NURS 1130 Adult Nursing III Unit I Chapters 27, 28, 29 Teresa Champion, RN, MSN 9/2012.

NURS 1130Adult Nursing III

Unit IChapters 27, 28, 29

Teresa Champion, RN, MSN 9/2012

Chapter 27

Neurologic Disorders

Anatomy and Physiology of the Nervous System

Neuron (Nerve Cell)

Functional unit of the nervous system that conducts electrical impulses from one area of the brain to another

Sensory neurons Transmit information from distal parts of the

body or environment toward the central nervous system

Motor neurons Carry motor information from the CNS to the

periphery

Axons and Dendrites

Branch off the main cell body Axons conduct impulses away from

the cell body Dendrites convey impulses toward

the cell body

Myelin Material that covers many axons and

dendrites Enhances conduction along nerve

fibers Gives the axons a white appearance;

cell bodies without myelin are gray

Figure 27-1

Central Nervous System (CNS)

Made up of the brain and spinal cord

Peripheral Nervous System

Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves

Brain

Divided into the cerebrum, cerebellum, and brainstem

Cerebrospinal Fluid (CSF)

Composed of water, glucose, sodium chloride, and protein

Acts as a shock absorber for the brain and spinal cord

Figure 27-2

Spinal Cord

Extends from the border of the first cervical vertebra (C1) to the level of the second lumbar vertebra (L2)

Thirty-one pairs of spinal nerve roots exit the spinal cord, each consisting of a posterior sensory (afferent) root and anterior motor (efferent) root

These roots, along with the 12 cranial nerves, make up the peripheral nervous system

Autonomic Nervous System

Controls the involuntary activities of the viscera, including smooth muscle, cardiac muscle, and glands

Two major subdivisions: sympathetic nervous system and the parasympathetic nervous system

Age-Related Changes

The number of nerve cells decreases Brain weight is reduced; ventricles increase in size Lipofuscin: aging pigment deposited in nerve cells

with amyloid, a type of protein Increased plaques and tangled fibers in nerve tissue Eye pupil often smaller; may respond to light more

slowly Reflexes intact except for Achilles tendon jerk, which

is often absent Reaction time increases, especially complex

reactions Tremors in the head, face, and hands are common Some develop dizziness and problems with balance

Pathophysiology of Neurologic Diseases

Types of Disorders

Developmental and genetic Trauma Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders

Nursing Assessment of Neurologic Function

Health history Note speech, behavior, coordination, alertness,

comprehension Chief complaint and history of present illness

Document what prompted the patient to seek medical attention

Describe any injuries If patient has pain, note the onset, severity, location,

and duration Past medical history

Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer

Record dates and types of immunizations


Family history Have immediate family members had heart

disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or Huntington’s disease?

Review of systems Fatigue or weakness, headache, dizziness,

vertigo, changes in vision/hearing, tinnitus, drainage from ears or nose, dysphasia, neck pain or stiffness, vomiting, bladder or bowel function, sexual dysfunction, fainting, blackouts, tremors, paralysis, incoordination, numbness or tingling, memory problems, mood changes


Functional assessment Document whether present symptoms interfere

with the patient’s usual activities and occupation Explore sources of stress, usual coping

strategies, and sources of support Physical examination

Level of consciousness, pupillary evaluation, neuromuscular response, and vital signs


Level of Consciousness: 1. Anxious, agitated, combative – hyper-stimulated2. Somnolence – unnatural drowsiness or sleepiness3. Lethargy – like Somnolence, is excessive

drowsiness4. Stupor – decreased responsiveness with a lack of

spontaneous motor activity5. Semi-comatose – decreased responsiveness, no

spontaneous motor activity (stuporous) but can be aroused usually with noxious or painful stimuli

6. Comatose (Coma) – not responsive, not spontaneous motor activity and cannot be aroused with even painful stimuli

Diagnostic Tests and Procedures Advanced neurologic examination

Cranial nerves Coordination and balance Neuromuscular function Sensory function

Pain Temperature Light touch Vibration Position Tactile discrimination

Figure 27-5

Figure 27-6

Figure 27-7

BABINSKI REFLEX – B) negative Babinski – normal for adults C) positive Babinski – abnormal for adults

Diagnostic Tests and Procedures

Lumbar puncture Electroencephalography Electromyography Radiologic studies

Brain scan Cerebral angiography and digital subtraction

angiography Computed tomography Magnetic resonance imaging

Figure 27-8

Figure 27-9

Figure 27-10

Figure 27-11

Common Therapeutic Measures Drug therapy

Antimicrobials Analgesics Anti-inflammatory Corticosteroids Anticonvulsants Diuretics Chemotherapeutic agents Dopaminergics Anticholinergics Cholinergics Antihistamines

Common Therapeutic Measures

Surgery Craniotomy

Surgical opening of the skull Craniectomy

Excision of a segment of the skull Cranioplasty

Any procedure done to repair a skull defect

Increased Intracranial Pressure (ICP)

Normal ICP is 0-15 mmHg (averages 10-15) Brain, Blood, Cerebral Spinal Fluid are

factors of ICP All must remain normal, if one factor increases

ICP will rise; unless the other two factors have a decrease.

When ICP increases, blood perfusion to brain decreases.

Assessment for Signs and Symptoms of Increasing ICP

Level of consciousness (most reliable), pulpillary characteristics, motor function, sesnory function, vital signs.

Abnormal motor function called posturing as ICP increases: Decorticate – abnormal flexation Decerebriate – abnormal extension (worse)

Cushing’s Triad – Life threatening signs!

Assessment for Signs and Symptoms of Increasing ICP

Cushing’s Triad - Hypertension with widening pulse pressure

Irregular, shallow respirations Bradycardia

Treating Increasing ICP

Positioning – Head of Bead no more than 30 Hyperventilation Fluid Management Mechanical drainage (ventriculostomy) Drug Therapy – Mannitol drug of choice,

diuretic helps decrease ICP, increases UO

External Ventriculostomy Drain

Disorders of the Nervous System

Migraine Headache

Intracranial vasoconstriction followed by vasodilation Triggered by menstruation, ovulation, alcohol, some

foods, stress Pain usually unilateral, often begins in the temple or

eye area and is very intense Tearing and nausea and vomiting may occur Hypersensitive to light and sound; prefers dark, quiet

environment Mild migraines treated with acetaminophen or aspirin;

severe ones with ergotamine (Cafergot) or sumatriptan (Imitrex) tablet or auto injector for self-injection

Cluster Headache

Occur in a series of episodes followed by a long period with no symptoms

Intensely painful and seem to be related to stress or anxiety

Usually have no warning symptoms Treatment may include cold application,

indomethacin (Indocin), and tricyclic antidepressants

Tension Headache

Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources, such as a brain tumor or an abscessed tooth

Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing

Treatment: correction of known causes, psychotherapy, massage, heat application, and relaxation techniques

Analgesics, usually nonopioid, may be prescribed to reduce anxiety

Seizure Disorder

Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior

Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors

Medical diagnosis Accurate history of the seizure disorder Electroencephalogram (EEG)

Seizure Disorder

Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior

Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors

Medical diagnosis Accurate history of the seizure disorder Electroencephalogram (EEG)

Seizure Disorder: Classification

Partial seizures Simple

Part of one cerebral hemisphere; consciousness not impaired

Complex Consciousness impaired; may exhibit bizarre behavior

Generalized seizures Involve the entire brain from the onset Consciousness lost during the ictal (seizure) period Types: tonic-clonic, absence, myoclonic, and atonic

Seizure Disorder: Phases of generalized tonic-clonic seizure (grand

mal) Tonic phase Loss of consciousness, falling, crying and

generalized stiffness. Clonic phase

Jerking of the limbs Salivary frothing

Postictal phase Deep sleep, extreme tiredness Headaches, confusion, irritability, vomitting

Seizure Disorder

Status epilepticus Medical emergency: continuous seizures or repeated

seizures in rapid succession for 30 minutes or more Aura

Dizziness, numbness, visual or hearing disturbance, noting an offensive odor, or pain may precede a seizure minutes to seconds before a seizure.

Medical treatment Resolution of the underlying condition Anticonvulsant drug therapy

Seizure Disorder

Surgical treatment Removal of seizure foci in the temporal lobe and

pallidotomy or vagal nerve stimulator

Seizure Disorder: Nursing Care

Assessment Describe the seizure episode, including the

postictal period (following the seizure), and document drug therapy

Seizure Disorder: Nursing Care

Risk for Injury Side rails of bed up and padded, suction

machine readily available, bed maintained in the low position

Quickly move objects away from the patient Do not attempt to restrain the patient

Ineffective Coping and Deficient Knowledge Teach family and patient about the seizure

disorder and the therapy Teaching must be directed toward helping the

patient and family adjust to a chronic condition Encourage questions and concerns

Head Injury: Types

Scalp injuries Lacerations, contusions, abrasions, and

hematomas Concussion

Trauma with no visible injury to the skull or brain Contusion

Bruising and bleeding in the brain tissue Hematoma

Subdural hematoma or epidural hematoma Intracerebral hemorrhage

From lesions within the tissue of the brain itself Penetrating injuries

Sharp objects penetrate the skull and brain tissue

Head Injury

Surgical treatment Directed at evacuating hematomas and

débriding damaged tissue

Head Injury: Nursing Care

Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Risk for Injury Risk for Infection Impaired Physical Mobility Disturbed Body Image and Ineffective Role

Performance

Brain Tumors

Etiology and risk factors Some congenital; others may be related to heredity Drug/environmental factors may play a role in development

Signs and symptoms Directly related to area of brain invaded by the tumor Visual disturbances and headache New-onset seizure activity Difficulties with balance and coordination

Medical treatment Surgery often followed by radiation with or without

chemotherapy

Brain Tumors: Nursing Care

Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping

Meningitis

Etiology and risk factors Inflammation of the meningeal coverings of the

brain and spinal cord caused by either viruses or bacteria

Signs and symptoms Headache, nuchal rigidity (stiffness of the back of

the neck), irritability, diminished level of consciousness, photophobia (sensitivity to light), hypersensitivity, and seizure activity

Positive Kernig’s sign and Brudzinski’s sign Medical diagnosis

Lumbar puncture to obtain CSF for lab analysis

Figure 27-16A

KERNIG’S SIGN – when leg is flexed at the knee the patient will not be able to extend the same leg

http://www.youtube.com/watch?v=rJ-5AFuP3YA

http://www.youtube.com/watch?v=rJ-5AFuP3YA

Figure 27-16B

BRUDZINSKI REFLEX – bend up head (flex neck) and hip flexes

http://www.youtube.com/watch?v=jO9PAPi-yus&feature=endscreen&NR=1

http://www.youtube.com/watch?v=jO9PAPi-yus&feature=endscreen&NR=1

Meningitis

Medical treatment Bacterial infections usually respond to

antimicrobial therapy, but no specific drugs effective against most viral infections

Anticonvulsants used to control seizure activity if necessary

Meningitis: Nursing Care

Assessment Assess vital signs and neurologic status

frequently to determine further deterioration or onset of complications

Meningitis: Nursing Care

Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Acute Pain Risk for Injury Deficient Fluid Volume

Encephalitis Etiology and risk factors

Inflammation of brain tissue caused by virus Signs and symptoms

Fever, nuchal rigidity (stiff neck), headache, confusion, delirium, agitation, and restlessness commonly seen

Comatose or exhibit aphasia, hemiparesis, facial weakness, and other alterations in motor activity

Medical treatment Enhance patient comfort and increase strength Because seizure activity is a potential problem,

take appropriate safety precautions

Encephalitis: Nursing Care

The nursing plan of care parallels that of the patient with meningitis

Guillain-Barré Syndrome

Etiology and risk factors Although specific cause unknown, it is believed

to be an autoimmune response to a viral infection

Patients often report some recent viral infection or vaccination


Initial phase Symmetric muscle weakness: begins in lower

extremities; ascends to trunk and upper extremities

Visual and hearing disturbances, difficulty chewing, and lack of facial expression

Mild paresthesias or anesthesia in feet and hands in a glove or stocking distribution pattern

Hypertension, orthostatic hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention


Plateau phase Remains essentially unchanged No further neurologic deterioration, but no

improvement either Recovery phase

Remyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes)


Medical diagnosis Characteristic onset and pattern of ascending

motor involvement Elevated protein level in the CSF Nerve conduction velocity studies reveal slowed

conduction speed in the involved nerves


Medical treatment Preserve vital function, particularly respiration Respiratory status is closely monitored and

mechanical ventilation initiated if vital capacity falls to 15 mL/kg of body weight

Massive doses of corticosteroids prescribed to suppress the inflammatory process

Plasmapheresis

Guillain-Barré Syndrome: Nursing Care

Assessment Health history describes the progression of

symptoms Note fears, coping strategies, and sources of

support Physical examination focuses on cranial nerve,

motor, respiratory, and cardiovascular function

Guillain-Barré Syndrome: Nursing Care

Interventions Ineffective Breathing Pattern Decreased Cardiac Output Risk for Disuse Syndrome Imbalanced Nutrition: Less Than Body

Requirements Anxiety Deficient Knowledge Rehabilitation

Parkinson’s Syndrome

Etiology and risk factors Progressive degenerative disorder of the basal

ganglia: an eventual loss of coordination and control over involuntary motor movement

Signs and symptoms Tremor, rigidity, and bradykinesia Loss of dexterity and power in affected limbs,

aching, monotone voice, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, reduced blinking, and slumped posture

Depression common; dementia may develop

Figure 27-17

Parkinson’s Syndrome

Medical diagnosis From health history and physical examination MRI to rule out other causes of the symptoms

Medical treatment Control symptoms: physical therapy and drug

therapy Massage, heat, exercise, and gait retraining Dopamine receptor agonists pramipexole (Mirapex) or

ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine); carbidopa/levodopa (Sinemet); anticholinergic drugs such as trihexyphenidyl (Artane) and benztropine (Cogentin)

Parkinson’s Syndrome: Nursing Care Assessment

Weakness, fatigue, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements

Note lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination

Interventions Impaired Physical Mobility Risk for Injury Imbalanced Nutrition: Less Than Body Requirements Ineffective Coping Deficient Knowledge

Multiple Sclerosis Etiology

Chronic, progressive degenerative disease Attacks the protective myelin sheath around

axons and disrupts the conduction of impulses through the CNS Chronic, progressive MS: progresses steadily Exacerbating-remitting MS: exacerbations and

remissions Relapsing-progressive MS: less stable periods than

exacerbating-remitting Stable MS: stable; no active disease for a year

Exact cause of MS is unknown; viral infections and autoimmune processes have been implicated

Multiple Sclerosis

Signs and symptoms Fatigue, weakness, and tingling in one or more

extremities; visual disturbances; problems with coordination; bowel and bladder dysfunction; spasticity; and depression

Figure 27-18

Multiple Sclerosis

Medical diagnosis Based on the physical examination and history of

cyclic remission-exacerbation periods Magnetic resonance imaging of the brain and

spinal cord may reveal plaques characteristic of MS

Multiple Sclerosis

Medical treatment Corticosteroids (ACTH, prednisone,

methylprednisolone) Interferon 1b (Betaseron) and interferon 1a

(Avonex) Glatiramer acetate (Copaxone) Immunosuppressants: mitoxantrone

(Novantrone) Amantadine (Symmetrel) Urinary retention treated with cholinergics, such

as bethanechol (Urecholine) or neostigmine (Prostigmine)

Multiple Sclerosis: Nursing Care

Assessment Onset and progression of symptoms, especially

those that affect mobility, vision, eating, and elimination

Range of motion and strength, gait abnormalities, tremors, and muscle spasms

Multiple Sclerosis: Nursing Care

Interventions Impaired Physical Mobility Disturbed Sensory Perception Self-Care Deficit Functional Urinary Incontinence Risk for Infection Ineffective Coping Deficient Knowledge

Amyotrophic Lateral Sclerosis (ALS)

Etiology Also known as Lou Gehrig’s disease; a

degenerative neurologic disease Virus suspected, but exact cause unknown

Pathophysiology Degeneration of the anterior horn cells and the

corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms

ALS

Signs and symptoms Weakness of voluntary muscles of the upper

extremities, particularly the hands Difficulty swallowing and speaking Eventually, respirations shallow; difficulty

clearing airway of pulmonary secretions Death results from aspiration, respiratory

infection, or respiratory failure

ALS

Medical diagnosis History and physical examination findings Electromyography

Medical treatment Because no known cure or treatment, therapy is

supportive; focuses on preventing complications and maintaining maximum function

ALS: Nursing Care

Assessment Dyspnea, dysphagia, muscle cramps, weakness,

twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis

ALS: Nursing Care

Interventions Ineffective Airway Clearance Impaired Physical Mobility Imbalanced Nutrition: Less Than Body

Requirements Impaired Verbal Communication Impaired Skin Integrity Anticipatory Grieving Situational Low Self-Esteem Interrupted Family Processes

Huntington’s Disease

Inherited degenerative neurologic disorder Usually begins in middle adulthood with

abnormal movements, emotional disturbance, and intellectual decline

Symptoms progress steadily: increasing disability and death in 15 to 20 years

Medical and nursing care are supportive only; there is no cure

Myasthenia Gravis

Etiology May have an autoimmune basis

Pathophysiology Insufficient receptor sites at the junction of the

motor nerve with the muscle With repeated stimulation, muscle becomes

exhausted; eventually unable to contract at all If respiratory muscles involved, death from

respiratory insufficiency or arrest possible

Myasthenia Gravis

Signs and symptoms Weakness of voluntary muscles, particularly

those of chewing, swallowing, and speaking Partial improvements of strength with rest Dramatic improvement with the use of

anticholinesterase drugs Ptosis and diplopia commonly seen

Myasthenia Gravis

Medical diagnosis Administering edrophonium (Tensilon)

Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes

Medical treatment Anticholinesterase drugs

Neostigmine and pyridostigmine (Mestinon)

Corticosteroids Cytotoxic therapies Thymectomy Plasmapheresis

Myasthenia Gravis: Nursing Care

Assessment Health history describes the onset of symptoms:

muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance

Interventions Ineffective Breathing Pattern Impaired Physical Mobility and Self-Care Deficit Impaired Swallowing Deficient Knowledge

Chapter 28

Cerebrovascular Accident

Cerebrum

Complex functions: initiation of movements, recognition of sensory input, higher-order thinking, regulating emotional behavior and endocrine and autonomic functions

Divided into two halves: hemispheres Each hemisphere controls the opposite side of

the body: the right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body

The cortex of each is divided into the parietal, frontal, temporal, and occipital lobes; each has a different area of function

Figure 28-1

Cerebrum

Brainstem Includes midbrain, pons, medulla, and part of the

reticular activating system Controls vital, basic functions, including

respiration, heart rate, and consciousness

Cerebellum

Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate movement, balance, and posture

Unlike the cerebrum, the right side of the cerebellum controls the right side of the body, and the left side of the cerebellum controls the left side of the body

Circulation

Carotid system Begins as one common artery; later divides into

the external and internal carotid arteries The external carotid arteries divide to supply blood

to the face The internal arteries further divide into the middle

cerebral artery and the anterior cerebral artery to supply blood to the brain

Circulation

Vertebral arteries Originate from the subclavian artery, travel up

the anterior neck to merge and form the basilar artery at the brainstem

Second division forms posterior cerebral artery Internal carotid and vertebrobasilar arteries

unite to form the circle of Willis

Figure 28-2

Risk Factors for Stroke

Nonmodifiable factors Risk factors that cannot be changed

Age, race, gender, and heredity

Modifiable factors Those that can be eliminated or controlled

Transient Ischemic Attack

Temporary neurologic deficit caused by impairment of cerebral blood flow

Blood vessels occluded by spasms, fragments of plaque, or blood clots

Important warning signs for the individual experiencing a full stroke


Signs and symptoms Dizziness, momentary confusion, loss of speech,

loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body

Medical diagnosis Health history, physical examination findings, and

results of brain imaging studies Laboratory studies, electrocardiography (ECG),

duplex ultrasonography, and cerebral angiography


Medical treatment Depends on the location of the narrowed vessel

and the degree of narrowing Acetylsalicylic acid (aspirin), ticlopidine

hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping

Warfarin (Coumadin) and heparin Carotid endarterectomy and transluminal

angioplasty

Figure 28-3

Stroke

An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours

Stroke: Pathophysiology

Hemorrhagic stroke (20%) Blood vessel in brain ruptures; bleeding into the

brain occurs Ischemic stroke (80%) – most common

Obstruction of blood vessel by atherosclerotic plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain

Figure 28-4

Stroke: Pathophysiology

Common locations of Hemorrhagic stroke: Intracerebral - within the cerebrum

Subdural – between dura and skull Subarachnoid – between arachnoid and pia matter Ventricular

Ischemic stroke (80%) – most common Obstruction of blood vessel by atherosclerotic

plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain

Stroke: Signs and Symptoms

Hemorrhagic stroke Occurs suddenly; may include severe

headache described as “the worst headache of my life”

Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures

Ischemic Strokes: Thrombotic – plaque build up causing narrowing Embolic – dislodged thrombi of plaque, blot clot

and occludes cerebral arteries


CARDINAL SIGNS OF STROKE: 1. Numbness or weakness of the face, arm or leg,

especially on one side of the body. visual problems,

2. Sudden confusion, trouble speaking or understanding

3. Sudden trouble seeing in one or both eyes4. Sudden trouble walking, dizziness, loss of balance

or coordination. 5. Sudden severe headache with no known cause.

Strokes:

Some additional terminology: Stroke in evolution – s/s of stroke are still present Stroke completed – s/s of stroke may or not be

present but neurological status is stabilized

Luncar Stroke – Ischemic type stroke from occlusions of small arteries deep in brain. These are less severe strokes and usually have no or less-pronounced neurological changes.

Figure 28-5


Aphasia A defect in the use of language; speech, reading, writing, or

word comprehension Dysarthria

The inability to speak clearly Dysphagia

Swallowing difficulty Dyspraxia

The partial inability to initiate coordinated voluntary motor acts Hemiplegia

Defined as paralysis of one side of the body

Figure 28-8

Perceptual Disturbances in hemiplegia


Sensory impairment Unable to feel touch, pain, or temperature in affected body

parts Unilateral neglect

Do not recognize one side of the body as belonging to them Homonymous hemianopsia

Perceptual problem: involves loss of one side of field of vision Elimination disturbances

Neurogenic bladder Flaccid bladder Bowel incontinence

Medical Diagnosis

Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance imaging, carotid ultrasound studies, cerebral and carotid angiography, electrocardiography, positron-emission tomography, and single-photon emission computed tomography

Complications

Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis, decubitus ulcers, and pneumonia

Sensory losses put patient at risk for traumatic and thermal injuries

Swallowing difficulties place patient at risk for pulmonary complications, such as choking and aspiration pneumonia

Prognosis

Prognosis for TIA or stroke increasingly hopeful Critical variables for recovery: patient’s condition

before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy

Long-term recovery may depend on the care received immediately after the stroke

Most recovery takes place in the first 3-6 months, but progress often continues long after that

Medical Treatment in the Acute Phase

Begins with the onset of signs and symptoms and continues until vital signs, particularly blood pressure and neurologic condition, stabilize

This phase usually lasts 24 to 48 hours Many medical management interventions

are directed at minimizing complications and deterioration of the patient’s condition after a stroke


Major focus areas Hypertension Oxygenation Hyperthermia Hyperglycemia

Drug therapy Tissue plasminogen activator (rt-PA, alteplase,

Activase) Given to dissolve clots in acute ischemic strokes


Other medications Mannitol Nimodipine (Nimotop) Phenytoin (Dilantin) and phenobarbital Acetylsalicylic acid (aspirin), ticlopidine

hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)


Surgical intervention An option for some patients with hemorrhagic

strokes Decisions about surgery are based on patient’s

age, intracranial pressure, and location of the hemorrhage


Fluids and nutrition Intravenous fluids Dietary order based on patient’s nutritional

requirements and ability to eat Regular, soft, or pureed

Total parenteral nutrition may be ordered for the malnourished patient


Urine elimination Indwelling catheter to manage urinary

incontinence Intermittent catheterization: controlling

incontinence caused by a flaccid bladder

Doctor Emergency Department

Door to Doctor = 10 minutes

Door to non-contrast CT or MRI

= 25 minutes

Emergency Department Timeline to Suspected Stroke:

Door to non-contrast CT or MRI

completed and read = 45 minutes

Door to Drug/Admission = 60 MIN

Emergency Department Timeline to Suspected Stroke:

60 MIN

<3hours from symptom onset to be a canidate for

drug (tPA). (could go up to 4.5 hours but outcomes are not as good).

o Glasgow Coma Scale or GCS is a neurological scale used for recording the conscious state of a person .

o Score between 3 (indicating deep unconsciousness) or 15 (fully conscious).

o Today, it is the most used scale on both acute medical and trauma patients.

GLASCOW COMA SCALE (GCS) - ADULT

• A tool often used to assess patients who have experienced a stroke, by use of a point system• Addresses: Motor Function, Visual Fields, Ataxia,

Speech, Language, Cognition and Motor and Sensory Abnormalities.

• Most facilities, especially those that have accreditation as a Stroke Center, require those that

administer the NIH Stroke Scale Examination to be Certified to ensure consistency among examiners.

• See page 504, Table 28-4, in your book for a condensed version of the NIH Stroke Scale.

National Institutes of Health (NIH) Stroke Scale

Nursing Care in the Acute Phase

Assessment Evaluate type and extent of the stroke: time of

onset, symptoms, other details Cincinnati Pre-hospital Stroke Scale

Health history Chief complaint and history of present illness Medical history Family history Review of systems Functional assessment


Physical examination Assess patient’s general appearance,

responsiveness, and behavior Record restlessness or agitation Measure vital signs; weight and height if possible Inspect the face for symmetry; mouth for

moisture and drooling Evaluate the alert patient’s ability to swallow Inspect pupils for size, equality, and reaction to

light


Physical examination Conduct a gross vision assessment Inspect skin color and palpate for moisture and

turgor Assess extremities for muscle tone and strength,

sensation, and voluntary movement Record evidence of incontinence or bladder

distention Frequently repeat neurologic checks: evaluating level

of consciousness, pupil appearance and response to light, the patient’s ability to follow commands, and the movement and sensation of extremities


Interventions Ineffective Airway Clearance and Ineffective

Breathing Patterns Risk for Injury Deficient Fluid Volume or Excess Fluid Volume Imbalanced Nutrition Disturbed Sensory Perception Ineffective Thermoregulation Disturbed Thought Processes


Interventions Impaired Verbal Communication Impaired Physical Mobility Total or Functional Urinary Incontinence Constipation and/or Bowel Incontinence Ineffective Coping Interrupted Family Processes

Nursing Care in the Rehabilitation Phase

Assessment Reassess patient’s abilities, expectations,

knowledge, motivation, and resources

Nursing Care in the Rehabilitation Phase

Interventions Self-Care Deficit Risk for Injury Ineffective Coping Impaired Verbal Communication Imbalanced Nutrition Impaired Physical Mobility Constipation Total and Functional Urinary Incontinence

Figure 28-6

Figure 28-7

Figure 28-9

Discharge

Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy

Outpatient therapy is an option for some patients

When able, patients are transitioned back into the home setting

Essential to include family, friends, and significant others in this process

Discharge

During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities

In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible

Chapter 29

Spinal Cord Injury

Anatomy and Physiology of the Spinal Cord

Vertebral Column

Consists of 33 vertebrae 7 cervical (C1 through C7) 12 thoracic (T1 through T12) 5 lumbar (L1 through L5) 5 sacral (S1 through S5) 4 fused coccygeal

Figure 29-1

Vertebral Column

Each vertebra consists of a body and an arch

The spinal cord passes through an opening in the center of each arch

Each arch has articulating surfaces against which adjacent vertebrae smoothly glide with movement

The bony column is supported by muscles and ligaments, which permit mobility and flexibility

Disks

Vertebrae separated by disks which serve as shock absorbers for the vertebral column

Composed of anulus fibrosus and nucleus pulposus anulus fibrosus: ring of tissue; encircles nucleus

pulposus Nucleus pulposus: saclike structure with a

gelatinous filling that has a high water content

As we age, nucleus pulposus loses much of its water; less effective as a shock absorber

Figure 29-2

Spinal Cord

Extends from the brainstem to L2 in pelvic cavity Surrounded by three protective meningeal layers

Dura mater Outermost layer

Arachnoid Middle layer: spaces containing cerebrospinal fluid

(CSF) Pia mater

Innermost layer: directly covers the spinal cord CSF circulates through the brain and spinal column,

bathing and protecting the entire central nervous system

Figure 29-3

Spinal Cord

Gray matter Consists of the bodies of nerve cells that control

motor and sensory activities White matter

Myelinated (surrounded by a sheath); consists of bundles of fibers

Convey information between the brain and the spinal cord

Tracts may be ascending or descending

Figure 29-4

Spinal Cord

Blood supply Major arterial supply to the spinal cord; consists

of the vertebral arteries posteriorly and the anterior spinal artery

Reflexive activity The sensory stimulus is received, and a response

is initiated at the level of the spinal cord

Spinal Cord

Relay activity Stimulus enters spinal cord; travels up ascending

tracts to relay sensory signals to the brain Information processed in the brain; responses

initiated by impulses transmitted to the body by way of descending tracts

Information conveyed to brain and spinal cord via peripheral nervous system


Neurologic examination Initial evaluation of the spinal cord: injured

patient provides the nurse with a baseline assessment of function and problems

Ongoing assessment necessary to monitor the effects of neurologic injury, detect related complications, and determine patient’s need for assistance in activities of daily living

Focuses on the motor and sensory systems


Imaging studies Radiography

Detects vertebral compression, fractures, or problems with alignment

Computed tomography (CT) Noninvasive examination of the specific levels of the

spinal cord to be visualized, bony vertebrae, and the spinal nerves

Magnetic resonance imaging (MRI) Produces precise, clear images of internal structures

Myelogram Visualizes the spinal cord and vertebrae

Pathophysiology of Spinal Cord Injury

Types of Injuries

Location Cervical, thoracic, or lumbar

Open or closed Closed: trauma in which the skin and meningeal

covering that surround the spinal cord remain intact Open: damage to the protective skin and meninges

Extent of damage to the cord Complete spinal cord injury occurs when the cord has

been completely severed, whereas an incomplete injury results from partial cutting of the cord

Effects of Spinal Cord Injury

Factors include extent of cut and level of injury

Sometimes cannot be fully determined because the symptoms of spinal cord edema may mimic partial or complete transection

With incomplete spinal cord injuries some function remains below the level of the injury Specific tracts may be involved, causing particular

patterns of neurologic dysfunction

Figure 29-6

Effects of Spinal Cord Injury

The higher the level of injury, the more encompassing the neurologic dysfunction

Quadriplegia High cervical spine injuries; loss of motor and

sensory function in all four extremities Paraplegia

Injuries at or below T2 may cause paralysis of the lower part of the body

Respiratory Impairment

Injuries at or above the level of C5 may result in instant death because the nerves that control respiration are interrupted

Cervical injuries below the level of C4 spare the diaphragm but can involve impairment of intercostal and abdominal muscles

Spinal Shock

An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases

Autonomic Dysreflexia

Exaggerated response of autonomic nervous system to noxious (painful) stimuli

With injury at or above the level of T6 The sympathetic nervous system is

stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system

Autonomic Dysreflexia

Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes

Spasticity

Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation

Impaired Sensory and Motor Function

Impaired motor function can affect the patient’s mobility and self-care and thus result in complications from immobility

Loss of sensation puts patient at risk for skin breakdown and other injuries because pressure and pain are not perceived

Impaired Bladder Function

During spinal shock, all bladder and bowel function ceases

Once spinal shock resolves, reflex activity returns

Impaired Bowel Function

Most spinal cord–injured patients can maintain bowel function because the large bowel musculature has its own neural center that responds to distention by the fecal mass

Impaired Temperature Regulations

May lose these regulatory mechanisms and be unable to adapt to temperature extremes

Impaired Sexual Function

Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels results in sexual dysfunction

Ability to achieve erection and ejaculation is variable

Impaired Skin Integrity

Because immobile patient can’t change positions, skin in sacral area and across bony prominences may break down

Loss of tone results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores

Altered Self-Concept and Body Image

French and Phillips (1991) describe the effects of spinal cord injury on body image as occurring in four phases: impact, retreat, acknowledgment, and reconstruction


Saving the Patient’s Life:Establish Airway

Conventional head-tilt–chin-lift: inappropriate with spinal injury; increases risk of cord damage

Risk of additional damage is especially high with cervical injury

Neck flexion, even that caused by a pillow or other support, must be avoided

Jaw-thrust method of opening the airway is preferred for these patients

Saving the Patient’s Life: Establish Airway

Once airway is open, administer 100% oxygen by mask and manual resuscitator

Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation

Any injury that compromises ventilation must be treated immediately

Preventing Further Cord Injury

Traction Immobilization with skeletal traction manages

cervical spinal cord injuries acutely Gardner-Wells tongs

Secured just above the ears; doesn’t actually penetrate skull

Crutchfield tongs Applied directly to the skull just behind the hairline

Halo vest: immobilizes and aligns cervical vertebrae; placed when surgery is done to internally stabilize fractures and relieve the compression of nerve roots

Figure 29-7

Figure 29-8


Special beds and cushions Kinetic bed, such as the Roto-Rest bed,

continually rotates the patient from side to side Overlay air mattresses: flotation devices placed

on standard hospital beds Air-fluidized and flotation beds may be used after

the spine has been stabilized Wedge-Stryker frame: canvas and metal frame

bed that may be used to help turn the patient Types of cushions include those inflated with air,

flotation devices, and gel pads

Figure 29-9


Drug therapy Methylprednisolone

Reduces the damage to the cellular membrane Administered within the first 8 hours of injury Completely paralyzed patients often regain about

20% of function Partially paralyzed have regained up to 75% of

function

Preserving Cord Function

Early surgical intervention to repair cord damage Cord compression by bony fragments, compound

vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable

Laminectomy Involves removing all or part of the posterior arch

of the vertebra Spinal fusion

If multiple vertebrae are involved Placing a piece of donor bone into area between

the involved vertebrae

Assessment

Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output

Health History

Present illness Event that brought the patient to the hospital Specific injuries incurred in the incident Describe pain and other symptoms in detail

Past Medical History

Other accidents or injuries and chronic illnesses such as diabetes, hypertension, heart disease, cancer, or seizure disorder

Previous hospitalizations and operations Obstetric history from female patient Identify and record current medications and

allergies

Family History

Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma

Review of Systems

Skin condition, headache or dizziness, vision disturbances, hearing impairment or tinnitus, nasal or ear drainage, dyspnea, nausea and vomiting, constipation or diarrhea, fecal incontinence, bladder dysfunction, sexual dysfunction, and impaired motor and sensory function

Functional Assessment

Patient’s self-care abilities Patient’s roles and responsibilities as a

family member Occupation, hobbies, usual activity pattern,

habits, and diet Emotional response to the spinal injury Usual coping strategies Spiritual beliefs; other sources of support

Physical Examination

Record the patient’s reported height and weight

Take vital signs Take the temperature Level of responsiveness, posture, and

spontaneous movements Inspect the skin for lesions Evaluate tissue turgor Inspect head for lesions and palpate for

masses and swelling

Physical Examination

Examine pupils for size, equality, reaction to light

Respiratory effort and breath sounds Inspect abdomen; auscultate for bowel

sounds Inspect extremities for open fractures or

abnormal positions Range of motion Ability to perceive sharp and dull sensation;

use a dermatome chart

Figure 29-10

Interventions

Ineffective Breathing Pattern Risk for Injury and Disturbed Sensory

Perception Risk for Autonomic Dysreflexia Risk for Disuse Syndrome Bowel Incontinence Impaired Urinary Elimination

Interventions

Risk for Infection Ineffective Thermoregulation Feeding/Dressing/Grooming Self-Care Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen

Management

Rehabilitation

Activities that assist individual to achieve highest possible level of self-care and independence

Well-organized interdisciplinary team that can address all aspects of function Physician, nurse, physical therapist, occupational

therapist, speech therapist, dietitian, social worker, psychologist, and counselor

Patient and family must be emotionally and physically prepared to make adjustments

Rehabilitation

Team helps the patient accomplish activities of daily living and self-care and addresses successful adjustment to social integration and gainful employment in the workplace

Although this phase of treatment may take more than a year, patient, family, and rehabilitation team can take pride in the realization that a life can once again be productive and happy

Nursing Care of the Laminectomy Patient

Preoperatively Assess patient’s vital signs and neurologic status

to establish baselines Patient’s understanding of surgical routines Tell patient what to expect in the immediate

postoperative period Ongoing assessment of neurologic status and on

promoting healing at the operative site


Assessment Vital signs, neurologic status, and breath sounds Frequently assess movement, strength, range of

motion, and ability to localize sensory stimulus Fluid intake and output Abdomen for bowel sounds; palpate bladder Inspect the surgical dressing for bleeding, clear

cerebrospinal fluid drainage, and foul drainage If the patient has pain, obtain a complete

description


Interventions Risk for Injury Ineffective Tissue Perfusion Acute Pain Impaired Urinary Elimination Constipation Impaired Physical Mobility Deficient Knowledge

NURS 1130 Adult Nursing III Unit I Chapters 27, 28, 29 Teresa Champion, RN, MSN 9/2012.

Documents

brainstem slide

balance slide

gray slide

periphery slide

cell body slide

spinal cord slide

autonomic nervous system

central nervous system