Transcript NURS 1130 Adult Nursing III Unit I Chapters 27, 28, 29 Teresa Champion, RN, MSN 9/2012

NURS 1130
Adult Nursing III
Unit I
Chapters 27, 28, 29
Teresa Champion, RN, MSN
9/2012
Chapter 27
Neurologic Disorders
Anatomy and Physiology of the
Nervous System
Neuron (Nerve Cell)
 Functional unit of the nervous system that
conducts electrical impulses from one area of the
brain to another
 Sensory neurons
 Transmit information from distal parts of the body or
environment toward the central nervous system
 Motor neurons
 Carry motor information from the CNS to the periphery
Axons and Dendrites
 Branch off the main cell body
 Axons conduct impulses away from the
cell body
 Dendrites convey impulses toward the
cell body
Myelin
 Material that covers many axons and
dendrites
 Enhances conduction along nerve fibers
 Gives the axons a white appearance; cell
bodies without myelin are gray
Figure 27-1
Central Nervous System (CNS)
 Made up of the brain and spinal cord
Peripheral Nervous System
 Comprises all the nerves of the peripheral parts of
the body, including spinal and cranial nerves
Brain
 Divided into the cerebrum, cerebellum, and
brainstem
Cerebrospinal Fluid (CSF)
 Composed of water, glucose, sodium chloride,
and protein
 Acts as a shock absorber for the brain and spinal
cord
Figure 27-2
Spinal Cord
 Extends from the border of the first cervical
vertebra (C1) to the level of the second lumbar
vertebra (L2)
 Thirty-one pairs of spinal nerve roots exit the
spinal cord, each consisting of a posterior sensory
(afferent) root and anterior motor (efferent) root
 These roots, along with the 12 cranial nerves,
make up the peripheral nervous system
Autonomic Nervous System
 Controls the involuntary activities of the viscera,
including smooth muscle, cardiac muscle, and
glands
 Two major subdivisions: sympathetic nervous
system and the parasympathetic nervous system
Age-Related Changes
 The number of nerve cells decreases
 Brain weight is reduced; ventricles increase in size
 Lipofuscin: aging pigment deposited in nerve cells
with amyloid, a type of protein
 Increased plaques and tangled fibers in nerve tissue
 Eye pupil often smaller; may respond to light more
slowly
 Reflexes intact except for Achilles tendon jerk, which
is often absent
 Reaction time increases, especially complex reactions
 Tremors in the head, face, and hands are common
 Some develop dizziness and problems with balance
Pathophysiology of
Neurologic Diseases
Types of Disorders
 Developmental and genetic
 Trauma
 Infections and inflammation
 Neoplasms
 Degenerative processes
 Vascular disorders
 Metabolic and endocrine disorders
Nursing Assessment of
Neurologic Function
 Health history
 Note speech, behavior, coordination, alertness,
comprehension
 Chief complaint and history of present illness
 Document what prompted the patient to seek medical
attention
 Describe any injuries
 If patient has pain, note the onset, severity, location, and
duration
 Past medical history
 Head injury, seizures, diabetes mellitus, hypertension, heart
disease, and cancer
 Record dates and types of immunizations
Nursing Assessment of
Neurologic Function
 Family history
 Have immediate family members had heart disease,
stroke, diabetes mellitus, cancer, seizure disorders,
muscular dystrophy, or Huntington’s disease?
 Review of systems
 Fatigue or weakness, headache, dizziness, vertigo,
changes in vision/hearing, tinnitus, drainage from ears
or nose, dysphasia, neck pain or stiffness, vomiting,
bladder or bowel function, sexual dysfunction, fainting,
blackouts, tremors, paralysis, incoordination, numbness
or tingling, memory problems, mood changes
Nursing Assessment of
Neurologic Function
 Functional assessment
 Document whether present symptoms interfere with
the patient’s usual activities and occupation
 Explore sources of stress, usual coping strategies, and
sources of support
 Physical examination
 Level of consciousness, pupillary evaluation,
neuromuscular response, and vital signs
Nursing Assessment of
Neurologic Function
 Level of Consciousness:
1. Anxious, agitated, combative – hyper-stimulated
2. Somnolence – unnatural drowsiness or sleepiness
3. Lethargy – like Somnolence, is excessive drowsiness
4. Stupor – decreased responsiveness with a lack of
spontaneous motor activity
5. Semi-comatose – decreased responsiveness, no
spontaneous motor activity (stuporous) but can be
aroused usually with noxious or painful stimuli
6. Comatose (Coma) – not responsive, not spontaneous
motor activity and cannot be aroused with even
painful stimuli
Diagnostic Tests and Procedures
 Advanced neurologic examination
 Cranial nerves
 Coordination and balance
 Neuromuscular function
 Sensory function
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Pain
Temperature
Light touch
Vibration
Position
Tactile discrimination
Figure 27-5
Figure 27-6
BABINSKI REFLEX –
B) negative Babinski – normal for adults
C) positive Babinski – abnormal for adults
Figure 27-7
Diagnostic Tests and Procedures
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Lumbar puncture
Electroencephalography
Electromyography
Radiologic studies
 Brain scan
 Cerebral angiography and digital subtraction
angiography
 Computed tomography
 Magnetic resonance imaging
Figure 27-8
Figure 27-9
Figure 27-10
Figure 27-11
Common Therapeutic Measures
 Drug therapy
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Antimicrobials
Analgesics
Anti-inflammatory
Corticosteroids
Anticonvulsants
Diuretics
Chemotherapeutic agents
Dopaminergics
Anticholinergics
Cholinergics
Antihistamines
Common Therapeutic Measures
 Surgery
 Craniotomy
 Surgical opening of the skull
 Craniectomy
 Excision of a segment of the skull
 Cranioplasty
 Any procedure done to repair a skull defect
Increased Intracranial Pressure (ICP)
 Normal ICP is 0-15 mmHg (averages 10-15)
 Brain, Blood, Cerebral Spinal Fluid are factors of
ICP
 All must remain normal, if one factor increases ICP will
rise; unless the other two factors have a decrease.
 When ICP increases, blood perfusion to brain
decreases.
Assessment for Signs and Symptoms of
Increasing ICP
 Level of consciousness (most reliable), pulpillary
characteristics, motor function, sesnory function,
vital signs.
 Abnormal motor function called posturing as ICP
increases:
 Decorticate – abnormal flexation
 Decerebriate – abnormal extension (worse)
 Cushing’s Triad – Life threatening signs!
Assessment for Signs and Symptoms of
Increasing ICP
 Cushing’s Triad Hypertension with
widening pulse pressure
Irregular, shallow
Bradycardia
respirations
Treating Increasing ICP
 Positioning – Head of Bead no more than 30
 Hyperventilation
 Fluid Management
 Mechanical drainage (ventriculostomy)
 Drug Therapy – Mannitol drug of choice, diuretic
helps decrease ICP, increases UO
External Ventriculostomy Drain
Disorders of the Nervous
System
Migraine Headache
 Intracranial vasoconstriction followed by vasodilation
 Triggered by menstruation, ovulation, alcohol, some foods,
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stress
Pain usually unilateral, often begins in the temple or eye area
and is very intense
Tearing and nausea and vomiting may occur
Hypersensitive to light and sound; prefers dark, quiet
environment
Mild migraines treated with acetaminophen or aspirin; severe
ones with ergotamine (Cafergot) or sumatriptan (Imitrex)
tablet or auto injector for self-injection
Cluster Headache
 Occur in a series of episodes followed by a long
period with no symptoms
 Intensely painful and seem to be related to stress
or anxiety
 Usually have no warning symptoms
 Treatment may include cold application,
indomethacin (Indocin), and tricyclic
antidepressants
Tension Headache
 Result from prolonged muscle contraction from
anxiety, stress, or stimuli from other sources, such
as a brain tumor or an abscessed tooth
 Pain location may vary; may have nausea and
vomiting, dizziness, tinnitus, or tearing
 Treatment: correction of known causes,
psychotherapy, massage, heat application, and
relaxation techniques
 Analgesics, usually nonopioid, may be prescribed
to reduce anxiety
Seizure Disorder
 Electrical impulses in the brain are conducted in a
highly chaotic pattern that yields abnormal
activity and behavior
 Related to trauma, reduced cerebral perfusion,
infection, electrolyte disturbances, poisoning, or
tumors
 Medical diagnosis
 Accurate history of the seizure disorder
 Electroencephalogram (EEG)
Seizure Disorder
 Electrical impulses in the brain are conducted in a
highly chaotic pattern that yields abnormal
activity and behavior
 Related to trauma, reduced cerebral perfusion,
infection, electrolyte disturbances, poisoning, or
tumors
 Medical diagnosis
 Accurate history of the seizure disorder
 Electroencephalogram (EEG)
Seizure Disorder: Classification
 Partial seizures
 Simple
 Part of one cerebral hemisphere; consciousness not
impaired
 Complex
 Consciousness impaired; may exhibit bizarre behavior
 Generalized seizures
 Involve the entire brain from the onset
 Consciousness lost during the ictal (seizure) period
 Types: tonic-clonic, absence, myoclonic, and atonic
Seizure Disorder: Phases of generalized
tonic-clonic seizure (grand mal)
 Tonic phase
 Loss of consciousness, falling, crying and generalized
stiffness.
 Clonic phase
 Jerking of the limbs
 Salivary frothing
 Postictal phase
 Deep sleep, extreme tiredness
 Headaches, confusion, irritability, vomitting
Seizure Disorder
 Status epilepticus
 Medical emergency: continuous seizures or repeated
seizures in rapid succession for 30 minutes or more
 Aura
 Dizziness, numbness, visual or hearing disturbance,
noting an offensive odor, or pain may precede a seizure
minutes to seconds before a seizure.
 Medical treatment
 Resolution of the underlying condition
 Anticonvulsant drug therapy
Seizure Disorder
 Surgical treatment
 Removal of seizure foci in the temporal lobe and
pallidotomy or vagal nerve stimulator
Seizure Disorder: Nursing Care
 Assessment
 Describe the seizure episode, including the postictal
period (following the seizure), and document drug
therapy
Seizure Disorder:
Nursing Care
 Risk for Injury
 Side rails of bed up and padded, suction machine
readily available, bed maintained in the low
position
 Quickly move objects away from the patient
 Do not attempt to restrain the patient
 Ineffective Coping and Deficient Knowledge
 Teach family and patient about the seizure disorder
and the therapy
 Teaching must be directed toward helping the
patient and family adjust to a chronic condition
 Encourage questions and concerns
Head Injury: Types
 Scalp injuries
 Lacerations, contusions, abrasions, and hematomas
 Concussion
 Trauma with no visible injury to the skull or brain
 Contusion
 Bruising and bleeding in the brain tissue
 Hematoma
 Subdural hematoma or epidural hematoma
 Intracerebral hemorrhage
 From lesions within the tissue of the brain itself
 Penetrating injuries
 Sharp objects penetrate the skull and brain tissue
Head Injury
 Surgical treatment
 Directed at evacuating hematomas and débriding
damaged tissue
Head Injury: Nursing Care
 Interventions
 Ineffective Tissue Perfusion
 Ineffective Breathing Pattern
 Risk for Injury
 Risk for Infection
 Impaired Physical Mobility
 Disturbed Body Image and Ineffective Role
Performance
Brain Tumors
 Etiology and risk factors
 Some congenital; others may be related to heredity
 Drug/environmental factors may play a role in development
 Signs and symptoms
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Directly related to area of brain invaded by the tumor
Visual disturbances and headache
New-onset seizure activity
Difficulties with balance and coordination
 Medical treatment
 Surgery often followed by radiation with or without chemotherapy
Brain Tumors: Nursing Care
 Interventions
 Acute Pain
 Disturbed Thought Processes
 Disturbed Sensory Perception
 Impaired Physical Mobility and Self-Care Deficit
 Ineffective Coping
Meningitis
 Etiology and risk factors
 Inflammation of the meningeal coverings of the brain
and spinal cord caused by either viruses or bacteria

Signs and symptoms
 Headache, nuchal rigidity (stiffness of the back of the
neck), irritability, diminished level of consciousness,
photophobia (sensitivity to light), hypersensitivity, and
seizure activity
 Positive Kernig’s sign and Brudzinski’s sign
 Medical diagnosis
 Lumbar puncture to obtain CSF for lab analysis
KERNIG’S SIGN – when leg is flexed at the knee
the patient will not be able to extend the same leg
http://www.youtube.com/watch?v=rJ-5AFuP3YA
Figure 27-16A
BRUDZINSKI REFLEX – bend up head (flex neck) and hip flexes
http://www.youtube.com/watch?v=jO9PAPi-yus&feature=endscreen&NR=1
Figure 27-16B
Meningitis
 Medical treatment
 Bacterial infections usually respond to antimicrobial
therapy, but no specific drugs effective against most
viral infections
 Anticonvulsants used to control seizure activity if
necessary
Meningitis: Nursing Care
 Assessment
 Assess vital signs and neurologic status frequently to
determine further deterioration or onset of
complications
Meningitis: Nursing Care
 Interventions
 Ineffective Tissue Perfusion
 Ineffective Breathing Pattern
 Acute Pain
 Risk for Injury
 Deficient Fluid Volume
Encephalitis
 Etiology and risk factors
 Inflammation of brain tissue caused by virus
 Signs and symptoms
 Fever, nuchal rigidity (stiff neck), headache, confusion,
delirium, agitation, and restlessness commonly seen
 Comatose or exhibit aphasia, hemiparesis, facial
weakness, and other alterations in motor activity
 Medical treatment
 Enhance patient comfort and increase strength
 Because seizure activity is a potential problem, take
appropriate safety precautions
Encephalitis: Nursing Care
 The nursing plan of care parallels that of the
patient with meningitis
Guillain-Barré Syndrome
 Etiology and risk factors
 Although specific cause unknown, it is believed to be an
autoimmune response to a viral infection
 Patients often report some recent viral infection or
vaccination
Guillain-Barré Syndrome
 Initial phase
 Symmetric muscle weakness: begins in lower
extremities; ascends to trunk and upper extremities
 Visual and hearing disturbances, difficulty chewing,
and lack of facial expression
 Mild paresthesias or anesthesia in feet and hands in a
glove or stocking distribution pattern
 Hypertension, orthostatic hypotension, cardiac
dysrhythmias, profuse sweating, paralytic ileus, and
urinary retention
Guillain-Barré Syndrome
 Plateau phase
 Remains essentially unchanged
 No further neurologic deterioration, but no
improvement either
 Recovery phase
 Remyelinization; muscle strength returns in a proximal-
to-distal pattern (head to toes)
Guillain-Barré Syndrome
 Medical diagnosis
 Characteristic onset and pattern of ascending motor
involvement
 Elevated protein level in the CSF
 Nerve conduction velocity studies reveal slowed
conduction speed in the involved nerves
Guillain-Barré Syndrome
 Medical treatment
 Preserve vital function, particularly respiration
 Respiratory status is closely monitored and mechanical
ventilation initiated if vital capacity falls to 15 mL/kg of
body weight
 Massive doses of corticosteroids prescribed to suppress
the inflammatory process
 Plasmapheresis
Guillain-Barré Syndrome: Nursing Care
 Assessment
 Health history describes the progression of symptoms
 Note fears, coping strategies, and sources of support
 Physical examination focuses on cranial nerve, motor,
respiratory, and cardiovascular function
Guillain-Barré Syndrome: Nursing Care
 Interventions
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Ineffective Breathing Pattern
Decreased Cardiac Output
Risk for Disuse Syndrome
Imbalanced Nutrition: Less Than Body Requirements
Anxiety
Deficient Knowledge
Rehabilitation
Parkinson’s Syndrome
 Etiology and risk factors
 Progressive degenerative disorder of the basal ganglia:
an eventual loss of coordination and control over
involuntary motor movement
 Signs and symptoms
 Tremor, rigidity, and bradykinesia
 Loss of dexterity and power in affected limbs, aching,
monotone voice, handwriting changes, drooling, lack of
facial expression, rhythmic head nodding, reduced
blinking, and slumped posture
 Depression common; dementia may develop
Figure 27-17
Parkinson’s Syndrome
 Medical diagnosis
 From health history and physical examination
 MRI to rule out other causes of the symptoms
 Medical treatment
 Control symptoms: physical therapy and drug therapy
 Massage, heat, exercise, and gait retraining
 Dopamine receptor agonists pramipexole (Mirapex) or
ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine);
carbidopa/levodopa (Sinemet); anticholinergic drugs such
as trihexyphenidyl (Artane) and benztropine (Cogentin)
Parkinson’s Syndrome: Nursing Care
 Assessment
 Weakness, fatigue, muscle cramps, sweating, dysphagia,
constipation, difficulty voiding, and unusual movements
 Note lack of facial expression, eyes fixed in one direction,
drooling, slurred speech, tearing, tremors, muscle stiffness,
and poor balance and coordination
 Interventions
 Impaired Physical Mobility
 Risk for Injury
 Imbalanced Nutrition: Less Than Body Requirements
 Ineffective Coping
 Deficient Knowledge
 Etiology
Multiple Sclerosis
 Chronic, progressive degenerative disease
 Attacks the protective myelin sheath around axons and
disrupts the conduction of impulses through the CNS
 Chronic, progressive MS: progresses steadily
 Exacerbating-remitting MS: exacerbations and remissions
 Relapsing-progressive MS: less stable periods than
exacerbating-remitting
 Stable MS: stable; no active disease for a year
 Exact cause of MS is unknown; viral infections and
autoimmune processes have been implicated
Multiple Sclerosis
 Signs and symptoms
 Fatigue, weakness, and tingling in one or more
extremities; visual disturbances; problems with
coordination; bowel and bladder dysfunction;
spasticity; and depression
Figure 27-18
Multiple Sclerosis
 Medical diagnosis
 Based on the physical examination and history of cyclic
remission-exacerbation periods
 Magnetic resonance imaging of the brain and spinal
cord may reveal plaques characteristic of MS
Multiple Sclerosis
 Medical treatment
 Corticosteroids (ACTH, prednisone,
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methylprednisolone)
Interferon  1b (Betaseron) and interferon 1a (Avonex)
Glatiramer acetate (Copaxone)
Immunosuppressants: mitoxantrone (Novantrone)
Amantadine (Symmetrel)
Urinary retention treated with cholinergics, such as
bethanechol (Urecholine) or neostigmine (Prostigmine)
Multiple Sclerosis: Nursing Care
 Assessment
 Onset and progression of symptoms, especially those
that affect mobility, vision, eating, and elimination
 Range of motion and strength, gait abnormalities,
tremors, and muscle spasms
Multiple Sclerosis: Nursing Care
 Interventions
 Impaired Physical Mobility
 Disturbed Sensory Perception
 Self-Care Deficit
 Functional Urinary Incontinence
 Risk for Infection
 Ineffective Coping
 Deficient Knowledge
Amyotrophic Lateral Sclerosis (ALS)
 Etiology
 Also known as Lou Gehrig’s disease; a degenerative
neurologic disease
 Virus suspected, but exact cause unknown
 Pathophysiology
 Degeneration of the anterior horn cells and the
corticospinal tracts, so patient exhibits upper and lower
motor neuron symptoms
ALS
 Signs and symptoms
 Weakness of voluntary muscles of the upper extremities,
particularly the hands
 Difficulty swallowing and speaking
 Eventually, respirations shallow; difficulty clearing
airway of pulmonary secretions
 Death results from aspiration, respiratory infection, or
respiratory failure
ALS
 Medical diagnosis
 History and physical examination findings
 Electromyography
 Medical treatment
 Because no known cure or treatment, therapy is
supportive; focuses on preventing complications and
maintaining maximum function
ALS: Nursing Care
 Assessment
 Dyspnea, dysphagia, muscle cramps, weakness,
twitching, joint stiffness, muscle atrophy, abnormal
reflexes and gait, and paralysis
ALS: Nursing Care
 Interventions
 Ineffective Airway Clearance
 Impaired Physical Mobility
 Imbalanced Nutrition: Less Than Body Requirements
 Impaired Verbal Communication
 Impaired Skin Integrity
 Anticipatory Grieving
 Situational Low Self-Esteem
 Interrupted Family Processes
Huntington’s Disease
 Inherited degenerative neurologic disorder
 Usually begins in middle adulthood with
abnormal movements, emotional disturbance, and
intellectual decline
 Symptoms progress steadily: increasing disability
and death in 15 to 20 years
 Medical and nursing care are supportive only;
there is no cure
Myasthenia Gravis
 Etiology
 May have an autoimmune basis
 Pathophysiology
 Insufficient receptor sites at the junction of the motor
nerve with the muscle
 With repeated stimulation, muscle becomes exhausted;
eventually unable to contract at all
 If respiratory muscles involved, death from respiratory
insufficiency or arrest possible
Myasthenia Gravis
 Signs and symptoms
 Weakness of voluntary muscles, particularly those of
chewing, swallowing, and speaking
 Partial improvements of strength with rest
 Dramatic improvement with the use of anticholinesterase
drugs
 Ptosis and diplopia commonly seen
Myasthenia Gravis
 Medical diagnosis
 Administering edrophonium (Tensilon)
 Muscle tone is markedly improved within 1 minute of
injection; persists for 4 to 5 minutes
 Medical treatment
 Anticholinesterase drugs
 Neostigmine and pyridostigmine (Mestinon)
 Corticosteroids
 Cytotoxic therapies
 Thymectomy
 Plasmapheresis
Myasthenia Gravis: Nursing Care
 Assessment
 Health history describes the onset of symptoms: muscle
weakness, diplopia, dysphagia, slurred speech,
breathing difficulties, and loss of balance
 Interventions
 Ineffective Breathing Pattern
 Impaired Physical Mobility and Self-Care Deficit
 Impaired Swallowing
 Deficient Knowledge
Chapter 28
Cerebrovascular Accident
Cerebrum
 Complex functions: initiation of movements,
recognition of sensory input, higher-order
thinking, regulating emotional behavior and
endocrine and autonomic functions
 Divided into two halves: hemispheres
 Each hemisphere controls the opposite side of the body:
the right hemisphere controls the left side of the body,
and the left hemisphere controls the right side of the
body
 The cortex of each is divided into the parietal, frontal,
temporal, and occipital lobes; each has a different area
of function
Figure 28-1
Cerebrum
 Brainstem
 Includes midbrain, pons, medulla, and part of the
reticular activating system
 Controls vital, basic functions, including respiration,
heart rate, and consciousness
Cerebellum
 Uses information received from the cerebrum, muscles, joints,
and inner ear to coordinate movement, balance, and posture
 Unlike the cerebrum, the right side of the cerebellum controls
the right side of the body, and the left side of the cerebellum
controls the left side of the body
Circulation
 Carotid system
 Begins as one common artery; later divides into the
external and internal carotid arteries
 The external carotid arteries divide to supply blood to the
face
 The internal arteries further divide into the middle
cerebral artery and the anterior cerebral artery to supply
blood to the brain
Circulation
 Vertebral arteries
 Originate from the subclavian artery, travel up the
anterior neck to merge and form the basilar artery at the
brainstem
 Second division forms posterior cerebral artery
 Internal carotid and vertebrobasilar arteries unite
to form the circle of Willis
Figure 28-2
Risk Factors for Stroke
 Nonmodifiable factors
 Risk factors that cannot be changed
 Age, race, gender, and heredity
 Modifiable factors
 Those that can be eliminated or controlled
Transient Ischemic Attack
 Temporary neurologic deficit caused by
impairment of cerebral blood flow
 Blood vessels occluded by spasms, fragments of
plaque, or blood clots
 Important warning signs for the individual
experiencing a full stroke
Transient Ischemic Attack
 Signs and symptoms
 Dizziness, momentary confusion, loss of speech, loss of
balance, tinnitus, visual disturbances, ptosis, dysarthria,
dysphagia, drooping mouth, weakness, and tingling or
numbness on one side of the body
 Medical diagnosis
 Health history, physical examination findings, and
results of brain imaging studies
 Laboratory studies, electrocardiography (ECG), duplex
ultrasonography, and cerebral angiography
Transient Ischemic Attack
 Medical treatment
 Depends on the location of the narrowed vessel and the
degree of narrowing
 Acetylsalicylic acid (aspirin), ticlopidine hydrochloride
(Ticlid), extended-release dipyridamole (Aggrenox), or
clopidogrel bisulfate (Plavix) decrease platelet
clumping
 Warfarin (Coumadin) and heparin
 Carotid endarterectomy and transluminal angioplasty
Figure 28-3
Stroke
 An abrupt impairment of brain function resulting
in a set of neurologic signs and symptoms that are
caused by impaired blood flow to the brain and
last more than 24 hours
Stroke: Pathophysiology
 Hemorrhagic stroke (20%)
 Blood vessel in brain ruptures; bleeding into the brain
occurs
 Ischemic stroke (80%) – most common
 Obstruction of blood vessel by atherosclerotic plaque,
blood clot, or a combination of the two, or by other
debris released into vessel that impedes blood flow to
an area of the brain
Figure 28-4
Stroke: Pathophysiology
 Common locations of Hemorrhagic stroke:
 Intracerebral - within the cerebrum
 Subdural – between dura and skull
 Subarachnoid – between arachnoid and pia matter
 Ventricular
 Ischemic stroke (80%) – most common
 Obstruction of blood vessel by atherosclerotic plaque,
blood clot, or a combination of the two, or by other
debris released into vessel that impedes blood flow to
an area of the brain
Stroke: Signs and Symptoms
 Hemorrhagic
 stroke Occurs suddenly; may include severe headache
described as “the worst headache of my life”
 Other symptoms: stiff neck, loss of consciousness,
vomiting, and seizures
 Ischemic Strokes:
 Thrombotic – plaque build up causing narrowing
 Embolic – dislodged thrombi of plaque, blot clot and
occludes cerebral arteries
Stroke: Signs and Symptoms
 CARDINAL SIGNS OF STROKE:
1. Numbness or weakness of the face, arm or leg, especially
on one side of the body. visual problems,
2. Sudden confusion, trouble speaking or understanding
3. Sudden trouble seeing in one or both eyes
4. Sudden trouble walking, dizziness, loss of balance or
coordination.
5. Sudden severe headache with no known cause.
Strokes:
Some additional terminology:
 Stroke in evolution – s/s of stroke are still present
 Stroke completed – s/s of stroke may or not be present
but neurological status is stabilized
 Luncar Stroke – Ischemic type stroke from occlusions of
small arteries deep in brain. These are less severe
strokes and usually have no or less-pronounced
neurological changes.
Figure 28-5
Stroke: Signs and Symptoms
 Aphasia
 A defect in the use of language; speech, reading, writing, or word
comprehension
 Dysarthria
 The inability to speak clearly
 Dysphagia
 Swallowing difficulty
 Dyspraxia
 The partial inability to initiate coordinated voluntary motor acts
 Hemiplegia
 Defined as paralysis of one side of the body
Perceptual Disturbances in hemiplegia
Figure 28-8
Stroke: Signs and Symptoms
 Sensory impairment
 Unable to feel touch, pain, or temperature in affected body parts
 Unilateral neglect
 Do not recognize one side of the body as belonging to them
 Homonymous hemianopsia
 Perceptual problem: involves loss of one side of field of vision
 Elimination disturbances
 Neurogenic bladder
 Flaccid bladder
 Bowel incontinence
Medical Diagnosis
 Blood studies, electrocardiogram (ECG),
computed tomography, magnetic resonance
imaging, carotid ultrasound studies, cerebral and
carotid angiography, electrocardiography,
positron-emission tomography, and single-photon
emission computed tomography
Complications
 Constipation, dehydration, contractures, urinary
tract infections, thrombophlebitis, decubitus
ulcers, and pneumonia
 Sensory losses put patient at risk for traumatic
and thermal injuries
 Swallowing difficulties place patient at risk for
pulmonary complications, such as choking and
aspiration pneumonia
Prognosis
 Prognosis for TIA or stroke increasingly hopeful
 Critical variables for recovery: patient’s condition before the
stroke, time between stroke and diagnosis, treatment and
support in acute phase (usually the first 48 hours), severity of
patient’s symptoms, and access to rehabilitative therapy
 Long-term recovery may depend on the care received
immediately after the stroke
 Most recovery takes place in the first 3-6 months, but progress
often continues long after that
Medical Treatment in the Acute Phase
 Begins with the onset of signs and symptoms and
continues until vital signs, particularly blood
pressure and neurologic condition, stabilize
 This phase usually lasts 24 to 48 hours
 Many medical management interventions are
directed at minimizing complications and
deterioration of the patient’s condition after a
stroke
Medical Treatment in the Acute Phase
 Major focus areas




Hypertension
Oxygenation
Hyperthermia
Hyperglycemia
 Drug therapy
 Tissue plasminogen activator (rt-PA, alteplase, Activase)
 Given to dissolve clots in acute ischemic strokes
Medical Treatment in the Acute Phase
 Other medications




Mannitol
Nimodipine (Nimotop)
Phenytoin (Dilantin) and phenobarbital
Acetylsalicylic acid (aspirin), ticlopidine hydrochloride
(Ticlid), Aggrenox, and clopidogrel (Plavix)
Medical Treatment in the Acute Phase
 Surgical intervention
 An option for some patients with hemorrhagic strokes
 Decisions about surgery are based on patient’s age,
intracranial pressure, and location of the hemorrhage
Medical Treatment in the Acute Phase
 Fluids and nutrition
 Intravenous fluids
 Dietary order based on patient’s nutritional
requirements and ability to eat
 Regular, soft, or pureed
 Total parenteral nutrition may be ordered for the
malnourished patient
Medical Treatment in the Acute Phase
 Urine elimination
 Indwelling catheter to manage urinary incontinence
 Intermittent catheterization: controlling incontinence
caused by a flaccid bladder
Emergency Department Timeline to Suspected Stroke:
Doctor Emergency Department
Door to Doctor =
10 minutes
Door to noncontrast CT or MRI
= 25 minutes
Emergency Department Timeline to Suspected Stroke:
Door to non-contrast
CT or MRI
completed and read
= 45 minutes
Door to Drug/Admission
= 60 MIN
60 MIN
<3hours from symptom
onset to be a canidate for
drug (tPA).
(could go up to 4.5 hours but
outcomes are not as good).
GLASCOW COMA SCALE (GCS) - ADULT
o Glasgow Coma Scale or GCS is a
neurological scale used for recording the
conscious state of a person .
o Score between 3 (indicating deep
unconsciousness) or 15 (fully conscious).
o Today, it is the most used scale on both
acute medical and trauma patients.
National Institutes of Health (NIH)
Stroke Scale
• A tool often used to assess patients who have
experienced a stroke, by use of a point system
• Addresses: Motor Function, Visual Fields, Ataxia,
Speech, Language, Cognition and Motor and
Sensory Abnormalities.
• Most facilities, especially those that have
accreditation as a Stroke Center, require those that
administer the NIH Stroke Scale Examination to be
Certified to ensure consistency among examiners.
• See page 504, Table 28-4, in your book for a
condensed version of the NIH Stroke Scale.
Nursing Care in the Acute Phase
 Assessment
 Evaluate type and extent of the stroke: time of onset,
symptoms, other details
 Cincinnati Pre-hospital Stroke Scale
 Health history





Chief complaint and history of present illness
Medical history
Family history
Review of systems
Functional assessment
Nursing Care in the Acute Phase
 Physical examination
 Assess patient’s general appearance, responsiveness,





and behavior
Record restlessness or agitation
Measure vital signs; weight and height if possible
Inspect the face for symmetry; mouth for moisture and
drooling
Evaluate the alert patient’s ability to swallow
Inspect pupils for size, equality, and reaction to light
Nursing Care in the Acute Phase
 Physical examination
 Conduct a gross vision assessment
 Inspect skin color and palpate for moisture and turgor
 Assess extremities for muscle tone and strength, sensation,
and voluntary movement
 Record evidence of incontinence or bladder distention
 Frequently repeat neurologic checks: evaluating level of
consciousness, pupil appearance and response to light, the
patient’s ability to follow commands, and the movement
and sensation of extremities
Nursing Care in the Acute Phase
 Interventions
 Ineffective Airway Clearance and Ineffective Breathing






Patterns
Risk for Injury
Deficient Fluid Volume or Excess Fluid Volume
Imbalanced Nutrition
Disturbed Sensory Perception
Ineffective Thermoregulation
Disturbed Thought Processes
Nursing Care in the Acute Phase
 Interventions
 Impaired Verbal Communication
 Impaired Physical Mobility
 Total or Functional Urinary Incontinence
 Constipation and/or Bowel Incontinence
 Ineffective Coping
 Interrupted Family Processes
Nursing Care in the
Rehabilitation Phase
 Assessment
 Reassess patient’s abilities, expectations, knowledge,
motivation, and resources
Nursing Care in the
Rehabilitation Phase
 Interventions








Self-Care Deficit
Risk for Injury
Ineffective Coping
Impaired Verbal Communication
Imbalanced Nutrition
Impaired Physical Mobility
Constipation
Total and Functional Urinary Incontinence
Figure 28-6
Figure 28-7
Figure 28-9
Discharge
 Patients may be discharged to home or go to
specialized rehabilitation centers for continued
therapy
 Outpatient therapy is an option for some patients
 When able, patients are transitioned back into the
home setting
 Essential to include family, friends, and significant
others in this process
Discharge
 During and after the rehabilitation phase, patients
and families need to be made aware of resources
to help them deal with continuing disabilities
 In rehabilitation, the patient is respectfully
challenged to return to the highest level of
function possible
Chapter 29
Spinal Cord Injury
Anatomy and Physiology of the
Spinal Cord
Vertebral Column
 Consists of 33 vertebrae
 7 cervical (C1 through C7)
 12 thoracic (T1 through T12)
 5 lumbar (L1 through L5)
 5 sacral (S1 through S5)
 4 fused coccygeal
Figure 29-1
Vertebral Column
 Each vertebra consists of a body and an arch
 The spinal cord passes through an opening in the
center of each arch
 Each arch has articulating surfaces against which
adjacent vertebrae smoothly glide with movement
 The bony column is supported by muscles and
ligaments, which permit mobility and flexibility
Disks
 Vertebrae separated by disks which serve as shock
absorbers for the vertebral column
 Composed of anulus fibrosus and nucleus
pulposus
 anulus fibrosus: ring of tissue; encircles nucleus
pulposus
 Nucleus pulposus: saclike structure with a gelatinous
filling that has a high water content
 As we age, nucleus pulposus loses much of its
water; less effective as a shock absorber
Figure 29-2
Spinal Cord
 Extends from the brainstem to L2 in pelvic cavity
 Surrounded by three protective meningeal layers
 Dura mater
 Outermost layer
 Arachnoid
 Middle layer: spaces containing cerebrospinal fluid (CSF)
 Pia mater
 Innermost layer: directly covers the spinal cord
 CSF circulates through the brain and spinal column, bathing
and protecting the entire central nervous system
Figure 29-3
Spinal Cord
 Gray matter
 Consists of the bodies of nerve cells that control motor
and sensory activities
 White matter
 Myelinated (surrounded by a sheath); consists of
bundles of fibers
 Convey information between the brain and the spinal
cord
 Tracts may be ascending or descending
Figure 29-4
Spinal Cord
 Blood supply
 Major arterial supply to the spinal cord; consists of the
vertebral arteries posteriorly and the anterior spinal
artery
 Reflexive activity
 The sensory stimulus is received, and a response is
initiated at the level of the spinal cord
Spinal Cord
 Relay activity
 Stimulus enters spinal cord; travels up ascending tracts
to relay sensory signals to the brain
 Information processed in the brain; responses initiated
by impulses transmitted to the body by way of
descending tracts
 Information conveyed to brain and spinal cord via
peripheral nervous system
Diagnostic Tests and Procedures
 Neurologic examination
 Initial evaluation of the spinal cord: injured patient
provides the nurse with a baseline assessment of
function and problems
 Ongoing assessment necessary to monitor the effects of
neurologic injury, detect related complications, and
determine patient’s need for assistance in activities of
daily living
 Focuses on the motor and sensory systems
Diagnostic Tests and Procedures
 Imaging studies
 Radiography
 Detects vertebral compression, fractures, or problems with
alignment
 Computed tomography (CT)
 Noninvasive examination of the specific levels of the spinal cord
to be visualized, bony vertebrae, and the spinal nerves
 Magnetic resonance imaging (MRI)
 Produces precise, clear images of internal structures
 Myelogram
 Visualizes the spinal cord and vertebrae
Pathophysiology of
Spinal Cord Injury
Types of Injuries
 Location
 Cervical, thoracic, or lumbar
 Open or closed
 Closed: trauma in which the skin and meningeal
covering that surround the spinal cord remain intact
 Open: damage to the protective skin and meninges
 Extent of damage to the cord
 Complete spinal cord injury occurs when the cord has
been completely severed, whereas an incomplete injury
results from partial cutting of the cord
Effects of Spinal Cord Injury
 Factors include extent of cut and level of injury
 Sometimes cannot be fully determined because
the symptoms of spinal cord edema may mimic
partial or complete transection
 With incomplete spinal cord injuries some
function remains below the level of the injury
 Specific tracts may be involved, causing particular
patterns of neurologic dysfunction
Figure 29-6
Effects of Spinal Cord Injury
 The higher the level of injury, the more
encompassing the neurologic dysfunction
 Quadriplegia
 High cervical spine injuries; loss of motor and sensory
function in all four extremities
 Paraplegia
 Injuries at or below T2 may cause paralysis of the lower
part of the body
Respiratory Impairment
 Injuries at or above the level of C5 may result in
instant death because the nerves that control
respiration are interrupted
 Cervical injuries below the level of C4 spare the
diaphragm but can involve impairment of
intercostal and abdominal muscles
Spinal Shock
 An immediate, transient response to injury in
which reflex activity below the level of the injury
temporarily ceases
Autonomic Dysreflexia
 Exaggerated response of autonomic nervous
system to noxious (painful) stimuli
 With injury at or above the level of T6
 The sympathetic nervous system is stimulated,
but an appropriate parasympathetic modulation
response cannot be elicited because of the spinal
cord injury that separates the two divisions of the
autonomic nervous system
Autonomic Dysreflexia
 Triggered by various stimuli including a
distended bladder, constipation, renal calculi,
ejaculation, or uterine contractions, but also may
be caused by pressure sores, skin rash, enemas, or
even sudden position changes
Spasticity
 Muscle spasms may be incapacitating for these
patients, hampering efforts at rehabilitation
Impaired Sensory and Motor Function
 Impaired motor function can affect the patient’s
mobility and self-care and thus result in
complications from immobility
 Loss of sensation puts patient at risk for skin
breakdown and other injuries because pressure
and pain are not perceived
Impaired Bladder Function
 During spinal shock, all bladder and bowel
function ceases
 Once spinal shock resolves, reflex activity returns
Impaired Bowel Function
 Most spinal cord–injured patients can maintain
bowel function because the large bowel
musculature has its own neural center that
responds to distention by the fecal mass
Impaired Temperature Regulations
 May lose these regulatory mechanisms and be
unable to adapt to temperature extremes
Impaired Sexual Function
 Spinal levels S2, S3, and S4 control sexual function,
so injury at or above these levels results in sexual
dysfunction
 Ability to achieve erection and ejaculation is
variable
Impaired Skin Integrity
 Because immobile patient can’t change positions,
skin in sacral area and across bony prominences
may break down
 Loss of tone results in vasodilation and pooling of
blood in the periphery; impedes perfusion of the
skin; and encourages the development of pressure
sores
Altered Self-Concept and Body Image
 French and Phillips (1991) describe the effects of
spinal cord injury on body image as occurring in
four phases: impact, retreat, acknowledgment,
and reconstruction
Medical Treatment in the Acute Phase
Saving the Patient’s Life:
Establish Airway
 Conventional head-tilt–chin-lift: inappropriate
with spinal injury; increases risk of cord damage
 Risk of additional damage is especially high with
cervical injury
 Neck flexion, even that caused by a pillow or
other support, must be avoided
 Jaw-thrust method of opening the airway is
preferred for these patients
Saving the Patient’s Life:
Establish Airway
 Once airway is open, administer 100% oxygen by
mask and manual resuscitator
 Endotracheal or tracheostomy tube is placed to
allow direct access to the airway and facilitate
optimal oxygenation
 Any injury that compromises ventilation must be
treated immediately
Preventing Further Cord Injury
 Traction
 Immobilization with skeletal traction manages cervical
spinal cord injuries acutely
 Gardner-Wells tongs
 Secured just above the ears; doesn’t actually penetrate skull
 Crutchfield tongs
 Applied directly to the skull just behind the hairline
 Halo vest: immobilizes and aligns cervical vertebrae;
placed when surgery is done to internally stabilize
fractures and relieve the compression of nerve roots
Figure 29-7
Figure 29-8
Preventing Further Cord Injury
 Special beds and cushions
 Kinetic bed, such as the Roto-Rest bed, continually
rotates the patient from side to side
 Overlay air mattresses: flotation devices placed on
standard hospital beds
 Air-fluidized and flotation beds may be used after the
spine has been stabilized
 Wedge-Stryker frame: canvas and metal frame bed that
may be used to help turn the patient
 Types of cushions include those inflated with air,
flotation devices, and gel pads
Figure 29-9
Preventing Further Cord Injury
 Drug therapy
 Methylprednisolone
 Reduces the damage to the cellular membrane
 Administered within the first 8 hours of injury
 Completely paralyzed patients often regain about 20% of
function
 Partially paralyzed have regained up to 75% of function
Preserving Cord Function
 Early surgical intervention to repair cord damage
 Cord compression by bony fragments, compound
vertebral fractures, and gunshot and stab wounds
 Surgery within the first 24 hours is most desirable
 Laminectomy
 Involves removing all or part of the posterior arch of
the vertebra
 Spinal fusion
 If multiple vertebrae are involved
 Placing a piece of donor bone into area between the
involved vertebrae
Assessment
 Monitor the patient’s level of consciousness, vital
signs, respiratory status, motor and sensory
function, and intake and output
Health History
 Present illness
 Event that brought the patient to the hospital
 Specific injuries incurred in the incident
 Describe pain and other symptoms in detail
Past Medical History
 Other accidents or injuries and chronic illnesses
such as diabetes, hypertension, heart disease,
cancer, or seizure disorder
 Previous hospitalizations and operations
 Obstetric history from female patient
 Identify and record current medications and
allergies
Family History
 Routine family history taken but not considered
specifically relevant to a diagnosis of spinal cord
injury resulting from trauma
Review of Systems
 Skin condition, headache or dizziness, vision
disturbances, hearing impairment or tinnitus,
nasal or ear drainage, dyspnea, nausea and
vomiting, constipation or diarrhea, fecal
incontinence, bladder dysfunction, sexual
dysfunction, and impaired motor and sensory
function
Functional Assessment
 Patient’s self-care abilities
 Patient’s roles and responsibilities as a family
member
 Occupation, hobbies, usual activity pattern, habits,
and diet
 Emotional response to the spinal injury
 Usual coping strategies
 Spiritual beliefs; other sources of support
Physical Examination
 Record the patient’s reported height and weight
 Take vital signs
 Take the temperature
 Level of responsiveness, posture, and
spontaneous movements
 Inspect the skin for lesions
 Evaluate tissue turgor
 Inspect head for lesions and palpate for masses
and swelling
Physical Examination
 Examine pupils for size, equality, reaction to light
 Respiratory effort and breath sounds
 Inspect abdomen; auscultate for bowel sounds
 Inspect extremities for open fractures or abnormal
positions
 Range of motion
 Ability to perceive sharp and dull sensation; use a
dermatome chart
Figure 29-10
Interventions
 Ineffective Breathing Pattern
 Risk for Injury and Disturbed Sensory Perception
 Risk for Autonomic Dysreflexia
 Risk for Disuse Syndrome
 Bowel Incontinence
 Impaired Urinary Elimination
Interventions
 Risk for Infection
 Ineffective Thermoregulation
 Feeding/Dressing/Grooming Self-Care Deficit
 Sexual Dysfunction
 Ineffective Coping
 Ineffective Therapeutic Regimen Management
Rehabilitation
 Activities that assist individual to achieve highest
possible level of self-care and independence
 Well-organized interdisciplinary team that can
address all aspects of function
 Physician, nurse, physical therapist, occupational
therapist, speech therapist, dietitian, social worker,
psychologist, and counselor
 Patient and family must be emotionally and
physically prepared to make adjustments
Rehabilitation
 Team helps the patient accomplish activities of
daily living and self-care and addresses successful
adjustment to social integration and gainful
employment in the workplace
 Although this phase of treatment may take more
than a year, patient, family, and rehabilitation
team can take pride in the realization that a life
can once again be productive and happy
Nursing Care of the
Laminectomy Patient
 Preoperatively
 Assess patient’s vital signs and neurologic status to
establish baselines
 Patient’s understanding of surgical routines
 Tell patient what to expect in the immediate
postoperative period
 Ongoing assessment of neurologic status and on
promoting healing at the operative site
Nursing Care of the
Laminectomy Patient
 Assessment
 Vital signs, neurologic status, and breath sounds
 Frequently assess movement, strength, range of motion,




and ability to localize sensory stimulus
Fluid intake and output
Abdomen for bowel sounds; palpate bladder
Inspect the surgical dressing for bleeding, clear
cerebrospinal fluid drainage, and foul drainage
If the patient has pain, obtain a complete description
Nursing Care of the
Laminectomy Patient
 Interventions
 Risk for Injury
 Ineffective Tissue Perfusion
 Acute Pain
 Impaired Urinary Elimination
 Constipation
 Impaired Physical Mobility
 Deficient Knowledge