ATI – Medical Surgical – Unit 1 Foundations for Adult Care; Unit 2 Neurosensory Disorders

Modifiable Variable
One that can be changed
Wellness
The ability to adapt emotionally and physically to a changing state of health and environment
Aspects of health and wellness
1. physical -activities of daily living
2. emotional – adapt to stress; express and identify emotions
3. social – interact successfully with others
External environment
social and physical
Variables
a) modifiable – may be changed: weight, smoking
b) nonmodifiable – cannot be changed such as gender, age, genetic traits
Health and wellness continuum
an assessment tool used to measure level of wellness
Emergency nursing principles
1. primary survey
2. airway cervical spine, breathing, circulation, disability and exposure (ABCDE)
3. triage guidelines
4. basic first aid
5. cardiac arrest and CPR
ABCDE Principle
A = airway/cervical spine
B = breating
C = circulation
D = Disability
E = Exposure
Airway / cervical spine
1. Most important step in the primary survey
2. If clients are awake and responsive, airway is open
3. Head tilt chin lift maneuver is most effective technique; DO NOT perform if clients have a potential cervical spine injury
Breathing
If clients are not breathing or are breathing inadequately, manual ventilation should be performed by a bag-valve mask with supplemental oxygen or mouth to mask ventilation until a bag-valve mask can be obtained
Interventions for effective circulation
1. CPR
2. Hemorrhage control
3. Monitoring infusion of fluids and/or blood
Shock
It may be developed if circulation is compromised. Shock is the body’s response to inadequate tissue perfusion and oxygenation. It manifests with an increased heart rate and hypotension and may result in tissue ischemia and necrosis
Shock interventions
1. administer oxygen
2. apply pressure to bleeding
3. elevate client’s feet to shunt blood to vital organs
4. monitor IV fluids and blood products as ordered
5. monitor vital signs
6. remain with client and provide support for anxiety
Glasgow coma scale
Tool for level of consciousness
a) eye opening
b) verbal response
c) motor response
Exposure
Hypothermia is a primary concern for clients. It leads to vasoconstriction and impaired oxygenation
Prevention of hypothermia
1. remove wet clothing from the client
2. cover the client with blankets
3. increase the temperature of the room
4. monitor infusion of warmed fluids as prescribed
Triage
Under usual conditions, guidelines ensure that clients with the highest acuity needs receive the quickest treatment. Mass Casualty conditions provide guidelines with a military form implemented with a focus of achieving the greatest good for the greatest number of people
Triage under mass casualty conditions: Classifications
a) Emergent or class I – identified with a RED tag indicating an immediate threat to life
b) Urgent or class II – identified with a YELLOW tag indicating major injuries that require immediate treatment
c) Nonurgent or class III – identified with a GREEN tag indicating minor injuries that do not require immediate treatment
d) Expectant or class IV – identified with a BLACK tag indicating one who is expected and allowed to die.
Bleeding in Basic First aid
1. identify any sources of bleeding and apply direct pressure to the wound site.
2. DO NOT remove impaled objects
3. internal bleeding may require intravascular volume replacement with fluids and or blood products or surgical intervention
Fractures and splinting in basic first aid
1. Check site for swelling, deformity and skin integrity
2. check temperature, distal pulses and mobility
3. apply a splint to immobilize the fracture. Cover any open areas with a sterile cloth if available
4. recheck neurovascular status after splinting
Sprains in basic first aid
1. Refrain from weight bearing
2. Apply ice to decrease inflammation
3. Apply compression dressing to minimize swelling
4. Elevate the affected limb
Cardiac Arrest in Basic First Aid
1. A sudden cessation of cardiac function, it is characterized by the absence of a carotid pulse in the adult and child 1 year to adolescent.
2. In infant’s up to 1 year, it is the absence of brachial pulse, check the infant’s carotid pulse. The brachial pulse is checked first because the carotid pulse may be difficult to palpate due to fatty tissue of the infant’s neck.
Findings in Cardiac Arrest
1. Ventricular fibrillation (VF) is the cause of sudden, nontraumatic cardiac arrest of 80 to 90% of the victims
2. May occur after respiratory arrest. Electrical activity may be present but not sufficient to stimulate cardiac contractions, called pulseless electrical activity
3. In children or infants, cardiac arrest is often secondary to hypoxemia or shock.
4. Without sufficient cardiac output, brain will suffer CELL ANOXIA (CELL DEATH) within 4 to 6 minutes, with death following shortly
CPR in basic first aid
Process of externally supporting the circulation and respirations of a client who has experienced a cardiac arrest. Defibrillation is used in the presence of ventricular fibrillation and ventricular tachycardia. Neither of these rhythms provide sufficient cardiac output to support life. CPR and defibrillation significantly increases the client’s chances of survival when initiated immediately.
Goal of BLS (basic life support)
Provide oxygen to the vital organs until appropriate advanced resuscitation measures can be initiated or until resuscitative efforts are ordered to be stopped. BLS involves airway, breathing, and circulation
Goal of ACLS (Advanced Cardiac Life Support)
Return of spontaneous breathing and circulation. IN addition to the ABCs of BLS, ACLS involves the diagnosis and treatment of underlying cardiac dysrhythmias; insertion of an oropharyngeal or endotracheal airway with bag ventilation and supplemental oxygen; administration of IV fluids, and administration of antidysrhythmic medications.
Emergency medication: EPINEPHRINE (adrenaline) Action I
Action: Vasoconstriction
Emergency medication: EPINEPHRINE (adrenaline) Therapeutic Use I
1. slows absorption of local anesthetics
2. manages superficial bleeding
3. reduces congestion of nasal mucosa
4. increases blood pressure
Emergency medication: EPINEPHRINE (adrenaline) Action II
1. Increases heart rate
2. Strengthens myocardial contractility
3. Increase rate of conduction through the AV node
Emergency medication: EPINEPHRINE (adrenaline) Therapeutic Use II
1. Treatment of AV block and cardiac arrest
Emergency medication: DOPAMINE (Intropin) Action
1. Increased heart rate
2. increased myocardial activity
3. increased rate of conduction through the AV node
4. Increased blood pressure
Emergency medication: DOPAMINE (Intropin)
Therapeutic Use
1. Shock
2. Hear Failure
Cerebral angiogram
Provides visualization of the cerebral blood vessels. Digital subtraction angiography subtracts the bones and tissues from the images, providing x-rays with only the vessels apparent. Used to assess blood flow to and within the brain, identify aneurysms, and define the vascularity of tumors (useful for surgical planning).
Pre Procedure for Cerebral angiogram
1. Instruct clients to refrain from consuming food or fluids for 4 to 8 hours prior to the procedure
2. Check allergy to shellfish, iodine which would require the use of a different contrast media. Any history of bleeding requires additional monitoring to assure clotting after the procedure.
3. Ensure clients are not wearing any jewelry
4. A mild sedative is administered prior to the procedure and vital signs are continuously monitored during procedure.
5. EDUCATION: Do not move during the procedure and about the need to keep the head immobilized
During Cerebral Angiogram
1. Client is placed on radiography table, head is secured
2. Catheter is placed into an artery (groin or neck), dye injected, x-ray pictures taken
3. Additional sedation if required
Postprocedure for Cerebral Angiogram
1. Monitor site to assure that clotting occurs
2. Restrict movement for 8 to 12 hours to prevent rebleeding at the catheter site.
CT Scan
Provides sectional cross-images of the cranial activity. Contrast medium is used to enhance the images.
Indications for CT Scan
Used to identify tumors and infarctions, detect abnormalities, monitor response to treatment and guide needles used for biopsies
Pre Procedure for CT Scan
1. NPO 4 to 8 hours prior to test
2. Check allergies to iodine or shellfish
3. Check renal function (BUN) because contrast media is excreted by kidneys.
3. Since client is in supine position, place pillows in the small of the client’s back to prevent back pain. Head must be secured to prevent unnecessary movement.
4. Ensure client’s jewelry is removed prior to this procedure. In general client, wears a hospital gown to prevent any metals from interfering with the x-ray
EEG
This noninvasive procedure assesses the electrical activity of the brain and is used to determine if there are abnormalities in the brain wave pattern.
Glasgow Coma Scale (GCS)
Concentrates on neurologic function and is useful to determine the level of consciousness and monitor response to treatment. The GCS is reported as a number, which allows providers to immediately determine if neurologic changes have occurred
Glasgow Coma Scale: Indications
Helpful in determining changes in the level of consciousness for clients with head injuries, space occupying lesions or cerebral infarctions, and encephalitis. This is important because complications related to neurologic injuries may occur rapidly and require immediate treatment
Glasgow Coma Scale: Interpretation of Findings
– The best possible score is 15. Total scores of GCS correlate with the degree or level of coma
– Less than 8 – associated with severe head injury and coma
– 9 to 12 – Indicate a moderate head injury
– Greater than 13 – Reflect minor head trauma
Glasgow Coma Scale: Procedure
Eye opening – best response ranging from 4 to 1
Verbal – best response ranging from 5 to 1
Motor – best response ranging from 6 to 1
Lumbar puncture (Spinal Tap)
A procedure in which a small amount of cerebrospinal fluid (CSF) is withdrawn from the spinal canal and then analyzed to determine its constituents.
Lumbar puncture (Spinal Tap) – Preprocedure
Nursing actions
1. Ensure that the clients jewelry has been removed and that the clients are wearing only hospital gown
2. Instruct clients to void prior to the procedure
3. Position clients to stretch the spinal canal. This may be done by having clients assume a cannonball position while on one side or by having clients stretch over an overbed table if sitting is preferred
Lumbar puncture – Indications
Used to detect the presence of certain diseases (MS, syphilis), infection and malignancies. A lumbar puncture may also be used to administer medication or chemotherapy directly to spinal fluid
Lumbar puncture (Spinal Tap) – Interpretation of Findings
– Presence of red or white blood cells in CSF indicates an intracranial bleed or other vascular pathological process in the brain
– Elevated CSF readings can also indicate increased intracranial pressure
Lumbar puncture (Spinal Tap) – Risks and Benefits
– a lumbar puncture is associated with severe complications, especially when performed in the presence of increased ICP (brain herniation)
– for clients with bleeding disorder or those taking anticoagulants, it may result in bleeding that compresses the spinal cord.
Lumbar puncture (Spinal Tap) – Intraprocedure
1. The area of the need insertion is cleansed and a local anesthesia is injected
2. This is not a painful procedure; there should be little need for pain or relaxing medication other than the local anesthesia
3. The needle is inserted and the CSF is withdrawn, after which the needle is removed
4. A manometer may be used to determine the opening pressure of the spinal cord. which is useful if increased pressure is a consideration.
MRI Scan
a) Provides cross-sectional images of the cranial activity. A contrast media may be used to enhance the images.
b) Unlike CT scans, MRI images re obtained using magnets, thus the consequences associated with radiation are avoided. This makes this procedure safer for women who are pregnant.
c) The use of magnets precludes the ability to scan a client who has an artificial device (pacemakers, surgical clips, IV access port). If these are present, shielding may be done to prevent injury
MRI Scan: Indications
1) May be used to detect abnormalities, monitor response to treatment, and guide needles used for biopsies
2) MRI’s are capable of discriminating soft tissue from tumor or bone. This makes the MRI scan more effective at determining tumor size and blood vessel locations.
MRI Scan: Interpretation of findings
Detailed three dimensional pictures provide location and size of cranial pathology, such as tumors, arteriovenous malformation and other vascular disorders
MRI Scan: Preprocedure
Nursing Actions
1. Ensure that the client’s jewelry is removed prior to this procedure. Have clients wear a hospital gown to prevent any metals from interfering with the magnet.
2. If sedation is expected, clients should refrain from food or fluids for 4 to 8 hours prior to the procedure.
3. Determine if clients have a history of claustrophobia and explain the tight space and noise.
4. Providers and family members who are in the scanning area while the magnet is on must remove all jewelry, pagers and phone to prevent damage to themselves or the magnet.
5. Placing pillows in the small of the clients back may assist in preventing back pain. The head must be secured to prevent unnecessary movement during the procedure.
MRI Scan: Intra – procedure
1. Clients must lie supine with his head stabilized
2. MRI Scanning is noisy, and earplugs or sedation may be provided.
PET and SPECT Scans
Nuclear medicine procedures tat produce three-dimensional images of the head. These images can be static (depicting vessels) or functional (depicting brain activity). A glucose-based tracer is injected into the blood stream prior to the PET/SPECT scan. This initiates regional metabolic activity, which is then documented by the scanner.
PET and SPECT Scans: Indications
Captures regional metabolic activity and is most useful in determining tumor activity and/or response to treatment. They are also able to determine the presence of DEMENTIA, indicated by the inability of the brain to respond to tracer. Also able to determine parts of the brain that are not functioning.
PET and SPECT Scans: Preprocedure
They use radiation, thus the risk/benefit consequences to any client who may be pregnant must be discussed.
PET and SPECT Scans: Preprocedure – NURSING action
Check for a history of DIABETES MELLITUS. While this condition does not preclude a PET/SPECT scan, alterations in the client’s medications may be necessary to avoid hyperglycemia or hypoglycemia before and after this procedure.
PET and SPECT Scans: Intraprocedure
1. While pictures are being obtained, clients must lie flat with the head restrained.
2. This procedure is not painful and SEDATION is NOT necessary.
PET and SPECT Scans: POST PROCEDURE – Nursing Action
No need for follow up care. Because THE TRACER IS GLUCOSE based and short acting (less than 2 hours), it is broken down within the body as a sugar, not excreted
Radiography (X-Ray)
Uses electromagnetic radiation to capture images of the internal structures of an individual. A structure’s image is light or dark relative to the amount of radiation the tissue absorbs. The image is recorded on a radiograph, which is a black and white image that is held up to light for visualization.
Radiography (X-Ray): Indications
Used to diagnose possible skull or spinal fractures. They also determine the cause of paralysis or paresthesia and increasing neurologic deficits.
Radiography (X-Ray): Findings
X-ray examinations of the skull and spine can reveal fracture, curvatures, bone erosion and dislocation, and possible soft tissue calcification, all of which can damage the nervous system
Radiography (X-Ray): Special considerations
a) Determine if clients are pregnant
b) Jewelry should be removed
c) Radition used is very small
d) Clients should remain still during the procedure
PHYSIOLOGY OF PAIN: Transduction
Conversion of painful stimuli to an electrical impulse through peripheral nerve fibers (nociceptors)
Nursing priority responsibility for pain
To continually collect data regarding a client’s pain level and to provide individualized interventions. They should determine the effectiveness of the interventions 30 to 60 minutes after implementation.
PHYSIOLOGY OF PAIN: Transmission
Occurs as the electrical impulse travels along the nerve fibers and is regulated by neurotransmitters
Pain Threshold
The point at which one feels pain
Pain tolerance
Amount of pain one is willing to bear
Substances that increase pain transmission and cause an inflammatory response
1. Substance P
2. Prostaglandins
3. Bradykinin
4. Histamine
Substances that decrease pain transmission and produce analgesia
1. Serotonin
2. Endorphins
Perception or awareness of pain
Occurs in the brain and is influenced by thought and emotional processes.
Modulation occurs in the spinal cord
Causing muscles to contract reflexively, moving the body away from painful stimuli.
Acute pain
1. Protective, temporary usually self-limiting and resolves with tissue healing.
2. Physiological responses (sympathetic nervous system), are fight or flight responses (tachycardia, hypertension, anxiety, diaphoresis, muscle tension)
3. Behavioral response include grimacing, moaning, flinching, and guarding.
4. Interventions include treatment of the underlying problem.
Chronic Pain
1. Not protective; ongoing and recurs frequently, lasting longer than 6 months and persisting beyond tissue healing
2. Physiological responses to not usually alter vital signs, but the client may experience depression, fatigue, and a decreased level of functioning.
3. Psychosocial implications may lead to disability
4. Chronic pain may not have a known cause, and it may not respond to interventions
5. Management of pain is aimed at symptomatic relief
6. Chronic pain can be malignant or non-malignant
Nociceptive Pain
a) Arises from damage to or inflammation of tissue other than that of the peripheral and central nervous system
b) It is usually throbbing aching and localized.
c) Typically responds to OPIOID and NONOPIOID medications.
Types of Nociceptive Pain
1. Somatic – bones, joints, muscle skins or connective tissue, and central nervous system
2. Visceral – in internal organs such as the stomach or intestines. It can cause referred pain in other other body locations not associated with the stimulus.
3. Cutaneous – in the skin or subcutaneous tissue
Neuropathic pain
1. Arises from abnormal or damaged pain nerves
2. Includes phantom limb pain, pain below the level of a spinal cord injury and diabetic neuropathy
3. Neuropathic pain is usually intense, shooting, burning, or described as pins and needles.
4. This pain typically responds to adjuvant medications (antidepressants, antispasmodic agents, skeletal muscle relaxants)
Causes of acute and chronic pain
1. Trauma
2. Surgery
3. Cancer
4. Arthritis
5. Fibromyalgia
6, Neuropathy
7. Diagnostic or treatment procedures (injection, intubation, radiation)
Data Collection of Pain: Parameters
1. Location
2. Quality
3. Intensity, strength
4. Timing
5. Setting
6. Associated Symptoms
7. Aggravating/Reliving Factors
Quality of Pain
Refers to how pain feels:
1. Sharp or dull
2. Aching or burning
3. Stabbing or pounding
4. Throbbing or shooting
5. Gnawing
6. Tender
7. Heavy or tight
8. Exhausting or sickening
9. Terrifying or torturing
10. Nagging or annoying
11. Intense
12. Unbearable
Acute pain
Temporarily increases blood pressure, pulse, and respiratory rate. Eventually, increases in vital signs will stabilize despite the persistence of pain. Therefore, physiologic indicators may not be an accurate measure of pain over time.
Nonpharmacological Pain Management: Cutaneous (skin) stimulation
Interruption of pain pathways, Cold for inflammation or Heat to increase blood flow and to reduce stiffness
1. transcutaneous electrical nerve stimulation (TENS),
2. heat,
3. cold,
4. therapeutic touch, and
5. massage
Nonpharmacological Pain Management
1. Distraction – ambulation, deep breathing, visitors, TV
2. Relaxation – meditation, yoga, progressive muscle relaxation
3. Imagery – pleasant thoughts, ability to concentrate
4. Acupuncture – needles along energy meridians. With heat, it is called MOXIBUSTION
5. Reduction of pain stimuli in environment
6. Elevation of extremities that are edematous
PAIN: Pharmacological Interventions (analgesics)
1. Opioids –
2. Nonopioids
3. Adjuvants
PAIN: Analgesic – NONOPIOIDS
ACETAMINOPHEN: analgesic and antipyretic, NSAIDS have analgesic, antiinflammatory, antiplatelet, and antipyretic effects. Beware of Hepatoxic effects. Monitor patients taking aspirin for vertigo, tinnitus, decreased hearing acuity. Prevent gastric upset by medication administration with food or antacids. Monitor client for bleeding with NSAID use
PAIN: Analgesic – OPIOIDS
Morphine sulfate, fentanyl (Sublimaze), codeine: appropriate for treating moderate to severe pain (postoperative, MI, Cancer pain)
PAIN: Analgesic – OPIOIDS – Management
1. Manage a client’s acute severe pain with short-term, (24 to 48 hr) around-the-clock opioids. Maintain consistency in timing and dosing to provide consistent pain control.
2. Monitor clients receiving parenteral opioids for immediate, short-term relief of acute
pain.
3. Use the oral route for chronic, nonfluctuating pain.
4. Monitor and intervene for adverse effects of opioid use.
PAIN: Analgesic – OPIOIDS – Management of Adverse Effects: Respiratory Depression
Monitor the client’s respiratory rate prior to and following administration of opioids (especially in clients who are opioid-nalve).
Initial treatment of respiratory depression and sedation is generally a reduction in opioid dose. Notify the charge nurse of respiratory depression for administration of naloxone (Narcan).
PAIN: Analgesic – OPIOIDS – Management of Adverse Effects: CONSTIPATION
Use a preventative approach (monitoring of bowel movements,
fluids, fiber intake, exercise, stool softeners); use stimulant laxatives, enemas when necessary.
PAIN: Analgesic – OPIOIDS – Management of Adverse Effects: ORTHOSTATIC HYPOTENSION
Advise clients to sit or lie down if symptoms of lightheadedness or dizziness occur. Instruct clients to avoid sudden changes in
position by slowly moving from a lying to a sitting or standing position. Provide assistance with ambulation as needed.
PAIN: Analgesic – OPIOIDS – Management of Adverse Effects: URINARY RETENTION
Monitor the client’s 1&0, check for distention, administer bethanechol (Urecholine), and catheterize as prescribed.
PAIN: Analgesic – OPIOIDS – Management of Adverse Effects: NAUSEA AND VOMITING, Sedation
Nausea/vomiting – Administer antiemetics, advise clients to lie still and/or move slowly, and eliminate odors.
Sedation – Monitor the client’s level of consciousness and take safety precautions. Sedation usually precedes respiratory depression.
PAIN: Analgesic – ADJUVANT ANALGESICS
Enhance the effects of nonopioids, help alleviate other symptoms that aggravate pain (depression, seizures, inflammation), and are useful for treatment of neuropathic pain.
– Anticonvulsants – carbamazepine (Tegretol)
– Antianxiety agents – diazepam (Valium)
– Tricyclic antidepressants – amitriptyline (Elavil)
– Antihistamine – hydroxyzine (Vistaril)
– Glucocorticoids – dexamethasone (Decadron)
– Antiemetics – ondansetron hydrochloride (Zofran)
Patient Controlled Analgesics
A medication delivery system that allows clients to self-administer safe doses of opioid analgesics.
o Constant plasma levels are maintained by small, frequent doses.
o The client experiences less lag time between identified need and delivery of medication, which increases the client’s sense of control and may decrease the amount of medication needed.
o Commonly used opioids are morphine sulfate and hydromorphone (Dilaudid).
o Monitor clients for sedation and respiratory depression.
o The client is the only person who should push the PCA button to prevent inadvertent dosing
Brain Tumors
Ocur in any part of the brain and are classified according to the cell or tissue of origin.
Types of brain tumors include:
a) malignant gliomas (neuroglial cells),
b) benign meningiomas (meninges),
c) pituitary tumors, and
d) acoustic neuromas (acoustic cranial nerve).
Brain Tumors: Effect on surrounding Systems
Brain tumors apply pressure to surrounding brain tissue, resulting in decreased outflow
of cerebrospinal fluid, increased intracranial pressure, cerebral edema, and neurological
deficits. Tumors that involve the pituitary gland may cause endocrine dysfunction.
Brain Tumors: Head Injuries
Can be classified as :
a) open (skull integrity is compromised – penetrating
trauma) or
b) closed (skull integrity is maintained – blunt trauma).Head injuries are also classified as
1) mild,
2) moderate, or
3) severe,

depending upon Glasgow Coma Scale (GCS) ratings
and the length of time the client was unconscious.

Head Injuries: Hemorrhage
May or may not be associated with hemorrhage (epidural, subdural, and intracerebral). Cerebrospinal fluid leakage is also possible. Any collection of fluid or foreign objects that occupies the space within the confines of the skull consequently poses a risk for cerebral edema, increased intracranial pressure, cerebral hypoxia, and brain herniation.
Primary and Secondary malignant brain tumors. Cranial metastatic Lesions
Primary malignant brain tumors originate from neuroglia tissue and rarely metastasize outside of the brain. Secondary malignant brain tumors are lesions that are metastases from a primary cancer located elsewhere in the body. Cranial metastatic lesions are most
common from breast, kidney, and gastrointestinal tract cancers.
Benign brain tumors
Develop from the meninges or cranial nerves and do not metastasize. These tumors have distinct boundaries and cause damage either by the pressure they exert within the cranial cavity and/or by impairing the function of the cranial nerve.
Brain tumors that occur in the cerebral hemispheres above the tentorium cerebelli
Classified as supratentorial tumors. Those below the tentorium cerebelli, such as tumors of the brainstem and cerebellum, are classified as infratentorial tumors.
Brain tumors: Risk Factors
• Genetics
• Environmental agents
• Exposure to ionizing radiation
• Exposure to electromagnetic fields
• Previous head injury
Brain tumor: Physical Assessment Findings
• Dysarthria
• Dysphagia
• Positive Romberg sign
• Positive Babinski’s sign
• Vertigo
• Hemiparesis
• Cranial nerve dysfunction (inability to discriminate sounds, loss of gag reflex, loss
of blink response)
SUPRATENTORIAL BRAIN TUMORS (above the tentorium cerebelli)
• Severe headache – worse upon awakening, but gets better over time
• Visual symptoms (blurring, visual field deficit)
• Seizures
• Loss of voluntary movement or the inability to control movement
• Change in cognitive function (memory loss, language impairment)
• Change in personality, inability to control emotions
• Nausea with or without vomiting
INFRATENTORIAL BRAIN TUMORS (below the tentorium cerebelli: brainstem and cerebellum)
• Hearing loss or ringing in the ear
• Facial drooping
• Difficulty swallowing
• Nystagmus, crossed eyes, or decreased vision
• Autonomic nervous system (ANS) dysfunction
• Ataxia or clumsy movements
• Hemiparesis
• Cranial nerve dysfunction (inability to
discriminate sounds, loss of gag reflex, loss of
blink response)
Brain Tumors: Laboratory Tests
• CBC and differential to rule out anemia or malnutrition
• Alcohol and illicit drug screen to rule out these as causes of abnormal physical
examination
• TB and HIV screening if social conditions warrant
Brain Tumors: Diagnostic Procedures
• X-ray; computed tomography (CT) imaging, magnetic resonance imaging (MRI), brain, and position emission tomography (PET) scans; and cerebral angiography are all used to determine the size, location, and extent of the tumor.
• Cerebral biopsy – performed to identify cellular pathology
Brain Tumor: Client Education: Cerebral Biopsy
a) Include specific instruction regarding medications.
b) Instruct clients to continue antiepileptic medications to prevent
seizure activity.
c) Instruct clients to discontinue aspirin products at least 72 hr prior
to the procedure to minimize the risk of intracerebral bleeding.
d) Inform clients that preprocedure activities may be resumed after
recovering from the general anesthetic.
e) Instruct clients to keep the incision clean and dry. If sutures are in
place, they need to be removed 1 to 7 days later.
f) Encourage clients to avoid driving or other dangerous activities
until follow-up appOintment occurs and diagnosis is known.
Brain Tumor: Nursing Interventions
o Maintain airway (monitor oxygen levels, administer oxygen as needed, monitor lung sounds).
o Monitor neurological status, in particular, observing for changes in level of consciousness, neurological deficits, and occurrence of seizures.
o Maintain client safety (assist with transfers and ambulation, provide assistive devices as needed).
o Implement seizure precautions.
o Administer medications as preSCribed.
Brain Tumor: Medication – Nonopioid and Opioid
o Nonopioid analgesics are used to treat headaches.
o Opioid medications are avoided, as they tend to decrease the client’s level of consciousness.
Brain Tumor: Medication – Corticosteroids
o Corticosteroids are used to reduce cerebral edema.
o Corticosteroid medications quickly reduce cerebral edema and may be rapidly administered to maximize their effectiveness.
o Chronic administration is used to control cerebral edema associated with the presence or treatment of benign or malignant brain tumors.
Brain Tumor: Medication – H2 Receptor Antagonists
* H2-receptor antagonists are used to decrease the acid content of the stomach, reducing the risk of stress ulcers.
* H2-receptor antagonist medications are administered during acute or stressful periods, such as after surgery, at the initiation of chemotherapy, or during the first several radiation therapy treatments.
Brain Tumor: Medication – ANTIEMETICS
o Antiemetics are used if nausea with or without vomiting is present.
• Nausea and vomiting may be present as a result of the increased intracranial pressure, the site of the tumor, or the treatment required.
• These medications are administered as prescribed, and may be provided as a preventative intervention, especially when the treatment is associated with nausea and/or vomiting.
Brain Tumor: Interdisciplinary Care
o Request appropriate referrals (social services, support groups, medical equipment, and physical, speech, and occupational therapy).
o Treatments include steroids, surgery, chemotherapy, conventional radiation therapy, stereotactic radiosurgery, and clinical trials. Chemotherapy and/or conventional radiation therapy may be administered prior to surgery to reduce the bulk of the
tumor.
o In cases where the tumor is a metastatic lesion from a primary lesion elsewhere in the body, treatments are palliative in nature. These treatments may consist of surgery, radiation, and chemotherapy, in any combination, and are aimed at controlling
intracerebral lesions.
Brain Tumor: Surgical Interventions
o Craniotomy – complete or partial resection of brain tumor through surgical opening in the skull
Brain Tumor: Craniotomy – Nursing Actions – Preoperative
~ Explain the procedure to clients, answering all appropriate questions. and providing emotional support.
~ Instruct clients to discontinue aspirin products at least 72 hr prior to the procedure.
Brain Tumor: Craniotomy – Nursing Actions – Postoperative
– Provide routine postoperative care to prevent complications
– Keep the client’s head elevated 30° and placed in a neutral position.
– Assist clients to avoid straining activities (moving up in bed and
attempting to have a bowel movement) to prevent increased intracranial pressure. Postoperative bleeding and seizure activity are the greatest risks.
Brain Tumor: Complications – SIADH
Syndrome of inappropriate antidiuretic hormone (SIADH)
o This is a condition where fluid is retained as a result of an overproduction of vasopressin or antidiuretic hormone (ADH) from the posterior pituitary gland.
o The condition occurs when the hypothalamus has been damaged and can no longer regulate the release of ADH.
o Treatment of SIADH consists of fluid restriction, desmopressin acetate tablets (DDAVP), and treatment of hyponatremia.
o If SIADH is present, the client may be diSOriented, report a headache, and/or vomit.
o If severe or untreated, this condition may cause seizures and/or a coma.
Brain Tumor: Complications – Diabetes Insipidus
Diabetes insipidus (DI)
o This is a condition where large amounts of urine are excreted as a result of a deficiency of ADH from the posterior pituitary gland.
o The condition occurs when the hypothalamus has been damaged and can no IOQger regulate the release of ADH.
o Treatment of DI consists of massive fluid replacement, careful attention to laboratory values, and replacement of essential nutrients as indicated.
HEAD INJURY: Skull Fractures
Skull fractures are often accompanied by brain injury. Damage to the brain tissue may be the result of decreased oxygen supply, or the direct impact from the skull fracture, which caused the trauma. The glucose levels in the brain are negatively affected, resulting in an
alteration in neurological synaptic ability.
HEAD INJURY: Open Head Injuries
Open-head injuries pose a high risk for infection.
HEAD INJURY: Cervical Spine
A cervical spine injury should always be suspected when a head injury occurs. A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.
HEAD INJURY: Data Collection
Risk Factors:
0 Males under 25 years of age
0 Motor vehicle or motorcycle crashes
0 Drug and alcohol use
0 Sports injuries
0 Assault
0 Gunshot wounds
0 Falls
HEAD INJURY: Data Collection – Subjective and Objective Data
o Presence of alcohol or illicit drugs at time of injury
o Amnesia (loss of memory) before or after the injury
o Loss of consciousness – Length of time the client is unconscious is significant
o Glasgow Coma Scale
o Signs of increased intracranial pressure
o Diagnostic Procedures
o Laboratory Testsigns of increased intracranial pressures
HEAD INJURY: Data Collection – Subjective and Objective Data: Glasgow Coma Scale
Glasgow Coma Scale
• Scores of:
o Less than 8 – Associated with severe head injury and coma
o 9 to 12 – Indicate a moderate head injury
o Greater than 13 – Reflect minor head trauma
HEAD INJURY: Data Collection – Subjective and Objective Data: Signs of Increased Intracranial Pressure
SIGNS OF INCREASED INTRACRANIAL PRESSURE (ICP)
• Severe headache
• Deteriorating level of consciousness, restlessness, irritability
• Dilated or pinpoint pupils that are slow to react or nonreactive
• Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea)
• Deterioration in motor function, abnormal posturing (decerebrate, decorticate, or flaccidity)
• Cushing reflex is a late sign characterized by severe hypertension with a widening pulse pressure (systolic – diastolic = pulse pressure) and bradycardia.
• Cerebrospinal fluid leakage from the nose and ears (“halo” sign – yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose)
• Seizures
HEAD INJURY: Data Collection – Subjective and Objective Data: Laboratory TESTS
• ABGs
• Alcohol level and drug screen
• CBC with differential and BUN – BUN is used to determine the client’s renal status. This information is needed prior to administration of radiology contrast media.
HEAD INJURY: Data Collection – Subjective and Objective Data: DIAGNOSTIC PROCEDURES
Diagnostic Procedures
• Cervical spine films are used to diagnose a cervical spine injury.
• Computerized tomography (CT) and/or a magnetic resonance imaging (MRI) of the head and/or neck (with and without contrast if indicated).
HEAD INJURY: Nursing Care
o There is a 1 hr “golden window” for treatment of head injuries. Emergency treatment provided during this time frame, especially for epidural hematomas, decreases the morbidity and mortality rates associated with these conditions.
o Instruct the client’s family on effective ways to communicate with the client (touch, talk, and assist with care as appropriate).
o Monitor at regularly scheduled intervals
HEAD INJURY: Nursing Care – Monitor at regularly scheduled intervals
• Respiratory status is the priority assessment: The brain is dependent upon oxygen to maintain function and has little
reserve available if oxygen is deprived. Brain function begins to diminish after 3 min of oxygen deprivation.
• Cranial nerve function (eye-blink response, gag reflex, tongue and shoulder movement)
• Pupillary changes (PERRLA, pinpoint, fixed/nonresponsive, dilated)
• Signs of infection (nuchal rigidity occurs with meningitis)
• Sensory and/or motor responses if spinal injury is present
• Changes in level of consciousness, using the GCS, provides the earliest indication of neurological deterioration.
• Intracranial pressure (ICP)
HEAD INJURY: Nursing Care – Intracranial Pressure Interventions I
a) Expected reference range for ICP level is 10 to 15 mm Hg. Implement actions that will decrease ICP:
b) Elevate head to reduce ICP and to promote venous drainage. Avoid extreme flexion, extension or rotation of the head, and maintain the body in a midline neutral position, with the head of the bed elevated 30°.
c) Maintain a patent airway. Administer oxygen as indicated to maintain an oxygen saturation level of greater than 95%. Discourage coughing and blowing nose forcefully.
d) Minimize endotracheal or oral tracheal suctioning. Do not routinely perform suctioning.
e) Maintain cervical spine stability until cleared by an x-ray. Report presence of cerebrospinal fluid (CSF) from nose or ears to the
provider.
HEAD INJURY: Nursing Care – Intracranial Pressure Interventions II
f) Provide a calm, restful environment (limit visitors, minimize noise). Implement measures to prevent complications of immobility (tum the client every 2 hr, footboard, and splints). Specialty beds can be used.
g) Monitor fluid and electrolyte values and osmolarity to detect changes in sodium regulation, the onset of diabetes insipidus, or severe hypovolemia.
h) Provide adequate fluids to maintain cerebral perfusion. When a large amount of IV fluids are prescribed, monitor the client carefully for excess fluid volume, which could increase ICP.
i) Maintain client safety and seizure precautions (side rails up, padded side rails, call light within the client’s reach).
j) Even if the level of consciousness is decreased, explain to the client the actions being taken and why. Hearing is the last sense affected by a head injury.
HEAD INJURY MEDICATIONS: Corticosteroids
o Corticosteroids – Dexamethasone (Decadron) and methylprednisolone (Solu-Medrol)
• Used to reduce cerebral edema
• NurSing Considerations
o Use with caution in the presence of diabetes mellitus, hypertension, glaucoma, or renal impairment. If these conditions exist, additional monitoring is reqUired as corticosteroids disrupt the stability of those conditions and can require alterations in care.
HEAD INJURY MEDICATIONS: Mannitol
Mannitol (Osmitrol)
• Osmotic diuretic used to treat acute cerebral edema
• Nursing Considerations
o Monitor clients receiving mannitol IV.
o Insert indwelling urinary catheter to monitor fluid and renal status.
HEAD INJURY MEDICATIONS: Pentobarbital (Nembutal)
Pentobarbital (Nembutal)
• Pentobarbital is used to induce a barbiturate coma to decrease cerebral metabolic demands.
• This treatment is performed when the ICP is refractory to treatment, has exceeded 25 mm Hg for 30 min, 30 mm Hg for 15 min, or 40 mm Hg for 1 min.
• A barbiturate coma is a treatment of last resort and aims to decrease elevated ICP by inducing vasoconstriction and decreasing cerebral metabolic demands.
• Nursing Considerations: Monitor clients receiving pentobarbital.
HEAD INJURY MEDICATIONS: Phenytoin (Dilantin)
Phenytoin (Dilantin)
• Used prophylactically to prevent or treat seizures that can occur
o Nursing Considerations
~ Check for medication interactions
HEAD INJURY MEDICATIONS: Morphine Sulfate or fentanyl (Sublimaze)
Morphine sulfate or fentanyl (Sublimaze)
• Analgesics used to control pain and restlessness
• Nursing Considerations
o Use opioids if client is receiving mechanical ventilation.
o Avoid the use of opioids due to the CNS depressant effect that will make a neurological assessment difficult.
HEAD INJURY: Interdisciplinary Care
o Care for a client with a head injury should include professionals from other disciplines as indicated. This may include a physical, occupational, recreational and/or speech therapist due to neurological deficits that may occur secondary to the area of the brain damaged. Rehabilitation facilities are frequently used to compress the time required to recover from a head injury and support re-emergence into society.
o Request referral for social services to provide links to social service agencies and
schools.
HEAD INJURY: Surgical Interventions: CRANIOTOMY
A craniotomy is the removal of nonviable brain tissue that allows for expansion and/or removal of epidural or subdural hematomas. It involves drilling a burr hole or creating a bone flap to permit access to the affected area. Treatment of intracranial hemorrhages require surgical evacuation.
CRANIOTOMY : Nursing Interventions
NURSING ACTIONS:
o Provide routine postoperative care to prevent complications.
CARE AFTER DISCHARGE: Client Education
• Recommend that clients wear helmets when skateboarding, riding a bike or motorcycle, skiing, playing football and any other sport that could cause a head
injury.
• Encourage clients to wear seat belts when driving or riding in a car.
• Encourage clients to avoid dangerous activities (speeding, driving under the influence of alcohol or drugs).
HEAD INJURY: Complications: Brain Herniation
o A brain herniation is the downward shift of brain tissue due to cerebral edema.
o Clinical signs include fixed dilated pupils, deteriorating level of consciousness, Cheyne-Stokes respirations, hemodynamic instability, and abnormal posturing.
o With treatment, severe neurological impairment usually persists.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS
• Meningitis is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord.
• Viral, or aseptic meningitis, is the most common form and commonly resolves without treatment.
• Bacterial, or septic meningitis, is a contagiOUS infection with a high mortality rate. The prognosis depends on how quickly care is initiated.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – Risk Factors
o VIRAL MENINGITIS
• Viral illnesses such as the mumps, measles, herpes, and arboviruses such as the mosquito-borne West Nile virus.o BACTERIAL MENINGITIS
• Bacterial-based infections, such as otitis media, pneumonia, or sinusitis, in which the infectious micro-organism is Neisseria meningitidis, Streptococcus pneumoniae, or Haemophilus influenzae
• Immunosuppression
• Invasive procedures, skull fracture, or penetrating head wound (direct access to CSF)
• Overcrowded or communal living conditions

NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – Subjective Data
o Excruciating, constant headache
o Nuchal rigidity (stiff neck)
o Photophobia (sensitivity to light)
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – Objective Data
Physical Assessment Findings
• Fever and chills, Nausea and vomiting
• Altered level of consciousness, Disorientation to person, place, and time.
• Abnormal eye movements
• Alterations in motor function (hemiparesis, hemiplegia)
• Positive Kernig’s sign (resistance and pain with extension of the client’s leg from a flexed position)
• Positive Brudzinski’s sign (flexion of extremities occurring with deliberate flexion of the client’s neck)
• Hyperactive deep-tendon reflexes
• Tachycardia and Seizures
• Red macular rash (meningococcal meningitis)
• Restlessness, irritability
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – LABORATORY TESTS
• Urine, throat, nose, blood, and culture and sensitivity: Perform culture and sensitivity of various body fluids to identify possible infectious bacteria and an appropriate broad-spectrum antibiotic. Not definitive for meningitis, but can guide initial selection of antimicrobial therapy.
• CBC – Elevated WBC count
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – Diagnostic Procedures: Cerebrospinal Fluid Analysis (CSF)
o CSF analysis is the most definitive diagnostic procedure. CSF is collected during a lumbar puncture performed by the provider.
o Results indicative of meningitis
~ Appearance of CSF – Cloudy (bacterial) or clear (viral)
~ Elevated WBC
~ Elevated protein
~ Decreased glucose (bacterial)
~ Elevated CSF pressure
o New enteroviral diagnostic test can be done on CSF to determine if infectious agent is viral or bacterial in 2.5 hr.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Data Collection – Diagnostic Procedures: CT Scan and MRI
A CT scan or an MRI may be performed to identify increased intracranial pressure (lCP) and/or an abscess.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – Nursing Care
o Isolate clients as soon as meningitis is suspected.
o Maintain isolation precautions (droplet precautions) per facility policy. This requires a private room or a room with cohorts, wearing of a surgical mask when within 3 ft of clients, appropriate hand hygiene, and use of designated equipment, such as a blood pressure cuff and thermometer. Continue until antibiotics have been administered for 24 hr.
o Implement fever-reduction measures, such as a cooling blanket, if necessary.
o Report meningococcal infections to the public health department.
o Decrease environmental stimuli.
• Provide a quiet environment.
• Minimize exposure to bright light (natural and electric).
o Maintain bed rest with the head of the bed elevated to 30°.
o Maintain client safety, such as seizure precautions.
o Monitor clients receiving IV fluids and electrolytes to maintain hydration.
o Monitor older adult clients for secondary complications, such as pneumonia
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – MEDICATIONS: Ceftriaxone (Rocephin) or cefotaxime (Claforan)
• Give antibiotics until culture and sensitivity results are available, which are effective for bacterial infections.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – MEDICATIONS: Phenytoin (Dilantin)
• Anticonvulsants are given if ICP increases or the client experiences a seizure.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – MEDICATIONS: Acetaminophen (Tylenol), ibuprofen (Motrin)
• Analgesics are given for headache and/or fever – nonopioid to avoid masking changes in the level of consciousness
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – MEDICATIONS: Ciprofloxacin (Cipro), rifampin (Rifadin)
• Prophylactic antibiotics are given to individuals in close contact with clients.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS – MEDICATIONS: Care after discharge
o Client Education
• Encourage adults who are immunocompromised, who have a chronic disease, who smoke cigarettes, or who live in a long-term care facility to receive the pneumococcal polysaccharide vaccine (PPSV).
• Encourage residential college students, older adults, and those who have chronic illness to receive the meningococcal vaccine (MCV4) for Neisseria meningitidis.
• Instruct clients to use an insect repellent when risk of being bitten by a mosquito exists.
• Client Outcomes:
o The client’s ICP and neurological status will return to their premeningitis parameters.
o The client’s headache, photophobia, and nuchal rigidity will resolve.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS: Complications – Increased ICP
Increased lCP (possibly to the point of brain herniation)
o Meningitis can cause ICP to increase.
o Nursing Actions
• Monitor for signs of increasing ICP (decreased level of consciousness, pupillary changes, and widening pulse pressure).
• Provide interventions to reduce ICP (positioning and avoidance of coughing and straining).
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS: Complications – SIADH
Syndrome of inappropriate antidiuretic hormone (SIADH)
o SIADH can be a complication of meningitis.
o Nursing Actions
• Monitor for signs and symptoms (dilute blood, concentrated urine).
• Provide interventions, such as the administration of demeclocycline
(Declomycin) and restriction of fluid.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS: Complications – Septic Embolid
Septic emboli (leading to disseminated intravascular coagulation or vascular compromise)
o Septic emboli can form during meningitis and travel to other parts of the body, particularly the hands.
o Development of gangrene will necessitate an amputation.
NEUROSENSORY DISORDERS: CNS and PNS – MENINGITIS: Nursing Actions
1) Monitor circulatory status of extremities and coagulation studies.
2) Report any alterations immediately to the provider.
Central and Peripheral Nervous System Disorders: Seizure Disorders
Overview of Seizure Disorders
• Seizures are abrupt, abnormal, excessive and uncontrolled electrical discharge of neurons within the brain that may cause alterations in the level of consciousness and/or changes in
motor and sensory ability and/or behavior.
• Epilepsy is the term used to define the medical disorder characterized by chronic recurring abnormal brain electrical activity.
• Three broad categories are used to describe seizures – generalized, partial or focal/local, and unclassified or idiopathic.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Risk Factors
o Genetic predisposition
o Acute febrile state
o Head trauma, cerebral edema, brain tumor
o Infection, metabolic disorders, hypoxia, fluid and electrolyte imbalances
o Acute drug and alcohol withdrawal
o Abrupt cessation of antiepileptic medications (AEDs)
o Triggering Factors
• Increased physical activity
• Excessive stress
• Overwhelming fatigue
• Acute alcohol ingestion
• Excessive caffeine intake
• Exposure to flashing lights
• Specific chemicals, such as cocaine, aerosols and inhaling glue products
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Generalized Seizures
Generalized seizures – Loss of consciousness occurs with involvement of both cerebral hemispheres
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Generalized Seizures – Tonic Clonic
o It may begin with an aura (alteration in vision, smell, or emotional feeling).
o Tonic phase – A 15- to 20-second episode of stiffening of muscles, loss of consciousness, cessation of breathing, dilated pupils and development of cyanosis.
o Clonic phase – A 1- to 2-min episode of rhythmic jerking of the extremities, irregular respirations, biting of the cheek or tongue and bladder and bowel incontinence may occur.
o Postictal phase – May last for several hours. Unconsciousness may last for 30 min at which time the client awakens slowly and is usually confused and disoriented. Reports of headache, fatigue, and muscle aches are not uncommon. Clients may have no memory of what happened just before the seizure.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Generalized Seizures – Absence Seizure
o Absence seizures are most common in children.
o The seizure consists of a loss of consciousness lasting a few seconds, accompanied by blank staring (appears to be daydreaming) and associated automatisms (behaviors that clients are unaware of, such as lip-smacking or picking at clothes).
o Baseline neurological function is resumed after seizures, with no apparent sequela.
o Clients are often unaware seizure is occurring.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Partial or focal / local seizures
Partial or focal/local seizure – Seizure activity begins in one cerebral hemisphere.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Partial or focal / local seizures – Complex Partial Seizure
o Complex partial seizures have associated automatisms (behaviors that clients are unaware of, such as lip-smacking or picking at clothes).
o The seizure can cause a loss of consciousness for several minutes.
o Amnesia may occur immediately prior to and after the seizure.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Partial or focal / local seizures – Simple Partial Seizure
o Consciousness is maintained throughout simple partial seizures.
o Seizure activity may consist of unusual sensations, a sense of deja vu, autonomic abnormalities, such as changes in heart rate and abnormal flushing, unilateral abnormal extremity movements, pain, or offensive smell.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Subjective and Objective Data: Unclassified or Idiopathic
Unclassified or idiopathic seizures do not fit into other categories. These types of seizures account for half of all seizures activities and occur for no known reason.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Laboratory Tests
Alcohol and illicit drug levels, HIV testing, and, if suspected, screen for the presence of toxins.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Diagnostic Procedures – EEG (Electroencephalogram)
An EEG records electrical activity and may identify the origin of seizure activity.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Data Collection – Diagnostic Procedures – MRI, CAT, CT, PET
Magnetic resonance imaging (MRI); computed tomography imaging (CT)/ computed axial tomography (CAT), and positron emission tomography (PET) scans; cerebrospinal fluid (CSF) analysis; and a skull x-ray can all be used to identify or rule out potential causes of seizures.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Nursing Care – During a Seizure
During a Seizure:
• Protect clients from injury.
o Move furniture away.
o Hold the client’s head in lap if she is on the floor.
o Position clients to provide a patent airway.
o Turn clients to the side to decrease the risk of aspiration.
o Be prepared to suction oral secretions.
o Loosen restrictive clothing.
o Do not attempt to restrain clients.
o Do not attempt to open jaw or insert airway during seizure activity (may damage teeth, lips, and tongue). Do not use padded tongue blades.
• Document onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis,
motor activity, incontinence).
Central and Peripheral Nervous System Disorders: Seizure Disorders – Nursing Care Post Seizure
•Maintain clients in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.
•Check vital Signs.
•Check for injuries.
•Perform neurological checks.
• Allow clients to rest if necessary.
• Reorient and calm clients (may be agitated or confused).
• Institute seizure precautions including placing the bed in the lowest position and padding the side rails to prevent future injury.
• Determine if the client experienced an aura, which can possibly indicate the origin of seizure in the brain.
• Try to determine possible trigger.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Medications and Nursing Consideration
Medications
o Antiepileptic drugs (AEDs) – diazepam (Valium), phenytoin (Dilantin), carbamazepine (Tegretol), valproic acid (Depakene), gabapentin (Neurontin), and fosphenytoin sodium (Cerebyx)
• Nursing Considerations .
o Monitor therapeutic plasma levels. Be aware of therapeutic levels for medications prescribed. Notify the provider of results.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Client Education
o Advise clients that treatment provides for control of seizures, not cure of the disorder.
o Encourage clients to keep a seizure frequency diary to monitor the effectiveness of therapy.
o Advise clients to take medications as prescribed, usually the same time every day. If a dose is forgotten, tell them to take the next scheduled dose. Extra doses should not be taken.
o Advise clients to not stop taking medications without consulting the provider. Sudden cessation of medication may result in seizures.
o Advise clients to avoid hazardous activities (driving, operating heavy machinery) until seizures are fully controlled.
o Instruct clients not to take any unprescribed medications and to be aware of drug-drug and drug-food interactions (decreased effectiveness of oral contraceptives).
o Advise clients of childbearing age to avoid pregnancy, as medications may cause birth defects and congenital abnormalities.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Surgical Interventions
o Surgical interventions include placement of a vagal nerve stimulator and excision of the portion of the brain causing the seizures for intractable seizures
Central and Peripheral Nervous System Disorders: Seizure Disorders – Surgical Interventions – Vagal Nerve Stimulator
o Vagal nerve stimulator
• This procedure is indicated for clients with simple or complex partial seizures. It is contraindicated for clients with generalized seizures.
• This procedure is performed under general anesthesia.
• The device is implanted into the left chest wall and connected to an electrode placed at the left vagus nerve. The device is then programmed to administer intermittent vagal nerve stimulation at a rate specific to the client’s needs.
• In addition to routine stimulation, clients may initiate vagal nerve stimulation by holding a magnet over the implantable device at the onset of seizure activity.
This either aborts the seizure or lessens its severity.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Surgical Interventions – After care discharge
o Educate clients about the importance of periodic laboratory testing to monitor AED levels.
o Encourage medication adherence.
o Encourage clients to wear a medical alert bracelet or necklace at all times.
o Refer clients to the state’s Department of Motor Vehicles to determine laws regarding driving for clients with seizure disorders.
Central and Peripheral Nervous System Disorders: Seizure Disorders – Complications
Status epilepticus
o This is prolonged seizure activity occurring over a 30-min time frame. The complications associated with this condition are related to decreased oxygen levels, inability of the brain to return to normal functioning, and continued assault on neuronal tissue. This acute condition requires immediate treatment to prevent loss of
brain function, which may become permanent.
o Nursing Actions
• Call for assistance.
• Maintain an airway, provide oxygen, and monitor pulse oximetry.
• Assist with emergency care as appropriate.
o Client Education • Provide support for the family.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE
Parkinson’s disease (PD) is a progressively debilitating disease that grossly affects motor function. It is characterized by four primary symptoms –
1) tremor,
2) muscle rigidity,
3) bradykinesia (slow movement), and
4) postural instability.
These symptoms occur due to overstimulation of the basal ganglia by acetylcholine.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE : Dopamine and Acetylcholine
The secretion of dopamine and acetylcholine in the body produce inhibitory and excitatory effects on the muscles respectively. Overstimulation of the basal ganglia by acetylcholine occurs because degeneration of the substantia nigra results in decreased dopamine production. This allows acetylcholine to dominate, making smooth, controlled movements difficult. Treatment of PD focuses on increasing the amount of dopamine or decreasing the amount of acetylcholine in a client’s brain.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: 5 Stages of Involvement
As Parkinson’s Disease is a progressive disease, there are 5 stages of involvement.
o Stage 1 – Unilateral shaking or tremor of one limb.
o Stage 2 – Bilateral limb involvement makes walking and balance difficult.
o Stage 3 – Physical movements slow down significantly, affecting walking more.
o Stage 4 – Tremors may decrease but Akinesia and rigidity make day-to-day tasks difficult.
o Stage 5 – Client is unable to stand or walk, is dependent for all care, and may exhibit dementia.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Risk Factors
o Onset of symptoms between age 40 to 70
o More common in men
o Genetic predisposition
o Exposure to environmental toxins
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Subjective Data
o Report of fatigue
o Report of decreased manual dexterity over time
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Objective Data – Physical Assessment
• Stooped posture
• Slow, shuffling, and propulsive gait
• Slow, monotonous speech
• Tremors/pill-rolling tremor of the fingers
• Muscle rigidity
• Bradykinesia/akinesia
• Mask-like expression
• Autonomic symptoms (orthostatic hypotension, flushing, diaphoresis)
• Difficulty chewing and swallowing
• Drooling
• Dysarthria
• Progressive difficulty with ADLs
• Mood swings
• Cognitive impairment (dementia)
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Objective Data – Laboratory Tests
• There are no definitive diagnostic procedures.
• Diagnosis is made based on symptoms, their progression, and by ruling out other diseases.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Nursing Care – Swallowing and Nutrition
Administer the client’s medications at prescribed times.
o Monitor swallowing and maintain adequate nutrition.
• Request a referral for a speech-language pathologist to assess swallowing if clients demonstrate a risk for choking.
• Consult the client’s dietician for appropriate diet.
• Document the client’s weight at least weekly.
• Keep a diet intake log.
• Encourage fluids and document intake.
• Provide smaller, more frequent meals.
• Add commercial thickener to thicken food.
• Provide supplements as prescribed.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Nursing Care – Mobility
o Maintain client mobility for as long as possible.
• Encourage exercise, such as yoga (may improve mental status as well).
• Encourage the use of assistive devices as the disease progresses.
• Encourage range-of-motion (ROM) exercises.
• Reinforce to clients to stop occasionally when walking to slow down speed and reduce the risk for injury.
• Pace activities by providing rest periods.
• Assist clients with ADLs as needed (hygiene, dressing).
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Nursing Care – Communication
o Promote client communication for as long as possible.
• Instruct clients to use facial muscle strengthening exercises.
• Encourage clients to speak slowly and to pause frequently.
• Use alternate forms of communication as appropriate.
• Request a referral for a speech-language pathologist.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Nursing Care – Mental and Cognitive Status
o Monitor a client’s mental and cognitive status.
• Observe for signs of depression and dementia. Provide a safe environment (no throw rugs, encourage the use of an electric
razor).
• Determine personal and family coping with the client’s chronic, degenerative disease.
• Provide a list of community resources (support groups) to the client and the client’s family.
• Request a referral for a social worker or case manager as the condition advances (financial issues, long-term home care, and respite care).
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications
o May take several weeks of use before improvement of symptoms is seen. While the client is taking a combination of medications, maintenance of therapeutic medication levels is necessary for adequate control.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications – Dopaminergics
• When given orally, medications, such as levodopa (Dopar), are converted to dopamine in the brain, increasing dopamine levels in the basal ganglia.
• Dopaminergics may be combined with carbidopa (Sinemet) to decrease peripheral metabolism of levodopa, requiring a smaller dose to make the same amount available to the brain. Side effects are subsequently less.
• Due to medication tolerance and metabolism, the client’s dosage and administration times must be adjusted to avoid periods of poor mobility.
• Nursing Considerations
o Monitor for the “wearing-off” phenomenon and dyskinesias (problems with movement), which can indicate the need to adjust the dosage or time of administration or the need for a medication holiday.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications – Dopamine Agonists
• Dopamine agonists, such as bromocriptine (Padodel) and pramipexole (Mirapex), activate the release of dopamine. May be used in conjunction with a doparninergic for better results.
• Nursing Considerations
o Monitor for orthostatic hypotension, dyskinesias, and hallucinations.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications – Anticholinergics
• Anticholinergics, such as benztropine (Cogentin) and trihexyphenidyl (Artane), help control tremors and rigidity.
• Nursing Considerations
o Monitor for anticholinergic effects (dry mouth, constipation, urinary
retention).
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications – Catechol O-methyltransferase (COMT) inhibitors
• COMT inhibitors, such as entacapone (Comtan), decrease the breakdown of levodopa, making it more available to the brain as dopamine. It can be used in conjunction with a dopaminergic and dopamine agonist for better results.
• Nursing Considerations
o Monitor for dyskinesia/hyperkinesia when used with levodopa.
o Check for diarrhea.
o Reassure clients that dark urine is an expected finding.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Medications – Antivirals
• Antivirals, such as amantadine (Symmetrel), stimulate the release of dopamine and prevent its reuptake.
• Nursing Considerations
o Monitor for swollen ankles and discoloration of the skin.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Interdisciplinary Care
During the later stages of the disorder, clients will need referrals to and support from such disciplines as speech, occupational, and physical therapists; social services; and finally, placement in a long-term care facility.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Surgical Interventions – Stereotactic pallidotomy
• Stereotactic pallidotomy is the destruction of a small portion of the brain within the Globus pallidus through the use of brain imaging and electrical stimulation.
• The target area is identified with a CT scan or an MRI.
• Mild electrical stimulation is provided through a burr hole to a target area.
• Client is assessed for a decrease in tremors and muscle rigidity.
• When a decrease is elicited, a temporary lesion is formed and the client is reassessed.
• If symptomatic relief is demonstrated, a permanent lesion is made.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Surgical Interventions – Deep Brain Stimulation
• An electrode is implanted in the thalamus.
• A current is delivered through an implanted pacemaker generator.
• The goal of the current is to interfere with electrical conduction in “tremor cells” decreasing tremors.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Client Outcomes
o The client will ambulate safely through the use of assistive devices.
o The client will maintain adequate hydration and nutrition via appropriate diet and
thickened liquids.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Complications – Aspiration Pneumonia
o As Parkinson’s Disease advances in severity, alterations in chewing and swallowing will worsen, increasing the risk for aspiration.
o Nursing Actions
Use swallowing precautions to decrease the risk for aspiration.
Follow the individual dietary plan based on the speech-language pathologist’s recommendations. Have a nurse in attendance when the client is eating. Encourage clients to eat slowly and chew thoroughly before swallowing. Feed clients in an upright position and have suction equipment on standby.
Central and Peripheral Nervous System Disorders: PARKINSON’S DISEASE: Complications – Altered cognition (dementia, memory deficits)
o Clients in advanced stages of Parkinson’s Disease may exhibit altered cognition in the form of dementia and memory loss.
o Nursing Actions
Acknowledge the client’s feelings. Provide for a safe environment.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE
1) Alzheimer’s disease (AD) is a nonreversible type of dementia (multiple cognitive deficits that impair memory and can affect language, motor skills, and/or abstract thinking) that progressively develops through seven stages over many years. A framework made up of seven stages has been designed to categorize the disease and its signs and symptoms. The framework is based on three general stages – Early stage, mid stage, and late stage.
2) Some people die 4 to 6 years after diagnosis, but others can live with the disease for up to 20 years.
3) Severe physical decline occurs along with deteriorating cognitive functions.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Risk Factors
o Advanced age
o Genetic predisposition
o Environmental agents (herpes virus, metal, or toxic waste)
o Previous head injury
o Apolipoprotein E.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 1
Stage 1: No impairment (Normal function)
• No memory problems
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 2
Stage 2: Very mild cognitive decline (May be normal age-related
changes or very early signs of AD)
– Forgetfulness, especially of everyday objects (eyeglasses or wallet)
– No memory problems evident to provider, friends, or coworkers
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 3
Stage 3: Mild cognitive decline objects
(Problems with memory or concentration may be measurable in clinical testing or during a detailed medical interview
• Mild cognitive deficits, including losing or misplacing important
decline objects
• Decreased ability to plan
• Short-term memory loss noticeable to close relatives
• Decreased attention span
• Difficulty remembering words or names
• Difficulty in social or work situations
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 4
Stage 4: Moderate cognitive decline especially in social or mentally challenging situations (Mild or early-stage AD; medical interview will detect clear-cut deficiencies)
• Personality changes – Appearing withdrawn or subdued, especially in social or mentally challenging situations
• Obvious memory loss
• Limited knowledge and memory of recent occasions, current
events, or personal history.
• Difficulty performing tasks that require planning and organizing
(paying bills or managing money)
• Difficulty with complex mental arithmetic
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 5
Stage 5: Moderately severe cognitive decline (Moderate or mid-stage AD)
• Increasing cognitive deficits emerge
• Inability to recall important details such as address, telephone
(number, or schools attended, but memory of information about
self and family remains intact
• Disorientation and confusion as to time and place
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 6
Stage 6: Severe cognitive decline (Moderately severe or mid-stage AD)
• Memory difficulties continue to worsen
• Loss of awareness of recent events and surroundings
• May recall own name, but unable to recall personal history
• Significant personality changes are evident (delusions,
hallucinations, and compulsive behaviors)
• Wandering behavior
• Requires assistance with usual daily activities such as dressing,
toileting, and other grooming
• Normal sleep/wake cycle is disrupted
• Increased episodes of urinary and fecal incontinence
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Data Collection – Stage 7
Stage 7: Very severe (Severe or late-stage AD)
• Ability to respond to environment, speak, and control movement
cognitive decline is lost
• Unrecognizable speech
• General urinary incontinence
• Inability to eat without assistance and impaired swallowing
• Gradual loss of all ability to move extremities (ataxia)
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Laboratory Tests
• Genetic testing for the presence of apolipoprotein E. can determine if late onset dementia is due to AD.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Diagnostic Procedures
There is no definitive diagnostic procedure, except brain tissue examination upon death.
• Magnetic resonance imaging (MRI); computed tomography (CT)
imaging/computed axial tomography (CAT, positron emission tomography (PET scans; and electroencephalogram (EEG) may be performed to rule out other possible causes of symptoms.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Nursing Care
o Check cognitive status, memory, judgment, and personality changes.
o Initiate bowel and bladder program with clients based on a set schedule.
o Encourage clients and their families to participate in an AD support group.
o Provide a safe environment.
o Keep clients on a sleeping schedule and monitor for irregular sleeping patterns.
o Provide verbal and nonverbal ways to communicate with clients.
o Offer snacks or finger foods if clients are unable to sit for long periods of time.
o Check the client’s skin weekly for breakdown.
o Provide cognitive stimulation.
o Provide memory training.
o Avoid overstimulation (keep noise and clutter to a minimum and avoid crowds)
o Promote consistency by placing commonly used objects in the same location and using a routine schedule.
o Validation therapy (later stages)
o Promote self-care as long as possible. Assist clients with activities of daily living as appropriate.
o Speak directly to clients in short, concise sentences.
o Reduce agitation (use calm, redirecting statements; provide a diversion).
o Provide a routine toileting schedule.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Nursing Care – Cognitive Stimulation
• Offer varied environmental stimulations such as walks, music, or craft activities.
• Keep a structured environment and introduce change gradually (client’s daily routine or a room change).
• Use a calendar to assist with orientation.
• Use short directions when explaining an activity or care clients need, such as a bath.
• Be consistent and repetitive.
• Use therapeutic touch.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Nursing Care – Memory Training
• Reminisce with clients about the past.
• Use memory techniques such as making lists and rehearsing.
• Stimulate the client’s memory by repeating the client’s last statement.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Nursing Care – Promoting Consistency
o Promote consistency by placing commonly used objects in the same location and
using a routine schedule.
• Reality orientation (early stages)
• Easily viewed clock and single-day calendar
• Pictures of family and pets
• Frequent reorientation to time, place, and person
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Nursing Care – Validation therapy (later stages)
• Acknowledge the client’s feelings.
• Don’t argue with clients; this will lead to clients becoming upset.
• Reinforce and use repetitive actions or ideas cautiously.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Medication
o Most medications for clients who have dementia attempt to target behavioral and emotional problems, such as anxiety, agitation, combativeness, and depression and include antipsychotics, anxiolytics and antidepressants. Clients receiving these
medications should be closely monitored for adverse effects.
o Alzheimer’s Disease medications temporarily slow the course of the disease and do not work for all clients.
o Benefits for those clients who do respond to medication include improvements in cognition, behavior, and function.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Medication – Donepezil (Aricept)
• Prevents the breakdown of acetylcholine (ACh), which increases the amount of ACh available. This results in increased nerve impulses at the nerve sites.
• Cholinesterase inhibitors help slow this process down.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Medication – Donepezil (Aricept) – Nursing considerations
Observe clients for frequent stools and or upset stomach.
Monitor clients for dizziness and or headache. Clients may feel lightheaded or have an unsteady gait. Use caution when administering this medication to clients who have
asthma or COPD.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Interdisciplinary Care
o Request a referral for social services and case managers for possible adult day care or long-term care facilities.
o Request a referral for clients to the Alzheimer’s Association and community outreach programs. This can include in-home or respite care.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Therapeutic Procedures
o Alternative therapy
• Ginkgo biloba, an herbal product taken to increase memory and blood circulation, can cause a variety of side effects and medication interactions. If a client is using ginkgo biloba or other nutritional supplements, that information should be shared with providers.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Care after Discharge – Client Education
• Reinforce to families/caregivers about illness, methods of care, and adaptation of the home environment.
• Instruct families in home safety measures:
– Remove scatter rugs.
– Install door locks that cannot be easily opened, and place alarms on doors. Keep a lock on the water heater and thermostat; keeping the water temperature turned down to a safe level.
– Provide good lighting, especially on stairs.
– Install handrails on stairs and marking step edges with colored tape. Place the mattress on the floor.
– Remove clutter and clearing hallways for walking.
– Secure electrical cords to baseboards.
– Keep cleaning supplies in locked cupboards.
– Install handrails in the bathroom, at bedside, and in the tub; placing a shower chair in the tub.
– Have clients wear a medical identification bracelet if living at home with caregiver.
– Monitor for improvement in memory and the client’s quality of life.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Care after Discharge – Support for caregivers
Review the resources available to the family as the client’s health
declines. Include long-term care options. A wide variety of home care and community resources, such as respite care, may be available to the family in many areas of the country, and these resources may allow clients to remain at home rather than in an institution.
Central and Peripheral Nervous System Disorders: ALZHEIMER’S DISEASE: Client outcomes
o The client will remain free from injury.
o The client will sleep 5 to 6 hours every night.
o The client will be able to perform self-care independently with verbal assistance.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes)
Cerebrovascular accidents (CVA) or strokes involve a disruption in the cerebral blood flow secondary to ischemia, hemorrhage, or embolism.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Three Types
1) Hemorrhagic – These occur secondary to a ruptured artery or aneurysm.
2) Thrombotic – These occur secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral artery that gradually shuts off the artery and causes ischemia distal to the occlusion. Symptoms of a thrombotic CVA evolve over a period
of several hours to days.
3) Embolic – These occur secondary to an embolus traveling from another part of the body to a cerebral artery. Blood to the brain distal to the occlusion is immediately shut off causing neurologic deficits or a loss of consciousness to instantly occur.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Risk Factors
0 Cerebral aneurysm
0 Arteriovenous malformation (AV)
0 Diabetes mellitus
0 Obesity
0 Hypertension
0 Atherosclerosis
0 Hyperlipidemia
0 Hypercoagulability
0 Atrial fibrillation
o Use of oral contraceptives
o Smoking
o Cocaine use
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Subjective Data
o Some clients report transient symptoms such as dizziness, slurred speech, and a weak extremity.
o These symptoms may indicate a transient ischemic attack (TIA), which can be a warning of an impending CVA.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Physical Assessment Findings
• Symptoms will vary based on the area of the brain that is deprived of oxygenated blood.
o The left cerebral hemisphere is responsible for language, mathematic skills, and analytic thinking.
o The right cerebral hemisphere is responsible for visual and spatial awareness and proprioception
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Physical Assessment Findings – Left Cerebral Hemisphere
o The left cerebral hemisphere is responsible for language, mathematic skills, and analytic thinking.
o Symptoms consistent with a left-hemispheric CVA
~ Expressive and receptive aphasia (ability to speak and understand language respectively)
~ Agnosia (unable to recognize familiar objects)
~ Alexia (reading difficulty)
~ Agraphia (writing difficulty)
~ Right extremity hemiplegia (paralysis) or hemiparesis (weakness)
~ Slow, cautious behavior
~ Depression, anger, and quick to become frustrated
~ Visual changes, such as hemianopsia (loss of visual field in one or both eyes)
~ One-sided neglect syndrome (ignore right side of the body – cannot see, feel or move affected side; so, client is unaware of its existence)
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Physical Assessment Findings – Right Cerebral Hemisphere
The right cerebral hemisphere is responsible for visual and spatial awareness and proprioception.
• Altered perception of deficits (overestimation of abilities)
One-sided neglect syndrome (ignore left side of the body – cannot see, feel, or move affected side; so, client is unaware of its existence) – more common with right-hemispheric CVAs
• Loss of depth perception
• Poor impulse control and impaired judgment
• Short attention span
• Left hemiplegia or hemiparesis
• Visual changes, such as hemianopsia
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Diagnostic Procedures
o Diagnostic Procedures
• A magnetic resonance imaging (MRI), computed tomography (CT) imaging, and/or a computed axial tomography (CAT) scan may be used to identify edema, ischemia, and necrosis.
• A magnetic resonance angiography (MRA) or a cerebral angiography are used to identify the presence of a cerebral hemorrhage, abnormal vessel structures (AV malformation, aneurysms), vessel ruptures, and regional perfusion of blood
flow in the carotid arteries and brain.
• A lumbar puncture is used to assess for the presence of blood in the cerebrospinal fluid (CSF) . A positive finding is consistent with a cerebral hemorrhage or ruptured aneurysm.
• The Glasgow Coma Scale score is used when clients have a decreased level of consciousness or orientation.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part I
o Monitor for changes in the client’s level of consciousness (increased ICP sign).
o Elevate the client’s head of the bed approximately 300 to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension of the neck, and maintain the client’s head in the midline neutral position.
o Initiate seizure precautions.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part II
o Assist with the client’s communication skills if his speech is impaired.
• Identify the ability to understand speech by asking clients to follow simple commands.
• Observe for consistently affirmative answers when the client actually does not comprehend what is being said.
• Determine accuracy of yes/no responses in relation to closed-ended questions.
• Supply clients with a picture board of commonly requested items/needs.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part III
o Assist with safe feeding.
• Check swallowing and gag reflexes before feeding. Follow recommendations of speech pathologist.
• Thicken clear liquids with a commercial thickener to avoid aspiration if a swallowing deficit is identified.
• Have clients eat in an upright position and swallow with the head and neck flexed slightly forward.
• Place food in the back of the mouth on the unaffected side.
• Have suction on standby.
• Maintain a distraction-free environment during meals.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part IV
o Maintain skin integrity.
• Reposition clients frequently and use padding.
• Monitor bony prominences, paying particular attention to the affected extremities.
• If clients have one-sided neglect, teach them to protect and care for the affected extremity to avoid injuring it in the wheel of the wheelchair or hitting/smashing it against a doorway.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part V
o Encourage passive range of motion every 2 hours to the affected extremities and active range of motion every 2 hours to the unaffected extremities. Show clients how to use the unaffected side to exercise the affected side of the body.
o Elevate the affected extremities to promote venous return and to reduce swelling. An elastic glove can be placed on the affected hand if swelling is severe. Show clients how to massage the affected hand by stroking it in a distal to proximal manner
encouraging fluid in the hand to move back into the wrist and arm.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part VI
o Maintain a safe environment to reduce the risk of falls. Use assistive devices during transfers such as transfer belts, sliding boards, and sit-to-stand lifts.
o If clients have homonymous hemianopsia (loss of the same half of the visual field in both eyes) instruct them to use a scanning technique (turning head from the direction
of the unaffected side to the affected side) when eating and ambulating.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part VII
o Apply sequential compression stockings, implement frequent position changes, and encourage mobilization to prevent deep vein thrombosis and complications from immobility.
o Provide assistance with ADLs as needed. Instruct clients to dress the affected side first and sit in a supportive chair that aids in balance. Have occupational therapy assess clients for adaptive aids, such as a plate guard, utensils with built-up handles,
a reaching tool to pick things up, and shirts and shoes that have hook and loop fasteners/tape instead of buttons and ties.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Nursing Care Part VIII
o Provide for frequent rest periods from sitting in the wheelchair by returning clients to bed after therapies and meals.
o Support the affected arm while in bed, the wheelchair, or during ambulation with an arm sling or strategically placed pillows.
o Support clients during periods of emotional lability and depression
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Medications – Anticoagulant
o Anticoagulants (aspirin, heparin sodium, enoxaparin [Lovenox], warfarin [Coumadin])
• These medications are usually given to clients who have experienced an embolic CVA to prevent development of additional emboli.
.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Medications – Antiplatelet
o Antiplatelets (ticlopidine [Ticlid], clopidogrel [Plavix])
• These medications are usually given to clients who have experienced a thrombotic CVA to prevent extension of the CVA.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Medications – Thrombolytic
o Thrombolytic medications alteplase (Activase, tPA)
• Can be given within 3 to 6 hours of onset of symptoms to dissolve embolism.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Medications – Antiepileptic
o Antiepileptic medications (phenytoin [Dilantin], gabapentin [Neurontin])
• These medications are not commonly given following a CVA unless clients develop seizures.
• Gabapentin can be given for paresthetic pain in an affected extremity
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Interdisciplinary Care – Speech Therapist
Recognize the need for speech and language therapists for language and swallowing evaluations.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Interdisciplinary Care – Physical Therapist
Request a referral for physical therapy for assistance with re-establishment of ambulation with or without assistive devices (single or quad cane, walker) or wheelchair support.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Occupational Therapists
Request a referral for occupational therapy for assistance with re-establishment of partial or full function of the affected hand and arm. If function does not return to the extremity, measures such as massage and elastic gloves will be prescribed by occupational therapy to prevent swelling of the extremity.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Social Worker
Request a referral for social services to make arrangements for rehabilitation services and temporary placement on a skilled rehabilitation unit or extended-care facility during provision of these services. Prior to discharge, the social worker may make a
home visit with selected therapists and nurses to evaluate the need for environmental alterations in the home and adaptive equipment needed for ADLs.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Therapeutic Procedures
Systemic or catheter-directed thrombolytic therapy restores cerebral blood flow. It must be administered within 3 hours of the onset of symptoms. It is contraindicated for treatment of a hemorrhagic CVA and for clients with an increased risk of bleeding due to anticoagulant therapy or another bleeding anomaly. Possibility of a hemorrhagic CVA is ruled out with an MRI prior to the initiation of thrombolytic therapy.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Surgical Interventions
Carotid endarterectomy is performed to open the artery by removing atherosclerotic plaque. This procedure is performed when the carotid artery is blocked or when clients
are experiencing TIAs.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – Care after discharge: Client education
• Encourage clients to receive early treatment of hypertension and to adhere to the prescribed regimen.
• Encourage clients who have diabetes mellitus to maintain blood glucose within expected range.
• Recommend smoking cessation.
• Recommend that clients maintain a healthy weight and participate in regular exercise.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Dysphagia and Aspiration
o Dysphagia can result from neurological involvement of the cranial nerves that innervate the face, tongue, soft palate, and throat. As a result, the client’s risk of aspiration is great.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Dysphagia and Aspiration – Nursing Actions
o Nursing Actions
• Start clients on a prescribed diet and observe closely for choking. Have the suction equipment available. Initial feedings should be done by an RN.
• Thicken oral liquids as prescribed. Use the appropriate amount of thickener to obtain the prescribed consistency.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Dysphagia and Aspiration – Client Education
o Client Education
• Reinforce to the client’s family how to thicken liquids to the proper consistency.
• Instruct clients to flex their head forward when swallowing to decrease the risk of choking.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Unilateral Neglect
o Unilateral neglect is the loss of awareness of the side affected by the CVA. Clients cannot see, feel, or move the affected side of the body; therefore, they forget that it exists.
o This lack of awareness poses a great risk for injury to the neglected extremities and creates a self-care deficit.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Unilateral Neglect : Nursing Actions
o Nursing Actions
• Observe the client’s affected extremities for injury (bruises and abrasions of the affected hand and arm, hyperflexion of the foot from it falling off of the wheelchair during transport).
• Apply an arm sling if clients are unable to remember to care for the affected extremity.
• Ensure the foot rest is on the wheelchair and an ankle brace is on the affected foot.
Central and Peripheral Nervous System Disorders: CEREBROVASCULAR ACCIDENTS (Strokes) – COMPLICATIONS – Unilateral Neglect – Client Education
o Client Education
• Instruct clients to dress the affected side first.
• Reinforce to clients how to care for the affected side.
• Instruct clients to use the unaffected hand to pull the affected extremity to midline and out of danger from the wheel of the wheelchair or from hitting or smashing it against a doorway.
• Reinforce to clients to scan the affected side.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES
Spinal cord injuries (SCIs) involve the loss of motor function, sensory function, reflexes, and control of elimination. Injuries in the cervical region result in quadriplegia – paralysis/paresis of all four extremities and trunk. Injuries below T1 result in paraplegia – paralysis/paresis of the lower extremities. Truncal instability also results if the lesion is in the upper thoracic region.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Fractures of the Vertebrae
Not all fractures of the vertebrae cause SCIs. Direct injury to the spinal cord secondary to the trauma or bone fragments in the spinal canal must occur for the spinal cord itself to become damaged.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Contusions and Lesions
SCIs range from contusions or incomplete lesions of the spinal cord to complete lesions caused by a lesion that extends across the entire diameter of the cord, or an actual transection of the cord. Complete lesions result in the loss of all voluntary movement
and sensation below the level of the injury. Incomplete lesions result in varying losses of voluntary movement, and sensation below the level of injury.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Health Promotion and Disease Prevention
Client Education
o Promote safe driving practices.
o Promote swimming and diving safety.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Risk Factors
o Males age 16 to 30
o High-risk activities (extreme sports or high-speed driving)
o Active in impact sports (football or diving)
o Acts of violence (gunshot and knife wounds)
o Alcohol and/or drug abuse
o Disease (metastatic cancer or arthritis of the spine)
o Falls, especially in older adults
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES :Subjective Data
o Report of lack of sensation of dermatomes below the level of the lesion
o Report of neck or back pain
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Physical Assessment Findings, Part I
• Inability to feel light touch when touched by a cotton ball, inability to discriminate between sharp and dull when touched with a safety pin or other sharp objects, and an inability to discriminate between hot and cold when touched with containers of hot and cold water.
• Absent deep-tendon reflexes
• Involuntary respirations can be affected due to a lesion at or above the phrenic nerve, or swelling from a lesion immediately below C4.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Physical Assessment Findings, Part II
• Impaired voluntary movement of muscles used in respiration (increase in depth or rate) may occur due to lesions in the cervical or upper thoracic area.
• Spinal shock, which accompanies spinal trauma, causes a total loss of all reflexive and autonomic function below the level of the injury for a period of several days to weeks. Hypotension (that is more severe when clients are sitting in an upright position), dependent edema, and loss of temperature regulation (hyperthermia or hypothermia) are common findings.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Physical Assessment Findings, Part III
• Clients who have upper motor neuron injuries (above L1 and L2) will convert to a spastic muscle tone after spinal shock.
• Paraplegics who have lower motor neuron injuries (below L1 and L2) will convert to a flaccid type of paralysis.
• Varying degrees of loss of sensation and motor function will be experienced depending on whether the lesion is complete or incomplete.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Physical Assessment Findings, Part IV
• Bowel and bladder
o Clients who have upper motor neuron injuries will develop a spastic bladder after the spinal shock resolves.
o Clients who have lower motor neuron injuries will develop a flaccid bladder.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Physical Assessment Findings, Part V
Quadriplegics and other clients who have upper motor neuron lesions are usually capable of reflexogenic erections (erections secondary to manual manipulation). Ejaculation coordinated with emission may or may not occur. Clients who have lower motor neuron injuries are less able to have reflexogenic erections, but clients who have incomplete injuries may be able to have a
combination of reflexogenic and psychogenic erections (erections stimulated by sexual thoughts and images).
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Laboratory Test
• Urinalysis, hemoglobin, ABGs
o Used to monitor for undiagnosed internal bleeding (clients may not feel pain from internal injuries) and impaired respiratory exchange (due to phrenic nerve involvement and/or inability to voluntarily increase depth and rate of respirations).
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Diagnostic Procedures
• X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) imaging/computed axial tomography (CAT) scan can be used to assess the extent of the damage and the location of blood and bone fragments.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part I
o Maintain respiratory function
• Monitor the client’s respiratory status.
• Provide the client with humidified oxygen and suction as needed.
• Assist with intubation and mechanical ventilation if necessary.
• Assist the client to cough by applying abdominal thrusts when the client is attempting to cough.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part II
o Maintain tissue perfusion
• Transfer the client to a wheelchair in stages.
• Raise the client’s head of the bed and be ready to lower the angle if the client reports dizziness.
• Transfer the client into a reclining wheelchair with the back of the wheelchair reclined.
• Be ready to lock and lean the wheelchair back to a fully reclined position if the client reports dizziness after the transfer. Do not attempt to return the client to bed.
• Monitor the client for signs of thrombophlebitis (swelling of extremity, absent/ decreased pulses, and areas of warmth and/or tenderness). The client may be on anticoagulants to prevent development of lower extremity thrombi.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part III
o Maintain NPO status several days if prescribed.
o Assist with the care of clients receiving IV fluids.
o Monitor clients for changes in neurological function.
o Monitor clients for changes in muscle strength in the affected extremities.
• Encourage active range of motion (ROM) exercises when possible, and assist with passive ROM if clients lack all motor function.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part IV
o Use measures to prevent skin breakdown. Use foam and air mattresses for beds and wheelchairs.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part V
Bladder and bowel function
• Spastic neurogenic bladder – Bladder management options for male clients include condom catheters and stimulation of the micturition reflex by tugging on the pubic hair. Female clients will need to use an indwelling urinary catheter due to the unpredictability of the release of urine.
• Flaccid neurogenic bladder – Bladder management options for males and females include intermittent catheterization and Crede’s method (downward pressure placed on the bladder to manually express the urine).
• Monitor for bowel sounds.
• Neurogenic bowel functioning does not differ a lot between upper and lower motor neuron injuries. Daily use of stool softeners or bulk forming laxatives is recommended to keep the stool soft. A bowel movement can be stimulated daily or every other day by administration of a bisacodyl (Dulcolax) suppository or digital stimulation (stimulation of the rectal sphincter with a gloved and
lubricated finger).
• Development of a schedule as part of bladder and bowel training is critical for the establishment of a routine.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Nursing Care Part VI
o Change the client’s position every 2 hours while in bed and every 1 hour when in a wheelchair. Use pressure-relief devices in both the bed and wheelchair.
o Reinforce to clients the alterations in sexual function and possible adaptive strategies.
o Administer medications as prescribed.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication- Glucocorticoids
• Adrenocortical steroids such as dexamethasone (Decadron) aid in decreasing swelling of the spinal cord, which can increase pressure on the spinal cord, and subsequently, areas of ischemia.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Vasopressors
Vasopressors
• Norepinephrine and dopamine are given to treat postural hypotension, particularly during spinal shock.
• Nursing Considerations
o Ensure medication has been given 30 min prior to sitting clients up in a wheelchair.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Plasma Expanders
Plasma expanders
Iron (Dextran) – Used to treat hypotension secondary to spinal shock.
Nursing Considerations
o Observe clients for symptoms of fluid overload.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Muscles Relaxants
Muscle relaxants
• Baclofen (Lioresal) and dantrolene sodium (Dantrium) – Given to clients who have severe muscle spasticity. Spasticity can be so severe that sitting in a wheelchair can be physically difficult.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Cholinergics
Cholinergics
• Bethanechol (Urecholine) – Decreases spasticity of the bladder allowing for easier bladder training and fewer accidents.
• Nursing Considerations
o Observe clients for urinary retention. Measure residual periodically.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Analgesics
Analgesics
• Opioids, non-opioids, and NSAIDs are given for pain. Clients mayor may not be able to feel pain from spinal cord injury. Clients who do have muscle spasticity may report feeling discomfort from the muscle spasms.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Anticoagulants
Anticoagulants
• Heparin or low-molecular-weight heparins are used for deep vein thrombosis prophylaxis
• Nursing Considerations
o Monitor INR, PT, and a PTT for therapeutic levels of anticoagulation.
o Observe for signs of gastrointestinal bleeding or bleeding secondary to unrecognized injury.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Stool Softeners and Bulk forming laxatives
Stool softeners and bulk-forming laxatives
• Docusate sodium (Colace) or polycarbophil (Fibercon) to prevent constipation and keep the stool soft
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES : Medication – Vasodilator
Vasodilators
• Hydralazine (Apresoline) and nitroglycerin (Nitrostat) – Used PRN to treat episodes of hypertension during automatic dysreflexia
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Interdisciplinary Care, part I
Recognize the need for intensive occupational and physical therapy to learn how to perform ADLs and re-establish mobility using either a manual or electric wheelchair, or braces and crutches. Clients will also be fitted for splints to prevent contractures
and/or provide wrist support for eating and manipulating a joy stick on an electric wheelchair.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Interdisciplinary Care, part II
o Request a referral for social services to determine the client’s financial resources, home care needs, and adaptations needed in the home prior to discharge.
o Request a referral to an SCI support group to aid in emotionally adapting to changes in body image and role.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Therapeutic Procedures
o Application of immobilization devices and traction
• Clients who have cervical fractures may be placed in a halo fixation device or cervical tongs. The purpose is to provide traction and/or immobilize the spinal column.
• Nursing Actions
o Maintain body alignment and ensure that cervical tong weights hang freely.
o Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as appropriate.
• Client Education
o Provide instruction on pin and vest care if clients go home with a halo fixation device on.
o Reinforce to clients signs of infection and skin breakdown
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Surgical Interventions
Spinal Surgery
• Spinal fusion is commonly done when a spinal fracture creates an area of instability of the spine.
• Spinal fusions done in the cervical area are usually done using an anterior approach through the front of the neck.
• Spinal fusions done in the thoracic or lumbar areas are done using a posterior approach and can be combined with a decompressive laminectomy.
• A decompressive laminectomy is done by removing a section of lamina, accessing the spinal canal, and removing bone fragments, foreign bodies, or hematomas that may be placing pressure on the spinal cord.
• Donor bone is often obtained from the iliac crest and used to fuse together the vertebrae that are unstable.
• Application of paravertebral rods can be used to mechanically immobilize several vertebral levels.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Surgical Interventions – Client Education
Client Education
* Inform clients that an area of decreased range of motion will always exist in the area of fusion or paravertebral rods.
* Inform clients that rods are usually not removed unless they cause pain. Removal can be done after the spine restabilizes.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Client Outcomes
o The client will integrate physiological changes in his body into a new, positive body Image.
o The client will be free of urinary complications.
o The client will develop a regular routine for bowel movements.
o The client will not experience autonomic dysreflexia.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Orthostatic hypotension
o Occurs when clients change position due to the interruption in functioning of the automatic nervous system and pooling of blood in lower extremities when clients are in an upright position.
o Nursing Actions
• Change client’s positioning slowly and place clients in a wheelchair that reclines.
• Use thigh-high elastic hose or elastic wraps to increase venous return. Elastic wraps may need to extend all the way up the client’s legs and include the client’s abdomen.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Neurogenic shock
o Neurogenic shock is a common response of the spinal cord following an injury.
o Symptoms of bradycardia, hypotension, flaccid paralysis, loss of reflex activity
below level of injury, and paralytic ileus accompany spinal shock due to the loss of
autonomic function.
o Nursing Actions
• Monitor vital signs for hypotension and bradycardia.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Autonomic dysreflexia
Autonomic dysreflexia
o Occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system. Clients who have lesions below T6 do not experience dysreflexia because the parasympathetic
nervous system is able to neutralize the sympathetic response.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Autonomic dysreflexia – Nursing Actions – Determine the Cause
Determine the cause .
* Sit clients up (to decrease blood pressure secondary to postural
hypotension).
* Notify the provider.
* Determine the cause.
~ Distended bladder is the most common cause (kinked or blocked
urinary catheter, urinary retention, or urinary calculi)
~ Fecal impaction
~ Cold stress or drafts on lower part of the body
~ Tight clothing
~ Undiagnosed injury or illness (kidney infection or stone, lower
extremity fracture)
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Autonomic dysreflexia – Nursing Actions – Treat the Cause
* Treat the cause.
~ Relieve the kink in the catheter or irrigate to remove blockage.
~ Catheterize clients.
~ Remove the impaction.
~ Adjust the room temperature and block drafts.
~ Remove tight clothing.
~ Check for injury, such as lower extremity fracture or kidney/bladder infection.
• Monitor vital signs for severe hypertension and bradycardia.
Central and Peripheral Nervous System Disorders: SPINAL CORD INJURIES – Complications – Autonomic dysreflexia – Client Education
Provide client education regarding potential causes of dysreflexia.
Instruct clients to space out fluid intake and increase frequency of intermittent catheterizations if fluid intake is temporarily increased.
Provide a list of possible actions to pursue if an episode of dysreflexia does occur.
Central and Peripheral Nervous System Disorders: Multiple Sclerosis and Amyotrophic Lateral Sclerosis
• Multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) are both neurologic diseases that affect the spinal cord, typically resulting in difficulties with gait, strength, and motor function.
Central and Peripheral Nervous System Disorders: Multiple Sclerosis
• MS is an autoimmune disorder characterized by the development of plaques in the white matter of the CNS. This plaque damages the myelin sheath and interferes with impulse transmission between the CNS and the body.
Central and Peripheral Nervous System Disorders: Amyotrophic Lateral Sclerosis
• ALS is a disease of the upper and lower motor neurons characterized by muscle weakness progressing to muscle atrophy and eventually paralysis and death. ALS does not involve
autonomic changes, sensory alterations, or cognitive changes.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS
MS follows several possible courses. The most common is:
a Relapsing and remitting – The disease is marked by relapses and remissions that may or may not return clients to their previous baseline level of function. Over time, clients may eventually progress to the point of quadriplegia. MS is a chronic and progressive disease with no known cure and symptoms progress in
severity over time. Initial symptoms may be so vague that diagnosis is not made for several years. Life expectancy is not adversely affected by this disease.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Risk Factors
o The onset of MS is typically between 20 and 40 years of age and occurs twice as often in women. The etiology of MS is unknown. There is a family history (first-degree relative) of MS in many cases.
o Since MS is an autoimmune disease, there are factors that trigger relapses.
• Viruses and infectious agents
• Living in a cold climate
• Physical injury
• Emotional stress
• Pregnancy
• Fatigue
• Overexertion
• Temperature extremes
• Hot shower/bath
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Subjective and Objective Data
o Fatigue – Especially of the lower extremities
o Pain or paresthesia
o Diplopia, changes in peripheral vision, decreased visual acuity
o Uhthoff’s sign (a temporary worsening of vision and other neurological functions commonly seen in clients with MS, or clients predisposed to MS, just after exertion or in situations where they are exposed to heat)
o Tinnitus, vertigo, decreased hearing acuity
o Dysphagia – Swallowing difficulties
o Dysarthria (speech difficulties – Slurred and nasal speech)
o Muscle spasticity
o Ataxia and/or muscle weakness
o Nystagmus
o Bowel dysfunction (constipation, fecal incontinence)
o Bladder dysfunction (areflexia, urgency, nocturia)
o Cognitive changes (memory loss, impaired judgment)
o Sexual dysfunction
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Laboratory Tests
Cerebrospinal fluid analysis – Elevated protein level and a slight increase in WBCs
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Diagnostic tests
Magnetic resonance imaging (MRI) – An MRI of the brain and spine is used to reveal plaques, which is mostly diagnostic.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Nursing Care, Part I
o Nurses caring for clients who have MS should monitor:
• Visual acuity
• Speech patterns – Fatigue with talking
• Swallowing
• Activity tolerance
• Skin integrity
o Encourage fluid intake and other measures to decrease the risk of developing a urinary tract infection. Assist clients with bladder elimination (intermittent self catheterization, bladder pacemaker, Crede [placing manual pressure on abdomen over the bladder to expel urine]).
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Nursing Care, Part II
o Monitor cognitive changes and take interventions to maintain function (reorient clients, place objects used daily in routine places).
o Facilitate effective communication (dysarthria) through the use of a communication board.
o Apply alternating eye patches to treat diplopia. Show clients scanning techniques.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Nursing Care, Part III
o Encourage clients to exercise and stretch involved muscles (avoid fatigue and overheating).
o Encourage clients to utilize energy conservation measures.
o Maintain a safe hospital environment to reduce the risk of injury (walk with wide base of support, assistive devices, skin precautions).
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Azathioprine (Imuran) and cyclosporine (Sandimmune)
• Use immunosuppressive agents to reduce the frequency of relapses.
• Nursing Considerations
o Monitor for long-term effects.
o Be alert for signs and symptoms of infection.
o Monitor for hypertension and kidney dysfunction.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Prednisone (Deltasone)
• Use corticosteroids to reduce inflammation in acute exacerbations.
• Nursing Considerations
o Monitor for increased risk of infection, hypervolemia, hypernatremia, hypokalemia, hyperglycemia, gastrointestinal bleeding, and personality changes.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Dantrolene (Dantrium), tizanidine (Zanaflex), baclofen (Lioresal), and diazepam (Valium)
• Use antispasmodics to treat muscle spasticity.
• Intrathecal baclofen can be used for severe cases of MS.
• Nursing Considerations
o Observe for increased weakness.
o Monitor for liver damage if taking tizanidine or dantrolene.
• Client Education
o Instruct clients to report increased weakness and/or jaundice to the provider.
o Encourage clients to avoid stopping baclofen abruptly.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Interferon beta (Betaseron)
• Use immunomodulators to prevent or treat relapses.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Carbamazepine (Tegretol)
• Use anticonvulsants for paresthesia.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Docusate sodium (Colace)
• Use stool softeners for constipation.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Propantheline (Pro-Banthine)
• Use anticholinergics for bladder dysfunction.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Medications – Primidone (Mysoline) and clonazepam (Klonopin)
• Use beta-blockers for tremors.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Interdisciplinary Care
o Request a referral for community resources and respite services for clients and their
families.
o Request a referral for occupational and physical therapy for home environment
assessment to determine safety and ease of mobility. Use adaptive devices to assist
with ADLs.
o Request a referral for a speech language therapist for dysarthria and dysphagia.
PN
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Care After Discharge
Client Education
• Encourage family members to maintain a safe home environment to reduce the risk of injury (eliminate scatter rugs, keep electrical cords along baseboards, adequate lighting)
• Encourage clients to use assistive devices for ambulation.
• Encourage clients to adhere to the medication regimen.
Central and Peripheral Nervous System Disorders: MULTIPLE SCLEROSIS – Client Outcomes
o The client will be able to ambulate without assistance and independently perform ADLs.
o The client will avoid triggers and exhibit fewer relapses.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Definition
Amyotrophic lateral sclerosis (ALS) is a degenerative neurological disorder of the upper and lower motor neurons that result in deterioration and death of the motor neurons.
This results in a progressive paralysis and muscle wasting that eventually causes respiratory paralysis and death. Cognitive function is not usually affected. Death usually occurs within 3 to 5 years of the initial symptoms due to respiratory failure. The cause of ALS is unknown and there is no cure.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Risk Factors
ALS affects more men than women, often developing between the ages of 40 to 70.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Subjective Data
o Fatigue
o Twitching and cramping of muscles
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Objective Data
o Physical Assessment Findings
• Muscle weakness – Usually begins in one part of the body
• Muscle atrophy
• Dysphagia
• Dysarthria
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Laboratory and Diagnostics
o Laboratory Tests
• Creatine kinase (CK-BB) level- Increased
o Diagnostic Procedures
• Electromyogram (EMG) – Reduction in number of functioning motor units of peripheral nerves
• Muscle biopsy – Reduction in number of motor units of peripheral nerves and atrophic muscle fibers
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Nursing Care
o Maintain a patent airway and suction as needed.
o Keep the head of the bed at 45°; turn, cough, and deep breathe every 2 hr; conduct incentive spirometry/chest physiotherapy.
o Facilitate effective communication (dysarthria) with the use of a communication board or a speech language therapist referral.
o Ensure safety with oral intake. Thicken fluids as needed.
o When no longer able to swallow, provide enteral nutrition as prescribed.
o Utilize energy conservation measures.
o Address the client’s interest in the establishment of advance directives/living wills.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Medication – Riluzole (Rilutek)
• Glutamate antagonist that can slow the deterioration of motor neurons by decreasing the release of glutamic acid. Must be taken early in disease process. Will add approximately 2 to 3 months of life to the client’s overall lifespan.
• Nursing Considerations
o Monitor liver function tests – Hepatotoxic risk.
o Observe for dizziness, vertigo, and somnolence.
• Client Education
o Suggest clients avoid drinking alcohol.
o Instruct clients to take medication at evenly spaced regular intervals (every 12 hr).
o Instruct clients to store medication away from bright light
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Medication – Baclofen (Lioresal), dantrolene sodium (Dantrium), diazepam (Valium)
• Use antispasmodics to decrease spasticity.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Interdisciplinary Care
o Request appropriate referrals (dietician, speech pathologist, social service, physical therapy, occupational therapy, clinical psychologist) for extended care in the home or
a long-term care facility as client’s condition deteriorates.
o Consider hospice referral to provide support to the client and family coping with the terminal phase of the illness.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Care After Discharge
Client Education
• Recommend genetic counseling for family members of clients who have ALS.
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Client Outcomes
o The client will remain independent in ADLs until severe weakness and paralysis develops. The client will be able to remain in the home with support services available to meet needs.
o The client will be free of infections (respiratory, urinary, integument).
Central and Peripheral Nervous System Disorders: AMYOTROPHIC LATERAL SCLEROSIS – Complications
Pneumonia
o Pneumonia can be caused by respiratory muscle weakness and paralysis contributing to ineffective airway exchange.
o Nursing Actions
• Monitor respiratory status and provide antimicrobial therapy as indicated.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome
Guillain-Barre syndrome (GBS) develops in relation to acute destruction of the myelin sheath of peripheral nerves due to an autoimmune disorder that results in varying degrees of muscle weakness and paralysis. After the acute phase, remyelination occurs and re-establishes nerve functions. However,
aggregates of lymphocytes can cause secondary damage, which can delay recovery or result in permanent deficits. Chronic inflammatory demyelinating polyneuropathy (ClOP) is a different type of GBS that progresses over a very long period, and recovery is rare.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Stages and Etiology
Three stages characterize the course of GBS:
o Initial period – 1 to 4 weeks; onset of symptoms until neurological deterioration stops
o Plateau period – Several days to 2 weeks; no deterioration, and no improvement occurs
o Recovery period – 4 to 6 months and up to 2 years; remyelination and return of muscle strength
• Etiology is unknown. Evidence indicates a cell-mediated immunologic reaction. A history
of a recent viral event is reported by many clients.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome :Risk Factors
Recent (within 1 to 3 weeks) history of:
• Acute illness (upper respiratory infection, gastrointestinal illness)
• Viruses such as Epstein-Barr virus (EBV) or cytomegalovirus (CMV)
• Vaccination (swine flu vaccination)
• Surgery
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Subjective Data
o Clients report increasing weakness with no recollection of injury.
o Clients report a virus within the previous 1 to 3 weeks.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Objective Data
o Acute progressive muscle weakness and paralysis
• Ascending (initially, bilateral lower extremity muscles are affected, then progresses upward through arms and thorax)
• Recovery is in descending order (initially, facial muscles recover, then improvement progresses downward)
o Muscle flaccidity without muscle atrophy
o Paresthesias – Creeping/crawling sensations across skin
o Cranial nerve symptoms (diplopia, facial weakness, dysarthria, dysphagia)
o Decreased/absent deep-tendon reflexes
o Signs of respiratory compromise when muscle weakness reaches thorax
o Autonomic dysfunction (fluctuating blood pressure, dysrhythmias)
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome :Diagnostic Procedures
• Electromyography (EMG) and nerve conduction velocity (NCV) – Shows evidence of denervation after 4+ weeks.
• WBC count – Leukocytosis can develop.
• Lumbar puncture (LP) – Shows an increase in protein within the cerebrospinal fluid without an increase in cell count, which is the distinguishing characteristic of GB
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Nursing Care, Part I
– Monitor respiratory status (rate and depth of respirations, pulse oximetry, ABGs). Have oxygen, suction equipment, and intubation tray readily available.
– Keep the head of the bed at 45°; have clients tum and cough, deep breathe, and use an incentive spirometer every 2 hr; institute chest physiotherapy if indicated.
– Monitor heart rhythms for irregularities and bradycardia.
– Monitor blood pressure and report fluctuations to the provider.
– Provide alternatives for communication such as an alphabet board if clients can still use hands.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Nursing Care, Part I I
o Check swallowing and gag reflexes before feeding. Follow recommendations of speech pathologist.
o Take measures to prevent skin breakdown. Clients may not be able to change position or feel pain when skin breakdown is occurring.
o Provide comfort measures (frequent repositioning, ice, heat, massage, distraction).
o Identify support systems and coping abilities. Communicate appropriately because cognitive functions are not affected.
o Administer medications as prescribed.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Medication – Morphine
Morphine
• An analgesic given for pain and paresthesias
• Nursing Considerations
o Monitor for respiratory depression and constipation.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Medication – IV Immunoglobin (IVig)
IV Immunoglobulin (IVIg)
• Given to suppress attack on immune system
• Nursing Considerations
o Monitor for side effects such as chills, fever, myalgia, and for possible complications including anaphylaxis or renal failure.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Medication – Neurontin (Gabapentin)
Neurontin (Gabapentin)
• Given for neuropathic pain
• Nursing Considerations
o Monitor for confuSion, depression, drowsiness, and ataxia.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Therapeutic Procedures
Plasmapheresis – A treatment where blood is removed from the body, run through a separator, and the circulating antibodies are removed from the plasma. This procedure decreases the attack against the myelin sheath. This may be done several times over a
period of several weeks.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Nursing Actions
o Preprocedure
~ Check vital signs, laboratory values, and weight.
PN ADULT MEDICAL SURGICAL NURSING 123 GUILLAIN-BARRE SYNDROME AND MYASTHENIA GRAVIS
o Postprocedure
~ Apply pressure dressing to access site.
~ Monitor for infection at access site.
~ Monitor laboratory values.
– Monitor for the possible complications of hypovolemia,
hypokalemia, and hypocalcemia.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Client Education
o Instruct clients that the procedure will typically last 2 to 5 hr.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Care after Discharge
o Client Education
• Instruct clients to adhere to the medication regimen.
Central and Peripheral Nervous System Disorders: Guillain-Barre Syndrome : Complications
• Respiratory compromise
o Recognize progressing paralysis and be prepared to intervene promptly.
o Nursing Actions
• Monitor respiratory status (rate and depth of respirations, pulse oximetry, ABGs).
• Have oxygen, suction equipment, and intubation tray readily available.
• Provide assistance in mobilization and removal of secretions.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS
Myasthenia gravis (MG) is a progressive autoimmune disease that produces severe muscular weakness. It is characterized by periods of exacerbation and remission. Muscle weakness improves with rest. It is caused by antibodies that interfere with the transmission of acetylcholine at the neuromuscular junction.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Data Collection – Risk Factors
• Risk Factors
o Associated with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus
o Causes
• Co-existing autoimmune disorder
• Frequently associated with hyperplasia of the thymus gland
o Factors that trigger exacerbations
• Infection
• Stress, emotional upset, and fatigue
• Pregnancy
• Increases in body temperature (fever, sunbathing, hot tubs)
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Subjective Data
o Progressive muscle weakness
o Diplopia (double vision)
o Fatigue after exertion
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Objective Data
o Physical Assessment Findings
• Impaired respiratory status (difficulty managing secretions, poor respiratory effort)
• Decreased swallowing ability
• Poor muscle strength, especially of the face, eyes, and proximal portion of major muscle groups
• Incontinence
• Drooping eyelids – Unilateral or bilateral
• Poor posture
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Diagnostic Procedures
Tensilon testing
o Baseline assessment of the cranial muscle strength is done.
o Edrophonium chloride (Tensilon) is administered.
.. Medication inhibits the breakdown of acetylcholine, making it available for use at the neuromuscular junction. A positive test results in marked improvement in muscle strength that lasts approximately 5 min.
o Nursing Actions
~ Assist provider in administering the test.
~ Observe for complications such as fasciculations around the eyes and face, as well as cardiac arrhythmias.
~ Have atropine available, which is the antidote for edrophonium
chloride (bradycardia, sweating, and abdominal cramps).
o Client Education
~ Explain purpose of the test to clients.
~ Encourage clients to follow the provider’s directions in moving
previously affected muscles.
~ Discourage clients from demonstrating improvement by increasing effort, which could skew the test results.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Diagnostic Procedures – Electromyography
o Shows the neuromuscular transmission characteristics of MG.
o Decrease in amplitude of the muscle is demonstrated over a series of consecutive muscle contractions.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Nursing Care I
* Monitor respiratory status (rate and depth of respirations, pulse oximetry, ABGs). Have oxygen, suction equipment, and intubation tray readily available.
* Check swallowing and gag reflexes before feeding. Follow recommendations of speech pathologist.
* Use energy conservation measures. Allow for periods of rest.
* Provide small, frequent high-calorie meals and schedule at times when medication is peaking.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Nursing Care II
* Have clients sit upright when eating and use thickener in liquids as necessary.
* Apply a lubricating eyedrop during the day and ointment at night if clients are unable to completely close their eyes. Clients may also need to patch or tape eye shut at night to prevent damage to the cornea.
* Encourage clients to wear a medical identification wristband or necklace at all times.
* Administer medications as prescribed and at specified times.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Medication
Anticholinesterase agents – Cholinesterase inhibitor medications are the first line in therapy .
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Medication – Nursing Considerations
o Ensure that the medication is given at the specified time – usually 4 times a day.
o If periods of weakness are observed, discuss change in administration times with the provider.
o Use cautiously in clients who have a history of asthma or cardiac dysrhythmias.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS -Medication – Client Education
o Instruct clients to take with small amount of food to minimize
gastrointestinal side effects.
o Instruct clients to eat meals within 45 min of taking the medication to strengthen chewing and reduce the risk for aspiration.
o Stress the importance of maintaining therapeutic levels and taking the medication at the same time each day.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS -Medication – Pyridostigmine (Mestinon) and neostigmine (Prostigmin)
• Used to increase muscle strength in the symptomatic treatment of MG. These medications inhibit the breakdown of acetylcholine and prolong its effects.
• Nursing Considerations
o Use cautiously in clients who have a history of asthma and cardiovascular disease.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS -Medication -Immunosuppressants such as azathioprine (lmuran) and prednisone (Deltasone)
• Use immunosuppressants during exacerbations when pyridostigmine is not adequately effective.
• Since MG is an autoimmune disease, immunosuppressants decrease the production of antibodies.
• A corticosteroid, such as prednisone, is the first medication of choice. Cytotoxic medications, such as azathioprine (lmuran), are given if corticosteroids are ineffective.
• Nursing Considerations
o Monitor for infection.
• Client Education
o Explain to clients the importance of slowly tapering off of a corticosteroid.
o Tell clients to observe for signs of infection and take precautions against exposure to viruses and contaminants.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS -Medication – IV immunoglobulins (lVIg) – Acute management
IVIg, an immunoglobulin, may be prescribed for MG that does not respond to the above treatments.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Interdisciplinary Care
o Request a referral for physical therapy for durable medical equipment needs.
o Request a referral for occupational therapy for assistive devices to facilitate ADLs.
o Request a referral to a speech and language therapist if weakening of facial muscles impacts communication or swallowing.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Therapeutic Procedures
Plasmapheresis – Removes circulating antibodies from the plasma. This is usually done several times over a period of days and may continue on a regular basis for some clients.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Surgical Interventions
o Thymectomy – Removal of the thymus gland is done to attain better control or complete remission.
• This may take months to years to see results due to the life of the circulating T cells.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Complications
• Myasthenic crisis and cholinergic crisis
o Myasthenic crisis occurs when clients are experiencing a stressor that causes an exacerbation of MG, such as infection, or are taking inadequate amounts of cholinesterase inhibitor.
o Cholinergic crisis occurs when clients have taken too much cholinesterase inhibitor.
o The symptoms of both can be very similar (muscle weakness, respiratory failure).
o The client’s highest risk for injury is due to respiratory compromise and failure.
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Complications – Myasthenic Crisis
Under Medication – Myasthenic Crisis
Respiratory muscle weakness – Mechanical ventilation
Myasthenic symptoms (weakness, incontinence, fatigue)
Hypertension
Temporary improvement of symptoms with administration of tensilon
Central and Peripheral Nervous System Disorders: MYASTHENIA GRAVIS – Complications – Cholinergic Crisis
Overmedication – Cholinergic Crisis
Muscle twitching to the point of respiratory muscle weakness – Mechanical ventilation
Cholinergic symptoms – Hypersecretions (nausea, diarrhea, respiratory secretions) and hypermotility (abdominal cramps)
Hypotension
• Tensilon has no positive effect on symptoms, it can actually worsen symptoms (more anticholinesterase – more
cholinergic symptoms).
• Symptoms improve with the administration of an anticholinergic medication, such as atropine.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – OVERVIEW
• Disorders of the eye can be caused by injury, disease, and the aging process.
• Disorders of the eye that nurses should be knowledgeable about include:
o Reduced vision
o Macular degeneration
o Retinal detachment
o Cataracts
o Glaucoma
• Macular degeneration (often called age-related macular degeneration [AMD]) is the central loss of vision, which affects the macula of the eye.
• There is no cure for macular degeneration.
• The number one cause for vision loss in people over the age of 60 is AMD.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION
• Visual acuity of 20/200 or less with corrective lenses constitutes legal blindness.
• Reduced visual acuity can be unilateral (one eye) or bilateral (both eyes).
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Risk Factors
o Age is the most significant risk factor for visual sensory alterations.
o Presbyopia – Age-related loss of the eye’s ability to focus on close objects
o Cataracts – Opacity of lens
o Glaucoma – Loss of peripheral vision
o Diabetic retinopathy – Microaneurysms
o Macular degeneration – Loss of central vision
o Eye infection, inflammation, or injury
o Brain tumor
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Subjective Data
0 Frequent headaches
0 Frequent eye strain
0 Blurred vision
0 Poor judgment of depth
0 Diplopia – Double vision
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Objective Data
o Tendency to close or favor one eye
o Poor hand-eye coordination
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Diagnostic Procedures
1) Ophthalmoscopy – An ophthalmoscope is used to examine the back part of the eyeball (fundus), including the retina, optic disc, macula, and blood vessels.
2) Visual acuity tests – Visual acuity tests include the Snellen chart and Rosenbaum Pocket Vision chart.
3) Tonometry – Tonometry is used to measure intraocular pressure (lOP). lOP (normal is 10 to 21 mm Hg) is elevated with glaucoma, especially angle-closure glaucoma.
4) Gonioscopy – Gonioscopy is used to examine the iridocorneal angle or anterior chamber of the eyes.
5) Slit lamp – The slit lamp is used to examine the anterior portion of the eye, such as the cornea, anterior chamber, and the lens.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Nursing Care
o Use the Snellen chart or the Rosenbaum Pocket Vision Screener to check distance vision.
• Have clients stand 20 ft from the Snellen chart.
• Have clients hold the Rosenbaum chart 14 inches away from their eyes.
o Identify how clients are adapting to their environment to maintain safety.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Medications
Anticholinergics, such as atropine (Isopto Atropine ophthalmic solution)
• Anticholinergics are used for intraocular exams/surgery. They provide mydriasis (dilation of the pupil) and cycloplegia (ciliary paralysis).
• Client Education
o Inform clients of adverse effects including reduced accommodation, blurred vision, and photophobia. With systemic absorption, there could be anticholinergic effects (tachycardia, decreased secretions).
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Client Education
• Recommend clients wear sunglasses to protect eyes.
• Recommend clients wear eye protection to prevent injury to the eye.
• Provide suggestions for home safety:
o Increase the amount of light in a room.
o Arrange the home to remove hazards, such as eliminating throw rugs.
o Use phones with large numbers and/or auto dial.
• Suggest clients use adaptive devices that accommodate for
reduced vision.
o Magnifying lens and large-print books/newspapers
o Talking devices, such as clocks and watches
•Recommend clients maintain blood pressure and cholesterol within appropriate reference range.
•Recommend clients who have diabetes mellitus to maintain blood glucose levels within appropriate reference range.
• Eat foods rich in antioxidants, such as green, leafy vegetables.
• Encourage adults 40 or older to have an annual examination including a measurement of lOP.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – REDUCED VISION – Complications
• Risk for Injury
o Reduced vision places clients at a higher risk for injury. In particular, disturbed visual sensory perception is a well-known risk factor for injury and mortality in older adults.
o Nursing Actions
• Monitor for safety risks, such as the ability to drive safely, and intervene to reduce risks.
o Client Education
• Encourage annual eye examinations.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT
Retinal detachment is a painless separation of the retina from the epithelium, resulting in the loss of vision in fields corresponding to the separation. Retinal detachment is a medical emergency, and the assistance of a provider should be sought immediately.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Risk Factors
0 Nearsightedness
0 Family history
0 Previous cataract surgery
0 Eye injury
0 Retinal tear – Trauma
0 Fibrous vitreous tissue – Pulls retina
0 Exudate – Forms under retina
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Subjective and Objective Data
o The onset of retinal detachment is abrupt.
o Bright flashes of light can occur.
o Floating dark spots, commonly referred to as floaters, can be seen.
o “Curtain drawing over visual field” sensation can occur.
o An examination reveals a sudden loss of vision without pain.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Diagnostic Procedures
• A detached retina can be determined with an ophthalmoscope examination. Depending on the type of retinal tear, laser and/or surgery can be used as an intervention.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Nursing Care
o Restrict activity to prevent additional detachment.
o Cover the affected eye with an eye patch.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Medication
o Terramycin with dexamethasone (TobraDex-ophthalmic solution)
• Antibiotic-steroid combination
• Prevents infection and decreases inflammation of the eye
• Client Education
o Remind clients to instill the drops as prescribed to prevent infection and
inflammation.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Interdisciplinary Care
o Recognize the need for a retinal specialist for surgery.
o Request referrals for services, such as community outreach programs, meals on wheels, and services for the blind as needed.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Scleral buckling
• Scleral buckling involves local or general anesthesia for the application of a silicone sponge held in place with stitches or an encircling band to promote attachment. An infiltration of a gas bubble can be done at the same time to push
the retina back against the wall of the eye.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Retinal rebinding
Retinal rebinding
• The application of diathermy (high-frequency current), cryotherapy (freezing
probes), or photocoagulation (laser beams) are used to create an inflammatory
response for the purpose of rebinding the retina.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Retinal rebinding – Nursing Actions
* Provide information about the procedure for clients.
* Rest the eye prior to the procedure.
* An eye patch and shield are applied, and clients will lie with the affected eye up, or as prescribed, if a gas bubble is injected during the procedure.
* Administer analgesics, antiemetics, antibiotics, and anti-inflammatory medications as prescribed.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Retinal rebinding – Client Education
* Avoid activities that cause rapid eye movement (reading, writing) for a specified period of time.
* Wear sunglasses while outside or in brightly lit areas.
* Rest the eye.
* Contact the surgeon immediately if there is acute pain of the affected eye.
* Contact the surgeon immediately if the eye has discharge or bleeds.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Retinal rebinding – Care after Discharge
Client Education
• Instruct clients to take precautions when engaging in sports that can cause a blow
to the head or the eye.
• Instruct clients to avoid activities that increase lOP
– Bending over at the waist
– Sneezing
– Coughing
– Straining
– Vomiting
– Head hyperflexion
– Restrictive clothing, such as tight shirt collars
– Clients should report if any changes occur, such as lid-swelling, decreased vision, bleeding or discharge, a sharp, sudden pain in the eye, and/or flashes of light or floating shapes.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – RETINAL DETACHMENT – Surgical Interventions – Retinal rebinding – Complications
• Loss of vision
o The final visual result is not always known for several months postoperatively. More than one attempt at repair of the eye may be required.
o Client Education
• Instruct clients to seek professional help immediately if signs of detachment occur.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: 3 TYPES
• A cataract is opacity in the lens of an eye that impairs vision.
• There are three types of cataracts:
1) A subcapsular cataract begins at the back of the lens.
2) A nuclear cataract forms in the center (nucleus) of the lens.
3) A cortical cataract forms in the lens cortex and extends from the outside of the lens to the center.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Risk Factors
0 Advanced age
0 Diabetes mellitus
0 Heredity
0 Smoking
0 Trauma
0 Excessive exposure to the sun
0 Chronic corticosteroid use
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Subjective Data
o Decreased visual acuity (prescription changes, reduced night vision, loss of color perception)
o Blurred vision
o Diplopia – Double vision
o Glare and light sensitivity – Photo sensitivity
o History of visual problems
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Objective Data
o Physical Assessment Findings
• Progressive and painless loss of vision
• Visible opacity
• Absent red reflex
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Diagnostics
Cataracts can be determined upon examination of the lens with an
ophthalmoscope.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Nursing Care
o Check the client’s visual acuity using the Snellen and Rosenbaum charts.
o Examine the external and internal eye structures using an ophthalmoscope.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Medication – Cholinesterase inhibitor (Atropine 1% ophthalmic solution)
• This medication prevents pupil constriction for prolonged periods of time and relaxes muscles in the eye. It is used to dilate the eye preoperatively and for visualization of the eye’s internal structures.
• Nursing Considerations
o The medication has a long duration, but a slow onset.
• Client Education
o Remind clients that the medication takes more than 24 hr to begin working.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Medication – Acetazolamide (Diamox – Oral medication)
• Use acetazolamide preoperatively to reduce lOP, to dilate pupils, and to create eye paralysis to prevent lens movement.
• Nursing Considerations
o Always ask clients if they have an allergy to sulfa. Acetazolamide is a sulfabased medication.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Surgical Intervention
o Surgical removal of the lens
A small incision is made and the lens is either removed in one piece, or in several pieces after being broken up using sound waves. The posterior capsule is retained. A replacement or intraocular lens is inserted. Replacement lenses can correct
refractive errors resulting in improved distant vision.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Surgical Intervention – Nursing Actions
Postoperative care should focus on:
~ Preventing infection.
~ Administering ophthalmic medications.
~ Providing pain relief.
~ Teaching clients about self-care at home.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Surgical Intervention – Client Education
* Wear sunglasses while outside or in brightly lit areas.
* Report signs of infection, such as yellow or green drainage.
* Avoid activities that increase lOP.
* Limit activities.
~ Avoid tilting the head back to wash hair.
~ Limit cooking and housekeeping.
~ Avoid rapid, jerky movements, such as vacuuming.
~ Avoid driving and operating machinery.
~ Avoid sports.
* Report pain with nausea/vomiting – indications of increased lOP or
hemorrhage.
* Best vision is not expected until 4 to 6 weeks following the surgery.
* Clients should report if any changes occur, such as lid-swelling, decreased vision, bleeding or discharge, a sharp, sudden pain in the eye, and/or flashes of light or floating shapes.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Surgical Intervention – Care after Discharge
o Client Education
• Recommend clients wear sunglasses to protect eyes.
• Recommend clients wear eye protection to prevent injury to the eye.
• Provide suggestions for home safety:
o Increase the amount of light in a room.
o Arrange the home to remove hazards, such as eliminating throw rugs.
o Use phones with large numbers and/or auto-dial.
• Suggest clients use adaptive devices that accommodate for reduced vision.
o Magnifying lens and large-print books/newspapers
o Talking devices, such as clocks and watches
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – CATARACTS: Complications
• Infection
o Infection can occur after surgery.
o Client Education
• Instruct client to report signs of infection, including yellow or green drainage, increased redness or pain, reduction in visual acuity, increased tear production, and/or photophobia.
• Bleeding
o Bleeding is a potential risk several days following surgery.
o Client Education
• Instruct clients to immediately report any sudden change in visual acuity or an increase in pain.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Overview
Glaucoma is a disturbance of the functional or structural integrity of the optic nerve. Decreased fluid drainage or increased fluid secretion increases lOP and can cause atrophic changes of the optic nerve and visual defects. An expected reference range for lOP is between 10 and 21 mm/Hg. Glaucoma is a leading cause of blindness. Early diagnosis and treatment is essential in
preventing vision loss from glaucoma.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Two Primary Types
1) Open-angle glaucoma is the most common form of glaucoma. Open-angle refers to the angle between the iris and sclera. The aqueous humor outflow is decreased due to blockages in the eye’s drainage system (canal of Schlemm and trabecular meshwork)
causing a rise in lOP.2) Angle-closure glaucoma is less common. lOP rises suddenly. With angle-closure glaucoma, the angle between the iris and the sclera suddenly closes causing a corresponding increase in lOP.

NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Risk Factors
0 Age
0 Infection
0 Tumors
0 Diabetes mellitus
0 Genetic predisposition
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Subjective and Objective Data – Open-angle glaucoma
• Loss of peripheral vision
• Decreased accommodation
• Elevated lOP (greater than 21 mm Hg)
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Subjective and Objective Data – Angle-closure glaucoma
• Rapid onset of elevated lOP
• Decreased or blurred vision
• Seeing halos around lights
• Pupils are nonreactive to light
• Severe pain and nausea
• Photophobia
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Diagnostic Procedures
• Visual assessments – Decrease in visual acuity and peripheral vision
• Tonometry – Tonometry is used to measure lOP. lOP is elevated with glaucoma, especially angle-closure.
• Gonioscopy – Gonioscopy is used to determine the drainage angle of the anterior chamber of the eyes.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Nursing Care
o Monitor clients for increased lOP.
o Monitor clients for decreased vision and light sensitivity.
o Check clients for aching or discomfort around the eye.
o Explain the disease process to clients and allow time for expression of feelings.
o Treat severe pain and nausea that accompanies angle-closure glaucoma with analgesics and antiemetics.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication – Timolol (Timoptic)
Topical nonselective beta blocker
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication – Betaxolol (Betoptic)
Topical cardiac selective beta, blocker
• Decreases lOP by reducing aqueous humor production.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication – Brimonidine (Alphagan) – Topical
• Alphaz adrenergic agonist that decreases production and may also decrease outflow of aqueous humor to lower lOP.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication – Latanoprost (Xalatan) – Topical
• Prostaglandin analog that increases aqueous humor outflow through relaxation of ciliary muscle.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication – Acetazolamide (Diamox) oral
• Anhydrase inhibitor that reduces production of aqueous humor by causing diuresis through renal effects
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Medication -Mannitol (Osmitrol) – IV mannitol
Is an osmotic diuretic used in the emergency treatment for angle-closure glaucoma to quickly decrease lOP.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Interdisciplinary Care
o Recognize the need for a referral to an ophthalmologist if surgery is necessary.
o Request a referral for community outreach programs, meals on wheels, and services for the blind.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Surgical Interventions
Glaucoma surgery
• Laser trabeculectomy, iridotomy, or the placement of a shunt are procedures used to improve the flow of the aqueous humor by opening a channel out of the anterior chamber of the eye.
• Nursing Actions
o lOP is checked 1 to 2 hr postoperatively by the surgeon.
o Instruct clients about the disease and the importance of adhering to the medication schedule to treat lOP.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Surgical Interventions – Patient Education
Instruct clients to:
~ Wear sunglasses while outside or in brightly lit areas.
~ Report signs of infection, such as yellow or green drainage.
~ Avoid activities that increase lOP.
~ Not lie on the operative side and to report severe pain or nausea
(possible hemorrhage).
~ Report if any changes occur, such as lid-swelling, decreased vision, bleeding or discharge, a sharp, sudden pain in the eye and/or flashes of light or floating shapes.
~ Limit activities.
~ Report pain with nausea/vomiting – indications of increased lOP or hemorrhage.
~ Inform clients that best vision is not expected until 4 to 6 weeks
postoperative.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Surgical Interventions -Care after Discharge
Client Education
• Emphasize the importance of adhering to a medication schedule to treat lOP.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Surgical Interventions – Client Outcomes
0 The client will be free from injury, infection, and pain.
o The client will have decreased lOP due to the eye surgery.
NEUROSENSORY DISORDERS: Sensory Disorders – Disorder of the eyes – GLAUCOMA: Complications
• Blindness
o Blindness is a potential consequence of undiagnosed and untreated glaucoma.
o Client Education
• Encourage adults 40 or older to have an annual examination, including a measurement of lOP.
Sensory Disorders: Hearing Loss and Middle and Inner Ear Disorders
Disorders related to hearing and balance can be caused by injury, disease, and/or the aging process.
• Auditory problems that nurses should be knowledgeable about include:
o Hearing loss
o Middle and inner ear disorders
Sensory Disorders: Hearing Loss
Hearing loss is difficulty in hearing or accurately interpreting sounds due to a problem in the middle or inner ear
There are two types of hearing loss:
1) Conductive hearing loss occurs when there is an alteration in the middle ear and sound waves are blocked before reaching the inner ear.
2) Sensorineural hearing loss occurs when there is an alteration in the inner ear that involves cranial nerve VIII and/or cochlear damage.
Sensory Disorders: Hearing Loss – Risk Factors – Conductive Hearing Loss
o Risk for and degree of hearing loss progressively advances with aging.
o Conductive hearing loss
• History of middle ear infections
• Older age (otosclerosis)
Sensory Disorders: Hearing Loss – Risk Factors – Sensorineural Hearing Loss
• Prolonged exposure to loud noises
• Ototoxic medications to include antibiotics (gentamicin [Garamycin], amikacin [Amikin], or metronidazole [Flagyl]), diuretics (furosemide [Lasix)), NSAIDs (aspirin or ibuprofen [Advil)), and chemotherapeutic agents (cisplatin [Abiplatin))
• Infectious processes
• Age-related (presbycusis – Decreased ability to hear high-pitched sounds)
Subjective and Objective Data: Conductive hearing loss
• Subjective
o Reports hearing better in a noisy environment
• Objective
o Clients speak softly
o Obstruction in external canal visualized (packed cerumen is very common)
o Abnormal tympanic membrane findings (holes, scarring)
o Rinne test that demonstrates time of air conduction of sound is greater than or equal to time of bone conduction of sound
o Weber test lateralizes to the affected ear
Subjective and Objective Data: Sensorineural Hearing Loss
• Subjective
o Tinnitus (ringing, roaring, or humming in ears)
o Dizziness
o Hears poorly in a noisy environment
• Objective
o Clients speak loudly
o Otoscopic exam shows no abnormalities
o Rinne test that demonstrates time of air conduction of sound is less than time of bone conduction of sound.
o Weber test lateralizes to the unaffected ear.
o Diagnosis of acoustic neuroma (benign tumor cranial nerve VIII)
Sensory Disorders: Hearing Loss Diagnostic Procedures – Weber test
Weber test
o Place a vibrating tuning fork stem on the center of the client’s head
o Ask the client to tell where the sound is heard the loudest.
o Expected finding – The sound is heard equally in both ears
o Unexpected finding – Lateralization to one ear
Sensory Disorders: Hearing Loss Diagnostic Procedures – Rinne Test
Rinne Test
* Place a vibrating tuning fork stem on the client’s mastoid process (bone conduction). When the client says he no longer hears the sound, move the tuning fork in front of the client’s ear, and have the client say when he no longer hears the sound.
* Expected finding – Air conduction is longer than or equal to bone
conduction.
* Unexpected finding – Bone conduction is longer than air conduction.
Sensory Disorders: Hearing Loss Diagnostic Procedures – Audiometry
Audiometry
* An audiogram identifies if hearing loss is sensorineural and/or conductive.
* Nursing Actions
~ Minimize environmental sounds during testing.
~ Follow protocol to test a client’s ability to hear various frequencies
(high versus low pitch) at various decibels (soft versus loud tones).
~ Have clients wear audiometer headphones and face away from person performing test.
~ Plot responses on a graph for each ear and compare to expected
findings based on age.
* Client Education
~ Instruct clients to indicate when a tone is heard and in which ear by raising the hand on the corresponding side.
Sensory Disorders: Hearing Loss Diagnostic Procedures – Tympanogram
Tympanogram
* A tympanogram measures the mobility of the tympanic membrane and
middle ear structures relative to sound.
* This test is effective in diagnosing disease of the middle ear.
Sensory Disorders: Hearing Loss Diagnostic Procedures — Otoscopy
Otoscopy
* An otoscope is used to examine the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM.
* Nursing Actions
~ Use the appropriate size speculum and introduce into the external ear.
~ Pull up and back on the auricle to straighten out the canal and
enhance visualization.
~ The tympanic membrane should be a waxy gray color and intact. It should provide complete structural separation of the outer and middle ear structures.
• The light reflex should be visible from the center of the TM anteriorly (S o’clock right ear; 7 o’clock left ear).
• In the presence of fluid or infection in the middle ear, the TM will
become inflamed and may bulge from the pressure of the exudate. This will also displace the light reflex, a significant diagnostic finding.
• Avoid touching the lining of the ear canal, which causes pain due to sensitivity.
Client Education
• Warn clients that to see the TM clearly, the auricle may need to be
pulled firmly.
Sensory Disorders: Hearing Loss – Nursing Care
o Monitor the client’s functional ability.
o Communication
• Get the client’s attention before speaking.
• Stand/sit facing clients in a well-lit, quiet room without distractions.
• Speak clearly and slowly to clients without shouting and without hands or other objects covering the mouth.
• Arrange for communication assistance (sign-language interpreter, closed-captions, phone amplifiers, teletypewriter [TTY] capabilities) as needed. Check the hearing of clients receiving ototoxic medications for more than S days.
Sensory Disorders: Hearing Loss – Interdisciplinary Care
If abnormality is identified during audiometry, clients should be referred to an audiologist for more sensitive testing.
Sensory Disorders: Hearing Loss – Therapeutic Procedures
Therapeutic Procedures
o Hearing aid – Conductive hearing loss
• Hearing aids are effective in treating conductive hearing loss.
• Hearing aids amplify sounds, but do not help clients interpret what they are hearing.
• Amplification of sound in a loud environment can be distracting and disturbing.
Sensory Disorders: Hearing Loss – Nursing Actions and Client Education
• Provide emotional support to clients using hearing aids for the first time.
• Instruct clients to use the lowest setting that allows hearing without feedback noise.
• Tell clients to follow manufacturer’s direction for cleaning and storing. To clean the ear mold, use mild soap and water while keeping hearing aid dry.
• Remind clients to turn off hearing aids when not in use to conserve the life of the batteries. Replacement batteries should always be kept on hand.
Sensory Disorders: Hearing Loss – Surgical Interventions
o Tympanoplasty/myringoplasty – Conductive hearing loss
• Tympanoplasty is a surgical reconstruction of the middle ear structures and myringoplasty is an eardrum repair.
• Nursing Actions
o Maintain sterile packing in the client’s ear postoperatively.
o Position clients flat with the operative ear facing up for 12 hr.
• Client Education
o Instruct clients to avoid forceful straining, coughing, sneezing with the mouth closed, and air travel.
o Only wash hair if the ear is covered with a dressing. No water should enter the ear.
o Remind clients that hearing will be impaired until packing is removed from the ear.
Sensory Disorders: Hearing Loss – Care After Discharge
o Client Education
• Encourage clients not to place any objects in the ears, including cotton-tipped swabs.
• Encourage clients to seek medical care if a foreign object is present in the ear or if ear is impacted with cerumen. Clients may use a commercial ceruminolytic (ear drops that soften cerumen) that can be instilled, followed by irrigation with warm water.
• Encourage clients to wear ear protection for exposure to high-intensity noise and/or risk for ear trauma.
• Encourage clients to keep volume as low as possible when wearing headphones.
Sensory Disorders: Middle and Inner Ear Disorders
•The middle ear consists of the tympanic membrane (eardrum), three bones (malleus, incus, and stapes), and connects to the oropharynx via the Eustachian tube.
• Middle ear infections are called otitis media.
• The inner ear consists of the oval window, cochlea (hearing organ), and the vestibular system (organ responsible for balance, which includes the semicircular canals).
• Middle and inner ear disorders cause many of the same symptoms due to their close proximity and adjoining structures.
• Inner ear problems are characterized by tinnitus (continuous ringing in ear), vertigo (whirling sensation), and dizziness.
•Visual, vestibular, and proprioceptive systems provide the brain with input regarding balance. Problems within any of these systems pose a risk for loss of balance.
Sensory Disorders: Inner Ear Disorders – Labyrinthitis and Meniere’s disease
o Labyrinthitis is an infection of the labyrinth, usually secondary to otitis media.
o Meniere’s disease is a vestibular disease characterized by a triad of symptoms – tinnitus, unilateral sensorineural hearing loss, and vertigo.
• Benign paroxysmal vertigo (BPV) is a disorder that occurs in response to a change in position. It is thought to be due to a disturbance of crystals in the semicircular canals initiating vertigo that lasts from days to months.
Sensory Disorders: Risk Factors – Middle ear disorders
• Recurrent colds and otitis media
• Enlarged adenoids
• Trauma
• Changes in air pressure (scuba diving, flying)
Sensory Disorders: Risk Factors – Inner ear disorders
• Viral or bacterial infection
• Ototoxic medications
Sensory Disorders: Middle Ear and Inner Ear: Subjective Data
o MIDDLE ear disorders
• Hearing loss
• Feeling of fullness and/or pain in the earo INNER ear disorders
• Hearing loss
• Tinnitus
• Dizziness or vertigo

Sensory Disorders: Middle Ear and Inner Ear: Objective Data
o MIDDLE ear disorders
• Red, inflamed ear canal and TM
• BulgingTM
• Fluid and/or bubbles behind TMo INNER ear disorders
• Vomiting
• Nystagmus
• Poor balance

Sensory Disorders: Middle Ear and Inner Ear Hearing Loss – Diagnostics: Hearing Acuity Tests
Hearing acuity tests (Refer to tests performed for middle ear disorders.)
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss – Diagnostics: Electronystagmography (ENG)
– ENG is done to determine the type of nystagmus elicited by the stimulation of the acoustic nerve.
– Electrodes are placed around the eyes, and movements of the eyes are recorded when the ear canal is stimulated with cold water instillation or injection of air. Recording of eye movements can be interpreted by a specialist as either normal or abnormal.
– Nursing Actions
~ Clients should be maintained on bed rest and NPO Postprocedure until vertigo subsides.
– Client Education
~ Instruct clients to fast immediately before the procedure and to restrict caffeine, alcohol, sedatives, and antihistamines 24 hours prior to the test.
Sensory Disorders:Middle Ear and Inner Ear Hearing Loss – Diagnostics: Caloric testing
• Water (warmer or cooler than body temperature) is instilled into the ear in an effort to induce nystagmus.
o The eyes’ response to the instillation of cold and warm water is diagnostic of vestibular disorders.
o This test can be done concurrently with ENG.
o Nursing Actions
~ Clients should follow the same restrictions as those for an ENG.
o Client Education
~ Inform clients of the above restrictions.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Nursing Care
o Monitor the client’s functional ability and balance. Take fall-risk precautions as necessary.
o Check the hearing of clients receiving ototoxic medications for more than 5 days.
o Assist with ENG and/or caloric testing as needed.
o Administer antivertigo and antiemetic medications as needed.
Sensory Disorders Middle Ear and Inner Ear: Hearing Loss: Medication – Meclizine (Antivert)
• Meclizine has antihistamine and anticholinergic effects and is used to treat the vertigo that accompanies inner ear problems.
• Nursing Considerations
o Contraindicated for clients who have closed-angle glaucoma.
o Observe clients for sedation and take appropriate precautions to ensure safe ambulation.
• Client Education
o Warn clients about the sedative effects of meclizine (avoid driving, operating heavy machinery).
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Medication – Antiemetics
• Droperidol (Inapsine) is one of several antiemetics used to treat nausea and vomiting associated with vertigo.
• Nursing Considerations
o Observe clients for postural hypotension and tachycardia.
o Tell clients to avoid abrupt changes in position.
• Client Education
o Warn clients about the hypotensive effects of droperidol.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Medication – Diphenhydramine (Benadryl) and dimenhydrinate (Dramamine)
• Antihistamines are effective in the treatment of vertigo and nausea that accompany inner ear problems.
• Nursing Considerations
o Observe clients for urinary retention.
o Observe clients for sedation and take appropriate precautions to ensure safe ambulation.
• Client Education
o Warn clients about the sedative effects (avoid driving, operating heavy machinery).
o Inform clients that dry mouth is to be expected.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Medication – Scopolamine (Transderm Scop)
• Anticholinergics, such as scopolamine, are effective in the treatment of nausea that accompanies inner ear problems.
• Nursing Considerations
o Observe clients for urinary retention.
o Observe clients for sedation and take appropriate precautions to ensure safe ambulation.
• Client Education
o Warn clients about the sedative effects of antihistamines (avoid driving, operating heavy machinery).
o Inform the client that dry mouth is to be expected.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Medication – Diazepam (Valium)
• Diazepam is a benzodiazepine that has antivertigo effects.
• Nursing Considerations
o Observe for sedation and take appropriate precautions to ensure safe ambulation.
• Client Education
o Warn clients about the sedative effects of diazepam (avoid driving; operating heavy machinery).
o Inform clients of diazepam’s addictive properties and appropriate use of the medication.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Interdisciplinary Care
o Vestibular rehabilitation is an option for clients who experience frequent episodes of vertigo and/or are incapacitated due to the vertigo. A team of health care providers is used to treat the cause and teach clients exercises that can help clients adapt to and
minimize the effects of vertigo. A combination of biofeedback, physical therapy, and stress management may be used. Postural education can teach clients positions to avoid, as well as positional exercises that can terminate an attack of vertigo.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Therapeutic Procedures
Vertigo-reducing activities
• Client Education
o Reinforce to clients to prevent stimulation/exacerbation of vertigo.
o Tell clients to space intake of fluids evenly throughout the day.
o Teach clients to decrease intake of salt and sodium-containing foods (processed meats, MSG).
o Have clients avoid caffeine and alcohol.
o Instruct clients to take a diuretic, if prescribed, to decrease the amount of fluid in semicircular canals.
o Tell clients to take these precautions when vertigo is present.
~ Encourage clients to rest in a quiet, darkened environment when the symptoms are severe. Have clients use assistive devices as needed (cane, walker) for safe ambulation to assist with balance.
~ Encourage clients to maintain a safe environment that is free of clutter.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Surgical Interventions – Stapedectomy – Conductive hearing loss
• A stapedectomy is a surgical procedure of the middle ear in which the stapes is
removed and replaced with a prothesis.
• The procedure is done when otosclerosis has developed and the bones of the
middle ear fuse together.
• Otosclerosis is one of the causes of conductive hearing loss in older adults.
• Nursing Actions
o The procedure is done through the external ear canal and TM.
o The stapes is completely or partially removed and replaced with a prosthesis.
o The TM is repaired and sterile ear packing is placed in the ear postoperatively.
o Monitor clients for facial nerve damage.
o Intervene for vertigo, nausea, and vomiting (common findings following the procedure).
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Surgical Interventions – Cochlear implant – Sensorineural hearing loss
• Cochlear implants consist of a microphone that picks up sound, a speech processor, a transmitter and receiver that converts sounds into electric impulses, and electrodes that are attached to the auditory nerve.
• The implant’s transmitter is located outside the head behind the ear and connects via a magnet to the receiver located immediately below it, under the skin.
• Young children and adults who lost their hearing after speech development adapt to cochlear implants more quickly than those who were totally deaf at birth. Intensive and prolonged language training is necessary for individuals who did not develop speech.• NURSING ACTION
* Placement of an implant can be done on an outpatient basis.

Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Surgical Interventions – Cochlear implant – Sensorineural hearing loss – • CLIENT EDUCATION
* Inform clients that immediately after surgery the unit is not turned on.
* Tell clients that 2 to 6 weeks after surgery, the external unit is applied and the speech processor is programmed.
* Instruct clients on precautions to prevent infection.
* Instruct clients that MRIs must be avoided.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Surgical Interventions – Labyrinthectomy
A labyrinthectomy is a surgical treatment for vertigo that involves removal of the labyrinthine portion of the inner ear.
• Nursing Actions
*The client will have severe nausea and vertigo postoperatively. Take
appropriate safety precautions and give antiemetics as needed.
• Client Education
* Inform clients that hearing loss is to be expected in the affected ear.
Sensory Disorders: Middle Ear and Inner Ear Hearing Loss: Client Outcomes
o The client will have decreased episodes of vertigo.
o The client will be free from injury.

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