What is the function of the neurological system?
Controls motor, sensory, autonomic, cognition and behavioral activities
- Links motor and sensory pathways,
- monitors body posturing,
- responds to internal/external environment
- Maintains homeostasis
- Directs all psychological, biologic and physical activities via chemical and electrical messages
- Acetacholine,seratonin,dopamine,GABA,endorphins
Divided into 2 systems
- Central nervous system (CNS) – Brain and spinal cord
- Peripheral nervous system (PNS) - Cranial nerves spinal nerves
- PNS divided into 2 systems
- Autonomic – involuntary
- Somatic - voluntary
BBB- sometimes have to give meds in the spine in order for it to get to the brain cells
Must have a MAP of over ____ to make sure the circulation in the brain is happening
60
Autonomic Nervous System
Hypothalamus is major center for regulation
Maintains and restores internal homeostasis
Regulates activities of internal organs
Lungs, blood vessels, digestive organs /glands
Divided into 2 systems – both producing stimulatory and inhibitory effects
Sympathetic
Fight or flight
Parasympathetic
Controls visceral functions
In nonstress situations parasympathetic rules
*Sympathetic and parasympathetic act to create the variables in the heart rate
If a patient vagals out what do we do?
give 400mL bolus of fluid
Assessment of the neurological system
Health History: - Include genetics - Clinical Manifestations – subtle/intense, fluctuating/permanent, inconvenient/devastating Pain - - Seizures - - Dizziness - - Visual Disturbances - - Weakness - - Abnormal Sensation - Could be subtle- numbness in feet, tingling in toes, top of feet feel sunburnt Vertigo
Physical Examination:
- Cerebral Function
- Mental Status
- Intellectual Function
- Thought Content
- Emotional Status - appropriate mood swings?
- Perception - motor or language, *Agnosia- can describe something but cannot name it or tell you the function
- Motor /language abilities
- Cranial Nerves
- Motor System
- Muscle Strength
- Chart 60-3
- Balance and Coordination
- Romberg- close eyes and hold hands out straight, they will fall to one side if there is a problem
- Reflexes
- Name and assess - 0-4, 2-3 considered normal, 4 is excessive and might have a seizure.
Sensory –
- Collection of subjective data
- Most deficits are peripheral neuropathies
- Tests – tactile sensation, superficial pain, vibration, position sense
Motor ability
Language ability
Impact on life
Notes:
- Dementia- chronic, not reversible
- Mental statuses can change because of drug toxicity
= Delirium- CNS damage, can be reversed, sometimes just need hydration, look at vitamin B, thyroid function
Infection and high temp- might cause delirium
Gerontology
- Structural changes, motor alterations, sensory alterations, temperature and pain perception, taste/smell alterations, tactile/visual alterations, mental status
- Gerontology- makes neuro testing harder. Slower reflexes. CT and MRI, PET scans
Define seizures
Disorders that involve periodic disturbances in the brain’s electrical activity, resulting in some degree of temporary brain dysfunction
- Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupt normal function
- May be associated with loss of consciousness, excess movement, or loss of tone/movement, disturbed behavior, mood, sensation, perception
- Most seizures are sudden and transient
- Often the symptom of underlying condition- systemic or metabolic disturbances are not considered to be epilepsy if seizures leave after condition clears
Etiology: High fevers Brain infections Metabolic disorders Inadequate brain oxygenation Structural damage (stroke, tumor) Fluid accumulation Toxic drugs/substance Withdrawal Certain drugs Drug allergy, defective genes that can’t take the drug Heart problems- not pumping enough blood to your brain Sleep deprivation
Seizure disorders
Classifications
- Partial Seizures - begin in 1 part of brain
- Simple partial
- Complex partial
- Generalized Seizures - involve electrical discharges in whole brain
- Tonic-Clonic (grand mal)
- Tonic
- Clonic
- Absence
- Atonic (fall down)
- Myoclonic (one muscle)
Nursing considerations for Tonic-Clonic (and all) Seizures
Lay on the floor (side-lying position), loosen clothes, roll on side, leave alone, DO NOT HOLD DOWN, Have suction available- nothing in the mouth, around the lips, Bed in low position, siderails up, padded, NO bite sticks
Speak calmly
Time each section if possible
Can last 1-5 minutes
Tonic- Neuronal hyperexcitation Loss of consciousness Apnea Dilated pupils Duration = 15-60 seconds
Clonic-
breathing, maybe try to get them oxygen.
Inhibitory neurons interrupt seizure discharge
Hyperventilation
Rhythmic jerking of extremities
Duration = 60-90 seconds
After seizure (Postictal) Deep sleep Muscle soreness Headache Amnesia Visual disturbances Dysphagia Aphasia Duration = variable Todd’s paralysis: temporary motor deficit of arm or leg that can last up to 24 hours
Diagnosis- can’t count on patient telling you they had a seizure, needs to have witnessed seizures, epilepsy means 2 witnessed seizures.
EEG
Deprive of 18-24 hours of sleep
take off of any neuro medications
check electrolytes and CBG
check for anemia
check kidney and liver function
anything that can cause low oxygenation, we check, then we hook them up to an EEG.
If we know the underlying cause, we will treat it. Probably do a CT or MRI of the brain to see any underlying cause.
Brain infection – encephalitis.
Observation and documentations of seizures
Circumstances prior to seizure Occurrence of an aura First obvious sign of seizure Types of movements Area of body involved Eyes –pupil size, open/closed, turned to one side? Presence of automatisms Incontinence Paralysis/weakness of extremities post Inability to speak post Movements at end Sleeps afterward cognitive status after Are they confused afterwards? How long does it take for the confusion to go away? Take VS, check for any type of injury
Epilepsy
- Condition in which a patient has spontaneous unprovoked recurring seizures caused by a chronic underlying condition
- Etiology is attributed to a group of abnormal neurons (seizure focus) that undergo spontaneous firing- possibly due to scarring (gliosis)
- New evidence that other cells may be the problem
- Incidence rate (new onset) high in 1st year of life (this could be due to high temps so we have to differentiate between high temps and epilepsy) declining in childhood & teens, plateauing in middle age and sharp rise in the elderly
- Previously a stigma but acceptable now
- Primary – idiopathic
- Secondary – cause is known and the epilepsy is a symptom of another underlying cause
- Causes
Idiopathic - genetic/developmental defect
Acquired - Hypoxemia - Medical management:
- Individualized due to the varied forms of the condition. - Management is aimed at prevention and management of seizures.
- Testing =EEG, CT,MRI,SPECT (looking for lesions in the brain, tumors, miswiring, test for genetics, toxic materials, may do lumbar puncture (spinal tap) )
- Pharmacologic Therapy – control w/o side effects (the goal)
- usually start on Dilantin (When on Dilantin: need to have a lot of blood work and monitor the levels. Take on an empty stomach. Make sure the doctor knows ALL medications they are currently taking. NO ALCOHOL!)
- Many available
- Start with single med with increasing dose, Monitor levels
- May need to switch meds if not working
- When sick or with weight change/stress may need dose adjustment
- SUDDEN WITHDRAWAL can cause freq seizures or status E
- Side effects – 1) idiosyncratic/allergic, 2) acute toxicity, 3) chronic toxicity
- If the patient gains or loses weight, could be over or underdosing. If the patient runs out of medicine and stops taking it, could go into status epilepticus, you can pretty much guarantee they will have at least one seizure.
Nursing management:
- Preventing Injury
- Reducing fear
- Improving coping
- Teach to keep a seizure diary
- Make sure they are getting proper rest
- Monitoring and managing potential complications
- PC Status Epilepticus, toxcity
Monitor drug levels: Subtherapeutic and toxic - - Speaking specifically about phenytoin, or Dilantin, drug levels must be monitored. - - Subtherapeutic and toxic levels are highly individualized. Toxic for one may be subtherapeutic of another. - - Breakthrough seizures - - Adverse effects - - - - Lethargy - - - - Nystagmus - - - - Ataxia, dysarthria
Food and drug interactions
- Delayed absorption
- Potentiated
- Inactivated
Phenytoin should not be taken with food.
Patients taking Dilantin should make sure that their physician is aware of all the medications they are taking because it commonly interferes with other drugs or it is interfered with by other drugs.
Diet to treat epilepsy
Ketogenic diet
- 4:1 fats to protein and carbohydrates
- May be useful in children
- Difficulty with compliance
The extremely high fat ketogenic diet seems to improve seizure control for a limited number of patients, more frequently children.
The mechanism by which this occurs is unknown.
Compliance with the regimen is problematic as it’s a distasteful diet. (No pun intended.)
Surgery for Epilepsy
- Extensive preoperative testing to determine eloquent areas (may include the use cortical stimulation to determine eloquent areas, such as the WADA test.)
- Prior to the surgery, subdural grids are placed.
These are internal EEG electrodes placed closely together that are laid over the areas of the brain where the seizure focus is thought to be. - The patient is videotaped and hooked up to a continuous EEG machine postoperatively.
- Seizure medications are withheld or reduced so that a seizure will be triggered.
- The results will help the neurologist and neurosurgeon decide if the patient is a surgical candidate.
- The epileptogenic focus must be identified and be unilateral.
- Usually these subdural grids are left in no longer than a week due to the risk of infection.
- Infection risk increases with each day.
Considerations
- Medically intractable epilepsy
- Feasibility of surgery
- Likelihood of success
- Risks and benefits are weighed.
- Surgery as an intervention for seizures is considered only when there is no control from medications.
(Usually multiple drugs have been tried over extended periods of time.) - Patients that are considered surgical candidates are often those who experience many recurrent seizures in a day and are unable to live normally either as a result of these frequent seizures or due to the side effects from the high doses of medications necessary to control the seizure activity.
*Complications of surgery include cranial nerve damage, hemorrhage, infection, and memory, speech, and/or visual deficits.
Vagal Nerve Stimulator
A non-surgical option that can now be offered is the vagal nerve stimulator.
It seems to be most useful for partial seizures.
The exact mechanism of action is not known.
The effect of the VNS controlling seizures was discovered by accident.
The vagal nerve lies between the carotid and the jugular vein. (It’s the only cranial nerve that is more easily accessible.)
The electrodes are wrapped around the left vagal nerve.
Medicines may be reduced with this
Status Epilepticus
Series of generalized seizures
- Clinical/electrical > 30 minutes
- Medical emergency
- Heavy metabolic load- low blood sugar
Respiration interruption and even arrest at peak, producing hypoxia
- Can lead to anoxia, cerebral edema, possible irreversible - brain damage and death
Precipitating factors – drug withdrawal, fever, infection
Medical Management-
- stop seizures (number one pirority) to promote adequate cerebral oxygenation
- Give Dilantin (Check Dilantin level) and lorazepam, Ativan, anti-seizure meds
- Airway, ET tube, O2
- Meds IV- if you can’t get an IV, give IM
- Monitored EEG,VS, labs to include lytes, glucose, med levels
- Position on their side
- Nothing in their mouth!!!
Nursing Management-
- Monitor respiratory and cardiac function
- Prevent injury to patient and self
- Suction/positioning
Potential complications of Seizures/Epilepsy
Aspiration Wernicke’s encephalopathy Neurological deterioration, continuation of SE Dehydration Fever Hypermetabolism Disability Metabolic ARF Autonomic dysfunction Cerebral edema Systemic complications Death
What is the main Goal of the critical care nurse caring for a patient in status?
prevention of complications.
These are listed here:
Thiamine, 100 mg., and an amp of D50 should be given to prevent encephalopathy.
Close monitoring is key including having a high index of suspicion about seizure activity.
Maintenance of normal bodily function is important.
This includes keeping the GI tract working with tube feedings and keeping the patient clean.
Autonomic dysfunction includes sweating.
Parkinson’s Disease
Slow progressive disabling neurologic moving disorder with gradual onset
- Tremor when muscles are at rest - often worse on one side than the other
- Rigidity with impaired movement
- Bradykinesia- slow movements
- Psych changes
- Lack of facial expression with infrequent blinking
- Micrographic- small handwriting
- Shuffling
- Monotone – soft quick, slurred words
- Difficulty swallowing- thicken fluids
- About 50 % develop dementia
- 2 of the first 3 = diagnosis
Diet: Need calories but can’t eat big meals- feed 6x a day
RN HAS TO FEED PARKINSON’S PATIENT BECAUSE THEY ARE AT RISK FOR ASPIRATION
Diagnostics: No real tests for parkinson’s.
- Based on S/S
–Difficult because aging can cause some of the same symptoms
- Give significant dose of carbidopa-levodopa (dopamine)
– If improved the positive for Parkinsons
- CT & MRI can be done to rule out any
structural disorders
- PET scan to evaluate levodopa uptake and conversion
Etiology of Parkinson’s
- Part of the basal ganglia degenerate, reducing the production of dopamine and the number of connections between nerve cells and the basal ganglia.
- Basal ganglia cannot smooth out the movements, leading to tremor, incoordination, and slowed reduced movement
- Most idiopathic but some secondary
- Mostly men in 50s, hard to pinpoint start time
- Not noticed at first
- S/S increase with stress/fatigue
- Variation in the genes can make the person more at risk but genetics does not play a role
- Exposure to toxins
- There is some thought that this could be autoimmune in nature
Medical Management for Parkinson’s
GOAL: TO PERFORM ADL’S ON THEIR OWN
- Care individualized
Meds:
- ***Dopamine precursor- Carbidopa-levodopa (most common)
- Dopamine agonist- acts like dopamine
- MAO-B inhibitor- prevents the breakdown of brain dopamine
- COMT inhibitors- prolong dopamine effect
- Anticholinergics- control the tremor
- Amatadine – antiviral- give early on
- Beta blockers- give to keep the heart rate regular
SE: hallucinations, sleepiness, compulsive behaviors, gambling, eating, sex
Build a tolerance to the meds as time goes on, so they often switch the meds
***Meds must be given 30 min-1 hour before eating because Parkinson’s can cause the person to have problems’s swallowing
Surgery: Palidotomy, stimulation, stem cell implants
Nursing care:
- Keep them mobile as long as we can- give them shoes that slide- walk without falling down (feet apart, penguinish)
- Maintain self care- we want the small muscles to stay as active as possible
- Increase fiber in their diet
- Probably won’t have much of an appetite
- At risk for aspiration
- Dysphagia
- Sense of smell is down (probably why they lose their appetite)
- *Give small meals (high calorie, stuff that they like, flavorful)- 6 meals a day
- Walk slow
- Helpful: massage, acupuncture, thai chi, art, meditaion, music
- At risk for falls
Multiple Sclerosis
What is it?
- Auto immune activity results in patches of myelin and the underlying nervous fibers are damaged or destroyed. Scarring is the result leading to slowing and blockage of the electrical impulses that control musc coordination, strength, sensation and vision
- Communication between the brain and target tissue is not working anymore after the sheath is gone
Diagnosis
- Probably see it at first in the eyes (need glasses changed often)
- Early diagnosis is difficult because we don’t know which nerve it will impact first. (a lot of times it is the eyes, but not always)
Causes:
- Genetic susceptibility
- Progression- eventually it will effect your eyes, mobility, and gait
- Flare-ups- could be triggered by things like the flu
- More at risk if you’ve had mono early on.
- Environment plays a big role- US and Canada have different versions than other countries
- Also have- thyroid problems, type 1 diabetes, inflammatory bowel (when you have 1 auto immune disease, you are more susceptible to more). Often smokers.
- ***Usually occurs in young women age 20-40
Patterns:
- Relapsing remitting clearly defined flare-ups
- Primary progressive –gradual decline
- Secondary progressive – second step of relapsing remitting
- Progressive relapsing – primary progressive with sudden worsening
Clinical Manifestations of MS
- **depends on the amount of damage done and to which nerves
- Numbness/weakness in limbs usually one side or bottom half of body
- Loss of vision partial or complete
- Double vision/blurring
- Tingling or pain in parts of body
- Electric shock sensation that occurs with certain head movements
- Fatigue- ataxia
- Dizziness
- Musc stiffness and spasticity
- Slurred speech, dysphagia
- Abnormal reflexes
- Paralysis problems with elimination and sexual function
- Mental changes: depression, seizures, up and down personality
- Bladder problems: may need to learn to how to self cath
Medical Management of MS
Goal: ADL’s without fatigue
Degenerative, will not get better, will have more attacks as time goes on
No cure
Individualized Diagnostics
- Pulmonary function
- Spinal tap- will see increased protein and WBCs
- MRI
- Electrical studies- EEG
- Diagnoses- made on s/s
Medications
- Virus fighters
- Immune suppressors/steroids
- Muscle relaxants
- ***Drugs to decrease relapse- the drugs we really want to give
- Pain meds
- Meds to rectify sexual, bowel, and bladder problems
- Baclaphin- muscle relaxant
- Copraxia – muscle relaxant
- Steroids- suppresses the immune system to avoid building the antibodies that are killing the myelin sheath- CHECK GLUCOSE
- Can give cancer drugs as well but a lot of SE
- Cytoxin- prostaglandin, give for ulcers often.
- Antacids
Treatments
- Plasmaphoresis (75% improvement but only lasts a few weeks)
- Physical therapy- must keep moving, stretching, OT can fit them with devices to help them perform ADLs
- Counseling - debilitating disease and you know you won’t get better
**Want them to stay cool in temperature – avoid extreme temps
Nursing Considerations:
GOAL: ADL’S WITHOUT A LOT OF FATIGUE
- Encourage rest, exercise, heat avoidance and a well-balanced diet (High protein, high carbs, ***low gluten, low fat)
- Enhance bladder/bowel control, sexual function
- Improve cognitive and sensory function
- Promote self-care
- Need to do self care as long as they can
- Relaxing exercises
- Push fluids
- Push oral marijuana recommended
- Discourage gaining a large amount of weight, it will be more difficult for them to move around
Myasthenia Gravis
What is it?
- Autoimmune disorder that impairs the passing of signals at the neural junction
- Antibodies attack the receptor sites
Causes:
- Blockage and/or destruction of the receptor site for the Ach pathway
- Thymus tumor- can remove and problem is solved
- A different antibody causing a different autoimmune problem
- Can be genetic
Triggers:
- Fatigue
- Stress
- Meds
- Most common in women younger than 40 and men younger than 60
- If it’s auto immune problem – no cure, will probably have other auto immunes- RA, Thyroid, Lupus
Diagnosis:
- Tensilon- medications we can give them to test if it is Myasthenia Gravis. Will get better after administration.
MUST TAKE MEDS ON TIME – before they eat to strengthen chewing and swallowing
