Management of the client with disruption of nervous system

CEREBROVASCULAR ACCIDENT (STROKE, BRAIN ATTACK)

• Stroke, cerebrovascular accident (CVA), or

brain attack is the disruption of blood supply
to the brain.
• Cause
• Ischemic (more than 70% of strokes)
• Hemorrhagic (associated with greater
morbidity and mortality).
 Clinical Manifestations

• Numbness (paresthesia), weakness (paresis), or loss

of motor ability (plegia) on one side of the body.
• Difficulty in swallowing (dysphagia).
• Loss of half of a visual field (hemianopsia), double
vision, photophobia.
• Altered cognitive abilities and psychological affect.
• Self-care deficits.
• Diagnostic Evaluation
• CT scan to determine cause and location of stroke.
 Management

• Maintain airway, breathing, oxygenation,

circulation.
• Diuretic treatment to reduce cerebral edema.
• Calcium channel blockers, nimodipine , to
reduce BP, promote vasodilatation, and prevent
cerebral vasospasm.
• Anticoagulation after hemorrhage is ruled out.
• Treatment of post stroke depression with
antidepressants.
 Complications

• Aspiration pneumonia
• Deep vein thrombosis, pulmonary embolism
• Poststroke depression
• Dysphagia in 25% to 50% of patients after
stroke
 Nursing Assessment

• Assess for voluntary or involuntary movements,

tone of muscles, presence of deep tendon
reflexes.
• Assess mental status, sensation.
• Monitor bowel and bladder function/control.
• Monitor effectiveness of anticoagulation
therapy.
• Assess for skin breakdown, contractures, and
other complications of immobility.
 Nursing Diagnoses

• Impaired Physical Mobility related to motor

deficits
• Disturbed Thought Processes related to brain
injury
• Impaired Verbal Communication related to
brain injury
• Self-Care Deficit: Bathing, Dressing, Toileting
related to hemiparesis/paralysis
• Imbalanced Nutrition: Less Than Body
Requirements related to impaired self-feeding,
chewing, swallowing
• Impaired Urinary Elimination related to
motor/sensory deficits
• Disabled Family Coping related to illness, and
care giving burden
• Goal
• Optimizing Cognitive Abilities
• Nursing intervention
• Be aware of the patient's cognitive alterations, and
adjust interaction.
• Participate in cognitive retraining program: reality
orientation (rehabilitation) .
• Be aware that depression is common and therapy
should include psychotherapy and pharmacological
agents.
• Attaining Bladder Control
• Insert indwelling bladder catheterization during acute
stage.
• Strengthening Family Coping
• Teach stress management techniques, such as
relaxation exercises.
• Provide information about stroke and expected
outcome.
• Teach family that stroke survivors do show depression
in the first 3 months of recovery.
 Evaluation: Expected Outcomes

• Oriented to person, place, and time

• Brushing teeth, putting on shirt and pants
independently
• Feeds self two-thirds of meal
• Voids on commode.
 Encephalitis
• Encephalitis is inflammation of the brain.
• usually occurs when the cerebral hemispheres,
brainstem, or cerebellum is infected by a
microorganism.
• Complications of encephalities include
epilepsy, parkinsonism, behavioral and
personality changes, and mental retardation.
• A comatose state may last for days, weeks, or
months after the acute infectious state.
• CAUSES
• Most cases of encephalitis are related to
viruses, and the most common cause is herpes
simplex Virus
• Clinical Manifestations
• Fever, headache, and neck rigidity (stiff neck).
• Altered mental status; confusion in older
patients.
• Signs of meningeal irritation include neck
rigidity and positive Brudzinski's and Kernig's
signs.
• To elicit Brudzinski's sign, place the patient
supine and flex the head upward.
• Resulting flexion of both hips, knees, and
ankles with neck flexion indicates meningeal
irritation.
• To test for Kernig's sign, once again place the
patient supine.
• Keeping the bottom leg straight, flex the other
hip and knee to form a 90-degree angle.
• Slowly extend the upper leg, resulting in pain
and spasm of the muscle. Resistance to
further extension can be felt.
 Diagnostic Evaluation

• Complete blood count to detect an elevated

leukocyte count in bacterial and viral meningitis.
• Blood cultures are obtained to indicate the organism.
• CSF evaluation for pressure and leukocytes.
• In acute bacterial meningitis, the CSF may indicate
elevated pressure and elevated leukocytes.
• In viral encephalitis, the CSF may indicate
normal/moderately elevated pressure, few elevated
leukocytes.
• Most patients are given I.V. antibiotics until the
laboratory findings determine the type of
meningitis (eg, viral, bacterial).
• However, cultures should be taken before
initiating antibiotics.
• To manage inflammation, dexamethasone
(Decadron) or another corticosteroid is given I.V.
– This steroid should be used before or with the
first dose of antibiotics
 Complications

• Seizures occur in 20% to 30% of patients.

• Increased ICP may result in cerebral edema,
decreased perfusion, and tissue damage.
• Severe brain edema may result in herniation or
compression of the brain stem.
• Nursing Diagnoses
• Hyperthermia related to the infectious process and
cerebral edema
• Risk for Imbalanced Fluid Volume related to fever and
decreased intake
• Ineffective Tissue Perfusion (cerebral) related
to infectious process and cerebral edema
• Acute Pain related to meningeal irritation
• Impaired Physical Mobility related to
prolonged bed rest
• Goal
• Reducing Fever
• Nursing Interventions
• Administer antimicrobial agents on time to
maintain optimal blood levels.
• Monitor temperature frequently or
continuously, and administer antipyretics as
ordered.
• Institute other cooling measures, such as tepid
sponging.
• Goal
• Maintaining Fluid Balance
• Nursing intervention
• Prevent I.V. fluid overload, which may worsen
cerebral edema.
• Monitor intake and output closely.
• Goal
• Reducing Pain
• Nursing intervention
• Administer analgesics as ordered; monitor for
response and adverse reactions.
• Darken the room if photophobia is present.
• Assist with position of comfort for neck stiffness.
• Elevate the head of the bed to decrease ICP and
reduce pain.
 TRAUMATIC BRAIN INJURY

• Traumatic brain injury (TBI), also known as

head injury, is the disruption of normal
brain function due to trauma-related
injury.
• The goal of treatment is to prevent
secondary brain injury by providing
supportive care.
•
• Classification
• Mild (GCS 13 to 15, with loss of consciousness
to 15 minutes)
• Moderate (GCS 9 to 12, with loss of
consciousness for up to 6 hours)
• Severe (GCS 3 to 8, with loss of consciousness
greater than 6 hours)
• Clinical Manifestations
• Disturbances in consciousness: confusion to coma
• Headache, vertigo
• Restlessness
• Respiratory irregularities
• Cognitive deficits (confusion, aphasia, reading
difficulties, writing difficulties, acalculi, memory
deficits such as amnesia and difficulty learning new
information)
• Pupillary abnormalities
• Diagnostic Evaluation
• CT scan to identify and localize lesions,
edema, bleeding.
• Management
• Assess and maintain patent airway.
-Intubate for GCS less than 8 (comatose)
-Placement of nasogastric tube with intubation to
prevent aspiration
• Administer oxygen as needed.
• Treat symptomatic anemia with iron
supplements.
• Antibiotics to prevent infection with open skull
fractures or penetrating wounds
• Surgery to evacuate intracranial hematomas,
debridement of penetrating wounds, elevation
of skull fractures, or repair of CSF leaks.
• Treatment of hyponatremia (due to cerebral
salt wasting) by monitoring daily fluid status,
fluid restriction, oral salt replacement, and I.V.
saline 0.9%.
• Complications
• Infections: neurologic(meningitis, ventriculitis)
• Increased ICP.
• Posttraumatic seizure disorder
• Permanent neurologic deficits: cognitive,
motor, sensory, speech
• Death
• Nursing Interventions
• Maintain a patent airway.
• Monitor respiratory rate, and depth.
 SEIZURE DISORDERS

• Seizures (also known as epileptic seizures and,

if recurrent, epilepsy) are defined as a sudden
alteration in normal brain activity.
• Seizures are thought to result from
disturbances in the cells of the brain. that
cause uncontrolled electrical discharges.
 Classification

1. Simple partial seizures without impairment of

consciousness.
2. Complex partial seizures have an impairment of
consciousness.
3. Generalized seizures have a loss of consciousness
with convulsive or non convulsive behaviors.
4. Simple partial seizures can progress to complex
partial seizures, and complex partial seizures can
secondarily become generalized.
 Etiology

• Trauma to head or brain resulting in scar

tissue or cerebral atrophy
• Tumors
• Cranial surgery
• Drug toxicity, such as theophylline.
• CNS infection
 Clinical Manifestations

• Impaired consciousness
• Disturbed muscle tone or movement
• Disturbances of behavior, mood, sensation, or
perception
• Disturbances of autonomic functions
• Diagnostic Evaluation
• CT scan to identify lesion that may be cause of
seizure
 Management
• Pharmacological
• Phenobarbital:2-6 mg/kg/day
• Phenytoin:4-12 mg/kg/day divided BID to
TID.
• Carbamazepine:10-40 mg/kg/day divided
BID
• Nursing Management
• Nursing Diagnoses
• Ineffective Tissue Perfusion (cerebral) related
to seizure activity
• Risk for Injury related to seizure activity
• Ineffective Coping related to psychosocial and
economic consequences of epilepsy
• Goal
• Maintaining Cerebral Tissue Perfusion
• Nursing Intervention
• Maintain a patent airway until patient is fully
awake after a seizure.
• Provide oxygen during the seizure if color
change occurs.
• Stress the importance of taking medications
regularly.
• Monitor patient for toxic adverse effects of
medications.
• Monitor liver functions for toxicity due to
medications.
• Status epilepticus
• Status epilepticus (acute, prolonged, repetitive
seizure activity) is a series of generalized seizures
without return to consciousness between attacks.
•
• The term has been broadened to include
continuous clinical and/or electrical seizures
lasting at least 5 minutes.
• Status epilepticus is considered a serious
neurologic emergency.
• It has high mortality and morbidity
(permanent brain damage, severe neurologic
deficits).
• Predisposing factor:
• medication withdrawal
• Fever
• Metabolic or environmental stresses
• Alcohol withdrawal
• Sleep deprivation.
 NURSING INTERVENTIONS

• Establish airway, and maintain blood pressure (BP).

• Administer oxygen there is some respiratory
depression associated with each seizure, which
may produce hypoxia of brain.
• Administer I.V. Diazepam [Valium]) slowly to
ensure effective brain tissue and serum
concentrations.
• If initial treatment is unsuccessful, general
anesthesia may be required.
 Preventing Injury

• Place the bed in a low position.

• Do not put anything in the patient's mouth
during a seizure.
• Place the patient on side during a seizure to
prevent aspiration.
• Provide a helmet to the patient who falls
during seizure.
 HEADACHE SYNDROMES

• Headaches are one of the most common

complaints of people seeking health care. Pain in
the head is a symptom of underlying pathology.
• Headaches is divided into two categories:
• 1. Primary headache disorders, which include
- Migraine
-Tension-type headache
-Cluster headache
• 2.Secondary headache disorders.
 Pathophysiology and Etiology

• Primary Headaches
• Diagnosis is generally based elimination of other
pathology such as stroke, intracranial bleed, or
brain tumor.
• 1. Migraine headache consists of initial vasospasm
followed by dilation of intracranial and extracranial
arteries; occurs in about 10% of population
• Caused by hyperactivity to the neurotransmitter
serotonin; familial predisposition.
2. Tension headache is due to irritation of sensitive
nerve endings in the head, jaw, and neck from
prolonged muscle contraction in the face, head, and
neck.
• Precipitating factors include fatigue, stress, poor
posture.
• 3. Cluster headache release of increased histamine
results in vasodilatation
-Usually unilateral, recurring.
• Secondary Headaches
• Headache due to a neurologic or systemic
disease.
• Mass lesion (tumor, abscess)
• Intracranial infection (bacterial/viral/fungal
meningitis or encephalitis)
• Inflammation
• Cerebrovascular disease ( intracranial
hemorrhage)
• Increased intracranial pressure
• Low-pressure headache (postlumbar
puncture, trauma induced)
• Sinus infection, viral infection such as
influenza, systemic illness
• Clinical Manifestations
1,Migraine: gradual onset of severe unilateral
headache, may become bilateral.
• Nausea, vomiting, and photophobia may
accompany moderate to severe headache
• Worsened by activity
• May last 4 to 72 hours and greatly impair
activities.
• Migraine head ache may be triggered in women
by hormonal fluctuations (menses, pregnancy),
excess or lack of sleep, and change in eating
habits.
2.Tension/muscle contraction:
• persistent pain and pressure in the back of the
head and neck, across forehead; may be tender
points of head or neck.
• Not aggravated by activity, but may be worsened
by noise and light.
• No nausea and vomiting, but may be associated
with anorexia.
• 3. Cluster headache:
• sudden, sharp, burning, unilateral pain
• Always involving facial area from neck to temple,
and often occurs during the evening or night;
more frequent in men.
-Associated with unilateral excessive tearing,
redness of the eye, stuffiness of nostril on affected
side, facial swelling, flushing, and sweating.
 Diagnostic procedure
• CT scan to rule out lesions, hemorrhage, and
chronic sinusitis
• Erythrocyte sedimentation rate and other blood
studies to help determine inflammatory process
with temporal arteritis
• Management
• Pharmacologic Treatment
• Medications are intended to reduce the
frequency, severity, and duration of the headache.
• Aspirin, acetaminophen, for mild to moderate
pain of tension, sinus, or mild vascular
headaches.
• Antihistamines and decongestants may be
effective for sinus headaches.
• Occasionally, opioid analgesics, muscle
relaxants, and antianxiety agents may be
needed for severe pain.
 Nursing Interventions

• Reduce environmental stimuli: light, noise, and

movement to decrease severity of pain.
• Apply warm, moist heat to areas of muscle tension.
• Teach progressive muscle relaxation to treat and
prevent tension headaches.
• Alternately tense and relax each group of muscles for a
count of five, starting with the forehead and working
downward to the feet.
• Relaxation of just head and neck may also be
helpful if time is limited.
 Disorders that cause paralysis
Hemiplegia
– Loss of muscle control & sensation on one side of
the body (L or R)
• Cause: most frequently stroke
– Also intracranial tumor or hemorrhage
• S/S: weakness of half of the face, aphasia,
etc.
 Paraplegia

• Paraplegia refers to loss of motion and sensation in the

lower extremities and all or part of the trunk.
• Cause
• damage to the thoracic or lumbar spinal cord or to the
sacral root.
• Quadriplegia
• Quadriplegia refers to the loss of movement and
sensation in all four extremities and the trunk.
• Cause:
• Associated with injury to the cervical spinal cord.
• Paraplegia & Quadriplegia
• Both conditions most frequently follow
trauma such as falls, injuries, and gunshot
wounds,
• But they may also be the result of spinal cord
lesions ( tumor), infections and abscesses of
the spinal cord.
• Signs and symptoms of Paraplegia &
Quadriplegia :
• loss of bowel & bladder control
• Sexual dysfunction.
• Low blood pressure and pulse
 Management of the Quadriplegic or Paraplegic Patient

• Nursing Interventions
• Rehabilitation care:
• Nursing care is one of the key factors
determining the success of the rehabilitation
program.
• The main objective is for the patient to live as
independently as possible in the home and
community.
• INCREASING MOBILITY
• Exercise Programs
• The unaffected parts of the body are built up to
optimal strength to promote maximal self-care.
• The muscles of the hands, arms, shoulders, chest,
spine, abdomen, and neck must be strengthened
in the paraplegic patient because he or she must
bear full weight on these muscles to ambulate.
• To strengthen these muscles, the patient can do
push-ups when in a prone position.
• Extending the arms while holding weights
• Squeezing rubber balls promotes hand strength.
• The sooner muscles are used, the less chance
there is muscle atrophy.
• Weight-bearing also reduces the possibility of
renal calculi and enhances many other metabolic
processes.
• Ambulation using crutches requires a high
expenditure of energy.
• wheelchairs provide greater independence
and mobility.
• Every effort should be made to encourage
the patient to be as mobile and active as
possible.
 Intervention for clients with peripheral
Nervous system disorder.

• CRANIAL NERVE DISORDERS

• BELL'S PALSY
• Bell's palsy is an acute peripheral facial
paralysis of the seventh cranial nerve (facial)
unilaterally.
• It is typically a self-limiting process that
usually improves in 3 to 6 months.
 cause
• Cause is unknown. Possible etiologies include:
• Vascular ischemia, and autoimmune.
• Virus
• Clinical Manifestations
• Facial muscles weak throughout forehead,
cheek, and chin;
• Can affect speech
• Diminished taste from anterior two-thirds of
tongue.
• Inability to close eye
• Painful eye sensations
• Photophobia
• Management
• Corticosteroid therapy initiated early to decrease
inflammation (eg, prednisone 1 mg/kg/day for 10
to 14 days, followed by a tapering dose).
• Eye care to maintain lubrication and moisture
if unable to close. May need to be patched
during sleep.
• Surgery to anastomose facial nerve to other
cranial nerve.
• Complications
• Corneal ulceration
• Impairment of vision
 Nursing Intervention
• Patch eye to keep shut at night as directed.
• Inspect eye for redness or discharge.
• Advise patient to report eye pain immediately.
• Administer or teach patient to administer
corticosteroids to reduce inflammation.
• Teach patient to apply moist heat to face.
• Perform or teach patient to perform facial
massage.
 PARKINSON'S DISEASE

• Parkinson's disease is a chronic, progressive

neurologic disease affecting the brain centers
responsible for control and regulation of
movement.
• population older than age 60 is affected by
Parkinson's disease.
• Cause
• A deficiency of dopamine.
• Underlying etiology may be related to a virus;
toxicity from pesticides, herbicides or
repeated head injuries.
• Signs and Symptoms
• Bradykinesia (slowness of movement), loss of
spontaneous movement and delay in initiating
movements.
• Tremor.
• Rigidity in performance of all movements.
• Rigidity is always present but increases during
movement. May lead to sensations of pain,
especially in the arms and shoulders.
• Poor balance when moving. May lead to falls.
• Sleeplessness, salivation, sweating, dizziness.
• Depression, dementia.
• Management
• Pharmacologic
• Anticholinergics to reduce transmission of
cholinergic pathways, which are thought to be
overactive when dopamine is deficient.
• These medications are most effective in
controlling tremor.
• Levodopa, a dopamine precursor.
 Complications

• Dementia
• Aspiration
• Injury from falls
• Nursing Interventions
• Improving Mobility
• Encourage the patient to participate in daily
exercise, such as walking, or gardening.
• Encourage the patient to take warm baths and
receive massages to help relax muscles.
• Instruct the patient to take frequent rest
periods to overcome fatigue and frustration.
• Assess safety in environment to reduce risk of
falls.
 ASSIGNMENT

1. Meningitis
2. Tetanus
3. Rabies
4. Anthrax
5. Poliomyelitis (section A 1-5)
6. Toxoplasmosis
7. Multiple sclerosis
8. Myasthenia gravis
9. Guillain-barr’s syndrome
10. Trigeminal neuralgia section B 6-10
11. Neuropathy
12. Neuritis
13.Parkinsonism
14. Huntington disease
15. Alzheimer’s disease SECTION C 11-15
16. Dementia
17. Aspiration
18. Impairment of vision
19. Intracranial infection
20. Cognitive deficits SECTION D 16-20