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Adult Nursing 2

Management of Patients With


Cerebrovascular Disorders

Learning Objectives
1.Describe the incidence and social impact of cerebrovascular
disorders.
2.Identify the risk factors for cerebrovascular disorders and
related measures for prevention.
3.Compare the various types of cerebrovascular disorders: their
causes, clinical manifestations, and medical management.
4.Apply the principles of nursing management to the care of a
patient in the acute stage of an ischemic stroke.
5.Use the nursing process as a framework for care of a patient
recovering from an ischemic stroke.
6.Use the nursing process as a framework for care of a patient
with a hemorrhagic stroke.
7.Identify essential elements for family teaching and
preparation for home care of the patient who has had a stroke.

Cerebrovascular Disorders
Functional abnormality of the CNS
that occurs when the blood supply is
disrupted
Stroke is the primary cerebrovascular
disorder and the third leading cause
of death in the U.S.
Stroke is the leading cause of serious
long-term disability in the U.S.

Prevention
Nonmodifiable risk factors

Age (over 55), male gender, African-American race

Modifiable risk factors

Hypertension is the primary risk factor

Cardiovascular disease

Elevated cholesterol or elevated hematocrit

Obesity

Diabetes

Oral contraceptive use

Smoking and drug and alcohol abuse

Stroke
Brain attack
Sudden loss of function resulting
from a disruption of the blood
supply to a part of the brain
Types of stroke
Ischemic (8085%)
Hemorrhagic (1520%)

Ischemic Stroke
Disruption of the blood supply due to an
obstruction, usually a thrombus or
embolism, that causes infarction of brain
tissue
Types
Large artery thrombosis
Small penetrating artery thrombosis
Cardiogenic embolism
Cryptogenic
Other

Manifestations of Ischemic
Stroke
Symptoms depend upon the location and
size of the affected area
Numbness or weakness of face, arm, or
leg, especially on one side
Confusion or change in mental status
Trouble speaking or understanding speech
Difficulty in walking, dizziness, or loss of
balance or coordination
Sudden, severe headache
Perceptual disturbances

Terms:

Hemiplegia
Hemiparesis
Dysarthria
Aphasia: expressive aphasia,
receptive aphasia
Hemianopsia

Transient Ischemic Attack


(TIA)
Temporary neurologic deficit
resulting from a temporary
impairment of blood flow
Warning of an impending stroke
Diagnostic workup is required to treat
and prevent irreversible deficits

Carotid Endarterectomy

Preventive Treatment and


Secondary Prevention
Health maintenance measures including a healthy
diet, exercise, and the prevention and treatment
of periodontal disease
Carotid endarterectomy
Anticoagulant therapy
Antiplatelet therapy: aspirin, dipyridamole
(Persantine), clopidogrel (Plavix), ticlopidine
(Ticlid)
Statins
Antihypertensive medications

Medical ManagementAcute Phase


of Stroke
Prompt diagnosis and treatment
Assessment of stroke: NIHSS assessment tool
Thrombolytic therapy

Criteria for tPA

IV dosage and administration

Patient monitoring

Side effectspotential bleeding

Elevate HOB unless contraindicated


Maintain airway and ventilation
Continuous hemodynamic monitoring and neurologic
assessment

Hemorrhagic Stroke
Caused by bleeding into brain tissue, the ventricles,
or subarachnoid space.
May be due to spontaneous rupture of small vessels
primarily related to hypertension; subarachnoid
hemorrhage due to a ruptured aneurysm; or
intracerebral hemorrhage related to amyloid
angiopathy, arterial venous malformations (AVMs),
intracranial aneurysms, or medications such as
anticoagulants.
Brain metabolism is disrupted by exposure to blood.
ICP increases due to blood in the subarachnoid space.
Compression or secondary ischemia from reduced
perfusion and vasoconstriction causes injury to brain
tissue.

Manifestations
Similar to ischemic stroke
Severe headache
Early and sudden changes in (LOC)
Level of Consciousness
Vomiting

Medical Management
Prevention: control of hypertension
Diagnosis: CT scan, cerebral angiography,
lumbar puncture if CT is negative and ICP is not
elevated to confirm subarachnoid hemorrhage
Care is primarily supportive
Bed rest with sedation
Oxygen
Treatment of vasospasm, increased ICP,
hypertension, potential seizures, and prevention
of further bleeding

Nursing Process:
The Patient Recovering from an Ischemic Stroke
Assessment

Acute phase
Ongoing/frequent monitoring of all systems including
vital signs and neurologic assessmentLOC, motor
symptoms, speech, eye symptoms
Monitor for potential complications including
musculoskeletal problems, swallowing difficulties,
respiratory problems, and signs and symptoms of
increased ICP and meningeal irritation

After the stroke is complete


Focus on patient function; self-care ability, coping,
and teaching needs to facilitate rehabilitation

Nursing Process:
The Patient Recovering from an Ischemic Stroke
Diagnoses

Impaired physical mobility


Acute pain
Self-care deficits
Disturbed sensory perception
Impaired swallowing
Urinary incontinence
Disturbed thought processes
Impaired verbal communication
Risk for impaired skin integrity
Interrupted family processes
Sexual dysfunction

Potential
Problems/Complications
Decreased cerebral blood flow
Inadequate oxygen delivery to brain
Pneumonia

Nursing Process:
The Patient Recovering from an Ischemic Stroke
Planning

Major goals may include:


Improved mobility
Avoidance of shoulder pain
Achievement of self-care
Relief of sensory and perceptual deprivation
Prevention of aspiration
Continence of bowel and bladder
Improved thought processes
Achieving a form of communication
Maintaining skin integrity
Restored family functioning
Improved sexual function
Absence of complications

Interventions
Focus on the whole person
Provide interventions to prevent
complications and to and promote
rehabilitation
Provide support and encouragement
Listen to the patient

Improving Mobility and Preventing


Joint Deformities
Turn and position in correct alignment every 2
hours
Use of splints
Passive or active ROM 45 times day
Positioning of hands and fingers
Prevention of flexion contractures
Prevention of shoulder abduction
Do not lift by flaccid shoulder
Measures to prevent and treat shoulder
proclaims

Positioning to Prevent Shoulder


Abduction

Prone Positioning to Help Prevent


Hip Flexion

Improving Mobility and Preventing


Joint Deformities

Passive or active ROM 45 times day


Encourage patient to exercise unaffected side
Establish regular exercise routine
Quadriceps setting and gluteal exercises
Assist patient out of bed as soon as possibleassess and help patient achieve balance,
move slowly
Ambulation training

Interventions
Enhancing self-care

Set realistic goals with the patient


Encourage personal hygiene
Assure that patient does not neglect the
affected side
Use of assistive devices and modification
of clothing

Support and encouragement


Strategies to enhance communication
Encourage patient to turn head, look to
side with visual field loss

Interventions
Nutrition

Consult with speech therapy or nutritional


services
Have patient sit upright, preferably OOB, to
eat
Chin tuck or swallowing method
Use of thickened liquids or pureed diet

Bowel and bladder control

Assessment of voiding and scheduled voiding


Measures to prevent constipationfiber, fluid,
toileting schedule
Bowel and bladder retraining

Nursing Process:
The Patient with a Hemorrhagic StrokeAssessment

Complete and ongoing neurologic


assessmentuse neurologic flow chart
Monitor respiratory status and oxygenation
Monitoring of ICP
Patients with intracerebral or subarachnoid
hemorrhage should be monitored in the ICU
Monitor for potential complications
Monitor fluid balance and laboratory data
All changes must be reported
immediately

Nursing Process: The Patient with a


Hemorrhagic StrokeDiagnoses
Ineffective tissue perfusion (cerebral)
Disturbed sensory perception
Anxiety

Potential
Problems/Complications

Vasospasm
Seizures
Hydrocephalus
Rebleeding
Hyponatremia

Nursing Process: The Patient with a


Hemorrhagic StrokePlanning
Goals may include:
Improved cerebral tissue perfusion
Relief of sensory and perceptual
deprivation
Relief of anxiety
The absence of complications

Aneurysm Precautions
Absolute bed rest
Elevate HOB 30 to promote venous drainage or flat
to increase cerebral perfusion
Avoid all activity that may increase ICP or BP;
Valsalva maneuver, acute flexion or rotation of neck
or head
Exhale through mouth when voiding or defecating to
decrease strain
Nurse provides all personal care and hygiene
Nonstimulating, nonstressful environment; dim
lighting, no reading, no TV, no radio
Prevent constipation
Visitors are restricted

Interventions
Relieving sensory deprivation and anxiety
Keep sensory stimulation to a minimum
for aneurysm precautions
Realty orientation
Patient and family teaching
Support and reassurance
Seizure precautions
Strategies to regain and promote selfcare and rehabilitation

Home Care and Teaching for the


Patient Recovering from a Stroke
Prevention of subsequent strokes, health promotion, and
follow-up care
Prevention of and signs and symptoms of complications
Medication teaching
Safety measures
Adaptive strategies and use of assistive devices for
ADLs
Nutritiondiet, swallowing techniques, tube feeding
administration
Eliminationbowel and bladder programs, catheter use
Exercise and activities, recreation and diversion
Socialization, support groups, and community resources

Question
What are expected patient outcomes
for a patient recovering from a
hemorrhagic stroke?
A. Exhibits absence of vasospasm
B. Residual aphasia
C. One to four seizures
D.Complains of visual changes

Answer
A
Expected patient outcomes for a
patient recovering from a
hemorrhagic stroke include absence
of vasospasm, no seizures, normal
speech patterns, and no visual
changes

Management of Patients With Neurologic


Trauma

Learning Objectives
On completion of this chapter, the learner should be able to:
1.Describe the mechanisms of injury, clinical signs and symptoms,
diagnostic testing, and treatment options for patients with
traumatic
brain and spinal cord injuries.
2.Describe the nursing management of patients with brain injury.
3.Use the nursing process as a framework for care of patients with
traumatic brain injury.
4.Identify the population at risk for spinal cord injury.
5.Describe the clinical features and management of the patient with
neurogenic shock.
6.Discuss the pathophysiology of autonomic dysreflexia and describe the
appropriate nursing interventions.
7.Use the nursing process as a framework for care of patients with spinal
cord injury.

Adult Nursing 2
Management of Patients
With
Neurologic Trauma

Head Injury
A broad classification that includes injury to the
scalp, skull, or brain
1.4 million people receive head injuries every year
in the U.S.
The most common cause of death from trauma
Most common cause of brain trauma is MVA
Group at highest risk group for brain trauma is
males age 1524
Those younger than 5 years and the elderly are
also at increased risk
Prevention

Pathophysiology of Brain
Damage
Primary injury: due to the initial
damage
Contusions, lacerations, damage to
blood vessels, acceleration/deceleration
injury, or due to foreign object
penetration

Secondary injury: damage evolves


after the initial insult
Due to cerebral edema, ischemia, or
chemical changes associated with the
trauma

Pathophysiology of Traumatic Brain


Injury

Manifestations
Manifestations depend upon the
severity and location of the injury
Scalp wounds

Tend to bleed heavily, and are also portals


for infection

Skull fractures

Usually have localized, persistent pain


Fractures of the base of the skull

Bleeding from nose pharynx or ears


Battles signecchymosis behind the ear
CSF leakhalo signring of fluid around the
blood stain from drainage

Basilar Fractures Allow CSF to Leak


from the Nose and Ears

Manifestations of Brain
Injury
Altered LOC
Pupillary abnormalities
Sudden onset of neurologic deficits
and neurologic changes; changes in
sense, movement, reflexes
Changes in vital signs
Headache
Seizures

Brain Injury

Closed brain injury (blunt trauma):


acceleration/deceleration injury occurs when the head
accelerates and then rapidly decelerates, damaging brain
tissue
Open brain injury: object penetrates the brain or trauma is
so severe that the scalp and skull are opened
Concussion: a temporary loss of consciousness with no
apparent structural damage
Contusion: more severe injury with possible surface
hemorrhage
Symptoms and recovery depend upon the amount of
damage and associated cerebral edema
Longer period of unconsciousness with more symptoms
of neurologic deficits and changes in vital signs

Brain Injury
Diffuse axonal injury: widespread axon
damage in the brain seen with head
trauma. Patient develops immediate
coma.
Intracranial bleeding
Epidural hematoma
Subdural hematoma
Acute and subacute
Chronic

Intracerebral hemorrhage and hematoma

Concussion
Patient may be admitted for observation
or sent home
Observation of patients after head
trauma; report immediately
Observe for any changes in LOC
Difficulty in awakening, lethargy, dizziness,
confusion, irritability, anxiety
Difficulty in speaking or movement
Severe headache
Vomiting

Patient should be aroused and assessed


frequently

Location of Subdural, Intracerebral


and Epidural Hemorrhages

Epidural Hematoma
Blood collection in the space between the skull and
the dura.
Patient may have a brief loss of consciousness with
return of lucid state then as hematoma expands
increased ICP will often suddenly reduce LOC.
An emergency situation!
Treatment include measures to reduce ICP, remove
the clot and stop bleedingburr holes or
craniotomy.
Patient will need monitoring and support of vital
body functions; respiratory support.

Subdural Hematoma
Collection of blood between the dura and the
brain
Acute/Subacute

Acute: symptoms develop over 2448 hours


Subacute: symptoms develop over 48 hours to 2
weeks
Requires immediate craniotomy and control of ICP

Chronic

Develops over weeks to months


Causative injury may be minor and forgotten
Clinical signs and symptoms may fluctuate
Treatment is evacuation of the clot

Intracerebral Hemorrhage
Hemorrhage occurs into the substance of
the brain
May be due to trauma or a nontraumatic
cause
Treatment

Supportive care
Control of ICP
Administration of fluids, electrolytes, and
antihypertensive medications
Craniotomy or craniectomy to remove clot and
control hemorrhage; this may not be possible
due the location or lack of circumscribed area of
hemorrhage

Diagnostic Evaluation

Physical and neurologic exam


Skull and spinal x-rays
CT scan
MRI
PET

Management of the Patient with a


Head Injury
Assume cervical spine injury until this is
ruled out
Therapy to preserve brain homeostasis and
prevent secondary damage
Treat cerebral edema
Maintain cerebral perfusion; treat hypotension,
hypovolemia and bleeding, monitor and manage
ICP
Maintain oxygenation; cardiovascular and
respiratory function
Manage fluid and electrolyte balance

Supportive Measures
Respiratory support; intubation and
mechanical ventilation
Seizure precautions and prevention
NG to manage reduced gastric
motility and prevent aspiration
Fluid and electrolyte maintenance
Pain and anxiety management
Nutrition

Nursing Process: The Care of the


Patient with Brain InjuryAssessment
Health history with focus upon the
immediate injury, time, cause, and
the direction and force of the blow
Baseline assessment
LOCGlasgow Coma Scale
Frequent and ongoing neurologic
assessment
Multisystem assessment

Nursing Process: The Care of the


Patient with Brain InjuryDiagnoses

Ineffective airway clearance and impaired gas exchange


Ineffective cerebral perfusion
Deficient fluid volume
Imbalanced nutrition
Risk for injury
Risk for imbalanced body temperature
Risk for impaired skin integrity
Disturbed thought patterns
Disturbed sleep pattern
Interrupted family process
Deficient knowledge

Potential Problems/Complications

Decreased cerebral perfusion


Cerebral edema and herniation
Impaired oxygenation and ventilation
Impaired fluid, electrolyte, and
nutritional balance
Risk of posttraumatic seizures

Nursing Process: The Care of the


Patient with Brain InjuryPlanning
Major goals may include maintenance of
patent airway, adequate CPP, fluid and
electrolyte balance, adequate nutritional
status, prevention of secondary injury,
maintenance of normal temperature,
maintenance of skin integrity, improvement
of cognitive function, prevention of sleep
deprivation, effective family coping,
increased knowledge about rehabilitation
process, and absence of complications.

Interventions
Ongoing assessment and monitoring is
vital
Maintenance of airway
Positioning to facilitate drainage of oral secretions
with HOB usually elevated 30 to decrease venous
pressure
Suctioning with caution
Prevention of aspiration and respiratory insufficiency
Monitor ABGs, ventilation, and mechanical ventilation
Monitor for pulmonary complications, potential ARDS

Interventions
I&O and daily weights
Monitor blood and urine electrolytes and
osmolality and blood glucose
Measures to promote adequate nutrition
Strategies to prevent injury

Assessment of oxygenation
Assessment of bladder and urinary output
Assessment for constriction due to dressings
and casts
Pad side-rails
Mittens to prevent self-injury; avoid
restraints

Interventions
Strategies to prevent injury

Reduce environmental stimuli


Adequate lighting to reduce visual hallucinations
Measures to minimize disruption of sleep-wake
cycles
Skin care
Measures to prevent infection

Maintaining body temperature

Maintain appropriate environmental temperature


Use of coveringssheets, blankets to patient
needs
Administration of acetaminophen for fever
Cooling blankets or cool baths; avoid shivering

Interventions
Support of cognitive function
Support of family

Provide and reinforce information


Measures to promote effective coping
Setting of realistic, well-defined, shortterm goals
Referral for counseling
Support groups

Patient and family teaching

Spinal Cord Injury (SCI)


A major health problem
200,000 persons in the U.S. live with disability from SCI
Causes include MVAs (35%), violence (24%), falls (22%), and sports
injuries (8%)
Males account for 82% of SCIs
Young people ages 1630 account for more than half of all new SCIs
AfricanAmericans are at higher risk
Risk factors include alcohol and drug use
Prevention

Spinal Cord Injury


The result of concussion, contusion, laceration or
compression of spinal cord.
Primary injury is the result of the initial trauma.
Secondary injury is usually the result of ischemia,
hypoxia, and hemorrhage that destroys the nerve
tissues.
Secondary injuries are thought to be
reversible/preventable during the first 46 hours
after injury.
Treatment is needed to prevent partial injury from
developing into more extensive, permanent damage.

Spinal and Neurogenic


Shock
Spinal shock

A sudden depression of reflex activity below the


level of spinal injury
Muscular flaccidity, lack of sensation and
reflexes

Neurogenic shock

Due to the loss of function of the autonomic


nervous system
Blood pressure, heart rate, and cardiac output
decrease
Venous pooling occurs due to peripheral
vasodilation
Paralyzed portions of the body do not perspire

Autonomic Dysreflexia
Acute emergency!
Occurs after spinal shock has resolved and may
occur years after the injury.
Occurs in persons with a SC lesion above T6.
Autonomic nervous system responses are
exaggerated.
Symptoms include severe pounding headache,
sudden increase in blood pressure, profuse
diaphoresis, nausea, nasal congestion and
bradycardia.
Triggering stimuli include distended bladder (most
common cause), distention or contraction of
visceral organs (such as constipation), or
stimulation of the skin.

Nursing Interventions
Place patient in seated position to lower BP
Rapid assessment to identify and eliminate
cause
Empty the bladder using a urinary catheter or
irrigate/change indwelling catheter
Examine rectum for fecal mass
Examine skin
Examine for any other stimulus

Administer ganglionic blocking agent such as


hydralazine hydrochloride (Apresoline) IV
Label chart or medical record that patient is at
risk for autonomic dysreflexia
Instruct patient in prevention and management

Nursing Process: The Care of the


Patient with SCIAssessment
Monitor respirations and breathing
pattern
Lung sounds and cough
Monitor for changes in motor or
sensory function; report immediately
Assess for spinal shock
Monitor for bladder retention or
distention, gastric dilation, and ilieus
Temperature; potential hyperthermia

Nursing Process: The Care of the


Patient with SCIDiagnoses

Ineffective breathing pattern


Ineffective airway clearance
Impaired physical mobility
Disturbed sensory perception
Risk for impaired skin integrity
Impaired urinary elimination
Constipation
Acute pain

Potential Problems /Complications


DVT
Orthostatic hypotension
Autonomic dysreflexia

Nursing Process: The Care of the


Patient with SCIPlanning
Major goals may include improved
breathing pattern and airway
clearance, improved mobility,
improved sensory and perceptual
awareness, maintenance of skin
integrity, promotion of comfort, and
absence of complications.

Promotion of Effective Breathing and


Airway Clearance
Monitor carefully to detect potential
respiratory failure
Pulse oximetry and ABGs
Lung sounds

Early and vigorous pulmonary care to


prevent and remove secretions
Suctioning with caution
Breathing exercises
Assisted coughing
Humidification and hydration

Improving Mobility
Maintain proper body alignment
Turn only if spine is stable and as
indicated by physician
Monitor blood pressure with position
changes
PROM at least four times a day
Use neck brace or collar, as
prescribed, when patient is mobilized
Move gradually to erect position

Interventions
Strategies to compensate for sensory and
perceptual alterations
Measures to maintain skin integrity
Temporary indwelling catherization or
intermittent catherization
NG tube to alleviate gastric distention
High-calorie, high-protein, high-fiber diet
Bowel program and use of stool softeners
Traction pin care
Hygiene and skin care related to traction
devices

Adult 2
Management of Patients With
Neurologic Infections,
Autoimmune Disorders, and
Neuropathies

Learning Objectives
On completion of this chapter, the learner will be able to:
1.Differentiate among the infectious disorders of the nervous
system according to causes, manifestations, medical care,
and nursing management.
2.Describe the pathophysiology, clinical manifestations, and
medical and nursing management of multiple sclerosis,
myasthenia gravis, and Guillain-Barr syndrome.
3.Use the nursing process as a framework for care of
patients with multiple sclerosis and Guillain-Barr syndrome.
4.Describe disorders of the cranial nerves, their
manifestations, and indicated nursing interventions.
5.Develop a plan of nursing care for the patient with a
cranial nerve disorder.

Infectious Neurologic
Disorders

Meningitis
Brain abscesses
Encephalitis
Creutzfeldt-Jakob disease and variant
Creutzfeldt-Jakob disease

Meningitis
Inflammation of the membranes and the fluid space
surrounding the brain and spinal cord
Types
Septic due to bacteria (Streptococcus pneumoniae,
Neisseria meningitidis)
Aseptic due viral infection, lymphoma, leukemia, or
brain abscess
N. meningitidis is transmitted by secretions or aerosol
contamination and infection is most likely in dense
community groups such as college campuses
Manifestations include headache, fever, changes in LOC,
behavioral changes, nuchal rigidity (stiff neck), positive
Kernig's sign, positive Brudzinskis sign, and photophobia

Brudzinskis Sign

Medical Management
Prevention by vaccination against
Haemophilus influenzae and S.
pneumoniae for all children and all
at-risk adults
Early administration of high doses of
appropriate IV antibiotics for
bacterial meningitis
Dexamethasone
Treatment dehydration, shock, and
seizures

Nursing Management
Frequent/continual assessment including VS and
LOC
Protect patient form injury related to seizure
activity or altered LOC
Monitor daily weight, serum electrolytes, urine
volume, specific gravity, and osmolality
Prevent complications associated with immobility
Infection control precautions
Supportive care
Measures to facilitate coping of patient and family

Brain Abscess
Collection of infectious material within brain tissue
Risk is increased in immunocompromised patient
Prevent by treating otitis media, mastoiditis,
sinusitis, dental infections, and systemic infections
promptly
Manifestations may include headache that is usually
worse in the morning, fever, vomiting, neurologic
deficits, signs and symptoms of increased ICP
Diagnosis by MRI or CT
CT-guided aspiration is used to identify the causative
organisms

Brain Abscess
Medical management

Control ICP
Drain abscess
Administer appropriate antibiotic therapy.
Corticosteroids may be used to treat
cerebral edema

Nursing management

Frequent and ongoing neurologic


assessment and of responses to treatment
Assure patient safety and protect from
injury
Provide supportive care

Encephalitis

Acute, inflammatory process of the brain tissue


Causes include viral infections (herpes simplex [HSV]),
vector-borne viral infections (West Nile, St. Louis), and
fungal infections
Manifestations may include headache fever, confusion,
changes in LOC; vector bornerash, flaccid paralysis,
Parkinson-like movements
Medical management
Acyclovir for HSV infection, amphotericin and/or other
antifungal agents for fungal infection
Nursing management
Frequent and ongoing assessment
Supportive care

Creutzfeldt-Jakob Disease (CJD) and


Variant Creutzfeldt-Jakob Disease (vCJD)
Rare, degenerative infectious, transmissible spongiform
encephalopathies (TSE)
TSEs are caused by prions: small proteinaceous particles which
are smaller than viruses and resistant to sterilization
The disease is not spread by casual contact; vCJD may be
contracted through ingestion of infected beef
Manifestations include affective, sensory, motor, and cognitive
impairments
No effective treatmentprogressive and fatal
Nursing management

Prevention of disease transmission; blood and body fluid


precautions

Supportive care

Autoimmune Neurologic
Disorders
Multiple sclerosis
Myasthenia gravis
Guillain-Barr syndrome

Myasthenia Gravis
Autoimmune disorder affecting the myoneural
junction
Antibodies directed at acetylcholine at the
myoneural junction impair transmission of
impulses
Manifestations
Myasthenia gravis, a motor disorder
Initially symptoms involve ocular muscles; diplopia
and ptosis
Weakness of facial muscles, swallowing and voice
impairment (dysphonia), generalized weakness

Myasthenia Gravis

Medical Management
Pharmacologic therapy
Cholinesterase inhibitor: pyrostigmine
bromide (Mestinon)
Immunomodulating therapy

Plasmapheresis
Thymectomy

Myasthenic Crisis
Result of disease exacerbation or
precipitating event, most commonly
a respiratory infection.
Severe generalized muscle weakness
with respiratory and bulbar
weakness.
Patient may develop respiratory
compromise failure.

Cholinergic Crisis
Caused by overmedication with
cholinesterase inhibitors
Severe muscle weakness with
respiratory and bulbar weakness
Patent may develop respiratory
compromise and failure

Management of Myasthenic
Crisis
Patient instruction in signs and symptoms of
myasthenic crisis and cholinergic crisis.
Assuring adequate ventilation; intubation
and mechanical ventilation may be needed.
Assessment and supportive measures
include:
Measures to ensure airway and respiratory
support
ABGS, serum electrolytes, I&O, and daily weight
If patient cannot swallow, nasogastric feeding
may be required
Avoid sedatives and tranquilizers

Nursing Process: The Care of the


Patient with Myasthenia Gravis

Focus on patient and family teaching


Medication teaching and management
Energy conservation
Strategies to help with ocular manifestations
Prevention and management of complications
and avoidance of crisis
Measures to reduce risk of aspiration
Avoidance of stress, infections, vigorous
physical activity some medications, and high
environmental temperatures

Guillain-Barr Syndrome
Autoimmune disorder with acute attack of
peripheral nerve myelin
Rapid demyelination may produce respiratory failure
and autonomic nervous system dysfunction with CV
instability
Most often follows a viral infection
Manifestations are variable and may include
weakness, paralysis, paresthesias, pain, and
diminished or absent reflexes starting with the lower
extremities and progressing upward; bulbar
weakness; cranial nerve symptoms; tachycardia;
bradycardia; hypertension; or hypotension

Guillain-Barr Syndrome
Medical management
Requires intensive care management
with continuous monitoring and
respiratory support
Plasmapheresis and IVIG are used to
reduce circulating antibodies

Recovery rates vary, but most


patients recover completely

Nursing Process: The Care of the Patient with


GuillainBarr Syndrome Assessment

Ongoing assessment for with emphasis on


early detection of life-threatening
complications of respiratory failure, cardiac
dysrhythmias, and deep vein thrombosis
Monitor for changes in vital capacity and
negative inspiratory force
Assess VS frequently/continuously
including continuous monitoring of ECG
Patient and family coping

Nursing Process: The Care of the Patient


with Guillain-Barr SyndromeDiagnoses

Ineffective breathing pattern


Impaired gas exchange
Impaired physical mobility
Imbalanced nutrition
Impaired verbal communication
Fear
Anxiety

Potential Complications

Respiratory failure
Autonomic dysfunction
Deep vein thrombosis (DVT)
Pulmonary embolism
Urinary retention

Nursing Process: The Care of the Patient


with Guillain-Barr SyndromePlanning

Major goals include:


Improved respiratory function
Increased mobility
Improved nutritional status
Effective communication
Decreased fear and anxiety
Effective patient and family coping
Absence of complications

Interventions
Enhancing physical mobility and prevention of
DVT
Support limbs in functional position
Passive ROM at least twice daily
Frequent position changes at least every 2 hours
Elastic compression hose and/or sequential
compression boots
Adequate hydration

Administer IV and parenteral nutrition as


prescribed
Carefully assess swallowing and gag reflex and
take measures to prevent aspiration

Interventions
Develop a plan for communication
individualized to patient needs
Decreasing fear and anxiety
Provide information and support
Referral to support group
Relaxation measures
Maintain positive attitude and atmosphere to
promote a sense of well-being
Diversional activities

Question
What is dysphonia?
A. Double vision or the awareness of two
images of the same object occurring in one
or more eyes.
B. Impaired ability to execute voluntary
movements.
C. Difficulty swallowing and causing the
patient to be at risk for aspiration.
D.Voice impairment or altered voice
production.

Answer
Diplopia is double vision or the
awareness of two images of the
same object occurring in one or more
eyes. Dyskinesia is impaired ability to
execute voluntary movements.
Dysphagia is difficulty swallowing
and causing the patient to be at risk
for aspiration. Dysphonia is voice
impairment or altered voice
production.

Multiple Sclerosis (MS)


A progressive immune-related demyelination
disease of the CNS
Clinical manifestations vary and have different
patterns
Frequently, the disease is relapsing and remitting,
has exacerbations and recurrences of symptoms
including fatigue, weakness, numbness, difficulty in
coordination, loss of balance, pain, and visual
disturbances
Medical management

Disease-modifying therapies; interferon -1a and


interferon -1b, glatiramer acetate (Copaxone), and IV
methylprednisolone
Symptom management of muscle spasms, fatigue, ataxia,
bowel and bladder control

Process of Demyelination

Types and Courses of MS

Nursing Process: The Care of the


Patient with MSAssessment
Neurologic deficits
Secondary complications
Impact of disease on physical, social,
and emotional function and on
lifestyle
Patient and family coping

Nursing Process: The Care of the


Patient with MSDiagnoses

Impaired physical mobility


Risk for injury
Impaired bowel and bladder function
Impaired verbal communication
Disturbed thought processes
Ineffective coping
Impaired home maintenance
Potential sexual dysfunction

Nursing Process: The Care of the


Patient with MSPlanning
Major goals may include:

Promotion of physical mobility


Avoidance of injury
Achievement of bowel and bladder
continence
Promotion of speech and swallowing
mechanisms
Improvement in cognitive function
Development of coping strengths
Improved home maintenance
Adaptation to sexual function

Interventions
Utilize a collaborative approach
Coordinate and refer as needed to health
care services; social services, speech
therapy, physical therapy, counseling
services, home care services, etc.
Activity and rest
Program of activity and daily exercise
Relaxation, coordination exercises, walking,
muscle stretching exercises
Avoid very strenuous activity and extreme fatigue

Interventions
Bowel and bladder control

Instruction or administration of prescribed


medications
Voiding schedule
Bowel training program
Adequate fluid and fiber to prevent constipation

Reinforce and encourage swallowing


instructions
Strategies to reduce risk of aspiration
Memory aides, structured environment, and
daily routine to enhance cognitive function

Interventions
Interventions to minimize stress
Maintenance of temperate
environmentair conditioning to
avoid excessive heat and avoidance
of exposure to extreme cold
Use assistive devices and
modifications for home care
management and independence in
ADLs
Support of coping

Cranial nerve disorders


Trigeminal neuralgia (tic douloureux)
Bells palsy

Trigeminal Neuralgia (Tic


Douloureux
Condition of the 5th cranial nerve characterized by
paroxysms of pain.
Most commonly occurs in the 2nd and 3rd branches
of this nerve. Vascular compression and pressure is
the probable cause.
Occurs more often in the fifth and sixth decade, and
in women and persons with MS.
Pain can occur with any stimulation such as washing
face, brushing teeth, eating, or a draft of air.
Patients may avoid eating, neglect hygiene, and
may even isolate themselves to prevent attacks.

Distribution of the Trigeminal Nerve


Branches

Medical Management
Antiseizure medications such as
carbamazepine (Tegretol), gabapentin
(Neurontin), phenyltoin, or antispasmodic
medication baclofen (Lioresal)
Surgical treatment
Microvascualr decompression of the
trigeminal nerve
Radiofrequency thermal coagulation
Percutaneous balloon microcompression

Nursing Interventions
Patient teaching related to pain prevention and
treatment regimen
Measures to reduce and prevent pain; avoidance
of triggers
Care of the patient experiencing chronic pain
Measures to maintain hygienewashing face,
oral care
Strategies to ensure nutrition; soft food, chew on
unaffected side, avoid hot and cold food
Recognize and provide interventions to address
anxiety, depression, insomnia

Bell Palsy
Facial paralysis due to unilateral
inflammation of the 7th cranial nerve
Manifestationsunilateral facial
muscle weakness or paralysis with
facial distortion, increased lacrimation,
and painful sensations in the face, may
have difficulty with speech and eating
Most patients recover completely in 3
5 weeks and the disorder rarely recurs.

Management
Medical

Corticosteroid therapy may be used to


reduce inflammation and diminish severity
of the disorder.

Nursing

Provide and reinforce information and


reassurance that stroke has not occurred.
Protection of the eye from injury; cover eye
with shield at night, instruct patient to close
eyelid, use of eye ointment, sunglasses.
Facial exercises and massage to maintain
muscle tone.

Management of Patients With Oncologic or Degenerative


Neurologic Disorders

Management of Patients With Oncologic or Degenerative


Neurologic Disorders

Learning Objectives
On completion of this chapter, the learner will be able to:
1.Identify the pathophysiologic processes responsible for oncologic disorders.
2.Describe brain and spinal cord tumors: their classification, clinical
manifestations, diagnosis, and medical and nursing management.
3.Use the nursing process as a framework for care of patients with cerebral
metastases or inoperable brain tumors.
4.Identify the pathophysiologic processes responsible for various
degenerative neurologic disorders.
5.Use the nursing process as a framework for care of patients with
Parkinsons disease.
6.Identify resources for patients and families with oncologic and degenerative
neurologic disorders.
7. Use the nursing process as a framework for care of patients following a
cervical diskectomy.

Question
What is akathisia?
A. Restlessness, urgent need to move
around, and agitation.
B. Very slow voluntary movements and
speech.
C. Impaired ability to execute voluntary
movements.
D.A sensation of numbness, tingling, or
a pins and needles sensation

Answer
A
Akathisia is restlessness, urgent need to
move around and agitation. Bradykinesia is
very slow voluntary movements and
speech. Dyskinesia is impaired ability to
execute voluntary movements. Paresthesia
is a sensation of numbness, tingling, or a
pins and needles sensation.

Pathophysiologic Results of
Neurologic Oncologic Disorders
Manifestations depend upon the
tissues infiltrated and compressed by
the neoplasm
Pathophysiologic events may include:
Increase ICP
Seizures
Hydrocephalus
Altered pituitary function

Question
Is the following statement True or
False?
Brain tumor classification is based upon
location and histological characteristics.

Answer
True
Brain tumor classification is based upon
location and histological characteristics.

Oncologic Tumors
Brain tumors

Benign or malignant
Classification is based upon location and
histological characteristics

Types of primary tumors


Gliomas
Meningiomas
Acoustic neuromas
Pituitary adenomas

Angiomasmasses of abnormal blood


vessels
Metastatic tumors

Brain Tumors
Symptoms are dependent upon the location
and size of the lesion and the compression
of associated structures
Manifestations:
Localized or generalized neurologic
symptoms
Symptoms of increased ICP
Headache
Vomiting
Visual disturbances
Hormonal effects with pituitary adenoma
Loss of hearing, tinnitus, and vertigo with
acoustic neuroma

Common Brain Tumor Sites

Diagnostic Evaluation

Neurologic examination
CT scan
MRI
PET scan
EEG
Cytological study of cerebral spinal
fluid
Biopsy

Medical Management
Specific treatment depends upon the type,
location, and accessibility of the tumor
Surgery
Goal is removal of tumor without increasing
neurologic symptoms or to relieve symptoms
by decompression
Craniotomy, transspenoidal surgery,
stereotactic procedures

Radiation therapy

External beam radiation


Brachytherapy

Chemotherapy

Spinal Cord Tumors


Classified according to their anatomic
relation to the spinal cord

Intramedullary: within the cord


Extramedullary: extradural; outside the dural
membrane

Manifestations include pain, weakness, and


loss of motor function, loss of reflexes, loss
of sensation
Treatment depends upon type of tumor and
location
Surgical removal
Measures to relieve compression:
dexamethasone combined with radiation

Nursing Process: The Care of the Patient with Cerebral Metastases or


Inoperable Brain TumorsAssessment

Baseline neurologic exam


Patient function and coping: self-care ability,
movement, walking, speech, vision, dealing with
seizures
Symptoms that may cause distress to the
patient: pain, respiratory symptoms, bowel and
bladder function, sleep, skin integrity, fluid
balance, and temperature regulation
Nutritional status and dietary history
Family coping and family process

Nursing Process: The Care of the Patient with Cerebral


Metastases or Inoperable Brain TumorsDiagnoses

Self-care deficit
Imbalanced nutrition
Anxiety
Interrupted family processes

Nursing Process: The Care of the Patient with Cerebral


Metastases or Inoperable Brain TumorsPlanning

Major goals may include


compensating for self-care deficits,
improving nutrition, reducing
anxiety, enhanced family coping
skills, and absence of complications

Interventions
Encourage independence for as long as
possible
Measures to improve cognitive function
Allow patient to participate in decision making
Allow patient to express fears and concerns
Presence of family, friends, spiritual advisor,
and health care personnel may be supportive
Referral to counselor, social worker, home
health care, support groups
Referral for hospice care

Improving Nutrition
Oral hygiene before meals
Plan meals for times when patient is
comfortable and well rested
Measures to make mealtime as pleasant
as possible
Offer preferred foods
Dietary supplements
Daily weight
Record dietary intake

Question
Is the following statement True or
False?
Parkinsons disease is a slowly
progressing neurologic movement
disorder that eventually leads to
disability.

Answer
True
Parkinsons disease is a slowly
progressing neurologic movement
disorder that eventually leads to
disability.

Parkinsons Disease
Associated with decreased levels of dopamine due
to destruction of cells in the substantia nigra in the
basal ganglia; this effects the neurotransmission of
impulses
Manifestations: tremor, rigidity, bradykinesia,
postural instability, depression and other
psychiatric changes, dementia, autonomic
symptoms, sleep disturbances,
Medical management
Pharmacologic treatment
Surgical procedures
Other therapies

Pathophysiology of Parkinsons
Disease

Nursing Process: The Care of the Patient


with Parkinsons DiseaseAssessment
Focus on the degree of disability and
function of the patient including ADLs,
IADLS, and cognitive function
Medications and responses to medications
Emotional responses and individual coping
Family processes and coping
Home care and teaching needs
Fall risk assessment
Manifestations and potential complications
related to the specific disorder

Nursing Process: The Care of the Patient


with Parkinsons DiseaseDiagnoses
Impaired physical mobility and risk for activity
intolerance
Disturbed thought processes
Self-care deficits
Imbalanced nutrition
Constipation
Impaired verbal communication
Ineffective coping and compromised family coping
Deficient knowledge
Risk for injury

Nursing Process: The Care of the Patient


with Parkinsons DiseasePlanning

Major goals may include improved


functional ability, maintaining
independence in activities of daily
living, achieving adequate bowel
elimination, attaining and
maintaining acceptable nutritional
status, achieving effective
communication, developing positive
individual and family coping skills.

Improving Mobility

Daily program of exercise


ROM exercises
Postural exercises
Consultation with physical therapy
Walking techniques for safety and
balance
Frequent rest periods
Proper shoes
Use of assistive devices

Interventions

Enhancing self-care ability


Encourage, teach, and support independence
Environmental modifications
Use of assistive and adaptive devices
Consultation with occupational therapy
Support of coping
Set achievable, realistic goals
Encourage socialization, recreation, and independence
Planned programs of activity
Support groups and referral to supportive servicescounselors, social worker, home care

Benztropine mesylate (Cogentin) is


an anticholinergic medication used to
control of tremor and rigidity and
counteracts the action of
acetylcholine with Parkinsons
disease. Diphenhydramine
hydrochloride (Benadryl),
orphenadrine citrate (Banflex),
phenindamine hydrochloride (NeoSynephrine) are antihistamines that

Alzheimer's Disease
AKA senile dementia
The most common cause of
dementia
A chronic, progressive, degenerative
brain disorder that effects 4.5 million
people in the United States
Research suggests oxidative stress
plays a role in the pathophysiology of
this disease

Amyotrophic Lateral
Sclerosis (ALS)
Lou Gehrigs disease
Loss of motor neurons in the anterior
horn of the spinal cord, and loss of
motor nuclei in the brainstem, cause
progressive weakness and atrophy of
the muscles of the extremities and
trunk. Weakness of the bulbar
muscles impairs swallowing and
talking. Respiratory function is also
impaired

Muscular Dystrophies
Incurable disorders characterized by
progressive weakening and wasting
of skeletal and voluntary muscles
Most are inherited disorders
Duchenne muscular dystrophy is the
most common and inherited as a
sex-linked trait

Degenerative Disk Disease


Low back pain is a significant public health disorder and has
significant economical and social costs.
Most back problems are related to disk disease.
Degenerative changes occur with aging or are the result of
previous trauma.
Radicupathy produces pain.
Continued pressure may produce degenerative changes in the
nerves with resultant changes in sensation and motor responses.
Treatment is usually conservativerest and medications.
Surgery may be required.

Normal Spinal Vertebral and


Ruptured Vertebral Disk

Nursing Process: The Care of the Patient with Cervical Diskectomy


Assessment

Determining the onset, location, and radiation of pain


Assessing for paresthesia, limited movement, and diminished
function of the neck, shoulders, and upper extremities
Determine whether the symptoms are bilateral
Cervical spine palpated to assess muscle tone and tenderness
Range of motion in neck and shoulders is evaluated
Health issues
Patient education

Nursing Process: The Care of the Patient


with Cervical DiskectomyDiagnoses

Acute pain related to the surgical


procedure
Impaired physical mobility related to
the postoperative surgical regimen
Deficient knowledge about the
postoperative course and home care
management

Nursing Process: The Care of the Patient with Cervical


DiskectomyCollaborative Problems/Potential Complications

Hematoma at the surgical site,


resulting in cord compression and
neurologic deficit
Recurrent or persistent pain after
surgery

Nursing Process: The Care of the Patient


with Cervical DiskectomyPlanning

The goals for the patient may include


relief of pain, improved mobility,
increased knowledge and self-care
ability, and prevention of
complications.

Nursing Process: The Care of the Patient with


Cervical DiskectomyNursing Interventions

Relieving pain
Improving mobility
Monitoring and managing potential
complications
Promoting home and communitybased care

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