NCSBN – Lesson 8C: Neurological System Study Guide,100% CORRECT

NCSBN – Lesson 8C: Neurological System Study Guide Severe neck stiffness in meningitis causes flexion of hips and knees with passive flexion of the neck, known as Brudzinski's sign. The inability to straighten the leg ...

NCSBN – Lesson 8C: Neurological System Study Guide Severe neck stiffness in meningitis causes flexion of hips and knees with passive flexion of the neck, known as Brudzinski's sign. The inability to straighten the legs when the hip is flexed to 90° due to hamstring stiffness, is Kernig's sign another physical finding in meningitis. When your client has been admitted with a head injury and the client has confusion and/or restlessness and/or the level of consciousness (LOC) is altered, this is an early sign of increased intracranial pressure and a nursing action is required. Contusion pain is common with a head injury but remember not to give a narcotic because it may alter the LOC. Stroke or CVA can cause paralysis, sensory disturbances, problems understanding or using language and emotional disturbances. But a further decrease in the level of consciousness would be indicative of progression of the CVA and would require immediate intervention. Protecting the airway is the top priority in a seizure, and the first action should be to roll the client on their side to open the airway and prevent aspiration in case of vomiting. If a child is actively convulsing, a patent airway and oxygenation must be assured. Nothing should be placed in the mouth when the client is having a seizure. Administration of the prescribed anticonvulsant would be another appropriate intervention for a prolonged seizure and to prevent further seizure activity during the post-ictal phase. A CT scan is the most commonly used diagnostic test to determine the size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information. Degenerative Disorders Degenerative disorders are based on degenerative cell changes that affect tissues or organs, which will increasingly deteriorate over time. The following section includes common neurologic degenerative disorders. (Note: some disorders can be classified into multiple categories.) Parkinson's Disease – Degenerative Disorders Parkinson's disease is a degenerative disorder of the dopamine-producing neurons. • Etiology o Parkinson's disease is linked to a genetic defect and results in dopamine depletion. It is more commonly found in older adult males. o Parkinson's disease is associated with neuroleptics, toxins and structural or vascular lesions in the brain. • Assessment Findings: TRAP (Classical Findings) o Findings may initially be unilateral, progressing to bilateral movements affected, such as: ▪ Resting tremors of the lips, jaw, tongue and limbs, especially a resting pill- rolling tremor of one hand that is absent during sleep ▪ Bradykinesia/akinesia ▪ Fatigue ▪ Stiffness and rigidity with movement ▪ Mask-like facial expression often accompanied with drooling ▪ Slow, shuffling walk in a stooped-over posture, gradually causing increased difficulty while walking ▪ Difficulty rising from sitting position ▪ Echolalia in most cases o Parkinson's clients in advanced stages are ultimately confined to a wheelchair. Their mental function remains intact unless there are other aggravating conditions. • Diagnostic Studies o Based on findings with history and response to pharmacologic agents o Electroencephalogram (EEG) o Magnetic resonance imaging (MRI) o Positron emission test (PET) • Management o The goal is to provide palliative symptom management and to postpone dependence. o Pharmacologic Interventions: ▪ Anticholinergics are used to minimize extrapyramidal effects: • Benzotropine mesylate • Procyclidine ▪ Dopamine hydrochloridergics: • Levodopa (L-Dopa), levodopa-carbidopa ▪ Dopamine receptor agonists: • Bromocriptine mesylate, rotigotine patch ▪ Antiparkinsonian agent such as amantadine HCl reduces rigidity and tremor ▪ MAO inhibitors: • selegiline, selegiline • COMT inhibitors: tolcapone • Entacapone (if combined with carbidopa and levodopa the medication is Stalevo) • Complementary & Integrative Health o There is some evidence that Tai Chi (along with medication) can improve balance and functional mobility. o There is no evidence that coenzyme Q10 or any other dietary supplements or herbal supplements are effective. o Physical, occupational and speech therapies are helpful. o Surgery may be recommended to decrease tremors. ▪ Stereotactic pallidotomy is used to pinpoint areas to be treated surgically ▪ Thalamotomy destroys a portion of the thalamus ▪ Deep brain stimulation is used when pharmacologic therapy is ineffective • Nursing Interventions o Maintain a safe environment for the client and foster independence in activities of daily living (ADL). The care plan will include interventions to prevent complications as a result of immobility. Reinforce the use of assistive devices for ambulation as indicated. o Promote good nutrition and suggest that the client eat small frequent meals and soft food. Increasing roughage with sufficient fluids is important to decrease constipation. o Monitor the effectiveness or ineffectiveness of administered medications. o Provide emotional support to the client and family members. o Client and family teaching will include: ▪ When and what side effects of the drugs to report ▪ Benefits of daily exercise ▪ Benefits of "drug holidays" (client stops taking medication, which in this case is a strategic treatment interruption) ▪ Safety and injury prevention Huntington's Disease – Degenerative Disorders Huntington's disease is a progressive atrophy of basal ganglia and some parts of the cerebral cortex. • Etiology o Huntington's disease is a genetic disorder, autosomal dominant. • Assessment Findings o Symptoms usually initially occur in middle age with increased involuntary movements and progressive decline in cognitive function. o Motor function impairment includes chewing and swallowing. The client will experience chorea, dystonic posture and gradually become bedridden. o Cognitive function declines and the client is less able to organize, plan and do things in a sequence behavior. Findings also include memory loss and declining speech. o Mental function decline includes personality changes, depression and even psychosis. • Diagnostic Studies o Client and family history o Physical exam o Genetic testing • Management o The goal is to provide palliative symptom management and postpone dependence. Speech and physical therapy also help the client maintain independence. Genetic counseling may be suggested if appropriate. o Psychotropic agents to manage cognitive changes and tetrabenazine to decrease chorea. • Nursing Interventions o The nurse will foster independence in ADLs and reinforce the use of assistive devices for ambulation as needed. o Maintaining a well-balanced diet with an increased caloric intake is important. Provide resources on support groups for the client, family and friends. It is important to begin to explore end-of-life issues. Amyotrophic Lateral Sclerosis – Degenerative Disorders Amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease) is a neurological disease in which progressive degeneration of the motor neurons of the anterior horn cells of the spinal cord, brainstem and motor cortex causes muscle weakness, disability and eventually death. • Etiology o The etiology of ALS is unknown. ALS's onset is in late middle age and is seen more often in men than women. Clients diagnosed with ALS usually die within 2- 6 years. • Assessment Findings o Progressive muscle weakness/twitching is the most common initial symptoms in the upper body (the head, arms and the distal portion first or leg) Clients often initially report mild clumsiness as well. o The disease will progress to total incapacity. Muscle wasting, atrophy, spasticity and speech disorders will occur. ▪ Tripping, dropping things, abnormal fatigue of the arms and/or legs, slurred speech, muscle cramps and twitches, and uncontrollable periods of laughing or crying. o There will not be a change in sensation or the autonomic nervous system. The mind remains intact while client has loss of voluntary and eventually involuntary muscle functions. o Death most often occurs from complications including respiratory failure, urinary or pulmonary infections. • Diagnostic Studies o Client history o Physical exam o Creatine kinase (CK) and electromyogram (EMG) are conducted • Management o The goal is to keep the client functionally independent as long as possible. o Pharmacologic Interventions: ▪ Muscle relaxants for spasticity ▪ Riluzole, which is a neuroprotector to extend life expectancy o Speech and physical therapy can help the client maintain independence. Respiratory and nutritional support will also be provided. • Nursing Interventions o Provide for respiratory care and referrals o Maintain a safe environment focused on infection prevention o Prevent complications of immobility, especially pulmonary and urinary stasis o Postpone dependence o Promote balanced nutrition o Provide emotional support, referrals to support groups and discuss end-of-life issues and the need for hospice Dementia – Degenerative Disorders Dementia is a loss of brain function that occurs with certain diseases, affecting memory, thinking, language, judgment and behavior. • Etiology o The etiology varies depending on the cause of dementia. o Reversible dementia is seen in clients with urinary tract infections or low levels of vitamin B12. It is also seen in clients on certain medications or with hypothyroidism. Once the cause is corrected, the dementia subsides. o Nonreversible (degenerative) dementia is seen in clients with Alzheimer's disease (the most common type of dementia) and vascular dementia (seen with stroke clients). o Other medical conditions that may cause dementia include Parkinson's disease, multiple sclerosis, Huntington's disease or long-term alcohol abuse. Dementia can also be caused by infections that can affect the brain including HIV/AIDS, syphilis and Lyme disease. • Assessment Findings o Dementia usually first appears as forgetfulness. The client will eventually develop difficulty with many areas of mental function, such as language, memory and perception. Clients may exhibit emotional behavior and changes in their personality. Dementia can affect higher levels of cognitive function, e.g., ability to think abstractly or perform calculations. • Diagnostic Studies o Any history of behavior changes will be documented and a physical exam completed. A neurological exam, including mental status test, MRI and CT of the head will be completed. o Laboratory tests will be conducted to rule out treatable causes, which may include B12 levels, blood ammonia levels, blood gas analysis, cerebrospinal fluid analysis, toxicology screen, blood glucose, liver enzyme tests, serum calcium, serum electrolytes, thyroid function tests, HIV screen, syphilis screen and/or Lyme titer. • Management o Treat underlying conditions that can lead to confusion, e.g., anemia, hypoxia, depression, heart failure, infections, nutritional disorders and/or thyroid disorders. o Pharmacologic interventions are used to control behavior problems caused by a loss of judgment, increased impulsivity and confusion. These include: ▪ Antipsychotics: haloperidol, risperidone, olanzapine ▪ Mood stabilizers: fluoxetine, imipramine, citalopram ▪ Serotonin-affecting drugs: trazodone, buspirone ▪ Stimulants: methylphenidate • Nursing Interventions o Meet the client's physical needs, establish a routine and promote the client's independence. Re-orient as appropriate and provide emotional support to the client and family while connecting them to community support resources. Be sure to promote your client's independence. Alzheimer's Disease – Degenerative Disorders Alzheimer's disease is a type of neurocognitive disorder in which there is memory impairment, as well as problems with language, decision-making ability, judgment and personality. • Etiology o The etiology of Alzheimer's disease is unknown, but thought to include both genetic and environmental factors. o Brain changes associated with Alzheimer's disease: ▪ Neurofibrillary tangles – twisted fragments of protein within nerve cells ▪ Neuritic plaques – abnormal clusters of dead and dying nerves and brain cells ▪ Senile plaques – dying nerve cells that accumulate around protein o The prognosis is incurable and fatal. • Assessment Findings o The client will present with cognitive deficits that include memory impairment. o One or more of the following will be observed: ▪ Difficulty naming objects (agnosia) ▪ Language disturbance (aphasia) ▪ Problems with organization and abstract thinking ▪ Difficulty with motor activities (apraxia) o There will be a noticeable decline in the level of functioning. o Cognitive difficulties are not related to other conditions. o Altered sensory perception include illusions and hallucinations. o Behavioral findings may include: ▪ Wandering – persistent aimless walking ▪ Verbally or physically abusive behavior ▪ Resisting care ▪ Socially inappropriate behavior ▪ Sundown syndrome (also called sundowning) o Alzheimer's disease is typically divided into three stages (reflected by behavioral changes and physical findings) ▪ Early Stage • Subtle personality changes include difficulty with abstract thinking • Forgetfulness and uncertainty causes anxiety, irritation and withdrawal • Difficulty making decisions, concentrating and handling work skills ▪ Middle Stage • Impaired language, motor activity and object recognition • Wandering • Inability to carry out ADLs • Impaired judgment • Severe disorientation, with personality and behavior changes • May have difficulty remembering family and friends • Psychotic symptoms, such as hallucinations and delusions ▪ Final/Terminal Stage • Client loses the ability to function physically and mentally • Client becomes mute, incontinent and totally dependent • Diagnostic Studies o A history of behavior changes and a physical exam will be completed. o Neurologic testing will be conducted, including mental status test, MRI and CT of the head. o Laboratory tests will be conducted to rule out other causes of dementia, including B12 levels, blood ammonia levels, blood chemistry, blood gas analysis, cerebrospinal fluid analysis, toxicology screen, blood glucose, liver enzyme tests, serum calcium, serum electrolytes, thyroid function tests, HIV screen, syphilis screen and/or Lyme titer. • Management o The goal will be managing progressive symptoms and maintenance of functional capacity. o Milieu management will include a structured routine and decreased stimulation. o Provide resources and care for the caregiver. • Pharmacologic Intervention o Drugs that enhance the action or inhibit the breakdown of acetylcholine in the brain: ▪ Galantamine: • Take with meals, twice a day or every morning (extended release) • Encourage fluids ▪ Donepezil: • Given once a day before bed • May be given with or without food ▪ Rivastigmine: • Given with food twice a day • May increase dosage at intervals for maximum effect o Memantine may be given to block glutamate accumulation and nerve cell destruction in the brain in cases of moderate to severe dementia o Antidepressants – selective serotonin reuptake inhibitors (SSRI) given for depression o Antipsychotics will be used to control hallucinations and delusions • Complementary & Integrative Health o There is no convincing evidence that any herbal remedy or dietary supplement (including ginkgo biloba, vitamins B and E, Asian ginseng, grape seed extract and curcumin) can prevent worsening of cognitive impairment. o Music therapy can decrease agitation, and improve depression and quality of life. • Nursing Interventions o Provide safe environment o Discuss legal issues, including living will, power of attorney and end-of-life care with the family o Review the client's nutrition needs o Monitor for depression o Provide memory aids o Provide a structured environment, including routines with minimal distractions and noise o Orient client as appropriate o Maintain elimination routine to decrease incontinence o Assist the family to enroll client in an identification/return program o Assess for findings of abuse/neglect o Discuss with family the need for daycare, respite care and long-term care o Support the family and caregivers Delirium, Dementia & Depression – Degenerative Disorders Delirium, dementia and depression may resemble each other but are not the same. Delirium Dementia Depression Onset Sudden/abrupt depends on cause; often occurs at twilight or in darkness Insidious/slow and often unrecognized; depends on cause Coincides with major life changes; often abrupt, but can be gradual Course Short, diurnal fluctuations in symptoms; worse at night, in darkness and on awakening Long, no diurnal effects; symptoms progressive yet relatively stable over time; may see deficits with increased stress Diurnal effects, typically worse in the morning; situational fluctuations, but less than with delirium Progression Abrupt Slow but uneven Variable; rapid or slow but even Duration Hours to less than one month; seldom longer Months to years At least six weeks; can be several months to years Consciousness Reduced Clear Clear Alertness Fluctuates; lethargic or hypervigilant Generally normal Normal Attention Impaired; fluctuates Generally normal Minimal impairment, but it's distractible Orientation Generally impaired; Generally normal Selective disorientation Delirium Dementia Depression severity varies Memory Recent and immediate impaired Recent and remote impaired Selective or "patchy" impairment; "islands" of intact memory; evaluation is often difficult due to low motivation Thinking Disorganized, distorted, fragmented; incoherent speech, either slow or accelerated Difficulty with abstraction; thoughts impoverished; judgment impaired; words difficult to find Intact but with themes of hopelessness, helplessness, or self-depression Perception Distorted; illusions, delusions, and hallucinations; difficulty distinguishing between reality and misconceptions Misperceptions usually absent Intact; delusions and hallucinations absent except in severe cases Psychomotor behavior Variable Hypokinetic Hyperkinetic and mixed Normal; may have apraxia Variable; psychomotor retardation or agitation Sleep/wake cycle Disturbed (cycle may be reversed) Fragmented Disturbed; usually early morning awakening Associated features Variable affective changes; symptoms of Affect tends to be superficial, inappropriate, and labile; Affect depressed; dysphoric mood; exaggerated and Delirium Dementia Depression autonomic hyperarousal; exaggeration of personality type; associated with acute physical illness attempts to conceal deficits in intellect; personality changes, aphasia, agnosia may be present; lacks insight detailed complaints; preoccupied with present insights; verbal elaboration; somatic complaints, poor hygiene, and neglect of self Assessment Distracted from task; numerous errors Failings highlighted by family, frequent "near miss" answers; struggles with test; great effort to find an appropriate reply; frequent requests for feedback on performance Failings highlighted by individual, frequent "don't knows"; little effort; frequently gives up; indifferent toward test: does not care or attempt to find answer Cerebrovascular Accident A cerebrovascular accident (stroke) is a sudden impairment of cerebral circulation which interrupts or diminishes the oxygen supply causing damage and/or necrosis in brain tissue. This section reviews the different types of strokes and how to manage the care of the stroke client. Cerebrovascular Accident (CVA) Information Cerebrovascular Accident (CVA) is often called a stroke or cerebral infarction. A stroke occurs when there is a decrease in blood supply to the brain. • Etiology o Risk factors for CVA include uncontrolled hypertension, smoking, obesity, increased blood cholesterol and triglycerides and atrial fibrillation. o Five Classes of Stroke by Severity: 1. A transient ischemic attack (TIA) o "angina" of the brain is a warning sign of an impending stroke. o It is a localized ischemic event and produces neurological deficits that last only minutes to hours. o A full functional recovery is seen within 24-72 hours. 2. A reversible ischemic neurological deficit (RIND) o is like a TIA. o Symptoms last between 24 hours and three weeks. o Usually clients will have a full functional recovery 3. A partial, non-progressing stroke o has some neurological deficit but the client is stabilized quickly. 4. A progressing stroke (stroke in evolution) o will present with a deteriorating neurological status and residual neurological deficits. 5. A completed stroke o leaves the client with permanent neurological deficits. • Two Basic Types of Stroke o Ischemic Stroke/Occlusive ▪ has a slow onset and is defined by an inadequate blood flow which leads to a cerebral infarction ▪ Ischemic stroke is caused by cerebral thrombosis or an embolism within the cerebral blood vessels. • The most common cause of all strokes is atherosclerosis. o Hemorrhagic Stroke ▪ Hemorrhagic stroke (bleeding) has an abrupt onset. There are four types of hemorrhagic strokes. 1. Intracerebral hemorrhagic stroke occurs when blood vessels rupture and bleed into the brain. This occurs most often in hypertensive older adults and can also be a result of anticoagulant or thrombolytic therapy. 2. Subarachnoid hemorrhage (SAH) is most often caused by the rupture of a saccular intracranial aneurysm. More than 90% of these are congenital aneurysms. 3. Epidural bleeds involve cerebral arterial vessels. Often a loss of consciousness for a short period of time occurs (transient unconsciousness). 4. Subdural bleeds involve the veins and may not be evident until months after an initial trauma. • Assessment Findings o The findings will be dependent on the location of the lesion. o Sensory-perceptual/vision-related symptoms include homonymous hemianopia, agnosia, apraxia, diplopia and sensory loss (touch, pain or cold). o Communication-related findings will include: ▪ Expressive aphasia or non-fluent aphasia (Broca's) occurs when the client knows what he or she wants to say, yet has difficulty communicating it to others ▪ Receptive aphasia or fluent aphasia (Wernicke's) occurs when the client can hear a voice or read the print but may not understand the meaning (or may take the message literally) ▪ Mixed aphasia (global) ▪ Dysarthria – a speech disorder caused by disturbance of muscular control ▪ Agraphia – inability to write or spell o Motor-related symptoms include hemiplegia, hemiparesis, flaccidity and spasticity. o Behavior-related symptoms include emotional lability, loss of social inhibitions, fear, anger and hostility. o Elimination-related symptoms include urinary frequency and urgency, and incontinence (bowel and urinary). o Neurologically-related symptoms include an altered level of consciousness, seizure and hyperthermia. • Right-sided o When the damage occurs on the right side of the brain, the left side of the body (and left side of the face) will be affected, ▪ which could produce paralysis on the left side of the body ▪ problems with processing information (visual and verbal) ▪ decreased cognitive skills (such as poor judgment, short attention span and short term memory loss). • Left-sided o When the damage occurs on the left side of the brain, the right side of the body (and right side of the face) will be affected ▪ which could produce paralysis on the right side of the body ▪ problems with communication (aphasia and dysarthria). • Diagnostic Studies o A history and physical exam will be performed and the health care provider should evaluate all suspected stroke victims within 10 minutes of their arrival at the hospital o A computerized tomogram (CT) scan should be taken within 25 minutes of arrival at the hospital (initially without contrast if hemorrhagic event is suspected) o Magnetic resonance imaging (MRI) o Doppler echocardiography flow analysis o Carotid artery duplex doppler ultrasonography o EEG – shows abnormal electrical activity o A lumbar puncture will show if blood is found in the cerebral spinal fluid as a result of a cerebral bleed (contraindicated with increased intracranial pressure) o Cerebral angiography may be done with or without contrast to show blood flow in cerebral arteries • Management o The management of a CVA is dependent on the type of CVA. ▪ Occlusive/ischemic Stroke • Pharmacologic Intervention: o Thrombolytics: tissue plasminogen activator (tPA), alteplase – (must rule out hemorrhagic stroke via CT scan prior to administration). o Antiplatelet therapy: aspirin, dipyridamole o Platelet aggregation inhibitor: clopidogrel, ticlopidine o Steroids: dexamethasone • Blood pressure management to maintain cerebral perfusion pressure (CPP). • Surgery is necessary if the carotid artery is stenotic or partially occluded. A carotid endarterectomy or angioplasty with stenting may be performed. ▪ Hemorrhagic Stroke • Pharmacologic Intervention: o Antihypertensive agents o Systemic steroids: dexamethasone o Osmotic diuretics: mannitol o Anti-fibrinolytic agents: aminocaproic acid o Anticonvulsants • A surgical excision of an aneurysm or clot/hematoma may be necessary. ▪ Both • Care will be based on the findings. • Early mobilization of rehabilitation therapies including physical, speech, occupational, behavioral and nutritional. • Nursing Interventions o Acute Stage ▪ Maintain airway patency (suctioning equipment must be available at the bedside) ▪ Monitor neurologic status and vital signs ▪ Note time, length, behaviors with seizure activity ▪ Maintain adequate fluids ▪ Elevate the head of the bed 15-30° and position the client turned or tilted to unaffected side, with head positioned midline ▪ Provide activity as ordered ▪ Perform passive and/or active range of motion exercises ▪ Maintain the client's proper body alignment ▪ Administer medications as ordered ▪ Care for postop clients as indicated ▪ Provide care for clients with increased intracranial pressure ▪ Prevent complications, i.e., contractures, stool impaction/constipation or pressure ulcers o Long-term Care ▪ Monitor clients to facilitate normal elimination patterns ▪ Teach/evaluate the use of supportive devices ▪ Maintain clients in a safe environment ▪ Prevent the effects of immobility ▪ Support the maintenance of adequate nutrition in light of feeding and swallowing problems ▪ Assist with eating and ADL as indicated ▪ Provide emotional support ▪ Provide methods of communication for clients with aphasia Client Care - Increased Intracranial Pressure Increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema or inflammation. *Since the cause of ICP is often localized, changes may initially be noticed unilaterally and progress to bilateral as the pressure increases. Level of consciousness (LOC) Early Findings* restlessness, agitation, irritability, disorientation, confusion, lethargy Late Findings stupor, semicomatose, comatose Pupils Early Findings* Late Findings *Since the cause of ICP is often localized, changes may initially be noticed unilaterally and progress to bilateral as the pressure increases. gradually dilated ipsilaterally, react slowly to light; changes in visual acuity, diplopia, blurred vision dilated bilaterally and fixed; no reaction to light Motor Activity Early Findings* Abnormal motor activity: contralateral hemiparesis Late Findings decorticate posture then decerebrate posture; flaccid muscles at end stage Reflexes Early Findings* Abnormal reflexes: hyper- or hyporeflexia Late Findings Vital Signs Early Findings* Vital signs within normal parameters Late Findings Vital signs: Cushing's triad (do not confuse with Cushing reflex): hypertension; progressively increasing systolic pressure with widening pulse pressure; bradycardia temperature initially may rise significantly then fall below normal parameters yawning, progressing to Cheyne- Stokes, progressing to central neurogenic hyperventilation, progressing to cluster or ataxic breathing and finally apnea Other Early Findings* vomiting, headache, seizures Late Findings The following is a list of nursing interventions for a client with increased ICP: • Elevate the head of the bed 15-30° with the client's head positioned midline (to encourage jugular venous drainage) • Monitor respiratory status and prevent hypoxia: o Administer oxygen as ordered o Avoid administration of morphine sulfate to prevent hypoxia from occurring • Maintain mechanical ventilation as prescribed (initial treatment to maintain PaCO2 at 30- 35 mm Hg will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and, therefore, decreased ICP) • Maintain body temperature, to prevent shivering (which can increase ICP) • Decrease environmental stimuli • Monitor electrolyte levels and acid-base balance • Monitor intake and output • Limit fluid intake to 1200 mL/day • Instruct the client to avoid straining activities: o Coughing, sneezing o Valsalva's maneuver o Laughing o Straining at stool o Vomiting o Restrictive clothing around neck o Anxiety o Pushing up in bed with heels or pulling on rails when turning • Administer medications as ordered: o Anticonvulsants o Antipyretics and muscle relaxants o Blood pressure medication o Corticosteroids o Intravenous fluids o Hyperosmotic agent • Institute seizure precautions • Monitor for changes in intracranial pressure: • Altered level of consciousness o Headache o Abnormal respirations o Rise in blood pressure with widening pulse pressure o Slowing pulse o Elevated temperature o Vomiting o Pupil changes o Changes in motor function: ▪ From weakness to hemiplegia ▪ A positive Babinski's reflex ▪ Decorticate or decerebrate posturing ▪ Seizures • Observe for herniation syndrome: o Irregular breathing o Irregular pulse o Loss of all brainstem reflexes, e.g., blinking, gagging, pupils reaction to light o Progressive loss of consciousness o Respiratory arrest o Cardiac arrest • Provide for the care of the unconscious client if decreased level of consciousness Infectious & Inflammatory Disorders This section involves infectious agents that invade the nervous system and as a result an inflammatory process occurs. Meningitis and encephalitis result from a disease process that affects the nervous system. Meningitis – Infectious & Inflammatory Disorders Meningitis is an acute or chronic inflammation of the meninges; the covering of the brain and spinal cord are involved. • Etiology o Bacterial meningitis is the most contagious form and requires isolation. Other forms include viral and fungal meningitis. o High-risk clients include infants, adults with weakened or suppressed immune systems, college students, especially freshman who reside in dormitories, and travelers to foreign countries where the disease is endemic. About 25% of cases are fatal and an additional 10-15% of cases result in brain damage or other serious side effects. • Assessment Findings o Signs of meningeal irritation include nuchal rigidity (stiff neck), a positive Kernig's sign and Brudzinski's sign and opisthotonic position. Changes in the level of consciousness and seizures may also be observed. o Infants may refuse feedings, vomit or have diarrhea. They often have a vacant stare and a high-pitched cry. Bulging fontanelles will also be observed. • Diagnostic Studies o History and physical exam o Positive Brudzinski's sign o Positive Kernig's sign • A lumbar puncture (LP) will be performed to evaluate the cerebral spinal fluid o Decreased glucose and increased protein in bacterial or fungal infections o LP is not done on clients with findings that may indicate elevated intracranial pressure • Sedation of a child may be required with midazolam, meperidine or fentanyl • CT scan or MRI, with and without contrast • Management o The goal is to cure the infection and prevent complications. o Pharmacologic Interventions: ▪ Type of antibiotic therapy will depend on the type of pathogen ▪ Antifungals if causative agent is fungus ▪ Anticonvulsants to prevent seizures ▪ Preventive therapy can be used for people exposed to those with meningococcal or Haemophilus influenzae (H flu) meningitis: rifampin; immunization also available ▪ Actions to minimize fever and prevent an increase of intracranial pressure or seizures • Nursing Interventions o Perform your organization's procedures for care of clients with increased intracranial pressure. o Seizure precautions: ▪ Administer medications as ordered. ▪ Monitor ABG, arterial pressures, body weight, serum electrolytes, urine volume, specific gravity and osmolality. ▪ Routinely assess neurologic and vital signs and provide comfort measures for pain. Implement droplet precautions for clients with Haemophilus influenczae type b and Neisseria meningitides. ▪ Reduce external stimuli and lighting if photophobic – maintain a quiet environment. ▪ Prevention includes a vaccine for clients 65+ with chronic disease and the Hib vaccine for infants. Seizure Precautions • This overview describes how to care for individuals who suffer from or are at risk for seizures, in both clinical and home settings. o Before a seizure (clinical settings): ▪ Bedrest with padded side rails ▪ Suction available at the bedside ▪ Oxygen available at bedside o During seizures: ▪ Do not leave the client who is seizing. ▪ If standing, attempt to break the client's fall by assisting them to the floor. ▪ If possible, place a pillow under the client's head. ▪ Loosen any tight or restrictive clothing. ▪ Do not place anything in the mouth. ▪ Do not hold the person down. ▪ Remove objects near the client, if possible. ▪ Support the ABCs (airway, breathing, circulation). ▪ Provide privacy. ▪ Observe the seizure as it runs its course: • Assess behavior at the onset of the seizure. • Be sure to note the time the seizure starts and ends. • Immediately notify the rapid response team if the seizure lasts longer than five minutes. o After the seizure: ▪ Turn the client on their side. ▪ Allow the client to rest/sleep. ▪ Document: • Characteristics and activity during seizure (do not label or diagnose type of seizure) • Duration • Incontinence • Precipitating factors • Client's response: o Immediate o At 15-minute intervals until stabile or as ordered o Daily life precautions at home, work and school: ▪ Use a helmet for uncontrolled seizures. ▪ Individuals with uncontrolled seizures should not drive. • Recommend that they are seizure free for six months before they are allowed to drive. • Guidelines vary from state-to-state. ▪ Instruct individuals not to: • Lock bathroom or shower doors • Swim alone • Climb to high places • Ride a bicycle alone Encephalitis – Infectious & Inflammatory Disorders Encephalitis is the inflammation of the parenchyma of the brain or spinal cord. • Etiology o Causes of encephalitis include an acute viral (most common) infection, a bacterial infection, hypoxic inflammation and poisoning (arsenic, carbon monoxide and ammonia-related liver failure). o Encephalitis can occur sporadically or as an epidemic. It may follow a systemic viral illness such as chicken pox. o Most cases in the U.S. are associated with sporadic encephalitis or the herpes simplex virus types 1 and 2. Common culprits include the rabies virus or arboviruses from the bite of infected ticks, mosquitos or other blood sucking insects (e.g., Equine, La Crosse, St. Louis and West Nile). o The death rate in encephalitis cases ranges up to 70%. • Assessment Findings o Adults present with: ▪ sudden fever ▪ severe headache and altered level of consciousness (can progress to stupor then coma with seizure activity) ▪ nuchal rigidity ▪ personality changes ▪ mild flu-like complaints. o Infants present with: ▪ Vomiting ▪ body stiffness ▪ constant crying that worsens when picked up ▪ constant full or bulging anterior fontanelle. • Diagnostic Studies o History and physical exam o CT scan, MRI and EEG o Polymerase chain reaction (PCR) assay o Cerebral spinal fluid collection to show if there is a decrease in glucose and elevated white blood cells. This suggests a bacterial or fungal infection (not done if elevated ICP suspected) • Management o The goal is to cure the infection and prevent complications. o Uncomplicated cases require supportive and preventive care which include rest, supportive nutrition and fluid balance maintenance. o Pharmacological Interventions: ▪ Antivirals such as acyclovir ▪ Anticonvulsants to prevent seizures o Prevent increased intracranial pressure. o Encephalitis prevention includes mosquito control and insect repellant. • Nursing Interventions o Control the client's fever and administer drugs as ordered. o Implement seizure precautions. o Implement care of the client with increased intracranial pressure. o When needed, ensure isolation and take airborne or droplet precautions (depending on causative agent). o Maintain patent airway to prevent further hypoxia. o Reduce stimuli and lighting if photophobic. Autoimmune Disorders of Neurologic System Autoimmune disorders occur when the body's immune system attacks healthy cells in the body by mistake. The following section discusses autoimmune disorders that affect the nervous system. Multiple Sclerosis (MS) – Autoimmune Disorders of Neurologic System Multiple sclerosis (MS) is the demyelination of white matter throughout the brain and spinal cord. • Etiology o The specific cause of MS is unknown, but there seems to be an increased incidence in temperate to cool climates; it is more common in women than men. It is the third most common cause of disability in clients aged 15-60. • Assessment Findings ▪ Findings will depend on the location of the demyelination. MS symptoms can improve and worsen unpredictably. ▪ Cranial nerve interference causes • blurred vision • dysphagia • diplopia • facial weakness and/or numbness ▪ Motor symptoms include • weakness, paralysis, spasticity and gait disturbances ▪ Sensory symptoms include • paresthesia and decreased proprioception ▪ Cerebellar symptoms include • dysarthria, tremor, incoordination, ataxia and vertigo ▪ Cognitive symptoms include • decrease in short-term memory • difficulty with new information • word-finding difficulty • short attention span ▪ Urinary retention or incontinence, loss of bowel control, sexual dysfunction and fatigue have also been reported • Diagnostic Studies o History and physical exam o Lumbar puncture o MRI and CT scan • Management o The primary goal is to alleviate symptoms and prevent complications. o Pharmacologic Intervention: ▪ Adrenocorticotropic hormone (ACTH) ▪ Beta Interferon ▪ Immunosuppressants ▪ Antispasmodics (Baclofen) o Therapies based on these findings can include physical, occupational and nutritional support. • Nursing Interventions o Maintain the client's functional independence in ADL and promote practicing a wide base walk, using a cane or walker for assistance. Prevent injury and complications from difficulties walking or immobility. Provide support resources for the client and family. o Client and family teaching will include: ▪ Avoid fatigue and stress and conserve energy ▪ Exercise regularly (resistance exercises, ROM) ▪ Know current medications and side effects ▪ Proper use of assistive devices ▪ Maintain a diet that supports nutrition and energy needs ▪ Avoid triggers such as stress, pregnancy and temperature extremes ▪ Use bladder control measures during exacerbations, e.g., anticholinergics and self-cauterization Guillain-Barré Syndrome – Autoimmune Disorders of Neurologic System Guillain-Barré syndrome is a group of autoimmune peripheral neuropathies resulting in symmetric and ascending motor paralysis. This acute condition is potentially fatal if respiratory muscles are affected. • Etiology o The etiology of Guillain-Barré syndrome is unknown, but precipitating factors include a prior bacterial or viral infection, surgery or a viral immunization within 1-2 weeks. • Assessment Findings o Muscle weakness is progressive, ascending and bilateral and leads to the paralysis of voluntary muscles and loss of superficial and deep tendon reflexes. o Bulbar weakness, dysphagia and dysarthria are reported as well. o Serious findings include respiratory failure, paresthesia and burning muscle pain. o Paralysis may vary from being partial (halfway up the body) to total paralysis. ▪ It can cause fluctuations in BP, heart rhythm and rate. o Paralysis may cause associated gastrointestinal and urinary symptoms, secondary to autonomic nervous system involvement. • Diagnostic Studies o History and physical exam o Lumbar puncture will show increase of protein in CSF o Electromyography (EMG) will show acute muscle denervation • Management o Nursing care includes preventing complications and maintaining body functions until the reversal of paralysis. o Management is based on the client's physiologic needs and which body systems are affected. Tracheostomy, ventilator support, IV fluids or plasmapheresis may be necessary. o Pharmacologic Interventions: ▪ Immunoglobulin therapy ▪ Morphine for pain control o Plasmapheresis - the removal, treatment and return of blood plasma into the blood circulation. • Nursing Interventions o Maintain care of the client on ventilator support and monitor respiratory status. o Prevent complications associated with immobilization. o Maintain a safe environment to minimize infection. o Maintain nutritional and fluid balance and provide adequate pain control. o Supply referrals to therapies such as speech, physical, occupational, counseling and nutritional support. Establish an alternate way to communicate with the client. Finally, refer the family to a support group. Myasthenia Gravis – Autoimmune Disorders of Neurologic System Myasthenia gravis (MG) is an autoimmune disorder characterized by progressive weakness and exhaustibility of voluntary muscles without atrophy or sensory disturbance. • Etiology o MG is caused by an autoimmune attack on acetylcholine receptors at neuromuscular junctions. It is progressive with occurrences of crises. It presents in two age clusters; women in early adulthood and men in late adulthood. • Assessment Findings o progressive fatigue and/or weakness of the voluntary muscles but without muscular atrophy o Sensation will remain intact o signs of restrictive lung disease. o Facial symptoms include: ▪ ptosis (drooping eyelid) ▪ reduced eye closure ▪ weak smile ▪ Diplopia ▪ blurred vision, ▪ speech and swallowing disorders. ▪ Weakness of the facial muscles makes it difficult to raise eyebrows and make different faces. • Diagnostic Studies o History and physical exam will be completed o Edrophonium (Tensilon) test – improved muscle strength after Tensilon injection indicates a positive test for MG o Single-fiber electromyography and a serum assay of circulating acetylcholine receptor antibodies will be completed • Management o The primary goal is to improve the client's strength and endurance. o Pharmacologic Intervention: ▪ Anticholinesterase agents: pyridostigmine, neostigmine ▪ Corticosteroid therapy ▪ Immunosuppressants: azathioprine o Thymectomy – surgical removal of the thymus gland. o Plasmapheresis – separation of blood components. o Management for the client in myasthenic crisis: ▪ Myasthenic crisis is usually caused by precipitating factors (triggers) such as stress, infection or inadequate medication dose. ▪ Findings include the sudden inability to swallow, speak or maintain patent airway. ▪ A Tensilon test will be performed. A positive test signals myasthenia gravis. (A negative test indicates a cholinergic crisis that will be treated with atropine.) ▪ Management includes ventilator support. o Management of a client in cholinergic crisis: ▪ Cholinergic crisis is caused by an overdose of pyridostigmine and results in increased acetylcholine. • Findings include profound weakness, gastrointestinal distress and respiratory failure. ▪ Atropine may be administered. Stop anticholinesterase agents and restart gradually when the client is stable. ▪ Management may include ventilator support. • Nursing Interventions o Identify any aggravating factors, such as infection, stress or changes in medication regime. o Provide ventilator support for clients in crisis and give medications as ordered and on time. Assist the client with ADLs and feeding as indicated. o Provide information about support groups for the client and family. o Provide emotional support, adequate rest periods and care of the post-surgical client if needed. • Client and family teaching will include: o Energy conservation techniques o Expectations, medications and side effects o Signs of impending crisis, both myasthenic and cholinergic, along with what actions to take o How to avoid or minimize stressors o How to avoid extremes of temperature o To avoid people with respiratory infections o To discuss with health care providers prior to taking any prescription or over-the- counter medications Seizure Disorders A seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in the client's behavior, movements, feelings and levels of consciousness. The following section reviews the different types of seizures. Seizure Disorders Information 1. Seizure disorders are a single event of abnormal electrical discharge in the brain. 2. Epilepsy is a chronic disorder of abnormal recurring, electrical discharge in the brain. • Etiology o The cause of a seizure disorder can include cerebral lesions or biochemical alteration, e.g. hypoglycemia or cerebral trauma. It can also be idiopathic. o Seizure can also be seen in acute febrile states (especially in children and infants). o Generalized seizures involve both hemispheres of the brain. o There are five types of generalized seizures: 1. Absence or petit mal seizures • present as brief periods (usually less than 10 seconds) of loss of consciousness and blank starring. • These are usually seen in clients between ages 4-14. 2. Myoclonic seizures • present as sudden, uncontrollable jerking movements of one or more extremities. • This seizure usually occurs in the morning and is seen in children. 3. Tonic seizures • present first as a loss of consciousness. • The muscles contract bilaterally. • The body will stiffen in an opisthotonos position with the jaws clenched and pupils dilated. • Clients may lose bladder control and may appear cyanotic and with periods of apnea. • Tonic seizures usually last <4 minutes and are most often seen in infants and children. 4. Tonic-clonic or grand mal seizures • most common type of seizure. • These seizures may be preceded by a prodromal such as an aura. • During the tonic phase, the client's movements will be bilateral. • This phase often lasts about 2-3 minutes. • During the clonic phase, the client will fixate and stare and be unresponsive for about five minutes. 5. Status epilepticus • is a rapid sequence of seizures without interruption or pauses and is a medical emergency. • It often occurs when a client suddenly stops their anticonvulsant medications. • Client is in a postictal state when the next seizure begins. If cerebral anoxia occurs, brain damage or death can follow. Additionally there is a risk for severe organ and muscle hypoxia. • Diagnostic Studies o Assess the event itself o History and physical exam o Laboratory draws will include a toxicology screen, arterial blood gases (ABGs), chemistry pane and anticonvulsant therapeutic drug level if the client is current taking an anticonvulsant o Electroencephalogram (EEG) o CT scan o Possible lumbar puncture • Management o The expected outcome will be to control or minimize the seizure activity and prevent complications by correcting the underlying problem. o Pharmacologic Intervention: ▪ Benzodiazepines, IV such as diazepam and lorazepam (active seizures) ▪ Hydantoin anticonvulsants such as phenytoin, fosphenytoin for maintenance ▪ Barbiturates such as phenobarbital for maintenance ▪ Succinimides such as ethosuximide for maintenance o Vagal nerve stimulation therapy may be helpful. o Surgery is reserved for those who are unresponsive to medication management. • Nursing Interventions o Administer medications as ordered. Be alert for drug interactions; these are very common with antiepileptic medications. o Client and family teaching will include: ▪ Wear a MedicAlert identification ▪ Understand medication effects, interactions and side effects ▪ Be aware of triggers ▪ Techniques to reduce stress ▪ Seizure care at home or at work o If a seizure occurs in a public area, after the tonic phase, turn the clients on their side. Headache A headache is the experience of regional pain in the head or neck. Treatment of a headache depends on the underlying cause, but it commonly involves pain medication. This section reviews common types and management of headaches. Headache Information • Headaches often present with pain located in the upper region of the head. This is one of the most common neurologic complaints. Classifications • Recurrent Migraine o Recurrent migraine headaches often run in families and have an adolescence or early adulthood onset. o These are often described as unilateral, throbbing pain that may be preceded by an aura or prodrome. o Migraine headaches can last hours to days. • Cluster Headaches o Cluster headaches are described as a sharp or stabbing pain, typically in the eye area. o These headaches can last up to 4 hours. • Tension Headaches o Tension headaches are the most common form. o They are associated with stress, anxiety, depression or drastic changes in caffeine consumption. • Non-recurrent Headaches o Non-recurrent headaches occur with systemic infections and are usually associated with fever. o They also occur as the result of a lesion, after an invasive spinal cord procedure such as a lumbar puncture or subarachnoid bleed. o Increased ICP can also cause this type of headache. Assessment Findings • Findings will vary by type of headache. • They may include throbbing, nausea, vomiting, visual disturbance, photophobia, tenderness, neck stiffness and focal neurological signs. Diagnostic Studies • History and physical exam • CT scan and MRI • Radiological exam of skull and cervical spine • Lumbar puncture if inflammation or infection is suspected Management • Headaches o The goal is to alleviate pain, treat the underlying cause and prevent recurrence. o The management strategy will depend on the type of headache, although vasoconstriction by applying pressure or a cold pack often helps. • Migraine o Pharmacologic Interventions: ▪ Non-narcotic analgesics (usually when onset noted): aspirin, acetaminophen and ibuprofen ▪ Opioid analgesics: codeine, meperidine and morphine ▪ Isometheptene ▪ Prophylactic treatment with beta-adrenergic blocking agents ▪ Serotonin antagonists ▪ Antidepressants – imipramine ▪ Anticonvulsants – topiramate ▪ Triptans used to stop migraine attacks: frovatriptan, rizatriptan, sumatriptan and zolmitriptan ▪ Alpha-adrenergic blocking agent blocker: ergotamine tartrate without caffeine or ergotamine with caffeine Complementary & Integrative health • Herbal remedies or dietary supplements – butterbur is effective for migraine prevention. Feverfew, magnesium and riboflavin are listed as "probably effective." Coenzyme Q10 is listed as "possibly efffective" for preventing migraines. • Mind and body practices such as biofeedback and acupuncture may be recommended. There is limited or inconsistent evidence about the benefits of massage, relaxation techniques, spinal manipulation or tai chi. • AVOID headache-precipitating foods such as MSG, tyramine, cheese, chocolate, asparutame or alcohol. o Cluster Headaches ▪ The inhalation of 100% oxygen is effective for about 80% of clients with cluster headaches. ▪ Pharmacologic Intervention: • Narcotic analgesics: codeine sulfate • Alpha-adrenergic blocking agent: ergotamine tartrate • Prophylactically with serotonin antagonists o Tension Headaches ▪ Pharmacologic Intervention: • Non-narcotic analgesics • Muscle relaxants • Prophylactically – antidepressants and/or doxepin ▪ Complementary and Integrative health techniques that help include biofeedback and acupuncture. Nursing Interventions • Suggest clients seek a quiet, dark environment and manage their pain by prompt medication administration or other comfort measures. • Help clients identify precipitating factors and actions for prevention. • Keep clients NPO (nothing by mouth) until nausea and vomiting subsides. • Teach clients to keep a headache diary which will help prevent headaches by identifying trigger factors. • Clients need to understand all expected medication actions and side effects, prevent accidental overdose. • Provide alternatives for pain relief, including referrals for alternative approaches and coping strategies for chronic pain. Head Trauma A head injury is any trauma to the scalp, skull or brain. The injury may be only a minor bump on the skull or a serious brain injury. The following section reviews the classifications, severity, types, complications and management of head traumas. Head Trauma Information There are two classifications of head trauma, closed versus open injury: 1. A closed head trauma is non-penetrating. There is no break in the integrity of the skull. 2. An open head trauma occurs when the skull is broken, creating a direct pathway to brain tissue. Severity: • A mild head trauma causes o only a momentary loss of consciousness with no neurological sequelae • A moderate head trauma cause o a momentary loss of consciousness with a change afterwards in neurological function, which is usually not permanent • A severe head trauma causes o a decreased LOC with serious neurological impairment and sequelae Types of Skull Fractures or Injury: • A linear fracture o is a simple break in the bone with no displacement of the skull. • A depressed fracture o occurs when part of skull is pushed in. • A basilar fracture o is located at base of the skull. o It may extend into the orbit or ear. o The ear or nose may leak CSF. ▪ Basilar fractures are the most difficult type to verify by X-ray. • Concussions o occur when there is jarring or shaking of the brain. o This leads temporary loss of neurologic function with complete recovery. Types of Bleeding Injuries/Hematomas: • Contusions o bruising on the surface of the brain. • Intracerebral bleed o bleeding directly in the brain tissue. o It occurs after invasive skull trauma/open fracture or hemorrhagic CVA. • Epidural bleeds o occur when blood vessels (arteries) are lacerated in the space between the skull and dura mater. o Often the middle meningeal artery is involved secondary to a skull fracture or contusion. o This is a medical emergency because there is a high risk of death with arterial bleeding. o Clients commonly lose consciousness after injury, followed by a lucid period, and then the LOC drops quickly within the next 24 hours. • Subdural bleeds o are lacerated blood vessels (veins) crossing the subdural space secondary to a closed head injury. ▪ Acute • findings surface in 24-72 hours after the injury with rapid neurologic deterioration. ▪ Subacute • findings surface 72 hours to two weeks after the injury with a slower progression of deterioration. ▪ Chronic • a gradual clot formation that forms over time, possibly developing over months with minimal deterioration. Complications • Cerebral Edema o Cerebral edema results in an increase in intracranial pressure and can cause cerebral ischemia, anoxia(severe hypoxia) and hypercapnia. • Diabetes Insipidus (DI) o DI results from a decreased release of antidiuretic hormone (ADH) and the body excreting too much fluid. o There will be an increase in urinary output and a low specific gravity. o DI is more common in the initial, acute phase of a head injury. • Stress Ulcer o Head injuries activate both the sympathetic and parasympathetic systems. o Stimulation of the sympathetic system leads to gastric ischemia from vasoconstriction. o Stimulation of the parasympathetic system leads to an increased release of hydrochloric acid (HCl) into the stomach. o Additionally, steroid therapy may contribute to the development of ulcers, since steroids increase gastric HCl. • Syndrome of Inappropriate Antidiuretic Hormone (SIADH) o SIADH occurs when too much ADH is produced and water is excessively retained. o The client's urinary output decreases and urine specific gravity increases. o This is more common in the chronic phase of care after a head injury. Seizure disorders can be a result of a head injury. Infections in the brain, lungs or urinary system can be a result of immobility. Hyperthermia or hypothermia can occur with a brain injury. Assessment Findings • The degree of neurological damage varies with the type and location of the injury • Initial restlessness and irritability can lead to a decrease in the LOC (lethargy, difficulty with arousal) • Headache • Nausea and vomiting – projectile vomiting indicates increased ICP • Otorrhea (ear drainage) • Pupillary changes • Seizure activity • Altered vital signs (Cushing's triad – late sign) • Posturing – decorticate or decerebrate with severe head trauma • CSF leakage from ears or nose – basilar skull fracture Diagnostic Studies • History (of event) and physical exam • CT scan and MRI • Radiological exam • Electroencephalogram (EEG) Management • The goal is to reduce or minimize increases in intracranial pressure and protect the nervous system. • Pharmacologic Intervention: o Osmotic diuretics: mannitol – IV piggyback or push. o Steroids: dexamethasone – IV push o Barbiturate coma may be induced to treat refractory increased intracranial pressure o Neuromuscular blocking agent such as vecuronium bromide to decrease agitation causing increased ICP, which must be used in conjunction with a sedative • Surgical correction of the underlying cause. • Intraventricular catheter, subarachnoid screw or bolt for management and monitoring intracranial pressure. • Treatment for findings and prevention of complications such as seizures, fever, infection, deep vein thrombosis (DVT) and stress ulcers. • Other therapies will include respiratory, physical, behavioral, speech, occupational and nutritional support. Nursing Interventions • Provide care to the client with increased intracranial pressure • Perform seizure care and precautions • Care of the client on ventilator – it is important to decrease PaCO2 to prevent ischemia, prevent hypercarbia and keep the PaCO2 35-38 • Observe for rhinorrhea, otorrhea and test for glucose if drainage is present • Care of the client undergoing surgery • Monitor for balanced nutrition and fluids • Assist with ADL as indicated • Prevent complications of immobility • Monitor neurologic signs, including level of consciousness and cranial nerve function • Assess and record Glasgow Coma Scale scores for eye opening, verbal response and motor response • Complete full neurological checks frequently • Monitor vital signs and look for abnormal respiratory patterns may be the first to indicate a change in neurologic function • Elevate the head of the bed 15-30° (or as advised by the health care provider) with the client's head positioned midline, avoiding extension or flexion of the neck • Administer medications as ordered • Provide emotional support with appropriate referrals for the family and client • With severe brain injury, discuss end-of-life and legal issues with the client's family Peripheral & Cranial Nerve Disorders Nerves are the communication pathway for the entire body, nerves can be damaged by injury, illness or an unknown etiology. Trigeminal neuralgia and Bells palsy are common nerve disorders. Trigeminal Neuralgia – Peripheral & Cranial Nerve Disorders Trigeminal neuralgia is a syndrome of chronic paroxysmal severe facial pain. • Etiology o The etiology of trigeminal neuralgia is not known. It occurs more often in middle age and older adults. Trigeminal neuralgia affects the cranial nerve V (trigeminal nerve) and only involves one side of the face. o The pain can be triggered by harmless events such as a breeze, or hot or cold liquids. • Assessment Findings o The client will experience intense facial pain lasting from a few seconds to a few minutes along the nerve branches. o Episodes may be as frequent as 100 times a day or as infrequent as a few times a year. o The pain may be described as "burning" or "shooting." • Diagnostic Studies o History and physical exam o CT to rule out other causes of findings • Management o The goal is to relieve pain and to minimize frequency. o Pharmacologic Intervention: ▪ Anticonvulsants: carbamazepine, phenytoin ▪ Skeletal muscle relaxant: baclofen ▪ Antidepressants: clients are often depressed and need to be monitored and treated for this ▪ Nerve block may be considered for temporary pain management o Surgical Interventions: ▪ Radio-frequency gangliolysis (heat destroys trigeminal ganglion) ▪ Glycerol gangliolysis (glycerol injected into subarachnoid space around gasserian ganglion) ▪ Microvascular decompression (move arterial loop away from posterior trigeminal root) • Nursing Interventions o Help clients to name triggers by identifying the aggravating incidents. o Recommend a restful environment with scheduled rest periods and reinforce the need for a balanced diet. o Assess clients for depression or suicidal thoughts. o Teach clients about medications and side effects and how to AVOID triggering agents. o Chewing on the opposite side of the mouth is helpful in avoiding pain and they should also avoid any very hot or cold foods. o Finally, clients should avoid exposing their face to extreme environmental temperatures. Facial Nerve Paralysis – Peripheral & Cranial Nerve Disorders Facial nerve paralysis (Bell's palsy) is a disorder of the (facial nerve) involving only one side of the face. • Etiology o The etiology of Bell's palsy is unknown, but it often occurs during periods of high stress. There may also be a link to the herpes simplex virus (HSV). • Assessment Findings o Symptoms often occur suddenly over 10-30 minutes (occurs unilaterally). o Ptosis with excessive tearing o The inability to close or blink the eye. o Typically, the lower face experiences paralysis and the client reports an impaired taste and difficulty with eating. You may also notice a flat nasolabial fold (smile lines/laugh lines). • Diagnostic Studies o History and physical exam to rule out other diagnoses such as stroke. • Management o The goal is to restore cranial nerve function. o Pharmacologic Intervention: ▪ Prednisone ▪ Antivirals – acyclovir ▪ Analgesics ▪ Moistening eye drops o Local comfort measures include heat, massage and electrical nerve stimulation for muscle tone. o Alternative therapies such as Reiki, massage and imagery have been shown to help. • Nursing Interventions o Reinforce balanced nutrition with a soft diet and administer drugs as ordered (teach client about medications). o Client teaching will include: ▪ To chew on the side opposite paralysis ▪ Use of protective eye wear (i.e. a patch or eyeglasses) during risk periods ▪ The use of eye lubricants, e.g. artificial tears, or ointment to protect the eye from corneal irritation ▪ Findings may disappear then return in times of high stress Spinal Cord Injuries Spinal cord injuries include any conditions that affect the spinal cord. These are usually due to trauma but may also be from diseases of the musculoskeletal system (arthritis) or congenital abnormalities (spina bifida). Spinal Cord Injuries Information A spinal cord injury is classified by whether it is a complete (no voluntary motor activity or sensation below the level of the injury) or incomplete cord injury (some voluntary motor activity or sensation below the level of injury). Clients will either be categorized as a paraplegic (thoracic vertebral injury or lower) or a tetraplegic (quadriplegic) when there is a cervical/vertebral injury and all four extremities are involved. • Types of Spinal Cord Injuries: o Contusion without direct trauma o Laceration o Hemorrhage o Penetrating wound or facture o Compression injury which is often dural/epidural hematoma; if pressure on the cord is not relieved early, the compression will cause ischemia, cord necrosis, and permeant damage • Etiology o Many types of traumas can cause a spinal cord injury, inducing trauma or dysfunction to the vertebrae or spinal cord, e.g., motor vehicle accidents, sports injuries, stabbing, gunshot wounds, tumors or infection. • Assessment Findings o The degree of the findings depends on type of injury, i.e., complete or incomplete transection of the spinal cord. o Neurologic Findings ▪ Spinal shock • Is a temporary loss of reflex function below the level of the injury • Occurs after complete transection of the cord, and to varying degrees with partial transection, contusions, compressions and ischemia of the spinal cord • Begins in the first hour following the injury and lasts for minutes to months, depending on the degree of injury • Findings of spinal shock: o Bradycardia o Hypotensive o Flaccid paralysis below level of injury o Areflexia (muscles don’t respond to stimuli) below level of injury o Loss of sensation (pain, touch, temperature, pressure) below the level of injury o Decrease/absence of visceral and somatic sensations below the level of the injury (absent bowel sounds) o Bowel and bladder dysfunction (bladder distention) o Loss of the ability to perspire below the level of the injury ▪ Neurogenic shock (if the injury involves the cervical or upper thoracic vertebrae) • results in an imbalance in the autonomic nervous system (sympathetic and parasympathetic systems) • The parasympathetic system causes massive vasodilatation, a drop in the systemic vascular resistance, and pooling of blood in the venous system, which leads to significant hypotension o Findings of neurogenic shock: ▪ Hypotension ▪ Bradycardia – until compensatory mechanisms begin ▪ Bounding pulse progressing to weak and thready pulse ▪ Warm, dry and pink skin progressing to pale and cool skin ▪ Mental status – restless, progressing to lethargy and coma ▪ Oliguria progressing to anuria ▪ Lower than normal body temperature ▪ Altered reflex patterns, i.e., areflexia, hypo or hyperreflexia ▪ Sensory changes, i.e., numbness, inability to feel pain or temperature, tingling o Cardiovascular Findings ▪ The client may have impaired control of the autonomic nervous system (ANS). As a result, they will experience hypotension, dysrhythmias and autonomic dysreflexia. o Respiratory Findings ▪ Breathing difficulties can occur from paralysis of the breathing muscles and phrenic nerve related to injury at C3 or above, e.g., hypoventilation or apnea. There may also be an absent or a decrease in protective mechanisms, i.e., cough. o Musculoskeletal Findings ▪ Musculoskeletal findings include weakness, incoordination, or paralysis below the level of the injury, i.e., paraplegia or quadriplegia and altered muscle tone, i.e., spasticity, flaccidity and rigidity. o Other findings include pain, bowel and bladder dysfunction, e.g., constipation, incontinence, bladder spasms and sexual dysfunction. • Diagnostic Studies o Radiological exam, CT and MRI are used to determine the level of the injury. • Management o Emergency Care ▪ Follow the ABCs of emergency care, stabilize vital signs and perform an assessment. Use a log roll on the client to avoid flexing, extending or rotating spine and immobilize the client's spine with a c-collar and spine board. ▪ Pharmacologic Intervention: • Corticosteroids – used to decrease spinal cord edema • Vasopressors – used to support blood pressure • Antispasmotics • Analgesics • Stool softeners – used to help prevent constipation • Anticonagulants – used to help prevent deep vein thrombosis • Proton pump inhibitors used to prevent ulcer development ▪ Surgery may be needed to insert hardware to stabilize and immobilize the spinal cord. Decompression laminectomy or a spinal fusion are additional surgeries that could be performed. • Nursing Interventions o Maintain proper alignment of spine and neck. o Monitor respiratory function and maintain patent airway. o Assess vital signs frequently for respiratory or cardiac compromise. o Maintain proper fluid and nutritional balance. o Administer medications as ordered. o Prevent complications via sequential compression device (SUDs), anticoagulants and regular skin assessments. o Monitor the client for signs of depression. o The nurse will teach the client and family how to perform self-catheterization, maintain hydration and adhere to a bowel program. o The nurse will also perform range of motion (ROM) exercises and demonstrate them for the family. The client should be repositioned every two hours. Senses – Vision The eye is a sensory organ with the ability to receive and process visual detail. The following section discusses disorders of the eye and how they can affect the client's ability to see. Disorders of the Eye: Senses – Vision Location Cornea Etiology Abrasion Treatment Cover the eye to protect and allow healing; eye drops (antibiotic, anti-inflammatory) Disorder Eye trauma Location Cornea Etiology Laceration Treatment Surgery; eye drops (antibiotic, anti-inflammatory) Disorder Eye trauma Location Aqueous humor increased Etiology Intraocular pressure increased Treatment Trabeculectomy, iridotomy, or iridectomy; eye drops (often miotics) Disorder Glaucoma Location Lens Etiology Cloudy Treatment ECCE (Extracapsular cataract extraction), phacoemulsion or ICCE (Intracapsular cataract extraction) Disorder Cataract Disorder Location Lens Etiology Loses elasticity, or ciliary muscles weaken Treatment Corrective lens or various types of outpatient laser surgery Disorders of refraction Location Retina Etiology Retina tears loose from back of eye; severs connection with optic nerve Treatment Laser surgery, cryotherapy, diathermy, scleral buckle or pharmacotherapy Disorder Retinal detachment Disorder Location Retina Etiology Rod and cone cells deteriorate Treatment None Retinal degeneration Location Entire eye Etiology Strabismus, cataracts, disorders of refraction in children Treatment Glasses (for refractive error); patch on normal eye; eye drops Disorder Amblyopia Disorders of Refraction: Senses – Vision • Myopia (near-sightedness) is blurred distance vision but clear close vision. • Hyperopia (far-sightedness) is blurred close vision but clear distant vision. • Presbyopia can occur in middle age when the lens loses elasticity with results of hyperopia. • Astigmatism occurs when the lens refracts light rays to focus on two different points of retina. Eye Trauma: Senses – Vision Eye trauma refers to damage caused by a direct blow to the eye. The trauma may affect not only the eye, but also the surrounding area, including the adjacent tissue and bone structure. There are many different forms of trauma, varying in severity from minor injury to medical emergencies. • Eye Trauma o Use eversion procedure and irrigate the affected eye with sterile normal saline eye irrigant. o If a foreign body has penetrated, do not remove the foreign body. • Corneal Abrasion o The disruption of the cells and loss of superficial epithelium can be caused by trauma, chemical irritant, foreign body or lack of moisture. o The client will report severe pain, blurred vision, halo around lights, lacrimation, inability to open the affected eye and photophobia. o Dx: by using fluorescein sodium dye. o Abrasions heal usually within 48 hours with no scarring or visual deficit. o Tx: includes short-acting analgesic drops, and eye rest with a soft or rigid eye patch. • Corneal Laceration o Corneal laceration has the same causes and findings as corneal abrasions, however lacerations are serious emergencies that require immediate attention. o Surgery is often required. • Penetrating Injury o A penetrating injury requires immediate care. o Do not remove the object or apply pressure of any kind to the eye or the object. o Cover the injured eye to protect movement of the object. o Cover the uninjured eye with soft or rigid eye patch to avoid sympathetic movement. The client will need to be seen in an emergency room immediately and surgery will be required. • Chemical Irritants o Flush the eye with plenty of tap water or sterile normal saline if available and get the client to the emergency room immediately. o Alkaline substances penetrate the cornea rapidly and must be removed quickly; these injuries are a priority. o Acids coagulate the eye's proteins and often result in relatively superficial, reversible damage. • Ultraviolet Burns o Ultraviolet burns often occur from sun exposure or welding flashes (looking at a welding flame without special glasses during the welding process). o The burn irritates the epithelium, which swells and scales off (desquamation). Care is the same as with lacerations. • General Management o Provide copious irrigation to the affected eye and apply bilateral rigid or soft eye patches to rest both eyes by decreasing eye movement. o Have clients use tinted glasses for photophobia to reduce eye discomfort from artificial lights or sunlight. o Encourage clients to avoid activities which increase intraocular pressure. o General pharmacotherapy for eye trauma includes topical anesthetics, anti- inflammatory and mydriatic-cycloplegic agents. Glaucoma: Senses – Vision Glaucoma is a group of eye conditions that lead to damage to the optic nerve due to increased intraocular pressure (IOP). There are four types of glaucoma 1. open-angle (chronic) glaucoma 2. angle-closure (acute) glaucoma 3. congenital glaucoma 4. secondary glaucoma. Chronic open-angle glaucoma occurs when the aqueous humor does not drain adequately which leads to increased intraocular pressure (IOP). This pressure on the optic nerve causes destruction of nerve fibers in the retina resulting in vision loss. This is the most common type of glaucoma. • Etiology o Glaucoma's etiology is unknown but there does seem to be a hereditary link. • Assessment Findings o Most clients are unaware of glaucoma until there is a disturbance in their vision. o Peripheral vision loss is affected first prior to total loss of vision. o Three classic assessment findings include visual field loss (peripheral), elevated intraocular pressure and cupping of the optic disk. • Management o The goal is to reduce the IOP and prevention of visual field defects. o Pharmacologic Intervention: ▪ Miotic eye drops (parasympathomimetic agents) ▪ Carbonic anhydrase inhibitors – acetazolamide ▪ Beta-adrenergic blocking agents – timolol maleate ophthalmic solution ▪ Epinephrine eye drops (contraindicated in clients with cardiac conditions) – used more often in emergency care o Trabeculectomy (filtration surgery) or laser trabeculectomy: ▪ Performed when pharmacological agents are not effective ▪ Small piece of sclera containing the trabecular network is removed and an iridectomy is performed ▪ Trabeculectomy may be combined with surgery to remove a cataract • Nursing Interventions o Pharmacotherapy Management: ▪ Reinforce the need for compliance with medical treatment ▪ Teach the client how to instill eye drops and when – usual recommended time is before bedtime ▪ Emphasize the need to reduce or eliminate safety risks related to impaired vision o Trabeculectomy by Traditional Surgery: ▪ Monitor the dressing for excessive bleeding ▪ Administer antiemetics, analgesics, corticosteroids and antibiotics as ordered ▪ Assist the client with ADL as needed • Trabeculectomy by Laser Surgery: ▪ Explain that the client's vision may be blurred for first day or two postop ▪ Teach the client to use soft or rigid eye patches or sunglasses for photophobia ▪ Discuss the use of analgesics as ordered o General Education: ▪ Stress the need to avoid activities that increase intraocular pressure, e.g., bending, stooping, straining, coughing, blowing nose and laughing ▪ Stress the importance of routine eye exams, usually yearly or more often if complications or noncompliance with medication regimen • Eye medications will need to be administered lifelong Tests - Eye • Electroretinography (ERG): o Detects diseases of the rods and the cones of the retina o Evaluates the electrical potential between the retina and the cornea o Uses: ▪ To evaluate disorders of the retina ▪ To determine if retinal surgery or cataract extraction is needed o Procedure takes about an hour: ▪ Usually the client's eyes are dilated and then anesthetic drops are placed in the eyes ▪ The eyelids are propped open with a speculum ▪ During the test, an electrode is incorporated into a device similar to a contact lenses and placed on the eye; an additional electrode is placed on the skin (to provide a ground) ▪ The client watches a standardized light stimulus and the resulting signal is interpreted in terms of its amplitude (voltage) and time course • Tonometry: o Indirect measurement of intraocular pressure (IOP) using a "puff" of air o Used to detect glaucoma • Intravenous fluorescein angiography: o Records the appearance of blood vessels within the eye o Used to evaluate for retinopathy and tumors o Procedure: ▪ Mydriatic drops are used to dilate pupil ▪ A contrast dye is injected intravenously and numerous photographs are taken of the fundus oculi (be sure to check client for sensitivity or allergy to fluorescein dye prior to the test) ▪ Photographs of the blood vessels of the eye are taken • Post-procedure affects/client teaching: o Possibly: ▪ Nausea and vomiting ▪ Vasovagal syncope: • Temporary change in skin color (yellowish) from the dye • Red after-image from the photoflash • Discoloration of the urine • Ocular ultrasonography: o Use of high frequency sound waves to evaluate eye structures o Useful in evaluating ocular tumors, as well as the retina when they are obscured by cataracts or hemorrhage Acute Closed-angle Glaucoma: Senses – Vision Acute closed-angle glaucoma occurs when the iris lies near the drainage channel (canal of Schlemm) and bulges forward against the cornea, blocking the trabecular network and increasing intraocular pressure. It is a medical emergency. • Etiology o No one is sure why this type of glaucoma occurs. o It does affect more women, usually after age 45. • Assessment Findings o Sudden onset of blurred vision o halos or colored rings around white lights o sudden frontal headache o Sudden severe eye pain o reddening of the eye o nausea and vomiting. o This is followed by a progression of findings as the pressure increases in the eye. Those include: ▪ Profuse lacrimation ▪ Mildly dilated, nonreactive pupil ▪ More severe nausea/vomiting ▪ Cornea appears hazy ▪ If left untreated, blindness may result in 2-5 days • Diagnostic Studies o History of findings o Ocular pressure readings • Management o The goal is to prevent or minimize the damaging effects of acute closed-angle glaucoma. o Emergency pharmacologic treatment to decrease intraocular pressure (IOP): ▪ Intravenous osmotic agents ▪ Topical miotic eye drops ▪ Systemic carbonic anhydrase inhibitors ▪ Systemic analgesics o Surgery: ▪ Iridotomy or iridectomy ▪ Procedure is usually then repeated on the unaffected eye • Nursing Interventions o Monitor for effectiveness of medications as ordered o Apply eye patch or sunglasses for postop photophobia o Inform clients that their vision will often be blurred for 1-2 days post-surgery o Stress the importance of routine yearly or more frequent eye examinations o Teach clients to avoid activities that increase intraocular pressure o Explain the correct procedure for instilling eye drops and have the client demonstrate correct procedure for instilling eye drops Cataract: Senses – Vision Cataracts are the clouding of the lens, whether unilateral or bilateral. Cataracts are one of the most common eye disorders. • Etiology o There are two types of cataracts. The senile cataract results from the process of aging. The traumatic cataract develops a few month after an eye trauma. Although it is painless, there will be a progressive loss of sight in one or both eyes. • Assessment Findings o Cloudy, blurred or dim vision o Increased difficulty with vision at night o Light halos around objects o Fading or yellowing of colors o Double vision in a single eye • Diagnostic Studies o History o Physical exam of eyes • Management o The goal is to correct the visual field defect. o Surgical removal of the cloudy lens will be performed one eye at a time if both are affected. Types of cataract extractions include: ▪ Extracapsular cataract extraction (ECCE): lens contents are removed and the posterior chamber is left intact – this is the treatment of choice ▪ Phacoemulsification (ultrasound fragments of the lens contents) ▪ Intracapsular cataract extraction (ICCE): the lens contents and lens capsule are removed and the eye becomes hypermetropic ▪ Intraocular lens implant is usually performed at the time of the extraction ▪ Peripheral iridectomy is usually performed as part of an ECCE or ICCE • Potential Post-surgical Complications o Hyphema ▪ Occurs when blood collects in the anterior chamber of the eye ▪ May require bed rest and wearing an eye patch ▪ Observe for increased IOP – indicated by complaints of severe pain ▪ May have prescribed miotics or cycloplegics o Vitreous Prolapse ▪ Allows vitreous humor to fall forward into wound ▪ May result in blocked pupil function ▪ May lead to retinal detachment ▪ Vitrectomy may be performed o Intraocular Infection ▪ Complaints of throbbing or pain with cloudy drainage from the eye ▪ Antibiotics (ophthalmic and/or systemic) • Nursing Interventions o Teach client to avoid any actions that cause IOP o Observe your client's ability to instill eye drops correctly and provide referrals if client is unable to self-medicate o Provide a written list of findings of complications to report • Client teaching will include: o For 6-8 weeks after surgery, the sensation of "sand in the eye" is normal o Photophobia, that may be present for months to years, which simply requires the use of sunglasses in bright light Retinal Detachment: Senses – Vision Retinal detachments are holes or breaks (tears) in the retina. • Etiology o Fluid, blood or a mass separates the retina's sensory layer from the pigmented epithelium (pigment cells). Common causes are inflammation, trauma, hemorrhage and tumors. Retinal detachment often begins in the periphery and spreads posteriorly. • Assessment Findings o A rapid separation gives the sense of a "curtain being pulled over the eye" so that clients have partial vision in affected eye. o A slow separation may be asymptomatic. o The ophthalmic exam reveals the detached area as a gray bulge, ripple or fold. • Diagnostic Studies o History and physical inspection to determine diagnosis. • Management o The goal is to correct and/or prevent further vision loss. The vast majority of retinal detachments are successfully repaired. o Laser Surgery/Photocoagulation is a procedure that uses a laser beam and is directed through a dilated pupil. The effect is to seal localized breaks or rips in the retina. o After consulting with the client, the surgeon may choose from several different procedures. Cryotherapy is a procedure that uses extreme cold and freezes rips in the retina. Diathermy uses heat applied with an ultrasonic probe to repair rips. A scleral buckle helps to mend the rip. o Pharmacotherapy – Local or Systemic: ▪ Adrenergic-mydriatic agents ▪ Cycloplegic agents ▪ Antibiotics • Nursing Interventions o Maintain the client in a proper position for bed or chair rest as ordered o Apply a postop rigid/soft eye patch to rest the eye (or both eyes) o Suggest dark lens glasses for photophobia o Administer medications as ordered o Prevent activities that increase IOP Visual Impairment: Senses – Vision Legal blindness is defined as a maximum visual acuity of 20/200 (with optimum correction) and/or a visual field that is reduced to a range of 20° (normal range=180°). • Etiology o The most common causes of visual impairment include retinal degeneration, glaucoma, cataract, amblyopia and macular degeneration ("central" loss of vision). • Nursing Interventions o Alert clients to your presence when you enter the room o Implement safety measures based on how clients accommodate the loss of sight o Orient clients to new surroundings o Use the numbers on a clock to orient your client to the location of furniture or food on a plate, i.e. your chicken is at 6 pm. o Assist clients with ADL as needed o To help your visually impaired client walk, do not grasp their elbow and lead from behind. Instead, instruct them to hold your elbow, as you walk slightly ahead of them. Color Blindness: Senses – Vision Color blindness is an abnormal condition characterized by the inability to clearly distinguish different colors of the spectrum. • Etiology o Color blindness is usually genetic but may be acquired through Alzheimer's disease, diabetes mellitus, glaucoma, leukemia, liver disease, chronic alcoholism, macular degeneration, multiple sclerosis or Parkinson's disease. o It can also be caused by medications (antibiotics, barbiturates or antitubercular drugs) or chemicals (carbon monoxide, fertilizers or lead). o Pre-term infants exhibit an increased prevalence of blue color blindness. o Types: ▪ Red-green – most common type of color blindness ▪ Blue-yellow (which are seen as white or gray): rare ▪ Achromatopsia: total inability to distinguish any color • Diagnostic Studies o Vision tests include American Optical/Hardy, Rand and Ritter Pseudoisochromatic test. • Management o Focus is on lifestyle changes and using environmental cues. Senses – Hearing The ear is a sensory organ responsible for hearing and balance. The following section discusses disorders of the ear and how they can affect a client's ability to hear. Otitis Externa: Senses – Hearing Otitis externa is an infection of the external auditory canal (also called "swimmer's ear"). • Etiology o This infection is most commonly caused by pseudomonas, also Staphylococcus and Streptococcus. o Also, localized trauma (from Q-Tips) or regular swimming or diving decreases the protective layer of cerumen and creates an environment for bacterial invasion. Although this is seen in all age groups, peak incidence is in children. • Assessment Findings o The client will present with a history of progressive ear pain, pruritus within the ear canal, purulent discharge and a feeling of fullness or pressure in the ear. • Diagnostic Studies o Usually a clinical diagnosis based on history and physical. • Management o Preventative: use earplugs when swimming and acidifying drops after swimming o Gentle cleaning and/or irrigation with a mix of peroxide and warm water (if tympanic membrane is intact) o Ear wick o Analgesics, antipruritics and antihistamines • Nursing Interventions o Teach the client the importance of keeping the ear dry and how to apply medication to the ear canal with a cotton wick. Otitis Media: Senses – Hearing Otitis media is an infection or inflammation of the middle ear and may be acute (AOM) or chronic. • Etiology o This infection is usually preceded by a respiratory infection. Bottle-feeding increases the risk of ear infection or inflammation. o Otitis media is second most common diagnosis in sick children in the U.S. after upper respiratory infections (URI). • Assessment Findings o Otalgia (ear pain) o Otorrhea (discharge from the ear) o Fever o Irritability o Headache o Concurrent (or recent) URI • Diagnostic Studies o Laboratory evaluation is usually not necessary for most cases o Tympanometry, reflectometry and/or hearing test for chronic cases o Imaging studies for infants or in chronic cases • Management o Put the client under observation (wait and see approach), administer over-the- counter pain reliever and apply a warm moist cloth over the affected ear for uncomplicated AOM with no effusion. o Chronic cases with effusion will need antibiotics, antihistamine-decongestants, steroids, NSAIDs and/or mucolytics. o In severe cases, surgery may be needed (tympanocentesis, myringotomy, TT insertion or adenoidectomy). o Probiotics and xylitol or herbal ear drops can be used after speaking to their provider (Calendula officinalis, Hypericum perfoliatum and Allium sativum). o Preventative Measures: ▪ Vaccinations, e.g., influenza vaccine, meningitis, Haemophilus influenzae type B, Streptococcus pneumoniae ▪ Handwashing ▪ Limit or eliminate use of pacifiers ▪ Elimination of foods that may increase risk of infections, especially wheat, dairy products, corn, peanuts or eggs • Nursing Interventions o Reinforce the need to take medications as prescribed o Reinforce the need for a follow-up visit to evaluate the effectiveness of the treatment o Postop care following surgical intervention o Complications: tympanic membrane perforation, chronic otitis media and bacterial meningitis Ménière's Disease: Senses – Hearing Ménière's disease is an inner ear disorder where the endolymphatic system dilates and the volume of endolymph expands. • Etiology o The etiology of Ménière's disease is unknown but it usually develops between the ages of 40-60. • Assessment Findings o Attacks are intermittent and there are three recurrent and progressive findings. These findings include: ▪ vertigo with prostrating nausea and vomiting ▪ tinnitus ▪ hearing loss • Diagnostic Studies o A complete history and physical is required and diagnostic tests can include the Weber and Rinne test or a CT scan. • Management o The goal is to prevent hearing loss and to control vertigo. ▪ Pharmacologic Intervention (during an attack): • Cholinergic blocking agents such as atropine • Antihistamines or decongestants ▪ Pharmacologic Intervention (remission): • Diuretics – decrease fluid accumulation • Vestibular suppressants, e.g., diazepam • Adrenergic neuron-blocking agents, e.g., epinephrine ▪ Low salt and low triglyceride diet is indicated. ▪ Surgical Interventions: • Decompression of endolymphatic sac: insertion of an endolymphatic subarachnoid shunt • Labyrinthectomy: client will lose all hearing in affected ear • Nursing Interventions o During an acute attack of Ménière's disease: ▪ Keep clients on bed rest in a quiet, dark room ▪ Avoid unnecessary movement of clients, especially of their head ▪ Give general care to clients with nausea and vomiting ▪ Restrict salt and water intake as ordered ▪ Have clients avoid tobacco and caffeine ▪ Institute precautions to prevent clients from falling ▪ Discuss the need to avoid a high triglyceride diet Hearing Loss: Senses – Hearing Hearing loss is an inability to perceive the range of sounds audible to an individual with normal hearing. • Etiology o Hearing loss can be caused from an infection, inflammation, foreign body, trauma or a buildup of ear wax. There are also congenital and age-related causes for hearing loss. • Assessment Findings o Decreased hearing o Tinnitus o Vertigo o Pain, fever and headache (infection) o Personality changes, e.g., irritability, depression, suspiciousness and withdrawal. • Diagnostic Studies o Otoscopic examination o Audiometry o Tests to evaluate hearing, e.g., pure-tone testing, speech testing and auditory brainstem response • Management o Management will depend on the type of hearing loss and its etiology. ▪ Conductive hearing loss: ▪ Surgery – skin graft for traumatically damaged ear drum; tympanoplasty ▪ Removal of ear wax ▪ Antibiotics o Sensory and neural hearing loss: ▪ Hearing aids o Speech therapy and balance (vestibular) rehabilitation may also be used. • Nursing Interventions o Use other modes of communication when appropriate and make sure to face the client when speaking; do not shout. • Client teaching will include: o The danger of workplace noise, noisy toys and recreational noise that can cause hearing loss o How to prevent falls (due to vertigo)