Neurological Disorders Review

Assessment of the Nervous System - Chapter 60 [Pages 1966-1991]

Overview of the Nervous System

  • The nervous system controls all motor, sensory, autonomic, cognitive, and behavioral activities.
  • It is divided into:
    • Central nervous system (brain and spinal cord)
    • Peripheral nervous system
    • Autonomic nervous system (communicates with internal organs and glands)
      • Sympathetic division (arousing; neurotransmitter: norepinephrine)
      • Parasympathetic division (calming; neurotransmitter: acetylcholine)
      • Functions to regulate activities of internal organs and to maintain and restore internal homeostasis.
    • Somatic nervous system (communicates with sense organs and voluntary muscles)
      • Sensory (afferent) nervous system (sensory input)
      • Motor (efferent) nervous system (motor output)

Autonomic Nervous System Functions

  • Sympathetic (Fight or Flight):
    • Pupil dilation
    • Increased heart rate
    • Dilation of bronchial tubules
    • Stimulation of sweat gland secretion
    • Blood vessel constriction
    • Increased rate of glycogen to glucose in the liver
    • Decreased digestive system activity
    • Adrenal gland stimulation to produce adrenaline
    • Relaxation of the uterus
    • Relaxation of the bladder
  • Parasympathetic (Rest & Digest):
    • Pupil constriction
    • Slowed heartbeat
    • Constriction of bronchial tubules
    • Stimulation of bile release from the liver
    • Stimulation of digestive system activity
    • Vaginal contraction
    • Increased urinary output

Basic Functional Unit

  • Neuron
    • Neuron Structure:
    • Nucleus
    • Dendrites: receive electrochemical messages
    • Axon: carries electrical impulses away from the cell body
    • Myelinated Sheath: Increases speed of conduction
    • Synaptic terminals
    • Neurilemma
    • Node of Ranvier
    • Neurotransmitters:
    • Communicate messages from one neuron to another or to a specific target tissue.
    • Can potentiate, terminate, or modulate a specific action, or can excite or inhibit a target cell.
    • Many neurologic disorders are caused by an imbalance in neurotransmitters.
    • Center (Resp Center) Cluster of cell bodies wit the same functions

Glasgow Coma Scale (GCS)

  • Evaluation for changes in mental status
  • Scored from 3 ā€“ 15 (Higher the score, higher the level of brain functioning)
  • Less than 8: Consider intubation for airway protection.
  • Components:
    • Eye opening (E)
    • Spontaneous: 4
    • To speech: 3
    • To pain: 2
    • Nil (no response): 1
    • Motor response (M)
    • Obeys: 6
    • Localizes: 5
    • Withdraws: 4
    • Abnormal flexor response: 3
    • Extensor response: 2
    • Nil (no response): 1
    • Verbal response (V)
    • Oriented: 5
    • Confused conversation: 4
    • Inappropriate words: 3
    • Incomprehensible sounds: 2
    • Nil: 1
    • Coma score (E+M+V) = 3 \,to \, 15

Neurological Changes with Age

  • With age:
    • Neuronal loss -> decreased brain mass
    • Decreased sensory receptors and nerves
    • Slower mental functions
    • Visual and hearing deficits
    • Gait Changes and balance difficulties
    • Less efficient temperature regulation
    • Never assume Changes in Mental Status are just normal aging.

Diagnostic Studies: Lumbar Puncture

  • Key Side effect that might show there is a CSF leak
    • ask if they have a headache
  • Increase fluids to flush out dye

Diagnostic Studies: Considerations for Medications

  • Askiftweyhaveiod leraise and warfarin
  • So there isn't a build up of metformin in the body

Diagnostic Studies (cont.)

  • Carotid Artery Duplex: evaluates degree of stenosis of carotid and vertebral arteries
    • Nursing Responsibility: explain procedure
  • Transcranial Doppler: evaluates blood flow velocities of intracranial blood vessels
    • Nursing Responsibility: explain procedure

Seizures - Chapter 61 [Pages 2017-2026]

  • Seizure: transient, uncontrolled electrical discharge of neurons in the brain that interrupts normal function
  • Epilepsy: neurological condition marked by recurring seizures
    • No underlying causes for the seizures.

Pathophysiology of Seizures

  • Abnormal episodes of motor, sensory, autonomic, or psychic activity resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons

Classification of Seizures

  • Figure out classification to see how to treat it
  • Focal Seizures:
    • Focal seizures with awareness ("simple partial")
    • Alert
    • Focal seizure with impaired awareness ("complex partial")
    • Altered
  • Generalized Seizures:
    • Tonic-clonic seizures ("grand mal")
    • Brief or possible altered consciousness
    • Absence seizures ("petit mal")
    • Brief or possible altered consciousness
    • Myoclonic seizures
    • Tonic seizures
    • Clonic seizures
    • Atonic seizures
    • Seizure classification
    • Probable altered consciousness

Stages of a Seizure

  • -patient Won't always have the 4 phase could have 2or 3
  • Actual Seizure
    • Last 1-3 minutes
  • Aura Stage
  • Tonic Stage
    • Stiff Body
  • Clonic Stage
    • Jerky Movements
  • Postictal Stage
    • -can be sleepy
    • -Weak
    • Confusion
    • Exhaustion
    • Sleepy
  • Ictal Phase
    • Hallucination
    • Incontinence
    • Dizzy
    • Numbness
    • Distorted Emotions
    • Epileptic Cry
    • Frothy Saliva
    • Weak Limbs
    • Blinking Eyes
    • Back Arched
    • - = Very sudden rhythmic Jerking
    • Short excessive Terking

Complications of Seizures

  • Seizure longer then 5 mins or multiple back to back seizures
  • Can cause:
    • -hypoxia
    • -decreased respirations

Assessment of Seizures

  • Need to determine:
    • 1)Type of Seizure
    • 2) Frequency
    • 3) Severity
    • 4) Triggers to see where the Seizure is located (one area or everywhere)
    • - rule out metabolic causes
    • - rule out Structural cause

Collaborative Care: Seizures disorders

  • Goal:
    • Prevent seizures
    • -Med adherence for their drugs
    • -Will be on meds ~ + of their life

Drug Therapy

  • Epoceure&Long-acting drugs (Dilantino phenobarbita Primidore Lysola
    • Side Effects
    • Diplopia
    • Drowsiness
    • Ataxia
    • Mental slowly
    • Nystagmus

Neurologic Assessment

  • Hand and gait coordination
  • Cognitive functioning
  • General Alertness

Surgical interventions

  • -only done of anti-seizure meds do not work
  • -will still take meds

Nursing Implementation

  • -See how their prodromal phase feels
  • -don't suction during Seizure only after
  • - something -so can give meds
  • -what are their triggers? No restrictive Clothing or Jewlery

Nursing Management: NDX & Planning

  • Nursing Diagnosis
    • Ineffective breathing pattern
    • Ineffective health management
    • Risk for injury
  • Planning
    • Be free from injury during seizure
    • Have optimal mental and physical functioning while taking antiseizure medications
    • Have satisfactory psychosocial functioning

Nursing Implementation

  • Safety is PRIORITY
  • Do not put anything in it's mouth

Nursing Management: Evaluation

  • Experience breathing pattern adequate to meet oxygen needs
  • Experience no seizure-related injury
  • Express acceptance of seizure disorder by admitting presence of epilepsy and adhering to recommended treatment

Cerebrovascular Accident (Stroke) - Chapter 62 [Pages 2031-2054]

Definition of Stroke

  • Stroke: AKA brain attack and cerebrovascular accident (CVA)
    • Ischemia to part of brain or Hemorrhage into the brain that results in death of brain cells
  • 5 SUDDEN WARNING SIGNS OF A STROKE
    • VISION PROBLEMS
    • DIZZINESS
    • WEAKNESS
    • TROUBLE SPEAKING
    • HEADACHE
  • Severity of the loss of function varies based on location and extent of the brain damage
  • Finding answers. For life.
  • Call 9-1-1 IMMEDIATELY

    If You See Any Of These Signs

Incidence of stroke

  • 5th most common cause of death in the U.S.
  • Leading cause of long-term disability
  • Disabilities:
    • Hemiparesis
    • Difficulty or inability to ambulate
    • Complete or partial assistance with ADLs
    • Aphasia
    • Depression

Risk Factors for Stroke

  • risk doubles each year post 55
  • m have more susceptible but w more likely to die
  • - smoking

Types of Stroke

  • Classified based on underlying pathophysiologic findings
  • Ischemic
    • Thrombotic
    • Embolic
  • Hemorrhagic
    • Intracerebral
    • Subarachnoid
  • Ischemic stroke vs Hemorrhagic stroke
    • A blood clot block the blood flow
    • A blood vessel rupture and bleeds
  • Ischemic Stroke
    • Thrombotic
    • A blood clot forms locally in the brain consequently blocking the blood flow
    • Embolic
    • A blood clot formed in the body travels through the bloodstream until it reaches the brain, where it blocks the artery
  • Hemorrhagic Stroke
    • Intracerebral Hemorrhage (ICH)
    • The bleeding occurs within the brain
    • Subarachnoid Hemorrhage (SAH)
    • The bleeding occurs in the subarachnoid space

Types of Ischemic Stroke

  • Thrombotic Stroke
    • Injury to blood vessel wall and formation of blood clot
    • Narrows blood vessel
    • Most common cause of stroke (60%)
    • Common in older adults
  • Embolic Stroke
    • Embolus lodges in and occludes a cerebral artery
    • Leads to infarction and edema of involved vessel
    • 2nd most common cause of stroke
    • Sudden onset
    • So they are on, anti-coagulants
    • Associated with atrial fibrillation, myocardial infarction, ineffective endocarditis, rheumatic heart disease,

Hemorrhagic Stroke

  • Loc , and hypertension
  • Manifestations: possible LOC , N & V, Seizures , stiffneck

Transient Ischemic Attack (TIA)

  • A warning Sign that something worse can happen

A & P Review: Blood Supply

  • Carotid Arteries
  • Vertebral Arteries
  • Each are of the brain is responsible for certain functions
  • Clinical manifestations based on the area of the brain affected by the CVA
  • Cells are very sensitive and affected within 5 min
  • Frontal lobe (thinking, memory, behaviour and movement)
  • Temporal lobe (hearing, learning and feelings)
  • Brain stem (breathing, heart rate and temperature)
  • Parietal lobe (language and touch)
  • Occipital lobe (sight)
  • Cerebellum (balance and coordination)

Right Hemispheric Stroke

  • RIGHT CVA
  • Right = Reckless
    • Paralyzed Left Side
    • Hemiplegia
    • Spacial-Perceptual Deficits
    • Tends to Minimize Problems
    • Short Attention Span
    • Visual Field Deficits
    • Impaired Judgment
    • Impulsive
    • Impaired Time Concept
    • Left-sided hemiPLEGIA
    • Impaired judgement, NEGLECT, does not know limitations
    • "I did not have a stroke"
    • Concerns for SAFETY

Left Hemispheric Stroke

  • LEFT CVA
  • Paralyzed Right Side
    • Hemiplegia
    • Impaired Speech and Language
    • Slow Performance
    • Visual Field Deficits
    • Aware of Deficits
    • Depression, Anxiety
    • Impaired Comprehension
    • Right-sided hemiPLEGIA
    • Completely aware of stroke deficits
    • Communication problems
    • SLOWER with performance
    • FRUSTRATED

Collaborative Care: Diagnostics

  • within 30 mins of pt arrival

Nursing Implementation: Diagnostics

  • Time of symptoms
  • lack anything that could cause Pt. to bleed out do it beforehand

Non-Surgical Intervention

  • Ischemic Stroke
    • Endovascular therapy
    • Open blocked arteries
    • Becoming most effective way of managing ischemic stroke
    • Insera SHELTER device retrieves and removes clots safely

Surgical Intervention

  • Craniotomy
  • Twist Drill
  • Burr Hole

Risk Factors and Prevention

  • Birth control causes higher risk for Stroke

Nursing Management

  • Nursing Diagnosis
    • Decreased intracranial adaptive capacity
    • Risk for aspiration
    • Impaired physical mobility
    • Impaired verbal communication
    • Unilateral neglect
    • Impaired swallowing
    • Situational low self-esteem

Nursing Implementation

  • To promote venous return
  • To maintain skin integrity
  • To improve communication
  • Preventing aspiration
  • Improving Nutrition

Evaluation

  • -maintain stable or improved level of consciousness
  • -attain maximum physical functioning
  • -attain maximum self-care abilities
  • -attain stable body functions
  • -attain effective communication
  • -maintain skin integrity
  • -regain urinary and bowel control
  • -demonstrate positive coping skills

Stroke Recognition

  • STROKE SYMPTOMS
  • Remember, recognize and act fast
  • F.A.S.T.
    • Face drooping
    • Arm weakness
    • Speech difficulties
    • Time to call

Education

  • To help prevent stroke

Surgical Prevention Interventions

  • Patients with TIA
    • Carotid endarterectomy
    • Transluminal angioplasty
    • Stenting

Multiple Sclerosis - Chapter 64 [Pages 2094-2099]

Objectives

  • DISCUSS THE ETIOLOGY AND PATHOPHYSIOLOGY OF MULTIPLE SCLEROSIS (MS)
  • IDENTIFY THE CLINICAL MANIFESTATIONS OF MS
  • DESCRIBE THE DIAGNOSTIC STUDIES FOR MS
  • DISCUSS TREATMENTS OF MS
  • IDENTIFY NURSING MANAGEMENT OF MS

Multiple Sclerosis Definition

  • -Episodes of exacerbation and remission
  • exertion

A & P Review: Pathophysiology

  • Trigger (unknown)
  • Activated T cells travel to the CNS & disrupt the blood-brain barrier
  • Antigen-antibody reaction within the CNS activates inflammatory response
  • Axon demyelination

Sensory vs Motor Neurons

  • SENSORY NEURONS
    • Neurons that carry sensory impulse from sensory organs to the central nervous system are known as sensory neurons
  • MOTOR NEURONS
    • A neuron that carries motor impulses from the central nervous system to specific effectors is known as motor neurons.

Etiology of Multiple Sclerosis

  • -Autoimmune disorder
  • Affects myelin sheath and nerve fibers of brain and spinal cord
  • -chronic, progressive,
  • Demyelination
  • -Nerve impulse slowed down
  • -Plaques develop in brain
  • -Permanent damage

Clinical Manifestations

  • Fatique is big S&S and the pls experience and find most debilitating
  • Central
    • Fatigue
    • Depression
    • Cognitive impairment
    • Unstable mood
  • Muscular
    • Weakness
    • Cramping
    • Spasm
    • lack of coordination
  • Senses
    • Increased sensitivity to pain
    • Tingling
    • Burning
    • Pins and needles feeling
  • Visual
    • Nystagumus
    • Optic neuritis
    • Diplopia
  • Throat
    • Dysphagia
  • Mouth
    • Difficulty swallowing food
    • Sudden slurring
    • or stuttering in speech
  • Urinary
    • Frequent urination
    • Incontinence
    • Sudden change
  • Digestive System
    • in urinary Frequency
    • Constipation
    • Diarrhea

Sensory vs Motor Impairments

  • Symptoms during cold sensitivity in multiple sclerosis
    • Lhermette's Sign
    • (an electrical Shock feeling)
    • Body stiffness \
    • Spastic paraparesis \
    • Spasticity\
    • Gripping force difficulties \
    • Dysarthria \
  • Symptoms during heat sensitivity in multiple sclerosis
    • Blurred vision \
    • Incoordination tremor and ataxia in extremities \
    • Fatigue\
    • Balance deficits \
    • Muscle strength weakness \

Diagnosis of Multiple Sclerosis

  • For a diagnosis of MS
    • Evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within CNS
    • Damage or an attack occurring at different times (usually more than 1 month apart)
    • All other possible diagnoses must have been ruled out

Collaborative Care

  • -No cure for MS- Collaborative management geared toward treating disease progression and symptoms, and improving quality of life
  • -Drug therapy used to slow progression of disease/relapses and treat symptoms
    • -Immunosuppressant's
    • -Anti-inflammatory/corticosteroids
    • -Muscle relaxants-baclofen(lioresal),dantrolene(dantrium) can help w/ muscle spasticity, help w/mobility
    • Immunomodulator drugs
    • interferon beta-1a(avonex, rebif), interferon beta-1B(betaseron)-used to modify the disease progression and prevent relapses
    • -Vitamin supplements- often vit D deficiency, to maintain bone strength
    • -Physical and speech therapy- to improve weakness and maintain ability to swallow

Triggers to Avoid

  • stress, trauma, infection, and immunizations

Nursing Implementation

  • -Minimize Stress
  • -Promote healthy lifestyle
  • -Avoid extreme temperatures
  • -Maintain good sleep regimen
  • -Encourage participation in social activities to prevent isolation
  • -Encourage self care independence
  • -Maintain or improve muscle strength and mobility
    • Regular exercise important
    • -High fiber diet-due to potential constipation issues
    • -Assess patient's self care abilities-assist only when needed to promote independence
    • Common Triggers: Stress , pregnancy,
    • -Anger, depression , euphoria ,isolation
    • extreme Temp. Changes , drug side effects , and lack of sleep
    • Dysarth rid

Nursing Management

  • Nursing Diagnosis & Plan
    • Nursing Diagnosis
    • Impaired physical mobility
    • Impaired urinary elimination
    • Ineffective health management
    • Plan/Goal
    • Maximize neuromuscular function
    • Maintain independence in ADLs for as long as possible
    • Manage disabling fatigue
    • Optimize psychosocial well-being
    • Adjust to the illness
    • ā†“ Factors that precipitate exacerbations

Nursing Implementation

  • Promote Physical Mobility
    • Teach patient:
    • Range of motion exercises
    • Muscle stretching and strengthening exercises
      • (swimming