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~THE NERVOUS
SYSTEM~
Common Health Problem and Disorders
JHOANNE D. DUERO
7/18/2009
NERVOUS SYSTEM
1. Central Nervous System
• Brain
• Spinal Cord
2. Peripheral Nervous System
• Cranial Nerves
• Spinal Nerves
Neuron
BRAIN
1. Frontal Lobe
• Largest lobe
• Location: front of the skull.
• Contains the primary motor cortex and responsible for functions related to motor
activity.
• The left frontal lobe contains Broca’s area (control the ability to produce spoken
words)
• The frontal lobe controls higher intellectual function, awareness of self, and
autonomic responses related to emotions
2. Parietal Lobe
• Sensory lobe
• Location: near the crown of the head.
• Contains the primary sensory cortex.
• One of its major functions is to process sensory input such as position sense,
touch, shape, and consistency of objects.
3. Temporal Lobe
• Location: around the temples.
• Contains the primary auditory cortex.
• Wernicke’s area is located on left temporal lobe.
• Contains the interpretative area where auditory, visual and somatic input are
integrated into thought and memory
4. Occipital Lobe
• Location: lower back of the head
• Contains the primary visual cortex
• Function: responsible for visual interpretation.
THE 4 LOBES
• Frontal- motor /controls higher intellectual function, awareness of self and autonomic
responses related to emotions.
• Parietal- sensory
• Temporal- auditory (Wernicke’s); Contains the interpretative area where auditory, visual
and somatic input are integrated into thought and memory
• Occipital- visual
Ventricles of the Brain
Diencephalon
• Lies on the top of the brain-stem
• Contains the thalamus, hypothalamus, epithalamus, and subthalamus.
1. Thalamus
• Lies on the either side of the third ventricle
• “Relay station” for all sensation except smell.
• All memory, sensation and pain impulses pass through this section.
2. Hypothalamus
• Located anterior and inferior to the thalamus.
• Has a variety of function and plays an important role in maintaining homeostasis.
• Regulation of body temperature, hunger and thirst; formation of autonomic
nervous system responses; and storage and secretion of hormones from the
pituitary gland.
3. Epithalamus
• Contains pineal gland.
4. Subthalamus
• Part of the extrapyramidal system of the autonomic nervous system and the basal
ganglia.
The Basal Ganglia
• Are masses of nuclei located deep in the cerebral hemispheres.
• Responsible for fine motor movements, including those of the hands and lower
extremities.
• Several motor disorders are associated with basal ganglia damage including
Huntington’s chorea and Parkinson’s disease.
BRAIN STEM
• Consist of the midbrain, pons, and medulla oblongata.
• Midbrain
➢ connects the pons and the cerebellum with the cerebral hemisphere, it contains
sensory and motor pathways
➢ center for auditory and visual reflexes
• Pons
➢ connects the two halves of the cerebrum
➢ involved in the integration of movements in the right and left sides of the body,
and the transmission of motor information from the higher brain areas and the
spinal cord to the cerebellum.
• Medulla oblongata
➢ involved in the respiration, circulation, gastrointestinal functioning, coughing,
sneezing, and swallowing.
CEREBELLUM
• Location: base of the brain.
• Responsible for coordination, balance and posture.
• Damage to the cerebellum can result in ataxia, a condition characterized by drunken-like
movements, severe tremors, and loss of balance.
SPINAL CORD
a. Cervical C1-4
b. Brachial plexus C5-8, T1
c. Intercostal T2-T12
d. Lumbar L1-L4
e. Sacral L4-L5, S1-S3
f. Pudendal S4
➢ I Olfactory nerve
➢ II Optic nerve
➢ III Oculomotor nerve
➢ IV Trochlear nerve
➢ V Trigeminal nerve
➢ VI Abducens nerve
➢ VII Facial nerve
➢ VIII Acoustic/Vestibulocochlear
➢ IX Glossopharyngeal nerve
➢ X Vagus nerve
➢ XI Accessory nerve
➢ XII Hypoglossal nerve
➢ Accommodation is tested by
observing pupillary constriction
when the client changes gaze
from a distant object to a near
object.
Sensory:
Parasympathetic:
XI. Spinal Accessory Motor: Assess shoulder and neck muscles for
Strength and Movement
turn head, shrug shoulders,
some actions for phonation ➢ Have the client shrug his/her
shoulders upward against your
hands.
SPINAL NERVES
• 31 pairs
• 8 cervical, 12 thoracic, 5 lumbar
• 5 sacral, 1 coccygeal
• Two roots
➢ Dorsal and Ventral - Each spinal nerve has a ventral root (motor) and a dorsal root
(sensory)
• Dermatome distribution
The dorsal roots contains sensory fibers that relay information from sensory receptors to
the spinal cord
The ventral root contains motor fibers that relay information from the spinal cord to the
body’s glands and muscles.
Dermatome distribution
2 Components of ANS
1. Sympathetic Nervous System
2. Parasympathetic Nervous System
Health History
Past Health History
Injuries and surgeries
Use of alcohol, medications, and illicit drugs
Onset of symptoms.
Duration of current complain
Recent trauma
The disorders involving neurologic system impairment are headache, dizziness or vertigo,
seizures, change in consciousness, altered sensation and visual disturbances.
Physical Examination
The brain and spinal cord cannot be examined directly as other system of the body.
V/S - abnormal respiration
breathing pattern
Pupillary reaction/pupillary changes
Eye movement & reflex response
Change in balance
Neurological Assessment
Recognition of change
Helps assess the patient’s ability to engage in self-care activities.
Neurologic assessment is divided to into 5 components:
Cerebral function
Cranial nerves
Motor system
Sensory system
Reflexes
1. Cerebral Function
Mental status: observe patient’s appearance, behavior, dressing, grooming and
personal hygiene.
a. Posture, gestures, movements, facial expression, motor activity, the
patient’s manner of speech and LOC are also assessed.
b. Level of Consciousness (LOC) – awareness of self and environment and
level of arousal (alert, lethargic, obtunded, stuporous, coma).
Altered Level of Consciousness (LOC) - can result from destruction of the brain stem or
its reticular formation of ascending nerves, or from other structural, metabolic, or
psychogenic disturbances.
Confusion • Impaired ability to think clearly
• Disturbed ability to perceive,
respond to, and remember current
stimuli
• Disorientation
• Functional in activities of daily
living (ADLs)
Coma • Unarousable
• Unresponsive to external stimuli or
internal needs
• Determination commonly
documented using Glasgow Coma
Scale score
Altered Movement
Involves certain neurotransmitters (ex. dopamine)
○ Hyperkinesia- excessive movement
○ Hypokinesia- decreased movement
Marked by paresis- partialloss of motor function and muscle power; commonly
described as weakness; can result from destruction of upper & lower motor
neurons
4. Sensory Function
Test for:
○ superficial tactile sensation superficial and deep pressure pain
○ thermal sensitivity
○ sensitivity to vibration
○ point localization
5. Reflexes
Evaluate deep and superficial reflexes (biceps, triceps, patellar, ankle reflexes)
and abnormal reflexes (Babinski’s reflex).
Diagnostic Tests
Myelography
➢ Contrast agents are injected into spinal
subarachnoid space to permit ✔ Explain the procedure.
visualization of spinal cord. ✔ Obtain a signed consent.
✔ Withhold oral intake 4-6 hours before
➢ Shows any distortion of the spinal cord the test.
or spinal dural sac caused by tumors, ✔ After the procedure:
cysts, herniated vertebral disks or other
lesions. For pantopaque myelogram
(oil-based) pt lies flat for 6-24
hours.
For metrizamide myelogram
(water-based), HOB is elevated
at 30 degrees for at least 8
hours.
✔ Encourage fluid intake.
Electroencephalography
➢ Graphic record of the electrical activity ✔ Explain the procedure; assure the client
generated in the brain. he/she will not receive electrical shock.
➢ EEG is a useful test for diagnosing and ✔ The nurse needs to check doctor’s order
evaluating seizure disorders, coma, or regarding the administration of anti-
organic brain syndrome. seizure medication prior to testing.
➢ A sleep EEG may be recorded after ✔ Withhold tranquillizer and stimulants
sedation because some abnormal brain for 24 to 48 hours.
waves are seen only when the patient is
✔ Inform the client that the standard EEG
asleep.
takes 45 to 60 minutes and 12 hours for
sleep EEG.
Electroencephalography
Lumbar Puncture
• Insertion of needle in the Subarachnoid Space
• Assess the CSF
Lumbar Puncture
➢ Is carried out by inserting a needle into ✔ Maintain position, usually lateral
the lumbar subarachnoid space to horizontal with knees to chest, chin on
withdraw CSF for diagnostic or chest.
therapeutic purposes.
✔ Obtain signed consent.
✔ Explain the procedure.
➢ The needle is usually inserted between
✔ Observe for complication following the
L4 and L5.
procedure.
✔ Keeping the patient in prone position
overnight may reduce the incidence of
headache.
Electromyography
➢ Obtain by inserting needle electrodes ✔ Explain the procedure.
into the skeletal muscles.
✔ The patient is warned to expect a
➢ Measure changes in the electrical sensation similar to that of an
potential of the muscles and the nerves intramuscular injection and the muscle
leading to them. examined may ache for a short time
after the procedure.
➢ Useful in determining neuromuscular
disorders and myopathies.
Electromyogram
Pneumoencephalography
➢ Special contrast study of the ventricular ✔ Secure written consent.
and cisternal system using air as
✔ Sedate as ordered. GA may be used.
contrast medium.
✔ Inform the client that the procedure
takes 2 hours.
➢ Permits accurate localization of brain
✔ Inform the client that he/she may
lesions by spinal or cisternal puncture
experience discomfort, N/V, after the
with x-ray examination.
procedure.
✔ After the procedure keep the client flat
in bed for 24 to 48 hours.
✔ Monitor VS and neurologic checks.
Common Health Problem of the Neonate and Infant
1. Cranial
Hydrocephalus
2. Spinal Cord
Meningocele
HYDROCEPHALUS
• Is an excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain.
• Reasons for excess:
○ over production of fluid by the choroid plexus in the 1st or 2nd ventricle
○ obstruction of the passageway of fluid somewhere between the point of origin and
the point of absorption
○ interference with the absorption of fluid from the subarachnoid space
• Classifications:
a. Congenital
b. Acquired
• The cause of congenital hydrocephalus is unknown.
• Incidence: 3 to 4 per 1000 live births
• In older child infections such as meningitis and encephalitis may leave adhesion that lead
to obstruction.
Nursing Assessment
Enlarged head
Prominent scalp vein.
Enlarged or full fontanels
Separated suture line
Increased head circumference
Sunset eyes
Shrill cry
Hyperactive reflexes
Signs of increased ICP
Decreased pulse
Increased temperature
Decreased respiration
Increased BP
Diagnostic Test
Sonogram, CT scan, MRI
Skull x-ray film will reveal the separating sutures and thinning of the skull bones.
Transillumination will reveal skull filled with fluid rather than solid brain substance.
Diagnostic Test
Neural tube defects can be discovered during intrauterine life by sonography, fetoscopy,
amniocentesis, or analysis of AFP in maternal serum.
When infants are detected having Myelomeningocele, they may born by cesarean
birth to avoid pressure and injury to the spinal cord.
Nursing Assessment
Saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar
area.
Myelomeningocele directly connects to subarachnoid space so hydrocephalus often
associated.
No response or varying response to sensation below level of sac.
May have constant dribbling of urine.
Retention of stool.
Nursing Goals and Interventions
Prevent trauma and infection.
Position on abdomen or on side and restrain.
Meticulously clean buttocks and genitals after each voiding and defecation.
May put protective covering over sac.
Observe sac for oozing of fluid or pus.
Crede bladder (apply downward pressure on bladder with thumbs, moving urine toward
the urethra) as ordered to prevent urinary stasis.
Assess amount of sensation and movement below defect.
Observe for complications.
Obtain occipital-frontal circumference baseline measurement, then measure head
circumference once a day (to detect hydrocephalus).
Check fontanelle for bulging.
CEREBRAL PALSY
• Group of non-progressive disorders of upper motor neuron impairment that result in
motor dysfunction.
• A child may also have speech or ocular difficulty, seizures, cognitive challenges, or
hyperactivity.
• Exact cause is unknown, but the disorder is associated with low birth weight, prebirth, or
birth injury.
• Occurs in approximately 2 in 1000 live births, occurring most frequently in very-low-
birth-weight infants
• It apparently occurs when brain anoxia leads to cell destruction of the motor tracts.
3. Ataxic Type
Children with ataxic involvement have an awkward, wide-base gait.
On neurologic examination, they are unable to perform finger-to-nose test or
perform rapid, repetitive movements (tests of cerebral function).
4. Mixed Type
Symptoms of both spasticity and athetoid movements are present together.
Nursing Assessment
Diagnosis is based on history and physical assessment.
On history, an episode of possible anoxia during prenatal life or at birth is documented.
Neurologic exam in infant is difficult. In all forms of CP may have sensory alteration.
REYE’S SYNDROME
• Is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs,
pancreas, and skeletal muscle.
• 1 to 18 years of age regardless of gender.
• The cause is unknown, but it generally occurs after a viral infection such as varicella or
influenza if the child is treated with salicylate.
• Avoiding the use of aspirin during viral infection has led to almost total prevention of the
syndrome.
Nursing Assessment
Children: Lethargic, vomiting, agitation, anorexia, confusion, and combativeness.
Laboratory diagnosis of Reye's syndrome is confirmed by:
Elevated Liver Enzyme Levels
Elevated Serum Ammonia
Normal Direct Bilirubin
Delayed Prothrombin Time and Partial Thromboplastin Time
Decreased Blood Glucose
Elevated BUN
Elevated Serum Amylase
Elevated Short-chain Fatty Acid
Elevated WBC Count
Neuromuscular Disorders
Multiple Sclerosis
Myasthenia Gravis
MULTIPLE SCLEROSIS
• Chronic, degenerative disease of the central nervous system that is characterized by
demyelination of the nerve fibers of the brain and spinal cord
• Gen. characterized by exacerbations and remissions (relapsing-remitting type)
• Although the cause of MS is unknown, it appears to be related to autoimmune disorder
and viral infections
• Commonly appears during adulthood (ages 20 to 40)
• W>M
• Areas of the CNS most commonly affected brainstem, cerebrum, cerebellum, optic
nerves, and the spinal cord.
Process of Demylination
Assessment
Sign and symptoms of MS is characterized by remissions and exacerbation of symptoms.
Symptoms vary depending on the area of the CNS involved, but generally include:
Visual disturbances (diplopia, partial or total loss of vision, nystagmus)
Scanning speech (slow, monotonous, slurred)
Tremors
Weakness/numbness of the extremities
Fatigue
Increased susceptibility to URTI
Dysphagia
Ataxic gait
Diagnostic Test
Lumbar Puncture-total CSF protein is normal; IgG (gamma globulin is elevated- IgG
reflects hyperactivity of the immune system due to chronic demyelination)
EEG-abnormalities in brain waves
CT scan/ MRI reveals multifocal white matter lesion
Myelogram
Skull x-ray
Nursing Diagnoses
Risks: Ineffective breathing pattern; airway clearance
Impaired—swallowing, physical mobility, skin integrity; altered nutrition; urinary
incontinence; constipation
Interventions
There is no specific treatment for MS.
Treatment includes:
• Physical therapy- to assist with motor dysfunction, such as problem with
balance, strength, and motor coordination.
• Speech therapy- to manage dysarthria
• Drug therapy
a. Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)- to
reduce edema of the myelin sheet; sppeds recovery from attack
b. Muscle relaxant (Baclofen)- to treat spasticity
c. Amantadine, Ritalin, or antidepressants– to manage fatigue
d. Low-dose TCAs- to manage sensory symptoms such as pains,
numbness, burning, and tingling sensationsAntihistamines with
vision therapy & exercises to minimize vertigo
Nursing Responsibilities/Considerations
Provide regular activity, rest, and relaxation.
Assist with physical therapy: muscle stretching, relaxation and coordination exercise,
walking exercise.
Encourage well balanced, high fiber diet.
Force fluids to prevent constipation.
Avoid hot baths.
Provide skin care to prevent skin breakdown.
Patient and family teaching to promote emotional stability
Help patient establish daily routine, and help family understand patient’s changes
in personality and physical capabilities.
Inform the pt that exacerbations are unpredictable, necessitating physical &
emotional adjustments in lifestyle
• eye patch
• Speech therapy
• Medicate and watch for adverse effects
Evaluate
Respiration; nutrition; ADLs; skin; bowel elimination; urinary incontinence
MYASTHENIA GRAVIS
• Progressive neuromuscular disorder that results in the failure to transmit nerve impulses
at the MYONEURAL JUNCTION causing extreme weakness
• Failure of transmission is due to decreased acetylcholine
• Women > Men; 3 times more common in w
• Young adults 20-30
• Secretion and increased cholinesterase at the nerve ending
• Autoimmune disease
• Characterized by progressive weakness and abnormal fatigability of the skeletal muscles
• Commonly affects muscles innervated by the cranial nerves (face, lips, tongue, neck, and
throat)
• Exacerbated by exercise & repetitive movement
• Occurs along with thymic abnormalities in 75% of pts
Pathophysiology
Transmission of nerve impulses at the neuromuscular junction FAILS.
Anti-receptor antibodies block, weaken, or reduce the number of acetylcholine Ach
receptors available at each neuromuscular junction, thereby impairing the muscle
depolarization necessary for movement
Cause
Autoimmune response leading to ineffective acetylcholine release and inadequate muscle
fiber response to Ach.
Complications
Aspiration
Pneumonia
Respiratory distress
Assessment
S&S
○ Skeletal muscle weakness, fatigue
○ Weak eye closure,ptosis, diplopia,
○ “snarl smile” (smiles slowly)
○ Masklike facial expression; Impaired speech; drooling
○ Weakened respiratory muscles
○ Muscles are usually strongest in the morning but become progressively weaker
during the day and following an exercise.
Rationale/Pathophysiologic Basis
Impaired neuromuscular transmission
Impaired neuromuscular transmission to the cranial nerves supplying the eye muscles
Impaired transmission of the cranial nerves innervating the facial muscles
Impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in
the appropriate junctions
Skeletal muscle weakness
Diagnostic Test
Tensilon Test (Edrophonium Chloride Test)
Short acting cholinergic is administered.
Reveals increased muscle strength is observed (+ Tensilon Test) within 30-60 secs
after IV injection of Edrophonium (Tensilon) or Neostigmine (Prostigmin) lasting
up to 30 mins.
Single fiber electromyography with neural stimulation at the specific muscle fiber-
progressive decrease in muscle fiber contraction
Chest x-ray- reveals thymoma in 15% of pts
Management
Narcotic analgesics; anticonvulsants
○ Tegretol
○ Dilantin
Alcohol injection of the nerve
Avoid extremes of heat and cold.
Correction of dental malocclusion
Surgical Management
○ Surgical division of the trigeminal nerve (neurectomy)
Nursing Management
Assessment
○ Complete history
○ Affected area; oral cavity
○ Record weight and ability to eat food
Diagnosis, Planning, and Interventions
○ Acute pain
Evaluate:
○ Pain; client cooperation
Causes
Hemorrhage
Herpes simplex or herpes zoster
Infection
Local trauma
Meningitis
Tumor
Viral disease
Pathophysiology
An inflammatory reaction occurs around cranial nerve VII, usually at the internal
auditory meatus, where the nerves leave bony tissue
The inflammatory reaction produces a conduction block that inhibits appropriate neural
stimulation to the muscle by the motor fibers of the facial nerve, resulting in the
characteristic unilateral or bilateral facial weakness.
Diagnostic Tests
based on clinical presentation
MRI-rules out tumor
Electromyography- 10 days after the onset of S/S
Treatment
Analgesics- to relieve pain
Steroids- to reduce facial nerve edema & improve edema & improve nerve conduction &
blood flow
Possible electrotherapy
Surgery for persistent paralysis
Nursing Considerations
Watch for adverse effects of steroids use
Apply moist heat to the affected side of the face-to reduce pain
Help the pt maintain muscle tone:
○ massaging the face with a gentle upward motion 2-3xdaily x 5-10mins
○ exercise by grimacing in front of a mirror
Protect eyes, have pt cover eye w/ an eye patch
Prevent excessive wt loss:
○ have him chew on unaffected side of his mouth
○ provide a soft, nutritionally balanced diet, eliminating hot foods & fluids
○ apply a facial sling to improve lip alignment
Provide frequent & complete mouth care
Offer psychological support
Classification
1. ischemic (a thrombus or embolus blocks circulation)
2. hemorrhagic (a blood vessel ruptures)
Risk factors
Increased alcohol intake or cocaine
Cardiac disease
Cigarrette smoking
DM
Familial hyperlipidemia
Family history of stroke
Hx of TIA
HPN
Obesity,sedentary lifestyle
Sickle cell disease
Use of hormonal contraceptive
Causes of Stroke
Ischemic
Thrombosis- occluded blood flow caused by thrombosis of the cerebral arteries
supplying the brain or the intracranial vessels
○ The most frequent cause of CVA
○ The most common cause of cerebral thrombosis is atherosclerosis; usually
affecting elderly persons.
○ Tends to occur during sleep or soon after arising.
○ This may tend to occur among clients with DM, and hypertension.
Embolism- from thrombus outside the brain, such as in the heart, aorta, or common
carotid artery.
○ The second most common cause of CVA.
○ Most commonly affecting younger people.
○ Most frequently caused by Rheumatic Heart Disease and MI.
○ Symptoms occur at any time and progress rapidly.
• Aphasia, dysphasia; visual fields deficits; and hemiparesis of affected side (more
severe in face & arms)- resulting from thrombosis or hemorrhage of middle cerebral
artery
• Weakness, paralysis, numbness; sensory changes; altered LOC; bruits over carotid artery;
and headache caused by thrombosis or hemorrhage of carotid artery
• Weakness, paralysis, numbness around lips & mouth; visual field deficits, diplopia,
nystagmus; poor coordination, dizziness, dysphagia, slurred speech; amnesia, and ataxia
resulting from thrombosis or hemorrhage of vertebrobasilar artery.
• Confusion, weakness, numbness; urinary incontenece; impaired motor & sensory
functions; and personality changes caused by thrombosis or hemorrhage of anterior
cerebral artery.
• Visual field deficits; sensory impairments; dyslexia; cortical blindness and coma resulting
from thrombosis or hemorrhage of posterior cerebral artery.
Assessment of CVA
• check for:
S&S of increased ICP.
Perceptual defects
Aphasia
Unstable respiration
Severe headache
Diagnostic procedure results
Unilateral neglect
Diagnostic Findings
• CT scan- identifies an ischemic stroke within the first 72 hours of symptom onset or
evidence of a hemorrhagic stroke (lesions >1 cm immediately)
• MRI-assists in identifying areas of ischemia or infarction and cerebral swelling
• Others: angiography, carotid duplex scan, EEG
Complications
• Hemiplegia – weakness/paralysis of half the body
• Cognitive impairment - Aphasia – maybe expressive or receptive; the partial or total
inability to produce & understand speech
• Apraxia – can move but cannot do the purpose; inability to perform complex movements
• Sensory impairement - Visual changes – Homonymous Hemianopsia; Agnosia – loss of
sense of smell
• Dysarthria - difficulty in speech articulation due to lack of muscle control
• Kinesthesia – loss of sensation (of bodily movement)
• Incontinence – maybe fecal/urine; inability to control urination or defecation
• Shoulder pain
• Contractures
• Fluid imbalances
• Cerebral edema
• Aspiration
• Altered LOC
• Infections such as pneumonia
Nursing Considerations
Maintain a patent airway and oxygenation:
○ If the pt is unconscious; vomiting- lateral position to prevent aspiration of saliva
Check v/s & neurologic status:
○ Monitor BP, LOC, pupillary changes, motor and sensory functions, speech, skin,
color, temp.
○ Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity
Watch for s/s of pulmonary emboli:
○ Chest pain, shortness of breath, dusky color, tachycardia, fever, and change in
sensorium
If the pt is unresponsive, monitor ABG as ordered
Monitor F & E balance:
○ Monitor I and O.
○ Administer IVF as ordered
○ Offer bedpan /urinal
Ensure adequate nutrition:
○ Check for gag reflex before offering small oral feedings of semisolid food
○ Teach the client to chew on the unaffected side.
○ If oral feeding is not possible, TPN, NGT feeding, gastrostomy feeding
Turn the patient frequently, at least q 2 hrs to prevent pneumonia.
Perform ROM exercises for affected & unaffected sides.
Massage if not contraindicated.
Provide meticulous eye care- Instill meds as ordered; patch the affected eye if the pt can’t
close eyelid.
Compensate for perceptual difficulties.
○ Care of the client with Hemianopsia.
○ Approach from the unaffected side.
○ Place articles on the unaffected side.
Promote communication
○ Care for the client with aphasia.
○ Say one word at time.
○ Give simple commands.
○ Allow the client to verbalize, no matter how long it takes him
Give medications as ordered- Tell the pt to watch out for side effects. (ex. Aspirin-GI
bleeding)
PARKINSON’S DISEASE
Slowly progressive degenerative disorder of basal ganglia function that results in variable
combinations of tremor, rigidity, and bradykinesia
Onset usually after age 40
men>women
Parkinson’s Disease: deficient in dopamine
Causes
Exact cause unknown
Possible causes:
○ Dopamine deficiency, which prevents affected brain cells from performing their
nomal inhibitory function in the CNS
○ Exposure to toxins( manganese dust or carbon monoxide)
○ Repeated trauma to the brain
○ Stroke
○ Brain tumors
Pathophysiology
Dopamine neurons degenerate, causing loss of available dopamine
Dopamine deficiency prevents affected brain cells from performing their normal
inhibitory function
Excess excitatory Ach occurs at the synapses
Nondopamineric receptors are also involve
Motor neurons are depressed
SEIZURE DISORDER
• Sudden explosive and disorderly discharge of cerebral neurons
• Abnormal and excessive discharge of neurons in the brain
• Types of seizures:
a. grand mal
b. petit mal
c. febrile seizures
d. status epilepticus
Petit mal
No aura
10-20 seconds
Common to children as well as adult
Little tonic-clonic movements
Cessation of ongoing physical activities
Jacksonian
With aura
With organic lesion
Group of muscle affectation
Psychomotor Seizure
With aura
With psychiatric involvement
Characterized with mental clouding
Violence, antisocial acts
Febrile Seizure
Related to temperature
Present among children
Status epilepticus
Prolonged seizure state
Can occur in any type of seizure
Rapid successions with no full consciousness in between
Brain damage can occur; most life threatening in tonic-clonic seizures
Common to clients who are in coma
Related to medication
a) Primary Seizure Disorder (Epilepsy)
○ Idiopathic
○ No apparent structural changes in the brain
b) Secondary Epilepsy
○ Characterized by structural changes or metabolic alterations of the
neuronal membranes that caused increased automacity
Causes of Seizures
Idiopathic- two-thirds of all seizure disorders
Anoxia
Birth trauma (inadequate supply of O2 supply to the brain, blood incompatibility,
hemorrhage)
Brain tumors
Drug or alcohol abuse or rapid withdrawal from abused drugs
Febrile illness
Genetic predisposition
Head injury or trauma
Infectious diseases
Ingestions of toxins( lead, mercury, or carbon monoxide)
Metabolic disorders, such as hypoglycemia or hyperparathyroidism
Perinatal infections
Pathophysiology
Some neurons of the brain may depolarize easily or hyperexcitable
On stimulation, these neurons fires locally or throughout the cerebrum and spreads
electric current to surrounding cells.
Cells fire in turn and the impulses cascades to one side of the brain (a partial seizure),
both sides of the brain (a generalized seizure), or the cortical, subcortical, and brain stem
areas.
Pathophysiologic changes
Recurring seizures, possibly of more than one type ( hallmark of epilepsy)
Visual, olfactory, or auditory hallucinations; sweating or flushing; dream states; anger, or
fear reactions resulting from simple partial seizures
Altered consciousness , such as amnesia for events around the time of the seizure,
resulting from complex partial seizures
Movement and muscle involvement resulting from tonic-clonic or myoclonic seizures
Brief changes in LOC without motor involvement due to absence seizures
Complications
Hypoxia or anoxia from airway occlusion
Traumatic injury
Brain damage
Depression and anxiety
Diagnostic Tests
CT scan or MRI- reveals abnormalities
EEG- reveals paroxysmal abnormalities
➢ in tonic-clonic seizures, high, fast voltage spikes are present in all leads
➢ In absence seizures, rounded spike wave complexes are present
➢ Note: a negative EEG doesn’t rule out epilepsy because the abnormalities occur
intermittently
Skull x-ray may show evidence of fractures or shifting of the pineal gland, bony erosion,
or separated sutures
Serum chemistry blood studies may reveal hypoglycemia, electrolyte imbalances, and
elevated liver enzyme & alcohol level
Treatment
Drug Therapy-
➢ Ex. Phenytoin (Dilantin) carbamazepine (Tegretol), phenobarbital (Barbita,
Luminal) –for generalized tonic clonic seizures and complex partial seizures
➢ Valproic acid (Depakene), clonazepam (Klonopin) for absence seizures
If drug therapy is ineffective, surgery to remove a demonstrated focal lesion, or to
remove the underlying cause (tumor, abscess)
I.V. diazepam ( valium), lorazepam (Ativan) phenytooin, or phenobarbital for status
epilepticus
Dextrose- for hypoglycemia
Thiamine-for chronic alcoholism or withdrawal
Nursing Considerations
Patent airway
Oxygenate as needed
Raise side rails
Ensure safety-during seizure:
➢ Avoid restraining the pt
➢ Help the pt to a lying position
➢ Loosen any tight clothing
➢ Clear the area of hard objects
➢ Don’t place anything into the pt’s mouth to prevent lacerating the mouth & lips or
displace teeth
➢ If vomiting occurs, turn the head to provide an open airway
After the seizure subsides, reorient the patient to time & place; inform him that he had a
seizure
Companion at bedside
Meds as ordered
• S&S
Increased HA
Nausea &Vomiting
Cushing’s triad
Restlessness
Eye involvement
Altered LOC
Sensory dysfunction
Elimination problem
Decorticate/decerebrate
• Nursing Management
Determine airway patency
Elevate HOB
Check VS/Neuro assessment
Record I&O
Enema restriction
Avoid coughing, vomiting, restraints, stress ulcer, suctioning
Seizure precaution
Edema reduction
Diuretics
Assessment
Sign and symptoms of increased ICP.
CSF leakage from ears and nose.
Battle’s sign (hematoma at the mastoid process) in basilar head trauma.
Management
Care for the client with increased ICP.
Monitor drainage from ears and nose.
Monitor for signs and symptoms of meningitis, atelectasis, pneumonia, UTI.
INTRACRANIAL TUMORS
• Intracranial tumors may be classified as: gliomas, meningiomas, neuromas,
hemangiomas.
• Gliomas account for about 50% of all brain tumors.
Assessment
Frontal lobe
○ Personality disturbance
○ Inappropriate affect
○ Indifference of bodily functions
Precental gyrus
○ Jacksonian seizures
Occipital lobe
○ Visual disturbances preceeding convulsions.
Temporal lobe
○ Olfactory, visual or gustatory hallucinations.
○ Psychomotor seizures with automatic behavior.
Parietal lobe
○ Inability to replicate pictures.
○ Loss of right-left discrimination
Management
Care for the client with increase ICP.
Surgery
○ Supratentorial craniotomy (post-op)
Semi-fowler’s position
○ Infratentorial craniotomy
Flat position; turn to sides, avoid supine position for the first 48 hours.
Avoid neck flexion.
Report immediately for presence of yellowish drainage on the head
dressing.
An increase in urine output may herald onset of diabetes insipidus.
Test the urine for glucose and acetone when steroids are administered.
Nursing Assessment
Injury; treatment given at scene
Neurologic assessment: Document findings
Vital signs; respiratory status
Movement and sensation below injury level
Signs
○ Worsening neurologic damage
○ Respiratory distress
○ Spinal shock
Nursing Diagnoses
Ineffective breathing pattern
Ineffective airway clearance
Neuropathic pain
Impaired physical mobility
Anxiety
Risks
○ Impaired gas exchange
○ Disuse syndrome
○ Ineffective coping
Medical Management
Cervical collar; cast or brace; traction; turning frame
IV; stabilization of vital signs
Corticosteroids
Surgical intervention
Surgical Management
Surgery to
○ Remove bone fragments
○ Repair dislocated vertebrae
○ Stabilize the spine
Management
Maintain airway patency
Immobilize
Suction PRN
Position
Nutrition
Elimination hygiene
Drugs
Evaluation
Adequate breathing
Pain relief
Mobility using minimal assistive devices
Reduced complications from inactivity
Coping with the challenge of rehabilitation
BRAIN INJURIES
• Closed (blunt) Brain Injury
• Open Brain Injury
• Concussion
• Contusion
• Diffuse Axonal Injury
• Intracranial Hemorrhage
Epidural Hematoma
Subdural Hematoma
• Intracerebral Hemorrhage and Hematoma
Pathophysiology