Nursing Management of the Adult Patient with Neurological Disorder

Nursing Management of the Adult Patient with Neurological Disorder Dr. Marietta Mercado

Objectives Upon completion of this lesson, the student will be able to • describe how cognitive alterations influence the neurological assessment. • list the changes in ICP that affect the cerebral perfusion pressure and cerebral oxygenation. • differentiate between the types of brain trauma. • state the etiology and course of the inflammation of the CNS and intracranial hemorrhage. • explain the different diagnostic studies and surgical approach

Brain Needs… • Blood flow • Glucose • Oxygen

Diagnostic Studies • Skull and Spinal Radiology • CT (Computerized Tomography) • MRI (Magnetic Resonance Imaging) • PET (Positron Emission Tomography) • EEG (Electroencephalogram) • EMG (Electromyelogram) • Cerebral Angiography

Computed Tomography (CT) scan • a type of brain scanning that may or may not require an injection of a dye • used to detect intracranial bleeding, space-occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain structures

AMERICAN DREAM REVIEW INSTITUTE

Magnetic resonance imaging (MRI) • a noninvasive procedure that identifies types of tissues, tumors, and vascular abnormalities • Similar to the CT scan but provides more detailed pictures and does not expose the client to ionizing radiation

Electroencephalography A graphic recording of the electrical activity of the superficial layers of the cerebral cortex

Cerebral angiography Injection of contrast through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions

Neurological Assessment • Level of Consciousness (LOC) • Pupils • Vital Signs (VS) • Neuromuscular status • Response to stimuli • Posturing • Glasgow Coma Scale (GCS)

I. Neurological Disorders • The normal functioning of the CNS can be affected by a number of disorders, the most common of which are headaches, tumors, vascular problems, infections, epilepsy, head trauma, demyelinating diseases, stroke and metabolic & nutritional diseases.

Not always chronic…be careful Headaches Classified based on characteristics of the headache Functional vs. Organic type May have more than one type of headache History & neurologic exam diagnostic keys

ONSET: Not reliable or diagnostic

HA: Essential History Onset this particular headache Character of pain, severity and duration Associated symptoms Prior history, pattern Original onset: prior testing, treatment Other therapeutic regimens

Physical Exam Neurologic examination Inspect for local infections, nuchal rigidity Palpation for tenderness, bony swellings Auscultation for bruits over major arteries

Organic vs. Traumatic vs. Functional: Diagnostics CBC: underlying illness, anemia Chem panel: if associated vomiting, dehydrated CT scan: for focal neurological signs, sinus No LP for suspected ICP; ↑ association with brain herniation

Don’t Miss It • Caused by subarachnoid hemorrhage from an aneurysm or head injury • “Worse headache of my life” • Changes in LOC, focal neurological signs • Highly correlated with CVA • Untreated, 50 % mortality

Headache Teaching Guide • Keep a calendar/diary • Avoid triggers • Medications (purpose, side effects) • Stress reduction • Dark quiet room, exercise, relaxation • Regular exercise

Intracranial Pressure (ICP) Brain Components • Skull is a rigid vault that does not expand • It contains 3 volume components: • Brain tissue: (80%) or 2% of TBW • Intravascualr blood: (10%) • CSF: (10%)

Increased Intracranial Pressure • An increase in ICP caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation • Can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

Intracranial Pressure (ICP) • Intracranial Pressure (ICP) is the pressure exerted by brain tissue, blood volume & cerebral spinal fluid (CSF) within the skull. • Normal ICP – 10 to 15 mmHg • Cerebral Perfusion Pressure (CPP) • Normal CPP – 70 to 100 mmHg • Normal CSF – 5 to 13 mmHg

IncreasedIntracranial Pressure (IICP) fluid pressure > 15 mm Hg • IICP is a life threatening situation that results from an  in any or all 3 components within the skull • > volume of brain tissue, blood, and / or CSF • Cerebral edema: > H2O content of tissue as a result of trauma, hemorrhage, tumor, abscess, or ischemia

Surgical Intervention for ICP Ventriculoperitoneal Shunt • Shunts CSF from ventricles into the peritoneum Implementation Postprocedure • Position the client supine and turn from back to non-operative side • Monitor for signs of increasing ICP resulting form shunt failure • Monitor for signs of infection

Acute Coma • Levels of consciousness diminish in stages: • Confusion: can’t think rapidly and clearly التشويش • Disorientation: begin to loose consciousness • Time, place, self • Lethargy: spontaneous speech and movement limited • Obtundation: arousal (awakeness) is reduced • Stupor: deep sleep or unresponsiveness • Open eyes to vigorous or repeated stimuli • Coma: respond to noxious stimuli only • Light (purposeful), full coma (non-purposeful), deep coma (no response)

Multiple Sclerosis • is a chronic autoimmune disorder affecting movement, sensation, and bodily functions. It is caused by destruction of the myelin sheath covering nerve fibres in the central nervous system (brain and spinal cord). • Causes: 1. Autoimmune destruction. 2. Heredity. 3. Viruses. 4. Environmental factors.

Diagnostic Test: 1. MRI. 2. Physical examination.

Clinical Manifestations: • * Early: 1. Muscle weakness causing difficulty walking 2. loss of coordination or balance 3. numbness or other abnormal sensations 4. visual disturbances, including blurred or double vision

* Late: 1. Fatigue . 2. Muscle spasticity and stiffness 3. Tremors. 4. Paralysis . 5. pain . 6. Vertigo. 7. Speech or swallowing difficulty . 8. Loss of bowel and bladder control. 9. Sexual dysfunction . 10. Changes in cognitive ability

Treatment: 1. Immunosuppressant drugs . These drugs include corticosteroids such as prednisone and methylprednisolone, the hormone adrenocorticotropic hormone (ACTH), and azathioprine. 2. Physiotherapy. 3. Occupational therapy.

Parkinson's Disease • is a progressive movement disorder marked by tremors, rigidity, slow movements (bradykinesia), and postural instability. It occurs when, for unknown reasons, cells in one of the movement-control centers of the brain begin to die. • Usually occurs in the older population • Causes: • 1. Degeneration of brain cells in the area known as the substantia nigra, one of the movement control centers of the brain. • 2. Drugs given for psychosis, such as haloperidol (Haldol) or chlorpromazine (Thorazine), may cause parkinsonism.

Clinical Manifestations 1. Tremors 2. Slow movements (bradykinesia), freezing in place during movements (akinesia). 3. Muscle rigidity or stiffness, occurring with jerky movements 4. Postural instability or balance difficulty occurs. 5. Masked face. 6. Depression 7. Speech changes 8. Problems with sleep 9. Emotional changes10. Incontinence. 11. Constipation. 12. Handwriting changes, 13. (dementia)

Treatment: 1. Maintain regular exercise (physical therapy, occupational therapy) 2. Provide good nutrition to maintain health. 3. Drugs that replace dopamine (levodopa) 4. If the patient is unresponsive or intolerant to pharmacotherapy, Electro convulsive therapy is indicated. Nursing Management * Observe the patient's mood, cognition; organization and general well being * Observe for features of depression, *Suicidal precautions to be followed, if the patient exhibits any suicidal ideas *Instruct the patients to speak slowly and clearly, and to pause and take a deep breath at appropriate levels.

Trigeminal Neuralgia (Tic Douloureux) • - disorder of cranial nerve V causing disabling and recurring attacks of severe pain along the sensory distribution of one or more branches of the trigeminal nerve

Medical management 1. anticonvulsant drugs : carbamazepine (Tegretol), phenytoin (Dilantin) 2. Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve; temporary effect, lasts 6-18 months 3. Surgery • a. peripheral – avulsion of peripheral branches of trigeminal nerve

Surgical management 1)retrogasserian rhizotomy – total severance of the trigeminal nerve intracranially; results in permanent anesthesia, numbness, heaviness, and stiffness in affected part; loss of corneal reflex 2) microsurgery – uses more precise cutting and may preserve facial sensation and corneal reflex

Seizure Disorders & Epilepsy Seizure: • paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function Epilepsy: • spontaneously recurring seizures caused by a chronic underlying condition Two major classes: • Generalized • Partial

SEIZURE Phases of Generalized Seizure Attack • Aura Phase – split second • Tonic Phase -15 – 20 sec unresponsiveness 5 to 15 sec of muscle rigidity • Clonic Phase – 1 to 5 minutes of convulsion • Post-ictal – 5 mins to 30 mins to hours of deep sleep Status Epilepticus– prolonged seizures or recurrent seizures without the patient completely recovered between episodes.

Aura Phase I smell bananas! I taste metal! I’m seeing spots I’m dizzy! I feel very angry!

Nursing Management of the Adult Patient with Neurological Disorder