Nervous-Sensory System (Outline) PDF

8/28/24 NERVOUS SYSTEM DAY 2 CARING FOR CLIENTS WITH CENTRAL AND PERIPHERAL NERVOUS SYSTEM DISORDERS (Meningiti...

8/28/24 NERVOUS SYSTEM DAY 2 CARING FOR CLIENTS WITH CENTRAL AND PERIPHERAL NERVOUS SYSTEM DISORDERS (Meningitis – Huntington Disease) Marian College Vocational Nursing Program Copyright © 2022 Wolters Kluwer · All Rights Reserved 1 Timby’s Introductory Medical– Surgical Nursing, 13e Chapter 37: Caring for Clients With Central and Peripheral Nervous System Disorders Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins 2 1  8/28/24 Increased Intracranial Pressure #1 Discussed on Day 1 Copyright © 2022 Wolters Kluwer · All Rights Reserved 3 Infectious and Inflammatory Disorders of the Nervous System: Meningitis #1 Inflammation of the meninges Causes: Spre ad via DR o Bacterial = Fatal Resp OPLET, irato ry Ro ute o Viral o Staph, Strep o Infection travels to meninges via bloodstream, ear infection, paranasal sinuses o Virus: herpes, mumps, enterovirus o Complications: cerebral coma, seizures, brain abscess, damage to cranial nerves. Copyright © 2022 Wolters Kluwer · All Rights Reserved 4 2  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Meningitis #2 Assessment Findings o Fever o Nausea & vomiting o Photophobia o Petechial rash o Nuchal Rigidity o Opisthotonos o Kernig’s Sign o Brudzinski’s Sign Copyright © 2022 Wolters Kluwer · All Rights Reserved 5 Classic Signs & Symptoms of Meningitis 6 Nuchal Rigidity Copyright © 2022 Wolters Kluwer · All Rights Reserved 6 3  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Meningitis #3 Diagnostic Tests: o LP to check organism (C & S) o CSF Pressure – high o CT scan o Blood culture o CBC Copyright © 2022 Wolters Kluwer · All Rights Reserved 7 Infectious and Inflammatory Disorders of the Nervous System: Meningitis #4 Medical Management: o IVF o ATBs after C & S o Anticonvulsants o For someone exposed: will be put on prophylactic oral Rifampin o For someone NOT exposed yet: Give Hib vaccine o Notify Department of Health Copyright © 2022 Wolters Kluwer · All Rights Reserved 8 4  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Meningitis #5 Nursing Management: o Isolate Client spread through respiratory/droplet route o Check vital signs frequently o Seizure Precautions o Dim Lights o Decrease Noise o Meds for Fever o O2 Therapy o Antibiotics o I&O Copyright © 2022 Wolters Kluwer · All Rights Reserved 9 Infectious and Inflammatory Disorders of the Nervous System: Encephalitis #1 Infection of white and gray matter of Spinal Cord & Brain Causes: o vector-borne viral infections, rubeola (measles), neurotoxic effects associated with childhood vaccination o Bacteria, fungi, virus o Measles o After vaccination o Ticks, Mosquitos o Poisoning o Complications: Cerebral edema, IICP, seizures, shock Copyright © 2022 Wolters Kluwer · All Rights Reserved 10 5  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Encephalitis #2 Assessment Findings: o Sudden fever o Severe headache o Stiff neck o Vomiting o Muscle weakness o Neuro: irritability, drowsiness, lethargy, delirium, coma, tremors, seizures, visual disturbances, spastic or flaccid paralysis Copyright © 2022 Wolters Kluwer · All Rights Reserved 11 Infectious and Inflammatory Disorders of the Nervous System: Encephalitis #3 Diagnostic Findings: o Lumbar puncture: CSF pressure is elevated, but fluid is clear o MRI and CT scan Medical and Nursing Management: o Supportive; symptoms are managed with antipyretics, anticonvulsants, anti-inflammatory drugs, analgesics o Monitor vital signs and LOC o I&O o Assess bowel function o See Client and Family Teaching 37-1 Copyright © 2022 Wolters Kluwer · All Rights Reserved 12 6  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #1 Acute, post-infectious polyneuropathy Affects peripheral nerves and spinal nerve roots Usually after a respiratory or gastrointestinal infection Most clients recover after 1 month Recovery may be slow; takes months to years Death can occur after complications such as pneumonia & infection Copyright © 2022 Wolters Kluwer · All Rights Reserved 13 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #2 Causes: o Unknown o Autoimmune reaction o History of recent vaccination o Increased incidence in clients with lupus erythematosus Copyright © 2022 Wolters Kluwer · All Rights Reserved 14 7  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #3 Signs and Symptoms: o Weakness that progress from the lower extremities upwards o Legs are weak first ! goes up to lungs! o If muscles of respiration are affected = DANGER! o Muscle weakness followed by paralysis o If Cranial nerves are affected: ▪ Chewing, talking, and swallowing may be difficult Copyright © 2022 Wolters Kluwer · All Rights Reserved 15 Signs and Symptoms of Guillain-Barre Syndrome Copyright © 2022 Wolters Kluwer · All Rights Reserved 16 8  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #4 Diagnostic Findings: o Lumbar puncture (Increase CSF pressure) o EEG o EMG Copyright © 2022 Wolters Kluwer · All Rights Reserved 17 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #5 Medical Management: o Plasmapharesis (removal of plasma from the blood) o After removal, reinfusion of cellular components with saline o Some clients improve after plasmapheresis o IVF o NGT (if can not take PO fluids and food) o TPN o Immune globulin (Gamimune N) o ET tube if needed Plasmapharesis Copyright © 2022 Wolters Kluwer · All Rights Reserved 18 9  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Guillain-Barre Syndrome #6 Nursing Management: o Assess signs of respiratory distress o Incentive spirometer o Skin care; change position every 2 hours o ROM exercises to prevent muscle atrophy Copyright © 2022 Wolters Kluwer · All Rights Reserved 19 Infectious and Inflammatory Disorders of the Nervous System: Brain Abscess #1 Infection in nearby structures such as the middle ear, sinuses, or teeth Causes: - Intracranial surgery or head trauma - Bacterial endocarditis - Bacteremia - Secondary to pulmonary or abdominal infections Copyright © 2022 Wolters Kluwer · All Rights Reserved 20 10  8/28/24 Infectious and Inflammatory Disorders of the Nervous System: Brain Abscess #2 Signs and Symptoms: o Increased ICP o Fever, headache o Paralysis | Seizures o Muscle weakness o Lethargy Diagnostic Findings: o WBC count o Lumbar puncture o CT | MRI o Skull radiographs Copyright © 2022 Wolters Kluwer · All Rights Reserved 21 Infectious and Inflammatory Disorders of the Nervous System: Brain Abscess #2 Medical Management o ATBs o Control of fever o Anticonvulsants o Osmotic diuretics o Mechanical ventilation o IV fluids, nutritional support o Surgical Management: Craniotomy Nursing Management See Nursing Care Plan 37-1 o Assessment for altered LOC o Assess changes in sensory and motor functions o Signs of increased ICP o Monitor vital signs | I&O o Same management as meningitis and IICP Copyright © 2022 Wolters Kluwer · All Rights Reserved 22 11  8/28/24 Neuromuscular Disorders: Multiple Sclerosis #1 Chronic, progressive, disease of the peripheral nerves Destruction of myelin sheath resulting in impaired nerve impulse conduction Main cause: Unknown Common: women; young adult & early middle life (20-40 years old) Common: cooler states (North) Copyright © 2022 Wolters Kluwer · All Rights Reserved 23 Neuromuscular Disorders: Multiple Sclerosis #2 Signs and Symptoms: o Has remissions and exacerbations o Eyes: Blurred vision, diplopia, nystagmus o Weakness, clumsiness, and numbness and tingling of an arm or a leg o Intentional tremors o Slurred, hesitant speech o Mood swings o Others: motor incoordination, bowel and bladder incontinence, loss of memory, difficulty concentrating, impaired judgment, pneumonia (leading cause of death) Copyright © 2022 Wolters Kluwer · All Rights Reserved 24 12  8/28/24 Neuromuscular Disorders: Multiple Sclerosis #3 Copyright © 2022 Wolters Kluwer · All Rights Reserved 25 Neuromuscular Disorders: Multiple Sclerosis #4 Diagnostic Findings: o Lumbar puncture and CSF analysis o Electrophoresis of CSF o CT scan o MRI o Diagnostic process may be long, tedious Copyright © 2022 Wolters Kluwer · All Rights Reserved 26 13  8/28/24 Neuromuscular Disorders: Multiple Sclerosis #5 Medical Management: No cure for MS! o Primary treatment: Keep client functional for as long as possible o Medications: ▪ Muscle Relaxants: " Robaxin " Soma Side Effects of Copaxone: " Baclofen - Chest tightness | palpitations - Flushing " Botox *Brief and mild reactions " Copaxone SQ*** *Call 911 if lasting more than 15 minutes Copyright © 2022 Wolters Kluwer · All Rights Reserved 27 27 Neuromuscular Disorders: Multiple Sclerosis #6 Medical Management o Medications: # Tranquilizers # Antibiotics # Steroids # Oxybutynin (Ditropan) – for urinary incontinence # Urecholine (Bethanicol) – for urinary retention Copyright © 2022 Wolters Kluwer · All Rights Reserved 28 28 14  8/28/24 Neuromuscular Disorders: Multiple Sclerosis #7 Nursing Management o Check respiratory function; prevent aspiration o ROM o TCDB o PT/OT o Check skin = turn q 2 o Encourage participation with ADL’s o Check B&B Functioning # Give stool softeners # Indwelling catheter Copyright © 2022 Wolters Kluwer · All Rights Reserved 29 29 Neuromuscular Disorders: Multiple Sclerosis #8 Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to weakening of muscles for respiration o Encourage client to deep breathe several times o Place client in a Fowler position and support the arms Nursing Diagnosis: Impaired Physical Mobility related to diminished muscle strength and inactivity o Provide rest between bathing, eating, and ambulating o Baclofen (Lioresal) and dantrolene (Dantrium) for muscle spasticity and rigidity Copyright © 2022 Wolters Kluwer · All Rights Reserved 30 15  8/28/24 Neuromuscular Disorders: Myasthenia Gravis #1 Neuromuscular disorder characterized by severe weakness of one or more groups of skeletal muscles Impaired transmission of nerve impulses to voluntary, skeletal muscle from a decrease of acetylcholine Causes severe weakness of one or more skeletal muscle groups Unknown cause = AUTOIMMUNE Common in women 20 – 50 years old Copyright © 2022 Wolters Kluwer · All Rights Reserved 31 Neuromuscular Disorders: Myasthenia Gravis #2 Assessment Findings o Most common: PTOSIS (drooping eyelids) o Muscle Weakness o Diplopia o Voice weakness o Dysphagia, difficulty chewing o Mask-like facial expression o Weakness of extremities Myasthenia Crisis: o Profound weakness, resp. distress o Difficulty swallowing, chewing, talking Copyright © 2022 Wolters Kluwer · All Rights Reserved 32 16  8/28/24 Neuromuscular Disorders: Myasthenia Gravis #3 Diagnostic Findings: o Confirmed by IV administration of edrophonium (Tensilon) ▪ Relieves muscular weakness in a few seconds ▪ The restored muscle strength dissipates in minutes o Chest radiography may show an enlargement of the thymus (thymoma) o Electromyography (EMG): measures the electrical potential of muscles Copyright © 2022 Wolters Kluwer · All Rights Reserved 33 Neuromuscular Disorders: Myasthenia Gravis #4 Medical Management o NO CURE o Medications (Anticholinesterase): o Pyridostigmine bromide (Mestinon) o Mytelase o Prostigmine o Neostigmine Copyright © 2022 Wolters Kluwer · All Rights Reserved 34 17  8/28/24 Neuromuscular Disorders: Myasthenia Gravis #5 Medical Management o Surgical removal of tumor (ex. thymus) o Prednisone o Plasmapharesis (if other treatments fail) o ET | intubation (if with respiratory distress) Copyright © 2022 Wolters Kluwer · All Rights Reserved 35 Neuromuscular Disorders: Myasthenia Gravis #6 Nursing Management o Provide periods of rest o Elevate the head of a bed o Suction secretions o Demonstrate patience and empathy to help the client deal with his or her changes in appearance, function, and lifestyle o Give meds on time for therapeutic levels o Check for Cholinergic crisis: - Abdominal pain, clenched jaws - Antidote: Atropine Sulfate Copyright © 2022 Wolters Kluwer · All Rights Reserved 36 18  8/28/24 To Recap… Myasthenia Crisis? What’s happening? ____________ Treatment: __________________ Cholinergic Crisis? What’s happening? _____________ Treatment: ___________________ Copyright © 2022 Wolters Kluwer · All Rights Reserved 37 Neuromuscular Disorders: Amyotrophic Lateral Sclerosis (ALS) #1 Progressive and fatal neurologic disorder Also known as Lou Gehrig’s disease Degeneration of the motor neurons of the spinal cord and brain stem; results in muscle weakness and wasting Causes: o Unknown o Autoimmune o Viral infection Copyright © 2022 Wolters Kluwer · All Rights Reserved 38 19  8/28/24 Neuromuscular Disorders: Amyotrophic Lateral Sclerosis (ALS) #2 Assessment Findings: o Progressive muscle weakness o Wasting of the arms, legs, and trunk o Muscle fasciculations (twitching) o If ALS affects the brain stem—difficulty speaking and swallowing, periods of inappropriate laughter and crying, respiratory failure and total paralysis Diagnostic Findings: o No specific diagnostic tests are available o EMG: validates weakness in the affected muscles Copyright © 2022 Wolters Kluwer · All Rights Reserved 39 Neuromuscular Disorders: Amyotrophic Lateral Sclerosis (ALS) #3 Medical Management: o No specific treatment o In many cases, death occurs several years after diagnosis o Death common after respiratory arrest and infection o Treated with riluzole (Rilutek), which slows the progression of ALS and delays the need for a tracheostomy o Mechanical ventilation Copyright © 2022 Wolters Kluwer · All Rights Reserved 40 20  8/28/24 Neuromuscular Disorders: Amyotrophic Lateral Sclerosis (ALS) #4 Nursing Management: o Prevent respiratory complications o TCDB o ROM o Assist with ADL’s o Encourage participation in ADL’s Copyright © 2022 Wolters Kluwer · All Rights Reserved 41 Cranial Nerve Disorders: Tic Douloureux #1 Also called Trigeminal Neuralgia Painful condition involving the 5th cranial nerve Involves mandibular, maxillary, & ophthalmic areas Affects chewing, facial movement, and sensations Copyright © 2022 Wolters Kluwer · All Rights Reserved 42 21  8/28/24 Cranial Nerve Disorders: Tic Douloureux #2 Causes: o Unknown o Related to compression of the trigeminal nerve root o Attack (pain) occurs: # Changes in temperature # Loud music | vibration # Passing breeze Copyright © 2022 Wolters Kluwer · All Rights Reserved 43 Cranial Nerve Disorders: Tic Douloureux #3 Signs and Symptoms: o Neuralgia (nerve pain) # Sudden, severe, burning pain # Lasts a few seconds to minutes # Cycle repeats many times a day o Twitching of the face o Increase in tears Copyright © 2022 Wolters Kluwer · All Rights Reserved 44 22  8/28/24 Cranial Nerve Disorders: Tic Douloureux #4 Diagnostic Findings: o Skull radiography o MRI | CT scan o Diagnosis based on symptoms Medical Management: o Supportive and symptomatic rather than curative o Narcotic analgesics o Anticonvulsants (Dilantin | Tegretol ) for pain o Referral to a dentist Copyright © 2022 Wolters Kluwer · All Rights Reserved 45 Cranial Nerve Disorders: Tic Douloureux #5 Medical Management: o Surgery if other treatments fail o Complications of surgery: 1. Problems with eating 2. Biting tongue without knowing 3. Food caught in mouth 4. aw deviates to operative side 5. Difficulty swallowing Copyright © 2022 Wolters Kluwer · All Rights Reserved 46 23  8/28/24 Cranial Nerve Disorders: Tic Douloureux #6 Nursing Management: o Check pain including LOCATION o Inspect oral cavity o Avoid extreme change in temperature o Avoid jarring bed, or any vibrations o Teach client: shield face from wind/breeze Copyright © 2022 Wolters Kluwer · All Rights Reserved 47 Cranial Nerve Disorders: Tic Douloureux #7 Client Teaching: o Take small sips or bites o Chew on opposite side o Avoid eating hot foods o Use mouth rinses after eating o Keep regular dental appointments # Tic douloureux can be mistaken as TMD*** Copyright © 2022 Wolters Kluwer · All Rights Reserved 48 24  8/28/24 Cranial Nerve Disorders: Bell’s Palsy #1 Inflammation around the nerve ! blocking motor impulses to facial muscles ! result: weakness and paralysis of facial muscles, including muscles of the eyelids on one side of the face Involves the 7th cranial nerve Affects movement of facial muscles Cause: unknown | viral link is suspected If paralysis doesn’t get better after 3 months, it can become permanent Copyright © 2022 Wolters Kluwer · All Rights Reserved 49 Cranial Nerve Disorders: Bell’s Palsy #2 Signs and Symptoms: o Facial paralysis o Facial pain o Pain behind ear o Numbness o Ptosis of eyelid o Decrease in blink reflex o Tearing on affected side o Difficulty speaking and chewing o Drooling Copyright © 2022 Wolters Kluwer · All Rights Reserved 50 25  8/28/24 Cranial Nerve Disorders: Bell’s Palsy #3 Diagnostic Findings: o Based on symptoms and visual examination of the face Medical Management: o Steroids (short-term) to decrease edema o Anti-viral meds: Zovirax, Flamvir, Valtrex o Analgesics o Vitamin B o Electrotherapy Copyright © 2022 Wolters Kluwer · All Rights Reserved 51 Cranial Nerve Disorders: Bell’s Palsy #4 Nursing Management: o Apply eye patch at night o Irrigate eye with NS o Provide oral hygiene o Encourage dental exams o Assure client: Bell’s palsy is non-progressive Copyright © 2022 Wolters Kluwer · All Rights Reserved 52 26  8/28/24 Extrapyramidal Disorders: Parkinson’s Disease #1 Deficiency of the neurotransmitter dopamine Causes: Unknown Exposure to environmental toxins such as insecticides, herbicides, self-administration of an illegal synthetic form of heroin known as MPTP Other causes: o Sequelae of head injuries and encephalitis o Parkinsonism: cluster of Parkinson-like symptoms o Phenothiazines (category of antipsychotic drugs) Copyright © 2022 Wolters Kluwer · All Rights Reserved 53 Extrapyramidal Disorders: Parkinson’s Disease #2 Signs and Symptoms: o Stiffness (rigidity) o Bradykinesia o Unintentional Tremors o Pill rolling o Masklike expression o Stooped posture o Hypophonia (low volume of speech) o Shuffling gait; difficulty redirecting forward motion Copyright © 2022 Wolters Kluwer · All Rights Reserved 54 27  8/28/24 Extrapyramidal Disorders: Parkinson’s Disease #3 Signs and Symptoms: o ”Cogwheel rigidity” - arms are rigid while walking o Late stage: # Jaw, tongue, larynx, are affected # Slurred speech, chewing & swallowing are affected # Increase in salivation (drooling) # Increase in rigidity (contractures) Copyright © 2022 Wolters Kluwer · All Rights Reserved 55 Extrapyramidal Disorders: Parkinson’s Disease #4 Diagnostic Findings: o No specific tests o Based on typical symptoms and neurologic examination o CT, MRI, EMG o Handwriting analysis to detect fine tremors Copyright © 2022 Wolters Kluwer · All Rights Reserved 56 28  8/28/24 Extrapyramidal Disorders: Parkinson’s Disease #5 Medical Management: o Prolong independence o See Drug Therapy Table 37-1* # Selegiline (Eldepryl) # Levodopa (Larodopa) # Sinemet # Symmetral # Parlodel # Cogentin o Physical therapy, occupational therapy, client and family education; nutritional counseling Copyright © 2022 Wolters Kluwer · All Rights Reserved 57 Extrapyramidal Disorders: Parkinson’s Disease #6 Surgical Management: 1. Stereotaxic Thalamotomy*** - destroys part of the thalamus to decrease excessive muscle contractions (Brain surgery). 2. Fetal Transplant - Brain tissue from aborted fetus is implanted to the recipient - Requires craniotomy - Experimental 3. Brain pacemaker – “shocks” the brain to decrease tremors Copyright © 2022 Wolters Kluwer · All Rights Reserved 58 29  8/28/24 Extrapyramidal Disorders: Parkinson’s Disease #7 Assist with ADLs*: dressing, eating, toileting Evaluate emotional and mental status Always administer medications on time Check medications: Levodopa causes exacerbations when therapeutic level is not maintained Safety measures: prevent falls, aspiration ROM Check skin integrity Check voiding amount & patterns Copyright © 2022 Wolters Kluwer · All Rights Reserved 59 Extrapyramidal Disorders: Huntington’s Disease #1 Hereditary disorder of the CNS Inherited by either sex Portions of brain (esp. cerebral cortex) degenerate In early stage: client is ok: performs ADL’s Late stage: hallucinations, delusions, impaired judgment and increase intensity of abnormal movements Copyright © 2022 Wolters Kluwer · All Rights Reserved 60 30  8/28/24 Extrapyramidal Disorders: Huntington’s Disease #2 Signs and Symptoms: o Occur slowly o Mental apathy o Choreiform Movement – uncontrollable twisting of the body o Grimacing o Dysphagia; difficulty chewing o Speech difficulty o Mental decline o Loss of B & B control o Severe depression = can lead to suicide Copyright © 2022 Wolters Kluwer · All Rights Reserved 61 Choreiform Movements Copyright © 2022 Wolters Kluwer · All Rights Reserved 62 31  8/28/24 Extrapyramidal Disorders: Huntington’s Disease #3 Diagnostic Findings: o Positron emission tomography (PET) o Genetic testing can predict which family members will develop the disease Medical Management: o Treatment is supportive because there is NO CURE o Tranquilizers and anti-Parkinson drugs relieve the choreiform movements o Genetic counseling before a pregnancy is advised Copyright © 2022 Wolters Kluwer · All Rights Reserved 63 Extrapyramidal Disorders: Huntington’s Disease #4 Nursing Management: o Supportive care o Prevent complications: Pneumonia, aspiration of food or fluids, infections, contractures o Assist client & family with ADL’s o Encourage independence when still able o Teach Client: 1. Hold drinking glass with both hands 2. Use a drinking straw 3. Wear slip-on shoes Copyright © 2022 Wolters Kluwer · All Rights Reserved 64 32  8/28/24 References Donnelly-Moreno, L.A. & Moseley, B. (2022). Timby’s Introductory Medical-Surgical Nursing. (13th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins Copyright © 2018 Wolters Kluwer Health | Lippincott Williams & Wilkins 65 33