NEUROLOGICAL NURSING



NEUROLOGICAL NURSING

Introduction:

The care of a neurological patient may be complex. Successful nursing care requires preparation, sound clinical skills, and systematic approach to the nursing process

1. Nervous System:

1. Regulates system

2. Controls communication

3. Coordinates Activities of body system

Divisions

* Central nervous system ( CNS) : brain and spinal cord –interprets incoming sensory information and sends out instruction based on past experiences

Brain:

* Cerebrum-Largest part of brain:outer layer called cerebral cortex composed of dendrites and cell bodies : controls mental processes: highest level of functioning

* Cerebellum: controls muscle tone coordination and maintains equilibrium

* Diencephalon:Consist of two major structures located between cerebrum and midbrain

* Hypothalamus: regulates the autonomic nervous system: controls blood pressure: hepls maintain normal body temperature and appetite: controls water balance and sleep

* Thalamus: acts as a relay station for incoming and outgoing nerve impulses:produces emotions o pleasantness and unpleasantness associated with sensations

Brainstem:

* Connects the cerebrum with the spinal cord

* Midbrain- relay center for eye and ear reflexes

* Pons- connecting link between cerebellum and rest of nervous system

* Medulla oblongata- contains center for respiration, heart rate, and vasomotor activity

Spinal Cord:

* Inner column composed of gray matter, shaped like a H, made up of dendrites and cell bodies: outer part composed of white matter, made up of bundles of axons called tracts

* Functions: sensory tract conducts impulses to brain motor tract conducts impulses from brain: center for all spinal cord reflexes

Protection for CNS:

* Bone- vertebrae surround cord: skull surrounds the brain

* Meninges: three connective tissue membranes that cover the brain and spinal cord

1. Dura mater: white fibrous tissue: outer layer

2. Arachnoid: delicate membranes: middle layer : contains subarachnoid fluid

3. Pia mater: inner layer contains blood vessels

* Cerebrospinal Fluid: acts as a shock absorber: acts in exchange of nutrients and waste materials

* Peripheral nervous system (PNS): Cranial and spinal nerves extending out from brain and spinal cord---carry impulses to and from brain and spinal cord. Caries voluntary and involuntary impulses

Cranial nerves:

|I olfactory |Nose to brain |Smell |

|II optic |Eye to brain |Vision |

|III oculomotor |Brain to eye and eye muscles |Contraction of upper eyelid |

| | |Maintain position of eyelid |

| | |Pupillary reflexes |

|IV Trochlear |Brain to external eye muscles |Eye movements |

|V trigeminal |From skin & mucous membranes of head & teeth to chewing |Sensations of head & teeth |

| |muscles |Muscles of chewing |

|VI Abducens |From brain to external eye muscles |Eye movements |

|VII Facial |From taste buds & facial muscles to muscles facial |Taste |

| |expression |Facial expressions |

|VIII Acoustic |From organ of corti to brain |Hearing |

|IX Glossopharyngeal |From pharynx & tongue to brain |Sensations of tastes& swallowing |

| |From brain to throat muscles and salivary glands |Secretion of salvia |

|X Vagus |From throat & organs in thoracic & abdominal cavities |Important in swallowing, speaking, peristalsis and|

| | |production of gastric juices |

|XI Accessory |From brain to shoulder and neck muscles |Rotation of head and raising shoulders |

|XII Hypoglossal |From brain to tongue |Movement of tongue |

Spinal nerves: 31 Pairs: conduct impulses necessary for sensation and voluntary movements: each group named for the corresponding part of spinal column

• Autonomic nervous system (ANS): functional classification of the PNS---regulates involuntary activities. Part of PNS: controls smooth muscle, cardiac muscle, and glands

It has two divisions;

1. Sympathetic-flight or fight response: increases heart rate and blood pressure; dilates pupils

2. Parasympathetic : dominates control under normal conditions: maintains homeostasis

* Somatic nervous system (SNS) : Functional classification of the PNS: --allows conscious or voluntary control of skeletal muscles

* Neurons or nerve cells

Respond to a stimulus, connect it into a nerve impulse (irritability), and transmit the impulse to neurons, muscle, or glands (conductivity), consists of three main parts

Neurons main parts

1. Cell body: contains nucleus and one or more fibers or process extending from the cell body

2. Dendrites: conduct impulses toward cell body: neurons has many dendrites

3. Axons: conduct impulses away from cell body: neuron has one axon

Types of neurons

1. Motor (efferent ): conduct impulses from CNS to muscle and glands

2. Sensory (afferent): conduct impulses toward CNS

3. Connecting ( interneuron): Conduct impulses from axon to dendrites

* Synapse-chemical transmission of impulses from axon to dendrites

* Myelin sheath – protects and insulates the axon fibers: increases the rate of transmission of nerve impulses

* Neurilemma– sheath covering the myelin: found in PNS : function is regeneration of nerve fiber

* Neuroglia- connective or supporting tissue—important in reaction of nervous system to injury or infection

* Ganglia-clusters of nerve cells outside CNS

* White Matter-bundles of myelinated nerve fibers – conducts impulses along fibers

* Gray matter- clusters of neuron cell bodies—fibers not covered with myelin –distributes impulses across selected synapses

Neurological Terms:

* Anesthesia- complete loss of sensation

* Aphasia-loss of ability to use language

* Auditory/receptive aphasia- loss of ability to understand

* Expressive aphasia- loss of ability to use spoken or written word

* Ataxia- uncoordinated movements

* Coma- state of profound unconsciousness

* Convulsion- involuntary contractions and relaxation of muscles

* Delirium- mental state characterized by restlessness and disorientation

* Diplopia- double vision

* Dyskeinesia- difficulty in voluntary movement

* Flaccid- without tone- limp

* Neuralgia- intermittent, intense pain, along the course of a nerve

* Neuritis- inflammation of a nerve or nerves

* Nuchal rigidity-stiff neck

* Nystagmus- involuntary, rapid movements of the eyeball

* Papilledema- swelling of optic nerve head

* Paresthesia- abnormal sensation without obvious cause, with numbness and tingling

* Spastic- convulsive muscular contractions

* Stupor- state of impaired consciousness with brief response only to vigorous and repeated stimulation

* Tic-spasmodic, involuntary twitching of a muscle

* Vertigo- dizziness

Transient Ischemic Attacks

TIA

Definition:

Altered cerebral tissue perfusion related to a temporary neurologic disturbance. It is manifested by sudden loss of motor or sensory function. It lasts for a few minutes to a few hours, caused by temporarily diminished blood supply to an area of the brain

Treatment:

Control hypertension

Low sodium diet

Possible anticoagulant therapy

Stop smoking

Cerebro Vascular Accident

(CVA)(Stroke)

Definition:

It is defined as decreased blood supply to a part of the brain, which caused by rupture, occlusion, or stenosis of the blood vessels. Its onset may be sudden or gradual

* Right CVA results in Left side involvement often associated with safety/ judgment

* Left CVA results in Right side involvement often associated with speech problems

* Approximately 50% of survivors permanently disabled

* High proportion experiencing recurrence within weeks to years

* Chances for complete recovery depending an circulation returning to normal soon after the initial stroke

* Third most common cause of neurological disability

Pathophysiology/Etiology:

1. Partial or complete occlusion of a cerebral blood vessel resulting from cerebral thrombosis (due to arteriosclerosis) or embolism.

2. Ischemia related to decreased blood flow to an area of the brain secondary to systemic disease, such as cardiac or metabolic disease.

3. Hemorrhage occurring outside the dura (extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or within the brain substance (intracerebral).

4. Risk factors include hypertension, TIAs, heart disease, elevated cholesterol, diabetes mellitus, obesity, carotid stenosis, polycythemia, cigarette smoking.

Predisposing factors-CVA:

Cigarette smoking

Family history

Incidence increased with aging

Atherosclerosis

Embolism

Thrombosis

Hemorrhage from ruptured cerebral aneurysm

Hypertension

History TIA’s

Hypertension

Arrhythmias

Atherosclerosis

Rheumatic Heart Disease

MI

DM

High serum triglyceride levels

Lack of exercise

Signs and Symptoms:

* Altered LOC

* Change in mental status

* Decreased attention span

* Decreased ability to think and reason

* Difficulty following simple directions

* Communication; motor and sensory aphasia difficulty with reading ,writing, speaking, or understanding

* Bowel and bladder dysfunction retention impaction or incontinence

* Seizures

* Limited motor function; paralysis, dysphgia, weakness , hemiplegia, loss of function or contractures

* Loss of sensation/ perception

* Headaches and syncope

* Loss of temp regulation elevated TPR and BP

* Absent of gag reflex ( aspiration)

* Unusual emotional responses; depression, anxiety, anger, verbal outburst, and crying: emotional lability

* Problems related with immobility

Diagnostic test:

Physical assessment

Pt and family history

EEG

CT scan

Lumbar puncture

Cerebral angiogram

Carotid ultra sonogram

Treatments:

* Remove cause, prevent complications, and maintain function, rehabilitation to restore function

* Medications

* Anti-hypertensive

* Anticoagulants

* Stool softeners

* Surgical removal of clot, repair of aneurysm, carotid endarterectomy or balloon angioplasty

Nursing Interventions:

Patent airway

o O2 with humidity

o Suction PRN

o Keep head turned to side

o Place in semi- fowler’s

Maintain therapeutic bed rest

o Use turn sheet

o Footboard

o Firm mattress

o Pillow and torchanter rolls

o Maintain proper body alignment

o Place items within reach

o Reposition q2h

o ROM passive and active

o Flotation mattress or sheepskin

o Skin assessment

o Prevent complications of immobility

o ADL’s

Assess nutrition daily with I&O, WT, %diet, calorie count

o Provide N/G or PEG feedings if needed

o Maintain IV fluids

o Progress to soft diet PRN

o TPN as ordered

o Aspiration precautions

o Dietary consult & Speech for swallowing

Establish means of communication

o Call bell pad and pencil

o Nonverbal gestures

o Use simple commands

o Speak slowly

o Explain all care

o Speech therapy

o Be nonjudgmental about personality changes

o Encourage family participation

o Provide diversional activities

o Be realistic

Assess LOC

Maintain safety

o Use side rails

o Restrain only as necessary

o Seizure precautions

Observe for ICP

V/S & Neuro CKS q 4 h

Ensure elimination

o Assess bowel sounds

o Monitor bowel movements

o I & O

o Indwelling catheter PRN

o Bowel and bladder training

Family support

Begin discharge teaching early

Rehabilitation therapy

o Physical therapy (see figures).

o Speech therapy

o Occupational therapy

PHYSICAL EXERCISES & RANGE OF MOTION

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