Pathology

The pathology involving the CNS arises from injuries, vascular insufficiency, tumors, infections and disorders from other diseases. Neurological medical problems are due to interference with normal functioning of the affected cells

Nervous SystemAnatomy and PhysiologyReview

The nervous system acts as a coordinated unit both structurally and functionally

Communication network responsible for coordinating and organizing the functions of all body parts

The body’s link to the environment Works with the endocrine system to maintain

homeostasis Reacts in a split second

Functions

1.Regulates system 2. Controls communication 3. Coordinates Activities of body system

Divisions

Central nervous system ( CNS) : brain and spinal cord –interprets incoming sensory information and sends out instruction based on past experiences

Peripheral nervous system ( PNS) : Cranial and spinal nerves extending out from brain and spinal cord---carry impulses to and from brain and spinal cord

Neurological Terms

Anesthesia- complete loss of sensation Aphasia-loss of ability to use language Auditory/receptive aphasia- loss of ability to understand Expressive aphasia- loss of ability to use spoken or

written word Ataxia- uncoordinated movements Coma- state of profound unconsciousness Convulsion- involuntary contractions and relaxation of

muscles

Neurological terms

Delirium- mental state characterized by restlessness and disorientation

Diplopia- double vision Dyskeinesia- difficulty in voluntary movement Flaccidd- without tone- limp Neuralgia- intermittent, intense pain, along the

course of a nerve

Neurological terms

Neuritis- inflammation of a nerve or nerves Nystagmus- involuntary, rapid movements of the

eyeball Paresthesia- abnormal sensation without obvious

cause, with numbness and tingling Stupor- state of impaired consciousness with brief

response only to vigorous and repeated stimulation Vertigo- dizziness

Preparing a patient for a diagnostic test

Answer question that the patient may need clarification

Diet orders –NPO??? Special room or equipment

used Special medications required

for test An informed patient will be

more cooperative Nursing assessment

Baseline vital signs and neuro cks

Know level education to develop an individualized teaching plan

Determine awareness of actual or potential medical diagnosis

Determine previous experence with Dx test

Diagnostic test/ methods

A. Computerized Tomography- CT or CAT scan computer analysis of tissues as x-rays pass through them; has replaced many of the usual tests: no special preparation or care after test

CT scan

Nursing Interventions– Explain procedure – will be enclosed tunel– Written consent– Assess allergies to iodine– Remove wigs hair pins or clips, partial denture plates – Assess for pacemakers– NPO 4 hours before if oral contrast is administered– Encourage patient to drink fluids to avoid renal complications

and to promote excretion of the dye

Diagnostic test/ methods

B. lumbar puncture- spinal tap– Done under local anesthesia a puncture is made at

the junction of the third and fourth lumbar vertebrae to obtain a specimen of cerebrospinal fluid (CSF)

– CSF pressure measured – Used to inject medications- spinal anesthesia– Used to inject diagnostic materials –air or dye-

myelogram

Lumbar puncture

Nursing interventions– Written consent– Monitor vital signs– Have patient empty bowel and bladder – Position the patient– Label and number specimens– Keep patient supine 4-8 hours– Observe for headache and nuchal rigidity– Observe for mobility of extremities, pain, ability to void– Monitor site for leakage

Diagnostic test/ methods

Cerebral Angiography- intraarterial injection of radiopaque dye to obtain an xray film of the cerebrovascular circulation

Cerebral angiography

Nursing interventions– Written consent– Assess for allergy to iodine– NPO past midnight– Administer preprocedure medications– Observe arterial puncture site– Monitor extremity for adequate circulation- pain tenderness

bleeding temperature and color– Pedal pulses and vital signs q 1 hour– Provide ice pack to puncture site– Bedrest 12- 24 hours– Force fluids- to increase excretion of dye

Diagnostic test/ methods

Electroencephalography (EEG)- electrodes are placed on unshaven scalp with tiny needles and electrode jelly

EEG

Nursing Inventions– Anticipate patient’s fears about electrocutions– Explain procedure– Written consent– Hair should be clean– Do not give stimulants/ depressants before test /consult with M.D. about meds– Administer sedatives or hypnotics if ordered– No smoking or caffeinated beverages before the test– Eat full meal before the test –hypoglycemia may alter brain waves– Stress need for restful sleep before the test sleep deprivation may cause

abnormal brain waves– Wash hair and scalp after test– Ensure safety precautions until effects of meds wear off

Diagnostic test/ methods

Brain Scan-after injection of a radioisotope, abnormal brain tissue will absorb more rapidly than normal tissue: this can be detected with a Geiger counter to diagnose brain tumors

Brain Scan

Nursing interventions– NPO 4 hours before test– Remove wigs, hair clips or pins,– Assess for iodine allergies– If ordered give sedation– Encourage fluids after test to increase excretion of

dye

Diagnostic test/ methods

Magnetic Resonance Imaging- ( MRI)

uses combination of radio waves and a strong magnetic field to view soft tissue ( does Not use x-rays or dyes) ; produces a computerized picture that depicts soft tissues in high –contrast color

MRI

Nursing interventions– Written consent– Explain procedure- will have to remain perfectly still

in the narrow cylinder-shaped machine . No pain or discomfort but no room for movement

– Assess for any metal contraindications-pacemaker, surgical clips, hair clips, belts

– Empty bladder before test

Diagnostic test/ methods

Myelogram- injection of a radiopaque dye into the subarachnoidd space via a lumbar puncture: performed to locate lesions of the spinal column or ruptured vertebral disk

Myleogram

Nursing interventions– Written consent– Prepare for LP– NPO for 4 hours before test– Positioning for LP– Vital signs– Observe for photophobia, fever stiff neck, occipital headaches, nausea ,

dizziness, and possibly seizures– Force fluids to promote dye excretion dehydration will result in severe

headache– Check with M.D. when withheld medications prior to test may be restarted– Observe site for leakage of CSF– Bedrest

Nursing Diagnosis and Interventions

Identify the patients needs Neuro checks Assessment of history from family Patient history Nursing observations

Impaired Physical Mobility

Neuro checks q2-4h Explain the need for regular

exercise program ROM to all joints q2-4h

foundations pg 243-244 Use assistive devices Protect the affect side from

injury Protection from falling Turn q2h

Risk for injury/infection related to fixed eyes ( no blinking)

Protect with eye shields Remove dry exudate

with warm saline Close eyes Inspect for inflammation

Ineffective breathing pattern related to neuromuscular impairment

Maintain patent airway Suction as needed Elevate HOB 30-60-

degrees Have trach set ready Provide O2 with humidity V/S with neuro cks q2h Oral hygiene q2h Lubricate lips

Maintain bed rest Keep unconscious pt in

lateral position to allow secretion drainage

Monitor for S/S pulmonary emboli

– Chest pain, SOB, Monitor ability to swallow

Risk for alteration in body temperature

Asses rectal temp q2h Use external heating or

cooling blankets

Risk for aspiration

Maintain NPO Position Pt on side: turn

q2h Provide N/G feedings Monitor IV fluid

Altered patterns of urinary elimination

1. Oligura-urinary retention

– Provide indwelling catheter

– Monitor I&O qh

– 2. Incontinence Wash dry and inspect

skin Implement measures to

prevent decubitus ulcers Implement bladder

training

Bowel incontinence/constipation

Incontinence

wash dry and inspect skin

Implement measures to prevent decubitus ulcers

Implement bowel training

Constipation

-Record bowel movements

-Provide stool softners, laxatives and enemas

-Check for impaction

-Increase fluid intake

-Increase Fiber in diet

-Increase activity

Altered Nutrition: less than body requirements related to dysphagia and fatigue

Prepare for N/G feedings

Check gag reflex Provide mouth care,

clean and care for dentures

Place food in patients visual field do patient can see food

Diet low salt low cholesterol

consult dietary Wt daily

Impaired Communication

Assess communication patterns

Provide calm environment with minimal distraction

Use touch to increase attention

Use familiar music to enhance recall

Simple verbal commands

Communication boards Pen and paper Gestures eye blinks

Fluid Volume deficit

Inability to meet needs:Coma

COMA-Unconscious state in which the Pt is unresponsive to verbal or painful stimuli: this occurs with many primary diseases: the Pt depends on the nurse for maintenance of all basic human needs, nourishment, bathing, elimination, respiration, prevention of complications and assessment and provision of care for problems

Coma : nursing interventions

Include family in nursing care and planning Note LOC q15 minutes Nero Ck q 15 minutes Demonstrate respect for Pt presence Provide quite restful environment Speak to Pt, use proper name, introduce self,

explain all care Provide privacy

Patient with paralysis

Paraplegia-paralysis of the lower extremities There may be no motion or sensory function or reflexes There may be uncontrollable muscle spasms Perspiration ceases then becomes profuse Loss of bowel and bladder control Anxiety, fear, depression, anger, and embarrassment May be totally dependant

Patient with paralysis

Quadriplegia- paralysis of all four extremities Same problems as paraplegia

Nursing interventions : Paralysis

Take measures to prevent complications of immobility Bowel and bladder training Prevent deformity: maintain joint mobility: correct

alignment Increase fluid intake Provide high protein diet Teach independence according to ability Work with health care team for rehabilitation Include family in planning and care

Increased intracranial pressure( ICP)

Fluid accumulation or a lesion takes up space in the cranial cavity, producing ICP: the brain is gradually compressed, or life-sustaining functions cease: may be sudden or progress slowly

ICPCauses

Tumors Hematoma Edema from trauma Abscesses from infection

ICPsigns and symptoms

Headache, restless, anxiety Vomiting,recurrent, projectile,

and not related to nausea or meds

Change in pupil response to light

Seizures Respiratory difficulty;

irregular, Cheyne-Stokes or Kussmaul

BP elevates ,with wide pulse pressure

Pulse Increases at first then slows to 40- 60

Alter LOC,lethargic, speech slows, confused, decrease level of response

Visual disturbances,diplopia and blurred vision

Progressive weakness or paralysis

Loss of consciousness,coma death

ICPTreatment

Depends on cause Craniotomy Meds

– Steroids– Anticonvulsants– Mannitol– dexamethasone

ICPNursing interventions

Elevate HOB to semi-Fowler’s Never place in Trendelenburg V/S and neuro cks q15 minutes Prevent aspiration Place Pt on Side Maintain airway- O2 Observe pupillary response ( usually unequal and may not react to light) Report changes in LOC immediately Seizure precations Provide care for Coma Pt Monitor IV fluids– Do not overhydrate NPO or fluid limited by M.D. I & O q1h

Convulsive disorders

Frequently a convulsion or seizure is not a disease but a symptom of a neurologic disorder:

Epilepsy is a disease characterized by a disposition for seizures;

Types of seizures

Generalized or grand mal Aura- There may be a premonition or sign The Pt cries out Loss of consciousness Enters tonic phase- the body is rigid and the jaw is clenched Then the clonic phase- jerking movements of muscles Cessation of respiration Fecal and urinary incontinence Lasts 1-2 minutes Followed by short period of unresponsiveness

Types of seizures

Partial or petit Mal Loss of consciousness that last 5- 30

seconds Normal activities may or may not ceas There may be amnesia concerning the time

Types of seizures

Jacksonian or Motor A focal seizure that may precede a grand mal

seizure

Convulsive Disorders Causes

May be secondary to another condition– CVA, head injury, brain tumor, elevated temp,

toxins, electrolyte imbalance

Epilepsy may have no known cause– Onset is usually during childhood or before age 30

Convulsive DisordersDiagnostic test

EEG CT scan MRI

Convulsive DisordersTreatment

Treat and remove cause Anticonvulsant drugs Surgery – sterotactic- electrical stimulation to

locate and reset ( destroy) epileptogenic focus

Convulsive DisordersNursing Interventions

Provide accurate observation and documentation Aura Time of onset Whether seizure is generalized or focal Specific parts of body involved Progression of seizure Eye movements Loss of consciousness Loss of bowel or bladder Condition after seizure Memory loss Weakness Any injury caused by seizure

Convulsive DisordersNursing interventions

Encourage Pt to wear medical alert tag Have suction available During seizure maintain airway Prevent head injury Place pt on side Protect extremities from injury Do not restrain Loosen clothing Remove pillows Maintain safety until fully conscious

Transient Ischemic AttacksTIA

Altered cerebral tissue perfusion related to a temporary neurologic disturbance

Manifested by sudden loss of motor or sensory function

Lasts for a few minutes to a few hours Caused by temporarily diminished blood supply

to an area of the brain High risk for stroke

TIATreatment

Control hypertension Low sodium diet Possible anticoagulant therapy Stop smoking

Cerebrovascular AccidentCVA Stroke

Decreased blood supply to a part of the brain caused by rupture , occlusion, or stenosis of the blood

vessels Onset may be sudden or gradual Symptoms and patient problems depend on location and

size of area of brain with reduced or absent blood supply right CVA results in Left side involvement often

associated with safety/ judgment Left CVA results in Right side involvement often

associated with speech problems

Cerebrovascular AccidentCVA Stroke

Symptoms related to location and size of brain area affected

Approximately 50% of survivors permanently disabled High proportion experiencing recurrence within weeks

to years Chances for complete recovery depending an

circulation returning to normal soon after the initial stroke

Third most common cause of neurological disability

Predisposing factors-CVA

History TIA’s Hypertension Arrhythmias Atherosclerosis Rheumatic Heart

Disease MI DM

High serum triglyceride levels

Lack of exercise Cigarette smoking Family history

CVACauses

Incidence increased with aging Atherosclerosis Embolism Thrombosis Hemorrhage from ruptured cerebral aneurysm hypertension

CVASigns and Symptoms

Altered LOC Change in mental status Decreased attention span Decreased ability to think and reason Difficulty following simple directions Communication; motor and sensory aphasia difficulty

with reading ,writing, speaking, or understanding Bowel and bladder dysfunction retention impaction or

incontinence

CVASigns and Symptoms

Seizures Limited motor function; paralysis, dysphgia, weakness ,

hemiplegia, loss of function Loss of sensation/ perception Headaches and syncope Loss of temp regulation elevated TPR and BP Absent of gag reflex ( aspiration) Unusual emotional responses; depression, anxiety,

anger, verbal outburst, and crying: emotional lability Problems related with immobility

CVADiagnostic test

Physical assessment Pt and family history EEG CT scan Lunbar puncture Cerebral angiogram Carotid ultrasonogram

CVATreatments

Remove cause, prevent complications, and maintain function, rehabilitation to restore function

Meds– Antihypertensives– Anticoagulants– Stool softners

Surgical removal of clot, repair of aneurysm, carotid endarterectomy or balloon agioplasty

CVANursing Interventions

Patent airway Maintain bedrest Provide complete care Use turn sheet Footboard Firm mattress Pillow and torchanter rolls Maintain proper body

alignment

Place items within reach Reposition q2h ROM passive and active Place in chair Flotation mattress or

sheepskin Skin assessment

CVANursing Interventions

O2 with humidity C,T, DB q2h Suction PRN Keep head turned to

side Place in semi- fowler’s

Assess nutrition daily with I&O, WT, %diet, calorie count

Provide N/G feedings if needed

Maintain IV fluids Progress to soft diet prn TPN as ordered Aspiration precautions Dietary consult & Speech for

swallowing

CVANursing interventions

Establish means of communication

Nonverbal gestures Speak slowly Explain all care Speech therapy

Encourage family participation

CVANursing Interventions

Assess LOC Maintain safety Use side rails Restrain only as

necessary Observe for ICP V/S & Neuro CKS q 4 h Seizure precations

Ensure elimination Assess bowel sounds Monitor bowel

movements I & O Indwelling catheter prn Bowel and bladder

training

CVANursing interventions

Family support Begin discharge

teaching early Physical therapy Speech therapy

Brain Tumor

A benign or malignant growth that grows a nd exerts pressure on vital centers of the brain decreasing function and causing increased intracranial pressure

Cause is unknown

Brain TumorSigns and Symptoms

Personality changes, fear and anxiety H/A , dizziness and visual disturbances Seizures Pituitary dysfunction ICP Local paralysis or anesthia Aphsia Problems with coordination

Brain tumorDiagnostic test

History Physical exam Neurologic assessment EEG CT Angiogram MRI

Brain tumortreatment

Surgical removal –craniotomy Combination of radiation or chemotherapy

Brain tumornursing interventions

Neuro cks q 1-4 hours depending on pt status

Safety Seizure precautions express fears and

feelings

POST OP care– Maintain airway– Seizure precautions– Regulate body temp– Position on unoperated side– Elevate HOB ONLY under

MD orders– Inspect dressing q30min– V/S neuro cks q 15 min

progress to q4h– Coma care

Head injuries

Trauma to scalp, skull, or brain. A fracture to skull may result either a simple break in the bone or bone fragmentation that penetrates the brain tissue, can also cause hemorrhage, concussion, or contusion

Head injuries

Cerebral concussion- injury to the head, patient may be dazed; or unconscious for a few minutes: some function(memory) may be impaired for as long as several weeks

Cerebral contusion- head injury causing bruising of brain tissue> person experiences stupor, confusion or loss of consciousness: if severe may go into coma

Head injuries

Cerebral laceration- a break in continuity of brain tissue

Causes– Blow to head– MVA– Fall

Head injuries Signs and Symptoms and diagnostic test

Nausea & vomiting Lethargic: increasing

loss of consciousness to impending coma

Disorientation Drainage of CSF from

ear or nose ICP

History and physical exam

X-ray of head Angiogram, doppler

studies CT head, MRI PET

Head injuriesTreatment

Anticonvulsulants Corticosteriods Mannitol Maintain fluid balance surgery

Head injuriesNursing interventions

Care for ICP COMA care Neuro cks & V/S q 15

min to q1h Maintain airway Seizure precations Observe ears and nose

for CSF

Multiple Sclerosis

A chronic progressive disease of the brainand spinal cord: lesions cause degeneration of the myelin sheath and interfere with conduction of motor nerve impulses: there are periods of remissions and exacerbations: onset occures in young adult: it has an unpredictable progression

Cause: unknown< exacerbates with stress

Multiple SclerosisSigns ands symptoms

Ataxia Paresthesia Weakness and loss of

muscle tone Loss of sense of position Vertigo Blurred vision –progress

to blindness

Inappropriate emotions– Euphoria, apathy,

depression

Dysphagia Slurred speech Bowel and bladder

dysfunction Sexual dysfunction spasticity

Multiple SclerosisDiagnostic test and treatments

History Physical exam Neuro Cks Ct MRI Exam of CSF

Treatment is symptomatic

Corticosteriods during acute excerbation

Multiple SclerosisNursing interventions

Prevent Complications of immobility

Encourage independence Patient should participate in

plan of care High calorie, vitamin, protein

diet Family education

Bowel and bladder training Safety Express feelings regarding

dependence and disabilities Avoid precipitating factors for

exacerbationsFatigue, cold, heat, infections,

stress

Parkinson’s Disease

A progressive , degenerative disease causing destruction of nerve cells in the basal ganglia of the brain caused by a deficiency of dopamine: limbs become rigid, fingers have characteristic pill rolling movement, and head has to and for movement: the patient has a bent position and walks in short, shuffling steps: facial expressions become blank with wide open eyes and infrequent blinking ( parkinson’s Mask)

Intelligence is NOT affected

Parkinson’s DiseaseSigns and symptoms

Tremor Voluntary movement is slow

and difficult Coordination is poor- ataxia Impaired chewing and eating Excessive salivation and

drooling Speech is slow Patient is soft spoken Written communication is

difficult

Excessive sweating Emotional changes

– Depression , confusion

dependency

Parkinson’s DiseaseDx test and treatments

History Physical exam Neuro cks

Many pt s respond to drug therapy and the disease is controlled with meds for the reminder of their lives

Others have no response to meds - invalidism

Parkinson’s Diseasenursing interventions

Foster independence ADL’s

Avoid social withdrawal –involve in work, social and diversional activities

Aviod embarrassment while eating

– Use straws, wipe drool, use bib, keep clothing clesn, use large handle grips

Soft diet Daily walking—safety Avoid fatigue Physical, Speech and

Occupational therapy Avoid constipation-stool

softner

Parkinson’s Diseasenursing interventions

Bowel and bladder training

Be patient when patient is slow and clumsy

Establish a means of communication

Reorientation Prevent pneumonia

Mouth care q4h Family participation

Spinal Cord Impairment

The vertebral column houses the spinal cord. A small cartilage disk acts as a cushion between the vertebrae. All sensory and motor nerves to the neck, trunk, and extremities branch out from the spinal cord. The degree of disability and patient problems is related the part of the body controlled by the injured or disease nerves

Spinal Cord Injuries

Trauma to spinal cord may cause complete or partial severing of the spinal cord

If severing is complete there is permanent paralysis of body parts below site of injury

When there is partial damage edema may cause a temporary paralysis

Spinal Cord Injuries

Cause : accident ,MVA diving, shooting S&S individual to site, respiratiory distress,

paralysis DX test: physical exam Treatment: immobilization

– Crutchfield tongs.halo traction.brace.body cast– Surgery corticosteroids, mannitol

Spinal Cord InjuriesNursing interventions

Care for paralysis patient Observe for complications of spinal shock Maintain airway and respiratory function