(7 | i Surgical Nursing i AT. Gee F a Gels SUAS aL FFNervous System Disorders and Its Management Body of fornix Cerebrum Corpus callosum Pituitary gland Pons varolii Vertebral column Spinal cord Dura Mater Ue Td Head Injury/Brain Injury Guillain Barre Syndrome Seizure (Epilepsy) Multiple Sclerosis Headache Bell’s Palsy Meningitis : Huntington’s Disease or Chorea Encephalitis Stroke (Cerebral Vascular Accident) Myasthenia Gravis Nursing Interventions of Nervous Parkinson’s Disease System DisordersNervous System Disorders and Its Management | AUK} AN JURY/BRAIN INJURY INTRODUCTION Head injury refers to damage to any of the structures of the head as a result of trauma. It is most often used to refer to an injury to brain. It may also involve the bones, muscles, blood vessels, skin and other organs of face or head. Mostly head injuries are caused by blows to the head from the numerous causes including motor vehicle accidents and falls. DEFINITION Injuries to the head involve trauma to the scalp, skill and brain. ETIOLOGY > Motor vehicle accidents. > Falls > Accidents. MECHANISM OF INJURY Acceleration: When head is fixed and objects are move. Deceleration: When head moving and objects are fixed. Deformation: Deformation refers to injuries in which the force results in deformation and disruption of the integrity of the impacted body part, e.g., skull fracture. wre BRAIN INJURY Traumatic Brain Injury (TBI), also known as head injury, is the disruption of normal brain function due to trauma-related injury. TYPES OF BRAIN INJURY 1. Concussion: Transient interruption in brain activity, no structural injury noted on radiographic. Cerebral Contusion: Bruising of the brain with associated swelling. 3. Intracerebral Haematoma: Bleeding into the brain tissue commonly associated with edema. Epidural Haematoma: Blood between the inner table of the skull and dura. Subdural Haematoma: Blood between the dura and arachnoid caused by venous bleeding. CLASSIFICATIONS 1. Mild (GCS 13 to 15) with loss of consciousness to 15 minutes. 2. Moderate (GCS 9 to 12) with loss of consciousness for up to 6 hours. 3. Severe (GCS 3 to 8) with loss of consciousness greater than 6 hours. CLINICAL MANIFESTATIONS > Respiration may be normal. > Altered LOC (Level of Consciousness) > Pupil are usually small. » Loss of normal eye movement. > Headache, vertigo. > Agitation (worry, disturb), restlessness. > Coma. » Sudden onset of neurologic deficit.204 Medical Surgical Nursing > Cardiac arrhythmias. > Change in body temperatures. > Otorrhea may indicate leakage of CSF from ear due to posterior fossa skull fracture > Abnormal bleeding due to coagulopathy. \ DIAGNOSTIC EVALUATIONS —EEEVALVATIONS a > History collection > Physical examination A > CT scan > MRI : > Radiography. COMPLICATIONS ———— > Increased ICP, hydrocephalus, brain herniation. > Permanent neurologic deficits (cognitive, motor, sensory, speech). > Neurobehavioural alterations (impulsivity, uninhibited aggression and emotional lability). MANAGEMENT Medical Management > Antiseizure medication, e.g., phenytoin. > Histamine antagonists (reduce risk of stress ulcer). ¥ > Mild analgesics. } > Antibiotic therapy for prevention secondary infection. » Osmotic diuretics, e.g., mannitol, to reduce ICP. > Dexamethasone (steroid) — In case of Tes ICP. Surgical Management > Craniotomy: Removal of haematoma by incision to cranium. Dietary Management > NPO (nothing by mouth) until peristalsis returns. > Enteral tube feeding with head elevated position. Nursing Management v= Open wound should be covered and pressure applied to control bleeding. 3 To clean the wound with antiseptic solution. j w= Check ABC (Airway, Breathing, Circulation) of patient and maintain them. | w= Manage ICP and cerebral edema. ° ‘ w= Surgery to evacuated intracranial haematoma. ws Make glasgow coma scale. ? v3 Determine CSF. % Monitor neurological status of patient. Nursing Diagnosis © Altered tissue perfusion related to Hypotension, Haematoma, Intracranial Hemorrhage. *" Altered body temperature related to disturbed metabolic process © Ineffective airway clearance related to coma, bleeding into airwayNervous System Disorders and Its Management | 205 q Imbalanced nutrition less th; coma Infection related to open injury High risk for injury related to restlessness and confusi Constipation related to loss of muscle tone refl on Urinary elimination impaired re] ‘es Sleep pattern disturbance related Impaired physical mobility rel ‘an body requirement related to loss of pharyngeal reflex or lated to altered consciousness. " i frequent assessment and loss of REM sleep. ba ) ‘ated to motor sensory deficits or ; < coma. Deficient fluid volume related to inability to take fluids by mouth. Risk for impaired skin integrity related to immobility. " , Interrupted family process related to health crisis. , Risk for seizure related to intracrania ; brain. 49999 gggsa 1 bleeding, infarction, trauma, hypoxia, injuries to ficient © Deficient knowledge related to new Procedures and treatment and expected outcome. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234 SEIZURE (EPILEPSY) DEFINITION —_—_——_ A seizure occurs when the nerve cells in the brain send out sudden, excessive, uncontrolled electrical signals. All brain functions including feeling, seeing, thinking and moving muscles depend on electrical signals present between nerve cells in the brain, 8 Convulsions: The term convulsion is sometimes used as a synonym for seizure but not all seizures are characterized by convulsions. Convulsions or fits are abnormal, involuntary contraction of muscles seen in seizure disorder. ‘ Epilepsy is a disorder characterized by recurring seizures. Means a pattern of repeated seizures is referred to as epilepsy. CAUSES > Unknown > Hypoxemia > Vascular insufficiency > Fever > Hyperglycemia > Hypocalcemia > Toxemia in pregnancy > CVA (Thrombosis, embolism, Hemorrhage) > Hypertension ~ > Infection of CNS > Metabolic change > Brain tumour > Drug withdrawal > Allergy > Degenerative brain disorder : > Head injury/Head trauma (conclusion, brain contusion) > Meningitis, encephalitis, brain abscess etc. CLASSIFICATION OF SEIZURES 1. Generalized Seizure (a) Tonic - clonic seizure (grand mal) (b) Absence (petit mal) (c) Minor, Motor Seizures (Akinetic, Myoclonic, Atonic)Medical Surgical Nursing 2. Partial (Focal) - () Complex vot (a) ar It is a state in which a client has continuous seizures ots Status Ep’ : Tt 3. lasting at least 30 minutes. oe i ical emergency: nis = aaa taal mal): It is a common type of epilepsy. A grand mal fe vs (a) Tonic- ; tages are: / . a fone of fits): This is an initial warning stage before the fit, 1, Au Symptoms are: - Aol disturbances > Hallucination > Psychogenic changes vein di t > Epigastric discomfor > Avoneinal sensation of smell, taste, nausea 2. Tonic: 30 sec. duration aout > Extension of legs > Flexion of arms ; f > Loss of consciousness > Tonic contraction of muscles > Acry sound due to spasm of respiratory muscles 3. Clonic: Duration (1-5 min) ; ; It is immediately followed by a clonic phase during which there is a violent jerking of face and limbs biting of tongue, incontinence of urine and faeces. 4. Postictal phase: Unconsciousness (coma) It lasts for few minutes to several hours. There may be headache, confusion, sleepiness, automatic behaviour. (>) Petit mal seizures (absence fits): It is typically seen in children during an absence attack. Symptoms are: > Child stops working > Looks confused > May blink or roll up the eyeball > Not responds to verbal commands. Pass CLINICAL MANIFESTATIONS > Impaired consciousness. > Excess or loss of muscle tone or movement. > Cyanosis. > Fixed jaw. > Dilated and fixed pupils. > Body stiffness. > Disturbance of behaviour, mood sensation and perception. > Disturbance of autonomic functions of the body. > Incontinence of urine. DIAGNOSTIC EVALUATIONS é o” psiedheltladdabclltertcidel ted ht) ° ow of seizures. » Electroencephalograph 4 vr > Neuropsychological tests for epilepsy MANAGEMENT Medical Management (Pharmacological Therapy) Anticonvulsant or Antiepileptic, e.g, > Phe i enytoin > CarbamazepineNervous System Disorders and Its Management |WAUMA > Phenobarbital » Valproate > Primidone. Surgical Management By destroying minute areas of the brain. Nursing Management Nursing care before seizures ws To maintain airway vs To prevent injury 3 To observe seizure % To administer drug. Nursing care after seizures To assist behavioural and conditions of patient after seizure. Instruct to patient that treatment of seizure will be long duration. To give instruction to family member's of patient about care giving during seizure. Drugs should not be discontinuing without permission of doctor. Do not drive alone, avoid swimming, horse-riding. Patient should sit on floor-when he/she feels Aura signs. GK KE Nursing Diagnosis Risk for injury related to seizures and cerebral edema. Hyperthermia related to infectious process. Ineffective tissue perfusion related to disease condition. Disturbed thought process related to personality changes. Risk for chronic low self-esteem related to seizure, social isolation, misperceptions. Deficient knowledge related to lack of exposure. Information misinterpretation, treatment and safety measures, 4q 9a aad Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. DEFINITION ‘ It is a symptom of an underlying disorder rather than a disease itself. ate Mainly two types: 1. Primary Headache 2. Secondary Headache 1, Primary Headache It is of three types. (a) Tension headache (b) Migraine or Vascular headache | (©) Cluster headache (a) Tension Headache: It is due to emotional and physical stress. It occurs mostly temporal area, forehead and back side of head. Also known as muscle contraction headache. Treatment: { > Narcotic analgesics. > NSAIDs > Muscle relaxant (Baclofen) - || Medical Surgical Nursing > Antidepressant and tranquilizers, ¢.8-, Nursing Management > Provide reassurance to patient. > Provide behavioral therapy to patient. current throbbing headache tha| imipramine. (b) Migraine (Vascular Headache): A re \ it characte. affects one side of the head. Due to spasm and subsequent overdilation of cert Stay in the brain. * ATterigg > Women are more susceptible than men. > It occurs in supraorbital, retro-orbital or temporal area. Signs/Symptoms . > Pain in one side of head > Periodic attack of pain > Nausea > Vomiting > Visual disturbance > Tingling > Photophobia. Treatment . > Analgesic, e.g., Acetaminophen. > 5HTI agonist, e.g., Sumatriptan (It rapidly reverse the dilation of blood Vessels) > Antihistamines, specially (cyploheptadine) which inhibits the effects of serotonin Prophylactic Measures . > Restrict chocolate, alcohol, onions, yeast product, caffeine product ete., in diet () Cluster Headache: It occurs mainly in men. It starts from eye orbit and then radiate to facial and temporal region. Signs/Symptoms > Throbbing pain > Nasal congestion > Watery eyes > Red skin on the affected side. Treatment > Cold application > Analgesics, e.g, indomethacin > Antidepressants, e.g., - Imipramine - Phenelzine — Fluoxetine. 2. Secondary Headache: It occurs in case of brain tumour, meningitis, subarachnoid haemorrhage and hypertension etc. > In brain tumour, headache characterized by weakness, visual loss and seizures. > In meningitis, stiffness of neck with headache is common. > In hypertension, headache may be dull and occipital type. It may occur in morning mostly. Treatment: Treatment with secondary disease management which causes headache. INTRODUCTION Meningitis is an infection of the meninges (the protective membranes that surround the brain and spinal cord. The infection is mostly caused by bacteria and virus, which leads to the meninges becoming inflamed (Swollen). It can damage the nerve and brain.Nervous System Disorders and Its Management |AUE) DEFINITION An inflammation of meninges (outer covering membrane of brain and spinal cord) of brain and y spinal cord. CAUSES/ETIOLOGY y > Meningococcal atin > Myobacterium tuberculli > ae Mus influenza » Pneumococcal—pneumococcus » Stap! ny coe inte . » Salmonella > Middle ear infection > Head injury > Cerebral abscess > Droplet infection from nasopharynx, sinuses mastoid. RISK FACTORS > Age ~ children younger than 5 years, > Use of immunosuppressive drug > Chronic malnutrition. > Overcrowdi ing » AIDS > Diabetes > CSF shunts > Pneumonia > Chronic alcoholism > Splenectomy. PATHOPHYSIOLOGY f Causative organism enters the blood stream Cross the blood brain barrier | Inflammatory reaction in meninges | | | Inflammation of subarachnoid ‘Space and pia mater occurs Inflammation may cause increase ICP | CSF flows in subarachnoid space | CSF cloudness or infected | , “CSF cell count in TYPES » > Bacterial meningitis > Viral meningitis | arigiti > Parasitic meningitis > Fungal meningitis a ps ‘i : i tis. > Neoplastic meningitis > Hospital acquired post craniotomy meningi CLINICAL MANIFESTATIONS IES TATIONS Confirmative Sign toh fi ft 1. Positive Kernig’s Sign: When patient lying with the thigh fixed = Sins inten can not completely extend his legs. Patient feel severe pain and s muscles in legs (see Fig. 10.1).YAIR) Medical Surgical Nursing place the patient supine and flex the heag 2. B inski’s Sign: To elicit, Brudzinski’s sign, HX Se ei and, Result d ankles with neck flexion indicates upward. Resulting flexion of both hips, knees an meningeal irritation (see Fig. 10.2). Fig. 10.1: Positive Kerning’s Sign. Fig. 10.2: Brudzinski’s Sign. COMMON SIGNS AND SYMPTOMS > Severe headache > Stiffness of neck > Irritability > Malaise > Restlessness > Nausea > Vomiting > Disorientation > High grade fever >» Tachycardia > Tachypnoea > Coma > Seizures > Sleeplessness > Photophobia (sensitivity to light) > Phonophobia (fear to loud voice) > Altered mental status (confusion). DIAGNOSTIC EVALUATIONS > By +ve signs > Physical examination > ‘History collection > Blood test > Lumber puncture > CBC > Blood cultures (to indicate the organism). > CSF evaluation for pressure, protein, glucose, leukocytes. > MRI/CT scan (to detect abscesses). COMPLICATIONS > Tes ICP may cause severe visual losses, cerebral edema, tissue damage.Nervous System Disorders and Its Management | WABI MANAGEMENT Medical Management > Antimicrobial therapy, eg. — Ceftrixone — Cefotaxime Antibiotics, e.g., Penicillin G, Ampicillin, Amoxy-clav-625 mg. > Antiviral: If viral infection, e.g., Acyclovir. > Symptomatic drug, e.g. Antipyretics, Analgesics, Antiemetics (Domperidone), Antiseizures, Anticonvulsants (Phenytoin). Anti-inflammatory agents, e.g., dexamethasone. > > Nursing Management % Management of shock by LV. therapy. Management of airway by O, administer. To eliminate infection with antimicrobial therapy. Provide supportive care to the patient. To control body temperature. Monitor regular vital signs. Maintain personal hygiene of patient. Provide comfort rest. VUKKEEE Nursing Diagnosis 4q Altered body temperature hyperpyrexia related to infectious process. Risk for imbalanced fluid volume R/T fever and Les intake of fluid. Ineffective tissue perfusion (cerebral) related to infectious process and cerebral edema. Potential for altered skin integrity related to impaired mobility. Acute pain related to neurologic effects from the disease Process. Risk for injury related to seizure. dag? Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. It is an acute inflammation of the brain. This is mostly caused by viral infection and can cause severe problems to nervous system. Encephalitis is more serious than meningitis. Encephalitis with meningitis is called as meningoencephalitis. There are two types primary encephalitis occurs due to virus and secondary encephalitis occurs first some when else in body and finally spread to the brain. DEFINITION An inflammation of brain parenchyma or brain tissue is known as Encephalitis. CAUSES > Lead, arsenic or carbon monoxide toxicity. > Infection, e.g., typhoid fever, measles, chickenpox. > Autoimmune.Medical Surgical Nursing > Viral: — Arbo virus — Herpes simplex — Rabies virus CLINICAL MANIFESTATIONS > Fever > Seizures > Confusion > Stupor and coma > Aphasia > Motor involvement > Involuntary’ movement > Headache > Nausea > Vomiting > Stiffness of neck > Photophobia > Neurological deficit > Tes ICP may cause unconsciousness > Motor weakness > Bizarre behaviour > Memory loss > Ataxia. DIAGNOSTIC EVALUATIONS > Physical examination > ByMRI > Brain biopsy > LP (Lumber Puncture) to evaluation of CSF > EEG. MANAGEMENT Medical Management > Diuretics to reduce ICP. Nursing Management > Antiviral drug - Acyclovir IV. > Anticonvulsant for seizures. = Maintain adequate fluid intake to prevent dehydration, but avoid fluid overload, that may increase cerebral edema. Maintain adequate nutrition. Give small, frequent meals or nasogastric tube or parenteral feedings. x To prevent constipation and minimize the risk of increased ICP resulting from straining at stool, provide a mild laxative or stool softener. Provide comfortable position to patient Provide mouth care frequently. Maintain a quiet environment. Darkening the room may decrease headache. During seizures, take precautions to protect him from injury. Monitor and record intake and output. If the patient becomes delirious or confused, try to reorient him often. Teach the patient and his family about the disease and its effects. 3 supplement meals with VoK KOO Nursing Intervention @ Provide psychotherapy To protect from injury : Other general care which are required in neurological disease Risk for injury related to seizures. Disturbed thought process related to personality changes. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. gaa4Nervous System Disorders and Its Management | yak) ‘ASTHENIA GRAVIS INTRODUCTION It is rare long-term disease cause muscle weakness that comes and goes. Most commonly affects the muscles that control the eyes and eyelids, facial expressions, chewing, swallowing and speaking. Myasthenia gravis affect people of any age, typically starting in women under 40 and men over 60. DEFINITION It is an autoimmune disease that leads to fluctuating muscular weakness and fatigue that worsens with exercise and improve with rest. It is caused by a breakdown in the normal communication between nerves and muscles. ETIOLOGY/CAUSES > Unknown. > Aging factors. >» Loss of acetylcholine receptors in the post synaptic neurons of the neuromuscular junction (see Fig. 10.3). Blocking of ACh Binding 4 PCat} 4 (b) Myasthenia Gravis - Fig. 10.3: Myasthenia Gravis (a) Normal ACh receptor site; (b) ACh receptor site in myasthenia gravis. CLINICAL MANIFESTATIONS > Facial muscles weakness _ _» Dysphonia > Dysphagia > Respiratory muscles weakness. > Ocular symptoms (ptosis, diplopia) > Drift (slowly or aimlessly movement) > Chewing and swallowing muscles weakness DIAGNOSTIC EVALUATIONS > History collection > Physical examination > CT scan > Electromyography > Serum test for acetylcholine receptor antibodies.Medical Surgical Nursing MANAGEMENT Medical Management _ - > Anticholinesterase Agents, 8. neostigmine, pyridostigmine, > Corticosteroids; To reduce the serum Ach level. Surgical Management > Thymectomy - Removal of thymus gland. Nursing Management ; We should make plan exercise, meals, patient care and activities to Make th energy peaks. , ; le ~ If swallowing difficulty, give semi-solid foods instead of liquids to lessen th choking. ® Tisk 3s We should encourage for energy saving techniques such as sitting to limit up and down stairs, etc. % Encourage or instruct to take balanced diet, rest, exercise and relaxation also q healthy life style. velop We should recommend participation in groups involved in fitness/exercise such help patient to stay motivated to remain active within limits of the conditions act cay w= Administer medications as indicated, e.g., amentadine (useful in treatment ef 7 TCAs useful in lifting mood). ‘atigueg Vitamin B complex (support nerve cell replication, enhance metabo! may increase sense of well-beings). Most of Perform Activitie, , ic functions ay 4 Nursing Diagnosis * Fatigue related to muscular weakness or disease condition. © Risk for low self esteem related to social isolation, increased secretions. © Risk for aspiration related to facial muscle weakness. © Deficient knowledge related to disease process. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234, AUN BN z.03 DEFINITION Parkinsonism is a chronic, progressive neurologic disease affecting the basal ganglia of the brain that leads to deficiency of neurotransmitter dopamine. It is characterized by muscles weakness, rigidity, resting tremor, bradykinesia (slow movement and gait disturbance). RISK FACTORS > Age factors > Atherosclerosis >» Diabetes > Deficiency of dopamine > Arterial hypertension > Hyper lipidemia. CLINICAL MANIFESTATIONS eee Three classical features: > Tremor > Rigidity > Akinesia (Bradykinesia) loss of musclés function.Nervous System Disorders and Its Management |W is Others: > Mask like facial expression Normal Dysphagia Neuron Normal Les sexual capacity movement : Gait changes : 5 Sleeplessness \/7 Salivation (drooling) Dopamine Sweating Mental disturbances Dementia Receptors Parkinson's affected Movement disorders Depression Weight loss Head bent forward Micrographia (changes in handwriting, small script) Dysarthria (a speech disorder in which pronunciation is unclear). VVVVVVVVVV Vv Fig, 10,4: Dopamine levels Ina normal anda Parkinson’s affected neuron, v PATHOPHYSIOLOGY Unknown Cause Deterioration of neurons in region of brain (substantia nigra) Decrease secretions of dopamine neurotransmitter Movement disturbance (tremor, DIAGNOSTIC EVALUATIONS » History collection > Physical examination >» CT scan > MRI >» Mental status examination. COMPLICATIONS | > Dementia > Aspiration > Injury due to falling. MANAGEMENT Medical Management Levodopa » Carbidopa with levodopa Anticholinergic drugs, e.g., Benzotropin mesylates Avoid Vit. B, > Amantadine (blocks the reuptake of dopamine). vvZACH) Medical Surgical Nursing Nursing Management ws Health assessment Provide ROM exercises daily Provide emotional support to family Physical therapy sa Provide stool softeners. ~s Maintain fluid intake oe zs Rehabilitation technique. Nursing Diagnosis @ Impaired phy: Self care deficit related to Akinesia Ineffective coping related to dysfunctio Impaired verbal communication relate Altered nutrition related to dysphagia. Constipation related to medications and decrease activity. Low self esteem related to body changes, dependency. ing Intervention of above Nursing Diagnosi: sical mobility related to Akinesia. and muscles weakness. n due to disease progression, loss of independence. d to dysarthria and psychological problems. 494449 Note: for Nurs: is refer page nos. 226-234. ~~ GUILLAIN BARRE SYNDROME NT ee nen ALLE) INTRODUCTION It is an autoimmune disorder of peripheral attacks part of the peripheral nervous syste can eventually cause paralysis. nervous system in which the body's immune system m that leads to weakness, numbness and tingling. It 1 DEFINITION Guillain-Barre Syndrome (GBS) is an acute rapid disease with progressing, ascending, inflammatory demyelinating polyneuropathy of peripheral sensory and motor nerves. ETIOLOGY > Unknown > URI > Glinfection > Mycoplasma pneumonia > HW. CLINICAL MANIFESTATIONS > Weakness > Dyskinesia > Paresthesia > Quardiplegia > Hyporeflexia > Pupillary disturbances > Areflexia > Ascending weakness > Difficulty in talking, chewing and swallowing (due to cranial nerve involvement). DIAGNOSTIC EVALUATIONS > History collection > Physical examination > CSF examination - Tes protein > Electrophysiologic studies.Nervous System Disorders and Its Management ee MANAGEMENT [basta arid > Supportive care > O, administration > Prevention of infection - > Analgesics and muscle relaxants are needed. » High dose immunoglobulin therapy is used to reduce the severity of the episode. Nursing Management ws Plan care with consistent rest periods between activities to reduces fatigue. w= Nurse should help patient and family to understand that fatigue is an integral part of neurodegenerative disorders. 2 We should minimize the stimuli in the environment and provide clear and simple directions. We should provide written materials if appropriate. x Allow adequate time for patient's response. x Provide knowledge about disease condition to patient and family members to enhance their coping abilities and decrease anxiety. Maintain quiet and comfortable environment, e.g., noise reduction, curtains closed, private room and dim lights. xs Assess the patient's gait, muscle weakness; strength, coordination and balance. ws Assess degree of mobility. xs Encourage self care as tolerated and seeking assistance when necessary, arrange for home care when needed. xs Provide position to avoid skin/tissue pressure damage, turn at regular intervals. x Provide meticulous skin care, massaging with emollients to promote circulation and skin elasticity. Nursing Diagnosis © Impaired physical mobility related to dyskinesia, paralysis. @ Imbalanced nutrition less than body requirement related to difficulty in chewing and swallowing due to cranial nerve involvement. @ Impaired verbal communication related to difficulty in speech due to cranial nerve involvement. @ Anxiety related to disease process. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. LTIPLE SCLEROSIS INTRODUCTION Multiple sclerosis is a chronic an 2-3 times more common in women Myelin is produced by oligodendrocytes w’ In multiple sclerosis demyelination occurs when the immune system ina, and destroy the myelin, which make common between neuron breakdown, sensory, motor and cognitive problem. d disabling disease that usually starts in young adult and is that men. It is caused by damage to nerve cells in the CNS. hch are a group of cells that support neurons. ppropriately attacts ultimately leading DEFINITION Multiple sclerosis is a demyelinating disease in which the insulting co brain and spinal cord are damaged. This damage disrupts the ability of nervous communicate resulting in a range of sign and symptoms. covers of nerve cells in the system toMedical Surgical Nursing a > Autoimmune dysfunction > Unknown > Infectious process SE A and rubella. > Infections such as measles, mumps a" Me jar > Emotional stress ; fie jury > Pregnancy > ee > Vitamin D Deficiency > Epstein-ba is Ai “3 Myelin degeneration of the brain Myelin degeneration of the spinal cord Fig. 10.5 (a): Demyelination of myelin sheath. PATHOPHYSIOLOGY " Environmental . ; Genetic factors Infectious triggers ‘Activation of myelin-reactive Th1/17 cells Infiltration into the CNS BBB breakdown, immune cell recruitment CNS tissue damage Neurological dysfunction CLINICAL MANIFESTATIONS ; a ame iWeaknicas > Tingling sensation (paresthesia) yr g vision > Bowel and bladder dysfunction paired speech > Emotional lability > Urinary dysfunction > Abnormal reflexes > Incoordination caused by cerebral involvementNervous System Disorders and Its Management Fig. 10.5 (b): Damaged myelin sheath. > Charcot’s neurologic triad: — Nystagmus — Dysarthri — Intenstion tremor yes DIAGNOSTIC EVALUATIONS > History collection (infection, genetic factors) > Neurological examination > MRI > CT Scan : > CSF Examination > Electrophoresis study > Visual evoked potential MANAGEMENT Medical Management > Corticosteroids therapy. > Alkylating agents, e.g., cyclophosphamide. > Use of interferon beta-1a (Avonex) and interferon beta-1f (Betaseron), for reducing rate and size of multiple sclerosis plaques in CNS also decreases severity. Nursing Management Provide psychological support to the patient and family. Increase comfort with massages and relaxing baths. Administer medications as prescribed. Promote emotional stability. Help the patient establish a daily routine to maintain optimal functioning. Keep bedpan or urinal readily accessible because the need to void is immediate. Encourage the patient to take adequate fluid and regular urination. Assess adverse reactions to administered medications. Monitor bowel and bladder function during hospitalization. Assess patient's neurologic status for deficits. Nurse should encourage patient and family to develop and strengthen problem solving skills to deal with situation. w= We should encoprage the patient/family for expression of feelings, including frustration, anger, hopelessness etc. ; . % Identify community resources, €.g., support groups, home care agencies, to provide information and opportunities to share with other similar patients/family. % Emphasize the importance of exercise. eK Ke ee KK KEMedical Surgical Nursing Nurse should teach the patient about bowel and bladder training if necessary, = Encourage patient input in planning schedule. / Encourage/instruct scheduling activities early in the day or during the time when en level in high. “tgy w= We should anticipate hygiene ne mouth and shaving eds and assist as necessary with care of nails, skin, h hair, Nursing Diagnosis ® Fatigue related to decrease energy/weakness. — Self care deficit related to neuromuscular and motor impairment, tremors, fatigue, Low self esteem related to dependence to other, body changes. pattern related to incontinence, retention, frequency of urine due to 944 Impaired urinary neuromuscular impairment. @ Risk for ineffective coping/disabled family cop psychological changes, anxiety, situational crisis, , © Deficient knowledge related to disease process, prognosis, treatment and needs, @ Impaired verbal communication related to impaired speech. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234, BELL’S PALSY (SEVENTH CRANIAL NERVE DISEASE) INTRODUCTION Bell's palsy is also known as facial palsy or facial paralysis. It can occur at any age. The exact cause is unknown but it is believed to be the result of swelling and inflammation of nerve that controls the muscles on one side of face. It may be a reaction which occurs after a viral ing related to physiological ch role changes. anges, infection. DEFINITION It is unilateral paralysis of the facial nerve causing weakness of muscles of one side of face. CAUSES = The exact cause of this disease is unknown, but many researchers believe it’s most likely triggered by a viral infection. — Herpes simplex virus — HIV — Herpes zoster virus — Epstein-Barr virus — Sarcoidosis, which causes organ inflammation — Lyme disease, which is a bacterial infection caused by infected ticks. CLINICAL MANIFESTATIONS > Drooping of eyes > Facial muscles weakness > Decrease tearing > Painful eye sensations > Decreased blink reflex > Photophobia > Drooling > Distorted body image. MANAGEMENT > Analgesics > Corticosteroids > Gentle massage > Moist heat application.a, 3 Nervous System Disorders and Its Management |W74l Nursing Management vx Assess pain for location, intensity, radiation and duration Identify the factors which increase pain and control them. Cae atta conosteralds and non-opoids analgesics to relieve pain and inflammation. Instruct the patient to apply moist heat to face to relieve symptoms. Perform and teach facial massage to alleviate feeling of stiffness. Teach the patient facial exercises and methods to get appropriate pronunciation, volume, eg., take a deep breathi ‘ . pe ‘ds with each breathe” before speaking to increase volume of sound and number of Exercise facial muscles by smiling, grimacing and puckering. Read around in front of mirror or into a tape recorder to monitor progress. Encourage the family to communicate with patient. Provide ot ag ae jeedback about any progress made with verbal communication ck increase confidence level and facili i i efforts to communicate verbally. ee DEERE SR PRETEEN Instruct/teach importance of follow-up care by rehabilitati . cocupational, speech, therapists iP y rehabilitation team, e.g., physio, a We should encourage for energy saving techniques such as sitting to perform activities, limit up and down stairs, etc. ya Encourage or instruct to take balanced diet, rest, exercise and relaxation also develop healthy life style. x Provide knowledge about disease condition to patient and family members to enhance their coping abilities and decrease anxiety. <= Consult with occupational therapist and rehabilitation team to enhances level of overall function and participation in activities. GRE RS $b G % Nursing Diagnosis © Chronic pain related to disease process. © Disturbed body image related to paralysis of facial nerve. & Low self esteem related to disease process. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. ’S DISEASE OR INTRODUCTION Huntington’s disease was originally called Hunt for dancing). This is because the involuntary movements associated with the condition can look like ferky dancing. Symptoms tend to worsen over time and disease often runs in families. In people with one parent with HB, the risks of them to develop it are 50-50. tington’s chorea (chorea is the Greek word used DEFINITION It is a genetically transmitted degenerative neurologic disease. It is characterized by abnormal movement (chorea), intellectual ‘decline and emotional disturbance progressive, leading to disability and death within 15-20 years.Medical Surgical Nursing ETIOLOGY » Aging factor > Unknown > Decrease production of GABA, acetylcho; . ine > Genetic is ine. > Increased concentration of dopam ‘ATIONS CLINICAL MANIFEST, > Choreiform movements (Dance like movemen > Hallucinations ectual decline > Emotional disturbances > Intel lectual . > Facial movements produce tics and gtimaces > penned thinking > Chewing and swallowing are difficult > Paranoid thu i 5 disorganized / ° aaa anne ain and uncontrollable movements of entire body occur as the disease progresses. DIAGNOSTIC EVALUATIONS > History collection > Physical examination > CT scan > MRI. MANAGEMENT > Antidepressant for depression >» Diazepam Soft diet should be provided > Provide good psychological support > > Haloperidol - Which block dopamine (to control abnormal movement) > Health education should be given to patient and family members. Nursing Management zs Keep environmental stimuli to a minimum to avoid confusion and agitation. x Provide adequate light if patient is hallucinated. x3 Avoid sedative drugs to avoid medication induced confusion. 23. Maintain quiet and comfortable environment, e.g,, noise reduction, curtains closed, private room and dim lights Prevent injury and possible skin breakdown Pad the sides and head of the bed Encourage ambulation with assistance to maintain muscle tone Secure the patient in bed or chair with padded protective devices making sure they are loosened frequently Keep patient as close to upright as possible while feedi ili i tly with one hand while feeding Pt while feeding. Stabilize patient's head gently %s Teach that regular moderate exercise can reduce stiffness and tremors. Assist with activities of daily living, emotional support and potential financial concerns ee GH ¥ Nursing Diagnosis © Risk for injury related to falls/due to constant movement. & Imbalanced nutrition, less than bo e s related to inadequate y id ‘ n , 'y requirements reNervous System Disorders and Its Management @ Disturbed thought process rel, ated to impaired social inter; @ Anxiety related to imp. ‘action. aired communication, Note: for Nursing Intervention of above Nursing Diagnosis refer Page nos. 226-234, 7? ——————— ‘ r | A stroke is a serious medical disorder th at occurs | when the blood supply to part of the br: ‘ain is cut off. Like other organs in body, brain also need the oxygen and nutrients provided by blood to function properly. If the supply of blood is stopped, brain cells begin to die. This can lead to brain damage and possibly death. Cerebral haemorrhage DEFINITION Stroke is an infarction (death) of a specifi¢ portion Cerebral , of brain due to interruption of blood flow that embolus r results to neurological deficit or loss of brain functions. Cerebral thrombosis i CAUSES Fig. 10.6: Causes of Cerebral Vascular Accident ‘ » Thrombosis: Blood clot in blood vessels (cva). of brain or neck. » Cerebral Embolism: The condition in which an embolus becomes lodged in an artery and obstruction of blood flow. » Ischemia: Low blood supply in any part of brain. > Vascular compression: Vein compression. » Arterial spasm: Artery contraction. RISK FACTORS > Hypertension » Previous transient ischemic attack » Heart disease (Atherosclerosis) > Elevated cholesterol level f& > Diabetes mellitus > Obesity » Cigarette smoking > Oral contraceptive | > Emotional stress > Familiar history | » Carotid bruit, red blood cell disorders > Dyslipidemia > Physical inactivity CLINICAL MANIFESTATIONS > The abnormal narrowing of a passage or opening, Such as a blood vessel or heart valve. Stenosis of greater blood vessel in neck. > Paralysis: Muscle weakness that varies in it. > Hemiplegia: Paralysis of one side of the body. It is caused by disease affecting the opposite hemisphere of the brain.Medical Surgical Nursing > Transient loss of speech. Paraesthesia (Spontaneous occurring abnormal tingling and prickling sensation “pins and needles” sensations). Common Sign & Symptoms: Vv > Headache > Vomiting > Seizure > Nose bleeding (Epistaxis) > Retinal haemorrhage > Motor and sensory disturbances > Vertigo > Nuchal rigidity > Fever > Confusion > Disorientation > Memory impairment > Weakness > Language disorder > Reflex changes > Improper sexual abnormalities > Depression > Numbness. SPECIFIC DEFICITS AFTER CVA > Hemiplegia: Paralysis of one side of body. > Aphasia: Defect in using and interpretating the symbols of language. > Agnosia: Unable to recognize the object. > Apraxia: It is a condition in which a client can move the affected part but cannot use it for specific purposeful actions. > Kinesthesia: Alterations in sensation. Incontinence: Inability to control the bladder and bowel. PATHOPHYSIOLOGY Due to cause, e.g., thrombosis, embolism Ischemia DIAGNOSTIC EVALUATIONS » Physical examination > History collection > Computer tomography > Angiography > CSF culture > Echoencephalography > MRI > General blood and urine examination. > PET: Positron - Emission - TomographyNervous System Disorders and Its Management MANAGEMENT Medical management of client after CVA is directed toward: >> Preserving life > Minimizing residual deformity > Reducing ICP > Preventing recurrence, Pharmacological Management > Mild analgesics, e.g., ibuprofen. > Steroids (anti-inflammatory), > Antiepileptics, e.g., phenytoin » Anticoagulant, e.g., heparin > Osmotics diuretics (for oedema), e.g., mannitol > Antihypertensive agents, e.g., verapamil Dietary Management Fluid diet should be given because patient is unable to swallow properly. Surgical Management It depends upon the site of infection and on particular causes. If ICP is more than 30-40 mm Hg than only surgery will performed. Surgeries are: 1. Evacuation of Haematoma. 2. Carotid endarterectomy (removal of material on inside of an artery) it is the surgical procedure used to reduce the risk of stroke by correcting stenosis in common carotid artery. Nursing Management % Give position to prevent contractures; use measures to relieve Pressure, assist in maintaining good body alignment and prevent compressive neuropathies. x Change position frequently place patient in a prone position for 15 to 30 minutes several times a day. %3 Provide full range of motion 4-5 times a day to maintain joint mobility, regain motor control, prevent contractures in the paralyzed extrémity, prevent further deterioration of the neuromuscular system and increase circulation % Start an active rehabilitation program when consciousness returns. 7% Never lift patient by the flaccid shoulder or pull on the affected arm or shoulder / %s We should elevate arm and hand to prevent dependent edema of the hand, administer i analgesic agents as needed. % We should encourage personal hygiene activities as soon as the patient can sit up; select | suitable self care activities that can be carried out with one hand. j % Provide emotional support and encouragement to prevent fatigue and discouragement. % Nurse should consult with speech therapist to evaluate gag reflexes; assist in teaching alternate swallowing techniques, advise patient to take smaller boluses of food and inform patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated. Provide high fiber diet and adequate fluid intake 2 to 3 litres per day % Provide strong emotional support and understanding to relieve anxietyMedical Surgical Nursing x While caring CVA‘s patient be consistent in schedule, routines ee written schedule, checklists and audiotapes may help with memory and concentration and a communication board may be used. ~ Maintain patient's attention when talking, with pi instruction at a time; allow patient time to process: aa aximum of ability to promote sense of control atient, speak slowly and give one xs Encourage patient to perform self-care to m and independence dlsedness vasculae i redn 7 ws Nurse should assess the skin for changes in colour, turgor an : ty %s Monitor fluid intake and hydration condition of skin and mucous membranes to detect dehydration. . ad on Nurse should provide soothing skin care, restrict use of soaps and apply ointments or creams because soap may dry the skin area ; ; Use baking soda baths to decrease itching and dryness than soaps identify bowel/bladder elimination patterns. Recommend adequate hydration and intake of fiber. = Use of use of stool softeners, laxatives and bowel training program to avoid constipation. Refer for vocational rehabilitation as needed or as possible. / Instruct patient to regular medical follow-up to evaluate and progression of degenerative ¢ go ¢ disease. Nursing Diagnosis © Altered cerebral tissue perfusion related to increased ICP. Impaired physical mobility related to paralysis. Self care deficit related to paralysis. Risk of injury related to paralysis. Risk for aspiration related to loss of swallowing reflex. Imbalanced nutrition less than body requirement related to inability to swallow/ paralysis. Impaired verbal communication related to aphasia. Altered thought process related to impaired cerebral blood flow, altered sensations. r Disturbed sensory perception related to altered sensory transmission or neurological eficient. Note: for Nursing Intervention of above Nursing Diagnosis refer page nos. 226-234. 994d 4 q SING INTERVENTIONS OF NERV S SYSTEM DISORDERS Altered Cerebral Tissue Perfusion Interventions: ¥ Monitor ICP regularly Y Monitor sign and symptoms, e.g., ICP v . Set at . Monitor vital signs, e.g., BP (Hypertension/Hy potension), Heart rate, rhythm, respiration. Y Assess or observe pupils, noting size, s i S r , g size, shape equality, light ivi function of optic and occulomotor cranial nerves, BBD reactivity to check response and Y Monitor neurological status to assess LOC and increase ICP. v Head should be elevated to decrease IcP, ‘ Y Prevent straining during voiding stool because it may cause increase ICP. Y Provide bed rest and quiet environment; restrict visitors and activities.