Assessment of Neurologic Function

Chapter 60 ● Assessment of Neurologic Function

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Describe the structures and functions of the central and peripheral nervous systems. 2. Differentiate between pathologic changes that affect motor control and those that affect sensory pathways. 3. Compare the functioning of the sympathetic and parasympathetic nervous systems. 4. Describe the signiﬁcance of physical assessment to the diagnosis of neurologic dysfunction. 5. Describe changes in neurologic function associated with aging and their impact on neurologic assessment ﬁndings. 6. Describe diagnostic tests used for assessment of suspected neurologic disorders and the related nursing implications.

1820 Chapter 60 Assessment of Neurologic Function 1821 Nurses in many types of practice settings encounter patients impulses away from the cell body. Nerve cell bodies occurring in with altered neurologic function. Disorders of the nervous system clusters are called ganglia or nuclei. A cluster of cell bodies with can occur at any time during the life span and can vary from mild, the same function is called a center (eg, the respiratory center). self-limiting symptoms to devastating, life-threatening disorders. Neuroglial cells, another type of nerve cell, support, protect, and The nurse must be skilled in the assessment of the neurologic sys- nourish neurons. tem whether the assessment is generalized or focused on specific areas of function. Assessment in either case requires knowledge Neurotransmitters of the anatomy and physiology of the nervous system and an understanding of the array of tests and procedures used to diag- Neurotransmitters communicate messages from one neuron to nose neurologic disorders. Knowledge about the nursing impli- another or from a neuron to a specific target tissue. Neurotrans- cations and interventions related to assessment and diagnostic mitters are manufactured and stored in synaptic vesicles. They testing is also essential. enable conduction of impulses across the synaptic cleft. The neurotransmitter has an affinity for specific receptors in the postsynaptic bulb. When released, the neurotransmitter crosses the Anatomic and Physiologic Overview synaptic cleft and binds to receptors in the postsynaptic cell mem- The nervous system consists of two divisions: the central nervous brane. The action of a neurotransmitter is to potentiate, termi- system (CNS), including the brain and spinal cord, and the pe- nate, or modulate a specific action and can either excite or inhibit ripheral nervous system, made up of the cranial and spinal nerves. the target cell’s activity. There are usually multiple neurotrans- The peripheral nervous system can be further divided into the mitters at work in the neural synapse. There are various types of somatic, or voluntary, nervous system, and the autonomic, or in- neurotransmitters (Bradley et al., 2000; Hickey, 2003); major voluntary, nervous system. The function of the nervous system is neurotransmitters are described in Table 60-1. to control all motor, sensory, autonomic, cognitive, and behav- Many neurologic disorders are due, at least in part, to an ioral activities. The nervous system has approximately 10 million imbalance in neurotransmitters—that is, a lack of gamma- sensory neurons that send information about the internal and ex- aminobutyric acid (GABA) and acetylcholine in Huntington’s ternal environment to the brain and 500,000 motor neurons that disease (Bradley et al., 2000), low serotonin levels in some forms control the muscles and glands. The brain itself contains more of epilepsy (Blows, 2000), and a decrease in dopamine in Parkin- than 20 billion nerve cells that link the motor and sensory path- son’s disease. In fact, probably all brain functions are modulated ways, monitor the body’s processes, respond to the internal and through neurotransmitter receptor site activity, including mem- external environment, maintain homeostasis, and direct all psy- ory and other cognitive processes. chological, biologic, and physical activity through complex There are two types of receptors: direct and indirect. Direct chemical and electrical messages (Bradley, Daroff, Fenichel & receptors are also known as inotropic because they are linked to Marsden, 2000). ion channels and allow passage of ions when opened. They can be excitatory or inhibitory and are rapid-acting (measured in milliseconds). Indirect receptors affect metabolic processes in the ANATOMY OF THE NERVOUS SYSTEM cell, which can take from seconds to hours to occur. Receptor Cells of the Nervous System sites are an expanding area of research because they are often the target for the action and development of new medications. These The basic functional unit of the brain is the neuron (Fig. 60-1). medications either block or stimulate neurotransmitters at re- It is composed of a cell body, a dendrite, and an axon. The den- ceptor sites and thus provide relief from symptoms (Blows, drite is a branch-type structure with synapses for receiving elec- 2000). Receptor sites are also sites for the action of addictive trochemical messages. The axon is a long projection that carries drugs.

Glossary agnosia: loss of ability to recognize objects delirium: transient loss of intellectual func- rigidity: increase in muscle tone at rest char- through a particular sensory system; may tion, usually due to systemic problems acterized by increased resistance to passive be visual, auditory, or tactile dendrite: portion of the neuron that con- stretch ataxia: inability to coordinate muscle move- ducts impulses toward the cell body reflex: an automatic response to stimuli ments, resulting in difficulty in walking, dysphagia: difficulty swallowing Romberg test: test for cerebellar dysfunction talking, and performing self-care activities flaccid: displaying lack of muscle tone; limp, requiring the patient to stand with feet autonomic nervous system: division of the floppy together, eyes closed and arms extended; nervous system that regulates the involun- myelography (myelogram): x-ray study of inability to maintain the position, with tary body functions the spinal cord after injection of a contrast either significant stagger or sway, is a axon: portion of the neuron that conducts agent into the subarachnoid space positive test impulses away from the cell body parasympathetic nervous system: division spasticity: sustained increase in tension of a Babinski reflex (sign): a reflex action of the of the autonomic nervous system active muscle when it is passively lengthened or toes, indicative of abnormalities in the primarily during nonstressful conditions, stretched motor control pathways leading from the controlling mostly visceral functions sympathetic nervous system: division of cerebral cortex photophobia: inability to tolerate light the autonomic nervous system with pre- clonus: abnormal movement marked by al- position (postural) sense: awareness of posi- dominantly excitatory responses, the ternating contraction and relaxation of a tion of parts of the body without looking “fight-or-flight” system muscle occurring in rapid succession at them; also referred to as proprioception tone: tension present in a muscle at rest 1822 Unit 14 NEUROLOGIC FUNCTION

Nucleus Myelin sheath Axon Node Neurolemma Synaptic Dendrites terminals

FIGURE 60-1 Neuron.

Another important area of ongoing research is diagnostic test- sure by the corpus callosum. The outside surface of the hemi- ing that can detect abnormal levels of neurotransmitters in the spheres has a wrinkled appearance that is the result of many brain. Positron emission tomography (PET), for example, can de- folded layers or convolutions called gyri, which increase the sur- tect dopamine, serotonin, and acetylcholine (Gjedde et al., face area of the brain, accounting for the high level of activity car- 2001). Single photon emission computed tomography (SPECT) ried out by such a small-appearing organ. The external or outer is similar to PET. Both PET and SPECT are discussed in more portion of the cerebrum (the cerebral cortex) is made up of gray detail later in this chapter. matter approximately 2 to 5 mm in depth; it contains billions of neurons/cell bodies, giving it a gray appearance. White matter The Central Nervous System makes up the innermost layer and is composed of nerve fibers and neuroglia (support tissue) that form tracts or pathways connect- ANATOMY OF THE BRAIN ing various parts of the brain with one another (transverse and as- The brain is divided into three major areas: the cerebrum, the sociation pathways) and the cortex to lower portions of the brain brain stem, and the cerebellum. The cerebrum is composed of two and spinal cord (projection fibers). The cerebral hemispheres are hemispheres, the thalamus, the hypothalamus, and the basal gan- divided into pairs of frontal, parietal, temporal, and occipital glia. Additionally, connections for the olfactory (cranial nerve I) lobes. The four lobes are as follows (see Fig. 60-2): and optic (cranial nerve III) nerves are found in the cerebrum. The brain stem includes the midbrain, pons, medulla, and con- • Frontal—the largest lobe. The major functions of this lobe nections for cranial nerves II and IV through XII. The cerebel- are concentration, abstract thought, information storage lum is located under the cerebrum and behind the brain stem or memory, and motor function. It also contains Broca’s (Fig. 60-2). The brain accounts for approximately 2% of the total area, critical for motor control of speech. The frontal lobe body weight; it weighs approximately 1,400 g in an average is also responsible in large part for an individual’s affect, young adult (Hickey, 2003). In the elderly, the average brain judgment, personality, and inhibitions. weighs approximately 1,200 g. • Parietal—a predominantly sensory lobe. The primary sensory cortex, which analyzes sensory information and relays Cerebrum. The cerebrum consists of two hemispheres that are the interpretation of this information to the thalamus and incompletely separated by the great longitudinal fissure. This sul- other cortical areas, is located in the parietal lobe. It is also cus separates the cerebrum into the right and left hemispheres. essential to an individual’s awareness of the body in space, The two hemispheres are joined at the lower portion of the fis- as well as orientation in space and spatial relations.

Table 60-1 • Major Neurotransmitters

NEUROTRANSMITTER SOURCE ACTION Acetylcholine (major transmitter of the Many areas of the brain; autonomic nervous Usually excitatory; parasympathetic effects parasympathetic nervous system) system sometimes restrain (stimulation of heart by vagal nerve) Serotonin Brain stem, hypothalamus, dorsal horn of Restraining, helps control mood and sleep, the spinal cord inhibits pain pathways Dopamine Substantia nigra and basal ganglia Usually restrains, affects behavior (attention, emotions) and ﬁne movement Norepinephrine (major transmitter of the Brain stem, hypothalamus, postganglionic Usually excitatory; affects mood and overall sympathetic nervous system) neurons of the sympathetic nervous activity system Gamma-aminobutyric acid (GABA) Spinal cord, cerebellum, basal ganglia, Excitatory amino acid some cortical areas Enkephalin, endorphin Nerve terminals in the spine, brain stem, Excitatory; pleasurable sensation, inhibits thalamus and hypothalamus, pituitary pain transmission gland Chapter 60 Assessment of Neurologic Function 1823

Central fissure (Rolando)

Parietal lobe Gyri

Frontal lobe

Lateral Occipital fissure lobe (Sylvius)

Temporal lobe Transverse fissure

Midbrain

Pons Cerebellum Medulla oblongata FIGURE 60-2 View of the external surface of the brain showing lobes, cerebellum, Spinal cord and brain stem.

• Temporal—contains the auditory receptive areas. Contains analytic functions. The nondominant hemisphere is responsible a vital area called the interpretive area that provides inte- for geometric, spatial, visual, pattern, and musical functions. gration of somatization, visual, and auditory areas and plays The basal ganglia are masses of nuclei located deep in the cere- the most dominant role of any area of the cortex in cerebral hemispheres that are responsible for control of fine motor bration. movements, including those of the hands and lower extremities. • Occipital—the posterior lobe of the cerebral hemisphere is The thalamus (see Fig. 60-3) lies on either side of the third responsible for visual interpretation. ventricle and acts primarily as a relay station for all sensation ex- The corpus callosum (Fig. 60-3) is a thick collection of nerve cept smell. All memory, sensation, and pain impulses also pass fibers that connects the two hemispheres of the brain and is re- through this section of the brain. sponsible for the transmission of information from one side of the The hypothalamus is located anterior and inferior to the thal- brain to the other. Information transferred includes sensation, amus. The hypothalamus lies immediately beneath and lateral to memory, and learned discrimination. Right-handed people and the lower portion of the wall of the third ventricle. It includes some left-handed people have cerebral dominance on the left side the optic chiasm (the point at which the two optic tracts cross) of the brain for verbal, linguistic, arithmetical, calculating, and and the mamillary bodies (involved in olfactory reflexes and emotional response to odors). The infundibulum of the hypothalamus connects it to the posterior pituitary gland. The hypo- Corpus callosum thalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence Thalamus metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilatation. The hypothalamus is the site of the hunger center and is involved in appetite control. It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior, Hypothalamus and emotional responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls and regulates the autonomic nervous system. The pituitary gland is located in the sella turcica at the base of Pituitary the brain and is connected to the hypothalamus. The pituitary is a common site for brain tumors in adults; frequently they are detected by physical signs and symptoms that can be traced to the FIGURE 60-3 Medial view of the brain. pituitary, such as hormonal imbalance or visual disturbances 1824 Unit 14 NEUROLOGIC FUNCTION secondary to pressure on the optic chiasm (further information pons and the cerebellum with the cerebral hemispheres; it con- on brain tumors is found later in this unit in Chap. 65). tains sensory and motor pathways and serves as the center for au- Nerve fibers from all portions of the cortex converge in each ditory and visual reflexes. Cranial nerves III and IV originate in hemisphere and exit in the form of a tight bundle of nerve fibers the midbrain. The pons is situated in front of the cerebellum be- known as the internal capsule. Having entered the pons and the tween the midbrain and the medulla and is a bridge between the medulla, each bundle crosses to the corresponding bundle from two halves of the cerebellum, and between the medulla and the the opposite side. Some of these axons make connections with cerebrum. Cranial nerves V through VIII connect to the brain in axons from the cerebellum, basal ganglia, thalamus, and hypo- the pons. The pons contains motor and sensory pathways. Por- thalamus; some connect with the cranial nerve cells. Other fibers tions of the pons also control the heart, respiration, and blood from the cortex and the subcortical centers are channeled through pressure. the pons and the medulla into the spinal cord. The medulla oblongata contains motor fibers from the brain Although the various cells in the cerebral cortex are quite sim- to the spinal cord and sensory fibers from the spinal cord to the ilar in appearance, their functions vary widely, depending on lo- brain. Most of these fibers cross, or decussate, at this level. Cra- cation. The topography of the cortex in relation to certain of its nial nerves IX through XII connect to the brain in the medulla. functions is shown in Figure 60-4. The posterior portion of each hemisphere (ie, the occipital lobe) is devoted to all aspects of Cerebellum. The cerebellum is separated from the cerebral hemi- visual perception. The lateral region, or temporal lobe, incorpo- spheres by a fold of dura mater, the tentorium cerebelli. The cere- rates the auditory center. The midcentral zone, or parietal zone, bellum has both excitatory and inhibitory actions and is largely posterior to the fissure of Rolando, is concerned with sensation; responsible for coordination of movement. It also controls fine the anterior portion is concerned with voluntary muscle move- movement, balance, position sense (awareness of where each ments. The large area behind the forehead (ie, the frontal lobes) part of the body is), and integration of sensory input. contains the association pathways that determine emotional attitudes and responses and contribute to the formation of thought STRUCTURES PROTECTING THE BRAIN processes. Damage to the frontal lobes as a result of trauma or dis- The brain is contained in the rigid skull, which protects it from ease is by no means incapacitating from the standpoint of mus- injury. The major bones of the skull are the frontal, temporal, cular control or coordination, but it affects a person’s personality, parietal, and occipital bones. These bones join at the suture lines as reflected by basic attitudes, sense of humor and propriety, self- (Fig. 60-5). restraint, and motivations. (Neurologic trauma and disease states The meninges (fibrous connective tissues that cover the brain that may result in frontal damage are discussed in later chapters and spinal cord) provide protection, support, and nourishment in this unit.) to the brain and spinal cord. The layers of the meninges are the dura, arachnoid, and pia mater (Fig. 60-6). Brain Stem. The brain stem consists of the midbrain, pons, and • Dura mater—the outermost layer; covers the brain and the medulla oblongata (see Fig. 60-2). The midbrain connects the spinal cord. It is tough, thick, inelastic, fibrous, and gray.

Motor cortex Sensory area (pain, touch, etc.)

Written speech

Visual interpretation area

Motor speech

Auditory receiving Visual area receiving area

Auditory interpretation area FIGURE 60-4 Topography of the cortex as it relates to function. Chapter 60 Assessment of Neurologic Function 1825

Sagittal suture process called herniation. Between the dura mater and the Parietal bone skull in the cranium, and between the periosteum and the Coronal suture dura in the vertebral column, is the epidural space, a poten- Lambdoidal tial space. suture Frontal • Arachnoid—the middle membrane; an extremely thin, del- bone icate membrane that closely resembles a spider web (hence the name arachnoid). It appears white because it has no Sphenoid bone blood supply. The arachnoid layer contains the choroid plexus, which is responsible for the production of cerebro- Nasal spinal fluid (CSF). This membrane also has unique finger- Occipital bone like projections, arachnoid villi, that absorb CSF. In the bone Zygomatic normal adult, approximately 500 mL of CSF is produced bone each day; all but 125 to 150 mL is absorbed by the villi Squamosal Maxilla (Hickey, 2003). When blood enters the system (from trauma suture or hemorrhagic stroke), the villi become obstructed and hy- Temporal bone drocephalus (increased size of ventricles) may result. The Mastoid subdural space is between the dura and the arachnoid layer, process Mandible and the subarachnoid space is located between the arachnoid and pia layers and contains the CSF. FIGURE 60-5 Bones and sutures of the skull. • Pia mater—the innermost membrane; a thin, transparent layer that hugs the brain closely and extends into every fold of the brain’s surface. There are four extensions of the dura: the falx cerebri, which separates the two hemispheres in a longitudinal plane; the CEREBROSPINAL FLUID tentorium, which is an infolding of the dura that forms a CSF, a clear and colorless fluid with a specific gravity of 1.007, is tough membranous shelf; the falx cerebelli, which is be- produced in the ventricles and is circulated around the brain and tween the two lateral lobes of the cerebellum; and the di- the spinal cord through the ventricular system. There are four aphragm sellae, which provides a “roof ” for the sella turcica. ventricles: the right and left lateral, and the third and fourth ven- The tentorium supports the hemispheres and separates tricles. The two lateral ventricles open into the third ventricle at them from the lower part of the brain. When excess pres- the interventricular foramen or the foramen of Monro. The third sure occurs in the cranial cavity, brain tissue may be com- and fourth ventricles connect via the aqueduct of Sylvius. The pressed against the tentorium or displaced downward, a fourth ventricle supplies CSF to the subarachnoid space and

Sagittal suture Arachnoid villus

Skin (cutis)

Skull

Dura mater

Meninges Arachnoid Venous Pia mater (dural) sinus

Gray matter Brain tissue White matter

FIGURE 60-6 Meninges and related structures. 1826 Unit 14 NEUROLOGIC FUNCTION down the spinal cord on the dorsal surface. CSF is returned to the At the base of the brain surrounding the pituitary gland, a ring brain and is then circulated around the brain, where it is absorbed of arteries is formed between the vertebral and internal carotid ar- by the arachnoid villi. terial chains. This ring is called the circle of Willis and is formed CSF is produced in the choroid plexus of the lateral, third, and from the branches of the internal carotid arteries, anterior and fourth ventricles. The ventricular and subarachnoid system con- middle cerebral arteries, and anterior and posterior communicat- tains approximately 125 to 150 mL of fluid, while 15 to 25 mL ing arteries (Fig. 60-7). Functionally, the posterior portion of the of CSF is located in each lateral ventricle. circulation and the anterior or carotid circulation usually remain The composition of CSF is similar to other extracellular flu- separate. The arteries of the circle of Willis can provide collateral ids (such as blood plasma), but the concentrations of the various circulation if one or more of the four vessels supplying it become constituents are different. The analysis and laboratory report of occluded or are ligated. CSF usually contains information on color, specific gravity, pro- The arterial anastomoses along the circle of Willis are frequent tein count, white blood cell count, glucose, and other electrolyte sites of aneurysms. These can be formed when the pressure at a levels; it may also be tested for immunoglobulins or lactate weakened arterial wall causes the artery to balloon out. Aneurysms (Hickey, 2003). Normal CSF contains a minimal number of may be congenital or the result of degenerative changes in the white blood cells and no red blood cells. vessel wall associated with arteriosclerotic vascular disease. If an artery with an aneurysm bursts or becomes occluded by vasospasm, CEREBRAL CIRCULATION an embolus, or a thrombus, the neurons distal to the occlusion The cerebral circulation receives approximately 15% of the car- are deprived of their blood supply and the cells quickly die. The diac output, or 750 mL per minute. The brain does not store nu- result is a hemorrhagic stroke (cerebrovascular accident or in- trients and has a high metabolic demand that requires the high farction). The effects of the occlusion depend on which vessels are blood flow. The brain’s blood pathway is unique because it flows involved and which areas of the brain these vessels supply. against gravity; its arteries fill from below and the veins drain Aneurysms and cerebrovascular accidents are discussed in more from above. In contrast to other organs that may tolerate de- detail in Chapter 62. creases in blood flow because of their adequate collateral circulation, the brain lacks additional collateral blood flow, which may Veins. Venous drainage for the brain does not follow the arterial result in irreversible tissue damage when blood flow is occluded circulation as in other body structures. The veins reach the brain’s for even short periods of time. surface, join larger veins, then cross the subarachnoid space and empty into the dural sinuses, which are the vascular channels Arteries. Two internal carotid arteries and two vertebral arteries lying within the tough dura mater (see Fig. 60-6). The network and their extensive system of branches provide the blood supply of the sinuses carries venous outflow from the brain and empties to the brain. The internal carotids arise from the bifurcation of into the internal jugular vein, returning the blood to the heart. the common carotid and supply much of the anterior circulation Cerebral veins and sinuses are unique because, unlike other veins of the brain. The vertebral arteries branch from the subclavian ar- in the body, they do not have valves to prevent blood from flow- teries, flow back and upward on either side of the cervical verte- ing backward and depend on both gravity and blood pressure. brae, and enter the cranium through the foramen magnum. The vertebral arteries join to become the basilar artery at the level of BLOOD–BRAIN BARRIER the brain stem; the basilar artery divides to form the two branches The CNS is inaccessible to many substances that circulate in the of the posterior cerebral arteries. The vertebrobasilar arteries sup- blood plasma (eg, dyes, medications, and antibiotics). After being ply most of the posterior circulation of the brain. injected into the blood, many substances cannot reach the neu-

Middle cerebral artery Anterior cerebral artery Anterior communicating artery Internal carotid artery Circle Posterior communicating artery of Willis Posterior cerebral artery Basilar artery

Vertebral artery

Anterior spinal artery

FIGURE 60-7 Arterial blood supply of the brain, including the circle of Willis, as viewed from the ventral surface. Chapter 60 Assessment of Neurologic Function 1827 rons of the CNS because of the blood–brain barrier. This barrier Sensory and Motor Pathways: The Spinal Tracts. The white is formed by the endothelial cells of the brain’s capillaries, which matter of the cord is composed of myelinated and unmyelinated form continuous tight junctions, creating a barrier to macromol- nerve fibers. The fast-conducting myelinated fibers form bun- ecules and many compounds. All substances entering the CSF dles that also contain glial cells. Fiber bundles with a common must filter through the capillary endothelial cells and astrocytes function are called tracts. There are six ascending tracts. Two (Hickey, 2003). Often altered by trauma, cerebral edema, and conduct sensation, principally the perception of touch, pres- cerebral hypoxemia, the blood–brain barrier has implications in sure, vibration, position, and passive motion from the same side the treatment and selection of medication for CNS disorders as of the body. Before reaching the cerebral cortex, these fibers well as serving a protective function. cross to the opposite side in the medulla. The two spinocerebellar tracts conduct sensory impulses from muscle spindles, ANATOMY OF THE SPINAL CORD providing necessary input for coordinated muscle contraction. The spinal cord and medulla form a continuous structure ex- They ascend essentially uncrossed and terminate in the cerebel- tending from the cerebral hemispheres and serving as the con- lum. The last two spinothalamic tracts are responsible for connection between the brain and the periphery. Approximately duction of pain, temperature, proprioception, fine touch, and 45 cm (18 in) long and about the thickness of a finger, it extends vibratory sense from the upper body to the brain. They ascend, from the foramen magnum at the base of the skull to the lower cross to the opposite side of the brain, and terminate in the thal- border of the first lumbar vertebra, where it tapers to a fibrous amus (Hickey, 2003). band called the conus medullaris. Continuing below the second There are eight descending tracts, seven of which are engaged lumbar space are the nerve roots that extend beyond the conus, in motor function. The two corticospinal tracts conduct motor which are called the cauda equina because they resemble a horse’s impulses to the anterior horn cells from the opposite side of the tail. Similar to the brain, the spinal cord consists of gray and white brain and control voluntary muscle activity. The three vestibu- matter. Gray matter in the brain is external and white matter is lospinal tracts descend uncrossed and are involved in some internal; in the spinal cord, gray matter is in the center and is sur- autonomic functions (sweating, pupil dilation, and circulation) rounded on all sides by white matter (Fig. 60-8). and involuntary muscle control. The corticobulbar tract conducts The spinal cord is surrounded by the meninges, dura, arach- impulses responsible for voluntary head and facial muscle move- noid, and pia layers. Between the dura mater and the vertebral ment and crosses at the level of the brain stem. The rubrospinal canal is the epidural space. The spinal cord is an H-shaped struc- and reticulospinal tracts conduct impulses involved with invol- ture with nerve cell bodies (gray matter) surrounded by ascend- untary muscle movement. ing and descending tracts (white matter) (see Fig. 60-8). The lower portion of the H is broader than the upper portion and cor- Vertebral Column. The bones of the vertebral column surround responds to the anterior horns. The anterior horns contain cells and protect the spinal cord and normally consist of 7 cervical, with fibers that form the anterior (motor) root end and are es- 12 thoracic, and 5 lumber vertebrae, as well as the sacrum (a sential for the voluntary and reflex activity of the muscles they infused mass of five vertebrae), and terminate in the coccyx. Nerve nervate. The thinner posterior (upper horns) portion contains roots exit from the vertebral column through the intervertebral cells with fibers that enter over the posterior (sensory) root end foramina (openings). The vertebrae are separated by disks, ex- and thus serve as a relay station in the sensory/reflex pathway. cept for the first and second cervical, the sacral, and the coccygeal The thoracic region of the spinal cord has a projection from vertebrae. Each vertebra has a ventral solid body and a dorsal seg- each side at the crossbar of the H of gray matter called the lateral ment or arch, which is posterior to the body. The arch is com- horn. It contains the cells that give rise to the autonomic fibers of posed of two pedicles and two laminae supporting seven the sympathetic division. The fibers leave the spinal cord through processes. The vertebral body, arch, pedicles, and laminae all en- the anterior roots in the thoracic and upper lumbar segments. case the vertebral canal.

Fasciculus gracilis White matter Fasciculus cuneatus Posterior spinocerebellar Lateral corticospinal Rubrospinal Anterior spinocerebellar Lateral spinothalamic

Anterior corticospinal Tectospinal FIGURE 60-8 Cross-sectional dia- Anterior spinothalamic Vestibulospinal gram of the spinal cord showing major spinal tracts. Descending fibers Ascending fibers Gray matter 1828 Unit 14 NEUROLOGIC FUNCTION

The Peripheral Nervous System • Cranial Nerves The peripheral nervous system includes the cranial nerves, the Table 60-2 spinal nerves, and the autonomic nervous system. CRANIAL NERVE TYPE FUNCTION CRANIAL NERVES I (olfactory) Sensory Sense of smell There are 12 pairs of cranial nerves that emerge from the lower II (optic) Sensory Visual acuity surface of the brain and pass through the foramina in the skull. III (oculomotor) Motor Muscles that move the Three are entirely sensory (I, II, VIII), five are motor (III, IV, VI, eye and lid, pupillary constriction, lens XI, and XII), and four are mixed (V, VII, IX, and X) as they have accommodation both sensory and motor functions (Downey & Leigh, 1998; IV (trochlear) Motor Muscles that move the eye Hickey, 2003). The cranial nerves are numbered in the order in V (trigeminal) Mixed Facial sensation, corneal which they arise from the brain. For example, cranial nerves I and reflex, mastication II attach in the cerebral hemispheres, whereas cranial nerves IX, VI (abducens) Motor Muscles that move the eye X, XI, and XII attach at the medulla (Fig. 60-9). Most cranial VII (facial) Mixed Facial expression and muscle nerves innervate the head, neck, and special sense structures. movement, salivation and Table 60-2 lists the names and primary functions of the cranial tearing, taste, sensation in nerves. the ear VIII (acoustic) Sensory Hearing and equilibrium SPINAL NERVES IX (glossopharyngeal) Mixed Taste, sensation in pharynx and tongue, pharyngeal The spinal cord is composed of 31 pairs of spinal nerves: 8 cervi- muscles cal, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each spinal X (vagus) Mixed Muscles of pharynx, larynx, nerve has a ventral root and a dorsal root (Fig. 60-10). and soft palate; sensation The dorsal roots are sensory and transmit sensory impulses in external ear, pharynx, from specific areas of the body known as dermatomes (Fig. 60-11) larynx, thoracic and to the dorsal ganglia. The sensory fiber may be somatic, carrying abdominal viscera; information about pain, temperature, touch, and position sense parasympathetic inner- (proprioception) from the tendons, joints, and body surfaces; or vation of thoracic and visceral, carrying information from the internal organs. abdominal organs XI (spinal accessory) Motor Sternocleidomastoid and The ventral roots are motor and transmit impulses from the trapezius muscles spinal cord to the body. These fibers are also either somatic or vis- XII (hypoglossal) Motor Movement of the tongue ceral. The visceral fibers include autonomic fibers that control the cardiac muscles and glandular secretions.

AUTONOMIC NERVOUS SYSTEM with predominantly excitatory responses, most notably the “ﬁght The autonomic nervous system regulates the activities of inter- or ﬂight” response, and the parasympathetic nervous system, nal organs such as the heart, lungs, blood vessels, digestive organs, which controls mostly visceral functions. and glands. Maintenance and restoration of internal homeostasis The autonomic nervous system innervates most body organs. is largely the responsibility of the autonomic nervous system. Although usually considered part of the peripheral nervous sys- There are two major divisions: the sympathetic nervous system, tem, it is regulated by centers in the spinal cord, brain stem, and

Name Location

Optic II Cerebral hemisphere Olfactory I

Oculomotor III Midbrain Trochlear IV Trigeminal V Abducens VI Pons Facial VII Acoustic VIII Glossopharyngeal IX Vagus X Hypoglossal XII Medulla FIGURE 60-9 Diagram of the base of the brain Spinal accessory XI showing entrance or exit of the cranial nerves. The right column shows the anatomic location of the connection of each cranial nerve to the central nervous system. Chapter 60 Assessment of Neurologic Function 1829

Ventral root Dorsal root White organ. Its regulatory effects are exerted not on individual cells but (efferent/motor) (afferent/sensory) matter on large expanses of tissue and on entire organs. The responses elicited do not occur instantaneously but after a lag period. These responses are sustained far longer than other neurogenic responses to ensure maximal functional efficiency on the part of receptor organs, such as blood vessels. To skin (sensory) The quality of these responses is explained by the fact that the and skeletal muscle (motor) autonomic nervous system transmits its impulses by way of nerve pathways, enhanced by chemical mediators, resembling in this respect the endocrine system. Electrical impulses, conducted through Gray nerve fibers, stimulate the formation of specific chemical agents at matter strategic locations within the muscle mass; the diffusion of these chemicals within the muscle is responsible for the contraction. The hypothalamus is the major subcortical center for the Spinal nerve root Spinal cord regulation of visceral and somatic activities, with an inhibitory– FIGURE 60-10 Cross-section of the spinal cord showing dorsal and ven- excitatory role in the autonomic nervous system. The hypothal- tral roots of a spinal nerve. amus has connections that link the autonomic system with the thalamus, the cortex, the olfactory apparatus, and the pituitary gland. Located here are the mechanisms for the control of visceral hypothalamus. The autonomic nervous system has two neurons and somatic reactions that were originally important for defense in a series extending between the centers in the CNS and the or- or attack, and are associated with emotional states (eg, fear, anger, gans innervated. The first neuron, the preganglionic neuron, is anxiety); for the control of metabolic processes, including fat, located in the brain or spinal cord, and its axon extends to the carbohydrate, and water metabolism; for the regulation of body autonomic ganglia. There, it synapses with the second neuron, temperature, arterial pressure, and all muscular and glandular ac- the postganglionic neuron, located in the autonomic ganglia, and tivities of the gastrointestinal tract; for control of genital functions; its axon synapses with the target tissue and innervates the effector and for the sleep cycle.

C2 C3 C2 C4 C3 C5 C6 C4 C7 C5 C8 T1 T 1 T 2 T2 T 3 T3 T 4 T4 T 5 T5 T 6 T 7 T6 T 8 T 9 T7 T 10 T8 T 11 C5 T 12 T1 T9 L 1 L 2 T10 L 3 C8 L 4 T11 L5 T12 S1 L1 S2 S3 S4 L2 C8 L3 S2 S1 L5

S2 L4

L5 S1

L4 FIGURE 60-11 Dermatome distribution. 1830 Unit 14 NEUROLOGIC FUNCTION

The autonomic nervous system is separated into the anatomically and functionally distinct sympathetic and parasympathetic divisions. Most of the tissues and the organs under autonomic control are innervated by both systems. Sympathetic stimuli are mediated by norepinephrine and parasympathetic impulses are mediated by acetylcholine. These chemicals produce opposing and mutually antagonistic effects. Both divisions produce stimu- latory and inhibitory effects. For example, the parasympathetic division causes contraction (stimulation) of the urinary bladder muscles and a decrease (inhibition) in heart rate, whereas the sympathetic division produces relaxation (inhibition) of the urinary bladder and an increase (stimulation) in the rate and force of the heartbeat. Table 60-3 compares the sympathetic and the parasympathetic effects on the different systems of the body.

Sympathetic Nervous System. The sympathetic division of the autonomic nervous system is best known for its role in the body’s “fight-or-flight” response. Under stress conditions from either physical or emotional causes, sympathetic impulses increase greatly. As a result, the bronchioles dilate for easier gas exchange; the heart’s contractions are stronger and faster; the arteries to the heart and voluntary muscles dilate, carrying more blood to these organs; peripheral blood vessels constrict, making the skin feel cool but shunting blood to essential organs; the pupils dilate; the liver releases glucose for quick energy; peristalsis slows; hair stands on end; and perspiration increases. The sympathetic neurotransmitter is norepinephrine (noradrenaline), and this increase in sympathetic discharge is the same as if the body has been given an injection of adrenalin—hence, the term adrenergic is often used to refer to this division. Sympathetic neurons are located in the thoracic and the lumbar segments of the spinal cord; their axons, or the preganglionic fibers, emerge by way of anterior nerve roots from the eighth cervical or first thoracic segment to the second or third lumbar segment. A short distance from the cord, these fibers diverge to join a chain, composed of 22 linked ganglia, that extends the entire length of the spinal column, adjacent to the vertebral bodies on both sides. Some form multiple synapses with nerve cells within the chain. Others traverse the chain without making connections or losing continuity to join large “prevertebral” ganglia in the thorax, the abdomen, or the pelvis or one of the “terminal” ganglia in the vicinity of an organ, such as the bladder or the rectum (Fig. 60-12). Postganglionic nerve fibers originating in the sympathetic chain rejoin the spinal nerves that supply the extremities and are distributed to blood vessels, sweat glands, and smooth muscle tissue in the skin. Postganglionic fibers from the prevertebral plexuses (eg, the cardiac, pulmonary, splanchnic, and pelvic plexuses) supply structures in the head and neck, thorax, abdomen, and pelvis, respectively, having been joined in these plexuses by fibers from the parasympathetic division. The adrenal glands, kidneys, liver, spleen, stomach, and duodenum are under the control of the giant celiac plexus, commonly known as the solar plexus. This receives its sympathetic nerve components by way of the three splanchnic nerves, composed of absence of peristaltic waves and the distention of the intestine by preganglionic fibers from nine segments of the spinal cord (T4 to gas) after fracture of any one of the lower dorsal or upper lumbar L1), and is joined by the vagus nerve, representing the parasym- vertebrae with hemorrhage into the base of the mesentery; and pathetic division. From the celiac plexus, fibers of both divisions the marked variations in pulse rate and rhythm that often follow travel along the course of blood vessels to their target organs. compression fractures of the upper six thoracic vertebrae. Sympathetic Syndromes. Certain syndromes are distinctive to Parasympathetic Nervous System. The parasympathetic nervous diseases of the sympathetic nerve trunks. Among these are dila- system functions as the dominant controller for most visceral ef- tion of the pupil of the eye on the same side as a penetrating fectors. During quiet, nonstressful conditions, impulses from wound of the neck (evidence of disturbance of the cervical sym- parasympathetic fibers (cholinergic) predominate. The fibers of pathetic cord); temporary paralysis of the bowel (indicated by the the parasympathetic system are located in two sections, one in the Chapter 60 Assessment of Neurologic Function 1831

Brain stem Nerves and Sympathetic and spinal cord chain ganglia Organs

Oculomotor n. Eye

Facial n. Lacrimal gland Glossopharyngeal n. Parotid gland Salivary gland Vagus n. Larynx

Lungs

Heart

Stomach

Celiac ganglion Liver and plexus Pancreas Adrenal gland Superior Kidney mesenteric ganglion

Inf. mesenteric Intestine ganglion and plexus

Colon

Bladder

FIGURE 60-12 Anatomy of the auto- Pelvic n. Reproductive nomic nervous system. organs brain stem and the other from spinal segments below L2. Be- verge into a tight bundle known as the internal capsule. A com- cause of the location of these fibers, the parasympathetic system paratively small injury to the capsule causes paralysis in more is referred to as the craniosacral division, as distinct from the tho- muscles than does a much larger injury to the cortex itself. racolumbar (sympathetic) division of the autonomic nervous Within the medulla, the motor axons from the cortex form the system. motor pathways or tracts, notably the corticospinal or pyramidal The parasympathetic nerves arise from the midbrain and the tracts. Here, most of the fibers cross (or decussate) to the oppo- medulla oblongata. Fibers from cells in the midbrain travel with site side, continuing as a crossed pyramidal tract. The remaining the third oculomotor nerve to the ciliary ganglia, where post- fibers enter the spinal cord on the same side as the direct pyrami- ganglionic fibers of this division are joined by those of the sym- dal tract. Each fiber in this tract finally crosses to the opposite side pathetic system, creating controlled opposition, with a delicate of the cord and terminates within the gray matter of the anterior balance maintained between the two at all times. horn on that side, in proximity to a motor nerve cell. Fibers of the crossed pyramidal tract terminate within the anterior horn Motor and Sensory Functions and make connections with anterior horn cells on the same side. of the Nervous System All of the motor fibers of the spinal nerves represent extensions of these anterior horn cells, with each of these fibers communicat- MOTOR SYSTEM FUNCTION ing with only one particular muscle fiber. The motor cortex, a vertical band within each cerebral hemi- The motor system is complex, and motor function depends sphere, controls the voluntary movements of the body. The exact on the integrity of the corticospinal tracts, the extrapyramidal locations within the brain at which the voluntary movements of system, and cerebellar function. A motor impulse consists of a the muscles of the face, thumb, hand, arm, trunk, and leg origi- two-neuron pathway (described below). The motor nerve pathways nate are known (Fig. 60-13). To initiate muscle movement, these are contained in the spinal cord. Some represent the pathways of particular cells must send the stimulus down along their fibers. the so-called extrapyramidal system, establishing connections be- Stimulation of these cells with an electric current will also result tween the anterior horn cells and the automatic control centers in muscle contraction. En route to the pons, the motor fibers con- located in the basal ganglia and the cerebellum. Others are 1832 Unit 14 NEUROLOGIC FUNCTION

Wrist

Trunk Elbow Hip and arm

Thigh

Knee Hand and Leg fingers Face and neck

Tongue Foot and ankle

Larynx FIGURE 60-13 Diagrammatic repre- sentation of the cerebrum showing locations for control of motor movement of various parts of the body. components of reflex arcs, forming synaptic connections between hence hyperactive deep tendon reflexes, diminished or absent anterior horn cells and sensory fibers that have entered adjacent superficial reflexes, and pathologic reflexes such as a Babinski re- or neighboring segments of the cord. sponse occur. Severe leg spasms can occur as the result of an upper motor neuron lesion; the spasms result from the preserved reflex Upper and Lower Motor Neurons. The voluntary motor system arc, which lacks inhibition along the spinal cord below the level consists of two groups of neurons: upper motor neurons and of injury. lower motor neurons. Upper motor neurons originate in the cere- There is little or no muscle atrophy, and muscles remain per- bral cortex, the cerebellum, and the brain stem and modulate the manently tense, exhibiting spastic paralysis or paresis (weakness). activity of the lower motor neurons. Upper motor neuron fibers Paralysis associated with upper motor neuron lesions usually af- make up the descending motor pathways and are located entirely fects a whole extremity, both extremities, and an entire half of the within the CNS. Lower motor neurons are located either in the body. Hemiplegia (paralysis of an arm and leg on the same side anterior horn of the spinal cord gray matter or within cranial of the body) can be the result of an upper motor neuron lesion. nerve nuclei in the brain stem. Axons of both extend through pe- If hemorrhage, an embolus, or a thrombus destroys the fibers ripheral nerves and terminate in skeletal muscle. Lower motor from the motor area in the internal capsule, the arm and the leg neurons are located in both the CNS and the peripheral nervous of the opposite side become stiff and very weak or paralyzed, and system. the reflexes are hyperactive (further discussion of hemiplegia is The motor pathways from the brain to the spinal cord, as well found in Chap. 62). When both legs are paralyzed, the condition as from the cerebrum to the brain stem, are formed by upper is called paraplegia; paralysis of all four extremities is quadriple- motor neurons. They begin in the cortex of one side of the brain, gia (more discussion of these can be found in Chap. 63). descend through the internal capsule, cross to the opposite side in the brain stem, descend through the corticospinal tract, and Lower Motor Neuron Lesions. A patient is considered to have synapse with the lower motor neurons in the cord. The lower lower motor neuron damage if a motor nerve is severed between motor neurons receive the impulse in the posterior part of the cord and run to the myoneural junction located in the peripheral muscle. The clinical features of lesions of upper and lower Comparison of Upper Motor Neuron and motor neurons are discussed in the sections that follow and in Table 60-4 • Lower Motor Neuron Lesions Table 60-4. Upper Motor Neuron Lesions. Upper motor neuron lesions can UPPER MOTOR LOWER MOTOR involve the motor cortex, the internal capsule, the spinal cord, NEURON LESIONS NEURON LESIONS and other structures of the brain through which the corticospinal Loss of voluntary control Loss of voluntary control tract descends. If the upper motor neurons are damaged or de- Increased muscle tone Decreased muscle tone stroyed, as frequently occurs with stroke or spinal cord injury, Muscle spasticity Flaccid muscle paralysis paralysis (loss of voluntary movement) results. However, because No muscle atrophy Muscle atrophy the inhibitory influences of intact upper motor neurons are now Hyperactive and abnormal reflexes Absent or decreased reflexes impaired, reflex (involuntary) movements are uninhibited, and Chapter 60 Assessment of Neurologic Function 1833 the muscle and the spinal cord. The result of lower motor neu- Tumors, infection, or abscess and increased intracranial pres- ron damage is muscle paralysis. Reflexes are lost, and the muscle sure can all affect the cerebellum. Cerebellar signs, such as ataxia, becomes flaccid (limp) and atrophied from disuse. If the patient incoordination, and seizures, as well as CSF obstruction and com- has injured the spinal trunk and it can heal, use of the muscles pression of the brain stem may be seen. Signs of increased in- connected to that section of the spinal cord may be regained. If tracranial pressure, including vomiting, headache, and changes in the anterior horn motor cells are destroyed, however, the nerves vital signs and level of consciousness, are especially common when cannot regenerate and the muscles are never useful again. Flac- CSF flow is obstructed. cid paralysis and atrophy of the affected muscles are the princi- Destruction or dysfunction of the basal ganglia leads not to pal signs of lower motor neuron disease. Lower motor neuron paralysis but to muscle rigidity, with disturbances of posture and lesions can be the result of trauma, infection (poliomyelitis), tox- movement. Such patients tend to have involuntary movements. ins, vascular disorders, congenital malformations, degenerative These may take the form of coarse tremors, most often in the processes, and neoplasms. Compression of nerve roots by herni- upper extremities, particularly in the distal portions; athetosis, ated intervertebral disks is a common cause of lower motor neu- movement of a slow, squirming, writhing, twisting type; or ron dysfunction. chorea, marked by spasmodic, purposeless, irregular, uncoordi- nated motions of the trunk and the extremities, and facial gri- Coordination of Movement. The smoothness, accuracy, and macing. Disorders due to lesions of the basal ganglia include strength that characterize the muscular movements of a normal Parkinson’s disease, Huntington’s disease (see Chap. 65), and person are attributable to the influence of the cerebellum and the spasmodic torticollis. basal ganglia. SENSORY SYSTEM FUNCTION The cerebellum (refer to Fig. 60-2), described earlier, is located beneath the occipital lobe of the cerebrum; it is responsible for Integrating Sensory Impulses. The thalamus, a major receiving the coordination, balance, and timing of all muscular move- and transmitting center for the afferent sensory nerves, is a large ments that originate in the motor centers of the cerebral cortex. structure connected to the midbrain. It lies next to the third ven- Through the action of the cerebellum, the contractions of op- tricle and forms the floor of the lateral ventricle (see Fig. 60-3). posing muscle groups are adjusted in relation to each other to The thalamus integrates all sensory impulses except olfaction. It maximal mechanical advantage; muscle contractions can be sus- plays a role in the conscious awareness of pain and the recogni- tained evenly at the desired tension and without significant fluc- tion of variation in temperature and touch. The thalamus is re- tuation, and reciprocal movements can be reproduced at high sponsible for the sense of movement and position and the ability and constant speed, in stereotyped fashion and with relatively to recognize the size, shape, and quality of objects. little effort. The basal ganglia, masses of gray matter in the midbrain be- Receiving Sensory Impulses. Afferent impulses travel from their neath the cerebral hemispheres, border the lateral ventricles and points of origin to their destinations in the cerebral cortex via the lie in proximity to the internal capsule. The basal ganglia play an ascending pathways directly, or they may cross at the level of the important role in planning and coordinating motor movements spinal cord or in the medulla, depending on the type of sensation and posture. Complex neural connections link the basal ganglia that is registered. Sensory information may be integrated at the with the cerebral cortex. The major effect of these structures is to level of the spinal cord or may be relayed to the brain. Knowledge inhibit unwanted muscular activity; disorders of the basal ganglia of these pathways is important for neurologic assessment and for result in exaggerated, uncontrolled movements. understanding symptoms and their relationship to various lesions. Impaired cerebellar function, which may occur as a result of Sensory impulses enter the spinal cord by way of the posterior an intracranial injury or some type of an expanding mass (eg, a root. These axons convey sensations of heat, cold, and pain and hemorrhage, abscess, or tumor), results in loss of muscle tone, enter the posterior gray column of the cord, where they make weakness, and fatigue. Depending on the area of the brain af- connections with the cells of secondary neurons. Pain and tem- fected, the patient has different motor symptoms or responses. perature fibers cross immediately to the opposite side of the cord and course upward to the thalamus. Fibers carrying sensations of The patient may demonstrate decorticate, decerebrate, or flaccid touch, light pressure, and localization do not connect immedi- posturing, usually as a result of cerebral trauma (Bateman, 2001). ately with the second neuron but ascend the cord for a variable For further explanation of this, see Figure 61-1 in Chapter 61. distance before entering the gray matter and completing this con- Decortication (decorticate posturing) is the result of lesions of the nection. The axon of the secondary neuron crosses the cord and internal capsule or cerebral hemispheres; the patient has flexion proceeds upward to the thalamus. and internal rotation of the arms and wrists and extension, inter- Position and vibratory sensation are produced by stimuli aris- nal rotation, and plantar flexion of the feet. Decerebration (de- ing from muscles, joints, and bones. These stimuli are conveyed, cerebrate posturing), the result of lesions at the midbrain, is more uncrossed, all the way to the brain stem by the axon of the pri- ominous than decortication. The patient has extension and ex- mary neuron. In the medulla, synaptic connections are made with ternal rotation of the arms and wrists and extension, plantar flex- cells of the secondary neurons, whose axons cross to the opposite ion, and internal rotation of the feet. Flaccid posturing is usually side and then proceed to the thalamus. the result of lower brain stem dysfunction; the patient has no motor function, is limp, and lacks motor tone. Sensory Losses. Destruction of a sensory nerve results in total Flaccidity preceded by decerebration in a patient with cerebral loss of sensation in its area of distribution. Transection of the injury indicates severe neurologic impairment, which may herald spinal cord yields complete anesthesia below the level of injury. brain death. However, before the declaration of brain death, the Selective destruction or degeneration of the posterior columns of patient must have spinal cord injury ruled out, the effects of all the spinal cord is responsible for a loss of position and vibratory neuromuscular paralyzing agents must have worn off, and any sense in segments distal to the lesion, without loss of touch, pain, other possible treatable causes of neurologic impairment must be or temperature perception. A lesion, such as a cyst, in the center investigated. of the spinal cord causes dissociation of sensation—loss of pain 1834 Unit 14 NEUROLOGIC FUNCTION at the level of the lesion. This occurs because the fibers carrying Neurologic disease may be stable or progressive, with both in- pain and temperature cross within the cord immediately on en- termittent symptom-free periods as well as times with fluctua- tering; thus, any lesion that divides the cord longitudinally ditions in symptoms. The health history therefore includes details vides these fibers. Other sensory fibers ascend the cord for variable about the onset, character, severity, location, duration, and fre- distances, some even to the medulla, before crossing, thereby by- quency of symptoms and signs; associated complaints; precipi- passing the lesion and avoiding destruction. tating, aggravating, and relieving factors; progression, remission, Lesions affecting the posterior spinal nerve roots may cause im- and exacerbation; and the presence or absence of similar symp- pairment of tactile sensation, including intermittent severe pain toms among family members. The nurse may also use the inter- that is referred to their areas of distribution. Tingling of the fingers view to inquire about any family history of genetic diseases. See and the toes can be a prominent symptom of spinal cord disease, the Genetics chart for assessment guidelines and Chapter 9 for presumably due to degenerative changes in the sensory fibers that additional information about genetics. extend to the thalamus (ie, belonging to the spinothalamic tract). Included in the health history is a review of the medical history, including a system-by-system evaluation. The nurse should be aware of any history of trauma or falls that may have involved the Assessment: The Neurologic Examination head or spinal cord. Questions regarding the use of alcohol, med- HEALTH HISTORY ications, and recreational drugs are also included. The history- taking portion of the neurologic examination is critical and, in An important aspect of the neurologic assessment is the history many cases of neurologic disease, leads to an accurate diagnosis. of the present illness. The initial interview provides an excellent opportunity to systematically explore the patient’s current con- CLINICAL MANIFESTATIONS dition and related events while simultaneously observing overall appearance, mental status, posture, movement and affect. De- The clinical manifestations of neurologic disease are as varied as pending on the patient’s condition, the nurse may need to rely on the disease processes themselves. Symptoms can be subtle or in- yes-or-no answers to questions, on a review of the medical record, tense, fluctuating or permanent, an inconvenience or devastating. or input from the family or a combination of these. An introduction to some of the most common symptoms associ-

GENETICS IN NURSING PRACTICE—Neurologic Disorders

DISEASES AND CONDITIONS INFLUENCED MANAGEMENT SPECIFIC TO GENETICS BY GENETIC FACTORS • Inquire whether DNA mutation or other genetic testing has • Alzheimer’s disease been performed on affected family members. • Amyotrophic lateral sclerosis (ALS) • If indicated, refer for further genetic counseling and evalua- • Duchenne muscular dystrophy tion so that family members can discuss inheritance, risk to • Epilepsy other family members, availability of genetic testing and • Friedrich ataxia gene-based interventions. • Huntington disease • Offer appropriate genetics information and resources. • Myotonic dystrophy • Assess patient’s understanding of genetics information. • Neurofibromatosis type I • Provide support to families with newly diagnosed genetic- • Parkinson’s disease related neurologic disorders. Spina bifida • • Participate in management and coordination of care of pa- Tourette syndrome • tients with genetic conditions and individuals predisposed to NURSING ASSESSMENTS develop or pass on a genetic condition. FAMILY HISTORY ASSESSMENT • Assess for other similarly affected relatives with neurologic GENETICS RESOURCES FOR NURSES AND THEIR impairment. PATIENTS ON THE WEB • Inquire about age of onset (eg, present at birth—spina bifida; Genetic Alliance: http://www.geneticalliance.org—a directory developed in childhood—Duchenne muscular dystrophy; of support groups for patients and families with genetic developed in adulthood—Huntington disease, Alzheimer’s conditions disease, amyotrophic lateral sclerosis) Gene Clinics: http://www.geneclinics.org—a listing of common • Inquire about the presence of related conditions such as men- genetic disorders with up-to-date clinical summaries, genetic tal retardation and/or learning disabilities (neurofibromatosis counseling and testing information type I). National Organization of Rare Disorders: http://www. PHYSICAL ASSESSMENT rarediseases.org—a directory of support groups and informa- • Assess for the presence of other physical features suggestive of tion for patients and families with rare genetic disorders an underlying genetic condition, such as skin lesions seen in OMIM: Online Mendelian Inheritance in Man: http://www. neurofibromatosis type 1 (café-au-lait spots). nchi.nlm.nih.gov/omim/stats/html—a complete listing of • Assess for other congenital abnormalities (eg, cardiac, ocular). inherited genetic conditions Chapter 60 Assessment of Neurologic Function 1835 ated with neurologic disease follows; detailed discussions regard- wide range of disability. Weakness can be sudden and permanent, ing how specific symptoms relate to a particular disorder will be as in stroke, or progressive, as in many neuromuscular diseases such covered in later chapters in this unit. as amyotrophic lateral sclerosis. Any muscle group can be affected.

Pain Abnormal Sensation Pain is considered an unpleasant sensory perception and emo- Numbness, abnormal sensation, or loss of sensation is a neuro- tional experience associated with actual or potential tissue damage logic manifestation of both central and peripheral nervous system or described in terms of such damage. Pain is therefore considered disease. Altered sensation can affect small or large areas of the multidimensional and entirely subjective (Loeser, 2001). Pain can body. It is frequently associated with weakness or pain and is po- be acute or chronic. In general, acute pain lasts for a relatively short tentially disabling. Both numbness and weakness can significantly period of time and remits as the pathology resolves. In neurologic affect balance and coordination. disease, this type of pain is often associated with spinal disc disease, trigeminal neuralgia, or other neuropathic pathology (eg, post- herpetic neuralgia, or painful neuropathies). In contrast, chronic PHYSICAL EXAMINATION pain extends for long periods of time and may represent a low level The neurologic examination is a systematic process that includes of pathology. This type of pain might also occur with discogenic a variety of clinical tests, observations, and assessments designed disease. to evaluate a complex system. Although the neurologic examination is often limited to a simple screening, the examiner must be able Seizures to conduct a thorough neurologic assessment when the patient’s history or other physical findings warrant it. Many neurologic Seizures are the result of abnormal paroxysmal discharges in the rating scales exist; some of the more common ones are discussed cerebral cortex, which then manifest as an alteration in sensation, here, but an in-depth discussion is beyond the scope of this chap- behavior, movement, perception, or consciousness (Hickey, ter (see Herndon [1997] and Rapp, Wakefield, Kundrat et al. 2003). The alteration may be short, as in a blank stare lasting only [2000] for full descriptions of neurologic rating scales). a second, or of longer duration, such as a tonic-clonic grand mal The brain and spinal cord cannot be examined as directly as seizure that can last several minutes. The type of seizure activity other systems of the body. Thus, much of the neurologic exami- is a direct result of the area of the brain affected. Seizures can nation is an indirect evaluation that assesses the function of the occur as isolated events, such as when induced by a high fever, specific body part or parts controlled or innervated by the ner- alcohol or drug withdrawal, or hypoglycemia. A seizure may also vous system. A neurologic assessment is divided into five compo- be the first obvious sign of a brain lesion. nents: cerebral function, cranial nerves, motor system, sensory system, and reflexes. As in other parts of the physical assessment, Dizziness the neurologic examination follows a logical sequence and pro- Dizziness is an abnormal sensation of imbalance or movement. It gresses from higher levels of cortical function such as abstract is fairly common in the elderly and one of the most common com- thinking to lower levels of function such as the determination of plaints encountered by health professionals. Dizziness can have a the integrity of peripheral nerves. variety of causes, including viral syndromes, hot weather, roller coaster rides, and middle ear infections, to name a few. One diffi- Assessing Cerebral Function culty confronting health care providers when assessing dizziness is the vague and varied terms patients use to describe the sensation. Cerebral abnormalities may cause disturbances in mental status, Vertigo, a specific form of dizziness, is defined as a sensation that intellectual functioning, and thought content and in patterns of is usually a manifestation of vestibular dysfunction. It can be so se- emotional behavior. There may also be alterations in perception, vere as to result in spatial disorientation, loss of equilibrium, and motor and language abilities, as well as lifestyle. nausea and vomiting (Greenberg, Aminoff, & Simon, 2002). MENTAL STATUS An assessment of mental status begins by observing the patient’s Visual Disturbances appearance and behavior, noting dress, grooming, and personal Visual defects that cause people to seek health care can range from hygiene. Posture, gestures, movements, facial expressions, and the decreased visual acuity associated with aging to sudden blind- motor activity often provide important information about the pa- ness caused by glaucoma. Normal vision depends upon func- tient. The patient’s manner of speech and level of consciousness tioning visual pathways through the retina and optic chiasm and are also assessed. Is the patient’s speech clear and coherent? Is the the radiations into the visual cortex in the occipital lobes. Lesions patient alert and responsive, or drowsy and stuporous? of the eye itself (eg, cataract), lesions along the pathway (eg, Assessing orientation to time, place, and person assists in eval- tumor), or lesions in the visual cortex (from stroke) interfere with uating mental status. Does the patient know what day it is, what normal visual acuity. Abnormalities of eye movement (as in the year it is, and the name of the president of the United States? Is nystagmus associated with multiple sclerosis) can also compro- the patient aware of where he or she is? Is the patient aware of mise vision by causing diplopia or double vision. who the examiner is and of his or her purpose for being in the room? Is the capacity for immediate memory intact? (See Chart Weakness 12-1: Mini-Mental State Examination in Chap. 12.) Weakness, specifically muscle weakness, is a common manifesta- INTELLECTUAL FUNCTION tion of neurologic disease. Weakness frequently coexists with other A person with an average IQ can repeat seven digits without fal- symptoms of disease and can affect a variety of muscles, causing a tering and can recite five digits backward. The examiner might 1836 Unit 14 NEUROLOGIC FUNCTION ask the patient to count backward from 100 or to subtract 7 from Successful performance requires the ability to understand the ac- 100, then 7 from that, and so forth (called serial 7s) (Johnson, tivity desired and normal motor strength. Failure signals cerebral 2001). The capacity to interpret well-known proverbs tests ab- dysfunction. stract reasoning, which is a higher intellectual function; for example, does the patient know what is meant by “the early bird LANGUAGE ABILITY catches the worm”? Patients with damage to the frontal cortex The person with normal neurologic function can understand and appear superficially normal until one or more tests of integrative communicate in spoken and written language. Does the patient capacity are performed. Questions designed to assess this capac- answer questions appropriately? Can he or she read a sentence ity might include the ability to recognize similarities: how are a from a newspaper and explain its meaning? Can the patient write mouse and dog or pen and pencil alike? Can the patient make his or her name or copy a simple figure that the examiner has judgements about situations—for instance, if the patient arrived drawn? A deficiency in language function is called aphasia. Dif- home without a house key, what alternatives are there? ferent types of aphasia result from injury to different parts of the brain (Chart 60-2). Aphasia is discussed in detail in Chapter 62. THOUGHT CONTENT During the interview, it is important to assess the patient’s IMPACT ON LIFESTYLE thought content. Are the patient’s thoughts spontaneous, natural, The nurse assesses the impact the neurologic impairment has on clear, relevant, and coherent? Does the patient have any fixed the patient’s lifestyle. Issues to consider include the limitations ideas, illusions, or preoccupations? What are his or her insights imposed on the patient by any deficit and the patient’s role in so- into these thoughts? Preoccupation with death or morbid events, ciety, including family and community roles. The plan of care hallucinations, and paranoid ideation are examples of unusual that the nurse develops needs to address and support adaptation thoughts or perceptions that require further evaluation. to the neurologic deficit and continued function to the extent possible within the patient’s support system. EMOTIONAL STATUS An assessment of cerebral functioning also includes the patient’s DOCUMENTATION OF FINDINGS emotional status. Is the patient’s affect (external manifestation of Interpretation and documentation of neurologic abnormalities, mood) natural and even, or irritable and angry, anxious, apathetic particularly mental status abnormalities, should be specific and or flat, or euphoric? Does his or her mood fluctuate normally, or nonjudgmental. Lengthy descriptions and the use of terms such does the patient unpredictably swing from joy to sadness during as “inappropriate” or “demented” should be avoided. Terms such the interview? Is affect appropriate to words and thought content? as these often mean different things to different people and are Are verbal communications consistent with nonverbal cues? therefore not useful when describing behavior. The examiner records and reports specific observations regarding orientation, PERCEPTION level of consciousness, emotional state, or thought content, all of The examiner may now consider more specific areas of higher which permit comparison by others over time. Analysis and the cortical function. Agnosia is the inability to interpret or recog- conclusions that may be drawn from these findings usually de- nize objects seen through the special senses. The patient may see pend on the examiner’s knowledge of neuroanatomy, neuro- a pencil but not know what it is called or what to do with it. The physiology, and neuropathology. patient may even be able to describe it but not to interpret its function. The patient may experience auditory or tactile agnosia Examining the Cranial Nerves as well as visual agnosia. Each of the dysfunctions implicates a different part of the cortex (Chart 60-1). Table 60-5 describes how to assess the cranial nerves. Opposite sides Screening for visual and tactile agnosia provides insight into of the face and neck are compared throughout the examination. the patient’s cortical interpretation ability. The patient is shown a familiar object and asked to identify it by name. Placing a fa- Examining the Motor System miliar object (eg, key, coin) in the patient’s hand and having him or her identify it with both eyes closed is an easy way to assess tac- A thorough examination of the motor system includes an assess- tile interpretation. ment of muscle size, tone, and strength, coordination, and balance. The patient is instructed to walk across the room while the exam- MOTOR ABILITY iner observes posture and gait. The muscles are inspected, and pal- Assessment of cortical motor integration is carried out by asking pated if necessary, for their size and symmetry. Any evidence of the patient to perform a skilled act (throw a ball, move a chair). atrophy or involuntary movements (tremors, tics) is noted. Mus- cle tone (the tension present in a muscle at rest) is evaluated by palpating various muscle groups at rest and during passive movement. Chart Resistance to these movements is assessed and documented. 60-1 Types of Agnosia and Corresponding Sites of Lesions Chart Type of Agnosia Affected Cerebral Area 60-2 Types of Aphasia and Region of Brain Involved Visual Occipital lobe Auditory Temporal lobe (lateral and Type of Aphasia Brain Area Involved superior portions) Auditory-receptive Temporal lobe Tactile Parietal lobe Visual-receptive Parietal-occipital area Body parts and relationships Parietal lobe (posteroinferior Expressive speaking Inferior posterior frontal areas regions) Expressive writing Posterior frontal area Chapter 60 Assessment of Neurologic Function 1837

Table 60-5 • Assessing Cranial Nerve Function

CRANIAL NERVE CLINICAL EXAMINATION I (olfactory) With eyes closed, the patient identifies familiar odors (coffee, tobacco). Each nostril is tested separately. II (optic) Snellen eye chart; visual fields; ophthalmoscopic examination III (oculomotor) For cranial nerves III, IV, and VI: test for ocular rotations, conjugate movements, nystagmus. Test for IV (trochlear) pupillary reflexes, and inspect eyelids for ptosis. VI (abducens) V (trigeminal) Have patient close the eyes. Touch cotton to forehead, cheeks, and jaw. Sensitivity to superficial pain is tested by using the sharp and dull ends of a broken tongue blade. Alternate between the sharp point and the dull end. Patient reports “sharp” or “dull” with each movement. If responses are incorrect, test for temperature sensation. Test tubes of cold and hot water are used alternately. While the patient looks up, lightly touch a wisp of cotton against the temporal surface of each cornea. A blink and tearing are normal responses. Have the patient clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting strength and equality. VII (facial) Observe for symmetry while the patient performs facial movements: smiles, whistles, elevates eyebrows, frowns, tightly closes eyelids against resistance (examiner attempts to open them). Observe face for flaccid paralysis (shallow nasolabial folds). Patient extends tongue. Ability to discriminate between sugar and salt is tested. VIII (acoustic) Whisper or watch-tick test Test for lateralization (Weber) Test for air and bone conduction (Rinne) IX (glossopharyngeal) Assess patient’s ability to discriminate between sugar and salt on posterior third of the tongue. X (vagus) Depress a tongue blade on posterior tongue, or stimulate posterior pharynx to elicit gag reflex. Note any hoarseness in voice. Have patient say “ah.” Observe for symmetric rise of uvula and soft palate. XI (spinal accessory) Palpate and note strength of trapezius muscles while patient shrugs shoulders against resistance. Palpate and note strength of each sternocleidomastoid muscle as patient turns head against opposing pressure of the examiner’s hand. XII (hypoglossal) While the patient protrudes the tongue, any deviation or tremors are noted. The strength of the tongue is tested by having the patient move the protruded tongue from side to side against a tongue depressor.

Abnormalities in tone include spasticity (increased muscle tone), ment is noted—or very severe weakness; and 0 indicates complete rigidity (resistance to passive stretch), and flaccidity. paralysis. A stick figure may be used to record muscle strength and is a precise form of documenting findings. Distal and proximal MUSCLE STRENGTH strength in both upper and lower extremities is recorded using the Assessing the patient’s ability to flex or extend the extremities five-point scale (Fig. 60-14). against resistance tests muscle strength. The function of an in- Assessment of muscle strength can be as detailed as necessary. dividual muscle or group of muscles is evaluated by placing the One may quickly test the strength of the proximal muscles of the muscle at a disadvantage. The quadriceps, for example, is a pow- upper and lower extremities, always comparing both sides. The erful muscle responsible for straightening the leg. Once the leg strength of the finer muscles that control the function of the hand is straightened, it is exceedingly difficult for the examiner to flex (hand grasp) and the foot (dorsiflexion and plantar flexion) can the knee. Conversely, if the knee is flexed and the patient is asked then be assessed. to straighten the leg against resistance, a more subtle disability can be elicited. The evaluation of muscle strength compares the BALANCE AND COORDINATION sides of the body to each other. For example, the right upper ex- Cerebellar influence on the motor system is reflected in balance tremity is compared to the left upper extremity. In this way, sub- control and coordination. Coordination in the hands and upper tle differences in muscle strength can be more easily detected and extremities is tested by having the patient perform rapid, alternat- accurately described. ing movements and point-to-point testing. First, the patient is in- Clinicians use a five-point scale to rate muscle strength structed to pat his or her thigh as fast as possible with each hand (O’Hanlon-Nichols, 1999). A 5 indicates full power of contrac- separately. Then the patient is instructed to alternately pronate tion against gravity and resistance or normal muscle strength; and supinate the hand as rapidly as possible. Lastly, the patient is 4 indicates fair but not full strength against gravity and a moderate asked to touch each of the fingers with the thumb in a consecutive amount of resistance or slight weakness; 3 indicates just sufficient motion. Speed, symmetry, and degree of difficulty are noted. strength to overcome the force of gravity or moderate weakness; Point-to-point testing is accomplished by having the patient 2 indicates the ability to move but not to overcome the force of touch the examiner’s extended finger and then his or her own gravity or severe weakness; 1 indicates minimal contractile nose. This is repeated several times. This assessment is then car- power—weak muscle contraction can be palpated but no move- ried out with the patient’s eyes closed. 1838 Unit 14 NEUROLOGIC FUNCTION

TECHNIQUE A reflex hammer is used to elicit a deep tendon reflex. The han- 2 4 dle of the hammer is held loosely between the thumb and index 1 finger, allowing a full swinging motion. The wrist motion is sim- 5 ilar to that used during percussion. The extremity is positioned so that the tendon is slightly stretched. This requires a sound knowledge of the location of muscles and their tendon attach- ments. The tendon is then struck briskly, and the response is compared with that on the opposite side of the body. A wide variation in reflex response may be considered normal; it is more im- 1 5 portant, however, that the reflexes be symmetrically equivalent. When the comparison is made, both sides should be equivalently relaxed and each tendon struck with equal force. Valid findings depend on several factors: proper use of the reflex hammer, proper positioning of the extremity, and a relaxed patient. If the reflexes are symmetrically diminished or absent, the 2 5 examiner may use reinforcement to increase reflex activity. This involves the isometric contraction of other muscle groups. If FIGURE 60-14 A stick figure may be used to record muscle strength as lower extremity reflexes are diminished or absent, the patient is follows: 5, full range of motion against gravity and resistance; 4, full range of instructed to lock the fingers together and pull in opposite direc- motion against gravity and a moderate amount of resistance; 3, full range of tions. Having the patient clench the jaw or press the heels against motion against gravity only; 2, full range of motion when gravity is eliminated; 1, a weak muscle contraction when muscle is palpated, but no move- the floor or examining table may similarly elicit more reliable bi- ment; and 0, complete paralysis. ceps, triceps, and brachioradialis reflexes. GRADING THE REFLEXES Coordination in the lower extremities is tested by having the The absence of reflexes is significant, although ankle jerks (Achilles patient run the heel down the anterior surface of the tibia of the reflex) may be normally absent in older people. Deep tendon reflex responses are often graded on a scale of 0 to 4+. A 4+ indicates other leg. Each leg is tested in turn. Ataxia is defined as incoor- + dination of voluntary muscle action, particularly of the muscle a hyperactive reflex, often indicating pathology; 3 indicates a re- groups used in activities such as walking or reaching for objects. sponse that is more brisk than average but may be normal or indicative of disease; 2+ indicates an average or normal response; The presence of ataxia or tremors (rhythmic, involuntary move- 1+ indicates a hypoactive or diminished response; and 0 indicates ments) during these movements suggests cerebellar disease. no response. As stated previously, scale ratings are highly subjective. It is not necessary to carry out each of these assessments for co- Findings can be recorded as a fraction, indicating the scale range ordination. During a routine examination, it is advisable to per- (eg, 2/4). Some examiners prefer to use the terms present, absent, form a simple screening of the upper and lower extremities by and diminished when describing reflexes. As with muscle strength having the patient perform either rapid, alternating movements recording, a stick figure such as the one shown in Chart 60-3 may or point-to-point testing. When abnormalities are observed, a also be used to record numerical findings. more thorough examination is indicated. The Romberg test is a screening test for balance. The patient BICEPS REFLEX stands with feet together and arms at the side, first with eyes open The biceps reflex is elicited by striking the biceps tendon of the and then with both eyes closed for 20 to 30 seconds. The exam- flexed elbow. The examiner supports the forearm with one arm iner stands close to reassure the patient of support if he or she be- while placing the thumb against the tendon and striking the gins to fall. Slight swaying is normal, but a loss of balance is thumb with the reflex hammer. The normal response is flexion at abnormal and is considered a positive Romberg test. Additional the elbow and contraction of the biceps (see Fig. 60-15A). cerebellar tests for balance in the ambulatory patient include hop- ping in place, alternating knee bends, and heel-to-toe walking TRICEPS REFLEX (both forward and backward). To elicit a triceps reflex, the patient’s arm is flexed at the elbow and positioned in front of the chest. The examiner supports the Examining the Reflexes patient’s arm and identifies the triceps tendon by palpating 2.5 to 5 cm (1 to 2 in) above the elbow. A direct blow on the tendon The motor reflexes are involuntary contractions of muscles or normally produces contraction of the triceps muscle and exten- muscle groups in response to abrupt stretching near the site of the sion of the elbow (see Fig. 60-15B). muscle’s insertion. The tendon is struck directly with a reflex hammer or indirectly by striking the examiner’s thumb, which is BRACHIORADIALIS REFLEX placed firmly against the tendon. Testing these reflexes enables With the patient’s forearm resting on the lap or across the ab- the examiner to assess involuntary reflex arcs that depend on the domen, the brachioradialis reflex is assessed. A gentle strike of the presence of afferent stretch receptors, spinal synapses, efferent hammer 2.5 to 5 cm (1 to 2 in) above the wrist results in flexion motor fibers, and a variety of modifying influences from higher and supination of the forearm. levels. Common reflexes that may be tested include the deep tendon reflexes (biceps, brachioradialis, triceps, patellar, and ankle PATELLAR REFLEX reflexes) and superficial or cutaneous reflexes (abdominal reflexes The patellar reflex is elicited by striking the patellar tendon just and plantar or Babinski response) (Fig. 60-15). below the patella. The patient may be in a sitting or a lying posi- Chapter 60 Assessment of Neurologic Function 1839

A B C

FIGURE 60-15 Techniques for eliciting major reflexes. (A) Biceps reflex. (B) Triceps reflex. (C) Patellar reflex. (D) Ankle or Achilles reflex. (E) Babinski response. From Weber, J. & Kelley, J. (2003). Health assessment in nursing (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. © B. Proud. tion. If the patient is supine, the examiner supports the legs to fa- CLONUS cilitate relaxation of the muscles. Contractions of the quadriceps When reflexes are very hyperactive, a phenomenon called clonus and knee extension are normal responses (see Fig. 60-15C ). may be elicited. If the foot is abruptly dorsiflexed, it may continue to “beat” two or three times before it settles into a position of rest. ANKLE REFLEX Occasionally with central nervous system disease this activity per- To elicit an ankle (Achilles) reflex, the foot is dorsiflexed at the sists and the foot does not come to rest while the tendon is being ankle and the hammer strikes the stretched Achilles tendon (see stretched but persists in repetitive activity. The unsustained clonus Fig. 60-15D). This reflex normally produces plantar flexion. If associated with normal but hyperactive reflexes is not considered the examiner cannot elicit the ankle reflex and suspects that the pathologic. Sustained clonus always indicates the presence of cen- patient cannot relax, the patient is instructed to kneel on a chair tral nervous system disease and requires further evaluation. or similar elevated, flat surface. This position places the ankles in dorsiflexion and reduces any muscle tension in the gastroc- SUPERFICIAL REFLEXES nemius. The Achilles tendons are struck in turn, and plantar flex- The major superficial reflexes include corneal, gag or swallowing, ion is usually demonstrated. upper/lower abdominal, cremasteric (men only), plantar, and 1840 Unit 14 NEUROLOGIC FUNCTION Chart 60-3 Documenting Reflexes

Deep tendon reﬂexes are graded on a scale of 0 to 4: ++ ++

0 No response ++ ++ 1+ Diminished (hypoactive) ++ ++ 2+ Normal + 3 Increased (may be interpreted as normal) + + 4+ Hyperactive (hyperreflexia) + + The deep tendon responses and plantar reflexes are commonly recorded on stick figures. The arrow points downward if the plantar ++ ++ response is normal and upward if the response is abnormal.

perianal. These reflexes are graded differently than the motor record (see Fig. 60-11). Most sensory deficits result from periph- flexes and are noted to be present (+) or absent (-). Of these, only eral neuropathy and follow anatomic dermatomes. Exceptions to three are tested commonly. The corneal reflex is tested carefully this include major destructive lesions of the brain; loss of sen- using a clean wisp of cotton and lightly touching the outer cor- sation, which may affect an entire side of the body; and the ner of each eye on the sclera. The reflex is present if the action neuropathies associated with alcoholism, which occur in a glove- elicits a blink. Conditions such as a cerebrovascular accident or and-stocking distribution or over the entire hand or foot in areas coma might result in loss of this reflex, either unilaterally or bi- traditionally covered by a glove or sock. laterally. Loss of this reflex indicates the need for eye protection Assessment of the sensory system involves tests for tactile sen- and possible lubrication to prevent corneal damage. sation, superficial pain, vibration, and position sense (proprio- The gag reflex is elicited by gently touching the posterior phar- ception). During the sensory assessment, the patient’s eyes are ynx with a cotton-tipped applicator; first on one side of the uvula closed. Simple directions and reassurance that the examiner will and then the other. Positive response is an equal elevation of not hurt or startle the patient encourage the cooperation of the the uvula and “gag” with stimulation. Absent response on one or patient. both sides can be seen following a cerebrovascular accident and Tactile sensation is assessed by lightly touching a cotton wisp requires careful evaluation and treatment of the resultant swal- to corresponding areas on each side of the body. The sensitivity lowing dysfunction to prevent aspiration of food and fluids into of proximal parts of the extremities is compared with that of the lungs. distal parts. The plantar reflex is elicited by stroking the lateral side of the Pain and temperature sensations are transmitted together in foot with a tongue blade or the handle of a reflex hammer. the lateral part of the spinal cord, so it is unnecessary to test Stimulation normally causes toe flexion. Toe fanning (positive for temperature sense in most circumstances. Determining the Babinski) is an abnormal response and is discussed below patient’s sensitivity to a sharp object can assess superficial pain (O’Hanlon-Nichols, 1999). perception. The patient is asked to differentiate between the sharp and dull ends of a broken wooden cotton swab or tongue BABINSKI RESPONSE blade; using a safety pin is inadvisable because it breaks the integrity A well-known reflex indicative of central nervous system disease of the skin. Both the sharp and dull sides of the object are applied affecting the corticospinal tract is the Babinski reflex. In some- with equal intensity at all times, and as with the motor evaluation one with an intact central nervous system, if the lateral aspect of the two sides are compared. the sole of the foot is stroked, the toes contract and are drawn to- Vibration and proprioception are transmitted together in the gether (see Fig. 60-15E ). In patients who have central nervous posterior part of the cord. Vibration may be evaluated through system disease of the motor system, however, the toes fan out and the use of a low-frequency (128- or 256-Hz) tuning fork. The are drawn back. This is normal in newborns but represents a se- handle of the vibrating fork is placed against a bony prominence, rious abnormality in adults. Several other reflexes convey similar and the patient is asked whether he or she feels a sensation and is information. Many of them are interesting but not particularly instructed to signal the examiner when the sensation ceases. informative. Common locations used to test for vibratory sense include the distal joint of the great toe and the proximal thumb joint. If the Sensory Examination patient does not perceive the vibrations at the distal bony prominences, the examiner progresses upward with the tuning fork The sensory system is even more complex than the motor system until the patient perceives the vibrations. As with all measure- because sensory modalities are carried in different tracts located ments of sensation, a side-to-side comparison is made. in different portions of the spinal cord. The sensory examination Position sense or proprioception may be determined by ask- is largely subjective and requires the cooperation of the patient. ing the patient to close both eyes and indicate, as the great toe is The examiner should be familiar with dermatomes that represent alternately moved up and down, in which direction movement the distribution of the peripheral nerves that arise from the spinal has taken place. Vibration and position sense are often lost Chapter 60 Assessment of Neurologic Function 1841 together, frequently in circumstances in which all others remain Temperature Regulation and Pain Perception. Other manifesta- intact. tions of neurologic changes are related to temperature regulation Integration of sensation in the brain is evaluated next. This and pain. The elderly patient may feel cold more readily than heat may be performed by testing two-point discrimination—when and may require extra covering when in bed; a room temperature the patient is touched with two sharp objects simultaneously, are somewhat higher than usual may be desirable. Reaction to painful they perceived as two or as one? If touched simultaneously on op- stimuli may be decreased with age. Because pain is an important posite sides of the body, the patient should normally report being warning signal, caution must be used when hot or cold packs are touched in two places. If only one site is reported, the one not used. The older patient may be burned or suffer frostbite before being recognized is said to demonstrate extinction. Another test being aware of any discomfort. Complaints of pain, such as ab- of higher cortical sensory ability is stereognosis. The patient is in- dominal discomfort or chest pain, may be more serious than the structed to close both eyes and identify a variety of objects (eg, patient’s perception might indicate and thus require careful keys, coins) that are placed in one hand by the examiner. evaluation.

Gerontologic Considerations Taste and Smell Alterations. The acuity of the taste buds decreases with age; along with an altered olfactory sense, this may The nervous system undergoes many changes during the normal cause a decreased appetite and subsequent weight loss. Extra sea- aging process and is extremely vulnerable to general systemic ill- soning often increases food intake as long as it does not cause ness. Changes throughout the nervous system vary in degree as gastric irritation. A decreased sense of smell due to atrophy of the person ages. Nerve fibers that connect directly to muscles olfactory organs may present a safety hazard, because elderly show little decline in function with age, as do simple neurologic people living alone may be unable to detect household gas leaks functions that involve a number of connections in the spinal or fires. Smoke and carbon monoxide detectors, important for all, cord. Disease in the elderly often makes it difficult to distinguish are critical for the elderly. normal from abnormal changes. However, it is important for clinicians not to attribute abnormality or dysfunction to aging Tactile and Visual Alterations. Another neurologic alteration in without appropriate investigation (Kaye & Quinn, 2000). the elderly patient is the dulling of tactile sensation due to a decrease in the number of areas of the body responding to all stimuli Structural Changes. There are a number of alterations that occur and in the number and sensitivity of sensory receptors. There may with increasing age. Brain weight decreases, as does the number be difficulty in identifying objects by touch, and because fewer of synapses. A loss of neurons occurs in select regions of the brain. tactile cues are received from the bottom of the feet, the person There is a reduction in cerebral blood flow and metabolism. may get confused as to body position and location. Temperature regulation becomes less efficient. In the peripheral These factors, combined with sensitivity to glare, decreased nervous system, myelin is lost, resulting in a decrease in conduc- peripheral vision, and a constricted visual field, may result in dis- tion velocity in some nerves. There is an overall reduction in orientation, especially at night when there is little or no light in muscle bulk and the electrical activity within muscles. Taste buds the room. Because the elderly person takes longer to recover visual atrophy and nerve cell fibers in the olfactory bulb degenerate. sensitivity when moving from a light to dark area, night-lights and Nerve cells in the vestibular system of the inner ear, cerebellum, a safe and familiar arrangement of furniture are essential. and proprioceptive pathways also degenerate. Deep tendon reflexes can be decreased or in some cases absent. Hypothalamic Mental Status. Mental status is evaluated while the history is ob- function is modified such that stage IV sleep is reduced. There is tained, and areas of judgment, intelligence, memory, affect, mood, an overall slowing of autonomic nervous system responses. Pupil- orientation, speech, and grooming are assessed. Family members lary responses are reduced or may not appear at all in the presence who bring the patient to the attention of the health care provider of cataracts (Kaye & Quinn, 2000). may have noticed changes in the patient’s mental status. Drug toxicity should always be suspected as a causative factor when the Motor Alterations. There is an overall reduction in muscle bulk, patient has a change in mental status. Delirium (mental confu- with atrophy most easily noted in the hands (Kaye & Quinn, sion, usually with delusions and hallucinations) is seen in elderly 2000). Changes in motor function often result in a flexed posture, patients who have underlying central nervous system damage or shuffling gait, and rigidity of movement. These changes can create are experiencing an acute condition such as infection, adverse difficulties for the older person in maintaining or recovering bal- medication reaction, or dehydration. About 25% of patients over ance. Strength and agility are diminished, and reaction time and the age of 70 admitted to the hospital have delirium (Johnson, movement time are decreased. Repetitive movements and mild 2001). The cause is often reversible and treatable (as in drug toxi- tremors may be noted during an examination and may be of con- city, vitamin B deficiency, or thyroid disease). Depression may cern to the individual. Observation of gait may reveal a wide-based produce impairment of attention and memory. For elderly pa- gait with balance difficulties. tients, delirium, which is an acute change in mental status attributable to a treatable medical problem, must be differentiated Sensory Alterations. Sensory isolation due to visual and hearing from dementia, which is a chronic and irreversible deterioration loss can cause confusion, anxiety, disorientation, misinterpretation of cognitive status. of the environment, and feelings of inadequacy. Sensory alterations may require modification of the home environment, such Nursing Implications. Nursing care for patients with age-related as large-print reading materials or sound enhancement for the changes to the nervous system and for patients with long-term telephone, as well as extra orientation to new surroundings. neurologic disability who are aging should include the modifica- Simple explanations of routines, the location of the bathroom, tions previously described. In addition, the consequences of any and how to operate the call bell are just a few examples of infor- neurologic deficit and its impact on overall function such as ac- mation the elderly patient needs when hospitalized. tivities of daily living, use of assistive devices, and individual 1842 Unit 14 NEUROLOGIC FUNCTION coping need to be assessed and considered in planning care for ning, the number of disorders and injuries that can be diagnosed patients. is increasing. Patient teaching is also affected because the nurse must understand the altered responses and the changing needs of the el- Nursing Interventions derly patient before beginning to teach. When caring for the elderly patient, the nurse adapts activities such as preoperative Essential nursing interventions include preparation for the pro- teaching, diet therapy, and instruction about new medications, cedure and patient monitoring. Preparation includes teaching the their timing, and doses to the patient’s needs and capabilities. patient about the need to lie quietly throughout the procedure. A The nurse considers the presence of decline in fine motor move- review of relaxation techniques may be helpful for claustropho- ment and failing vision. When using visual materials for teaching bic patients. or menu selection, adequate lighting without glare, contrasting Sedation can be used if agitation, restlessness, or confusion colors, and large print are used to offset visual difficulties caused will interfere with a successful study (Hinkle, 1999a). Ongoing by rigidity and opacity of the lens in the eye and slower pupillary patient monitoring during sedation is necessary. If a contrast reaction. agent is used, the patient must be assessed before the CT scan for Procedures and preparations needed for diagnostic tests are ex- an iodine/shellfish allergy, as the contrast agent is iodine-based. plained, taking into account the possibility of impaired hearing An intravenous line for injection of the contrast agent and a pe- and slowed responses in the elderly. Even with hearing loss, the riod of fasting (usually 4 hours) are required prior to the study. elderly patient often hears adequately if the speaker uses a low- Patients who receive an intravenous or inhalation contrast agent pitched, clear voice; shouting only makes it harder for the patient are monitored during and after the procedure for allergic re- to understand the speaker. Providing auditory and visual cues actions and other side effects, including flushing, nausea, and aids understanding; if the patient has a significant hearing or vi- vomiting. sual loss, assistive devices, a signer, or a translator may be needed. Teaching at an unrushed pace and using reinforcement enhance learning and retention. Material should be short, concise, POSITRON EMISSION TOMOGRAPHY and concrete. Vocabulary is matched to the patient’s ability, and Positron emission tomography (PET) is a computer-based nu- terms are clearly defined. The elderly patient requires adequate clear imaging technique that produces images of actual organ time to receive and respond to stimuli, to learn, and to react. functioning. The patient either inhales a radioactive gas or is in- These measures allow comprehension, memory, and formation jected with a radioactive substance that emits positively charged of association and concepts. particles. When these positrons combine with negatively charged electrons (normally found in the body’s cells), the resultant gamma rays can be detected by a scanning device that produces a Diagnostic Evaluation series of two-dimensional views at various levels of the brain. This information is integrated by a computer and gives a composite COMPUTED TOMOGRAPHY SCANNING picture of the brain at work. Computed tomography (CT) makes use of a narrow x-ray beam PET permits the measurement of blood flow, tissue composi- to scan the head in successive layers. The images provide cross- tion, and brain metabolism and thus indirectly evaluates brain sectional views of the brain, with distinguishing differences in tis- function. The brain is one of the most metabolically active or- sue densities of the skull, cortex, subcortical structures, and gans, consuming 80% of the glucose the body uses. PET mea- ventricles. The brightness of each slice of the brain in the final sures this activity in specific areas of the brain and can detect image is proportional to the degree to which it absorbs x-rays. changes in glucose use. The image is displayed on an oscilloscope or TV monitor and is This test is useful in showing metabolic changes in the brain photographed and stored digitally (Hinkle, 1999a). (Alzheimer’s disease), locating lesions (brain tumor, epilepto- Lesions in the brain are seen as variations in tissue density dif- genic lesions), identifying blood flow and oxygen metabolism in fering from the surrounding normal brain tissue. Abnormalities patients with strokes, evaluating new therapies for brain tumors, of tissue indicate possible tumor masses, brain infarction, dis- and revealing biochemical abnormalities associated with mental placement of the ventricles, and cortical atrophy. Whole-body illness. The isotopes used have a very short half-life and are ex- CT scanners allow sections of the spinal cord to be visualized. pensive to produce, requiring specialized equipment for pro- The injection of a water-soluble iodinated contrast agent into the duction. PET scanning has been useful in research settings for subarachnoid space through lumbar puncture improves the visu- the last 20 years and is now becoming more available in clinical alization of the spinal and intracranial contents on these images. settings. Improvements in scanning itself and the production of The CT scan, along with magnetic resonance imaging (MRI), has isotopes, as well as the advent of reimbursement by third-party largely replaced myelography as a diagnostic procedure for the di- payers, has increased the availability of PET studies (Gjedde et agnosis of herniated lumbar disks. al., 2001). CT scanning is usually performed first without contrast material and then with intravenous contrast enhancement. The pa- Nursing Interventions tient lies on an adjustable table with the head held in a fixed position, while the scanning system rotates around the head and Key nursing interventions include patient preparation, which in- produces cross-sectional images. The patient must lie with the volves explaining the test and teaching the patient about inhala- head held perfectly still without talking or moving the face, be- tion techniques and the sensations (eg, dizziness, lightheadedness, cause head motion will distort the image. and headache) that may occur. The intravenous injection of the CT scanning is noninvasive and painless and has a high degree radioactive substance produces similar side effects. Relaxation ex- of sensitivity for detecting lesions. With advances in CT scan- ercises may reduce anxiety during the test. Chapter 60 Assessment of Neurologic Function 1843

SINGLE PHOTON EMISSION magnets in a magnetic field. In combination with radiofrequency COMPUTED TOMOGRAPHY pulses, the protons emit signals, which are converted to images. MRI has the potential for identifying a cerebral abnormality Single photon emission computed tomography (SPECT) is a earlier and more clearly than other diagnostic tests. It can provide three-dimensional imaging technique that uses radionuclides and information about the chemical changes within cells, allowing the instruments to detect single photons. It is a perfusion study that clinician to monitor a tumor’s response to treatment. It is partic- captures a moment of cerebral blood flow at the time of injection ularly useful in the diagnosis of multiple sclerosis and can describe of a radionuclide (Huntington, 1999). Gamma photons are emit- the activity and extent of disease in the brain and spinal cord. ted from a radiopharmaceutical agent administered to the patient MRI does not involve ionizing radiation. and are detected by a rotating gamma camera or cameras; the Several newer MRI techniques, including magnetic reso- image is sent to a minicomputer. This approach allows areas be- nance angiography (MRA), diffusion-weighted imaging (DWI), hind overlying structures or background to be viewed, greatly in- perfusion-weighted imaging (PWI), and fluid attenuation inver- creasing the contrast between normal and abnormal tissue. It is sion recovery (FLAIR), are becoming more widely used (Hinkle, relatively inexpensive, and the duration is similar to that of a CT 1999b; Shellock, 2001). The use of MRA allows visualization of scan. the cerebral vasculature without the administration of an arterial SPECT is useful in detecting the extent and location of ab- contrast agent. A substantial amount of research on the tech- normally perfused areas of the brain, thus allowing detection, lo- niques of DWI, PWI, and FLAIR shows promise for clearer calization, and sizing of stroke (before it is visible by CT scan), visualization and the early diagnosis of ischemic stroke (Hinkle, localization of seizure foci in epilepsy, and evaluation of perfu- 1999b). At present MRI is most valuable in the diagnosis of sion before and after neurosurgical procedures. Pregnancy and breastfeeding are contraindications to SPECT. nonacute conditions, as the test takes up to an hour to complete.

Nursing Interventions Nursing Interventions The nursing interventions for SPECT primarily include patient Patient preparation should include teaching relaxation tech- preparation and patient monitoring. Teaching about what to ex- niques and informing the patient that he or she will be able to talk pect before the test can allay anxiety and ensure patient coopera- to the staff by means of a microphone located inside the scanner. tion during the test. Premenopausal women are advised to Many MRI suites provide headphones so patients can listen to practice effective contraception before and for several days after the music of their choice during the procedure. testing, and the woman who is breastfeeding is instructed to stop Before the patient enters the room where the MRI is to be per- nursing for the period of time recommended by the nuclear med- formed, all metal objects and credit cards (the magnetic field can icine department. erase them) are removed. No metal objects may be brought into The nurse may need to accompany and monitor the patient the room where the MRI is located (Shellock, 2001): this in- during transport to the nuclear medicine department for the cludes oxygen tanks, traditional ventilators, or even stethoscopes. scan. Patients are monitored during and after the procedure for The magnetic field generated by the unit is so strong that any allergic reactions to the radiopharmaceutical agent. In a few metal-containing items will be strongly attracted and literally can institutions nurses with special education and training inject be pulled away with such force that they fly like projectiles toward the contrast agent before a SPECT scan (Fischbach, 2002; the magnet. There is a risk of severe injury and death; further- Huntington, 1999). more, damage to a very expensive piece of equipment may occur. A patient history is obtained to determine the presence of any MAGNETIC RESONANCE IMAGING metal objects (eg, aneurysm clips, orthopedic hardware, pace- makers, artificial heart valves, intrauterine devices). These objects Magnetic resonance imaging (MRI) uses a powerful magnetic could malfunction, be dislodged, or heat up as they absorb en- field to obtain images of different areas of the body (Fig. 60-16). ergy. Cochlear implants will be inactivated by MRI; therefore, This diagnostic test involves altering hydrogen ions in the body. other imaging procedures are considered. Placing the patient into a powerful magnetic field causes the hydrogen nuclei (protons) within the body to align like small NURSING ALERT For patient safety, the nurse must make sure no patient care equipment (eg, portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is ! located.

The patient lies on a ﬂat platform that is moved into a tube housing the magnet. The scanning process is painless, but the patient hears loud thumping of the magnetic coils as the magnetic ﬁeld is being pulsed. Because the MRI scanner is a narrow tube, patients may experience claustrophobia; sedation may be prescribed in these circumstances. Newer versions of MRI machines are less claustrophobic than the earlier devices and are available in some locations. However, the images produced on these machines are not optimal, and the traditional device is preferable for FIGURE 60-16 Technician explains what to expect during an MRI. accurate diagnosis. 1844 Unit 14 NEUROLOGIC FUNCTION

CEREBRAL ANGIOGRAPHY or other lesions. Water-based agents have replaced oil-based agents and their use has reduced side effects and complications; Cerebral angiography is an x-ray study of the cerebral circulation these agents disperse upward through the CSF. Myelography is with a contrast agent injected into a selected artery. Cerebral performed less frequently today because of the sensitivity of CT angiography is a valuable tool to investigate vascular disease, scanning and MRI (Hickey, 2003). aneurysms, and arteriovenous malformations. It is frequently performed before craniotomy to assess the patency and adequacy of the cerebral circulation and to determine the site, size, and nature Nursing Interventions of the pathologic processes (Fischbach, 2002; Frizzell, 1998). Because many patients have misconceptions about this proce- Most cerebral angiograms are performed by threading a catheter dure, the nurse clarifies the explanation given by the physician through the femoral artery in the groin and up to the desired ves- and answers questions. The patient is informed about what to ex- sel. Alternatively, direct puncture of the carotid or vertebral artery pect during the procedure and should be aware that changes in or retrograde injection of a contrast agent into the brachial artery position may be made during the procedure. The meal that nor- may be performed. mally would be eaten before the procedure is omitted. A sedative In digital subtraction angiography (DSA), x-ray images of the may be prescribed to help the patient cope with this rather area in question are obtained before and after the injection of a lengthy test. Patient preparation for lumbar puncture is discussed contrast agent. The computer analyzes the differences between the later in this chapter. two images and produces an enhanced image of the carotid and After myelography, the patient lies in bed with the head of the vertebral arterial systems. The injection for a DSA can be given bed elevated 30 to 45 degrees. The patient is advised to remain through a peripheral vein (Fischbach, 2002; Rowland, 2000). in bed in the recommended position for 3 hours or as prescribed by the physician. The patient is encouraged to drink liberal Nursing Interventions amounts of fluid for rehydration and replacement of CSF and to decrease the incidence of postlumbar puncture headache. The The patient should be well hydrated, and clear liquids are usually blood pressure, pulse, respiratory rate, and temperature are mon- permitted up to the time of a regular arteriogram or DSA. Before itored, as well as the patient’s ability to void. Untoward signs in- going to the x-ray department, the patient is instructed to void. clude headache, fever, stiff neck, photophobia (sensitivity to The locations of the appropriate peripheral pulses are marked light), seizures, and signs of chemical or bacterial meningitis. with a felt-tip pen. The patient is instructed to remain immobile during the angiogram process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in the jaw, teeth, NONINVASIVE CAROTID FLOW STUDIES tongue, and lips, and a metallic taste when the contrast agent is Noninvasive carotid flow studies use ultrasound imagery and injected. Doppler measurements of arterial blood flow to evaluate carotid and After the groin is shaved and prepared, a local anesthetic is ad- deep orbital circulation. The graph produced indicates blood ve- ministered to prevent pain at the insertion site and to reduce ar- locity. Increased blood velocity can indicate stenosis or partial ob- terial spasm. A catheter is introduced into the femoral artery, struction. These tests are often obtained before arteriography, flushed with heparinized saline, and filled with contrast agent. which carries a higher risk of stroke or death (Fischbach, 2002; Fluoroscopy is used to guide the catheter to the appropriate ves- Hickey, 2003). Carotid Doppler, carotid ultrasonography, oculo- sels. During injection of the contrast agent, images are made of plethysmography, and ophthalmodynamometry are four common the arterial and venous phases of circulation through the brain. noninvasive vascular techniques that permit evaluation of arterial Nursing care after cerebral angiography includes observation blood flow and detection of arterial stenosis, occlusion, and plaques. for signs and symptoms of altered cerebral blood flow. In some instances, patients may experience major or minor arterial blockage due to embolism, thrombosis, or hemorrhage, producing a TRANSCRANIAL DOPPLER neurologic deficit. Signs of such an occurrence include alterations Transcranial Doppler uses the same noninvasive techniques as in the level of responsiveness and consciousness, weakness on one carotid flow studies except that it records the blood flow veloci- side of the body, motor or sensory deficits, and speech distur- ties of the intracranial vessels. Flow velocities of the basal artery bances. Therefore, it is necessary to observe the patient frequently can be measured through thin areas of the temporal and occipi- for these signs and to report them immediately if they occur. tal bones of the skull. A hand-held Doppler probe emits a pulsed The injection site is observed for hematoma formation (a lo- beam; the signal is reflected by the moving red blood cells within calized collection of blood), and an ice bag may be applied inter- the blood vessels (Falyar, 1999). Transcranial Doppler sonogra- mittently to the puncture site to relieve swelling and discomfort. phy is a noninvasive technique that is helpful in assessing va- Because a hematoma at the puncture site or embolization to a dis- sospasm (a complication following subarachnoid hemorrhage), tant artery affects the peripheral pulses, these pulses are moni- altered cerebral blood flow found in occlusive vascular disease or tored frequently. The color and temperature of the involved stroke, and other cerebral pathology. extremity are assessed to detect possible embolism. Nursing Interventions MYELOGRAPHY When a carotid flow study or transcranial Doppler is scheduled, A myelogram is an x-ray of the spinal subarachnoid space taken the procedure is described to the patient. The patient is informed after the injection of a contrast agent into the spinal subarachnoid that this is a noninvasive test, that a hand-held transducer will be space through a lumbar puncture. It outlines the spinal sub- placed over the neck and orbits of the eyes, and that some type of arachnoid space and shows any distortion of the spinal cord or water-soluble jelly is used on the transducer. Either one of these spinal dural sac caused by tumors, cysts, herniated vertebral disks, low-risk tests can be performed at the patient’s bedside. Chapter 60 Assessment of Neurologic Function 1845 ELECTROENCEPHALOGRAPHY EVOKED POTENTIAL STUDIES An electroencephalogram (EEG) represents a record of the elec- In evoked potential studies, electrodes are applied to the scalp and trical activity generated in the brain. It is obtained through elec- an external stimulus is applied to peripheral sensory receptors to trodes applied on the scalp or through microelectrodes placed elicit changes in the brain waves. Evoked changes are detected within the brain tissue. It provides a physiologic assessment of with the aid of computerized devices that extract the signal, dis- cerebral activity. play it on an oscilloscope, and store the data on magnetic tape or The EEG is a useful test for diagnosing and evaluating seizure disk. These studies are based on the concept that any insult or dys- disorders, coma, or organic brain syndrome. Tumors, brain ab- function that can alter neuronal metabolism or disturb membrane scesses, blood clots, and infection may cause abnormal patterns function may change evoked responses in brain waves. In neuro- in electrical activity. The EEG is also used in making a determi- logic diagnosis, they reflect conduction times in the peripheral nation of brain death. nervous system. In clinical practice, the visual, auditory, and Electrodes are applied to the scalp to record the electrical ac- somatosensory systems are most often tested. tivity in various regions of the brain. The amplified activity of the In visual evoked responses, the patient looks at a visual stimu- neurons between any two of these electrodes is recorded on con- lus (flashing lights, a checkerboard pattern on a screen). The av- tinuously moving paper; this record is called the encephalogram. erage of several hundred stimuli is recorded by EEG leads placed For a baseline recording, the patient lies quietly with both eyes over the occiput. The transit time from the retina to the occipital closed. The patient may be asked to hyperventilate for 3 to 4 min- area is measured using computer-averaging methods. utes and then look at a bright, flashing light for photic stimulation. Auditory evoked responses or brain stem evoked responses are These activation procedures are performed to evoke abnormal elec- measured by applying an auditory stimulus (a repetitive auditory trical discharges, such as seizure potentials. A sleep EEG may be click) and measuring the transit time up the brain stem into the recorded after sedation because some abnormal brain waves are cortex. Specific lesions in the auditory pathway modify or delay seen only when the patient is asleep. If the epileptogenic area is the response. inaccessible to conventional scalp electrodes, nasopharyngeal elec- In somatosensory evoked responses, the peripheral nerves are trodes may be used. stimulated (electrical stimulation through skin electrodes) and Depth recording of EEG is performed by introducing elec- the transit time up the spinal cord to the cortex is measured and trodes stereotactically (radiologically placed using instrumentation) recorded from scalp electrodes. into a target area of the brain, as indicated by the patient’s seizure This test is used to detect a deficit in spinal cord conduction pattern and scalp EEG. It is used to identify patients who may and to monitor spinal cord function during operative procedures. benefit from surgical excision of epileptogenic foci. Because myelinated fibers conduct impulses at a higher rate of Special transsphenoidal, mandibular, and nasopharyngeal elec- speed, nerves with an intact myelin sheath record the highest ve- trodes can be used, and video recording combined with EEG locity. Demyelination of nerve fibers leads to a decrease in speed monitoring and telemetry is used in hospital settings to capture of conduction, as found in Guillain-Barré syndrome, multiple epileptiform abnormalities and their sequelae. Some epilepsy cen- sclerosis, and polyneuropathies. ters provide long-term ambulatory EEG monitoring with portable recording devices. Nursing Interventions There is no specific patient preparation other than to explain the Nursing Interventions procedure and to reassure the patient and encourage him or her to To increase the chances of recording seizure activity, it is some- relax. The patient is advised to remain perfectly still throughout the times recommended that the patient be deprived of sleep on the recording to prevent artifacts (signals not generated by the brain) night before the EEG. Antiseizure agents, tranquilizers, stimu- that interfere with the recording and interpretation of the test. lants, and depressants should be withheld 24 to 48 hours before an EEG because these medications can alter the EEG wave pat- ELECTROMYOGRAPHY terns or mask the abnormal wave patterns of seizure disorders (Hickey, 2003). Coffee, tea, chocolate, and cola drinks are omit- An electromyogram (EMG) is obtained by introducing needle ted in the meal before the test because of their stimulating effect. electrodes into the skeletal muscles to measure changes in the The meal is not omitted, however, because an altered blood glu- electrical potential of the muscles and the nerves leading to them. cose level can also cause changes in the brain wave patterns. The electrical potentials are shown on an oscilloscope and am- The patient is informed that the standard EEG takes 45 to plified by a loudspeaker so that both the sound and appearance 60 minutes, 12 hours for a sleep EEG. The patient is assured that of the waves can be analyzed and compared simultaneously. the procedure does not cause an electric shock and that the EEG An EMG is useful in determining the presence of a neuro- is a diagnostic test, not a form of treatment. An EEG requires pa- muscular disorder and myopathies. They help to distinguish tient cooperation and ability to lie quietly during the test. Seda- weakness due to neuropathy (functional or pathologic changes tion is not advisable as it may lower the seizure threshold in in the peripheral nervous system) from weakness due to other patients with a seizure disorder and alter brain wave activity in all causes. patients. Patients with seizures do not stop taking their antiseizure medication prior to testing. Nursing Interventions Routine EEGs use a water-soluble lubricant for electrode contact, which at the conclusion of the study can be wiped off and The procedure is explained and the patient is warned to expect a removed by shampooing. Sleep EEGs involve the use of col- sensation similar to that of an intramuscular injection as the nee- lodion glue for electrode contact, which requires acetone for dle is inserted into the muscle. The muscles examined may ache removal. for a short time after the procedure. 1846 Unit 14 NEUROLOGIC FUNCTION

NERVE CONDUCTION STUDIES the result if the specimens are allowed to stand. (See Appendix B for the normal values of CSF.) Nerve conduction studies are performed by stimulating a peripheral nerve at several points along its course and recording the muscle action potential or the sensory action potential that re- Post–Lumbar Puncture Headache sults. Surface or needle electrodes are placed on the skin over the A post–lumbar puncture headache, ranging from mild to severe, nerve to stimulate the nerve fibers. This test is useful in the study may appear a few hours to several days after the procedure. This of peripheral neuropathies. is the most common complication, occurring in 15% to 30% of patients (Connolly, 1999). It is a throbbing bifrontal or occipital headache, dull and deep in character. It is particularly severe on LUMBAR PUNCTURE AND EXAMINATION sitting or standing but lessens or disappears when the patient lies OF CEREBROSPINAL FLUID down. The headache is caused by CSF leakage at the puncture site. A lumbar puncture (spinal tap) is carried out by inserting a nee- The fluid continues to escape into the tissues by way of the dle into the lumbar subarachnoid space to withdraw CSF. The needle track from the spinal canal. It is then absorbed promptly test may be performed to obtain CSF for examination, to mea- by the lymphatics. As a result of this leak, the supply of CSF in sure and reduce CSF pressure, to determine the presence or ab- the cranium is depleted to a point at which it is insufficient to sence of blood in the CSF, to detect spinal subarachnoid block, maintain proper mechanical stabilization of the brain. This and to administer antibiotics intrathecally (into the spinal canal) leakage of CSF allows settling of the brain when the patient as- in certain cases of infection. sumes an upright position, producing tension and stretching The needle is usually inserted into the subarachnoid space be- the venous sinuses and pain-sensitive structures. Both traction tween the third and fourth or fourth and fifth lumbar vertebrae. and pain are lessened and the leakage is reduced when the pa- Because the spinal cord divides into a sheaf of nerves at the first tient lies down. lumbar vertebra, insertion of the needle below the level of the Post–lumbar puncture headache may be avoided if a small- third lumbar vertebra prevents puncture of the spinal cord. gauge needle is used and if the patient remains prone after the A successful lumbar puncture requires that the patient be re- procedure. When a large volume of fluid (more than 20 mL) is laxed; an anxious patient is tense, and this may increase the pres- removed, the patient is positioned prone for 2 hours, then flat in sure reading. CSF pressure with the patient in a lateral recumbent a side-lying position for 2 to 3 hours, and then supine or prone position is normally 70 to 200 mm H2O. Pressures of more than for 6 more hours. Keeping the patient flat overnight may reduce 200 mm H2O are considered abnormal. the incidence of headaches. A lumbar puncture may be risky in the presence of an in- The postpuncture headache is usually managed by bed rest, tracranial mass lesion because intracranial pressure is decreased by analgesic agents, and hydration (Connolly, 1999). Occasionally, the removal of CSF, and the brain may herniate downward if the headache persists, the epidural blood patch technique may through the tentorium and the foramen magnum. be used. Blood is withdrawn from the antecubital vein and injected into the epidural space, usually at the site of the previous spinal puncture. The rationale is that the blood acts as a gelati- Queckenstedt’s Test nous plug to seal the hole in the dura, preventing further loss of CSF. A lumbar manometric test (Queckenstedt’s test) may be performed by compressing the jugular veins on each side of the neck during the lumbar puncture. The increase in pressure caused by Other Complications of Lumbar Puncture the compression is noted; then the pressure is released and pressure readings are made at 10-second intervals. Normally, CSF Herniation of the intracranial contents, spinal epidural abscess, pressure rises rapidly in response to compression of the jugular spinal epidural hematoma, and meningitis are rare but serious veins and returns quickly to normal when the compression is re- complications of lumbar puncture. Other complications include leased. A slow rise and fall in pressure indicates a partial block due temporary voiding problems, slight elevation of temperature, to a lesion compressing the spinal subarachnoid pathways. If backache or spasms, and stiffness of the neck. there is no pressure change, a complete block is indicated. This test is not performed if an intracranial lesion is suspected. HOME AND COMMUNITY-BASED CARE See Chart 60-4 for nursing guidelines for assisting with a lumbar puncture. Teaching Patients Self-Care Many diagnostic tests that were once performed as part of a hos- Cerebrospinal Fluid Analysis pital stay are now carried out in short-procedure units or outpatient testing settings or units. As a result, family members The CSF should be clear and colorless. Pink, blood-tinged, or often provide the postprocedure care. Therefore, the patient and grossly bloody CSF may indicate a cerebral contusion, laceration, family must receive clear verbal and written instructions about or subarachnoid hemorrhage. Sometimes with a difficult lumbar precautions to take after the procedure, complications to watch puncture, the CSF initially is bloody because of local trauma but for, and steps to take if complications occur. Because many pa- then becomes clearer. tients undergoing neurologic diagnostic studies are elderly or Usually, specimens are obtained for cell count, culture, and have neurologic deficits, provisions must be made to ensure that glucose and protein testing. The specimens should be sent to the transportation and postprocedure care and monitoring are avail- laboratory immediately because changes will take place and alter able. Chapter 60 Assessment of Neurologic Function 1847 Chart 60-4 Guidelines for Assisting with a Lumbar Puncture A needle is inserted into the subarachnoid space through the third and fourth or fourth and fifth lumbar inter- face to withdraw spinal fluid. Preprocedure 5. The nurse describes the procedure step by step to the patient as 1. Determine whether written consent for the procedure has been it proceeds. obtained. 6. The physician cleanses the puncture site with an antiseptic solu- 2. Explain the procedure to the patient and describe sensations that tion and drapes the site. are likely during the procedure (ie, a sensation of cold as the site 7. Local anesthetic is injected to numb the puncture site, and is cleansed with solution, a needle prick when local anesthetic is then a spinal needle is inserted into the subarachnoid space injected). through the third and fourth or fourth and fifth lumbar 3. Determine whether the patient has any questions or misconcep- interspace. tions about the procedure; reassure the patient that the needle 8. A specimen of CSF is removed and usually collected in three test will not enter the spinal cord or cause paralysis. tubes, labeled in order of collection. A pressure reading may be 4. Instruct the patient to void before the procedure. obtained. The needle is withdrawn. Procedure (performed by the physician) 9. A small dressing is applied to the puncture site. 1. The patient is positioned on one side at the edge of the bed or 10. The tubes of CSF are sent to the laboratory immediately. examining table with back toward the physician; the thighs and Postprocedure legs are flexed as much as possible to increase the space between 1. Instruct the patient to lie prone for 2 to 3 hours to separate the the spinous processes of the vertebrae, for easier entry into the alignment of the dural and arachnoid needle punctures in the subarachnoid space. meninges, to reduce leakage of CSF.

Third lumbar vertebra

Dura mater Subarachnoid space Cauda equina

2. A small pillow may be placed under the patient’s head to maintain the spine in a horizontal position; a pillow may be placed between the legs to prevent the upper leg from rolling forward. 3. The nurse assists the patient to maintain the position to 2. Monitor the patient for complications of lumbar puncture; avoid sudden movement, which can produce a traumatic notify physician if complications occur. (bloody) tap. 3. Encourage increased ﬂuid intake to reduce the risk of post- 4. The patient is encouraged to relax and is instructed to breathe procedure headache. normally, because hyperventilation may lower an elevated pressure.

Continuing Care Critical Thinking Exercises Contacting the patient and family after diagnostic testing enables ?? the nurse to determine whether they have any questions about the procedure or whether the patient had any untoward results. During 1. A 68-year old patient with a long history of type 1 dia- these phone calls, teaching is reinforced and the patient and fam- betes is admitted to the hospital to rule out an ischemic ily are reminded to make and keep follow-up appointments. stroke and is scheduled for an MRI. Explain why the MRI Patients, family members, and health care providers are focused is indicated for this patient and what, if any, precautions on the immediate needs, issues, or deﬁcits that necessitated the must be taken because this patient is diabetic. What nursing diagnostic testing. This is also a good time to remind them of the observations and assessments are indicated because of the need for and importance of continuing health promotion and occurrence of these two disorders? What safety precautions screening practices and make referrals to appropriate health care are essential in the MRI suite, and why? providers. 1848 Unit 14 NEUROLOGIC FUNCTION

2. Your clinic patient will be having an EEG. Describe the Rowland, L. (2000). Merritts’ neurology (10th ed.). Philadelphia: Lippin- procedure, its duration, and preparation for this test, includ- cott Williams & Wilkins. ing medication/diet restrictions, if any. How would the pres- Shellock, F. (2001). Magnetic resonance procedures: Health effects and safety. New York: CRC Press. ence of a seizure disorder alter your plan of care? Stewart-Amidei, C., & Kunkel, J. (2001). AANN’s neuroscience nursing: 3. Your patient is scheduled to undergo digital subtraction Human responses to neurologic dysfunction (2nd ed.). Philadelphia: angiography (DSA). He tells you that he recently had an W. B. Saunders. angiogram. What explanation can you give to the patient Weiner, L., Levitt, L. P., Rae-Grant, A., & Weiner, H. L. (1999). Neu- and his wife regarding the difference between the two pro- rology (6th ed.). Philadelphia: Lippincott Williams & Wilkins. cedures? What additional information will help prepare the Journals patient to undergo this procedure? Asterisks indicate nursing research articles. Bateman, D. (2001). Neurological assessment of coma. Journal of Neu- rology, Neurosurgery and Psychiatry, 71, Suppl 1, i13–i17. Blows, W. (2000). Neurotransmitters of the brain: Serotonin noradrenaline, norepinephrine, and dopamine.Journal of Neuroscience Nurs- ing, 32(4), 234–238. REFERENCES AND SELECTED READINGS Connolly, M. (1999). Postdural puncture headache. American Journal of Nursing, 99(11), 48–49. Books Cunning, S. (1999). Preventing secondary brain injuries. Dimensions in Bickley, L. S. & Szilagyi, P. G. (1999). Bates’ guide to physical examina- Critical Care Nursing, 18(5), 20–22. tion and history taking (7th ed.). Philadelphia: Lippincott Williams Downey, D., & Leigh R. (1998). Eye movements: Pathophysiology, ex- & Wilkins. amination and clinical importance. Journal of Neuroscience Nursing, Bradley, W., Daroff, R., Fenichel, R., & Marsden, C. (Eds.). (2000). 30(1), 15–24. Neurology in clinical practice (vol. II, 3d ed.). Boston: Butterworth Falyar, C. (1999). Using transcranial Doppler sonography to augment Heineman. the neurology examination after aneurysmal subarachnoid hemor- Fischbach, F. (2002). Common laboratory and diagnostic tests (3d ed.). rhage. Journal of Neuroscience Nursing, 31(5), 285–293. Philadelphia: Lippincott Williams & Wilkins. Frizzell, J. (1998). Cerebral angiography. American Journal of Nursing, Gilman, S. (1999). Clinical examination of the nervous system. New York: 98(9), 16II-16JJ. McGraw-Hill. Hinkle, J. (1999a). CT scanning. American Journal of Nursing, 99(6), Gjedde, A., Hansen, S., Knudsen, G., & Paulson, O. (Eds.). (2001). 24AA–24FF. Physiological imaging of the brain with PET. San Diego: Academic Hinkle, J. (1999b). Magnetic resonance imaging. American Journal of Press. Nursing, 99(11), 24CC–24JJ. Goetz, C. G., & Pappert, E. J. (1999). Textbook of clinical neurology. Huntington, N. (1999). The nurse’s role in delivery of radioisotope for Philadelphia: W. B. Saunders. ictal SPECT scan. Journal of Neuroscience Nursing, 31(4), 208–215. Greenberg, D. A., Aminoff, M., & Simon, R. (2002). Clinical neurology Johnson, M. (2001). Assessing confused patients. Journal of Neurology, (5th ed.). Stamford, CT: Lange Medical Books, McGraw Hill. Neurosurgery and Psychiatry, 71, Suppl. 1, i7–i12. Herndon, R. M. (1997). Handbook of neurological rating scales. New King, D. (1999). Central nervous system infections: Basic concepts. York: Demos Vermande. Nursing Clinics of North America, 34(3), 761–771. Hickey, J. (2003). Clinical practice of neurologic and neurosurgical nurs- O’Hanlon-Nichols, T. (1999). Neurologic assessment. American Jour- ing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. nal of Nursing, 99(6), 44–50. Joynt, R., Griggs, R., & Haerer, A. (2000). Baker’s clinical neurology on *Rapp, C., Wakeﬁeld, B., Kundrat, M., et al. (2000). Acute confusion CD-ROM. Philadelphia: Lippincott Williams & Wilkins. assessment instruments: Clinical versus research usability. Applied Kaye, J., & Quinn, J. (2000). Clinical changes associated with normal Nursing Research, 13(1), 37–45. aging. In C. M. Clark & J. Trojanowski (eds.), Neurodegenerative *Souder, E., & O’Sullivan, P. (2000). Nursing documentation versus dementias. New York: McGraw-Hill. standardized assessment of cognitive status in hospitalized medical Loeser, J., Butler, S. H., Chapman, P. C., et al. (ed.). (2000). Bonica’s patients. Applied Nursing Research, 13(1), 29–36. management of pain (3d ed.). Philadelphia: Lippincott Williams & Stewart-Amidei, C. (1998). Neurologic monitoring in the ICU. Criti- Wilkins. cal Care Nursing Quarterly, 21(3), 47–60. Lueckenotte, A. (2000). Gerontological nursing (2d ed.). St Louis: Sullivan, J. (1999). Determining brain death. Critical Care Nursing, Mosby. 19(2), 37–46. Chapter 61Chapter ● Management of Patients With Neurologic Dysfunction

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Describe the special nursing needs of patients with varied neurologic dysfunction. 2. Describe the multiple needs of the patient with altered level of consciousness. 3. Use the nursing process as a framework for care of the patient with altered level of consciousness. 4. Identify the early and late clinical manifestations of increased intracranial pressure. 5. Use the nursing process as a framework for care of the patient with increased intracranial pressure. 6. Describe the needs of the patient undergoing intracranial or transsphenoidal surgery. 7. Use the nursing process as a framework for care of the patient undergoing intracranial/transsphenoidal surgery. 8. Identify the various types and causes of seizures. 9. Use the nursing process to develop a plan of care for the patient experiencing seizures. 10. Identify the needs of the patient experiencing headaches.

1849 1850 Unit 14 NEUROLOGIC FUNCTION This chapter discusses care of the patient with an altered level Some conditions can be treated and neurologic impairments can of consciousness, the patient with increased intracranial pres- be reversed; others result in permanent deficits. sure (ICP), and the patient undergoing neurosurgical procedures, Although neuroscience nursing is a specialty requiring an un- experiencing seizures, or experiencing headaches. Some of the derstanding of neuroanatomy, neurophysiology, neurodiagnostic topics in this chapter, such as headaches and seizures, may be testing, critical care nursing, and rehabilitation nursing, nurses in symptoms of dysfunction in another body system. Conversely, all settings care for patients with neurologic disorders. Ongoing headaches and seizures can be quite serious symptoms of a severe assessment of the patient’s neurologic function and health needs, disruption of the neurologic system. These disorders can also be identification of problems, mutual goal setting, development and diagnosed at times as “idiopathic,” or without an identifiable implementation of care plans (including teaching, counseling, cause. The commonality in these disorders is not in the diagno- and coordinating activities), and evaluation of the outcomes of sis or the medical treatment; it is in the behaviors and needs of care are nursing actions integral to the recovery of the patient. the patient and the manner in which nurses can best support the The nurse also collaborates with other members of the health care patient through these episodes. team to provide essential care, offer a variety of solutions to prob- The central nervous system contains a vast network of neurons lems, help patients and families gain control of their lives, and ex- controlling the body’s vital functions. Yet this system is vulnerable, plore the educational and supportive resources available in the and its optimal function depends on several key factors. First, the community. The goals are to achieve as high a level of function neurologic system relies on its own structural integrity for sup- as possible and to enhance the quality of life for the patient with port and homeostasis. Examples of structural disruption include neurologic impairment and his or her family. head injury, brain tumor, intracranial hemorrhage, infection, and stroke. As brain tissue expands in the inflexible cranium, ICP rises Altered Level of Consciousness and cerebral perfusion is impaired. Further expansion places pressure on vital centers, which can cause permanent neurologic An altered level of consciousness (LOC) is apparent in the pa- deficits or lead to brain death. tient who is not oriented, does not follow commands, or needs Second, the neurologic system also relies on the body’s ability persistent stimuli to achieve a state of alertness. LOC is gauged to maintain a homeostatic environment. It requires the body to on a continuum with a normal state of alertness and full cognition deliver the essential elements of oxygen and glucose and to filter (consciousness) on one end and coma on the other end. Coma is out substrates toxic to the neurons. Sepsis, hypovolemia, myo- a clinical state of unconsciousness in which the patient is unaware cardial infarction, respiratory arrest, hypoglycemia, electrolyte of self or the environment for prolonged periods (days to months imbalance, drug and/or alcohol overdose, encephalopathy, and or even years). Akinetic mutism is a state of unresponsiveness to ketoacidosis are all examples of circumstances in which the neuro- the environment in which the patient makes no movement or logic system is depressed due to a toxic metabolic effect or due to sound but sometimes opens the eyes. Persistent vegetative state the body’s mechanical inability to provide essential substrates. is a condition in which the patient is described as wakeful but de- Glossary akinetic mutism: unresponsiveness to the acterized by extreme extension of the the cranial contents—brain tissue, blood, environment; the patient makes no move- upper and lower extremities or CSF—causes a change in the volume of ment or sound but sometimes opens the decortication: an abnormal posture associ- the others eyes ated with severe brain injury, character- persistent vegetative state: condition in altered level of consciousness: condition of ized by abnormal flexion of the upper which the patient is wakeful but devoid being less responsive to and aware of envi- extremities and extension of the lower of conscious content, without cognitive or ronmental stimuli extremities affective mental function autoregulation: ability of cerebral blood epidural monitor: a sensor placed between primary headache: a headache for which no vessels to dilate or constrict to maintain the skull and the dura to monitor intra- specific organic cause can be found stable cerebral blood flow despite changes cranial pressure seizures: paroxysmal transient disturbance in systemic arterial blood pressure epilepsy: a group of syndromes character- of the brain resulting from a discharge of ized by paroxysmal transient disturbances brain death: irreversible loss of all functions abnormal electrical activity of brain function. of the entire brain, including the brain stem status epilepticus: episode in which the coma: prolonged state of unconsciousness fiberoptic monitor: a system that uses light patient experiences multiple seizure bursts craniotomy: a surgical procedure that in- refraction to determine intracranial with no recovery time in between volves entry into the cranial vault pressure craniectomy: a surgical procedure that in- herniation: abnormal protrusion of tissue secondary headache: headache identified as volves removing a portion of the skull through a defect or natural opening a symptom of another organic disorder Cushing’s response: brain’s attempt to intracranial pressure: pressure exerted by (eg, brain tumor, hypertension) restore blood flow by increasing arterial the volume of the intracranial contents subarachnoid screw or bolt: device placed pressure to overcome the increased within the cranial vault into the subarachnoid space to measure intracranial pressure migraine headache: a severe, unrelenting intracranial pressure Cushing’s triad: three classic signs— headache often accompanied by symp- transsphenoidal: surgical approach to the bradycardia, hypertension, and toms such as nausea, vomiting, and visual pituitary via the sphenoid sinuses bradypnea— seen with pressure on the disturbances ventriculostomy: a catheter placed in one medulla as a result of brain stem herniation Monro-Kellie hypothesis: theory that states of the lateral ventricles of the brain to decerebration: an abnormal body posture that due to limited space for expansion measure intracranial pressure and allow associated with a severe brain injury, char- within the skull, an increase in any one of for drainage of fluid Chapter 61 Management of Patients With Neurologic Dysfunction 1851 void of conscious content, without cognitive or affective mental If the patient is comatose, with localized signs such as abnor- function. The level of responsiveness and consciousness is the mal pupillary and motor responses, it is assumed that neurologic most important indicator of the patient’s condition. disease is present until proven otherwise. If the patient is comatose and pupillary light reflexes are preserved, a toxic or metabolic dis- Pathophysiology order is suspected. Procedures used to identify the cause of unconsciousness in- Altered LOC is not a disorder itself; rather, it is a function and clude scanning, imaging, tomography (eg, computed tomogra- symptom of multiple pathophysiologic phenomena. The cause phy, magnetic resonance imaging, positron emission tomography), may be neurologic (head injury, stroke), toxicologic (drug over- and electroencephalography. Laboratory tests include analysis of dose, alcohol intoxication), or metabolic (hepatic or renal failure, blood glucose, electrolytes, serum ammonia, and blood urea ni- diabetic ketoacidosis). trogen levels, as well as serum osmolality, calcium level, and par- The underlying causes of neurologic dysfunction are disrup- tial thromboplastin and prothrombin times. Other studies may tion in the cells of the nervous system, neurotransmitters, or brain be used to evaluate serum ketones and alcohol, drug levels, and anatomy (see Chap. 60). arterial blood gas levels. A disruption in the basic functional units (neurons) or neurotransmitters results in faulty impulse transmission, impeding Complications communication within the brain or from the brain to other parts of the body. These disruptions are caused by cellular edema and Potential complications for the patient with altered LOC include other mechanisms such as antibodies disrupting chemical trans- respiratory failure, pneumonia, pressure ulcers, and aspiration. mission at receptor sites. Respiratory failure may develop shortly after the patient becomes Intact anatomic structures of the brain are needed for proper unconscious. If the patient cannot maintain effective respirations, function. The two hemispheres of the cerebrum must communi- supportive care is initiated to provide adequate ventilation. Pneu- cate, via an intact corpus callosum, and the lobes of the brain monia is common in patients receiving mechanical ventilation or (frontal, parietal, temporal, and occipital) must communicate in those who cannot maintain and clear the airway. The patient and coordinate their specific functions (see Chap. 60). Additional with altered LOC is subject to all the complications associated anatomic structures of importance are the cerebellum and the with immobility, such as pressure ulcers, venous stasis, muscu- brain stem. The cerebellum has both excitatory and inhibitory ac- loskeletal deterioration, and disturbed gastrointestinal function- tions and is largely responsible for coordination of movement. ing. Pressure ulcers may become infected and act as a source of The brain stem contains areas that control the heart, respiration, sepsis. Aspiration of gastric contents or feedings may occur, pre- and blood pressure. Disruptions in the anatomic structures are cipitating the development of pneumonia or airway occlusion. caused by trauma, edema, pressure from tumors as well as other mechanisms such as an increase or decrease in blood or cerebro- Medical Management spinal fluid (CSF) circulation. The first priority of treatment for the patient with altered LOC Clinical Manifestations is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Alterations in LOC occur along a continuum, and the clinical Until the patient’s ability to breathe on his or her own is deter- manifestations depend on where the patient is along this con- mined, a mechanical ventilator is used to maintain adequate oxy- tinuum. As the patient’s state of alertness and consciousness genation. The circulatory status (blood pressure, heart rate) is decreases, there will be changes in the pupillary response, eye open- monitored to ensure adequate perfusion to the body and brain. ing response, verbal response, and motor response. Initial changes An intravenous catheter is inserted to provide access for fluids and may be reflected by subtle behavioral changes such as restlessness intravenous medications. Neurologic care focuses on the specific or increased anxiety. The pupils, normally round and quickly re- neurologic pathology, if any. Nutritional support, using either a active to light, become sluggish (response is slower); as the patient feeding tube or a gastrostomy tube, is initiated as soon as possi- becomes comatose, the pupils become fixed (no response to light). ble. In addition to measures to determine and treat the under- The patient in a coma does not open the eyes, respond verbally, lying causes of altered LOC, other medical interventions are aimed or move the extremities in response to a request to do so. at pharmacologic management of complications and strategies to prevent complications. Assessment and Diagnostic Findings NURSING PROCESS: The patient with an altered LOC is at risk for alterations in every THE PATIENT WITH AN ALTERED LEVEL body system. A complete assessment is performed, with particular attention to the neurologic system. The neurologic examina- OF CONSCIOUSNESS tion should be as complete as the LOC allows. It includes an Assessment evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sen- Where to begin assessing the patient with an altered LOC de- sory function. LOC, a sensitive indicator of neurologic function, pends somewhat on each patient’s circumstances, but clinicians is assessed based on the criteria in the Glasgow Coma Scale: eye often start by assessing the verbal response. Determining the pa- opening, verbal response, and motor response (Bateman, 2001). tient’s orientation to time, person, and place assesses verbal re- The patient’s responses are rated on a scale from 3 to 15. A score sponse. The patient is asked to identify the day, date, or season of 3 indicates severe impairment of neurologic function; a score of the year and to identify where he or she is or to identify the of 15 indicates that the patient is fully responsive (see Chap. 63 clinicians, family members, or visitors present. Other questions for more discussion about the Glasgow Coma Scale). such as, “Who is the president?” or “What is the next holiday?” 1852 Unit 14 NEUROLOGIC FUNCTION are also helpful in determining the patient’s processing of infor- • Impaired oral mucous membranes related to mouth- mation in the environment. (Verbal response cannot be evaluated breathing, absence of pharyngeal reflex, and altered fluid when the patient is intubated or has a tracheostomy, and this intake should be clearly documented.) • Risk for impaired skin integrity related to immobility Alertness is measured by the patient’s ability to open the eyes • Impaired tissue integrity of cornea related to diminished or spontaneously or to a stimulus. Patients with severe neurologic absent corneal reflex dysfunction cannot do this. The nurse should assess for peri- • Ineffective thermoregulation related to damage to hypo- orbital edema or trauma, which may prevent the patient from thalamic center opening the eyes, and document if this interferes with eye opening. • Impaired urinary elimination (incontinence or retention) Motor response includes spontaneous, purposeful move- related to impairment in neurologic sensing and control ment (eg, the awake patient can move all four extremities with • Bowel incontinence related to impairment in neurologic equal strength), movement only in response to noxious stimuli sensing and control and also related to transitions in nutri- (eg, pressure/pain), or abnormal posturing (Bateman, 2001). If tional delivery methods the patient is not responding to commands, the motor response • Disturbed sensory perception related to neurologic im- is tested by applying a painful stimulus (firm but gentle pres- pairment sure) to the nailbed or by squeezing a muscle. If the patient at- • Interrupted family processes related to health crisis tempts to push away or withdraw, the response is recorded as purposeful or appropriate (“patient withdraws to painful stim- COLLABORATIVE PROBLEMS/ uli”). This response is considered purposeful if the patient can POTENTIAL COMPLICATIONS cross from one side of the body to the other in response to nox- Based on the assessment data, potential complications may include: ious stimuli. An inappropriate or nonpurposeful response is • Respiratory distress or failure random and aimless. Posturing may be decorticate or decere- • Pneumonia brate (Fig. 61-1; see Chap. 60). The most severe neurologic im- • Aspiration pairment results in flaccidity. Occasionally, posturing cannot be • Pressure ulcer elicited if the patient has been given pharmacologic paralyzing • Deep vein thrombosis agents. In addition to LOC, the nurse monitors parameters such as Planning and Goals respiratory status, eye signs, and reflexes on an ongoing basis. Table 61-1 summarizes the assessment and the clinical signifi- The goals of care for the patient with altered LOC include main- cance of the findings. Body functions (circulation, respiration, tenance of a clear airway, protection from injury, attainment of elimination, fluid and electrolyte balance) are examined in a sys- fluid volume balance, achievement of intact oral mucous mem- tematic and ongoing manner. branes, maintenance of normal skin integrity, absence of corneal irritation, attainment of effective thermoregulation, and effective urinary elimination. Additional goals include bowel continence, Diagnosis accurate perception of environmental stimuli, maintenance of in- NURSING DIAGNOSES tact family or support system, and absence of complications Based on the assessment data, the major nursing diagnoses may (Jacobson & Winslow, 2000). include the following: Because the unconscious patient’s protective reflexes are impaired, the quality of nursing care provided literally may mean • Ineffective airway clearance related to altered level of con- the difference between life and death. The nurse must assume re- sciousness sponsibility for the patient until the basic reflexes (coughing, • Risk of injury related to decreased level of consciousness blinking, and swallowing) return and the patient becomes con- • Deficient fluid volume related to inability to take in fluids scious and oriented. Thus, the major nursing goal is to compen- by mouth sate for the absence of these protective reflexes.

Flexed

A Plantar flexedInternally rotated Flexed Adducted

FIGURE 61-1 Abnormal posture response to stimuli. (A) Decorticate posturing, involving adduction and flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet. (B) Decerebrate posturing, involving extension and outward rotation of B Plantar flexed Flexed Pronated Extended Adducted upper extremities and plantar flexion of the feet. Table 61-1 • Nursing Assessment of the Unconscious Patient

EXAMINATION CLINICAL ASSESSMENT CLINICAL SIGNIFICANCE Level of responsiveness or Eye opening; verbal and motor responses; pupils Obeying commands is a favorable response and consciousness (size, equality, reaction to light) demonstrates a return to consciousness. Pattern of respiration Respiratory pattern Disturbances of respiratory center of brain may result in various respiratory patterns. Cheyne-Stokes respiration Suggests lesions deep in both hemispheres; area of basal ganglia and upper brain stem Hyperventilation Suggests onset of metabolic problem or brain stem damage Ataxic respiration with irregularity in depth/rate Ominous sign of damage to medullary center Eyes Pupils Equal, normally reactive pupils Suggests that coma is toxic or metabolic in origin (size, equality, reaction to light) Equal or unequal diameter Helps determine location of lesion Progressive dilation Indicates increasing ICP Fixed dilated pupils Indicates injury at level of midbrain

Eye movements Normally, eyes should move from side to side. Functional and structural integrity of brain stem is assessed by inspection of extraocular movements; usually absent in deep coma. Corneal reﬂex When cornea is touched with a wisp of clean Tests cranial nerves V and VII; helps determine cotton, blink response is normal. location of lesion if unilateral; absent in deep coma

Facial symmetry Asymmetry (sagging, decrease in wrinkles) Sign of paralysis Swallowing reflex Drooling versus spontaneous swallowing Absent in coma Paralysis of cranial nerves X and XII Neck Stiff neck Subarachnoid hemorrhage, meningitis Absence of spontaneous neck movement Fracture or dislocation of cervical spine Response of extremity to noxious Firm pressure on a joint of the upper and lower Asymmetric response in paralysis stimuli extremity Observe spontaneous movements. Absent in deep coma Deep tendon reflexes Tap patellar and biceps tendons. Brisk response may have localizing value. Asymmetric response in paralysis Absent in deep coma Pathologic reflexes Firm pressure with blunt object on sole of foot, Flexion of the toes, especially the great toe, is moving along lateral margin and crossing to normal except in newborn. the ball of foot Dorsiflexion of toes (especially great toe) indicates contralateral pathology of corticospinal tract (Babinski reflex). Helps determine location of lesion in brain

Abnormal posture Observation for posturing (spontaneous or in Deep extensive brain lesion response to noxious stimuli) Seen with cerebral hemisphere pathology and in Flaccidity with absence of motor response metabolic depression of brain function Decorticate posture (ﬂexion and internal rota- Decerebrate posturing indicates deeper and more tion of forearms and hands) severe dysfunction than does decorticate pos- Decerebrate posture (extension and external turing; implies brain pathology; poor rotation) prognostic sign.

1853 1854 Unit 14 NEUROLOGIC FUNCTION

Nursing Interventions nurse’s responsibility to see that these advocacy needs are met (Elliott & Wright, 1999; Villanueva, 1999). MAINTAINING THE AIRWAY The most important consideration in managing the patient with MAINTAINING FLUID BALANCE altered LOC is to establish an adequate airway and ensure venti- AND MANAGING NUTRITIONAL NEEDS lation. Obstruction of the airway is a risk because the epiglottis Hydration status is assessed by examining tissue turgor and mu- and tongue may relax, occluding the oropharynx, or the patient cous membranes, assessing intake and output trends, and analyz- may aspirate vomitus or nasopharyngeal secretions. ing laboratory data. Fluid needs are met initially by giving the The accumulation of secretions in the pharynx presents a se- required fluids intravenously. However, intravenous solutions rious problem. Because the patient cannot swallow and lacks pharyngeal reflexes, these secretions must be removed to elimi- (and blood transfusions) for patients with intracranial conditions nate the danger of aspiration. Elevating the head of the bed to must be administered slowly. If given too rapidly, they may in- 30 degrees helps prevent aspiration. Positioning the patient in a crease ICP. The quantity of fluids administered may be restricted lateral or semiprone position will also help as it permits the jaw to minimize the possibility of producing cerebral edema. and tongue to fall forward, thus promoting drainage of secretions. If the patient does not recover quickly and sufficiently enough Positioning alone is not always adequate, however. The pa- to take adequate fluids and calories by mouth, a feeding tube will tient may require suctioning and oral hygiene. Suctioning is per- be inserted for the administration of fluids and enteral feedings formed to remove secretions from the posterior pharynx and upper (Day, Stotts, Frankfurt et al., 2001). trachea. With the suction off, a whistle-tip catheter is lubricated with a water-soluble lubricant and inserted to the level of the pos- PROVIDING MOUTH CARE terior pharynx and upper trachea. Continuous suction is applied The mouth is inspected for dryness, inflammation, and crusting. as the catheter is withdrawn using a twisting motion of the thumb The unconscious patient requires conscientious oral care because and forefinger. This twisting maneuver prevents the suctioning there is a risk of parotitis if the mouth is not kept scrupulously end of the catheter from causing irritation, which increases se- clean. The mouth is cleansed and rinsed carefully to remove secretions and causes mucosal trauma and bleeding. Before and cretions and crusts and to keep the mucous membranes moist. A after suctioning, the patient is hyperoxygenated and hyperventi- thin coating of petrolatum on the lips prevents drying, cracking, lated to prevent hypoxia (Hickey, 2003). In addition to these and encrustations. If the patient has an endotracheal tube, the interventions, chest physiotherapy and postural drainage may be tube should be moved to the opposite side of the mouth daily to initiated to promote pulmonary hygiene, unless contraindicated prevent ulceration of the mouth and lips. by the patient’s underlying condition. Also, the chest should be auscultated at least every 8 hours to detect adventitious breath MAINTAINING SKIN AND JOINT INTEGRITY sounds or absence of breath sounds. Preventing skin breakdown requires continuing nursing assess- Despite these measures, or because of the severity of impairment and intervention. Special attention is given to unconscious ment, the patient with altered LOC often requires intubation and patients because they cannot respond to external stimuli. Assess- mechanical ventilation. Nursing actions for the mechanically ment includes a regular schedule of turning to avoid pressure, ventilated patient include maintaining the patency of the endo- which can cause breakdown and necrosis of the skin. Turning also tracheal tube or tracheostomy, providing frequent oral care, mon- provides kinesthetic (sensation of movement), proprioceptive itoring arterial blood gas measurements, and maintaining ventilator (awareness of position), and vestibular (equilibrium) stimulation. settings (see Chap. 25). After turning, the patient is carefully repositioned to prevent ischemic necrosis over pressure areas. Dragging the patient up in PROTECTING THE PATIENT bed must be avoided, because this creates a shearing force and For the protection of the patient, padded siderails are provided friction on the skin surface. and raised at all times. Care should be taken to prevent injury from Maintaining correct body position is important; equally im- invasive lines and equipment, and other potential sources of portant is passive exercise of the extremities to prevent contrac- injury should be identified (eg, restraints, tight dressings, envi- tures. The use of splints or foam boots aids in the prevention of ronmental irritants, damp bedding or dressings, tubes and drains). footdrop and eliminates the pressure of bedding on the toes. Trochanter rolls supporting the hip joints keep the legs in proper NURSING ALERT If the patient begins to emerge from un- alignment. The arms should be in abduction, the fingers lightly consciousness, every measure that is available and appropriate flexed, and the hands in slight supination. The heels of the feet for calming and quieting him or her should be used. Any form of should be assessed for pressure areas. Specialty beds, such as flu- restraint is likely to be countered by the patient with resistance, idized or low-air-loss beds, may be used to decrease pressure on leading to self-injury or to a dangerous increase in ICP. Therefore, bony prominences. ! physical restraints should be avoided if possible; a written pre- scription must be obtained if their use is essential for the patient’s PRESERVING CORNEAL INTEGRITY well-being. Some unconscious patients have their eyes open and have inadequate or absent corneal reflexes. The cornea is likely to become Protection also encompasses the concept of protecting the pa- irritated or scratched, leading to keratitis and corneal ulcers. The tient’s dignity during altered LOC. Simple measures such as pro- eyes may be cleansed with cotton balls moistened with sterile nor- viding privacy and speaking to the patient during nursing care mal saline to remove debris and discharge. If artificial tears are activities preserve the patient’s humanity. Not speaking nega- prescribed, they may be instilled every 2 hours. Periocular edema tively about the patient’s condition or prognosis is also important, (swelling around the eyes) often occurs after cranial surgery. Cold because patients in a light coma may be able to hear. The co- compresses may be prescribed, and care must be exerted to avoid matose patient has an increased need for advocacy, and it is the contact with the cornea. Eye patches should be used cautiously Chapter 61 Management of Patients With Neurologic Dysfunction 1855 because of the potential for corneal abrasion from the cornea program may be initiated to ensure complete emptying of the coming in contact with the patch. bladder at intervals, if indicated. An external catheter (condom catheter) for the male patient ACHIEVING THERMOREGULATION and absorbent pads for the female patient can be used for the un- High fever in the unconscious patient may be caused by infection conscious patient who can urinate spontaneously although invol- of the respiratory or urinary tract, drug reactions, or damage to untarily. As soon as consciousness is regained, a bladder-training the hypothalamic temperature-regulating center. A slight eleva- program is initiated. The incontinent patient is monitored fre- tion of temperature may be caused by dehydration. The envi- quently for skin irritation and skin breakdown. Appropriate skin ronment can be adjusted, depending on the patient’s condition, care is implemented to prevent these complications. to promote a normal body temperature. If body temperature is elevated, a minimum amount of bedding—a sheet or perhaps PROMOTING BOWEL FUNCTION only a small drape—is used. The room may be cooled to 18.3°C The abdomen is assessed for distention by listening for bowel (65°F). However, if the patient is elderly and does not have an el- sounds and measuring the girth of the abdomen with a tape mea- evated temperature, a warmer environment is needed. sure. There is a risk of diarrhea from infection, antibiotics, and hyperosmolar fluids. Frequent loose stools may also occur with fecal impaction. Commercial fecal collection bags are available NURSING ALERT The body temperature of an unconscious patient is never taken by mouth. Rectal or tympanic (if not con- for patients with fecal incontinence. traindicated) temperature measurement is preferred to the less Immobility and lack of dietary fiber may cause constipation. ! accurate axillary temperature. The nurse monitors the number and consistency of bowel movements and performs a rectal examination for signs of fecal impaction. Stool softeners may be prescribed and can be administered Because of damage to the heat-regulating center in the brain or with tube feedings. To facilitate bowel emptying, a glycerine sup- severe intracranial infection, unconscious patients often develop pository may be indicated. The patient may require an enema very high temperatures. Such temperature elevations must be con- every other day to empty the lower colon. trolled because the increased metabolic demands of the brain can overburden cerebral circulation and oxygenation, resulting in cere- PROVIDING SENSORY STIMULATION bral deterioration (Hickey, 2003). Persistent hyperthermia with Sensory stimulation is provided at the appropriate time to help no identified clinical source of infection indicates brain stem overcome the profound sensory deprivation of the unconscious damage and a poor prognosis. patient. Efforts are made to maintain the sense of daily rhythm Strategies for reducing fever include: by keeping the usual day and night patterns for activity and sleep. • Removing all bedding over the patient (with the possible ex- The nurse touches and talks to the patient and encourages fam- ception of a light sheet or small drape) ily members and friends to do so. Communication is extremely • Administering repeated doses of acetaminophen as pre- important and includes touching the patient and spending scribed enough time with him or her to become sensitive to his or her • Giving a cool sponge bath and allowing an electric fan to needs. It is also important to avoid making any negative comments blow over the patient to increase surface cooling about the patient’s status or prognosis in the patient’s presence. Using a hypothermia blanket The nurse orients the patient to time and place at least once • every 8 hours. Sounds from the patient’s home and workplace Frequent temperature monitoring is indicated to assess the re- may be introduced using a tape recorder. Family members can sponse to the therapy and to prevent an excessive decrease in tem- read to the patient from a favorite book and may suggest radio perature and shivering. and television programs that the patient previously enjoyed as a means of enriching the environment and providing familiar input PREVENTING URINARY RETENTION (Hickey, 2003). The patient with an altered LOC is often incontinent or has uri- When arousing from coma, many patients experience a period nary retention. The bladder is palpated or scanned at intervals to of agitation, indicating that they are becoming more aware of determine whether urinary retention is present, because a full their surroundings but still cannot react or communicate in an ap- bladder may be an overlooked cause of overflow incontinence. A propriate fashion. Although disturbing for many family members, portable bladder ultrasound instrument is a useful tool in bladder this is actually a good clinical sign. At this time, it is necessary to management and retraining programs (O’Farrell, Vandervoort, minimize the stimulation to the patient by limiting background Bisnaire et al., 2001). noises, having only one person speak to the patient at a time, If there are signs of urinary retention, initially an indwelling giving the patient a longer period of time to respond, and allow- urinary catheter attached to a closed drainage system is inserted. ing for frequent rest or quiet times. A catheter may be inserted during the acute phase of illness to When the patient has regained consciousness, videotaped fam- monitor urinary output. Because catheters are a major factor in ily or social events may assist the patient in recognizing family and causing urinary tract infection, the patient is observed for fever friends and allow him or her to experience missed events. and cloudy urine. The area around the urethral orifice is inspected for drainage. The urinary catheter is usually removed MEETING FAMILIES’ NEEDS when the patient has a stable cardiovascular system and if no di- The family of the patient with altered LOC may be thrown into uresis, sepsis, or voiding dysfunction existed before the onset of a sudden state of crisis and go through the process of severe anx- coma. Although many unconscious patients urinate sponta- iety, denial, anger, remorse, grief, and reconciliation. Depending neously after catheter removal, the bladder should be palpated or on the disorder that caused the altered LOC and the extent of the scanned with a portable ultrasound device periodically for urinary patient’s recovery, the family may be unprepared for the changes retention (O’Farrell et al., 2001). An intermittent catheterization in the cognitive and physical status of their loved one. If the 1856 Unit 14 NEUROLOGIC FUNCTION patient has significant residual deficits, the family may require count and arterial blood gas measurements are assessed to deter- considerable time, assistance, and support to come to terms with mine whether there are adequate red blood cells to carry oxygen these changes. To help family members mobilize their adaptive and whether ventilation is effective. Chest physiotherapy and capacities, the nurse can reinforce and clarify information about suctioning are initiated to prevent respiratory complications such the patient’s condition, permit the family to be involved in care, as pneumonia. If pneumonia develops, cultures are obtained to and listen to and encourage ventilation of feelings and concerns identify the organism so that appropriate antibiotics can be while supporting them in their decision-making process about administered. posthospitalization management and placement (Hauber & The patient with altered LOC is monitored closely for evi- Testani-Dufour, 2000). Families may benefit from participation dence of impaired skin integrity, and strategies to prevent skin in support groups offered through the hospital, rehabilitation fa- breakdown and pressure ulcers are continued through all phases cility, or community organizations. of care, including hospital, rehabilitation, and home care. Factors In some circumstances, the family may need to face the death that contribute to impaired skin integrity (eg, incontinence, in- of their loved one. The neurologic patient is often pronounced adequate dietary intake, pressure on bony prominences, edema) brain dead before physiologic death occurs. The term brain death are addressed. If pressure ulcers develop, strategies to promote describes irreversible loss of all functions of the entire brain, in- healing are undertaken. Care is taken to prevent bacterial conta- cluding the brain stem. The term may be misleading to the family mination of pressure ulcers, which may lead to sepsis and septic because although brain function has ceased, the patient appears shock. Assessment and management of pressure ulcers are dis- to be alive, with the heart rate and blood pressure sustained by vaso- cussed in Chapter 11. active medications, and breathing continues by mechanical ven- The patient should also be monitored for signs and symptoms tilation. When discussing a patient who is brain dead with family of deep vein thrombosis. Patients who develop deep vein throm- members, it is important to use the term “dead”; the term “brain bosis are at risk for pulmonary embolism. Prophylaxis such as sub- dead” may confuse them (Shewmon, 1998). Chart 61-1 discusses cutaneous heparin or low-molecular-weight heparin (Fragmin, ethical issues related to patients with severe neurologic damage. Orgaran) should be prescribed (Karch, 2002). Thigh-high elas- End-of-life care is discussed in Chapter 17. tic compression stockings or pneumatic compression stockings should also be prescribed to reduce the risk for clot formation. Measures to assess for deep vein thrombosis, such as Homans’ MONITORING AND MANAGING sign, may be clinically unreliable in this population, and the nurse POTENTIAL COMPLICATIONS should observe for redness and swelling in the lower extremities. Pneumonia, aspiration, and respiratory failure are potential complications in any patient who has a depressed LOC and who can- Evaluation not protect the airway or turn, cough, and take deep breaths. The longer the period of unconsciousness, the greater the risk for pul- EXPECTED PATIENT OUTCOMES monary complications. Expected patient outcomes may include: Vital signs and respiratory function are monitored closely to 1. Maintains clear airway and demonstrates appropriate detect any signs of respiratory failure or distress. Total blood breath sounds 2. Experiences no injuries 3. Attains/maintains adequate fluid status a. Has no clinical signs or symptoms of dehydration • Ethics and Related Issues b. Demonstrates normal range of serum electrolytes Chart 61-1 c. Has no clinical signs or symptoms of overhydration 4. Attains/maintains healthy oral mucous membranes What Ethical Principles Apply When Treatment Is 5. Maintains normal skin integrity Withdrawn From the Patient in a Persistent 6. Has no corneal irritation Vegetative State? 7. Attains or maintains thermoregulation Situation 8. Has no urinary retention The family of a 55-year-old woman who has been diagnosed as 9. Has no diarrhea or fecal impaction being in a persistent vegetative state wants to withdraw tube feed- 10. Receives appropriate sensory stimulation ings and let her die. The nursing staff express concern about re- 11. Family members cope with crisis moving the feeding tube, relating that the patient has wakeful a. Verbalize fears and concerns periods and sometimes seems to move her eyes toward them when b. Participate in patient’s care and provide sensory stim- they care for her. The family’s wishes, however, are honored and the ulation by talking and touching medical team discontinues all tube feedings and intravenous lines 12. Is free of complications and orders comfort measures only. The patient dies 7 days later. a. Has arterial blood gas values within normal range Dilemma b. Displays no signs or symptoms of pneumonia How do nurses reconcile their ethical obligations of respect for per- c. Exhibits intact skin over pressure areas sons and sanctity of life in the face of a decision to withdraw treat- d. Does not develop deep vein thrombosis ment? Is the ethical principle of justice upheld? Discussion Is the maintenance of medical treatment obligatory in patients in a Increased Intracranial Pressure persistent vegetative state to provide respect for the patient and the sanctity of life? What mechanisms can the nursing staff use to assist The rigid cranial vault contains brain tissue (1,400 g), blood them in resolving these dilemmas? (75 mL), and CSF (75 mL) (Hickey, 2003). The volume and pressure of these three components are usually in a state of equi- Chapter 61 Management of Patients With Neurologic Dysfunction 1857 librium and produce the ICP. ICP is usually measured in the lat- or both, associated with an increase in brain tissue volume. eral ventricles; normal ICP is 10 to 20 mm Hg (Hickey, 2003). Edema can occur in the gray, white, or interstitial matter. As The Monro-Kellie hypothesis states that because of the lim- brain tissue swells within the rigid skull, several mechanisms at- ited space for expansion within the skull, an increase in any one tempt to compensate for the increasing ICP. These mechanisms of the components causes a change in the volume of the others. include autoregulation and decreasing the production and flow Because brain tissue has limited space to change, compensation of CSF. Autoregulation refers to the brain’s ability to change the typically is accomplished by displacing or shifting CSF, increas- diameter of its blood vessels automatically to maintain a constant ing the absorption of CSF, or decreasing cerebral blood volume. cerebral blood flow during alterations in systemic blood pressure. Without such changes, ICP will begin to rise. Under normal circumstances, minor changes in blood volume and CSF volume CEREBRAL RESPONSE TO INCREASED ICP occur constantly due to alterations in intrathoracic pressure As ICP rises, compensatory mechanisms in the brain work to (coughing, sneezing, straining), posture, blood pressure, and sys- maintain blood flow and prevent tissue damage. The brain can temic oxygen and carbon dioxide levels. maintain a steady perfusion pressure when the arterial systolic blood pressure is 50 to 150 mm Hg and ICP is less than 40 mm Pathophysiology Hg. The cerebral perfusion pressure is calculated by subtracting the ICP from the mean arterial pressure. For example, if the mean Increased ICP is a syndrome that affects many patients with acute arterial pressure is 100 and the ICP is 15, then the cerebral per- neurologic conditions. This is because pathologic conditions alter fusion pressure is 85 mm Hg. The normal cerebral perfusion the relationship between intracranial volume and pressure. pressure is 70 to 100 mm Hg (Hickey, 2003; Young et al., 1998). Although an elevated ICP is most commonly associated with head As ICP rises, however, and the autoregulatory mechanism of the injury, it also may be seen as a secondary effect in other condi- brain is overwhelmed, cerebral perfusion pressure can rise to tions, such as brain tumors, subarachnoid hemorrhage, and toxic greater than 100 mm Hg or fall to less than 50 mm Hg. Patients and viral encephalopathies. Increased ICP from any cause de- with a cerebral perfusion pressure less than 50 mm Hg experience creases cerebral perfusion, stimulates further swelling (edema), irreversible neurologic damage. If ICP equals mean arterial pres- and shifts brain tissue through openings in the rigid dura, result- sure, cerebral circulation ceases (Porth, 2002). ing in herniation, a dire, frequently fatal event. A clinical phenomenon known as the Cushing’s response (or Cushing’s reflex) is seen when cerebral blood flow decreases DECREASED CEREBRAL BLOOD FLOW significantly. When ischemic, the vasomotor center triggers a rise Increased ICP may significantly reduce cerebral blood flow, re- in arterial pressure in an effort to overcome the increased ICP. A sulting in ischemia and cell death. In the early stages of cerebral sympathetically mediated response causes a rise in the systolic ischemia, the vasomotor centers are stimulated and the systemic blood pressure with a widening of the pulse pressure and cardiac pressure rises to maintain cerebral blood flow. Usually a slow slowing. This response, which is mediated by the sympathetic bounding pulse and respiratory irregularities accompany this. nervous system, is seen clinically as a rise in systolic blood pres- These changes in blood pressure, pulse, and respiration are im- sure, widening of the pulse pressure, and reflex slowing of the portant clinically because they suggest increased ICP. heart rate. This is a sign requiring immediate intervention; how- The concentration of carbon dioxide in the blood and in the ever, perfusion may be recoverable if treated rapidly. brain tissue also has a role in the regulation of cerebral blood flow. At a certain volume or pressure, the brain’s ability to auto- A rise in carbon dioxide partial pressure (PaCO2) causes cerebral regulate becomes ineffective and decompensation (ischemia and vasodilatation, leading to increased cerebral blood flow and in- infarction) begins (Young et al., 1998). When this occurs, the pa- creased ICP; a fall in PaCO2 has a vasoconstrictive effect (Young, tient exhibits significant changes in mental status and vital signs. Ropper & Bolton, 1998). Decreased venous outflow may also in- The bradycardia, hypertension, and bradypnea associated with this crease cerebral blood volume, thus raising ICP. deterioration are known as Cushing’s triad, a grave sign. At this point, herniation of the brain stem and occlusion of the cerebral CEREBRAL EDEMA blood flow occur if therapeutic intervention is not initiated. Her- Cerebral edema or swelling is defined as an abnormal accumula- niation refers to the shifting of brain tissue from an area of high tion of water or fluid in the intracellular space, extracellular space, pressure to an area of lower pressure (Fig. 61-2). The herniated

3 2 FIGURE 61-2 Cross section of normal brain (left) and brain with intracranial shifts from supratentorial lesions (right). (1) Her- niation of the cingulated gyrus. (2) Herniation of the temporal lobe into the tentorial notch. (3) Downward displacement of the brainstem through the notch. 1858 Unit 14 NEUROLOGIC FUNCTION tissue exerts pressure on the brain area to which it has herniated SIADH is the result of increased secretion of antidiuretic hor- or shifted, interfering with the blood supply in that area. Cessa- mone. The patient becomes volume-overloaded, urine output dition of cerebral blood flow results in cerebral ischemia and in- minishes, and serum sodium concentration becomes dilute. farction and brain death. Treatment of SIADH includes fluid restriction, which is usually sufficient to correct the hyponatremia; severe cases call for judi- Clinical Manifestations cious administration of a 3% hypertonic saline solution (Hickey, 2003). Patients with chronic SIADH may respond to lithium car- When ICP increases to the point at which the brain’s ability to bonate or demeclocycline, which reduces renal tubule respon- adjust has reached its limits, neural function is impaired; this siveness to antidiuretic hormone. Further discussion of SIADH may be manifested by clinical changes first in LOC and later by is presented in Chapters 14 and 42. abnormal respiratory and vasomotor responses. Management NURSING ALERT The earliest sign of increasing ICP is a change in LOC. Slowing of speech and delay in response to verbal sugges- Increased ICP is a true emergency and must be treated promptly. ! tions are other early indicators. Invasive monitoring of ICP is an important component of management, but immediate management to relieve increased ICP Any sudden change in the patient’s condition, such as rest- involves decreasing cerebral edema, lowering the volume of CSF, lessness (without apparent cause), confusion, or increasing drowsi- or decreasing cerebral blood volume while maintaining cerebral ness, has neurologic significance. These signs may result from perfusion (Cunning & Houdek, 1999). These goals are accom- compression of the brain due to swelling from hemorrhage or plished by administering osmotic diuretics and corticosteroids, edema, an expanding intracranial lesion (hematoma or tumor), restricting fluids, draining CSF, controlling fever, maintaining or a combination of both. systemic blood pressure and oxygenation, and reducing cellular As ICP increases, the patient becomes stuporous, reacting only metabolic demands. Judicious use of hyperventilation is recom- to loud auditory or painful stimuli. At this stage, serious impair- mended only if the ICP is refractory to other measures. ment of brain circulation is probably taking place, and immediate intervention is required. As neurologic function deteriorates MONITORING ICP further, the patient becomes comatose and exhibits abnormal The purposes of ICP monitoring are to identify increased pressure motor responses in the form of decortication, decerebration, or early in its course (before cerebral damage occurs), to quantify the flaccidity (see Fig. 61-1). When the coma is profound, with the degree of elevation, to initiate appropriate treatment, to provide pupils dilated and fixed and respirations impaired, death is usu- access to CSF for sampling and drainage, and to evaluate the ef- ally inevitable. fectiveness of treatment. An intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducer-tipped catheter placed in the subdural Assessment and Diagnostic Findings space or the ventricle can be used to monitor ICP (Fig. 61-3). The diagnostic studies used to determine the underlying cause of When a ventriculostomy or ventricular catheter monitoring increased ICP are discussed in detail in Chapter 60. The patient device is used for monitoring ICP, a fine-bore catheter is inserted may undergo cerebral angiography, computed tomography (CT) into a lateral ventricle, usually in the nondominant hemisphere scanning, magnetic resonance imaging (MRI), or positron emis- of the brain (Hickey, 2003). The catheter is connected by a fluid- sion tomography (PET). Transcranial Doppler studies provide filled system to a transducer, which records the pressure in the information about cerebral blood flow. The patient with increased form of an electrical impulse. In addition to obtaining continu- ICP may also undergo electrophysiologic monitoring to monitor ous ICP recordings, the ventricular catheter allows CSF to drain, cerebral blood flow indirectly. Evoked potential monitoring mea- particularly during acute rises in pressure. The ventriculostomy sures the electrical potentials produced by nerve tissue in response also can be used to drain the ventricle of blood. Also, continuous to external stimulation (auditory, visual, or sensory). Lumbar drainage of ventricular fluid under pressure control is an effective puncture is avoided in patients with increased ICP because the method of treating intracranial hypertension. Another advantage sudden release of pressure can cause the brain to herniate. of an indwelling ventricular catheter is the access it provides for the intraventricular administration of medications and the instil- Complications lation of air or a contrast agent for ventriculography. Complica- tions include ventricular infection, meningitis, ventricular Complications of increased ICP include brain stem herniation, collapse, occlusion of the catheter by brain tissue or blood, and diabetes insipidus, and syndrome of inappropriate antidiuretic problems with the monitoring system. hormone (SIADH). The subarachnoid bolt (or screw) is a hollow device inserted Brain stem herniation results from an excessive increase in through the skull and dura mater into the cranial subarachnoid ICP, when the pressure builds in the cranial vault and the brain space (Hickey, 2003). It has the advantage of not requiring a ven- tissue presses down on the brain stem. This increasing pressure tricular puncture. The subarachnoid screw is attached to a pres- on the brain stem results in the cessation of blood flow to the sure transducer, and the output is recorded on an oscilloscope. brain, causing irreversible brain anoxia and brain death. The hollow screw technique has the advantage of avoiding com- Diabetes insipidus is the result of decreased secretion of anti- plications from brain shift and small ventricle size. Complications diuretic hormone. The patient has excessive urine output, and include blockage of the screw by clot or brain tissue, which leads hyperosmolarity results (Young et al., 1998). Therapy consists of to a loss of pressure tracing and a decrease in accuracy at high ICP administration of fluid volume, electrolyte replacement, and va- readings. sopressin (desmopressin, DDAVP) therapy. Diabetes insipidus is An epidural monitor uses a pneumatic flow sensor that func- discussed in Chapters 14 and 42. tions on a nonelectrical basis. This pneumatic epidural ICP mon- Chapter 61 Management of Patients With Neurologic Dysfunction 1859

FIGURE 61-3 ICP monitoring. A ﬁber-optic, transducer-tipped device placed in (A) the ventricle or (B) the subarachnoid space. These devices connect to a pressure transducer and a display system.

itoring system has a low incidence of infection and complications appear to be related to rhythmic variations of the systemic arte- and appears to read pressures accurately. Calibration of the system rial blood pressure and respirations. is maintained automatically, and abnormal pressure waves trigger an alarm system. One disadvantage of the epidural catheter is DECREASING CEREBRAL EDEMA the inability to withdraw CSF for analysis. Osmotic diuretics (mannitol) may be given to dehydrate the A fiberoptic monitor, or transducer-tipped catheter, is be- brain tissue and reduce cerebral edema. They act by drawing coming a widely used alternative to standard intraventricular, water across intact membranes, thereby reducing the volume of subarachnoid, and subdural systems (Hickey, 2003). The minia- brain and extracellular fluid. An indwelling urinary catheter is ture transducer reflects pressure changes, which are converted to usually inserted to monitor urinary output and to manage the re- electrical signals in an amplifier and displayed on a digital moni- sulting diuresis. When a patient is receiving osmotic diuretics, tor. The catheter can be inserted into the ventricle, subarachnoid serum osmolality should be determined to assess hydration sta- space, subdural space, or brain parenchyma or under a bone flap. tus. Corticosteroids (eg, dexamethasone) help reduce the edema If inserted into the ventricle, it can also be used in conjunction with a CSF drainage device. Waves of high pressure and troughs of relatively normal pressure indicate changes in ICP. Waveforms are captured and recorded on an oscilloscope. These waves have been classified as A waves (plateau waves), B waves, and C waves (Fig. 61-4). The plateau waves (A waves) are transient, paroxysmal, recurring elevations of ICP that may last 5 to 20 minutes and range in amplitude from 50 to 100 mm Hg (Hickey, 2003). Plateau waves have clinical significance and indicate changes in vascular volume within the intracranial compartment that are beginning to compromise cerebral perfusion. A waves may increase in amplitude and frequency, reflecting cerebral ischemia and brain damage that can occur before overt signs and symptoms of raised ICP are seen clinically. B waves are shorter (30 seconds to 2 minutes), with smaller amplitude (up to 50 mm Hg). They have less clinical significance, but if seen in runs in a patient with depressed consciousness, they may precede the appearance of A waves. B waves FIGURE 61-4 Intracranial pressure waves. Composite diagram of A may be seen in patients with intracranial hypertension and de- (plateau) waves, which indicate cerebral ischemia; B waves, which indicate creased intracranial compliance. C waves are small, rhythmic os- intracranial hypertension and variations in the respiratory cycle; and C waves, cillations with frequencies of approximately six per minute. They which relate to variations in systemic arterial pressure and respirations. 1860 Unit 14 NEUROLOGIC FUNCTION surrounding brain tumors when a brain tumor is the cause of REDUCING METABOLIC DEMANDS increased ICP. Cellular metabolic demands may be reduced through the ad- Another method for decreasing cerebral edema is fluid restric- ministration of high doses of barbiturates when the patient is un- tion (Hickey, 2003). Limiting overall fluid intake leads to dehy- responsive to conventional treatment. The mechanism by which dration and hemoconcentration, drawing fluid across the osmotic barbiturates decrease ICP and protect the brain is uncertain, gradient and decreasing cerebral edema. Conversely, overhydra- but the resultant comatose state is thought to reduce the meta- tion of the patient with increased ICP is avoided, as this will in- bolic requirements of the brain, thus providing some protection crease cerebral edema. (Greenberg, 2001). It has been hypothesized that lowering body temperature will Another method of reducing cellular metabolic demand and decrease cerebral edema, reduce the oxygen and metabolic re- improving oxygenation is the administration of pharmacologic quirements of the brain, and protect the brain from continued is- paralyzing agents. The patient who receives these agents cannot chemia. If body metabolism can be reduced by lowering body move, decreasing the metabolic demands and resulting in a de- temperature, the collateral circulation in the brain may be able crease in cerebral oxygen demand. Because the patient cannot re- to provide an adequate blood supply to the brain. The effect of spond or report pain, sedation and analgesia must be provided hypothermia on ICP requires more study (Slade, Kerr & Marion, because the paralyzing agents do not provide either. 1999), but as yet induced hypothermia has not been proven to be Patients receiving high doses of barbiturates or pharmacologic beneficial in the brain-injured patient (Clifton, Miller, Choi et al., paralyzing agents require continuous cardiac monitoring, endo- 2001). Inducing and maintaining hypothermia is a major clini- tracheal intubation, mechanical ventilation, ICP monitoring, and cal procedure and requires knowledge and skilled nursing obser- arterial pressure monitoring. Pentobarbital (Nembutal), thiopen- vation and management. tal (Pentothal), and propofol (Diprivan) are the most common agents used for high-dose barbiturate therapy (Greenberg, 2001). MAINTAINING CEREBRAL PERFUSION Serum barbiturate levels must be monitored (Hickey, 2003). The cardiac output may be manipulated to provide adequate The ability to perform serial neurologic assessments on the pa- perfusion to the brain. Improvements in cardiac output are made tient is lost with the use of barbiturates or paralyzing agents using fluid volume and inotropic agents such as dobutamine hydro- (Greenberg, 2001). Therefore, other monitoring tools are needed chloride. The effectiveness of the cardiac output is reflected in the to assess the patient’s status and response to therapy. Important cerebral perfusion pressure, which is maintained at greater than parameters that must be assessed include ICP, blood pressure, 70 mm Hg (Young et al., 1998). A lower cerebral perfusion pres- heart rate, respiratory rate, and response to ventilator therapy (eg, sure indicates that the cardiac output is insufficient to maintain bucking the ventilator). The level of pharmacologic paralysis is adequate cerebral perfusion. adjusted based on serum levels and the assessed parameters. Po- tential complications include hypotension due to decreased sym- REDUCING CSF AND INTRACRANIAL BLOOD VOLUME pathetic tone and myocardial depression (Greenberg, 2001). CSF drainage is frequently performed because the removal of CSF with a ventriculostomy drain may dramatically reduce ICP TRENDS IN NEUROLOGIC MONITORING and restore cerebral perfusion pressure. Caution should be used One controversial trend in cerebral monitoring is the ongoing in draining CSF because excessive drainage may result in collapse measurement of venous oxygen saturation in the jugular bulb of the ventricles. (SjO2). Readings taken from a catheter residing in the jugular Hyperventilation, which results in vasoconstriction, has been outflow tract theoretically allow for a comparison of arterial and used for many years in patients with increased ICP. Recent re- venous oxygen saturation, and the balance of cerebral oxygen search has demonstrated that hyperventilation may not be as ben- supply and demand is demonstrated. Venous jugular desatura- eficial as once thought (Hickey, 2003). The reduction in the tions can reflect early cerebral ischemia, alerting the clinician PaCO2 may result in hypoxia, ischemia, and an increase in cere- prior to a rise in ICP. Minimizing elevations in ICP can poten- bral lactate levels. Maintaining the PaCO2 at 30 to 35 mm Hg tially improve outcome (Clay, 2000). This type of monitoring may prove beneficial. Hyperventilation is indicated in patients appears beneficial in the management of patients at risk for cere- whose ICP is unresponsive to conventional therapies, but it bral ischemia; however, the invasive nature of this type of moni- should be used judiciously. toring and current limitations in technology mandate caution in its use. More study is needed before SjO2 monitoring can be con- CONTROLLING FEVER sidered a valid and reliable tool for the management of cerebral Preventing a temperature elevation is critical because fever in- ischemia (Clay, 2000). creases cerebral metabolism and the rate at which cerebral edema forms. Strategies to reduce temperature include administration of antipyretic medications, as prescribed, and use of a cooling blan- NURSING PROCESS: ket. Additional strategies for reducing fever are included in the THE PATIENT WITH INCREASED ICP Nursing Process: The Patient With an Altered Level of Con- Assessment sciousness section of this chapter. The patient’s temperature is monitored closely, and the patient is observed for shivering, which Initial assessment of the patient with increased ICP includes ob- should be avoided because it increases ICP (Sund-Levander & taining a history of events leading to the present illness and other Wahren, 2000). subjective data; it may be necessary to obtain this information from family or friends. The neurologic examination should be as MAINTAINING OXYGENATION complete as the patient’s condition allows. It includes an evaluation Arterial blood gases must be monitored to ensure that systemic of mental status, LOC, cranial nerve function, cerebellar function oxygenation remains optimal. Hemoglobin saturation can also be (balance and coordination), reflexes, and motor and sensory func- optimized to provide oxygen more efficiently at the cellular level. tion. Because the patient is critically ill, ongoing assessment will Chapter 61 Management of Patients With Neurologic Dysfunction 1861 be more focused, including pupil checks, assessment of selected therapist in monitoring PaCO2, which is usually maintained at cranial nerves, frequent measurements of vital signs and intra- 35 to 45 mm Hg (Hickey, 2003). cranial pressure, and use of the Glasgow Coma Scale. Assessment A neurologic observation record (Fig. 61-5) is maintained, of the patient with altered LOC is summarized in Table 61-1. and all observations are made in relation to the patient’s baseline condition. Repeated assessments of the patient are made (sometimes minute by minute) so that improvement or deterioration Diagnosis may be noted immediately. If the patient’s condition deteriorates, NURSING DIAGNOSES preparations are made for surgical intervention. Based on the assessment data, the major nursing diagnoses for patients with increased ICP include the following: OPTIMIZING CEREBRAL TISSUE PERFUSION In addition to ongoing nursing assessment, strategies are initi- • Ineffective airway clearance related to diminished protective ated to reduce factors contributing to the elevation of ICP reflexes (cough, gag) (Table 61-2). • Ineffective breathing patterns related to neurologic dys- Proper positioning helps to reduce ICP. The head is kept in function (brain stem compression, structural displacement) a neutral (midline) position, maintained with the use of a cervi- • Ineffective cerebral tissue perfusion related to the effects of cal collar if necessary, to promote venous drainage. Elevation of increased ICP the head is maintained at 0 to 60 degrees to aid in venous • Deficient fluid volume related to fluid restriction drainage unless otherwise prescribed (Sullivan, 2000). Extreme • Risk for infection related to ICP monitoring system rotation of the neck and flexion of the neck are avoided because (fiberoptic or intraventricular catheter) compression or distortion of the jugular veins increases ICP. Ex- Other relevant nursing diagnoses are included in the section treme hip flexion is also avoided because this position causes an on caring for patients with altered LOC. increase in intra-abdominal and intrathoracic pressures, which can produce a rise in ICP. Relatively minor changes in position COLLABORATIVE PROBLEMS/ may significantly affect ICP (Sullivan, 2000). If monitoring parameters demonstrate that turning the patient raises ICP, rotat- POTENTIAL COMPLICATIONS ing beds, turning sheets, and holding the patient’s head during Based on the assessment data, potential complications include: turning may minimize the stimuli that increase ICP. • Brain stem herniation The Valsalva maneuver, which can be produced by straining at • Diabetes insipidus defecation or even moving in bed, raises ICP and is to be avoided. • SIADH Stool softeners may be prescribed. If the patient is alert and able to eat, a diet high in fiber may be indicated. Abdominal distention, which increases intra-abdominal and intrathoracic pressure Planning and Goals and ICP, should be noted. Enemas and cathartics are avoided if The goals for the patient include maintenance of a patent airway, possible. When moving or being turned in bed, the patient can normalization of respiration, adequate cerebral tissue perfusion be instructed to exhale (which opens the glottis) to avoid the through reduction in ICP, restoration of fluid balance, absence Valsalva maneuver. of infection, and absence of complications. Mechanical ventilation presents unique problems for the patient with increased ICP. Before suctioning, the patient should be preoxygenated and hyperventilated using 100% oxygen on the Nursing Interventions ventilator (Hickey, 2003). Suctioning should not last longer than 15 seconds. High levels of positive end-expiratory pressure are MAINTAINING A PATENT AIRWAY avoided because they may decrease venous return to the heart and The patency of the airway is assessed. Secretions obstructing the decrease venous drainage from the brain through increased intra- airway must be suctioned with care, because transient elevations thoracic pressure (Hickey, 2003). of ICP occur with suctioning (Hickey, 2003). The patient is hy- Activities that raise ICP, as indicated by changes in wave- peroxygenated before and after suctioning to maintain adequate forms, should be avoided if possible. Spacing nursing interven- oxygenation. Hypoxia caused by poor oxygenation leads to cere- tions may prevent transient increases in ICP. During nursing bral ischemia and edema. Coughing is discouraged because interventions, the ICP should not rise above 25 mm Hg and coughing and straining also increase ICP. The lung fields are aus- should return to baseline levels within 5 minutes. Patients with cultated at least every 8 hours to determine the presence of ad- increased ICP should not demonstrate a significant increase in ventitious sounds or any areas of congestion. Elevating the head pressure or change in the ICP waveform. Patients with the po- of the bed may aid in clearing secretions as well as improving ve- tential for a significant increase in ICP should receive sedation or nous drainage of the brain. “paralyzation” before initiation of many nursing activities (Hickey, 2003; McConnell, 2001). ACHIEVING AN ADEQUATE BREATHING PATTERN Emotional stress and frequent arousal from sleep are avoided. The patient must be monitored constantly for respiratory irreg- A calm atmosphere is maintained. Environmental stimuli (noise, ularities. Increased pressure on the frontal lobes or deep midline conversation) should be minimal. Isometric muscle contractions structures may result in Cheyne-Stokes respirations, whereas are also contraindicated because they raise the systemic blood pressure in the midbrain may cause hyperventilation. When the pressure and hence the ICP. lower portion of the brain stem (the pons and medulla) is involved, respirations become irregular and eventually cease. MAINTAINING NEGATIVE FLUID BALANCE If hyperventilation therapy is deemed appropriate to reduce The administration of various osmotic and loop diuretics is part ICP (by causing cerebral vasoconstriction and a decrease in cere- of the treatment protocol to reduce ICP. Corticosteroids are used bral blood volume), the nurse collaborates with the respiratory (text continues on page 1864) 1862 Unit 14 NEUROLOGIC FUNCTION

NURSING ADDRESSOGRAPH NEUROLOGICAL CRITICAL Date CARE FLOWSHEET Time Initials Person Level of Place orientation Date and time (✓) No orientation Voice Touch Awakens to Noxious stimuli (✓) Painful stimuli No response Clear and appropriate Clear and inappropriate Difficulty speaking* Best Perseveration verbal Aphasic expressive (non-fluent) response (✓) Aphasic receptive (fluent) Sounds no speech No response ETT/TRACH Moves all extremities purposefully Withdraws and lifts to painful stimuli Best Moves to painful stimuli motor Triple flexes (spinal reflex) response (✓) Decorticates (spinal reflex) Decerebrates (spinal reflex) No response R R R R R R R R R R R R No drifts (R/L) L L L L L L L L L L L L R R R R R R R R R R R R Best motor Drift (R/L) L L L L L L L L L L L L strength Can only lift forearm (R/L) R R R R R R R R R R R R upper L L L L L L L L L L L L Trace movement of hand or arm (R/L) R R R R R R R R R R R R extremities L L L L L L L L L L L L R R R R R R R R R R R R (✓) Trace movement of fingers only (R/L) L L L L L L L L L L L L R R R R R R R R R R R R No response (R/L) L L L L L L L L L L L L Raises leg off bed (R/L) R R R R R R R R R R R R Best L L L L L L L L L L L L R R R R R R R R R R R R strength Drags heel on bed and lifts knee (R/L) L L L L L L L L L L L L R R R R R R R R R R R R lower Trace movement of foot or leg (R/L) L L L L L L L L L L L L extremities Trace movement of toes only (R/L) R R R R R R R R R R R R ✓ L L L L L L L L L L L L ( ) R R R R R R R R R R R R No response (R/L) L L L L L L L L L L L L Seizure No seizure activity activity With loss of consciousness* ✓ ( ) Without loss of consciousness* Gross ataxia Ataxia Fine motor ataxia (✓) Does not apply Ventriculostomy MLS ICP ICP mm Hg monitoring Not applicable *= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT

FIGURE 61-5 A neurological assessment ﬂow sheet. Chapter 61 Management of Patients With Neurologic Dysfunction 1863

PUPIL GAUGE (mm)

23 4 5 6

ADDRESSOGRAPH Date 78 9 Time B=Brisk, S=Sluggish, F=Fixed Initials

Incision Dry and intact +/– Drainage R R R R R R R R R R R R Size (R/L) L L L L L L L L L L L L Pupils Regular (R/L) R R R R R R R R R R R R refer to L L L L L L L L L L L L R R R R R R R R R R R R gauge Irregular* (R/L) L L L L L L L L L L L L (✓) R R R R R R R R R R R R Reaction (R/L) (B) - (S) - (F) L L L L L L L L L L L L (+)=Present R R R R R R R R R R R R (–)=Absent Ptosis (R/L) (+) (–) L L L L L L L L L L L L R R R R R R R R R R R R Gaze preference (R/L) (+)* (–) L L L L L L L L L L L L Meningeal Headache signs Nuchal rigidity (+)=Present (–)=Absent Photophobia Right upper outer Visual fields (+)=Present Right lower outer (–)=Absent* Left upper outer NA=Not applicable Left lower outer Nystagmus R R R R R R R R R R R R Lateral (R/L) L L L L L L L L L L L L (+)=Present R R R R R R R R R R R R (–)=Absent Vertical (R/L) L L L L L L L L L L L L III, IV, VI, Extra occular movements R R R R R R R R R R R R VII – Peripheral facial droop (R/L) L L L L L L L L L L L L R R R R R R R R R R R R Cranial XII – Tongue deviation (R/L) L L L L L L L L L L L L nerves IX – Gag reflex (+)=Present R R R R R R R R R R R R (–)=Absent V, VII – Corneal reflex (R/L) L L L L L L L L L L L L X, IX – Cough reflex Doll's eyes if appropriate Two step verbal command Follows One step verbal command commands Unable to follow command

*= FURTHER DOCUMENTATION IS REQUIRED TO VALIDATE ASSESSMENT Initials Signature Title Initials Signature Title 1864 Unit 14 NEUROLOGIC FUNCTION

Table 61-2 • Increased ICP and Interventions

FACTOR PHYSIOLOGY INTERVENTIONS RATIONALE Cerebral edema Can be caused by contusion, tumor, Administer osmotic diuretics as pre- Promotes venous return or abscess; water intoxication (hypo- scribed (monitor serum osmolality). osmolality); alteration in the blood– Maintain head of bed elevated Prevents impairment of venous re- brain barrier (protein leaks into the 30 degrees. turn through the jugular veins tissue, causing water to follow) Maintain alignment of the head.

Hypoxia A decrease in the PaO2 causes cerebral Maintain PaO2 greater than Prevents hypoxia and vasodilation vasodilation at less than 60 mm Hg. 60 mm Hg. Maintain oxygen therapy. Monitor arterial blood gas values. Suction when needed. Maintain a patent airway.

Hypercapnia Causes vasodilation Maintain PaCO2 (normally Decreased PaCO2 prevents vaso- (elevated PaCO2) 35–45 mm Hg) through dilation and thus reduces the hyperventilation. cerebral blood volume. Impaired venous return Increases the cerebral blood volume Maintain head alignment. Hyperextension, rotation, or hyper- Elevate head of bed 30 degrees. ﬂexion of the neck causes decreased venous return. Increase in intrathoracic Increase in these pressures due to Monitor arterial blood gas values and To keep secretions loose and easy or abdominal pressure coughing, PEEP, Valsalva maneuver keep PEEP as low as possible. to suction or expectorate causes a decrease in venous return. Provide humidiﬁed oxygen. Administer stool softeners as Soft bowel movements will prevent prescribed. straining or Valsalva maneuver.

to reduce cerebral edema, and fluids may be restricted. All of these for loose connections because they cause leakage and contamina- treatment modalities promote dehydration. tion of the CSF as well as inaccurate readings of ICP. The nurse Skin turgor, mucous membranes, and serum and urine os- should observe the character of the CSF drainage and report ob- molality are monitored to assess fluid status. If fluids are given servations of increasing cloudiness or blood. The patient is mon- intravenously, the nurse ensures they are administered at a slow itored for signs and symptoms of meningitis: fever, chills, nuchal to moderate rate with an intravenous infusion pump to prevent (neck) rigidity, and increasing or persisting headache. too-rapid administration and avoid overhydration. For the patient receiving mannitol, the nurse observes for the possible MONITORING AND MANAGING development of heart failure and pulmonary edema, because the POTENTIAL COMPLICATIONS intent of treatment is for fluid to shift from the intracellular The primary complication of increased ICP is brain herniation compartment to the intravascular system, thus controlling cere- resulting in death (see Fig. 61-2). Nursing management focuses bral edema. on detecting early signs of increasing ICP because medical inter- For patients undergoing dehydrating procedures, vital signs, ventions are usually ineffective once later signs develop. Frequent including blood pressure, must be monitored to assess fluid vol- neurologic assessment and documentation and analysis of trends ume status. An indwelling urinary catheter is inserted to permit will reveal the subtle changes that may herald rising ICP. assessment of renal function and fluid status. During the acute phase, urine output should be monitored every hour. An output Detecting Early Indications of Increasing ICP greater than 200 mL/hr for 2 consecutive hours may indicate the The nurse assesses for and immediately reports any of the fol- onset of diabetes insipidus (Cruz, 1998). These patients also need lowing early signs or symptoms of increasing ICP: careful oral hygiene because mouth dryness is associated with dehydration. Frequently rinsing the mouth, lubricating the lips, and • Disorientation, restlessness, increased respiratory effort, pur- removing encrustations relieve dryness and promote comfort. poseless movements, and mental confusion; these are early clinical indications of rising ICP because the brain cells re- PREVENTING INFECTION sponsible for cognition are extremely sensitive to decreased Risk for infection is greatest when ICP is monitored with an in- oxygenation traventricular catheter. Most health care facilities have written • Pupillary changes and impaired extraocular movements; protocols for managing these systems and maintaining their these occur as the increasing pressure displaces the brain sterility; strict adherence to them is essential. against the oculomotor and optic nerves (cranial nerves II, The dressing over the ventricular catheter must be kept dry be- III, IV, and VI) arising from the midbrain and brain stem cause a wet dressing is conducive to bacterial growth. Aseptic (see Chap. 60) technique must be used when managing the system and changing • Weakness in one extremity or on one side of the body; this the ventricular drainage bag. The drainage system is also checked occurs as increasing ICP compresses the pyramidal tracts Chapter 61 Management of Patients With Neurologic Dysfunction 1865

• Headache that is constant, increasing in intensity, and aggravated by movement or straining; this occurs as increasing ICP causes pressure and stretching of venous and arterial vessels in the base of the brain

Detecting Later Signs of Increased ICP As ICP rises, the patient’s condition worsens, as manifested by the following later signs and symptoms: • LOC continues to deteriorate until the patient is comatose. • The pulse rate and respiratory rate decrease or become er- ratic, and the blood pressure and temperature rise. The pulse pressure (the difference between the systolic and the diastolic pressures) widens. The pulse fluctuates rapidly, varying from bradycardia to tachycardia. • Altered respiratory patterns develop, including Cheyne- Stokes breathing (rhythmic waxing and waning of rate and depth of respirations alternating with brief periods of apnea) and ataxic breathing (irregular breathing with a random sequence of deep and shallow breaths). • Projectile vomiting may occur with increased pressure on the reflex center in the medulla. FIGURE 61-6 Location of the foramen of Monro for calibration of intra- • Hemiplegia or decorticate or decerebrate posturing may de- cranial pressure monitoring system. velop as pressure on the brain stem increases. Bilateral flaccidity occurs before death. • Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign. tute observation, comparison of findings with previous observations, and interventions can assist in preventing life-threatening Monitoring ICP ICP elevations. Because clinical assessment is not always a reliable guide in recognizing increased ICP, especially in comatose patients, ICP mon- Monitoring for Secondary Complications itoring is an essential part of management (Hickey, 2003). ICP is The nurse also assesses for complications of increased ICP, in- monitored closely for continuous elevation or significant increase cluding diabetes insipidus and SIADH (see Chaps. 14 and 42). over baseline. The trend of ICP measurements over time is an im- Urine output should be monitored closely. Diabetes insipidus re- portant indication of the patient’s underlying status. Vital signs quires fluid and electrolyte replacement, along with the adminis- are assessed when the increase in ICP is noted. tration of vasopressin, to replace and slow the urine output. Serum Strict aseptic technique is used when handling any part of the electrolyte levels should be monitored for imbalances. SIADH re- monitoring system. The insertion site is inspected for signs of quires fluid restriction and monitoring of serum electrolyte levels. infection. Temperature, pulse, and respirations are closely monitored for systemic signs of infection. All connections and stop- Evaluation cocks are checked for leaks, because even small leaks can distort pressure readings. EXPECTED PATIENT OUTCOMES When ICP is monitored with a fluid system, the transducer is Expected patient outcomes may include: calibrated at a particular reference point, usually 2.5 cm (1 in) 1. Maintains patent airway above the ear with the patient in the supine position; this point 2. Attains optimal breathing pattern corresponds to the level of the foramen of Monro (Fig. 61-6). a. Breathes in a regular pattern (CSF pressure readings depend on the patient’s position.) For b. Attains or maintains arterial blood gas values within subsequent pressure readings, the head should be in the same po- acceptable range sition relative to the transducer. Fiberoptic catheters are cali- 3. Demonstrates optimal cerebral tissue perfusion brated before insertion and do not require further referencing; a. Increasingly oriented to time, place, and person they do not require the head of the bed to be at a specific position b. Follows verbal commands; answers questions correctly to obtain an accurate reading. 4. Attains desired fluid balance Whenever technology is associated with patient management, a. Maintains fluid restriction the nurse must be certain that the technology is functioning prop- b. Demonstrates serum and urine osmolality values within erly. The most important concern, however, must be the patient acceptable range who is attached to the technology. The patient and family must 5. Has no signs or symptoms of infection be informed about the technology and the goals of its use. The pa- a. Has no fever tient’s response is monitored and appropriate comfort measures b. Shows no signs of infection at arterial, intravenous, and are implemented to ensure that the patient’s stress is minimized. urinary catheter sites ICP measurement is only one parameter: repeated neurologic c. Has no purulent drainage from invasive intracranial checks and clinical examinations remain important measures. As- monitoring device 1866 Unit 14 NEUROLOGIC FUNCTION

6. Absence of complications (which has a self-controlled system to stop the drill when the bone a. Has ICP values that remain within normal limits is penetrated). Burr holes are made for exploration or diagnosis. b. Demonstrates urine output and serum electrolyte levels They may be used to determine the presence of cerebral swelling within acceptable limits and injury and the size and position of the ventricles. They are also a means of evacuating an intracranial hematoma or abscess and for making a bone flap in the skull and allowing access to the Intracranial Surgery ventricles for decompression, ventriculography, or shunting procedures. Other cranial procedures include craniectomy (excision A craniotomy involves opening the skull surgically to gain access of a portion of the skull) and cranioplasty (repair of a cranial de- to intracranial structures. This procedure is performed to remove fect using a plastic or metal plate). a tumor, relieve elevated ICP, evacuate a blood clot, and control hemorrhage. The surgeon cuts the skull to create a bony flap, which Preoperative Management can be repositioned after surgery and held in place by periosteal or wire sutures. One of two approaches through the skull is used: Preoperative diagnostic procedures may include CT scanning to (1) above the tentorium (supratentorial craniotomy) into the supra- demonstrate the lesion and show the degree of surrounding brain tentorial compartment, or (2) below the tentorium into the in- edema, the ventricular size, and the displacement. MRI provides fratentorial (posterior fossa) compartment. A transsphenoidal information similar to that of the CT scan and examines the le- approach through the mouth and nasal sinuses is used to gain sion in other planes (Tornqvist, 2001). Cerebral angiography access to the pituitary gland. Table 61-3 compares the three dif- may be used to study the tumor’s blood supply or give informa- ferent surgical approaches: supratentorial, infratentorial, and trans- tion about vascular lesions. Transcranial Doppler flow studies are sphenoidal. used to evaluate the blood flow of intracranial blood vessels. Alternatively, intracranial structures may be approached Most patients are placed on an antiseizure medication such as through burr holes (Fig. 61-7), which are circular openings made phenytoin (Dilantin) or a phenytoin metabolite (Cerebyx) before in the skull by either a hand drill or an automatic craniotome surgery to reduce the risk of postoperative seizures (paroxysmal

Table 61-3 • Comparison of Cranial Surgical Approaches

SUPRATENTORIAL INFRATENTORIAL TRANSSPHENOIDAL

Site of Surgery Above the tentorium Below the tentorium, brain stem Sella turcica Incision Location Incision is made above the area Incision is made at the nape of the Incision is made beneath the upper lip to gain access into the nasal to be operated on; is usually neck, around the occipital lobe. cavity. located behind the hairline. Selected Nursing Interventions Maintain head of bed elevated Maintain neck in straight alignment. Maintain nasal packing in place and reinforce as needed. 30 to 45 degrees, with neck Avoid ﬂexion of the neck to prevent Instruct patient to avoid blowing the nose. in neural alignment. possible tearing of the suture line. Provide frequent oral care. Position patient on either side or Position the patient on either side. Keep head of bed elevated to promote venous drainage and drainage back. (Avoid positioning pa- (Check surgeon’s preference for from the surgical site. tient on operative side if a large positioning of patient.) tumor has been removed.) Chapter 61 Management of Patients With Neurologic Dysfunction 1867

water, blanket, and other frequently used items may help improve communication. Preparation of the patient and family includes providing information about what to expect during and after surgery. The surgical site is shaved immediately before surgery (usually in the operating room) so that any resultant superﬁcial abrasions do not have time to become infected. An indwelling urinary catheter is inserted in the operating room to drain the bladder during the administration of diuretics and to permit urinary output to be monitored. The patient may have a central and arterial line placed for ﬂuid administration and monitoring of pressures after surgery. The large head dressing applied after surgery may impair hearing temporarily. Vision may be limited if the eyes are swollen shut. If a tracheostomy or endotracheal tube is in place, the patient will be unable to speak until the tube is removed, so an alternative method of communication should be established. An altered cognitive state may make the patient unaware of the impending surgery. Even so, encouragement and attention to the patient’s needs are necessary. Whatever the state of awareness of the patient, the family needs reassurance and support because they recognize the seriousness of brain surgery.

Postoperative Management Postoperatively, an arterial line and a central venous pressure line FIGURE 61-7 Burr holes may be used in neurosurgical procedures to make a bone flap in the skull, to aspirate a brain abscess, or to evacuate a may be in place to monitor and manage blood pressure and cen- hematoma. tral venous pressure. The patient may be intubated and may receive supplemental oxygen therapy. Ongoing postoperative management is aimed at detecting and reducing cerebral edema, transient disturbances of the brain resulting from a discharge of relieving pain and preventing seizures, and monitoring ICP. abnormal electrical activity) (Hickey, 2003; Karch, 2002). Before surgery, corticosteroids such as dexamethasone (Decadron) may REDUCING CEREBRAL EDEMA be administered to reduce cerebral edema. Fluids may be re- Medications to reduce cerebral edema include mannitol, which stricted. A hyperosmotic agent (mannitol) and a diuretic agent increases serum osmolality and draws free water from areas of the such as furosemide (Lasix) may be given intravenously immedi- brain (with an intact blood–brain barrier). The fluid is then ex- ately before and sometimes during surgery if the patient tends to creted by osmotic diuresis. Dexamethasone (Decadron) may be retain fluid, as do many who have intracranial dysfunction. The administered intravenously every 6 hours for 24 to 72 hours; the patient may be given antibiotics if there is a chance of cerebral route is switched to oral as soon as possible and dosage is tapered contamination; diazepam may be prescribed before surgery to over 5 to 7 days (Karch, 2002). allay anxiety. RELIEVING PAIN AND PREVENTING SEIZURES Preoperative Nursing Management Acetaminophen is usually prescribed for temperature exceeding 99.6°F (37.5°C) and for pain. Commonly, the patient has a The preoperative assessment serves as a baseline against which headache after a craniotomy, usually as a result of the scalp nerves postoperative status and recovery are compared. This assessment being stretched and irritated during surgery. Codeine, given par- includes evaluating LOC and responsiveness to stimuli and iden- enterally, is often sufficient to relieve headache. Morphine sulfate tifying any neurologic deficits, such as paralysis, visual dysfunc- may also be used in the management of postoperative pain in the tion, alterations in personality or speech, and bladder and bowel craniotomy patient (Leith, 1998). disorders. Distal and proximal motor strength in both upper and Antiseizure medication (phenytoin, diazepam) is prescribed lower extremities is recorded using the 5-point scale. Testing of for patients who have undergone supratentorial craniotomy be- motor function is discussed in Chapter 60 (see Fig. 60-14). cause of the high risk of seizures after supratentorial neurosurgical The patient’s and family’s understanding of and reactions to procedures. Serum levels are monitored to keep the medications the anticipated surgical procedure and its possible sequelae are as- within the therapeutic range. sessed, as is the availability of support systems for the patient and family. Adequate preparation for surgery, with attention to the MONITORING ICP patient’s physical and emotional status, can reduce the risk for A ventricular catheter or other type of drain frequently is inserted anxiety, fear, and postoperative complications. The patient is as- in patients undergoing intracranial surgery. The catheter is con- sessed for neurologic deficits and their potential impact after nected to an external drainage system. The patency of the catheter surgery. If there are motor deficits or weakness or paralysis of the is noted by the pulsations of the fluid in the tubing. The ICP can arms or legs, trochanter rolls are applied to the extremities and be assessed using a stopcock attached to the pressure tubing and the feet are positioned against a footboard. A patient who can am- transducer. The ICP is measured by turning the three-way stop- bulate is encouraged to do so. If the patient is aphasic, writing cock to the appropriate position (Hickey, 2003). Care is required materials or picture and word cards showing the bedpan, glass of to ensure that the system is tight at all connections and that the 1868 Unit 14 NEUROLOGIC FUNCTION stopcock is in the proper position to avoid drainage of CSF; col- • Infection lapse of the ventricles and brain herniation may result if fluid is • Seizures removed too rapidly (Hickey, 2003). The catheter is removed when the ventricular pressure is normal and stable. The neurosurgeon must be notified if the catheter appears to be obstructed. Planning and Goals The major goals for the patient include neurologic homeostasis NURSING PROCESS: to improve cerebral tissue perfusion, adequate thermoregulation, THE PATIENT UNDERGOING normal ventilation and gas exchange, ability to cope with sensory deprivation, adaptation to changes in body image, and absence of INTRACRANIAL SURGERY complications. Assessment After surgery, the frequency of postoperative monitoring is based Nursing Interventions on the patient’s clinical status. Assessing respiratory function is MAINTAINING CEREBRAL TISSUE PERFUSION essential because even a small degree of hypoxia can increase cere- Attention to the patient’s respiratory status is essential because bral ischemia. The respiratory rate and pattern are monitored, even slight decreases in the oxygen level (hypoxia) can cause cere- and arterial blood gas values are assessed frequently. Fluctuations bral ischemia and can affect the clinical course and outcome. The in vital signs are carefully monitored and documented because endotracheal tube is left in place until the patient shows signs of they indicate increased ICP. The patient’s temperature is mea- awakening and has adequate spontaneous ventilation, as evalu- sured at intervals to assess for hyperthermia secondary to damage ated clinically and by arterial blood gas analysis. Secondary brain to the hypothalamus. Neurologic checks are made frequently to damage can result from impaired cerebral oxygenation. detect increased ICP resulting from cerebral edema or bleeding. Some degree of cerebral edema occurs after brain surgery; it A change in LOC or response to stimuli may be the first sign of tends to peak 24 to 36 hours after surgery, producing decreased increasing ICP. responsiveness on the second postoperative day. The control of The surgical dressing is inspected for evidence of bleeding and cerebral edema is discussed in the earlier section of this chapter CSF drainage. The nurse must be alert to the development of com- on management of increased ICP. Nursing strategies used to plications; all assessments are carried out with these problems in control factors that may raise ICP are found earlier in this chap- mind. Chart 61-2 provides an overview of the nursing management ter in Nursing Process: The Patient With Increased ICP. Intra- of the patient after intracranial surgery. Seizures are a potential com- ventricular drainage is carefully monitored, using strict asepsis plication, and any seizure activity is carefully recorded and reported. when any part of the system is handled. Restlessness may occur as the patient becomes more responsive or Vital signs and neurologic status (LOC and responsiveness, may be due to pain, confusion, hypoxia, or other stimuli. pupillary and motor responses) are assessed every 15 minutes to every 1 hour. Extreme head rotation is avoided because this raises Diagnosis ICP. After supratentorial surgery, the patient is placed on his or her back or side (unoperated side if a large lesion was removed) NURSING DIAGNOSES with one pillow under the head. The head of the bed may be Based on the assessment data, the patient’s major nursing diag- elevated 30 degrees, depending on the level of the ICP and the noses after intracranial surgery may include the following: neurosurgeon’s preference. After posterior fossa (infratentorial) • Ineffective cerebral tissue perfusion related to cerebral surgery, the patient is kept flat on one side (off the back) with the edema head on a small, firm pillow. The patient may be turned on either • Potential for ineffective thermoregulation related to dam- side, keeping the neck in a neutral position. When the patient is age to the hypothalamus, dehydration, and infection being turned, the body should be turned as a unit to prevent plac- • Potential for impaired gas exchange related to hypoventila- ing strain on the incision and possibly tearing the sutures. The tion, aspiration, and immobility head of the bed may be elevated slowly as tolerated by the patient. • Disturbed sensory perception related to periorbital edema, The patient’s position is changed every 2 hours, and skin care head dressing, endotracheal tube, and effects of ICP is given frequently. During position changes, care is taken to pre- • Body image disturbance related to change in appearance or vent disrupting the ICP monitoring system. A turning sheet physical disabilities placed under the head to the midthigh makes it easier to move and turn the patient safely. Other nursing diagnoses may include impaired communication (aphasia) related to insult to brain tissue and high risk for REGULATING TEMPERATURE impaired skin integrity related to immobility, pressure, and in- Moderate temperature elevation can be expected after intracra- continence. There may be impaired physical mobility related to nial surgery because of the reaction to blood at the operative site a neurologic deficit secondary to the neurosurgical procedure or or in the subarachnoid space. Injury to the hypothalamic centers to the underlying disorder. that regulate body temperature can occur during surgery. High fever is treated vigorously to combat the effect of an elevated tem- COLLABORATIVE PROBLEMS/ perature on brain metabolism and function. POTENTIAL COMPLICATIONS Nursing interventions include monitoring the patient’s tem- Potential complications include: perature and using the following measures to reduce body tem- • Increased ICP perature: removing blankets, applying ice bags to axilla and groin • Bleeding and hypovolemic shock areas, using a hypothermia blanket as prescribed, and adminis- • Fluid and electrolyte disturbances tering prescribed medications to reduce fever. Chapter 61 Management of Patients With Neurologic Dysfunction 1869 Chart 61-2 Overview of Nursing Management for the Patient After Intracranial Surgery Postoperative Interventions (1) Eye opening (spontaneous, to sound, to pain); pupillary Nursing Diagnosis: Risk for ineffective breathing pattern related to reactions to light postoperative cerebral edema (2) Response to commands Goal: Achievement of adequate respiratory function (3) Assessment of spinal motor reflexes (pinch Achilles ten- 1. Establish proper respiratory exchange to eliminate systemic don, arm, or other body site) hypercapnia and hypoxia, which increase cerebral edema. (4) Observation of patient’s spontaneous activity a. Unless contraindicated, place the patient in a lateral or a b. Maintain a neurologic flow sheet to assess and document semiprone position to facilitate respiratory gas exchange neurologic status, fluid administration, laboratory data, until consciousness returns. medications, and treatments. b. Suction trachea and pharynx cautiously to remove secretions; c. Evaluate for signs and symptoms of increasing ICP, which suctioning can raise ICP. can lead to ischemia and further impairment of brain c. Maintain patient on controlled ventilation if prescribed to function. maintain normal ventilatory status; monitor arterial blood (1) Assess patient minute by minute, hour by hour, for: gas results to determine respiratory status. • Diminished response to stimuli d. Elevate the head of the bed 30.5 cm (12 in) after patient is • Fluctuations of vital signs conscious to aid venous drainage of the brain. • Restlessness e. Administer nothing by mouth until active coughing and • Weakness and paralysis of extremities swallowing reflexes are demonstrated, to prevent aspiration. • Increasing headache Nursing Diagnosis: Risk for imbalanced fluid volume related to intra- • Changes or disturbances of vision; pupillary changes cranial pressure or diuretics (2) Modify nursing management to prevent further increases Goal: Attainment of fluid and electrolyte balance in ICP. 1. Monitor for polyuria, especially during first postoperative d. Control postoperative cerebral edema as prescribed. week; diabetes insipidus may develop in patients with lesions (1) Administer corticosteroids and osmotic diuretics as pre- around the pituitary or hypothalamus. scribed to reduce brain swelling. a. Measure urinary specific gravity at intervals. (2) Monitor fluid intake; avoid overhydration. b. Monitor serum and urinary electrolyte levels. (3) Maintain a normal temperature. Temperature control 2. Evaluate patient’s electrolyte status; patients may retain water may be impaired in certain neurologic states, and fever and sodium. increases the metabolic demands of the brain. a. Early postoperative weight gain indicates fluid retention; a • Monitor rectal temperature at specified intervals. Assess greater-than-estimated weight loss indicates negative water temperature of extremities, which may be cold and dry balance. due to impaired heat-losing mechanisms (vasodilation b. Loss of sodium and chloride will produce weakness, and sweating). lethargy, and coma. • Employ measures as prescribed to reduce fever: ice bags c. Low potassium levels will cause confusion and decreased to axillae and groin; hypothermia blanket. Use ECG level of responsiveness. monitoring to detect dysrhythmias during hypothermia 3. Weigh patient daily; keep intake and output record. procedures. 4. Administer prescribed intravenous fluids cautiously—rate and (4) Employ hyperventilation when prescribed and indicated composition depend on fluid deficit, urine output, and blood (results in respiratory alkalosis, which causes cerebral loss. Fluid intake and fluid losses should remain relatively equal. vasoconstriction and reduces intracranial pressure). Nursing Diagnosis: Disturbed sensory perception (visual/auditory) re- (5) Elevate head of bed to reduce ICP and facilitate lated to periorbital edema and head dressings respirations. Goal: Compensate for sensory deprivation; prevention of injury (6) Avoid excessive stimuli. 1. Perform supportive measures until the patient can care for self. (7) Use ICP monitoring if patient is at risk for intracranial a. Change position as indicated; position changes can increase hypertension. ICP. 2. Intracranial hemorrhage b. Administer prescribed analgesics (codeine) that do not mask a. Postoperative bleeding may be intraventricular, intracerebel- the level of responsiveness. lar, subdural, or extradural. 2. Use measures prescribed to relieve signs of periocular edema. b. Observe for progressive impairment of state of consciousness a. Lubricate eyelids and around eyes with petrolatum. and other signs of increasing ICP. b. Apply light, cold compresses over eyes at specified intervals. c. Prepare deteriorating patient for return to surgery for evacu- c. Observe for signs of keratitis if cornea has no sensation. ation of hematoma. 3. Put extremities through range-of-motion exercises. 3. Seizures (greater risk with supratentorial operations) 4. Evaluate and support patient during episodes of restlessness. a. Administer prescribed antiseizure agents; monitor anti- a. Evaluate for airway obstruction, distended bladder, seizure medication blood levels. meningeal irritation from bloody CSF. b. Observe for status epilepticus, which may occur after any b. Pad patient’s hands and bed rails to prevent injury. intracranial surgery. 5. Reinforce blood-stained dressings with sterile dressing; blood- 4. Infections soaked dressings act as a culture medium for bacteria. a. Urinary tract infections 6. Orient patient frequently to time, place, and person. b. Pulmonary infections related to aspiration secondary to de- Monitor and Manage Complications pressed level of responsiveness; may result in atelectasis and 1. Cerebral edema aspiration pneumonia a. Assess patient’s level of responsiveness/consciousness; de- c. CNS infections (postoperative meningitis, CSF shunt creased level of consciousness may be the first sign of in- infection) creased ICP. d. Surgical site infections/septicemia (continued) 1870 Unit 14 NEUROLOGIC FUNCTION Chart 61-2 Overview of Nursing Management for the Patient After Intracranial Surgery (Continued) 5. Venous thrombosis Evaluation a. Assess for Homans’ sign. Expected patient outcomes b. Apply elastic compression stockings. 1. Demonstrates normal breathing pattern c. Administer anticoagulant therapy as prescribed. a. Absence of crackles 6. Leakage of CSF b. Demonstrates active swallowing and coughing reflexes a. Differentiate between CSF and mucus. 2. Attains/maintains fluid balance (1) Collect fluid on Dextrostix; if CSF is present, the indica- a. Takes fluids orally tor will have a positive reaction, as CSF contains glucose. b. Maintains weight within expected range (2) Assess for moderate elevation of temperature and mild 3. Compensates for sensory deprivation neck rigidity. a. Makes needs known b. Caution patient against nose blowing or sniffing. b. Demonstrates improvement of vision c. Elevate head of bed as prescribed. 4. Exhibits absence of complications d. Assist with insertion of lumbar CSF drainage system if in- a. No evidence of increased ICP serted to reduce CSF pressure. b. Opens eyes on request (1) Ventricular catheters may be inserted in the patient un- c. Obeys commands dergoing surgery of the posterior fossa (ventricu- d. Has appropriate motor responses lostomy); the catheter is connected to a closed drainage e. Shows increasing alertness system. f. No evidence of rhinorrhea, otorrhea, or CSF leakage (2) Administer antibiotics as prescribed. g. Absence of fever 7. Gastrointestinal ulceration; monitor for signs and symptoms of h. No evidence of inflammation or infection at surgical site hemorrhage, perforation, or both (probably caused by stress i. Absence of seizures response).

Conversely, hypothermia may be seen after lengthy neurosur- surgery. A hematoma may form under the scalp and spread down gical procedures. Therefore, frequent measurements of rectal to the orbit, producing an area of ecchymosis (black eye). temperature are necessary. Rewarming should occur slowly to Before surgery, the patient and family should be informed that prevent shivering, which increases cellular oxygen demands. one or both eyes may be edematous temporarily after surgery. After surgery, placing the patient in a head-up position (if not IMPROVING GAS EXCHANGE contraindicated) and applying cold compresses over the eyes will The patient undergoing neurosurgery is at risk for impaired gas ex- help reduce the edema. If periorbital edema increases signifi- change and pulmonary infections because of immobility, immuno- cantly, the surgeon is notified because it may indicate that a post- suppression, decreased LOC, and fluid restriction. Immobility operative clot is developing or that there is increasing ICP and compromises the respiratory system by causing pooling and sta- poor venous drainage. Health care personnel should announce sis of secretions in dependent areas and the development of at- their presence when entering the room to avoid startling the pa- electasis. The patient whose fluid intake is restricted may be more tient whose vision is impaired due to periorbital edema or neu- vulnerable to atelectasis as a result of inability to expectorate rologic deficits. thickened secretions. Pneumonia is frequently seen in neuro- Additional factors that can affect sensation include a bulky surgical patients, possibly related to aspiration and restricted head dressing, the presence of an endotracheal tube, and effects mobility. of increased ICP. The first postoperative dressing change is usually performed by the neurosurgeon. In the absence of bleeding The nurse assesses the patient for signs of respiratory infection, or a CSF leak, every effort is made to minimize the size of the which include temperature elevation, increased pulse rate, and head dressing. If the patient requires an endotracheal tube for changes in respirations, and auscultates the lungs for decreased mechanical ventilation, every effort is made to extubate the pa- breath sounds and adventitious sounds. tient as soon as clinical signs indicate it is possible. The patient is Repositioning the patient every 2 hours will help to mobilize monitored closely for the effects of elevated ICP. pulmonary secretions and prevent stasis. When the patient regains consciousness, additional measures to expand collapsed alveoli can ENHANCING SELF-IMAGE be instituted, such as yawning, sighing, deep breathing, incentive The patient is encouraged to verbalize feelings and frustrations spirometry, and coughing (unless contraindicated). If necessary, about any change in appearance. Nursing support is based on the the oropharynx and trachea are suctioned to remove secretions that patient’s reactions and feelings. Factual information may need to cannot be raised by coughing; however, coughing and suctioning be provided if the patient has misconceptions about puffiness increase ICP. Therefore, suctioning should be used cautiously. In- about the face, periorbital bruising, and hair loss. Attention to creasing the humidity in the oxygen delivery system may help to grooming, the use of the patient’s own clothing, and covering the loosen secretions. The nurse and the respiratory therapist work to- head with a turban (and ultimately a wig until hair growth occurs) gether to monitor the effects of chest physical therapy. are encouraged. Social interaction with close friends, family, and hospital personnel may increase the patient’s sense of self-worth. MANAGING SENSORY DEPRIVATION As the patient assumes more responsibility for self-care and Periorbital edema is a common consequence of intracranial participates in more activities, a sense of control and personal surgery because fluid drains into the dependent periorbital areas competence will develop. The family and social support system when the patient has been positioned in a prone position during can be of assistance while the patient recovers from surgery. Chapter 61 Management of Patients With Neurologic Dysfunction 1871

MONITORING AND MANAGING Patients undergoing surgery for brain tumors often receive POTENTIAL COMPLICATIONS large doses of corticosteroids and thus tend to develop hyper- Complications that may develop within hours after surgery in- glycemia. Therefore, serum glucose levels are measured every clude increased ICP, bleeding and hypovolemic shock, altered 4 hours. These patients are prone to gastric ulcers, and therefore fluid and electrolyte balance (including water intoxication), in- histamine-2 receptor antagonists (H2 blockers) are prescribed to fection, and seizures. These complications require close collabo- suppress the secretion of gastric acid. The patient is monitored ration between the nurse and the surgeon. for bleeding and assessed for gastric pain. If the surgical site is near, or causes edema to, the pituitary Monitoring for Increased ICP and Bleeding gland and hypothalamus, the patient may develop symptoms of Increased ICP and bleeding are life-threatening to the patient who diabetes insipidus, which is characterized by excessive urinary has undergone intracranial neurosurgery. The following must be output. The urine specific gravity is measured hourly, and fluid kept in mind when caring for all patients who undergo such intake and output are monitored. Fluid replacement must com- surgery: pensate for urine output, and serum potassium levels must be monitored. • An increase in blood pressure and decrease in pulse with res- SIADH, which results in water retention with hyponatremia piratory failure may indicate increased ICP. and serum hypo-osmolality, occurs in a wide variety of central • An accumulation of blood under the bone flap (extradural, nervous system disorders (brain tumor, head trauma) causing fluid subdural, intracerebral) may pose a threat to life. A clot disturbances. Nursing management includes careful intake and must be suspected in any patient who does not awaken as output measurements, specific gravity determinations of urine, expected or whose condition deteriorates. An intracranial and monitoring of serum and urine electrolyte studies, while hematoma is suspected if the patient has any new postoper- following directives for fluid restriction. SIADH is usually self- ative neurologic deficits (especially a dilated pupil on the limiting. operative side). In these events, the patient is returned to the operating room immediately for evacuation of the clot if Preventing Infection indicated. The patient undergoing neurosurgery is at risk for infection re- • Cerebral edema, infarction, metabolic disturbances, and lated to the neurosurgical procedure (brain exposure, bone expo- hydrocephalus are conditions that may mimic the clinical sure, wound hematomas) and the presence of intravenous and manifestations of a clot. arterial lines for fluid administration and monitoring. Risk for in- The patient is monitored closely for indicators of complica- fection is increased in patients who undergo lengthy intracranial tions, and early signs and trends in clinical status are reported to operations and those with external ventricular drains in place the surgeon. Treatments are initiated promptly, and the nurse as- longer than 48 to 72 hours. sists in evaluating the response to treatment. The nurse also pro- The incision site is monitored for redness, tenderness, bulging, separation, or foul odor. The dressing is often stained with blood vides support to the patient and family. in the immediate postoperative period. It is important to re- Should signs and symptoms of increased ICP occur, efforts to inforce the dressing with sterile pads so that contamination and decrease the ICP are initiated: alignment of the head in a neutral infection are avoided. (Blood is an excellent culture medium for position without flexion to promote venous drainage, elevation bacteria.) If the dressing is heavily stained or displaced, this should of the head of the bed to 30 degrees, administration of mannitol be reported immediately. (A drain is sometimes placed in the (an osmotic diuretic), and possible administration of pharmaco- craniotomy incision to facilitate drainage.) logic paralyzing agents. After suboccipital surgical procedures, CSF may leak through the incision. This complication is dangerous because of the pos- Managing Fluid and Electrolyte Disturbances sibility of meningitis. Any sudden discharge of fluid from a cra- Fluid and electrolyte imbalances may occur because of the pa- nial incision is reported at once because a massive leak requires tient’s underlying condition and its management or as complica- direct surgical repair. Attention should be paid to the patient who tions of surgery. Fluid and electrolyte disturbances can contribute complains of a salty taste, because this can be due to CSF trick- to the development of cerebral edema. ling down the throat. The patient is advised to avoid coughing, The postoperative fluid regimen depends on the type of neu- sneezing, or nose blowing, which may cause CSF leakage by cre- rosurgical procedure and is determined on an individual basis. ating pressure on the operative site. The volume and composition of fluids are adjusted according to Aseptic technique is used when handling dressings, drainage daily serum electrolyte values, along with fluid intake and output. systems, and intravenous and arterial lines. The patient is moni- Sodium retention may occur in the immediate postoperative tored carefully for signs and symptoms of infection, and cultures period. Serum and urine electrolytes, blood urea nitrogen, blood are obtained from the patient with suspected infection. Appro- glucose, weight, and clinical status are monitored. Intake and priate antibiotics are administered as prescribed. output are measured in view of losses associated with fever, res- Other causes of infection in the patient undergoing intra- piration, and CSF drainage. Fluids may have to be restricted in cranial surgery are similar to those in other postoperative patients: patients with cerebral edema. pneumonia and urinary tract infections. Oral fluids are usually resumed after the first 24 hours (Hickey, 2003). The presence of gag and swallowing reflexes must be Monitoring for Seizure Activity checked before initiation of oral fluids. Some patients with pos- Seizures and epilepsy may be complications after any intracranial terior fossa tumors may have impaired swallowing, so fluids may neurosurgical procedure. Preventing seizures is essential to avoid need to be administered by alternative routes. The patient should further cerebral edema. Administering the prescribed antiseizure be observed for signs and symptoms of nausea and vomiting as medication before and immediately after surgery may prevent the the diet is progressed (Hickey, 2003). development of seizures in subsequent months and years. Status 1872 Unit 14 NEUROLOGIC FUNCTION epilepticus (prolonged seizures without recovery of consciousness NURSING RESEARCH PROFILE 61-1 in the intervals between seizures) may occur after craniotomy and also may be related to the development of complications Suitability of Printed Patient (hematoma, ischemia). The management of status epilepticus is Education Materials described later in this chapter. Murphy, P. W., Chesson, A., Berman, S. A., Arnold, C., & Gallowat, G. (2001). Neurology patient education materials: do our educational aids fit Monitoring and Managing Later Complications our patients’ needs? Journal of Neuroscience Nursing, 33(2), 99–112. Other complications may occur during the first 2 weeks or later and may threaten the patient’s recovery. The most important of Purpose these are thromboembolic complications (deep vein thrombosis, Nurses often rely on printed patient education materials to supple- pulmonary embolism), pulmonary and urinary tract infection, ment patient teaching. The purpose of the study was to assess the and pressure ulcers (Warbel, Lewicki & Lupica, 1999). Most of suitability of neurology patient education brochures and related in- these complications may be avoided with frequent changes of formation available on the Internet to determine their appropri- ateness for patients with low literacy skills. position, adequate suctioning of secretions, assessment for pulmonary complications, observation for urinary complications, Study Sample and Design and skin care. In this descriptive, cross-sectional study, the reading levels of patients and patient education materials were assessed. The Rapid Es- PROMOTING HOME AND COMMUNITY-BASED CARE timate of Adult Literacy in Medicine tool was used to evaluate a convenience sample of 520 neurology patients. Forty-three patient Teaching Patients Self-Care education materials—35 brochures produced by national organiza- The recovery at home of a neurosurgical patient depends on the tions and 8 electronic documents from various Internet sources— extent of the surgical procedure and its success. The patient’s were assessed using the Fog Index and the Suitability Assessment of strengths as well as limitations are explained to the family, along Materials Scale. The mean age of patients was 46 years; 40% were with their part in promoting recovery. Because administration of African American and 59% Caucasian; 44% were female; the average educational level was 12th grade, with a mean reading level of antiseizure medication is a priority, the patient and family are en- 7th to 8th grade. couraged to use a check-off system to ensure that the medication is taken as prescribed. Findings Usually no dietary restrictions are required unless another Patient education materials were classified as not suitable, adequate, health problem requiring a special diet exists. Although taking or superior for use. Organizations with materials at the suitable a shower or tub bath is permitted, the scalp should be kept dry level include those of the Epilepsy Foundation of America, the Na- until all the sutures have been removed. A clean scarf or cap may tional Multiple Sclerosis Society, and the American Heart Associ- be worn until a wig or hairpiece is purchased. If skull bone has ation. The National Stroke Association, the American Academy of Neurology, the American Sleep Medicine, and the Muscular Dys- been removed, the neurosurgeon may suggest a protective hel- trophy Association had brochures in the adequate range. Overall, met. After a craniotomy, the patient may require rehabilitation, only 14% of the materials were considered to have superior suit- depending on the postoperative level of function. The patient ability, whereas 58% were adequate; 28% were determined not may require physical therapy for residual weakness and mobil- suitable. Of the materials available from the Internet, 88% were not ity issues. Occupational therapy is consulted to assist with self- suitable. The authors concluded that readily available neurology care issues. If the patient is aphasic, speech therapy may be patient education aids are not matched to the patient population necessary. or to the average reading levels of patients. Nursing Implications Continuing Care Nurses should keep in mind that the brochures evaluated in this Barring complications, patients are discharged from the hospital study represent primarily those available at national meetings and as soon as possible. Patients with severe motor deficits require ex- a small sample of those available on the Internet. The study re- tensive physical therapy and rehabilitation. Those with post- inforces that there is a need to consider the reading level of the pa- operative cognitive and speech impairments require psychological tient when distributing printed material. The last grade attended in evaluation, speech therapy, and rehabilitation. The nurse works school may not reflect reading ability. Nurses should consider mod- collaboratively with the physician and other health care profes- ifying existing materials or developing new materials with attention sionals during hospitalization and home care to achieve as com- to instructional graphics, simpler words, patient interaction, and cultural sensitivity. plete a rehabilitation as possible. When tumor, injury, or disease makes the prognosis poor, care is directed toward making the patient as comfortable as possible. With return of the tumor or cerebral compression, the members of the need for health promotion and recommended patient becomes less alert and aware. Other possible conse- health screening. quences include paralysis, blindness, and seizures. The home care nurse, hospice nurse, and social worker work with the family to plan for additional home health care or hospice services or Evaluation placement of the patient in an extended-care facility. (See also EXPECTED PATIENT OUTCOMES the section on cerebral metastases in Chap. 65.) The patient and Expected patient outcomes may include: family are encouraged to discuss end-of-life preferences for care; the patient’s end-of-life preferences must be respected (see 1. Achieves optimal cerebral tissue perfusion Chap. 17). a. Opens eyes on request; uses recognizable words, pro- The nurse involved in home and continuing care of patients gressing to normal speech following cranial surgery needs to remind patients and family b. Obeys commands with appropriate motor responses Chapter 61 Management of Patients With Neurologic Dysfunction 1873

2. Attains thermoregulation and normal body temperature Deep breathing is taught before surgery. The patient is in- a. Registers normal body temperature structed that following the surgery he or she will need to avoid 3. Has normal gas exchange vigorous coughing, blowing the nose, sucking through a straw, or a. Has arterial blood gas values within normal ranges sneezing, because these actions may cause a CSF leak (Greenberg, b. Breathes easily; lung sounds clear without adventitious 2001; Hickey, 2003). sounds c. Takes deep breaths and changes position as directed Postoperative Management 4. Copes with sensory deprivation 5. Demonstrates improving self-concept Because the procedure disrupts the oral and nasal mucous mem- a. Pays attention to grooming branes, management focuses on preventing infection and pro- b. Visits and interacts with others moting healing. Medications include antimicrobial agents (which 6. Absence of complications are continued until the nasal packing inserted at the time of a. Exhibits ICP within normal range surgery is removed), corticosteroids, analgesic agents for discom- b. Has minimal bleeding at surgical site; surgical incision fort, and agents for the control of diabetes insipidus when neces- is healing without evidence of infection sary (Greenberg, 2001). c. Shows fluid balance and electrolyte levels within desired ranges Nursing Management d. Exhibits no evidence of seizures An overview of care of the patient undergoing intracranial Vital signs are measured to monitor hemodynamic, cardiac, and surgery is presented in Chart 61-2. ventilatory status (Eisenberg & Redick, 1998). Because of the anatomic proximity of the pituitary gland to the optic chiasm, visual acuity is assessed at regular intervals. One method is to ask the TRANSSPHENOIDAL SURGERY patient to count the number of fingers held up by the nurse. Evi- dence of decreasing visual acuity suggests an expanding hematoma. Tumors within the sella turcica and small adenomas of the pitu- The head of the bed is raised to decrease pressure on the sella itary can be removed through a transsphenoidal approach: an turcica and to promote normal drainage. The patient is cau- incision is made beneath the upper lip and entry is then gained tioned against blowing the nose or engaging in any activity that successively into the nasal cavity, sphenoidal sinus, and sella tur- raises ICP, such as bending over or straining during urination or cica (see Table 61-3). Although an otorhinolaryngologist may defecation. make the initial opening, the neurosurgeon completes the open- Intake and output are measured as a guide to fluid and elec- ing into the sphenoidal sinus and exposes the floor of the sella. trolyte replacement. The urine specific gravity is measured after Microsurgical techniques provide improved illumination, mag- each voiding (Greenberg, 2001). Daily weight is monitored. Flu- nification, and visualization so that nearby vital structures can be ids are generally given when nausea ceases, and the patient then avoided. progresses to a regular diet. The transsphenoidal approach offers direct access to the sella The nasal packing inserted during surgery is checked fre- with minimal risk of trauma and hemorrhage (Greenberg, 2001). quently for blood or CSF drainage. The major discomfort is re- It avoids many of the risks of craniotomy, and the postoperative lated to the nasal packing and to mouth dryness and thirst from discomfort is similar to that of other transnasal surgical proce- mouth-breathing. Oral care is provided every 4 hours or more fre- dures. It may also be used for pituitary ablation (removal) in pa- quently. Usually, the teeth are not brushed until the incision tients with disseminated breast or prostatic cancer. above the teeth has healed. The use of warm saline mouth rinses and a cool mist vaporizer is helpful. Petrolatum is soothing when Complications applied to the lips. A room humidifier assists in keeping the mucous membranes moist. The packing is removed in 3 to 4 days, Manipulation of the posterior pituitary gland during surgery may and only then can the area around the nares be cleaned with the produce transient diabetes insipidus of several days’ duration prescribed solution to remove crusted blood and moisten the mu- (Greenberg, 2001). It is treated with vasopressin but occasionally cous membranes (Hickey, 2003). persists. Other complications include CSF leakage, visual distur- Home care considerations include advising the patient to use bances, postoperative meningitis, and SIADH. a room humidifier to keep the mucous membranes moist and to soothe irritation. The head of the bed is elevated for at least Preoperative Evaluation 2 weeks after surgery. The preoperative workup includes a series of endocrine tests, rhi- nologic evaluation (to assess the status of the sinuses and nasal Seizure Disorders cavity), and neuroradiologic studies. Funduscopic examination SEIZURES and visual field determinations are performed, because the most serious effect of pituitary tumor is localized pressure on the optic Seizures are episodes of abnormal motor, sensory, autonomic, or nerve or chiasm. In addition, the nasopharyngeal secretions are psychic activity (or a combination of these) resulting from sud- cultured because a sinus infection is a contraindication to an in- den excessive discharge from cerebral neurons (Greenberg, 2001; tracranial procedure through this approach. Corticosteroids may Hickey, 2003). A part or all of the brain may be involved. The be administered before and after surgery (because the surgery in- international classification of seizures differentiates between two volves removal of the pituitary, the source of adrenocorticotropic main types: partial seizures that begin in one part of the brain, and hormone [ACTH] is removed). Antibiotics may or may not be generalized seizures that involve electrical discharges in the whole administered prophylactically (Greenberg, 2001). brain (Chart 61-3). Most seizures are sudden and transient. 1874 Unit 14 NEUROLOGIC FUNCTION

Chart International Classification of Seizures • The type of movements in the part of the body involved 61-3 • The areas of the body involved (turn back bedding to ex- Partial Seizures (seizures beginning locally) pose patient) The size of both pupils. Are the eyes open? Did the eyes or Simple partial seizures (with elementary symptoms, generally • without impairment of consciousness) head turn to one side? • With motor symptoms • The presence or absence of automatisms (involuntary • With special sensory or somatosensory symptoms motor activity, such as lip smacking or repeated swallowing) • With autonomic symptoms • Incontinence of urine or stool • Compound forms • Duration of each phase of the seizure Complex partial seizures (with complex symptoms, generally • Unconsciousness, if present, and its duration with impairment of consciousness) • Any obvious paralysis or weakness of arms or legs after the • With impairment of consciousness only seizure • With cognitive symptoms • With affective symptoms • Inability to speak after the seizure • With psychosensory symptoms • Movements at the end of the seizure • With psychomotor symptoms (automatisms) • Whether or not the patient sleeps afterward • Compound forms • Cognitive status (confused or not confused) after the seizure Partial seizures secondarily generalized In addition to providing data about the seizure, nursing care Generalized Seizures (convulsive or nonconvulsive, bilaterally symmetric, without local onset) is directed at preventing injury and supporting the patient. This Tonic-clonic seizures includes supporting the patient not only physically but also psy- Tonic seizures chologically. Consequences such as distress, embarrassment, fa- Clonic seizures tigue, and depression can be devastating to the patient (Buelow, Absence seizures 2001). Steps to prevent or minimize injury to the patient are pre- Atonic seizures sented in Chart 61-4. Myoclonic seizures (bilaterally massive epileptic) Nursing Management After a Seizure After a patient has a seizure, the nurse’s role is to document the The underlying cause is an electrical disturbance (dysrhyth- events leading to and occurring during the seizure and to prevent mia) in the nerve cells in one section of the brain, causing them complications (eg, aspiration, injury). The patient is at risk for to emit abnormal, recurring, uncontrolled electrical discharges. hypoxia, vomiting, and pulmonary aspiration. To prevent com- The characteristic seizure is a manifestation of this excessive neu- plications, the patient is placed in the side-lying position to facil- ronal discharge. There may be associated loss of consciousness, itate drainage of oral secretions and is suctioned, if needed, to excess movement or loss of muscle tone or movement, and dis- maintain a patent airway and prevent aspiration, as described in turbances of behavior, mood, sensation, and perception. Chart 61-4. Seizure precautions are maintained, including having The specific causes of seizures are varied and can be catego- available fully functioning suction equipment with a suction rized as idiopathic (genetic, developmental defects) and acquired. catheter and oral airway. The bed is placed in a low position with Among the causes of acquired seizures are hypoxemia of any side rails up and padded if necessary to prevent patient injury. cause, including vascular insufficiency, fever (childhood), head The patient may be drowsy and may wish to sleep after the injury, hypertension, central nervous system infections, metabolic seizure; he or she may not remember events leading up to the and toxic conditions (eg, renal failure, hyponatremia, hypocal- seizure and for a short time thereafter. cemia, hypoglycemia, pesticides), brain tumor, drug and alcohol withdrawal, and allergies (Schumacher, Pruitt & Phillips, 2000). Cerebrovascular disease is the leading cause of seizures in the THE EPILEPSIES elderly (Berges, Moulin, Berger et al., 2000). Epilepsy is a group of syndromes characterized by recurring seizures. Epileptic syndromes are classified by specific patterns of Nursing Management During a Seizure clinical features, including age of onset, family history, and seizure type (Schachter, 2001). Types of epilepsies are differentiated by A major responsibility of the nurse is to observe and record the how the seizure activity manifests (see Chart 61-3), the most sequence of symptoms. The nature of the seizure usually indicates common syndromes being those with generalized seizures and the type of treatment that is required (Wulf, 2000). Before and those with partial-onset seizures. Epilepsy can be primary (idio- during a seizure, the following are assessed and documented: pathic) or secondary, when the cause is known and the epilepsy • The circumstances before the seizure (visual, auditory, or is a symptom of another underlying condition such as a brain olfactory stimuli, tactile stimuli, emotional or psychologi- tumor (Schachter, 2001). cal disturbances, sleep, hyperventilation) An estimated 2 to 4 million people in the United States have • The occurrence of an aura (visual, auditory, or olfactory) epilepsy (1 in 100 adults is affected), and onset occurs before the • The first thing the patient does in a seizure—where the age of 20 years in greater than 75% of patients (Schacter, 2001). movements or the stiffness starts, conjugate gaze position, The improved treatment of cerebrovascular disorders, head in- and the position of the head at the beginning of the seizure. juries, brain tumors, meningitis, and encephalitis has increased This information gives clues to the location of the seizure the number of patients at risk for seizures following recovery from origin in the brain. (In recording, it is important to state these conditions (Berges et al., 2000). Also, advances in EEG whether the beginning of the seizure was observed.) have aided in the diagnosis of epilepsy. The general public has Chapter 61 Management of Patients With Neurologic Dysfunction 1875 Chart 61-4 Guidelines for Seizure Care Nursing Care During a Seizure • If possible, place the patient on one side with head flexed forward, which allows the tongue to fall forward and facilitates • Provide privacy and protect the patient from curious on-lookers. drainage of saliva and mucus. If suction is available, use it if (The patient who has an aura [warning of an impending seizure] necessary to clear secretions. may have time to seek a safe, private place.) • Ease the patient to the floor, if possible. Nursing Care After the Seizure Protect the head with a pad to prevent injury (from striking a • Keep the patient on one side to prevent aspiration. Make sure the hard surface). • airway is patent. Loosen constrictive clothing. • There is usually a period of confusion after a grand mal seizure. Push aside any furniture that may injure the patient during the • • A short apneic period may occur during or immediately after a seizure. • generalized seizure. If the patient is in bed, remove pillows and raise side rails. • The patient, on awakening, should be reoriented to the If an aura precedes the seizure, insert an oral airway to reduce the • • environment. possibility of the tongue or cheek being bitten. If the patient becomes agitated after a seizure (postictal), use calm Do not attempt to pry open jaws that are clenched in a spasm to in- • • persuasion and gentle restraint. sert anything. Broken teeth and injury to the lips and tongue may result from such an action. • No attempt should be made to restrain the patient during the seizure because muscular contractions are strong and restraint can produce injury.

Oxygen and suction Privacy provided apparatus available as soon as possible

Side rails up and padded

Oxygen tubing

Loosened clothing

Pillow under head Patient in Side rails up side-lying position (padding not shown Bed in lowest position (immediately postseizure) to allow for see-through effect)

been educated about epilepsy, which has reduced the stigma as- rum, head injuries, some infectious diseases (bacterial, viral, sociated with it; as a result, more people are willing to acknowl- parasitic), toxicity (carbon monoxide and lead poisoning), circu- edge the diagnosis. latory problems, fever, metabolic and nutritional disorders, and Although there is evidence that susceptibility to some types of drug or alcohol intoxication (Schachter, 2001). It is also associ- epilepsy may be inherited, the cause of seizures in many people is ated with brain tumors, abscesses, and congenital malformations. unknown. Epilepsy can follow birth trauma, asphyxia neonato- In most cases of epilepsy, the cause is unknown (idiopathic). 1876 Unit 14 NEUROLOGIC FUNCTION

Pathophysiology taken, including events of pregnancy and childbirth, to seek evidence of preexisting injury. The patient is also questioned about Messages from the body are carried by the neurons (nerve cells) illnesses or head injuries that may have affected the brain. In ad- of the brain by means of discharges of electrochemical energy that dition to physical and neurologic evaluations, diagnostic exami- sweep along them. These impulses occur in bursts whenever a nations include biochemical, hematologic, and serologic studies. nerve cell has a task to perform. Sometimes, these cells or groups MRI is used to detect lesions in the brain, focal abnormalities, of cells continue firing after a task is finished. During the period cerebrovascular abnormalities, and cerebral degenerative changes of unwanted discharges, parts of the body controlled by the er- (Schachter, 2001). rant cells may perform erratically. Resultant dysfunction ranges The electroencephalogram (EEG) furnishes diagnostic evi- from mild to incapacitating and often causes unconsciousness dence in a substantial proportion of patients with epilepsy and (Greenberg, 2001; Hickey, 2003). When these uncontrolled, ab- aids in classifying the type of seizure (Schachter, 2001). Abnor- normal discharges occur repeatedly, a person is said to have an malities in the EEG usually continue between seizures or, if not epileptic syndrome (Schachter, 2001). apparent, may be elicited by hyperventilation or during sleep. Epilepsy is not associated with intellectual level. People with Microelectrodes can be inserted deep in the brain to probe the epilepsy without other brain or nervous system disabilities fall action of single brain cells. Some people with seizures have nor- within the same intelligence ranges as the overall population. mal EEGs, whereas others who have never had seizures have ab- Epilepsy is not synonymous with mental retardation or illness. normal EEGs. Telemetry and computerized equipment are used Many who are developmentally disabled because of serious neu- to monitor electrical brain activity while patients pursue their rologic damage, however, have epilepsy as well. normal activities and to store the readings on computer tapes for analysis. Video recording of seizures taken simultaneously with Clinical Manifestations EEG telemetry is useful in determining the type of seizure as well as its duration and magnitude. This type of intensive monitoring Depending on the location of the discharging neurons, seizures is changing the treatment of severe epilepsy. may range from a simple staring episode to prolonged convulsive Single photon emission computed tomography (SPECT) is movements with loss of consciousness. Seizures have been classi- an additional tool sometimes used in the diagnostic workup. It fied according to the area of the brain involved and have been is useful for identifying the epileptogenic zone so that the area identified as partial, generalized, and unclassified (Greenberg, in the brain giving rise to seizures can be removed surgically 2001; Hickey, 2003). Partial seizures are focal in origin and af- (Huntington, 1999). fect only part of the brain. Generalized seizures are nonspecific in origin and affect the entire brain simultaneously. Unclassified seizures are so termed because of incomplete data. Women With Epilepsy The initial pattern of the seizures indicates the region of the More than 1 million American women have epilepsy, and they brain in which the seizure originates (see Chart 61-2). In simple face particular needs associated with the syndrome (Schachter, partial seizures, only a finger or hand may shake, or the mouth Krishnamurthy & Cantrell, 2000). Women with epilepsy often may jerk uncontrollably. The person may talk unintelligibly, may note an increase in seizure frequency during menses; this has been be dizzy, and may experience unusual or unpleasant sights, sounds, linked to the increase in sex hormones that alter the excitability odors, or tastes, but without loss of consciousness (Greenberg, of neurons in the cerebral cortex. Women of childbearing age re- 2001; Hickey, 2003). quire special care and guidance before, during, and after preg- In complex partial seizures, the person either remains mo- nancy. Many women note a change in the pattern of seizure tionless or moves automatically but inappropriately for time and activity during pregnancy. Fetal malformation has been linked to place, or may experience excessive emotions of fear, anger, ela- the use of multiple antiseizure medications (Karch, 2002). The tion, or irritability. Whatever the manifestations, the person does effectiveness of contraceptives is decreased by antiseizure med- not remember the episode when it is over. ications. Therefore, patients should be encouraged to discuss Generalized seizures, previously referred to as grand mal seizures, family planning with their primary health care provider and to involve both hemispheres of the brain, causing both sides of the obtain preconception counseling if they are considering child- body to react (Greenberg, 2001; Hickey, 2003). There may be bearing (Liporace, 1997). intense rigidity of the entire body followed by alternating muscle Because of bone loss associated with the long-term use of anti- relaxation and contraction (generalized tonic–clonic contrac- seizure medications, patients receiving antiseizure agents should tion). The simultaneous contractions of the diaphragm and chest be assessed for low bone mass and osteoporosis. They should muscles may produce a characteristic epileptic cry. The tongue is be instructed about other strategies to reduce their risks for often chewed, and the patient is incontinent of urine and stool. osteoporosis. After 1 or 2 minutes, the convulsive movements begin to subside; the patient relaxes and lies in deep coma, breathing noisily. The Gerontologic Considerations respirations at this point are chiefly abdominal. In the postictal state (after the seizure), the patient is often confused and hard to Elderly people have a high incidence of new-onset epilepsy arouse and may sleep for hours. Many patients complain of (Schachter, 2001). Increased incidence is associated with stroke, headache, sore muscles, fatigue, and depression (Buelow, 2001). head injury, dementia, infection, alcoholism, and aging. Treat- ment depends on the underlying cause. Because many elderly Assessment and Diagnostic Findings people have chronic health problems, they may be taking other medications that can interact with medications prescribed for The diagnostic assessment is aimed at determining the type of seizure control. In addition, the absorption, distribution, metab- seizures, their frequency and severity, and the factors that pre- olism, and excretion of medications are altered in the elderly as a cipitate them (Schachter, 2001). A developmental history is result of age-related changes in renal and liver function. There- Chapter 61 Management of Patients With Neurologic Dysfunction 1877 fore, the elderly must be monitored closely for adverse and toxic the medication is initially prescribed; or (3) chronic toxicity, effects of antiseizure medications and for osteoporosis. The cost which occurs late in the course of therapy. of antiseizure medications can lead to poor adherence to the pre- The manifestations of drug toxicity are variable, and any organ scribed regimen in elderly patients on fixed incomes. system may be involved. Gingival hyperplasia (swollen and tender gums) can be associated with long-term use of phenyt- Prevention oin (Dilantin), for example (Karch, 2002). Periodic physical and dental examinations and laboratory tests are performed for pa- Society-wide efforts are the key to the prevention of epilepsy. The tients receiving medications known to have hematopoietic, gen- risk for congenital fetal anomaly is two to three times higher in itourinary, or hepatic effects. Table 61-4 lists the medications in mothers with epilepsy. The effects of maternal seizures, antiseizure current use. medications, and genetic predisposition are all mechanisms that contribute to possible malformation. Because the unborn infants NURSING ALERT Nurses must take care when administering of mothers who take certain antiseizure medications for epilepsy lamotrigine (Lamictal), an antiseizure medication. The drug pack- are at risk, these women need careful monitoring, including blood aging was recently changed in an attempt to reduce medication studies to detect the level of antiseizure medications taken through- errors as this medication has been confused with terbinafine out pregnancy (Karch, 2002). High-risk mothers (teenagers, (Lamisil), labetalol hydrochloride (Trandate), lamivudine (Epivir), women with histories of difficult deliveries, drug use, patients maprotiline (Ludiomil), as well as the combination diphenoxylate with diabetes or hypertension) should be identified and moni- ! and atropine (Lomotil). Any patient given an incorrect medication tored closely during pregnancy because damage to the fetus during may suffer adverse effects, and patients with epilepsy are at risk for pregnancy and delivery may increase the risk for epilepsy. All of status epilepticus from having their medication regimen interrupted these issues need further study (Schachter, Krishnamurthy & (Vernarec, 2001). Cantrell, 2000). Head injury is one of the main causes of epilepsy that can be SURGICAL MANAGEMENT prevented. Through highway safety programs and occupational Surgery is indicated for patients whose epilepsy results from in- safety precautions, lives can be saved and epilepsy due to head intracranial tumors, abscess, cysts, or vascular anomalies. Some pa- jury prevented; these programs are discussed in Chapter 63. tients have intractable seizure disorders that do not respond to medication. There may be a focal atrophic process secondary to Medical Management trauma, inflammation, stroke, or anoxia. If the seizures originate in a reasonably well-circumscribed area of the brain that can be The management of epilepsy is individualized to meet the needs excised without producing significant neurologic deficits, the re- of each patient and not just to manage and prevent seizures. Man- moval of the area generating the seizures may produce long-term agement differs from patient to patient because some forms of control and improvement (Wiebe, Blume, Girvin et al., 2001). epilepsy arise from brain damage and others are due to altered This type of neurosurgery has been aided by several advances, brain chemistry. including microsurgical techniques, depth EEGs, improved illumination and hemostasis, and the introduction of neurolept- PHARMACOLOGIC THERAPY analgesic agents (droperidol and fentanyl). These techniques, Many medications are available to control seizures, although the combined with use of local anesthetic agents, enable the neuro- mechanisms of their actions are still unknown (Karch, 2002). surgeon to perform surgery on an alert and cooperative patient. The objective is to achieve seizure control with minimal side Using special testing devices, electrocortical mapping, and the pa- effects. Medication therapy controls rather than cures seizures. tient’s response to stimulation, the boundaries of the epilepto- Medications are selected on the basis of the type of seizure being genic focus are determined (Huntington, 1999). Any abnormal treated and the effectiveness and safety of the medications (Shafer, epileptogenic focus (ie, abnormal area of the brain) is then re- 1999a, 1999b; Winkelman, 1999). If properly prescribed and moved (Wiebe et al., 2001). taken, medications control seizures in 50% to 60% of patients As an adjunct to medication and surgery in adolescents and with recurring seizures and provide partial control in another adults with partial seizures, a generator may be implanted under the 15% to 35%. The condition is not improved by any available clavicle. The device is connected to the vagus nerve in the cervical medication in 20% and 35% of patients with generalized and area, where it delivers electrical signals to the brain to control and partial epilepsy, respectively (Devinsky, 1999). reduce seizure activity (Kennedy & Schallert, 2001). An external Treatment is usually started with a single medication. The programming system is used by the physician to change stimulator starting dose and the rate at which the dosage is increased depend settings. Patients can turn the stimulator on and off with a magnet. on the occurrence of side effects. The medication levels in the blood are monitored because the rate of drug absorption varies NURSING PROCESS: among patients. Changing to another medication may be neces- THE PATIENT WITH EPILEPSY sary if seizure control is not achieved or if toxicity makes it impossible to increase the dosage. The medication may need to Assessment be adjusted because of concurrent illness, weight changes, or in- The nurse elicits information about the seizure history. The pa- creases in stress. Sudden withdrawal of these medications can tient is asked about the factors or events that may precipitate the cause seizures to occur with greater frequency or can precipitate seizures. Alcohol intake is documented. The nurse determines if the development of status epilepticus (Greenberg, 2001). the patient has an aura (a premonitory or warning sensation) be- Side effects of antiseizure agents may be divided into three fore an epileptic seizure, which may indicate the origin of the groups: (1) idiosyncratic or allergic disorders, which present pri- seizure (eg, seeing a flashing light may indicate the seizure origi- marily as skin reactions; (2) acute toxicity, which may occur when nated in the occipital lobe). Observation and assessment during 1878 Unit 14 NEUROLOGIC FUNCTION

Table 61-4 • Major Antiseizure Medication

MEDICATION DOSE-RELATED SIDE EFFECTS TOXIC EFFECTS carbamazepine (Tegretol) Dizziness, drowsiness, unsteadiness, nausea and vomiting, Severe skin rash, blood dyscrasias, hepatitis diplopia, mild leukopenia clonazepam (Klonopin) Drowsiness, behavior changes, headache, hirsutism, alope- Hepatotoxicity, thrombocytopenia, bone cia, palpitations marrow failure, ataxia ethosuximide (Zarontin) Nausea and vomiting, headache, gastric distress Skin rash, blood dyscrasias, hepatitis, lupus erythematosus felbamate (Felbatol) Cognitive impairments, insomnia, nausea, headache, fatigue Aplastic anemia, hepatotoxicity gabapentin (Neurotonin) Dizziness, drowsiness, somnolence, fatigue, ataxia, weight Leukopenia, hepatotoxicity gain, nausea lamotrigine (Lamictal) Drowsiness, tremor, nausea, ataxia, dizziness, headache, Severe rash (Stevens-Johnson syndrome) weight gain levetiracetam (Keppra) Somnolence, dizziness, fatigue Unknown oxacarbazepine (Trileptal) Dizziness, somnolence, double vision, fatigue, nausea, Hepatotoxicity vomiting, loss of coordination, abnormal vision, abdominal pain, tremor, abnormal gait phenobarbital (Luminal) Sedation, irritability, diplopia, ataxia Skin rash, anemia phenytoin (Dilantin) Visual problems, hirsutism, gingival hyperplasia, dysrhyth- Severe skin reaction, peripheral neuropathy, mias, dysarthria, nystagmus ataxia, drowsiness, blood dyscrasias primidone (Mysoline) Lethargy, irritability, diplopia, ataxia, impotence Skin rash tiagabine (Gabitril) Dizziness, fatigue, nervousness, tremor, difficulty concentrat- Unknown ing, dysarthria, weak or buckling knees, abdominal pain topiramate (Topamax) Fatigue, somnolence, confusion, ataxia, anorexia, depres- Nephrolithiasis sion, weight loss valproate (Depakote, Depakene) Nausea and vomiting, weight gain, hair loss, tremor, Hepatotoxicity, skin rash, blood menstrual irregularities dyscrasias, nephritis zonisamide (Zonegran, Excegran) Somnolence, dizziness, anorexia, headache, nausea, agita- Leukopenia, hepatotoxicity tion, rash and after a seizure assist in identifying the type of seizure and its Nursing Interventions management. The effects of epilepsy on the patient’s lifestyle are assessed PREVENTING INJURY (Buelow, 2001). What limitations are imposed by the seizure dis- Injury prevention for the patient with seizures is a priority. If at order? Does the patient have a recreational program? Social con- risk for injury (depending on the seizure type), the patient should tacts? Is the patient working, and is it a positive or stressful be placed on the floor and any obstructive items should be re- experience? What coping mechanisms are used? moved. The patient should never be forced into a position, nor should anyone attempt to insert anything into the patient’s mouth Diagnosis once a seizure has begun. Patients on seizure precautions should have pads applied to side rails while in bed. NURSING DIAGNOSES Based on the assessment data, the patient’s major nursing diag- REDUCING FEAR OF SEIZURES noses may include the following: Fear that a seizure may occur unexpectedly can be reduced by the • Risk for injury related to seizure activity patient’s adherence to the prescribed treatment regimen. Coop- • Fear related to the possibility of seizures eration of the patient and family and their trust in the prescribed • Ineffective individual coping related to stresses imposed by regimen are essential for control of seizures (Schachter, 2001). It epilepsy should be emphasized that the prescribed antiseizure medication • Deficient knowledge related to epilepsy and its control must be taken on a continuing basis without fear of drug dependence or addiction. Periodic monitoring is necessary to ensure the COLLABORATIVE PROBLEMS/ adequacy of the treatment regimen and to prevent side effects. POTENTIAL COMPLICATIONS In an effort to control seizures, factors that may precipitate The major potential complication of patients with epilepsy is as them are identified: emotional disturbances, new environmen- follows: tal stressors, onset of menstruation in female patients, or fever • Status epilepticus (Greenberg, 2001). The patient is encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimu- lants), exercise, and rest (sleep deprivation may lower the seizure Planning and Goals threshold). Moderate activity is therapeutic, but excessive exer- The major goals for the patient may include prevention of injury, cise should be avoided. control of seizures, achievement of a satisfactory psychosocial ad- Photic stimulation (bright flickering lights, television viewing) justment, acquisition of knowledge and understanding about the may precipitate seizures; wearing dark glasses or covering one eye condition, and absence of complications. may be preventive. Tension states (anxiety, frustration) induce Chapter 61 Management of Patients With Neurologic Dysfunction 1879

NURSING RESEARCH PROFILE 61-2 tainty. The patient must cope with the constant fear of a seizure Nursing Observation and Documentation and its consequences (Buelow, 2001). Children with epilepsy may be ostracized and excluded from school and peer activities. These of Seizures problems are compounded during adolescence and add to the Wulf, J. A. (2000). Evaluation of seizure observation and documentation. challenges of dating, not being able to drive, and feeling different. Journal of Neuroscience Nursing, 32(1), 27–36. Adults face these problems in addition to the burden of finding employment, concerns about relationships and childbearing, in- Purpose surance problems, and legal barriers. Alcohol abuse may compli- The observation and documentation of seizure activity are chal- cate matters. Family reactions may vary from outright rejection of lenging yet essential aspects of nursing assessment. Despite their the person with epilepsy to overprotection. As a result, many importance, there is a wide variability in nursing observation and documentation skills. The purpose of this study was to evaluate people with epilepsy have psychological and behavioral problems. how demographic characteristics and knowledge levels of staff Counseling assists the individual and family to understand affected seizure documentation skills. the condition and the limitations imposed by it. Social and recreational opportunities are necessary for good mental health. Nurses Study Sample and Design can improve the quality of life for patients with epilepsy by edu- This descriptive study included 58 participants: 38 RNs, 17 certi- cating them and their families about symptoms and their man- fied nursing assistants, and 3 licensed practical nurses or recrea- agement (Rice, 2000). tional therapists employed at a hospital with an epilepsy center. All participants had received mandatory seizure observation training PROVIDING PATIENT AND FAMILY EDUCATION within the 2 years preceding the study. Participants observed and documented the same six videotaped seizure events in a randomly Of all the care contributed by the nurse to the person with epilepsy, ordered sequence over 4 to 6 weeks. Participants used an event re- perhaps the most valuable facets are education and efforts to cord form with observational guidelines similar to those used in the modify the attitudes of the patient and family toward the dis- clinical setting. Two raters evaluated and scored the seizure event order. The person who experiences seizures may consider every records, rating each record for detail and quality. seizure a potential source of humiliation and shame. This may result in anxiety, depression, hostility, and secrecy on the part of Findings the patient and family. Ongoing education and encouragement Seizure event ratings did not vary significantly according to observer characteristics of educational level, employment position, years of should be given to patients to enable them to overcome these feel- employment, or clinical experience with epilepsy. Certified nursing ings. The patient with epilepsy should carry an emergency med- assistants with clinical experience with epilepsy had significantly ical identification card or wear a medical information bracelet. higher mean seizure rating scores (indicating higher quality and de- The patient and family need to be educated about medications as tail) compared to nursing assistants without experience ( p < 0.01). well as care during a seizure. There were no differences in RNs with and without experience. A master score sheet was developed for each seizure event, and sei- MONITORING AND MANAGING zures with excess motor activity as an attribute had the highest POTENTIAL COMPLICATIONS scores, indicating that a greater number of details about the seizure Status epilepticus, the major complication, is described below. An- were observed compared to the master score sheet. Participants other complication is the toxicity of medications. The patient and missed some details of the seizure events and also documented details not present on the videotapes, such as seizure classification. family are instructed about side effects and are given specific guide- Opportunities to review videotapes or actual seizures periodically lines to assess and report signs and symptoms indicating medication improved observation and documentation skills. overdose. Many antiseizure medications require careful monitoring for therapeutic levels. Patients should plan to have serum drug lev- Nursing Implications els drawn at regular intervals. There are also many known drug in- The findings of this study suggest that use of a videotape of seizures teractions with antiseizure medications. A complete pharmacologic and a scoring tool is useful for initial training and certification and profile should be reviewed with the patient to avoid interactions ei- may assist in periodic retraining of all personnel responsible for ther potentiating or inhibiting the effectiveness of the medications. seizure observation to maintain quality of observation and documentation. Nurses involved in teaching these skills should keep in mind that observation instruction should emphasize not only pre- PROMOTING HOME AND COMMUNITY-BASED CARE dominate seizure features such as motor movements but also less Teaching Patients Self-Care frequently made observations such as responsiveness that may assist in seizure classification. Nurses observing and documenting seizure Thorough oral hygiene after each meal, gum massage, daily floss- activity should be cautioned not to include items such as seizure clas- ing, and regular dental care are essential to prevent or control gin- sification that are not direct observations and may be incorrect. gival hyperplasia in patients receiving phenytoin (Dilantin). The patient is also instructed to inform all health care providers of the medication being taken because of the possibility of drug interactions. An individualized comprehensive teaching plan is needed seizures in some patients. Classes in stress management may be of to assist the patient and family to adjust to this chronic disorder value. Because seizures are known to occur with alcohol intake, (Shafer, 1999). Written patient education materials must be ap- alcoholic beverages should be avoided. propriate for the patient’s reading level (Murphy, Chesson, Berman et al., 2001). See Chart 61-5 for home care instruction points. IMPROVING COPING MECHANISMS It has been noted that the social, psychological, and behavioral Continuing Care problems frequently accompanying epilepsy can be more of a Because epilepsy is a long-term disorder, the use of costly med- handicap than the actual seizures. Epilepsy may be accompanied ications may create a significant financial burden. The Epilepsy by feelings of stigmatization, alienation, depression, and uncer- Foundation of America offers a mail-order program to provide 1880 Unit 14 NEUROLOGIC FUNCTION

Chart 61-5 Home Care Checklist • The Patient With Epilepsy

At the completion of the home instruction, the patient and caregiver will be able to: Patient Caregiver • Take medications daily as prescribed to keep the drug level constant to prevent seizures. The patient should never discontinue medications, even when there is no seizure activity. ✓ • Keep a medication and seizure chart, noting when medications are taken and any seizure activity. ✓✓ • Notify the patient’s physician if patient cannot take medications due to illness. ✓✓ • Have antiseizure serum levels checked regularly. When testing is prescribed, the patient should report to the laboratory for blood sampling before taking morning medication. ✓ • Avoid activities that require alertness and coordination (driving, operating machinery) until after the effects of the medication have been evaluated. ✓ • Report signs of toxicity so dosage can be adjusted. Common signs include drowsiness, lethargy, dizziness, difﬁculty walking, hyperactivity, confusion, inappropriate sleep, and visual disturbances. ✓✓ • Avoid over-the-counter medications unless approved by the patient’s physician. ✓ • Carry a medical alert bracelet or identiﬁcation card specifying the name of the patient’s antiseizure medication and physician. ✓ • Avoid seizure triggers, such as alcoholic beverages, electrical shocks, stress, caffeine, constipation, fever, hyperventilation, hypoglycemia. ✓ • Take showers rather than tub baths to avoid drowning if seizure occurs; never swim alone. ✓ • Exercise in moderation in a temperature-controlled environment to avoid excessive heat. ✓ • Develop regular sleep patterns to minimize fatigue and insomnia. ✓✓ • Use the Epilepsy Foundation of America’s special services, including help in obtaining medications, vocational rehabilitation, and coping with epilepsy. ✓✓

medications at minimal cost and access to life insurance. This or- 2. Exhibits decreased fear ganization serves as a referral source for special services for people 3. Displays effective individual coping with epilepsy. 4. Exhibits knowledge and understanding of epilepsy For many, overcoming employment problems is a challenge. a. Identifies the side effects of medications State vocational rehabilitation agencies can provide information b. Avoids factors or situations that may precipitate seizures about job training. The Epilepsy Foundation of America has a (flickering lights, hyperventilation, alcohol) training and placement service. If seizures are not well controlled, c. Follows a healthy lifestyle by getting adequate sleep and information about sheltered workshops or home employment eating meals at regular times to avoid hypoglycemia programs may also be obtained. Federal and state agencies and 5. Absence of complications federal legislation may be of assistance to people with epilepsy who experience job discrimination. As a result of the Americans With Disabilities Act, the number of employers who knowingly STATUS EPILEPTICUS hire people with epilepsy may be increasing, but barriers to em- Status epilepticus (acute prolonged seizure activity) is a series of ployment still exist (Buelow, 2001). generalized seizures that occur without full recovery of con- People who have uncontrollable seizures accompanied by psy- sciousness between attacks (Greenberg, 2001). The term has been chological and social difficulties can be referred to comprehensive broadened to include continuous clinical or electrical seizures epilepsy centers where continuous audio-video and EEG moni- lasting at least 30 minutes, even without impairment of con- toring, specialized treatment, and rehabilitation services are avail- sciousness. It is considered a medical emergency. Status epilepti- able (Schachter, 2001). Patients and their families need to be cus produces cumulative effects. Vigorous muscular contractions reminded of the importance of following the prescribed treat- impose a heavy metabolic demand and can interfere with respi- ment regimen and keeping follow-up appointments. In addition, rations. There is some respiratory arrest at the height of each they are reminded of the importance of participating in health seizure that produces venous congestion and hypoxia of the brain. promotion activities and recommended health screenings to pro- Repeated episodes of cerebral anoxia and edema may lead to ir- mote a healthy lifestyle. Genetic and preconception counseling is reversible and fatal brain damage. Factors that precipitate status advised. epilepticus include withdrawal of antiseizure medication, fever, and concurrent infection. Evaluation EXPECTED PATIENT OUTCOMES Medical Management Expected patient outcomes may include: The goals of treatment are to stop the seizures as quickly as pos- 1. Sustains no injury during seizure activity sible, to ensure adequate cerebral oxygenation, and to maintain a. Complies with treatment regimen and identifies the the patient in a seizure-free state. An airway and adequate oxy- hazards of stopping the medication genation are established. If the patient remains unconscious and b. Patient and family can identify appropriate care during unresponsive, a cuffed endotracheal tube is inserted. Intravenous seizure diazepam (Valium), lorazepam (Ativan), or fosphenytoin (Cere- Chapter 61 Management of Patients With Neurologic Dysfunction 1881 byx) is given slowly in an attempt to halt seizures immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state. An intravenous line is established, and blood samples are obtained to monitor serum electrolytes, glucose, and phenytoin levels (Greenberg, 2001). EEG monitoring may be useful in determining the nature of the seizure activity. Vital signs and neurologic signs are monitored on a continuing basis. An intravenous infusion of dextrose is given if the seizure is due to hypoglycemia. If initial treatment is unsuccessful, general anesthesia with a short-acting barbiturate may be used. The serum concentration of the antiseizure medication is measured because a low level suggests that the patient was not taking the medication or that the dosage was too low. Cardiac involvement or respiratory depression may be life-threatening. There is also the potential for postictal cerebral edema.

Nursing Management The nurse initiates ongoing assessment and monitoring of respiratory and cardiac function because of the risk for delayed depression of respiration and blood pressure secondary to administration of antiseizure medications and sedatives to halt the seizures. Nursing assessment also includes monitoring and documenting the seizure activity and the patient’s responsiveness. The patient is turned to a side-lying position if possible to assist Inflammation of the cranial arteries is characterized by a severe in draining pharyngeal secretions. Suction equipment must be headache localized in the region of the temporal arteries. The in- available because of the risk for aspiration. The intravenous line is flammation may be generalized (in which cranial arteritis is part closely monitored because it may become dislodged during seizures. of a vascular disease) or focal (in which only the cranial arteries A person who has received long-term antiseizure therapy has are involved). Cranial arteritis is a cause of headache in the older a significant risk for fractures resulting from bone disease (osteo- population, reaching its greatest incidence in those older than porosis, osteomalacia, and hyperparathyroidism), a side effect of 70 years of age. therapy. Thus, during seizures, the patient should be protected A secondary headache is a symptom associated with an or- from injury using seizure precautions and monitored closely. No ganic cause, such as a brain tumor or an aneurysm. Most headaches effort should be made to restrain movements. The patient having do not indicate serious disease, although persistent headaches re- seizures can inadvertently injure nearby people, so nurses should quire further investigation. Serious disorders related to headache protect themselves. Other nursing interventions for the person include brain tumors, subarachnoid hemorrhage, stroke, severe having seizures are presented in Chart 61-4. hypertension, meningitis, and head injuries.

Headache Assessment and Diagnostic Evaluation Headache, or cephalgia, is one of the most common of all human The diagnostic evaluation includes a detailed history, a physical physical complaints. Headache is actually a symptom rather than assessment of the head and neck, and a complete neurologic ex- a disease entity; it may indicate organic disease (neurologic or other amination. Headaches may manifest differently within an indi- disease), a stress response, vasodilation (migraine), skeletal muscle vidual over the course of a lifetime, and the same type of headache tension (tension headache), or a combination of factors. A primary may present differently from patient to patient. The health his- headache is one for which no organic cause can be identified. tory focuses on assessing the headache itself, with emphasis on the These types of headache include migraine, tension-type, and clus- factors that precipitate or provoke it. Patients are asked to deter headaches (Lin, 2001). Cranial arteritis is another common scribe headaches in their own words. cause of headache. A classification of headaches was issued by the Because headache is often the presenting symptom of various Headache Classification Committee of the International Headache physiologic and psychological disturbances, a general health his- Society in 1988; an abbreviated list is shown in Chart 61-6. tory is an essential component of the patient database. Headache Migraine is a symptom complex characterized by periodic may be a symptom of endocrine, hematologic, gastrointestinal, and recurrent attacks of severe headache. The cause of migraine infectious, renal, cardiovascular, or psychiatric disease. Therefore, has not been clearly demonstrated, but it is primarily a vascular questions addressed in the health history should cover major disturbance that occurs more commonly in women and has a medical and surgical illness as well as a body systems review. strong familial tendency. The typical time of onset is puberty, and The medication history can provide insight into the patient’s the incidence is highest in adults 20 to 35 years of age. There are overall health status. Antihypertensive agents, diuretic medica- seven subtypes of migraine, including migraine with and without tions, anti-inflammatory agents, and monoamine oxidase in- aura. Most patients have migraine without an aura. hibitors are a few of the categories of medications that can provoke Tension headaches tend to be more chronic than severe and are headaches. Although sometimes exaggerated in importance, emo- probably the most common type of headache. Cluster headaches tional factors can play a role in precipitating headaches. Stress is are a severe form of vascular headache. They are seen five times thought to be a major initiating factor in migraine headaches; more frequently in men than women (Greenberg, 2001). therefore, sleep patterns, level of stress, recreational interests, 1882 Unit 14 NEUROLOGIC FUNCTION appetite, emotional problems, and family stressors are relevant exact mechanism of pain in migraine is not completely understood (Cunningham, 2000). There is a strong familial tendency for but is thought to be related to the cranial blood vessels, the inner- headache disorders, and a positive family history may help in vation of the vessels, and the reflex connections in the brain stem. making a diagnosis. Migraines can be triggered by menstrual cycles, bright lights, A direct relationship may exist between exposure to toxic sub- stress, depression, sleep deprivation, fatigue, overuse of certain stances and headache. Careful questioning may uncover chem- medications, and certain foods containing tyramine, monosodium icals to which a worker has been exposed. Under the Right to glutamate, nitrites, or milk products. Foods in these categories Know law, employees have access to the material safety data include aged cheese and many processed foods. Use of oral con- sheets (commonly referred to as MSDSs) for all the substances traceptives may be associated with increased frequency and sever- with which they come in contact in the workplace. The occupa- ity of attacks in some women. tional history also includes assessment of the workplace as a pos- Emotional or physical stress may cause contraction of the sible source of stress and a possible ergonomic basis for muscle muscles in the neck and scalp, resulting in tension headache. The strain and headache. pathophysiology of cluster headache is not fully understood. One A complete description of the headache itself is crucial. The theory is that it is due to dilation of orbital and nearby extracra- age at onset of headache; the headache’s frequency, location, and nial arteries. Cranial arteritis is thought to represent an immune duration; the type of pain; factors that relieve and precipitate the vasculitis in which immune complexes are deposited within the event; and associated symptoms are reviewed. The data obtained walls of affected blood vessels, producing vascular injury and in- should include the patient’s own words about the headache in flammation. A biopsy may be performed on the involved artery response to the following questions: to make the diagnosis. • What is the location? Is it unilateral or bilateral? Does it radiate? Clinical Manifestations What is the quality—dull, aching, steady, boring, burning, • MIGRAINE intermittent, continuous, paroxysmal? The migraine with aura can be divided into four phases: pro- How many headaches occur during a given time? • drome, aura, the headache, and recovery (headache termination What are the precipitating factors, if any (environmental, • and postdrome). such as sunlight and weather change; foods; exertion; other)? Prodrome. The prodrome phase is experienced by 60% of pa- • What makes the headache worse (coughing, straining)? tients with symptoms that occur hours to days before a migraine • What time (day or night) does it occur? headache. Symptoms include depression, irritability, feeling cold, • Are there any associated symptoms, such as facial pain, food cravings, anorexia, change in activity level, increased urina- lacrimation (excessive tearing), or scotomas (blind spots in tion, diarrhea, or constipation. Patients usually experience the the field of vision)? same prodrome with each migraine headache. • What usually relieves the headache (aspirin, NSAIDs, ergot preparation, food, heat, rest, neck massage)? Aura Phase. Aura occurs in up to 31% of patients who have mi- • Does nausea, vomiting, weakness, or numbness in the ex- graines (Goadsby et al., 2002). The aura usually lasts less than an tremities accompany the headache? hour and may provide enough time for the patient to take the • Does the headache interfere with daily activities? prescribed medication to avert a full-blown attack (described in • Do you have any allergies? a later section). This period is characterized by focal neurologic • Do you have insomnia, poor appetite, loss of energy? symptoms. Visual disturbances (ie, light flashes and bright spots) • Is there a family history of headache? are common and may be hemianopic (affecting only half of the • What is the relationship of the headache to lifestyle or phys- visual field). Other symptoms that may follow include numbness ical or emotional stress? and tingling of the lips, face, or hands; mild confusion; slight • What medications are you taking? weakness of an extremity; drowsiness; and dizziness. This period of aura corresponds to the painless vasoconstric- Diagnostic testing is often not helpful in the investigation of tion that is the initial physiologic change characteristic of classic headache as there are often few objective findings. In patients migraine. Cerebral blood flow studies performed during migraine who demonstrate abnormalities on the neurologic examination, headaches demonstrate that during all phases of the attack, cere- CT, cerebral angiography, or MRI may be used to detect under- bral blood flow is reduced throughout the brain, with subsequent lying causes, such as tumor or aneurysm. Electromyography loss of autoregulation and impaired CO responsiveness. (EMG) may reveal a sustained contraction of the neck, scalp, or 2 facial muscles. Laboratory tests may include complete blood Headache Phase. As vasodilation and a decline in serotonin lev- count, erythrocyte sedimentation rate, electrolytes, glucose, cre- els occur, a throbbing headache (unilateral in 60% of patients) atinine, and thyroid hormone levels. intensifies over several hours. This headache is severe and incapacitating and is often associated with photophobia, nausea, Pathophysiology and vomiting. Its duration varies, ranging from 4 to 72 hours (Goadsby et al., 2002). The cerebral signs and symptoms of migraine result from dysfunction of the brain stem pathways that normally modulate Recovery Phase. In the recovery phase (termination and post- sensory input (Goadsby, Lipton & Ferrari, 2002). Abnormal me- drome), the pain gradually subsides. Muscle contraction in the tabolism of serotonin, a vasoactive neurotransmitter found in neck and scalp is common, with associated muscle ache and lo- platelets and cells of the brain, plays a major role. The headache is calized tenderness, exhaustion, and mood changes. Any physical preceded by a rise in plasma serotonin, which dilates the cerebral exertion exacerbates the headache pain. During this postheadache vessels, but migraines are more than just vascular headaches. The phase, patients may sleep for extended periods. Chapter 61 Management of Patients With Neurologic Dysfunction 1883

OTHER HEADACHE TYPES tion, reduce inflammation, and may reduce pain transmission. The tension headache is characterized by a steady, constant feel- The five triptans in routine clinical use include sumatriptan ing of pressure that usually begins in the forehead, temple, or (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitrip- back of the neck. It is often bandlike or may be described as “a tan (Zomig), and almotriptan (Goadsby et al., 2002). Numerous weight on top of my head.” serotonin receptor agonists are under study. Cluster headaches are unilateral and come in clusters of one to Ergotamine preparations (taken orally, sublingually, subcuta- eight daily, with excruciating pain localized to the eye and orbit and neously, intramuscularly, by rectum, or by inhalation) may be ef- radiating to the facial and temporal regions. The pain is accompa- fective in aborting the headache if taken early in the migraine nied by watering of the eye and nasal congestion. Each attack lasts process. They are low in cost. Ergotamine tartrate acts on smooth 30 to 90 minutes and may have a crescendo–decrescendo pattern muscle, causing prolonged constriction of the cranial blood vessels. (Greenberg, 2001). The headache is often described as penetrat- Each patient’s dosage is based on individual needs. Side effects in- ing and steady. clude aching muscles, paresthesias (numbness and tingling), nau- Cranial arteritis often begins with general manifestations, such sea, and vomiting. Cafergot, a combination of ergotamine and as fatigue, malaise, weight loss, and fever. Clinical manifestations caffeine, can arrest or reduce the severity of the headache if taken associated with inflammation (heat, redness, swelling, tenderness, at the first sign of an attack (Karch, 2002). or pain over the involved artery) usually are present. Sometimes Perhaps the most widely used triptan is sumatriptan succinate a tender, swollen, or nodular temporal artery is visible. Visual (Imitrex); it is available in oral, intranasal, and subcutaneous prepa- problems are caused by ischemia of the involved structures. rations and is effective for the treatment of acute migraine and cluster headaches in adults (McAlhany, 2001). The subcutaneous form Prevention usually relieves symptoms within an hour and is available in an auto- injector for immediate patient use, although it is expensive in this Prevention begins by having the patient avoid specific triggers form. Sumatriptan has been found to be effective in relieving mod- that are known to initiate the headache syndrome. Preventive erate to severe migraines in a large number of adult patients. Suma- medical management of migraine involves the daily use of one or triptan may cause chest pain and is contraindicated in patients with more agents that are thought to block the physiologic events lead- ischemic heart disease (Goadsby et al., 2002). Careful administra- ing to an attack. Medication therapy should be considered for mi- tion and dosing instructions to patients are important to prevent graine if attacks occur 3 to 4 days per month (Goadsby et al., adverse reactions such as increased blood pressure, drowsiness, 2002). Treatment regimens vary greatly, as do patient responses; muscle pain, sweating, and anxiety. There are possible interactions thus, close monitoring is indicated. when taken in conjunction with St. John’s wort (Karch, 2002). There are several proven or widely used medications for the Many of the triptan medications are available in a variety of prevention of migraine. Two beta-blocking agents, propranolol formulations, such as nasal sprays, inhalers, suppositories, or in- (Inderal) and metoprolol (Lopressor), inhibit the action of beta- jections; however, 80% of patients prefer the oral formulations receptors—cells in the heart and brain that control the dilation (Goadsby et al., 2002). None of these medications should be taken of blood vessels. This is thought to be a major reason for their antimigraine action. Other medications that are prescribed for mi- concurrently with medications containing ergotamine due to the graine prevention include amitriptyline hydrochloride (Elavil), potential for a prolonged vasoactive reaction (Karch, 2002). divalproex (Valproate), flunarizine, and several serotonin antag- The medical management of an acute attack of cluster head- onists (Goadsby et al., 2002). aches may include 100% oxygen by face mask for 15 minutes, Calcium antagonists (verapamil HCl) are widely used but may ergotamine tartrate, sumatriptan, steroids, or a percutaneous require several weeks at a therapeutic dosage before improvement sphenopalatine ganglion blockade (Greenberg, 2001). is noted. Calcium-channel blockers are not as effective as beta- The medical management of cranial arteritis consists of early blockers for prevention but may be more appropriate for some administration of a corticosteroid to prevent the possibility of loss patients, such as those with bradycardia, diabetes mellitus, or of vision due to vascular occlusion or rupture of the involved asthma (Goadsby et al., 2002). artery (Greenberg, 2001). The patient is instructed not to stop Alcohol, nitrites, vasodilators, and histamines may precipitate the medication abruptly because this can lead to relapse. Anal- cluster headaches. Eliminating these factors helps in preventing gesic agents are prescribed for comfort. the headaches (Silberstein & Rosenberg, 2000). Prophylactic medication therapy may include beta-blockers, ergotamine tar- Nursing Management trate (occasionally), lithium, naproxen (Naprosyn), and methy- sergide (Sansert); such therapy is effective in 20% to 40% of cases When migraine or the other types of headaches described above (Greenberg, 2001). have been diagnosed, the goals of nursing management are to enhance pain relief. It is reasonable to try nonpharmacologic inter- Medical Management ventions first, but the use of pharmacologic agents should not be delayed. The goal is to treat the acute event of the headache and Therapy for migraine headache is divided into abortive (sympto- to prevent recurrent episodes. Prevention involves patient educa- matic) and preventive approaches. The abortive approach, best tion regarding precipitating factors, possible lifestyle or habit employed in patients who suffer less frequent attacks, is aimed at changes that may be helpful, and pharmacologic measures. relieving or limiting a headache at the onset or while it is in progress. The preventive approach is used in patients who expe- RELIEVING PAIN rience more frequent attacks at regular or predictable intervals Individualized treatment depends on the type of headache and and may have medical conditions that preclude the use of abortive differs for migraine, cluster headaches, cranial arteritis, and ten- therapies (Evans & Lipton, 2001). sion headache (Greenberg, 2001; Silberstein & Rosenberg, 2000). The triptans, serotonin receptor agonists, are the most specific Nursing care is directed toward treatment of the acute episode. antimigraine agents available. These agents cause vasoconstric- A migraine or a cluster headache in the early phase requires 1884 Unit 14 NEUROLOGIC FUNCTION

Chart 61-7 Home Care Checklist • The Patient With Migraine Headaches

At the completion of the home instruction, the patient or caregiver will be able to: Patient Caregiver • Define migraine headaches and describe characteristics and manifestations. ✓✓ • Identify triggers of migraine headaches and how to avoid such triggers as: ✓✓ Foods that contain tyramine, such as chocolate, cheese, coffee, dairy products Dietary habits that result in long periods between meals Menstruation and ovulation (causes hormone fluctuation) Alcohol (causes vasodilation of blood vessels) Fatigue and fluctuations in sleep patterns • State importance of keeping and how to develop a headache diary. ✓✓ • State stress management and lifestyle changes to minimize the frequency of headaches. ✓✓ • State pharmacologic management: acute therapy and prophylaxis, to include medication regimen and side effects. ✓✓ • Identify comfort measures during headache attacks, such as resting in a quiet and dark environment, applying cold compresses to the painful area, and elevating the head. ✓✓ • Identify resources for education and support, such as the National Headache Foundation. ✓✓

abortive medication therapy instituted as soon as possible. Some headaches may be prevented if the appropriate medications are Critical Thinking Exercises taken before the onset of pain. Nursing care during a fully devel- ?? oped attack includes comfort measures such as a quiet, dark en- 1. Your patient has signs of increased ICP, including dis- vironment and elevation of the head of the bed to 30 degrees. In orientation and right-sided weakness. Describe the medical addition, symptomatic treatment such as antiemetics may be in- management you would anticipate to control the ICP and dicated (Goadsby et al., 2002). the nursing measures that are indicated. How would you Symptomatic pain relief for tension headache may be obtained determine if your interventions were effective in alleviating by application of local heat or massage. Additional strategies may the increased ICP? What are signs and symptoms of further include the use of analgesic agents, antidepressant medications, deterioration in neurologic status? Explain the physiologic and muscle relaxants. cause of each sign and symptom. HOME AND COMMUNITY-BASED CARE 2. Compare and contrast the possible characteristics, causes, prognoses, and nursing interventions for a) the patient who Teaching Patients Self-Care. Headaches, especially migraines, is unconscious, b) the patient in a persistent vegetative state, are more likely to occur when the patient is ill, overly tired, or and c) the patient in coma. stressed. Nonpharmacologic therapies are important and include patient education about the type of headache, its mechanism 3. A patient is admitted to your unit after undergoing (if known), and appropriate changes in lifestyle to avoid triggers. transsphenoidal surgery for a brain tumor. Describe the Regular sleep, meals, exercise, avoidance of peaks and troughs of major complications to assess for, along with the signs and relaxation, and avoidance of dietary triggers may be helpful in symptoms of each. Describe the nursing measures that are avoiding headaches (Goadsby et al., 2002; Rice, 2000). indicated postoperatively. What patient and family teaching The patient with tension headaches needs teaching and reas- is important for the patient and family? How would you surance that the headache is not due to a brain tumor. This is a modify your teaching and discharge planning if the patient common unspoken fear. Stress reduction techniques, such as understands little English? If the patient lives alone? biofeedback, exercise programs, and meditation, are examples of 4. You are caring for an 18-year-old patient admitted to the nonpharmacologic therapies that may prove helpful. Patients and hospital to evaluate the recent onset of seizures and an their families need to be reminded of the importance of follow- episode of status epilepticus. He is angry about his situation ing the prescribed treatment regimen for headache and keeping and states that he has no intention of taking medications or follow-up appointments. In addition, they are reminded of the giving up his driver’s license. Describe your approach to importance of participating in health promotion activities and caring for him. How would your approach differ if the recommended health screenings to promote a healthy lifestyle. patient is a 28-year-old woman who is 6 months pregnant? See Chart 61-7 for a home care checklist for the patient with migraine headaches.

Continuing Care. The National Headache Foundation (see Re- sources at end of the chapter) provides a list of clinics in the REFERENCES AND SELECTED READINGS United States and the names of physicians who specialize in Books headache and who are members of the American Association for Abram, S. E., & Haddox, J. D. (Eds.). (1999). The pain clinic manual the Study of Headache. (2nd ed.). Philadelphia: Lippincott Williams & Wilkins. Chapter 61 Management of Patients With Neurologic Dysfunction 1885

Bickley, L. S., & Szilagyi, P. G. (1999). Bates’ guide to physical examina- Clifton, G., Miller, E., Choi, S., et al. (2001). Lack of effect of induc- tion and history taking (7th ed.). Philadelphia: Lippincott Williams tion of hypothermia after acute brain injury. New England Journal of & Wilkins. Medicine, 344(8), 556–563. Cruz, J. (Ed.). (1998). Neurological and neurosurgical emergencies. Cunning, S., & Houdek, D. (1999). Preventing secondary brain in- Philadelphia: W. B. Saunders. juries. Dimensions of Critical Care Nursing, 18(5), 20–22. Fischbach, F. (2002). Common laboratory and diagnostic tests (3rd ed.). Hauber, R., & Testani-Dufour, L. (2000). Living in limbo: The low- Philadelphia: Lippincott Williams & Wilkins. level brain-injured patient and the patient’s family. Journal of Greenberg, M. (2001). Handbook of neurosurgery (4th ed.) New York: Neuroscience Nursing, 32(1), 22–26. Thieme Medical Publishers. Johnson, L. (1999). 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(2000). The brain- thermia on the incidence and treatment of intracranial hypertension. storms woman: Epilepsy in our lives. Philadelphia: Lippincott Williams Journal of Neuroscience Nursing, 31(5), 264–269. & Wilkins. *Sullivan, J. (2000). Positioning of patients with severe traumatic brain Stewart-Amidei. Ç, & Kunkel, J. (2001). AANN’s neuroscience nursing: injury: Research-based practice. Journal of Neuroscience Nursing, 32(4), 204–209. Human responses to neurologic dysfunction (2nd ed.) Philadelphia: *Sund-Levander, M., & Wahren, L. (2000). Assessment and prevention W. B. Saunders. of shivering in patients with severe cerebral injury. A pilot study. Young, G., Ropper, A., & Bolton, C. (1998). Coma and impaired con- Journal of Clinical Nursing, 9(1), 55–61. sciousness: A clinical perspective. New York: McGraw-Hill. Winkelman, C. (2000). Effect of backrest position on intracranial and Journals cerebral perfusion pressures in traumatically brain-injured adults. Asterisks indicate nursing research articles. American Journal of Critical Care, 9(6), 373–380. General Neurosurgical Care Bateman, D. (2001). Neurological assessment of coma. Journal of Neu- Eisenberg, A., & Redick, E. (1998). Transsphenoidal resection of pitu- rology, Neurosurgery and Psychiatry, 71(Suppl 1), i13–i17. itary adenoma: Using a critical pathway. Dimensions of Critical Care *Day, L., Stotts, N., Frankfurt, A., et al. (2001) Gastric versus duodenal Nursing, 17(6), 306–312. feeding in patients with neurological disease: A pilot study. Journal Leith, B. (1998). Pharmacological management of pain after intracranial surgery. Journal of Neuroscience Nursing, 30(4), 220–224. of Neuroscience Nursing, 33(3), 148–159. Rafferty-Mitchell, C., Scanlon, J., & Laskowski-Jones, L. (1999). Henker, R. (1999). Evidence-based practice: Fever-related interventions. Gamma knife radiosurgery. 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(1997). Cerebral resuscitation after global brain 3–8. ischemia: Linking research to practice. AACN Clinical Issues, 8(2), *Buelow, J. (2001). Epilepsy management issues and techniques. Jour- 171–181. nal of Neuroscience Nursing, 33(5), 260–269. Headache Devinsky, O. (1999). Patients with refractory seizures. New England Cunningham, S. (2000). Migraine: Helping clients choose treatment Journal of Medicine, 340(20), 1565–1570. and identify triggers. British Journal of Nursing, 8(22), 1515–1523. Huntington, N. (1999). The nurse’s role in delivery of radioisotope for Evans, R., & Lipton, R. (2001). Topics in migraine management. Neu- ictal SPECT scan. Journal of Neuroscience Nursing, 31(4), 208–215. rologic Clinics, 19(1), 1–20. Kennedy, P., & Schallert, G. (2001). Practical issues and concepts in Goadsby, P., Lipton, R., & Ferrari, M. (2002). Migraine—current un- vagus nerve stimulation: A nursing review. Journal of Neuroscience derstanding and treatment. New England Journal of Medicine, Nursing, 33(2), 105–112. 346(4), 257–270. Liporace, J. D. (1997). Women’s issues in epilepsy: Menses, childbear- Lin, J. (2001). Overview of migraine. Journal of Neuroscience Nursing, ing, and more. Postgraduate Medicine, 102(1), 123–138. 33(1), 6–13. Lowenstein, D. H., & Alldredge, B. K. (1998). Current concepts: McAlhany, A. (2001). Efﬁcacy of sumatriptan in the treatment of mi- Status epilepticus. New England Journal of Medicine, 338(14), graine: A review of the literature. Journal of Neuroscience Nursing, 970–976. 33(5), 270–277. Schumacher, L., Pruitt, J., & Phillips, M. (2000). Identifying patients Silberstein, S., & Rosenberg, J. (2000). Multispecialty consensus on di- “at risk” for alcohol withdrawal syndrome and a treatment protocol. agnosis and treatment of headache. Neurology, 54, 1553. Journal of Neuroscience Nursing, 32(3), 158–163. Increased Intracranial Pressure Schachter, S. (2001). Epilepsy. Neurologic Clinics, 19(1), 57–78. Clay, H. (2000). Validity and reliability of the SjO2 catheter in neuro- Shafer, P. (1999a). Epilepsy and seizures. Advances in seizure assess- logically impaired patients: A critical review of the literature. Journal ment, treatment, and self-management. Nursing Clinics of North of Neuroscience Nursing, 32(4), 194–203. America, 34(3), 743–759. 1886 Unit 14 NEUROLOGIC FUNCTION

Shafer, P. (1999b). New therapies in the management of acute or clus- *Villanueva, N. (1999). Experiences of critical care nurses caring ter seizures and seizure emergencies. Journal of Neuroscience Nursing, for unresponsive patients. Journal of Neuroscience Nursing, 31(4), 31(4), 224–230. 16–23. Vernarec, E. (2001). Lamictal packaging gets makeover to reduce errors. RN, 64(10), 96. Wiebe, S., Blume, W., Girvin, J., & Eliasziw, M. (2001). A randomized, controlled trial of surgery for temporal-lobe epilepsy. New England RESOURCES AND WEBSITES Journal of Medicine, 345(5), 311–318. Winkelman, C. (1999). A review of pharmacodynamics and pharmaco- American Headache Society, 19 Mantua Rd., Mount Royal, NJ 08061; kinetics in seizure management. Journal of Neuroscience Nursing, (856) 423-0043; http://www.ahsnet.org. 31(1), 50–53. Brain Injury Association, 105 North Alfred St., Alexandria, VA 22314; *Wulf, J. (2000). Evaluation of seizure observation and documentation. (703) 235-6000; http://www.biausa.org. Journal of Neuroscience Nursing, 32(1), 27–36. Epilepsy Foundation, 4351 Garden City Dr., Landover, MD 20785- Unconsciousness and Coma 2223; (301) 459-3700; http://www.epilepsyfoundation.org. *Elliott, R., & Wright, L. (1999). Verbal communication: What do crit- Hydrocephalus Association, 870 Market St., Suite 705, San Francisco, ical care nurses say to their unconscious or sedated patients? Journal CA 94102; (415) 732-7040; fax (415) 732-7044; email: hydroassoc@ of Advanced Nursing, 29(6), 12–20. aol.com. Jacobson, A., & Winslow, E. (2000). Caring for unconscious patients. National Headache Foundation, 428 W St. James Pl., 2d ﬂoor, Chicago, American Journal of Nursing, 100(1), 69. IL 60614-2750; 1-888-NHF-5552; http://www.headaches.org. Chapter 62 ● Management of Patients With Cerebrovascular Disorders

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Describe the incidence and social impact of cerebrovascular disorders. 2. Identify the risk factors for cerebrovascular disorders and related measures for prevention. 3. Compare the various types of cerebrovascular disorders: their causes, clinical manifestations, and medical management. 4. Relate the principles of nursing management to the care of a patient in the acute stage of an ischemic stroke. 5. Use the nursing process as a framework for care of a patient recovering from an ischemic stroke. 6. Use the nursing process as a framework for care of a patient with a cerebral aneurysm. 7. Identify essential elements for family teaching and preparation for home care of the stroke patient.

1887 1888 Unit 14 NEUROLOGIC FUNCTION “ erebrovascular disorders” is an umbrella term that refers to Cany functional abnormality of the central nervous system (CNS) Table 62-1 • Major Types of Stroke and Their Causes that occurs when the normal blood supply to the brain is disrupted. Stroke is the primary cerebrovascular disorder in the CLASSIFICATION CAUSES United States and in the world. Although preventive efforts have brought about a steady decline in incidence over the last several Ischemic Large artery thrombosis Small penetrating artery thrombosis years, stroke is still the third leading cause of death. Approxi- Cardiogenic embolic mately 500,000 people experience a new stroke, 100,000 experi- Cryptogenic (no known cause) ence a recurrent stroke, and approximately 160,000 die of a Other stroke each year. With over 4 million survivors (2.2 million men Hemorrhagic Intracerebral hemorrhage and 2.3 million women), stroke is the leading cause of serious, Subarachnoid hemorrhage long-term disability in the United States (American Heart Asso- Cerebral aneurysm ciation, 2000). Arteriovenous malformation Strokes can be divided into two major categories: ischemic (85%), in which vascular occlusion and significant hypoperfu- sion occur, and hemorrhagic (15%), in which there is extravasa- tion of blood into the brain (American Heart Association, 2000). Ischemic strokes are subdivided into five different types ac- Although there are some similarities between the two broad cording to their cause: large artery thrombosis (20%), small pen- types of stroke, overall the etiology, pathophysiology, medical etrating artery thrombosis (25%), cardiogenic embolic stroke management, surgical management, and nursing care differ. (20%), cryptogenic (30%) and other (5%) (see Table 62-1). Table 62-1 reviews the major types of ischemic and hemorrhagic Large artery thrombotic strokes are due to atherosclerotic strokes. plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction. Ischemic Stroke Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Approximately 400,000 people have an ischemic stroke in the Small artery thrombotic strokes are also called lacunar strokes be- United States each year (Hock, 1999). An ischemic stroke, cere- cause of the cavity that is created once the infarcted brain tissue brovascular accident (CVA), or what is now being termed “brain disintegrates. attack” is a sudden loss of function resulting from disruption of Cardiogenic embolic strokes are associated with cardiac dys- the blood supply to a part of the brain. This event is usually the rhythmias, usually atrial fibrillation. Emboli originate from the result of long-standing cerebrovascular disease. The term “brain heart and circulate to the cerebral vasculature, most commonly attack” is being used to suggest to health care practitioners and the left middle cerebral artery, resulting in a stroke. Embolic the public that a stroke is an urgent health care issue similar to a strokes may be prevented by the use of anticoagulation therapy heart attack. This change in terms also reflects a similar manage- in patients with atrial fibrillation. ment strategy in both diseases. Early treatment results in fewer The last two classifications of ischemic strokes are cryptogenic symptoms and less loss of function. Only 8% of ischemic strokes strokes, which have no known cause, and other strokes, from result in death within 30 days (American Heart Association, causes such as cocaine use, coagulopathies, migraine, and spon- 2000). taneous dissection of the carotid or vertebral arteries (Hock, The net lifetime stroke-related costs in patients over the age 1999; Schievink, 2001). of 65 with a first ischemic stroke are estimated at $62,000 ($45,000 direct costs plus $17,000 indirect costs). The cost for Pathophysiology younger patients (those less than 65 years) is even greater, at $198,000 per year ($65,000 direct costs plus $133,000 indirect In an ischemic brain attack, there is disruption of the cerebral costs). The approximate annual cost in the United States for blood flow due to obstruction of a blood vessel. This disruption ischemic stroke care is over $71.8 billion (Matchar & Samsa, in blood flow initiates a complex series of cellular metabolic 2000). events referred to as the ischemic cascade (Fig. 62-1). Glossary agnosia: failure to recognize familiar objects dysarthria: defects of articulation due to Korsakoff ’s syndrome: personality dis- perceived by the senses neurologic causes order characterized by psychosis, dis- aneurysm: a weakening or bulge in an arter- expressive aphasia: inability to express one- orientation, delirium, insomnia, and ial wall self; often associated with damage to the hallucinations aphasia: inability to express oneself or to left frontal lobe area penumbra region: area of low cerebral understand language hemianopsia: blindness of half of the field blood flow apraxia: inability to perform previously of vision in one or both eyes perseveration: continued and automatic learned purposeful motor acts on a hemiplegia/hemiparesis: weakness/paralysis repetition of an activity or word or phrase voluntary basis of one side of the body, or part or it, due that is no longer appropriate ataxia: impaired ability to coordinate move- to an injury to the motor areas of the brain receptive aphasia: inability to understand ment, often seen as a staggering gait or infarction: a zone of tissue deprived of what someone else is saying; often associ- postural imbalance blood supply ated with damage to the temporal lobe area Chapter 62 Management of Patients With Cerebrovascular Disorders 1889

Clinical Manifestations Physiology/Pathophysiology An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs or symptoms: • Numbness or weakness of the face, arm, or leg, especially on one side of the body • Confusion or change in mental status • Trouble speaking or understanding speech • Visual disturbances • Difficulty walking, dizziness, or loss of balance or coordination • Sudden severe headache Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted. Table 62-2 reviews the neurologic deficits frequently seen in patients with strokes. Table 62-3 compares the symptoms seen in right hemispheric stroke with those seen in left hemispheric stroke. Patients exhibit deficits in specific locations as well as different behavior.

MOTOR LOSS FIGURE 62-1 Processes contributing to ischemic brain cell injury. Cour- tesy of National Stroke Association, Englewood, Colorado. A stroke is a lesion of the upper motor neurons and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis of one side of The ischemic cascade begins when cerebral blood flow falls the body) due to a lesion of the opposite side of the brain. Hemi- to less than 25 mL/100 g/min. At this point, neurons can no paresis, or weakness of one side of the body, is another sign. longer maintain aerobic respiration. The mitochondria must then In the early stage of stroke, the initial clinical features may be switch to anaerobic respiration, which generates large amounts of flaccid paralysis and loss of or decrease in the deep tendon re- lactic acid, causing a change in the pH level. This switch to the flexes. When these deep reflexes reappear (usually by 48 hours), less efficient anaerobic respiration also renders the neuron inca- increased tone is observed along with spasticity (abnormal in- pable of producing sufficient quantities of adenosine triphosphate crease in muscle tone) of the extremities on the affected side. (ATP) to fuel the depolarization processes. Thus, the membrane pumps that maintain electrolyte balances begin to fail and the COMMUNICATION LOSS cells cease to function. Other brain functions affected by stroke are language and com- Early in the cascade, an area of low cerebral blood flow, re- munication. In fact, stroke is the most common cause of aphasia. ferred to as the penumbra region, exists around the area of in- The following are dysfunctions of language and communication: farction. The penumbra region is ischemic brain tissue that can Dysarthria (difficulty in speaking), caused by paralysis of be salvaged with timely intervention. The ischemic cascade • the muscles responsible for producing speech threatens cells in the penumbra because membrane depolariza- Dysphasia or aphasia (defective speech or loss of speech), tion of the cell wall leads to an increase in intracellular calcium • which can be expressive aphasia, receptive aphasia, or and the release of glutamate (Hock, 1999). The penumbra area global (mixed) aphasia can be revitalized by administration of tissue plasminogen acti- • Apraxia (inability to perform a previously learned action), vator (t-PA), and the influx of calcium can be limited with the use as may be seen when a patient picks up a fork and attempts of calcium channel blockers. The influx of calcium and the re- to comb his hair with it lease of glutamate, if continued, activate a number of damaging pathways that result in the destruction of the cell membrane, the PERCEPTUAL DISTURBANCES release of more calcium and glutamate, vasoconstriction, and the Perception is the ability to interpret sensation. Stroke can result generation of free radicals. These processes enlarge the area of in- in visual-perceptual dysfunctions, disturbances in visual-spatial farction into the penumbra, extending the stroke. relations, and sensory loss. Each step in the ischemic cascade represents an opportunity Visual-perceptual dysfunctions are due to disturbances of the for intervention to limit the extent of secondary brain damage primary sensory pathways between the eye and visual cortex. caused by a stroke. Medications that protect the brain from sec- Homonymous hemianopsia (loss of half of the visual field) may ondary injury are called neuroprotectants (Reed, 2000). A num- occur from stroke and may be temporary or permanent. The af- ber of clinical trials are focusing on calcium channel antagonists fected side of vision corresponds to the paralyzed side of the body. that block the calcium influx, glutamate antagonists, antioxidants, Disturbances in visual-spatial relations (perceiving the relation and other neuroprotectant strategies that will help prevent sec- of two or more objects in spatial areas) are frequently seen in pa- ondary complications (NINDS, 1999; Reed, 2000). tients with right hemispheric damage. Table 62-2 • Neurologic Deficits of Stroke: Manifestations and Nursing Implications

NEUROLOGIC DEFICIT MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS Visual Field Deficits Homonymous hemianopsia • Unaware of persons or objects on Place objects within intact field of vision. (loss of half of the visual side of visual loss Approach the patient from side of intact field of vision. field) • Neglect of one side of the body Instruct/remind the patient to turn head in the direction of visual loss • Difficulty judging distances to compensate for loss of visual field. Encourage the use of eyeglasses if available. When teaching the patient, do so within patient’s intact visual field. Loss of peripheral vision • Difficulty seeing at night Avoid night driving or other risky activities in the darkness. • Unaware of objects or the borders Place objects in center of patient’s intact visual field. of objects Encourage the use of a cane or other object to identify objects in the periphery of the visual field. Diplopia • Double vision Explain to the patient the location of an object when placing it near the patient. Consistently place patient care items in the same location. Motor Deficits Hemiparesis • Weakness of the face, arm, and leg Place objects within the patient’s reach on the nonaffected side. on the same side (due to a lesion Instruct the patient to exercise and increase the strength on the un- in the opposite hemisphere) affected side. Hemiplegia • Paralysis of the face, arm, and leg Encourage the patient to provide range-of-motion exercises to the on the same side (due to a lesion affected side. in the opposite hemisphere) Provide immobilization as needed to the affected side. Maintain body alignment in functional position. Exercise unaffected limb to increase mobility, strength, and use. Ataxia • Staggering, unsteady gait Support patient during the initial ambulation phase. • Unable to keep feet together; Provide supportive device for ambulation (walker, cane). needs a broad base to stand Instruct the patient not to walk without assistance or supportive device. Dysarthria • Difficulty in forming words Provide the patient with alternative methods of communicating. Allow the patient sufficient time to respond to verbal communication. Support patient and family to alleviate frustration related to difficulty in communicating. Dysphagia • Difficulty in swallowing Test the patient’s pharyngeal reflexes before offering food or fluids. Assist the patient with meals. Place food on the unaffected side of the mouth. Allow ample time to eat. Sensory Deficits Paresthesia (occurs on the • Numbness and tingling of Instruct the patient to avoid using this extremity as the dominant limb side opposite the lesion) extremity due to altered sensation. • Difficulty with proprioception Provide range of motion to affected areas and apply corrective devices as needed. Verbal Deficits Expressive aphasia • Unable to form words that are Encourage patient to repeat sounds of the alphabet. understandable; may be able to speak in single-word responses Receptive aphasia • Unable to comprehend the spoken Speak slowly and clearly to assist the patient in forming the sounds. word; can speak but may not make sense Global (mixed) aphasia • Combination of both receptive Speak clearly and in simple sentences; use gestures or pictures when able. and expressive aphasia Establish alternative means of communication. Cognitive Deficits • Short- and long-term memory loss Reorient patient to time, place, and situation frequently. • Decreased attention span Use verbal and auditory cues to orient patient. • Impaired ability to concentrate Provide familiar objects (family photographs, favorite objects). • Poor abstract reasoning Use noncomplicated language. • Altered judgment Match visual tasks with a verbal cue; holding a toothbrush, simulate brushing of teeth while saying, “I would like you to brush your teeth now.” Minimize distracting noises and views when teaching the patient. Repeat and reinforce instructions frequently. Emotional Deficits • Loss of self-control Support patient during uncontrollable outbursts. • Emotional lability Discuss with the patient and family that the outbursts are due to the • Decreased tolerance to stressful disease process. situations Encourage patient to participate in group activity. • Depression Provide stimulation for the patient. • Withdrawal Control stressful situations, if possible. • Fear, hostility, and anger Provide a safe environment. • Feelings of isolation Encourage patient to express feelings and frustrations related to disease process.

1890 Chapter 62 Management of Patients With Cerebrovascular Disorders 1891

Chart The Stroke Continuum: Time Course Classification Table 62-3 • Comparison of Left and Right 62-1 Hemispheric Strokes Strokes are commonly classified using the time course in the following manner: (1) transient ischemic attack (TIA), (2) reversible LEFT HEMISPHERIC STROKE RIGHT HEMISPHERIC STROKE ischemic neurologic deficit, (3) stroke in evolution, and (4) com- Paralysis or weakness on right Paralysis or weakness on left pleted stroke (Hock, 1999). side of body side of body Transient Ischemic Attack Right visual field deficit Left visual field deficit Temporary episode of neurologic dysfunction manifested by a Aphasia (expressive, receptive, Spatial-perceptual deficits sudden loss of motor, sensory, or visual function. It may last a few or global) Increased distractibility seconds or minutes but not longer than 24 hours. Complete recov- Altered intellectual ability Impulsive behavior and poor ery usually occurs between attacks. The symptoms result from tem- Slow, cautious behavior judgment porary impairment of blood flow to a specific region of the brain Lack of awareness of deficits due to atherosclerosis, obstruction of cerebral microcirculation by a small embolus, a decrease in cerebral perfusion pressure (CPP), or cardiac dysrhythmias. A TIA may serve as a warning of impending stroke, which has SENSORY LOSS its greatest incidence in the first month after the first attack. Lack The sensory losses from stroke may take the form of slight im- of evaluation and treatment of a patient who has experienced pre- pairment of touch or may be more severe, with loss of proprio- vious TIAs may result in a stroke and irreversible deficits. ception (ability to perceive the position and motion of body Reversible Ischemic Neurologic Deficits parts) as well as difficulty in interpreting visual, tactile, and audi- Signs and symptoms are consistent with but more pronounced than tory stimuli. a TIA and last more than 24 hours. Symptoms resolve in days with no permanent neurologic deficit. COGNITIVE IMPAIRMENT AND PSYCHOLOGICAL EFFECTS Stroke in Evolution If damage has occurred to the frontal lobe, learning capacity, Worsening of neurologic signs and symptoms over several minutes memory, or other higher cortical intellectual functions may be or hours. This is a progressing stroke. impaired. Such dysfunction may be reflected in a limited atten- Completed Stroke tion span, difficulties in comprehension, forgetfulness, and a lack Stabilization of the neurologic signs and symptoms. This indicates of motivation, which cause these patients to become frustrated in no further progression of the hypoxic insult to the brain from this their rehabilitation program. Depression is common and may be particular ischemic event. exaggerated by the patient’s natural response to this catastrophic event. Other psychological problems are common and are manifested by emotional lability, hostility, frustration, resentment, and lack of cooperation. sent carotid pulsations in the neck. Diagnostic tests for TIA may include carotid phonoangiography; this involves auscultation, di- Assessment and Diagnostic Findings rect visualization, and photographic recording of carotid bruits. Any patient with neurologic deficits needs a careful history and a Oculoplethysmography measures the pulsation of blood flow complete physical and neurologic examination. Initial assessment through the ophthalmic artery. Carotid angiography allows visu- will focus on airway patency, which may be compromised by loss alization of intracranial and cervical vessels. Digital subtraction of gag or cough reflexes and altered respiratory pattern; cardio- angiography is used to define carotid artery obstruction and pro- vascular status (including blood pressure, cardiac rhythm and vides information on patterns of cerebral blood flow. rate, carotid bruit), and gross neurologic losses. Stroke patients may present to the acute care facility at any Prevention point along a continuum of neurologic involvement. A system that uses the time course to classify patients along this continuum may Primary prevention of ischemic stroke is the best approach. Stroke be used to guide treatment. Strokes using the time course are com- risk screenings are an ideal opportunity to lower stroke risk by monly classified in the following manner: (1) transient ischemic identifying high-risk individuals or groups and educating the pa- attack (TIA); (2) reversible ischemic neurologic deficit; (3) stroke tients and the community about recognition and prevention of in evolution; and (4) completed stroke (Hock, 1999) (Chart 62-1). stroke (Lindsey, 2000; Manzella & Galante, 2000). The initial diagnostic test for a stroke is a noncontrast com- Advanced age, gender, and race are well-known non-modifiable puted tomography (CT) scan performed emergently to deter- risk factors for stroke (American Heart Association, 2000). mine if the event is ischemic or hemorrhagic (which determines Specifically, high-risk groups include people over the age of 55, treatment). Further diagnostic workup for ischemic stroke in- because the incidence of stroke more than doubles in each suc- volves attempting to identify the source of the thrombi or emboli. cessive decade, and men, who have a higher rate of stroke than A 12-lead electrocardiogram and a carotid ultrasound are stan- women (due to the higher prevalence of women in the elderly dard tests. Other studies may include cerebral angiography, trans- population, however, the absolute numbers of men and women cranial Doppler flow studies, transthoracic or transesophageal with stroke are similar). Another high-risk group is African Amer- echocardiography, magnetic resonance imaging of the brain and/or icans: the incidence of first stroke in African Americans is almost neck, xenon CT, and single photon emission CT (Bonnono et al., twice that in Caucasians. African Americans also suffer more 2000; Petty et al., 2000). extensive physical impairments and are twice as likely to die from In a patient with a TIA, a bruit (abnormal sound heard on aus- stroke than Caucasians. Hispanic, Native American Indian, Alaska cultation resulting from interference with normal blood flow) native, and Asian/Pacific Islander ethnic groups also have a higher may be heard over the carotid artery. There are diminished or ab- relative risk of stroke compared to Caucasians. 1892 Unit 14 NEUROLOGIC FUNCTION

Modifiable risk factors for ischemic stroke include hyperten- atrial fibrillation are treated with dose-adjusted warfarin sodium sion, cardiovascular disease, high cholesterol, obesity, smoking, (Coumadin) unless contraindicated. The INR target is 2.5. and diabetes (Chart 62-2). For people at high risk, interventions When warfarin is contraindicated, aspirin is used in doses be- that alter modifiable factors, such as treating hypertension and tween 50 and 325 mg/d (Wolf et al., 1999). hyperglycemia and stopping smoking, will reduce stroke risk. Platelet-inhibiting medications (aspirin, dipyridamole [Per- Many health promotion efforts involve encouraging a healthy santine], clopidogrel [Plavix], and ticlopidine [Ticlid]) decrease lifestyle, including eating a low-fat, low-cholesterol diet and in- the incidence of cerebral infarction in patients who have experi- creasing exercise. Recent evidence suggests that eating fish two or enced TIAs from suspected embolic or thrombotic causes. Cur- more times per week reduces the risk of thrombotic stroke for rently the most cost-effective antiplatelet regimen is aspirin 50 mg/d women (Iso et al., 2001). and dipyridamole 400 mg/d (Sarasin et al., 2000). Several methods of preventing recurrent stroke have been identified for patients with TIAs or mild ischemic stroke. Patients THROMBOLYTIC THERAPY with moderate to severe carotid stenosis are treated with carotid Thrombolytic agents are used to treat ischemic stroke by dis- endarterectomy (Wolf et al., 1999). In patients with atrial fibril- solving the blood clot that is blocking blood flow to the brain. lation, which increases the risk of emboli, administration of war- Recombinant t-PA is a genetically engineered form of t-PA, a farin (Coumadin), an anticoagulant that inhibits clot formation, thrombolytic substance made naturally by the body. It works by may prevent both thrombotic and embolic strokes. binding to fibrin and converting plasminogen to plasmin, which stimulates fibrinolysis of the atherosclerotic lesion. Rapid diagnosis of stroke and initiation of thrombolytic therapy (within NURSING ALERT Many people take herbal remedies and nutritional supplements but do not think of them as “medications” and 3 hours) in patients with ischemic stroke leads to a decrease in the do not always report their use to health care providers. Patients size of the stroke and an overall improvement in functional out- receiving anticoagulation following a stroke, TIA, or diagnosis of come after 3 months (NINDS t-PA Stroke Study Group, 1995). atrial fibrillation need to be cautioned that two herbs, ginkgo and To realize the full potential of thrombolytic therapy, community garlic, have demonstrated effects on warfarin (Coumadin). Ginkgo education directed at recognizing the symptoms of stroke and ! has been associated with increased bleeding times and increased obtaining appropriate emergency care is necessary to ensure rapid rates of spontaneous hemorrhage and subdural hematomas. Garlic transport to a hospital and initiation of therapy within the 3-hour and warfarin taken together can greatly increase the International time frame (Manzella & Galante, 2000). Delays make the patient Normalized Ratio (INR), increasing the risk for bleeding (Evans, ineligible for thrombolytic therapy because revascularization of 2000). necrotic tissue (which develops after 3 hours) increases the risk for cerebral edema and hemorrhage.

Medical Management Enhancing Prompt Diagnosis. After being notified by emergency Patients who have experienced a TIA or mild stroke from atrial medical service personnel, the emergency department calls the fibrillation or from suspected embolic or thrombotic causes are appropriate staff (neurologist, neuroradiologist, radiology department, nursing staff, and electrocardiogram technician) and candidates for nonsurgical medical management. Those with informs them of the patient’s imminent arrival at the hospital. Many institutions have brain attack teams that respond rapidly, ensuring that treatment occurs within the allotted time frame (Alberts et al., 2000; Bonnono et al., 2000). Chart 62-2 Initial management requires the definitive diagnosis of an is- Modifiable Risk Factors for Ischemic chemic stroke by CT scanning and determination of whether the and Hemorrhagic Stroke patient meets all the criteria for t-PA therapy (Chart 62-3). Some of the contraindications for thrombolytic therapy include symp- • Hypertension (controlling hypertension, the major risk factor, tom onset greater than 3 hours prior to admission, a patient who is the key to preventing stroke) • Cardiovascular disease (cerebral emboli may originate in the is anticoagulated, a patient who has had a recent myocardial in- heart) farction, or a patient who has had any type of intracranial pathol- • Atrial fibrillation ogy (eg, stroke, head injury, trauma). Once it is determined that • Coronary artery disease the patient is a candidate for t-PA therapy, no anticoagulants are • Heart failure to be administered in the next 24 hours. • Left ventricular hypertrophy Before receiving t-PA, the patient should be assessed using the • Myocardial infarction (especially anterior) National Institutes of Health Stroke Scale (NIHSS), which con- • Rheumatic heart disease tains 42 items evaluating neurologic deficits and is useful in dif- • High cholesterol levels ferentiating between ischemic strokes and TIAs (Table 62-4). A • Obesity patient with an NIHSS score of greater than 22 is not eligible to • Elevated hematocrit (increases the risk of cerebral infarction) receive t-PA. • Diabetes mellitus (associated with accelerated atherogenesis) • Oral contraceptive use (increases risk, especially with coexisting Dosage and Administration. hypertension, smoking, and high estrogen levels) The patient is weighed to deter- • Smoking mine the dose of t-PA. The minimum dose is 0.9 mg/kg; the • Drug abuse (especially cocaine) maximum dose is 90 mg. The loading dose is 10% of the calcu- • Excessive alcohol consumption lated dose and is administered over 1 minute. The remaining dose is administered over 1 hour via an infusion pump. After the in- Hock, 1999; Summers et al., 2000. fusion is completed, the line is flushed with 20 mL of normal saline solution to ensure that all the medication is administered. Chapter 62 Management of Patients With Cerebrovascular Disorders 1893

Chart Eligibility Criteria for t-PA Administration • Neurologic assessment to determine whether the stroke is 62-3 evolving or whether other acute complications are developing, such as bleeding from anticoagulation or medication- Age 18 years or older induced bradycardia, which can result in hypotension and Clinical diagnosis of stroke with NIH stroke scale score under 22 Time of onset of stroke known and is 3 hours or less subsequent decreases in cardiac output and cerebral perfu- BP systolic ≤ 185; diastolic ≤ 110 sion pressure. Not a minor stroke or rapidly resolving stroke See the acute ischemic stroke clinical guidelines in Appendix A. No seizure at onset of stroke Not taking warfarin (Coumadin) MANAGING POTENTIAL COMPLICATIONS Prothrombin time ≤ 15 seconds or INR ≤ 1.7 Not receiving heparin during the past 48 hours with elevated Adequate cerebral blood flow is essential for cerebral oxygenation. partial thromboplastin time If cerebral blood flow is inadequate, the amount of oxygen sup- Platelet count ≥ 100,000 plied to the brain will decrease and tissue ischemia will result. Blood glucose level between 50 and 400 mg/dL Therefore, maintaining cardiac output within the normal range No acute myocardial infarction of 4 to 8 L/min, or sometimes greater, can improve the cerebral No prior intracranial hemorrhage, neoplasm, arteriovenous blood flow and oxygen delivery. Adequate oxygenation begins malformation, or aneurysm with pulmonary care, maintenance of a patent airway, and ad- No major surgical procedures within 14 days ministration of supplemental oxygen as needed. The importance No stroke or serious head injury within 3 months No gastrointestinal or urinary bleeding within last 21 days of adequate gas exchange cannot be overemphasized in these pa- Not lactating or postpartum within last 30 days tients, many of whom are elderly and more prone to developing pneumonia, which can interfere with gas exchange.

ENDARTERECTOMY FOR PREVENTION OF ISCHEMIC STROKE The patient is admitted to the intensive care unit, where con- The main surgical procedure for managing TIAs and small stroke tinuous cardiac monitoring is implemented. Vital signs are ob- is carotid endarterectomy, currently the most frequently per- tained every 15 minutes for the first 2 hours, every 30 minutes for formed peripheral vascular procedure in the United States the next 6 hours, then every hour for 16 hours. Blood pressure (Krenzer, 1999). A carotid endarterectomy is the removal of an should be maintained with the systolic pressure less than 180 mm atherosclerotic plaque or thrombus from the carotid artery to pre- Hg and the diastolic pressure less than 100 mm Hg. Airway man- vent stroke in patients with occlusive disease of the extracranial agement is instituted based on the patient’s clinical condition and cerebral arteries (Fig. 62-2). This surgery is indicated for patients arterial blood gas values. with symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) Side Effects. Bleeding is the most common side effect of t-PA ad- stenosis with other significant risk factors (Wolf et al., 1999). ministration, and the patient should be closely monitored for any bleeding (intracranial, intravenous [IV] insertion sites, urinary Nursing Management. The primary complications of carotid en- catheter site, endotracheal tube, nasogastric tube, urine, stool, darterectomy are stroke, cranial nerve injuries, infection or emesis, other secretions) (Scroggins, 2000). Intracranial bleeding hematoma at the incision, and carotid artery disruption. It is im- is a major complication that occurs in approximately 6.5% of pa- portant to maintain adequate blood pressure levels in the imme- tients (NINDS t-PA Stroke Study Group, 1995). diate postoperative period. Hypotension is avoided to prevent cerebral ischemia and thrombosis. Uncontrolled hypertension THERAPY FOR PATIENTS WITH ISCHEMIC STROKE NOT may precipitate cerebral hemorrhage, edema, hemorrhage at the RECEIVING t-PA surgical incision, or disruption of the arterial reconstruction. Not all patients are candidates for t-PA therapy. Other treatments Sodium nitroprusside is commonly used to reduce the blood pres- include anticoagulant administration (IV heparin or low-molecular- sure to previous levels. Close cardiac monitoring is necessary be- weight heparin) for ischemic strokes and careful maintenance of cause these patients have a high incidence of coronary artery disease. cerebral hemodynamics to maintain cerebral perfusion. Increased A neurologic flow sheet is used to monitor and document all intracranial pressure (ICP) and its associated complications may body systems, with particular attention to neurologic status, fol- occur following a large ischemic stroke. Interventions during lowing carotid endarterectomy. The neurosurgeon is notified this period include methods to reduce ICP, such as administer- immediately if a neurologic deficit develops. Formation of a ing an osmotic diuretic (eg, mannitol), maintaining PaCO2 thrombus at the site of the endarterectomy is suspected if there within the range of 30 to 35 mm Hg, and positioning to avoid hy- is a sudden increase in neurologic deficits, such as weakness on poxia. Other treatment measures include the following: one side of the body. The patient should be prepared for repeat • Elevation of the head of the bed to promote venous endarterectomy. drainage and to lower increased ICP Difficulty in swallowing, hoarseness, or other signs of cranial • Intubation with an endotracheal tube to establish a patent nerve dysfunction must be assessed. The nurse should focus on airway, if necessary assessment of cranial nerves VI, X, XI, and XII (Krenzer, 1999). • Continuous hemodynamic monitoring. Systolic pressure Some swelling in the neck after surgery is expected; if large should be maintained at less than 180 mm Hg, diastolic enough, however, swelling and hematoma formation can obstruct pressure at less than 100 mm Hg. Maintaining the blood the airway. Emergency airway supplies, including those needed pressure within this range reduces the potential for addi- for a tracheostomy, must be available. Table 62-5 provides more tional bleeding or further ischemic damage. information about potential complications of carotid surgery. Table 62-4 • Summary of NIH Stroke Scale

BASELINE CATEGORY DESCRIPTION SCORE DATE/TIME DATE/TIME 1a. Level of Consciousness (alert, Alert 0 drowsy, etc) Drowsy 1 Stuporous 2 Coma 3 1b. LOC Questions (Month, age) Answers both correctly 0 Answers one correctly 1 Incorrect 2 1c. LOC Commands (Open, close Obeys both correctly 0 eyes, make fist, let go) Obeys one correctly 1 Incorrect 2 2. Best Gaze (Eyes open—patient Normal 0 follows examiner’s finger or face) Partial Gaze Palsy 1 Forced Deviation 2 3. Visual (Introduce visual stimu- No Visual Loss 0 lus/threat to patient’s visual field Partial Hemianopia 1 quadrants) Complete Hemianopia 2 Bilateral Hemianopia 3 4. Facial Palsy (Show teeth, raise Normal 0 eyebrows and squeeze eyes shut) Minor 1 Partial 2 Complete 3 5a. Motor Arm—Left (Elevate No Drift 0 extremity to 90° and score Drift 1 drift/movement) Can’t Resist Gravity 2 No Effort Against Gravity 3 No Movement 4 Amputation, joint fusion (explain) 9 5b. Motor arm—Right (Elevate No Drift 0 extremity to 90° and score Drift 1 drift/movement) Can’t Resist Gravity 2 No Effort Against Gravity 3 No Movement 4 Amputation, joint fusion (explain) 9 6a. Motor leg—Left (Elevate No Drift 0 extremity to 30° and score Drift 1 drift/movement) Can’t Resist Gravity 2 No Effort Against Gravity 3 No Movement 4 Amputation, joint fusion (explain) 9 6a. Motor leg—Right (Elevate No Drift 0 extremity to 30° and score Drift 1 drift/movement) Can’t Resist Gravity 2 No Effort Against Gravity 3 No Movement 4 Amputation, joint fusion (explain) 9 7. Limb ataxia (Finger-to-nose and Absent 0 heel-to-shin testing) Present in One limb 1 Present in Two Limbs 2 8. Sensory (Pin prick to face, arm, Normal 0 trunk and leg—compare side Partial Loss 1 to side) Severe Loss 2 9. Best Language (Name items, No Aphasia 0 describe a picture and read Mild to Moderate Aphasia 1 sentences) Severe Aphasia 2 Mute 3 10. Dysarthria (Evaluate speech Normal Articulation 0 clarity by patient repeating Mild to Moderate Dysarthria 1 words) Near to Unintelligible or Worse 2 Intubated or Other Physical Barrier 9 11. Extinction and Inattention No Neglect 0 (Use information from LOC and Partial Neglect 1 motor testing to identify neglect) Complete Neglect 2 Individual Administering Scale: ______

1894 Chapter 62 Management of Patients With Cerebrovascular Disorders 1895 NURSING PROCESS: THE PATIENT RECOVERING FROM AN ISCHEMIC STROKE The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body systems is essential as long as the patient requires care. The patient who has had a stroke is at risk for multiple complications, including deconditioning and other External carotid musculoskeletal problems, swallowing difficulties, bowel and blad- artery der dysfunction, inability to perform self-care, and skin breakdown. After the stroke is complete, management focuses on the Internal prompt initiation of rehabilitation for any deficits. carotid artery Assessment Plaque During the acute phase, a neurologic flow sheet is maintained to provide data about the following important measures of the patient’s clinical status: • Change in the level of consciousness or responsiveness as evidenced by movement, resistance to changes of position, and response to stimulation; orientation to time, place, and person • Presence or absence of voluntary or involuntary movements of the extremities; muscle tone; body posture; and position FIGURE 62-2 Plaque, a potential source of emboli in TIA and stroke, is of the head surgically removed from the carotid artery. • Stiffness or flaccidity of the neck

Table 62-5 • Selected Complications of Carotid Endarterectomy and Nursing Interventions

COMPLICATION CHARACTERISTICS NURSING INTERVENTIONS Incision hematoma Occurs in 5.5% of patients. Large or rapidly expand- Monitor neck discomfort and wound expansion. ing hematomas require emergency treatment. If the Report swelling, subjective feelings of pressure in airway is obstructed by the hematoma, the incision the neck, difficulty breathing. may be opened at the bedside. Hypertension Poorly controlled hypertension increases the risk of Risk is highest in the first 48 hours after surgery. postoperative complications, including hematoma Check blood pressure frequently and report devia- and hyperperfusion syndrome. There is an increased tions from baseline. Observe for and report new incidence of neurologic impairment and death due onset of neurologic deficits. to intracerebral hemorrhage. May be related to surgically induced abnormalities of carotid baroreceptor sensitivity. Postoperative hypotension Occurs in approximately 5% of patients. Treated Monitor blood pressure and observe for signs and with fluids and low-dose phenylephrine infusion. symptoms of hypotension. Usually resolves in 24 to 48 hours. Patients with hypotension should have serial ECGs to rule out myocardial infarction. Hyperperfusion syndrome Occurs when cerebral vessel autoregulation fails. Observe for severe unilateral headache improved by Arteries accustomed to diminished blood flow sitting upright or standing. may be permanently dilated; increased blood flow after endarterectomy coupled with insufficient vasoconstriction leads to capillary bed damage, edema, and hemorrhage. Intracerebral hemorrhage Occurs infrequently, but is often fatal (60%) or re- Monitor neurologic status and report any changes in sults in serious neurologic impairment. Can occur mental status or neurologic functioning immediately. secondary to hyperperfusion syndrome. Increased risk with advanced age, hypertension, presence of high-grade stenosis, poor collateral flow, and slow flow in the region of the middle cerebral artery. 1896 Unit 14 NEUROLOGIC FUNCTION

• Eye opening, comparative size of pupils and pupillary reac- the patient was like before the stroke: his or her illnesses, abilities, tions to light, and ocular position mental and emotional state, behavioral characteristics, and activ- • Color of the face and extremities; temperature and moisture ities of daily living. It is also helpful for clinicians to be knowl- of the skin edgeable about the relative importance of predictors of stroke • Quality and rates of pulse and respiration; arterial blood gas outcome (age, gender, NIHSS score at time of admission, to name values as indicated, body temperature, and arterial pressure a few) in order to provide stroke survivors and their families with • Ability to speak realistic goals (Demchuk & Buchan, 2000). • Volume of fluids ingested or administered; volume of urine The major goals for the patient (and family) may include im- excreted each 24 hours proved mobility, avoidance of shoulder pain, achievement of self- • Presence of bleeding care, relief of sensory and perceptual deprivation, prevention of • Maintenance of blood pressure within the desired param- aspiration, continence of bowel and bladder, improved thought eters processes, achieving a form of communication, maintaining skin integrity, restored family functioning, improved sexual function, After the acute phase, the nurse assesses mental status (memory, and absence of complications. attention span, perception, orientation, affect, speech/language), sensation/perception (usually the patient has decreased awareness of pain and temperature), motor control (upper and lower Nursing Interventions extremity movement), swallowing ability, nutritional and hydra- Nursing care has a significant impact on the patient’s recovery. tion status, skin integrity, activity tolerance, and bowel and blad- Often many body systems are impaired as a result of the stroke, der function. Ongoing nursing assessment continues to focus on and conscientious care and timely interventions can prevent de- any impairment of function in the patient’s daily activities, because bilitating complications. During and after the acute phase, nurs- the quality of life after stroke is closely related to the patient’s ing interventions focus on the whole person. In addition to functional status. providing physical care, nurses can encourage and foster recovery by listening to patients and asking questions to elicit the mean- Diagnosis ing of the stroke experience (Eaves, 2000; Pilkington, 1999). NURSING DIAGNOSES IMPROVING MOBILITY AND PREVENTING Based on the assessment data, the major nursing diagnoses for a JOINT DEFORMITIES patient with a stroke may include: A hemiplegic patient has unilateral paralysis (paralysis on one • Impaired physical mobility related to hemiparesis, loss of side). When control of the voluntary muscles is lost, the strong balance and coordination, spasticity, and brain injury flexor muscles exert control over the extensors. The arm tends to • Acute pain (painful shoulder) related to hemiplegia and adduct (adductor muscles are stronger than abductors) and to ro- disuse tate internally. The elbow and the wrist tend to flex, the affected • Self-care deficits (hygiene, toileting, grooming, and feeding) leg tends to rotate externally at the hip joint and flex at the knee, related to stroke sequelae and the foot at the ankle joint supinates and tends toward plan- • Disturbed sensory perception related to altered sensory re- tar flexion. ception, transmission, and/or integration Correct positioning is important to prevent contractures; • Impaired swallowing measures are used to relieve pressure, assist in maintaining good • Incontinence related to flaccid bladder, detrusor instability, body alignment, and prevent compressive neuropathies, especially confusion, or difficulty in communicating of the ulnar and peroneal nerves. Because flexor muscles are stronger • Disturbed thought processes related to brain damage, con- than extensor muscles, a posterior splint applied at night to the fusion, or inability to follow instructions affected extremity may prevent flexion and maintain correct po- • Impaired verbal communication related to brain damage sitioning during sleep. (See Chap. 11 for additional information.) • Risk for impaired skin integrity related to hemiparesis/ hemiplegia, or decreased mobility Preventing Shoulder Adduction • Interrupted family processes related to catastrophic illness To prevent adduction of the affected shoulder while the patient and caregiving burdens is in bed, a pillow is placed in the axilla when there is limited ex- • Sexual dysfunction related to neurologic deficits or fear of ternal rotation; this keeps the arm away from the chest. A pillow failure is placed under the arm, and the arm is placed in a neutral (slightly flexed) position, with distal joints positioned higher than COLLABORATIVE PROBLEMS/ the more proximal joints. Thus, the elbow is positoned higher POTENTIAL COMPLICATIONS than the shoulder and the wrist higher than the elbow. This Potential complications include: helps to prevent edema and the resultant joint fibrosis that will limit range of motion if the patient regains control of the arm • Decreased cerebral blood flow due to increased ICP (Fig. 62-3). • Inadequate oxygen delivery to the brain • Pneumonia Positioning the Hand and Fingers The fingers are positioned so that they are barely flexed. The hand Planning and Goals is placed in slight supination (palm faces upward), which is its most functional position. If the upper extremity is flaccid, a volar Although rehabilitation begins on the day the patient has the resting splint can be used to support the wrist and hand in a func- stroke, the process is intensified during convalescence and requires tional position. If the upper extremity is spastic, a hand roll is not a coordinated team effort. It is helpful for the team to know what used, because it stimulates the grasp reflex. In this instance a dor- Chapter 62 Management of Patients With Cerebrovascular Disorders 1897

mobility, regain motor control, prevent contractures in the paralyzed extremity, prevent further deterioration of the neuromuscular system, and enhance circulation. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus. Repetition of an activity forms new pathways in the CNS and therefore encourages new patterns of motion. At first, the extremities are usually flaccid. If tightness occurs in any area, the range-of-motion exercises should be performed more frequently (see Chap. 11). The patient is observed for signs and symptoms that may indicate pulmonary embolus or excessive cardiac workload during exercise; these include shortness of breath, chest pain, cyanosis, FIGURE 62-3 Correct positioning to prevent shoulder adduction. and increasing pulse rate with exercise. Frequent short periods of exercise always are preferable to longer periods at infrequent intervals. Regularity in exercise is most important. Improvement in muscle strength and maintenance of range of motion can be sal wrist splint is useful in allowing the palm to be free of pres- achieved only through daily exercise. sure. Every effort is made to prevent hand edema. The patient is encouraged and reminded to exercise the un- Spasticity, particularly in the hand, can be a disabling com- affected side at intervals throughout the day. It is helpful to de- plication after stroke. Researchers have recently reported that in- velop a written schedule to remind the patient of the exercise tramuscular injections of botulinum toxin A decreased spasticity activities. The nurse supervises and supports the patient during in the wrist and fingers and increased functional ability in dress- these activities. The patient can be taught to put the unaffected ing, washing, and other activities of daily living (Brashear et al., leg under the affected one to move it when turning and exercis- 2002). ing. Flexibility, strengthening, coordination, endurance, and bal- ancing exercises prepare the patient for ambulation. Quadriceps Changing Positions muscle setting and gluteal setting exercises are started early to im- The patient’s position should be changed every 2 hours. To place prove the muscle strength needed for walking; these are per- a patient in a lateral (side-lying) position, a pillow is placed be- formed at least five times daily for 10 minutes at a time. tween the legs before the patient is turned. To promote venous return and prevent edema, the upper thigh should not be acutely Preparing for Ambulation flexed. The patient may be turned from side to side, but the As soon as possible, the patient is assisted out of bed. Usually, amount of time spent on the affected side should be limited if when hemiplegia has resulted from a thrombosis, an active reha- sensation is impaired. bilitation program is started as soon as the patient regains con- If possible, the patient is placed in a prone position for 15 to sciousness; a patient who has had a cerebral hemorrhage cannot 30 minutes several times a day. A small pillow or a support is participate actively until all evidence of bleeding is gone. placed under the pelvis, extending from the level of the umbili- The patient is first taught to maintain balance while sitting cus to the upper third of the thigh (Fig. 62-4). This helps to pro- and then to learn to balance while standing. If the patient has dif- mote hyperextension of the hip joints, which is essential for ficulty in achieving standing balance, a tilt table, which slowly normal gait and helps prevent knee and hip flexion contractures. brings the patient to an upright position, can be used. Tilt tables The prone position also helps to drain bronchial secretions and are especially helpful for patients who have been on bed rest for prevents contractural deformities of the shoulders and knees. prolonged periods and are having orthostatic blood pressure During positioning, it is important to reduce pressure and change changes. position frequently to prevent pressure ulcers. If the patient needs a wheelchair, the folding type with hand brakes is the most practical because it allows the patient to ma- nipulate the chair. The chair should be low enough to allow the Establishing an Exercise Program patient to propel it with the uninvolved foot and narrow enough The affected extremities are exercised passively and put through to permit it to be used in the home. When the patient is trans- a full range of motion four or five times a day to maintain joint ferred from the wheelchair, the brakes must be applied and locked on both sides of the chair. The patient is usually ready to walk as soon as standing balance is achieved. Parallel bars are useful in these first efforts. A chair or wheelchair should be readily available in case the patient suddenly becomes fatigued or feels dizzy. The training periods for ambulation should be short and frequent. As the patient gains strength and confidence, an adjustable cane can be used for support. Generally, a three- or four-pronged cane provides a stable support in the early phases of rehabilitation.

PREVENTING SHOULDER PAIN FIGURE 62-4 Prone position with pillow support helps prevent hip Up to 70% of stroke patients suffer severe pain in the shoulder flexion. that prevents them from learning new skills, because shoulder func- 1898 Unit 14 NEUROLOGIC FUNCTION tion is essential in achieving balance and performing transfers and Chart self-care activities. Three problems can occur: painful shoulder, 62-4 Assistive Devices to Enhance Self-Care subluxation of the shoulder, and shoulder–hand syndrome. After Stroke A flaccid shoulder joint may be overstretched by the use of excessive force in turning the patient or from overstrenuous arm The following list identifies products that may help neurologically and shoulder movement. To prevent shoulder pain, the nurse impaired patients perform self-care more easily and safely after a should never lift the patient by the flaccid shoulder or pull on stroke or other disorders. the affected arm or shoulder. If the arm is paralyzed, subluxation Eating Devices (incomplete dislocation) at the shoulder can occur from over- Nonskid mats to stabilize plates stretching the joint capsule and musculature by the force of grav- Plate guards to prevent food from being pushed off plate ity when the patient sits or stands in the early stages after a stroke. Wide-grip utensils to accommodate a weak grasp This results in severe pain. Shoulder–hand syndrome (painful Bathing and Grooming Devices shoulder and generalized swelling of the hand) can cause a frozen Long-handled bath sponge shoulder and ultimately atrophy of subcutaneous tissues. When Grab bars, nonskid mats, hand-held shower heads a shoulder becomes stiff, it is usually painful. Electric razors with head at 90 degrees to handle Shower and tub seats, stationary or on wheels Medications are helpful in the management of post-stroke pain. Amitriptyline hydrochloride (Elavil) has been used but it Toileting Aids can cause cognitive problems, has a sedating effect, and is not Raised toilet seat effective in all patients. A recent study showed the efficacy of an Grab bars next to toilet antiseizure medication lamotrigine (Lamictal) in treating post- Dressing Aids stroke pain (Jensen et al., 2001). Velcro closures Many shoulder problems can be prevented by proper patient Elastic shoelaces movement and positioning. The flaccid arm is positioned on a Long-handled shoe horn table or with pillows while the patient is seated. Some clinicians Mobility Aids advocate the use of a properly worn sling when the patient first Canes, walkers, wheelchairs becomes ambulatory to prevent the paralyzed upper extremity Transfer devices such as transfer boards and belts from dangling without support. Range-of-motion exercises are important in preventing painful shoulder. Overstrenuous arm movements are avoided. The patient is instructed to interlace the fingers, place the palms together, and push the clasped hands The patient’s morale will improve if ambulatory activities are slowly forward to bring the scapulae forward; he or she then raises carried out in street clothes. The family is instructed to bring in both hands above the head. This is repeated throughout the day. clothing that is preferably a size larger than that normally worn. The patient is instructed to flex the affected wrist at intervals and Clothing fitted with front or side fasteners or Velcro closures is move all the joints of the affected fingers. He or she is encouraged the most suitable. The patient has better balance if most of the to touch, stroke, rub, and look at both hands. Pushing the heel dressing activities are done in a seated position. of the hand firmly down on a surface is useful. Elevation of the Perceptual problems may make it difficult for the patient to arm and hand is also important in preventing dependent edema dress without assistance because of an inability to match the of the hand. Patients with continuing pain after movement and clothing to the body parts. To assist the patient, the nurse can positioning have been attempted may require the addition of take steps to keep the environment organized and uncluttered, analgesia to their treatment program. because the patient with a perceptual problem is easily distracted. The clothing is placed on the affected side in the order in which ENHANCING SELF-CARE the garments are to be put on. Using a large mirror while dress- As soon as the patient can sit up, personal hygiene activities are ing promotes the patient’s awareness of what he or she is putting encouraged. The patient is helped to set realistic goals; if feasible, on the affected side. Each garment is put on the affected side first. a new task is added daily. The first step is to carry out all self-care The patient has to make many compensatory movements when activities on the unaffected side. Such activities as combing the dressing; these can produce fatigue and painful twisting of the in- hair, brushing the teeth, shaving with an electric razor, bathing, tercostal muscles. Support and encouragement are provided to and eating can be carried out with one hand and are suitable for prevent the patient from becoming overly fatigued and discour- self-care. Although the patient may feel awkward at first, the var- aged. Even with intensive training, not all patients can achieve ious motor skills can be learned by repetition, and the unaffected independence in dressing. side will become stronger with use. The nurse must be sure that the patient does not neglect the affected side. Assistive devices will MANAGING SENSORY-PERCEPTUAL DIFFICULTIES help make up for some of the patient’s deficits (Chart 62-4). A Patients with a decreased field of vision should be approached on small towel is easier to control while drying after bathing, and the side where visual perception is intact. All visual stimuli (clock, boxed paper tissues are easier to use than a roll of toilet tissue. calendar, and television) should be placed on this side. The pa- Return of functional ability is important to the patient recov- tient can be taught to turn the head in the direction of the defec- ering after a stroke. An early baseline assessment of functional tive visual field to compensate for this loss. The nurse should ability with an instrument such as the Functional Independence make eye contact with the patient and draw his or her attention Measure (FIM) is important in team planning and goal setting to the affected side by encouraging the patient to move the head. for the patient. The FIM is a widely used instrument in stroke re- The nurse may also want to stand at a position that encourages habilitation and also provides valuable functional information the patient to move or turn to visualize who is in the room. during the acute phase of care (Hinkle, 2000, 2001). Increasing the natural or artificial lighting in the room and providing eyeglasses are important in increasing vision. Chapter 62 Management of Patients With Cerebrovascular Disorders 1899

The patient with homonymous hemianopsia (loss of half of pattern is analyzed and the urinal or bedpan offered on this pat- the visual field) turns away from the affected side of the body and tern or schedule. The upright posture and standing position are tends to neglect that side and the space on that side; this is called helpful for male patients during this aspect of rehabilitation. amorphosynthesis. In such instances, the patient cannot see food Patients may also have problems with bowel control or con- on half of the tray, and only half of the room is visible. It is im- stipation, with constipation being more common. Unless con- portant for the nurse to constantly remind the patient of the traindicated, a high-fiber diet and adequate fluid intake (2 to 3 L other side of the body, to maintain alignment of the extremities, per day) should be provided and a regular time established (usu- and, if possible, to place the extremities where the patient can see ally after breakfast) for toileting. See Chapter 11 for bowel and them. bladder retraining programs.

MANAGING DYSPHAGIA IMPROVING THOUGHT PROCESSES Stroke can result in swallowing problems (dysphagia) due to im- After a stroke, the patient may have problems with cognitive, be- paired function of the mouth, tongue, palate, larynx, pharynx, or havioral, and emotional deficits related to brain damage. In many upper esophagus. Patients must be observed for paroxysms of instances, however, a considerable degree of function can be re- coughing, food dribbling out of or pooling in one side of the covered because not all areas of the brain are equally damaged; mouth, food retained for long periods in the mouth, or nasal re- some remain more intact and functional than others. gurgitation when swallowing liquids. Swallowing difficulties After assessment that delineates the patient’s deficits, the neu- place the patient at risk for aspiration, pneumonia, dehydration, ropsychologist, in collaboration with the primary care physician, and malnutrition. psychiatrist, nurse, and other professionals, structures a training A speech therapist will evaluate the patient’s gag reflexes and program using cognitive-perceptual retraining, visual imagery, ability to swallow. Even if partially impaired, swallowing func- reality orientation, and cueing procedures to compensate for tion may return in some patients over time, or the patient may be losses. taught alternative swallowing techniques, advised to take smaller The role of the nurse is supportive. The nurse reviews the boluses of food, and taught about which foods are easier to swal- results of neuropsychological testing, observes the patient’s per- low. The patient may initially be started on a thick liquid or formance and progress, gives positive feedback, and, most impor- puréed diet because these foods are easier to swallow than thin tantly, conveys an attitude of confidence and hope. Interventions liquids. Having the patient sit upright, preferably out of bed in a capitalize on the patient’s strengths and remaining abilities while chair, and instructing him or her to tuck the chin toward the attempting to improve performance of affected functions. Other chest as he or she swallows, will help prevent aspiration. The diet interventions are similar to those for improving cognitive func- may be advanced as the patient becomes more proficient at swal- tioning after a head injury (see Chap. 63). lowing. If the patient cannot resume oral intake, a gastrointestinal feeding tube will be placed for ongoing tube feedings. IMPROVING COMMUNICATION Aphasia, which impairs the patient’s ability to understand what Managing Tube Feedings is being said and to express himself or herself, may become ap- Enteral tubes can be either nasogastric (placed in the stomach) or parent in various ways. The cortical area responsible for integrat- nasoenteral (placed in the duodenum) to reduce the risk of aspi- ing the myriad of pathways required for the comprehension and ration. Nursing responsibilities in feeding include elevating the formulation of language is called Broca’s area. It is located in a head of the bed at least 30 degrees to prevent aspiration, check- convolution adjoining the middle cerebral artery. This area is re- ing the position of the tube before feeding, ensuring that the cuff sponsible for control of the combinations of muscular move- of the tracheostomy tube (if in place) is inflated, and giving the ments needed to speak each word. Broca’s area is so close to the tube feeding slowly. The feeding tube is aspirated periodically to left motor area that a disturbance in the motor area often affects ensure that the feedings are passing through the gastrointestinal the speech area. This is why so many patients paralyzed on the tract. Retained or residual feedings increase the risk for aspiration. right side (due to damage or injury to the left side of the brain) Patients with retained feedings may benefit from the placement cannot speak, whereas those paralyzed on the left side are less of a gastrostomy tube or a percutaneous endoscopic gastrostomy likely to have speech disturbances. tube. In a patient with a nasogastric tube, the feeding tube should The speech pathologist assesses the communication needs of be placed in the duodenum to reduce the risk of aspiration. For the stroke patient, describes the precise deficit, and suggests the long-term feedings, a gastrostomy tube is preferred. Management best overall method of communication. With many language in- of patients with tube feedings is discussed in Chapter 36. tervention strategies for the aphasic adult, the program can be in- dividually tailored. The patient is expected to take an active part ATTAINING BOWEL AND BLADDER CONTROL in establishing goals. After a stroke, the patient may have transient urinary inconti- A person with aphasia may become depressed because of the nence due to confusion, inability to communicate needs, and in- inability to talk. The inability to talk on the telephone, answer a ability to use the urinal or bedpan because of impaired motor and question, or participate in conversation causes anger, frustration, postural control. Occasionally after a stroke, the bladder becomes fear of the future, and hopelessness. Nursing interventions in- atonic, with impaired sensation in response to bladder filling. clude doing everything possible to make the atmosphere con- Sometimes control of the external urinary sphincter is lost or di- ducive to communication. This includes being sensitive to the minished. During this period, intermittent catheterization with patient’s reactions and needs and responding to them in an ap- sterile technique is carried out. When muscle tone increases and propriate manner, always treating the patient as an adult. The deep tendon reflexes return, bladder tone increases and spasticity nurse provides strong moral support and understanding to allay of the bladder may develop. Because the patient’s sense of aware- anxiety. ness is clouded, persistent urinary incontinence or urinary reten- A common pitfall is for the nurse or other health care team tion may be symptomatic of bilateral brain damage. The voiding member to complete the thoughts or sentences of the patient. 1900 Unit 14 NEUROLOGIC FUNCTION

This should be avoided because it may cause the patient to feel The patient’s skin must be kept clean and dry; gentle massage more frustrated at not being allowed to speak and may deter ef- of healthy (nonreddened) skin and adequate nutrition are other forts to practice putting thoughts together and completing the factors that help to maintain normal skin and tissue integrity (see sentence. A consistent schedule, routines, and repetitions help the Chap. 11). patient to function despite significant deficits. A written copy of the daily schedule, a folder of personal information (birth date, IMPROVING FAMILY COPING address, names of relatives), checklists, and an audiotaped list Family members play an important role in the patient’s recovery. help improve the patient’s memory and concentration. The pa- Some type of counseling and support system should be available tient may also benefit from a communication board, which has to them to prevent the care of the patient from taking a signifi- pictures of common needs and phrases. The board may be trans- cant toll on their health and interfering too radically with their lated into several languages. lives. Involving others in the patient’s care and teaching stress When talking with the patient, it is important to have the pa- management techniques and methods for maintaining personal tient’s attention, speak slowly, and keep the language of instruc- health also facilitate family coping. tion consistent. One instruction is given at a time, and time is The family may have difficulty accepting the patient’s disabil- allowed for the patient to process what has been said. The use of ity and may be unrealistic in their expectations. They are given gestures may enhance comprehension. Speaking is thinking out information about the expected outcomes and are counseled to loud, and the emphasis is on thinking. The patient must sort out avoid doing for the patient those things that he or she can do. incoming messages and formulate a response. Listening requires They are assured that their love and interest are part of the pa- mental effort; the patient must struggle against mental inertia and tient’s therapy. needs time to organize an answer. The family needs to be informed that the rehabilitation of the In working with the aphasic patient, the nurse must remem- hemiplegic patient requires many months; progress may be slow. ber to talk to the patient during care activities. This provides so- The gains made by the patient in the hospital or rehabilitation cial contact for the patient. Chart 62-5 describes points to keep unit must be maintained. All should approach the patient with a in mind when communicating with the aphasic patient. supportive and optimistic attitude, focusing on the abilities that remain. The rehabilitation team, the medical and nursing team, MAINTAINING SKIN INTEGRITY the patient, and the family all must be involved in developing at- The stroke patient may be at risk for skin and tissue breakdown tainable goals for the patient at home. because of altered sensation and inability to respond to pressure Most relatives of stroke patients handle the physical changes and discomfort by turning and moving. Therefore, preventing better than the emotional aspects of care. The family should be skin and tissue breakdown requires frequent assessment of the prepared to expect occasional episodes of emotional lability. The skin, with emphasis on bony areas and dependent parts of the patient may laugh or cry easily and may be irritable and de- body. During the acute phase, a specialty bed (eg, low-air-loss manding or depressed and confused. The nurse can explain to the bed) may be used until the patient can move independently or as- family that the patient’s laughter does not necessarily connote sist in moving. happiness, nor does crying reflect sadness, and that emotional la- A regular turning and positioning schedule must be followed bility usually improves with time. to minimize pressure and prevent skin breakdown. Pressure- relieving devices may be employed but do not replace regular turn- HELPING THE PATIENT COPE ing and positioning. The turning schedule (at least every 2 hours) WITH SEXUAL DYSFUNCTION must be adhered to even if pressure-relieving devices are used to Sexual functioning can be profoundly altered by stroke. Often prevent tissue and skin breakdown. When the patient is posi- stroke is such a catastrophic illness that the patient experiences tioned or turned, care must be used to minimize shear and friction loss of self-esteem and value as a sexual being. Although research forces, which cause damage to tissues and predispose the skin to in this area of stroke management is limited, it appears that stroke breakdown. patients consider sexual function to be important, but most have sexual dysfunction. The combined effects of age and stroke cause a marked decline in many aspects of sexuality (Lipski & Alexan- der, 1997). In-depth assessments to determine sexual history before and after the stroke should be followed by appropriate Chart Communicating With the Aphasic Patient 62-5 interventions. Interventions for the patient and partner focus on providing relevant information, education, reassurance, adjust- • Face the patient and establish eye contact. ment of medications, counseling regarding coping skills, sugges- • Speak in a normal manner and tone. tions for alternative positions, and a means of sexual expression • Use short phrases and pause between phrases to allow the patient time to understand what is being said. and satisfaction (Lipski & Alexander, 1997). • Limit conversation to practical and concrete matters. • Use gestures, pictures, and objects. PROMOTING HOME AND COMMUNITY-BASED CARE • As the patient uses and handles an object, say what the object is. It helps to match the words with the object or action. Teaching Patients Self-Care • Be consistent in using the same words and gestures each time Patient and family education is a fundamental component of re- you give instructions or ask a question. habilitation, and ample opportunity for learning about stroke, its • Keep extraneous noises and sounds to a minimum. Too much causes and prevention, and the rehabilitation process should be background noise can distract the patient or make it difficult to provided (Mumma, 2001). In both acute care and rehabilitation sort out the message being spoken. facilities, the focus is on teaching patients to resume as much self- care as possible. This may entail using assistive devices or modi- Chapter 62 Management of Patients With Cerebrovascular Disorders 1901 fying the home environment to help the patient live with a dis- (planned short-term care to relieve the family from having to pro- ability. vide continuous 24-hour care) may be available from an adult day An occupational therapist may be helpful in assessing the care center. Some hospitals also offer weekend respite care that home environment and recommending modifications to help the can provide caregivers with needed time to themselves. Nurses patient become more independent. For example, a shower is should encourage families to arrange for such services and should more convenient than a tub for the hemiplegic patient because provide information to assist them. most patients do not gain sufficient strength to get up and down The nurse involved in home and continuing care also needs to from a tub. Sitting on a stool of medium height with rubber suc- remind patients and family members of the need for continuing tion tips permits the patient to wash with greater ease. A long- health promotion and screening practices. Patients who have not handled bath brush with a soap container is helpful to the patient been involved in these practices in the past are educated about who has only one functional hand. If a shower is not available, a their importance and are referred to appropriate health care stool may be placed in the tub and a portable shower hose at- providers, if indicated. tached to the faucet. Handrails may be attached beside the bath- tub and the toilet. Other assistive devices include special utensils for eating, grooming, and dressing (see Chart 62-3).

Continuing Care NURSING RESEARCH PROFILE 62-1 The recovery and rehabilitation process after stroke may be prolonged, requiring patience and perseverance on the part of the pa- Caregiving Experience tient and family. Depending on the specific neurologic deficits Teel, C. S., Duncan, P., & Lai, S. M., (2001). Caregiving experiences resulting from the stroke, the patient at home may require the ser- after stroke. Nursing Research, 50(1), 53–60. vices of a number of health care professionals. The nurse often coordinates the care of the patient at home. The family (often the Purpose spouse) will require assistance in planning and providing care. Family caregiving is often a source of stress for family members. The caregiver often requires reminders to attend to his or her However, despite the high prevalence of stroke, little is known health problems and well-being. about the experience of family caregiving after stroke. The primary The family is advised that the patient may tire easily, become purpose of this study was to examine relationships between patient irritable and upset by small events, and is likely to show less in- characteristics, characteristics of the caregiver, and caregiver coping terest in things. Because a stroke frequently occurs in the later resources with caregiver physical and mental health outcomes at 3 and 6 months following a stroke. stages of life, there is the possibility of intellectual decline related to dementia. Study Sample and Design Emotional problems associated with stroke are often related This longitudinal, correlational study was conducted in collabora- to speech dysfunction and frustrations about being unable to tion with a study of patient outcomes after stroke. The presence of communicate. A speech therapist who visits the home allows the stroke was confirmed by clinical assessment, CT, or MRI; stroke family to be involved and gives the family practical instructions severity was assessed using the Orpington Prognostic Scale. Multi- to help the patient between therapy sessions. ple instruments were used to assess the characteristics of family Depression is a common and serious problem in the stroke pa- caregivers as well as their fatigue, vigor, mood disturbances, stress, tient. Antidepressant therapy may help if depression dominates spirituality, reactions to caregiving situation, coping resources, and the patient’s life. As progress is made in the rehabilitation program, physical and mental health status. These instruments were com- some problems will diminish. The family can help by continuing pleted at 1, 3, and 6 months after a stroke. The sample for this study consisted of 83 caregivers, the majority of whom were female, to support the patient and by giving positive reinforcement for Caucasian, and married and had at least a high school education. the progress that is being made. Their mean age was 57 years. Community-based stroke support groups allow the patient and family to learn from others with similar problems and to Findings share their experiences (Olson, 2001). The patient is encouraged The caregivers reported stable perceptions of fatigue, vigor, recur- to continue with hobbies, recreational and leisure interests, and rent sorrow, perceived stress, finances, family support, physical contact with friends to prevent social isolation. All nurses com- health, and depressive symptoms at 1, 3, and 6 months. Caregivers ing in contact with the patient should encourage the patient to with more fatigue, sorrow, stress, depression, difficulty with sched- keep active, adhere to the exercise program, and remain as self- uling and finances, and difficulty with family support had more sufficient as possible. physical health problems. Also less vigor, less importance of spirituality, and less perceived self-esteem (a reaction to caregiving) cor- The nurse should recognize the potential effects of caregiving related with more physical health issues at 3 and 6 months. on the family (Teel et al., 2001). Not all families have the adaptive coping skills and psychological functioning necessary for the Nursing Implications long-term care of another. The patient’s spouse may be elderly, Nurses working with stroke patients and families should note that with his or her own health problems; in some instances the stroke comprehensive assessments of caregivers of stroke survivors should patient may have been the provider of care to the spouse. Even include physical and mental health components. Early identifica- healthy caregivers may find it difficult to maintain a schedule that tion of caregivers with more fatigue, sorrow, stress, depression, includes being available around the clock. Some effects of sus- problems with scheduling and finances, and difficulty with family support may help identify persons at greater risk for physical tained caregiving include increased risk for depression and sub- health issues in the continuing care role. This would permit nurses stance abuse, and increased use of health care services by the to provide assistance, support, and referral to social services to caregiver (King et al., 2001). Depressed caregivers are more likely family caregivers at greatest risk for physical and mental health to resort to physical or emotional abuse of the patient and are issues. more likely to place the patient in a nursing home. Respite care 1902 Unit 14 NEUROLOGIC FUNCTION

Evaluation aneurysm or AVM ruptures, causing subarachnoid hemorrhage (hemorrhage into the cranial subarachnoid space). Normal brain EXPECTED PATIENT OUTCOMES metabolism is disrupted by the brain being exposed to blood; by Expected patient outcomes may include: an increase in ICP resulting from the sudden entry of blood into 1. Achieves improved mobility the subarachnoid space, which compresses and injures brain tissue; a. Avoids deformities (contractures and footdrop) or by secondary ischemia of the brain resulting from the reduced b. Participates in prescribed exercise program perfusion pressure and vasospasm that frequently accompany c. Achieves sitting balance subarachnoid hemorrhage. d. Uses unaffected side to compensate for loss of function of hemiplegic side INTRACEREBRAL HEMORRHAGE 2. Reports absence of shoulder pain An intracerebral hemorrhage, or bleeding into the brain sub- a. Demonstrates shoulder mobility; exercises shoulder stance, is most common in patients with hypertension and cere- b. Elevates arm and hand at intervals bral atherosclerosis because degenerative changes from these 3. Achieves self-care; performs hygiene care; uses adaptive diseases cause rupture of the vessel. They also may be due to cer- equipment tain types of arterial pathology, brain tumor, and the use of med- 4. Turns head to see people or objects ications (oral anticoagulants, amphetamines, and illicit drugs 5. Demonstrates improved swallowing ability such as crack and cocaine). 6. Achieves normal bowel and bladder elimination The bleeding is usually arterial and occurs most commonly in 7. Participates in cognitive improvement program the cerebral lobes, basal ganglia, thalamus, brain stem (mostly the pons), and cerebellum (Qureshi et al., 2001). Occasionally, the 8. Demonstrates improved communication bleeding ruptures the wall of the lateral ventricle and causes in- 9. Maintains intact skin without breakdown traventricular hemorrhage, which is frequently fatal. a. Demonstrates normal skin turgor b. Participates in turning and positioning activities INTRACRANIAL (CEREBRAL) ANEURYSM 10. Family members demonstrate a positive attitude and cop- An intracranial (cerebral) aneurysm is a dilation of the walls of a ing mechanisms cerebral artery that develops as a result of weakness in the arterial a. Encourage patient in exercise program wall. The cause of aneurysms is unknown, although research is b. Take an active part in rehabilitation process ongoing. An aneurysm may be due to atherosclerosis, resulting in c. Contact respite care programs or arrange for other fam- a defect in the vessel wall with subsequent weakness of the wall; ily members to assume some responsibilities for care a congenital defect of the vessel wall; hypertensive vascular dis- 11. Has positive attitude regarding alternative approaches to ease; head trauma; or advancing age. sexual expression Any artery within the brain can be the site of cerebral aneurysms, but they usually occur at the bifurcations of the large arteries at Hemorrhagic Stroke the circle of Willis (Fig. 62-5). The cerebral arteries most commonly affected by an aneurysm are the internal carotid artery Hemorrhagic strokes account for 15% of cerebrovascular disor- (ICA), anterior cerebral artery (ACA), anterior communicating ders and are primarily caused by an intracranial or subarachnoid artery (ACoA), posterior communicating artery (PCoA), poste- hemorrhage. Each year in the United States there are approxi- rior cerebral artery (PCA), and middle cerebral artery (MCA). mately 50,000 intracerebral hemorrhages and 25,000 cases of Multiple cerebral aneurysms are not uncommon. subarachnoid hemorrhage from ruptured intracranial aneurysm ARTERIOVENOUS MALFORMATIONS (Pfohman & Criddle, 2001; Qureshi et al., 2001). An AVM is due to an abnormality in embryonal development Patients generally have more severe deﬁcits and a longer re- that leads to a tangle of arteries and veins in the brain without a covery time compared to those with ischemic stroke (AHCPR, 1995). The mean cost per discharge for subarachnoid hemorrhage was estimated at $39,994, compared to $21,535 for intracranial hemorrhage. The mean length of stay was 22 days for subarachnoid hemorrhage and 19 for intracranial hemorrhage Anterior cerebral (Matchar & Samsa, 2000). artery Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Primary intracerebral hemorrhage from a spontaneous rupture of small vessels Anterior accounts for approximately 80% of hemorrhagic strokes and is communicating primarily caused by uncontrolled hypertension (Qureshi et al., artery 2001). Secondary intracerebral hemorrhage is associated with Intracranial aneurysm Middle cerebral arteriovenous malformations (AVMs), intracranial aneurysms, artery or certain medications (eg, anticoagulants and amphetamines) (Qureshi et al., 2001). Internal carotid artery Pathophysiology The pathophysiology of hemorrhagic stroke depends on the cause and type of cerebrovascular disorder. Symptoms are produced when an aneurysm or AVM enlarges and presses on nearby cranial nerves or brain tissue or, more dramatically, when an FIGURE 62-5 Intracranial aneurysms. Chapter 62 Management of Patients With Cerebrovascular Disorders 1903 capillary bed. The absence of a capillary bed leads to dilation of the arteries and veins and eventual rupture. They are commonly Chart 62-6 • Ethics and Related Issues a cause of hemorrhage in young people. DNR Orders in Severe Stroke

SUBARACHNOID HEMORRHAGE Situation A subarachnoid hemorrhage (hemorrhage into the subarachnoid An 85-year-old patient is admitted with a large intracerebral hem- space) may occur as a result of an AVM, intracranial aneurysm, orrhage, severe neurologic deficits, and a past medical history of trauma, or hypertension. The most common cause is a leaking coronary artery bypass graft surgery, hypertension, atrial fibrilla- aneurysm in the area of the circle of Willis or a congenital AVM tion, and gout. The attending physician suggests a do-not-resuscitate of the brain. (DNR) order to the family. Dilemma Clinical Manifestations Does the principle of autonomy include death with dignity, or is beneficence keeping the patient alive at all costs? Does the fam- The patient with a hemorrhagic stroke can present with a wide ily have the right to refuse? If the patient goes into cardiac arrest variety of neurologic deficits, similar to the patient with ischemic and cardiopulmonary resuscitation (CPR) is not provided, have stroke. A comprehensive assessment will reveal the extent of the the health care workers “killed” the patient? neurologic deficits. Many of the same motor, sensory, cranial Discussion nerve, cognitive, and other functions that are disrupted following What arguments would you pose in favor of the DNR order? ischemic stroke are altered following a hemorrhagic stroke. Table What arguments would you pose against the DNR order? 62-2 reviews the neurologic deficits frequently seen in stroke pa- Is a DNR order an example of “patient abandonment” by health tients. Table 62-3 compares the symptoms seen in right hemi- care workers, or an attempt to limit treatment and avoid CPR in a spheric stroke with those seen in left hemispheric stroke. patient with an anticipated poor outcome? In addition to the neurologic deficits that are similar to ischemic stroke, the patient with an intracranial aneurysm or AVM can have some unique clinical manifestations. Rupture of an aneurysm or AVM usually produces a sudden, unusually severe Prevention headache and often loss of consciousness for a variable period. There may be pain and rigidity of the back of the neck (nuchal Primary prevention of hemorrhagic stroke is the best approach rigidity) and spine due to meningeal irritation. Visual distur- and includes managing hypertension and ameliorating other sig- bances (visual loss, diplopia, ptosis) occur when the aneurysm is nificant risk factors (Pfohman & Criddle, 2001). Control of hy- adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemi- pertension, especially in individuals over 55 years of age, clearly paresis may also occur. reduces the risk for hemorrhagic stroke (Qureshi et al., 2001). At times, an aneurysm or AVM leaks blood, leading to the for- Additional factors are similar to the risks for ischemic stroke and mation of a clot that seals the site of rupture. In this instance, the include smoking, excessive alcohol intake, and high cholesterol patient may show little neurologic deficit. In other cases, severe (see Chart 62-2). Stroke risk screenings provide an ideal oppor- bleeding occurs, resulting in cerebral damage followed rapidly by tunity to lower hemorrhagic stroke risk by identifying high-risk coma and death. individuals or groups and educating the patients and the com- Prognosis depends on the neurologic condition of the patient, munity about recognition and prevention (Pfohman & Criddle, age, associated diseases, and the extent and location of an intra- 2001). cranial aneurysm. Subarachnoid hemorrhage from an aneurysm is a catastrophic event with significant morbidity and mortality (Pfohman & Criddle, 2001). Chart 62-6 discusses ethical issues related to the patient with a severe hemorrhagic stroke.

Assessment and Diagnostic Findings Any patient suspected of having a hemorrhagic stroke should undergo CT scanning to determine the size and location of the hematoma as well as the presence or absence of ventricular blood and hydrocephalus (Qureshi et al., 2001). CT scan and cerebral angiography confirm the diagnosis of an intracranial aneurysm or AVM. These tests show the location and size of the lesion and provide information about the affected arteries, veins, adjoining vessels, and vascular branches. Lumbar puncture is performed if there is no evidence of increased ICP, the CT scan results are negative, and subarachnoid hemorrhage must be confirmed. Lumbar puncture in the presence of increased ICP could result in brain stem herniation or rebleeding. In diagnosing a hemorrhagic stroke in a patient younger than 40, some clinicians obtain a tox- icology screen for illicit drug use. The Hunt-Hess classification system guides the physician in diagnosing the severity of subarachnoid hemorrhage after an aneurysmal bleed (Table 62-6). Classifying the patient by severity of neurologic deficit provides a baseline for future comparison. 1904 Unit 14 NEUROLOGIC FUNCTION

A prevention effort unique to hemorrhagic stroke is to increase orientation), or a new focal neurologic deficit (aphasia, hemi- the public’s awareness about the association between phenyl- paresis [partial paralysis affecting one side of the body]). propanolamine (an ingredient found in appetite suppressants as Vasospasm frequently occurs 4 to 14 days after initial hemor- well as cold and cough agents) and hemorrhagic stroke. Recent rhage when the clot undergoes lysis (dissolution), increasing the research has found that phenylpropanolamine is an independent chances of rebleeding. risk factor for hemorrhagic stroke, especially in women (Kernan It is believed that early surgery to clip the aneurysm prevents et al., 2000). Many products have been removed voluntarily from rebleeding and that removal of blood from the basal cisterns the market, but consumers should continue to look for this in- around the major cerebral arteries may prevent vasospasm. The gredient on labels. IV administration of the calcium-channel blocker nimodipine during the critical time in which vasospasm may occur may pre- Medical Management vent delayed ischemic deterioration. Advances in technology have led to the introduction of interventional neuroradiology for the The goals of medical treatment of hemorrhagic stroke are to allow treatment of aneurysms. Endovascular techniques may be used in the brain to recover from the initial insult (bleeding), to prevent selected patients to occlude the artery supplying the aneurysm or minimize the risk for rebleeding, and to prevent or treat com- with a balloon or to occlude the aneurysm itself. As more studies plications. Management consists of bed rest with sedation to pre- on these techniques are completed, their use will increase. vent agitation and stress, management of vasospasm, and surgical Management of vasospasm remains difficult and controver- or medical treatment to prevent rebleeding. Analgesics (codeine, sial. Based on one theory that vasospasm is caused by an increased acetaminophen) may be prescribed for head and neck pain. The influx of calcium into the cell, medication therapy may be used patient is fitted with elastic compression stockings to prevent to block or antagonize this action and prevent or reverse the ac- deep vein thrombosis, a threat to any patient on bed rest. tion of vasospasm already present. Calcium-channel blockers may include nimodipine (Nimotop), verapamil (Isoptin), and nifedi- COMPLICATIONS pine (Procardia). Other therapy for vasospasm is aimed at mini- Potential complications include rebleeding; cerebral vasospasm mizing the deleterious effects of the associated cerebral ischemia resulting in cerebral ischemia; acute hydrocephalus, which results and includes fluid volume expanders and induced arterial hyper- when free blood obstructs the reabsorption of cerebrospinal fluid tension, normotension, or hemodilution. (CSF) by the arachnoid villi; and seizures. Increased ICP. An increase in ICP can follow either an ischemic Cerebral Hypoxia and Decreased Blood Flow. Immediate com- or hemorrhagic stroke but almost always follows a subarachnoid plications of a hemorrhagic stroke include cerebral hypoxia, de- hemorrhage, usually because of disturbed circulation of CSF creased cerebral blood flow, and extension of the area of injury. caused by blood in the basal cisterns. If the patient shows evi- Providing adequate oxygenation of blood to the brain minimizes dence of deterioration from increased ICP (due to cerebral cerebral hypoxia. Brain function is dependent on available oxy- edema, herniation, hydrocephalus, or vasospasm), CSF drainage gen being delivered to the tissues. Administering supplemental may be instituted by cautious lumbar puncture or ventricular oxygen and maintaining the hemoglobin and hematocrit at ac- catheter drainage, and mannitol is given to reduce ICP. When ceptable levels will assist in maintaining tissue oxygenation. mannitol is used as a long-term measure to control ICP, dehy- Cerebral blood flow is dependent on the blood pressure, car- dration and disturbances in electrolyte balance (hyponatremia or diac output, and integrity of cerebral blood vessels. Adequate hy- hypernatremia; hypokalemia or hyperkalemia) may occur. Man- dration (IV fluids) must be ensured to reduce blood viscosity and nitol acts by pulling water out of the brain tissue by osmosis as improve cerebral blood flow. Extremes of hypertension or hy- well as by reducing total-body water through diuresis. The pa- potension need to be avoided to prevent changes in cerebral tient is monitored for signs of dehydration and for rebound ele- blood flow and the potential for extending the area of injury. vation of ICP. A seizure can also compromise cerebral blood flow. Seizures occur in approximately 5% of stroke patients (Berges et al., Systemic Hypertension. Preventing sudden systemic hyperten- 2000). Observation for and appropriate treatment of seizure ac- sion is critical in hemorrhagic stroke management. The goal tivity is an important component of care following a hemorrhagic of therapy is to maintain the systolic blood pressure at about stroke (Qureshi et al., 2001). 150 mm Hg. If blood pressure is elevated, antihypertensive therapy (labetalol [Normodyne], nicardipine [Cardene], nitroprusside Vasospasm. The development of cerebral vasospasm (narrowing [Nitropress]) may be prescribed. Hemodynamic monitoring by of the lumen of the involved cranial blood vessel) is a serious com- arterial line during the administration of antihypertensives is im- plication of subarachnoid hemorrhage and accounts for 40% to portant to detect and avoid a precipitous drop in blood pressure, 50% of the morbidity and mortality of those who survive the ini- which can produce brain ischemia. Because seizures cause blood tial intracranial bleed. The mechanism responsible for the spasm pressure elevation, antiseizure agents are administered prophy- is not clear, but vasospasm is associated with increasing amounts lactically. Stool softeners are used to prevent straining, which can of blood in the subarachnoid cisterns and cerebral fissures, as also elevate the blood pressure. visualized by CT scan. Vasospasm leads to increased vascular resistance, which im- SURGICAL MANAGEMENT pedes cerebral blood flow and causes brain ischemia and infarc- Many patients with a primary intracerebral hemorrhage are not tion. The signs and symptoms reflect the areas of the brain treated surgically. However, surgical evacuation is strongly rec- involved. Vasospasm is often heralded by a worsening headache, ommended for the patient with a cerebellar hemorrhage if the di- a decrease in level of consciousness (confusion, lethargy, and dis- ameter exceeds 3 cm and the Glasgow Coma Scale score is below Chapter 62 Management of Patients With Cerebrovascular Disorders 1905

14 (Qureshi et al., 2001). Surgical evacuation is most frequently All patients should be monitored in the intensive care unit fol- accomplished via a craniotomy (see Chap. 61). lowing an intracerebral hemorrhage (Qureshi et al., 2001). Neu- The patient with an intracranial aneurysm is prepared for sur- rologic assessment findings are documented and reported as gical intervention as soon as the condition is considered stable. indicated. The frequency of these assessments varies depending The Hunt-Hess classification system guides the physician in on the patient’s condition. Any changes in the patient’s condition diagnosing the severity of subarachnoid hemorrhage after an require reassessment and thorough documentation; changes aneurysm bleeds and in timing the surgery (see Table 62-6). Mor- should be reported immediately. bidity and mortality from surgery are high if the patient is stu- Alteration in level of consciousness often is the earliest sign of porous or comatose (grade IV or V). Surgical treatment of the deterioration in a patient with a hemorrhagic stroke. Because patient with an unruptured aneurysm is an option (Pfohman & nurses have the most frequent contact with patients, they are in Criddle, 2001). the best position to detect what may be subtle changes. Mild The goal of surgery is to prevent bleeding in an unruptured drowsiness and slight slurring of speech may be early signs that aneurysm and further bleeding in an already ruptured aneurysm. the level of consciousness is deteriorating. Frequent nursing as- This objective is accomplished by isolating the aneurysm from its sessment is crucial in the patient with known or suspected cere- circulation or by strengthening the arterial wall. An aneurysm bral aneurysm. may be excluded from the cerebral circulation by means of a lig- ature or a clip across its neck. If this is not anatomically possible, the aneurysm can be reinforced by wrapping it with muslin or Diagnosis some other substance to provide support and induce scarring. NURSING DIAGNOSES An extracranial-intracranial arterial bypass may be performed Based on the assessment data, the patient’s major nursing diag- to establish collateral blood supply to allow surgery on the noses may include the following: aneurysm. Alternatively, an extracranial method may be used, whereby the carotid artery is gradually occluded in the neck to re- • Ineffective cerebral tissue perfusion related to bleeding duce pressure within the blood vessel. After ligation of the carotid • Disturbed sensory perception related to medically imposed artery, there is some risk for cerebral ischemia and sudden hemi- restrictions (aneurysm precautions) plegia because during the surgical procedure, there is a temporary • Anxiety related to illness and/or medically imposed restric- occlusion of the blood supply to the brain (unless a temporary by- tions (aneurysm precautions) pass shunt is used). In anticipation of these complications, cerebral blood flow and internal carotid pressure may be measured to COLLABORATIVE PROBLEMS/ identify patients at risk for postoperative ischemic episodes. POTENTIAL COMPLICATIONS Several less invasive endovascular treatments are now being Based on the assessment data, potential complications that may used for aneurysms. These procedures are performed by neuro- develop include the following: surgeons in neurointerventional radiology suites. Two procedures are endovascular treatment (occlusion of the parent artery) and • Vasospasm aneurysm coiling (obstruction of the aneurysm site with a coil). • Seizures While associated with lower risks than intracranial surgery in gen- • Hydrocephalus eral, secondary stroke and rupture of the aneurysm are still po- • Rebleeding tential complications (Pfohman & Criddle, 2001). Postoperative complications include psychological symptoms Planning and Goals (disorientation, amnesia, Korsakoff’s syndrome, personality changes), intraoperative embolization, postoperative internal The goals for the patient may include improved cerebral tissue artery occlusion, fluid and electrolyte disturbances (from dys- perfusion, relief of sensory and perceptual deprivation, relief of function of the neurohypophyseal system), and gastrointestinal anxiety, and the absence of complications. bleeding. Nursing Interventions NURSING PROCESS: OPTIMIZING CEREBRAL TISSUE PERFUSION THE PATIENT WITH A The patient is closely monitored for neurologic deterioration oc- HEMORRHAGIC STROKE curring from recurrent bleeding, increasing ICP, or vasospasm. A neurologic flow record is maintained. The blood pressure, pulse, Assessment level of responsiveness (an indicator of cerebral perfusion), pupillary responses, and motor function are checked hourly. Respira- A complete neurologic assessment is performed initially and tory status is monitored because a reduction in oxygen in areas of should include evaluation for the following: the brain with impaired autoregulation increases the chances of a • Altered level of consciousness cerebral infarction. Any changes are reported immediately. • Sluggish pupillary reaction • Motor and sensory dysfunction Implementing Aneurysm Precautions • Cranial nerve deficits (extraocular eye movements, facial Cerebral aneurysm precautions are implemented for the patient droop, presence of ptosis) with a diagnosis of aneurysm to provide a nonstimulating envi- • Speech difficulties and visual disturbance ronment, prevent increases in ICP pressure, and prevent further • Headache and nuchal rigidity or other neurologic deficits bleeding. The patient is placed on immediate and absolute bed 1906 Unit 14 NEUROLOGIC FUNCTION rest in a quiet, nonstressful environment because activity, pain, therapy is initiated at this time if not already prescribed. The and anxiety elevate the blood pressure, which increases the risk medication of choice is phenytoin (Dilantin) because this agent for bleeding. Visitors, except for family, are restricted. usually provides adequate antiseizure action while causing no The head of the bed is elevated 15 to 30 degrees to promote drowsiness at therapeutic levels. venous drainage and decrease ICP. Some neurologists, however, prefer that the patient remain flat to increase cerebral perfusion. Hydrocephalus Any activity that suddenly increases the blood pressure or ob- Blood in the subarachnoid space impedes the circulation of CSF, structs venous return is avoided. This includes the Valsalva ma- resulting in hydrocephalus. A CT scan that indicates dilated ven- neuver, straining, forceful sneezing, pushing up in bed, acute tricles confirms the diagnosis. Hydrocephalus can occur within flexion or rotation of the head and neck (which compromises the the first 24 hours (acute) after subarachnoid hemorrhage or days jugular veins), and cigarette smoking. Any activity requiring ex- (subacute) to several weeks (delayed) later. Symptoms vary ac- ertion is contraindicated. The patient is instructed to exhale cording to the time of onset and may be nonspecific. Acute hydro- through the mouth during voiding or defecation to decrease cephalus is characterized by sudden onset of stupor or coma strain. No enemas are permitted, but stool softeners and mild lax- and is managed with a ventriculostomy drain to decrease ICP. atives are prescribed. Both prevent constipation, which would Symptoms of subacute and delayed hydrocephalus include cause an increase in ICP, as would enemas. Dim lighting is help- gradual onset of drowsiness, behavioral changes, and ataxic gait. ful because photophobia (visual intolerance of light) is common. A ventriculoperitoneal shunt is surgically placed to treat chronic Coffee and tea, unless decaffeinated, are usually eliminated. hydrocephalus. Changes in patient responsiveness are reported Thigh-high elastic compression stockings or sequential com- immediately. pression boots may be prescribed to decrease the incidence of deep vein thrombosis resulting from immobility. The legs are ob- Rebleeding served for signs and symptoms of deep vein thrombosis (tender- The rate of recurrent hemorrhage is approximately 2% following ness, swelling, warmth, discoloration, positive Homans’ sign), a primary intracerebral hemorrhage. Hypertension is the most se- and abnormal findings are reported. rious risk factor, suggesting the importance of appropriate anti- The nurse administers all personal care. The patient is fed and hypertensive treatment (Qureshi et al., 2001). bathed to prevent any exertion that might raise the blood pres- Aneurysm rebleeding occurs most frequently in the first 2 weeks sure. External stimuli are kept to a minimum, including no tele- after the initial hemorrhage and is considered a major complica- vision, no radio, and no reading. Visitors are restricted in an effort tion. Symptoms of rebleeding include sudden severe headache, to keep the patient as quiet as possible. This precaution must be nausea, vomiting, decreased level of consciousness, and neuro- individualized based on the patient’s condition and response to logic deficit. A CT scan is performed to confirm rebleeding. Blood visitors. A sign indicating this restriction should be placed on the pressure is carefully maintained with medications. Antifibri- door of the room, and the restrictions should be discussed with nolytic medications (epsilon-aminocaproic acid) may be admin- both patient and family. The purpose of aneurysm precautions istered to delay the lysis of the clot surrounding the rupture. The should be thoroughly explained to both the patient (if possible) most effective preventive treatment is early clipping of the aneurysm and family. if the patient is a candidate for surgery.

RELIEVING SENSORY DEPRIVATION AND ANXIETY PROMOTING HOME AND COMMUNITY-BASED CARE Sensory stimulation is kept to a minimum for patients on aneurysm precautions. For patients who are awake, alert, and ori- Teaching Patients Self-Care ented, an explanation of the restrictions helps reduce the patient’s The patient and family are provided with information that will sense of isolation. Reality orientation is provided to help main- enable them to cooperate with the care and restrictions required tain orientation. during the acute phase of hemorrhagic stroke and to prepare them Keeping the patient well informed of the plan of care provides to return home. Patient and family teaching includes informa- reassurance and helps minimize anxiety. Appropriate reassurance tion about the causes of hemorrhagic stroke and its possible con- also helps relieve the patient’s fears and anxiety. The family also sequences. In addition, the patient and family are informed about requires information and support. the medical treatments that are implemented, including surgical intervention if warranted, and the importance of interventions MONITORING AND MANAGING taken to prevent and detect complications (ie, aneurysm precau- POTENTIAL COMPLICATIONS tions, close monitoring of the patient). Depending on the presence and severity of neurologic impairment and other complications Vasospasm resulting from the stroke, the patient may be transferred to a re- The patient is assessed for signs of possible vasospasm: intensified habilitation unit or center, where additional patient and family headaches, a decrease in level of responsiveness (confusion, dis- teaching will focus on strategies to regain ability to manage self- orientation, lethargy), or evidence of aphasia or partial paralysis. care. Teaching may also address the use of assistive devices or These signs may develop several days after surgery or on the ini- modification of the home environment to help the patient live tiation of treatment and must be reported immediately. If va- with a disability. Modifications of the home may be required to sospasm is diagnosed, calcium-channel blockers or fluid volume provide a safe environment (Olson, 2001). (See Nursing Research expanders may be prescribed. Profile 62-2.)

Seizures Continuing Care Seizure precautions are maintained for every patient who may be During the acute and rehabilitation phase of care for the patient at risk for seizure activity. Should a seizure occur, maintaining the with a hemorrhagic stroke, the focus is on obvious needs, issues, airway and preventing injury are the primary goals. Medication and deﬁcits. The patient and family are reminded of the impor- Chapter 62 Management of Patients With Cerebrovascular Disorders 1907 NURSING RESEARCH PROFILE 62-2 The Experience of Stroke for Eight African-American Elders Eaves, Y. (2000). “What happened to me”: Rural African American elders’ experiences of stroke. Journal of Neuro- science Nursing, 32(1), 37–48.

Purpose ranged from 8 to 60 years. Five main themes were revealed in this The rate of stroke is higher in African Americans compared to Cau- study: (1) discovering stroke, (2) delaying treatment, (3) living with casians, yet little is known about the subjective experiences of stroke uncertainty, (4) discovering the impact of stroke, and (5) recon- in this group and their families. The purpose of this study was to ex- structing life. Each of the five themes revealed at least two patterns; amine the experience of stroke from the perspective of rural African- discovering stroke, for example, included stroke signs and explaining American elders and their family members. stroke. The findings revealed that several of the participants hid their stroke symptoms from family members and delayed seeking treatment Study Sample and Design for a prolonged time. This descriptive, qualitative study was part of a larger study on caregiving. A purposive sample of eight African-American stroke survivors Nursing Implications and their families participated. The survivors had each experienced a Nurses in acute care, home care, rehabilitation, and community set- stroke in the preceding 4 months, were 55 years or older, and recently tings involved with stroke patients and their families can use this in- had been discharged from a rehabilitation center. The qualitative formation to better understand how African-American elders live method of descriptive narrative analysis was used to explain the stroke through and respond to the experience of stroke. The identified experience. Interactive audiotaped interviews and focused observa- themes of how, when, and why rural African-American elders seek tions with written field notes took place in the home of each partici- treatment for stroke symptoms can assist nurses in educating this pant over several sessions. The qualitative text analysis software group about signs and symptoms of stroke, stroke prevention, and the MARTIN was used for data analysis of the transcribed audiotaped emergent nature of stroke. This would permit the development of interviews and written field notes. appropriate strategies to target this high-risk group. Findings The eight stroke survivors ranged in age from 56 to 79 years; primary caregivers ranged in age from 21 to 70 years and secondary caregivers

tance of following recommendations to prevent further hemor- in the past are educated about their importance and are referred to rhagic stroke and keeping follow-up appointments with health care appropriate health care providers, if indicated. Chart 62-7 lists providers for monitoring. Referral for home care may be warranted teaching points for the patient recovering from a stroke. to assess the home environment and the ability of the patient and to ensure that the patient and family are able to manage at home. The physical and psychological status of the patient and ability of Evaluation the family to cope with any alterations in the patient’s status are EXPECTED PATIENT OUTCOMES monitored during home visits. In addition, the nurse involved in home and continuing care needs to remind patients and family Expected patient outcomes may include: members of the need for continuing health promotion and screen- 1. Demonstrates intact neurologic status and normal vital ing practices. Patients who have not been involved in these practices signs and respiratory patterns

Chart 62-7 Home Care Checklist • The Patient Recovering From A Stroke

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • Discuss measures to prevent subsequent strokes. ✓✓ • Identify signs and symptoms of speciﬁc complications. ✓✓ • Identify potential complications and discuss measures to prevent them (blood clots, aspiration, pneumonia, urinary tract infection, fecal impaction, skin breakdown, contracture). ✓✓ • Identify psychosocial consequences of stroke and appropriate interventions. ✓✓ • Identify safety measures to prevent falls. ✓✓ • State names, doses, indications, and side effects of medications. ✓✓ • Demonstrate adaptive techniques for accomplishing ADLs. ✓✓ • Demonstrate swallowing techniques (for patients with dysphagia). ✓✓ • Demonstrate care of enteric feeding tube, if applicable. ✓✓ • Demonstrate home exercises, use of splints or orthotics, proper positioning, and need for frequent repositioning. ✓✓ • Describe procedures for maintaining skin integrity. ✓✓ • Demonstrate indwelling catheter care, if applicable. Describe a bowel and bladder elimination program as appropriate. ✓✓ • Identify appropriate recreational or diversional activities, support groups, and community resources. ✓✓ 1908 Unit 14 NEUROLOGIC FUNCTION

a. Is alert and oriented to time, place, and person American Heart Association. (2000). American Heart Association heart b. Demonstrates normal speech patterns and intact cogni- and stroke 2000 statistical update. Dallas: Author. tive processes Cohen, S. (Ed.). (2000). Management of ischemic stroke. New York: c. Demonstrates normal and equal strength, movement, McGraw-Hill. and sensation of all four extremities Hickey, J. V. (2003). The clinical practice of neurological and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. d. Exhibits normal deep tendon reflexes and pupillary re- Lipski, M., & Alexander, C. (1997). Sexual function in people with dis- sponses ability and chronic illness. Gaithersburg, MD: Aspen. 2. Demonstrates normal sensory perceptions Matchar, D. B., & Samsa, G. P. (2000). Secondary and tertiary preven- a. States rationale for aneurysm precautions tion of stroke. Patient Outcomes Research Team (PORT) Final Re- b. Exhibits clear thought processes port, Phase 1. (Prepared by Duke University Medical Center under 3. Exhibits reduced anxiety level Contract No. 290-91-0028). AHRQ Pub. No. 00-N001. Rockville, a. Is less restless MD: Agency for Healthcare Research and Quality. b. Exhibits absence of physiologic indicators of anxiety National Institute of Neurologic Disorders and Stroke. (1999). Stroke: (eg, normal vital signs; normal respiratory rate; absence Hope through research. NINDS Office of Communications and Pub- of excessive, fast speech) lic Liaison. NIH Pub. No. 99-2222. Bethesda, MD: National Insti- tutes of Health. 4. Is free of complications a. Exhibits absence of vasospasm Journals b. Exhibits normal vital signs and neuromuscular activity Asterisks indicate nursing research articles. without seizures Alberts, M., Hademenos, G., Latchaw, R., et al. (2000). Recommenda- c. Verbalizes understanding of seizure precautions tions for the establishment of primary stroke centers. Journal of the d. Exhibits normal mental status and normal motor and American Medical Association, 283(23), 3102–3109. sensory status Bahouth, M., & LaMonte, M. (2000). Update on stroke prevention and e. Reports no visual changes initial acute stroke management. Primary Care Practice, 4(6), 545–562. Berges, S., et al. (2000). Seizures and epilepsy following strokes: Recur- rence factors. European Neurology, 43(3), 3–8. Bonnono, C., Criddle, L., et al. (2000). Emergi-paths and stroke teams: An emergency department approach to acute ischemic stroke. Jour- Critical Thinking Exercises nal of Neuroscience Nursing, 32(6), 298–305. ?? Brashear, A., Gordon, M., Elovic, E., et al. (2002). Intramuscular injec- 1. Your patient had symptoms of an ischemic stroke ap- tion of botulinum toxin for the treatment of wrist and finger spastic- proximately 2 hours ago and is undergoing a confirmatory ity after a stroke. New England Journal of Medicine, 347(6), 395–400. Demchuk, A., & Buchan, A. (2000). Predictors of stroke outcome. Neu- CT scan in 30 minutes. You know t-PA must be adminis- rologic Clinics, 19(2), 455–473. tered within 3 hours of the symptoms. What actions would *Eaves, Y. (2000). What happened to me: Rural African American el- you take? What is your rationale for these actions? ders’ experiences of stroke. Journal of Neuroscience Nursing, 32(1), Your patient has expressive aphasia following an ischemic 37–48. 2. Evans, V. (2000). Herbs and the brain: Friend or foe? Journal of Neuro- stroke. How would you explain this phenomenon to the science Nursing, 32(4), 229–232. patient and family? Describe appropriate techniques for *Hinkle, J. L. (2001). A descriptive study of function in acute motor communicating with a patient with this type of aphasia. stroke. Western Journal of Nursing Research, 23(3), 296–312. 3. Your patient is admitted with hemorrhagic stroke and Hinkle, J. L. (2000). The use of the FIM instrument in the poststroke exhibits homonymous hemianopsia. How would you explain population. Topics in Stroke Rehabilitation, 7(3), 47–66. Hock, N. H. (1999). Brain attack: The stroke continuum. Nursing Clin- this phenomenon to the patient and family? How would you ics of North America, 34(3), 689–715. modify your care for this patient? Describe ways that the pa- Iso, H., et al. (2001). Intake of fish and omega-3 fatty acids and risk of tient and family may work together to compensate for this stroke in women. Journal of American Medical Association, 285(3), problem. 304–312. Kernan, W., Viscoli, C., Brass, L., et al. (2000). Phenylpropanolamine 4. A 50-year-old patient is expected to be discharged to and the risk of hemorrhagic stroke. New England Journal of Medi- home today following a 5-day stay for an ischemic stroke. cine, 343(25), 1826–1832. He tells you that he lives alone in a small apartment and *King, B., Carlson, C., Shade-Zeldow, Y., et al. (2001). Transition to knows none of his neighbors. He has some residual right- home care after stroke: Depression, physical health, and adaptive sided weakness. What teaching would be indicated to pre- processes in support persons. Research in Nursing & Health, 24, vent another stroke? What resources may be needed to 307–323. enable him to go home as scheduled? Krenzer, M. (1999). Unplugging the mystery of carotid endarterectomy patient care. Critical Care Nursing Clinics of North America, 11(2), 189–208. Lindsey, J. (2000). Implementing a stroke risk assessment program in a community setting. Journal of Neuroscience Nursing, 32(5), 266–270. REFERENCES AND SELECTED READINGS Manzella, S., & Galante, K. (2000). Establishment of stroke treatment plans: One hospital’s experience. Journal of Neuroscience Nursing, Books 32(6), 306–310. Agency for Health Care Policy and Research, Public Health Service. U.S. Mumma, C. (2001). Rehabilitation and rehabilitation nursing. Critical Department of Health and Human Services. (1995). Post-stroke re- Care Nursing Clinics of North America, 13(3), 335–340. habilitation. Clinical Practice Guideline. AHCPR Publication No. National Institute of Neurologic Disorders and Stroke (NINDS) rt-PA 95-0662. Rockville, MD. Stroke Study Group. (1995). Tissue plasminogen activator for acute Chapter 62 Management of Patients With Cerebrovascular Disorders 1909

ischemic stroke. New England Journal of Medicine, 333(24), Scroggins, N. (2000). Hemorrhagic disorders associated with throm- 1581–1587. bolytic therapy. Critical Care Nursing Clinics of North America, 12(3), Olson, R. (2001). Community re-entry after critical illness. Critical Care 353–363. Nursing Clinics of North America, 13(3), 449–461. Summers, D., Pyle, J., Stahl, M., & Hileman, J. (2000). The heart-brain Petty, G. W., Brawn, R. D., Whisnant, J. P., et al. (2000). Ischemic connection. Journal of Neuroscience Nursing, 32(2), 108–116. stroke subtypes: A population-based study of functional outcome, *Teel, C., Duncan, P., & Lai, S. (2001). Caregiving experiences after survival, and recurrence. Stroke, 31, 1062–1068. stroke. Nursing Research, 50(1), 53–60. Pfohman, M., & Criddle, L. (2001). Epidemiology of intracranial Vestergaard, K., Andersen, G., Gottrup, H., et al. (2001). Lamotrigine aneurysm and subarachnoid hemorrhage. Journal of Neuroscience for central poststroke pain: A randomized controlled trial. Neurology, Nursing, 33(1), 39–41. 56(2), 184–190. *Pilkington, F. B. (1999). A qualitative study of life after stroke. Jour- Wolf, P., Clagett, P., Easton, D., et al. (1999). Preventing ischemic nal of Neuroscience Nursing, 31(6), 336–347. stroke in patients with prior stroke and transient ischemic attack. Qureshi, A., Tuhrim, S., Broderick, J., et al. (2001). Spontaneous in- Stroke, 30, 1991–1884. tracerebral hemorrhage. New England Journal of Medicine, 344(19), 1450–1460. Reed, S. (2000). Pharmacological therapy for acute stroke. Current RESOURCES AND WEBSITES Opinion in Investigational Drugs, 1(3), 329–339. Robinson-Smith, G., Johnston, M. V., & Allen, J. (2000). Self-care, American Stroke Association, a Division of the American Heart Associ- self-efficacy, quality of life, and depression after stroke. Archives of ation, 7272 Greenville Avenue, Dallas, TX 75231-5129; (800) Physical Medicine and Rehabilitation, 81, 460–464. 553-6321 or (214) 706-1398; fax (214) 706-5231; http://www. Sarasin, F. P., Gaspoz, J. M., & Bounameaux, H. (2000). Cost- americanheart.org. effectiveness of new antiplatelet regimens used as secondary pre- National Institute of Neurological Disorders and Stroke, National In- vention of stroke or transient ischemic attack. Archives of Internal stitutes of Health. Bethesda, MD 20892; http:/www.ninds.nih.gov. Medicine, 160(18), 2773–2778. National Stroke Association, 9707 Easter Ln, Englewood, CO 80112- Schievink, W. (2001). Spontaneous dissection of the carotid and verte- 3754; (800) 787-6537 or (303) 649-9299; fax (303) 649-1328; bral arteries. New England Journal of Medicine, 344(12), 898–906. http://www.stoke.org. Chapter 63 ● Management of Patients With Neurologic Trauma

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Differentiate among patients with head injuries according to mechanism of injury, clinical signs and symptoms, diagnostic testing, and treatment options. 2. Describe the nursing management of head-injured patients. 3. Use the nursing process as a framework for care of patients with brain injury. 4. Identify the population at risk for spinal cord injury. 5. Describe three clinical features of the patient with neurogenic shock. 6. Discuss the pathophysiology of autonomic dysreﬂexia and describe the appropriate nursing interventions. 7. Use the nursing process as a framework for care of patients with spinal cord injury.

1910 Chapter 63 Management of Patients With Neurologic Trauma 1911

rauma involving the central nervous system can be life- Chart T Chart Head and Spinal Cord Injury Prevention threatening. Even if not life-threatening, brain and spinal cord in- 63-1 jury may result in major physical and psychological dysfunction and can alter the patient’s life completely. Neurologic trauma The most effective treatment for brain and spinal cord injury is pre- affects the patient, the family, the health care system, and soci- vention. To decrease the incidence of these devastating and catastrophic injuries, the following steps should be taken: ety as a whole because of its major sequelae and the costs of acute • Drivers should obey traffic laws, particularly not speeding or and long-term care of patients with trauma to the brain and driving when under the influence of drugs or alcohol. spinal cord. • All drivers and passengers should wear seat belts and shoulder harnesses. Children under 12 should be restrained in an age/size-appropriate system in the back seat. Head Injuries • Passengers should not ride in the back of pick-up trucks. • Motorcyclists, scooters, bicyclists, skateboarders, and roller Head injury is a broad classification that includes injury to the scalp, skaters should wear helmets. skull, or brain. It is the most common cause of death from trauma • Educational programs should be directed toward violence in the United States. Approximately 1 million people receive and suicide prevention in the community. treatment for head injuries every year. Of these, 230,000 are hos- • Water safety instruction should be provided. pitalized, 80,000 have permanent disabilities, and 50,000 people • Steps should be taken to prevent falls, particularly in the die (Centers for Disease Control and Prevention [CDC], 2001). elderly. Traumatic brain injury is the most serious form of head injury. • Athletes should use protective devices; coaches should be The most common causes of traumatic brain injury are motor educated in proper coaching techniques. vehicle crashes, violence, and falls. Groups at highest risk for trau- • Owners of firearms should keep them locked in a secure area where children cannot access them. matic brain injury are persons age 15 to 24 years and males, who suffer traumatic brain injury at a rate almost twice that of females. The very young (under 5) and the very old (over 75) are also at increased risk. It is estimated that 5.3 million Americans today are living with a disability as a result of a traumatic brain injury rigid closed compartment (Bader & Palmer, 2000). Unlike an in- (CDC, 2001). The best approach to head injury is prevention jured ankle, in which the covering skin expands with swelling, the (Chart 63-1). confines of the skull do not allow for the expansion of cranial contents. Thus, any bleeding or swelling within the skull increases the Pathophysiology volume of contents within a container of fixed size and so can cause increased intracranial pressure (ICP) (see Chap. 61). If the Research suggests that not all brain damage occurs at the moment increased pressure is high enough, it can cause a downward or lat- of impact. Damage to the brain from traumatic injury takes two eral displacement of the brain through or against the rigid struc- forms: primary injury and secondary injury. Primary injury is the tures of the skull. This causes restriction of blood flow to the initial damage to the brain that results from the traumatic event. brain, decreasing oxygen delivery and waste removal. Cells within This may include contusions, lacerations, and torn blood vessels the brain become anoxic and cannot metabolize properly, pro- from impact, acceleration/deceleration, or foreign object penetra- ducing ischemia, infarction, irreversible brain damage, and even- tion (Blank-Reid & Reid, 2000; Porth, 2002). Secondary injury tually brain death (Fig. 63-1). evolves over the ensuing hours and days after the initial injury and is due primarily to brain swelling or ongoing bleeding. SCALP INJURY An injured brain is different from other injured body areas due Isolated scalp trauma is generally classified as a minor head injury. to its unique characteristics. It resides within the skull, which is a Because its many blood vessels constrict poorly, the scalp bleeds Glossary autonomic dysreflexia: a life-threatening concussion: a temporary loss of neurologic paraplegia: paralysis of the lower extremities emergency in spinal cord injury patients function with no apparent structural with dysfunction of the bowel and blad- that causes a hypertensive emergency; damage to the brain der from a lesion in the thoracic, lumbar, also called autonomic hyperreflexia contusion: bruising of the brain surface or sacral regions of the spinal cord brain injury: an injury to the skull or brain complete spinal cord lesion: a condition quadriplegia (tetraplegia): paralysis of both that is severe enough to interfere with that involves total loss of sensation and arms and legs, with dysfunction of bowel normal functioning voluntary muscle control below the lesion and bladder from a lesion of the cervical brain injury, closed (blunt): occurs when halo vest: a lightweight vest with an at- segments of the spinal cord the head accelerates and then rapidly detached halo that stabilizes the cervical secondary injury: an insult to the brain sub- celerates or collides with another object spine sequent to the original traumatic event and brain tissue is damaged, but there is incomplete spinal cord lesion: a condition spinal cord injury (SCI): an injury to the no opening through the skull and dura where there is preservation of the sensory spinal cord, vertebral column, supporting brain injury, open: occurs when an object or motor fibers, or both, below the lesion soft tissue, or intervertebral disks caused penetrates the skull, enters the brain, and neurogenic bladder: bladder dysfunction by trauma damages the soft brain tissue in its path that results from a disorder or dysfunc- transection: severing of the spinal cord it- (penetrating injury), or when blunt trauma tion of the nervous system; may result in self; transection can be complete (all the to the head is so severe that it opens the either urinary retention or bladder over- way through the cord) or incomplete scalp, skull, and dura to expose the brain activity (partially through) 1912 Unit 14 NEUROLOGIC FUNCTION

Physiology/Pathophysiology

Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for expansion of contents so intracranial pressure increases

Pressure on blood vessels within the brain causes blood flow to the brain to slow Basilar skull fracture

Cerebral hypoxia and ischemia occur

Intracranial pressure continues to rise. Brain may herniate

Cerebral blood flow ceases

FIGURE 63-1 Pathophysiology of traumatic brain injury.

profusely when injured. Trauma may result in an abrasion (brush wound), contusion, laceration, or hematoma beneath the layers FIGURE 63-2 Basilar fractures allow cerebrospinal ﬂuid to leak from the of tissue of the scalp (subgaleal hematoma). Large avulsions of the nose and ears. Adapted from Hickey, J. V. (2003). The clinical practice of neuro- scalp may be potentially life-threatening and are true emergen- logical and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams cies. Diagnosis of any scalp injury is based on physical examina- & Wilkins. tion, inspection, and palpation. Scalp wounds are potential portals of entry of organisms that cause intracranial infections. There- seen over the mastoid (Battle’s sign). Basal skull fractures are fore, the area is irrigated before the laceration is sutured to remove suspected when cerebrospinal ﬂuid escapes from the ears (CSF foreign material and to reduce the risk for infection. Subgaleal otorrhea) and the nose (CSF rhinorrhea). A halo sign (a blood hematomas (hematomas below the outer covering of the skull) stain surrounded by a yellowish stain) may be seen on bed linens usually absorb on their own and do not require any specific or the head dressing and is highly suggestive of a CSF leak. treatment. Drainage of CSF is a serious problem because meningeal infec- SKULL FRACTURES tion can occur if organisms gain access to the cranial contents A skull fracture is a break in the continuity of the skull caused by through the nose, ear, or sinus through a tear in the dura. Bloody forceful trauma. It may occur with or without damage to the CSF suggests a brain laceration or contusion. brain. Skull fractures are classified as linear, comminuted, depressed, or basilar. A fracture may be open, indicating a scalp Assessment and Diagnostic Findings laceration or tear in the dura (eg, from a bullet or an ice pick), or closed, in which the dura is intact (Fig. 63-2). Although a rapid physical examination and evaluation of neurologic status detect the more obvious brain injuries, a computed tomography (CT) scan can detect less apparent abnormalities by Clinical Manifestations the degree to which the soft tissue absorbs the x-rays. It is a fast, The symptoms, apart from those of the local injury, depend on accurate, and safe diagnostic study that shows the presence, nature, the severity and the distribution of brain injury. Persistent, local- location, and extent of acute lesions. It is also helpful in the on- ized pain usually suggests that a fracture is present. Fractures of going management of patients with head injury as it can dis- the cranial vault may or may not produce swelling in the region close cerebral edema, contusion, intracerebral or extracerebral of the fracture; therefore, an x-ray is needed for diagnosis. hematoma, subarachnoid and intraventricular hemorrhage, and Fractures of the base of the skull tend to traverse the paranasal late changes (infarction, hydrocephalus). Magnetic resonance sinus of the frontal bone or the middle ear located in the tempo- imaging (MRI) is used to evaluate patients with head injury when ral bone (see Fig. 63-2). Thus, they frequently produce hemor- a more accurate picture of the anatomic nature of the injury is rhage from the nose, pharynx, or ears, and blood may appear warranted and when the patient is stable enough to undergo this under the conjunctiva. An area of ecchymosis (bruising) may be longer diagnostic study. Chapter 63 Management of Patients With Neurologic Trauma 1913

Cerebral angiography may also be used; it identifies supra- Chart tentorial, extracerebral, and intracerebral hematomas and cere- 63-2 Clinical Manifestations of Brain Injury bral contusions. Lateral and anteroposterior views of the skull are obtained. • Altered level of consciousness • Confusion • Pupillary abnormalities (changes in shape, size, and response to Medical Management light) Nondepressed skull fractures generally do not require surgical • Altered or absent gag reflex • Absent corneal reflex treatment; however, close observation of the patient is essential. • Sudden onset of neurologic deficits Nursing personnel may observe the patient in the hospital, but if • Changes in vital signs (altered respiratory pattern, hypertension, no underlying brain injury is present, the patient may be allowed bradycardia, tachycardia, hypothermia or hyperthermia) to return home. If the patient is discharged home, specific in- • Vision and hearing impairment structions (see the section on concussions below) must be given to • Sensory dysfunction the family. Many depressed skull fractures are managed conserva- • Spasticity tively; only contaminated or deforming fractures require surgery. • Headache If surgery is necessary, the scalp is shaved and cleansed with • Vertigo copious amounts of saline to remove debris. The fracture is then • Movement disorders exposed. After the skull fragments are elevated, the area is débrided. • Seizures Large defects can be repaired immediately with bone or artificial grafts; if significant cerebral edema is present, repair of the defect can be delayed for 3 to 6 months. Penetrating wounds require surgical débridement to remove foreign bodies and devitalized from a few seconds to a few minutes. The jarring of the brain may brain tissue and to control hemorrhage (Blank-Reid & Reid, be so slight as to cause only dizziness and spots before the eyes 2000). Antibiotic treatment is instituted immediately, and blood (“seeing stars”), or it may be severe enough to cause complete loss component therapy is administered if indicated. of consciousness for a time. If the brain tissue in the frontal lobe As stated previously, fractures of the base of the skull are se- is affected, the patient may exhibit bizarre irrational behavior, rious because they are usually open (involving the paranasal whereas involvement of the temporal lobe can produce temporary sinuses or middle or external ear) and result in CSF leakage. The amnesia or disorientation. nasopharynx and the external ear should be kept clean. Usually The patient may be hospitalized overnight for observation or a piece of sterile cotton is placed loosely in the ear, or a sterile discharged from the hospital in a relatively short time after a con- cotton pad may be taped loosely under the nose or against the ear cussion. Treatment involves observing the patient for headache, to collect the draining fluid. The patient who is conscious is cau- dizziness, lethargy, irritability, and anxiety. The occurrence of these tioned against sneezing or blowing the nose. The head is elevated symptoms after injury is referred to as postconcussion syndrome. 30 degrees to reduce ICP and promote spontaneous closure of the Giving the patient information, explanations, and encouragement leak (Sullivan, 2000), although some neurosurgeons prefer that may reduce some of the problems of postconcussion syndrome. the bed be kept flat. Persistent CSF rhinorrhea or otorrhea usually The patient is advised to resume normal activities slowly, and the requires surgical intervention. family is instructed to observe for the following signs and symptoms and to notify the physician or clinic (or bring the patient to Brain Injury the emergency department) if they occur: • Difficulty in awakening The most important consideration in any head injury is whether • Difficulty in speaking or not the brain is injured. Even seemingly minor injury can cause • Confusion significant brain damage secondary to obstructed blood flow and • Severe headache decreased tissue perfusion. The brain cannot store oxygen and • Vomiting glucose to any significant degree. Because the cerebral cells need • Weakness of one side of the body an uninterrupted blood supply to obtain these nutrients, irre- A concussion was once thought of as a minor head injury versible brain damage and cell death occur when the blood sup- without significant sequelae. However, studies have demonstrated ply is interrupted for even a few minutes. Clinical manifestations that there are often disturbing and sometimes residual effects, in- of brain injury are listed in Chart 63-2. Closed (blunt) brain cluding headache, lethargy, personality and behavior changes, injury occurs when the head accelerates and then rapidly decel- attention deficits, difficulty with memory, and disruption in work erates or collides with another object (eg, a wall or dashboard of habits (Ponsford et al., 1999). a car) and brain tissue is damaged, but there is no opening through the skull and dura. Open brain injury occurs when an object Gerontologic Considerations penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to Elderly patients must be assessed very carefully. Even given the head is so severe that it opens the scalp, skull, and dura to similar mechanisms of injury, an elderly person will often suffer expose the brain. more severe injury than a young person and will often recover more slowly and with more complications (Perdue et al., 1998). Concussion The elderly patient with confusion or behavioral disturbances should be assessed for head injury, because unrecognized “minor” A cerebral concussion after head injury is a temporary loss of head trauma may account for behavioral and confusional episodes neurologic function with no apparent structural damage. A con- in some elderly people (Walshaw, 2000). A misdiagnosed or un- cussion generally involves a period of unconsciousness lasting treated episode of confusion in an elderly patient may result in 1914 Unit 14 NEUROLOGIC FUNCTION long-term disability that might have been avoided if the injury pression by a hematoma are variable and depend on the speed had been detected and treated promptly. with which vital areas are affected and the area that is injured. In general, a rapidly developing hematoma, even if small, may be Contusion fatal, whereas a larger but slowly developing collection of blood may allow compensation for increases in ICP. Cerebral contusion is a more severe injury in which the brain is bruised, with possible surface hemorrhage. The patient is un- EPIDURAL HEMATOMA (EXTRADURAL HEMATOMA conscious for more than a few seconds or minutes. Clinical signs OR HEMORRHAGE) and symptoms depend on the size of the contusion and the amount After a head injury, blood may collect in the epidural (extradural) of associated cerebral edema. The patient may lie motionless, space between the skull and the dura. This can result from a skull with a faint pulse, shallow respirations, and cool, pale skin. Often fracture that causes a rupture or laceration of the middle meningeal there is involuntary evacuation of the bowels and the bladder. artery, the artery that runs between the dura and the skull infe- The patient may be aroused with effort but soon slips back into rior to a thin portion of temporal bone. Hemorrhage from this unconsciousness. The blood pressure and the temperature are artery causes rapid pressure on the brain. subnormal, and the picture is somewhat similar to that of shock. Symptoms are caused by the expanding hematoma. Usually, In general, patients with severe brain injury who have abnor- there is a momentary loss of consciousness at the time of injury, mal motor function, abnormal eye movements, and elevated ICP followed by an interval of apparent recovery (lucid interval). have poor outcomes—that is, brain damage, disability, or death. Although the lucid interval is considered a classic characteristic of Conversely, the patient may recover consciousness but pass into an epidural hematoma, no lucid interval has been reported in a stage of cerebral irritability. In this stage, the patient is conscious many patients with this lesion (Servadei, 1997), and thus it should and easily disturbed by any form of stimulation such as noises, not be considered a critical defining criterion. During the lucid light, and voices; he or she may become hyperactive at times. interval, compensation for the expanding hematoma takes place Gradually, the pulse, respirations, temperature, and other body by rapid absorption of CSF and decreased intravascular volume, functions return to normal, but full recovery can be delayed for both of which help maintain a normal ICP. When these mecha- months. Residual headache and vertigo are common, and im- nisms can no longer compensate, even a small increase in the paired mental function or seizures may occur as a result of volume of the blood clot produces a marked elevation in ICP. irreparable cerebral damage. Then, often suddenly, signs of compression appear (usually deterioration of consciousness and signs of focal neurologic deficits Diffuse Axonal Injury such as dilation and fixation of a pupil or paralysis of an extremity), Diffuse axonal injury involves widespread damage to axons in the and the patient deteriorates rapidly. cerebral hemispheres, corpus callosum, and brain stem. It can be An epidural hematoma is considered an extreme emergency; seen in mild, moderate, or severe head trauma and results in axonal marked neurologic deficit or even respiratory arrest can occur swelling and disconnection (Porth, 2002). Clinically, with severe within minutes. Treatment consists of making openings through injury, the patient has no lucid intervals and experiences imme- the skull (burr holes) to decrease ICP emergently, remove the diate coma, decorticate and decerebrate posturing (see Fig. 61-1 clot, and control the bleeding. A craniotomy may be required to in Chap. 61 and discussion in Chap. 60), and global cerebral remove the clot and control the bleeding. A drain is usually in- edema. Diagnosis is made by clinical signs in conjunction with a serted after creation of burr holes or a craniotomy to prevent CT scan or MRI. Recovery depends on the severity of the axonal reaccumulation of blood. injury. SUBDURAL HEMATOMA Intracranial Hemorrhage A subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of Hematomas (collections of blood) that develop within the cra- fluid. The most common cause of subdural hematoma is trauma, nial vault are the most serious brain injuries (Porth, 2002). A but it may also occur from coagulopathies or rupture of an hematoma may be epidural (above the dura), subdural (below aneurysm. A subdural hemorrhage is more frequently venous in the dura), or intracerebral (within the brain) (Fig. 63-3). Major origin and is due to the rupture of small vessels that bridge the symptoms are frequently delayed until the hematoma is large subdural space. A subdural hematoma may be acute, subacute, or enough to cause distortion of the brain and increased ICP. The chronic, depending on the size of the involved vessel and the signs and symptoms of cerebral ischemia resulting from the com- amount of bleeding present.

Subdural Intracerebral Epidural FIGURE 63-3 Locations of intra- hematoma hematoma hematoma cranial hemorrhages. Chapter 63 Management of Patients With Neurologic Trauma 1915

Acute and Subacute Subdural Hematoma. Acute subdural hema- cludes supportive care, control of ICP, and careful administration tomas are associated with major head injury involving contusion of fluids, electrolytes, and antihypertensive medications. Surgical or laceration. Clinical symptoms develop over 24 to 48 hours. intervention by craniotomy or craniectomy permits removal of Signs and symptoms include changes in the level of consciousness the blood clot and control of hemorrhage but may not be possi- (LOC), pupillary signs, and hemiparesis. There may be minor or ble because of the inaccessible location of the bleeding or the lack even no symptoms with small collections of blood. Coma, in- of a clearly circumscribed area of blood that can be removed. creasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring Management of Brain Injuries immediate intervention. Subacute subdural hematomas are the result of less severe con- Assessment and diagnosis of the extent of injury are accomplished tusions and head trauma. Clinical manifestations usually appear by the initial physical and neurologic examinations. CT and MRI between 48 hours and 2 weeks after the injury. Signs and symp- are the primary neuroimaging diagnostic tools and are useful in toms are similar to those of an acute subdural hematoma. evaluating soft tissue injuries. Positron emission tomography If the patient can be transported rapidly to the hospital, an (PET scan) is available in some trauma centers; this method of immediate craniotomy is performed to open the dura, allowing scanning examines brain function rather than structure. A flow- the subdural clot to be evacuated. Successful outcome also de- chart developed by the Brain Trauma Foundation for the initial pends on the control of ICP and careful monitoring of respira- management of brain-injured patients is presented in Figure 63-4 tory function (see “The Patient Undergoing Intracranial Surgery” (Brain Trauma Foundation, 2000). in Chap. 61). The mortality rate for patients with acute and sub- Any individual with a head injury is presumed to have a cer- acute subdural hematomas is high because of associated brain vical spine injury until proven otherwise. From the scene of the damage. injury, the patient is transported on a board with the head and neck maintained in alignment with the axis of the body. A cervi- Chronic Subdural Hematoma. Chronic subdural hematomas can cal collar should be applied and maintained until cervical spine develop from seemingly minor head injuries and are seen most x-rays have been obtained and the absence of cervical spinal cord frequently in the elderly. The elderly are prone to this type of injury documented. head injury secondary to brain atrophy, which is an expected con- All therapy is directed toward preserving brain homeostasis sequence of the aging process. Seemingly minor head trauma may and preventing secondary brain injury. “Secondary injury” is a produce enough impact to shift the brain contents abnormally. term used to describe injury to the brain subsequent to the orig- The time between injury and onset of symptoms may be lengthy inal traumatic event (Bader & Palmer, 2000). Common causes (eg, 3 weeks to months), so the actual insult may be forgotten. of secondary injury are cerebral edema, hypotension, and respi- A chronic subdural hematoma resembles other conditions and ratory depression that may lead to hypoxemia and electrolyte may be mistaken for a stroke. The bleeding is less profuse and imbalance. Treatments to prevent this include stabilization of there is compression of the intracranial contents. The blood cardiovascular and respiratory function to maintain adequate within the brain changes in character in 2 to 4 days, becoming cerebral perfusion, control of hemorrhage and hypovolemia, and thicker and darker. In a few weeks, the clot breaks down and has maintenance of optimal blood gas values (Wong, 2000). the color and consistency of motor oil. Eventually, calcification or ossification of the clot takes place. The brain adapts to this for- TREATMENT OF INCREASED INTRACRANIAL PRESSURE eign body invasion, and the clinical signs and symptoms fluctu- As the damaged brain swells with edema or as blood collects within ate. There may be severe headache, which tends to come and go; the brain, a rise in ICP occurs; this requires aggressive treatment. alternating focal neurologic signs; personality changes; mental de- See Chapter 61 for a discussion of the relationship of ICP to cere- terioration; and focal seizures. Unfortunately, the patient may be bral perfusion pressure (CPP). If the ICP remains elevated, it can labeled neurotic or psychotic if the cause of the symptoms is over- decrease the CPP. Initial management is based on the principle looked. of preventing secondary injury and maintaining adequate cere- The treatment of a chronic subdural hematoma consists of bral oxygenation (see Fig. 63-4). surgical evacuation of the clot. The procedure may be carried out Surgery is required for evacuation of blood clots, débridement through multiple burr holes, or a craniotomy may be performed and elevation of depressed fractures of the skull, and suture of se- for a sizable subdural mass that cannot be suctioned or drained vere scalp lacerations. ICP is monitored closely; if increased, it is through burr holes. managed by maintaining adequate oxygenation, elevating the head of the bed, and maintaining normal blood volume. Devices INTRACEREBRAL HEMORRHAGE AND HEMATOMA to monitor ICP or drain CSF can be inserted during surgery or Intracerebral hemorrhage is bleeding into the substance of the at the bedside using aseptic technique. The patient is cared for in brain. It is commonly seen in head injuries when force is exerted the intensive care unit, where expert nursing care and medical to the head over a small area (missile injuries or bullet wounds; treatment are readily available. stab injury). These hemorrhages within the brain may also result from systemic hypertension, which causes degeneration and rup- SUPPORTIVE MEASURES ture of a vessel; rupture of a saccular aneurysm; vascular anom- Treatment also includes ventilatory support, seizure prevention, alies; intracranial tumors; systemic causes, including bleeding fluid and electrolyte maintenance, nutritional support, and pain disorders such as leukemia, hemophilia, aplastic anemia, and and anxiety management. Comatose patients are intubated and thrombocytopenia; and complications of anticoagulant therapy. mechanically ventilated to ensure adequate oxygenation and pro- Nontraumatic causes of intracerebral hemorrhage are discussed tect the airway. in Chapter 62. Because seizures are common after head injury and can cause The onset may be insidious, beginning with the development secondary brain damage from hypoxia, antiseizure agents may be of neurologic deficits followed by headache. Management in- administered. If the patient is very agitated, benzodiazepines may 1916 Unit 14 NEUROLOGIC FUNCTION

be prescribed to calm him or her without decreasing LOC. These determination of brain death and in the process of organ pro- medications do not affect ICP or CPP, making them good choices curement. Since 1981, all 50 states have recognized the Uni- for the head-injured patient. form Determination of Brain Death Act (Lovasik, 2000). This A nasogastric tube may be inserted because reduced gastric act states that death will be determined with accepted medical motility and reverse peristalsis are associated with head injury, standards and that death will indicate irreversible loss of all making regurgitation and aspiration common in the first few hours. brain function. The patient has no neurologic activity upon clinical examination; adjunctive tests such as EEG and cerebral BRAIN DEATH blood flow (CBF) studies are often used to confirm brain death When a patient has sustained a severe head injury incompatible (Lovasik, 2000). Many of these patients are potential organ with life, the nurse may assist in the clinical examination for donors, and the nurse may provide information to the family Chapter 63 Management of Patients With Neurologic Trauma 1917 and assist them with this decision-making process about organ Chart Glasgow Coma Scale donation. 63-4 The Glasgow Coma Scale is a tool for assessing a patient’s response NURSING PROCESS: to stimuli. Scores range from 3 (deep coma) to 15 (normal). THE PATIENT WITH A BRAIN INJURY Eye opening response Spontaneous 4 Assessment To voice 3 To pain 2 Depending on the patient’s neurologic status, the nurse may elicit None 1 information from the patient, family, or witnesses or from emer- Best verbal response Oriented 5 gency rescue personnel (Munro, 2000). Although it may not be Confused 4 possible to obtain all usual baseline data initially, the immediate Inappropriate words 3 health history should include the following questions: Incomprehensible sounds 2 • When did the injury occur? None 1 • What caused the injury? A high-velocity missile? An object Best motor response Obeys command 6 striking the head? A fall? Localizes pain 5 What was the direction and force of the blow? Withdraws 4 • Flexion 3 Since a history of unconsciousness or amnesia after a head in- Extension 2 jury indicates a significant degree of brain damage, and since None 1 changes that occur minutes to hours after the initial injury can re- Total 3 to 15 flect recovery or indicate the development of secondary brain damage, the nurse should try to determine if there was a loss of consciousness, what the duration of the unconscious period was, and if the patient could be aroused. In addition to questions that establish the nature of the injury tient, whose condition can worsen dramatically and irrevocably and the patient’s condition immediately after the injury, the if subtle signs are overlooked. More information on assessment is nurse should examine the patient thoroughly. This assessment provided below and in Figure 63-5 and Table 63-1. should include determining the patient’s LOC, ability to respond to verbal commands (if conscious), response to tactile stimuli (if unconscious), pupillary response to light, status of corneal Diagnosis and gag reflexes, motor function, and Glasgow Coma Scale score NURSING DIAGNOSES (Chart 63-4). Based on the assessment data, the patient’s major nursing diag- Additional detailed neurologic and systems assessments are noses may include the following: made initially and at frequent intervals throughout the acute phase of care (Dibsie, 1998). The baseline and ongoing assess- • Ineffective airway clearance and impaired gas exchange re- ments are critical nursing interventions for the brain-injured pa- lated to brain injury • Ineffective cerebral tissue perfusion related to increased ICP and decreased CPP • Deficient fluid volume related to decreased LOC and hormonal dysfunction • Imbalanced nutrition, less than body requirements, related Chart 63-3 • Ethics and Related Issues to metabolic changes, fluid restriction, and inadequate intake • Risk for injury (self-directed and directed at others) related What If a Family Does Not Want Life to seizures, disorientation, restlessness, or brain damage Support Stopped? • Risk for imbalanced (increased) body temperature related Situation to damaged temperature-regulating mechanism A 16-year-old involved in a motor vehicle crash suffered a severe • Potential for impaired skin integrity related to bed rest, closed head injury. Extensive medical tests have determined con- hemiparesis, hemiplegia, and immobility clusively that he is brain dead. He remains in the ICU on a • Disturbed thought processes (deficits in intellectual function, mechanical ventilator with multiple medications to keep his heart communication, memory, information processing) related beating. The patient’s medical condition and ultimate physical to brain injury death cannot be prevented by any medical interventions, yet the family refuses to discontinue any of the medical treatments, hoping • Potential for disturbed sleep pattern related to brain injury for a “miracle.” and frequent neurologic checks • Potential for compromised family coping related to un- Dilemma responsiveness of patient, unpredictability of outcome, pro- The family’s wish to continue care for their son conflicts with the medical reality of the patient’s condition. longed recovery period, and the patient’s residual physical and emotional deficit Discussion • Deficient knowledge about recovery and the rehabilitation What arguments could you make in favor of the family’s position process to continue life support? What arguments could you make in favor of withdrawal of life support? The nursing diagnoses for the unconscious patient and the patient with increased ICP also apply (see Chap. 61). 1918 Unit 14 NEUROLOGIC FUNCTION

A B

C D

FIGURE 63-5 Assessment parameters for the patient with a head injury include (A) eye opening and responsiveness, (B) vital signs, and (C, D) motor response reﬂected in hand strength or response to painful stimulus. Photo © B. Proud.

COLLABORATIVE PROBLEMS/ MONITORING FOR DECLINING NEUROLOGIC FUNCTION POTENTIAL COMPLICATIONS The importance of ongoing assessment and monitoring of the Based on all the assessment data, the major complications include brain-injured patient cannot be overstated. The following para- the following: meters are assessed initially and as frequently as the patient’s • Decreased cerebral perfusion condition requires. As soon as the initial assessment is made, the • Cerebral edema and herniation use of a neurologic ﬂow chart is started and maintained. • Impaired oxygenation and ventilation • Impaired ﬂuid, electrolyte, and nutritional balance Level of Consciousness • Risk of post-traumatic seizures The LOC is regularly assessed because changes in it precede all other changes in vital and neurologic signs. The Glasgow Planning and Goals Coma Scale, which is used to assess LOC, is based on the three criteria of eye opening, verbal responses, and motor responses The goals for the patient may include maintenance of a patent to verbal commands or painful stimuli. It is particularly useful airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance for monitoring changes during the acute phase, the first few of normal body temperature, maintenance of skin integrity, im- days after a head injury. It does not take the place of an in- provement of cognitive function, prevention of sleep deprivation, depth neurologic assessment; rather, it is used to monitor the effective family coping, increased knowledge about the rehabili- patient’s motor, verbal, and eye-opening responses. The pa- tation process, and absence of complications. tient’s best responses to predetermined stimuli are recorded (see Chart 63-4). Each response is scored (the greater the num- Nursing Interventions ber the better the functioning), and the sum of these scores gives an indication of the severity of coma and a prediction of The nursing interventions for the patient with a head injury are possible outcome. The lowest score is 3 (least responsive); the extensive and diverse; they include making nursing assessments, highest is 15 (most responsive). A score of 8 or less is generally setting priorities for nursing interventions, anticipating needs and accepted as indicating a severe head injury (Teasdale & Jennett, complications, and initiating rehabilitation. 1974). Chapter 63 Management of Patients With Neurologic Trauma 1919

Table 63-1 • Summary of Multisystem Assessment Measures for the Brain-Injured Patient

SYSTEM-SPECIFIC CONSIDERATIONS ASSESSMENT DATA Neurologic System • Severe head injury will result in unconsciousness and will alter • Assessment of neurologic signs many neurologic functions. • Assessment for signs and symptoms of ICP elevation • All body functions must be supported. • Calculation of cerebral perfusion pressure if ICP monitor is in • Increased ICP and herniation syndromes are life-threatening place • Measures are instituted to control elevated ICP. • Monitoring of antiseizure medication blood levels Integumentary System (Skin and Mucous Membranes) • Immobility secondary to injury and unconsciousness contributes • Assessment of skin integrity and character of the skin to the development of pressure areas and skin breakdown. • Assessment of oral mucous membrane • Intubation causes irritation of the mucous membrane. Musculoskeletal System • Immobility contributes to musculoskeletal changes. • Assessment of range of motion of joints and development of • Decerebrate or decorticate posturing makes proper positioning deformities or spasticity difficult. Gastrointestinal System • Administration of corticosteroids places the patient at high risk for • Assessment of abdomen for bowel sounds and distention GI hemorrhage. • Monitoring for decreased hemoglobin • Injury to the GI tract can result in paralytic ileus. • Constipation can result from bed rest, NPO status, fluid restriction, and opioids given for pain control. • Bowel incontinence is related to the patient’s unconscious state or altered mental state. Genitourinary System • Fluid restriction or use of diuretics can alter the amount of urinary • Intake and output record output. • Urinary incontinence is related to the patient’s unconscious state. Metabolic (Nutritional) System • The patient receives all fluids intravenously for the first few days • Assessment of fluid and electrolyte balance until the GI tract is functioning. • Recording of weight, if possible • A nutritional consultation is initiated within the first 24–48 h; par- • Hematocrit enteral nutrition may be started. • Electrolyte studies Respiratory System • Complete or partial airway obstruction will compromise the • Assessment of respiratory function oxygen supply to the brain. — Auscultate chest for breath sounds. • An altered respiratory pattern can result in cerebral hypoxia. — Note the respiratory pattern if possible (not possible if • A short period of apnea at the moment of impact can result in a ventilator is being used). spotty atelectasis. — Note the respiratory rate • Systemic disturbances from head injury can cause hypoxemia. — Note whether the cough reflex is intact. • Brain injury can alter brain stem respiratory function. • Arterial blood gas levels • Shunting of blood to the lungs as a result of a sympathetic dis- • Complete blood count charge at the time of injury can cause neurogenic pulmonary • Chest x-ray studies edema. • Sputum cultures • O2 saturation using pulse oximetry Cardiovascular System • The patient may develop cardiac dysrhythmias, tachycardia, • Assessment of vital signs or bradycardia. • Monitoring for cardiac dysrhythmias • The patient may develop hypotension or hypertension. • Assessment for deep vein thromboses of legs • Because of immobility and unconsciousness, the patient is at high • Electrocardiogram risk for deep vein thromboses and pulmonary emboli. • Electrolyte studies • Fluid and electrolyte imbalance can be related to several problems, • Blood coagulation studies including alterations in antidiuretic hormone (ADH) secretion, the • I125 fibrinogen scan of legs stress response, or fluid restriction. • Blood glucose level • Specific conditions may occur: • Blood acetone level — Diabetes insipidus (DI) • Blood osmolality — Syndrome of inappropriate secretion of ADH (SIADH) • Urine specific gravity — Electrolyte imbalance — Hyperosmolar nonketotic hyperglycemia Psychological/Emotional Response • The severely head-injured patient is unconscious. • Collection of information about the family and the role of the • The family needs emotional support to deal with the crisis. head-injured person within the family • Assessment of the family to determine how functional it was before the injury occurred 1920 Unit 14 NEUROLOGIC FUNCTION

Vital Signs neurologic deficit can worsen if the patient is hypoxic. Therapy Although a change in LOC is the most sensitive neurologic indi- is directed toward maintaining optimal oxygenation to preserve cation of deterioration of the patient’s condition, vital signs are cerebral function. An obstructed airway causes CO2 retention monitored at frequent intervals also to assess the intracranial sta- and hypoventilation, which can produce cerebral vessel dilation tus. Table 63-1 depicts the general assessment parameters for the and increased ICP. patient with a head injury. Interventions to ensure an adequate exchange of air are dis- Signs of increasing ICP include slowing of the heart rate cussed in Chapter 61 and include the following: (bradycardia), increasing systolic blood pressure, and widening Keep the unconscious patient in a position that facilitates pulse pressure. As brain compression increases, respirations be- • drainage of oral secretions, with the head of the bed elevated come rapid, the blood pressure may decrease, and the pulse slows about 30 degrees to decrease intracranial venous pressure further. This is an ominous development, as is a rapid fluctuation (Bader & Palmer, 2000). of vital signs (March, 2000). A rapid rise in body temperature is Establish effective suctioning procedures (pulmonary secre- regarded as unfavorable because hyperthermia increases the meta- • tions produce coughing and straining, which increase ICP). bolic demands of the brain and may indicate brain stem damage, Guard against aspiration and respiratory insufficiency. a poor prognostic sign. The temperature is maintained at less • Closely monitor arterial blood gas values to assess the ade- than 38°C (100.4°F). Tachycardia and arterial hypotension may • quacy of ventilation. The goal is to keep blood gas values indicate that bleeding is occurring elsewhere in the body. within the normal range to ensure adequate cerebral blood flow. Motor Function Monitor the patient who is receiving mechanical ventilation. Motor function is assessed frequently by observing spontaneous • Monitor for pulmonary complications such as acute respi- movements, asking the patient to raise and lower the extremities, • ratory distress syndrome (ARDS) and pneumonia (Munro, and comparing the strength and equality of the hand grasp and 2000). pedal push at periodic intervals. To assess the hand grasp, the nurse instructs the patient to squeeze the examiner’s fingers tightly. The nurse assesses lower extremity motor strength (pedal push) MONITORING FLUID AND ELECTROLYTE BALANCE by placing the hands on the soles of the patient’s feet and asking Brain damage can produce metabolic and hormonal dysfunctions. the patient to push down against the examiner’s hands. Motor as- The monitoring of serum electrolyte levels is important, especially sessment is discussed in Chapter 60 in more detail. The presence in patients receiving osmotic diuretics, those with inappropriate or absence of spontaneous movement of each extremity is also antidiuretic hormone secretion, and those with post-traumatic noted, and speech and eye signs are assessed. diabetes insipidus. If the patient does not demonstrate spontaneous movement, Serial studies of blood and urine electrolytes and osmolality responses to painful stimuli are assessed. Motor response to pain are carried out because head injuries may be accompanied by dis- is assessed by applying a central stimulus, such as pinching the orders of sodium regulation. Hyponatremia is common follow- pectoralis major muscle, to determine the patient’s best response. ing head injury due to shifts in extracellular fluid, electrolytes, Peripheral stimulation may provide inaccurate assessment data and volume. Hyperglycemia, for example, may cause an increase because it may result in a reflex movement rather than a voluntary in extracellular fluid that lowers sodium (Hickey, 2003). Hyper- motor response. Abnormal responses (lack of motor response; natremia may also occur due to sodium retention that may last extension responses) are associated with a poorer prognosis. several days, followed by sodium diuresis. Increasing lethargy, confusion, and seizures may be due to electrolyte imbalance. Other Neurologic Signs Endocrine function is evaluated by monitoring serum elec- In addition to the patient’s spontaneous eye opening evaluated trolytes, blood glucose values, and intake and output. Urine is with the Glasgow Coma Scale, the size and equality of the pupils tested regularly for acetone. A record of daily weights is main- and their reaction to light are assessed. A unilaterally dilated and tained, especially if the patient has hypothalamic involvement poorly responding pupil may indicate a developing hematoma, and is at risk for the development of diabetes insipidus. with subsequent pressure on the third cranial nerve due to shifting of the brain. If both pupils become fixed and dilated, this in- PROMOTING ADEQUATE NUTRITION dicates overwhelming injury and intrinsic damage to the upper Head injury results in metabolic changes that increase calorie brain stem and is a poor prognostic sign. consumption and nitrogen excretion (Donaldson et al., 2000). The patient with a head injury may develop focal nerve palsies There is an increased demand for protein. As soon as possible, nu- such as anosmia (lack of sense of smell) or eye movement abnor- trition should be provided. Early initiation of nutritional therapy malities and focal neurologic deficits such as aphasia, memory has been shown to improve outcomes in head-injured patients deficits, and post-traumatic seizures or epilepsy. Patients may be (Bader & Palmer, 2000). Parenteral nutrition via a central line or left with residual organic psychological deficits (impulsiveness, enteral feedings administered via a nasogastric or nasojejunal emotional lability, or uninhibited, aggressive behaviors) and, as a feeding tube may be used. If there is discharge of CSF from the consequence of the impairment, lack insight into their emotional nose (CSF rhinorrhea), an oral feeding tube should be inserted in responses (Davis, 2000). place of a nasal tube. Laboratory values should be monitored closely in patients re- MAINTAINING THE AIRWAY ceiving parenteral nutrition. Elevating the head of the bed and as- One of the most important nursing goals in the management of pirating the enteral tube for evidence of residual feeding before the patient with a head injury is to establish and maintain an ad- administering additional feedings can help prevent distention, re- equate airway. The brain is extremely sensitive to hypoxia, and a gurgitation, and aspiration. A continuous-drip infusion or pump Chapter 63 Management of Patients With Neurologic Trauma 1921 may be used to regulate the feeding. The principles and technique • If incontinence occurs, consider use of an external sheath of enteral feedings are discussed in Chapter 36. Enteral or par- catheter on a male patient. Because prolonged use of an in- enteral feedings are usually continued until the swallowing reflex dwelling catheter inevitably produces infection, the patient returns and the patient can meet caloric requirements orally. may be placed on an intermittent catheterization schedule.

PREVENTING INJURY MAINTAINING BODY TEMPERATURE As the patient emerges from coma, there is often a period of An increase in body temperature in the head-injured patient can lethargy and stupor followed by a period of agitation. Each phase be the result of damage to the hypothalamus, cerebral irritation is variable and depends on the individual, the location of the in- from hemorrhage, or infection. The nurse monitors the patient’s jury, the depth and duration of coma, and the patient’s age. The temperature every 4 hours. If the temperature rises, efforts are patient emerging from a coma may become increasingly agitated undertaken to identify the cause and to control it using acetamin- toward the end of the day. Restlessness may be due to hypoxia, ophen and cooling blankets as prescribed (Bader & Palmer, fever, pain, or a full bladder. It may indicate injury to the brain but 2000). Cooling blankets should be used with caution so as not to may also be a sign that the patient is regaining consciousness. (Some induce shivering, which increases ICP. If infection is suspected, restlessness may be beneficial because the lungs and extremities are potential sites of infection are cultured and antibiotics are pre- exercised.) Agitation may also be due to discomfort from catheters, scribed and administered. intravenous lines, restraints, and repeated neurologic checks. Alter- natives to restraints must be used whenever possible. MAINTAINING SKIN INTEGRITY Strategies to prevent injury include the following: Patients with traumatic head injury often require assistance in • Assess the patient to ensure that oxygenation is adequate turning and positioning because of immobility or unconscious- and the bladder is not distended. Check dressings and casts ness. Prolonged pressure on the tissues will decrease circulation for constriction. and lead to tissue necrosis. Potential areas of breakdown need to • To protect the patient from self-injury and dislodging of be identified early to avoid the development of pressure ulcers. tubes, use padded side rails or wrap the patient’s hands in Specific nursing measures include the following: mitts (Fig. 63-6). Restraints are avoided because straining • Assess all body surfaces and document skin integrity at least against them can increase ICP or cause other injury. En- every 8 hours. closed or floor-level specialty beds may be indicated. • Turn and reposition the patient every 2 hours. • Avoid using opioids as a means of controlling restlessness • Provide skin care every 4 hours. because these medications depress respiration, constrict the • Assist patient to get out of bed to a chair three times a day pupils, and alter responsiveness. if physically able. • Minimize environmental stimuli by keeping the room quiet, limiting visitors, speaking calmly, and providing fre- IMPROVING COGNITIVE FUNCTIONING quent orientation information (eg, explaining where the pa- Although many patients with head injury survive because of re- tient is and what is being done). suscitative and supportive technology, they frequently have sig- Provide adequate lighting to prevent visual hallucinations. • nificant cognitive sequelae that may not be detected during the Minimize disruption of the patient’s sleep/wake cycles. • acute phase of injury. Cognitive impairment includes memory Lubricate the skin with oil or emollient lotion to prevent • deficits, decreased ability to focus and sustain attention to a task irritation due to rubbing against the sheet. (distractibility), reduced ability to process information, and slowness in thinking, perceiving, communicating, reading, and writing. Psychiatric or emotional problems develop in as many as 44% of patients with head injury (van Reekum et al., 2000). Re- sulting psychosocial, behavioral, emotional, and cognitive impairments are devastating to the family as well as to the patient (Davis, 2000; Perlesz, Kinsella, & Crowe, 1999). These problems require collaboration among many disciplines (Bader & Palmer, 2000). A neuropsychologist (specialist in evaluating and treating cognitive problems) plans a program and initiates therapy or counseling to help the patient reach maximal potential. Cognitive rehabilitation activities help the patient to devise new problem-solving strategies. The retraining is carried out over an extended period and may include the use of sensory stimulation and reinforcement, behavior modification, reality orientation, computer-training programs, and video games. As- sistance from many disciplines is necessary during this phase of recovery. Even if intellectual ability does not improve, social and behavioral abilities may. FIGURE 63-6 Hands of the patient with a head injury may be placed in The patient recovering from a brain injury may experience a Posey mitt to prevent self-injury. This mitt has finger holes so that circula- fluctuations in the level of cognitive function, with orientation, tion can be assessed without removing the mitt. Photo courtesy of Sarah attention, and memory frequently affected. When pushed to a level Trainer, RN, Roxborough Memorial Hospital, Philadelphia. greater than the impaired cortical functioning allows, the patient 1922 Unit 14 NEUROLOGIC FUNCTION may show symptoms of fatigue, anger, and stress (headache, often very helpful to family members in making decisions about dizziness). The Rancho Los Amigos Level of Cognitive Function organ donation and in helping them cope with stress. is a scale frequently used to assess cognitive function and evaluate ongoing recovery from head injury. Nursing management MONITORING AND MANAGING and a description of each level are included in Table 63-2. POTENTIAL COMPLICATIONS PREVENTING SLEEP PATTERN DISTURBANCE Decreased Cerebral Perfusion Patients who require frequent monitoring of neurologic status Maintenance of adequate CPP is important to prevent serious may experience sleep deprivation. They are awakened hourly to complications of head injury due to decreased cerebral perfusion assess LOC and as a result are deprived of long periods of sleep and (Bader & Palmer, 2000; March, 2000). Adequate CPP is greater rest. In an effort to allow the patient longer times of uninter- than 70 mm Hg. Any decrease in this pressure can impair cerebral rupted sleep and rest, the nurse can group nursing care activities perfusion and cause brain hypoxia and ischemia, leading to per- so that the patient is disturbed less frequently. Environmental manent damage. Therapy (eg, elevation of the head of the bed noise is decreased and the room lights are dimmed. Back rubs and and increased intravenous fluids) is directed toward decreasing other activities to increase comfort can assist in promoting sleep cerebral edema and increasing venous outflow from the brain. and rest. Systemic hypotension, which causes vasoconstriction and a significant decrease in CPP, is treated with increased intravenous SUPPORTING FAMILY COPING fluids. Having a loved one sustain a serious head injury can produce a great deal of prolonged stress in the family. This stress can result Cerebral Edema and Herniation from the patient’s physical and emotional deficits, the unpre- The patient with a head injury is at risk for additional complica- dictable outcome, and altered family relationships. Families report tions such as increased ICP and brain stem herniation. Cerebral difficulties in coping with changes in the patient’s temperament, edema is the most common cause of increased ICP in the patient behavior, and personality. Such changes are associated with dis- with a head injury, with the swelling peaking approximately 48 ruption in family cohesion, loss of leisure pursuits, and loss of work to 72 hours after injury. Bleeding also may increase the volume capacity, as well as social isolation of the caretaker. The family of contents within the rigid closed compartment of the skull, may experience anger, grief, guilt, and denial in recurring cycles causing increased ICP and herniation of the brain stem and re- (Perlesz et al., 1999). sulting in irreversible brain anoxia and brain death. Measures to To promote effective coping, the nurse can ask the family how control ICP are listed in Chart 63-5 (Zafonte et al., 1999) and the patient is different at this time: What has been lost? What is discussed in Chapter 61. most difficult about coping with this situation? Helpful interventions include providing family members with accurate and Impaired Oxygenation and Ventilation honest information and encouraging them to continue to set Impaired oxygen and ventilation may necessitate mechanical ven- well-defined, mutual, short-term goals. Family counseling helps tilatory support. The patient must be monitored for a patent air- address the family members’ overwhelming feelings of loss and way, altered breathing patterns, and hypoxemia and pneumonia. helplessness and gives them guidance for the management of in- Interventions may include endotracheal intubation, mechanical appropriate behaviors. Support groups help the family members ventilation, and positive end-expiratory pressure. These topics share problems, develop insight, gain information, network, and are discussed in further detail in Chapters 25 and 61. gain assistance in maintaining realistic expectations and hope. The National Head Injury Foundation serves as a clearing- house for information and resources for patients with head in- Impaired Fluid, Electrolyte, and Nutritional Balance juries and their families, including specific information on coma, Fluid, electrolyte, and nutritional imbalances are common in the rehabilitation, behavioral consequences of head injury, and fam- patient with a head injury. Common imbalances may include ily issues. This organization can provide names of facilities and hyponatremia, which is often associated with the syndrome of in- professionals who work with patients with head injuries and can appropriate secretion of antidiuretic hormone (see Chaps. 14 and assist families in organizing local support groups. See the end of 42), hypokalemia, and hyperglycemia (Hickey, 2003). Modifica- this chapter for more information on resources. tions in fluid intake with tube feedings or intravenous fluids Many patients with severe head injury die of their injuries, and may be necessary to treat these imbalances. Insulin administra- many of those who survive experience long-term problems that tion may be prescribed to treat hyperglycemia. prevent them from resuming their previous roles and functions. Undernutrition is also a common problem in response to the During the most acute phase of injury, family members need sup- increased metabolic needs associated with severe head injury. If port and facts from the health care team. the patient cannot eat, enteral feedings or parenteral nutrition Many individuals with severe head injuries that result in brain may be initiated within 24 hours of injury to provide adequate death are young and otherwise healthy and are therefore consid- calories and nutrients. ered for organ donation. Family members of patients with such injuries need support during this extremely stressful time and as- Post-traumatic Seizures sistance in making decisions to end life support and permit do- Patients with head injury are at an increased risk for post- nation of organs. They need to know that the brain-dead patient traumatic seizures. Post-traumatic seizures are classified as im- whose respiratory and cardiovascular systems are maintained mediate (within 24 hours of injury), early (within 1 to 7 days of through life support is not going to survive and that the severe injury), or late (more than 7 days following injury) (Kado & Patel, head injury, not the removal of the patient’s organs or the re- 1999). Seizure prophylaxis refers to the practice of administering moval of life support, is the cause of patient’s death. Bereavement antiseizure medications to patients following head injury to pre- counselors and members of the organ procurement team are vent seizures. It is important to prevent post-traumatic seizures, Table 63-2 • Rancho Los Amigos Scale: Levels of Cognitive Function

COGNITIVE LEVEL DESCRIPTION NURSING MANAGEMENT For levels I–III, the key approach is to provide stimulation. I: No response Completely unresponsive to all stimuli, including Multiple modalities of sensory input should be painful stimuli used. Examples are listed below, but should be individualized and expanded based on available materials and patient preferences (determined by obtaining information from the family). II: Generalized response Nonpurposeful response; responds to pain, but in Olfactory: perfumes, ﬂowers, shaving lotion a nonpurposeful manner Visual: family pictures, card, personal items III: Localized response Responses more focused: withdraws to pain; turns Auditory: radio, television, tapes of family voices toward sound; follows moving objects that pass or favorite recordings, talking to patient (nurse, within visual ﬁeld; pulls on sources of dis- family members). The nurse should tell patient comfort (eg, tubes, restraints); may follow what is going to be done, discuss the environ- simple commands but inconsistently and in ment, provide encouragement. a delayed manner Tactile: touching of skin, rubbing various textures on skin Movement: range of motion exercises, turning, repositioning, use of water mattress

For levels IV–VI, the key approach is to provide structure. IV: Confused, agitated Alert, hyperactive state in which patient responds For level IV, which lasts 2–4 weeks, interven- response to internal confusion/agitation; behavior non- tions are directed at decreasing agitation, purposeful in relation to the environment; increasing environmental awareness, and pro- aggressive, bizarre behavior common moting safety. • Approach patient in a calm manner, and use a soft voice. • Screen patient from environmental stimuli (eg, sounds, sights); provide a quiet, controlled environment. • Remove devices that contribute to agitation (eg, tubes), if possible. • Functional goals cannot be set, because the patient is unable to cooperate. V: Confused, inappropriate When agitation occurs, it is the result of external For levels V and VI, interventions are directed response rather than internal stimuli; focused attention is at decreasing confusion, improving cognitive difﬁcult; memory is severely impaired; responses function, and improving independence in are fragmented and inappropriate to the situa- performing ADLs. tion; there is no carryover of learning from one • Provide supervision. situation to the other. • Use repetition and cues to teach ADLs. Focus the patient’s attention and help to increase his or her concentration. VI: Confused, appropriate Follows simple directions consistently but is in- • Help the patient organize activity. response consistently oriented to time and place; short- • Clarify misinformation and reorient when term memory worse than long-term memory; confused. can perform some ADLs • Provide a consistent, predictable schedule (eg, post daily schedule on large poster board).

For levels VII–X, the key approach is integration into the community. VII: Automatic, appropriate Appropriately responsive and oriented within the For levels VII–X, interventions are directed at response hospital setting; needs little supervision in increasing the patient’s ability to function with ADLs; some carryover of learning; patient has minimal or no supervision in the community. superﬁcial insight into disabilities; has decreased • Reduce environmental structure. judgment and problem-solving abilities; lacks • Help the patient plan for adapting ADLs realistic planning for future for self into the home environment. • Discuss and adapt home living skills (eg, cleaning, cooking) to patient’s ability. VIII: Purposeful, appropriate Alert, oriented, intact memory; has realistic goals • Provide stand-by assistance as needed for for the future. Able to complete familiar tasks ADLs and home living skills. for 1 hour in a distracting environment; over- estimates or underestimates abilities, argumen- tative, easily frustrated, self-centered. Uncharacteristically dependent/independent. (continued)

1923 1924 Unit 14 NEUROLOGIC FUNCTION

Table 63-2 • Rancho Los Amigos Scale: Levels of Cognitive Function (Continued)

COGNITIVE LEVEL DESCRIPTION NURSING MANAGEMENT IX: Purposeful, appropriate Independently shifts back and forth between tasks • Provide assistance on request for adapting and completes them accurately for at least two ADLs and home living skills. consecutive hours. Uses assistive memory devices to recall schedule and activities. Aware of and acknowledges impairments and disabilities when they interfere with task completion. Depression may continue. May be easily irritable and have a low frustration tolerance. X: Purposeful, appropriate Able to handle multiple tasks simultaneously in • Monitor for signs and symptoms of all environments but may require periodic depression. breaks. Independently initiates and carries out • Help the patient plan, anticipate concerns, familiar and unfamiliar tasks but may require and solve problems. more than usual amount of time and/or compensatory strategies to complete them. Accu- rately estimates abilities and independently adjusts to task demands. Periodic periods of depression may occur. Irritability and low frustration tolerance when sick, fatigued and/or under stress.

Used with permission from Los Amigos Research and Education Institute, Inc., Downey, CA, 2002. especially in the immediate and early phase of recovery, as seizures seizure prophylaxis improves outcomes in patients with head in- may increase ICP and decrease oxygenation. Many antiseizure jury. Research evidence supports the use of prophylactic antiseizure medications impair cognitive performance, prolonging the dura- agents to prevent immediate and early seizure after head injury, tion of rehabilitation. Therefore, it is important to weigh the but not for prevention of late seizures (Brain Trauma Foundation, overall benefit of these medications against their side effects. American Association of Neurological Surgeons, Joint Section on Currently, there is no conclusive evidence that long-term anti- Neurotrauma and Critical Care, 2000).

NURSING RESEARCH PROFILE 63-1 The Experience of Hope for the Relatives of Head-Injured Patients Gelling, L. (1999). The experience of hope for the relatives of head-injured patients admitted to a neuroscience critical care unit: A phenomenological study. Nursing in Critical Care, 4(5), 214–221.

Background nurses helped the family members to feel comfortable and safe with Helping the family members of patients with their emotional needs is the care their loved ones were receiving; 2) Information—Inadequate a crucial aspect of ICU care. Previous research has demonstrated that or poorly delivered information led to uncertainty and difficulty in meeting needs can be beneficial to both families and patients. One of maintaining hope; 3) The Past—Lack of knowledge and initial nega- the most important needs families have identified is to maintain hope. tive experiences in the hospital made hope more difficult; 4) The The purpose of this study was to develop a better understanding of Present—Unfamiliar terminology, devices, and situations needed to what hope means to family members in order to help nurses better be assimilated by the family before they could become hopeful; 5) The meet their needs. future—Goal setting helped the family members have hope for a future for the patient; 6) Loss of control—Relatives felt that though they Study Methods and Design were asked by the nurses to participate in decisions, they often felt ill Participants were selected by approaching family members of consec- equipped to do so, leading to feelings of hopelessness; 7) Emotions— utive patients admitted to a neuroscience ICU. Family members were Family members were often so fearful for the patient that it was diffi- approached after the patient had been in the ICU at least 48 hours. A cult to have hope. total of seven patients had family members who agreed to participate. In this phenomenologic study family members were interviewed Nursing Implications about their experiences using a semi-structured format. The inter- Meeting the needs of families is a key part of nursing care of the pa- views were transcribed and returned to the informants for verification tients in a neuroscience unit and furthermore an important compo- of content. Data were analyzed for emergent themes. A summary of nent of a holistic nursing approach. Nurses need to be acutely aware the findings was returned to the participants for verification. of the pivotal role they play in helping the family members to cope and maintain hope in a difficult situation. Nurses should encourage Results supportive relationships with the families, and maintain an open and Seven themes emerged from analysis of the interview data. The honest dialogue. Families need accurate, current information on a themes that relatives felt most influenced their experience of hope level they can understand and assimilate. Nurses need to be cognizant when they had a loved one admitted to the ICU were: 1) Relation- that their care is crucial not just for the patient, but for the entire ships—The positive relationships between the family members and family. Chapter 63 Management of Patients With Neurologic Trauma 1925

Chart writing. Depending on the patient’s prognosis and physical and 63-5 Controlling ICP in Severely cognitive status, the patient may be included in teaching about Brain-Injured Patients self-care management strategies. Because of the risk for post-traumatic seizures, antiseizure med- • Elevate the head of bed 30 degrees. ications may be prescribed for 1 to 2 years after injury. The patient • Maintain the patient’s head and neck in neutral alignment and family require instruction about the side effects of these med- (no twisting). ications and about the importance of continuing to take them as • Initiate measures to prevent the Valsalva maneuver (eg, stool prescribed. softeners). • Maintain normal body temperature. Continuing Care • Administer O2 to maintain PaO2 > 90 mm Hg. • Maintain fluid balance with normal saline solution. Rehabilitation of the patient with a head injury begins at the time • Avoid noxious stimuli (eg, excessive suctioning, painful of injury and extends into the home and community. Depending procedures). on the degree of brain damage, the patient may be referred to a • Administer sedation to reduce agitation. rehabilitation setting that specializes in cognitive restructuring of • Maintain cerebral perfusion pressure > 70 mm Hg. the brain-injured patient. The patient is encouraged to continue the rehabilitation program after discharge because improvement in status may continue 3 or more years after injury. Changes in the head-injured patient and the effects of long-term rehabilitation Nurses must assess patients carefully for the development of on the family and their coping abilities need frequent assessment. post-traumatic seizures. Risk factors that increase the likelihood Teaching and continued support of the patient and family are es- of seizures are brain contusion with subdural hematoma, skull sential as their needs and the patient’s status change. Teaching fracture, loss of consciousness or amnesia of 1 day or more, and points to address with the family of the head-injured patient who age over 65 years (Annegers & Coan, 2000). The nursing man- is about to return home are described in Chart 63-6. agement of seizures is addressed in Chapter 61. Depending on his or her status, the patient is encouraged to Other complications after traumatic head injury include sys- return to normal activities gradually. Referral to support groups temic infections (pneumonia, urinary tract infection [UTI], sep- and the National Head Injury Foundation may be warranted. ticemia), neurosurgical infections (wound infection, osteomyelitis, During the acute and rehabilitation phase of care, the focus of meningitis, ventriculitis, brain abscess), and heterotrophic ossifi- teaching is on obvious needs, issues, and deficits. The nurse needs cation (painful bone overgrowth in weight-bearing joints). to remind patients and family members of the need for continuing health promotion and screening practices following these initial PROMOTING HOME AND COMMUNITY-BASED CARE phases. Patients who have not been involved in these practices in the past are educated about their importance and are referred to Teaching Patients Self-Care appropriate health care providers. Teaching early in the course of head injury often focuses on reinforcing information given to the family about the patient’s condition and prognosis. As the patient’s status and expected outcome Evaluation change over time, family teaching may focus on interpretation EXPECTED PATIENT OUTCOMES and explanation of changes in the patient’s physical and psycho- Expected patient outcomes may include: logical responses. If the patient’s physical status allows him or her to be dis- 1. Attains or maintains effective airway clearance, ventilation, charged home, the patient and family are instructed about limi- and brain oxygenation tations that can be expected and complications that may occur. a. Achieves normal blood gas values and has normal Monitoring for complications that merit contacting the neuro- breath sounds on auscultation surgeon is explained to the patient and family verbally and in b. Mobilizes and clears secretions

Chart 63-6 Home Care Checklist • The Patient With a Head Injury

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • Explain the need for monitoring for changes in neurologic status and for complications ✓✓ • Identify changes in neurologic status and signs and symptoms of complications that should be reported to the neurosurgeon or nurse ✓ • Demonstrate safe techniques to assist patient with self-care, hygiene, and ambulation ✓ • Demonstrate safe technique for eating, feeding patient, or assisting patient with eating ✓✓ • Explain rationale for taking medications as prescribed ✓✓ • Identify need for close monitoring of behavior due to changes in cognitive functioning ✓ • Describe household modiﬁcations needed to ensure safe environment for the patient ✓ • Describe strategies for reinforcing positive behaviors ✓ • State importance of continuing follow-up by health care team ✓✓ 1926 Unit 14 NEUROLOGIC FUNCTION

2. Achieves satisfactory fluid and electrolyte balance there is a greater range of mobility in the vertebral column in a. Demonstrates serum electrolytes within normal range these areas (Dibsie, 1998). b. Has no clinical signs of dehydration or overhydration 3. Attains adequate nutritional status a. Has less than 50 mL of aspirate in stomach before each Pathophysiology tube feeding Damage to the spinal cord ranges from transient concussion b. Is free of gastric distention and vomiting (from which the patient fully recovers) to contusion, laceration, c. Shows minimal weight loss and compression of the cord substance (either alone or in com- 4. Avoids injury bination), to complete transection of the cord (which renders the a. Shows lessening agitation and restlessness patient paralyzed below the level of the injury). b. Is oriented to time, place, and person SCIs can be separated into two categories: primary injuries 5. Does not have a fever and secondary injuries (Porth, 2002). Primary injuries are the re- 6. Demonstrates intact skin integrity sult of the initial insult or trauma and are usually permanent. Sec- a. Exhibits no redness or breaks in skin integrity ondary injuries are usually the result of a contusion or tear injury, b. Exhibits no pressure ulcers in which the nerve fibers begin to swell and disintegrate. A sec- 7. Shows improvement in cognitive function and improved ondary chain of events produces ischemia, hypoxia, edema, and memory hemorrhagic lesions, which in turn result in destruction of myelin 8. Demonstrates normal sleep/wake cycle and axons (Hickey, 2003). These secondary reactions, believed to 9. Demonstrates absence of complications be the principal causes of spinal cord degeneration at the level of a. Exhibits normal ICP, normal vital signs and body injury, are now thought to be reversible 4 to 6 hours after injury. temperature, and increasing orientation to time, place, Therefore, if the cord has not suffered irreparable damage, some and person method of early treatment is needed to prevent partial damage b. Demonstrates reduced ICP from developing into total and permanent damage (see the section 10. Patient experiences no post-traumatic seizures on management) (Zafonte et al., 1999). a. Takes antiseizure medications as prescribed b. Identifies side effects/adverse effects of antiseizure medications Clinical Manifestations 11. Demonstrate adaptive coping mechanisms for family members Manifestations depend on the type and level of injury (Chart 63-7). a. Join support group The type of injury refers to the extent of injury to the spinal cord b. Share feelings with appropriate health care personnel itself. Incomplete spinal cord lesions are classified according to c. Make end-of-life decisions, if needed the area of spinal cord damage: central, lateral, anterior, or periph- 12. Participate in rehabilitation process as indicated for pa- eral. The American Spinal Injury Association (ASIA) provides tient and family members another standard classification of SCI according to the degree of a. Take active role in identifying rehabilitation goals and sensory and motor function present after injury (Chart 63-8). participating in recommended patient care activities “Neurologic level” refers to the lowest level at which sensory and b. Prepare for discharge of patient motor functions are normal. Below the neurologic level, there is total sensory and motor paralysis, loss of bladder and bowel control (usually with urinary retention and bladder distention), loss Spinal Cord Injury of sweating and vasomotor tone, and marked reduction of blood pressure from loss of peripheral vascular resistance. A complete Spinal cord injury (SCI) is a major health problem. Nearly spinal cord lesion can result in paraplegia (paralysis of the lower 200,000 people in the United States live each day with a dis- body) or quadriplegia (paralysis of all four extremities). ability from SCI, with an estimated 11,000 new injuries occur- If conscious, the patient usually complains of acute pain in the ring each year. SCI occurs almost four times more often in males back or neck, which may radiate along the involved nerve. Ab- than females. Young people aged 16 to 30 suffer more than half sence of pain, however, does not rule out spinal injury, and a care- of the new SCIs each year. African Americans are at a higher risk ful assessment of the spine should be done in the face of any than Caucasians, with the incidence rising in recent years. The significant mechanism of injury. Often the patient speaks of fear most common cause of SCI is motor vehicle crashes, which ac- that the neck or back is broken. count for 35% of the injuries. Violence-related injures account Respiratory dysfunction is related to the level of injury. The for nearly as many SCIs (30%), with falls causing 19% and muscles contributing to respiration are the abdominals and in- sports-related injuries causing 8% (CDC, 2001). There is a high tercostals (T1 to T11) and the diaphragm. In high cervical cord frequency of associated injuries and medical complications. injury, acute respiratory failure is the leading cause of death. The predominant risk factors for SCI include age, gender, and alcohol and drug use. The frequency with which these risk fac- Assessment and Diagnostic Findings tors are associated with SCI serves to emphasize the importance of primary prevention. The same interventions suggested earlier A detailed neurologic examination is performed. Diagnostic x-rays in this chapter for head injury prevention will serve to decrease (lateral cervical spine x-rays) and CT scanning are usually per- the incidence of SCI as well (see Chart 63-1) (CDC, 2001; Elovic formed initially. An MRI scan may be ordered as a further work- & Kirschblum, 1999). up if a ligamentous injury is suspected, since significant spinal The vertebrae most frequently involved in SCI are the 5th, cord damage may exist even in the absence of bony injury. A 6th, and 7th cervical (neck), the 12th thoracic, and the 1st lum- search is made for other injuries, because spinal trauma often is bar vertebrae. These vertebrae are the most susceptible because accompanied by concomitant injuries, commonly to the head Chart 63-7 Effects of Spinal Cord Injuries Central Cord Syndrome Area of • Characteristics: Motor deficits (in the upper extremities com- cord damage pared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. • Cause: Injury or edema of the central cord, usually of the cervical area.

Loss of motor power and sensation

Incomplete loss

Central Cord Syndrome

Anterior Cord Syndrome • Characteristics: Loss of pain, temperature, and motor function is Area of noted below the level of the lesion; light touch, position, and cord damage vibration sensation remain intact. • Cause: The syndrome may be caused by acute disk herniation or hyperﬂexion injuries associated with fracture-dislocation of vertebra. It also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two thirds of the spinal cord.

Loss of motor power, pain, and temperature sensation, with preservation of position, vibration, and touch sense

Anterior Cord Syndrome

Brown-Sequard Syndrome (Lateral Cord Syndrome) Area of • Characteristics: Ipsilateral paralysis or paresis is noted, together cord damage with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature. • Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture- dislocation of a unilateral articular process, or possibly an acute ruptured disk.

Loss of pain and temperature sensation on opposite side

Loss of voluntary motor control on the same side as the cord damage

Brown-Séquard Syndrome

Adapted from Hickey, L. (2003). The clinical practice of neurological and neurosurgical nursing (5th ed., pp. 419–421). Philadelphia: Lippincott Williams & Wilkins.

1927 1928 Unit 14 NEUROLOGIC FUNCTION

Management of Spinal Cord Injuries Chart ASIA Impairment Scale 63-8 (Acute Phase) A ϭ Complete: No motor or sensory function is preserved in the The goals of management are to prevent further SCI and to ob- sacral segments S4-S5. serve for symptoms of progressive neurologic deﬁcits. The patient ϭ B Incomplete: Sensory but not motor function is preserved is resuscitated as necessary, and oxygenation and cardiovascular below the neurologic level, and includes the sacral segments stability are maintained. Many changes in the treatment of SCI S4-S5. C ϭ Incomplete: Motor function is preserved below the neuro- have occurred during the past 20 years. Treatments such as hypo- logic level, and more than half of key muscles below the thermia, corticosteroids, and naloxone were investigated and used neurologic level have a muscle grade less than 3. during the 1980s; of these, high-dose corticosteroids have shown D ϭ Incomplete: Motor function is preserved below the neuro- the most promise, but their use remains controversial (Short et al., logic level, and at least half of key muscles below the neurologic 2000). Currently, regeneration therapy is being investigated; this level have a muscle grade of 3 or greater. involves transplanting fetal tissue into the injured spinal cord in E ϭ Normal: Motor and sensory function are normal. hopes of regenerating the damaged tissue (Vacanti et al., 2001). SCI continues to be a devastating event, and new treatment Used with permission of American Spinal Injury Association. methods are continually being investigated.

PHARMACOLOGIC THERAPY In some studies, the administration of high-dose corticosteroids, and chest. Continuous electrocardiographic monitoring may be specifically methylprednisolone, has been found to improve indicated if a cord injury is suspected since bradycardia (slow motor and sensory outcomes at 6 weeks, 6 months, and 1 year if heart rate) and asystole (cardiac standstill) are common in acute given within 8 hours of injury (Hickey, 2003). In other studies, spinal injuries. little improvement was found (Short et al., 2000). Use of high- dose methylprednisolone, a corticosteroid, is accepted as standard Emergency Management therapy in many countries and remains an established clinical The immediate management of the patient at the scene of the in- practice in most institutions in the United States (Bracken, 2000; jury is critical, because improper handling can cause further dam- Hickey, 2003). age and loss of neurologic function. Any patient involved in a motor vehicle or diving injury, a contact sports injury, a fall, or RESPIRATORY THERAPY any direct trauma to the head and neck must be considered to Oxygen is administered to maintain a high arterial PO2 because have SCI until such an injury is ruled out. Initial care must in- hypoxemia can create or worsen a neurologic deficit of the spinal clude a rapid assessment, immobilization, extrication, stabiliza- cord. If endotracheal intubation is necessary, extreme care is tion or control of life-threatening injuries, and transportation to taken to avoid flexing or extending the patient’s neck, which can the most appropriate medical facility. result in an extension of a cervical injury. At the scene of the injury, the patient must be immobilized on In high cervical spine injuries, spinal cord innervation to a spinal (back) board, with head and neck in a neutral position, the phrenic nerve, which stimulates the diaphragm, is lost. Di- to prevent an incomplete injury from becoming complete. One member of the team must assume control of the patient’s head to prevent flexion, rotation, or extension; this is done by placing the hands on both sides of the patient’s head at about the ear to limit movement and maintain alignment while a spinal board or cervical immobilizing device is applied. If possible, at least four people should slide the victim carefully onto a board for transfer to the hospital. Any twisting movement may irreversibly damage the spinal cord by causing a bony fragment of the vertebra to cut into, crush, or sever the cord completely. The patient must be referred to a regional spinal injury or trauma center because of the multidisciplinary personnel and support services required to counteract the destructive changes that occur in the first few hours after injury. During treatment in the emergency and x-ray departments, the patient is kept on the transfer board. The patient must always be maintained in an extended position. No part of the body should be twisted or turned, nor should the patient be allowed to sit up. Once the extent of the injury has been determined, the patient may be placed on a rotating bed (Fig. 63-7) or in a cervical collar (Fig. 63-8). Later, if SCI and bone instability have been ruled out, the patient can be moved to a conventional bed or the collar removed without harm. If a rotating bed is needed but not available, the patient should be placed in a cervical collar and on a firm mattress with FIGURE 63-7 Roto Rest® bed. Courtesy of Kinetic Concepts, San a bedboard under it. Antonio, TX. Chapter 63 Management of Patients With Neurologic Trauma 1929

placement. The traction force is exerted along the longitudinal axis of the vertebral bodies, with the patient’s neck in a neutral position. The traction is then gradually increased by adding more weights. As the amount of traction is increased, the spaces between the intervertebral disks widen and the vertebrae may slip back into position. Reduction usually takes place after correct alignment has been restored. Once reduction is achieved, as ver- ified by cervical spine x-rays and neurologic examination, the weights are gradually removed until the amount of weight needed to maintain the alignment is identified. The weights should hang freely so as not to interfere with the traction. Traction is sometimes supplemented with manual manipulation of the neck by a surgeon to help achieve realignment of the vertebral bodies. A halo device may be used initially with traction or may be applied after removal of the tongs. It consists of a stainless-steel halo ring that is fixed to the skull by four pins. The ring is attached to FIGURE 63-8 Cervical collar. Courtesy of Aspen Medical Products. a removable halo vest, which suspends the weight of the unit cir- cumferentially around the chest. A metal frame connects the ring to the chest. Halo devices provide immobilization of the cervical spine while allowing early ambulation (Fig. 63-10). aphragmatic pacing (electrical stimulation of the phrenic nerve) Thoracic and lumbar injuries are usually treated with surgical attempts to stimulate the diaphragm to help the patient breathe. intervention followed by immobilization with a fitted brace. Diaphragmatic pacing may be considered for the patient with a Traction is not indicated either before or after surgery. high cervical lesion but is usually carried out after the acute phase.

SKELETAL FRACTURE REDUCTION AND TRACTION Surgical Management Management of SCI requires immobilization and reduction of Surgery is indicated in any of the following instances: dislocations (restoration of normal position) and stabilization of the vertebral column. • Compression of the cord is evident. Cervical fractures are reduced and the cervical spine is aligned • The injury results in a fragmented or unstable vertebral with some form of skeletal traction, such as skeletal tongs or body. calipers, or with use of the halo device. Early surgical stabilization • The injury involves a wound that penetrates the cord. has reduced the need for cervical traction in many patients with • There are bony fragments in the spinal canal. cervical spine injuries (Gaebler et al., 1999). A variety of skeletal • The patient’s neurologic status is deteriorating. tongs are available, all of which involve fixation in the skull in Surgery is performed to reduce the spinal fracture or dislocation some manner (Fig. 63-9). The Gardner-Wells tongs require no or to decompress the cord. A laminectomy (excision of the pos- predrilled holes in the skull. Crutchfield and Vinke tongs are in- terior arches and spinous processes of a vertebra) may be indi- serted through holes made in the skull with a special drill under cated in the presence of progressive neurologic deficit, suspected local anesthesia. epidural hematoma, bony fragments, or penetrating injuries that Traction is applied to the tongs by weights, the amount de- require surgical débridement, or to permit direct visualization pending on the size of the patient and the degree of fracture dis- and exploration of the cord. Vertebral bodies may also be surgically fused to create a stable spinal column.

Management of Complications of Spinal Cord Injury SPINAL AND NEUROGENIC SHOCK The spinal shock associated with SCI represents a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. The muscles innervated by the part of the spinal cord segment below the level of the lesion are without sensation, paralyzed, and flaccid, and the reflexes are absent. In particular, the reflexes that initiate bladder and bowel function are affected. Bowel distention and paralytic ileus can be caused by depression of the reflexes and are treated with intestinal decompression by insertion of a nasogastric tube (Hickey, 2003). Neurogenic shock develops due to the loss of autonomic nervous system function below the level of the lesion (Hickey, 2003). The vital organs are affected, causing the blood pressure and heart FIGURE 63-9 Traction for cervical fractures may be applied with tongs. rate to fall. This loss of sympathetic innervation causes a variety 1930 Unit 14 NEUROLOGIC FUNCTION

A B FIGURE 63-10 Halo systems for cervical and thoracic vertebral injuries. (A) Halo cervical skeletal traction. Cour- tesy of Acromed Corp., Cleveland, OH. (B) Halo and vest. Courtesy of Bremer Medical, Inc., Darwin Road, Jack- sonville, FL.

of other clinical manifestations, including a decrease in cardiac DEEP VEIN THROMBOSIS output, venous pooling in the extremities, and peripheral vaso- Deep vein thrombosis (DVT) is a potential complication of dilation. In addition, the patient does not perspire on the para- immobility and is common in patients with SCI. Patients who lyzed portions of the body because sympathetic activity is blocked; develop DVT are at risk for pulmonary embolism (PE), a life- therefore, close observation is required for early detection of an threatening complication. One estimate from a meta-analysis of abrupt onset of fever. (A discussion of neurogenic shock can be recent studies of the incidence of DVT and PE in SCI patients found in Chap. 15.) put the rate at 6.3% for PE and 17.4% for DVT (Velmahos et al., 2000). Manifestations of PE include pleuritic chest pain, anxiety, shortness of breath, and abnormal blood gas values NURSING ALERT The patient’s vital organ functions and body (increased PaCO2 and decreased PaO2). Thigh and calf mea- defenses must be supported and maintained until spinal and neuro- surements are made daily. The patient is evaluated for the genic shock abates and the neurologic system has recovered from presence of DVT if there is a significant increase in the cir- ! the traumatic insult; that can take up to 4 months (Hickey, 2003). cumference of one extremity. Low-dose anticoagulation therapy usually is initiated to prevent DVT and PE, along with thigh-high elastic compression stockings or pneumatic com- With injuries to the cervical and upper thoracic spinal cord, pression devices. In some cases, permanent indwelling filters innervation to the major accessory muscles of respiration is lost (see Chap. 31) may be placed in the vena cava to prevent dis- and respiratory problems develop. These include decreased vital lodged clots (emboli) from migrating to the lungs and causing capacity, retention of secretions, increased PaCO2 levels and de- pulmonary emboli (Velmahos et al., 2000). creased oxygen levels, respiratory failure, and pulmonary edema. OTHER COMPLICATIONS In addition to respiratory complications (respiratory failure, pneumonia) and autonomic dysreﬂexia (characterized by pounding NURSING ALERT Special attention also must be directed to headache, profuse sweating, nasal congestion, piloerection [“goose the respiratory system. The patient may be unable to generate sufﬁcient intrathoracic pressure to cough effectively. Chest physical bumps”], bradycardia, and hypertension), other complications ! therapy and suctioning may assist in clearance of pulmonary that may occur include pressure ulcers and infection (urinary, secretions. respiratory, and local infection at the skeletal traction pin sites) (Sullivan, 1999). Chapter 63 Management of Patients With Neurologic Trauma 1931

NURSING PROCESS: • Urinary retention related to inability to void spontaneously THE PATIENT WITH ACUTE • Constipation related to presence of atonic bowel as a result SPINAL CORD INJURY of autonomic disruption • Acute pain and discomfort related to treatment and pro- Assessment longed immobility

The breathing pattern is observed, the strength of the cough is as- COLLABORATIVE PROBLEMS/ sessed, and the lungs are auscultated, because paralysis of ab- POTENTIAL COMPLICATIONS dominal and respiratory muscles diminishes coughing and makes Based on the assessment data, potential complications that may it difficult to clear bronchial and pharyngeal secretions. Reduced develop include: excursion of the chest also results. The patient is monitored closely for any changes in motor or • DVT sensory function and for symptoms of progressive neurologic dam- • Orthostatic hypotension age. It may be impossible in the early stages of SCI to determine • Autonomic dysreflexia whether the cord has been severed, because signs and symptoms of cord edema are indistinguishable from those of cord transection. Planning and Goals Edema of the spinal cord may occur with any severe cord injury and may further compromise spinal cord function. The goals for the patient may include improved breathing pat- Motor and sensory functions are assessed through careful neu- tern and airway clearance, improved mobility, improved sensory rologic examination. These findings are recorded most often on a and perceptual awareness, maintenance of skin integrity, relief of flow sheet so that changes in the baseline neurologic status can be urinary retention, improved bowel function, promotion of com- closely monitored accurately. The American Spinal Injury Associ- fort, and absence of complications. ation (ASIA) classification is commonly used to describe level of function for SCI patients. Chart 63-7 also gives an example of Nursing Interventions nursing assessment of spinal cord function. • Motor ability is tested by asking the patient to spread the PROMOTING ADEQUATE BREATHING fingers, squeeze the examiner’s hand, and move the toes or AND AIRWAY CLEARANCE turn the feet. Possible impending respiratory failure is detected by observing • Sensation is evaluated by gently pinching the skin or touch- the patient, measuring vital capacity, monitoring oxygen satura- ing it lightly with a small object such as a tongue blade, tion through pulse oximetry, and monitoring arterial blood gas starting at shoulder level and working down both sides of values. Early and vigorous attention to clearing bronchial and the extremities. The patient should have both eyes closed so pharyngeal secretions can prevent retention of secretions and at- that the examination reveals true findings, not what the pa- electasis. Suctioning may be indicated, but caution must be tient hopes to feel. The patient is asked where the sensation used during suctioning because this procedure can stimulate the is felt. vagus nerve, producing bradycardia, which can result in cardiac • Any decrease in neurologic function is reported immediately. arrest. If the patient cannot cough effectively because of decreased in- The patient is also assessed for spinal shock, a complete loss of spiratory volume and inability to generate sufficient expiratory all reflex, motor, sensory, and autonomic activity below the level pressure, chest physical therapy and assisted coughing may be in- of the lesion that causes bladder paralysis and distention. The dicated. Specific breathing exercises are supervised by the nurse lower abdomen is palpated for signs of urinary retention and to increase the strength and endurance of the inspiratory muscles, overdistention of the bladder. Further assessment is made for particularly the diaphragm. Assisted coughing promotes clearing gastric dilation and ileus due to an atonic bowel, a result of auto- of secretions from the upper respiratory tract and is similar to nomic disruption. using abdominal thrusts to clear an airway (see Chap. 25). It is Temperature is monitored because the patient may have peri- important to ensure proper humidification and hydration to pre- ods of hyperthermia as a result of alteration in temperature vent secretions from becoming thick and difficult to remove even control due to autonomic disruption. with coughing. The patient is assessed for signs of respiratory infection (cough, fever, dyspnea). Smoking is discouraged because Diagnosis it increases bronchial and pulmonary secretions and impairs ciliary action. NURSING DIAGNOSES Ascending edema of the spinal cord in the acute phase may Based on the assessment data, the patient’s major nursing diag- cause respiratory difficulty that requires immediate intervention. noses may include the following: Therefore, the patient’s respiratory status must be monitored • Ineffective breathing patterns related to weakness or paral- frequently. ysis of abdominal and intercostal muscles and inability to clear secretions IMPROVING MOBILITY • Ineffective airway clearance related to weakness of inter- Proper body alignment is maintained at all times. The patient costal muscles is repositioned frequently and is assisted out of bed as soon as • Impaired physical mobility related to motor and sensory the spinal column is stabilized. The feet are prone to footdrop; impairment therefore, various types of splints are used to prevent footdrop. • Disturbed sensory perception related to motor and sensory When used, the splints are removed and reapplied every 2 hours. impairment Trochanter rolls, applied from the crest of the ilium to the • Risk for impaired skin integrity related to immobility and midthigh of both legs, help prevent external rotation of the hip sensory loss joints. 1932 Unit 14 NEUROLOGIC FUNCTION

Patients with lesions above the midthoracic level have loss of The patient’s skin should be kept clean by washing with a mild sympathetic control of peripheral vasoconstrictor activity, lead- soap, rinsed well, and blotted dry. Pressure-sensitive areas should ing to hypotension. These patients may tolerate changes in posi- be kept well lubricated and soft with bland cream or lotion. The tion poorly and require monitoring of blood pressure when patient is informed about the danger of pressure ulcers to en- positions are changed. Usually the patient is turned every 2 hours. courage understanding of the reason for preventive measures. See If not on a rotating bed, the patient should not be turned unless Chapter 11 for other aspects of the prevention of pressure ulcers. the spine is stable and the physician has indicated that it is safe to do so. NURSING ALERT Never massage the calves or thighs due to the Contractures develop rapidly with immobility and muscle danger of dislodging an undetected DVT. paralysis. A joint that is immobilized too long becomes fixed as a ! result of contractures of the tendon and joint capsule. Atrophy of the extremities results from disuse. Contractures and other com- MAINTAINING URINARY ELIMINATION plications may be prevented by range-of-motion exercises that help Immediately after SCI, the urinary bladder becomes atonic and preserve joint motion and stimulate circulation. Passive range-of- cannot contract by reflex activity. Urinary retention is the imme- motion exercises should be implemented as soon as possible after diate result. Because the patient has no sensation of bladder dis- injury. Toes, metatarsals, ankles, knees, and hips should be put tention, overstretching of the bladder and detrusor muscle may through a full range of motion at least four, and ideally five, times occur, delaying the return of bladder function. daily. Intermittent catheterization is carried out to avoid over- For most patients with a cervical fracture without neurologic distention of the bladder and UTI. If this is not feasible, an in- deficit, reduction in traction followed by rigid immobilization dwelling catheter is inserted temporarily. At an early stage, family for about 6 to 8 weeks restores skeletal integrity. These patients members are shown how to carry out intermittent catheterization are allowed to move gradually to an erect position. A four-poster and are encouraged to participate in this facet of care, because neck brace or molded collar is applied when the patient is mobi- they will be involved in long-term follow-up and must be able to lized after traction is removed (see Fig. 63-8). recognize complications so that treatment can be instituted. The patient is taught to record fluid intake, voiding pattern, PROMOTING ADAPTATION TO SENSORY amounts of residual urine after catheterization, characteristics of AND PERCEPTUAL ALTERATIONS urine, and any unusual sensations that may occur. The manage- The nurse assists the patient to compensate for sensory and per- ment of a neurogenic bladder is discussed in detail in Chapter 11. ceptual alterations that occur with SCI. The intact senses above the level of the injury are stimulated through touch, aromas, IMPROVING BOWEL FUNCTION flavorful food and beverages, conversation, and music. Additional Immediately after SCI, a paralytic ileus usually develops due to strategies include the following: neurogenic paralysis of the bowel; therefore, a nasogastric tube is • Providing prism glasses to enable the patient to see from the often required to relieve distention and prevent aspiration. supine position Bowel activity usually returns within the first week. As soon as • Encouraging use of hearing aids, if indicated, to enable the bowel sounds are heard on auscultation, the patient is given a patient to hear conversations and environmental sounds high-calorie, high-protein, high-fiber diet, with the amount of • Providing emotional support to the patient food gradually increased. The nurse administers prescribed stool • Teaching the patient strategies to compensate for or cope softeners to counteract the effects of immobility and pain med- with these deficits ications. A bowel program is instituted as early as possible.

MAINTAINING SKIN INTEGRITY PROVIDING COMFORT MEASURES Because the patient with SCI is immobilized and has loss of sen- After cervical injury, if pins, tongs, or calipers are in place, the sation below the level of the lesion, there is an ever-present, life- skull is assessed for signs of infection, including drainage. The threatening risk of pressure ulcers. In areas of local tissue ischemia, back of the head is checked periodically for signs of pressure, with where there is continuous pressure and where the peripheral cir- care taken not to move the neck. The hair around the tongs usu- culation is inadequate as a result of the spinal shock and recum- ally is shaved to facilitate inspection. Probing under encrusted bent position, pressure ulcers have developed within 6 hours. areas is avoided. Prolonged immobilization of the patient on a transfer board increases the risk of pressure ulcers. The most common sites are The Patient in Halo Traction over the ischial tuberosity, the greater trochanter, and the sacrum. Patients who have been placed in a halo device after cervical sta- In addition, patients who wear cervical collars for prolonged pe- bilization may have a slight headache or discomfort around the riods may develop breakdown from the pressure of the collar skull pins for several days after the pins are inserted. The patient under the chin, on the shoulders, and at the occiput. initially may be bothered by the rather startling appearance of this The patient’s position is changed at least every 2 hours. Turn- apparatus but usually readily adapts to it because the device pro- ing not only assists in the prevention of pressure ulcers but also pre- vides comfort for the unstable neck. The patient may complain vents the pooling of blood and tissue fluid in the dependent areas. of being caged in and of noise created by any object coming in Careful inspection of the skin is made each time the patient contact with the steel frame, but he or she can be reassured that is turned. The skin over the pressure points is assessed for redness adaptation to such annoyances will occur. or breaks; the perineum is checked for soilage and the catheter is The areas around the pin sites are cleansed daily and observed observed for adequate drainage. The patient’s general body align- for redness, drainage, and pain. The pins are observed for loos- ment and comfort are assessed. Special attention should be given ening, which may contribute to infection. If one of the pins be- to pressure areas in contact with the transfer board. comes detached, the head is stabilized in a neutral position by one Chapter 63 Management of Patients With Neurologic Trauma 1933 person while another notifies the neurosurgeon. A torque screw- Orthostatic Hypotension driver should be readily available should the screws on the frame For the first 2 weeks after SCI, the blood pressure tends to be un- need tightening. stable and quite low. There is a gradual return to preinjury levels, The skin under the halo vest is inspected for excessive perspi- but periodic episodes of severe orthostatic hypotension frequently ration, redness, and skin blistering, especially on the bony promi- interfere with efforts to mobilize the patient. Interruption in the nences. The vest is opened at the sides to allow the torso to be reflex arcs that normally produce vasoconstriction in the upright washed. The liner of the vest should not become wet, because position, coupled with vasodilation and pooling in abdominal dampness causes skin excoriation. Powder is not used inside the and lower extremity vessels, can result in blood pressure readings vest, because it may contribute to the development of pressure ul- of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypo- cers. The liner should be changed periodically to promote hygiene tension is a particularly common problem for patients with lesions and good skin care. If the patient is to be discharged with the vest, above T7. In some quadriplegic patients, even slight elevations of detailed instructions must be given to the family and time allowed the head can result in dramatic changes in blood pressure. for them to return demonstrate the necessary skills (Chart 63-9). A number of techniques can be used to reduce the frequency of hypotensive episodes. Close monitoring of vital signs before MONITORING AND MANAGING and during position changes is essential. Vasopressor medication POTENTIAL COMPLICATIONS can be used to treat the profound vasodilation. Thigh-high elastic Thrombophlebitis compression stockings should be applied to improve venous re- Thrombophlebitis is a relatively common complication in patients turn from the lower extremities. Abdominal binders may also be after SCI. DVT occurs in a high percentage of SCI patients; thus, used to encourage venous return and provide diaphragmatic sup- they are at risk for PE. The patient must be assessed for symptoms port when upright. Activity should be planned in advance and of thrombophlebitis and PE: chest pain, shortness of breath, and adequate time given for a slow progression of position changes changes in arterial blood gas values must be reported promptly to from recumbent to sitting and upright. Tilt tables frequently are the physician. The circumferences of the thighs and calves are helpful in assisting patients to make this transition. measured and recorded daily; further diagnostic studies will be performed if a significant increase is noted. Patients remain at Autonomic Dysreflexia high risk for thrombophlebitis for several months after the ini- Autonomic dysreflexia (autonomic hyperreflexia) is an acute tial injury. Patients with paraplegia or quadriplegia are at in- emergency that occurs as a result of exaggerated autonomic re- creased risk for the rest of their lives. Immobilization and the sponses to stimuli that are harmless in normal people. It occurs associated venous stasis, as well as varying degrees of autonomic only after spinal shock has resolved. This syndrome is characterized disruption, contribute to the high risk and susceptibility for DVT by a severe, pounding headache with paroxysmal hypertension, (Zafonte et al., 1999). profuse diaphoresis (most often of the forehead), nausea, nasal Anticoagulation is initiated once head and other systemic in- congestion, and bradycardia. It occurs among patients with cord juries have been ruled out. Low-dose fractionated or unfraction- lesions above T6 (the sympathetic visceral outflow level) after ated heparin may be followed by long-term oral anticoagulation spinal shock has subsided. The sudden rise in blood pressure may (ie, warfarin) or subcutaneous fractionated heparin injections. cause a rupture of one or more cerebral blood vessels or lead to Additional measures such as range-of-motion exercises, thigh- increased ICP. A number of stimuli may trigger this reflex: high elastic compression stockings, and adequate hydration are distended bladder (the most common cause); distention or con- important preventive measures. Pneumatic compression devices traction of the visceral organs, especially the bowel (from consti- may also be used to reduce venous pooling and promote venous pation, impaction); or stimulation of the skin (tactile, pain, thermal return. It is also important to avoid external pressure on the lower stimuli, pressure ulcer). Because this is an emergency situation, extremities that may result from flexion of the knees while the the objective is to remove the triggering stimulus and to avoid the patient is in bed. possibly serious complications.

Chart 63-9 Home Care Checklist • The Patient With a Halo Vest

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • Describe the rationale for use of the halo vest ✓✓ • Demonstrate assessment of frame, traction, tongs, and pins ✓ • Describe emergency measures if respiratory or other complications develop while patient is in halo vest or if frame becomes dislodged ✓ • Demonstrate pin care using correct technique ✓ • Identify signs and symptoms of infection ✓✓ • Assess the skin for reddened or irritated areas and breakdown ✓ • Demonstrate care of skin ✓ • Explain the reasons for and the method for changing the vest liner ✓✓ • Demonstrate safe techniques to assist patient with self-care, hygiene, and ambulation ✓ • Identify signs and symptoms of complications (deep venous thrombosis, respiratory impairment, urinary tract infection) ✓✓ 1934 Unit 14 NEUROLOGIC FUNCTION

The following measures are carried out: assisting them to assume responsibility for increasing aspects of • The patient is placed immediately in a sitting position to patient care and management. Care for the SCI patient involves lower blood pressure. members of all the health care disciplines; these may include nurs- • Rapid assessment to identify and alleviate the cause is im- ing, medicine, rehabilitation, respiratory therapy, physical and perative. occupational therapy, case management, social services, and so • The bladder is emptied immediately via a urinary catheter. forth. The nurse often serves as coordinator of the management If an indwelling catheter is not patent, it is irrigated or re- team and as a liaison with rehabilitation centers and home care placed with another catheter. agencies. The patient and family often require assistance in deal- • The rectum is examined for a fecal mass. If one is present, a ing with the psychological impact of the injury and its conse- topical anesthetic is inserted 10 to 15 minutes before the quences; referral to a psychiatric clinical nurse specialist or other mass is removed, because visceral distention or contraction mental health care professional often is helpful. can cause autonomic dysreflexia. The nurse should reassure female SCI patients that pregnancy • The skin is examined for any areas of pressure, irritation, or is not contraindicated, but pregnant women with acute or broken skin. chronic SCI pose unique management challenges. The normal • Any other stimulus that can be the triggering event, such as physiologic changes of pregnancy may predispose women with an object on the skin or a draft of cold air, must be removed. SCI to many potentially life-threatening complications, includ- • If these measures do not relieve the hypertension and ex- ing autonomic dysreflexia, pyelonephritis, respiratory insuffi- cruciating headache, a ganglionic blocking agent (hydralazine ciency, thrombophlebitis, PE, and unattended delivery hydrochloride [Apresoline]) is prescribed and given slowly (Atterbury & Groome, 1998). intravenously. As more patients survive acute SCI, they will face the changes • The medical record or chart should be labeled with a clearly associated with aging with a disability. Thus, teaching in the visible note about the risk for autonomic dysreflexia. home and community focuses on health promotion and ad- • The patient is instructed about prevention and manage- dresses the need to minimize risk factors (eg, smoking, alcohol ment measures. and drug abuse, obesity). Home care nurses and others who have • Any patient with a lesion above the T6 segment is informed contact with patients with SCI are in a position to teach patients that such an episode is possible and may even occur many about healthy lifestyles, remind them of the need for health years after the initial injury. screenings, and make referrals as appropriate. Assisting patients to identify accessible health care providers and imaging centers The rehabilitation of the patient with a SCI (ie, the quadri- may increase the likelihood that they will participate in health plegic or paraplegic patient) is discussed below. screening (eg, gynecologic examinations, mammograms, etc.). PROMOTING HOME AND COMMUNITY-BASED CARE Evaluation Teaching Patients Self-Care In most cases, SCI patients need long-term rehabilitation. The EXPECTED PATIENT OUTCOMES process begins during hospitalization as acute symptoms begin to Expected patient outcomes may include: subside or come under better control and the overall deficits and 1. Demonstrates improvement in gas exchange and clearance long-term effects of the injury become clear. The goals begin to of secretions, as evidenced by normal breath sounds on shift from merely surviving the injury to learning strategies nec- auscultation essary to cope with the alterations that injury imposes on activi- a. Breathes easily without shortness of breath ties of daily living. The emphasis shifts from ensuring that the b. Performs hourly deep-breathing exercises, coughs effec- patient is stable and free of complications to specific assessment tively, and clears pulmonary secretions and planning designed to meet the patient’s rehabilitation needs. c. Is free of respiratory infection (ie, has normal tempera- Patient teaching may initially focus on the injury and its effects ture, respiratory rate, and pulse, normal breath sounds, on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the absence of purulent sputum) injury, the focus of teaching may broaden to address issues nec- 2. Moves within limits of the dysfunction and demonstrates essary to carry out the tasks of daily living. Teaching begins in the completion of exercises within functional limitations acute phase and continues throughout rehabilitation and through- 3. Demonstrates adaptation to sensory and perceptual alter- out the patient’s life as changes occur, the patient ages, and ations problems arise. a. Uses assistive devices (eg, prism glasses, hearing aids, Caring for the SCI patient at home may at first seem a daunt- computers) as indicated ing task to the family. They will require dedicated nursing sup- b. Describes sensory and perceptual alterations as a conse- port to gradually assume full care of the patient (Craig et al., quence of injury 1999). 4. Demonstrates optimal skin integrity Although maintaining function and preventing complications a. Exhibits normal skin turgor; skin is free of reddened will remain important, goals regarding self-care and preparation areas or breaks for discharge will assist in a smooth transition to rehabilitation b. Participates in skin care and monitoring procedures and eventually to the community. within functional limitations 5. Regains urinary bladder function Continuing Care a. Exhibits no signs of UTI (ie, has normal temperature; The ultimate goal of the rehabilitation process is independence. voids clear, dilute urine) The nurse becomes a support to both the patient and the family, b. Has adequate fluid intake Chapter 63 Management of Patients With Neurologic Trauma 1935

c. Participates in bladder training program within func- NURSING PROCESS: tional limitations THE PATIENT WITH QUADRIPLEGIA 6. Regains bowel function OR PARAPLEGIA a. Reports regular pattern of bowel movement b. Consumes adequate dietary fiber and oral fluids Assessment c. Participates in bowel training program within functional limitations Assessment focuses on the patient’s general condition, complica- 7. Reports absence of pain and discomfort tions, and how the patient is managing at that particular point in 8. Is free of complications time. A head-to-toe assessment and review of systems should be a. Demonstrates no signs of thrombophlebitis, DVT, or PE part of the database, with emphasis on the areas prone to prob- b. Exhibits no manifestations of pulmonary embolism lems in this population. A thorough inspection of all areas of the (eg, no chest pain or shortness of breath; arterial blood skin for redness or breakdown is critical. It is also important to gas values are normal) review with the patient the established bowel and bladder pro- c. Maintains blood pressure within normal limits gram, because the program must continue uninterrupted. Patients d. Has no lightheadedness with position changes with quadriplegia or paraplegia have varying degrees of loss of e. Exhibits no manifestations of autonomic dysreflexia motor power, deep and superficial sensation, vasomotor control, bladder and bowel control, and sexual function. They are faced (ie, no headache, diaphoresis, nasal congestion, brady- with potential complications related to immobility, skin break- cardia, or diaphoresis) down and pressure ulcers, recurring UTI, contractures, and psychosocial disruptions. Knowledge about these particular issues Management of the Quadriplegic can further guide the assessment in any setting. Nurses in all or Paraplegic Patient settings, including home care, must be aware of these potential complications in the lifetime management of these patients. Quadriplegia refers to the loss of movement and sensation in all An understanding of the emotional and psychological responses four extremities and the trunk, associated with injury to the cer- to quadriplegia or paraplegia is achieved by observing the responses vical spinal cord. Paraplegia refers to loss of motion and sensation and behaviors of the patient and family and by listening to their in the lower extremities and all or part of the trunk as a result of concerns (see Chart 63-10 for a discussion of ethical issues). damage to the thoracic or lumbar spinal cord or to the sacral root. Documenting these assessments and reviewing the plan with the Both conditions most frequently follow trauma such as falls, in- entire team on a regular basis provide insight into how both the pa- juries, and gunshot wounds, but they may also be the result of tient and the family are coping with the changes in lifestyle and spinal cord lesions (intervertebral disk, tumor, vascular lesions), body functioning. Additional information frequently can be gath- multiple sclerosis, infections and abscesses of the spinal cord, and ered from the social worker or psychiatric/mental health worker. congenital disorders. The patient faces a lifetime of great disability, requiring ongoing follow-up and care and the expertise of a number of health professionals, including physicians (specifically a physiatrist), re- • Ethics and Related Issues habilitation nurses, occupational therapist, physical therapist, Chart 63-10 psychologist, social worker, rehabilitation engineer, and vocational counselor at different times as the need arises. When the Patient Wants to Die . . . As the years go by, these patients also have the same medical Situation problems as others in the aging population. In addition, they face A 70-year-old man has been in neurologic intensive care since he the threat of complications associated with their disability. Usu- suffered a complete C1-C2 cervical fracture 2 weeks ago, which left ally the patient is encouraged to attend a spinal clinic when com- him quadriplegic and ventilator-dependent. Since his admission, plications and other issues arise. Lifetime care includes assessment he has asked to be allowed to die. He has a living will and his wife of the urinary tract at prescribed intervals, because there is the is his designated durable power of attorney for health care. Before likelihood of continuing alteration in detrusor and sphincter his injury, his health was exceptional. He played golf daily and was function and the patient is prone to UTI. very active. He is awake, alert, and oriented and can communicate by letter board. He states that he does not want to spend his life un- Long-term problems and complications of SCI include disuse able to do the things he enjoys. He continues to request extubation syndrome, autonomic dysreflexia (discussed earlier), bladder and so that he can die. His family and friends are with him, and he has kidney infections, spasticity, and depression. Pressure ulcers with asked his attorneys to tend to his affairs. With the loving support potential complications of sepsis, osteomyelitis, and fistulas occur of his family, the decision to remove the ventilator has been made. in about 10% of patients. Flexor muscle spasms may be particu- Sedatives will be administered to help him deal with hypoxia and larly disabling and occur in up to 25% of patients (Sullivan, anoxia. 1999). Heterotopic ossification (overgrowth of bone) in the hips, Dilemma knees, shoulders, and elbows occurs in up to 30% of SCI patients. What is the nurse’s role in caring for this patient at this time? This complication is painful and can produce a loss of range of Discussion motion (Mitcho & Yanko, 1999; Subbarao & Garrison, 1999). Is the removal of the ventilator an act of assisted suicide? Is it active Management includes observing for and addressing any alter- or passive euthanasia? What is the nurse’s role in caring for the pa- ation in physiologic status and psychological outlook, and the tient if this action conflicts with his/her personal beliefs? If no other prevention and treatment of long-term complications. The nurs- nurse is available to provide care? If the physician writes the order ing role involves emphasizing the need for vigilance in self- for the nurse to remove the ventilator? assessment and care. 1936 Unit 14 NEUROLOGIC FUNCTION

It takes time for the patient and family to comprehend the shoulders, chest, spine, abdomen, and neck must be strengthened magnitude of the disability. They may go through stages of grief, in the paraplegic patient because he or she must bear full weight including shock, disbelief, denial, anger, depression, and accep- on these muscles to ambulate. The triceps and the latissimus dorsi tance. During the acute phase of the injury, denial can be a pro- are important muscles used in crutch walking. The muscles of the tective mechanism to shield patients from the overwhelming abdomen and the back also are necessary for balance and for reality of what has happened. As they realize the permanent na- maintaining the upright position. ture of paraplegia or quadriplegia, the grieving process may be To strengthen these muscles, the patient can do push-ups prolonged and all-encompassing because of the recognition that when in a prone position and sit-ups when in a sitting position. long-held plans and expectations may be interrupted or perma- Extending the arms while holding weights (traction weights can nently altered. A period of depression often follows as the patient be used) also develops muscle strength. Squeezing rubber balls or experiences a loss of self-esteem in areas of self-identity, sexual crumbling newspaper promotes hand strength. functioning, and social and emotional roles. Exploration and as- With encouragement from all members of the rehabilitation sessment of these issues can assist in developing a meaningful plan team, the paraplegic patient can develop the increased exercise of care. tolerance needed for gait training and ambulation activities. The importance of maintaining cardiovascular ﬁtness is stressed to the Diagnosis patient. Alternative exercises to increase the heart rate to target levels must be designed within the patient’s abilities. NURSING DIAGNOSES Based on the assessment data, the major nursing diagnoses of Mobilization the patient with quadriplegia or paraplegia may include the following: When the spine is stable enough to allow the patient to assume an upright posture, mobilization activities are initiated. A brace • Impaired physical mobility related to loss of motor function or vest may be used, depending on the level of the lesion. A pa- • Risk for disuse syndrome tient whose paralysis is due to complete transection of the cord • Risk for impaired skin integrity related to permanent sen- can begin weight-bearing early because no further damage can be sory loss and immobility incurred. The sooner muscles are used, the less chance there is • Urinary retention related to level of injury of disuse atrophy. The earlier the patient is brought to a stand- • Constipation related to effects of spinal cord disruption ing position, the less opportunity for osteoporotic changes to • Sexual dysfunction related to neurologic dysfunction take place in the long bones. Weight-bearing also reduces the • Ineffective coping related to impact of dysfunction on daily possibility of renal calculi and enhances many other metabolic living processes. • Deﬁcient knowledge about requirements for long-term Braces and crutches enable some paraplegic patients to ambu- management late for short distances. Ambulation using crutches requires a high expenditure of energy. Motorized wheelchairs and specially COLLABORATIVE PROBLEMS/ equipped vans can provide greater independence and mobility for POTENTIAL COMPLICATIONS patients with high-level SCI or other lesions. Every effort should Based on all the assessment data, potential complications of quad- be made to encourage the patient to be as mobile and active as riplegia or paraplegia that may develop include: possible. • Spasticity • Infection and sepsis PREVENTING DISUSE SYNDROME Patients are at high risk for developing contractures as a result Planning and Goals of disuse syndrome due to the musculoskeletal system changes (atrophy) brought about by the loss of motor and sensory functions The goals for the patient may include attainment of some form below the level of injury. Range-of-motion exercises must be pro- of mobility, maintenance of healthy, intact skin, achievement of vided at least four times a day, and care is taken to stretch the bladder management without infection, achievement of bowel Achilles tendon with exercises (Hickey, 2003). The patient is control, achievement of sexual expression, strengthening of coping repositioned frequently and maintained in proper body align- mechanisms, and absence of complications. ment whether in bed or in a wheelchair (Hickey, 2003).

PROMOTING SKIN INTEGRITY Nursing Interventions Because these patients spend a great portion of their lives in wheel- The patient requires extensive rehabilitation, which is less dif- chairs, pressure ulcers are an ever-present threat. Contributing ficult if appropriate nursing management has been carried out factors are permanent sensory loss over pressure areas; immobil- during the acute phase of the injury or illness. Nursing care is one ity, which makes relief of pressure difficult; trauma from bumps of the key factors determining the success of the rehabilitation (against the wheelchair, toilet, furniture, and so forth) that cause program. The main objective is for the patient to live as inde- unperceived abrasions and wounds; loss of protective function of pendently as possible in the home and community. the skin from excoriation and maceration due to excessive perspiration and possible urinary and fecal incontinence; and poor INCREASING MOBILITY general health (anemia, edema, malnutrition), leading to poor tissue perfusion. The prevention and management of pressure Exercise Programs ulcers are discussed in detail in Chapter 11. The unaffected parts of the body are built up to optimal strength The person with quadriplegia or paraplegia must take respon- to promote maximal self-care. The muscles of the hands, arms, sibility for monitoring (or directing) his or her skin status. This Chapter 63 Management of Patients With Neurologic Trauma 1937 involves relieving pressure and not remaining in any position for the cord lesion involves the sacral segment or nerve roots, anal longer than 2 hours, in addition to ensuring that the skin receives massage is not performed because the anus may be relaxed and meticulous attention and cleansing. The patient is taught that ul- lack tone. Massage is also contraindicated if there is spasticity of cers develop over bony prominences exposed to unrelieved pres- the anal sphincter. The anal sphincter is massaged by inserting a sure in the lying and sitting positions. The most vulnerable areas gloved finger (which has been adequately lubricated) 2.5 to 3.7 cm are identified. The paraplegic patient is instructed to use mirrors, (1 to 1.5 in) into the rectum and moving it in a circular motion if possible, to inspect these areas morning and night, observing for or from side to side. It soon becomes apparent which area triggers redness, slight edema, or any abrasions. While in bed, the patient the defecation response. This procedure should be performed should turn at 2-hour intervals and then inspect the skin again at the same time (usually every 48 hours), after a meal, and at a for redness that does not fade on pressure. The bottom sheet time that will be convenient for the patient at home. The patient should be checked for wetness and for creases. The quadriplegic also is taught the symptoms of impaction (frequent loose stools; or paraplegic patient who cannot perform these activities is en- constipation) and cautioned to watch for hemorrhoids. A diet couraged to direct others to check these areas and prevent ulcers with sufficient fluids and fiber is essential to a successful bowel from developing. training program, avoiding constipation, and decreasing the risk The patient is taught to relieve pressure while in the wheelchair of autonomic dysreflexia. by doing push-ups, leaning from side to side to relieve ischial pressure, and tilting forward while leaning on a table. The caregiver COUNSELING ON SEXUAL EXPRESSION for the quadriplegic patient will need to perform these activities if Many paraplegic and quadriplegic patients can have some form the patient cannot do so independently. A wheelchair cushion is of meaningful sexual relationship, although some modifications prescribed to meet individual needs, which may change in time will be necessary. The patient and partner benefit from counsel- with changes in posture, weight, and skin tolerance. A referral can ing about the range of sexual expression possible, special techniques be made to a rehabilitation engineer, who can measure pressure and positions, exploration of body sensations offering sensual levels while the patient is sitting and then tailor the cushion and feelings, and urinary and bowel hygiene as related to sexual ac- other necessary aids and assistive devices to the patient’s needs. tivity. For men with erectile failure, penile prostheses enable them The diet for the patient with quadriplegia or paraplegia should to have and sustain an erection. Sildenafil (Viagra) is an oral be high in protein, vitamins, and calories to ensure minimal wast- smooth muscle relaxant that causes blood to flow into the penis, ing of muscle and the maintenance of healthy skin, and high in resulting in an erection (see Chap. 49). fluids to maintain well-functioning kidneys. Excessive weight Sexual education and counseling services are included in the gain and obesity should be avoided because they limit mobility. rehabilitation services at spinal centers. Small-group meetings in which the patients can share their feelings, receive information, IMPROVING BLADDER MANAGEMENT and discuss sexual concerns and practical aspects are helpful in The effect of the spinal cord lesion on the bladder depends on the producing effective attitudes and adjustments (Sipski & Alexander, level of injury, the degree of cord damage, and the length of time 1997). after injury. A patient with quadriplegia or paraplegia usually has either a reflex or a nonreflex bladder (see Chaps. 11 and 44). Both ENHANCING COPING MECHANISMS bladder types increase the risk of UTI. The impact of the disability and loss becomes marked when pa- The nurse emphasizes the importance of maintaining an ade- tients return home. Each time something new enters their lives quate flow of urine by encouraging a fluid intake of about 2.5 L (eg, a new relationship, going to work), they are reminded anew daily. The patient should empty the bladder frequently so there of their limitations. Grief reactions and depression are common. is minimal residual urine and should pay attention to personal To work through this depression, patients must have some hygiene, because infection of the bladder and kidneys almost hope for relief in the future. Thus, the nurse can encourage them always occurs by the ascending route. The perineum must be kept to feel confident in their ability to achieve self-care and relative clean and dry and attention given to the perianal skin after defe- independence. The role of the nurse ranges from caretaker during cation. Underwear should be cotton (more absorbent) and changed the acute phase to teacher, counselor, and facilitator as patients at least once a day. gain mobility and independence. If an external catheter (condom catheter) is used, the sheath is The patient’s disability affects not only the patient, but also removed nightly; the penis is cleansed to remove urine and is the entire family. In many cases, family therapy is helpful to help dried carefully, because warm urine on the periurethral skin pro- work through issues as they arise. motes the growth of bacteria. Attention also is given to the col- Adjustment to the disability leads to the development of re- lection bag. The nurse emphasizes the importance of monitoring alistic goals for the future, making the best of the abilities that for indications of UTI: cloudy, foul-smelling urine or hematuria are left intact and reinvesting in other activities and relation- (blood in the urine), fever, or chills. ships. Rejection of the disability causes self-destructive neglect The female patient who cannot achieve reflex bladder control and noncompliance with the therapeutic program, which leads or self-catheterization may need to wear pads or waterproof to more frustration and depression. Crises for which interven- undergarments. Surgical intervention may be indicated in some tions may be sought include social, psychological, marital, sexual, patients to create a urinary diversion. and psychiatric problems. The family usually requires counseling, social services, and other support systems to help them cope ESTABLISHING BOWEL CONTROL with the changes in their lifestyle and socioeconomic status. The objective of a bowel training program is to establish bowel A major goal of nursing management is to help patients over- evacuation through reflex conditioning. This technique is de- come their sense of futility and to encourage them in the emo- scribed in Chapter 38. If a cord injury occurs above the sacral seg- tional adjustment that must be made before they are willing to ments or nerve roots and there is reflex activity, the anal sphincter venture into the outside world. However, an excessively sympa- may be massaged (digital stimulation) to stimulate defecation. If thetic attitude on the part of the nurse may cause patients to 1938 Unit 14 NEUROLOGIC FUNCTION develop an overdependence that defeats the purpose of the entire system function (eg, excessive stress, drug abuse, excessive alcohol rehabilitation program. Patients are taught and assisted when intake). necessary, but the nurse should avoid performing activities that If infection occurs, the patient requires thorough assessment patients can do for themselves with a little effort. This approach and prompt treatment. Antibiotic therapy and adequate hydra- to care more than repays itself in the satisfaction of seeing a com- tion, in addition to local measures (depending on the site of pletely demoralized and helpless patient become independent infection), are initiated immediately. and find meaning in a newly emerging lifestyle. UTIs are minimized or prevented by: Aseptic technique in catheter management MONITORING AND MANAGING • Adequate hydration POTENTIAL COMPLICATIONS • • Bladder training program Spasticity • Prevention of overdistention of the bladder and stasis Muscle spasticity is one of the most problematic complications of Skin breakdown and infection are prevented by: quadriplegia and paraplegia. These incapacitating flexor or extensor spasms, which occur below the level of the spinal cord le- • Maintenance of a turning schedule sion, interfere with both the rehabilitation process and activities • Frequent back care of daily living. Spasticity results from an imbalance between the • Regular assessment of all skin areas facilitatory and inhibitory effects on neurons that exist normally. • Regular cleansing and lubrication of the skin The area of the cord distal to the site of injury or lesion becomes • Passive range-of-motion exercise to prevent contractures disconnected from the higher inhibitory centers located in the • Pressure relief, particularly over broken skin areas, bony brain. Facilitatory impulses, which originate from muscles, skin, prominences, and heels and ligaments, thus predominate. • Wrinkle-free bed linen Spasticity is defined as a condition of increased muscle tone Pulmonary infections are managed and prevented by: in a muscle that is weak. Initial resistance to stretching is quickly followed by sudden relaxation. The stimulus that precipitates • Frequent coughing, turning, and deep-breathing exercises spasm can be either obvious, such as movement or a position and chest physiotherapy change, or subtle, such as a slight jarring of the wheelchair. Most • Aggressive respiratory care and suctioning of the airway if a patients with quadriplegia or paraplegia have some degree of tracheostomy is present spasticity. With SCI, the onset of spasticity usually occurs from • Assisted coughing a few weeks to 6 months after the injury. The same muscles that • Adequate hydration are flaccid during the period of spinal shock will develop spas- Infections of any kind can be life-threatening. Therefore, ag- ticity during recovery. The intensity of spasticity tends to peak gressive nursing interventions are key to their prevention and around 2 years after the injury, after which the spasms tend to management. regress. Management of spasticity is based on the severity of symptoms PROMOTING HOME AND COMMUNITY-BASED CARE and the degree of incapacitation. Antispasmodic medications such as diazepam (Valium), baclofen (Lioresal), and dantrolene Teaching Patients Self-Care (Dantrium) are frequently effective in controlling spasm but Patients with quadriplegia or paraplegia are at risk for complica- cause drowsiness, weakness, and vertigo in some patients. Passive tions for the rest of their lives. Thus, a major aspect of nursing range-of-motion exercises and frequent turning and reposition- care is teaching patients and their families about these complica- ing are helpful because stiffness tends to increase spasticity. These tions and about strategies to minimize this risk. UTIs, contractures, activities also are essential in the prevention of contractures, pres- infected pressure ulcers, and sepsis may necessitate hospitaliza- sure ulcers, and bowel and bladder dysfunction. tion. Other late complications that may occur include lower ex- Contractures can complicate day-to-day care, increasing the tremity edema, joint contractures, respiratory dysfunction, and difficulty with positioning and decreasing mobility. A number of pain. To avoid these and other complications, the patient and a surgical procedures have been tried with varying degrees of suc- family member are taught skin care, catheter care, range-of-motion cess. These techniques are used if more conservative approaches exercises, breathing exercises, and other care techniques. Teaching fail. The best treatment is prevention. is initiated as soon as possible and extends into the rehabilitation or long-term care facility and home. Infection and Sepsis Patients with quadriplegia and paraplegia are at increased risk for Continuing Care infection and sepsis from a variety of sources: urinary tract, res- Referral for home care is often appropriate for assessment of the piratory tract, and pressure ulcers. Sepsis remains a major cause home setting, patient teaching, and evaluation of the patient’s of death and complications in these patients. Prevention of in- physical and emotional status. During visits by the home care fection and sepsis is essential through maintenance of skin in- nurse, teaching about strategies to prevent or minimize potential tegrity, complete emptying of the bladder at regular intervals, and complications is reinforced. The home environment is assessed prevention of urinary and fecal incontinence. The risk of respira- for adequacy for care and for safety. Environmental modifications tory infection can be decreased by avoiding contact with people are made and specialized equipment is obtained, ideally before with symptoms of respiratory infection, performing coughing the patient goes home. and deep-breathing exercises to prevent pooling of respiratory se- The home care nurse also assesses the patient’s and the family’s cretions, receiving yearly influenza vaccines, and giving up smok- adherence to recommendations and their use of coping strategies. ing. A high-protein diet is important in maintaining an adequate The use of inappropriate coping strategies such as drug and alco- immune system, as is avoiding factors that may reduce immune hol use is assessed and referrals to counseling are made for the Chapter 63 Management of Patients With Neurologic Trauma 1939 patient and family. Appropriate and effective coping strategies 3. A patient with a T4 SCI has just returned to the nursing are reinforced. The nurse reviews previous teaching and deter- unit from physical therapy. He reports a severe, pounding mines the need for further physical or psychological assistance. headache and nausea. His blood pressure is very elevated and The patient’s self-esteem and body image may be very poor at this his pulse is slow. What are the possible causes of these signs time. Because people with high levels of social support often re- and symptoms? What immediate actions should you take? port feelings of well-being despite major physical disability, it is What treatments can you anticipate? What teaching is beneficial for the nurse to assess and promote further develop- warranted, and why? ment of the support system and effective coping strategies of each patient. The patient requires continuing, life-long follow-up by the physician, physical therapist, and other rehabilitation team members because the neurologic deficit is usually permanent and new REFERENCES AND SELECTED READINGS deficits and complications can develop. These require prompt attention before they take their toll in additional physical impair- Books ment, time, morale, and financial costs. The local counselor for The Brain Trauma Foundation (2000). Guidelines for the management the Office of Vocational Rehabilitation works with the patient of severe head injury. New York: The Brain Trauma Foundation. with respect to job placement or additional educational or voca- The Brain Trauma Foundation (2000). Guidelines for the pre-hospital management of traumatic brain injury. New York: The Brain Trauma tional training. Foundation. The nurse is in a good position to remind patients and family Cammermeyer, M., & Appledorn, C. (Eds.). (1996). Core curriculum members of the need for continuing health promotion and for neuroscience nurses (4th ed.). Chicago: American Association of screening practices. Referral to accessible health care providers Neuroscience Nurses. and imaging centers is important in health promotion. Consortium for Spinal Cord Medicine. (1998). Neurogenic bowel management in adults with spinal cord injury. Clinical Practice Guidelines, Paralyzed Veterans of America, Washington, D.C. Evaluation Hickey, J. V. (2003). The clinical practice of neurological and neurosurgical EXPECTED PATIENT OUTCOMES nursing (5th ed.). Philadelphia: Lippincott Williams & Wilkins. Kaye, A. (1997). Essential neurosurgery (2nd ed.). New York: Churchill Expected patient outcomes may include: Livingstone. 1. Attains some form of mobility Porth, C. M. (2002). Pathophysiology concepts of altered health states 2. Contractures do not develop (6th ed.). Philadelphia: Lippincott Williams & Wilkins. 3. Maintains healthy, intact skin Sipski, M. L., & Alexander, C. J. (1997). Sexual function in people with 4. Achieves bladder control, absence of UTI disability and chronic illness: A health professional’s guide. Gaithersburg, MD: Aspen. 5. Achieves bowel control Young, G. B., Ropper, A. H., & Bolton, C. F. (1998). Coma and im- 6. Reports sexual satisfaction paired consciousness: A clinical perspective. New York: McGraw-Hill. 7. Shows improved adaptation to environment and others Ylvisaker, M. (1998) Traumatic brain injury rehabilitation: Children and 8. Exhibits reduction in spasticity adolescents (2nd ed). Boston: Butterworth-Heinemann. a. Reports understanding of the precipitating factors Journals b. Reports understanding of measures to reduce spasticity 9. Describes long-term management required Asterisks indicate nursing research articles. Head Injury 10. Exhibits absence of complications Annegers, J., & Coan, S. (2000). The risks of epilepsy after traumatic brain injury. Seizure, 9(7), 453–457. Bader, M. K., & Palmer, S. (2000). Keeping the brain in the zone: Applying the severe head injury guidelines to practice. Critical Care Nursing Clinics of North America, 12(4), 413–427. Blank-Reid, C. & Reid, P. C. (2000). Penetrating trauma to the head. Critical Thinking Exercises Critical Care Nursing Clinics of North America, 12(4), 477–487. ?? Bogner, J. A., Corrigan, J. D., Stange, M., & Rabold, D. (1999). Focus 1. A patient has been brought to the emergency department on clinical research. Reliability of the agitated behavior scale. Journal after he was hit in the head with a bat during a company base- of Head Trauma Rehabilitation, 14(1), 91–96. ball game. His coworkers report that he was unconscious for Brain Trauma Foundation, American Association of Neurological Sur- geons, Joint Section on Neurotrauma and Critical Care. (2000) Role about 3 minutes. He now seems alert and oriented. What of antiseizure prophylaxis following head injury. Journal of Neuro- type of injury has he most likely sustained? What discharge trauma, 17(6–7), 549–553. instructions are warranted for this patient’s family? How Davis, A. (2000). Cognitive impairments following traumatic brain in- would you modify your discharge instructions if the patient jury. Critical Care Nursing Clinics of North America, 12(4), 447–455. lives alone? *Faragi, B., & Yu, P. (1998). Serum phenytoin levels of patients on 2. A 25-year-old man with paraplegia secondary to SCI is gastrostomy tube feeding. Journal of Neuroscience Nursing, 30(1), scheduled to return home after an 8-month stay in a rehabil- 55–59. *Gelling, L. (1999). The experience of hope for the relatives of head in- itation facility. What health promotion strategies are relevant jured patients admitted to a neurosciences critical care unit: A phe- to teach the patient prior to discharge? What modifications nomenological study. Nursing in Critical Care, 4(5), 214–221. in patient teaching would be indicated if the patient were a Grzankowski, J. A. (1997). Altered thought processes related to trau- 50-year-old woman? matic brain injury and their nursing implications. Rehabilitation Nursing, 22(1), 24–31. 1940 Unit 14 NEUROLOGIC FUNCTION

Hagen, C., Malkmus, D., & Durham, P. (1972). Communication Dis- Munro, N. (2000). Pulmonary challenges in neurotrauma. Critical Care orders Service, Rancho Los Amigos Hospital, Downey CA 1972. Re- Nursing Clinics of North America, 12(4), 457–464. vised 11/15/74 by Danese Malkmus, M. A., and Kathryn Stenderup. Velmahos, G., Kern, J., Chan, L., et al. (2000). Prevention of venous Kado, R., & Patel, A. (1999). Posttraumatic epilepsy prophylaxis in trau- thromboembolism after injury: an evidence-based report—part II: matic brain injury. Journal of Cognitive Rehabilitation, 17(5), 16–20. Analysis of risk factors and evaluation of the role of vena caval fil- Lovasik, D. (2000). Brain death and organ donation. Critical Care ters. Journal of Trauma-Injury Infection & Critical Care, 49(1), Nursing Clinics of North America,12(4), 531–538. 140–144. March, K. (2000). Intracranial pressure monitoring and assessing intra- Zafonte, R. D., Giap, B. T., Coplin, W. M., & Pangilian, P. (1999). cranial compliance in brain injury. Critical Care Nursing Clinics of Traumatic brain injury and spinal cord injury: Pathophysiology and North America, 12(4), 429–436. acute therapeutic strategies. Topics in Spinal Cord Injury Rehabilita- Mitchell, P. H., & Habermann, B. (1999). Rethinking physiologic tion, 5(2), 21–40. stability: Touch and intracranial pressure. Biological Research for Spinal Cord Injury Nursing, 1(1), 12–19. Atterbury, J. L., & Groome, L. J. (1998). Pregnancy in women with National Institutes of Health. (1998). Consensus statement: Rehabilita- spinal cord injuries. Nursing Clinics of North America, 33(4), tion of persons with traumatic brain injury. October 26–28, 1998. 603–613. Patyk, M., Gaynor, S., Kelly, J., & Ott, V. (1998). Touch screen com- Bracken, M. B. (2000). Pharmacological interventions for acute spinal puterized education for patients with brain injuries. Rehabilitation cord injury. Cochrane Database of Systematic Reviews [computer file]. Nursing, 23(2), 84–87. (2):CD001046. Perdue P., Watts, D., Kaufmann, C., & Trask, A. (1998) Differences in Craig, A., Hancock, K., & Dickson, H. (1999). Improving the long- mortality between elderly and younger adult trauma patients: Geri- term adjustment of spinal cord injured persons. Spinal Cord, 37(5), 345–350. atric status increases risk of delayed death. Journal of Trauma-Injury Dibsie, L. G. (1998). Clearing cervical spine injuries: A discussion of the Infection & Critical Care, 45(4), 805–810. process and the problems. Critical Care Nursing Quarterly, 21(2), Perlesz, A., Kinsella, G., & Crowe, S. (1999). Impact of traumatic brain 36–41. injury on the family: A critical review. Rehabilitation Psychology, Gaebler, C., Maier, R., Kutscha-Lissberg, F., et al. (1999). Results of 44(1), 6–35. spinal cord decompression and thoracolumbar pedicle stabilisation Ponsford, J., Willmott, C., Rothwell, A., et al. (1999) Cognitive and in relation to the time of operation. Spinal Cord, 37(1), 33–39. behavioral outcome following mild traumatic head injury in children. Halbert, L. A. (1998). Breastfeeding in the woman with a compromised Journal of Head Trauma Rehabilitation, 14(4), 360–372. nervous system. Journal of Human Lactation, 14(4), 327–331. Ramritu, P. L., & Croft, G. (1999). Needs of parents of the child hos- Huston, C. J. (1998). Cervical spine injury. American Journal of Nursing, pitalised with acquired brain damage. International Journal of Nursing 98(6), 33. Studies, 36(3), 209–216. Johnson, R. L., Gerhart, K. A., McGray, J., et al. (1998). Secondary con- Segatore, M. (1999). Corticosteroids and traumatic brain injury: Status ditions following spinal cord injury in a population-based sample. at the end of the decade of the brain. Journal of Neuroscience Nursing, Spinal Cord, 36(1), 45–50. 31(4), 239–250. Kannisto, M., Merikanto, J., & Alaranta, H. (1998). Comparison of Servadei, F. (1997). Prognostic factors in severely head injured adult health-related quality of life in three subgroups of spinal cord injury patients with epidural haematomas. Acta Neurochirurgica, 139(4), patients. Spinal Cord, 36(3), 193–199. 273–278. Lucke, K. T. (1998). Pulmonary management following acute SCI. *Sullivan, J. (2000). Positioning of patients with severe traumatic brain Journal of Neuroscience Nursing, 30(2), 91–104. injury: Research-based practice. Journal of Neuroscience Nursing, Mitcho, K., & Yanko, J. R. (1999). Acute care management of spinal 32(4), 204–209. cord injuries. Critical Care Nursing Quarterly, 22(2), 60–79. Teasdale, G. & Jennett, B. (1974). Assessment of coma and impaired Nolan, M., & Nolan, J. (1998). Rehabilitation following spinal injury: consciousness. A practical scale. Lancet, 2(7872), 81–84. The nursing response. British Journal of Nursing, 7(2), 97–104. van Reekum, R., Cohen, T., & Wong, J. (2000). Can traumatic brain *Prieto-Fingerhut, T., Banovac, K., & Lynne, C. M. (1997). A study injury cause psychiatric disorders? Journal of Neuropsychiatry & comparing sterile and non-sterile urethral catheterization in patients Clinical Neurosciences, 12(3), 316–327. with spinal cord injury. Rehabilitation Nursing, 22(6), 299–302. *Villanueva, N. E. (1999). Experiences of critical care nurses caring Short, D. J., El Masry, W. S., & Jones, P. W. (2000). High-dose for unresponsive patients. Journal of Neuroscience Nursing, 31(4), methylprednisolone in the management of acute spinal cord injury: 216–223. A systematic review from a clinical perspective. Spinal Cord, 38(5), Walshaw, L. K. (2000). Assessment of head injuries in a minor injuries 273–286. unit. Accident & Emergency Nursing, 8(4), 210–213. Subbarao, J., & Garrison, S. (1999). Heterotopic ossification: Diagnosis Wong, F. W. H. (2000). Prevention of secondary brain injury. Critical and management, current concepts and controversies. Journal of Care Nurse, 20(5), 18–27. Spinal Cord Medicine, 22(4), 273–283. Neurotrauma Stillwell, S. B. (2000). When you suspect epidural hematoma. American Journal of Nursing, 100(9), 68–76. Donaldson, J., Borzatta, M. A., & Matossian, D. (2000). Nutrition strate- *Sullivan, J. (1999). Spinal cord injury research: Review and synthesis. gies in neurotrama. Critical Care Nursing Clinics of North America, Critical Care Nursing Quarterly, 22(2), 80–99. 12(4), 465–473. Travers, P. L. (1999). Autonomic dysreflexia: A clinical rehabilitation Centers for Disease Control and Prevention, National Center for Injury problem. Rehabilitation Nursing, 24(1), 19–23. Prevention and Control (2001). Scientific Data, Surveillance, & Vacanti, M. P., Leonard, J. L., Dore, B. et al. (2001). Tissue-engineered Injury Statistics: Web-based Injury Statistics Query and Reporting spinal cord. Transplantation Proceedings, 33(1–2), 592–598. System (WBISQRS) http://www.cdc.gov/ncipc/osp/data.htm; http:// www.cdc.gov/safeusa/home/sci.htm; http://www.cdc.gov/ncipc/ RESOURCES AND WEBSITES dacrrdp/tbi.htm. Elovic, E., & Kirschblum, S. (1999). Epidemiology of spinal cord injury American Association of Neuroscience Nurses (AANN), 4700 W. Lake and traumatic brain injury: The scope of the problem. Topics in Spinal Ave, Chicago, IL 60025-1485; (847) 375-4733; (888)-557-2266; Cord Injury Rehabilitation, 5(2), 1–20. http://www.aann.org. Chapter 63 Management of Patients With Neurologic Trauma 1941

American Association of Spinal Cord Injury Nurses (AASCIN), 75-20 The Library of Congress, Division of the Blind and Physically Hand- Astoria Blvd., Jackson Heights, NY 11370-1177; (718) 803-3782; icapped, 1291 Taylor St., NW, Washington, DC 20542; (202) http://www.aascin.org. 707-5100; http://www.loc.gov/access/. American Paralysis/Spinal Cord Hotline, (800) 526-3456; http://www. National Head Injury Foundation, 1776 Massachusetts Ave., NW, Suite scihotline.org. 100, Washington DC 20036; family help line (800) 444-6443; Association of Rehabilitation Nurses, 5700 Old Orchard Rd., Skokie, http://www.healthy.net/pan/cso/cioi/nhif. IL 60077; (708) 966-8673; http://www.rehabnurse.org. National Rehabilitation Information Center, 1010 Wayne Avenue, The Brain Injury Association, Inc., 105 N. Alfred St., Alexandria, Suite 800, Silver Spring, MD 20910; (800) 346-2742, TTY (301) VA 22314; (703) 236-6000; family help line: (800) 444-6443; 495-5626; http://www.naric.com. http://www.biausa.org. National Spinal Cord Injury Association, 8300 Colesville Rd., Silver The Brain Trauma Foundation 523 East 72d Street, New York, NY 10021; Spring, MD 20910; (301) 588-6959; http://www.spinalcord.org. (212) 772-0608; http://www.braintrauma.org. Centers for Disease Control and Prevention, National Center for Injury Paralyzed Veterans of America, 801 18th St., NW, Washington, DC Prevention and Control, Mailstop K65, 4770 Buford Highway 20006; (202) 872-1300; http://www.pva.org. NE, Atlanta, GA 30341-3724; (770) 488-1506; http://www.cdc. Rehabilitation Services Administration, Department of Human Services, gov/ncipc/ncipchm.htm. 605 G Street, NW, Room 101M, Washington, DC 20001; (202) Information Center for Individuals with Disabilities, Fort Point 727-3211; http://www.ed.gov/ofﬁces/OSERS/RSA/rsa.html. Place, 27-43 Wormwood St., Boston, MA 02210-1606; (617) Waiting.com, run by and for the families of traumatic brain injury: 727-5540; http://www.disability.net. http://www.waiting.com. 64Chapter ● Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Differentiate among the infectious disorders of the nervous system according to causes, manifestations, medical care, and nursing management. 2. Describe the pathophysiology, clinical manifestations, and medical and nursing management of multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome. 3. Use the nursing process as a framework for care of patients with multiple sclerosis, myasthenia gravis, and Guillain-Barré syndrome. 4. Describe disorders of the cranial nerves, their manifestations, and indicated nursing interventions. 5. Develop a plan of nursing care for the patient with a cranial nerve disorder.

1942 Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1943 The diverse group of neurologic disorders that make up in- 2001). This increase focused attention on the need to develop a fectious and autoimmune disorders, and cranial and peripheral vaccine for high-risk populations. neuropathies present unique challenges for nursing care. Infec- tious processes of the nervous system sometimes cause death or Pathophysiology permanent dysfunction. Autoimmune disorders usually have a slow, progressive course, requiring the nurse to manage symp- Meningeal infections generally originate in one of two ways: toms and facilitate patients’ and families’ understanding of the through the bloodstream as a consequence of other infections, or disease process. Cranial and peripheral nerve disorders may affect by direct extension, such as might occur after a traumatic injury the patient’s comfort, functional independence, and self-esteem. to the facial bones, or secondary to invasive procedures. The nurse who cares for patients with these disorders must N. meningitidis concentrates in the nasopharynx and is trans- have a clear understanding of the pathologic processes and the mitted by secretion or aerosol contamination. Bacterial or meningo- clinical outcomes. Some of the issues nurses must help patients coccal meningitis also occurs as an opportunistic infection in and families confront include adaptation to the effects of the dis- patients with acquired immunodeficiency syndrome (AIDS) and ease, potential changes in family dynamics, and, possibly, end-of- as a complication of Lyme disease (Chart 64-1). S. pneumoniae is life issues. the most frequent causative agent of bacterial meningitis associated with AIDS (Rosenstein, Perkins, Stephens et al., 2001). Once the causative organism enters the bloodstream, it crosses Infectious Neurologic Disorders the blood–brain barrier and causes an inflammatory reaction in the meninges. Independent of the causative agent, inflammation The infectious disorders of the nervous system include meningi- of the subarachnoid space and pia mater occurs. Since there is tis, brain abscesses, various types of encephalitis, and Creutzfeldt- little room for expansion within the cranial vault, the inflamma- Jakob and new-variant Creutzfeldt-Jakob disease. The clinical tion may cause increased intracranial pressure. Cerebrospinal manifestations, assessment, and diagnostic findings as well as the fluid (CSF) flows in the subarachnoid space, where inflammatory medical and nursing management are related to the specific in- cellular material from the affected meningeal tissue enters and ac- fectious process. cumulates in the subarachnoid space, thereby increasing the CSF cell count (Coyle, 1999). MENINGITIS The prognosis for bacterial meningitis depends on the causative Meningitis is an inflammation of the meninges, the protective organism, the severity of the infection and illness, and the time- membranes that surround the brain and spinal cord. Meningitis liness of treatment. In acute fulminant presentations there may is classified as aseptic or septic. In aseptic meningitis, bacteria are be adrenal damage, circulatory collapse, and widespread hemor- not the cause of the inflammation; the cause is viral or secondary rhages (Waterhouse-Friderichsen syndrome). This syndrome is to lymphoma, leukemia, or brain abscess. Septic meningitis refers the result of endothelial damage and vascular necrosis caused by to meningitis caused by bacteria, most commonly Neisseria the bacteria. Complications include visual impairment, deafness, meningitidis, although Haemophilus influenzae and Streptococcus seizures, paralysis, hydrocephalus, and septic shock. pneumoniae are also causative agents. Outbreaks of N. meningitidis infection are most likely to occur Clinical Manifestations in dense community groups, such as college campuses and military installations. Though infections occur year round, the peak inci- Headache and fever are frequently the initial symptoms. Fever dence is in the winter and early spring. Factors that increase the tends to remain high throughout the course of the illness. The risk for developing bacterial meningitis include tobacco use and headache is usually severe as a result of meningeal irritation. viral upper respiratory infection because they increase the amount Meningeal irritation results in a number of other well-recognized of droplet production. Otitis media and mastoiditis increase the signs common to all types of meningitis: risk of bacterial meningitis because the bacteria can cross the • Nuchal rigidity (stiff neck) is an early sign. Any attempts at epithelium membrane and enter the subarachnoid space. Persons flexion of the head are difficult because of spasms in the with immune system deficiencies are also at greater risk for de- muscles of the neck. Forceful flexion causes severe pain. veloping bacterial meningitis. Between 1992 and 1996 there was • Positive Kernig’s sign: When the patient is lying with the a 28% increase in the number of new cases reported in the 12-to- thigh flexed on the abdomen, the leg cannot be completely 29-year-old age group (Rosenstein, Perkins, Stephens et al., extended (Fig. 64-1).

Glossary ataxia: impaired coordination of movements dysphagia: difficulty swallowing, causing prion: a particle smaller than a virus that bulbar paralysis: immobility of muscles the patient to be at risk for aspiration is resistant to standard sterilization innervated by cranial nerves with their dysphonia: voice impairment or altered procedures cell bodies in the lower portion of the voice production spasticity: muscular hypertonicity with in- brain stem myoclonus: spasms of a single muscle or creased resistance to stretch often associ- diplopia: double vision, or the awareness of group of muscles ated with weakness, increased deep two images of the same object occurring neuropathy: general term indicating a dis- tendon reflexes, and diminished super- in one or both eyes order of the nervous system ficial reflexes dyskinesia: impaired ability to execute paresthesia: a sensation of numbness or spongiform: having the appearance or qual- voluntary movements tingling or a “pins and needles” sensation ity of a sponge 1944 Unit 14 NEUROLOGIC FUNCTION

Chart Meningitis in Specific Populations • Positive Brudzinski’s sign: When the patient’s neck is flexed, 64-1 flexion of the knees and hips is produced; when passive flexion of the lower extremity of one side is made, a similar Meningitis can occur as a complication of other diseases and is an movement is seen in the opposite extremity (see Fig. 64-1). opportunistic infection seen with greater frequency in patients with acquired immunodeficiency syndrome (AIDS) • Photophobia: extreme sensitivity to light; this finding is common, although the cause is unclear. Meningitis in AIDS Patients • Aseptic, cryptococcal, and tuberculous forms of meningitis A rash can be a striking feature of N. meningitidis infection, have been reported in patients with AIDS. occurring in about half of patients with this type of meningitis. • Acute and chronic forms of aseptic meningitis may occur with Skin lesions develop, ranging from a petechial rash with purpuric AIDS; both are accompanied by headache, but signs of lesions to large areas of ecchymosis. meningeal irritation generally occur with the acute form. Disorientation and memory impairment are common early in • Aseptic meningitis may be accompanied by cranial nerve the course of the illness. The changes depend on the severity of palsies. The meningitis is thought to be related to direct the infection as well as the individual response to the physiologic infection of the central nervous system by human immuno- processes. Behavioral manifestations are also common. As the deficiency virus (HIV) because it can be isolated from the illness progresses, lethargy, unresponsiveness, and coma may cerebrospinal fluid (CSF). develop. • Cryptococcal meningitis is the most common fungal infection of the central nervous system in patients with AIDS and has a Seizures and increased intracranial pressure (ICP) are also as- 50% to 60% relapse rate. Patients may experience headache, sociated with meningitis. Seizures occur secondary to focal areas nausea, vomiting, seizures, confusion, and lethargy. Treatment of cortical irritability. Intracranial pressure increases secondary consists of IV administration of amphotericin B followed by to accumulation of purulent exudate. The initial signs of in- fluconazole. Maintenance therapy with fluconazole may be creased ICP include decreased level of consciousness and focal necessary to prevent relapse. motor deficits. If ICP is not controlled, the uncus of the temporal • Some immunosuppressed patients develop few if any symptoms lobe may herniate through the tentorium into the brain stem. because of blunted inflammatory responses; others develop Brain stem herniation is a life-threatening event causing cranial atypical features. nerve dysfunction and depressing the centers of vital functions, Meningitis in Lyme Disease such as the medulla (Rowland, 2000). (See Chap. 61 for discus- • Lyme disease is a multisystem inflammatory process caused by sion of the patient with a change in level of consciousness or in- the tick-transmitted spirochete Borrelia burgdorferi. creased ICP.) • Neurologic abnormalities are seen in later stages (stages 2 or 3). A fulminating infection occurs in about 10% of patients with Stage 2 occurs either with the characteristic rash or from 1 to meningococcal meningitis, with signs of overwhelming sep- 6 months after it has disappeared. ticemia: an abrupt onset of high fever, extensive purpuric lesions • Neurologic abnormalities include aseptic meningitis, chronic (over the face and extremities), shock, and signs of disseminated lymphocytic meningitis, and encephalitis. intravascular coagulopathy (DIC). Death may occur within a few • Cranial nerve inflammation, including Bell’s palsy and other hours of onset of the infection. peripheral neuropathies, is common. • Stage 3 (the chronic form of the disease) begins years after the initial tick infection and is characterized by arthritis, skin Assessment and Diagnostic Findings lesions, and neurologic abnormalities. • Most patients with stage 2 and 3 Lyme disease are treated with When the clinical presentation points to meningitis, diagnostic intravenous antibiotics, usually ceftriaxone or penicillin G. testing to identify the causative organism is conducted. Bacterial • Meningeal and systemic symptoms begin to improve within culture and Gram staining of CSF and blood are key diagnostic days, although other symptoms, such as headache, may persist tests (Fischbach, 2002). The presence of polysaccharide antigen for weeks. in CSF further supports the diagnosis of bacterial meningitis (Rosenstein et al., 2001).

Pain Pain

Kernig's Sign Brudzinski's Sign

FIGURE 64-1 Testing for meningeal irritation. (A) Kernig’s sign. (B) Brudzinski’s sign. Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1945

Prevention to prevent fluid overload. Fever also will increase the workload of the heart and cerebral metabolism. ICP will increase in response In 1971, the military began vaccinating all new recruits against to increased cerebral metabolic demands. Therefore, measures are meningococcal meningitis, resulting in a dramatic decrease in the taken to reduce body temperature as quickly as possible. incidence. Researchers suggested vaccination of college freshman Other important components of nursing care include: as surveillance studies indicated that freshmen living in dormito- ries were at highest risk for developing meningococcal meningitis. • Monitoring body weight, serum electrolytes, and urine vol- At this time vaccination is not required for college freshmen; ume, specific gravity, and osmolality, especially if the syn- however, the American Academy of Pediatrics provides informa- drome of inappropriate antidiuretic hormone (SIADH) tion to college freshmen and their parents about the risk of dis- secretion is suspected ease and the availability of vaccination (Bruce et al., 2001; Centers • Protecting the patient from injury secondary to seizure ac- for Disease Control and Prevention [CDC], 2000). tivity or altered level of consciousness People in close contact with patients with meningococcal • Preventing complications associated with immobility, such meningitis should be treated with antimicrobial chemopro- as pressure ulcers and pneumonia phylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride • Instituting droplet precautions until 24 hours after the ini- (Cipro), or ceftriaxone sodium (Rocephin) (CDC, 2000). Ther- tiation of antibiotic therapy (oral and nasal discharge is con- apy should be started as soon as possible after contact; a delay in sidered infectious) the initiation of therapy will limit the effectiveness of the pro- Any sudden, critical illness can be devastating to the family. phylaxis (Rosenstein et al., 2001). Vaccination should also be Because the patient’s condition is often critical and the progno- considered as an adjunct to antibiotic chemoprophylaxis for any- sis guarded, the family needs to be informed about the patient’s one living with a person who develops meningococcal infection. condition and permitted to see the patient at intervals, even Vaccination for children and at-risk adults should be encouraged though the priority is to address the patient’s need for immediate to avoid meningitis caused by H. influenzae and S. pneumoniae. and intensive treatment. An important aspect of the nurse’s role is to support the patient and to assist the family in identifying Medical Management others who can be supportive to them during the crisis. Successful outcomes depend on the early administration of an antibiotic that crosses the blood–brain barrier into the subarachnoid BRAIN ABSCESS space in sufficient concentration to halt the multiplication of bac- Although brain abscess is relatively rare, it is a complication en- teria. Penicillin antibiotics (eg, ampicillin, piperacillin) or one of countered increasingly in patients whose immune systems have the cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) been suppressed either through therapy or disease. may be used. Vancomycin hydrochloride alone or in combination with rifampin may be used if resistant strains of bacteria are identified. High doses of the appropriate antibiotic are adminis- Pathophysiology tered intravenously. A brain abscess is a collection of infectious material within the Dexamethasone has been shown to be beneficial as adjunct tissue of the brain. It may occur by direct invasion of the brain therapy in the treatment of acute bacterial meningitis and in from intracranial trauma or surgery; by spread of infection from pneumococcal meningitis if given 15 to 20 minutes before the nearby sites, such as the sinuses, ears, and teeth (paranasal sinus first dose of antibiotic and every 6 hours for the next 4 days. infections, otitis media, dental sepsis); or by spread of infection Studies indicate that dexamethasone improves the outcome in from other organs (lung abscess, infective endocarditis) (Hickey, adults and does not increase the risk of gastrointestinal bleeding 2003). To prevent brain abscess, otitis media, mastoiditis, sinusi- (de Gans & van de Beek, 2002). tis, dental infections, and systemic infections should be treated Dehydration and shock are treated with fluid volume ex- promptly. panders. Seizures, which may occur in the early course of the disease, are controlled with phenytoin (Dilantin). Increased ICP is treated as necessary (see Chap. 61). Clinical Manifestations The clinical manifestations of a brain abscess result from alter- Nursing Management ations in intracranial dynamics (edema, brain shift), infection, or the location of the abscess (Chart 64-2). Headache, usually worse The patient may be critically ill; therefore, so many of the nurs- in the morning, is the most prevailing symptom. Vomiting is also ing interventions are collaborative with those of the physician, common. Focal neurologic signs (weakness of an extremity, de- respiratory therapist, and other members of the health care team. creasing vision, seizures) may occur, depending on the site of the The patient’s prognosis may depend on the supportive care abscess. There may be a change in mental status, as reflected in provided. lethargic, confused, irritable, or disoriented behavior. Fever may Neurologic status and vital signs are continually assessed. or may not be present. Pulse oximetry and arterial blood gas values are used to quickly identify the need for respiratory support as the increasing ICP Assessment and Diagnostic Findings compromises the brain stem. Insertion of a cuffed endotracheal tube (or tracheotomy) and mechanical ventilation may be neces- Repeated neurologic examinations and continuing assessment of sary to maintain adequate tissue oxygenation. the patient are necessary to determine the location of the abscess. Arterial blood pressures are monitored to assess for incipient A computed tomography (CT) scan is invaluable in locating the shock, which precedes cardiac or respiratory failure. Rapid intra- site of the abscess, after the evolution and resolution of suppura- venous (IV) fluid replacement may be prescribed, but care is taken tive lesions, and in determining the optimal time for surgical inter- 1946 Unit 14 NEUROLOGIC FUNCTION

Chart The patient with a brain abscess is extremely ill, and neuro- 64-2 Symptoms of Brain Abscesses logic deficits may remain after treatment, such as hemiparesis, seizures, visual deficits, and cranial nerve palsies. Focal seizures Frontal Lobe are the most common sequelae, occurring in about 30% of pa- Hemiparesis tients (Hickey, 2003). The nurse must assess the family’s ability Aphasia (expressive) Seizures to express their distress at the patient’s condition, cope with the Frontal headache patient’s illness and deficits, and obtain support. Temporal Lobe Localized headache HERPES SIMPLEX VIRUS ENCEPHALITIS Changes in vision Facial weakness Encephalitis is an acute inflammatory process of the brain tissue. Aphasia Herpes simplex virus (HSV) is the most common cause of acute encephalitis in the United States (Levitz, 1998). There are two Cerebellar Abscess herpes simplex viruses, HSV-1 and HSV-2. HSV-1 typically Occipital headache affects children and adults. Ataxia (inability to coordinate movements) Nystagmus (rhythmic, involuntary movements of the eye) Pathophysiology Adapted from Hickey, J. V. (2003). The clinical practice of neurological and neurosurgical nursing (5th ed.). Philadelphia: Lippincott Williams There are two possible modes of HSV-1 infection. In most cases, & Wilkins. primary HSV-1 infection of the buccal mucosa occurs, followed by retrograde spread along the trigeminal nerve to the brain. It is also believed that latent virus in brain tissue may reactivate and result in encephalitis (Roos, 1999). HSV-2 most commonly affects vention. A magnetic resonance imaging (MRI) scan is useful to neonates and is discussed in pediatric textbooks (Gutierrez & obtain images of the brain stem and posterior fossa if an abscess Prober, 1998). is suspected in these areas. Clinical Manifestations Medical Management HSV-1 encephalitis causes inflammation and necrosis in the tem- Brain abscess is treated with antimicrobial therapy and surgical poral lobe, frontal lobe, and limbic system. The initial symptoms incision or aspiration. If the abscess is encapsulated, CT-guided include fever, headache, confusion, and behavioral abnormalities stereotactic needle aspiration under local anesthesia may be per- (Roos, 1999). Focal neurologic symptoms reflect the areas of cere- formed. Antimicrobial treatment is prescribed to eliminate the bral inflammation and necrosis and include behavioral change, causative organism or reduce its virulence. focal seizures, dysphasia, hemiparesis, and altered level of con- Penicillin G (20 million U) and chloramphenicol (Chloro- sciousness. Focal symptoms are present within 7 days of infection mycetin) (4 to 6 g/day given intravenously in divided doses) are and progress for 14 to 21 days. usually prescribed because anaerobic streptococci and Bacterioides are the most common causative organisms (Hickey, 2003). Large Assessment and Diagnostic Findings IV doses are usually prescribed preoperatively to penetrate the Neuroimaging studies, electroencephalography (EEG), and CSF blood–brain barrier and reach the abscess. The therapy is con- examination are used to diagnose HSV encephalitis. MRI is the tinued postoperatively. Corticosteroids may be prescribed to help neuroimaging study of choice in the diagnosis of HSV encephali- reduce the inflammatory cerebral edema if the patient shows tis as it can help identify lesions in the temporal lobe. evidence of an increasing neurologic deficit. Antiseizure medica- The EEG demonstrates a specific wave pattern in 66% of cases tions (phenytoin, phenobarbital) may be prescribed to prevent of biopsy-proven HSV encephalitis. CSF reveals a high opening seizures. Multiple abscesses may be treated with appropriate anti- pressure and low glucose and high protein levels. Viral cultures microbial therapy alone, with close monitoring by CT scans. are almost always negative. Since 1996, the polymerase chain reaction (PCR) technique has been used to diagnose HSV en- Nursing Management cephalitis (Roos, 1999). PCR will identify the DNA bands of the HSV specifically. The validity of PCR is very high between the Nursing care focuses on ongoing assessment of the neurologic sta- third and tenth day of symptom onset. tus, administering medications, assessing the response to treatment, and providing supportive care. Ongoing neurologic assessment alerts the nurse to changes in Medical Management ICP, which may indicate a need for more aggressive intervention. Acyclovir (Zovirax), an antiviral agent, is the medication of The nurse also assesses and documents the responses to medica- choice in HSV treatment (Karch, 2002). The mode of action is tions. Blood laboratory test results, specifically blood glucose and the inhibition of viral DNA replication. It is usually well toler- serum potassium levels, need to be closely monitored when cor- ated by the patient. To prevent relapse, treatment should con- ticosteroids are prescribed. Medical intervention may be required tinue for up to 3 weeks. Slow administration over 1 hour will to return these values to normal or acceptable levels. prevent crystallization of the medication in the urine. The usual Patient safety is also a key nursing responsibility. Injury may dose of acyclovir is decreased if the patient has a history of renal result from decreased level of consciousness and falls related to insufficiency (Karch, 2002). In the rare case of acyclovir resis- motor weakness or seizures. tance, foscarnet sodium (Foscavir) is prescribed (Roos, 1999). Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1947

Nursing Management Medical Management Assessment of neurologic function is key to monitoring the pro- There is no specific medication for arboviral encephalitis. Medical gression of disease. Comfort measures to reduce headache include management is aimed at controlling seizures and increased ICP dimming the lights, limiting noise, and administering analgesic (Roos, 1999) agents. Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. Focal seizures and Nursing Management altered level of consciousness require care directed at injury prevention and safety. Nursing care addressing patient and family If the patient is very ill, hospitalization may be required. The anxiety is ongoing throughout the illness. Monitoring of blood nurse carefully assesses neurologic status and identifies improve- chemistry test results and urinary output will alert the nurse to ment or deterioration in the patient’s condition. Injury preven- the presence of renal complications related to acyclovir therapy. tion is key in light of the potential for falls or seizures. Arboviral encephalitis may result in death or life-long residual health issues. The family will need support and teaching to cope with these ARTHROPOD-BORNE outcomes. VIRUS ENCEPHALITIS Public education addressing the prevention of arboviral en- Arthropod vectors transmit several types of viruses that cause cephalitis is a key nursing role. Clothing that provides coverage encephalitis. The primary vector in North America is the mos- and insect repellents should be used in high-risk areas. Community quito. Arbovirus infection occurs in specific geographic areas mosquito control is advocated. during the summer and fall. The four types of arboviral encephalitis that occur in North America are LaCrosse encephalitis, FUNGAL ENCEPHALITIS St. Louis encephalitis, Western equine encephalitis, and Eastern equine encephalitis (Roos, 1999). Fungal infections of the CNS occur rarely in healthy people. The presentation of fungal encephalitis is related to geographic area and a compromised immune system (Leedom & Underman, 2000). Pathophysiology The common fungi found around the world that can infect the Viral replication occurs at the site of the mosquito bite. If ade- CNS include Cryptococcus neoformans, Histoplasma capsulatum, quate virus is inoculated, a viremia ensues. The virus gains access Aspergillus, and Candida albicans (Davis, 1999). Other fungi are to the central nervous system (CNS) via the cerebral capillaries. found only in certain regions: Coccidioides immitis, for example, It spreads from neuron to neuron, predominantly affecting the is found in soil in central California, the southwest United States, cortical gray matter, the brain stem, and the thalamus. Meningeal northern Mexico, and areas of Argentina (Davis, 1999). exudates compound the clinical presentation by irritating the meninges and increasing ICP (Roos, 1999). Pathophysiology Clinical Manifestations The fungal spores enter the body via inhalation. They initially infect the lungs, causing vague respiratory symptoms. In some All arboviral encephalitis begins with a flu-like prodrome, but cases, the fungi may enter the bloodstream, causing a fungemia. specific neurologic manifestations depend on the viral type. If the fungemia overcomes the person’s immune system, the LaCrosse encephalitis, for example, may present with focal neuro- fungus may spread to the CNS. The initial presentation is menin- logic symptoms and seizures. Mortality is low but residual seizures gitis followed by encephalitis and brain abscesses. In addition to may occur. A unique clinical feature of St. Louis encephalitis is infecting the brain, the fungi may infect the spinal cord, produc- SIADH with hyponatremia. The mortality rate is 10% to 20%. ing an abscess. The abscess will produce symptoms of spinal cord The clinical manifestations of Eastern equine encephalitis are compression (Davis, 1999). acute and carry a high mortality rate of 50% to 75% (Roos, 1999). Although the clinical manifestations of Western equine Clinical Manifestations encephalitis are nonspecific, the morbidity rate is high. The common symptoms of fungal encephalitis include fever, Assessment and Diagnostic Findings malaise, headache, nuchal rigidity, lethargy, and mental status changes (Davis, 1999). C. neoformans is the most common Neuroimaging is not useful in diagnosing many types of en- fungus to infect the CNS. Symptoms of increased ICP related to cephalitis. In Eastern equine encephalitis, however, CT scan and hydrocephalus often occur (Go et al., 2000). Vascular changes are MRI may reveal lesions in the basal ganglia and thalamus (Roos, associated with C. immitis and Aspergillus (Leedom & Underman, 1999). The CSF analysis shows a normal glucose level, elevated 2000). Manifestations of vascular change may include arteritis or protein level, and polymorphonuclear leukocytic pleocytosis. cerebral infarction. St. Louis, Eastern equine, and Western equine encephalitis viruses are rarely isolated in the CSF (Roos, 1999). Assessment and Diagnostic Findings The age of the patient is important information in making a specific viral diagnosis. La Crosse virus encephalitis is the most CNS fungal infections present a diagnostic challenge because common pediatric arboviral encephalitis. St. Louis encephalitis their presentations mimic other causes of encephalitis. The symp- affects adults over 50 years of age; Eastern equine encephalitis toms develop over a 2-week period. Fungal infection may also be is not age-specific (Roos, 1999). Western equine encephalitis can present in organs such as the lungs or kidney (Davis, 1999). The present as pediatric encephalitis but is less prevalent. presence of a compromised immune system and a history of living 1948 Unit 14 NEUROLOGIC FUNCTION in or recently having traveled to a geographic area where specific amphotericin B is dose-limiting. Monitoring the serum creati- fungi are found in the soil may suggest fungal encephalitis (Davis, nine and blood urea nitrogen levels may alert the nurse to the de- 1999; Leedom & Underman, 2000). Laboratory evaluation of velopment of renal insufficiency and the need to address the blood shows an elevated white cell count and anemia. In some patient’s renal status. cases, serologic tests may show fungal antibodies in serum (Davis, Providing support will assist the patient and family to cope 1999). The CSF shows an elevated white cell count and protein with the illness. Work-up of the patient for immunodeficiency levels. C. neoformans is readily identified in the CSF fungal cul- diseases such as AIDS may put additional stress on the family. ture. The CSF culture is positive for other fungi in 50% of cases The nurse may need to mobilize community support systems for (Davis, 1999). the patient and family. Neuroimaging is used to identify CNS changes related to fungal infection and will demonstrate fungal foci in organs initially CREUTZFELDT-JAKOB AND NEW-VARIANT invaded by the fungus. Although both MRI and CT scan are used in the workup for fungal encephalitis, MRI is more sensitive. The CREUTZFELDT-JAKOB DISEASE MRI may indicate lesions in the basal ganglia or thalamus, as well Creutzfeldt-Jakob disease (CJD) and new-variant Creutzfeldt-Jakob as hemorrhage, vascular complications, ischemia, aneurysm for- (nvCJD) disease belong to a group of degenerative, infectious mation, or hydrocephalus (Go et al., 2000). neurologic disorders called transmissible spongiform encephalopathies (TSE). Although CJD and nvCJD have distinct clini- Medical Management cal and histologic differences, they have many features in common. Both are rare and have incubation periods ranging from months Medical management is directed at the causative fungus and the to decades. In both, the symptoms are progressive, there is no neurologic consequences of the infection. Seizures are controlled definitive treatment, and the outcome is fatal. by standard antiseizure medications. Increased ICP is controlled CJD occurs primarily in adults ages 50 to 70. The incidence by repeated lumbar punctures or shunting of CSF. In contrast to of disease is 1 per million worldwide (Weihl & Roos, 1999). patients with cryptococcal meningitis, the use of repeated (once nvCJD occurs in younger patients and has a prolonged duration or twice daily) lumbar punctures in patients with fungal infec- of illness compared to CJD. The risk of nvCJD in the United tions has been an effective strategy to control increased ICP and States is thought to be low as cattle are fed primarily with soy- has been associated with improved survival with fewer neurologic derived feed (see Pathophysiology, below). Only a few rare cases sequelae (Davis, 1999). of TSE have occurred in the United States to date (Weihl & Antifungal agents are given for a specific period of time to Roos, 1999). cure the infection in patients with competent immune systems. Patients with compromised immune systems will receive anti- Pathophysiology fungal therapy until the infection is controlled, after which they will receive a maintenance dose of the medication for an indefi- Although still debated, the causative agent appears to be a prion, nite period of time. a proteinaceous, infectious particle smaller than a virus (Davis & Although the dose and duration of treatment depend on the Kennedy, 2000). The prion converts a normal cellular protein to causative fungi, amphotericin B (Abelcet, AmBisome, Amphocin, an abnormal form, thus destroying neurons and glial cells. The Amphotec, Fungizone, and Fungizone IV) is the standard anti- gray matter takes on a spongy appearance (spongiform changes). fungal agent used in treatment (Karch, 2002). Dosing must be Lesions, or plaques, also appear in various locations in the CNS high enough to penetrate the blood–brain barrier without causing (Weihl & Roos, 1999). renal toxicity. In CJD, the method of transmission is frequently unknown; Fluconazole (Diflucan) or flucytosine (5-FC, 5-fluorocytosine, however, direct transmission (by contact with infected animals) Ancobon) may be administered in conjunction with ampho- of the prion to humans may initiate the degenerative neurologic tericin B. Both can be given orally and may be used as mainte- process. The disease is also heritable, and familial groups account nance therapy. Potential side effects of fluconazole include for approximately 15% of cases, clustering in certain parts of the nausea, abdominal pain, headache, dizziness, rash, reversible world. Iatrogenic transmission accounts for approximately 5% of alopecia, and a transient increase in liver enzymes. When flucy- cases and is due to contaminated neurosurgical devices and blood tosine is prescribed in conjunction with amphotericin B, bone transfusions and the use of cadaver-derived growth hormone marrow suppression may occur. Therefore, patients receiving (growth hormone is now created synthetically) (World Health these medications in combination should have leukocyte and Organization, 2001). platelet counts monitored twice a week (Davis, 1999). Based primarily on an outbreak of cases in England in the late 1980s and through the 1990s, it was discovered that in nvCJD, Nursing Management the primary mode of transmission appeared to be the ingestion of CNS tissue of infected cattle. However, in 1998, additional con- If hydrocephalus develops and inflammation progresses, ICP will cerns were raised about the safety of the English blood supply. rise. Nursing assessment aimed at early identification of increased The prion exists in lymphoid tissue and blood in all of the TSEs, ICP is necessary to ensure early control and management. (See but the incidence is higher in nvCJD. In light of the rising in- Chap. 61 for management of the patient with increased ICP.) cidence of nvCJD, concern arose about the risk of infection Patient comfort may be optimized by administering nonopioid through transfusion of blood products. There is no method avail- analgesics, limiting environmental stimuli, and positioning. able to screen blood for infectivity. All blood must be leukocyte- Administration of amphotericin B may cause fever, chills, and depleted prior to transfusion. In 1998, the use of plasma derived body aches. Giving diphenhydramine (Benadryl) and acetamin- from citizens of the United Kingdom for use in manufacturing ophen (Tylenol) approximately 30 minutes before giving am- blood-derived products was banned in the U.S. (Weihl & Roos, photericin B may prevent these side effects. Renal toxicity due to 1999). Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1949

Clinical Manifestations line the stringent sterilization methods that must be used to destroy the prion on surfaces. Many patients with CJD have vague prodromal symptoms prior to specific neurologic changes. Symptoms usually include behavioral changes, dementia, mutism, visual changes, cerebellar, Autoimmune Processes pyramidal, and extrapyramidal signs, and myoclonic jerks. The myoclonic jerks may be spontaneous or precipitated by auditory Autoimmune nervous system disorders include multiple sclero- or tactile stimuli. The myoclonus (spasms) may involve a single sis, myasthenia gravis, and Guillain-Barré syndrome. muscle group, a limb, or the entire body. The symptoms progress until the patient is completely unaware of the environment and MULTIPLE SCLEROSIS immobilized. Although the same type of agent, a prion, causes nvCJD, there Multiple sclerosis (MS) is an immune-mediated progressive de- are distinct differences in the clinical manifestations of nvCJD myelinating disease of the CNS. Demyelination refers to the de- and CJD. In nvCJD, there are more prion-reactive plaques, re- struction of myelin, the fatty and protein material that surrounds ferred to as florid plaques, surrounding spongiform tissue through- certain nerve fibers in the brain and spinal cord; it results in im- out the cerebrum and cerebellum. The characteristic EEG changes paired transmission of nerve impulses (Fig. 64-2). MS typically present in CJD are absent in nvCJD. Anxiety, depression, and be- presents in young adults ages 20 to 40, and it affects women more havioral changes are the initial symptoms of nvCJD. Cerebellar frequently than men (Boyden, 2000). symptoms occur, with gait changes and ataxia. Myoclonus is The cause of MS is an area of ongoing research. Autoimmune activity results in demyelination, but the sensitized antigen has present in most patients diagnosed with nvCJD. Memory and not been identified. Multiple factors play a role in the initiation cognitive impairments occur late in the course of nvCJD. of the immune process. Geographic prevalence is highest in Mutism occurs in both nvCJD and CJD (Almond, 1998). northern Europe, southern Australia, the northern United States, and southern Canada (Noseworthy, Lucchinetti, Rodriguez et al., Assessment and Diagnostic Findings 2000). It is believed that an environmental exposure at a young age may play a role in the development of MS later in life. Historically, sharp waves and spikes on the EEG were the only Genetic predisposition is indicated by the presence of a spe- features available to support the diagnosis of CJD. Recent detec- cific cluster (haplotype) of human leukocyte antigens (HLA) on tion of a polyclonal antibody (protein 14-3-3) in CSF has enabled the cell wall. The presence of this haplotype may promote sus- the diagnosis of CJD (Poser, Mollenhauder, Krab et al., 1999). ceptibility to factors, such as viruses, that trigger the autoimmune In addition to the presence of a polyclonal antibody in CSF, a response activated in MS. A specific virus capable of initiating the protein increase is demonstrated along with the presence of enzymes indicative of neuronal loss. CT scan is used to rule out disorders that may mimic the symptoms of CJD. MRI scans are useful, identifying lesions in the basal ganglia in most cases of CJD. Definitive diagnosis is made by brain biopsy or at autopsy. Neuron

Medical Management Myelin sheath After the onset of specific neurologic symptoms, progression of disease occurs quickly. There is no effective treatment for CJD or nvCJD. The care of the patient is supportive and palliative. Goals of care include prevention of injury related to immobility and de- Axon of A mentia, promotion of patient comfort, and provision of support nerve fiber and education for the family. The duration of disease is 4 to 5 months in CJD and 16 months in nvCJD, with death occurring as a result of respiratory failure or sepsis (Weihl & Roos, 1999). Nerve fiber Myelin Nursing Management B Nerve fiber As with medical management, the nursing care of patients is primarily supportive and palliative. Psychological and emotional support of patients and families throughout the course of the illness is needed This care extends to providing for a dignified death C and supporting the family through the processes of grief and loss. Hospice care should be used either at home or at an inpatient facility. (See Chap. 17 for an in-depth discussion of end-of-life issues.) Prevention of disease transmission is an important part of D nursing care. Although patient isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of FIGURE 64-2 The process of demyelination. A and B depict a normal equipment. Conventional methods of sterilization do not destroy nerve cell and axon with myelin. C and D show the slow disintegration of the prion. The CDC guidelines (based on WHO guidelines) out- myelin, resulting in a disruption in axon function. 1950 Unit 14 NEUROLOGIC FUNCTION autoimmune response has not been identified. It is believed that health care and treatment. Eighty percent to 85% of cases of MS DNA on the virus mimics the amino acid sequence of myelin, begin with a relapsing–remitting course, with complete recovery resulting in an immune system cross-reaction in the presence of between clearly defined symptomatic exacerbations (Noseworthy a defective immune system (Boyden, 2000). et al., 2000). This form of the disease does not progress between relapses, although the majority of cases with this initial type of Pathophysiology course change to a secondary-progressive course after some years (Halper, 2001). Secondary-progressive MS begins as relapsing– Sensitized T cells typically cross the blood–brain barrier; their remitting disease but changes to a course in which there is not full function is to check the CNS for antigens and then leave. In MS, recovery but rather continued progression between defined re- the sensitized T cells remain in the CNS and promote the infil- lapses. Ten percent to 20% percent of patients have a primary tration of other agents that damage the immune system. The im- progressive course (Noseworthy et al., 2000; Halper, 2001), in mune system attack leads to inflammation that destroys myelin which symptoms progress throughout the disease, with increasing (which normally insulates the axon and speeds the conduction of disability. Primary progressive MS is characterized by continuous impulses along the axon) and oligodendroglial cells that produce decline, with the potential development of quadriparesis, cogni- myelin in the CNS. tive dysfunction, visual loss, and brain stem syndromes. Plaques of sclerotic tissue appear on demyelinated axons, fur- The signs and symptoms of MS are varied and multiple, re- ther interrupting the transmission of impulses. Demyelination flecting the location of the lesion (plaque) or combination of interrupts the flow of nerve impulses and results in a variety of lesions. The primary symptoms most commonly reported are manifestations, depending on which nerves are affected. De- fatigue, depression, weakness, numbness, difficulty in coordina- myelinated axons are scattered irregularly throughout the CNS tion, loss of balance, and pain. Visual disturbances due to lesions (Fig. 64-3). The areas most frequently affected are the optic nerves, in the optic nerves or their connections may include blurring of chiasm, and tracts; the cerebrum; the brain stem and cerebellum; vision, diplopia, patchy blindness (scotoma), and total blindness. and the spinal cord. Eventually the axons themselves begin to de- Fatigue impairs optimal function throughout the course of generate, resulting in permanent and irreversible damage (Bashir the disease. Fatigue is exacerbated when febrile illness, environ- & Whitaker, 2002; Halper, 2001). mental temperature, hot showers, and normal circadian rhythms during the afternoon elevate body temperature. Depression may Clinical Manifestations relate to the pathophysiology or may occur as a reaction to the diagnosis. Suicide as the cause of death occurs 7.5 times more fre- The course of MS may assume many different patterns (Fig. 64-4). quently among persons diagnosed with MS than among the age- In some patients, the disease follows a benign course, with a matched general population. If suicide occurs, it is likely to occur normal life span and symptoms so mild that patients do not seek within the first 5 years of diagnosis (Walther & Hohlfeld, 1999).

A B

FIGURE 64-3 Multiple sclerosis. (A) A CT scan of brain demonstrates an area of demyelination in the periventric- ular white matter of the right frontal lobe. The plaque is perpendicular to the lateral ventricle, a typical finding in MS. (B) An MRI of the spinal cord in the same patient highlights another typical finding: a flame-shaped area of demyelination within the midcervical region of the spinal cord. Courtesy of the Danbury Hospital Department of Radiology. Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1951

1. Relapsing-remitting 2. Primary progressive

FIGURE 64-4 Types and courses of MS. 1. Relapsing Increasing disability remitting (RR) MS is characterized by clearly acute attacks Increasing disability with full recovery or with sequelae and residual deﬁcit Time Time upon recovery. Periods between disease relapses are characterized by lack of disease progression. 2. Primary progressive (PP) MS is characterized by disease showing progression 3. Secondary progressive 4. Progressive-relapsing of disability from onset, without plateaus or remissions or with occasional plateaus and temporary minor improvements. 3. Secondary progressive (SP) MS begins with an initial RR course, followed by progression of variable rate, which may also include occasional relapses and minor remissions. 4. Progressive-relapsing (PR) MS shows progression from onset but with clear acute relapses with or without recovery. Lublin, F. D., Reingold, F. C., et al. (1996). Deﬁning the clinical course of multiple sclerosis: Results of Increasing disability Increasing disability an international survey. Neurology, 46(64), 907–911. Used Time Time with permission from Lippincott Williams & Wilkins.

Pain occurs in 66% of patients with MS. Pain may be due to de- indicating an immune system abnormality). Evoked potential myelination of pain fibers, mechanical stress on muscles, bones, studies can help define the extent of the disease process and mon- and joints due to disability, or treatment measures (Maloni, itor changes. Underlying bladder dysfunction is diagnosed by 2000). urodynamic studies. Neuropsychological testing may be indi- Spasticity (muscle hypertonicity) of the extremities and loss cated to assess cognitive impairment. A sexual history helps to of the abdominal reflexes are due to involvement of the main motor identify changes in sexual function. pathways (pyramidal tracts) of the spinal cord. Disruption of the sensory axons may produce sensory dysfunction (paresthesias, Gerontologic Considerations pain). Cognitive and psychosocial problems may reflect frontal or parietal lobe involvement; some degree of cognitive change (eg, Due to improved treatment and an increase in the average life memory loss, decreased concentration) occurs in about half of pa- span for patients with MS, more individuals are living to become tients, but severe cognitive changes with dementia (progressive elderly. These patients may have chronic health problems for organic mental disorder) are rare. Involvement of the cerebellum which they may be taking additional medications that could in- or basal ganglia can produce ataxia (impaired coordination of teract with medications prescribed for MS. The absorption, dis- movements) and tremor. Loss of the control connections between tribution, metabolism, and excretion of medications are altered the cortex and the basal ganglia may occur and cause emotional in the elderly as a result of age-related changes in renal and liver lability and euphoria. Bladder, bowel, and sexual dysfunctions are functions. Therefore, the elderly must be monitored closely for common. adverse and toxic effects of MS medications and for osteoporosis Secondary complications of MS include urinary tract infections, (particularly with frequent corticosteroid use, which may be re- constipation, pressure ulcers, contracture deformities, dependent quired for exacerbations). The cost of medications could lead to pedal edema, pneumonia, reactive depression, and decreased bone poor adherence to the prescribed regimen in elderly patients on mass. Emotional, social, marital, economic, and vocational prob- fixed incomes. lems may also be a consequence of the disease. Elderly MS patients have specific physical and psychosocial Exacerbations and remissions are characteristic of MS. During challenges. Physical challenges include impaired mobility, spas- exacerbations, new symptoms appear and existing ones worsen; dur- ticity, pain and bladder dysfunction, impaired sleep, and an in- ing remissions, symptoms decrease or disappear. Relapses may be creased need for assistance with self-care (Klewer et al., 2001). associated with periods of emotional and physical stress. MRI stud- Psychosocial issues include depression and suicidal thoughts ies demonstrate that many plaques do not produce serious symp- (Klewer et al., 2001). toms; however, the disease may be very active, as demonstrated by MRI. There also is evidence that remyelination actually occurs in Medical Management some patients. No cure exists for MS. An individualized, organized, and ratio- Assessment and Diagnostic Findings nal treatment program is indicated to relieve the patient’s symptoms and provide continuing support, particularly for individuals MRI is the primary diagnostic tool for visualizing plaques, docu- with cognitive changes (50%), who may need more structure and menting disease activity, and evaluating the effect of treatment. support. The goals of treatment are to delay the progression of Electrophoresis of CSF identifies the presence of oligoclonal the disease, manage chronic symptoms, and treat acute exacer- banding (several bands of immunoglobulin G bonded together, bations. Many patients with MS have stable disease and require 1952 Unit 14 NEUROLOGIC FUNCTION only intermittent treatment, whereas others experience steady quire nerve blocks or surgical intervention. Fatigue that interferes progression of their disease. Symptoms requiring intervention with activities of daily living may be treated with amantadine include spasticity, fatigue, bladder dysfunction, and ataxia. (Symmetrel), pemoline (Cylert), or fluoxetine (Prozac). Ataxia is Management strategies target the various motor and sensory a chronic problem most resistant to treatment. Medications used symptoms and effects of immobility that can occur. to treat ataxia include beta-adrenergic blockers (Inderal), antiseizure agents (Neurontin), and benzodiazepines (Klonopin). PHARMACOLOGIC THERAPY Various strategies for pain management can be implemented, Three medications, referred to as the “ABC (and R) drugs,” are based on the type of pain that exists. Acute pain may be treated currently the main pharmacologic therapy for MS. The inter- with antidepressants, opiates, or antiseizure medications. Surgi- ferons beta-1a (Avonex) and beta-1b (Betaseron) reduce the fre- cal procedures may be required to interrupt the pain pathway. quency of relapse by 30% and decrease the appearance of new Subacute pain as well as chronic back pain can be effectively lesions on MRI by 80% (Tselis & Lisak, 1999). Glatiramer ac- treated with NSAIDs. Physical therapy may also benefit the patient etate (Copaxone) also reduces the number of lesions on MRI by improving posture and strength. and the relapse rate. In March 2002, the FDA approved a fourth Pain may also be due to osteoporosis (Maloni, 2000). Peri- agent, Rebif, for the treatment of relapsing MS (PRISMS Study menopausal women with MS are more likely to develop osteo- Group, 2001). porosis than those without MS. Immobility, corticosteroid therapy, All of these medications have multiple immune activities. The and estrogen loss play a role in the development of osteoporosis interferons reduce T-cell proliferation; glatiramer acetate inhibits in women with MS. Bone mineral density testing is recommended antigen-specific T-cell activation (Noseworthy et al., 2000). All for this high-risk group (Smeltzer, Zimmerman, Capriotti & of the disease-modifying medications, the “ABC (and R) drugs,” Fernandes, 2002). Diagnosis and treatment of osteoporosis are require injections. Interferon beta-1b (Betaseron) is administered discussed at length in Chapter 68. subcutaneously every other day, interferon beta-la (Avonex) is Management of bladder and bowel control is often among the given by intramuscular injection once a week, and glatiramer ac- patient’s most difficult problems and a variety of medications etate (Copaxone) is administered by subcutaneous injection every (anticholinergics, alpha-adrenergic blockers, or antispasmodic day. Rebif is administered subcutaneously three times a week. agents) may be prescribed. Nonpharmacologic strategies also as- Seventy-five percent of patients taking one of the interferons ex- sist in establishing effective bowel and bladder elimination (see perience flu-like symptoms; these symptoms can be controlled Nursing Process section). with nonsteroidal anti-inflammatory drugs (NSAIDs) and usu- Urinary tract infection is often superimposed on the under- ally resolve after a few months of therapy (Walther & Hohlfeld, lying neurologic dysfunction. Ascorbic acid (vitamin C) may be 1999). Patients receiving these injectable medications and their prescribed to acidify the urine, making bacterial growth less families must be instructed in injection technique and must be- likely. Antibiotics are prescribed when appropriate. come knowledgeable about site reactions and other possible side effects (Ross, 2001). Mitoxantrone (Novantrone), which received FDA approval in NURSING PROCESS: 2000 (Rolak, 2001), is an antineoplastic agent used primarily to THE PATIENT WITH MULTIPLE SCLEROSIS treat leukemia and lymphoma. It received approval to treat secondary progressive MS due to its immunosuppressive qualities Assessment (Rolak, 2001). Patients need to have laboratory tests (complete Nursing assessment addresses actual and potential problems as- blood count) performed, and the results must be closely monitored sociated with the disease, including neurologic problems, sec- due to the potential for leukopenia and cardiac toxicity. A few pa- ondary complications, and the impact of the disease on the tients (2% to 3%) will develop signs and symptoms of cardio- patient and family. The patient’s movements and walking are ob- myopathy and heart failure due to cardiac toxicity (Rolak, 2001). served to determine if there is danger of falling. Assessment of Corticosteroids modulate the immune response and are used function is carried out both when the patient is well rested and to limit the severity and duration of exacerbations. These agents when fatigued. The patient is assessed for weakness, spasticity, vi- suppress the immune response and decrease inflammatory change. sual impairment, incontinence, and disorders of swallowing and Nerve conduction is restored with variable degrees of sympto- speech. Additional areas of assessment include the following: matic recovery. Typically the patient receives high-dose IV methyl- How has MS affected the patient’s lifestyle? How well is the pa- prednisolone followed by an oral prednisone taper. The nurse tient coping? What would the patient like to do better? must carefully monitor the patient for side effects related to corticosteroids such as mood changes and fluid and electrolyte alterations and teach the patient and family about side effects. Diagnosis Researchers continue to investigate other possible treatments NURSING DIAGNOSES for MS. Many agents that have been investigated have proven to Based on the assessment data, the patient’s major nursing diag- be too toxic for clinical use. Researchers are studying strategies noses may include the following: that facilitate the proliferation of anti-inflammatory cytokines. T-cell vaccination and agents that inhibit oxygen radicals and • Impaired physical mobility related to weakness, muscle proteases are under study (Noseworthy et al., 2000). paresis, spasticity Medications are also prescribed for management of specific • Risk for injury related to sensory and visual impairment symptoms. Baclofen (Lioresal), a GABA agonist, is the medica- • Impaired urinary and bowel elimination (urgency, frequency, tion of choice in treating spasms. It can be administered orally or incontinence, constipation) related to nervous system by intrathecal injection. Benzodiazepines (Valium), tizanidine dysfunction (Zanaflex), and dantrolene (Dantrium) may also be used to treat • Impaired speech and swallowing related to cranial nerve spasms. Patients with disabling spasms and contractures may re- involvement Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1953

• Disturbed thought processes (loss of memory, dementia, is advised to take frequent short rest periods, preferably lying down. euphoria) related to cerebral dysfunction Extreme fatigue may contribute to the exacerbation of symptoms. • Ineffective individual coping related to uncertainty of course of MS Minimizing Effects of Immobility • Impaired home maintenance management related to phys- Because of the decrease in physical activity that often occurs with ical, psychological, and social limits imposed by MS MS, complications associated with immobility, including pres- • Potential for sexual dysfunction related to spinal cord in- sure ulcers, expiratory muscle weakness, and accumulation of volvement or psychological reactions to condition bronchial secretions, need to be considered and steps taken to prevent them. Measures to prevent such complications include assessment and maintenance of skin integrity and coughing and Planning and Goals deep-breathing exercises. The major goals for the patient may include promotion of physical mobility, avoidance of injury, achievement of bladder and PREVENTING INJURY bowel continence, promotion of speech and swallowing mecha- If motor dysfunction causes problems of incoordination and nisms, improvement of cognitive function, development of coping clumsiness, or if ataxia is apparent, the patient is at risk for falling. strengths, improved home maintenance management, and adap- To overcome this disability, the patient is taught to walk with feet tation to sexual dysfunction. wide apart to widen the base of support and to increase walking stability. If there is loss of position sense, the patient is taught to watch the feet while walking. Gait training may require assistive Nursing Interventions devices (walker, cane, braces, crutches, parallel bars) and instruc- An individualized program of physical therapy, rehabilitation, tion about their use by a physical therapist. If the gait remains in- and education is combined with emotional support. The nursing efficient, a wheelchair or motorized scooter may be the solution. interventions include face-to-face and telephone interactions that The occupational therapist is a valuable resource person in sug- address patient education to enable the person with MS to deal gesting and securing aids to promote independence. If incoordi- with the physiologic, social, and psychological problems that ac- nation is a problem and tremor of the upper extremities occurs company chronic disease (Madonna & Keating, 1999). when voluntary movement is attempted (intention tremor), weighted bracelets or wrist cuffs are helpful. The patient is trained PROMOTING PHYSICAL MOBILITY in transfer and activities of daily living. Relaxation and coordination exercises promote muscle efficiency. Because sensory loss may occur in addition to motor loss, pres- Progressive resistive exercises are used to strengthen weak muscles sure ulcers are a continuing threat to skin integrity. Confinement because diminishing muscle strength is often significant in MS. to a wheelchair increases the risk. See Chapter 11 for a discussion of the prevention and treatment of pressure ulcers. Exercises Walking improves the gait, particularly when there is loss of po- ENHANCING BLADDER AND BOWEL CONTROL sition sense of the legs and feet. If certain muscle groups are irre- Generally, bladder symptoms fall into the following categories: versibly affected, other muscles can be trained to take over their (1) inability to store urine (hyperreflexic, uninhibited); (2) inabil- actions. Instruction in the use of assistive devices may be needed ity to empty the bladder (hyporeflexic, hypotonic); and (3) a mix- to ensure their correct and safe use. ture of both types. The patient with urinary frequency, urgency, or incontinence requires special support. The sensation of the Minimizing Spasticity and Contractures need to void must be heeded immediately, so the bedpan or uri- Muscle spasticity is common and, in its later stages, is character- nal should be readily available. A voiding time schedule is set up ized by severe adductor spasm of the hips with flexor spasm of the (every 1.5 to 2 hours initially, with gradual lengthening of the hips and knees. If this is not relieved, fibrous contractures of these interval). The patient is instructed to drink a measured amount joints with resultant pressure ulcers over the sacrum and hips of fluid every 2 hours and then attempt to void 30 minutes after (due to diminished sensation and the inability to position the drinking. Using a timer or wristwatch with an alarm may be help- patient properly) occur. Warm packs may be beneficial, but hot ful for the patient who does not have enough sensation to signal the baths should be avoided because of risk for burn injury secondary need to empty the bladder. The nurse encourages the patient to to sensory loss and increasing symptoms that may occur with an take the prescribed medications to treat bladder spasticity because elevation of the body temperature. this allows greater independence. Intermittent self-catheterization Daily exercises for muscle stretching are prescribed to mini- has been successful in maintaining bladder control in patients mize joint contractures. Special attention is given to the ham- with MS. (See Chap. 11 for a discussion of intermittent self- strings, gastrocnemius muscles, hip adductors, biceps, and wrist catheterization.) If the female patient has permanent urinary in- and finger flexors. Muscle spasticity is common and interferes continence, urinary diversion procedures may be considered. The with normal function. A stretch–hold–relax routine is helpful for male patient may wear a condom appliance for urine collection. relaxing and treating muscle spasticity. Swimming and stationary Bowel problems include constipation, fecal impaction, and in- bicycling are useful, and progressive weight-bearing can relieve continence. Adequate fluids, dietary fiber, and a bowel-training spasticity in the legs. The patient should not be hurried in any of program are frequently effective in solving these problems. (See these activities because this often increases spasticity. Chap. 11 for a discussion of promoting bowel continence.)

Activity And Rest MANAGING SPEECH AND SWALLOWING DIFFICULTIES The patient is encouraged to work to a point just short of fatigue. When the cranial nerves controlling the mechanisms of speech Very strenuous physical exercise is not advisable because it raises and swallowing are involved, dysarthrias (defects of articulation) the body temperature and may aggravate symptoms. The patient marked by slurring, low volume of speech, and difficulties in 1954 Unit 14 NEUROLOGIC FUNCTION phonation may occur. Swallowing disturbances (dysphagia) may updated list of the assistive devices, services, and resources that also occur. A speech therapist evaluates speech and swallowing are available. and instructs the patient, family, and health team members about Coping through problem solving involves helping the patient strategies to compensate for speech and swallowing problems. define the problem and develop alternatives for its management. The nurse reinforces this instruction and encourages the patient Careful planning and maintaining flexibility and a hopeful atti- and family to adhere to the plan. Impaired swallowing increases tude are useful for psychological and physical adaptation. the patient’s risk for aspiration; therefore, strategies (eg, having suction apparatus available, careful feeding, proper positioning IMPROVING SELF-CARE ABILITIES for eating) are needed to reduce that risk (Galvan, 2001). MS can affect every facet of daily living. After certain abilities are lost, they are often impossible to regain. Physical function may IMPROVING SENSORY AND COGNITIVE FUNCTION vary from day to day. Modifications that allow independence in Measures may be taken if visual defects (the cranial nerves affecting self-care should be implemented (eg, assistive eating devices, vision may be affected by MS) or changes in cognitive status occur. raised toilet seat, bathing aids, telephone modifications, long- handled comb, tongs, modified clothing). Physical and emotional Vision stresses should be avoided as much as possible because these may An eye patch or a covered eyeglass lens may be used to block vi- worsen symptoms and impair performance. Exposure to heat in- sual impulses of one eye when the patient has diplopia (double creases fatigue and muscle weakness, so air conditioning in at least vision). Prism glasses may be helpful for the bedridden patient one room is recommended. Exposure to extreme cold may in- who is having difficulty reading in the supine position. People crease spasticity. unable to read regular-print materials are eligible for the free talking book services of the Library of Congress or may obtain large- PROMOTING SEXUAL FUNCTIONING type books from local libraries. Patients with MS and their partners face problems that interfere with sexual activity, arising not only as a direct consequence of Cognition and Emotional Responses nerve damage but also from psychological reactions to the disease. Cognitive impairment and emotional lability may occur early in Easy fatigability, conflicts arising from dependency and depres- MS in some patients and may impose numerous stresses on the sion, emotional lability, loss of self-esteem, and feelings of low patient and family. Some patients with MS are forgetful and self-worth compound the problem. Erectile and ejaculatory dis- easily distracted and may exhibit emotional lability. orders in men and orgasmic dysfunction and adductor spasms of Patients adapt to illness in a variety of ways, which may in- the thigh muscles in women can make sexual intercourse difficult clude denial, depression, withdrawal, and hostility. Emotional or impossible. Bladder and bowel incontinence and urinary tract support assists patients and their families to adapt to the changes infections add to the difficulties. and uncertainties associated with MS and to cope with the dis- An experienced sexual counselor helps bring into focus the ruption in their lives. The patient is assisted to set meaningful and patient’s or partner’s sexual resources and suggests relevant in- realistic goals to achieve a sense of purpose, to remain as active as formation and supportive therapy (Sipski & Alexander, 1997). possible, and to keep up social interests and activities. Hobbies Sharing and communicating feelings, planning for sexual activ- may help the patient’s morale and provide satisfying interests if ity (to minimize the effects of fatigue), and exploring alternative the disease progresses to the stage in which formerly enjoyed ac- methods of sexual expression may open up a wide range of sexual tivities can no longer be pursued. enjoyment and experiences. The family should be made aware of the nature and degree of cognitive impairment. The environment is kept structured, and PROMOTING HOME AND COMMUNITY-BASED CARE lists and other memory aids are used to help the patient with cognitive changes to maintain a daily routine. The occupational ther- Teaching Patients Self-Care apist can be helpful in formulating a structured daily routine. As the disease progresses, the patient and family need to learn new strategies to maintain optimal independence. Teaching of new Strengthening Coping Mechanisms self-care techniques may be initiated in the hospital or clinic set- The diagnosis of MS is always distressing to the patient and fam- ting and reinforced in the home. Teaching about self-care may ily. They need to know that no two patients with MS have iden- address the use of assistive devices, self-catheterization, and ad- tical symptoms or courses of illness. Although some patients do ministration of medications that affect the course of the disease experience significant disability early, others have a near-normal or treat complications. Although the disease-modifying medica- life span with minimal disability. Some families, however, face tions (the “ABC and R medications”) may slow the progression overwhelming frustrations and problems. MS affects people who of disease and disability in many persons with MS, they are not are often in a productive stage of life and concerned about career effective in all patients. Patients who receive these medications and family responsibilities. Family conflict, disintegration, sepa- will require teaching and support, while those unable to take ration, and divorce are not uncommon. Often, very young family them or for whom the medications have not been effective need members assume the responsibility of caring for a parent with MS. continued support and assistance in coping with this reality. Nursing interventions in this area include alleviating stress and Exercises that enable the patient to continue some form of activ- making appropriate referrals for counseling and support to min- ity or that maintain or improve swallowing, speech, or respiratory imize the adverse effects of dealing with chronic illness. function may be taught to the patient and family (Chart 64-3). The nurse, mindful of these complex problems, initiates home care and coordinates a network of services, including social ser- Continuing Care vices, speech therapy, physical therapy, and homemaker services. After discharge, the home care nurse often provides teaching and To strengthen the patient’s coping skills, as much information as reinforcement of these new techniques in the patient’s home. possible is provided. People who live with chronic illness need an Nurses in the home setting assess for changes in the patient’s Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1955

Chart 64-3 Home Care Checklist • The Patient With Multiple Sclerosis

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • State how to access the local chapter of the National MS Society and available resources. ✓✓ • Discuss the clinical course of MS. ✓✓ • Identify strategies to manage symptoms (pain, cognitive responses, dysphagia, tremors, visual disturbances). ✓✓ • State how to prevent complications (pressure ulcers, pneumonia, depression). ✓✓ • Identify coping strategies. ✓✓ • Identify ways to minimize fatigue. ✓✓ • Explain how to prevent injury. ✓✓ • State ways to adapt to sexual dysfunction. ✓✓ • Discuss ways to control bowel and bladder function. ✓✓ • Name beneﬁts of exercise and physical activity. ✓✓ • Identify ways to minimize immobility and spasticity. ✓✓ • Describe medication regimen and potential adverse effects. ✓✓ • Demonstrate correct techniques of administering injectable medications, if prescribed. ✓✓ physical and emotional status, provide physical care to the patient Evaluation if required, coordinate outpatient services and resources, and encourage health promotion, appropriate health screenings, and EXPECTED PATIENT OUTCOMES adaptation. If changes in the disease or its course are noted, the Expected patient outcomes may include: home care nurse encourages the patient to contact the primary 1. Improved physical mobility care provider because treatment of an acute exacerbation or new a. Participates in gait-training and rehabilitation program problem may be indicated. Continuing health care and follow- b. Establishes a balanced program of rest and exercise up are recommended. c. Uses assistive devices correctly and safely The patient with MS is encouraged to contact the local chapter 2. Is free of injury of the National Multiple Sclerosis Society for services, publica- a. Uses visual cues to compensate for decreased sense of tions, and contact with others with MS. Local chapters also pro- touch or position vide direct services to patients. Through group participation, the b. Asks for assistance when necessary patient has an opportunity to meet others with similar problems, 3. Attains or maintains control of bladder and bowel patterns to share experiences, and to learn self-help methods in a social a. Monitors self for urine retention and employs intermit- environment. tent self-catheterization technique, if indicated

NURSING RESEARCH PROFILE 64-1 Quality of Life for People With Multiple Sclerosis Stuifbergen, A., Seraphine, A., & Roberts, G. (2000). An explanatory model of health promotion and quality of life in chronic disabling conditions. Nursing Research, 49(3), 122–129.

Purpose Findings The purpose of this study was to test an explanatory model of The analysis revealed that the original model was generally well speci- variables influencing health promotion and quality of life in per- fied, with an adequate fit to the data. The model supported the hypoth- sons with multiple sclerosis (MS). This was the second phase of a esis that quality of life is the outcome of a complex interplay between project designed to investigate the issues surrounding the health- contextual factors (severity of illness), antecedent variables, and health- promotion needs of individuals with chronic disabling conditions promoting behaviors. The revised model, with the addition of two paths and the outcomes associated with the performance of health-promoting between personal resources and barriers, had an improved fit of the data behaviors. compared to the original model. The original and revised models are depicted in the article. Resources, barriers, self-efficacy, and accep- Study Sample and Design tance accounted for 58% of the variance in the frequency of health- This was a one-time cross-sectional design using mailed question- promoting behaviors and 66% of the variance in perceived quality of life. naires. Participants were recruited for the study using targeted mail- ings to individuals with MS on the mailing lists of national MS Nursing Implications Society chapters. The study sample included 786 persons with MS Further testing of the model was recommended, especially in samples (630 women and 156 men) who returned surveys. Instruments used of differing ethnic and cultural backgrounds. Nurses working with included the Incapacity Status Scale (ISS), Barriers to Health Pro- MS patients should be aware that quality of life is the outcome of the moting Activities for Disabled Persons Scale, Personal Resource Ques- interaction of many variables. The authors suggest that nurses can im- tionnaire, Acceptance of Illness Scale, Self-Rated Abilities for Health prove health-promoting behaviors and quality of life using inter- Practices scale, Health Promoting Lifestyle Profile-II (HPLP-II), and ventions that enhance social support, decrease barriers, and increase the Quality of Life Index (QLI). specific self-efficacy for health behaviors. 1956 Unit 14 NEUROLOGIC FUNCTION

b. Identifies the signs and symptoms of urinary tract myoneural junction. Therefore, fewer receptors are available for infection stimulation, resulting in voluntary muscle weakness that escalates c. Maintains adequate fluid and fiber intake with continued activity (Fig. 64-5). These antibodies are found 4. Participates in strategies to improve speech and swallowing in 80% to 90% of the people with myasthenia gravis. Eighty per- a. Practices exercises recommended by speech therapist cent of persons with myasthenia gravis have either thymic hyper- b. Maintains adequate nutritional intake without aspiration plasia or a thymic tumor (Roos, 1999), and the thymus gland is 5. Compensates for altered thought processes believed to be the site of antibody production. In patients who a. Uses lists and other aids to compensate for memory are antibody negative, it is believed that the offending antibody losses is directed at a portion of the receptor site rather than the whole b. Discusses problems with trusted advisor or friend complex. c. Substitutes new activities for those that are no longer possible 6. Demonstrates effective coping strategies Clinical Manifestations a. Maintains sense of control The initial manifestation of myasthenia gravis usually involves b. Modifies lifestyle to fit goals and limitations the ocular muscles. Diplopia (double vision) and ptosis (drooping c. Verbalizes desire to pursue goals and developmental of the eyelids) are common. However, the majority of patients tasks of adulthood also experience weakness of the muscles of the face and throat d. Adheres to plan for home maintenance management (bulbar symptoms) and generalized weakness. Weakness of the e. Uses appropriate self-care techniques to maintain in- facial muscles will result in a bland facial expression. Laryngeal dependence involvement produces dysphonia (voice impairment) and in- f. Engages in health promotion activities and health screen- creases the patient’s risk for choking and aspiration. Generalized ings as appropriate weakness affects all the extremities and the intercostal muscles, 8. Adapts to changes in sexual function resulting in decreasing vital capacity and respiratory failure. a. Is able to discuss problem with partner and appropriate Myasthenia gravis is purely a motor disorder with no effect on health professional sensation or coordination. b. Identifies alternate means of sexual expression

Assessment and Diagnostic Findings MYASTHENIA GRAVIS An anticholinesterase test is used to diagnose myasthenia gravis. Myasthenia gravis, an autoimmune disorder affecting the myo- Anticholinesterase agents stop the breakdown of acetylcholine, neural junction, is characterized by varying degrees of weakness thereby increasing acetylcholine availability. Edrophonium chlo- of the voluntary muscles. Women tend to develop the disease ride (Tensilon) is injected intravenously, 2 mg at a time to a total at an earlier age (20 to 40 years of age) compared to men (60 to of 10 mg. Thirty seconds after injection, facial muscle weakness 70 years of age), and women are affected more frequently and ptosis should resolve for about 5 minutes. This immediate (Heitmiller, 1999). improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. Atropine 0.4 mg should be available to control the side effects of Pathophysiology edrophonium, which include bradycardia, sweating, and cramping (Roos, 1999). Normally, a chemical impulse precipitates the release of acetyl- The acetylcholine receptor antibody titers are elevated as in- choline from vesicles on the nerve terminal at the myoneural dicated previously. Repetitive nerve stimulation tests record the junction. The acetylcholine attaches to receptor sites on the motor electrical activity in targeted muscles after nerve stimulation. A end plate, stimulating muscle contraction. Continuous binding 15% decrease in successive action potentials is observed in pa- of acetylcholine to the receptor site is required for muscular con- tients with myasthenia gravis (Heitmiller, 1999). The thymus traction to be sustained. gland, which is a site of acetylcholine receptor antibody produc- In myasthenia gravis, autoantibodies directed at the acetyl- tion, is enlarged in myasthenia gravis. MRI demonstrates this en- choline receptor sites impair transmission of impulses across the largement in 90% of cases (Wilkins & Bulkley, 1999).

Axon

Nerve ACh vesicles terminal ACh receptors Antibodies

ABMuscle endplate

FIGURE 64-5 Myasthenia gravis. (A) Normal ACh receptor site. (B) ACh receptor site in myasthenia gravis. Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1957

Medical Management Cytotoxic medications have also been used, although the precise mechanism of action in myasthenia is not fully under- Management of myasthenia gravis is directed at improving function stood. Medications such as azathioprine (Imuran), cyclophos- and reducing and removing circulating antibodies. Therapeutic phamide (Cytoxan), and cyclosporine reduce the circulating anti- modalities include administration of anticholinesterase agents and acetylcholine receptor antibody titers. Side effects are significant; immunosuppressive therapy, plasmapheresis, and thymectomy. therefore, these agents are reserved for patients who do not respond to other forms of therapy. PHARMACOLOGIC THERAPY A number of medications are contraindicated for patients with Anticholinesterase agents such as pyridostigmine bromide (Mesti- myasthenia gravis because they worsen myasthenic symptoms. non) and neostigmine bromide (Prostigmin) provide symptomatic Risks and benefits should be weighed by the physician and the relief by increasing the relative concentration of available acetyl- patient before taking any new medications, including antibiotics, choline at the neuromuscular junction. Dosage is increased grad- cardiovascular medications, antiseizure and psychotropic med- ually until maximal benefits (improved strength, less fatigue) are ications, morphine, quinine and related agents, beta-blockers, and obtained. Adverse effects of anticholinesterase therapy include ab- nonprescription medications. Procaine (Novocain) should be dominal pain, diarrhea, nausea, and increased oropharyngeal secre- avoided, and the patient’s dentist is so advised. tions. Pyridostigmine tends to have fewer side effects (Chart 64-4). Improvement with anticholinesterase therapy is not complete or PLASMAPHERESIS long-lasting (Heitmiller, 1999). Plasma exchange (plasmapheresis) is a technique used to treat exacerbations. The patient’s plasma and plasma components are removed through a centrally placed large-bore double-lumen NURSING ALERT Maintenance of stable blood levels of anti- catheter. The blood cells and antibody-containing plasma are sep- cholinergic medication is imperative to stabilize muscle strength. arated; then the cells and a plasma substitute are reinfused. Plasma Therefore, the anticholinesterase medications must be given on exchange produces a temporary reduction in the titer of circulat- time. Any delay in administration of medications may exacerbate ! muscle weakness and make it impossible for the patient to take ing antibodies. Plasma exchange improves the symptoms in 75% medications orally. of patients, although improvement lasts only a few weeks unless plasmapheresis is continued or other forms of treatment such as immunosuppression with corticosteroids are initiated (Bedlack & Sanders, 2000). IV immune globulin (IVIG) has recently been The goal of immunosuppressive therapy is to reduce the pro- shown to be nearly as effective as plasmapheresis in controlling duction of the antibody. Corticosteroids suppress the patient’s symptom exacerbation (Qureshi, Choudhry, Akbar et al., 1999). immune response, thus decreasing the amount of antibody pro- However, neither therapy is a cure as it does not stop the production. As the corticosteroid dosage is gradually increased, the duction of the acetylcholine receptor antibodies. anticholinesterase dosage is lowered. The patient’s ability to maintain effective respirations and to swallow is monitored through- SURGICAL MANAGEMENT out. Prednisone, taken on alternate days to lower the incidence Thymectomy (surgical removal of the thymus gland) can produce of side effects, appears to be successful in suppressing the disease. antigen-specific immunosuppression and result in clinical im- The patient sometimes shows a marked decrease in muscle strength provement. It can decrease or eliminate the need for medication. right after therapy is started, but this is usually only temporary. In one study 92% of post-thymectomy patients had symptomatic improvement, with 50% of them no longer requiring pharmacologic therapy (Wilkins & Bulkley, 1999). The entire gland must be removed for optimal clinical outcomes; therefore, surgeons Chart 64-4 • PHARMACOLOGY prefer the transsternal surgical approach. After surgery, the pa- Potential Adverse Effects tient is monitored in an intensive care unit, with special atten- of Anticholinesterase Medications tion to respiratory function. After the thymus gland is removed, it may take up to 1 year for the patient to benefit from the pro- CNS Gastrointestinal cedure due to the long life of circulating T cells (Wilkins & Irritability Abdominal cramps Bulkley, 1999). Anxiety Nausea Insomnia Vomiting Complications: Myasthenic Crisis Headache Diarrhea Versus Cholinergic Crisis Dysarthria Anorexia Syncope Increased salivation A myasthenic crisis is an exacerbation of the disease process char- Seizures Skeletal Muscles acterized by severe generalized muscle weakness and respiratory Coma Fasciculations and bulbar weakness that may result in respiratory failure. Crisis Diaphoresis Spasms may result from disease exacerbation or a specific precipitating Weakness Respiratory event. The most common precipitator is infection; others include Bronchial relaxation Genitourinary medication change, surgery, pregnancy, and high environmental Increased bronchial secretions Frequency temperature (Bella & Chad, 1998). Urgency Symptoms of anticholinergic overmedication (cholinergic Cardiovascular Integumentary crisis) may mimic the symptoms of exacerbation. Differentiation Tachycardia Rash can be achieved with the edrophonium chloride (Tensilon) test. Hypotension Flushing The patient with myasthenic crisis improves immediately following administration of edrophonium, while the patient with 1958 Unit 14 NEUROLOGIC FUNCTION cholinergic crisis may experience no improvement or deteriorate. instill artificial tears. Patients who wear eyeglasses can have If myasthenic crisis is diagnosed, neostigmine methylsulfate “crutches” attached to help lift the eyelids. Patching one eye can (PMS-Neostigmine, Prostigmin) is administered intramuscularly help with double vision. or intravenously until the patient is able to swallow oral anti- The patient is reminded of the importance of maintaining cholinesterase medications. Plasmapheresis and IVIG, which re- health promotion practices and of following health care screen- duce the antibody load, also may be used to treat myasthenic ing recommendations. Factors that will exacerbate symptoms and crisis. If cholinergic crisis is identified, all anticholinesterase med- potentially cause crisis should be noted and avoided: emotional ications are stopped. The patient receives atropine (Atropine sul- stress, infections (particularly respiratory infections), vigorous fate), the antidote for the anticholinesterase medications. physical activity, some medications, and high environmental Neuromuscular respiratory failure is the critical complication temperature. The Myasthenia Gravis Foundation of America of crisis. Respiratory muscle and bulbar weakness combine to cause provides support groups, services, and educational materials for respiratory compromise. Weak respiratory muscles will not sup- patients, families, and health care providers. port inhalation. An inadequate cough and an impaired gag reflex caused by bulbar weakness result in poor airway clearance. Values MANAGING MYASTHENIC AND CHOLINERGIC CRISES on two respiratory function tests, the negative inspiratory force Respiratory distress and varying degrees of dysphagia (difficulty and vital capacity, will be the first clinical signs to deteriorate. swallowing), dysarthria (difficulty speaking), eyelid ptosis, diplopia, Careful monitoring of these values enables the nurse to monitor and prominent muscle weakness are symptoms of myasthenic for impending respiratory failure. Respiratory support and airway and cholinergic crisis. The patient is placed in an intensive care protection are key interventions for the nurse caring for the pa- unit for constant monitoring because of associated intense and tient in crisis. Endotracheal intubation and mechanical ventila- sudden fluctuations in clinical condition. tion may be needed (see Chap. 25). Nutritional support may be IV edrophonium chloride (Tensilon) is used to differentiate needed if the patient is intubated for a long period. the type of crisis. It improves the condition of the patient in myasthenic crisis and temporarily worsens that of the patient in cholin- Nursing Management ergic crisis. If the patient is in true myasthenic crisis, neostigmine methylsulfate is administered intramuscularly or intravenously. If Because myasthenia gravis is a chronic disease and most patients the edrophonium test is inconclusive or there is increasing respi- are seen on an outpatient basis, much of the nursing care focuses ratory weakness, all anticholinesterase medications are stopped, on patient and family teaching. Educational topics for outpatient and atropine sulfate is given to reduce excessive secretions. self-care include medication management, energy conservation, Providing ventilatory assistance takes precedence in the im- strategies to help with ocular manifestations, and prevention and mediate management of the patient with myasthenic crisis. On- management of complications. going assessment for respiratory failure is essential. The nurse Medication management is a crucial component of ongoing assesses the respiratory rate, depth, and breath sounds and mon- care. Understanding the action of the medications and taking itors pulmonary function parameters (vital capacity and negative them on schedule is emphasized, as are the consequences of de- inspiratory force) to detect pulmonary problems before respira- laying medication and the signs and symptoms of myasthenic and tory dysfunction progresses. Blood is drawn for arterial blood gas cholinergic crisis. The patient can determine the best times for analysis. Endotracheal intubation and mechanical ventilation daily dosing by keeping a diary to determine fluctuation of symp- may be needed (see Chap. 25). toms and to learn when the medication is wearing off. The med- When there is severe weakness of the abdominal, intercostal, ication schedule can then be manipulated to maximize strength and pharyngeal muscles, the patient cannot cough, take deep throughout the day. breaths, or clear secretions. Chest physical therapy, including The patient is also taught srategies to conserve energy. To do postural drainage to mobilize secretions, and suctioning to re- this, the nurse helps the patient identify the best times for rest pe- move secretions may have to be performed frequently. (Postural riods throughout the day. If the patient lives in a two-story home, drainage should not be performed for 30 minutes after feeding.) the nurse can suggest that frequently used items such as hygiene Assessment strategies and supportive measures include the products, cleaning products, and snacks be kept on each floor to following: minimize travel between floors. The patient is encouraged to apply for a handicapped license plate to minimize walking from • Arterial blood gases, serum electrolytes, input and output, parking spaces and to schedule activities to coincide with peak en- and daily weight are monitored. ergy and strength levels. • If the patient cannot swallow, nasogastric tube feedings may To minimize the risk of aspiration, mealtimes should coincide be prescribed. with the peak effects of anticholinesterase medication. In addition, • Sedatives and tranquilizers are avoided because they aggra- rest before meals is encouraged to reduce muscle fatigue. The pa- vate hypoxia and hypercapnia and can cause respiratory and tient is advised to sit upright during meals with the neck slightly cardiac depression. flexed to facilitate swallowing. Soft foods in gravy or sauces can be swallowed more easily; if choking occurs frequently, the nurse GUILLAIN-BARRÉ SYNDROME can suggest pureéing food to a pudding consistency. Suction should be available at home and the patient and family instructed Guillain-Barré syndrome is an autoimmune attack of the periph- in its use. Gastrostomy feedings may be necessary in some patients eral nerve myelin. The result is acute, rapid segmental demyeli- to ensure adequate nutrition. nation of peripheral nerves and some cranial nerves, producing Impaired vision results from ptosis of one or both eyelids, ascending weakness with dyskinesia (inability to execute volun- decreased eye movement, or double vision. To prevent corneal tary movements), hyporeflexia, and paresthesias (numbness). In damage when the eyelids do not close completely, the patient is 66% of cases, there is a predisposing event, most often a respira- instructed to tape the eyes closed for short intervals and regularly tory or gastrointestinal infection, although vaccination, pregnancy, Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1959 and surgery have also been identified as antecedent events (Bella rapidly. Guillain-Barré does not affect cognitive function or level & Chad, 1998). Infection with Campylobacter jejuni (a relatively of consciousness. common gastrointestinal bacterial pathogen) precedes Guillain- While the classic clinical features include areflexia and as- Barreé syndrome in a few cases (Ho & Griffin, 1999; Lindenbaum, cending weakness, variation in presentation occurs. There may be Kissel & Mendel, 2001). a sensory presentation, with progressive sensory symptoms, an The antecedent event usually occurs 2 weeks before symptoms atypical axonal destruction, and the Miller-Fisher variant, which begin. Weakness usually begins in the legs and progresses upward includes paralysis of the ocular muscles, ataxia, and areflexia for about 1 month. Maximum weakness varies but usually in- (Ho & Griffin, 1999). cludes neuromuscular respiratory failure and bulbar weakness. The duration of the symptoms is variable: complete functional Assessment and Diagnostic Findings recovery may take up to 2 years (Hickey, 2003). Any residual symptoms are permanent and reflect axonal damage from de- The patient presents with symmetric weakness, diminished remyelination. flexes, and upward progression of motor weakness. A history of The annual incidence of Guillain-Barré is 0.6 to 1.9 cases per a viral illness in the previous few weeks suggests the diagnosis. 100,000. Eighty-five percent of patients recover with minimal Changes in vital capacity and negative inspiratory force are as- residual symptoms. Severe residual deficits occur in up to 10% of sessed to identify impending neuromuscular respiratory failure. patients. Residual deficits are most likely in patients with rapid Serum laboratory tests are not useful in the diagnosis. However, disease progression, those who require mechanical ventilation, or elevated protein levels are detected in CSF evaluation, without an those 60 years of age or older. Death occurs in 3% to 8% of cases, increase in other cells. Evoked potential studies demonstrate a resulting from respiratory failure, autonomic dysfunction, sepsis, progressive loss of nerve conduction velocity (Bella & Chad, 1999). or pulmonary emboli (Bella & Chad, 1998). Medical Management Pathophysiology Because of the possibility of rapid progression and neuromuscular respiratory failure, Guillain-Barré is a medical emergency, re- Myelin is a complex substance that covers nerves, providing in- quiring intensive care unit management. Careful assessment of sulation and speeding the conduction of impulses from the cell changes in motor weakness and respiratory function alert the body to the dendrites. The cell that produces myelin in the pe- clinician to the physical and respiratory needs of the patient. ripheral nervous system is the Schwann cell. In Guillain-Barré Respiratory therapy or mechanical ventilation may be necessary the Schwann cell is spared, allowing for remyelination in the to support pulmonary function and adequate oxygenation. recovery phase of the disease. Mechanical ventilation may be required for an extended period. Guillain-Barré is the result of a cell-mediated immune attack The patient is weaned from mechanical ventilation when the res- on peripheral nerve myelin proteins (Ho & Griffin, 1999). The piratory muscles can again support spontaneous respiration and best-accepted theory is that an infectious organism contains an maintain adequate tissue oxygenation. amino acid that mimics the peripheral nerve myelin protein. The Other interventions are aimed at preventing the complications immune system cannot distinguish between the two proteins and of immobility. These may include the use of anticoagulant agents attacks and destroys peripheral nerve myelin. Studies indicate and thigh-high elastic compression stockings or sequential com- that an exact location within the peripheral nervous system, the pression boots to prevent thrombosis and pulmonary emboli. ganglioside GM1b, is the most likely target of the immune attack Plasmapheresis and IVIG are used to directly affect the pe- (Yuki, Ang, Koga et al., 2000). With the autoimmune attack there ripheral nerve myelin antibody level. Both therapies decrease cir- is an influx of macrophages and other immune-mediated agents culating antibody levels and reduce the amount of time the patient that attack myelin, cause inflammation and destruction, and leave is immobilized and dependent on mechanical ventilation. Studies the axon unable to support nerve conduction. indicate that IVIG and plasmapheresis are equally effective in treating Guillain-Barré (Bella & Chad, 1999; Winer, 2002). Clinical Manifestations The cardiovascular risks posed by autonomic dysfunction require continuous ECG monitoring. Tachycardia and hypertension Classic Guillain-Barré begins with muscle weakness and dimin- are treated with short-acting medications such as alpha-adrenergic ished reflexes of the lower extremities. Hyporeflexia and weakness blocking agents. Hypotension is managed by increasing the progress and may result in quadriplegia. Demyelination of the amount of IV fluid administered. The use of short-acting agents nerves that innervate the diaphragm and intercostal muscles re- is important because autonomic dysfunction is very labile. sults in neuromuscular respiratory failure. Twenty-five percent of patients will require mechanical ventilation within 18 days of NURSING PROCESS: symptom onset (Bella & Chad, 1998). Sensory symptoms include paresthesias of the hands and feet and pain related to the de- THE PATIENT WITH myelination of sensory fibers. GUILLAIN-BARRÉ SYNDROME Cranial nerve demyelination can result in a variety of clinical Assessment manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the Ongoing assessment for disease progression is critical. The pa- glossopharyngeal and vagus nerves results in an inability to tient is monitored for life-threatening complications (respiratory swallow or clear secretions. Vagus nerve demyelination results in failure, cardiac dysrhythmias, DVTs) so that appropriate inter- autonomic dysfunction, manifested by instability of the cardio- ventions can be initiated. Because of the threat to the patient in vascular system. The presentation is variable and may include this sudden, potentially life-threatening disease, the nurse must tachycardia, bradycardia, hypertension, or orthostatic hypoten- assess the patient’s and family’s ability to cope and their use of sion. The symptoms of autonomic dysfunction occur and resolve appropriate coping strategies. 1960 Unit 14 NEUROLOGIC FUNCTION

Diagnosis functional positions, and passive range-of-motion exercises are performed at least twice daily. NURSING DIAGNOSES DVT and pulmonary embolism are threats to the paralyzed Based on the assessment data, the patient’s major nursing diag- patient. Nursing interventions are aimed at preventing DVT. noses may include the following: Range-of-motion exercises, altering positioning, anticoagulation, • Ineffective breathing pattern and impaired gas exchange re- thigh-high elastic compression stockings or sequential com- lated to rapidly progressive weakness and impending respi- pression boots, and adequate hydration will decrease the risk ratory failure for DVT. • Impaired physical mobility related to paralysis Padding may be placed over bony prominences such as the el- • Imbalanced nutrition, less than body requirements, related bows and heels to reduce the risk for pressure ulcers. The need for to inability to swallow consistent position changes every 2 hours cannot be overempha- • Impaired verbal communication related to cranial nerve sized. The nurse evaluates laboratory test results that may indi- dysfunction cate malnutrition or dehydration, both of which increase the risk • Fear and anxiety related to loss of control and paralysis for pressure ulcers. Collaboration with the physician and dietitian will result in a plan to meet the patient’s nutritional and hydra- COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS tion needs. Based on the assessment data, potential complications that may develop include the following: PROVIDING ADEQUATE NUTRITION • Respiratory failure Paralytic ileus may result from insufficient parasympathetic ac- • Autonomic dysfunction tivity. In this event, the nurse administers IV fluids and parenteral nutrition as prescribed and monitors for the return of bowel sounds. If the patient cannot swallow due to bulbar paralysis Planning and Goals (immobility of muscles), a gastrostomy tube may be placed to administer nutrients. The nurse carefully assesses the return of the The major goals for the patient may include improved respiratory gag reflex and bowel sounds before resuming oral nutrition. function, increased mobility, improved nutritional status, effective communication, decreased fear and anxiety, and absence of IMPROVING COMMUNICATION complications. Because of paralysis and ventilator management, the patient cannot talk, laugh, or cry and thus has no method for communicating Nursing Interventions needs or expressing emotion. Establishing some form of communication with picture cards or an eye blink system will provide MAINTAINING RESPIRATORY FUNCTION a means of communication. Collaboration with the speech ther- Respiratory function can be maximized with incentive spirome- apist may be helpful in developing a communication mechanism try and chest physiotherapy. Monitoring for changes in vital ca- that is most effective for a specific patient. pacity and negative inspiratory force are key to early intervention for neuromuscular respiratory failure. Mechanical ventilation is DECREASING FEAR AND ANXIETY required if the vital capacity falls, making spontaneous breathing The patient and family are faced with a sudden, potentially life- impossible and tissue oxygenation inadequate. threatening disease, and anxiety and fear are constant themes Parameters for determining the appropriate time to begin me- for them. The impact of disease on the family will depend on the chanical ventilation include a vital capacity of 12 to 15 mL/kg, patient’s age and role within the family. Referral to a support downward vital capacity trend over 4 to 6 hours, and an inability group may provide information and support to the patient and to clear secretions (Bella & Chad, 1999). The potential need for family. mechanical ventilation should be discussed with the patient and The family may feel helpless in caring for the patient. Me- family on admission to provide time for psychological prepara- chanical ventilation and monitoring devices may frighten and tion and decision-making. Intubation and mechanical ventilation intimidate them. Family members often want to participate in will result in less anxiety if it is initiated on a nonemergent basis physical care; with instruction and support by the nurse, they to a well-informed patient. The patient may require mechanical should be allowed to do so. ventilation for a long period. Nursing management of the patient In addition to fear, the patient may experience isolation, lone- requiring mechanical ventilation is discussed in Chapter 25. liness, and lack of control. Nursing interventions that increase the Bulbar weakness that impairs the ability to swallow and clear patient’s sense of control include providing information about secretions is another factor in the development of respiratory fail- the condition, emphasizing a positive appraisal of coping resources, ure in the patient with Guillain-Barré. Suctioning may be needed and teaching relaxation exercises and distraction techniques. The to maintain a clear airway. positive attitude and atmosphere of the multidisciplinary team The nurse assesses the blood pressure and heart rate frequently are important to promote a sense of well-being. to identify autonomic dysfunction so that interventions can be Diversional activities are encouraged to decrease loneliness initiated quickly if needed. Medications are administered or a and isolation. Encouraging visitors, engaging visitors or volun- temporary pacemaker is placed for clinically significant brady- teers to read to the patient, listening to music or books on tape, cardia (Winer, 2002). and watching television are ways to alleviate the patient’s sense of isolation. ENHANCING PHYSICAL MOBILITY Nursing interventions to enhance physical mobility and prevent MONITORING AND MANAGING POTENTIAL COMPLICATIONS the complications of immobility are key to the function and sur- Thorough assessment of respiratory function at regular intervals vival of these patients. The paralyzed extremities are supported in is essential because respiratory insufficiency and subsequent fail- Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1961 ure due to weakness or paralysis of the intercostal muscles and di- Continuing Care aphragm may develop quickly. Respiratory failure is the major Most patients with Guillain-Barré syndrome experience complete cause of mortality, which is reported to be as high as 10% to 20%. recovery. Patients who have experienced total or prolonged paral- Vital capacity is monitored frequently and at regular intervals in ysis require intensive rehabilitation; the extent depends on the pa- addition to respiratory rate and the quality of respirations, so that tient’s needs. Approaches include a comprehensive inpatient respiratory insufficiency can be anticipated. Decreasing vital ca- program if deficits are significant, an outpatient program if the pacity associated with weakness of the muscles used in swallowing, patient can travel by car, or a home program of physical and oc- which causes difficulty in both coughing and swallowing, indi- cupational therapy. The recovery phase may be long and will re- cates impending respiratory failure. Signs and symptoms include quire patience as well as involvement on the part of the patient breathlessness while speaking, shallow and irregular breathing, and family. use of accessory muscles, tachycardia, and changes in respiratory During acute care the focus is on obvious needs, issues, and pattern. deficits. The nurse needs to remind or instruct patients and fam- Parameters for determining the onset of respiratory failure are ily members of the need for continuing health promotion and established on admission, allowing intubation and the initiation screening practices following this initial phase of care. of mechanical ventilation on a nonemergent basis. This also allows the patient to be prepared for the procedure in a controlled Evaluation manner, which reduces anxiety and complications. Other complications include cardiac dysrhythmias, which ne- EXPECTED PATIENT OUTCOMES cessitate ECG monitoring, transient hypertension, orthostatic Expected patient outcomes may include: hypotension, DVT, pulmonary embolism, urinary retention, and 1. Maintains effective respirations and airway clearance other threats to any immobilized and paralyzed patient. These re- a. Has normal breath sounds on auscultation quire monitoring and attention to prevent them and prompt b. Demonstrates gradual improvement in respiratory treatment if indicated. function PROMOTING HOME AND COMMUNITY-BASED CARE 2. Shows increasing mobility a. Regains use of extremities Teaching Patients Self-Care b. Participates in rehabilitation program Patients with Guillain-Barré syndrome and their families are usu- c. Demonstrates no contractures and minimal muscle ally frightened by the sudden onset of life-threatening symptoms atrophy and their severity. Therefore, teaching the patient and family 3. Receives adequate nutrition and hydration about the disorder and its generally favorable prognosis is impor- a. Consumes diet adequate to meet nutritional needs tant (Chart 64-5). During the acute phase of the illness, the patient b. Swallows without aspiration and family are instructed about strategies they can implement to 4. Demonstrates recovery of speech minimize the effects of immobility and other complications. As a. Can communicate needs through alternative strategies function begins to return, family members and other home care b. Practices exercises recommended by the speech therapist providers are instructed about care of the patient and their role in 5. Shows lessening fear and anxiety the rehabilitation process. Preparation for discharge is an inter- 6. Absence of complications disciplinary effort requiring family or caregiver education by all a. Breathes spontaneously team members, including the nurse, physician, occupational and b. Has vital capacity within normal range physical therapists, speech therapist, and respiratory therapist. c. Exhibits normal arterial blood gases and oximetry

Chart 64-5 Home Care Checklist • The Patient With Guillain-Barré Syndrome

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • Describe the disease process of Guillain-Barré syndrome. ✓✓ • Manage respiratory needs: tracheostomy care, suctioning. ✓ • Demonstrate proper body mechanics regarding lifting and transfers. ✓ • Practice gait training and strength endurance. ✓✓ • Perform range-of-motion exercises. ✓✓ • Perform activities of daily living and manage self-care: • Nutrition ✓✓ • Bowel and bladder management ✓✓ • Skin care ✓✓ • Adaptive equipment for bathing, hygiene, grooming, dressing ✓✓ • Operate and explain function of medical equipment and mobility aids: walkers, wheelchairs, bedside commodes, tub transfer benches, adaptive devices ✓✓ • Use coping mechanisms and diversional activities appropriately. ✓✓ • Implement safety measures in the home. ✓✓ • Know how to contact and use community resources and the Guillain-Barré Syndrome Foundation International. ✓✓ 1962 Unit 14 NEUROLOGIC FUNCTION Cranial Nerve Disorders generative changes in the gasserian ganglion are suggested causes. Vascular pressure from structural abnormalities (loop of an artery) Because the brain stem and cranial nerves involve vital motor, encroaching on the trigeminal nerve, gasserian ganglion, or root sensory, or autonomic functions of the body, these nerves may be entry zone has also been suggested as a cause. affected by conditions arising primarily within these structures or Trigeminal neuralgia is 400 times more common in patients in secondary extension from adjacent disease processes. The cra- with MS than in the general population. The pain is more often nial nerves (Fig. 64-6) are examined separately and in sequence cyclic and affects men with MS at a higher rate than women with (see Chap. 60). Some cranial nerve deficits can be detected by ob- MS (Maloni, 2000). serving the patient’s face, eye movements, speech, and swallow- Early attacks, appearing most often in the fifth decade of life, ing. Electromyography (EMG) is used to investigate motor and are usually mild and brief. Pain-free intervals may be measured in sensory dysfunction. MRI is used to obtain images of the cranial terms of minutes, hours, days, or longer. With advancing years, nerves and brain stem. An overview of disorders that may affect the painful episodes tend to become more frequent and agonizing. each of the cranial nerves, including clinical manifestations and The patient lives in constant fear of attacks. nursing interventions, is presented in Table 64-1. The following Paroxysms can occur with any stimulation of the terminals of discussion centers on trigeminal neuralgia, a condition affecting the affected nerve branches, such as washing the face, shaving, the fifth cranial nerve, and Bell’s palsy, caused by involvement of brushing the teeth, eating, and drinking. A draft of cold air and the seventh cranial nerve. These are the most common disorders direct pressure against the nerve trunk may also cause pain. of the cranial nerves. Certain areas are called trigger points because the slightest touch immediately starts a paroxysm or episode. To avoid stimulating these areas, patients with trigeminal neuralgia try not to touch or TRIGEMINAL NEURALGIA wash their faces, shave, chew, or do anything else that might cause (TIC DOULOUREUX) an attack. These behaviors are a clue to diagnosis. Trigeminal neuralgia is a condition of the fifth cranial nerve char- Medical Management acterized by paroxysms of pain in the area innervated by any of the three branches, but it most commonly occurs in the second and PHARMACOLOGIC THERAPY third branches of the trigeminal nerve (Maloni, 2000) (Fig. 64-7). Antiseizure agents, such as carbamazepine (Tegretol), relieve pain The pain ends as abruptly as it starts and is described as a uni- in most patients with trigeminal neuralgia by reducing the trans- lateral shooting and stabbing sensation. The unilateral nature of mission of impulses at certain nerve terminals. Carbamazepine is the pain is an important diagnostic characteristic (Preul, 2001). taken with meals. Serum levels must be monitored to avoid tox- Associated involuntary contraction of the facial muscles can cause icity in patients who require high doses to control the pain. Side sudden closing of the eye or a twitch of the mouth, hence the effects include nausea, dizziness, drowsiness, and aplastic anemia. name tic douloureux (painful twitch). The cause is not certain, but The patient is monitored for bone marrow depression during long- chronic compression or irritation of the trigeminal nerve or de- term therapy. Gabapentin (Neurontin) and baclofen (Lioresal)

Olfactory tract (I) Optic n. (II) Oculomotor n. (III) Trochlear n. (IV) Trigeminal n. (V)

Abducens n. (VI) Optic n. (II) Facial n. (VII) Glossopharyngeal n. (IX) Acoustic n. (VIII) Vagus n. (X) Glossopharyngeal n. (IX) Spinal accessory n. (XI) Vagus n. (X) Hypoglossal n. (XII) Spinal accessory n. (IX)

Hypoglossal n. (XII)

A B

FIGURE 64-6 The cranial nerves. (A) Inferior view of the brain showing the cranial nerve. (B) Lateral view showing a schematic version of the cranial nerves. Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1963

Table 64-1 • Disorders of Cranial Nerves

DISORDER CLINICAL MANIFESTATIONS NURSING INTERVENTIONS Olfactory Nerve—I Head trauma Unilateral or bilateral anosmia (temporary or Assess sense of smell. Intracranial tumor persistent) Assess for cerebrospinal fluid rhinorrhea if Intracranial surgery Diminished taste for food patient has sustained head trauma. Optic Nerve—II Optic neuritis Lesions of optic tract producing homony- Assess visual acuity. Increased intracranial pressure mous hemianopsia Restructure environment to prevent injuries. Pituitary tumor Teach patient to accommodate for visual loss. Oculomotor Nerve—III Trochlear Nerve—IV Abducens Nerve—VI Vascular Dilation of pupil with loss of light reflex on Assess extraocular movement and for non- Brain stem ischemia one side reactive pupil. Hemorrhage and infarction Impairment of ocular movement Neoplasm Diplopia Trauma Gaze palsies Infection Ptosis of eyelid Trigeminal Nerve—V Trigeminal neuralgia Pain in face Assess for pain and triggering mechanisms Head trauma Diminished or loss of corneal reflex for pain. Cerebellopontine lesion Chewing dysfunction Assess for difficulty in chewing. Sinus tract tumor and metastatic disease Discuss trigger zones and pain precipitants Compression of trigeminal root by tumor with patient. Protect cornea from abrasion. Ensure good oral hygiene. Educate patient about medication regimen. Facial Nerve—VII Bell’s palsy Facial dysfunction; weakness and paralysis Recognize facial paralysis as emergency; Facial nerve tumor Hemifacial spasm refer for treatment as soon as possible. Intracranial lesion Diminished or absent taste Teach protective care for eyes. Herpes zoster Pain Select easily chewed foods; patient should eat and drink from unaffected side of mouth. Emphasize importance of oral hygiene. Provide emotional support for changed appearance of face. Acoustic Nerve—VIII Tumors and acoustic neuroma Tinnitus Assess pattern of vertigo. Vascular compression of nerve Vertigo Provide for safety measures to prevent falls. Ménière’s syndrome Hearing difficulties Ensure that patient can obtain balance before ambulating. Caution patient to change positions slowly. Assist with ambulation. Encourage use of activity of daily living aids. Glossopharyngeal Nerve—IX Glossopharyngeal neuralgia from neuro- Pain at base of tongue Assess for paroxysmal pain in throat, vascular compression of cranial nerves IX Difficulty in swallowing decreased or absent swallowing, gag and X Loss of gag reflex and cough reflexes. Trauma Palatal, pharyngeal, and laryngeal paralysis Monitor for dysphagia, aspiration, nasal Inflammatory conditions dysarthric speech. Tumor Position patient upright for eating or tube Vertebral artery aneurysms feeding. Vagus Nerve—X Spastic palsy of larynx; bulbar paralysis; Voice changes (temporary or permanent Assess for airway obstruction/provide airway high vagal paralysis hoarseness) management. Guillain-Barré syndrome Vocal paralysis Prevent aspiration. Vagal body tumors Dysphagia Support patient having voice reconstruction Nerve paralysis from malignancy, procedures. surgical trauma such as carotid endarterectomy (continued) 1964 Unit 14 NEUROLOGIC FUNCTION

Table 64-1 • Disorders of Cranial Nerves (Continued)

DISORDER CLINICAL MANIFESTATIONS NURSING INTERVENTIONS Spinal Accessory Nerve—XI Spinal cord disorder Drooping of affected shoulder with limited Support patient undergoing diagnostic tests. Amyotrophic lateral sclerosis shoulder movement Trauma Weakness or paralysis of head rotation, Guillain-Barré syndrome flexion, extension; shoulder elevation Hypoglossal Nerve—XII Medullary lesions Abnormal movements of tongue Observe swallowing ability. Amyotrophic lateral sclerosis Weakness or paralysis of tongue muscles Observe speech pattern. Polio and motor system disease, which may Difficulty in talking, chewing, and Be aware of swallowing or vocal difficulties. destroy hypoglossal nuclei swallowing Prepare for alternate feeding methods (tube Multiple sclerosis feeding) to maintain nutrition. Trauma

are also used for pain control. If pain control is still not achieved, sionally by a vein. With the aid of an operating microscope, the phenytoin (Dilantin) may be used as adjunctive therapy (Rowland, artery loop is lifted from the nerve to relieve the pressure, and a 2000). small prosthetic device is inserted to prevent recurrence of im- Alcohol or phenol injection of the gasserian ganglion and pe- pingement on the nerve. This procedure relieves facial pain while ripheral branches of the trigeminal nerve relieves pain for several preserving normal sensation, but it is a major procedure, involving months. However, the pain returns with nerve regeneration. a craniotomy. The postoperative management is the same as for other intracranial surgeries (see Chap. 61). SURGICAL MANAGEMENT When these methods fail to relieve pain, a number of surgical Percutaneous Radiofrequency Trigeminal Gangliolysis. Percu- options are available. The choice of procedure depends on the taneous radiofrequency interruption of the gasserian ganglion, in patient’s preference and health status. which the small unmyelinated and thinly myelinated ﬁbers that conduct pain are thermally destroyed, is the surgical procedure of Microvascular Decompression of the Trigeminal Nerve. An in- choice for trigeminal neuralgia (Tronnier, Rasche, Hamer et al., tracranial approach can be used to decompress the trigeminal 2001). Use of stereotactic MRI for identiﬁcation of the trigemi- nerve. The pain may be caused by vascular compression of the nal nerve followed by gamma knife radiosurgery is being used at entry zone of the trigeminal root by an arterial loop and occa- some centers with good results (Maesawa et al., 2001).

Ophthalmic division (V1)

V1 Trigeminal nerve (V)

Mandibular division (V3) Maxillary division (V2)

FIGURE 64-7 Distribution of trigeminal nerve branches. Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1965

Under local anesthesia, the needle is introduced through the Facial cheek on the affected side. Under fluoroscopic guidance, the nerve needle electrode is guided through the foramen magnum into the gasserian ganglion. The divisions of the gasserian ganglion (mandibular, maxillary, and ophthalmic) are encountered se- quentially. The nerve is stimulated with a small current while the patient is awake. The patient reports when a tingling sensation is felt. When the electrode needle is in the desired position, the patient is anesthetized brieﬂy and a radiofrequency current (heating current to destroy the nerve) is passed in a controlled manner to injure the trigeminal ganglion and rootlets thermally. The patient is then awakened from the anesthesia and examined for sensory deﬁcits. This is repeated until the desired effect is achieved. The procedure takes less than 1 hour and provides permanent pain relief in most patients. Touch and proprioceptive functions are left intact. In the patient with trigeminal neuralgia and MS who is refractory to medical pain management, the surgical treatment of choice is trigeminal rhizotomy (Maloni, 2000). See Chapter 13 for care of the patient following a rhizotomy.

Nursing Management PREVENTING PAIN Preoperative management of a patient with trigeminal neuralgia occurs mostly on an outpatient basis and includes recognizing factors that may aggravate excruciating facial pain, such as food that is too hot or too cold or jarring the patient’s bed or chair. Even washing the face, combing the hair, or brushing the teeth may produce acute pain. The nurse can assist the patient in preventing or reducing this pain by providing instructions about preventive strategies. Providing cotton pads and room-temperature water for washing the face, instructing the patient to rinse with mouthwash after eating when tooth-brushing causes pain, and FIGURE 64-8 Distribution of facial nerve. performing personal hygiene during pain-free intervals are all effective strategies. The patient is instructed to take food and fluids at room temperature, to chew on the unaffected side, and to ingest soft foods. The nurse recognizes that anxiety, depression, 34 cases per 100,000; it increases with age and among pregnant and insomnia often accompany chronic painful conditions and women in the third trimester (Campbell & Brundage, 2002; uses appropriate interventions and referrals. (See Chap. 13 for Shmorgun, Chan & Ray, 2002). management of patients with chronic pain.) Bell’s palsy is considered by some to represent a type of pressure paralysis. The inflamed, edematous nerve becomes com- PROVIDING POSTOPERATIVE CARE pressed to the point of damage, or its nutrient vessel is occluded, Postoperative neurologic assessments are conducted to evaluate producing ischemic necrosis of the nerve. There is distortion of the patient for facial motor and sensory deficits in each of the the face from paralysis of the facial muscles; increased lacrimation three branches of the trigeminal nerve. If the surgery results in (tearing); and painful sensations in the face, behind the ear, and sensory deficits to the affected side of the face, the patient is in- in the eye. The patient may experience speech difficulties and structed not to rub the eye, because pain will not be felt if there may be unable to eat on the affected side because of weakness or is injury. The eye is assessed for irritation or redness. Artificial paralysis of the facial muscles. tears may be prescribed to prevent dryness in the affected eye. The patient is cautioned not to chew on the affected side until numb- Management ness has diminished. The patient is observed carefully for any difficulty in eating and swallowing foods of different consistency. The objectives of treatment are to maintain the muscle tone of the face and to prevent or minimize denervation. The patient BELL’S PALSY should be reassured that no stroke has occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Bell’s palsy (facial paralysis) is due to unilateral inflammation of Corticosteroid therapy (prednisone) may be prescribed to re- the seventh cranial nerve, which results in weakness or paralysis duce inflammation and edema; this reduces vascular compression of the facial muscles on the affected side (Fig. 64-8). The cause is and permits restoration of blood circulation to the nerve. Early unknown, although possible causes may include vascular ischemia, administration of corticosteroid therapy appears to diminish the viral disease (herpes simplex, herpes zoster), autoimmune disease, severity of the disease, relieve the pain, and prevent or minimize or a combination of all of these factors. The incidence is 13 to denervation. 1966 Unit 14 NEUROLOGIC FUNCTION

Facial pain is controlled with analgesic agents. Heat may be tient frequently describes some part of the extremity as numb. applied to the involved side of the face to promote comfort and Autonomic features include decreased or absent sweating, ortho- blood flow through the muscles. static hypotension, nocturnal diarrhea, tachycardia, impotence, Electrical stimulation may be applied to the face to prevent and atrophic skin and nail changes. muscle atrophy. Although most patients recover with conserva- Peripheral nerve disorders are diagnosed by history, physical tive treatment, surgical exploration of the facial nerve may be in- examination, EMG, and somatosensory evoked potentials. dicated in patients who are suspected of having a tumor or for surgical decompression of the facial nerve and for surgical treat- MONONEUROPATHY ment of a paralyzed face. Mononeuropathy is limited to a single peripheral nerve and its PROMOTING HOME AND COMMUNITY-BASED CARE branches. It arises when the trunk of the nerve is compressed or entrapped (as in carpal tunnel syndrome); traumatized, as when Teaching Patients Self-Care. While the paralysis lasts, the in- bruised by a blow, or overstretched, as in joint dislocation; punc- volved eye must be protected. Frequently, the eye does not close tured by a needle used to inject a drug or damaged by the drugs completely and the blink reflex is diminished, so the eye is vul- thus injected; or inflamed because an adjacent infectious process nerable to dust and foreign particles. Corneal irritation and ul- extends to the nerve trunk. Mononeuropathy frequently is seen ceration may occur if the eye is unprotected. Distortion of the in patients with diabetes. lower lid alters the proper drainage of tears. To prevent injury, Pain is seldom a major symptom of mononeuropathy when the eye should be covered with a protective shield at night. The the condition is due to trauma, but in patients with complicating eye patch may abrade the cornea, however, because there is some inflammatory conditions such as arthritis, pain is prominent. difficulty in keeping the partially paralyzed eyelids closed. The Pain is increased by all body movements that tend to stretch, strain, application of eye ointment at bedtime causes the eyelids to ad- or cause pressure on the injured nerve and by sudden jarring of here to one another and remain closed during sleep. The patient the body (eg, coughing and sneezing). The skin in the areas sup- can be taught to close the paralyzed eyelid manually before going plied by nerves that are injured or diseased may become reddened to sleep. Wrap-around sunglasses or goggles may be worn to de- and glossy; the subcutaneous tissue may become edematous, and crease normal evaporation from the eye. the nails and hair in this area become defective. Chemical injuries to a nerve trunk, such as those caused by drugs injected into or Continuing Care. When the sensitivity of the nerve to touch de- near it, are often permanent. creases and the patient can tolerate touching the face, the nurse The objective of treatment of mononeuropathy is to remove the can suggest massaging the face several times daily, using a gentle cause, if possible, such as by freeing the compressed nerve. Local upward motion, to maintain muscle tone. Facial exercises, such corticosteroid injections may reduce inflammation and the pres- as wrinkling the forehead, blowing out the cheeks, and whistling, sure on the nerve. Aspirin or codeine may be used to relieve pain. may be performed with the aid of a mirror in an effort to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided. Critical Thinking Exercises Disorders of the Peripheral Nervous System ?? 1. A 19-year-old college student is suspected of having PERIPHERAL NEUROPATHIES meningococcal meningitis. Identify two neurologic changes A peripheral neuropathy (disorder of the nervous system) is a that may reflect increased ICP. What interventions would disorder affecting the peripheral motor, sensory, or autonomic be included in your plan of care to protect the patient from nerves. Peripheral nerves connect the spinal cord and brain to all injury? The patient’s family has many questions about the other organs. They transmit motor impulses from the brain and disease and their risk of contracting meningitis. Develop a relay sensory impulses to the brain. A mononeuropathy affects a teaching plan that would describe meningococcal meningitis single peripheral nerve; multiple mononeuropathy or mono- and prophylactic therapy for the patient’s family and close neuritis multiplex indicates the involvement of multiple single contacts. peripheral nerves or their branches. Polyneuropathies are charac- 2. Your patient has been receiving one of the injectable terized by bilateral and symmetric disturbance of function, usually interferon medications for the treatment of MS for about beginning in the feet and hands. (Most nutritional, metabolic, 6 months. She reports that she is becoming very discouraged and toxic neuropathies take this form.) because the medication does not seem to improve her symp- The most common causes of peripheral neuropathy are dia- toms. In addition, she reports that she has developed skin betes, alcoholism, and occlusive vascular disease. These disorders lesions at the injection sites. Identify the areas of assessment result in hypoxia or atrophy of the peripheral nerve. Many bac- that are of priority at this time. Describe nursing interven- terial and metabolic toxins and exogenous poisons also cause pe- tions, including teaching and referral, that you would con- ripheral neuropathy. Because of the growing use of chemicals in sider at this time. Provide the rationale for your interventions. industry, agriculture, and medicine, the number of substances causing peripheral neuropathies and the incidence of peripheral 3. Your patient has been admitted to the hospital with a neuropathies have increased. In developing countries, leprosy is diagnosis of possible Guillain-Barré. Identify the priorities a major cause of severe nerve disease because Mycobacterium leprae of assessment for this patient and the nursing and medical invade the peripheral nervous system. interventions that you would anticipate. The major symptoms of peripheral nerve disorders are loss of 4. Your patient has myasthenia gravis. Although she reports sensation, muscle atrophy, weakness, diminished reflexes, pain, that her condition has been stable and that she has been able and paresthesia (numbness, tingling) of the extremities. The pa- Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1967

to manage without assistance, she reports increasing weakness Roos, K. (1999). Encephalitis. Neurologic Clinics, 17(4), 813–834. and fatigue. What nursing assessments and interventions are Rubin, L. (2000). Pneumococcal vaccine. Pediatric Clinics of North warranted for her? What discharge plans are indicated if she America, 47(2), 269–283. is to return home to the care of her family? How would your Rosenstein, N. E., & Perkins, B. (2000). Update on Haemophilus in- discharge planning change if she lives alone in an apartment fluenzae serotype b and meningococcal vaccines. Pediatric Clinics of North America, 47(2), 337–348. on the second floor of a building without an elevator? Rosenstein, N. E., Perkins, B. A., Stephens, D. S., et al. (2001). 5. A 52-year-old man has just been diagnosed with trigemi- Meningococcal disease. New England Journal of Medicine, 334(18), nal neuralgia. Tegretol has been prescribed for pain manage- 1378–1388. ment. 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LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Identify the pathophysiologic processes responsible for oncologic disorders. 2. Describe brain and spinal cord tumors: their classiﬁcation, clinical manifestations, diagnosis, and medical and nursing management. 3. Use the nursing process as a framework for care of patients with cerebral metastases or inoperable brain tumors. 4. Identify the pathophysiologic processes responsible for various degenerative neurologic disorders. 5. Use the nursing process as a framework for care of patients with degenerative neurologic disorders. 6. Identify resources for patients and families with oncologic and degenerative neurologic disorders.

1969 1970 Unit 14 NEUROLOGIC FUNCTION Disease processes that are oncologic or degenerative produce a (DeAngelis, 2001). Additional possible causes have been investi- unique set of problems when they occur in the neurologic system. gated, but results of studies are conflicting and unconvincing; Oncologic processes include brain and spinal cord tumors. suggested causes have included use of cellular telephones, expo- Degenerative neurologic disorders include Parkinson’s disease, sure to high-tension wires, use of hair dyes, head trauma, dietary Huntington’s disease, Alzheimer’s disease, amyotrophic lateral exposure to such factors as nitrates (found in some processed and sclerosis, muscular dystrophies, and degenerative disc disease. A barbecued foods), and other sources (DeAngelis, 2001). relatively new phenomenon, post-polio syndrome, may be de- The incidence of brain tumors appears to have increased in the generative in nature and is therefore included in this chapter. past few decades. Epidemiologic data, however, suggest that this is due more to aggressive and accurate diagnosis rather than to an actual rise in incidence. It is estimated that there are about 17,000 Oncologic Disorders of the Brain new cases of primary brain tumors per year, 9,600 in men and 7,400 in women (American Cancer Society, 2002). Secondary and Spinal Cord tumors or metastases to the brain from a systemic primary cancer Oncologic disorders in the brain and spinal cord include several are more common (DeAngelis, 2001). The highest incidence of types of neoplasms, each with its own biology, prognosis, and brain tumors in adults occurs in the fifth, sixth, and seventh treatment options. Because of the unique anatomy and physiol- decades, with a slightly higher incidence in men. In adults, most ogy of the central nervous system (CNS), this collection of neo- brain tumors originate from glial cells (glial cells make up the plasms is challenging to diagnose and treat. The pathophysiology, structure and support system of the brain and spinal cord) and clinical manifestations, assessment findings, and medical and are supratentorial (located above the covering of the cerebellum). nursing management of brain tumors and spinal cord tumors are Neoplastic lesions in the brain ultimately cause death by impair- discussed in the following sections. ing vital functions, such as respiration, or by increasing intracranial pressure (ICP).

PRIMARY BRAIN TUMORS Pathophysiology A brain tumor is a localized intracranial lesion that occupies space Brain tumors may be classified into several groups: those arising within the skull. Tumors usually grow as a spherical mass, but from the coverings of the brain (eg, dural meningioma), those de- they can grow diffusely and infiltrate tissue. The effects of neo- veloping in or on the cranial nerves (eg, acoustic neuroma), those plasms occur from the compression and infiltration of tissue. A originating within brain tissue (eg, gliomas), and metastatic le- variety of physiologic changes result, causing any or all of the fol- sions originating elsewhere in the body. Tumors of the pituitary lowing pathophysiologic events: and pineal glands and of cerebral blood vessels are also types of • Increased intracranial pressure (ICP) and cerebral edema brain tumors. Relevant clinical considerations include the loca- • Seizure activity and focal neurologic signs tion and the histologic character of the tumor. Tumors may be • Hydrocephalus benign or malignant. A benign tumor can occur in a vital area • Altered pituitary function and can grow large enough to have effects as serious as those of a malignant tumor. Primary brain tumors originate from cells and structures within the brain. Secondary, or metastatic, brain tumors develop GLIOMAS from structures outside the brain and occur in 20% to 40% of all Glial tumors, the most common type of brain neoplasm, are di- patients with cancer. Brain tumors rarely metastasize outside the vided into many categories (DeAngelis, 2001). See Chart 65-1 CNS, but metastatic lesions to the brain occur commonly from for the classification of brain tumors. Astrocytomas are the most the lung, breast, lower gastrointestinal tract, pancreas, kidney, common type of glioma and are graded from I to IV, indicating and skin (melanomas). the degree of malignancy. The grade is based on cellular density, The cause of primary brain tumors is unknown. The only cell mitosis, and appearance. Usually, these tumors spread by in- known risk factor is exposure to ionizing radiation. Both glial filtrating into the surrounding neural connective tissue and there- and meningeal neoplasms have been linked to irradiation of the fore cannot be totally removed without causing considerable cranium, with a latency period of 10 to 20 years after exposure damage to vital structures. Glossary akathisia: restlessness, urgent need to move dyskinesia: impaired ability to execute vol- paresthesia: a sensation of numbness, around, and agitation untary movements tingling, or a “pins and needles” sensation bradykinesia: very slow voluntary move- dysphonia: abnormal voice quality caused radiculopathy: disease of a spinal nerve ments and speech by weakness and incoordination of mus- root, often resulting in pain and extreme chorea: rapid, jerky, involuntary, purpose- cles responsible for speech sensitivity to touch less movements of the extremities or facial micrographia: very minute and often illegi- sciatica: inflammation of the sciatic nerve, muscles, including facial grimacing ble handwriting resulting in pain and tenderness along the dementia: a progressive organic mental dis- neurodegenerative: a disease, process, or nerve through the thigh and leg order characterized by personality condition that leads to deterioration of spondylosis: degenerative arthritis or osteo- changes, confusion, disorientation, and normal cells or function of the nervous arthritis of the cervical or lumbar verte- deterioration of intellect associated with system brae, resulting in stiffness of the vertebral impaired memory and judgment papilledema: edema of the optic nerve joint Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1971

hypothalamus by a short stalk (hypophyseal stalk) and is divided Chart Classification of Adult Brain Tumors 65-1 into two lobes: the anterior (adenohypophysis) and the posterior (neurohypophysis). I. Intracerebral Tumors A. Gliomas—infiltrate any portion of the brain; most Pressure Effects of Pituitary Adenomas. Pressure from a pitu- common type of brain tumor 1. Astrocytomas (grades I and II) itary adenoma may be exerted on the optic nerves, optic chiasm, 2. Glioblastoma multiforme (astrocytoma grades III or optic tracts or on the hypothalamus or the third ventricle when and IV) the tumor invades the cavernous sinuses or expands into the sphe- 3. Oligodendrocytoma (low and high grades) noid bone. These pressure effects produce headache, visual dys- 4. Ependymoma (grades I to IV) function, hypothalamic disorders (eg, disorders of sleep, appetite, 5. Medulloblastoma temperature and emotions), increased ICP, and enlargement and II. Tumors Arising From Supporting Structures erosion of the sella turcica. A. Meningiomas B. Neuromas (acoustic neuroma, schwannoma) Hormonal Effects of Pituitary Adenomas. Functioning pituitary C. Pituitary adenomas tumors can produce one or more hormones normally produced III. Developmental Tumors by the anterior pituitary. These hormones may cause prolactin- A. Angiomas secreting pituitary adenomas (prolactinomas), growth hormone- B. Dermoid, epidermoid, teroma, craniopharyngioma secreting pituitary adenomas that produce acromegaly in adults, IV. Metastatic Lesions and adrenocorticotropic hormone (ACTH)-producing pituitary adenomas that result in Cushing’s disease. Adenomas that secrete thyroid-stimulating hormone or follicle-stimulating hormone Oligodendroglial tumors are another type of glial tumor, rep- and luteinizing hormone occur infrequently, whereas adenomas resenting 20% of gliomas (DeAngelis, 2001). The histologic that produce both growth hormone and prolactin are relatively distinction between astrocytomas and oligodendrogliomas is common. difficult to make but important, as recent research shows that The female patient whose pituitary gland is secreting excessive oligodendrogliomas are more sensitive to chemotherapy than quantities of prolactin presents with amenorrhea or galactorrhea astrocytomas. These tumors are categorized as low-grade and high- (excessive or spontaneous flow of milk). Male patients with pro- grade (anaplastic). lactinomas may present with impotence and hypogonadism. Acromegaly, caused by excess growth hormone, produces en- MENINGIOMAS largement of the hands and feet, distortion of the facial features, Meningiomas, which represent 20% of all primary brain tumors, and pressure on peripheral nerves (entrapment syndromes). The are common benign encapsulated tumors of arachnoid cells on clinical features of Cushing’s disease, a condition associated with the meninges (DeAngelis, 2001). They are slow-growing and prolonged overproduction of cortisol, occur with excessive pro- occur most often in middle-aged adults (more often in women). duction of ACTH. Manifestations include a form of obesity with redistribution of fat to the facial, supraclavicular, and abdominal Meningiomas most often occur in areas proximal to the venous areas; hypertension; purple striae and ecchymoses; osteoporosis; sinuses. Manifestations depend on the area involved and are the elevated blood glucose levels; and emotional disorders. result of compression rather than invasion of brain tissue. Standard treatment is surgery with complete removal or partial dissection. ANGIOMAS Brain angiomas (masses composed largely of abnormal blood ves- ACOUSTIC NEUROMAS sels) are found either in or on the surface of the brain. They occur An acoustic neuroma is a tumor of the eighth cranial nerve, the in the cerebellum in 83% of cases. Some persist throughout life cranial nerve most responsible for hearing and balance. It usually without causing symptoms; others cause symptoms of a brain arises just within the internal auditory meatus, where it frequently tumor. Occasionally, the diagnosis is suggested by the presence expands before filling the cerebellopontine recess. of another angioma somewhere in the head or by a bruit (an ab- An acoustic neuroma may grow slowly and attain considerable normal sound) audible over the skull. Because the walls of the size before it is correctly diagnosed. The patient usually experi- blood vessels in angiomas are thin, these patients are at risk for a ences loss of hearing, tinnitus, and episodes of vertigo and stag- cerebral vascular accident (stroke). In fact, cerebral hemorrhage gering gait. As the tumor becomes larger, painful sensations of the in people younger than 40 years of age should suggest the possi- face may occur on the same side as a result of the tumor’s com- bility of an angioma. pression of the fifth cranial nerve. With improved imaging techniques and the use of the oper- Clinical Manifestations ating microscope and microsurgical instrumentation, even large tumors can be removed through a relatively small craniotomy. Brain tumors can produce either focal or generalized neurologic Some of these tumors may be suitable for stereotactic radiother- signs and symptoms. Generalized symptoms reflect increased apy rather than surgery. See the discussion of stereotactic radio- ICP, and the most common focal or specific signs and symptoms therapy later in this chapter. result from tumors interfering with functions in specific brain regions. Figure 65-1 indicates common tumor sites in the brain. PITUITARY ADENOMAS Pituitary tumors represent about 8% to 12% of all brain tumors INCREASING ICP and cause symptoms as a result of pressure on adjacent structures As discussed in Chapter 61, the skull is a rigid compartment con- or hormonal changes (hyperfunction or hypofunction of the pi- taining essential noncompressible contents: brain matter, intra- tuitary). The pituitary gland, also called the hypophysis, is a rel- vascular blood, and cerebrospinal fluid (CSF). According to the atively small gland located in the sella turcica. It is attached to the modified Monro-Kellie hypothesis, if any one of these skull 1972 Unit 14 NEUROLOGIC FUNCTION

Corpus callosum Lateral ventricle astrocytoma ependymoma oligodendroglioma glioblastoma multiforme lipoma Third ventricle and area ependymoma Cerebrum astrocytoma oligodendroglioma lymphoma metastatic tumors

Pineal area pineocytoma pineoblastoma

Optic chiasm astrocytoma

Pituitary area craniopharyngioma Acoustic nerve pituitary adenoma neuroma Cerebellum epidermoid cyst medulloblastoma astrocytoma Brain stem hemangioblastoma astrocytoma metastatic tumors glioblastoma multiforme metastatic tumors

Fourth ventricle ependymoma

FIGURE 65-1 Common brain tumor sites. components increases in volume, ICP increases unless one of the described as deep or expanding or as dull but unrelenting. Frontal other components decreases in volume. Consequently, any change tumors usually produce a bilateral frontal headache; pituitary in volume occupied by the brain (as occurs with disorders such as gland tumors produce pain radiating between the two temples brain tumor or cerebral edema) produces signs and symptoms (bitemporal); in cerebellar tumors, the headache may be located of increased ICP. in the suboccipital region at the back of the head. Symptoms of increased ICP result from a gradual compression of the brain by the enlarging tumor. The effect is a disruption of Vomiting. Vomiting, seldom related to food intake, is usually the equilibrium that exists between the brain, the CSF, and the due to irritation of the vagal centers in the medulla. If the vom- cerebral blood, all located within the skull. As the tumor grows, iting is of the forceful type, it is described as projectile vomiting. compensatory adjustments may occur through compression of intracranial veins, reduction of CSF volume (by increased ab- Visual Disturbances. Papilledema (edema of the optic nerve) is sorption or decreased production), a modest decrease of cerebral present in 70% to 75% of patients and is associated with visual blood flow, and reduction of intracellular and extracellular brain disturbances such as decreased visual acuity, diplopia (double tissue mass. When these compensatory mechanisms fail, the pa- vision), and visual field deficits. tient develops signs and symptoms of increased ICP. The three most common signs of increased ICP are headache, nausea and LOCALIZED SYMPTOMS vomiting, and a sixth-nerve palsy (DeAngelis, 2001). Personality The most common focal or localized symptoms are hemiparesis, changes and a variety of focal deficits, including motor, sensory, seizures, and mental status changes (DeAngelis, 2001). When and cranial nerve dysfunction, are also common. specific regions of the brain are affected, additional local signs and symptoms occur, such as sensory and motor abnormalities, visual Headache. Headache, although not always present, is most com- alterations, alterations in cognition, and language disturbances mon in the early morning and is made worse by coughing, strain- such as aphasia. The progression of the signs and symptoms is ing, or sudden movement. It is thought to be caused by the tumor important because it indicates tumor growth and expansion. For invading, compressing, or distorting the pain-sensitive structures example, a rapidly developing hemiparesis is more typical of a highly or by edema that accompanies the tumor. Headaches are usually malignant glioma than a low-grade tumor (DeAngelis, 2001). Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1973

Although some tumors are not easily localized because they lie in so-called silent areas of the brain (ie, areas in which functions are not definitely determined), many tumors can be localized by correlating the signs and symptoms to known areas of the brain, as follows: • A motor cortex tumor produces seizure-like movements localized on one side of the body, called Jacksonian seizures. • An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations. • A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction. • A frontal lobe tumor frequently produces personality disorders, changes in emotional state and behavior, and an un- interested mental attitude. The patient often becomes extremely untidy and careless and may use obscene language. • A cerebellopontine angle tumor usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms. Tinnitus and vertigo appear first, soon followed by progressive nerve deafness (eighth cranial nerve dysfunction). Numbness and tingling of the face and FIGURE 65-2 Low-grade glioma. MRI of the brain shows a mass of the tongue occur (due to involvement of the fifth cranial abnormal density in the right temporal lobe. Courtesy of the Hospital of the nerve). Later, weakness or paralysis of the face develops University of Pennsylvania, Nuclear Medicine Section, Philadelphia, (seventh cranial nerve involvement). Finally, because the Pennsylvania. enlarging tumor presses on the cerebellum, abnormalities in motor function may be present.

Assessment and Diagnostic Findings Gerontologic Considerations The history of the illness and the manner and time frame in Intracranial tumors can produce personality changes, confusion, which the symptoms evolved are key components in the diagno- speech dysfunction, or disturbances of gait. In elderly patients sis of brain tumors. A neurologic examination indicates the areas early signs and symptoms of intracranial tumors can be easily of the CNS involved. To assist in the precise localization of the overlooked and incorrectly attributed to cognitive and neurologic lesion, a battery of tests is performed. Computed tomography changes associated with normal aging. The most frequent tumor (CT) scans, enhanced by a contrast agent, can give specific infor- types in the elderly are anaplastic astrocytoma, glioblastoma multi- mation concerning the number, size, and density of the lesions forme, and cerebral metastases from other sites. The incidence of and the extent of secondary cerebral edema. CT scans can pro- primary brain tumors and the likelihood of malignancy increase vide information about the ventricular system. Magnetic reso- with age. Signs and symptoms in the elderly must be carefully nance imaging (MRI) is the most helpful diagnostic tool for evaluated because 10% of brain metastases occur in patients with detecting brain tumors, particularly smaller lesions, and tumors a history of prior cancer (Rude, 2000). in the brain stem and pituitary regions, where bone interferes with CT (Fig. 65-2). In a few instances, the appearance of a brain Medical Management tumor on an MRI is so characteristic that a biopsy is unnecessary, especially when the tumor is located in a part of the brain that is A variety of medical treatment modalities, including chemother- difficult to biopsy (American Cancer Society, 2001). apy and external-beam radiation therapy, are used alone or in In centers where positron emission tomography (PET) is avail- combination with surgical resection. Radiation therapy, the corner- able, it is used to supplement MRI. On PET scans, low-grade tu- stone of treatment of many brain tumors, decreases the incidence mors are associated with hypometabolism and high-grade tumors of recurrence of incompletely resected tumors. Brachytherapy show hypermetabolism. This information can be useful in treat- (the surgical implantation of radiation sources to deliver high ment decisions (DeAngelis, 2001). Computer-assisted stereotactic doses at a short distance) has had promising results for primary (three-dimensional) biopsy is being used to diagnose deep-seated malignancies. It is generally used as an adjunct to conventional brain tumors and to provide a basis for treatment and prognosis. radiation therapy or as a rescue measure for recurrent disease. Cerebral angiography provides visualization of cerebral blood Intravenous (IV) autologous bone marrow transplantation is vessels and can localize most cerebral tumors. used in some patients who will receive chemotherapy or radiation An electroencephalogram (EEG) can detect an abnormal therapy because it has the potential to “rescue” the patient from the brain wave in regions occupied by a tumor and is used to evalu- bone marrow toxicity associated with high doses of chemother- ate temporal lobe seizures and assist in ruling out other disorders. apy and radiation. A fraction of the patient’s bone marrow is as- Cytologic studies of the CSF may be performed to detect ma- pirated, usually from the iliac crest, and stored. The patient receives lignant cells because CNS tumors can shed cells into the CSF. large doses of chemotherapy or radiation therapy to destroy large 1974 Unit 14 NEUROLOGIC FUNCTION numbers of malignant cells. The marrow is then reinfused intra- tumor, which theoretically leaves behind fewer cells to become venously after treatment is completed. resistant to radiation or chemotherapy. Corticosteroids may be used before and after treatment to Stereotactic approaches involve use of a three-dimensional reduce cerebral edema and promote a smoother, more rapid re- frame that allows very precise localization of the tumor; a stereo- covery. Gene-transfer therapy uses retroviral vectors to carry genes tactic frame and multiple imaging studies (x-rays, CT scans) are to the tumor, reprogramming the tumor tissue for susceptibil- used to localize the tumor and verify its position (Fig. 65-3). New ity to treatment. This approach is being tested. brain-mapping technology helps determine how close diseased A new technique being investigated is photodynamic therapy. areas of the brain are to structures essential for normal brain This is a treatment of primary malignant brain tumors that de- function. Lasers or radiation can be delivered with stereotactic ap- livers a targeted therapy while conserving healthy brain tissue proaches. Radioisotopes such as iodine 131 (131I) can also be im- (Goodell & Muller, 2001). planted directly into the tumor to deliver high doses of radiation to the tumor (brachytherapy) while minimizing effects on sur- SURGICAL MANAGEMENT rounding brain tissue. The objective of surgical management is to remove or destroy the The use of the gamma knife to perform radiosurgery allows entire tumor without increasing the neurologic deficit (paralysis, deep, inaccessible tumors to be treated, often in a single session. blindness) or to relieve symptoms by partial removal (decom- Precise localization of the tumor is accomplished using the stereo- pression). A variety of treatment modalities may be used; the spe- tactic approach and by minute measurements and precise posi- cific approach depends on the type of tumor, its location, and tioning of the patient. Multiple narrow beams then deliver a very accessibility. In many patients, combinations of these modalities high dose of radiation. An advantage of this method is that no may be used. Most pituitary adenomas are treated by transsphe- surgical incision is needed; a disadvantage is the lag time between noidal microsurgical removal (see Chap. 61), whereas the re- treatment and the desired result (Rafferty-Mitchell, Scanlon & mainder of tumors that cannot be removed completely are treated Laskowski-Jones, 1999). by radiation. An untreated brain tumor ultimately leads to death, either from increasing ICP or from the damage to brain tissue it causes. Nursing Management Conventional surgical approaches require an incision into the skull (craniotomy). See Chapter 61 for a discussion of care of the The patient with a brain tumor may be at an increased risk for as- patient following craniotomy. This approach is used in patients piration due to cranial nerve dysfunction. Preoperatively, the gag with meningiomas, acoustic neuromas, cystic astrocytomas of the reflex and ability to swallow are evaluated. In patients with di- cerebellum, colloid cysts of the third ventricle, congenital tumors minished gag response, care includes teaching the patient to direct such as dermoid cyst, and some of the granulomas. For patients food and fluids toward the unaffected side, having the patient sit with malignant glioma, complete removal of the tumor and cure upright to eat, offering a semisoft diet, and having suction readily are not possible, but the rationale for resection includes relieving available. Function should be reassessed postoperatively because ICP, removing any necrotic tissue, and reducing the bulk of the changes can occur.

A B

FIGURE 65-3 (A) Using stereotactic or “brain-mapping” guided approach, a 3-D computer image fuses the CT and MRI to pinpoint the exact location of the brain tumor. This low-grade astrocytoma is localized adjacent to the brain stem, is nonoperable, and is treated with radiation. Note the optic chasm and optic nerves. (B) Computerized image of the prescribed radiation dose. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1975

The effects of increased ICP caused by the tumor mass are re- in ICP. Antiseizure agents (eg, phenytoin) are used to prevent viewed in Chapter 61. The nurse performs neurologic checks, and treat seizures (Nevidjon & Sowers, 2000). Venous throm- monitors vital signs, maintains a neurologic flow chart, spaces boembolic events, such as deep vein thrombosis (DVT) and pul- nursing interventions to prevent rapid increase in ICP, and re- monary embolism (PE), occur in about 15% of patients and are orients the patient when necessary to person, time, and place. Pa- associated with significant morbidity. Anticoagulants are gener- tients with changes in cognition caused by the lesion require ally not prescribed because of the risk for CNS hemorrhage; how- frequent reorientation and the use of orienting devices (personal ever, prophylactic therapy with low-molecular-weight heparin is possessions, photographs, lists, clock), supervision of and assis- under investigation. tance with self-care, and ongoing monitoring and intervention Chemotherapy plays a small role in managing brain metastasis for prevention of injury. Patients with seizures are carefully mon- as a result of poor penetration across the blood–brain barrier. itored and protected from injury. Poor drug penetration and sensitivity of brain cells are two factors Motor function is checked at intervals because specific motor that determine the responsiveness of metastatic brain tumors to deficits may occur, depending on the tumor’s location. Sensory chemotherapy. Research is being directed at multidrug regimens disturbances are assessed. Speech is evaluated. Eye movement and and drug resistance (American Cancer Society, 2001). Encourag- pupillary size and reaction may be affected by cranial nerve in- ing results have been seen with chemotherapeutic agents such as volvement. In one study that examined the experience of brain carmustine (BCNU), lomustine (CCNU), and PCV (a triple- tumor patients 3 to 5 days postoperatively, the basic needs of drug combination of procarbazine hydrochloride, lomustine, and patients were met, but changes suggested included minimizing vincristine). Promising results have been seen with the use of the atmosphere of urgency and hurry, appointing a primary nurse topotecan (Hycamtin), another chemotherapy agent. for each patient, and giving more postoperative information Pain is managed in a stepladder progression in the doses and (Lepola et al., 2001). The nursing process for patients undergoing type of analgesic agents needed for relief. If the patient has severe neurosurgery is discussed in Chapter 61. pain, morphine can be infused into the epidural or subarachnoid space through a spinal needle and a catheter as near as possible to CEREBRAL METASTASES the spinal segment where the pain is projected. Small doses of morphine are administered at prescribed intervals (see Chap. 13). A significant number of patients with cancer experience neurologic deficits caused by metastasis to the brain. Metastatic lesions NURSING PROCESS: to the brain constitute the most common neurologic complica- THE PATIENT WITH CEREBRAL tion, occurring in 20% to 30% of patients with cancer (Nevidjon & Sowers, 2000). This becomes important clinically as more pa- METASTASES OR INCURABLE tients with all forms of cancer live longer as a result of improved BRAIN TUMOR therapies. Neurologic signs and symptoms include headache, Assessment gait disturbances, visual impairment, personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis, The nursing assessment includes a baseline neurologic examina- aphasia, and seizures. These signs and symptoms can be devas- tion and focuses on how the patient is functioning, moving, and tating to both patient and family. walking; adapting to weakness or paralysis and to visual and speech loss; and dealing with seizures. Assessment addresses symptoms Medical Management that cause distress to the patient, including pain, respiratory problems, bowel and bladder disorders, sleep disturbances, and The treatment of metastatic brain cancer is palliative and involves impairment of skin integrity, fluid balance, and temperature reg- eliminating or reducing serious symptoms. Even when palliation ulation. Tumor invasion, compression, or obstruction may cause is the goal, distressing signs and symptoms can be relieved, thereby these disorders. improving the quality of life for both the patient and family. Pa- Nutritional status is assessed because cachexia (weak and ema- tients with intracerebral metastases who are not treated have a ciated condition) is common in patients with metastases. The steady downhill course with a limited survival time, whereas those nurse explores changes associated with poor nutritional status who are treated may survive for slightly longer periods. The me- (anorexia, pain, weight loss, altered metabolism, muscle weakness, dian survival for patients with no treatment for brain metastases malabsorption, and diarrhea) and asks the patient about altered is 1 month; with corticosteroid treatment alone it is 2 months; taste sensations that may be secondary to dysphagia, weakness, radiation therapy extends the median survival to 3 to 6 months and depression and about distortions and impaired sense of smell (Nevidjon & Sowers, 2000). (anosmia). The therapeutic approach includes radiation therapy (the The nurse takes a dietary history to assess food intake, intol- foundation of treatment), surgery (usually for a single intracranial erance, and preferences. Calculation of body mass index can con- metastasis), and chemotherapy; more often some combination firm the loss of subcutaneous fat and lean body mass (see Chap. 5). of these treatments is the optimal method. Gamma knife radio- Biochemical measurements (albumin, transferrin, total lympho- surgery is considered when three or fewer lesions are present. cyte count, creatinine index, and urinary tests) are reviewed to assess the degree of malnutrition, impaired cellular immunity, and PHARMACOLOGIC THERAPY electrolyte balance. A dietitian assists in determining the caloric Corticosteroids are useful in relieving headache and alterations in needs of the patient. level of consciousness. It is thought that corticosteroids (dexa- The nurse works with other members of the health care team methasone, prednisone) reduce inflammation around the metasta- to assess the impact of the illness on the family in terms of home tic deposits and decrease the edema surrounding them. Other care, altered relationships, financial problems, time pressures, and medications used include osmotic agents (mannitol, glycerol) to family problems. This information is important in helping family decrease the fluid content of the brain, which leads to a decrease members cope with the diagnosis and changes associated with it. 1976 Unit 14 NEUROLOGIC FUNCTION

Diagnosis The patient needs to be clean, comfortable, and free of pain for meals, in an environment that is as attractive as possible. Oral NURSING DIAGNOSES hygiene before meals helps to improve intake. Offensive sights, Based on the assessment data, the patient’s major nursing diag- sounds, and odors are eliminated. Creative strategies may be re- noses may include the following: quired to make food more palatable, provide enough fluids, and • Self-care deficit (feeding, bathing, and toileting) related to increase opportunities for socialization during meals. The family loss or impairment of motor and sensory function and de- may be asked to keep a daily weight chart and to record the quan- creased cognitive abilities tity of food eaten to determine the daily calorie count. Dietary • Imbalanced nutrition, less than body requirements, related supplements, if acceptable to the patient, can be provided to meet to cachexia due to treatment and tumor effects, decreased increased caloric needs. If the patient is not interested in most nutritional intake, and malabsorption usual foods, those foods preferred by the patient should be of- • Anxiety related to fear of dying, uncertainty, change in ap- fered. When the patient shows marked deterioration as a result of pearance, altered lifestyle tumor growth and effects, some other form of nutritional support • Interrupted family processes related to anticipatory grief (eg, tube feeding, parenteral nutrition) may be indicated if con- and the burdens imposed by the care of the person with a sistent with the patient’s end-of-life preferences. Nursing inter- terminal illness ventions include assessing the patency of the central and IV line or feeding tube, monitoring the insertion site for infection, check- Other nursing diagnoses of the patient with cerebral metas- ing the infusion rate, monitoring intake and output, and chang- tases may include acute pain related to tumor compression; im- ing the IV tubing and dressing. Family members are instructed paired gas exchange related to dyspnea; constipation related to in these techniques if they will be providing care at home. Par- decreased fluid and dietary intake and medications; impaired uri- enteral nutrition can also be provided at home if indicated. nary elimination related to reduced fluid intake, vomiting, and The patient’s quality of life may guide the selection, initiation, reactions to medications; sleep pattern disturbances related to dis- and maintenance of nutritional support. The nurse and family comfort and fear of dying; impairment of skin integrity related to should not place too much emphasis on eating or on discussions cachexia, poor tissue perfusion, and decreased mobility; deficient about food as the patient may not desire aggressive nutritional in- fluid volume related to fever, vomiting, and low fluid intake; and tervention. The subsequent course of action must be congruent ineffective thermoregulation related to hypothalamic involve- with the wishes and choices of the patient and family. ment, fever, and chills. See Chapter 16 for assessment and nursing interventions for the patient with cancer. RELIEVING ANXIETY Patients with cerebral metastases may be restless, with changing moods that may include intense depression, euphoria, paranoia, Planning and Goals and severe anxiety. The response of patients to terminal illness re- The goals for the patient may include compensating for self-care flects their pattern of reaction to other crisis situations. Serious deficits, improving nutrition, reducing anxiety, enhancing fam- illness imposes additional strains that often bring other unre- ily coping skills, and absence of complications. solved problems to light. The patient’s own coping strategies can help deal with anxious and depressed feelings. Caregivers need to be sensitive to the patient’s concerns and fears. Nursing Interventions Patients need the opportunity to exercise some control over their situation. A sense of mastery can be gained as they learn to COMPENSATING FOR SELF-CARE DEFICITS understand the disease and its treatment and how to deal with The patient may have difficulty participating in goal setting as the their feelings. The presence of family, friends, a spiritual advisor, tumor metastasizes and affects cognitive function. It is important and health professionals may be supportive. Support groups such to encourage the family to keep the patient as independent as pos- as the Brain Tumor Support Group may provide a feeling of sup- sible for as long as possible. Increasing assistance with self-care ac- port and strength. tivities is required. Because the patient with cerebral metastasis Spending time with patients allows them time to talk and to and the family live with uncertainty, they are encouraged to plan communicate their fears and concerns. Open communication for each day and to make the most of each day. The tasks and and acknowledging fears are often therapeutic. Touch is also a challenges are to assist the patient to find useful coping mecha- form of communication. These patients need reassurance that nisms, adaptations, and compensations in solving problems that continuing care will be provided and that they will not be aban- arise. This helps patients maintain some sense of control. An in- doned. The situation becomes more endurable when others share dividualized exercise program helps maintain strength, endurance, in the experience of dying. If a patient’s emotional reactions are and range of motion. Eventually, referral for home or hospice very intense or prolonged, additional help from a spiritual advi- care may be necessary (see Chap. 17). sor, social worker, or mental health professional may be indicated.

IMPROVING NUTRITION ENHANCING FAMILY PROCESSES Patients with nausea, vomiting, diarrhea, breathlessness, and pain The family needs to be reassured that their loved one is receiving are rarely interested in eating (Wilkes, 2000). These symptoms are optimal care and that attention will be paid to the patient’s managed or controlled through assessment, planning, and care. changing symptoms and to their concerns. When the patient can The nurse teaches the family how to position the patient for no longer carry out self-care, the family, additional support sys- comfort during meals. Meals are planned for the times the pa- tems (social worker, home health aid, home care nurse, hospice tient is rested and in less distress from pain or the effects of nurse) may be needed. A nursing goal is to keep anxiety at a man- treatment. ageable level. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1977

Chart 65-2 Home Care Checklist • The Patient With Cerebral Metastases

At the completion of home care instruction, the patient or caregiver will be able to: Patient Caregiver • State effects of the tumor according to its location in the brain and type. ✓✓ • Describe side effects of treatment. ✓✓ • Identify community resources, including: • Home health services ✓✓ • Hospices ✓✓ • Support groups ✓✓ • Identify coping strategies, such as: • Taking control, setting daily goals, and staying positive ✓✓ • Rehabilitation to improve self-care ✓ • Relaxation techniques ✓✓ • Family support ✓ • Verbalize an understanding of the treatment plan for: • Medications and pain control ✓✓ • Nutritional needs ✓✓ • Contacting the health care provider ✓✓

PROMOTING HOME AND COMMUNITY-BASED CARE Evaluation Teaching Patients Self-Care EXPECTED PATIENT OUTCOMES The patient and family often have major responsibility for care at Expected patient outcomes may include: home. Therefore, teaching includes strategies of pain manage- 1. Engages in self-care activities as long as possible ment, prevention of complications related to treatment strate- a. Uses assistive devices or accepts assistance as needed gies, and methods to ensure adequate fluid and food intake b. Schedules periodic rest periods to permit maximal par- (Chart 65-2). Teaching needs of the patient and family regarding ticipation in self-care care priorities are likely to change as the disease progresses. It is 2. Maintains as optimal a nutritional status as possible important to assess the changing needs of the patient and the a. Eats and accepts food within limits of condition and family and to inform them about resources and services early to preferences assist them to deal with changes in the patient’s condition. b. Accepts alternative methods of providing nutrition if indicated Continuing Care 3. Reports being less anxious Home care nursing and hospice services are valuable resources a. Is less restless and is sleeping better that should be made available to the patient and the family early b. Verbalizes concerns and fears about death in the course of a terminal illness. Anticipating needs before they c. Participates in activities of personal importance as long occur can assist in smooth initiation of services. Home care needs as feasible and interventions focus on four major areas: palliation of symp- 4. Family members seek help as needed toms and pain control, assistance in self-care, control of treatment a. Demonstrate ability to bathe, feed, and care for the pa- complications, and administration of specific forms of treatment, tient and participate in pain management and preven- such as parenteral nutrition. The home care nurse assesses pain tion of complications management, respiratory status, complications of the disorder b. Express feelings and concerns to appropriate health and its treatment, and the patient’s cognitive and emotional sta- professionals tus. Additionally, the nurse assesses the family’s ability to perform c. Discuss and seek hospice care as an option necessary care and notifies the physician about changing needs or complications if indicated. SPINAL CORD TUMORS The patient and family who elect to care for the patient at home as the disease progresses benefit from the care and support Tumors within the spine are classified according to their anatomic provided through hospice services. Steps to initiate hospice care, relation to the spinal cord. They include intramedullary lesions including discussion of hospice care as an option, should not be (within the spinal cord), extramedullary-intradural lesions (within postponed until death is imminent. Exploration of hospice care or under the spinal dura), and extramedullary-extradural lesions as an option should be initiated at a time when hospice care can (outside the dural membrane). Tumors occurring within the provide support and care to the patient and family consistent spinal cord or exerting pressure on it cause symptoms ranging with their end-of-life decisions and assist in allowing death with from localized or shooting pains and weakness and loss of reflexes dignity. End-of-life care is further described in Chapter 13. above the tumor level to progressive loss of motor function and 1978 Unit 14 NEUROLOGIC FUNCTION paralysis. Usually, sharp pain occurs in the area innervated by the be due to vertebral collapse associated with spinal cord infarction. spinal roots that arise from the cord in the region of the tumor. Frequent neurologic checks are carried out, with emphasis on In addition, increasing sensory deficits develop below the level of movement, strength, and sensation of the upper and lower ex- the lesion. tremities. Assessment of sensory function involves pinching the skin of the arms, legs, and trunk to determine if there is loss of Assessment and Diagnostic Findings feeling and, if so, determining at what level. Vital signs are monitored at regular intervals. Neurologic examination and diagnostic studies are used to make the diagnosis. Neurologic examination includes assessment of MANAGING PAIN pain, loss of reflexes, loss of sensation or motor function, and the The prescribed pain medication should be administered in ade- presence of weakness and paralysis. Helpful diagnostic studies in- quate amounts and at appropriate intervals to relieve pain and clude x-rays, radionuclide bone scans, and MRI. MRI is the most prevent its recurrence. Pain is the hallmark of spinal metastasis. sensitive diagnostic tool and is particularly helpful in detecting Patients with sensory root involvement or vertebral collapse may epidural spinal cord compression and vertebral bone metastases suffer excruciating pain, which requires effective pain management. (Jacobs & Perrin, 2001; Nevidjon & Sowers, 2000). The bed is usually kept flat initially. The nurse turns the patient as a unit, keeping shoulders and hips aligned and the back Medical Management straight. The side-lying position is usually the most comfortable Treatment of specific intraspinal tumors depends on the type and because this position imposes the least pressure on the surgical location of the tumor and the presenting symptoms and physical site. Placement of a pillow between the knees of the patient in a status of the patient. Surgical intervention is the primary treat- side-lying position helps to prevent extreme knee flexion. ment for most spinal cord tumors. Other treatment modalities include partial removal of the tumor, decompression of the spinal MONITORING AND MANAGING cord, chemotherapy, and radiation therapy, particularly for in- POTENTIAL COMPLICATIONS tramedullary tumors and metastatic lesions (Jacobs & Perrin, If the tumor was in the cervical area, the possibility of postoper- 2001). ative respiratory compromise arises. The nurse monitors the pa- Epidural spinal cord compression occurs in approximately 5% tient for asymmetric chest movement, abdominal breathing, and of patients who die of cancer and is considered a neurologic emer- abnormal breath sounds. For a high cervical lesion, the endotra- gency (Nevidjon & Sowers, 2000). In the patient with epidural cheal tube remains in place until adequate respiratory function is spinal cord compression resulting from metastatic cancer (most ensured. The patient is encouraged to perform deep-breathing commonly from breast, prostate, or lung), high-dose dexametha- and coughing exercises. sone combined with radiation therapy is effective in relieving The area over the bladder is palpated or a bladder scan is per- pain (Nevidjon & Sowers, 2000). formed to assess for urinary retention. The nurse also monitors for incontinence because urinary dysfunction usually implies sig- SURGICAL MANAGEMENT nificant decompensation of spinal cord function. An intake and Tumor removal is desirable but not always possible. The goal is output record is maintained. Additionally, the abdomen is aus- to remove as much tumor as possible while sparing uninvolved cultated for bowel sounds. portions of the spinal cord. Microsurgical techniques have im- Staining of the dressing may indicate leakage of CSF from the proved the prognosis for patients with intramedullary tumors. Prognosis is related to the degree of neurologic impairment at the surgical site, which may lead to serious infection or to an inflam- time of surgery, the speed with which symptoms occurred, and matory reaction in the surrounding tissues that can cause severe the tumor origin. Patients with extensive neurologic deficits be- pain in the postoperative period. fore surgery usually do not make significant functional recovery even after successful tumor removal. PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care. In preparation for discharge, pa- Nursing Management tients are assessed for their ability to function independently in the home and for the availability of resources such as family members PROVIDING PREOPERATIVE CARE to assist in caregiving. Patients with residual sensory involvement The objectives of preoperative care include recognition of neuro- are cautioned about the dangers of extremes in temperature. They logic changes through ongoing assessments, pain control, and management of altered activities of daily living due to sensory and should be alert to the dangers of heating devices (eg, hot water motor deficits and bowel and bladder dysfunction. The nurse as- bottles, heating pads, and space heaters). The patient is taught to sesses for weakness, muscle wasting, spasticity, sensory changes, check skin integrity daily. Patients with impaired motor function bowel and bladder dysfunction, and potential respiratory prob- related to motor weakness or paralysis may require training in lems, especially if a cervical tumor is present. The patient is also activities of daily living and safe use of assistive devices, such as a evaluated for coagulation deficiencies. A history of aspirin intake cane, walker, or wheelchair. is obtained and reported because the use of aspirin may impede The patient and family member are instructed about pain hemostasis postoperatively. Breathing exercises are taught and management strategies, bowel and bladder management, and demonstrated preoperatively. Postoperative pain management assessment for signs and symptoms that should be reported strategies are discussed with the patient before surgery. promptly.

ASSESSING THE PATIENT AFTER SURGERY Continuing Care. Referral for inpatient or outpatient rehabilita- The patient is monitored for deterioration in neurologic status. tion may be warranted to improve self-care abilities. A home care A sudden onset of neurologic deficit is an ominous sign and may referral may be indicated and provides the home care nurse with Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1979 the opportunity to assess the patient’s physical and psychological Pathophysiology status and the patient’s and family’s ability to adhere to recommended management strategies. During the home visit, the nurse Parkinson’s disease is associated with decreased levels of dopamine determines whether changes in neurologic function have oc- due to destruction of pigmented neuronal cells in the substantia curred. The patient’s respiratory and nutritional status is assessed. nigra in the basal ganglia of the brain (Fig. 65-4). The nuclei of The adequacy of pain management is assessed, and modifications the substantia nigra project fibers or neuronal pathways to the are made to ensure adequate pain relief. The need for hospice services or placement in an extended-care facility is discussed with the patient and family if warranted, and the patient is asked about preferences for end-of-life care (Chart 65-3). Additionally, social Physiology/Pathophysiology workers may be consulted to assist the patient and family members in identifying support groups and agencies that can provide help in coping with the disease process. Corpus striatum Degenerative Disorders Neurologic disorders of the central and peripheral nervous system that are degenerative in nature include Parkinson’s disease, Hunt- ington’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis, muscular dystrophies, and degenerative disc disease. A relatively new phenomenon, post-polio syndrome, may be degenerative in nature and is also discussed. A slow onset of signs and symptoms characterizes these disorders. Patients are managed at home for as long as possible and admitted to the acute care setting for exacerbations, treatments, and surgical interventions as needed.

PARKINSON’S DISEASE Substantia nigra Parkinson’s disease is a slowly progressing neurologic movement disorder that eventually leads to disability. The degenerative or idiopathic form is the most common; there is also a secondary form Destruction of dopaminergic neuronal with a known or suspected cause. Although the cause of most cases cells in the substantia nigra is unknown, research suggests several causative factors, including ge- in the basal ganglia netics, atherosclerosis, excessive accumulation of oxygen free radicals, viral infections, head trauma, chronic antipsychotic medication use, and some environmental exposures. Parkinsonian symptoms usually ﬁrst appear in the ﬁfth decade of life; however, cases have Depletion of dopamine stores been diagnosed at the age of 30 years. It is the fourth most common neurodegenerative disease. Parkinson’s disease affects men more frequently than women and nearly 1% of the population older than Degeneration of the dopaminergic 60 years of age (Gray & Hildebrand, 2000). nigrostriatal pathway

Imbalance of excitatory (acetylcholine) and Chart 65-3 • Ethics and Related Issues inhibiting (dopamine) neurotransmitters in the corpus striatum What Constitutes Assisted Suicide? Situation A 76-year-old man is admitted to the hospital with a metastatic Impairment of extrapyramidal tracts spinal cord tumor. He is in respiratory distress and near death. The controlling complex body movements patient and family state they want no heroic measures and the physician writes a “do not resuscitate” order on the chart. Dilemma What is the nurse’s role in caring for this patient at this time? TremorsRigidity Bradykinesia Discussion Is the “do not resuscitate” order an act of patient-assisted suicide? FIGURE 65-4 Pathophysiology of Parkinson’s disease. The nuclei in the Is it active or passive euthanasia? What is the nurse’s role in caring substantia nigra project fibers to the corpus striatum. The nerve fibers carry for the patient if this action conflicts with his/her personal beliefs? dopamine to the corpus striatum. The loss of dopamine nerve cells from the If no other nurse is available to provide care, does the nurse have brain’s substantia nigra is thought to be responsible for the symptoms of the right to refuse? Is this patient abandonment? parkinsonism. 1980 Unit 14 NEUROLOGIC FUNCTION corpus striatum, where neurotransmitters are key to control of thumb against the fingers as if rolling a pill (Fig. 65-5). Tremor complex body movements. Through the neurotransmitters acetyl- is present while the patient is at rest; it increases when the patient choline (excitatory) and dopamine (inhibitory), striatal neurons is walking, concentrating, or feeling anxious. relay messages to the higher motor centers that control and refine motor movements. The loss of dopamine stores in this area of the RIGIDITY brain results in more excitatory neurotransmitters than inhibitory Resistance to passive limb movement characterizes muscle rigidity. neurotransmitters, leading to an imbalance that affects voluntary Passive movement of an extremity may cause the limb to move in movement. jerky increments referred to as cogwheeling. Rigidity of the pas- Basic science research in the past two decades has revealed sive extremity increases when another extremity is engaged in that more neurotransmitter pathways in the brain than just the voluntary active movement. Stiffness of the neck, trunk, and shoul- dopaminergic system are involved. Parts of the glutamatergic, ders is common. Early in the disease, the patient may complain cholinergic, tryptaminergic, noradrenergic, adrenergic, seroton- of shoulder pain. ergic, and peptidergic pathways (responsible for cell metabolism, growth, nutrition, and so forth) show damage in Parkinson’s dis- BRADYKINESIA ease (Chase, Oh & Konitsiotis, 2000; Przuntek, 2000; Rascol, One of the most common features of Parkinson’s disease is brady- 2000). kinesia. Patients take longer to complete most activities and have Clinical symptoms do not appear until 60% of the pigmented difficulty initiating movement, such as rising from a sitting posi- neurons are lost and the striatal dopamine level is decreased by tion or turning in bed. 80%. Cellular degeneration impairs the extrapyramidal tracts that Hypokinesia (abnormally diminished movement) is also com- control semiautomatic functions and coordinated movements; mon and may appear after the tremor. The freezing phenomenon motor cells of the motor cortex and the pyramidal tracts are not is a transient inability to perform active movement and is thought affected. to be an extreme form of bradykinesia. Additionally, the patient tends to shuffle and exhibits a decreased arm swing. As dexterity Clinical Manifestations declines, micrographia (shrinking, slow handwriting) develops. The face becomes increasingly masklike and expressionless and Parkinson’s disease has a gradual onset and symptoms progress the frequency of blinking decreases. Dysphonia (soft, slurred, slowly over a chronic, prolonged course. The three cardinal signs low-pitched, and less audible speech) may occur due to weakness are tremor, rigidity, and bradykinesia (abnormally slow move- and incoordination of the muscles responsible for speech. In ments). Other features include hypokinesia, gait disturbances, many cases, the patient develops dysphagia, begins to drool, and and postural instability (Gray & Hildebrand, 2000). is at risk for choking and aspiration. The patient commonly develops postural and gait problems. TREMOR There is a loss of postural reflexes, and the patient stands with the Although symptoms are variable, a slow, unilateral, resting tremor head bent forward and walks with a propulsive gait. The posture is present in 70% of patients at the time of diagnosis. Resting is caused by the forward flexion of the neck, hips, knees, and el- tremor characteristically disappears with purposeful movement bows. The patient may walk faster and faster, trying to move the but is evident when the extremities are motionless. The tremor feet forward under the body’s center of gravity (shuffling gait). may present as a rhythmic, slow turning motion (pronation– Difficulty in pivoting and loss of balance (either forward or back- supination) of the forearm and the hand and a motion of the ward) places the patient at risk for falls.

ABC FIGURE 65-5 Manifestations of Parkinson’s disease: (A) “cogwheeling” accompanies passive movement of the hand and arm; (B) “pill-rolling” tremor; (C) postural instability, forward stoop, shufﬂing gait. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1981

NURSING RESEARCH PROFILE 65-1 Approximately 41% of women and 25% of men with Parkin- Falls and Risk Factors son’s disease experience sleep disturbances. This may be connected to depression, dementia, or medications. Auditory and visual hal- Gray, P., & Hildebrand, K. (2000). Fall risk factors in Parkinson’s lucinations have been reported in approximately 37% of persons disease. Journal of Neuroscience Nursing, 32(4), 222–228. with Parkinson’s and may be associated with depression, demen- Purpose tia, lack of sleep, or adverse effects of medications (Herndon et al., Patients with Parkinson’s disease have frequent falls, yet there is 2000). little research on identifying risk factors specific to these patients. Complications associated with Parkinson’s disease are com- The purpose of this study was to identify risk factors associated with mon and are typically related to disorders of movement. As the falls in a group of patients with Parkinson’s disease. disease progresses, patients are at risk for respiratory and urinary tract infection, skin breakdown, and injury from falls. The ad- Study Sample and Design verse effects of medications used to treat the symptoms are asso- The sample for this descriptive, exploratory study was recruited ciated with numerous complications. from a hospital-based clinic in Canada. Patients who could stand, walk, and had no other medical conditions that predisposed them to falls were included. The Unified Parkinson’s Disease Rating Assessment and Diagnostic Findings Scale established the degree of symptoms. Multiple instruments were used to assess demographic, environmental, and medical in- Laboratory tests and imaging studies are not helpful in the diag- formation; participants also completed fall diaries for 12 weeks. nosis of Parkinson’s disease, although PET scanning has been The sample consisted of 118 patients; 48 (41%) reported no falls used in evaluating levodopa (precursor of dopamine) uptake and and 70 (59%) reported one or more falls. Participants in the study conversion to dopamine in the corpus striatum (Freed et al., included 73 (62%) males. 2001). Currently, the disease is diagnosed clinically from the pa- Findings tient’s history and the presence of two of the three cardinal man- Demographic, environmental, and medical information and fall di- ifestations: tremor, muscle rigidity, and bradykinesia. aries were analyzed to identify factors that appeared to increase the Early diagnosis can be difficult because the patient can rarely risk for falls. A total of 237 falls were reported in the 3-month study pinpoint when symptoms started. Often a family member notices period; 59% of the participants reported one or more falls. Males, a change such as stooped posture, a stiff arm, a slight limp, tremor, as well as patients over age 80 years, reported higher rates of falls. or slow, small handwriting. The medical history, presenting symp- Factors associated with a high risk for falls included duration and toms, neurologic examination, and response to pharmacologic severity of parkinsonian symptoms including freezing, involuntary management are carefully evaluated when making the diagnosis. movements, and walking and postural difficulties. Postural hypotension and daily intake of alcohol were additional factors associated with a high risk for falls. Medical Management Nursing Implications Treatment is directed at controlling symptoms and maintaining Nurses, especially home care nurses, can use the findings of this functional independence because there are no medical or surgical study to help identify patients with risk factors: “freezing,” invol- approaches that prevent disease progression. Care is individual- untary movements, walking and postural difficulties, postural hy- ized for each patient based on presenting symptoms and social, potension, and daily use of alcohol. Patients with these risk factors occupational, and emotional needs. Pharmacologic management should be targeted for intervention programs and specific patient is the mainstay of treatment, although advances in research have and family education to reduce falls. Early identification of risk fac- led to increased interest in surgical interventions. Patients are usu- tors would permit nurses to provide assistance, education, support, and appropriate referrals to patients at high risk for falls. ally cared for at home and admitted to the hospital only for complications or to initiate new treatments.

PHARMACOLOGIC THERAPY OTHER MANIFESTATIONS Antiparkinsonian medications act by 1) increasing striatal dopa- The effect of Parkinson’s disease on the basal ganglia often pro- minergic activity, 2) reducing the excessive influence of excitatory duces autonomic symptoms that include excessive and un- cholinergic neurons on the extrapyramidal tract, thereby restor- controlled sweating, paroxysmal flushing, orthostatic hypotension, ing a balance between dopaminergic and cholinergic activities, or gastric and urinary retention, constipation, and sexual distur- 3) acting on neurotransmitter pathways other than the dopami- bances (Herndon et al., 2000). nergic pathway. Psychiatric changes are often interrelated and may be predictive of one another. They include depression, dementia (progressive Antiparkinsonian Medications. Levodopa (Dopar, Larodopa) is mental deterioration), sleep disturbances, and hallucinations the most effective agent and the mainstay of treatment (Karch, (Herndon et al., 2000). Depression is common; whether it is a 2002; Obeso et al., 2001). Because levodopa is thought to pre- reaction to the disorder or is related to a biochemical abnormal- cipitate oxidation, which further damages the substantia nigra ity remains a question. Mental changes may appear in the form and eventually speeds disease progression, physicians delay pre- of cognitive, perceptual, and memory deficits, although intellect scribing the medication or increasing the dosage for as long as is not usually affected. A number of psychiatric manifestations possible (Karch, 2002). Levodopa is converted to dopamine in (personality changes, psychosis, dementia, and acute confusion) the basal ganglia, producing symptom relief. The beneficial ef- are common among the elderly. The prevalence of dementia is fects of levodopa are most pronounced in the first few years of about 25% and the pattern is similar to that of patients with treatment. Benefits begin to wane and adverse effects become Alzheimer’s disease. Although there is no direct documented causal more severe over time. Confusion, hallucinations, depression, relationship, the rates of depression and dementia are highly cor- and sleep alterations are associated with prolonged use. Levodopa related in these patients (Herndon et al., 2000). is usually given in combination with carbidopa (Sinemet), an 1982 Unit 14 NEUROLOGIC FUNCTION amino acid decarboxylase inhibitor that helps to maximize the be used without levodopa for treatment of early disease and with beneficial effects of levodopa by preventing its breakdown out- levodopa in advanced stages. Cabergoline (Dostinex), an ergot side the brain and reducing its adverse effects (Karch, 2002). alkaloid with a long duration of action, has been approved for use. Within 5 to 10 years, most patients develop a response to the medication characterized by dyskinesia (abnormal involun- Monoamine Oxidase Inhibitors (MAO Inhibitors). Of the MAO tary movements), including facial grimacing, rhythmic jerking inhibitors, selegiline (Eldepryl) is one of the most exciting and movements of the hands, head bobbing, chewing and smacking controversial developments in the pharmacotherapy of Parkin- movements, and involuntary movements of the trunk and extrem- son’s disease (Herndon et al., 2000). This medication inhibits ities. The patient may experience an on–off syndrome in which dopamine breakdown and is thought to slow the progression of sudden periods of near immobility (“off effect”) are followed by the disease. Researchers believe this medication may have a neuro- a sudden return of effectiveness (“on effect”). Various adjunctive protective effect in the early stages of Parkinson’s disease, but this therapies are used to minimize dyskinesias (Przuntek, 2000; has not been shown in clinical trials. Selegiline is currently used Rascol, 2000). in combination with a dopamine agonist to delay the use of car- Budipine, available in Europe but not the United States, is a bidopa or levodopa therapy. Adverse effects are similar to those non-dopaminergic, antiparkinsonian medication that significantly of levodopa. reduces akinesia, rigidity, and tremor. It is non-dopaminergic because the action appears to be on neurotransmitter pathways other Catechol-O-methyltransferase (COMT) Inhibitors. Clinical trials than the dopaminergic pathway. It may be used as monotherapy suggest that the COMT inhibitors entacapone (Comtess) and or in conjunction with other available antiparkinsonian medica- tolcapone (Tasmar) have little effect on parkinsonian symptoms tions (Przuntek, 2000; Przuntek et al., 2002). The usual dose of when given alone but can increase the duration of action of car- 40 to 60 mg is reached gradually. Nausea and dry mouth are the bidopa or levodopa when given in combination with them. most common side effects, although 75% of patients experienced COMT inhibitors block an enzyme that metabolizes levodopa, no side effects in clinical drug trials (Przuntek, 2000). making more levodopa available for conversion to dopamine in the brain. Entacapone and tolcapone reduce motor fluctuations Anticholinergic Therapy. Anticholinergic agents (trihexyphenidyl, in patients with advanced Parkinson’s disease. cycrimine, procyclidine, biperiden, and benztropine mesylate) are Antidepressants. effective in controlling tremor and rigidity. They may be used in Tricyclic antidepressants may be prescribed to combination with levodopa. They counteract the action of the alleviate the depression that is so common in Parkinson’s disease. The usual dosage is one-third to one-half the dosage used in de- neurotransmitter acetylcholine. Because the side effects include pressed patients without Parkinson’s disease. Amitriptyline is typ- blurred vision, flushing, rash, constipation, urinary retention, and ically prescribed because of its anticholinergic and antidepressant acute confusional states, these medications are often poorly tol- effect. Serotonin reuptake inhibitors, such as fluoxetine hydro- erated in elderly patients. Intraocular pressure must be closely chloride (Prozac) and bupropion hydrochloride (Wellbutrin), are monitored: these medications are contraindicated in patients effective for treating depression but may aggravate parkinsonism. with narrow-angle glaucoma. Patients with prostate hyperplasia are monitored for signs of urinary retention. Antihistamines. Diphenhydramine hydrochloride (Benadryl), orphenadrine citrate (Banflex), and phenindamine hydrochloride Antiviral Therapy. Amantadine hydrochloride (Symmetrel) is an (Neo-Synephrine) have mild central anticholinergic and sedative antiviral agent used in early Parkinson’s treatment to reduce effects and may reduce tremors. rigidity, tremor, and bradykinesia. It is thought to act by releasing dopamine from neuronal storage sites. Studies suggest it may also SURGICAL MANAGEMENT have antiglutamatergic properties that affect the glutamatergic The limitations of levodopa therapy, improvements in stereotac- pathway, thus improving levodopa-induced dyskinesias (Rascol, tic surgery, and new approaches in transplantation have renewed 2000). Amantadine has a low incidence of side effects, which in- interest in the surgical treatment of Parkinson’s disease. In pa- clude psychiatric disturbances (mood changes, confusion, depres- tients with disabling tremor, rigidity, or severe levodopa-induced sion, hallucinations), lower extremity edema, nausea, epigastric dyskinesia, surgery may be considered. Although surgery provides distress, urinary retention, headache, and visual impairment. some relief in selected patients, it has not been shown to alter the course of the disease or produce permanent improvement. Dopamine Agonists. Bromocriptine mesylate and pergolide (ergot derivatives) are dopamine receptor agonists and are useful in Stereotactic Procedures. Thalamotomy and pallidotomy are postponing the initiation of carbidopa or levodopa therapy. effective in relieving many of the symptoms of Parkinson’s dis- Dopamine agonists are often added to the medication regimen ease. Patients eligible for these procedures are those who have had when carbidopa or levodopa loses effectiveness. Pergolide (Permax) an inadequate response to medical therapy; they must meet strict is 10 times more potent than bromocriptine mesylate (Parlodel), criteria to be eligible. Candidates eligible for these procedures are although this provides no therapeutic advantage. Adverse re- patients with idiopathic Parkinson’s disease who are taking max- actions to these medications include nausea, vomiting, diar- imum doses of antiparkinsonian medications. Patients with de- rhea, lightheadedness, hypotension, impotence, and psychiatric mentia and atypical Parkinson’s disease are usually not considered effects. for stereotactic procedures. Parkinson’s disease rating scales and Two new dopamine agonists, ropinirole hydrochloride (Requip) specific neurologic testing are used to identify eligible patients. and pramipexole (Mirapex) (nonergot derivatives), are primarily The intent of thalamotomy and pallidotomy is to interrupt for patients in the early stages of Parkinson’s disease and are not the nerve pathways and thereby alleviate tremor or rigidity. expected to have the potentially serious adverse effects of per- During thalamotomy, a stereotactic electrical stimulator destroys golide and bromocriptine mesylate. Pramipexole (Mirapex) can part of the ventrolateral portion of the thalamus in an attempt to Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1983 reduce tremor; the most common complications are ataxia and thalamus and connected to a pulse generator implanted in a hemiparesis. Pallidotomy involves destroying part of the ventral subcutaneous subclavicular or abdominal pouch. The battery- aspect of the medial globus pallidus through electrical stimula- powered pulse generator sends high-frequency electrical impulses tion in patients with advanced disease. The procedure is effective through a wire placed under the skin to a lead anchored to the in reducing rigidity, bradykinesia, and dyskinesia, thus improv- skull (Fig. 65-7). The electrode blocks nerve pathways in the ing motor function and activities of daily living in the immediate brain that cause tremors. These devices are not without compli- postoperative course. In small studies, clinical improvements cations, both from the surgical procedure needed for implanta- have been demonstrated over 3 to 4 years. The clinical benefit is tion and from complications (such as lead leakage) of the device greater in patients younger than 60 years (Freed et al., 2001). itself (Koller et al., 2001; Obeso et al., 2001). Complications include hemiparesis, stroke, and visual changes. CT, x-rays, MRI, or angiography is used to localize the ap- NURSING PROCESS: propriate surgical site in the brain. Then the patient’s head is po- THE PATIENT WITH PARKINSON’S DISEASE sitioned in a stereotactic frame (Fig. 65-6). The surgeon makes an incision in the skin and then a burr hole. Next, the surgeon Assessment passes an electrode through the burr hole to the target area in the thalamus or globus pallidum. The desired response of the patient Assessment focuses on how the disease has affected the patient’s to the electrical stimulation is the basis for the final site chosen by activities of daily living and functional abilities. Patients are ob- the neurosurgeon. Stereotactic procedures are completed on served for degree of disability and the functional changes that one side of the brain at a time. If rigidity or tremor is bilateral, occur throughout the day, such as responses to medication. Nearly a 6-month interval is suggested between procedures. every patient with a movement disorder has some functional alteration and may have some type of behavioral dysfunction. The following questions may be useful to assess alterations: Neural Transplantation. Surgical implantation of adrenal medullary tissue into the corpus striatum is performed in an effort to • Do you have leg or arm stiffness? reestablish normal dopamine release. Preliminary evidence has • Have you experienced any irregular jerking of your arms or shown high morbidity and mortality rates, and the implants ap- legs? pear to improve parkinsonian symptoms for only 6 months. Re- • Have you ever been “frozen” or rooted to the spot and un- searchers are conducting studies to determine if transplanting able to move? human fetal brain cells or genetically engineered cells into the ni- • Does your mouth water excessively? Have you (or others) grostriatal region is effective (Aminoff, 2000). Legal and ethical noticed yourself grimacing or making faces or chewing issues surrounding the use of fetal brain cells have limited the im- movements? plementation of this procedure. Recently, fetal pig neuronal cells • What specific activities do you have difficulty doing? survived transplantation into a patient with Parkinson’s dis- During this assessment, the nurse observes the patient for ease; this may provide an alternative to human cell transplants quality of speech, loss of facial expression, swallowing deficits (Aminoff, 2000).

Deep Brain Stimulation. Recently approved by the FDA, pacemaker-like brain implants show promising results in relieving Stimulator tremors. The stimulation can be bilateral or unilateral, although bilateral stimulation of the subthalamic nucleus is thought to be of greater beneﬁt to patients than results achieved with thalamotomy, pallidotomy, or fetal nigral transplantation (Obeso et al., 2001). In deep brain stimulation, an electrode is placed in the Thalamus

Pulse generator Clavicle area

FIGURE 65-7 Deep brain stimulation is provided by a pulse generator surgically implanted in a pouch beneath the clavicle. The generator sends FIGURE 65-6 A stereotactic frame is applied to a patient’s head in prepa- high-frequency electrical impulses to the thalamus, thereby blocking the ration for pallidotomy. The frame immobilizes the head. nerve pathways associated with tremors in Parkinson’s disease. 1984 Unit 14 NEUROLOGIC FUNCTION

(drooling, poor head control, coughing), tremors, slowness of and to use a heel-toe placement of the feet with long strides. The movement, weakness, forward posture, rigidity, evidence of men- patient is advised to practice walking to marching music or to the tal slowness, and confusion. Parkinsonian symptoms, as well as sound of a ticking metronome because this provides sensory re- side effects of medications, put these patients at high risk of inforcement. Doing breathing exercises while walking helps to falls; therefore, a fall risk assessment should be included (Gray & move the rib cage and to aerate parts of the lungs. Frequent rest Hildebrand, 2000). periods aid in preventing frustration and fatigue.

Diagnosis ENHANCING SELF-CARE ACTIVITIES Encouraging, teaching, and supporting the patient during activ- NURSING DIAGNOSES ities of daily living promote self-care. See Chapter 11 for rehabil- Based on the assessment data, the patient’s major nursing diag- itation techniques. noses may include the following: Environmental modifications are necessary to compensate for • Impaired physical mobility related to muscle rigidity and functional disabilities. Patients may have severe mobility prob- motor weakness lems that make normal activities impossible. Adaptive or assistive • Self-care deficits (feeding, dressing, hygiene, and toileting) devices may be useful. A hospital bed at home with bedside rails, related to tremor and motor disturbance an overbed frame with a trapeze, or a rope tied to the foot of the • Constipation related to medication and reduced activity bed can provide assistance in pulling up without help. An occu- • Imbalanced nutrition, less than body requirements, related pational therapist can evaluate the patient’s needs in the home to tremor, slowness in eating, difficulty in chewing and and make recommendations regarding adaptive devices and teach swallowing the patient and caregiver how to improvise. Impaired verbal communication related to decreased speech • IMPROVING BOWEL ELIMINATION volume, slowness of speech, inability to move facial muscles • Ineffective coping related to depression and dysfunction The patient may have severe problems with constipation. Among due to disease progression the factors causing constipation are weakness of the muscles used in defecation, lack of exercise, inadequate fluid intake, and de- Other nursing diagnoses may include sleep pattern distur- creased autonomic nervous system activity. The medications used bances, deficient knowledge, risk for injury, risk for activity infor the treatment of the disease also inhibit normal intestinal se- tolerance, disturbed thought processes, and compromised family cretions. A regular bowel routine may be established by encour- coping. aging the patient to follow a regular time pattern, consciously increase fluid intake, and eat foods with a moderate fiber content. Planning and Goals Laxatives should be avoided. Psyllium, for example, decreases constipation but carries the risk for bowel obstruction (Herndon et al., The goals for the patient may include improving functional mo- 2000). A raised toilet seat is useful because the patient has diffi- bility, maintaining independence in activities of daily living, culty in moving from a standing to a sitting position. achieving adequate bowel elimination, attaining and maintaining acceptable nutritional status, achieving effective communication, IMPROVING NUTRITION and developing positive coping mechanisms. Patients may have difficulty maintaining their weight. Eating becomes a very slow process, requiring concentration due to a dry Nursing Interventions mouth from medications and difficulty chewing and swallowing. They are at risk for aspiration because of impaired swallowing and IMPROVING MOBILITY the accumulation of saliva. They may be unaware that they are A progressive program of daily exercise will increase muscle aspirating, and subsequently bronchopneumonia may develop. strength, improve coordination and dexterity, reduce muscular Monitoring weight on a weekly basis indicates whether caloric rigidity, and prevent contractures that occur when muscles are intake is adequate. Supplemental feedings increase caloric intake. not used. Walking, riding a stationary bicycle, swimming, and As the disease progresses, a nasogastric tube or percutaneous en- gardening are all exercises that help maintain joint mobility. doscopic gastroscopy may be necessary to maintain adequate nu- Stretching (stretch–hold–relax) and range-of-motion exercises trition. A dietitian can be consulted regarding nutritional needs. promote joint flexibility. Postural exercises are important to counter the tendency of the head and neck to be drawn forward ENHANCING SWALLOWING and down. A physical therapist may be helpful in developing an Swallowing disorders can be due to poor head control, tongue individualized exercise program and can provide instruction to tremor, hesitancy in initiating swallowing, difficulty in shaping the patient and caregiver on exercising safely. Faithful adherence food into a bolus, and disturbances in pharyngeal motility. To to an exercise and walking program helps to delay the progress of offset these problems, the patient should sit in an upright posi- the disease. Warm baths and massage in addition to passive and tion during mealtime. A semisolid diet with thick liquids is easier active exercises help relax muscles and relieve painful muscle to swallow than solids; thin liquids should be avoided. It is help- spasms that accompany rigidity. ful for patients to think through the swallowing sequence. The Balance may be adversely affected because of the rigidity of the patient is taught to place the food on the tongue, close the lips arms (arm swinging is necessary in normal walking). Special and teeth, lift the tongue up and then back, and swallow. The pa- walking techniques must be learned to offset the shuffling gait tient is encouraged to chew first on one side of the mouth and and the tendency to lean forward. The patient is taught to con- then on the other. To control the buildup of saliva, the patient is centrate on walking erect, to watch the horizon, and to use a reminded to hold the head upright and make a conscious effort wide-based gait (ie, walking with the feet separated). A conscious to swallow. Massaging the facial and neck muscles before meals effort must be made to swing the arms, raise the feet while walking, may be beneficial. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1985

Chart 65-4 Home Care Checklist • The Patient With Parkinson’s Disease

At the completion of the home care instruction, the patient or caregiver will be able to: Patient Caregiver • Define Parkinson’s disease and discuss its long-term effects. ✓✓ • Identify the medication regimen and name adverse effects, and precautions. ✓✓ • Discuss the risk for injury, prevent falls; implement adaptive measures in the home. ✓✓ • Describe nutritional needs, dietary restrictions, dysphagia management, and ways to prevent aspiration. ✓✓ • Manage constipation: fluid intake, bowel routine. ✓✓ • Manage urinary problems: functional incontinence, retention (Foley catheter care, suprapubic catheter care). ✓✓ • Explain effects of immobility and define preventive care: skin breakdown (frequent turning, pressure release, skin care), pneumonia (deep breathing, movement), contractures (range-of-motion exercises). ✓✓ • Define benefits of daily exercise program. ✓✓ • Walk and balance safely. ✓ • Demonstrate speech and communication skills: speech exercises, communication techniques, breathing exercises. ✓ • Name signs and symptoms of infection (urinary and respiratory) and state when health care provider should be notified. ✓✓ • Describe strategies to promote self-care activities and independence. ✓✓ • Identify resources: American Parkinson’s Disease Association, National Parkinson’s Disease Foundation, and local support groups. ✓✓

ENCOURAGING THE USE OF ASSISTIVE DEVICES Every effort should be made to encourage patients to carry out An electric warming tray keeps food hot and permits the patient the tasks involved in meeting their own daily needs and to remain to rest during the prolonged time that it takes to eat. Special uten- independent. Doing things for the patient merely to save time is sils also assist at mealtime. A plate that is stabilized, a nonspill contrary to the basic goal of improving coping abilities and pro- cup, and eating utensils with built-up handles are useful self-help moting a positive self-concept. devices. The occupational therapist can assist in identifying appropriate adaptive devices. PROMOTING HOME AND COMMUNITY-BASED CARE IMPROVING COMMUNICATION Teaching Patients Self-Care Speech disorders are present in most patients with Parkinson’s Patient and family education is important in the management of disease. Their low-pitched, monotonous, soft speech requires that Parkinson’s disease. Teaching needs depend on the severity of they make a conscious effort to speak slowly, with deliberate at- symptoms and the stage of the disease. Care must be taken not to tention to what they are saying. Patients are reminded to face the overwhelm the patient and family with too much information listener, exaggerate the pronunciation of words, speak in short early in the disease process. The patient’s and family’s need for sentences, and take a few deep breaths before speaking. information is ongoing as adaptations become necessary. The A speech therapist may be helpful in designing speech im- education plan should include a clear explanation of the disease, provement exercises and assisting the family and health care per- assisting the patient to remain functionally independent as long sonnel to develop and use a method of communication to meet as possible. Every effort is made to explain the nature of the dis- the patient’s needs. A small electronic amplifier is helpful if the ease and its management to offset disabling anxieties and fears. patient has difficulty being heard. The patient and family must be taught about the effects and side effects of medications and about the importance of reporting side SUPPORTING COPING ABILITIES effects to the physician (Chart 65-4). Support can be given by encouraging the patient and pointing out that activities are being maintained through active participation. A combination of physiotherapy, psychotherapy, medica- Continuing Care tion therapy, and support group participation may help reduce In the early stages patients can be managed well at home. Family the depression that often occurs. members often serve as caregivers, with home care or community Patients often feel embarrassed, apathetic, inadequate, bored, services available to assist in meeting health care needs as the dis- and lonely. These feelings may be due, in part, to physical slow- ease progresses. The family caregiver may be under considerable ness and the great effort that even small tasks require. Patients are stress from living with and caring for a person with a significant assisted and encouraged to set achievable goals (eg, improvement disability. Providing information about treatment and care pre- of mobility). vents many unnecessary problems. The caregiver is included in Because parkinsonism tends to lead to withdrawal and de- the plan and may be advised to learn stress reduction techniques, pression, patients must be active participants in their therapeutic to include others in the caregiving process, to obtain periodic re- program, including social and recreational events. There should lief from responsibilities, and to have a yearly health assessment. be a planned program of activity throughout the day to prevent Allowing family members to express feelings of frustration, anger, too much daytime sleeping as well as disinterest and apathy. and guilt is often helpful to them. 1986 Unit 14 NEUROLOGIC FUNCTION

The patient should be evaluated in the home for adaptation NURSING RESEARCH PROFILE 65-2 and safety needs and compliance with the plan of care. In the ad- Coping Patterns Following Gene Testing vanced stages, patients usually enter long-term care facilities when family support is absent. Periodically, admission to an acute care Williams, J. K., Schutte, D., Evers, C., & Holkup, P. A. (2000). Redefini- facility may be necessary for changes in medical management or tion: Coping with normal results from predictive gene testing for neurodegenerative disorders. Research in Nursing & Health, 23, 260–269. treatment of complications. Nurses provide support, education, and monitoring of patients over the course of illness. Purpose The nurse involved in home and continuing care needs to Predictive testing for an inherited neurodegenerative disease is a remind patients and family members of the need to address source of intense stress for adults. The purpose of this study was to health promotion needs such as screening for hypertension and describe the psychosocial impact and coping process of normal stroke risk assessments in this predominantly elderly popula- (negative) results from predictive testing for an inherited neuro- tion. Patients who have not been involved in these practices in degenerative disease. the past are educated about their importance and are referred to Study Sample and Design appropriate health care providers. Informational booklets and a The study used a qualitative, descriptive design and the constant newsletter for patient education are published by the National comparative method of data analysis. Ten adults with normal re- Parkinson’s Foundation, Inc. and the American Parkinson’s sults of predictive testing for Huntington’s disease (HD) or the Disease Association. pallido-pont-nigral degeneration (PPND) gene mutation participated in semistructured interviews 1 and 6 months following gene testing. The sample included 8 females, the age range was 33 to 59 Evaluation years, 80% were married, and 80% had known they were at risk for one of the diseases for more than 5 years. EXPECTED PATIENT OUTCOMES Expected patient outcomes may include: Findings The major descriptive theme identified was redefinition. The rede- 1. Strives toward improved mobility finition occurred in the following three domains: redefinition of a. Participates in exercise program daily self, relationships with family, and role in society. The process b. Walks with wide base of support; exaggerates arm swing- evolved from a personal level at 1 month to a more future-oriented ing when walking perspective at 6 months following normal gene test results. c. Takes medications as prescribed Nursing Implications 2. Progresses toward self-care Nurses working with individuals at risk for HD and PPND should a. Allows time for self-care activities keep in mind that many people prepare for the worst results when b. Uses self-help devices undergoing gene testing. The coping process following negative re- 3. Maintains bowel function sults (ie, absence of gene for the disease) evolves from a personal a. Consumes adequate fluid focus at 1 month to a broader future perspective at 6 months after b. Increases dietary intake of fiber testing. These components of the redefinition process are impor- c. Reports regular pattern of bowel function tant considerations in planning interventions to promote coping 4. Attains improved nutritional status with normal gene results within at-risk families during an extremely stressful time. a. Swallows without aspiration b. Takes time while eating 5. Achieves a method of communication a. Communicates needs b. Practices speech exercises 6. Copes with effects of Parkinson’s disease cerebellum, the area that coordinates voluntary muscle activity. a. Sets realistic goals Researchers now believe that a building block for protein called b. Demonstrates persistence in meaningful activities glutamine abnormally collects in the cell nucleus, causing cell c. Verbalizes feelings to appropriate person death. The reason that the protein destroys only certain brain cells is unknown. The cells’ destruction results in a lack of the neurotransmitters gamma-aminobutyric acid (GABA) and acetyl- HUNTINGTON’S DISEASE choline, which inhibit nerve action (Bradley et al., 2000). Onset usually occurs between the ages of 35 and 45 years, although Huntington’s disease is a chronic, progressive, hereditary disease about 10% of patients are children. The disease progresses slowly. of the nervous system that results in progressive involuntary cho- Despite a ravenous appetite, patients usually become emaciated reiform movement and dementia. It affects men and women of and exhausted. Patients succumb in 10 to 20 years to heart failure, all races. Because it is transmitted as an autosomal dominant ge- pneumonia, or infection, or as a result of a fall or choking. netic disorder, each child of a parent with Huntington’s disease has a 50% risk of inheriting the illness (Bradley et al., 2000). Clinical Manifestations Pathophysiology The most prominent clinical features of the disease are abnormal involuntary movements (chorea), intellectual decline, and, often, The basic pathology involves premature death of cells in the stria- emotional disturbance. As the disease progresses, a constant tum (caudate and putamen) of the basal ganglia, the region deep writhing, twisting, uncontrollable movement may involve the within the brain involved in the control of movement. There is entire body. These motions are devoid of purpose or rhythm, also loss of cells in the cortex, the region of the brain associated although patients may try to turn them into purposeful move- with thinking, memory, perception, and judgment, and in the ment. All of the body musculature is involved. Facial movements Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1987 produce tics and grimaces. Speech is affected, becoming slurred, respond to antipsychotic medications. Psychotherapy aimed at hesitant, often explosive, and eventually unintelligible. Chewing allaying anxiety and reducing stress may be beneficial (Hofman, and swallowing are difficult, and there is a constant danger of 1999). It is imperative that nurses look beyond the disease to choking and aspiration. Choreiform movements persist but di- focus on the patient’s needs and capabilities (Chart 65-5). One minish during sleep. study showed improved physical, mental, and social functioning As with speech, the gait becomes disorganized to the point in a small group of patients with Huntington’s disease using re- that ambulation eventually is impossible. Although independent motivation therapy and providing a more stimulating environ- ambulation should be encouraged for as long as possible, a wheel- ment (Sullivan, Bird, Alpay et al., 2001). Surgically implanted chair usually becomes necessary. Eventually, the patient is con- fetal neural allografts are being tested in hopes of improving the fined to bed when the chorea interferes with walking, sitting, and functional, motor, and cognitive function of patients (Bachoud- all other activities. Bladder and bowel control is lost. Levi, Remy, Nguyen et al., 2000; Diederich & Goetz, 2000). Cognitive function is usually affected, with dementia usually occurring. Initially, the patient generally is aware that the disease PROMOTING HOME AND COMMUNITY-BASED CARE is responsible for the myriad dysfunctions that are occurring. The mental and emotional changes that occur may be more devastat- Teaching Patients Self-Care. The needs of the patient and fam- ing to the patient and family than the abnormal movements. Per- ily for education depend on the nature and severity of physical, sonality changes may result in nervous, irritable, or impatient cognitive, and psychological changes experienced by the patient. behaviors. In the early stages, patients are particularly subject to Patients and family members are taught about the medications uncontrollable fits of anger, profound, often suicidal depression, prescribed and about signs indicating a need for change in med- apathy, anxiety, psychosis, or euphoria (Hofmann, 1999). Judg- ication or dosage. The teaching plan addresses strategies to man- ment and memory are impaired, and dementia eventually ensues. age symptoms such as chorea, swallowing problems, limitations Hallucinations, delusions, and paranoid thinking may precede in ambulation, and loss of bowel and bladder function. Con- the appearance of disjointed movements. Emotional symptoms sultation with a speech therapist may be indicated to assist in often become less acute as the disease progresses. identifying alternative communication strategies if speech is affected. Assessment and Diagnostic Findings Individuals of child-bearing age often seek information about their risk for transmitting the disease. Even though presympto- The diagnosis is made based on the clinical presentation of char- matic testing has been offered since 1986, approximately 75% of acteristic symptoms, a positive family history, and exclusion of individuals at risk choose not to be tested (Hayden, 2000). For other causes. Imaging studies, such as CT and MRI, may show most people, the benefits of testing are unclear because of ethical atrophy of the caudate nuclei once the disease is well established and confidentiality issues. Genetic counseling is crucial following (Bradley et al., 2000). testing, and patients and their families may require long-term A genetic marker for Huntington’s has been identified psychological counseling and emotional, financial, and legal sup- through the use of recombinant DNA technology. As a result, report (Williams, Schutte, Evers et al., 2000). searchers can now identify presymptomatic individuals who will develop this disease. Although this presymptomatic test can re- Continuing Care. A program combining medical, nursing, psy- move the uncertainty, it offers no hope of cure or even specific chological, social, occupational, speech, and physical rehabilita- prediction of the timing of its onset. Researchers continue to tion services is needed to help the patient and family cope with study the genetic causes that lead to the death of brain cells this severely disabling illness. Huntington’s exacts enormous (Bradley et al., 2000). emotional, physical, social, and financial tolls on every member of the patient’s family. The family often live under a heavy burden Management of uncertainty, anxiety, and guilt. Regular follow-up helps to allay the fear of abandonment. Although no treatment halts or reverses the underlying process, Home care assistance, day care centers, respite care, and even- several methods of management have fairly good palliative results tually skilled long-term care can assist the patient and family in (Bradley et al., 2000; Sawle, 1999). Thiothixene hydrochloride coping with the constant strain of the illness. Although the re- (Navane) and haloperidol decanoate (Haldol), which predominantly block dopamine receptors, improve the chorea in many lentless progression of the disease cannot be halted, families can patients (Bradley et al., 2000). Chorea also is lessened by reser- benefit from supportive care. pine (depletes presynaptic dopamine) and tetrabenazine (reduces Voluntary organizations can be major aids to families and have dopaminergic transmission). Motor signs must be assessed and been largely responsible for bringing the illness to national atten- evaluated on an ongoing basis so that optimal therapeutic drug tion. The Huntington’s Disease Foundation of America helps pa- levels can be reached. Akathisia (motor restlessness) in the over- tients and families by providing information, referrals, family and medicated patient is dangerous because it may be mistaken for public education, and support for research. the restless fidgeting of the illness and consequently can be overlooked. ALZHEIMER’S DISEASE In certain types of the disease, hypokinetic motor impairment resembles parkinsonism. In patients who present with rigidity, Alzheimer’s disease, or senile dementia of the Alzheimer’s type, is some temporary benefit may be obtained from antiparkinson a chronic, progressive, and degenerative brain disorder accompa- medication, such as levodopa. nied by profound effects on memory, cognition, and ability for Patients who have emotional disturbances, particularly de- self-care. About 10% of the population older than age 65 are af- pression, may be helped by antidepressant medications. The fected, and the prevalence reaches 47% by age 85. Research sug- threat of suicide is always present. Psychotic symptoms usually gests that inflammation plays a role in the pathophysiology of the 1988 Unit 14 NEUROLOGIC FUNCTION Chart 65-5 Care of the Patient With Huntington’s Disease Nursing Diagnosis Give between-meal feedings. Constant movement expends more Risk for injury from falls and possible skin breakdown (pressure calories. Patients often have voracious appetites, particularly for ulcers, abrasions), resulting from constant movement sweets. Nursing Interventions Use blenderized meals if patient cannot chew; do not repeatedly Pad the sides and head of the bed; ensure that the patient can see give the same strained baby foods; gradually introduce increased over the sides of bed. textures and consistencies to the diet. Use padded heel and elbow protectors. For swallowing difficulties: Keep the skin meticulously clean. Apply gentle deep pressure around the patient’s mouth. Apply emollient cleansing agent and skin lotion frequently. Rub fingers in circles on the patient’s cheeks. Use soft sheets and bedding. Rub fingers simultaneously down each side of the patient’s throat. Have patient wear football padding or other forms of padding. Develop skill in Heimlich maneuver (to be used in the event of Encourage ambulation with assistance to maintain muscle tone. choking). Secure the patient (only if necessary) in bed or chair with padded Nursing Diagnosis protective devices, making sure that they are loosened Anxiety and impaired communication from excessive grimacing and frequently. unintelligible speech Nursing Diagnosis Nursing Interventions Imbalanced nutrition, less than body requirements, due to inadequate Read to the patient. intake and dehydration resulting from swallowing or chewing dis- Employ biofeedback and relaxation therapy to reduce stress. orders and danger of choking or aspirating food Consult with speech therapist to help maintain and prolong Nursing Interventions communication abilities. Administer phenothiazines as prescribed before meals (appears to Try to devise a communication system, perhaps using cards with calm some patients). words or pictures of familiar objects, before verbal communica- Use a warming tray. tion becomes too difficult. Patients can indicate correct card by Talk to the patient before mealtime to promote relaxation; use hitting it with hand, grunting, or blinking the eyes. mealtime for social interaction. Provide undivided attention. Learn how this particular patient expresses needs and wants— Help the patient enjoy the mealtime experience. particularly nonverbal messages (widening of eyes, responses). Learn the position that is best for this patient. Keep patient as close Patients can understand even if unable to speak. Do not isolate to upright as possible while feeding. Stabilize patient’s head patients by ceasing to communicate with them. gently with one hand while feeding. Nursing Diagnosis Show the food and tell the patient what the foods are (eg, whether Disturbed thought processes and impaired social interaction hot or cold). Encircle the patient with one arm and get as close as possible to pro- Nursing Interventions vide stability and support. Use pillows and wedges for additional Have clock, calendar, and wall posters to view. support. Interact with the patient in a creative manner. Do not interpret stiffness, turning away, or sudden turning of Use every opportunity for one-to-one contact. the head as rejection; these are uncontrollable choreiform Use music for relaxation. movements. Reorient the patient after awakening. For feeding, use a long-handled spoon (iced-tea spoon). Place spoon Have the patient wear an identification bracelet with name, on middle of tongue and exert slight pressure. telephone number, and “memory impaired” on it. Place bite-sized food between patient’s teeth. Serve stews, casseroles, Keep the patient in the social mainstream. thick liquids; avoid too many milk drinks (produces mucus). Recruit and train volunteers for social interaction. Role model Disregard messiness. Treat the person with dignity. appropriate interactions. Wait for the patient to chew and swallow before introducing Do not abandon a patient because the disease is eventually terminal. another spoonful. Make sure that bite-sized food is small. Patients are living until the end.

disease and that anti-inflammatory agents such as nonsteroidal nuclei of the lower brain stem. As these cells die, the muscle fibers anti-inflammatory drugs (NSAIDs) may be helpful adjuncts in that they supply undergo atrophic changes. Neuronal degenera- treatment (Neuroinflammation Working Group, 2000). tion may occur in both the upper and lower motor neuron systems. Alzheimer’s is one of the most feared disorders of modern Several theories exist regarding the cause of ALS, including times because it has catastrophic consequences for the patient and autoimmune disease and free radical damage. The leading theory family, who experience what has been termed an endless funeral. held by researchers is that overexcitation of nerve cells by the Chapter 12 discusses the manifestations, management, and nurs- neurotransmitter glutamate leads to cell injury and neuronal ing care of the patient with Alzheimer’s disease. degeneration. The incidence of ALS is 203 cases per 100,000 in the general AMYOTROPHIC LATERAL SCLEROSIS population (Charles & Swash, 2001; Brown, Meininger & Swash, 2000). ALS affects more men than women, with onset occurring Amyotrophic lateral sclerosis (ALS) is a disease of unknown cause usually in the fifth or sixth decade. It is often referred to as in which there is a loss of motor neurons (nerve cells controlling Lou Gehrig’s disease after the famous baseball player who suffered muscles) in the anterior horns of the spinal cord and the motor from it. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1989

Clinical Manifestations Most patients with ALS are managed at home and in the community, with hospitalization for acute problems. The most Clinical manifestations depend on the location of the affected common reasons for hospitalization are dehydration and malnu- motor neurons, because specific neurons activate specific muscle trition, pneumonia, and respiratory failure (Lechtzin, Wiener, fibers. The chief symptoms are fatigue, progressive muscle weak- Clawson et al., 2001). Recognizing these problems at an earlier ness, cramps, fasciculations (twitching), and incoordination stage in the illness will allow for the development of preventive (Brown, Meininger & Swash, 2000). Loss of motor neurons in strategies. the anterior horns of the spinal cord results in progressive weak- A patient experiencing problems with aspiration and swal- ness and atrophy of the muscles of the arms, trunk, or legs. lowing may require enteral feeding. The American Academy of Spasticity usually is present, and the deep tendon stretch reflexes Neurology practice guidelines suggest the placement of a percu- become brisk and overactive. Usually, the anal and bladder taneous endoscopic gastrostomy tube before the forced vital ca- sphincters are intact because the spinal nerves that control mus- pacity drops below 50% of predicted (Boitano, Jordan & Benditt, cles of the rectum and urinary bladder are not affected. 2001). This tube can be safely placed in patients who are using In about 25% of patients, weakness starts in the muscles sup- noninvasive positive-pressure ventilation for ventilatory support plied by the cranial nerves, and there is difficulty talking, swal- (Boitano, Jordan & Benditt, 2001). lowing, and ultimately breathing. When the patient ingests Mechanical ventilation (using negative-pressure ventilators) is liquids, soft palate and upper esophageal weakness causes the liq- an option when alveolar hypoventilation develops. A small study uid to be regurgitated through the nose. Weakness of the poste- of patients who used noninvasive positive-pressure ventilation at rior tongue and palate impairs the ability to laugh, cough, or even night showed that hypoventilation and sleep disturbances were at blow the nose. When bulbar muscles are impaired, there is pro- least partially improved, enhancing their cognitive function gressive difficulty in speaking and swallowing, and aspiration (Newsom-Davis et al., 2001). The use of noninvasive positive- becomes a risk. The voice assumes a nasal sound, and articulation pressure ventilation also postpones the decision of whether to becomes so disrupted that the speech is unintelligible. Some emo- undergo a tracheotomy for long-term mechanical ventilation tional liability may be present, but intellectual function is not im- (Rowland & Shneider, 2001). paired. Eventually, respiratory function is compromised. Decisions about life support measures are made by the patient The prognosis generally is based on the area of the CNS in- and family and should be based on a thorough understanding of volved and the speed with which the disease progresses. Death the disease, the prognosis, and the implications of initiating such usually occurs as a result of infection, respiratory failure, or aspi- therapy. Patients are encouraged to complete an advance directive ration. The average time from onset of the disease to death is or “living will” to preserve their autonomy in decision-making. about 3 years. A few patients survive for longer periods. The ALS Association has broad programs of research funding, patient and clinical services, patient information and support, Assessment and Diagnostic Findings and medical and public information. The ALS Association Quar- terly Newsletter is a source of practical information. ALS is diagnosed on the basis of the signs and symptoms because no clinical or laboratory tests are specific for this disease. EMG studies of the affected muscles indicate reduction in the number MUSCULAR DYSTROPHIES of functioning motor units. MRI may show high signal intensity The muscular dystrophies are a group of chronic muscle disor- in the corticospinal tracts; this differentiates it from a multifocal ders characterized by progressive weakening and wasting of the motor neuropathy (Rowland & Shneider, 2001). skeletal or voluntary muscles. Most of these diseases are inherited. Duchenne muscular dystrophy is the most common and occurs Management in 1 of every 3,000 male births (Bach, 1999). The pathologic features include degeneration and loss of muscle fibers, variation in There is no specific therapy for ALS. The main focus of medical muscle fiber size, phagocytosis and regeneration, and replacement and nursing management is on interventions to maintain or im- of muscle tissue by connective tissue. The common characteris- prove function, well-being, and quality of life (Brown, Meininger tics of these diseases include varying degrees of muscle wasting & Swash, 2000). One study of 60 patients with ALS found that de- and weakness, abnormal elevation in blood muscle enzymes, and spite the decline in physical function, quality of life and religiosity myopathic findings on EMG and muscle biopsy (Bach, 1999). change little over time (Robbins, Simmons, Bremer et al., 2001). The differences center on the pattern of inheritance, the muscles The medication riluzole (Rilutek), a glutamate antagonist, was involved, the age of onset, and the rate of progression. The approved by the FDA in 1995 after clinical trials found that it unique needs of these patients, who in the past did not live to slows the deterioration of motor neurons. How riluzole works is adulthood, must be addressed as they live longer as a result of not clear, but its pharmacologic properties suggest that it may better supportive care (Carson & Hieber, 2001). have a neuroprotective effect in the early stages of ALS. Two randomized drug trials showed a dose of 100 mg riluzole per day to Medical Management be modestly effective in prolonging survival time for patients with ALS (Miller, Mitchell & Moore, 2001). Treatment of the muscular dystrophies at this time focuses on sup- Symptomatic treatment and rehabilitative measures are em- portive care and preventing complications in the absence of a cure ployed to support the patient and improve the quality of life. or specific pharmacologic interventions (Bach, 1999; Carson & Baclofen (Lioresal), dantrolene sodium (Dantrium), or diazepam Hieber, 2001). Supportive management aims to keep the patient (Valium) may be useful for patients troubled by spasticity, which active and functioning as normally as possible and to minimize causes pain and interferes with self-care. Several neurotrophic fac- functional deterioration. An individualized therapeutic exercise tors that facilitate nutrition and metabolism for nerve tissue are program is prescribed to prevent muscle tightness, contractures, being investigated (Rowland & Shneider, 2001). and disuse atrophy. Night splints and stretching exercises are used 1990 Unit 14 NEUROLOGIC FUNCTION to delay contractures of the joints, especially the ankles, knees, and tient and family require information and instruction about the hips. Braces may compensate for muscle weakness. disorder, its anticipated course, and care and management strate- Spinal deformity is a severe problem. Weakness of trunk mus- gies that will optimize the patient’s growth and development and cles and spinal collapse occur almost routinely in patients with physical and psychological status. Members of a variety of health- severe neuromuscular disease. In the battle against spinal defor- related disciplines are involved in patient and family teaching; mity, the patient is fitted with an orthotic jacket to improve sitting recommendations are communicated to all members of the health stability and reduce trunk deformity. This measure also supports care team so that they may work toward common goals. cardiovascular status. In time, spinal fusion is performed to maintain spinal stability. Other procedures may be carried out to cor- Continuing Care. Both the neuromuscular disease and the asso- rect deformities. ciated deformities may progress in adolescence and adulthood. Compromised pulmonary function may be due either to pro- Self-help and assistive devices can aid in maintaining maximum gression of the disease or to deformity of the thorax secondary to independence. Additional self-help devices, recommended by severe scoliosis. Intercurrent illnesses, upper respiratory infec- physical and occupational therapists, often become necessary as tions, and fractures from falls must be vigorously treated in a way more muscle groups are affected. that minimizes immobilization because joint contractures be- The family is taught to monitor the patient for respiratory come worse when the patient’s activities are more restricted than problems, as respiratory infection and cardiac failure are the most usual. common causes of death (Carson & Hieber, 2001). As respira- Other difficulties may be manifested in relation to the under- tory difficulties develop, patients and their families need infor- lying disease. Dental and speech problems may result from weak- mation regarding respiratory support. Options currently exist ness of the facial muscles, which makes it difficult to attend to that can provide ventilatory support (negative-pressure devices, dental hygiene and to speak coherently. Gastrointestinal tract positive-pressure ventilators) while allowing mobility (Bach, 1999). problems may include gastric dilation, rectal prolapse, and fecal Patients can remain relatively independent in a wheelchair, for impaction. Finally, cardiomyopathy appears to be a common example, while being maintained on a ventilator at home for complication in all forms of muscular dystrophy. many years. Genetic counseling is advised for parents and siblings of the The patient is encouraged to continue with range-of-motion patient because of the genetic nature of this disease. The Muscular exercises to prevent contractures, which are particularly disabling. Dystrophy Association works to combat neuromuscular disease Practical adaptations must be made, however, to cope with the through research, programs of patient services and clinical care, effects of chronic neuromuscular disability. The patient at vari- and professional and public education. ous stages of the disease may require a manual or an electric wheelchair, gait aids, upper and lower extremity and spinal or- Nursing Management thoses, seating systems, bathroom equipment, lifts, ramps, and additional assistive devices, all of which require a team approach The goals of the patient and the nurse are to maintain function (Bach, 1999). The home care nurse assesses how the patient and at optimal levels and to enhance the quality of life. Therefore, the family are managing, makes referrals, and coordinates the activi- patient’s physical requirements, which are considerable, are ad- ties of the physical therapist, occupational therapist, and social dressed without losing sight of emotional and developmental services. needs (Carson & Hieber, 2001). The patient and family are Of great concern to the patient are the issues surrounding the actively involved in decision-making, including end-of-life threat of increasing disability and dependence on others, accom- decisions. panied by a significant deterioration in health-related quality of During hospitalization for treatment of complications, the life (Natterlund, Gunnarsson & Ahlstrom, 2000). The patient is knowledge and expertise of the patient and family members re- faced with a progressive loss of function, leading eventually to sponsible for caregiving in the home are assessed. Because the death. Feelings of helplessness and powerlessness are common. patient and family caregivers often have developed caregiving Each functional loss is accompanied by grief and mourning. The strategies that work effectively for them, these strategies need to patient and family are assessed for depression, anger, or denial. be acknowledged and accepted, and provisions must be made to The patient and family are assisted to address decisions about ensure that they are maintained during hospitalization (Carson end-of-life options before their need arises. & Hieber, 2001). A psychiatric nurse clinician or other mental health profes- Families of chronically ill individuals often need assistance to sional may assist the patient to cope and adapt to the disease. By shift the focus of care from pediatric to adult care. Nursing goals understanding and addressing the physical and psychological include assisting the person with a chronic condition to make the needs of the patient and family, the nurse provides a hopeful, transition to adult values and expectations while providing age- supportive, and nurturing environment. appropriate ongoing care (Carson & Hieber, 2001). The nurse may need to help build the confidence of an older adolescent or DEGENERATIVE DISK DISEASE adult patient by encouraging him or her to pursue job training to become economically independent. Other nursing interventions Low back pain is a significant public health disorder in the United might include guidance in accessing adult health care and finding States (Bigos et al., 1994). It is a challenging disorder to quantify. appropriate programs in sex education (Carson & Hieber, 2001). Current estimates are that between 22% and 65% of individuals have an episode of back pain in any given year, and between 11% PROMOTING HOME AND COMMUNITY-BASED CARE and 84% of adults have an episode within their lifetime (Walker, 2000). This results in significant economic and social costs. Acute Teaching Patients Self-Care. The management goals are ad- low back pain has a duration of less than 3 months; chronic or de- dressed in special rehabilitation programs or in the patient’s home generative disease has a duration of 3 months or longer. Most and community (Natterlund & Ahlstrom, 1999). Thus, the pa- back problems are related to disk disease. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1991

Pathophysiology low back pain, including fracture, tumor, infection, or cauda equina syndrome (Bigos et al., 1994). The intervertebral disk is a cartilaginous plate that forms a cush- MRI has become the diagnostic tool of choice for localizing ion between the vertebral bodies (Fig. 65-8A). This tough, fibrous even small disk protrusions, particularly for lumbar spine disease. material is incorporated in a capsule. A ball-like cushion in the If the clinical symptoms are not consistent with the pathology center of the disk is called the nucleus pulposus. In herniation of seen on MRI, CT and myelography are then performed. A neu- the intervertebral disk (ruptured disk), the nucleus of the disk rologic examination is carried out to determine if there is reflex, protrudes into the annulus (the fibrous ring around the disk), sensory, or motor impairment from root compression and to pro- with subsequent nerve compression. Protrusion or rupture of the vide a baseline for future assessment. EMG may be used to local- nucleus pulposus usually is preceded by degenerative changes that ize the specific spinal nerve roots involved. occur with aging. Loss of protein polysaccharides in the disk decreases the water content of the nucleus pulposus. The development of radiating cracks in the annulus weakens resistance to Medical Management nucleus herniation. After trauma (falls and repeated minor stresses Herniations of the cervical and the lumbar disks occur most com- such as lifting), the cartilage may be injured. monly and are usually managed conservatively with bed rest and For most patients, the immediate symptoms of trauma are medication. The specific conservative management strategies, short-lived, and those resulting from injury to the disk do not ap- along with surgical interventions for each form of herniation, are pear for months or years. Then, with degeneration in the disk, discussed next. the capsule pushes back into the spinal canal, or it may rupture and allow the nucleus pulposus to be pushed back against the SURGICAL MANAGEMENT dural sac or against a spinal nerve as it emerges from the spinal In general, surgical excision of a herniated disk is performed when column (see Fig. 65-8B). This sequence produces pain due to there is evidence of a progressing neurologic deficit (muscle weak- pressure in the area of distribution of the involved nerve endings ness and atrophy, loss of sensory and motor function, loss of (radiculopathy). Continued pressure may produce degenerative sphincter control) and continuing pain and sciatica (leg pain re- changes in the involved nerve, such as changes in sensation and sulting from sciatic nerve involvement) that are unresponsive to deep tendon reflexes. conservative management. The goal of surgical treatment is to reduce the pressure on the nerve root to relieve pain and reverse Clinical Manifestations neurologic deficits (Hall, 1999). Microsurgical techniques are making it possible to remove only the amount of tissue that is A herniated disk with accompanying pain may occur in any por- necessary, better preserving the integrity of normal tissue and im- tion of the spine: cervical, thoracic (rare), or lumbar. The clinical posing less trauma on the body. During these procedures, spinal manifestations depend on the location, the rate of development cord function can be monitored electrophysiologically. (acute or chronic), and the effect on the surrounding structures. To achieve the goal of pain relief, several surgical techniques are used, depending on the type of disk herniation, surgical mor- Assessment and Diagnostic Findings bidity, and overall results of surgery: A thorough health history and physical examination are impor- • Discectomy: removal of herniated or extruded fragments of tant to rule out potentially serious conditions that may present as intervertebral disk

Cauda equina (from Latin words meaning tail of the horse)

Spinal nerve root Spinous process Cauda equina Lamina

Intervertebral Spinal disc nerve root

Vertebral body

Spinal nerve root Herniated nucleus pulposus A B compresses nerve root FIGURE 65-8 (A) Normal lumbar spine vertebrae, intervertebral disks, and spinal nerve root; (B) ruptured vertebral disk. 1992 Unit 14 NEUROLOGIC FUNCTION

• Laminectomy: removal of the bone between the spinal shown that a male patient may suffer more skin irritation if he process and facet pedicle junction to expose the neural ele- shaves; the beard offers a natural form of padding. ments in the spinal canal (Hall, 1999); allows the surgeon to inspect the spinal canal, identify and remove pathology, PHARMACOLOGIC THERAPY and relieve compression of the cord and roots Analgesic agents (NSAIDs, propoxyphene [Darvon], oxycodone • Hemilaminectomy: removal of part of the lamina and part [Tylox], or hydrocodone [Vicodin]) are prescribed during the of the posterior arch of the vertebra acute phase to relieve pain, and sedatives may be administered to • Partial laminectomy or laminotomy: creation of a hole in control the anxiety often associated with cervical disk disease. the lamina of a vertebra (Hall, 1999) Muscle relaxants (cyclobenzaprine [Flexeril], methocarbamol • Discectomy with fusion: a bone graft (from iliac crest or [Robaxin], metaxalone [Skelaxin]) are administered to interrupt bone bank) is used to fuse the vertebral spinous process; the the cycle of muscle spasm and to promote comfort. NSAIDs (as- object of spinal fusion is to bridge over the defective disk to pirin, ibuprofen [Motrin, Advil], naproxen [Naprosyn, Anaprox]) stabilize the spine and reduce the rate of recurrence or corticosteroids are prescribed to treat the inflammatory re- • Foraminotomy: removal of the intervertebral foramen to in- sponse that usually occurs in the supporting tissues and affected crease the space for exit of a spinal nerve, resulting in re- nerve roots. Occasionally, an injection of a corticosteroid into the duced pain, compression, and edema epidural space may be administered for relief of radicular (spinal nerve root) pain. NSAIDs are given with food and antacids to Surgical procedures for herniated cervical disk and lumbar prevent gastrointestinal irritation. Hot, moist compresses (for 10 disk are discussed in the sections that follow. to 20 minutes) applied to the back of the neck several times daily increase blood flow to the muscles and help relax the spastic HERNIATION OF A CERVICAL muscles and the patient. INTERVERTEBRAL DISK SURGICAL MANAGEMENT The cervical spine is subjected to stresses that result from disk de- Surgical excision of the herniated disk may be necessary when generation (from aging, occupational stresses) and spondylosis there is a significant neurologic deficit, progression of the deficit, (degenerative changes occurring in disk and adjacent vertebral evidence of cord compression, or pain that either worsens or fails bodies). Cervical disk degeneration may lead to lesions that can to improve. A cervical discectomy, with or without fusion, may cause damage to the spinal cord and its roots. be performed to alleviate symptoms. An anterior surgical ap- A cervical disk herniation usually occurs at the C5-6 and proach may be used through a transverse incision to remove disk C6-7 interspaces. Pain and stiffness may occur in the neck, the material that has herniated into the spinal canal and foramina, or top of the shoulders, and the region of the scapulae. Sometimes a posterior approach may be used at the appropriate level of the patients interpret these signs as symptoms of heart trouble or cervical spine. Potential complications with the anterior approach bursitis. Pain may also occur in the upper extremities and head, include carotid or vertebral artery injury, recurrent laryngeal accompanied by paresthesia (tingling or a “pins and needles” nerve dysfunction, esophageal perforation, and airway obstruc- sensation) and numbness of the upper extremities. Cervical MRI tion. Complications of the posterior approach include damage to usually confirms the diagnosis. the nerve root or the spinal cord due to retraction or contusion of either of these structures, resulting in weakness of muscles sup- Medical Management plied by the nerve root or cord. Microsurgery, such as endoscopic microdiscectomy, may be The goals of treatment are (1) to rest and immobilize the cervical performed in selected patients through a small incision and using spine to give the soft tissues time to heal and (2) to reduce in- magnification techniques. The patient who undergoes micro- flammation in the supporting tissues and the affected nerve roots surgery usually has less tissue trauma and pain and consequently in the cervical spine. Bed rest (usually 1 to 2 days) is important a shorter hospital stay than after conventional surgical approaches. because it eliminates the stress of gravity and relieves the cervical spine from the need to support the head. It also reduces inflam- NURSING PROCESS: mation and edema in soft tissues around the disk, relieving pressure on the nerve roots. Proper positioning on a firm mattress THE PATIENT UNDERGOING may bring dramatic relief from pain. A CERVICAL DISCECTOMY The cervical spine may be rested and immobilized by a cervi- Assessment cal collar, cervical traction, or a brace. A collar allows maximal opening of the intervertebral foramina and holds the head in a The patient is asked about past injuries to the neck (whiplash) be- neutral or slightly flexed position. The patient may have to wear cause unresolved trauma may cause persistent discomfort, pain the collar 24 hours a day during the acute phase. The skin under and tenderness, and symptoms of arthritis in the injured joint of the collar is inspected for irritation. When the patient is free of the cervical spine. Assessment includes determining the onset, pain, cervical isometric exercises are started to strengthen the neck location, and radiation of pain, paresthesias, limited movement, muscles. and diminished function of the neck, shoulders, and upper ex- Cervical traction is accomplished by means of a head halter at- tremities. It is important to determine whether the symptoms are tached to a pulley and weight. It increases vertebral separation bilateral because with large herniations, bilateral symptoms may and thus relieves pressure on the nerve roots. The head of the bed be due to cord compression. The area around the cervical spine is elevated to provide countertraction (see Chap. 67). If the skin is palpated to assess muscle tone and tenderness. Range of motion becomes irritated, the halter can be padded. Experience has in the neck and shoulders is evaluated. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1993

The patient is asked about any health concerns that may in- (midline) position. Patients are assisted during position changes, ﬂuence the postoperative course. The nurse determines the pa- making sure that head, shoulders, and thorax are kept aligned. tient’s need for information about the surgical procedure and When assisting a patient to a sitting position, the nurse supports reinforces what the physician has explained. Strategies for pain the patient’s neck and shoulders. Patients should wear shoes management are discussed with the patient. when ambulating to increase stability.

Diagnosis MONITORING AND MANAGING POTENTIAL COMPLICATIONS NURSING DIAGNOSES The patient is evaluated for bleeding and hematoma formation Based on the assessment data, the patient’s major nursing diag- by assessing for excessive pressure in the neck or severe pain in noses may include the following: the incision area. The dressing is inspected for serosanguineous • Acute pain related to the surgical procedure drainage, which suggests a dural leak. In this event, meningitis is • Impaired physical mobility related to the postoperative sur- a threat. A complaint of headache requires careful evaluation. gical regimen Neurologic checks are made for swallowing deficits and upper • Deficient knowledge about the postoperative course and and lower extremity weakness because cord compression may home care management produce rapid or delayed onset of paralysis. The patient who has had an anterior cervical discectomy is also assessed for a sudden Other nursing diagnoses may include preoperative anxiety, return of radicular (spinal nerve root) pain, which may indicate postoperative constipation, urinary retention related to surgical instability of the spine. procedure and dehydration, self-care deficits related to neck or- Throughout the postoperative course, the patient is moni- thosis, and sleep pattern disturbance related to disruption in tored frequently to detect any signs of respiratory difficulty be- lifestyle. cause retractors during surgery may injure the recurrent laryngeal nerve, resulting in hoarseness and the inability to cough effec- COLLABORATIVE PROBLEMS/ tively and clear pulmonary secretions. In addition, the blood pres- POTENTIAL COMPLICATIONS sure and pulse are monitored to evaluate cardiovascular status. Based on all the assessment data, the potential complications may Bleeding at the surgical site and subsequent hematoma for- include the following: mation may occur. Severe localized pain not relieved by analgesic • Hematoma at the surgical site, resulting in cord compres- agents should be reported to the surgeon. A change in neurologic sion and neurologic deficit status (motor or sensory function) should be reported promptly Recurrent or persistent pain after surgery because it suggests hematoma formation that may necessitate • surgery to prevent irreversible motor and sensory deficits.

Planning and Goals PROMOTING HOME AND COMMUNITY-BASED CARE The goals for the patient may include relief of pain, improved Teaching Patients Self-Care mobility, increased knowledge and self-care ability, and preven- The patient’s hospital stay is likely to be short; therefore, the tion of complications. patient and family should understand the care that is important for a smooth recovery. A cervical collar is usually worn for about Nursing Interventions 6 weeks. The patient is instructed in use and care of the cervical collar. Patients are instructed to alternate tasks in which the body RELIEVING PAIN does not move (eg, reading) with tasks that require greater body The patient may be kept flat in bed for 12 to 24 hours. If the pa- movement. tient has had a bone fusion with bone removed from the iliac The patient is instructed about strategies for pain manage- crest, considerable pain may be experienced. Interventions consist ment and about signs and symptoms that may indicate compli- of monitoring the donor site for hematoma formation, adminis- cations that should be reported to the physician. The nurse assesses tering the prescribed postoperative analgesic agent, positioning the patient’s understanding of these management strategies, lim- for comfort, and reassuring the patient that the pain can be itations, and recommendations. Additionally, the nurse assists relieved. If the patient experiences a sudden reappearance or the patient in identifying strategies to cope with activities of daily increase of pain, extrusion of the graft may have occurred, requiring living (ie, self-care and childcare) and minimize risks to the sur- reoperation and surgical repositioning of the graft. This should gical site (Chart 65-6). be promptly reported to the surgeon. A discharge teaching plan is developed collaboratively by The patient may experience a sore throat, hoarseness, and dys- members of the health care team to decrease the risk for recurrent phagia due to temporary edema. These symptoms are relieved by disk herniation. Topics include those previously discussed as well throat lozenges, voice rest, and humidification. A puréed diet may as proper body mechanics, maintenance of optimal weight, be given if the patient has dysphagia. proper exercise techniques, and modifications in activity.

IMPROVING MOBILITY Continuing Care Postoperatively, a cervical collar (neck orthosis) is usually worn, Patients are instructed to see their physician at prescribed inter- which contributes to limited neck motion and altered mobility. vals to document the disappearance of old symptoms and for as- Patients are instructed to turn the body instead of the neck when sessment of range of motion of the neck. Recurrent or persistent looking from side to side. The neck should be kept in a neutral pain may occur despite removal of the offending disk or disk 1994 Unit 14 NEUROLOGIC FUNCTION

Chart 65-6 Home Care Checklist • The Patient With Cervical Discectomy and Cervical Collar

At the completion of home care instruction, the patient or caregiver will be able to: Patient Caregiver • Care for the surgical incision site. • Keep staples or sutures clean and dry and cover with dry dressing. ✓ • Notify physician if any signs or symptoms of infection occur, such as fever, redness or irritation, drainage, increased pain. ✓✓ • Demonstrate proper body mechanics and prescribed exercise techniques. ✓ • Modify activity: • Avoid sitting or standing for more than 30 minutes. ✓ • Avoid twisting, flexing, extending, or rotating the neck. ✓ • Avoid long automobile rides. ✓ • Avoid sleeping in a prone position or use of pillows, to minimize neck flexion in bed; keep head in a neutral position. ✓ • Use adequate mattress and chair support. ✓ • Wear low-heeled shoes. ✓ • Follow physician’s instructions regarding lifting, climbing stairs, driving a car, sexual activity, sports, exercise, and return to work. ✓ • Practice stress reduction and relaxation techniques. ✓ • Care of the cervical collar: • Wear the collar at all times until directed otherwise by the physician. ✓ • Wash the neck twice a day with mild soap. ✓✓ • Keep the neck still while the collar is open. ✓ • With the assistance of a helper, wash the neck in steps: • Lie flat and supine. ✓ • Open the Velcro tabs on each side of the collar and remove its front portion. ✓ • Gently wash and dry the neck. ✓ • Replace the front part of the collar and refasten the tabs. ✓ • Turn to one side with a thin pillow under the head. ✓ • Open one tab. ✓ • Gently wash and dry the back of the neck. Refasten the tab. ✓ • Turn to the other side and wash and dry this side. Refasten the tab. ✓ • Place a wrinkle-free silk scarf under the collar to increase comfort. ✓✓ • For men: Shave without twisting or moving the neck. This may be done with help while lying flat or sitting. Remove only the front part of the collar for shaving. ✓✓

fragments. Patients who undergo discectomy usually have con- a. Demonstrates progressive participation in self-care sented to surgery after prolonged pain; they have often undergone activities repeated courses of ineffective conservative management and pre- b. Identifies prescribed activity limitations and restrictions vious surgeries to relieve the pain. Therefore, the recurrence or c. Demonstrates proper body mechanics persistence of symptoms postoperatively, including pain and sen- 3. Is knowledgeable about postoperative course, medications, sory deficits, is often discouraging for the patient and family. The and home care management. patient who experiences recurrence of symptoms requires emo- a. Lists the signs and symptoms to be reported post- tional support and understanding. Additionally, the patient is operatively assisted in modifying activities and in considering options for b. Identifies dose, action, and potential side effects of subsequent treatment. medications The patient with degenerative disk disease tends to focus on c. Identifies appropriate home care management activities obvious needs, issues, and deficits. The nurse needs to remind pa- and any restrictions 4. Absence of complications tients and family members of the need for participating in health a. Reports no increase in incision pain or sensory symptoms promotion and health screening practices. b. Demonstrates normal findings on neurologic assessment

Evaluation HERNIATION OF A LUMBAR DISK EXPECTED PATIENT OUTCOMES Most lumbar disk herniations occur at the L4-5 or the L5-S1 Expected patient outcomes may include: interspaces (Humphreys & Eck, 1999). A herniated lumbar disk 1. Reports decreasing frequency and severity of pain produces low back pain accompanied by varying degrees of sen- 2. Demonstrates improved mobility sory and motor impairment. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1995

Clinical Manifestations Complications of Disk Surgery. A patient undergoing a disk procedure at one level of the vertebral column may have a degenera- The patient complains of low back pain with muscle spasms, tive process at other levels. A herniation relapse may occur at the followed by radiation of the pain into one hip and down into the same level or elsewhere, so that the patient may become a candi- leg (sciatica). Pain is aggravated by actions that increase intra- date for another disk procedure. Arachnoiditis (inflammation of spinal fluid pressure (bending, lifting, straining, as in sneezing the arachnoid membrane) may occur after surgery (and after and coughing) and usually is relieved by bed rest. Usually there is myelography); it involves an insidious onset of diffuse, frequently some type of postural deformity, because pain causes an alteration burning pain in the lower back, radiating into the buttocks. Disk of the normal spinal mechanics. If the patient lies on the back and excision can leave adhesions and scarring around the spinal nerves attempts to raise a leg in a straight position, pain radiates into the and dura, which then produce inflammatory changes that create leg because this maneuver, called the straight leg-raising test, chronic neuritis and neurofibrosis. Disk surgery may relieve pres- stretches the sciatic nerve. Additional signs include muscle weak- sure on the spinal nerves, but it does not reverse the effects of ness, alterations in tendon reflexes, and sensory loss. neural injury and scarring and the pain that results. Failed disk syndrome (recurrence of sciatica after lumbar discectomy) re- Assessment and Diagnostic Findings mains a common cause of disability. The diagnosis of lumbar disk disease is based on the history and physical findings and the use of imaging techniques such as MRI, Nursing Management CT, and myelography. PROVIDING PREOPERATIVE CARE Most patients fear surgery on any part of the spine and therefore Medical Management need explanations about the surgery and reassurance that surgery will not weaken the back. When data are being collected for the The objectives of treatment are to relieve pain, slow disease pro- health history, any reports of pain, paresthesia, and muscle spasm gression, and increase the patient’s functional ability. Bed rest for are recorded to provide a baseline for comparison after surgery. 1 to 2 days on a firm mattress (to limit spinal flexion) is encour- Preoperative assessment also includes an evaluation of movement aged to reduce the weight load and gravitational forces, thereby of the extremities as well as bladder and bowel function. To facil- freeing the disk from stress (Humphrey & Eck, 1999). The pa- itate the postoperative turning procedure, the patient is taught to tient is allowed to assume a comfortable position; usually, a semi- turn as a unit (called logrolling) as part of the preoperative prepa- Fowler’s position with moderate hip and knee flexion relaxes the ration (Fig. 65-9). Before surgery, the patient is also encouraged back muscles. When the patient is in a side-lying position, a pil- to take deep breaths, cough, and perform muscle-setting exercises low is placed between the legs. To get out of bed, the patient lies to maintain muscle tone. on one side while pushing up to a sitting position. Because muscle spasm is prominent during the acute phase, ASSESSING THE PATIENT AFTER SURGERY muscle relaxants are used. NSAIDs and systemic corticosteroids may be administered to counter the inflammation that usually After lumbar disk excision, vital signs are checked frequently and occurs in the supporting tissues and the affected nerve roots. the wound is inspected for hemorrhage because vascular injury is Moist heat and massage help to relax spastic muscles and have a a complication of disk surgery. Because postoperative neurologic sedative effect. Antidepressant agents appear to help in low back deficits may occur from nerve root injury, the sensation and motor pain that is neuropathic in origin (Fishbain, 2000). See also strength of the lower extremities are evaluated at specified inter- Nursing Process: The Patient With Low Back Pain in Chapter 13 vals, along with the color and temperature of the legs and sensa- for nursing interventions. tion of the toes. It is important to assess for urinary retention, another sign of neurologic deterioration. In discectomy with fusion, the patient has an additional sur- SURGICAL MANAGEMENT gical incision if bone fragments were taken from the iliac crest or In the lumbar region, surgical treatment includes lumbar disk ex- fibula to serve as wedges in the spine. The recovery period is cision through a posterolateral laminotomy and the newer tech- longer than for those patients who underwent discectomy with- niques of microdiscectomy and percutaneous discectomy. In out spinal fusion because bony union must take place. microdiscectomy, an operating microscope is used to visualize the offending disk and compressed nerve roots; it permits a small incision (2.5 cm [1 inch]) and minimal blood loss and takes about POSITIONING THE PATIENT 30 minutes of operating time. Generally, it involves a short hos- To position the patient, a pillow is placed under the head and the pital stay, and the patient makes a rapid recovery. Percutaneous knee rest is elevated slightly to relax the back muscles. When the discectomy is an alternative treatment for herniated intervertebral patient is lying on one side, however, extreme knee flexion must disks of the lumbar spine at the L4-5 level. One approach in cur- be avoided. The patient is encouraged to move from side to side rent use is through a 2.5-cm (1-inch) incision just above the iliac to relieve pressure and is reassured that no injury will result from crest. A tube, trocar, or cannula is inserted under x-ray guidance moving. When the patient is ready to turn, the bed is placed in a through the retroperitoneal space to the involved disk space. Spe- flat position and a pillow is placed between the legs. The patient cial instruments are used to remove the disk. The operating time turns as a unit (logrolls), without twisting the back. is about 15 minutes. Blood loss and postoperative pain are min- To get out of bed, the patient lies on one side while pushing imal, and the patient is generally discharged within 2 days after up to a sitting position. At the same time, the nurse or family surgery. The disadvantage of this procedure is the possibility of member eases the patient’s legs over the side of the bed. Coming damage to structures in the surgical pathway. to a sitting or standing posture is accomplished in one long, smooth 1996 Unit 14 NEUROLOGIC FUNCTION

Pathophysiology The exact cause of post-polio syndrome is not known, but researchers suspect that with aging or muscle overuse the neurons not destroyed originally by the poliovirus cannot continue generating axon sprouts. These new terminal axon sprouts reinner- vated the affected muscles following the initial insult but may be more vulnerable as the body ages (Chasens & Umlauf, 2000).

Assessment and Diagnostic Findings No speciﬁc diagnostic test exists for this syndrome. The clinical diagnosis is made on the basis of the history and physical examination and exclusion of other medical conditions that may be causing the new symptoms. Patients report a history of paralytic poliomyelitis with partial or complete recovery of function with a plateau of function for at least 10 years and then the recurrence of symptoms (Chasens & Umlauf, 2000; Chasens, Umlauf, Valappil et al., 2001).

Management No specific medical or surgical treatment is available for this syndrome, and therefore nursing plays a pivotal role in the team approach to assisting patients and families in dealing with the symptoms of progressive loss of muscle strength and significant fatigue. Other health care professionals who may assist in patient FIGURE 65-9 Before the patient undergoes laminectomy surgery, the logrolling technique that will be used for turning the patient should be care include physical, occupational, speech, and respiratory ther- demonstrated. The patient’s arms will be crossed and the spine aligned. To apists. Nursing interventions are aimed at slowing the loss of avoid twisting the spine, the head, shoulders, knees, and hips are turned at strength and maintaining the patient’s physical, psychological, the same time so that the patient rolls over like a log. When in a side-lying and social well-being. position, the patient’s back, buttocks, and legs are supported with pillows. Patients need to plan and coordinate activities to conserve energy and reduce fatigue. Rest periods should be planned and assistive devices used to reduce weakness and fatigue. Important activities should be planned for the morning, as fatigue often increases in the afternoon and evening (Chasens & Umlauf, 2000). motion. Most patients walk to the bathroom the same day as One study investigated the barriers (internal and external en- surgery. Sitting is discouraged except for defecation. vironmental phenomena) that created further disability in polio survivors (Harrison & Stuifbergen, 2001). Disability, the inability to perform societal roles, was correlated with perceived barri- PROMOTING HOME AND COMMUNITY-BASED CARE ers to health but not with functional limitations, comorbidity, or Teaching Patients Self-Care. The patient is advised to gradually secondary conditions. Secondary conditions were correlated with the number of years that the patient had lived with the condition. increase activity as tolerated because it takes up to 6 weeks for the Pain in muscles and joints may be a problem. Nonpharmaco- ligaments to heal. Excessive activity may result in spasm of the logic techniques such as the application of heat and cold are most paraspinal muscles. appropriate because these patients tend to have strong reactions Activities that produce flexion strain on the spine (eg, driving to medications (Chasens & Umlouf, 2000). a car) should be avoided until healing has taken place. Heat may Maintaining a balance between adequate nutritional intake be applied to the back to relax muscle spasms. Scheduled rest pe- yet avoiding excess calories that can lead to obesity in this seden- riods are important, and the patient is advised to avoid heavy tary group of patients is a challenge. Pulmonary hygiene and ad- work for 2 to 3 months after surgery. Exercises are prescribed to equate fluid intake can help with airway management. Several strengthen the abdominal and erector spinal muscles. A back interventions can improve sleep, including limiting caffeine in- brace or corset may be necessary if back pain persists. take before bedtime and assessing for nocturia. If nocturia is an issue, the patient needs to be evaluated for obstructive sleep apnea (Chasens et al., 2001). Supportive ventilation may be appropri- POST-POLIO SYNDROME ate with continuous positive airway pressure if sleep apnea is a problem. Patients who survived the polio epidemic of the 1950s, many Bone density testing in patients with post-polio syndrome has now elderly, are developing new symptoms of weakness, fatigue, demonstrated low bone mass and osteoporosis. Thus, the impor- and musculoskeletal pain. It is estimated that between 60% and tance of identifying risks, preventing falls, and treating osteo- 80% of the 640,000 polio survivors are experiencing the phe- porosis must be discussed with patients and families. The nurse nomenon known as post-polio syndrome. Men and women also needs to remind patients and family members of the need for appear to be equally at risk (Chasens & Umlauf, 2000). health promotion activities and health screening. Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1997

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Chapter 6666 ● Assessment of Musculoskeletal Function

LEARNING OBJECTIVES ● On completion of this chapter, the learner will be able to: 1. Describe the anatomy and physiology of the musculoskeletal system. 2. Discuss the signiﬁcance of the health history to the assessment of musculoskeletal health. 3. Describe the signiﬁcance of physical assessment to the diagnosis of musculoskeletal dysfunction. 4. Specify the diagnostic tests used for assessment of musculoskeletal function. 5. Describe physical assessment of the musculoskeletal system.

2002