Care of the Patient With a Neurological Disorder

biologyofneurologicaldisorders1

Neurological Assessment

  • History
  • Headaches
  • Loss of function
  • Visual acuity
  • Seizures
  • Numbness
  • Pain
  • Personality change
  • Mood swing
  • Fatigue
  • Mental Status
  • Orientation
  • Mood and behavior
  • General knowledge
  • Short term memory
  • Long term memor
  • Level of consciousness
  • Glasgow Coma Scale
  • Eye opening
  • Verbal response
  • Motor response
  • Language and Speech
  • Aphasia:
  • Sensory
  • Expressive
  • Global

Cranial Nerves

  • I. Olfactory
  • II. Optic
  • III. Oculomotor
  • IV. Trochlear
  • V. Trigeminal
  • VI. Abducens
  • VII. Facial
  • VIII. Acoustic
  • IX. Glossopharyngeal
  • X. Vagus
  • XI. Spinal Accessory
  • XII. Hypoglossal

 

Neuro Assessment

  • Motor Function
  • Paralysis
  • Paresis
  • Flaccid
  • Spastic
  • Sensory and Perceptual Status
  • Pain
  • Touch
  • Temperature
  • Proprioception
  • Unilateral neglect
  • Hemianopia
  • Blood and urine
  • ABG
  • Lumbar puncture
  • Imaging
  • EEG
  • EMG
  • Carotid Duplex

 

Neurological Problems

  • Headache

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  • Vascular – migraine, cluster, hypertensive
  • Tension – stress
  • Traction-inflammatory – infection, occlusion vessels
  • Increased Intracranial Pressure (IIP)
  • Occurs slowly or rapidly
  • May lead to brain stem herniation and death

 

Assessment of IIP

  • Subjective
  • Diplopia
  • Personality change
  • Thought processes change
  • Headache
  • Nausea
  • Objective
  • Decreasing LOC
  • Hyperthermia
  • Weakness
  • Vomiting
  • Seizures
  • Papilledema
  • Posturing
  • Wide pulse pressure
  • Bradycardia
  • Altered respirations
  • Pupils fixed & dilated
  • Diagnostic tests:
  • CT scan, MRI
  • Close observation
  • Craig’s screw

 

Medical Management of IIP

  • Craniotomy
  • Craniectomy
  • Tumor removal
  • Drainage of ventricles
  • Drainage of hematoma
  • Intubation
  • Medications
  • Osmotic diuretics – Mannitol
  • Corticosteroids – Decadron
  • Anticonvulsants – Dilantin
  • Internal monitoring

 

Nursing Care of the Patient With IIP

  • Elevate HOB
  • Neck in neutral position
  • Avoid flexion hips, waist and neck
  • Avoid isometric activity or Valsalva
  • Restrict fluids
  • Foley
  • Suctioning
  • O2
  • Hypothermia blanket

Neurological Disorders – Seizures

  • Seizures
  • Disorderly neuron discharges in brain
  • Transitory
  • Different types affect body differently
  • Involuntary movement usually
  • Generalized:
  • Tonic-clonic – grand mal
  • Absence – Petit mal
  • Myoclonic
  • Atonic or akinetic
  • Localized: (Focal)
  • Partial (Jacksonian)
  • Psychomotor

 

Causes:

  • Hypoglycemia
  • Infection
  • Electrolyte imbalance
  • Trauma
  • IIP
  • Toxins

Seizure Medications

  • Dilantin (Phenytoin)
  • Phenobarbital
  • Mysoline
  • Tridione
  • Valium (Diazepam)
  • Depakene
  • Clonopin
  • Mesantoin
  • Neurontin
  • Lamictal
  • Felbatol
  • Cerebyx

 

Nursing role in seizures:

  • Medications
  • Continue meds
  • Medic alert ID
  • Avoid alcohol, avoid driving, get adequate rest
  • If on Dilantin, instruct on oral hygiene
  • Protect
  • Lower to the floor; pad side rails; pillow under head; don’t restrain
  • No bite block or padded tongue blade
  • Allow for post-ictal rest
  • Prevent aspiration (airway)
  • Turn side; loosen clothing around neck
  • Document everything

 

Degenerative Neuro Diseases

  • Multiple Sclerosis
  • Parkinson’s Disease
  • Alzheimer’s Disease
  • Myasthenia Gravis
  • Amyotrophic Lateral Sclerosis (ALS)
  • Huntington’s Disease (chorea)

 

Multiple Sclerosis

  • Common degenerative neurological disease.
  • Myelin sheath is destroyed.
  • Symptoms vary.
  • Relapsing/remitting.
  • Usually ages 20-40

Multiple Sclerosis – Symptoms

 

Subjective:

  • Shakiness, difficulty walking
  • Fatigue, muscle weakness
  • Numbness, tingling
  • Tinnitus
  • Visual problems
  • Difficulty chewing and speaking
  • Incontinent; impotent

Objective:

  • Ataxia
  • Changes in behavior & emotions
  • Nystagmus
  • Spasticity, tremors, dysphagia, facial palsy, speech impaired, fatigue
  • Incontinence
  • Impaired judgment

Multiple Sclerosis – Tests

  • CSF
  • CT scan
  • MRI

 

Multiple Sclerosis – Treatment

Medications:

  • Anti inflammatory
  • ACTH, Solu Medrol, Prednisone
  • Immuno Modifiers
  • Avonex, Betaseron, Capoxone
  • Muscle Relaxants
  • Valium

 

Multiple Sclerosis – Nursing Interventions

  • Nutrition
  • Skin Care
  • Activity
  • Control of environment
  • Emotional support
  • Patient teaching

 

Parkinson’s Disease

  • Unknown cause
  • Lack of dopamine.
  • Parkinsonism: encephalitis, toxic chemicals, meds, drugs

Symptoms include:

  • Muscular tremors and rigidity
  • Emotional instability
  • Judgment defects
  • Heat intolerance
  • Mask-like facial appearance
  • Dysphagia and drooling

Parkinson’s Testing

  • No specific test to diagnose Parkinson’s
  • Diagnosis based on symptoms

 

Parkinson’s – Medical Treatment

Medications

  • Sinemet, Symmetrol, Levodopa or Cogentin
  • Less effective over time
  • Surgery
  • Experimental

 

Parkinson’s – Nursing Care

  • Prevent injury (fall or aspiration)
  • Prevent urinary retention and constipation
  • Patient teaching about medication
  • Patient and family support

 

Alzheimer’s

  • Unknown cause, but genetic link
  • Very common; risk increases with age
  • Brain changes:
  • plaques
  • tangled neurons
  • blood vessel degeneration
  • chemical changes

Alzheimer’s – Symptoms

1st– memory lapses, difficult word finding, decreased attention span

2nd – increased memory problems, disoriented to time, loses things, confabulates

3rd – total disorientation, apraxia, wanders

4th – severe impairment

 

Alzheimer’s – Testing

  • No definitive test
  • Family history
  • Diagnosis: autopsy

 

Alzheimer’s – Medical Management

  • Medication to treat symptoms
  • Memory:Cognex, Aricept
  • Agitation: Mellaril, Haldol
  • Supplements
  • Folic Acid & Vitamin B12
  • Low fat diet
  • NSAIDS

Alzheimer’s – Nursing Care

  • 2 key points for all care:
  • Prevent overstimulation
  • Provide structured, orderly environment
  • Other concerns
  • Communication
  • Family support and education

 

Myasthenia Gravis

  • Autoimmune disorder
  • Myoneural junction problem
  • Symptoms:
  • ptosis, diplopia,
  • weakness, dysarthria, dysphagia, difficulty sitting up, respiratory distress

Myasthenia Gravis – Treatment

  • Medication
  • to improve impulse transmission (Mestinon)
  • to suppress immune system (steroids, Cytoxan)
  • Plasmapheresis
  • Respiratory support
  • Safety

 

Amyotrophic Lateral Sclerosis ALS – Lou Gehrig’s disease

  • Motor neurons in brain stem and spinal cord degenerate
  • Brain’s messages don’t reach the muscles
  • Symptoms – weakness, dysarthria, dysphagia
  • No loss of cognitive function
  • No cure, death occurs in 2-6 years

 

Huntington’s Disease Chorea

  • Genetic
  • Onset at age 35-45
  • Excessive involuntary movements
  • Death in 10-20 years
  • No cure
  • Nursing interventions are palliative
  • Give meds
  • Provide for safety
  • Provide adequate diet
  • Emotional support
  • Genetic counseling

 

Cerebrovascular Accident (CVA)

  • Ischemia of brain tissue
  • Hemorrhage
  • Thrombus
  • Embolus
  • 3rd leading cause of death in the US
  • All ages, but usually elderly

 

CVA – Contributing Factors

  • Atherosclerosis
  • Heart disease
  • Kidney disease
  • Hypertension
  • Obesity
  • High cholesterol
  • Cigarette smoking
  • Stress
  • Sedentary
  • Diabetes
  • Oral contraceptives
  • Cocaine

 

Cerebral Thrombosis

  • Most common cause of CVA
  • Most often:
  • Atheroclerosis   –> Thrombus —> CVA

 

Cerebral Embolism

  • 2nd most common cause of CVA
  • Most often: Heart disease —> Thrombus –> Embolus —> CVA

Cerebral Hemorrhage

  • 3rd most common cause of CVA
  • Most often: Hypertension –> Ruptured cerebral blood vessel –> CVA

Transient Ischemic Attack

  • Cerebrovascular insufficiency
  • Causes – same as CVA
  • Warning sign of impending CVA

 

CVA – Assessment

  • Motor changes
  • Opposite side
  • Balance, coordination, gait, proprioception
  • Glasgow Coma Scale
  • Sensory Changes
  • Aphasia =can’t speak or write
  • Agnosia =can’t recognize familiar objects/people
  • Apraxia =can’t perform purposeful acts or use objects properly
  • Neglect Syndrome
  • Visual problems, including hemianopsia
  • Cognitive changes
  • denial
  • impaired memory, judgment
  • can’t concentrate
  • disoriented
  • slow and cautious versus impulsive
  • depressed, anxious versus euphoric
  • angers quickly versus constantly smiling

 

CVA – Testing

  • CT or MRI
  • Cerebral angiogram
  • CBC, PT, PTT, electrolytes

 

CVA – Medical Management

  • Thrombolytic (“clot buster”)
  • Anticoagulants
  • Antiplatelet drugs
  • Aneurysm repair
  • Carotid endarterectomy

 

CVA – Nursing Care

  • Assess LOC
  • IV, NG, Foley, Vent.
  • Nutrition
  • Encourage perform ADLs
  • Bladder and bowel training
  • ROM
  • Teaching and emotional support

 

Trigeminal Neuralgia Tic Douloureux

  • Trigeminal nerve – degeneration, pressure
  • Facial pain
  • Medication, surgery
  • Avoid triggers

 

Bell’s Palsy

  • Facial nerve inflammation
  • Unilateral weakness of facial muscles
  • Steroids, Zovirax, warm moist cloth, massage, facial exercises

 

Infection and Inflammation

  • Meningitis
  • Encephalitis
  • Brain abscess
  • Guillain-Barré
  • Neurosyphilis
  • Poliomyelitis
  • Herpes zoster
  • AIDS

 

Guillain-Barré – Polyneuritis

  • Peripheral nerve disease
  • Prior infection; autoimmune response
  • Weakness and paralysis, begins in extremities and works up
  • Respiratory failure may occur

 

Meningitis

  • Acute infection of the meninges
  • Viral or bacterial
  • Severe headache, irritable, fever, delirium, N/V, neck stiffness
  • Kernig’s sign
  • Brudzinski’s sign

 

Meningitis-Medical Management

  • Diagnosed by LP
  • Medications
  • Respiratory isolation
  • Cool, dark quiet room
  • Maintain hydration
  • Prevent injury

 

Acquired Immunodeficiency Syndrome – AIDS

  • AIDS dementia complex
  • Infection of CNS
  • Dementia
  • Treatment depends on infection
  • Treat symptoms, maintain safety

 

Spinal Cord Trauma

  • Complete cord injury – all voluntary movement below level of trauma is lost
  • Autonomic hyperreflexia
  • stimulus
  • sympathetic nervous system response

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