Transcript No Slide Title

Neurological Systems
Mary Roche, RN, MSN, CS
Community College of Rhode Island
April 22,2003
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
1
Credits
All materials for this presentation are based on:
Medical-Surgical Nursing Across the Health Care Continuum by
Ignatavicius, Workman, and Mishler - Volume 2 - 3rd Edition W.B. Saunders Company - 1991
This presentation was built for and is the copyrighted
property of Mary Roche.
This presentation is publicly available for viewing under
the Web Developments section at www.stacyhouse.com
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
2
Goals of this Course
Following attendance at this series of lectures, you should be:
1. Familiar with the nomenclature and functions of the
nervous system,
2. In possession of a viable summary of the course
textbook,
3. Empowered to find information in a timely fashion, and
4. Prepared to initiate nursing practice in neurological
situations.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
3
Anatomy and Physiology Review
The nervous system is the basis for all
human function. It is the center of thinking,
memory, judgment, sensation, movement,
cognition, communication, behavior, and
personality.
In addition to its direct control over many
processes, the nervous system innervates
many other body systems.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
4
Anatomy and Physiology Review
The major divisions of the nervous system are the
Central Nervous System and the Peripheral
Nervous System.
The brain and spinal cord are the major
components of the Central Nervous System.
The Peripheral Nervous System is composed of
12 pairs of cranial nerves, 1 pairs of spinal
nerves and the autonomic nervous system.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
5
Anatomy and Physiology Review
Neurons
The Neuron Is the Basic Unit of the Nervous
System.
When a neuron receives an impulse from another neuron,
the effect may be excitation or inhibition.
Neurons Function to Transmit Impulses.
Sensory – facilitate sensation.
Motor – facilitate movement.
Some process information; some retain information
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
6
Anatomy and Physiology Review
Structure
Each neuron has a cell body, a short branching
process called a dendrite and a single axon.
Each dendrite synapses with another cell body,
axon or dendrite.
Axons are covered by a myelin sheath.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
7
Anatomy and Physiology Review
Pathways
Dendritic process is called afferent pathway.
Axonic process is called efferent pathway.
Also called white matter.
Non-myelinated – gray matter.
Nodes of Ranvier – gaps in the myelin.
Terminal knob – large distal end of each axon.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
8
Anatomy and Physiology Review
Pathways
Within the synaptic knobs are mechanisms for
manufacturing, storing, and releasing a transmitter
substance.
Each neuron produces a specific substance. Either
enhances or inhibits impulses.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
9
Anatomy and Physiology Review
Nerve Impulse Conduction
Mechanism for nerve impulse conduction – the sodium
and chloride ions.
Sodium and chloride are heavily concentrated outside the cell.
Intracellular concentration of potassium
Due to these different concentrations – a neuron is always charged.
Via stimulus – polarity changes = depolarization.
Proteins function as gates and open to either potassium or
sodium (NOT BOTH).
Sodium in – potassium out; then repolarization with sodium being
actively pumped back out. In the membranes this occurs as an
action potential.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
10
Anatomy and Physiology Review
Synapse
Neuron to neuron / Muscle to muscle
Factors affecting transmission:
1. Strength of the stimulus
2. Inadequate supply of substance
3. Cerebrospinal Fluid (CSF) changes
4. Lack of oxygen
5. Acidosis/alkalosis
6. Drugs
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
11
See Table 43-1,
page 993
Anatomy and Physiology Review
Transmitters
Chemical substances that enhance or inhibit
nerve conduction.
Amines:
Acetylcholine
Brain, brain stem, basal ganglia, ANS
Nerve and muscle transmission.
Parasympathetic and preganglionic systems.
Excitatory, but some inhibitory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
12
Anatomy and Physiology Review
Transmitters
Gamma-aminobutyric acid (GABA)
Brain, brain stem, Nerve and muscle basal ganglia, spinal
cord, cerebellum Possibly one-third of brain neurons.
Inhibitory.
Histamine / Serotonin
Brain, spinal cord, PNS Medial brain stem, hypothalamus, dorsal horn
of spinal cord.
Possible onset of sleep, mood control, pain pathway inhibitor.
Inhibitory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
13
Anatomy and Physiology Review
Transmitters
Catecholamines:
Dopamine
Substantia nigra to basal ganglia. Complex movement, emotional response
regulation, attention.
Usually inhibitory.
Norepinephrine
Hypothalamus, brain stem, reticular formation, cerebellum, sympathetic
nervous system. Maintenance of arousal, reward system, dreaming sleep,
mood regulation.
Mainly excitatory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
14
Anatomy and Physiology Review
Transmitters
Amino Acids:
Aspartic acid
Brain, spinal cord interneurons
Sensation.
Excitatory.
Glutamic acid
Sensory pathways
Sensation
Excitatory.
Glycine
Spinal cord interneurons Muscle control. Inhibitory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
15
Anatomy and Physiology Review
Transmitters
Polypeptides:
Substance P
Brain, neurons in spinal cord
Pain transmission
Excitatory
Endorphins, enkephalins
Brain, neurons in spinal cord
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
Pain transmission
Excitatory
16
Anatomy and Physiology Review
Glial Cells
Glial cells – two main classes: Microglia and Macroglia
Microglia cells respond to infections or trauma in CNS.
Macroglia Cells are divided into four subsets:
Astroglia (star-shaped) cells provide physical support for
neurons, regulate chemical environment, nourish.
Oligodendrocyte and Schwann cells – form the myelin
sheath.
Ependymal cells for lining of ventricles of the spinal
cord. Also part of blood-brain barrier.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
17
Central Nervous System
Central Nervous System
Components
Brain - directs regulation and function of the nervous
system and other systems of the body.
Spinal Cord - initiates reflex activity and transmits
impulses to and from the brain.
Cranium And Vertebral Column - Brain and spinal
cord are encased, respectively, in cranium and vertebral
column.
Vertebrae - 7 cervical, 12 thoracic, 5 lumbar, 5 fused sacral, fused
coccygeal.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
19
Central Nervous System
The Brain
Meninges - form the immediate protective covering of the
brain and spinal cord.
1. Pia Mater - thin, delicate and vascular membrane.
Adheres to the brain and spinal cord.
2. Arachnoid - the next layer which is thin, delicate
and fibrous. CSF fills tissue.
3. Dura Mater - The outer layer which is heavy,
fibrous, nonelastic.
Subarachnoid - situated between arachnoid and pia
mater is subarachnoid space where CSF circulates.
Venous sinuses are between two layers of dura.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
20
Central Nervous System
Cerebrum
Lobes and Ventricles
Two hemispheres. Right and left lobes joined by corpus
callosum.
Dominant hemisphere for most people is the left
hemisphere.
Within the cerebrum are the right and left lateral
ventricles.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
21
Central Nervous System
Cerebrum
Cerebral Cortex
Cerebral cortex divided into lobes by sulci and are
named the same as the overlying bones.
Speech Areas: Wernicke’s and Broca’s areas: higher
brain functions
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
22
Table 43-2,
Page 994
Central Nervous System
Brain Lobe Functions
Frontal Lobe
Primary motor area. Broca’s speech center. Eye field, access
to current sensory data. Access to past info. Affective
response. Behavior. Judgment. Ability to develop long-term
goals and to weigh pros and cons.
Parietal Lobe
Understand sensation, texture, size, shape, and spatial
relations. Playing musical instruments. Processing nonverbal
visual experiences. Perception of body parts and body
position awareness. Taste impulses for interpretation.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
23
Table 43-2,
Page 994
Central Nervous System
Brain Lobe Functions
Temporal Lobe
Auditory center for sound interpretation. Complicated
memory patterns. Wernicke’s area for speech.
Occipital Lobe
Primary visual center.
Limbic Lobe
Emotional and visceral patterns connected with survival.
Learning and memory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
24
Central Nervous System
Brain
Diencephalon - lies below the cerebrum and
includes:
Thalamus – the ‘central switchboard’ for the CNS
Hypothalamus - intellectual function
Epithalamus - controls pineal gland
Hypophysis (pituitary gland) – situated in the sella
turcica of the ethmoid bone and is connected to the
hypothalamus by the hypophyseal stalk.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
25
Central Nervous System
Brain Stem
Midbrain
Contains the cerebral aqueduct or aqueduct of Sylvius.
Location of periaqueductal gray, which, when stimulated,
may abolish pain. Cranial nerve nuclei III (oculomotor) and
IV (trochlear) located here
Pons
Cardiac acceleration and vasocontriction centers pneumotaxic center helps control respiration pattern and rate.
- Four cranial nerves originate from the pons: V (trigeminal),
VI (abducens), VII (facial), and VIII (acoustic)
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
26
Central Nervous System
Brain Stem
Medulla
Cardiac-slowing center - Respiratory center Cranial nerves IX (glossopharyngeal),
X (vagus),
XII (spinal accessory), and
XII (hypoglossal) and
portions of VII (facial) and
VIII (acoustic) emerge from the medulla
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
27
Table 43-3,
Page 995
Central Nervous System
Diencephalon Functions
Hypothalamus
Regulates water metabolism, appetite, sleep-wake cycle,
temperature control, and thirst
Hormonal activity
Posterior pituitary hormones such as vasopressin and oxytocin
Anterior pituitary hormone excretion
Growth, thyrotropin, and follicle stimulating hormones, prolactin, and
corticotropin
Emotions and drives basic to self-preservation
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
28
Central Nervous System
Diencephalon Functions
Thalamus
All sensation except smell
Sensation perceived at the thalamic level is crude and cannot be
localized or quantified
Epithalamus
By young adulthood often calcified and is radiopaque. Used as point of
reference on an x-ray or a CT scan
Subthalamus
Contains sensory tracts. Connections to basal ganglia
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
29
Central Nervous System
Cerebellum
The Cerebellum receives instantaneous and continuous
information about the condition of muscles, joints, and
tendons.
Cerebellar function enables a person to:
1.
2.
3.
4.
5.
Keep a moving part from overshooting intended destination
Move in an orderly sequence
Predict distance, gauge speed of approaching object
Control voluntary movement
Maintain equilibrium
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
30
Cerebral Circulation
Blood Distribution To The Brain
Cerebrospinal Fluid
Spinal Cord
Blood Distribution
Cerebral Circulation
Cerebral circulation originates from carotid and vertebral
arteries.
Anterior, middle, and posterior cerebral arteries are joined together
by communicating arteries which for the circle of Willis.
Venous drainage occurs through cerebral veins into dural
sinuses.
Cerebral veins have no valves therefore intracranial
pressure can be affected by central venous pressure.
Two sinuses are of particular importance: superior saggital
sinus and cavernous sinus.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
32
Blood Distribution
Internal Carotid Artery Distribution
Hypophyseal
Posterior pituitary.
Ophthalmic
Eye, frontal scalp, frontal and ethmoid sinuses.
Anterior chorioidal
Choroid plexus (lateral), optic tract, uncus, amygdaloid
body, hippocampus, globus pallidus, lateral geniculate
nucleus, Internal capsule.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
33
Blood Distribution
Internal Carotid Artery Distribution
Letinculostriate
Putamen, caudate nucleus, globus pallidus, internal
capsule, corona radiata.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
34
Internal Carotid Artery Distribution
Basilar Artery Branches
Anterior inferior cerebellar
Cortex and inferior surface cerebellum, cerebellar nuclei,
upper medulla, lower pons.
Internal auditory – Inner ear
Pontine – Pons
Superior cerebellar
Cortex, white matter and nuclei of cerebellum, pons,
superior cerebellar peduncle, inferior peduncle, inferior
colliculus.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
35
Internal Carotid Artery Distribution
Vertebral Artery Branches
Posterior cerebellar
Medulla. Posterior cerebellum, inferior vermis,
cerebellar nuclei, choroid plexus (fourth ventricle),
posterolateral medulla.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
36
Cerebrospinal Fluid Circulation
CSF surrounds and cushions the brain and spinal
cord.
While circulating through the subarachnoid space,
the fluid is continuously reabsorbed by the
arachnoid villi and then channeled into the
superior sagittal sinus.
The spinothalamic tracts begin in the spinal cord
and end primarily in the thalamus.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
37
Spinal Cord
Function
Controls body movement; regulates visceral function;
processes sensory information, and transmits information to
and from the brain.
It contains gray matter (neuron cell bodies) that is Hshaped and surrounded by white matter (myelinated
axions).
White matter is divide into posterior, lateral, and anterior
columns.
Gray matter divisions are posterior, intermediolateral, and
anterior.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
38
Spinal Cord
Components
Ascending tracts generally begin in the spinal cord and end
in the brain.
groups of cells in white matter
Three ascending tracts are important for understanding neurologic
problems: spinothalamic, spinocerebellar and fasciculi gracilis and
cuneatus (posterior white columns).
The spinothalamic tracts - begin in the spinal cord and end
primarily in the thalamus.
The posterior and anterior spinocerebellar tracts - begin
in the spinal cord and end in the cerebellum.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
39
Spinal Cord
Transmissions
Posterior white columns transmit to the thalamus:
The sensation of proprioception from muscles, joints, and
tendons.
1. Vibratory sense.
2. Light touch from the skin.
3. Discrete localization.
4. Two-point discrimination.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
40
Spinal Cord
Descending tracts
Begin in the brain and end in the spinal cord.
Pyramidal tract (lateral corticospinal) – of major
importance in understanding neurological problems.
Originates in the motor cortex of the frontal lobe and
portions of the parietal lobe.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
41
Spinal Cord
Circulation
Spinal cord circulation – comes from three main arteries:
1. Anterior spinal artery which originates from a branch
of the vertebral arteries.
2. The two posterior spinal arteries originate from either
the vertebral or posterior inferior cerebellar artery.
Additional circulation is supplied by branches of the
descending aorta.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
42
Peripheral Nervous System
The peripheral nervous system is composed of
the spinal nerves, the twelve cranial nerves,
and the autonomic nervous system (ANS).
Peripheral Nervous System
Spinal Nerves
There are 31 pairs exiting from the spinal cord.
(8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1
coccygeal)
Each spinal nerve is responsible for the muscle
innervation and sensory reception of a given area
of the body.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
44
Peripheral Nervous System
Sensory Receptors
Monitor and Transmit
as well as
impulses of pain,
temperature,
touch,
vibration,
pressure,
visceral sensation, and
proprioception,
sensations of vision,
taste,
smell, and
hearing.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
45
Peripheral Nervous System
Lower Motor Neurons and Plexuses
Each motor neuron that leaves the spinal cord joins other
nerves to form plexuses.
Plexuses continue as trunks, cords, divisions and finally
branch into individual peripheral nerves.
The major plexuses are: cervical, brachial, lumbar and
sacral. Here are major concentrations of nerves.
The nerves of each plexus pass through or are surrounded
by bone.
Injury to the area or entrapment of a nerve can cause multiple
problems.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
46
Peripheral Nervous System
Reflexes
Reflexes consist of sensory input from:
The muscles, tendons, skin, organs, and special senses.
Small cells in the spinal cord lying between the posterior
and anterior gray matter (interneurons).
Anterior motor neurons, along with the muscles they
innervate.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
47
Peripheral Nervous System
12 Cranial Nerves
I. Olfactory
VII. Facial
II. Optic
VIII. Vestibulocochlear
III. Oculomotor
IX. Glossopharyngeal
IV. Trochlear
X. Vagus
V. Trigeminal
XI. Spinal accessory
VI. Abducens
XII. Hypoglossal
The type, origin and function of the cranial nerves are
will be explained in the next few slides.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
48
Cranial Nerves
I: Olfactory
Assessment
With the client’s eyes closed, the nurse tests one of the client’s nostrils
at a time; the client occludes the other with a finger.
The nurse asks the client to identify familiar odors, such as coffee,
tobacco, mint, or soap.
Alcohol sponges and ammonia are not used because they stimulate the
trigeminal nerve rather than the olfactory nerve.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
49
Cranial Nerves
II: Optic
Assessment
Each eye is tested individually, with the other eye covered but open.
The nurse tests central vision, or visual acuity, using the Snellen chart.
Clients are tested with and without glasses. Visual fields or peripheral
vision are assessed by asking the client to focus on the nurse’s nose.
The nurse wiggles one finger of each hand in the superior field, asking
the client where the movement is. The client should see movement on
both sides.
This is then repeated with the inferior field.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
50
Cranial Nerves
III: Oculomotor
Assessment
Pupil constriction is tested with the room darkened. The nurse brings
the penlight in from the side or from above or below the client’s head
and shines the light in the client’s eye. The pupil should constrict and
stay constricted. This is direct response. The response in the other eye
is consensual and is less than the eye being tested. Pupils should be
equal, round, regular, and react to light and accommodation.
(PERRLA).
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
51
Cranial Nerves
IV: Trochlear
Assessment
Eye movement (inferior and medial) is tested with assessment of cranial
nerve VI.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
52
Cranial Nerves
V: Trigeminal
Assessment
The nurse tests all three branches of the trigeminal nerve:
ophthalmic branch – forehead
maxillary branch – cheek
mandibular branch – jaw.
Using an object that has sharp and blunt aspects (a safety pin), the nurse
asks the client to indicate whether the sensation is sharp or dull and then
repeats the process. The motor aspect can be tested with the eyes open.
The nurse palpates the jaw muscles for strength and equality.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
53
Cranial Nerves
VII: Facial
Assessment
Only the motor portion of the facial nerve is tested.
Taste on the anterior portion of the tongue is tested with cranial nerve
IX.
The nurse asks the client to frown, smile puff out cheeks looking for
symmetry.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
54
Cranial Nerves
VIII: Vestibulocochlear (Acoustic)
Assessment
Hearing is tested initially with the client’s eyes closed. The nurse rubs
a thumb and finger together next to the client’s ear and asks where
sound is heard. The nurse then repeats this maneuver for the other ear.
The nurse may use the Weber and Rinne tests (with the client’s eyes
open) to check for conductive or sensorineural hearing loss.
Conductive hearing loss is caused by external-ear and middle-ear
problems, such as excessive cerumen , presence of pus, ossicle fusion,
or a damaged eardrum. Sensorineural hearing loss is due to cochlear
or nerve damage.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
55
Cranial Nerves
IX: Glossopharyngeal
Assessment
The motor portion is tested with cranial nerve X assessment. Taste is
often not tested unless the client reports loss of taste.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
56
Cranial Nerves
X: Vagus
Assessment
To test the motor portion, the nurse asks the client to say “Ah” when
looking into the throat. The uvula and palate should rise bilaterally and
equally.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
57
Cranial Nerves
XI: Spinal Accessory
Assessment
The nurse assesses the strength of the client’s sternocleidomastoid and
trapezius muscles by having the client turn the head against resistance.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
58
Cranial Nerves
XII: Hypoglossal
Assessment
The nurse tests motor innervation to the tongue by asking the client to
stick out the tongue. The nurse checks for deviation to one side or the
other. The tongue deviates toward the same side where the lesion has
occurred in the brain.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
59
Autonomic Nervous System
The Autonomic Nervous System is
composed of two parts:
Sympathetic Nervous System, and
Parasympathetic Nervous System.
Autonomic Nervous System
Sympathetic vs. Parasympathetic
Sympathetic
If almost any portion of the sympathetic nervous system is
stimulated, the whole system responds (the fight or flight
response).
During periods of excessive sympathetic stimulation:
– Skeletal muscle vessels dilate
– The heart pumps faster
– The liver releases extra glucose
– The thyroid is stimulated
– Sweating increases
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
61
Autonomic Nervous System
Sympathetic vs. Parasympathetic
Parasympathetic
The PAS nervous system conserves the body’s resources.
Parasympathetic fibers to the viscera have some sensory
ability in addition to motor function.
Sensations of irritation, stretching of an organ, or decrease in
tissue oxygen are transmitted to the thalamus through
pathways not yet fully understood.
Table 43-7 page 1003-1004 compares the action of
sympathetic and parasympathetic systems in the body.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
62
Neurological Changes
Associated with Aging
Motor / Sensory Ability
Mental Status
Diagnostic Assessment
Aging
Motor / Sensory Ability
Sensory changes in older people can affect their daily
activities.
Pupils decrease in size and adapt more slowly.
Touch sensation decreases.
Vibration sense may be lost in ankles and feet.
Hearing also decreases.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
64
Aging
Mental Status
Memory is one of the most important criteria for
neurologic assessment. Loss of memory (esp. recent) tends
to be an early sign of neurologic problems.
Anxiety, insomnia, and depression may cause change in
mental status.
Circadian rhythm disorders may alter normal sleep
patterns.
Long term memory seems better than recall or immediate
memory.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
65
Assessment of Mental Status
Personal And Family
History
Level of
Consciousness
Demographic Data
Lethargic
Past Medical History
Stuporous
Current History
Current symptoms
Social History
Comatose
The client is also asked questions
to indicate orientation to person,
place, and time.
Activities
Habits
Other
Appropriateness
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
66
Assessment of Mental Status
Abnormal Posturing
Decortication
is abnormal posturing seen in the client with lesions that interrupt the
corticospinal pathways.
The client’s arms, wrists, and fingers are flexed with internal rotation
and plantar flexion of the legs.
Decerebration
is abnormal posturing and rigidity characterized by extension of the
client’s arms and legs, pronation of the arms, plantar flexion, and
opisthotonos.
It is usually associated with dysfunction in the brain stem area.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
67
Assessment of Mental Status
Glasgow Coma Scale*
Eye Opening
Spontaneous
To sound
To pain
Never
Verbal Responses
4
3
2
1
Motor Responses
Obeys commands
Localizes pain
Normal flexion
Abnormal flexion
Extension
Nil
4/22/2003 version
6
5
4
3
2
1
Oriented
Confused Conversation
Inappropriate words
Incomprehensible Sounds
None
5
4
3
2
1
* The highest score is 15.
Copyright - Mary Roche, RN, MSN, CS
68
Assessment of Mental Status
Diagnostic Assessment
X-rays of the Skull and Spine
x-rays are used to determine bony fractures, curvatures, bone erosion,
done dislocation, and possible calcification of soft tissue.
Cerebral Angiography
illuminates the cerebral circulation. Contrast medium is injected into an
artery, and x-rays are taken as the medium flows with the blood.
Digital Subtraction Angiography
(DSA) is used to evaluate the carotid and other cerebral arteries.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
69
Assessment of Mental Status
Diagnostic Assessment
Myelography
Myelography enables the vertebral column, intervertebral disks, spinal
nerve roots, and blood vessels to be visualized. A contrast medium is
inserted into the subarachnoid space of the spine. A lumbar puncture is
the usual insertion site.
Contrast Media Method
A contrast medium is injected and x-rays are taken. Follow-up care
requires vital and neuro signs, bed rest for 6 hours, extremity used is
checked for adequate circulation demonstrated by skin color and
temperature, pulses distal to the injection site and capillary refill.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
70
Assessment of Mental Status
Diagnostic Assessment
Computerized Tomography - With the aid of a computer,
pictures are taken at many horizontal slices of the brain or spinal cord.
The nurse must ascertain if the client is allergic to iodine. The client
must be completely still for the procedure which takes 10 minutes or
less.
Positron Emission Tomography / Single Photon Emission Computed
Tomography. PET scanning provides information about the function of
the brain.
Lumbar Puncture - (spinal tap) is the insertion of a needle into
the subarachnoid space between the third and fourth lumbar vertebrae.
Used to obtain pressure readings, obtain CSF, inject medium, inject
medication, reduce increased ICP.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
71
Spinal Cord Injury
Manifestations / Classifications/
Symptoms
Nursing Assessment
Nursing Diagnoses
Spinal Cord Injury
Manifestations / Classifications
SCI often result in loss of
• motor function
• sensation
• reflex activity, and
• bowel and bladder control
The client may experience significant behavior and
emotional problems as a result of changes in body image,
role performance, and self-concept.
SCI are classified as complete or incomplete.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
73
Spinal Cord Injury
Symptoms
Specific syndromes seen after SCI and damage to the ANS are spinal
shock and autonomic dysreflexia.
Spinal Shock
occurs immediately after injury and is characterized by flaccid paralysis,
loss of reflex activity below the level of the lesion, bradycardia,
hypotension and occasionally paralytic ileus.
Autonomic Dysreflexia
is usually seen in injuries above the level of the sixth thoracic vertebra.
It generally occurs after the period of spinal shock is completed. Key
features are: severe, rapidly occurring HTN, bradycardia, flushing
above level of lesion, severe, throbbing headache, nasal stuffiness,
sweating, nausea, blurred vision.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
74
Spinal Cord Injury
Nursing Assessment
Respiratory Status
Assess the client’s respiratory status; monitor for atelectasis,
pneumonia, and pulmonary embolus.
Vital Signs
Take vital signs q1h or more often if clinically indicated; monitor for
orthostatic hypotension.
Neurologic Status
Perform neurologic status checks q1h or more often if clinically
indicated. Notify physician immediately of a deterioration of motor
status. Watch for and immediately treat autonomic dysreflexia.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
75
Spinal Cord Injury
Nursing Assessment
Assess Bladder
Function
Palpate for distention.
Begin retraining as appropriate.
Assess intake and output.
Assess Bowel
Function
Auscultate bowel sounds.
Palpate for distention.
Chart stool frequency.
Begin a bowel program as
appropriate.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
76
Spinal Cord Injury
Nursing Assessment
Medical
Give pain medication as ordered;
Document the client’s response.
Prevent immobility complications.
Have the client TCDB q2h.
Use pneumatic boots or compression stockings.
Check skin for breakdown.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
77
Spinal Cord Injury
Nursing Assessment
Monitor Nutritional Status
including a calorie count, and collaborate with dietitian to identify an
appropriate diet.
Assess Psychological Status
Communicate with the client.
Answer questions honestly; refer questions you can’t answer to
someone who can.
Assess for signs of depression or anger.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
78
Emergency Care
Autonomic Dysreflexia
Positioning
Raise the head of the bed to a high Fowler position.
Loosen tight clothing on the client.
Physical Care
Monitor blood pressures every 10-15 minutes
Check the Foley catheter tubing (if present) for kinks or obstruction.
If a Foley is not present, check for bladder distention and catheterize
immediately.
Check the client for fecal impaction; if present, disimpact immediately
using anesthetic ointment.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
79
Emergency Care
Autonomic Dysreflexia
Notification
Call the physician and notify him or her of the emergency.
Environment
Check the room temperature to ensure that it is not too cool or drafty.
Medication
Give nitrates or Hydralazine (Apresoline, Novo-Hylazin) as ordered.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
80
Spinal Cord Injury
Common Cord Syndromes
Complete Lesion
total loss of motor sensory, and reflex activity.
Anterior Cord Syndrome
Loss of motor function with preservation of position, vibration, and
touch senses.
Brown-Sequard Syndrome
Loss of pain, temperature, and light touch on opposite side. Loss of
motor function and vibration, position, and deep touch sensation on
same side as the cord damage.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
81
Spinal Cord Injury
Common Cord Syndromes
Central Cord Syndrome
Loss of motor function and incomplete loss of motor function.
Conus Medullaris and Cauda Equina Syndromes
Loss of motor and/or sensory function in various patterns, with
potential for recovery of function with regeneration of peripheral
nerves; neurogenic bowel and bladder.
Please see text Figure 5-5 for the above common cord syndromes
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
82
Spinal Cord Injury
Assessment
Respiratory Pattern
Initial assessment is respiratory
pattern to assure adequate
airway.
Muskuloskeletal
Psychosocial
Laboratory
Diagnostic
Sensation
Motor Ability
Cardiovascular
GI/GU
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
83
Spinal Cord Injury
Assessment Of Motor Function
C-5 apply downward pressure while the client shrugs his shoulders
upward.
C5-6 apply resistance while the client pulls up his arms.
C7
apply resistance while the client straightens his flexed arms.
C-8 make sure that the client is able to grasp an object and form a fist.
L2
apply resistance while the client lifts his legs from the bed.
L5
apply resistance while the client dorsiflexes his or her feet.
S1
apply resistance while the client plantar flexes his feet.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
84
Spinal Cord Injury
Nonsurgical Management
Vital Signs and Neuro Signs
Nurse assesses vital signs and neuro signs every hour. In the first 2hours after injury the client is at risk for neurogenic shock which is
manifested by bradycardia and hypotension (most often associated
with cervical spine injuries).
Fixed Skeletal Traction
The client with a cervical spine injury is usually placed in fixed
skeletal traction to realign the vertebrae, facilitate bone healing and
prevent further injury.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
85
Spinal Cord Injury
Nonsurgical Management
Immobilization – Cervical Injuries
Most commonly used is the halo fixator and cervical tongs. Halo
fixator is a static traction device.
Immobilization – thoracic and lumbar/sacral injuries. Bed rest,
immobilization with a body cast.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
86
(See page 1070 in
text for illustration
of these devices).
Spinal Cord Injury
Use Of A Halo Device
1. Be aware that the weight of the halo device alters balance. Be
careful when leaning forward or backward.
2. Wear loose clothing preferably with Velcro fasteners.
3. Bath in the tub or sponge bathe.
4. Wash under lamb’s wool liner to prevent rash; use powders or
lotions sparingly under vest.
5. Have someone change liner if it becomes odorous.
6. Support head with small pillow when sleeping.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
87
(See page 1070 in
text for illustration
of these devices).
Use Of A Halo Device
1. Try to resume activities to the extent possible. Avoid contact
sports, swimming.
2. Do not drive, vision is impaired with the device.
3. Use straws to drink fluids.
4. Cut food into small pieces to facilitate chewing and swallowing.
5. Have someone clean pin sites according to hospital protocol.
6. Observe pin sites daily for drainage or redness.
7. Increase fluid and fiber in the diet to prevent constipation.
8. Use a position of comfort during sexual activity.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
88
Spinal Cord Injury
Drug Therapy
Solu-Medrol
in high dosages within first 8 hours of injury is the first course of
treatment. Clients receiving this medication show significant
improvement in motor and sensory function.
Dextran
a plasma expander, may be used to increase capillary blood flow within
the spinal cord and to prevent or treat hypotension.
Atropine sulfate
is used to treat bradycardia.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
89
Spinal Cord Injury
Drug Therapy
Dopamine and Isoproterenol
used to treat severe hypotension.
Dantrium [Bacolfan]
may be used to treat spasticity.
Didronel
may be ordered for patient with heterotopic ossification.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
90
Spinal Cord Injury
Surgical Management
Emergency Surgery
Emergency surgery may be indicated if there is evidence of spinal
cord compression. It may be necessary to remove bone fragments
from a vertebral fracture, evacuate a hematoma, or remove penetrating
objects.
Compressive laminectomy allows for cord expansion from edema.
Additional typical procedures include: Harrington rods to stabilize
thoracic spinal injuries.
Postop the client usually wears a brace or TLSO to keep operative
area immobile.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
91
Spinal Cord Injury
Surgical Management
Postop Care
The nurse assesses the client’s neurological status and vital signs at
least every hour. Complications of surgery, such as hematoma and
edema, are manifested by a deterioration in neurologic status.
The client is at risk for cardiovascular instability because of the loss of
sympathetic innervation. Logrolling is used when moving the patient.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
92
Some Nursing Diagnoses
Associated With Spinal Cord Injury
Ineffective Airway Clearance;
Ineffective Breathing Pattern;
Impaired Gas Exchange
Expectations
The client is expected to maintain a patent airway and not experience
respiratory complications, such as pneumonia, atelectasis, and
aspiration.
Interventions
Turn the client every 2 hours.
Instruct the client to breathe as deeply as possible.
Assist cough.
Use incentive spirometer.
Possible use of suction.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
94
Impaired Physical Mobility;
Self-Care Deficit
Expectations
The client is expected to be free from complications of immobility and
learn to perform activities of daily living as independently as possible.
Interventions
The client with an SCI is especially at risk for pressure ulcers,
contractures, and deep venous thrombosis or pulmonary emboli.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
95
Impaired Physical Mobility;
Self-Care Deficit
Preventing Complications of Immobility
Reposition or teach client to reposition every 2 hours. Use of special
pressure relief pads. ROM exercises at least once every 8 hours. The
nurse collaborates with PT and OT to determine the most appropriate
positioning and exercise techniques, to assess need for hand splints, to
develop plan for foot drop.
Compression stockings or boots are used. Coumadin is used to
prevent DVT.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
96
Impaired Physical Mobility;
Self-Care Deficit
Preventing Orthostatic Hypotension
Clients with cervical cord injuries are especially at high risk for
orthostatic (postural) hypotension. If the client moves from a lying to
a sitting or a standing position quickly, he may experience
hypotension which could result in dizziness and falls because of
autonomic innervation in which blood vessels do not respond quickly
enough to push blood up to the brain. To help prevent this, the nurse
instructs the client to move slowly. Thigh high embolism stockings
also help.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
97
Impaired Physical Mobility;
Self-Care Deficit
Promoting Self-Care
The most important thing is to set realistic goals. The nurse
collaborates with PT and OT to do this and maximize self-care.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
98
Altered Urinary Elimination;
Constipation
Expectations
The client is expected to achieve continence of stool and urine.
Interventions
Clients with SCIs have reflex or neurogenic loss of bowel and bladder
control. Many clients can become continent if they rigorously adhere
to an established program.
The type program depends on whether the injury involves upper motor
neurons or lower motor neurons.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
99
Altered Urinary Elimination;
Constipation
Establishing a Bladder Retraining Program Catheterization
Client typically is catheterized every 3 hours and more frequently if
output is greater than 500 cc. Over time intervals between
catheterizations are increased and adjusted to intake and sleep times.
Other techniques may be used. Urecholine may be prescribed. To
ascertain effectiveness of these maneuvers, the nurse catheterizes the
client for residual urine after voiding.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
100
Altered Urinary Elimination;
Constipation
Establishing a Bowel Retraining Program
The essential elements of a bowel program are:
• A consistent time for bowel elimination.
• A high fluid intake (at least 2000 cc a day).
• A high fiber diet.
• Rectal stimulation with or without suppositories.
• If needed, a stool softener.
If the client has sustained an LMN injury, the resulting flaccid large bowel
may require the client to perform or to have manual disimpaction.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
101
The Mitrofanoff Procedure
Creates a catheterizable channel between a stoma on the skin
of the abdomen (usually the umbilicus) and the bladder
Allows patients to intermittently empty their bladder by
inserting a disposable catheter into the channel.
Also called an appendicovesicostomy because the appendix
is used to create the channel.
First described in 1980, has become the most widely used
alternative to urethral self-catheterization in the world.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
102
The Mitrofanoff Procedure
It is highly successful with continence achieved in more than
90% of patients.
Is used for patients who have:
a neurogenic bladder or other conditions that interfere with
continence and
who are unable to easily self-catheterize through the
urethra.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
103
The Mitrofanoff Procedure
Typically, this procedure is performed in pediatric specialty
institutions or major medical centers.
Understanding this procedure is important if you work in
med-surg, long-term care, school, or rehab setting.
For most patients, the primary reason to undergo the
Mitrofanoff procedure is physiological – to maintain a healthy
urinary tract and establish urinary continence through
intermittent catheterization via an easily accessible stoma.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
104
The Mitrofanoff Procedure
For patients with spinal cord injuries, the procedure can help
stem the continued potential for deterioration of renal
function.
For others, there is improved quality of life.
It is essential to make sure that the patient has the physical
ability, mental capacity, self-discipline, and psychological
readiness to perform the self-catheterizations.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
105
Screening Candidates
The majority of patients who undergo a Mitrofanoff
procedure will require a rigid schedule of self-catheterization
– typically once every four hours while awake – to achieve
dryness and prevent the complications of continued
incontinence.
There is extensive bowel prep, antibiotic therapy and
laboratory work preop.
Cystourethrogram and renal ultrasound are needed to assess
the patient for any structural abnormalities of the urinary
tract.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
106
Using The Appendix
to Create a Channel
During the procedure, a channel from the bladder to the
abdomen is created to achieve entrance to the bladder.
Because the appendix has a constant, reliable blood supply,
supple muscular wall, and adequate lumen, it has proven to be
the ideal tissue with which to create the channel.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
107
Using The Appendix
to Create a Channel
After the mucosa to mucosa anastomy a flap valve is created
to prevent reflux and leakage of urine.
The stoma is then created and concealed in the umbilicus.
Postoperatively, patients generally have a 12F cath placed
through their appendicovesicostomy.
While undergoing surgery some patients may undergo bladder
augmentation with segment of stomach or intestine.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
108
Using The Appendix
to Create a Channel
The catheter remains in place about three weeks and the
patient goes home with them.
After then, the stoma is healed and functional.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
109
Post Op And Followup
Patients are sent home with the appendicovesicostomy and
urethral catheters in place, though the appendicovesicostomy
catheter is clamped.
Approximately three weeks postop, the patient returns to the
hospital.
Both catheters are removed and the patient is taught how to
perform self-cath through the appendicovesicostomy.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
110
Post Op And Followup
Patient must be explained that since the catheter is entering
the bladder from above, emptying is like siphoning liquid
from a gas tank.
The container must be lower than the bladder, and when
urine begins to flow, the catheter should be pushed in
another one to one-and-one-half inches to insure adequate
bladder drainage.
Patients should be taught to use sterile technique and report
any signs of infection.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
111
Post Op And Followup
Patients must use the conduit regularly to ensure patency.
To date, minimal complications have been reported.
Stomal stenosis must be watched for and 7% to 24% of
patients experience this.
Stomal stenosis can occur if the appencovesicostomy is
not dilated frequently enough.
Repeated self dilation by intermittent self-catheterization
can usually remedy this problem.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
112
Post Op And Followup
Stone formation in the bladder or kidney can be a long-term
complication.
The longer a channel is in place, the greater the chance for
stone formation.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
113
Impaired Adjustment
Expectations
The client is expected to demonstrate the ability to cope with the
changes caused by the injury and verbalize his or her feelings about
the injury and changes in lifestyle.
Interventions:
The nurse encourages the client to discuss his perception of the
situation and what coping skills can be used. Referrals to clergy,
rabbis, or other spiritual leaders or a psychologist are offered. Support
groups are available to family and friends. Social workers can help
with insurance status and appropriate social service agencies as
necessary.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
114
Spinal Cord Injury
Home Care Management
If the client is discharged home or returns home for a weekend visit
from the rehab setting, the environment must be assessed to ensure
that it is free from hazards and can accommodate the client’s special
needs.
OT or PT works in collaboration with rehab in the home setting.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
115
Spinal Cord Injury
Health Teaching
The teaching plan for the client with an SCI includes:
Physical mobility and activity skills
ADL skills
Bowel and bladder retraining program
Skin care
Medication regimen
Sexuality education
The information should be reinforced with handouts.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
116
Spinal Cord Injury
Health Teaching
Learning mobility skills is important so that the client can negotiate
movement on sidewalks and carpeting and other flooring surfaces.
The client must also be able to negotiate sidewalk curbs while walking
independently with crutches, cane, or in a wheelchair.
Some clients are discharged to home with a halo vest that has a significant
physical and psychological impact on clients. Clients find it difficult to
perform mobility skills and ADLs independently.
ADL training includes a structured exercise program to promote strength and
endurance.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
117
Spinal Cord Injury
Psychosocial Preparation
Nurse teaches name and purpose of medication and side effects. Client
should understand possible interaction of prescribed medication with
OTC and illegal drugs and alcohol.
Psychosocial adaptation is one of the critical factors in determining
the success of rehab. The nurse should prepare the client for reactions
of others outside the rehab. For example, the client can practice
answering questions about why he is in a wheelchair.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
118
Spinal Cord Injury
Health Care Resources
The nurse or case manager refers the client to appropriate
organizations.
There is a National Spinal Cord Injury Association and hotline.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
119
Spinal Cord Tumors
Key Features
Manifestations
Spinal Cord Tumors
Key Features
Occur most frequently in the thoracic area. Venous occlusion by the
tumor may lead to spinal cord congestion and infarction.
The appearance of neurologic signs and symptoms is related to the
rate of tumor growth. The spinal cord can often accommodate a slow
growing tumor. On the other hand, a fast growing tumor quickly leads
to spinal cord compression.
Anatomically, spinal cord tumors may be extramedullary or
intramedullary, i.e. originate within or out of the spinal cord.
Spinal cord tumors account for about 1% of all tumors in adults.
The majority of tumors are benign.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
121
Spinal Cord Tumors
General Symptoms
Pain
Quadriparesis
Sensory loss or impairment
Stiff neck
Motor loss or impairment
Nystagmus
Sphincter disturbance (bladder
before bowel)
Cranial nerve dysfunction
Cervical
Pain in the arms and shoulders
High cervical
Respiratory distress
Diaphragm paralysis
Occipital headache
4/22/2003 version
Low cervical
Weakness
Paresthesia
Motor loss
Horner's syndrome
Copyright - Mary Roche, RN, MSN, CS
122
Spinal Cord Tumors
Specific
Thoracic
Lumbosacral
Sensory loss
Low back pain
Spastic paralysis
Paresis
Positive Babinski’s sign
Spastic paralysis
Bladder and bowel dysfunction
Sensory loss
Pain in the chest and the back
Bladder and bowel dysfunction
Muscle atrophy
Sexual dysfunction
Muscle weakness in the legs
Decreased-to-absent ankle and
knee reflexes
Foot drop
See Table
1,
4/22/2003
version
123
p. 1077 in
text for- Mary
Location
andMSN,
Treatment
of Spinal Cord Tumors
Copyright
Roche, RN,
CS
Spinal Cord Tumors
Assessment/Clinical Manifestations
Clinical manifestations depend on the location of the tumor and its
rate of growth.
The nurse assesses for weakness, clumsiness, spasticity, and
hyperactive reflexes and compares the responses on both sides of the
body.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
124
Problems Of The
Peripheral Nervous System
Peripheral Nervous System
Guillain-Barre Syndrome (GBS)
is an acute inflammatory process characterized by varying degrees of
motor weakness and pathology.
In GBS the immune system starts to destroy the myelin sheath that
surrounds the axons.
Etiology
cell mediated immunologic reaction.
Lab Assessment
No single finding confirms diagnosis. Physician does a lumbar
puncture to evaluate CSF. Peripheral blood tests may show
leukocytosis early in the illness. ESR is typically WNL.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
126
Peripheral Nervous System
Myasthenia Gravis (MG)
Myasthenia Gravis means ‘grave muscle weakness’ or weakness of the
voluntary or striated muscles.
May take many forms, from mild ocular muscle disturbance to severe
weakness leading to death from respiratory failure.
Clients with MG develop specific antibodies to one or more ACh
receptor sites, possibly because of autoimmune injury.
Etiology
Research suggests that MG is caused by antibodies to ACh receptors.
Evidence also suggests a relationship between MG and hyperplasia of
the thymus gland.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
127
Myasthenia Gravis (MG)
Assessment
Subjective complaints are noted. Inquiry re: eye problems, ability with
performing ADLs, respiratory difficulty, presence of paresthesia or
aching, weakened muscles.
Any history of thymus gland tumor is elicited.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
128
Myasthenia Gravis
Clinical Manifestations
Progressive paresis, ocular palsies, ptosis, diplopia, weak or
incomplete eye closure.Diagnostic assessment - Response to
cholinergic drugs. Thyroid function should be tested. Assessment for
thyoma by CT.
Tensilon testing - This test can be used to evaluate myasthenic crisis
(under medication with cholinesterase inhibitors).
EMG – electrical testing to detect defective neuromuscular
transmission.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
129
Myasthenia Gravis
Interventions
Assistance with activities.
Active or passive ROM. Turn
q. 2 h.
Self-care.
Drug therapy: Three groups of
drugs used –
anticholinesterases
(Prostigmin), Corticosteroids
(Prednisone),
immunosuppressants
(Imuran).
Assistance with
communication.
Plasmapheresis is a method by
which offending autoantibodies
are removed from the plasma.
Lifestyle changes.
4/22/2003
version
Respiratory
Nutritional support.
Eye protection.
Surgical management
(thymectomy) .
Copyright - Mary Roche, RN, MSN, CS
support.
130
Myasthenia Gravis
Crisis
Sudden increases in weakness and the inability to clear secretions,
swallow, or breathe adequately indicate that the client is experiencing
crisis. There are two types of crisis:
Myasthenic crisis
an exacerbation of the myasthenic symptoms caused by under
medication with anticholinesterase drugs. Myasthenic crisis is often
preceded by some type of infection.
Cholinergic crisis
an acute exacerbation of muscle weakness caused by overmedication
with cholinergic (anticholinesterase) drugs.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
131
Characteristics of Crises
Increased pulse and
respiration.
Rise in blood
pressure. Anoxia.
Cyanosis.
Bowel and bladder
incontinence.
Nausea, vomiting,
diarrhea.
Restlessness.
Abdominal
cramps.
Dysphagia.
Blurred vision.
Pallor.
Decreased urinary
output.
Facial muscle
twitching.
Absence of cough
and swallow reflex.
Pupillary miosis.
4/22/2003 version
Hypotension.App
rehension.
Copyright
- Mary Roche, RN, MSN, CS
Dyspnea.
Dysarthria.
Increased lacrimation.
Increased salivation.
Diaphoresis.
Generalized weakness.
132
Myasthenia Gravis
Treatment
In either crisis, an adequate airway and artificial respiration must be
maintained.
Because both have many common characteristics, the type of crisis the
client is experiencing must be identified for effective treatment to be
provided.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
133
Myasthenia Gravis
Improving Nutrition In Clients
Assess the client’s gag reflex and
ability to chew and swallow.
Provide frequent oral hygiene as
needed.
Collaborate with the dietitian,
speech and language pathologist,
to plan and implement a meal the
client can enjoy.
Keep the head of the bed elevated
during meals and for 0 minutes
after.
Avoid liquids as they can easily
cause choking and aspiration.
Provide a soft diet.
Monitor food intake carefully.
Weigh the client daily.
Offer small, frequent meals.
Observe client for choking, nasal
regurgitation, and aspiration.
Provide high-calorie snacks or
supplements such as puddings
4/22/2003 version
Monitor serum transferring and
albumin levels.
Administer anticholinesterase
drugs, as ordered: 0-60 minutes
before each meal.
134
Copyright - Mary Roche, RN, MSN, CS
Peripheral Nervous System
Polyneuritis and Polyneuropathy
Manifestations
Systemic diseases, infections, trauma, vascular or metabolic
disturbances, alcohol, medications, heavy metals may damage cranial
and peripheral nerves.
Although the term polyneuritis implies an inflammatory process, it
may denote noninflammatory lesions as well.
Hallmarks
Terms polyneuritis, polyneuropathy, and peripheral neuropathy may
describe syndromes whose clinical hallmarks are muscle weakness
with or without atrophy, pains and paresthesia, impaired reflexes, or a
combination of these symptoms.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
135
Polyneuritis and Polyneuropathy
Assessment
Interventions:
Examination of sensory and motor
ability. Position sense, pain, signs
of injury of which the client may
be unaware. The nurse also
assesses the client for:
Orthostatic hypotension
Abnormal sweating
Miosis
Sphincter disturbances.
Removal of the underlying
cause.
Supplementation of diet.
Client teaching.
Other dysfunctions that may
accompany neuropathy.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
136
Peripheral Nervous System
Restless Leg Syndrome
The client complains of intense “crawling-type” sensations in the
limbs and subsequently feels the need to move the limbs repeatedly.
Diagnosis is made on history and there is no known etiology.
Management is symptomatic.
Antiembolism stockings may be helpful.
Some medications that may help include: Catapres, Tegretol,
Clonidine.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
137
Peripheral Nervous System
Trigeminal Neuralgia
Also called tic douloureux.
Entails a type of facial pain, which occurs in abrupt, intense
paroxysms. Usually provoked by minimal stimulation of a trigger
zone. Is unilateral and confined to the area innervated by the
trigeminal nerve, most often the second and third branches.
Usually in persons over 50.
Cause is thought to be related to impaired inhibitory mechanisms in
the brain stem.
Approximately 70% respond to carbamazepine (Tegretol).
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
138
Peripheral Nervous System
Facial Paralysis (Bell’s Palsy)
Onset is acute.
Cause remains obscure.
Management consists of prednisone and analgesics.
Nursing care is directed toward managing the major
neurologic deficits and providing psychosocial support.
80% of clients recover fully within a few months.
Approximately 20% have residual weakness; a few have
permanent neurologic deficits.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
139
Interventions For Critically Ill Clients
With Neurologic Problems
Some neurologic problems, such as cerebrovascular accident (CVA),
head injury, brain tumor, can cause increased intracranial pressure
(ICP), a life-threatening complication.
Through prompt recognition and aggressive management of this
complication, permanent neurologic dysfunction or death may be
prevented.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
140
Cerebrovascular Accident
– “stroke”, is a disruption in the normal blood supply to the brain. It
often occurs suddenly and produces focal neurologic deficits.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
141
Cerebrovascular Accident
Pathophysiology
Through the process of cerebral autoregulation, blood flow to the brain
is maintained at a fairly constant rate of 1000mL/min. In the event of a
CVA, ischemia occurs in the brain tissue supplied by the affected artery.
Ischemia leads to hypoxia or anoxia and hypoglycemia.
These processes then cause infarction or death of the neurons, the glia,
and the involved area of the brain. In addition, brain metabolism after
stroke is affected in the involved area as well as in the contralateral
hemisphere.
Small lacunar infarcts may also occur. Lacunae are small, deep cavities
within the brain that result from occlusion of a small vessel.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
142
Cerebrovascular Accident
Classifications
CVAs are generally classified as ischemic (occlusive) or hemorrhagic.
Ischemic strokes are further divided into thrombotic strokes and
embolic strokes.
Ischemic Stroke – caused by occlusion of a cerebral artery by either
a thrombus or an embolus.
Hemorrhagic Stroke - In this type of stroke, the integrity of the
vessel is interrupted. Hemorrhage into the brain tissue generally
results from a ruptured saccular (berry) aneurysm, rupture of an AV
malformation or, hypertension. A ruptured cerebral aneurysm is
another cause of hemorrhagic stroke.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
143
Transient Ischemic Attack
TIA and Reversible Ischemic Neurologic Deficit – RIND. Warning
signs or silent strokes.
Etiology – Strokes are caused by an occlusion in an artery from a
thrombus or an embolus; also from hypertension.
Risk factors include: smoking, substance abuse (particularly
cocaine), obesity, sedentary lifestyle, high stress levels, elevated
cholesterol, lipoprotein, triglycerides, previous CVA or TIA, heavy
alcohol use.
Sudden discontinuation of antihypertensive medications can cause
hemorrhagic stroke.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
144
Transient Ischemic Attack
African-Americans affected more frequently as a result of
high frequency of diabetes and HTN in this group.
Prevalence – Estimated million stroke survivors in U.S.
The number of strokes occurring in the younger
population is increasing as a result of IV drug abuse.
Those using crack cocaine experience increased incidence
of stroke due to changes in clotting mechanism caused by
the drugs or sudden increase in systolic BP.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
145
Key Features of
Transient Ischemic Attack
Visual Deficits
Blurred vision
Sensory Deficits
Diplopia
Transient numbness (face, arm,
or hand)
Blindness in one eye
Vertigo
Tunnel vision
Speech Deficits
Motor Deficits
Transient weakness (arm, hand,
or leg)
Aphasia
Dysarthria (slurred speech)
Gait disturbance
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
147
Monitoring for
Increased Intracranial Pressure
Client is at most risk for increased intracranial pressure (ICP) resulting
from edema during the first 72-hours after the onset of the stroke.
Nurse elevates the HOB to 0-5 degrees and maintains the client’s head
in a midline position.
Avoid clustering activities and nursing procedures.
Hyperoxygenate the client prior to suctioning.
Quiet environment in presence of headache.
Lights lowered for clients with photophobia.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
148
Key Features of
Increased Intracranial Pressure
Decreased LOC (lethargy to
coma).
Behavior changes; restless,
irritable, and confused.
Ataxia.
Headache.
Nausea and vomiting.
Change in speech pattern.
Aphasia.
Slurred speech.
Change in sensorimotor status.
4/22/2003 version
Pupillary changes; dilated and
nonreactive or constricted and
nonreactive pupils.Cranial nerve
dysfunction.
Seizures.
Cushing’s triad: increased BP,
widening of pulse rate and decreased
heart rate.
Abnormal posturing: Decerebrate
(latest stage) or decorticate (latest
stage).
Copyright - Mary Roche, RN, MSN, CS
149
Head Injury
Craniocerebral Trauma
commonly referred to as head trauma, is a traumatic insult to the brain
caused by an external physical force that may produce a diminished or
altered state of consciousness.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
150
Head Injury
Direct vs. Indirect Injury
Various terms are used to describe brain injuries that are produced
when a mechanical force is applied either directly or indirectly to the
brain.
A force produced by a blow to the head is a direct injury.
A force applied to another body part with a rebound effect to the brain
is an indirect injury.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
151
Head Injury
Shearing Injuries
The brain may also rebound or rotate on the brain stem, causing
diffuse axonal injury (shearing injuries).
This moving brain may be contused or lacerated as it moves over the
inner surfaces of the cranium, which is irregularly shaped and sharp.
Damage most frequently occurs to the frontal and temporal lobes of
the brain, especially the raised surfaces of the summits of the gyri.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
152
Primary Brain Injury
Results from the physical stress (force) within the brain tissue caused
by open or closed trauma.
Open Head Injury
occurs when there is a fracture of the skull or the skull is pierced. The
integrity of the brain and the dura is violated and there is exposure to
the outside. Damage may occur to underlying vessels, dural sinus,
brain, and the cranial nerves.
Closed head injury is the result of blunt trauma; the integrity of the
skull is not violated. It is the more serious of the two types of injury.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
153
Primary Brain Injury
Open Head Injury
Four types of fractures associated with open head injuries.
linear fracture - A linear fracture is a simple, clean break in which
the impacted area of bone bends inward, whereas the area around it
bends outward. Linear fractures account for about 80% of head
fractures.
depressed fracture - In a depressed fracture the bone is pressed
inward into the brain tissue to at least the thickness of the skull.
open fracture - In an open fracture, the scalp is lacerated, creating a
direct opening to the brain tissue.
comminuted fracture - involves fragmentation of the bone, with
depression of the bone into the brain tissue.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
154
Primary Brain Injury
Unique Fracture
A unique fracture is the basilar skull fracture.
It occurs at the base of the skull and results in CSF leakage
from the nose or ears. Of significance with this fracture is
the potential development of hemorrhage caused by
damage to the internal carotid artery; damage to cranial
nerves I, II, VII, and VIII; and infection.
The majority of penetrating injuries to the skull are caused
by gunshot wounds and knife injuries. The degree of
injury to the brain tissue depends on the velocity, mass,
shape, and direction of impact.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
155
Primary Brain Injury
Closed Head Injury
Caused by blunt trauma and lead to concussions, contusions, and
lacerations of the brain.
Concussion - is characterized by a brief LOC. Damage occurs to
the gray matter of the cerebral cortex or possibly to the diencephalon
or brain stem. The damage to the axons is functional, not structural,
which is why permanent neurologic dysfunction is generally not seen.
Contusion - Contusion is bruising of the brain tissue.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
156
Primary Brain Injury
Types of force
Acceleration Injury
An acceleration injury is caused by the head in motion.
Deceleration Injury
A deceleration injury occurs when the head is suddenly stopped or hits
a stationary object.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
157
Primary Brain Injury
Secondary Responses and Insults
The most frequently occurring response is the development of
increased Intracranial pressure (ICP) attributable to edema,
hemorrhage, hematoma development, impaired cerebral
autoregulation, or hydrocephalus.
Hypoxemia, hypercapnia, or systemic hypotension may precipitate
increased ICP.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
158
Secondary Responses and Insults
Increased Intracranial Pressure
The brain is composed of brain tissue, blood, and cerebrospinal fluid
encased in a rigid skull. Through the processes of accommodation and
compliance, the ICP is maintained at its normal level of 10-15 mmHg
despite transient increases in pressure that occur.
Increased ICP is the leading cause of death from head trauma in
clients who reach the hospital alive. It occurs when compliance no
longer takes place.
As the ICP increases, cerebral blood flow decreases, leading to tissue
hypoxia, a decrease in serum pH level, and an increase in CO2 levels.
This process causes cerebral vasodilation, edema, and a further
increase in the ICP, and the cycle continues.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
159
Secondary Responses and Insults
Increased Intracranial Pressure
If not treated, the brain herniates downward toward the brain stem,
causing irreversible brain damage and possible death.
Two types of edema may cause ICP: vasogenic and cytotoxic. A third
type (interstitial edema) occurs in the presence of acute brain swelling.
Vasogenic edema - is seen most often as a cause of increased ICP in
the adult. Fluid accumulates mostly in the white matter.
Cytotoxic or cellular, edema - may occur as a result of a hypoxic
insult, which causes a disturbance in cellular metabolism, the
sodium pump, and active ion transport. This results in an abnormal
amount of fluid in the brain cells. Cytotoxic edema may lead to
vasogenic edema and further increase in ICP.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
160
Focus on the Elderly: Head Injury
It is the fifth leading cause of death. 65-75 year old group has second
highest incidence of head injury of all age groups. Falls and motor
vehicle accidents are most common cause.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
161
Focus on the Elderly: Head Injury
High Mortality Factors
The following factors contribute to high mortality:
Falls causing subdural hematomas – especially CSH.
Poorly tolerated systemic stress.
Medical complications, such as hypotension, hypertension, and
cardiac problems.
Decreased protective mechanisms, which make clients
susceptible to infections (especially pneumonia).
Decreased immunologic competence, further diminished by head
injury.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
162
Physical Assessment
Clinical Manifestations
The goals of nursing assessment are the establishment of baseline data
and the early detection of and prevention of increased ICP, systemic
hypotension, hypoxia, or hypercapnia.
Because it is estimated that 5% to 20% of clients with head trauma
have associated cervical spinal cord injuries, all clients with head
trauma are treated as though they have spinal cord injury until
radiographic studies prove otherwise.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
163
Nursing Assessments
The nurse makes the following assessments:
Airway and breathing pattern
Vital signs
Neurologic
Eye
Motor
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
164
Other Assessments
The following assessments are also made:
Laboratory – there are no laboratory tests to diagnose
primary brain injury; however, several tests are used to
prevent secondary damage. ABGs, CBC, serum glucose,
electrolytes and osmolality.
Radiography.
Other – Magnetic Resonance Imaging is particularly
useful.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
165
Common Respiratory Patterns in
Comatose Clients
PATTERN
LOCATION OF LESION
Cheyne-Stokes
Usually bilateral in cerebral
Respiration
hemispheres. Cerebellar
sometimes. Midbrain. Upper pons
Central neurogenic
Hyperventilation
Low midbrain. Upper pons.
Apneustic breathing
Mid pons. Low pons.
Cluster breathing
Low pons. High medulla.
Ataxic breathing
Medulla.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
166
Minor Head Injury
If the person is sleeping, wake him every - hours for the first two
days,asking name, where the client is, and identification of caregiver.
Expect the person to complain of headache, nausea, or dizziness for at
least 2-hours. If these symptoms are severe or do not improve, contact the
physician immediately or take the person back to the ER.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
167
Head Injury
Altered Cerebral Tissue Perfusion
Expectations
The client is expected to maintain a normal ICP, maintain appropriate
vital signs and ABGs, and improve LOC.
Interventions
Severe head injuries – admitted to CCU or trauma center.
Minor head injuries – either admitted to general nursing unit for 2hour observation or sent home with instructions.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
168
Head Injury
Nonsurgical Management
Interventions are directed toward preventing or detecting increased
ICP, promoting fluid and electrolyte balance, and monitoring the
effects of treatments and medications.
Vital signs are assessed q. 1-2 hours.
Nurse positions client to avoid extreme flexion or extension of the
neck and maintain the head in midline position.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
169
Head Injury
Nonsurgical Management
Prophylactic hyperventilation during the first 20 hours after injury is
usually avoided as it may produce ischemia.
Induction of barbiturate coma: for clients whose ICP cannot be
controlled by other means, the client may be given Nembutal to
decrease metabolic demands of the brain and cerebral blood flow, thus
decreasing edema.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
170
Head Injury
Drug Therapy
Mannitol used as an osmotic diuretic.
Codeine or Sublimaze may be used with ventilated clients to decrease
agitation and control restlessness.
Narcan reverses these.
Neuromuscular blocking agents such as Pavulon help decrease
cerebral metabolic rate and must never be used without sedation.
Anticonvulsants such as Dilantin are given for seizures.
Tylenol or aspirin are given to reduce fever.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
171
Head Injury
Surgical Management
The physician may elect to insert an intracranial
pressure monitoring device. Various types are used.
Craniotomy
In extreme cases where ICP cannot be controlled,
the physician may elect to perform a craniotomy.
Removal of nonvital brain tissue allows expansion
of brain tissue. A craniotomy may also be
performed to removed epidural or subdural
hematomas.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
172
Brain Tumors
Key Features
Cerebral Tumors
Headache (most common
feature)
Vomiting unrelated to
food intake
Hypokinesia
Hyperesthesia,
paresthesia, decreased
tactile discrimination
Seizures
Changes in visual acuity
and visual fields; diplopia
Aphasia
Hemiparesis or
hemiplegia
Changes in personality
and/or behavior
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
173
Brain Tumors
Brain Stem Tumors
Hearing loss (acoustic neuroma)
Facial pain and weakness
Dysphagia, decreased gag reflex
Nystagmus
Hoarseness
Ataxia and Dysarthria (cerebellar tumors)
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
174
Brain Tumors
Key Features of Brain Tumors
Complications of Tumors
Cerebral edema results from changes in capillary endothelial tissue
permeability which allows plasma to seep into the extracellular
spaces.
This leads to increased ICP, and herniation of brain tissue may occur.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
175
Brain Tumors
Key Features
A variety of focal neurologic deficits result from edema, infiltration,
and compression of surrounding brain tissue.
Increased ICP may also result from obstruction of the flow of CSF or
displacement of the lateral ventricles by the expanding lesion.
Typically, a tumor obstructs the aqueduct of Sylvius or one of the
ventricles or encroaches on the subarachnoid space.
Posterior fossa tumors may obstruct the flow of CSF from the fourth
ventricle to the foramen of Luschka of Magendie.
With any brain tumor, the obstruction of normal CSF flow causes
hydrocephalus and eventually leads to increased ICP.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
176
Brain Tumors
Classifications
Malignant
Benign
Acoustic neuroma
Astrocytoma (grades 2, , )
Meningioma
Oligodendroglioma
Pituitary adenoma
Ependymoma
Astrocytoma (a grade 1 may
become malignant)
Medulloblastoma
Chondrosarcoma
Chondroma
Craniopharyngioma
Hemangioblastoma
4/22/2003 version
Glioma
Lymphoma
Copyright - Mary Roche, RN, MSN, CS
177
Brain Tumors
Incidence / Assessment
Incidence/Prevalence
Brain tumors account for % of
all cancer deaths.
Each year 6,000 primary cases
are diagnosed and 18,000
secondary cases are found.
Brain tumors in the adult
population are seen primarily
in clients 0-60 years old.
4/22/2003 version
Assessment
Clinical manifestations vary.
Diagnosis based on history,
neuro assessment, clinical
exam and testing.
Noninvasive diagnostic studies
CT and MRI and done first.
Additionally EEG and PET
may be indicated.
Copyright - Mary Roche, RN, MSN, CS
178
Interventions
Nonsurgical:
Surgical:
drug therapy,
Craniotomy.
radiation,
chemotherapy,
radiosurgical procedures.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
179
Surgical Management
after Craniotomy
Focus of Postop care is to monitor the client to detect changes in status
and prevent or minimize complications.
Positioning based on type of surgery. NPO status for 2-hours.
Monitoring the dressing: check for drainage (typical amount is 0-50 cc
per shift). Excessive amounts of drainage should be reported to
physician immediately.
Monitoring lab values: CBC, electrolytes, osmolality, coag studies and
ABGs. HCT and HGB
Drug therapy: Routinely given meds include anticonvulsants,
histamine blockers and corticosteroids.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
180
Continuing Care
after Craniotomy
The client with a brain tumor is managed at home if possible.
Seizures are a potential complication that can occur at any time for as
long as a year or more postoperatively.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
181
Preventing
Postoperative Complications
Increased ICP is the major postop complication of cranial surgery.
Symptoms include severe headache, deteriorating LOC, restlessness,
irritability and dilated or pinpoint pupils.
Treatment includes placing the client supine with HOB elevated 0-5
degrees. Osmotic diuretics may be given to decrease edema. Surgery may
be necessary.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
182
Preventing
Postoperative Complications
Hydrocephalus - caused by obstruction of the normal CSF pathway
from edema, an expanding lesion such as a hematoma, or blood in the
subarachnoid space. A surgical shunt may be placed for treatment.
Respiratory Problems - Complications include atelectasis, pneumonia,
and neurogenic pulmonary edema. Frequent deep breaths, movement,
incentive spirometry are useful in preventing these complications.
Wound infection - Occur more in debilitated clients. If infection occurs
the wound will be red and puffy. The nurse may treat a localized infection.
For more severe infection, systemic antibiotic treatment is given.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
183
Preventing
Postoperative Complications
Meningitis
an inflammation of the Meninges and may occur as a result of wound
infection, CSF leak or contamination during surgery.
Fluid And Electrolyte Imbalance
Complications include diabetes insipidus and syndrome of
inappropriate antidiuretic hormone (SIADH). Clients are on strict
I&O. The nurse assesses the client carefully for indications of fluid
overload or dehydration during treatment. Serum electrolyte levels and
osmolality are measured daily or more often if indicated clinically.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
184
Brain Abscess
A brain abscess is a prurulent infection of the brain in which pus forms
in the extradural, subdural, or intracerebral area of the brain.
Organisms enter from the ear, sinus, or the mastoid area.
Organisms cause a local infection.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
185
Brain Abscess
Physical Assessment/Clinical
Manifestations
Clinical manifestations are insidious.
Mild lethargy, some confusion.
Pupillary response is normal in the early stage.
As increased ICP progresses, the pupils dilate and become
nonresponsive.
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
186
Key Features
of Brain Abscess
Early
Manifestations
Headache
Late Manifestations
Confusion
Increased intracranial
pressure (ICP)
Fever
Focal neurologic deficits
Dilated and
nonresponsive pupils
Lethargy
Visual field deficits
Cushing’s triad
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
187
Antibiotics Used
To Treat Brain Abscesses
Streptococcus
Penicillin
Enterobacteriaceae
Toxoplasma
Cefotaxime
Chloramphenicol
Pyrimethamine
Anaerobes
Staphylococcus
Sulfonamides
Metronidazole
Trimethoprimsulfamethoxazole
Nafcillin
Methicillin
Clindamycin
Fluconazole
Vancomycin
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
188
Presentation Credits
This presentations was developed for Mary Roche under
contact with Peter Martin, dba Stacy House Designs.
The presentation is the sole, copyrighted property of Mary
Roche.
Copies of this and other presentations can be seen on the
Internet at http://www.StacyHouse.com. Please fill out the
guestbook selection when visiting that site.
Thank you.
Mary Roche & Peter Martin
4/22/2003 version
Copyright - Mary Roche, RN, MSN, CS
189
The End
Mary Roche, MSN, RN, CS