Adult Nursing 2

Management of Patients With Cerebrovascular Disorders

Learning Objectives

• 1. Describe the incidence and social impact of cerebrovascular disorders.

• 2. Identify the risk factors for cerebrovascular disorders and related measures for prevention.

• 3. Compare the various types of cerebrovascular disorders: their causes, clinical manifestations, and medical management.

• 4. Apply the principles of nursing management to the care of a patient in the acute stage of an ischemic stroke.

• 5. Use the nursing process as a framework for care of a patient recovering from an ischemic stroke.

• 6. Use the nursing process as a framework for care of a patient with a hemorrhagic stroke.

• 7. Identify essential elements for family teaching and preparation for home care of the patient who has had a stroke.

Cerebrovascular Disorders

• Functional abnormality of the CNS that occurs when the blood supply is disrupted

• Stroke is the primary cerebrovascular disorder and the third leading cause of death in the U.S.

• Stroke is the leading cause of serious long-term disability in the U.S.

Prevention• Nonmodifiable risk factors

– Age (over 55), male gender, African-American race

• Modifiable risk factors

– Hypertension is the primary risk factor

– Cardiovascular disease

– Elevated cholesterol or elevated hematocrit

– Obesity

– Diabetes

– Oral contraceptive use

– Smoking and drug and alcohol abuse

Stroke

• “Brain attack”• Sudden loss of function resulting from a

disruption of the blood supply to a part of the brain

• Types of stroke

– Ischemic (80–85%) – Hemorrhagic (15–20%)

Ischemic Stroke

• Disruption of the blood supply due to an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue

• Types– Large artery thrombosis– Small penetrating artery thrombosis– Cardiogenic embolism– Cryptogenic– Other

Manifestations of Ischemic Stroke

• Symptoms depend upon the location and size of the affected area

• Numbness or weakness of face, arm, or leg, especially on one side

• Confusion or change in mental status• Trouble speaking or understanding speech• Difficulty in walking, dizziness, or loss of balance or

coordination• Sudden, severe headache• Perceptual disturbances

Terms:

• Hemiplegia• Hemiparesis• Dysarthria• Aphasia: expressive aphasia, receptive aphasia• Hemianopsia

Transient Ischemic Attack (TIA)

• Temporary neurologic deficit resulting from a temporary impairment of blood flow

• “Warning of an impending stroke”• Diagnostic workup is required to treat and

prevent irreversible deficits

Carotid Endarterectomy

Preventive Treatment and Secondary Prevention

• Health maintenance measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease

• Carotid endarterectomy• Anticoagulant therapy • Antiplatelet therapy: aspirin, dipyridamole

(Persantine), clopidogrel (Plavix), ticlopidine (Ticlid)• “Statins” • Antihypertensive medications

Medical Management—Acute Phase of Stroke

• Prompt diagnosis and treatment

• Assessment of stroke: NIHSS assessment tool

• Thrombolytic therapy

– Criteria for tPA

– IV dosage and administration

– Patient monitoring

– Side effects—potential bleeding

• Elevate HOB unless contraindicated

• Maintain airway and ventilation

• Continuous hemodynamic monitoring and neurologic assessment

Hemorrhagic Stroke• Caused by bleeding into brain tissue, the ventricles, or

subarachnoid space. • May be due to spontaneous rupture of small vessels

primarily related to hypertension; subarachnoid hemorrhage due to a ruptured aneurysm; or intracerebral hemorrhage related to amyloid angiopathy, arterial venous malformations (AVMs), intracranial aneurysms, or medications such as anticoagulants.

• Brain metabolism is disrupted by exposure to blood.• ICP increases due to blood in the subarachnoid space.• Compression or secondary ischemia from reduced

perfusion and vasoconstriction causes injury to brain tissue.

Manifestations

• Similar to ischemic stroke• Severe headache• Early and sudden changes in (LOC) Level of Consciousness• Vomiting

Medical Management

• Prevention: control of hypertension• Diagnosis: CT scan, cerebral angiography, lumbar

puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage

• Care is primarily supportive• Bed rest with sedation • Oxygen• Treatment of vasospasm, increased ICP, hypertension,

potential seizures, and prevention of further bleeding

Nursing Process: The Patient Recovering from an Ischemic Stroke—Assessment

• Acute phase – Ongoing/frequent monitoring of all systems including vital

signs and neurologic assessment—LOC, motor symptoms, speech, eye symptoms

– Monitor for potential complications including musculoskeletal problems, swallowing difficulties, respiratory problems, and signs and symptoms of increased ICP and meningeal irritation

• After the stroke is complete– Focus on patient function; self-care ability, coping, and teaching

needs to facilitate rehabilitation

Nursing Process: The Patient Recovering from an Ischemic Stroke—Diagnoses

• Impaired physical mobility• Acute pain• Self-care deficits• Disturbed sensory perception• Impaired swallowing• Urinary incontinence• Disturbed thought processes• Impaired verbal communication• Risk for impaired skin integrity• Interrupted family processes• Sexual dysfunction

Potential Problems/Complications

• Decreased cerebral blood flow• Inadequate oxygen delivery to brain• Pneumonia

Nursing Process: The Patient Recovering from an Ischemic Stroke—Planning

• Major goals may include: – Improved mobility – Avoidance of shoulder pain– Achievement of self-care – Relief of sensory and perceptual deprivation – Prevention of aspiration– Continence of bowel and bladder– Improved thought processes– Achieving a form of communication– Maintaining skin integrity – Restored family functioning – Improved sexual function – Absence of complications

Interventions

• Focus on the whole person• Provide interventions to prevent

complications and to and promote rehabilitation

• Provide support and encouragement• Listen to the patient

Improving Mobility and Preventing Joint Deformities

• Turn and position in correct alignment every 2 hours

• Use of splints• Passive or active ROM 4–5 times day• Positioning of hands and fingers• Prevention of flexion contractures • Prevention of shoulder abduction• Do not lift by flaccid shoulder• Measures to prevent and treat shoulder proclaims

Positioning to Prevent Shoulder Abduction

Prone Positioning to Help Prevent Hip Flexion

Improving Mobility and Preventing Joint Deformities

• Passive or active ROM 4–5 times day• Encourage patient to exercise unaffected side• Establish regular exercise routine• Quadriceps setting and gluteal exercises• Assist patient out of bed as soon as possible-

assess and help patient achieve balance, move slowly

• Ambulation training

Interventions

• Enhancing self-care– Set realistic goals with the patient– Encourage personal hygiene– Assure that patient does not neglect the affected

side– Use of assistive devices and modification of

clothing • Support and encouragement• Strategies to enhance communication• Encourage patient to turn head, look to side

with visual field loss

Interventions

• Nutrition – Consult with speech therapy or nutritional

services– Have patient sit upright, preferably OOB, to eat– Chin tuck or swallowing method– Use of thickened liquids or pureed diet

• Bowel and bladder control– Assessment of voiding and scheduled voiding– Measures to prevent constipation—fiber, fluid,

toileting schedule– Bowel and bladder retraining

Nursing Process: The Patient with a Hemorrhagic Stroke—Assessment

• Complete and ongoing neurologic assessment—use neurologic flow chart

• Monitor respiratory status and oxygenation• Monitoring of ICP• Patients with intracerebral or subarachnoid

hemorrhage should be monitored in the ICU • Monitor for potential complications• Monitor fluid balance and laboratory data• All changes must be reported immediately

Nursing Process: The Patient with a Hemorrhagic Stroke—Diagnoses

• Ineffective tissue perfusion (cerebral)• Disturbed sensory perception• Anxiety

Potential Problems/Complications

• Vasospasm• Seizures• Hydrocephalus• Rebleeding• Hyponatremia

Nursing Process: The Patient with a Hemorrhagic Stroke—Planning

• Goals may include: – Improved cerebral tissue perfusion – Relief of sensory and perceptual deprivation – Relief of anxiety – The absence of complications

Aneurysm Precautions

• Absolute bed rest• Elevate HOB 30° to promote venous drainage or flat to

increase cerebral perfusion• Avoid all activity that may increase ICP or BP; Valsalva

maneuver, acute flexion or rotation of neck or head• Exhale through mouth when voiding or defecating to

decrease strain• Nurse provides all personal care and hygiene• Nonstimulating, nonstressful environment; dim lighting, no

reading, no TV, no radio• Prevent constipation• Visitors are restricted

Interventions

• Relieving sensory deprivation and anxiety• Keep sensory stimulation to a minimum for

aneurysm precautions• Realty orientation• Patient and family teaching• Support and reassurance• Seizure precautions• Strategies to regain and promote self-care and

rehabilitation

Home Care and Teaching for the Patient Recovering from a Stroke

• Prevention of subsequent strokes, health promotion, and follow-up care

• Prevention of and signs and symptoms of complications • Medication teaching• Safety measures• Adaptive strategies and use of assistive devices for ADLs• Nutrition—diet, swallowing techniques, tube feeding

administration• Elimination—bowel and bladder programs, catheter use• Exercise and activities, recreation and diversion• Socialization, support groups, and community resources

Question

What are expected patient outcomes for a patient recovering from a hemorrhagic stroke?

A. Exhibits absence of vasospasmB. Residual aphasia C. One to four seizuresD. Complains of visual changes

Answer

A

Expected patient outcomes for a patient recovering from a hemorrhagic stroke include absence of vasospasm, no seizures, normal speech patterns, and no visual changes

Management of Patients With Neurologic Trauma

Learning Objectives On completion of this chapter, the learner should be able to:• 1. Describe the mechanisms of injury, clinical signs and symptoms, diagnostic testing, and treatment options for patients with traumatic brain and spinal cord injuries.• 2. Describe the nursing management of patients with brain injury.• 3. Use the nursing process as a framework for care of patients with traumatic brain injury.• 4. Identify the population at risk for spinal cord injury.• 5. Describe the clinical features and management of the patient with neurogenic

shock.• 6. Discuss the pathophysiology of autonomic dysreflexia and describe the

appropriate nursing interventions.• 7. Use the nursing process as a framework for care of patients with spinal cord

injury.

Adult Nursing 2

Management of Patients With Neurologic Trauma

Head Injury

• A broad classification that includes injury to the scalp, skull, or brain

• 1.4 million people receive head injuries every year in the U.S.

• The most common cause of death from trauma• Most common cause of brain trauma is MVA• Group at highest risk group for brain trauma is males age

15–24• Those younger than 5 years and the elderly are also at

increased risk• Prevention

Pathophysiology of Brain Damage

• Primary injury: due to the initial damage– Contusions, lacerations, damage to blood vessels,

acceleration/deceleration injury, or due to foreign object penetration

• Secondary injury: damage evolves after the initial insult– Due to cerebral edema, ischemia, or chemical

changes associated with the trauma

Pathophysiology of Traumatic Brain Injury

Manifestations

• Manifestations depend upon the severity and location of the injury

• Scalp wounds – Tend to bleed heavily, and are also portals for

infection • Skull fractures – Usually have localized, persistent pain– Fractures of the base of the skull

• Bleeding from nose pharynx or ears • Battle’s sign—ecchymosis behind the ear • CSF leak—halo sign—ring of fluid around the blood stain

from drainage

Basilar Fractures Allow CSF to Leak from the Nose and Ears

Manifestations of Brain Injury

• Altered LOC• Pupillary abnormalities• Sudden onset of neurologic deficits and

neurologic changes; changes in sense, movement, reflexes

• Changes in vital signs• Headache• Seizures

Brain Injury• Closed brain injury (blunt trauma): acceleration/deceleration injury occurs

when the head accelerates and then rapidly decelerates, damaging brain tissue

• Open brain injury: object penetrates the brain or trauma is so severe that the scalp and skull are opened

• Concussion: a temporary loss of consciousness with no apparent structural damage

• Contusion: more severe injury with possible surface hemorrhage– Symptoms and recovery depend upon the amount of damage and

associated cerebral edema– Longer period of unconsciousness with more symptoms of neurologic

deficits and changes in vital signs

Brain Injury

• Diffuse axonal injury: widespread axon damage in the brain seen with head trauma. Patient develops immediate coma.

• Intracranial bleeding– Epidural hematoma– Subdural hematoma• Acute and subacute • Chronic

– Intracerebral hemorrhage and hematoma

Concussion• Patient may be admitted for observation or sent

home• Observation of patients after head trauma; report

immediately– Observe for any changes in LOC– Difficulty in awakening, lethargy, dizziness, confusion,

irritability, anxiety– Difficulty in speaking or movement – Severe headache– Vomiting

• Patient should be aroused and assessed frequently

Location of Subdural, Intracerebral and Epidural Hemorrhages

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 include measures to reduce ICP, remove the

clot and stop bleeding—burr holes or craniotomy.• Patient will need monitoring and support of vital body

functions; respiratory support.

Subdural Hematoma• Collection of blood between the dura and the

brain• Acute/Subacute– Acute: symptoms develop over 24–48 hours– Subacute: symptoms develop over 48 hours to 2 weeks– Requires immediate craniotomy and control of ICP

• Chronic– Develops over weeks to months– Causative injury may be minor and forgotten– Clinical signs and symptoms may fluctuate– Treatment is evacuation of the clot

Intracerebral Hemorrhage

• Hemorrhage occurs into the substance of the brain

• May be due to trauma or a nontraumatic cause• Treatment – Supportive care – Control of ICP – Administration of fluids, electrolytes, and

antihypertensive medications– Craniotomy or craniectomy to remove clot and

control hemorrhage; this may not be possible due the location or lack of circumscribed area of hemorrhage

Diagnostic Evaluation

• Physical and neurologic exam• Skull and spinal x-rays• CT scan• MRI• PET

Management of the Patient with a Head Injury

• Assume cervical spine injury until this is ruled out• Therapy to preserve brain homeostasis and

prevent secondary damage– Treat cerebral edema – Maintain cerebral perfusion; treat hypotension,

hypovolemia and bleeding, monitor and manage ICP– Maintain oxygenation; cardiovascular and respiratory

function– Manage fluid and electrolyte balance

Supportive Measures

• Respiratory support; intubation and mechanical ventilation

• Seizure precautions and prevention• NG to manage reduced gastric motility and

prevent aspiration• Fluid and electrolyte maintenance• Pain and anxiety management• Nutrition

Nursing Process: The Care of the Patient with Brain Injury—Assessment

• Health history with focus upon the immediate injury, time, cause, and the direction and force of the blow

• Baseline assessment• LOC—Glasgow Coma Scale • Frequent and ongoing neurologic assessment• Multisystem assessment

Nursing Process: The Care of the Patient with Brain Injury—Diagnoses

• Ineffective airway clearance and impaired gas exchange• Ineffective cerebral perfusion• Deficient fluid volume • Imbalanced nutrition• Risk for injury• Risk for imbalanced body temperature• Risk for impaired skin integrity• Disturbed thought patterns• Disturbed sleep pattern• Interrupted family process• Deficient knowledge

Potential Problems/Complications

• Decreased cerebral perfusion• Cerebral edema and herniation• Impaired oxygenation and ventilation• Impaired fluid, electrolyte, and nutritional

balance• Risk of posttraumatic seizures

Nursing Process: The Care of the Patient with Brain Injury—Planning

• Major goals may include maintenance of patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about rehabilitation process, and absence of complications.

Interventions

• Ongoing assessment and monitoring is vital • Maintenance of airway– Positioning to facilitate drainage of oral secretions with

HOB usually elevated 30° to decrease venous pressure– Suctioning with caution– Prevention of aspiration and respiratory insufficiency– Monitor ABGs, ventilation, and mechanical ventilation– Monitor for pulmonary complications, potential ARDS

Interventions

• I&O and daily weights • Monitor blood and urine electrolytes and

osmolality and blood glucose• Measures to promote adequate nutrition• Strategies to prevent injury– Assessment of oxygenation – Assessment of bladder and urinary output– Assessment for constriction due to dressings and

casts– Pad side-rails– Mittens to prevent self-injury; avoid restraints

Interventions• Strategies to prevent injury– Reduce environmental stimuli– Adequate lighting to reduce visual hallucinations– Measures to minimize disruption of sleep-wake cycles– Skin care– Measures to prevent infection

• Maintaining body temperature– Maintain appropriate environmental temperature– Use of coverings—sheets, blankets to patient needs – Administration of acetaminophen for fever– Cooling blankets or cool baths; avoid shivering

Interventions

• Support of cognitive function

• Support of family– Provide and reinforce information– Measures to promote effective coping– Setting of realistic, well-defined, short-term goals– Referral for counseling– Support groups

• Patient and family teaching

Spinal Cord Injury (SCI)• A major health problem

• 200,000 persons in the U.S. live with disability from SCI

• Causes include MVAs (35%), violence (24%), falls (22%), and sports injuries (8%)

• Males account for 82% of SCIs

• Young people ages 16–30 account for more than half of all new SCIs

• African–Americans are at higher risk

• Risk factors include alcohol and drug use

• Prevention

Spinal Cord Injury

• The result of concussion, contusion, laceration or compression of spinal cord.

• Primary injury is the result of the initial trauma.• Secondary injury is usually the result of ischemia, hypoxia,

and hemorrhage that destroys the nerve tissues.• Secondary injuries are thought to be

reversible/preventable during the first 4–6 hours after injury.

• Treatment is needed to prevent partial injury from developing into more extensive, permanent damage.

Spinal and Neurogenic Shock

• Spinal shock – A sudden depression of reflex activity below the

level of spinal injury – Muscular flaccidity, lack of sensation and reflexes

• Neurogenic shock – Due to the loss of function of the autonomic

nervous system – Blood pressure, heart rate, and cardiac output

decrease– Venous pooling occurs due to peripheral

vasodilation– Paralyzed portions of the body do not perspire

Autonomic Dysreflexia• Acute emergency!• Occurs after spinal shock has resolved and may occur

years after the injury.• Occurs in persons with a SC lesion above T6.• Autonomic nervous system responses are exaggerated. • Symptoms include severe pounding headache, sudden

increase in blood pressure, profuse diaphoresis, nausea, nasal congestion and bradycardia.

• Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (such as constipation), or stimulation of the skin.

Nursing Interventions• Place patient in seated position to lower BP• Rapid assessment to identify and eliminate cause– Empty the bladder using a urinary catheter or

irrigate/change indwelling catheter– Examine rectum for fecal mass– Examine skin– Examine for any other stimulus

• Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV

• Label chart or medical record that patient is at risk for autonomic dysreflexia

• Instruct patient in prevention and management

Nursing Process: The Care of the Patient with SCI—Assessment

• Monitor respirations and breathing pattern• Lung sounds and cough• Monitor for changes in motor or sensory

function; report immediately• Assess for spinal shock• Monitor for bladder retention or distention,

gastric dilation, and ilieus• Temperature; potential hyperthermia

Nursing Process: The Care of the Patient with SCI—Diagnoses

• Ineffective breathing pattern• Ineffective airway clearance• Impaired physical mobility• Disturbed sensory perception• Risk for impaired skin integrity• Impaired urinary elimination• Constipation• Acute pain

Potential Problems /Complications

• DVT• Orthostatic hypotension• Autonomic dysreflexia

Nursing Process: The Care of the Patient with SCI—Planning

• Major goals may include improved breathing pattern and airway clearance, improved mobility, improved sensory and perceptual awareness, maintenance of skin integrity, promotion of comfort, and absence of complications.

Promotion of Effective Breathing and Airway Clearance

• Monitor carefully to detect potential respiratory failure– Pulse oximetry and ABGs– Lung sounds

• Early and vigorous pulmonary care to prevent and remove secretions

• Suctioning with caution• Breathing exercises • Assisted coughing• Humidification and hydration

Improving Mobility

• Maintain proper body alignment• Turn only if spine is stable and as indicated by

physician • Monitor blood pressure with position changes• PROM at least four times a day• Use neck brace or collar, as prescribed, when

patient is mobilized • Move gradually to erect position

Interventions• Strategies to compensate for sensory and

perceptual alterations• Measures to maintain skin integrity• Temporary indwelling catherization or

intermittent catherization• NG tube to alleviate gastric distention• High-calorie, high-protein, high-fiber diet• Bowel program and use of stool softeners• Traction pin care• Hygiene and skin care related to traction devices

Adult 2

• Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

Learning Objectives

On completion of this chapter, the learner will be able to:• 1. Differentiate among the infectious disorders of the nervous

system according to causes, manifestations, medical care, and nursing management.

• 2. Describe the pathophysiology, clinical manifestations, and medical and nursing management of multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome.

• 3. Use the nursing process as a framework for care of patients with multiple sclerosis and Guillain-Barré syndrome.

• 4. Describe disorders of the cranial nerves, their manifestations, and indicated nursing interventions.

• 5. Develop a plan of nursing care for the patient with a cranial nerve disorder.

Infectious Neurologic Disorders

• Meningitis• Brain abscesses• Encephalitis• Creutzfeldt-Jakob disease and variant

Creutzfeldt-Jakob disease

Meningitis• Inflammation of the membranes and the fluid space surrounding the

brain and spinal cord• Types

– Septic due to bacteria (Streptococcus pneumoniae, Neisseria meningitidis)

– Aseptic due viral infection, lymphoma, leukemia, or brain abscess• N. meningitidis is transmitted by secretions or aerosol contamination

and infection is most likely in dense community groups such as college campuses

• Manifestations include headache, fever, changes in LOC, behavioral changes, nuchal rigidity (stiff neck), positive Kernig's sign, positive Brudzinski’s sign, and photophobia

Brudzinski’s Sign

Medical Management

• Prevention by vaccination against Haemophilus influenzae and S. pneumoniae for all children and all at-risk adults

• Early administration of high doses of appropriate IV antibiotics for bacterial meningitis

• Dexamethasone • Treatment dehydration, shock, and seizures

Nursing Management

• Frequent/continual assessment including VS and LOC• Protect patient form injury related to seizure activity

or altered LOC• Monitor daily weight, serum electrolytes, urine

volume, specific gravity, and osmolality• Prevent complications associated with immobility • Infection control precautions• Supportive care• Measures to facilitate coping of patient and family

Brain Abscess

• Collection of infectious material within brain tissue• Risk is increased in immunocompromised patient• Prevent by treating otitis media, mastoiditis, sinusitis,

dental infections, and systemic infections promptly• Manifestations may include headache that is usually

worse in the morning, fever, vomiting, neurologic deficits, signs and symptoms of increased ICP

• Diagnosis by MRI or CT• CT-guided aspiration is used to identify the causative

organisms

Brain Abscess

• Medical management– Control ICP– Drain abscess– Administer appropriate antibiotic therapy.

Corticosteroids may be used to treat cerebral edema

• Nursing management– Frequent and ongoing neurologic assessment and

of responses to treatment– Assure patient safety and protect from injury– Provide supportive care

Encephalitis• Acute, inflammatory process of the brain tissue• Causes include viral infections (herpes simplex [HSV]), vector-borne viral

infections (West Nile, St. Louis), and fungal infections• Manifestations may include headache fever, confusion, changes in LOC;

vector borne—rash, flaccid paralysis, Parkinson-like movements• Medical management

– Acyclovir for HSV infection, amphotericin and/or other antifungal agents for fungal infection

• Nursing management– Frequent and ongoing assessment – Supportive care

Creutzfeldt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD)

• Rare, degenerative infectious, transmissible spongiform encephalopathies (TSE)

• TSEs are caused by prions: small proteinaceous particles which are smaller than viruses and resistant to sterilization

• The disease is not spread by casual contact; vCJD may be contracted through ingestion of infected beef

• Manifestations include affective, sensory, motor, and cognitive impairments

• No effective treatment—progressive and fatal• Nursing management

– Prevention of disease transmission; blood and body fluid precautions

– Supportive care

Autoimmune Neurologic Disorders

• Multiple sclerosis • Myasthenia gravis • Guillain-Barré syndrome

Myasthenia Gravis

• Autoimmune disorder affecting the myoneural junction

• Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses

• Manifestations – Myasthenia gravis, a motor disorder – Initially symptoms involve ocular muscles; diplopia and

ptosis – Weakness of facial muscles, swallowing and voice

impairment (dysphonia), generalized weakness

Myasthenia Gravis

Medical Management

• Pharmacologic therapy– Cholinesterase inhibitor: pyrostigmine bromide

(Mestinon)– Immunomodulating therapy

• Plasmapheresis• Thymectomy

Myasthenic Crisis

• Result of disease exacerbation or precipitating event, most commonly a respiratory infection.

• Severe generalized muscle weakness with respiratory and bulbar weakness.

• Patient may develop respiratory compromise failure.

Cholinergic Crisis

• Caused by overmedication with cholinesterase inhibitors

• Severe muscle weakness with respiratory and bulbar weakness

• Patent may develop respiratory compromise and failure

Management of Myasthenic Crisis

• Patient instruction in signs and symptoms of myasthenic crisis and cholinergic crisis.

• Assuring adequate ventilation; intubation and mechanical ventilation may be needed.

• Assessment and supportive measures include:– Measures to ensure airway and respiratory

support– ABGS, serum electrolytes, I&O, and daily weight– If patient cannot swallow, nasogastric feeding may

be required– Avoid sedatives and tranquilizers

Nursing Process: The Care of the Patient with Myasthenia Gravis

• Focus on patient and family teaching• Medication teaching and management• Energy conservation• Strategies to help with ocular manifestations• Prevention and management of complications and

avoidance of crisis• Measures to reduce risk of aspiration• Avoidance of stress, infections, vigorous physical

activity some medications, and high environmental temperatures

Guillain-Barré Syndrome

• Autoimmune disorder with acute attack of peripheral nerve myelin

• Rapid demyelination may produce respiratory failure and autonomic nervous system dysfunction with CV instability

• Most often follows a viral infection • Manifestations are variable and may include weakness,

paralysis, paresthesias, pain, and diminished or absent reflexes starting with the lower extremities and progressing upward; bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension

Guillain-Barré Syndrome

• Medical management – Requires intensive care management with

continuous monitoring and respiratory support – Plasmapheresis and IVIG are used to reduce

circulating antibodies • Recovery rates vary, but most patients recover

completely

Nursing Process: The Care of the Patient with Guillain–Barré Syndrome— Assessment

• Ongoing assessment for with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis

• Monitor for changes in vital capacity and negative inspiratory force

• Assess VS frequently/continuously including continuous monitoring of ECG

• Patient and family coping

Nursing Process: The Care of the Patient with Guillain-Barré Syndrome—Diagnoses

• Ineffective breathing pattern • Impaired gas exchange• Impaired physical mobility• Imbalanced nutrition• Impaired verbal communication• Fear• Anxiety

Potential Complications

• Respiratory failure• Autonomic dysfunction• Deep vein thrombosis (DVT)• Pulmonary embolism• Urinary retention

Nursing Process: The Care of the Patient with Guillain-Barré Syndrome—Planning

• Major goals include: – Improved respiratory function – Increased mobility– Improved nutritional status – Effective communication – Decreased fear and anxiety– Effective patient and family coping– Absence of complications

Interventions

• Enhancing physical mobility and prevention of DVT– Support limbs in functional position– Passive ROM at least twice daily– Frequent position changes at least every 2 hours– Elastic compression hose and/or sequential

compression boots– Adequate hydration

• Administer IV and parenteral nutrition as prescribed

• Carefully assess swallowing and gag reflex and take measures to prevent aspiration

Interventions

• Develop a plan for communication individualized to patient needs

• Decreasing fear and anxiety– Provide information and support– Referral to support group– Relaxation measures– Maintain positive attitude and atmosphere to promote

a sense of well-being– Diversional activities

Question

What is dysphonia?A. Double vision or the awareness of two images of

the same object occurring in one or more eyes.B. Impaired ability to execute voluntary movements.C. Difficulty swallowing and causing the patient to

be at risk for aspiration.D. Voice impairment or altered voice production.

Answer

• Diplopia is double vision or the awareness of two images of the same object occurring in one or more eyes. Dyskinesia is impaired ability to execute voluntary movements. Dysphagia is difficulty swallowing and causing the patient to be at risk for aspiration. Dysphonia is voice impairment or altered voice production.

Multiple Sclerosis (MS)• A progressive immune-related demyelination disease of

the CNS• Clinical manifestations vary and have different patterns• Frequently, the disease is relapsing and remitting, has

exacerbations and recurrences of symptoms including fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbances

• Medical management– Disease-modifying therapies; interferon -1a and interferon -

1b, glatiramer acetate (Copaxone), and IV methylprednisolone – Symptom management of muscle spasms, fatigue, ataxia,

bowel and bladder control

Process of Demyelination

Types and Courses of MS

Nursing Process: The Care of the Patient with MS—Assessment

• Neurologic deficits• Secondary complications• Impact of disease on physical, social, and

emotional function and on lifestyle• Patient and family coping

Nursing Process: The Care of the Patient with MS—Diagnoses

• Impaired physical mobility• Risk for injury• Impaired bowel and bladder function• Impaired verbal communication• Disturbed thought processes• Ineffective coping• Impaired home maintenance• Potential sexual dysfunction

Nursing Process: The Care of the Patient with MS—Planning

• Major goals may include: – Promotion of physical mobility – Avoidance of injury– Achievement of bowel and bladder continence– Promotion of speech and swallowing mechanisms – Improvement in cognitive function– Development of coping strengths – Improved home maintenance – Adaptation to sexual function

Interventions

• Utilize a collaborative approach • Coordinate and refer as needed to health care

services; social services, speech therapy, physical therapy, counseling services, home care services, etc.

• Activity and rest– Program of activity and daily exercise– Relaxation, coordination exercises, walking, muscle

stretching exercises – Avoid very strenuous activity and extreme fatigue

Interventions

• Bowel and bladder control– Instruction or administration of prescribed

medications – Voiding schedule– Bowel training program– Adequate fluid and fiber to prevent constipation

• Reinforce and encourage swallowing instructions

• Strategies to reduce risk of aspiration• Memory aides, structured environment, and

daily routine to enhance cognitive function

Interventions

• Interventions to minimize stress • Maintenance of temperate environment—air

conditioning to avoid excessive heat and avoidance of exposure to extreme cold

• Use assistive devices and modifications for home care management and independence in ADLs

• Support of coping

Cranial nerve disorders

• Trigeminal neuralgia (tic douloureux)• Bells’ palsy

Trigeminal Neuralgia (Tic Douloureux

• Condition of the 5th cranial nerve characterized by paroxysms of pain.

• Most commonly occurs in the 2nd and 3rd branches of this nerve. Vascular compression and pressure is the probable cause.

• Occurs more often in the fifth and sixth decade, and in women and persons with MS.

• Pain can occur with any stimulation such as washing face, brushing teeth, eating, or a draft of air.

• Patients may avoid eating, neglect hygiene, and may even isolate themselves to prevent attacks.

Distribution of the Trigeminal Nerve Branches

Medical Management

• Antiseizure medications such as carbamazepine (Tegretol), gabapentin (Neurontin), phenyltoin, or antispasmodic medication baclofen (Lioresal)

• Surgical treatment– Microvascualr decompression of the trigeminal

nerve– Radiofrequency thermal coagulation– Percutaneous balloon microcompression

Nursing Interventions

• Patient teaching related to pain prevention and treatment regimen

• Measures to reduce and prevent pain; avoidance of triggers

• Care of the patient experiencing chronic pain• Measures to maintain hygiene—washing face, oral care• Strategies to ensure nutrition; soft food, chew on

unaffected side, avoid hot and cold food • Recognize and provide interventions to address anxiety,

depression, insomnia

Bell’ Palsy

• Facial paralysis due to unilateral inflammation of the 7th 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

• Most patients recover completely in 3–5 weeks and the disorder rarely recurs.

Management

• Medical – Corticosteroid therapy may be used to reduce

inflammation and diminish severity of the disorder.

• Nursing– 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, sunglasses.

– Facial exercises and massage to maintain muscle tone.

Management of Patients With Oncologic or Degenerative Neurologic Disorders

Management of Patients With Oncologic or Degenerative Neurologic Disorders

Learning ObjectivesOn completion of this chapter, the learner will be able to:• 1. Identify the pathophysiologic processes responsible for oncologic disorders.• 2. Describe brain and spinal cord tumors: their classification, clinical manifestations,

diagnosis, and medical and nursing management.• 3. Use the nursing process as a framework for care of patients with cerebral

metastases or inoperable brain tumors.• 4. Identify the pathophysiologic processes responsible for various degenerative

neurologic disorders.• 5. Use the nursing process as a framework for care of patients with Parkinson’s

disease.• 6. Identify resources for patients and families with oncologic and degenerative

neurologic disorders.• 7. Use the nursing process as a framework for care of patients following a cervical

diskectomy.

Question

What is akathisia?A. Restlessness, urgent need to move around,

and agitation.B. Very slow voluntary movements and speech.C. Impaired ability to execute voluntary

movements.D. A sensation of numbness, tingling, or a “pins

and “needles” sensation

Answer

A

Akathisia is restlessness, urgent need to move around and agitation. Bradykinesia is very slow voluntary movements and speech. Dyskinesia is impaired ability to execute voluntary movements. Paresthesia is a sensation of numbness, tingling, or a “pins and “needles” sensation.

Pathophysiologic Results of Neurologic Oncologic Disorders

• Manifestations depend upon the tissues infiltrated and compressed by the neoplasm

• Pathophysiologic events may include:– Increase ICP– Seizures– Hydrocephalus– Altered pituitary function

Question

Is the following statement True or False?

Brain tumor classification is based upon location and histological characteristics.

Answer

True

Brain tumor classification is based upon location and histological characteristics.

Oncologic Tumors

• Brain tumors– Benign or malignant– Classification is based upon location and

histological characteristics• Types of primary tumors– Gliomas– Meningiomas – Acoustic neuromas– Pituitary adenomas

• Angiomas—masses of abnormal blood vessels• Metastatic tumors

Brain Tumors

• Symptoms are dependent upon the location and size of the lesion and the compression of associated structures

• Manifestations:– Localized or generalized neurologic symptoms– Symptoms of increased ICP– Headache– Vomiting– Visual disturbances

• Hormonal effects with pituitary adenoma• Loss of hearing, tinnitus, and vertigo with acoustic neuroma

Common Brain Tumor Sites

Diagnostic Evaluation

• Neurologic examination• CT scan• MRI• PET scan• EEG • Cytological study of cerebral spinal fluid• Biopsy

Medical Management• Specific treatment depends upon the type,

location, and accessibility of the tumor• Surgery – Goal is removal of tumor without increasing

neurologic symptoms or to relieve symptoms by decompression

– Craniotomy, transspenoidal surgery, stereotactic procedures

• Radiation therapy– External beam radiation– Brachytherapy

• Chemotherapy

Spinal Cord Tumors• Classified according to their anatomic relation to

the spinal cord– Intramedullary: within the cord– Extramedullary: extradural; outside the dural

membrane• Manifestations include pain, weakness, and loss of

motor function, loss of reflexes, loss of sensation• Treatment depends upon type of tumor and

location– Surgical removal– Measures to relieve compression: dexamethasone

combined with radiation

Nursing Process: The Care of the Patient with Cerebral Metastases or Inoperable Brain Tumors—Assessment

• Baseline neurologic exam• Patient function and coping: self-care ability, movement,

walking, speech, vision, dealing with seizures• Symptoms that may cause distress to the patient: pain,

respiratory symptoms, bowel and bladder function, sleep, skin integrity, fluid balance, and temperature regulation

• Nutritional status and dietary history• Family coping and family process

Nursing Process: The Care of the Patient with Cerebral Metastases or Inoperable Brain Tumors—Diagnoses

• Self-care deficit• Imbalanced nutrition• Anxiety• Interrupted family processes

Nursing Process: The Care of the Patient with Cerebral Metastases or Inoperable Brain Tumors—Planning

• Major goals may include compensating for self-care deficits, improving nutrition, reducing anxiety, enhanced family coping skills, and absence of complications

Interventions

• Encourage independence for as long as possible• Measures to improve cognitive function • Allow patient to participate in decision making • Allow patient to express fears and concerns• Presence of family, friends, spiritual advisor, and

health care personnel may be supportive• Referral to counselor, social worker, home health

care, support groups • Referral for hospice care

Improving Nutrition

• Oral hygiene before meals• Plan meals for times when patient is comfortable

and well rested• Measures to make mealtime as pleasant as

possible• Offer preferred foods• Dietary supplements• Daily weight • Record dietary intake

Question

Is the following statement True or False?

Parkinson’s disease is a slowly progressing neurologic movement disorder that eventually leads to disability.

Answer

True

Parkinson’s disease is a slowly progressing neurologic movement disorder that eventually leads to disability.

Parkinson’s Disease

• Associated with decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia; this effects the neurotransmission of impulses

• Manifestations: tremor, rigidity, bradykinesia, postural instability, depression and other psychiatric changes, dementia, autonomic symptoms, sleep disturbances,

• Medical management – Pharmacologic treatment– Surgical procedures– Other therapies

Pathophysiology of Parkinson’s Disease

Nursing Process: The Care of the Patient with Parkinson’s Disease—Assessment

• Focus on the degree of disability and function of the patient including ADLs, IADLS, and cognitive function

• Medications and responses to medications• Emotional responses and individual coping • Family processes and coping• Home care and teaching needs• Fall risk assessment• Manifestations and potential complications related

to the specific disorder

Nursing Process: The Care of the Patient with Parkinson’s Disease—Diagnoses

• Impaired physical mobility and risk for activity intolerance• Disturbed thought processes• Self-care deficits • Imbalanced nutrition• Constipation• Impaired verbal communication• Ineffective coping and compromised family coping• Deficient knowledge• Risk for injury

Nursing Process: The Care of the Patient with Parkinson’s Disease—Planning

• Major goals may include improved functional ability, maintaining independence in activities of daily living, achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, developing positive individual and family coping skills.

Improving Mobility

• Daily program of exercise• ROM exercises• Postural exercises• Consultation with physical therapy• Walking techniques for safety and balance• Frequent rest periods• Proper shoes • Use of assistive devices

Interventions• Enhancing self-care ability

– Encourage, teach, and support independence– Environmental modifications– Use of assistive and adaptive devices – Consultation with occupational therapy

• Support of coping– Set achievable, realistic goals– Encourage socialization, recreation, and independence– Planned programs of activity– Support groups and referral to supportive services- counselors, social

worker, home care

• Benztropine mesylate (Cogentin) is an anticholinergic medication used to control of tremor and rigidity and counteracts the action of acetylcholine with Parkinson’s disease. Diphenhydramine hydrochloride (Benadryl), orphenadrine citrate (Banflex), phenindamine hydrochloride (Neo-Synephrine) are antihistamines that may reduce tremors.

Alzheimer's Disease

• AKA senile dementia• The most common cause of dementia• A chronic, progressive, degenerative brain

disorder that effects 4.5 million people in the United States

• Research suggests oxidative stress plays a role in the pathophysiology of this disease

Amyotrophic Lateral Sclerosis (ALS)

• “Lou Gehrig’s disease”• Loss of motor neurons in the anterior horn of

the spinal cord, and loss of motor nuclei in the brainstem, cause progressive weakness and atrophy of the muscles of the extremities and trunk. Weakness of the bulbar muscles impairs swallowing and talking. Respiratory function is also impaired

Muscular Dystrophies

• Incurable disorders characterized by progressive weakening and wasting of skeletal and voluntary muscles

• Most are inherited disorders• Duchenne muscular dystrophy is the most

common and inherited as a sex-linked trait

Degenerative Disk Disease • Low back pain is a significant public health disorder and has significant

economical and social costs.

• Most back problems are related to disk disease.

• Degenerative changes occur with aging or are the result of previous trauma.

• Radicupathy produces pain.

• Continued pressure may produce degenerative changes in the nerves with resultant changes in sensation and motor responses.

• Treatment is usually conservative—rest and medications.

• Surgery may be required.

Normal Spinal Vertebral and Ruptured Vertebral Disk

Nursing Process: The Care of the Patient with Cervical Diskectomy—Assessment

• Determining the onset, location, and radiation of pain

• Assessing for paresthesia, limited movement, and diminished function of the neck, shoulders, and upper extremities

• Determine whether the symptoms are bilateral

• Cervical spine palpated to assess muscle tone and tenderness

• Range of motion in neck and shoulders is evaluated

• Health issues

• Patient education

Nursing Process: The Care of the Patient with Cervical Diskectomy—Diagnoses

• Acute pain related to the surgical procedure• Impaired physical mobility related to the

postoperative surgical regimen• Deficient knowledge about the postoperative

course and home care management

Nursing Process: The Care of the Patient with Cervical Diskectomy—Collaborative Problems/Potential Complications

• Hematoma at the surgical site, resulting in cord compression and neurologic deficit

• Recurrent or persistent pain after surgery

Nursing Process: The Care of the Patient with Cervical Diskectomy—Planning

• The goals for the patient may include relief of pain, improved mobility, increased knowledge and self-care ability, and prevention of complications.

Nursing Process: The Care of the Patient with Cervical Diskectomy—Nursing Interventions

• Relieving pain• Improving mobility• Monitoring and managing potential

complications• Promoting home and community-based care