unit v part astudentneuro spring 2011

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Medical-Surgical Nursing, 4/ePriscilla LeMone and Karen Burke

Copyright ©2008 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

Adult Health IIUnit V-a Neuro

Care of Clients withIntracranial Disorders,CVA, Spinal Cord Injuries

(Chapters 43, 44, 45)

Spring 2011KB1




Copyright ©2008 by Pearson Education, Inc.

The CentralNervous System





Synaptic Transmission

Click here to view an animation on synaptic transmission






Brain and Spinal CordBrain

± Control center±

Thoughts± Emotions± Speech

Four Regions of the Brain± Cerebrum± Diencephalon± Brainstem± Cerebellum






Frontal Lobe

Occipital Lobe

Temporal Lobe

Parietal Lobe






Anatomy/Physiology± Meninges

PiaArachnoidDura






Blood flow to brain± Blood vessels

(Circle of Willis)± Blood-brain

barrier






Anatomy/Physiology (cont.)± Limbic system±

Reticular formation± Spinal cord± Messages conduction± Upper motor neurons± Lower motor neurons





Damage to motor neurons

Damage to upper motor neurons incr muscletone, decr muscle strength and coordination,hyperactive reflexesDamage to lower motor neurons (ant graycolumn of cord to muscle) decrease muscletone, muscle atrophy, fasciculations(involuntary twitching), loss of reflexes





The PeripheralNervous System

Links CNS to rest of bodyNerves, ganglia, and sensory receptors31 pairs of spinal nerves12 pairs of cranial nervesReflexesRapid, involuntary, predictable motor responses tostimulusSomatic reflexesAutonomic reflexes





The PNS: Cranial Nerves





The PNS: Reflex Arch





The AutonomicNervous System

Division of the PNS that regulates the normalenvironment; divided into:

1. sympathetic2.parasympathetic

See pg 1511-12





Autonomic Nervous System

Sympathetic NS Parasympathetic(craniosacral) NS





Sympathetic Nervous System

Sympathetic division prepares to handlestress and crises; cell bodies in lateral horns of spinal cord T1-L2; ganglia extend to organswith these effects:Dilates pupils, inhibits secretions, sweat, incr HR,dilates cor arteries and bronchioles,decr digestion,

incr glucose in liver, decr urine; incr blood clotting,metabolic rate, mental alertness, skinvasoconstriction





Parasympathetic Nervous System

Parasympathetic division non-stressfulsituations; cell bodies located in brainstem(CN) and later gray matter of S2-S4;stimulation causes:pupil construction, glandular secreations, decrHR, vasoconstriction of coronary arteries,const of bronchioles incr peristalsis and gisecretions





Health HistoryAssessment Topics

Information about Neurologic Changes± Numbness, tingling, tremors, coordination, loss of

movement

Information about Perception Difficulties± Visual and/or auditory disturbances, cognitive

difficulties

Review of Client s Medications





Health HistoryAssessment Topics

Occupational HazardsUse of Tobacco, Drugs, Alcohol

Safety Measures± Seatbelt use± Bike helmet use





Diagnostic Tests

CTMRI (soft tissue abnormalities), MRA (magnetic resonance

angiography--vascular problems), MRS (magnetic resonancespectroscopy Alz, trauma damage)

PET or SPECT(positron emission tomography or singlephoton emission computed tomography blood flow and

volume, types of dementia, tumors)Cerebral Angiogram (vessel patterns aneurysms,AV malformations, etc)





Carotid Duplex Study velocity of blood flow incarotids

EEG, MEG (electroencephalogram ormagnetoencephalogram electrical activity of brain)

EMG (electromyogram electrical activity of skeletalmuscles at rest)





Diagnostic Tests

Lumbar Puncture± Purpose measure pressure and get csf sample± Prep consent, void, on side in fetal position± Post vital signs, neuro checks q4h x 24h, monitor

site for csf leak or hematoma, vd within 8 hr± Teaching Force fluids, analgesics for HA, flat in

bed (4-24 hrs)





Age-AssociatedAssessment Findings

Slowed nerve conductionSlowed retrieval of information from long-term memorySlowed response to multiple stimuliSlower reflexesSlowed response to balance changesDecreased readiness to learnGreater distractability





Neurologic Assessment

Overall evaluation of mental and physicalstatus

Neuro check (5 parts)1. Level of consciousness (response to auditory &/or tactilestimulus)

2. Vital signs

3. Pupillary response to light4. Strength (handgrip or bil extrem movement)5. Ability to sense touch/pain in extemities





Glasgow Coma Scale (3 sections)High score (15) is best

Eyes open 1-44 Spontaneously3 To speech2 To pain1 No response

Best motor response 1-66 Obeys commands5 Localizes pain4 Flexion-withdrawal3 Abnormal flexion2 Abnormal extension1 No response

Best verbal response 1-55 Oriented

4 Confused3 Inappropriate words2 Incomprehensible sounds1 No response



Neurologic AssessmentCranial nerve assessment

±

I Olfactory (smell test)± II Optic visual acuity (snellen chart)

± III, IV, VI oculomotor, trochlear, abducens (PERRLA) (extraocularmovements or field of vision)

± V Trigeminal (facial sensation) (Cotton ball test)

± VII Facial (facial muscles) (taste) (frown, blow out cheeks, raise eyebrows,smile, close eyes)

± VIII Acoustic (hearing and equilibrium) (whisper test)

± IX and X Glosspharyngeal (swallowing, gag reflex) and Vagus(symmetrical rise of the soft pallet and uvula) (Say ah )

± XI Spinal Accessory (head and neck movement) (shrug shoulders) (turnhead against resistance)

± XII Hypoglossal (speech and swallowing) (Stick out tongue)





Abnormal NeurologicFindings

Anosmia inability to smell

Nystagmus invol eye movements

Ptosis droopy lids

Trigeminal Neuralgia (tic douloureaux CN V severefacial pain)

Bell s Palsy (CN VII unilateral facila nerve paralysis)

Dysphagia difficulty swallowing

Dysarthria difficulty speaking






Sensory function assessments± Sensations± Stereognosis recognize objects by touch± Graphesthesia recognize writing by touch± 2 point discrimination






Motor function assessment± Muscle tone and strength± Tremors or fasciculations (uncontrolled twitching)

± Flaccidity (loss of muscle tone)

± Spasticity (muscular hypertonicity)

Cerebellar functions assessment± Ataxia (staggering gait)

± Romberg s stand with feet together, eyes closed; minimal swaying 20sec. (positive seen in cerebellar ataxia)



Babinski s Reflex: Dorsiflexion of the big toe and

fanning of the other toes is seen with upper motorneuron disease of the pyramidal tract.



Brudzinski s Sign: Flex head to chest. Should be no pain,resistance, or flexion of the hips or knees.

Excessive pain or resistance occurs with meningealirritation.



Kernig s Sign: Flex the knees and hips, then straightenthe knee. There should be no pain or resistance.

Excessive pain or resistance occurs with meningealirritation.



Decorticate Posturing: posturing occurs with lesions of the corticospinal tract.



Decerebrate Posturing: Posturing occurs with lesions of the midbrain, pons, and diencephalon.





Alterations in LOC

Level of Consciousness condition in which theperson is aware of self and environment and is ableto respond appropriate to stimuli.

± Confusion± Disorientation± Obtundation± Stupor± Semicomatose± Coma





Alterations of Level of Consciousness

Progressive respiratory changes± Cheynes-Stokes respirations± Neurogenic hyperventilation± Apneustic respirations (prolonged insp with expir apnea; 1.5

cycles/min)± Ataxic/apneic respirations

Pupillary/oculomotor responses± Ipsilateral (same side of the body) pupil changes with localized

problem± Bilateral pupil changes with generalized problems± Pupil fixation± Doll s eyes movements: As brainstem function

deteriorates, this function is lost.



Alterations of Level of Consciousness

Late Sign of increased Intracranial Pressure(IICP) is Cushing's Response: Vitals: Increasedsystolic BP, widening pulse pressure, andbradycardia.

Brainstem s final effort to maintain cerebral

perfusion.



Alterations in LOC

--Doll s eyes movements: As brainstem functiondeteriorates, this function is lost.





Alterations in LOC

Motor Responses± Responds to commands± Localizes pain± Withdrawal from pain± Decorticate posturing± Decerebrate posturing± Flaccid





PersistentVegetative State

Irreversible ComaPermanent Condition of CompleteUnawarenessLoss of all Cognitive FunctionsEtiology

± Death of the cerebral hemispheres± Continued function of brainstem/cerebellum





Locked-In Syndrome

Alert and fully aware of the environmentIntact cognitive abilities

Unable to communicate through speechUnable to move: locked inside paralyzed body.Usual Cause: Injury (infarction, hemorrhage)

to the pons, but spares the RASUpper CN I-IV may remain intact.





Brain Death

Cessation of all Brain Functions± Including the brainstem

General Criteria±

Unresponsive coma± Absent motor and reflex movements± No spontaneous respirations (apnea)± Pupils fixed and dilated.± Absent ocular response to head turning and caloric

stimulation (irrigate ear with ice cold water. Eyes movetoward irrigation, then back to midline.)





Alterations in LOC

Prognosis depends upon± Age± General medical condition± Underlying cause± Pathologic process

Recovery of consciousness within 2 weeks isfavorableInterdisciplinary Care

±

Identification of underlying cause± Preservation of function± Prevention of deterioration



Medical-Surgical Nursing, 4/ePriscilla LeMone and Karen Burke Copyright ©2008 by Pearson Education, Inc.

Treatments for ICP

ICP Monitoring± Normal CP is 70-95 cmH 20

Neuromuscular blocking agent for

sedation and paralysisIntubation and mechanicalventilation

± Reason for Hyperventilation:

prevents hypoxia and hyper-capnia which incr ICP




Seizures

Abnormal electrical discharge that causesabrupt, temporary altered state of cerebralfunction; may involve all or part of brain; maybe provoked or non-provoked; varyingamounts of time may lapse between seizures.




Partial seizures

Simple partial seizures involves only portionof brain; alters motor function, sensory signs,autonomic or psychic symptomsComplex partial seizures as above but withimpaired consciousness




Absence Seizures (petit mal)

Sudden brief (usu 5-10 sec) cessation of motoractivity with a blank stare or lack of responsivenessMore common in childrenMay involve eye fluttering, lip twitching, etc




Tonic-Clonic Seizures (grand mal)

Most common type in adults; follows apattern; may have aura or occur withoutwarningMuscle rigidity with jaw clenched; loss of bowel and bladder controlBreathing my cease and cyanosis set in duringclonic phaseNeed to protect from injury




Status Epilepticus

Seizure activity becomes continuous; dangerof hypoxia, acidosis, hypoglycemia,hyperthermia, exhaustion if activity nothalted; life-threatening emergency thatrequires immediate treatmentTx: D50 (prevent hypoglycemia), Valium or

Ativan; Dilantin, phenobarb




Traumatic Brain Injury

Any injury of the scalp, skull, or brainLeading cause of death and disability in theU.S.Penetrating (open) or closed (blunt trauma)Acceleration

Head is struck by a moving object




Traumatic Brain Injury

DecelerationHead hits a stationary objectAcceleration-Deceleration InjuryCoup-contrecoup phenomenon

Head hits an object, brain rebounds within skull




Deformation Injuries

Skull FractureLinear FracturesComminuted and Depressed Skull FracturesBasal Skull FracturesNursing Care

o Focuses on risk for infection and teaching for

nonhospitalized clientso Risk for infection




Head Injuries

Closed Head Injuries± Primary injury results from impact± Secondary injury is progression of the initial injury

Focal Brain Injury± Confined to one area of the brain± Contusion± Epidural Hematoma± Subdural Hematoma± Intracranial Hemorrhage




Intracranial Hematomas

Epidural - often occur from meningeal artery tear; may loseconsciousness and then have brief lucid period before LOCrapidly declines; ipsilateral dilated pupil on same side ashematoma; contralateral hemiparesis.Subdural - most common; between dura and arachnoid;slowed thinking; drowsiness; lethargy; unilateral HA;confusion. Can be acute, subacute, or chronic.Int racerebral- Located directly in the brain; associated with

contusions; can be single or multiple; s/s vary by location;expanding clot increases ICP and herniation may occur.




Intracranial Hematomas




Diffuse Brain Injury (DBI)

Affects the entire brainCaused by a shaking motion

Rotational acceleration is primary mechanismof injuryMild concussionClassic cerebral concussion




Diffuse Axonal Injury (DAI)

Widespread disruption of white matter axonsPrognosis is poorMost die or remain in a persistent vegetative state

Interdisciplinary CareRapid recognition of injuryTransport to an EDSupport of ABCsDetection and management of IICP



T ti B i I j




Traumatic Brain InjuryNursing Diagnoses

± #1 Decreased intracranial adaptive capacity (Hasor is at high risk for IICP)

Elev HOB

Asp precautionsSkin, body alignmentIf nasal drainage, test for csf (+ glucose)

± Ineffective airway clearance± Ineffective breathing pattern± Risk for infection and skin integrity with skull fx




Brain Tumors

Patho:± Tumor causes edema, increasing

ICP, disruption of CSF,

hydrocephalus, herniation,tissue deathTypes:

± Benign or malignant± Primary or metastatic± Glioblastomas most common




Brain Tumors

Treatments based on the type, location,response to therapyCorticosteroidsAnticonvulsants

± Diazepam (Valium)± Lorazepam (Ativan)± Phenytoin(Dilantin)

Chemotherapy and/or Radiation




Brain Tumors

Chemotherapy and/or RadiationSurgical removal or debulking of tumors

± Burr hole± Craniotomy± Craniectomy± Cranioplasty




Pre-op/Post-op Care

Safety needs/ prevent injury/seizures




Tumor Surgery

O mmaya reservoir for medication administration. In a craniotomy, a portion of the skull and overlyingscalp is removed to allow access to the brain.

N i Di




Nursing DiagnosesPre- and Post-op Care

Risk for Injury--Safety needs/ preventinjury/seizuresAnxietyRisk for InfectionSituational Low Self-esteemIneffective Protection r/t cranial surgeryAcute Pain




Chapter 45

Nursing Care of Clients withCerebrovascular and

Spinal Cord Disorders





Stroke

Risk factors specific to women± Oral contraceptive use± Pregnancy± Childbirth± Menopause± Migraine headaches with aura± Autoimmune disorders± Clotting disorders



Ischemic Strokes



Ischemic Strokes± Transient Ischemic Attack (TIA)--

Signs: sudden, brief sx(<24 hr, usu 1-2h): one-sidednumbness of body part, aphasia, visual disturbances,one eye blindness, blurring. Hx of TIA is treated withantiplatelet drugs such as aspirin, plavix, ticlid, and

persantine.± Thrombotic Stroke

Causes: clot formed in carotids, vertebrals, vertebral andcerebral junction; older adults in sleep

± Embolic StrokeCauses: moving clot settles in bifurcation; usu in carotidand middle cerebral arteries; A fib; younger & whileawake





Manifestations of Stroke

Commo n st roke symp t oms i n clude: 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 trouble walking, dizziness, loss of balance orcoordination

Sudden severe headache with no known cause





Complications of Stroke

Sensory-perceptual Deficits± A. Normal left field of vision with loss of

vision in right field.± B. Loss of vision in temporal half of both

fields (bitemporal hemianopia).± C . Loss of vision in nasal field of right eyeand temporal field of left eye (homonymous

hemianopia).

Agnosia inability to recognize one or moreobjects that were previously familiar

Apraxia inability to carry out a familiarmotor activity even with motor strength andcoordination intact





Neglect Syndrome

Disorder of attention; cannot use or integrateperception from affected side of body or fromthe environment on the affected side; ignores

the part. Most common in strokes of Rhemisphere.






Cognitive and Behavior Changes± Change in LOC and confusion± Emotional lability

Intellectual Changes± Memory loss,± Decreased attention span± Poor judgement± Inability to think abstractly






Communication Disorders± Expressive aphasia (Broca s) can understand what is

being said but can only respond in very short phrases

± Receptive aphasia (Wernicke s) can t understandspoken word; can speak but inappropriate content

± Aphasia inability to use or understand language.± Dysarthria-- muscular disruption of speech






Motor Deficits± Hemiplegia paralysis of one side of body± Hemiparesis weakness of one side of body.± Flaccidity absent muscle tone± Spasticity increased muscle tone

Elimination Changes may have retention or

loss of control± Bladder watch for DI± Bowel

R & L CVA





R & L CVA

Left Hemisphere± Paralysis on R side± R visual field defects± Aphasia- expressive,

receptive or globalFluent- speak, but can tunderstand, babble, mixup wordsNonfluent- can t speak,Broca s area

± Slow, cautious± Altered intellect

Right Hemisphere± Paralysis on L± L visual field defects± Spatial-perceptual

deficits± Increased distractibility± Impulsive behavior ± Poor judgment, lack of

awareness of deficits± L sided neglect



k





Stroke

Goals of Stoke Care± Rapid recognition of stroke s/s (restlessness, resp

changes, IICP)± Rapid reaction± Rapid EMS dispatch± Rapid EMS system transport±

Hospital prenotification± Rapid diagnosis and treatment



S i l C d I j



Medical-Surgical Nursing, 4/e

Priscilla LeMone and Karen BurkeCopyright ©2008 by Pearson Education, Inc.

Spinal Cord Injury

Etiology± Excessive force± Abnormal movements±

Penetrating injuryPathophysiology

± Primary injury: microscopic hemorrhages/edema± Secondary injury: increase size of primary injury (+ or 2

vertebrae)± Necrosis of both the white and gray matter

S i l C d I j





Spinal Cord Injury

S i l C d I j





Spinal Cord Injury

Complete SCI± Complete interruption of motor/sensory neural

pathways±

Total loss of motor/sensory function below levelof injury

Incomplete SCI± Partial interruption of motor/sensory neural

pathways± Alterations in function dependent upon level of

injury

Spin l Cord Inj r





Spinal Cord Injury

Upper Motor Neuron Interruption (responsible for voluntarymovement)

± Spastic paralysis± Hyperreflexia± Inability to carry out skilled movement

Lower Motor Neuron Interruption (responsible for innervationand contraction of skeletal muscles)

± Muscle flaccidity± Extensive muscle atrophy± Loss of voluntary/involuntary movement

Spinal Cord Injury





Spinal Cord Injury

Thoracic, lumbar or sacral injuries± Paraplegia or weakness of lower extremeties± T1-T7 phrenic nerve intact but intercostal and

abdominal muscles affected± S2-S4 and above may cause neurogenic bladder

and bowel dysfunction



Spinal Cord Injury





Spinal Cord Injury

Prehospital Management± Rapid assessment of ABCs± Immobilizing and stabilizing head/neck± Rapid transport

Guidelines for Emergency Care± Avoid flexing, extending, or rotating neck± Immobilize neck± Secure head± Maintain supine position± Transfer with backboard in place± Ng tube, foley

Immobilization of SCI





Provides stabilization of cervicaland upper thoracic vertebraeTraction

± Gardner-Wells tongs

External Fixation± Halo external fixation device± Halo ring attached to rigid plastic

vest

Spinal Cord Injury





Spinal Cord Injury

Surgery± Removal of bone fragments or hematoma± Stabilization and support of spine± Decompression laminectomy± Spinal fusion± Insertion of metal rods

SCI Emergency Care





SCI Emergency Care

Avoid bending neck in any way (immobilize)Supine positionABCs

Paralytic ileusFoley for bladder distentionMonitors vitals, ABGs, Swan-Ganz, ECG

Meds

Spinal Cord Injury





Emergency Meds

High-dose steroid therapy protocol within 8 hours of the injuryGMI ganglioside for 3-4 weeks (experimental)VasopressorsAntispasmodics Baclofen (Lioresal) or ValiumAnalgesicsProton Pump Inhibitors

AnticoagulantsStool Softeners

Spinal Cord Injury





Spinal Cord Injury

ICU or Nursing Unit Management± Respiratory problems± Paralytic ileus± Atonic bladder± Cardiovascular alterations



Spinal Cord Injury





Spinal Cord Injury

Autonomic Dysreflexia or Hyperreflexia± Neurological emergency - potentially fatal if not

treated!±

Exaggerated sympathetic response with massivevasoconstriction and vagus nerve response.± Occurs in lesions above T6 after Spinal Shock

phase over±

Triggered by distended bowel or bladder, pain(stones or pressure ulcers) or visceral contractions



Spinal Cord Injury




Priscilla LeMone and Karen Burke


Spinal Cord Injury

Nursing diagnoses± #1 Ineffective breathing pattern± Impaired physical mobility±

Impaired gas exchange± Dysreflexia± Altered urinary elimination± Constipation± Sexual dysfunction± Low self-esteem

Teaching with SCI




Priscilla LeMone and Karen Burke


Teaching with SCI

Goal prevent secondary complications of immobility and altered function; preventinjuries

Bladder and bowel training/care; self-cathSexual dysfunction

Skin careTurning/changing positionsAssistive devices



Intracranial Aneurysm



Ineffective tissue perfusion : (Post rupture)Keep pt in quiet, darkened, private room.

Elevate HOB 30-45 degrees to promote venous return.Limit visits and duration.

Allow reading, TV, or radio to promote relaxation.Administer stool softeners.Monitor VS and neuro status Q15 min - 4 HrsSeizure precautions

Avoid IICP activities: coughing; vomiting; blowing nose, flexinghead, enemas, moving self up in bed, sneezing.

unit v part astudentneuro spring 2011

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