Chapter 37 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

Increased intracranial pressure is primarily due to the dilation or constriction of cerebral blood vessels that reacts to changes in blood pressure, blood oxygen levels, and blood pH, aiming to maintain consistent tissue perfusion. Several causes can lead to increased ICP, such as:

• Brain tumors

• Traumatic brain injury: Swelling or bleeding from head trauma can significantly elevate ICP.

• Infectious and inflammatory disorders: Conditions like meningitis and encephalitis contribute to increased ICP.

The consequences of elevated ICP can include impaired cellular function, which may lead to temporary or permanent neurological dysfunction and potentially result in death.

Assessment Findings

When assessing for increased ICP, the following findings may be noted:

• Level of Consciousness (LOC): Individuals may exhibit a decreasing LOC, characterized by stupor, confusion, restlessness, and possible disorientation.

• Headache: Often more severe in the morning.

• Cushing triad: A distinctive set of signs which includes an initially elevated pulse rate that later decreases, a rise in systolic blood pressure accompanied by widening pulse pressure, and irregular respiratory patterns.

• Cheyne-Stokes respirations: A pattern of breathing that could be observed in cases of elevated ICP.

• Other relevant symptoms include vomiting, papilledema, and abnormal posturing (decorticate or decerebrate).

Diagnostic Findings

Diagnosing increased ICP can involve:

• Skull radiography

• Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)

• Lumbar Puncture for cerebrospinal fluid (CSF) analysis

• Cerebral Angiography

Medical Management

The primary goals in managing increased ICP focus on maintaining blood pressure, preventing hypoxia, and ensuring adequate cerebral perfusion. Key interventions include:

• Administering isotonic normal saline, lactated Ringer's, or hypertonic saline solutions, while avoiding hypotonic solutions or those containing glucose.

• Supplemental oxygen should be provided to maintain oxygen saturation levels at or above 95%.

• Maintain the patient's head in a midline position at a 30-degree elevation.

• Seizure control: Utilize diazepam and sedatives like midazolam to manage agitation and transient ICP increases.

Nurse Management of Increased ICP

Assessment and Monitoring

Nursing care plans should include:

1. Collecting comprehensive patient history.

2. Evaluating LOC and vital signs regularly.

3. Assisting with a thorough head-to-toe physical assessment.

4. Conducting neurological evaluations using scales such as the Glasgow Coma Scale (GCS) or the Rancho Los Amigos Scale every 30 to 60 minutes.

5. Monitoring weight and fluid balance; tracking intake and output meticulously.

6. Analyzing laboratory results focusing on serum electrolytes and arterial blood gases.

7. Checking for the presence of bowel sounds, ensuring normal bowel function.

8. Observing any seizure activity.

Infectious and Inflammatory Disorders of the Nervous System

Meningitis

Pathophysiology and Etiology

Meningitis involves inflammation of the meninges, typically caused by infectious microorganisms such as:

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

• Viruses: Including herpes simplex virus and mumps virus.

• Other pathogens like fungi and parasites can also cause meningitis.

Assessment Findings

Symptoms may include:

• Headache, fever, nuchal rigidity (stiff neck), nausea, vomiting, photophobia, irritability, seizures, and signs such as Brudzinski and Kernig's signs.

Diagnostic Tests

Diagnosis typically employs lumbar puncture for CSF analysis, blood cultures, complete blood counts (CBC), and CT scans.

Medical Management

Management strategies include:

• Intravenous (IV) fluids and antimicrobial therapy.

• Anticonvulsants to manage seizures.

• Promotion of vaccination to prevent meningococcal infections.

Encephalitis

Pathophysiology and Etiology

Encephalitis implies swelling of the brain due to pathologic changes affecting both white and gray matter. This can arise from vector-borne viral infections, rubeola (measles), or neurotoxic effects from vaccinations.

Assessment Findings

Indicators of encephalitis may encompass sudden fever, severe headache, stiff neck, vomiting, and altered mental status including drowsiness, delirium, or coma.

Diagnostic Findings

Diagnosis can be confirmed via lumbar puncture showing elevated CSF pressure, imaging through MRI or CT scans.

Medical Management

Supportive care includes managing symptoms with:

• Antipyretics

• Anticonvulsants

• Anti-inflammatory medications

• Analgesics to relieve pain.

Guillain–Barré Syndrome

Pathophysiology and Etiology

This is an autoimmune disorder where antibodies attack the Schwann cells, leading to inflammation and edema of affected nerves.

Assessment Findings

Symptoms often include progressive weakness, numbness, and paralysis. Patients may experience difficulties with chewing, talking, and swallowing.

Diagnostic Findings

Diagnosis can involve lumbar puncture and electrophysiologic testing.

Medical Management

Management may involve plasmapheresis and administration of immune globulins (Gamimune N).

Brain Abscess

Pathophysiology and Etiology

Brain abscess originates from infections in nearby structures (like the middle ear or sinuses) and can also be related to head trauma and surgery.

Assessment Findings

Typical symptoms include increased ICP, fever, headache, and neurological deficits like paralysis or seizures.

Medical Management

Therapeutic interventions comprise antimicrobial therapy, controlling fever, and potentially surgical intervention (craniotomy). Careful nursing assessment is crucial.

Neuromuscular Disorders

Multiple Sclerosis

• Pathophysiology and Etiology: A demyelinating disease resulting in the destruction of the myelin sheath.

• Assessment Findings: Patients often report blurred vision, weakness, and mood swings.

• Diagnostic Findings: Confirmed via lumbar puncture, CT, and MRI.

Myasthenia Gravis

• Pathophysiology and Etiology: Characterized by muscle weakness due to antibodies binding to acetylcholine receptors.

• Diagnostic Findings: Confirmed via edrophonium (Tensilon) test and electrophysiology.

Amyotrophic Lateral Sclerosis (ALS)

• Pathophysiology and Etiology: A progressive neurodegenerative disease affecting motor neurons.

• Diagnosis: No specific tests; assessed via electromyography.

Cranial Nerve Disorders

Trigeminal Neuralgia

• Pathophysiology: Involves the trigeminal nerve, leading to intense facial pain.

• Nursing Management: Focus on pain pattern and oral health.

Bell Palsy

• Pathophysiology: Facial nerve inflammation causes motor impulse disruption.

• Medical Management: Corticosteroids with antivirals are standard.

Extrapyramidal Disorders

Parkinson's Disease

• Pathophysiology: Characterized by dopamine deficiency.

• Assessment Findings: Include stiffness, tremors, and bradykinesia.

Huntington's Disease

• Pathophysiology: Neurodegeneration in basal ganglia, leading to movement and cognitive deficits.

Seizure Disorders

Assessment Findings

Include abnormal motor or sensory function during episodes. Various seizure types have distinctive features assessed over time.

Medical Management

Anticonvulsant medications are key in controlling seizures and nursing management focuses on safety and documentation of events surrounding the seizures.

Brain Tumors

• Assessment Findings: Include morning headaches, nausea, and neurological signs related to tumor growth.

• Medical Management: Includes surgical and non-surgical interventions such as chemotherapy, radiation therapy, and symptom management.

Summary: Students Teach Back

Students should focus on explaining critical aspects like the causes and symptoms associated with increased ICP, as well as discussing nursing interventions specifically tailored for each neurological disorder. It's essential to grasp the diagnostic methods used for conditions like meningitis, encephalitis, and the management of Guillain-Barré syndrome, among others. Each disorder carries unique nursing considerations to ensure effective patient care.