Neurologic System 401 CHAPTER TWENTY PHYSIOLOGY OF THE NERVOUS SYSTEM A. Central nervous system (CNS) (Figure 20-1). B. Peripheral nervous system. 1. Twelve pairs of cranial nerves. 2. Thirty-one pairs of spinal nerves. 3. Autonomic nervous system (ANS). a. Sympathetic system: “fight or flight.” b. Parasympathetic system. Cells of the Nervous System A. Neuron: the functional cell of the nervous system. B. Function/classification. C. Supporting cells provide support, nourishment, and pro- tection to the neuron. D. Myelin sheath. 1. Dense membrane or insulator around the axon. 2. Facilitates function of the neuron. 3. Contributes to the blood-brain barrier to protect the CNS from harmful molecules. E. Nerve regeneration: entire neuron is unable to undergo complete regeneration. 1. Neuron regeneration in the CNS is very limited, pos- sibly because of the lack of neurilemma (membrane surrounding the neuron). 2. Scar tissue is a major deterrent to successful cellular regeneration. F. Impulse conduction. 1. Reflex arc. a. A reflex arc is the functional unit that provides pathways over which nerve impulses travel. b. The passage of impulses over a reflex arc is called a reflex act or a reflex and is an involuntary response to a stimulus. c. Reflex arc: the afferent neuron carries the stimulus to the spine, integrates it into and through the spine (CNS) to the efferent neuron, and crosses the synapse with the message from the CNS to the organ or muscle, which responds to the stimu- lus. This is the sequence of events evaluated when the deep tendon reflexes are tested. 2. Synaptic transmission. a. A chemical synapse maintains a one-way com- munication link between neurons. b. Chemical neurotransmitters (neuromediators) facilitate the transmission of an impulse across the synapse. (1) Acetylcholine. (2) Norepinephrine. (3) Dopamine. (4) Histamine. c. Impulses pass in only one direction. Central Nervous System The brain and the spinal cord within the vertebral column make up the CNS (see Figure 20-1). A. The brain and the spinal column are protected by the rigid bony structure of the skull and the vertebral column. B. Meninges: protective membranes that cover the brain and are continuous with those of the spinal cord. 1. Pia mater: a delicate vascular connective tissue layer that covers the surfaces of the brain and the spinal column; part of the blood-brain barrier. 2. Arachnoid: a delicate nonvascular, waterproof mem- brane that encases the entire CNS; the subarachnoid space contains the cerebrospinal fluid (CSF). 3. Dura mater: a tough white fibrous connective tissue, the outer layer of protection to the brain and spinal cord. C. Cerebrospinal fluid (CSF). 1. Serves to cushion and protect the brain and spinal cord; brain literally floats in CSF. 2. CSF is clear, colorless, watery fluid; approximately 100 to 200 mL in total volume, with a normal fluid pressure of 60 to 100 mm H 2 O. 3. Formation and circulation of CSF (Figure 20-2). a. Fluid is secreted by the choroid plexus located in the ventricles of the brain. b. CSF flows through the lateral ventricles into the third ventricle, then flows through the aqueduct of Sylvius into the fourth ventricle, where the central canal of the spinal column opens. c. From the fourth ventricle, CSF flows around the spinal cord and brain. d. Because CSF is formed continuously, it is reab- sorbed at a comparable rate by the arachnoid villi.
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Neurologic System
401
CHAPTER TWENTY
PHYSIOLOGY OF THE NERVOUS SYSTEM
A. Centralnervoussystem(CNS)(Figure20-1).B. Peripheralnervoussystem.
a. Sympatheticsystem:“fightorflight.”b. Parasympatheticsystem.
Cells of the Nervous SystemA. Neuron:thefunctionalcellofthenervoussystem.B. Function/classification.C. Supportingcellsprovidesupport,nourishment,andpro-
a. A reflex arc is the functional unit that providespathwaysoverwhichnerveimpulsestravel.
b. Thepassageofimpulsesoverareflexarciscalledareflexactorareflexandisaninvoluntaryresponsetoastimulus.
c. Reflexarc:theafferentneuroncarriesthestimulusto the spine, integrates it into and through thespine (CNS) to the efferent neuron, and crossesthe synapse with the message from the CNS totheorganormuscle,whichrespondstothestimu-lus.Thisisthesequenceofeventsevaluatedwhenthedeeptendonreflexesaretested.
2. Synaptictransmission.a. A chemical synapse maintains a one-way com-
municationlinkbetweenneurons.
b. Chemical neurotransmitters (neuromediators)facilitatethetransmissionofanimpulseacrossthesynapse.(1) Acetylcholine.(2) Norepinephrine.(3) Dopamine.(4) Histamine.
c. Impulsespassinonlyonedirection.
Central Nervous SystemThebrainandthespinalcordwithinthevertebralcolumnmakeuptheCNS(seeFigure20-1).A. The brain and the spinal column are protected by
the rigid bony structure of the skull and the vertebralcolumn.
B. Meninges: protective membranes that cover the brainandarecontinuouswiththoseofthespinalcord.1. Piamater:adelicatevascularconnectivetissue layer
that covers the surfaces of the brain and the spinalcolumn;partoftheblood-brainbarrier.
d. Hypothalamus.(1) Homeostasis: regulationof visceral activities,
includingbodytemperature,fluidandelectro-
FIGURE 20-1 Major divisions of the central nervous system. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)
Cerebralhemisphere
Diencephalon
MidbrainPonsMedulla
Brainstem Cerebellum
Spinal cord
{
FIGURE 20-2 Circulation of the cerebrospinal fluid. (From Monahan FD et al: Medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)
Arachnoid villi
Choroidplexus(thirdventricle)
Choroidplexus(fourth
ventricle)
Foramen ofMagendie
Foramen ofLuschka
Aqueduct ofSylvius
Lateralventricle
Subarachnoidspace
Superiorsagittal sinus
Foramen ofMonro
Cisternamagna
D. Brain.1. Cerebrum:thelargestportionofthebrain;separated
into hemispheres; the cerebral cortex is the surfacelayerofeachhemisphere.
2. Majorlobesofthecentralcortex.a. Frontal.
(1) Responsibleforintelligenceandpersonality.(2) Coordination of voluntary skeletal muscle
movement.(3) Abstractthinking,morals,judgment.(4) Broca’s area for speech, motor-speech area,
VIII Acoustic ReceptionofhearingandmaintenanceofequilibriumIX Glossopharyngeal Senseoftasteonposteriortongue
SalivationSwallowingorgagreflex
X Vagusnerve AssistsinswallowingactionMotorfiberstolarynxforspeechInnervationoforgansinthoraxandabdomenImportantinrespiratory,cardiac,andcirculatoryreflexes
XI Accessory(spinal) AbilitytorotatetheheadandraisetheshoulderXII Hypoglossal Musclesofthetongue
b. Nucleuspulposusisthefibrocartilaginousportionof the intravertebral disk; acts as shock absorberforthespinalcord.
4. Uppermotorneurons:originate in thebrain; trans-mit impulses from the brain to the lower motorneurons.
5. Lower motor neurons: originate in the spinal cord;transmit impulses to themusclesandorgans.Theseneuronsformthereflexarc.
as the connection between the afferent pathway(sensory)andtheefferentpathway(motor).
b. Testing of the reflex arc (deep tendon reflexes)allowsevaluationofthe lowermotorneuronandthesensory/motorfibersfromthespinalcolumn.For example, if the biceps reflex is normal, the lower motor neurons and the nerve fibers at C5 and C6 are intact.
2. Each spinal nerve is connected to the cord by tworoots.a. Dorsal (posterior root): a sensory nerve carrying
messagestotheCNS.b. Ventral (anterior root): a motor nerve carrying
neuron messages to glands and the peripheralareas.
C. Somatic nervous system: consists of peripheral nervefiberssendingsensorystimulitoCNSandmotornervefibersthatstimulateskeletalmuscle.
D. Autonomicnervoussystem(ANS):regulatesinvoluntaryactivity (cardiovascular, respiratory, metabolic, bodytemperature,etc.).1. Consists of two divisions that have antagonistic
activity.2. Parasympathetic division: maintains normal body
functions.3. Sympathetic division: prepares the body to meet a
4. Mostof theorgansof thebody receive innervationfromboththeparasympatheticandthesympatheticdivisions. The divisions are usually antagonistic ineffectonindividualorgans:onestimulates;theotherrelaxes.
5. Chemical mediators: facilitate transmission ofimpulsesintheANS.a. Acetylcholineisreleasedbythefibersinbothdivi-
a. Paralysisorparesthesia,syncope.b. Headache,dizziness,speechproblems.c. Visualproblems,changesinpersonality.d. Memoryloss,nausea,vomiting.
B. Physicalassessment.1. Generalobservationofclient.
a. Posture,gait,coordination;performRombergtest.b. Positionofrestfortheinfantoryoungchild.c. Personalhygiene,grooming.d. Evaluatespeechandabilitytocommunicate.
NURSING PRIORITY: When assessing a client’s neurologic status, always evaluate symmetry. If asymmetrical findings are detected, refine exam to determine CNS versus peripheral nervous system as origin of asymmetry.
4. Evaluatemotorfunction.a. Assess face andupper extremities for equalityof
movementandsensation.b. Evaluate appropriateness of motor movement-
e. Abilityofaninfanttosuckandtoswallow.f. Asymmetricalcontractionoffacialmuscles.
FIGURE 20-3 Assessment of the neurologic system: pupillary check. (From Zerwekh J, Gaglione T: Mosby’s assessment memory notecards: visual, mnemonic, and memory aids for nurses, ed 1, St. Louis, 2007, Mosby.)
deephyperpnea.(3) Ataxic: completely irregular pattern with
randomdeepandshallowrespirations.c. Temperature: evaluate changes in temperatureas
relatedtoneurologiccontrolversusinfection.
DISORDERS OF THE NEUROLOGIC SYSTEM
Increased Intracranial PressureAn increase in intracranial pressure (ICP) occurs any time there is an increase in the size or amount of intracranial contents.A. Thecranialvaultisrigid,andthereisminimalroomfor
a reciprocal change in other cranial contents; this fre-quently results in ischemiaofbrain tissue.An increaseinICPresultsfromoneofthefollowing:1. Increasedintracranialbloodvolume(vasodilation).2. IncreasedCSF.3. Increaseinthebulkofthebraintissue(edema).
C. Cerebraledema.1. Edemaoccurswhenthereisanincreaseinthevolume
ofbraintissuecausedbyanincreaseinthepermeabil-ity of the walls of the cerebral vessels. Protein-richfluidleaksintotheextracellularspace.Edemaismostoften the cause of increased ICP in adults, whichreachesmaximumpressurein48to72hours.
2. Cytotoxic (cellular) edema occurs as a result ofhypoxia. This results in abnormal accumulation offluidwithinthecells(intracellular)andadecreaseinextracellularfluid.
D. Poorventilationwillprecipitate respiratoryacidosis,oranincreaseinthePaco2.1. Carbondioxidehasavasodilatingeffectonthecere-
bral arteries, which increases cerebrovascular bloodflowandincreasesICP.
E. Regardless of the cause, increased ICP will result inprogressive neurologic deterioration; the specific defi-ciencies seenaredeterminedby theareaandextentofcompressionofbraintissue.
F. If the infant’s cranial suture lines are open, increasedICP will cause separation of the suture lines and anincreaseinthecircumferenceofthehead.
NURSING PRIORITY There is no single set of symptoms for all clients with increased ICP; symptoms depend on the cause and on how rapidly increased ICP develops.
AssessmentA. Riskfactors/etiology.
1. Cerebral edema caused by some untoward event ortrauma,includingtoxicexposure,blunttrauma,fluidandelectrolyteimbalance.
B. Clinical manifestations (bedside neurologic checks)(Figure20-4).
ALERT Determine change in a client’s neurologic status. Be able to rapidly evaluate the client and recognize incremental changes in the neurologic signs that indicate an increase in ICP (Box 20-3).
a. Tense,bulgingfontanel(s).b. Separatedcranialsutures.c. Increasingfrontal-occipitalcircumference.d. High-pitchedcry.
C. Diagnostics(seeAppendix20-1).1. DirectICPmonitoring.2. Romberg test:measuresbalance.Client standswith
feet together andarmsat side,firstwitheyesopen,thenwitheyesclosedfor20to30seconds.
3. Calorictesting:testisperformedatbedsidebyintro-ducingcoldwaterintotheexternalauditorycanal.Ifthe eighth cranial nerve is stimulated, nystagmusrotates toward the irrigated ear. If no nystagmusoccurs,apathologicconditionispresent.
4. Doll’seyereflex(oculocephalicreflex).a. Doll’s eye reflex is normal when the client’s
head is moved from side to side and the eyesmove in the direction opposite that of theturning.
b. Doll’s eye reflex is abnormal when the client’seyes remain in a fixed, midline position whenthe head is turned from side to side (possiblebrainsteminvolvement).
c. Contraindicateduntilriskforspinalcordinjuryisruledout.
5. Papilledema: edema of the optic nerve; observedbyexaminingretinaareawithanophthalmoscope.
7. Lumbarpunctureisgenerallynotperformed;decreasein CSF pressure could precipitate herniation of thebrainstem.
TreatmentA. Treatment of the underlying cause of increasing
pressure.B. Neurologiccheckseveryhourorasordered.
1. Mayinvolvecorrelationofseveralvariablesincludinglevel of consciousness, vital signs, speech, facialsymmetry, grasp strength, leg strength, and pupilresponses.
for both adults and children)— irritability, rest-lessness, confusion, lethargy, and difficulty inarousing—maybesignificant.
NURSING PRIORITY The first sign of a change in the level of ICP is a change in level of consciousness; this may progress to a decrease in level of consciousness.
respiration,hyperventilation).d. Assess temperature with regard to overall prob-
lems;temperatureusuallyincreases.
NURSING PRIORITY Cushing’s triad: increasing systolic pressure, with increased pulse pressure, decreased pulse rate, and Cheyne-Stokes respirations. Increased ICP is well established when this occurs.
3. Pupillary response: normal pupils should be round,midline,equalinsize,andequallybrisklyreactivetolightandshouldaccommodatetodistance.Abnormalfindingsinclude:a. Ipsilateral: pupillary changes occurring on the
C. Intravenous(IV)andoralfluidstomaintainnormalfluidvolumestatusifmeanarterialpressure(MAP)islowtonormal.Often,normalsalinesolutionisfluidofchoice;5%dextroseinwaterpotentiatescerebraledema.
D. Medications.1. Osmoticdiureticcorticosteroids.2. Anticonvulsants,antihypertensives.
E. MaintainadequateventilationbymeansofmechanicalventilationtolowerPaco2(25to35mmHg)topreventvasodilationofcerebralvessels.
F. Placementofventriculoperitonealshuntduringdecom-pressionsurgery.
FromLewisSLetal:Medical-surgical nursing: assessment and management of clinical problems,ed7,St.Louis,2007,Mosby.*Addedtotheoriginalscalebymanycenters.
ALERT Change client’s position. If the client with increased ICP develops hypovolemic shock, do not place client in Trendelenburg position.
C. Change client’s position slowly; avoid extreme hipflexionandextremerotationorflexionofneck.Maintaintheheadmidline.
D. Monitorurineosmolarityandspecificgravity.E. Evaluateintakeandoutput.
1. Inresponsetodiuretics.2. Ascorrelatedwithchangesindailyweight.3. For complications of diabetes insipidus (see
NURSING PRIORITY An obstructed airway is one of the most common problems in the unconscious client; position to maintain patent airway or use airway adjuncts.
A. Preventrespiratoryproblemsofimmobility.B. Evaluatepatencyof airway frequently; as levelof con-
sciousnessdecreases,clientisatincreasedriskforaccu-mulating secretions and airway obstruction by thetongue.
C. KeepPaco2levelsnormal.D. Suctionasnecessarybriefly.E. Client may require intubation and respiratory support
fromaventilator(seeAppendixes15-5and15-8).Goal: Toprotectclientfrominjury.A. Maintainseizureprecautions(seeAppendix20-5).B. Restrain client only if absolutely necessary; struggling
ALERT Notify primary health care provider when client demonstrates signs of potential complications; interpret what data for a client need to be reported immediately.
B. Supratentorial: tumors occurring within the anteriortwo-thirdsofthebrain,primarilythecerebrum.
C. Infratentorial:tumorsoccurringintheposteriorthirdofthe brain (or below the tentorium), primarily in thecerebellumorthebrainstem.
D. Regardlessoftheorigin,site,orpresenceofmalignancy,problemsofincreasedICPoccurbecauseofthelimitedarea in the brain to accommodate an increase in theintracranialcontents.
sivelybecomesprojectile.3. Papilledema(edemaoftheopticdisc).4. Seizures(focalorgeneralized).5. Dizzinessandvertigo.6. Mental status changes: lethargy and drowsiness,
B. Radiation: x-rays, gamma knife, stereotactic radiosur-gery.
C. Surgical intervention: craniotomy/craniectomy, biopsy,shuntplacement,reservoirplacement,laserremoval.
ComplicationsComplications include meningitis, brainstem herniation,diabetes insipidus, and syndrome of inappropriate antidi-uretichormonesecretion(seeChapter13).Residualeffectsincludeawidearrayofcomplicationssuchasseizures,dys-arthria, dysphasia, disequilibrium, and permanent braindamage.
Nursing InterventionsGoal: To provide appropriate preoperative nursing
G. Maintainsemi-Fowler’spositionifthereisaCSFleakfromearsornose.
H. Postoperative positioning for client who has hadinfratentorialsurgeryisasfollows:1. Bedshouldbeflat.2. Positionclientoneitherside;avoidsupineposition.3. Maintainheadandneckinmidline.4. Keep NPO for 24 hours to reduce edema around
medullaandreducevomiting. I. Postoperativepositionforclientwhohashadsupraten-
torialsurgery:semi-tolow-Fowler’sposition. J. Trendelenburg position is contraindicated for clients
who have had either infratentorial or supratentorialsurgery.
K. Maintainfluidregulation.1. Afterclientisawakeandtheswallowandgagreflexes
B. Children and infants are more capable of absorbingdirectimpactbecauseofthepliabilityoftheskull.
C. Coup-contrecoup injury: damage to the site of impact(coup) and damage on the side opposite the site of
FIGURE 20-5 Formation of head injury after hematoma. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, Philadelphia, 2009, Saunders.)
Dura
A. Subdural hematoma B. Epidural hematoma C. Intracerebral hematoma
D. Primary injury to the brain occurs by compressionand/or tearing and shearing stresses on vessels andnerves.
E. Althoughbrain volume remainsunchanged, secondaryinjuryoccursfromthecerebraledemainresponsetotheprimary injury and frequently precipitates an increaseinICP.
F. Typesofheadinjuries(Figure20-5).1. Concussion: temporary interference in brain func-
tion; may affect memory, speech, reflexes, balance,andcoordination.a. Onlysmallnumberofvictimsactually“blackout.”b. Usually from blunt trauma including contact
3. Intracranialhemorrhage.a. Epidural (extradural) hematoma: a large vessel
(often a meningeal artery or vein) in the duramater is damaged; a hematoma rapidly formsbetween the dura and the skull, precipitating anincreaseinICP.(1) Momentarylossofconsciousness,thenfreeof
symptoms (lucid period), and then lethargyandcoma-seldomevidentinchildren.
(2) Symptoms of increasing ICP may developwithinminutesafterthelucidinterval.
(3) Tentorial herniation may occur withoutimmediateintervention.
b. Subduralhematoma:acollectionofbloodbetweentheduraandarachnoidareafillingthebrainvault;usuallytheresultofseriousheadinjury.(1) May be acute (manifesting in less than 24
hours) or “chronic” (developing over days toweeks).
NURSING PRIORITY The primary treatment objectives for the client with a head injury are to maintain a patent airway, to prevent hypoxia and hypercapnia resulting in acidosis, and to identify the occurrence of increased ICP.
A. Themajorityof clientswhoexperience concussionaretreatedathome.
B. Aperiodof unconsciousness or presenceof seizures isconsideredaseriousindicationofinjury.
C. Surgicalintervention.1. Burrholestoevacuatethehematoma.2. Craniotomy/craniectomy.
Nursing InterventionsGoal: To provide instruction for care of the client in the
ALERT Determine family’s understanding of the consequences of the client’s illness. Written and oral instructions should be given to the client and to the family. Increased anxiety may affect comprehension of oral directions (see Box 20-4).
Box 20-4 DISCHARGE INSTRUCTIONS FOR CLIENTS WITH HEAD INJURY
Arousetheclientevery3to4hoursforthefirst24hours.Anticipatecomplaintsofdizziness,headaches.Donotallowclienttoblowhisnose;trytopreventsneezing.Noalcoholorsedativesforsleep.Acetaminophenforheadaches.Noexercisingovernext2to3days.Call the doctor if any of the following is noted:• Changeinvision:Blurredordiplopia• Poorcoordination:Walking,grasping• Drainage(serousorbloody)fromthenoseorears• Forcefulvomiting• Increasingsleepiness,moredifficulttoarouse• Slurredspeech• Headachethatdoesnotrespondtomedicationandcontin-
Reye’s SyndromeReye’s syndrome is a rare acute illness that occurs after a viral illness (frequently, after aspirin has been consumed) and results in fatty infiltration of the liver and subsequent liver degeneration and increased intracranial pressure.A. Damaged liver cells no longer adequately convert
E. Decreasestress,anxiety:childmaynotremembereventsbeforethecriticalphase.
Goal: To monitor for and implement nursing actionsappropriateforincreasingICP.
Stroke (Brain Attack)Stroke, or brain attack, is the disruption of the blood supply to an area of the brain, resulting in tissue necrosis and sudden loss of brain function. It is the leading cause of adult disability in the United States.A. Atherosclerosis (see Chapter 16), resulting in cerebro-
a. Thrombotic stroke: formation of a clot thatresults in the narrowing of a vessel lumen andeventual occlusion; accounts for about 80% ofstrokes.(1) Associated with hypertension and diabetes
2. Completestroke(occurssuddenlywithanembolism,more gradually with hemorrhage or thrombosis);manifestations vary according to which cerebralvesselsareinvolved.a. Hemiplegia:lossofvoluntarymovement;damage
to the right sideof thebrainwill result in left-sidedweaknessandparalysis.
b. Aphasia: defect in using and interpreting thesymbolsoflanguage;mayincludewritten,printed,orspokenwords.
c. Maybeunawareoftheaffectedside;neglectsyn-dromeensues.
d. Cranial nerve impairment: chewing, gag reflex,dysphagia,impairedtonguemovement.
e. Maybeincontinentinitially.f. Agnosia:aperceptualdefectthatcausesadistur-
banceininterpretingsensoryinformation;client
FIGURE 20-6 Manifestations of right-brain and left-brain stroke. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)
Right-brain damage(stroke on right side of the brain)
Left-brain damage(stroke on left side of the brain)
• Paralyzed left side: hemiplegia• Left-sided neglect• Spatial-perceptual deficits• Tends to deny or minimize problems• Rapid performance, short attention span• Impulsive, safety problems• Impaired judgment• Impaired time concepts
• Paralyzed right side: hemiplegia• Impaired speech/language aphasias• Impaired right/left discrimination• Slow performance, cautious• Aware of deficits: depression, anxiety• Impaired comprehension related to language, math
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CHAPTER 20 Neurologic System 415
maynotbeabletorecognizepreviouslyfamiliarobjects.
g. Cognitiveimpairmentofmemory,judgment,pro-prioception(awarenessofone’sbodyposition).
h. Hypotonia(flaccidity)fordaystoweeks,followedbyhypertonia(spasticity).
i. Visualdefects.(1) Homonymoushemianopia:lossofsamehalf
B. Immediate treatment (differs depending on whetherthromboticorhemorrhagicstroke).1. Medical.
a. Medicationstodecreasecerebraledema.(1) Osmoticdiuretics.(2) Corticosteroids(dexamethasone).
b. Anticoagulants for thrombotic stroke (neveradministeredtoaclientwithhemorrhagicstroke).
c. Anticonvulsants.
d. Thrombolytictherapyorfibrinolytictherapy(suchas recombinant tissue plasminogen activator(rtPA[Retavase])consideredfornonhemorrhagicstrokes within 3 hours of first manifestation ofstrokesigns.
e. Antihypertensivesandantidysrhythmics.2. Surgical.
a. Carotid endarterectomy, especially for transientischemicattack.
b. Craniotomyforevacuationofhematoma.c. Extracranial-intracranialbypassformildstrokes.
C. Specifictherapiestoresolvephysical,speechoroccupa-tionalcomplications,includinguseofassistivedevices.
stoolsofteners,etc.4. Provide privacy and decrease emotional trauma
relatedtoincontinence.
FIGURE 20-7 Transfer from bed to wheelchair by client with hemiplegia. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 7, Philadelphia, 2005, Saunders.)
EDC
BA
NURSING PRIORITY Protect the client’s affected side: do not give injections on that side, watch for pressure areas when positioning, have client spend less time on affected side than in other positions.
F. Assessforadductionandinternalrotationoftheaffectedarm;maintainarminaneutral(slightlyflexed)positionwitheachjointslightlyhigherthantheprecedingone.
G. Restraintsshouldbeavoidedbecausetheyoftenincreaseagitation.
H. Maintainjointsinpositionofnormalfunctiontopreventflexioncontractures.
I. Assist client out of bed on the unaffected side; thisallowsclient toprovide some stabilizationandbalancewiththegoodside(Figure20-7).
ALERT Mobility: Assist client to ambulate, perform active and passive ROM exercises, assess for complications of immobility, prevent DVT, prevent skin breakdown and encourage independence.
ALERT Assess and manage a client with an alteration in elimination. Establish a toileting schedule; the client who has had a stroke will need assistance in reestablishing a normal bowel and bladder routine.
D. Prevent problems of skin breakdown through properpositioningandgoodskinhygiene.
E. Assistclienttoidentifyproblemsofvision.
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CHAPTER 20 Neurologic System 417
F. Maintainpsychologichomeostasis.1. Clientmaybeveryanxiousbecauseofalackofunder-
J. Evaluate family supportandtheneed forhomehealthservices.
bral aneurysm occurring in the arterial junction of the circle of Willis. A ruptured cerebral aneurysm often results in hemorrhagic stroke.A. Asubarachnoidhemorrhageisapotentiallyfatalcondi-
tion in which blood accumulates below the arachnoidmaterinthesubarachnoidspace;mostoftenoccurssec-ondarytoananeurysm.
B. An aneurysm frequently ruptures and bleeds into thesubarachnoidspace.
C. Symptomsoccurwhenananeurysmenlarges,orwhenit ruptures. As blood collects in the subarachnoidspace, it compresses and damages the surroundingbraintissue.
D. Subarachnoidhemorrhagemayleadtoneurologiccom-promise including seizures, stroke, permanent braindamage,andevendeath.
E. Often, symptoms do not appear until rupture hasoccurred.
H. Surgicalintervention:ligationor“clipping”oftheaneu-rysm to reduce the swellingandminimize the risk forre-bleeding.
I. Procedure to block abnormal arteries or veins andpreventbleeding.
ALERT Assist family to manage care of a client with long-term care needs; determine needs of family regarding ability to provide home care after discharge.
Cerebral Aneurysm, Subarachnoid HemorrhageA cerebral aneurysm occurs when a weakened saccular outpouching of the cerebral vasculature bulges from pres-sure on the weakened tissue. A Berry aneurysm is a cere-
ComplicationsA. IncreasingICPresultinginpermanentbraindamage.B. Visualandhearingdeficits,paralysis.C. Subdural effusion; may be aspirated or allowed to
is identified; place client in a private room (Appendix6-9).
B. Begin administration of IV antibiotics after lumbarpunctureduringwhichCSFsamplewasobtained.
C. Identify family members and close contacts who mayrequireprophylactictreatment.
NURSING PRIORITY If the client survives the rupture of the aneurysm and re-bleeding occurs, it is most likely to occur within the next 24 to 48 hours.
Goal: To assess for and implement nursing measures todecreaseICP(seenursinggoalsforincreasedICP).
Goal: To provide appropriate preoperative nursing inter-ventions(seenursinggoalsforbraintumor).
Goal: To maintain homeostasis and monitor changes inICPaftercraniotomy(seenursinggoalsforcraniotomy).
MeningitisMeningitis is an acute viral or bacterial infection that causes inflammation of the meningeal tissue covering the brain and spinal cord.A. Infectious process increases permeability of protective
fort;clientgenerallyassumesaside-lyingposition.G. Seizureprecautions.H. Preventcomplicationsofimmobility. I. Goodrespiratoryhygiene. J. Measurestodecreasefever.
encephalitisEncephalitis is an inflammatory process of the CNS, or “inflammation of the brain.”
AssessmentA. Riskfactors/etiology.
1. Commonly occurs as a complication after a viralinfection(measles,chickenpox,mumps).
Nursing InterventionsNursinginterventionsforencephalitisarethesameasthosefor meningitis, with the exception of antibiotic therapy.Encephalitisiscausedbyaviralagentandisnotresponsivetoantibiotic therapy;antibiotic therapymaybeorderedtopreventbacterialinfection.
Spinal Cord InjurySpinal cord injury (SCI) is damage to the spinal cord housed inside the spinal column. Most SCIs exist with the spinal cord intact yet compromised from injury or disease. SCI most often occurs as a result of direct trauma to the head or neck area.A. Riskfactors.
culationtothespinalcordisdecreased;hemorrhageandedemaoccur,causinganincreaseintheischemicprocess,which progresses to necrotic destruction of the spinalcord.
C. ConsequencesofSCIdependontheextentofdamage,aswellasthelevelofcordinjury(Figure20-8).1. Thehigherthelesion,themoreseverethesequelae.
a. ClientswithlesionsatC4orhighermayrequireventilatorysupport.
b. LesionsbetweenT1andT8oftenallowuseofthehands.
c. LesionsbelowT8oftenallowupperbodycontrol.2. Complete transection (complete cord dissolution,
completelesion):immediatelossofallsensationand
ALERT Identify changes in client’s mental status; treat client with seizures.
FIGURE 20-8 Spinal cord injury: areas of paralysis. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby.)
voluntary movement below the level of injury;minimal,ifany,returnoffunction.
3. Incomplete(partial).a. Central cord syndrome: center of cord is
damaged; results primarily in impairment ofupperextremities.
b. Damagetoonesideofthecord(Brown-Séquardsyndrome): motor function and position sensemaybepresentononeside;temperatureandsen-sationmaybelostontheoppositeside.
c. Anterior cord damage: disruption of blood flowresultsinamixedlossofsensoryandmotorfunc-tionbelowthelevelofinjury.
D. Spinalcordshock(areflexia):temporarylossordysfunc-tion of spinal reflex activity; occurs predominantly incompletecord lesions; lossof communicationwith thehighercentersofcontrolresultsinflaccidityandlossoffunctionalcontrolbelowthelevelofinjury.1. SCIinterruptssympatheticnerveimpulsetransmis-
sion; parasympathetic impulses are not counter-checked, resulting in vasodilation; loss of venousreturn results in hypotension, which is neurogenicshock.
2. Hypothalamus loses control of body temperature,which assists in vasoconstriction and vasodila-tion.
3. Conditionmaypersist forseveralweeksandreversespontaneously; resolution of spinal shock will beevidentbyreturnofreflexes.
E. AutonomicdysreflexiaoccursinclientswithaninjuryatT6orhigher.1. A noxious stimulus below the level of injury trig-
gers the sympathetic nervous system, which causesa release of catecholamines (epinephrine, norepi-nephrine).
2. Mostcommonstimulicausingtheresponseareafullbladder or bowel, UTI, pressure ulcers, and skinstimulation.
3. Severe hypertension (systolic may be greater than300), nausea, poundingheadache, bradycardia, rest-lessness,flushingpiloerection,andblurredvisionarethemostcommonbodyresponses.
F. Bladderdysfunctionwilloccurasaresultoftheinjury;normalbladdercontrolisdependentonthesensoryandmotor pathways and the lower motor neurons beingintact.1. Neurogenicbladderoccursinclientswithbothupper
andlowermotorneurondisorders.a. Upper motor neuron disorders produce a spastic
orreflexbladder.
b. Lowermotorneurondisorders produce aflaccidbladder.
B. Maintainadequaterespiratoryfunction,asindicated.1. Chestphysiotherapy.2. Incentivespirometry.3. Changingpositionwithinlimitsofinjury.4. Assess for complications of atelectasis, pulmonary
tioningclient.D. Apply antiembolism stockings or elastic wraps to the
legstofacilitatevenousreturn.(Lackofmuscletoneandlossofsympathetictoneintheperipheralvesselsresultin decreases in both venous tone and venous return,whichpredisposeclienttodeepveinthrombosis.)
E. Implementmeasurestopromotevenousreturn.
NURSING PRIORITY Do not hyperextend the neck in a client with a suspected cervical injury. Airway should be opened by the jaw-lift method. Improper handling of the client often results in extension of the damaged area.
5. Maintain in extended position with no twisting orturning;donotremovecervicalcollarorspinalboarduntilareaofinjuryisidentified.
B. Preventcomplicationsofnauseaandvomiting.C. Evaluatebowelsoundsandclient’sabilitytotolerateoral
fluids.D. Increase protein and calories in diet; may need to
decreasecalciumintake.E. Evaluateforpresenceofparalyticileus.F. Increaseroughageindiettopromotebowelfunction.Goal: To prevent complications of immobility (see
C. Anticipateandacceptperiodsofdepressioninclient.D. Encourageindependencewheneverpossible;allowclient
to participate in decisions regarding care and to gaincontroloverenvironment.
ALERT Prevent complications of immobility; prevent venous stasis: identify symptoms of deep venous thrombosis, apply compression stockings, and change client’s position.
ALERT Assess and manage a client with alteration in elimination; initiate a toileting schedule; the client with SCI may need bowel and bladder retraining, depending on level of the injury.
ALERT Plan measures to deal with client’s anxiety and promote client’s adjustment to changes in body image; assist client and significant others to adjust to role changes. Note: These items are all part of the test plan, and the test could include questions about the client with SCI.
E. Encouragefamily involvement in identifyingappropri-atediversionalactivities.
F. Avoidsympathyandemphasizeclient’spotential.G. Initiate frank, open discussion regarding sexual func-
tioning.H. Assistclientandfamilytoidentifycommunityresources. I. Assistclienttosetrealisticshort-termgoals.
Myasthenia GravisMyasthenia gravis is a sporadic, progressive neuromuscu-lar disease characterized by a decrease in the acetylcholine level at the receptor sites in the neuromuscular junction. This inadequate acetylcholine level results in a distur-bance in nerve impulse transmission, causing progressive weakness in skeletal muscles. Myasthenia gravis literally means “grave muscle weakness.”
1. Primaryproblemisskeletalmusclefatiguewithsus-tained muscle contraction; symptoms are predomi-nantlybilateral.a. Muscularfatigueincreaseswithactivity.b. Ptosis (drooping of the eyelids) and diplopia
(doublevision)arefrequentlythefirstsymptoms.(Ophthalmologist may be first contact regardingdysfunction.)
c. Impairmentoffacialmobilityandexpression.d. Impairmentofchewingandswallowing.e. Speechimpairment(dysarthria).f. No sensory deficit, loss of reflexes, or muscular
atrophy.g. Poorbowelandbladdercontrol.
2. Courseisvariable.a. Maybeprogressive.b. Maystabilize.c. May be characterized by short remissions and
exacerbations.
L
CHAPTER 20 Neurologic System 423
3. Myastheniccrisis:anacuteexacerbationofsymptomsthatmayrequireintubationandmechanicalventila-tion to support respiratory effort; caused by majormuscularweaknessandinabilitytomaintainrespira-toryfunction.a. Severerespiratorydistressandhypoxia.b. Increasedpulseandbloodpressure.c. Decreasedorabsentcoughorswallowreflex.
B. Corticosteroids(seeAppendix6-7).C. Plasma electrophoresis (plasmapheresis): separation
of plasma to remove autoantibodies from the blood-stream.
D. Immunosuppressivetherapy.E. Surgicalremovalofthethymus(thymectomy).
Nursing InterventionsClientmaybehospitalizedforacutemyastheniccrisisorforrespiratorytractinfection.Goal: Tomaintainrespiratoryfunction.A. Assess for increasing problems of difficulty breathing.
B. Ifptosisbecomessevere,clientmayneedtowearaneyepatchtoprotectcornea(alternateeyepatchesifproblemisbilateral).
C. Emotionalupset,severefatigue,infections,andexposureto extreme temperatures may precipitate a myastheniccrisis.
Multiple SclerosisMultiple sclerosis (MS) is characterized by multiple areas of demyelination from inflammatory scarring of the neurons in the brain and spinal cord (CNS).A. Theprogressionofthediseaseresultsintotaldestruction
B. Clinicalcourse.1. Relapsing-remitting MS: most common course,
causing sporadic attacks with exacerbations andremissions lasting days to months; client has a sig-nificant“flare-up”orexacerbation,followedbypartialorcompleterecovery.
2. Primary-progressiveMS:afteranumberofyearsofthe relapsing-remitting form, client experiences aslow steady worsening of symptoms without com-plete improvement between exacerbations; plateausofseveritymayoccur,butbaselinefunctionprogres-sivelyworsens.
nervesites.1. Antiinflammatoryagents.2. Immunosuppressiveagents:interferons.3. Adrenocorticotropic hormone for acute exacerba-
tions.
Nursing InterventionsClient may be hospitalized for diagnostic workup or fortreatmentofacuteexacerbationandcomplications.Goal: Tomaintainhomeostasisandpreventcomplications
B. Maintainurinarytractfunction.1. Preventurinarytractinfection.2. Increasefluidintake,atleast2000mL/24hr.3. Evaluate voiding: assess for retention and inconti-
E. Client should understand that relapses are frequentlyassociatedwith an increase inphysiologic andpsycho-logicstress.
ALERT Determine client’s ability to care for self; plan with family to assist client to meet self-care needs.
Guillain-Barré SyndromeGuillain-Barré syndrome is an acute, rapidly progressing motor neuropathy involving segmental demyelination of nerve roots in the spinal cord and medulla. Demyelination causes inflammation, leading to edema, nerve root com-pression, decreased nerve conduction, and rapidly ascend-ing paralysis. Both sensory and motor impairment occur. It is also called Landry’s paralysis.
AssessmentA. Risk factors/etiology: cause is unknown; frequently,
C. If assent of paralysis is rapid, prepare for endotrachealintubationandrespiratoryassistance.
D. Prevent complications of immobility during period ofparalysis(seeChapter3).
E. Assess for involvement of the autonomic nervoussystem.1. Orthostatichypotension.2. Hypertension.3. Cardiacdysrhythmias.4. Urinaryretentionandparalyticileus.
Goal: To prevent complications of hypoxia if respiratorymusclesbecomeinvolved(seeChapter15).
Goal: Tomaintainpsychologichomeostasis.A. Simpleexplanationofprocedures.B. Completerecoveryisanticipated.C. Provide psychologic support during period of assisted
Amyotrophic Lateral SclerosisAmyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a rapidly progressive, invariably fatal degeneration of nerves controlling voluntary muscles. Replacement of motor neurons with fibrous tissues causes hardening of anterior and lateral columns of the spinal cord, thus “lateral sclerosis.”
difficultchoicestheyface.D. Assist family and client to identify need for advanced
directivesandtocompletethem.
Muscular DystrophyMuscle dystrophy (MD) is a group of genetic diseases characterized by progressive weakness and skeletal muscle degeneration affecting a variety of muscle groups. The term pseudohypertrophy describes the characteristic muscle enlargement (caused by fatty infiltration) that occurs in muscular dystrophy.A. Duchenne’s muscular dystrophy is the most common
andmostsevereformofMD.B. Condition is characterized by gradual degeneration of
2. Onset generally occurs between the ages of 3 and5years.
B. Clinicalmanifestations.1. Historyofdelay inmotordevelopment,particularly
adelayinwalking.
NURSING PRIORITY Of the neuromuscular disorders, Guillain-Barré syndrome is the most rapidly developing and progressive condition. It is potentially fatal if unrecognized.
A. Assist parents to understand importance of indepen-dence and self-help skills; frequently, parents areover-protectiveofthechild.
B. Counseling to assist parents and family members toidentify family activities that can be modified to meetchild’sneeds.
C. Mothermayfeelparticularlyguiltybecauseoftransmis-sionofdiseasetoherson.
D. Identifyavailablecommunityresources.E. Counselingtoassistfamilyandchildwithchronicillness
andchild’seventualdeath.
Cerebral PalsyCerebral palsy is a nonprogressive, lifelong neuromuscu-lar genetic disorder resulting from damaged motor centers of the brain that cause nerve impulses to be incorrectly sent and/or received. The overall result is impairment of muscle control with poor muscle coordination.
Nursing InterventionsChildisfrequentlycaredforathomeandonanoutpatientbasisunlesscomplicationsoccur.Goal: To assist child to become as independent and self-
sufficientaspossible.A. Physical therapy program designed to assist individual
childtogainmaximumfunction.B. Assist child to progress according to developmental
level and functional abilities; encourage crawling,sitting, and balancing appropriate to developmentallevel.
C. Assist child to carry out ADLs as age and capacitiespermit.
D. Speechtherapy,asindicated.E. Encourageplayappropriateforage.F. Encourageappropriateeducationalactivities.G. Bowelandbladdertrainingmaybedifficultbecauseof
atedevelopmentallevel.F. Assistparentsinproblemsolvinginhomeenvironment.G. Identifyavailablecommunityresources.H. Utilize principles in caring for chronically ill pediatric
client(Chapter2).
Parkinson’s Disease (Paralysis Agitans)Parkinson’s disease is a progressive neurologic disorder with gradual onset that causes destruction and degenera-tion of nerve cells in the basal ganglia; results in damage to the extrapyramidal system, causing difficulty in control and regulation of movement.A. Dopamine,aneurotransmitter,isresponsiblefornormal
functioningoftheextrapyramidalsystem.B. The condition is correlated with a depletion of or
imbalance in dopamine and increased activity ofacetylcholine.
C. Maintainmusclefunction.1. FullROMtoextremitiestopreventcontracture.2. Decreaseeffectsoftremors.3. Exerciseandstretchdaily.4. Physicaltherapy,asindicated.
D. Closelymonitor response toor changes in response tomedications.
accompanied by dizziness, tinnitus, or lacrimation;associatedwithstressandpremenstrualsyndrome.
2. Migraine:constrictionofintracranialvessels leadingtoan intense throbbingpainwhenvessels return tonormal; prodromal or aura; crescendo quality; uni-lateral pain, often beginning in eye area; nausea,vomiting, photophobia—migraines are seriouslydebilitating and may require lifestyle and occupa-tional changes.
3. Clusterheadache:rareheadachethatismorecommoninmen;occurs innumerousepisodesorclusters;noaura; unilateral pain often arising in nostril andspreadingtoforeheadandeye;oftenoccursatsametimeofday.
C. Encourage client to keep a “headache diary” for bestmanagementandtreatment.
Trigeminal NeuralgiaTrigeminal neuralgia is a fleeting unilateral sensory dis-turbance of cranial nerve V, causing brief, paroxysmal pain and facial spasm; also known as tic douloureux.
AssessmentA. Riskfactors/etiology.
1. Onset generally occurs between 20 and 40 yearsofage.
1. Abruptonsetofparoxysmalintensepaininthelowerandupperjaw,cheek,andlips.a. Tearingoftheeyesandfrequentblinking.b. Facialtwitchingandgrimacing.c. Painisusuallybrief;endsasabruptlyasitbegins.d. Pain may be described as severe, stabbing, and
shock-like.2. Recurrenceofpainisunpredictable.3. Pain is initiated by cutaneous stimulation of the
ALERT Identify situations that necessitate role changes; evaluate family involvement in health care; review necessary modifications to promote home safety.
Goal: Topromoteapositiveself-image.A. Encouragediversionalactivities.B. Assistclienttosetrealisticgoals.C. Explore reasons for depression; encourage client to
HeadacheHeadache is a very common symptom of various underly-ing pathologic conditions in which pain-sensitive nerve fibers respond to unacceptable levels of stress and tension, muscular contraction in the upper body, pressure from a tumor, or increased ICP.
Bell’s PalsyBell’s palsy is a transient cranial nerve disorder affecting the facial nerve (cranial nerve VII), characterized by a dis-ruption of the motor branches on one side of the face, which results in muscle weakness or flaccidity on the affected side.
AssessmentA. Clinicalmanifestations.
1. Lagorinabilitytocloseeyelidonaffectedside.2. Droopingofthemouth.3. Decreasedtastesensation.4. Upward movement of the eyeball when the eye is
Skull and Spine X-Ray Studies Simple x-ray films areobtainedtodeterminefractures,calcifications,etc.Electroencephalography (EEG) Arecordingoftheelectri-calactivityof thebrain tophysiologicallyassesscerebralactivity;usefulfordiagnosingseizuredisorders;usedasascreeningproce-dure for coma; also serves as an indicator for brain death. Mayalso be used to assess sleep disorders, metabolic disorders andencephalitis.Nursing Implications1. Explain to client that procedure is painless and there is no
exam,assistclienttowashelectrodepasteoutofhair.Carotid Doppler Ultrasonography A noninvasive ultra-soundscantoestimatebloodflowincarotidandcerebralvesselstoassessforstenosis.Nopreparationisnecessary.Magnetic Resonance Imaging (MRI) Cellnucleihavemag-netic properties; the MRI machine records the signals from thecellsinamannerthatprovidesinformationtoevaluatesofttissuestructures(tumors,bloodvessels).Nursing Implications1. Procedurewilltakeapproximately1hour.2. Allmetalobjects shouldbe removed from theclient (hearing
aids,hairclips,jewelry,buckles,etc.).3. The client will be placed in a long magnetic tunnel for the
tovisualizethebrainfromdifferentangles.3. Theclientshouldnotexperienceanypain.Caloric Testing Test is performed at bedside by introducingcoldwaterintotheexternalauditorycanal.Itiscontraindicatedintheclientwitharupturedtympanicmembraneandisnotdoneonthe client who is awake. If the 8th cranial nerve is stimulated,nystagmusrotatestowardtheirrigatedear.Ifnonystagmusoccurs,apathologicconditionispresent.Positron Emission Tomography (PET) See Appendix17-1.Lumbar Puncture AneedleisinsertedintothelumbarareaattheL4-L5level;spinalfluidiswithdrawn,andspinalfluidpressureismeasured;contraindicated inpresenceof increased intracranialpressure. Normal spinal fluid values: opening pressure, 60 to150mmwater;specificgravity,1.007;pH,7.35;clearfluid;proteinconcentration, 15 to 45 mg/dL; glucose concentration, 45 to75mg/dL;nomicroorganismspresent.Nursing ImplicationsBefore test
1. Haveclientemptybladder.2. Explain position (lateral recumbent with knees flexed) to
client(Figure20-10).3. Advisephysician if there isachange in theclient’sneuro-
After test1. Keep client flat at least 3 hours, and sometimes up to 12
hours,todecreaseoccurrenceofheadache.2. Encouragehighfluidintake.3. Observe forspinalfluid leakfrompuncturesite; if leakage
occurs,itmayprecipitateasevereheadache.Myelogram An outpatient procedure in which dye is injectedintothesubarachnoidspaceandx-rayfilmsofthespinalcordandvertebralcolumnareobtainedtoidentifyspinallesions.
Appendix 20-1 NEUROLOGIC SYSTEM DIAGNOSTICS
FIGURE 20-10 Lumbar puncture. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 7, Phila-delphia, 2005, Saunders.)
orimmediatelyaftertheexamination.Cerebral Angiogram Injection of contrast material into thecerebralcirculation;seriesofx-rayfilmsistakentostudythecere-bralbloodflow;dye isusually injected via a soft catheter that isinsertedandthreadedthroughthefemoralartery.Nursing ImplicationsBefore test
MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSCholinergic Medications Intensify transmission of impulses throughout the CNS, where acetylcholine is necessary for transmission.
MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAnticholinergics Inhibit action of acetylcholine at sites throughout the body and CNS. Decrease synaptic transmissions in the CNS.
A seizure disorder is the interruption of normal brain function-ing by uncontrolled paroxysmal discharge of electrical stimuli from the neurons.
Classification of SeizuresSimple Partial Seizures (remains conscious throughout seizure)Rarely last longer than 1 minute; an aura may occur before theseizure.1. Confinedtoaspecificarea(hand,arm,leg);clientmayexperi-
Complex Partial Seizures (may have impairment of consciousness)1. Maylooseconsciousnessfor1to3minutes.2. Mayproduceautomatisms(lipsmacking,grimacing,repetitive
handmovements).3. Client may be unaware of environment and wonder what is
happeningatthebeginningoftheseizure.4. In theperiodafter theseizure,clientmayexperienceamnesia
Generalized Seizures (Bilaterally Symmetric and Without Local Onset)Nowarningoraura,asclientlosesconsciousnessforafewsecondstoseveralminutes.1. Absence (petit mal): Characterized by a short period of time
2. Tonic-clonic seizures: May last 2 to 5 minutes. Full recoverymay take several hours; clientmaybe confused, amnesic, andirritableduringthisrecoveryperiod.Tonic phase:Lossofconsciousnesswithstiffeningandrigidity
of muscles. Apnea and cyanosis are common during thisperiod;phasegenerallylastsforabout1minute.
FIGURE 20-11 Tonic-clonic seizure activity. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive out-comes, ed 8, Philadelphia, 2009, Saunders.)
Tonic phase
Clonic phase
Postictal phase
A
B
C
NURSING PRIORITY Airway management and ventilation cannot be performed on a client who is experiencing a tonic-clonic seizure. After the seizure is over, evaluate the airway and initiate ventilations as necessary.
4. Protect the client from injury (risk for falling out of bed orstrikingselfonbedrails,etc).
5. Loosenanyconstrictiveclothing.6. Do not restrain client during seizure activity; allow seizure
movementstooccur,butprotectclientfrominjury.7. Evaluate respiratory status; if vomitingoccurs,beprepared to
suctiontheclienttocleartheairwayandpreventaspiration.8. Maintain calm atmosphere and provide for privacy after the
seizureactivity.9. Reorientclient.
ALERT Report characteristics of a client’s seizure; determine changes in client’s neurologic status.
Client Education1. Identifyactivities/eventsthatprecipitatetheseizureactivity.2. Avoidalcoholintake,fatigue,andlossofsleep.3. Takemedicationsasdirected.4. Counseling for the familyand for theclient toassist themin
Aphasia is a total loss of comprehension and use of language. Dysphasia is the difficulty related to the comprehension or use of language and is due to a partial disruption or loss; patterns of dysphasia differ because the stroke affects different parts of the brain. The condition is precipitated by a problem in the cerebral cortex. The most common cause of aphasia is a vascular problem involving the middle cerebral artery. The
Appendix 20-6 APHASIA
speech center is located in the dominant side of the cerebral hemisphere. The speech center for a right-handed person is located in the left cerebral hemisphere. Clients with aphasia are often frustrated and irritable. Emotional lability is common. Accept the behavior in a manner that prevents embarrassment for the client.
TYPES OF APHASIA NURSING IMPLICATIONSSensory aphasia (receptive or fluent, Wernicke’s area):Cannot
Study Questions Neurologic System More questions on companion CD!
1. The nurse is obtaining a health history from a clientwho states he is having pain in his left arm. Whichquestionbythenursewillelicitthemostusefulresponsefromtheclient?1 “Does the pain feel like pins and needles in your
3. Thenurse is caring for a clientwhohashad a right-sided stroke.Whatwouldbeappropriatenursingcareforthisclient?1 PerformingpassiveROMexercisestoaffectedside,
activeROMonunaffectedside2 Placing food on the affected side of the client’s
mouth3 Applying hot packs to the right leg to decrease
5. Aclientwhohashadastrokeisaphasic;ithasbeenaweek since his stroke. He is beginning to show func-tional improvement and demonstrates an ability tofollow verbal directions.What will rehabilitation nowinclude?1 Aright-legbrace2 Ambulationtraining3 Speechtraining4 Vocationalretraining
6. Thenurseiscaringforaclientwhoisdoingwellafterhiscraniotomy.Whatwillthebowelcareforthisclientinclude?1 An enema every other day to avoid the Valsalva
maneuver2 High-fiber diet and stool softeners to prevent
constipation3 Low-residue diet to decrease stool formation and
preventconstipation4 Daily checking for impaction caused by loss of
bowelinnervation
7. After a grand mal seizure, what nursing action is thehighestpriority?1 Loosenorremoveconstrictingclothingandprotect
clientfrominjuringhimselforherself.2 Maintainapatent airwayby turning the clienton
10. When obtaining a health history, the nurse expects aclientwitharecentdiagnosisofParkinson’sdiseasetoreportwhichsignorsymptom?1 Weightloss2 Slownessofmovement3 Continualmotortremors4 Depression
12. Pneumonia is a common problem in children withspastic cerebral palsy.Thenurseunderstands that thisoccursbecause:1 Thereisanassociateddysfunctionoftherespiratory