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 – 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
  • ↓ Factors that precipitate exacerbations

Nursing Implementation

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