Chapter037

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Chapter 37: Caring for Clients with Central and Peripheral Nervous System

Disorders


Increased Intracranial Pressure Increased Intracranial Pressure • Anatomy: Brain tissue (84%); Blood (4%); CSF (12%)

– Significant increase without compensation Increased Intracranial Pressure

• Pathophysiology and Etiology

– Brain tumors; Head trauma; Infectious, inflammatory disorders

• Signs and Symptoms

– Decreasing LOC; Headache; Papilledema

– Late signs: Cushing’s triad; Cheyne-Stokes respirations


Increased Intracranial Pressure Increased Intracranial Pressure • Diagnostic Findings

– CT; MRI; Lumbar puncture; Cerebral angiography; Skull radiography

• Medical and Surgical Management

– Immediate goal: Decrease ICP by relieving cause

– Goals

• Maintain BP

• Prevent hypoxia

• Ensure cerebral perfusion


Intracranial HerniationsIntracranial Herniations

Figure 37-1 Major types of intracranial herniations


Meningitis Meningitis • Meningeal inflammation, often extends to cerebral

cortex


– Bacteria (most serious, most contagious form); Viruses; Fungi, Parasites

• Signs and Symptoms

– Headache; Fever; Nuchal rigidity

– N/V; Photophobia; Kerning’s sign

– Brudzinski sign; Opisthotonos; Petechiae


Meningitis Meningitis • Diagnostic Findings

– Lumbar puncture; CSF analysis

• C & S

– CT scan; CBC; Blood culture, etc.

• Medical Management

– Reduction of ICP

– IV fluids; Antimicrobial therapy

– Anticonvulsants

– Immunizations


Nursing ProcessNursing Process

• Assessment

– Health history

– Vital signs

– Neurologic examination

• Diagnosis, Planning, and Interventions

– Risk for impaired gas exchange

– Hyperthermia; Acute pain; Seizures

• Evaluation of Expected Outcomes


EncephalitisEncephalitis

• Inflammatory process Brain edema; Pathologic changes in gray, white matter, surrounding meninges

• Pathophysiology, Etiology: Vector-borne viral infection; Vaccination adverse effect

• Signs and Symptoms: Sudden fever; Severe HA; Stiff neck, Vomiting; Drowsiness

– Later: Tremors; Seizure; Paralysis; Weakness

• Diagnostics: Lumbar puncture; EEG; MRI

• Medical Management: Supportive treatment; Medication therapy

• Nursing Management


Guillain-Barré SyndromeGuillain-Barré Syndrome• Pathophysiology, Etiology: Autoimmune reaction;

Myelin destruction

• Signs and Symptoms: Tingling; Progressive weakness; Paralysis

• Diagnostic tests


– Plasmapheresis; IV immune globulin

– Recovery


– Monitor respiratory distress, vital signs; Prevent immobility complications; Meticulous skin care


Brain AbscessBrain Abscess• Pathophysiology and Etiology

– Infection; Intracranial surgery; Head trauma

• Assessment Findings

– IICP; Fever; Headache; Neurologic changes

– Diagnostic tests: Labs; CT; MRI; Radiographs

• Medical and Surgical Management: Antimicrobial therapy; Craniotomy


– Assess: LOC; Sensory, motor function; Signs of IICP

– Monitor vital signs; Intake, output


Multiple Sclerosis Multiple Sclerosis • Pathophysiology, Etiology

– Unknown cause: Autoimmune disorder; Progressive demyelinating disease

• Signs and Symptoms (vague, can be temporary): Fatigue; Vision changes; Weakness; Clumsiness; Paresthesias; Incontinence

• Diagnostic Findings: Lumbar puncture; CSF with electrophoresis; CT; MRI

• Medical Management: No cure

– Maintaining functional capacity

– Drug therapy


Multiple SclerosisMultiple Sclerosis

Figure 37-6 The process of demyelination


Nursing ProcessNursing Process

• Assessment

– Neurologic; Respiratory; Muscle strength; Coping ability; Elimination patterns


– Risks: Ineffective breathing pattern; Airway clearance; Impaired: Swallowing, physical mobility, skin integrity; Altered nutrition; Urinary incontinence; Constipation



Myasthenia Gravis Myasthenia Gravis • Severe weakness of one or more skeletal muscle

groups

• Pathophysiology, Etiology

– Cause: Unknown; Believed autoimmune origin

• Signs and Symptoms: Muscle weakness; Difficulty swallowing; Ptosis; Diplopia; Mask-like expression

• Diagnostic tests: IV: Edrophonium; Radiograph; Electromyography

• Medical and Surgical Management: Drug therapy; Plasmapheresis; Thymus removal; Respiratory support



Amyotrophic Lateral Sclerosis (ALS) Amyotrophic Lateral Sclerosis (ALS) • Progressive, fatal; Unknown cause

• Pathophysiology, Etiology: Motor neuron degeneration

• Signs and Symptoms: Progressive muscle weakness, wasting, fasciculations; Difficulty speaking, swallowing; Paralysis

• Diagnostic tests: Difficult to diagnose

• Medical Management: No specific treatment

– Death: Respiratory complications, infection



Cranial Nerve Disorders: Trigeminal Neuralgia (Tic Douloureux) Cranial Nerve Disorders: Trigeminal Neuralgia (Tic Douloureux)

• Pathophysiology and Etiology: Possible fifth cranial nerve root compression


– Severe cyclic pain

– Skull radiography; MRI; CT


– Narcotic analgesics; Anticonvulsants

– Correction of dental malocclusion

• Surgical Management: Surgical division of the trigeminal nerve


Nursing Process: The Client With Trigeminal Neuralgia Nursing Process: The Client With Trigeminal Neuralgia

• Assessment

– Complete history

– Affected area; Oral cavity

– Record weight and ability to eat food


– Acute pain


– Pain; Client cooperation


Nursing Process: The Client With Trigeminal Neuralgia Nursing Process: The Client With Trigeminal Neuralgia

Figure 37-9 Areas innervated by the three branches of the trigeminal nerve


Cranial Nerve Disorders: Bell’s Palsy Cranial Nerve Disorders: Bell’s Palsy • Pathophysiology and Etiology

– Suspected viral link

– Inflammation of seventh cranial nerve


– Facial pain; Numbness; Diminished blink reflex; Ptosis

– Diagnosis: Symptoms; Visual examination

• Medical Management: Short-term corticosteroid therapy with prednisone; Analgesics; Electrotherapy


Nursing Process: Client With Bell’s Palsy Nursing Process: Client With Bell’s Palsy • Assessment

– History; Physical examination; Speech; Chewing


– Risks: Eye infection; Impaired oral mucous membranes, verbal communication


– Understanding eye medication techniques

– No infection; Unaffected vision

– Intact mouth tissue and teeth

– Satisfactory spoken communication


Extrapyramidal Disorders: Parkinson’s Disease Extrapyramidal Disorders: Parkinson’s Disease

• Pathophysiology and Etiology:

– Deficiency of dopamine

– Slow deterioration


– Signs and symptoms: Hypophonia; Pill-rolling; bradykinesia; Drooling

– Diagnostic findings: Neurologic examination


Extrapyramidal Disorders: Parkinson’s Disease Extrapyramidal Disorders: Parkinson’s Disease


– Drug therapy; Rehabilitation

• Surgical Management

– Stereotaxic pallidotomy; DBS; Gene therapy



Extrapyramidal Disorders: Huntington’s Disease Extrapyramidal Disorders: Huntington’s Disease


– Genetic transmission


– Choreiform movements; Intellectual decline; Elimination difficulties

– Diagnosis: History; PET; Genetic testing


– Antiparkinson drugs; Genetic counseling



Seizure Disorders Seizure Disorders • Pathophysiology and Etiology

– Idiopathic or acquired

– Epilepsy: Injury; Inborn metabolism error

• Types of Seizures

– Partial seizures

• Elementary; Complex

– Generalized seizures

• Absence seizures; Myoclonic seizures; Tonic-clonic seizures; Other seizure types


Seizure DisordersSeizure Disorders• Assessment Findings

– Description by witness

– Neurologic examination; EEG; CT scan; MRI; serology; Serum electrolyte levels


– Anticonvulsant drugs

• Surgical Management

– Seizures caused by brain tumor, brain abscess, and other disorders


Brain Tumors Brain Tumors • Pathophysiology and Etiology

– Congenital; Head trauma; Viral infection

– Radiation; Immunosuppression

• Assessment Findings: Signs and Symptoms

– IICP; Seizures; Neurologic function

• Assessment Findings: Diagnostic Findings

– CT; Brain scan; MRI; Angiography


– Radiation, chemotherapy, and drug therapy


Brain TumorsBrain Tumors• Surgical Management

– Craniotomy; Craniectomy

– Gamma-knife; Radiosurgery



End of Presentation

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Chapter037