Chapter 14 – Disorders of the NeurologicOverview of Anatomy and Physiology

Structural divisionsCentral nervous system (CNS)

Brain and spinal cordPeripheral nervous system

Somatic nervous systemSends messages from the CNS to the skeletal muscles;

voluntaryAutonomic nervous system

Sends messages from the CNS to the smooth muscle, cardiac muscle and certain glands; involuntary

Overview of Anatomy and PhysiologyCells of the nervous system

NeuronNeuromuscular junctionNeurotransmitters

Acetylcholine; norepinephrine; dopamine; serotoninNeuron coverings

Central nervous systemBrain

CerebrumDiencephalonCerebellumBrain stem

Midbrain; pons; medulla oblongata; coverings of the brain and spinal cord; ventricles

Spinal cord

Peripheral nervous systemSpinal nervesCranial nervesAutonomic nervous system

Sympathetic nervous systemParasympathetic nervous system

Effects of Normal Aging on the Nervous SystemLoss of brain weight

Loss of neuronsReduction in cerebral blood flowDecrease in brain metabolism and oxygen utilizationDecreased blood supply to spinal cord causes decreased reflexes

Prevention of neurological problemsAvoid drug and alcohol useSafe use of motor vehiclesSafe swimming practicesSafe handling and storage of firearmsUse of hardhats in dangerous construction areasUse of protective padding as needed for sports

HistoryMental statusLevel of consciousness

Glasgow coma scaleLanguage and speechCranial nerve functionMotor functionSensory and perceptual status

Laboratory and Diagnostic ExaminationsBlood and urine

CultureDrug screensArterial blood gases

Cerebrospinal fluidComputed tomography (CT)Brain scanMRI scanPET scanLumbar punctureElectroencephalogramMyelogramAngiogramCarotid duplexDigital subtraction angiographyElectromyogramEchoencephalogram

Common Disorders of the Neurological SystemHeadaches

Etiology/pathophysiologySkull and brain tissues are not able to feel sensory painVascular headaches

MigraineHypertensive

Tension headachesTraction-inflammation headaches

Common Disorders of the Neurological SystemHeadaches (continued)

Clinical manifestations/assessmentHead painMigraine headaches

Prodromal (early sign/symptom)Visual field defects, unusual smells or sounds,

disorientation, paresthesiasDuring headache

Nausea, vomiting, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema

Common Disorders of the Neurological SystemHeadaches (continued)

Medical management/nursing interventionsDiet: limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or

marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork

PsychotherapyMedications

Migraine headachesAspirin, acetaminophen, ibuprofenErgotamine tartrateCodeine; Inderal

Common Disorders of the Neurological SystemHeadaches (continued)

Medical management/nursing interventionsTension headaches

Non-narcotic analgesicsTraction-inflammatory headaches

Treat causeComfort measures

Cold packs to forehead or base of skullPressure to temporal arteriesDark room; limit auditory stimulation

Common Disorders of the Neurological SystemIncreased intracranial pressure

Etiology/pathophysiology

Increase in any content of the craniumSpace-occupying lesions, cerebrospinal problems, cerebral edema

Clinical manifestations/assessmentDiplopiaHeadacheDecreased level of consciousnessPupillary signs

Common Disorders of the Neurological SystemIncreased intracranial pressure (continued)

Clinical manifestations/assessment (continued)Widening pulse pressureBradycardiaRespiratory problemsHigh, uncontrolled temperaturesPositive Babinski’s reflexSeizures PosturingVomitingSingultus

Common Disorders of the Neurological SystemIncreased intracranial pressure (continued)

Medical management/nursing interventionsTreat cause if possibleMechanical decompression

CraniotomyCraniectomy

Internal monitoring devicesCommon Disorders of the Neurological SystemDisturbances in muscle tone and motor function

Etiology/pathophysiologyDamage to the nervous system causes serious problems in mobility

Clinical manifestations/assessmentFlaccid or hyperreflexic muscle toneClumsiness or incoordinationAbnormal gait

Common Disorders of the Neurological SystemDisturbances in muscle tone and motor function (continued)

Medical management/nursing interventionsMuscle relaxantsProtect from fallsAssess skin integrityPositioningSit up and tuck chin when eatingEncourage patient to assist with ADLsEmotional support

Other Disorders of the Neurological System

Epilepsy or seizuresEtiology/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 epilepticusOther Disorders of the Neurological SystemEpilepsy or seizures (continued)

Clinical manifestations/assessmentDepends on type of seizureAuraPostictal period

Medical management/nursing interventionsDuring seizure: protect from aspiration and injuryAnticonvulsant medicationsSurgery

Removal of brain tissue where seizure occursOther Disorders of the Neurological SystemEpilepsy or seizures (continued)

Medical management/nursing interventions (continued)Adequate restGood nutritionAvoid alcoholAvoid driving, operating machinery, and swimming until seizures

are controlledGood oral hygieneMedical alert tag

Degenerative DiseasesMultiple sclerosis

Etiology/pathophysiologyDegenerative neurological disorder with demyelination of the brain

stem, spinal cord, optic nerves, and cerebrumFigure 14-13Degenerative DiseasesMultiple sclerosis (continued)

Clinical manifestations/assessmentVisual problemsUrinary incontinenceFatigueWeaknessIncoordination Sexual problemsSwallowing difficulties

Degenerative DiseasesMultiple sclerosis (continued)

Medical management/nursing interventionsNo specific treatmentAdrenocorticotropic hormone (ACTH)SteroidsValiumBetaseron (interferon beta-1b)Avonex (interferon beta-1a)Pro-banthine; urecholineBactrim, Septra, and Macrodantin

Degenerative DiseasesParkinson’s disease

Etiology/pathophysiologyDeficiency of dopamine

Clinical manifestations/assessmentMuscular tremors; bradykinesiaRigidity; propulsive gaitEmotional instabilityHeat intoleranceDecreased blinking“Pill-rolling” motions of fingers

Figure 14-14Degenerative DiseasesParkinson’s disease (continued)

Medical management/nursing interventionsMedications

LevodopaSinemetArtaneCogentinSymmetrol

SurgeryPallidotomy

Degenerative DiseasesAlzheimer’s disease

Etiology/pathophysiologyImpaired intellectual functioning Degeneration of the cells of the brain

Degenerative DiseasesAlzheimer’s disease (continued)

Clinical manifestations/assessmentEarly stage

Mild memory lapses; decreased attention spanSecond stage

Obvious memory lapses

Third stageTotal disorientation to person, place, and timeApraxia; wandering

Terminal stageSevere mental and physical deterioration

Degenerative DiseasesAlzheimer’s disease (continued)

Medical management/nursing interventionsMedications

Agitation: lorazepam; HaldolDementia: Cognex; Aricept

NutritionFinger foods; frequent feedings; encourage fluids

SafetyRemove burner controls at nightDouble-lock all doors and windowsConstant supervision

Degenerative DiseasesMyasthenia gravis

Etiology/pathophysiologyNeuromuscular disorder; nerve impulses fail to pass at the

myoneural junction; causes muscular weaknessClinical manifestations/assessment

Ptosis; diplopiaSkeletal weakness; ataxiaDysarthria; dysphagiaBowel and bladder incontinence

Degenerative DiseasesMyasthenia gravis (continued)

Medical management/nursing interventionsAnticholinesterase drugs

ProstigminMestinon

CorticosteroidsMay require mechanical ventilation

Degenerative DiseasesAmyotrophic lateral sclerosis (ALS)

Etiology/pathophysiologyMotor neurons in the brain stem and spinal cord gradually

degenerateElectrical and chemical messages originating in the brain do not

reach the muscles to activate themLou Gehrig’s disease

Degenerative DiseasesAmyotrophic lateral sclerosis (ALS) (continued)

Clinical manifestations/assessment

Weakness of the upper extremitiesDysarthria; dysphagiaMuscle wastingCompromised respiratory function

Medical management/nursing interventionsNo cureRilutec (Riluzole)Multidisciplinary ALS teams; emotional support

Degenerative DiseasesHuntington’s disease

Etiology/pathophysiologyOveractivity of the dopamine pathwaysGenetically transmitted

Clinical manifestations/assessmentAbnormal and excessive involuntary movements (chorea)Ataxia to immobilityDeterioration in mental functions

Degenerative DiseasesHuntington’s disease (continued)

Medical management/nursing interventionsNo cure; palliative treatmentAntipsychoticsAntidepressantsAntichoreasSafe environmentEmotional supportHigh-calorie diet

Vascular ProblemsStroke (cerebrovascular accident)

Etiology/pathophysiologyAbnormal condition of the blood vessels of the brain: thrombosis;

embolism; hemorrhageResults in ischemia of the brain tissue

Clinical manifestations/assessmentHeadacheSensory deficitHemiparesis; hemiplegiaDysphasia or aphasia

Figure 14-16Vascular ProblemsStroke (cerebrovascular accident) (continued)

Medical management/nursing interventionsThrombosis or embolism

ThrombolyticsHeparin and Coumadin

Decadron

Neurological checksFeeding tubePhysical, occupational, and/or speech therapy

Cranial and Peripheral Nerve DisordersTrigeminal neuralgia

Etiology/pathophysiologyDegeneration of or pressure on the trigeminal nerve; tic douloureux

Clinical manifestations/assessmentExcruciating, burning facial pain

Medical management/nursing interventionsTegretolSurgical resection of the trigeminal nerveAvoid stimulation of face on affected side

Cranial and Peripheral Nerve DisordersBell’s palsy (peripheral facial paralysis)

Etiology/pathophysiologyInflammatory process involving the facial nerve

Clinical manifestations/assessmentFacial numbness or stiffnessDrawing sensation of the faceUnilateral weakness of facial musclesReduction of salivaPain behind the earRinging in ear or other hearing loss

Cranial and Peripheral Nerve DisordersBell’s palsy (peripheral facial paralysis) (continued)

Medical management/nursing interventionsElectrical stimulationMoist heatSteroidsMassage of the affected areaFacial exercises

Cranial and Peripheral Nerve DisordersGuillain-Barré syndrome

Etiology/pathophysiologyInflammation and demyelination of the peripheral nervous systemPossibly viral or autoimmune reaction

Cranial and Peripheral Nerve DisordersGuillain-Barré syndrome (continued)

Clinical manifestations/assessmentSymptoms are progressiveParalysis usually starts in the lower extremities and moves upward;

may stop at any pointRespiratory failure if intercostal muscles are affectedMay have difficulty swallowing, breathing, and speaking

Cranial and Peripheral Nerve Disorders

Guillain-Barré syndrome (continued)Medical management/nursing interventions

Adrenocortical steroidsApheresisMechanical ventilationGastrostomy tubeMeticulous skin careRange-of-motion exercises

Cranial and Peripheral Nerve DisordersMeningitis

Etiology/pathophysiologyAcute infection of the meningesBacterial or aseptic

Cranial and Peripheral Nerve DisordersMeningitis (continued)

Clinical manifestations/assessmentHeadache; stiff neckIrritability; restlessnessMalaiseNausea and vomitingDeliriumElevated temperature, pulse, and respirationsKernig’s and Brudzinski’s signs

Cranial and Peripheral Nerve DisordersMeningitis (continued)

Medical management/nursing interventionsAntibiotics

Massive dosesMultiple typesIV or intrathecal

SteroidsAnticonvulsantsDark, quiet room

Cranial and Peripheral Nerve DisordersIntracranial tumors

Etiology/pathophysiologyBenign or malignantPrimary or metastaticMay affect any area of the brain

Cranial and Peripheral Nerve DisordersIntracranial tumors (continued)

Clinical manifestations/assessmentHeadacheHearing lossMotor weaknessAtaxia

Decreased alertness and consciousnessAbnormal pupil response and/or unequal sizeSeizuresSpeech abnormalities

Cranial and Peripheral Nerve DisordersIntracranial tumors (continued)

Medical management/nursing interventionsSurgical removal of tumor

CraniotomyIntracranial endoscopy

RadiationChemotherapyCombination of above

TraumaCraniocerebral trauma

Etiology/pathophysiologyMotor vehicle and motorcycle accidents, falls, industrial accidents,

assaults, and sports traumaDirect trauma: head is directly injuredIndirect trauma: tension strains and shearing forcesOpen head injuriesClosed head injuriesHematomas

TraumaCraniocerebral trauma

Clinical manifestations/assessmentHeadacheNauseaVomitingAbnormal sensationsLoss of consciousnessBleeding from ears or noseAbnormal pupil size and\or reactionBattle’s sign

TraumaCraniocerebral trauma (continued)

Medical management/nursing interventionsMaintain airwayOxygenMannitol and dexamethasoneAnalgesicsAnticonvulsants

TraumaSpinal cord trauma

Etiology/pathophysiologyAutomobile, motorcycle, diving, surfing, other athletic accidents,

and gunshot woundsFracture of vertebraComplete cord injuryIncomplete cord injury

Figure 14-22TraumaSpinal cord trauma (continued)

Clinical manifestations/assessmentLoss of muscle function depends on level of injurySpinal shockAutonomic dysreflexiaSexual dysfunction

TraumaSpinal cord trauma (continued)

Medical management/nursing interventionsRealignment of bony column for fractures or dislocations:

immobilization; skeletal tractionSurgery for spinal decompression

MethylprednisoloneMobility: slowly increase sitting upUrinary function: Foley catheter; bladder training

Intermittent catheterizationBowel program

Nursing ProcessNursing diagnoses

Autonomic dysreflexiaCommunication, impairedCoping, compromised familyDisuse syndrome, risk forGrievingInfection, risk forKnowledge, deficientMemory, impaired

Nursing ProcessNursing diagnoses (continued)

Mobility, impaired physicalNutrition, imbalanced: less than body requirementsPain, acute, chronicSelf-care deficitSwallowing, impairedThought process, disturbedTissue perfusion (cerebral), ineffective