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C.

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

Definition: degenerative disorder of the dopamine-producing neurons


• results in dopamine depletion
• usually occurs in older adult males
• Etiology
• linked to genetic defect
• associated with neuroleptics, toxins, structural or vascular lesions in the brain
• Findings: may initially be unilateral, progressing to bilateral movements affected
• resting tremors of the lips, jaw, tongue, and limbs, especially a resting pill-rolling tremor of one hand that is absent during
sleep
• bradykinesia/akinesia
• fatigue
• stiffness and rigidity with movement
• mask-like facial expression often accompanied with drooling
• slow, shuffling walk in a stooped-over posture; gradually more difficulty with walking
• difficulty rising from sitting position
• ultimately confined to a wheelchair
• mental function remains intact unless other aggravating conditions
• echolalia in most cases
To remember the classic findings of Parkinson's disease, think T.R.A.P.
T = tremors
R = rigidity
A = akinesia/bradykinesia
P = postural instability
Diagnostics
• based on findings with history, response to pharmacologic agents
• electroencephalogram (EEG)
• magnetic resonance imaging (MRI)
• positron emission test (PET)
• Management
• expected outcomes: palliative and to postpone dependence
• pharmacologic
• anticholinergics - minimize extrapyramidal effects
• benzotropine mesylate
• procyclidine
• dopamine hydrochloridergics: Levodopa (L-Dopa), levodopa-carbidopa
• dopamine receptor agonists: bromocriptine mesylate, rotigotine patch
• antiparkinsonian agent: amantadine HCl reduces rigidity and tremor
• MAO inhibitors: selegiline, selegiline
• others
• COMT inhibitors: tolcapone
• entacapone (if combined with carbidopa and levodopa the medication is Stalevo)
• complementary & integrative health
• mind & body practices - there's some evidence that tai chi (along with medication) can improve balance and functional
mobility
• there is no evidence that coenzyme Q10 or any other dietary supplements or herbal supplements are effective
• therapies: physical, occupational, speech
• surgery - to decrease tremor
• stereotactic pallidotomy - pinpoint areas to be treated surgically
• thalamotomy
• deep brain stimulation - when pharmacologic therapy ineffective
Nursing interventions
• maintain safety of client
• prevent effects of immobility
• foster independence in activities of daily living (ADL)
• reinforce the use of assistive devices for ambulation as indicated
• promote good nutrition
• small, frequent meals
• soft foods
• roughage with sufficient fluids to decrease constipation
• monitor effectiveness or ineffectiveness of administered medications
• provide emotional support to client and family members
• teach client
• when and what side effects of the drugs to report
• the benefits of daily exercise
• the benefits of "drug holidays"
• safety and injury prevention

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

C. Amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease)


• Definition: neurological disease in which progressive degeneration of the motor neurons of the anterior horn cells of the
spinal cord, brainstem, and motor cortex causes muscle weakness, disability, and eventually death
• Etiology: unknown
• onset in later middle age; more in men than in women
• clients with ALS usually die within 2 to 6 years
• Findings
• usually beginning in the upper body (the head and arms, the distal portion first) or may begin with muscle twitching and
weakness in an arm or leg
• mild clumsiness progressing to total incapacity
• muscle wasting, atrophy, spasticity
• speech disorders
• no change in sensation or autonomic system
• death most often from complications including respiratory failure, urinary or pulmonary infections
• mind remains intact while client has loss of voluntary and eventually involuntary muscle functions
• Diagnostics: history and physical exam, creatine kinase (CK), and electromyogram (EMG)
• Management - goal is to keep client functionally independent as long as possible
• pharmacologic
• muscle relaxants for spasticity
• Riluzole - neuroprotector to extend life expectancy
• therapies
• speech
• physical
• respiratory support
• nutritional support
• Nursing interventions
• provide for respiratory care and referrals
• maintain a safe environment focused toward infection prevention
• prevent complications of immobility, especially pulmonary and urinary stasis
• postpone dependence
• promote balanced nutrition
• provide emotional support and referrals to support groups
• discuss end of life issues and the need for hospice

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

F. Comparing and contrasting delirium, dementia, and depression


Use this chart to better understand the similarities and differences between delirium (an acute condition), dementia (can be
acute or chronic), and depression.

Delirium Dementia Depression

Sudden/abrupt; depends Coincides with major life


Insidious/slow and often
Onset on cause; often at twilight changes; often abrupt, but
unrecognized; depends on cause
or in darkness can be gradual

Short, diurnal fluctuations Long, no diurnal effects; Diurnal effects, typically


in symptoms; worse at symptoms progressive yet worse in the morning;
Course
night, in darkness, and on relatively stable over time; may situational fluctuations, but
awakening see deficits with increased stress less than with delirium

Variable; rapid or slow but


Progression Abrupt Slow but uneven
even

Hours to less than one At least 6 weeks; can be


Duration Months to years
month; seldom longer several months to years

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

Selective or “patchy” impairment;


Recent and immediate “islands” of intact memory;
Memory Recent and remote impaired
impaired evaluation often difficult due to
low motivation

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

Sleep/Wake Disturbed; cycle may Disturbed; usually early morning


Fragmented
cycle be reversed awakening

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

Failings highlighted by family,


frequent “near miss” answers; Failings highlighted by individual,
struggles with test; great effort frequent“don’t knows”; little effort;
Distracted from task;
Assessment to find an appropriate reply; frequently gives up; indifferent
numerous errors
frequent requests for feedback toward test: does not care or
on attempt to find answer
performance

 Cerebrovascular Accident (CVA, Stroke, Cerebral Infarction)


• Definition: decreased blood supply to the brain
• Risk factors
• hypertension (uncontrolled)
• smoking
• obesity
• increased blood cholesterol and triglycerides
• atrial fibrillation
• Five classes of stroke - by severity
• 1. transient ischemic attack (TIA), "angina" of the brain
• TIA is warning sign of stroke
• localized ischemic event
• produces neurological deficits lasting only minutes or hours
• full functional recovery within 48 to 72 hours
• 2. reversible ischemic neurological deficit (RIND)
• similar to TIA
• symptoms last between 24 hours and three weeks
• usual full functional recovery
• 3. partial, nonprogressing stroke: some neurological deficit, but stabilized
• 4. progressing stroke (stroke in evolution)
• deteriorating neurological status
• residual neurological deficits
• 5. completed stroke - neurological deficits permanent
Two basic types of stroke
• 1. ischemic (also known as occlusive) stroke - slower onset
• results from inadequate blood flow leading to a cerebral infarction
• caused by cerebral thrombosis or embolism within the cerebral blood vessels
• most common cause of all strokes (typically due to atherosclerosis)
2. hemorrhagic stroke (bleeding) - abrupt onset
• intracerebral hemorrhagic stroke
• blood vessels rupture with a bleed into the brain
• occurs most often in hypertensive older adults
• may also result during anticoagulant or thrombolytic therapy
• subarachnoid hemorrhage (SAH)
• most often caused by rupture of saccular intracranial aneurysms
• more than 90% are congenital aneurysms
• epidural bleeds
• cerebral arterial vessels are involved
• often a loss of consciousness for a short period of time called transient unconsciousness
• subdural bleeds
• veins are involved
• may not be evident until months after an initial trauma

Findings (depend on the location of the lesion)


• Sensoriperceptual/vision-related - homonymous hemianopia, agnosia, apraxia, diplopia, sensory loss (touch, pain, cold)
• Communication-related
• expressive aphasia or non-fluent aphasia (Broca's) - the client knows what he or she wants to say, yet has difficulty
communicating it to others
• receptive aphasia or fluent aphasia (Wernicke's) - the client can hear a voice or read the print but may not understand the
meaning (or may take the message literally)
• mixed aphasia (global)
• dysarthria - a speech disorder caused by disturbance of muscular control
• agraphia - inability to write or spell
• Motor-related - hemiplegia, hemiparesis, flaccidity, spasticity
• Behavior-related - emotional lability, loss of social inhibitions, fear, anger, hostility
• Elimination-related - urinary frequency and urgency, incontinence (bowel and urinary)
• Neurologically-related - altered level of consciousness, seizures, hyperthermia
Diagnostics
• History and physical exam; provider should evaluate all suspected stroke victims within 10 minutes of arrival to hospital
• Computerized tomogram (CT) scan within 25 minutes of arrival to hospital (initially without contrast if hemorrhagic event is
suspected)
• Magnetic resonance imaging (MRI)
• Doppler echocardiography flow analysis
• Carotid artery duplex doppler ultrasonography
• EEG - shows abnormal electrical activity
• Lumbar puncture - shows if blood is found in the cerebral spinal fluid as a result of a cerebral bleed (contraindicated with
increased intracranial pressure)
• Cerebral angiography - may be done with or without contrast to show blood flow in cerebral arteries
Management: dependent on the type of CVA
• 1. Occlusive/ischemic stroke
• pharmacologic
• thrombolytics: tissue plasminogen activator (tPA), alteplase - must rule out hemorrhagic stroke via CT scan prior to
administration
• anticoagulant therapy: heparin, warfarin
• antiplatelet therapy: aspirin, dipyridamole
• platelet aggregation inhibitor: clopidogrel, ticlopidine
• steroids: dexamethasone
• blood pressure management: to maintain cerebral perfusion pressure (CPP)
• surgery - if carotid artery is stenotic or partially occluded - carotid endarterectomy or angioplasty with stenting
• 2. Hemorrhagic stroke
• pharmacologic
• antihypertensive agents
• systemic steroids: dexamethasone
• osmotic diuretics: mannitol
• antifibrinolytic agents: aminocaproic acid
• anticonvulsants
• surgical excision of aneurysm or clot/hematoma
• 3. Common to both types of stroke
• care based on findings
• care of the client with elevated ICP
• early mobilization of rehabilitation therapies
• physical
• speech
• occupational
• behavioral
• nutrition
CLIENT CARE- ICP
Increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation.

Early Findings* Late Findings


*Since the cause of ICP is often localized, changes may initially be noticed unilaterally and progress to bilateral as
the pressure increases.
Level of
restlessness, agitation, irritability,
consciousness stupor, semicomatose, comatose
disorientation, confusion, lethargy
(LOC)

gradually dilated ipsilaterally, react


Pupils slowly to light; changes in visual dilated bilaterally and fixed; no reaction to light
acuity, diplopia, blurred vision

Abnormal motor activity: decorticate posture then decerebrate posture; flaccid


Motor Activity
contralateral hemiparesis muscles at end stage

Abnormal reflexes: hyper- or


Reflexes
hyporeflexia

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

Other vomiting, headache, seizures


The following is a list of nursing interventions for a client with increased ICP.
•Elevate the head of the bed 15 - 30▪, with the client's head positioned midline (to encourage jugular venous drainage)
•Monitor respiratory status and prevent hypoxia
•Administer oxygen as ordered
•Avoid administration of morphine sulfate to prevent hypoxia from occurring
•Maintain mechanical ventilation as prescribed (initial treatment to maintain PaCO2 at 30-35 mm Hg will result in
vasoconstriction of the cerebral blood vessels, decreased blood flow, and, therefore, decreased ICP)
•Maintain body temperature, to prevent shivering (which can increase ICP)
•Decrease environmental stimuli
•Monitor electrolyte levels and acid-base balance
•Monitor intake and output
•Limit fluid intake to 1200 mL/day
•Instruct the client to avoid straining activities
•coughing, sneezing
•Valsalva's maneuver
•Laughing
•Straining at stool
•Vomiting
•Restrictive clothing around neck
•Anxiety
•Pushing up in bed with heels or pulling on rails when turning
•Administer medications as ordered
•Anticonvulsants
•Antipyretics and muscle relaxants
•Blood pressure medication
•Corticosteroids
•Intravenous fluids
•Hyperosmotic agent
•Institute seizure precautions
•Monitor for changes in intracranial pressure
•Altered level of consciousness
•Headache
•Abnormal respirations
•Rise in blood pressure with widening pulse pressure
•Slowing pulse
•Elevated temperature
•Vomiting
•Pupil changes
•Changes in motor function
•from weakness to hemiplegia
•a positive Babinski's reflex
•decorticate or decerebrate posturing
•seizures
•Observe for herniation syndrome
•Irregular breathing
•Irregular pulse
•Loss of all brainstem reflexes, e.g., blinking, gagging, pupils reaction to light
•Progressive loss of consciousness
•Respiratory arrest
•Cardiac arrest
•Provide for the care of the unconscious client if decreased level of consciousness
Nursing interventions
• 1. In acute stage of stroke
• maintain airway patency (suctioning equipment must be available at the bedside)
• monitor neurologic status and vital signs
• note time, length, behaviors with seizure activity
• maintain adequate fluids
• position with head of bed elevated 15 to 30▪ with client turned or tilted to unaffected side with head positioned midline
• provide activity as ordered
• perform passive and/or active range of motion exercises
• maintain client's proper body alignment
• administer medications as ordered
• care for post op client as indicated
• provide care for client with increased intracranial pressure
• prevent complications, i.e., contractures, stool impaction/constipation, pressure ulcers
• 2. Long-term care of client with stroke
• monitor to facilitate normal elimination patterns
• teach/evaluate the use of supportive devices
• maintain client in a safe environment
• prevent the effects of immobility
• support the maintenance of adequate nutrition in light of feeding and swallowing problems
• assist with eating and ADL as indicated
• provide emotional support
• provide methods of communication for client with aphasia

 Infectious & Inflammatory Disorders


• A. Meningitis
• Definition
• acute or chronic inflammation of the meninges - the covering of the brain and spinal cord are involved
• average length of illness - 4 months
• Etiology
• a. bacterial: most contagious; requires isolation
• meningococcal - most common
• most common in children 2 to 18 years-old
• high risk groups
• infants
• adults with weakened or suppressed immune systems
• college students, especially freshman in particular who reside in dormitories
• travelers to foreign countries where disease is endemic
• up to 25% of cases are fatal
• 10 - 15 % of cases result in brain damage or other serious side effects
• Haemophilus influenzae: those at risk are children in child care settings and children with no access to vaccine (Hib
vaccine administration should start at 2 months of age)
• pneumococcal: those at risk are children under the age of 2 years-old and adults with weakened or suppressed immune
systems
• b. viral
• isolation is not required
• aseptic meningitis is the most common form in the U.S.
• usually complete recovery
• c. fungal: cryptococcal disease
• often from bird droppings
• organism is found in dirt
• more common in clients with AIDS
• Findings
• severe headache
• sudden high fever and chills - bacterial
• altered level of consciousness, e.g. confusion
• photophobia/diplopia
• nuchal rigidity: severe pain in the back of neck when the chin is moved toward the chest with the client resisting movement
• positive Kernig's and Brudzinski's signs
• seizures
• petechial rash (meningococcal meningitis)
Diagnostics
• history and physical exam
• positive Kernig's sign: 90▪ flexion of hip and knee with extension of knee causes pain
• positive Brudzinski's sign: flexion of neck causes flexion of hip and knee
• lumbar puncture (LP) for characteristics of cerebral spinal fluid:
• decreased glucose and increased protein in bacterial or fungal infections
• LP not done for clients with findings that may indicate elevated intracranial pressure
• sedation of child may be required - midazolam, meperidine or fentanyl
• CT or MRI with and without contrast

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

Staphylococcus aureus • enterotoxins form in foods that are held at room


temperature (especially foods with mayonnaise
base)

• findings appear within 7 hours of ingestion -


weakness, acute nausea and vomiting; intestinal
cramps; diarrhea
Clostridium perfringens • enteric type

• occurs in food that are cooled and then reheated


• findings appear within 24 hours of ingestion -
nausea and vomiting, abdominal pain, diarrhea
Vibrio parahaemolyticus • enteric type

• multiplies in uncooked seafood


• findings appear within 24 hours of ingestion -
nausea and vomiting, abdominal pain, diarrhea
Bacillus cereus • enteric type

• anaerobic spore; multiplies in food held at room


temperature
• findings appear within 24 hours of ingestion -
nausea and vomiting, abdominal pain, diarrhea
Clostridium botulinum • forms a toxin in improperly processed food in
anaerobic conditions (especially with improperly
canned or dented food cans)

• findings appear within 36 hours of ingestion - dry


mouth, diplopia, nausea and vomiting, cramps,
diarrhea precedes dysphagia and dysarthria

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

E. Nipah & Hendra Viruses


• Definition: a paramyxovirus that causes encephalitis in humans and is transmitted from animals
• Etiology: emerging worldwide infection; potential for use as a biological agent (see Lesson 2: Safety and Infection
Control for other viral agents used as biologic agents)
• Hendra virus: the cause of a highly fatal respiratory virus disease of horses
• Nipah virus: transmitted from bats and is zoonotic, causing a highly fatal infection in humans
• Findings:
• human infections range from asymptomatic to fatal encephalitis
• initially influenza-like symptoms, e.g., fever, headache, myalgia, vomiting and sore throat
• some people experience atypical pneumonia and severe respiratory problems
• encephalitis and seizures occur in severe cases, progressing to coma within 24 to 48 hours
• Diagnostics
• no standard protocol exists for detection
• methods used to confirm viral infection
• history/clinical signs
• enzyme-linked immunosorbent assay (ELISA)
• laboratory tests to detect antibody (IgG and IgM) in serum, cerebrospinal fluid
• Management: there is no treatment or vaccine available for either people or animals; ribavirin has been used with limited
effectiveness
• Nursing interventions
• intensive supportive care with treatment of symptoms
• regular hand washing

 Various Disorders of the Neurologic System


• A. Multiple sclerosis
• Definition: demyelination of white matter throughout brain and spinal cord
Etiology
• specific cause unknown
• third most common cause of disability in clients age 15 to 60 years-old
• increased incidence in temperate to cool climates
• illness improves and worsens unpredictably
• more common in women than men
• Findings: depend on the location of the demyelination
• cranial nerve: blurred vision, dysphagia, diplopia, facial weakness and/or numbness
• motor: weakness, paralysis, spasticity, gait disturbances
• sensory: paresthesias, decreased proprioception
• cerebellar: dysarthria, tremor, incoordination, ataxia, vertigo
• cognitive: decreased short-term memory, difficulty with new information, word-finding difficulty, short attention span
• urinary retention or incontinence
• loss of bowel control
• sexual dysfunction
• fatigue

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

B. Guillain-Barre syndrome (also called postinfectious polyneuropathy)


• Definition: a group of autoimmune peripheral neuropathies resulting in symmetric and ascending motor paralysis; an acute
condition; potentially fatal if respiratory muscles are affected
• Etiology: unknown, but precipitating factors include prior bacterial or viral infection, surgery, or viral immunization within one
to two weeks
• Findings
• muscle weakness - progressive, ascending, bilateral
• leads to paralysis of voluntary muscles
• loss of superficial and deep tendon reflexes
• bulbar weakness
• dysphagia
• dysarthria
• respiratory failure
• sensory findings - paresthesia, burning muscle pain
• paralysis
• may vary from being partial (half-way up the body) to total paralysis
• may cause fluctuations in blood pressure, heart rhythm and rate
• may cause associated gastrointestinal and urinary symptoms, secondary to autonomic nervous system involvement
Diagnostics
• history and physical exam
• lumbar puncture - increased protein in CSF
• electromyography (EMG) - acute muscle denervation
• Management: expected outcomes include preventing complications and maintaining body functions until reversal of
paralysis
• based on physiologic needs and body system(s) affected - possible tracheostomy, ventilatory support, IV fluids,
plasmapheresis
• pharmacologic
• immunoglobulin therapy
• morphine for pain control
• plasmapheresis
• nutritional support
• Nursing interventions
• maintain the care of client on ventilatory support/monitor respiratory status
• provide for care of the immobilized client
• have a safe environment to minimize infection
• maintain nutrition and fluid balance
• refer families or client to support groups
• supply referrals to therapies such as speech, physical, occupational and counseling
• provide adequate pain control
• establish alternate ways to communicate

C. Myasthenia gravis (MG)


• Definition: an autoimmune disorder characterized by progressive weakness and exhaustibility of voluntary muscles without
atrophy or sensory disturbance
• Etiology
• caused by an autoimmune attack on acetylcholine receptors at neuromuscular junctions
• progressive with occurrences of crises
• two age clusters - women in early adulthood and men in late adulthood
• Findings
• progressive fatigue and/or weakness of voluntary muscles, but no muscular atrophy
• sensation remains intact
• facial
• ptosis (drooping eyelid) and reduced eye closure
• weak smile
• diplopia, blurred vision
• speech and swallowing disorders
• weakness of facial muscles - difficulty to raise eyebrows, make different faces
• signs of restrictive lung disease
• Diagnostics
• history and physical exam
• edrophonium (Tensilon) test - improved muscle strength after Tensilon injection indicates a positive test for MG
• single-fiber electromyography
• serum assay of circulating acetylcholine receptor antibodies
Management
• expected outcomes: to improve strength and endurance
• pharmacologic
• anticholinesterase agents: pyridostigmine, neostigmine
• corticosteroid therapy
• immunosuppressants: azathioprine
• thymectomy
• plasmapheresis
• myasthenic crisis
• usually caused by precipitating factors (triggers) such as stress or infection, inadequate medication dose
• findings include sudden inability to swallow, speak, or maintain patent airway
• edrophonium (Tensilon) test
• positive test signals myasthenia gravis
• negative test indicates a cholinergic crisis - treat with atropine
• management includes ventilatory support
• cholinergic crisis
• caused by overdose of pyridostigmine - results in increased acetylcholine
• findings include profound weakness, gastrointestinal distress, respiratory failure
• atropine may be administered
• stop anticholinesterase agents and restart gradually when client stable
• management may include ventilatory support
Nursing interventions
• identify aggravating factors, such as:
• infection
• stress
• changes in medication regime - especially when increasing dose
• ventilatory support for client in crisis
• give medications as ordered and on time
• help with activities of daily living and feeding as indicated
• provide information about support groups for client and family
• provide
• emotional support
• adequate rest periods
• care of the post-surgical client
• teach client
• energy conservation techniques
• expectations, side effects, and medications
• signs of impending crisis, both myasthenic and cholinergic along with what actions to take
• to avoid stressors or how to minimize stressors
• avoid extremes of temperature
• avoid people with respiratory infections
• to discuss with health care provider prior to taking any prescription or over-the-counter medications

 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

B. Types of skull fractures and injury


• 1. Linear: simple break in the bone; no displacement of the skull
• 2. Depressed: part of skull is pushed in
• 3. Basilar: at base of skull; may extend into orbit or ear; ear or nose may leak CSF; most difficult to verify by x-ray
• 4. Concussion: jarring or shaking of the brain; temporary loss of neurologic function with complete recovery

C. Types of bleeding injuries or hematomas


• 1. Contusion: bruising on the surface of the brain
• 2. Intracerebral: bleeding directly in the brain tissue; secondary to invasive skull trauma/open fracture or hemorrhagic CVA
• 3. Epidural
• lacerated blood vessels (arteries) in the space between the skull and dura mater; often the middle meningeal artery is
involved secondary to a skull fracture or contusion
• arterial bleeding, the risk of death is greatest
• client commonly looses consciousness after injury then is lucid; then level of consciousness drops quickly within the next 24
hours
• 4. Subdural
• lacerated the blood vessels (veins) crossing the subdural space secondary to closed head injury
• acute: findings surface in 24 to 72 hours after injury with rapid neurologic deterioration
• subacute: findings surface 72 hours to 2 weeks after injury with a slower progression of deterioration
• chronic: gradual clot formation over time, possibly months with minimal deterioration
D. Progression of skull fracture injury
• 1. Onset: contusions and lacerations of nerve cells
• 2. Neuron death: gradual demyelinization of affected nerve fibers
• 3. Scarring: meninges adheres to injured area of brain

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

F. Findings of head trauma


• Degree of neurological damage varies with type and location of injury
• Restlessness and irritability - initially
• Decreased level of consciousness - lethargy, difficulty with arousal
• Headache
• Nausea and vomiting - projectile vomiting indicates increased intracranial pressure
• Otorrhea
• Pupillary changes
• Seizure activity
• Altered vital signs (Cushing's triad - late sign)
• Posturing - decorticate or decerebrate with severe head trauma
• CSF leakage from ears or nose - basilar skull fracture
G. Diagnostics
• History (of event) and physical exam
• Computerized tomogram (CT) scan
• Magnetic resonance imaging (MRI)
• Radiological exam
• Electroencephalogram (EEG)

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

 Peripheral Nerve & Cranial Nerve Disorders


• A. Trigeminal neuralgia (facial neuralgia; tic douloureux)
• Definition: syndrome of chronic paroxysmal severe facial pain
• Etiology: unknown
• occurs more often in middle age and older adults
• affects cranial nerve V (trigeminal nerve)
• involves one side only
• is triggered by harmless events such as a breeze, hot or cold liquids
• Findings
• intense facial pain lasting a few seconds to a few minutes along the nerve branches; episodes may be as frequent as 100
times a day or as infrequent as a few times a year
• extreme facial sensitivity
• pain may be described as "burning" or "shooting"
• Diagnostics
• history and physical exam
• computed tomography (CT) to rule out other causes of findings
Management
• expected outcomes: to relieve pain and to minimize frequency
• anticonvulsants: carbamazepine, phenytoin
• skeletal muscle relaxant baclofen
• antidepressants: clients are often depressed and need to be monitored for this and treated
• nerve block: temporary pain management
• surgery
• radio-frequency gangliolysis: heat destroys trigeminal ganglion
• glycerol gangliolysis: glycerol injected into subarachnoid space around gasserian ganglion
• microvascular decompression: move arterial loop away from posterior trigeminal root
• Nursing interventions
• help client to name triggers with identification of aggravating incidents
• recommend restful environment with scheduled rest periods
• reinforce the need for balanced nutrition
• provide appropriate care of the client undergoing surgery
• assess client for depression or suicidal thoughts
• teach client
• about medications and side effects
• AVOID triggering agents
• to chew on the opposite side of the mouth
• AVOID drafts
• AVOID very hot or very cold foods or fluids
• importance of continuing oral hygiene and care
• avoid exposing face to extreme environmental temperatures

B. Facial nerve paralysis (Bell's palsy)


• Definition: a disorder of cranial nerve VII (facial nerve) involving one side of the face only (unilateral)

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

 Spinal Cord Injuries


• Definition: conditions that can affect the spinal cord are usually due to trauma, but may also be from diseases of the
musculoskeletal system (arthritis) or congenital abnormalities (spina bifida)
• classification of the injury using the following parameters:
• complete or incomplete cord injury
• cause of the injury
• level of the injury
• types of injuries - if the structures near the spinal cord are injured, surround structures will be affected, e.g., a bulging disc
may place pressure on the spinal cord
• a. contusion
• b. laceration
• c. hemorrhage
• d. transection, complete or incomplete spinal cord injuries
• e. damage to blood vessels that supply the spinal cord
The incomplete SCI syndromes are further characterized clinically as follows:
• Anterior cord syndrome: damage to anterior spinal artery, resulting in hyperflexion paralysis, loss of pain and/or temperature
sensation
• Posterior cord syndrome: vertebral dislocation, herniated disc, compression weakness in certain muscles groups resulting in
tingling, pain, abnormal reflexes, and bowel and bladder dysfunction
• Brown-Séquard syndrome: penetrating trauma with ipsilateral loss of proprioception and motor function and contralateral loss
of pain and temperature sensation
• Central cord syndrome: cord transection from a hyperextension injury, resulting in partial flaccid paralysis of upper extremities
with spastic paralysis of the lower extremities; varying degrees of bowel, bladder and sexual dysfunction
• Other cord syndromes:
• Cauda equina syndrome: injury to the lumbosacral nerve roots secondary to central lumbar disk herniation, resulting in
areflexia of affected limbs, areflexia of bowel and/or bladder and varying degrees of motor and sensory loss
• Conus medullaris syndrome: sacral cord injury resulting in areflexia of the bladder, bowel, and less prominently in the lower
limbs, resulting in varying degrees of motor and sensory loss in the lower limbs
Etiology: anything inducing trauma or dysfunction to the vertebrae or spinal cord, ex: motor vehicle accident, sports injuries,
stabbing, gun shot wound, tumor, infection
• Findings: the degree depends on type of injury, i.e., complete or incomplete transection of the spinal cord
• Neurologic
• a. spinal shock - Is a temporary loss of reflex function below the level of the injury
• Occurs after complete transection of the cord, and to varying degrees with partial transection, contusions, compressions and
ischemia of the spinal cord
• Begins in the first hour following the injury and lasts for minutes to months, depending on the degree of injury
• Findings of spinal shock
• Flaccid paralysis below level of injury
• Areflexia below level of injury
• Loss of sensation (pain, touch, temperature, pressure) below the level of injury
• Absence of visceral and somatic sensations below the level of the injury (absent bowel
sounds)
• Bowel and bladder dysfunction (bladder distention)
• Loss of the ability to perspire below the level of the injury
• b. neurogenic shock (if the injury involves the cervical or upper thoracic vertebrae)
• altered reflex patterns, i.e., areflexia, hypo or hyperreflexia
• sensory changes, i.e., numbness, inability to feel pain or temperature, tingling
• Neurogenic shock results in an imbalance in the autonomic nervous system (sympathetic and parasympathetic systems)
• The parasympathetic system causes massive vasodilatation, a drop in the systemic vascular resistance, and pooling of blood
in the venous system, which leads to significant hypotension
• Findings of neurogenic shock:
• hypotension
• bradycardia - until compensatory mechanisms begin
• bounding pulse progressing to weak and thready pulse
• warm, dry, and pink skin progressing to pale and cool skin
• mental status - restless, progressing to lethargy and coma
• oliguria progressing to anuria
• lower than normal body temperature
• Cardiovascular - impaired control of the autonomic nervous system (ANS)
• hypotension
• dysrhythmias
• autonomic dysreflexia
• Respiratory
• breathing difficulties from paralysis of the breathing muscles and phrenic nerve related to injury at C3 or above, e.g.,
hypoventilation, apnea
• absent or decreased protective mechanisms, i.e., cough
• Musculoskeletal
• weakness, incoordination, or paralysis below the level of the injury, i.e., paraplegia or quadriplegia
• altered muscle tone, i.e., spasticity, flaccidity, rigidity
• Other: pain, bowel and bladder dysfunction, e.g., constipation, incontinence, bladder spasms, and sexual dysfunction
Diagnostics: used to identify the level and extent of injury
• Radiological exam
• CT
• MRI
• Somatosensory evoked potential
• Complications
• spinal shock
• neurogenic shock
• autonomic dysreflexia
• osteoporosis
• pathologic fractures
• muscle atrophy
• paralytic or stress ulcers
• sexual dysfunction
• stool incontinence and or impaction
• decubitus ulcers
• urinary incontinence and or retention
• permanent paralysis
• Management
• Emergency care
• follow the ABCs of emergency care
• log roll client to avoid flexing, extending, or rotating spine
• immobilize spine with c-collar and spine board
• Pharmacologic
• corticosteroids - to decrease spinal cord edema
• vasopressors - to support blood pressure
• antispasmotics
• analgesics
• stool softeners - to help prevent constipation
• anticonagulants - to help prevent deep vein thrombosis
• proton pump inhibitors - to prevent ulcer development
• Surgery
• decompression laminectomy
• spinal fusion
• insertion of hardware to stabilize and immobilize, e.g. Gardner-Wells tongs
• Nursing interventions
• Maintain proper alignment of spine and neck
• Monitor respiratory function and maintain patent airway
• Assess vital signs frequently for respiratory or cardiac compromise
• Maintain proper fluid/nutrition balance
• Administer medications as ordered
• Prevent complications
• sequential compression devise to lower extremities
• anticoagulant administration
• maintain skin integrity
• Monitor for depression
• Elimination
• teach self catheterization
• maintain hydration
• teach bowel retraining programs
• Mobility
• passive and/or active range of motion (ROM)
• reposition every 2 hours
• maintain skin integrity

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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