Week 1 Lecture - C. 34 Medical & Surgical Nursing PDF

MEDICAL & SURGICAL NURSING WEEK 1 Chapters 60 – 65 N e u ro l o g i c a l Fu n c t i o n  ADPIE REVIEW How do these learning goal differ from previous courses? Developing your own nursing 2 diagnoses from your assessment What are the abn...

MEDICAL & SURGICAL NURSING WEEK 1 Chapters 60 – 65 N e u ro l o g i c a l Fu n c t i o n  ADPIE REVIEW How do these learning goal differ from previous courses? Developing your own nursing 2 diagnoses from your assessment What are the abnormal findings from your assessment Risk Assessments vs Active Diagnosis Prioritize diagnosis based on ABC’s Integrating health assessment, pathophysiology, and med/surg theory and sciences into a diagnosis 1. A D P I E 1. The progressive care nurse - W H AT I S T H E Q U E S T I O N charts this assessment on a new 3 A S K I N G ? admission to the unit: - W H AT I N F O R M AT I O N I S - GCS: 14, AOx2 G I V E N A B O U T T H E PAT I E N T ? - Capillary Refill: 5 seconds to BUE - W H AT S H O U L D T H E N U R S E - Radial Pulses bilaterally: +1 B E D O I N G ? - Past Medical History includes dementia 2. A B C ’ S - HR: 105, BP: 98/54, O2: 94% on - P R I O R I T I Z E B A S E D O N A B C ’ S RA 3. N U R S I N G D I A G N O S I S What is the nurse’s priority - R I S K V S D I A G N O S I S intervention? a) Place patient in restraints 4. M A S LO W ’ S b) Place patient on supplemental oxygen c) Place patient with a sitter d) Auscultate lung sounds 1. A D P I E 1. The progressive care nurse charts - W H AT I S T H E Q U E S T I O N this assessment on a patient who 4 A S K I N G ? previously fell out of bed this - W H AT I N F O R M AT I O N I S morning, hitting his head: G I V E N A B O U T T H E PAT I E N T ? - GCS: 14, AOx2 - W H AT S H O U L D T H E N U R S E - Capillary Refill: 2 seconds B E D O I N G ? - Radial Pulses bilaterally: +2 2. A B C ’ S - Past Medical History includes - P R I O R I T I Z E B A S E D O N COPD, dementia A B C ’ S - Stage 2 pressure ulcer on sacrum - HR: 97, BP: 98/54, O2: 94% on RA 3. N U R S I N G D I A G N O S I S - R I S K V S D I A G N O S I S What is the nurse’s priority intervention? 4. M A S LO W ’ S a) Turn patient every two hours b) Place patient on supplemental oxygen c) Ensure wound care gets completed d) Auscultate lung sounds  CHAPTER 60 ASSESSMENT OF NEUROLOGIC FUNCTION  Central Nervous System (CNS) Brain and Spinal Cord STRUCTURE Peripheral Nervous System (PNS) Includes Cranial and Spinal nerves AND Autonomic and Somatic systems FUNCTION OF Basic Functional Unit: NEURON T H E N E RVO U S Controls all motor, sensory, SYSTEM autonomic, cognitive, and behavioral activities NEUROTRANSMITTERS Communicate messages from one neuron to another or to a specific target tissue Neurotransmitters can activate or suppress a specific action among it’s target cell A reactionary process is called Negative Feedback Loop. These processes typically reduce the fluctuations in the output Example: Blood glucose control – as blood sugar rises, cells in the pancreas release insulin until BG level normalizes. It takes some time before the BG level rises and the pancreas can release insulin and then for that insulin to decrease BG levels. A proactive process is called Positive Feedback Loop. These processes typically accelerates a response and reinforces change Example: Blood clotting - Platelets will release chemicals when a blood vessel is damaged until there is a big enough clot to stop the bleed. The body doesn’t wait until bleeding has occurred or worsened Many neurologic disorders are caused by an imbalance in neurotransmitters H O M E O S TA S I S Homeostasis is the condition in which a system in the human body is maintained in a more-or-less steady state. It is the job of the cells, neurotransmitters, and organs to maintain homeostasis and keep things balanced What does the body focus on maintaining homeostasis? Body temperature pH Cardiac Output Perfusion Electrolytes and Blood Glucose Blood Pressure (MAP) Energy, Nutrition, and Protein/Fat B RA I N A N AT O M Y Frontal Lobe Thalamus Hypothalamus Temporal Lobe Medulla Oblongata Parietal Lobe Occipital Lobe Cerebellum Pons  SKULL A N AT O M Y  A RT E R I A L B L O O D S U P P LY TO BRAIN  Functions to regulate the activities of internal organs and maintain homeostasis Sympathetic Nervous System (SNS) “Fight or Flight” responses AUTONOMIC (Adrenergic System) Think of that picture in Pharmacology N E RVO U S with signs/symptoms SYSTEM Main neurotransmitter = norepinephrine (Levophed) Parasympathetic Nervous System (PNS) “Rest and Digest” (Cholinergic System) Controls visceral functions  What’s included? Consciousness and Cognition Cranial Nerves Motor Systems Sensory Systems Reflexes N E U R O LO G I C A L Remember for the exam: Gradings and what they mean ASSESSMENT How to perform the assessments What the results mean For example: A patient is unable to perform alternating hand movements on the right side. What would you suscept is going on? Another example: A patient has +1 bilateral patellar reflexes. What does this indicate? DIAGNOSTIC TESTS Computed tomography (CT) Positron emission tomography (PET) Single-photon emission computed tomography (SPECT) Magnetic resonance imaging (MRI) Cerebral angiography Myelography Noninvasive carotid flow studies Transcranial Doppler Electroencephalography (EEG) Electromyography (EMG) Lumbar puncture  COMPUTED TOMOGRAPHY (CT) SCANNING Cross-sectional views to see Allows viewers to see tissue density (similar to percussion) Can be with or without contrast Nursing Interventions when a client has a CT Lie quietly (obtains clearer picture) Address claustrophobia (CT scan are short time period, patients typically tolerate) Allergies with contrast - Iodine NPO? – depends on the test Flushing out contrast – give fluids!!  Nuclear imaging exam Requires inhalation of radioactive gas or IV radiation POSITRON Measures brain activity EMISSION Alzheimer disease, TOMOGRAPHY lesions/tumors, CVA (PET) Nursing Interventions Inhalation teaching Side effects Dizziness HA  Injects dye into blood stream Nuclear imaging exam SINGLE Visualizes blood flow to the brain PHOTON CVA, seizures/epilepsy, tumor EMISSION growth COMPUTED Nursing Interventions TOMOGRAPHY Patient teaching – what to expect Contraindications (SPECT) Pregnancy Breastfeeding  Magnetic field Clearer images MAGNETIC CVA, tumor, MS RESONANCE Nursing Interventions Claustrophobia (typically longer IMAGING duration required for imaging) (MRI / MRA) Metal objects Thumping sounds (can frighten people) Open vs Closed MRI Now have standing MRIs  Looks at circulation to the brain Assesses for narrowing, aneurysms (ballooning) and can be used to place stents or obtain biopsies Access via femoral artery – for bleeding Post arterial stick - needle is removed, CEREBRAL what are interventions needed to prevent bleeding out? ANGIOGRAPHY Nursing Interventions Hydrate before procedure to avoid hypotension from blood loss Void before procedure Headrush and metallic taste Frequent neuro checks after the exam Assess puncture site – what are important to assess after removal of catheter?  X-ray or CT scan of subarachnoid space among the spinal cord Contrast via lumbar puncture is administered to show up on imaging Not widely used now that MRIs are less invasive Nursing Interventions MYELOGRAPHY Sedation for lumbar puncture Bedrest for 3 hours (pressure on the puncture) HOB elevated. Why? Encourage fluids. Why? H/A & photophobia typically are linked to CSF leak Stiff neck with fever (infection) are typically linked to CSF infection  Looks at blood flow of cranial arteries TRANSCRANIAL Ultrasound exam DOPPLER Nursing Interventions Cold jelly Usually performed at client’s bedside ELECTROENCEPHALOGRAPHY (EEG) Electrical activity of the brain Electrodes to the scalp Seizure disorders, tumors, abscesses, clots Brain death evaluation Nursing Interventions Client deprived of sleep – helps induce one Withhold medications Avoid caffeine – cause false readings About 1 hour in length – in hospital, could be a day or can be continuous E L E C T R O M YO G RA P H Y ( E M G ) Needles inserted into skeletal muscles to assess for ability to move (reflex) Analyzes suspected causes of weakness Nursing Interventions Patient teaching (needles) Aching post-procedure No lotions or creams 24 hours before LU M B AR P U NC T U R E Spinal tap Obtain CSF samples Clear vs. pink-tinged (first tube from puncture) What this measures: Cell count Culture Glucose Protein Nursing Interventions Headache (leaking CSF) Bedrest and flat for at least 2-3 hours Hydrate  CHAPTER 61 M A N A G E M E N T O F PAT I E N T S W I T H N E U R O LO G I C DY S F U N C T I O N A LT E R E D L E V E L O F CONSCIOUSNESS Level of responsiveness and consciousness is the most important indicator of the patient's condition Not a disorder but the result of a pathology Coma – unarousable, unresponsive (2 – 4 weeks) Akinetic mutism – unresponsive to environment, may move their eyes Persistent vegetative state – devoid of cognitive function, follow a night/day time pattern Locked-in syndrome – unable to move except for eye movement  Know prior mental status / LOC Subtle changes in behavior Verbal response Motor response Glasgow Coma Scale CLINICAL Eye opening M A N I F E S TAT I O N S Verbal response Motor response Pupillary response (PERRLA) Brisk – quick reaction to light Sluggish – opposite of brisk Fixed - No Response to light (worst) D E C O RT I C AT E P O S T U R I N G D E C E R E B RAT E P O S T U R I N G  Respiratory failure C O M P L I C AT I O N S Pneumonia – ventilators W I T H A LT E R E D Pressure ulcers LEVEL OF Aspiration CONSCIOUSNESS DVT Contractures Nursing Diagnosis: while Altered LOC is not a nursing diagnosis… the items above tend to be. Ineffective Cerebral Tissue Perfusion Acute Confusion Ineffective Breathing Pattern Risk for Falls Impaired Mobility Risk for Impaired Skin Integrity  Airway Breathing MEDICAL Circulation MANAGEMENT Nutritional support Prevention of complications (Risk Factors)  Maintenance of clear airway Protection from injury Attainment of fluid volume balance Maintenance of skin integrity Absence of corneal irritation Effective thermoregulation Accurate perception of environmental stimuli Maintenance of intact family or support system Absence of complications NURSING I N T E RV E N T I O N S  Frequent monitoring of respiratory status including auscultation of lung sounds Position the patient to minimize aspiration HOB elevated 30° Lateral or semi-prone position MAINTENANCE Suctioning OF CLEAR Oral hygiene A I RWAY CPT – chest physiotherapy (banging chest to break apart mucous) Mechanical ventilation / Intubation – this can be prophylactic or definitive treatment  Assess skin frequently, especially areas with high potential for breakdown Frequent turning; use turning schedule Careful positioning in correct body alignment; use of splints, foam M A I N TA I N I N G boots, trochanter rolls, and specialty beds as needed TISSUE Passive ROM INTEGRITY Clean eyes with cotton balls moistened with saline Use artificial tears as prescribed Measures to protect eyes; use eye patches cautiously because the cornea may contact patch Frequent, scrupulous oral care  Assess skin turgor Inspect mucosa Review labs. Which ones? Monitor I&O M A I N TA I N I N G Monitor IV infusion F LU I D S TAT U S Administer slowly – those sensitive to fluids ICP (increased intracranial pressure) Promote / Restrict fluids – must be provider’s orders E F F E C T I V E T H E R M O R E G U L AT I O N Adjust environment and cover patient appropriately – cannot thermoregulate Administer antipyretics as ordered Use hypothermia blanket if needed Give a cooling sponge bath Allow fan to blow over patient to increase cooling Monitor temperature frequently and use measures to prevent shivering  Assess for urinary retention and urinary incontinence May require indwelling or intermittent catheterization PROMOTE Bladder training program BOWEL AND Assess for abdominal distention, potential constipation, and bowel BLADDER incontinence FUNCTION Monitor bowel movements Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated Diarrhea may result from infection, medications, or hyperosmolar fluids  Talk to and touch the patient and encourage the family to do the same Maintain normal day/night pattern of activity AC C U RAT E Orient the patient frequently PERCEPTION OF E N V I R O N M E N TA L A patient aroused from coma STIMULI may experience a period of agitation; minimize stimulation at this time Initiate programs for sensory stimulation  INCREASED INTRACRANIAL PRESSURE (ICP) Normal range is 10 – 20 mm Hg The skull prevents the brain from expanding Brain compensates by displacing CSF or blood volume If this compensation fails, ICP will increase Cerebral edema will occur (brain dies) ICP: CEREBRAL PERFUSION PRESSURE (CPP) CPP is closely linked to ICP CPP = MAP – ICP Normal CPP is 70 to 100 mm Hg A CPP of less than 50 results in permanent damage C L I N I C A L M A N I F E S T A T I O N S - E A R LY Changes in level of consciousness Any change in condition Restlessness, confusion, increasing drowsiness, increased respiratory effort, and purposeless movements Pupillary changes and impaired ocular movements Weakness in one extremity or one side Headache: constant, increasing in intensity, or aggravated by movement or straining  Respiratory and vasomotor changes Projectile vomiting Changes in vital signs Increase in SBP Decrease in HR Rapid fluctuations from tachycardia to CLINICAL bradycardia M A N I F E S TAT I O N S Fever - L AT E Further deterioration of LOC; stupor to coma Hemiplegia, decortication, decerebration, or flaccidity Respiratory alterations including Cheyne- Stokes breathing and respiratory arrest Loss of brain stem reflexes pupil, gag, corneal, and swallowing CUSHING’S TRIAD Herniation of brain stem Cessation of cerebral blood flow Brain death CUSHING’S TRIAD  ICP MONITORING  ICP MONITORING VIA EXTERNAL VENTRICULAR DEVICE (EVD) ICP AND EVD MONITORING I N S E RT I N G A N E V D  Infection Brain stem herniation Diabetes insipidus – excessive C O M P L I C AT I O N S urine output SIADH (syndrome of inappropriate ADH)  SIADH – Think of it as INCREASED ADH What to know: Sodium levels for each Urine output for each S/S for each Let’s think about treatments…. B RA I N S T E M H E R N I AT I O N  Monitor ICP Drainage of CSF Decrease cerebral edema Mannitol – not good for CHF MEDICAL Maintain cerebral perfusion Dobutamine MANAGEMENT Levophed Control fever Maintain oxygenation Reduce metabolic demands N U R S I N G I N T E RV E N T I O N S Maintain a patent airway / breathing pattern Optimize cerebral tissue perfusion Maintain negative fluid balance Prevent infection Monitor/Manage complications  Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous NURSING drainage INTERVENTIONS: Avoid hip flexion, Valsalva maneuver, abdominal distention, or INTRACRANIAL other stimuli that may increase ICP PRESSURE Maintain a calm, quiet atmosphere and protect patient from stress Monitor fluid status carefully; every hour I&O during acute phase Use strict aseptic technique for management of ICP monitoring system  Frequent monitoring of respiratory status and lung sounds M A I N TA I N A Monitor breathing pattern Cheyne-Stokes respirations PAT E N T Hyperventilation A I RWAY / Irregular respirations B R E AT H I N G Maintain a patent airway PAT T E R N Suctioning (effects on ICP) – increases risk, but we will still do it Discourage coughing Elevate HOB  Avoid the valsalva maneuver (bearing-down) Space suctioning and other interventions OPTIMIZE Maintain a calm environment CEREBRAL Positioning TISSUE Keep head in midline position PERFUSION Elevate HOB Avoid rotation of the neck Avoid hip flexion Turning of clients  To reduce ICP Monitor for dehydration M A I N TA I N Administer IV fluids slowly N E G AT I V E Monitor for congestive heart F LU I D failure and/or pulmonary edema BALANCE Monitor for diabetes insipidus – amount of output the patient has Provide frequent oral hygiene  Primary concern is brain herniation Early detection of signs of increased ICP is key MONITOR/MANAGE Frequent neuro checks C O M P L I C AT I O N S Hourly Monitor for diabetes insipidus Monitor for SIADH Frequent vital signs  INTRACRANIAL S U R G E RY Craniotomy – opening of skull Supratentorial – incision made on forehead Infratentorial – incision on back of skull Transsphenoidal – through nose or mouth Burr holes – drill holes on sides to relieve swelling BURR HOLES BURR HOLES MEDICAL MANAGEMENT Seizures Cerebral edema Infection  Episodes of abnormal brain activity that result from sudden excessive firing of cerebral neurons Partial Simple SEIZURES Consciousness remains intact Complex Impairment of consciousness Generalized  Cerebrovascular disease Hypoxemia Fever (childhood) Head injury SPECIFIC Hypertension CAUSES OF Central nervous system infections SEIZURES Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Allergies  Abnormal episodes of motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from a sudden, abnormal, uncontrolled electrical discharge from cerebral neurons Classification of seizures SEIZURES Focal: originates in one hemisphere Generalized: occur and engage bilaterally Unknown: epilepsy spasms “Provoked” related to acute, reversible condition  Observe and record: Before the seizure started Aura Where the seizure begins BEFORE AND Movements Area of the body involved BEGINNING OF Pupils A SEIZURE Turning of head Automatisms – involuntary motor activities Incontinence  Observe and record: Duration Loss of consciousness Paralysis DURING A Speech Movements at the end of the SEIZURE seizure Sleep Confusion SEIZURE PRECAUTIONS Protect the client Safe position Protect the head Loosen clothing Clear the area Raise and pad side rails Bed in lowest position Suction set-up – REQUIRED! Do not apply restraints Do not insert anything into client’s mouth  SEIZURE PRECAUTIONS SPECIFIC CAUSES OF SEIZURES Cerebrovascular disease Hypoxemia Fever (childhood) Head injury Hypertension Central nervous system infections Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal Allergies EPILEPSY Recurring seizures Primary – idiopathic MOST COMMON Secondary – know the cause 3% of population Most common in children Menses Contraception Pregnancy Bone loss Cause is generally unknown C L I N I C A L M A N I F E S TAT I O N S Absent seizure Loss of consciousness Grand mal seizure Sleepiness after seizure HA Soreness Fatigue Depression SEIZURES  Preventing injury Reducing fear of seizures Improving coping mechanisms NURSING Providing education INTERVENTIONS Monitoring and managing potential complications Promoting home care  Lower gently to the floor Remove harmful objects Clear area PREVENTING Do not restrain I N J U RY Do not insert anything into client’s mouth Padded side rails Side-lying position  Help client understand how to REDUCING FEAR control seizure activity OF SEIZURES Take medications as ordered Identify causative factors Moderate routine/lifestyle Avoid excessive exercise Ketogenic diet Photic stimulation Stress management ETOH  Medication regimen Oral care (Dilantin) Adjustment to chronic seizures Record seizure activity PROMOTING Prevention of seizures HOME CARE Medical alert bracelet/card Swimming / bathing Adequate sleep / rest S TAT U S EPILEPTICUS Acute prolonged seizure activity Generalized seizures No recovery between seizures Lasts at least 30 minutes Medical emergency Respiratory compromise Hypoxia of the brain Fatal brain damage  Cephalgia Primary Migraine (4 – 72 hours) Tension-type (most common) Cluster (severe vascular, more common in men) HEADACHE Cranial arteritis (old age) Secondary Brain tumor Aneurysm  Prodromal phase (hours or days before) Aura phase (1 hours before) CLINICAL M A N I F E S TAT I O N S Headache phase Recovery phase (starts to recede)  Abortive therapies Relief of H/A once it has occurred For client’s with less frequent occurrences MEDICAL Prevention of triggers MANAGEMENT Pain relief Medications Imitrex  Relieving pain Medications Pain control Associated symptoms Non-pharmacological methods NURSING Quiet environment INTERVENTIONS Dark room Promoting home care Identify/Avoid triggers Adequate rest/sleep Stress management  CHAPTER 62 M A N A G E M E N T O F PAT I E N T S W I T H C E R E B R O VA S C U L A R D I S O R D E R S C E R E B R O VA S C U L A R A C C I D E N T CVA Stroke Brain attack 4th leading cause of death #1 cause of long-term disability 700,000 people in the United States experience a stroke in a given year STROKE PREVENTION Nonmodifiable risk factors Age (over 55) Male gender African American race Modifiable risk factors HTN Cardiovascular disease Elevated cholesterol Obesity Smoking DM S T R O K E ( C VA )  Ischemic 85% Decreased oxygenation to the brain S/S TYPES OF Numbness and weakness to one side of the body STROKE Hemorrhagic 15% Bleeding into the skull S/S Serious HA ISCHEMIC STROKE Disruption of the blood supply caused by an obstruction, usually a thrombus or embolism, that causes infarction of brain tissue Types Large artery thrombosis Small penetrating artery thrombosis Cardiogenic embolism Early treatment is key Thrombolytic therapy Stroke alerts 3-hour treatment window Contraindications for thrombolytic therapy  Numbness or weakness on one side of the body Confusion CLINICAL Speaking difficulties M A N I F E S TAT I O N S Visual disturbances Difficulty walking Severe HA  Hemiplegia – paralysis on one side Hemiparesis – weakness on one side Dysarthria – difficultly speaking CLINICAL Dysphasia – difficulty speaking M A N I F E S TAT I O N S Aphasia - Expressive – can’t express Receptive – cant understand Global - both  Apraxia – can’t complete previously learned action Homonymous Hemianopia Loss of half of the field of vision in both eyes Loss of peripheral vision Patient may neglect one side of CLINICAL their body M A N I F E S TAT I O N S Teach patient in scanning techniques Loss of proprioception – knowing where body is without seeing Agnosias – cant recognize a previous known object C VA A S S E S S M E N T Hand grip strength Orientation Facial drooping Dysphagia Pupillary changes Ipsilateral dilation (on the same side) Contralateral dilation (on the opposing side) Requires immediate intervention!  Temporary neurologic deficit resulting from a temporary impairment of blood flow TRANSIENT “Warning of an impending ISCHEMIC stroke” AT TA C K ( T I A ) Diagnostic work-up is required to treat and prevent irreversible deficits  Coumadin INR level (2-3) CT scan Platelet inhibitors Plavix, Ticlid, Persantine Thrombolytics MEDICAL Tissue Plasminogen Activator (TPA) 3-hour window MANAGEMENT RISK FOR INJURY IS TOP PRIORITY! Elevate head of bed (HOB) unless contraindicated Maintain airway and ventilation Continuous hemodynamic monitoring and neurologic assessment  18 years or older Verified ischemic stroke 3-hour window SBP not > 185 ELIGIBILITY DBP not > 110 CRITERIA FOR No seizure activity T PA Not taking blood thinners Platelet count > 100,000 No major surgery within 2 weeks No GI or urinary bleeding  Carotid endarterectomy – remove plaque Removal of plaque or clot from a carotid artery Recommended for clients with a SURGICAL blockage greater than 70% PREVENTION Also recommended for clients with a blockage greater than 50% if there are other risk factors present  CAROTID E N D A RT E R E C T O M Y Treatment as preventive option for Ischemic Stroke caused by atherosclerosis  Improving mobility Enhancing self-care Managing sensory-perceptual difficulties Assisting with nutrition Attaining bowel and bladder NURSING control INTERVENTIONS Improving thought processes * These are your nursing diagnoses for stroke patients… (impaired mobility, acute pain, altered nutrition, etc.) IMPROVING MOBILITY ROM exercises Change client’s position OOB asap Ambulate client asap Work closely with PT  Promote self-care Do not neglect the affected side ENHANCING Add a task each day SELF-CARE Encourage family members to allow client to provide their own care  Approach client from appropriate side (non effected side) MANAGING Put items in the room within the S E N S O R Y- client’s view P E RC E P T U A L However, encourage the client to turn their head and use their D I F F I C U LT I E S affected side also  Dysphagia ASSISTING Swallow study WITH Thickened liquids NUTRITION Enteral tubes AT TA I N I N G B O W E L A N D BLADDER CONTROL Transient urinary incontinence Catheterization Bladder training Constipation IMPROVING THOUGHT PROCESSES Cognitive, behavioral and emotional deficits Document client’s performance Note improvements Encourage client I M P R O V I N G C O M M U N I C AT I O N Aphasia Seen mostly with right-side paralysis Work with speech therapist Maintain eye contact Speak normally but with short sentences Minimize background noise Allow client to write Give client time to communicate Encourage client M A I N TA I N I N G S K I N I N T E G R I T Y r/t altered sensation and impaired mobility Assess the client’s skin frequently Reposition every 2 hours Keep skin warm and dry I M P R O V I N G F A M I LY C O P I N G Stress management Encourage family to assist client but not to perform tasks that the client can do Anticipate slow progress Support groups HELPING THE CLIENT COPE WITH S E X U A L DY S F U N C T I O N Medical and psychological factors Encourage dialogue between client and s/o Changes in sexual practices and abilities PROMOTING HOME CARE Rehabilitation continues at home OT / PT Focus is on self-care Client and family education Depression of client with loss of independence and function Depression of caregivers with increased responsibilities  Caused by bleeding into brain tissue, the ventricles, or subarachnoid space Brain metabolism is disrupted by exposure to blood ICP increases due to blood in the HEMORRHAGIC subarachnoid space STROKE Uncontrolled HTN is most common cause Intracranial aneurysm Higher mortality rate Longer recovery time C L I N I C A L M A N I F E S TAT I O N S Similar to ischemic stroke Severe headache Early and sudden changes in LOC Vomiting  Vasospasm Narrowing of blood vessel Leads to brain ischemia Up to ½ of deaths are r/t this occurrence Triple H therapy C O M P L I C AT I O N S Hypervolemia Hypertension Hemodilution Increased ICP HTN  Control of hypertension MEDICAL CT scan, cerebral angiography, MANAGEMENT and lumbar puncture if CT is negative and ICP is not elevated Care is primarily supportive Bed rest with sedation Oxygen Surgery Medications Nimodipine Hypertonic Saline (3%)  Similar to those with ischemic NURSING stroke INTERVENTIONS Monitoring and managing potential complications  Vasospasm Look for S/S MONITORING HA AND MANAGING Confusion Aphasia POTENTIAL Seizures C O M P L I C AT I O N S Cause further injury to the brain Prevention  Hydrocephalus Look for S/S Sudden coma (acute) MONITORING Drowsiness (gradual) AND MANAGING Rebleeding 2% POTENTIAL Control hypertension C O M P L I C AT I O N S Hyponatremia 10-40% of patients Monitor lab values  Aneurysm precautions Strict bedrest Quiet environment Restriction of visitors MONITORING HOB at 30 degrees AND MANAGING No caffeine POTENTIAL Avoid valsalva maneuver C O M P L I C AT I O N S Stool softeners Avoid exertion Allow client to relax  CHAPTER 63 M A N A G E M E N T O F PAT I E N T S WITH NEUROLOGIC TRAUMA HEAD INJURIES A broad classification that includes injury to the scalp, skull, or brain 1.4 million people in the U.S. receive head injuries every year Head injury is the most common cause of death from trauma Most common cause of brain trauma is MVC Group at highest risk for brain trauma are males age 15 to 24 Those younger than 5 years and the elderly are also at increased risk PAT H O P H Y S I O L O GY O F B RA I N D A M A G E Primary injury: consequence of direct contact to head/brain during the instant of initial injury Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal Secondary injury: damage evolves over ensuing days and hours after the initial injury Caused by cerebral edema, ischemia, or chemical changes associated with the trauma T RA U M AT I C B RA I N I N J U R I E S  Wear seat belts and helmets Children should sit in the back PREVENTING seat Back of pickup trucks INJURIES Prevent falls Secure firearms  Manifestations depend on the severity and location of the injury Scalp wounds SCALP Tend to bleed heavily and are portals for infection WOUNDS AND Skull fractures SKULL Usually have localized, persistent FRACTURES pain Fractures of the base of the skull Bleeding from nose pharynx or ears Battle sign—ecchymosis behind the ear CSF leak: halo sign—ring of fluid around the blood stain from drainage M A N I F E S TAT I O N S O F B RA I N I N J U RY Altered level of consciousness Pupillary abnormalities Sudden onset of neurological deficits and neurological changes; changes in sense, movement, and reflexes Changes in vital signs Headache Seizures  Closed (blunt) - acceleration/ deceleration injury occurs when the head accelerates then rapidly decelerates, damaging brain tissue Open (penetrating) - object penetrates the brain or trauma is so severe that the scalp and skull are opened Concussion - a temporary loss of consciousness with no apparent structural damage B RA I N I N J U RY Contusion – more severe than concussion Diffuse axonal injury – widespread axon damage in the brain seen with head trauma; patient develops immediate coma Intracranial hemorrhage Epidural hematoma Subdural hematoma Intracerebral hemorrhage and hematoma  LO C AT I O N O F EPIDURAL, SUBDURAL, AND INTRACEREBRAL H E M AT O M A S  Blood collection in the space between the skull and the dura Patient may have a brief loss of consciousness with return of lucid state; then as hematoma expands, increased ICP will often suddenly reduce LOC EPIDURAL An emergency situation H E M AT O M A Treatment includes measures to reduce ICP, remove the clot, and stop bleeding (burr holes or craniotomy) Patient will need monitoring and support of vital body functions; respiratory support  Collection of blood between the dura and the brain Acute or subacute Acute: symptoms develop over 24 to 48 hours Subacute: symptoms develop over 48 hours to 2 weeks SUBDURAL Requires immediate craniotomy and control of ICP H E M AT O M A Chronic Develops over weeks to months Causative injury may be minor and forgotten Clinical signs and symptoms may fluctuate Treatment is evacuation of the clot  Hemorrhage occurs into the substance of the brain Also known as Subarachnoid (SAH) May be caused by trauma or a nontraumatic cause Treatment Supportive care INTRACEREBRAL Control of ICP HEMORRHAGE Administration of fluids, electrolytes, and antihypertensive medications Craniotomy or craniectomy to remove clot and control hemorrhage; this may not be possible because of the location or lack of circumscribed area of hemorrhage  Patient may be admitted for observation or sent home Observation of patients after head trauma; report immediately Observe for any changes in level of consciousness Diffi culty in awakening, lethargy, CONCUSSION dizziness, confusion, irritability, and anxiety Diffi culty in speaking or moving Severe headache Vomiting Patient should be aroused and assessed frequently  More severe than a concussion Unconscious May lie motionless, faint pulse, shallow breathing, pale skin CONTUSION Bladder and bowel incontinence Presents similar to shock (low BP) Varying outcomes  Treatment of increased ICP Supportive measures MANAGEMENT Ventilator Seizure prevention OF BRAIN Fluids and electrolyte INJURIES maintenance Nutritional support  Uniform Determination of Brain Death Act Organ donation 3 cardinal signs B RA I N D E AT H Coma Absence of brain-stem reflexes Apnea GLASGOW COMA SCALE  Decreased cerebral perfusion Cerebral edema and herniation NURSING Impaired oxygenation and DIAGNOSIS ventilation Impaired fluid, electrolyte, and FOR TBI nutritional balance Risk for posttraumatic seizures  Monitoring for declining neurologic NURSING function I N T E RV E N T I O N S Maintaining the airway Monitoring fluid and electrolyte balance Promoting adequate nutrition Preventing injury Maintaining body temperature Maintaining skin integrity Improving cognitive functioning Preventing sleep pattern disturbance Supporting family coping Monitoring and managing potential complications Promoting home care MONITORING FOR DECLINING NEUROLOGIC FUNCTION Monitor neurologic function LOC with GCS Vital signs Motor function Other neurologic signs I&O and daily weights Monitor blood and urine electrolytes and osmolality and blood glucose  Drainage of oral secretions Suctioning Monitor for aspiration M A I N TA I N I N G ABGs T H E A I RWAY Mechanical ventilation Pneumonia  Hyponatremia MONITORING Hyperglycemia F LU I D AN D Monitor intake and output E L E C T R O LY T E Monitor IV site and fluids BALANCE Monitor lab values  Calorie consumption is increased Higher demand for protein PROMOTING TPN (total parenteral nutrition) A D E Q U AT E Enteral feedings NUTRITION Monitor all feedings as discussed previously  Implement strategies to prevent injury Assess oxygenation Assess bladder and urinary output Assess for constriction due to PREVENTING dressings and casts I N J U RY Pad side rails Use mittens to prevent self- injury Avoid restraints – use least restricted first  Maintain appropriate environmental temperature Use coverings: sheets, blankets as per patient needs Administer acetaminophen for fever Use cooling blankets or cool baths M A I N TA I N I N G Prevent shivering BO DY T E M P E RAT U R E  Turn every 2 hours M A I N TA I N I N G Assess skin frequently SKIN Provide skin care every 4 hours OOB tid INTEGRITY  Memory deficits IMPROVING Inability to focus COGNITIVE Slowness in thinking Emotional difficulties FUNCTIONING  Clients are awakened often for assessments PREVENTING Neuro checks are often ordered SLEEP every hour PAT T E R N Darken room DISTURBANCE Allow naps throughout the day Reduce environmental noise  Implement measures to promote effective coping S U P P O RT I N G Provide and reinforce information F A M I LY C O P I N G Set realistic, well-defined, short- term goals Refer client and family for counseling and support groups  Increased ICP Cerebral edema MONITORING Impaired oxygenation AND MANAGING Impaired fluid and electrolyte POTENTIAL balance Impaired nutritional balance C O M P L I C AT I O N S Seizures SPINAL CORD I N J U RY SCI 200,000 persons in the U.S. live with disability from SCI Major causes of death are pneumonia, pulmonary embolism (PE), and sepsis Causes: MVCs (35%) Violence (24%) Falls (22%) Sports injuries (8%) SPINAL CORD INJURIES  The result of concussion, contusion, laceration, or compression of spinal cord Primary injury is the result of the initial trauma and usually permanent Secondary injury resulting from SCI include edema and hemorrhage Major concern for critical care nurses Treatment is needed to prevent PAT H O P H Y S I O LO GY partial injury from developing OF SPINAL CORD into more extensive, permanent damage I N J U RY  SHOCK Spinal Shock A sudden depression of reflex activity below the level of spinal injury Muscular flaccidity and lack of sensation and reflexes Neurogenic Shock Due to the loss of function of the autonomic nervous system Blood pressure, heart rate decrease, and cardiac output decrease Venous pooling occurs due to peripheral vasodilation Paralyzed portions of the body do not perspire Patient can get too hot  Acute emergency Occurs after spinal shock has resolved and may occur years after the injury Occurs in persons with a SC lesion above T6 Autonomic nervous system responses are exaggerated AUTONOMIC Symptoms include severe pounding headache, sudden increase in blood DY S R E F L E X I A pressure, profuse diaphoresis, nausea, nasal congestion, and bradycardia Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (e.g., constipation), or stimulation of the skin AUTONOMIC DY S R E F L E X I A Interventions Place client in sitting position immediately Check patency of urinary catheter Examine for a fecal mass Examine the skin Examine the environment for any stimulus Hydralazine/Apresoline (IV) to lower BP  Promoting adequate breathing Improving mobility Promoting adaptation to sensory and perceptual alterations Maintaining skin integrity NURSING INTERVENTIONS Maintaining urinary elimination Improving bowel function Providing comfort measures Monitoring and managing complications  CHAPTER 64 M A N A G E M E N T O F PAT I E N T S W I T H NEUROLOGIC INFECTIONS, AUTOIMMUNE D I S O R D E R S , A N D N E U R O PAT H I E S INFECTIOUS NEUROLOGIC DISORDERS Meningiti Brain Encephal s Abscess itis  Inflammation of the pia matter, arachnoid, and subarachnoid space Septic Aseptic N. meningitidis is transmitted by secretions or aerosol contamination, and infection is MENINGITIS most likely in dense community groups Diagnostic test is a lumbar puncture (CSF) Higher incidence rates among those living in close proximity such as bigger cities and college students living in dorms MENINGITIS KERNIG’S SIGN BRUDZINSKI’S SIGN  Prevention by vaccination against H. influenzae and S. pnuemoniae for all children and at-risk adults Early administration of high MEDICAL doses of appropriate IV antibiotics for bacterial MANAGEMENT meningitis Dexamethasone – administer before antibiotic Treatment of dehydration, shock, and seizures  Conduct frequent/continual assessment including VS and LOC Protect patient form injury related to seizure activity or NURSING altered LOC Monitor daily weight, serum MANAGEMENT electrolytes, urine volume, specific gravity, and osmolality Prevent complications associated with immobility NURSING MANAGEMENT Frequent or continual assessment, including VS and LOC Pain and fever management Protect patient from injury related to seizure activity or altered LOC Monitor daily weight, serum electrolytes, urine volume, specific gravity, and osmolality Prevent complications associated with immobility Infection control precautions Supportive care Measures to facilitate coping of patient and family  Collection of infectious material within brain tissue Risk is increased in immunocompromised patient Prevent by treating otitis media, mastoiditis, sinusitis, dental infections, and systemic infections promptly BRAIN Diagnosis by MRI or CT; aspirate ABSCESS fluid CT-guided aspiration is used to identify the causative organisms Manifestations may include headache that is usually worse in the morning, fever, vomiting, neurologic deficits, signs and symptoms of increased ICP  BRAIN ABSCESS Medical Management Nursing Management Control ICP Conduct frequent and ongoing Drain abscess – why abscess neurologic assessment and responses Antibiotic therapy to treatment Ensure patient safety and protect Treat cerebral edema from injury Provide supportive care Monitor for neurologic deficits  Acute, inflammatory process of the brain tissue Causes include viral infections (herpes simplex [HSV]), vector- borne viral infections (West Nile, St. Louis), and fungal infections Manifestations may include headache, fever, confusion, hallucinations; vector borne—rash, ENCEPHALITIS flaccid paralysis, Parkinson-like movements Medical management Acyclovir for HSV infection, amphotericin or other antifungal agents for fungal infection Nursing management Frequent and ongoing assessment Supportive care  Multiple sclerosis AUTOIMMUNE Myasthenia gravis NEUROLOGICAL Guillain-Barré syndrome DISORDERS  A progressive immune-related demyelination disease of the CNS Clinical manifestations vary and have different patterns Frequently, the disease is relapsing and remitting; has exacerbations and recurrences of symptoms, including fatigue, weakness, M U LT I P L E numbness, diffi culty in coordination, SCLEROSIS loss of balance, pain, and visual disturbances Medical management Disease-modifying therapies; interferon -1a and interferon -1b, glatiramer acetate, and IV methylprednisolone Symptom management of muscle spasms, fatigue, ataxia, bowel and bladder control  PROCESS OF D E M Y E L I N AT I O N M U LT I P L E S C L E R O S I S Nursing Management Promote physical mobility Prevent injury Enhance bladder and bowel control Manage swallowing diffi culties Improve sensory/cognitive function Teach patient to scan the environment if having trouble with peripheral vision Improve home management Promote sexual functioning  Autoimmune disorder affecting the myoneural junction M YA S T H E N I A G RAV I S Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses Manifestations Initially symptoms involve ocular muscles; diplopia and ptosis Weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness  Medical Management Directed at improving function and reducing and removing circulating antibodies Pharmacologic therapy M YA S T H E N I A Anticholinesterase medications and immunosuppressive therapy G RAV I S Intravenous immune globulin (IVIG) Therapeutic plasma exchange Thymectomy  C O M P L I C AT I O N S O F M G M YA S T H E N I C C R I S I S CHOLINERGIC CRISIS Result of disease Caused by overmedication exacerbation or with cholinesterase precipitating event, most commonly a respiratory inhibitors infection Severe muscle weakness Severe generalized muscle with respiratory and bulbar weakness with respiratory and bulbar weakness weakness Patient may develop Patient may develop respiratory compromise respiratory compromise and failure failure  Result of disease exacerbation or a precipitating event, most commonly a respiratory infection Severe generalized muscle weakness with respiratory and bulbar weakness M YA S T H E N I C Patient may develop respiratory CRISIS compromise failure Patient is admitted to ICU and closely monitored  Autoimmune disorder with acute attack of peripheral nerve myelin Rapid demyelination Ascending weakness (start lower extremities and travel upper-ward) May produce respiratory failure and autonomic nervous system dysfunction GUILLAIN- with CV instability Most often follows a viral infection BARRÉ Related to influenza vaccine? (live virus) SYNDROME Manifestations are variable and may include weakness, paralysis, paresthesia, pain, and diminished or absent reflexes, starting with the lower extremities and progressing upward; bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension  Medical Management Medical emergency (in ICU) GUILLAIN- Requires intensive care management with continuous BARRÉ monitoring and respiratory support Plasmapheresis and IVIG are used to SYNDROME reduce circulating antibodies  Nursing Management Maintaining respiratory function Enhancing physical mobility Providing adequate nutrition Improving communication Decreasing fear and anxiety GUILLAIN- Monitoring and managing potential complications BARRÉ Promoting home care SYNDROME  Condition of the fifth cranial nerve characterized by paroxysms of pain Most commonly occurs in the second and third branches of this nerve. Vascular compression and TRIGEMINAL pressure is the probable cause NEURALGIA Occurs more often in the fifth and sixth decades and in women and (TIC persons with MS Pain can occur with any DOULOUREUX) stimulation such as washing face, brushing teeth, eating, or a draft of air Patients may avoid eating, neglect hygiene, and even isolate themselves to prevent attacks DISTRIBUTION OF THE TRIGEMINAL N E RV E BRANCHES  Anticonvulsant agents such as carbamazepine Gabapentin and antispasmodic MEDICAL such as baclofen MANAGEMENT Phenytoin as adjunctive therapy OF Surgical treatment TRIGEMINAL Microvascular decompression of the trigeminal nerve NEURALGIA Radiofrequency thermal coagulation Percutaneous balloon microcompression  Patient education related to pain prevention and treatment regimen Measures to reduce and prevent pain; avoidance of triggers NURSING Care of the patient experiencing INTERVENTIONS chronic pain FOR Measures to maintain hygiene: TRIGEMINAL washing face, oral care NEURALGIA Strategies to ensure nutrition; soft food, chew on unaffected side, avoid hot and cold food Recognize and provide interventions to address anxiety, depression, and insomnia  Facial paralysis caused by unilateral inflammation of the seventh cranial nerve Manifestations: unilateral facial muscle weakness or paralysis with facial distortion, increased B E L L ’ S PA L S Y lacrimation, and painful sensations in the face; may have difficulty with speech and eating Most patients recover completely in 3 to 5 weeks, and the disorder rarely recurs DISTRIBUTION OF THE FA C I A L N E RV E  Medical Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder Nursing MANAGEMENT Provide and reinforce information OF BELL’S and reassurance that stroke has not occurred PA L S Y Protection of the eye from injury; cover eye with shield at night, instruct patient to close eyelid, use of eye ointment and sunglasses Facial exercises and massage to maintain muscle tone  CHAPTER 65 M A N A G E M E N T O F PAT I E N T S W I T H O N C O LO G I C O R D E G E N E RAT I V E NEUROLOGIC DISORDERS  Benign or malignant Classification is based on location and histologic characteristics Types of primary tumors Gliomas BRAIN TUMORS Meningiomas Acoustic neuromas Pituitary adenomas Angiomas: masses of abnormal blood vessels Metastatic tumors BRAIN TUMORS Symptoms depend on the location and size of the lesion and the compression of associated structures Manifestations Localized or generalized neurologic symptoms Symptoms of increased ICP Headache Vomiting Visual disturbances Seizures Hormonal effects with pituitary adenoma Loss of hearing, tinnitus, and vertigo with acoustic neuroma  COMMON BRAIN TUMOR SITES  Specific treatment depends on the type, location, and accessibility of the tumor Surgery Goal is removal of tumor without BRAIN TUMOR- increasing neurologic symptoms or to relieve symptoms by MEDICAL decompression MANAGEMENT Craniotomy, transsphenoidal surgery, stereotactic procedures Radiation therapy Chemotherapy Pharmacologic therapy TRANSSPHENOIDAL HYPOPHYSECTOMY  Nursing Management Risk for aspiration Monitor/treat increased ICP BRAIN TUMOR Monitor motor movements Assess for sensory disturbances Evaluate speech  Cancer often originates elsewhere in the body and then spreads to the brain 25% of all cancer patients (it metastasizes to brain) Clinical Manifestations: CEREBRAL HA M E TA S TA S E S Gait disturbances Visual impairment Personality changes Memory loss and confusion Weakness Aphasia Seizures  Classified according to their anatomic relation to the spinal cord Intramedullary: within the cord Extramedullary: intradural; within or under the spinal dura Extramedullary-extradural: outside the dural membrane SPINAL CORD Manifestations include pain, TUMORS weakness, loss of motor function, loss of reflexes, loss of sensation Treatment depends on the type of tumor and location Surgical removal Measures to relieve compression: dexamethasone combined with radiation  Baseline neurologic exam with focus: ASSESSMENT Patient function, moving, and walking; adapting to weakness OF THE and paralysis and to loss of vision PAT I E N T W I T H and speech; dealing with seizures N E RVO U S Pain, respiratory symptoms, bowel and bladder function, SYSTEM sleep, skin integrity, fluid M E TA S TA S E S balance, and temperature regulation O R P R I M A RY Nutritional status and dietary BRAIN TUMOR history Family coping and family process  Parkinson’s Disease Huntington’s Disease Amyotrophic Lateral Sclerosis D E G E N E RAT I V E Muscular Dystrophies DISORDERS Degenerative Disk Disease Herniation Postpolio Syndrome PA R K I N S O N ’ S D I S E A S E Slow, progressive neurologic movement disorder associated with decreased levels of dopamine Manifestations: Cardinal: tremor, rigidity, bradykinesia/akinesia, postural instability Autonomic: sweating, drooling, flushing, orthostatic hypotension, gastric and urinary retention Dysphagia Psychiatric changes: depression, anxiety, dementia, delirium, hallucinations PA R K I N S O N ’ S D I S E A S E Medical Management Control of symptoms Maintenance of functional independence Surgery Medically managed Levodopa Cogentin Symmetrel Dopamine agonists MAO inhibitors Antidepressants Antihistamines  Sinemet Increases the amount of dopamine available Levodopa is converted to dopamine Carbidopa protects levodopa L E VO D O PA - Aids in muscle function C A R B I D O PA Monitor for toxicity Muscle twitching Facial grimacing Spasmodic eye winking  Nursing Management PA R K I N S O N ’ S Daily program of exercise DISEASE ROM exercises Consultation with physical therapy Walking techniques for safety and balance Frequent rest periods Encourage, teach, and support independence Encourage socialization, recreation, and independence Prevent constipation Risk for aspiration / malnutrition  A chronic progressive hereditary disease that results in choreiform movement and dementia Transmitted as an autosomal HUNTINGTON’S dominant trait DISEASE Pathology involves premature death of cells in the striatum of the basal ganglia (control of movement) and the cortex (thinking, memory, perception, judgment)  “Lou Gehrig disease” Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei of the A M YO T R O P H I C lower brainstem L AT E RA L Manifestations SCLEROSIS Progressive weakness and atrophy of muscle cramps, twitching, and (ALS) lack of coordination Spasticity, deep tendon reflex brisk, and overactive Diffi culty speaking, swallowing, breathing  Clinical Manifestations: Fatigue Progressive muscle weakness Cramps A M YO T R O P H I C Fasciculations L AT E RA L Incoordination SCLEROSIS Diffi culty in talking Diffi culty in swallowing Diffi culty in breathing  Incurable disorders characterized by progressive weakening and wasting of skeletal and voluntary muscles Most are inherited disorders MUSCULAR Duchenne muscular dystrophy (DMD) is the most common and DY S T R O P H I E S inherited as a sex-linked trait Common characteristics: Varying degrees of muscle wasting and weakness Abnormal elevation in serum levels of muscle enzymes D E G E N E RAT I V E D I S K DISEASE Low back pain is a significant public health disorder and has significant economic and social costs Most back problems are related to disc disease Degenerative changes occur with aging or are the result of previous trauma Radiculopathy produces pain Continued pressure may produce degenerative changes in the nerves with resultant changes in sensation and motor responses Treatment is usually conservative: rest and medications Surgery may be required  Cervical disk herniation Lumbar disk herniation Spondylosis – stiffness of vertebra Paresthesia H E R N I AT I O N Pain and stiffness in the neck and shoulders Low back pain, especially with activity Postural deformity  Medical Management Medications Surgery Nursing Management H E R N I AT I O N Relief of pain Improve mobility Monitor for bleeding / hematoma Frequent neuro checks Monitor for dysphagia  Determining the onset, location, and radiation of pain Assessing for paresthesia, limited movement, and diminished function of the neck, shoulders, and upper extremities Determine whether the symptoms are bilateral Cervical spine palpated to assess muscle tone and tenderness Range of motion in neck and ASSESSMENT OF shoulders is evaluated T H E PAT I E N T Health issues Mood and stress levels UNDERGOING A Patient education C E RV I C A L DISCECTOMY  PLANNING AND GOALS The goals for the patient may include: FOR THE Relief of pain PAT I E N T Improved mobility Increased knowledge and self-care UNDERGOING ability A C E RV I C A L Prevention of complications DISCECTOMY  NURSING Relieving pain INTERVENTIONS Improving mobility FOR THE Monitoring and managing PAT I E N T potential complications UNDERGOING A Promoting home, community- CERVICAL based, and transitional care DISCECTOMY