexion. 1.213 Flaccidity (hypotonia) refers to decreased muscle tone. The muscle is weak, soft, and flabby and fatigues easily. 1.22 Muscle Tone in the Unconscious Client : can be assessed by guiding the extremities through PROM. Rigidity, flaccidity, and spasticity can be noted by these simple maneuvers. Unconcious clients can exhibit abnormal muscle tone or stereotyped postures initiated by noxious stimuli. 1.221 Decortication is characterized by adduction of the arm at the shoulder with flexion at the elbow and pronation and flexion at the wrist; the legs extend at the hips and knee. This posture implies as structural lesion of the cerebral hemisphere or diencephalons., brain abscess, stroke, and head injury. Decorticate posture indicates damage to the corticospinal tract (the pathway between the brain and spinal cord).

13

Although a serious sign, it is usually more favorable than decerebrate posture.

Figure 4. Decorticate (Flexor) Posture 1.222 Decerebration includes extended, adducted, and internally rotated (hyperpronated) of the arm; there is flexion of the wrist and fingers; the legs are extended and the feet are plantarflexed. Opisthotonos (a severe muscle spasm of the neck and back) may accompany decerebrate posture in severe cases. Usually, decerebrate posture indicates deterioration of the structures of the nervous system, particularly the upper brain stem. Common causes include stroke, Intracranial hemorrhage, primary brain tumor, head injury and severe metabolic disorder (hepathic encephalopathy). Decerebrate posture occurs in many patterns. It can occur on one side, on both sides, or in just the arms. It may alternate with decorticate posture (abnormal posturing due to corticospinal tract injury), or a person can have decorticate posture on one side and decerebrate posture on the other.

Figure 5.

Decerebrate (Extensor) Posture

NOTE: Decortication and decerebration are the result of rostral-caudal deterioration. Rostral-caudal deterioration describes the progressive deterioration in cerebral and brain function that occurs with expansion of a supratentorial lesion, thus producing pressure on the brain stem and a pattern of progressive neurological dysfunction. Early recognition and reversal of the process are imperative if permanent severe brainstem damage or death is to be prevented. Clinicaly, the client can change from decerebtation to decortication or vice versa and both are poor prognostic signs, although decerebration is a more ominous sign than decortication.

1.3 Assessment of Muscle Strength: Is evaluated by asking the patient to move a muscle actively against gravity and with the resistance provided by the examiner.

14

1.31 In the conscious, cooperative client muscle strength is assessed by active and active resistive movements. For the lower extremities, asking the patient to move each leg and wiggle his toes and feet provides minimal data on function. In examining the lower extremities, proceed from hip to the feet. Make your directions clear and demonstrate movements as necessary. 1.32 In the unconscious client, muscle strength is assessed through observing the patient lying in bed and by applying noxious stimuli and noting response. The following responses are possible in response to painful stimuli: Purposeful Nonpurposeful Unresponsive (see page 8) 1.33 Muscle strength can be rated using a scale of 0-5 and recorded together with the maximum grade achievable at the scale (example 4 out of 5). Compare the functional level of each muscle and compare it to the functional level on the opposite side. Grading of Muscle Strength: Grade Strength 5 Active movement against gravity and full resistance; normal muscle strength 4 Active movement against gravity and resistance; the examiner can overcome the muscle resistance 3 Active movement against the gravity 2 Active movement of the body part when gravity is eliminated 1 A very weak muscle contraction is palpated; only a trace of a contraction is evident, but no active movement of body part is noted. 0 No muscle contraction is detectable

some

1.4 Assessment of Movement, Posture, and Gait 1.41 Movement the presence of invloluntary movements, such as tremors, choreiform movements, myclonus, athetosis, tics, spasms, or ballism is noted (see insert). 1.42 Posture is the position of orientation of the body in space. 1.43 Gait is the manner of progression in walking. The patient is observed while walking and the following characteristics are noted: erect, stooped, or leaning toward one side; position of the arms in relationship to the body (do arms swing naturally?); and quality and amount of movement in the lower extremities (see insert for description of common gait abnormalities). Tandem walking have the patient walk heel to toe, walk on the toes only, and walk on the heels only. With cerebellar hemispheric involvement, the patient often falls towards the side of the lesion and there is ataxia. With midline cerebellar dysfunction, the gait is widebased and tandem gait walking cannot be performed. NOTE: The examiner should be ready and prepared to protect the client from FALLS and INJURY.

15

1.5 Assessment of Cerebellar Function: The integrity of the cerebellum can be tested by having the patient to walk heel to toe along a line (tandem gait) and by performing Rombergs Test. 1.51 Rombergs Test assesses balance in space and is a test of posterior column (spinal cord tracts). Ask the patient to stand erect with feet together, first with eyes open and then with eyes closed (stand beside the client). If the patient loses balance with eyes opened or can stand with the eyes opened but sways or falls when the eyes are closed, Rombergs sign is positive. NOTE: The examiner should be ready and prepared to protect the client from FALLS and INJURY. 1.6 Neurovital Signs and Clinical Implications: The relationship between vital signs and neurological function is based on hemodynamics. Without adequate cerebral perfusion pressure, cerebral ischemia develops, affecting cerebral metabolism, and neurological dysfunction occurs. CNS ischemic response is characterized by PROFOUND BRADYCARDIA ( ISCHEMIA ---- chemosensitive cells -------efferent command that stimulates vagal and sympathetic nerves -------all other circulation in other organs are reduced-------rise in arterial pressure -----increase mycordial contractility -----slowing of heart rate (vagus nerve has strong effect on SA node). 1.61 Cushings Response (Reflex) a special type of CNS ischemic response that results from increased ICP and is a compensatory response that helps protect the brain from loss of adequate blood flow (Increased ICP ---------Interferes with cerebral artery circulation------compression ----decreased cerebral blood flow ------ cushings reflex is activated -------rise in arterial pulse pressure ---------cerebral blood flow is reestablished-----------ischemia is relieved). NOTE: Clinically, the nurse should realize that changes in VS are late findings in rostral-caudal deterioration, therefore do not wait for changes in vital signs to occur before intervening. VS monitoring is both quantitative and qualitative. 1.62 Brainstem where vital signs centers are located Anterior hypothalamus regulation of body heat Ventrolateral medulla controls blood pressure - controls heart rate Ventrolateral medulla & Pons controls respiration 1.63 Abnormal Respiratory Patterns associated with Intracranial Conditions (see transparency). Role of the nurse: 1.631 Periodically assess and document the rate, rhythm and characteristics; 1.632 Implement interventions to maintain a patent airway and promote respiratory function; 1.633 Assess for secondary conditions that may cause respiratory pattern or rate changes; 1.634 Assess for respiratory complications or insufficiency; and 1.635 Notify the physician if respiratory problem occur. 1.64 Pulse and Heart Rate rate, rhythm, and quality of the pulse and heart rate should be assessed, documented, and compared with previous data. 1.641 Changes in Pulse Rate Bounding/thready Pulse often accompanies rising ICP Thready Pulse terminal stages of neurologic demise, or with hemorrhage. 1.642 Changes in Heart Rate:

16

Tachycardia may indicate hypoxia, increasing ICP, internal bleeding Bradycardia - later stages of progressive increased ICP as part of cushing response Bradycardia+HpoTN secondary to cervical spinal cord injury Arrhythmias more common on patients with blood on CSF (SA HMRGE, HI). - continuous cardiac monitoring is necessary.

1.65 Blood Pressure the nurse monitors for hypertension, hypotension and pulse pressure. 1.651 Common Findings: Hypertension rising ICP Elevated SP, widening pulse p, bradycardia cushings response Hypotension rarely attributable to cerebral injury. HpoTN + Tachycardia occult internal hemorrhage HpoTN+Bradycardia cervical spinal injury 1.66 Temperature should be recorded in flowsheet and shivering should be prevented because it increases ICP. 1.661 Common Findings: Hypothermia spinal shock, metabolic/toxic coma, destructive brainstem or hypothalamic lesion. Nursing Care: Warm blanket, adjust room temperature Hyperthermia infectious origins, drug-induced (dilantin, analgesics, anticholinergics, and antibiotics), nueroleptic malignant syndrome (related to use of antipsychotic drugs). Central Fever is caused by space occupying lesion at the brain stem and characterized by high fever up to 41.5C and perspiration is absent (cardinal symptoms). Nursing Considerations: - Steroids may mask infection; monitor patient for signs of infection like foul-smelling urine, yellowish-foul smelling sputum, assess adventitious breath sounds. - All dressing and drainage should be assessed. 1.7 Neurodiagnostic Tests patients undergoing a diagnostic procedure need a general explanation of the procedure with special emphasis on what to expect and their role as participants. For outpatient procedures, nurses must knowledgeable about procedures and related protocols. Written consent is required for many diagnostic procedures. If a patient has an altered LOC, cognitive deficits, or other impairments that will affect ability to give informed consent, a family member must provide written consent and it must be witnessed however, it is usually the physicians responsibility to obtain written consent after explaining the procedure, the risks, and answering questions. 1.71 X-rays of the Head, Vertebral Column and Spine 1.711 Purpose/s: One of the most frequent reasons for ordering skull films is to determine whether skull fracture is present , with regard to spinal films, usually indicated if there is trauma, or severe back pain or motor or sensory impairment. 1.712 Patient Management: Other than encouraging the patient to lie still for the few moments necessary to take the films, there is no preparation or post procedural care required. Remove also any metal pins from the patient and any other hard objects that might block the x-rays, such as jewelry, hearing aids, glasses, or dentures. 1.72 Anatomic Imaging Techniques 1.711 Computed Tomography first introduced in 1972 by Hounsfield, is based on use of ionizing radiation. CT images are generated

17

by scanning the head in successive layers with x-ray beams that pass through the head from multiple directions. Detectors measure the degree of attenuation of the exiting radiuation. Computers integrate this information and construct the images in cross-section.

Figure 6., Example of a CT scan of the head showing a hematoma caused by an injury to the back of the skull during a car accident. B, a CT scan of the spine showing spinal stenosis, and a disc fragment in the spinal canal. C, a CTA showing an aneurysm on the basilar artery

Figure 7. A radiology technician controls the CT scanner table and communicates with you through an intercom. It is important to hold your breath and lie very still when pictures are taken. 1.711.1 Mechanism: The thickness of a cross section, which is called cut or slice, can vary from 1.5 to 10mm. Each cut is subdivided into a grid of tiny cubes or volume elements called voxels. The degree of attenuation within each voxel is measured as numeric value of tissue density. The density number for each voxel is converted to gray scale with lower numbers coded as black (CSF) and higher number coded as black (bone). Brain tissues appear in various shades of gray depending on density. The cut is visually displayed as a dot matrix and the use of radiopaque dye medium enhances the image.

18

1.711.2 Clinical Applications: The CT scan is most useful to identify hemorrhage, ventricle size, cerebral atrophy, and larger space-occupying lesions. 1.711.3 Procedure: The patient lies on a movable radiographic table with his or head carefully positioned and immobilized. A movable circular frame encircles the head and resolves around it, making a clicking sounds, while taking radiographic readings. The head is scanned several times at different angles to collect data. The entire procedure takes 10-20 minutes. 1.711.4 Pre procedural Care: All jewelry, eyeglasses, and hair clips or pins should be removed from the head and neck. Premedication such as lorazepam may be administered before the procedure for severely anxious patients. When contrast medium is used, a skin test is performed to check for allergic reaction. Most protocols require the patient to have had NPO 4-8 hours before the procedure. Some patients experience flushing or feeling of warmth, transient headache, a salty taste in the mouth, nausea or vomiting when the contrast medium is administered, patients should be prepared for these reactions.

1.711.5 Post Procedural Care: After the procedure, patients who have received contrast medium should be observed for signs and symptoms of delayed allergic reactions such as hives, skin rash, itching, nausea and headache. Intravenous hydration or oral increasing fluid intake is necessary to facilitate clearance of the medium.

1.712

Magnetic Resonance Imaging - a noninvasive procedure that identifies types of tissues, tumors and vascular abnormalities. It uses strong magnetic fields rather than ionized radiation (client is not exposed to radiation) and provides a more detailed picture.

1.712.1 Implementation pre procedure: Remove all metal objects from the client. Determine if the client has a pacemaker, implanted defibrillator, or metal implants such as a hip prosthesis or vascular clips because these clients cannot have this test performed. Provide an assessment of the client with claustrophobia. Determine if a contrast agent is to be used (gadolinium diethylenetriamine- pentaacetic acid is the usual non-iodine-base contrast medium used for enhancement). Instruct the client to remain still during the procedure (usually takes approximately 5-50 minutes to complete). 1.712.2 Implementation post procedure: Client may resume normal activities Expect diuresis if a contrast agent was used. 1.73 Physiologic Imaging Techniques 1.731 Positron Emission Tomography (PET) measures regional physiologic functions such as glucose uptake and metabolism, oxygen uptake, and CBF patterns . It provides a clearer understanding about epilepsy, dementia, cerebrovascular Ds, and

19

mental illness ( patient receives an IV injection of isotope or inhales Fflourodeoxyglucose <FDG> ----- once inside the body, the tag concentrates in the area of clinical interest --------emits positron --------- as the positron decays, they emit photons -----moves diametrically ------recorded by detectors --------- multiple scanners detect and encode these data into a computerized database ----------reconstructs cross-sectional images of the tissue). 1.731.1 Implementation Pre Procedure: No caffeine, alcohol or nicotine before 24 hours of the test. NPO x 6-12 hours No glucose IV solution because it may interfere at test result. An arterial line is inserted to draw blood samples. The radiopharmaceutical agent is injected through venous site access. The client sits quietly in a dimly lit room foe about 45 minutes while waiting for the uptake of agent. The head is placed in scanner (takes 45 minutes) and the client may be asked to perform cognitive acts such as speaking, calculations or reasoning. If blood samples are required, they are drawn quietly by the technician, the entire procedure takes 2-3 hours. 1.731.2 Implementation Post Procedure Encourage liberal fluid intake to clear the isotope 1.732 Single-Photon Computed Emission Tomography (SPECT) measures CBF and perfusion. The SPECT scan is based on the same principles as PET technology, but the decay of the radioactive tags emits only a single photon and a rotating gamma camera is used. It is specifically helpful in acute ischemia and monitoring seizure foci. 1.732.1 Implementation Pre Procedure: No special preparation is required other than the usual explanation of the procedure to the patient. The client lies quietly on a padded stretcher and the isotope is administered. The isotope decays in about 1 hour, so the study must be conducted within that window of time. The client must lie quietly during the scan. The entire study takes about 1-2 hours. 1.732.2 Implementation Post Procedure: No special care is required after the procedure. 1.73 Lumbar Puncture insertion of spinal needle through L3-L4 interspace into the lumbar subarachnoid space to obtain CSF, measure CSF or pressure, or instill air, dye or medications. The procedure is CI in clients with increased ICP, because the procedure will cause rapid decrease in pressure within the CSF around the spinal cord, leading to brain hermiation. 1.731 Implementation Pre Procedure Obtain a consent. Have the client empty the bladder. Prepare LP Set

20

Position the client in knee-chest position, usually done at clients bed side. Assist with the collection of specimens (label the specimens in sequence). Maintain strict aseptic technique.

1.732 Implementation Post Procedure: Monitor NeuroVS Position the client flat on bed as prescribed (6-8 hours) Force fluids Monitor I & O 1.74 Cerebrovascular Studies 1.741 Transcranial Doppler (TCD) - uses the principles of Doppler technology to provide information about the patency, flow velocity, turbulence and directional flow of blood in basal cerebral arteries. It is inexpensive, noninvasive, safe, portable, and can be done at the bed side. 1.741.1 Procedure: A Doppler ultrasonic hand-held probe; which sends low frequency pulsed sound waves, is placed on the skin over the thinned-skull area of the temporal bone or window. The sound waves reflect back the velocity of blood flow. These data are amplified, and graphic recordings of the waveforms common to each vessel are recorded. The test takes 10-30 minutes. No special preparation required. 1.742 Cerebral Angiography is the definitive standard diagnostic procedure for aneurysms, areteriovenous malformations, and other cerebrovascular abnormalities.The procedure usually include the injection of contrast through the femoral artery into the carotid arteries. 1.742.1 Implementation Pre Procedure: Obtain a consent Assess the client for allergy in iodine and shellfish. Encourage hydration for 2 days before the test. NPO 4-6 before the procedure as prescribed. Obtain a baseline NeuroVS Mark peripheral pulses 1.742.2 Implementation Post Procedure Monitor neurological status and vital signs frequently until stable. Monitor for the swelling in the neck and for difficulty swallowing and notify the physician if the symptoms occur. Maintain bed rest for 12 hours as prescribed. Elevate the head part of the bed 15-30 only if prescribed. Keep the bed flat if the femoral pulse is used. Assess peripheral pulses Apply sand bag or pressure dressings to the injection site as prescribed.

21

1.75 Biopsies are usually when noninvasive methods such as imaging studies provide inconclusive diagnostic information and when a structure is superficial with easy accessibility. 1.751 Brain biopsy may be warranted for diagnosis of brain tumor and brain abscess. 1.752 Nerve biopsy may be done to aid in the diagnosis of infection or inflammatory changes, vasculitis or neoplasms. 1.753 Temporal artery biopsy for patients who experience facial pain. 1.754 Patient management Explain the procedure to the client, a surgical permit may need to be signed. Medication for sedation may be ordered before the procedure. After the procedure, observe the dressing for bleeding. Vital signs and neurological status should be monitored. 1.76 Electroencephalography (EEG) a graphic recording of the electrical activity of the superficial layers of the cerebral cortex. 1.761 Classification of Brain Waves 1.761.1 Alpha rhythms (8-12 Hz) are most prominent in occipital head (can be blocked by opening the eyes, anxiety, apprehension, and sudden noise or touch). 1.761.2 Beta rhythms (13-35 Hz) are most prominent in frontal and central areas ( triggered by mental activities). 1.761.3 Theta rhythms (4-7 Hz) originate from the temporal lobes (very small amount in normal adults and increases slightly at the age of 60). 1.761.4 Delta rhythms (1-3 Hz) are not normally present in awake adults ( seen usually in stages 3-4 of sleep <slow wave sleep>). 1.762 Implementation Pre Procedure: Wash the clients hair. Inform the client that electrodes are attached to the head and that electricity does not enter the head. Withhold stimulants, antidepressants, tranquilizers, and anticonvulsants for 24-48 hours prior to the test. Premedicate for sedation as prescribed. 1.763 Implementation Post Procedure Wash the clients hair Maintain side rails and safety precautions if the client was sedated. 1.77 Emerging Technologies in Neuroimaging 1.771 Magnetic Resonance Spectroscopy (MRS) is a noninvasive method of studying the biochemistry of living tissue. N-acetyl-aspartate is a marker of neuronal function and MRS may reveal a metabolite that is usually present in the brain, and therefore, may be valuable in investigating the pathophysiology of automal diseases in the brain.

22

1.772 Functional Magnetic Resonance Imaging can map functional cortical activity by detecting cortical regional tissue changes in venous blood circulation. 1.773 Diffusion and Perfusion Magnetic Resonance Imaging can detect cerebral abnormalities related to ischemia by detecting the tiny random movements of water molecules in tissues. Note: teaching, preparation, and care of patient who undergoes these emerging neuroimaging techniques are the same as those for a patient who undergoes a standard MRI. C. Nursing Care Planning for Clients with Neurological Dysfunctions

There is no known cure for many neurological dysfunctions. The nursing goal is to help the client adapt to dysfunction and continue with life in as meaningful a way as possible. Many clients with neurological dysfunctions face a wide variety of possible nursing diagnoses, including the following: y Ineffective breathing pattern y Impaired swallowing y Impaired skin integrity y Impaired physical integrity y Self care defects y Pain y Hyperthermia y Altered oral mucous membranes y Impaired tissue integrity y Altered nutrition: less than body requirements y Altered thought process y Sexual dysfunction y Ineffective individual coping y Altered family process The goal for the client with neurological dysfunctions includes improved respiratory status and swallowing, maintenance of skin integrity and in general, absence of complications (respiratory failure, pneumonia, aspiration, and pressure ulcers). D. Nursing strategies for Common Neurological Problems 1. Management of Clients Undergoing Neurosurgical Procedures 1.1 Informed Consent 1.2 Preoperative Teaching Support 1.3 Intraoperative Nursing Management 1.31 General Considerations (insert FC, shaving) 1.32 Positioning (sitting, lateral o prone positions), support devices (arm rests). 1.33 General Monitoring 1.4 Selected Neurosurgical Procedures 1.41 Transphenoidal Hypophysectomy afford access to the pituitary gland by means of an incision made inside the superior upper lip, in front of the hard palate (for pituitary adenomas or complete hypophysectomy for control of bone in metastatic cancer). 1.42 Craniotomy is a surgical opening of the skull to provide access to the intracranial contents for reasons such as removal of tumor, clipping of an aneurysm or repair of cerebral injury. 1.43 Ventricular Shunt it is used to treat hydrocephalus and a catheter is implanted surgically under the scalp to provide drainage of excessive CSF and drains at the peritoneal cavity. 1.5 Post Operative Nursing Management 1.51 Cardiopulmonary management (oxygenation, pulse oximetry and ABG). 1.52 Prevention of Complications y hypovolemic shock fluid replacement

23

y y y y y

Cardiac arrhythmias - continuous cardiac monitoring Aspiration proper positioning Cerebral hemorrhage ER surgery Seizes anticonvulsants Wound infection strict aseptic technique in changing dressing 1.53 Conservative Nursing Management y Give hygienic care y Skin care y Turning y Pull up side rails y ROM exercises 2. Management of Intracranial Hypertension 2.1 Intracranial Pressure is the pressure normally exerted by CSF that circulates around the brain and spinal cord and within the cerebral ventricles referenced to the atmosphere on which cardiac and respiratory components are superimposed. 2.2 Normal Pressure 0-10 or 15 mmgHg/76-200 mmH2O2.3 Monro-Kellie hypothesis the average intracranial volume in adult is approximately 1,700 ml, brain (1,400ml), CSF (150ml). It states that the skull, a rigid compartment is filled to capacity with essentially noncompressible content interstitial fluid 80%, intravascular blood and CSF 20%. if the volume of any component increases, another component must decrease reciprocally for the overall volume and dynamic equilibrium to remain constant; otherwise, ICP will rise. This hypothesis applies only when the skull is fused. 2.4 Intracranial hypertension is sustained elevated ICP for 15 mmHg or higher . The term MALINANT HYPERTENSION has been used by some authors to described a sustained ICP of 20 mmHg or higher. Common causes include trauma, hemorrhage, growths or tumors, hydrocephalus, edema or inflammation. 2.5 Assessment Findings: LOC-most sensitive and earliest indication for increasing ICP. Headache Rise in BP with widening pulse pressure Slowing of pulse Vomiting +babinski reflex, decorate, decerebrate posturing, seizures Late signs Increased systolic pressure, widened pulse pressure, and slowed heart rate. 2.6 Nursing Management Elevate head 30-40 Avoid trendelenberg position Prevent hypoxia Prevent shivering Decrease environmental stimuli Avoid straining activities

3. Management of the Unconscious Neurological Client Unconsciousness VS Coma unconsciousness is a physiological state in which the patient is unresponsive to sensory stimuli and lacks awareness of self and the environment (fainting) while coma is reserved for a clinical presentation in which the state of unconsciousness is maintained for a prolonged period, from hours to months. Fainting temporary loss of consciousness that can lead to coma (weeks to months) Coma maintained for longer periods (damage to both cerebral hemispheres, brain, stem or both). 3.1 y y y y y Common Collaborative Problems of Unconscious Clients Atelectasis Ventilator Osteoporosis Pressure ulcer Gastric ulcer * Deep vein thrombosis * Anemia * Tracheal necrosis * Electrolyte imbalance * Acute urinary retention

24

y 3.2

Corneal ulceration

* Joint dislocation

Nursing Interventions 3.21 A patent airway is the highest priority (cough reflex is absent therefore at risk for respiration). May insert endotracheal tube on emergency basis to prevent aspiration if unconsciousness is prolonged, and the patient continuously in need of artificial airway, a tracheostomy tube will be needed. Suctioning should be limited to prevent hypoxemia. Lungs must be oxygenated with few breathes before and after suctioning to control hypoxemia. Suctioning equipment is checked at the beginning of every shift and maintained in a ready state for immediate use. 3.22 Lateral recumbent positioning promotes drainage of secretion, facilities respiration and prevents the tongue from obstructing the airway. 3.23 Periodic oropharyngeal or tracheal suctioning may be necessary to clear the airway. 3.24 Chest physiotherapy is of great help. 3.25 Turn and reposition the patient every 2 hours. 3.26 Skin, mouth, eye, hair and scalp care. 3.27 Prevent nosocomial infections 3.28 Nutritional support through TPN or NGT OF 4. Management of Client with Injury to the Neurological System 4.1 Craniocerebral Trauma (Head Injury) 4.11 General Information 4.111 Craniocerebral trauma is a general designation to denote injury to the skull, brain, or both, that is of sufficient magnitude to interfere with normal function and to require treatment. The more accurate term to describe the major traumatic event, however, is traumatic brain injury. 4.112 Unusually caused by car accidents, fall, assaults 4.12 Types 4.121 Concussion: severe blow to the head jostles, causing it to strike the skull; results in temporary neural dysfunction. 4.122 Contusion: results from more severe blow that bruises the brain and disrupts neural functions 4.123 Hemorrhage 4.123.1 Epidural Hematoma: accumulation of blood between dura mater and skull, commonly results from laceration of middle meningeal artery during skull fracture; blood accumulates rapidly. 4.123.2 Subdural Hematoma: accumulation of blood between dura and arachnoid; venous bleeding that forms slowly, may be acute or chronic. 4.123.3 Subarachnoid Hematoma: bleeding in sub arachnoid space. 4.123.4 Intracerebral Hematoma: acuumulation of blood within cerebrum 4.124 Fracture: linear, depressed, comminuted and compo

CEREBRAL ANEURYSM A. General Information 1. Dilation of the walls of cerebral artery, resulting in a sac like out pouching of vessel 2. Caused by congenital weakness in the vessel, trauma, arteriosclerosis, hypertension 3. Pathophysiology a. Aneurysm compresses nearby cranial nerves or brain substance reproducing dysfunction b. Aneurysm may rapture, causing sub arachnoids hemorrhage or intracerebral hemorrhage c. Initially a clot forms at the site of rupture, but fibrinolysis (dissolution of the cloth) tends to occur within 7-10 days and may cause bleeding B. Assessment findings:

25

1. Severe headache and pain in the eyes 2. Diplopia, tinnitus, dizziness 3. Nuchal rigidity, ptosis, decreasing LOC, seizures C. Nursing Management 1. Maintain a patent airway and adequate ventilation ask the client to take deep breaths but to avoid coughing Suction only with the specific order 2. Monitor VS and neuro checks and observe for signs of vasospasm, increased ICP, hypertension, seizures and hyperthermia 3. Enforce strict bed rest and provide complete care 4. Keep head of bed flat or elevated to 20-30 degrees as ordered 5. Maintain a quite environment 6. Avoid taking temperature rectally and instruct client to avoid sneezing, coughing and straining at stool 7. Enforced fluid restriction as ordered, maintain accurate I & O 8 Administer medications as ordered: a. Antihypertensive agents to maintain normotensive levels b. Corticosteroids to prevent increased ICP c. Anti convulsants to prevent seizures d. Stool softeners to prevent straining 9. Prevent complications of immobility 10. Institute seizure precautions 11. Provide nursing care for the unconscious client if needed 12. Prepare client for surgery if indicated CEREBROVASCULAR Accident (CVA) A. General Information 1.Destruction (infarction) of brain cells caused by reduction in cerebral blood flow and oxygen 2. Affects men more than women; incidence increase with age 3. Caused by thrombosis, embolism and hemorrhage 4. Risk factors: a. Hypertension, diabetes, arteriosclerosis, cardiac disease (valvular displacement, M.I.) b. Lifestyle: Obesity, smoking, inactivity, stress, use of oral contraceptives 5. Pathophysiology a. Interruption of cerebral blood flow for 5 minutes or more causes deaths of neurons in affected are with irreversible loss of function b. Modifying factors: 1. cerebral edema - develops around affected area causing further impairment 2. vasospasm constriction of cerebral blood flow when there is compromise of main blood supply 6. Assessment Findings: 1. Headache 2. Generalized assigns: vomiting, seizures, confusion, disorientation. decreased LOC, nuchal rigidity, fever, hypertension, slow bounding pulse, Cheyne-stokes respiration 3. Focal signs: (related to site of infarction) 4. Diagnostic tests: CT scan / brain scan may reveal lesions EEG: abnormal changes Cerebral arteriography= may show occlusion or malformation of blood vessels

26

NURSING MANAGEMENT: (CVA) 1. Maintain patent airway and adequate ventilation 2. Monitor VS neuro check and observed signs of increased ICP, shock, hyperthermia 3. Provide complete bed rest 4. Maintain fluid and electrolyte balance and ensure adequate nutrition a. IV therapy for first few days b. NGT feedings if patient unable to swallow c. Fluid restriction as ordered to decreased cerebral edema 5. Maintain proper positioning and body alignment a. head of the bed may elevate 30-4- degrees to decrease UCP b. turn and reposition every 2 hours c. passive ROM exercise every 4 hours 6. Promote optimum skin integrity turn patient and apply lotion every 2 hours 7. Maintain adequate elimination a. offer bedpan or urinal every 2 hours-catheterize if needed b. administer stool softener and suppositories as ordered to prevent constipation and fecal impaction 8. Provide quiet and restful environment 9. Establish a means of communicating with the client 10. Administer medications as order: a. Hyper osmotic agents, corticosteroids to decrease cerebral edema b. Anticonvulsant drug to prevent seizures c. Anti-coagulants for stroke in evolution or embolic stroke i. Heparin ii. Warfarin (caumadin) for long term therapy iii. Aspirin and Persantine to inhibit platelet aggregation in treating transient ischemic attack iv. Anti- hypertensive if indicated for elevated BP HEAD INJURY A. General Information 1. Usually caused by car accidents, falls, assaults 2 Types a. concussion: severe blow to the head jostles brain, causing it to strike the skull; results in temporary neural dysfunction b. Contusion: results from more severe blow that bruises the brain and disrupts neural function c. Hemorrhage: 1. Epidural hematoma: accumulation of blood between dura mater and skull, commonly results from laceration of middle meningeal artery during skull fracture; blood accumulates rapidly 2. Subdural hematoma: accumulation of blood between dura and arachnoid: venous bleeding that forms slowly, may be acute, sub acute or chronic 3. Sub arachnoid hematoma: bleebing in sub arachnoid space 4. Intracerebral hematoma: accumulation of blood within cerebrum d. Fracture: linear, depressed, comminuted and compound B. Assessment Findingds (depend on type of injury) 1. Concusion: headache, transient loss of consciousness, post traumatic amnesia, nausea, dizziness, irritability 2. Contusion: neurologic deficits depend on the site and extent of damage 3. Hemorrhages: a. Epidural hematoma: brief loss of consciousness followed by lucid interval, progresses to severe headache, vomiting, rapidly deteriorating LOC, possible seizures, papillary dilation

27

b. Subdural hematoma: alterations in LOC, neurologic deficits, personality changes, papillary dilation c. Intracerebral hematoma: headache, deceased LOC, hemiplegia, pupillary dilation 4. Fractures a. Headache, pain over fracture site b. Compound fractures: Rhinorrhea (leakage of CSF from nose), Otorrhea (leakage of CSF from ear) 5. Diagnostic tests: a. Skull x-ray: reveals skull fracture or intracranial shift b. CT Scan: reveals hemorrhage C. Nursing Interventions: 1. Maintain patent airway and adequate ventilation 2. Monitor VS and neuro check: observe for changes in neurologic status: signs of ICP, shock, seizures and hyperthermia 3. Observe for CSF leakage a. check discharge for positive test tape for glucose: bloody spot encircled by watery, pale ring on pillow cases or sheets b. Never attempt to clean the ears or nose of a head injured client or use nasal suction unless cleared by physician. 4. If CSF lead is present a. instruct the client not to blow from nose b. elevate head of bed 30 degrees as ordered c. observe for signs of meningitis sand administer antibiotics to prevent meningitis as ordered d. place cotton ball in the ear to absorb otorrhea, replace frequently e. gently place a sterilized gauze pad at bottom of the nose for rhinorrhea, replace frequently 5. Prevent complication of immobility 6. Prepare client for surgery if needed 7. Provide psychological support to client 8. Observe for hemiplegia, aphasia and sensory problems, and plan care accordingly 9. Provide client teachings and discharge planning concerning rehabilitation for neurologic deficits; note availability of agencies

SPINAL INJURY A. General Information 1. Occurs commonly in young adults males between 15-25 2. Common traumatic causes: motor vehicle accidents, sports injuries, gunshot wound, diving in shallow water, falls, industrial accidents 3. Non-traumatic causes: tumors, hematomas, aneurysm, congenital defects 4. Classified by extent, level and mechanism of injury a. extent injury 1. may effect the vertebral column: fracture, dislocation 2. may effect anterior or posterior ligaments, causing compression of spinal cord 3. may be to the spinal cord ad its roots: conclusion, contusion, compression or laceration by fracture b. level of injury: cervical, thoracic and lumbar

c. mechanism of injury 1. Hyperflexion 2. Hyperextension 3. Axial loading (force exerted straight up or down as in a diving accidents)

28

4. Pathophsyiology: hemorrhage and edema cause ischema, leading to necrosis and destruction of the cord B. Medical Management: immobilization and maintenance of normal spinal alignment to promote fracture healing 1. horizontal turning frames 2. skeletal traction: to immobilize the fracture and maintain alignment of the cervical spine a. cervical tongs (crutchfield) inserted through a burr holes; traction is provided by a rope extended from the center tongs over a pulley with weights attached to the end b. halo traction * Stainless steel halo ring fits around the head and is attached to the skull with four pins; halo is attached to plastic vest * Permits early mobilization, decreased period of hospitalization and reduces complication of immobility 3. surgery: decompression laminectomy, spinal fusion, depends on type of injury indications: unstable fracture, cord compression, progression of neurologic deficits C. Assessment Findings: 1. Spinal shock a. Occurs immediately after injury as a result of the insult to the CNS b. Temporary condition lasting from several days to 3 months c. Characterized by absence of reflexes below the level of the lesions, lack of temperature control in affected parts, hypotension with bradycardia, retention of urine and feces 2. Symptoms depend on the level and extent of the injury a. Level of injury 1) Quadriplegic: cervical injuries (C1-C8) cause paralysis of all four extremities: respiratory paralysis occurs in lesion above C4 due to lack of innervations to the diaphragm 2) Paraplegic: Thoraco-lumbar injuries (T1-L4) cause paralysis of the lower half of the body involving both legs Diagnostic tests: spinal x-rays may reveal fracture D. Nursing Intervention: Emergency care a. Assess airway, breathing and circulation Do not move the client during assessment If airway obstruction or inadequate ventilation exists: do not hyper extend neck to open airway, use jaw-thrust maneuver b. Perform quick head to toe assessment: check LOC, signs of trauma to head and neck, leakage of nuclear fluid from ears, nose, signs of motor and sensory impairment c. Immobilize the client in the position found until help arrives d. Once emergency help arrives, assist in the immobilizing the head and neck with a cervical collar and place the client on a spinal board e. Have suction available to clear airway and prevent aspiration of the client vomits; client may be turn slightly to the side if secured to a board E. Nursing Intervention: Acute Care 1. Maintain Optimum respiratory function a. Observe for weak or labored respirations: monitor arterial blood gases b. Prevent pneumonia and atelectasis: turn every 2 hrs; cough and deep breath every hour c. Tracheostomy and mechanical ventilation may be necessary if respiratory insufficiency occurs 2. Maintain optimal cardiovascular function a. Maintain VS; observe for bradycardia, arrhythmias, hypotension b. Apply thigh high elastic stockings

29

c. Change position slowly and gradually elevate the head of the bed to prevent postural hypotension d. Observe signs of deep vein thrombosis 3. Maintain fluid and electrolytes balance and nutrition a. Nasogastric tube may be inserted until bowel sound return b. Maintain IV therapy as ordered; avoid overhydration (edema) c. Check bowel sounds before feeding client (paralytic ileus is common) d. Progress slowly from clear liquid to regular diet Provide diet high in protein, carbohydrates and calories 4. Maintain immobilization and spinal alignment always a. turn every hour on turning frame b. maintain cervical traction at all times 5. Prevent complications of immobility: use footboard to prevent foot drop, provide splint for quadriplegic client to prevent wrist drop 6. Maintain urinary elimination a. Provide intermittent catheterization or maintain indwelling catheter as ordered b. Increase fluid intake to 3000 ml/day 7. Maintain bowel elimination: administer stool softener and suppositories to prevent impact as ordered 8. Monitor temperature control a. Check temperature every hours b. Regulate environment closely c. Avoid excessive covering or exposure 9. Observe and prevent infection a. Observe tongs or pin site if or redness and drainage b. Provide tong or pin site care. Cleanse with antiseptic solution according to agency policy c. Observe for signs of respiratory or urinary infection 10. Observe for and prevent stress ulcers a. Assess for epigastric or shoulder pain b. If costicosteroids are ordered, give with food or an antacids, administer cimetidine (Tagamet) as ordered c. Check nasagostric tube contents and stools for blood BRAIN TUMORS A. General Information 1. Tumor within the cranial cavity, may be benign or malignant 2. Types a. Primary: originates in brain tissue (meningioma) b. Secondary: metastasize from tumor elsewhere in the body (lungs, breast) B. Medical Management: 1. Craniotomy: to remove the tumor when possible 2. Radiation therapy and chemotherapy: mat follow surgery; also for inaccessible tumors and metastatic tumors 3. Drug therapy: hyperosmotic agents, corticosteroids, diuretics to manage increase ICP (edema) C. Assessment Findings: 1. Headache worse in the morning and with straining and stooping 2. Vomiting 3. Papilledema 4. Seizures

30

5. Changes in mental status 6. Neurologic deficit (aphasia, hemiparesis, sensory problems) 7. Diagnostic tests: Skull x-ray, CT Scan, MRI, brain scan reveal presence of tumor Abnormal EEG Brain biopsy D. Nursing Management: 1. Monitor VS and neuro check 2. Observe signs of increased ICP 3. Administer medication as ordered a. Drugs that decrease ICP (dexamethasone Decadron) b. Anti-convulsant drug (phenytoin Dilantin) c. Analgesics for headache (acetaminophen (Tylenol)) 4. Provide support care for any neurological deficit 5. Prepare client for surgery 6. Provide care for effects of radiation therapy 7. Provide psychological support to client and significant others 8. Provide client teaching and discharge planning concerning a. Use side effects of prescribed drugs b. Rehabilitation program for residual deficits

Seizures and Epilepsy Seizure a single event of abnormal discharge in the brain that results in an abrupt and temporary altered state of cerebral function Epilepsy - a chronic disorder of abnormal, recurrent, excessive and self-terminating discharge from neurons. Clinically, epilepsy is characterized by recurring seizures accompanied by a disturbance in some type of behavior. 1. Common causes: Genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity and infections. 2. Status Epilepticus involves a rapid succession of epileptic spasms without intervals of consciousness; it is a potential complication that can occur with any type of seizure, and brain damage may occur. 3. Types of seizures 3.1 Generalized seizures 3.11 Tonic Clonic (grand mal) may begin with an aura - tonic phase involves the stiffening or rigidity of the muscles and usually lasts 10-20 secs, followed by loss of consciousness. - Clonic phase consist of extremities and lasts for 30 secs.

3.12 Absence (petit mal) the individual may or may not consciousness - may occur several times a day - appears to be day dreaming - more common in children 3.13. Myoclonic a brief generalized jerking or stiffening of extremities. 3.14. Atonic or akinetic (drop attacks) sudden loss of muscle tone. Partial seizures 3.21. Simple Partial localized or confined to a specific area - Client remains and may report an aura.

31

3.22. Complex Partial a psychomotor seizure - Temporal lobe is most commonly involved - client loses consciousness for a few seconds Nursing Management: 1. Note time and duration of seizure. 2. If the client is standing or sitting, place the client on a floor and protect the head. 3. Remain patent airway (do not forced the jaws open). 4. Administer oxygen 5. Turn the clients head to the side 6. Administer medications such as IV diazepam, phenytoin, Phenobarbital sodium as prescribed. 7. Instruct the client to avoid alcohol, excessive stress, and fatigue. Cranial Nerve Diseases 1. Trigeminal Neuralgia 1.1. Description a sensory disorder of the fifth cranial nerve that results in severe, recurrent, sharp, facial pain along the trigeminal nerve. 1.2. Assessment pain on the lips, gums, nose or across the checks. Situations that stimulate symptoms are cold, washing the face and after eating meals. 1.3. Nursing Management: 1.31. avoid hot or cold fluids 1.32. small feedings of liquid and soft food 1.33. medications carbamezephine (tegretol), diazepam (valium)

2. Bells Palsy (facial paralysis) 2.1. Description a lower motor neuron lesion of the 7th cranial nerve that may occur as a result of trauma, hemorrhage, meningitis or tumor. It results in one side of the face and recovery usually occurs in few weeks without residual effects. 2.2. Assessment flaccid facial muscles, inability to raise the eyebrows, frown or smile, close the eyelids, or puff out the cheeks, loss of taste. 2.3 Nursing Management: 2.31 Encourage active facial exercises 2.32 Protect the eyes from dryness 2.33 Frequent oral care 2.34 Instruct the client to chew on the unaffected side. 2.35 Administer analgesics and corticosteroids as prescribed. 3. Menieres Disease 3.1 Description: Characterized by recurrent attacks of vertigo associated with deafness and tinnitus and affects both the cochlear and vestibular branches of CN 7. 3.2 Assessment vertigo (rotating), N/v, a feeling in the ears and possible remission between bouts/ 3.3 Nursing management 3.31 Prevent falls because of vertigo 3.32 Proper positioning 3.33 Administer medications such as antihistamine (meclizine) and mild sedatives hypnotics. 4. Glassopharyngeal Neuralgia 4.1 Description the pain is located at the base of the tongue and the throat and much rarer than trigeminal neuralgia. 4.2 Assessment pain may be localized to ears or may radiate from ear to throat and pain may be triggered by swallowing, talking, yawning, laughing. 4.3 Nursing management is same with trigeminal neuralgia.

MENINGITIS A. General Information 1. Inflammation of the meninges of the brain and spinal cord 2. Cause by bacteria, virus or other microorganism 3. May reach CNS

32

a. via the blood, CSF, lymph b. by direct extension from adjacent cranial structure (nasal, mastoid bone, ear, skull fracture) c. by oral or nasopharyngeal route 4. Most common organism: meningococcus, pneumococcus,H. Influenza, Streptococcus B. Assessment findings 1. Headache, photophobia, malaise and irritability 2. Chills and fever 3. Signs of meningeal irritation: a. Nuchal rigidity: Stiff neck b. Kernigs sign: contraction or pain in the hamstring muscle when attempting to extend the leg when hip is flexed c. Opisthotonos: head and heels bent backward and body arched forward d. Brudzinkski sign: Flexion at the hip and knee in response to forward flexion of the neck 4. Vomiting 5. Seizures 6. decreasing LOC C. Diagnostic Test: Lumbar puncture (measurement and analysis of CSF shows increased pressure, elevated WBC and protein, decreased glucose and culture positive for specific microorganism) D. Nursing Management: 1 Administer large doses of antibiotics IV as ordered 2. Enforce respiratory isolation for 24 hours after initiation of antibiotic therapy for some types if meningitis (consult hospital infection control manual for directions) 3. Provide nursing care for increased ICP, seizures, hyperthermia if they occur 4. Provide nursing care for delirious or unconscious client as need 5. Provide bed rest, keep room quiet and dark if client has headache or photophobia 6. Administer analgesic for headache as ordered 7. Maintain fluid electrolyte balance 8. Prevent complications of immobility 9. Monitor vital signs and neuro check frequently 10. Provide client teaching and discharge planning concerning: a. Importance of good diet: high protein, high calorie with small frequent feedings b. Rehabilitation program for residual deficits

ENCEPHALITIS A. General Information 1. Collection of free encapsulated pus within the brain tissue 2. Usually follows an infectious process elsewhere in the body (ear, sinuses, mastoid bone) B. assessment findings: 1. Headache, malaise, anorexia 2. Vomiting 3. Signs of increased ICP 4. Focal neurologic deficits (hemiparesis, seizures) C. Nursing Management 1. Administer large doses of antibiotics as ordered 2. Monitor VS and neuro check 3. Provide symptomatic and supportive care 4. Prepare client for surgery if indicated

DEMENTIA: a generic name that indicates a deterioration of memory and other acquired higher abilities from a normal pre-morbid level of intellectual and social functioning

33

S/S memory impairment (inability to learn new information or recall pre-leraned information) Aphasia (language expression disturbance) Apraxia (impaired ability to carry out motor function activities despite intact motor function) Disturbance in executive functioning (planning, organizing, etc.) Agnosia (failure to recognize or identify objects despite motor function) Diagnostic examination: CT scan/MRI and neuropsychological testing Management: 1. Treat underlying causes B12, deficiency, decrease thyroid function, drug toxicity and brain tumor 2. Safety concern must be mange in patient with problematic behaviors, eq. agitation, sleep disorders 3. Treat depression it is always co-existence with dementia 4. Supportive and sensitive care approach to maintain highest quality life ALZHEIMERS DISEASE: Most common cause of dementia S/S y y y y y y Impaired short and long term memory Difficulty learning, language and vicious spatial functioning Agnosia Apraxia Impaired abstract thinking, judgment and personality Psychiatric manifestation (paranoia, delusions, agitation, depression)

Treatment: y y No specific know cure for A.D the only goal is to improve or slow down loss of memory and cognitive function Maintain independent function for a long time as much as possible

Drug= cholinesterase inhibitors (anticholinesterase) eq. Tacrine, Deneperzil NURSING Management: 1. 2. 3. 4. Safety for patient who are wandering Collaborative multidisciplinary approach Altering physical environment participate in home care

Related Nursing Diagnosis: 1. 2. 3. 4. 5. High risk for injury related to poor memory judgement and control Altered though processes Self care and self management deficit Sleep pattern disturbance related to agitation Altered communication related to cognitive decline

PARKINSONS DISEASE A. General Information

34

i. A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular functions; disorder of the extrapyramidal system ii. Usually occurs in older people iii. Cause unknown; predominantly idiopathic, but sometimes disorder is postencephalitic, toxic arteriosclerotic, trauma or drug induced (aldomet, haloperidol, phenothiazine) iv. Pathophysiology 1. Disorder causes degeneration of the dopamine producing neurons in the substantia nigra in the midbrain 2. Dopamine influences purposeful movement 3. Depletion of dopamine results in degeneration of the basal ganglia B. Assessment Findings: i. Tremor: mainly upper limb ii. Rigidity iii. Bradykinesia: slowness of movement iv. Fatigue v. Stooped posture: shuffling, propulsive gait vi. Difficulty rising from sitting position vii. Mask like face with decreased blinking of eyes viii. Quiet, monotype of speech ix. Emotional lability, depression x. Increase salivation, drooling xi. Autonomic symptoms: excessive sweating, lacrimation, constipation, decreased sexual capacity C. Nursing Management: 1. Administer medication as ordered: a. Levodopa (L-dopa) y increase level of dopamine in the brain, relieves tremor, rigidity and bradykinesia y side effects: anorexia, hallucinations, nausea vomiting, postural hypotension, mental changes, cardiac arrhythmias, GI irritation y administer food or snack to decrease GI irritation y inform client that urine and sweat may be darkened b. Anticholinergic drugs (Cogentin, Artane) y Relieve tremor and rigidity y Inhibits action of acethylcoline y Side effects: dry mouth, blurred vision, constipation, urinary retention, confusion c. Antihistamine (Bendaryl) y decrease tremors and anxiety y side effect: drowsiness 2. Provide safe environment y side rails up y no scatter rugs y handle bars in toilet, hallways 3. Provide measures to increase mobility y active and passive range of motion; stretching exercise, warm baths y assistive devices (crutches, canes, walker etc.) 4. 5. 6. 7. 8. Encourage independence in self care activities Improve communication abilities: practice reading loudly, listen to own voice Refer for speech therapy Maintain adequate nutrition Avoid constipation and maintain adequate bowel elimination

35

9. Provide psychological support

MULTIPLE SCLEROSI (MS) A. General Information 1. Chronic intermittently progressive disease of the CNS, characterized by scatter patches of demyelination within the brain and spinal cord 2. Incidences: a. affects more women than men b. usually occurs from 20-40 years of age c. more frequent in cool climate 3. Cause: unknown, may be slow growing virus or possibly of autoimmune origin B. Diagnostic tests: y CSF studies: increased protein y EEG (electroencephalogram) y CT scan (increase density of white mater) y MRI shows demyelination C. Assessment findings: 1. Visual disturbances: blurred vision, diplopia 2. Impaired sensation: touch, pain, temperature, numbness and tingling 3. Euphoria or mood swings 4. Impaired motor function: weakness, paralysis, spasticity 5. Impaired cerebellar function: ataxic gait, nystagmus, tremor, 6. Bladder retention or incontinence 7. Sexual impotence in male D. Nursing Management 1. Asses client for specific deficits 2. Promote optimum mobility 3. Administer medication as ordered y Corticosteroids- reduces edema at the sight of demyelination y Diazepam (valium), Baclofen (Lioresal) for spasticity 4. Encourage independence in self-care activities 5. Prevents complications of mobility 6. Institute bowel program 7. Maintain urinary elimination 8. Prevent injury related to sensory problems y Test bath water with thermometer y Avoid heating pads, hot bottles y Frequent positioning 9. Provide psychological support 10. Refer for sexual counseling. Alternative methods of sexual gratification

MYASTHENIA GRAVIS A. General Information 1. A neuro muscular disorder which there is a disturbance in the transmission of impulse from nerve to muscle cells at neuromuscular junction, causing extreme muscle weakness 2. Incidence: highest between 20-30 y/o, affects more women than men 3. Cause: though to be autoimmune disorder whereby antibodies destroy acetylcholine receptors site 4. Voluntary muscles are affected, especially those muscles innervated by the cranial nerves A. Assessment findings 1. Diplopia, dysphagia 2. Extreme muscle weakness, increased with activity and reduced with rest

36

3. Ptosis, mask like facial expression 4. Weak voice and horseness B. Diagnostic tests: 1. Tensilon test: IV injection of Tensilon provides spontaneous relief of symptoms (last 5- 10 minutes) 2. EMG (Electromyography) amplitude of evoked potentials decreased rapidly 3. C. Nursing Management 1. Administer anticholinesterase drugs as ordered y Give medication exactly on time y Give with milk and crackers to decrease GI upset y Asses muscle strength before and after medications y Avoid use of morphine and strong sedatives (it results to respiratory depression) 2. Promote optimal nutrition 3. Monitor respiratory status frequently 4. Observe for the following crisis: a. Myasthenic crisis: generalized weakness with inability to swallow, speak or maintain respirations due to great physical and emotional stress and also infectin b. Cholinergic crisis: excessive salivation and sweating, abdominal cramps, diarrhea, nausea and vomiting due to over medication 5. Provide client teaching and discharge planning concerning: a. Nature of the disease b. Use of prescribed medication: side effects and toxicity c. Need top avoid stress, people with URTI d. Use of eye patch for diplopia (alternate eyes) e. Need to wear medic alert bracelet AMYOTROPHIC LATERAL SCLEROSIS (Lou Gehrigs disease) A. General Information: 1. 2. 3. 4. Progressive motor neuron disease, which usually leads to death in 2-6 years Onset usually between 40-70 y/o; affects more men than women Cause still unknown There is no cure or specific treatment: death usually occur as result of respiratory infection secondary to respiratory insufficiency

B. Assessment findings: 1. Progressive weakness and atrophy of the muscles of the arms, trunk or legs 2. Dysphagia 3. Respiratory insufficiency C. Diagnostic tests: EMG and muscle biopsy can rule out disease D. Nursing Management: 1. Provide nursing measures for muscle weakness and dysphagia 2. Promote adequate ventilation 3. Prevent complication of immobility 4. Encourage diversional activity 5. Provide intensive support and understanding 6. Promote independence as much as possible

37