WEEK 1: Care of the Patient with a Neurological Issue in a Med-Surg Setting

Anatomy of Nervous System - Neurons

Basic functional units of the nervous system, responsible for transmitting electrical and chemical signals

Anatomy of Nervous System - Neurotransmitters

Chemical messengers that transmit signals across synapses from one neuron to another (e.g., dopamine, serotonin, acetylcholine)

Anatomy of Nervous System - CNS - Brain - Cerebrum

Largest part of the brain, responsible for higher brain functions such as thought, memory, and voluntary movement

Anatomy of Nervous System - CNS - Brain - Brainstem

• Connects the brain to the spinal cord

• Controls vital functions such as HR, breathing, and consciousness

Anatomy of Nervous System - CNS - Brain - Cerebellum

Coordinates voluntary movements, balance, and posture

Anatomy of Nervous System - Cerebrospinal Fluid (CSF)

Clear fluid that cushions the brain and spinal cord, provides nutrients, and removes waste

Anatomy of Nervous System - Blood Supply

• Provided by the internal carotid arteries and vertebral arteries

• Essential for delivering oxygen and nutrients to the brain

Peripheral and ANS - Cranial Nerves and Their Functions

• Twelve pairs of nerves that emerge directly from the brain

• Responsible for sensory and motor functions (e.g., olfactory nerve for smell, optic nerve for vision, facial nerve for facial expressions)

Peripheral and ANS - Autonomic Nervous System - Sympathetic Division

• Activates the “fight or flight” response

• Increases HR, dilates pupils, and inhibits digestion

Peripheral and ANS - Autonomic Nervous System - Parasympathetic Division

• Activates the “rest and digest” response

• Decreases HR, constricts pupils, and stimulates digestion

Peripheral and ANS - Motor Functions

Control voluntary and involuntary movements

Peripheral and ANS - Sensory Functions

Transmit sensory information from the body to the CNS (e.g., touch, pain, temperature)

Neurological Assessment - Health History and Common Concerns

• Pain: Headaches, neuropathic pain

• Headache: Migraine, tension-type, cluster headaches

• Seizures: Frequency, duration, triggers

• Dizziness: Vertigo, lightheadedness

• Visual Disturbances: Blurred vision, double vision

• Weakness: Muscle weakness, paralysis

• Abnormal Sensations: Numbness, tingling, burning sensations

“check for baseline: look for trends, check GCS, how/has it changed?”

Neurologic Assessment - Physical Assessment

• Glasgow Coma Scale (GCS): Assesses eye opening, motor response, and verbal response to determine the LOC

  • “any change ≥2 is clinically significant”

• Cerebral Function: Assessing mental status, memory, attention, and cognitive abilities

• Motor Examination: Assessing muscle strength, tone, coordination, and reflexes

• Sensory Examination: Evaluating the patient’s ability to feel touch, pain, temperature, and vibration

Diagnostic Evaluations - Computed Tomography (CT)

Uses x-rays to create detailed images of the brain and spinal cord

• Useful for detecting bleeding, tumors, and structural abnormalities

  • “soft tissues”

Diagnostic Evaluations - Positron Emission Tomography (PET)

Uses radioactive tracers to visualize metabolic activity in the brain

• Helpful in diagnosing Alzheimer’s disease and other dementias

Diagnostic Evaluations - Single Photon Emission Computed Tomography (SPECT)

Similar to PET but uses different tracers

• Provides information about blood flow and activity in the brain

  • “almost never covered by insurance”

Diagnostic Evaluations - Magnetic Resonance Imaging (MRI)

Uses magnetic fields and radio waves to create detailed images of the brain and spinal cord

• Useful for detecting tumors, inflammation, and structural abnormalities

Diagnostic Evaluations - Cerebral Angiography

Uses contrast dye and x-rays to visualize blood vessels in the brain

• Helps diagnose aneurysms and vascular malformations

Diagnostic Evaluations - Myelogram

Uses contrast dye and x-rays to visualize the spinal cord and nerve roots

• Useful for diagnosing spinal stenosis and herniated discs

Diagnostic Evaluations - Electroencephalogram (EEG)

Records electrical activity in the brain

• Used to diagnose epilepsy and other seizure disorders

Diagnostic Evaluations - Electromyogram (EMG)

Measures electrical activity in muscles

• Helps diagnose neuromuscular disorders

Diagnostic Evaluations - Lumbar Puncture (Spinal Tap)

Involves inserting a needle into the spinal canal to collect cerebrospinal fluid (CSF)

• Used to diagnose infections, bleeding, and other conditions affected the CNS

Introduction to Neurologic Trauma

Definition:

• Neurologic trauma includes injuries to the brain, spinal cord, and peripheral nerves

Significance:

• Traumatic brain injury (TBI) is the most common cause of death from trauma in the United States

Primary Injury:

• Initial damage to the brain from the trauma (e.g., contusion, lacerations)

Secondary Injury:

• Damage resulting from the sequelae of the primary injury (e.g., increased ICP, cerebral edema)

Types of Head Injuries - Skull Fractures

Types:

• Linear

• Depressed

• Basilar

Symptoms:

• Persistent, localized pain

• Possible CSF leakage

Treatment:

• Non-depressed fractures may not require surgery

• Depressed fractures usually require surgical intervention

Types of Head Injuries - Concussion

Symptoms:

• Headache, dizziness, lethargy, irritability, anxiety, photophobia, phonophobia, difficulty concentrating, memory difficulties

Treatment:

• Observation and symptom management

  • “can lead to TBI”

Types of Head Injuries - Contusion

Bruising of the brain with possible surface hemorrhage

Types of Head Injuries - Diffuse Axonal Injury

Widespread damage to axons in the cerebral hemispheres

Intracranial Hemorrhage - Epidural Hematoma

• Collection of blood between the skull and dura mater

• Often associated with skull fractures

Intracranial Hemorrhage - Subdural Hematoma (SDH)

• Collection of blood between the dura mater and the brain

• Can be acute or chronic

Intracranial Hemorrhage - Intracerebral Hemorrhage (ICH)

Bleeding into the brain parenchyma

Intracranial Hemorrhage - Treatment Goals

• Preserve brain homeostasis

• Prevent secondary brain injury

Altered Level of Consciousness (LOC)

Definition:

• A state where the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve alertness

Causes:

• Neurologic

• Metabolic

• Toxicologic

Continuum:

• Ranges from normal alertness to coma

Assessment:

• Systematic and thorough evaluation is necessary

Managing Complications of Altered LOC

Cerebral Edema:

• Treatment:

  • Often with mannitol to reduce swelling

Fever Control:

• Importance of maintaining normothermia

BP and Oxygenation:

• Ensuring adequate perfusion and oxygen delivery to the brain

Metabolic Demand:

• Reducing metabolic demand to prevent further brain injury

  • “preserve oxygen reserves”

Seizure Prevention:

• Use of anticonvulsants as needed

Spinal Cord Injury (SCI)

Prevalence:

• Approximately 333,000 people in the U.S. live with disabilities from SCI

Types of SCI:

• Complete vs. incomplete spinal cord lesions

Emergency Management:

• Critical at the scene of injury

Treatment Goals:

• Preservation, stabilization, and realignment of the spinal cord

• Surgical vs. nonsurgical interventions

Complications of SCI

Spinal and Neurogenic Shock:

• Immediate response to SCI

Deep Vein Thrombosis (DVT):

• Risk due to immobility

Orthostatic HTN:

• Sudden drop in BP upon standing

Autonomic Dysreflexia:

• Life-threatening condition causing high blood pressure

Nursing Management of SCI

Assessment:

• Breathing patterns, motor and sensory function, bladder and bowel function

Goals:

• Improved breathing and airway clearance

• Enhanced mobility and sensory awareness

• Maintenance of skin integrity

• Relief of urinary retention and improved bowel function

• Promotion of comfort and prevention of complications

Introduction to Neurologic Disorders

Overview:

• Neurologic disorders encompass a wide range of conditions affecting the nervous system, including the brain, spinal cord, and peripheral nerves

Importance:

• Effective nursing management is crucial for improving patient outcomes and quality of life

Common Disorders:

• Seizure disorders

• Infectious neurologic disorders

• Neurodegenerative and neuromuscular disorders

Neurologic Disorders - Seizure Disorders

Seizures are temporary episodes of abnormal motor, sensory, autonomic, or psychic activity due to sudden excessive electrical discharge from cortical neurons

Types:

• Epilepsy: Unprovoked, recurring seizures

• Status Epilepticus: Series of generalized seizures without full recovery of consciousness between attacks (>5 minutes)

Management Goals:

• Stop seizures quickly

• Ensure adequate cerebral oxygenation

• Maintain seizure-free state

Medications:

• Phenytoin

• Possibly neurosurgery

Nursing Priorities:

• Prevent injury (including aspiration)

• Control seizures

• Psychosocial adjustment

• Patient education

• Prevent complications

Guidelines for Nursing Care - Nursing Care During a Seizure

• Provide privacy and protect the patient from onlookers

• Ease the patient to the floor, if possible

• Protect the head with padding

• Loosen constrictive clothing and remove eyeglasses

• Move any objects that may injure the patient

• If in bed, remove extra pillows and raise side rails

• Do NOT attempt to pry open the mouth or insert anything between teeth

• Do NOT restrain the patient

  • Muscular contractions are strong and restraint can cause harm

• Place patient on one side to allow drainage of saliva and mucus

  • Suction if needed

Guidelines for Nursing Care - Nursing Care After the Seizure

• Keep the patient on one side to prevent aspiration and ensure airway patency

• Expect a period of confusion after a tonic-clonic seizure

• A short apneic period may occur immediately after

• Reorient the patient upon awakening

• If patient is agitated (postictal), use calm persuasion

Infectious Neurologic Disorders - Meningitis

Inflammation of the protective membranes covering the brain and spinal cord

Types:

• Septic (Bacterial): Requires immediate antibiotic treatment

  • “worse bc bacteria eats sugar (which is the only food source of the brain), so needs to be treated immediately)

• Aseptic (Viral): Often self-limiting

Symptoms:

• Headache, fever, nuchal rigidity (stiff neck)

Treatment:

• Early administration of antibiotics that cross the blood-brain barrier

Nursing Care:

• Vigilant assessment and interventions to monitor and manage symptoms

  • “Baseline, LOC, keep fever controlled”

Infectious Neurologic Disorders - Encephalitis

Acute inflammation of the brain tissue (cerebral cortex) secondary to viruses, bacteria, fungi, or parasites

Causes:

• Arboviral: West Nile virus

• Herpes Simplex Virus (HSV): Acyclovir is the treatment of choice

Symptoms:

• Fever, headache, confusion, seizures

Management:

• Control seizures

• Manage increased intracranial pressure (ICP)

Public Education:

• Importance of preventing mosquito bites and other preventive measures

  • “LOC, Cushing’s Triad (Bradycardia, HTN, bradypnea) , GCS”

Infectious Neurologic Disorders - Bell Palsy

Unilateral inflammation of the seventh cranial nerve, resulting in weakness or paralysis of the facial muscles

Cause: UNKNOWN

Symptoms:

• Distorted facial appearance due to muscle paralysis

Treatment:

• Analgesics for pain

• Corticosteroids to reduce inflammation

Neurodegenerative Disorders - Multiple Sclerosis (MS)

An immune-mediated, progressive demyelinating disease of the central nervous system

Etiology: UNKNOWN

Course:

• Most patients have a relapsing-remitting (RR) course

Symptoms:

• Varying motor and sensory losses

• Multiple secondary complications

Treatment Goals:

• Treat acute exacerbations

• Delay disease progression

• Manage chronic symptoms

Neurodegenerative Disorders - Myasthenia Gravis (MG)

An autoimmune disorder affecting the neuromuscular junction, characterized by fatiguability and weakness of voluntary muscles

Cause:

• Reduction in the number of acetylcholine receptor sites

Symptoms:

• Muscle weakness

• Visual problems

Treatment:

• Anticholinesterase medications

• Immunosuppressants

Nursing Priorities:

• Medication management

• Minimizing aspiration risk

• Enhancing vision

• Managing activity

Complications:

• Myasthenic crisis (exacerbation of symptoms)

• Cholinergic crisis (overmedication)

Neurodegenerative Disorders - Guillain-Barre Syndrome

An autoimmune attack on the myelin of peripheral nerves and some cranial nerves

Symptoms:

• Sudden motor and sensory losses

Management Priorities:

• Emergency management of respiratory function

• Managing mobility

• Enhancing nutrition

• Decreasing anxiety

• Promoting communication

Neurodegenerative Disorders - Parkinson Disease (PD)

A slowly progressing neurologic movement disorder that eventually leads to disability

Cause:

• Decreased levels of dopamine due to destruction of pigmented neuronal cells in the basal ganglia

Symptoms:

• Tremor, rigidity, akinesia/bradykinesia (without or decreased body movement), postural disturbances

Treatment:

• Antiparkinsonian medications

• Deep brain stimulation

Nursing Priorities:

• Enhancing mobility

• Self-care

• Nutrition

• Bowel function

• Swallowing

• Communication

• Coping ability

Neurodegenerative Disorders - Alzheimer Disease (AD)

A progressive, irreversible, degenerative neurologic disease characterized by gradual losses of cognitive function and behavioral disturbances

Symptoms:

• Early signs include forgetfulness and subtle memory loss, followed by personality changes

Nursing Care Goals:

• Promoting physical safety

• Independence in self-care

• Reducing anxiety and agitation

• Improving communication

• Socialization

• Intimacy

• Promoting adequate nutrition

• Balanced activity and rest

• Supporting and educating family caregivers

Delirium

An acute, fluctuating change in mental status characterized by confusion, reduced awareness of the environment, and impaired cognitive function

Causes:

• Often multifactorial, including severe illness, infection, medication side effects, surgery, alcohol or drug use or withdrawal, and electrolyte imbalances

Symptoms:

• Reduced Awareness: difficulty focusing, easily distracted, withdrawn

• Cognitive Impairment: Poor memory, disorientation, trouble with speech and understanding

• Behavioral Changes: Anxiety, agitation, hallucinations, mood swings, restlessness, or lethargy

Types:

• Hyperactive Delirium: restlessness, agitation, rapid mood changes, hallucinations

• Hypoactive Delirium: Inactivity, sluggishness, drowsiness, reduced interaction

• Mixed Delirium: symptoms of both

Management:

• Identifying and Treat Underlying Causes: address infections, medication adjustments, correct electrolyte imbalances

• Supportive Care: ensure a safe environment, reorient the patient, provide hydration and nutrition

• Medications: May include antipsychotics or sedatives for severe agitation

Neurodegenerative Disorders - Amyotrophic Lateral Sclerosis (ALS)

A degenerative disease characterized by the loss of both upper and lower motor neurons

Symptoms:

• fatigue, limb weakness, gradual onset of asymmetric, progressive weakness

Management Focus:

• Maintaining or improving function, well-being, and quality of life

Neurodegenerative Disorders - Degenerative Disk Disease

Manifestations:

• Pain, motor and sensory deficits

• Alterations of reflexes

Treatment:

• Conservative management, surgical intervention if necessary

Disk Herniation:

• Cervical and lumbar herniation

• Treatment goals include pain relief, slowing disease progression, increasing functional ability

Types of Strokes: Ischemic Stroke

Caused by an occluded artery, leading to reduced blood flow and oxygen to the brain

Types of Strokes: Hemorrhagic Stroke

Caused by a ruptured artery, resulting in bleeding in or around the brain

Types of Stroke: Epidemiology

Fifth leading cause of death, high incidence prompting primary stroke centers and educational campaigns

Pathophysiology of Stroke

Ischemic Cascade:

• Series of metabolic events leading to brain cell death

Transient Ischemic Attack (TIA):

• Temporary symptoms with the same pathophysiologic mechanism as ischemic stroke

Hemorrhagic Stroke:

• Bleeding interferes with normal brain metabolism

Risk Factor for Stroke

Modifiable Risk Factors:

• HTN, smoking, diabetes, dyslipidemia, atrial fibrillation, diet, obesity, sleep apnea, lack of exercise

Non-modifiable Risk Factors:

• Family history

• Age

• Race

Prevention:

• Primordial and primary prevention programs

• Secondary prevention for stroke survivors

Symptoms of Stroke

• Numbness or weakness of the face, arm, or leg, especially on one side of the body

• Confusion or change in mental status

• Trouble speaking or understanding speech

• Visual disturbances

• Difficulty swallowing

• Difficulty walking, dizziness, or loss of balance or coordination

• Sudden, severe headache

Acute Stroke Assessment

Emergency Level:

• Level 2 emergency

Phases of Care:

• Hyperacute phase (first 24 hours) and acute care during hospitalization

Diagnosis:

• Based on CT or MRI

• Blood chemistries

• Coagulation studies

• Blood cell counts

• Cardiac rhythm status

Stroke Triage Flow - Walk-in Pathway

• Symptom onset <6 hours (last known well <6 hours)

• Sudden unilateral numbness/weakness of face, arm, or leg

• Facial droop; flattening of nasolabial fold; asymmetric smile

• Arm drift (check for pronator drift)

• Sudden confusion or trouble speaking; difficulty answering orientation questions

• Sudden severe headache (‘is this atypical or the worst headache?’)

• Sudden trouble seeing in one or both eyes (diplopia or monocular visual loss)

• Sudden trouble walking or lack of coordination (listing, foot drag, heel-to-shin difficulty)

• Blood glucose >50 mg/dL

• If any positive symptom, consider calling a stroke alert

Stroke Triage Flow - Ambulance Pathway

• Symptom onset <6 hours

• Pre-hospital positive stroke screen

• Blood glucose >50 mg/dL

• If all above criteria are YES, call a stroke alert

Medical Management of Stroke: Ischemic Stroke

Thrombolysis with recombinant tissue plasminogen activator (rtPA)

Medical Management of Stroke: Hemorrhagic Stroke

Measures to lower intracranial pressure (ICP), possibly including surgery

Acute Stroke Recovery Care

Rehabilitation Goals:

• Improved mobility

• Avoidance of shoulder pain

• Achievement of self-care

• Relief of sensory and perceptual deprivation

• Prevention of aspiration

Additional Goals:

• Promoting continence

• Improving thought processes and communication

• Maintaining skin integrity

• Restoring family functioning and sexual function

• Preventing complications

• Preventing recurrent stroke

Focused Assessment: Left Hemispheric Stroke - Signs and Symptoms

• Paralysis or weakness on right side of body

• Right visual field deficit

• Aphasia (expressive, receptive, or global)

• Altered intellectual ability

• Slow, cautious behavior

Focused Assessment: Right Hemispheric Stroke - Signs and Symptoms

• Paralysis or weakness on left side of body

• Left visual field deficit

• Spatial-perceptual deficits

• Increased distractibility

• Impulsive behavior and poor judgment

• Lack of awareness of deficits

Nursing Care for Stroke Patients

Comprehensive Assessment:

• Mental status

• Motor control

• Swallowing ability

• Hydration status

• Fluid output

• Skin integrity

• Activity level

Interventions:

• Improving mobility, preventing joint deformities, correct positioning

• Exercise program

• Pain management

• Promotion of self-care

• Managing sensory-perceptual difficulties

• Assisting with nutrition

• Promoting bowel and bladder control

• Improving thought processes

• Enhancing communication

• Maintaining skin integrity

• Promoting family functioning

• Promoting sexual health

• Preparing for discharge