By Diana Blum Msn NURS 2150 Metropolitan Community

By: Diana Blum Msn NURS 2150 Metropolitan Community College

Selective Anatomy � 12 cranial nerves 31 spinal nerves � Neuron transmits impulses to facilitate movement or sensation � Meninges serve as protection of the brain and spinal cord � Bronca’s area in frontal lobe forms speech � Hypothalamus regulates water, appetite, temp � CSF: surrounds and cushions brain and cord

Physical assessment � Orientation � LOC � Memory ◦ LTM (DOB) ◦ STM (mode of transportation to hospital) ◦ Immediate memory (repeat 3 words after 5 minutes) � Attention ◦ Serial 7 test � Language/copying ◦ Follows simple commands � Cognition ◦ Current events

functional Assessment � Appearance � Speech � Motor function � Family history � Ethnicity � Diet � ADLs � Right handed or left handed ◦ Brain injury is more pronounced in dominant hemisphere

Sensory assessment � Pain and temp ◦ Cotton ball vs paper clip ◦ Cold vs warm � Touch ◦ Pt closes eyes and you touch hand etc and then have them touch where you touched ABNORMAL FINDINGS �Propioception-position sense below injury �Contralateral- loss of sensation in opposite side of body affected

Motor assessment � Hand grasps � Foot strength � Arm drift � Coordination � Gait � Balance � Reflexes ABNORMAL FINDINGS tremors, weakness, paralysis, jerking muscles

Rapid assessment � Glascow coma scale: eye opening, motor response, and verbal response ◦ painful stimuli �Supraorbital pressure �Sternal rub �Mandibular pressure �Trapezius squeeze ◦ LOC �Decortication-hands/arms turned in �Decerebration- hands/ arms turned out ◦ Pupil assess �Response to light

The GCS is scored between 3 and 15, 3 being the worst score, and 15 the best. It is composed of three parts: Best Eye Response, Best Verbal Response, Best Motor Response When doing a neuro assessment it is important to watch for trends indicating a decreasing LOC. Keep in mind that when patients have ingested alcohol, mind altering drugs, have hypoglycemia or shock with a systolic BP <80, the GCS may be invalid. 9 to 12 is a moderate injury 8 or less is a severe brain injury. 7 or less = Coma

A client has a 5 on the Glasgow Coma Scale. When assessing this client, the nurse would expect what level of consciousness? Sleepy or drowsy Stuporous Fully alert and oriented Comatose

That was review from nurs 2520 and A&P This is testable material. . So read CHAPTER 20

Seizures/Epilepsy Seizure: abnormal sudden, excessive, uncontrollable electrical d/c of neurons w/in the brain that may result in altered LOC, motor/sensory ability, and/or behavior. • No known cause but may be from tumors

Tonic-Clonic: lasts 2 -5 minutes • Rigidity/stiffening arms/legs and Loss of Consciousness cyanosis excess drooling Tonic: loss of consciousness, muscle contraction and relaxation Clonic: rhythmic jerking, may bite tongue, incontinence • Post seizure lethargy Absence: more common in kids, runs in families, blank staring, loss of consciousness (resembles daydreaming) Myoclonic: brief jerking or stiffening, symmetric or assymetric movement Atonic (akinetic): sudden loss of muscle tone, lasts for few seconds confusion after seizure. Partial: begin in one part of cerebral hemisphere, most often in adults and are less responsive to medical treatment Complex Partial: blacks out for 1 -3 minutes and automatisms present (lip smacking, picking), amnesia after seizure, temporal lobe most affected Simple partial: remains conscious, senses unusual sensation, smell, or pain before (déjà vu). Unilateral movement during seizure, and may have tachycardia, flushing, or psychic symptoms Idopathic: account for ½ of seizures, no known cause Types of Seizures

Causes Metabolic disorders Triggers ETOH withdrawl • • • Electrolyte disturbances Heart disease Altered gene function • Defective genes for channels that regulate ions in/out of cell • Myoclonus clients are missing cystain B protein • Etc. Physical activity Stress Fatigue Alcohol or caffeine Certain foods

Epilepsy Def: chronic disorder characterized by recurrent unprovoked seizure activity. • May be caused from abnormality in electrical neuronal activity, abnormal transmitters, or both. Approximately 2 million people in the USA with epilepsy

can be defined as abnormal, uncontrolled electrical activity in brain cells. Nerve cells transmit signals to and from the brain in two ways by • (1) altering the concentrations of salts (sodium, potassium, calcium) within the cell • (2) releasing chemicals called neurotransmitters (gamma aminobutyric acid). The change in salt concentration conducts the impulse from one end of the nerve cell to the other.

Primary or idopathic • Not associated with identifiable brain lesion Secondary • Most common cause is brain lesion, tumor or trauma Status epilepticus • Prolonged seizures that last greater than 5 minutes or repeated seizures over the course of thirty minutes. • Causes: • • • Med withdrawl Infection Acute alcohol withdrawl Head trauma Cerebral edema Metabolic disturbances Types of Epilepsy

CONVULSIVE STATUS EPIEPTICUS IS A NEUROLOGICAL EMERGENCY AND MUST BE TREATED PROMPTLY AND AGGRESSIVELY. • Call 911 or staff emergency • Get airway established if needed by RT, Anesthesia • O 2 as needed • Establish large bore IV access • Start NS • Get ABGs • Transfer to ICU

Education of seizure/epilepsy patient Teach importance of taking meds as prescribed Promote balanced diet, rest, and stress reduction techniques Instruct pt. to keep a seizure diary to identify causative factors

Phases of seizures Preicteral phase: aura present. . The first phase involves alterations in smell, taste, visual perception, hearing, and emotional state. This is known as an aura, which is actually a small partial seizure that is often followed by a larger event. Ictus: The seizure. . There are two major types of seizure: partial and generalized. What happens to the person during the seizure depends on where in the brain the disruption of neural activity occurs. Postictal state: The period in which the brain recovers from the insult it has experienced. Drowsiness and confusion are commonly experienced during this phase. the period in which the brain recovers from the insult it has experienced

TREATMENT Nonsurgical Teach family • Antiepileptic drugs • Seizure precautions • • • During: • • • Protect the client from injury Do not force anything into mouth Turn client to side Loosen restrictive clothes Do not restrain • After • • • Take vitals Perform neuro checks Keep on side Allow rest document Info about disease Info about medication Support groups available Teach about alcohol avoidance To investigate state laws pertaining to driving and working with machinery • Care of seizure client

Surgical treatment Vagal nerve stimulation • For simple or complex partial seizures • Stimulating device is surgically placed in the left chest wall with a lead wire on the vagus nerve • Activates with hand held magnet Corpuscalostomy • Used for tonic-clonic seizures • For those not candidates for other surgical procedures • Sections of the anterior and 2/3 of the corpus collosum are created to prevent neural discharges

Nursing diagnosis Risk for falls Ineffective coping Risk for ineffective breathing

HUNTINGTON’S DISEASE Formerly huntington’s chorea Hereditary Transmitted as an autosomal dominant trait at time of conception 25000 people in usa have 2 main symptoms are progressive mental status changes and choreiform movements (rapid, jerky) in the limbs trunk and face

No known cause No known treatment Only prevention is to not have children Antipsychotics and monoamine depleting agents used to manage movement TX: PT, OT, speech therapy, meal planning by dietician, HHC, social work to line up community resources

Osteoporosis

Metabolic condition Bone demineralizes Easy to fracture Wrist, hip, and vertebrae are most affected

Osteopenia: low bone mass Osteoclasic: bone resorption Decreased bone mineral density 40 -45% loss in women throughout lifespan Trebecular (Spongy bone) is lost first Then Cortical (compact bone) lost 2 nd Pathophysiology is unknown

classes Generalized: involves many structures • Primary: more common • Post menopausal women • Men in 60 s-70 s • seconday Regional: limb involved • r/t fx, injury, paralysis, joint inflammation • Immobilization greater than 8 -12 weeks • Weightless environment (astronauts)

Health prevention Teach about exercise Teach about diet rich in calcium Teach about bone health Teach about safety

Assessment Risk for falls Head to toe assessment • Inspect and palpate vertebrae Assess pain Assess for fallophobia No definitive lab tests Bone scan to check density

Nursing diagnosis Risk for falls Impaired physical mobility Acute or chronic pain

Interventions Client education is #1 Hormone replacements Calcium supplements Multivitamins Diet Fall prevention Exercise Pain management Braces

Osteomalacia Softening of the bone tissue Inadequate mineralization of osteoid (mature compact and spongy bone) Vitamin D deficiency is a key player Similar characteristics with osteoporosis Rare in USA Prevent with vitamin D, sun exposure, and diet

s/s: early stages : nonspecific • Muscle weakness • Bone pain • Hypophosphatemia • Hypocalcemia • Generalized bone tenderness

Paget’s Disease

Metabolic disorder of bone remodeling Bone deposits that are weak, enlarged, and disorganized Phases: • Active increased osteoclasts cause massive bone destruction • Osteoclasts are multinuclear • Mixed • Inactive 2 nd phase • New bone becomes sclerotic and very hard • Osteoclasts return to normal amount 2 nd most common bone disease Most common sites are vertebrae, femur, skull, sternum, and pelvis Unknown cause

Assessment 80% asymptomatic Assess past history of fractures, skin color and temp, gout, hyperparathyroidism, lethargy, hyperuricemia Pain that is aching, deep, poor description Pain worsens with weight bearing and pressure Pain most noticeable at nite or at rest Arthritis at infected joints Assess posture, gait, and balance Assess vision, speech, and swallowing, hydrocephalus, Neoplasm is the dreaded complication

Diagnostics Serum alk phosphate • Those treated for paget’s need ALP drawn 3 -4 times/year Urine hydroxyproline • Shows bone collagen turnover and degree of severity Calcium levels are normal or elevated Increase noted in uric acid • May initially be thought to be gout X-rays, CT, MRI, bone biopsy

Treatment Drugs for pain relief Drugs to decrease bone resorption Calcitonin (thyroid hormone) Mithramycin (antineoplastic) Biphosphanates Heat therapy Gentle massage Exercise PT Diet Osteotomy or joint replacement

osteomylelitis

Inflammatory process Increase in vascularity and edema Vessel becomes thrombosed once inflamed Ischemia is next Then necrosis Sequestrium forms and retards bone healing

Categories Exogenous: infection enters from outside Endogenous: infection enters from inside Contiguous: results from skin infection The most common offending organism is pseudomonas aeruginosa Staph, salmonella are aslo culprits

s/s. Painand assessment Fever Erythema Heat Swelling Assess circulation Assess for septic shock

Treatment Contact precautions IV antibx therapy PICC line Use sterile techniques Pain meds Hyperbaric oxygen therapy Bone grafts Muscle flaps Amputations

Bone tumors

Chondrogenic Osteochondroma: most common, benign, tumor…onsets in childhood, grows until skeletal maturity. . has a bony stalk like appearance. . may become malignant Chondroma: lesion of mature hyaline cartilage of the hand feet. Ribs, sternum, spine, and long bones can also be affected…can get at any age or gender

Osteogenic Osteoid osteoma: pinkish granular appearance. . any bone affected. . femur and tibia most affected Osteoblastoma: affects vertebrae and long bones. . large in size and lies in spongy bone. . reddish granular appearance Giant cell tumor: origin unknown. . aggressive and extensive. . affects women 20 s-30 s

Assessment/ tx Assess pain Palpate involved area CT scan and MRI done for diagnosis Interventions • Meds and surgery combination • Pain meds • Meds taken with meals or milk •

Malignant bone tumors Primary: originate in bone / 2 nd ary: mets to bone • Primary Osteosarcoma: most common • Large lesion, pain and swelling of short duration, warm site, central portion is sclerotic, usually mets to lung in 2 yrs then death Ewing’s sarcoma: most malignant • Pain and swelling, fever, anemia, leukocytosis, pelvis and lower extremities most affected, any age. . but kids and young adults age 20 s more • Pelvic yields poor prognosis Chondrosarcoma: dull pain, swelling for long period. . • pelvis and femur fore affected • Destroys bone and often calcifies • Affect middle age to elders and more in men Fibrosarcoma: from fibrous tissue; most common in long bones of legs and mets to lungs • Histiocytoma is most malignant type • Local tenderness, with or w/o mass palpated

Bone Mets Primary tumors are in prostate, breast, kidney, thyroid, and lung Fractures are major problem with management • Femur and acetabulum Primarily affects those under 40

Assess/ diagnostics Assess pain, swelling, palpate for masses Monitor vs Assess ADLs Assess support structures Assess coping skills Check ALP levels for elevation CT scan Stage tumor

Nursing diagnosis/tx Pain Anticipatory grieving Disturbed body image Fear Anxiety Tx • Pain management, chemo, radiation, surgery, dressing changes, be active listener, establish goals, safety precautions, HHC

Carpal Tunnel

Education Use ergonomic work stations Teach client to take regular breaks s/s • Parathesia in hands • Weak pinch, clumsiness, weakness • Hand activity worsens symtoms • Swelling may occur Tx: nsaids, surgery

Dupuytren’s contractures Slow progressive contracture Common problem Affects 4 th or 5 th digit of the hand Trigger finger release surgery performed to fix

Disorders of the foot Hammertoe: fix with surgery Tarsal tunnel syndrome: ankle version of carpal tunnel Plantar fasciitis: inflammation of the plantar fascia located in the arch of the foot • s/s: pain in arch, pain worsens w/ wt bearing • Tx: ice, rest, stretches, strapping, nsaids, surgery Hallux valgus: aka bunion

Vertigo Associated with 8 th cranial nerve or cellebellum Menieres disease is an example of a disorder of vertigo. most common 30 -60 Ultimately just means dizzy

The� Headaches brainpg 506 ◦ 3 MAIN types �Migraine-genetic predisposition �s/s: sensitive scalp, anorexia, photophobia, N/V �Spasming of arteries at the base of the brain causing arterial constriction, decrease cerebral blood flow, platelets clump, and serotonin released. Other ateries release prostoglandins that cause swelling and inflammation �With aura- sensation that signals onset �Most are without aura �Atypical- less common �Tx: tylenol, migraine medicine, beta blocker, yoga, meditation, relaxation, etc.

Cluster headache � one sided headache usually felt deep around eye. They come and go � Onset is associated with relaxation, napping or REM sleep � s/s: ipsilateral (one side) tearing of the eye, rhinorrhea(runny nose), ptosis(droopy), eyelid edema, facial sweating, miosis (abn. Constriction of eye). There may be bradycardia, pallor, increased temp. � Tx: same as migraine, wear sunglasses, O 2 for 15 minutes, surgery

Tension headache Muscle and shoulder tenderness, base of skull and forehead pain. Similar s/s to migraines Classic s/s: N/V, photophobia, phonophobia, aggravates with activity Tx: NSAIDS, muscle relaxers

Parkinson’s http: //www. youtube. com/watch? v=Tt. M-a. P 9 Gr 28

Alzheimer’s Disease http: //www. youtube. com/watch? v=Z 6 l. A 1 P 2 t. F 0 o&feature=related

Stages Early • mild Middle • moderate Late • severe

s/s. Aggressive Rapid mood swings Increased confusion at nite (sundowner’s) Decrease interest in personal appearance Inappropriate clothing selection Loss of bowel/bladder Decreased appetite

diagnosis CBC BMP Folate level checked Thyroid and liver function test Test for syphilis Drug tox screening (OTC) Alcohol screening CT MRI PET EEG

Nursing diagnosis Chronic confusion Risk for injury Disturbed sleep pattern

Tx Meds Prevent overstimulation Be consistent Reorient Promote independence Bowel/bladder training Promote facial recognition Speech therapy Safety precautions Minimize agitations

http: //www. youtube. com/watch? v=Xv 1 t. Mio. G g. XI

Nutrition Monitor electrolytes especially sodium levels and protein levels Chart 8 -2 talks about labs to monitor– albumin transferrin---prealbumin total lymphocytes. Diets chart 8 -4

glaucoma 2 types • Primary open angle: most common • Angle closure: less common. . emergency

s/s. Open angle: small cresent shaped defect Angle closure: visual fields quickly decrease, severe pain around eye, headache, n/v, halos, blurred vision

Macular degeneration Central vision declines Mild blurring or distortion More rapid to produce in smokers

Chapter 24 Spinal Cord Injury (SCI)

Causes of SCI Primary • • • Hyperflexion (moved forward excessively) Hyperextension (MVA) Axial loading (blow at top of head causes shattering) Excessive rotation (turning beyond normal range) Penetrating (knife, bullet) Secondary • • • Neurogenic shock Vascular insult Hemorrhage Ischemia Electrolyte imbalance

Types Complete: spinal cord severed and no nerve impulses below level of injury • Cervical/Thoracic Incomplete: allow some function and movement below level of injury • • Includes: Central cord syndrome Anterior cord syndrome Brown-Séquard syndrome

Complete Tetraplegia (quadriplegia): paralysis from neck down • Loss of bowel and bladder control • Loss of motor function • Loss of reflex activity • Loss of sensation • Coping issues *Christopher Reeve is example of this injury*

Incomplete Central Cord Syndrome • Hyperextension damage to center of spinal cord • Greater loss of function in upper extremities Anterior Cord Syndrome • Cause: Direct injury to anterior spinal cord or disrupted anterior spinal artery • Paralysis, loss of pain and temperature sensation • Light touch, vibration, proprioception preserved • Prognosis for recovery is variable

Incomplete Posterior cord lesion • Damage to posterior white and gray matter • Motor function intact, but loss of vibratory sense, crude touch, and position sensation Brown Sequard syndrome • Result of penetrating injury that causes hemisection of spinal cord. • Motor function , proprioception, vibration, and deep touch are lost on the same side as injury (ipsilateral) • On the other side (contralateral) the sensation of pain, temperature and light touch are affected

Assessment 1 st -respiratory status 2 nd - intra-abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse) 3 rd assess motor function • • C 4 -5 apply downward pressure while the client shrugs C 5 -6 apply resistance while client pulls up arms C 7 apply resistance while pt straightens flexed arms C 8 check hand grasp L 2 -4 apply resistance while the client lifts legs from bed L 5 apply resistance while client dorsiflexes feet S 1 apply resistance while client plantar flexes feet

Complications Cerebral ischemia DVT/PE Pneumonia/Atelectasis Vomiting and Aspiration GI stress ulcers Constipation UTI Pressure Ulcers

Autonomic Dysreflexia Severe HTN, bradycardia, sever headache, nasal stuffiness, and flushing • Caused by noxious stimuli like distended bladder or constipation Immediate interventions • • Place in sitting position Call doctor Loosen tight clothes Check foley tubing if present Check for impaction Check room temp Monitor BP q 10 -15 minutes Give nitrates or hydralazine per md order

Immobilize fx- C-collar. Treatment Proper body alignment • Traction is possible Monitor VS q 4 hr and prn Neuro checks q 4 hr and prn Monitor for neurogenic shock (hypotension and bradycardia) Prepare for possible surgery Teach skin care, ADLs, wound prevention techniques, bowel and bladder training, medications, and sexuality

NRSG DX for SCI Ineffective tissue perfusion r/t interruption of arterial flow Ineffective airway clearance r/t SCI Ineffective breathing pattern r/t SCI Impaired gas exchange r/t SCI

Traumatic Brain Injury (TBI)

Head Injury Classification: Severe Head Injury----GCS score of 8 or less Moderate Head Injury----GCS score of 9 to 12 Mild Head Injury----GCS score of 13 to 15 (Adapted from: Advanced Trauma Life Support: Course for Physicians, American College of Surgeons, 1993).

Common Superficial Injuries Abrasions “Goose Eggs” Lacerations • Scalp is very vascular Xray if suspect skull fracture

Skull Fractures Categorized according to type and severity Frequently seen in conjunction with brain injuries Linear skull fractures Comminuted skull fractures Basal skull fractures Possible associated cranial nerve deficits

Open Skull Fractures Linear- simple clean break Depressed - bone pressed in towards tissue Open -lacerated scalp that creates opening to brain tissue Comminuted - bone fragments and depresses into brain tissue Basilar- unique fx at base of skull with CSF leaking though the ear or nose • Racoon eyes/Battles sign

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http: //www. pearlau. com. au/jpg/raccoon%2520 eyes

Closed Skull Fractures Closed- blunt trauma • Mild concussion-brief LOC • Diffuse axonal injury- usually from MVA • May go into coma • Contusion-bruising of brain • Site of impact (coupe) • Opposite side of impact (contrecoupe)

Intracranial Hematomas Epidural- bleed b/w skull and dura • Laceration of artery or vien Subdural-bleed below dura and arachoid layers • Acute, subacute, chronic Intracerebral-accumulation of blood in brain tissue • Blunt trauma • Penetrating wounds • Acceleration/deceleration injuries

Pg 568 Increased Intracranial Pressure (ICP)

Increase is caused by an increase in the volume of any of the intracranial components Drivers of increased ICP • Hypoxia – triggers the vasodilatory cascade • Ischemia in acute brain injury

Increased ICP Normal ICP 10 -15 mm. Hg Normal increases occur with coughing, sneezing, defecation Leading cause of death for head trauma As ICP increases cerebral perfusion decreases causing tissue hypoxia, decrease serum p. H, and increase in CO 2

ICP continued 3 types of edema • Vasogenic: increase in brain tissue volume • Cytotoxic: result of hypoxia • Interstitial: occurs with brain swelling

Assessment

Hydrocephalus abnormal increase in CSF volume Causes: impaired reabsorption from subarachnoid hemorrhage or menengitis

Brain Herniation Increased ICP will shift and move brain tissue downward Central Herniation • Downward shift to brainstem • S/S • Cheyne stokes , pinpoint pupils, hemodynamic instability The most life threatening is Uncal because it causes pressure on the 3 rd cranial nerve • S/S • Dilated, nonreactive pupils, ptosis, rapidly decreased LOC

Herniation syndromes.

Movement/musculoskeletal

Rheumatoid Arthritis

Most common connective tissue disorders Most destructive to joints RA factors looked for in lab Assess sedrate Assess immunoglobins MRIs performed EMGs are performed to measure function

Assessment/ S/S continued Joint stiffness Swelling Pain Fatigue Weight loss Reddened joints Deformity of joints Baker’s cysts may occur and cause pain Dry eyes, dry mouth, dry vagina Assess ADLs, coping, pain

interventions Nsaids Immunosuppressive drug Rest Proper positioning Pain management Ice Heart parafin wax Plasmapheresis Fish oil tablets

Gout Type of arthritis Urate crystals deposit in joints Primary gout is most common Inflammation is key sign 2 nd ary is when too much uric acid in blood Can affect kidneys Meds to treat Pain management

Fibromyalgia Chronic pain syndrome Pain is burning or gnawing Headache and jaw pain are also common Chest pain is common Pain control is the key • Muscle relaxers, nsaids, antidepressants

Muscular distrophies 9 types Progression is slow or fast Most common is severe X linked recessive Diagnosis is difficult Comfort is key Treat symptoms

AMPUTATION REVIEW

amputations Removal of part of the body Types • Surgical-example digit • Traumatic- example digit Levels • Lower extremity: digits, bka, aka, midfoot • Upper extremity: hands, fingers, arms Complications • Hemorrhage • Infection • Phantom limb pain: perceive pain in the amputated limb • Immobility • Neuroma: sensitive tumor consisting of nerve cells found at several nerve endings • Contractures

TIPS!! Review Meds on 599 -604 Review cranial nerves