SEMINAR PRESENTATION

ON
MANAGEMENT OF
CENTRAL NERVOUS
SYSTEM DISORDERS
 INTRODUCTION
• The central nervous system contains a vast
network of neurons controlling the body’s vital
functions . This system is vulnerable, and its
optimal function depends on several key
factors.
• Examples of structural disruption include head
injury, brain tumor, intracranial hemorrhage,
infection, and stroke.
• Second, the neurologic system also relies on the
body’s ability to maintain a homeostatic environment.
• It requires the body to deliver the essential elements of
oxygen and glucose and to filter out substrates toxic to
the neurons.
• Sepsis, hypovolemia , myocardial infarction,
respiratory arrest, hypoglycemia, electrolyte imbalance,
drug and alcohol overdose, encephalopathy, and
ketoacidosis are all examples of circumstances in
which the neurologic system is depressed due to a toxic
metabolic effect or due to the body’s mechanical
inability to provide essential substrates.
1. ALTERED LEVEL
OF
CONSCIOUSNESS
• An altered level of consciousness (LOC) is apparent
in the patient who is not oriented, does not follow
commands, or needs persistent stimuli to achieve a
state of alertness.
• Coma is a clinical state of unconsciousness in which
the patient is unaware of self or the environment for
prolonged periods (days to months or even years).
• Akinetic mutism is a state of unresponsiveness to the
environment in which the patient makes no movement
or sound but sometimes opens the eyes.
 CLINICAL MANIFESTATIONS

• Alertness and consciousness decreases

• Changes in the pupillary response eye opening
response, verbal response, and motor response.
• Changes such as restlessness or increased
anxiety.
• The pupils, normally round and quickly
reactive to light, become sluggish
ASSESSMENT AND DIAGNOSTIC FINDINGS

• Neurologic examination
• Mental status
• Cranial nerve function, cerebellar function (balance and
coordination), reflexes, and motor and sensory function.
• Glasgow Coma Scale: eye opening, verbal response, and
motor response.
• The patient’s responses are rated on a scale from 3 to 15.
A score of 3 indicates severe impairment of neurologic
function; a score of 15 indicates that the patient is fully
responsive.
• Identify the cause of unconsciousness
include scanning, imaging, tomography (eg,
computed tomography, magnetic resonance
imaging, positron emission tomography), and
electroencephalography.
• Laboratory tests include analysis of blood
glucose, electrolytes, serum ammonia, and
blood urea nitrogen levels, as well as serum
osmolality, calcium level, and partial
thromboplastin and prothrombin times.
 COMPLICATIONS

• Respiratory failure,
• Pneumonia,
• Pressure ulcers
• Aspiration
• Musculoskeletal deterioration
• Disturbed gastrointestinal functioning.
• Aspiration of gastric contents
 MANAGEMENT

• Maintain a patent airway.

• Orally or nasally intubated, or a tracheostomy may be
performed.
• Mechanical ventilator is used to maintain adequate
oxygenation.
• The circulatory status (blood pressure, heart rate) is
monitored to ensure adequate perfusion to the body and brain
• An intravenous catheter is inserted to provide access for
fluids and intravenous medications.
• Nutritional support, using either a feeding tube or a
gastrostomy tube,
 2. INCREASED
INTRACRANIAL
PRESSURE
• The rigid cranial vault contains brain tissue (1,400 g), blood (75
mL), and CSF (75 mL).
• The volume and pressure of these three components are usually in a
state of equilibrium and produce the ICP.
• ICP is usually measured in the lateral ventricles; normal ICP is 10
to 20 mm Hg.
• Because brain tissue has limited space to change, compensation
typically is accomplished by displacing or shifting CSF, increasing
the absorption of CSF, or decreasing cerebral blood volume.
• Without such changes, ICP will begin to rise.
• Under normal circumstances, minor changes in blood volume and
CSF volume occur constantly due to alterations in intrathoracic
pressure (coughing, sneezing, straining), posture, blood pressure,
and systemic oxygen and carbon dioxide levels
PATHOPHYSIOLOGY
 Compliance of ICP

Compression of ventricles

Decrease cerebral blood flow

Decrease 02 with death of brain cells

Edema around necrotic tissue

Increased ICP with compression of brainstem and respiratory
center
Accumulation of co2

Vasodilation
Increased ICP resulting from increased
blood volume ( brain herniation)

Death
 CLINICAL PRESENTATION
• Neural function is impaired
• Abnormal respiratory and vasomotor
responses.
• Restlessness
• Compression of the brain due to swelling from
hemorrhage or edema,
• Respirations impaired
 ASSESSMENT AND DIAGNOSTIC FINDINGS

• Cerebral angiography
• Computed tomography (CT) scanning
• Magnetic resonance imaging (MRI)
• Positron emission tomography (PET).
• Transcranial Doppler studies provide
information about cerebral blood flow
 COMPLICATIONS

• Brain stem herniation,

• Diabetes insipidus,
• Syndrome of inappropriate antidiuretic
hormone (SIADH).
• Excessive urine output, and hyperosmolarity
• Fluid volume, electrolyte replacement, and
vasopressin (desmopressin, DDAVP) therapy.
 MANAGEMENT
• Increased ICP is a true emergency and must be treated promptly.
• Immediate management to relieve increased ICP involves decreasing cerebral edema, lowering
the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion
• These goals are accomplished by administering osmotic diuretics and corticosteroids,
restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and
oxygenation, and reducing cellular metabolic demands.
• An intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural
catheter, or a fiberoptic transducer-tipped catheter placed in the subdural space or the ventricle
can be used to monitor ICP
• Receiving osmotic diuretics, serum osmolality should be determined to assess hydration status
• Corticosteroids (eg, dexamethasone) help reduce the edema surrounding brain tumors when a
brain tumor is the cause of increased ICP.
• Improvements in cardiac output are made using fluid volume and inotropic agents such as
dobutamine hydrochloride.
• CSF drainage is frequently performed because the removal of CSF with a ventriculostomy
drain may dramatically reduce ICP and restore cerebral perfusion pressure
• Strategies to reduce temperature include administration of antipyretic medications, as
prescribed, and use of a cooling blanket.
• Administration of high doses of barbiturates when the patient is unresponsive to conventional
treatment.
 SEIZURE
DISORDERS
 
A. SEIZURES
• Seizures are episodes of abnormal motor,
sensory, autonomic, or psychic activity (or a
combination of these) resulting from sudden
excessive discharge from cerebral neurons.
• A part or all of the brain may be involved.
• The international classification of seizures
differentiates between two main types: partial
seizures that begin in one part of the brain, and
generalized seizures that involve electrical
discharges in the whole brain.
• Most seizures are sudden and transient.
 NURSING MANAGEMENT DURING A SEIZURE

A major responsibility of the nurse is to

observe and record the sequence of symptoms.
The nature of the seizure usually indicates the
type of treatment that is required. Before and
during a seizure, the following are assessed
and documented:
• The circumstances before the seizure (visual, auditory, or
olfactory stimuli, tactile stimuli, emotional or psychological
disturbances, sleep, hyperventilation)
• The size of both pupils.
• Incontinence of urine or stool
• Duration of each phase of the seizure
• Unconsciousness, if present, and its duration
• Any obvious paralysis or weakness of arms or legs after the
seizure
• Inability to speak after the seizure
• Movements at the end of the seizure
• Whether or not the patient sleeps afterward
• Cognitive status (confused or not confused) after the seizure
 NURSING MANAGEMENT AFTER A SEIZURE

• After a patient has a seizure, the nurse’s role is to document the events
leading to and occurring during the seizure and to prevent
complications (eg, aspiration, injury).
• The patient is at risk for hypoxia, vomiting, and pulmonary aspiration.
• To prevent complications, the patient is placed in the side-lying
position to facilitate drainage of oral secretions and is suctioned, if
needed, to maintain a patent airway and prevent aspiration.
• Seizure precautions are maintained, including having available fully
functioning suction equipment with a suction catheter and oral airway.
• The bed is placed in a low position with side rails up and padded if
necessary to prevent patient injury.
• The patient may be drowsy and may wish to sleep after the seizure
B. THE EPILEPSIES
• Epilepsy is a group of syndromes characterized by
recurring seizures. Epileptic syndromes are classified
by specific patterns of clinical features, including age
of onset, family history, and seizure type.
• Types of epilepsies are differentiated by how the
seizure activity manifests, the most common
syndromes being those with generalized seizures and
those with partial-onset seizures.
• Epilepsy can be primary (idiopathic) or secondary,
when the cause is known and the epilepsy is a symptom
of another underlying condition such as a brain tumor.
 CLINICAL MANIFESTATIONS
• Prolonged convulsive movements with loss of consciousness.
• In simple partial seizures, only a finger or hand may shake, or the
mouth may jerk uncontrollably.
• The person may talk unintelligibly, may be dizzy, and may
experience unusual or unpleasant sights, sounds, odors, or tastes,
but without loss of consciousness.
• In complex partial seizures, the person either remains motionless or
moves automatically but inappropriately for time and place, or may
experience excessive emotions of fear, anger, elation, or irritability
• There may be intense rigidity of the entire body followed by
alternating muscle relaxation and contraction
• The tongue is often chewed, and the patient is incontinent of urine
and stool.
 ASSESSMENT AND DIAGNOSTIC
FINDINGS
• A developmental history is taken, including events of
pregnancy and childbirth, to seek evidence of
preexisting injury.
• physical and neurologic evaluations, diagnostic
examinations
• MRI is used to detect lesions in the brain, focal
abnormalities, cerebrovascular abnormalities, and
cerebral degenerative changes.
• electroencephalogram (EEG)
• Single photon emission computed tomography (SPECT)
 NURSING MANAGEMENT
• The nurse initiates ongoing assessment and monitoring of respiratory and
cardiac function because of the risk for delayed depression of respiration and
blood pressure secondary to administration of antiseizure medications and
sedatives to halt the seizures.
• Nursing assessment also includes monitoring and documenting the seizure
activity and the patient’s responsiveness.
• The patient is turned to a side-lying position if possible to assist in draining
pharyngeal secretions. Suction equipment must be available because of the risk
for aspiration. The intravenous line is closely monitored because it may become
dislodged during seizures
• A person who has received long-term antiseizure therapy has a significant risk
for fractures resulting from bone disease (osteoporosis, osteomalacia, and
hyperparathyroidism), a side effect of therapy.
• Thus, during seizures, the patient should be protected from injury using seizure
precautions and monitored closely. No effort should be made to restrain
movements. The patient having seizures can inadvertently injure nearby people,
so nurses should protect themselves.
4. HEADACHE
• Headache, or cephalgia, is one of the most common of
all human physical complaints.
• Headache is actually a symptom rather than a disease
entity; it may indicate organic disease (neurologic or
other disease), a stress response, vasodilation
(migraine), skeletal muscle tension (tension headache),
or a combination of factors.
• A primary headache is one for which no organic cause
can be identified. These types of headache include
migraine, tension-type, and cluster headaches.
• Cranial arteritis is another common cause of headache.
ASSESSMENT AND DIAGNOSTIC EVALUATION

• history, a physical assessment of the head and

neck, and a complete neurologic examination.
 Management
• Antihypertensive agents,
• Diuretic medications,
• Anti-inflammatory agents, and
• Monoamine oxidase inhibitors are a few of the
categories of medications that can provoke
headaches.
5. MIGRAINE
• The cerebral signs and symptoms of migraine
result from dysfunction of the brain stem
pathways that normally modulate sensory input.
• Abnormal metabolism of serotonin, a vasoactive
neurotransmitter found in platelets and cells of
the brain, plays a major role.
• The headache is preceded by a rise in plasma
serotonin, which dilates the cerebral vessels, but
migraines are more than just vascular headaches.
PATHOPHYSIOLOGY
 CLINICAL MANIFESTATIONS
A. MIGRAINE
The migraine with aura can be divided into four phases: prodrome, aura, the headache, and
recovery (headache termination and postdrome).
B. PRODROME
The prodrome phase is experienced by 60% of patients with symptoms that occur hours to
days before a migraine headache. Symptoms include depression, irritability, feeling cold, food
cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation.
C. AURA PHASE
Aura occurs in up to 31% of patients who have migraines. The aura usually lasts less than an
hour and may provide enough time for the patient to take the prescribed medication to avert a
full-blown attack (described in a later section). This period is characterized by focal neurologic
symptoms.
D. HEADACHE PHASE
As vasodilation and a decline in serotonin levels occur, a throbbing headache (unilateral in
60% of patients) intensifies over several hours. This headache is severe and incapacitating and is
often associated with photophobia, nausea, and vomiting. Its duration varies, ranging from 4 to
72 hours.
E. RECOVERY PHASE
In the recovery phase (termination and postdrome), the pain gradually subsides. Muscle
contraction in the neck and scalp is common, with associated muscle ache and localized
tenderness, exhaustion, and mood changes. Any physical exertion exacerbates the headache pain.
During this postheadache phase, patients may sleep for extended periods.
 PREVENTION

• Preventive medical management of migraine

involves the daily use of one or more agents
that are thought to block the physiologic
events leading to an attack.
• Medication therapy should be considered for
migraine if attacks occur 3 to 4 days per
month.
 Management
• Two beta-blocking agents, propranolol (Inderal) and
metoprolol (Lopressor), inhibit the action of
betareceptors cells in the heart and brain that control
the dilation of blood vessels.
• This is thought to be a major reason for their
antimigraine action.
• Other medications that are prescribed for migraine
prevention include amitriptyline hydrochloride
(Elavil), divalproex (Valproate), flunarizine, and
several serotonin antagonists.
NURSING MANAGEMENT
• When migraine or the other types of headaches
described above have been diagnosed, the goals of
nursing management are to enhance pain relief.
• It is reasonable to try nonpharmacologic interventions
first , but the use of pharmacologic agents should not
be delayed.
• The goal is to treat the acute event of the headache and
to prevent recurrent episodes.
• Prevention involves patient education regarding
precipitating factors, possible lifestyle or habit changes
that may be helpful, and pharmacologic measures.
 BIBLIOGRAPHY

1. Brunner and suddharth’s , textbook of

medical-surgical nursing, eleventh edition,
volume 2, page no. 2160-2172.
2. Medical surgical nursing, assessment and
management of clinical problem, lewis ,sixth
edition, page no. 1562-1577
3. www.wikipedia.com
4. www.slideshare.com