Med Surg Ch 22 & 23

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The Neurologic System & The Care of Patients with Head and Spinal Cord Injuries

Hemiplegia

Paralysis and loss of sensation in an extremity

Hemiparesis

One-sided weakness

Quadriplegic

Four limbs paralyzed; Also called tetraplegia

Afferent Division

PNS Interaction with CNS---- Carries impulses to the CNS

Efferent Division

PNS Interaction with CNS---- Carries impulses away from the CNS

Autonomic

PNS Interaction with CNS---- Active in maintaining internal body balance (homeostasis) and is involuntary in its actions

Somatic

PNS Interaction with CNS---- The cranial and spinal nerves are part of the somatic subsystem and respond to changes in the outside world

Sympathetic

PNS Interaction with CNS---- Nerves that provide the fight or flight response; Mobilize energy to initiate changes aimed at maintaining or restoring homeostasis

Parasympathetic

PNS Interaction with CNS---- Nerves calm you back down; Conserve and restore energy that has been used to maintain homeostasis

Meninges

Protection of CNS---- Consists of pia mater, arachnoid, and dura mater; Cover the brain and spinal cord

Olfactory

Cranial Nerves & Functions---- Sensory: Smell

Optic

Cranial Nerves & Functions---- Sensory: Visual acuity, field of vision, pupillary response (afferent impulse)

Oculomotor

Cranial Nerves & Functions---- Motor: Eyelid elevation, extraocular eye movement, pupil size, covergence, pupillary constriction (efferent impulse)

Trochlear

Cranial Nerves & Functions---- Motor: Extraocular eye movement (inferior and lateral)

Trigeminal

Cranial Nerves & Functions---- Sensory: Corneal reflex && Motor: Facial sensation; chewing, biting, lateral jaw movement

Abducens

Cranial Nerves & Functions---- Motor: Extraocular eye movement (lateral)

Facial

Cranial Nerves & Functions---- Sensory: Taste && Motor: Facial muscle movement, including muscles of expression; lacrimal gland and salivary gland control

Acoustic

Cranial Nerves & Functions---- Sensory: Hearing, sense of balance

Glossopharyngeal

Cranial Nerves & Functions---- Sensory: Sensations of the throat, taste (posterior tongue) && Motor: Gagging and swallowing movements

Vagus

Cranial Nerves & Functions---- Sensory: Sensations of posterior tongue, throat, larynx; impulses from heart, lungs, bronchi, and gastrointestinal tract

Spinal Accessory

Cranial Nerves & Functions---- Motor: Shoulder movement and head rotation

Hypoglossal

Cranial Nerves & Functions---- Motor: Tongue movement, articulation of speech

Orthostatic Hypotension

Complications of Spinal Cord Injury---- Vasoconstriction is impaired after spinal cord injury, and the lack of muscle function in the legs causes pooling of blood in the lower extremities

Renal Complications

Complications of Spinal Cord Injury---- Urinary reflux may occur leading impaired bladder function; Bladder infections from immobility and caths also kidney infections

Infection

Complications of Spinal Cord Injury---- Pneumonia and invasive airways; Indwelling catheter or frequent catheterization

Muscle Spasms

Complications of Spinal Cord Injury---- Seen with flaccid paralysis; Strong, involuntary contractions of the skeletal muscles; Safety and hope of recovery may be false; Baclofen (Lioresal) orally or intrathecally may decrease the severity of the spasms

Spinal Shock

Complications of Spinal Cord Injury---- Neurogenic shock; Disruption in the nerve communication pathways between upper motor neurons and lower motor neurons; Characteristics: Flaccid paralysis, loss of reflex activity below the level of the damage, bradycardia, hypotension and occasionally paralytic ileus

Heterotopic Ossification

Complications of Spinal Cord Injury---- May occur with long-term immobility; Bony overgrowth that may invade muscle

Skin Breakdown

Complications of Spinal Cord Injury---- Decreased mobility and pressure sites

Acetylcholine

Neurotransmitters----
Location: CNS & PNS
Function: Generally excitatory but is inhibitory to some visceral effectors
Comments: Found in skeletal neuromuscular junctions and in many ANS synapses

Norepinephrine

Neurotransmitters----
Location: CNS & PNS
Function: May be excitatory or inhibitory depending on the receptors
Comments: Found in visceral and cardiac muscle neuromuscular junctions; Cocaine and amphetamines exaggerate the effects

Epinephrine

Neurotransmitters----
Location: CNS & PNS
Function: May be excitatory or inhibitory depending on the receptors
Comments: Found in pathways concerned with behavior and mood

Dopamine

Neurotransmitters----
Location: CNS & PNS
Function: Generally excitatory
Comments: Found in pathways that regulate emotional responses; Decreased levels in Parkinson's disease

Serotonin

Neurotransmitters----
Location: CNS
Function: Generally inhibitory
Comments: Found in pathways that regulate temperature, sensory perception, mood, onset of sleep

Gamma-aminobutyric acid (GABA)

Neurotransmitters----
Location: CNS
Function: Generally inhibitory
Comments: Inhibits excessive discharge of neurons

Endorphins and Enkephalins

Neurotransmitters----
Location: CNS
Function: Generally inhibitory
Comments: Inhibit release of sensory pain neurotransmitters; Opiates mimic the effects of these peptides

Body Homeostasis

Age-Related Changes---- is more difficult to maintain or regain

Short-term Memory

Age-Related Changes---- is affected due to degeneration in myelin sheath

Reflexes

Age-Related Changes---- may be diminished or absent due to degeneration of the myelin sheath

Coordination and Balance

Evaluation of Neurologic Status---- Romberg's test (pt. stands with feet together, eyes closed); If tested positive, will sway back and forth; If normal, steady posture and no swaying; Assess gait; Hold up finger, ask pt to touch your finger then her nose, move finger to different locations

Reflexes

Evaluation of Neurologic Status---- One efferent and one afferent impulse occurs with one synapse; Babinski

Positron emission tomography (PET)

Diagnostic Test for Neurologic Disorders----
Purpose: To assess for cell death, damage in brain tissue
Description: Radioactive material is given and provides differing color in areas of cellular activity
Nursing Implications: Procedure requires a signed consent form. Explain that two IV lines will be inserted. Patient is to avoid sedatives or tranquilizers before test. Patient may be asked to perform various activities during the test.

Decorticate Posturing

Neurologic and Neuromuscular Status---- (flexor); The extension of the legs and internal rotation and adduction of the arms with the elbows bent upward; Indicates damage to the cortex

Decerebrate Posturing

Neurologic and Neuromuscular Status---- (extensor); Arms are stiffly extended and held close to the body, and the wrists are flexed outward; Indicates damage to the midbrain or brainstem; Very serious injury

Receptive

Aphasia---- Difficulty in interpreting written or spoken communication

Expressive

Aphasia---- Difficulty expressing self in speech or writing

Global

Aphasia---- Combination of receptive and expressive aphasia

Concussion

Pathophysiology of Head Injuries---- A brief alteration in consciousness related to a minor closed head injury such as amnesia regarding the occurrence and a headache

Skull Fractures

Pathophysiology of Head Injuries---- You will see opposite side motor deficit and same side pupil response change; Described as: Linear or depressed; Simple, comminuted, or compound; Closed or open

Contusion

Pathophysiology of Head Injuries---- Brain tissue is bruised, blood from broken vessels accumulates, and edema develops, causing increased intracranial pressure (ICP)

Coup-contrecoup Injury

Pathophysiology of Head Injuries---- Also called acceleration-deceleration injury; Occurs when head is moving rapidly and hits a stationary object, such as windshield; The contents within the cranium hit the inside of the skull and then bounce back and hit the bony area opposite the site of impact, causing a second injury

Subdural Hematoma

Pathophysiology of Head Injuries---- SLOW; Usually occurs in elderly due to falls; Small rupture blood vessels leak blood into the space under the dura mater

Anticoagulant Therapy

Pathophysiology of Head Injuries---- Puts patients at risk for a subdural hematoma with even the smallest hit to the head

Epidural Hematoma

Pathophysiology of Head Injuries---- Rapid leak that tears a large middle meningeal artery with a large amount of blood above the dura mater causing ICP rapidly; Treatment is a craniotomy to relieve pressure and suture the artery

Intracerebral Hematoma

Pathophysiology of Head Injuries---- Head injuries; May occur within the brain from a blow to the head; Small vessels within the brain have torn and bled

Raccoon Eyes

Sign and Symptoms of Head Injuries---- Ecchymoses

Battle's Sign

Sign and Symptoms of Head Injuries----Ecchymoses behind the ear

Otorrhea

Sign and Symptoms of Head Injuries----Fluid from the ear; Check for dextrose

Rhinorrhea

Sign and Symptoms of Head Injuries----Fluid from the nose; Check for dextrose

Epidural Hematoma

Sign and Symptoms of Head Injuries---- may include unconsciousness at the time of the injury, a brief lucid interval followed by decreasing LOC, headache, nausea and vomiting, and dilation of the ipsilateral pupil. The patient is observed for signs of increased ICP

Nuchal Rigidity

Sign and Symptoms of Head Injuries---- May occur with bleeding into the subarachnoid space or with meningitis

Acute

Types of Subdural Hematomas---- Pt is unconscious; Hemiplegia on contralateral side (opposite), dilated pupils on ipsilateral side (same), also monitor for increased irritability, dull headache, and nodding off

Subacute

Types of Subdural Hematomas---- Mix of acute and chronic

Chronic

Types of Subdural Hematomas---- ICP builds up over a period of time, usually from minor head trauma; Blurred vision, personality changes, loss of appetite, weakness, lethargy

Alert

Progression of Decreased LOC---- Responds appropriately to questions and commands with little stimulation. Attends to surroundings.

Confused

Progression of Decreased LOC---- Somewhat disoriented to surroundings, time, or people. Judgement may be impaired. Needs to be cued to respond to commands.

Lethargic

Progression of Decreased LOC---- Drowsy, but easily aroused; Needs gentle touch or verbal stimulation to attend to commands.

Obtunded

Progression of Decreased LOC---- More difficult to arouse and responds slowly to stimulation. Needs repeated stimulation to maintain attention and to respond to the environment.

Stuporous

Progression of Decreased LOC---- Responds to vigorous stimulation only slightly; May only moan or mutter in response.

Comatose

Progression of Decreased LOC---- No observable response to stimulation

Subdural Hematoma

Treatment of Head Injuries---- Removed surgically either via burr holes or by craniotomy incision; The hematoma is evacuated by suction or surgical instruments

Epidural Hematoma

Treatment of Head Injuries---- Necessitates immediate, emergency craniotomy to prevent death from increased ICP

Increased Intracranial Pressure

Signs amd Systems---- Lethargy and decreasing consciousness, accompanied by a slowing of speech and delay in response to verbal cues is the earliest signs

Herniation

Signs and Symptoms---- Due to increased BP to get more O2 to brain

Supportive Care

Treatment and Care of Increased ICP---- no increase in ICP

Osmotic diuretics

Treatment and Care of Increased ICP---- EX) mannitol, glycerol, urea

Systemic dieuretics

Treatment and Care of Increased ICP---- EX) Lasix

Dexamethasone

Treatment and Care of Increased ICP---- (Decadron); Decreases inflammation of brain

H2 Blockers

Treatment and Care of Increased ICP---- Proton pump inhibitors; Given to protect mucosa of stomach

Intraventrical Catheter

Treatment and Care of Increased ICP---- Placed when ICP is too high or the Glasgow coma scale is 9 or less. Placed in lateral ventricle to drain small amounts of CSF

Cerebral Perfusion Pressure (CPP)

Treatment and Care of Increased ICP---- Monitors pressure in the subarachnoid or epidural space; Normal: 70 to 100 mm Hg

Respiratory Support

Treatment and Care of Increased ICP---- Placed on ventilator; Pavulon is used to paralyze the patient; Hyperventiliation will help decrease ICP

Barbiturates

Treatment and Care of Increased ICP---- Heavy sedation will help slow metabolism leading to decrease in ICP; Pentobarbitol or Phenytoin will be given to prevent seizures

Temperature Control

Treatment and Care of Increased ICP---- Use hypothermia blanket if fever occurs, or warmed blankets and tepid baths for decreased temp (due to damage to hypothalamus!!!!!!!!)

Seizures

Complications---- Damage to brain cells from injury and during periods of increased ICP may cause residual scarring and

Hydrocephalus

Complications---- Excessive accumulation of CSF; causing motor deficits, cranial nerve deficits, or decreased cognitive ability; Rehabilitation efforts are focused on eliminating or decreasing deficits and promoting as much cognitive and physical function as possible

Diabetes Insipidus

Complications---- May occur from injury or edema of the pituitary gland; Antidiuretic hormone is released in inadequate amounts, resulting in polyuria, and the awake patient may complain of polydipsia (excessive thirst); Intravenous vasopressin and fluid replacement are the preferred treatments. Carefully monitor intake and output and electrolyte balance; Watch for large amounts of pale urine

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