Neurologic Disorders

Elvin Gene B. Colcol, RN, MN, MAN

UNCONSCIOUS CLIENT

General Information

State of depressed cerebral functioning with unresponsiveness to sensory and motor function. Not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

Terminologies

Coma clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods
Akinetic mutism state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes

Persistent vegetative state condition in which the patient is described as wakeful but devoid of conscious content, without cognitive/affective mental function.
Brain death irreversible loss of all functions of the entire brain, including the brain stem

Causes

Neurologic head injury, stroke

Toxicologic drug overdose, alcohol intoxication Metabolic hepatic/kidney failure, diabetes ketoacidosis

Assessment Findings

Unarousable No response to painful stimuli Altered respirations Decreased cranial nerve and reflex activity Pupillary changes Decreased GCS Initially restlessness and anxiety

Laboratory Tests

Blood glucose Serum electrolytes Serum ammonia Clotting time Serum ketones BUN / serum creatinine Serum osmolality Arterial blood gas (ABG) Serum drug and alcohol level

Complications

Respiratory failure Pneumonia Pressure ulcers Aspiration Venous stasis / DVT Musculoskeletal deterioration Disturbed GI functioning

Medical Management

Maintain a patent airway

Circulation heart rate and blood pressure Intravenous access

Nutritional support

Nursing Diagnoses

Ineffective airway clearance

Risk for injury

Deficient fluid volume

Impaired oral mucous membrane Risk for impaired skin integrity

Nursing Interventions:

Airway, Breathing, Circulation, Disability Place the client in a semi-Fowlers position Change position of the client every 2 hours avoiding injury when turning Protect patient at all times (side rails, restraints) Assess for edema Monitor for fluid and electrolyte imbalances Monitor intake and output and daily weight Maintain NPO status until consciousness returns Provide intravenous or enteral feedings as prescribed

Continuation on interventions:

Assess bowel sounds Maintain urinary output to prevent stasis, infection and calculus formation Monitor the status of skin integrity Provide frequent mouth care Remove dentures and contact lenses Assess for cerebrospinal fluid leakage Assume that the unconscious client can hear Initiate seizure precautions Use footboard or high-topped sneakers to prevent footdrop

Increased ICP

Normal ICP is 10 20 mmHg

Brain tissue (1400g); blood (75mL); CSF (75mL) Impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

Assessment:

Altered LOC Headache Abnormal respirations Increased BP with widening pulse pressure Slowing of pulse Elevated temperature Vomiting Pupil changes Changes in motor function

Complications:

Brain stem herniation

Diabetes Insipidus SIADH

Medical Management

Goal

Decrease cerebral edema Lower volume of CSF Decrease cerebral blood flow while maintaining adequate perfusion

Administer osmotic diuretic and cortecosteroids Restricting fluids Drain CSF Control fever Maintain BP and oxygenation Reduce cellular metabolic demand

Nursing Diagnoses

Ineffective airway clearance

Impaired breathing pattern

Altered cerebral tissue perfusion

Deficient fluid volume Risk for infection

Nursing Interventions:

Elevate the head of the bed 30 to 40 degrees as prescribed Avoid the administration of morphine Maintain mechanical ventilation Maintain body temperature Prevent shivering Decrease environmental stimuli Monitor intake and output Monitor electrolyte and acid base balance Instruct client to avoid straining activities such as coughing and sneezing Instruct the client to avoid valsalvas manuever

Medications:

Anticonvulsants Antipyretics and muscle relaxants

Blood pressure medication

Corticosteroids Intravenous fluids Hyperosmotic agents

Ventriculoperitoneal Shunt

Shunts cerebrospinal fluid from the ventricles into the peritoneum

Monitor infection
Monitor signs on increasing ICP Position the client supine

Late signs of increased ICP:

Deteriorating LOC
Altered respiratory patterns

Projectile vomiting
Hemiplegia and abnormal posturing Loss of brain stem reflexes

CEREBRAL ANEURYSM

Cerebral Aneurysm

Dilation of the walls of a weakened cerebral artery Aneurysm can lead to rupture

Assessment findings:

Headache Irritability Diplopia Blurred vision Tinnitus Hemiparesis Nuchal rigidity Seizures

Nursing Interventions:

Maintain a patent airway

Administer oxygen as prescribed

Monitor vital signs and for hypertension or dysrhythmias

Avoid taking temperatures via the rectum Initiate aneurysm precautions

Aneurysm Precautions:

Maintain bed rest on semi-Fowlers or side lying position Maintain a darkened room Provide a quiet environment Limit visitors Maintain fluid restrictions Avoid overstimulants in diet Avoid valsalvas maneuver Administer care gently

Limit invasive procedures Maintain normothermia Prevent hypertension Provide sedation Provide pain control Administer prophylactic anticonvulsant Provide DVT prophylaxis as prescribed

MENINGITIS

Meningitis:

Inflammation of the meninges of the brain and spinal cord

Caused by bacteria, viruses, or other microorganisms May reach CNS through:

Blood, CSF, lymph Direct extension Oral or nasopharyngeal route

Assessment findings:

Headache, photophobia, malaise, irritability Chills, vomiting and fever Possible seizure and altered LOC Lumbar puncture result Signs of meningeal irritation

Nuchal rigidity Kernigs sign Opisthotonos body arched forward Brudzinkis sign

Nursing Interventions:

Administer large doses of antibiotics IV as ordered (penicillin and cephalosporin) Enforce respiratory isolation for 24 hours after initiation of antibiotic therapy Provide nursing care for increased ICP, seizures, and hyperthermia Provide nursing care for delirious, or unconscious client as needed Provide bed rest Administer analgesic for headache

Maintain fluid and electrolyte balance Prevent complications of immobility Monitor vital signs and neuro checks frequently Provide client teaching and discharge planning concerning

Importance of good diet Rehabilitation program of residual deficits

ENCEPHALITIS

Encephalitis

Inflammation of the brain caused by a virus May be associated with other diseases such as measles, mumps, chickenpox

Assessment findings:

Headache
Fever, chills, vomiting Signs of meningeal irritation Possible seizures Alterations in LOC

Nursing Interventions:

Monitor vital signs and neuro checks frequently

Provide nursing measures for increased ICP, seizures, hyperthermia if they occur Provide nursing care for confused or unconscious client as needed Provide client teaching and discharge planning

BRAIN TUMOR

Brain Tumor

Tumor within the cranial cavity; may be benign or malignant Types:

Primary originates in brain tissue (glioma, meningioma) Secondary metastasizes from tumor elsewhere in the body

Medical Management:

Craniotomy remove tumor when possible

Radiation therapy and chemotherapy for inaccessible and metastatic tumors Drug therapy to manage increased ICP

Assessment findings:

Headache Vomiting Papilledema Seizures Changes in mental status Neurologic deficits hemiparesis, sensory problem Diagnostic tests

Skull x-ray, CT scan, MRI EEG and brain biopsy

Nursing Interventions:

Monitor vital signs and neuro checks Administer medications as ordered (corticosteroids, anticonvulsant, analgesic) Provide supportive care for neurologic deficit Prepare client for surgery Provide care for effects of radiation therapy or chemotherapy Provide psychologic support

BRAIN ABSCESS

Brain Abscess

Collection of free or encapsulated pus within the brain tissue Usually follows an infectious process elsewhere in the body (ear, sinuses, mastoid bone, trauma)

Assessment findings:

Headache, malaise, anorexia

Vomiting

Signs of increased ICP

Hemiparesis Seizures

Nursing Interventions:

Adminitster large doses of antibiotics as ordered (penicillin and chloramphenicol) Monitor vital signs and neuro checks Provide symptomatic and supportive care Prepare client for surgery if indicated Corticosteroids and antiseizure drugs

HEADACHE

Headache

Diffuse pain in different parts of the head

Types:

Functional / primary

Organic secondary to intracranial or systemic disease

Tension - anxiety Migraine recurrent throbbing headache Cluster recurrent with remissions

Assessment findings:

Tension pain usually bilateral; occurs at the back of the neck extending on top of head
Migraine severe, throbbing pain, often in temporal or supraorbital area, lasting several hours to days; N and V, irritability, pallor and sweating Cluster intense, throbbing pain, usually affecting only one side of face and head; abrupt onset, lasts 30-90 minutes, skin reddens, teary eyes due to pain

Nursing Interventions:

Carefully assess details regarding the headache Provide quiet, dark environment Provide nonpharmacologic pain relief measures Administer medication as ordered

Nonnarcotic analgesic Fiorinal Midrin Sumatriptan Ergotamine tartrate (migraine)

CEREBROVASCULAR ACCIDENT

Cerebrovascular Accident

Destruction or brain cells caused by a reduction in cerebral blood flow and oxygen Interruption of cerebral blood flow for 5 minutes or more causes death of neurons in affected area with irreversible loss of function Affects men more than women; incidence increases with age Caused by thrombosis, embolism, hemorrhage

Risk factors:

Hypertension, diabetes mellitus, arteriosclerosis, atherosclerosis, cardiac disease (valvular disease, atrial fibrillation, MI)
Lifestyle: obesity, smoking, inactivity, stress, use of oral contraceptives

Modifying factors:

Cerebral edema develops around affected area causing further impairment

Vasospasm constriction of cerebral blood vessel causing further decrease in blood flow Collateral circulation help to maintain cerebral blood flow when there is compromise of main blood supply

Stages of development:

Transient ischemic attack

Warning sign of impending stroke Brief period of neurologic deficit Less than 24 hours

Stroke in evolution progressive symptoms over hours or days

Completed stroke neurologic deficit remains unchanged for a 2- to 3-day period

Assessment findings:

Headache Generalized signs: vomiting, seizures, confusion, disorientation, decreased LOC, nuchal rigidity, fever, hypertension, slow bounding pulse, cheynestokes respirations Focal signs: hemiplegia, aphasia, homonymous hemianopsia Diagnostic tests:

CT scan EEG Cerebral arteriography

Nursing Interventions:

Maintain patent airway and adequate ventilation Monitor vital signs and neuro checks Provide complete bed rest Maintain fluid and electrolyte balance and ensure adequate nutrition Maintain proper positioning and body alignment Promote optimum skin integrity Provide a quiet, restful environment Establish a means of communicating with the client Rehabilitation care

Medications:

Hyperosmotic agents
Anticonvulsants

Thrombolytics
Anticoagulant Antihypertensive

TRIGEMINAL NEURALGIA

General Information

Disorder of cranial nerve V causing disabling and recurring attacks of severe pain along the sensory distribution of one or more branches of the trigeminal nerve A unilateral shooting and stabbing pain
Involuntary contraction of facial muscles caused twitching of the mouth (tic douloureux) Incidence increased in elderly women Cause unknown

Medical Management

Anticonvulsant drugs: carbamazepine (Tegretol), Gabapentin (Neurontin), Baclofen (Lioresal), and phenytoin (Dilantin) Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve; temporary effect, lasts 6-18 months Surgery

Peripheral: avulsion of peripheral branches of trigeminal nerve Intracranial: microvascular decompression

Assessment Findings

Sudden paroxysms of extremely severe shooting pain in one side of the face Attacks may be triggered by a cold breeze, foods/fluids with extreme temperature, toothbrushing, chewing, talking, or touching the face

During attack: twitching, grimacing, and frequent blinking/tearing of the eye

Poor eating and hygiene habits

Withdrawal from interactions with others

Diagnostic tests: X-rays of the skull, teeth, and sinuses may identify dental or sinus infection as an aggravating factor

Nursing Interventions

Assess characteristics of the pain including triggering factors, trigger points, and pain management techniques Administer medications as ordered; monitor response Maintain room at an even, moderate temperature, free from drafts Provide small, frequent feedings of lukewarm, semiliquid, or soft foods that are easily chewed Provide the client with a soft washcloth and lukewarm water and perform hygiene during periods when pain is decreased

Nursing Interventions

Prepare the client for surgery of indicated Provide client teaching and discharge planning concerning

Need to avoid outdoor activities during cold, windy, or rainy weather Importance of good nutrition and hygiene Use of medications, side effects, and signs of toxicity Specific instructions following surgery for residual effects of anesthesia and loss of corneal reflex

BELLS PALSY

General Information

Disorder of cranial nerve VII resulting in the loss of ability to move the muscles on one side of the face
Inflamed, edematous nerve becomes compressed to the point of damage or nutrient vessel is occluded producing ischemic necrosis Cause unknown; may be viral or autoimmune Complete recovery in 3-5 weeks in majority of clients

Assessment Findings

Loss of taste over anterior two-thirds of tongue on affected side

Complete paralysis of one side of face Loss of expression, displacement of mouth toward unaffected side, and inability to close eyelid (all on affected side) Painful sensations in the face, behind the ear, and in the eye

Nursing Interventions

Assess facial nerve function regularly Administer medications as ordered

Corticosteroids (prednisone) Mild analgesics as necessary

Provide soft diet with supplementary feedings as indicated Instruct to chew on unaffected side, avoid hot fluids/foods, and perform mouth care after each meal Provide special eye care to protect the cornea.

Dark glasses or eyeshield Artificial tears to prevent drying of the cornea Ointment and eye patch at night to keep eyelid closed

Provide support and reassurance

AMYOTROPHIC LATERAL SCLEROSIS

General Information

Progressive motor neuron disease, which usually leads to death in 2-6 years.
Onset usually between ages 40 and 70; affects men more than women Cause unknown; overexcitation of the nerve cells by the neurotransmitter glutamate leads to cell injury and neuronal degeneration There is no cure or specific treatment; death usually occurs as a result to respiratory infection secondary to respiratory insufficiency; RILUZOLE (RILUTEK) a glutamate antagonists

Assessment Findings

Progressive weakness and atrophy of the muscles of the arms, trunk, or legs
Dysarthria, dysphagia

Fasciculations (twitching)
Respiratory insufficiency

Diagnostic tests: EMG and muscle biopsy can rule out other diseases; MRI (motor neuropathy)

Nursing Interventions

Provide nursing measures for muscle weakness and dysphagia Promote adequate ventilatory function Prevent complications of immobility Encourage diversional activities; spend time with the client Provide compassion and intensive support to client/significant others Provide or refer for physical therapy as indicated

Promote independence for as long as possible

GUILLAIN BARRE SYNDROME

General Information

Symmetrical, bilateral, peripheral polyneuritis characterized by ascending paralysis Can occur at any age; affects women and men equally

Cause unknown; may be an autoimmune process

Precipitating factors: antecedant viral infection, immunization Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usually from 3-6 months; may have residual deficits

Medical Management

Mechanical ventilation if respiratory problems present

Plasmapheresis to reduce circulating antibodies

Propanolol to prevent tachycardia

Atropine may be given to prevent episodes of bradycardia during endotracheal suctioning and physical therapy

Assessment Findings

Mild sensory changes; in some clients severe misinterpretation of sensory stimuli resulting in extreme discomfort Clumsiness: usually the first symptom Progressive motor weakness in more than one limb (ascending and symmetrical) Ventilatory insufficiency if paralysis ascends to respiratory muscles Absence of deep tendon reflexes

Autonomic dysfunction
Diagnostic tests:

CSF studies: increased protein EMG: slowed nerve conduction

Nursing Interventions

Maintain adequate ventilation Check individual muscle group every 2 hours in acute phase to check for progression of muscle weakness Assess cranial nerve function: gag reflex Monitor vital signs and observe for signs of autonomic dysfunction such as acute periods of hypertension fluctuating with hypotension, tachycardia, arrhythmias Administer corticosteroids to suppress immune reaction as ordered Administer antiarrhythmic agents as ordered Prevent complications of immobility

Promote comfort
Promote optimum nutrition Provide psychologic support and encouragement

MULTIPLE SCLEROSIS

General Information

Chronic, intermittently progressive disease of the CNS, characterized by scattered patches of demyelination within the brain and spinal cord
Incidence

Affects women more than men Usually occurs from 20-40 years of age More frequent in cool or temperate climates

Cause unknown; may be a slow-growing virus or possibly of autoimmune origin (sensitized T cells) Signs and symptoms are varied and multiple, reflecting the location of demyelination within the CNS Characterized by remissions and exacerbations

Assessment Findings

Visual disturbances: blurred vision, scotomas (blind spots), diplopia

Impaired sensation: touch, pain, temperature, or position sense; paresthesias such as numbness, tingling Euphoria or mood swings Impaired motor function: weakness, paralysis, spasticity Impaired cerebellar function: scanning speech, ataxic gait, nystagmus, dysarthria, intention tremor Bladder: retention or incontinence Constipation Sexual impotence in the male

Medical Management

MRI primary diagnostic test for visualizing plaques, documenting disease activity and evaluating the effect of treatment Medications (ABC and R drugs)

Interferon beta-1a (Avonex) Interferon beta-1b (Betaseron) Glatiramer acetate (Copaxone) Rebif Corticosteroids

Nursing Interventions

Assess the client for specific deficits related to location of demyelinization

Promote optimum mobility

Administer medications as ordered

Encourage independence in self-care activities

Prevent complications of immobility

Institute bowel program

Nursing Interventions

Maintain urinary elimination

Prevent injury related to sensory problems

Prepare client for plasma exchange if indicated

Provide psychological support to client and SO

Provide client teaching and discharge planning

MYASTHENIA GRAVIS

General Information

A neuromuscular disorder in which there is a disturbance in the transmission of impulses from the nerve to muscle cells at the neuromuscular junction, causing extreme muscle weakness Incidence

Highest between ages 15 and 35 for women, over 40 for men Affects women more than men

Cause: thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction Voluntary muscles are affected, especially those muscles innervated by the cranial nerves

Assessment Findings

Diplopia, dysphagia Extreme muscle weakness, increased with activity and reduced with rest Ptosis, masklike facial expression Weak voice, hoarseness Diagnostic tests:

Tensilon test IV injection of Tensilon provides spontaneous relief of symptoms (lasts 5-10 minutes) EMG amplitude of evoked potentials decreases rapidly Presence of antiacetylcholine receptor antibodies in the serum

This is also called the Simpson test in which fatigue is observed on sustained lid and eye elevation.

Animated picture of a patient with right Cogan's twitch sign on rapid up gaze. Note the overshooting of the lid before settling down to the original ptotic level.

Medical Management

Drug therapy

Anticholinesterase drugs: neostigmine, pyridostigmine (Mestinon)

Block the action of cholinesterase and increase levels of acetylcholine at the neuromuscular junction Side effects: excessive salivation and sweating, abdominal cramps, nausea and vomiting, diarrhea, fasciculations (muscle twitching)

Corticosteroids: prednisone

Used if other drugs are not effective Suppress autoimmune response

Plasma Exchange

Removes circulating acetylcholine receptor antibodies Use in clients who do not respond to other types of therapy

Surgery (thymectomy) see new neuro pics

Surgical removal of the thymus gland (involved in the production of acetylcholine receptor antibodies) May cause remission in some clients especially if performed early in the disease

Nursing Management

Administer anticholinesterase drugs as ordered

Promote optimal nutrition Monitor respiratory status frequently: rate, depth, vital capacity, ability to deep breathe and cough Assess muscle strength frequently; plan activity to take advantage of energy peaks and provide frequent rest periods

Observe for signs of myasthenic or cholinergic crisis

Provide nursing care for the client with a thymectomy Provide client teaching and discharge planning

ALZHEIMERS DISEASE

General Information

In dementia, the elderly client is alert with a progressive decline in memory and cognition accompanied by personality and behavioral changes
Alzheimers disease accounts for 60-75% of all dementias and is the number one reason for institutionalization of the elderly

Medical Management

Rule out other conditions that might be causing symptoms. A definitive diagnosis of Alzheimers disease can only be made upon autopsy Medications for treatment include tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), or galantamine (Reminyl)
Treatment goals are to minimize behavioral symptoms and maximize quality of life

Assessment Findings

Early in the disease process

Early, mild impairment

Depressed or anxious Increased risk of suicide

Last 2-4 years Short-term memory loss Social withdrawal Decreased interest in usual activities Mood swings Irritability Insight is diminished

Assessment Findings

Middle, moderate impairment

Late, severe impairment

Last several years Memory and math calculations faulty Disoriented to time and place Can no longer drive Needs assistance with complex ADLs Personality changes Incontinence begins

Assistance with all ADLs Nonverbal or communication is incoherent Becomes nonambulatory Requires total support in all activities Incontinent in bowel and bladder Indifference in food Agitation and aggression seen

Nursing Interventions

Provide a safe environment

Provide structured environment and simple routines Enlist caregivers assistance in assessing routine and establishing plan of care Use touch and a calm, relaxed manner in approaching the client Facilitate effective communication Encourage orientation with use of calendars and clocks

Nursing Interventions

Having family bring items that stimulate memory

Encourage mobility and provide opportunities for exercise Avoid isolating the client Provide nutritious, high-fiber foods and adequate fluids to maintain weight and hydration

Promote bowel and bladder continence by toileting at regular intervals

Provide a simple bedtime routine that facilitates sleep, and encourage daytime activities to avoid excess napping

PARKINSONS DISEASE

General Information

A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular function; disorder of the extrapyramidal system
Usually occurs in the older population Cause unknown, predominantly idiopathic, but sometimes disorder is postencephalic, toxic, arteriosclerotic, traumatic, or drug induced (reserpine, methyldopa, haloperidol, phenothiazines)

Pathophysiology

Disorder causes degeneration of the dopamine-producing neurons in the substantia nigra in the midbrain
Dopamine influences purposeful movement

Depletion of dopamine results in degeneration of the basal ganglia

Assessment Findings

Tremors: at the upper limb, pill-rolling, resting tremor; most common initial symptom
Rigidity: cogwheel type Bradykinesia: slowness of movement Fatigue Stooped posture; shuffling, propulsive gait Difficulty rising from sitting position

Assessment Findings

Masklike face with decreased blinking of eyes

Quiet, monotone speech

Emotional lability, depression

Increased salivation, drooling

Cramped, small handwriting

Autonomic symptoms: excessive sweating, seborrhea, lacrimation, constipation; decreased sexual capacity

Nursing Interventions

Administer medications as ordered

Provide a safe environment Provide measures to increase mobility

Encourage independence in self-care activities

Improve communication abilities

Nursing Interventions

Refer for speech therapy when indicated

Maintain adequate nutrition

Avoid constipation and maintain adequate bowel elimination

Provide psychological support to client and SO

Provide client teaching and discharge planning concerning