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Neuro Disorders

Acute/ Chronic / Traumatic
by

Molly McClelland

on 18 February 2016

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Transcript of Neuro Disorders

Neurological Disorders
Acute
Chronic
Traumatic
Parkinsons
Spinal Cord Injury
Neuro Review
Epilepsy –

•Status epilepticus is a medical emergency. Even if seizures stop, patient at risk for further seizures. Priority to keep patient safe.
Pad side rails
Apply oxygen
Have sxn tube available.
(don’t insert anything into mouth. No need for IV’s or NG tubes unless other problems are also occurring like hypovolemia or vomiting)
This is a steadily progressive disease with gradual worsening of symptoms (not acute and exacerbations not expected like other chronic neuro disorders. Triad of symptoms: tremors at rest, cogwheel rigidity and shuffling, forward leaning gate.
•Difficulty chewing – watch for choking, cut food into small pieces. Often lose weight because of decreased tongue, mouth, swallowing muscle tone.
•Difficulty getting up and down from seated position (use armed chairs and elevated toilet seats)
•Shuffled gait typical, keep patient safe with good shoes, avoid carpets, good lighting, etc…
•Drugs:
- L-dopa is drug of choice - Limit high protein foods if on L-dopa because it decreases effectiveness of drug. Drugs effectiveness can decrease after a few years of treatment.
- Carbidopa/levodopa (Sinemet) used for Parkinsons but dyskinesia (uncontrolled movements ) is an adverse effect. If noted, may need to change medication, decrease dose, etc…..

•Watch for
autonomic dysreflexia
(T6 and above) caused by full bowel and bladder, skin triggers (too hot / too cold), pressure which can trigger it, if occurs it’s a medical emergency - HTN w <HR, pounding HA
•Patients should eat foods high in protein to assist with healing and muscle development
•Teach coughing techniques (use of abdominal thrust), prone to resp. infections
•Sexuality is a huge issue, don’t be afraid to discuss it with SCI patients. Can still have kids.
•Patients with T6 injuries and above are prone to develop neurogenic shock. Watch for triad including hypotension, bradycardia, warm extremities due to massive vasodilataion.
•Teach patients with thorasic injuries to self catheterize at regular intervals in order to avoid spaciticiy and incontinence due to over stretching of bladder walls (neurogenic
reflex bladder).
•Spasticity and hyperactive reflexes occur in later phases of injuries.
•Patient will have loss of movement and sensation below level of injury. Risk for DVT's, orthostatic hypotension
•Level of function depends on where injury occurred.
C3/4 will need ventilator because diaphragm is paralyzed, (C 4-6), use of shoulders
T1 and lower will have full use of upper body (T 1-12), known as paraplegia
Lumbar (L 1-5) sexual functioning.
Epilepsy Cont'd
Different types of seizures.
Tonic – Clonic – massive jerking seizures. Patient will lose consciousness

Drugs
Lorazepam (Ativan) usually given for tonic-clonic seizures (IV). This is a rapidly acting benzodiazepine to stop seizure activity
Dilatnin (Phenotin) is also used to prevent seizures but is long term and doesn’t act rapidly. Can cause oral side effects (gingival hyperplasia)

RN role for epileptic patients:
Teach patient and family how to be safe during seizures, what symptoms to watch for, proper management.
Nurse should also assess side effects of medications. Most likely sleepy so teach about driving, using heavy equipment.
Teach about community agencies and services that might be available
Delirium
– Usually has rapid or actue onset. Causes disorientation, incoherent or confused speech (sun downing, medication response, etc….)
Dementia
- Gradual, long term, increasing confusion over several years. May become confused, incoherent speech. Seen in alzheimers, disease.
•Drugs: Donepezil (Aricept). Teach spouse or caretaker about when to give and what to watch for.
•Family to help with new skills, like when and how to take prescribed meds.
•Forgetfulness / difficulty learning new things symptom of dementia
Alzheimers Disease -
•Diagnosis made by rule out only
•Age is the most important risk factor for the development of the disease
•May run in families but that’s not proven in research. Controversial.
•Medication can slow progression of disease by slowing deteriotation of brain by does not dramatically reverse the effects of the disease.
•Brain atrophy is a common finding – also noted in other brain disorders so not confirmatory of AD if that’s the only symptom.
•Develop routines and consistency for patient. Helps to decrease anxiety and confusion.
•AD forgets events from past in late stages.
•Re-orienting to time and place isn’t super helpful.
•Provide activities but not reading – they lose this skill.
T
rigeminal Neuralgia
– (Face pain). Cranial nerve 5
•Can have acute flare-ups. They avoid eating and drinking r/t pain. Assess nutritional status and I’s & O’s to assure adequate intake
•Touching face stimulates pain – avoid that, don’t have patient talk a lot, don’t put anything on the face

Bell’s palsy
– (face paralyzed). Cranial nerve 7
•Caused by virus (often previous herpes simplex infection)
•Pain or herpes sores near the tragus, upper jaw area can indidcate onset of Bells palsy.
•Corticosteroid therapy rapidly is drug treatment of choice to reduce symptoms.
•No prevention, just identify early and treat quickly. Know to watch for it following herpes infected patients.
CVA is not technically same thing as intracranial bleed. Tumors / stroke will have same manifestations based on location in brain. Ie…frontal lobe problems = judgment/personality/ intellectual things. Parietal = speech & some movement, weakness. Brainstem is swallowing and other vital organs.
Head Injuries –
• Watch for Cushings triad = systolic hypertension with widening pulse pressure, bradycardia, respiratory changes means ICP is increasing and herniation may be imminent.
• Keep patient calm and quiet. Dim lights in room, allow one or two family members to stay (not a whole party).
• Explain stuff to family and support staff.
• Posturing =
• Watch for drainage with CSF in it – which has glucose.
• Minor injuries, like concussions cause diffuse, microscopic injury to brain and may have memory loss, check outpatients for neuro status , instruct family member what to watch for and when to return . N & V, dizziness – patient to return
post concussion syndrome = short term memory loss (retrograde amnesia – not remembering what happened is common and expected)
don’t let person drive or operate heavy machinery until neuro is OK
monitor for 24 hours
tx pain like any other headache. If minor Tylenol OK, may need to use narcotics – that’s OK
• Battles sign = basilar skull fx. Clear drainage may mean csf leak. Don’t insert ng tubes, don’t blow nose,watch for s/s of infection
ICP –
• If elevated treat with mannitol. If its working., you’ll see the ICP decreasing within a few minutes.
• If monitoring devices in place to check ICP or drain fluid ,maintain aseptic technique to prevent infection
• Keep O2 sat high, don’t have patient cough
• Keep HOB at 30 degrees and straight,
• Don’t flex hips or knees
• Keep nursing duties quick and short….don’t do hours at a time.
Meningitis

• Bacterial is medical emergency. Tx with antx stat IV
- Menningiococcal meningitis is spread via respiratory secrections (resp. precautions necessary)
• Viral tx w/ supportive therapies, steroids, rest, fluids, nutrition
- Shock is serious complication (watch for that & tx quickly)
- Photophobia / nucal rigidity / Kernig's sign / Positive Brudzinski’s sign
Ominous signs: >HR, <GCS, >age, > co-morbidities
- Risks for an unfavorable outcome of meningitis include older age, a heart rate greater than 120 beats/minute, low Glasgow Coma Scale score, cranial nerve palsies, and a positive Gram stain 1 hour after presentation to the hospital.
Bleeds –
•Epidural = usually emergent and needs OR
•Subdural may have surgery to evacuate or drain or just a monitor,
- Caused by trauma, HTN, AVM's, aneursyms
Headaches:
Cluster - tx w/ Oxygen, short duration,
Tension - tx pain (start w Tylenol, hot packs, may need to add muscle relaxors / sedatives if no relief)
Migraine - caused by vasospasm
Guillain - Barre' Syndrome
Progressive movement disorder r/t demyelinization of nerves. (Vagus nerve = cardiac complications
Typically full recovery
Caution with ADL's, nutrition, respiration when acute phase -
watch for resp. weakness, prepare for intubation.
MS -
Common symptoms:
bladder spasticity
decreased swallow function (caution with aspiration)
urine retention (Crede'method useful) / incontinence
decreased libido
vision changes
Increased muscle rigidity /slowing of movements
Tremors with movement (better at rest)
Symptoms can exacerbate w stress / fatigue/ postpartum
Review of Cranial Nerve Function:

I - Olfactory =
II- Optic =
III - Oculomotor =
IV - Trochelar -
V - Trigeminal -
VI - Abducens -
VII - Facial -
VIII - Acoustic -
IX - Glossopharyngeal -

X - Vagus -

XI - Spinal -
XII - Hypoglossal -
MS Interventions:
Allow for periods of rest
Teach techniques to reduce spasms
Stretching
Heat
Meds: Baclofen, Valium, etc...
Consider anti-seizure meds to control gross motor movements (ie...Neurontin)
Assess for side effects of MS meds
(ie...cardiac toxicity, reduced WBC's, drug levels)
Describe the functions of the lobes:
Frontal: Response to environment, consciousness, judgement, emotions, expressive language
Parietal: touch perception, visual comprehension, integrates senses to make sense of environment,
Temporal: Hearing, face recognition, short-term memory, visual perception
Occipital: Field vision loss, reading loss, word recognition loss, color agnosia
Cerebellum: Coordination & Movement
Brain Stem: Vital signs
smell
Vision
pupil and eye movement function
down & inward eye movement
facial movement & sensation
lateral eye movement
face muscles / taste / saliva & tear secretion
Hearing & Equilibrium
pharynx function (swallow/talk - bulbar weakness), posterior tast, parotid glad/carotid reflex (parasympathetic)
Pharynx/larynx (talk & swallow), pharynx sensation, parasympathetic response
Movement of trapezius and sternomastoid
movement of tongue
Brain Death

The three cardinal signs of brain death on clinical examination are
coma
, the
absence of brain stem reflexes
, and
apnea
.

Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG), transcranial Doppler, and brain stem auditory-evoked potential, are often used to confirm brain death.
Spinal Cord Injuries
Complications of SCI
Potential complications that may develop include: DVT, orthostatic hypotension, autonomic dysreflexia, neurogenic shock, body image problems, muscle atrophy, respiratory complications, bowel / bladder disorders, muscle spacticity, adjustments to lifestyle (wheelchairs, modes of transportation, etc), skin breakdown
First addressed in the acute phase, however, impacting the rehabilitative process is the prevention of joint contractures. The nursing care provided at an early period can prevent further complications in the rehabilitative phase.
Neuro Terms r/t dysfunction
Dysarthria
is characterized by poor articulation of words due to muscle weakness or loss of muscle control.
Dysphasia
is characterized by the compromised ability to put words together meaningfully.
Ataxia
is a dysfunction of the parts of the nervous system that coordinate movement.
Dysphagia
is difficulty with swallow
Chorea
is a rapid, jerky, involuntary, purposeless movement of the extremities of facial muscles, including facial grimacing.
Akithisia
is restlessness.
Dyskinesia
is impaired ability to execute voluntary movements.
Paresthesia
is a sensation of numbness, tingling, or a "pins and needles" sensation.
Agnosia
inability to identify objects by touch (a sign of a parietal lobe tumor)
A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain.

Treatment includes pre/post testing and REST. quiet, dark, low stimulation environments.
Concussions
The
Monro-Kellie hypothesis
refers to the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.
TUMORS
Brain tumors may lead to seizures and hydrocephalus, a client with an angioma is at high risk for hemorrhagic stroke because the walls of the blood vessels in angiomas are thin. Meningiomas are benign but still need to be removed. Astrocytomas & Glioblastomas are very aggressive and often fatal.
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