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Neurologic System

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CHAPTER TWENTY

PHYSIOLOGY OF THE NERVOUS SYSTEM

A. Centralnervoussystem(CNS)(Figure20-1).B. Peripheralnervoussystem.

1. Twelvepairsofcranialnerves.2. Thirty-onepairsofspinalnerves.3. Autonomicnervoussystem(ANS).

a. Sympatheticsystem:“fightorflight.”b. Parasympatheticsystem.

Cells of the Nervous SystemA. Neuron:thefunctionalcellofthenervoussystem.B. Function/classification.C. Supportingcellsprovidesupport,nourishment,andpro-

tectiontotheneuron.D. Myelinsheath.

1. Densemembraneorinsulatoraroundtheaxon.2. Facilitatesfunctionoftheneuron.3. Contributestotheblood-brainbarriertoprotectthe

CNSfromharmfulmolecules.E. Nerveregeneration:entireneuronisunabletoundergo

completeregeneration.1. NeuronregenerationintheCNSisverylimited,pos-

siblybecauseof the lackofneurilemma(membranesurroundingtheneuron).

2. Scartissueisamajordeterrenttosuccessfulcellularregeneration.

F. Impulseconduction.1. Reflexarc.

a. A reflex arc is the functional unit that providespathwaysoverwhichnerveimpulsestravel.

b. Thepassageofimpulsesoverareflexarciscalledareflexactorareflexandisaninvoluntaryresponsetoastimulus.

c. Reflexarc:theafferentneuroncarriesthestimulusto the spine, integrates it into and through thespine (CNS) to the efferent neuron, and crossesthe synapse with the message from the CNS totheorganormuscle,whichrespondstothestimu-lus.Thisisthesequenceofeventsevaluatedwhenthedeeptendonreflexesaretested.

2. Synaptictransmission.a. A chemical synapse maintains a one-way com-

municationlinkbetweenneurons.

b. Chemical neurotransmitters (neuromediators)facilitatethetransmissionofanimpulseacrossthesynapse.(1) Acetylcholine.(2) Norepinephrine.(3) Dopamine.(4) Histamine.

c. Impulsespassinonlyonedirection.

Central Nervous SystemThebrainandthespinalcordwithinthevertebralcolumnmakeuptheCNS(seeFigure20-1).A. The brain and the spinal column are protected by

the rigid bony structure of the skull and the vertebralcolumn.

B. Meninges: protective membranes that cover the brainandarecontinuouswiththoseofthespinalcord.1. Piamater:adelicatevascularconnectivetissue layer

that covers the surfaces of the brain and the spinalcolumn;partoftheblood-brainbarrier.

2. Arachnoid:adelicatenonvascular,waterproofmem-branethatencasestheentireCNS;thesubarachnoidspacecontainsthecerebrospinalfluid(CSF).

3. Duramater:atoughwhitefibrousconnectivetissue,theouter layerofprotectiontothebrainandspinalcord.

C. Cerebrospinalfluid(CSF).1. Serves to cushion and protect the brain and spinal

cord;brainliterallyfloatsinCSF.2. CSF is clear, colorless, watery fluid; approximately

100to200mLintotalvolume,withanormalfluidpressureof60to100mmH2O.

3. FormationandcirculationofCSF(Figure20-2).a. Fluidissecretedbythechoroidplexuslocatedin

theventriclesofthebrain.b. CSFflowsthroughthelateralventricles intothe

third ventricle, then flows through the aqueductof Sylvius into the fourth ventricle, where thecentralcanalofthespinalcolumnopens.

c. Fromthefourthventricle,CSFflowsaroundthespinalcordandbrain.

d. Because CSF is formed continuously, it is reab-sorbedatacomparableratebythearachnoidvilli.

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402 CHAPTER 20 Neurologic System

c. Temporal.(1) Auditory area: interprets meaning of certain

sounds.(2) Wernicke’s area for speech, sensory speech

area, comprehension and formulation ofspeech (understanding spoken and writtenwords).

d. Occipital area: interprets vision and controlsabilitytounderstandwrittenwords.

3. Motorareasofthecerebralcortex.a. Primary function is coordination and control of

skeletalmuscleactivity.b. Corticospinaltracts(pyramidaltracts).

(1) Descendingtractfromthemotorareaofthecerebralcortextothespinalcord.

(2) Majorityofmotornervescrossinthemedullatotheoppositesidebeforedescendingintothespinalcord.

(3) Thesecorticospinaltractsdonotcrossover.c. Braincellsandthenervefibersinthedescending

tractsoftheCNSarecalleduppermotorneurons.4. Movementiscontrolledby:

a. Cerebral cortex: voluntary initiation of motoractivity.

b. Basalganglia:assistinmaintainingposture.c. Cerebellum:coordinatesmusclemovement.

5. Cerebellum:attachedtothemedullaandthepons.a. Primarily concerned with coordination of motor

movement, muscular tone, and maintenance ofequilibrium.

b. Nervefibers spreadupward to thecerebrumanddownwardtothepons,medulla,andspinalcord.(1) Visual reflexes: pupillary constriction and

movementoftheeye.(2) Auditoryreflexes:turningoftheheadtoward

sound.6. Brainstem:consistsoftheponsandthemedulla.

a. Pons:containsbothmotorandsensorypathwaysrelayingmessagesbetweenthecerebrumandthespinalcord;alsoregulatesrespiration.

b. Medulla oblongata: a continuation of the spinalcord as it enters into the cranial vault in thebrain.(1) Conductioncenterandcrossingcenterforthe

uppermotorneurons.(2) Maintainscontrolofcardiacrate.(3) Vasomotor center for constriction and dila-

tionofvessels.(4) Respiratory center for changes in rate and

depthofbreathing.(5) Vomitingandswallowingreflexcenter.

c. Thalamus.(1) Organization and distribution of incoming

sensoryimpulses.(2) Activitiesrelatedtoconsciousness.

d. Hypothalamus.(1) Homeostasis: regulationof visceral activities,

includingbodytemperature,fluidandelectro-

FIGURE 20-1 Major divisions of the central nervous system. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)

Cerebralhemisphere

Diencephalon

MidbrainPonsMedulla

Brainstem Cerebellum

Spinal cord

{

FIGURE 20-2 Circulation of the cerebrospinal fluid. (From Monahan FD et al: Medical-surgical nursing: health and illness perspectives, ed 8, St. Louis, 2007, Mosby.)

Arachnoid villi

Choroidplexus(thirdventricle)

Choroidplexus(fourth

ventricle)

Foramen ofMagendie

Foramen ofLuschka

Aqueduct ofSylvius

Lateralventricle

Subarachnoidspace

Superiorsagittal sinus

Foramen ofMonro

Cisternamagna

D. Brain.1. Cerebrum:thelargestportionofthebrain;separated

into hemispheres; the cerebral cortex is the surfacelayerofeachhemisphere.

2. Majorlobesofthecentralcortex.a. Frontal.

(1) Responsibleforintelligenceandpersonality.(2) Coordination of voluntary skeletal muscle

movement.(3) Abstractthinking,morals,judgment.(4) Broca’s area for speech, motor-speech area,

areaofexpressiveability(tospeakandwrite).b. Parietal.

(1) Interpretssensorynerveimpulses(pain,tem-perature,touch).

(2) Maintainsproprioception.(3) Recognition of size, texture, and shape of

objects.

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CHAPTER 20 Neurologic System 403

lyteregulation,motilityandsecretionsofthegastrointestinaltract,arterialbloodpressure.

(2) Nerveconnectionswiththethalamusandthecerebralcortexmakeitpossibleforemotionsto influence visceral activity (e.g., spasticcolon).

(3) Regulationof endocrineglandsvia influenceonthepituitarygland.

(4) Neurosecretion of antidiuretic hormone,whichisstoredinthepituitarygland.

7. Cerebralcirculation.a. Theinternalcarotidarteriesenterthecranialvault

atthetemporalarea.b. The circleofWillis is an arterial anastomosis at

thebaseofthebrain.Thecircleensurescontinuedcirculationifoneofthemainvesselsisdisrupted.

E. Spinalcord.1. Thespinalcordiscontinuouswiththemedullaand

extendsdownthevertebralcolumntothelevelofthefirstorsecondlumbarvertebrae.

2. Each column is divided into functional groups ofnervefibers.a. Ascending tracts: transmit impulses to the brain

(sensorypathway).b. Descending tracts: transmit impulses from the

braintothevariouslevelsofthespinalcord(motorpathways).

3. Structure.a. Intervertebral disks lie between the vertebrae to

provideflexibilitytothespinalcolumn.

Table 20-1 CRANIAL NERVES

No. Name Function

I Olfactory SenseofsmellII Optic Vision:conductsinformationfromtheretinaIII Oculomotor Downwardandoutwardmovementoftheeye

PupillaryconstrictionandaccommodationMuscleoftheuppereyelid(abilitytokeeptheeyeopen)

IV Trochlear MovementoftheeyeV Trigeminal:

Ophthalmic Cornealreflex Maxillary Sensoryfibersoftheface Mandibular Motornervesforchewingandswallowing

VI Abducens InwardmovementoftheeyeVII Facial Facialexpression

SenseoftasteonanteriortongueMuscleoftheeyelid(abilitytoclosetheeye)

VIII Acoustic ReceptionofhearingandmaintenanceofequilibriumIX Glossopharyngeal Senseoftasteonposteriortongue

SalivationSwallowingorgagreflex

X Vagusnerve AssistsinswallowingactionMotorfiberstolarynxforspeechInnervationoforgansinthoraxandabdomenImportantinrespiratory,cardiac,andcirculatoryreflexes

XI Accessory(spinal) AbilitytorotatetheheadandraisetheshoulderXII Hypoglossal Musclesofthetongue

b. Nucleuspulposusisthefibrocartilaginousportionof the intravertebral disk; acts as shock absorberforthespinalcord.

4. Uppermotorneurons:originate in thebrain; trans-mit impulses from the brain to the lower motorneurons.

5. Lower motor neurons: originate in the spinal cord;transmit impulses to themusclesandorgans.Theseneuronsformthereflexarc.

6. Reflexactivity.a. Thereflexarcmustbeintact;thespinalcordserves

as the connection between the afferent pathway(sensory)andtheefferentpathway(motor).

b. Testing of the reflex arc (deep tendon reflexes)allowsevaluationofthe lowermotorneuronandthesensory/motorfibersfromthespinalcolumn.For example, if the biceps reflex is normal, the lower motor neurons and the nerve fibers at C5 and C6 are intact.

Peripheral Nervous SystemThecranialandspinalnerves,whichconnecttheCNSwiththebodyparts,constitutetheperipheralnervoussystem.A. Cranialnerves(Table20-1).

1. Twelvepairsofcranialnerves.2. Originatefromunderthesurfaceofthebrain.

B. Spinalnerves.1. Eachpairofnervesisnumberedaccordingtothelevel

ofthespinalcordfromwhichitoriginates(e.g.,C1,C2,etc.).

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2. Each spinal nerve is connected to the cord by tworoots.a. Dorsal (posterior root): a sensory nerve carrying

messagestotheCNS.b. Ventral (anterior root): a motor nerve carrying

neuron messages to glands and the peripheralareas.

C. Somatic nervous system: consists of peripheral nervefiberssendingsensorystimulitoCNSandmotornervefibersthatstimulateskeletalmuscle.

D. Autonomicnervoussystem(ANS):regulatesinvoluntaryactivity (cardiovascular, respiratory, metabolic, bodytemperature,etc.).1. Consists of two divisions that have antagonistic

activity.2. Parasympathetic division: maintains normal body

functions.3. Sympathetic division: prepares the body to meet a

challengeoranemergency(preparationfor“fightorflight”)(Table20-2).

4. Mostof theorgansof thebody receive innervationfromboththeparasympatheticandthesympatheticdivisions. The divisions are usually antagonistic ineffectonindividualorgans:onestimulates;theotherrelaxes.

5. Chemical mediators: facilitate transmission ofimpulsesintheANS.a. Acetylcholineisreleasedbythefibersinbothdivi-

sionsoftheANS.b. Norepinephrineisreleasedprimarilybythesym-

patheticdivision.

c. Mentalstatusmustbeassessedbeforethehistorydatafromtheclientcanbeassumedtobeaccurate.

Table 20-2 AUTONOMIC NERVOUS SYSTEM

Area Affected Sympathetic Parasympathetic

Pupil Dilates ConstrictsBronchi Dilates ConstrictsHeart Increasesrate DecreasesrateGastrointestinal Inhibitsperistalsis Stimulatesperistalsis

Stimulatessphincter InhibitssphinctersBladder Relaxesbladder

muscleContractsbladder

muscleConstrictssphincter Relaxessphincter

Adrenalglands Increasessecretionofepinephrineandnorepinephrine

ALERT Identify pathophysiology related to an acute or chronic condition (e.g., signs and symptoms).

System AssessmentA. History.

1. Neurologichistory.a. Avoidsuggestingsymptomstotheclient.b. The manner in which the problems first pre-

sented and the overall course of the illness arevery important.

NURSING PRIORITY In the older adult client, assess orientation and mental status before continuing assessment of neurologic function (Box 20-1).

Box 20-1 OLDER ADULT CARE FOCUS

Assessing Neurologic Function in Older Adults

Signs of Cognitive Impairment• Significantmemoryloss(person,place,andtime).• Person:Doesclientknowwhoheorsheis,andcanclient

giveyouhisorherfullname?• Place:Canclientidentifyhisorherhomeaddressandwhere

heorsheisnow?• Time:Whatwasthemostrecentholiday;whatmonth,time

ofday,dayoftheweekisitnow?• Doesclientshowalackofjudgment?• Isclientagitatedand/orsuspicious?• As determined from client’s appearance and family’s

response,doesclienthaveproblemswithADLs?• Short-termmemory:Cantheclientrecallyourname,name

ofthePresident,ornameofhisorherdoctor?• Short-term recall: Ask the client to name three or four

commonobjects; thenaskclient to recall themwithin thenext5minutes.

• Doestheclienthavesensorydeficits(hearingandvision)ofwhichheorsheisnotaware?

2. Medicalhistory.a. Assesscomorbidities(Box20-2).b. Complete medication profile including comple-

mentarymedications.

Box 20-2 OLDER ADULT CARE FOCUS

Causes of Confusion in the Older Adult Client

Decreased Cardiac Output• Myocardialinfarction• Dysrhythmias• Congestiveheartfailure

Hypoxia/Respiratory Acidosis• Pneumonia• Infection• Hypoventilation

Neurologic• Vascularinsufficiency• Infections• Cerebraledema

Metabolic—Altered Homeostasis• Electrolyteimbalance• Hypoglycemia/hyperglycemia• Dehydration• Urinarytractinfections

Environmental• Strangesurroundings• Hypothermia/hyperthermia

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c. Birth (or delivery) history. Was client a difficultdelivery?

d. Sequenceofgrowthanddevelopment.3. Familyhistory:presenceofhereditaryor congenital

problems.4. Personalhistory:activitiesofdailyliving(ADLs),any

changeinroutine.5. Historyandsymptomsofcurrentproblem.

a. Paralysisorparesthesia,syncope.b. Headache,dizziness,speechproblems.c. Visualproblems,changesinpersonality.d. Memoryloss,nausea,vomiting.

B. Physicalassessment.1. Generalobservationofclient.

a. Posture,gait,coordination;performRombergtest.b. Positionofrestfortheinfantoryoungchild.c. Personalhygiene,grooming.d. Evaluatespeechandabilitytocommunicate.

(1) Paceofspeech:rapid,slow,halting.(2) Clarity:slurredordistinct.(3) Tone:high-pitched,rough.(4) Vocabulary:appropriatechoiceofwords.

e. Facialfeaturesmaysuggestspecificsyndromesinchildren.

2. Mentalstatus(musttake intoconsiderationthecli-ent’scultureandeducationalbackground).

d. PERRLA:indicatesthatPupilsareEqual,Round,and Reactive to Light and that Accommodationispresent.

NURSING PRIORITY Level of consciousness and mental status are assessment data for the client with neurologic deficits.

a. Levelofconsciousness.(1) Orientedtoperson,place,time,andsituation

(inorderofimportance).(2) Appropriate response to verbal and tactile

stimuli.(3) Memory,problem-solvingabilities.

b. Mood.c. Thoughtcontentandintellectualcapacity.d. Generalappearanceandbehavior.

3. Assess pupillary status and eye movements (Figure20-3).a. Sizeofpupilsshouldbeequal.b. Reactionofpupils.

(1) Accommodation: pupillary constriction toaccommodatenearvision.

(2) Directlightreflex:constrictionofpupilwhenlightisshonedirectlyintoeye.

(3) Consensualreflex:constrictionofthepupilintheoppositeeyewhenthedirectlightreflexistested.

c. Evaluateabilitytomoveeye.(1) Notenystagmus:fine,jerkingeyemovement.(2) Abilityofeyestomovetogether.(3) Restingpositionoftheirisshouldbeatmid-

positionoftheeyesocket.(4) Assessforlidlag(ptosis).

NURSING PRIORITY: When assessing a client’s neurologic status, always evaluate symmetry. If asymmetrical findings are detected, refine exam to determine CNS versus peripheral nervous system as origin of asymmetry.

4. Evaluatemotorfunction.a. Assess face andupper extremities for equalityof

movementandsensation.b. Evaluate appropriateness of motor movement-

spontaneousandoncommand.c. Movementofextremitiesshouldalwaysbeevalu-

atedbilaterally;tone,strength,andmusclemove-ment of each side should be compared (e.g.,bilateralhandgripsofequalstrength).

d. Presence of inappropriate, nonpurposeful move-ment(e.g.,posturing).(1) Decerebrate: extension and adduction of the

arms,hyperextensionofthelegs.(2) Decorticate: flexion, internal rotation of the

arms,extensionofthelegs.(3) Presenceofnonpurposefulinvoluntarymove-

mentssuchastremors,jerking,twitching,tics,ormusclefasciculation.

(4) Opisthotonos:extremehyperextensionoftheheadanddorsalarching.

e. Abilityofaninfanttosuckandtoswallow.f. Asymmetricalcontractionoffacialmuscles.

FIGURE 20-3 Assessment of the neurologic system: pupillary check. (From Zerwekh J, Gaglione T: Mosby’s assessment memory notecards: visual, mnemonic, and memory aids for nurses, ed 1, St. Louis, 2007, Mosby.)

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5. Evaluatereflexes.a. Gagorcoughreflex.b. Swallowreflex.c. Cornealreflex.d. Babinski reflex: normal is negative in adults and

childrenolderthan1year;positivesignisdorsalflexionof the footand large toewith fanningoftheothertoes.

e. Deeptendonreflexes(simplestretchreflex).6. Assess vital signs and correlate with other data;

changes often occur slowly, and the overall trendneedstobeevaluated.a. Blood pressure and pulse: intracranial problems

precipitate changes; systolic blood pressure mayincrease,andpulseratemaydecrease.

b. Respirations:rate,depth,andrhythmaresensitiveindicatorsofintracranialproblems.(1) Cheyne-Stokes respiration: periodic breath-

inginwhichhyperpneaalternateswithapnea.(2) Neurogenic hyperventilation: regular, rapid,

deephyperpnea.(3) Ataxic: completely irregular pattern with

randomdeepandshallowrespirations.c. Temperature: evaluate changes in temperatureas

relatedtoneurologiccontrolversusinfection.

DISORDERS OF THE NEUROLOGIC SYSTEM

Increased Intracranial PressureAn increase in intracranial pressure (ICP) occurs any time there is an increase in the size or amount of intracranial contents.A. Thecranialvaultisrigid,andthereisminimalroomfor

expansionoftheintracranialcomponents.B. Anincrease inanyoneof thecomponentsnecessitates

a reciprocal change in other cranial contents; this fre-quently results in ischemiaofbrain tissue.An increaseinICPresultsfromoneofthefollowing:1. Increasedintracranialbloodvolume(vasodilation).2. IncreasedCSF.3. Increaseinthebulkofthebraintissue(edema).

C. Cerebraledema.1. Edemaoccurswhenthereisanincreaseinthevolume

ofbraintissuecausedbyanincreaseinthepermeabil-ity of the walls of the cerebral vessels. Protein-richfluidleaksintotheextracellularspace.Edemaismostoften the cause of increased ICP in adults, whichreachesmaximumpressurein48to72hours.

2. Cytotoxic (cellular) edema occurs as a result ofhypoxia. This results in abnormal accumulation offluidwithinthecells(intracellular)andadecreaseinextracellularfluid.

D. Poorventilationwillprecipitate respiratoryacidosis,oranincreaseinthePaco2.1. Carbondioxidehasavasodilatingeffectonthecere-

bral arteries, which increases cerebrovascular bloodflowandincreasesICP.

2. Clients shouldbeventilated toanormocapnic statetopreventcyclicvasodilation,whichincreasesintra-cranialpressure.

E. Regardless of the cause, increased ICP will result inprogressive neurologic deterioration; the specific defi-ciencies seenaredeterminedby theareaandextentofcompressionofbraintissue.

F. If the infant’s cranial suture lines are open, increasedICP will cause separation of the suture lines and anincreaseinthecircumferenceofthehead.

NURSING PRIORITY There is no single set of symptoms for all clients with increased ICP; symptoms depend on the cause and on how rapidly increased ICP develops.

AssessmentA. Riskfactors/etiology.

1. Cerebral edema caused by some untoward event ortrauma,includingtoxicexposure,blunttrauma,fluidandelectrolyteimbalance.

2. Braintumors.3. Intracranialhemorrhagecausedbyepiduralorsubdu-

ralbleeding (closedhead injuriesor rupturedbloodvessels).

4. Subarachnoidhemorrhage,hydrocephalus.5. Cerebralembolism, resulting innecrosisandedema

ofareassuppliedbytheinvolvedvessel.6. Cerebralthrombosis,resultinginischemiaofthearea

andleadingtoedemaandcongestionofaffectedarea.7. Encephalitis/meningitis.

B. Clinical manifestations (bedside neurologic checks)(Figure20-4).

ALERT Determine change in a client’s neurologic status. Be able to rapidly evaluate the client and recognize incremental changes in the neurologic signs that indicate an increase in ICP (Box 20-3).

FIGURE 20-4 Increased intracranial pressure. (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.)

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c. Unilateraldilationofpupils.d. Sluggishornopupillaryresponsetolightandpoor

orabsentaccommodation.4. Motorandsensory function:normal is indicatedby

theabilitytomoveallextremitieswithequalstrength.Abnormalfindingsinclude:a. Unilateralorbilateralweaknessorparalysis.b. Failuretowithdrawfrompainfulstimuli.c. Posturing: decerebrate, decorticate, flaccid, or

opisthotonos.d. Seizureactivity,ataxia.

5. Headache.a. Constantwithincreasingintensity.b. Exacerbatedbymovement.c. Photophobia.

6. Vomiting:projectilevomitingwithoutpriornausea.7. Infants.

a. Tense,bulgingfontanel(s).b. Separatedcranialsutures.c. Increasingfrontal-occipitalcircumference.d. High-pitchedcry.

C. Diagnostics(seeAppendix20-1).1. DirectICPmonitoring.2. Romberg test:measuresbalance.Client standswith

feet together andarmsat side,firstwitheyesopen,thenwitheyesclosedfor20to30seconds.

3. Calorictesting:testisperformedatbedsidebyintro-ducingcoldwaterintotheexternalauditorycanal.Ifthe eighth cranial nerve is stimulated, nystagmusrotates toward the irrigated ear. If no nystagmusoccurs,apathologicconditionispresent.

4. Doll’seyereflex(oculocephalicreflex).a. Doll’s eye reflex is normal when the client’s

head is moved from side to side and the eyesmove in the direction opposite that of theturning.

b. Doll’s eye reflex is abnormal when the client’seyes remain in a fixed, midline position whenthe head is turned from side to side (possiblebrainsteminvolvement).

c. Contraindicateduntilriskforspinalcordinjuryisruledout.

5. Papilledema: edema of the optic nerve; observedbyexaminingretinaareawithanophthalmoscope.

6. Nuchal rigidity:herniationofbrainstemmayoccur;anemergentcrisis.

7. Lumbarpunctureisgenerallynotperformed;decreasein CSF pressure could precipitate herniation of thebrainstem.

TreatmentA. Treatment of the underlying cause of increasing

pressure.B. Neurologiccheckseveryhourorasordered.

1. Mayinvolvecorrelationofseveralvariablesincludinglevel of consciousness, vital signs, speech, facialsymmetry, grasp strength, leg strength, and pupilresponses.

1. Assessforchanges inlevelofconsciousness,becausechangeisthecardinalindicatorofincreasedintracra-nialpressure.a. Anyalterationinlevelofconsciousness(earlysign

for both adults and children)— irritability, rest-lessness, confusion, lethargy, and difficulty inarousing—maybesignificant.

NURSING PRIORITY The first sign of a change in the level of ICP is a change in level of consciousness; this may progress to a decrease in level of consciousness.

Box 20-3 INCREASING INTRACRANIAL PRESSURE

AdultEarly:Restless,irritable,lethargicIntermediate:Unequalpupilresponse,projectilevomiting,vital

signschangesLate: Decreased level of consciousness, decreased reflexes,

hypoventilation,dilatedpupils,posturing

Infant/ChildEarly:Poorfeeding,tensefontanel,headache,nauseaandvom-

iting,increasedpitchofcry,unsteadygaitIntermediate (younger than 18 months): Increased head cir-

cumference, altered consciousness, bulging fontanel; shrillcry,severeheadache,blurredvision,stiffneck

Late:Sameasadult

b. Inappropriateverbalandmotorresponse;delayedorsluggishresponses.

c. As the client loses consciousness, hearing is thelastsensetobelost.

2. Changesinvitalsigns.a. Increaseinsystolicbloodpressurewithincreasein

pulsepressure.b. Decreaseinpulserate.c. Alteration inrespiratorypattern(Cheyne-Stokes

respiration,hyperventilation).d. Assess temperature with regard to overall prob-

lems;temperatureusuallyincreases.

NURSING PRIORITY Cushing’s triad: increasing systolic pressure, with increased pulse pressure, decreased pulse rate, and Cheyne-Stokes respirations. Increased ICP is well established when this occurs.

3. Pupillary response: normal pupils should be round,midline,equalinsize,andequallybrisklyreactivetolightandshouldaccommodatetodistance.Abnormalfindingsinclude:a. Ipsilateral: pupillary changes occurring on the

samesideasacerebrallesion.b. Contralateral:pupillarychangesoccurringonthe

sideoppositeacerebrallesion.

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2. Carefulcomparisontopreviousassessmentiscriticaltodetectincrementalchanges.

C. Intravenous(IV)andoralfluidstomaintainnormalfluidvolumestatusifmeanarterialpressure(MAP)islowtonormal.Often,normalsalinesolutionisfluidofchoice;5%dextroseinwaterpotentiatescerebraledema.

D. Medications.1. Osmoticdiureticcorticosteroids.2. Anticonvulsants,antihypertensives.

E. MaintainadequateventilationbymeansofmechanicalventilationtolowerPaco2(25to35mmHg)topreventvasodilationofcerebralvessels.

F. Placementofventriculoperitonealshuntduringdecom-pressionsurgery.

ComplicationsA. CSFleaks,especiallyinclientwithbasilarskullfracture,

maycausemeningitis.B. Herniation: shifting of the intracranial contents from

one compartment to another; involves herniationthroughthetentoriumcerebelli;affectsareaforcontrolofvitalfunctions.

C. Permanentbraindamage.

Nursing InterventionsGoal: ToidentifyanddecreaseproblemofincreasedICP.A. Neurologicchecks,asindicatedbyclient’sstatus(Tables

20-3and20-4).B. Maintainheadofbedinsemi-Fowler’sposition(15-30

degrees) to promote venous drainage and respiratoryfunction.

Table 20-3 GLASGOW COMA SCALE (GCS)

Category of Response Appropriate Stimulus Response Score

Eyesopen Approachbedside Spontaneousresponse 4Verbalcommand Openingofeyestonameorcommand 3Pain Lackofopeningofeyestopreviousstimulibut

openingtopain2

Lackofopeningofeyestoanystimulus 1Untestable U

Bestverbalresponse Verbalquestioningwithmaximumarousal

Appropriateorientation,conversant,correctidentificationofself,place,year,andmonth

5

Confusion;conversant,butdisorientatedinoneormorespheres

4

Inappropriateordisorganizeduseofwords(e.g.,cursing),lackofsustainedconversation

3

Incomprehensiblewords,sounds(e.g.,moaning) 2Lackofsound,evenwithpainfulstimuli 1Untestable U

Bestmotorresponse Verbalcommand(e.g.,“raiseyourarm,holduptwofingers”)

Obedienceinresponsetocommand 6

Pain(pressureonproximalnailbed)

Localizationofpain,lackofobediencebutpresenceofattemptstoremoveoffendingstimulus

5

Flexionwithdrawal*,flexionofarminresponsetopainwithoutabnormalflexionposture

4

Abnormalflexion,flexingofarmatelbowandpronation,makingafist

3

Abnormalextension,extensionofarmatelbow,usuallywithadductionandinternalrotationofarmatshoulder

2

Lackofresponse 1Untestable U

FromLewisSLetal:Medical-surgical nursing: assessment and management of clinical problems,ed7,St.Louis,2007,Mosby.*Addedtotheoriginalscalebymanycenters.

ALERT Change client’s position. If the client with increased ICP develops hypovolemic shock, do not place client in Trendelenburg position.

C. Change client’s position slowly; avoid extreme hipflexionandextremerotationorflexionofneck.Maintaintheheadmidline.

D. Monitorurineosmolarityandspecificgravity.E. Evaluateintakeandoutput.

1. Inresponsetodiuretics.2. Ascorrelatedwithchangesindailyweight.3. For complications of diabetes insipidus (see

Chapter13).F. Maintainintakeevenlyduringtherapeutictreatment.

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G. Minimizerespiratorysuctioningandensurehyperoxy-genationbeforesuctioning.

H. Sedativesandnarcoticscandepressrespiration;usewithcautionbecausetheymasksymptomsofincreasingICP.

I. Client should avoid strenuous coughing, Valsalvamaneuver,andisometricmuscleexercises.

J. Avoid straining with stools (increases intrathoracicpressuresporadically).

K. In infants, measure frontal-occipital circumference toevaluateincreaseinsizeofthehead.

L. Controlhyperthermia.M. Maintainheadandspinalcolumninmidlineposition.Goal: Tomaintainrespiratoryfunction.

Table 20-4 MODIFIED GLASGOW COMA SCORE FOR PEDIATRIC CLIENTS

Activity Score Infant’s Best Response Children (4 years or older)

Eyesopening 4 Spontaneous Spontaneous3 Tospeech Tospeech2 Topain Topain1 Noresponse Noresponse

Verbalresponse 5 Coos,babbles Oriented;smiles,interacts,followsobjects4 Irritablecry Confused,disoriented,uncooperative3 Criesinresponsetopain Inappropriatewords,persistentcries,inconsolable,

inconsistentawarenessofenvironment2 Moansinresponsetopain Incomprehensiblesounds,agitated,restless,unawareof

environment1 Noresponse Noresponse

Motorresponse 6 Normalspontaneousmovements Normalspontaneousmovements5 Withdrawsfromtouch Localizespain4 Withdrawsfrompain Withdrawsfrompain3 Abnormalflexion Abnormalflexion2 Abnormalextension Abnormalextension1 Noresponse Noresponse

NURSING PRIORITY An obstructed airway is one of the most common problems in the unconscious client; position to maintain patent airway or use airway adjuncts.

A. Preventrespiratoryproblemsofimmobility.B. Evaluatepatencyof airway frequently; as levelof con-

sciousnessdecreases,clientisatincreasedriskforaccu-mulating secretions and airway obstruction by thetongue.

C. KeepPaco2levelsnormal.D. Suctionasnecessarybriefly.E. Client may require intubation and respiratory support

fromaventilator(seeAppendixes15-5and15-8).Goal: Toprotectclientfrominjury.A. Maintainseizureprecautions(seeAppendix20-5).B. Restrain client only if absolutely necessary; struggling

againstrestraintsincreasesICP.C. Donotcleantheearsornasalpassagesofaclientwith

a head injury or a client who has had neurosurgery.CheckforevidenceofaCSFleak:CSFhasglucosein

it;testitwithadipstick.CSFalsoleavesayellow“halo”stain.

D. Aspirationisamajorproblemintheunconsciousclient;placetheclientinsemi-Fowler’spositionfortubefeedingafterensuringcorrecttubeplacement.

E. Maintainquiet,nonstimulatingenvironment.F. Inspecteyesandpreventcornealulceration.

1. Protectiveclosingofeyes,ifeyesremainopen.2. Irrigationwithnormal saline solutionormethylcel-

lulosedropstorestoremoisture.Goal: Tomaintainpsychologicequilibrium.A. Neurologicchecksshouldbedoneonacontinualbasis

todetectpotentialproblems.B. Encourageverbalizationoffearsregardingcondition.C. Give simple explanation of procedures to client and

family.D. Altered states of consciousness will cause increased

anxietyandconfusion;maintainrealityorientation.E. Ifclientisunconscious,continuetotalktohimorher;

describeproceduresandtreatments;alwaysassumethatclientcanhear.

F. Assist parents and family to work through feelings ofguiltandanger.

Goal: Topreventcomplicationsofimmobility(seeChapter3).

Goal: Tomaintainelimination.A. Urinary incontinence: may use condom catheter or

indwellingbladdercatheter.B. Keepperinealareaclean,preventexcoriation.C. Monitorbowelfunction;evaluateforfecalimpaction.

ALERT Notify primary health care provider when client demonstrates signs of potential complications; interpret what data for a client need to be reported immediately.

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Home CareA. TeachclientandfamilysignsofincreasedICP.B. Callthedoctorifanyofthefollowingareobserved:

1. Changesinvision.2. Increaseddrainagefromincisionareaorcleardrain-

ageintheears.3. Abruptchangesinsleepingpatternsorirritability.4. Headachethatdoesnotrespondtomedication.5. Changesincoordination,disorientation.6. Slurredspeech,unusualbehavior.7. Seizureactivity,vomiting.

C. Reviewcareofsurgicalincision,wounds,ordrains.

Brain TumorsA. Brain tumorsmaybebenign,malignant,ormetastatic;

malignant brain tumors rarely metastasize outside theCNS.

B. Supratentorial: tumors occurring within the anteriortwo-thirdsofthebrain,primarilythecerebrum.

C. Infratentorial:tumorsoccurringintheposteriorthirdofthe brain (or below the tentorium), primarily in thecerebellumorthebrainstem.

D. Regardlessoftheorigin,site,orpresenceofmalignancy,problemsofincreasedICPoccurbecauseofthelimitedarea in the brain to accommodate an increase in theintracranialcontents.


1. Age:highestincidenceinpeopleolderthan70years;commoninchildrenyoungerthan8years.

2. Presenceofmetastaticcancerofthelungorbreast.3. Familyhistory:gliomastendtooccurinotherfamily

members.4. Occupation: people who work with high levels of

radiation,formaldehyde(pathologists),vinylchloride(plastics manufacturers), and other chemicals are atincreasedriskforbraintumors.

B. Clinical manifestations: symptoms correlate with theareaofthebraininitiallyinvolved.1. Headache.

a. Recurrent. May vomit on arising and then feelbetter.

b. Moresevereinthemorning.c. Affectedbyposition.d. Headacheininfantmaybeidentifiedbypersis-

tent,irritatedcryingandheadrolling.2. Vomiting:initiallywithorwithoutnausea;progres-

sivelybecomesprojectile.3. Papilledema(edemaoftheopticdisc).4. Seizures(focalorgeneralized).5. Dizzinessandvertigo.6. Mental status changes: lethargy and drowsiness,

confusion,disorientation,andpersonalitychanges.7. Localizedmanifestations:

a. Focalweakness:hemiparesis.

8. Sensorydisturbances.a. Languagedisturbances.b. Coordinationdisturbances.c. Visualdisturbances.

9. Headtilt:childmaytilttheheadbecauseofdamagetoextraocularmuscles;maybefirst indicationofadecreaseinvisualacuity.

10. ChangesinvitalsignsindicativeofincreasingICP(Cushing’striad).

11. Cranialenlargementintheinfantyoungerthan18months.

C. Diagnostics(seeAppendix20-1).

TreatmentA. Medical.

1. Dexamethasone(seeAppendix6-7).2. Chemotherapy.3. Anticonvulsants(seeAppendix20-2).4. Complementaryandalternativemedicine.

B. Radiation: x-rays, gamma knife, stereotactic radiosur-gery.

C. Surgical intervention: craniotomy/craniectomy, biopsy,shuntplacement,reservoirplacement,laserremoval.

ComplicationsComplications include meningitis, brainstem herniation,diabetes insipidus, and syndrome of inappropriate antidi-uretichormonesecretion(seeChapter13).Residualeffectsincludeawidearrayofcomplicationssuchasseizures,dys-arthria, dysphasia, disequilibrium, and permanent braindamage.

Nursing InterventionsGoal: To provide appropriate preoperative nursing

interventions.A. Generalpreoperativecarewithexceptions,asnoted(see

Chapter3).B. Carefullyassessanddiscusswithsurgeontheappropri-

atenessofapreoperativeenema.C. Prepare client and family for appearance of the client

aftersurgery,includingpartialorcompletehairloss.D. Encourage verbalization regarding concerns about

surgery.E. Skinpreparationisusuallydoneintheoperatingroom.Goal: To monitor changes in ICP after craniotomy (see

Box20-3).A. Obtain vital signs and perform neurologic checks and

cranialnerveassessmentsasnecessary.B. Maintainpulmonaryfunctionandhygiene.C. Anticipateuseofanticonvulsantsandantiemetics.D. Discouragecoughing.E. Carefullyevaluatelevelofconsciousness;increasingleth-

argyorirritabilitymaybeindicativeofincreasingICP.F. Evaluatedressing.

1. Locationandamountofdrainage.2. Clarifywithsurgeonwhetherthenurseorthesurgeon

willchangedressing.3. EvaluateforCSFleakthroughtheincision.

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G. Maintainsemi-Fowler’spositionifthereisaCSFleakfromearsornose.

H. Postoperative positioning for client who has hadinfratentorialsurgeryisasfollows:1. Bedshouldbeflat.2. Positionclientoneitherside;avoidsupineposition.3. Maintainheadandneckinmidline.4. Keep NPO for 24 hours to reduce edema around

medullaandreducevomiting. I. Postoperativepositionforclientwhohashadsupraten-

torialsurgery:semi-tolow-Fowler’sposition. J. Trendelenburg position is contraindicated for clients

who have had either infratentorial or supratentorialsurgery.

K. Maintainfluidregulation.1. Afterclientisawakeandtheswallowandgagreflexes

havereturned,beginofferingclearliquidsbymouth.2. Closelymonitorintakeandoutput.

L. Evaluateneurologicstatus inresponsetofluidbalanceanddiuretics.

M. Evaluatechangesintemperature:maybeduetorespira-torycomplicationsortoalterationinthefunctionofthehypothalamus.

N. Provideappropriatepostoperativepainrelief.1. Avoidnarcoticanalgesics.2. Acetaminophenisfrequentlyused.3. Maintainquiet,dimatmosphere.4. Avoidsuddenmovements.

O. Preventcomplicationsofimmobility(seeChapter3). P. Maintainseizureprecautions(seeAppendix20-5).

Home CareSeehomecareforclientwithincreasingICP.

Head InjuryA. Classification.

1. Penetratinghead injury:dura ispierced, as in stab-bingorshooting.

2. Closedorbluntheadinjury:headiseitherdrasticallyaccelerated(whiplash)ordecelerated(collision);mostcommonheadinjuryincivilianlife.

B. Children and infants are more capable of absorbingdirectimpactbecauseofthepliabilityoftheskull.

C. Coup-contrecoup injury: damage to the site of impact(coup) and damage on the side opposite the site of

FIGURE 20-5 Formation of head injury after hematoma. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, Philadelphia, 2009, Saunders.)

Dura

A. Subdural hematoma B. Epidural hematoma C. Intracerebral hematoma

impact(contrecoup)whenbrain“bounces”freelyinsideskull.

D. Primary injury to the brain occurs by compressionand/or tearing and shearing stresses on vessels andnerves.

E. Althoughbrain volume remainsunchanged, secondaryinjuryoccursfromthecerebraledemainresponsetotheprimary injury and frequently precipitates an increaseinICP.

F. Typesofheadinjuries(Figure20-5).1. Concussion: temporary interference in brain func-

tion; may affect memory, speech, reflexes, balance,andcoordination.a. Onlysmallnumberofvictimsactually“blackout.”b. Usually from blunt trauma including contact

sports.c. Usuallydoesnotcausepermanentdamage.d. Transient,self-limiting.

2. Contusion(abruiseonthebrain).a. Multipleareasofpetechialhemorrhages.b. Headache,pupillarychanges,dizziness,unilateral

weakness.c. Bloodsupplyisalteredintheareaofinjury;swell-

ing,ischemia,andincreasedICP.d. Maylastseveralhourstoweeks.

3. Intracranialhemorrhage.a. Epidural (extradural) hematoma: a large vessel

(often a meningeal artery or vein) in the duramater is damaged; a hematoma rapidly formsbetween the dura and the skull, precipitating anincreaseinICP.(1) Momentarylossofconsciousness,thenfreeof

symptoms (lucid period), and then lethargyandcoma-seldomevidentinchildren.

(2) Symptoms of increasing ICP may developwithinminutesafterthelucidinterval.

(3) Tentorial herniation may occur withoutimmediateintervention.

b. Subduralhematoma:acollectionofbloodbetweentheduraandarachnoidareafillingthebrainvault;usuallytheresultofseriousheadinjury.(1) May be acute (manifesting in less than 24

hours) or “chronic” (developing over days toweeks).

(2) Whenneurologiccompromisepresents, sub-duralhematomabecomesanemergentevent.

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Emergencyneurosurgerymaybe required torelievepressureandpreventbrainherniation.

(3) Treatment may also include diuretics andanticonvulsants.

(4) Persistent neurologic complications—includ-ing dysarthria, unilateral weakness, memoryloss,andseizures—maycontinue.

4. With presence of retinal hemorrhage, evaluate for“shakenbabysyndrome.”


1. Historyoftrauma.2. Epidural hematomas are rare in children younger

than4years.3. Subduralhematomasarecommonininfantsandmay

resultfrombirthtrauma.B. Clinicalmanifestations.

1. Epidural hematoma: decreased GCS, pupillarychanges,unilateralweakness.

2. Subdural hematoma: headache, change in LOC,numbness, headache, slurred speech, or inability tospeak.


ComplicationsComplications include increased ICP, meningitis, diabetesinsipidus,seizures,andpermanentneurologiccompromise.

Treatment

3. Bleedingorwaterydrainagefromtheearsornose.4. Lossoffeelingorsensationinanyextremity.5. Blurredvision,slurredspeech,vomiting.

NURSING PRIORITY The primary treatment objectives for the client with a head injury are to maintain a patent airway, to prevent hypoxia and hypercapnia resulting in acidosis, and to identify the occurrence of increased ICP.

A. Themajorityof clientswhoexperience concussionaretreatedathome.

B. Aperiodof unconsciousness or presenceof seizures isconsideredaseriousindicationofinjury.

C. Surgicalintervention.1. Burrholestoevacuatethehematoma.2. Craniotomy/craniectomy.

Nursing InterventionsGoal: To provide instruction for care of the client in the

homeenvironment(Box20-4).A. Problemsfrequentlydonotoccuruntil24hoursormore

aftertheinitialinjury.B. Observetheclientforincreasedperiodsofsleep;ifclient

isasleep,awakenevery2to3hourstodeterminewhetherclientcanbearousednormally.

C. Maintaincontactwithphysicianforreevaluationifcom-plicationsoccur.

D. Healthcareprovidershouldbenotifiedwhenanyofthefollowingareobserved:1. Any change in level of consciousness (increased

drowsiness,confusion).2. Inabilitytoarouseclient,seizures.

ALERT Determine family’s understanding of the consequences of the client’s illness. Written and oral instructions should be given to the client and to the family. Increased anxiety may affect comprehension of oral directions (see Box 20-4).

Box 20-4 DISCHARGE INSTRUCTIONS FOR CLIENTS WITH HEAD INJURY

Arousetheclientevery3to4hoursforthefirst24hours.Anticipatecomplaintsofdizziness,headaches.Donotallowclienttoblowhisnose;trytopreventsneezing.Noalcoholorsedativesforsleep.Acetaminophenforheadaches.Noexercisingovernext2to3days.Call the doctor if any of the following is noted:• Changeinvision:Blurredordiplopia• Poorcoordination:Walking,grasping• Drainage(serousorbloody)fromthenoseorears• Forcefulvomiting• Increasingsleepiness,moredifficulttoarouse• Slurredspeech• Headachethatdoesnotrespondtomedicationandcontin-

uestogetworse• Occurrenceofaseizure

Goal: Tomaintainhomeostasisandtomonitorandiden-tifyearlysymptomsofincreasedICP.

A. Bedrestandclearliquidsinitially.B. FrequentneurologicchecksforincreasedICP.

1. Changeordecrease in levelof consciousness is fre-quentlythefirstindication.

2. Instructclientswithheadinjurynottocough,sneeze,orblownose.

C. Evaluatedrainagefromnose,ears,andmouth.1. Donotcleanouttheears:place loosecottoninthe

auditorycanalandchangewhensoiled.2. Checkcontinuouscleardrainagefromthenosewith

Dextrostix; ifglucose ispresent, it is indicativeofaCSF leak; spinalfluid alsodrieswith a yellowhaloaroundedgesofdrainage.

3. IfaCSFleakoccurs,keeptheheadofthebedele-vated and monitor for development of an infection(meningitis).

D. Seizureprecautions(seeAppendix20-5).E. Maintain adequate fluid intake by IV infusion or oral

intake;donotoverhydrate.F. Assessforotherundetectedinjuries;stabilizespineafter

headinjuryuntilspinalcordinjuryisruledout.Goal: Toprovideappropriatenursinginterventionsforthe

clientexperiencinganincreaseinICP(seenursinggoalsforincreasedICP).

Goal: To provide adequate nutritional and caloric intakefortheclientwithaheadinjury.

A. Provideenteralfeedingsifclientisunabletoeat.B. Assistclienttotakeoralfeedingsonceswallowreflexis

normal;clientisatincreasedriskforaspiration.

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Hydrocephalus Hydrocephalus is a condition caused by an imbalance in the pro-duction and absorption of CSF in the ventricles of the brain.

Classification: PrimaryA. Noncommunicating(obstructive):circulationofCSFis

blockedwithintheventricularsystemofthebrain.B. Communicating:CSFflowsfreelywithintheventricular

systembutisnotadequatelyabsorbed.

Classification: SecondaryA. Congenital.B. Acquired—possiblyfromtrauma,infection,ortumor.


1. Neonate:usuallytheresultofacongenitalmalforma-tion.

2. Olderchild,adult.a. Space-occupyinglesion.b. Preexistingdevelopmentaldefects.

B. Clinicalmanifestations:infant.1. Headenlargement:increasingcircumferenceinexcess

ofnormal2cmpermonthforfirst3months.2. Separationofcranialsuturelines.3. Fontanelbecomestenseandbulging.4. Dilatedscalpveins.5. Frontalenlargement,bulging“sunseteyes.”6. SymptomsofincreasingICP.

C. Clinicalmanifestations:olderchild,adult.1. SymptomsofincreasingICP.2. Specificmanifestationsrelatedtositeofthelesion.

D. Diagnostics(seeAppendix20-1).1. Increasingheadcircumferenceisdiagnosticininfants.

TreatmentA. Noncommunicating and communicating: ventriculo-

peritonealshunt;CSFisshuntedintotheperitoneum.B. Obstructive: removal of the obstruction (cyst, hema-

toma,tumor).

Nursing InterventionsGoal: TomonitorforthedevelopmentofincreasingICP.A. Daily measurement of the frontal-occipital circumfer-

enceoftheheadininfants.B. AssessforsymptomsofincreasingICP(seeBox20-3).C. Infantisoftendifficulttofeed;administersmallfeedings

atfrequentintervalsbecausevomitingmaybeaproblem.Goal: TomaintainpatencyoftheshuntandmonitorICP

aftershuntprocedure.A. Position supine, with head turned opposite side up to

preventpressureontheshuntvalveandtopreventtoo-rapiddepletionofCSF.

B. Positionisnotaproblemwithchildrenwhoarehavingashuntrevision;theyhavenothadanincreaseinven-tricularpressure.

C. MonitorforincreasingICPandcomparewithpreviousdata.

D. Monitorforinfection,especiallymeningitisorenceph-alitis.

Home CareA. TeachparentssymptomsofincreasingICP.B. Have parents participate in care of the shunt before

client’sdischarge.C. Encourage parents and family to ventilate feelings

regardingclient’scondition.D. Referclienttoappropriatecommunityagencies.

Reye’s SyndromeReye’s syndrome is a rare acute illness that occurs after a viral illness (frequently, after aspirin has been consumed) and results in fatty infiltration of the liver and subsequent liver degeneration and increased intracranial pressure.A. Damaged liver cells no longer adequately convert

ammoniatoureaforexcretionfromthebody.B. Circulatingammoniacrossestheblood-brainbarrierto

produceacuteneurologiceffects.


1. Mostoftenprecededbyanacuteviralinfection.2. Primarilyaffectschildrenfromtheageof6months

toadolescence.3. Frequently, the affected childhas received salicylate

(aspirin) for control of fever during the precedingviralinfection.

4. With warning labels now on aspirin, problem hassignificantlydecreased.

B. Clinicalmanifestations.1. Stage1.

a. Initialsymptommaybeseverepersistentvomiting.b. Lethargy,listlessness.

2. Stage2.a. Irritability,disorientation.b. ProgressestostateofincreasedICPwithdeepen-

ingcomaandposturing.C. Diagnostics(seeAppendix19-1).

1. Definitivediagnosisisaliverbiopsy.2. Prolongedprothrombintime.3. Elevatedbloodammonialevels.4. Elevated serum aspartate aminotransferase and ala-

nineaminotransferaselevels.

TreatmentA. Primarily supportive, based on stage of the disease;

mechanicalventilation,fluidandelectrolytebalance.B. MeasurestodecreaseICP.C. Earlyinterventioncriticaltosuccessfultreatment.

Nursing InterventionsGoal: To monitor progress of disease state and maintain

homeostasis.A. IVfluids.B. Monitorserumelectrolytesandliverfunctionstudies.C. Maintainrespiratorystatus;preventhypoxia.D. Assessforproblemsofimpairedcoagulation.

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E. Decreasestress,anxiety:childmaynotremembereventsbeforethecriticalphase.

Goal: To monitor for and implement nursing actionsappropriateforincreasingICP.

Stroke (Brain Attack)Stroke, or brain attack, is the disruption of the blood supply to an area of the brain, resulting in tissue necrosis and sudden loss of brain function. It is the leading cause of adult disability in the United States.A. Atherosclerosis (see Chapter 16), resulting in cerebro-

vasculardisease,frequentlyprecedesthedevelopmentofastroke.

B. Typesofstroke.1. Ischemicstroke.

a. Thrombotic stroke: formation of a clot thatresults in the narrowing of a vessel lumen andeventual occlusion; accounts for about 80% ofstrokes.(1) Associated with hypertension and diabetes

(i.e.,conditionsthatacceleratetheatheroscle-roticprocess).

(2) Producesischemiaofthecerebraltissuedistalto occlusion and edema to the surroundingareas.

b. Embolic stroke:occlusionof a cerebral arterybyanembolus.(1) Commonsiteoforiginistheendocardium.(2) May affect any age group; associated with

atrialfibrillation,endocarditis,andprostheticcardiacvalves.

2. Hemorrhagicstroke.a. Ruptureofacerebralarterycausedbyhyperten-

sion,trauma,oraneurysm.b. Bloodcompressesthebrain.

C. The area of edema resulting from tissue damage mayprecipitatemoredamagethanthevasculardamageitself.

D. TIAandRIND.1. Transientischemicattack(TIA,silentstroke).

a. Brief episode, less than 24 hours, of neurologicdysfunction; usually resolves within 30 to 60minutes.

b. Shouldbeconsideredawarningsignofanimpend-ingstroke.

c. Neurologicdysfunction ispresent forminutes tohours, but no permanent neurologic deficitremains.

2. Reversibleischemicneurologicdeficit(RIND).a. SymptomssimilartoTIA.b. Neurologic symptoms last longer than 24 hours

butlessthanaweek.3. Stroke:clienthasneurologicdeficitsrelatedtomobil-

ity,sensation,andcognition.E. Neuromusculardeficits resulting froma stroke aredue

todamageofmotorneuronsofthepyramidaltract.1. Damage to the left side of the brain will result in

paralysisoftherightsideofthebody(Figure20-6).

2. Bothupperandlowerextremitiesoftheinvolvedsideareaffected.

AssessmentA. Riskfactors/etiology(Box20-5).B. Clinicalmanifestations.

1. Transientischemicattack(TIA)andreversibleisch-emicneurologicdeficit(RIND).a. Visualdefects:blurredvision,diplopia,blindness

ofoneeye,tunnelvision.b. Transienthemiparesis,gaitproblems.c. Slurredspeech,confusion.d. Transientnumbnessofanextremity.

2. Completestroke(occurssuddenlywithanembolism,more gradually with hemorrhage or thrombosis);manifestations vary according to which cerebralvesselsareinvolved.a. Hemiplegia:lossofvoluntarymovement;damage

to the right sideof thebrainwill result in left-sidedweaknessandparalysis.

b. Aphasia: defect in using and interpreting thesymbolsoflanguage;mayincludewritten,printed,orspokenwords.

c. Maybeunawareoftheaffectedside;neglectsyn-dromeensues.

d. Cranial nerve impairment: chewing, gag reflex,dysphagia,impairedtonguemovement.

e. Maybeincontinentinitially.f. Agnosia:aperceptualdefectthatcausesadistur-

banceininterpretingsensoryinformation;client

FIGURE 20-6 Manifestations of right-brain and left-brain stroke. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby.)

Right-brain damage(stroke on right side of the brain)

Left-brain damage(stroke on left side of the brain)

• Paralyzed left side: hemiplegia• Left-sided neglect• Spatial-perceptual deficits• Tends to deny or minimize problems• Rapid performance, short attention span• Impulsive, safety problems• Impaired judgment• Impaired time concepts

• Paralyzed right side: hemiplegia• Impaired speech/language aphasias• Impaired right/left discrimination• Slow performance, cautious• Aware of deficits: depression, anxiety• Impaired comprehension related to language, math

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maynotbeabletorecognizepreviouslyfamiliarobjects.

g. Cognitiveimpairmentofmemory,judgment,pro-prioception(awarenessofone’sbodyposition).

h. Hypotonia(flaccidity)fordaystoweeks,followedbyhypertonia(spasticity).

i. Visualdefects.(1) Homonymoushemianopia:lossofsamehalf

ofvisualfieldineacheye;clienthasonlyhalfofnormalvision.

(2) Horner’ssyndrome:ptosisoftheuppereyelid,constrictionofthepupil,andlackoftearingintheeye.

j. Apraxia:canmovetheaffectedlimbbutisunabletocarryoutlearnedmovements.

k. IncreasedICP,drowsinesstocoma. l. Painineye,nose,orface.m. Gaitdisturbances.


TreatmentA. Prophylactic.

1. Aspirin,plateletinhibitors.2. Antihypertensives,anticoagulants.

B. Immediate treatment (differs depending on whetherthromboticorhemorrhagicstroke).1. Medical.

a. Medicationstodecreasecerebraledema.(1) Osmoticdiuretics.(2) Corticosteroids(dexamethasone).

b. Anticoagulants for thrombotic stroke (neveradministeredtoaclientwithhemorrhagicstroke).

c. Anticonvulsants.

d. Thrombolytictherapyorfibrinolytictherapy(suchas recombinant tissue plasminogen activator(rtPA[Retavase])consideredfornonhemorrhagicstrokes within 3 hours of first manifestation ofstrokesigns.

e. Antihypertensivesandantidysrhythmics.2. Surgical.

a. Carotid endarterectomy, especially for transientischemicattack.

b. Craniotomyforevacuationofhematoma.c. Extracranial-intracranialbypassformildstrokes.

C. Specifictherapiestoresolvephysical,speechoroccupa-tionalcomplications,includinguseofassistivedevices.

Nursing InterventionsGoal: Topreventstrokethroughclienteducation(seeBox

20-5).A. Identificationof individualswith reversible risk factors

andmeasurestoreducethem.B. Appropriate medical attention for control of chronic

conditionsconducivetothedevelopmentofstroke.C. Teach high-risk clients early signs ofTIA and RIND

andtoseekmedicalattentionimmediatelyiftheyoccur.Goal: To maintain patent airway and adequate cerebral

oxygenation.A. Placeclientinside-lyingpositionwithheadelevated.B. Assess for symptomsofhypoxia; administeroxygenor

assistwithendotrachealintubationandmechanicalven-tilationasnecessary(seeAppendix15-8).

C. Maintain patent airway; use oropharyngeal airway topreventairwayobstructionbythetongue.

D. Client is prone to obstructed airway and pulmonaryinfection; have client cough and deep-breathe every2hours.

Goal: To assess for and implement measures to decreaseICP(seenursinggoalsforincreasedICP).

Goal: Tomaintainadequatenutritionalintake.A. Beforeoralfeedings,evaluateneedforswallowstudies.B. Administeroralfeedingswithcaution;startafterfirst24

hours;checkforpresenceofgagandswallowingreflexesbeforefeeding.

C. Place foodon theunaffected sideof themouth;beginwithclearfoods(gelatins).

D. Selectfoodsthatareeasytocontrolinthemouth(thickliquids) and easy to swallow; liquids often promotecoughing,becauseclientisunabletocontrolthem.

E. Maintainhigh-Fowler’spositionforfeeding.F. Maintainprivacyandunrushedatmosphere.G. Ifclientisunabletotolerateoralintake,enteralfeedings

maybeinitiated.

Box 20-5 RISK FACTORS ASSOCIATED WITH STROKE

Modifiable• Smoking• Obesity• Increasedsaltintake• Sedentarylifestyle• Increasedstress• Oralcontraceptives

Partially Modifiable• Hypertension• Cardiacvalvedisease• Dysrhythmias• Diabetesmellitus• Hypercholesterolemia

Nonmodifiable• Sex:Increasedincidenceinmen• Age• Race: Increased incidence in the African-American popu-

lation• Hereditarypredisposition

ALERT Identify potential for aspiration; assess client’s ability to eat.

Goal: Topreservefunctionofthemusculoskeletalsystem.A. Passiverangeofmotion(ROM)onaffectedside;begin

earlybecausetheexercisesaremoredifficult ifmusclesbegintotighten.

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B. ActiveROMonunaffectedside.C. Prevent foot drop: passive exercises; rigid boots; have

clientoutofbedassoonaspossible.D. Legsshouldbemaintainedinaneutralposition;prevent

externalrotationofaffectedhipbyplacingatrochanterrollorrolledpillowatthethigh.

E. Repositionevery2hours,but limit theperiodof timespentontheaffectedside.

Goal: Tomaintainhomeostasis.A. Evaluateadequacyofcardiacoutput.B. Monitorhydrationstatus:preventfluidoverload.

1. CarefullyregulateIVfluidintake.2. Evaluateresponsetodiuretics.3. Assessforthedevelopmentofperipheraledema.4. Restrictfluidintake,asindicated.5. Assess respiratory parameters indicative of fluid

overload.6. Monitordailyweight.

C. Determinepreviousbowelpatternsandpromotenormalelimination.1. Avoiduseofurinarycatheter, ifpossible; ifcatheter

isnecessary,removeassoonaspossible.2. Offerbedpanorurinalevery2hours;helpestablish

aschedule.3. Preventconstipation:provide increasedbulk indiet,

stoolsofteners,etc.4. Provide privacy and decrease emotional trauma

relatedtoincontinence.

FIGURE 20-7 Transfer from bed to wheelchair by client with hemiplegia. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 7, Philadelphia, 2005, Saunders.)

EDC

BA

NURSING PRIORITY Protect the client’s affected side: do not give injections on that side, watch for pressure areas when positioning, have client spend less time on affected side than in other positions.

F. Assessforadductionandinternalrotationoftheaffectedarm;maintainarminaneutral(slightlyflexed)positionwitheachjointslightlyhigherthantheprecedingone.

G. Restraintsshouldbeavoidedbecausetheyoftenincreaseagitation.

H. Maintainjointsinpositionofnormalfunctiontopreventflexioncontractures.

I. Assist client out of bed on the unaffected side; thisallowsclient toprovide some stabilizationandbalancewiththegoodside(Figure20-7).

ALERT Mobility: Assist client to ambulate, perform active and passive ROM exercises, assess for complications of immobility, prevent DVT, prevent skin breakdown and encourage independence.

ALERT Assess and manage a client with an alteration in elimination. Establish a toileting schedule; the client who has had a stroke will need assistance in reestablishing a normal bowel and bladder routine.

D. Prevent problems of skin breakdown through properpositioningandgoodskinhygiene.

E. Assistclienttoidentifyproblemsofvision.

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F. Maintainpsychologichomeostasis.1. Clientmaybeveryanxiousbecauseofalackofunder-

standingofwhathashappenedandbecauseofhisorherinabilitytocommunicate.

2. Speak slowly and clearly and explain what hashappened.

3. Assess client’s communication abilities and identifymethodstopromotecommunication.

Home CareA. EncourageindependenceinADLs.B. Provideclothingthatiseasytogetinandoutof.C. ActiveparticipationinROM;haveclientdohisorher

ownROMonaffectedside.D. Physical,occupational,andspeechtherapyforretraining

oflostfunction.E. Assist client tomaintain senseofbalancewhen in the

sittingposition;clientwillfrequentlyfalltotheaffectedside(unilateralneglectsyndrome).

F. Encourage participation in carrying out daily personalhygiene.

G. Teach client safe transfer from bed to wheelchair andprovideassistanceasneeded(seeFigure20-7).

H. Bowelandbladdertrainingprogram.1. Topromotebladdertone,encourageurination(with

or without assistance) every 2 hours rather thanallowingtheclienttovoidwhenheorshefeelstheurge.

2. TeachclienttoperformKegelexercisesregularly.3. Adviseclienttoavoidcaffeineintake.4. Increased bulk in diet will help avoid constipation

(seeTable18-2).5. Increasefluidsto2000mLperdayastolerated.6. AdministerstoolsoftenersPRN.7. Establishregulardailytimeforbowelmovements.

I. Encouragesocialinteraction(seeAppendix20-6).1. Speechtherapy.2. Frequentandmeaningfulverbalstimuli.3. Allowclientplentyoftimetorespond.4. Speakslowlyandclearly;donotgivetoomanydirec-

tionsatonetime.Useshortsentences.5. Donot“talkdownto”clientortreatclientasachild

(elderspeak).6. Client’smentalstatusmaybenormal;donotassume

itisimpaired.7. Nonverbalclientsdonotlosetheirhearingability.

J. Evaluate family supportandtheneed forhomehealthservices.

bral aneurysm occurring in the arterial junction of the circle of Willis. A ruptured cerebral aneurysm often results in hemorrhagic stroke.A. Asubarachnoidhemorrhageisapotentiallyfatalcondi-

tion in which blood accumulates below the arachnoidmaterinthesubarachnoidspace;mostoftenoccurssec-ondarytoananeurysm.

B. An aneurysm frequently ruptures and bleeds into thesubarachnoidspace.

C. Symptomsoccurwhenananeurysmenlarges,orwhenit ruptures. As blood collects in the subarachnoidspace, it compresses and damages the surroundingbraintissue.

D. Subarachnoidhemorrhagemayleadtoneurologiccom-promise including seizures, stroke, permanent braindamage,andevendeath.

E. Often, symptoms do not appear until rupture hasoccurred.


1. Age:morecommoninadults30to60yearsofage.2. Atherosclerosis, connective tissue disease, cigarette

smoking,andhypertension—causingfragility in thevesselwall.

3. Head trauma and congenital vessel weakness mayincreasetherisk.

B. Clinicalmanifestations.1. Rupturemaybeprecededby:

a. Severeheadache.b. Intermittentnausea.

2. Rupturefrequentlyoccurswithoutwarning.a. Suddensevereheadache,seizures.b. Nuchalrigidity,hemiparesis.c. Lossofconsciousness.d. Symptoms of increasing ICP: nausea, vomiting,

photophobia.3. Severityofsymptomsdependsonthesiteandamount

ofbleeding.C. Diagnostics(seeAppendix20-1).

TreatmentA. Aminocaproicacid:inhibitsfibrinolysisinlife-threaten-

ingsituations.B. Osmoticdiuretics,anticonvulsants.C. Corticosteroids:dexamethasone(Decadron).D. Calcium channel blockers: minimize vasospasm after

hemorrhage.E. Stoolsofteners.F. Analgesicsforrecurrentheadache.G. Fluids to maintain systolic blood pressure at 100 to

150mmHg(increaseinvolumeandpressureincreasesbloodflowthroughnarrowedvessels).

H. Surgicalintervention:ligationor“clipping”oftheaneu-rysm to reduce the swellingandminimize the risk forre-bleeding.

I. Procedure to block abnormal arteries or veins andpreventbleeding.

ALERT Assist family to manage care of a client with long-term care needs; determine needs of family regarding ability to provide home care after discharge.

Cerebral Aneurysm, Subarachnoid HemorrhageA cerebral aneurysm occurs when a weakened saccular outpouching of the cerebral vasculature bulges from pres-sure on the weakened tissue. A Berry aneurysm is a cere-

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Nursing InterventionsGoal: To prevent further increase in ICP and possible

rupture.A. Immediate bed rest; bathroom privileges may be

permitted.B. PreventValsalvamaneuver.C. Client should avoid straining, sneezing, pulling up in

bed,andacuteflexionoftheneck.D. Elevate head of the bed 30 degrees to 45 degrees to

promotevenousreturn.E. Quiet, dim, nonstimulating environment: disconnect

telephone;promoterelaxation.F. Constantmonitoringofconditiontoidentifyoccurrence

of bleeding, as evidenced by symptoms of increasingICP.

G. Administeranalgesicscautiously;theclientshouldcon-tinuetobeeasilyarousedsothatneurologiccheckscanbeperformed.

H. No hot or cold beverages or food, no caffeine, nosmoking.

I. Maintainseizureprecautions.

3. Chillsandhighfever.4. Severeandpersistentheadache.5. Increasing irritability, malaise, changes in level of

consciousness.6. Respiratorydistress.7. Generalizedseizures.8. Nauseaandvomiting.9. PositiveKernigsign:resistanceorpainattheknee

andthehamstringmuscleswhenclientattemptstoextendthelegafterthighflexion.

10. Positive Brudzinski sign: reflex flexion of the hipswhentheneckisflexed.

11. Photophobia.C. Clinicalmanifestations:neonateandinfant.

1. Fever.2. Apneicepisodes.3. Bulgingfontanel.4. Seizures.5. Cryingwithpositionchange.6. Opisthotonospositioning:adorsalarchedposition.7. Changesinsleeppattern,increasingirritability.8. Poorsucking;mayrefusefeedings.9. Poormuscletone,diminishedmovement.

10. Irritability.D. Diagnostics(seeAppendix20-1).

1. LumbarpuncturerevealsincreasingCSFpressure;ifICPispresent,thenaCTscanmaybedonebeforetheprocedure.

2. ElevatedWBCs.3. CSFandbloodculturespositive formeningococcus

bacteria.

TreatmentA. Respiratory isolation until positive organism is

identified.B. IVantibiotics,steroids(seeAppendixes6-9,6-7).C. Optimumhydration.D. Anticonvulsantmedications(seeAppendix20-2).E. Antivirals(seeAppendix7-1).F. Maintainventilation.

ComplicationsA. IncreasingICPresultinginpermanentbraindamage.B. Visualandhearingdeficits,paralysis.C. Subdural effusion; may be aspirated or allowed to

absorbwhenmeningitistreatmentisstartedandproteinleakstops.

Nursing InterventionsGoal: To identify the causative organism, control spread,

andinitiatetherapy.A. Maintainrespiratorydropletprecautionsuntilorganism

is identified; place client in a private room (Appendix6-9).

B. Begin administration of IV antibiotics after lumbarpunctureduringwhichCSFsamplewasobtained.

C. Identify family members and close contacts who mayrequireprophylactictreatment.

NURSING PRIORITY If the client survives the rupture of the aneurysm and re-bleeding occurs, it is most likely to occur within the next 24 to 48 hours.

Goal: To assess for and implement nursing measures todecreaseICP(seenursinggoalsforincreasedICP).

Goal: To provide appropriate preoperative nursing inter-ventions(seenursinggoalsforbraintumor).

Goal: To maintain homeostasis and monitor changes inICPaftercraniotomy(seenursinggoalsforcraniotomy).

MeningitisMeningitis is an acute viral or bacterial infection that causes inflammation of the meningeal tissue covering the brain and spinal cord.A. Infectious process increases permeability of protective

membraneandresultsinanincreasedproteinconcentra-tionintheCSF.

B. Inflammatoryprocessresultsinthedevelopmentofcere-braledema.

C. Bacterial meningitis is less common but more severethanviralmeningitis.


1. Pathogenicorganismmostoftengainsentryfromaninfectionelsewhereinthebody.

2. Meningococcal meningitis is the only form that isreadilycontagious;transmittedbydirectcontactwithdropletsfromtheairwayofaninfectedperson.

3. Increasedmortalityrateamonginfants.B. Clinicalmanifestations:olderchildandadult.

1. Rash,petechiae,purpura.2. Nuchalrigidity.

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Goal: To monitor course of infection and preventcomplications.

A. FrequentnursingassessmentforincreasedICP(seeBox20-3).

B. Maintain adequate hydration; cerebral edema mayrequirelimitingfluidintake.

C. MonitorinfusionsiteforcomplicationsofIVpiggybackantibiotics.

D. Assessforsideeffectsofhighdosageofantibiotics.E. Decreasestimuliinenvironment:dimlights,quietenvi-

ronment,noloudnoises.F. Avoidmovementorpositioningthat increasesdiscom-

fort;clientgenerallyassumesaside-lyingposition.G. Seizureprecautions.H. Preventcomplicationsofimmobility. I. Goodrespiratoryhygiene. J. Measurestodecreasefever.

encephalitisEncephalitis is an inflammatory process of the CNS, or “inflammation of the brain.”


1. Commonly occurs as a complication after a viralinfection(measles,chickenpox,mumps).

2. Maybe transmittedbyavector suchas amosquitoortick.

3. Causative organism may be herpes simplex virus inmiddle-agedadults.

B. Clinicalmanifestations.1. Severeheadache,nuchalrigidity.2. Suddenfever.3. Seizures.4. Changesinlevelofconsciousness.5. Motor involvement: ataxia, dysphasia, tremor,

convulsions.6. Drowsiness,confusion,disorientation.7. Irritability.8. Bulgingfontanelsininfants.

C. Diagnostics.1. ExaminationoftheCSF.2. Viralstudiestoisolatethevirus.3. EEGforseizureactivity.4. BloodtestforWestNilevirus.

TreatmentA. Anticonvulsants.B. TreatmenttodecreaseICP.C. Hydration,bedrest,propernutrition.

Nursing InterventionsNursinginterventionsforencephalitisarethesameasthosefor meningitis, with the exception of antibiotic therapy.Encephalitisiscausedbyaviralagentandisnotresponsivetoantibiotic therapy;antibiotic therapymaybeorderedtopreventbacterialinfection.

Spinal Cord InjurySpinal cord injury (SCI) is damage to the spinal cord housed inside the spinal column. Most SCIs exist with the spinal cord intact yet compromised from injury or disease. SCI most often occurs as a result of direct trauma to the head or neck area.A. Riskfactors.

1. Morethan80%ofclientswithSCIsaremale.2. MorethanhalfofSCIsoccurbetweentheagesof16

and35years.3. Alsoanincreasedriskafter60yearsofage,whenfalls

becomemorecommon.4. Otherriskfactors:osteoarthritis,cancer,involvement

insports.B. Initiallyaftertheinjury,thenervefibersswell,andcir-

culationtothespinalcordisdecreased;hemorrhageandedemaoccur,causinganincreaseintheischemicprocess,which progresses to necrotic destruction of the spinalcord.

C. ConsequencesofSCIdependontheextentofdamage,aswellasthelevelofcordinjury(Figure20-8).1. Thehigherthelesion,themoreseverethesequelae.

a. ClientswithlesionsatC4orhighermayrequireventilatorysupport.

b. LesionsbetweenT1andT8oftenallowuseofthehands.

c. LesionsbelowT8oftenallowupperbodycontrol.2. Complete transection (complete cord dissolution,

completelesion):immediatelossofallsensationand

ALERT Identify changes in client’s mental status; treat client with seizures.

FIGURE 20-8 Spinal cord injury: areas of paralysis. (From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby.)

Tetraplegia C8

Paraplegia T1Phrenic nerve (C3-C5)Upper limbs (C5-T1)

Head

Lower limbs

Bladder, bowel, and external genitalia

Sympatheticoutflow (T1-L4)

Temperaturecontrol

Bloodvessels

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voluntary movement below the level of injury;minimal,ifany,returnoffunction.

3. Incomplete(partial).a. Central cord syndrome: center of cord is

damaged; results primarily in impairment ofupperextremities.

b. Damagetoonesideofthecord(Brown-Séquardsyndrome): motor function and position sensemaybepresentononeside;temperatureandsen-sationmaybelostontheoppositeside.

c. Anterior cord damage: disruption of blood flowresultsinamixedlossofsensoryandmotorfunc-tionbelowthelevelofinjury.

4. Cordedemapeaksinabout2to3daysandsubsideswithinabout7daysaftertheinjury.

5. Lumbosacralinjuries.a. Variablepatternofmotorandsensoryloss.b. Frequentlyresultinneurogenicbowelandbladder.

D. Spinalcordshock(areflexia):temporarylossordysfunc-tion of spinal reflex activity; occurs predominantly incompletecord lesions; lossof communicationwith thehighercentersofcontrolresultsinflaccidityandlossoffunctionalcontrolbelowthelevelofinjury.1. SCIinterruptssympatheticnerveimpulsetransmis-

sion; parasympathetic impulses are not counter-checked, resulting in vasodilation; loss of venousreturn results in hypotension, which is neurogenicshock.

2. Hypothalamus loses control of body temperature,which assists in vasoconstriction and vasodila-tion.

3. Conditionmaypersist forseveralweeksandreversespontaneously; resolution of spinal shock will beevidentbyreturnofreflexes.

4. Hyperreflexiawilloccurasrecoveryprogresses;spasticmovementsmaybeprecipitatedbyemotionandcuta-neousstimulation.

E. AutonomicdysreflexiaoccursinclientswithaninjuryatT6orhigher.1. A noxious stimulus below the level of injury trig-

gers the sympathetic nervous system, which causesa release of catecholamines (epinephrine, norepi-nephrine).

2. Mostcommonstimulicausingtheresponseareafullbladder or bowel, UTI, pressure ulcers, and skinstimulation.

3. Severe hypertension (systolic may be greater than300), nausea, poundingheadache, bradycardia, rest-lessness,flushingpiloerection,andblurredvisionarethemostcommonbodyresponses.

F. Bladderdysfunctionwilloccurasaresultoftheinjury;normalbladdercontrolisdependentonthesensoryandmotor pathways and the lower motor neurons beingintact.1. Neurogenicbladderoccursinclientswithbothupper

andlowermotorneurondisorders.a. Upper motor neuron disorders produce a spastic

orreflexbladder.

b. Lowermotorneurondisorders produce aflaccidbladder.

2. Managementofbladderproblemsdependsonclient’spreferencesandlifestyle,aswellasclient’sfunctionalabilities.

G. Long-term rehabilitation potential depends on theamountofdamagedonetothecord,whichmaynotbeevidentuntilseveralweeksaftertheinjury.

AssessmentA. Clinical manifestations: depend on level of SCI (see

Figure20-8).1. Injury at C3 through C5 will cause respiratory

compromise.2. Dependingondegreeofinjury,thedegreeofparalysis

andamountofsensorylossbelowthelevelofinjurywillvary.

3. Spinalshock.a. Generallyoccurswithin72hoursandmaylastfor

severalweeks.b. Flaccidparalysis.c. Lossofsensationandabsenceofreflexes.d. Bowelandbladderdysfunction.e. Hypotensionandbradycardia.f. After spinal shock, reflexes and autonomic

activity return, as evidenced by development ofspasticity.

4. Autonomicdysreflexia inclientswith injuriesatT6orhigher.a. Severehypertension,bradycardia.b. Complaintsofheadache.c. Flushing and diaphoresis above level of

injury.B. Diagnostics(seeAppendix20-1).C. Complications.

1. Respiratorystasis;pulmonaryedemaandemboli.2. Cardiovascular compromise from neurogenic shock,

orautonomicdysreflexia.3. Skin breakdown resulting in localized and systemic

infections.4. Immobility issues causing renal andgastrointestinal

compromise.5. Psychologic,social,andbodyimageissues.

TreatmentA. Emergencyinterventionrequired.B. Corticosteroids within 8 hours of injury (methylpred-

nisolone).C. Immobilization of the vertebral column in cervical

fracture.1. Cervicaltongs(Crutchfield,Gardner-Wells)forcer-

vicalimmobility.2. Halovest/jackettractiontopromotemobility.3. Sterno-occipital mandibular immobilizer (SOMI)

bracewornwithcervicalfusion.D. Spinal surgery to remove bone fragments and assure

spinalalignment.E. Respiratorysupportasnecessary.

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Nursing InterventionsGoal: To maintain stability of the vertebral column and

preventfurthercorddamage.A. Emergencycareandtreatment.

1. SuspectSCIifthereisanyevidenceofdirecttraumatotheheadorneckarea(contactsports,divingacci-dents,motorvehicleaccident).

2. Immobilizeclientandplaceonspinalboardwiththeheadandneckinaneutralposition;donotallowthenecktoflex.

3. Airway, status of breathing, and circulation are theprimaryconcernsinitiallyafterinjury.

4. Neurogenic shock may occur within the first 24hours;observefordecreasedB/P,severebradycardia.

Goal: To identify level of damage and changes in neuro-logicstatus.

A. Assess respiratory function: symmetrical chest expan-sion,bilateralbreath sounds,presenceof retractionsordyspnea.

B. Motorandsensoryevaluation.1. Ability tomoveextremities; strengthof extremities.2. Sensoryexamination,includingtouchandpain.3. Presenceofdeeptendonreflexes.

C. Ongoingassessmentandstatusof:1. Bladder,gastric,bowelfunction.2. Psychologicadjustmenttotheinjury.

D. Evaluatehistoryofhowinjuryoccurred;obtaininforma-tionregardinghowclientwastransported.

E. Determinestatusofpain.Goal: Tomaintainrespiratoryfunction.A. Frequentassessmentof respiratory functionduringthe

first48hours.1. Changesinbreathingpattern.2. Observe breathing pattern for use of sternocleido-

mastoidandintercostalmusclesforrespiration.3. Evaluatearterialbloodgasvaluesandpulseoximetry.4. Determinedevelopmentofhypoxia.

B. Maintainadequaterespiratoryfunction,asindicated.1. Chestphysiotherapy.2. Incentivespirometry.3. Changingpositionwithinlimitsofinjury.4. Assess for complications of atelectasis, pulmonary

emboli,andpneumonia.5. Nasopharyngealorendotrachealsuctioningbasedon

airwayandlevelofinjury.Goal: Tomaintaincardiovascularstability.A. Spinalshock.

1. Monitorvitalsignsandevaluatechanges.2. Vagal stimulation, hypothermia, and hypoxia may

precipitatespinalshock.3. Assess deep tendon reflexes and muscle strength as

resolutionofshockoccurs.B. Assess for development of autonomic dysreflexia; if it

occurs:1. Elevate the head of the bed, and check the client’s

bloodpressure.2. Assess for sources of stimuli: distended bladder

(checkurinarytubing),fecalimpaction,constipation,tightclothing.

3. Relievethestimuli,anddysreflexiawillsubside.4. Maintain cardiovascular support during period of

hypertension.5. A hypertensive crisis from dysreflexia will require

immediateintervention.C. Evaluatecardiovascularresponseswhenturningorsuc-

tioningclient.D. Apply antiembolism stockings or elastic wraps to the

legstofacilitatevenousreturn.(Lackofmuscletoneandlossofsympathetictoneintheperipheralvesselsresultin decreases in both venous tone and venous return,whichpredisposeclienttodeepveinthrombosis.)

E. Implementmeasurestopromotevenousreturn.

NURSING PRIORITY Do not hyperextend the neck in a client with a suspected cervical injury. Airway should be opened by the jaw-lift method. Improper handling of the client often results in extension of the damaged area.

5. Maintain in extended position with no twisting orturning;donotremovecervicalcollarorspinalboarduntilareaofinjuryisidentified.

6. Maintainpatentairwayduringtransportation.B. Maintainstabilityof thevertebralcolumnas indicated

bythelevelofinjury.1. Prescribeandmaintainbedrestonfirmmattresswith

supportive devices (sandbags, skin traction, etc.);maintain alignment in the supine position; logrollwithoutanyflexionortwisting.

2. Maintaincervicaltraction:tongsareinsertedintotheskullwithtractionandweightsapplied;donotremoveweights;logrolltomaintainspinalimmobility.

3. Halo vest/jacket traction: maintains cervical immo-bilitybutallowsclienttobemobile.a. If bolts or screws come loose, keep the client

immobilizedandcallthedoctor.b. Cleanpinsitesaccordingtofacilitypolicy,observe

forinfection.c. Rollclientontohisorhersideattheedgeofthe

bedandallowclienttopushupfromthemattresstoasittingposition.Neverusethehalovestframetoassisttheclienttoturnorsitup.

d. Correctsizeofwrenchshouldbekeptatbedsideto remove the anterior bolts in case ofemergency.

e. Assist client tomaintainbalancewhenstanding;thetractionisheavyforapersonwhoisweak,andtheclientisatincreasedriskforfalling.

4. Maintainextremitiesinneutral,functionalposition.

ALERT Apply, maintain, or remove orthopedic devices (e.g. traction, splints, braces, casts).

C. Performappropriatenursinginterventionwhensurgeryisindicatedtostabilizetheinjury.

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Goal: Tomaintainadequatefluidandnutritionalstatus.A. Duringthefirst48hours,evaluategastrointestinalfunc-

tionfrequently;decreaseinfunctionmaynecessitateuseofanasogastrictubetodecreasedistention.

B. Preventcomplicationsofnauseaandvomiting.C. Evaluatebowelsoundsandclient’sabilitytotolerateoral

fluids.D. Increase protein and calories in diet; may need to

decreasecalciumintake.E. Evaluateforpresenceofparalyticileus.F. Increaseroughageindiettopromotebowelfunction.Goal: To prevent complications of immobility (see

Chapter3).Goal: Topromotebowelandbladderfunction.A. Urineisretainedasaresultofthelossofautonomicand

reflexivecontrolofthebladder.1. Intermittent catheterization or indwelling catheter

maybeusedinitiallytopreventbladderdistention.2. Perform nursing interventions to prevent urinary

tract infection; avoid urinary catheterization, ifpossible.

B. Determinetypeofbladderdysfunctionbasedonlevelofinjury.

C. Assessclient’sawarenessofbladderfunction.D. Initiatemeasurestoinstitutebladdercontrol.

1. Establishascheduleforvoiding;haveclientattempttovoidevery2hours.

2. UsetheCredémethod(inadults)formanualexpres-sionofurine.

3. Maybenecessarytoteachclientself-catheterization.4. Recordoutputandevaluate forpresenceof residual

urine.E. Evaluatebowelfunctioning.

1. Incontinenceandparalyticileusfrequentlyoccurwithspinalshock.

2. Incontinenceandimpactionarecommonlater.F. Initiatemeasurestopromotebowelcontrol(afterspinal

shockisresolved).1. Identifyclient’sbowelhabitsbeforeinjury.2. Maintainsufficientfluidintakeandadequatebulkin

thediet.3. Establish specific time each day for bowel evacua-

tion.4. Assessclient’sawarenessofneedtodefecate.5. Teach client effective use of the Valsalva maneuver

toinducedefecation.6. Inducedefecationbydigitalstimulation,suppository,

orasalastresort,enema.

Goal: Tomaintainpsychologicequilibrium.A. Providesimpleexplanationsofallprocedures.B. Anticipate outbursts of anger and hostility as client

beginstoworkthroughthegrievingprocessandadjuststochangesinbodyimage.

C. Anticipateandacceptperiodsofdepressioninclient.D. Encourageindependencewheneverpossible;allowclient

to participate in decisions regarding care and to gaincontroloverenvironment.

ALERT Prevent complications of immobility; prevent venous stasis: identify symptoms of deep venous thrombosis, apply compression stockings, and change client’s position.

ALERT Assess and manage a client with alteration in elimination; initiate a toileting schedule; the client with SCI may need bowel and bladder retraining, depending on level of the injury.

ALERT Plan measures to deal with client’s anxiety and promote client’s adjustment to changes in body image; assist client and significant others to adjust to role changes. Note: These items are all part of the test plan, and the test could include questions about the client with SCI.

E. Encouragefamily involvement in identifyingappropri-atediversionalactivities.

F. Avoidsympathyandemphasizeclient’spotential.G. Initiate frank, open discussion regarding sexual func-

tioning.H. Assistclientandfamilytoidentifycommunityresources. I. Assistclienttosetrealisticshort-termgoals.

Myasthenia GravisMyasthenia gravis is a sporadic, progressive neuromuscu-lar disease characterized by a decrease in the acetylcholine level at the receptor sites in the neuromuscular junction. This inadequate acetylcholine level results in a distur-bance in nerve impulse transmission, causing progressive weakness in skeletal muscles. Myasthenia gravis literally means “grave muscle weakness.”


1. Autoimmunedisease.2. Morecommoninwomenyoungerthan40andmen

olderthan60butmayoccuratanyage.B. Clinicalmanifestations.

1. Primaryproblemisskeletalmusclefatiguewithsus-tained muscle contraction; symptoms are predomi-nantlybilateral.a. Muscularfatigueincreaseswithactivity.b. Ptosis (drooping of the eyelids) and diplopia

(doublevision)arefrequentlythefirstsymptoms.(Ophthalmologist may be first contact regardingdysfunction.)

c. Impairmentoffacialmobilityandexpression.d. Impairmentofchewingandswallowing.e. Speechimpairment(dysarthria).f. No sensory deficit, loss of reflexes, or muscular

atrophy.g. Poorbowelandbladdercontrol.

2. Courseisvariable.a. Maybeprogressive.b. Maystabilize.c. May be characterized by short remissions and

exacerbations.

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3. Myastheniccrisis:anacuteexacerbationofsymptomsthatmayrequireintubationandmechanicalventila-tion to support respiratory effort; caused by majormuscularweaknessandinabilitytomaintainrespira-toryfunction.a. Severerespiratorydistressandhypoxia.b. Increasedpulseandbloodpressure.c. Decreasedorabsentcoughorswallowreflex.

4. Cholinergiccrisis:atoxicresponsetotheanticholin-esterase medications; anticholinesterase medicationsmustbewithheld—thisresponseisrarewithproperdosingofMestinon.a. Nausea,vomiting,anddiarrhea.b. Weaknesswithdifficultyinswallowing,chewing,

andspeaking.c. Increasedsecretionsandsaliva.d. Musclefasciculation,constrictedpupils.

C. Diagnostics(seeAppendix20-1).1. Electromyography: shows a decreasing response of

musclestostimuli.2. Ice pack test: assess clients with ptosis; muscles

improvewithcoldapplication;placepackonclosedlidsfor2minutestoseewhetherptosisimproves.

3. Tensilontest.a. Usedfordiagnosingmyastheniagravis.b. Usedtodifferentiatecholinergiccrisisfrommyas-

theniccrisis.c. IV injection of neostigmine or edrophonium

causes immediate, although short-lived, relief ofmuscleweakness.

TreatmentA. Anticholinesterase (cholinergic) medications (see

Appendix20-3).1. Neostigmine(Prostigmin).2. Pyridostigmine(Mestinon).

B. Corticosteroids(seeAppendix6-7).C. Plasma electrophoresis (plasmapheresis): separation

of plasma to remove autoantibodies from the blood-stream.

D. Immunosuppressivetherapy.E. Surgicalremovalofthethymus(thymectomy).

Nursing InterventionsClientmaybehospitalizedforacutemyastheniccrisisorforrespiratorytractinfection.Goal: Tomaintainrespiratoryfunction.A. Assess for increasing problems of difficulty breathing.

Measureforcedvitalcapacityfrequentlytoassessrespi-ratorystatus.

B. Determine client’s medication schedule. When wasmedicationlasttaken?

C. Assess ability to swallow; prevent problems ofaspiration.

D. Evaluateeffectivenessofcoughreflex.E. Bepreparedtointubateorprovideventilatoryassistance.Goal: To distinguish between a myasthenic crisis and a

cholinergiccrisis.A. Maintainadequateventilatorysupportduringcrisis.B. AssistinadministrationofTensilontesttodifferentiate

crisis.1. Myastheniccrisis:client’sconditionwillimprove.2. Cholinergiccrisis:client’sconditionwilltemporarily

worsen.C. If myasthenic crisis occurs, neostigmine may be

administered.D. If cholinergic crisis occurs, atropine may be adminis-

tered,andcholinergicmedicationsmaybereevaluated.E. Avoid use of sedatives and tranquilizers, which causes

respiratorydepression.F. Providepsychologicsupportduringcrisis.

Home CareA. Teach client importance of taking medication on a

regularbasis;peakeffectofthemedicationshouldcoin-cidewithmealtimes.

B. Ifptosisbecomessevere,clientmayneedtowearaneyepatchtoprotectcornea(alternateeyepatchesifproblemisbilateral).

C. Emotionalupset,severefatigue,infections,andexposureto extreme temperatures may precipitate a myastheniccrisis.

Multiple SclerosisMultiple sclerosis (MS) is characterized by multiple areas of demyelination from inflammatory scarring of the neurons in the brain and spinal cord (CNS).A. Theprogressionofthediseaseresultsintotaldestruction

ofthemyelin,andthenervefibersbecomeinvolved.1. Lossofmyelinsheathcausesdecreasedimpulsecon-

duction,destructionofthenerveaxon,andablockageoftheimpulseconduction.

2. The demyelination occurs in irregular scatteredpatchesthroughouttheCNS.

3. Theoriesastocauseincludeautoimmunityandexpo-suretoviruses.

B. Clinicalcourse.1. Relapsing-remitting MS: most common course,

causing sporadic attacks with exacerbations andremissions lasting days to months; client has a sig-nificant“flare-up”orexacerbation,followedbypartialorcompleterecovery.

2. Primary-progressiveMS:afteranumberofyearsofthe relapsing-remitting form, client experiences aslow steady worsening of symptoms without com-plete improvement between exacerbations; plateausofseveritymayoccur,butbaselinefunctionprogres-sivelyworsens.

3. Secondary-progressive MS: progressively worsensfrom onset with acute exacerbations; baseline func-tioncontinuestoworsen.

ALERT Identify clients at high risk for aspiration; do not give the client experiencing a myasthenic crisis anything to eat or drink.

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4. Progressive-relapsingMS:gradualprogressivewors-eningofdiseasewithoutremissions;onsetinthirdorfourthdecadeoflifewithequalincidenceinmenandwomen.

AssessmentA. Riskfactors/etiology:causeisunknown.

1. Morecommoninwomen.2. Problemofyoungadults.3. Morecommonincoolerclimates.

B. Clinicalmanifestations.1. Signsandsymptomsvaryfrompersontoperson,as

wellaswithinthesameindividual,dependingontheareaofinvolvement.

2. Cerebellardysfunction:nystagmus,ataxia,dysarthria,dysphagia.

3. Motordysfunction:weaknessofeyemuscles,weak-nessorspasticityofmusclesinextremities.

4. Sensory: vertigo, blurred vision, decreased hearing,tinnitus.

5. Bowelandbladderdysfunction.6. Sexualdysfunction.7. Psychosocial.

a. Intellectualfunctioningremainsintact.b. Emotionallability:increasedexcitabilityandinap-

propriateeuphoria.c. Emotional effects of the chronic illness and

changesinbodyimage.C. Diagnostics:nodefinitivediagnostictest.

TreatmentA. Nocure;medical treatment isdirected toward slowing

ofthediseaseprocessandreliefofsymptoms.B. Medicationstodecreaseedemaandinflammationofthe

nervesites.1. Antiinflammatoryagents.2. Immunosuppressiveagents:interferons.3. Adrenocorticotropic hormone for acute exacerba-

tions.

Nursing InterventionsClient may be hospitalized for diagnostic workup or fortreatmentofacuteexacerbationandcomplications.Goal: Tomaintainhomeostasisandpreventcomplications

duringanacuteexacerbationofdiseasesymptoms.A. Maintainadequaterespiratoryfunction.

1. Preventrespiratorytractinfection.2. Goodpulmonaryhygiene.3. Preventaspiration;sittingpositionforeating.4. Evaluateadequacyofcoughreflex.

B. Maintainurinarytractfunction.1. Preventurinarytractinfection.2. Increasefluidintake,atleast2000mL/24hr.3. Evaluate voiding: assess for retention and inconti-

nence.C. Maintainnutrition.

1. Evaluatecoughingandswallowingreflexes.2. Providefoodthatiseasytochew.

3. Ifclientisexperiencingdifficultyswallowing,observeclientcloselyduringfluidintake.

Goal: To prevent complications of immobility (seeChapter3).

Goal: Topromotepsychologicwell-being.A. Focusonremainingcapabilities.B. Encourageindependenceandassistclienttogaincontrol

overenvironment.C. Ifimpotenceisaproblem,initiatesexualcounseling.D. Assistclienttoworkthroughthegrievingprocess.E. Identifycommunityresourcesavailable.

Home CareA. Medicalregimenandsideeffectsofthemedications.B. Physical therapy to maintain muscle function and

decreasespasticity.C. Measures to maintain voiding; may need to perform

self-catheterization.D. Safetymeasuresbecauseofdecreasedsensation.

1. Checkbathwatertemperature.2. Wearprotectiveclothinginthewinter.3. Avoidheatingpadsandclothingthatisconstrictive.

E. Client should understand that relapses are frequentlyassociatedwith an increase inphysiologic andpsycho-logicstress.

ALERT Determine client’s ability to care for self; plan with family to assist client to meet self-care needs.

Guillain-Barré SyndromeGuillain-Barré syndrome is an acute, rapidly progressing motor neuropathy involving segmental demyelination of nerve roots in the spinal cord and medulla. Demyelination causes inflammation, leading to edema, nerve root com-pression, decreased nerve conduction, and rapidly ascend-ing paralysis. Both sensory and motor impairment occur. It is also called Landry’s paralysis.

AssessmentA. Risk factors/etiology: cause is unknown; frequently,

clienthasarecenthistoryofacuteillness.B. Clinicalmanifestations.

1. Progressiveweaknessandparalysisbegininthelowerextremitiesandascendbilaterally.

2. Paralysisascendsthebodysymmetrically.a. Paralysisofrespiratorymuscles.b. Cranial nerve involvement, most often facial

nerve (CN VII), produces difficulty talking andswallowing.

3. Loss of sensation and function of bowel andbladder.

4. Manifestations may progress rapidly over hours ormayoccurover2to4weeks.

5. Muscleatrophyisminimal.6. Paralysisdecreasesastheclientbeginsrecovery;most

often,therearenoresidualeffects.

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C. Diagnostics(seeAppendix20-1).1. ElevatedproteinconcentrationinCSF.

Treatment (Supportive)A. Respiratorysupport,possiblymechanicalventilation.B. Corticosteroids.C. Immunosuppressivesandimmunoglobulins.D. Plasmapheresis:plasmaexchange.

Nursing InterventionsGoal: Toevaluateprogressofparalysisandinitiateactions

topreventcomplications.A. Evaluate rate of progress of paralysis; carefully assess

changesinrespiratorypattern.B. Frequentevaluationofcoughandswallowreflexes.

1. Remainwithclientwhileclientiseating;havesuctionequipmentavailable.

2. MaintainNPO(nothingbymouth)statusifreflexesareinvolved.

C. If assent of paralysis is rapid, prepare for endotrachealintubationandrespiratoryassistance.

D. Prevent complications of immobility during period ofparalysis(seeChapter3).

E. Assess for involvement of the autonomic nervoussystem.1. Orthostatichypotension.2. Hypertension.3. Cardiacdysrhythmias.4. Urinaryretentionandparalyticileus.

Goal: To prevent complications of hypoxia if respiratorymusclesbecomeinvolved(seeChapter15).

Goal: Tomaintainpsychologichomeostasis.A. Simpleexplanationofprocedures.B. Completerecoveryisanticipated.C. Provide psychologic support during period of assisted

ventilation.D. Keepclientandfamilyawareofprogressofdisease.

Amyotrophic Lateral SclerosisAmyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is a rapidly progressive, invariably fatal degeneration of nerves controlling voluntary muscles. Replacement of motor neurons with fibrous tissues causes hardening of anterior and lateral columns of the spinal cord, thus “lateral sclerosis.”

AssessmentA. Clinicalmanifestations.

1. Twitching,cramping,andmuscleweakness.2. Dysarthriaanddysphagia.3. Fatigue;asymmetricalmuscleatrophyandweakness.

4. Progressivemuscleweakness.a. Begins with upper extremities and progressively

involvesmusclesofneckandthroat.b. Trunk and lower extremities are involved late in

courseofdisease.5. Mostoftenfatalwithin2to5yearsafteronset.6. Intellectualfunctioningandallfivesensesareusually

unaffected.B. Diagnostics: electromyography and nerve conduction

studies. Muscle biopsy may be performed to rule outotherpathologies.

TreatmentA. Riluzole (Rilutek)prolongs lifeby a fewmonths;pro-

tectsmotorneuronsfromdegenerationanddeath.B. Supportivecare.

Nursing InterventionsGoal: Toprovideongoingassessmentinassistingclientto

dealwithprogressivesymptoms.A. PromoteindependenceinADLs.

1. Conserveenergy;spaceactivities.2. Avoidextremesofhotandcold.3. Useofappliancestoprolongindependenceinambu-

lationandADLs.B. Promotenutrition.

1. Smallfrequentfeedings.2. Have client sit upright with head slightly flexed

forwardwhileeating.3. Keep suction equipment easily available during

meals.C. Encouragefamilyandclienttotalkaboutlossesandthe

difficultchoicestheyface.D. Assist family and client to identify need for advanced

directivesandtocompletethem.

Muscular DystrophyMuscle dystrophy (MD) is a group of genetic diseases characterized by progressive weakness and skeletal muscle degeneration affecting a variety of muscle groups. The term pseudohypertrophy describes the characteristic muscle enlargement (caused by fatty infiltration) that occurs in muscular dystrophy.A. Duchenne’s muscular dystrophy is the most common

andmostsevereformofMD.B. Condition is characterized by gradual degeneration of

musclefibersandprogressivesymmetricalweaknessandwastingofskeletalmuscle.


1. Genetic: sex-linked disorder primarily affectingmales.

2. Onset generally occurs between the ages of 3 and5years.

B. Clinicalmanifestations.1. Historyofdelay inmotordevelopment,particularly

adelayinwalking.

NURSING PRIORITY Of the neuromuscular disorders, Guillain-Barré syndrome is the most rapidly developing and progressive condition. It is potentially fatal if unrecognized.

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2. Abnormalwaddlinggait.a. Child falls frequentlyanddevelopscharacteristic

mannerofrising.b. Gower’s sign: from sitting or squatting position,

thechildassumesakneelingpositionandpushesthetorsoupby“walking”hisorherhandsupthethighs.

3. Progressive muscle weakness, atrophy, and contrac-tures.a. Ambulationisfrequentlyimpossiblebytheageof

9to11years.b. Ultimately destroys essential muscles of respira-

tion;deathoccursfromrespiratorytractinfectionorcardiacfailure.

C. Diagnostics.1. Electromyography,musclebiopsy.2. Serum enzymes: creatinine phosphokinase level is

increasedinneonate,thengraduallydeclines.

TreatmentA. Steroids administered to boys older than 5 years

ofage.

Nursing InterventionsChildisfrequentlycaredforathomeandhospitalizedonlywhencomplicationsoccur.Goal: To maintain optimal motor function as long as

possible.A. Regularphysicaltherapyforstretchingandstrengthen-

ingmuscles;ROMexercises.B. Maintainchild’sindependenceinADLs.C. Assistfamilytoidentifyresources,toadaptphysiologic

barriers within the home, and to promote mobility ofthechildinawheelchair.

D. Assistfamilytoidentifymethodsofpreventingrespira-torytractinfection;assessforrespiratoryproblems.

E. Provide braces, splints, and assistive devices asneeded.

Goal: Toassistparentsandchild tomaintainpsychologicequilibriumandtoadapttochronicillness.

A. Assist parents to understand importance of indepen-dence and self-help skills; frequently, parents areover-protectiveofthechild.

B. Counseling to assist parents and family members toidentify family activities that can be modified to meetchild’sneeds.

C. Mothermayfeelparticularlyguiltybecauseoftransmis-sionofdiseasetoherson.

D. Identifyavailablecommunityresources.E. Counselingtoassistfamilyandchildwithchronicillness

andchild’seventualdeath.

Cerebral PalsyCerebral palsy is a nonprogressive, lifelong neuromuscu-lar genetic disorder resulting from damaged motor centers of the brain that cause nerve impulses to be incorrectly sent and/or received. The overall result is impairment of muscle control with poor muscle coordination.


1. Mayresultfromexistingprenatalbrainabnormalities(kernicterus,hemolyticdiseaseofnewborn).

2. Prematurityissinglemostimportantdeterminantofcerebralpalsy;however,inabout24%ofcases,causeisnotidentifiable.

B. Clinicalmanifestations.1. Delayedachievementofdevelopmentalmilestones.2. Increased or decreased resistance to passive move-

ment.3. Abnormalposture.4. Presenceofinfantilereflexes(tonicneckreflex,exag-

geratedMororeflex).5. Associateddisabilities.

a. Mentalretardation,seizures.b. Attention-deficitproblems.c. Visionandhearingimpairment.

6. Muscletightnessandspasms.C. Diagnostics.

1. Diagnosticteststoruleoutotherneurologicdysfunc-tion:EEG,MRI,bloodtests.

2. Frequentlydifficulttodiagnoseinearlymonths;con-ditionmaynotbeevidentuntilchildattemptstositaloneorwalk.

3. Gaitlabanalysis:evaluateswalkingability.

TreatmentA. Maintainandpromotemobilitywithorthopedicdevices

andphysicaltherapy.B. Skeletalmusclerelaxants.C. Anticonvulsants,asindicated.

Nursing InterventionsChildisfrequentlycaredforathomeandonanoutpatientbasisunlesscomplicationsoccur.Goal: To assist child to become as independent and self-

sufficientaspossible.A. Physical therapy program designed to assist individual

childtogainmaximumfunction.B. Assist child to progress according to developmental

level and functional abilities; encourage crawling,sitting, and balancing appropriate to developmentallevel.

C. Assist child to carry out ADLs as age and capacitiespermit.

D. Speechtherapy,asindicated.E. Encourageplayappropriateforage.F. Encourageappropriateeducationalactivities.G. Bowelandbladdertrainingmaybedifficultbecauseof

poorcontrol.Goal: Tomaintainphysiologichomeostasis.A. Maintainadequatenutrition.

1. Mayexperiencedifficultyeatingbecauseofspasticity;may drool excessively; use of manual jaw controlwhenfeeding.

2. Encourage independence in eating and use of self-helpdevices.

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3. Provideabalanceddietwithincreasedcaloricintaketomeetextraenergydemands.

B. Maintainsafetyprecautionstopreventinjury.C. Increasedsusceptibilitytoinfections,especiallyrespira-

torytractinfections,becauseofpoorcontrolofintercos-talmusclesanddiaphragm.

D. Increased incidence of dental problems; schedule fre-quentdentalcheckups.

Goal: To promote a positive self-image in the child andprovidesupporttothefamily.

A. Usepositivereinforcementfrequently.B. Assistparentstosetrealisticgoals.C. Encourage recreation and educational activities, espe-

ciallythoseinvolvingotherchildrenwithcerebralpalsy.D. Encourage child to express feelings regarding the

disorder.E. Donot“talkdown”tochild;communicateatappropri-

atedevelopmentallevel.F. Assistparentsinproblemsolvinginhomeenvironment.G. Identifyavailablecommunityresources.H. Utilize principles in caring for chronically ill pediatric

client(Chapter2).

Parkinson’s Disease (Paralysis Agitans)Parkinson’s disease is a progressive neurologic disorder with gradual onset that causes destruction and degenera-tion of nerve cells in the basal ganglia; results in damage to the extrapyramidal system, causing difficulty in control and regulation of movement.A. Dopamine,aneurotransmitter,isresponsiblefornormal

functioningoftheextrapyramidalsystem.B. The condition is correlated with a depletion of or

imbalance in dopamine and increased activity ofacetylcholine.

FIGURE 20-9 Parkinson’s disease. (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.)


1. Ingeneral,onsetoccursafterage60.2. Morecommoninmales.

B. Clinicalmanifestations(Figure20-9).1. Tremor.

a. Affectsthearmsandhandsbilaterally:often,thefirstsign.

b. Tremors usually occur at rest; voluntary move-ment may decrease tremors; tremors during vol-untarymovementarenotascommon.

c. Describedas“pill-rolling”tremor.d. Exacerbated by emotional stress and increased

concentration.2. Musclerigidity.

a. Increasedresistancetopassivemovement.b. Movementmaybedescribedas“cog-wheelrigid-

ity”becauseofjerkymovementofextremities.3. Bradykinesia:slowactivity.

a. Decreasedblinkingoftheeyelids.b. Lossofabilitytoswallowsaliva.c. Facialexpressionisblankor“mask-like.”d. Lossofnormalarmswingwhilewalking.e. Difficultyinitiatingmovement.

4. Stoopedposture,shufflingpropulsivegait.5. Mayexhibitmentaldeteriorationsimilartothatasso-

ciatedwithAlzheimer’sdisease.6. Depressionoccursintwo-thirdsofclients.

C. Diagnostics:nospecificdiagnostictest.

TreatmentA. Medicationtoenhancedopaminesecretion(seeAppen-

dix20-4).B. Anticholinergicmedications todecreaseeffectsof ace-

tylcholine(seeAppendix20-4).

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C. Clients frequentlybecome tolerant tomedications andrequireadjustmentsintypesofmedicationsandmedica-tionschedules.

D. Surgicaltherapy:aimistodecreasesymptoms.1. Ablation(destructionoftissue).2. Deepbrainstimulation(DBS).

Nursing InterventionsGoal: Tomaintainhomeostasis.A. EncourageindependenceinADLswithuseofself-help

devices.B. Maintainnutrition.

1. Increase calories and protein; provide more easilychewedfoods.

2. Frequentsmallmeals.3. Allowampletimeforeating.4. Monitorweightloss.5. Providepleasantatmosphereatmealtime;clientfre-

quentlypreferstoeatalonebecauseofdifficultyswal-lowingandinabilitytocontrolsaliva.

6. Increasefluid intakewith increasedbulk inthediettodecreaseproblemwithconstipation.

C. Maintainmusclefunction.1. FullROMtoextremitiestopreventcontracture.2. Decreaseeffectsoftremors.3. Exerciseandstretchdaily.4. Physicaltherapy,asindicated.

D. Closelymonitor response toor changes in response tomedications.

accompanied by dizziness, tinnitus, or lacrimation;associatedwithstressandpremenstrualsyndrome.

2. Migraine:constrictionofintracranialvessels leadingtoan intense throbbingpainwhenvessels return tonormal; prodromal or aura; crescendo quality; uni-lateral pain, often beginning in eye area; nausea,vomiting, photophobia—migraines are seriouslydebilitating and may require lifestyle and occupa-tional changes.

3. Clusterheadache:rareheadachethatismorecommoninmen;occurs innumerousepisodesorclusters;noaura; unilateral pain often arising in nostril andspreadingtoforeheadandeye;oftenoccursatsametimeofday.

TreatmentA. Migraine: sumatriptan (Imitrex); dihydroergotamine

mesylate(Migranal).B. Nonsteroidalantiinflammatorydrugs.C. Relaxation,yoga,stressmanagement.D. Clusterheadachestreatedwithhighflowoxygen.

Nursing InterventionsA. Prevention: recognize triggers, decrease stress, adjust

medicationsduringmenstrualcycle.B. Watch for signsofominousheadache:new-onsetuni-

lateralheadacheinpersonolderthan35years;vomitingnotaccompaniedbynausea;painthatawakensclient.

C. Encourage client to keep a “headache diary” for bestmanagementandtreatment.

Trigeminal NeuralgiaTrigeminal neuralgia is a fleeting unilateral sensory dis-turbance of cranial nerve V, causing brief, paroxysmal pain and facial spasm; also known as tic douloureux.


1. Onset generally occurs between 20 and 40 yearsofage.

2. Increasedfrequencywithaging.B. Clinicalmanifestations.

1. Abruptonsetofparoxysmalintensepaininthelowerandupperjaw,cheek,andlips.a. Tearingoftheeyesandfrequentblinking.b. Facialtwitchingandgrimacing.c. Painisusuallybrief;endsasabruptlyasitbegins.d. Pain may be described as severe, stabbing, and

shock-like.2. Recurrenceofpainisunpredictable.3. Pain is initiated by cutaneous stimulation of the

affectednervearea.a. Chewing.b. Washingtheface.c. Extremesoftemperature:eitheronthefaceorin

food.d. Brushingteeth.

ALERT Identify situations that necessitate role changes; evaluate family involvement in health care; review necessary modifications to promote home safety.

Goal: Topromoteapositiveself-image.A. Encouragediversionalactivities.B. Assistclienttosetrealisticgoals.C. Explore reasons for depression; encourage client to

discusschangesoccurringinlifestyle.D. Assist client ingainingcontrolofADLsandenviron-

ment.E. Assistclienttoidentifyandavoidactivitiesthatincrease

frustrationlevels.F. Encouragegoodpersonalhygiene.

HeadacheHeadache is a very common symptom of various underly-ing pathologic conditions in which pain-sensitive nerve fibers respond to unacceptable levels of stress and tension, muscular contraction in the upper body, pressure from a tumor, or increased ICP.

AssessmentA. Typesofheadaches.

1. Tension headache (muscle contraction headache):most commonof allheadaches; feelingof tightnesslikeabandaroundthehead;onsetisgradual;maybe

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TreatmentA. Medicalmanagementofpain(seeAppendix20-2):car-

bamazepine(Tegretol)andgabapentin(Neurontin).B. Surgicalintervention.

1. Localnerveblock.2. Surgical intervention to interrupt nerve impulse

transmission.a. Percutaneous stereotactic rhizotomy—destroys

someofthenervefibers;assiststomanagepain.b. Microvascular decompression (craniotomy) to

relievepainandpreservefacialsensation.

Nursing InterventionsGoal: Tocontrolpain.A. Assessthenatureofapainfulattack.B. Identify triggering factors; adjust environment to

decreasefactors.1. Keeproomataneven,comfortabletemperature.2. Avoidtouchingclient.3. Avoidjarringthebed.4. AllowclienttocarryoutownADLsasnecessary.

C. Administeranalgesicstodecreasepain.

4. Maintainmeticulousoralhygiene.5. Havefrequentdentalcheckups.

Bell’s PalsyBell’s palsy is a transient cranial nerve disorder affecting the facial nerve (cranial nerve VII), characterized by a dis-ruption of the motor branches on one side of the face, which results in muscle weakness or flaccidity on the affected side.

AssessmentA. Clinicalmanifestations.

1. Lagorinabilitytocloseeyelidonaffectedside.2. Droopingofthemouth.3. Decreasedtastesensation.4. Upward movement of the eyeball when the eye is

beingclosed.B. Diagnostics(seeAppendix20-1).

TreatmentA. Corticosteroids:administrationshouldbestartedimme-

diatelyaftersymptomsarise.B. Antivirals.C. Moistheatmayrelievepain,ifpresent.

Nursing InterventionsGoal: Toassessnervefunctionandpreventcomplications.A. Analgesicstodecreasepain.B. Evaluateabilityofclienttoeat.C. Meticulousoralhygiene.D. Preventdryingofthecorneaontheaffectedside.

1. Instill methylcellulose drops frequently duringtheday.

2. Ophthalmic ointment and eye patches may berequiredatnight.

E. As function returns, active facial exercises may beperformed.

Goal: Toassistclienttomaintainapositiveself-image.A. Changesinphysicalappearancemaybedramatic.B. Tellclientthattheconditionisusuallyself-limitingwith

minimal,ifany,residualeffects.C. Clientmayrequirecounseling,ifchangeinfacialappear-

anceispermanent.

NURSING PRIORITY Because of the severe pain caused by the condition, clients are susceptible to severe depression and suicide.

Goal: Tomaintainnutrition.A. Frequently,clientdoesnoteatbecauseofreluctanceto

stimulatethepain.B. Providelukewarmfoodthatcanbeeasilychewed.C. Increaseproteinandcalories.

Home CareA. Identifypresenceofcornealreflex;provideprotectiveeye

careifreflexisabsent.B. Ifthereislossofsensationtothesideoftheface,client

should:1. Chewontheunaffectedside.2. Avoidtemperatureextremesinfoods.3. Check themouthafter eating to remove remaining

particlesoffood.

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Skull and Spine X-Ray Studies Simple x-ray films areobtainedtodeterminefractures,calcifications,etc.Electroencephalography (EEG) Arecordingoftheelectri-calactivityof thebrain tophysiologicallyassesscerebralactivity;usefulfordiagnosingseizuredisorders;usedasascreeningproce-dure for coma; also serves as an indicator for brain death. Mayalso be used to assess sleep disorders, metabolic disorders andencephalitis.Nursing Implications1. Explain to client that procedure is painless and there is no

dangerofelectricalshock.2. Determinefromphysicianifanymedicationsshouldbewith-

heldbeforetest,especiallytranquilizersandsedatives.3. Frequently,coffee,tea,cola,andotherstimulantsareprohibited

beforeexamination.4. Client’shairshouldbecleanbeforetheexamination;afterthe

exam,assistclienttowashelectrodepasteoutofhair.Carotid Doppler Ultrasonography A noninvasive ultra-soundscantoestimatebloodflowincarotidandcerebralvesselstoassessforstenosis.Nopreparationisnecessary.Magnetic Resonance Imaging (MRI) Cellnucleihavemag-netic properties; the MRI machine records the signals from thecellsinamannerthatprovidesinformationtoevaluatesofttissuestructures(tumors,bloodvessels).Nursing Implications1. Procedurewilltakeapproximately1hour.2. Allmetalobjects shouldbe removed from theclient (hearing

aids,hairclips,jewelry,buckles,etc.).3. The client will be placed in a long magnetic tunnel for the

procedure.4. PoorcandidatesforMRIincludethefollowing.

a. Clientswithpacemakers(themagneticfieldinterfereswiththefunctionofthepacemakerandinterfereswiththetestaswell).

b. Clients with implanted insulin pumps or joint replace-ments.

c. Pregnantclients.d. Obeseclients.e. Anyclientwhorequireslife-supportequipment(theequip-

mentwillmalfunctioninamagneticfield).Computerized Axial Tomography (CAT) Scan Com-puter-assistedx-rayexaminationofthincross-sectionsofthebrainto identify hemorrhage, tumor, edema, infarctions, and hydro-cephalus.Machineislargedonut-shapedtubewithtablethroughthemiddle.Nursing Implications1. Explainappearanceofscannertoclientandexplainimportance

ofremainingabsolutelystillduringtheprocedure.2. Remove all objects from client’s hair; for 4 to 6 hours before

test,clientreceivesfluidsonly.3. Dyewillbeinjectedviavenipuncture;assessforiodineallergy

andadvisetheclientthathe/shemayexperienceaflushingorwarmsensationwhenthedyeisinjected.

4. Contrastdyemaydiscolorurineforabout24hours.5. Dyemaybe injected into spinal cord forassessmentof inter-

vertebraldisksandbonedensity.Brain Scan Ascannertracestheuptakeofradioactivedyeinthebraintissue.Thedyeisconcentratedinthedamagedtissue;itwilltakeapproximately2hoursafterdyeisinjectedforthescantobecompleted.

Nursing Implications1. Determine whether medications need to be withheld before

procedure.2. Clientwillbeaskedtochangepositionsduringthetestinorder

tovisualizethebrainfromdifferentangles.3. Theclientshouldnotexperienceanypain.Caloric Testing Test is performed at bedside by introducingcoldwaterintotheexternalauditorycanal.Itiscontraindicatedintheclientwitharupturedtympanicmembraneandisnotdoneonthe client who is awake. If the 8th cranial nerve is stimulated,nystagmusrotatestowardtheirrigatedear.Ifnonystagmusoccurs,apathologicconditionispresent.Positron Emission Tomography (PET) See Appendix17-1.Lumbar Puncture AneedleisinsertedintothelumbarareaattheL4-L5level;spinalfluidiswithdrawn,andspinalfluidpressureismeasured;contraindicated inpresenceof increased intracranialpressure. Normal spinal fluid values: opening pressure, 60 to150mmwater;specificgravity,1.007;pH,7.35;clearfluid;proteinconcentration, 15 to 45 mg/dL; glucose concentration, 45 to75mg/dL;nomicroorganismspresent.Nursing ImplicationsBefore test

1. Haveclientemptybladder.2. Explain position (lateral recumbent with knees flexed) to

client(Figure20-10).3. Advisephysician if there isachange in theclient’sneuro-

logicstatusbeforethetest;increasedintracranialpressureisacontraindicationtoalumbarpuncture.

After test1. Keep client flat at least 3 hours, and sometimes up to 12

hours,todecreaseoccurrenceofheadache.2. Encouragehighfluidintake.3. Observe forspinalfluid leakfrompuncturesite; if leakage

occurs,itmayprecipitateasevereheadache.Myelogram An outpatient procedure in which dye is injectedintothesubarachnoidspaceandx-rayfilmsofthespinalcordandvertebralcolumnareobtainedtoidentifyspinallesions.

Appendix 20-1 NEUROLOGIC SYSTEM DIAGNOSTICS

FIGURE 20-10 Lumbar puncture. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 7, Phila-delphia, 2005, Saunders.)

Dura mater

End of spinal cord

Caudaequina

Third lumbarvertebra

Subarachnoidspace (CSF inlumbar cistern)

Needleinsertion

site

L2

L3

L4

L5

S1

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Nursing ImplicationsBefore test

1. Sameasforlumbarpuncture.2. Checkwhetherclienthasanyallergiestodye.

After test1. Keep the head of the bed elevated 30 to 50 degrees to

decreasedispersionofthedyeintheCSFandtothebrain.2. Headachemayoccurasa resultof irritationof thecentral

nervoussystem.3. Clientshouldnotreceiveanyofthephenothiazinesbefore

orimmediatelyaftertheexamination.Cerebral Angiogram Injection of contrast material into thecerebralcirculation;seriesofx-rayfilmsistakentostudythecere-bralbloodflow;dye isusually injected via a soft catheter that isinsertedandthreadedthroughthefemoralartery.Nursing ImplicationsBefore test

1. Clientshouldbewell-hydrated,butshouldreceivenothingbymouthfor6to8hoursbeforethetest;clientshouldvoidbeforeprocedure.

2. Determineifclienthasanyallergiestoiodineortoshellfish.3. Informclientthatheorsheshouldremainverystillduring

theprocedure.4. Afeelingofwarmthinthefaceandmouthandametallic

tasteinthemoutharecommonwhendyeisinjected.

Appendix 20-1 NEUROLOGIC SYSTEM DIAGNOSTICS—cont’d

After test1. Evaluate client’s neurologic status; complications involve

occlusionofcerebralarteries.2. Observeinjectionsiteforhematomaformation.3. Posttestcomplicationsincludecontinuousbleedingatinjec-

tionsite,rash,dizziness,andtinglinginanextremity.4. Checkcirculationdistaltoareaofpuncture.

Electromyography (EMG) Measureselectricaldischargefromamuscle.Flatelectrodesorsmallneedlesareplacedinthemuscle.Theclientmaybeaskedtomoveandperformsimpleactivities;theelectricalstimulusforthemusclewillberecorded.Usefulfordiag-nosis in spinal cord deformity, muscular dystrophy, myastheniagravisoramyotrophiclateralsclerosis.Nursing ImplicationsBefore test

1. Maydeterminepretestserummuscledeterminations.2. Explaintotheclientthatsmallneedleswillbeinsertedinto

theskin.After test

1. Client may need something for pain because of musclestimulation.

2. Assessneedle sites forareasofhematomas; apply icepacktopreventand/orrelieve.

Appendix 20-2 ANTIEPILEPTICS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAntiepileptics (AED) Suppress discharge of neurons within a seizure focus to reduce seizure activity.

Phenobarbital(Sodium Luminal):IM,PO,rectal,IV

Drowsiness,ataxia,excitationinchildrenandtheelderly

1. Clientshouldavoidpotentialhazardousactivitiesrequiringmentalalertness.

Primidone(Mysoline):PO 2. Suddenwithdrawalfromchronicusemayprecipitatesymptoms.

3. Closelyobserveresponseinchildrenandelderly.

4. Usedtotreatgrandmalandfocalseizures.5. SeeAppendix15-5forcareofclientwith

seizures.

Phenytoin(Dilantin):PO,IV Gingivalhyperplasia,skinrash,hypoglycemia

Bradycardia,hypotensionVisualchanges:nystagmus,diplopia,

blurredvision

1. AdministerPOpreparationswithmealsormilktodecreasegastricirritation.

2. Frequentlyusedwithphenobarbitalforcontrolofgrandmalseizures.

3. IMinjectionisnotrecommended.4. Donotmixwithanyothermedications

whenadministeringIVsolution.5. Promotegoodoralhygiene;gumhyperplasia

isaproblemwithlong-termuse.6. SeeAppendix15-5forcareofclientwith

seizures.7. AEDsshouldbewithdrawnslowlyover6

weekstoseveralmonthswhenmedicationtherapyisdiscontinued.

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MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSDivalproexsodium(Depakote):

POGIdisturbances,rash,weightgain,

hairloss,tremor,blooddyscrasias1. Shouldnotbegiventoclientswithsevere

liverdysfunction.GI,dermatologiceffects,blood

dyscrasias2. Potentiatesactionofphenobarbital,

phenytoin,diazepam.3. Uses:seizures,bipolardisorder,migraine.

Carbamazepine(Tegretol):PO,suspension

Drowsiness,dizziness,headache;visualdisturbancescommonduringfirstfewweeksoftreatment

1. Weanclientfrommedicationassoonasseizuresarecontrolled.

2. Antimanicpropertiesaswell.

Clonazepam(Klonopin):PO CNSdepression,ataxia 1. Antianxietyeffectsmayassistwithseizurecontrol.

2. Monitorresultsofliverfunctiontests.

CNS,Centralnervoussystem;GI,gastrointestinal;IM,intramuscular;IV,intravenous;PO,bymouth(orally).

Appendix 20-2 ANTIEPILEPTICS—cont’d

Appendix 20-3 CHOLINERGIC (ANTICHOLINESTERASE) MEDICATIONS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSCholinergic Medications Intensify transmission of impulses throughout the CNS, where acetylcholine is necessary for transmission.

Neostigminebromide(Prostigmin):PO,subQ,IM

Excessivesalivation,increasedGImotility,urinaryurgency,bradycardia,visualproblems

1. Primarygroupofmedicationsusedfortreatmentofmyastheniagravis.

2. Atropineistheantidoteforoverdose.3. Intreatmentofmyastheniagravis,medication

isfrequentlyadministered30to45minutesbeforemeals.

4. Mestinonisgivenasmaintenancetherapyfortheclientwithmyastheniagravis.

5. Tensilonisusedfordiagnosticpurposes;notrecommendedformaintenancetherapy.

6. Teachclientsymptomsofsideeffectsandadviseclienttocallthedoctoriftheyarepresent.

Pyridostigminebromide(Mestinon):PO,IM,IV

Edrophoniumchloride(Tensilon):IV,IM

CNS,Centralnervoussystem;GI,gastrointestinal;IM,intramuscular;IV,intravenous;PO,bymouth(orally);subQ,subcutaneous.

Appendix 20-4 ANTIPARKINSONISM AGENTS

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSAnticholinergics Inhibit action of acetylcholine at sites throughout the body and CNS. Decrease synaptic transmissions in the CNS.

Benztropinemesylate(Cogentin):PO,IM,IV

Trihexyphenidylhydrochloride(Artane):PO,IM,IV

Procyclidine(Kemadrin):PO

Paralyticileus,urinaryretention,cardiacpalpitations,blurredvision,nauseaandvomiting,sedation,dizziness

Minorsideeffectssuchasdrymouth,jitteriness,andnausea

1. AdministerPOpreparationswithmealstodecreasegastricirritation.

2. Medicationshavecumulativeeffect.3. Shouldnotbeusedinclientswithglaucoma,

myastheniagravis,GUorGItractobstructionorinchildrenyoungerthan3years.

4. Monitorclientcarefullyforbowelandbladderproblems.

5. MaybeusedtotreatsideeffectsofThorazine.

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Appendix 20-4 ANTIPARKINSONISM AGENTS—cont’d

MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONSDopaminergics Assist to restore normal transmission of nerve impulses.

Levodopa(L-DOPA, Larodopa):PO

Early:Anorexia,nauseaandvomiting,abdominaldiscomfort,posturalhypotension

Long-term:Abnormal,involuntarymovements,especiallyinvolvingtheface,mouth,andneck;behavioraldisturbancesinvolvingconfusion,agitation,andeuphoria

1. AdministerPOpreparationswithmealstodecreaseGIdistress.

2. Almostallclientswillexperiencesomesideeffects,whicharedoserelated;dosagegraduallyincreasedaccordingtoclient’stoleranceandresponse.

3. Onsetofactionisslow;therapeuticresponsemayrequireseveralweekstomonths.

4. VitaminB6(pyridoxine)isantagonistictotheeffectsofthemedication;decreaseclient’sintakeofmultiplevitaminsandfortifiedcereals.

Carbidopa/levodopa Sameasforlevodopa 1. Sameasforlevodopa.(Sinemet):PO 2. Useofcarbidopasignificantlydecreasesthe

amountoflevodoparequiredfortherapy.3. Preventsinhibitoryeffectsoflevodopaonvitamin

B6.

Amantadinehydrochloride(Symmetrel):PO

Orthostatichypotension,dyspnea,dizziness,drowsiness,blurredvision,constipation,urinaryretention(sideeffectsaredoserelated)

1. Lesseffectivethanlevodopa;producesamorerapidclinicalresponse.

CNS,Centralnervoussystem;GI,gastrointestinal;GU,genitourinary;IM,intramuscular;IV,intravenous;PO,bymouth(orally).

A seizure disorder is the interruption of normal brain function-ing by uncontrolled paroxysmal discharge of electrical stimuli from the neurons.

Classification of SeizuresSimple Partial Seizures (remains conscious throughout seizure)Rarely last longer than 1 minute; an aura may occur before theseizure.1. Confinedtoaspecificarea(hand,arm,leg);clientmayexperi-

enceunusualsensations.2. One-sidedmovementofanextremity.3. Autonomicchanges;skinflushing,changeinheartrate,epigas-

tricdiscomfort.

Complex Partial Seizures (may have impairment of consciousness)1. Maylooseconsciousnessfor1to3minutes.2. Mayproduceautomatisms(lipsmacking,grimacing,repetitive

handmovements).3. Client may be unaware of environment and wonder what is

happeningatthebeginningoftheseizure.4. In theperiodafter theseizure,clientmayexperienceamnesia

andconfusion.5. Alsocalledtemporallobeseizuresorpsychomotor.

Appendix 20-5 SEIZURE DISORDERS

Generalized Seizures (Bilaterally Symmetric and Without Local Onset)Nowarningoraura,asclientlosesconsciousnessforafewsecondstoseveralminutes.1. Absence (petit mal): Characterized by a short period of time

whentheclientisinanalteredlevelofconsciousness.Staring,blinkingperiod(followedbyresumptionofnormalactivity)ischaracteristic.Mayoccurmorethan100timesperday;maygounnoticed;ingeneral,onsetisinchildhoodbetweentheagesof4and12years.

2. Tonic-clonic seizures: May last 2 to 5 minutes. Full recoverymay take several hours; clientmaybe confused, amnesic, andirritableduringthisrecoveryperiod.Tonic phase:Lossofconsciousnesswithstiffeningandrigidity

of muscles. Apnea and cyanosis are common during thisperiod;phasegenerallylastsforabout1minute.

Clonic phase:Hyperventilation,withrapidjerkingmovements.Tonguebiting,incontinence,andheavysalivationmayoccurduringthisperiod(Figure20-11).

Seizure EtiologyAcute Disorders• Increasedintracranialpressure,metabolicalterations• Infections, febrile episodes in children (generally between 6

monthsand3years)

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Chronic (Recurrent, Epilepsy)• Braininjuryatbirth,trauma,vasculardisease• Braintumors,geneticfactors,idiopathic

Nursing Assessment1. Identify any activities that occurred immediately before the

seizure.2. Wastheclientawareaseizurewasgoingtooccur?Ifso,how

didclientknow?3. Describe typeofmovements thatoccurred and thebody area

affected(e.g.,jawclenched,tonguebiting).

4. Presenceofincontinence.5. Periodofapneaandcyanosis.6. Presenceofautomatisms(lipsmacking,grimacing,chewing).7. Durationofseizure.8. Changesinlevelofconsciousness.9. Conditionofclientafterseizure:oriented,levelofactivity,any

residualparalysisormuscleweakness.

Appendix 20-5 SEIZURE DISORDERS—cont’d

FIGURE 20-11 Tonic-clonic seizure activity. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive out-comes, ed 8, Philadelphia, 2009, Saunders.)

Tonic phase

Clonic phase

Postictal phase

A

B

C

NURSING PRIORITY Airway management and ventilation cannot be performed on a client who is experiencing a tonic-clonic seizure. After the seizure is over, evaluate the airway and initiate ventilations as necessary.

Nursing Management1. Remainwiththeclientwhoishavingaseizure;notethetime

theseizurebeganandhowlongitlasted.2. Donotattempttoforceanythingintotheclient’smouthifthe

jawsareclenchedshut.3. If the jaws are not clenched, place an airway in the client’s

mouth.Thisprotectsthetongueandalsoprovidesamethodofsuctioningtheairway,shouldtheclientvomit.

4. Protect the client from injury (risk for falling out of bed orstrikingselfonbedrails,etc).

5. Loosenanyconstrictiveclothing.6. Do not restrain client during seizure activity; allow seizure

movementstooccur,butprotectclientfrominjury.7. Evaluate respiratory status; if vomitingoccurs,beprepared to

suctiontheclienttocleartheairwayandpreventaspiration.8. Maintain calm atmosphere and provide for privacy after the

seizureactivity.9. Reorientclient.

ALERT Report characteristics of a client’s seizure; determine changes in client’s neurologic status.

Client Education1. Identifyactivities/eventsthatprecipitatetheseizureactivity.2. Avoidalcoholintake,fatigue,andlossofsleep.3. Takemedicationsasdirected.4. Counseling for the familyand for theclient toassist themin

maintainingpositivecopingmechanisms.5. Wearmedicalalertbraceletorhaveidentificationcard.

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Aphasia is a total loss of comprehension and use of language. Dysphasia is the difficulty related to the comprehension or use of language and is due to a partial disruption or loss; patterns of dysphasia differ because the stroke affects different parts of the brain. The condition is precipitated by a problem in the cerebral cortex. The most common cause of aphasia is a vascular problem involving the middle cerebral artery. The

Appendix 20-6 APHASIA

speech center is located in the dominant side of the cerebral hemisphere. The speech center for a right-handed person is located in the left cerebral hemisphere. Clients with aphasia are often frustrated and irritable. Emotional lability is common. Accept the behavior in a manner that prevents embarrassment for the client.

TYPES OF APHASIA NURSING IMPLICATIONSSensory aphasia (receptive or fluent, Wernicke’s area):Cannot

understandoralorwrittencommunication.Clientcannotinterpretorcomprehendspeechorread.

Motor aphasia (expressive, Broca’s aphasia):Inabilitytospeakortowrite.However,theclientcancomprehendincomingspeechandcanread.

Mixed:Mostaphasiainvolvesboththesensoryandmotoraspectsofspeech.Rarelyisaphasiaonlysensoryoronlymotor.

Global aphasia:Allcommunicationandreceptivefunctionislost.Dysarthria:Adisturbanceinthemuscularcontrolofspeech.

Doesnotaffectthemeaningofcommunicationorcomprehension,justthemechanicsofspeech—pronunciation,articulation,andphonation.

1. Standinfrontoftheclient;speakclearlyandslowly.2. Donotshoutorspeakloudly;theclientcanhear.3. Bepatient;givetheclienttimetorespond;donotpresshim

orherforimmediateanswers.4. Usenonverbalcommunicationssuchastouch,smiles,and

gestures.5. Assisttheclientwithmotoraphasiatopracticerepeating

simplewordssuchasyes,no,andplease.6. Listencarefully,trytounderstand,andtrytocommunicate;

thisconveystotheclientthatyoucare.7. nvolvefamilymembersinpracticeandassistthemtoidentify

waystheycansupporttheclient.

ALERT Assist client to communicate effectively.

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Study Questions Neurologic System More questions on companion CD!

1. The nurse is obtaining a health history from a clientwho states he is having pain in his left arm. Whichquestionbythenursewillelicitthemostusefulresponsefromtheclient?1 “Does the pain feel like pins and needles in your

arm?”2 “Doesthepainradiatefromyournecktoyourarms?”3 “Canyoudescribethepainyouareexperiencingin

yourarm?”4 “Is the numbness in your arm intermittent or

constant?”2. Thenurseisassessingaclientwithatentativediagnosis

ofabraintumor.Whatwouldthenurseanticipatetheclient’sprimarycomplainttobe?1 Decreasedappetite2 Frequentinsomnia3 Recurrentheadaches4 Peripheraledema

3. Thenurse is caring for a clientwhohashad a right-sided stroke.Whatwouldbeappropriatenursingcareforthisclient?1 PerformingpassiveROMexercisestoaffectedside,

activeROMonunaffectedside2 Placing food on the affected side of the client’s

mouth3 Applying hot packs to the right leg to decrease

musclespasms4 Turningclientevery2hoursandmaintainingposi-

tionontherightsidefor2hours4. A client is scheduled for an electroencephalogram.

Whatwillthenurseexplaintotheclientregardingthepurposeofthistest?1 Evaluateselectricalcurrentsofskeletalmuscles2 Measuresultrasonicwavesinthebrain3 Determinessizeandlocationofbrainactivity4 Recordsbrainelectricalactivity

5. Aclientwhohashadastrokeisaphasic;ithasbeenaweek since his stroke. He is beginning to show func-tional improvement and demonstrates an ability tofollow verbal directions.What will rehabilitation nowinclude?1 Aright-legbrace2 Ambulationtraining3 Speechtraining4 Vocationalretraining

6. Thenurseiscaringforaclientwhoisdoingwellafterhiscraniotomy.Whatwillthebowelcareforthisclientinclude?1 An enema every other day to avoid the Valsalva

maneuver2 High-fiber diet and stool softeners to prevent

constipation3 Low-residue diet to decrease stool formation and

preventconstipation4 Daily checking for impaction caused by loss of

bowelinnervation

7. After a grand mal seizure, what nursing action is thehighestpriority?1 Loosenorremoveconstrictingclothingandprotect

clientfrominjuringhimselforherself.2 Maintainapatent airwayby turning the clienton

hissideandsuctioning,ifnecessary.3 Remainwiththeclientandadministeranticonvul-

santmedicationsasorderedbythephysician.4 Describeandrecordeventsbeforetheonsetofthe

seizure,duringtheseizure,andaftertheseizure.8. A client with Parkinson’s disease is experiencing

anorexia and vomiting.The client is taking levodopa.Whatwillbetheinitialnursingactivity?1 Assessclient’sfoodpreferences.2 Monitorclient’sbloodpressure.3 Holdclient’smedicationandnotifythephysician.4 Administerclient’smedicationwithfood.

9. An8-year-oldchildisadmittedafteranaccidentwherehesustainedaclosedheadinjury.Thechildisalertandorientedbutverylethargic.Thereisclearfluiddrainingfromthechild’snose.Whatisthebestnursingaction?1 Gentlysuctionthefluidfromthenasalarea.2 Turnfromsidetosideonly.3 Keepheadofbedelevated.4 Encourageparticipationingamestoplayinbed.

10. When obtaining a health history, the nurse expects aclientwitharecentdiagnosisofParkinson’sdiseasetoreportwhichsignorsymptom?1 Weightloss2 Slownessofmovement3 Continualmotortremors4 Depression

11. Whilecaring foraclientwhohas recentlybeendiag-nosedwithParkinson’sdisease,thenurseshouldunder-standthat:1 Intellectualcapabilitieswilldecrease.2 Diversionalinterestsmaydecrease.3 Moodfluctuationsmayoccur.4 Communicationskillsmayfluctuate.

12. Pneumonia is a common problem in children withspastic cerebral palsy.Thenurseunderstands that thisoccursbecause:1 Thereisanassociateddysfunctionoftherespiratory

centerinthecentralnervoussystem.2 Theimmunologicsystemisimmatureanddoesnot

produceadequateantibodiestofightinfection.3 Decreased mobility leads to stasis of secretions in

therespiratorypassages.4 There is aweaknessof the voluntarymuscles that

controlrespiration.

Answers and rationales to these questions are in the section at the end of the book titled Chapter Study Questions: Answers and Rationales.

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