CHAPTER TWENTY

Neurologic System

PHYSIOLOGY OF THE NERVOUS SYSTEM b. Chemical neurotransmitters (neuromediators) A. Central nervous system (CNS) (Figure 20-1). facilitate the transmission of an impulse across the B. Peripheral nervous system. synapse. 1. Twelve pairs of cranial nerves. (1) Acetylcholine. 2. Thirty-one pairs of spinal nerves. (2) Norepinephrine. 3. Autonomic nervous system (ANS). (3) Dopamine. a. Sympathetic system: “fight or flight.” (4) Histamine. b. Parasympathetic system. c. Impulses pass in only one direction.

Cells of the Nervous System Central Nervous System A. Neuron: the functional cell of the nervous system. The brain and the spinal cord within the vertebral column B. Function/classification. make up the CNS (see Figure 20-1). C. Supporting cells provide support, nourishment, and pro- A. The brain and the spinal column are protected by tection to the neuron. the rigid bony structure of the skull and the vertebral D. Myelin sheath. column. 1. Dense membrane or insulator around the axon. B. Meninges: protective membranes that cover the brain 2. Facilitates function of the neuron. and are continuous with those of the spinal cord. 3. Contributes to the blood-brain barrier to protect the 1. Pia mater: a delicate vascular connective tissue layer CNS from harmful molecules. that covers the surfaces of the brain and the spinal E. Nerve regeneration: entire neuron is unable to undergo column; part of the blood-brain barrier. complete regeneration. 2. Arachnoid: a delicate nonvascular, waterproof mem- 1. Neuron regeneration in the CNS is very limited, pos- brane that encases the entire CNS; the subarachnoid sibly because of the lack of neurilemma (membrane space contains the cerebrospinal fluid (CSF). surrounding the neuron). 3. Dura mater: a tough white fibrous connective tissue, 2. Scar tissue is a major deterrent to successful cellular the outer layer of protection to the brain and spinal regeneration. cord. F. Impulse conduction. C. Cerebrospinal fluid (CSF). 1. Reflex arc. 1. Serves to cushion and protect the brain and spinal a. A reflex arc is the functional unit that provides cord; brain literally floats in CSF. pathways over which nerve impulses travel. 2. CSF is clear, colorless, watery fluid; approximately b. The passage of impulses over a reflex arc is called 100 to 200 mL in total volume, with a normal fluid

a reflex act or a reflex and is an involuntary response pressure of 60 to 100 mm H2O. to a stimulus. 3. Formation and circulation of CSF (Figure 20-2). c. Reflex arc: the afferent neuron carries the stimulus a. Fluid is secreted by the choroid plexus located in to the spine, integrates it into and through the the ventricles of the brain. spine (CNS) to the efferent neuron, and crosses b. CSF flows through the lateral ventricles into the the synapse with the message from the CNS to third ventricle, then flows through the aqueduct the organ or muscle, which responds to the stimu- of Sylvius into the fourth ventricle, where the lus. This is the sequence of events evaluated when central canal of the spinal column opens. the deep tendon reflexes are tested. c. From the fourth ventricle, CSF flows around the 2. Synaptic transmission. spinal cord and brain. a. A chemical synapse maintains a one-way com- d. Because CSF is formed continuously, it is reab- munication link between neurons. sorbed at a comparable rate by the arachnoid villi. L 401 402 CHAPTER 20 Neurologic System

H Cerebral c. Temporal. hemisphere H (1) Auditory area: interprets meaning of certain H sounds. H (2) Wernicke’s area for speech, sensory speech H5 Diencephalon area, comprehension and formulation of H speech (understanding spoken and written Midbrain H words). Pons Brainstem Cerebellum H { Medulla d. Occipital area: interprets vision and controls H ability to understand written words. H10 3. Motor areas of the cerebral cortex. H a. Primary function is coordination and control of H skeletal muscle activity. Spinal cord H b. Corticospinal tracts (pyramidal tracts). H (1) Descending tract from the motor area of the H15 cerebral cortex to the spinal cord. H (2) Majority of motor nerves cross in the medulla H to the opposite side before descending into the H spinal cord. H FIGURE 20-1 Major divisions of the central nervous system. (From (3) These corticospinal tracts do not cross over. H20 Lewis SL et al: Medical-surgical nursing: assessment and management c. Brain cells and the nerve fibers in the descending H of clinical problems, ed 7, St. Louis, 2007, Mosby.) tracts of the CNS are called upper motor neurons. H 4. Movement is controlled by: H a. Cerebral cortex: voluntary initiation of motor H activity. H25 b. Basal ganglia: assist in maintaining posture. Superior Arachnoid villi sagittal sinus H Subarachnoid c. Cerebellum: coordinates muscle movement. space H Lateral 5. Cerebellum: attached to the medulla and the pons. ventricle Choroid H plexus a. Primarily concerned with coordination of motor Foramen of (third H Monro movement, muscular tone, and maintenance of ventricle) H30 Choroid Cisterna equilibrium. plexus magna H (fourth b. Nerve fibers spread upward to the cerebrum and H ventricle) Foramen of downward to the pons, medulla, and spinal cord. Luschka H Foramen of (1) Visual reflexes: pupillary constriction and Magendie H Aqueduct of movement of the eye. H35 Sylvius (2) Auditory reflexes: turning of the head toward H FIGURE 20-2 Circulation of the cerebrospinal fluid. (From Monahan FD sound. H et al: Medical-surgical nursing: health and illness perspectives, ed 8, St. 6. Brainstem: consists of the pons and the medulla. H Louis, 2007, Mosby.) a. Pons: contains both motor and sensory pathways H relaying messages between the cerebrum and the H40 spinal cord; also regulates respiration. H D. Brain. b. Medulla oblongata: a continuation of the spinal H 1. Cerebrum: the largest portion of the brain; separated cord as it enters into the cranial vault in the H into hemispheres; the cerebral cortex is the surface brain. H layer of each hemisphere. (1) Conduction center and crossing center for the H45 2. Major lobes of the central cortex. upper motor neurons. H a. Frontal. (2) Maintains control of cardiac rate. H (1) Responsible for intelligence and personality. (3) Vasomotor center for constriction and dila- H (2) Coordination of voluntary skeletal muscle tion of vessels. H movement. (4) Respiratory center for changes in rate and H50 (3) Abstract thinking, morals, judgment. depth of breathing. H (4) Broca’s area for speech, motor-speech area, (5) Vomiting and swallowing reflex center. H area of expressive ability (to speak and write). c. Thalamus. H b. Parietal. (1) Organization and distribution of incoming H (1) Interprets sensory nerve impulses (pain, tem- sensory impulses. H55 perature, touch). (2) Activities related to consciousness. H56 (2) Maintains proprioception. d. Hypothalamus. H57 (3) Recognition of size, texture, and shape of (1) Homeostasis: regulation of visceral activities, H58 L objects. including body temperature, fluid and electro- CHAPTER 20 Neurologic System 403

lyte regulation, motility and secretions of the b. Nucleus pulposus is the fibrocartilaginous portion gastrointestinal tract, arterial blood pressure. of the intravertebral disk; acts as shock absorber (2) Nerve connections with the thalamus and the for the spinal cord. cerebral cortex make it possible for emotions 4. Upper motor neurons: originate in the brain; trans- to influence visceral activity (e.g., spastic mit impulses from the brain to the lower motor colon). neurons. (3) Regulation of endocrine glands via influence 5. Lower motor neurons: originate in the spinal cord; on the pituitary gland. transmit impulses to the muscles and organs. These (4) Neurosecretion of antidiuretic hormone, neurons form the reflex arc. which is stored in the pituitary gland. 6. Reflex activity. 7. Cerebral circulation. a. The reflex arc must be intact; the spinal cord serves a. The internal carotid arteries enter the cranial vault as the connection between the afferent pathway at the temporal area. (sensory) and the efferent pathway (motor). b. The circle of Willis is an arterial anastomosis at b. Testing of the reflex arc (deep tendon reflexes) the base of the brain. The circle ensures continued allows evaluation of the lower motor neuron and circulation if one of the main vessels is disrupted. the sensory/motor fibers from the spinal column. E. Spinal cord. For example, if the biceps reflex is normal, the lower 1. The spinal cord is continuous with the medulla and motor neurons and the nerve fibers at C5 and C6 extends down the vertebral column to the level of the are intact. first or second lumbar vertebrae. 2. Each column is divided into functional groups of Peripheral Nervous System nerve fibers. The cranial and spinal nerves, which connect the CNS with a. Ascending tracts: transmit impulses to the brain the body parts, constitute the peripheral nervous system. (sensory pathway). A. Cranial nerves (Table 20-1). b. Descending tracts: transmit impulses from the 1. Twelve pairs of cranial nerves. brain to the various levels of the spinal cord (motor 2. Originate from under the surface of the brain. pathways). B. Spinal nerves. 3. Structure. 1. Each pair of nerves is numbered according to the level a. Intervertebral disks lie between the vertebrae to of the spinal cord from which it originates (e.g., C1, provide flexibility to the spinal column. C2, etc.).

Table 20-1 CRANIAL NERVES

No. Name Function I Olfactory Sense of smell II Optic Vision: conducts information from the retina III Oculomotor Downward and outward movement of the eye Pupillary constriction and accommodation Muscle of the upper eyelid (ability to keep the eye open) IV Trochlear Movement of the eye V Trigeminal: Ophthalmic Corneal reflex Maxillary Sensory fibers of the face Mandibular Motor nerves for chewing and swallowing VI Abducens Inward movement of the eye VII Facial Facial expression Sense of taste on anterior tongue Muscle of the eyelid (ability to close the eye) VIII Acoustic Reception of hearing and maintenance of equilibrium IX Glossopharyngeal Sense of taste on posterior tongue Salivation Swallowing or gag reflex X Vagus nerve Assists in swallowing action Motor fibers to larynx for speech Innervation of organs in thorax and abdomen Important in respiratory, cardiac, and circulatory reflexes XI Accessory (spinal) Ability to rotate the head and raise the shoulder XII Hypoglossal Muscles of the tongue L 404 CHAPTER 20 Neurologic System

H 2. Each spinal nerve is connected to the cord by two c. Mental status must be assessed before the history H roots. data from the client can be assumed to be accurate. H a. Dorsal (posterior root): a sensory nerve carrying H messages to the CNS. NURSING PRIORITY In the older adult client, assess H5 b. Ventral (anterior root): a motor nerve carrying orientation and mental status before continuing assessment of H neuron messages to glands and the peripheral neurologic function (Box 20-1). H areas. H C. Somatic nervous system: consists of peripheral nerve 2. Medical history. H fibers sending sensory stimuli to CNS and motor nerve a. Assess comorbidities (Box 20-2). H10 fibers that stimulate skeletal muscle. b. Complete medication profile including comple- H D. Autonomic nervous system (ANS): regulates involuntary mentary medications. H activity (cardiovascular, respiratory, metabolic, body H temperature, etc.). Box 20-1 OLDER ADULT CARE FOCUS H 1. Consists of two divisions that have antagonistic H15 activity. Assessing Neurologic Function in Older Adults H 2. Parasympathetic division: maintains normal body H functions. Signs of Cognitive Impairment • Significant memory loss (person, place, and time). H 3. Sympathetic division: prepares the body to meet a • Person: Does client know who he or she is, and can client H challenge or an emergency (preparation for “fight or give you his or her full name? H20 flight”) (Table 20-2). • Place: Can client identify his or her home address and where H 4. Most of the organs of the body receive innervation he or she is now? H from both the parasympathetic and the sympathetic • Time: What was the most recent holiday; what month, time H divisions. The divisions are usually antagonistic in of day, day of the week is it now? H effect on individual organs: one stimulates; the other • Does client show a lack of judgment? H25 relaxes. • Is client agitated and/or suspicious? H 5. Chemical mediators: facilitate transmission of • As determined from client’s appearance and family’s H impulses in the ANS. response, does client have problems with ADLs? H a. Acetylcholine is released by the fibers in both divi- • Short-term memory: Can the client recall your name, name of the President, or name of his or her doctor? H sions of the ANS. • Short-term recall: Ask the client to name three or four H30 b. Norepinephrine is released primarily by the sym- common objects; then ask client to recall them within the H pathetic division. next 5 minutes. H • Does the client have sensory deficits (hearing and vision) of ALERT Identify pathophysiology related to an acute or chronic H which he or she is not aware? H condition (e.g., signs and symptoms). H35 H System Assessment Box 20-2 OLDER ADULT CARE FOCUS H A. History. Causes of Confusion in the Older Adult Client H 1. Neurologic history. H a. Avoid suggesting symptoms to the client. Decreased Cardiac Output H40 b. The manner in which the problems first pre- • Myocardial infarction H sented and the overall course of the illness are • Dysrhythmias H very important. • Congestive heart failure H Hypoxia/Respiratory Acidosis H • Pneumonia H45 Table 20-2 AUTONOMIC NERVOUS SYSTEM • Infection H • Hypoventilation H Area Affected Sympathetic Parasympathetic Neurologic H Pupil Dilates Constricts • Vascular insufficiency H Bronchi Dilates Constricts • Infections H50 Heart Increases rate Decreases rate • Cerebral edema H Gastrointestinal Inhibits peristalsis Stimulates peristalsis Metabolic—Altered Homeostasis H Stimulates sphincter Inhibits sphincters • Electrolyte imbalance H Bladder Relaxes bladder Contracts bladder • Hypoglycemia/hyperglycemia muscle muscle H • Dehydration Constricts sphincter Relaxes sphincter • Urinary tract infections H55 Adrenal glands Increases secretion of Environmental H56 epinephrine and H57 • Strange surroundings norepinephrine • Hypothermia/hyperthermia H58 L CHAPTER 20 Neurologic System 405

c. Birth (or delivery) history. Was client a difficult delivery? d. Sequence of growth and development. 3. Family history: presence of hereditary or congenital problems. 4. Personal history: activities of daily living (ADLs), any change in routine. 5. History and symptoms of current problem. a. Paralysis or paresthesia, syncope. b. Headache, dizziness, speech problems. c. Visual problems, changes in personality. d. Memory loss, nausea, vomiting. B. Physical assessment. 1. General observation of client. a. Posture, gait, coordination; perform Romberg test. b. Position of rest for the infant or young child. c. Personal hygiene, grooming. d. Evaluate speech and ability to communicate. (1) Pace of speech: rapid, slow, halting. (2) Clarity: slurred or distinct. (3) Tone: high-pitched, rough. (4) Vocabulary: appropriate choice of words. FIGURE 20-3 Assessment of the neurologic system: pupillary check. e. Facial features may suggest specific syndromes in (From Zerwekh J, Gaglione T: Mosby’s assessment memory notecards: children. visual, mnemonic, and memory aids for nurses, ed 1, St. Louis, 2007, 2. Mental status (must take into consideration the cli- Mosby.) ent’s culture and educational background).

d. PERRLA: indicates that Pupils are Equal, Round, NURSING PRIORITY Level of consciousness and mental and Reactive to Light and that Accommodation status are assessment data for the client with neurologic deficits. is present.

NURSING PRIORITY: When assessing a client’s neurologic a. Level of consciousness. status, always evaluate symmetry. If asymmetrical findings are (1) Oriented to person, place, time, and situation detected, refine exam to determine CNS versus peripheral (in order of importance). nervous system as origin of asymmetry. (2) Appropriate response to verbal and tactile stimuli. 4. Evaluate motor function. (3) Memory, problem-solving abilities. a. Assess face and upper extremities for equality of b. Mood. movement and sensation. c. Thought content and intellectual capacity. b. Evaluate appropriateness of motor movement- d. General appearance and behavior. spontaneous and on command. 3. Assess pupillary status and eye movements (Figure c. Movement of extremities should always be evalu- 20-3). ated bilaterally; tone, strength, and muscle move- a. Size of pupils should be equal. ment of each side should be compared (e.g., b. Reaction of pupils. bilateral hand grips of equal strength). (1) Accommodation: pupillary constriction to d. Presence of inappropriate, nonpurposeful move- accommodate near vision. ment (e.g., posturing). (2) Direct light reflex: constriction of pupil when (1) Decerebrate: extension and adduction of the light is shone directly into eye. arms, hyperextension of the legs. (3) Consensual reflex: constriction of the pupil in (2) Decorticate: flexion, internal rotation of the the opposite eye when the direct light reflex is arms, extension of the legs. tested. (3) Presence of nonpurposeful involuntary move- c. Evaluate ability to move eye. ments such as tremors, jerking, twitching, tics, (1) Note nystagmus: fine, jerking eye movement. or muscle fasciculation. (2) Ability of eyes to move together. (4) Opisthotonos: extreme hyperextension of the (3) Resting position of the iris should be at mid- head and dorsal arching. position of the eye socket. e. Ability of an infant to suck and to swallow. (4) Assess for lid lag (ptosis). f. Asymmetrical contraction of facial muscles. L 406 CHAPTER 20 Neurologic System

H 5. Evaluate reflexes. 2. Clients should be ventilated to a normocapnic state H a. Gag or cough reflex. to prevent cyclic vasodilation, which increases intra- H b. Swallow reflex. cranial pressure. H c. Corneal reflex. E. Regardless of the cause, increased ICP will result in H5 d. Babinski reflex: normal is negative in adults and progressive neurologic deterioration; the specific defi- H children older than 1 year; positive sign is dorsal ciencies seen are determined by the area and extent of H flexion of the foot and large toe with fanning of compression of brain tissue. H the other toes. F. If the infant’s cranial suture lines are open, increased H e. Deep tendon reflexes (simple stretch reflex). ICP will cause separation of the suture lines and an H10 6. Assess vital signs and correlate with other data; increase in the circumference of the head. H changes often occur slowly, and the overall trend H needs to be evaluated. H a. Blood pressure and pulse: intracranial problems NURSING PRIORITY There is no single set of symptoms for all clients with increased ICP; symptoms depend on the cause H precipitate changes; systolic blood pressure may and on how rapidly increased ICP develops. H15 increase, and pulse rate may decrease. H b. Respirations: rate, depth, and rhythm are sensitive H indicators of intracranial problems. Assessment H (1) Cheyne-Stokes respiration: periodic breath- A. Risk factors/etiology. H ing in which hyperpnea alternates with apnea. 1. Cerebral edema caused by some untoward event or H20 (2) Neurogenic hyperventilation: regular, rapid, trauma, including toxic exposure, blunt trauma, fluid H deep hyperpnea. and electrolyte imbalance. H (3) Ataxic: completely irregular pattern with 2. Brain tumors. H random deep and shallow respirations. 3. Intracranial hemorrhage caused by epidural or subdu- H c. Temperature: evaluate changes in temperature as ral bleeding (closed head injuries or ruptured blood H25 related to neurologic control versus infection. vessels). H 4. Subarachnoid hemorrhage, hydrocephalus. H DISORDERS OF THE NEUROLOGIC 5. Cerebral embolism, resulting in necrosis and edema H SYSTEM of areas supplied by the involved vessel. H 6. Cerebral thrombosis, resulting in ischemia of the area H30 Increased Intracranial Pressure and leading to edema and congestion of affected area. H An increase in intracranial pressure (ICP) occurs any time 7. Encephalitis/meningitis. H there is an increase in the size or amount of intracranial B. Clinical manifestations (bedside neurologic checks) H contents. (Figure 20-4). H A. The cranial vault is rigid, and there is minimal room for H35 expansion of the intracranial components. ALERT Determine change in a client’s neurologic status. H B. An increase in any one of the components necessitates Be able to rapidly evaluate the client and recognize incremental H a reciprocal change in other cranial contents; this fre- changes in the neurologic signs that indicate an increase in ICP H quently results in ischemia of brain tissue. An increase (Box 20-3). H in ICP results from one of the following: H40 1. Increased intracranial blood volume (vasodilation). H 2. Increased CSF. H 3. Increase in the bulk of the brain tissue (edema). H C. Cerebral edema. H 1. Edema occurs when there is an increase in the volume H45 of brain tissue caused by an increase in the permeabil- H ity of the walls of the cerebral vessels. Protein-rich H fluid leaks into the extracellular space. Edema is most H often the cause of increased ICP in adults, which H reaches maximum pressure in 48 to 72 hours. H50 2. Cytotoxic (cellular) edema occurs as a result of H hypoxia. This results in abnormal accumulation of H fluid within the cells (intracellular) and a decrease in H extracellular fluid. H D. Poor ventilation will precipitate respiratory acidosis, or

H55 an increase in the Paco2. H56 1. Carbon dioxide has a vasodilating effect on the cere- FIGURE 20-4 Increased intracranial pressure. (From Zerwekh J, H57 bral arteries, which increases cerebrovascular blood Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, H58 L flow and increases ICP. 2008, Nursing Education Consultants.) CHAPTER 20 Neurologic System 407

c. Unilateral dilation of pupils. Box 20-3 INCREASING INTRACRANIAL PRESSURE d. Sluggish or no pupillary response to light and poor or absent accommodation. Adult 4. Motor and sensory function: normal is indicated by Early: Restless, irritable, lethargic the ability to move all extremities with equal strength. Intermediate: Unequal pupil response, projectile vomiting, vital signs changes Abnormal findings include: Late: Decreased level of consciousness, decreased reflexes, a. Unilateral or bilateral weakness or paralysis. hypoventilation, dilated pupils, posturing b. Failure to withdraw from painful stimuli. Infant/Child c. Posturing: decerebrate, decorticate, flaccid, or Early: Poor feeding, tense fontanel, headache, nausea and vom- opisthotonos. iting, increased pitch of cry, unsteady gait d. Seizure activity, ataxia. Intermediate (younger than 18 months): Increased head cir- 5. Headache. cumference, altered consciousness, bulging fontanel; shrill a. Constant with increasing intensity. cry, severe headache, blurred vision, stiff neck b. Exacerbated by movement. Late: Same as adult c. Photophobia. 6. Vomiting: projectile vomiting without prior nausea. 7. Infants. a. Tense, bulging fontanel(s). 1. Assess for changes in level of consciousness, because b. Separated cranial sutures. change is the cardinal indicator of increased intracra- c. Increasing frontal-occipital circumference. nial pressure. d. High-pitched cry. a. Any alteration in level of consciousness (early sign C. Diagnostics (see Appendix 20-1). for both adults and children)— irritability, rest- 1. Direct ICP monitoring. lessness, confusion, lethargy, and difficulty in 2. Romberg test: measures balance. Client stands with arousing—may be significant. feet together and arms at side, first with eyes open, then with eyes closed for 20 to 30 seconds. 3. Caloric testing: test is performed at bedside by intro- NURSING PRIORITY The first sign of a change in the level ducing cold water into the external auditory canal. If of ICP is a change in level of consciousness; this may progress to the eighth cranial nerve is stimulated, nystagmus a decrease in level of consciousness. rotates toward the irrigated ear. If no nystagmus occurs, a pathologic condition is present. b. Inappropriate verbal and motor response; delayed 4. Doll’s eye reflex (oculocephalic reflex). or sluggish responses. a. Doll’s eye reflex is normal when the client’s c. As the client loses consciousness, hearing is the head is moved from side to side and the eyes last sense to be lost. move in the direction opposite that of the 2. Changes in vital signs. turning. a. Increase in systolic blood pressure with increase in b. Doll’s eye reflex is abnormal when the client’s pulse pressure. eyes remain in a fixed, midline position when b. Decrease in pulse rate. the head is turned from side to side (possible c. Alteration in respiratory pattern (Cheyne-Stokes brainstem involvement). respiration, hyperventilation). c. Contraindicated until risk for spinal cord injury is d. Assess temperature with regard to overall prob- ruled out. lems; temperature usually increases. 5. Papilledema: edema of the optic nerve; observed by examining retina area with an ophthalmoscope. 6. Nuchal rigidity: herniation of brainstem may occur; NURSING PRIORITY Cushing’s triad: increasing systolic an emergent crisis. pressure, with increased pulse pressure, decreased pulse rate, 7. Lumbar puncture is generally not performed; decrease and Cheyne-Stokes respirations. Increased ICP is well established in CSF pressure could precipitate herniation of the when this occurs. brainstem.

3. Pupillary response: normal pupils should be round, Treatment midline, equal in size, and equally briskly reactive to A. Treatment of the underlying cause of increasing light and should accommodate to distance. Abnormal pressure. findings include: B. Neurologic checks every hour or as ordered. a. Ipsilateral: pupillary changes occurring on the 1. May involve correlation of several variables including same side as a cerebral lesion. level of consciousness, vital signs, speech, facial b. Contralateral: pupillary changes occurring on the symmetry, grasp strength, leg strength, and pupil side opposite a cerebral lesion. responses. L 408 CHAPTER 20 Neurologic System

H 2. Careful comparison to previous assessment is critical Nursing Interventions H to detect incremental changes. Goal: To identify and decrease problem of increased ICP. H C. Intravenous (IV) and oral fluids to maintain normal fluid A. Neurologic checks, as indicated by client’s status (Tables H volume status if mean arterial pressure (MAP) is low to 20-3 and 20-4). H5 normal. Often, normal saline solution is fluid of choice; B. Maintain head of bed in semi-Fowler’s position (15-30 H 5% dextrose in water potentiates cerebral edema. degrees) to promote venous drainage and respiratory H D. Medications. function. H 1. Osmotic diuretic corticosteroids. H 2. Anticonvulsants, antihypertensives. H10 E. Maintain adequate ventilation by means of mechanical ALERT Change client’s position. If the client with increased ICP develops hypovolemic shock, do not place client in Trendelenburg H ventilation to lower Paco (25 to 35 mm Hg) to prevent 2 position. H vasodilation of cerebral vessels. H F. Placement of ventriculoperitoneal shunt during decom- H pression surgery. C. Change client’s position slowly; avoid extreme hip H15 flexion and extreme rotation or flexion of neck. Maintain H Complications the head midline. H A. CSF leaks, especially in client with basilar skull fracture, D. Monitor urine osmolarity and specific gravity. H may cause meningitis. E. Evaluate intake and output. H B. Herniation: shifting of the intracranial contents from 1. In response to diuretics. H20 one compartment to another; involves herniation 2. As correlated with changes in daily weight. H through the tentorium cerebelli; affects area for control 3. For complications of diabetes insipidus (see H of vital functions. Chapter 13). H C. Permanent brain damage. F. Maintain intake evenly during therapeutic treatment. H H25 H Table 20-3 GLASGOW COMA SCALE (GCS) H H Category of Response Appropriate Stimulus Response Score H Eyes open Approach bedside Spontaneous response 4 H30 Verbal command Opening of eyes to name or command 3 H Pain Lack of opening of eyes to previous stimuli but 2 H opening to pain H Lack of opening of eyes to any stimulus 1 H Untestable U H35 Best verbal response Verbal questioning with Appropriate orientation, conversant, correct 5 H maximum arousal identification of self, place, year, and month H Confusion; conversant, but disorientated in one or 4 H more spheres H Inappropriate or disorganized use of words (e.g., 3 cursing), lack of sustained conversation H40 Incomprehensible words, sounds (e.g., moaning) 2 H Lack of sound, even with painful stimuli 1 H Untestable U H Best motor response Verbal command (e.g., “raise your Obedience in response to command 6 H arm, hold up two fingers”) H45 Pain (pressure on proximal nail Localization of pain, lack of obedience but 5 H bed) presence of attempts to remove offending H stimulus H Flexion withdrawal*, flexion of arm in response to 4 H pain without abnormal flexion posture H50 Abnormal flexion, flexing of arm at elbow and 3 H pronation, making a fist H Abnormal extension, extension of arm at elbow, 2 H usually with adduction and internal rotation of H arm at shoulder Lack of response 1 H55 Untestable U H56 H57 From Lewis SL et al: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St. Louis, 2007, Mosby. H58 L *Added to the original scale by many centers. CHAPTER 20 Neurologic System 409

Table 20-4 MODIFIED GLASGOW COMA SCORE FOR PEDIATRIC CLIENTS

Activity Score Infant’s Best Response Children (4 years or older) Eyes opening 4 Spontaneous Spontaneous 3 To speech To speech 2 To pain To pain 1 No response No response Verbal response 5 Coos, babbles Oriented; smiles, interacts, follows objects 4 Irritable cry Confused, disoriented, uncooperative 3 Cries in response to pain Inappropriate words, persistent cries, inconsolable, inconsistent awareness of environment 2 Moans in response to pain Incomprehensible sounds, agitated, restless, unaware of environment 1 No response No response Motor response 6 Normal spontaneous movements Normal spontaneous movements 5 Withdraws from touch Localizes pain 4 Withdraws from pain Withdraws from pain 3 Abnormal flexion Abnormal flexion 2 Abnormal extension Abnormal extension 1 No response No response

G. Minimize respiratory suctioning and ensure hyperoxy- it; test it with a dipstick. CSF also leaves a yellow “halo” genation before suctioning. stain. H. Sedatives and narcotics can depress respiration; use with D. Aspiration is a major problem in the unconscious client; caution because they mask symptoms of increasing ICP. place the client in semi-Fowler’s position for tube feeding I. Client should avoid strenuous coughing, Valsalva after ensuring correct tube placement. maneuver, and isometric muscle exercises. E. Maintain quiet, nonstimulating environment. J. Avoid straining with stools (increases intrathoracic F. Inspect eyes and prevent corneal ulceration. pressure sporadically). 1. Protective closing of eyes, if eyes remain open. K. In infants, measure frontal-occipital circumference to 2. Irrigation with normal saline solution or methylcel- evaluate increase in size of the head. lulose drops to restore moisture. L. Control hyperthermia. Goal: To maintain psychologic equilibrium. M. Maintain head and spinal column in midline position. A. Neurologic checks should be done on a continual basis Goal: To maintain respiratory function. to detect potential problems. B. Encourage verbalization of fears regarding condition. C. Give simple explanation of procedures to client and NURSING PRIORITY An obstructed airway is one of the family. most common problems in the unconscious client; position to D. Altered states of consciousness will cause increased maintain patent airway or use airway adjuncts. anxiety and confusion; maintain reality orientation. E. If client is unconscious, continue to talk to him or her; A. Prevent respiratory problems of immobility. describe procedures and treatments; always assume that B. Evaluate patency of airway frequently; as level of con- client can hear. sciousness decreases, client is at increased risk for accu- F. Assist parents and family to work through feelings of mulating secretions and airway obstruction by the guilt and anger. tongue. Goal: To prevent complications of immobility (see Chapter

C. Keep Paco2 levels normal. 3). D. Suction as necessary briefly. Goal: To maintain elimination. E. Client may require intubation and respiratory support A. Urinary incontinence: may use condom catheter or from a ventilator (see Appendixes 15-5 and 15-8). indwelling bladder catheter. Goal: To protect client from injury. B. Keep perineal area clean, prevent excoriation. A. Maintain seizure precautions (see Appendix 20-5). C. Monitor bowel function; evaluate for fecal impaction. B. Restrain client only if absolutely necessary; struggling against restraints increases ICP. C. Do not clean the ears or nasal passages of a client with ALERT Notify primary health care provider when client a head injury or a client who has had neurosurgery. demonstrates signs of potential complications; interpret what Check for evidence of a CSF leak: CSF has glucose in data for a client need to be reported immediately. L 410 CHAPTER 20 Neurologic System

H 8. Sensory disturbances. H Home Care a. Language disturbances. H A. Teach client and family signs of increased ICP. b. Coordination disturbances. H B. Call the doctor if any of the following are observed: c. Visual disturbances. H5 1. Changes in vision. 9. Head tilt: child may tilt the head because of damage H 2. Increased drainage from incision area or clear drain- to extraocular muscles; may be first indication of a H age in the ears. decrease in visual acuity. H 3. Abrupt changes in sleeping patterns or irritability. 10. Changes in vital signs indicative of increasing ICP H 4. Headache that does not respond to medication. (Cushing’s triad). H10 5. Changes in coordination, disorientation. 11. Cranial enlargement in the infant younger than 18 H 6. Slurred speech, unusual behavior. months. H 7. Seizure activity, vomiting. C. Diagnostics (see Appendix 20-1). H C. Review care of surgical incision, wounds, or drains. H Treatment H15 A. Medical. H Brain Tumors 1. Dexamethasone (see Appendix 6-7). H A. Brain tumors may be benign, malignant, or metastatic; 2. Chemotherapy. H malignant brain tumors rarely metastasize outside the 3. Anticonvulsants (see Appendix 20-2). H CNS. 4. Complementary and alternative medicine. H20 B. Supratentorial: tumors occurring within the anterior B. Radiation: x-rays, gamma knife, stereotactic radiosur- H two-thirds of the brain, primarily the cerebrum. gery. H C. Infratentorial: tumors occurring in the posterior third of C. Surgical intervention: craniotomy/craniectomy, biopsy, H the brain (or below the tentorium), primarily in the shunt placement, reservoir placement, laser removal. H cerebellum or the brainstem. H25 D. Regardless of the origin, site, or presence of malignancy, Complications H problems of increased ICP occur because of the limited Complications include meningitis, brainstem herniation, H area in the brain to accommodate an increase in the diabetes insipidus, and syndrome of inappropriate antidi- H intracranial contents. uretic hormone secretion (see Chapter 13). Residual effects H include a wide array of complications such as seizures, dys- H30 Assessment arthria, dysphasia, disequilibrium, and permanent brain H A. Risk factors/etiology. damage. H 1. Age: highest incidence in people older than 70 years; H common in children younger than 8 years. Nursing Interventions H 2. Presence of metastatic cancer of the lung or breast. Goal: To provide appropriate preoperative nursing H35 3. Family history: gliomas tend to occur in other family interventions. H members. A. General preoperative care with exceptions, as noted (see H 4. Occupation: people who work with high levels of Chapter 3). H radiation, formaldehyde (pathologists), vinyl chloride B. Carefully assess and discuss with surgeon the appropri- H (plastics manufacturers), and other chemicals are at ateness of a preoperative enema. H40 increased risk for brain tumors. C. Prepare client and family for appearance of the client H B. Clinical manifestations: symptoms correlate with the after surgery, including partial or complete hair loss. H area of the brain initially involved. D. Encourage verbalization regarding concerns about H 1. Headache. surgery. H a. Recurrent. May vomit on arising and then feel E. Skin preparation is usually done in the operating room. H45 better. Goal: To monitor changes in ICP after craniotomy (see H b. More severe in the morning. Box 20-3). H c. Affected by position. A. Obtain vital signs and perform neurologic checks and H d. Headache in infant may be identified by persis- cranial nerve assessments as necessary. H tent, irritated crying and head rolling. B. Maintain pulmonary function and hygiene. H50 2. Vomiting: initially with or without nausea; progres- C. Anticipate use of anticonvulsants and antiemetics. H sively becomes projectile. D. Discourage coughing. H 3. Papilledema (edema of the optic disc). E. Carefully evaluate level of consciousness; increasing leth- H 4. Seizures (focal or generalized). argy or irritability may be indicative of increasing ICP. H 5. Dizziness and vertigo. F. Evaluate dressing. H55 6. Mental status changes: lethargy and drowsiness, 1. Location and amount of drainage. H56 confusion, disorientation, and personality changes. 2. Clarify with surgeon whether the nurse or the surgeon H57 7. Localized manifestations: will change dressing. H58 L a. Focal weakness: hemiparesis. 3. Evaluate for CSF leak through the incision. CHAPTER 20 Neurologic System 411

G. Maintain semi-Fowler’s position if there is a CSF leak impact (contrecoup) when brain “bounces” freely inside from ears or nose. skull. H. Postoperative positioning for client who has had D. Primary injury to the brain occurs by compression infratentorial surgery is as follows: and/or tearing and shearing stresses on vessels and 1. Bed should be flat. nerves. 2. Position client on either side; avoid supine position. E. Although brain volume remains unchanged, secondary 3. Maintain head and neck in midline. injury occurs from the cerebral edema in response to the 4. Keep NPO for 24 hours to reduce edema around primary injury and frequently precipitates an increase medulla and reduce vomiting. in ICP. I. Postoperative position for client who has had supraten- F. Types of head injuries (Figure 20-5). torial surgery: semi- to low-Fowler’s position. 1. Concussion: temporary interference in brain func- J. Trendelenburg position is contraindicated for clients tion; may affect memory, speech, reflexes, balance, who have had either infratentorial or supratentorial and coordination. surgery. a. Only small number of victims actually “black out.” K. Maintain fluid regulation. b. Usually from blunt trauma including contact 1. After client is awake and the swallow and gag reflexes sports. have returned, begin offering clear liquids by mouth. c. Usually does not cause permanent damage. 2. Closely monitor intake and output. d. Transient, self-limiting. L. Evaluate neurologic status in response to fluid balance 2. Contusion (a bruise on the brain). and diuretics. a. Multiple areas of petechial hemorrhages. M. Evaluate changes in temperature: may be due to respira- b. Headache, pupillary changes, dizziness, unilateral tory complications or to alteration in the function of the weakness. hypothalamus. c. Blood supply is altered in the area of injury; swell- N. Provide appropriate postoperative pain relief. ing, ischemia, and increased ICP. 1. Avoid narcotic analgesics. d. May last several hours to weeks. 2. Acetaminophen is frequently used. 3. Intracranial hemorrhage. 3. Maintain quiet, dim atmosphere. a. Epidural (extradural) hematoma: a large vessel 4. Avoid sudden movements. (often a meningeal artery or vein) in the dura O. Prevent complications of immobility (see Chapter 3). mater is damaged; a hematoma rapidly forms P. Maintain seizure precautions (see Appendix 20-5). between the dura and the skull, precipitating an increase in ICP. Home Care (1) Momentary loss of consciousness, then free of See home care for client with increasing ICP. symptoms (lucid period), and then lethargy and coma-seldom evident in children. (2) Symptoms of increasing ICP may develop Head Injury within minutes after the lucid interval. A. Classification. (3) Tentorial herniation may occur without 1. Penetrating head injury: dura is pierced, as in stab- immediate intervention. bing or shooting. b. Subdural hematoma: a collection of blood between 2. Closed or blunt head injury: head is either drastically the dura and arachnoid area filling the brain vault; accelerated (whiplash) or decelerated (collision); most usually the result of serious head injury. common head injury in civilian life. (1) May be acute (manifesting in less than 24 B. Children and infants are more capable of absorbing hours) or “chronic” (developing over days to direct impact because of the pliability of the skull. weeks). C. Coup-contrecoup injury: damage to the site of impact (2) When neurologic compromise presents, sub- (coup) and damage on the side opposite the site of dural hematoma becomes an emergent event.

Dura

A. Subdural hematoma B. Epidural hematoma C. Intracerebral hematoma FIGURE 20-5 Formation of head injury after hematoma. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, Philadelphia, 2009, Saunders.) L 412 CHAPTER 20 Neurologic System

H Emergency neurosurgery may be required to Box 20-4 DISCHARGE INSTRUCTIONS FOR H relieve pressure and prevent brain herniation. CLIENTS WITH HEAD INJURY H (3) Treatment may also include diuretics and H anticonvulsants. H5 (4) Persistent neurologic complications—includ- Arouse the client every 3 to 4 hours for the first 24 hours. Anticipate complaints of dizziness, headaches. H ing dysarthria, unilateral weakness, memory Do not allow client to blow his nose; try to prevent sneezing. H loss, and seizures—may continue. No alcohol or sedatives for sleep. H 4. With presence of retinal hemorrhage, evaluate for Acetaminophen for headaches. H “shaken baby syndrome.” No exercising over next 2 to 3 days. H10 Call the doctor if any of the following is noted: H Assessment • Change in vision: Blurred or diplopia H A. Risk factors/etiology. • Poor coordination: Walking, grasping H 1. History of trauma. • Drainage (serous or bloody) from the nose or ears H 2. Epidural hematomas are rare in children younger • Forceful vomiting H15 than 4 years. • Increasing sleepiness, more difficult to arouse H 3. Subdural hematomas are common in infants and may • Slurred speech • Headache that does not respond to medication and contin- H result from birth trauma. ues to get worse H B. Clinical manifestations. • Occurrence of a seizure H 1. Epidural hematoma: decreased GCS, pupillary H20 changes, unilateral weakness. H 2. Subdural hematoma: headache, change in LOC, 3. Bleeding or watery drainage from the ears or nose. H numbness, headache, slurred speech, or inability to 4. Loss of feeling or sensation in any extremity. H speak. 5. Blurred vision, slurred speech, vomiting. H C. Diagnostics (see Appendix 20-1). ALERT Determine family’s understanding of the consequences H25 of the client’s illness. Written and oral instructions should H Complications be given to the client and to the family. Increased anxiety may H Complications include increased ICP, meningitis, diabetes affect comprehension of oral directions (see Box 20-4). H insipidus, seizures, and permanent neurologic compromise. H Goal: To maintain homeostasis and to monitor and iden- H30 Treatment tify early symptoms of increased ICP. H A. Bed rest and clear liquids initially. H NURSING PRIORITY The primary treatment objectives for B. Frequent neurologic checks for increased ICP. H the client with a head injury are to maintain a patent airway, to 1. Change or decrease in level of consciousness is fre- H prevent hypoxia and hypercapnia resulting in acidosis, and to quently the first indication. H35 identify the occurrence of increased ICP. 2. Instruct clients with head injury not to cough, sneeze, H or blow nose. H A. The majority of clients who experience concussion are C. Evaluate drainage from nose, ears, and mouth. H treated at home. 1. Do not clean out the ears: place loose cotton in the H B. A period of unconsciousness or presence of seizures is auditory canal and change when soiled. H40 considered a serious indication of injury. 2. Check continuous clear drainage from the nose with H C. Surgical intervention. Dextrostix; if glucose is present, it is indicative of a H 1. Burr holes to evacuate the hematoma. CSF leak; spinal fluid also dries with a yellow halo H 2. Craniotomy/craniectomy. around edges of drainage. H 3. If a CSF leak occurs, keep the head of the bed ele- H45 Nursing Interventions vated and monitor for development of an infection H Goal: To provide instruction for care of the client in the (meningitis). H home environment (Box 20-4). D. Seizure precautions (see Appendix 20-5). H A. Problems frequently do not occur until 24 hours or more E. Maintain adequate fluid intake by IV infusion or oral H after the initial injury. intake; do not overhydrate. H50 B. Observe the client for increased periods of sleep; if client F. Assess for other undetected injuries; stabilize spine after H is asleep, awaken every 2 to 3 hours to determine whether head injury until spinal cord injury is ruled out. H client can be aroused normally. Goal: To provide appropriate nursing interventions for the H C. Maintain contact with physician for reevaluation if com- client experiencing an increase in ICP (see nursing goals H plications occur. for increased ICP). H55 D. Health care provider should be notified when any of the Goal: To provide adequate nutritional and caloric intake H56 following are observed: for the client with a head injury. H57 1. Any change in level of consciousness (increased A. Provide enteral feedings if client is unable to eat. H58 L drowsiness, confusion). B. Assist client to take oral feedings once swallow reflex is 2. Inability to arouse client, seizures. normal; client is at increased risk for aspiration. CHAPTER 20 Neurologic System 413

D. Monitor for infection, especially meningitis or enceph- Hydrocephalus alitis. Hydrocephalus is a condition caused by an imbalance in the pro- duction and absorption of CSF in the ventricles of the brain. Home Care A. Teach parents symptoms of increasing ICP. Classification: Primary B. Have parents participate in care of the shunt before A. Noncommunicating (obstructive): circulation of CSF is client’s discharge. blocked within the ventricular system of the brain. C. Encourage parents and family to ventilate feelings B. Communicating: CSF flows freely within the ventricular regarding client’s condition. system but is not adequately absorbed. D. Refer client to appropriate community agencies.

Classification: Secondary Reye’s Syndrome A. Congenital. Reye’s syndrome is a rare acute illness that occurs after a B. Acquired—possibly from trauma, infection, or tumor. viral illness (frequently, after aspirin has been consumed) and results in fatty infiltration of the liver and subsequent Assessment liver degeneration and increased intracranial pressure. A. Risk factors/etiology. A. Damaged liver cells no longer adequately convert 1. Neonate: usually the result of a congenital malforma- ammonia to urea for excretion from the body. tion. B. Circulating ammonia crosses the blood-brain barrier to 2. Older child, adult. produce acute neurologic effects. a. Space-occupying lesion. b. Preexisting developmental defects. Assessment B. Clinical manifestations: infant. A. Risk factors/etiology. 1. Head enlargement: increasing circumference in excess 1. Most often preceded by an acute viral infection. of normal 2 cm per month for first 3 months. 2. Primarily affects children from the age of 6 months 2. Separation of cranial suture lines. to adolescence. 3. Fontanel becomes tense and bulging. 3. Frequently, the affected child has received salicylate 4. Dilated scalp veins. (aspirin) for control of fever during the preceding 5. Frontal enlargement, bulging “sunset eyes.” viral infection. 6. Symptoms of increasing ICP. 4. With warning labels now on aspirin, problem has C. Clinical manifestations: older child, adult. significantly decreased. 1. Symptoms of increasing ICP. B. Clinical manifestations. 2. Specific manifestations related to site of the lesion. 1. Stage 1. D. Diagnostics (see Appendix 20-1). a. Initial symptom may be severe persistent vomiting. 1. Increasing head circumference is diagnostic in infants. b. Lethargy, listlessness. 2. Stage 2. Treatment a. Irritability, disorientation. A. Noncommunicating and communicating: ventriculo- b. Progresses to state of increased ICP with deepen- peritoneal shunt; CSF is shunted into the peritoneum. ing coma and posturing. B. Obstructive: removal of the obstruction (cyst, hema- C. Diagnostics (see Appendix 19-1). toma, tumor). 1. Definitive diagnosis is a liver biopsy. 2. Prolonged prothrombin time. Nursing Interventions 3. Elevated blood ammonia levels. Goal: To monitor for the development of increasing ICP. 4. Elevated serum aspartate aminotransferase and ala- A. Daily measurement of the frontal-occipital circumfer- nine aminotransferase levels. ence of the head in infants. B. Assess for symptoms of increasing ICP (see Box 20-3). Treatment C. Infant is often difficult to feed; administer small feedings A. Primarily supportive, based on stage of the disease; at frequent intervals because vomiting may be a problem. mechanical ventilation, fluid and electrolyte balance. Goal: To maintain patency of the shunt and monitor ICP B. Measures to decrease ICP. after shunt procedure. C. Early intervention critical to successful treatment. A. Position supine, with head turned opposite side up to prevent pressure on the shunt valve and to prevent too- Nursing Interventions rapid depletion of CSF. Goal: To monitor progress of disease state and maintain B. Position is not a problem with children who are having homeostasis. a shunt revision; they have not had an increase in ven- A. IV fluids. tricular pressure. B. Monitor serum electrolytes and liver function studies. C. Monitor for increasing ICP and compare with previous C. Maintain respiratory status; prevent hypoxia. L data. D. Assess for problems of impaired coagulation. 414 CHAPTER 20 Neurologic System

H E. Decrease stress, anxiety: child may not remember events H before the critical phase. H Goal: To monitor for and implement nursing actions H appropriate for increasing ICP. H5 H H Stroke (Brain Attack) H Stroke, or brain attack, is the disruption of the blood H supply to an area of the brain, resulting in tissue necrosis H10 and sudden loss of brain function. It is the leading cause H of adult disability in the United States. H A. Atherosclerosis (see Chapter 16), resulting in cerebro- H vascular disease, frequently precedes the development of H a stroke. H15 B. Types of stroke. Right-brain damage Left-brain damage H 1. Ischemic stroke. (stroke on right side of the brain) (stroke on left side of the brain) • Paralyzed left side: hemiplegia • Paralyzed right side: hemiplegia H a. Thrombotic stroke: formation of a clot that • Left-sided neglect • Impaired speech/language H results in the narrowing of a vessel lumen and • Spatial-perceptual deficits aphasias H eventual occlusion; accounts for about 80% of • Tends to deny or minimize • Impaired right/left discrimination H20 strokes. problems • Slow performance, cautious • Rapid performance, • Aware of deficits: depression, H (1) Associated with hypertension and diabetes short attention span anxiety H (i.e., conditions that accelerate the atheroscle- • Impulsive, safety problems • Impaired comprehension related H rotic process). • Impaired judgment to language, math H (2) Produces ischemia of the cerebral tissue distal • Impaired time concepts FIGURE 20-6 Manifestations of right-brain and left-brain stroke. (From H25 to occlusion and edema to the surrounding Lewis SL et al: Medical-surgical nursing: assessment and management H areas. of clinical problems, ed 7, St. Louis, 2007, Mosby.) H b. Embolic stroke: occlusion of a cerebral artery by H an embolus. H (1) Common site of origin is the endocardium. 2. Both upper and lower extremities of the involved side H30 (2) May affect any age group; associated with are affected. H atrial fibrillation, endocarditis, and prosthetic H cardiac valves. Assessment H 2. Hemorrhagic stroke. A. Risk factors/etiology (Box 20-5). H a. Rupture of a cerebral artery caused by hyperten- B. Clinical manifestations. H35 sion, trauma, or aneurysm. 1. Transient ischemic attack (TIA) and reversible isch- H b. Blood compresses the brain. emic neurologic deficit (RIND). H C. The area of edema resulting from tissue damage may a. Visual defects: blurred vision, diplopia, blindness H precipitate more damage than the vascular damage itself. of one eye, tunnel vision. H D. TIA and RIND. b. Transient hemiparesis, gait problems. H40 1. Transient ischemic attack (TIA, silent stroke). c. Slurred speech, confusion. H a. Brief episode, less than 24 hours, of neurologic d. Transient numbness of an extremity. H dysfunction; usually resolves within 30 to 60 2. Complete stroke (occurs suddenly with an embolism, H minutes. more gradually with hemorrhage or thrombosis); H b. Should be considered a warning sign of an impend- manifestations vary according to which cerebral H45 ing stroke. vessels are involved. H c. Neurologic dysfunction is present for minutes to a. Hemiplegia: loss of voluntary movement; damage H hours, but no permanent neurologic deficit to the right side of the brain will result in left- H remains. sided weakness and paralysis. H 2. Reversible ischemic neurologic deficit (RIND). b. Aphasia: defect in using and interpreting the H50 a. Symptoms similar to TIA. symbols of language; may include written, printed, H b. Neurologic symptoms last longer than 24 hours or spoken words. H but less than a week. c. May be unaware of the affected side; neglect syn- H 3. Stroke: client has neurologic deficits related to mobil- drome ensues. H ity, sensation, and cognition. d. Cranial nerve impairment: chewing, gag reflex, H55 E. Neuromuscular deficits resulting from a stroke are due dysphagia, impaired tongue movement. H56 to damage of motor neurons of the pyramidal tract. e. May be incontinent initially. H57 1. Damage to the left side of the brain will result in f. Agnosia: a perceptual defect that causes a distur- H58 L paralysis of the right side of the body (Figure 20-6). bance in interpreting sensory information; client CHAPTER 20 Neurologic System 415

d. Thrombolytic therapy or fibrinolytic therapy (such Box 20-5 RISK FACTORS ASSOCIATED WITH STROKE as recombinant tissue plasminogen activator (rtPA [Retavase]) considered for nonhemorrhagic strokes within 3 hours of first manifestation of Modifiable stroke signs. • Smoking e. Antihypertensives and antidysrhythmics. • Obesity • Increased salt intake 2. Surgical. • Sedentary lifestyle a. Carotid endarterectomy, especially for transient • Increased stress ischemic attack. • Oral contraceptives b. Craniotomy for evacuation of hematoma. Partially Modifiable c. Extracranial-intracranial bypass for mild strokes. • Hypertension C. Specific therapies to resolve physical, speech or occupa- • Cardiac valve disease tional complications, including use of assistive devices. • Dysrhythmias • Diabetes mellitus Nursing Interventions • Hypercholesterolemia Goal: To prevent stroke through client education (see Box Nonmodifiable 20-5). • Sex: Increased incidence in men A. Identification of individuals with reversible risk factors • Age and measures to reduce them. • Race: Increased incidence in the African-American popu- B. Appropriate medical attention for control of chronic lation conditions conducive to the development of stroke. • Hereditary predisposition C. Teach high-risk clients early signs of TIA and RIND and to seek medical attention immediately if they occur. Goal: To maintain patent airway and adequate cerebral oxygenation. may not be able to recognize previously familiar A. Place client in side-lying position with head elevated. objects. B. Assess for symptoms of hypoxia; administer oxygen or g. Cognitive impairment of memory, judgment, pro- assist with endotracheal intubation and mechanical ven- prioception (awareness of one’s body position). tilation as necessary (see Appendix 15-8). h. Hypotonia (flaccidity) for days to weeks, followed C. Maintain patent airway; use oropharyngeal airway to by hypertonia (spasticity). prevent airway obstruction by the tongue. i. Visual defects. D. Client is prone to obstructed airway and pulmonary (1) Homonymous hemianopia: loss of same half infection; have client cough and deep-breathe every of visual field in each eye; client has only half 2 hours. of normal vision. Goal: To assess for and implement measures to decrease (2) Horner’s syndrome: ptosis of the upper eyelid, ICP (see nursing goals for increased ICP). constriction of the pupil, and lack of tearing Goal: To maintain adequate nutritional intake. in the eye. A. Before oral feedings, evaluate need for swallow studies. j. Apraxia: can move the affected limb but is unable B. Administer oral feedings with caution; start after first 24 to carry out learned movements. hours; check for presence of gag and swallowing reflexes k. Increased ICP, drowsiness to coma. before feeding. l. Pain in eye, nose, or face. C. Place food on the unaffected side of the mouth; begin m. Gait disturbances. with clear foods (gelatins). C. Diagnostics (see Appendix 20-1). D. Select foods that are easy to control in the mouth (thick liquids) and easy to swallow; liquids often promote Treatment coughing, because client is unable to control them. A. Prophylactic. E. Maintain high-Fowler’s position for feeding. 1. Aspirin, platelet inhibitors. F. Maintain privacy and unrushed atmosphere. 2. Antihypertensives, anticoagulants. G. If client is unable to tolerate oral intake, enteral feedings B. Immediate treatment (differs depending on whether may be initiated. thrombotic or hemorrhagic stroke). 1. Medical. ALERT Identify potential for aspiration; assess client’s ability a. Medications to decrease cerebral edema. to eat. (1) Osmotic diuretics. (2) Corticosteroids (dexamethasone). Goal: To preserve function of the musculoskeletal system. b. Anticoagulants for thrombotic stroke (never A. Passive range of motion (ROM) on affected side; begin administered to a client with hemorrhagic stroke). early because the exercises are more difficult if muscles c. Anticonvulsants. begin to tighten. L 416 CHAPTER 20 Neurologic System

H B. Active ROM on unaffected side. Goal: To maintain homeostasis. H C. Prevent foot drop: passive exercises; rigid boots; have A. Evaluate adequacy of cardiac output. H client out of bed as soon as possible. B. Monitor hydration status: prevent fluid overload. H D. Legs should be maintained in a neutral position; prevent 1. Carefully regulate IV fluid intake. H5 external rotation of affected hip by placing a trochanter 2. Evaluate response to diuretics. H roll or rolled pillow at the thigh. 3. Assess for the development of peripheral edema. H E. Reposition every 2 hours, but limit the period of time 4. Restrict fluid intake, as indicated. H spent on the affected side. 5. Assess respiratory parameters indicative of fluid H overload. H10 6. Monitor daily weight. NURSING PRIORITY Protect the client’s affected side: do H C. Determine previous bowel patterns and promote normal not give injections on that side, watch for pressure areas when H positioning, have client spend less time on affected side than in elimination. H other positions. 1. Avoid use of urinary catheter, if possible; if catheter H is necessary, remove as soon as possible. H15 2. Offer bedpan or urinal every 2 hours; help establish H F. Assess for adduction and internal rotation of the affected a schedule. H arm; maintain arm in a neutral (slightly flexed) position 3. Prevent constipation: provide increased bulk in diet, H with each joint slightly higher than the preceding one. stool softeners, etc. H G. Restraints should be avoided because they often increase 4. Provide privacy and decrease emotional trauma H20 agitation. related to incontinence. H H. Maintain joints in position of normal function to prevent H flexion contractures. ALERT Assess and manage a client with an alteration in H I. Assist client out of bed on the unaffected side; this elimination. Establish a toileting schedule; the client who has had H allows client to provide some stabilization and balance a stroke will need assistance in reestablishing a normal bowel H25 with the good side (Figure 20-7). and bladder routine. H H ALERT Mobility: Assist client to ambulate, perform active and H passive ROM exercises, assess for complications of immobility, D. Prevent problems of skin breakdown through proper H prevent DVT, prevent skin breakdown and encourage positioning and good skin hygiene. H30 independence. E. Assist client to identify problems of vision. H H H A B H H35 H H H H H40 H H H H C D E H45 H H H H H50 H H H H H55 H56 H57 FIGURE 20-7 Transfer from bed to wheelchair by client with hemiplegia. (From Black JM, Hawks JH: Medical-surgical nursing: clinical management H58 L for positive outcomes, ed 7, Philadelphia, 2005, Saunders.) CHAPTER 20 Neurologic System 417

F. Maintain psychologic homeostasis. bral aneurysm occurring in the arterial junction of the 1. Client may be very anxious because of a lack of under- circle of Willis. A ruptured cerebral aneurysm often results standing of what has happened and because of his or in hemorrhagic stroke. her inability to communicate. A. A subarachnoid hemorrhage is a potentially fatal condi- 2. Speak slowly and clearly and explain what has tion in which blood accumulates below the arachnoid happened. mater in the subarachnoid space; most often occurs sec- 3. Assess client’s communication abilities and identify ondary to an aneurysm. methods to promote communication. B. An aneurysm frequently ruptures and bleeds into the subarachnoid space. Home Care C. Symptoms occur when an aneurysm enlarges, or when A. Encourage independence in ADLs. it ruptures. As blood collects in the subarachnoid B. Provide clothing that is easy to get in and out of. space, it compresses and damages the surrounding C. Active participation in ROM; have client do his or her brain tissue. own ROM on affected side. D. Subarachnoid hemorrhage may lead to neurologic com- D. Physical, occupational, and speech therapy for retraining promise including seizures, stroke, permanent brain of lost function. damage, and even death. E. Assist client to maintain sense of balance when in the E. Often, symptoms do not appear until rupture has sitting position; client will frequently fall to the affected occurred. side (unilateral neglect syndrome). F. Encourage participation in carrying out daily personal Assessment hygiene. A. Risk factors/etiology. G. Teach client safe transfer from bed to wheelchair and 1. Age: more common in adults 30 to 60 years of age. provide assistance as needed (see Figure 20-7). 2. Atherosclerosis, connective tissue disease, cigarette H. Bowel and bladder training program. smoking, and hypertension—causing fragility in the 1. To promote bladder tone, encourage urination (with vessel wall. or without assistance) every 2 hours rather than 3. Head trauma and congenital vessel weakness may allowing the client to void when he or she feels the increase the risk. urge. B. Clinical manifestations. 2. Teach client to perform Kegel exercises regularly. 1. Rupture may be preceded by: 3. Advise client to avoid caffeine intake. a. Severe headache. 4. Increased bulk in diet will help avoid constipation b. Intermittent nausea. (see Table 18-2). 2. Rupture frequently occurs without warning. 5. Increase fluids to 2000 mL per day as tolerated. a. Sudden severe headache, seizures. 6. Administer stool softeners PRN. b. Nuchal rigidity, hemiparesis. 7. Establish regular daily time for bowel movements. c. Loss of consciousness. I. Encourage social interaction (see Appendix 20-6). d. Symptoms of increasing ICP: nausea, vomiting, 1. Speech therapy. photophobia. 2. Frequent and meaningful verbal stimuli. 3. Severity of symptoms depends on the site and amount 3. Allow client plenty of time to respond. of bleeding. 4. Speak slowly and clearly; do not give too many direc- C. Diagnostics (see Appendix 20-1). tions at one time. Use short sentences. 5. Do not “talk down to” client or treat client as a child Treatment (elder speak). A. Aminocaproic acid: inhibits fibrinolysis in life-threaten- 6. Client’s mental status may be normal; do not assume ing situations. it is impaired. B. Osmotic diuretics, anticonvulsants. 7. Nonverbal clients do not lose their hearing ability. C. Corticosteroids: dexamethasone (Decadron). J. Evaluate family support and the need for home health D. Calcium channel blockers: minimize vasospasm after services. hemorrhage. E. Stool softeners. ALERT Assist family to manage care of a client with long-term F. Analgesics for recurrent headache. care needs; determine needs of family regarding ability to provide G. Fluids to maintain systolic blood pressure at 100 to home care after discharge. 150 mm Hg (increase in volume and pressure increases blood flow through narrowed vessels). H. Surgical intervention: ligation or “clipping” of the aneu- Cerebral Aneurysm, Subarachnoid Hemorrhage rysm to reduce the swelling and minimize the risk for A cerebral aneurysm occurs when a weakened saccular re-bleeding. outpouching of the cerebral vasculature bulges from pres- I. Procedure to block abnormal arteries or veins and sure on the weakened tissue. A Berry aneurysm is a cere- prevent bleeding. L 418 CHAPTER 20 Neurologic System

H Nursing Interventions 3. Chills and high fever. H Goal: To prevent further increase in ICP and possible 4. Severe and persistent headache. H rupture. 5. Increasing irritability, malaise, changes in level of H A. Immediate bed rest; bathroom privileges may be consciousness. H5 permitted. 6. Respiratory distress. H B. Prevent Valsalva maneuver. 7. Generalized seizures. H C. Client should avoid straining, sneezing, pulling up in 8. Nausea and vomiting. H bed, and acute flexion of the neck. 9. Positive Kernig sign: resistance or pain at the knee H D. Elevate head of the bed 30 degrees to 45 degrees to and the hamstring muscles when client attempts to H10 promote venous return. extend the leg after thigh flexion. H E. Quiet, dim, nonstimulating environment: disconnect 10. Positive Brudzinski sign: reflex flexion of the hips H telephone; promote relaxation. when the neck is flexed. H F. Constant monitoring of condition to identify occurrence 11. Photophobia. H of bleeding, as evidenced by symptoms of increasing C. Clinical manifestations: neonate and infant. H15 ICP. 1. Fever. H G. Administer analgesics cautiously; the client should con- 2. Apneic episodes. H tinue to be easily aroused so that neurologic checks can 3. Bulging fontanel. H be performed. 4. Seizures. H H. No hot or cold beverages or food, no caffeine, no 5. Crying with position change. H20 smoking. 6. Opisthotonos positioning: a dorsal arched position. H I. Maintain seizure precautions. 7. Changes in sleep pattern, increasing irritability. H 8. Poor sucking; may refuse feedings. H 9. Poor muscle tone, diminished movement. H NURSING PRIORITY If the client survives the rupture of 10. Irritability. H25 the aneurysm and re-bleeding occurs, it is most likely to occur D. Diagnostics (see Appendix 20-1). within the next 24 to 48 hours. H 1. Lumbar puncture reveals increasing CSF pressure; if H ICP is present, then a CT scan may be done before H Goal: To assess for and implement nursing measures to the procedure. H decrease ICP (see nursing goals for increased ICP). 2. Elevated WBCs. H30 Goal: To provide appropriate preoperative nursing inter- 3. CSF and blood cultures positive for meningococcus H ventions (see nursing goals for brain tumor). bacteria. H Goal: To maintain homeostasis and monitor changes in H ICP after craniotomy (see nursing goals for craniotomy). Treatment H A. Respiratory isolation until positive organism is H35 identified. H Meningitis B. IV antibiotics, steroids (see Appendixes 6-9, 6-7). H Meningitis is an acute viral or bacterial infection that C. Optimum hydration. H causes inflammation of the meningeal tissue covering the D. Anticonvulsant medications (see Appendix 20-2). H brain and spinal cord. E. Antivirals (see Appendix 7-1). H40 A. Infectious process increases permeability of protective F. Maintain ventilation. H membrane and results in an increased protein concentra- H tion in the CSF. Complications H B. Inflammatory process results in the development of cere- A. Increasing ICP resulting in permanent brain damage. H bral edema. B. Visual and hearing deficits, paralysis. H45 C. Bacterial meningitis is less common but more severe C. Subdural effusion; may be aspirated or allowed to H than viral meningitis. absorb when meningitis treatment is started and protein H leak stops. H Assessment H A. Risk factors/etiology. Nursing Interventions H50 1. Pathogenic organism most often gains entry from an Goal: To identify the causative organism, control spread, H infection elsewhere in the body. and initiate therapy. H 2. Meningococcal meningitis is the only form that is A. Maintain respiratory droplet precautions until organism H readily contagious; transmitted by direct contact with is identified; place client in a private room (Appendix H droplets from the airway of an infected person. 6-9). H55 3. Increased mortality rate among infants. B. Begin administration of IV antibiotics after lumbar H56 B. Clinical manifestations: older child and adult. puncture during which CSF sample was obtained. H57 1. Rash, petechiae, purpura. C. Identify family members and close contacts who may H58 L 2. Nuchal rigidity. require prophylactic treatment. CHAPTER 20 Neurologic System 419

Goal: To monitor course of infection and prevent ALERT Identify changes in client’s mental status; treat client complications. with seizures. A. Frequent nursing assessment for increased ICP (see Box 20-3). B. Maintain adequate hydration; cerebral edema may require limiting fluid intake. Spinal Cord Injury C. Monitor infusion site for complications of IV piggyback Spinal cord injury (SCI) is damage to the spinal cord antibiotics. housed inside the spinal column. Most SCIs exist with the D. Assess for side effects of high dosage of antibiotics. spinal cord intact yet compromised from injury or disease. E. Decrease stimuli in environment: dim lights, quiet envi- SCI most often occurs as a result of direct trauma to the ronment, no loud noises. head or neck area. F. Avoid movement or positioning that increases discom- A. Risk factors. fort; client generally assumes a side-lying position. 1. More than 80% of clients with SCIs are male. G. Seizure precautions. 2. More than half of SCIs occur between the ages of 16 H. Prevent complications of immobility. and 35 years. I. Good respiratory hygiene. 3. Also an increased risk after 60 years of age, when falls J. Measures to decrease fever. become more common. 4. Other risk factors: osteoarthritis, cancer, involvement in sports. Encephalitis B. Initially after the injury, the nerve fibers swell, and cir- Encephalitis is an inflammatory process of the CNS, or culation to the spinal cord is decreased; hemorrhage and “inflammation of the brain.” edema occur, causing an increase in the ischemic process, which progresses to necrotic destruction of the spinal Assessment cord. A. Risk factors/etiology. C. Consequences of SCI depend on the extent of damage, 1. Commonly occurs as a complication after a viral as well as the level of cord injury (Figure 20-8). infection (measles, chicken pox, mumps). 1. The higher the lesion, the more severe the sequelae. 2. May be transmitted by a vector such as a mosquito a. Clients with lesions at C4 or higher may require or tick. ventilatory support. 3. Causative organism may be herpes simplex virus in b. Lesions between T1 and T8 often allow use of the middle-aged adults. hands. B. Clinical manifestations. c. Lesions below T8 often allow upper body control. 1. Severe headache, nuchal rigidity. 2. Complete transection (complete cord dissolution, 2. Sudden fever. complete lesion): immediate loss of all sensation and 3. Seizures. 4. Changes in level of consciousness. 5. Motor involvement: ataxia, dysphasia, tremor, convulsions. 6. Drowsiness, confusion, disorientation. 7. Irritability. 8. Bulging fontanels in infants. C. Diagnostics. Tetraplegia C8 Phrenic nerve (C3-C5) 1. Examination of the CSF. Paraplegia T1 Upper limbs (C5-T1) 2. Viral studies to isolate the virus. Head 3. EEG for seizure activity. Sympathetic 4. Blood test for West Nile virus. outflow (T1-L4)

Temperature Blood Treatment control vessels A. Anticonvulsants. B. Treatment to decrease ICP. C. Hydration, bed rest, proper nutrition. Lower limbs

Bladder, bowel, and Nursing Interventions external genitalia Nursing interventions for encephalitis are the same as those for meningitis, with the exception of antibiotic therapy. Encephalitis is caused by a viral agent and is not responsive FIGURE 20-8 Spinal cord injury: areas of paralysis. (From Lewis SL to antibiotic therapy; antibiotic therapy may be ordered to et al: Medical-surgical nursing: assessment and management of clinical prevent bacterial infection. problems, ed 7, St Louis, 2007, Mosby.) L 420 CHAPTER 20 Neurologic System

H voluntary movement below the level of injury; b. Lower motor neuron disorders produce a flaccid H minimal, if any, return of function. bladder. H 3. Incomplete (partial). 2. Management of bladder problems depends on client’s H a. Central cord syndrome: center of cord is preferences and lifestyle, as well as client’s functional H5 damaged; results primarily in impairment of abilities. H upper extremities. G. Long-term rehabilitation potential depends on the H b. Damage to one side of the cord (Brown-Séquard amount of damage done to the cord, which may not be H syndrome): motor function and position sense evident until several weeks after the injury. H may be present on one side; temperature and sen- H10 sation may be lost on the opposite side. Assessment H c. Anterior cord damage: disruption of blood flow A. Clinical manifestations: depend on level of SCI (see H results in a mixed loss of sensory and motor func- Figure 20-8). H tion below the level of injury. 1. Injury at C3 through C5 will cause respiratory H 4. Cord edema peaks in about 2 to 3 days and subsides compromise. H15 within about 7 days after the injury. 2. Depending on degree of injury, the degree of paralysis H 5. Lumbosacral injuries. and amount of sensory loss below the level of injury H a. Variable pattern of motor and sensory loss. will vary. H b. Frequently result in neurogenic bowel and bladder. 3. Spinal shock. H D. Spinal cord shock (areflexia): temporary loss or dysfunc- a. Generally occurs within 72 hours and may last for H20 tion of spinal reflex activity; occurs predominantly in several weeks. H complete cord lesions; loss of communication with the b. Flaccid paralysis. H higher centers of control results in flaccidity and loss of c. Loss of sensation and absence of reflexes. H functional control below the level of injury. d. Bowel and bladder dysfunction. H 1. SCI interrupts sympathetic nerve impulse transmis- e. Hypotension and bradycardia. H25 sion; parasympathetic impulses are not counter- f. After spinal shock, reflexes and autonomic H checked, resulting in vasodilation; loss of venous activity return, as evidenced by development of H return results in hypotension, which is neurogenic spasticity. H shock. 4. Autonomic dysreflexia in clients with injuries at T6 H 2. Hypothalamus loses control of body temperature, or higher. H30 which assists in vasoconstriction and vasodila- a. Severe hypertension, bradycardia. H tion. b. Complaints of headache. H 3. Condition may persist for several weeks and reverse c. Flushing and diaphoresis above level of H spontaneously; resolution of spinal shock will be injury. H evident by return of reflexes. B. Diagnostics (see Appendix 20-1). H35 4. Hyperreflexia will occur as recovery progresses; spastic C. Complications. H movements may be precipitated by emotion and cuta- 1. Respiratory stasis; pulmonary edema and emboli. H neous stimulation. 2. Cardiovascular compromise from neurogenic shock, H E. Autonomic dysreflexia occurs in clients with an injury at or autonomic dysreflexia. H T6 or higher. 3. Skin breakdown resulting in localized and systemic H40 1. A noxious stimulus below the level of injury trig- infections. H gers the sympathetic nervous system, which causes 4. Immobility issues causing renal and gastrointestinal H a release of catecholamines (epinephrine, norepi- compromise. H nephrine). 5. Psychologic, social, and body image issues. H 2. Most common stimuli causing the response are a full H45 bladder or bowel, UTI, pressure ulcers, and skin Treatment H stimulation. A. Emergency intervention required. H 3. Severe hypertension (systolic may be greater than B. Corticosteroids within 8 hours of injury (methylpred- H 300), nausea, pounding headache, bradycardia, rest- nisolone). H lessness, flushing piloerection, and blurred vision are C. Immobilization of the vertebral column in cervical H50 the most common body responses. fracture. H F. Bladder dysfunction will occur as a result of the injury; 1. Cervical tongs (Crutchfield, Gardner-Wells) for cer- H normal bladder control is dependent on the sensory and vical immobility. H motor pathways and the lower motor neurons being 2. Halo vest/jacket traction to promote mobility. H intact. 3. Sterno-occipital mandibular immobilizer (SOMI) H55 1. Neurogenic bladder occurs in clients with both upper brace worn with cervical fusion. H56 and lower motor neuron disorders. D. Spinal surgery to remove bone fragments and assure H57 a. Upper motor neuron disorders produce a spastic spinal alignment. H58 L or reflex bladder. E. Respiratory support as necessary. CHAPTER 20 Neurologic System 421

Nursing Interventions Goal: To identify level of damage and changes in neuro- Goal: To maintain stability of the vertebral column and logic status. prevent further cord damage. A. Assess respiratory function: symmetrical chest expan- A. Emergency care and treatment. sion, bilateral breath sounds, presence of retractions or 1. Suspect SCI if there is any evidence of direct trauma dyspnea. to the head or neck area (contact sports, diving acci- B. Motor and sensory evaluation. dents, motor vehicle accident). 1. Ability to move extremities; strength of extremities. 2. Immobilize client and place on spinal board with the 2. Sensory examination, including touch and pain. head and neck in a neutral position; do not allow the 3. Presence of deep tendon reflexes. neck to flex. C. Ongoing assessment and status of: 3. Airway, status of breathing, and circulation are the 1. Bladder, gastric, bowel function. primary concerns initially after injury. 2. Psychologic adjustment to the injury. 4. Neurogenic shock may occur within the first 24 D. Evaluate history of how injury occurred; obtain informa- hours; observe for decreased B/P, severe bradycardia. tion regarding how client was transported. E. Determine status of pain. Goal: To maintain respiratory function. NURSING PRIORITY Do not hyperextend the neck in a A. Frequent assessment of respiratory function during the client with a suspected cervical injury. Airway should be opened first 48 hours. by the jaw-lift method. Improper handling of the client often results in extension of the damaged area. 1. Changes in breathing pattern. 2. Observe breathing pattern for use of sternocleido- mastoid and intercostal muscles for respiration. 5. Maintain in extended position with no twisting or 3. Evaluate arterial blood gas values and pulse oximetry. turning; do not remove cervical collar or spinal board 4. Determine development of hypoxia. until area of injury is identified. B. Maintain adequate respiratory function, as indicated. 6. Maintain patent airway during transportation. 1. Chest physiotherapy. B. Maintain stability of the vertebral column as indicated 2. Incentive spirometry. by the level of injury. 3. Changing position within limits of injury. 1. Prescribe and maintain bed rest on firm mattress with 4. Assess for complications of atelectasis, pulmonary supportive devices (sandbags, skin traction, etc.); emboli, and pneumonia. maintain alignment in the supine position; logroll 5. Nasopharyngeal or endotracheal suctioning based on without any flexion or twisting. airway and level of injury. 2. Maintain cervical traction: tongs are inserted into the Goal: To maintain cardiovascular stability. skull with traction and weights applied; do not remove A. Spinal shock. weights; logroll to maintain spinal immobility. 1. Monitor vital signs and evaluate changes. 3. Halo vest/jacket traction: maintains cervical immo- 2. Vagal stimulation, hypothermia, and hypoxia may bility but allows client to be mobile. precipitate spinal shock. a. If bolts or screws come loose, keep the client 3. Assess deep tendon reflexes and muscle strength as immobilized and call the doctor. resolution of shock occurs. b. Clean pin sites according to facility policy, observe B. Assess for development of autonomic dysreflexia; if it for infection. occurs: c. Roll client onto his or her side at the edge of the 1. Elevate the head of the bed, and check the client’s bed and allow client to push up from the mattress blood pressure. to a sitting position. Never use the halo vest frame 2. Assess for sources of stimuli: distended bladder to assist the client to turn or sit up. (check urinary tubing), fecal impaction, constipation, d. Correct size of wrench should be kept at bedside tight clothing. to remove the anterior bolts in case of 3. Relieve the stimuli, and dysreflexia will subside. emergency. 4. Maintain cardiovascular support during period of e. Assist client to maintain balance when standing; hypertension. the traction is heavy for a person who is weak, and 5. A hypertensive crisis from dysreflexia will require the client is at increased risk for falling. immediate intervention. 4. Maintain extremities in neutral, functional position. C. Evaluate cardiovascular responses when turning or suc- tioning client. D. Apply antiembolism stockings or elastic wraps to the ALERT Apply, maintain, or remove orthopedic devices (e.g. legs to facilitate venous return. (Lack of muscle tone and traction, splints, braces, casts). loss of sympathetic tone in the peripheral vessels result in decreases in both venous tone and venous return, C. Perform appropriate nursing intervention when surgery which predispose client to deep vein thrombosis.) is indicated to stabilize the injury. E. Implement measures to promote venous return. L 422 CHAPTER 20 Neurologic System

H ALERT Prevent complications of immobility; prevent venous Goal: To maintain psychologic equilibrium. H stasis: identify symptoms of deep venous thrombosis, apply A. Provide simple explanations of all procedures. H compression stockings, and change client’s position. B. Anticipate outbursts of anger and hostility as client H begins to work through the grieving process and adjusts H5 to changes in body image. H Goal: To maintain adequate fluid and nutritional status. C. Anticipate and accept periods of depression in client. H A. During the first 48 hours, evaluate gastrointestinal func- D. Encourage independence whenever possible; allow client H tion frequently; decrease in function may necessitate use to participate in decisions regarding care and to gain H of a nasogastric tube to decrease distention. control over environment. H10 B. Prevent complications of nausea and vomiting. H C. Evaluate bowel sounds and client’s ability to tolerate oral ALERT Plan measures to deal with client’s anxiety and promote H fluids. client’s adjustment to changes in body image; assist client and significant others to adjust to role changes. Note: These items are H D. Increase protein and calories in diet; may need to all part of the test plan, and the test could include questions H decrease calcium intake. about the client with SCI. H15 E. Evaluate for presence of paralytic ileus. H F. Increase roughage in diet to promote bowel function. E. Encourage family involvement in identifying appropri- H Goal: To prevent complications of immobility (see ate diversional activities. H Chapter 3). F. Avoid sympathy and emphasize client’s potential. H Goal: To promote bowel and bladder function. G. Initiate frank, open discussion regarding sexual func- H20 A. Urine is retained as a result of the loss of autonomic and tioning. H reflexive control of the bladder. H. Assist client and family to identify community resources. H 1. Intermittent catheterization or indwelling catheter I. Assist client to set realistic short-term goals. H may be used initially to prevent bladder distention. H 2. Perform nursing interventions to prevent urinary H25 tract infection; avoid urinary catheterization, if Myasthenia Gravis H possible. Myasthenia gravis is a sporadic, progressive neuromuscu- H B. Determine type of bladder dysfunction based on level of lar disease characterized by a decrease in the acetylcholine H injury. level at the receptor sites in the neuromuscular junction. H C. Assess client’s awareness of bladder function. This inadequate acetylcholine level results in a distur- H30 D. Initiate measures to institute bladder control. bance in nerve impulse transmission, causing progressive H 1. Establish a schedule for voiding; have client attempt weakness in skeletal muscles. Myasthenia gravis literally H to void every 2 hours. means “grave muscle weakness.” H 2. Use the Credé method (in adults) for manual expres- H sion of urine. Assessment H35 3. May be necessary to teach client self-catheterization. A. Risk factors/etiology. H 4. Record output and evaluate for presence of residual 1. Autoimmune disease. H urine. 2. More common in women younger than 40 and men H E. Evaluate bowel functioning. older than 60 but may occur at any age. H 1. Incontinence and paralytic ileus frequently occur with B. Clinical manifestations. H40 spinal shock. 1. Primary problem is skeletal muscle fatigue with sus- H 2. Incontinence and impaction are common later. tained muscle contraction; symptoms are predomi- H F. Initiate measures to promote bowel control (after spinal nantly bilateral. H shock is resolved). a. Muscular fatigue increases with activity. H 1. Identify client’s bowel habits before injury. b. Ptosis (drooping of the eyelids) and diplopia H45 2. Maintain sufficient fluid intake and adequate bulk in (double vision) are frequently the first symptoms. H the diet. (Ophthalmologist may be first contact regarding H 3. Establish specific time each day for bowel evacua- dysfunction.) H tion. c. Impairment of facial mobility and expression. H 4. Assess client’s awareness of need to defecate. d. Impairment of chewing and swallowing. H50 5. Teach client effective use of the Valsalva maneuver e. Speech impairment (dysarthria). H to induce defecation. f. No sensory deficit, loss of reflexes, or muscular H 6. Induce defecation by digital stimulation, suppository, atrophy. H or as a last resort, enema. g. Poor bowel and bladder control. H 2. Course is variable. H55 a. May be progressive. H56 ALERT Assess and manage a client with alteration in elimination; b. May stabilize. H57 initiate a toileting schedule; the client with SCI may need bowel c. May be characterized by short remissions and H58 L and bladder retraining, depending on level of the injury. exacerbations. CHAPTER 20 Neurologic System 423

3. Myasthenic crisis: an acute exacerbation of symptoms D. Evaluate effectiveness of cough reflex. that may require intubation and mechanical ventila- E. Be prepared to intubate or provide ventilatory assistance. tion to support respiratory effort; caused by major Goal: To distinguish between a myasthenic crisis and a muscular weakness and inability to maintain respira- cholinergic crisis. tory function. A. Maintain adequate ventilatory support during crisis. a. Severe respiratory distress and hypoxia. B. Assist in administration of Tensilon test to differentiate b. Increased pulse and blood pressure. crisis. c. Decreased or absent cough or swallow reflex. 1. Myasthenic crisis: client’s condition will improve. 4. Cholinergic crisis: a toxic response to the anticholin- 2. Cholinergic crisis: client’s condition will temporarily esterase medications; anticholinesterase medications worsen. must be withheld—this response is rare with proper C. If myasthenic crisis occurs, neostigmine may be dosing of Mestinon. administered. a. Nausea, vomiting, and diarrhea. D. If cholinergic crisis occurs, atropine may be adminis- b. Weakness with difficulty in swallowing, chewing, tered, and cholinergic medications may be reevaluated. and speaking. E. Avoid use of sedatives and tranquilizers, which causes c. Increased secretions and saliva. respiratory depression. d. Muscle fasciculation, constricted pupils. F. Provide psychologic support during crisis. C. Diagnostics (see Appendix 20-1). 1. Electromyography: shows a decreasing response of Home Care muscles to stimuli. A. Teach client importance of taking medication on a 2. Ice pack test: assess clients with ptosis; muscles regular basis; peak effect of the medication should coin- improve with cold application; place pack on closed cide with mealtimes. lids for 2 minutes to see whether ptosis improves. B. If ptosis becomes severe, client may need to wear an eye 3. Tensilon test. patch to protect cornea (alternate eye patches if problem a. Used for diagnosing myasthenia gravis. is bilateral). b. Used to differentiate cholinergic crisis from myas- C. Emotional upset, severe fatigue, infections, and exposure thenic crisis. to extreme temperatures may precipitate a myasthenic c. IV injection of neostigmine or edrophonium crisis. causes immediate, although short-lived, relief of muscle weakness. Multiple Sclerosis Treatment Multiple sclerosis (MS) is characterized by multiple areas A. Anticholinesterase (cholinergic) medications (see of demyelination from inflammatory scarring of the Appendix 20-3). neurons in the brain and spinal cord (CNS). 1. Neostigmine (Prostigmin). A. The progression of the disease results in total destruction 2. Pyridostigmine (Mestinon). of the myelin, and the nerve fibers become involved. B. Corticosteroids (see Appendix 6-7). 1. Loss of myelin sheath causes decreased impulse con- C. Plasma electrophoresis (plasmapheresis): separation duction, destruction of the nerve axon, and a blockage of plasma to remove autoantibodies from the blood- of the impulse conduction. stream. 2. The demyelination occurs in irregular scattered D. Immunosuppressive therapy. patches throughout the CNS. E. Surgical removal of the thymus (thymectomy). 3. Theories as to cause include autoimmunity and expo- sure to viruses. Nursing Interventions B. Clinical course. Client may be hospitalized for acute myasthenic crisis or for 1. Relapsing-remitting MS: most common course, respiratory tract infection. causing sporadic attacks with exacerbations and Goal: To maintain respiratory function. remissions lasting days to months; client has a sig- A. Assess for increasing problems of difficulty breathing. nificant “flare-up” or exacerbation, followed by partial Measure forced vital capacity frequently to assess respi- or complete recovery. ratory status. 2. Primary-progressive MS: after a number of years of B. Determine client’s medication schedule. When was the relapsing-remitting form, client experiences a medication last taken? slow steady worsening of symptoms without com- C. Assess ability to swallow; prevent problems of plete improvement between exacerbations; plateaus aspiration. of severity may occur, but baseline function progres- sively worsens. 3. Secondary-progressive MS: progressively worsens ALERT Identify clients at high risk for aspiration; do not give the from onset with acute exacerbations; baseline func- client experiencing a myasthenic crisis anything to eat or drink. tion continues to worsen. L 424 CHAPTER 20 Neurologic System

H 4. Progressive-relapsing MS: gradual progressive wors- 3. If client is experiencing difficulty swallowing, observe H ening of disease without remissions; onset in third or client closely during fluid intake. H fourth decade of life with equal incidence in men and Goal: To prevent complications of immobility (see H women. Chapter 3). H5 Goal: To promote psychologic well-being. H Assessment A. Focus on remaining capabilities. H A. Risk factors/etiology: cause is unknown. B. Encourage independence and assist client to gain control H 1. More common in women. over environment. H 2. Problem of young adults. C. If impotence is a problem, initiate sexual counseling. H10 3. More common in cooler climates. D. Assist client to work through the grieving process. H B. Clinical manifestations. E. Identify community resources available. H 1. Signs and symptoms vary from person to person, as H well as within the same individual, depending on the Home Care H area of involvement. A. Medical regimen and side effects of the medications. H15 2. Cerebellar dysfunction: nystagmus, ataxia, dysarthria, B. Physical therapy to maintain muscle function and H dysphagia. decrease spasticity. H 3. Motor dysfunction: weakness of eye muscles, weak- C. Measures to maintain voiding; may need to perform H ness or spasticity of muscles in extremities. self-catheterization. H 4. Sensory: vertigo, blurred vision, decreased hearing, D. Safety measures because of decreased sensation. H20 tinnitus. 1. Check bath water temperature. H 5. Bowel and bladder dysfunction. 2. Wear protective clothing in the winter. H 6. Sexual dysfunction. 3. Avoid heating pads and clothing that is constrictive. H 7. Psychosocial. E. Client should understand that relapses are frequently H a. Intellectual functioning remains intact. associated with an increase in physiologic and psycho- H25 b. Emotional lability: increased excitability and inap- logic stress. H propriate euphoria. H c. Emotional effects of the chronic illness and ALERT Determine client’s ability to care for self; plan with H changes in body image. family to assist client to meet self-care needs. H C. Diagnostics: no definitive diagnostic test. H30 H Treatment H A. No cure; medical treatment is directed toward slowing Guillain-Barré Syndrome H of the disease process and relief of symptoms. Guillain-Barré syndrome is an acute, rapidly progressing H B. Medications to decrease edema and inflammation of the motor neuropathy involving segmental demyelination of H35 nerve sites. nerve roots in the spinal cord and medulla. Demyelination H 1. Antiinflammatory agents. causes inflammation, leading to edema, nerve root com- H 2. Immunosuppressive agents: interferons. pression, decreased nerve conduction, and rapidly ascend- H 3. Adrenocorticotropic hormone for acute exacerba- ing paralysis. Both sensory and motor impairment occur. H tions. It is also called Landry’s paralysis. H40 H Nursing Interventions Assessment H Client may be hospitalized for diagnostic workup or for A. Risk factors/etiology: cause is unknown; frequently, H treatment of acute exacerbation and complications. client has a recent history of acute illness. H Goal: To maintain homeostasis and prevent complications B. Clinical manifestations. H45 during an acute exacerbation of disease symptoms. 1. Progressive weakness and paralysis begin in the lower H A. Maintain adequate respiratory function. extremities and ascend bilaterally. H 1. Prevent respiratory tract infection. 2. Paralysis ascends the body symmetrically. H 2. Good pulmonary hygiene. a. Paralysis of respiratory muscles. H 3. Prevent aspiration; sitting position for eating. b. Cranial nerve involvement, most often facial H50 4. Evaluate adequacy of cough reflex. nerve (CN VII), produces difficulty talking and H B. Maintain urinary tract function. swallowing. H 1. Prevent urinary tract infection. 3. Loss of sensation and function of bowel and H 2. Increase fluid intake, at least 2000 mL/24 hr. bladder. H 3. Evaluate voiding: assess for retention and inconti- 4. Manifestations may progress rapidly over hours or H55 nence. may occur over 2 to 4 weeks. H56 C. Maintain nutrition. 5. Muscle atrophy is minimal. H57 1. Evaluate coughing and swallowing reflexes. 6. Paralysis decreases as the client begins recovery; most H58 L 2. Provide food that is easy to chew. often, there are no residual effects. CHAPTER 20 Neurologic System 425

4. Progressive muscle weakness. NURSING PRIORITY Of the neuromuscular disorders, Guillain-Barré syndrome is the most rapidly developing and a. Begins with upper extremities and progressively progressive condition. It is potentially fatal if unrecognized. involves muscles of neck and throat. b. Trunk and lower extremities are involved late in course of disease. 5. Most often fatal within 2 to 5 years after onset. C. Diagnostics (see Appendix 20-1). 6. Intellectual functioning and all five senses are usually 1. Elevated protein concentration in CSF. unaffected. B. Diagnostics: electromyography and nerve conduction Treatment (Supportive) studies. Muscle biopsy may be performed to rule out A. Respiratory support, possibly mechanical ventilation. other pathologies. B. Corticosteroids. C. Immunosuppressives and immunoglobulins. Treatment D. Plasmapheresis: plasma exchange. A. Riluzole (Rilutek) prolongs life by a few months; pro- tects motor neurons from degeneration and death. Nursing Interventions B. Supportive care. Goal: To evaluate progress of paralysis and initiate actions to prevent complications. Nursing Interventions A. Evaluate rate of progress of paralysis; carefully assess Goal: To provide ongoing assessment in assisting client to changes in respiratory pattern. deal with progressive symptoms. B. Frequent evaluation of cough and swallow reflexes. A. Promote independence in ADLs. 1. Remain with client while client is eating; have suction 1. Conserve energy; space activities. equipment available. 2. Avoid extremes of hot and cold. 2. Maintain NPO (nothing by mouth) status if reflexes 3. Use of appliances to prolong independence in ambu- are involved. lation and ADLs. C. If assent of paralysis is rapid, prepare for endotracheal B. Promote nutrition. intubation and respiratory assistance. 1. Small frequent feedings. D. Prevent complications of immobility during period of 2. Have client sit upright with head slightly flexed paralysis (see Chapter 3). forward while eating. E. Assess for involvement of the autonomic nervous 3. Keep suction equipment easily available during system. meals. 1. Orthostatic hypotension. C. Encourage family and client to talk about losses and the 2. Hypertension. difficult choices they face. 3. Cardiac dysrhythmias. D. Assist family and client to identify need for advanced 4. Urinary retention and paralytic ileus. directives and to complete them. Goal: To prevent complications of hypoxia if respiratory muscles become involved (see Chapter 15). Muscular Dystrophy Goal: To maintain psychologic homeostasis. Muscle dystrophy (MD) is a group of genetic diseases A. Simple explanation of procedures. characterized by progressive weakness and skeletal muscle B. Complete recovery is anticipated. degeneration affecting a variety of muscle groups. The C. Provide psychologic support during period of assisted term pseudohypertrophy describes the characteristic muscle ventilation. enlargement (caused by fatty infiltration) that occurs in D. Keep client and family aware of progress of disease. muscular dystrophy. A. Duchenne’s muscular dystrophy is the most common and most severe form of MD. Amyotrophic Lateral Sclerosis B. Condition is characterized by gradual degeneration of Amyotrophic lateral sclerosis (ALS), also known as Lou muscle fibers and progressive symmetrical weakness and Gehrig’s disease, is a rapidly progressive, invariably fatal wasting of skeletal muscle. degeneration of nerves controlling voluntary muscles. Replacement of motor neurons with fibrous tissues causes Assessment hardening of anterior and lateral columns of the spinal A. Risk factors/etiology. cord, thus “lateral sclerosis.” 1. Genetic: sex-linked disorder primarily affecting males. Assessment 2. Onset generally occurs between the ages of 3 and A. Clinical manifestations. 5 years. 1. Twitching, cramping, and muscle weakness. B. Clinical manifestations. 2. Dysarthria and dysphagia. 1. History of delay in motor development, particularly 3. Fatigue; asymmetrical muscle atrophy and weakness. a delay in walking. L 426 CHAPTER 20 Neurologic System

H 2. Abnormal waddling gait. Assessment H a. Child falls frequently and develops characteristic A. Risk factors/etiology. H manner of rising. 1. May result from existing prenatal brain abnormalities H b. Gower’s sign: from sitting or squatting position, (kernicterus, hemolytic disease of newborn). H5 the child assumes a kneeling position and pushes 2. Prematurity is single most important determinant of H the torso up by “walking” his or her hands up the cerebral palsy; however, in about 24% of cases, cause H thighs. is not identifiable. H 3. Progressive muscle weakness, atrophy, and contrac- B. Clinical manifestations. H tures. 1. Delayed achievement of developmental milestones. H10 a. Ambulation is frequently impossible by the age of 2. Increased or decreased resistance to passive move- H 9 to 11 years. ment. H b. Ultimately destroys essential muscles of respira- 3. Abnormal posture. H tion; death occurs from respiratory tract infection 4. Presence of infantile reflexes (tonic neck reflex, exag- H or cardiac failure. gerated Moro reflex). H15 C. Diagnostics. 5. Associated disabilities. H 1. Electromyography, muscle biopsy. a. Mental retardation, seizures. H 2. Serum enzymes: creatinine phosphokinase level is b. Attention-deficit problems. H increased in neonate, then gradually declines. c. Vision and hearing impairment. H 6. Muscle tightness and spasms. H20 Treatment C. Diagnostics. H A. Steroids administered to boys older than 5 years 1. Diagnostic tests to rule out other neurologic dysfunc- H of age. tion: EEG, MRI, blood tests. H 2. Frequently difficult to diagnose in early months; con- H Nursing Interventions dition may not be evident until child attempts to sit H25 Child is frequently cared for at home and hospitalized only alone or walk. H when complications occur. 3. Gait lab analysis: evaluates walking ability. H Goal: To maintain optimal motor function as long as H possible. Treatment H A. Regular physical therapy for stretching and strengthen- A. Maintain and promote mobility with orthopedic devices H30 ing muscles; ROM exercises. and physical therapy. H B. Maintain child’s independence in ADLs. B. Skeletal muscle relaxants. H C. Assist family to identify resources, to adapt physiologic C. Anticonvulsants, as indicated. H barriers within the home, and to promote mobility of H the child in a wheelchair. Nursing Interventions H35 D. Assist family to identify methods of preventing respira- Child is frequently cared for at home and on an outpatient H tory tract infection; assess for respiratory problems. basis unless complications occur. H E. Provide braces, splints, and assistive devices as Goal: To assist child to become as independent and self- H needed. sufficient as possible. H Goal: To assist parents and child to maintain psychologic A. Physical therapy program designed to assist individual H40 equilibrium and to adapt to chronic illness. child to gain maximum function. H A. Assist parents to understand importance of indepen- B. Assist child to progress according to developmental H dence and self-help skills; frequently, parents are over- level and functional abilities; encourage crawling, H protective of the child. sitting, and balancing appropriate to developmental H B. Counseling to assist parents and family members to level. H45 identify family activities that can be modified to meet C. Assist child to carry out ADLs as age and capacities H child’s needs. permit. H C. Mother may feel particularly guilty because of transmis- D. Speech therapy, as indicated. H sion of disease to her son. E. Encourage play appropriate for age. H D. Identify available community resources. F. Encourage appropriate educational activities. H50 E. Counseling to assist family and child with chronic illness G. Bowel and bladder training may be difficult because of H and child’s eventual death. poor control. H Goal: To maintain physiologic homeostasis. H Cerebral Palsy A. Maintain adequate nutrition. H Cerebral palsy is a nonprogressive, lifelong neuromuscu- 1. May experience difficulty eating because of spasticity; H55 lar genetic disorder resulting from damaged motor centers may drool excessively; use of manual jaw control H56 of the brain that cause nerve impulses to be incorrectly when feeding. H57 sent and/or received. The overall result is impairment of 2. Encourage independence in eating and use of self- H58 L muscle control with poor muscle coordination. help devices. CHAPTER 20 Neurologic System 427

3. Provide a balanced diet with increased caloric intake Assessment to meet extra energy demands. A. Risk factors/etiology. B. Maintain safety precautions to prevent injury. 1. In general, onset occurs after age 60. C. Increased susceptibility to infections, especially respira- 2. More common in males. tory tract infections, because of poor control of intercos- B. Clinical manifestations (Figure 20-9). tal muscles and diaphragm. 1. Tremor. D. Increased incidence of dental problems; schedule fre- a. Affects the arms and hands bilaterally: often, the quent dental checkups. first sign. Goal: To promote a positive self-image in the child and b. Tremors usually occur at rest; voluntary move- provide support to the family. ment may decrease tremors; tremors during vol- A. Use positive reinforcement frequently. untary movement are not as common. B. Assist parents to set realistic goals. c. Described as “pill-rolling” tremor. C. Encourage recreation and educational activities, espe- d. Exacerbated by emotional stress and increased cially those involving other children with cerebral palsy. concentration. D. Encourage child to express feelings regarding the 2. Muscle rigidity. disorder. a. Increased resistance to passive movement. E. Do not “talk down” to child; communicate at appropri- b. Movement may be described as “cog-wheel rigid- ate developmental level. ity” because of jerky movement of extremities. F. Assist parents in problem solving in home environment. 3. Bradykinesia: slow activity. G. Identify available community resources. a. Decreased blinking of the eyelids. H. Utilize principles in caring for chronically ill pediatric b. Loss of ability to swallow saliva. client (Chapter 2). c. Facial expression is blank or “mask-like.” d. Loss of normal arm swing while walking. e. Difficulty initiating movement. Parkinson’s Disease (Paralysis Agitans) 4. Stooped posture, shuffling propulsive gait. Parkinson’s disease is a progressive neurologic disorder 5. May exhibit mental deterioration similar to that asso- with gradual onset that causes destruction and degenera- ciated with Alzheimer’s disease. tion of nerve cells in the basal ganglia; results in damage 6. Depression occurs in two-thirds of clients. to the extrapyramidal system, causing difficulty in control C. Diagnostics: no specific diagnostic test. and regulation of movement. A. Dopamine, a neurotransmitter, is responsible for normal Treatment functioning of the extrapyramidal system. A. Medication to enhance dopamine secretion (see Appen- B. The condition is correlated with a depletion of or dix 20-4). imbalance in dopamine and increased activity of B. Anticholinergic medications to decrease effects of ace- acetylcholine. tylcholine (see Appendix 20-4).

FIGURE 20-9 Parkinson’s disease. (From Zerwekh J, Claborn J: Memory notebook of nursing, vol 1, ed 4, Ingram, Texas, 2008, Nursing Education Consultants.) L 428 CHAPTER 20 Neurologic System

H C. Clients frequently become tolerant to medications and accompanied by dizziness, tinnitus, or lacrimation; H require adjustments in types of medications and medica- associated with stress and premenstrual syndrome. H tion schedules. 2. Migraine: constriction of intracranial vessels leading H D. Surgical therapy: aim is to decrease symptoms. to an intense throbbing pain when vessels return to H5 1. Ablation (destruction of tissue). normal; prodromal or aura; crescendo quality; uni- H 2. Deep brain stimulation (DBS). lateral pain, often beginning in eye area; nausea, H vomiting, photophobia—migraines are seriously H Nursing Interventions debilitating and may require lifestyle and occupa- H Goal: To maintain homeostasis. tional changes. H10 A. Encourage independence in ADLs with use of self-help 3. Cluster headache: rare headache that is more common H devices. in men; occurs in numerous episodes or clusters; no H B. Maintain nutrition. aura; unilateral pain often arising in nostril and H 1. Increase calories and protein; provide more easily spreading to forehead and eye; often occurs at same H chewed foods. time of day. H15 2. Frequent small meals. H 3. Allow ample time for eating. Treatment H 4. Monitor weight loss. A. Migraine: sumatriptan (Imitrex); dihydroergotamine H 5. Provide pleasant atmosphere at mealtime; client fre- mesylate (Migranal). H quently prefers to eat alone because of difficulty swal- B. Nonsteroidal antiinflammatory drugs. H20 lowing and inability to control saliva. C. Relaxation, yoga, stress management. H 6. Increase fluid intake with increased bulk in the diet D. Cluster headaches treated with high flow oxygen. H to decrease problem with constipation. H C. Maintain muscle function. Nursing Interventions H 1. Full ROM to extremities to prevent contracture. A. Prevention: recognize triggers, decrease stress, adjust H25 2. Decrease effects of tremors. medications during menstrual cycle. H 3. Exercise and stretch daily. B. Watch for signs of ominous headache: new-onset uni- H 4. Physical therapy, as indicated. lateral headache in person older than 35 years; vomiting H D. Closely monitor response to or changes in response to not accompanied by nausea; pain that awakens client. H medications. C. Encourage client to keep a “headache diary” for best H30 management and treatment. H ALERT Identify situations that necessitate role changes; H evaluate family involvement in health care; review necessary H modifications to promote home safety. Trigeminal Neuralgia H Trigeminal neuralgia is a fleeting unilateral sensory dis- H35 Goal: To promote a positive self-image. turbance of cranial nerve V, causing brief, paroxysmal pain H A. Encourage diversional activities. and facial spasm; also known as tic douloureux. H B. Assist client to set realistic goals. H C. Explore reasons for depression; encourage client to Assessment H discuss changes occurring in lifestyle. A. Risk factors/etiology. H40 D. Assist client in gaining control of ADLs and environ- 1. Onset generally occurs between 20 and 40 years H ment. of age. H E. Assist client to identify and avoid activities that increase 2. Increased frequency with aging. H frustration levels. B. Clinical manifestations. H F. Encourage good personal hygiene. 1. Abrupt onset of paroxysmal intense pain in the lower H45 and upper jaw, cheek, and lips. H a. Tearing of the eyes and frequent blinking. H Headache b. Facial twitching and grimacing. H Headache is a very common symptom of various underly- c. Pain is usually brief; ends as abruptly as it begins. H ing pathologic conditions in which pain-sensitive nerve d. Pain may be described as severe, stabbing, and H50 fibers respond to unacceptable levels of stress and tension, shock-like. H muscular contraction in the upper body, pressure from a 2. Recurrence of pain is unpredictable. H tumor, or increased ICP. 3. Pain is initiated by cutaneous stimulation of the H affected nerve area. H Assessment a. Chewing. H55 A. Types of headaches. b. Washing the face. H56 1. Tension headache (muscle contraction headache): c. Extremes of temperature: either on the face or in H57 most common of all headaches; feeling of tightness food. H58 L like a band around the head; onset is gradual; may be d. Brushing teeth. CHAPTER 20 Neurologic System 429

Treatment 4. Maintain meticulous oral hygiene. A. Medical management of pain (see Appendix 20-2): car- 5. Have frequent dental checkups. bamazepine (Tegretol) and gabapentin (Neurontin). B. Surgical intervention. 1. Local nerve block. Bell’s Palsy 2. Surgical intervention to interrupt nerve impulse Bell’s palsy is a transient cranial nerve disorder affecting transmission. the facial nerve (cranial nerve VII), characterized by a dis- a. Percutaneous stereotactic rhizotomy—destroys ruption of the motor branches on one side of the face, some of the nerve fibers; assists to manage pain. which results in muscle weakness or flaccidity on the b. Microvascular decompression (craniotomy) to affected side. relieve pain and preserve facial sensation. Assessment Nursing Interventions A. Clinical manifestations. Goal: To control pain. 1. Lag or inability to close eyelid on affected side. A. Assess the nature of a painful attack. 2. Drooping of the mouth. B. Identify triggering factors; adjust environment to 3. Decreased taste sensation. decrease factors. 4. Upward movement of the eyeball when the eye is 1. Keep room at an even, comfortable temperature. being closed. 2. Avoid touching client. B. Diagnostics (see Appendix 20-1). 3. Avoid jarring the bed. 4. Allow client to carry out own ADLs as necessary. Treatment C. Administer analgesics to decrease pain. A. Corticosteroids: administration should be started imme- diately after symptoms arise. B. Antivirals. NURSING PRIORITY Because of the severe pain caused by C. Moist heat may relieve pain, if present. the condition, clients are susceptible to severe depression and suicide. Nursing Interventions Goal: To assess nerve function and prevent complications. A. Analgesics to decrease pain. Goal: To maintain nutrition. B. Evaluate ability of client to eat. A. Frequently, client does not eat because of reluctance to C. Meticulous oral hygiene. stimulate the pain. D. Prevent drying of the cornea on the affected side. B. Provide lukewarm food that can be easily chewed. 1. Instill methylcellulose drops frequently during C. Increase protein and calories. the day. 2. Ophthalmic ointment and eye patches may be Home Care required at night. A. Identify presence of corneal reflex; provide protective eye E. As function returns, active facial exercises may be care if reflex is absent. performed. B. If there is loss of sensation to the side of the face, client Goal: To assist client to maintain a positive self-image. should: A. Changes in physical appearance may be dramatic. 1. Chew on the unaffected side. B. Tell client that the condition is usually self-limiting with 2. Avoid temperature extremes in foods. minimal, if any, residual effects. 3. Check the mouth after eating to remove remaining C. Client may require counseling, if change in facial appear- particles of food. ance is permanent.

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H Appendix 20-1 NEUROLOGIC SYSTEM DIAGNOSTICS H H Skull and Spine X-Ray Studies Simple x-ray films are Nursing Implications H obtained to determine fractures, calcifications, etc. 1. Determine whether medications need to be withheld before H5 Electroencephalography (EEG) A recording of the electri- procedure. H cal activity of the brain to physiologically assess cerebral activity; 2. Client will be asked to change positions during the test in order H useful for diagnosing seizure disorders; used as a screening proce- to visualize the brain from different angles. H dure for coma; also serves as an indicator for brain death. May 3. The client should not experience any pain. H also be used to assess sleep disorders, metabolic disorders and Caloric Testing Test is performed at bedside by introducing H10 encephalitis. cold water into the external auditory canal. It is contraindicated in H Nursing Implications the client with a ruptured tympanic membrane and is not done on 1. Explain to client that procedure is painless and there is no the client who is awake. If the 8th cranial nerve is stimulated, H danger of electrical shock. nystagmus rotates toward the irrigated ear. If no nystagmus occurs, H 2. Determine from physician if any medications should be with- a pathologic condition is present. H held before test, especially tranquilizers and sedatives. Positron Emission Tomography (PET) See Appendix H15 3. Frequently, coffee, tea, cola, and other stimulants are prohibited 17-1. H before examination. Lumbar Puncture A needle is inserted into the lumbar area at H 4. Client’s hair should be clean before the examination; after the the L4-L5 level; spinal fluid is withdrawn, and spinal fluid pressure H exam, assist client to wash electrode paste out of hair. is measured; contraindicated in presence of increased intracranial H Carotid Doppler Ultrasonography A noninvasive ultra- pressure. Normal spinal fluid values: opening pressure, 60 to H20 sound scan to estimate blood flow in carotid and cerebral vessels 150 mm water; specific gravity, 1.007; pH, 7.35; clear fluid; protein H to assess for stenosis. No preparation is necessary. concentration, 15 to 45 mg/dL; glucose concentration, 45 to H Magnetic Resonance Imaging (MRI) Cell nuclei have mag- 75 mg/dL; no microorganisms present. netic properties; the MRI machine records the signals from the Nursing Implications H cells in a manner that provides information to evaluate soft tissue Before test H structures (tumors, blood vessels). 1. Have client empty bladder. H25 Nursing Implications 2. Explain position (lateral recumbent with knees flexed) to H 1. Procedure will take approximately 1 hour. client (Figure 20-10). H 2. All metal objects should be removed from the client (hearing 3. Advise physician if there is a change in the client’s neuro- H aids, hair clips, jewelry, buckles, etc.). logic status before the test; increased intracranial pressure is H 3. The client will be placed in a long magnetic tunnel for the a contraindication to a lumbar puncture. H30 procedure. After test H 4. Poor candidates for MRI include the following. 1. Keep client flat at least 3 hours, and sometimes up to 12 H a. Clients with pacemakers (the magnetic field interferes with hours, to decrease occurrence of headache. H the function of the pacemaker and interferes with the test as 2. Encourage high fluid intake. well). 3. Observe for spinal fluid leak from puncture site; if leakage H b. Clients with implanted insulin pumps or joint replace- occurs, it may precipitate a severe headache. H35 ments. Myelogram An outpatient procedure in which dye is injected H c. Pregnant clients. into the subarachnoid space and x-ray films of the spinal cord and H d. Obese clients. vertebral column are obtained to identify spinal lesions. H e. Any client who requires life-support equipment (the equip- H ment will malfunction in a magnetic field). End of spinal cord L2 H40 Computerized Axial Tomography (CAT) Scan Com- Dura mater L3 puter-assisted x-ray examination of thin cross-sections of the brain Third lumbar H L4 to identify hemorrhage, tumor, edema, infarctions, and hydro- vertebra H Subarachnoid L5 cephalus. Machine is large donut-shaped tube with table through space (CSF in Cauda H lumbar cistern) the middle. equina H S1 Nursing Implications H45 1. Explain appearance of scanner to client and explain importance H of remaining absolutely still during the procedure. H 2. Remove all objects from client’s hair; for 4 to 6 hours before H test, client receives fluids only. H 3. Dye will be injected via venipuncture; assess for iodine allergy H50 and advise the client that he/she may experience a flushing or H warm sensation when the dye is injected. 4. Contrast dye may discolor urine for about 24 hours. H Needle 5. Dye may be injected into spinal cord for assessment of inter- insertion H site H vertebral disks and bone density. H55 Brain Scan A scanner traces the uptake of radioactive dye in the brain tissue. The dye is concentrated in the damaged tissue; it will FIGURE 20-10 Lumbar puncture. (From Black JM, Hawks JH: Medical- H56 take approximately 2 hours after dye is injected for the scan to be surgical nursing: clinical management for positive outcomes, ed 7, Phila- H57 completed. delphia, 2005, Saunders.) H58 L CHAPTER 20 Neurologic System 431

Appendix 20-1 NEUROLOGIC SYSTEM DIAGNOSTICS—cont’d

Nursing Implications After test Before test 1. Evaluate client’s neurologic status; complications involve 1. Same as for lumbar puncture. occlusion of cerebral arteries. 2. Check whether client has any allergies to dye. 2. Observe injection site for hematoma formation. After test 3. Posttest complications include continuous bleeding at injec- 1. Keep the head of the bed elevated 30 to 50 degrees to tion site, rash, dizziness, and tingling in an extremity. decrease dispersion of the dye in the CSF and to the brain. 4. Check circulation distal to area of puncture. 2. Headache may occur as a result of irritation of the central Electromyography (EMG) Measures electrical discharge from nervous system. a muscle. Flat electrodes or small needles are placed in the muscle. 3. Client should not receive any of the phenothiazines before The client may be asked to move and perform simple activities; the or immediately after the examination. electrical stimulus for the muscle will be recorded. Useful for diag- Cerebral Angiogram Injection of contrast material into the nosis in spinal cord deformity, muscular dystrophy, myasthenia cerebral circulation; series of x-ray films is taken to study the cere- gravis or amyotrophic lateral sclerosis. bral blood flow; dye is usually injected via a soft catheter that is Nursing Implications inserted and threaded through the femoral artery. Before test Nursing Implications 1. May determine pretest serum muscle determinations. Before test 2. Explain to the client that small needles will be inserted into 1. Client should be well-hydrated, but should receive nothing the skin. by mouth for 6 to 8 hours before the test; client should void After test before procedure. 1. Client may need something for pain because of muscle 2. Determine if client has any allergies to iodine or to shell fish. stimulation. 3. Inform client that he or she should remain very still during 2. Assess needle sites for areas of hematomas; apply ice pack the procedure. to prevent and/or relieve. 4. A feeling of warmth in the face and mouth and a metallic taste in the mouth are common when dye is injected.

Appendix 20-2 ANTIEPILEPTICS

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

Phenobarbital (Sodium Drowsiness, ataxia, excitation in 1. Client should avoid potential hazardous Luminal): IM, PO, rectal, IV children and the elderly activities requiring mental alertness. Primidone (Mysoline): PO 2. Sudden withdrawal from chronic use may precipitate symptoms. 3. Closely observe response in children and elderly. 4. Used to treat grand mal and focal seizures. 5. See Appendix 15-5 for care of client with seizures.

Phenytoin (Dilantin): PO, IV Gingival hyperplasia, skin rash, 1. Administer PO preparations with meals or hypoglycemia milk to decrease gastric irritation. Bradycardia, hypotension 2. Frequently used with phenobarbital for Visual changes: nystagmus, diplopia, control of grand mal seizures. blurred vision 3. IM injection is not recommended. 4. Do not mix with any other medications when administering IV solution. 5. Promote good oral hygiene; gum hyperplasia is a problem with long-term use. 6. See Appendix 15-5 for care of client with seizures. 7. AEDs should be withdrawn slowly over 6 weeks to several months when medication therapy is discontinued.

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H H Appendix 20-2 ANTIEPILEPTICS—cont’d H MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS H Divalproex sodium (Depakote): GI disturbances, rash, weight gain, 1. Should not be given to clients with severe H5 PO hair loss, tremor, blood dyscrasias liver dysfunction. H GI, dermatologic effects, blood 2. Potentiates action of phenobarbital, H dyscrasias phenytoin, diazepam. H 3. Uses: seizures, bipolar disorder, migraine. H H10 Carbamazepine (Tegretol): PO, Drowsiness, dizziness, headache; visual 1. Wean client from medication as soon as H suspension disturbances common during first seizures are controlled. H few weeks of treatment 2. Antimanic properties as well. H H Clonazepam (Klonopin): PO CNS depression, ataxia 1. Antianxiety effects may assist with seizure control. H15 2. Monitor results of liver function tests. H H CNS, Central nervous system; GI, gastrointestinal; IM, intramuscular; IV, intravenous; PO, by mouth (orally). H H H20 H Appendix 20-3 CHOLINERGIC (ANTICHOLINESTERASE) MEDICATIONS H H MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS H Cholinergic Medications Intensify transmission of impulses throughout the CNS, where H25 acetylcholine is necessary for transmission. H H Neostigmine bromide (Prostigmin): Excessive salivation, increased GI 1. Primary group of medications used for H PO, subQ, IM motility, urinary urgency, treatment of myasthenia gravis. H Pyridostigmine bromide (Mestinon): bradycardia, visual problems 2. Atropine is the antidote for overdose. H30 PO, IM, IV 3. In treatment of myasthenia gravis, medication H Edrophonium chloride (Tensilon): is frequently administered 30 to 45 minutes H IV, IM before meals. 4. Mestinon is given as maintenance therapy for H the client with myasthenia gravis. H 5. Tensilon is used for diagnostic purposes; not H35 recommended for maintenance therapy. H 6. Teach client symptoms of side effects and H advise client to call the doctor if they are H present. H H40 CNS, Central nervous system; GI, gastrointestinal; IM, intramuscular; IV, intravenous; PO, by mouth (orally); subQ, subcutaneous. H H H H Appendix 20-4 ANTIPARKINSONISM AGENTS H45 H MEDICATIONS SIDE EFFECTS NURSING IMPLICATIONS H Anticholinergics Inhibit action of acetylcholine at sites throughout the body and CNS. Decrease H synaptic transmissions in the CNS. H H50 Benztropine mesylate (Cogentin): Paralytic ileus, urinary retention, cardiac 1. Administer PO preparations with meals to H PO, IM, IV palpitations, blurred vision, nausea decrease gastric irritation. H and vomiting, sedation, dizziness 2. Medications have cumulative effect. H Trihexyphenidyl hydrochloride Minor side effects such as dry mouth, 3. Should not be used in clients with glaucoma, H (Artane): PO, IM, IV jitteriness, and nausea myasthenia gravis, GU or GI tract obstruction or H55 Procyclidine (Kemadrin): PO in children younger than 3 years. 4. Monitor client carefully for bowel and bladder H56 problems. H57 5. May be used to treat side effects of Thorazine. H58 L CHAPTER 20 Neurologic System 433

Appendix 20-4 ANTIPARKINSONISM AGENTS—cont’d

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

Levodopa (L-DOPA, Larodopa): Early: Anorexia, nausea and 1. Administer PO preparations with meals to PO vomiting, abdominal discomfort, decrease GI distress. postural hypotension 2. Almost all clients will experience some side Long-term: Abnormal, involuntary effects, which are dose related; dosage gradually movements, especially involving the increased according to client’s tolerance and face, mouth, and neck; behavioral response. disturbances involving confusion, 3. Onset of action is slow; therapeutic response may agitation, and euphoria require several weeks to months. 4. Vitamin B6 (pyridoxine) is antagonistic to the effects of the medication; decrease client’s intake of multiple vitamins and fortified cereals.

Carbidopa/levodopa Same as for levodopa 1. Same as for levodopa. (Sinemet): PO 2. Use of carbidopa significantly decreases the amount of levodopa required for therapy. 3. Prevents inhibitory effects of levodopa on vitamin

B6.

Amantadine hydrochloride Orthostatic hypotension, dyspnea, 1. Less effective than levodopa; produces a more (Symmetrel): PO dizziness, drowsiness, blurred vision, rapid clinical response. constipation, urinary retention (side effects are dose related)

CNS, Central nervous system; GI, gastrointestinal; GU, genitourinary; IM, intramuscular; IV, intravenous; PO, by mouth (orally).

Appendix 20-5 SEIZURE DISORDERS

A seizure disorder is the interruption of normal brain function- Generalized Seizures (Bilaterally Symmetric and Without ing by uncontrolled paroxysmal discharge of electrical stimuli Local Onset) from the neurons. No warning or aura, as client loses consciousness for a few seconds to several minutes. Classification of Seizures 1. Absence (petit mal): Characterized by a short period of time Simple Partial Seizures (remains conscious when the client is in an altered level of consciousness. Staring, throughout seizure) blinking period (followed by resumption of normal activity) is Rarely last longer than 1 minute; an aura may occur before the characteristic. May occur more than 100 times per day; may go seizure. unnoticed; in general, onset is in childhood between the ages of 1. Confined to a specific area (hand, arm, leg); client may experi- 4 and 12 years. ence unusual sensations. 2. Tonic-clonic seizures: May last 2 to 5 minutes. Full recovery 2. One-sided movement of an extremity. may take several hours; client may be confused, amnesic, and 3. Autonomic changes; skin flushing, change in heart rate, epigas- irritable during this recovery period. tric discomfort. Tonic phase: Loss of consciousness with stiffening and rigidity of muscles. Apnea and cyanosis are common during this Complex Partial Seizures (may have impairment of period; phase generally lasts for about 1 minute. consciousness) Clonic phase: Hyperventilation, with rapid jerking movements. 1. May loose consciousness for 1 to 3 minutes. Tongue biting, incontinence, and heavy salivation may occur 2. May produce automatisms (lip smacking, grimacing, repetitive during this period (Figure 20-11). hand movements). 3. Client may be unaware of environment and wonder what is Seizure Etiology happening at the beginning of the seizure. Acute Disorders 4. In the period after the seizure, client may experience amnesia • Increased intracranial pressure, metabolic alterations and confusion. • Infections, febrile episodes in children (generally between 6 5. Also called temporal lobe seizures or psychomotor. months and 3 years)

Continued L 434 CHAPTER 20 Neurologic System

H H Appendix 20-5 SEIZURE DISORDERS—cont’d H 4. Presence of incontinence. H A 5. Period of apnea and cyanosis. H5 6. Presence of automatisms (lip smacking, grimacing, chewing). H 7. Duration of seizure. H 8. Changes in level of consciousness. H 9. Condition of client after seizure: oriented, level of activity, any H residual paralysis or muscle weakness. H10 H Tonic phase H NURSING PRIORITY Airway management and ventilation H cannot be performed on a client who is experiencing a tonic- clonic seizure. After the seizure is over, evaluate the airway and H initiate ventilations as necessary. H15 H H B Nursing Management H Clonic phase 1. Remain with the client who is having a seizure; note the time H the seizure began and how long it lasted. H20 2. Do not attempt to force anything into the client’s mouth if the H jaws are clenched shut. 3. If the jaws are not clenched, place an airway in the client’s H mouth. This protects the tongue and also provides a method of H suctioning the airway, should the client vomit. H 4. Protect the client from injury (risk for falling out of bed or H25 striking self on bedrails, etc). H 5. Loosen any constrictive clothing. C H Postictal phase 6. Do not restrain client during seizure activity; allow seizure movements to occur, but protect client from injury. H FIGURE 20-11 Tonic-clonic seizure activity. (From Black JM, Hawks 7. Evaluate respiratory status; if vomiting occurs, be prepared to H JH: Medical-surgical nursing: clinical management for positive out- suction the client to clear the airway and prevent aspiration. H30 comes, ed 8, Philadelphia, 2009, Saunders.) H 8. Maintain calm atmosphere and provide for privacy after the H seizure activity. 9. Reorient client. H H Chronic (Recurrent, Epilepsy) ALERT Report characteristics of a client’s seizure; determine H35 • Brain injury at birth, trauma, vascular disease changes in client’s neurologic status. H • Brain tumors, genetic factors, idiopathic H Nursing Assessment Client Education H 1. Identify any activities that occurred immediately before the 1. Identify activities/events that precipitate the seizure activity. H seizure. 2. Avoid alcohol intake, fatigue, and loss of sleep. H40 2. Was the client aware a seizure was going to occur? If so, how 3. Take medications as directed. H did client know? 4. Counseling for the family and for the client to assist them in H 3. Describe type of movements that occurred and the body area maintaining positive coping mechanisms. H affected (e.g., jaw clenched, tongue biting). 5. Wear medical alert bracelet or have identification card. H H45 H H H H H50 H H H H H55 H56 H57 H58 L CHAPTER 20 Neurologic System 435

Appendix 20-6 APHASIA

Aphasia is a total loss of comprehension and use of language. speech center is located in the dominant side of the cerebral Dysphasia is the difficulty related to the comprehension or use hemisphere. The speech center for a right-handed person is of language and is due to a partial disruption or loss; patterns located in the left cerebral hemisphere. Clients with aphasia are of dysphasia differ because the stroke affects different parts of often frustrated and irritable. Emotional lability is common. the brain. The condition is precipitated by a problem in the Accept the behavior in a manner that prevents embarrassment cerebral cortex. The most common cause of aphasia is a for the client. vascular problem involving the middle cerebral artery. The

TYPES OF APHASIA NURSING IMPLICATIONS Sensory aphasia (receptive or fluent, Wernicke’s area): Cannot 1. Stand in front of the client; speak clearly and slowly. understand oral or written communication. Client cannot 2. Do not shout or speak loudly; the client can hear. interpret or comprehend speech or read. 3. Be patient; give the client time to respond; do not press him Motor aphasia (expressive, Broca’s aphasia): Inability to speak or to or her for immediate answers. write. However, the client can comprehend incoming speech 4. Use nonverbal communications such as touch, smiles, and and can read. gestures. Mixed: Most aphasia involves both the sensory and motor aspects 5. Assist the client with motor aphasia to practice repeating of speech. Rarely is aphasia only sensory or only motor. simple words such as yes, no, and please. Global aphasia: All communication and receptive function is lost. 6. Listen carefully, try to understand, and try to communicate; Dysarthria: A disturbance in the muscular control of speech. this conveys to the client that you care. Does not affect the meaning of communication or 7. nvolve family members in practice and assist them to identify comprehension, just the mechanics of speech—pronunciation, ways they can support the client. articulation, and phonation. ALERT Assist client to communicate effectively.

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H More questions on H Study Questions Neurologic System companion CD! H H 1. The nurse is obtaining a health history from a client 7. After a grand mal seizure, what nursing action is the H5 who states he is having pain in his left arm. Which highest priority? H question by the nurse will elicit the most useful response 1 Loosen or remove constricting clothing and protect H from the client? client from injuring himself or herself. H 1 “Does the pain feel like pins and needles in your 2 Maintain a patent airway by turning the client on H arm?” his side and suctioning, if necessary. H10 2 “Does the pain radiate from your neck to your arms?” 3 Remain with the client and administer anticonvul- H 3 “Can you describe the pain you are experiencing in sant medications as ordered by the physician. H your arm?” 4 Describe and record events before the onset of the H 4 “Is the numbness in your arm intermittent or seizure, during the seizure, and after the seizure. H constant?” 8. A client with Parkinson’s disease is experiencing H15 2. The nurse is assessing a client with a tentative diagnosis anorexia and vomiting. The client is taking levodopa. H of a brain tumor. What would the nurse anticipate the What will be the initial nursing activity? H client’s primary complaint to be? 1 Assess client’s food preferences. H 1 Decreased appetite 2 Monitor client’s blood pressure. H 2 Frequent insomnia 3 Hold client’s medication and notify the physician. H20 3 Recurrent headaches 4 Administer client’s medication with food. H 4 Peripheral edema 9. An 8-year-old child is admitted after an accident where H 3. The nurse is caring for a client who has had a right- he sustained a closed head injury. The child is alert and H sided stroke. What would be appropriate nursing care oriented but very lethargic. There is clear fluid draining H for this client? from the child’s nose. What is the best nursing action? H25 1 Performing passive ROM exercises to affected side, 1 Gently suction the fluid from the nasal area. H active ROM on unaffected side 2 Turn from side to side only. H 2 Placing food on the affected side of the client’s 3 Keep head of bed elevated. H mouth 4 Encourage participation in games to play in bed. H 3 Applying hot packs to the right leg to decrease 10. When obtaining a health history, the nurse expects a H30 muscle spasms client with a recent diagnosis of Parkinson’s disease to H 4 Turning client every 2 hours and maintaining posi- report which sign or symptom? H tion on the right side for 2 hours 1 Weight loss H 4. A client is scheduled for an electroencephalogram. 2 Slowness of movement H What will the nurse explain to the client regarding the 3 Continual motor tremors H35 purpose of this test? 4 Depression H 1 Evaluates electrical currents of skeletal muscles 11. While caring for a client who has recently been diag- H 2 Measures ultrasonic waves in the brain nosed with Parkinson’s disease, the nurse should under- H 3 Determines size and location of brain activity stand that: H 4 Records brain electrical activity 1 Intellectual capabilities will decrease. H40 5. A client who has had a stroke is aphasic; it has been a 2 Diversional interests may decrease. H week since his stroke. He is beginning to show func- 3 Mood fluctuations may occur. H tional improvement and demonstrates an ability to 4 Communication skills may fluctuate. H follow verbal directions. What will rehabilitation now 12. Pneumonia is a common problem in children with H include? spastic cerebral palsy. The nurse understands that this H45 1 A right-leg brace occurs because: H 2 Ambulation training 1 There is an associated dysfunction of the respiratory H 3 Speech training center in the central nervous system. H 4 Vocational retraining 2 The immunologic system is immature and does not H 6. The nurse is caring for a client who is doing well after produce adequate antibodies to fight infection. H50 his craniotomy. What will the bowel care for this client 3 Decreased mobility leads to stasis of secretions in H include? the respiratory passages. H 1 An enema every other day to avoid the Valsalva 4 There is a weakness of the voluntary muscles that H maneuver control respiration. H 2 High-fiber diet and stool softeners to prevent H55 constipation Answers and rationales to these questions are in the section at H56 3 Low-residue diet to decrease stool formation and the end of the book titled Chapter Study Questions: Answers H57 prevent constipation and Rationales. H58 L 4 Daily checking for impaction caused by loss of bowel innervation