Adult nursing
Neurological system disease
University of Babylon /college of nursing
Submited by
Haider H. Ali
BSN , MSN. Psych
The human nervous system:
* Its purpose is to control motor, sensory, and autonomic functions of the body.
* This is accomplished by coordination and initiation of cellular activity through the transmission of electrical impulses and various hormones.
* The nervous system is divided into:
* The central nervous system, consisting of the brain and spinal cord.
* The peripheral nervous system, which consists of the cranial nerves and spinal nerves.
* The autonomic nervous system, which is part of the peripheral nervous system and consists of sympathetic and para-sympathetic systems.
The brain :
* Composed of gray matter and white matter, the brain controls, initiates, and integrates body functions through the use of electrical impulses and complex molecules.
Physiology of the brain:
* The brain is contained within the skull, or cranium.
* Three coverings of the brain, called the meninges. They are the dura mater, arachnoid mater, and pia mater.
The brain hemisphere :
* The right side receives information from and controls the left side of the body. Specializes in perception of physical environment, art, music, nonverbal communication, spiritual aspects.
* The left receives information from and controls the right side of the body. Specializes in analysis, calculation, problem solving, verbal communication, interpretation, language, reading, and writing.
The spinal cord :
* A continuation of the brain stem.
* Exits the skull through the foramen magnum, an opening in the base of the skull.
Cerebrospinal fluid (CSF):
* Provides for shock absorption and bathes the brain and spinal cord.
* Production 500 milliliter /L daily
* CSF, clear, colorless, odorless.
* Specific gravity (1.007)
* Normal pressure (60-180)mm water
* Normal amount in adult (125-150)ml
* Accumulation of CSF in children (hydrocephaly) in adult (SOL) space accuping lesion.
Peripheral Nervous System:
1- Cranial Nerves:
* Twelve pairs of cranial nerves have sensory, motor, or mixed functions.
Olfactory
Sensory;smell
Optic
Sensory;Vision
Oculomotor
Motor; Pupil
Constriction
Trochlear
Motor;upper eyelid elevation
Trigeminal
cornea, nose, oral mucosa; mastication
Abducens
Motor; Extraocular eye movement
Facial
Motor (facial muscles); Sensory (taste)
Acoustic
Sensory;
Hearing; Equilibrium
Glosso-
Pharyngeal
Taste; Swallowing
Vagus
Motor and Sensory
Spinal Accessory
Motor
Hypoglossal
Tongue Movement
2-Spinal Nerves
3-Autonomic Nervous System:
* Main function is to maintain internal homeostasis.
* Two subdivisions of ANS:
* The sympathetic system (activated by stress, prepares body for “fight or flight” response).
* The parasympathetic system (conserves, restores, and maintains vital body functions, slowing heart rate, increasing gastrointestinal activity, and activating bowel and bladder evacuation).
Cerebral Function: Assessment:
Glasgow Coma scale :
Common Diagnostic Tests for Nervous System Disorders:
* Lumbar puncture (LP).
* Electroencephalogram (EEG).
* Electromyogram (EMG).
* Imaging Procedures.
* Cerebral Angiography.
* Brain scan., MRI
* Myelogram.
Cerebrovascular Accident (CVA):
* Also known as stroke, CVA is a sudden loss of brain function accompanied by neurological deficit.
* Third highest cause of death in U.S.
* Strokes are caused by ischemia (oxygen deprivation) resulting from a thrombus, embolus, severe vasospasm, or cerebral hemorrhage.
Transient Ischemic Attacks (TIAs):
* Frequently preceding CVAs, TIAs are temporary or transient episodes of neurological dysfunction caused by temporary impairment of blood flow to the brain.
Classic symptom:
* Blurred vision or blindness .
* Loss of balance or coordination.
* Difficulty speaking or understanding.
* Weaknesses ,numbness ,paralysis in the face, arm, leg .
Clinical manifestation :
S & S according to the location effected .
* Hemiplegia: paralysis of one side of the body.
* Hemiparesis: weaknesses of one side of the body.
* Impaired of speech caused by muscle dysfunction.
* Dysphagia :impaired swallowing muscle .
* Emotional liability :loss of emotion control .
* Sensory deficit: decrease sensation of touch, pain, cold or heat.
* Confuse and disoriented.
* Intellectual deficit : memory impairment, poor judgment .
* Bowl and bladder dysfunction.
Nursing management with CVA:
1. Maintain pt. airway.
2. Maintain fluid and electrolyte balance.
3. Administer O2 and medication prescribed.
4. Monitoring vital signs, urological status ,I&O and pulse oximetry.
5. Ensure adequate nutrition.
6. Provide care for eye , mouth .
7. Keep client in correct alignment and put the footboard to prevent foot drop.
8. Turn client at lest every 2 hours to prevent pneumonia and bed sore.
9. Assist client to perform (ROM) exercise using unaffected side exercise the affected side.
Epilepsy/Seizure Disorder
* Epilepsy is a disorder of cerebral function in which the client experiences sudden attacks of altered consciousness, motor activity, or sensory phenomenon.
* Most clinicians use the term seizure disorder for epilepsy or seizures
* Seizures are classified as generalized or partial.
Cause of electrical disturbance :
* Birth trauma , hypoxia , infection , tumor
* Alcohol toxicity
* Drug withdrawal
* Vascular abnormalities such as (CVA).
* Hypoglycemia electrolyte imbalance
* Fever .
* Unknown cause .
Type of epilepsy :
1. General epilepsy:
* this arise from poth cerebral hemisphere.
* May be preceded by a sensory warning (aura )which specific for each patient .
A- Grand mal epilepsy:
* The pt. often warning.
* After seizer Falls to the ground unconscious.
* Tonic and clonic present
* Pt. become synotic.
* Incontinence of urine or stool.
B-Petit mal epilepsy (myoclonic)
* Very mild, sudden, involuntary contraction of muscles group or rapid .
* Usually occurred in the trunk or extremities .
* No loss of conscious.
2. Partial epilepsy :
* Seizer are simple or complex .
A- simple :
* the area affected my be (hand, finger, talk, sense such as smell.
* Consciousness not loss.
B- complex:
* Loss of conscious and my produce cognitive, psychomotor ,psycho sensory symptom
* Client my perform inappropriate behavior.
* The client not remember the episode.
Specific diagnostic test:
* EEG. To identify the abnormal electrical activity .
* CT.Scan . To identify lesion
Nsg. management during seizure :
* Provide privacy and product the pt. from curios looker.
* Put the pt. in the floor if there is enough time.
* Protect the head by a pad to avoid injury.
* Loosen constrictive clothing.
* If aura precedes the seizure , insert a hand kerchief or towel between teeth to avoid bitten tongue .
* No attempt to restrain the pt. during seizure
* Put the pt. in lateral position to facilitate drainage mucous and saliva and avoid aspiration.
* Increase intracranial pressure ( ICP): Is the first signs of (C.N.S disease).
1. Headache: it is not continuous, more common in early morning & increase during strength (cough, sneezing, defecations ).
2. Vomiting :recurrent and may projectile, not preceded to nausea usually occur before breakfast .
3. Papill edema: swelling of optic disc of retina of the eye
Late signs & symptom (ICP):
1. Change in vital signs
* Pulse & respiration slow, BP &Temp rise
* Bradycardia (40- 60).
* Deferent between systolic & diastolic pressure to high (90).
2.Skin dry and worm and pink or red color.
3. Dilated pupils or unequal in size.
4. Chang level of consciousness .
5. Weaknesses in motor function e.g.. Weakness of facial muscle
6. Vertigo and mental changes.
Nsg . management :
* Check vital signs frequently.
* Measure level of consciousness by give the pt. stimulation(verbal,physical, painful)
* Nurse must record changes or weaknesses.
* Elevated head at lest (30-45)degree to increase venous drainage of the brain.
* Fluid is limited to decrease edema.
* Measure fluid input and output.
* Minimize strength during cough, vomiting, defecations.
Unconscious patient
Patient problem assessment.
* Ineffective airway: related to accumulation of secretion.
* Nutritional alteration: related to inability to ingested food and fluid.
* Alteration in bladder , bowl elimination and self care deficit : related to unconscious state .
Nursing management with (Unconscious patient :
1. Airway: accumulation of secretion cause serious problem. Removed by
* Lyining on side to facilitate circulation o2 in the lung and facilitate draining of oral secretion .
* Sectioning
2. Vital signs :check vital signs every (30-60)min and rectal temperature .
3. Skin : check texture, moisture, temp and pressure ulcer.
4.Nutrition :first 24hours (iv fluid) and N.G tube --- 100-300 cc milk, meet water every 2 hour
5. Environmental :
* Room temp(70F), ventilated.
* One sheet only cover.
* Elevated bed sidereal.
6.hygien:
* Washing of hear.
* Clean nose , ear and nil
7.Elimination :catheter and check input ,out put
8.Check dressing post operation .
9. If present otorhea or rhenorhea must be.
* Pt. isolation
* Aseptic techniques .
* Sterile cotton in nose or ear.