■ Broca’s area for speech

■ Morals, emotions, reasoning and judgment, concentration, and abstraction 

■ Interpretation of taste, pain, touch, temperature, and pressure

■ Spatial perception 

■ Auditory center

■ Wernicke’s area for sensory and speech 

■ Emotional and visceral patterns for survival

■ Learning and memory 

a. Regulates autonomic responses of the sympathetic and parasympathetic nervous systems

b. Regulates the stress response, sleep, appetite, body temperature, fluid balance, and emotions

c. Responsible for the production of hormones secreted by the pituitary gland and the hypothalamus

1. Description

a. Radiographs of the skull reveal the size and shape of the skull bones, suture separation in infants, fractures or bony defects, erosion, and calcification.

b. Spinal radiographs identify fractures, dislocation, compression, curvature, erosion, narrowed spinal cord, and degenerative processes.

2. Preprocedure interventions

a. Provide nursing support for the confused, combative, or ventilator-dependent client.

b. Maintain immobilization of the neck if a spinal fracture is suspected.

c. Remove metal items from the client.

d. If the client has thick and heavy hair, this should be documented, because it could affect interpretation of the x-ray film.

3. Postprocedure intervention: Maintain immobilization until results are known.

Always check with the client about the possibility of pregnancy before any radiographic procedures are done.

1. Description

a. Computed tomography is a type of brain scanning that may or may not require injection of a dye.

b. It is used to detect intracranial bleeding, space-occupying lesions, cerebral edema, infarctions, hydrocephalus, cerebral atrophy, and shifts of brain structures.

2. Preprocedure interventions

a. Obtain informed consent if a dye is used.

b. Assess for allergies to iodine, contrast dyes, or shellfish if a dye is used.

c. Instruct the client of the need to lie still and flat during the test.

d. Instruct the client to hold his or her breath when requested.

e. Initiate an intravenous line if prescribed.

f. Remove objects from the head, such as wigs, barrettes, earrings, and hairpins.

g. Assess for claustrophobia.

h. Inform the client of possible mechanical noises as the scanning occurs.

i. Inform the client that there may be a hot flushed sensation and a metallic taste in the mouth when the dye is injected.

j. Note that some clients may be given the dye even if they report an allergy; they are treated with an antihistamine and corticosteroids before the injection to reduce the severity of a reaction.

Assess the need to withhold metformin (Glucophage) if iodinated contrast dye is used for a diagnostic procedure because of the risk for metformin-induced lactic acidosis.

3. Postprocedure interventions

a. Provide replacement fluids because diuresis from the dye is expected.

b. Monitor for an allergic reaction to the dye.

c. Assess dye injection site for bleeding or hematoma, and monitor the extremity for color, warmth, and the presence of distal pulses.

1. Description

a. Magnetic resonance imaging is a noninvasive procedure that identifies tissues, tumors, and vascular abnormalities.

b. It is similar to CT scanning but provides more detailed pictures.

2. Preprocedure interventions

a. Remove all metal objects from the client.

b. Determine whether the client has a pacemaker, implanted defibrillator, or other metal implants such as a hip prosthesis or vascular clips because these clients cannot have this test performed.

c. Insert an intermittent infusion device (saline lock) to all intravenous accesses prior to the procedure (intravenous fluid pumps are not allowed in the MRI room).

d. Provide precautions for the client who is attached to a pulse oximeter because it can cause a burn during testing if coiled around the body or a body part.

e. Provide an assessment of the client with claustrophobia (may not be necessary if an open MRI machine is used).

f. Administer medication as prescribed for the client with claustrophobia.

g. Determine whether a contrast agent is to be used and follow the prescription related to the administration of food, fluids, and medications.

h. Instruct the client that he or she will need to remain still during the procedure.

An MRI is contraindicated in a pregnant woman because the increase in amniotic fluid temperature that occurs during the procedure may be harmful to the fetus.

3. Postprocedure interventions

a. Client may resume normal activities.

b. Expect diuresis if a contrast agent is used.

1. Description

a. Insertion of a spinal needle through the L3-L4 interspace into the lumbar subarachnoid space to obtain cerebrospinal fluid (CSF), measure CSF fluid or pressure, or instill air, dye, or medications

b. The test is contraindicated in clients with increased intracranial pressure because the procedure will cause a rapid decrease in pressure in the CSF around the spinal cord, leading to brain herniation.

2. Preprocedure interventions

a. Obtain informed consent.

b. Have the client empty the bladder.

3. Interventions during the procedure

a. Position the client in a lateral recumbent position and have the client draw the knees up to the abdomen and the chin onto the chest; the prone position may be required for radiologically guided punctures.

b. Assist with the collection of specimens (label the specimens in sequence).

c. Maintain strict asepsis.

4. Postprocedure interventions

a. Monitor vital signs and neurological signs to check for the presence of leakage of CSF and also monitor for headache.

b. Position the client flat as prescribed.

c. Encourage fluids to replace CSF obtained from the specimen collection or from leakage.

d. Monitor intake and output.

1. Description: Injection of a contrast material usually through the femoral artery (or another artery) into the carotid arteries to visualize the cerebral arteries and assess for lesions

2. Preprocedure interventions

a. Obtain informed consent.

b. Assess the client for allergies to iodine and shellfish.

c. Assess for a medication history of anticoagulation therapy; withhold the anticoagulant medication prior to the procedure as prescribed.

d. Encourage hydration for 2 days before the test.

e. Maintain the client on NPO status 4 to 6 hours before the test as prescribed.

f. Perform a neurological assessment, which will serve as a baseline for postprocedure assessments.

g. Mark the peripheral pulses.

h. Remove metal items from the hair.

i. Administer premedication as prescribed.

3. Postprocedure interventions

a. Monitor neurological status, vital signs, and neurovascular status of the affected extremity frequently until stable.

b. Monitor for swelling in the neck and for difficulty swallowing; notify a health care provider (HCP) if these symptoms occur.

c. Maintain bed rest for 12 hours as prescribed.

d. Elevate the head of the bed 15 to 30 degrees only if prescribed.

e. Keep the bed flat, as prescribed, if the femoral artery is used.

f. Assess peripheral pulses.

g. Apply sandbags or another device to immobilize the limb and a pressure dressing to the injection site to decrease bleeding as prescribed.

h. Place ice on the puncture site as prescribed.

i. Encourage fluid intake.

1. Description: Graphic recording of the electrical activity of the superficial layers of the cerebral cortex

2. Preprocedure interventions

a. Wash the client’s hair.

b. Inform the client that electrodes are attached to the head and that electricity does not enter the head.

c. Withhold stimulants such as coffee, tea, and caffeine beverages, antidepressants, tranquilizers, and possibly anticonvulsants for 24 to 48 hours before the test as prescribed.

d. Allow the client to have breakfast if prescribed.

e. Premedicate for sedation as prescribed.

3. Postprocedure interventions

a. Wash the client’s hair.

b. Maintain side rails and safety precautions, if the client was sedated.

1. Description: Caloric testing provides information about the function of the vestibular portion of the eighth cranial nerve and aids in the diagnosis of cerebellar and brainstem lesions.

2. Procedure

a. Patency of the external auditory canal is confirmed.

b. The client is positioned supine with the head of the bed elevated 30 degrees.

c. Water that is warmer or cooler than body temperature is infused into the ear.

d. A normal response is the onset of vertigo and nystagmus (involuntary eye movements) within 20 to 30 seconds

e. Absent or disconjugate eye movements indicate brainstem damage.

Cheyne-Stokes

■ Rhythmic, with periods of apnea

■ Can indicate a metabolic dysfunction or dysfunction in the cerebral hemisphere or basal ganglia

Neurogenic Hyperventilation

■ Regular rapid and deep sustained respirations

■ Indicates a dysfunction in the low midbrain and middle pons

Apneustic

■ Irregular respirations, with pauses at the end of inspiration and expiration

■ Indicates a dysfunction in the middle or caudal pons

Ataxic

■ Totally irregular in rhythm and depth

■ Indicates a dysfunction in the medulla

Cluster

■ Clusters of breaths with irregularly spaced pauses

■ Indicates a dysfunction in the medulla and pons 

Posturing indicates a deterioration of the condition.

2. Flexor (decorticate posturing)

a. Client flexes one or both arms on the chest and may extend the legs stiffly.

b. Flexor posturing indicates a nonfunctioning cortex.

3. Extensor (decerebrate posturing)

a. Client stiffly extends one or both arms and possibly the legs.

b. Extensor posturing indicates a brainstem lesion.

4. Flaccid posturing: Client displays no motor response in any extremity. 

Babinski Reflex

■ Dorsiflexion of the big toe, and fanning of the other toes; elicited by firmly stroking the lateral aspect of the sole of the foot

■ Is a pathological or abnormal reflex in anyone older than 2 years and represents the presence of central nervous system (CNS) disease

Corneal (Blink) Reflex

■ Involuntary closure of the eyelids in response to stimulation of the cornea

■ Loss of the blink reflex indicates a dysfunction of cranial nerve V

Gag Reflex

■ Contraction of pharyngeal muscle, elicited by touching the back of the throat

■ Loss of the gag reflex indicates a dysfunction of cranial nerves IX and X

General Findings

■ Irritability

■ Nuchal rigidity

■ Severe, unrelenting headaches

■ Generalized muscle aches and pains

■ Nausea and vomiting

■ Fever and chills

■ Tachycardia

■ Photophobia

■ Nystagmus

■ Abnormal pupil reaction and eye movement

Brudzinski’s Sign

■ Involuntary flexion of the hip and knee when the neck is passively flexed; indicates meningeal

irritation

Kernig’s Sign

■ Loss of the ability of a supine client to straighten the leg completely when it is fully flexed at the

knee and hip; indicates meningeal irritation

Motor Response

■ Hemiparesis, hemiplegia, and decreased muscle tone

■ Cranial nerve dysfunction, especially cranial nerves III, IV, VI, VII, and VIII

Memory Changes

■ Short attention span

■ Personality and behavioral changes

■ Bewilderment 

Assess patency of the airway and keep an airway and emergency equipment at the bedside.

Monitor blood pressure, pulse, and heart sounds.

Assess respiratory and circulatory status.

Do not leave the client unattended if unstable.

Maintain a patent airway and ventilation because a high CO2 level increases intracranial pressure.

Assess lung sounds for the accumulation of secretions.

Suction fluids from the airway as needed.

Assess neurological status, including level of consciousness, pupillary reactions, and motor and sensory function, using a coma scale.

Place the client in a semi-Fowler’s position.

Change position of the client every 2 hours, avoiding injury when turning.

Avoid Trendelenburg’s position.

Use side rails unless contraindicated or according to agency protocol.

Assess for edema.

Monitor for dehydration.

Monitor intake and output and daily weight.

Maintain NPO status until consciousness returns.

Maintain nutrition as prescribed, and monitor fluid and electrolyte balance.

Check the gag and swallow reflex before resuming a diet, and begin the diet with ice chips and fluids when the client becomes alert.

Provide intravenous or enteral feedings as prescribed.

Assess bowel sounds.

Monitor elimination patterns.

Monitor for constipation, impaction, and paralytic ileus.

Maintain urinary output to prevent stasis, infection, and calculus formation.

Monitor the status of skin integrity.

Initiate measures to prevent skin breakdown.

Provide frequent mouth care.

Remove dentures and contact lenses.

Assess the eyes for the presence of a corneal reflex and irritation, and instill artificial tears or cover the eyes with eye patches.

Monitor drainage from the ears or nose for the presence of cerebrospinal fluid.

Assume that the unconscious client can hear.

Avoid restraints.

Initiate seizure precautions if necessary.

Provide range-of-motion exercises to prevent contractures.

Use a footboard or high-topped sneakers to prevent footdrop.

Use splints to prevent wrist deformities.

Initiate physical therapy as appropriate.

A. Description

1. Increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation.

2. Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death.

B. Assessment

1. Altered level of consciousness, which is the most sensitive and earliest indication of increasing ICP

2. Headache

3. Abnormal respirations (see Box 66-2)

4. Rise in blood pressure with widening pulse pressure

5. Slowing of pulse

6. Elevated temperature

7. Vomiting

8. Pupil changes

9. Late signs of increased ICP include increased systolic blood pressure, widened pulse pressure, and slowed heart rate.

10. Other late signs include changes in motor function from weakness to hemiplegia, a positive Babinski reflex, decorticate or decerebrate posturing, and seizures.

C. Interventions

1. Monitor respiratory status and prevent hypoxia.

2. Avoid the administration of morphine sulfate to prevent the occurrence of hypoxia.

3. Maintain mechanical ventilation as prescribed; maintaining the PaCO2 at 30 to 35 mm Hg will

result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP.

4. Maintain body temperature.

5. Prevent shivering, which can increase ICP.

6. Decrease environmental stimuli.

7. Monitor electrolyte levels and acid-base balance.

8. Monitor intake and output.

9. Limit fluid intake to 1200 mL/day.

10. Instruct the client to avoid straining activities, such as coughing and sneezing.

11. Instruct the client to avoid Valsalva’s maneuver.

For the client with increased intracranial pressure, elevate the head of the bed 30 to 40 degrees, avoid the Trendelenburg position, and prevent flexion of the neck and hips.

D. Medications

Anticonvulsants

Seizures increase metabolic requirements and cerebral blood flow and volume, thus increasing intracranial pressure.

Anticonvulsants may be given prophylactically to prevent seizures.

Antipyretics and Muscle Relaxants

Temperature reduction decreases metabolism, cerebral blood flow, and thus intracranial pressure.

Antipyretics prevent temperature elevations.

Muscle relaxants prevent shivering.

Blood Pressure Medication

Blood pressure medication may be required to maintain cerebral perfusion at a normal level.

Notify the HCP if the blood pressure range is lower than 100 or higher than 150 mm Hg systolic.

Corticosteroids

Corticosteroids stabilize the cell membrane and reduce leakiness of the blood-brain barrier.

Corticosteroids decrease cerebral edema.

A histamine blocker may be administered to counteract the excess gastric secretion that occurs with the corticosteroid.

Clients must be withdrawn slowly from corticosteroid therapy to reduce the risk of adrenal crisis.

Intravenous Fluids

Fluids are administered intravenously via an infusion pump to control the amount administered.

Hypertonic intravenous solutions are avoided because of the risk of promoting additional cerebral edema.

Hyperosmotic Agent

A hyperosmotic agent increases intravascular pressure by drawing fluid from the interstitial spaces and from the brain cells.

Monitor renal function.

Diuresis is expected.

E. Surgical intervention:

Ventriculoperitoneal Shunt

Description

A ventriculoperitoneal shunt diverts cerebrospinal fluid from the ventricles into the peritoneum.

Postprocedure Interventions

Position the client supine and turn from the back to the nonoperative side.

Monitor for signs of increasing intracranial pressure resulting from shunt failure.

Monitor for signs of infection.

A. Description

1. Temperature higher than 105° F, which increases the cerebral metabolism and increases the risk of hypoxia

2. Causes include infection, heat stroke, exposure to high environmental temperatures, and dysfunction of the thermoregulatory center

B. Assessment

1. Temperature higher than 105° F

2. Shivering

3. Nausea and vomiting

C. Interventions

1. Maintain a patent airway.

2. Initiate seizure precautions.

3. Monitor intake and output and assess the skin and mucous membranes for signs of dehydration.

4. Monitor lung sounds.

5. Monitor for dysrhythmias.

6. Assess peripheral pulses for systemic blood flow.

7. Induce normothermia with fluids, cool baths, fans, or a hypothermia blanket.

1. Prevent shivering, which will increase intracranial pressure and oxygen consumption.

2. Administer medications as prescribed to prevent shivering and to lower body temperature.

3. Monitor neurological status.

4. Monitor for infection and respiratory complications because hyperthermia may mask the signs of infection.

5. Monitor for cardiac dysrhythmias.

6. Monitor intake and output and fluid balance.

7. Prevent trauma to the skin and tissues.

8. Apply lotion to the skin frequently.

9. Inspect for frostbite if a hypothermia blanket is used.

A. Description

1. Head injury is trauma to the skull, resulting in mild to extensive damage to the brain.

2. Immediate complications include cerebral bleeding, hematomas, uncontrolled increased ICP, infections, and seizures.

3. Changes in personality or behavior, cranial nerve deficits, and any other residual deficits depend on the area of the brain damage and the extent of the damage.

B. Types of head injuries

1. Open

a. Scalp lacerations

b. Fractures in the skull

c. Interruption of the dura mater

2. Closed

a. Concussions

b. Contusions

c. Fractures

Concussion

■ Concussion is a jarring of the brain within the skull, with no loss of consciousness. 

Contusion

■ Contusion is a bruising type of injury to the brain tissue.

■ Contusion may occur along with other neurological injuries, such as with subdural or extradural collections of blood.

Skull Fractures

■ Linear

■ Depressed

■ Compound

■ Comminuted

Epidural Hematoma

■ The most serious type of hematoma, epidural hematoma forms rapidly and results from arterial bleeding.

■ Epidural hematoma forms between the dura and skull from a tear in the meningeal artery.

■ It is often associated with temporary loss of consciousness, followed by a lucid period, that rapidly progresses to coma.

■ Epidural hematoma is a surgical emergency.

Subdural Hematoma

■ Subdural hematoma forms slowly and results from a venous bleed.

■ Subdural hematoma occurs under the dura as a result of tears in the veins crossing the subdural space.

Intracerebral Hemorrhage

■ Intracerebral hemorrhage occurs when a blood vessel within the brain ruptures allowing blood to leak inside the brain.

Subarachnoid Hemorrhage

■ A subarachnoid hemorrhage is bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously, such as from a ruptured cerebral aneurysm.

1. Description: Hematoma is a collection of blood in the tissues and can occur as a result of a subarachnoid hemorrhage or an intracerebral hemorrhage.

2. Assessment

a. Assessment findings depend on the injury.

b. Clinical manifestations usually result from increased ICP.

c. Changing neurological signs in the client

d. Changes in level of consciousness

e. Airway and breathing pattern changes

f. Vital signs change, reflecting increased ICP.

g. Headache, nausea, and vomiting

h. Visual disturbances, pupillary changes, and papilledema

i. Nuchal rigidity (not tested until spinal cord injury is ruled out)

j. CSF drainage from the ears or nose

k. Weakness and paralysis

l. Posturing

m. Decreased sensation or absence of feeling

n. Reflex activity changes

o. Seizure activity

CSF can be distinguished from other fluids by the presence of concentric rings (bloody fluid surrounded by yellowish stain, Halo sign) when the fluid is placed on a white sterile background, such as a gauze pad. CSF also tests positive for glucose when tested using a strip test.

3. Interventions

a. Monitor respiratory status and maintain a patent airway because increased CO2 levels increase cerebral edema.

b. Monitor neurological status and vital signs, including temperature.

c. Monitor for increased ICP.

d. Maintain head elevation to reduce venous pressure.

e. Prevent neck flexion.

f. Initiate normothermia measures for increased temperature.

g. Assess cranial nerve function, reflexes, and motor and sensory function.

h. Initiate seizure precautions.

i. Monitor for pain and restlessness.

j. Morphine sulfate may be prescribed to decrease agitation and control restlessness caused by pain for the head-injured client on a ventilator; administer with caution because it is a respiratory depressant and may increase ICP.

k. Monitor for drainage from the nose or ears because this fluid may be CSF.

l. Do not attempt to clean the nose, suction, or allow the client to blow his or her nose if drainage occurs.

m. Do not clean the ear if drainage is noted, but apply a loose, dry sterile dressing.

n. Check drainage for the presence of CSF.

o. Notify the HCP if drainage from the ears or nose is noted and if the drainage tests positive for CSF.

p. Instruct the client to avoid coughing because this increases ICP.

q. Monitor for signs of infection.

r. Prevent complications of immobility.

s. Inform the client and family about the possible behavior changes that may occur, including those that are expected and those that need to be reported.

1. Description

a. Surgical procedure that involves an incision through the cranium to remove accumulated blood or a tumor

b. Complications of the procedure include increased ICP from cerebral edema, hemorrhage, or obstruction of the normal flow of CSF.

c. Additional complications include hematomas, hypovolemic shock, hydrocephalus, respiratory and neurogenic complications, pulmonary edema, and wound infections.

d. Complications related to fluid and electrolyte imbalances include diabetes insipidus and inappropriate secretion of antidiuretic hormone.

e. Stereotactic radiosurgery (SRS) may be an alternative to traditional surgery and is usually used to treat tumors and arteriovenous malformations.

2. Preoperative interventions

a. Explain the procedure to the client and family.

b. Ensure that informed consent has been obtained.

c. Prepare to shave the client’s head as prescribed (usually done in the operating room) and cover the head with an appropriate covering.

d. Stabilize the client before surgery.

3. Postoperative interventions

Monitor vital signs and neurological status every 30 to 60 minutes.

Monitor for increased intracranial pressure.

Monitor for decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes, and personality changes.

Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased intracranial pressure.

Assess a health care provider’s (HCP’s) prescription regarding client positioning.

Avoid extreme hip or neck flexion, and maintain the head in a midline neutral position.

Provide a quiet environment.

Monitor the head dressing frequently for signs of drainage.

Mark any area of drainage at least once each nursing shift for baseline comparison.

Monitor the Hemovac or Jackson-Pratt drain, which may be in place for 24 hours.

Maintain suction on the Hemovac or Jackson-Pratt drain.

Measure drainage from the Hemovac or Jackson-Pratt drain every 8 hours, and record the amount and color.

Notify the HCP if drainage is more than the normal amount of 30 to 50 mL per shift.

Notify the HCP immediately of excessive amounts of drainage or a saturated head dressing.

Record strict measurement of hourly intake and output.

Maintain fluid restriction at 1500 mL/day as prescribed.

Monitor electrolyte levels.

Monitor for dysrhythmias, which may occur as a result of fluid or electrolyte imbalance.

Apply ice packs or cool compresses as prescribed; expect periorbital edema and ecchymosis of one or both eyes, which is not an unusual occurrence.

Provide range-of-motion exercises every 8 hours.

Place antiembolism stockings on the client as prescribed.

Administer anticonvulsants, antacids, corticosteroids, and antibiotics as prescribed.

Administer analgesics such as codeine sulfate or acetaminophen (Tylenol) as prescribed for pain.

4. Postoperative positioning

Positions prescribed following a craniotomy vary with the type of surgery and the specific

postoperative health care provider’s (HCP’s) prescription.

Always check the HCP’s prescription regarding client positioning.

Incorrect positioning may cause serious and possibly fatal complications.

Removal of a Bone Flap for Decompression

To facilitate brain expansion, the client should be turned from the back to the nonoperative side,

but not to the side where the operation was performed.

Posterior Fossa Surgery

To protect the operative site from pressure and minimize tension on the suture line, position the client on the side, with a pillow under the head for support, and not on the back.

Infratentorial Surgery

Infratentorial surgery involves surgery below the tentorium of the brain.

The HCP may prescribe a flat position without head elevation or may prescribe that the head of the bed be elevated at 30 to 45 degrees.

Do not elevate the head of the bed in the acute phase of care following surgery without a HCP’s prescription.

Supratentorial Surgery

Supratentorial surgery involves surgery above the tentorium of the brain.

The HCP may prescribe that the head of the bed be elevated at 30 degrees to promote venous outflow through the jugular veins.

Do not lower the head of the bed in the acute phase of care following surgery without a HCP’s prescription.

A. Description

1. Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons.

2. The injury can involve contusion, laceration, or compression of the cord.

3. Spinal cord edema develops; necrosis of the spinal cord can develop as a result of compromised capillary circulation and venous return.

4. Loss of motor function, sensation, reflex activity, and bowel and bladder control may result.

5. The most common causes include motor vehicle accidents, falls, sporting and industrial accidents, and gunshot or stab wounds.

6. Complications related to the injury include respiratory failure, autonomic dysreflexia, spinal shock, further cord damage, and death.

B. Most frequently involved vertebrae

1. Cervical—C5, C6, and C7

2. Thoracic—T12

3. Lumbar—L1

E. Assessment of spinal cord injuries

1. Dependent on the level of the cord injury

2. Level of spinal cord injury: Lowest spinal cord segment with intact motor and sensory function

3. Respiratory status changes

4. Motor and sensory changes below the level of injury

5. Total sensory loss and motor paralysis below the level of injury

6. Loss of reflexes below the level of injury

7. Loss of bladder and bowel control

8. Urinary retention and bladder distention

9. Presence of sweat, which does not occur on paralyzed areas

I. Emergency interventions

Always suspect spinal cord injury when trauma occurs until this injury is ruled out.

Immobilize the client on a spinal backboard with the head in a neutral position to prevent an incomplete injury from becoming complete.

1. Emergency management is critical because improper movement can cause further damage and loss of neurological function.

2. Assess the respiratory pattern and maintain a patent airway.

3. Prevent head flexion, rotation, or extension.

4. During immobilization, maintain traction and alignment on the head by placing hands on both sides of the head by the ears.

5. Maintain an extended position.

6. Logroll the client.

7. No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position.

8. In the emergency department, a client who has sustained a cervical fracture should be placed immediately in skeletal traction via skull tongs or halo traction to immobilize the cervical spine and reduce the fracture and dislocation

J. Interventions during hospitalization

1. Respiratory system

a. Assess respiratory status because paralysis of the intercostal and abdominal muscles occurs with C4 injuries.

b. Monitor arterial blood gas levels and maintain mechanical ventilation if prescribed to prevent respiratory arrest, especially with cervical injuries.

c. Encourage deep breathing and the use of an incentive spirometer.

d. Monitor for signs of infection, particularly pneumonia.

2. Cardiovascular system

a. Monitor for cardiac dysrhythmias.

b. Assess for signs of hemorrhage or bleeding around the fracture site.

c. Assess for signs of shock, such as hypotension, tachycardia, and a weak and thready pulse.

d. Assess the lower extremities for deep vein thrombosis.

e. Measure circumferences of the calf and thigh to identify increases in size.

f. Apply thigh-high antiembolism stockings as prescribed.

g. Remove antiembolism stockings daily to assess the skin.

h. Monitor for orthostatic hypotension when repositioning the client.

3. Neuromuscular system

a. Assess neurological status.

b. Assess motor and sensory status to determine the level of injury.

c. Assess motor ability by testing the client’s ability to squeeze hands, spread the fingers, move the toes, and turn the feet.

d. Assess absence of sensation, hyposensation, or hypersensation by pinching the skin or pricking it with a pin, starting at the shoulders and working down the extremities.

e. Monitor for signs of autonomic dysreflexia and spinal shock.

f. Immobilize the client to promote healing and prevent further injury.

g. Assess pain.

h. Initiate measures to reduce pain.

i. Administer analgesics as prescribed.

j. Monitor for complications of immobility.

k. Prepare the client for decompression laminectomy, spinal fusion, or insertion of instrumentation or rods if prescribed.

l. Collaborate with the physical therapist and occupational therapist to determine appropriate exercise techniques, assess the need for hand and wrist splints, and develop an appropriate plan to prevent footdrop.

4. Gastrointestinal system

a. Assess abdomen for distention and hemorrhage.

b. Monitor bowel sounds and assess for paralytic ileus.

c. Prevent bowel retention.

d. Initiate a bowel control program as appropriate.

e. Maintain adequate nutrition and a high-fiber diet.

5. Renal system

a. Prevent urinary retention.

b. Initiate a bladder control program as appropriate.

c. Maintain fluid and electrolyte balance.

d. Maintain adequate fluid intake of 2000 mL/day.

e. Monitor for urinary tract infection and calculi.

6. Integumentary system

a. Assess skin integrity.

b. Turn the client every 2 hours.

7. Psychosocial integrity

a. Assess psychosocial status.

b. Encourage the client to express feelings of anger and depression.

c. Discuss the sexual concerns of the client.

d. Promote rehabilitation with self-care measures, setting realistic goals based on the client’s potential functional level.

e. Encourage contact with appropriate community resources.

1. Complete transection of the cord: The spinal cord is severed completely, with total loss of sensation, movement, and reflex activity below the level of injury.

2. Partial transection of the cord

a. The spinal cord is damaged or severed partially.

b. The symptoms depend on the extent and location of the damage.

c. If the cord has not suffered irreparable damage, early treatment is needed to prevent partial damage from developing into total and permanent damage.

a. Central cord syndrome occurs from a lesion in the central portion of the spinal cord.

b. Loss of motor function is more pronounced in the upper extremities, and varying degrees and patterns of sensation remain intact.

a. Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter of the spinal cord.

b. Motor function, pain, and temperature sensation are lost below the level of injury; however, the sensations of position, vibration, and touch remain intact.

a. Posterior cord syndrome is caused by damage to the posterior portion of the gray and white matter of the spinal cord.

b. Motor function remains intact, but the client experiences a loss of vibratory sense, crude touch, and position sensation.

a. Brown-Séquard syndrome results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half the cord.

b. Motor function, vibration, proprioception, and deep touch sensations are lost on the same side of the body (ipsilateral) as the lesion or cord damage.

c. On the opposite side of the body (contralateral) from the lesion or cord damage, the sensations of pain, temperature, and light touch are affected.

a. Conus medullaris syndrome follows damage to the lumbar nerve roots and conus medullaris in the spinal cord.

b. Client experiences bowel and bladder areflexia and flaccid lower extremities.

c. If damage is limited to the upper sacral segments of the spinal cord, bulbospongiosus penile(erection) and  micturition reflexes will remain.

a. Cauda equina syndrome occurs from injury to the lumbosacral nerve roots below the conus medullaris.

b. The client experiences areflexia of the bowel, bladder, and lower reflexes.

■ Injury occurring between C1 and C8

■ Paralysis involving all four extremities 

■ Injury occurring between T1 and L4

■ Paralysis involving only the lower extremities 

1. Injury at C2 to C3 is usually fatal.

2. C4 is the major innervation to the diaphragm by the phrenic nerve.

3. Involvement above C4 causes respiratory difficulty and paralysis of all four extremities.

4. Client may have movement in the shoulder if the injury is at C5 through C8, and may also have decreased respiratory reserve.

1. Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury.

2. Leg paralysis (paraplegia) may occur.

3. Autonomic dysreflexia with lesions or injuries above T6 and in cervical lesions may occur.

4. Visceral distention from a noxious stimuli such as a distended bladder or impacted rectum may cause reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and goose flesh.

1. Loss of movement and sensation of the lower extremities may occur.

2. S2 and S3 center on micturition; therefore, below this level, the bladder will contract but not empty (neurogenic bladder).

3. Injury above S2 in males allows them to have an erection, but they are unable to ejaculate because of sympathetic nerve damage.

4. Injury between S2 and S4 damages the sympathetic and parasympathetic response, preventing erection or ejaculation.

1. Description

a. Spinal shock: A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord’s response to the injury. It usually lasts less than 48 hours but can continue for several weeks

b. Neurogenic shock: Occurs most commonly in clients with injuries above T6 and usually is experienced soon after the injury. Massive vasodilation occurs, leading to pooling of the blood in blood vessels, tissue hypoperfusion, and impaired cellular metabolism.

2. Assessment

Neurogenic Shock

■ Hypotension

■ Bradycardia

Spinal Shock

■ Flaccid paralysis

■ Loss of reflex activity below the level of the injury

■ Bradycardia

■ Hypotension

■ Paralytic ileus

3. Interventions

a. Monitor for signs of spinal shock following a spinal cord injury.

b. Monitor for hypotension and bradycardia.

c. Monitor for reflex activity.

d. Assess bowel sounds.

e. Monitor for bowel and urinary retention.

f. Provide supportive measures as prescribed, based on the presence of symptoms.

g. Monitor for the return of reflexes.

1. Description

a. Autonomic dysreflexia is also known as autonomic hyperreflexia.

b. Autonomic dysreflexia generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions.

c. It is commonly caused by visceral distention from a distended bladder or impacted rectum.

d. It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke.

2. Assessment

■ Sudden onset, severe throbbing headache

■ Severe hypertension and bradycardia

■ Flushing above the level of the injury

■ Pale extremities below the level of the injury

■ Nasal stuffiness

■ Nausea

■ Dilated pupils or blurred vision

■ Sweating

■ Piloerection (goose bumps)

■ Restlessness and a feeling of apprehension

3. Interventions

1. Raise the head of the bed.

2. Loosen tight clothing on the client.

3. Check for bladder distention or other noxious stimulus.

4. Administer an antihypertensive medication.

5. Document the occurrence, treatment, and response.

Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to contact a health care provider (HCP) and sit the client up in bed in a high Fowler’s position and remove the noxious stimulus.

The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact the client, if necessary. The nurse assesses the environment to ensure that it is not too cool or too drafty and also monitors vital signs, particularly the blood pressure, every 15 minutes. Antihypertensive medication may be prescribed by the HCP to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response.

1. Description

a. Skeletal traction is used to stabilize fractures or dislocations of the cervical or upper thoracic spine.

b. Two types of equipment used for cervical traction are skull (cervical) tongs and halo traction (halo fixation device).

2. Skull tongs

a. Skull tongs are inserted into the outer aspect of the client’s skull, and traction is applied.

b. Weights are attached to the tongs, and the client is used as countertraction. The nurse should not add or remove weights.

c. Monitor the neurological status of the client.

d. Determine the amount of weight prescribed to be added to the traction.

e. Ensure that weights hang securely and freely at all times.

f. Ensure that the ropes for the traction remain within the pulley.

g. Maintain body alignment and maintain care of the client on a special bed (such as a RotoRest bed or Stryker or Foster frame) as prescribed.

h. Turn the client every 2 hours.

i. Assess insertion site of the tongs for infection.

j. Provide sterile pin site care as prescribed.

3. Halo traction

a. Halo traction is a static traction device that consists of a headpiece with four pins, two anterior and two posterior, inserted into the client’s skull.

b. The metal halo ring may be attached to a vest (jacket) or cast when the spine is stable, allowing increased client mobility.

c. Monitor the client’s neurological status for changes in movement or decreased strength.

d. Never move or turn the client by holding or pulling on the halo traction device.

e. Assess for tightness of the jacket by ensuring that one finger can be placed under the jacket.

f. Assess skin integrity to ensure that the jacket or cast is not causing pressure.

g. Provide sterile pin site care as prescribed.

Notify a health care provider (HCP) if the halo vest (jacket) or ring bolts loosen.

Use fleece or foam inserts to relieve pressure points.

Keep the vest lining dry.

Clean the pin site daily.

Notify the HCP if redness, swelling, drainage, open areas, pain, tenderness, or a clicking sound occurs from the pin site.

A sponge bath or tub bath is allowed; showers are prohibited.

Assess the skin under the vest daily for breakdown, using a flashlight.

Do not use any products other than shampoo on the hair.

When shampooing the hair, cover the vest with plastic.

When getting out of bed, roll onto the side and push on the mattress with the arms.

Never use the metal frame for turning or lifting.

Use a rolled towel or pillowcase between the back of the neck and bed or next to the cheek when lying on the side, and raise the head of the bed to increase sleep comfort.

Adapt clothing to fit over the halo device.

Eat foods high in protein and calcium to promote bone healing.

Have the correct-sized wrench available at all times for an emergency (tape the wrench to the vest).

If cardiopulmonary resuscitation is required, the anterior portion of the vest will be loosened and the posterior portion will remain in place to provide stability.

1. Bed rest

2. Immobilization with a body cast if prescribed

3. Assess for respiratory impairment and paralytic ileus, possible complications of the body cast.

4. Use of a brace or corset when the client is out of bed

1. Decompressive laminectomy

a. Removal of one or more laminae

b. Allows for cord expansion from edema; performed if conventional methods fail to prevent neurological deterioration

2. Spinal fusion

a. Spinal fusion is used for thoracic spinal injuries.

b. Bone is grafted between the vertebrae for support and to strengthen the back.

3. Postoperative interventions

a. Monitor for respiratory impairment.

b. Monitor vital signs, motor function, sensation, and circulatory status in the lower extremities.

c. Encourage breathing exercises.

d. Assess for signs of fluid and electrolyte imbalances.

e. Observe for complications of immobility.

f. Keep the client in a flat position as prescribed.

g. Provide cast care if the client is in a full body cast.

h. Turn and reposition frequently by logrolling side to back to side, using turning sheets and pillows between the legs to maintain alignment.

i. Administer pain medication as prescribed.

j. Maintain on NPO status until the client is passing flatus.

k. Monitor bowel sounds.

l. Provide the use of a fracture bedpan.

m. Monitor intake and output.

n. Maintain nutritional status.

P. Medications

1. Dexamethasone (Decadron)

a. Used for its antiinflammatory and edema-reducing effects

b. May interfere with healing

2. Dextran: Plasma expander used to increase capillary blood flow within the spinal cord and to prevent or treat hypotension

3. Dantrolene (Dantrium), baclofen (Lioresal): These medications are used for clients with upper motor neuron injuries to control muscle spasticity.

A. Description

1. Dilation of the walls of a weakened cerebral artery

2. Aneurysm can lead to rupture.

B. Assessment

1. Headache and pain

2. Irritability

3. Diplopia

4. Blurred vision

5. Tinnitus

6. Hemiparesis

7. Nuchal rigidity

8. Seizures

C. Interventions

1. Maintain a patent airway (suction only with an HCP’s prescription).

2. Administer oxygen as prescribed.

3. Monitor vital signs and for hypertension or dysrhythmias.

4. Avoid taking temperatures via the rectum.

5. Initiate aneurysm precautions

Maintain the client on bed rest in a semi-Fowler’s or a side-lying position.

Maintain a darkened room (subdued lighting and avoid direct, bright, artificial lights) without stimulation (a private room is optimal).

Provide a quiet environment (avoid activities or startling noises); a telephone in the room is not usually allowed.

Reading, watching television, and listening to music are permitted, provided that they do not overstimulate the client.

Limit visitors.

Maintain fluid restrictions.

Provide diet as prescribed; avoid stimulants in the diet.

Prevent any activities that initiate the Valsalva maneuver (straining at stool, coughing); provide stool softeners to prevent straining.

Administer care gently (such as the bath, back rub, range of motion).

Limit invasive procedures.

Maintain normothermia.

Prevent hypertension.

Provide sedation.

Provide pain control.

Administer prophylactic anticonvulsant medications.

Provide deep vein thrombosis (DVT) prophylaxis as prescribed.

A. Description

1. Seizures are an abnormal, sudden, excessive discharge of electrical activity within the brain.

2. Epilepsy is a disorder characterized by chronic seizure activity and indicates brain or CNS irritation.

3. Causes include genetic factors, trauma, tumors, circulatory or metabolic disorders, toxicity, and infections.

4. Status epilepticus involves a rapid succession of epileptic spasms without intervals of consciousness; it is a potential complication that can occur with any type of seizure, and brain damage may result.

B. Types of seizures

1. Generalized seizures

2. Partial seizures

C. Assessment

1. Seizure history

2. Type of seizure

3. Occurrences before, during, and after the seizure

4. Prodromal signs, such as mood changes, irritability, and insomnia

5. Aura: Sensation that warns the client of the impending seizure

6. Loss of motor activity or bowel and bladder function or loss of consciousness during the seizure

7. Occurrences during the postictal state, such as headache, loss of consciousness, sleepiness, and impaired speech or thinking

D. Interventions

If the client is having a seizure, maintain a patent airway. Do not force the jaws open or place anything in the client’s mouth.

1. Note the time and duration of the seizure.

2. Assess behavior at the onset of the seizure: If the client has experienced an aura, if a change in facial expression occurred, or if a sound or cry occurred from the client

3. If the client is standing or sitting, place the client on the floor and protect the head and body.

4. Support the ABCs—airway, breathing, and circulation.

5. Administer oxygen.

6. Prepare to suction secretions.

7. Turn the client to the side to allow secretions to drain while maintaining the airway.

8. Prevent injury during the seizure.

9. Remain with the client.

10. Do not restrain the client.

11. Loosen restrictive clothing.

12. Note the type, character, and progression of the movements during the seizure.

13. Monitor for incontinence.

14. Administer intravenous medications as prescribed to stop the seizure.

15. Document the characteristics of the seizure.

16. Provide privacy, if possible.

17. Monitor behavior following the seizure, such as the state of consciousness, motor ability, and speech ability.

18. Instruct the client about the importance of lifelong medication and the need for follow-up determination of medication blood levels.

19. Instruct the client to avoid alcohol, excessive stress, fatigue, and strobe lights.

20. Encourage the client to contact available community resources, such as the Epilepsy Foundation of America.

21. Encourage the client to wear a Medic-Alert bracelet.

Generalized Seizures

Tonic-Clonic

Tonic-clonic seizures may begin with an aura.

The tonic phase involves the stiffening or rigidity of the muscles of the arms and legs and usually lasts 10 to 20 seconds, followed by loss of consciousness.

The clonic phase consists of hyperventilation and jerking of the extremities and usually lasts about 30 seconds.

Full recovery from the seizure may take several hours.

Absence

A brief seizure that lasts seconds, and the individual may or may not lose consciousness.

No loss or change in muscle tone occurs.

Seizures may occur several times during a day.

The victim appears to be daydreaming.

This type of seizure is more common in children.

Myoclonic

Myoclonic seizures present as a brief generalized jerking or stiffening of extremities.

The victim may fall to the ground from the seizure.

Atonic or Akinetic (Drop Attacks)

An atonic seizure is a sudden momentary loss of muscle tone.

The victim may fall to the ground as a result of the seizure.

Partial Seizures

Simple Partial

The simple partial seizure produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area.

The client remains conscious and may report an aura.

Complex Partial

The complex partial seizure is a psychomotor seizure.

The area of the brain most usually involved is the temporal lobe.

The seizure is characterized by periods of altered behavior of which the client is not aware.

The client loses consciousness for a few seconds.

A. Description

1. A stroke or brain attack is a sudden focal neurological deficit caused by cerebrovascular disease.

2. A stroke is a syndrome in which the cerebral circulation is interrupted, causing neurological deficits.

3. Cerebral anoxia lasting longer than 10 minutes causes cerebral infarction with irreversible change.

4. Cerebral edema and congestion cause further dysfunction.

5. Diagnosis is determined by a CT scan, electroencephalography, cerebral arteriography, and MRI.

6. Transient ischemic attack may be a warning sign of an impending stroke.

7. The permanent disability cannot be determined until the cerebral edema subsides.

8. The order in which function may return is facial, swallowing, lower limbs, speech, and arms.

9. Carotid endarterectomy is a surgical intervention used in stroke management; it is targeted at stroke prevention, especially in clients with symptomatic carotid stenosis.

10. The National Institutes of Health through the National Institute of Neurological Disorders and

Stroke (NINDS) developed the Know Stroke. Know the Signs. Act in Time campaign to help educate the public about the symptoms of stroke and the importance of getting to the hospital quickly (http://stroke.nih.gov).

B. Causes

1. Thrombosis

2. Embolism

3. Hemorrhage from rupture of a vessel

C. Risk factors

1. Atherosclerosis

2. Hypertension

3. Anticoagulation therapy

4. Diabetes mellitus

5. Stress

6. Obesity

7. Oral contraceptives

D. Assessment

1. Assessment findings depend on the area of the brain affected; stroke scales may be used by the health care facility for assessment.

2. Lesions in the cerebral hemisphere result in manifestations on the contralateral side, which is the side of the body opposite the stroke.

3. Airway patency is always a priority.

4. Pulse (may be slow and bounding)

5. Respirations (Cheyne-Stokes)

6. Blood pressure (hypertension)

7. Headache, nausea, and vomiting

8. Facial drooping

9. Nuchal rigidity

10. Visual changes

11. Ataxia

12. Dysarthria

13. Dysphagia

14. Speech changes

15. Decreased sensation to pressure, heat, and cold

16. Bowel and bladder dysfunctions

17. Paralysis

1. Expressive

a. Damage occurs in Broca’s area of the frontal brain.

b. The client understands what is said but is unable to communicate verbally.

2. Receptive

a. Injury involves Wernicke’s area in the temporoparietal area.

b. The client is unable to understand the spoken and often the written word.

3. Global or mixed: Language dysfunction occurs in expression and reception.

4. Interventions for aphasia

a. Provide repetitive directions.

b. Break tasks down to one step at a time.

c. Repeat names of objects frequently used.

d. Allow time for the client to communicate.

e. Use a picture board, communication board, or computer technology. 

1. Maintain a patent airway and administer oxygen as prescribed.

2. Monitor vital signs.

3. Usually a blood pressure of 150/100 mm Hg is maintained to ensure cerebral perfusion.

4. Suction secretions as prescribed, but never suction nasally or for longer than 10 seconds to prevent increased ICP.

5. Monitor for increased ICP because the client is most at risk during the first 72 hours following the stroke.

6. Position the client on the side, with the head of the bed elevated 15 to 30 degrees as prescribed.

7. Monitor level of consciousness, pupillary response, motor and sensory response, cranial nerve function, and reflexes.

8. Maintain a quiet environment.

9. Insert a Foley catheter as prescribed.

10. Administer intravenous fluids as prescribed.

11. Maintain fluid and electrolyte balance.

12. Prepare to administer anticoagulants, antiplatelets, diuretics, antihypertensives, and anticonvulsants as prescribed.

13. Establish a form of communication.

1. Continue with interventions from the acute phase.

2. Position the client 2 hours on the unaffected side and 20 minutes on the affected side.

3. Position the client in the prone position if prescribed, for 30 minutes three times daily.

4. Provide skin, mouth, and eye care.

5. Perform passive range-of-motion exercises to prevent contractures.

6. Place antiembolism stockings on the client; remove daily to check skin.

7. Measure thighs and calves daily for an increase in size.

8. Monitor the gag reflex and ability to swallow.

9. Provide sips of fluids and slowly advance diet to foods that are easy to chew and swallow.

10. Provide soft and semisoft foods and flavored, cool or warm, thickened fluids rather than thin liquids because the stroke client can tolerate these types of food better; speech therapists may do swallow studies to recommend consistency of food and fluids.

11. When the client is eating, position the client sitting in a chair or sitting up in bed, with the head and neck positioned slightly forward and flexed.

12. Place food in the back of the mouth on the unaffected side to prevent trapping of food in the affected cheek.

1. Neglect syndrome

a. Client is unaware of the existence of his or her paralyzed side (unilateral neglect), which places the client at risk for injury.

b. Teach the client to touch and use both sides of the body.

2. Hemianopsia

a. Client has blindness in half the visual field.

b. Homonymous hemianopsia is blindness in the same visual field of both eyes.

c. Encourage the client to turn the head to scan the complete range of vision; otherwise, he or she does not see half of the visual field.

3. Approach the client from the unaffected side.

4. Place the client’s personal objects within the visual field.

5. Provide eye care for visual deficits.

6. Place a patch over the affected eye if the client has diplopia.

7. Increase mobility as tolerated.

8. Encourage fluid intake and a high-fiber diet.

9. Administer stool softeners as prescribed.

10. Encourage the client to express her or his feelings.

11. Encourage independence in activities of daily living.

12. Assess the need for assistive devices such as a cane, walker, splint, or braces.

13. Teach transfer technique from bed to chair and from chair to bed.

14. Provide gait training.

15. Initiate physical and occupational therapy for assessment and the need for adaptive equipment or other supports for self-care and mobility.

16. Refer client to a speech and language pathologist as prescribed.

17. Encourage the client and family to contact available community resources.

A. Description

1. Multiple sclerosis is a chronic, progressive, noncontagious, degenerative disease of the CNS characterized by demyelinization of the neurons.

2. It usually occurs between the ages of 20 and 40 years and consists of periods of remissions and exacerbations.

3. The causes are unknown, but the disease is thought to be the result of an autoimmune response or viral infection.

4. Precipitating factors include pregnancy, fatigue, stress, infection, and trauma.

5. Electroencephalographic findings are abnormal.

6. Assessment of a lumbar puncture indicates an increased gamma globulin level, but the serum globulin level is normal.

B. Assessment

1. Fatigue and weakness

2. Ataxia and vertigo

3. Tremors and spasticity of the lower extremities

4. Paresthesias

5. Blurred vision, diplopia, and transient blindness

6. Nystagmus

7. Dysphasia

8. Decreased perception to pain, touch, and temperature

9. Bladder and bowel disturbances, including urgency, frequency, retention, and incontinence

10. Abnormal reflexes, including hyperreflexia, absent reflexes, and a positive Babinski reflex

11. Emotional changes such as apathy, euphoria, irritability, and depression

12. Memory changes and confusion

C. Interventions

1. Provide energy conservation measures during exacerbation.

2. Protect the client from injury by providing safety measures.

3. Place an eye patch on the eye for diplopia.

4. Monitor for potential complications such as urinary tract infections, calculi, pressure ulcers, respiratory tract infections, and contractures.

5. Promote regular elimination by bladder and bowel training.

6. Encourage independence.

7. Assist the client to establish a regular exercise and rest program.

8. Instruct the client to balance moderate activity with rest periods.

9. Assess the need for and provide assistive devices.

10. Initiate physical and speech therapy.

11. Instruct the client to avoid fatigue, stress, infection, overheating, and chilling.

12. Instruct the client to increase fluid intake and eat a balanced diet, including low-fat, high-fiber foods and foods high in potassium.

13. Instruct the client in safety measures related to sensory loss, such as regulating the temperature of bath water and avoiding heating pads.

14. Instruct the client in safety measures related to motor loss, such as avoiding the use of scatter rugs and using assistive devices.

15. Instruct the client in the self-administration of prescribed medications.

16. Provide information about the National Multiple Sclerosis Society.

A. Description

1. Myasthenia gravis is a neuromuscular disease characterized by considerable weakness and abnormal fatigue of the voluntary muscles.

2. A defect in the transmission of nerve impulses at the myoneural junction occurs.

3. Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness of the muscle fibers to acetylcholine.

B. Assessment

1. Weakness and fatigue

2. Difficulty chewing and swallowing

3. Dysphagia

4. Ptosis

5. Diplopia

6. Weak, hoarse voice

7. Difficulty breathing

8. Diminished breath sounds

9. Respiratory paralysis and failure

C. Interventions

1. Monitor respiratory status and ability to cough and deep-breathe adequately.

2. Monitor for respiratory failure.

3. Maintain suctioning and emergency equipment at the bedside.

4. Monitor vital signs.

5. Monitor speech and swallowing abilities to prevent aspiration.

6. Encourage the client to sit up when eating.

7. Assess muscle status.

8. Instruct the client to conserve strength.

9. Plan short activities that coincide with times of maximal muscle strength.

10. Monitor for myasthenic and cholinergic crises.

11. Administer anticholinesterase medications as prescribed.

12. Instruct the client to avoid stress, infection, fatigue, and over-the-counter medications.

13. Instruct the client to wear a Medic-Alert bracelet.

14. Inform the client about services from the Myasthenia Gravis Foundation.

1. Description

a. Myasthenic crisis is an acute exacerbation of the disease.

b. The crisis is caused by a rapid, unrecognized progression of the disease, inadequate amount of medication, infection, fatigue, or stress.

2. Assessment

a. Increased pulse, respirations, and blood pressure

b. Dyspnea, anoxia, and cyanosis

c. Bowel and bladder incontinence

d. Decreased urine output

e. Absent cough and swallow reflex

3. Interventions

a. Assess for signs of myasthenic crisis.

b. Increase anticholinesterase medication, as prescribed.

1. Description

a. Cholinergic crisis results in depolarization of the motor end plates.

b. The crisis is caused by overmedication with anticholinesterase.

2. Assessment

a. Abdominal cramps

b. Nausea, vomiting, and diarrhea

c. Blurred vision

d. Pallor

e. Facial muscle twitching

f. Hypotension

g. Pupillary miosis

3. Interventions

a. Withhold anticholinesterase medication.

b. Prepare to administer the antidote, atropine sulfate, if prescribed. 

Have atropine sulfate available when performing the Tensilon test.

1. Description

a. May also be known as the Tensilon test; this test is performed by the neurologist to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis.

b. The test places the client at risk for ventricular fibrillation and cardiac arrest; the nurse must be prepared for this possibility.

2. To diagnose myasthenia gravis

a. Edrophonium injection is administered to the client.

b. Positive for myasthenia gravis: Client shows improvement in muscle strength after the administration of edrophonium.

c. Negative for myasthenia gravis: Client shows no improvement in muscle strength, and strength may even deteriorate after injection of edrophonium.

3. To differentiate crisis

a. Myasthenic crisis: Edrophonium is administered and, if strength improves, the client needs more medication.

b. Cholinergic crisis: Edrophonium is administered and, if weakness is more severe, the client is overmedicated; prepare to administer atropine sulfate, the antidote, as prescribed.

A. Description

1. Parkinson’s disease is a degenerative disease caused by the depletion of dopamine, which interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the extrapyramidal system.

2. It is a slow, progressive disease that results in a crippling disability.

3. The debilitation can result in falls, self-care deficits, failure of body systems, and depression.

4. Mental deterioration occurs late in the disease.

B. Assessment

1. Bradykinesia, abnormal slowness of movement, and sluggishness of physical and mental

responses

2. Akinesia

3. Monotonous speech

4. Handwriting that becomes progressively smaller

5. Tremors in hands and fingers at rest (pill rolling)

6. Tremors increasing when fatigued and decreasing with purposeful activity or sleep

7. Rigidity with jerky movements

8. Restlessness and pacing

9. Blank facial expression; masklike faces

10. Drooling

11. Difficulty swallowing and speaking

12. Loss of coordination and balance

13. Shuffling steps, stooped position, and propulsive gait

C. Interventions

1. Assess neurological status.

2. Assess ability to swallow and chew.

3. Provide high-calorie, high-protein, high-fiber soft diet with small, frequent feedings.

4. Increase fluid intake to 2000 mL/day.

5. Monitor for constipation.

6. Promote independence along with safety measures.

7. Avoid rushing the client with activities.

8. Assist with ambulation and provide assistive devices.

9. Instruct the client to rock back and forth to initiate movement.

10. Instruct the client to wear low-heeled shoes.

11. Encourage the client to lift feet when walking and to avoid prolonged sitting.

12. Provide a firm mattress and position the client prone, without a pillow, to facilitate proper posture.

13. Instruct in proper posture by teaching the client to hold the hands behind the back to keep the spine and neck erect.

14. Promote physical therapy and rehabilitation.

15. Administer antiparkinsonian medications to increase the level of dopamine in the CNS.

16. Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications.

17. Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis.

A. Description

1. Trigeminal neuralgia is a sensory disorder of the trigeminal (fifth cranial) nerve.

2. It results in severe, recurrent, sharp, facial pain along the trigeminal nerve.

B. Assessment

1. Client has severe pain on the lips, gums, or nose, or across the cheeks.

2. Situations that stimulate symptoms include cold, washing the face, chewing, or food or fluids of 

C. Interventions

1. Instruct the client to avoid hot or cold foods and fluids.

2. Provide small feedings of liquid and soft foods.

3. Instruct the client to chew food on the unaffected side.

4. Administer medications as prescribed (see Chapter 67).

D. Surgical interventions

1. Microvascular decompression: Surgical relocation of the artery that compresses the trigeminal nerve as it enters the pons, which may relieve pain without compromising facial sensation

2. Radiofrequency waveforms: Create lesions that provide relief of pain without compromising touch or motor function

3. Rhizotomy: Resection of the root of the nerve to relieve pain

4. Glycerol injection: Destroys the myelinated fibers of the trigeminal nerve (may take up to 3 weeks for pain relief to occur)

A. Description

1. Bell’s palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor.

2. It results in paralysis of one side of the face.

3. Recovery usually occurs in a few weeks, without residual effects.

B. Assessment

1. Flaccid facial muscles

2. Inability to raise the eyebrows, frown, smile, close the eyelids, or puff out the cheeks

3. Upward movement of the eye when attempting to close the eyelid

4. Loss of taste

C. Interventions

1. Encourage facial exercises to prevent the loss of muscle tone (a face sling may be prescribed to

prevent stretching of weak muscles).

2. Protect the eyes from dryness and prevent injury.

3. Promote frequent oral care.

4. Instruct the client to chew on the unaffected side.

A. Description

1. Guillain-Barré syndrome is an acute infectious neuronitis of the cranial and peripheral nerves.

2. The immune system overreacts to the infection and destroys the myelin sheath.

3. The syndrome usually is preceded by a mild upper respiratory infection or gastroenteritis.

4. The recovery is a slow process and can take years.

The major concern in Guillain-Barré syndrome is difficulty breathing; monitor respiratory status closely.

B. Assessment

1. Paresthesias

2. Pain and/or hypersensitivity such as with the weight of bed sheets or other items touching the

body

3. Weakness of lower extremities

4. Gradual progressive weakness of the upper extremities and facial muscles

5. Possible progression to respiratory failure

6. Cardiac dysrhythmias

7. CSF that reveals an elevated protein level

8. Abnormal electroencephalogram

C. Interventions

1. Care is directed toward the treatment of symptoms, including pain management.

2. Monitor respiratory status.

3. Provide respiratory treatments.

4. Prepare to initiate respiratory support.

5. Monitor cardiac status.

6. Assess for complications of immobility.

7. Provide the client and family with support.

A. Description

1. Amyotrophic lateral sclerosis is also known as Lou Gehrig’s disease.

2. It is a progressive degenerative disease involving the motor system.

3. The sensory and autonomic systems are not involved, and mental status changes do not result from the disease.

4. The cause of the disease may be related to an excess of glutamate, a chemical responsible for relaying messages between the motor neurons.

5. As the disease progresses, muscle weakness and atrophy develop until a flaccid tetraplegia develops.

6. Eventually, the respiratory muscles become affected, leading to respiratory compromise, pneumonia, and death.

7. No cure is known, and the treatment is symptomatic.

B. Assessment

1. Respiratory difficulty

2. Fatigue while talking

3. Muscle weakness and atrophy

4. Tongue atrophy

5. Dysphagia

6. Weakness of the hands and arms

7. Fasciculations of the face

8. Nasal quality of speech

9. Dysarthria

C. Interventions

1. Care is directed toward the treatment of symptoms.

2. Monitor respiratory status and institute measures to prevent aspiration.

3. Provide respiratory treatments.

4. Prepare to initiate respiratory support.

5. Assess for complications of immobility.

6. Address advance directives as appropriate

7. Provide the client and family with support.

A. Description

1. Encephalitis is an inflammation of the brain parenchyma and often of the meninges.

2. It affects the cerebrum, brainstem, and cerebellum.

3. It most often is caused by a viral agent, although bacteria, fungi, or parasites also may be involved.

4. Viral encephalitis is almost always preceded by a viral infection.

B. Transmission

1. Arboviruses can be transmitted to human beings through the bite of an infected mosquito or tick.

2. Echovirus, coxsackievirus, poliovirus, herpes zoster virus, and viruses that cause mumps and chickenpox are common enteroviruses associated with encephalitis.

3. Herpes simplex type 1 virus can cause viral encephalitis.

4. The organism that causes amebic meningoencephalitis can enter the nasal mucosa of persons swimming in warm fresh water—for example, in a pond or lake.

C. Assessment

1. Presence of cold sores, lesions, or ulcerations of the oral cavity

2. History of insect bites and swimming in fresh water

3. Exposure to infectious diseases

4. Travel to areas where the disease is prevalent

5. Fever

6. Nausea and vomiting

7. Nuchal rigidity

8. Changes in level of consciousness and mental status

9. Signs of increased ICP

10. Motor dysfunction and focal neurological deficits

D. Interventions

1. Monitor vital and neurological signs.

2. Assess level of consciousness using the Glasgow Coma Scale.

3. Assess for mental status changes and personality and behavior changes.

4. Assess for signs of increased ICP.

5. Assess for the presence of nuchal rigidity and a positive Kernig’s sign or Brudzinski’s sign, indicating meningeal irritation

6. Assist the client to turn, cough, and deep-breathe frequently.

7. Elevate the head of the bed 30 to 45 degrees.

8. Assess for muscle and neurological deficits.

9. Administer acyclovir (Zovirax) as prescribed (usually is the medication of choice for herpes encephalitis).

10. Initiate rehabilitation as needed for motor dysfunction or neurological deficits.

A. Description

1. West Nile virus infection is a potentially serious illness that affects the CNS.

2. The virus is contracted primarily by the bite of an infected mosquito (mosquitoes become carriers when they feed on infected birds).

3. Symptoms typically develop between 3 and 14 days after being bitten by the infected mosquito.

4. Neurological effects can be permanent.

B. Assessment

1. Many individuals will not experience any symptoms.

2. Mild symptoms include fever; headache and body aches; nausea; vomiting; swollen glands; or a rash on the chest, stomach, or back.

3. Severe symptoms include a high fever, headache, neck stiffness, stupor, disorientation, tremors, muscle weakness, vision loss, numbness, paralysis, seizures, or coma.

C. Interventions are supportive; there is no specific treatment for the virus.

D. Prevention

1. Use insect repellents containing DEET (diethyltoluamide) when outdoors and wear long sleeves and pants and light-colored clothing.

2. Stay indoors at dusk and dawn when mosquitoes are most active.

3. Ensure that mosquito breeding sites are eliminated, such as standing water and water in bird baths, and keep wading pools empty and on their sides when not in use.

A. Description

1. Meningitis is inflammation of the arachnoid and pia mater of the brain and spinal cord.

2. It is caused by bacterial and viral organisms, although fungal and protozoan meningitis also occur.

3. Predisposing factors include skull fractures, brain or spinal surgery, sinus or upper respiratory infections, the use of nasal sprays, and a compromised immune system.

4. Cerebrospinal fluid is analyzed to determine the diagnosis and type of meningitis. In meningitis, CSF is cloudy, with increased protein, increased white blood cells, and decreased glucose counts.

B. Transmission: Transmission occurs in areas of high population density, crowded living areas such as college dormitories, and prisons.

Transmission of meningitis is by direct contact, including droplet spread.

C. Assessment 

1. Mild lethargy

2. Photophobia

3. Deterioration in the level of consciousness

4. Signs of meningeal irritation, such as nuchal rigidity and a positive Kernig’s sign and

Brudzinski’s sign

5. Red, macular rash with meningococcal meningitis

6. Abdominal and chest pain with viral meningitis

D. Interventions

1. Monitor vital signs and neurological signs.

2. Assess for signs of increased ICP.

3. Initiate seizure precautions.

4. Monitor for seizure activity.

5. Monitor for signs of meningeal irritation.

6. Perform cranial nerve assessment.

7. Assess peripheral vascular status (septic emboli may block circulation).

8. Maintain isolation precautions as necessary with bacterial meningitis.

9. Maintain urine and stool precautions with viral meningitis.

10. Maintain respiratory isolation for the client with pneumococcal meningitis.

11. Elevate the head of the bed 30 degrees, and avoid neck flexion and extreme hip flexion.

12. Prevent stimulation and restrict visitors.

13. Administer analgesics as prescribed.

14. Administer antibiotics as prescribed.