Neurological System Disorders - University of Belize PDF

UNIVERSITY OF BELIZE NEUROLOGICAL SYSTEM DISORDERS NURS3101 – CARE OF THE ADULT POPULATION (ALOC; ICP; SEIZURE DISORDER) WEEK TWELVE BACHELORS OF SCIE...

UNIVERSITY OF BELIZE NEUROLOGICAL SYSTEM DISORDERS NURS3101 – CARE OF THE ADULT POPULATION (ALOC; ICP; SEIZURE DISORDER) WEEK TWELVE BACHELORS OF SCIENCE IN NURSING No. MS. MICHELLE COX HOARE ( 125 MINUTES) Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. LEARNING OBJECTIVES At the end of this session students will be able to: 1. define altered level of consciousness. 2. describe pathophysiology of altered level of consciousness. 3. apply nursing process as a framework for care of clients with altered level of consciousness. 4. identify early and late clinical manifestations of increased intracranial pressure. 5. identify the types and causes of seizures. 6. apply nursing process as a means of caring for the client experiencing seizures. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. INTRODUCTION The human brain requires a constant supply of oxygen an glucose for normal functioning. Interruption in this supply will cause loss of consciousness within a few seconds and may even cause permanent brain damage. The central nervous system (CNS) contains a vast network of neurons that control the body’s vital functions. however this system is vulnerable, and its optimal function depends on several key factors. The neurologic system relies on its structural integrity for support and homeostasis. When this structure becomes disrupted as a result of disease or injury, intracranial hemorrhage, infection or stroke its integrity and homeostasis is affected. When brain tissue expands in the cranium, increase intracranial pressure (ICP) develops and brain perfusion is impaired. This session presents an overview of care of patients with neurological disorders that disrupts the normal functioning of the brain namely: altered level of consciousness (LOC) , patient with increased intracranial pressure (ICP), and the patient experiencing seizures. Seizures are usually clinical manifestation of other neurological disorders or another systemic condition , the pathophysiological changes, clinical manifestations and focus as it relates to nursing management of patients diagnosed with these conditions. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. ALTERED LEVEL OF CONSCIOUSNESS (LOC) An altered level of consciousness (LOC) refers to a change in a patient's state of awareness (ability to relate to self and the environment) and arousal (alertness) – ranging from a state of unconsciousness to hyperarousal. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Pathophysiology The underlying cause of neurologic dysfunction is disruption in the cells of the nervous system, neurotransmitters, or brain anatomy. Disruptions result from cellular edema or other mechanisms, such as disruption of impulse transmission at receptor sites by antibodies. The two hemispheres of the cerebrum must communicate, via an intact corpus callosum, and the lobes of the brain (frontal, parietal, temporal, and occipital) must communicate and coordinate their specific functions. The cerebellum has both excitatory and inhibitory actions and is largely responsible for coordination of movement. The brainstem contains areas that control the heart, respiration, and blood pressure. Impedes transmission within the brain or from brain to other parts of the body. CAUSES Trauma, edema, pressure from tumors, or other mechanisms (toxicologic - drugs; metabolic failure - hepatic, renal, diabetic ketoacidosis), such as an increase or decrease in the circulation of blood or cerebrospinal fluid (CSF). Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Clinical Manifestations As the patient’s state of alertness and consciousness decreases, changes occur in the pupillary response, eye opening response, verbal response, and motor response. - initial alterations in LOC may be reflected by subtle behavioral changes, such as restlessness or increased anxiety. The pupils, normally round and quickly reactive to light, become sluggish (response is slower) - In comatose patients the pupils become fixed (no response to light). - The patient in a coma does not open the eyes to voice or command, respond verbally, or move the extremities in response to a request to do so. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Assessment and Diagnostic Findings A complete assessment is performed, with particular attention to the neurologic system The neurologic examination - evaluation of mental status, cranial nerve function, cerebellar function (balance and coordination), reflexes, and motor and sensory function. - Glasgow Coma Scale - LOC: eye opening, verbal response, and motor response. The patient’s responses are rated on a scale from 3 to 15 A score of 3 (minimum score) indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response A score of 15 (maximum score) indicates that the patient is fully responsive A GCS less than 8 means that the patient cannot protect their own airway - intubate Common diagnostic procedures used to identify the cause of unconsciousness include: - computed tomography (CT) scanning - magnetic resonance imaging (MRI) - electroencephalography (EEG) Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Medical Management First priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. - Oral or nasal intubation, or insertion of a tracheostomy - Mechanical ventilator is used to maintain adequate oxygenation and ventilation - Circulatory status (blood pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain - Intravenous (IV) catheter is inserted to provide access for IV fluids and medications - Neurologic care focuses on the specific neurologic pathology, if known - Nutritional support, via a feeding tube or a gastrostomy tube, is initiated as soon as possible Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. NURSING PROCESS Assessment Assessing the level of consciousness (LOC) - Glasgow Coma Scale (GCS): eye opening; verbal response; motor response Patient’s orientation (x4): person, place, time, and event/situation Assess for alertness measured by the patient’s ability to open the eyes spontaneously or in response to a vocal or noxious stimulus (pressure or pain) Assesses for periorbital edema (swelling around the eyes) or trauma, which may prevent the patient from opening the eyes, and documents any such condition that interferes with eye opening Motor response includes spontaneous, purposeful movement (e.g., the awake patient can move all four extremities with equal strength on command), movement only in response to painful stimuli, or abnormal posturing - Decorticate and flexion (protecting their core) of upper extremities, internal rotation of upper extremities and plantar flexion of the feet - Decerebrate posturing (not protecting their core) extension and outward rotation of upper extremities and plantar flexion of the feet Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize.  Nursing Diagnoses Based on the assessment data, major nursing diagnoses may include the following: Ineffective airway clearance related to altered LOC Risk of injury related to decreased LOC Deficient fluid volume related to inability to take fluids by mouth Risk for imbalanced nutrition: less than body requirements related to inability to ingest nutrients to meet metabolic needs Impaired oral mucous membrane related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake Risk for impaired skin integrity related to prolonged immobility Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Nursing Diagnoses Potential complications may include the following: Respiratory distress or failure Pneumonia Aspiration Pressure ulcer Venous thromboembolism (VTE) Contractures Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Planning and Goals Maintenance of a clear airway Protection from injury Attainment of fluid volume balance Achievement of intact oral mucous membranes Maintenance of normal skin integrity Absence of corneal irritation Attainment of effective thermoregulation Effective urinary elimination Additional goals include bowel continence, restoration of health maintenance, maintenance of intact family or support system, and absence of complications. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Nursing Interventions Maintaining The Airway Protecting The Patient Maintaining Fluid Balance and Managing Nutritional Needs Providing Mouth Care Maintaining Skin and Joint Integrity Preserving Corneal Integrity Maintaining Body Temperature Preventing Urinary Retention; Promoting Bowel Function ; Restoring Health Maintenance; Meeting the Family’s needs. Monitoring and Managing Potential complications. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. INCREASED INTRACRANIAL PRESSURE The rigid cranial vault contains brain tissue (1,400 g), blood (75 mL), and CSF (75 mL). The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP An increase in any one of the components causes a change in the volume of the others CAUSES Increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation. Increased ICP can impede circulation to the brain (decrease cerebral perfusion), impede the absorption of CSF, affect the functioning of nerve cells, and lead to brain stem compression and death. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Pathophysiology Although elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. Increased ICP from any cause decreased cerebral perfusion, stimulates further swelling (edema), and may shift brain tissue, resulting in herniation—a dire and frequently fatal event. Decreased Cerebral Blood Flow - Increased ICP may reduce cerebral blood flow, resulting in ischemia and cell death. - In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. Slow bounding pulse and respiratory irregularities. - These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Cerebral Edema - Cerebral edema or swelling is defined as an abnormal accumulation of water or fluid in the intracellular space, extracellular space, or both, associated with an increase in the volume of brain tissue. As brain tissue swells within the rigid skull, several mechanisms attempt to compensate for the increasing ICP. Herniation - shifting of brain tissue from an area of high pressure to an area of lower pressure A clinical phenomenon known as the Cushing’s response (or Cushing’s reflex) is seen when cerebral blood flow decreases significantly. Ischemia, the vasomotor center triggers an increase in arterial pressure in an effort to overcome the increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure with a widening of the pulse pressure and cardiac slowing. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Clinical Manifestations If ICP increases to the point at which the brain’s ability to adjust has reached its limits, neural function is impaired; this may be manifested at first by clinical changes in LOC and later by abnormal respiratory and vasomotor responses. Restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance. As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication (abnormal flexion of the upper extremities and extension of the lower extremities), decerebration (extreme extension of the upper and lower extremities), or flaccidity. If the coma is profound, with the pupils dilated and fixed and respirations impaired or absent, death is usually inevitable Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Assessment and Diagnostic Findings Assessment 1. Altered level of consciousness, which is the most sensitive and earliest indication of increasing ICP 2. Headache 3. Abnormal respirations 4. Rise in blood pressure with widening pulse pressure 5. Slowing of pulse 6. Elevated temperature 7. Vomiting 8. Pupil changes 9. Late signs of increased ICP include increased systolic blood pressure, widened pulse pressure, and slowed heart rate. 10. Other late signs include changes in motor function from weakness to hemiplegia, a positive Babinski’s reflex, decorticate or decerebrate posturing, and seizures. The most common diagnostic tests are CT scanning and MRI. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Medical Management Increased ICP is a true emergency and must be treated promptly. Invasive monitoring of ICP is an important component of management. Immediate management to relieve increased ICP requires decreasing cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion. When a ventriculostomy or intraventricular catheter monitoring device is used for monitoring ICP, a fine- bore catheter is inserted into a lateral ventricle, preferably in the nondominant hemisphere of the brain (Hickey, 2009). An epidural monitor uses a pneumatic flow sensor to detect ICP. Osmotic diuretics such as mannitol may be administered to dehydrate the brain tissue and reduce cerebral edema. Cardiac output may be manipulated to provide adequate perfusion to the brain. CSF drainage is frequently performed, because the removal of CSF with a ventriculostomy drain can dramatically reduce ICP and restore CPP. Preventing a temperature elevation Arterial blood gases and pulse oximetry are monitored to ensure that systemic oxygenation remains optimal. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Medications for Increased Intracranial Pressure (ICP) Antiseizure ▪ Seizures increase metabolic requirements and cerebral blood flow and volume, thus increasing intracranial pressure (ICP). ▪ Medications may be given prophylactically to prevent seizures. Antipyretics and Muscle Relaxants ▪ Temperature reduction decreases metabolism, cerebral blood flow, and thus ICP. ▪ Antipyretics prevent temperature elevations. ▪ Muscle relaxants prevent shivering. ▪ Blood Pressure Medication ▪ Blood pressure medication may be required to maintain cerebral perfusion at a normal level. ▪ Notify the primary health care provider if the blood pressure range is lower than 100 or higher than 150 mm Hg systolic. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Corticosteroids ▪ Corticosteroids stabilize the cell membrane and reduce leakiness of the bloodbrain barrier. ▪ Corticosteroids decrease cerebral edema. ▪ A histamine blocker may be administered to counteract the excess gastric secretion that occurs with the corticosteroid. ▪ Clients must be withdrawn slowly from corticosteroid therapy to reduce the risk of adrenal crisis. Intravenous Fluids ▪ Fluids are administered intravenously via an infusion pump to control the amount administered. ▪ Infusions are monitored closely because of the risk of promoting additional cerebral edema and fluid overload. Hyperosmotic Agent ▪ A hyperosmotic agent increases intravascular pressure by drawing fluid from the interstitial spaces and from the brain cells. ▪ Monitor renal function. ▪ Diuresis is expected. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Nursing Interventions 1. Monitor respiratory status and prevent hypoxia. 2. Avoid the administration of morphine sulfate to prevent the occurrence of hypoxia. 3. Maintain mechanical ventilation as prescribed; maintaining the PaCO2 at 30 to 35 mm Hg (30 to 35 mm Hg) will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP. 4. Maintain body temperature 5. Prevent shivering, which can increase ICP 6. Decrease environmental stimuli 7. Monitor electrolyte levels and acid–base balance 8. Monitor intake and output 9. Limit fluid intake to 1200 mL/day 10. Instruct the client to avoid straining activities, such as coughing and sneezing 11. Instruct the client to avoid Valsalva’s maneuver Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. SEIZURE DISORDERS Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) that result from sudden excessive discharge from cerebral neurons (Hickey, 2009). Stages of seizures: prodromal (, aura (warning signs that a seizure is imminent), ictus (actual seizure-1-3 mins; > than 5 mins, Status epilepticus) and the post ictus (recovery stage) CLASSIFICATION OF SEIZURES Generalized Seizures Tonic (Stiffening of the body, increase muscle tone) – Clonic (recurrent jerking) Absence seizure; petit mal; hallmark finding is staring; short seconds long Focal Seizures Focal onset aware Focal onset unaware – impaired awareness; motor symptoms (Automatism) Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Pathophysiology The underlying cause is an electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges. The characteristic seizure is a manifestation of this excessive neuronal discharge. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Causes The specific causes of seizures are varied and can be categorized as genetic, due to a structural or metabolic condition, or the cause may be yet unknown (Berg et al., 2010). Causes of seizures include: Cerebrovascular disease Hypoxemia of any cause, including vascular insufficiency Fever (childhood) Head injury Hypertension CNS infections Metabolic and toxic conditions (e.g., renal failure, hyponatremia, hypocalcemia, hypoglycemia, pesticide exposure) Brain tumor Drug and alcohol withdrawal Allergies Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Assessment and Diagnostic Findings A developmental history is taken, including events of pregnancy and childbirth, to seek evidence of preexisting injury. The patient is also questioned about illnesses or head injuries that may have affected the brain. In addition to physical and neurologic evaluations, diagnostic examinations include biochemical, hematologic, and serologic studies. - White cell count : ability to fight infection - Hemoglobin: substance in RBC that Carries oxygen) - MCV - size of the RBCs - Platelet: Which help blood to clot in case of an injury or hemorrhage MRI is used to detect structural lesions such as focal abnormalities, cerebrovascular abnormalities, and cerebral degenerative changes (AANN, 2009). EEG - assists with classifying the type of seizure. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Nursing Management Before and during a seizure, the patient is assessed and the following items are documented: Assess for risk factors Assess for history of seizures (assess stages of seizures; types of seizures they normally have; seizure medication history) Implement seizure precautions Circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional or psychological disturbances; sleep; hyperventilation) Occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or olfactory) First thing the patient does in the seizure Type of movements in the part of the body involved Areas of the body involved (turn back bedding to expose patient) Size of both pupils and whether the eyes are open Whether the eyes or head are turned to one side Presence or absence of automatisms (involuntary motor activity, such as lip smacking or repeated swallowing) Incontinence of urine or stool Duration of each phase of the seizure Do not restrain; Do not insert anything in the patient’s mouth; remove restrictive items Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. After a Seizure After a patient has a seizure, the nurse’s role is to document the events leading to and occurring during and after the seizure and to prevent complications (e.g., aspiration, injury). Maintain a patent airway and prevent aspiration The patient is at risk for hypoxia, vomiting, and pulmonary aspiration. Vital signs Perform Neurological assessment Prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions, and suctioning is performed, if needed. Seizure precautions are maintained, including having available functioning suction equipment with a suction catheter and oral airway. Blood draw for laboratory studies Withhold seizure medications until after blood draw Health Education on Seizures triggers, causes, stages, electrolyte and metabolic issues Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Summary We defined altered level of consciousness. ALOC is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. States of ALOC , Coma, Akinetic mutism and Persistent vegetative state. Level of consciousness is assessed using the GCS. Described pathophysiology of altered level of consciousness. The underlying cause of neurologic dysfunction is disruption in the cells of the nervous system, neurotransmitters, or brain anatomy. Disruptions result from cellular edema or other mechanisms, such as disruption of chemical transmission at receptor sites by antibodies. Inability of the hemispheres in the brain to communicate. ALOC is caused by trauma, edema, pressure from tumors, or other mechanisms (toxicologic - drugs; metabolic failure - hepatic, renal, diabetic ketoacidosis), such as an increase or decrease in the circulation of blood or cerebrospinal fluid (CSF). Applied nursing process as a framework for care of clients with altered level of consciousness. Reviewed the early and late clinical manifestations of increased intracranial pressure. Changes occur in the pupillary response, eye opening response, verbal response, and motor response. Identified the types and causes of seizures. Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) that result from sudden excessive discharge from cerebral neurons (Hickey, 2009). There are different types of seizures based on the level of discharge from cerebral neurons: Tonic-clonic; Myoclonic, and Focal seizures. Nursing Management before and after seizures. Applied the nursing process as a means of caring for the client experiencing seizures. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize. Practice Questions 1. What are the 3 components of the GCS? 2. What is the pathophysiologic changes in ALOC and which are the main clinical manifestations? 3. What are the highest and lowest possible score a patient can receive on the GCS? 4. How should a nurse describe a patient who is drowsy but can be aroused by the nurse? 5. Which GCS is an indication that the patient requires intubation? 6. Which is the action of osmotic diuretics? 7. Which are the classic clinical manifestations in increase intracranial pressure? 8. What are the categorizations as it relates to causes of seizures? 9. List nursing assessments of a patient before and during a seizure? Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize.  REFERENCES Hinkle. J. and Cheever, K.H. (2014). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 13th. Ed. Wolters Kluwer. Lippincott Williams and Wilkins Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize.  The End Recorded Lecture Policy: Students who are unable to attend virtual classes or consultation sessions have the right to download and view recorded lectures and consultation sessions for their personal study only. Lectures recorded for this purpose may not be shared with other people without the consent of the instructor. The recorded lectures may not be published without the express consent of the instructor and without giving proper identity and credit to the instructor. Students who use screen-recording softwares are required to adhere to the recording guidelines stated above. Copyright© 2020 University of Belize. All rights reserved Not to be reproduced or disseminated without permission from the University of Belize.