TARLAC STATE UNIVERSITY - Nervous System Unit PDF

TARLAC STATE UNIVERSITY College of Science | Department of Nursing Unit 7: Nervous System Patient Assessment: Nervous System 1 Prof. EDRMBugayong Neurological History v Chief Complaint o Beg...

TARLAC STATE UNIVERSITY College of Science | Department of Nursing Unit 7: Nervous System Patient Assessment: Nervous System 1 Prof. EDRMBugayong Neurological History v Chief Complaint o Begin by asking the patient to describe their main problem in their own words. o This helps establish the primary concern and sets the direction for further questioning. o Example: "What brings you to the hospital today?" or "What's your main concern?" 2 Neurological History v History of Present Illness o Use the NOPQRST format to analyze the patient's symptoms in detail: Nature: What exactly is the symptom? Onset: When did it start? Was it sudden or gradual? Provocation/Palliation: What makes it better or worse? Quality: How would you describe it? (e.g., sharp, dull, throbbing) Region/Radiation: Where is it? Does it spread anywhere? Severity: On a scale of 1-10, how bad is it? Timing: Is it constant? Intermittent? How long does it last? 3 Neurological History v History of Present Illness o Key neurological symptoms to inquire about: Headaches Balance or coordination Dizziness or vertigo issues Vision changes Memory problems or Hearing changes or tinnitus confusion Speech difficulties Seizures or loss of Swallowing problems consciousness Weakness or paralysis Numbness or tingling 4 Neurological History v Past Medical History o Gather information about: Previous neurological conditions (e.g., strokes, seizures, head injuries) Other medical conditions (e.g., diabetes, hypertension, heart disease) Surgeries, especially those involving the brain or spine Hospitalizations Childhood illnesses and immunizations 5 Neurological History v Medications and Allergies o Current medications (prescription and over-the-counter) o Herbal supplements or alternative therapies o Drug allergies and reactions 6 Neurological History v Family History o Ask about neurological conditions in close relatives, including: Stroke Epilepsy Migraines Dementia Multiple sclerosis Parkinson's disease Other relevant conditions (e.g., cardiovascular disease, diabetes) 7 Neurological History v Social History o Gather information about: Occupation and work environment (potential exposures) Living situation and support system Substance use (alcohol, tobacco, recreational drugs) Diet and exercise habits Sleep patterns Stress levels and coping mechanisms Travel history (relevant for certain infectious diseases) 8 Neurological History v Review of Systems o Briefly review other body systems for related symptoms: General: Fatigue, weight changes HEENT: Visual changes, hearing loss, sinus problems Cardiovascular: Chest pain, palpitations Respiratory: Shortness of breath, cough Gastrointestinal: Nausea, changes in bowel habits Genitourinary: Incontinence, sexual dysfunction Musculoskeletal: Joint pain, muscle weakness Skin: Rashes, changes in skin sensation 9 Neurological Physical Examination v Mental Status Examination o Level of Consciousness Assess using the Glasgow Coma Scale (GCS): ü Eye Opening (E): Spontaneous (4), To speech (3), To pain (2), None (1) ü Verbal Response (V): Oriented (5), Confused (4), Inappropriate words (3), Incomprehensible sounds (2), None (1) ü Motor Response (M): Obeys commands (6), Localizes pain (5), Withdrawal from pain (4), Abnormal flexion (3), Abnormal extension (2), None (1) Total GCS score ranges from 3 (deep coma) to 15 (fully awake and oriented). 10 Neurological Physical Examination v Mental Status Examination o Orientation Assess orientation to person, place, time, and situation. o Attention and Concentration Use tests such as digit span or serial 7s subtraction. o Memory Test immediate recall, recent memory, and long-term memory. 11 Neurological Physical Examination v Mental Status Examination o Language Assess fluency, comprehension, repetition, naming, reading, and writing. o Executive Function Evaluate abstract thinking, judgment, and problem-solving skills. 12 Neurological Physical Examination v Motor Examination o Inspection Observe for muscle atrophy, fasciculations, or abnormal movements. o Tone Assess for normal tone, spasticity, rigidity, or flaccidity. 13 Neurological Physical Examination v Motor Examination o Strength Test major muscle groups using the Medical Research Council (MRC) scale: ü 0: No contraction ü 1: Flicker of contraction ü 2: Active movement with gravity eliminated ü 3: Active movement against gravity ü 4: Active movement against gravity and resistance ü 5: Normal power 14 Neurological Physical Examination v Motor Examination o Coordination Finger-to-nose test Heel-to-shin test Rapid alternating movements Romberg test 15 Neurological Physical Examination v Cranial Nerve Examination o CN I (Olfactory): Test smell in each nostril o CN II (Optic): Check visual acuity and visual fields o CN III, IV, VI (Oculomotor, Trochlear, Abducens): Assess extraocular movements and pupillary reactions o CN V (Trigeminal): Test facial sensation and corneal reflex o CN VII (Facial): Evaluate facial expressions and taste on anterior 2/3 of tongue 16 Neurological Physical Examination v Cranial Nerve Examination o CN VIII (Vestibulocochlear): Assess hearing and balance o CN IX, X (Glossopharyngeal, Vagus): Check gag reflex and voice quality o CN XI (Spinal Accessory): Test shoulder shrug and head turning o CN XII (Hypoglossal): Observe tongue movements 17 Neurological Physical Examination v Reflex Examination o Grading scale: 0: No response 1+: Diminished 2+: Normal 3+: Increased 4+: Very brisk, often with clonus 18 Neurological Physical Examination v Reflex Examination o Deep Tendon Reflexes Test and grade (0-4+) the following reflexes: ü Biceps (C5-C6): § Technique: Place your thumb on the biceps tendon and strike your thumb with the reflex hammer. § Normal response: Flexion of the elbow ü Triceps (C7-C8): § Technique: Strike the triceps tendon above the elbow while supporting the arm. § Normal response: Extension of the elbow 19 Neurological Physical Examination v Reflex Examination o Deep Tendon Reflexes Test and grade (0-4+) the following reflexes: ü Brachioradialis (C5-C6): § Technique: Strike the radius about 10 cm above the wrist. § Normal response: Flexion and slight supination of the forearm ü Patellar (L2-L4): § Technique: Strike the patellar tendon below the kneecap. § Normal response: Extension of the knee 20 Neurological Physical Examination v Reflex Examination o Deep Tendon Reflexes Test and grade (0-4+) the following reflexes: ü Achilles (S1-S2): § Technique: Strike the Achilles tendon while the foot is dorsiflexed. § Normal response: Plantar flexion of the foot 21 Neurological Physical Examination v Reflex Examination o Superficial Reflexes Plantar reflex (Babinski sign): ü Technique: Stroke the lateral aspect of the sole from heel to toe. ü Normal adult response: Plantar flexion of the toes ü Abnormal (positive Babinski): Great toe dorsiflexion with or without fanning of other toes 22 Neurological Physical Examination v Reflex Examination o Superficial Reflexes Abdominal reflexes: ü Technique: Lightly stroke the abdominal skin toward the umbilicus in all four quadrants. ü Normal response: Contraction of abdominal muscles, causing umbilicus to move toward the stimulated area 23 Neurological Physical Examination v Reflex Examination o Pathological Reflexes Clonus: ü Technique: Quickly dorsiflex the foot and hold. ü Abnormal response: Rhythmic oscillation of the foot Hoffman's sign: ü Technique: Flick the nail of the middle finger downward. ü Abnormal response: Flexion and adduction of the thumb and/or flexion of other fingers 24 Neurological Physical Examination v Sensory Examination o Test the following sensory modalities bilaterally: Light touch: ü Use a cotton wisp or tissue and lightly touch various dermatomes. ü Ask patient to indicate when they feel the touch. Pain (pinprick): ü Use a sterile pin or broken tongue depressor. ü Ask patient to distinguish between sharp and dull sensations. 25 Neurological Physical Examination v Sensory Examination o Test the following sensory modalities bilaterally: Temperature: ü Use tubes of hot and cold water or thermal discs. ü Ask patient to identify hot vs. cold. Vibration: ü Use a 128 Hz tuning fork on bony prominences. ü Ask patient to indicate when vibration starts and stops. 26 Neurological Physical Examination v Sensory Examination o Test the following sensory modalities bilaterally: Proprioception: ü Move the patient's finger or toe up or down. ü Ask patient to identify the direction of movement. Two-point discrimination: ü Use calipers or a bent paperclip. ü Determine the minimal distance at which two points can be distinguished. 27 Neurological Physical Examination v Gait and Station o Observe normal gait: Watch patient walk, noting stride length, arm swing, stability, and any abnormalities. o Test tandem gait: Ask patient to walk heel-to-toe in a straight line. Observe for balance and coordination. o Assess ability to stand on toes and heels: Ask patient to stand on tiptoes, then on heels. Observe for strength and balance. 28 Neurological Physical Examination v Meningeal Signs o Nuchal rigidity: Flex the patient's neck while they're supine. Resistance or pain indicates a positive sign. o Kernig's sign: Flex the patient's hip and knee to 90 degrees, then attempt to extend the knee. Pain or resistance indicates a positive sign. o Brudzinski's sign: Flex the patient's neck while they're supine. Involuntary flexion of hips and knees indicates a positive sign. 29 Neurological Physical Examination v Autonomic Function o Check for orthostatic hypotension: Measure blood pressure and pulse lying down, then standing. A drop in systolic BP >20 mmHg or diastolic BP >10 mmHg upon standing is significant. o Assess sweating patterns: Observe for excessive or absent sweating in specific areas. Can use starch-iodine test for more detailed assessment. 30 Neurological Physical Examination v Additional Neurological Tests o Pronator drift test: Ask patient to extend arms forward with palms up and eyes closed. Watch for downward drift or pronation of one arm. o Dix-Hallpike maneuver for vertigo: Quickly move patient from sitting to lying with head extended and turned to one side. Observe for nystagmus or vertigo. 31 Neurological Physical Examination v Additional Neurological Tests o Cerebellar function tests: Finger-to-finger test: Patient alternately touches their nose and the examiner's finger. Rapid alternating movements: Patient quickly pronates and supinates hands on thighs. Heel-to-shin test: Patient slides heel down opposite shin. 32 Neurological Physical Examination v Vital Signs in Neurological Assessment o Blood Pressure: Monitor for hypertension (Cushing's response) or hypotension o Heart Rate: Watch for bradycardia (increased ICP) or tachycardia o Respiratory Rate and Pattern: Note abnormal patterns (e.g., Cheyne- Stokes respiration) o Temperature: Assess for fever (infection) or hypothermia (brainstem dysfunction) 33 Neurological Physical Examination v Signs of Increased Intracranial Pressure (ICP) o Decreased level of consciousness o Pupillary changes (sluggish or fixed dilated pupils) o Cushing's triad (hypertension, bradycardia, irregular respirations) o Focal neurological deficits o Papilledema (on fundoscopic exam) 34 Neurological Physical Examination v Documentation o Clearly document all findings, noting: Positive and negative results Symmetry or asymmetry of findings Any limitations in performing the exam Changes from previous examinations 35 Impact of Neurological Dysfunction on Patient's Living Patterns v Importance of Functional Evaluation o Provides a holistic view of the patient's condition o Helps set realistic goals for treatment and rehabilitation o Guides the development of patient-centered care plans o Assists in determining the need for additional support or resources o Facilitates communication with patients, families, and other healthcare providers about the practical implications of the neurological condition 36 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Activities of Daily Living (ADLs) Bathing ü Can the patient bathe independently? ü Are there safety concerns (e.g., risk of falls)? Dressing ü Can the patient dress themselves? ü Are there issues with buttons, zippers, or shoe laces? Eating ü Can the patient feed themselves? ü Are there swallowing difficulties? 37 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Activities of Daily Living (ADLs) Toileting ü Can the patient use the toilet independently? ü Is there incontinence? Mobility ü Can the patient walk independently? ü Is there a need for assistive devices? 38 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Instrumental Activities of Daily Living (IADLs) Cooking ü Can the patient prepare meals safely? ü Are there concerns about using appliances? Cleaning ü Can the patient maintain their living space? ü Are there safety concerns with cleaning tasks? Shopping ü Can the patient shop for necessities? ü Are there issues with transportation or carrying items? 39 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Instrumental Activities of Daily Living (IADLs) Managing medications ü Can the patient take medications as prescribed? ü Are there cognitive issues affecting medication management? Handling finances ü Can the patient manage their money and pay bills? ü Are there concerns about financial decision-making? 40 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Work or School Performance Can the patient continue in their current job or educational program? Are accommodations needed? Is retraining or a career change necessary? 41 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Social Interactions and Relationships How has the neurological condition affected relationships with family and friends? Are there communication difficulties impacting social interactions? Has there been a change in the patient's ability to participate in social activities? 42 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Hobbies and Leisure Activities Can the patient continue to engage in previous hobbies? Are there new limitations on leisure activities? Is there a need to explore alternative recreational options? 43 Impact of Neurological Dysfunction on Patient's Living Patterns v Areas to Evaluate o Emotional and Psychological Well-being Has the neurological condition led to anxiety or depression? Are there changes in the patient's self-image or self-esteem? How is the patient coping with changes in their abilities? 44 Impact of Neurological Dysfunction on Patient's Living Patterns v Assessment Techniques o Patient Interviews Use open-ended questions to encourage detailed responses Ask about a typical day and any challenges encountered Inquire about changes in routine since the onset of neurological symptoms o Observation Watch the patient perform tasks when possible Note any compensatory strategies the patient has developed Assess safety during task performance 45 Impact of Neurological Dysfunction on Patient's Living Patterns v Assessment Techniques o Family/Caregiver Reports Gather information from those who see the patient in their home environment Ask about changes in the patient's abilities and behaviors Inquire about the level of assistance required o Standardized Assessment Tools Barthel Index for ADLs Lawton-Brody IADL Scale Functional Independence Measure (FIM) Quality of Life in Neurological Disorders (Neuro-QoL) 46 Impact of Neurological Dysfunction on Patient's Living Patterns v Incorporating Findings into Care Planning o Identify areas where the patient needs additional support or intervention o Set realistic, patient-centered goals based on functional abilities and limitations o Develop interventions that address specific functional challenges o Consider referrals to other healthcare professionals (e.g., occupational therapy, physical therapy, speech therapy) o Educate patients and caregivers about adaptive strategies and assistive devices o Plan for regular reassessment of functional status 47 Neurodiagnostic Studies v Neuroradiologic Techniques o Computed Tomography (CT) Purpose: Rapid imaging of brain and skull structures Indications: Trauma, suspected hemorrhage, tumors, stroke Procedure: ü Patient lies still on table while x-ray beams rotate around head ü Images are computer-reconstructed to show "slices" of brain 48 Neurodiagnostic Studies v Neuroradiologic Techniques o Computed Tomography (CT) Nursing Implications: ü Educate patient about need to remain still ü Remove metal objects from scan area ü Monitor for allergic reactions if contrast is used ü Ensure proper positioning, especially for trauma patients 49 Neurodiagnostic Studies v Neuroradiologic Techniques o Magnetic Resonance Imaging (MRI) Purpose: Detailed imaging of brain and spinal cord structures Indications: Suspected tumors, inflammatory conditions, demyelinating disorders Procedure: ü Patient lies in cylindrical machine generating strong magnetic field ü Radio waves are used to produce detailed images 50 Neurodiagnostic Studies v Neuroradiologic Techniques o Magnetic Resonance Imaging (MRI) Nursing Implications: ü Screen for metal implants or devices (pacemakers, aneurysm clips) ü Provide ear protection due to loud noise ü Manage claustrophobia with education or sedation if necessary ü Ensure patient safety with MRI-compatible equipment 51 Neurodiagnostic Studies v Neuroradiologic Techniques o Positron Emission Tomography (PET) and Single-Photon Emission Computed Tomography (SPECT) Purpose: Imaging of brain metabolism and blood flow Indications: Alzheimer's disease, epilepsy, brain tumors Procedure: ü Radioactive tracer is injected or inhaled ü Special cameras detect tracer distribution in brain 52 Neurodiagnostic Studies v Neuroradiologic Techniques o Positron Emission Tomography (PET) and Single-Photon Emission Computed Tomography (SPECT) Nursing Implications: ü Educate about radioactive tracer and safety precautions ü Monitor for allergic reactions to tracer ü Ensure proper hydration to aid tracer elimination 53 Neurodiagnostic Studies v Angiography and Digital Subtraction Angiography o Purpose: Detailed imaging of blood vessels o Indications: Suspected aneurysms, arteriovenous malformations, vascular occlusions o Procedure: Catheter inserted into artery (usually femoral) Contrast dye injected while x-rays are taken 54 Neurodiagnostic Studies v Angiography and Digital Subtraction Angiography o Nursing Implications: Monitor insertion site for bleeding or hematoma Assess distal pulses and circulation Maintain flat bed rest as ordered post-procedure Monitor for signs of allergic reaction to contrast 55 Neurodiagnostic Studies v Cerebral Blood Flow Studies o Purpose: Evaluate blood flow to brain regions o Indications: Suspected stroke, vasospasm, brain death evaluation o Procedures: Radioisotope brain scan Perfusion CT o Nursing Implications: Educate about radioactive tracer for isotope studies Monitor for allergic reactions Ensure proper positioning during scans 56 Neurodiagnostic Studies v Myelography o Purpose: Imaging of spinal cord and surrounding structures o Indications: Suspected herniated disks, spinal cord compression, tumors o Procedure: Contrast dye injected into subarachnoid space via lumbar puncture X-rays or CT scans taken as dye flows through spinal canal 57 Neurodiagnostic Studies v Myelography o Nursing Implications: Position patient properly during and after procedure Monitor for headache, nausea, or signs of increased intracranial pressure Encourage fluid intake to replace CSF and eliminate contrast 58 Neurodiagnostic Studies v Ultrasonography and Noninvasive Cerebrovascular Studies o Transcranial Doppler Purpose: Measure blood flow velocity in cerebral arteries Indications: Suspected vasospasm, monitoring after subarachnoid hemorrhage Procedure: ü Ultrasound probe placed on specific areas of skull ü Sound waves measure blood flow velocity 59 Neurodiagnostic Studies v Ultrasonography and Noninvasive Cerebrovascular Studies o Transcranial Doppler Nursing Implications: ü Assist with proper patient positioning ü Ensure stillness during examination ü No special aftercare required 60 Neurodiagnostic Studies v Ultrasonography and Noninvasive Cerebrovascular Studies o Carotid Duplex Scan Purpose: Evaluate blood flow in carotid arteries Indications: Suspected carotid stenosis, stroke risk assessment Procedure: ü Ultrasound probe moved over neck area ü Images and Doppler waveforms analyzed Nursing Implications: ü Position patient with neck slightly extended ü No special preparation or aftercare required 61 Neurodiagnostic Studies v Electrophysiologic Studies o Electroencephalography (EEG) Purpose: Record electrical activity of brain Indications: Seizure disorders, altered mental status, brain death evaluation Procedure: ü Electrodes placed on scalp ü Brain wave patterns recorded for specified time 62 Neurodiagnostic Studies v Electrophysiologic Studies o Electroencephalography (EEG) Nursing Implications: ü Ensure scalp is clean and free of oils ü Assist patient in staying still and relaxed ü Note any medications that may affect results 63 Neurodiagnostic Studies v Electrophysiologic Studies o Evoked Potentials Purpose: Measure brain's response to specific sensory stimuli Types: Visual (VEP), Auditory (BAEP), Somatosensory (SSEP) Procedure: ü Electrodes placed on scalp and specific stimuli presented ü Brain's electrical response recorded and analyzed Nursing Implications: ü Explain procedure and importance of patient cooperation ü Ensure proper functioning of stimuli (visual, auditory, or sensory) ü Monitor patient comfort during prolonged testing 64 Neurodiagnostic Studies v Lumbar Puncture for Cerebrospinal Fluid Examination o Purpose: Obtain CSF for analysis, measure intracranial pressure o Indications: Suspected meningitis, subarachnoid hemorrhage, multiple sclerosis o Procedure: Patient positioned in lateral recumbent or sitting position Needle inserted between L3-L4 or L4-L5 vertebrae CSF collected and pressure measured 65 Neurodiagnostic Studies v Lumbar Puncture for Cerebrospinal Fluid Examination o Nursing Implications: Assist with proper patient positioning Monitor for post-procedure headache, bleeding, or signs of infection Encourage fluid intake and bed rest as ordered Contraindicated in patients with increased intracranial pressure 66 Neurodiagnostic Studies v General Nursing Considerations for Neurodiagnostic Studies o Patient Education: Explain purpose and procedure of test Discuss any necessary preparations Address patient concerns and anxiety o Safety: Verify patient identity and consent Check for contraindications (allergies, implants, pregnancy) Ensure proper positioning and support 67 Neurodiagnostic Studies v General Nursing Considerations for Neurodiagnostic Studies o Monitoring: Assess vital signs before, during, and after procedures as appropriate Monitor neurological status, especially for invasive procedures Watch for signs of allergic reactions or complications 68 Neurodiagnostic Studies v General Nursing Considerations for Neurodiagnostic Studies o Documentation: Record patient's tolerance of procedure Note any complications or unexpected events Document post-procedure care and patient education provided o Follow-up: Communicate results to healthcare team Assist in coordinating any necessary follow-up care or additional tests 69 Critical Thinking Question No. 01 v A 68-year-old patient is admitted to the neurology unit with complaints of dizziness and difficulty walking. During the neurological examination, you want to assess the patient's cerebellar function. Which of the following tests would be most appropriate? A. Babinski reflex test B. Finger-to-nose test C. Rinne test D. Homonymous hemianopsia test 70 Critical Thinking Question No. 01 v Correct Answer: B) Finger-to-nose test v Feedback: o The finger-to-nose test is an appropriate assessment of cerebellar function. It tests coordination and can reveal ataxia or dysmetria, which are signs of cerebellar dysfunction. 71 Critical Thinking Question No. 02 v A 45-year-old patient presents to the emergency department with sudden onset of right-sided weakness and slurred speech. During the neurological examination, you notice that the patient's right pupil is dilated and non-reactive to light, while the left pupil is normal. What is the most likely explanation for this finding? A. Left-sided ischemic stroke B. Right-sided ischemic stroke C. Uncal herniation compressing the left oculomotor nerve D. Uncal herniation compressing the right oculomotor nerve 72 Critical Thinking Question No. 02 v Correct Answer: C) Uncal herniation compressing the left oculomotor nerve v Feedback: o Uncal herniation on the left side can compress the left oculomotor nerve (CN III), which innervates the pupillary constrictors. This compression results in an ipsilateral dilated and non-reactive pupil (in this case, the right pupil). The right-sided weakness and slurred speech suggest a left-sided brain lesion, which could be causing the herniation. 73 Critical Thinking Question No. 03 v You are caring for a patient who experienced a severe traumatic brain injury 24 hours ago. The patient's Glasgow Coma Scale (GCS) score has decreased from 12 to 8 over the past 4 hours. The patient's blood pressure has increased from 120/80 to 160/90 mmHg, heart rate has decreased from 80 to 60 bpm, and respiratory rate has become irregular. Based on these findings, what is the most appropriate next step in management? A. Administer mannitol to reduce intracranial pressure B. Perform a stat CT scan of the head C. Initiate mechanical ventilation D. Administer a sedative to control agitation 74 Critical Thinking Question No. 03 v Correct Answer: B) Perform a stat CT scan of the head v Feedback: o The patient's declining GCS score and the presence of Cushing's triad (increased systolic blood pressure, bradycardia, and irregular respirations) strongly suggest increasing intracranial pressure. A stat CT scan is the most appropriate next step to identify the cause of the increased ICP (e.g., expanding hematoma, cerebral edema) and guide further management. 75 Do you have any questions? Thank you for the time and attention!  TARLAC STATE UNIVERSITY College of Science | Department of Nursing Unit 7: Nervous System Patient Management: Nervous System 1 Prof. EDRMBugayong Physiologic Principles of Intracranial Pressure v Intracranial Dynamics o Monro-Kellie Doctrine Skull is a rigid, non-expansile space Intracranial contents: ü Brain tissue (80% water) ü Blood in vessels (3-10%) ü Cerebrospinal fluid (CSF) (8-12%) Total intracranial volume must remain constant ü Increase in one component requires decrease in others o Normal ICP: 0-15 mm Hg Intracranial hypertension: ICP > 20-25 mm Hg 2 Physiologic Principles of Intracranial Pressure v Cerebral Blood Flow (CBF) o Autoregulation Definition: Brain's ability to maintain constant blood flow despite changes in perfusion pressure Normal CBF: ~750 mL/min (15-20% of cardiac output at rest) Functional range: ü Cerebral Perfusion Pressure (CPP) > 60 mm Hg ü Mean Arterial Pressure (MAP) < 160 mm Hg ü Systolic pressure: 60-140 mm Hg ü ICP < 30 mm Hg 3 Physiologic Principles of Intracranial Pressure v Cerebral Blood Flow (CBF) o Factors affecting autoregulation: Hypoxia Hypercapnia Brain trauma 4 Physiologic Principles of Intracranial Pressure v Cerebrospinal Fluid (CSF) Circulation o Production: Primarily in choroid plexus of ventricles o Circulation: Closed system through ventricles and subarachnoid space o Absorption: Primarily by arachnoid villi into venous system o Potential disturbances: Overproduction Obstruction of circulation (obstructive hydrocephalus) Impaired absorption (communicating hydrocephalus) 5 Physiologic Principles of Intracranial Pressure v Volume-Pressure Relationship o Intracranial compliance: Ability to change volume related to pressure change o Volume-pressure curve Initial phase: Small volume increase, minimal ICP change Decompensation phase: Small volume increase, large ICP change 6 Physiologic Principles of Intracranial Pressure v Cerebral Perfusion Pressure (CPP) o Definition: Blood pressure gradient across the brain o Calculation: CPP = MAP - ICP o Optimal range: 60-100 mm Hg < 60 mm Hg: Risk of inadequate perfusion 100 mm Hg: Risk of hyperperfusion and increased ICP 7 Physiologic Principles of Intracranial Pressure v Cerebral Edema o Types: Vasogenic edema ü Disruption of blood-brain barrier ü Fluid and protein leak into extracellular space ü Affects primarily white matter Cytotoxic edema ü Swelling of neurons and endothelial cells ü Increases intracellular fluid ü Affects primarily gray matter 8 Physiologic Principles of Intracranial Pressure v Herniation o Definition: Displacement of brain tissue through rigid openings in skull or dura o Caused by: Increased ICP, mass effect o Types: Transtentorial, uncal, subfalcine, tonsillar 9 Physiologic Principles of Intracranial Pressure v ICP Waveforms o Normal waveform components: P1 (percussion wave) P2 (tidal wave) P3 (dicrotic wave) o Abnormal waveforms: A waves (plateau waves): Indicate decreased intracranial compliance B waves: Associated with changes in respiration C waves: Related to blood pressure changes 10 Intracranial Pressure Monitoring v Indications for ICP Monitoring o Severe brain injury (Glasgow Coma Scale score 3-8) o Abnormal CT scan findings: Hematoma Contusion Edema Compressed basal cisterns 11 Intracranial Pressure Monitoring v Indications for ICP Monitoring o Normal CT scan with two or more of: Age > 40 years Motor posturing Systolic blood pressure < 90 mm Hg o Other conditions: Subarachnoid hemorrhage Intracerebral hemorrhage Large ischemic infarction Hydrocephalus 12 Intracranial Pressure Monitoring v ICP Monitoring Devices o Intraventricular Catheters (IVCs) Gold standard for accuracy Allows CSF drainage Risks: infection, hemorrhage o Fiberoptic Monitors Versatile placement options No need for transducer adjustment Cannot be recalibrated once placed 13 Intracranial Pressure Monitoring v ICP Monitoring Devices o Parenchymal Monitors Easy insertion Low infection risk Cannot drain CSF o Subarachnoid Monitors Simple for single readings Lower infection risk Contraindicated with increased ICP 14 Intracranial Pressure Monitoring v ICP Monitoring Devices o Subdural Monitors Easy insertion Risk of serious infection o Epidural Monitors Low infection risk Less accurate than intradural measurements 15 Intracranial Pressure Monitoring v Complications of ICP Monitoring o Infection Risk varies by device type Higher with longer monitoring duration o Hemorrhage 1.1% to 2.8% risk for hematoma formation 16 Intracranial Pressure Monitoring v Complications of ICP Monitoring o Malfunction or obstruction 6% to 10% for IVCs 9% to 40% for parenchymal devices o Measurement drift (for some devices) 17 Intracranial Pressure Monitoring v ICP Waveforms o Normal waveform components: P1 (percussion wave): Reflects arterial pulsations P2 (tidal wave): Reflects intracranial compliance P3 (dicrotic wave): Follows dicrotic notch 18 Intracranial Pressure Monitoring v ICP Waveforms o Abnormal waveforms: A waves (plateau waves) ü Indicate decreased intracranial compliance ü Rapid increases of 50-200 mm Hg ü Last 5-20 minutes 19 Intracranial Pressure Monitoring v ICP Waveforms o Abnormal waveforms: B waves ü Small, rhythmic waves up to 50 mm Hg ü Frequency: 0.5-2 per minute ü Related to respiration 20 Intracranial Pressure Monitoring v ICP Waveforms o Abnormal waveforms: C waves ü Small, rhythmic waves up to 20 mm Hg ü Frequency: ~6 per minute ü Related to blood pressure 21 Intracranial Pressure Monitoring v ICP Measurements o Normal range: 0-15 mm Hg o Intracranial hypertension: > 20-25 mm Hg o Critical level: > 60 mm Hg (usually fatal) 22 Intracranial Pressure Monitoring v Multimodal Monitoring o Transcranial Doppler Ultrasound Assesses intracranial circulation non-invasively Measures flow velocity in cerebral arteries o Near-Infrared Spectroscopy (NIRS) Measures regional brain oxygenation Non-invasive, continuous monitoring 23 Intracranial Pressure Monitoring v Multimodal Monitoring o Brain Tissue Oxygenation Probes Measures local oxygen levels in brain tissue Requires insertion into brain parenchyma o Microdialysis Measures local metabolic biomarkers Requires insertion of a microdialysis catheter 24 Intracranial Pressure Monitoring v Nursing Considerations o Proper positioning of transducers o Regular calibration and zeroing of devices o Strict infection control measures o Vigilant monitoring for complications o Accurate documentation of ICP readings and waveforms o Integration of ICP data with other clinical parameters o Proper patient positioning (head elevation, neutral neck alignment) o Management of environmental stimuli to prevent ICP spikes 25 Management of Increased Intracranial Pressure v Treatment Goals o Reduce ICP o Optimize cerebral perfusion pressure (CPP) o Maintain adequate tissue oxygenation o Avoid brain herniation 26 Management of Increased Intracranial Pressure v First-Tier Therapies o Hyperosmolar Therapy Hypertonic Saline ü Concentrations: 2% to 23.4% ü Administration: Bolus or continuous infusion ü Mechanism: Increases plasma osmolarity, draws fluid from brain tissue ü Target: Serum sodium up to 320 mEq/L ü Caution: Risk of osmotic demyelination syndrome 27 Management of Increased Intracranial Pressure v First-Tier Therapies o Hyperosmolar Therapy Mannitol ü Dosage: 0.25 to 2 g/kg body weight ü Administration: IV bolus over 10-30 minutes ü Mechanism: Reduces blood viscosity, increases CBF ü Monitoring: Serum osmolarity (target < 320 mOsm) ü Caution: Risk of acute tubular necrosis at high doses 28 Management of Increased Intracranial Pressure v First-Tier Therapies o Respiratory Support Normocapnia: Essential for stable ICP Hyperventilation ü Use: Temporary strategy for malignant ICP ü Mechanism: Decreases PaCO2, causes cerebral vasoconstriction ü Caution: Avoid prophylactic use (PaCO2 < 35 mm Hg) in first 24 hours post-injury ü Severe hyperventilation (PaCO2 < 25 mm Hg): Reserved for refractory cases 29 Management of Increased Intracranial Pressure v First-Tier Therapies o Pharmacologic Therapy Analgesics (Opioids) ü Agents: Fentanyl, morphine ü Benefits: Pain control, facilitates mechanical ventilation ü Monitoring: Vital signs, pulse oximetry ü Caution: Respiratory depression, decreased GI motility 30 Management of Increased Intracranial Pressure v First-Tier Therapies o Pharmacologic Therapy Sedatives (Benzodiazepines) ü Agents: Midazolam, diazepam, lorazepam ü Benefits: Anxiety reduction, potentiation of analgesics ü Monitoring: Sedation scale, vital signs ü Caution: Respiratory depression, hypotension 31 Management of Increased Intracranial Pressure v First-Tier Therapies o Pharmacologic Therapy Anesthetics ü Propofol § Benefits: Easily titrated, short half-life § Caution: Hypotension, propofol infusion syndrome with prolonged use ü Dexmedetomidine § Benefits: Sedation without respiratory depression § Caution: Hypotension 32 Management of Increased Intracranial Pressure v First-Tier Therapies o Blood Pressure Management Goal: Maintain adequate CPP (60-100 mm Hg) Hypertension management ü Agents: Hydralazine, labetalol, nicardipine, nitroprusside ü Target: Systolic BP < 185 mm Hg, diastolic BP < 110 mm Hg in acute ischemic stroke ü Caution: Avoid rapid BP reduction 33 Management of Increased Intracranial Pressure v First-Tier Therapies o Seizure Prophylaxis Agents: Phenytoin, levetiracetam, lacosamide Duration: Typically 7 days post-injury Acute seizure treatment: Lorazepam 34 Management of Increased Intracranial Pressure v Second-Tier Therapies o Barbiturate Coma Indications: Severe, refractory elevated ICP Monitoring: ICP, blood pressure, EEG (target: burst suppression) Duration: Typically < 72 hours Caution: Hypotension, prolonged recovery 35 Management of Increased Intracranial Pressure v Second-Tier Therapies o Therapeutic Hypothermia Target temperature: Not firmly established Benefits: Reduces brain's metabolic demands Challenges: Preventing shivering, which can raise ICP 36 Management of Increased Intracranial Pressure v Second-Tier Therapies o Decompressive Craniectomy Procedure: Removal of large skull flap Indications: ü Malignant cerebral edema in ischemic stroke (patients < 60 years) ü Refractory intracranial hypertension in traumatic brain injury ü Cerebellar infarction with swelling Timing: Debated, but early intervention may be beneficial in some cases 37 Management of Increased Intracranial Pressure v Monitoring and Adjustment o Regular assessment of ICP, CPP, and neurological status o Titration of therapies based on patient response o Escalation to second-tier therapies when first-tier interventions are insufficient 38 Patient Care Considerations for Increased ICP v Positioning o Head of bed elevation Maintain at 30 degrees unless contraindicated Promotes venous drainage and decreases ICP o Head and neck alignment Keep in neutral position Avoid extreme flexion, extension, or rotation o Body alignment Avoid hip flexion greater than 90 degrees Reduces intra-abdominal and intrathoracic pressures 39 Patient Care Considerations for Increased ICP v Ventilation and Oxygenation o Assess respiratory patterns and rate regularly o Suctioning technique Preoxygenate with 100% O2 Limit to 1-2 catheter passes No more than 10 seconds per insertion Prevents increased CO2 and excessive coughing o Monitor continuous pulse oximetry and blood gases o Maintain normocapnia (PaCO2 35-40 mmHg) 40 Patient Care Considerations for Increased ICP v Neurological Assessment o Establish baseline neurological status Perform at the beginning of each shift Include mental status, pupil assessment, and motor function o Monitor for subtle changes from baseline o Review ordered parameters for physician notification o Familiarize with emergency algorithms for neurological deterioration 41 Patient Care Considerations for Increased ICP v Hemodynamic Monitoring o Regularly assess vital signs Pay attention to trends in blood pressure Mean Arterial Pressure (MAP) directly affects Cerebral Perfusion Pressure (CPP) o Monitor for Cushing's triad: Increased pulse pressure Bradycardia Irregular respiration 42 Patient Care Considerations for Increased ICP v Environmental Stimuli Management o Minimize environmental noise o Speak with a soft voice o Use caution with unpleasant conversations near the patient o Implement therapeutic interventions for emotional upset o Avoid clustering patient care activities Space out interventions to prevent prolonged ICP spikes 43 Patient Care Considerations for Increased ICP v Temperature Control o Perform frequent temperature checks Oral or rectal preferred if not contraindicated o Implement early and aggressive fever treatment Increased temperature raises cerebral metabolic rate and ICP o Use gradual cooling methods Avoid shivering, which can increase ICP 44 Patient Care Considerations for Increased ICP v Glycemic Control o Monitor serum glucose and fingerstick glucose as ordered Typically every 4-6 hours o Adhere closely to insulin protocols o Maintain euglycemia Alterations in glucose can affect neurological status 45 Patient Care Considerations for Increased ICP v Bowel and Bladder Management o Implement a bowel regimen Administer stool softeners as ordered Avoid enemas (risk of increased intra-abdominal pressure) o Monitor Foley catheter patency o Maintain strict intake and output records Important for fluid balance, especially with osmotic diuretics 46 Patient Care Considerations for Increased ICP v Seizure Precautions o Implement seizure precautions per hospital protocol o Monitor serum levels of antiepileptic medications o Be prepared for acute seizure management Position patient on side Administer oxygen Have lorazepam readily available 47 Patient Care Considerations for Increased ICP v Patient Transport Considerations o Confirm necessity and timing of off-unit procedures o Prepare for transport: Ensure adequate staff (RN, RT) Gather necessary equipment (e.g., portable monitor, emergency medications) o Maintain ICP monitoring during transport and procedures o Continue to monitor and record hemodynamics and ICP 48 Patient Care Considerations for Increased ICP v Family Education and Support o Explain the purpose of interventions o Teach family about signs of increasing ICP o Provide emotional support o Involve family in care as appropriate 49 Patient Care Considerations for Increased ICP v Documentation and Communication o Accurately document all assessments and interventions o Communicate changes in patient status promptly to the healthcare team o Ensure clear handoff communication between shifts 50 Critical Thinking Question No. 01 v A patient with severe traumatic brain injury has an ICP monitor in place. The nurse observes that the patient's ICP has risen from 15 mm Hg to 28 mm Hg over the past hour. Which of the following interventions should the nurse implement first? A. Administer a bolus of mannitol B. Elevate the head of the bed to 30 degrees C. Initiate hyperventilation D. Notify the physician immediately 51 Critical Thinking Question No. 01 v Correct Answer: B) Elevate the head of the bed to 30 degrees v Feedback: o Elevating the head of the bed to 30 degrees is a simple, immediate intervention that can help reduce ICP by promoting venous drainage from the brain. 52 Critical Thinking Question No. 02 v A patient with an epidural hematoma has an ICP of 22 mm Hg, MAP of 90 mm Hg, and a GCS score of 10. The nurse calculates the cerebral perfusion pressure (CPP). Based on this information, which of the following statements is true? A. The patient's CPP is within the normal range B. The patient is at high risk for cerebral ischemia C. The patient requires immediate surgical intervention D. The patient needs vasopressor therapy to increase CPP 53 Critical Thinking Question No. 02 v Correct Answer: A) The patient's CPP is within the normal range v Feedback: o The CPP is calculated as MAP - ICP. In this case, 90 - 22 = 68 mm Hg. The normal range for CPP is 60-100 mm Hg, so this patient's CPP is within the normal range. 54 Critical Thinking Question No. 03 v A patient with subarachnoid hemorrhage has been receiving 3% hypertonic saline for ICP management. The latest lab results show a serum sodium of 158 mEq/L and serum osmolality of 330 mOsm/L. Which of the following is the most appropriate next step in management? A. Continue the current dose of hypertonic saline B. Increase the concentration of hypertonic saline to 7.5% C. Discontinue hypertonic saline and start mannitol D. Reduce the dose of hypertonic saline and closely monitor serum sodium 55 Critical Thinking Question No. 03 v Correct Answer: D) Reduce the dose of hypertonic saline and closely monitor serum sodium v Feedback: o The serum sodium and osmolality are above the target range (sodium >155 mEq/L, osmolality >320 mOsm/L). Reducing the dose and closely monitoring serum sodium is the most appropriate action to prevent complications while still managing ICP. 56 Do you have any questions? Thank you for the time and attention!  TARLAC STATE UNIVERSITY College of Science | Department of Nursing Unit 7: Nervous System Common Neurosurgical and Neurologic Disorders 1 Prof. EDRMBugayong Neurologic Surgery v Brain Tumors o Definition: Any neoplasm arising within the intracranial space Primary tumors: Originate within the brain tissue itself. Examples include gliomas, meningiomas, and pituitary adenomas. Metastatic tumors: Spread from cancers elsewhere in the body, commonly from lung, breast, or melanoma. 2 Neurologic Surgery v Brain Tumors o Classification and Grading World Health Organization (WHO) grading system: Grades tumors from I to IV based on histological features and malignancy. ü Grade I: Slow-growing, benign tumors with good prognosis ü Grade II: Relatively slow-growing tumors, some of which progress to higher grades ü Grade III: Malignant tumors with cells that look abnormal and actively growing ü Grade IV: Highly malignant and fast-growing tumors, such as glioblastoma multiforme 3 Neurologic Surgery v Brain Tumors o Etiology Mostly unknown, but research suggests several potential factors: ü Genetic predisposition: Certain inherited conditions like neurofibromatosis increase risk ü Ionizing radiation: High-dose exposure has been linked to increased tumor risk ü Environmental factors: Still under investigation, no definitive links established 4 Neurologic Surgery v Brain Tumors o Pathophysiology Disruption of blood-brain barrier: Tumors can cause breakdown of this protective barrier Vasogenic edema: Fluid accumulation in the brain due to increased vascular permeability Increased intracranial pressure (ICP): Result of tumor growth, edema, and CSF obstruction 5 Neurologic Surgery v Brain Tumors o Clinical Manifestations General signs: ü Headaches: Often worse in the morning or when lying down ü Seizures: Can be focal or generalized depending on tumor location ü Mental status changes: Confusion, personality changes, memory problems 6 Neurologic Surgery v Brain Tumors o Clinical Manifestations Focal signs: Depend on tumor location, may include: ü Motor or sensory deficits ü Visual disturbances ü Language difficulties ü Balance problems 7 Neurologic Surgery v Brain Tumors o Diagnosis Imaging studies: ü CT: Quick initial assessment, can show larger tumors and bleeding ü MRI: Gold standard for detailed tumor imaging ü PET: Can help differentiate tumor recurrence from radiation necrosis Biopsy: Surgical removal of a small piece of tumor for definitive diagnosis and grading 8 Neurologic Surgery v Brain Tumors o Management Surgical: ü Stereotactic biopsy: Minimally invasive procedure to obtain tissue sample ü Craniotomy: Open surgical procedure for tumor removal Pharmacologic: ü Corticosteroids: Reduce brain edema ü Anticonvulsants: Control seizures if present 9 Neurologic Surgery v Brain Tumors o Management Radiation therapy: ü External beam radiation ü Stereotactic radiosurgery for smaller tumors Chemotherapy: ü Oral or intravenous drugs to kill tumor cells ü May be used in conjunction with surgery and radiation 10 Neurologic Surgery v Brain Tumors o Nursing Management Assessment of neurological status: ü Regular neurological checks including Glasgow Coma Scale ü Monitoring for new or worsening symptoms Management of increased ICP: ü Elevating head of bed ü Administering medications as prescribed ü Monitoring for signs of herniation 11 Neurologic Surgery v Brain Tumors o Nursing Management Patient and family education: ü Explaining diagnosis, treatment options, and potential outcomes ü Teaching about medication side effects and when to seek medical attention ü Providing resources for support and further information 12 Neurologic Surgery v Aneurysms o Definition: Weakening in the arterial wall causing ballooning or distention Can occur in any artery, but intracranial aneurysms are of particular concern 13 Neurologic Surgery v Aneurysms o Types Saccular (berry): Most common type, appearing as a rounded outpouching on one side of the artery Fusiform: Dilated segment of artery, often associated with atherosclerosis Mycotic: Rare type caused by infection, often bacterial 14 Neurologic Surgery v Aneurysms o Etiology Combination of congenital and degenerative factors: ü Congenital weakness in arterial wall ü Progressive degeneration over time Risk factors: ü Hypertension: Increases stress on arterial walls ü Smoking: Damages blood vessel walls and increases blood pressure ü Genetic predisposition: Certain inherited disorders increase risk 15 Neurologic Surgery v Aneurysms o Pathophysiology Defect in smooth muscle layer of artery: ü Weakens the arterial wall ü Allows for outpouching or dilation High-velocity blood flow creates whirlpool effect: ü Further weakens the arterial wall ü Can lead to enlargement or rupture of the aneurysm 16 Neurologic Surgery v Aneurysms o Clinical Manifestations Sudden onset of "worst headache of life": ü Classic symptom of subarachnoid hemorrhage (SAH) ü Often described as a "thunderclap" headache Nausea, vomiting, focal neurologic deficits: ü May include vision changes, weakness, or numbness Subarachnoid hemorrhage (SAH): ü Life-threatening bleeding into the space surrounding the brain ü Can lead to severe neurological deficits or death 17 Neurologic Surgery v Aneurysms o Diagnosis CT scan: First-line imaging to detect SAH Lumbar puncture: May be performed if CT is negative but SAH is still suspected Cerebral angiogram: Gold standard for detailed imaging of cerebral vasculature 18 Neurologic Surgery v Aneurysms o Management Surgical clipping: ü Open surgical procedure to place a clip across the neck of the aneurysm ü Prevents blood flow into the aneurysm sac Endovascular coiling: ü Minimally invasive procedure to fill aneurysm with platinum coils ü Promotes clotting and isolation of the aneurysm from circulation "The Pipeline" treatment for larger aneurysms: ü Placement of a flow-diverting stent to redirect blood flow away from the aneurysm 19 Neurologic Surgery v Aneurysms o Complications Vasospasm: ü Narrowing of blood vessels, can lead to ischemic stroke ü Typically occurs 3-14 days after initial bleed Hydrocephalus: ü Buildup of cerebrospinal fluid in the brain ü May require temporary or permanent shunt placement Rebleeding: ü Risk is highest in the first 24-48 hours after initial rupture ü Can lead to severe neurological deterioration or death 20 Neurologic Surgery v Aneurysms o Nursing Management Neurological assessment: ü Frequent monitoring of level of consciousness and neurological function ü Use of standardized scales like the Glasgow Coma Scale Management of complications: ü Monitoring for signs of vasospasm, hydrocephalus, or rebleeding ü Implementing medical interventions as prescribed 21 Neurologic Surgery v Aneurysms o Nursing Management Patient and family education: ü Explaining the condition, treatment options, and potential outcomes ü Teaching about lifestyle modifications to reduce risk factors 22 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Definition: Lesions consisting of dilated arteries and veins without intervening capillary system Abnormal direct connections between arteries and veins 23 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Etiology Mostly congenital: ü Believed to develop during fetal development ü Exact cause unknown May enlarge with age: ü Can grow larger over time due to hemodynamic stress 24 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Pathophysiology Failure of capillary development: ü Normal capillary beds do not form between arteries and veins Direct shunting of arterial blood to venous circulation: ü Creates high-pressure flow in veins not designed to handle it ü Can lead to vessel dilation and potential rupture 25 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Clinical Manifestations Hemorrhage (most common): ü Can cause sudden severe headache, neurological deficits, or loss of consciousness Seizures: ü May be focal or generalized depending on AVM location Headaches: ü Can be migraine-like or more generalized Neurological deficits: ü May include weakness, numbness, or visual disturbances 26 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Diagnosis CT and MRI: ü Initial imaging to detect presence and location of AVM Cerebral angiography: ü Detailed imaging of blood vessel structure and blood flow patterns 27 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Management Endovascular embolization: ü Minimally invasive procedure to block blood flow to the AVM ü May be used alone or in combination with other treatments Surgical resection: ü Complete removal of the AVM ü Most definitive treatment but carries higher risks 28 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Management Stereotactic radiosurgery: ü Focused radiation to cause gradual closure of the AVM ü Used for smaller, deep AVMs or in patients who can't undergo surgery Multimodal approach for complex cases: Combination of above treatments based on individual patient factors 29 Neurologic Surgery v Arteriovenous Malformations (AVMs) o Nursing Management Neurological assessment: ü Regular monitoring of neurological status ü Watching for signs of hemorrhage or new deficits Management of complications: ü Monitoring for seizures, headaches, or signs of increased ICP Patient and family education: ü Explaining the nature of AVMs and treatment options ü Teaching about potential symptoms that require immediate medical attention 30 Neurologic Surgery v Surgical Approaches o Stereotactic Biopsy Used for small or deep lesions: ü Allows sampling of tumors that are difficult to access with open surgery Provides tissue for pathologic diagnosis: ü Essential for determining tumor type and grade Procedure: ü Uses 3D imaging guidance for precise needle placement ü Minimally invasive with small incision 31 Neurologic Surgery v Surgical Approaches o Craniotomy Removal of bone flap for access to brain: ü Provides direct visualization and access to brain structures Used for tumor resection, aneurysm clipping, AVM removal: ü Allows for maximal safe resection of lesions Procedure: ü Involves creating a window in the skull ü Bone flap is typically replaced at end of surgery 32 Neurologic Surgery v Surgical Approaches o Transsphenoidal and Transnasal Surgeries Used for pituitary tumors and cysts: ü Provides access to sellar region through the nose Benefits: ü Avoids brain retraction ü No visible scars Procedure: ü May be done with endoscope or microscope ü Approach through nasal cavity and sphenoid sinus 33 Neurologic Surgery v Surgical Approaches o Neuroendoscopy Minimally invasive technique: ü Uses small incisions and specialized instruments Improves visualization of normal anatomy and lesions: ü High-definition cameras provide detailed views Applications: ü Tumor biopsy or resection ü Treatment of hydrocephalus ü Cyst fenestration 34 Neurologic Disorders v Stroke o Definition: A neurologic deficit with sudden onset, resulting in permanent brain damage caused by cerebrovascular disease Also referred to as a "brain attack" to emphasize urgency Can lead to long-term disability or death if not treated promptly 35 Neurologic Disorders v Stroke o Types Ischemic (75% of cases) ü Thrombotic: Caused by a blood clot forming within a brain artery ü Embolic: Caused by a clot or debris from another part of the body traveling to the brain Hemorrhagic (25% of cases) ü Intracerebral: Bleeding directly into brain tissue ü Subarachnoid: Bleeding into the space between the brain and the surrounding membrane 36 Neurologic Disorders v Stroke o Pathophysiology Disruption of blood flow to brain tissue ü Leads to oxygen and nutrient deprivation in affected areas ü Can cause rapid cell death within minutes Ischemic cascade leading to cell death ü Includes processes like excitotoxicity, oxidative stress, and inflammation ü Results in an expanding area of damage over time 37 Neurologic Disorders v Stroke o Clinical Manifestations Sudden onset of neurological deficits ü May include weakness, numbness, speech difficulties, or vision problems ü Often unilateral (affecting one side of the body) Symptoms vary based on affected brain area ü Anterior circulation strokes may affect motor function and speech ü Posterior circulation strokes may affect balance, vision, and consciousness 38 Neurologic Disorders v Stroke o Diagnosis Clinical assessment (NIHSS - National Institutes of Health Stroke Scale) ü Standardized tool to quantify stroke severity ü Assesses level of consciousness, gaze, visual fields, facial palsy, motor arm/leg, ataxia, sensory, language, dysarthria, and extinction/inattention 39 Neurologic Disorders v Stroke o Diagnosis Neuroimaging (CT, MRI) ü CT: Quick, widely available; rules out hemorrhage ü MRI: More sensitive for early ischemic changes; can show old and new infarcts Additional tests (ECG, blood work) ü To identify potential causes (e.g., atrial fibrillation) and assess overall health status 40 Neurologic Disorders v Stroke o Management Time-sensitive treatment ("Time is Brain") ü Emphasis on rapid assessment and treatment initiation ü Goal is to restore blood flow as quickly as possible Thrombolytic therapy (t-PA) for ischemic stroke ü Administered within 3-4.5 hours of symptom onset ü Dissolves blood clots to restore blood flow 41 Neurologic Disorders v Stroke o Management Mechanical thrombectomy ü Physical removal of large clots using specialized devices ü Can be performed up to 24 hours after symptom onset in selected patients Supportive care and prevention of complications ü Management of blood pressure, glucose levels, and temperature ü Prevention of deep vein thrombosis, aspiration pneumonia, and pressure ulcers 42 Neurologic Disorders v Stroke o Nursing Management Neurological assessment ü Regular monitoring of neurological status using standardized scales ü Early detection of neurological deterioration Monitoring for complications ü Vigilance for signs of increased intracranial pressure, seizures, or infections ü Implementation of fall prevention strategies 43 Neurologic Disorders v Stroke o Nursing Management Patient and family education ü Teaching about stroke risk factors, warning signs, and lifestyle modifications ü Providing information on rehabilitation and community resources 44 Neurologic Disorders v Seizures o Definition: Episode of abnormal and excessive electrical discharge of cerebral neurons Can result in altered sensory, motor, or behavioral activities May be associated with changes in level of consciousness 45 Neurologic Disorders v Seizures o Types Generalized seizures ü Involve both cerebral hemispheres from the onset ü Include tonic-clonic, absence, and atonic seizures Partial (focal) seizures ü Begin in one area of the brain ü Can be simple (no alteration in consciousness) or complex (with altered consciousness) 46 Neurologic Disorders v Seizures o Etiology Idiopathic (genetic) ü No identifiable cause other than possible hereditary factors ü More common in children and young adults Symptomatic (secondary to other conditions) ü Can result from head trauma, stroke, tumors, infections, or metabolic disturbances ü May be acute (new onset) or chronic (epilepsy) 47 Neurologic Disorders v Seizures o Pathophysiology Abnormal neuronal excitation and synchronization ü Disruption in the balance of excitatory and inhibitory neurotransmitters ü Can lead to the spread of abnormal electrical activity to surrounding neurons 48 Neurologic Disorders v Seizures o Clinical Manifestations Vary based on seizure type and affected brain area ü Generalized tonic-clonic: Widespread muscle rigidity followed by rhythmic jerking ü Absence: Brief staring spells, often with eyelid fluttering ü Focal: Can cause localized motor symptoms, sensory changes, or complex behaviors 49 Neurologic Disorders v Seizures o Diagnosis Clinical history ü Detailed description of seizure events from patient and witnesses ü Information about potential triggers or precipitating factors EEG (Electroencephalogram) ü Records brain's electrical activity ü Can show abnormal patterns even between seizures Neuroimaging ü CT or MRI to look for structural causes of seizures 50 Neurologic Disorders v Seizures o Management Pharmacological (antiepileptic drugs) ü Choice depends on seizure type, patient age, and potential side effects ü May require trials of different medications or combinations Surgical interventions for refractory cases ü Resection of seizure focus or placement of stimulation devices ü Considered when medications fail to control seizures 51 Neurologic Disorders v Seizures o Management Lifestyle modifications ü Avoidance of known triggers (e.g., sleep deprivation, alcohol) ü Stress reduction techniques 52 Neurologic Disorders v Seizures o Nursing Management Seizure precautions ü Ensuring safe environment to prevent injury during seizures ü Proper positioning and airway management during active seizures Medication management ü Administration of antiepileptic drugs as prescribed ü Monitoring for side effects and therapeutic levels 53 Neurologic Disorders v Seizures o Nursing Management Patient and family education ü Teaching about seizure first aid and safety measures ü Importance of medication adherence and follow-up care 54 Neurologic Disorders v Guillain-Barré Syndrome o Definition: Inflammatory peripheral neuropathy causing rapid-onset muscle weakness Autoimmune disorder affecting the peripheral nervous system Can progress to complete paralysis in severe cases 55 Neurologic Disorders v Guillain-Barré Syndrome o Etiology Often follows an infection ü Commonly associated with Campylobacter jejuni gastroenteritis ü Other triggers include viral infections and rarely, vaccinations Autoimmune response against peripheral nerves ü Body's immune system mistakenly attacks nerve tissues ü Exact mechanism not fully understood 56 Neurologic Disorders v Guillain-Barré Syndrome o Pathophysiology Demyelination of peripheral nerves ü Immune attack strips away myelin sheath from nerve fibers ü Results in slowed or blocked nerve conduction Possible axonal damage ü In severe cases, the axons themselves can be damaged ü Can lead to longer recovery times or incomplete recovery 57 Neurologic Disorders v Guillain-Barré Syndrome o Clinical Manifestations Ascending paralysis ü Typically starts in legs and moves upward ü Can progress over hours to days Sensory symptoms ü Numbness, tingling, or pain in extremities ü May precede or accompany weakness Possible respiratory involvement ü Weakness of diaphragm and intercostal muscles ü May require mechanical ventilation in severe cases 58 Neurologic Disorders v Guillain-Barré Syndrome o Diagnosis Clinical presentation ü Rapidly progressive, symmetric weakness with absent reflexes ü Detailed neurological examination Cerebrospinal fluid analysis ü Typically shows elevated protein with normal cell count (albuminocytologic dissociation) Nerve conduction studies ü Demonstrate slowed nerve conduction velocities ü Help confirm diagnosis and determine severity 59 Neurologic Disorders v Guillain-Barré Syndrome o Management Supportive care ü Close monitoring, especially of respiratory function ü Management of complications (e.g., autonomic dysfunction, pain) Plasmapheresis ü Removes antibodies from the blood ü Can speed recovery if started early Intravenous immunoglobulin (IVIG) ü Modulates immune response ü Equally effective as plasmapheresis 60 Neurologic Disorders v Guillain-Barré Syndrome o Nursing Management Respiratory monitoring ü Frequent assessments of respiratory function ü Preparation for potential intubation and mechanical ventilation Prevention of complications ü Deep vein thrombosis prophylaxis ü Pressure ulcer prevention ü Pain management 61 Neurologic Disorders v Guillain-Barré Syndrome o Nursing Management Psychological support ü Addressing anxiety and fear related to paralysis ü Providing information about the typically good long-term prognosis 62 Neurologic Disorders v Myasthenia Gravis o Definition: Autoimmune disorder affecting neuromuscular junction transmission Characterized by fluctuating muscle weakness and fatigue Can affect any voluntary muscle, but commonly involves ocular and bulbar muscles 63 Neurologic Disorders v Myasthenia Gravis o Etiology Autoantibodies against acetylcholine receptors ü Body produces antibodies that attack and destroy acetylcholine receptors ü In some cases, antibodies target other proteins at the neuromuscular junction 64 Neurologic Disorders v Myasthenia Gravis o Pathophysiology Reduced number of functional acetylcholine receptors ü Fewer receptors available for neurotransmitter binding ü Results in weaker muscle contractions Impaired neuromuscular transmission ü Inadequate depolarization of the postsynaptic membrane ü Leads to muscle fatigue with repeated use 65 Neurologic Disorders v Myasthenia Gravis o Clinical Manifestations Fluctuating muscle weakness ü Typically worsens with continued activity and improves with rest ü May vary throughout the day Ocular and bulbar symptoms ü Ptosis (drooping eyelids) and diplopia (double vision) are common early symptoms ü Difficulty swallowing, speaking, or chewing 66 Neurologic Disorders v Myasthenia Gravis o Clinical Manifestations Possible respiratory involvement ü Weakness of respiratory muscles in severe cases ü Can lead to myasthenic crisis requiring mechanical ventilation 67 Neurologic Disorders v Myasthenia Gravis o Diagnosis Clinical presentation ü Characteristic pattern of weakness and fatigue ü Detailed neurological examination Edrophonium (Tensilon) test ü Short-acting acetylcholinesterase inhibitor ü Temporary improvement in muscle strength supports diagnosis 68 Neurologic Disorders v Myasthenia Gravis o Diagnosis Acetylcholine receptor antibody test ü Blood test to detect specific antibodies ü Positive in about 85% of patients with generalized myasthenia gravis Electromyography (EMG) ü Shows characteristic decremental response to repetitive nerve stimulation 69 Neurologic Disorders v Myasthenia Gravis o Management Anticholinesterase drugs o Pyridostigmine is the most commonly used o Improves neuromuscular transmission by increasing acetylcholine availability Immunosuppression o Corticosteroids, azathioprine, or other immunosuppressants o Aims to reduce the autoimmune attack on receptors 70 Neurologic Disorders v Myasthenia Gravis o Management Thymectomy o Surgical removal of the thymus gland o Can lead to improvement or remission in some patients Management of myasthenic crisis o Rapid intervention with respiratory support and immunomodulating therapies 71 Neurologic Disorders v Myasthenia Gravis o Nursing Management Medication administration ü Proper timing of anticholinesterase drugs in relation to meals and activities ü Monitoring for side effects of medications Monitoring for respiratory compromise ü Regular assessment of respiratory function ü Early recognition of impending myasthenic crisis 72 Neurologic Disorders v Myasthenia Gravis o Nursing Management Patient and family education ü Teaching about disease process and management ü Strategies for energy conservation and safe activities of daily living 73 Critical Thinking Question No. 01 v A 68-year-old patient is admitted to the emergency department with sudden onset of right-sided weakness and slurred speech. The symptoms started 2 hours ago. What is the most appropriate initial action? A. Administer aspirin B. Order an MRI scan C. Perform a CT scan of the head D. Administer tissue plasminogen activator (t-PA) 74 Critical Thinking Question No. 01 v Correct Answer: C) Perform a CT scan of the head v Feedback: o The correct initial action is to perform a CT scan of the head. In a patient presenting with sudden onset of neurological deficits suggestive of stroke, a rapid CT scan is crucial to differentiate between ischemic and hemorrhagic stroke. This distinction is critical because the treatment approaches differ significantly. 75 Critical Thinking Question No. 02 v A 25-year-old patient is diagnosed with Guillain-Barré syndrome. Three days after admission, the patient's respiratory rate increases, and they complain of difficulty breathing. What is the most likely explanation for this change, and what immediate action should be taken? A. The patient is anxious; administer an anxiolytic B. The patient is developing pneumonia; start antibiotics C. The ascending paralysis is affecting respiratory muscles; prepare for possible intubation D. The patient is hyperventilating; encourage slow, deep breathing 76 Critical Thinking Question No. 02 v Correct Answer: C) The ascending paralysis is affecting respiratory muscles; prepare for possible intubation v Feedback: o The correct answer reflects an understanding of the pathophysiology and progression of Guillain-Barré syndrome (GBS). GBS is characterized by ascending paralysis, which can affect the respiratory muscles, including the diaphragm. Respiratory compromise is a serious complication of GBS and can occur rapidly. The increasing respiratory rate and subjective difficulty breathing suggest that the patient's respiratory muscles are becoming involved. The immediate action should be to prepare for possible intubation and mechanical ventilation. This includes close monitoring of respiratory function (e.g., frequent vital capacity measurements), arterial blood gas analysis, and having intubation equipment ready. 77 Critical Thinking Question No. 03 v A 42-year-old patient with myasthenia gravis presents to the emergency department with increasing weakness, difficulty swallowing, and shortness of breath. The patient mentions running out of pyridostigmine two days ago. Which of the following is the most appropriate initial management strategy? A. Immediately administer a double dose of pyridostigmine B. Start plasmapheresis C. Administer intravenous immunoglobulin (IVIG) D. Withhold cholinesterase inhibitors and closely monitor respiratory function 78 Critical Thinking Question No. 03 v Correct Answer: D) Withhold cholinesterase inhibitors and closely monitor respiratory function v Feedback: o The correct answer demonstrates an understanding of the complexities in managing myasthenia gravis (MG) exacerbations. This patient is presenting with symptoms suggestive of a myasthenic crisis, which can be precipitated by medication non- compliance. However, it's crucial to differentiate between a myasthenic crisis (undertreatment) and a cholinergic crisis (overtreatment), as the management differs significantly. In this scenario, withholding cholinesterase inhibitors and closely monitoring respiratory function is the safest initial approach. This allows for assessment of whether the symptoms improve (suggesting cholinergic crisis) or worsen (suggesting myasthenic crisis). 79 Do you have any questions? Thank you for the time and attention!  TARLAC STATE UNIVERSITY College of Science | Department of Nursing Unit 7: Nervous System Traumatic Brain Injury 1 Prof. EDRMBugayong Mechanisms of Traumatic Brain Injury (TBI) v TBI is a leading cause of disability and death in the United States v Approximately 2.87 million TBIs occur each year v Falls are the leading cause (49.1%), followed by motor vehicle-related injuries (24.5%) and unintentional blunt trauma (17.1%) 2 Mechanisms of Traumatic Brain Injury (TBI) v Typical Mechanisms of Injury o Acceleration Injuries Occur when a moving object strikes the stationary head Examples: ü A bat striking the head ü A missile fired into the head 3 Mechanisms of Traumatic Brain Injury (TBI) v Typical Mechanisms of Injury o Acceleration-Deceleration Injuries Occur when the head in motion strikes a stationary object Examples: ü Head striking the windshield in a motor vehicle collision ü Falls ü Physical assaults 4 Mechanisms of Traumatic Brain Injury (TBI) v Typical Mechanisms of Injury o Coup-Contrecoup Injuries Brain "bounces" back and forth within the skull Strikes both poles of the brain (front and back or right and left sides) Coup: Area of initial forceful contact with the skull Contrecoup: Second impact area, usually on the opposite side Assessment note: Evaluate for injury to both impact sites 5 Mechanisms of Traumatic Brain Injury (TBI) v Typical Mechanisms of Injury o Rotational Forces Cause the brain to twist within the meninges and skull Results in stretching and tearing of blood vessels and shearing of neurons Examples: ü Physical assaults ü Motor vehicle collisions 6 Mechanisms of Traumatic Brain Injury (TBI) v Typical Mechanisms of Injury o Penetration Injuries Object travels at high velocity to disrupt skull integrity Examples: ü Bullet ü Shrapnel ü Sharp objects Note: Underlying brain structures may or may not be injured depending on speed and trajectory 7 Mechanisms of Traumatic Brain Injury (TBI) v Important Considerations o Cervical Spine Injury Must be automatically assumed in all types of TBI Systematically excluded before removing immobilization devices 8 Mechanisms of Traumatic Brain Injury (TBI) v Important Considerations o TBI Severity Classification Based on: ü Radiographic injury ü Glasgow Coma Scale (GCS) score 9 Mechanisms of Traumatic Brain Injury (TBI) v Important Considerations o TBI Severity Classification Severity Categories (Table 33-1) ü Mild TBI § GCS score: 13-15 § Loss of consciousness: 5-60 minutes § CT scan: No abnormality § Hospital stay: >48 hours 10 Mechanisms of Traumatic Brain Injury (TBI) v Important Considerations o TBI Severity Classification Severity Categories (Table 33-1) ü Moderate TBI § GCS score: 9-12 § Loss of consciousness: 1-24 hours § CT scan: May have abnormality 11 Mechanisms of Traumatic Brain Injury (TBI) v Important Considerations o TBI Severity Classification Severity Categories (Table 33-1) ü Severe TBI § GCS score: 3-8 § Loss of consciousness: >24 hours § May have: Cerebral contusion, laceration, or intracranial hematoma 12 Mechanisms of Traumatic Brain Injury (TBI) v Primary vs. Secondary Brain Injury o Primary Brain Injury Occurs at the time of trauma Immediate disruption of skull, brain structures, and functions o Secondary Brain Injury Begins immediately after the traumatic event Physiologic response to brain injury Includes: ü Cerebral edema ü Cerebral ischemia ü Biochemical changes 13 Mechanisms of Traumatic Brain Injury (TBI) v Management Focus o Preventing and mitigating secondary brain injury o Maximizing chances for positive functional outcomes 14 Primary and Secondary Brain Injury v Primary Brain Injury o Definition Injury occurring at the time of trauma Immediate disruption of skull, brain structures, and functions 15 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Scalp Laceration ü Causes significant bleeding due to scalp vascularity ü May be associated with underlying injuries ü Treatment: Suturing or surgical repair Skull Fracture ü Types: Compound, displaced, linear, depressed ü Locations: Anterior, middle, posterior fossae, or base of the skull ü Basilar skull fractures: Risk of CSF leakage (otorrhea or rhinorrhea) 16 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Concussion ü Definition: Alteration in mental status from trauma ü Characteristics: § May or may not involve loss of consciousness § No structural abnormalities on imaging § Associated with cellular metabolic crisis ü Postconcussive syndrome: Symptoms lasting longer than 3 months 17 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Contusion ü Localized bleeding and injury to brain tissue ü Often located in frontal and temporal lobes ü Complications: Hematoma expansion, cerebral edema Epidural Hematoma ü Blood collection between dura and skull ü Often caused by middle meningeal artery laceration ü Requires prompt surgical intervention 18 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Subdural Hematoma ü Blood accumulation below dura, above arachnoid layer ü Types: Acute, subacute, chronic ü Higher risk in older adults and those with alcohol use disorder Intracerebral Hematoma ü Blood collection within brain tissue ü Causes: Depressed skull fractures, penetrating injuries ü Management: Surgical or medical, depending on severity 19 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Traumatic Subarachnoid Hemorrhage ü Blood in the subarachnoid space ü Often accompanies other severe brain injuries ü Complications: Hydrocephalus, cerebral vasospasm Diffuse Axonal Injury (DAI) ü Characterized by microscopic tearing of axons ü Caused by rotational and acceleration-deceleration forces ü Classification: Mild, moderate, severe based on coma duration 20 Primary and Secondary Brain Injury v Primary Brain Injury o Types of Primary Brain Injuries Cerebrovascular Injury ü Includes carotid or vertebral artery dissection ü Risk of ischemic stroke ü Diagnosis: Cerebral angiograp