NURSING MANAGEMENT FOR NEUROLOGICAL DISORDERS MDJ2213 Medical Surgical Nursing II.

NURSING MANAGEMENT FOR NEUROLOGICAL DISORDERS

MDJ2213 Medical Surgical Nursing II

Learning Outcomes

At the end of the session, students will be able to:

Describe the special nursing needs of patients with neurological dysfunctions

Use the nursing process as a framework for care of the patient with neurological dysfunctions

Assess neurological status of a client using the Glasgow Coma Scale

Prepare patient for a myelogram

Nursing Management

Head and Spinal Injuries Headaches Cerebral Vascular Accident (CVA) Intracranial Infections Glasgow Coma Scale Preparation of Patient for Myelogram

Craniocerebral Trauma

Head injuries amongst most frequent and serious neurologic disorders

Causes usually include: RTAs/MVAs Falls Sports injuries Assaults Gunshot wounds

Craniocerebral Trauma

Specific damage is related to mechanism of injury Acceleration injury, head struck by moving

object Decelaration injury, head hits stationary

object Acceleration-deceleration injury (coup-

countrecoup phenomenon), head hits and object and the brain “rebounds”

Deformation, force results in deformation and disruption of integrity of impacted body part (e.g. skull fracture)

Craniocerebral Trauma: The Client With a Brain Injury

Diffuse or local damage to the brain Primary or secondary

Primary: brain damage due to impact Secondary: brain damage due to swelling,

bleeding (hematomas), infection, cerebral hypoxia, or ischemia that follows the primary injury


Cerebral concussion Concussion means

to “shake violently” Transient,

temporary, neurogenic dysfunction caused by mechanical force to the brain (Hickey, 1997).

Mechanism: Acceleration-deceleration


Cerebral contusion Bruising on the

surface of the brain, typically accompanied by small, diffuse venous hemorrhages

Occur when the brain strikes the skull

Most frequently near bony prominences of the skull


Diffuse Axonal Injury Widespread disruption of axons in the white

matter Immediate loss of consciousness Poor prognosis


Concussion or contusion: Close observation for development of

manifestations of increased cerebral edema, which leads to increased ICP

GCS charting

The Client With a Spinal Cord Injury

Mechanisms of injury: Hyperflexion (forcible forward bending) Hyperextension (forcible backward

bending) Axial loading (compression, vertical force to

spinal column) Excessive rotation


Classifications of Injury Classified according to systems

Complete or incomplete cord injury Cause of injury Level of injury


Spinal shock Temporary areflexia (loss of reflex function)

below the level of injury Manifestations vary in degree, but usually

includes: Bradycardia Hypotension Flaccid paralysis of skeletal muscles Loss of sensations Bowel and bladder dysfunction Loss of the ability to perspire


Paraplegia and Tetraplegia Paraplegia: paralysis of the lower portion of

the body Tetraplegia (a.k.a. quadriplegia): cervical

segments of the cord are injured impairing function of the arms, trunk, legs and pelvic organs


Emergency Care at the Scene: When injury is at C1 – C4, repiratory

paralysis is common Injuries below C4 may increase risk of

respiratory failure if edema ascends the cord

Critically important not to complicate initial injury during transport to the hospital


Emergency Care at the Scene: All people who have sustained trauma to

the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury

Pre-hospital management: rapid assessment, immobilizing and stabilizing head and neck, removal from site of injury, stabilizing other life-threatening injuries, rapid transport to the appropriate facility


Emergency Care: Avoid flexing, extending or rotating the

neck Immobilize the neck (e.g. rolled

towels/blankets, cervical collar) Secure head by placing belt/tape across

forehead and securing it to the stretcher Supine Transfer from stretcher directly to bed that

will be used throughout hospitalization


Emergency Department Management: Cervical injury:

Paralysis /weakness of extremities Respiratory distress Bradycardia Systolic BP below 80 Decreased peristalsis


Emergency Department Management: Thoracic and lumbar injury:

Paralysis /weakness of extremities


Emergency Department Management: Acute spinal shock:

Loss of skin sensation Flaccid paralysis, areflexia Absent bowel sounds Bladder distention Decreasing BP Absence of the cremasteric reflex in males

(retraction of the left or right testicle in response to stimulation of the inner thigh)

The Client With a Spinal Cord Injury: Nursing Care

Impaired Physical Mobility Goals of care: reduce the effects of

spasticity and to prevent complications involving the skin, CVS, and joint function


Impaired Physical Mobility Passive ROM exercises: help prevent

contractures and stretch spastic muscles, promoting rehabilitation

Maintaining skin integrity: Risk for altered skin integrity due to lack of sensory warning mechanisms and of voluntary motor control of skin dermatomes

Assess lower extremities for symptoms of thrombophlebitis. Antiembolic stockings are adviced.


Impaired Gas Exchange Injuries at C3 or above have paralysis of the

respiratory muscles and cannot breathe without a ventilator

Injuries at level of C8 to C5: Phrenic nerve is intact, but innervation of

intercostal muscle is affected, compromising respiratory dysfunction

Abdominal muscles also paralyzed unable to expectorate secretions


Impaired Gas Exchange Monitor vital capacity and respiratory

effectiveness, assessing for tachycardia, restlessness

Monitor for signs of ascending edema of the spinal cord, inc. difficulty in swallowing or coughing

Help with coughing exercises


Main goal: Prevent further complications Rehabilitation

The Client with Headaches

Pain within the cranial vault (Hickey, 1997)

May occur as a result of benign or pathologic conditions, intracranial or extracranial conditions, diseases of other body systems, stress, musculoskeletal tension, or a combination

The Client with Headaches

Migraine headaches (with or without aura)

Cluster headache Tension-type headache

The Client with Headaches: Nursing Care

Pain Interventions focus on teaching the client

self-care measures to control or relieve the pain, and reducing any associated problems, such as nausea and vomiting or anxiety


Pain Teach client to maintain a diary of

headaches: chart duration, onset, location, relation to menstruation/food intake, related manifestations, factors that relieve or increase intensity

Pain score charting to evaluate effectiveness of pain relief measures

Teach client to minimize light, noise and activity. Reduce noxious stimuli that may increase pain intensity


Pain Teach non-invasive and non-pharmacologic

relief measures as appropriate Educate client on importance of good

nutrition, regular exercise and sleep. Emphasize on minimizing stress.

The Client with a CVA

CVA or stroke: Condition in which neurologic deficits occur as a result of decreased blood flow to a focal (localized) area of brain tissue

Increased risk: Hypertension DM Sickle cell disease Substance abuse Artherosclerosis

The Client with a CVA: Nursing Care

Altered Cerebral Tissue Perfusion Acute phase: time of admission until client

is stabilized (24 to 72 hours after admission)

Goal: maintain body functions and prevent complications


Altered Cerebral Tissue Perfusion Monitor respiratory status and airway

patency Monitor neurological status Continuously monitor cardiac status,

observing for dysrythmias Monitor body temperature: may develop if

CVA affects the hypothalamus Strict IO charting: CVA may damage

pituitary gland, resulting in diabetes insipidus and possibility of dehydration


Altered Cerebral Tissue Perfusion Monitor for seizures: may result due to

cerebral tissue damage or increased ICP


Impaired Physical Mobility: Goals: Maintain

and improve functional abilities (by maintaining normal function and alignment), preventing edema of extremities and reducing plasticity


Impaired Physical Mobility: Encourage active and passive ROM

exercises Turning every 2 hours, maintaining body

alignment Monitor lower extremities for symptoms of

thrombophlebitis Collaborate with physiotherapist and

occupational therapist for rehabilitation


Impaired Swallowing Weakness or lack of coordination of the

tongue, attention deficits, and deficits involving the swallowing reflex

Dysphagia may result in choking, drooling, aspiration or regurgitation

Goal: Maintain safety by preventing aspiration and on ensuring adequate nutrition


Impaired Swallowing Ensure client is sitting upright Ensure food/fluids prepared are of

appropriate consistency as ordered Once client completes a meal, check the

mouth for “pocketing” of food Reduce distraction so client can focus on

eating and swallowing


Other Nursing Diagnoses: Self Care Deficit Impaired Verbal Communication Sensory/Perceptual Alterations Altered Urinary Elimination and

Constipation Risk for Injury Altered Thought Processes Ineffective Airway Clearance

The Client with Intracranial Infections

MENINGITIS Bacterial or viral Inflammation of the meninges of brain and

spinal cord ENCEPHALITIS

Usually viral Acute inflammation of the parenchyma of

the brain and spinal cord


Prognosis depends on supportive care given


Altered Protection Less able to protect themselves against

insults from both internal and external sources: pain, fever, altered LOC, seizures, increased ICP, cranial nerve dysfunction.

Monitor client for manifestations of altered protection and report abnormal findings so that treatment can be instituted to prevent further complications


Altered Protection Assess neurological status on a regular

basis Assess vital signs, including temperature,

on a regular basis Assess for and report decreasing levels of

consciousness: levels of orientation, memory, attention span, and response to stimuli

Assess and monitor for seizure activity, and institute precautions


Altered Protection Assess for and report manifestations of

increase ICP Administer prescribed medications, and

maintain prescribed fluid restrictions


Risk for Fluid Volume Deficit Related to increased metabolic rate,

diaphoresis, and fluid restrictions


Other Nursing Diagnoses Hyperthermia r.t. infection and abnormal

temperature regulation Pain r.t. headache, muscle, neck pain, joint aches,

and malaise secondary to meningeal irritation Altered Cerebral Tissue Perfusion r.t. increased

ICP or cerebral edema Risk for Injury r.t. seizures and changes in

mentation and LOC Decreased Adaptive Capacity: Cranial r.t.

intracranial hypertension

GLASGOW COMA SCALE (GCS) Most common scoring system used to

describe level of consciousness in a client following a traumatic brain injury

Reliable and objective, simple to use, and correlates well with outcome following brain injury

GLASGOW COMA SCALE (GCS) GCS measures:

Eye opening Verbal response Motor response

GLASGOW COMA SCALE (GCS) Every brain injury is different Generally, classified as:

Severe: GCS 3 – 8 Moderate: GCS 9 – 12 Mild: GCS 13 - 15

GLASGOW COMA SCALE (GCS)

GLASGOW COMA SCALE (GCS) Limitations:

Drug use Alcohol intoxication Shock Low oxygen saturation

Infants and children: Use a modified version PGCS

The Client going for a Myelogram Radiologic examination of the

subarachnoid space of the spinal canal, using a contrast agent

Visualized lumbar, thoracic or cercival area, or the whole spinal axis

The Client going for a Myelogram To perform a myelogram:

Lumbar puncture is done About 10ml of CSF is removed before a

contrast medium is injected into the space Head of X-ray table is kept elevated at 30

degrees and the client is kept quiet to prevent rapid upward dispersion risk of seizures

The Client going for a Myelogram Preparation of Client:

Informed consent signed NPO Client should be well hydrated Enemas or laxatives to ensure the lumbar

spine can be visualized Pre-procedure sedatives as prescribed

The Client going for a Myelogram During Procedure:

Different positions may be used Patient strapped to prevent falls as table

may be tilted during examination Vital signs checked regularly

The Client going for a Myelogram Post Procedure Care:

CRIB x 6 – 12hours (according to physician orders)

Vital signs Assess site of lumbar puncture for leakage

of CSF or bleeding Encourage increased intake of oral fluids to

help decrease post myelogram headache Ensure client voids within 8 hours after

examination

The Client going for a Myelogram Post Procedure Care:

Analgesia as ordered Head elevated at least 30 degrees for 12

hours, or as ordered

Any Questions?

NURSING MANAGEMENT FOR NEUROLOGICAL DISORDERS MDJ2213 Medical Surgical Nursing II.

Documents

primary injury slide

brain injury concussion

spinal cord injury paraplegia

skull slide

object decelaration

level of injury manifestations

myelogram slide

brain damage