NURSING MANAGEMENT FOR NEUROLOGICAL DISORDERS
MDJ2213 Medical Surgical Nursing II
Learning Outcomes
At the end of the session, students will be able to:
Describe the special nursing needs of patients with neurological dysfunctions
Use the nursing process as a framework for care of the patient with neurological dysfunctions
Assess neurological status of a client using the Glasgow Coma Scale
Prepare patient for a myelogram
Nursing Management
Head and Spinal Injuries Headaches Cerebral Vascular Accident (CVA) Intracranial Infections Glasgow Coma Scale Preparation of Patient for Myelogram
Craniocerebral Trauma
Head injuries amongst most frequent and serious neurologic disorders
Causes usually include: RTAs/MVAs Falls Sports injuries Assaults Gunshot wounds
Craniocerebral Trauma
Specific damage is related to mechanism of injury Acceleration injury, head struck by moving
object Decelaration injury, head hits stationary
object Acceleration-deceleration injury (coup-
countrecoup phenomenon), head hits and object and the brain “rebounds”
Deformation, force results in deformation and disruption of integrity of impacted body part (e.g. skull fracture)
Craniocerebral Trauma: The Client With a Brain Injury
Diffuse or local damage to the brain Primary or secondary
Primary: brain damage due to impact Secondary: brain damage due to swelling,
bleeding (hematomas), infection, cerebral hypoxia, or ischemia that follows the primary injury
Craniocerebral Trauma: The Client With a Brain Injury
Cerebral concussion Concussion means
to “shake violently” Transient,
temporary, neurogenic dysfunction caused by mechanical force to the brain (Hickey, 1997).
Mechanism: Acceleration-deceleration
Craniocerebral Trauma: The Client With a Brain Injury
Cerebral contusion Bruising on the
surface of the brain, typically accompanied by small, diffuse venous hemorrhages
Occur when the brain strikes the skull
Most frequently near bony prominences of the skull
Craniocerebral Trauma: The Client With a Brain Injury
Diffuse Axonal Injury Widespread disruption of axons in the white
matter Immediate loss of consciousness Poor prognosis
Craniocerebral Trauma: The Client With a Brain Injury
Concussion or contusion: Close observation for development of
manifestations of increased cerebral edema, which leads to increased ICP
GCS charting
The Client With a Spinal Cord Injury
Mechanisms of injury: Hyperflexion (forcible forward bending) Hyperextension (forcible backward
bending) Axial loading (compression, vertical force to
spinal column) Excessive rotation
The Client With a Spinal Cord Injury
Classifications of Injury Classified according to systems
Complete or incomplete cord injury Cause of injury Level of injury
The Client With a Spinal Cord Injury
Spinal shock Temporary areflexia (loss of reflex function)
below the level of injury Manifestations vary in degree, but usually
includes: Bradycardia Hypotension Flaccid paralysis of skeletal muscles Loss of sensations Bowel and bladder dysfunction Loss of the ability to perspire
The Client With a Spinal Cord Injury
Paraplegia and Tetraplegia Paraplegia: paralysis of the lower portion of
the body Tetraplegia (a.k.a. quadriplegia): cervical
segments of the cord are injured impairing function of the arms, trunk, legs and pelvic organs
The Client With a Spinal Cord Injury
Emergency Care at the Scene: When injury is at C1 – C4, repiratory
paralysis is common Injuries below C4 may increase risk of
respiratory failure if edema ascends the cord
Critically important not to complicate initial injury during transport to the hospital
The Client With a Spinal Cord Injury
Emergency Care at the Scene: All people who have sustained trauma to
the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury
Pre-hospital management: rapid assessment, immobilizing and stabilizing head and neck, removal from site of injury, stabilizing other life-threatening injuries, rapid transport to the appropriate facility
The Client With a Spinal Cord Injury
Emergency Care: Avoid flexing, extending or rotating the
neck Immobilize the neck (e.g. rolled
towels/blankets, cervical collar) Secure head by placing belt/tape across
forehead and securing it to the stretcher Supine Transfer from stretcher directly to bed that
will be used throughout hospitalization
The Client With a Spinal Cord Injury
Emergency Department Management: Cervical injury:
Paralysis /weakness of extremities Respiratory distress Bradycardia Systolic BP below 80 Decreased peristalsis
The Client With a Spinal Cord Injury
Emergency Department Management: Thoracic and lumbar injury:
Paralysis /weakness of extremities
The Client With a Spinal Cord Injury
Emergency Department Management: Acute spinal shock:
Loss of skin sensation Flaccid paralysis, areflexia Absent bowel sounds Bladder distention Decreasing BP Absence of the cremasteric reflex in males
(retraction of the left or right testicle in response to stimulation of the inner thigh)
The Client With a Spinal Cord Injury: Nursing Care
Impaired Physical Mobility Goals of care: reduce the effects of
spasticity and to prevent complications involving the skin, CVS, and joint function
The Client With a Spinal Cord Injury: Nursing Care
Impaired Physical Mobility Passive ROM exercises: help prevent
contractures and stretch spastic muscles, promoting rehabilitation
Maintaining skin integrity: Risk for altered skin integrity due to lack of sensory warning mechanisms and of voluntary motor control of skin dermatomes
Assess lower extremities for symptoms of thrombophlebitis. Antiembolic stockings are adviced.
The Client With a Spinal Cord Injury: Nursing Care
Impaired Gas Exchange Injuries at C3 or above have paralysis of the
respiratory muscles and cannot breathe without a ventilator
Injuries at level of C8 to C5: Phrenic nerve is intact, but innervation of
intercostal muscle is affected, compromising respiratory dysfunction
Abdominal muscles also paralyzed unable to expectorate secretions
The Client With a Spinal Cord Injury: Nursing Care
Impaired Gas Exchange Monitor vital capacity and respiratory
effectiveness, assessing for tachycardia, restlessness
Monitor for signs of ascending edema of the spinal cord, inc. difficulty in swallowing or coughing
Help with coughing exercises
The Client With a Spinal Cord Injury: Nursing Care
Main goal: Prevent further complications Rehabilitation
The Client with Headaches
Pain within the cranial vault (Hickey, 1997)
May occur as a result of benign or pathologic conditions, intracranial or extracranial conditions, diseases of other body systems, stress, musculoskeletal tension, or a combination
The Client with Headaches
Migraine headaches (with or without aura)
Cluster headache Tension-type headache
The Client with Headaches: Nursing Care
Pain Interventions focus on teaching the client
self-care measures to control or relieve the pain, and reducing any associated problems, such as nausea and vomiting or anxiety
The Client with Headaches: Nursing Care
Pain Teach client to maintain a diary of
headaches: chart duration, onset, location, relation to menstruation/food intake, related manifestations, factors that relieve or increase intensity
Pain score charting to evaluate effectiveness of pain relief measures
Teach client to minimize light, noise and activity. Reduce noxious stimuli that may increase pain intensity
The Client with Headaches: Nursing Care
Pain Teach non-invasive and non-pharmacologic
relief measures as appropriate Educate client on importance of good
nutrition, regular exercise and sleep. Emphasize on minimizing stress.
The Client with a CVA
CVA or stroke: Condition in which neurologic deficits occur as a result of decreased blood flow to a focal (localized) area of brain tissue
Increased risk: Hypertension DM Sickle cell disease Substance abuse Artherosclerosis
The Client with a CVA: Nursing Care
Altered Cerebral Tissue Perfusion Acute phase: time of admission until client
is stabilized (24 to 72 hours after admission)
Goal: maintain body functions and prevent complications
The Client with a CVA
Altered Cerebral Tissue Perfusion Monitor respiratory status and airway
patency Monitor neurological status Continuously monitor cardiac status,
observing for dysrythmias Monitor body temperature: may develop if
CVA affects the hypothalamus Strict IO charting: CVA may damage
pituitary gland, resulting in diabetes insipidus and possibility of dehydration
The Client with a CVA
Altered Cerebral Tissue Perfusion Monitor for seizures: may result due to
cerebral tissue damage or increased ICP
The Client with a CVA
Impaired Physical Mobility: Goals: Maintain
and improve functional abilities (by maintaining normal function and alignment), preventing edema of extremities and reducing plasticity
The Client with a CVA
Impaired Physical Mobility: Encourage active and passive ROM
exercises Turning every 2 hours, maintaining body
alignment Monitor lower extremities for symptoms of
thrombophlebitis Collaborate with physiotherapist and
occupational therapist for rehabilitation
The Client with a CVA
Impaired Swallowing Weakness or lack of coordination of the
tongue, attention deficits, and deficits involving the swallowing reflex
Dysphagia may result in choking, drooling, aspiration or regurgitation
Goal: Maintain safety by preventing aspiration and on ensuring adequate nutrition
The Client with a CVA
Impaired Swallowing Ensure client is sitting upright Ensure food/fluids prepared are of
appropriate consistency as ordered Once client completes a meal, check the
mouth for “pocketing” of food Reduce distraction so client can focus on
eating and swallowing
The Client with a CVA
Other Nursing Diagnoses: Self Care Deficit Impaired Verbal Communication Sensory/Perceptual Alterations Altered Urinary Elimination and
Constipation Risk for Injury Altered Thought Processes Ineffective Airway Clearance
The Client with Intracranial Infections
MENINGITIS Bacterial or viral Inflammation of the meninges of brain and
spinal cord ENCEPHALITIS
Usually viral Acute inflammation of the parenchyma of
the brain and spinal cord
The Client with Intracranial Infections
Prognosis depends on supportive care given
The Client with Intracranial Infections
Altered Protection Less able to protect themselves against
insults from both internal and external sources: pain, fever, altered LOC, seizures, increased ICP, cranial nerve dysfunction.
Monitor client for manifestations of altered protection and report abnormal findings so that treatment can be instituted to prevent further complications
The Client with Intracranial Infections
Altered Protection Assess neurological status on a regular
basis Assess vital signs, including temperature,
on a regular basis Assess for and report decreasing levels of
consciousness: levels of orientation, memory, attention span, and response to stimuli
Assess and monitor for seizure activity, and institute precautions
The Client with Intracranial Infections
Altered Protection Assess for and report manifestations of
increase ICP Administer prescribed medications, and
maintain prescribed fluid restrictions
The Client with Intracranial Infections
Risk for Fluid Volume Deficit Related to increased metabolic rate,
diaphoresis, and fluid restrictions
The Client with Intracranial Infections
Other Nursing Diagnoses Hyperthermia r.t. infection and abnormal
temperature regulation Pain r.t. headache, muscle, neck pain, joint aches,
and malaise secondary to meningeal irritation Altered Cerebral Tissue Perfusion r.t. increased
ICP or cerebral edema Risk for Injury r.t. seizures and changes in
mentation and LOC Decreased Adaptive Capacity: Cranial r.t.
intracranial hypertension
GLASGOW COMA SCALE (GCS) Most common scoring system used to
describe level of consciousness in a client following a traumatic brain injury
Reliable and objective, simple to use, and correlates well with outcome following brain injury
GLASGOW COMA SCALE (GCS) GCS measures:
Eye opening Verbal response Motor response
GLASGOW COMA SCALE (GCS) Every brain injury is different Generally, classified as:
Severe: GCS 3 – 8 Moderate: GCS 9 – 12 Mild: GCS 13 - 15
GLASGOW COMA SCALE (GCS)
GLASGOW COMA SCALE (GCS) Limitations:
Drug use Alcohol intoxication Shock Low oxygen saturation
Infants and children: Use a modified version PGCS
The Client going for a Myelogram Radiologic examination of the
subarachnoid space of the spinal canal, using a contrast agent
Visualized lumbar, thoracic or cercival area, or the whole spinal axis
The Client going for a Myelogram To perform a myelogram:
Lumbar puncture is done About 10ml of CSF is removed before a
contrast medium is injected into the space Head of X-ray table is kept elevated at 30
degrees and the client is kept quiet to prevent rapid upward dispersion risk of seizures
The Client going for a Myelogram Preparation of Client:
Informed consent signed NPO Client should be well hydrated Enemas or laxatives to ensure the lumbar
spine can be visualized Pre-procedure sedatives as prescribed
The Client going for a Myelogram During Procedure:
Different positions may be used Patient strapped to prevent falls as table
may be tilted during examination Vital signs checked regularly
The Client going for a Myelogram Post Procedure Care:
CRIB x 6 – 12hours (according to physician orders)
Vital signs Assess site of lumbar puncture for leakage
of CSF or bleeding Encourage increased intake of oral fluids to
help decrease post myelogram headache Ensure client voids within 8 hours after
examination
The Client going for a Myelogram Post Procedure Care:
Analgesia as ordered Head elevated at least 30 degrees for 12
hours, or as ordered
Any Questions?