Chapter 77 Nervous System Disorder

Front 1

(2) Differentiate among the following diagnostic tests: CT, PET, MRI, cerebral angiography,

Back 1

CT incorporates x ray and computer technology to produce an image of a transverse body plane

MRI uses powerful magnetic field which produces precise images.

PET is a type of tomography used to study changes within the brain. Glucose containing a radioisotope is injected into the brain. After the scan the client remains flat in bed for a few hours and is observed for irritation such as stiff neck or pain when bending head forward.

Cerebral Angiography is an x ray study of a blood vessel. ANTERIORGRAM is the study of an artery; both use a dye injected into the carotid or femoral artery; x ray are taken of the brain’s blood vessels to detect abnormalities.

Front 2

2) Differentiate among the following diagnostic tests: cerebral arteriography, myelography, brain scan, electroencephalography and videotelemetry

Back 2

Myelography performed to visualize the spinal cord. Less commonly used. A lumbar puncture is done and a radiopaque substance is injected into the spinal canal. PRONE position; little side effects since water soluble solution is used today.

Brain Scan involved the injection of radioactive substance which is ten detected by a scanner that generates images as the substance circulates within the brain vasculature

Electroencephalography EEG records the brain’s electrical impulses as a graph; used frequently in the diagnosis of seizure disorders, brain tumors, blood clots and infections and sleep disorders. Collodion glue used with electrodes to place on forehead; painless, no aftereffects, takes one to two hours to complete. No electric shock will be given and the procedure cannot detect mental thoughts.
Depending on the situation some test require no sleep the night before and others require a sedative. Lights may be flashed on a monitor wherein the brains’ response is recorded.

Front 3

(3) Discuss the nurisng care involved for a client before and after an LP

Back 3

1. Identify the client and ask the client to empty the bladder. RATIONALE: Proper identification of the client is essential to ensure that the procedure is completed for the correct person. Emptying the bladder helps the client avoid the discomfort of a full bladder.

2.Take and record the client’s vital signs before the procedure. RATIONALE: Obtaining vital signs before the procedure provides a baseline assessment for later comparison.

3.Assist the client with removing any clothing and putting on a gown; drape the client with a bath blanket or sheet. RATIONALE: The gown provides easy access to the proper site. Draping provides privacy and warmth, if needed

4.Place equipment within the physician’s reach. Open packs and make sure extra sterile gloves are available. Provide extra lighting as necessary. RATIONALE: Organizing sup-plies and equipment enhances efficiency.

5.Position the client on his or her side with the lower part of the back at the edge of the bed. Help the client to draw his o

Front 4

3) Discuss the nurisng care involved for a client before and after an LP

Back 4

6.When the procedure begins, move the drape to uncover the client’s back. Tell the person to lie very still, holding the client in place if necessary. RATIONALE: Any sudden movement is dangerous and could cause spinal cord damage.

7.Talk to the client during the procedure, offering reassurance as necessary. RATIONALE: This procedure can be frightening. The client needs to relax and remain still
8.Assist as requested, such as with removing caps on bottles, labeling specimens, or assisting with dressing placement over the LP site. RATIONALE: The procedure must be done using strict aseptic technique. Assistance helps to minimize the possibility of contamination.

9.Note the beginning CSF pressure, as measured by the physician. Also look at the color and clarity of the CSF, which should be pale and clear. RATIONALE: This information is important in determining the client’s disorder.

10. Monitor the client for any difficulties or problems. RATIONALE: Untoward side effects are rare, but they can

Front 5

(4) Compare and contrast migraine and cluster headaches, including nursing considerations for each condition

Back 5

MIGRAINE:
Cause Unknown / Vascular Disturbance
a/k/a Vascular Headache
Sensory Warnings/Premonitions
Run in Families
Mood Swings, Anorexia
Numbness of body part, Visual symptoms (flashing lights)
CLUSTER
a/k/a Histamine headache
Cause from vascular disturbance
Occur in clusters at night
Occur more in Men than Women
Affects one side, involves the eye
diaphoresis (sweating), Lacrimation (tears)

Front 6

(5) Identify the main characteristic of at least three types of partial seizures and at least six types of general seizures

Back 6

Partial or Focal Seizure
1. Partial/Simple localized shaking movements
2. Complex consciousness is impaired but not totally lost
3. Jacksonian rhythmic jerking movements
4. Adversive person may become combative
5. Sensory:unpleasant hallucinations, talks unintelligibly, vertigo

General Seizure- involves both hemispheres of the brain
1. Tonic-clinic (grad mal) convulsion, temporary loss of consciousness
2. Absence of seizure (petit mal) between 5-15; no convulsion but demonstrates twitching facial muscles and fluttering eyelids
3. Tonic Seizures – severe muscle spasms
4. Atonic Seizures – brief periods, usually in children, complete loss of muscle tone and consciousness
5. Myoclonic seizure—quick jerking of one or more limbs or trunk; brief but repetitive, no loss of consciousness.
6. Status epilepticus—medical emergency; intense muscle contractions and dyspnea lasting 15 minutes or more.
Unclassified: all seizures cannot be classified; s/s
high fever,malaise

Front 7

(6) Identify the key components of nursing care for a client with a seizure disorder, epilepsy, status epilepticus

Back 7

Place on seizure precautions: oral airway, suction setup, setup of piggyback port on an open IV, rectal or tympanic temperature probe, raised and padded side rails (all four rails). Concern for the drugs given IV danger of overdose; be alert for CNS signs (drowsiness, lethargy) respiratory depression and cardiovascular signs; Monitor kidney function: drugs cause damage.

Documentation must include what the person was doing at the seizure onset, where the seizure began and if and how the person fell, time of day, triggering events, seizure progression, symmetry, eye response, responsiveness, results of commands and memory tests, duration, direction of eye gaze, eye movements, confusion, incontinence, drooling and diaphoresis. Document what client says and does, check eye signs and LOC.

Front 8

Discuss the causes, signs and symptoms, and nursing implications for the following involving nerves: trigeminal neuralgia, Bell's Palsy, herpes zoster

Back 8

Trigeminal Neuralgia has pain at 5th cranial nerve (jaw and part of face) cause unknown; older people.
S/S
Treatment: medication or surgery

Bell’s Palsy temporary, partial, one-sided facial paralysis and weakness caused by ischemia or inflammation of the 7th cranial nerve.
s/s lopsided facial appearance, eye on affected side will not close, drooling
Treatment: special eye care, hear and massage, Prednisone (Meticorten, Orasone) may take months to for symptoms to subside.

METICORTEN-

ORASONE-

Herpes Zoster a/k/a Shingles, acute viral inflammation of nerve caused by varicella-zoster virus; results from reactivation of latent virus cells.
s/s mild to moderate Pruritis “ITCHING”, tenderness, pain frequently precedes the appearance of vesicles (3 to 5 days): GI upset and malaise; Vesicles on trunk cause pain but are not always visible on the skin; pain last several weeks to months; confined to one region to the body.
Treatment: Treat symptoms: pain and pruritus with narcotics anti-i

Front 9

(8) Compare paraplegia with quadriplegia, including a discussion of at least four differences in nursing care for each condition

Back 9

After any spinal cord injury the client is at risk for respiratory arrest and spinal shock.
PARAPLEGIA means paralysis of the legs and lower body, it usually results form injury to the cord below the first thoracic vertebra

QUADRIPLEGIA means paralysis of all four extremities and usually results from an injury above the first thoracic vertebra.

Nursing Care:

Front 10

(9) Describe at least five signs and symptoms of autonomic dysreflexia

Back 10

Autonomic dysreflexia: occurs in injury to upper spinal cord
S/S elevated blood pressure, sudden, throbbing headache, chills, pallor, goose flesh, nausea with metallic taste. Requires immediate treatment; elevate client’s head and notify doctor.

Front 11

(10) Discuss the causes, signs and symptoms, therapies, and at least give nurisng considerations for each of the following degenerative disorders: Parkinson's Disease

Back 11

Parkinson’s Disease neurologic disease, chronic progressive disease that affects the dopamine producing cells of the brain.
s/s occur gradually; bradykinesia (slowness of movement) fine, rhythmic tremors of the hands, arms, legs, jaw and face; limbs and trunk become rigid and stiff; unsteady gait.
Treatment: No test to predict; no preventive measures; Surgery performed in carefully selected cases to Thalamus:
Anti-parkinsonism Drug: LEVODOPA “L-dopa”, “Dopa”—replenishes missing dopamine, a neurotransmitter found in the brain; medication may darken the urine.

EDUCATION: be independent as possible; no stress or fatigue; eat well-balanced diet, eye exams, exercise with ROM exercises.

Info about L-dopa: may cause hemolytic anemia; must be used carefully in client with glaucoma, monitor intracculr pressure; may aggravate skin lesions; must avoid certain foods, high protein foods retard absorption of the food and foods high in Vit B which counteract positive effects of L-dopa.

Front 12

(10) Discuss the causes, signs and symptoms, therapies, and at least give nurisng considerations for each of the following degenerative disorders: Multiple Scerosis

Back 12

(MS) is one of the most common nerve disorders in the United States, typically affecting young adult sand people living in northern temperate climates. It is slightly more common in females. Mylein Sheath is damaged causing nerve damage.
Signs and Symptoms
Initially, MS may be manifested as difficulty walking, tremors, lack of coordination, “pins and needles” numbness, and visual changes, including loss of vision. Symptoms may disappear in the early stages, and the person may appear normal and well for years. Each time symptoms reappear, they are more severe and of longer duration. Thus, the disease can be marked by remissions and exacerbations. A person may live 20 years or more after the disease is diagnosed, but disabilities develop over time.
With recurrent episodes, increasingly severe symptoms such as paralysis, dysphagia (difficulty in swallowing), and bladder and bowel dysfunctions develop. Cognitive dysfunction, depression, and emotional upsets are common. The client may complain of fatigue

Front 13

10) Discuss the causes, signs and symptoms, therapies, and at least give nurisng considerations for each of the following degenerative disorders: Huntington Disease

Back 13

Huntington Disease is a chronic, progressive hereditary condition in which brain cells in the basal ganglia prematurely die.
S/S physical, intellectual and emotional symptoms such as abnormal involuntary movements called CHOREA (fidgeting, jerking) Personality changes: irritability, mood swings, depression, loss of judgment. Intellectual: difficulty making decisions and learning new things. These symptoms progress to constant writhing and uncontrollable movement, changes in speech and ability to swallow, great weakness, severe personality disorders, and psychosis. The disease progresses at different rates.
Eventually the person loses bowel and bladder control and all purposeful movement, and is confined to bed rest. Death usually results from pneumonia or another disorder-related complication associated with immobility.
Diagnostic Tests
A thorough medical and family history is important. A genetic test to search for the HD gene is available. Neurologic tests and laboratory tests can be used to differenti

Front 14

10) Discuss the causes, signs and symptoms, therapies, and at least give nurisng considerations for each of the following degenerative disorders: Myasthenia Gravis

Back 14

Myasthenia Gravis chronic autoimmune disorder characterized by an episode of weakness in the voluntary muscles
s/s eye muscle affected first, looking sleepy and expressionless; drooping eyelids “ptosis”; respiratory muscles are affecting causing breathing difficulty; unable to expectorate secretions causing pneumonia; gets tired easily
Diagnostic Test: Lab test to detect antibodies to acetylcholine receptors; Edrophonium test aids in diagnosis wherein “Tensilon” is injected IV and the client will experience temporary relief of symptoms.
TREATMENT: therapies to reduce weakness and improve muscle strength.
Mestinon, anticholinesterase agent; Prednisone, Cyclosporine to suppress the production of antibody. DO NOT USE SEDATIVES: MORPHINE.
PLASMAPHERESIS procedure in which antibodies are removed from the blood.
Surgical: Thymectomy surgical removal of the thymus gland.

Front 15

10) Discuss the causes, signs and symptoms, therapies, and at least give nurisng considerations for each of the following degenerative disorders: Amyotrophic Lateral Scelorosis

Back 15

Amyotrophic lateral sclerosis also known as LouGehrig’s disease,
is a rapidly progressive, fatal neurologic disorder resulting in destruction of motor neurons of the cortex, brain stem, and spinal cord. Voluntary muscle movement gradually degenerates. ALS usually strikes between ages 50and 70 years and affects more men than women.
S/S: the loss of motor neurons causes muscles to atrophy. Initially the individual may fall frequently and lose motor control of the hands and arms. The individual experiences weakness, fatigue, and spasticity of the arms. As the disease advances, muscles atrophy, with flaccidquadriplegia. Eventually, the respiratory muscles are involved. The course of the disease is consistent, with no remissions.ALS always progresses to respiratory dysfunction and death, generally within 5 years after onset, although the course of the
Treatment
There is no cure or therapy that will lessen the progress of or reverse the disorder. The first drug shown to prolong survival of ALS clients is ril

Front 16

(11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders:Brain Abscess

Back 16

Brain abscess
collection of pus that may result from an infection of the ears, mastoid, sinus, or skull. It can also directly result from brain surgery. S/S mimic those of a brain tumor. The person may also experience a fever if the primary infection site is still infected. Those with brain abscesses are at risk for ↑ICP and seizures, as well as spread of the infection.
TREATMENT: Surgical treatment is necessary to drain the abscess. Massive doses of IV antibiotics are given preoperatively and postoperatively. The person may be left with some brain damage or may be completely cured.
Nursing Considerations:

Front 17

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Meningitis

Back 17

Meningitis is an inflammation of the meninges, the membranes that cover the brain and the spinal cord. Infection can travel to the meninges from nearby structures, such as the sinuses or the middle ear. The bloodstream also may carry the infection. Meningitis is a contagious infection. Direct contact with respiratory secretions can transmit the organism from one person to another.
RISK: children and caregivers in daycare centers along with military personnel, college students living in dormitories, and infants and young children. People who are exposed to active or passive tobacco smoke are also at risk.
CAUSE: Viruses, fungi, or bacteria cause meningitis. Three organisms (Streptococcus pneumoniae, Neisseriameningitides, and Haemophilus in fluenzae, type b) cause about70% of bacterial meningitis.
S/S: fever, chills, severe headache, nausea and vomiting, nuchal rigidity (stiff neck), and irritability. A change in LOC is present. Two neurologic signs a represent: positive Kernig’s sign and positive Br

Front 18

(11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Meningitis
CARD TWO --Diagnostic Test

Back 18

Diagnostic Tests
Meningitis is diagnosed based on a general neurologic examination that includes two special neurologic signs:

Kernig’s sign: The client lies on the back and brings one leg up so that the hip and knee are both flexed at 90°. He or she then straightens the knee (the sole of the foot toward the ceiling). Pain or resistance indicates meningeal and spinal root inflammation. Brudzinski’s sign: The client lies on the back and brings the head forward toward the chest. Pain or resistance indicates meningeal irritation, arthritis, or a neck injury. If the person responds by flexing the hips and knees, meningeal inflammation is indicated. Medical Treatment
LP and a culture and sensitivity test of CSF may be ordered to determine the causative organism. The client is given antibiotics.
Nursing Considerations
Provide nursing care with the awareness that the person is critically ill. The person is generally placed on seizure precautions. Side rails should be raised and padded for the clien

Front 19

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Encephalitis

Back 19

Encephalitis
Is inflammation of the white and gray matter of the brain.
Signs and Symptoms
Encephalitis can attack suddenly, causing violent headache, fever, nausea, vomiting, and drowsiness. The person may show muscular weakness, tremors, or visual disturbances.
Medical Treatment
No drug for the specific treatment of encephalitis has been found. Treatment is similar to the care of a client with meningitis.
Nursing Considerations
Nursing care focuses on reducing fever and maintaining a quiet environment. Warm, moist packs may be ordered to relieve muscle spasms. Tube feedings or TPN is necessary for clients who are unresponsive. If acute respiratory distress occurs, a tracheostomy and mechanical ventilation may be required. The client with encephalitis is subject to seizures. Side rails should be in place. The family needs instructions for safety to
prevent injury. The family also needs to be aware that the client may exhibit mental changes such as irritability and confusion.

Front 20

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Guillain-Barre Syndrome

Back 20

Guillain-Barré syndrome is an autoimmune disorder of the peripheral nervous system. It may also be called acute febrile, acute idiopathic, or infectious polyneuritis. Antibodies start to destroy the myelin sheath of peripheral nerves.
Signs and Symptoms
After the non-specific febrile illness, onset is often sudden. However, 3 to 4 weeks may pass before the development of signs and symptoms. Symmetrical pain and weakness follow. The syndrome usually begins in the lower extremities, ascends, and may progress to total paralysis. Disability ranges from muscle weakness to total body paralysis. Vital functions such as breathing, heart rate, and blood pressure can be compromised. Eventually the progression of the disease stops and stabilizes. The client generally then begins a gradual recovery.
Diagnosis
Diagnosis is made after obtaining a careful history and review of systems. No differential diagnostic procedure or laboratory test exists. An LP may be done, possibly revealing increased protein levels in CSF

Front 21

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Guillain-Barre Syndrome
CARD TWO for Gullain Barre

Back 21

Treatment
Some success has resulted from two types of treatments: plasmapheresis and injection of high-dose immunoglobulins. However, the effects of both are temporary.
Plasmapheresis may be helpful because it removes the antibodies that are destroying the myelin sheaths. Immunoglobulin therapy maybe effective because it provides normal support to an immune system that is under abnormal attack. Steroid therapy is controversial because even though it may reduce symptoms, it may be deleterious to the client’s progress.
Nursing Considerations
The nurse must keep in mind that this client has an excel-lent chance of total or nearly total recovery. Therefore, excellent nursing care is necessary to prevent permanent damage. Emergency interventions, such as tracheostomy and mechanical ventilation, may be necessary when the respiratory muscles fail. Maintenance of muscle function is required to prevent atrophy and skeletal deformities. Adequate nutrition may necessitate tube feedings or TPN. Family and other

Front 22

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Post-polie Syndrome

Back 22

Post- polio syndrome
Post-polio syndrome or post poliomyelitis muscular atrophy (PPMA) affects 25% to 40% of individuals who had paralytic polio in childhood. Thirty or more years after the acute attack of polio the individuals experience mild to severe muscle pain and weakness as a delayed complication of the first infection. The affected muscles may be the same as those affected earlier, or they may be different

Nursing considerations
Supportive care in ADL and maintenance of muscle tissue. Referral to physical and occupational therapy.

Front 23

11) Discuss the causes, signs and symptoms, therapies, and at least five nursing considerations for each of the following inflammatory disorders: Acute Transverse Myelitis

Back 23

Acute transverse myelitis
Acute transverse myelitis is an inflammatory condition affecting the spinal cord. It results from inflammation or destruction of the myelin of the spinal cord neurons.
S/S: impaired bowel and bladder function, generalized weakness of the extremities, and loss of sensation.

Nursing Considerations
Nursing care for the client with acute transverse myelitis involves supportive and preventive measures. Be alert for urinary retention, constipation, skin breakdown, thrombus formation, and other complications of immobility.

Front 24

(12) Explain at least four causes of increased intracranial pressure

Back 24

Edema of brain
Hemorrhage
Increased amounts of CSF due to head injury or trauma

Front 25

(13) Explain the nursing care repquired for clients with concussion, brain laceration and contusion

Back 25

Concussion results of any blow to the head and may not damage any brain structures but temporary unconsciousness is possible. The length of time a person remains unconscious varies. Some recover with no ill effects except loss of memory; Others have blurred vision or severe headaches. In Coup-contrecoup injuries, damage occurs both at and opposite to the site of impact. The brain can be hit on one side (coup) and bounce off the other side of the skull (contrecoup). With direct and rebound trauma flood vessels, nerve tracts and brain tissue are bruised or torn. After original injury, post concussion syndrome may persist for several weeks to months.
S/S headache, anxiety, fatigue or vertigo.
Nursing Care:

Front 26

13) Explain the nursing care repquired for clients with skull fractures and hematoma

Back 26

Skull Fracture

Hematoma refers to a blood clot within the skull. CAUSE: hypertension, trauma. S/S: ICP, and specific s/s depend on the area of the brain affected.
Nursing Considerations: require sensitive nursing care of specific needs as a result of trauma. Any blow to the head requires careful observation until certain the injury has not damaged the brain. Knowledge that symptoms of brain damage do not always appear immediately. Symptoms of brain damage are:

Keep client quiet with complete bed rest and observe for signs if ICP: headache, dizziness, visual impairment, hearing loss, nausea, or clear/bloody drainage from the ear, nose or mouth. Projectile vomiting is indicative of brain injury. Observe for change in B/P and pupils; monitor LOC and personality changes

Front 27

(14) State at least three nursing considerations related to care of a client with a brain tumor

Back 27

Surgery Nursing Considerations: shave head or portion of the head if this is not going to be done in operating room. Tell client the head will be shaved. Informed consent for hair shaving and for surgical procedure. The shaved hair will be put in a bag and labeled.
Sedation will be determined by the physician; advise client if they will be treated with mild sedative to remain awake for evaluation and question asking of nerve functions. Medication: VERSED sedative/hypnotic. Pain at IV site; caution with obese pt/match weight to dose.
Client and family empathy is a concern as all will be apprehensive; little pain involved but may be noisy; headache after surgery is anticipated; Surgery last 2 to 6 hours. Assist the family member during the wait.
POST OP CARE: requires expert observation usually in ICU using baseline assessment to monitor for changes. Key points that are followed up on the floor by the Nurse.
Monitor vital signs
Elevating the head of the bed
Performing nasogastric suction

Front 28

(15) Identify at least three pre and post operative nursing considerations for a client undergoing craniotomy

Back 28

Pre-op Craniotomy, HAIR: the client’s head may need to be shaved; inform the client before doing so. Hair may be shaved in the operating room. CONSENT: The client must sign an informed consent before hair can be removed or surgery is done. (Shaved hair is put into a paper bag and labeled SEDATIVE: The physician will inform the client if he or she is to remain awake during a craniotomy. Mild sedatives may be given to relax the client, while allowing him or her to respond to various stimuli applied to parts of the brain during surgery. Advise the client beforehand if the surgeon will ask questions or ask for specific movements during surgery. Midazolam (Versed) may be given so the client does not recall the procedure.
POST OP: Elevating the head of the bed
•Performing nasogastric suction to help prevent aspiration
•Positioning the client as ordered.

Front 29

(16) Identify dietary modification for the client wiht nervous system disorders

Back 29

Diet: caffiene may cause jitteriness.

Front 30

(17) Identify common medications for the client with nervous system disorders

Back 30

Ativan, Valium

Front 31

(18) Discuss general client and family teaching for clients with a nervous system disorder, include ages across the life span

Back 31

Client Teaching involves reinforceing what the physician has ordered. medication regimeman will be important and prevention of accident. Treating the symptoms and preventive measures