Nursing: Central Nervous System Disorders

• Class 19.3, Chapter 48 covers the nursing care of patients with central nervous system disorders, found on pages 963-982 and 988-994.
• Learning outcomes include differentiating signs/symptoms of traumatic brain injury, brain tumors, intracranial surgery, spinal disorders, and spinal cord injury.
• Determine appropriate safety measures for these conditions.
• Identify diagnostic tests for selected CNS disorders.
• Describe brain injuries and appropriate interventions and treatment measures.
• Explain causes, risk factors, and pathophysiology of neurodegenerative disorders like Parkinson's and Huntington's diseases.

Traumatic Brain Injury (TBI)

• Can result from Trauma, which includes hemorrhage, contusion, and laceration.
• Can cause cerebral edema, hyperemia, hydrocephalus, brain herniation, and death.
• Motor Vehicle Accidents (MVA) are the most common cause of TBI, followed by falls, assaults, and sports-related injuries.
• Open head injury involves a penetrating injury, while a closed head injury is non-penetrating.
• Mechanisms of injury include acceleration, deceleration, acceleration-deceleration, and rotational forces.
• Types of injuries include concussion, contusion, subdural and epidural hematoma.
• Diagnosed via CT scan, MRI, and neuropsychological testing.
• Therapeutic interventions involve surgical removal of hematoma and controlling increased ICP via ICP monitoring.
• Increased ICP controlled using osmotic diuretics like Mannitol.
• Mannitol requires monitoring urinary output and mechanical hyperventilation and therapeutic coma may be induced.
• Complications of TBI are brain herniation, diabetes insipidus, acute hydrocephalus, labile vital signs, post-traumatic syndrome, cognitive and personality changes.
• Nursing diagnoses may include ineffective cerebral tissue perfusion, ineffective airway clearance, and ineffective breathing pattern.
• Additional nursing diagnoses: acute confusion, self-care deficit, acute/chronic pain, disturbed sensory perception, impaired physical mobility, and risk for injury.

Brain Tumor

• Pathophysiology involves neoplastic growth in the brain or meninges that can be primary or metastatic.
• Tumors compress/infiltrate brain tissue and cause increased ICP.
• Signs and symptoms: seizures, motor/sensory deficits, headaches, speech/vision disturbances, personality changes, hormone disturbances.
• Diagnosed using MRI, angiogram, magnetic resonance angiogram (MRA), and hormone levels.
• Therapeutic interventions: surgical removal, radiation therapy, chemotherapy, complimentary and alternative therapies and symptom control with anticonvulsants and steroids like Dexamethasone to reduce swelling.
• Complications: seizures, headaches, memory impairment, cognitive changes, ataxia, hemiparesis, aphasia, lethargy, coma, and death.
• Nursing diagnoses: Risk for acute or chronic confusion, self-care deficit (dressing/feeding/toileting), acute or chronic pain, risk for injury secondary to disturbed sensory perception, impaired physical mobility, and risk for injury.

Intracranial Surgery

• Indications: hematoma, tumor, arteriovenous (AV) malformation, trauma, and seizures.
• Types of intracranial surgery include Craniotomy, Craniectomy and Cranioplasty.
• Preoperative care involves patient education, anxiety control, and intensive care unit (ICU) visit.
• Postoperative nursing diagnoses: risk for ineffective cerebral tissue perfusion, risk for infection, disturbed body image, and deficient knowledge.

Herniated Disk

• Pathophysiology: Herniation of nucleus pulposus, compression of nerve root(s).
• Common in the cervical and lumbar regions.
• Etiology: injury or can be unknown.
• Signs and symptoms: pain, muscle spasm, numbness/tingling of extremity, weakness, and atrophy.
• Diagnostic tests are MRI and myelogram.
• Therapeutic interventions: rest, physical therapy, traction, muscle relaxants, NSAIDs/analgesics and epidural anesthetic/steroid injections, surgery.
• Types of surgery: laminectomy, diskectomy, spinal fusion, and artificial disk.
• Complications after surgery are hemorrhage, nerve root damage, reherniation, and herniation of another disk.
• Preoperative care involves routine teaching and instruction on log-rolling technique.
• Postoperative nursing diagnoses are acute pain, impaired urinary elimination, and impaired physical mobility.

Spinal Stenosis

• Spinal canal compresses the spinal cord.
• Arthritis is a major cause.
• Laminectomy is a treatment.

Spinal Cord Injury

• Pathophysiology: damage to nerve fibers interfering with communication between the brain and body.
• Causes: MVA, falls, sports injuries and assault.
• Cervical injury can cause paralysis, paresthesias, impaired respiration, loss of bladder/bowel control and quadriplegia/paresis.
• C3 or above injury could be fatal.
• Thoracic/lumbar injury can cause paraplegia/paresis and altered bowel/bladder control.
• Spinal shock involves sympathetic nervous system (SNS) disruption causing vasodilation, hypotension, bradycardia, hypothermia along with urine and feces retention.
• Complications: infection, DVT, orthostatic hypotension, skin breakdown, renal complications, depression/substance abuse and autonomic dysreflexia, which involves thoracic nerves of the spine or above T6.
• Therapeutic measures include care in the ER and immobilization until assessed.
• Diagnostic tests include X-Ray, CT scan, and MRI.
• Emergency management involves respiratory, gastrointestinal, and genitourinary support and immobilization.
• Surgical management to stabilize spine: halo brace, rods, corset, brace, or body cast
• Skeletal traction is also an intervention and includes Crutchfield tongs and Gardner-Wells tongs.
• Nursing Diagnoses: impaired gas exchange, ineffective airway clearance, risk for autonomic dysreflexia, reflex urinary incontinence, constipation, and impaired physical mobility.
• Additional Nursing Diagnoses: self-care deficit (dressing/feeding/bathing), risk for impaired skin integrity, ineffective role performance, risk for sexual dysfunction and anxiety.

Parkinson’s Disease

• Destruction of substantia nigra, decreased dopamine production, relative excess of acetylcholine, and impairment of semiautomatic movements.
• Etiology can be unknown, genetic, or related to certain drugs or encephalitis.
• Signs and symptoms: muscular rigidity, bradykinesia, changes in posture, pill-rolling tremor, difficulty initiating movement, and shuffling and freezing gait.
• Symptoms of autonomic nervous system (ANS) dysfunction: diaphoresis, constipation, orthostatic hypotension, drooling, dysphagia, seborrhea, and frequent urination.
• Diagnostic tests: history, physical examination, and MRI.
• Therapeutic interventions: dopamine agonists, monoamine oxidase B inhibitors, catechol-O-methyltransferase (COMT) inhibitors, pallidotomy, and deep brain stimulation.
• Dopamine drugs used for parkinsonism are Amantadine, Apomorphine, Bromocriptine (Parlodel), *Carbidopa-levodopa (Sinemet), Entacapone (Comtan), Levodopa (Larodopa), Pramipexole (Mirapex), Ropinirole (Requip), Selegiline (L-Deprenyl, Eldepryl), and Tolcapone (Tasmar).
• Medical Management goals include controlling symptoms with physical therapy and drug therapy.
• Beneficial PT programs: massage, heat, exercise, and gait training and speech therapy include swallowing and speech issues.
• Early in the course of the disease: dopamine receptor agonists, such as Pramipexole (Mirapex) or Ropinirole (Requip) maximize the intrinsic dopamine.
• Nursing diagnoses: impaired physical mobility, self-care deficit (dressing/feeding/toileting/bathing), risk for injury, also diagnoses for dementia.
• Primary focus in Nursing Care is to maintain mobility and prevent injury.
• Assessment: weakness, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements.
• Alert for lack of facial expression, fixed eyes in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, poor balance and coordination.
• As disease progresses: immobility ensues.

Huntington’s Disease

• Pathophysiology/Etiology: Genetic, autosomal dominant and degeneration of parts of the brain.
• Signs and Symptoms: dementia: personality changes, inappropriate behavior, paranoia, and violence.
• Other symptoms: Choreiform Movements, Dysphagia, Depression, and Death.
• Diagnosis: Family history, MRI, CT scan, and Genetic Testing/Counseling.
• Therapeutic Interventions include Antipsychotics, Antidepressants, Antichorea Agents, and Stem Cell Transplants (experimental).
• Nursing Care is provided on an outpatient basis.
• Attention to swallowing difficulty and encouraged to discuss End-of-life care.

Comparison of Parkinson’s Disease and Huntington’s Disease

• Tremors are present in Parkinson's and absent in Huntington's.
• Bradykinesia/akinesia are present in Parkinson's and absent in Huntington's.
• Muscle rigidity is present in Parkinson's and absent in Huntington's.
• Memory dysfunction is late in both diseases.
• Cognitive dysfunction is late in Parkinson's and present in Huntington's.
• Inability to perform ADLs is progressive in both.
• Involuntary movements are absent in Parkinson's and present in Huntington's.
• Depression is present in both.

Practice Analysis Tip

• Licensed practical nurse/licensed vocational nurse (LPN/LVN) roles promote client self-esteem and therapeutic environment.
• Assist in care of cognitively impaired clients, provide care to immobilized clients, evaluate oxygen saturation, and participate in staff education.

Case Study With Concept Map: Mr. Diaz

• Mr. Diaz is a 23-year-old veteran, T4 spinal cord injury from gunfire and complaints being tired.
• Has a fever of 100.4°F (38°C) orally, BP 140/82 (abnormally high for him).
• Reports drinking 10 beers a day and feeling emasculated due to urinary catheter and bowel control issues.
• BUN = 35 mg/dL and creatinine of 1.56 mg/dL.

Case Study for SBAR Hand-Off Report: Mr. Gomez

• 87-year-old gentleman admitted for anorexia due to Parkinson disease with NG tube in place for oral medications.
• Incontinent of bowel, alert/oriented x3.
• The nurse needs to give levodopa dose and initiate tube feedings.
• SBAR Hand-Off Report: Scenario: Mr. Gomez admitted at 1100.
• Background: Parkinson's. Assessment: Admitted anorexia, alert/oriented x3, NG tube in place, stool incontinent.
• Recommendation: Keep head of bed up 30 degrees, give Levodopa due at 1600 via NG tube.

Review Questions

• Post brain tumor removal, padded side rails is the priority nursing intervention.
• In a patient with Parkinson's Disease you expect to see Bradykinesia, depression, and muscle rigidity.
• For cervical spine injury with sudden increase in blood pressure, bladder scan is the priority assessment.