Nursing of Adults with Medical & Surgical Conditions

1. Nursing of Adults withMedical & Surgical Conditions Neurological Disorders

2. Laboratory and Diagnostic Exams • Blood and Urine • Culture • Urinary tract infection • Drug screens • Rule out drugs as cause of symptoms • Arterial Blood Gases • Monitor the oxygen content of the blood • Low levels indicate altered breathing patterns

3. Cerebrospinal Fluid • Normal Values • Specific gravity: 1.007 • pH: 7.35 to 7.45 • Chloride: 120 to 130 mEq/L • Glucose: 50 to 75 mg/dl • Pressure: 80 to 200 mm water • Total Volume: 80 to 200 ml • Total Protein: 5 to 45 mg/dl • Gamma globulin: 6% to 13% of total protein • Cell Count: • RBC None • WBC 0-10 cells (lymphocytes and monocytes)

4. Cerebrospinal Fluid (Cont) • Elevated lymphocytes may indicate infection • Decreased chloride and glucose levels may indicate tuberculosis meningitis • Culture or smear is done to determine the causative organism in meningitis • Protein is elevated with degenerative disease or brain tumors • Blood indicates hemorrhage from somewhere in the ventricular system • Protein electrophoresis may give evidence of MS

5. Computed Tomography (CT) Scan • Detects pathological conditions of the cerebrum and spinal cord • May be done with or without contrast • Brain Scan • Uses radioactive isotopes • MRI Scan • Uses magnetic forces to image the cerebrum and spinal cord

6. PET Scan • Positron Emission Tomography • Used following stroke, Alzheimer’s, epilepsy and Parkinson’s • Injection of deoxyglucose with radioactive fluorine is given • Color scan is done; different shade can be translated into different pathological conditions

7. Lumbar Puncture • Obtain CSF for examination • Relieve pressure • Inject dye or medication • Contraindicated in patients with increased intracranial pressure

8. Electroencephalogram (EEG) • Used to provide evidence of focal or generalized disturbances of brain function by measuring the electrical activity of the brain • Epilepsy, mass lesions, cerebrovascular lesions and brain injury • Procedure • Patient is kept awake the night before • Hair and scalp must be clean • Electrodes are placed on the scalp

9. Myelogram • Used to identify lesions in the intradural or extradural compartments of the spinal canal by observing the flow of radiopaque dye through the subarachnoid space. • Used to diagnose herniated or protruding intervertebral disk. Spinal tumors, adhesions, bony deformations, and arteriovenous malformations • Lumbar puncture is performed, dye injected, and fluoroscopic and radiopaque films are taken

10. Angiogram • Used to visualize the cerebral arterial system by injecting radiopaque material • Allows the detection of arterial aneurysms, vessel anomalies, ruptured vessels, and displacement of vessels by tumors or masses

11. Carotid Duplex • Uses combined ultrasound and pulsed Doppler • Noninvasive study that evaluates carotid occlusive disease • Electromyogram (EMG) • Used to measure the contraction of a muscle in response to electrical stimulation • Provides evidence of lower motor neuron disease; primary muscular disease; and defects in the transmission of electrical impulses

12. Echoencephalogram • Uses ultrasound to depict the intracranial structures of the brain • Detects ventricular dilation and a major shift of midline structures in the brain as a result of an expanding lesion

13. Headaches • Etiology/Pathophysiology • Skull and brain tissues are not able to feel sensory pain • Pain arises from the scalp, blood vessels, muscles, dura mater, and sinuses • Vascular Headaches • Migraine • Vessels are dilated • Hypertensive • Excessive pressure • Tension Headaches • Psychological problems • tension, stress, • Cervical arthritis • Traction-Inflammation Headaches • Infection, intracranial or extracranial causes, occlusive vascular structures, temporal arteritis

14. Headaches • Signs & Symptoms • Head pain • Migraine headaches • Prodromal (early s/s) • visual field defects, experiencing unusual smells or sounds, disorientation, paresthesias, and rarely paralysis of a part of the body • During headache • nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema

15. Headache • Treatment • Diet • Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork • Psychotherapy • Decrease stress factors • Medications • Migraine Headaches • aspirin, acetaminophen, ibuprofen • ergotamine tartrate • Constricts vessels • Codeine • Inderal

16. Headaches • Tension Headaches • Nonnarcotic analgesics • acetaminophen, propoxyphene, phenacetin, ibuprofen, and aspirin • Traction-inflammatory Headaches • Treat cause • Comfort Measures • Cold packs to forehead or base of skull • Pressure to temporal arteries • Dark room; limit auditory stimulation

17. Increased Intracranial Pressure • Etiology/Pathophysiology • Increase in any content of the cranium • Cranium is rigid and nonexpandable • Space-occupying lesions, cerebrospinal problems, cerebral edema

18. Increased Intracranial Pressure • Signs & Symptoms • Diplopia • double vision • Headache • increases with coughing, straining, or stooping • Decrease in level of consciousness • disorientation, restlessness, lethargy • Pupillary signs • ipsilateral pupil dilation • lesion is one hemisphere • bilateral pupil dilation • both halves of brain are involved

19. Increased Intracranial Pressure • Widening pulse pressure • increased systolic and decreased diastolic B/P • Bradycardia • Respiratory problems • vary related to the level of brainstem involvement • High, uncontrolled temperatures • Positive Babinski’s reflex • Toes fan out when bottom of foot is stroked • Seizures

20. Increased Intracranial Pressure • Posturing • decorticate • flexion of arms, wrists, and fingers with adduction of arms • decerebrate • All four extremities in rigid extension, with hyperpronation of forearmsand plantar extension of feet • Vomiting • Singultus

21. Increased Intracranial Pressure • Treatment • Treat cause if possible • Mechanical decompression • Craniotomy • remove bone flap and replace • Craniectomy • remove bone flap and not replaced • Internal Monitoring Devices • Diagnose and monitor increased intracranial pressure • Ventricular catheter, subarachnoid bolt or screw, and the epidural sensor • produce pressure waves to indicate status of IIP

22. Epilepsy or Seizures • Etiology/Pathophysiology • Transitory disturbance in consciousness or in motor, sensory, or autonomic function with or without loss of consciousness • Sudden, excessive, and disorderly discharges in the neurons of the brain • Results in sudden, violent, involuntary contraction of a group of muscles • Hypoglycemia, infection, and electrolyte imbalance.

23. Epilepsy or Seizures • Types of seizures • Grand Mal • Generalized • Tonic-clonic movements • Loss of consciousness • Petit Mal • Sudden impairment or loss of consciousness • Little or no tonic-clonic movement • Vacant facial expression; eye straight ahead • Psychomotor • Sudden change in awareness • Behaves as if partially conscious • May appear intoxicated • Antisocial behavior • exposing self or violence

24. Epilepsy or Seizures • Jacksonian-focal • One body part is affected • hand, foot, face • May end in grand mal seizure • Myoclonic • Sudden involuntary contraction of muscle group • usually in extremities or trunk • No loss of consciousness • Akinetic • Generlaized tonelessness • Falls in flaccid state • Unconsciousness for 1-2 minutes

25. Epilepsy or Seizures • Signs & Symptoms • Depends on type of seizure • Aura • Sensation that may precede a seizure • flashing lights, smells, numbness, tingling, hallucinations • Postictal Period • Rest period of variable length • Groggy and disoriented • Headache and muscle aches • May sleep

26. Epilepsy or Seizures • Status epilepticus • recurrent, gernalized seizure activity occurs at such frequency that full consciousness is not regained

27. Epilepsy or Seizures • Treatment • During seizure • Protect from aspiration and injury • Lower to the floor • Move away from furniture and equipment • Turn the head to the side if possible • Loosen clothing around neck • DO NOT RESTRAIN • DO NOT PUT ANYTHING IN MOUTH • Medications • Page 608; table 15-5 • Surgery • Removal of brain tissue where seizure occurs

28. Epilepsy or Seizures • Adequate rest • Good nutrition • Avoid alcohol • Avoid driving, operating machinery, & swimming until seizures are controlled • Good oral hygiene esp. if on Dilantin • causes gingival hyperplasia • edematous and enlarged gums • Medical alert tag

29. Multiple Sclerosis • Etiology/Pathophysiology • Degenerative neurological disorder • Cause unknown • Possibly genetic • Most common in wet cold climates • Demyelination of the brain stem, spinal cord, optic nerves, and cerebrum • causes an interruption or distortion of the nerve impulse

30. Multiple Sclerosis • Signs & Symptoms • Visual problems • diplopia • scotomata (spots) • blindness • nystagmus • Urinary incontinence • Fatigue • Weakness • Incoordination • Sexual problems • Swallowing difficulties

31. Multiple Sclerosis • Remissions may last for a year or more • Exacerbaions precipitated by • fatigue • chilling • emotional disturbances

32. Multiple Sclerosis • Treatment • No specific treatment • Adrenocorticotropic hormone (ACTH) • Steroids • prednisone • Deltasone or Decadron • Valium • Betaseron (Interferon beta-1b) • reduces frequency of exacerbations • Avonex (Interferon beta-1a) • reduce neurological attacks and slow progress of physical disability

33. Multiple Sclerosis • Pro-Banthine • decrease urinary frequency and urgency • Urecholine • antispasmodic for neurogenic bladder • Bactrim, Septra, & Macrodanitn • Urinary tract infections

34. Parkinson’s Disease • Etiology/Pathophysiology • Deficiency of dopamine • necessary for the normal transmission of nerve impulses • Viral, toxic, vascular and genetic causes • May be drug induced • Reserpine, phenothiazines, haloperidol, cocaine

35. Parkinson’s Disease • Signs & Symptoms • Muscular tremors • Rigidity • mask-like facial appearance • monotonous speech • drooling • Propulsive gait • Emotional instability • Heat intolerance • Decreased blinking • “Pill-rolling” motions of fingers • Bradykinesia • slowness of voluntary movements and speech

36. Parkinson’s Disease

37. Parkinson’s Disease • Treatment • Medications • side effects may be worse than disease • Levodopa • converted to dopamine • Sinemet • Artane • Cogentin • Symmetrol • Surgery • Pallidotomy • Destroying portions of the brain that control the rigidity or tremor • Human fetal dopamine cell transplants

38. Alzheimer’s Disease • Etiology/Pathophysiology • Impaired intellectual functioning • Degeneration of the cells of the brain • Cause is unknown • Possible genetic link

39. Alzheimer’s Disease • Signs & Symptoms • Early Stage • Mild memory lapses • Decreased attention span • Second Stage • Obvious memory lapses • Esp. short term • Disorientation to time • Loss of personal belongings • Third Stage • Total disorientation to person, place, & time • Apraxia • impaired ability to perform purposeful acts or use objects • Wandering • Terminal Stage • Severe mental and physical deterioration

40. Alzheimer’s Disease • Treatment • Medications • Agitation • Lorazepam • Haldol • Dementia • Cognex • Aricept • Nutrition • Finger foods • Frequent feedings • Encourage fluids

41. Alzheimer’s Disease • Safety • Removing burner controls at night • Double-locking all doors and windows • Constant supervision

42. Myasthenia Gravis • Etiology/Pathophysiology • Neuromuscular disorder • Nerve impulses fail to pass at the myo-neural junction; causes muscular weakness • Possible causes • Inadequate production of acetylcholine • Excessive quantities of cholinesterase • Non-response of the muscle fibers to acetylcholine

43. Myasthenia Gravis • Signs & Symptoms • Ocular • Ptosis • eyelid drooping • Diplopia • double vision • Generalized • Skeletal weakness • Dysarthria • Dysphagia • Ataxia • Bowel and bladder incontinence

44. Myasthenia Gravis • Treatment • Anticholinesterase drugs • Prostigmin • Mestinon • Corticosteroids • May require mechanical ventilation

45. Amyotrophic Lateral Sclerosis (ALS)Lou Gehrig’s Disease • Etiology/Pathophysiology • Motor neurons in the brainstem and spinal cord gradually degenerate • Electrical and chemical messages originating in the brain do not reach the muscles to activate them

46. Amyotrophic Lateral Sclerosis (ALS)Lou Gehrig’s Disease • Signs & Symptoms • Weakness of the upper extremities • Dysarthria • Dysphagia • Muscle wasting • Compromised respiratory function • death usually occurs due to infection

47. Amyotrophic Lateral Sclerosis (ALS)Lou Gehrig’s Disease • Treatment • No cure • Rilutec (riluzole) • Helps protect damaged motor neurons • Multidisciplinary ALS Teams • experimental drugs • physical, occupational, and speech therapy • nutritional regimens • psychological support • Emotional support • Mentally healthy; physically wasting away

48. Huntington’s Disease • Etiology/Pathophysiology • Overactivity of the dopamine pathways • opposite of Parkinson’s • Genetically transmitted

49. Huntington’s Disease • Signs & Symptoms • Abnormal and excessive involuntary movements (chorea) • Writhing, twisting movements of the face, limbs, and body • Abnormal facial movements • affect speech, chewing, and swallowing • Ataxia to immobility • Deterioration in mental functions

50. Huntington’s Disease • Treatment • No cure; pallative treatment • Antipsychotics • Antidepressants • Antichoreas • Safe environment • Emotional support • High calorie diet