chapter 48: nursing care of patients w/ central nervous system disorders Flashcards
meningitis: pathophysiology
- infection/inflammation of brain and spinal cord
- purulent exudate
- increased intracranial pressure (ICP)
- possible cranial nerve involvement
etiology of meningitis: bacterial
- neisseria meningitidis
- streptococcus pneumoniae
- group b strep
- haemophilus influenzae type b
- may also be viral
signs and symptoms of meningitis
- severe headache
- no appetite or thirst
- fever
- photophobia
- petechial rash
- nuchal rigidity
- positive kernig and bruzinski signs
- nausea and vomiting
- encephalopathy
kernig’s sign
test for this by bending the knee
brudzinski’s sign
test for this by lifting the back of the head
complications of meningitis
- seizures
- cranial nerve damage
- occasional permanent neurological deficits
diagnostic tests for meningitis
- lumbar puncture
- culture and sensitivity
- CT scan, MRI
therapeutic interventions for meningitis
- antibiotics
- antipyretics
- cooling blanket as needed
- dark, quiet environment
- analgesics: codeine products
- corticosteroids
- antiemetics
- droplet isolation if bacterial
encephalitis: pathophysiology
- inflammation of brain tissue
- nerve damage, edema, necrosis
- increased ICP
encephalitis: etiology
- viruses: west nile, infectious mononucleosis, herpes simplex virus
signs and symptoms of encephalitis
- headache
- fever
- nausea and vomiting
- nuchal rigidity
- confusion
- decreased level of consciousness (LOC)
- seizures
- photophobia
- ataxia
- hemiparesis
- tremors
- coma
- death
complications of encephalitis
- cognitive disabilities
- personality changes
- ongoing seizures
- motor deficits
- blindness
diagnostic tests
- CT scan
- MRI
- electroencephalogram (EEG)
- lumbar puncture w/ CSF analysis
therapeutic interventions for encephalitis
- analgesics
- anticonvulsants
- antipyretics
- corticosteroids
- antivirals
- sedatives
- neurological assessment
- symptomatic care
increased intracranial pressure: pathophysiology
= increase in brain, blood, csf
etiology of increased ICP
- brain trauma
- brain tumor
- intracranial hemorrhage
increased ICP: signs & symptoms
- restlessness
- irritability
- decrease in LOC
- hyperventilation
- pupil changes
- Cushing triad
monitoring of increased ICP
- external ventricular drain
- subarachnoid bolt
- intraparenchymal monitor
Cushing’s triad
bradycardia
irregular respirations
widened pulse pressure (MAP)
Nursing Diagnoses for Central Nervous System Infections
- hyperthermia
- risk for acute confusion
- self care deficit (dressing/feeding/toileting)
- acute/chronic pain
- risk for injury
- impaired physical mobility
primary headaches
- migraine
- tension
- cluster
- others
secondary headaches
- head and/or neck trauma
- infection
- other
nursing care for headaches
- “what’s up”
W here is the pain
H ow does the headache feel?
A ggravating or alleviating factors
T iming: when does it typically occur? how long does it last? - ask pt to rate severity
- ask about other useful data
- determine the pts perception of the headache
patient education for headaches
- keep diary
- record triggers, timing, symptoms
- teach relaxation and stress reduction
- teach about medications
seizures
- abnormal electrical discharges in the brain related to instability of neuronal cell membranes
- classification:
partial
generalized
partial seizures
begin on one side of cerebral cortex
generalized
both hemispheres involved
etiology
idiopathic
acquired
idiopathic
no cause identified
acquired
underlying neurological disorder
brain injury
signs and symptoms of seizures: aura
- visual distortion
- odor
- sound
partial seizures
- automatisms
- maintain consciousness
- usually <1 minute
- paresthesias
- visual disturbances
complex partial
- lose consciousness, 2-15 minutes
generalized seizures
- absence (petit mal)
- staring
tonic clonic
-m may have aura
- usually lose consciousness
- rigidity followed by muscle contraction and relaxation
- incontinence
- postictal period
diagnostic tests for seizures
- eeg
- look for underlying cause
therapeutic interventions for seizures
- correct cause
- anticonvulsant medication
- surgical resection
emergency care with seizures
- monitor airway
- turn on side to prevent aspiration
- pad side rails
- prevent injury
- do not restrain
- suction as needed
- observe and document
nursing diagnoses
- risk for injury
- risk for ineffective health management
- risk for situational low self esteem related to negative perception of self worth due to perception of disease
status epilepticus
- 30 minutes of continuous seizure activity
- therapeutic interventions
- ensure airway and oxygenation
- administer diazepam or lorazepam
traumatic brain injury
- trauma: hemorrhage, contusion, laceration
traumatic brain injury can cause
- cerebral edema
- hyperemia
- hydrocephelus
- brain herniation
- death
etiology of traumatic brain injury
- motor vehicle collision most common
- falls
- assaults
- sports related injuries
mechanisms of injury
- acceleration
- deceleration
- acceleration-deceleration
- rotational
types of injury
concussion
contusion
hematoma
subdural
epidural
diagnostic tests for TBi
ct scan
MRI
neuropsychological testing
therapeutic interventions
- surgical removal of hematoma
- control increased ICP
- therapeutic coma
ways to control increased ICP
icp monitoring
osmotic diuretic
mechanical ventilation
complications of TBI
- brain herniation
- diabetes insipidus
- acute hydrocephalus
- labile vital signs
- ptsd
- cognitive and personality changes
Nursing diagnoses
- ineffective cerebral tissue perfusion
- ineffective airway clearance
- ineffective breathing pattern
- risk for acute confusion
- self care deficit
- acute/chronic pain
- disturbed sensory perception
- impaired physical mobility
- risk for injury
brain tumor: pathophysiology
- neoplastic growth of the brain or meninges
- primary or metastatic
- compress or infiltrate brain tissue
- cause increased ICP
signs and symptoms of brain tumor
- seizures
- motor and sensory deficits
- headaches
- speech and vision disturbances
- personality changes
- hormone disturbances
diagnosis for brain tumors
- mri
- angiogram
- magnetic resonance angiogram
- hormone levels
therapeutic interventions for brain tumor
- surgical removal
- radiation therapy
- chemotherapy
- symptom control
symptom control for brain tumors
anticonvulsants
steroids
complications of brain tumor
- seizures
- headaches
- memory impairment
- cognitive changes
- ataxia
- hemiparesis
- aphasia
- lethargy
- coma
- death
nursing diagnoses for brain tumors
- risk for acute or chronic confusion
- self care deficit
- acute or chronic pain
- risk for injury secondary to disturbed sensory perception
- impaired physical mobility
- risk for injury
intracranial surgery: indications
- hematoma
- tumor
- arteriovenous malformation
- trauma
- seizures
types of intracranial surgery
- craniotomy (skull removal)
- craniectomy (put bone back)
- cranioplasty (metal/titanium plate)
preoperative care for intracranial surgery
- patient education
- anxiety management
- intensive care unit visit
postoperative nursing diagnoses
- risk for ineffective cerebral tissue perfusion
- risk for infection
- disturbed body image
- deficient knowledge
herniated disk: pathophysiology
- herniation of nucleus pulposus
- compression of nerve root(s)
- cervical, lumbar most common
herniated disk: etiology
- injury
- may be unknown
signs and symptoms of herniated disk
- pain
- muscle spasm
- numbness or tingling of extremity
- weakness
- atrophy
diagnostic tests for herniated disk
mri
myelogram
herniated disk: therapeutic interventions
- rest
- physical therapy
- traction
- muscle relaxants
- NSAIDs, analgesics
- epidural anesthetic/steroid caution excessive use
- surgery
types of surgery for herniated disks
- laminectomy
- diskectomy
- spinal fusion
- artificial disk
complications of surgery
- hemorrhage
- nerve root damage
- reherniation
- herniation of another disk
preoperative care for herniated disks
routine teaching
teach log rolling technique
postop nursing diagnoses for herniated disks
acute pain
impaired urinary elimination
impaired physical mobility
pathophysiology of spinal cord injuries
- damage to nerve fibers
- interference w/ communication between brain and body
causes of spinal cord injuries
- mvc’s
- falls
- sports injuries
- assault
signs and symptoms of cervical injury
- paralysis
- paresthesias
0 impaired respiration - loss of bladder and bowel control
- quadriplegia/paresis
- c3 or above fatal
signs and symptoms of thoracic/lumbar injury
- paraplegia/paresis
- altered bowel and bladder control
spinal shock: sympathetic nervous system disruption
- vasodilation
- hypotension
- bradycardia
- hypothermia
- urine and feces retention
diagnostic tests for spinal cord injury
- x ray
- ct scan
- mri
emergency management for spinal cord injuries
- respiratory
- gastrointestinal
- genitourinary
- immobilization
surgical management of spinal cord injuries
stabilize spine
- halo brace
- rods
- corset
- brace
- body cast
nursing diagnoses for spinal cord injuries
- impaired gas exchange
- ineffective airway clearance
- risk for autonomic dysreflexia
- reflex urinary incontinence
- constipation
- impaired physical mobility
- self care deficit
- risk for impaired skin integrity
- ineffective role performance
- risk for sexual dysfunction
- anxiety
dementia
- significantly impaired intellectual functioning
- impaired normal activities and relationships
- impaired problem solving and emotional control
- personality changes
- behavioral problems
dementia etiology
- Huntington disease
- Parkinson disease
- Alzheimer disease
- vascular dementia
- chronic alcoholism
- medications
lower risk for dementia
- higher education
- higher socioeconomic status
- engagement in simulating intellectual and leisure activities
dementia signs and symptoms
- recent memory affected first
- remote memory affected later
- forget how to perform simple tasks
- wandering
- aphasia
- behavioral problems
- total dependence
diagnostic tests for dementia
- neuropsychological testing
- depression testing
- medication review
- MRI, CT scan, positron emission tomography (PET) scan for underlying cause
therapeutic interventions for dementia
- medications
- end of life decision making
types of medications that delay dementia progression
- cholinesterase inhibitors
- n methyl d aspartate (NMDA) agonist
nursing diagnoses for dementia
- risk for injury
- imbalanced nutrition
- chronic confusion
- risk for caregiver role rstrain
delirium
- temporary mental disturbance
- medical emergency
- underlying cause must be corrected
some causes of delirium
- pain
- hypoxia
- medications
- illness
parkinson disease
- destruction of substantia nigra
- decreased dopamine production
- relative excess of acetylcholine
- impairment of semiautomatic movements
parkinson disease etiology
- unknown
- genetic
- certain drugs
- encephalitis
signs and symptoms of parkinson disease
- muscular rigidity
- bradykinesia
- change in posture
- pill rolling tremor
- difficulty initiating movement
- shuffling and freezing gait
- masklike facial expression
- soft voice
- drooling, dysphagia
- hand tremors at rest
- constipation
- frequent urination
- flexion of knees an hips shifts center of gravity forward
symptoms of autonomic nervous system dysfunction
- diaphoresis
- constipation
- orthostatic hypotension
- drooling
- dysphagia
- seborrhea
- frequent urination
diagnostic tests for parkinson disease
- history
- physical examination
- MRI
therapeutic interventions for parkinson disease
- dopamine agonist
- monoamine oxidase b inhibitors
- catechol o methyltransferase (COMT) inhibitor
- pallidotomy
- deep brain stimulation
nursing diagnoses
- impaired physical mobility
- self care deficit
- risk for injury
- also diagnoses for dementia
pathophysiology/etiology
genetic
- autosomal dominant
- degeneration of parts of brain
signs and symptoms of huntington’s disease
- personality changes
- inappropriate behavior
- paranoia
- violence
- choreiform movements
- dysphagia
- depression
- death
diagnostic tests for Huntington’s
- family history
- mri
- ct scan
- genetic testing
- counseling
therapeutic interventions
- antipsychotics
- antidepressants
- antichoreic agents
- stem cell transplants: experimental
pathophysiology of Alzheimer’s disease
- progressive degenerative disease
- neurofibrillary tangles
- neuritic plaques
etiology of alzheimer disease
- unknown
- may be genetic
- down syndrome
signs and symptoms of alzheimer’s: stages
stage 1
stage 2
stage 3
stage 1of alzheimer’s
- increasing forgetfulness
stage 2 of alzheimer’s disease
- progressive memory loss
- irritability
- depression
- aphasia
- sleep disruption
- hallucinations
- seizures
stage 3 of alzheimer’s disease
- complete dependency
- bowel and bladder control lost
- emotional control lost
- inability to recognize significant others
- death
diagnostic tests for Alzheimer’s
- history
- physical examination
- MRI
- PET scan, single photon emission computed tomography (SPECT) scan
- autopsy
therapeutic interventions for Alzheimer’s
- cholinesterase inhibitors
- NMDA antagonists
- antidepressants
- antipsychotics
- antianxiety agents
nursing diagnoses for Alzheimer’s
- risk for injury
- imbalanced nutrition
- chronic confusion
- risk for caregiver role strain
the LPN will…
- promote positive self esteem of client
- promote a therapeutic environment
- assist in the care of the cognitively impaired client
- provide care to immobilized client based on need
- evaluate client oxygen saturation
- participate in staff education
