Caring for Clients With Central and Peripheral Nervous System Disorders

Chapter 37: Caring for Clients With Central and Peripheral Nervous System Disorders

Increased Intracranial Pressure (ICP)

Pathophysiology and Etiology

  • Dilation or constriction of cerebral blood vessels in response to changes in blood pressure, blood oxygen levels, and blood pH maintains constant and consistent tissue perfusion.

Causes

  • Brain tumors

  • Swelling or bleeding from head trauma.

  • Infectious and inflammatory disorders of the brain (e.g., meningitis, encephalitis).

Consequences

  • Impaired cellular activity.

  • Temporary or permanent neurologic dysfunction.

  • Death.

Assessment Findings (Refer to Box 37-1)

  • Decreasing level of consciousness (LOC): stuporous, semicomatose, comatose, confusion, restlessness, periodic disorientation.

  • Headache: more severe in the morning.

  • Cushing triad: consists of a pulse rate that increases initially but then decreases, systolic BP that rises with a widening pulse pressure, and a respiratory rate that is irregular.

  • Cheyne–Stokes respirations: a specific pattern of breathing that cycles between periods of deep breathing and apnea.

  • Other signs include vomiting, papilledema, and decorticate or decerebrate posturing.

Diagnostic Findings

  • Skull radiography.

  • Computed tomography (CT).

  • Magnetic resonance imaging (MRI).

  • Lumbar puncture.

  • Cerebral angiography.

Medical Management

  • Goals: Maintain blood pressure, prevent hypoxia, and ensure cerebral perfusion.

  • Fluid Management: Utilize isotonic normal saline, lactated Ringer’s solution, or hypertonic (3%) saline solutions. Avoid hypotonic solutions and solutions containing glucose as they may increase ICP.

  • Supplemental Oxygen: Maintain oxygen saturation (SaO2) at 95%.

  • Patient Positioning: Maintain head in midline at a 30-degree elevation to enhance venous drainage.

  • Temperature Control: Avoid hypothermia.

  • Seizure Management: Administer diazepam (Valium) to control seizures.

  • Sedation: Use midazolam (Versed) to sedate agitated clients as hyperactivity can contribute to transient rises in ICP.

  • Indwelling Catheters: Consider placement of a nasogastric tube, stool softener, histamine antagonists like famotidine (Pepcid).

Assessment Questions

Question 1

  • Identify nursing interventions that help prevent further increase in ICP:

    • (A) Encourage fluids.

    • (B) Elevate the head of bed.

    • (C) Provide physical therapy.

    • (D) Reposition client frequently.

Answer 1

  • Correct Answer: (B) Elevate the head of bed.
    Rationale: Elevation of the head reduces cranial pressure. All other options may increase ICP.

Infectious and Inflammatory Disorders of the Nervous System: Meningitis

Pathophysiology and Etiology

  • Inflammation of the meninges surrounding the brain and spinal cord.

Causes

  • Infectious microorganisms:

    • Bacteria: Meningococci (Neisseria meningitidis), Streptococci (Streptococcus pneumoniae).

    • Viruses: Herpes simplex virus, mumps virus, enteroviruses; viral meningitis is more prevalent in children and older adults.

    • Other: fungi, parasites.

Assessment Findings

  • Symptoms: Headache, fever, nuchal rigidity, nausea, vomiting, photophobia, restlessness, irritability, seizures, opisthotonos, positive Brudzinski and Kernig signs.

Diagnostic Tests

  • Lumbar puncture (C&S), CT scan, blood cultures, complete blood count (CBC).

Medical Management

  • Fluid Therapy: Intravenous (IV) fluids.

  • Antimicrobial Therapy: Target infectious agents.

  • Anticonvulsants: Manage seizures.

  • Immunization: Consider meningococcal meningitis vaccination (Menomune).

Encephalitis

Pathophysiology and Etiology

  • Swelling of the brain with pathological changes in both white and gray matter and surrounding meninges.

Causes

  • Vector-borne viral infections, including rubeola (measles) and neurotoxic effects related to childhood vaccinations.

  • Notable viruses: St. Louis, Western equine, Eastern equine, West Nile viruses.

Assessment Findings

  • Symptoms: Sudden fever, severe headache, stiff neck (nuchal rigidity), vomiting, drowsiness, tremors, seizures, spastic or flaccid paralysis, irritability, muscle weakness, lethargy, delirium, coma, incontinence, visual disturbances.

Diagnostic Findings

  • Lumbar puncture: CSF shows elevated pressure with clear fluid.

  • MRI and CT scans for imaging.

Medical Management

  • Supportive Care: Manage symptoms using antipyretics, anticonvulsants, anti-inflammatory drugs, and analgesics.

Nursing Management

  • Monitor vital signs, level of consciousness (LOC), intake and output (I&O), and bowel function.

  • Refer to Client and Family Teaching 37-1 for additional resources.

Guillain–Barré Syndrome

Pathophysiology and Etiology

  • Autoimmune response where antibodies attack Schwann cells leading to demyelination; inflamed and edematous nerves.

  • Causes: Unknown; associated with infections like influenza, or conditions such as lupus erythematosus.

Assessment Findings

  • Symptoms: Weakness, numbness, tingling in arms and legs, progressive weakness, and paralysis which may affect chewing, talking, and swallowing.

Diagnostic Findings

  • Lumbar puncture and electrophysiologic testing.

Medical Management

  • Plasmapheresis: A procedure to filter blood and remove harmful antibodies.

  • Immune Globulin: Administered (Gamimune N).

Nursing Management

  • Assess respiratory distress, monitor with a spirometer, provide skin care, reposition every 2 hours, and incorporate range of motion (ROM) exercises to prevent muscle atrophy.

Brain Abscess

Pathophysiology and Etiology

  • Infection resulting from bacteria collecting in the brain, often due to nearby infections in structures like the middle ear or sinuses.

Causes

  • Intracranial surgery, head trauma, bacterial endocarditis, and bacteremia originating from pulmonary or abdominal infections.

Assessment Findings

  • Symptoms: Increased ICP, fever, headache, paralysis, seizures, muscle weakness, lethargy.

Diagnostic Findings

  • Laboratory tests such as WBC count, lumbar puncture, CT scan, MRI, skull radiographs.

Medical Management

  • Antimicrobial Therapy: To treat infection.

  • Supportive Care: Includes controlling fever, IV fluids, and nutritional support.

  • Surgical Management: Craniotomy may be required to drain the abscess.

Nursing Management

  • Monitor for altered LOC, assess sensory and motor function changes, signs of increased ICP, and vital signs. Measure intake and output (I&O).

Neuromuscular Disorders: Multiple Sclerosis

Pathophysiology and Etiology

  • A demyelinating disease causing permanent degeneration/destruction of myelin sheath surrounding nerve fibers.

Assessment Findings

  • Symptoms: Blurred vision, diplopia, nystagmus, weakness, clumsiness, and numbness of extremities; also, intention tremors, scanning speech, mood swings.

  • Other findings may include motor incoordination and bowel/bladder incontinence.

Diagnostic Findings

  • Lumbar puncture and CSF analysis, electrophoresis of CSF, CT scan, MRI.

Nursing Care Plan

  • Diagnosis: Risk for ineffective breathing pattern due to muscle weakness affecting respiration.

    • Intervention: Encourage deep breathing exercises and position client appropriately (Fowler’s position).

  • Diagnosis: Impaired physical mobility related to diminished muscle strength and inactivity.

    • Intervention: Provide rest periods between activities (bathing, eating, ambulating).

  • Medications such as baclofen (Lioresal) and dantrolene (Dantrium) for spasticity and rigidity.

Myasthenia Gravis

Pathophysiology and Etiology

  • A neuromuscular disorder characterized by severe weakness due to antibodies binding and degrading acetylcholine receptors on skeletal muscles.

Assessment Findings

  • Symptoms include muscle weakness such as ptosis (drooping eyelids), difficulty chewing and swallowing, diplopia, voice weakness, and facial expression changes.

Diagnostic Findings

  • Confirmation through intravenous administration of edrophonium (Tensilon), which briefly alleviates muscular weakness.

  • Assess acetylcholine receptor antibody titers; chest X-ray may show thymoma.

  • Electromyography measures electrical potentials in muscles.

Medical Management

  • Medication: Anticholinesterase drug (e.g., pyridostigmine bromide, Mestinon).

  • Other treatments: Prednisone, immunosuppressants, and plasmapheresis.

  • Surgical Management: Removal of the thymus gland if necessary.

Nursing Management

  • Provide periods of rest for the client, elevate the head of the bed, suction to manage secretions, and cultivate empathy to assist with psychosocial adjustments due to changes in appearance, function, and lifestyle.

Amyotrophic Lateral Sclerosis (ALS)

Pathophysiology and Etiology

  • A progressive and fatal neurologic disorder marked by degeneration of motor neurons in the spinal cord and brain stem leading to muscle weakness and atrophy.

    • Cause: Unknown.

Assessment Findings

  • Symptoms include progressive muscle weakness and wasting affecting limbs, with muscle fasciculations (twitching) noted.

  • Brainstem involvement leads to difficulties in speech and swallowing, emotional lability, respiratory failure, and total paralysis.

Diagnostic Findings

  • No specific tests; confirmed by electromyography which validates muscle weakness.

Medical Management

  • No specific treatments available; interventions focus on managing symptoms and slowing disease progression.

  • Medication: Riluzole (Rilutek) can slow progression and delay the need for tracheostomy.

Nursing Management

  • Support clients with activities of daily living (ADLs), transitioning to total dependence on caregivers in later stages of the disease.

Trigeminal Neuralgia (Tic Douloureux)

Pathophysiology and Etiology

  • Involves the fifth cranial nerve (trigeminal nerve); affects its three branches: mandibular, maxillary, and ophthalmic.

  • Plays a key role in chewing, facial movement, and sensation; often related to nerve root compression.

Assessment Findings

  • Symptoms: Sudden, severe, and burning facial pain.

Diagnostic Findings

  • Utilize skull radiography, MRI, and CT scans.

Surgical Management

  • If medical management fails, consider surgical division of the sensory root of the trigeminal nerve for permanent pain relief.

Nursing Management

  • Identify location, pattern, and events associated with pain; inspect the oral cavity for signs of injury.

Bell Palsy

Pathophysiology and Etiology

  • Inflammation around one of the paired facial nerves causing motor impulse blockage on one side of the face.

    • Cause: Unknown, suspected viral links.

Assessment Findings

  • Symptoms include facial pain, pain behind the ear, numbness, diminished blink reflex, ptosis, and tearing on the affected side.

Diagnostic Findings

  • Diagnosis based on physical examination and symptoms observed.

Medical Management

  • Include corticosteroid therapy combined with antiviral acyclovir (Zovirax) to reduce symptoms duration.

  • Use analgesics as needed for pain management.

Nursing Management

  • Obtain client history regarding viral infections.

  • Perform physical examinations to assess facial involvement and monitor for speech impairment, difficulty chewing, and swallowing.

Extrapyramidal Disorders: Parkinson Disease

Pathophysiology and Etiology

  • Characterized by a deficiency of the neurotransmitter dopamine.

    • Causes: Unknown; environmental toxins, head injuries, encephalitis, and some antipsychotic medications.

Assessment Findings

  • Symptoms: Stiffness, tremors (particularly pill rolling), bradykinesia, masklike facial expression, stooped posture, hypophonia, shuffling gait, difficulty redirecting forward motion.

Diagnostic Findings

  • Diagnosis based on characteristic symptoms; neurologic examination; no specific tests exist.

Medical Management

  • Drug Therapy Goals: Prolong patient independence. Medications include selegiline (Eldepryl) and levodopa (Larodopa).

  • Therapies: Incorporation of physical and occupational therapy, along with client and family education, and nutritional counseling.

  • Surgical Management: Options include stereotaxic pallidotomy, deep brain stimulation (DBS), gene therapy utilizing glial cell-derived neurotrophic factor (GDNF).

Nursing Care Plan

  • Diagnosis: Impaired physical mobility and self-care deficit related to muscular rigidity, tremors, and dementia.

    • Management: Assist with ambulation while minimizing fatigue, providing adequate rest periods.

  • Diagnosis: Impaired verbal communication related to the inability to articulate words.

    • Management: Anticipate client needs, reduce environmental noise, encourage slower speech.

Assessment Questions
Question 2

  • Identify interventions to prevent falls in a client with Parkinson’s disease:
    (A) Keep the client’s call light within reach.
    (B) Apply a soft vest restraint when the client is in bed.
    (C) Avoid use of throw rugs.
    (D) Maintain the client’s bed in a low position.
    (E) Provide a cane or walker for ambulation.

Answer 2

  • Correct Answers: (A), (C), (D), (E).
    Rationale: All given actions contribute to fall prevention protocols.

Huntington Disease

Pathophysiology and Etiology

  • Degeneration of the basal ganglia and parts of the cerebral cortex.

    • Cause: Genetic transmission, affecting both genders equally.

Assessment Findings

  • Symptoms include mental apathy, emotional disturbances, choreiform movements, and difficulty with chewing, swallowing, and speech.

  • Intellectual decline and loss of bowel and bladder control may also occur; severe depression can lead to suicidal thoughts.

Diagnostic Findings

  • Utilize positron emission tomography (PET); genetic testing can predict which family members may develop the condition.

Medical Management

  • Medications: Use tranquilizers and antiparkinson drugs to relieve choreiform movements.

  • Genetic Counseling: Recommended prior to pregnancy.

Nursing Management

  • As clients become totally dependent, monitor for complications such as pneumonia, contractures, infections, aspiration, falls, and pressure ulcers.

Seizure Disorders

Pathophysiology and Etiology

  • Characterized by brief episodes of abnormal electrical activity in the brain.

    • Causes: High fever, electrolyte imbalances, uremia, hypoglycemia, hypoxia, brain tumors, drug abuse, alcohol withdrawal.

Seizure Classifications

  • Partial Seizures: Include focal seizures and complex partial seizures.

  • Generalized Seizures: Include absence, myoclonic, and tonic-clonic seizures.

  • Preictal phase, aura, and status epilepticus are relevant concepts.

Assessment Findings

  • Normal motor, sensory, and neurologic functions outside of seizure episodes.

  • Seizure Types:

    • Absence seizure: client stares blankly, eyelids flutter.

    • Myoclonic seizure: sudden exaggerated jerking movement.

    • Tonic-clonic seizure: alternating muscle contraction and relaxation, with associated jerking movements.

Diagnostic Findings

  • EEG, CT scan, MRI, serology, serum electrolyte levels, and EGG are diagnostic tools utilized.

Medical Management

  • Anticonvulsant Drugs: Medications include phenytoin (Dilantin), phenobarbital, carbamazepine (Tegretol), intravenous barbiturates, or diazepam (Valium).

Nursing Management

  • Position client on their side to prevent aspiration, loosen any restrictive clothing, ensure airway patency, suction as needed; provide oxygen if indicated.

  • Proper documentation includes noting circumstances preceding seizure, duration, and involved body parts to identify triggers.

  • Measure vital signs, oxygen saturation, and capillary blood glucose levels following a seizure.

Brain Tumors

Pathophysiology and Etiology

  • Classified based on characteristics (benign vs malignant), cell type, and tumor site.

    • Causes: Include viral infections, radiation exposure, head trauma, and immunosuppression.

Assessment Findings

  • Symptoms: Morning headaches (most common), progressively severe headaches, vomiting without nausea, papilledema, seizures, speech difficulty, and paralysis.

Diagnostic Findings

  • CT scan, MRI, brain scans, and cerebral angiography form the basis for evaluation.

Medical Management

  • Treatment Options: Involve surgical intervention, radiation therapy, and chemotherapy.

    • Additional pharmacological management may include corticosteroids, osmotic diuretics, and anticonvulsants.

  • Surgical Options: Include craniotomy, craniectomy, and gamma knife radiosurgery.

Nursing Management

  • Support clients through adverse effects of chemotherapy and radiation treatment.

  • Develop a teaching plan regarding medication regimens, appointments, nutritional support, home care, and referrals for further management.