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- 1. Module 11 Neurologic Disorders Part 2 ATI CHAPTERS 5, 7-10, 14, 16 HINKLE AND CHEEVER 68-70
- 2. Head Trauma
- 3. Head Injury A broad classification that includes injury to the scalp, skull, or brain 2.5 million people receive head injuries every year in the United States The most common cause of death from trauma Most common cause of brain trauma is falls Groups at highest risk for brain trauma Children 0 to 4 years old, adolescents ages 15 to 19 years, and adults 65 years and older Prevention is the best approach
- 5. Pathophysiology of Brain Damage Primary injury: consequence of direct contact to head/brain during the instant of initial injury Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal injury Secondary injury: damage evolves over ensuing days and hours after the initial injury Cerebral edema, ischemia, or chemical changes associated with the trauma
- 6. Preventing Injuries Wear seat belts and helmets Children should sit in the back seat Back of pickup trucks- no! Prevent falls Secure firearms Do not drive under the influence of drugs or alcohol
- 7. Clinical Manifestations Manifestations depend on the severity and location of the injury Scalp wounds Tend to bleed heavily and are portals for infection Skull fractures Usually have localized, persistent pain, and swelling Brain might be damaged as a result Fractures of the base of the skull Bleeding from nose pharynx or ears Battle sign: ecchymosis behind the ear Halo sign: indicates a CSF leak. Ring of fluid around the blood stain from drainage
- 8. Basilar Fractures Allow CSF to Leak From the Nose and Ears
- 9. Manifestations of Brain Injury Loss of consciousness: length of time is significant Amnesia before or after the event CSF leakage from the nose and ears Manifestations of increased ICP Altered level of consciousness, restlessness, irritability Pupillary abnormalities Cranial nerve dysfunction Sudden onset of neurological deficits and neurological changes; changes in senses, movement, and reflexes Cushing’s triad Headache, NV Seizures
- 10. Brain Injury Classification Open head injury Integrity of the skull is compromised by a penetrating or blunt force trauma High risk of infection Closed head injury Occurs from blunt trauma that causes acceleration of the head and then deceleration or hits a stationary object Mild, moderate, or severe Depending on GCS and length of time unconscious
- 12. Types of Brain Injuries Concussion or mild traumatic brain injury Change in neurologic function No identified brain damage Usually resolves within 72 hr. Post-concussion syndrome Persistent cognitive and physical manifestations Contusion Brain is bruised A period of unconsciousness associated with stupor or confusion
- 13. Types of Brain Injuries Diffuse axonal injury Widespread shearing injury Results in coma Severe head trauma Intracranial hemorrhage Collection of blood in the epidural, subdural, or intracerebral space Chronic subdural or subacute bleeding; the manifestations are delayed for weeks to months
- 14. Concussion Patient may be admitted for observation or sent home Observation of patients after head trauma; report immediately Observe for any changes in level of consciousness Difficulty in awakening, lethargy, dizziness, confusion, irritability, and anxiety Difficulty in speaking or moving Severe headache Vomiting Patient should be aroused and assessed frequently
- 15. Contusion More severe than a concussion Unconscious May lie motionless, faint pulse, shallow breathing, pale skin Bladder and bowel incontinence Presents similar to shock (low BP) Varying outcomes
- 17. Epidural Hematoma Blood collection in the space between the skull and the dura Patient may have a brief loss of consciousness with return of lucid state; then, as hematoma expands, increased ICP will often suddenly reduce LOC An emergency situation! Treatment includes measures to reduce ICP, remove the clot, and stop bleeding Burr holes or craniotomy Patient will need monitoring and support of vital body functions and respiratory support
- 18. Subdural Hematoma Collection of blood between the dura and the brain Acute: symptoms develop over 24 to 48 hours Changes in LOC, pupillary signs, hemiparesis Coma, increasing BP, decreasing HR, slowing R- rapidly expanding mass- immediate intervention needed! Subacute: symptoms develop over 48 hours to 2 weeks Requires immediate craniotomy and control of ICP
- 19. Subdural Hematoma Continued Chronic Develops over weeks to months Causative injury may be minor and forgotten Clinical signs and symptoms may fluctuate Severe HA, intermittent; alternating focal neurologic signs; personality changes; mental deterioration; focal seizures Treatment is evacuation of the clot
- 20. Intracerebral Hemorrhage Hemorrhage occurs into the substance of the brain May be due to trauma or a nontraumatic cause HTN, aneurysm, tumors, bleeding disorders, anticoagulant therapy Treatment Supportive care Control of ICP Administration of fluids, electrolytes, and antihypertensive medications Craniotomy or craniectomy to remove clot and control hemorrhage unless area is inaccessible
- 21. Initial Management of the Patient With Traumatic Brain Injury
- 22. Management of Brain Injuries Always assume cervical spine injury until it is ruled out! Treatment of increased ICP Adequate oxygenation Elevating HOB Maintaining normal blood volume Drain CSF if needed Supportive measures Ventilator Seizure prevention Fluids and electrolyte maintenance Nutritional support Management of pain and anxiety
- 23. Head Injury Nursing Interventions Assess and monitor regularly: Respiratory status (priority assessment) Brain injury or death occurs within 3 to 5 minutes of hypoxia Changes in LOC using the GCS provide the earliest indication of neurologic deterioration Cranial nerve function Eye blink response, gag reflex, tongue and shoulder movement Assess pupils for size, equality, and reaction to light Bilateral sensory and motor response
- 24. Head Injury Nursing Interventions Calculate CPP using the ICP monitor, if in place Maintain c-spine precautions until cleared by x-ray Report presence of CSF from the nose or ears to the provider Monitor fluid, electrolytes, and osmolality to detect changes in sodium regulation (DI or SIADH) Provide adequate fluids to maintain cerebral perfusion pressure When giving large amounts of IVF, monitor for fluid overload and cerebral edema Maintain safety and seizure precautions Support the client’s family- coping can be difficult If brain death occurs, support the family when deciding whether to donate organs
- 25. Brain Death Uniform Determination of Brain Death Act Provides a comprehensive and sound basis for determining death in all situations. Adopted by US in 1981 Organ donation Nurse assists with exam for determination of brain death and helps with process of organ procurement 3 cardinal signs Coma Absence of brain-stem reflexes Apnea
- 28. Spinal Cord Injury (SCI) 276,000 persons in the U.S. live with disability from SCI (2014) Males account for 80% of SCIs Young people ages 16 to 30 account for more than half of all new SCIs Risk factors include younger age, male gender, alcohol and drug use Causes: MVCs (35%) Violence (24%)- predominantly gunshot wounds Falls (22%) Sports injuries (8%)
- 29. SCI Involve the loss of motor function, sensory function, reflexes, and control of elimination Level of injury dictates the consequence C-spine injuries can result in quadriplegia T1 or below injuries can result in paraplegia C4 or above injuries can result in impaired ventilation d/t involvement of phrenic nerve SCI from contusions, incomplete/complete lesions, or actual transection of the spinal cord Complete lesions result in complete loss of all voluntary movement and sensation below the level of injury Incomplete lesions result in varying losses
- 30. Primary and secondary injury Primary injury is the result of the initial trauma and usually permanent Secondary injury resulting from SCI include edema and hemorrhage Treatment is needed to prevent partial injury from developing into more extensive, permanent damage
- 31. Spinal Shock A sudden, but temporary loss of all reflexes and autonomic function below the level of spinal injury Muscular flaccidity and lack of sensation and reflexes Paralytic ileus from the loss of autonomic function Can have hypotension and bradycardia Response from inflammation caused by the injury Keep the mean arterial pressure at least 85 mm Hg can prevent further damage Administer plasma expanders (dextran) Lasting days to weeks
- 32. Neurogenic shock Sudden loss of communication within the sympathetic nervous system Blood pressure & heart rate decrease, and cardiac output decreases Venous pooling occurs due to peripheral vasodilation Paralyzed portions of the body do not perspire because sympathetic activity is blocked- watch for early detection of fever Can occur within 24 hours of injury and can last for several weeks
- 33. Neurogenic Shock- Nursing Actions Stabilizing the spinal cord with proper positioning Monitor VS, temp, and dependent edema Treat with appropriate medications (vasopressors such as norepinephrine/dopamine or atropine) and IV fluids Patient is at greater risk for venous thromboembolism (VTE) Monitor for manifestations such as swelling, decreased pulses, areas of warmth and/or tenderness Administer anticoagulants as prescribed for DVT prophylaxis
- 34. Autonomic Dysreflexia Stimulation of the sympathetic nervous system and an inadequate compensatory response by the parasympathetic nervous system Acute emergency Occurs after spinal shock has resolved and may occur years after the injury Occurs in persons with a SC lesion above T6 Sympathetic stimulation is usually caused by a triggering stimulus in the lower part of the body Distended bladder MOST COMMON CAUSE CHECK PATENCY OF FOLEY CATHETER Distention or contraction of visceral organs Such as constipation Stimulation of the skin
- 35. Autonomic Dysreflexia- Symptoms Extreme hypertension Severe pounding headache Pallor below the level of SC lesion’s dermatome Flushing and profuse diaphoresis above the spinal level of lesion Blurred vision Restlessness Nausea Nasal congestion Bradycardia
- 36. Autonomic Dysreflexia- Nursing Actions Place client in sitting position immediately Notify the provider Determine and treat the cause Check patency of urinary catheter or insert catheter for distended bladder Remove fecal impaction Assess for injury (skin, fractures, infection) Remove tight clothing Adjust room temperature and block drafts Monitor VS Administer antihypertensives (nitrates or hydralazine)
- 37. Respiratory Status- Nursing Care Monitoring respiratory status is the first priority Assess respirations, breathing pattern, lung sounds, cough Monitor oxygen saturation and ABGs Respirations can be affected from a SCI at or below C4 Provide oxygen and careful suctioning as needed Assist with intubation and mechanical ventilation as needed Assist the client to cough by applying abdominal pressure when attempting to cough Encourage the use of IS and CDB (cough and deep breathe) regularly
- 38. Orthostatic Hypotension Common complication of SCI Caused by an interruption in functioning of the autonomic nervous system and pooling of blood in lower extremities when in an upright position Nursing actions Change positioning slowly Use a reclining wheelchair Use thigh-high hose or elastic wraps to increase venous return May extend all the way up the client’s leg and include the abdomen
- 39. Muscle Strength and Tone- Nursing Care Determine baseline and monitor for increased loss of muscle strength Encourage active ROM and assist if the client lacks all motor function Upper motor neuron injuries (above L1L2) Spastic muscle tone after neurogenic shock If severe, they can develop pressure injures It can be painful if sensation is intact Administer muscle relaxants (baclofen and dantrolene) for severe spasticity Monitor for drowsiness and muscle weakness Lower motor neuron injuries (below L1L2) Flaccid type of paralysis
- 40. Mobility- Nursing Care Those with an incomplete injury can regain some function Use of braces Wheelchair provides the best functional mobility Clients with high level injuries may experience postural hypotension when sitting upright Avoid footdrop and contractures Use of specialty beds Wheelchair transfer stages (ATI, 2019) 1. Raise the HOB (lower the angle if client reports dizziness) 2. Transfer the client into reclining wheelchair with the back of the wheelchair reclined 3. Be ready to lock and lean the wheelchair back onto the knee to a fully-reclined position if the client reports dizziness 4. Do not attempt to return the client to the bed
- 41. RotoRest Bed
- 42. Bowel and Bladder Function- Nursing Care Spastic neurogenic bladder Upper neuron injuries Males use a condom catheter and micturition reflex stimulation (tugging on the pubic hair) Females use an indwelling urinary catheter d/t unpredictable urine release Administer cholinergic (bethanechol) to decrease spasticity of the bladder Flaccid neurogenic bladder Lower neuron injuries Males' and females' interventions include intermittent catheterization and Crede’s method (downward pressure placed on the bladder to manually express the urine) Bowel function Daily use of stool softeners or bulk-forming laxatives Stimulate a bowel movement daily or every other day with Bisacodyl suppository or digital stimulation Developing a schedule is critical in preventing complications
- 43. Other Nursing Actions Intake and Output The client may be NPO for several days Nutritional support is necessary Maintain soft stools Neurologic status Determine baseline and monitor for further loss of function GI function Ileus can develop, monitor bowel sounds Skin integrity Change position every 2 hours, every 1 hour if in wheelchair Pressure ulcers can develop within 6 hours Cervical collars- skin breakdown under chin, on the shoulders, and at the occiput Use pressure relief devices continuously
- 44. Halo Traction or Cervical Tongs Provides traction and or immobilizes the spinal column Nursing actions Maintain body aliment and ensure weights hang freely Monitor skin integrity- assessing under the vest Provide pin care Do not use device to turn or move the client Good skin care- dry, no powder Teach vest care- liner should not get wet, liner should be changed periodically
- 45. Pin Care
- 46. Spinal Surgery Spinal fusion is commonly performed to stabilize the spine Decompressive laminectomy removes a section of lamina, removes bone fragments, foreign bodies, or hematomas that can place pressure on the cord Donor bone is often obtained from the iliac crest and is used to fuse the vertebrae together Paravertebral rods are used to immobilize several vertebral levels Nursing actions Assess for airway compromise from swelling or hemorrhage with cervical fusions Assess neurological status and VS every hour the first 4 hr. post op
- 47. Neurologic infections, Autoimmune disorders, and Neuropathies
- 48. Meningitis Inflammation of the meninges which cover brain and spinal cord Types Aseptic is viral and is the most common form that usually resolves without treatment Measles, mumps, herpes, West Nile virus Fungal meningitis is common with AIDS Cryptococcus neoformans Septic is bacterial and is a contagious infection with a high mortality rate Otitis media, pneumonia, sinusitis Neisseria meningitides, streptococcus pneumonias, or haemophilus influenzae
- 49. Meningitis Health Promotion and Prevention N. meningitidis is transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups Three vaccines Hemophilus influenzae type b (Hib) Infants, 4 doses starting at 2 months of age Pneumococcal polysaccharide vaccine (PPSV) Also intended to prevent respiratory infections For adults who are at risk (immunosuppressed or crowded living conditions) Meningococcal vaccine (MCV4) Adolescents prior to living in a college dorm or military base Recommended at age 11 or 12 with a booster at age 16
- 50. Meningitis Signs And Symptoms Excruciating, constant headache Nuchal rigidity Altered level of consciousness Positive Kernig's sign- thigh flexed on abdomen, can’t fully extend Positive Brudzinski’s sign- neck flexed, flexion of knees and hips is produced Fever and chills NV Behavioral changes Photophobia Hyperactive deep tendon reflexes Tachycardia Seizures Red macular rash Restlessness, irritability
- 51. Meningitis Signs And Symptoms
- 52. CSF Analysis via Lumbar Puncture Most definite diagnostic procedure for meningitis Results Appearance of CSF Cloudy: bacterial Clear: viral Elevated WBC Elevated protein Decreased glucose: bacterial Elevated CSF pressure
- 53. Meningitis Nursing Care Isolate the client as soon as meningitis is suspected! Droplet precautions Continue precautions until antibiotics have been administered for 24 hr. and secretions are no longer infectious. Those with bacterial meningitis may need precautions continuously. Follow hospital policy. Monitor VS and assess for septic shock Implement fever-reduction measures Bedrest with HOB at 30° Monitor for increased ICP. Avoid increasing ICP Seizure precautions Provide a calm and quite environment with dim lights Report meningococcal infections to the public health department
- 54. Meningitis Medications Ceftriaxone or cefotaxime in combination with vancomycin Given until C&S results are available Early administration of high doses of appropriate IV antibiotics for bacterial meningitis Phenytoin Anticonvulsant if ICP increases or the client has a seizure Acetaminophen, ibuprofen Analgesic for HA and/or fever Prefer nonopioids to avoid masking changes of LOC Prophylactic antibiotics (ceftriaxone, ciprofloxacin, rifampin) for those in close contact with the client
- 55. Meningitis Complications Increased ICP Leads to brain herniation and death Monitor signs of increased ICP and treat with mannitol SIADH Monitor blood and urine labs Provide interventions such as demeclocycline and restrict fluids Daily weights Septic emboli Can occur in the hands and feet Lead to gangrene and DIC
- 56. Brain Abscess Collection of infectious material within brain tissue Risk is increased in immunocompromised patients Prevent by treating otitis media, mastoiditis, sinusitis, dental infections, and systemic infections promptly Diagnosis by MRI or CT CT-guided aspiration is used to identify the causative organisms
- 57. Brain Abscess Signs and Symptoms Headache that is usually worse in the morning Fever Vomiting Neurologic deficits- weakness, decreasing vision Signs and symptoms of increased ICP- decreasing LOC and seizures
- 58. Brain Abscess Management Medical Management Control ICP Drain abscess Antibiotic therapy Treat cerebral edema- corticosteroids Nursing Management Conduct frequent and ongoing neurologic assessment and responses to treatment Ensure patient safety and protect from injury Provide supportive care Monitor for neurologic deficits
- 59. Encephalitis Acute, inflammatory process of the brain tissue Causes Viral infections HSV West Nile St. Louis Fungal infections
- 60. Encephalitis Signs and Symptoms Headache Fever Confusion Changes in LOC Vector-borne rash Flaccid paralysis Parkinson’s-like movements
- 61. Encephalitis Management Medical Management Acyclovir for HSV infection Amphotericin B and/or other antifungal agent for fungal infection Control seizures Control ICP Nursing Management Frequent and ongoing assessment Dim lights Limit noise PRN pain meds Use cautiously- may mask neuro symptoms Monitor intake and output- alert for presence of renal complications from antiviral therapy Monitor for seizures
- 62. Multiple Sclerosis (MS) A chronic progressive immune-related demyelination disease of the CNS Demyelination interrupts the flow of nerve impulses Plaques can occur on axons Unable to regenerate and causing irreversible damage Most common areas include optic nerve, cerebrum, brainstem, cerebellum, and spinal cord Different possible courses Relapsing-remitting MS is the most common type After relapse they may not return to baseline Eventually progresses to the point of quadriplegia Aggressive forms can shorten lifespan
- 63. Four Basic Types of MS
- 64. MS Risk Factors Most common b/t the ages of 20-40 years More common in women- twice as often Family history Researching the cause Association with the interleukin (IL)-7 and IL-2 receptor genes Geographical trends- more common in Europe, New Zealand, southern Australia, northern US, southern Canada. Less prevalent in Asians Triggers of relapse Infection, injury, emotional stress, pregnancy, fatigue, overexertion, and extreme temperatures
- 65. MS Signs and Symptoms Clinical manifestations vary and have different patterns Fatigue Weakness Numbness Difficulty in coordination Loss of balance Pain or paresthesia Visual disturbances Difficulty with speech Muscle spasticity Bowel and bladder dysfunction Cognitive dysfunction Sexual dysfunction
- 66. Diagnostic Procedure CSF reveals elevated protein level and a slight increase in WBC MRI reveals plaques of the brain and spine
- 67. Nursing Care Monitor the following Visual acuity Speech patterns Swallowing Activity intolerance Skin integrity Discuss coping mechanisms and resources Encourage fluid intake and other measures to decrease the risk of UTI Assist with bladder elimination Establish a voiding time schedule Every 1.5 to 2 hours Monitor cognitive changes Plan interventions to promote cognitive function Reorient as needed, place objects used in routine places Use a communication board as needed Apply eye patches to treat diplopia Alternate eyes every few hours Teach scanning technique Exercise and stretch affected muscles Balance activity and rest Maintain a safe environment- fall risk! Walk with feet apart- widen base of support Watch the feet while walking
- 68. MS Medications Interferons beta-1a and beta-1b Start early in the course of disease Used to prevent and treat relapses Adverse effects: flu-like symptoms Corticosteroids (prednisone, dexamethasone, methylprednisolone) Reduce inflammation in acute exacerbations Adverse effects: infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, GI bleeding, and personality changes Antispasmodics (dantrolene, baclofen, diazepam) for muscle spasticity Anticonvulsants (carbamazepine) is used to treat paresthesia Anticholinergics (propantheline) is used for bladder dysfunction
- 69. Myasthenia Gravis Impaired transmission of impulses across the myoneural junction Considered a motor disorder- varying degrees of weakness of the voluntary muscles Women affected more than men Age Women (20-40 years) Men (60-70 years)
- 70. Myasthenia Gravis Signs and Symptoms Diplopia Ptosis Weakness of facial muscles Dysphonia- caused my laryngeal involvement Dysphagia- increased choking and aspiration Generalized weakness- affects extremities, intercostal muscles which leads to respiratory failure
- 71. Tensilon Test Administration of Tensilon will do nothing in a normal client Will cause a temporary improvement of muscle weakness in a client with MG There is a slight risk of Ventricular Fibrillation (V-Fib) and therefore cardiac arrest The antidote is atropine sulfate
- 72. Myasthenia Gravis Medical Management Pharmacologic Therapy Anticholinesterase meds- inhibits breakdown of acetylcholine Therapeutic Plasma Exchange (Plasmapheresis) Exchange of plasma Reduces the number of antibodies circulating in the bloodstream Temporary relief from symptoms- few weeks Surgery Thymectomy- removal produces antigen-specific immunosuppression and clinical improvement
- 73. Myasthenia Gravis Nursing Management Medication management- understanding actions of meds and schedule of taking them Conservation of energy- identify times of rest throughout the day Risk of aspiration- meals should coincide with peak effects of anticholinesterase meds Impaired vision- tape eyes closed for short periods, artificial tears, eye patches Avoid factors that exacerbate symptoms- emotional stress, infections, rigorous activity, heat Support groups
- 74. Myasthenic Crisis Result of disease exacerbation or a precipitating event, most commonly a respiratory infection THE COMMON COLD!!! Severe generalized muscle weakness with respiratory and bulbar weakness Patient may develop respiratory compromise failure Patient is admitted to ICU and closely monitored
- 75. Management of Myasthenic Crisis Patient instruction in signs and symptoms of myasthenic crisis and cholinergic crisis Ensuring adequate ventilation; intubation and mechanical ventilation may be needed Assessment and supportive measures include: Ensure airway and respiratory support Take ABGs, serum electrolytes, I&O, and daily weight If patient cannot swallow, nasogastric feeding may be required Avoid sedatives and tranquilizers- aggravate hypoxia & hypercapnia, cause respiratory & cardiac depression
- 76. Guillain-Barré Syndrome Autoimmune disorder with acute attack of peripheral nerve myelin Rapid demyelination Ascending weakness May produce respiratory failure and autonomic nervous system dysfunction with CV instability Most often follows a viral infection Related to influenza vaccine?
- 77. Guillain-Barré Syndrome More common in males Ages (16-25) and (45-60) years 60-75% of patients will recover completely 20-25% of patients will have some type of residual effects 5% will die
- 78. Guillain-Barré Syndrome Signs and Symptoms Weakness Paralysis Paresthesias Pain Diminished or absent reflexes that start in the lower extremities and progress upward Bulbar weakness (lower cranial nerves) Cranial nerve syndromes Changes in vital signs- vagus nerve affected- tachycardia, bradycardia, hypertension, orthostatic hypotension
- 79. Guillain-Barré Syndrome Medical Management Medical emergency Requires intensive care management with continuous monitoring and respiratory support TPE (Plasmapheresis) and IVIG are used to reduce circulating antibodies Nursing Management Maintaining respiratory function Enhancing physical mobility Providing adequate nutrition Improving communication Decreasing fear and anxiety Monitoring and managing potential complications Promoting home care
- 80. Guillain-Barré Syndrome Maintaining respiratory function Mechanical ventilation IS Chest physiotherapy Suctioning- bulbar weakness impairs swallowing Assess vital signs frequently to identify autonomic dysfunction Enhancing physical mobility Prevent complications associated with immobility DVT PE Pressure ulcers- pad bony prominences, change positions frequently
- 81. Guillain-Barré Syndrome Providing adequate nutrition Assess for bowel sounds (paralytic ileus) NG tube or PEG tube Improving communication Paralysis can interfere with talking, laughing, and crying Work with speech therapist Use of picture cards Eye blinking
- 82. Guillain-Barré Syndrome Monitoring and managing potential complications Frequent assessment of respiratory status ECG monitoring for cardiac dysrhythmias DVT / PE Promoting home care Educate regarding generally favorable prognosis Rehabilitation process Remember, most clients will experience a complete recovery
- 83. Brain Tumors Many have unknown origins Genetics Exposure to radiation and electromatic fields Previous head injury Cell phones High-tension wires Hair dye Incidence is increasing
- 84. Brain Tumors Primary Originate in the brain Unknown cause Secondary Originate outside of the brain Metastasize (spreads) to the brain Twice as common as primary brain tumors
- 85. Brain Tumors Signs and Symptoms Symptoms are dependent upon the location and size of the lesion and the compression of associated structures Localized or generalized neurologic symptoms Symptoms of increased ICP Headache (most common in morning) Vomiting Visual disturbances (edema on CN III) Seizures Hemiparesis Mental status changes Nystagmus Tinnitus Personality changes
- 86. Brain Tumors Diagnostic Tests CT, MRI, PET scan, cerebral angiogram Determines size, location and extent of the tumor LP should not be done if the client has manifestations of increased ICP to prevent brain herniation Cerebral biopsy Usually guided by CT or MRI scan Abnormal cerebral tissue is sent to pathology Benefits-minimally disruptive to the rest of the brain, decreased recovery time, and not associated with risk of an open craniotomy Negative- does not remove or debulk the tumor, results can be inconclusive, and possible misdiagnosis
- 87. Brain Tumors Nursing Care Maintain ABCs Monitor neurologic status Assess for changes in LOC, neurological deficits, and occurrence of seizures Monitor and treat increased ICP Maintain safety Implement seizure precautions Monitor for complications SIADH and DI
- 88. Stereotactic Image of Brain Tumor and Computerized Image of a Prescribed Radiation Dose
- 89. Brain Tumors Medications & Management Non-opioid analgesics Avoid opioids as they can decrease LOC Corticosteroids Reduce cerebral edema Relieves headaches, improves LOC Osmotic diuretics Decrease fluid content of the brain Decreases ICP Anticonvulsant medication Control and prevent seizures H2-antagonist Decreases the risk of stress ulcers Antiemetics Radiation/chemotherapy Craniotomy
- 90. Bell's Palsy Facial paralysis caused by unilateral inflammation of the seventh cranial nerve Manifestations- unilateral facial muscle weakness or paralysis with facial distortion, increased lacrimation, and painful sensations in the face; may have difficulty with speech and eating
- 91. Bell's Palsy Medical Management Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder Nursing Management Provide and reinforce information and reassurance that stroke has not occurred Protection of the eye from injury; cover eye with shield at night, instruct patient to close eyelid, use of eye ointment and sunglasses Facial exercises and massage to maintain muscle tone
- 92. Parkinson’s Disease Slowly progressing and debilitating disorder of movement Decreased levels of dopamine which allows acetylcholine to dominate Onset of findings between age 40 to 70 1% of those older than 65 years 2% of those older than 85 years More common in men Genetic predisposition Chronic use of antipsychotic medication No definitive diagnostic procedures R/O other diseases
- 94. Parkinson’s Disease Signs and Symptoms Four primary findings Tremor Muscle rigidity Bradykinesia Postural instability Fatigue Stooped posture/postural instability Slow, monotonous speech Masklike facial expression Difficulty chewing and swallowing Drooling Dysarthria Mood swings Cognitive impairment Autonomic findings Orthostatic hypotension Flushing Diaphoresis
- 95. Parkinson’s Disease Signs and Symptoms
- 96. Parkinson’s Disease Nursing Care Monitor swallowing Maintain adequate nutrition and weight May need a high-calorie, high-protein diet Document the client’s weight at least weekly Keep a diet intake log Small frequent meals Consult with speech therapy if the client demonstrates a risk of choking Consult with occupational therapist for eating devices Maintain mobility Encourage daily exercise/ROM, balance activity and rest Consult with PT
- 97. Parkinson’s Disease Nursing Care Continued Promote communication Facial muscle strengthening exercises Encourage the client to speak slowly and pause frequently Monitor mental and cognitive status Observe for manifestations of depression and dementia Provide a list of community resources Assess for personal and family coping Provide a safe environment No throw rugs, use of an electric razor
- 98. Medications- Dopaminergic Levodopa (dopaminergic) is converted to dopamine in the brain Carbidopa protects levodopa from being metabolized before it reaches the brain Allows for smaller doses and less adverse effects Nursing actions Monitor for the “wearing-off” Dose needs to be adjusted or needs a medication holiday Aids in muscle function Monitor for toxicity Muscle twitching Facial grimacing Spasmodic eye winking
- 99. Parkinson's Disease- Medications Dopamine agonists (pramipexole) Combine with dopaminergic for better results Adverse effects: orthostatic hypotension, dyskinesias, and hallucinations Anticholinergics (benztropine) Decrease tremors and rigidity Adverse effects: anticholinergic effects COMT inhibitors (entacapone) Decrease the breakdown of levodopa Adverse effects: dark urine, diarrhea MAO-B inhibitors (selegiline) Reduce the wearing off phenomenon Avoid foods high in tyramine- can cause hypertensive crisis
- 100. Therapeutic Procedures Stereotactic pallidotomy or thalamotomy When clients are unresponsive to other therapies Causes destruction of a small portion of the brain Nursing actions: post-op- assess for neurologic impairment and brain hemorrhage Deep brain stimulation Electrode is implanted in the thalamus Current is delivered through a small pulse generator implanted under the skin of the upper chest Decreases tremors and involuntary movements Nursing actions: post-op- assess for infection, brain hemorrhage, and stroke-like findings
- 101. Huntington’s Disease A chronic progressive hereditary disease that results in choreiform movement and dementia Pathology involves premature death of cells in the striatum of the basal ganglia (control of movement) and the cortex (thinking, memory, perception, judgment) Occurs at midlife
- 102. Huntington’s Disease Signs and Symptoms Chorea Intellectual decline Emotional disturbance Uncontrollable movement Tics and grimaces Speech problems- slurred, hesitant, explosive Dysphagia- risk for aspiration Disturbed gait with eventual bedrest Impaired judgment and memory Anger, dementia, and psychosis eventually ensue
- 103. Huntington’s Disease Management Medications to reduce chorea Monitor for akathisia (motor restlessness) because it may be mistaken for the restless fidgeting of the disease itself when pt is actually overmedicated Depression Suicide prevention
- 104. Alzheimer's Disease (AD) A chronic, progressive, degenerative brain disorder that effects 4.5 million people in the United States Nonreversible type of dementia that progressively develops over many years Survival after diagnosis is approximately 10 years, but some live up to 20 years Characterized by memory loss, problems with judgement and changes in personality Risk factors Advanced age Chemical imbalances Family history Environmental agents (herpes virus, metal, or toxic waste) Percious head injury female Ethnicity/race (African American and Hispanic people)
- 105. Stages of Alzheimer's Disease Three general stages 1. Mild Alzheimer's Stages 1-3 2. Moderate Alzheimer's Stages 4 and 5 3. Severe Alzheimer's Stages 6 and 7
- 106. Alzheimer's Disease Nursing Care Provide a safe environment Frequent monitoring/visual checks Keep client from stairs, elevators, exits Remove or secure dangerous items in the client's environment Provide frequent walks to avoid wondering Maintain a sleeping schedule Check skin weekly for breakdown Reality orientation if in early stages Validation in the later stages Acknowledge feelings Do not argue with the patient Offer cognitive stimulation Walks, music, and crafts Provide memory training Reminisce about the past, making lists and rehearsing Promote consistency Promote self-care as long as possible Reduce agitation Provide routine toileting
- 107. Alzheimer's Disease Medications Antipsychotics Antidepressants Anxiolytics AD Medications may temporarily slow the course of disease Donepezil prevents the breakdown of acetylcholine Memantine blocks nerve cell damage caused by excess glutamate Adverse effects: frequent stools, upset stomach, and dizziness/headache
- 108. Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s Disease Unknown cause Progressive illness Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei of the lower brainstem Occurs most between 40 and 60 years of age
- 109. ALS Signs and Symptoms Fatigue Progressive muscle weakness Cramps Fasciculations (twitching) Incoordination Difficulty in talking Difficulty in swallowing Difficulty in breathing
- 110. ALS Management No specific therapy Control symptoms- improve quality of life, well-being Delay progression of disease Average survival time is 2 years Enteral feeding Suctioning Mechanical ventilation Decisions about life support Suicide risk
- 111. Muscular Dystrophies Incurable disorders characterized by progressive weakening and wasting of skeletal and voluntary muscles Most are inherited disorders Muscle tissue is replaced with connective tissue
- 112. Muscular Dystrophies Medical Management Supportive care Prevention of complications Orthotic jacket- prevent spinal deformity and supports CV status Spinal fusion Pulmonary function decreases due to disease progression or deformity of thorax secondary to severe scoliosis Muscular Dystrophy Association- research, patient services, clinical care, professional & public education Nursing Management Assist client in maintaining function and enhancing the quality of life
- 113. Degenerative Disc Disease Low back pain is a significant public health disorder and has significant economic and social costs Most back problems are related to disc disease Degenerative changes occur with aging or are the result of previous trauma Continued pressure may produce degenerative changes in the nerves with resultant changes in sensation and motor responses Treatment is usually conservative Rest and medication Surgery may be required
- 114. Normal Spinal Vertebral and Ruptured Vertebral Disc
- 115. Disc Herniation Cervical disc herniation Lumbar disc herniation Spondylosis- degenerative changes in disc and adjacent vertebral bodies Paresthesia- numbness, tingling, pins & needles Pain and stiffness in the neck and shoulders Low back pain, especially with activity Postural deformity
- 116. Disc Herniation Medical Management Medications- analgesics, NSAIDs, muscle relaxers, corticosteroids Surgery- discectomy with or without fusion Nursing Management Relief of pain Improve mobility Monitor for bleeding / hematoma Frequent neuro checks- spinal cord compression may produce rapid or delayed onset of paralysis Monitor for dysphagia
Editor's Notes
- Image: https://parkinsonsnebraska.org/understanding-parkinsons-disease/
- Image: https://parkinsonsnebraska.org/understanding-parkinsons-disease/