Neurological disorders - part 2 - NUR 201 (Head injuries, brain tumors, seizures, meningitis, MS, Parkinsons)

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Head injuries

poor prognosis if they have: intracranial hemorrhage, older age, abnormal motor responses, impaired or no eye movements, no pupil reaction, hypotension, hypercapnia, increased ICP > 20, Glasgow coma score <7

Diffuse injury (generalized)

damage to the brain cannot be localized to one particular area of the brain
ex. concussion - S&S brief disruption in LOC, amnesia regarding the event and HA, recovery with no permanent damage usually occurs within 24 hrs

Focal injury (localized)

can be minor to severe and can be localized to an area of injury
Ex: lacerations, contusions, hematomas, and cranial nerve injuries
contusion - bruising of brain tissue with rupture of small blood vessels and edema caused by a blunt blow to the head
closed head injury - occurs when the skull is not fractured but the brain tissue is injured and blood vessels may be ruptured by the force exerted against the skull
contrecoup injury - when the skull and brain hit a solid object, it causes the brain to rebound against the opposite side of the skull

Open head injury

injuries involving fractures or penetration of the brain by missiles or sharp objects

Depressed skull fracture

involves displacement of a piece of bone below the level of the skull - blood supply to the area is impaired and considerable pressure is exerted on the brain

Head injury complications

epidural hematoma - bleeding between the dura and the inner surface of the skull
S&S - initial period of unconsciousness at the scene with a brief lucid interval followed by decreased LOC, HA, N/V
Rx: rapid surgical intervention (burr hole) to prevent cerebral herniation

Subdural hematoma

bleeding between the dura mater and the arachnoid layer - usually venous origin - patient may develop decreased LOC and headache within 48 hrs of a head injury

Intracerebral hematoma

bleeding within the brain tissue, usually occurs within the frontal and temporal lobes

Subarachnoid hemorrhage

occurs when there is intracranial bleeding into the CSF filled space between arachnoid space and the pia mater
major cause is aneurysm
S&S: severe HA (worst in my life), altered LOC, photophobia, nuchal rigidity, N/V, focal deficits
Dx: H&P, CT, lumbar puncture (blood in CSF confirms), angiogram
Tx: volume expanders, BP control, Amicar (increase clot formation), Nimotop (prevent vasospasms)

Care of patient with head injury

respiratory - maintain patent airway: 1st priority, change in personality or behavior, keep cervical collar in place, if draining CSF apply loose dressing, neuro status Q2H, hx of injury
Raise HOB 30-45 degrees, administer O2 to maintain SAT > 92%, hyperventilate patient to keep the PaCO2 between 30-35 (to reduce the cerebral blood flow and decrease ICP), monitor for cushing's triad, don't attempt to suction or allow client to blow nose*, seizure precautions

Brain Tumor

abnormal mass resulting from excessive multiplication of cells
S&S: H/A only symptom in 20% of cases (worse in mornings), papilledema present in 70-75%, S&S IICP, personality changes

Brain tumor: surgical intervention

Craniotomy - incision through cranium with several burr holes
Craniectomy - excision of portion of the skull and complete removal of bone flap
Cranioplasty - plastic repair of skull after craniotomy

Intracranial surgery: pre op nursing care

consent, prophylactic meds: dilantin (monitor level *normal 10-20 - can cause hyperplasia) & decadron, prepare site, baseline assessment

Intracranial surgery: post op nursing care

VS and neuro assessment, resp status, ability to swallow, incision site (monitor for infix), HA, N/V, seizures, report yellow or clear drainage on dressing - test for glucose, report frequent swallowing or post-nasal drip, monitor for S&S meningitis, avoid activities that IICP, encourage deep breathing but no vigorous coughing

Supratentorial surgery

position low-semi fowlers on back or side opposite incision, bedrest 24-48 hrs

infratentoral surgery

position flat with small pillow to support head, position on side, bedrest 3-5 days

Meningitis

acute inflammation of the meningeal tissues surrounding the brain and spinal cord

Meningitis: clinical manifestations

fever, severe HA, N/V, decreased LOC, photophobia, signs of IICP, nuchal rigidity, positive Kernings sign, positive brudzinski's sign
possible skin rash and petechia

Meningitis: diagnostic studies

blood culture, CT scan, lumbar puncture, xrays of skull, MRI

Bacterial meningitis management

IV antibiotics, respiratory isolation x 24 hrs, corticosteroid may be given, symptomatic treatment for fever and IICP

Viral meningitis

causes: enteroviruses, arboviruses, HIV, HSV
S&S: HA, fever, stiff neck, photophobia
Dx: xpert EV test is used to dx viral meningitis
Tx: managed symptomatically
full recovery expected

Meningitis: nursing care

isolation, antipyretics, cooling blanket, report to health dept., decrease environmental stimuli, administer antibiotics after blood cultures drawn, seizure precautions
meds: antibiotics, anticonvulsants if IICP (Dilantin), antipyretics

Why do you maintain hyperventilation in head injury patients?

to reduce the cerebral blood flow and decrease ICP

What is recommended PaCO2 level maintained for hyperventilation

30-35

What is the normal cerebral perfusion pressure (CPP)

60-100

What is the normal ICP

5-15

What is the normal MAP

70-110

In which case may the patient develop decreased LOC and HA within 48 hrs of head injury

subdural hematoma

A nurse is caring for a patient who is scheduled for cerebral angiogram with contrast dye. Which statements should the nurse communicate to the MD?

I may be pregnant, I take coumadin, I am allergic to shellfish

When assessing a client with meningitis, the nurse looks for which of the following as a frequent first sign of IICP

change in mood or attention level (change in LOC)

The nurse is giving discharge instructions to a client who has been in the hospital with bacterial meningitis. What is the highest priority instruction?

take all antibiotics as directed until completely gone

Which of the following nursing interventions are appropriate for a patient who has meningitis at risk for IICP?

implement seizure precautions, turn room lights off and tv, administer antibiotics after blood cultures obtained

Seizure

abrupt abnormal excessive and uncontrolled electrical discharge of neurons within the brain.

Generalized seizure (grand mal or tonic-clonic)

may begin with an aura, has two phases
Tonic: begins with a 15-20 seconds of stiffening of muscles and loss of consciousness.

Absence seizure: petit mal seizure

seizure consists of a loos of consciousness lasting a few seconds. Typical clinical manifestation is a brief staring spell.

Status epilepticus

state of continuous seizure activity. Seizures recur in rapid succession without return to consciousness between seizure. Most serious complication of epilepsy and is a medical emergency - neurons become exhausted and cease to function - permanent brain damage can result

Seizure disorder: management

anticonvulsant therapy: ex. phenobarbital avoid use with alcohol, management of status epileptic - top priority is airway - keep patient side lying, meds: ativan, phenobarbital, Dilantin for long term therapy
-document in detail: aura, length of time of tonic and clonic phase, any frothing, loss of consciousness, medicines given, seizure precautions applied, etc.

A patient calls and tells nurse that her monring dose of Dilantin was accidentally skipped and it is now 3 hrs before the next dose is due. The client typically takes Dilantin 3 times a day. What should the nurse tell the patient to do?

wait until the next scheduled time and take a regular dose (b/c the Dilantin is scheduled 3 times a day)

Multiple Sclerosis (MS)

-chronic, progressive degenerative disorder of the CNS
-it is an autoimmune disease
-demyelination and scarring of sites along the central nervous system
-marked by relapses and remissions that may or may not return the patient to their previous baseline level of function
-periods of exacerbations and remissions
-disease progresses eventually to the point of quadriplegia
-onset 20-40 years old

MS: clinical manifestations

-fatigue (space activities throughout day with periods of rest
-visual changes (diplopia - double vision, scotomas - white spots in visual field)
-weakness and spasticity of arms and legs, ataxia
-intension tremors
-dysphagia
-cognitive changes, emotional problems
-bowel and bladder dysfunction

MS: diagnosis

can take months or years
MRI - shows presence of plaques
CSF - increased levels IGG antibody, protein and WBCs
CT - increased density of white matter

MS: management

treat symptoms and give supportive care, suppress immune system and decrease inflammation (chemo drugs and steroids), PREVENT INFECTION, manage muscle spasticity, neurogenic bladder, paresthesia and cerebellar ataxia

Parkinson's disease

progressive, degenerative neurological disease which affects the motor functions
DECREASED levels of dopamine
causes uncoordinated movements
symptoms occur d/t the overstimulation of the basal ganglia by acetylcholine

Parkinsons: clinical manifestations

Cardinal signs: tremors, muscle rigidity, bradykinesia, postural instability
-stooped posture, mask like face, short rapid shuffling and propulsive gait, slow to respond, pill rolling

Parkinsons disease: focus of nursing care

administer meds at prescribed times, monitor swallowing, maintain mobility as long as possible, promote patient communication as long as possible Safety

Parkinsons: medication

Dopaminergics (dopamin agonists) - increase amount of available dopamine at junction. Take with food, change positions slowly and wear TED hose
anticholinergics: ease tremors, drooling, and rigidity, blocks effects of acetylcholine
watch for:
blurred vision & photophobia, dry mouth (use gum, hard candy, frequent mouth care), delayed gastric emptying, urinary retention

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