Nervous System

unilateral neglect

In perception, a spatial deficit for one half of the visual field.

myelin disorders

Lukodystrophies, Multiple Sclerosis

V Trigeminal

Ophthalmic branch Maxillary branch Mandibular branch From skin and mucous membrane of head to brain; from teeth to brain; from brain to chewing muscles Sensations of face, scalp, and teeth; chewing movements

Corpus callosum

a broad transverse nerve tract connecting the two cerebral hemispheres

reticular formation

a complex neural network in the central core of the brainstem

limbic system

a doughnut-shaped system of neural structures at the border of the brainstem and cerebral hemispheres; associated with emotions such as fear and aggression and drives such as those for food and sex. Includes the hippocampus, amygdala, and hypothalamus.

neurilemma

a layer of cells that covers the axons of peripheral neurons; concerned with nerve regeneration

myelin sheath

a layer of fatty tissue segmentally encasing the fibers of many neurons; enables vastly greater transmission speed of neural impulses as the impulse hops from one node to the next

Hypothalamus

a neural structure lying below the thalamus; directs eating, drinking, body temperature; helps govern the endocrine system via the pituitary gland, and is linked to emotion

Flaccid

Weak, soft, and flabby; lacking normal muscle tone.

Cerebellum

a major division of the vertebrate brain, the "little brain" attached to the rear of the brainstem; it helps coordinate voluntary movement and balance

Meninges

a membrane (one of 3) that envelops the brain and spinal cord

presynaptic neuron

a neuron that propagates nerve impulses toward a synapse

cholinergic fibers

secrete ACh, include proganglionic fibers of both divisions, the postgangionic fibers of the parasympathetic, and a few sympathetic postganglionic fibers (innervate sweat glands and some blood vessels)

Sulci

shallow grooves in the brain

Preganglionic neurons

visceral motor neurons in the CNS

Neurologic Disorders Part 3

•Parkinson's Syndrome • Etiology and risk factors - Progressive degenerative disorder of the basal ganglia: an eventual loss of coordination and control over involuntary motor movement • Parkinson's Syndrome • Signs and symptoms - Tremor, rigidity, and bradykinesia - Loss of dexterity and power in affected limbs, aching, monotone voice, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, reduced blinking, and slumped posture - Depression common; dementia may develop • Parkinson's Syndrome • Medical diagnosis - From health history and physical examination - MRI to rule out other causes of the symptoms • Parkinson's Syndrome • Medical treatment - Control symptoms: physical therapy and drug therapy • Massage, heat, exercise, and gait retraining • Dopamine receptor agonists pramipexole (Mirapex) or ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine); carbidopa/levodopa (Sinemet); anticholinergic drugs such as trihexyphenidyl (Artane) and benztropine (Cogentin) • Parkinson's Syndrome: Nursing Care • Assessment - Weakness, fatigue, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements - Note lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination • Parkinson's Syndrome: Nursing Care • Interventions - Impaired Physical Mobility - Risk for Injury - Imbalanced Nutrition: Less Than Body Requirements - Ineffective Coping - Deficient Knowledge • Multiple Sclerosis • Etiology - Chronic, progressive degenerative disease - Exact cause of MS is unknown; viral infections and autoimmune processes have been implicated • Multiple Sclerosis • Etiology - Attacks the protective myelin sheath around axons and disrupts the conduction of impulses through the CNS • Chronic, progressive MS: progresses steadily • Exacerbating-remitting MS: exacerbations and remissions • Relapsing-progressive MS: less stable periods than exacerbating-remitting • Stable MS: stable; no active disease for a year • Multiple Sclerosis • Signs and symptoms - Fatigue, weakness, and tingling in one or more extremities; visual disturbances; problems with coordination; bowel and bladder dysfunction; spasticity; and depression • Multiple Sclerosis • Medical diagnosis - Based on the physical examination and history of cyclic remission-exacerbation periods - Magnetic resonance imaging of the brain and spinal cord may reveal plaques characteristic of MS • Multiple Sclerosis • Medical treatment - Corticosteroids (ACTH, prednisone, methylprednisolone) - Interferon 1b (Betaseron) and interferon 1a (Avonex) - Glatiramer acetate (Copaxone) • Multiple Sclerosis • Medical treatment - Immunosuppressants: mitoxantrone (Novantrone) - Amantadine (Symmetrel) - Urinary retention treated with cholinergics, such as bethanechol (Urecholine) or neostigmine (Prostigmine) • Multiple Sclerosis: Nursing Care • Assessment - Onset and progression of symptoms, especially those that affect mobility, vision, eating, and elimination - Range of motion and strength, gait abnormalities, tremors, and muscle spasms • Multiple Sclerosis: Nursing Care • Interventions - Impaired Physical Mobility - Disturbed Sensory Perception - Self-Care Deficit - Functional Urinary Incontinence - Risk for Infection - Ineffective Coping - Deficient Knowledge • Amyotrophic Lateral Sclerosis (ALS) • Etiology - Also known as Lou Gehrig's disease; a degenerative neurologic disease - Virus suspected, but exact cause unknown • Pathophysiology - Degeneration of the anterior horn cells and the corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms • ALS • Signs and symptoms - Weakness of voluntary muscles of the upper extremities, particularly the hands - Difficulty swallowing and speaking - Eventually, respirations shallow; difficulty clearing airway of pulmonary secretions - Death results from aspiration, respiratory infection, or respiratory failure • ALS • Medical diagnosis - History and physical examination findings - Electromyography • Medical treatment - Because no known cure or treatment, therapy is supportive; focuses on preventing complications and maintaining maximum function • ALS: Nursing Care • Assessment - Dyspnea, dysphagia, muscle cramps, weakness, twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis • ALS: Nursing Care • Interventions - Ineffective Airway Clearance - Impaired Physical Mobility - Imbalanced Nutrition: Less Than Body Requirements - Impaired Verbal Communication - Impaired Skin Integrity - Anticipatory Grieving - Situational Low Self-Esteem - Interrupted Family Processes • Huntington's Disease • Inherited degenerative neurologic disorder • Usually begins in middle adulthood with abnormal movements, emotional disturbance, and intellectual decline • Symptoms progress steadily: increasing disability and death in 15 to 20 years • Medical and nursing care are supportive only; there is no cure • Myasthenia Gravis • Etiology - May have an autoimmune basis • Pathophysiology - Insufficient receptor sites at the junction of the motor nerve with the muscle - With repeated stimulation, muscle becomes exhausted; eventually unable to contract at all - If respiratory muscles involved, death from respiratory insufficiency or arrest possible • Myasthenia Gravis • Signs and symptoms - Weakness of voluntary muscles, particularly those of chewing, swallowing, and speaking • Partial improvements of strength with rest • Dramatic improvement with the use of anticholinesterase drugs - Ptosis and diplopia commonly seen • Myasthenia Gravis: Nursing Care • Assessment - Health history describes the onset of symptoms: muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance • Myasthenia Gravis: Nursing Care • Interventions - Ineffective Breathing Pattern - Impaired Physical Mobility and Self-Care Deficit - Impaired Swallowing - Deficient Knowledge • Myasthenia Gravis • Medical diagnosis - Administering edrophonium (Tensilon) • Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes • Medical treatment - Anticholinesterase drugs • Neostigmine and pyridostigmine (Mestinon) - Corticosteroids - Cytotoxic therapies - Thymectomy - Plasmapheresis • TIA • Transient Ischemic Attack • Transient ischemic attacks • are sudden, brief attacks of neurologic impairment caused by a temporary interruption in cerebral blood flow. • Symptoms may disappear within 1 hour; some continue for as long as 1 day. • When the symptoms terminate, the client resumes his or her presymptomatic state. A TIA is a warning that a CVA can occur in the near future. • TIA - Pathophysiology and Etiology • TIAs result form impaired blood circulation in the brain. • Common causes of impaired cerebral blood flow include atherosclerosis and arteriosclerosis, cardiac disease, and diabetes. • Dysrythmias and ineffective heart contraction are the catalysts for thrombi that can travel to cerebral vessels. • TIA - Pathophysiology and Etiology • Hypertension, which is associated with some of the previously mentioned etiologies, reduces the blood traveling to the brain and increases the potential for ruptured cerebral vessels from the elevated pressure. • Smoking and other forms of tobacco use aggravate hypertension. • Some medications, such as estrogens used for hormone replacement therapy and oral contraceptives are thrombogenic • TIA - Pathophysiology and Etiology • Hypertension, which is associated with some of the previously mentioned etiologies, reduces the blood traveling to the brain and increases the potential for ruptured cerebral vessels from the elevated pressure. • Smoking and other forms of tobacco use aggravate hypertension. • Some medications, such as estrogens used for hormone replacement therapy and oral contraceptives are thrombogenic • Assessment Findings • Symptoms of a TIA include - temporary light-headedness, - confusion, speech disturbances, - loss of vision, - diplopia, - variable changes in consciousness - numbness, weakness, impaired muscle coordination, or paralysis on one side. • Assessment Findings • A neurologic examination during an attack reveals neurologic deficits. • Auscultation of the carotid artery may reveal a bruit (abnormal sound caused by blood flowing over the rough surface of one or both carotid arteries). • Ultrasound examination of the carotid artery shows an irregular shape to the artery lining caused by atherosclerotic plaques. • Assessment Findings • A carotid arteriogram shows narrowing of the carotid artery. • A CT scan or magnetic resonance imaging (MRI) is used to rule out other neurologic disorders with similar manifestations, such as brain tumor. • Medical and Surgical Management • Antiplatelet and anticoagulant therapy with aspirin, dypyridamole (Persantine), Ticlopidine (Ticlid), and warfarin (Coumadin) are prescribed. • Hypertension is controlled with drug and diet therapy. • Medical and Surgical Management • If narrowing of the carotid artery by atherosclerotic plaques is the cause, and carotid endarterectomy is a treatment option. • A balloon angioplasty, a procedure similar to a percutaneous transluminal coronary artery angioplasty, is performed to dilate the carotid artery and increase blood flow to the brain. • Nursing Management • Obtain a complete history of symptoms and medical, drug, and allergy histories. • Weigh the client and monitor for obesity, hyperlipidemia, and atherosclerosis these are related to cerebrovascular disease. • Check the client's capillary blood sugar to help identify hyperglycemia associated with underdiagnosed or uncontrolled diabetes mellitus. • Nursing Management • Monitor vital signs and note if blood pressure (BP) is 140/90 mm Hg or greater. • ask the client about smoking habits. • Perform neurologic examination to identify the client's current status and establish a baseline for future comparisons. • document and report even subtle changes. • Nursing Management • If the client undergoes carotid artery surgery, the nurse performs frequent neurologic checks to detect paralysis, confusion, facial asymmetry, or aphasia. • He or she monitors the heart rhythm because dysrhythmias can alter blood flow to the brain as well. • Nursing Management • Because it is possible for the neck to swell after surgery, the nurse observes the client closely for difficulty breathing or swallowing and hoarseness. • The nurse places an airway at the bedside and is prepared for endotracheal intubation if an airway obstruction occurs. • Patient Teachings • Maintain hydration by drinking the equivalent of eight glasses of fluid a day, unless contraindicated. • Follow directions for drug therapy, including medications for controlling hypertension and diabetes • Patient Teachings • Monitor for signs of bruising or bleeding if antiplatelet or anticoagulant drugs are prescribed. • Keep appointments for laboratory tests and medical follow-up to monitor the effectiveness of therapy. • Report any future instances of sensory or motor impairment, or call 911 for emergency assistance. • CEREBROVASCULAR ACCIDENT • STROKE • Etiology & Pathophysiology • A cerebrovascular accident or stroke is a prolonged interruption in the flow of blood through one if the arteries supplying the brain. • Brain and cerebral nerve cells are extremely nerve cells are extremely sensitive to a lack of oxygen; if the brain is deprived of oxygenated blood for 3 to 7 minutes, both the brain and nerve cells begin to die. • Etiology & Pathophysiology • Once these cells are destroyed, the outcome is irreversible. • Although the site of the cellular damage is located in the brain, the consequences are widespread. • SPINAL CORD INJURIES • Disorders of Neurologic Function • Meningitis - Etiology/Pathophysiology • An infection of the meninges; may be bacterial, viral, or fungal; bacterial is the most common - Clinical Manifestations • Fever, vomiting, headache, irritability, photophobia, and nuchal rigidity • Progresses to decreased level of consciousness and seizures • Positive Kernig's sign and Brudzinski's sign • Disorders of Neurologic Function • Meningitis (continued) - Medical Management • Immediate IV administration of appropriate antibiotic therapy; usually continues for at least 10 days; isolation until 24 hours after antibiotic therapy began - Nursing Interventions and Patient Teaching • Rest should be promoted in the initial phase of the disease and environmental stimuli kept to a minimum. • Observe vital signs, LOC, I&O, and neurologic signs. • Disorders of Neurologic Function • Encephalitis - Etiology/Pathophysiology • An inflammation of the CNS, mainly the brain and spinal cord - Clinical Manifestations • Malaise, fever, headache, dizziness, nuchal rigidity, nausea, vomiting, ataxia, tremors, seizures, and coma; may proceed to death • Disorders of Neurologic Function • Encephalitis (continued) - Medical Management • Hospitalization for strict observation and supportive care; control fever, ensure adequate hydration and nutrition, and monitor vital signs. - Nursing Interventions • Administer medications; control fever; and monitor neurologic status and vital signs. • Provide emotional support to the child and family.

Endorphins

"morphine within"--natural, opiatelike neurotransmitters linked to pain control and to pleasure.

Table 54-5 Normal Characteristics of Cerebrospinal Fluid

DETERMINATION VALUE Specific gravity 1.007 pH 7.35-7.45 Chloride 120-130 mEq/L Glucose 50-75 mg/dL Pressure 80-200 mm H2O Total volume 80-200 mL (15 mL in ventricles) Total protein 15-45 mg/dL (lumbar) 10-25 mg/dL (cisternal) 5-15 mg/dL (ventricular) Gamma globulin 6%-13% of total protein Cell count Red blood cells None White blood cells 0-10 cells (all lymphocytes and monocytes) Culture and sensitivity No organisms present Serology for syphilis Negative

Hemianopia

Defective vision or blindness if half of the visual field.

Dysarthria

Difficult, poorly articulated speech resulting from interference in the control over the muscles and speech.

Dysphagia

Difficulty swallowing.

Table 54-2 Levels of Consciousness Disorientation

Disoriented; unable to follow simple commands; thinking slowed; inattentive, flat affect

Diplopia

Double vision.

I (olfactory)

Identification of common odors

Apraxia

Impairment of the ability to perform purposeful acts; inability to use objects properly.

Nystagmus

Involuntary, rhythmic movement of the eyes. Oscillations may be horizontal, vertical rotary, or mixed.

Spastic

Involuntary, sudden movement s or muscular contractions with increased reflexes.

Deep brain stimulation(DBS)

Involves placing an electrode in either the thalamus, globus pallidus, or subthalamic nucleus and connecting it to a generator placed in the upper chest ( like a pacemaker).

Table 54-2 Levels of Consciousness Semicomatose

Is in impaired state of consciousness, characterized by obtundation and stupor, from which a patient can be aroused only by energetic stimulation

Guillain-berre syndrome(GBS)

It is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It results in widespread inflammation and demyelination of the peripheral nervous system.

V (trigeminal)

Jaw strength and sensation of face, corneal reflex

afferent neurons

Neurons that transmit messages from sense organs to the central nervous system.

Hyperreflexia

Neurotic condition characterized by increased reflex reactions. '

Table 54-2 Levels of Consciousness Comatose

Unable to respond to painful stimuli; cornea and pupillary reflexes are absent Cannot swallow or cough Is incontinent of urine and feces Electroencephalogram pattern demonstrates decreased or absent neuronal activity

Serotonin

a neurotransmitter that affects hunger,sleep,arousal,and mood. appears in lower than normal levels in depressed persons

acetylcholine

a neurotransmitter that enables learning and memory and also triggers muscle contraction

nucleus

a part of the cell containing DNA and RNA and responsible for growth and reproduction

reflex

a simple, automatic, inborn response to a sensory stimulus, such as the knee-jerk response

glioma

a tumor of the brain consisting of neuroglia

withdrawal reflex

a type of neural control mechanism; such as a hand moving away from heat or fire

Choroid plexus

a vascular plexus of the cerebral ventricles that regulate intraventricular pressure

Catecholamine

are sympathomimetic "fight-or-flight" hormones that are released by the adrenal glands in response to stress. They are part of the sympathetic nervous system.

oligodendrocytes

form myelin sheath around axons in the CNS, one cane myelinate up to 50 axons

Ganglia

groups of nerve cells

endoneurium

inner layer of connective tissue on the spinal nerve; composed of delicate connective tissue fibers that surround individual axons

cell body

largest part of a typical neuron; contains the nucleus and much of the cytoplasm

astrocytes

largest, most numerous glial cells; maintain blood-brain barrier to isolate CNS from general circulation; provide structural support for CNS; regulate ion and nutrient concentrations; perform repairs to stabilize tissue and prevent further injury

Diencephalon

located between the midbrain and the cerebrum and consists of the thalamus, hypothalamus, optic chiasma, and pineal body

Anesthesia

loss of bodily sensation with or without loss of consciousness

Thalamus anti-diuretic

m

perineurium

middle layer of connective tissue on the spinal nerve; partions the nerve into a series of bundles (fascicles) and conveys blood vessels into each individual fiber

postsynaptic neuron

neuron on the receiving end of a synapse

sensory neurons

neurons that carry incoming information from the sense receptors to the central nervous system

motor neurons

neurons that carry outgoing information from the central nervous system to the muscles and glands

Dopamine

neurotransmitter that influences voluntary movement, attention, alertness; lack of dopamine linked with Parkinson's disease; too much is linked with schizophrenia

epineurium

outermost layer of connective tissue on the spinal nerve; a dense network of collagen fibers

Pons

part of the brain, works with the cerebellum in coordinating voluntary movement; neural stimulation studied in activation synthesis theory may originate here

nucleus of schwann cell

pink pertursion on the long white tube (7)

Lumbar puncture

removal by centesis of fluid from the subarachnoid space of the lumbar region of the spinal cord for diagnostic or therapeutic purposes

Proprioception

sensation pertaining to stimuli originating from within the body regarding spatial position and muscular activity stimuli or to the sensory receptors that those stimuli activate. This sensation gives one the ability to know the position of the body without looking at it and ability to "know objectively the sense of touch."

reflex arc

sensory receptor, sensory neuron, motor neuron, and effector that are involved in a quick response to a stimulus

Ventricles

spaces located in the inner brain that contain cerebrospinal fluid

glia

sustentacular tissue that surrounds and supports neurons in the central nervous system

synaptic cleft

synaptic gap or synaptic space; tiny gap between the terminal of one neuron and the dendrites of another neuron (almost never touch); location of the transfer of an impulse from one neuron to the next

axon

the extension of a neuron, ending in branching terminal fibers, through which messages pass to other neurons or to muscles or glands

Pia mater

the highly vascular innermost of the 3 meninges

synapse

the junction between the axon tip of the sending neuron and the dendrite or cell body of the receiving neuron. The tiny gap at this junction is called the synaptic gap or cleft.

Midbrain

the middle division of brain responsible for hearing and sight; location where pain is registered; includes temporal lobe, occipital lobe, and most of the parietal lobe

Dura mater

thick, outermost layer of the meninges surrounding and protecting the brain and spinal cord

Meninges

three membranes that cover the brain and spinal cord, consisting of the dura mater, pia mater, and arachnoid mater

herpes zoster or shingles

what is the recurrent infection of varicella-zoster virus

white matter

whitish nervous tissue of the CNS consisting of neurons and their myelin sheaths

Spinal Cord Injury: ppt

• Anatomy and Physiology of the Spinal Cord • Vertebral Column • Consists of 33 vertebrae • 7 cervical (C1 through C7) • 12 thoracic (T1 through T12) • 5 lumbar (L1 through L5) • 5 sacral (S1 through S5) • 4 fused coccygeal • Spinal Cord • Blood supply • Major arterial supply to the spinal cord; consists of the vertebral arteries posteriorly and the anterior spinal artery • Reflexive activity • The sensory stimulus is received, and a response is initiated at the level of the spinal cord • Diagnostic Tests and Procedures • Neurologic examination • Initial evaluation of the spinal cord: injured patient provides the nurse with a baseline assessment of function and problems • Ongoing assessment necessary to monitor the effects of neurologic injury, detect related complications, and determine patient's need for assistance in activities of daily living • Focuses on the motor and sensory systems • Diagnostic Tests and Procedures • Imaging studies • Radiography • Detects vertebral compression, fractures, or problems with alignment • Computed tomography (CT) • Noninvasive examination of the specific levels of the spinal cord to be visualized, bony vertebrae, and the spinal nerves • Magnetic resonance imaging (MRI) • Produces precise, clear images of internal structures • Myelogram • Visualizes the spinal cord and vertebrae • Pathophysiology of Spinal Cord Injury • Types of Injuries • Location • Cervical, thoracic, or lumbar • Open or closed • Closed: trauma in which the skin and meningeal covering that surround the spinal cord remain intact • Open: damage to the protective skin and meninges • Extent of damage to the cord • Complete spinal cord injury occurs when the cord has been completely severed, whereas an incomplete injury results from partial cutting of the cord • Effects of Spinal Cord Injury • Factors include extent of cut and level of injury • Sometimes cannot be fully determined because the symptoms of spinal cord edema may mimic partial or complete transection • With incomplete spinal cord injuries some function remains below the level of the injury • Specific tracts may be involved, causing particular patterns of neurologic dysfunction • Effects of Spinal Cord Injury • The higher the level of injury, the more encompassing the neurologic dysfunction • Quadriplegia • High cervical spine injuries; loss of motor and sensory function in all four extremities • Paraplegia • Injuries at or below T2 may cause paralysis of the lower part of the body • Respiratory Impairment • Injuries at or above the level of C5 may result in instant death because the nerves that control respiration are interrupted • Cervical injuries below the level of C4 spare the diaphragm but can involve impairment of intercostal and abdominal muscles • Spinal Shock • An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases • Autonomic Dysreflexia • Exaggerated response of autonomic nervous system to noxious (painful) stimuli • With injury at or above the level of T6 • The sympathetic nervous system is stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system • Autonomic Dysreflexia • Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes • Spasticity • Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation • Impaired Sensory and Motor Function • Impaired motor function can affect the patient's mobility and self-care and thus result in complications from immobility • Loss of sensation puts patient at risk for skin breakdown and other injuries because pressure and pain are not perceived • Impaired Bladder Function • During spinal shock, all bladder and bowel function ceases • Once spinal shock resolves, reflex activity returns • Impaired Bowel Function • Most spinal cord-injured patients can maintain bowel function because the large bowel musculature has its own neural center that responds to distention by the fecal mass • Impaired Temperature Regulations • May lose these regulatory mechanisms and be unable to adapt to temperature extremes • Impaired Sexual Function • Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels results in sexual dysfunction • Ability to achieve erection and ejaculation is variable • Impaired Skin Integrity • Because immobile patient can't change positions, skin in sacral area and across bony prominences may break down • Loss of tone results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores • Altered Self-Concept and Body Image • French and Phillips (1991) describe the effects of spinal cord injury on body image as occurring in four phases: impact, retreat, acknowledgment, and reconstruction • Medical Treatment in the Acute Phase • Saving the Patient's Life: Establish Airway • Conventional head-tilt-chin-lift: inappropriate with spinal injury; increases risk of cord damage • Risk of additional damage is especially high with cervical injury • Neck flexion, even that caused by a pillow or other support, must be avoided • Jaw-thrust method of opening the airway is preferred for these patients • Saving the Patient's Life: Establish Airway • Once airway is open, administer 100% oxygen by mask and manual resuscitator • Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation • Any injury that compromises ventilation must be treated immediately • Preventing Further Cord Injury • Traction • Immobilization with skeletal traction manages cervical spinal cord injuries acutely • Gardner-Wells tongs • Secured just above the ears; doesn't actually penetrate skull • Crutchfield tongs • Applied directly to the skull just behind the hairline • Halo vest: immobilizes and aligns cervical vertebrae; placed when surgery is done to internally stabilize fractures and relieve the compression of nerve roots • Preventing Further Cord Injury • Special beds and cushions • Kinetic bed, such as the Roto-Rest bed, continually rotates the patient from side to side • Overlay air mattresses: flotation devices placed on standard hospital beds • Air-fluidized and flotation beds may be used after the spine has been stabilized • Wedge-Stryker frame: canvas and metal frame bed that may be used to help turn the patient • Types of cushions include those inflated with air, flotation devices, and gel pads • Preventing Further Cord Injury • Drug therapy • Methylprednisolone • Reduces the damage to the cellular membrane • Administered within the first 8 hours of injury • Completely paralyzed patients often regain about 20% of function • Partially paralyzed have regained up to 75% of function • Preserving Cord Function • Early surgical intervention to repair cord damage • Cord compression by bony fragments, compound vertebral fractures, and gunshot and stab wounds • Surgery within the first 24 hours is most desirable • Laminectomy • Involves removing all or part of the posterior arch of the vertebra • Spinal fusion • If multiple vertebrae are involved • Placing a piece of donor bone into area between the involved vertebrae • Assessment • Monitor the patient's level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output • Health History • Present illness • Event that brought the patient to the hospital • Specific injuries incurred in the incident • Describe pain and other symptoms in detail • Past Medical History • Other accidents or injuries and chronic illnesses such as diabetes, hypertension, heart disease, cancer, or seizure disorder • Previous hospitalizations and operations • Obstetric history from female patient • Identify and record current medications and allergies • Family History • Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma • Review of Systems • Skin condition, headache or dizziness, vision disturbances, hearing impairment or tinnitus, nasal or ear drainage, dyspnea, nausea and vomiting, constipation or diarrhea, fecal incontinence, bladder dysfunction, sexual dysfunction, and impaired motor and sensory function • Functional Assessment • Patient's self-care abilities • Patient's roles and responsibilities as a family member • Occupation, hobbies, usual activity pattern, habits, and diet • Emotional response to the spinal injury • Usual coping strategies • Spiritual beliefs; other sources of support • Physical Examination • Record the patient's reported height and weight • Take vital signs • Take the temperature • Level of responsiveness, posture, and spontaneous movements • Inspect the skin for lesions • Evaluate tissue turgor • Inspect head for lesions and palpate for masses and swelling • Physical Examination • Examine pupils for size, equality, reaction to light • Respiratory effort and breath sounds • Inspect abdomen; auscultate for bowel sounds • Inspect extremities for open fractures or abnormal positions • Range of motion • Ability to perceive sharp and dull sensation; use a dermatome chart • Interventions • Ineffective Breathing Pattern • Risk for Injury and Disturbed Sensory Perception • Risk for Autonomic Dysreflexia • Risk for Disuse Syndrome • Bowel Incontinence • Impaired Urinary Elimination • Interventions • Risk for Infection • Ineffective Thermoregulation • Feeding/Dressing/Grooming Self-Care Deficit • Sexual Dysfunction • Ineffective Coping • Ineffective Therapeutic Regimen Management • Rehabilitation • Activities that assist individual to achieve highest possible level of self-care and independence • Well-organized interdisciplinary team that can address all aspects of function • Physician, nurse, physical therapist, occupational therapist, speech therapist, dietitian, social worker, psychologist, and counselor • Patient and family must be emotionally and physically prepared to make adjustments • Rehabilitation • Team helps the patient accomplish activities of daily living and self-care and addresses successful adjustment to social integration and gainful employment in the workplace • Although this phase of treatment may take more than a year, patient, family, and rehabilitation team can take pride in the realization that a life can once again be productive and happy • Nursing Care of the Laminectomy Patient • Preoperatively • Assess patient's vital signs and neurologic status to establish baselines • Patient's understanding of surgical routines • Tell patient what to expect in the immediate postoperative period • Ongoing assessment of neurologic status and on promoting healing at the operative site • Nursing Care of the Laminectomy Patient • Assessment • Vital signs, neurologic status, and breath sounds • Frequently assess movement, strength, range of motion, and ability to localize sensory stimulus • Fluid intake and output • Abdomen for bowel sounds; palpate bladder • Inspect the surgical dressing for bleeding, clear cerebrospinal fluid drainage, and foul drainage • If the patient has pain, obtain a complete description • Nursing Care of the Laminectomy Patient • Interventions • Risk for Injury • Ineffective Tissue Perfusion • Acute Pain • Impaired Urinary Elimination • Constipation • Impaired Physical Mobility • Deficient Knowledge

Life Span Considerations Older Adults Neurologic Disorder

• As neurons are lost with aging, neurologic function deteriorates, resulting in slowed reflex and reaction time. • Tremors that increase with fatigue are commonly observed. • The sense of touch and fine motor coordination diminish with aging. • Most older people possess the ability to learn, but the speed of learning is slowed. Short-term memory is more affected by aging than long-term memory. • The incidence of physiologic dementia or organic brain syndrome—including Alzheimer's disease, Pick's disease, and multiinfarct dementia—increases with age. • The incidence of stroke increases with age. The prognosis is affected by the location and extent of the cerebral damage. Rehabilitation potential after a stroke is often reduced by advanced age and coexisting medical problems. • Nerve irritation from arthritis, joint injuries, or spinal-cord compression can cause chronic pain or weakness. PREVENTION OF NEUROLOGIC PROBLEMS

Functions of the Cerebrum PARIETAL LOBE

• Interpretation of sensory impulses from the skin, such as touch, pain, and temperature. • Recognition of body parts. • Determination of left from right. • Determination of shapes, sizes, and distances.

Functions of the Cerebrum OCCIPITAL LOBE

• Interpretation of visual impulses from the retina.

Functions of the Cerebrum TEMPORAL LOBE

• Wernicke's area: Language comprehension. When Wernicke's area is damaged in the person's dominant hemisphere, receptive aphasia results. The person hears sound, but it has no meaning, like hearing a foreign language. • Integration of auditory stimuli.

Functions of the Cerebrum FRONTAL LOBE

• Written speech: Ability to write. • Motor speech, Broca's area: Ability to speak. Motor speech is mediated in Broca's area in the frontal lobe. When an injury to Broca's area (or the hemisphere in general) occurs, expressive aphasia can result and the patient will not be able to speak. The patient can only produce a garbled sound, but can understand language and knows what he or she wants to say. • Motor ability: Movements of body. The left side of the brain controls the right side of the body, and the right side of the brain controls the left side of the body. • Intellectualization: The ability to form concepts, personality, emotion, behavior. • Judgment formation.

IV (trochlear)

Tested with oculomotor; testing eye movements

VI (abducens)

Tested with oculomotor; testing eye movements

III (oculomotor)

Testing of ability of eyes to move together in all directions, testing pupillary response

dendrites

branching extensions of neuron that receives messages from neighboring neurons

tracts

bundles of axons in the white matter of the CNS that share common origins, destinations and functions

neurotransmitters

chemical messengers that traverse the synaptic gaps between neurons. When released by the sending neuron, neurotransmitters travel across the synapse and bind to receptor sites on the receiving neuron, thereby influencing whether that neuron will generate a neural impulse.

Parkinson disease

condition of slowly progressive degeneration of an area of the brainstem (substantia nigra) resulting in a decrease of dopamine ( a chemical neurotransmitter that is necessary for proper movement); characterized by tremor; rigidity of muscles, and slow movements (bradykinesia), usually occurring later in life

Medulla oblongata

contains centers that control several visceral functions, including breathing, heart and blood vessel activity, swallowing, vomiting, and digestion.

Neurologic Disorders Part 2

Seizure Disorder Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors Medical diagnosis Accurate history of the seizure disorder Electroencephalogram (EEG) Seizure Disorder: Classification Partial seizures Simple Part of one cerebral hemisphere; consciousness not impaired Complex Consciousness impaired; may exhibit bizarre behavior Seizure Disorder: Classification Generalized seizures Involve the entire brain from the onset Consciousness lost during the ictal (seizure) period Types: tonic-clonic, absence, myoclonic, and atonic Seizure Disorder Status epilepticus Medical emergency: continuous seizures or repeated seizures in rapid succession for 30 minutes or more Aura Dizziness, numbness, visual or hearing disturbance, noting an offensive odor, or pain may precede a seizure Medical treatment Resolution of the underlying condition Anticonvulsant drug therapy Seizure Disorder Surgical treatment Removal of seizure foci in the temporal lobe and pallidotomy or vagal nerve stimulator Seizure Disorder: Nursing Care Assessment Describe the seizure episode, including the postictal period (following the seizure), and document drug therapy Seizure Disorder: Nursing Care Risk for Injury Side rails of bed up and padded, suction machine readily available, bed maintained in the low position Quickly move objects away from the patient Do not attempt to restrain the patient Ineffective Coping and Deficient Knowledge Teach family and patient about the seizure disorder and the therapy Teaching must be directed toward helping the patient and family adjust to a chronic condition Encourage questions and concerns Head Injury: Types Scalp injuries Lacerations, contusions, abrasions, and hematomas Concussion Trauma with no visible injury to the skull or brain Contusion Bruising and bleeding in the brain tissue Head Injury: Types Hematoma Subdural hematoma or epidural hematoma Intracerebral hemorrhage From lesions within the tissue of the brain itself Penetrating injuries Sharp objects penetrate the skull and brain tissue Skull Fractures (usually subdural) Clinical Manifestations Battle Sign, ecchymosis over mastoid process Racoon Eyes, bilateral periorbital ecchymosis Hemoptympanum, blood visible behind the tympanic membrane Rhinorrhea, CSF leakage through the nose Otorrhea, CSF leakage through the ear Head Injury Surgical treatment Directed at evacuating hematomas and débriding damaged tissue Head Injury: Nursing Care Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Risk for Injury Risk for Infection Impaired Physical Mobility Disturbed Body Image and Ineffective Role Performance Brain Tumors Etiology and risk factors Some congenital; others may be related to heredity Drug/environmental factors may play a role in development Signs and symptoms Directly related to area of brain invaded by the tumor Visual disturbances and headache New-onset seizure activity Difficulties with balance and coordination Medical treatment Surgery often followed by radiation with or without chemotherapy Brain Tumors: Nursing Care Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping Meningitis Etiology and risk factors Inflammation of the meningeal coverings of the brain and spinal cord caused by either viruses or bacteria Meningococci (Neisseria meningitides) and streptococci (Streptococcus pneumoniae)and Haemophilus influenzae are the most common causative bacteria and highly contagious forms of meningitis. Meningitis Signs and symptoms Headache, nuchal rigidity (stiffness of the back of the neck), irritability, diminished level of consciousness, photophobia (sensitivity to light), hypersensitivity, and seizure activity Positive Kernig's sign and Brudzinski's sign. positive Kernig's sign (inability to extend the leg when the thigh is flexed on the abdomen) positive Brudzinski's sign (flexion of the neck produces flexion of the knees and hips) Meningitis Signs and symptoms client with meningoccal meningitis may have multiple, small to large petechiae that spread about the body, giving the appearance of a rug burn. The petechiae intensity and coalesce (fuse together) to resemble purpura or ecchymoses due to a secondary disturbance in blood coagulation from thrombocytopenia or disseminated intravascular coagulation. Meningitis Medical diagnosis Lumbar puncture to obtain CSF for lab analysis The CSF pressure is elevated, glucose concentration is decreased, protein levels are elevated, and white blood cell (WBC) and red blood cell counts are elevated. Culture and sensitivity studies are done to identify the specific causative bacteria. If meningitis is viral, the results of culture and sensitivity studies are negative. A CT scan, blood culture, complete to rule out other possible disorders. Meningitis Medical treatment Bacterial infections usually respond to antimicrobial therapy, but no specific drugs effective against most viral infections Anticonvulsants used to control seizure activity if necessary The appropriate antibiotic, usually penicillin, a cephalosporin, rifampin (Rifadin), vancomycin (Vancocin), or chloramphenicol (Chloromycetin), is identified from the results of the sensitivity tests. Drug therapy is continued after the acute phase of the illness to prevent recurrence. Meningitis Medical treatment Clients with viral meningitis are provided supportive treatment, but pleconaril, a new antiviral drug that may be helpful in treating viral meningitis and other viral infections, is nearing completion of Phase III clinical trials (Quinonez, 2003). Anticonvulsants are necessary if seizures occur. People who have had recent contact with the person with meningococcal meningitis are placed on prophylactic oral rifampin (Rifadin). The local public health department is notified of all cases. Meningitis: Nursing Care Assessment Assess vital signs and neurologic status frequently to determine further deterioration or onset of complications Evaluate the client's ability to swallow and clear the airway of secretions. The nurse provides for intake and output measurements. He or she records bowel elimination to ensure that constipation does not develop. The nurse asks the client to indicate the severity of a headache, when present. If a seizure occurs, the nurse notes its duration, physical manifestations, and whether it involved only one side of the body or started in one site and spread elsewhere. Meningitis: Nursing Care Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Acute Pain Risk for Injury Deficient Fluid Volume Meningitis: Nursing Care Interventions Keep an oral airway at the bedside; insert it immediately if respiratory distress develops. An oral airway holds the tongue forward so it does not occlude the pharynx. Administer oxygen as prescribed. Supplement oxygen increases the percentage of oxygen in inhaled gas higher than that in room air. Report respiratory difficulty, which may require emergency intubation. Respiratory distress that is unrelieved by repositioning the head, inserting an oral airway, and administering oxygen may require medical interventions to prevent hypoxemia\ Meningitis: Nursing Care Interventions Elevate the head of the bed. Head elevation lowers abdominal organs away from the diaphragm, which facilitates inhalation of a greater volume of air. Hyperoxygenate and hyperventilate before and after airway suctioning. Suctioning removes oxygen as well as secretions from the respiratory passages. Use caution when giving oral fluids, food, or medications to a lethargic client. A who is not alert may aspirate food, fluids, and oral medications. Encephalitis Etiology and risk factors Inflammation of brain tissue caused by virus Signs and symptoms Fever, nuchal rigidity (stiff neck), headache, confusion, delirium, agitation, and restlessness commonly seen Comatose or exhibit aphasia, hemiparesis, facial weakness, and other alterations in motor activity Encephalitis Medical treatment Enhance patient comfort and increase strength Because seizure activity is a potential problem, take appropriate safety precautions Encephalitis Nursing Management The nurse monitors vital signs and LOC frequently and compares findings with previous assessments. If urinary retention or urinary incontinence develops, the nurse consults the physician to discuss whether an indwelling urethral catheter is appropriate. The nurse measures fluid intake and output to detect signs of fluid volume deficit and electrolyte imbalances. Encephalitis: Nursing Care The nursing plan of care parallels that of the patient with meningitis BRAIN ABSCESS Pathophysiology and Etiology A brain abscess occurs from an infection in nearby structures such as the middle ear, sinuses, or teeth, or from an infection in other organs. A brain abscess can develop after intracranial surgery or head trauma. It can be secondary to such disorders as bacterial endocarditis, bacteremia, and pulmonary or abdominal infections. BRAIN ABSCESS Pathophysiology and Etiology A brain abscess produces Neurologic changes according to its location. Because it occupies space in the cranium, IICP can develop. Complications include paralysis, mental deterioration, seizure disorder, and visual disturbances. BRAIN ABSCESS Assessment Findings: Manifestations of a brain abscess include signs of IICP, fever, headache, and Neurologic changes such as paralysis, seizures, muscle weakness, and lethargy. Laboratory tests show an elevated WBC count. Analysis of CSF obtained by lumbar puncture helps confirm the diagnosis, but this procedure has a risk of herniation of the brain stem. A CT scan, MRI, and skull radiographs are safer techniques for diagnosing and locating the abscess. BRAIN ABSCESS Medical and Surgical Management Antimicrobial therapy begins once the diagnosis is confirmed. A craniotomy, discussed later in this chapter, typically is performed to drain the abscess. Cerebral edema and seizures are treated with drug therapy. Additional treatment includes control of fever, mechanical ventilation, IV fluids, and nutritional support. BRAIN ABSCESS Nursing Management The nurse assesses frequently for altered LOC, changes in sensory and motor functions, and signs of IICP. Monitor vital signs. The nurse measures fluid intake and output because overhydration can lead to cerebral edema. Guillain-Barré Syndrome Etiology and risk factors Although specific cause unknown, it is believed to be an autoimmune response to a viral infection Patients often report some recent viral infection or vaccination Guillain-Barré Syndrome Initial phase Symmetric muscle weakness: begins in lower extremities; ascends to trunk and upper extremities Visual and hearing disturbances, difficulty chewing, and lack of facial expression Mild paresthesias or anesthesia in feet and hands in a glove or stocking distribution pattern Hypertension, orthostatic hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention Guillain-Barré Syndrome Plateau phase Remains essentially unchanged No further neurologic deterioration, but no improvement either Recovery phase Remyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes) Guillain-Barré Syndrome Medical diagnosis Characteristic onset and pattern of ascending motor involvement Elevated protein level in the CSF Nerve conduction velocity studies reveal slowed conduction speed in the involved nerves Guillain-Barré Syndrome Medical treatment Preserve vital function, particularly respiration Respiratory status is closely monitored and mechanical ventilation initiated if vital capacity falls to 15 mL/kg of body weight Massive doses of corticosteroids prescribed to suppress the inflammatory process Plasmapheresis Guillain-Barré Syndrome Medical treatment Plasmapheresis, removal of plasma from the blood and reinfusion of the cellular components with saline, has been shown to shorten the course of the disease if performed within the first 2 weeks. Administering of intravenous immune globulin known as Gamimune N soon after symptoms manifest may enhance improvement. Otherwise, treatment is primarily supportive. For example, the physician may order gaBAPENTIN (Neurontin) or a tricyclic antidepressant such as amitriptyline (Elavil) or a narcotic to relieve discomfort (Worsham, 2000). Guillain-Barré Syndrome Medical treatment If the respiratory muscles are involved, endotracheal intubation and mechanical ventilation become necessary. Difficulty chewing and swallowing necessitate the administration of IV fluids, gastric tube feedings, or total parenteral nutrition (TPN). Guillain-Barré Syndrome: Nursing Care Assessment Health history describes the progression of symptoms Note fears, coping strategies, and sources of support Physical examination focuses on cranial nerve, motor, respiratory, and cardiovascular function Guillain-Barré Syndrome: Nursing Care Interventions Ineffective Breathing Pattern Decreased Cardiac Output Risk for Disuse Syndrome Imbalanced Nutrition: Less Than Body Requirements Anxiety Deficient Knowledge Rehabilitation Guillain-Barré Syndrome: Nursing Care NURSING MANAGEMENT The nurse observes the client closely for signs of respiratory distress. He or she uses a spirometer to evaluate the client's ventilation capacity. To assess for pneumonia, the nurse checks vital signs and lung sounds frequently. Guillain-Barré Syndrome: Nursing Care NURSING MANAGEMENT Because immobility incapacitates the client, the nurse provides meticulous skin care and changes the client's position every 2 hours. Help the client perform range-of-motion (ROM) exercises to prevent muscle atrophy. For further aspects of nursing management, manage the care similar to a client with an infectious or inflammatory Neurologic disorder. INCREASED INTRACRANIAL PRESSURE Pathophysiology and Etiology: Under normal circumstances, autoregulatroy mechanisms keep brain tissue prefused with adequate oxygen and glucose. Dilation or constriction of cerebral blood vessels in response to changes in blood pressure, blood oxygen levels, and blood pH maintains constant and consistent tissue perfusion. For example, increased PaCO2 (carbon dioxide level in the blood), decreased blood pH, or decreased PaO2 (oxygen level in the blood) causes cerebral blood vessels to dilate. INCREASED INTRACRANIAL PRESSURE Pathophysiology and Etiology: Range of ICP should remain at 15 mm Hg or below to ensure normal cerebral perfusion pressure (CCP) of 70 to 100 mm Hg. Many conditions, including brain tumors, swelling or bleeding within the brain from head trauma, and infectious and inflammatory disorders of the brain (e.g., meningitis, encephalitis), cause increased intracranial pressure (IICP). INCREASED INTRACRANIAL PRESSURE Pathophysiology and Etiology: Hypotension and hypoxia lead to vasodilation, which contributes to IICP, compressing blood vessels, which leads to cerebral ischemia. If IICP continues to be unrecognized or untreated, the contents of the cranium are compressed further. Unrelieved pressure causes brain tissue to herniated or shift from normal locations intracranially and extracranially As IICP progresses, the consequences include impaired cellular activity, temporary or permanent neurologic dysfunction, or death. INCREASED INTRACRANIAL PRESSURE Signs and Symptoms Decreasing level of consciousness (LOC) is one of the earliest signs of IICP. Confusion, restlessness, and periodic disorientation often accompany decreasing LOC. Headache is another symptom of IICP. Headache, which severe in the morning, increases with activities that elevate ICP, such as coughing, sneezing, or straining at stool. Rest or elevation of the head relieves the pain. A constant headache is a grave sign. INCREASED INTRACRANIAL PRESSURE Signs and Symptoms Vomiting when associated with a neurologic condition also suggests increasing ICP. Emesis commonly occurs without any forewarning of nausea. Papilledema (swelling of the optic nerve) is cased by interference with venous drainage from the eye and is observed through examination with an opthalmoscope. Pressure on the oculomotor nerve usually accompanies IICP and affects papillary response to light. Normal pupil response to strong light is rapid constriction. In IICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated. INCREASED INTRACRANIAL PRESSURE Signs and Symptoms Changes in ICP also influence vital signs. Body temperature may rise or fall depending on the etiology of the IICP or because of its effect on the temperature-regulation center. The pulse increases initially by then decreases, systolic BP rises with a widening pulse pressure (the difference between the systolic and diastolic measurement), Respiratory rate is irregular - three signs called Cushing's triad. Cushing's triad occurs late in IICP. Later, Cheyne-Stokes respirations occur, consisting of shallow, rapid breathing followed by periods of apnea. INCREASED INTRACRANIAL PRESSURE Signs and Symptoms Decorticate or decerebrate posturing develops spontaneously or in response to a painful stimulus when ICP is increased. Cushing's Triad Response to Increased ICP-Review: Assessment of ICP Early signs = blurred vision & diplopia because of pressure in visual pathway Later signs = headache and vomiting Most Significant = Change in LOC... as pressure increases from front to back, LOC deteriorates ! Cushing's Triad Response to Increased ICP: Increased Systolic Blood Presure while diastolic remains the same. Widening pulse pressure Reflex Bradycardia from stimulation of carotid bodies CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA (TIC DOULOUREUX) Trigeminal neuralgia is a painful condition that involves the fifth cranial nerve (the trigeminal nerve), which has three major branches; mandibular, maxillary, and ophthalmic. This sensory and motor nerve is important to chewing, facial movement, and sensation. CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA (TIC DOULOUREUX)Pathophysiology and Etiology The cause of the disorder is unknown. It has been suggested that it is related to compression of the trigeminal nerve root by an aneurism,artery or tumor Trauma or infection can precipitate an attack. For reasons not fully understood, the client experiences neuralgia (nerve pain) in one or more branches of the trigeminal nerve. CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA (TIC DOULOUREUX)Pathophysiology and Etiology The slightest stimulus (e.g., vibrations of music, passing breeze, temperature change) over trigger points (areas that provoke the pain)ingestion of cold or hot liquids can initiate an attack. The forehead over the eyebrow is a common trigger point when the ophthalmic branch of the nerve is affected. CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA (TIC DOULOUREUX) MEDICAL TREATMENT -MEDICAL: Phenitoin(Dilantin) and Carbamazepine(Tegretol) -In acute attacks alcohol or phenol may be injected into the affected branch with pain relief for 8 to 16 months -SURGICAL -Patients with very painful and debilitating cases may go to surgical resection or electrocoagulation of the sensory fibers of the nerve CRANIAL NERVE DISORDERS TRIGEMINAL NEURALGIA (TIC DOULOUREUX) Intervention:Talking,chewing,ingesting cold or hot food may be avoided may avoid some activities or sudden changes of temperature may produce social isolation-need teaching coping strategies BELL'S PALSY Bell's palsy involves the seventh cranial nerve, which is responsible for movement of the facial muscles. BELL'S PALSY Pathophysiology and Etiology The cause of Bell's palsy is unknown, but a viral link is inspected. Inflammation occurs around the nerve compression leads to impaired nerve function. As a result, there is weakness and paralysis of facial muscles, including the muscles of the eyel

Postganglionic neurons

axons connecting ganglion cells with peripheral effectors

ppt nervous system

•Overview of Anatomy and Physiology Structural divisions Central nervous system (CNS) • Brain and spinal cord Peripheral nervous system • Somatic nervous system Sends messages from the CNS to the skeletal muscles; voluntary • Autonomic nervous system Sends messages from the CNS to the smooth muscle, cardiac muscle, and certain glands; involuntary • Overview of Anatomy and Physiology • Cells of the nervous system Neuron Neuromuscular junction Neurotransmitters • Acetylcholine; norepinephrine; dopamine; serotonin Neuron coverings • Figure 14-1 • Overview of Anatomy and Physiology • Central nervous system Brain • Cerebrum • Diencephalon • Cerebellum • Brain stem Midbrain; pons; medulla oblongata; coverings of the brain and spinal cord; ventricles • Spinal cord • Figure 14-2 • Overview of Anatomy and Physiology • Peripheral nervous system Spinal nerves Cranial nerves Autonomic nervous system • Sympathetic nervous system • Parasympathetic nervous system • Figure 14-4 • Overview of Anatomy and Physiology • Effects of normal aging on the nervous system Loss of brain weight Loss of neurons Reduction in cerebral blood flow Decrease in brain metabolism and oxygen utilization Decreased blood supply to spinal cord causes decreased reflexes • Overview of Anatomy and Physiology • Prevention of neurological problems Avoid drug and alcohol use Safe use of motor vehicles Safe swimming practices Safe handling and storage of firearms Use of hardhats in dangerous construction areas Use of protective padding as needed for sports • Assessment of the Neurological System • History • Mental status • Level of consciousness Glasgow coma scale • Language and speech • Cranial nerve function • Motor function • Sensory and perceptual status • Laboratory and Diagnostic Examinations • Blood and urine Culture Drug screens Arterial blood gases • Cerebrospinal fluid • Computed tomography (CT) • Brain scan • MRI scan • PET scan • Lumbar puncture • Figure 14-6 • Laboratory and Diagnostic Examinations • Electroencephalogram • Myelogram • Angiogram • Carotid duplex • Digital subtraction angiography • Electromyogram • Echoencephalogram • Common Disorders of the Neurological System • Headaches Etiology/pathophysiology • Skull and brain tissues are not able to feel sensory pain • Vascular headaches Migraine Cluster Hypertensive • Tension headaches • Traction-inflammation headaches • Common Disorders of the Neurological System • Headaches (continued) Clinical manifestations/assessment • Head pain • Migraine headaches Prodromal (early sign/symptom) o Visual field defects, unusual smells or sounds, disorientation, paresthesias During headache o Nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema • Common Disorders of the Neurological System • Headaches (continued) Medical management/nursing interventions • Pharmacological management Migraine headaches o Aspirin, acetaminophen, ibuprofen o Ergotamine tartrate o Codeine; Inderal • Dietary recommendations Limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork • Psychotherapy • Common Disorders of the Neurological System • Headaches (continued) Medical management/nursing interventions • Cluster headaches Narcotic analgesics • Tension headaches Non-narcotic analgesics • Traction-inflammatory headaches Treat cause • Comfort measures Cold packs to forehead or base of skull Pressure to temporal arteries Dark room; limit auditory stimulation • Common Disorders of the Neurological System • Neuropathic pain Etiology and pathophysiology • May arise from several occurrences • The pain transmission is not fully understood Clinical manifestations • Ranges from mild to excruciating • Changes in ability to carry out ADLs Medical management/nursing implications • Pharmacological management Anticonvulsants; nonopioid analgesics; antidepressants • Comfort measures • Common Disorders of the Neurological System • Increased intracranial pressure Etiology/pathophysiology • Increase in any content of the cranium • Space-occupying lesions, cerebrospinal problems, cerebral edema Clinical manifestations/assessment • Diplopia • Headache • Decreased level of consciousness • Pupillary signs • Common Disorders of the Neurological System • Increased intracranial pressure (continued) Clinical manifestations/assessment (continued) • Widening pulse pressure • Bradycardia • Respiratory problems • High, uncontrolled temperatures • Positive Babinski's reflex • Seizures • Posturing • Vomiting • Singultus • Common Disorders of the Neurological System • Increased intracranial pressure (continued) Medical management/nursing interventions • Treat cause if possible • Pharmacological management Corticosteroids Antacids; histamine-receptor blockers Anticonvulsants • Mechanical decompression Craniotomy Craniectomy • Internal monitoring devices • Common Disorders of the Neurological System • Disturbances in muscle tone and motor function Etiology/pathophysiology • Damage to the nervous system causes serious problems in mobility Clinical manifestations/assessment • Flaccid or hyperreflexic muscle tone • Clumsiness or incoordination • Abnormal gait • Common Disorders of the Neurological System • Disturbances in muscle tone and motor function (continued) Medical management/nursing interventions • Muscle relaxants • Protect from falls • Assess skin integrity • Positioning • Sit up and tuck chin when eating • Encourage patient to assist with ADLs • Emotional support • Other Disorders of the Neurological System • Epilepsy or seizures Etiology/pathophysiology • Transitory disturbance in consciousness or in motor, sensory, or autonomic function due to sudden, excessive, and disorderly discharges in the neurons of the brain; results in sudden, violent, involuntary contraction of a group of muscles • Types: grand mal; petit mal; psychomotor; Jacksonian-focal; myoclonic; akinetic • Status epilepticus • Other Disorders of the Neurological System • Epilepsy or seizures (continued) Clinical manifestations/assessment • Depends on type of seizure • Aura • Postictal period Medical management/nursing interventions • During seizure: Protect from aspiration and injury • Anticonvulsant medications • Surgery Removal of brain tissue where seizure occurs • Other Disorders of the Neurological System • Epilepsy or seizures (continued) Medical management/nursing interventions (continued) • Adequate rest • Good nutrition • Avoid alcohol • Avoid driving, operating machinery, and swimming until seizures are controlled • Good oral hygiene • Medic Alert tag • Degenerative Diseases • Multiple sclerosis Etiology/pathophysiology • Degenerative neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum • Figure 14-13 • Degenerative Diseases • Multiple sclerosis (continued) Clinical manifestations/assessment • Visual problems • Urinary incontinence • Fatigue • Weakness • Incoordination • Sexual problems • Swallowing difficulties • Degenerative Diseases • Multiple sclerosis (continued) Medical management/nursing interventions • No specific treatment • Pharmacological management Adrenocorticotropic hormone (ACTH) Steroids Valium Betaseron (interferon beta-1b) Avonex (interferon beta-1a) Pro-banthine; urecholine Bactrim, Septra, and Macrodantin • Degenerative Diseases • Multiple sclerosis (continued) Medical management/nursing interventions • Nutrition • Skin care • Activity • Environmental controls • Patient teaching • Degenerative Diseases • Parkinson's disease Etiology/pathophysiology • Deficiency of dopamine Clinical manifestations/assessment • Muscular tremors; bradykinesia • Rigidity; propulsive gait • Emotional instability • Heat intolerance • Decreased blinking • "Pill-rolling" motions of fingers • Figure 14-14 • Degenerative Diseases • Parkinson's disease (continued) Medical management/nursing interventions • Pharmacological management Levodopa Sinemet Artane Cogentin Symmetrol • Surgery • Activity • Nutrition • Degenerative Diseases • Alzheimer's disease Etiology/pathophysiology • Impaired intellectual functioning • Chronic, progressive degeneration of the cells of the brain • Brain changes include plaques in the cortex, neurofibrillary tangles, and the loss of connections between cells and cell death • Degenerative Diseases • Alzheimer's disease (continued) Clinical manifestations/assessment • Early stage Mild memory lapses; decreased attention span • Second stage Obvious memory lapses • Third stage Total disorientation to person, place, and time Apraxia; wandering • Terminal stage Severe mental and physical deterioration • Degenerative Diseases • Alzheimer's disease (continued) Medical management/nursing interventions • Pharmacological management Agitation: Lorazepam; Haldol Dementia: Cognex; Aricept • Nutrition Finger foods; frequent feedings; encourage fluids • Safety Remove burner controls at night Double-lock all doors and windows Constant supervision • Degenerative Diseases • Myasthenia gravis Etiology/pathophysiology • Neuromuscular disorder; nerve impulses fail to pass at the myoneural junction; causes muscular weakness Clinical manifestations/assessment • Ptosis; diplopia • Skeletal weakness; ataxia • Dysarthria; dysphagia • Bowel and bladder incontinence • Degenerative Diseases • Myasthenia gravis (continued) Medical management/nursing interventions • Pharmacological management Anticholinesterase drugs o Prostigmin o Mestinon Corticosteroids • May require mechanical ventilation • Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) Etiology/pathophysiology • Motor neurons in the brain stem and spinal cord gradually degenerate • Electrical and chemical messages originating in the brain do not reach the muscles to activate them • Lou Gehrig's disease • Degenerative Diseases • Amyotrophic lateral sclerosis (ALS) (continued) Clinical manifestations/assessment • Weakness of the upper extremities • Dysarthria; dysphagia • Muscle wasting • Compromised respiratory function Medical management/nursing interventions • No cure • Rilutec (Riluzole) • Multidisciplinary ALS teams; emotional support • Degenerative Diseases • Huntington's disease Etiology/pathophysiology • Overactivity of the dopamine pathways • Genetically transmitted Clinical manifestations/assessment • Abnormal and excessive involuntary movements (chorea) • Ataxia to immobility • Deterioration in mental functions • Degenerative Diseases • Huntington's disease (continued) Medical management/nursing interventions • No cure; palliative treatment • Pharmacological management Antipsychotics Antidepressants Antichoreas • Safe environment • Emotional support • High-calorie diet • Vascular Problems • Stroke (cerebrovascular accident) Etiology/pathophysiology • Abnormal condition of the blood vessels of the brain: thrombosis; embolism; hemorrhage • Results in ischemia of the brain tissue Clinical manifestations/assessment • Headache • Sensory deficit • Hemiparesis; hemiplegia • Dysphasia or aphasia • Figure 14-17 • Vascular Problems • Stroke (cerebrovascular accident) (continued) Medical management/nursing interventions • Thrombosis or embolism Thrombolytics Heparin and Coumadin • Decadron • Neurological checks • Nutritional interventions • Physical, occupational, and/or speech therapy • Cranial and Peripheral Nerve Disorders • Trigeminal neuralgia Etiology/pathophysiology • Degeneration of or pressure on the trigeminal nerve; tic douloureux Clinical manifestations/assessment • Excruciating, burning facial pain Medical management/nursing interventions • Tegretol • Surgical resection of the trigeminal nerve • Avoid stimulation of face on affected side • Cranial and Peripheral Nerve Disorders • Bell's palsy (peripheral facial paralysis) Etiology/pathophysiology • Inflammatory process involving the facial nerve Clinical manifestations/assessment • Facial numbness or stiffness • Drawing sensation of the face • Unilateral weakness of facial muscles • Reduction of saliva • Pain behind the ear • Ringing in ear or other hearing loss • Cranial and Peripheral Nerve Disorders • Bell's palsy (peripheral facial paralysis) (continued) Medical management/nursing interventions • Pharmacological management Corticosteroids Antiviral medications • Electrical stimulation • Moist heat • Massage of the affected area • Facial exercises • Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome Etiology/pathophysiology • Inflammation and demyelination of the peripheral nervous system • Possibly viral or autoimmune reaction • Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome (continued) Clinical manifestations/assessment • Symptoms are progressive • Paralysis usually starts in the lower extremities and moves upward; may stop at any point • Respiratory failure if intercostal muscles are affected • May have difficulty swallowing, breathing, and speaking • Cranial and Peripheral Nerve Disorders • Guillain-Barré syndrome (continued) Medical management/nursing interventions • Adrenocortical steroids • Apheresis • Mechanical ventilation • Gastrostomy tube • Meticulous skin care • Range-of-motion exercises • Cranial and Peripheral Nerve Disorders • Meningitis Etiology/pathophysiology • Acute infection of the meninges • Bacterial or aseptic • Increased incidence in winter and fall months • Cranial and Peripheral Nerve Disorders • Meningitis (continued) Clinical manifestations/assessment • Headache; stiff neck • Irritability; restlessness • Malaise • Nausea and vomiting • Delirium • Elevated temperature, pulse, and respirations • Kernig's and Brudzinski's signs • Cranial and Peripheral Nerve Disorders • Meningitis (continued) Medical management/nursing interventions • Pharmacological management Antibiotics o Massive doses o Multiple types o IV or intrathecal Corticosteroids Anticonvulsants Antipyretics • Dark, quiet room • Cranial and Peripheral Nerve Disorders • Encephalitis Etiology and pathophysiology • Acute inflammation of the brain caused by a virus Clinical manifestations • Headache • Fever • Seizures • Change in LOC Medical management and nursing interventions • Primarily supportive • Cranial and Peripheral Nerve Disorders • West Nile virus Etiology and pathophysiology • Principal route of infection through the bite of an infected mosquito Clinical manifestations • Fever • Headache • Back pain • Myalgia Prevention • Cranial and Peripheral Nerve Disorders • Brain abscess Etiology and pathophysiology • Accumulation of pus within the brain tissue Clinical manifestations • Headache • Fever • Drowsiness, changes in LOC • Seizures Medical management/nursing interventions • Antimicrobial therapy • Supportive care • Cranial and Peripheral Nerve Disorders • Acquired immunodeficiency syndrome Etiology and pathophysiology • Symptoms may develop from the infection with HIV or as a result of an associated infection Clinical manifestations • AIDS dementia complex (ADC) • Memory loss • Global cognitive dysfunction Medical management/nursing interventions • Antiviral, antifungal, antibacterial agents • Anticonvulsants • Safety • Cranial and Peripheral Nerve Disorders • Brain tumors Etiology/pathophysiology • Benign or malignant • Primary or metastatic • May affect any area of the brain • Cranial and Peripheral Nerve Disorders • Brain tumors (continued) Clinical manifestations/assessment • Headache • Hearing loss • Motor weakness • Ataxia • Decreased alertness and consciousness • Abnormal pupil response and/or unequal size • Seizures • Speech abnormalities • Cranial and Peripheral Nerve Disorders • Brain tumors (continued) Medical management/nursing interventions • Surgical removal of tumor Craniotomy Intracranial endoscopy • Radiation • Chemotherapy • Combination of above • Trauma • Craniocerebral trauma Etiology/pathophysiology • Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma • Direct trauma: Head is directly injured • Indirect trauma: Tension strains and shearing forces • Open head injuries • Closed head injuries • Hematomas • Trauma • Craniocerebral trauma Clinical manifestations/assessment • Headache • Nausea • Vomiting • Abnormal sensations • Loss of consciousness • Bleeding from ears or nose • Abnormal pupil size and/or reaction • Battle's sign • Trauma • Craniocerebral trauma (continued) Medical management/nursing interventions • Maintain airway • Oxygen • Mannitol and dexamethasone • Analgesics • Anticonvulsants • Trauma • Spinal cord trauma Etiology/pathophysiology • Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds • Fracture of vertebra • Complete cord injury • Incomplete cord injury • Figure 14-24 • Trauma • Spinal cord trauma (continued) Clinical manifestations/assessment • Loss of muscle function depends on level of injury • Spinal shock • Autonomic dysreflexia • Sexual dysfunction • Trauma • Spinal cord trauma (continued) Medical management/nursing interventions • Realignment of bony column for fractures or dislocations: Immobilization; skeletal traction Surgery for spinal decompression • Methylprednisolone • Mobility: Slowly increase sitting up • Urinary function: Foley catheter; bladder training Intermittent catheterization • Bowel program • Nursing Process • Nursing diagnoses Autonomic dysreflexia Communication, impaired Coping, compromised family Disuse syndrome, risk for Grieving Infection, risk for Knowledge, deficient Memory, impaired • Nursing Process • Nursing diagnoses (continued) Mobility, impaired physical Nutrition, imbalanced: less than body requirements Pain, acute, chronic Self-care deficit Swallowing, impaired Thought process, disturbed Tissue perfusion (cerebral), ineffective

IX (glossopharyngeal)

Identification of taste

Chapter 27 Neurologic Disorders

Anatomy and Physiology of the Nervous System Neuron (Nerve Cell) Functional unit of the nervous system that conducts electrical impulses from one area of the brain to another Sensory neurons Transmit information from distal parts of the body or environment toward the central nervous system Motor neurons Carry motor information from the CNS to the periphery Axons and Dendrites Branch off the main cell body Axons conduct impulses away from the cell body Dendrites convey impulses toward the cell body Myelin Material that covers many axons and dendrites Enhances conduction along nerve fibers Gives the axons a white appearance; cell bodies without myelin are gray Central Nervous System (CNS) Made up of the brain and spinal cord Peripheral Nervous System Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves Brain Divided into the cerebrum, cerebellum, and brainstem Cerebrospinal Fluid (CSF) Composed of water, glucose, sodium chloride, and protein Acts as a shock absorber for the brain and spinal cord Spinal Cord Extends from the border of the first cervical vertebra (C1) to the level of the second lumbar vertebra (L2) Thirty-one pairs of spinal nerve roots exit the spinal cord, each consisting of a posterior sensory (afferent) root and anterior motor (efferent) root These roots, along with the 12 cranial nerves, make up the peripheral nervous system Autonomic Nervous System Controls the involuntary activities of the viscera, including smooth muscle, cardiac muscle, and glands Two major subdivisions: sympathetic nervous system and the parasympathetic nervous system Age-Related Changes The number of nerve cells decreases Brain weight is reduced; ventricles increase in size Lipofuscin: aging pigment deposited in nerve cells with amyloid, a type of protein Increased plaques and tangled fibers in nerve tissue Eye pupil often smaller; may respond to light more slowly Age-Related Changes Reflexes intact except for Achilles tendon jerk, which is often absent Reaction time increases, especially complex reactions Tremors in the head, face, and hands are common Some develop dizziness and problems with balance Pathophysiology of Neurologic Diseases Types of Disorders Developmental and genetic Trauma Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders Nursing Assessment of Neurologic Function Health history Note speech, behavior, coordination, alertness, comprehension Chief complaint and history of present illness Document what prompted the patient to seek medical attention Describe any injuries If patient has pain, note the onset, severity, location, and duration Past medical history Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer Record dates and types of immunizations Nursing Assessment of Neurologic Function Family history Have immediate family members had heart disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or Huntington's disease? Nursing Assessment of Neurologic Function Review of systems Fatigue or weakness, headache, dizziness, vertigo, changes in vision/hearing, tinnitus, drainage from ears or nose, dysphagia, neck pain or stiffness, vomiting, bladder or bowel function, sexual dysfunction, fainting, blackouts, tremors, paralysis, incoordination, numbness or tingling, memory problems, mood changes Nursing Assessment of Neurologic Function Functional assessment Document whether present symptoms interfere with the patient's usual activities and occupation Explore sources of stress, usual coping strategies, and sources of support Physical examination Level of consciousness, pupillary evaluation, neuromuscular response, and vital signs Diagnostic Tests and Procedures Advanced neurologic examination Cranial nerves Coordination and balance Neuromuscular function Sensory function Pain Temperature Light touch Vibration Position Tactile discrimination Diagnostic Tests and Procedures Lumbar puncture Electroencephalography Electromyography Radiologic studies Brain scan Cerebral angiography and digital subtraction angiography Computed tomography Magnetic resonance imaging Common Therapeutic Measures Drug therapy Antimicrobials Analgesics Anti-inflammatory Corticosteroids Anticonvulsants Diuretics Chemotherapeutic agents Dopaminergics Anticholinergics Cholinergics Antihistamines Common Therapeutic Measures Surgery Craniotomy Surgical opening of the skull Craniectomy Excision of a segment of the skull Cranioplasty Any procedure done to repair a skull defect Disorders of the Nervous System Migraine Headache Intracranial vasoconstriction followed by vasodilation Triggered by menstruation, ovulation, alcohol, some foods, stress Pain usually unilateral, often begins in the temple or eye area and is very intense Migraine Headache Tearing and nausea and vomiting may occur Hypersensitive to light and sound; prefers dark, quiet environment Mild migraines treated with acetaminophen or aspirin; severe ones with ergotamine (Cafergot) or sumatriptan (Imitrex) tablet or autoinjector for self-injection Cluster Headache Occur in a series of episodes followed by a long period with no symptoms Intensely painful and seem to be related to stress or anxiety Usually have no warning symptoms Treatment may include cold application, indomethacin (Indocin), and tricyclic antidepressants Tension Headache Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources, such as a brain tumor or an abscessed tooth Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing Tension Headache Treatment: correction of known causes, psychotherapy, massage, heat application, and relaxation techniques Analgesics, usually nonopioid, may be prescribed to reduce anxiety END Intro to: Nervous System Disorders

Cranial and spinal nerves

2 nerves that make up the peripheral nervous system

fascicles

Bundle of muscle fibers

VIII (acoustic, or vestibulocochlear)

Testing of hearing through whisper or other means and checking equilibrium and balance

Stroke

An abnormal condition of the blood vessels of the brain characterized by hemorrhage into the brain; formation of an embolus or thrombus resulting in ischemia of the brain tissues normally perfused by the damaged vessels. The sequelae depend on the location and extent of the ischemia.

multiple sclerosis

A chronic disease of the central nervous system marked by damage to the myelin sheath. Plaques occur in the brain and spinal cord causing tremor, weakness, incoordination, paresthesia, and disturbances in vision and speech

Paresis

A lesser degree of movement deficit from partial or incomplete paralysis.

Aneurysm

A localized dilation of the wall of the blood vessel, usually caused by atherosclerosis, hypertension, and less commonly by a congenital weakness in a vessel wall.

Glasgow coma scale

A quick, practical, standardized system for assessing the degree of conscious impairment in the critically ill; also used for predicting the duration and ultimate outcome of coma, primarily in patients with head injuries.

Postrictal period

A rest period of variable length after a tonic-clonic seizure

II (optic)

Testing of visual acuity and visual fields

microglia

Act as phagocytes, eating damaged cells and bacteria, act as the brains immune system

Unilateral neglect

Condition in which an individual is perceptually unaware of and inattentive to one side of the body.

sympathetic postganglionic neurons

Adrenergic (alpha or beta)- release catecholamines (NE, E or dopamine); Can go to same targets as PSNS; NE stored in vesicles, released, when vesicles fuse with membrane on depolarization, across the synapse

Bradykinesia

An abnormal condition characterized by slowness of voluntary movements and speech.

VII (facial)

Ability of face to move in symmetry, identification of tastes

Ataxia

Abnormal condition characterized by impaired ability to coordinate movement.

Aphasia

Abnormal neurologic condition in which language function is defective or absent because of an injury to certain areas of the cerebral cortex.

blood-brain barrier(BBB)

An anatomic-physiological feature of the brain tissue that prevents or slows the passage of some drugs and other chemical compounds and disease causing orgnanisms such as viruses from entering the central nervous system. This barrier is created by the modification of brain capillaries that prevents many substances from leaving the blood and crossing the capillary walls into the brain tissues.

Enkephalins

An opioid neuromodulator. Widespread throughout the brain and dorsal horn of the spinal cord, are considered less potent then endorphins.

Autonomic or visceral effectors

Any muscle or gland (effector) found within the cavities of the body and controlled by the ANS; examples inculde cardiac muscle tissue, smooth muscle tissue, and internal glands with glandular epithelial tissue

adrenergic fibers

Any of the fibers that transmit impulses to other nerve cells, smooth muscle, or gland cells by norepinephrine

norephrine

Associated with dreaming, attention, arousal, fatigue and depression

Global cognitive dysfunction

Generalized impairment of intellect, awareness, and judgment.

Central and Peripheral Nervous PPT

Central and Peripheral Nervous System Medications Learning Objectives Identify the major classes of drugs that affect the central nervous system List different actions of antimigraine products Explain the major actions of drugs used to treat disorders of the central nervous system Nervous System & Medication Adrenergic fibers Cholinergic fibers Receptors: alpha 1 and 2; beta blockers Antimigraine Agents Action: block nerve impulses in the receptors of the sympathetic nervous system Relieve pain by narrowing dilated cerebral arteries Use: prevention and treatment of migraine headaches Table 16-1 Adverse Reactions- Antimigraine Agents Drug Interactions: other vasoconstrictors; MAOIs Nursing Implications: assessment, diagnosis, planning, implementation, and evaluation Patient Teaching: administration considerations Anticonvulsants or Antiepileptic Drugs Seizures: sudden muscle contractions that happen without conscious control Etiology: disease or disorders; head injury Idiopathic Epilepsy, convulsions, seizures Table 16-3 Barbiturates Long duration of action and sedative effect on the brain; action occurs in the brainstem Use: status epilepticus; prevent and control grand mal seizures May treat seizures caused by tetanus, fever, or drugs Benzodiazepines CNS depressants; suppress electrical discharge in seizures Use: treat minor motor seizures; Lennox-Gestault syndrome (petit mal) Hydantoins Action: work primarily on the motor cortex, where they stop the spread of seizure activity by increasing or decreasing Na+ ion movement across the motor cortex during the generation of nerve impulses Use: grand mal and psychomotor seizures; status epilepticus, migraines, and trigeminal neuralgia Succinimides Action: elevation of the seizure threshold in the cortex and basal ganglia and reduced synaptic response to low-frequency repetitive stimulation Use: petit mal seizures Other Drugs: Table 16-2 Nursing Considerations Nursing Implications: assessment, diagnosis, planning, implementation, and evaluation Patient Teaching Antiemetic-Antivertigo Agents Some drugs, metabolic disorders, radiation, motion, gastric irritation, vestibular neuritis, or increases in central trigger zone dopamine levels or vomiting center acetylcholine levels may provoke nausea and vomiting Act to redirect stimulation by stopping or reducing stimulation of the vomiting center Used to prevent and treat motion sickness or the nausea and vomiting that occur with surgery, anesthesia, and cancer treatment Adverse Reactions Drowsiness and drug tolerance with long-term therapy Anticholinergic effects Drug Interactions Nursing Considerations Assessment: patient history Secondary problems: nutrition and hydration Antiparkinsonian Agents Actions: Change the neurotransmitters produced in the brain: excessive acetylcholine; deficient dopamine Block the uptake of acetylcholine and elevate the functional levels of dopamine in the motor regulatory centers Use: Control of the symptoms of Parkinson's disease Adverse Reactions Dysrhythmias, muscle twitching, GI symptoms, etc. Anticholinergic agents Drug Interactions Many; read product information closely Nursing Implications Assessment, diagnosis, planning, implementation, and evaluation Psychotherapeutic Agents Antianxiety Medications Antidepressants Antipsychotic Drugs Antimanic Drugs Sedation-Hypnotic Medications Antianxiety Agents Anxiety is common Problematic when it interferes with a person's ability to perform activities of daily living Overview Benzodiazepine action: produce a calming effect Used to relieve anxiety, tension, and fear that occur May be used to manage alcohol withdrawal symptoms; preoperatively; relieve muscle spasm Adverse Reactions Common adverse reactions Drug Interactions Increase effects Antagonize effects Nursing Implications and Patient Teaching Assessment, diagnosis, planning, implementation, evaluation Teaching: dosing; appointments and follow-up; adverse reactions; safety with storage; drug and alcohol interactions Habit forming: should be used for the least time possible Antidepressants Overview Depression may interfere with activities of daily living Not all patients respond to medications MAOIs Tricyclics SSRIs Tricyclic Antidepressants Used to treat endogenous depression; mild depression due to exogenous causes Action believed to inhibit the reuptake of norepinephrine and or/serotonin Adverse reactions Drug interactions Nursing implications and patient teaching Monoamine Oxidase Inhibitors MAO: enzyme found in the mitochondria of cells located in nerve endings, kidneys, liver, and intestines Acts by inactivating dopamine, norepinephrine, epinephrine, and serotonin...regulates the intercellular levels Used to relieve the symptoms of severe reactive or of endogenous depression that have not responded to tricyclic antidepressants, ECT, or psychotherapy Selective Serotonin Reuptake Inhibitors Act by inhibiting CNS neuronal uptake of serotonin Used short-term for treatment of outpatients with a diagnosis listed as a category of Major Depressive Disorders in the DSM-IV Used long-term for dysthymic and minor depressive disorders Adverse reactions Drug interactions Nursing implications and patient teaching Miscellaneous Antidepressants Tetracyclic compounds: maprotiline, mirtazapine (Remeron), trazodone (Desyrel) Unrelated products: bupropion (Wellbutrin), nefazodone (Serzone), venlafaxine (Effexor) Antipsychotic Drugs Used in the treatment of severe mental illness May be used in combination with major tranquilizers Act by blocking the action of dopamine in the brain Phenothiazines and Thioxanthenes Action: block dopamine at the postsynaptic receptor, thus increasing the metabolism of dopamine; reduce sensory simulation and produce a sedating effect; act as an antiemetic by inhibiting action in the chemoreceptor center Used for reducing and relieving acute and chronic psychosis: schizophrenia, schizoaffective disorders, and involutional psychosis Nonphenothiazines Mechanism of action for these products is often not precisely understood Antimanics Lithium action is unknown; alters sodium transport at the nerve endings, and enhances the uptake of serotonin and norepinephrine by the cells (inactivates these neurotransmitters) Mood stabilizing drug Used in the treatment of patients with manic-depressive psychosis who are in acute mania; prevents recurrent mania episodes Sedative-Hypnotic Medications Used to relax patients and induce sleep; before medical testing; treatment of insomnia caused by mental and physical stress Sedative agent: relaxes the patient and allows him or her to sleep Hypnotic agent produces sleep in the patient Sedative-Hypnotic Medications (cont.) Adverse Reactions Drug Interactions Nursing Implications Patient Teaching

interneurons

Central nervous system neurons that internally communicate and intervene between the sensory inputs and motor outputs

sympathetic preganglionic neurons

Cholinergic- produce, store, and release Ach; Ach released when neurons are electrically depolarized, which then cause the nicotinic receptors at postganglionic cell to depolarize, beginning another action potential

Table 54-4 FOUR Score Coma Scale CATEGORY OF RESPONSE RESPONSE SCORE Eye response (E)

Eye response (E) Eyelids open or opened, tracking, or blinking to command 4 Eyelids open but not tracking 3 Eyelids closed, open to loud noise, not tracking 2 Eyelids closed, open to pain, not tracking 1 Eyelids remain closed with pain 0 Brainstem reflexes (B) Pupil and corneal reflexes present 4 One pupil wide and fixed 3 Pupil or corneal reflexes absent 2 Pupil and corneal reflexes absent 1 Absent pupil, corneal, and cough reflex 0 Motor response (M) Thumbs up, fist or peace sign, to command 4 Localizing to pain 3 Flexion response to pain 2 Extensor posturing 1 No response to pain or generalized myoclonus status epilepticus 0 Respiration (R) Not intubated, regular breathing pattern 4 Not intubated, Cheyne-Stokes breathing pattern 3 Not intubated, irregular breathing pattern 2 Breathes above ventilator rate 1 Breathes at ventilator rate or apnea 0

Glasgow Coma Scale: Demonstrating Measurement of Level of Consciousness CATEGORY OF RESPONSE APPROPRIATE STIMULUS RESPONSE SCORE

Eyes Open • Approach to bedside • Verbal command • Pain Spontaneous response 4 Opening of eyes to name or command 3 Lack of opening of eyes to previous stimuli but opening to pain 2 Lack of opening of eyes to any stimulus 1 Untestable U Best Verbal Response • Verbal questioning with maximum arousal Appropriate orientation, conversant; correct identification of self, place, year, and month 5 Confusion; conversant, but disorientation in one or more spheres 4 Inappropriate or disorganized use of words (e.g., cursing), lack of sustained conversation 3 Incomprehensible words, sounds (e.g., moaning) 2 Lack of sound, even with painful stimuli 1 Untestable U Best Motor Response • Verbal command (e.g., "raise your arm, hold up two fingers") • Pain (pressure on proximal nailbed) Obedience of command 6 Localization of pain, lack of obedience but presence of attempts to remove offending stimulus 5 Flexion withdrawal,* flexion of arm in response to pain without abnormal flexion posture 4 Abnormal flexion, flexing of arm at elbow and pronation, making a fist 3 Abnormal extension, extension of arm at elbow usually adduction and internal rotation of arm at shoulder 2 Lack of response 1 Untestable U

Cerebrospinal fluid(CSF)

Fluid that circulates throughout the brain and spinal cord

XI Spinal accessory

From brain to certain shoulder and neck muscles Shoulder movements (trapezius muscle) and turning movements of head (sterno-cleidomastoid muscles)

IV Trochlear

From brain to external eye muscles Down and inward movement of eye

VI Abducens

From brain to external eye muscles Lateral movement of eye

III Oculomotor

From brain to eye muscles Eye movements, extraocular muscles, pupillary control (pupillary constriction)

XII Hypoglossal

From brain to muscles of tongue Tongue movements

VIII Acoustic (vestibulocochlear)

From ear to brain Hearing; sense of balance (equilibrium)

II Optic

From eye to brain Vision

I Olfactory

From nose to brain Sense of smell

VII Facial

From taste buds of tongue to brain; from brain to facial muscles Sense of taste on anterior two thirds of tongue; contraction of muscles of facial expression

IX Glossopharyngeal

From throat and taste buds of tongue to brain; from brain to throat muscles and salivary glands Sensations of throat, taste, swallowing movements, gag reflex, taste posterior one third of tongue, secretion of saliva

X Vagus

From throat, larynx, and organs in thoracic and abdominal cavities to brain; from brain to muscles of throat and to organs in thoracic and abdominal cavities Sensations of throat, larynx, and thoracic and abdominal organs; swallowing, voice production, slowing of heartbeat, acceleration of peristalsis

X (vagus)

Gag reflex, movement of uvula and soft palate

nodes of ranvier

Gaps in the myelin sheath of the axons of peripheral neruons. Action potentials can 'hump' from node to node, thus increasing the speed of conduction (saltatory conduction).

Hemiplegia

Paralysis of one side of the body.

Autonomic neurons

Preganglionic autonomic neurons conduct from spinal cord or brainstem to an autonomic ganglion; post-ganglionic neurons conduct from autonomic ganglia to cardiac muscle, smooth muscle, & glandular epithelial tissue

Safety Alert!

Preventing Neurologic Injuries • One of the best ways to prevent head injuries is to prevent car and motorcycle accidents. • Become active in campaigns that promote safe driving. Speak to driver's education classes regarding the danger of unsafe driving and driving after drinking alcohol or taking drugs. • The use of seatbelts in cars and the use of helmets for riding on motorcycles are the most effective measures for increasing survival after accidents. • Individual states have legislation requiring the use of automobile safety devices for both children and adults. • Recommend the wearing of protective helmets by lumberjacks, construction workers, miners, horseback riders, bicycle riders, snowboarders, and skydivers

Table 54-2 Levels of Consciousness Alert

Responds appropriately to auditory, tactile, and visual stimuli

Table 54-2 Levels of Consciousness Stupor

Responds to verbal commands with moaning or groaning, if at all; seems unaware of the surroundings

Aura

Sensation, as of light or warmth, that may precede the onset of a migraine or an epileptic seizure. An epileptic aura may be psychic, or may be sensory with olfactory, visual, auditory, or taste hallucinations.

XI (spinal accessory)

Shoulder and neck movement

receptors

Special structures that allow living organisms to sense the conditions of their internal or external environment

salutatory conduction

The mechanism of propagation of nerve impulse in a myelinated nerve fibre; actually travels by leaping through the nodes of Ranvier in a myelinated fibre; thus, the local circuits occur only at the nodes where action potential is boosted to the same height by ionic mechanisms

grey matter

The portions of the central nervous system that are abundant in cell bodies of neurons rather than axons. The colour appears grey relative to white matter

myelinated fibers

The propagation of a nerve signal that jumps from node to node. Fast, but decremental (loses strenghth) until it gets to a Ranvier node where voltage regulated gates are located.

synaptic knob

The swelling at the end of a neurone where it forms a junction (synapse) with another neurone.

Cerebral nuclei

The term for the clusters of gray matter found within the white matter of the brain.

XII (hypoglossal)

Tongue motion

Agnosia

Total or partial loss of the ability to recognize familiar objects or people through sensory stimuli; results from organic brain damage.

Timby/Smith: Introductory Medical-Surgical Nursing, 9/e Chapter 45: Caring for Clients With Head and Spinal Cord

Trauma Head Injuries: Concussion Pathophysiology and Etiology Blow to the head that jars the brain Temporary neurologic impairment Assessment Findings Brief lapse of consciousness; disorientation Headache; blurred or double vision Emotional irritability; dizziness Skull radiography, CT scan, MRI Head Injuries: Concussion Medical Management Halting of activity Mild analgesia Observation for neurologic complications Nursing Management Neurologic assessment Close observation for signs of IICP Client instruction: Contact physician or return to ED if symptoms of IICP occur Head Injuries: Contusion Pathophysiology and Etiology Coup and contrecoup injury Cerebral edema Assessment Findings Hypotension; rapid, weak pulse Shallow respirations; pale, clammy skin Temporary amnesia Effects of permanent brain damage Skull radiography; CT scan; MRI Head Injuries: Contusion Medical Management Drug therapy; mechanical ventilation Nursing Management Periodically monitor LOC; neurologic changes; respiratory distress; signs of IICP; vital signs Steps to prevent head injuries Seatbelts; infant car seats; protective headgear; neck restraints; no alcohol or drugs while driving Head Injuries: Cerebral Hematomas Pathophysiology and Etiology Head trauma Cerebral vascular disorders Types: Epidural; subdural; intracerebral Assessment Findings Depends on location; rate of bleeding; size of hematoma; autoregulation MRI; CT scan; ICP monitoring Head Injuries: Cerebral Hematomas Head Injuries: Cerebral Hematomas Medical Management Indications of surgical emergency Rapid change in LOC Signs of uncontrolled IICP Surgical Management Burr holes Intracranial surgery: Craniotomy, craniectomy, and cranioplasty Surgical approaches Supratentorial Infratentorial Head Injuries: Cerebral Hematomas Nursing Management All head injuries are emergencies Nurse's role History; neurologic examination; vital signs; LOC Movement in limbs; pupil examination Trauma Head examination Respiratory status Neurologic changes Head Injuries: Cerebral Hematomas Nursing Management Preoperative nursing care Hair removal; vital signs; neurologic assessment; antiembolism stockings If indicated: IV; catheter Restrict: Fluids Postoperative nursing care Supine or side-lying position Regular monitoring; observe for IICP Control thrombus or embolus; cerebral edema Head Injuries: Skull Fractures Pathophysiology and Etiology Head injuries: Open; closed Skull fractures: Simple; depressed; basilar Assessment Findings Signs and symptoms Localized headache; bump, bruise, or laceration; hemiparesis; shock Rhinorrhea; otorrhea Periorbital ecchymosis; Battle's sign Conjunctival hemorrhages; seizures Head Injuries: Skull Fractures Assessment Findings Diagnostic findings: Skull radiographs; CT scan; MRI Medical and Surgical Management Simple fracture: Bed rest; observation for IICP Lacerated scalp: Clean, débride, and suture Depressed skull fracture: Craniotomy; antibiotics; osmotic diuretics; anticonvulsants Head Injuries: Skull Fractures Nursing Management Signs of head trauma Drainage from the nose or ear Halo sign Neurologic assessments Hourly: LOC; pupil, motor, and sensory status Every 15 to 30 minutes: Vital signs Prepare for the possibility of seizures Spinal Cord Injuries Pathophysiology and Etiology Accidents (vehicular); violence Spinal shock (Areflexia): Poikilothermia Autonomic dysreflexia (hyperreflexia) Assessment Findings Pain; difficulty breathing Numbness; paralysis Neurologic examination Radiography; myelography; MRI; CT scan Spinal Cord Injuries Medical Management Cervical collar; cast or brace; traction; turning frame IV; stabilization of vital signs Corticosteroids Surgical intervention Surgical Management Surgery to Remove bone fragments Repair dislocated vertebrae Stabilize the spine Nursing Process: Care of the Client With Spinal Trauma Assessment Injury; treatment given at scene Neurologic assessment: Document findings Vital signs; respiratory status Movement and sensation below injury level Signs Worsening neurologic damage Respiratory distress Spinal shock Nursing Process: Care of the Client With Spinal Trauma Diagnosis, Planning, and Interventions Ineffective breathing pattern Ineffective airway clearance Neuropathic pain Impaired physical mobility Anxiety Risks Impaired gas exchange Disuse syndrome Ineffective coping Nursing Process: Care of the Client With Spinal Trauma Evaluation of Expected Outcomes Adequate breathing Pain relief Mobility using minimal assistive devices Reduced complications from inactivity Coping with the challenge of rehabilitation Spinal Nerve Root Compression Pathophysiology and Etiology Trauma Herniated intervertebral disks Tumors of the spinal cord Assessment Findings Weakness; paralysis Pain; paresthesia Spinal radiography; CT MRI; myelography Electromyography Spinal Nerve Root Compression Spinal Nerve Root Compression Medical Management Cervical collar or brace; bed rest; skin traction; hot moist packs Skeletal muscle relaxants; drug therapy; corticosteroids; analgesics Surgical Management Diskectomy Laminectomy Spinal fusion Chemonucleolysis Spinal Nerve Root Compression Nursing Management Neurologic examination Conservative therapy Spinal support and alignment; bed rest in Williams' position; tractions Proper body mechanics Muscle relaxants and analgesics; moist heat application Evaluation of client response to therapy Spinal Nerve Root Compression Nursing Management After spinal surgery Monitor vital signs Hourly deep breathing exercises Examine the dressing for CSF leakage or bleeding Assess neurovascular status Voiding status Fracture bed pan General Considerations Nutritional Considerations Hypercalcemia Adequate, regular fluid intake High-fiber diet Tetraplegics and paraplegics Adjust calorie intake to avoid weight gain Nutrient needs may be stable or higher Clients with skin breakdown Increased requirements for protein, vitamin C and zinc to promote healing General Considerations Pharmacologic Considerations Mannitol: Reduction of ICP after surgery Respiratory depressant effects less likely with codeine Antipyretics and other measures relieve elevated temperature Skeletal muscle relaxant or tranquilizer may lead to drowsiness and dizziness Medications in liquid form for clients with impaired swallowing General Considerations Gerontologic Considerations Older adults Often respond less favorably to therapies for a neurologic deficit May incur a chronic fluid volume deficit Encourage a fluid intake of 1,500 to 2,000 mL/day End of Presentation

Hydrocephalus

an abnormal condition in which cerebrospinal fluid collects in the ventricles of the brain

fight or flight response

an emotional and physiological reaction to an emergency that increases readiness for action

ganglion

an encapsulated neural structure consisting of a collection of cell bodies or neurons

mitochondrion

an organelle containing enzymes responsible for producing energy

Cerebrum

anterior portion of the brain consisting of two hemispheres

nerve

any bundle of nerve fibers running to various organs and tissues of the body

schwann cell

any cell that covers the nerve fibers in the peripheral nervous system and forms the myelin sheath

Cerebrovascular accident (CVA)

damage to the brain caused by cerebrovascular disease; e.g. occlusion of a blood vessel by an embolus or thrombus or intracranial hemorrhage after rupture of an aneurysm

Gyri

elevated ridges on cortical surface of the cerebral hemisphere, which increase the surface area and provide space for additional cortical neurons