Nursing Management of the Adult Patient with Neurological AlterationsPrepared by:

Hikmet Qubeilat. RN,MSC.

Brain Needs… Blood flow Glucose Oxygen

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

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

I. Neurological Disorders The normal functioning of the CNS can be

affected by a number of disorders, the most common of which are headaches, tumors, vascular problems, infections, epilepsy, head trauma, demyelinating diseases, and metabolic & nutritional diseases.

Headaches

Classified based on characteristics of the headache

Functional vs. Organic type May have more than one type of headache History & neurologic exam diagnostic keys

Not always chronic…be careful

Pattern Tension Migraine Cluster

Site Bilateral, basilar, band-like

Unilateral, anterior

Unilateral, occular

Quality Squeezing, constant

Throbbing Severe

Pattern Cycles, years Periodic, years Remitting, relapsing

Duration Days, weeks, months

Hours, days 30-90 min

Onset Anytime Prodrome, starts in AM

Nocturnal

Assoc. S&S

Stiff neck N&V, photo/phono-phobia

Horner syndrome

ONSET: Not reliable or diagnostic

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

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

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

herniation

Don’t Miss It

1. Caused by subarachnoid hemorrhage from an aneurysm or head injury

2.“Worse headache of my life”

3. Changes in LOC, focal neurological signs

4. Highly correlated with CVA

5. Untreated, 50 % mortality

Headache Teaching Guide Keep a calendar/diary Avoid triggers Medications (purpose, side effects) Stress reduction

Dark quiet room, exercise, relaxation Regular exercise

Intracranial Pressure (ICP)Brain Components Skull is a rigid vault that does not expand

It contains 3 volume components: Brain tissue: (80%) or 2% of TBW Intravascualr blood: (10%) CSF: (10%)

Intracranial Pressure (ICP) is the pressure exerted by brain tissue, blood volume & cerebral spinal fluid (CSF) within the skull.

ICV = Vbrain + Vblood + Vcsf Normal ICP – 10 to 15 mmHg Cerebral Perfusion Pressure (CPP)

CPP = MAP – ICP Normal CPP – 70 to 100 mmHg

Normal CSF – 5 to 13 mmHg

Intracranial Pressure (ICP)

Increased Intracranial Pressure (IICP) fluid pressure > 15 mm Hg

IICP is a life threatening situation that results from an in any or all 3 components within the skull > volume of brain tissue, blood, and / or CSF Cerebral edema: > H2O content of tissue as a result

of trauma, hemorrhage, tumor, abscess, or ischemia

Acute Coma Levels of consciousness diminish in stages:

• Confusion: can’t think rapidly and clearly التشويش• Disorientation: begin to loose consciousness

• Time, place, self• Lethargy: spontaneous speech and movement limited• Obtundation: arousal (awakeness) is reduced• Stupor: deep sleep or unresponsiveness

• Open eyes to vigorous or repeated stimuli• Coma: respond to noxious stimuli only

• Light (purposeful), full coma (non-purposeful), deep coma (no response)

19

Multiple Sclerosis

is a chronic autoimmune disorder affecting movement, sensation, and bodily functions. It is caused by destruction of the myelin sheath covering nerve fibres in the central nervous system (brain and spinal cord).

Causes:1. Autoimmune destruction. 2. Heredity. 3. Viruses. 4. Environmental factors.

20

Diagnostic Test:

1. MRI.

2. Physical examination.

21

* Early:

1. Muscle weakness causing difficulty walking

2. loss of coordination or balance

3. numbness or other abnormal sensations

4. visual disturbances, including blurred or double vision

Clinical Manifestations:

22

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

23

Treatment:

1. Immunosuppressant drugs . These drugs include corticosteroids such as prednisone and methylprednisolone, the hormone adrenocorticotropic hormone (ACTH), and azathioprine.

2. Physiotherapy.

3. Occupational therapy.

24

Parkinson's Disease

is a progressive movement disorder marked by tremors, rigidity, slow movements (bradykinesia), and postural instability. It occurs when, for unknown reasons, cells in one of the movement-control centers of the brain begin to die.

Causes: 1. Degeneration of brain cells in the area known as the

substantia nigra, one of the movement control centers of the brain.

2. Drugs given for psychosis, such as haloperidol (Haldol) or chlorpromazine (Thorazine), may cause parkinsonism.

25

Clinical Manifestations1. Tremors2. Slow movements (bradykinesia), freezing in place during movements

(akinesia). 3. Muscle rigidity or stiffness, occurring with jerky movements

4. Postural instability or balance difficulty occurs.

5. Masked face.

6. Depression

7. Speech changes8. Problems with sleep9. Emotional changes10. Incontinence. 11. Constipation. 12. Handwriting changes, 13. (dementia)

26

Treatment:

1. Maintain regular exercise (physical therapy, occupational therapy)

2. Provide good nutrition to maintain health.

3. Drugs that replace dopamine (levodopa)

4. If the patient is unresponsive or intolerant to pharmacotherapy, Electro convulsive therapy is indicated.

Nursing Management

* Observe the patient's mood, cognition; organization and general well being

* Observe for features of depression,

*Suicidal precautions to be followed, if the patient exhibits any suicidal ideas

*Instruct the patients to speak slowly and clearly, and to pause and take a deep breath at appropriate levels.

27

Parkinson's Disease (cont’d) *In dementia, environmental modification is followed

*Avoid frequent change in the environment to minimise confusion if the memory deficit is very severe, name boards and signboards by the side of the rooms and things will be very helpful.

*Sedatives are used if sleep related problems are noticed, when sleep hygiene is unsuccessfully.

* Patients should not be forced into situations in which they feel ashamed of their appearance.

*Encourage the patient to participate in moderate exercises, free-moving

sports like swimming. *Advise the patient to organize thoughts before speaking and encourage the

client to use facial expression and gestures if possible to assist with communication.

Seizure Disorders & EpilepsySeizure:

paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function

Epilepsy: spontaneously recurring seizures caused by a chronic

underlying condition

Two major classes: Generalized Partial

Depending on type, phases may include: Prodromal phase- signs & activity preceeding seizure Aural phase- sensory warning Ictal phase- full seizure Postictal phase- recovery

Aura Phase

I’m dizzy

!

I smell bananas!

I taste metal!I’m

seeing spots

I feel very angry!

Seizure Disorders & EpilepsyDrug Therapy for Tonic-Clonic and Partial Seizures

Carbamezepine/ Tegretol Divalproex/ Depakote Gabapentin/ Neurontin Lamotrigine/ Lamictal Levetiracetam/ Keppra

Phenytoin/ Dilantin Tiagabine/ Gabitril Topiramate/ Topamax Valproic Acid/ Depakene Felbamate/ Felbatol * Phenobarbitol**

*Felbatol has been associated with aplastic anemia**Phenobarbitol is a barbituate

Seizure Disorders & Epilepsy:Nursing Care Assure oxygen and suction equipment at bedside Safety precautions in active stage

Support/ protect head Turn to side Lossen constricted clothing Ease to floor

Time seizure, record details of seizure and post-ictal phase

Seizure Disorders & Epilepsy:Nursing Care Patient teaching:

importance of good seizure control using medication as ordered

Medical alert bracelet Avoid decreased sleep, increased fatigue Regular meals/ snacks

Seizure Disorders & Epilepsy: Status Epilepticus Medical emergency Seizure repeated continuously

Tonic clonic: hypoxia could develop if muscle contraction is lengthened. Also: hypoglycemia, acidosis, hypothermia, brain damage, death IV administration of antiepileptics Maintain airway patency

Intracranial surgery Craniotomy:

Opening the skull surgically to gain access to intracranial structures

Intracranial surgery Burr hole

Circular opening made in the skull by a drill

Intracranial surgery Craniectomy

An excision of a portion of the skull

Intracranial surgery Cranioplasty

Repair of a cranial defect by means of a plastic or metal plate

Intracranial surgery Transsphenoidal

Through the nasal sinuses to gain access to the pituitary gland

Types of Stroke

Ischemic: embolic or thrombotic blocked blood flow to the brain

Hemorrhagic: ICH, SAH, ruptured cerebral aneurysm

TIA: This is a stroke, although symptoms resolve within an hour

Signs and Symptoms of Stroke Sudden numbness or weakness of the face, arm or leg,

especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden dizziness, loss of balance or coordination or

trouble walking Sudden severe headache with no known cause

Risk Factors

High blood pressure Carotid artery disease Physical inactivity Excess alcohol intake Atrial fibrillation Diabetes Heart disease Smoking Family history Prior stroke/TIA High cholesterol Obesity

Treatment for Ischemic Stroke tPA=Thrombolytic agent Document time of symptom

onset. (If awoke with symptoms, must go by time when last seen normal)

Immediate head CT (check for blood)

Evaluate for tPA administration (review exclusion/inclusion criteria)

Treatment Cont… If not a tPA candidate, ASA in ED. Rectal ASA

if fails swallow eval. or if swallow eval. not complete.

Keep NPO, until a formal swallow eval. is done. Admit as Inpatient and perform diagnostic

testing: Carotid US, Echo, TEE, ECG monitoring for a-fib, MRI, fasting Lipid, Clotting disorder blood work (Antiphospholipid, Factor V, Antithrombin III)

Rehabilitation

Hemorrhagic Stroke Treatment Do not give antithrombotics or

anticoagulants Monitor and treat blood

pressure greater than 150/105 (Table 6, 2005 Guidelines update)

NPO, until swallow eval is completed

Anticipate Neurosurgical consult

Possible administration of blood products

Meningitis

An inflammation of the meninges of the brain and spinal cord Bacterial

Causes:Meningococcus and pneumococcus ,Haemophilus-influenza

Organisms enter brain by: Blood stream Respiratory tract Pentrating wonds of skullIt is secondary to another infections such as otitismedia, upper

respiratory infection,pneumonia Viral (aseptic): less severe than bacterial

Clinical Presentations High fever, tachycardia, chills, petechial rash headache, photophobia, stiff neck Nausea, vomiting papilledema (> ICP),confusion, altered LOC Restlessness and irritability Seizures Brudzinski’s: passive flexion of the neck produces pain &

increased rigidity Kernig’s: Flex hip and knee and then straighten the knee…

pain or resistance?

complication of MeningitisSeizuresSepsisCranial nerve dysfunctionsCerebral infarctionComaDeath

Collaborative care Bacterial menigitis is a medical emergency Treatment focus on rapid diagnosis and starting IV antibiotic

therapy immediately(7-21 days) Isolation Antipyretics Analgesics Anticonvulsants Osmotic diuretics IV fluids

Diagnosis

lumbar puncture :collect samples of CSF Bacterial:

Cloudy csf Elevated protein level Increased WBC Decreased glucose level Elevated CSF pressure

C&S OF CSF CBC Cultures from Blood, urine, throat, nose