Lecture for Undergraduate Nursing Students

1. Nursing Management of
patients with nervous system
disorders
Adult Nursing
Prepared By
Dr. Zuhair Rushdi Mustafa
Lecturer at University of Duhok/
College of Nursing

2. Intracranial Pressure (ICP)
 Skull has three essential components:
- Brain tissue = 78%
- Blood = 12%
- Cerebrospinal fluid (CSF) = 10%
Normal ICP = 4 -15 mmHg

3. Components of the Brain
Fig. 55-1

4.  Raised intracranial pressure
 ICP is the recordable pressure within the
skull caused by three intracranial
components: brain tissue, CSF & blood.
 As the skull is a rigid structure, any
increase in volume in any of the three
components will lead to an increase in
ICP.

5.  Causes
 Several conditions can lead to an increase in ICP,
including:
1. Increased volume of normal intracranial constituents:
(a) Brain: Cerebral edema (b) Cerebrospinal fluid:
Hydrocephalus
(c) Blood volume: bleeding in
the brain due to a head injury

6. 2. A space-occupying lesion, e.g. a brain tumour,
Hematoma, and Cyst.
3. Brain inflammation & infection, e.g. a brain abscess.

7. Causes (con’t)
 If Left untreated, raised ICP can lead to poor
perfusion of the brain as the cerebral arteries
and veins become compressed and the brain
herniates or shifts as it becomes compressed
within the skull.

8.  Common signs and symptoms of increased ICP in
the early stages are:
1. decreasing levels of consciousness
2. Headache: Often continuous and worse in the
morning
3. sluggish pupil reaction
4. visual disturbances
5. abnormal breathing patterns
6. impaired motor responses.
7. Vomiting: Not preceded by nausea
Projectile

9.  Common signs and symptoms of increased ICP in
the later stages are:
 In the later stages the individual may experience:
1. further deterioration in level of consciousness
2. a rise in systolic BP & a fall in diastolic BP
4. irregular shallow, slow breathing
5. slow pulse
6. a high temperature.
7. As neurologic function deteriorates further, the patient
becomes comatose and exhibits abnormal motor
responses in the form of decorticate or decerebrate
posture. When the coma is profound, with the pupils
dilated and fixed and respirations impaired, death is
usually inevitable.

10. 10

11. Investigations
 URGENT brain CT scan.
 Skull X-rays: – Separated sutures
 Magnetic Resonance
Imaging (MRI)
 Lumbar puncture is CONTRAINDICATED because the
sudden release of pressure can cause the brain to herniate.
Brain tumer

12. Rational for Contraindication
 A simple analogy
Performing a LP in the
presence of I-ICP,
may result in herniation

13.  Care and management of the patient at risk of
increased intracranial pressure
 Patients require frequent, accurate neurological
assessment in order to detect problems early.
1. Removal of the cause
2. A neurological assessment should include:
• conscious level
• pupil size and reactivity
• vital signs, and blood oxygen saturation
• limb movements
• Use of Glasgow Coma Scale

14.  Glasgow Coma Scale

15. 3. Hyperventilation therapy: suctioning → hyperventilate with
100% oxygen.
4. Drug therapy
a. Mannitol : 20% 1g/kg IV single dose or 0.25-0.5g/kg Q8h
b. Loop diuretics: Furosemide (Lazix): 1mg/kg IV single dose
or 0.25-.05mg/kg every 8h
c. Corticosteroids
d. Barbiturates & Sedation to control agitation & reduces
metabolic needs.
e. Antiseizure drugs like carbamazepine (Tegritol)

16. 16Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.
Route Location of Fluid Drain
Ventriculo-peritoneal shunt (VP
shunt)
Peritoneal cavity
Ventriculo-atrial shunt (VA shunt) Right atrium of the heart
Ventriculo-pleural shunt (VPL
shunt)
Pleural cavity
Lumbar-peritoneal shunt (LP
shunt)
Peritoneal cavity
f. CSF withdrawal through Ventriculo-peritoneal
shunt
No lumbar puncture

17. 5. Nutritional therapy
 Patient is in hypermetabolic state so:
 There is increase Need for glucose
 Keep patient normovolemic
• IV 0.45% or 0.9% sodium chloride

18. Nursing Management
Overall goals:
•Maintain patent airway
•Normal fluid and electrolyte balance
•No complications secondary to immobility
•Maintain Respiratory function
•Maintain Fluid and electrolyte balance
•Body position maintained in head-up
position.
•Protection from injury: positioning/turning
•Pain control
•Psychologic considerations

19.  Stroke (cerebrovascular accident)
 A cerebrovascular accident (CVA) or ‘stroke’ or brain
attack occurs as a direct result of impaired blood flow
to the brain either because of vessel occlusion or
haemorrhaging due to a ruptured vessel.
 Stroke is the 3rd most common cause of death and a
leading cause of adult disability in worldwide.
 stroke is primarily a disease experienced by older
people and is more likely to be experienced by men
(although women who experience a stroke are more
likely to die)

20.  The nature and extent of neurological impairment
that the patient may suffer is dependent on:
A) the amount and location of oxygen starvation that the
brain tissue has experienced.
B) the severity of cerebral bleeding that has occurred.
 factors that are causing stroke
1. Age 2. smoking 3.obesity
4. history of heart disease or hypertension
5. Hyperlipidaemia
6. DM
7. a family history of stroke at a young age (less than 50
years of age).

21.  Types of stroke
 There are two main types of stroke – ischaemic
stroke and haemorrhagic stroke.
 Ischaemic stroke, which accounts for 85% of all
strokes, occurs when a blood clot blocks an artery to
the brain, causing an interruption of blood flow to the
brain cells. A high cholesterol level causing a furring or
covering of the arteries is a common cause of this type
of stroke.

22.  Types of stroke (cont)
Haemorrhagic stroke
 which accounts for 10_15% occurs when a blood
vessel in or around the brain ruptures, causing
bleeding and increased pressure in the skull, resulting
in compression and eventual ischaemia to brain
tissue.
 Untreated hypertension is a common cause of this
type of stroke.
 While hemorrhagic strokes are less common
than ischemic strokes, they tend to be more deadly.
 Haemorrhagic stroke however, tend to be faster in
term of recovery and good prognosis.

23. Clinical Manifestations
1. Numbness or weakness of the face, arm, or leg,
especially on one side of the body
2. Confusion or change in mental status
3. Trouble speaking or not understanding speech
4. Visual disturbances
5. Difficulty walking, dizziness, or loss of balance.
6. Sudden severe headache

24.  Signs and symptoms of stroke according to side of
brain affected.
Damage to right side of brainDamage to left side of brain
Loss of motor function to the left side of
the body
Loss of motor function to the right side
of the body
Language centers not affectedLanguage impairment – either an
inability to express self – expressive
aphasia, or difficulty in understanding
or using speech appropriately
Left visual field deficitRight visual field deficit
Apparent unconcern over loss of
independence
Frustration and depression due to loss
of independence
Poor judgement and impulsive
behaviour
Intellectual impairment

25. Quick test to diagnose stroke called FAST

26.  Transient ischaemic attack (TIA)
A transient ischaemic attack or ‘mini’ stroke is a
temporary interruption in blood flow to the brain which
can result in numbness, temporary paralysis and
impaired speech. Whilst the symptoms experienced are
not permanent and by definition resolve within 24 hours.
a TIA is often a warning of an impending, more
serious cerebrovascular accident.

27.  Pharmacological management
This aims to prevent the reoccurrence of stroke or TIA.
1. In the first 3 hours of an ischaemic stroke occurring,
the use of thrombolytic therapy, e.g. alteplase, is
important to dissolve thrombus and decrease sings and
symptoms (contraindicated for Hemorrhagic stroke) .
2. Aspirin or Clopidogrel (Plavix) may be prescribed to
reduce platelet aggregation in the case of TIA or
ischaemic stroke. (contraindicated for Hemorrhagic
stroke)

28. 3. Antihypertensive may be prescribed for patients who
have high blood pressure such as Candesartan
(Atakand).
4. Cholesterol-reducing drugs such as Atrovastatin,
simvastatin and Lopid to reduce triglycerides should be
prescribed to prevent recurrent ischaemic stroke or TIA

29.  Non-pharmacological management
1. Carotid endarterectomy (removal of fatty plaques from
the wall of the carotid artery) may be performed in
patients with stenosis (narrowing) of the carotid arteries
that supply blood to the brain.
2. The patient should be educated to diet that is low in
fat and lipid lowering agent should be lifelong.

30.  Non-pharmacological management (con’t)
3. Patients who are overweight or obese need support to
lose weight and be encouraged to take regular exercise.
4. Support the patients to stop smoking and reduce
alcohol intake.
5. Regular monitoring of blood pressure and patient
should be encouraged to reduce salt intake.

31.  Nursing Care and of stroke
1. Frequent monitoring vital signs and neurological
function during the acute phase using an the Glasgow
Coma Scale.
2. Keeping the patient nil by mouth until an assessment
of the swallowing reflex can be carried out.
3. Protecting the patient from injury due to possible
seizures, motor and visual deficits.

32. 4. Preventing pressure sore formation as immobility and
incontinence by frequent changing position every 2
hours and use electric air mattress and keep the skin
dry.
5. Maintain adequate hydration and nutrition through I.V
fluid or NG tube if the patient unable to tolerate through
orally to avoid dehydration and renal failure.

33. 6. Providing psychological support to alleviate anxiety
and fear.
7. Involving the patient to a speech therapist to enable
the patients to express themselves effectively.
8. Collaborating with other healthcare professionals such
as physiotherapist to teach the patient adaptive
measures to enable them to carry out their activities of
daily living, e.g. bathing, eating, dressing and toileting,
as independently as possible.

34.  Meningitis
Meningitis is an inflammation of the lining around the
brain and spinal cord caused by bacteria or viruses
 Meningitis can be the primary reason a patient
is hospitalized or can develop during hospitalization.
 Meningitis is classified as septic or aseptic.
Septic meningitis is caused by bacteria.
In aseptic meningitis, the cause is viral or secondary to
lymphoma, leukemia, or HIV.

35.  Eatiology
 The bacteria Streptococcus pneumoniae and
Neisseria meningitides are responsible for 80% of
cases of meningitis in adults.
 Outbreaks of N. meningitidis infection are most likely
to occur in dense community groups, such as college
campuses and military systems.
 the peak incidence is in the winter and early spring.

36.  Factors that increase the risk of bacterial meningitis
include:
1. tobacco use
2. viral upper respiratory infection, because they
increase the amount of droplet production.
3. Otitis media and mastoiditis.

37.  Pathophysiology
 Meningeal infections generally originate in one of two
ways: through the bloodstream as a consequence of
other infections or by direct spread, such as might
occur after a traumatic injury to the facial bones or
secondary to invasive procedures.

38.  Clinical Manifestations
1. Headache and fever are frequently the initial
symptoms.
The headache is usually either steady or throbbing and
very severe as a result of meningeal irritation.
2. Fever tends to remain high throughout the course of
the illness.
3. Neck mobility: Neck stiffness . A stiff and painful neck
can be an early sign and any attempts at flexion of the
head are difficult because of spasms in the muscles of
the neck.

39. 4. Positive Kernig’s sign: When the patient is lying with
the thigh flexed on the abdomen, the leg cannot be
completely extended.
Kernig’s Sign Brudzinski’s Sign

40. 5. Positive Brudzinski’s sign: When the patient’s neck is
flexed (after ruling out cervical trauma or injury),
flexion of the knees and hips is produced; when the
lower extremity of one side is passively flexed, a similar
movement is seen in the opposite extremity.
Kernig’s Sign
Brudzinski’s Sign

41. 6. Photophobia (extreme sensitivity to light): This finding
is common, although the cause is unclear.
7. A rash can be a striking feature of N. meningitidis
infection, occurring in 50% of patients with this type of
meningitis.
8. Skin lesions develop, ranging from a petechial rash
with purpuric lesions to large areas of ecchymosis.
9. Disorientation and memory impairment are common.
10. lethargy, unresponsiveness, and coma may develop.
11. Seizures can occur

42. petechial rash
purpuric lesions
ecchymosis

43.  Assessment and Diagnostic Findings
1. CT-scan or MRI scan is used to detect a shift in brain
contents (which may lead to herniation) prior to a lumbar
puncture.
2. Bacterial culture and Gram staining of CSF and blood
are key diagnostic tests.
3. CSF studies demonstrate low glucose, high protein
levels, and high white blood cell count.

44. Prevention
meningococcal conjugated vaccine be given to
adolescents entering high school and to college.
Medical Management
Successful outcomes depend on the early administration
of an antibiotic.
1. Vancomycin hydrochloride in combination with one of
the cephalosporins (eg, ceftriaxone sodium, cefotaxime
sodium) is administered intravenously (IV).

45. 2. Dexamethasone (Decadron) is beneficial therapy in
the treatment of acute bacterial meningitis and in
pneumococcal meningitis if it is administered 15 to 20
minutes before the first dose of antibiotic and every 6
hours for the next 4 days.
3. Dehydration and shock are treated with fluid volume
expanders.
4. Seizures, which may occur early in the course of
the disease, are controlled with phenytoin (Dilantin).
5. Increased ICP is treated as necessary.

46.  Brain abscesses
Brain abscesses are more common in males
during the first 20 years of life and are rare in
immunocompetent people; they are more
frequently diagnosed in people who are
immunosuppressed as a result of an underlying
disease or use of immunosuppressive
mediations.

47.  Pathophysiology
 A brain abscess is a collection of infectious
material within the tissue of the brain.
 Bacteria are the most common causative
organisms.
 The most common predisposing conditions for
abscesses among immunocompetent adults are
otitis media and rhinosinusitis.

48.  Pathophysiology (con’t)
 An abscess can result from intracranial surgery,
penetrating head injury, or tongue piercing.
 Organisms causing brain abscess may reach the brain
by hematologic spread from the lungs, gums, tongue,
or heart, or from a wound or intra-abdominal infection.
 Brain abscesses in immunocompromised people may
result from various pathogens.
 To prevent brain abscess, otitis media, mastoiditis,
rhinosinusitis, dental infections, and systemic
infections should be treated promptly.

49.  Clinical Manifestations
1. Headache, usually worse in the morning, is the most
prevailing symptom.
2. Fever
3. Vomiting
4. Focal deficits such as weakness and decreasing
vision reflect the area of brain that is involved.
5. As the abscess expands, symptoms of increased ICP
such as decreasing LOC and seizures are observed.

50.  Assessment and Diagnostic Findings
1. MRI or CT scanning can identify the size and location
of the abscess. The MRI or CT scans reveal a ring
around a hypodense area.
2. Aspiration of the abscess, guided by CT or MRI, is the
best method to culture and identify the infectious
organism.
3. Blood cultures.
4. Chest x-ray is performed to rule out predisposing lung
infections.
5. an electroencephalogram (EEG) may help localize the
lesion

51.  Medical Management
1. Large IV doses of antibiotics based on culture and
sensitivity testing are administered to penetrate the
blood–brain barrier and reach the abscess.
2. CT-guided aspiration may be used to drain the
abscess.
3.
3. Corticosteroids may be prescribed to help reduce the
inflammatory cerebral edema.
4. Antiseizure medications (phenytoin, phenobarbital)
may be prescribed to prevent or treat seizures.