Professional Documents
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NERVOUS SYSTEM
A. Central Nervous System B. Peripheral Nervous System C. Autonomic Nervous System
B. Peripheral Nerves
31 pairs ( cervical, thoracic, lumbar, sacral, coccygeal)
Neurons
Dendrites
Cell body
Axon
Nerve Structure
Skull
Frontal View
Location for placement of ICP catheters Anterior to coronal suture & off midline (Saggital sinus underneath)
Midline
Frontal
Skull
Lateral View
Frontal Temporal Parietal Occipital
Coronal suture
Frontal Parietal
Sutures
Separation between bones Underlying coronal suture is motor strip
Temporal Occipital
Dura Mater
Tough outer layer, inelastic, fibrous membrane Double layered Attaches to
skull - periosteum brain - meningeal forms compartments
Dura Mater
Compartments
Right & left side Supratentorial (contains cerebral hemispheres) Infratentorial (posterior fossa contains brain stem & cerebellum)
Arachnoid Membrane
Middle layer Delicate avascular membrane Forms the subarachnoid space and cisterns
Arachnoid Membrane
Contains CSF (cerebral spinal fluid) in space below Arachnoid granulations project into venous sinus Clinical relevance
Subarachnoid hemorrhage (SAH)
Pia Mater
Innermost layer adherent to brain Mesh-like, vascular
Arterial Circulation
Circle of Willis
Interconnection of arteries that supply blood to cerebral hemispheres
Posterior circulation
Supplies blood to brainstem
Venous Drainage
Occurs through the bridging veins Brain - through arachnoid - dural sinus
Venous Drainage
Clinical Observations
About 80% blood volume is venous Avoid sagittal sinus with placement of Monitoring (ICP, Licox) Obstruction of venous pathways - ICP
Brain
Cerebral Lobes
Frontal Parietal Temporal Occipital
Parietal Occipital
Frontal
Temporal
Frontal Lobe
Motor function
Contraction and synchronization
Cognitive functions
Judgment Uniqueness of personality Reasoning
Parietal Lobe
Sensory interpretation
Touch Temperature Taste
Occipital Lobe
Visual brain Appreciation of size, shape, and color
Temporal Lobe
Sensation and interpretation of sounds Interpret sense of smell Control behavior patterns
Ventricular System
Fluid filled cavities deep in cerebrum filled with Cerebrospinal Fluid (CSF)
Ventricular System
Four ventricles
2 Lateral
Location for ventricular catheters
Third Fourth
Connected by
Foramen of Monro
Landmark used to zero transducers & EDVs
Ventricular System
Lateral View AP View
Ventricular System
Choroid Plexus
Very vascular Found throughout ventricular system but mostly in lateral 500cc CSF produced daily Approx 20cc produced hourly 150cc in the system at any time
CSF Flow-path
Lateral ventricles thru Foramen of Monro to 3rd ventricle thru aqueduct of Sylvius to 4th ventricle. Exits through Foramen of Magendie & Foramen of Luschke. Travels around spinal cord & exits thru Arachnoid Granulations.
Hydrocephalus
Non-communicating
CSF unable to flow thru the system Congenital Obstruction Cysts
VP shunt
Diencephalon
Thalamus
Process incoming sensory information before distribution to the somatosensory cortex Process motor information from the cerebral cortex and cerebellum and projects its analysis back to the motor cortex Contributes to the concentrating ability by filtering out distracting sensory input Contributes to emotional component of sensations (pleasant or unpleasant)
Diencephalon
Hypothalamus
forms a crucial part of the neural path by which emotions and other cerebral functions can alter vital, automatic functions. (heartbeat, BP, peristalsis, and gland secretions) Secretes neuropeptides (TRH and LH-RH) Produces ADH and oxytocin Contains appetite center, satiety center and temperature regulating center Maintains waking state (arousal or alerting neural pathway)
Midbrain
Located between pons, diencephalon and cerebrum Integrates and analyzes sensory input from the ears, eyes, and various regions of the cerebral cortex Reflex centers for cranial nerves III and IV Pineal body
Brainstem
Medulla
Conducts impulses between the cord and brain Contains important reflex centers for heart, blood vessel diameter, respiratory reflexes, vomiting, coughing, and swallowing
Brainstem
Pons
Conducts impulses between the cord and various parts of the brain Contains reflex centers for cranial nerves V, VI, VII, and VIII. Contains pneumotaxic center
Cerebellum
Exerts synergic control over the skeletal muscles producing smooth, steady, and precise movements Coordinates skeletal muscle contractions and play an essential part in producing normal postures and maintaining equilibrium
Spinal Cord
Cervical
Thoracic
Lumbar
Sacral
Spinal cord
Spinal Cord
From foramen of magnum to the 1st lumbar vertebra Inner core consist of gray matter, shaped like a three dimensional H Long columns of white matter surround the cords inner core of gray matter (composed of numerous sensory and motor tracts).
Right and left anterior columns Lateral and posterior columns
Spinal cord
A. Cranial Nerves
12 pairs
B. Peripheral Nerves
31 pairs ( cervical, thoracic, lumbar, sacral, coccygeal)
Cranial Nerves
Cranial I and II direct extensions of receptor organ Cranial Nerve III, IV midbrain Cranial Nerve V, VI, VII, VIII pons Cranial Nerve IX, X, XI, XII - medulla
Head Injury
Includes
Scalp injury Skull Brain
Pathophysiology
Two Forms
Primary
Initial damage to the brain
Secondary
Evolves over the ensuing hours and days after the initial injury Due to brain swelling and ongoing bleeding
SCALP INJURY
Scalp trauma bleeds profusely when injured Abrasion, contusion, laceration, or hematoma beneath the layers of the scalp (subgaleal hematoma) Diagnosis: physical exam, inspection, palpation. Potential portals for organisms Irrigate before suturing
SKULL FRACTURES
Break in the continuity of the skull With or without damage to the brain Linear, comminuted, depressed, or basilar. May be open scalp laceration, tear in the dura May be closed dura is intact
MEDICAL MANAGEMENT
Conservative Management
For non-depressed skull fracture
Surgical Management
Contaminated or deforming fractures If significant cerebral edema is present, surgery may be delayed for 3 to 6 months Penetrating wounds require surgical debridement Antibiotic treatment
Rigid close compartment Do not allow expansion Any bleeding or swelling increases volume increases ICP Increase ICP downward and lateral displacement of the brain Displacement restriction of blood flow oxygen delivery Brain becomes anoxic irreversible brain damage
Verbal response: Oriented (5) Confused (4) Inappropriate words (3) Incomprehensible sounds (2) No response (1)
CONCUSSION
Temporary loss of neurologic function with no apparent structural damage Involves a period of unconsciousness for a few seconds to minutes May be hospitalized for observation
CONCUSSION
OBSERVE FOR
headache Dizziness Lethargy Irritability Anxiety Post concussion syndrome
CONCUSSION
Advise to resume normal activities slowly Instruct family to observe the following
Difficulty in awakening Difficulty in speaking Confusion Severe headache Vomiting Weakness on one side of the body
CONTUSION
More severe injury Brain is bruised Unconscious for few secs to mins Symptoms depend on the size, and amount of edema
HEMATOMAS
EPIDURAL SUBDURAL INTRACEREBRAL
EPIDURAL HEMATOMA
Lucid interval -- loss of consciousness followed by an interval of apparent recovery Considered an extreme emergency Treatment: Surgery: Burr holes / craniotomy Drain usually inserted
SUBDURAL HEMATOMA
Mainly due to rupture of bridging veins in the subdural space May also be caused by coagulopathy May be acute, subacute, or chronic
Acute
Symptoms develop over 24 to 48 hours Requires immediate intervention
Subacute
Appear between 48 hours to 2 weeks
INTRACEREBRAL HEMATOMA
Bleeding into the substance of the brain Onset may be insidious from neurologic deficit to headache
Potential Complications
Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolytes, and nutritional balance Risk of post-traumatic seizures
Brain Tumors
Etiology and pathophysiology Either benign or malignant Classified according to tissue of origin Meningioma: occurs outside brain from covering meninges; usually benign
Brain Tumors
Acoustic neuroma and optic nerve spongloblastoma; occur from the cranial nerves Gliomas; originate in neural tissue; usually malignant and include astrocytoma; glioblastoma, oligodendroglioma Hemangioblastomas and angiomas; occur from within blood vessels
Brain Tumors
Metastatic tumors; originate elsewhere in the body, most commonly the lung and breast
Clinical findings
Subjective: headache that increases when supine or stooping; lethargy Objective: signs of increased intracranial pressure; abnormal CT scan, MRI, EEG Symptoms may vary depending on location of tumor
Brain Tumors
Frontal lobe: personality changes, focal seizures, blurred vision, hemiparesis, altered thought processes Temporal lobe: seizures, headache, papilledema, receptive aphasia, tinnitus Parietal lobe: visual loss, motor and sensory focal seizures Occipital region: focal seizures, visual hallucinations, homonymous hemianopsia
Brain Tumors
Cerebellar region: loss of coordination, tremors, nystagmus
Therapeutic interventions
Radiation therapy and/or chemotherapy Surgery for partial or complete removal of the lesion
Brain Tumors
Stereotactic radiosurgery; employs computer-directed radiation to eradicate tissue Steroids, anticonvulsives, and osmotic diuretics to control symptoms
Brain Tumors
Neurologic status Unilateral nonreactive and/or dilated pupil progressing to bilateral as intracranial pressure increases Signs of increased intracranial pressure Decreased level of consciousness Rapid rise in body temperature; decreased pulse rate; changes in respiratory pattern
Brain Tumors
Increased systolic pressure; widening pulse pressure Restlessness Headache Weakness or paralysis Visual and other sensory disturbances;papilledema Vomiting Seizures
Brain Tumors
Analysis/Nursing Diagnoses
Ineffective breathing pattern related to compromised neurologic function Decreased adaptive capacity: intracranial, related to increased ICP Anxiety related to uncertain prognosis
Planning/Implementation
Perform routine neurologic assessments
Provide emotional support for the client and family; refer to additional resources such as clergy and support groups Administer analgesics and antiemetics as ordered Provide small, frequent feedings, supplements, and oral hygiene Provide care for the client requiring brain surgery Obtain consent for surgery and removal of hair After surgery keep the client`s head elevated 30 degrees
Support respiratory function by encouraging deep breathing, appropriate positioning, and suctioning to maintain the airway Use strict aseptic technique with ICP monitoring Observe dressings for cerebrospinal fluid leakage or hemorrhage Maintain intake and output Use hypothermia as ordered if the client is febrile; fever increases metabolic needs of the brain
Brain Tumors
Assist client to focus on abilities rather than disabilities Emphasize need for continued health care supervision
Evaluation/Outcomes
Maintains adequate respiratory function Oriented to person, place, and time Establishes effective communication
Stroke
Is a brain attack
Needing emergency management, including specific treatments and secondary and tertiary prevention.
Is an emergency
No allowances for worsening are tolerated
Is treatable
Through proven, affordable, acceptable means
Is preventable
In implementable ways across all levels of society
STROKE
3rd leading cause of death in the U.S. 2nd leading cause of death in the Philippines
STROKE
Two Major Categories
Ischemic Vascular occlusion and significant hypoperfusion occur Hemorrhagic Extravasation of blood into the brain
STROKE
Ischemic Large artery thrombosis Lacunar Cardiogenic embolic Cryptogenic Other Hemorrhagic Intracerebral Hemorrhage Subarachnoid Hemorrhage Cerebral Aneurysm Arteriovenous malformation
Cardiogenic Emboli
Pathophysiology
Stroke in Evolution
Worsening of neurologic signs and symptoms over several minutes. Progressing stroke.
Completed Stroke
Stabilization of the neurologic signs and symptoms
Clinical Manifestations
Visual Field Deficits Motor Deficits Sensory Deficits Verbal Deficits Cognitive Deficits Emotional Deficits
Motor Deficits
Hemiparesis
Place objects within patients reach on the non-affected side Instruct patient to exercise and increase strength on non-affected side
Motor Deficit
Hemiplegia
Provide ROM exercises Maintain body alignment Exercise unaffected limb to increase immobility
Ataxia
Support patient during initial ambulation Provide supportive device Instruct patient not to walk without assistance
Dysarthria
Provide patient with alternative methods of communicating Allow the patient sufficient time to respond Support patient and family to alleviate frustration
Dysphagia
Test the patients pharyngeal reflexes before offering food or fluids Assist the patient with meals Place food on the unaffected side of the mouth Allow ample time to eat
Sensory Defictis
Paresthesias
Instruct patient to avoid using this extremity as the dominant limb Provide range of motion to affected areas
Expressive aphasia
Encourage patient to repeat sounds of the alphabet
Receptive aphasia
Speak slowly and clearly to assist patient in forming the sounds
Global aphasia
Use simple sentences Use gestures or pictures when able Establish alternative means of communication
Cognitive Deficits
Short and Long term memory loss
Reorient patient to time, place, and situation frequently
Altered Judgement
Minimize distracting noises Repeat and reinforce instructions frequently
Emotional deficits
Support patient during uncontrollable outbursts
Emotional lability
Discuss with patient and family that the outburst are due to disease process
Depression
Provide stimulation for the patient
Feelings of Isolation
Encourage patient to express feelings and frustrations
Medical Management
Warfarin : INR target 2.5 ASA, clopidogrel, ticlopidine, dipyridamole Heparin: PTT
THROMBOLYTIC THERAPY
Used to treat ischemic stroke by dissolving the blood clot Recombinant t-PA (rt-PA) must be given within 3 hours of stroke onset. Leads to an overall improvement in functional outcome after 3 months
Eligibility Criteria
Age 18 years or older NIHSS under 22 Within 3 hours or less BP systolic < 185 diastolic < 110 No seizure at onset Not taking warfarin PROTHROMBIN TIME < 15 sec INR < 1.7
Eligibility Criteria
Not receiving heparin during the past 48 hours w/o elevated PTT Platelet count > 100,000 CBG 50 to 400 No MI No Intracranial hemorrhage, neoplasm, AV mal, aneurysm
Eligibility Criteria
No major surgical procedures within14 days No stroke or head injury within 14 days No gastrointestinal or urinary bleeding within last 21 days
THROMBOLYTIC THERAPY
Community Education directed at:
Recognizing symptoms of stroke Obtaining appropriate emergency care Ensure rapid transport to a hospital and initiate therapy within a 3 hour time frame Delays make the patient ineligible for thrombolytic therapy
Other treatments
Reduce ICP with osmotic diuretics Maintaining pCO2 to 30 to 35 mmHg Elevation of the head Intubation if necessary Maintaining cerebral perfusion: MAP Avoiding precipitous drop in blood pressure Neurologic exam to determine if stroke is evolving or complications of treatment develop.
Hypertension
Postoperative hypotension Hyperperfusion syndrome Intracerebral hemorrahage
Hemorrhagic Stroke
15% of cerebrovascular disease Two types:
Subarachnoid Hemorrhage
Aneurysms
Intracerebral Hemorrhage
AVM Hypertensive Bleeds
Pathophysiology: ICH
Bleeding into the brain substance or parenchyma Most common in patients with hypertension, and cerebral atherosclerosis May also be due to AVM, brain tumors, and medications.
Pathophysiology: SAH
Secondary to intracranial aneurysms Aneurysms is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall May be due atherosclerosis May congenital Head trauma most common cause of SAH
CLINICAL MANIFESTATIONS
Are similar to patients with ischemic stroke. Would depend the site or area of the brain involved
Prevention
Managing hypertension Control of other risk factors Smoking Alcohol Intake High cholesterol level
Medical Management
Allow brain to recover Prevent, minimize risk of rebleeding Prevent, treat complications Bed rest with sedation Analgesics Compression stockings
Complications
Rebleeding Cerebral vasospasm Acute hydrocephalus Seizures
Systemic Hypertension
Preventing sudden systemic hypertension If elevated, may be given labetalol, nicardipine, nitroprusside Stool softeners are used
Surgical Management
ICH: Most frequently via craniotomy SAH: Clipping of aneurysm ASAP
Newer endovascular procedures such as Coiling is now available.
Complications: Hydrocephalus
Can occur within the first 24 hours, or days to several weeks later. Sudden onset of stupor or coma Managed with ventriculostomy drain to decrease ICP VP shunt for chronic hydrocephalus
SEIZURE DISORDERS
SEIZURES
Are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from excessive discharge from cerebral neurons. A part or all of the brain may be involved. Most seizures are sudden and transient. Specific causes of seizures are varied and can be idiopathic or acquired.
Acquired Seizures Hypoxemia Fever (childhood) Head injury Hypertension CNS infections Metabolic renal failure, hyponatremia, hypoglycemia, hypocalcemia Toxic - pesticides Brain tumor Drug and alcohol withdrawal CVD leading cause of seizures in the elderly.
EPILEPSY
Group of syndromes characterized by recurring seizures Classified by specific patterns of clinical features, including age of onset, family history, and seizure type. Can be primary or secondary when the cause is known and the seizures is a symptom of an underlying condition. In most cases, the cause is unknown or idiopathic.
Clinical Manifestations
Depends on the location of the discharging neurons May range from simple starting episode to prolonged convulsive movements with loss of consciousness Partial seizures are focal in origin Generalized are nonspecific in origin Initial pattern of the seizures indicates the region of the brain in which the seizure originates
Absence (petit mal) brief transient loss of consciousness ( 3-5 secs) with or without minor motor movements of eyes, head or extremities Myoclonic brief, transient rigidity or jerking of extremities, singly or in groups Status epilepticus prolonged repetitive seizure without recovery between attacks; may result in complete exhaustion and lead to death Febrile seizure associated with hyperpyrexia. Occurs only once
COMPLEX
Begins as simple partial and progress to impairment of consciousness. Cognitive, psychosensory, psychomotor, or affective effect Person does not remember the episode when it is over
Medical Management
PHARMACOLOGIC THERAPY Objective is to achieve seizure control with minimal side effects. Anticonvulsant therapy continued throughout life; diazepam (Valium) given IV to treat status epilepticus Sedatives used to reduce emotional stress
Surgical Management
Indicated for patients whose epilepsy results from intracranial tumors, abscess, or vascular anomalies. Seizures that do not respond to medications.
INTERVENTIONS
Preventing Injury Reducing fear of seizures
Improving coping mechanisms Providing patient and family education Monitoring and managing complications
Bell`s Palsy
Clinical findings
Subjective: facial pain; altered taste; impaired ability to chew and swallow Objective: distortion of face; drooping of mouth on affected side; difficulty with articulation; diminished blink reflex; upward movement of eyeball when closing eye; increased lacrimation
Bell`s Palsy
Therapeutic interventions
Prednisone therapy Heat, massage, and electric stimulation to maintain circulation and muscle tone Prevention of corneal irritation with eyedrops and use of protective eye shield
Bell`s Palsy
Nursing Care of Clients with Bell`s Palsy
Assessment Presence or absence of blink reflex and ability to close the eye Facial pain; extent of facial paralysis Nutritional intake and the ability to chew and swallow
Bell`s Palsy
Analysis/Nursing Diagnoses
Pain related to inflammation or compression of facial nerve Risk for injury related to absent or diminished blink reflex Body image disturbance related to change in facial appearance
Planning/Implementation
Teach prevention of corneal irritation by using artificial tears, manually closing the eye, and applying an eye shield Teach importance of keeping face warm
Bell`s Palsy
Teach gentle massage of face; simple exercises such as blowing; institute only when acute phase is over Encourage ventilation of feelings Support nutritional status by providing privacy, small, frequent feedings, and encourage favoring the unaffected side while eating
Bell`s Palsy
Evaluation/Outcomes
Maintains corneal integrity Expresses a positive body image States pain is reduced
Clinical findings
Subjective: burning or knifelike pain lasting 1 to 15 minutes, usually in lip, chin, or teeth; pain precipitated by brushing hair, eating, cold drafs Objective: sudden closure of an eye; twitching of mouth and cheek
Therapeutic interventions
Anticonvulsants to relieve and prevent acute attacks Injection of alcohol into the ganglion to relieve pain for several months or years until nerve regenerates
Trigeminal Neuralgia
Surgical intervention
Severing of the sensory root of the nerve, which will cause loss of all sensation in the area supplied by the nerve Microscopic relocation of arterial loop that may cause vascular compression of trigeminal nerve
Percutaneous radio frequency trigeminal gangliolysis: thermal lesion destroys nerve, providing permanent relief for most clients
Trigeminal Neuralgia
Nursing Care of Clients with Trigeminal Neuralgia Assessment
Descriptions of pain and factors that precipitates attacks Effect on activities (e.g., eating, shaving, washing the face, brushing the teeth) because of fear of precipitating an attack
Trigeminal Neuralgia
Analysis/Nursing Diagnoses
Fear related to triggering an attack Pain related to irritation of the trigeminal nerve Altered nutrition: less than body requirements related to reluctance to chew
Planning/Implementation
Teach factors to limit triggering an attack which can result in exhaustion
Trigeminal Neuralgia
Avoid foods that are too cold or too hot Chew foods on unaffected side Use cotton pads to gently wash face and for oral hygiene Keep the room free of drafts; avoid jarring Provide teaching to clients who have sensory loss as a result of treatment Inspection of the eye several times a day for foreign bodies, which the client will not be able to feel
Trigeminal Neuralgia
Warm normal saline irrigation of the affected eye two or three times a day is helpful in preventing a corneal infection Dental checkups every 6 months, because caries will not produce pain
Teach about anticonvulsants and the need for continued medical supervision
Trigeminal Neuralgia
Evaluation/Outcomes Reports decreased severity of attacks Consumes nutritionally balanced diet Develops mechanisms to cope with fear
Clinical findings
Subjective: mild, diffuse, muscular pain; stiffness and rigidity, particularly of large joints; depression; emotional lability may be present, but intelligence is usually not impaired Objective Increased difficulty in performing usual activities such as writing, dressing, and eating Generalized tremor commonly accompanied by pill-rolling movements of the thumb against the fingers; nonintention tremors usually reduced by purposeful movements
Parkinson`s Disease
Various disorders of locomotion (e.g., bent posture, difficulty in rising from sitting position, shuffling propulsive gait, loss of rhythmic arm swing when walking, bradykinesia) Masklike facial expression with unblinking eyes Low-pitched, slow,poorly modulated, poorly articulated speech Drooling; difficulty in swallowing saliva Various autonomic symptoms (e.g., lacrimation, constipation, incontinence, decreased sexual capacity, excessive perspiration)
Dementia and confusion in 15% to 20% of individuals, especially the elderly Therapeutic interventions Medical regimen is palliative rather than curative Pharmacologic intervention (see Antiparkinson Agents in Pharmacology) Physiotherapy to reduce rigidity of muscles and prevent contractures The role of surgical intervention is limited Destruction of thalamus or globus pallidus for intractable tremor and rigidity Transplantation of tissue of adrenal medulla into brain to produce dopamine and transplantation of fetal tissue has been tried
Parkinson`s Disease
Nursing Care of Clients with Parkinson`s Disease
Assessment
History of onset and progression of symptoms Observations of tremors, gait, facial expression,and bradykinesia Nutritional status Elimination status Horizontal and vertical blood pressures to identify postural hypotension
Parkinson`s Disease
Analysis/Nursing Diagnoses
Impaired physical mobility related to neuromuscular degeneration Risk for injury related to postural changes and bradykinesia Self-esteem disturbance related to loss of independence Risk for aspiration related to dysphagia
Parkinson`s Disease
Planning/Implementation
Provide a safe environment Teach client or family to cut food into small bitesized pieces or alter the consistency to prevent chocking; encourage diet rich in nutrient-dense foods such as fruits, vegetables; whole grains, and legumes to improve and maintain nutritional status and prevent possible drug-induced nutrient deficiencies Suction to maintain an adequate airway (usually advanced stages)
Parkinson`s Disease
Encourage an adequate intake of roughage and fluids to avoid constipation Teach activities to limit postural deformities (e.g., use firm mattress without a pillow, periodically lie prone, keep head and neck as erect as possible, think about posture when walking) Teach activities to maintain gait as normal as possible; utilize cane or walker as necessary
Teach and encourage daily physical therapy to limit rigidity and prevent contractures (e.g., warms baths, passive and active exercises) Avoid rushing as stress intensifies symptoms Encourage continuation of medications even though results may be minimal Teach client and family about antiparkinson agents Assist in setting achievable goals to improve self-esteem
Parkinson`s Disease
Evaluation/Outcomes
Maintains patent airway Participates in daily exercise program Complies with prescribed medical therapy Remains free from injuries
Multiple Sclerosis
Clinical findings
Subjective Paresthesia; altered position sense; ataxia Dysphagia Weakness; fatigue Blurred vision; diplopia Altered emotional affect (depression, apathy, or euphoria) Objective Charcot`s triad: intention tremor, nystagmus, scanning (clipped) speech Shuffling gait; increased deep tendon reflexes; spastic paralysis
Multiple Sclerosis
Impaired bowel and bladder function Impotence Cognitive loss (advanced stage) Pallor of optic discs; blindness Increased immunoglobulin G (IgG) levels in the CSF MRI indicates demyelination
Multiple Sclerosis
Therapeutic interventions
Generally palliative Corticosteroids or ACTH Baclofen is used to control spasticity Interferon beta-1b (Betaseron) Physiotherapy and psychotherapy Carbamazepine for paresthesias and trigeminal neuralgia Immunosuppressive drugs (e.g., cyclophosphamide, azathioprine)
Multiple Sclerosis
Nursing Care of Clients with Multiple Sclerosis
Assessment History of onset and progression of motor and sensory loss Factors that intensify symptoms Neurologic status Analysis/Nursing Diagnoses Risk for aspiration related to impaired swallowing Impaired physical mobility related to spasticity and muscle fatigue
Multiple Sclerosis
Risk for injury related to unsteady gait, altered sensations, and impaired vision Constipation related to immobility and neuromuscular impairment Urinary retention related to spasticity Hopelessness related to progression of the disease
Multiple Sclerosis
Planning/Implementation
Incorporate frequent rest periods Avoid hot baths, which can increase symptoms Teach use of assistive devices when carrying out activities of daily living Assist family to understand why client should be encouraged to be active
Multiple Sclerosis
Assist client and family to plan and implement a bowel and bladder regimen Explain the disease process to both client and family in understanding terms Do not encourage false hopes during periods of remission Spend time listening to both client and family; encourage ventilation of feelings
Multiple Sclerosis
Refer client and family to the National Multiple Sclerosis Society Encourage counseling and rehabilitation Explain to client and family that mood swings and emotional alterations are part of the disease process Help client maintain self-esteem Teach how to compensate for problems with gait: walk with feet farther apart to broaden base of support; use low-heeled shoes; use assistive devices when necessary (tripod cane, walker, wheelchair)
Multiple Sclerosis
Teach how to compensate for loss of sensation: use a thermometer to test water temperature; avoid constricting stockings; use protective clothing in cold weather; change position frequently Teach how to compensate for difficulty in swallowing; take small bites; chew well; use a straw with liquids; eat foods of more solid consistency
Multiple Sclerosis
Provide a diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain nutritional status and compensate for nutrient interactions of corticosteroid medications Provide skin care to prevent formation of pressure ulcers; turn frequently Prevent dysfunctional contractures; provide range-of-motion exercises; splints
Multiple Sclerosis
Evaluation/Outcomes
Maintains a patent airway Remains free from injury Establishes exercise/activity and rest/sleep routine that avoids fatigue Maintains bowel and bladder function Copes with changes in physical abilities and life-style changes
Myasthenia Gravis
Etiology and pathophysiology
Chronic, progressive, neuromuscular disorder with remissions and exacerbations; there is a disturbance in the transmission of impulses at the myoneural junction resulting in profound weakness Dysfunction thought to be caused by a reduced number of acetylcholine receptors (AChR) and an alteration of the postsynaptic membrane of the muscle end-plate
Myasthenia Gravis
Autoimmune theory: it is believed that complement and antibodies to AChR cause accelerated destruction and blockage of the AChR Highest incidence in young adult females Myasthenic crisis refers to sudden inability to swallow or maintain respirations because of the weakness of the muscles of respiration
Myasthenia Gravis
Clinical findings
Subjective: Extreme muscle weakness; becomes progressively worse with use, but disappears with rest; dyspnea, dysphagia (difficulty chewing and swallowing); dysarthria (difficulty speaking); diplopia Objective
Physical: ptosis of the eyelid; strabismus; weak voice (dysphonia); myasthenic smile (snarling, nasal smile)
Myasthenia Gravis
Diagnostic measures: spontaneous relief of symptoms with administration of subcutaneous neostigmine (Prostigmin) or IV administration of edrophonium (Tensilon); edrophonium used to distinguish myasthenic crisis from cholinergic crisis (toxic effects of excessive neostigmine)
Therapeutic interventions
Medications that block the action of cholinesterase at the myoneural junction
Myasthenia Gravis
X-ray therapy or surgical removal of the thymus may cause partial remission Corticosteroids or ACTH Tracheostomy with mechanical ventilation as necessary in myasthenic crisis Plasmapheresis and immunosuppressives to reduce circulating antibody titer
Myasthenia Gravis
Nursing Care of Clients with Myasthenia Gravis
Assessment
History of onset and progression of motor and sensory loss; factors that intensify symptoms Neurologic status (see Neurologic Assessment)
Analysis/Nursing Diagnoses
Fatigue related to profound muscle weakness Ineffective airway clearance related to inability to cough or swallow
Myasthenia Gravis
Planning/Implementation
Administer medications on strict time schedule to prevent onset of symptoms Observe for signs of dyspnea, dysphagia, and dysarthria; may be caused by worsening of myasthenia (myasthenic crisis) or overdose of anticholinergic drugs (cholinergic crisis) Have an emergency tracheostomy set at bedside Plan activity to avoid fatigue based on the individual`s tolerance
Myasthenia Gravis
Teach to avoid people with upper respiratory tract infections, because pneumonia may develop as a result of fatigued respiratory muscles Encourage use of a medical alert card Avoid administering morphine to clients receiving cholinesterase inhibitors; these drugs potentiate effects of morphine and may cause respiratory depression
Myasthenia Gravis
Provide emotional support and close client contact to allay anxiety Administer tube feedings to avoid aspiration if client has difficulty swallowing Administer artificial tears to keep cornea moist if client has difficulty closing eyes Encourage client and family to participate in planning care Ensure that client understands the signs and symptoms of myasthenic and cholinergic crises
Myasthenia Gravis
Refer client and family to Myasthenia Gravis Foundation and local self-help groups In severe instances anticipate all needs, because the client is too weak to turn, drink, or even request assistance Maintain a patent airway; suction as necessary; provide tracheostomy care; maintain mechanical ventilation as ordered
Myasthenia Gravis
Evaluation/Outcomes
Maintains a balance between activity and rest Maintains effective respiratory function Identifies signs and symptoms of crises
Guillain-Barr Syndrome
Clinical findings
Subjective:generalized weakness; paresthesia; muscle pain; diplopia Objective Paralysis begins in lower extremities; ascends within the body; maximal deficit usually by 4 weeks Respiratory paralysis Autonomic neuropathy (e.g., hypertension, tachycardia, diaphoresis) Abnormal CSF and electrophysiologic studies
Guillain-Barr Syndrome
Therapeutic interventions
Intravenous therapy with IgG Plasmapheresis Support of vital functions
Guillain-Barr Syndrome
History of any recent illness (particularly viral infections) Onset and progression of symptoms
Analysis/Nursing Diagnoses
Inability to sustain spontaneous ventilation related to muscle weakness Altered role performance related to lengthy recovery period Impaired physical mobility related to impaired neuromuscular function
Guillain-Barr Syndrome
Planning/Implementation
Monitor vital signs, breath sounds, and arterial blood gases Maintain airway and keep tracheostomy set at the bedside Monitor functioning of the respirator and suction as necessary Provide emotional support for the client and family because of the severity of adaptations and lengthy convalescent period
Guillain-Barr Syndrome
Prevent complications of immobility: skin care; range-of-emotion exercises; position changes; coughing and deep breathing; antiembolism stockings Refer client and family to Guillain-Barre Foundation for additional information and community resources Maintains effective respiratory function Remains free from complications of immobility Discusses feelings with family and other health-team members
Evaluation/Outcomes
Clinical findings
Subjective: muscular weakness; malaise; fatigue Objective Fasciculations (irregular spasmodic twitching of small muscle groups); spasticity; atrophy Difficulty in breathing, chewing, swallowing, speaking Outbursts of laughter or crying Abnormal electromyography
Planning/Implementation
Encourage client to remain active as long as possible, employing supportive devices as needed
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Clotting (Helitene)
Helitene
Autoregulation
vascular resistance maintains constant pressure
Concepts of ICP
I C 20 P
10 0
Volume
Blood
vasodilatation, cerebrovascular disease, intracerebral bleeding
CSF
hydrocephalus
hydrocephalus
Normal ICP ~ 0 15
Moderate elevation > 20 mmHg
The END
Time for the Test