Author:
blearyeyed
ID:
21380
Filename:
Study Guide NUR 275
Updated:
2010-06-06 15:24:16
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Neurological Nursing
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Description:
Neurological Exam Study Guide
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  1. Plan and implement care for a comatose patient.
    • The unconscious patient is in a state of depressed cerebral functioning with unresponsiveness to sensory and motor function.
    • Some causes include head trauma, cerebral toxins, shock, hemorrhage, tumor, and infection.
    • A Glasgow Coma score lower than 8 indicates that a coma is present.

    • Assessment:
    • Unarousable
    • Primitive or no response to painful stimuli.
    • Altered respirations.
    • Decreased cranial nerve and reflex activity.

    • Interventions:
    • Assess patency of airway and keep an airway and emergency equipment at bedside.
    • Monitor blood pressure, pulse and heart sounds.
    • Assess respiratory and circulatory status.
    • Maintain a patent airway and ventilation because a high CO2 level increases intracranial pressure
    • Assess lung sounds for the accumulation of secretions
    • Suction fluids from airway as needed.
    • Assess for neurological status, including LOC, pupillary reactions, and motor and sensory function, using the Glasgow Coma Scale.
    • Place the client in a semi-Fowler's positions.
    • Change posittion of the client every 2 hours, avoiding injury when turning.
    • Avoid the Trendelenburg's position.
    • Use side rails at all times.
    • Assess for edema.
    • Monitor for dehydration.
    • Monitor intake and output and daily weight
    • Maintain NPO status until consciousness returns
    • Maintain nutrition as prescribed, and monitor fluid and electrolyte balance.
    • Check the gag and swallow reflex before resuming a diet, and begin the diet with ice chips and fluids when the client becomes alert.
    • Provide IV or enteral feedings as prescribed.
    • Assess bowel sounds.
    • Monitor elimination patterns.
    • Monitor for constipation, impaction, and paralytic ileus.
    • Maintain urinary output to prevent stasis, infection, and calculus formation.
    • Monitor skin integrity.
    • Initiate measures to prevent skin breakdown.
    • Provide frequent mouth care.
    • Remove dentures and contact lenses.
    • Assess the eyes for presence of corneal reflex and irritation, and instill artificial tears or cover the eyes with eye patches.
    • Monitor drainage from the ears or nose for the presence of CSF
    • Assume that the unconscious client can hear.
    • Avoid restraints.
    • Do not leave the unattended if unstable.
    • Initiate seizure precautions if necessary.
    • Provide ROM excercises to prevent contractures.
    • Use a footboard or high-topped sneakers to prevent footdrop.
    • Use splint to prevent wrist deformities
    • Initiate physical therapy as appropriate.
  2. Identify a surgically implanted device to the dorsal aspect of the spinal cord that relieves chronic pain.
    Baclofen pump

    • Baclofen (Lioresal)
    • Causes CNS effects such as drowsiness, dizziness, weakness, and fatigue and nausea, constipation and urinary retention.
    • Administer with caution in the client with renal or hepatic dysfunction or a seizure disorder
    • Baclofen can be administered by the physician through intrathecal infusion using an implantable pump or direct intrathecal administration over 1 minute.
    • Instruct the client with an implantable pump to maintian medication refill appointments to prevent pump from emptying and experiencing sudden withdrawal symptoms (which could be life-threatening)
    • The pump is screened with a test dose by lumbar puncture. (If it produces a positive effect, client is a good candidate for implant)
    • Pump is the size of a hockey puck and placed in the subcutaneous space of the abdomen with a catheter tunneled to the lumbar area.
    • Patient is usually hospitalized for 3-5 days to adjust pump dosage and heal. Outpatient refills of the pump are usually every 4 to 6 weeks.
  3. Define epilepsy
    • Epilepsy is a disorder characterized by chronic seizure activity and indicates brain or CNS irritation.
    • Causes include genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity, and infections.
    • May result from congenital or acquired brain disease. Infants born with lipid storage diseases, tuberous sclerosis, or cortical dysplasia may have recurrent seizures.
    • Children born with intracranial hemorrhage or anoxic brain injury may have recurrent seizures as well.
    • Found in about 2 to 3% of the population. Incidence highest in children (under 10 years old) and in older people (over 70).

    • Symptoms:
    • Vary from almost imperceptible alteration in consciousness, as in absence seizures, to dramatic loss of consciousness, tonic-clonic convulsions of all extremities, urinary and fecal incontinence, and amnesia for the event.
    • Some attacks are preceded by an aura; others provide no warning.
    • Other forms are limited to muscular contractions of a localized area or only one side of the body.

    • Diagnosis:
    • Careful assessment of patient's history, augmented by diagnostic studies.
    • Typically includes bloods tests to assess for metabolic disarray, brain imaging usign MRI or CT and electroenecephalography.
    • Treatment:
    • Prevention and control of recurrent seizures.
    • Antiepileptic agents often include phenytoin or carbamazepine for partial seizures, valproic acid for absence seizures, and any of these agents or phenobarbital, with or without newer drugs, such as gabapentin or lamotrigine, for generalized seizures.
    • All of these agents may have siginificant side effects, and have a range of drug-drug interactions.
    • Surgical therapy to remove an epileptic focus within the brain is used occasionally to manage seizures difficult to control medically.
    • Surgery may cure or reduce impact of epilepsy in about 75% of patients.
  4. Teach a group of expectant parents how to prevent Reye's Syndrome
    • Reye's Syndrome
    • An acute encephalopathy that follows a viral illness and characterized pathologically by cerebral edema and fatty changes in the liver.
    • The exact cause is not clear.
    • Administration of aspirin is NOT RECOMMENDED for children with varicella or influenca because of its association with Reye's Syndrome.
    • Acetaminophen (Tylenol) is considered the medication of choice for pediatric clients.
    • The goal of treatment is to maintain effective cerebral perfusion and control increasing ICP.

    • Assessment:
    • History of systemic viral illness 4 to 7 days before the onset of symptoms
    • Malaise
    • Nausea and vomiting
    • Progressive neurological deterioration

    • Interventions:
    • Assess neurological status
    • Monitor for altered LOC and signs of increased ICP
    • Monitor intake and output
    • Provide rest and decrease stimulation in the environment
    • Monitor for signs of bleeding and signs of impaired coagulation, such as prolonged bleeding time
    • Monitor liver function studies
  5. Plan care for a client who is suspected of having bacterial meningitis.
    • Meningitis
    • An infectious process of the CNS caused by bacteria and viruses that my be acquired as a primary disease, or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections.
    • Diagnosis is made by testin CSF obtained by lumbar puncture: the fluid is cloudy with increased pressure, increased WBC count and elevated protein and decreased glucose levels.
    • Bacterial meningitis (Haemophilus influenza type B, Streptococcus pneumoniae, or Neisseria meningititidis) occurs in epidemic form and can be transmitted by droplets from nasopharyngeal secretions.
    • Viral meningitis is associated with viruses such as mumps, paramyxovirus, herpesvirus, and enterovirus.

    • Assesment (children)
    • Signs and symptoms vary, depending on the type, age of the child, and the duration of the preceding illness.
    • Fever, chills, headache
    • Vomiting, diarrhea
    • Poor feeding or anorexia
    • Nuchal rigidity
    • Poor or high-pitched cry
    • Altered LOC, such as lethargy or irritability
    • Bulging anterior fontanel in infant
    • Postive Kernig sign = inability to extend the leg when the thigh is flexed anteriorly at the hip (pain)
    • Positive Brudzinki sign = neck flexion causes adduction and flexion movements of the lower extremities
    • Muscle or joint pain
    • Petechial or purpuric rashes (meningococcal infection)

    • Interventions
    • Provide isolation and maintain it for at least 24 hours after antibiotics are initiated
    • Administer antibiotics and antipyretics as prescribed
    • Perform neurological assessment and monitor for seizures; assess for the complication of SIADH causin fluid retention (cerebral edema) and dilutional hyponatremia
    • Assess for changes in LOC and irritability
    • Monitor intake and output
    • Assess nutritional status
    • Determine close contacts of the child with meningitis because the contacts will need prophylactic treatment
    • Meningococcal vaccine is recommended to protect against meningitis.
  6. Describe concussion.
    • Concussion
    • A jarring of the brain within the skull, with temporary loss of consciousness.
    • Defined as transient, temporary, neurogenic dysfunction caused by mechanical force to the brain.
    • Cerebral concussions are the most common form of head injury.
    • Classified as mild or classic, based on degree of symptoms, particularly those of unconsciousness and memory loss
    • Mild concussion is a temporary neurological dysfunction without loss of consciousness or memory.
    • Classic concussion inclused temporary neurological dysfunction with unconsciousness and memory loss.
    • Recovery from concussion usually takes minutes to hours.
    • Most concussion patients recovery fully within 48 hours, but subtle residual impairment may occur.

    • Interventions:
    • Cerebral perfusion promotion
    • Environmental management
    • Surveillance
    • Cerebral edema management
    • Family support
    • Medication management

    • Collaborative Management
    • Generally examined in the ER and discharged home.
    • Family memebr is instructed to evaluate patient routinely and bring pt back to hospital if any further neurological symptoms appear
    • Patients are often told to wake a child every hour for 24 hours to make sure that the patient does not have neurological signs and symptoms.
    • Treatment generally consists of bed rest with the HOB elevated at least 30 degrees, observation, and pain relief.
  7. Prepare a child for a CT scan.
    • For older kids:
    • Explain what the contrast material does
    • Remind them to lie still
    • Show picture of the machine
    • Explain that it is not painful
    • May use chin or cheek pads to prevent head movement, and straps to prevent body position changes
    • Tell children that they are like an astronaut
    • May have to sedate children with oral chloral hydrate
    • Use EMLA for local anesthetic before IV insertion
    • Prevent aspiration
    • Assess LOC and vital signs
    • Assess pupillary responses and motor movement frequently
  8. Identify normal reflexes in a 2 month old
    • Newborn to 2 months have primitive reflexes:
    • Babinski reflex -- toes fan outward when sole of foot is stroked (abnormal after 1 year)
    • Moro reflex (startle reflex) -- extends arms then bends and pulls them in toward body, accompanied by a brief cry, often triggered by loud
    • sounds or sudden movements
    • Palmar hand grasp -- infant closes hand and "grips" your finger
    • Placing -- leg extends when sole of foot is stimulated
    • Plantar grasp -- infant flexes the toes and forefoot
    • Rooting and sucking -- turns head in search of nipple when cheek is touched and begins to suck when nipple touches lips
    • Stepping and walking -- takes brisk steps when both feet placed on a surface, with body supported
    • Tonic neck response -- left arm extends when infant gazes to the left, while right arm and leg flex inward, and vice versa
  9. Plan and implement care for a child with increased intracranial pressure.
    Identify signs and symptoms that indicate need for immediate attention.
    Assessment

    • Early signs:
    • Headache
    • Visual disturbances, diplopia
    • Nausea and vomiting
    • Dizziness or vertigo
    • Slight change in vital signs
    • Change in pupillary response and equality
    • Sunsetting eyes: sclera visible above the iris
    • Slight change in LOC
    • Infant: bulging fontanel, wide sutures, increased head circumference, dilate scalp veins, high-pitched cry
    • Child: headache, nausea, vomiting, ataxia, nystagmus

    • Late signs:
    • Significant decrease in LOC
    • Bradycardia
    • Decorticate posturing: adduction of the arms at the shoulders; arms are flexed on the chest with the wrists flexed and the hands fisted, and the lower exremities are extended and adducted; seen with severe dysfunction of the cerebral cortex.
    • Decerebrate posturing: Rigid extension and pronation of the arms and legs; a sign of dysfunction at the level of the midbrain.
    • Fixed dilated pupils.


    • Interventions:
    • Monitor the airway
    • Assess injuries; immobilize the neck if a cervical injury is suspected
    • Monitor vital signs and neurological function
    • Monitor for decreased responsiveness to pain (a significant sign of altered LOC)
    • Initiate seizure precautions
    • Maintain an NPO status or provide clear liquids, if prescribed, until it is determined that vomiting will not occur
    • Administer oxygen and IV fluids as prescribed
    • Monitor IV fluids carefully to avoid aggravating any cerebral edema and to minimize the possibility of overhydration
    • Elevate the HOB 15 to 30 degrees, if not contraindicated, to facilitate venous drainage
    • Position the client so that the head is maintained at midline to avoid jugular vein compression, which can increase ICP
    • Assess wound dressings for the presence of drainage and monitor for nose or ear drainage, which could indicate leakage of CSF; drainage that is positive for glucose (as tested with regent strips) indicates leakage of CSF from a skull fracture.
    • Administer tepid sponge baths or place a hypothermia blanket if hyperthermia occurs
    • Avoid suctioning throught he nares because of the possibility of the catheter entering the brain through a fracture and placing the child at high risk for secondary infection
    • As prescribed, administer Tylenol for headache, anticovulsants for seizures, antibiotics if a laceration is present, and osmotic diuretic (Mannitol) to reduce cerebral edema, and tetanus toxoid as appropriate
    • Withhold sedating medications during the acute phase of the injury so that changes in levels of consciousness can be assessed
    • Monitor for signs of brainstem involvement (deep, rapid, or intermittent and gasping respirations; wide fluctuations or noticeable slowing of the pulse; widening pulse pressure or extreme fluctuations in BP)
    • Monitor for signs of epidural hematoma: asymmetrical pupils, one dilated, nonreactive pupil. This can be a neurosurgical emergency that require evacuation of the hematoma.
    • Keep stimuli to minimum; attempt to minimize crying in infant

    • Cushing Response/Reflex:
    • A reflex due to cerebral ischemia that causes an increase in systemic blood pressure. This maintains cerebral perfusion during increased intracranial pressure:

    • Cushing's triad:
    • Bradycardia with full bounding pulse
    • Increasing systolic blood pressure (widening pulse pressure)
    • Irregular respiratory patterns
  10. Identify causes for a revision of a shunt (ventriculoperitoneal/atrioventricular shunt in the treatment of hydrocephalus)
    • Malfunction
    • Growth
    • Continued infection
    • Accidental damage to shunt

    • Ventriculopertioneal Shunt = the CSF drains into the peritoneal cavity from the lasteral ventricle.
    • Atrioventricular Shunt = CSF drains into the right atrium of the heart from the lateral ventricle, bypassing the obstruction (used in older children and in children with pathological conditions of the abdomen.
  11. Plan and implement post operative nursing care for an infant with hydrocephalus who has had a ventriculoperitoneal shunt placed, include family teaching.
    • Hydrocephalus
    • An imbalance of CSF absorption or production caused by malformations, tumors, hemorrhage, infections, or trauma
    • Results in head enlargement and increased ICP
    • Two types:
    • Communicating: occurs as a result of impaired absorption within the subarachnoid space. Interference of the CSF in teh ventricular system does not occur.
    • Noncommunicating: obstruction of cerebrospinal blood flow in the ventericular system does occur.



    Assessment

    • Infant:
    • Increased head circumference
    • Thin, widely separated bones of the head that produce a cracked pot sounds ( Macewen's sign) on percussion.
    • Anterior fontanel tense, bulging, and nonpulsating
    • Dilated scalp veins
    • Frontal bossing
    • Sunsetting eyes

    • Child:
    • Behavior changes, such as irritability and lethargy
    • Headache on awakening
    • Nausea and vomiting
    • Ataxia
    • Nystagmus

    • Late signs:
    • High, shrill cry and seizures


    • Surgical Interventions:
    • Goal: to prevent further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where it is reabsorbed.
    • In a ventriculoperitoneal shunt, the CSF drains into the peritoneal cavity from the lateral ventricle.

    • Pre-operative interventions:
    • Monitor intake and output
    • Give small frequent feedings as tolerated until a preoperative NPO status is prescribed
    • Reposition head frequently and use an egg crate mattress under the head to prevent pressure sores
    • Prepare child and family for diagnostic procedures and surgery

    • Post-operative care & teaching:
    • Monitor vital signs and neurological signs
    • Position child on the unoperated side to prevent pressure on the shunt valve
    • Keep the child as flat as prescribed to avoid reapid reduction of intracranial fluid.
    • Observe for increased ICP; if increased ICP occurs, elevate the head of bed to 15 to 30 degrees to enhance gravity flow through the shunt.
    • Monitor for signs of infection and assess dressing for drainage
    • Measure head circumference
    • Monitor intake and output
    • Provide comfort measures; administer medications as prescribed, which may include diuretics, antibiotics or anticonvulsants
    • Instruct the parents on how to recognize shunt infection of malfunction
    • In an infant, irritability, lethargy, and feeding poorly may indicate shunt infection or malfunction
    • In a toddler, headache and lack of appetite are the earliest common signs of shunt malfunction
    • In older children: the most valuable indicator of shunt malfunction is an alteration in LOC
  12. Differentiate assessment findings for increased intracranial pressure between infant and child
    • Infant:
    • Increased head circumference
    • Thin, widely separated bones of head that produce a cracked pot sound (Macewen's sign) on percussion)
    • Anterior fontanel tense, bulging, and nonpulsating
    • Dilated scalp veins
    • Frontal bossing
    • Sunsetting eyes

    • Child:
    • Behavior changes such as irritability and lethargy
    • Headache on awakening
    • Nausea and vomiting (may be projectile)
    • Ataxia
    • Nystagmus

    • Late signs:
    • High, shrill cry and seizures
  13. Teach the family with a child with myelomeningocele what chronic health problems to anticipate.
    • Myelomeningocele
    • A protrusion of the meninges, CSF, nerve roots, and a portioni of the spinal cord.
    • The sac is covered by a thin membane prone to leakage or rupture.
    • Neurological defects are evident.
    • Results from failure of neural tube to close during embryoning development (about 28 days after conception)
    • Prevention: Folic acid supplementation recommended for all women of childbearing age. It reduces the risk but does not completely eliminate the risk of severe neural tube defects like myelomeningocele.

    • Assessment:
    • Visible spinal defect
    • Flaccid paralysis of the legs
    • Altered bladder and bowel function (urinary incontinence/neurogenic bladder)
    • Hip and joint deformities
    • Hydrocephalus

    • Patient care
    • When diagnosed prenatally: parents should be referred for genetic counseling.
    • After birth, the defect is cleansed gently, and foam or sheepskin support provided to prevent pressure, skin breakdown, and infection
    • Parental bonding is encouraged
    • Infant should be prone positioned when held on one's lap
    • Fluid balance is monitored and adequate nutrition provided
    • Passive ROM exercises help minimize contractures
    • Surgical repair of the defect is followed by careful monitoring for hydrocephalus, infection, shock and increased ICP (bulging fontanels are the most common indicator in infants)
    • The wound is inspected and redressed according to protocol.
    • Leg casts may be needed to treat hip and knee deformities
    • Close assessments of the child's growth and development and ongoing physical and occupational therapy will be needed throughout the child's life, along with psychological support for the child and the parents
    • Mental stimulation helps ensure maximal development
    • Bladder and bowel training are taught, with management dependent on the severity of the deficit
    • Social services may be able to assist parents with financial needs
    • Counseling and careful follow-up care are needed to optimize outcomes
    • Parents may acquire additional support from the Spina Bifida Association of America (800-621-3141)

    • Patient teaching about long-term home care:
    • Positioning, feeding, skin care, and ROM exercises
    • Performing clean intermittent catheterization technique
    • Administering prophantheline (Pro-Banthine) as prescribed to improve continence
    • Implement a bowel program including a high fiber diet, increased fluids, suppositories as needed.
    • The child is at high risk for latex allergy.
  14. Teach patient about the detection and treatment of spina bifida
    • Spina Bifida
    • A CNS defect resulting from the failure of the neural tube to close during embryoning development.
    • Associated deficits may include sensorimotor disturbance, dislocated hips, talipes equinovarus (clubfoot), and hydrocephalus
    • Defect closure is done immediately after birth
    • Patient is usually transferred to a specialized facility and have early surgical interventions such as closure of the myelomeningocele sac
    • It is the most common defect of the CNS


    Types

    • Spina bifida occulta:
    • Posterior vertebral arches fail to close in the lumbosacral area
    • Spinal cord remains intacts and usually is not visible
    • Meninges are not exposed on the skin surface
    • Neurological deficits are not usually present

    • Spina bifida cystica
    • Protrusion of the spinal cord and/or its meninges
    • Defect results in incomplete closure of the vertebral and neural tubes, resulting in a sac-like protrusion in the lumbar or sacral area, with varying degrees of nevous tissue involvement
    • Defect can include meningocele, myelomeningocele, lipomeningocele, and lipomeningomyelocele

    • Meningocele
    • Protrusion involves meninges and a sac-like cyst that contains CSF in the midline of the back, usually in the lumbosacral area
    • Spinal cord is not involved
    • Neurological deficits are usually not present

    • Myelomeningocele
    • Protrusion of the meninges, CSF, nerve roots, and a portion of the spinal cord
    • The sac is covered by a thin membrane rpone to leakage or rupture
    • Neurological deficits are evident



    • Detection:
    • Maternal serum alpha feto-protein (AFP) screening is a blood test used to help detect neural tube defects.
    • Couples can choose whether or not they want a serum AFP screening performed.
    • The test is usuallycarried out between 16 and 18 weeks of pregnancy, but can be performed up to 20 weeks.
    • If the result is normal, much of the probability that the fetus has a neural tube defect will have beenremoved.
    • The serum AFP value is raised in 70-85% of fetuses with spina bifida.
    • If the result is high you will be asked to come back for further tests:
    • First, a detailed ultrasound examination will be performed to check the stage of pregnancy, to look for twins and to see whether the fetus has spina bifida or not.
    • Then, if no cause for the raised alpha-feto protein is found amniocentesis may be recommended to clarify the situation.
    • Chorionic Villus Sampling (CVS) CANNOT detect neural tube defects such as spina bifida. It can only detect genetic disorders such as sickle cell, Down Syndrome, sex chromosome abnormalities.


    • Nursing Interventions
    • Evaluate sac and measure the lesion
    • Perform neurological assessment
    • Monitor for increased ICP, which might indicate developing hydrocephalus
    • Measure head circumference, assess the anterior fontanel for fullness
    • Protect sac; cover with streile, moist (normal saline), nonadherent dressing to maintain the moisture of the sac and contents.
    • Change the dressing every 2 to 4 hours are prescribed
    • Place in a prone position to minimize tension on the sac and the risk for trauma; the head is turned to one side for feeding
    • Change the dressin covering the sac whenever it becomes soiled because of the risk of infection
    • Diapering may be contraindicated until the defect is repaired
    • Use aseptic technique to prevent infection
    • Early signs of infection include elevated temperature, irritability, lethargy and nuchal rigidity
    • Assess for physical impairments such as hip and joint deformities
    • Prepare the child and family for surgery
    • Administer antibiotics preoperatively, as prescribed, to prevent infection

    • Teach the parents and eventually the child about long-term home care:
    • Positioning, feeding, skin care, and ROM exercises
    • Performing clean intermittent catheterization
    • Pro-Banthine (prophantheline) as prescribed to improve continence
    • High-fiber diet, increased fluids, and suppositories as needed
    • The child is at high risk for latex allergy
  15. Describe Duchenne Muscular Dystrophy
    • The most severe and most common MD of childhood
    • It is inherited, X-linked recessive trait, and the single-gene defect is located on the short arm of the X chromosome.
    • Genetic counseling is an important aspect of the care of the family.
    • Males are affected almost exclusively
    • Result from mutations of the gene that encodes dystrophin, a protein product in skeletal muscle
    • Dystrophin is absent from the muscle of children with DMD
    • Most children with DMD reach appropriate developmental milestones early in life, although they may have mild, subtle delays.
    • Evidence of muscle weakness usually appears during the third to seventh year, although there may have been a history of delay in motor development, particularly walking
    • Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted
    • Later, abnormal gait on a level surface become apparent
    • Child may have difficulty rising from a sitting or supine position
    • Affected boys have a waddling gait and lordosis, fall frequently, and develop a characterisitc manner of rising from a squatting position or sitting position on the floor (Gower sign)
    • Parents may also notice the child has enlarged calves
    • Ultimately the disease process involves the diaphragm and auxiliary muscles of respiration, and cardiovascular involvement (cardiomyopathy, dysrhythmias, and heart failure)
    • Mild mental delay is common in roughly 30% of all individuals with MD; many will have permanent learning disabilities
    • Children with DMD should be transitioned into early learning programs and eventually into regular classrooms as much as possible
    • The eventual cause of death is usually respiratory tract infection or cardiac failure; however, much progress has been made in providing ventilation methods to prolong quality of life


    • Diagnosis
    • Primarily established by blood polymerase chain reaction (PCR) for the dystrophin gene mutation.
    • Prenatal diagnosis is also possible as early as 12 weeks gestation
    • Serum enzyme measurement, muscle biopsy and EMG
    • Serum creatinine kinase levels are extremely high in the first 2 years of life, before the onset of clinical weakness

    • Therapeutic Management
    • No effective treatment exists for childhood MD
    • The use of corticosteroids prednisone and deflazacort has been evaluated as a treatment for DMD
    • Some clinical trials showed increased muscle strength and improved performance and pulmonary function when prednisone awas administered for 6 months
    • Children with DMD who remain as active as possible are able to avoid wheelchair confinement for a longer period of time
    • Maintenance of function often involves stretching exercises, strength and muscle training, breathing exercises to increase and maitain vital lung capacity, ROM exercises, surgery to release contracture deformities, bracing, and performance of ADLs
    • Because respiratory tract infections are most troublesome in these children, influenza and pneumococcal vacciens are encouraged and contact with persons with respiratory infections should be avoided
    • Eventually respiratory and cardiac problems become the central focus of the illness (long-term ventilation, tracheostomies may be necessary)
    • Cardiac and respiratory assessment during wake-sleep cycles is imperative
    • Genetic counselling is recommended for parents
  16. Discuss the causes of Cerebral Palsy
    • Cerebral Palsy
    • An "umbrella" term for a group of nonprogressive but often changin motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development.
    • A symptom complex rather than a specific disease.
    • CP rarely occurs without associated defects such as mental retardation (60% of cases) or epilepsy (50% of cases)
    • Disorder characterized by impaired movement and posture resulting form an abnormality in the extrapyramidal or pyramidal motor system
    • The most comon clinical type is spastic cerebral palsy, which represents upper motor neuron-type of muscle weakness
    • Less common types of cerebral palsy are athetoid, ataxic, and mixed

    • Causes:
    • Most often from existing prenatal abnormalities; however the exact cause of these abnormalities remain elusive
    • As many as 80% of CP are caused by unknown prenatal factors
    • Intrauterine exposure to maternal chorioamionitis is associated with an increased risk in CP in infants of normal birth weight and preterm infants. However, not all infants exposed to chorioamnionitis develop CP
    • The prevalence of CP in infants born before 36 weeks gestation and weighing less than 2000 g (4.4 lbs) has been reported to be 12%
    • The strongest independent risk factor for CP was periventricular leukomalacia
    • Damage occurring as a result of shaken bab syndrome may also result in CP in survivors
    • Additional factors that may contribute to CP postnatally include bacterial meningitis, viral encephalitis, motor vehicle accidents, and child abuse
    • A significant percentage (15-60%) of children with CP will also have epilepsy

    • Risk Factors are divided into three groups:
    • 1.) Those occurring prior to pregnancy, such as an unusually short interval (< 3 months) or unusually long interval since the previous pregnancy
    • 2.) Those occurring during pregnancy: physical malformation, twin gestation, abnormal fetal presentation, fetal growth retardation, or maternal hypothyroidism
    • 3.) Perinatal facotrs such as prematurity, premature separation of the placenta, newborn encephalopathy
    • **Nonetheless, among infants with one or more of tehse risk factors, 95% do not have CP

    • Assessment:
    • Extreme irritability and crying
    • Feeding difficulties
    • Stiff and rigid arms or legs
    • Delayed developmental milestones
    • Abnormal motor performance
    • Alterations of muscle tone
    • Abnormal posturing such as opisthotonos (exaggerated archin of the back)
    • Persistence of primitive infantile reflexes (Moro, tonic neck) after 6 months
    • Seizures

    • Interventions
    • Goal: early recognition and maximizing child's abilities
    • Therapeutic management includes physical therapy, occupational therapy, speech therapy, education and recreation
    • Assess the child's developmental level and intelligence
    • Encourage early intervention and participation in school programs
    • Prepare for using mobilizing devices to help prevent or reduce deformities
    • Encourage communication and interaction with child on his or her developmental level rather than chronological age level
    • Provide a safe environment (remove sharp objects, use a protective helmet if the child falls frequently, seizure precautions)
    • Position the child upright after meals
    • Administer medications as prescribed to decrease spasticity
    • Surgical interventions are reserved for the child who does not respond to more conservative measures or for the child whose spasticity causes progressive deformity
    • Intrathecal baclofen (Lioresal) may be used to provide relief of spasticity
  17. Explain the causes of autonomic dysreflexia, which patients are vulnerable, and nursing management
    • Autonomic Dysreflexia
    • Also known as autonomic hyperreflexia
    • Generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions
    • It is commonly caused by visceral distention from a distended bladder or impacted rectum
    • It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke.
    • A life threatening uninhibited sympathetic response of the nervous system to a noxious (harmful) stimulus (usually a distended bladder or bowel). Other triggers are a hot or cold stimulus (sitting in a drafty hall), skin pressure (e.g. tight clothing or staying in one position too long), pressure ulcers, ingrown toenail, or bowel and bladder stimulation durin bowel and bladder training regimens.

    • Assessment:
    • Sudden onset, severe, throbbing headache
    • Severe hypertension
    • Flushing above the level of the lesion
    • Pale extremities below the level of the lesion
    • Nasal stuffiness
    • Nausea
    • Dilated pupils or blurred vision
    • Sweating
    • Piloerection (goosebumps)
    • Restlessness and a feeling of apprehension

    • Interventions:
    • Notify physician if signs of autonomic dysreflexia occur
    • Assess for potential cause and remove the stimulus
    • Raise the HOB to a high Fowler's position
    • Loosen tight clothing
    • Monitor vital signs, particularly blood pressure, every 15 minutes
    • Assess for bladder distention and prepare urinary catheterization
    • If a urinary catheter is present, check for kinks in the tubing and for drainage
    • Assess for fecal impaction and disimpact immediately
    • Assess environment to ensure it is not too cool or too drafty
    • Administer antihypertensives as prescribed


    • FIRST LINE AND INITIAL TREATMENT FOR AUTONOMIC DYSREFLEXIA
    • Identify and remove noxious stimulus
    • Elevate HOB
    • Administer antihypertensives
    • Administer nitroglycerine ointment
    • Administer nifedipine
    • Administer hydralazine IV
  18. Plan and implement nursing care for a spinal cord injury during the acute and sub acute phases of injury.
    • Spinal Cord Injury
    • Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons
    • Injury can involve a contusion, a laceration or compression of the cord
    • Loss of motor function, sensation, reflex activity, bowel and bladder control may result
    • The most common causes include motor vehicle accidents, falls, sporting and industrial accidents, and gunshot or stab wounds
    • Complications related to the injury include respiratory failure, autonomic dysreflexia, spinal shock, further cord damage, and death.

    • Cervical Injuries
    • Injury at C2 to C3 is usually fatal
    • C4 is the major innervation to the diaphragm by the phrenic nerve
    • Involvement above C4 causes respiratory difficulty and paralysis of all four extremities
    • Client may be have movement in the shoulder if the injury is at C5 or below

    • Thoracic Level Injuries
    • Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury
    • Leg paralysis (paraplegia) may occur
    • Autonomic Dysreflexia with lesions or injuries above T6 and in cervical lesions may occur
    • Visceral distention from a distended bladder or impacted rectum may cause reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and goose flesh

    • Lumbar and sacral level injuries
    • Loss of movement and sensation of the lower extremities
    • S2 and S3 center on micturition; therefore, below this level, the bladder will contract but not empty (neurogenic bladder)
    • Injury above S2 in males allows them to have an erection but they are unable to ejaculate because of sympathetic nerve damage
    • Injury between S2 and S4 damages the sympathetic and parasympathetic response, preventing erection or ejaculation

    • EMERGENCY INTERVENTIONS
    • Emergency management is critical because improper movement can cause further damage and loss of neurological function
    • Assess the respiratory pattern and maintain a patent airway
    • Always suspect a spinal cord injury until ruled out
    • Immobilize the client on a spinal backboard with the head in a neutral position to prevent an incomplete injury from becoming complete
    • Prevent head flexion, rotation or extension
    • During immobilization, maintain traction and alignment on the head by placing the hands on both side of the head by the ears
    • Maintain an extended position
    • Logroll the client
    • No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position
    • In the ER, the client who has sustained a severe cervical injury should be placed immediately in skeletal traction via skull tongs or halo traction to immobilize the cervical spine and reduce the fracture and dislocation


    Interventions during hospitalization

    • Respiratory Sytem
    • Assess respiratory status because paralysis of the intercostal and abdominal muscles occurs with C4 injuries
    • Monitor ABGs and maintain mechanical ventilation if prescribed to prevent respiratory arrest, especially with cervical injuries
    • Encourage deep breathing and use of incentive spirometer
    • Monitor for signs of infection, particularly pneumonia

    • Cardiovascular System
    • Monitor for cardiac dysrhthmias
    • Assess for signs of hemorrhage or bleeding around the fracture site
    • Assess for signs of shock such as hypotension, tachycardia, and a weak and thready pulse
    • Assess the lower extremities for deep vein thrombosis
    • Apply thigh-high antiembolism stockings as prescribed
    • Measure calf and thigh circumference to identify increases in size
    • Remove antiembolism stockings daily to assess the skin
    • Monitor for orthostatic hypotension when repositioning the client

    • Neuromuscular System
    • Assess neurological status
    • Assess motor and sensory status to determine level of injury
    • Assess motor ability by testing the client's ability to squeeze hands, spread the fingers, move the toes, and turn the feet
    • Assess absence of sensation, hyposensation, or hypersensation by pinching the skin or pricking it with a pin, starting at the shoulders and working down the extremities
    • Monitor for signs of autonomic dysreflexia and spinal shock
    • Immobilize the client to promote healing and prevent further injury
    • Assess pain
    • Initiate measures to reduce pain
    • Administer analgesics as prescribed
    • Monitor for complications of immobility
    • Prepare the client for decompression laminectomy, spinal fusion, or insertion of instrumentation or rods if prescribed
    • Collaborate with the physical therapist to determine appropriate exercise techniques, assess the need for hand and wrist splints, and develop an appropriate plan to prevent foot drop

    • Gastrointestinal Sytem
    • Assess abdomen for distention and hemorrhage
    • Monitor bowel sounds and assess for paralytic ileus
    • Prevent bowel retention
    • Initiate a bowel control program as appropriate
    • Maintian adequate nutrition and a high-fiber diet


    • Renal System
    • Prevent urinary retention
    • Initiate a bladder control program as appropriate
    • Maintain fluid and electrolyte balance
    • Maintain adequate fluid intake of 2000 ml/day
    • Monitor for urinary tract infection and calculi

    • Integumentary System
    • Assess skin integrity
    • Turn the client every 2 hours

    • Psychosocial Integrity
    • Assess psychosocial status
    • Encourage client to express feelings of anger and depression
    • Discuss the sexual concerns of the client
    • Promote self-care, setting realistic goals based on the client's functional level
    • Encourage contact with appropriate community resources
  19. Care for client in the ER with a spinal cord injury
    • EMERGENCY INTERVENTIONS
    • Emergency management is critical because improper movement can cause further damage and loss of neurological function
    • Assess the respiratory pattern and maintain a patent airway
    • Always suspect a spinal cord injury until ruled out
    • Immobilize the client on a spinal backboard with the head in a neutral position to prevent an incomplete injury from becoming complete
    • Prevent head flexion, rotation or extension
    • During immobilization, maintain traction and alignment on the head by placing the hands on both side of the head by the ears
    • Maintain an extended position
    • Logroll the client
    • No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position
    • In the ER, the client who has sustained a severe cervical injury should be placed immediately in skeletal traction via skull tongs or
    • halo traction to immobilize the cervical spine and reduce the fracture and dislocation

    • First line and initial treatment for SCI:
    • Immobilize patient
    • Monitor ABCs (airway, breathing, circulation)

    • Medication therapy:
    • Atropine to treat bradycardia
    • Dopamine (Intropin) to treat hypotension
    • methyprednisolone (Solu-Medrol) given as a bolus dose of 30 mg/kg over 15 minutes followed by a 5.4 mg/kg per hour for the next 23 hours if diagnosis is made in less the 3 hours. If the period of tiem from the SCI to treatement is between 3 hours and less than 8 hours, the initial bolus of Solu-Medrol is given and a continuous drip of 5.4 mg/kg/hr is given over 48 hours. -- This is used to decrease cord swelling, inflammation, glutamate release, and free radical accumulation, thereby limiting spinal cord injury
    • Crystalloid and colloid fluid replacement is used to maintain normal BP, along with vasopressors
    • Plasma expanders such as dextran increase capillary blood flow within the spinal cord
    • Hyperbaric oxygenation is used in some facilities after 12 to 24 hours of injury. It supplies 100% O2 in a pressurized chamber, which allows the blood to carry more O2 and is though to improve O2 perfusion to the spinal cord, thus decreasing ischemic injury
  20. Describe the complications fo SCI and nursing management
    Nursing Management to prevent complications:

    • If the patient is in a halo fixation device with jacket, four pins are inserted into the skull with the fixation device adn then the jacket is applied, which stabilizes the halo from the chest.
    • To maintain cervical stability:
    • assess skin and jacket to make sure no pressure areas are present.
    • One should be able to insert one finger easily under the jacket
    • Assess pins for a secure tight fit, administer pin care
    • Assess for signs and symptoms of pin infection
    • Ensure that a "key" or Allen wrench is taped to the outer chest of the jacket for easy removal in the event of a cardiac arrest

    • If the patient is immobilized by Gardner-Wells tongs (skull tongs), which consists of two tongs inserted in the outer aspect of the skull with traction added, nursing care is focused on the traction of this device and infection control:
    • Ensure that the prescribed weights are on the device and are hanging freely at all times
    • Make sure the patient is in proper alignment and that the ropes remain in the pulley device
    • Assess neurological signs at least every 4 hours or more frequently as prescribed
    • Inspect pins for signs and symptoms of infection, and administer pin care with 1/2 hydrogen peroxide and 1/2 NS solution every shift (or as the hospital policy dictates)

    • Patient is at increased risk for hypoventilation, pneumonia, and pulmonary embolism.
    • To prevent problems of immobility:
    • Perform respiratory assessment and breath sounds assessment every 2 hours or as prescribed
    • Suction as necessary to keep airway clear using aseptic technique
    • Provide chest physiotherapy per unit protocol
    • Monitor sputum cultures, PT, PTT, INR
    • Ensure adequate hydration to help liquefy secretions
    • Apply antiembolic stockins, SCDs or both
    • Get the patient out of bed three to fou tiems a day when the spinal cord is stabilized
    • Encourage deep breathing and use of incentive spirometry eveyr hour while the patient is awake (coughing may increase spinal cord pressure)
    • Measure vital capacity and tidal volumes, and monitor pulse oximetry and arterial blood gases

    • If patient had a surgical intervention to immobilize portion of the spinal cord with bone plugs or wires and rods, the nurse shoudl initiate the following post-operative measures:
    • Empty Jackson Pratt (JP) drains and record drainage at least every shift
    • Assess neurological signs (motor and sensory) based on the level of the SCI to detect changes from baseline values
    • Change spinal cord dressing as prescribed, usually after a few days, it is left open to air
    • Prevent damage by immobilizing the area, using special beds and equipment
    • Logroll the patient from side to side, and use additional help if needed
    • Assess for hypotension, bradycardia, and vasovagal reflex, which may result in cardiac arrest; be prepared to institute advanced cardiovascular life support (ACLS)
    • Hyperoxygenate before and after suctioning to prevent hypoxia and vasovagal reactions
    • Avoid placing peripheral IV lines in paralytic limbs
    • Prevent DVT and skin breakdown with proper positioning, frequent turning, therapeutic ROM exercises, anti-embolism stockings, and prophylactic anticoagulant therapy as prescribed
    • Apply splints or high-top tennis shoes to feet on a 2-hours-on and 2-hours-off schedule to maintain normal alignment and prevent footdrop

    • Fluid volume deficit may result from hemorrhage, gastric dilation (vomiting), or gastric ulceration. Urine retention may occur due to anatomic bladder or areflexia and can result in UTIs, stone formation, or renal deterioration. The nurse needs to consider the following when addressing these issues:
    • Administer histamine-2 antagonists, antacids, gastric lavage, and fluids as prescribed
    • Inspect abdomen for distention
    • Place indwelling urinary catheters during hemodynamic instability
    • Monitor urine cultures as necessary
    • Initiate intermittent catheterization or self-catheterization programs when the patient's condition stabilizes
    • Begin patient teaching regarding self-catheterization as soon as feasible
    • Provide supportive care and treatment of complications resulting from the injury, such as arrhythmias, especially tachycardia adn bradycardia, which are common in patients with SCIs.
    • Respiratory disturbances are also common and associated with the level of injury.
    • High cervical neck injuries result in respiratory nerve paralysis; therefore the patient is ventilateor dependent
  21. Explain the pathology and the signs and symptoms of spinal shock
    • Spinal shock
    • Also known as neurogenic shock
    • A sudden depression of reflex activity in the spinal cord occurs below the level of injury (areflexia)
    • Spinal shock occurs wihtin the first hou of injury and can last days to months
    • The muscles become completely paralyzed and flaccid, and the reflexes are absent
    • Spinal shock ends when the reflexes are regained

    • Assessment:
    • Flaccid paralysis
    • Loss of reflex activity below the level of the lesion
    • Bradycardia
    • Paralytic ileus
    • Hypotension

    • Interventions
    • Monitor for signs of spinal shock following a spinal cord injury
    • Monitor for hypotension and bradycardia
    • Monitor for reflex activity
    • Assess bowel sounds
    • Monitor for bowel and urinary retention
    • Provide supportive emasures as prescribed based on the presence of symptoms
    • Monitor for the return of reflexes
  22. Teach the patient and family who is to be discharged from the ER with a diagnosis of a concussion
    • Concussion
    • Jarring of the brain within the skull, with temporary loss of consciousness
    • Most common form of head injury
    • Classified as mild or classic.
    • Mild: temporary neurological dysfunctionwithout loss of consciousness or memory
    • Classic: temporary neurological dysfunction with unconsciousness and memory loss
    • Recovery from concussion usually takes minutes to hours
    • Most patients recover fully within 48 hours, but subtle residual impairment may occur

    • Collaborative Care:
    • Patients with mild head injury often are examined in the ER and discharged home
    • Generally, a family member is instructed to evaluate the patient routinely and to bring the patient back to the hospital if any further neurological symptoms appear.
    • Parents are often told to wake a child every hour for 24 hours to make sure that the patient does not have worsening neurological signs and symptoms.
    • Treatment generally consists of bedrest with the head of bed elevated at least 30 degrees, observation, and pain relief.

    **Narcotic analgesics and sedatives are contraindicated because they may mask neurological changes that indicate a worsening condition



    Teaching

    • Recognize signs and symptoms of complications:
    • Increased drowsiness
    • Headache
    • Irritability
    • Visual disturbances

    • Teach client that occassional vomiting after sustaining a cerebral concussion is normal.
    • The patient should not go home alone, because ensuing complications are apt to include decreased awareness and confusion.
    • Instruct the patient/caregive not to administer any analgesixs stronger that acetaminophen. Aspirin may increase risk of bleeding.
    • A responsible caregiver should continue to observe the patient at home for developin complications.
    • Awaken the patient every 1 to 2 hours throughout the night to assess his/her condition
    • Explain how to check the patient's orientation to place and person.
    • Teach the client to return to the hospital if the patient experiences persistent or worsening headache, blurred vision, personality changes, abnormal eyes movements, a staggering gait, twitching, or constant vomiting.
    • Teach the patient to recognize the symptoms of postconcussion syndrome, which may last for several weeks and include headache, dizziness, vertigo, anxiety and fatigue.

    If the client is admitted to the hospital, institute seizure precautions if necessary. Ensure that the patient rests by creating a calm, peaceful atmosphere and a quiet environment. Limit visitors to the immediate family or partner, and enoucrage the patient to rest for 24 hours without television or loud music.

  23. Define and describe a chronic subdural hematoma
    • Subdural Hematoma
    • Forms slowly and results from a venous bleed
    • Occurs under the dura as a result of tears in the veins crossing the subdural space
    • Classified as either acute or chronic.
    • Acute - have clinical findings that are evident within 24 to 72 hours after the traumatic event
    • Subacute - produces symptoms within 2 to 10 days
    • Chronic - symptoms appear within weeks or months

    • Chronic SDH usually occurs in the elderly or in problem drinkers who experience atrophy of the brain; often associated with falls
    • Symptoms of chronic SDH:
    • Interval when patient appears to recover and then progressive deterioration occurs
    • Drowsiness
    • Inattention
    • Personality changes
    • Headache
    • Progresses to hemiparesis, pupil changes, decreased mental status
  24. Plan and implement nursing care for a client suffering from a head injury
    • Nursing Interventions for a clietn with a head injury:
    • Monitor respiratory status and maintain a patent airway because increased CO2 levels increase cerebral edema
    • Monitor neurological status and vital signs, including temperature
    • Monitor for increased ICP
    • Maintain head elevation to reduce venous pressure
    • Prevent neck flexion
    • Initiate normothermia measures for increased temperature
    • Assess cranial nerve function, reflexes, and motor and sensory function
    • Initiate seizure precautions
    • Monitor for pain and restlessness
    • Morphine sulfate may be prescribed to decrease agitation and control restlessness caused by pain for the head injured client on a ventilator; administer with caution because it is a respiratory depressant and may increase ICP
    • Monitor for drainage from the nose or ears because this fluid may be CSF
    • Do not attempt to clean the nose, suction, or allow the client to blow his or her nose if drainage occurs.
    • Do not clean the ear if drainage is noted, but apply a loose, dry, sterile dressing.
    • Check drainage for the presence of CSF
    • Notify the physician if drainage from the ears or nose is noted and if drainage tests positive for CSF
    • Instruct patient to avoid coughing becasue this increases ICP
    • Monitor for signs of infeciton
    • Prevent complications of immobility
    • If a nasogastric tube is needed, extreme caution is needed during placement. An undiagnosed skull fracture could allow the NG tube to perforate the parenchyma of the brain
    • A drop of more than 2 points in the total Glasgow Coma Scale is a sign of dangerous neurologic deterioration
    • Pupil changes will be on the same side (ipsilateral) as the brain injury; extremity symptoms (weakness) will be in the opposite side (contralateral)
    • Corticosteroid therapy = current research indicated that the use of steroids is not beneficial in the treatment of ICP. In addition, they suppress the immune response, placing the patient at increased risk for infection. However, the drug is not contraindicated and may still be used in some hospital settings.
  25. Teach pt that is given Dilantin (Phenytoin) about the medication
    • Hydantoins
    • Ethotoin (Peganone), Fosphenytoin (Cerebyx), Phenytoin (Dilantin)
    • Used to treat partial and generalized tonic-clonic seizures.
    • Patient teaching for anticonvulsants:
    • Take the prescribed medication in the prescribed dose and frequency
    • Take with food to decrease GI irritation, but avoid milk and antacids, which impair absorption
    • If taking liquid medication, shake well before ingesting
    • Do not discontinue the medicaitons
    • Avoid alcohol
    • Avoid over-the-counter medications
    • Wear a Medic-Alert bracelet
    • Use caution when drivign or performing activities that require alertness
    • Maintain good oral hygiene and use a soft toothbrush
    • Maintain preventative dental check-ups
    • Maintain follow-up health-care visits with periodic blood studies related to determining toxicity
    • Monitor serum glucose levels (diabetes mellitus)
    • Urine may be a harm less pink-red, or red-brown in color
    • Report symptoms of sore throat, bruising, and nosebleeds, which may indicate a blood dyscrasia
    • Inform the physician if adverese reactions occur, such as gingivitis, nystagmus, slurred speech, rash or dizziness

    • Phenytoin decreases effectiveness of some birth control pills and can have teratogenic effects if taken during pregnancy.
    • Phenytoin is also used to treat dysrhythmias.

    • Side effects:
    • Gingival hyperplasia (reddened gums that bleed easily)
    • Slurred speech
    • Confusion
    • Sedation and drowsiness
    • Nausea and vomiting
    • Blurred vision and nystagmus
    • Headaches
    • Blood dyscrasias: decreased platelet count and decreased white blood cell count
    • Elevated blood glucose level
    • Alopecia or hirsutism
    • Skin rash or pruritis

    • Interventions - RN
    • Oral tube feedings may interfere with the absorption of orally administered phenytoin and diminish the effectiveness of the medication; therefore feedings should be scheduled as far as possible from the time of phenytoin administration
    • Monitor therapeutic serum levels to assess for toxicity
    • Monitor for signs of toxicity
    • When administering phenytoin IV, dilute in NS because dextrose causes the medication to precipitate
    • When administering phenytoin IV to treat status epilepticus, infuse no faster than 25 to 50 mg/min; otherwise, hypotension and cardiac dysrhythmias can occur
    • Assess for ataxia (staggering gait)
    • Instruct the client to consult withthe physician before taking other medications to ensure compatibility with anticonvulsants
  26. Differentiate between an absence seizure, complex partial, simple partial, and tonic-clonic seizures
    • Seizures
    • Abnormal, sudden, excessive discharge of electrical activity within the brain
    • Epilepsy is a disorder characterized by chronic seizure activity and indicates brain or CNS irritation
    • Causes include genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity, and infections
    • Status epilepticus involves a rapid succession of epileptic spasm without intervals of consciousness. It is a potential complication that can occur in any type of seizure, and brain damage may result.

    TYPES OF SEIZURES

    • Generalized Seizures - Tonic-Clonic, Absence, Myoclonic, Atonic or Akinetic (Drop Attacks)
    • Partial Seizures - Simple Partial, Complex Partial


    GENERALIZED SEIZURES

    • Tonic Clonic
    • May begin with an aura
    • Tonic phase - stiffening or rigidity of the muscles of the arms and legs; usually lasts 10 to 20 seconds, followed by loss of consciousness
    • Clonic phase - hyperventilation and jerkin of extremities; usually lasts about 30 seconds
    • Full recovery from the seizure may take several hours

    • Absence
    • A brief seizure lasts seconds, and the individual may or may not lose consciousness
    • No loss or change in muscle tone occcurs
    • Seizures may occur several times during the day
    • The victim appears to be daydreaming
    • More common in children

    • Myoclonic
    • Present as a brief generalized jerking or stiffening of extremities
    • The victim may fall to the ground from the seizure

    • Atonic or Akinetic (Drop Attacks)
    • Sudden momentary loss of muscle tone
    • Victim may fall to the ground as a result of the seizure


    PARTIAL SEIZURES

    • Simple Partial
    • Produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area
    • The client remains conscious and may report an aura

    • Complex Partial
    • A psychomotor seizure
    • Area of the brain most usually involved is the temporal lobe
    • The seizure is characterized by periods of altered behavior of which the client is not aware
    • The client loses consciousness for a few seconds

  27. Describe the nursing management of a client having a seizure
    • Assessment:
    • Seizure history
    • Type of seizure
    • Occurrences before, during, and after the seizure
    • Prodromal signs: mood changes, irritability, insomnia
    • Aura: sensation that warns the client of impending seizure
    • Occurrences during the postictal state, such as headache, loss of consciousness, sleepiness, and impaired speech or thinking

    • INTERVENTIONS
    • Note the time and duration of seizure
    • Assess behavior at the onset of the seizure: if the client has experienced has an aura, if a change in facial expression occurred, or if a sound or cry occurred from the client
    • If the client is standing, place the client on the floor and protect head and body
    • Support the ABCs (airway, breathing, circulation)
    • Maintain a patent airway (do not force the jaws open or place anything in client's mouth)
    • Administer oxygen
    • Prepare to suction secretions from the airway
    • Turn the client to the side to allow for secretions to drain while maintaining the airway
    • Prevent injury during the seizure
    • Remain with the client
    • Do not restrain the client
    • Loosen restrictive clothing
    • Note the type, character, and progression of the movements during the seizure
    • Monitor for incontinence
    • Administer IV medications as prescribed to stop the seizure
    • Document the characteristics of the seizures
    • Provide privacy, if possible
    • Monitor behavior following the seizure, such as the state of consciousness, motor ability, and speech ability
    • Instruct the client about the importance of life-long medication and the need for follow-up medication blood levels
    • Instruct the client to avoid alcohol, excessive stress, fatigue and strobe lights
    • Encourage the client to contact available community resources, such as the Epilepsy Foundation of America
    • Encourage the client to wear a Medic-Alert bracelet
  28. Compare and contrast Multiple Sclerosis, Myasthenia Gravis, and Amyotrophic Lateral Sclerosis
    MULTIPLE SCLEROSIS

    • What is it?
    • A chronic, progressive, noncontagious, degenerative disease of the CNS characterized by the demyelinization of the neurons
    • Usually occurs between the ages of 20 and 40 years and consists of periods of remissions and exacerbations
    • The causes are unknown, but the disease is thought to be the result of an autoimmune response or viral infection
    • Precipitating factors include pregnanyc, fatigue, stress, infection, and trauma
    • Electroencephalographic findings are abnormal
    • Assessment of a lumber puncture indicates an increased gamma globulin level, but the serum globulin level is normal.

    • MS - Assessment:
    • Fatigue and weakness
    • Ataxia and vertigo
    • Tremors and spasticity of the lower extremities
    • Parethesias
    • Blurred vision, diplopia, and transient blindness
    • Nystagmus
    • Dysphasia
    • Decreased perception of pain touch and temperature
    • Bladder and bowel disturbances, includin urgency, frequency, retention, and incontinence
    • Abnormal reflexes, including hyperreflexia, absent reflexes, and a positive Babinski's reflex
    • Emotional changes such as apathy, euphoria, irritability and depression
    • Memory changes and confusion

    • MS - Interventions
    • Provide bed rest during exacerbation
    • Protect the client from injury by providing safety measures
    • Place an eye patch on the eye for diplopia
    • Monitor for potential complications such as urinary tract infections, calculi, pressure ulcers, respiratory tract infections, and contractures
    • Promote regular elimination by bladder and bowel training
    • Encouage independence
    • Assist the client to balance moderate activity with rest periods
    • Assess the need for and provide assistive devices
    • Initiate physical and speech therapy
    • Instruct client to avoid fatigue, stress, infection, overheating, and chilling
    • Instruct the client to increase fluid intake and eat a balanced diet, including low fat, high-fiber foods and foods high in potassium
    • Instruct the client in safety measures related to motor loss, such as avoiding the use of scatter rugs and using assistive devices
    • Instruct the client in self administration of prescribed medications:
    • Baclofen, Valium, Dantrium - used to lessen muscle spasticity
    • Bethanechol - used to prevent urinary retention
    • Carbamazepine - Used to treat paresthesia
    • Corticosteroids - Used to reduce edema and inflammatory response; used to decrease length of tiem the client's symptoms are exacerbated and to improve degree of recovery
    • Immunosuppressive medications - used to treat chronic, progressive MS to stabilize the disease process
    • Oxybutin chloride - Used to decrease bladder spasms and control urge incontinence and frequency
    • Propranolol, Clonazepam - Used to treat cerebellar ataxia

    Provide information about the National Multiple Sclerosis Society



    • MYASTHENIA GRAVIS

    • What is it?
    • A neuromuscular disease characterized by considerable weakness and abnormal fatigue of the voluntary muscles
    • A defect in the transmission of nerve impulses at the myoneural junction occurs
    • Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness fo the muscle fibers to acetylcholine

    • MG - Assessment
    • Weakness and fatigue
    • Difficulty chewing
    • Dysphagia
    • Ptosis
    • Diplopia
    • Weak, hoarce voice
    • Difficulty breathing
    • Diminished breath sounds
    • Respiratory paralysis and failure

    • MG - Interventions
    • Monitor respiratory status and ability to cough and deep breath adequately
    • Monitor for respiratory failure
    • Maintain suctioning and emergency equipment at the bed side
    • Monitor vital signs
    • Monitor speech and swallowing abilities to prevent aspiration
    • Encourage client to sit up when eating
    • Assess muscle status
    • Instruct the client to conserve strength
    • Plan short activities that coincide with times of maximal muscle strength
    • Monitor for myasthenic and cholinergic crises
    • Administer anticholinesterase medications as prescribed
    • Instruct client to avoid stress, infection, fatigue, and over-the-counter medications
    • Instruct the client to wear a Medic-Alert bracelet
    • Inform the client about services from teh Myasthenia Gravis Foundation

    • Anticholinesterase medications
    • Action: Increase levels of acetylcholine at the myoneural junction
    • Medications: Neostigmine bromide (Prostigmin), Pyridostigmine bromide (Mestinon), Edrophonium chloride (Tensilon)
    • Side Effects: Sweating, salivation, nausea, diarrhea and abdominal cramps, bradycardia, hypotension
    • Interventions:
    • Administer medications on time.
    • Administer medications 30 minutes before meals with milk and crackers to reduce GI upset
    • Monitor and record muscle strength
    • Note that excessive doses lead to cholinergic crisis
    • Have the antidote (atropine sulfate) available

    • MYASTHENIC CRISIS
    • An acute exacerbation of MG
    • Crisis is caused by rapid, unrecognized progression of the disease, inadequate amount of medication, infection, fatigue, or stress
    • Assessment:
    • Increased pulse, respirations and BP
    • Anoxia and cyanosis
    • Bowel and bladder incontinence
    • Decreased urinary output
    • Absent cough and swallow reflex
    • Interventions
    • Assess for signs of myasthenic crisis
    • Increase anticholinesterase medications, as prescribed

    • CHOLINERGIC CRISIS
    • Results in depolarization of the motor end plates
    • Caused by overmedication with anticholinesterase
    • Assessment:
    • Abdominal cramps
    • Nausea, vomiting, and diarrhea
    • Blurred vision
    • Pallor
    • Facial muscle twitching
    • Hypotension
    • Pupillary miosis
    • Interventions
    • Hold anticholinesterase medication
    • Prepare to administer antidote, atropine sulfate, if prescribed

    • TENSILON TEST
    • Performed to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis
    • To diagnose MG:
    • Endophonium (Tensilon) injection is administered to the client
    • Positive for MG: Client shows improvement in muscle strength after the administration of Tensilon
    • Negative for MG: Client shows no improvement in muscle strength, and strength may even deteriorate after Tensilon administration
    • To differentiate crisis:
    • Myasthenic crisis: Tensilon is administered and, if strength improves, the client needs more medication
    • Cholinergic crisis: Tensilon is administered and, if weakness is more severe, the client is overmedicated; administer atropine sulfate, the antidote, as prescribed.


    • AMYOTROPHIC LATERAL SCLEROSIS
    • Also known as Lou Gehrig's disease
    • It is a progressive degenerative disease involving the motor system
    • The sensory and autonomic systems are not involved, and mental status changes do not result from the disease
    • The cause of the disease may be related to an excess of glutamate, a chemical responsible for relaying messages between motor neurons
    • As the disease progresses, muscle weakness and atrophy develop until a flaccid quadriplegia develops
    • Eventually, the respiratory muscles become affected leading to respiratory compromise, pneumonia, and death.
    • No cure is known, and the treatment is symptomatic
    • Assessment:
    • Fatigue
    • Fatigue while talking
    • Muscle weakness and atrophy
    • Tongue atrophy
    • Dysphagia
    • Weakness of the hands and arms
    • Fasciculations of the face (Involuntary contraction or twitching of muscle fibers, visible under the skin)
    • Nasal quality of speech
    • Dysarthria (Impairments or clumsiness in the uttering of words due to diseases that affect the oral, lingual, or pharyngeal muscles; patient's speech may be difficult to understand, but there is no evidence of aphasia)
    • INTERVENTIONS:
    • Care is directed toward the treatment of symptoms
    • Monitor respiratory status
    • Provide respiratory treatments
    • Prepare to initiate respiratory support
    • Assess for complications of immobility
    • Provide the client and family with support
  29. Differentiate between a Myasthenia Gravis Crisis and a Cholinergic Crisis.
    • MYASTHENIC CRISIS
    • An acute exacerbation of MG
    • Crisis is caused by rapid, unrecognized progression of the disease, inadequate amount of medication, infection, fatigue, or stress
    • Assessment:
    • Increased pulse, respirations and BP
    • Anoxia and cyanosis
    • Bowel and bladder incontinence
    • Decreased urinary output
    • Absent cough and swallow reflex
    • Interventions:
    • Assess for signs of myasthenic crisis
    • Increase anticholinesterase medications, as prescribed



    • CHOLINERGIC CRISIS
    • Results in depolarization of the motor end plates
    • Caused by overmedication with anticholinesterase
    • Assessment:
    • Abdominal cramps
    • Nausea, vomiting, and diarrhea
    • Blurred vision
    • Pallor
    • Facial muscle twitching
    • Hypotension
    • Pupillary miosis
    • Interventions:
    • Hold anticholinesterase medication
    • Prepare to administer antidote, atropine sulfate, if prescribed

    • TENSILON TEST
    • Performed to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis
    • To diagnose MG:
    • Endophonium (Tensilon) injection is administered to the client
    • Positive for MG: Client shows improvement in muscle strength after the administration of Tensilon
    • Negative for MG: Client shows no improvement in muscle strength, and strength may even deteriorate after Tensilon administration
    • To differentiate crisis:
    • Myasthenic crisis: Tensilon is administered and, if strength improves, the client needs more medication
    • Cholinergic crisis: Tensilon is administered and, if weakness is more severe, the client is overmedicated; administer atropine sulfate, the antidote, as prescribed.
  30. Plan nursing care for a client with an exacerbation of Myasthenia Gravis.
    • Assessment for MG:
    • Weakness and fatigue
    • Difficulty chewing
    • Dysphagia
    • Ptosis
    • Diplopia
    • Weak, hoarse, voice
    • Difficulty breathing
    • Diminished breath sounds
    • Respiratory paralysis and failure

    • Interventions:
    • Monitor respiratory status and ability to cough and deep breathe adequately
    • Monitor for respiratory failure
    • Maintain suctioning and emergency equipment at bedside
    • Monitor vital signs
    • Monitor for speech and swallowing difficulties to prevent aspiration
    • Encourage client to sit up when eating
    • Assess muscle status
    • Instruct client to conserve strength
    • Plan short activities that coincide with times of maximal muscle strength
    • Monitor for myasthenic and cholinergic crises
    • Administer anticholinesterase medications as prescribed
    • Instruct the client to avoid stress, infection, fatigue, and over-the-counter medications
    • Instruct the client to wear a Medic-Alert bracelet
    • Inform the client about services from the Myasthenia Gravis Foundation

    • MYASTHENIA CRISIS
    • Assessment:
    • Increased pulse, respirations and BP
    • Anoxia and cyanosis
    • Bowel and bladder incontinence
    • Decreased urine output
    • Absent cough and swallow reflex
    • Interventions:
    • INCREASE anticholinesterase medication, as presrcibed

    • Interventions relating to medication administration:
    • Administer medications on time
    • Administer medications 30 minutes before meals with milk and crackers to reduce GI upset
    • Monitor and record muscle strength
    • Not that excessive doses does lead to cholinergic crisis
    • Have the antidote (atropine sulfate) available
  31. Describe the signs and symptoms of Parkinson’s and typical problems associated with this chronic illness.
    • Parkinson's Disease
    • A degenerative disease caused by the depletion of dopamine, which interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the extrapyramidal system
    • Extrapyramidal motor system: functional system that includes all descending fibers arising in cortical and subcortical motor centers that reach the medulla and spinal cord by pathways other than the recognized corticospinal tracts. The system is important in maintenance of equilibrium and muscle tone
    • Slow, progressive disease that results in a crippling disability
    • The debilitation can result in falls, self-care deficits, failure of body systems, and depression
    • Mental deterioration occurs late in the disease
    • Other complications: skin breakdown from immobility, urinary tract infections. Death is usually caused by aspiration pneumonia or other infection

    • Assessment:
    • Bradykynesia, abnormal slowness of movement and sluggishness of physical and mental responses
    • Akinesia
    • Monotonous speech
    • Handwriting that becomes progressively smaller
    • Tremors in the hands and fingers at rest (pill rolling)
    • Tremors increasing when fatigued and decreasing with purposeful activity or sleep
    • Rigidity with jerky movements
    • Restlessness and pacing
    • Blank facial expression--mask-like facies
    • Drooling
    • Difficulty swallowing and speaking
    • Loss of coordination and balance
    • Shuffling steps, stooped position, and propulsive gait

    • Interventions:
    • Assess neurological status
    • Assess ability to swallow and chew
    • Provide high-calorie, high-protein, high-fiber soft diet with small, frequent feedings
    • Increase fluid intake to 2000 ml/day
    • Monitor for constipation
    • Promote independence along with safety measures
    • Avoid rushing the client with activities
    • Assist with ambulation and provide assistive devices
    • Instruct the client to rock back and forth to initiate movement
    • Instruct the client to wear low-heeled shoes
    • Encourage the client to lift feet when walking and to avoid prolonged sitting
    • Provide a firm mattress and position the client prone, without a pillow, to facilitate proper posture
    • Instruct proper posture by teaching the client to hold hands behind the back to keep the spine and neck erect
    • Promote physical therapy and rehabilitation
    • Administer anticholinergic medications as prescribed to treat tremors and rigidity and to inhibit the action of acetylcholine
    • Administer antiparkinsonian medications to increase the level of dopamine in the CNS
    • Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications
    • Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis
  32. Instruct a client with Parkinson’s disease how to improve safety when walking.
    • Assist with ambulation and provide assistive devices
    • Instruct the client to rock back and forth to initiate movement
    • Instruct the client to wear low-heeled shoes
    • Encourage the client to lift feet when walking and to avoid prolonged sitting
    • Promote physical therapy and rehabilitation
    • Encourage proper posture by teaching the client to hold hands behind the back to keep the spine and neck erect
    • Administer anticholinergic medications as prescribed to treat tremors and rigidity and to inhibit the action of acetylcholine
    • Administer antiparkinsonian medications to increase level of dopamine in the CNS
  33. Plan interventions to improve or maintain mobility in the client with MS.
    • Provide bed rest during exacerbation
    • Encourage independence
    • Assist the client to establish a regular exercise and rest program
    • Instruct the client to balance moderate activity with rest periods
    • Assess the need for and provide assistive devices
    • Initiate physical and speech therapy
    • Instruct the client to avoid fatigue, stress, infection, overheating, and chilling
    • Muscle stretching for spastic muscles and selective strengthening exercises for weakness are prescribed
    • A social service agency may be required to help the family deal with the often expensive and long-term financial effect of the disease
    • Vocational redirection may also be required
    • Consult with a physical therapist if the patient needs to learn how to use assistive devices or needs to learn exercises to maintain muscle tone and joint mobility
    • Explain to patient that baths and showers may be relaxing but may also exacerbate MS symptoms
    • Conduct ROM exercises at least twice daily
    • If necessary, teach client how to use a walker or a cane
  34. Assess a client with an exacerbation of MS for common problems associated with this disease.
    • Assessment findings:
    • Fatigue and weakness
    • Ataxia and vertigo
    • Tremors and spasticity of the lower extremities
    • Paresthesias
    • Blurred vision, diplopia, and transient blindness
    • Nystagmus
    • Dysphasia
    • Decreased perception to pain, touch, and temperature
    • Bladder and bowel disturbances, including urgency, frequency, retention, and incontinence
    • Abnormal reflexes, including hyperreflexia, absent reflexes, a positive Babinski's reflex
    • Emotional changes such as apathy, euphoria, irritability, and depression
    • Memory changes and confusion

    • So HIGH risk for:
    • UTIs
    • Injuries
    • Depression
    • Problems of immobility such (skin breakdown, contractures, pressure ulcers, calculi)
  35. Identify the purpose of Baclofen (lioresal) in the treatment for MS.
    Baclofen (Lioresal) is a skeletal muscle relaxant used to lessen muscles spasticity in Multiple Sclerosis

    • Nursing considerations:
    • Baclofen causes CNS effects such as drowsiness, dizziness, weakness and fatigue and nausea, constipation, and urinary retention
    • Administer with caution in the client with renal or hepatic dysfunction or a seizure disorder
    • Baclofen can be administered by the physician through intrathecal infusion using an implantable pump or direct intrathecal administration over 1 minute
    • Instruct the client with an implantable pump to maintain medication refill appointments to prevent pump from emptying and experiencing sudden withdrawal symptoms (which could be life threatening)
  36. Describe the pathophysiology of Multiple Sclerosis (MS).
    MULTIPLE SCLEROSIS

    • A chronic, progressive, degenerative disease that affects the myelin sheath of the white matter of the brain and spinal cord.
    • Disease affects quality rather than duration of life
    • Nerve impulses are conducted between the brain and the spinal cord along neurons protected by the myelin sheath, which is a high conductive fatty material.
    • When plaques form in the myelin sheath, causing inflammation and eventual demyelination, nerve transmission becomes erratic.
    • Areas commonly involved are the optic nerves, cerebrum, and cervical spinal cord
    • Usually occurs between the ages of 20 and 40 years and consists of periods of remissions and exacerbations

    • CAUSES
    • Unknown.
    • Some evidence suggests that an infective agent causes a predisposition to MS, although this agents has not been identified.
    • Thought to be the result of an autoimmune response or viral infection.
    • Precipitating factors include pregnancy, fatigue, stress, infection and trauma
  37. Plan and implement care of a client post craniotomy, differentiate between normal and abnormal assessment findings.
    Nursing Care Following Craniotomy:

    • Monitor vital signs and neurological status every 30 to 60 minutes
    • Monitor for increased ICP
    • Monitor for decreased LOC, motor weakness or paralysis, aphasia, visual changes, and personality changes
    • Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased ICP
    • Assess the physician's order regarding client positioning
    • Avoid extreme hip or neck flexion, and maintain the client in a midline neutral position
    • Provide a quiet environment
    • Monitor the head dressing frequently to monitor for signs of drainage
    • Mark the area of drainage at least once each nursing shift for a baseline comparison
    • Monitor the Hemovac or Jackson Pratt drain which may be in place for 24 hours
    • Measure drainage from the Hemovac or Jackson Pratt drain every 8 hours, and record the amount and color
    • Notify the physician if drainage is more than the normal amount of 30 to 50 ml per shift
    • Notify the physician immediately of excessive amounts of drainage or a saturated head dressing
    • Record strict measurement of hourly intake and output
    • Maintain fluid restriction at 1500 ml/day as prescribed
    • Monitor electrolyte levels
    • Monitor for dysrhythmias, which may occur as a result of fluid and electrolyte imbalance
    • Apply ice-pack or cool compresses as prescribed for periorbital edema and ecchymosis of one or both eyes, which is not an unusual occurrence
    • Provide ROM exercises every 8 hours
    • Place anti-embolism stockings on the client as prescribed
    • Administer anticonvulsants, antacids, corticosteroids, and antibiotics as prescribed
    • Administer analgesics such as codeine sulfate and acetaminophen as prescribed for pain
  38. Identify signs and symptoms of Increased Intracranial Pressure in general and specifically for a client with a subarachnoid hemorrhage.
    • An increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema or inflammation
    • Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

    • Assessment:
    • Altered LOC, which is the most sensitive and earliest indication of increasing ICP
    • Headache
    • Abnormal respirations
    • Rise in blood pressure with widening pulse pressure
    • Slowing of pulse
    • Elevated temperature
    • Vomiting
    • Pupil changes
    • Changes in motor function from weakness to hemiplegia, a positive Babinski's reflex, decorticate or decerebrate posturing, and seizures
    • Late signs: increased systolic blood pressure, widened pulse pressure, and slowed heart rate

    • SUBARACHNOID HEMORRHAGE
    • Direct hemorrhage of arterial blood into the subarachnoid space
    • Immediately after rupture, ICP rises, resulting in fall in cerebral perfusion
    • Furthermore, the expanding hematoma acts as a space-occupying lesion, as it compresses or displaces brain tissue
    • Blood in the subarachnoid space may impede the flow and reabsorption of CSF, thus resulting in hydrocephalus
  39. Plan and implement care for a client with both expressive and receptive aphasia.
    • Expressive Aphasia
    • Damage occurs in Broca's Area of the frontal brain
    • Client understands what is said but is unable to communicate verbally

    • Receptive Aphasia
    • Injury involves Wernicke's area in the temporoparietal area
    • Client is unable to understand the spoken and often the written word

    • Global or Mixed Aphase
    • Language dysfunction occurs in expression and reception

    • INTERVENTIONS FOR APHASIA
    • Provide repetitive directions
    • Breaks tasks down to one step at a time
    • Repeat names of objectes frequently used
    • Allow time for the client to communicate
    • Use a picture board, communication board, or computer technology
    • Decrease distracting stimuli
    • Present one idea at a time
    • Keep questions simple (yes or no)
    • Do not interrupt
    • Don't push if upset or in pain
    • Provide body contact
    • Speak in a normal tone
  40. Identify the location(s) in the brain for speech and differentiate between lesions causing expressive aphasia versus receptive aphasia.
    • Expressive Aphasia
    • Damage occurs in Broca's Area of the frontal brain
    • Client understands what is said but is unable to communicate verbally

    • Receptive Aphasia
    • Injury involves Wernicke's area in the temporoparietal area
    • Client is unable to understand the spoken and often the written word
  41. Identify nursing interventions to prevent subluxation of the shoulder in a patient with right hemiplegia.
    • Careful positioning and moving of affected arm
    • Don't immobilize affected arm because it can cause shoulder-hand syndrome
    • Avoid pulling of affected arm, use supports/slings or pillows
    • Use hand cones to reduce chance of hand contracture
    • Lap board to prevent shoulder displacement
  42. Identify treatment to prevent foot drop, and external rotation of the hip in a stroke patient.
    • Prevent external hip rotation by applying a trochanter roll at the hip outside of the legs.
    • Prevent footdrop with posterior leg splints, footboards, or high-top tennis shoes.
  43. Plan and implement nursing care for a client with left hemiplegia and homonymous hemianopsia.
    Right brain damage (stroke on right side of the brain)

    • Assessment:
    • Paralysis on LEFT side: left hemiplegia
    • Left-side neglect
    • Special-perceptual deficits
    • Tends to deny or minimize problems
    • Rapid performance, short attention span
    • Impulsive, safety problems
    • Impaired judgment
    • Impaired timed concepts

    • Interventions:
    • Teach the client to touch and use both sides of the body
    • Client is unaware of the existence of his or her paralyzed side (unilateral neglect) which places the client at risk for injury

    • Hemianopsia
    • Client has blindness in half the visual field
    • Homonymous hemianopsia is blindess in the same visual field of both eyes

    • Interventions:
    • Encourage the client to turn the head to scan the complete range of vision' otherwise he or she does not see half of the visual field
    • Approach the client from the unaffected side
    • Place the client's personal objects within the visual field
    • Provide eye care for visual deficits
    • Place a patch over the affected eye if the client has diplopia
    • Assess the need for assistive devices such as a cane, walker, splints, or braces
  44. Distinguish between risk factors for hemorrhagic and ischemic stroke
    • Hypertension
    • Atherosclerosis
    • Atrial-fibrillation
    • Anticoagulation therapy
    • Diabetes Mellitus
    • Stress
    • Obesity
    • Smoking
    • Alcohol abuse
    • MI
    • Cardiac valve abnormalities
    • Cardiac congenital defects
    • Oral contraceptives

    ISCHEMIC STROKE - results form inadequate blood flow to the brain from partial or complete occlusion of artery. These strokes are further divided into thrombotic and embolic

    • Thrombotic Stroke
    • Ooccurs from injury to a blood vessel wall and formation of a blood clot
    • The lumen of the vessel becomes narrowed, and if it becomes occluded, infarction occurs.
    • Thrombosis developes readily where atheresclerotic plaques have already narrowed blood vessels
    • The most common kind of stroke
    • 2/3 of thrombotic strokes are assoicated with hypertension and diabetes, both of which accelerates atherosclerosis
    • In 30% to 50% of individuals, thrombotic strokes have been preceded by a TIA
    • Most pts with ischemic strokes do not have a decreased LOC in the first 24 hours
    • Ischemic stroke symptoms may progress in the first 72 hours, as infarction and cerebral edema increase

    • Lacunar stroke
    • A stroke form occlusion of a small penetrating artery with development of a cavity in the place of the infarcted brain tissue.
    • Most commonly occurs in the basal ganglia, thalamus, internal capsule, or pons
    • Can cause considerable deficits if symptoms are present

    • Embolic Stroke
    • Occurs when an embolus lodges in and occludes a cerebral arter, resulting in infarction and edema of the area supplied by the involved vessel
    • Second most common cause of stroke
    • Majority of emboli originate in the endocardial (inside) layer of the heart, with plaque breaking off from the endocardium and entering the circulation.
    • Heart conditions associated with emboli: atrial-fibrillation, myocardial infarction, infective endocarditis, rheumatic heart disease, valvular prostheses, atrial septal defects
    • Pt with embolic stroke commonly has a rapid occurence of severe clinical symptoms
    • Onset is usually sudden and may or may not be related to activity
    • Patient usually remains conscious, although he or she may have a headache
    • Effects of emboli initially characterized by severe neurologic deficits which can be temporary if the clot breaks up and allows blood to flow
    • Recurrence of embolic stroke is common unless the underlying cause is aggressively treated


    • HEMORRHAGIC STROKE
    • Account for approximately 15% of all strokes and result from bleeding into brain tissue itself (intracerebral or intreparenchymal hemorrhage) or into the subarachnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage)

    • Intracerebral Hemorrhage
    • Bleeding within the brain caused by a rupture of a vessel and accounts for about 10% of all stroke
    • The prognosis is poor: 30-day mortality rate is 40% to 80%; 50% occur within the first 48 hours
    • Hypertension is the most important cause of intracerebral hemorrhage
    • Other causes: cerebral amyloid angiopathy, vascular malformations, coagulation disorders, anticoagulant and thrombolytic drugs, trauma, brain tumors, and rupture aneurysms
    • Hemorrhage commonly occurs during periods of activity
    • There is most often a sudden onset of symptoms, with progression over minutes to hours because of ongoing bleeding
    • Symptoms:
    • neurological deficits
    • headache
    • nausea and vomiting
    • decreased LOC
    • hypertension
    • Initially, patients experience a severe headache with nause and vomiting
    • Progression of symptoms related to severe hemorrhage includes hemiplegia, fixed and dilated pupils, abnormal body posturing, and coma

    • Subarachnoid Hemorrhage
    • Occurs when there is intracranial bleeding into the cerebrospinal fluid-filled space between the arachnoid and pia mater membranes on the surface of the brain
    • Subarachnoid hemorrhage is commonly caused by rupture of a cerebral aneurysm (congenital or acquired weakness and ballooning of vessels)
    • Aneurysms may be saccular or berry aneurysms, ranging from a few millimeters to 20 to 30 mm in size
    • Aneurysms can also be fusiform atherosclerotic aneurysms
    • The majority of aneurysms are in the circle of Willis
    • Other causes of subarachnoid hemorrhage: arteriovenous malformations (AVMs), trauma, and illicit drug (cocaine) abuse. About 35% of people who have a hemorrhagic stroke due to a rupture aneurysm die during the first episode; 15% die from subsequent bleeding
    • Incidence increases with age and is higher in women than men
    • Patient may have warning symptoms oif the ballooning artery applies pressure to brain tissue, or minor warning symptoms may result from leaking of an aneurysm before major rupture
    • Characteristic presentation of a ruptured aneurysm: sudden onset of severe headache that is different from a previous headache and typically the "worst headache of one's life"
    • Loss of consciousness may or may not occur
    • Other symptoms include: focal neurologic deficits (including cranial nerve deficits), nausea, vomiting, seizures, and stiff neck
  45. Differentiate between a CVA and a TIA.
    • Transient Ischemic Attack (TIA)
    • Temporary focal loss of neurologic function caused by ischemia of one of the vascular territories of the brain
    • Lasting <24 hours and often lasting <15 minutes
    • Most TIAs resolve within 3 hours
    • TIAs may be due to microemboli that temporarily block the blood flow
    • TIAs are a warning sign of progressive cerebrovascular disease
    • The signs and symptoms depend on the blood vessel that is involved and the area of the brain that is ischemic
    • If the carotid system is involved, patients may have a temporary loss of vision in one eye (amaurosis fugax), transient hemiparesis, numbness or loss of sensation, or a sudden inability to speak
    • Signs of TIA involving the vertebrobasilar system may include tinnitus, vertigo, darkened or blurred vision, diplopia, ptosis, dysarthria, dysphagia, ataxia, and unilateral or bilateral numbness or weakness
    • CT scan of the brain without contrast media is the most important initial diagnostic study.
    • Cardiac monitoring and tests may reveal an underlying cardiac condition that is reponsible for clot formation
    • Drugs that preven platelet aggregation and anticoagulant drugs may be prescribed fro long-term therapy in TIA.


    • Cerebrovascular Accident
    • Sudden loss of neurological function, caused by vascular injury (loss of blood flow) to an area of the brain.
    • Classified as ischemic or hemorrhagic.
  46. Define and differentiate between decorticate and decerebrate posturing.
    • Decorticate posturing
    • Flexion posturing
    • Client flexes one or both arms on the chest and may extend legs stiffly
    • Indicates a nonfunctioning cortex

    • Decerebrate posturing
    • Extensor posturing
    • Client stiffly extends one or both arms and possibly the legs
    • Extensor posturing indicates a brainstem lesion

    • Flaccid Posturing
    • Client displays no motor resonse in any extremity
  47. Recognize and implement nursing actions/responsibilities in the care of a patient with or suspected of having Increased Intracranial Pressure.
    • Increased Intracranial Pressure
    • Intracranial Pressure = made up of blood flow, brain tissue and CSF
    • An increase in ICP may caused by trauma, hemorrhage, tumor growth, hydrocephalus, edema, or inflammation
    • Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

    • Assessment
    • Altered LOC - the most sensitive and earliest indication of increasing ICP
    • Headache
    • Abnormal respirations
    • Rise in blood pressure with widening pulse pressure
    • Bradycardia
    • Elevated temperature
    • Vomiting
    • Pupil changes
    • Changes in motor function from weakness to hemiplegia, a positivie Babinski's reflex, decorticate or decerebrate posturing, and seizures.
    • Late signs: increased systolic BP, widened pulse pressure, and slowed HR

    • Interventions:
    • Elevate the HOB 30 to 40 degrees as prescribed
    • Avoid the Trendelenburg's position
    • Prevent flexion at the neck and hips
    • Monitor respiratory status and prevent hypoxia
    • Avoid admisnitration of morphine sulfate to prevent occurrence of hypoxia
    • Maintain mechanical ventilation as prescribed; maintaining the PaCO2 at 30 to 35 mmHg will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP (high CO2 = cerebral vasodilation)
    • Maintain body temperature
    • Prevent shivering, which can increase ICP
    • Decrease environmental stimuli
    • Monitor electrolyte levels and acid-base balance
    • Moniotr intake and output
    • Limit fluid intake to 1200 ml/day
    • Instruct the patient to avoid straining activities such as coughing and sneezing
    • Instruct client to avoid Valsalva's maneuver
  48. Outline the nursing responsibilities in the care of a client on Mannitol and/or Dexamethasone.
    • Mannitol (Osmitrol)
    • Osmotic Diuretics increase osmotic pressure of the glomerular filtrate, inhibiting reabsorption of water and electrolytes
    • Used for oligura to prevent renal failure, decrease intracranial pressure, and decrease intraocular pressur ein clients with narrow-angle glaucoma
    • Mannitol is used with chemotherapy to induce diuresis
    • Side effects:
    • Fluid and electrolyte imbalances
    • Pulmonary edema from rapid shifts of fluid
    • Nausea and vomiting
    • Headache
    • Tachycardia from rapid fluid loss
    • Hyponatremia and dehydration
    • Interventions:
    • Monitor vital signs
    • Monitor weight
    • Monitor urine output
    • Monitor electrolyte levels
    • Monitor lungs and heart sounds for signs of pulmonary edema
    • Monitor for signs of dehydration
    • Monitor neurological status
    • Monitor for increased intracranial pressure
    • Change the client's position slowly to prevent orthostatic hypotension
    • Monitor for crystallization in the vial of mannitol before administering the medication; if crystallization is noted, do not administer the medicaiton from that vial

    • Dexamethasone
    • anti inflammatories steroidal
    • Suppresses inflammation and the normal immune response
    • Corticosteroids stabilize the cell membrane and reduce the leakiness in the blood-brain barrier
    • Corticosteroids decrease cerebral edema
    • A histamin-blocker may be administered to counteract the excess gastric secretion that occurs with the corticosteroid
    • Client must be withdrawn slowly from corticosteroid therapy to reduce risk of adrenal crisis
    • Side effects:
    • depression, euphoria
    • hypertension
    • peptic ulceration, anorexia, nausea, increased appetite, vomiting
    • acne, decreased wound healing, ecchymoses, hirsutism, petechiae
    • adrenal suppression, hyperglycemia
    • thromboembolism
    • weight gain
    • muscle wasting
    • osteoporosis
    • cushingoid appearance (moon face, buffalo hump)
    • Nursing:
    • Monitor intake and output and daily weights
    • Assess for signs of adrenal insufficiency (hypotension, weight loss, nausea and vomiting, confusion) before and periodically during therapy
    • Observe for peripheral edema, steady weight gain, rales/crackles or dyspnea
    • Assess for changes in level of consciousness and headache throughout therapy
    • Monitor serum electrolytes and glucose
    • May cause hyperglycemia, especially in pts with diabetes
    • Increased risk for infection
    • Administer with meals to minimize GI irriation if PO; tablets may be crushed and administered with soft food, chocolate syrup, or fluids for patients with difficulty swallowing
    • Direct IV: may be given undiluted. Administer over 1 to 4 minutes if dose is <10 mg.
  49. Describe the pathophysiology involved in Increased Intracranial Pressure.
    • Increased Intracranial Pressure may be caused by:
    • trauma
    • hemorrhage
    • tumor growth
    • hydrocephalus
    • edema
    • inflammation

    • Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect functioning of nerve cells, and lead to brainstem compression and death. Increased ICP is significant because it decreased CPP (cerebral perfusion pressure) - the pressure needed to ensure blood flow to the brain. CPP = MAP - ICP
    • Normal ICP is the total pressure exerted by 3 componenets: brain tissue, CSF and blood flow. Any alterations of the 3 causes the otehr 2 to compensate. Normal ICP is 0-15 mmHg

    First symptom of IICP is altered LOC

    • Cushing's Triad:
    • Hypertension (rise in systolic BP = widening pulse pressure)
    • Bradycardia
    • Irregular Respirations
  50. Identify the cranial nerve that you are assessing when you check for pupillary response in a client.
    • Cranial Nerve III (oculomotor); cranial nerve IV (trochlear); cranial nerve VI (abducens)
    • The motor functions of these nerves overlap; therefore, they need to be tested together
    • First, inspect the eyelids for ptosis (drooping); then assess ocular movements and note any eye deviation
    • Test the eyes for size, regularity, equality, direct and consensual light reflexes, and accommodation (PERRLA - pupils equally round, reactive to light, and accommodation)
    • Test extraocular movements (EOMs) by the cardinal positions of gaze
    • Test for nystagmus by assessing downward and inward eye movements

    • Cranial Nerve II (Optic)
    • Assess visual acuity with a Snellen Chart or newspaper, or ask the client to count how many fingers the examiner is holding up
    • Check the visual fields by confrontation
    • Have the client sit directly in front of the examiner and stare at the examiner's nose; then the examiner slowly moves his or her finger from the periphery toward the center until the client says it can be seen.
    • Check color vision by asking the client to name the colors of several nearby objects
  51. Differentiate between methods to assess for visual, auditory, and tactile agnosia.
    • Agnosia = total or partial loss of the ability to recognize familiar objects or persons through sensory stimuli
    • Visual = can see, but patient is unable to tell what the item is
    • Auditory = understands sounds, but doesn't know where the sound is coming from
    • Tactile = can feel items but can't identify them
    • Hemianopsia = blindness in 1/2 the visual field
    • Homonymous hemianopsia = blindness in the same visual field of both eyes
    • Apraxia = inability to carry out a purposeful activity
  52. Assess a client for abstract reasoning.
    • Ask the client to interpret a well-known proverb such as "the early bird gets the worm."
    • Ask the client to compare objects. For example, "how are an apple and an orange the same?"
    • Note client's ability to joke/use puns, which requires abstract reasoning.
    • Note client's cultural factors/educational level.
  53. Describe assessment findings that you would expect in a client with an occipital lobe lesion.
    Cerebral Cortex

    • Frontal Lobe
    • Broca's area for speech
    • Morals, emotions
    • Reasoning and judgment
    • concentration and abstraction

    • Parietal lobe
    • Interpretation of taste, pain, touch, temperature, and pressure
    • Spatial perception

    • Temporal lobe
    • Auditory center
    • Wernicker's area for sensory and speech

    • Occipital lobe
    • Visual area

    • Limbic lobe
    • Emotional and visceral patterns for survival
    • Learning and memory


    Lesion in occipital lobe = visual disturbances; partial loss of vision
  54. Recognize problems that a client with cerebellar dysfunction might exhibit.
    • Cerebellum
    • Coordinates smooth muscle movement, posture, equilibrium, and muscle tone
    • Responsible for coordination of voluntary movements, the speed, trajectory and stopping of movements, and for maintainin posture and balance


    Cerebellar dysfunction = ataxia, incoordination, unsteady gait
  55. Care for a client who has had surgery for a tumor or has sustained an injury to the pituitary gland.
    • Post-craniotomy Nursing Care
    • Monitor vital signs and neurological status every 30 to 60 minutes
    • Monitor for increased ICP
    • Monitor for decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes and personality changes
    • Maintain mechanical ventilaiton and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased intracranial pressure
    • Assess the physician's orders regarding client positioning
    • Avoid extreme flexing of the hip or neck flexion, and maintain the head in a midline neutral position
    • Provide a quiet environment
    • Monitor the head dressing frequently for signs of drainage
    • Mark the area of drainage at least once each nursing shift for baseline comparison
    • Monitor the Hemovac or Jackson-Pratt drain, which may be in place for 24 hours
    • Maintain suction on the Hemovac, or Jackson-Pratt drain
    • Measure drainage from the Hemovac or Jackson-Pratt drain every 8 hours; record the amount and color
    • Notify the physician if drainage is more than normal amount of 30 to 50 ml per shift
    • Notify the physician immediately if excessive amounts of drainage or a saturated head dressing
    • Record strict measurement of hourly intake and output. (Detect early development of DI or SIADH)
    • Maintain fluid restriction at 1500ml/day as prescribed
    • Monitor electrolyte levels
    • Monitor for dysrhythmias, which may occur as a result of fluid and electrolyte imbalances
    • Apply ice packs or cool compresses as prescribed for periorbital edema and ecchymosis of one or both eyes, which is not an unusual occurrence
    • Provide range-of-motion exercises every 8 hours
    • Place anti-embolism stockings on the client as prescribed
    • Administer anticonvulsants, antacids, corticosteroids, and antibiotics as prescribed
    • Administer analgesics such as codeine sulfate and acetaminophen as prescribed for pain
  56. Perform and recognize tests that assess a client’s muscle strength, muscle tone, gait and balance.
    Neurological Assessment

    • Motor
    • Assess for involuntary movements, muscle symmetry, atrophy
    • Muscle tone: flex and extend wrists, elbows, ankles and knees; slight continuous resistance to passive movement is normal. Note any decreased (flaccid) or increased (rigid or spastic) muscle tone
    • Motor strength: have pt move against resistance
    • Muscle strength Grading Scale:
    • 0 - no rmuscle movement
    • 1 - Visible muscle movement, but no joint movement
    • 2 - Joint movement, but not against gravity
    • 3 - Movement against gravity, but not against resistance
    • 4 - Movement against resistance, but less than normal
    • 5 - Normal strength

    • Gait/Balance
    • Observe gait while patient walks across the room and back
    • Have the patient walk heel-to-toe on heels in a straight line
    • Have patient hop in place on each foot
    • Have patient do shallow knee bend
  57. Teach a client who is scheduled for a cerebral angiogram and an MRI.
    • Cerebral Angiogram
    • Injection of contrast material through the femoral artery into the carotid arteries to visualize the cerebral arteries and assess for lesions
    • Preprocedure interventions:
    • Obtain informed consent
    • Assess the client for allergies to iodine and shellfish
    • Encourage hydration for 2 says before the test
    • Maintain the client on NPO status 4 to 6 hours before the test is prescribed
    • Obtain a baseline neurological assessment
    • Mark the peripheral pulses
    • Remove metal items from hair
    • Administer premedication as prescribed


    • Magnetic Resonance Imaging (MRI)
    • MRI is a noninvasive procedure that identifies the types of tissues, tumors and vascular abnormalities
    • It is similar to CT scanning but provides more detailed pictures
    • Preprocedure interventions:
    • Remove all metal objects from the client
    • Determine if teh client has a pacemaker, implanted difibrillator, or other metal implants such as a hip prosthesis, or vascular clips, because these clients cannot have this test performed
    • Remove IV pumps during the test
    • Provide precautions for the client who is attached to a pulse oximeter because it can cause a burn during testing if coiled around the body or a body part
    • Provide an assessment of the client with claustrophobia
    • Administer medication as prescribed for the client with claustrophobia
    • Determine whether a contrast agent is to be used and follow the prescription related to administation of food, fluids, and medications
    • Instruct the client that he or she will need to remain still during the procedure
    • Postprocedure interventions:
    • Client may resume normal activities
    • Expect diuresis if a contrast media is used
  58. Plan the care for a client post cerebral angiogram.
    • Monitor neurological status and vital signs frequently until stable
    • Monitor for swelling in the neck and for difficulty swallowing, notify the physician if these symptoms occur
    • Maintain bed rest for 12 hours as prescribed
    • Elevate the head 15 degrees to 30 degrees only if prescribed
    • Assess peripheral pulses
    • Apply sandbags or another device to immobilize the limb and pressure dressing to the injection site to decrease bleeding as prescribed
    • Place ice on the puncture site as prescribed
    • Encourage fluid intake