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Chapter 38 Care of the Patient with a Neurological Disorder Christensen Leslie Lehmkuhl, RN 2009 Kockrow, White, Broyles 5 th ed. Agnosia: inability to recognize familiar objects or persons. Can be partial or total

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Chapter 38 Care of the Patient with a Neurological Disorder


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    1. Chapter 38 Care of the Patient with a Neurological Disorder Christensen Leslie Lehmkuhl, RN 2009 Kockrow, White, Broyles 5th ed

    2. Agnosia: inability to recognize familiar objects or persons. Can be partial or total Aneurysm: dilation of the wall of a blood vessel usually caused by artheriosclerosis and HTN Aphasia: absence or impairment of the ability to communicate through speech, writing, or signs because of a brain dysfunction (damage to the cerebral cortex) Apraxia: inability to perform purposeful acts or to use objects properly. Ataxia: Defective muscular coordination (e.g. balance) Aura: sensation (e.g. light touch) precedes migraine or epileptic sz. Bradykinesia: extreme slowness of movement Diplopia: double vision Dysarthria: Difficulty articulating speech Dysphagia: severe swallowing difficulty Key Terms

    3. Flaccid: weak soft and flabby. Lacking normal muscle tone. Glasgow Coma Scale: Assessment of impaired consciousness (eye, motor and verbal) Global Cognitive Dysfunction : generalized impairment of cognitive function (e.g. intellect, awareness, judgment) Hemianopia: defective vision in ½ of the visual field Hemiplegia: unilateral paralysis Hyperreflexia: increased reflex action Nystagmus: involuntary movements of the eye (back and forth or cyclical) Paresis: partial or incomplete paralysis Postictal Period: rest period that occurs after sz Proprioception: spatial positioning (e.g. muscle, posture, position, weight) Spastic: involuntary, sudden movement (spasm like) or muscular contraction Unilateral Neglect: perceptually unaware of an inattentive to one side of the body Key Terms

    4. Central nervous system (CNS) Brain and spinal cord (body’s control center) Peripheral nervous system (PNS) Somatic nervous system Sends messages from the CNS to the skeletal muscles; voluntary Autonomic nervous system Sends messages from the CNS to the smooth muscle, cardiac muscle and certain glands; involuntary *note: a & i are vowels Structural divisions

    5. Cells of the nervous system Neuron (fundamental unit of the nervous system) Overview of Anatomy and Physiology

    6. Neurons Consist of three main parts—dendrites; cell body of neuron; and axon Dendrites conduct impulses to cell body of neuron Axons conduct impulses away from cell body of neuron Neurons classified according to function Sensory (afferent) neurons: conduct impulses to the spinal cord and brain Motor (efferent) neurons: conduct impulses away from brain and spinal cord to muscles and glands Interneurons: conduct impulses from sensory neurons to motor neurons CELLS OF THE NERVOUS SYSTEM

    7. (A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby. B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.) A, Diagram of a typical neuron. B, Scanning electron micrograph of a neuron. C, Myelinated axon.

    8. Myelin and nerve structure Myelin is the layer that forms around nerves. Its purpose

    9. Neuromuscular junction Neurotransmitters Acetylcholine; norepinephrine; dopamine; serotonin Neuron coverings Myelin sheath Schwann Cell (PNS only) Cells of the Nervous System

    10. (A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby. B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.) A, Diagram of a typical neuron. B, Scanning electron micrograph of a neuron. C, Myelinated axon.

    11. Brain: Cerebrum interprets sensory messages (e.g. pain, light touch, pressure). Plays a vital role in temp regulation, fluid balance, appetite and some emotions. Influences the HR & hormone secretions Brainstem carries all nerve fibers between the spinal cord and the cerebrum. Contains the midbrain and pons, aka bridge that connects midbrain and medulla Cerebellum is responsible for coordination of voluntary muscles, maintenance of balance, equilibrium, and muscle tone. Spinal cord conducts impulses to and from the brain, serves as a center for reflex action Central Nervous System

    12. Brain Stem/Cranial Nerves • Brain stem (base of the brain) contains: • Midbrain (CN III-IV) • pons (CN V-VIII) • medulla oblongata (CN IX-XII) • coverings of the brain and spinal cord; ventricles

    13. Spinal Cord • Spinal cord (17 to 18 inches long) is a 2 way conductor pathway between the brain and peripheral nervous system.

    14. Brain

    15. Figure 14-2 (From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.) Sagittal section of the brain (note position of midbrain).

    16. Figure 14-3 (From Thibodeau, G. A., Patton, K. T. [1990]. Anthony’s textbook of anatomy and physiology. [13th ed.]. St. Louis: Mosby.) Neural pathway involved in the patellar reflex.

    17. Spinal nerves (31) Cranial nerves (12)- all CN transport impulses between the head, neck and brain except the Vagus nerve which serves organs in the thoracic and abd cavities. Autonomic nervous system Sympathetic nervous system “flight or fight” (face threat or run from threat) Parasympathetic nervous system “vegetative activities” (e.g. digestion, defecation, urination) Peripheral Nervous System

    18. Loss of brain weight (1% per year p 50 y/o) Loss of neurons (substantial loss p 50 y/o) Reduction in cerebral blood flow Decrease in brain metabolism and oxygen utilization Decreased blood supply to spinal cord causes decreased reflexes Effects of Normal Aging on the Nervous System

    19. Aged Nervous Tissue Aged nervous tissue Aged nervous tissue is less able to rapidly communicate

    20. Avoid drug and alcohol use Safe use of motor vehicles Safe swimming practices Safe handling and storage of firearms Use of hardhats in dangerous construction areas Use of protective padding as needed for sports Cigarette smoking decreases lung cancer which frequently will metabolize to the brain Prevention of neurological problems

    21. History of patients subjective C/O (do not use leading questions) Mental status Level of consciousness Glasgow coma scale *note a decreased LOC is the earliest sign of increases ICP Language and speech (sensory, motor, global aphasia) Cranial nerve function Motor function Sensory and perceptual status Assessment of the Neurological System

    22. Blood and urine Culture, r/o infection Drug screens-ingested Arterial blood gases Guillain-barre Cerebrospinal fluid- contents see table 14-3 Computed tomography (CT)- check for allergies to seafood and iodine MRI scan- no metal PET scan-Alz, tumor, Park. Non -invasive Lumbar puncture- lay flat the first 8 hrs p obtaining CSF sample. Assess for leakage, give analgesic/ice for HA Laboratory, Diagnostic & Nursing Considerations

    23. Intracerebellar Hemorrhage - CT Scan

    24. MRI MRI of the brain

    25. Lumbar Puncture (spinal tap)

    26. Figure 14-5 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Position and angle of the needle when lumbar puncture is performed.

    27. Electroencephalogram (EEG)- clean hair Myelogram- lay flat for 4 hrs+check for allergies Angiogram-allergies Carotid duplex- non invasive. U/s and doppler technology combined used for TIA’s Electromyogram (EMG)- muscle contraction measurement in response to electrical stimulus. No special prep Echoencephalogram-U/S to view intracranial structures, no spec prep Laboratory and Diagnostic Examinations

    28. Etiology/pathophysiology Skull and brain tissues are not able to feel sensory pain Vascular headaches Migraine Hypertensive Tension headaches Traction-inflammation headaches Clinical manifestations/assessment Head pain Prescience of sinus drainage Migraine headaches Prodromal (early sign/symptom) Visual field defects, unusual smells (aura) or sounds, disorientation, paresthesias During headache Nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema Headaches

    29. Medical management/nursing interventions Diet: limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork Psychotherapy to help identify areas of stress Medications Migraine headaches Aspirin, acetaminophen, ibuprofen Ergotamine tartrate (constricts cerebral blood vessels thus reducing cerebral blood flow. Cause a decrease in inflammation and may reduce pain transmission) Codeine; Inderal Headaches (cont)

    30. Headache

    31. Medical management/nursing interventions Tension headaches Non-narcotic analgesics Cluster headaches Narcotics during attacks Comfort measures Cold packs to forehead or base of skull Pressure to temporal arteries Dark room; limit auditory stimulation Headaches (continued)

    32. Headache

    33. Tension-type headache

    34. Etiology/pathophysiology Increase in any content of the cranium Space-occupying lesions, cerebrospinal problems, cerebral edema Usually effects one side of the brain which eventually effects both sides -DX Usually ICP is an emergency situation lending little time for diagnostic tests (CT or MR scan is sometimes used) Note: Lumbar puncture is not used D/T extraction of CSF can cause pressure changes and poss. lead to brain hemorrhage Subdural hematoma ICP

    35. ICP

    36. S/S Diplopia (double vision) Headache Changes in level of consciousness is the earliest sign Monitor Glasgow Coma Scale and be ready to intervene, contact MD and use measures to decreases ICP.. Pupillary signs change on the same side as the lesion and later may become dilated and fixed. Widening pulse pressure Bradycardia Respiratory problems (lumbar puncture is not used d/t poss brain stem hernia ion) cheynestokes. High, uncontrolled temperatures Positive Babinski’s reflex (great toe extends and outer toes fan out) Seizures Posturing Vomiting Singultus (hiccup) Blown pupil (fixed and dilated) unilateral eventually Bilateral Increased Intracranial Pressure

    37. Intracranial Pressure Pupillary changes

    38. Treatment Treat cause if possible Mechanical decompression Craniotomy (bone flap removed and later replaced) Craniectomy (bone flap removed and not replaced) Internal monitoring devices Elevate HOB 30-45 degrees to promote venous return Place neck in neutral position (non-flexed or extended) to promote venous return No nasal suctioning for head injuries D/T possible CSF leakage.. Corticosteroids (Decadron) reduces cerebral edema.. Osmotic diuretics (Mannitol) reduce fluid in brain tissue.. Increased Intracranial Pressure (continued)

    39. ICP Monitoring

    40. Common Disorders of the Neurological System • Disturbances in muscle tone and motor function • Etiology/pathophysiology • Damage to the nervous system causes serious problems in mobility • Clinical manifestations/assessment • Flaccid or hyperreflexic muscle tone • Clumsiness or incoordination • Abnormal gait