Neurological Disorders Flashcards by Kelsey Klipfel

Acute autoimmune attack on peripheral nerve myelin - antibodies destroying the myelin that allows motor neuron signal - end up mostly weakness and paralysis - not interfere with pain sensation
Demyelination
Ascending paralysis (Ground to Brain) - remits same way - head to feet
Dyskinesia/paresthesias (lot weakness)
Flaccid paralysis (not interfere with pain receptors) and LOT severe pain
Resp. impairment when reaches level diaphragm - thoracic muscles that help us breathe affected first
acute/chronic
Chronic - disease process stops somewhere and not remit
3 phases - acute (1-4 weeks - active: progressing forward and have further paralysis; stays here until no further advancement); plateau (days up to two weeks - stays exactly where at; not remit or go forward); recovery (2 months to 4 yrs - get back to norm state after disease process
Aka Acute idiopathic polyneuritis

Patho - Neurological disorders - Guillain-Barre Syndrome

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Viral Infections (most common)
Campylobacter jejuni 25-50%
H. influenza
Mycoplasma pneumonia
HIV
Immunization - some studies
Immune disorders - other disorders set this off
Other stresses in body cause it

Triggers - Neurological disorders - Guillain-Barre Syndrome

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Begins in lower extremities
With Muscle weakness leading to paralysis
Diminished reflexes (Hypo-reflexia)
Ascending paralysis - up to head
Respiratory failure - start with thoracic muscles - not able breathe first; if progresses upward - will lose airway - often end up on ventilator
2-4-week peak severity
Can last Longer = chronic inflammatory demyelinating polyneuropathy/demyelination

CM - Neurological disorders - Guillain-Barre Syndrome

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Diagnosis
CSF elevated protein - lumbar puncture for this elevated protein
Loss of nerve conduction
Critical care needed
Mechanical ventilation - often intubated
DVT/PE prophylaxis - not moving at all; no muscles help pump blood back up to heart - SCDs and heparin
IVIG-decrease circulating antibodies attacking myelin

Med treatment - Neurological disorders - Guillain-Barre Syndrome

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Ineffective breathing pattern - #1 depending on where paralysis
Impaired gas exchange
Impaired physical mobility
Imbalanced nutrition: Inability to swallow - feed through PEG tube, NG tube, post-pyloric tube, TPN through central line
Impaired verbal communication
Anxiety - not affecting mental status; only motor neuron
Fear

N. diagnosis - Neurological disorders - Guillain-Barre Syndrome

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Maintain respiratory function - watching and assessing as not able breathe and take action quickly - must report symp and move quickly
Enhancing physical mobility - lot passive ROM - not lose muscle mass while paralyzed
Providing good adequate nutrition - watching for infection if have central line and tolerating tube feeding
Improved communication
Decreased anxiety - med/calm enviornment
Monitoring for complications - BIG ONE

N. interventions - Neurological disorders - Guillain-Barre Syndrome

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Autoimmune disorder affecting myoneural junction. - normal Ach released from muscles - antibodies onto muscle and stopping Ach from being absorbed - muscle weakness and some paralysis
Acetylcholine receptor sites impair transmission/impaired
Decreased receptor stimulation
Muscle weakness escalates with continued activity - limited amount of Ach
Women greater than Men
75% thymus gland issue - thioma and need thymus gland removed

Pathophysiology - Neurological disorders - myasthenia gravis

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Diplopia/ptosis (80%) - Double vision and drooping eyelids
Face and throat muscle weakness - meds 45-60 min to prevent aspiration isues
Dysphonia - diff talking
Dysphagia - Increase risk choking/aspiration
Generalized weakness - motor involvement so lots pain
Pure motor; no sensory involvement

CM - Neurological disorders - myasthenia gravis

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Acetylcholinesterase inhibitor test - only used diagnose; not work as long-term therapy; marked improvement of weakness - esp in face
WARNING: likes cause cardiac arrhythmias/arrest - if do this want know antidote (atropine) available
Lab: acetylcholine antibodies
Ice test - hold over area that has muscle weakness - allows for reabsoprtion and see symptom disappear
Repetitive nerve stimulation - weaken area

Diagnostics - Neurological disorders - myasthenia gravis

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Pharmacologic therapy: Pyridostigmine; Main med; increasing concentration of available acetylcholine 4X day
Take before meals (45-60 minutes before)
Therapeutic plasma exchange - Plasmapheresis; looks like dialysis; removes offending antibodies
Surgical management
Thymectomy

Med surg treatment - Neurological disorders - myasthenia gravis

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Ineffective airway clearance - weaker not able get airway open
Interrupted family process
Fatigue
Impaired physical mobility - big deal with myasthenic crisis; could also have complete resp failure and need be intubated
Imbalanced nutrition
Impaired swallowing
Hard time with getting muscles move

N. diagnosis - Neurological disorders - myasthenia gravis

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Conserve energy
Consistent routines
Avoid excessive activity/stress
Avoid High environmental temp - decreased Ach ability be reabsorbed
Medication prior to meals - Prevent choking/aspiration
Tape eye closed /eye drops - crisis/relapse - Prevent corneal damage

N. interventions - Neurological disorders - myasthenia gravis

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Loss of dopamine stores
Results in more excitatory neurotransmitters
Imbalance affects voluntary movement
Males greater than Women
15% early onset due to genetic mutation
Involuntary movements: tremors, walking, eating (high rate aspiration)

Patho - Neurological disorders - Parkinson’s Disease

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Four cardinal signs
Tremor
Rigidity
Bradykinesia/akinesia - slow to no movement
Postural Instability
2 Types
Tremor dominate
Non-tremor dominate - a kinetic-rigid and postural instability
Diagnosis - need at least 2 of 4 cardinal symp

CM - Neurological disorders - Parkinson’s Disease

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Unilateral (1) limb involvement
Minimal weakness
Hand and arm trembling

Stage 1 (Initial Stage) - Neurological disorders - Parkinson’s Disease

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Bilateral limb involvement
Masklike face – flat affect and face
Slow, shuffling gain - not able walk well - gait disturbances

Stage 2 (Mild Stage) - Neurological disorders - Parkinson’s Disease

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Postural instability
Increase gait disturbances

Stage 3 (Moderate Disease) - Neurological disorders - Parkinson’s Disease

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Akinesia - not moving well at all and lot rigidity
Rigidity

Stage 4 (Severe Disability) - Neurological disorders - Parkinson’s Disease

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As get into later stages - also psychiatric component - can have hallucinations

Stage 5 (Complete ADL Dependence) - Neurological disorders - Parkinson’s Disease

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Good History
Four cardinal signs (need 2 of 4)
Diagnosis confirmed by a positive response to a levodopa trial - relieve manifestations of PD
PET – Rule out for any other disease process; not diagnostics for PD
Single-photon emission CT – Rule out for any other disease process; not diagnostics for PD

Diagnostics - Neurological disorders - Parkinson’s Disease

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Pharmacotherapy
Levodopa-most effective; reuprtake
Converts to dopamine –relieves manifestations
Surgical Treatment
Deep brain stimulation (DBS)
Electrode implanted/blocks anticholinergic release
Blocks Ach allowing more dopamine to be absorbed

Medical management - Neurological disorders - Parkinson’s Disease

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Impaired physical mobility
Self-care deficits
Constipation - lack good phys mobility
Impaired nutrition - high risk of aspiration
Risk for injury
Impaired verbal communication
Knowledge deficit
Family and patient

N. diagnosis - Neurological disorders - Parkinson’s Disease

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Improve mobility within safety
Enhancing self care activities - providing assistive devices, built up spoons, walkers, help them be as independent
Improved bowel elimination - up walking; stool softeners
Improved nutrition - Aspiration risk; speech therapy
Enhanced swallowing
Assistive devices
Family/Pt education - lots pt and fam edu - PT, OT, speech

N. interventions - Neurological disorders - Parkinson’s Disease

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Cognitive, functional, and behavioral changes eventually destroy a person’s ability to function
Phys and mental
Subtle in onset; progress slowly
Not a normal part of aging
Non-Alzheimer dementias; Vascular dementia (multiple small infarcts in the brain that eventually cause the person not be able to func)

Patho - Neurological disorders - Dementia

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Specific neuropathologic and biochemical changes that interfere with neurotransmission Neurolgoic and biochem change that affect neurotransmission Most common disease process with dementia Early onset (familial/genetically 40-65 years) Late onset (greater than 65 years) - MOST COMMON Risk factors

Alzheimer’s - Neurological disorders - Dementia

Age Gender Genetics

risk factors - Alzheimer’s - Neurological disorders - Dementia

Independent in ADLs - Care of self on own Denies presence of symptoms - not deny it Forgets names; misplaces household items Has short-term memory loss and difficulty recalling new information - STM big one; LTM good Shows subtle changes in personality and behavior Loses initiative and is less engaged in social relationships Has mild impaired cognition and problems with judgment Demonstrates decreased performance, especially when stressed - confused easily when stress Unable to travel alone to new destinations Often has decreased sense of smell

Early (Mild), or Stage I (First Symptoms up to 4 Years) - CM - Neurological disorders - Dementia

Has impairment of all cognitive functions Demonstrates problems with handling or unable to handle money and finances Is disoriented to time, place, and event Is possibly depressed and/or agitated - LOT AGITATION Is increasingly dependent in ADLs Has visuospatial deficits: has difficulty driving and gets lost - end up ditch; nothing not where think should be Has speech and language deficits: less talkative, decreased use of vocabulary, increasingly nonfluent speech, and eventually aphasic Incontinent Psychotic behaviors, such as delusions, hallucinations, and paranoia Has episodes of wandering; trouble sleeping - lots agitation at this time

Middle (Moderate), or Stage II (2 to 3 Years) - CM - Neurological disorders - Dementia

Completely incapacitated; bedridden Totally dependent in ADLs Has loss of mobility and verbal skills Possibly has seizures and tremors Has agnosia

Late (Severe), or Stage III - CM - Neurological disorders - Dementia

Clients can show manifestations from any stage at any time Clients can have issues from any stage at anytime Mix and Match from diff stages and can slide between stages Health promotion - not mitigate or prevent but ward it off for slow period time

CM - Neurological disorders - Dementia

History - HUGE Physical assessment/manifestations Psychosocial assessment Laboratory – Rule out Radiological – Rule out

Diagnostics (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Behavioral management structured environment (NEED Consistency) Cognitive stimulation - bringing up to present Memory training Validation therapy (Orientation) - re-orientatin - care with this because can become agitated Redirection Pharmacologic therapies: Donepezil (Aricept) - not cure; only Improves symptoms

Med surg treatment (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Supporting Cognitive Function Promoting Physical Safety - locked unit - often wander off Promoting Independence in Self-Care Activities Reducing Anxiety and Agitation - consistency and calm enviornment Improving Communication Providing for Socialization and Intimacy Needs - hypersexuality often experienced Promoting Adequate Nutrition Promoting Balanced Activity and Rest Home, Community and Transitional to memory Care unit

N. management (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Calm, predictable environment; Limit environmental stimuli Quiet, pleasant manner of speaking, clear and simple explanations Use of good memory aids; Displayed clocks and calendars Active participation help patients maintain cognitive, functional, and social interaction abilities for a longer period

Supporting Cognitive Function - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Simplify daily activities by organizing them into short, achievable steps Lessen bulk ADLs into steps

Promoting Independence in Self-Care Activities - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Remove fall risks/hazards; install hand rails - slip hazards removed Secure doors Wandering –gentle distraction/ persuasion/redirection Avoid restraints - lot more agitated

Promoting Physical Safety - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Need constant emotional support that reinforces a positive self-image Environment should be kept familiar and noise free Combative, agitated state: remain calm and unhurried; never force - try to redirect Move to familiar environment; try stroking, rocking, music; Be sure pain free

Reducing Anxiety and Agitation - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Use of clear, easy-to-understand sentences to convey messages Tactile stimuli (hugs or hand pats) signs of affection, concern, and security.

Improving Communication - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Encourage to participate in simple activities Care of plants or a pet - good positive reinforcement

Providing for Socialization and Intimacy Needs - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Keep simple and calm, without confrontations Cueing may be necessary to encourage adequate nutrition and hydration Food is cut into small pieces to prevent choking. Liquids may be easier to swallow if they are thickened temperature of the foods should be checked to prevent burns

Promoting Adequate Nutrition - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Exhibit sleep disturbances, wandering, etc.; occur when there are unmet underlying physical or psychological needs - look for sleep disturbances Music, warm milk, or a back rub may help the patient relax Help Participate in exercise; discourage long periods of daytime sleeping

Promoting Balanced Activity and Rest - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Enormous emotional burden on family/Family provide 80% of home care Check into this as nurse; fam caregiver strain - horrible toll on fam/pt May cling to the hope-diagnosis is incorrect and relative will improve - forthright - progressive state Numerous difficult decisions (stop driving, assume responsibility for finances) - taking away independence Aggression and hostility exhibited often when misunderstood by caregivers Neglect or abuse of the patient can occur responsibility of nurse is to report suspected abuse, not to prove it Family support groups, respite (relief) care, and adult day care may be available through different community resources Nursing home placement

Home, Community and Transitional Care - Nursing (Dementia - Alzheimer’s) - Neurological disorders - Dementia

Seizures: Abnormal sudden, excessive, uncontrolled electrical discharge of neurons within a section of brain Characteristic “seizure” manifestation of this excessive neuronal discharge Can be Genetic or Structural /metabolic condition in nature Lab and imaging to find out what is going on Pseudoseizures - non-electronic

Patho - Neurological disorders - seizure disorders

Generalized Tonic/Clonic Granmal Partial Absence Many subcategories Epilepsy: two or more seizures experienced by a person - idiopathic condition

Classifications - Neurological disorders - seizure disorders

History MRI - structural probs in brain (tumors) EEG - electrical abnormalities Microelectrodes/Depth Electrode Placement - electrodes inside brain and see where seizure coming from and ablate track to stop seizure

Diagnostics - Neurological disorders - seizure disorders

Medications Anticonvulsants Dilantin Tegretol Surgical Removal Tumors, abscesses, cysts, or revascularization of vascular anomalies Refractory to meds vagal nerve stimulator (VNS) responsive neurostimulation system (RNS)

Med surg treatment - Neurological disorders - seizure disorders

Acute confusion - during and after seizure Social isolation Risk for ineffective airway clearance Risk for falls Risk for Injury Risk for powerlessness

N. diagnosis - Neurological disorders - seizure disorders

Observation and documentation of seizure - have an aura, length of seizure, presentation of seizure, post-ictal period (until back awake and functioning normally) Side rails up and padded Side-lying position - not until seizure done - left side preferred Oxygen Suction equipment - actively seizing only between teeth and cheek - can bite through easily swallow and obstruct airway Airway IV access Monitor Complications-lab Medications must be on time - missed dose and therapeutic labs fall

N. interventions - Neurological disorders - seizure disorders

Provide privacy and protect patient from curious onlookers Ease patient to floor, if possible, if standing Protect pts head with a padding to prevent injury Loosen constrictive clothing and remove eyeglasses - if in bed and start seizing - first thing is hang self on gown Push aside any furniture, etc. that may injure patient during seizure If patient is in bed, remove pillows and raise side rails Do not attempt insert anything in the mouth during a seizure. - bite through it If suction is available, use it if necessary, to clear secretions and while actively seizing between teeth and cheeck

Nursing care during a seizure

5 min to 3-4 hrs Make sure the airway is patent. - diff to keep airway open Place the patient on one side to prevent aspiration. - left side best On awakening, reorient the patient to the environment. If the patient is confused or wandering, guide the patient gently to a bed or chair. If the patient becomes agitated (does happen) after a seizure (postictal), stay a distance away, but close enough to prevent injury until the patient is fully aware. Stay with until 100% back

Nursing care after (postictal) seizure

Oxygen tubing Oxygen and suction apparatus available Loosened clothing Two to three side rails up and padded Bed in lowest position Patient in side-lying position (immediate post-seizure) Privacy provided ASAP

What do in seizure

Interfere with respirations Repeated episodes of cerebral anoxia and edema - can lead to death; irreversible and fatal brain damage

Prolonged seizures last more than 5 minutes or repeated seizures over course of 30 minutes - Status epilepticus: medical emergency!

Interruption of anticonvulsant medication Fevers - high; lower threshold Concurrent infection

Risk events - Status epilepticus: medical emergency!

Establish airway ABCs IV push lorazepam, diazepam - anticonvulsants not work; benzo work on CNS to depress Rectal diazepam (if no IV) IV phenytoin Later to keep seizure free ICU Happens almost always go to ICU - put into pentobarbital coma to keep from seizing until figure how what need to do to prevent it May need IV drip to keep seizure free

Emergency care - Status epilepticus: medical emergency!

Take anticonvulsant daily as prescribed to keep the drug level constant Never discontinue medications, even if there is no seizure activity Keep a medication and seizure record - if possible; auras; seizure length Notify the primary provider if unable to take medications due to illness Have anticonvulsant medication serum levels checked regularly - too high or low - bad; need therapeutic range Carry identification card: name medication and primary provider; med alert bracelet Avoid seizure triggers: alcoholic beverages, stress, fever, hypoglycemia; strobe light Take showers; never swim alone; not take baths Avoid excessive heat - higher temp lower seizure threshold Develop regular sleep patterns to minimize fatigue and insomnia If recognize aura - get some place where safe

Nursing education: epilepsy

Inflammation of the meninges, which cover and protect the brain and spinal cord. - inflammation of brain and SC 2 diff ways: bloodstream infection/spread directly from fracture of skull allows infection Big deal: basilar skull fracture Infection through blood stream or direct spread Proliferates in CSF - heavily saturated with glucose Can cause Inflammation and Increase ICP

Patho - Neurological disorders - meningitis

Hemorrhages/vascular necrosis (Waterhouse–Friderichsen syndrome) - adrenal gland failure causing necrosis within the brain - started by meningitis Circulatory collapse Septic shock Blindness/deafness - attacking optic tract Paralysis/seizures Hydrocephalus - water on brain

Comps - Neurological disorders - meningitis

Severe headache - because of Increased ICP Neck immobility (nuchal rigidity) - not move neck Photophobia - any type of light bother them Also see either + Kernig sign (lying with thigh flexed on abdomen and leg cannot be completely extended; bilateral meningeal irritation)/Brudzinski sign (neck flexed after ruling out cervical trauma - flexion knees and hip produced and when LE or one side passively flexed similar movement seen in oppositie extremity)

CM - Neurological disorders - meningitis

Identify causative agent - hit by something Lumbar Puncture CSF culture and sensitivity Viral or Bacterial or Fungal What do they look like? Blood culture and sensitivity CT if altered LOC

Diagnostics - Neurological disorders - meningitis

Broad-spectrum antibiotic - start until know causative agent Steroids - high risk for infection and hyperglycemia IV fluid volume expanders –shock - prob with circ collapse Anticonvulsants-seizures Prophylaxis treatment for those in close contact with meningitis-infected patient - college dorms Vaccinations available

Med surg treatment - Neurological disorders - meningitis

Ineffective airway clearance Impaired comfort - neck; nuchal rigidity Impaired mobility Acute pain Risk for aspiration Risk for injury

N. diagnosis - Neurological disorders - meningitis

Ensure patent airway Pain management Good I&O and good VS management - start consider sepsis encourage fluid intake and make sure getting good peripheral/central IV fluids Encourage fluid intake Close neurologic monitoring - trend if getting better/worse; worse - contacting and collab with PCP Collaborative with physician

N. interventions - Neurological disorders - meningitis

Infection control precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious - in area) Assisting with pain management Assisting with getting rest in a quiet, darkened room - high risk for seizures Treat elevated temperature: antipyretic agents and cooling blankets - high risk for seizures Maintaining hydration either orally or peripherally Ensuring close neurologic/respiratory monitoring Protecting from injury secondary to seizure activity or altered LOC - increasing ICP Monitoring daily body weight; serum electrolytes; and urine volume, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected Preventing complications of immobility: pressure ulcers and pneumonia (SCDS and heparin)

Nursing - Neurological disorders - meningitis

involves local necrotizing hemorrhage that becomes more generalized, followed by edema. - dead tissue, blood coming out, fluid accumulating on the brain viral, bacterial, fungal: Herpes simplex most common cause in US

Pathophysiology - Neurological disorders - encephalitis

Fever, headache, confusion, and hallucinations Focal neurologic symptoms reflect areas of cerebral inflammation and necrosis - wherever affecting brain - reflected out within body

Clinical manifestations - Neurological disorders - encephalitis

Diagnosis: MRI, LP (lumbar puncture), EEG Medication Antiviral: Acyclovir - very good for this because can cross blood-brain barrier Complications Atelectasis or pneumonia

Medical - Neurological disorders - encephalitis

Ensure airway Pain management I&O Encourage fluid intake Close neurologic monitoring Collaborative with physician

N. interventions - Neurological disorders - encephalitis

Primary Direct contact to the head/brain during the instant of initial injury This what cause the injury Secondary Inadequate delivery of nutrients and oxygen to the cells Swelling stops from O2 and nutrients causing further injury Results in increased intracranial pressure (ICP)

Patho - Neurological disorders - traumatic brain injury

Decreased cerebral perfusion - could cause: Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance HIGH Risk of posttraumatic seizures

Comps - Neurological disorders - traumatic brain injury

Diagnostics See what trending specimens tell us Neuro exam CT, MRI, PET - look for deformities Medical/Surgical Treat increased ICP - mannitol Supportive measures - intubation, blood pressure support Brain death - Potential donor

Med surg treatment - Neurological disorders - traumatic brain injury

Ventilatory support Airway support Seizure prevention - anticonvulsant Fluid and electrolyte maintenance, GOOD nutritional support Assess for Pain and anxiety NG tube

Supportive measures - Neurological disorders - traumatic brain injury

Ineffective airway clearance and impaired gas exchange Risk for ineffective cerebral tissue perfusion Deficient fluid Imbalanced nutrition: less than body requirements Risk for injury Risk for impaired skin integrity

N. diagnosis - Neurological disorders - traumatic brain injury

ICU admission Maintain airway Monitor neuro function - BIG: GCS; below 8 need to intubate Monitor fluid and electrolytes Promote adequate nutrition Prevent injury Maintain body temperature - esp if hypothalamus involved Maintain skin integrity

N. interventions - Neurological disorders - traumatic brain injury

Occupies space within the skull, growing as a spherical mass or diffusely infiltrating tissue. - lesions as well Cause: Increased intracranial pressure Seizure activity Hydrocephalus - water on brain Primary Tumor arose from brain tissue Secondary Cancer metastasized from somewhere else in body Often in lung cancer pts

Patho - Neurological disorders - brain tumors

Increased intracranial pressure as seen by: Headache Vomiting Visual disturbances Seizures Pupillary changes - incredibly late sign Localized manifestations

CM - Neurological disorders - brain tumors

Neurologic exam - trending of the data CT scan - Structure of brain MRI - Structure of brain Computer assisted stereotactic biopsy - get into tumor PET scan - tag for cancer related cells

Diagnostics - Neurological disorders - brain tumors

Surgical management - crainectomy and tumor removal Radiation therapy - intrathecal - intrabrain - omein reservoir sunk into head Chemotherapy Pharmacologic therapy

Med surg treatment - Neurological disorders - brain tumors

Acute confusion Fear Decreased intracranial adaptive capacity - lead to herniation Acute pain Vision loss Risk for injury

N. diagnosis - Neurological disorders - brain tumors

Assess neuro status/reorient as necessary Alleviate fear Treat pain - lot neurological disorders not want lot pain meds because mask events Assess for visual acuity - grow around optic chiasm and end up blind Provide safe environment - low stimulation enviornment

N. interventions - Neurological disorders - brain tumors

An injury to spinal cord, vertebral column, supporting soft tissue, or intervertebral discs caused by trauma; including: Transient concussion Contusion Laceration Compression/transection Can lead to: Paraplegia or Tetraplegia (quadriplegia)

Patho - Neurological disorders - SCI

Type and level of injury Cervical (C5-C7) - above C5 hard time staying alive but automatically need be on ventilator Thoracic (T12) Lumbar (L1) Complete vs incomplete Complete - all stuff cut out Incomplete - some cut out Primary and Secondary injury Primary - first thing that happened then as SC swells might see other injuries occur within the SC

CM - Neurological disorders - SCI

Acute respiratory failure is a leading cause of death Respiratory dysfunction related level of injury diaphragm (C4), - on vent intercostal (T1–T6), Abdominal muscles (T6–T12) C4 or above-ventilator support

Primary - Neurological disorders - SCI

Hemorrhage Ischemia Hypovolemia Impaired tissue perfusion Local edema – spinal shock Hypoesthesia decreased sensation Hyperesthesia increased sensation Where located and how affected SC

Secondary injury - Neurological disorders - SCI

Critical improper handling of patient can cause further damage Patients in motor vehicle crash, diving/sports injury, fall, or any direct trauma to head and neck treat as SCI until such an injury is ruled out! Immobilized on a spinal (back) board; maintained in extended position - immobilize neck; put on rotating beds without hurting neck Head and neck maintained in a neutral position - keep neck immobilized Not allowed to sit up Referred to a regional spinal injury or trauma center Extent of injury determined Placed on a rotating specialty bed or in a cervical collar

Emergency management - Neurological disorders - SCI

Neurologic exam X-rays/CT scan/MRI/EKG Complications Spinal shock/Neurogenic shock Venous Thromboembolism - not moving anything not push blood back up allowing it to coag

Diagnostics - Neurological disorders - SCI

Acute Prevent secondary Injury/complications Pharmacologic Therapy IV corticosteroids - stop swelling which cause further paralysis if SC invovled Oxygen Hypoxemia worsen injury Feeding SC Skeletal Fracture Reduction and Traction Surgical Management - includes caging

Med surg treatment - Neurological disorders - SCI

Ineffective breathing patterns Ineffective airway clearance Impaired bed and physical mobility Risk for injury Risk for impaired skin integrity - BIG Impaired urinary catheter elimination - huge in autonomic hyper/dysreflexia Constipation - huge in autonomic hyper/dysreflexia

N. diagnosis - Neurological disorders - SCI

Promoting adequate breathing and airway clearance Improving mobility Preventing injury Maintaining skin integrity - can cause autonomic hyper/dysreflexia Maintaining urinary elimination - can cause autonomic hyper/dysreflexia Improving bowel function - can cause autonomic hyper/dysreflexia Providing comfort measures

N. interventions - Neurological disorders - SCI

Acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli (Cord lesions above T6) - usually above T6 Occurs only after spinal shock has resolved - shock over and another issue revealed Severe, pounding headache with paroxysmal hypertension (230/150, profuse diaphoresis above spinal level of lesion (most often forehead), nausea, nasal congestion, and bradycardia. Sudden increase in blood pressure may cause retinal hemorrhage, hemorrhagic stroke, myocardial infarction, or seizures Distended bladder (the most common cause); constipation; or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer) - main reasons see this Must remove the offending issue

Recognizing autonomic dysreflexia

Pt immediately placed in a sitting position to lower blood pressure Rapid assessment to alleviate cause - must do this bladder is emptied/bowel emptied/skin examined - palpate bladder; check skin and bowel Any other stimulus: object next to skin or a draft of cold air can cause this, must be removed - take care of that - still have HTN Measures do not relieve hypertension and causes excruciating headache, antihypertensive medications may be prescribed; slow IV route. - bring HTN down Once autonomic dysreflexia started even if remove offending structure, BP stay high - must use antihypertensives Medical record labeled with risk of autonomic dysreflexia Instructed about prevention and management measures - since could happen at home

Care of autonomic dysreflexia rxn

Chronic disease characterized by demyelination and axonal nerve damage SCI Immune mediated Women greater than men; 25 – 35-year-old Risk Factors Viruses-Epstein-Barr virus Genetic predisposition Types Relapsing-remitting (85%) Have relapse and have probs then go back to norm when done; until not then relapse and nothing happens Primary progressive Secondary progressive Progressive-relapsing

Patho - Neurological disorders - multiple sclerosis

Depends on location of lesions-mild to severe Where located within SC/brain Fatigue/Weakness Spasticity lower extremities - baclofen to relax muscles Bowel, Bladder, sexual dysfunction Pain, paresthesia's Visual disturbances (double vision) - muscle issue or optic tract Emotional lability/disturbances

CM - Neurological disorders - multiple sclerosis

MRI Presence of multiple plaques CNS GOLD STANDARD Where plaques located see neurological dysfunc Lumbar puncture- cerebral spinal fluid (CSF) sample

Diagnosis - Neurological disorders - multiple sclerosis

No cure/ONLY Delay progression Symptom management Medication therapy Acute exacerbation relapse Methylprednisolone IV Followed by oral prednisone taper Have use steroids to slow autoimmune Reduce relapses Interferons

Medical - Neurological disorders - multiple sclerosis

Impaired home maintenance management - fall hazards Ineffective coping Impaired physical mobility - loss Risk for injury RT sensory and visual impairment

Nursing Diagnosis - Neurological disorders - multiple sclerosis

Promoting physical mobility - strengthening, adaptive devices Preventing injury Enhancing bladder and bowel control Enhancing communication and managing swallowing difficulties

Nursing Interventions - Neurological disorders - multiple sclerosis

Maximize neuromuscular function Maintain independence of ADL as long as possible - adaptive measures (house one level, no step house, no slip trip hazards) Manage disabling fatigue Optimize psychological well-being Adjust to chronic illness Prevent complications of immobility - VTE or atelectasis in lungs Reduce triggers that precipitate exacerbations Energy conservation Optimal nutrition Environmental safety Protection from heat, cold, pressure Vision disturbances Bladder problems – UTI common - keep clean Constipation - increase fiber; stool softeners Emotional support for patient and family

Nursing - Neurological disorders - multiple sclerosis

Medications Purpose, dose, route, schedule, side effects, and precautions Steroids - increase risk infection and hyperglycemia When to contact HCP - esp feel relapse/remission coming on Environnemental modifications and adaptive techniques Strategies to manage symptoms (pain, cognitive responses, dysphagia, tremors, visual disturbances). Optimal nutritional intake; consider weight reduction if obese Manage bowel and bladder function Self-catheterization knowledge due to Neurogenic Bladder Minimize immobility/spasticity Identify sources of support - community resources; fam Prevent complications (e.g., pressure ulcers, pneumonia, depression).

Pt edu - Neurological disorders - multiple sclerosis

Exact cause unknown Thought: Over excitation of nerve cells by neurotransmitter glutamate results in cell injury and neuronal degeneration Motor neuron cells die in anterior horn of spinal cord and lower brainstem Muscle fibers atrophy

Patho - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)

Viral infections Autoimmune disease Environmental exposures to toxins Genetics-Autosomal dominant Age 40-60 Males

Risk factors - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)

Cognition intact while body wastes away - brain works perfectly Muscle weakness Atrophy of muscles including Arms-trunk-legs Spasticity - motor only; lot of pain Fasciculation's (twitching) Lack of coordination Resp. insufficiency/Aspiration risk Bowel and bladder not affected

CM - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)

Manifestations No clinical/labs testing available Neuropsychological testing MRI scan may show high signal intensity in corticospinal tracts

Diagnosis - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)

No cure Riluzole, a glutamate antagonist Baclofen - muscle spasticity Psychosocial ramifications Trapped, dependent on others Explore suicidal ideation Anti-depressives May need counseling Life support - decision if want be on life support

Med surg treatment - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)

Maintain patent airway Prevent aspiration & respiratory infection Facilitate communication Provide diversional activities Maintain optimal nutrition Decrease risk of injury related to falls Decrease pain secondary to muscle weakness Support patient and family to manage disease process including grieving related to loss of motor function and ultimate death Encourage exercise to reduce spasticity Patient / Family coping resources Support self-care abilities Support nutrition - include PEG tube/enteral feeding Adequate rest Self-help devices Physical therapy Occupational therapy Speech therapy

Nursing - Neurologic disorders - Amyotrophic Lateral Sclerosis (ALS)