Care of the Patient With a Neurological
Disorder
LEARNING OBJECTIVE
At the end of this lesson student should be able to:
1. Explain the causes, pathophysiology and sign/symptom
of neurological disorder.
2. Explain the Surgical and Nursing management of
common Neurological Disorders:-
Cerebrovascular disease, Cerebro-Vascular
Accident, Seizure disorders, GuilleinBarre-
Syndrome, Myasthenia Gravis, Head injury, Spinal
cord injury, meningitis and altered level of
consciousness.
Anatomy and Physiology
Central nervous system Peripheral nervous
(CNS) system
Brain Somatic (voluntary)
Spinal cord Autonomic
(involuntary)
3
Anatomy and Physiology
Neurons Glial cells
Transmitter cells Support and protect
Carry messages to and neurons
from brain and spinal Produce cerebral spinal
cord fluid
4
Anatomy and Physiology
CNS: brain
Cerebrum – lobe functions
Diencephalon – thalamus, hypothalamus
Cerebellum – balance, coordination
Brain stem – midbrain, pons, medulla oblongata
5
Anatomy and Physiology
PNS: Somatic (voluntary)
31 pairs of spinal nerves
12 pair of cranial nerves
6
Anatomy and Physiology
PNS: Autonomic (involuntary)
Controls:
Smooth Muscles
Cardiac Muscles
Glands
Check and balance system:
Sympathetic nervous system
Parasympathetic nervous system
7
Neurological Assessment
History
Headaches Pain
Loss of function Personality change
Visual acuity Mood swing
Seizures Fatigue
Numbness
8
Neuro Assessment
Mental Status
Orientation
Mood and behavior
General knowledge
Short term memory
Long term memory
9
Neuro Assessment
Level of consciousness
Glasgow Coma Scale
Eye opening
Verbal response
Motor response
10
www.studentbmj.com/back_issues/ 0500/education/140.html
11
Neuro Assessment
Language and Speech
Aphasia
Sensory
Expressive
Global
12
Cranial Nerves
I. Olfactory VII. Facial
II. Optic VIII. Acoustic
III. Oculomotor IX. Glossopharyngeal
IV. Trochlear X. Vagus
V. Trigeminal XI. Spinal Accessory
VI. Abducens XII. Hypoglossal
13
Neuro Assessment
Motor Function
Paralysis
Paresis
Flaccid
Spastic
14
Neuro Assessment
Sensory and Perceptual Status
Pain
Touch
Temperature
Proprioception
Unilateral neglect
Hemianopia
15
Neuro Assessment
Blood and urine
ABG
Lumbar puncture
Imaging
EEG
EMG
Carotid Duplex
16
Neurological Problems
Headache
Vascular – migraine, cluster, hypertensive
Tension – stress
Traction-inflammatory – infection, occlusion
vessels
17
Neurological Problems
Increased Intracranial Pressure (IIP)
Occurs slowly or rapidly
May lead to brain stem herniation and death
18
Assessment of IIP
Subjective
Diplopia
Personality change
Thought processes change
Headache
Nausea
19
Assessment of IIP
Objective
Decreasing LOC
Hyperthermia Posturing
Weakness Wide pulse pressure
Vomiting Bradycardia
Seizures Altered respirations
Papilledema Pupils fixed & dilated
20
Assessment of IIP
Diagnostic tests:
CT scan, MRI
Close observation
Craig’s screw
21
Medical Management of IIP
Craniotomy
Craniectomy
Tumor removal
Drainage of ventricles
Drainage of hematoma
Intubation
22
Medical Management of IIP
Medications
Osmotic diuretics - Mannitol
Corticosteroids - Decadron
Anticonvulsants - Dilantin
Internal monitoring
23
Nursing Care of the Patient
With IIP
Elevate HOB Restrict fluids
Neck in neutral Foley
position Suctioning
Avoid flexion hips, O2
waist and neck Hypothermia blanket
Avoid isometric
activity or Valsalva
24
Neurological Disorders-
Seizures
Seizures
Disorderly neuron discharges in brain
Transitory
Different types affect body differently
Involuntary movement usually
25
Seizures
Generalized: Localized: (Focal)
Tonic-clonic – Partial (Jacksonian)
grand mal Psychomotor
Absence - Petit mal
Myoclonic
Atonic or akinetic
26
Seizures
Causes:
Hypoglycemia
Infection
Electrolyte imbalance
Trauma
IIP
Toxins
27
Seizure Medications
Dilantin (Phenytoin) Clonopin
Phenobarbital Mesantoin
Mysoline Neurontin
Tridione Lamictal
Valium (Diazepam) Felbatol
Depakene Cerebyx
28
Seizure Medications
Nursing:
Medications
Continue meds
Medic alert ID
Avoid alcohol, avoid driving, get adequate rest
If on Dilantin, instruct on oral hygiene
29
Seizures: Nursing Care
Protect
Lower to the floor; pad side rails; pillow under
head; don’t restrain
No bite block or padded tongue blade
Allow for post-ictal rest
Prevent aspiration (airway)
Turn side; loosen clothing around neck
Document everything
30
Degenerative Neuro Diseases
Multiple Sclerosis Myasthenia Gravis
Parkinson’s Disease Amyotrophic Lateral
Sclerosis (ALS)
Alzheimer’s Disease
Huntington’s Disease
(chorea)
31
Multiple Sclerosis
Common degenerative neurological disease.
Myelin sheath is destroyed.
Symptoms vary.
Relapsing/remitting.
Usually ages 20-40.
32
Multiple Sclerosis - Symptoms
Subjective:
Shakiness, difficulty walking
Fatigue, muscle weakness
Numbness, tingling
Tinnitus
Visual problems
Difficulty chewing and speaking
Incontinent; impotent
33
Multiple Sclerosis - Symptoms
Objective:
Ataxia
Changes in behavior & emotions
Nystagmus
Spasticity, tremors, dysphagia, facial palsy,
speech impaired, fatigue
Incontinence
Impaired judgment
34
Multiple Sclerosis - Tests
CSF
CT scan
MRI
35
Multiple Sclerosis-Treatment
Meds:
Anti inflammatory
ACTH, Solu Medrol, Prednisone
Immuno Modifiers
Avonex, Betaseron, Capoxone
Muscle Relaxants
Valium
36
Multiple Sclerosis-Nursing
Interventions
Nutrition
Skin Care
Activity
Control of environment
Emotional support
Patient teaching
37
Parkinson’s Disease
Unknown cause
Lack of dopamine.
Parkinsonism: encephalitis, toxic chemicals,
meds, drugs
38
Parkinson’s
Symptoms include:
Muscular tremors and rigidity
Emotional instability
Judgment defects
Heat intolerance
Mask-like facial appearance
Dysphagia and drooling
39
Parkinson’s Testing
No specific test to diagnose Parkinson’s
Diagnosis based on symptoms
40
Parkinson’s – Medical
Treatment
Medications
Sinemet, Symmetrol, Levodopa or Cogentin
Less effective over time
Surgery
41
Parkinson’s – Nursing Care
Prevent injury (fall or aspiration)
Prevent urinary retention and constipation
Patient teaching about medication
Patient and family support
42
Alzheimer’s
Unknown cause, but genetic link
Very common; risk increases with age
Brain changes:
plaques
tangled neurons
blood vessel degeneration
chemical changes
43
Alzheimer’s - Symptoms
1st– memory lapses, difficult word finding,
decreased attention span
2nd – increased memory problems,
disoriented to time, loses things,
confabulates
3rd – total disorientation, apraxia, wanders
4th – severe impairment
44
Alzheimer’s - Testing
No definitive test
Family history
Diagnosis: autopsy
45
Alzheimer’s – Medical
Management
Medication to treat symptoms
Memory:Cognex, Aricept
Agitation: Mellaril, Haldol
Supplements
Folic Acid & Vitamin B12
Low fat diet
NSAIDS
46
Alzheimer’s – Nursing Care
2 key points for all care:
Prevent overstimulation
Provide structured, orderly environment
Other concerns
Communication
Family support and education
47
Myasthenia Gravis
Autoimmune disorder
Myoneural junction problem
Symptoms:
ptosis, diplopia,
weakness, dysarthria, dysphagia, difficulty
sitting up, respiratory distress
48
Myasthenia Gravis - Treatment
Medication
to improve impulse transmission (Mestinon)
to suppress immune system (steroids, Cytoxan)
Plasmapheresis
Respiratory support
Safety
49
Amyotrophic Lateral Sclerosis
ALS – Lou Gehrig’s disease
Motor neurons in brain stem and spinal cord
degenerate
Brain’s messages don’t reach the muscles
Symptoms – weakness, dysarthria, dysphagia
No loss of cognitive function
No cure, death occurs in 2-6 years
50
Huntington’s Disease
Chorea
Genetic
Onset at age 35-45
Excessive involuntary movements
Death in 10-20 years
No cure
51
Huntington’s Disease
Nursing interventions are palliative
Give meds
Provide for safety
Provide adequate diet
Emotional support
Genetic counseling
52
Cerebrovascular Accident
(CVA)
Ischemia of brain tissue
Hemorrhage
Thrombus
Embolus
3rd leading cause of death in the US
All ages, but usually elderly
53
CVA – Contributing Factors
Atherosclerosis High cholesterol
Heart disease Cigarette smoking
Kidney disease Stress
Hypertension Sedentary
Obesity Diabetes
Oral contraceptives
Cocaine
54
Cerebral Thrombosis
Most common cause of CVA
Most often:
Atheroclerosis
↓
Thrombus
↓
CVA
55
Cerebral Embolism
2nd most common cause of CVA
Most often:
Heart disease
↓
Thrombus
↓
Embolus
↓
CVA
56
Cerebral Hemorrhage
3rd most common cause of CVA
Most often:
Hypertension
↓
Ruptured cerebral blood vessel
↓
CVA
57
Transient Ischemic Attack
Cerebrovascular insufficiency
Causes – same as CVA
Warning sign of impending CVA
58
CVA - Assessment
Motor changes
Opposite side
Balance, coordination, gait, proprioception
Glasgow Coma Scale
59
CVA Assessment
Sensory Changes
Aphasia =can’t speak or write
Agnosia =can’t recognize familiar objects/people
Apraxia =can’t perform purposeful acts or use
objects properly
Neglect Syndrome
Visual problems, including hemianopsia
60
CVA Assessment
Cognitive changes
denial
impaired memory, judgment
can’t concentrate
disoriented
slow and cautious versus impulsive
depressed, anxious versus euphoric
angers quickly versus constantly smiling
61
CVA - Testing
CT or MRI
Cerebral angiogram
CBC, PT, PTT, electrolytes
62
CVA – Medical Management
Thrombolytic (“clot buster”)
Anticoagulants
Antiplatelet drugs
Aneurysm repair
Carotid endarterectomy
63
CVA-Nursing Care
Assess LOC
IV, NG, Foley, Vent.
Nutrition
Encourage perform ADLs
Bladder and bowel training
ROM
Teaching and emotional support
64
Infection and Inflammation
Meningitis Neurosyphilis
Encephalitis Poliomyelitis
Brain abscess Herpes zoster
Guillain-Barré AIDS
65
Guillain-Barré - Polyneuritis
Peripheral nerve disease
Prior infection; autoimmune response
Weakness and paralysis, begins in
extremities and works up
Respiratory failure may occur
66
Meningitis
Acute infection of the meninges
Viral or bacterial
Severe headache, irritable, fever, delirium,
N/V, neck stiffness
Kernig’s sign
Brudzinski’s sign
67
Meningitis-Medical
Management
Diagnosed by LP
Medications
Respiratory isolation
Cool, dark quiet room
Maintain hydration
Prevent injury
68
Acquired Immunodeficiency
Syndrome - AIDS
AIDS dementia complex
Infection of CNS
Dementia
Treatment depends on infection
Treat symptoms, maintain safety
69
Spinal Cord Injury (SCI)
Spinal cord injury causes myelopathy or
damage to white matter or myelinated fiber
tracts that carry sensation and motor signals to
and from the brain.
It also damages gray matter in the central
part of the spinal, causing segmental losses of
interneurons and motoneurons.
Sapiah R 2012
Spinal Cord Injury (SCI)
Complete cord injury – all voluntary
movement below level of trauma is lost
Autonomic hyperreflexia
stimulus
sympathetic nervous system response
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Pathophysiology:
• Damage to the spinal cord ranges from transient concussion
to contusion, laceration and compression of the cord
substance, to complete transaction of the cord.
Separated into 2 categories:
• Primary injuries
- are the result of the initial insult or trauma and are
usually permanent.
• Secondary injuries
- are usually the result of a contusion or tear injury, in
which the nerve fibers begin to swell and disintegrate.
Causes:
• Trauma
- such as automobile accidents, falls, gunshots, diving
accidents, war injuries, etc.
• Tumor
- such as meningiomas and metastatic cancer.
• Ischemia
- resulting from occlusion of spinal blood vessels,
including dissecting aortic aneurisms, emboli,
arteriosclerosis.
•Developmental disorders
- such as spina bifida & meningomyolcoele
•Others examples: Neurodegenerative diseases, Multiple
Sclerosis, aneurysm and etc.
Treatment:
•Acute Traumatic Spinal Cord Injuries : high dose
methylprednisolone if the injury occurred within 8
hours.
•Stem Cell Transplants - to help or cure paralysis
caused by spinal injury.
HEAD INJURIES
Sapiah R 2012
HEAD INJURY
CLASSIFICATION:
LACERATION OF THE SCALP
SKULL INJURY
BRAIN INJURY
INTRACRANIAL
HEMORRHAGE
CONCUSSION
CONTUSION
•EPIDURAL
LACERATION
•SUBDURAL
COMPRESSION
•INTRACEREBRAL OR
SUBARACHNOID
Pathophysiology
Brain suffers from Cerebral blood flow
traumatic injury decreases
Brain swelling or bleeding Intracranial pressure
increases intracranial continues to rise. Brain
volume may herniate
Rigid cranium allows no
room for expansion of Cerebral hypoxia and
contents so ICP increases ischemia occurs
Pressure on blood vessels
within the brain causes
blood flow to the brain
slowly
Scalp Injuries
They bleed profusely because of the
abundance of blood vessels in the scalp.
Infection is of major concern.
Sapiah R 2012
Skull Injuries
May occur with or without brain injury,
Fracture usually caused by extreme force,
Skull fractures considered closed if dura
mater is intact; open if dura mater is torn.
Sapiah R 2012
Types of Skull Fractures
Linear (nondisplaced cracks in the bone).
Comminuted (bone broken into fragments).
Depressed (bone fragments pressing into
intracranial cavity).
Basiliar (fractures of the bones in the base of
the skull).
Sapiah R 2012
Brain Injuries: Causes
Acceleration-deceleration force (acceleration
injuries caused by moving objects striking the head;
e.g. baseball bat. Deceleration injuries result when
head is moving and strikes object, e.g. dashboard).
Rotational (twisting of the cerebrum on the brain
stem, e.g. whiplash).
Penetrating missile (direct penetration of an object,
e.g. bullet, into brain tissue).
Sapiah R 2012
Brain Injuries: Open
Brain injuries resulting from skull fractures
and penetrating injuries are referred to as
open head injuries.
Hemorrhaging from the nose, pharynx, or
ears; ecchymosis over the mastoid area
(Battle’s sign) or blood in the conjunctiva
may occur in conjunction with open head
injuries.
Sapiah R 2012
Brain Injuries: Closed
Caused by blunt force to the head.
Types of closed head injuries include
concussion, contusion, and laceration.
Sapiah R 2012
Concussion
Transient neurological deficits caused by the
shaking of the brain.
Clinical manifestations may include
immediate loss of consciousness lasting from
minutes to hours, momentary loss of reflexes,
respiratory arrest for several seconds, an
amnesia afterwards.
Sapiah R 2012
Contusions
Surface bruises of the brain.
Skin is cool and pale.
Pulse, blood pressure, and respirations are
below normal.
Cerebral edema may occur in conjunction
with widespread injury.
Sapiah R 2012
Cerebral Lacerations
Tearing of cortical tissue.
Symptoms include deep coma from time of
impact, decerebate posturing, autonomic
dysfunction, nonreactive pupils, respiratory
difficulty.
Sapiah R 2012
Clinical Manifestations:
Depend on the severity and the distribution of the brain injury.
Persistent localized pain usually suggest that a fracture is present.
Fractures of the cranial vault may or may not produced swelling in the
region of the fracture
• Battle’s Sign - an area of ecchymosis (bruising) which is
seen over the mastoid.
• CSF Otorrhea - cerebrospinal fluid leaking through the
ears.
• CSF Rhinorrhea - cerebrospinal fluid leaking through the
nose.
• Halo Sign - it is a blood stain surrounded by a yellowish
stain (CSF) which is usually seen on bed linens or pillows.
Back to topic
Hemorrhage
Intracranial hemorrhage is common
complication of any head injury.
Treatment is surgery to evacuate the
hematoma, stop the bleeding, and relieve
pressure on the brain.
Sapiah R 2012
HEAD INJURY
Nursing Care:
Emergency Care:
airway
supine straight, then turned to lateral or semi-prone
possible cervical collar: no neck flexion &
hyperextension
keep pt covered, quiet & undisturbed
General Care:
• airway • prophylactic tetanus
• prevent aspiration • observe csf leakage:
• otorrhea, rhinorrhea
• check cardiovascular
• battle’s sign
complications
• observe for s/sx of increased
• search evidence of
ICP
spinal injury
• control restlessness & pain:
• check skull & scalp NO NARCOTICS
injuries • maintain fluid &electrolyte,
acid-base balance
92
Thanks For Listening…
