NEUROLOGICAL SYSTEM
2.
Physiology of the Neurologic System Space Occupying Lesions Interruption of Cerebral circulation Inflammatory Problems Spinal Cord Injury Neuromuscular Disorders Peripheral Nerve Disorders
3. a. b. c.
Glial Glial cells cells – protec protectiv tive e cells cells in the CNS; CNS; respo responsi nsible ble for for the formation of the myelin. Myelin sh sheath. Dense Dense memb membran rane e or insu insulat lator or arou around nd the the axon. axon. Facilit Facilitate ates s func functi tion on of the the neur neuron, on, Cont Contri ribu bute tes s to the blood blood-b -bra rain in barri barrier er to prot protec ectt the the central nervous system against harmful molecules.
C. Nerve Nerve regene regenerat ration ion – entire entire neuron neuron is unable unable to underg undergo o
The neurologic or nervous system is composed of two primary areas; the central nervous system which includes the brain and the spinal cord, and the peripheral nervous system which includes all the network of nerves extending from the central system. In order to enhance the understanding of a very complex system, common disord disorders ers and condit condition ions s are catego categoriz rized ed accord according ing to the physio physiolog logica icall origin origin of the the proble problem, m, as well well as to simila similarit rities ies involved involved in nursing nursing care. The concept concept of increased increased intracranial intracranial press pressure ure is presen presented ted,, follow followed ed by a discus discussio sion n of common common condit condition ions s involv involved. ed. Neurom Neuromusc uscula ularr degene degenerat rative ive diseas diseases, es, inflammato inflammatory ry conditions conditions,, spinal spinal cord injuries and problems problems of cerebral cerebral circulation circulation are broad categories categories under which specific specific conditions are addressed.
complete regeneration. 1. The axons of the PNS may regenerate via the connective tissue neurilemma, providing the cell body of the neuron remains viable. 2. Neuron regeneration in the CNS is very limited, possibly due to the lack of neurilemma. 3. Scar Scar tiss tissue ue is a majo majorr deter deterre rent nt to succ succes essf sful ul cell cellul ular ar regeneration.
D. Impulse conduction. 1. Reflex arc. a. Reflex are is the functional unit which provides pathways over which nerve impulses travel. b. Passage of impulses over a reflex arc is called a reflex act or a reflex. c. Reflex arc – The afferent neuron carries the stimulus to the spine; integrates it into and through the spine (CNS) to the efferent neuron; neuron; crosses the synapse with the message message from the CNS to the organ or muscle which responds to the stimuli. This is the sequence of events when testing the deep tendon reflexes. 2. Synaptic transmission. a. A chemical synapse maintains a one-way communication link between neurons. b. Chemical Chemical neurotrans neurotransmitt mitters ers (neuro-me (neuro-mediato diators) rs) facilitate facilitate the transmission of the impulse across the synapse. 1). Acetylcholine. 2). Norepinephrine. 3). Dopamine. 4). Histamine. c. Impulses pass in only one direction.
PHYSIOLOGY OF THE NEUROLOGIC SYSTEM Organization of the Nervous System
A. Central nervous system (CNS). 1. Brain 2. Spinal Cord B. Peripheral nervous system (PNS). 1. Twelve pairs of cranial nerves 2. Thirty-one pairs of spinal nerves 3. Autonomic nervous system a. Sympathetic system b. Parasympathetic system. CELLS OF THE NERVOUS SYSTEM
A. Neuron-the functional cell of the nervous system. 1. Common characteristics. characteristics. a. Responds or reacts to stimuli b. Conducts impulses c. Influences other neurons. 2. Structure. a. Cell Cell bodybody-con contai tains ns the the cell cell nucleu nucleus s which which contro controls ls cellul cellular ar activity. b. Axon-conducts impulses away from the cell body c. Dendrites Dendrites-rec -receive eive incoming stimuli and transmit transmit them to the axon of another neuron. 3. Function/classification. Function/classification. a. Afferent neurons (sensory) transmit information away from the CNS. b. Efferent Efferent neurons (motor) transmit transmit informati information on away from the CNS. c. Somatic system 1). Afferent are sensory neurons that transmit impulses from the skeletal muscles and skin to the CNS. 2). Efferent are motor neurons that transmit impulses that lead to contraction and control of skeletal muscle. d. Visceral system. 1). Afferent are sensory sensory neurons that transmit transmit impulses from smooth muscle and cardiac muscle to the CNS. 2) Efferent are motor neurons that transmit impulses to the glands, cardiac muscle, and smooth muscle. e. Syna Synaps pse e or syna synapt ptic ic term termin inals als are are area areas s of chem chemic ical al transmission of an impulse from the axon of one neuron to the dendrites of another neuron.
CENTRAL NERVOUS SYSTEM The brain and the spinal cord within the vertebral column make up the central nervous system.
A. B. 1.
2.
3.
C. 1. 2.
3. a.
B. Supporting cells provide support, nourishment, and protection to the neuron.
b. 1. a. b. c.
Neuril Neurilem emma ma – protect protective ive cells cells which which surro surround und the the axons axons in the PNS. Provide Provide for for effective effective regenerati regeneration on of of PNS PNS nerve fibers. fibers. From From the the myelin myelin sheath sheath in the the PNS. PNS. No neu neuri rilem lemma ma pre prese sent nt in in the the CNS. CNS.
c.
1
The brain and the spinal column are protected by the rigid bony structure of the skull and the vertebral column. Meninges –protective membranes that cover the brain and are continuous with those of the spinal cord. Pia Pia mat mater-a er-a deli delica cate te vasc vascul ular ar conn connec ecti tive ve tissue layer that covers the surfaces of the brain barrier. Arachn Arachnoid oid-a -a delic delicate ate nonv nonvasc ascula ular, r, wate waterpr rproof oof membrane that encases the entire CNS; the subarachn subarachnoid oid space contains the cerebral cerebral spinal fluid. Dura Dura mate materr-a a tough tough memb membra rane ne imme immedia diate tely ly outside the arachnoid; provides protection to the brain and spinal cord. Cerebral spinal fluid (CSF). Serv Serves es to cush cushio ion n and prot protec ectt the brai brain n and spinal cord; brain literally floats in CSF. CSF is cl ea ear, colorless, watery flu id id; approximately 100 to 200 cc total volume, with a normal fluid pressure of 70 to 150 mm of water 9average-125 cm water pressure). Forma Formatio tion n and and circul circulati ation on of CSF. CSF. Fluid luid is secre ecretted by the the choro horoid ids s plex plexus us located in the ventricles of the brain. CSF CSF flows flows thro throug ugh h the the later lateral al ventr ventric icle les s into the third ventricle, flows through the Aqueduct of Sylvius into the fourth ventricle where the central of the spinal column opens. From From the the four fourth th vent ventri ricl cle, e, ther there e are openi opening ngs s into into the the crania craniall subarac subarachno hnoid id space; space; CSF flows around the spinal cord ad brain.
d.
Sinc ince CSF CSF is for formed cont contin inuo uous usly ly,, it is reab reabso sorb rbed ed at a comp compar arab able le rate rate by the the arachnoid villi.
4. Respiratory center for changes in rate and depth of breathing. 5. Vomiting reflex center. 6. Swallowing reflex center. c. Thalamus. 1. Organizat Organization ion and distributi distribution on of incoming incoming sensory impulses. 2. Activities related to consciousness. d. Hypothalamus. 1. Regu Regulat latio ion n of visc viscer eral al acti activi viti ties es-b -bod ody y temperature, motility and secretions of the GI tract, arterial blood pressure. 2. Nerve connections with the thalamus and the the cere cerebr bral al cort cortex ex make make it poss possib ible le for for our our emotions to influence visceral activity. 3. Regulation of endocrine glands via influence on the pituitary gland. 4. Neuros Neurosecr ecreti etion on of antidi antidiure uretic tic hormo hormone ne (ADH) which is stored in the pituitary.
D.
Brain. Cere Cerebr brum um – the larg larges estt porti portion on of the the brain brain is separa separated ted into into hemisp hemispher heres; es; the cerebr cerebral al cortex is the surface layer of each hemisphere. 2. Majo Majorr lobes lobes of of the the centr central al cor corte tex. x. a. Frontal. 1). Coordi Coordinat nation ion of volunt voluntary ary skelet skeletal al muscle muscle movement. 2). Abstract thinking, morals, judgment. 3). Speech area, motor speech area (Broca’s area) located in only one hemisphere. b. Parietal. 1. Inte Interpr rpret ets s sens sensor ory y nerv nerve e impu impuls lses es (pai (pain, n, temperature, touch). 2. Maintains proprioception. 3. Reco Recogn gnit itio ion n of size size,, text textur ure, e, and and shap shape e of objects. c. Temporal. 1. Audito Auditory ry areaarea- interp interpret rets s meanin meaning g of certai certain n sounds. 2. Wernicke’s area- comprehension and formulation of speech. 1.
7. Cerebral circulation. a. The internal internal carotid carotid arteries arteries enter the cranial vault at the temporal area; the main branches are: b. Vertebral arteries arise from the subclavian artery and enter the brain at the foramen magnum. c. The Circle of Willis is an arterial anastomosis at the base of the brain. The circle ensures continued circulation if one of the main vessels is disrupted. E. Spinal Cord. 1. The spinal cord is continuous with the medulla and extend extends s down down the the verteb vertebral ral column columns s to the level of the first and second lumbar vertebra. 2. Each column is divided into functional groups of nerve fibers. a. Ascending tracts – transmit impulses to the brain (sensory pathway). b. Descending tracts – transmit impulses from the brain to the various levels of the spinal cord (motor pathways). 4. Structure. a. Clos Closel ely y appr approx oxim imat atel ely y vert verteb ebra rae e prov provid ide e protection from the spinal cord and nerve roots. b. Intervertebral discs lie between each vertebra to provide flexibility to the spinal column. c. Nucleus pulposus is a gelatin substance in the vertebral disc. 5. Upper Upper motor motor neuron neurons-o s-orig rigina inate te in the brain, brain, transm transmit it impuls impulses es to the muscle muscles s and organs organs.. These neurons from the reflex arc. 6. Lower motor neurons – originate in the spinal cord, transmit impulses to the muscles and organs. These neurons form the reflex arc: 7. Reflex activity. a. The reflex arch must be intact, the spinal cord serve serves s as the connec connecti tion on betwee between n the affere afferent nt pathwa pathway y (senso (sensory) ry),, and the effere efferent nt pathwa pathway y (motor).
d.Occipital area-interprets vision and controls ability to understand written words. 3. Motor areas of the cerebral cortex. a. Primary function is coordination and control of skeletal muscle activity. b. Corticospinal tracts (pyramidal tracts). 1. Descending tract from the motor area of the cerebral cortex to the spinal cord. 2. Majority of nerves cross in the medulla to the opposite side before descending into the spinal cord. 3. These pathways do not cross over. c. Brain cells and the nerve fibers in the descending tracts tracts of the the centr central al nervo nervous us syste system m are called called upper motor neurons. d. Basal ganglia (cerebral nuclei) – regulate and program program muscle muscle activity activity coming coming from the cerebral cerebral cortex. 4. Movements is controlled by: a. Cerebral Cerebral cortex – voluntary voluntary initiation initiation of motor motor activity. b. Basal ganglia-assist to maintain posture. c. Cerebellum-coordinates muscle movement. 5. Cerebe Cerebellu llum-a m-att ttach ached ed to the the medull medulla a and the the pons. a. Prim Primar aril ily y conc concer erne ned d with with coor coordi dinat natio ion n of muscular activity and maintenance of equilibrium. b. Nerve fibers spread upward to the cerebrum and downward to the pons, medulla, and spinal cord. 1). Visual Visual reflex reflexeses-pup pupill illary ary constr constrict iction ion and movement of the eyeball. 2). Auditory Auditory reflexes-t reflexes-turning urning of the head toward sound. 6. Brai Brain n stem stem – cons consis ists ts of the the pons pons and and the the medulla. a. Pons-cont Pons-contains ains the reticular reticular formation formation,, which is responsible for alertness. b. Medulla oblongata-a continuation of the spinal cord as it enters into the cranial vault in the brain. 1. Conduction center and crossing center for the upper motor neurons. 2. Maintains control of cardiac rate. 3. Vasomotor center for constriction and dilation of vessels.
b. By testing the reflex arc (deep tendon reflexes), the lower lower motor motor neuron neuron and the sensor sensory/ y/mot motor or fibers from the spinal column can be evaluated. For example, if the biceps reflex is normal, then the lower motor neurons and the nerve fibers at C5 and C6 are intact. c. Babinski reflex- normal up to one year, should not be positive in clients over one year of age.
PERIPHERAL NERVOUS SYSTEM (PNS) The cranial and spinal nerves which connect the CNS with the body parts continue the PNS. The peripheral peripheral nervous system is further further divided divided into subdivisions based on the destination of the nerves
2
which compromise the cranial and spinal nerves. The autonomi autonomic c nervou nervous s syst system em is part part of the the subdivision. A. Cran Crania iall nerv erves 1. Twelve elve pai pairs rs of of cra cranial nial nerves. 2. Originate from under the surface of the brain. B. Spina pinall nerv erves. es. 1. Each ach pair pair of ner nerves is num numbere bered d according to the level of the spinal cord from which it originates.
2.
Muscle of the eyelid (ability to close the eye)
Each Each spin spinal al nerv nerve e is conn connec ecte ted d to the cord by two roots. a. Dors Dorsal al (pos (poste teri rior or root root))a sensory nerve carryi carrying ng messa messages ges to the CNS. b. Vent Ventra rall (ant (anter erio iorr root root)) – a motor nerve carrying neur neuron on mess messag ages es to gla nd nds and to the peripheral area.
VIII.
Acoustic
IX.
Glossopharyngeal
X.
Vagus nerve
XI.
Accessory (Spinal)
XII.
Hypoglossal
b.
3.
The The roots roots fuse fuse at at the the exit exit from from the the vert vertebr ebra a to form a mixed spinal nerve. C. Somatic nervous system – fibers which connect the CNS with the structures of the body wall. D. auto autono nomi mic c nerv nervou ous s syst system em – regu regula late tes s involuntar involuntary y activity activity (cardiovas (cardiovascular cular,, respirato respiratory, ry, metabolic, body temperature, etc.) 1. Consists of two divisions that have antagonistic activity. 2. Parasymp Parasympathet athetic ic division division – maintains maintains normal normal body functions. 3. Sympathetic division-prepares the body to meet a challe challenge nge or an emerge emergency ncy (prepa (preparat ration ion for “fight/flight”). 4. Most Most of the the orga organs ns of the the body body rece receiv ive e innervation from both the Parasympathetic and the sympathet sympathetic ic divisions. divisions. The divisions divisions are usually usually antagonistic, the other relaxes. 5. Chemical mediators – facilitate transmission of impulses in the autonomic nervous system. a. Acetylcholine is released by the fibers in both divisions of the autonomic nervous system. 1. Cholin Cholinerg ergic ic fiber fibers s – those those fibers fibers releas releasing ing acetylcholine. 2. Acet Acetyl ylch chol olin ine e is dest destro roye yed d by the the enzy enzyme me cholinesterase.
1. 2. 3.
NAME Olfactory Optic
III.
Oculomotor
IV. V.
Trochlear Trigeminal: Opthalmic Macillary Mandibular
VI. VII.
Abducens Facial
Nore Norepi pine neph phri rine ne rele releas ased ed prim primar aril ily y by the the sympathetic division. Adre Adrene nerg rgic ic fibe fibers rs – thos those e fibe fibers rs rele releas asin ing g norepinephrine. Effe Effect cts s are are wide widesp spre read ad and and augm augmen entted by secretions from the adrenal medulla. Nore Norepi pine neph phri rine ne is inacti inactiva vate ted d by monoam monoamin ine e oxidase (MAO) medications.
System Assessment A. 1. a. b.
c.
2. a. b. c. d. 3.
CRANIAL NERVES NUMBER I. II.
Reception Reception of hearing hearing and maintenance of equilibrium Sense of taste on posterior tongue Salivation Swallowing or gag reflex Assi Assist sts s in swal swallo lowi wing ng action Motor Motor fibers fibers to larynx larynx for speech Innerv Innervati ation on of organs organs in thorax and abdomen Impor Importan tantt in respir respirato atory, ry, cardiac cardiac,, and circul circulato atory ry reflexes Abilit Ability y to rotate rotate the the head head and raise the shoulder Muscles of the tongue
4. FUNCTION Sense of smell Vision-conducts information from the retina Down and outward movement of the eye Pupill Pupillary ary constr constrict iction ion and accommodation Muscle of the upper eyelid (abi (abili lity ty to keep eep the the eye eye open) Movement of the eye
5. a. b. c. d. e. f. g. h.
History. Neur Neurol olog ogic ic hist histor ory. y. Avoid Avoid sugg suggest esting ing sympto symptoms ms to to the the clien client. t. The manner manner in whic which h the the probl problems ems began began and and the the over overal alll cour course se of the the illn illnes ess s are are very very important. Ment Mental al status atus must ust be ass assesse essed d befor efore e assuming assuming the history history data from the client is accurate. Medi Medic cal his history. ory. Chroni Chronic, c, concur concurren rentt medi medical cal proble problems. ms. Medications (especial ly ly tranquilizers, sedatives, narcotics, etc). Pregna Pregnancy ncy and and deli deliver very y histor history y of infa infants nts and and young children. Sequen Sequence ce of growth growth and develo developm pment ent.. Fami Family ly hist histor oryy-pr pres esen ence ce of here heredi dita tary ry or congenital problems. Pers Person onal al hist histor oryy-ac acti tivi viti ties es of daily daily livin living, g, any any change in routine. Histo History ry and and symp symptom toms s of curren currentt probl problem. em. Para Paraly lysi sis s or or par pares esth thes esia ia.. Sync Syncop ope, e, dizz dizzin ines ess s Headache. Speec peech h pro probl blem ems. s. Visu isual prob proble lem ms. Chan Change ges s in pers person onal alit ity. y. Memory lo loss. Naus Nause ea, vom vomit itin ing. g.
AUTONOMIC NERVOUS SYSTEM Area Af Affected Sympathetic Parasympathetic Pupil Dilates Constricts
Corneal reflex Sensory fibers of the face Motor Motor nerves nerves for chewin chewing g and swallowing Inward movement of the eye Facial expression Sense Sense of taste taste on anteri anterior or tongue
3
Bronchi
Dilates
Constricts
Heart
Increases rate
Decreases rate
Gastrointestinal
Inhibits peristalsis
Stimulates peristalsis
Stimulates sphincter Bladder
Rela Relax xes muscle
blad bladde der r Cont Contra ract cts s muscle
Constricts sphincter
e. deep tendon reflexes (simple stretch reflex). 6. Assess vital signs and correlate with other data; changes often occur slowly and the overall trend needs to be evaluated. a. Blood pressure pressure and pulse-intr pulse-intracran acranial ial problems problems precipitat precipitate e chang changes, es, blood blood press pressure ure may may increa increase se and pulse pulse rate rate may decrease. b. Respirations – rate, depth, and rhythm are sensitive indicators of intracranial problems. 1. Cheyne Cheyne Stokes Stokes – period periodic ic breath breathing ing in which which hyperp hyperpnea nea alternates with apnea, rapid, deep hyperpnea. 2. Neurogenic hyperventilation-regular, rapid, deep h yperpnea. 3. Ataxic – completel completely y irregular irregular pattern pattern with random deep and shallow respirations.
Inhibits sphincters blad bladde der r
Relaxes sphincter
Adrenal glands Increases Increases secretion secretion of epinep epinephri hrine ne and norepinephrine B. Physical Assessment. 1. General observation of client. a. Posture, gait.. b. Position of rest for the infant or young child. c. Personal hygiene, grooming. d. Evaluate speech and ability to communicate. 1. Pace of speech-rapid, slow, halting. 2. Clarity – slurred or distinct. 3. Tone – high pitched, rough. 4. Vocabulary – appropriate choice of words. e. Facial features may suggest specific syndromes in children. 2. mental status 9must take into consideration the client’s culture and educational background). a. General appearance and behavior. b. Level of consciousness. 1. Oriented to time, person, place. 2. Appropriate response to verbal and tactile stimuli. 3. Memory, problem-solving abilities. c. Mood. d. Thought content and intellectual capacity. 3. Assess papillary status and eye movements. a. Size of pupils should be equal. b. Reaction of pupils. 1. Acco Accom mmoda modati tion on– – papi papill llar ary y cons constr tric icti tion on to accommodate near visions. 2. Direct light reflex – constricti constriction on of pupil when light is shown directly into eye. 3. Consensual reflex – constriction of the opposite eye for the direct light reflex. c. Evaluate ability to move eye. 1. Note nystagmus-fine, nystagmus-fine, jerking eye movement. 2. Ability of eyes to move together. 3. Resting position should be at mid position of the eye socket.
c. Temperature – evaluate changes in temperature as related to a neurological control versus infection. >Nur >Nursi sing ng Alert Alert< < Beds Bedsid ide e neur neuro o chec checks ks-e -eva valu luat ate e leve levell of cons consci ciou ousn snes ess; s; resp respir irat ator ory y patt patter erns ns;; papi papilla llary ry sign signs; s; eye eye movements; motor responses; vital signs. C. Neuro checks – parameters for frequent nursing evaluation of neurological symptoms. 1. Assess level of consciousness (LOC). a. Verbal and motor response to command. b. Appropriate conversation and speech. c. Prese Presence nce of delaye delayed d respon response se to stimul stimuli, i, from from lethar lethargic gic to unresponsive. d. Appropriate behavior in infants and young children. e. Be explicit in describing LOC; may utilize a specific coma scale (Glasgow).
2. Respiratory patterns – evaluate current respiratory pattern and assess for changes in pattern. 3. Pupillary response. a. Equality of pupils. b. Presence of consensual, direct, and accommodation reflexes. c. Position of pupils at rest. 4. Motor function. a. Ability to move all extremities with equal strength. b. Presence of posturing. c. Basins reflex. d. Presence of seizure activity. e. Presence of gag and cough reflex.
d. PERRLA – indicates that pupils are equal, round, reactive to light and accommodation is present.
5. Vital signs. a. Correlate blood pressure and pulse changes. b. Assess respiratory pattern. c. Assess temperature in regard to overall condition.
4. Evaluate motor function. a. Assess face and upper extremities for equality of movement and sensation. b. Evaluate appropriateness of motor movement, spontaneous and on command. c. Movement of extremities should always be evaluated bilaterally, comparing tone, strength, and muscle movement of each side. d. Presence Presence of inappropr inappropriate, iate, non-purpos non-purposeful eful movement movement,, i.e., posturing. 1.Decerebrate – extension and adduction of the arms, hyperextension of the leg. 2. Decort Decortica icatete-fle flexio xion, n, intern internal al rotati rotation on of the the arms, arms, extension of the leg. 3. Presence Presence of non-purpos non-purposeful eful involuntar involuntary y movement movements s such as tremors, jerking, twitching.
6. Assess for presence of pain, headache. 7. Presence of projective vomiting not associated with nausea. 8. Infants-assess fontanel and suture lines. a. Size of fontanel for growth and development level. b. Fontanel should be soft to touch with slight pulsations. c. Normal approximation of cranial suture lines.
SPACE OCCUPYING LESIONS Concept of Increased Intracranial Pressure (IICP) An increase in intracranial pressure occurs any time there is an increase in the size of the intracranial contents.
e. Ability of an infant to suck and to swallow. f. Asymmetrical contraction of facial muscles. 5. Evaluate reflexes. a. Gag or cough reflex. b. Swallow reflex. c. Corneal reflex. d. Babinski reflex– normal is negative in adults and children over one year, positive sign is dorsal flexion of the foot and large toe with fanning of the other toes.
A.
B.
4
The crania craniall vault vault is rigi rigid, d, and and ther there e is minimal minimal area for expansion expansion of the intracranial components. An increase in any one of the comp compon onen entts nec necess essitat itates es a reciprocal reciprocal change in other other cranial cranial contents; contents; this frequently frequently results in ischemia of brain tissue. An increase
1. 2. 3. C. 1.
2.
D.
1.
2.
E.
F.
in ICP ICP res results ults from from one one of the the following: Incr Increa ease sed d intrac intracra rani nial al blood blood volum volume e (vasodilation). Incr Increa ease sed d CSF CSF flui fluid. d. Incr ncreas ease in the the bulk bulk of the the bra brain tissue (edema). Cere Cerebr bral al ed edema. ema. Vasogenic edema o cc ccurs whe n there is an increase in the volume of brain tissue caused by increase in the permeability of the walls of the cerebral cerebral vessels. vessels. Protein-ri Protein-rich ch fluid leaks into the extra cellular space. Most Most ofte often n the the caus cause e of IICP IICP in adults. Cytoto Cytotoxic xic (cell (cellula ular) r) edema edema occurs occurs as a result of hypoxia. This results in abno abnorm rmal al accu accumu mula lati tion on of flui fluid d within within the cell (intracell (intracellular) ular) and a decrease of extra cellular fluid. Cerebral arterie s dilate with a decre as ase in the delivery of oxygenated blood. Incr Increa ease se in PCO PCO2 2 and acc accum umul ulat atio ion n of lactic acid precipitates an acidotic state. An acid acidot otic ic stat state e incre increas ases es cere cerebr bral al vascul vascular ar dilata dilatatio tion n which, which, in turn, turn, increases increases cerebral cerebral vascular vascular blood flow flow and and incr increa ease ses s intr intrac acra rani nial al pressure. Rega Regard rdle less ss of the the cause ause,, IICP IICP will will result in progre ss ssive neuro deteri or orati on on; th e spe ci cific deficiencies seen are determined by the area area of compre compressi ssion on of brain brain tissue. In infa infant nts s wher where e the the crani cranial al sutu suture re lines are open, increased ICP will caus cause e furt furthe herr sepa separa rati tion on of the the sutu suture re line lines s and and incre increas ased ed the the circumference of the head.
1.
Cushing’s Cushing’s triad – increas increasing ing systo systolic lic press pressure, ure, decreased decreased pulse rate, and irregular respirations. Increased pressure is established when this occurs. 2. Alte Altera rati tion on in resp respir irat ator ory y patt patter ern n (Che (Cheyn ynee-St Stok okes es,, hyperventilation). 3. Temp Temper erat atur ure e usual usually ly incr increa ease ses. s. c. Pupil upilla lary ry ch change anges. s. 1. Ipsi Ipsila late teral ral – papi papill llar ary y chan change ges s occu occurr rrin ing g on the same same side as the lesion. 2. Cont Contra rala late tera rall – papi papill llar ary y chan change ges s occu occurr rrin ing g on the the opposite side of the lesion. 3. Unila Unilate tera rall dilat dilatat atio ion n of pupi pupils ls.. 4. Pupill Pupillary ary resp respons onse e to light light may may be from from slow, slow, slugg sluggish ish reaction to fixed, dilated with no response. d. Papi Papill lled edem ema a – edem edema a of the optic optic nerve nerve is evalu evaluat ated ed when examining the retinal area with an opthalmoscope. e. Doll’s Doll’s eyes eyes phen phenome omena na is abno abnorma rmall when when it is pres present ent and may occur occur as the client client begins begins to experi experienc ence e a decrease in the level o f consciousness. 1. Eyes Eyes norma normally lly move move from from side side to to side side when when the head head is is tuned. 2. “Doll’ “Doll’s s eyes” eyes” occur occur when when the clien client’s t’s head head is move moved d from from side to side and the eyes remain in a fixed, midline position. f. Decr Decrea ease se in in moto motorr and and sens sensor ory y func functi tion on.. 1) Weakness. 2) Hemiplegia. 3) Failu Failure re to withdr withdraw aw from from painfu painfull stimu stimuli. li. 4) Posturing. 5) Seiz Seizur ure e acti activi vity ty.. g. Headache. 1) Const Constant ant with with incre increasi asing ng int intens ensity ity.. 2) Aggr Aggrav avat ated ed by move moveme ment nt.. h. Vomi Vomiti ting ng – proj projec ecti tile le vom vomit itin ing. g. i. Infants. 1). Tense, bulging fontanel. 2). Separated cranial sutures. 3). Increasing frontal occipital circumference. 4). High-pitched cry. 3. a. b. c. d. e.
ASSESSMENT 1. a. b. c. d. e. f. g. 2.
Risk Risk fact factor ors/ s/et etio iolo logy gy.. Cerebr Cerebral al edema edema seco seconda ndary ry to to the initi initial al damag damage. e. Bra in in tumors. Intrac Intracran ranial ial hemor hemorrha rhage ge due to to closed closed head head injuri injuries. es. Intrac Intracran ranial ial hemor hemorrha rhage ge due to to rupture ruptured d vessel vessels. s. Cerebr Cerebral al embolis embolism m result resulting ing in necro necrosis sis and and edema edema of areas supplied by the involved vessel. Cere Cerebr bral al throm thrombo bosi sis s result resultin ing g in necro necrosi sis s and edema edema and leading to edema and congestion of affected area. Hyd Hydroc rocepha ephalu lus s. Clin Clinic ical al mani manife fest stat atio ions ns..
f.
Diagnostics CAT scan. Cere Cerebr bral al angi angiog ogra ram. m. Direct Direct intrac intracran ranial ial press pressure ure moni monitor toring ing.. Elec Electr troe oenc ncep epha halo logr gram am (EEG (EEG). ). Calo Calori ric c testi esting ng – test est is perf erform ormed at bed bedside side by introducing cold water into the external auditory canal. If the eighth cranial nerve is stimulated, nystagmus nystagmus occurs, pathology is present. Lumbar Lumbar punc punctu ture re is gener generall ally y not perf perform ormed; ed; decr decreas ease e in CSF pressure could precipitate herniation of the brain stem.
TREATMENT 1. 2.
It is essential for the safe care of the neurologically impaired client that the nurse be able to rapidly evaluate the client and recogn recognize ize change changes s in the neuro neuro signs signs that that indica indicate te an increase in the intracranial pressure. a.
3. a. b. c. 4.
Assess Assess for change changes s in leve levell of cons conscio ciousn usness ess..
NURSING PRIORITY: The first sign of a change in the level of intracranial pressure is alteration in level of consciousness.
Complications
1.
1.
2.
b.
Any alter alterati ation on in level level of consc consciou iousne sness ss (earl (early y sign sign for both both adults adults and childr children) en) irrita irritabil bility ity,, restle restlessn ssness ess,, confus confusion ion,, lethar lethargy, gy, diffic difficult ult to arouse arouse,, etc. etc. may may be significant. As the clien clientt loses loses consci consciou ousn snes ess, s, heari hearing ng is the the last last sense to the lost.
a. b. c. d.
Chan Change ges s in in vit vital al sig signs ns..
5
Treatment of the underlying cause of increasing pressure. Flui Fluid d rest restric ricti tion ons s (flu (fluid ids s may may be incre increas ased ed in the client with vascular damage to decrease the problem of vascular spasm). Medications. Osmo Osmoti tic c diur diuret etic ics. s. Cort Cortic icos ostteroi eroids ds.. Antic nticon onv vulsa ulsant nts. s. Main Mainta tain in adeq adequa uate te ven venti tila lati tion on..
Tent Tentor orial ial hern hernia iati tion on – the the shif shifti ting ng of the intra intracr cran ania iall contents from one compartment to another. Most often involves supratentorial herniation through the tentorial notch. Brai Brain n com compr pres essi sion on occu occurs rs.. Distor Distortio tion n of other other brai brain n struc structu tures res.. Comp Compro romi mise se in in the the vas vascu cula larr bed. bed. Obstru Obstruct ction ion of of the the cereb cerebros rospin pinal al flui fluid. d.
e. 2. 3.
Irre Irreve vers rsibl ible e bra brain in dama damage ge.. Late Latera rall transt transten ento tori rial al herni herniat atio ion n (unc (uncal al ) occu occurs rs as a result of a laterally laterally expanding mass (hematoma). Cent Centra rall hern hernia iati tion on occur occurs s as a resu result lt of a cent centra rall lly y expanding mass that shifts the brain stem downward.
Potent Potential ial Impai Impaired red Tissu Tissue e Integr Integrity ity:: Cornea Corneall relate related d to ulcerations and drying. Anxiety/Fear (Family) related to uncertain state of client and prognosis. Incontinence related to unconsciousness state. Pote Potent ntia iall for for inef ineffe fect ctiv ive e Airw Airway ay Clea Cleara ranc nce e rela relate ted d to unconscious state.
NURSING INTERVENTION
1. 2.
Goal: to identify and decrease problem of IICP. Neuro Neuro chec checks ks as as indica indicated ted by by client client sta status tus.. maint maintain ain semi-F semi-Fowl owler’ er’s s positio position n to promot promote e venous venous drainage and respiratory function.
1. 2.
NURS NURSIN ING G ALER ALERT T > If the the clie client nt with with IICP IICP deve develo lops ps hypovolemic shock, do not place client in Trendelenburg’s position, position, elevate the lower extremities extremities to enhance enhance venous venous return.
3.
4. NURSING DIAGNOSES: Increased Intracranial Pressure Impai Impaired red Gas Exchan Exchange ge relate related d to decrea decreased sed level level of consciousness. Altera Alteratio tion n in Senso Sensory ry Percep Percepti tion on relate related d to increa increase sed d pressure. Alteration in Fluid Volume, Excess related to cerebral edema. Alteration in Tissue Perfusion related to IICP, and shock. Alteration in Nutrition, Less Than Body Requirements related to decrease decreased d level of consciousn consciousness ess and tendency tendency toward toward aspiration. Alteration in Comfort related to headache. Poten otenttial ial for Inju njury relat elated ed to chang hange e in lev level of consciousness. Fear related to severity and prognosis of condition.
5. 6. a. b.
Goal: to maintain psychological equilibrium. Neur Neuro o chec checks ks are are a cont contin inuo uous us remi remind nder er of pote potent ntia iall problem. 2. Encourage Encourage verbalizat verbalization ion of fears regarding regarding condition. condition. 3. Give simple simple explanat explanation ion of procedures procedures to client client and family. family. 4. Alte Altere red d stat states es of consci consciou ousn snes ess s will will caus cause e incr increa ease sed d anxiety and confusion; maintain reality orientation. 5. If client client is unconsc unconscious, ious, continue continue to to talk to him/her, him/her, describe describe procedures and treatments; always assume that client can hear. 6. Assis Assistt parents parents and and family family to work work throug through h feeling feelings s of guilt guilt and anger. Goal: to prevent complications of immobility. Goal: to maintain elimination. 1. Urin Urinary ary inco incont ntin inen ence ce – may may use condo condom m cathet catheter er or indwelling bladder catheter. 2. Keep Keep perin perineal eal area area free free from from excori excoriati ation. on. 3. Monitor Monitor bowel function; function; evaluate evaluate for fecal impaction. impaction.
Change Change clie client’ nt’s s positi position on slowl slowly y and gent gently; ly; avoi avoid d jerky movements. 4. Maint Maintain ain flui fluid d res restr tric icti tion. on. 5. Eval Evalua uate te inta intake ke and and out output put.. a. In resp respons onse e to to diu diure reti tics cs.. b. As corr correla elated ted with with chan changes ges in in daily daily weigh weight. t. c. For For compl complica icatio tions ns of of diabe diabetes tes insipi insipidus dus.. 6. Maint Maintain ain intak intake e evenly evenly over over twenty twenty-fo -four ur hour hour time time period. 7. Sedati Sedatives ves and and narcot narcotics ics can can depre depress ss respi respirat ration ion and mask symptoms indicating increasing ICP. 8. Client Client shoul should d avoid avoid strenuo strenuous us coughi coughing, ng, Valsa Valsalva lva’s ’s maneuver, and isometric muscle exercises. 9. In infant infants, s, measur measure e frontal frontal occip occipita itall circumf circumfere erence nce to evaluate increase in size of the head. 10. Control Control hyperther hyperthermia mia as indic indicated. ated.
BRAIN TUMORS A. 1.
Goal: to maintain respiratory function.
2.
NURSING PRIORITY > Airway is one of the most common problems in the unconscious client, position them to maintain patent airway or use airway adjuncts. 1. 2.
3. 4. 5.
Take Take seiz seizur ure e pre preca caut utio ions ns.. Restra Restrain in client client only if absolu absolutel tely y necessa necessary; ry; strug struggli gling ng against restraints will increase ICP. Do not not clean clean the the ears ears or nasal nasal pass passag ages es of a head head injury, or neuro surgery client. If bleeding or drainage occurs from these areas, evaluate carefully as it may be cerebral spinal fluid. Aspir Aspirati ation on is a major major probl problem em in the the unconsc unconsciou ious s client client.. Carefully assess the swallow reflex in clients who are not fully conscious; position the client in Semi-Fowler’s for tube feeding. Maintain Maintain quiet, quiet, nonstimu nonstimulating lating environme environment nt if condition condition is unstable. Inspec Inspectt eyes eyes and prev prevent ent corn corneal eal ulce ulcerat ration ion.. Protec Protectiv tive e closing closing of eyes eyes ifif the the eyes eyes remain remain open open.. Norm Normal al sali saline ne irri irriga gati tion on or methy methylc lcel ellu lulo lose se drops drops to restore moisture.
1.
3.
Goal: to protect from injury.
3. 4. B.
Preven Preventt respir respirato atory ry probl problems ems of of immob immobili ility. ty. Eval Evalua uate te pate patenc ncy y of airw airway ay freq freque uent ntly ly;; as leve levell of consciousness decreases, client is at an increased risk for for resp respir irat ator ory y obst obstru ruct ctio ion n by the tongu ongue e and and accumulating secretions. Keep Keep PCO2 PCO2 leve levels ls wit within hin norm normal al to to low low range range.. Suct Suctio ion n as neces necessa sary ry,, but in shor shortt durati duration on with with rest rest periods. Clie Client nt may requ requir ire e intu intuba bati tion on and contr control ol on a volu volume me ventilator.
C.
D. E.
F.
Nursing Diagnoses: Unconscious Client
Clas Classi sifi fica cati tion on of of tum tumor ors. s. Tumor Tumors s arising arising from from the prote protecti ctive ve coveri covering ng of the brain brain-i.e., dural meningiomas. Tumo Tumors rs deve develo lopi ping ng I or arou around nd cran crania iall nerv nerves es-i -i.e .e., ., acoustic neuromas. Tumors Tumors origin originating ating in the the brain brain tissue-i.e tissue-i.e., ., gliomas. gliomas. Meta Metast stat atic ic tumo tumors rs orig origin inat atin ing g else elsewh wher ere e in the the body body;; frequently, metastasis is from the lung or the breast. Glioma Gliomas s are the the most comm common on tumors tumors;; freque frequentl ntly y are malignant. Brain Brain tumors tumors may may be benign, benign, malign malignant ant,, or metastat metastatic; ic; malignant brain tumors rarely metastasize outside the CNS. Supratent Supratentorial orial – tumors tumors occurri occurring ng within within the the anterior anterior twotwothirds of the brain, primarily the cerebrum. Infrat Infratent entori orial al – tumors tumors occur occurrin ring g in the poste posterio riorr third of the brain (or below the tento tentoriu rium); m); primaril primarily y in the cerebellum or the brain stem. Regardless Regardless of the the origin, origin, site, site, or presence presence of of maligna malignancy, ncy, proble problems ms of increa increased sed intrac intracran ranial ial pressu pressure re occur occur because of the limited area in the intracranial contents.
Assessment
Self Care Deficit related to unresponsive condition Potent Potential ial for infect infection ion relat related ed to immobi immobilit lity y and invasi invasive ve procedures.
1. a.
6
Risk Risk fact factor ors/ s/et etio iolo logy gy.. Adul Adults ts-h -hig ighe hest st incid inciden ence ce betwe between en 55 and and 70 years years of age.
b.
Progno Prognosis sis is gene general rally ly poorer poorer in the the infant infant than than in olde older r children. c. Presen Presence ce of meta metasta static tic canc cancer er of the the lung lung or breas breast. t. 2. Clin Clinic ical al mani manife fest stat atio ions ns – symp sympto toms ms corr correl elat ate e with with the area of the brain initially involved. a. Headache. 1). Recurrent. 2). Progressive. 3). More severe in the morning. 4). Affected by position. 5). Headache in infant may be identified by persistent, irritated crying and head rolling. b. Vomiti Vomiting ng – initially initially with with or without without nausea nausea;; progres progressiv sively ely becomes projectile. c. Coordinati Coordination on disturbanc disturbances es (ataxia, (ataxia, staggerin staggering g gait). gait). d. Hypo Hypoto toni nia, a, hypo hypore refl flex exia ia..
1. 2. 3. 4. 5.
1. 2. a. b. c. d.
Visual Visual change changes s due due to locali localizin zing g effec effects ts.. Nystagmus. Diplopia. Decr Decrea ease se in visu visual al acui acuity ty.. Visu Visual al fie field ld def defic icit its. s. Head Head tilttilt- chil child d may tilt tilt the the head head due to to damage damage to to extra extra ocular muscles; may be first indication of a decrease in visual acuity. g. Beha Behavi vior oral al chan change ges. s. 1) Obvi Obviou ous s pers person onal alit ity y chan change ges. s. 2) Decrea Decreasin sing g leve levell of of consci conscious ousnes ness. s. 3) Decrea Decreasin sing g activit activity, y, incre increase ased d sleep sleep periods periods in the infant. h. Decrea Decrease se in musc muscle le stren strength gth or loss loss of of specif specific ic areas areas of movement. i. Change Changes s in vital vital sign signs s indic indicati ative ve of of incre increasi asing ng ICP. ICP. j. j. Seiz Seizur ures es (foc (focal al or gene genera rali lize zed) d).. k. Crania Craniall enlarge enlargemen mentt in the infant infant under under eigh eightee teen n months months old. l. Papi Papill lled edem ema a (ede (edema ma of of the the opti optic c disc disc). ). m. Dizz Dizzin ines ess s and and ver verti tigo. go. NURSING DIAGNOSES: Brain Tumor
e. 3.
4. a. b. c. 5. 6. a. b. c. 7. 8. 9. a.
Injury: Injury: High Risk related to gait disorders, disorders, vertigo, visual disturbances, or compression/displacement of brain tissue. Anxiety Anxiety related to implication implications s of condition condition and uncertain uncertain future. Self Self-c -car are e Defi Defici citt relat related ed to inab inabil ilit ity y to perf perfor orm m ADL’ ADL’s s secondary to sensory-motor sensory-motor impairment. Altered Altered Family Family Processe Processes s rela relate ted d to the the natu nature re of the the condition, role disturbances, and uncertain future.
b. c. d. e.
Goal: Goal: to mainta maintain in homeos homeostas tasis is and monito monitor r chan changes ges incr increa ease sed d intr intrac acra rani nial al pres pressu sure re postoperative craniotomy. Neur Neuro o che check cks s as as nec neces essa sary ry.. Maint Maintain ain pulm pulmona onary ry func functio tion n and and hygie hygiene. ne. Paten t ai rw rwa y. y. Prev Preven entt aspi aspira rati tion on.. Increa Increase se respi respirat ratory ory excu excursi rsion on by deep deep breat breathin hing. g. Anti Antiem emet etic ics s to decr decrea ease se vomi vomiti ting ng and and poss possib ibil ilit ity y of aspiration. Disc Discou oura rage ge vig vigor orou ous s coug coughi hing. ng. Careful Careful evaluati evaluation on of the level of consci consciousne ousness; ss; regression regression to more lethargic or irritable state may be indicativ indicative e of increasing ICP. Eval Evalua uate te dres dressi sing ng.. Loca Locati tion on and and amo amount unt of dra drain inag age. e. Evalu Evaluate ate for for CSF CSF leak leak throu through gh the the incis incision ion.. Do not not change change dres dressin sing g initial initially, ly, but but reinf reinforc orce e it. Position Position in low to to semi-Fow semi-Fowler’s ler’s if there there is is a spinal spinal fluid leak from ears or nose. Position Position postopera postoperativel tively y for infratent infratentorial orial surgery. surgery. Bed shoul hould d be be fla flatt. Positi Position on clien clientt on eith either er side; side; keep keep off off back back.. Maint Maintain ain head head and and neck in in midlin midline e and slight slightly ly exten extended ded.. Positi Position on postop postopera erativ tively ely for supraten supratentor torial ial surgery surgery-se -semi mi to low Fowler’s. Trend Trendele elenbu nburg rg positi position on is contrai contraindi ndicat cated ed in both types types of surgery. Maint Maintain ain flui fluid d reg regul ulat atio ion. n. Begi Begin n clear clear liqu liquid ids s PO afte afterr swallo swallow w and gag refle reflexe xes s return and client is awake. Maint Maintain ain IV IV fluid fluid until until clien clientt toler tolerate ates s fluids fluids.. Clos Closel ely y moni monito torr inta intake ke and and outp output ut.. Client Client may be on fluid fluid restri restrict ction ion.. Evalu Evaluate ate neuro neuro statu status s in respons response e to fluid fluid balanc balance e and diuretics. Carefully Carefully evaluate evaluate changes changes in tempe temperatur rature-may e-may be be due to respiratory complications or to alteration in the function of the hypothalamus. Provide Provide appropriat appropriate e pain pain relief. relief. Avoi Avoid d nar narco coti tic c ana analg lges esic ics. s. Aspir Aspirin in or or TYLE TYLENOL NOL is freq frequen uently tly used. used. Maint Maintain ain qui quiet et,, dim dim atmo atmosp sphe here re.. Avoi Avoid d sudd sudden en move moveme ment nts. s. Prevent Prevent complicati complications ons of of immobil immobility. ity. Maintain Maintain seizure seizure precautio precautions. ns.
e. 1. 2. 3. 4. f.
3. a.
Goal: to provide appropriate preoperative nursing intervention. Gener General al preope preoperat rative ive care care with with excepti exceptions ons as noted noted.. Shave Shave the the head, head, save save the hair hair and ret return urn it to to the famil family, y, or dispose of its indicated by institutional policy. If there there is incre increase ased d ICP, ICP, general generally ly do not adm adminis inister ter an enema. Prepar Prepare e client, client, fami family, ly, and and parents parents for for appear appearanc ance e of the client postoperatively. Encourage Encourage verbalizat verbalization ion regarding regarding concerns concerns of surgery. surgery.
b. c. d. 10. 11.
Diagn os osti cs cs. Clin Clinic ical al mani manife fest stat atio ions ns exhib exhibit ited ed in the the neur neurol ologi ogica call exam. EEG. CAT scan. Brain scan. Cere Cerebr bral al angi angiog ogra ram. m.
12. a. b. c. d. 13. 14.
Treatment 1. Medical. a. Dexamethasone b. Ant Antico iconvu nvulsa lsants nts c. Radiat Radiation ion and chemot chemother herapy apy if malign malignant ant.. 2. Surg Surgic ical al exci excisi sion on-c -cra rani niot otom omy. y.
HEAD INJURY Trauma to the cranium and its contents. A. 1. 2. B.
Complications Meningitis, respiratory aspiration, brain stem herniation; diabetes insipidus, inappropriate ADH secretion.
C.
Nursing Intervention See Nursin Nursing g Diagno Diagnosis sis for Increa Increased sed Intrac Intracran ranial ial Pressure.
D.
Preope Preoperat rative ive manag manageme ement nt – see nursin nursing g goals goals for increased intracranial pressure.
7
Class lassif ific icat atiion. on. Clos Closed ed – no fra fract ctur ure e pres presen ent. t. Open-sim Open-simple ple skull skull fracture fracture to compou compound nd deep deep skull skull fractu fracture. re. Childr Children en and infant infants s are more more capable capable or absorb absorbing ing direct direct impact due to pliability of the skull. Coup Coup-C -Con ontr trec ecou oup p inju injury ry-d -dam amag age e to the the site site of impa impact ct (coup (coup)) and damage damage on the the opposi opposite te side side of the injury injury (contrecoup). Inju Injury ry to the the brai brain n occu occurs rs by comp compre ress ssio ion, n, teari tearing ng and shearing stresses on vessels and nerves.
E.
Alth Althou ough gh brai brain n volu volume me rema remain ins s unch unchan ange ged, d, cere cerebr bral al edema edema occurs occurs in respon response se to the injury injury and frequ frequent ently ly precipitates an increase in intracranial pressure. F. Type Types s of head head inju injuri ries es.. 1. Concussion. a. Immedi Immediate ate brie brieff period period of of uncons unconscio ciousn usness ess.. b. Genera Generally lly follo followed wed by amn amnesi esia a from from the mome moment nt of injur injury y impact and short period afterward. 2. Cont Contus usio ion n (bru (bruis isin ing) g).. a. Produces Produces small hemorrhag hemorrhages es along along the the surfac surface e of the brain without penetration of the brain tissue. b. May May caus cause e foca focall dist distur urba banc nces es.. c. Bloo Blood d supply supply is alter altered ed in the area area of inju injury ry,, swellin swelling, g, ischemia, and occurrence of IICP. 3. Intr Intrac acra rani nial al hemo hemorr rrha hage ge.. a. Epidural Epidural (extradur (extradural) al) hematomahematoma- a large vwessel (generally (generally an artery) in the dura mater is damaged; a hematoma rapidly forms between the dura and the skull precipitating an increase in intracranial pressure. 1. Momentar Momentary y loss of conscious consciousness ness then free of symptoms symptoms (lucid period). 2. Within minutes to hours, symptoms of increasing intracranial pressure (ipsilateral papillary symptoms, contra lateral weakness or paralysis). 3. Symptoms Symptoms of increasing increasing ICP may develop develop after after the lucid interval. 4. Tentorial herniation may occur without immediate intervention. b. Subdur Subdural al hemato hematoma ma –bleed –bleeding ing betwee between n the dura dura and arachn arachnoid oid area, area, usually usually due to the rupture rupture of veins veins in the subdural space. 1) 2) 3) 4)
contributes to the cerebral edema; close observation and prompt recognition of IICP. 1. 2.
3. a. b.
majo majorit rity y of clien clients ts who exper experie ienc nce e conc concus ussi sion on are treated agt home. A peri period od of unco uncons nsci ciou ousn snes ess s or prese presenc nce e of seizures seizures are considered considered serious indication indications s of injury. Surg Surgic ical al int inter erve vent ntio ion n Burr Burr holes holes to evacua evacuate te the the hemat hematoma oma Craniotomy
NURSING INTERVENTION See Nursin Nursing g Diagno Diagnosis sis for Increa Increased sed Intrac Intracran ranial ial Pressure.
b.
Goal: to provide instruction for care of the client in the home environment. Prob Proble lems ms frequ frequent ently ly do not not occu occurr unti untill twent twenty y four four hours or more after the initial injury. Obse Observ rve e the the client client for for incr increa ease sed d peri period ods s of sleep; sleep; if client is asleep, awaken every two to three hours to see if he can be aroused normally. Main Mainta tain in cont contac actt with with physic physicia ian n for for re-e re-eva valu luat atio ion n if complications occur. doct doctor or sho should uld be not notif ifie ied d for: for: Any chang hanges es in LOC LOC (inc (incre reas ased ed dro drowsin wsines ess s, confusion). Unab Unable le to to arou arouse se cli clien ent. t.
c. d. e. f. g. h.
Seiz eizures ures occur. cur. Bleedi Bleeding ng or wate watery ry drain drainage age from from the the ears ears or nos nose. e. Loss Loss of feel feeling ing or or sensa sensatio tion n in any any extre extremit mity. y. Blurred vi vision Slur lurring ring speec peech. h. Vomiting
1. 2.
3. 4. a.
Develo Develops ps more more slowl slowly y – may be be acute, acute, suba subacut cute, e, or chronic. Suba Subacu cute te may not becom become e symp sympto toma mati tic c for for seve severa rall days to weeks. Acute Acute injury injury is is manifest manifested ed within within 24 hours hours of of the the injury. injury. Sympt Symptoms oms of increa increasin sing g intracra intracrania niall pressure pressure develo develop p gradually.
NURSING PRIORITY: Instructions should be given to the client and to the family in writing. Frequently clients have increa increased sed anxiety anxiety in the emergenc emergency y room room and do not comprehend verbal directions.
Assessment 1. Risk factors/etiology. a. Falls b. Motor vehicle accidents c. Epidural hematomas are uncommon in children under four years of age. d. Subdural hematomas are common in infants and may be the result of birth trauma. 2. Clinical manifestations-see individual types of injury. 3. Diagnostics. a. Neurologic history. b. Skull X-ray c. Cerebral angiogram d. CAT scan Nursing Diagnoses: Head Injury
Goal: to maintain homeostasis; monitor and identify early symptoms of increased intracranial pressure in the hospitalized client.
1. 2. a.
Genera Generally lly on on bed rest rest and and clear clear liqu liquids ids initi initiall ally. y. Frequ Frequent ent neuro neuro chec checks ks for for incr increas eased ed ICP. ICP. Decrea Decreased sed level level of consc consciou iousne sness ss frequ frequent ently ly the firs firstt indication. Inst Instru ruct ct head head inju injury ry client clients s not not to cough cough,, snee sneeze ze or blow his nose. Evalua Evaluate te drai drainag nage e from from nose nose,, ears ears and and mout mouth. h. Do not cle clean an out the the ears ears-p -pla lace ce loos loose e cotto cotton n in the auditory canal and changes as soiled. Check Check cont continu inuous ous clea clearr draina drainage ge from from the the nose nose with with a dextrose stix; if glucose is present, it is indicative of CSF. Seiz Seizur ure e prec precau auti tion ons s Main Mainta tain in adeq adequa uate te fluid fluid inta intake ke via via IV or PO; do not not over hydrate. Assess Assess for other other unde undete tecte cted d injur injuries ies..
b. 3. a. b.
Impai Impaired red Physic Physical al Mobilit Mobility y relate related d to motor, motor, sensor sensory, y, or proprioceptive deficits, depressed level of consciousness. Injury: High Risk related to restlessness and confusion. Sleep Pattern Disturbance related to frequent assessments and loss of REM sleep. Altered Thought Processes related to memory deficit, impaired reasoning ability, altered LOC, confusion, speech impairment, or sensory deprivation. Seizures: High Risk related to brain injury or hypoxia.
4. 5. 6.
Complications
Goal Goal:: to prov provid ide e appr approp opria riate te nurs nursin ing g intervention intervention for the client experiencin experiencing g an increase in intracranial pressure.
HYDROCEPHALUS
Increased Increased intracran intracranial ial pressure, pressure, meningitis meningitis,, diabetes diabetes insipidus, permanent brain damage.
A condition caused by an imbalance imbalance in the production production and absorption of CSF in the ventricles of the brain.
Treatment
Classification
Nursing Priority: the initial treatment of the head injury client is to maintain adequate respiratory function to prevent hypoxia and hypercapnia resulting in acidosis which causes vasodilation and
8
1.
2. 3.
Nonc Noncom ommu munic nicat atin ingg-ci circ rcul ulat atio ion n of CSF CSF is bloc blocke ked d within the ventricular system of the brain; may also be referred to as obstructive. Com Communic unicat atin ing g – CSF CSF flows lows free reely wit within hin the the ventricular system but is not adequately absorbed. Frequ Frequent ently ly associ associate ated d with menin meningom gomyel yeloce ocele le in the newborn.
3. 4.
proble problem m with with child children ren who are having having a shunt shunt revi revisi sion on,, they they have have not not had had an incr increa ease se in ventricular pressure. Monit Monitor or for for increa increasin sing g ICP and and compa compare re data data with with previous data. Monit Monitor or for for infe infecti ction, on, a comm common on prob problem lem..
Goal Goal:: to assi assist sts s fami family ly and and chil child d to unde unders rsta tand nd implications of the problem and measures to maintain and promote health post shunt procedure.
Assessment 1. Risk factors/etiology. a. Neonate. 1) Non Non comm ommunic unicat atin ing g usua usuall lly y the the res result ult of a congenital malformation. 2) Intr Intraut auter erin ine e infec infecti tion on 3) Peri Perina nattal hem hemor orrh rhag age e 4) Neon Neonat atal al menin meningo goen ence ceph phal alit itis is b. Other child,adult. 1) Spac Space e occu occupy pyin ing g lesi lesion. on. 2) Pre-ex Pre-exist isting ing develo developme pmenta ntall defe defects cts..
1. 2. 3. 4.
Teach Teach pare parents nts sympto symptoms ms of increa increasin sing g ICP. ICP. Have Have parent parents s partic participa ipate te in care care of of the shun shuntt prior prior to client’s discharge. Encour Encourage age paren parents ts and and family family to to ventila ventilate te feeli feelings ngs regarding client’s condition. Refer Refer client client to to appropr appropriat iate e commun community ity agenc agencies ies..
INTERRUPTION OF CEREBRAL CIRCULATION Cerebral Vascular Accident (CVA)
2. Clinical manifestations-infant. manifestations-infant. a. Head enlargement, increasing circumference. b. Separation of cranial suture lines. c. Fontanel becomes tense and bulging d. Dilated scalp veins. e. Frontal enlargement, bulging “sunset eyes”. f. Symptoms of increasing ICP.
Also known as a stroke, CVA is the disruption of the blood supply to an area of the brain resulting in tissue necrosis and sudden loss of brain function. A.
3. Clinical manifestations – older child, adult. a. Symptoms of increasing ICP. b. Specific manifestations related to site of the lesion.
B. 1. a.
4. Diagnostics. a. Same as for brain tumor b. Increasing head circumference is diagnostic in infants.
b. c. 2.
Treatment 1.Non communicating and communicating. a. Ventri Ventricul culoat oatria riall shuntshunt-CSF CSF is shunte shunted d into into the the right right atrium. b. Ventricul Ventriculoperi operitonea toneall shuntshunt- CSF is shunted shunted into the peritoneum (preferred).
a. b.
3. a.
2. Obstructive-removal of the obstruction (cyst, hematoma, tumor).
b. NURSING DIAGNOSES: Hydrocephalus C. Nursing Diagnosis for Increased Intracranial Pressure. Potential for Altered Growth and Development related to brain damage. Alteration Alteration in Family Family Process Process related to acute illness of infant.
D. 1. 2.
Nursing Intervention
3.
Goal: to monitor for the development of increasing ICP. 1. Daily mea su su re rement of the frontal occipital occipital circumferenc circumference e of the head in infants. 2. Asse Assess ss for for symp sympto toms ms of incr increa easi sing ng ICP. 3. Infants i s often difficult to feed; administe administerr small feedings at frequent frequent intervals. 4. Eval Evalua uate te LOC. LOC. It is freq freque uent ntly ly the the first first symptom of increasing ICP.
4.
E.
Ather Atherosc oscler lerosi osis s – result resulting ing in cerebra cerebrall vascula vascularr disease, disease, frequently precedes the development of a CVA. Types pes of str stroke. oke. Thro Thromb mbos osis is-f -for orma mati tion on of a clot clot which which resul results ts in the the narrowing of a vessel lumen and eventual occlusion. Asso Associ ciat ated ed with with hype hypert rten ensi sion on and and diab diabet etes es (i.e (i.e., ., conditions which accelerate atherosclerotic process). Assoc Associat iated ed with with atherosc atheroscler leroti otic c disease disease of the the carotid carotid,, subclavian, and vertebral arteries. Genera Generally lly a cond conditi ition on of of the the elde elderly rly.. Emboli bolis sm – occ occlusi lusion on of a cere erebral bral art artery ery by an embolus. common common site site of origin origin is the the endo endocar cardiu dium. m. May May effe effect ct any age grou group; p; frequ frequen entl tly y asso associ ciat ated ed with with rheumatic heart disease and atrial fibrillation. Cere Cerebr bral al hemo hemorr rrha hage ge.. Ruptur Rupture e of a cerebral cerebral artery artery secon secondar dary y to hyperte hypertensi nsion, on, trauma, or aneurysm. Blood Blood leaks leaks into into the brain brain tiss tissue ue and the the subara subarachn chnoid oid space; creates a mass that displaces the brain. The The area of edema edema resul resulti ting ng from from tissu tissue e dama damage ge may precipita precipitate te more damage than the vascular vascular damage itself. Trans Transien ientt isch ischemi emic c att attack ack (TIA (TIA). ). Brief Brief episo episode de of neurol neurologi ogical cal dysf dysfunc unctio tion. n. Freq Freque uent ntly ly indi indica cati tive ve of adva advanc nced ed athe athero rosc scle lero roti tic c disease of the cerebral vessels. Shoul hould d be consi onside dere red d a warn warnin ing g sym symptom ptom of an impending CVA. Neurol Neurologic ogic dysfu dysfunct nction ion is prese present nt for minut minutes es to hours, hours, but no permanent neurological deficit remains. Neuromusc Neuromuscular ular deficits deficits result resulting ing from from a stroke stroke are are due due to damage of motor neurons of the pyramidal tract.
RISK RISK FACT FACTO ORS ASSO ASSOCI CIAT ATED ED VASCULAR ACCIDENT Reversible: Smoking Obesity Increased salt intake Sedentary life style Oral contraceptives • •
Goal: Goal: to mainta maintain in patenc patency y of the shunt shunt and monit monitor or intracranial pressure post shunt procedure. 1. Posit ositio ion n on the unope nopera rati tiv ve side ide to prev preven entt pressure on the shunt valve. 2. may be be positi positione oned d flat flat immedi immediate ately ly after after surg surgery ery to to prevent too rapid depletion of CSF. This is not a
• • •
Partially Reversible: Hypertension •
9
WITH WITH
CERE CEREBR BRAL AL
• • • •
Treatment 1. Proph yl ylactic. a. Aspirin. b. Persantine c. Anti Antihy hype pert rten ens sives ives.. 2. Medical a. Medica Medicatio tions ns to to decre decrease ase cerebr cerebral al edema edema.. 1. Osmotic otic diu diure rettics ics 2. Cortic Corticost ostero eroids ids (dexam (dexameth ethas asone one). ). b. Medica Medicall measure measuremen ments ts to main maintai tain n homeos homeostas tasis. is. 3. Surgical. a. Caro Caroti tid d enda endart rter erec ecto tomy my.. b. Cere Cerebr bral al rev revas ascu cula lari riza zati tion. on.
Cardiac valve disease Dysrhythmias Diabetes mellitus Hypercholesterolemia
Nonreversible: Sex (increased incidence in men) Age Increased incidence in the black Hereditary predisposition • • • •
1.
2.
Damage Damage to the left side of the the brain brain will will result result in paralys paralysis is of the right side of the body (hemiplegia-paralysis of one side of the body). Both upper and lower lower extremit extremities ies of of the the involv involved ed side side are are affected.
Nursing Intervention Goal: to prevent CVA through client education. 1.
Assessment: 1. Risk Risk factor factors/E s/Etio tiolog logy: y: (see (see previ previous ous tabl table) e) 2. Clin Clinic ical al Mani Manife fest stat atio ions ns:: a. TIA 1. Temp Tempor orar ary y loss loss of of visi vision on in in one eye eye 2. Tran Transi sien entt hemi hemipa pare res sis 3. Tinnitus 4. Vertigo 5. Confusion 6. Nos Noseble ebleed eds( s(ep epis ista taxi xis) s) b. Completed CVA (occurs suddenly with an embolism more gradually in hemorrhage or thrombosis) 1. Hemiplegia – loss of voluntary movement, damage to the right side of the brain will result in left-sided weakness and paralysis 2. Aphasia – defect in using and interpreting the symbols of language, may include written, printed or spoken words, may be partial or complete. 3. Proble Problem m of neurom neuromusc uscula ularr contr control ol of respir respirati ation. on. 4. Proble Problem m of neuromu neuromuscu scular lar contr control ol over over swallow swallowing ing and and cough reflex. 5. Init Initia ially lly may may be inc incon onti tine nent nt.. 6. Agnosi Agnosiaa- a percept perceptual ual defec defectt that that causes causes a disturb disturbanc ance e in interpreting sensory information, client may not be able to recognize previously familiar objects. 7. Emot Emotio iona nall labi labili lity ty.. 8. Impair Impairmen mentt of of judg judgmen mentt and and memory memory.. 9. Hypo Hypoto toni nia a (fla (flacc ccid idit ity) y) for days days to weeks weeks follow followed ed by hypertonia (spasticity). 10. Visual Visual defects defects homonym homonymous ous hemiano hemianopsi psia, a, the loss loss of vision in one half of the visual field. 11. Percep Perceptu tual al defect defects. s. 12. Apraxia Apraxia inability inability to carry carry out learned learned movements. movements.
2.
Goal: Goal: to mainta maintain in patent patent airway airway and adequa adequate te cerebr cerebral al oxygenation. 1. Positi Position on side side-ly -lying ing with with head head elev elevate ated. d. 2. Asse Assess ss for symp sympto toms ms of hypox hypoxia; ia; ET intub intubat atio ion n and and mechanical ventilation may be necessary. 3. Main Mainta tain in patent patent airway airway;; use use orop oropha hary ryng ngea eall airw airway ay to prevent airway obstruction by the tongue. 4. Clie Client nt is prone prone to obstr obstruc ucte ted d airway airway and pulmo pulmona nary ry infection; have/her cough and deep breathe as indicated. Goal: to assess for and implement measures to decrease intracranial pressure Goal: to maintain adequate nutritional intake. 1. Admini Administ ster er PO feedin feedings gs with with caution caution;; check check presenc presence e of gag reflex and swallowing before feeding. 2. Place Place food food on on the the unaffe unaffecte cted d side side of the the mout mouth. h. 3. Select Select food foods s that that are easy easy to to contr control ol in the the mouth mouth and and swallo swallow; w; liquid liquids s often often promot promote e coughi coughing ng as client client is unable to control them. 4. Mainta Maintain in high high Fowl Fowler’ er’s s positi position on for for feed feeding ing.. 5. Mainta Maintain in priva privacy cy and and unrus unrushed hed atm atmosp ospher here. e. 6. If clien clientt is unab unable le to toler tolerat ate e PO intak intake, e, tube tube feedi feedings ngs may be initiated. Goal: to preserve function of the musculoskeletal system to prevent joint contraction and muscle atrophy. 1. 2. 3.
Nursing Diagnosis: Cerebral Vascular Accident (CVA)
4.
Ineffectiv Ineffective e Airway Airway Clearance Clearance related related to neurologic neurological al deficits deficits inability to cough. Altere Altered d Tissue Tissue Perfus Perfusion ion relat related ed to interr interrupt upted ed cerebr cerebral al vascular blood supply. Impaired Verbal Communications related to visual and speech impairment. Potential for Injury related to seizures and neurological deficits. Alteration In Nutrition: Less Than Body Requirements related difficulty in swallowing and potential for aspiration. Impaired Impaired Physical Mobility related to severe severe weakness weakness and paralysis. Knowledge Deficit related to prognosis.
5.
3. a. b. c. d.
Identi Identific ficati ation on of individu individuals als with with reversib reversible le risk factor factors s and measures to reduce them. Appr Approp opri riat ate e medi medica call atte attent ntio ion n for for cont contro roll of chroni chronic c conditions conducive to the development of CVA (Partial reversible risk factors).
6.
7. 8.
Pass Passiv ive e ROM ROM on affe affect cted ed sid side. e. Acti Active ve ROM ROM on una unaff ffec ecte ted d side side.. Utiliz Utilize e footboa footboard rd to keep keep at right right angles angles and and prevent prevent foot foot drop. Legs Legs should should be maint maintain ained ed in a neutral neutral posit position ion;; prevent prevent external rotation of affected hip by placing a trochanter roll or sandbag at the thigh. Posi Positi tion on every every two hour hours s but limit limit the the period period of time time spent on the affected side. Assess Assess for for adduct adduction ion and and internal internal rotation rotation of of the the affect affected ed arm; maintain maintain arm in a neutral neutral (slightly flexed) flexed) position position with each joint slightly higher than the preceding one. Rest Restra rain ints ts shoul hould d be avoi avoide ded, d, they hey ofte often n inc increas rease e agitation. Mainta Maintain in joints joints in in positi position on of normal normal funct function ion to to prevent prevent flexion contractures.
Goal: to maintain maintain homeostas homeostasis is through through continued continued nursing assessment and appropriate nursing intervention.
Diagnostics Clinical Clinical manife manifestat stations ions elicited elicited in the the neurolo neurological gical exam. exam. Cere Cerebr bral al arte arteri riog ogra ram. m. Lum Lumbar bar pun punctur cture e CAT CAT an and br brain ain sc scan. an.
1. 2. a. b.
10
Evalua Evaluate te adequa adequacy cy of cardia cardiac c out output put.. Monitor hydrati on on statu ss-pre ve ven t overload. Care Carefu fully lly regu regulat late e IV int intak ake. e. Eval Evaluat uate e respo respons nse e to diur diuret etic ics. s.
flu id id
c. d. e. 3. a. b. c. d. 4. 5. a.
b. c.
Asse Assess ss for the the deve develo lopm pmen entt of perip periphe hera rall edema. Restri Restrict ct fluid fluid intake intake as indica indicate ted. d. Asse Assess ss resp respir irat ator ory y para parame mete ters rs indi indica cati tive ve of fluid overload (rales, dyspnea, etc.) Mainta Maintain in and and prom promot ote e normal normal elimin eliminati ation. on. Avoid Avoid urina urinary ry cathe catheter ter ifif possib possible; le; ifif cathet catheter er is necessary, remove as soon as possible. Offe Offerr bedpa bedpan n or urina urinall every every two two hours hours;; help help establish a schedule. Preven Preventt const constipa ipatio tionn- incre increase ase bulk bulk in in the diet diet,, stool softeners, etc. Prov rovide ide priv rivacy acy and and dec decreas ease emot motiona ionall trauma related to incontinence. Prev Preven entt proble problems ms of skin skin brea breakd kdow own n throug through h proper positioning and good skin hygiene. Mainta Maintain in psycho psycholog logica icall homeos homeostas tasis is Cli Client ent is very ery anxi nxious ous due due to the the flac lack of unde unders rsta tand ndin ing g of what what has has happ happen ened ed to him/her and the inability to communicate. Spea Speak k slowl slowly, y, clea clearl rly, y, and and explain explain what what has happened. Asse Assess ss client client’s ’s comm communi unica cati tion on abilit abilities ies and identify methods to promote communication.
b. c. d. 2.
Goal: to assist assist client to become independent independent in activi activitie ties s of daily daily living living as rehabi rehabilit litati ation on phase phase progresses.
3. a. b. c.
1. 2. 3.
Enco Encour urag age e self self-f -fee eedi ding ng Provid Provide e cloth clothing ing easy easy to get in and and out out of. of. Acti Active ve parti partici cipa pati tion on in ROM; ROM; do his/he his/herr own ROM on affected side. 4. Physic Physical al therap therapy y for retra retraini ining ng of lost lost funct function ion.. 5. When When in the sitt sittin ing g posit positio ion, n, assi assist st clie client nt to main mainta tain in sens sense e of bala balanc nce; e; clie client nt will will frequently fall to the affected side. 6. Enco Encour urag age e part partic icip ipat atio ion n in carryi carrying ng out daily daily personal hygiene. 7. Assi Assist st/t /teac each h clie client nt safe safe trans transfe ferr from from bed to wheelchair. 8. Mainta Maintain in bowel bowel and and blad bladder der trai trainin ning g progr program. am. 9. Prom Promot ote e urin urinar ary y con conti tine nenc nce. e. 10. Encourage Encourage social social interactio interaction. n. a. Spee ch ch th therapy b. Frequ Frequent ent and meanin meaningfu gfull verba verball stimu stimuli. li. c. Allow Allow clie client nt plen plenty ty of time time to respon respond. d. d. Spea Speak k slowl slowly y and and clea clearl rly; y; do not not give give too too many directions at one time. e. Do not not “tal “talk k down down to” to” or or treat treats s as a child. child. f. Menta Mentall statu status s may may be norm normal; al; do not assume assume it is impaired.
Treatment 1. Osmo Osmoti tic c diur diuret etic ics. s. 2. Anti Antihy hype pert rtens ensiv ive e medi medica cati tion ons. s. 3. Surg Surgic ical al inte interv rven enti tion on-l -lig igat atio ion n aneurysm.
C.
“cli “clipp ppin ing” g”
of
the the
1. 2.
Imme Immedi diat ate, e, stri strict ct bed bed res rest. t. Prev Preven entt Vals Valsal alva va’s ’s man maneu euve ver. r.
3.
Client should avoid straining, sneezing, pulling up in bed, acute flexion of the neck, cigarette smoking. Elev Elevat ate e head head of of the the bed bed 15˚ 15˚ to to 30˚. 30˚. Quiet, Quiet, dim, dim, nonsti nonstimul mulati ating ng envir environm onment ent..
4. 5.
6.
7.
Constant monitoring of condition to identify occurrence of bleedi bleeding ng as eviden evidenced ced by sympto symptoms ms of increa increasin sing g intracranial pressure. Admi Adminis niste terr anal analges gesic ics s caut cautio ious usly ly,, the the clie client nt shoul should d continue to be easily aroused in order to perform neuro checks.
Nursin Nursing g Prior Priority ity:: If the client client surviv survives es the ruptur rupture e of the aneurysm, it is most likely to rebleed within the next 24 to 48 hours.
A dilation of the wall of a cerebral cerebral artery (Berry (Berry aneurysm) most most often arises from an arterial junction in the Circle of Willis.
B.
or
Nursing Intervention Goal: Goal: to prevent prevent further increase increase in intracran intracranial ial pressure pressure and possible rupture.
CEREBRAL ANEURYSM, SUBARACHNOID HEMORRHAGE
A.
Atherosclerosis resulting in weakness of the vessel wall. Hyp Hypert ertensi ension on;; head head traum rauma a may enhance the problem. Most Most oft often en occ occur urs s in mid middl dle e life life.. Clin Clinic ical al mani manife fest stat atio ions ns.. a. A Rupture may be preceded by: 1) Severe headache. 2 ) Intermi ttttent nausea. b. Rupture frequently occurs without warning. 1) Sever evere e hea head dache ache.. 2) Seizures. 3) Nucha uchall rigid igidit ity y 4) Hemipare si sis. 5) Loss of consciousness. 6) Over verall all symp sympttoms oms depe depend nds s on the the site and amount of bleedi bleeding; ng; overal overalll prognosis is poor. Diagn os osti cs cs. Lumb Lumbar ar punc punctu ture re,, reveal revealin ing g blood blood in the spinal fluid. Cere Cerebr bral al angi angiog ogra ram. m. CAT scan.
Goal: Goal: to assess assess for for and implem implement ent nursin nursing g measur measures es to decrease intracranial pressure.
An aneu aneury rys sm freq freque uent ntly ly rupt ruptur ures es and bleeds into the subarachn subarachnoid oid space. Symp Sympto toms ms occur occur when when aneu aneury rys sm enlarges and exerts pressure on the brain tissue, or when it ruptures. Fre qu quently th e vasopasm that accompanies the rupture causes a significant significant increase increase in the area of damage.
Goal: to provide appropriate preoperative nursing intervention. Goal: Goal: to mainta maintain in homeos homeostas tasis is and monito monitorr change changes s in intracranial pressure postoperative craniotomy.
INFLAMMATORY PROBLEMS Meningitis Meningitis Meningitis is an inflammatory inflammatory condition of the meningeal meningeal tissue covering the brain.
Assessment
A. Types. 1. a.
Risk Risk fact factor ors/ s/et etio iolo logy gy.. Congen Congenita itall defor deformit mities ies of the vessel vessel..
1. Bacterial. 2. Fungal.
11
3. Viral (aseptic). 4. Parasitic.
Treatment 1. Respir Respirato atory ry isolati isolation on for at least least twentytwenty-fo four ur hours hours after after initiation of treatment or until positive organism identified. 2. IV ant antibio ibiottics ics. 3. Opti Optimu mum m hydr hydrat atio ion. n. 4. Anti Antico conv nvul ulsa sant nt med medic icat atio ions ns 5. Main Mainta tain in ven venti tila lati tion on..
B. Infect Infectiou ious s proces process s of inflam inflammat mation ion,, exudat exudation ion,, and accumulation of white blood cells and tissue damage. C. Inflam Inflammat matory ory proces process s result results s in the the develo developme pment nt of cerebral edema. Assessment
Complications 1. Increa Increasin sing g ICP resul resultin ting g in perman permanent ent brain brain dama damage. ge. 2. Resp Respir irat ator ory y comp complic licat atio ions ns.. 3. Damage Damage to to sense senses-b s-blin lindne dness ss and and heari hearing ng loss loss.. 4. Meni Mening ngoc ococ occa call infe infect ctio ion. n. a. Adren drenal al dama damage ge.. b. Perip eriph heral eral circu ircula lattory colla ollaps pse e (Wat (Wate er-Ho r-Hous useeFriedeichsen syndrome, frequently fatal) 5. Inappr Inappropr opriat iate e secre secreti tion on of ADH (SIADH (SIADH))
1. Risk factors/etiology. factors/etiology. a. Pathog Pathogeni enic c organi organism sm most most often often gains gains entry entry from from an infection elsewhere in the body. b. Organisms. 1) Hemo Hemoph phil ilus us infl influe uenz nza. a. 2) Strep Strepto toco cocc ccus us pne pneum umon onia iae. e. 3) Neisse Neisseria ria meni meningi ngitis tis (menin (meningoc gococc occus) us).. 4) Stap Staphy hylo loco cocc ccus us aure aureus us.. 5) Myco Mycoba bact cter eriu ium m tuberc tubercul ulos osis is.. c. Meni Mening ngoc ococ occi cic c meni mening ngit itis is is the the only only form form read readily ily contagious. 1. 2.
Nursing Intervention Goal: to identify identify the organism, organism, control spread, and initiate initiate therapy. 1. Mainta Maintain in respi respirat ratory ory isol isolati ation on as indi indicat cated. ed. 2. Init Initia iate te IV anti antibi biot otic ics s afte afterr lumb lumbar ar punctu puncture re and and flui fluid d sample are obtained. 3. Estab Establis lish h IV IV infu infusio sion n as as indi indicat cated. ed. 4. Iden Identi tify fy fami family ly cont contac acts ts who who may may requ requir ire e prop prophy hyla lact ctic ic treatment.
Tran Transm smit itte ted d by dire direct ct cont contac act, t, espe especi cial ally ly by dropl droplet et infection from nasopharyngeal secretions. Occu Occurs rs pred predom omin inat ately ely in the the sch schoo ooll-ag age e chi child ld
d. Increased mortality in infants. 2. Clinical manifestations-older child, adult. a. Nuchal rigidity. b.Chills and fever c. Headache. d. Increasing irritability, changes in LOC. e. Respiratory distress. f. Generalized seizures. g. Vomiting h. Postive Kernig’s sign-resistance or pain at the knee and the hamstring muscles when attempting to extend the leg after thigh flexion. i. Positive Brudzinski’s sign-reflex flexion of the hips when the neck is flexed. j. Photophobia. k. Petechiae, Petechiae, purpuric rash (especially (especially in meningoco meningococcal ccal meningitis). 3. Clinical manifestations-neonate and infant. a. Fever. b. Apneic episodes. c. Bulging fontanel d. Seizures. e. High-pitched cry. f. Opisthotonos positioning-a dorsal arched position. g. Petechiae Petechiae,, purpuric purpuric rash (especially (especially in meningoco meningococcal ccal meningitis). h. Changes in sleep pattern, increasing irritability. i. Poor sucking, may refuse feedings. j. Poor muscle tone, diminished movement. Nursing Diagnoses: Meningitis
Goal: to identify identify the organism, organism, control spread, and initiate initiate therapy. 1. Mainta Maintain in respi respirat ratory ory isol isolati ation on as indi indicat cated. ed. 2. Initia Initiate te IV antib antibiot iotics ics after after lumba lumbarr punctur puncture e and fluid sample are obtained. 3. Establ Establish ish IV infusi infusion on as indica indicated ted.. 4. Iden Identi tify fy famil amily y cont contac acts ts who who may requ requir ire e prophylactic treatment. Goal: oal: to monit onitor or cours ourse e of inf infect ection ion and and prev preven entt complications. 1. Frequ Frequent ent nurs nursing ing asses assessme sment nt for for increa increase sed d ICP. ICP. 2. Mainta Maintain in adequa adequate te hydrat hydration ion;; may be on fluid fluid restric restrictio tion n if increased ICP present. 3. Monit onitor or inf infusio usion n site ite for compl omplic icat atio ions ns of IVPB antibiotics. 4. Assess Assess for side effects effects of high dosage dosage of of antibio antibiotics tics.. 5. Decr Decrea ease se stim stimul ulii in envi enviro ronm nmen entt-di dim m ligh lights ts,, quie quiett environment, no loud noises. 6. Avo id id movement or positi on oning tha t increases discomfort; client generally assumes a sidelying position. 7. Seiz Seizur ure e pre preca caut utio ions ns.. 8. Preven Preventt comp complic licati ations ons of immobi immobilit lity. y. 9. Good Good resp respir irat ator ory y hygi hygien ene. e. 10. Measur Measures es to decre decrease ase feve fever. r. 11. Asses Assess s for incr increas eased ed ICP. ICP.
ENCEPHALITIS
Potential Potential for Infectio Infection n Transmis Transmission sion related to presence presence of meningococcal bacteria in spinal fluid. Potential for alteration in Fluid Volume: Deficit related to loss of body fluid from temperature elevation. Pote Potent ntial ial for for Inef Ineffe fect ctiv ive e Airw Airway ay Clea Cleara ranc nce e rela relate ted d to complication of IICP.
This is an inflammatory process of the CNS. Assessment 1. Risk Risk fac facto tors rs/e /eti tiol olog ogy y a. May May occur occur as a compl complic icat atio ion n follow followin ing g a vira virall infec infecti tion on (measles, chicken pox, mumps) b. May be tran transm smitt itted ed by by a vect vector or – mosqui mosquito to and and tick ticks s c. Causat Causative ive organi organism sm may be herpes herpes simple simplex x viru virus s
4. Diagnostics. a. b. 1. 2. 3.
Lumb Lumbar ar punc punctu ture re – reve reveal als s incr increa easi sing ng spinal fluid pressure. Exam Examin inat atio ion n of the the spi spina nall flui fluid. d. Cult Cultur ure e and and stai stainn-in infe fect ctiv ive e orga organi nism sm present. Incr Increas eased ed prot protein ein cont conten ent. t. Clou Cloudy dy yell yellow ow flui fluid. d.
2. a. b. c. d. e.
12
Clin Clinic ical al Mani Manife fest stat atio ions ns (sim (simil ilar ar to meni mening ngit itis is generally less severe} onset onset genera generally lly more more gradu gradual al than than with with mening meningiti itis s headache fever seizures change in in LO LOC
but but
f. 3.
moto otor invol nvolv vemen ementt
3. Condition may mask symptoms of hemorrhage in the trauma client. E. Autonomic dysreflexia (AD) occurs in clients with an injury at T-6 or higher. 1. A noxi noxiou ous s stim stimul ulii belo below w the the leve levell of inju injury ry trig trigge gers rs the the symp sympat athe heti tic c nerv nervou ous s syst system em whic which h caus causes es a rele releas ase e of catecholamines resulting in bnypertension. 2. Spinal injury blocks the normal transmission of sensory impulses and the impulses cannot reach the brain, but they rebound and stimulate the sympathetic nervous system. 3. there is an exaggerated response to the sensory stimuli, most common common stimuli stimuli causing the response response are a full bladder, fecal impaction, and skin stimulation. 4. Severe Severe hypert hypertens ension ion,, poundi pounding ng headac headache, he, bradyc bradycard ardia, ia, restless restlessness, ness, skin flushed and warm are not uncommon uncommon body responses. 5. Treatment is directed identifying and removing noxious stimuli. E. Bladder dysfunction will occur as a result of the injury. Normal bladde bladderr contr control ol is depend dependent ent on both both the sensory sensory and motor pathways, and the lower motor neurons being intact. 1. Reflex Reflex neurogenic neurogenic bladder bladder (spastic, (spastic, autonomous autonomous)occ )occurs urs in client clients s with with cord cord lesion lesions s above above the level of lower lower lumbar lumbar and caudal area of the spine. The lower motor neuron pathway remains intact below the level of the injury. a.There is loss of voluntary muscle control, and depending on the level of the injury, there is loss or decreased sensation. b. Bladder will retain a volume of urine, then reflexive involuntary voiding will occur. c. Bladder empties autonomically in response to stretching of the detrusor muscles. 2. Nonreflex Nonreflexic ic neurogenic neurogenic bladder (flaccid) (flaccid) occurs occurs in clients clients will cord lesions at the lower lumbar and caudal area of the spine. The lower motor neurons are damaged. a. The sensory function may remain unimpaired, there is loss of bladder tone and voluntary control. b. Bladder retains a volume volume of urine, becomes distended distended and overflows. c. There is no b ladder muscle contraction or forceful emptying. F. Long-term rehabilitati rehabilitation on potential potential depends on the amount amount of damage done to the cord which may not be evident for several weeks after the injury. Assessment 1. Risk Risk factor factors/ s/eti etiolo ologygy-acc accide idents nts.. 2. Clin Clinic ical al manife manifest stat atio ions ns-d -dep epen end d on level level of cord injury. a. C1-C 1-C3-us 3-usua uall lly y fatal atal at the scene ene of the accident due to respiratory arrest. b. Flacci Flaccid d paral paralysi ysis s and and sensor sensory y loss loss below below the the level of injury. c. Spina l shock. 1) Gene Genera rall lly y occu occurs rs with within in seve sevent ntyytwo hours and may last for several weeks. 2) Flac Flacci cid d para paraly lysi sis. s. 3) Loss Loss of sen sensa sati tion on and and absen absenc ce of reflexes. 4) Bowe Bowell and bla bladd dder er dysf dysfun unct ctio ion. n. 5) Hypo Hypote tens nsio ion n and bra brady dyca card rdia ia.. 6) Afte Afterr spin spinal al shock shock,, refl reflex exes es,, and and auto autono nomi mic c acti activi vity ty retu return rn as evid eviden ence ced d by deve develo lopm pmen entt of spasticity. d. Neuro euroge geni nic c sho shoc ck 1) Hypot Hypotens ensio ion n from from vasod vasodila ilati tion on.. 2) Brady Bradycar cardia dia from from increa increased sed vagal vagal tone tone.. 3) Skin Skin rema remain ins s war warm m and and dry. dry. 4) May requ requir ire e vaso vasoac acti tive ve medi medica cati tion ons s (dopa dopami mine ne and and dobut obutam amin ine) e) for hypotension and bradycardia. e. Autono Autonomic mic dys dysref reflex lexia ia in clien clients ts with with injur injuries ies at T6 or higher. 1) Seve Severe re hyp hyper erttensi ension on.. 2) Seve Severe re brad bradyc ycar ardi dia. a. 3) Comp Compla lain ints ts of head headac ache he.. 4) Flus Flushin hing g and diapho diaphore resi sing ng above above level level of injury.
Diag Diagnos nosti tics cs – exam examin inat atio ion n of the spin spinal al flui fluid, d, specif specific ic viral studies to isolate the virus.
Treatment: 1. Vidara Vidarabin bine e for for herpes herpes simp simplex lex ence encepha phalit litis is 2. Antic ntico onvu nvulsan lsantts 3. Trea Treatm tment ent to decr decrea ease se ICP ICP 4. Hydration Nursing Intervention: Generally the same as for meningitis with the exception of antibiotic therapy (encephalitis is caused by a viral agent and is not responsive to antibiotic therapy; antibiotic therapy may be done to prevent bacterial infection). Give emphasis or focus on client safety and seizure precautions.
SPINAL CORD INJURY Generally occurs as a result of direct trauma to the head or neck area. A. Initially after the injury, the nerve fibers swell and circulation to the spinal spinal cord cord is decrea decreased sed;; hemorr hemorrhag hage e and edema edema occur occur causing an increase in the ischemic process which progresses to necrotic destruction of the spinal cord. Nursing Nursing Priority: Priority: Within twenty-four twenty-four hours of the injury, edema secondary to the inflammatory process results in compression of the cord; the edema extends above and below the area of injury and increases the area of ischemic damage. B. Consequences of cord injury depend on the extent of damage as well as the level of cord injury. 1. The higher the lesion, the more severe the sequela. 2. Complete Complete transactio transaction n (complete (complete cord dissolutio dissolution, n, complete complete lesion)-paralysis below the level of injury; minimum, if any, return of function. a. Loss of sensory function. b. Loss of voluntary motor activity c. Loss of sense of position (proprioception). d. Minimum, if any return of function. 3. Incomplete. a. Centr Central al cord cord syndr syndrome ome-ce -cente nterr of cord cord is damage damaged, d, result results s primarily in impairment in upper extremities. b. Damage to one side of the cord (Brown-Sequard syndrome)motor function and position sense may be present on one side, temperature and sensation may be lost on the opposite side. c. Anterior cord damage-disruption of blood flow results in a mixed loss of sensory and motor function below the level of injury. C. Spinal Cord Shock (areflexia)-occurs predominantly in complete cord lesions. Because of the loss of communication with the higher centers of control, the muscles below the level of injury will become flaccid and all functional control will cease. 1. Spinal Spinal cord injury interrupts interrupts the sympathetic sympathetic nerve impulse impulse transm transmiss ission ion,, the the parasy parasympa mpath theti etic c impuls impulses es are not counte counter r checked and vasodilation occurs; this results in hypovolemia and hypotension.
2. There is loss of the hypothalamus to control body temperature by vasoconstriction and dilation. 3. Cond Condit itio ion n may may pers persis istt for for seve severa rall week weeks s and and reve revers rse e spontaneously, resolution of spinal shock will be evident by the return of reflexes. 4. Spasticity will occur as recovery progresses. Spastic movements may be precipitated by emotion and cutaneous stimulation. D. Neurogenic shock. 1. Dominance of the parasympathetic nervous system results in loss loss in vasomo vasomotor tor tone tone and increa increased sed vagal vagal tone tone leadin leading g to hypotension and bradycardia. 2. skin stays warm and dry due to loss of sympathetic response of vasoconstriction.
13
d) Maintain Maintain extremiti extremities es in neutral, neutral, functional functional position. position. 3. Appropriate nursing intervention when surgery is indicated for stability of the injury. Goal: to maintain maintain ongoing assessment assessment to identify identify level of damage and changes in neurological status. 1. Motor and sensory evaluation. a. Ability to move all extremities; strength of extremities. b. Sensory examination including touch and pain. c. Presence of deep tendon reflexes. 2. Ongoing assessment and status of: a) Blad Bladde derr func functi tion on.. b) Gastr astric ic func functi tion on.. c) Respir Respirato atory ry and and cardi cardiova ovasc scula ularr syste systems. ms. d) Bowel owel func functtion. on. e) Psych Psycholo ologic gical al adju adjustm stment ent to the the inju injury. ry.
Nursing Diagnosis: Spinal Cord Injury Potential for Aspiration related to inability to cough. Alteration in Elimination, bowel and Bladder related to level of injury. Impaired Physical Mobility related to level of injury. Disturbance in Body Image related to dependency on others and change in body function. Self Care Deficit related to anticipated losses. Grieving related to anticipated losses. Altered Altered Family Family Process Process related to adjustmen adjustmentt of family member to permanent disability. 3. Diagnostics a. History of accident b. clinical manifestations. manifestations. c. X-rays to determine level of damage. d. MRI. e. CT scan. Treatment 1. Immobilization of the vertebral column in cervical fracture. a. Stryker frame. b. Circular electric bed. c. Cerv Cervic ical al tongs tongs (Crut (Crutch chfi fiel eld) d) for for cerv cervic ical al immobility. 2. Respiratory support as indicated. 3. Immobilization of spinal column by bed rest in lumbar fracture. 4. Stabi Stabiliz lizat atio ion n of spin spinal al colu column mn by surg surgic ical al procedures. 5. Corticosteroids to decrease cord edema.
Goal: to maintain respiratory function. 1. Frequent Frequent assessment assessment of respirato respiratory ry function function during first forty-eight hours. a) Evalu Evaluate ate for for chan changes ges in breat breathin hing g patter pattern. n. b) Evalu Evaluate ate client client’s ’s complai complaints nts of increas increasing ing diffic difficult ulty y in breathing; utilization of sternocleidomastoid and intercostals muscles for respiration. c) Evaluate AB ABG. d) Evalu Evaluate ate for for prese presence nce of of increa increasin sing g hypoxi hypoxia. a. 2. Maintain adequate respiratory function as indicated. a) Ches Chestt phys physio ioth ther erap apy. y. b) Ince Incent ntiv ive e spir spirom omet etry ry.. c) Changi Changing ng posit position ion within within limi limits ts of of injur injury. y. d) Asses Assess s for compli complicat cation ions s of atelect atelectasi asis, s, pulmo pulmonar nary y emboli, and pneumonia e) Nasop asopha hary ryn ngeal geal or end endotr otrach acheal eal suct uctioni ioning ng suctioning as indicated. Goal: to maintain cardiovascular stability. 1. Neurogenic shock. a) Monit Monitor or vital vital signs signs close closely ly for firs firstt 24 hour hours s post injury. b) Caref Carefully ully titr titrate ate IV IV fluids fluids as as client client is is at high high risk risk for fluid overload. c) Asse Assess ss othe otherr clie client nt para parame metters ers for for evid eviden ence ce of hemorrhage and other injuries. 1) Abdo Abdomi mina nall musc muscle les s will rema remain in flacc flaccid id in presence of abdominal injuries. 2) With the loss of vascular tone the symptoms of hemorrhage will be masked. 2. Spinal shock. a) Monitor vital signs and eval evalu uate ate chan change ges s with ith regard regard to develo developme pment nt of neur neurog ogen enic ic shoc hock and hemorrhage. b) Vagal stimulation, hypoth hypotherm ermia, ia, and hypoxi hypoxia a may precipitate spinal shock. c) Deve Develo lopm pmen entt of spas spasti tici city ty of muscle muscles s below below the the level level of injury indicates resolution of spinal shock. 3. Assess for developmental of autonomic dysreflexia, if it occurs: a) Elevat Elevate e the the head head of of the the bed (if possib possible) le).. b) Asse Assess ss for for sour source ces s of stim stimul uli-d i-dis iste tend nded ed blad bladde der, r, fecal impaction, or constipation. c) Reliev Relieve e the the stimu stimuli li and and freque frequentl ntly y dysr dysrefl eflexi exia a will will subside. d) Maint Maintain ain cardiov cardiovas ascu cula larr supp suppor ortt duri during ng peri period od of hypertension. 4. Evaluate cardiovascular responses when or suctioning. 5. If turning on a circular electric bed, evaluate for postural hypotension.
Nursing Intervention Goal: to maintains stability of the vertebral column and prevent further cord damage. 1. Emergency care and treatment. a. Suspect spinal cord injury if there is any evidence of direct trauma to the head or neck area (contact sports, diving accidents, MVA). b. Immobilize and place on spinal board with the head and neck in a neutral position; do not allow the neck to flex. Nursing Priority: Do not hyperextend the neck in the client client with with a suspec suspected ted cervic cervical al injury injury.. Airway Airways s should be opened by the jaw lift method. Improper handling of the client at the scene of the accident often results in extension of the damaged area. c.
Maint Maintain ain in exten extended ded posit position ion with with no twist twisting ing or turn turning ing;; do not remove from the spinal board until area of injury is identified. d. Maint Maintain ain pate patent nt airway airway duri during ng trans transpor portat tation ion.. 2. Maintain stability of the vertebral column as indicated by the level of injury. a) Bed rest rest on on firm firm mattr mattress ess with with supp support ortive ive devi devices ces (sandbags,skin traction, etc.); maintain alignment in the supine position; logroll without any flexion or twisting. b) Maintain Maintain cervic cervical al tracti traction-t on-tongs ongs are inserted inserted into the skull skull with with tract traction ion and weight weights s applie applied; d; do not remo remove ve weig weight hts; s; logr logrol olll to maint aintai ain n spin spinal al immobility. c) Stryk ryker frame ame or circ circle le bed bed perm ermit chang hange e of position from prone to supine; frequently utilized in conjunctio conjunction n with cervical cervical traction; traction; maintain safety safety precautions when turning.
14
6. Antiembolism Antiembolism stockings stockings or elastic elastic wraps to the legs to facilitat facilitate e venous venous return. (Lack of muscle muscle tone and loss of sympat sympathet hetic ic tone tone in the the periph periphera erall vessel vessels s result results s in a decrease decrease in venous venous tone and in venous venous return return predisposi predisposing ng the client to the d evelopment of deep vein thrombosis).
9.
Assist Assist clien clientt to set real realist istic ic short short-te -term rm goals goals..
NEUROMUSCULAR NEUROMUSCULAR DISORDERS The neuromuscular disorders have many common nursing implications. The nursing diagnoses for the condi conditi tion ons s are are esse essent ntia ially lly the the same same and and are are included at the beginning of this section.
Goal: to maintain adequate fluid and nutritional status. 1. During During the the first first fort forty-e y-eigh ightt hours, hours, eval evaluat uate e GI function frequently; decrease in function may necessitate utilization of a nasogastric tube to decrease distention. 2. Preven Preventt compl complica icati tions ons of nausea nausea and and vomit vomiting ing.. 3. Eval Evalua uate te bowel bowel sound sounds s and client client’s ’s abili ability ty to tolerate PO fluids. 4. Increa Increase se prote protein in and and calori calories es in diet diet;; may need need to decrease calcium intake. 5. Evalu Evaluate ate for presen presence ce of paraly paralytic tic ileus. ileus. 6. Incr Increa ease se roug rougha hage ge in diet diet to promo promote te bowe bowell function. Goal: to prevent complications of immobility. Goal: to promote bowel and bladder function 1. Urine Urine is reta retaine ined d due to the the loss loss of of autono autonomic mic and reflexive control of the b ladder. a. Inte Interm rmit itte tent nt cath cathet eter eriz izat atio ion n or indw indwel elli ling ng catheter initially to prevent bladder distention. b. Nurs Nursin ing g interv interven enti tion on to preve prevent nt urina urinary ry trac tractt infection. 2. Det Determi ermine ne type type of blad bladde derr dysf dysfun unct ctio ion n and and assist client to determine appropriate method of bladder emptying. 3. Asses Assess s client client’s ’s aware awarenes ness s of bladd bladder er funct function ion.. 4. Initia Initiate te measu measures res to to institu institute te bladd bladder er contr control. ol. a. Esta Establ blis ish h a sched schedul ule e for voidi voiding ng;; have have clie client nt attempt voiding every two hours. b. Utilize the Créde method for manual expression of urine. c. May be necessary to teach client sel ffcatheterization. d. Record Record outp output ut and and evalu evaluat ate e for residu residual al urine urine.. 5.Evaluate bowel functioning. a. Incontinence and paralytic ileus frequently occur with spinal shock. b. Incontinence and impaction are common later. 6. Initiate measures to promote bowel control (after spinal shock is resolved). a) Iden Identi tify fy clie client nt’s ’s bowe bowell habi habits ts prio priorr to injury. b) Main Mainttain ain suff ufficie icient nt fluid luid int intake ake and adequate bulk in the diet. c) Establ Establish ish specif specific ic time time each each day for bowel bowel evacuation. d) Asse Assess ss clien client’ t’s s awar awaren enes ess s of need need to defecate. e) Teac Teach h client client effec effecti tive ve utili utiliza zati tion on of the Valsalva maneuver to induce defecation. f) Indu Induce ce defec defecat atio ion n by digita digitall stimu stimulat latio ion, n, suppository or as a last resort, enema. Goal: To maintain psychological equilibrium. 1. Simple Simple explan explanati ation on of all proced procedure ures. s. 2. Anti Antici cipa pate te outbu outburs rstt of ange angerr and and host hostil ilit ity y as client client begins begins to work work throug through h the grievi grieving ng process and adjustments in body image. 3. Antici Anticipat pate e and acce accept pt perio periods ds of depr depress ession ion in in client. 4. Encour Encourage age inde indepen penden dence ce when wheneve everr possi possible; ble; allo allow w clie client nt to part partic icip ipat ate e in deci decisi sion ons s rega regard rdin ing g care care and and to gain gain cont contro roll over over environment. 5. Enco Encour urag age e fami family ly invo involv lvem emen entt in iden identi tify fyin ing g appropriate diversional activities. 6. Avoid oid sympa ympatthy and and empha mphas size ize cli client ent’s potential. 7. Init Initia iate te fran frank, k, open open disc discus ussi sion on rega regard rdin ing g sexual functioning. 8. Assi Assist st clie client nt fami family ly to iden identi tify fy comm commun unit ity y resources.
MYASTHENIA GRAVIS A neurom neuromusc uscula ularr diseas disease e charac character terize ized d by a decrease in acetylcholine at the receptor sites i n the neuromuscular junction; precipitates a disturbance in the transmission of nerve impulses. Assessment 1. Risk factors/etiology. a) Cond Condit itio ion n has has been een ass associ ociated ated with ith dysfunction of the thymus gland. b) Auto Autoim immu mune ne in in orig origin in.. c) More More comm common on in wome women. n. d) Peak Peak inc incid iden ence ce bet betwe ween en 20 20 and and 30. 30. 2. Clinical manifestations. a. Primar Primary y proble problem m is skelet skeletal al muscle muscle fatigu fatigue; e; symptoms are predominantly bilateral. 1) Musc Muscul ular ar fatig atigue ue incr increa eas ses with ith activity. 2) Ptos Ptosis is(d (dro roop opin ing g of the eyel eyelid ids) s) and and dipl diplop opia ia (doub double le visi ision) on) are are frequently the first symptoms. 3) Impa Impair irme ment nt of faci facial al mobil mobilit ity y and and expression. 4) Impairment of chewing and swallowing. 5) Speech Speech impair impairmen mentt (dysar (dysarthr thria) ia).. 6) No sens sensor ory y defic deficit it,, loss loss of refle reflexe xes, s, or muscular atrophy. b. Course is variable. 1) May May be prog progre ress ssiv ive. e. 2) May stab stabil iliz ize. e. 3) May be char charact acteri erized zed by shor shortt remis remissio sions ns and exacerbations c. Myas Myasth then enic ic crisi crisiss-an an acute acute exace exacerb rbat atio ion n of symptoms symptoms of the condition condition characterize characterized d by weak weakne ness ss of the the muscl uscles es cont contro roll llin ing g swal swallo lowi wing ng and and brea breath thin ing g (dys (dysph phag agia, ia, dysarthria dysarthria,, dyspnea). dyspnea). Occurs as a result result of insufficient acetylcholine (anticholinesterase)or exacerbation of disease state. d. Choli Choline nerg rgic ic cris crisis is is a toxi toxic c respo respons nse e to the the anticholinesterase medications. e. The The sympt symptom oms s of a myas myasth then enic ic cris crisis is and and a cholinergic crisis are essentially the same. 1. Diff Diffic icul ulty ty brea breath thin ing, g, swall swallow owin ing, g, chew chewin ing, g, or speaking. 2. Increa Increased sed secr secreti etions ons (sal (saliva iva,, bronch bronchial ial). ). 3. Rest Restle less ssne ness ss and and appre apprehe hens nsio ion. n. 4. Tensil Tensilon on test test to diff differe erenti ntiate ate crisis crisis.. 3. Diagnostics. a. Clinical manifestations. b. Electromyography-shows a decreasing response of muscles to stimuli. c. TENSI TENSILON LON testtest- utiliz utilized ed for diagno diagnosti stics cs and different differentiatin iating g types types of crisis crisis ( cholinergi cholinergic c crisis versus myasthenic crisis).
Treatment
15
1. 2. 3. 4. 5.
Antich Anticholi olines nester terase ase (choli (choliner nergic gic)) medicati medications ons Steroids Plas Plasma ma elec electr trop ophor hores esis is.. Immu Immuno nosu supp ppre ress ssiv ive e ther therap apy. y. Surgic Surgical al remov removal al of the the thym thymus us (thym (thymect ectomy omy). ).
Goal: to assist client to understand implications of disease process and measures to maintain health. 1. Impo Import rtan ance ce of tak takin ing g medic medicat atio ion n on a regular basis; peak effect of the medica medicatio tion n should should coinci coincide de with with mealtimes. 2. If ptosis ptosis become becomes s seve severe, re, client client may need to wear an eye patch to protect cornea cornea (alter (alternat nate e eye eye patche patches s if problem is bilateral). 3. Emot Emotio iona nall ups upset, et, seve severe re fati fatigu gue, e, infections, and exposure to extreme tem tempera peratu ture res s may may prec precip ipit itat ate e myasthenic crisis.
Nursing Intervention ( Client generally hospitalized for acute myasthenic crisis or for respiratory infection). Goal: to maintain respiratory function. 1. Asse Assess ss for for incr increa easi sing ng prob proble lems ms of diff diffic icul ultt breathing. 2. Determ Determine ine clie client’ nt’s s medic medicati ation on sched schedule ule;; when when was medication last taken? 3. Asses Assess s abilit ability y to swal swallow low;; preven preventt proble problems ms of aspiration. 4. Evalu Evaluate ate effect effective ivenes ness s of cough cough refl reflex. ex. 5. Have Have emerge emergency ncy trache tracheoto otomy my set set avail availabl able. e.
MULTIPLE SCLEROSIS The disease is characterized by multiple areas of demye demyelini linizat zation ion of the the neuron neurons s in the brain brain and spinal cord (CNS).
Nurs Nursin ing g Prio Priori rity ty:: Do not not give give the clie client nt in myasthenic crisis anything to eat or drink, there is significant increased risk for aspirating during this time.
A.
Goal: to distinguish between myasthenic crisis and cholinergic crisis. 1. Main Mainta tain in adeq adequa uate te vent ventil ilat atory ory suppor supportt duri during ng crisis. 2. Assist sist in adm adminis nistrat tratio ion n of TENSI NSILON LON to differentiate crisis a) Myas Myasth then enic ic cris crisis is-c -cli lien ent’ t’s s cond condit itio ion n will improve. b) Choli Choline nerg rgic ic cris crisis is-c -cli lient ent’s ’s cond condit itio ion n will improve. 3. If myast myasthe heni nic c cris crisis is,, neos neosti tigm gmin ine e may may be administered. 4. If cholinergic cri si sis, atro pi pin e may be administe administered red and all cholinergic cholinergic medications medications discontinued. 5. Avoid Avoid use use of sedati sedatives ves and tran tranqui quiliz lizers ers whic which h cause respiratory depression. 6. Provid Provide e psycho psycholog logica icall suppor supportt during during cris crisis. is.
B.
1. 2.
3. C.
Initia Initially lly the the myeli myelin n sheath sheath is is demyel demyelini inized zed,, but with no effect on the transmission of nerve impu impuls lses es.. The The myel myelin in rege regene nera rate tes s and and symptoms disappear. The prog progres ressio sion n of the the disea disease se resul results ts in tota totall destruction of the myelin and the nerve fibers become involved. Damage Damaged d myeli myelin n is replac replaced ed by scar scar tiss tissue. ue. Loss Loss of myel myelin in shea sheath th cause causes s dec decreas reased ed impulse conduction, destruction of the nerve axon axon,, and and a bloc block kage age of the the impul mpuls se conduction. The demy emyeli eliniz nizatio ation n occ occurs urs in irre irreg gular ular scattered patches throughout the CNS. The The cond condit itio ion n is chron chronic ic with with unpr unpred edic icta tabl ble e remissions and exacerbations; with repeated exacerbations there is a progressive scarring and deterioration of the neurological function.
Assessment 1. Risk Risk fact factor ors/ s/et etio iolo logy gy.. a. Auto Autoim imm mune une diso disord rder er.. 1) Asso Associ ciat ated ed with with a defe defect ct in the the Tlymphocytes. 2) Correlated with previou s viral infections. b. Incr Increas eased ed inc incid iden ence ce in in wome women. n. c. Cons Consid ider ered ed a diseas disease e of young young adult adults, s, onse onsett generally between ages 20 and 40. d. Fami Famili lial al tend tenden ency cy.. 2. Clin Clinic ical al mani manife fest stat atio ions ns (var (vary y from from per perso son n to person as well as within the same individual depending on the area of involvement). a. Onset Onset is is usual usually ly gradu gradual; al; sym sympto ptoms ms may may occu occur r intermittently over several years.
Nursing Diagnosis: Neuromuscular Disorders Potential Complications: Respiratory failure, Renal failure, Pneumonia Potential for Ineffective Breathing Patterns related to neurological deficits and immobility. Dist Distur urba banc nce e In Self Self Conf Confid iden ence ce rela relate ted d to debilitating condition. Potential for Injury related to loss of coordination of movement, visual disturbances. Impair Impaired ed Verbal Verbal commun communica icatio tion n second secondary ary to cranial nerve damage. Potential Alteration In Nutrition: Less Than Body Requirements related to difficulty eating and chewing. Activity Intolerance related to fatigue. Potential for Disuse Syndrome related to effects of immobility. Alteration In Elimination: Urinary related to sensory motor deficit.
b.
c.
Alteration Alteration in Growth Growth and Development Development related to onset of debilitation and inability of client to meet developmental milestones. Sexual dysfunction related to changes in libido, or neurosensory deficits. Potential Potential for Injury Injury related related to decreased decreased sensory perception of pain, and touch. Altered Family Process related to family member with chronic debilitating disease.
d.
e.
16
Cere Cerebe bella llarr dysf dysfun unct ctio ion. n. 1) Nystagmus. 2) Ataxia. 3) Dysarthria . 4) Dysphagia. Mot Motor dysf dysfun unct ctio ion. n. 1) Weak Weakne ness ss prog progre ress ssin ing g to para paraly lysi sis s of extremities. 2) Spas Spasti tici city ty of the the muscl muscles es of the the invol involve ved d extremities. 3) Diplopia. Sensory. 1) Vertigo. 2) Blurr lurred ed vis vision. ion. 3) Decr Decrea ease sed d heari hearing ng,, tinni tinnitu tus. s. Bowe Bowell and and blad bladde derr dysf dysfun unct ctio ion. n. 1) Urin Urinar ary y rete retent ntio ion, n, loss loss of sens sensat atio ion n to void.
f.
g.
3. a. b.
2) Unin Uninhib hibit ited ed spa spast stic ic bla bladd dder er.. 3) Cons Consttipat ipatio ion. n. Impotency. 1) Physio Physiolog logica icall impot impotenc ence e in the male. male. 2) Decr Decrea ease sed d sens sensat atio ion n prev preven ents ts norm normal al sexual response in males and females. Psycho so so ci cial. 1) Intell Intellect ectual ual func functio tionin ning g remain remains s intact intact.. 2) Emot Emotio iona nall labil labilit ityy-in incr crea ease sed d exci excita tabi bili lity ty and inappropriate euphoria. 3) Emot Emotio iona nall effe effect cts s of the the chro chronic nic illn illnes ess s and changes in body image. Diagnostics. No def defin init itiv ive e diag diagno nost stic ic tes test. t. Diag Diagno nost stic ics s base based d on hist histor ory y and and clini linica call manifestations.
c. 3. a. b. c. 4. a. b. c. 5.
GUILLAIN-BARRÉ SYNDROME
Treatment 1. No cure cure;; medic medical al treat treatmen mentt is direc directe ted d toward toward trea treatm tmen entt of the the dise diseas ase e proc proces ess s and and symptoms. 2. Medications to decrease edema and inflammation of the nerve site. a. Anti Anti-i -inf nfla lamm mmat ator ory. y. b. Antis ntisp pasm asmodic odic.. c. Immu Immuno nosu supp ppre ress ssiv ive. e. d. Antich Anticholi oliner nergic gic and cholin cholinerg ergic. ic. e. Interferon s. s.
This condition involves segmental demyelination of nerv nerve e root root in the the spin spinal al cord ord and and medu medull lla. a. Demyelina Demyelination tion occurs, occurs, leading leading to inflammat inflammation, ion, edema edema and nerve root compression compression which causes causes decreased nerve conduction and rapidly ascending paralysis. Both sensory and motor impairment, also called polyradiculitis. Assessment 1. Risk factors/etiology. a) Poss Possib ibly ly aut autoi oimm mmun une e in ori origi gin. n. b) May effect effect any age group, group, more more comm common on in ages 20 to 50. c) May be associated with swine flu immunizations. d) Freq Freque uent ntly ly prece precede ded d by mild mild resp respir irat atory ory of intestinal infection. 2. Clinical manifestations. a) Begin egins s in the low lower ext extrem remiti ities and and ascends bilaterally. 1. Weakness. 2. Ataxia. 3. Bilat ilater eral al par paresth esthes esia ia prog progre ress ssin ing g to complete paralysis. b). paralysis ascends the body symmetrically and produc produces es proble problems ms of the lower lower brain brain stem. 1) Paralysis of respiratory muscles. 2) Difficulty talking and swallowing. 3) Cran Crania iall ner nerve ve involv involvem emen ent. t. c). Loss of sensation and function of bowel and bladder. d). Manifestations may progress rapidly or occur over two to three weeks. e). Muscle atrophy is minimum.
Nursing Intervention (Client hospitalized generally for diagnostic workup or for acute exacerbation and complications). Goal Goal:: to main mainta tain in home homeos osta tasi sis s and and prev preven entt complications in an an acute exacerbation of disease symptoms. 1. a. b. c. d. 2. a. b. c. d. 3. a. b. c.
Gait train in ing and devices to ma in intain ambulation. Meas Measur ures es to to main mainta tain in voi voidi ding ng.. Partic Participa ipatio tion n in in blad bladder der retrai retrainin ning. g. Créd Créde e met metho hod d of of voi voidi ding ng Interm Intermitt ittent ent self-c self-cat athet heteri erizat zation ion as indicat indicatededresidual urine should be less than 150 cc. Safety Safety meas measure ures s due to to decrea decreased sed sens sensati ation. on. Chec Check k bath bath wat water er tem tempe perat ratur ure. e. Wear Wear prot protect ective ive clothi clothing ng in in the the winte winter. r. Avoi void heat eating ing pads pads and and clot lothing hing that hat is constrictive. Clie Client nt shou should ld unde unders rsttand and that that rela relaps pses es are are freque frequentl ntly y associ associat ated ed with with an increa increase se in physiological and psychological stress.
Mainta Maintain in adeq adequat uate e respi respirat ratory ory funct function ion.. Prev Preven entt respi respira rato tory ry infe infect ctio ion. n. Good ood pulm pulmon onar ary y hygi hygien ene. e. Preven Preventt aspira aspiratio tion; n; sittin sitting g positi position on for for eating. eating. Evalu Evaluate ate adequa adequacy cy of cough cough reflex reflex.. Main Mainta tain in urin urinar ary y trac tractt funct functio ion. n. Preven Preventt urinar urinary y tract tract infect infection ion.. Incr Increa ease se flui fluid d inta intake ke.. Eval Evalua uate te void voidin ingg-as asse sess ss for for ret retenti ention on and and incontinence. Prov Provid ide e goo good d per perin inea eall car care. e. Main Mainta tain in nutr nutrit itio ion. n. Evalu Evaluate ate coughi coughing ng and and swal swallow lowing ing refl reflex. ex. Prov Provid ide e food food tha thatt is eas easy y to chew chew.. If client client is expe experi rien enci cing ng diff diffic icult ulty y swall swallow owin ing, g, observe closely with fluid intake.
Goal: to prevent complications of immobility. Goal: to promote psychological well being. 1. Focu Focus s on remai remaini ning ng capa capabi bili liti ties es.. 2. Enco Encour urag age e inde indepe pend nden ence ce and assi assist st client client to gain control over environment. 3. If impot impoten ence ce is a prob proble lem, m, initi initiat ate e sexu sexual al counseling. 4. Assi Assist st clien clientt to work work throu through gh the griev grievin ing g process. 5. Identi Identify fy comm communi unity ty reso resourc urces es avai availab lable. le.
Nursing Nursing Priority: Priority: Of the neuromusc neuromuscular ular disorders disorders,, Guillain-Barre is the most rapidly developing and progre progress ssive ive condit condition ion.. It is potent potential ially ly fatal fatal if unrecognized. 3. Diagno Diagnosti stics cs – based based primar primarily ily on the the clinic clinical al manifestations. Treatment (Supportive).
Goal: to assist client to understand implications of the diseas disease e proces process s and measur measures es to mainta maintain in health. 1. Medic edical al regi regim men and side side effe effec cts of the medications. 2. Phys Physic ical al therapy therapy to mainta maintain in muscl muscle e func functi tion on and decrease spasticity. a. Water ater exerc xercis ises es.. b. Stre Stretc tchi hing ng exer exerci cise ses. s.
1. 2.
Cort Cortic icos ostteroi eroids ds.. Main Mainta tain in resp respir irat ator ory y func functi tion on;; may may req require uire mech mechan anic ical al ventilation.
Nursing Intervention Goal: to evaluate progress of paralysis and initiate actions to prevent complications. 1. Evalua Evaluate te rate rate of prog progres ress s of paral paralysi ysis; s; care careful ful assessment of changes in respiratory pattern.
17
2.
3. 4.
Freq Freque uent nt eval evalua uati tion on of coug cough h and and swal swallo low w reflex. a) Rema Remain in with ith clien lientt whil while e eati eatin ng; have suction equipment available. b) NPO NPO if refl reflex exes es are are inv invol olve ved. d. If paral paralysi ysis s is rapi rapid, d, prepa prepare re for for ET intuba intubatio tion n and respiratory assistance. Prev Preven entt comp compli lica cati tions ons of immo immobi bilit lity y duri during ng period of paralysis.
Treatment No definitive therapy. Nursing Intervention (Child (Child is frequently frequently cared for at home; hospitalize hospitalized d only for complications). Goal: to maintain function as long as possible. 1. Maintain child’s independence in ADL and maintain social contact with peers as long as possible. 2. Assist parents to identify resources for assistance with physical therapy and exercise program at home. 3. Assist Assist famil family y to identi identify fy resour resources ces to adapt adapt to physiological barriers within the home and to promote mobility of the child in a wheelchair. 4. Assist Assist family family to identi identify fy method methods s of preven preventin ting g respirator respiratory y infection infection and to assess assess for increasing increasing respiratory problems.
Goal Goal:: To prev preven entt comp complic licat atio ions ns of hypo hypoxi xia a if respiratory muscles become involved.
Goal: to maintain p sychological homeostasis. 1. Simple explanation of procedures. 2. Gene Genera rall lly y comp complet lete e reco recove very ry is is anticipate anticipated; d; residual residual problems problems are not common. 3. prov provid ide e psyc psycho holo logi gica call supp suppor ortt duri during ng peri period od of ass assiste isted d ventilation. 4. Keep Keep clie client nt and and fam family ily awar aware e of progress of disease.
Goal Goal:: to assi assist st pare parent nts s and and chil child d to main mainta tain in psychological equilibrium and to adapt to chronic l ongterm illness. 1)
2)
MUSCULAR DYSTROPHY The term term pseud seudoh ohy ypert pertro roph phy y des describe ribes s charac character terist istic ic muscle muscle enlarg enlargeme ement nt due to fatty fatty infiltration which occurs in muscular dystrophy. A. B. C.
3) 4) 5)
Musc Muscul ular ar dystr dystrop ophy hy is the the most most signi signifi fica cant nt group of childhood diseases of the muscles. Duch Duchen enne ne’s ’s is the the most most commo common n type type and is also the most severe. Condition is characterized by gradual degeneration of muscle fibers and progressive symmetrical weakness and wasting of skeletal muscle.
Assist Assist pare parents nts to to unders understa tand nd impor importan tance ce of inde indepe pend nden ence ce and and self self-h -hel elp p skil skills ls;; frequently parents are overprotective of the child. Coun Counse seli ling ng to assis assistt pare parent nts s and and fami family ly members to identify family activities that can be modified to meet child’s needs. Mother Mother may may feel feel part particu icular larly ly guilt guilty y becaus because e of transmission of disease to her son. Identi Identify fy comm communi unity ty reso resourc urces es avail availabl able. e. Coun Counse seli ling ng to assi assist st fami family ly and chil child d with with chro chroni nic c long long-t -ter erm m illn illnes ess s and and chil child’s d’s eventual death.
CEREBRAL PALSY (CP) A non progre progressi ssive ve abnorm abnormalit ality y in the pyrami pyramidal dal system (motor cortex, basal ganglia, and cerebellum) resulting resulting in impairment impairment of muscle muscle control. control. May be class classifi ified ed accord according ing to the specif specific ic area area of brain brain inv involv olvemen ementt and and to the resul esultting ing clini linica call manifestations.
Assessment 1. Risk Risk fact factor ors/ s/et etio iolo logy gy.. a. Geneti Genetic-s c-sex ex linked linked disor disorder der prima primaril rily y affect affecting ing males. b. Onset Onset genera generally lly betwee between n 1 to 5 year years. s. 2. Clin Clinic ical al manif manifes esta tati tion ons. s. a. His History ory of dela delay y in mot motor devel evelo opmen pment, t, particularly in walking. b. Abno Abnorm rmal al wad waddl dlin ing g gait gait.. 1. Falls Falls frequ frequent ently ly and and deve develo lops ps char charac acte teri rist stic ic manner of rising. 2. Gower’ Gower’s s sign-f sign-from rom sitt sitting ing or squat squattin ting g positio position, n, the child child assume assumes s a kneeli kneeling ng positi position on and pushes pushes his/her his/her torso up by walking walking his/her hands up the thighs. c. Progre Progressi ssive ve musc muscle le weak weaknes ness s and and atrop atrophy. hy. 1) Defo Deform rmit itie ies s of of the the join joints ts.. 2) Ambulat Ambulation ion freque frequentl ntly y impo impossi ssible ble by age 12. 3 ) Ultimately destroys essential muscles of respiration; death occurs from respiratory infection or cardiac failure. 3. Diagnostics. a. Elec Electr trom omyo yogr grap aphy hy (EMG (EMG). ). b. Muscle bi biop sy sy. c. Serum en enzymes. 1) Incr Increa ease ses s SGOT SGOT in in the the firs firstt 2 year years s of life before the o nset of symptoms. 2) Increa Increased sed creati creatinin nine e phos phospho phokin kinase ase and aldolase.
Assessment 1. Risk Risk fact factor ors/ s/et etio iolo logy gy.. a. Associated with cere br bral anoxia during pregnancy or perinatal period. b. Prenatal. 1) Maternal anemia, metabolic disturbances. 2) Intr Intrau aute teri rine ne infe infect ctio ion. n. 3) Bloo Blood d inca incapa pata tabil bilit itie ies. s. 4) Toxemia. c. Perinatal. 1) Prema tu turity. 2) Trau Trauma ma duri during ng deli delive very ry.. 3) Hype Hyperb rbil ilir irub ubin inem emia ia.. d. Postnatal. 1) Cere Cerebr bral al tra traum uma. a. 2) CVA 3) Infection.
2.
18
Clin Clinic ical al manif manifes esta tati tion ons. s. a) Delayed achievement of developmental milestones. b) Neur Neurom omot otor or dysf ysfunc unctio tion in motor tor performances. c) Incr Increas eased ed or decr decrea ease sed d resis resista tanc nce e to passive movement. d) Abno Abnorm rmal al post postur ure. e.
e)
Pres Presen ence ce of infa infant ntil ile e refl reflex exes es (ton (tonic ic neck reflex, exaggerated moro). f) Asso Associ ciat ated ed dis disab abil ilit ities ies incl includ ude: e: 1. Mental retardation; approximately 1/3 of the children aff affect ected are are of norm ormal or superior intelligence. 2. Seizures 3. Atte Attent ntio ionn-de defi fici citt probl problem ems. s. 4. Vision and hearing sensory impairments 3. Diagn os osti cs cs. a. Neur Neurol olog ogic ical al exam examin inat atio ion n and contributing history. b. Diag Diagno nos stics ics test ests to rule rule out othe otherr neur neurol olog ogic ical al dysfunction. c. Frequently difficult to diagnose in early months; cond condit itio ion n may may not not be evident until child attempts to walk. Treatment (Generally supportive). 1. 2. 3.
c)
d) e) f) g)
Enco ncourag urage e recr recrea eati tion on and and edu educat cationa ionall activities activities,, especially especially those those involving involving other other cerebral palsy children. Encourage chi ld ld to express feeling s regarding his/her disorder. Do not not “tal “talk k down” down” to chil child; d; comm communi unicat cate e at appropriate mental level.. Assi Assist sts s paren parents ts in pro probl blem em sol solvi ving ng in home home environment. Identi Identify fy comm communi unity ty reso resourc urces es avail availabl able. e.
PARKINSON’S DISEASE (PARALYSIS AGITANS) a progressive disorder causing destruction and degeneration of nerve cells in the basal ganglia resulting in damage to the extrapyramidal system difficulty in control and regulation of movement.
-
A.
Dopami Dopamine ne a neurotr neurotrans ansmit mitter ter is respo responsi nsible ble for for normal functioning of the extrapyramidal system. The The conditi condition on is corre correlat lated ed with with a depleti depletion on of, or or imbalance in, dopamine and an increased activity of acetylcholine.
B.
Maint Maintain ain and promo promote te mobil mobilit ity y wit wit orth orthop opedi edic c devices and physical therapy. Skel Skelet etal al musc muscle le rela relaxa xant nt.. Anti Antico conv nvul ulsa sant nt as as indi indica cate ted. d.
Assessment: 1. Risk Risk fact factor ors/ s/et etiol iology ogy:: a. No sex sexual ual,, econ econom omic ical al or cult cultur ural al preferences b. Gene Genera rall onse onsett is is aft after er age age 50 c. Rarely Rarely occurs occurs in the the blac black k popu populat lation ion
Nursing Intervention: (Child (Child is freque frequentl ntly y cared cared for a home home and on an outpatient basis unless complications occur.)
2.
Clin Clinic ical al Mani Manife fest stat atio ions ns:: a. Tremor 1) Generally affects the arms and hands bilaterally – often the first sign 2) Tremors may be increased or decreased with purposeful movement 3) Described as “pill rolling” tremor 4) Aggravated by emotional stress and increased concentration
Goal: to assist child to become as independent and self sufficient as possible. a) Physic Physical al thera therapy py progr program am desig designed ned to to assist assist individual child to gain maximum function. b) Assis ssistt child hild to prog progre res ss acc accordi ordin ng to developmental level and functional abilities; encourage encourage crawling, crawling, sitting sitting and balancing balancing appropriate to developmental, level. c) Assi Assist st chil child d to carry carry out out activ activit itie ies s of daily daily living as age and capacities permit (feeding, dressing and personal hygiene). d) Spee Speech ch the thera rapy py is is indi indica cate ted. d. e) Encour Encourage age play play appr appropr opriat iate e for for age. age. f) Encourage appropriate educational activities. g) Bowe Bowell and bladd bladder er trai trainin ning g may be diffi difficu cult lt due to poor control.
b. Muscle rigidity 1) Increased resistance to passive movement 2) Movement may be described as “cog wheel rigidity” due to jerky movement of extremities 3) Precipitates slowlessness of movement c. Bradykinesia 1) Decreased blinking of the eyelids 2) Loss of ability to swallow saliva 3) Facial expression is blank or “mask like” 4) Loss of normal arm swing while walking 5) Difficulty initiating movement
Goal: to maintain maintain physiological homeostasis. a) Main Mainta tain in ade adequ quat ate e nutr nutrit itio ion n 1. may expe experi rien enc ce dif difficul icultty eati ating due due to spas spasti tici city ty;; may may droo drooll excessively. 2. encourage independence in eating; utilize self help devices 3. provide a balanced diet with increased increased caloric intake to meet extra energy demands. b) Main Mainta tain in safet safety y and precau precauti tion ons s to prev preven entt injury. c) Incr ncreas eased susc suscep epttibili bility ty to inf infect ections ions,, especially respiratory infectio0ns due to poor control of intercostals muscle and diaphragm. d) Incr Increa ease sed d inci incide denc nce e of dent dental al prob proble lems ms;; frequent dental check up.
d. Stood posture e. Shuffling propulsive gait f. Onset usually gradual 3.
Diagno Diagnost stic ic – no no speci specific fic diagno diagnosti stic c test test
Treatment: 1.
2.
Goal: to promote a positive self- image I the child and provide support to the family. a) Use Use pos posit itiv ive e reinf reinfor orce ceme ment nt b) Assist Assist parent parents s to set realis realistic tic goals. goals.
Medica Medicatio tion n to enhanc enhance e dopam dopamine ine secret secretion ion a. Levo Levodo dopa pa (L-D (L-DOP OPA) A) b. Sinemet Antich Anticholi oliner nergic gic medica medicatio tions ns to to decre decrease ase effects of acetylcholine a. Artane b. Cogentin
Nursing Intervention: Goal: to maintain homeostasis 1. Enco Encour urag age e inde indepe pend nden ence ce in ADL ADL util utiliz izin ing g self help devices
19
2.
Main Mainta tain in nutr nutrit itio ion: n: a. Incr Increa ease se calor calorie ies, s, prote protein in and easily chewed foods b. Freq Freque uent nt smal smalll mea meals ls c. Allo Allow w ampl ample e tim time e for for eati eating ng d. Moni Monito torr weig weight ht loss loss e. Prov Provid ide e plea pleasa sant nt atm atmos osph pher ere e at meal mealti time me;; clie client nt freq freque uent ntly ly pref prefer ers s to eat eat alon alone e due due to difficulty swallowing and inability to control saliva f. Increase fluid intake with incr increa ease sed d bulk bulk in the the diet diet to decrease problem with constipation 3. Maintain muscle function a. Full range of motion to extremities to prevent contracture b. Decrease effects of tremors c. Encourage activity d. Physical Therapy as indicated
Goal: to control pain. 1. 2. a. b. c. d. 3.
Asses Assess s the the natu nature re of of a painfu painfull attac attack. k. Iden Identi tify fy trig trigge geri ring ng fact factor ors; s; adju adjust st envi enviro ronm nmen entt decrease factors. Keep Keep room room at an an even, even, comfo comforta rtable ble temp tempera eratur ture. e. Avoi Avoid d touc touchi hing ng cli clien ent. t. Avoi Avoid d jar jarri ring ng the the bed bed.. Allow Allow clie client nt to to carry carry out out own own ADL ADL as nece necessa ssary. ry. Admini Administ ster er anal analges gesics ics to decrea decrease se pain pain..
to
Nursing Diagnosis: Trigeminal Neuralgia Alteration In Comfort: Acute Pain related to condition. Knowledge Deficit related to inadequate knowledge regarding condition, precipitating factors, and treatment. Potential for Self Harm related to inability to cope with pain.
Goal: to promote a positive self-image 1. Encour Encourage age divers diversion ional al activi activitie ties s 2. Assist Assist client client to set realis realistic tic goals goals 3. Explore reasons for depression; encour encourage age client client to discus discuss s change changes s occurring in life style. 4. Assist client in gaining control of environment. 5. Assi st st cli en ent to id en enti fy fy and avo id id activities that increase frustration levels. 6. Enco Encour urag age e good good perso persona nall hygie hygiene ne..
Nursing Nursing Priority: Priority: Due to the severe pain of the condition, condition, clients are susceptible to severe depression and suicide. Goal: to maintain nutrition. 1. Frequently client does not eat due to reluctance to stimulate the pain. 2. Provid e lukewarm fo od od which is easil y chewed. 3. Incr Increas ease e prot protei ein n and and calo calori ries es.. Goal: to evaluate residual effects and prevent complications postoperative surgical intervention. 1. 2.
PERIPHERAL NERVE DISORDERS Trigeminal Neuralgia
a. b. c.
A Cranial nerve disorder affecting the sensory branches of the trigeminal (cranial nerve V).
d. e.
Assessment Risk factors/etiology. a. Onset Onset gener generall ally y betw between een 20 20 and 40 40 years years of age. age. b. Incr Increa easi sing ng freq freque uenc ncy y with with aging. aging. 2. Clinical Clinical manifestations. a. Abrupt onset of paroxysmal pain in the lower and upper jaw, cheek, and lips. 1) Tearin Tearing g of the the eyes eyes and and frequ frequent ent blin blinkin king. g. 2) Faci Facial al twit twitch chin ing g and grim grimac acin ing. g. 3) Pain Pain usually usually brief; brief; ends ends as as abrupt abruptly ly as itit begins begins.. b. Recurrence of pain is unpredictable. c. Pain is initiated by cutaneous stimulation of the affected nerve area. 1) Chewing. 2) Washi ashing ng the fac face. e. 3) Extremes Extremes of temper temperature ature-eith -either er on the face face or or in food. 4) Brus Brushi hin ng tee teetth. 3. Diagnostics. a. clinical manifestations. manifestations. b. Test to rule out other neurologic dysfunctions.
Identi Identify fy presen presence ce of cornea corneall reflex; reflex; provi provide de protect protective ive eye care if reflex is absent. If there there is loss loss of of sensat sensation ion to to the side side of the the face face client client should: Chew Chew on the the unaf unaffe fect cted ed sid side. e. Avoid Avoid temper temperatu ature re extrem extremes es in in food foods. s. Chec Check k the the mout mouth h afte afterr eati eating ng to remov remove e rema remain inin ing g particles of food. Mainta Maintain in meti meticul culous ous oral oral hygien hygiene. e. Have Have fre frequ quent ent dent dental al che check ckup ups. s.
BELL’S PALSY A cranial cranial nerve disorder disorder affectin affecting g the facial nerve nerve (cranial (cranial nerve VII),characteriz VII),characterized ed by a disruption of the motor branches on one side of the face. The disruption of the motor branches results in muscle flaccidity of the affected side of the face. Assessment 1. Risk Risk fact factor ors/ s/et etio iolo logy gy.. a. Can affec affectt any age age group; group; increa increased sed inci inciden dence ce betwee between n ages 20 and 40. b. Curr Curren entt theori eories es sugg sugges estt the the inf inflamma ammattion ion and demyeliniz demyelinization ation of the nerve is precipita precipitated ted by a viral agent, possibly herpes simplex. 2. Clin Clinic ical al manif manifes esta tati tion ons. s. a. Lag or or inabil inability ity to to close close eyeli eyelid d on affect affected ed side. side. b. Droo Droopi ping ng of the the mou mouth th.. c. Decr Decrea ease sed d tas taste te sens sensat atio ion. n. d. May experienc experience e pain behind behind the ear of of the the affecte affected d side. side. 3. Diagno Diagnosti stics cs-no -no spec specifi ific c diagno diagnosti stic c test. test.
Treatment 1. Medical management of pain. a. DILANTIN. b. TEGRETOL. 2. Surgical intervention. a. Local nerve block. b. Surgical intervention to interrupt nerve impulse transmission.
Treatment 1. Cort Cortic icos ostteroi eroids ds.. 2. Vasodi la lato rs rs.
Nursing Intervention Goal: to assess nerve function and prevent complications.
Nursing Intervention
20
1. 2. 3. 4.
Anal Analge gesi sics cs to decr decrea ease se pain pain.. Evalu Evaluate ate abilit ability y of of clie client nt to eat. eat. Meti Meticu culo lous us oral oral hygi hygien ene. e. Prev Preven entt dryin drying g of the corn cornea ea on the the affec affecte ted d side. Instil Instilll methylc methylcell ellulos ulose e drops drops frequen frequently tly durin during g the day. Ophtha Ophthalmi lmic c oint ointmen mentt and and eye eye patc patches hes may be required at night. As funct function ion retu returns rns,, active active faci facial al exerc exercise ises. s.
Goal: to assist client to maintain a positive self-image. 1. Change Changes s in physi physical cal appe appeara arance nce may may be dram dramati atic. c. 2. Disc Discus uss s with with clien clientt that that the condit conditio ion n is usual usually ly selfselflimiting with minimum, If any, residual effects. 3. Clie Client nt may requi require re couns counsel elin ing g if facia faciall appe appear aran ance ce is permanent.
A. SPINA BIFIDA OCCULTA 1. Most Most com commo mon n type, type, may may occur occur in as many many as as 25% of of otherwise normal children. 2. The bon bony def defect ect may rang range e from rom a very ery thin hin slit lit separating one lamina from the spinous process to a complete absence of spine and laminae. 3. A thin, thin, fibrous fibrous membr membrane ane somet sometimes imes covers covers the the defect defect.. 4. The The spinal spinal cord cord and its its menin meninges ges may may be conn connect ected ed with with a fistul fistulous ous tract tract extend extending ing to and openin opening g onto onto the surface of the skin. 5. Most Most pat patie ient nts s have have no no symp sympto toms ms:: a. They They may may have have a dimple dimple on on the skin skin or or a growth growth of of hair hair over the malformed vertebra. b. There There is no extern externall ally y visi visible ble sac. sac. c. With With grow growth th,, the child child may deve develo lop p foot weak weakne ness ss or bowel and bladder sphincter disturbances.
Nursing Diagnosis: Bell’s Palsy
B. MENINGOCELE
a. b. 5.
1. Disturbance in Body Image related to facial deficits. Potential for Injury: Eye related to loss of normal blink reflex. Potential for alteration in Nutrition: Less Than Normal Body Requirements related to difficulty eating.
a. b. 2.
SPINA BIFIDA 3. Spina Bifida – refers to a malformation of the spine in which the posterior portion of the larrinae of the vertebrae fails to close. It affects approximately 1 out of every l,000 babies born in U.S.A., malformation of the neural tube a cylinder of embryonic tissue that develops into the brain and Spinal cord during the 1st month of gestation. gestation. It’s the most common common developme developmental ntal defect of the Central Nervous System. MOST COMMON TYPES 1. SPINA SPINA BIFI BIFIDA DA OCCUL OCCULTA TA,, in which which the the defect defect is is only in in the vertebrae. The spinal cord and meninges are normal. 2. MENI MENING NGOC OCEL ELE, E, in whic which h the the meni mening nges es prot protru rude de through the opening in the spinal canal, forming a cyst filled with Cerebro Spinal Fluid and covered with skin. 3. MENING MENINGOM OMYEL YELOC OCELE ELE OR OR MYELOM MYELOMENI ENINGO NGOCEL CELE E –in which which both both the spinal spinal cord cord and cord membra membranes nes protrude through the defect in the laminae of the spinal canal canal.. Meni Mening ngom omye yelo loce celes les are are cove covere red d by a thin thin membrane. Rachischisis neural tube defect extends the length of the spine which is always fatal. Spina bifida cystica is also another term used to describe Meningomyelocele. ETIOLOGY: 1. unkn unknow own, n, but gener general ally ly thoug thought ht to resu result lt from from gene geneti tic c pred predis ispo posi siti tion on trig trigge gere red d by some sometthing hing in the the environment.
4. 5. a. b. 6.
An exter external nal cyst cystic ic defec defectt can be be seen seen in the spin spinal al cord, cord, usually in the center line. The The sac is comp compose osed d only of of mening meninges es and and is fille filled d with with CSF. The The cord cord and nerve nerve root roots s are are usually usually normal normal.. The The defect defect may may occur occur anywh anywher ere e in the the cord. cord. Highe Higher r def defect ect (fr (from the thora horax x and and up) are are usual sually ly meningoceles. Ther There e is seld seldom om evid evidenc ence e of weak weakne ness ss of the the legs or lack of sphincter control. Surgical Surgical correctio correction n is necessary necessary to prevent prevent rupture rupture of the sac and subsequent infection. Hydroc Hydroceph ephalu alus s may be an ass associ ociate ated d findin findings gs and may may be aggravated after surgery for a meningocele. Occu Occurs rs in abo about ut 9% 9% of pati patient ents s Usually no t associ at ate d with the Arno ld ld-Chiari malformation Progno Prognosis sis is is good good with with surg surgica icall corre correct ction ion..
C. MENINGOMYELOCELE ( MYELOMENINGOCELE)
1. 2.
3.
4.
5. a.
2.
It involv involves es an arrest arrest in the orderly orderly forma formatio tion n of the vertebral arches and spinal cord that occurred between the 4th and 6th week of embryogenesis. THEORIES CAUSATION: A). There is incomplete closure of the neural tube during the 4th week of embryonic life. B). The neural tube forms adequately but then ruptures. INCIDENCE: 1. Geographic Geographical al distributi distribution on and incidence incidence vary widely. widely. 2. Condit Condition ion occur occurs s in approxi approximat mately ely 1 per 1,000 1,000 live live birth births s in the U.S. 3. most most comm common on devel developm opment ental al defec defectt of / CNS. CNS. 4. more more comm ommon in Cauc Caucas asia ians ns than han in non non whit hite population specially those of celtic ancestry and those living in South Eastern U.S. 5. cond condit itio ion n may have have othe otherr conge ongeni nita tall anom anoma alies lies associated with it. 6. Wome Women n who have have spin spina a bifid bifida a and pare parent nts s who have have one affected child have an increased risk of producing children with neural tube defects. ALTERED PHYSIOLOGY AND CLINICAL MANIFESTATIONS:
b.
c.
d.
e.
most most comm common on type type of open open spina spinall defect defect – occur occurs s 4-5 times more frequently than meningocele. A round, round, rais raised, ed, and and poorly poorly epit epithel helial ialize ized d area may may be noted at any level of the spinal column. However, the highest incidence of the lesion occurs in the lumbosacral area. The The lesi lesion on cont contains ains both both the the spin spinal al cord cord and and cord cord membranes. A bluish area may be evident on the top because of exposed neural tissue. The The sac may may leak leak in utero utero and and may rupt ruptur ure e after after birth birth allowing free drainage of CSF. This renders the child highly susceptible to meningitis. Prognosis. Influe Influence nced d by the the site site of the the lesion lesion and and the pres presenc ence e and degree degree of associated associated hydrocepha hydrocephalus. lus. Generally, Generally, the higher the defect, the greater the extent of neurologic deficit and the greater the likelihood of hydrocephalus. In the absen bsenc ce of treat reatm ment ent, most ost inf infant ants with ith meningomyelocele die early in infancy. Surgical intervention is most effective if it’s done early in the neonatal period, preferably within the 1 st few days of life. Even Even with with surgica surgicall interve interventi ntion, on, infant infants s can be expect expected ed to manifest associated neurosurgical, orthopedic and or urologic problems. New New tech techni niqu ques es of trea treatm tment ent,, intens intensiv ive e rese resear arch ch and improved services have increased life expectancy and have have greatl greatly y enhanc enhanced ed the the qualit quality y of life life for most children who received treatment for the defect.
CLINICAL PROBLEMS COMMONLY ASSOCIATED WITH MENINGOMYELOCELE A. Neurologic Problems.
1. Arnold-Chiari malformation a). associated malformation involving the brain stem and cerebellum b). causes block-flow-CSF thru the ventricles and leads to failure n the reabsorption mechanism of CSF
21
POST OPERATIVE CARE:
c). Produces significant hydrocephalus in approximately 2/3 of children wit meningomyelocele 2. Loss of motor control and sensation below the level of the lesion.
Take vital signs and monitor the infant’s ability to feed. In addition to a flat diaper under the infant, put a piece of sterile plastic above the anus to deflect feces away from the surgical site. Watch for fever, signs of infection Watch Watch for leakag leakage e of CSF at the closure closure site, site, and evidence of hydrocephalus. Do a complete orthopedic and urinary assessment.
B. Mobility and Orthopedic Problems 1. 2. 3. 4.
Contra ct ctu re res Clubfeet Scoliosis Ambul Ambulati ation on and and abil ability ity to be upri upright ght.. C. Urologic Problems - sacral nerves innervate the the bladder. D. Bowel Problems – poor innervation of the anal sphincter and bowel musculature. E.Skin Problems Problems – areas areas of decrea decreased sed sensatio sensation n have have a tendency to break down.
F. Dietary Problems – children become overweight because of activity limitations. Dietary control to prevent obesity. obesity. G. Developmental Problems – average intellectual ability despite hydrocephalus. DIAGNOSTICS – prenatal screening for neural tube defects. A blood blood test test may reveal reveal high high levels levels of matern maternal al AFP AFP – serum serum alphaf alphafeto etopro protei tein n indica indicatin ting g a break break in the neural neural tube tube that that is allowing too much of this protein to seep into amniotic fluid and subseq subsequen uently tly into into the mother mother’s ’s blood. blood. The result results s must must be confirmed by ultrasound and amniocentesis, although these tests can’t determine the severity of the defect. TREATMENT AND NURSING INTERVENTIONS INTERVENTIONS: Depends on the extent of the neurologic deficit, level of the lesion, and and any any comp compli lica cati tion on she she may may have have – most ost comm common only ly hydrocephalus and UTI. A number of interventions have significantly increased the survival rate and quality of life; Early surgical repair of the defect, antibiotic therapy to reduce the incidence of: meningitis and ventriculitis , shunting shunting to relieve relieve hydroceph hydrocephalus, alus, and early management management of urinary problems. In caring for a newborn of spina bifida, the nurse’s major concern is preventing infection. Screening - indentation or tuft of hair hair may be the only visible sign of mild forms of spina bifida. In more severe cases - the defect is obvious: a portion of the spinal cord protrudes protrudes from the infant’s infant’s back. Tissues Tissues and nerves are either completely exposed or covered by a thin membrane of skin. Cover the protruding sac – whether open or closed – right away with a non adherent, sterile gauze dressing soaked with sterile saline. Keeping it moist will help prevent infection before referring her to a neurosurgeon. Surgery to repair the sac with intact tissue and skin grafts within the next 48 to 72 hrs. (others within 24 hrs.) Before surgery: Nurses Nurses do complete physical physical examination - Since musculosk musculoskeleta eletall problems problems such as dislocated dislocated hips and clubfeet frequently accompany myelomeningocele – pay particular attention to the lower extremities. To keep the spine aligned and to avoid pressure on the baby’s back, back, place place her on her abdome abdomen n on an elevat elevated ed wooden wooden box covered with sheepskin. The baby stays in this position during feedin feedings. gs. Do range range of motio motion n exerci exercises ses gently gently every every hour hour to prevent pressure sores. Urine and feces - that remain for any length of time in the baby’s diaper increase the risk of infection. So instead of diapering simply place one underneath her. A foley cathether is inserted before surgery. To further protect against infection – start a continuous IV infusion of Gentamycin (Garamycin) or Ampicillin ( Polycillin – N) as per Doctor’s order. Change the gauze dressing at least once a shift and right before surgery.
22