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NEURO
Neurological Anatomy and Physiology
• A. Central nervous system (CNS) - coordinates and controls body functions
• 1. Brain
• a. cerebrum
• hemispheres right and left
• frontal lobe - higher intellectual functions, social behavior, personality, memory retention, expressive speech
• parietal lobe - perceives and interprets sensory input
• temporal lobe - emotional response, memory, receptive speech, organization of sensory input (hearing, taste and smell)
• occipital lobe - vision
• b. cerebellum - provide equilibrium and muscle coordination
• c. brain stem - midbrain, pons and medulla oblongata; controls basic body functions and relays impulses to and
from spinal cord; the connection between the brain and spinal cord
2. Spinal cord
• a. descending tract - anterior portion of cord carrying motor information (associate "d"escending to "d"own impulses are
carried to peripheral nerves)
• b. ascending tract - the posterior portion of cord that carries sensory information up to the brain
c. 31 segments
• eight cervical - neck and upper extremities
• 12 thoracic - thoracic and abdomen
• five lumbar - lower extremities
• five sacral - lower extremities, urine and bowel control
• one coccygeal
B. Peripheral nervous system - connects the central nervous system to sensory organs (eye, ear) and other organs,
muscles, blood vessels and glands
• 1. Sensory nervous system - sends information to the CNS from internal organs or from external stimuli
• 12 pairs of cranial nerves (see next page for more detail)
• 31 pairs of spinal nerves - contain both sensory and motor neurons
• 31 pair - innervate area of skin called dermatome
• 8 cervical - neck and upper extremities
• 12 thoracic - thoracic area and abdomen
• 5 lumbar - lower extremities
• 5 sacral - lower extremities; urine and bowel control
• 1 coccygeal
2. Motor nervous system - carries information from the CNS to organs, muscles, and glands
• a. somatic nervous system - controls skeletal muscle and external sensory organs
• b. autonomic nervous system - controls involuntary muscles, such as smooth and cardiac muscle
• sympathetic - controls activities that increase energy expenditures (speeds up heart rate, dilate pupils, and relax the bladder)
- involved in "fight or flight response"
• parasympathetic - controls activities that conserve energy expenditures (inhibiting heart rate, constricting pupils, contracting
the bladder, maintain GI peristalsis)
C. Cranial nerves - 12 pairs of nerves that arise from the brain and brain stem, carrying motor and or sensory
information
Degenerative disorders
• A. Parkinson's disease
B. Huntington's disease
• Definition: progressive atrophy of basal ganglia and some parts of cerebral cortex
• Etiology: genetic disorder, autosomal dominant
• Findings: usually occurs in middle age, increased involuntary movements, progressive decline in cognitive function
• motor function
• impaired chewing and swallowing
• chorea
• dystonic posture
• gradually becomes bedridden
• cognitive function: less able to organize, plan and sequence behavior; memory loss; declining speech
• mental function: personality changes, depression, even psychosis
• Diagnostics: history and physical exam, genetic testing
• Management
• expected outcome - postpone dependence
• supportive care for findings
• speech and physical therapies
• genetic counseling
• psychotropic agents to manage cognitive changes and tetrabenazine to decrease chorea
• Nursing interventions
• foster independence in ADLs
• reinforce the use of assistive devices for ambulation as needed
• teach client
• maintain good nutrition, increase caloric intake
• get emotional support from support groups, family, friends
• encourage genetic counseling
• discuss end of life issues with partner/family
D. Dementia
• Definition: a loss of brain function that occurs with certain diseases, affecting memory, thinking, language, judgment, and
behavior
• Etiology: varied, depending on cause
• a. reversible dementia
• urinary tract infections
• low levels of vitamin B12
• medications
• hypothyroidism
• b. nonreversible (degenerative) dementia
• Alzheimer's disease - the most common type of dementia
• Vascular dementia - due to stroke or a series of small strokes
• Long-term alcohol abuse
• Other medical conditions including Parkinson's disease, multiple sclerosis, Huntington's disease
• Infections that can affect the brain, including HIV/AIDS, syphilis, Lyme disease
• Findings
• usually first appears as forgetfulness
• difficulty with many areas of mental function:
• language
• memory
• perception
• emotional behavior or personality
• higher levels of cognitive function, e.g., ability to think abstractly, perform calculations
• Diagnostics
• history of behavior changes
• physical exam
• neurological exam, including mental status test, MRI and CT of the head
• laboratory tests to rule out treatable causes: B12 levels, blood ammonia levels, blood gas analysis, cerebrospinal fluid
analysis, toxicology screen, blood glucose, liver enzyme tests, serum calcium, serum electrolytes, thyroid function tests, HIV
screen, Syphilis screen, Lyme titer
• Medical management
• treating conditions that can lead to confusion, e.g., anemia, hypoxia, depression, heart failure, infections, nutritional
disorders, thyroid disorders
• pharmacologic - to control behavior problems caused by a loss of judgment, increased impulsivity, and confusion
• antipsychotics: haloperidol, risperidone, olanzapine
• mood stabilizers: fluoxetine, imipramine, citalopram
• serotonin-affecting drugs: trazodone, buspirone
• stimulants: methylphenidate
• Nursing interventions
• meet client's physical needs
• promote client's independence
• establish a routine
• re-orientation as appropriate
• provide emotional support
• support and reinforce family teaching regarding home care needs of client
E. Alzheimer's disease
• Definition: a type of neurocognitive disorder in which there is memory impairment, as well as problems with language,
decision-making ability, judgment, and personality
• Etiology
• unknown; thought to include genetic and environmental factors
• brain changes associated with Alzheimer's disease:
• neurofibrillary tangles - twisted fragments of protein within nerve cells
• neuritic plaques - abnormal clusters of dead and dying nerve and brain cells
• senile plaques - dying nerve cells that accumulate around protein
• prognosis - incurable and fatal
• Findings
• cognitive deficits with memory impairment
• one or more of the following:
• difficulty naming objects (agnosia)
• language disturbance (aphasia)
• problems with organization and abstract thinking
• difficulty with motor activities (apraxia)
• noticeable decline in level of functioning
• cognitive difficulties are not related to other conditions
• altered sensory perception:
• illusions
• hallucinations
• behaviorial findings:
• wandering - persistent aimless walking
• verbal or physical abuse
• resisting care
• socially inappropriate behavior
• sundown syndrome (also called sundowning)
• Alzheimer's disease typically divided into 3 stages (reflected by behavior changes and physical findings)
EARLY STAGE • subtle personality changes difficulty with abstract
thinking
• forgetfulness and uncertainty causes anxiety,
irritation and withdrawal
• difficulty making decisions, concentrating and
handling work skills
MIDDLE STAGE • impaired language, motor activity and object
recognition
• wandering
• inability to carry out ADLs
• impaired judgment
• severe disorientation, with personality and behavior
changes
• may have difficulty remembering family and friends
• psychotic symptoms, such as hallucinations and
delusions
FINAL/TERMINAL STAGE • client loses the ability to function physically and
mentally
• client becomes mute, incontinent, and totally
dependent
Diagnostics
• history of behavior changes
• physical exam
• neurologic testing, including mental status test, MRI and CT of the head
• laboratory tests to rule out other cause of dementia, including B12 levels, blood ammonia levels, blood chemistry, blood gas
analysis, cerebrospinal fluid analysis, toxicology screen, blood glucose, liver enzyme tests, serum calcium, serum
electrolytes, thyroid function tests, HIV screen, Syphilis screen, Lyme titer
• Medical management
• milieu management - structured routine, decreased stimulation
• managing progressive symptoms and maintenance of functional capacity
• care for the caregiver
• pharmacologic
• drugs that enhance the action or inhibit the breakdown of acetylcholine in the brain:
• a. galantamine
• with meals, twice a day, or every morning (extended release)
• encourage fluids
• b. donepezil
• given once a day before bed
• may be given with or without food
• c. rivastigmine
• given with food twice a day
• may increase dosage at intervals for maximum effect
• memantine - drug that blocks glutamate accumulation and nerve cell destruction in the brain; for moderate to severe
dementia
• antidepressants - selective serotonin reuptake inhibitors (SSRI) given for depression
• antipsychotics - used for control of hallucinations/delusions
• complementary & integrative health
• herbal remedies or dietary supplements - dietary there is no convincing evidence that any dietary supplement (including
ginkgo biloba, vitamins B and E, Asian ginseng, grape seed extract and curcumin) can prevent worsening of cognitive
impairment
• mind & body practices - music therapy can decrease agitation, improve depression and quality of life
• Nursing interventions
• provide safe environment
• discuss legal issues, i.e., living will, power of attorney, end of life
• balanced diet
• monitor for depression
• memory aids
• structured environment, including routines with minimal distractions and noise
• orient client as appropriate
• maintain elimination routine to decrease incontinence
• assist family to enroll client in an identification/return program
• assess for finding of abuse/neglect
• discuss with family the need of daycare/respite care/long-term care
• support family and caregivers
Consciousn
Reduced Clear Clear
ess
Fluctuates; lethargic or
Alertness Generally normal Normal
hypervigilant
Minimal impairment, but it’s
Attention Impaired; fluctuates Generally normal
distractible
Generally impaired;
Orientation Generally normal Selective disorientation
severity varies
Disorganized,
Difficulty with abstraction;
distorted, fragmented; Intact but with themes of
thoughts impoverished;
Thinking incoherent speech, hopelessness, helplessness, or
judgment impaired; words
either slow or self-depression
difficult to find
accelerated
Distorted; illusions,
delusions, and
Intact; delusions and
hallucinations; difficulty
Perception Misperceptions usually absent hallucinations absent except in
distinguishing between
severe cases
reality and
misconceptions
Variable; hypokinetic,
Psychomotor Variable; psychomotor retardation
hyperkinetic, and Normal; may have apraxia
behavior or agitation
mixed
Variable affective
changes; symptoms of Affect tends to be superficial, Affect depressed; dysphoric
autonomic inappropriate, and labile; mood; exaggerated and detailed
Associated hyperarousal; attempts to conceal deficits in complaints; preoccupied with
features exaggeration intellect; personality changes, insight present; verbal
of personality type; aphasia, agnosia may be elaboration; somatic complaints,
associated with acute present; lacks insight poor hygiene, and neglect of self
physical illness
Vital signs:
- Cushing's triad (do not confuse with Cushing reflex):
hypertension; progressively increasing systolic
pressure with widening pulse pressure; bradycardia
Vital signs within normal
Vital Signs - temperature initially may rise significantly then fall
parameters
below normal parameters
- yawning, progressing to Cheyne-Stokes, progressing
to central neurogenic hyperventilation, progressing to
cluster or ataxic breathing and finally apnea
Management
• expected outcomes: to cure the infection and prevent complications
• pharmacologic
• antibiotic therapy depends on the type of pathogen
• antifungals if causative agent is fungus
• anticonvulsants to prevent seizures
• preventive therapy for people exposed to those with meningococcal or Haemophilus influenzae (H flu) meningitis: rifampin;
immunization also available
• actions to minimize fever
• prevention of increased intracranial pressure or seizures
• Nursing interventions
• care of client with increased intracranial pressure
• seizure precautions
• administer medications as ordered
• IV fluids
• monitor electrolytes
• assess neurologic and vital signs
• assess peripheral vascular collapse if causative agent is meningococci
• provide comfort measures for pain
• reduce external stimuli and lighting if photophobic - maintain quiet environment
CLIENT CARE- SEIZURE
The following is an overview of information about the type of care and considerations for individuals who suffer from seizures,
in both clinical and home settings.
• Before a seizure - clinical settings
• Bed rest with padded side rails
• Suction available at the bedside
• Oxygen available at bedside
• During seizures
• Do not leave the client who is seizing
• If standing, attempt to break the client's fall by assisting him/her to floor
• If possible, place a pillow under the client's head
• Loosen any tight or restrictive clothing
• Do not place anything in the mouth
• Do not hold the person down
• Remove objects near the client, if possible
• Support the ABCs (airway, breathing, circulation)
• Provide privacy
• Observe the seizure as it runs its course
• assess behavior at onset of seizure
• be sure to note the time the seizure starts and ends
• immediately notify the rapid response team if the seizure lasts longer than 5 minutes
• After the seizure
• Turn victim on his/her side
• Allow victim to rest/sleep
• Document
• describe characteristics and activity during seizure (do not label or diagnose type of seizure)
• duration
• incontinence
• precipitating factors
• client's response
• immediate
• at 15 minute intervals until stabile or as ordered
• Daily life precautions at home, work and school
• Use a helmet for uncontrolled seizures
• Individuals with uncontrolled seizures should not drive
• generally, they need to be seizure free for six months before they are allowed to drive
• guidelines vary from state-to-state
• Instruct individuals not to
• lock bathroom or shower doors
• swim alone
• climb to high places
• ride a bicycle alone
• Instruct individuals to wear MedicAlert╟ identification at all times
B. Parameningeal infections
• Definition
• localized collection of exudate in the brain or in the spinal cord
• a recurrent aseptic meningitis
• considered noninfectious
• Findings
• similar to meningitis
• headache, fever, stiff neck, altered consciousness - decreased
• Diagnostics
• NO lumbar puncture - may cause herniation
• computerized tomogram (CT) scan
• Management
• expected outcomes - to cure infection and prevent complications
• surgical decompression of abscess
• symptomatic and preventive treatment as with meningitis
• drugs: antibiotics if bacterial, anticonvulsants until infection resolved
• Nursing interventions: same as meningitis except that infectious precautions are not required
C. Encephalitis
• Definition: inflammation of the parenchyma of the brain or spinal cord
• Etiology
• causes: acute viral (most common), bacterial, inflammatory (hypoxic), poisoning (arsenic, carbon monoxide, ammonia [liver
failure])
• can occur as epidemics or sporadically
• may follow a systemic viral illness such as chicken pox
• most cases in the U.S. associated with sporadic encephalitis is herpes simplex virus types 1 and 2, rabies virus, or
arboviruses from the bite of infected ticks, mosquito or other blood sucking insects, e.g., Equine, La Crosse, St. Louis, West
Nile
• death rate ranges up to 70%
• Findings
• adult
• sudden fever
• severe headache
• altered level of consciousness, progressing to stupor then coma with seizure activity
• nuchal rigidity
• change in personality
• mild flu-like complaints
• infant
• vomiting
• body stiffness
• constant crying that worsens when child picked up
• constant full or bulging anterior fontanelle
Diagnostics
• history and physical exam
• CT scan, MRI, EEG
• polymerase chain reaction (PCR) assay
• cerebral spinal fluid - decreased glucose and elevated white blood cells suggests bacterial or fungal infection (not done if
elevated ICP suspected)
• Management
• expected outcomes: to cure infection and prevent infections
• uncomplicated cases require supportive and preventive care
• rest
• support nutritional needs
• monitor for fluid balance maintenance
• pharmacological
• herpes simplex calls for antivirals: acyclovir, vidarabine
• antivirals such as acyclovir
• anticonvulsants - prevent seizures
• prevention of increased intracranial pressure
• mosquito control
• use of insect repellant
• Nursing interventions
• comfort measures for fever
• administer drugs as ordered
• seizure precautions
• care of the client with increased intracranial pressure
• when needed, ensure isolation and airborne or droplet precautions (depending on causative agent)
• maintain patent airway to prevent further hypoxia
• reduce stimuli and lighting if photophobic
• provide family support
D. Botulism
• Definition: acute flaccid paralysis
• Etiology
• food poisoning from anaerobic bacillus Clostridium botulism contaminated food
• three types: infantile, classic, wound
• Findings
• CNS findings usually appear within 12 to 36 hours
• blurred vision, diplopia, lethargy, vomiting and dysphagia, weakness, difficulty speaking, life threatening progressive
respiratory paralysis
CAUSATIVE AGENTS
Management
• supportive - dependent on body system affected
• protect ventilation, respiration, and provide nutrition
• pharmacologic: botulism antitoxin
• Nursing interventions
• observe for and report signs of neuromuscular weakness
• provide time for test - client will tire easily
• assess for swallowing difficulties
• teaching points
• rest during recovery
• normal bowel elimination may not return for a while; no enemas or cathartics
Diagnostics
• history and physical exam
• lumbar puncture
• magnetic resonance imagery (MRI)
• computerized tomogram (CT) scan
• evoked potentials or response - the EEG record of electrical activity at one of several levels in the CNS by stimulation of an
area of the sensory nerve system
• Management
• expected outcomes: to alleviate findings and prevent complications
• pharmacologic: adrenocorticotropic hormone (ACTH), beta Interferon
• therapies based on findings
• physical
• occupational
• pharmacologic
• nutritional
• Nursing interventions
• maintain client's functional independence in activities of daily living
• determine effectiveness of administered medications
• prevent complications of immobility
• prevent injury from difficulties walking
• provide emotional support to client and family
• provide counseling for sexual dysfunction
• teach client
• avoid fatigue and stress
• conserve energy
• exercise regularly
• know drugs and side effects
• use self-help devices
• maintain a diet that supports nutrition and energy needs
• avoid triggers - stress, pregnancy, temperature extremes
• use bladder control measures during exacerbations, e.g., anticholinergics, self-cath
Seizure Disorders
• Definition
• Seizure (layman's term - "convulsion"): single event of abnormal electrical discharge in the brain
• Epilepsy: chronic disorder of abnormal recurring, electrical discharge in the brain
• Etiology
• cerebral lesions
• biochemical alteration, e.g. hypoglycemia
• cerebral trauma
• idiopathic
• acute febrile states (especially in children and infants)
A classification of seizure types: partial, simple, complex, generalized
• 1. Partial seizures
• characteristics
• focal motor
• seizure activity only in specific parts of the brain
• usually client remains conscious
• types
• a. simple partial - with findings associated with:
• motor findings
• special sensory findings
• autonomic findings
• psychic findings
• psychomotor actions
• no loss of consciousness
• b. complex partial
• psychomotor seizure
• impairment of consciousness
• progressing to generalized tonic-clonic
2. Generalized seizures involve both hemispheres of the brain - eight types
• a. absence - also called petit mal
• brief periods (usually less than 10 seconds) of loss of consciousness and blank starring
• usually begin between ages 4 and 14
• b. myoclonic
• sudden, uncontrollable jerking movements of one or more extremities
• usually occurs in the morning
• c. clonic
• characterized by violent bilateral muscle movements
• hyperventilation
• face contortion
• excessive salivation
• diaphoresis
• tachycardia
• d. tonic
• first, client loses consciousness suddenly and muscles contract bilaterally
• body stiffens in opisthotonos position
• jaws clenched
• may lose bladder control
• apnea with cyanosis
• pupils dilated and unresponsive
• usually lasts less than a minute
e. tonic-clonic (also called grand mal) - most common type of seizure
• tonic-clonic movements bilaterally
• may be preceded by prodromal
• lasts 2 to 3 minutes
• often incontinent of bowel/bladder
• after clonic phase, client is unresponsive for about five minutes
• arms and legs go limp
• breathing returns to normal
• possible disorientation or confusion for sometime afterwards
• possible headache and fatigue afterwards
• f. atonic: sudden loss of postural muscle tone with collapse
• g. unclassified seizures
• h. status epilepticus:
• rapid sequence of seizures without interruption or pauses
• medical and nursing emergency
• client in postictal state when next seizure begins
• often occurs due to a sudden stop of maintenance anticonvulsants
• if cerebral anoxia occurs, brain damage or death can follow
• risk for severe organ and muscle hypoxia
Diagnostics
• By the event itself - refer to previous pages
• History and physical exam
• Laboratory
• toxicology screen
• arterial blood gases (ABGs)
• electrolytes
• anticonvulsant therapeutic drug level
• Electroencephalogram (EEG)
• Computerized tomogram (CT) scan
• Possible lumbar puncture
Management
• Expected outcomes: to control or minimize the seizure activity and prevent complications
• Correction of underlying problem
• Pharmacologic
• benzodiazepines, IV such as diazepam, lorazepam - active seizures
• hydantoin anticonvulsants such as phenytoin, fosphenytoin - maintenance
• barbiturates such as phenobarbital - maintenance
• succinimides such as ethosuximide - maintenance
• Vagal Nerve Stimulation Therapy
• Surgery - reserved for those who are unresponsive to medical management
• Nursing interventions
• Administer medications as ordered; be alert for drug interactions that are very common with antiepileptic medications
• Seizure care and precautions
• Teach client
• wear MedicAlert╟ identification
• about medication effects, interactions, and side effects
• be aware of triggers
• techniques to reduce stress
• seizure care at home or at work
• if in public area, after the tonic phase, turn client to side
HEADACHE
Definition
• Pain located in the upper region of the head
• One of the most common neurologic complaints
• Classifications
Recurrent migraine headache
• onset in adolescence or early adulthood
• familial
• involves unilateral, throbbing pain
• may be preceded by an aura or prodrome
• lasts hours to days
• Cluster headaches
• sharp or stabbing pain
• typically eye area
• lasts minutes, up to 4 hours
• Recurrent muscular-contraction headache (pressure, tension headache)
• most common form of headache
• may be direct result of stress, anxiety, depression, drastic changes in caffeine consumption
• Nonrecurrent headaches
• occur with systemic infections and are usually associated with fever
• occur as the result of a lesion, after an invasive spinal cord procedure such as a lumbar puncture, or subarachnoid bleed
• caused by increased intracranial pressure
Findings
• Vary by type of headache
• May include throbbing, nausea, vomiting, visual disturbance, photophobia, tenderness, neck stiffness, and focal neurological
signs
• *Most headaches are caused by muscle contraction or blood flow problem.
Diagnostics
• History and physical exam
• Computing tomogram (CT) scan
• Magnetic resonance imaging (MRI)
• Radiological exam of skull and cervical spine
• Lumbar puncture if inflammation or infection suspected
1. Management of headaches
• Expected outcomes: to alleviate pain, treat underlying cause, prevent recurrence
• Vasoconstriction by pressure or cold
• Management of migraine
• pharmacologic
• non-narcotic analgesics (usually when onset noted): aspirin, acetaminophen, ibuprofen
• opioid analgesics: codeine, meperidine, morphine
• isometheptene
• prophylactic treatment with
• beta-adrenergic blocking agents
• serotonin antagonists
• antidepressants- imipramine
• anticonvulsants- topiramate
• triptans used to stop migraine attacks: frovatriptan, rizatriptan, sumatriptan, and zolmitriptan
• alpha-adrenergic blocking agent blocker: ergotamine tartrate without caffeine or ergotamine with caffeine
• complementary & integrative health
• herbal remedies or dietary supplements - butterbur is effective for migraine prevention; feverfew, magnesium and riboflavin
are listed as "probably effective", coenzyme Q10 is listed as "possibly efffective" for preventing migraines
• mind & body practices - biofeedback and acupuncture; there is limited or inconsistent evidence about the benefits of
massage, relaxation techniques, spinal manipulation or tai chi
• AVOID headache-precipitating foods such as MSG, tyramine, cheese, chocolate, aspartame, alcohol, or sudden
discontinuation of drinks
• 2. Management of cluster headaches
• inhalation of 100 percent oxygen is effective for about 80 percent of clients with cluster headaches
• pharmacologic
• narcotic analgesics: codeine sulfate
• alpha-adrenergic blocking agent: ergotamine tartrate
• prophylactically with serotonin antagonists
• 3. Management of tension headaches
• pharmacologic
• non-narcotic analgesics
• muscle relaxants
• prophylactically - antidepressants and/or doxepin
• complementary & integrative health - biofeedback and acupuncture
Nursing interventions
• Suggest a quiet, dark environment
• Manage pain by prompt medication administration or other comfort measures
• Help client identify precipitating factors and actions for prevention
• Keep NPO until nausea and vomiting subside
• Teach client
• to keep a headache diary
• expected medication actions and side effects, prevent accidental overdose
• alternatives for pain relief including referrals for alternative approaches
• to avoid or minimize trigger factors
• preventive measures
• coping strategies for chronic pain
Head Trauma
• A. Classifications
• Closed versus open injury
• closed is non-penetrating; no break in the integrity of the skull
• open injury: skull is broken, creating direct pathway to brain tissue
Severity
• mild: only momentary loss of consciousness with no neurological sequelae
• moderate: momentary loss of consciousness with a change afterwards in neurological function which is usually not
permanent
• severe: decreased level of consciousness with serious neurological impairment and sequelae
E. Complications
• 1. Cerebral edema
• results in increased intracranial pressure
• results directly from cerebral ischemia, anoxia, and hypercapnia
• 2. Diabetes insipidus (DI)
• DI results from a decreased release of antidiuretic hormone (ADH) and the body excreting too much fluid
• increase in urinary output results in a low specific gravity
• more common in the initial, acute phase of head injury
• 3. Stress ulcer
• head injuries activate both the sympathetic and parasympathetic systems
• stimulation of sympathetic system leads to gastric ischemia from vasoconstriction
• stimulation of parasympathetic system leads to increased release of hydrochloric acid (HCl) into the stomach
• steroid therapy may contribute to the development of ulcers since steroids increase HCl acid
• 4. Syndrome of inappropriate antidiuretic hormone (SIADH)
• too much ADH is produced
• water is excessively retained - hemodilution
• urinary output decreases; urine specific gravity increases effect
• more common in the chronic phase of care after a head injury
• 5. Seizure disorders
• 6. Infection - brain, lungs, urinary system from immobility
• 7. Hyperthermia or hypothermia
H. Management - goal is to reduce or minimize increases in intracranial pressure and protect the
nervous system
• Medications to control increased intracranial pressure
• osmotic diuretics; mannitol - IV piggyback or push
• steroids: dexamethasone - IV push
• barbiturate coma may be induced to treat refractory increased intracranial pressure
• neuromuscular blocking agent such as vecuronium bromide to decrease agitation causing increased ICP; must be used in
conjunction with a sedative
• Surgical correction of underlying cause
• Intraventricular catheter, subarachnoid screw or bolt for management, monitoring intracranial pressure
• Treatment for findings and prevention of complications: seizures, fever, infection, deep vein thrombosis (DVT), stress ulcers
• Therapies
• nutritional support
• respiratory
• occupational
• I. Nursing interventions
• Provide care of the client with increased intracranial pressure
• seizure care and precautions
• care of the client on ventilator - important to decrease PaCO2 to prevent ischemia; prevent hypercarbia and keep the PaCO2
35-38
• observe for rhinorrhea, otorrhea and test for glucose if drainage present
• care of the client undergoing surgery
• Monitor for balanced nutrition and fluids
• Assist with activities of daily living as indicated
• Prevent complications of immobility
• Monitor neurologic signs, including level of consciousness and cranial nerve function
• Assess and record Glasgow Coma Scale scores for eye opening, verbal response and motor response
• Complete full neurological checks frequently
• Monitor vital signs - abnormal respiratory patterns may be the first to indicate change in neurologic function
• Positioning - head of the bed elevated 15▪ to 30▪ (or as advised by health care provider) with head positioned midline
avoiding extension or flexion of the neck
• Administer medications as ordered
• Provide emotional support with appropriate referrals for family and client
• With severe brain injury, discuss end of life/legal issues with family
Etiology: unknown
• often occurs during periods of high stress
• possible herpes simplex virus (HSV) involvement
• Findings: often occur suddenly over 10 to 30 minutes (occurs unilaterally)
• ptosis with excessive tearing
• cannot close or blink eye
• flat nasolabial fold
• impaired taste
• lower face paralysis
• difficulty eating - impaired mastication of food and difficulty swallowing
• Diagnostics: history and physical exam (must rule out other diagnoses such as stroke)
Management
• expected outcome: to restore cranial nerve function
• pharmacologic
• prednisone
• antivirals - acyclovir
• analgesics
• moistening eye drops
• local comfort measures: heat, massage and electrical nerve stimulation for muscle tone
• alternative therapies: Reiki, massage, imagery
• Nursing interventions
• reinforce balanced nutrition with a soft diet
• administer drugs as ordered
• teach client
• to chew on the side opposite paralysis
• how to use protective eye wear during risk periods - patch or glasses over eye
• actions and side-effects of medication
• the use of eye drugs, e.g. artificial tears, or ointment to protect the eye from corneal irritation
• once findings disappear, their return may occur especially in times of high stress
• continue meticulous oral hygiene and care
• disorder is typically temporary and function is restored in about six months
• provide support for client and family
POINTS TO REMEMBER
• The American Stroke Association lists weakness on one side of the body as one initial warning sign of a stroke, along with
sudden confusion, sudden trouble speaking or understanding, sudden trouble seeing or sudden headache.
• Parkinson's disease does not initially affect intellectual ability; however, some clients with PD may eventually experience
changes in memory, thinking or reasoning. Also, many clients may develop depression later in the disease process, which is
characterized by withdrawal, sadness, loss of appetite and sleep disturbances.
• Clients diagnosed with myasthenia gravis experience progressive muscle weakness. To minimize the risk of aspiration and to
facilitate chewing and swallowing, anticholinesterase inhibitors, such as pyridostigmine (Mestinon), should be taken before
meals.
• The pain of a cluster headache comes on suddenly and usually subsides quickly, before even over-the-counter pain relievers
such as ibuprofen or acetaminophen can start working. Triptans can provide effective acute treatment for cluster headaches.
• Questions requiring a simple yes or no response (close-ended questions) are used if thinking abilities are impaired.
• Delirium, or acute confusional state, is not a disease but a transient and potentially reversible disorder of cognition. It is often
mistaken for a neurocognitive disorder (formerly referred to as dementia) or even an acute schizophrenic reaction.
• Trigeminal neuralgia is one of more common causes of chronic and excruciating facial pain. Anticonvulsants help to decrease
pain impulses and produce pain relief. The muscle relaxant baclofen may be used as an adjunct to anticonvulsants.
• These are some of the classic findings of meningitis, which can occur quickly or over several days after exposure. However,
infants may present with high fever, constant crying, excessive sleepiness or irritability and poor feeding.
• Rigid contracture of muscles (the tonic phase) is usually brief. The clonic component is the rhythmic shaking that occurs
during the seizure; it lasts longer than the tonic component. A generalized tonic-clonic seizure is also known as a grand mal
seizure.
• Many things can trigger migraine headaches, including hormonal changes, stress, sensory stimuli and sleep (too much or too
little). Common food triggers include alcohol, aged cheeses (which contain tyramine), chocolate, overuse of caffeine and
MSG.
• Ischemic strokes account for about 87% of all stroke cases and are caused by an obstruction within a blood vessel supplying
blood to the brain (either a thrombosis or embolism).
• Guillain-Barré is a progressive, inflammatory autoimmune response occurring in the peripheral nervous system. The
autoimmune response results in damage to myelin sheath and slows or alters nerve conduction. It is not caused by an acute
infection.
• General Points
• Peripheral nerves can regenerate whereas nerves in the spinal cord do not regenerate.
• In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition and bowel
control.
• Tremors associated with Parkinson's disease occur at rest ("resting tremor"); the tremor usually stops when the client begins
an action, such as reaching for something.
• The client with myasthenia gravis will have more severe muscle weakness in the evening due to the fact that muscles
weaken with activity - described as progressive muscle weakness - and clients usually regain strength with rest.
• When caring for a comatose client, remember that the hearing is the last sense to be lost.
• Changes in a client's respirations (rate, rhythm and depth) are more sensitive indicators of increases in intracranial pressure
than blood pressure and pulse.
• Spinal cord injury and traumatic brain injury causes major life changes. Monitor for depression and provide support for client
and family.
• Monitor respiratory status of client with amyotrophic lateral sclerosis and discuss end of life issues/care.
• Clients with migraines should be taught to avoid triggers and take medication at the onset of pain.
• Alzheimer's Disease
• Alzheimer's victims should not be concurrently treated with donepezil and the antidepressant paroxetine; donepezil increases
acetylcholine in the brain and paroxetine works by decreasing acetylcholine levels in the brain.
• Monitor and prevent injury to the client with Alzheimer's disease when wandering; divert activity if possible.
• Stroke
• Clients with CVAs are at a greater risk for aspiration; a speech language therapist should evaluate for dysphagia.
• After a CVA, clients often have a loss of memory, emotional lability and a decreased attention span.
• Communication difficulties of a client with a CVA usually indicate involvement of the dominant hemisphere (usually the left
brain) and is associated with right-sided hemiplegia or hemiparesis.
• A major problem often associated with a left-sided brain infarction (CVA) is an alteration in communication.
• Seizures
• Teach clients with a seizure disorder to routinely take prescribed medication and not abruptly discontinue the medication.
• The priority when caring for a client having a seizure is to protect the client from injury - side rails should be up and padded;
oxygen and suction should be at the bedside at all times.
• During a seizure, do not force anything into the client's mouth or attempt to suction the mouth.
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