Pathology

1. Pathology The pathology involving the CNS arises from injuries, vascular insufficiency, tumors, infections and disorders from other diseases. Neurological medical problems are due to interference with normal functioning of the affected cells

2. Page 585 ChristensenPage 585 Christensen

3. Functions 1.Regulates system 2. Controls communication 3. Coordinates Activities of body system

4. Divisions Central nervous system ( CNS) : brain and spinal cord �interprets incoming sensory information and sends out instruction based on past experiences Peripheral nervous system ( PNS) : Cranial and spinal nerves extending out from brain and spinal cord---carry impulses to and from brain and spinal cord Page 585 ChristensenPage 585 Christensen

5. Neurological Terms Anesthesia- complete loss of sensation Aphasia-loss of ability to use language Auditory/receptive aphasia- loss of ability to understand Expressive aphasia- loss of ability to use spoken or written word Ataxia- uncoordinated movements Coma- state of profound unconsciousness Convulsion- involuntary contractions and relaxation of muscles

6. Neurological terms Delirium- mental state characterized by restlessness and disorientation Diplopia- double vision Dyskeinesia- difficulty in voluntary movement Flaccidd- without tone- limp Neuralgia- intermittent, intense pain, along the course of a nerve

7. Neurological terms Neuritis- inflammation of a nerve or nerves Nystagmus- involuntary, rapid movements of the eyeball Paresthesia- abnormal sensation without obvious cause, with numbness and tingling Stupor- state of impaired consciousness with brief response only to vigorous and repeated stimulation Vertigo- dizziness

8. Preparing a patient for a diagnostic test Answer question that the patient may need clarification Diet orders �NPO??? Special room or equipment used Special medications required for test An informed patient will be more cooperative Nursing assessment Baseline vital signs and neuro cks Know level education to develop an individualized teaching plan Determine awareness of actual or potential medical diagnosis Determine previous experence with Dx test

9. Diagnostic test/ methods A. Computerized Tomography- CT or CAT scan computer analysis of tissues as x-rays pass through them; has replaced many of the usual tests: no special preparation or care after test

10. CT scan Nursing Interventions Explain procedure � will be enclosed tunel Written consent Assess allergies to iodine Remove wigs hair pins or clips, partial denture plates Assess for pacemakers NPO 4 hours before if oral contrast is administered Encourage patient to drink fluids to avoid renal complications and to promote excretion of the dye Foundations page 310 picture too Foundations page 310 picture too

11. Diagnostic test/ methods B. lumbar puncture- spinal tap Done under local anesthesia a puncture is made at the junction of the third and fourth lumbar vertebrae to obtain a specimen of cerebrospinal fluid (CSF) CSF pressure measured Used to inject medications- spinal anesthesia Used to inject diagnostic materials �air or dye-myelogram

12. Lumbar puncture Nursing interventions Written consent Monitor vital signs Have patient empty bowel and bladder Position the patient Label and number specimens Keep patient supine 4-8 hours Observe for headache and nuchal rigidity Observe for mobility of extremities, pain, ability to void Monitor site for leakage Page 594 Page 594, foundations page 313, position on 719Page 594 Page 594, foundations page 313, position on 719

13. Diagnostic test/ methods Cerebral Angiography- intraarterial injection of radiopaque dye to obtain an xray film of the cerebrovascular circulation

14. Cerebral angiography Nursing interventions Written consent Assess for allergy to iodine NPO past midnight Administer preprocedure medications Observe arterial puncture site Monitor extremity for adequate circulation- pain tenderness bleeding temperature and color Pedal pulses and vital signs q 1 hour Provide ice pack to puncture site Bedrest 12- 24 hours Force fluids- to increase excretion of dye AHN page 595-96AHN page 595-96

15. Diagnostic test/ methods Electroencephalography (EEG)- electrodes are placed on unshaven scalp with tiny needles and electrode jelly

16. EEG Nursing Inventions Anticipate patient�s fears about electrocutions Explain procedure Written consent Hair should be clean Do not give stimulants/ depressants before test /consult with M.D. about meds Administer sedatives or hypnotics if ordered No smoking or caffeinated beverages before the test Eat full meal before the test �hypoglycemia may alter brain waves Stress need for restful sleep before the test sleep deprivation may cause abnormal brain waves Wash hair and scalp after test Ensure safety precautions until effects of meds wear off Foundations page 312 AHN page 594 picture page 595Foundations page 312 AHN page 594 picture page 595

17. Diagnostic test/ methods Brain Scan-after injection of a radioisotope, abnormal brain tissue will absorb more rapidly than normal tissue: this can be detected with a Geiger counter to diagnose brain tumors Foundations pg 308 AHN pg 593Foundations pg 308 AHN pg 593

18. Brain Scan Nursing interventions NPO 4 hours before test Remove wigs, hair clips or pins, Assess for iodine allergies If ordered give sedation Encourage fluids after test to increase excretion of dye

19. Diagnostic test/ methods Magnetic Resonance Imaging- ( MRI) uses combination of radio waves and a strong magnetic field to view soft tissue ( does Not use x-rays or dyes) ; produces a computerized picture that depicts soft tissues in high �contrast color

20. MRI Nursing interventions Written consent Explain procedure- will have to remain perfectly still in the narrow cylinder-shaped machine . No pain or discomfort but no room for movement Assess for any metal contraindications-pacemaker, surgical clips, hair clips, belts Empty bladder before test Foundations pg 313 AHN pg 593Foundations pg 313 AHN pg 593

21. Diagnostic test/ methods Myelogram- injection of a radiopaque dye into the subarachnoidd space via a lumbar puncture: performed to locate lesions of the spinal column or ruptured vertebral disk

22. Myleogram Nursing interventions Written consent Prepare for LP NPO for 4 hours before test Positioning for LP Vital signs Observe for photophobia, fever stiff neck, occipital headaches, nausea , dizziness, and possibly seizures Force fluids to promote dye excretion dehydration will result in severe headache Check with M.D. when withheld medications prior to test may be restarted Observe site for leakage of CSF Bedrest

23. Nursing Diagnosis and Interventions Identify the patients needs Neuro checks Assessment of history from family Patient history Nursing observations

24. Impaired Physical Mobility Neuro checks q2-4h Explain the need for regular exercise program ROM to all joints q2-4h foundations pg 243-244 Use assistive devices Protect the affect side from injury Protection from falling Turn q2h

25. Risk for injury/infection related to fixed eyes ( no blinking) Protect with eye shields Remove dry exudate with warm saline Close eyes Inspect for inflammation

26. Ineffective breathing pattern related to neuromuscular impairment Maintain patent airway Suction as needed Elevate HOB 30-60-degrees Have trach set ready Provide O2 with humidity V/S with neuro cks q2h Oral hygiene q2h Lubricate lips Maintain bed rest Keep unconscious pt in lateral position to allow secretion drainage Monitor for S/S pulmonary emboli Chest pain, SOB, Monitor ability to swallow

27. Risk for alteration in body temperature Asses rectal temp q2h Use external heating or cooling blankets

28. Risk for aspiration Maintain NPO Position Pt on side: turn q2h Provide N/G feedings Monitor IV fluid

29. Altered patterns of urinary elimination 1. Oligura-urinary retention Provide indwelling catheter Monitor I&O qh 2. Incontinence Wash dry and inspect skin Implement measures to prevent decubitus ulcers Implement bladder training

30. Bowel incontinence/constipation Incontinence wash dry and inspect skin Implement measures to prevent decubitus ulcers Implement bowel training Constipation -Record bowel movements -Provide stool softners, laxatives and enemas -Check for impaction -Increase fluid intake -Increase Fiber in diet -Increase activity

31. Altered Nutrition: less than body requirements related to dysphagia and fatigue Prepare for N/G feedings Check gag reflex Provide mouth care, clean and care for dentures Place food in patients visual field do patient can see food Diet low salt low cholesterol consult dietary Wt daily

32. Impaired Communication Assess communication patterns Provide calm environment with minimal distraction Use touch to increase attention Use familiar music to enhance recall Simple verbal commands Communication boards Pen and paper Gestures eye blinks

33. Fluid Volume deficit

34. Inability to meet needs:Coma COMA-Unconscious state in which the Pt is unresponsive to verbal or painful stimuli: this occurs with many primary diseases: the Pt depends on the nurse for maintenance of all basic human needs, nourishment, bathing, elimination, respiration, prevention of complications and assessment and provision of care for problems

35. Coma : nursing interventions Include family in nursing care and planning Note LOC q15 minutes Nero Ck q 15 minutes Demonstrate respect for Pt presence Provide quite restful environment Speak to Pt, use proper name, introduce self, explain all care Provide privacy

36. Patient with paralysis Paraplegia-paralysis of the lower extremities There may be no motion or sensory function or reflexes There may be uncontrollable muscle spasms Perspiration ceases then becomes profuse Loss of bowel and bladder control Anxiety, fear, depression, anger, and embarrassment May be totally dependant

37. Patient with paralysis Quadriplegia- paralysis of all four extremities Same problems as paraplegia

38. Nursing interventions : Paralysis Take measures to prevent complications of immobility Bowel and bladder training Prevent deformity: maintain joint mobility: correct alignment Increase fluid intake Provide high protein diet Teach independence according to ability Work with health care team for rehabilitation Include family in planning and care

39. Increased intracranial pressure( ICP) Fluid accumulation or a lesion takes up space in the cranial cavity, producing ICP: the brain is gradually compressed, or life-sustaining functions cease: may be sudden or progress slowly

40. ICPCauses Tumors Hematoma Edema from trauma Abscesses from infection

41. ICPsigns and symptoms Headache, restless, anxiety Vomiting,recurrent, projectile, and not related to nausea or meds Change in pupil response to light Seizures Respiratory difficulty; irregular, Cheyne-Stokes or Kussmaul BP elevates ,with wide pulse pressure Pulse Increases at first then slows to 40- 60 Alter LOC,lethargic, speech slows, confused, decrease level of response Visual disturbances,diplopia and blurred vision Progressive weakness or paralysis Loss of consciousness,coma death

42. ICPTreatment Depends on cause Craniotomy Meds Steroids Anticonvulsants Mannitol dexamethasone

43. ICPNursing interventions Elevate HOB to semi-Fowler�s Never place in Trendelenburg V/S and neuro cks q15 minutes Prevent aspiration Place Pt on Side Maintain airway- O2 Observe pupillary response ( usually unequal and may not react to light) Report changes in LOC immediately Seizure precations Provide care for Coma Pt Monitor IV fluids� Do not overhydrate NPO or fluid limited by M.D. I & O q1h

44. Convulsive disorders Frequently a convulsion or seizure is not a disease but a symptom of a neurologic disorder: Epilepsy is a disease characterized by a disposition for seizures;

45. Types of seizures Generalized or grand mal Aura- There may be a premonition or sign The Pt cries out Loss of consciousness Enters tonic phase- the body is rigid and the jaw is clenched Then the clonic phase- jerking movements of muscles Cessation of respiration Fecal and urinary incontinence Lasts 1-2 minutes Followed by short period of unresponsiveness

46. Types of seizures Partial or petit Mal Loss of consciousness that last 5- 30 seconds Normal activities may or may not ceas There may be amnesia concerning the time

47. Types of seizures Jacksonian or Motor A focal seizure that may precede a grand mal seizure

48. Convulsive Disorders Causes May be secondary to another condition CVA, head injury, brain tumor, elevated temp, toxins, electrolyte imbalance Epilepsy may have no known cause Onset is usually during childhood or before age 30

49. Convulsive DisordersDiagnostic test EEG CT scan MRI

50. Convulsive DisordersTreatment Treat and remove cause Anticonvulsant drugs Surgery � sterotactic- electrical stimulation to locate and reset ( destroy) epileptogenic focus

51. Convulsive DisordersNursing Interventions Provide accurate observation and documentation Aura Time of onset Whether seizure is generalized or focal Specific parts of body involved Progression of seizure Eye movements Loss of consciousness Loss of bowel or bladder Condition after seizure Memory loss Weakness Any injury caused by seizure

52. Convulsive DisordersNursing interventions Encourage Pt to wear medical alert tag Have suction available During seizure maintain airway Prevent head injury Place pt on side Protect extremities from injury Do not restrain Loosen clothing Remove pillows Maintain safety until fully conscious

53. Transient Ischemic AttacksTIA Altered cerebral tissue perfusion related to a temporary neurologic disturbance Manifested by sudden loss of motor or sensory function Lasts for a few minutes to a few hours Caused by temporarily diminished blood supply to an area of the brain High risk for stroke

54. TIATreatment Control hypertension Low sodium diet Possible anticoagulant therapy Stop smoking

55. Cerebrovascular AccidentCVA Stroke Decreased blood supply to a part of the brain caused by rupture , occlusion, or stenosis of the blood vessels Onset may be sudden or gradual Symptoms and patient problems depend on location and size of area of brain with reduced or absent blood supply right CVA results in Left side involvement often associated with safety/ judgment Left CVA results in Right side involvement often associated with speech problems

56. Cerebrovascular AccidentCVA Stroke Symptoms related to location and size of brain area affected Approximately 50% of survivors permanently disabled High proportion experiencing recurrence within weeks to years Chances for complete recovery depending an circulation returning to normal soon after the initial stroke Third most common cause of neurological disability

57. Predisposing factors-CVA History TIA�s Hypertension Arrhythmias Atherosclerosis Rheumatic Heart Disease MI DM High serum triglyceride levels Lack of exercise Cigarette smoking Family history

58. CVACauses Incidence increased with aging Atherosclerosis Embolism Thrombosis Hemorrhage from ruptured cerebral aneurysm hypertension

59. CVASigns and Symptoms Altered LOC Change in mental status Decreased attention span Decreased ability to think and reason Difficulty following simple directions Communication; motor and sensory aphasia difficulty with reading ,writing, speaking, or understanding Bowel and bladder dysfunction retention impaction or incontinence

60. CVASigns and Symptoms Seizures Limited motor function; paralysis, dysphgia, weakness , hemiplegia, loss of function Loss of sensation/ perception Headaches and syncope Loss of temp regulation elevated TPR and BP Absent of gag reflex ( aspiration) Unusual emotional responses; depression, anxiety, anger, verbal outburst, and crying: emotional lability Problems related with immobility

61. CVADiagnostic test Physical assessment Pt and family history EEG CT scan Lunbar puncture Cerebral angiogram Carotid ultrasonogram

62. CVATreatments Remove cause, prevent complications, and maintain function, rehabilitation to restore function Meds Antihypertensives Anticoagulants Stool softners Surgical removal of clot, repair of aneurysm, carotid endarterectomy or balloon agioplasty

63. CVANursing Interventions Patent airway Maintain bedrest Provide complete care Use turn sheet Footboard Firm mattress Pillow and torchanter rolls Maintain proper body alignment Place items within reach Reposition q2h ROM passive and active Place in chair Flotation mattress or sheepskin Skin assessment

64. CVANursing Interventions O2 with humidity C,T, DB q2h Suction PRN Keep head turned to side Place in semi- fowler�s Assess nutrition daily with I&O, WT, %diet, calorie count Provide N/G feedings if needed Maintain IV fluids Progress to soft diet prn TPN as ordered Aspiration precautions Dietary consult & Speech for swallowing

65. CVANursing interventions Establish means of communication Nonverbal gestures Speak slowly Explain all care Speech therapy Encourage family participation

66. CVANursing Interventions Assess LOC Maintain safety Use side rails Restrain only as necessary Observe for ICP V/S & Neuro CKS q 4 h Seizure precations Ensure elimination Assess bowel sounds Monitor bowel movements I & O Indwelling catheter prn Bowel and bladder training

67. CVANursing interventions Family support Begin discharge teaching early Physical therapy Speech therapy

68. Brain Tumor A benign or malignant growth that grows a nd exerts pressure on vital centers of the brain decreasing function and causing increased intracranial pressure Cause is unknown

69. Brain TumorSigns and Symptoms Personality changes, fear and anxiety H/A , dizziness and visual disturbances Seizures Pituitary dysfunction ICP Local paralysis or anesthia Aphsia Problems with coordination

70. Brain tumorDiagnostic test History Physical exam Neurologic assessment EEG CT Angiogram MRI

71. Brain tumortreatment Surgical removal �craniotomy Combination of radiation or chemotherapy

72. Brain tumornursing interventions Neuro cks q 1-4 hours depending on pt status Safety Seizure precautions express fears and feelings POST OP care Maintain airway Seizure precautions Regulate body temp Position on unoperated side Elevate HOB ONLY under MD orders Inspect dressing q30min V/S neuro cks q 15 min progress to q4h Coma care

73. Head injuries Trauma to scalp, skull, or brain. A fracture to skull may result either a simple break in the bone or bone fragmentation that penetrates the brain tissue, can also cause hemorrhage, concussion, or contusion

74. Head injuries Cerebral concussion- injury to the head, patient may be dazed; or unconscious for a few minutes: some function(memory) may be impaired for as long as several weeks Cerebral contusion- head injury causing bruising of brain tissue> person experiences stupor, confusion or loss of consciousness: if severe may go into coma

75. Head injuries Cerebral laceration- a break in continuity of brain tissue Causes Blow to head MVA Fall

76. Head injuries Signs and Symptoms and diagnostic test Nausea & vomiting Lethargic: increasing loss of consciousness to impending coma Disorientation Drainage of CSF from ear or nose ICP History and physical exam X-ray of head Angiogram, doppler studies CT head, MRI PET

77. Head injuriesTreatment Anticonvulsulants Corticosteriods Mannitol Maintain fluid balance surgery

78. Head injuriesNursing interventions Care for ICP COMA care Neuro cks & V/S q 15 min to q1h Maintain airway Seizure precations Observe ears and nose for CSF

79. Multiple Sclerosis A chronic progressive disease of the brainand spinal cord: lesions cause degeneration of the myelin sheath and interfere with conduction of motor nerve impulses: there are periods of remissions and exacerbations: onset occures in young adult: it has an unpredictable progression Cause: unknown< exacerbates with stress

80. Multiple SclerosisSigns ands symptoms Ataxia Paresthesia Weakness and loss of muscle tone Loss of sense of position Vertigo Blurred vision �progress to blindness Inappropriate emotions Euphoria, apathy, depression Dysphagia Slurred speech Bowel and bladder dysfunction Sexual dysfunction spasticity

81. Multiple SclerosisDiagnostic test and treatments History Physical exam Neuro Cks Ct MRI Exam of CSF Treatment is symptomatic Corticosteriods during acute excerbation

82. Multiple SclerosisNursing interventions Prevent Complications of immobility Encourage independence Patient should participate in plan of care High calorie, vitamin, protein diet Family education Bowel and bladder training Safety Express feelings regarding dependence and disabilities Avoid precipitating factors for exacerbations Fatigue, cold, heat, infections, stress

83. Parkinson�s Disease A progressive , degenerative disease causing destruction of nerve cells in the basal ganglia of the brain caused by a deficiency of dopamine: limbs become rigid, fingers have characteristic pill rolling movement, and head has to and for movement: the patient has a bent position and walks in short, shuffling steps: facial expressions become blank with wide open eyes and infrequent blinking ( parkinson�s Mask) Intelligence is NOT affected

84. Parkinson�s DiseaseSigns and symptoms Tremor Voluntary movement is slow and difficult Coordination is poor- ataxia Impaired chewing and eating Excessive salivation and drooling Speech is slow Patient is soft spoken Written communication is difficult Excessive sweating Emotional changes Depression , confusion dependency

85. Parkinson�s DiseaseDx test and treatments History Physical exam Neuro cks Many pt s respond to drug therapy and the disease is controlled with meds for the reminder of their lives Others have no response to meds - invalidism

86. Parkinson�s Diseasenursing interventions Foster independence ADL�s Avoid social withdrawal �involve in work, social and diversional activities Aviod embarrassment while eating Use straws, wipe drool, use bib, keep clothing clesn, use large handle grips Soft diet Daily walking�safety Avoid fatigue Physical, Speech and Occupational therapy Avoid constipation-stool softner

87. Parkinson�s Diseasenursing interventions Bowel and bladder training Be patient when patient is slow and clumsy Establish a means of communication Reorientation Prevent pneumonia Mouth care q4h Family participation

88. Spinal Cord Impairment The vertebral column houses the spinal cord. A small cartilage disk acts as a cushion between the vertebrae. All sensory and motor nerves to the neck, trunk, and extremities branch out from the spinal cord. The degree of disability and patient problems is related the part of the body controlled by the injured or disease nerves

89. Spinal Cord Injuries Trauma to spinal cord may cause complete or partial severing of the spinal cord If severing is complete there is permanent paralysis of body parts below site of injury When there is partial damage edema may cause a temporary paralysis

90. Spinal Cord Injuries Cause : accident ,MVA diving, shooting S&S individual to site, respiratiory distress, paralysis DX test: physical exam Treatment: immobilization Crutchfield tongs.halo traction.brace.body cast Surgery corticosteroids, mannitol

91. Spinal Cord InjuriesNursing interventions Care for paralysis patient Observe for complications of spinal shock Maintain airway and respiratory function