Neurologic Function - Neurologic Dysfunction and Trauma

INTRACRANIAL SURGERY

1. Craniotomy

• A craniotomy involves opening the skull surgically to gain access to intracranial structures.

• This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or
control hemorrhage.

• The surgeon cuts the skull to create a bony flap, which can be repositioned after surgery and
held in place by periosteal or wire sutures.

• One of two approaches through the skull is used: (1) above the tentorium (supratentorial
craniotomy) into the supratentorial compartment, or (2) below the tentorium into the
infratentorial (posterior fossa) compartment.

• A third approach, the transsphenoidal approach (through the mouth and nasal sinuses) is often
used to gain access to the pituitary gland.

• Other cranial procedures include craniectomy (excision of a portion of the skull) and
cranioplasty (repair of a cranial defect using a plastic or metal plate).
Preoperative Management: Medical Management

• Most patients are prescribed an anticonvulsant medication such as phenytoin (Dilantin),

levetiracetam (Keppra), or a phenytoin metabolite fosphenytoin sodium (Cerebyx) before
surgery to reduce the risk of postoperative seizures (paroxysmal transient disturbance of the
brain resulting from a discharge of abnormal electrical activity).

• Before surgery, corticosteroids such as dexamethasone may be given to reduce cerebral edema
if the patient has a brain tumor. Fluids may be restricted.

• A hyperosmotic agent (mannitol) and a diuretic agent such as furosemide (Lasix) may be
administered IV immediately before and sometimes during surgery if the patient tends to retain
fluid, as do many who have intracranial dysfunction.

• Antibiotic agents may be given if there is a chance of cerebral contamination; diazepam

(Valium) or lorazepam (Ativan) may be prescribed before surgery to allay anxiety.

Preoperative Management: Nursing Management

• The patient is assessed for neurologic deficits and their potential impact after surgery.

• For motor deficits or weakness or paralysis of the arms or legs, trochanter rolls are applied to
the extremities, and the feet are positioned against a footboard or the ankles are supported in a
neutral position with orthotic boots.

• A patient who can ambulate is encouraged to do so. If the patient is aphasic, writing materials or
picture and word cards showing the bedpan, glass of water, blanket, and other frequently used
items may help improve communication.

Postoperative Management

1. Reducing Cerebral Edema

- Medications to reduce cerebral edema include mannitol.

- Dexamethasone may be administered IV every 6 hours for 24 to 72 hours; the route is changed
to oral as soon as possible, and the dosage is tapered over 5 to 7 days.

2. Relieving Pain and Preventing Seizures

- Acetaminophen is usually prescribed for temperatures exceeding 37.5°C and for mild pain.

- Codeine, administered IV or orally, is often sufficient to relieve headache.

- Morphine sulfate may also be used in the management of postoperative pain.

- Anticonvulsant medication (phenytoin, levetiracetam) is often prescribed prophylactically.

3. Monitoring Intracranial Pressure

- A patient undergoing intracranial surgery may have an ICP or cerebral oxygenation monitor
inserted during surgery.
- Strict adherence to written protocols for managing these systems is essential, as discussed
earlier, for preventing infection and managing ICP.

- The system is removed after the ICP or cerebral oxygenation is normal and stable.

- The neurosurgeon must be notified immediately if the system is not functioning.

SEIZURE DISORDERS

• Seizures are episodes of abnormal motor, sensory, autonomic, or psychic activity (or a
combination of these) that result from sudden excessive discharge from cerebral neurons
(Hickey, 2014).

• A localized area or all of the brain may be involved.

• The International League Against Epilepsy (ILAE) has defined epilepsy as at least two
unprovoked seizures occurring more than 24 hours apart.

• The ILAE differentiates between three main seizure types: focal, generalized, and unknown
seizures: focal, generalized, and unknown seizures.

1. Generalized seizures - occur in and rapidly engage bilaterally distributed networks.

2. Focal seizures - thought to originate within one hemisphere in the brain.

3. Unknown type - includes epileptic spasms.

• Unclassified seizures are so termed because of incomplete data but are not considered a
classification.

• Seizures may also be characterized as “provoked,” or related to acute, reversible conditions such
as structural, metabolic, immune, infectious or unknown etiologies.

Pathophysiology
• The underlying cause is an electrical disturbance (dysrhythmia) in the nerve cells in one section
of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges.

• The characteristic seizure is a manifestation of this excessive neuronal discharge.

• Associated loss of consciousness, excess movement or loss of muscle tone or movement, and
disturbances of behavior, mood, sensation, and perception may also occur.

• Causes of seizures include:

1. Cerebrovascular disease

2. Hypoxemia of any cause, including vascular insufficiency

3. Fever (childhood)

4. Head injury

5. Hypertension

6. CNS infections

7. Metabolic and toxic conditions (e.g., kidney injury, hyponatremia, hypocalcemia, hypoglycemia,
pesticide exposure)

8. Brain tumor

9. Drug and alcohol withdrawal

10. Allergies

Clinical Manifestations

• Depending on the location of the discharging neurons, seizures may range from a simple staring
episode (generalized absence seizure) to prolonged convulsive movements with loss of
consciousness.

• The initial pattern of the seizures indicates the region of the brain in which the seizure
originates. Only a finger or hand may shake, or the mouth may jerk uncontrollably. The person
may talk unintelligibly; may be dizzy; and may experience unusual or unpleasant sights, sounds,
odors, or tastes, but without loss of consciousness.

• Generalized seizures often involve both hemispheres of the brain, causing both sides of the
body to react. Intense rigidity of the entire body may occur, followed by alternating muscle
relaxation and contraction (generalized tonic–clonic contraction).

• The simultaneous contractions of the diaphragm and chest muscles may produce a
characteristic epileptic cry. The tongue is often chewed, and the patient is incontinent of urine
and feces. After 1 or 2 minutes, the convulsive movements begin to subside; the patient relaxes
and lies in deep coma, breathing noisily.
• In the postictal state (after the seizure), the patient is often confused and hard to arouse and
may sleep for hours. Many patients report headache, sore muscles, fatigue, and depression.

• Focal seizures are subdivided into events characterized by both motor and non-motor
symptoms. There may be an impairment of consciousness or awareness or other dyscognitive
features, localization, and progression of symptoms.

Assessment and Diagnostic Findings

• A developmental history is taken, including events of pregnancy and childbirth, to seek evidence
of pre-existing injury.

• The patient is also questioned about illnesses or head injuries that may have affected the brain.

• In addition to physical and neurologic evaluations, diagnostic examinations include biochemical,

hematologic, and serologic studies.

• MRI is used to detect structural lesions such as focal abnormalities, cerebrovascular

abnormalities, and cerebral degenerative changes.

• The EEG furnishes diagnostic evidence for a substantial proportion of patients with epilepsy and
assists in classifying the type of seizure.

Nursing Management: During a Seizure

• A major responsibility of the nurse is to observe and record the sequence of signs. The nature of
the seizure usually indicates the type of treatment required.

• Before and during a seizure, the patient is assessed and the following items are documented:

1. Circumstances before the seizure (visual, auditory, or olfactory stimuli; tactile stimuli; emotional
or psychological disturbances; sleep; hyperventilation)

2. Occurrence of an aura (a premonitory or warning sensation, which can be visual, auditory, or

olfactory)

3. First thing the patient does in the seizure—where the movements or the stiffness begins,
conjugate gaze position, and the position of the head at the beginning of the seizure.

4. Type of movements in the part of the body involved

5. Areas of the body involved (turn back bedding to expose patient)

6. Size of both pupils and whether the eyes are open

7. Whether the eyes or head are turned to one side

8. Presence or absence of automatisms (involuntary motor activity, such as lip smacking or

repeated swallowing)

9. Incontinence of urine or stool

10. Duration of each phase of the seizure

 11. Unconsciousness, if present, and its duration

12. Any obvious paralysis or weakness of arms or legs after the seizure Inability to speak after the
seizure

13. Movements at the end of the seizure

14. Whether or not the patient sleeps afterward

15. Cognitive status (confused or not confused) after the seizure

After a Seizure

• Document the events leading to and occurring during and after the seizure and to prevent
complications (e.g., aspiration, injury).

• The patient is at risk for hypoxia, vomiting, and pulmonary aspiration. To prevent complications,
the patient is placed in the side-lying position to facilitate drainage of oral secretions, and
suctioning is performed, if needed, to maintain a patent airway and prevent aspiration.

• Seizure precautions are maintained, including having available functioning suction equipment
with a suction catheter and oral airway.

• The bed is placed in a low position with two to three side rails up and padded, if necessary, to
prevent injury to the patient.

Pathophysiology

• Messages from the body are carried by the neurons (nerve cells) of the brain by discharges of
electrochemical energy that sweep along them.

• These impulses occur in bursts whenever a nerve cell has a task to perform.

• Sometimes, these cells or groups of cells continue firing after a task is finished.

• During the period of unwanted discharges, parts of the body controlled by the errant cells may
perform erratically.

• Resultant dysfunction ranges from mild to incapacitating and often causes loss of consciousness.

• If these uncontrolled, abnormal discharges occur repeatedly, a person is said to have an

epileptic syndrome.
Medical Management

2. Surgical Management

- If the seizures originate in a reasonably well-circumscribed area of the brain that can be excised
without producing significant neurologic deficits, the removal of the area generating the
seizures may produce long-term control and improvement.

- When seizures are refractory to medication in adolescents and adults with focal seizures, a vagal
nerve stimulator (VNS) may be implanted under the clavicle.

- Another surgical option for patients with refractory seizure activity is the responsive
neurostimulation system (RNS). This is a surgically implanted device with electrodes that sense
and record brain electrical activity. The RNS works by interrupting brainwave activity before a
clinical seizure can occur.

Status Epilepticus

• Status epilepticus (acute prolonged seizure activity) is a series of generalized seizures that occur
without full recovery of consciousness between attacks.
• The term has included continuous clinical or electrical seizures (on EEG) lasting at least 30
minutes, even without impairment of consciousness.

• It is considered a medical emergency.

• Status epilepticus produces cumulative effects. Vigorous muscular contractions impose a heavy
metabolic demand and can interfere with respirations.

• Some respiratory arrest at the height of each seizure produces venous congestion and hypoxia
of the brain.

• Repeated episodes of cerebral anoxia and edema may lead to irreversible and fatal brain
damage.

• Factors that precipitate status epilepticus include interruption of anticonvulsant medication,

fever, concurrent infection, or other illness.

Medical Management

• The goals of treatment are to stop the seizures as quickly as possible, to ensure adequate
cerebral oxygenation, and to maintain the patient in a seizure-free state.

• An airway and adequate oxygenation are established.

• If the patient remains unconscious and unresponsive, an endotracheal tube is inserted.

• IV diazepam (Valium), lorazepam (Ativan), or fosphenytoin is given slowly in an attempt to halt

seizures immediately.

• Other medications (phenytoin, phenobarbital) are given later to maintain a seizure-free state.

Nursing Management

• The patient is turned to a side-lying position, if possible, to assist in draining pharyngeal

secretions.

• Suction equipment must be available because of the risk of aspiration.

• The IV line is closely monitored, because it may become dislodged during seizures.

• A person who has received long-term anticonvulsant therapy has a significant risk for fractures
resulting from bone disease (osteoporosis, osteomalacia, and hyperparathyroidism), which is a
side effect of therapy.

• Therefore, during seizures, the patient is protected from injury with the use of seizure
precautions and is monitored closely.

HEADACHE
• Headache is a symptom rather than a disease entity; it may indicate organic disease (neurologic
or other disease), a stress response, vasodilation (migraine), skeletal muscle tension (tension
headache), or a combination of factors.

• A primary headache is one for which no organic cause can be identified. This type of headache
includes migraine, tension-type, and cluster headaches (Hickey, 2014).

• Migraine is a complex of symptoms characterized by periodic and recurrent attacks of severe

headache lasting from hours to days in adults. There are many subtypes of migraine headache,
including migraine with and without aura.

• Tension-type headaches tend to be chronic and less severe and are probably the most common
type of headache.

• Trigeminal autonomic cephalalgias include cluster headaches and paroxysmal hemicrania.

Cluster headaches are relatively uncommon and seen more frequently in men than in women.

• Types of headaches not subsumed under these categories fall into the other primary headache
group and include headaches triggered by cough, exertion, and sexual activity.

Pathophysiology

• The cerebral signs and symptoms of migraine result from a hyperexcitable brain that is
susceptible to a phenomenon known as cortical spreading depression, a wave of depolarization
over the cerebral cortex, cerebellum, and hippocampus.

• This depolarization activates inflammatory neuropeptides and other neurotransmitters

(including serotonin), resulting in the stimulation of meningeal nociceptors.
 • Vascular changes, inflammation, and a continuation of pain signal stimulation occur.

• As the attack progresses, central sensitization occurs, and the migraine becomes much harder to
treat.

• Attacks can be triggered by hormonal changes associated with menstrual cycles, bright lights,
stress, depression, sleep deprivation, fatigue, or odors. Certain foods containing tyramine
(especially aged cheese), monosodium glutamate, and chocolate may be food triggers
(Grossman & Porth, 2014).

• The use of oral contraceptives may be associated with increased frequency and severity of
attacks in some women.

• Emotional or physical stress may cause contraction of the muscles in the neck and scalp,
resulting in tension headache.

Clinical Manifestations: Migraine

1. Premonitory Phase

• The premonitory phase is experienced by more than 80% of adult migraine sufferers, with
symptoms that occur hours to days before a migraine headache.

• Symptoms may include depression, irritability, feeling cold, food cravings, anorexia, change in
activity level, increased urination, diarrhea, or constipation.

• Patients may experience the same prodrome with each migraine headache.

• A current theory regarding premonitory symptoms is that they involve the neurotransmitter
dopamine.

2. Aura Phase

• An aura may be a variable feature for patients who experience migraines.

• An aura is characterized by focal neurologic symptoms.

• Visual disturbances (i.e., light flashes and bright spots) are most common and may be
hemianopic (affecting only half of the visual field).

• Other symptoms that may follow include numbness and tingling of the lips, face, or hands; mild
confusion; slight weakness of an extremity; drowsiness; and dizziness.

3. Headache Phase

• Migraine headache is severe and incapacitating and is often associated with photophobia (light
sensitivity), phonophobia (sound sensitivity), or allodynia (abnormal perception of innocuous
stimuli) (Charles, 2013).

• Research differs in the role of vascular changes (either vasodilatory or vasoconstrictive) with
respect to migraine pathophysiology and the experience of migraine headache.
• Symptoms of migraine can also include nausea and vomiting.

4. Postdrome Phase

• In the postdrome phase, the pain gradually subsides, but patients may experience tiredness,
weakness, cognitive difficulties, and mood changes for hours to days.

• Muscle contraction in the neck and scalp is common, with associated muscle ache and localized
tenderness.

• Physical exertion may exacerbate the headache pain.

• During this post headache phase, patients may sleep for extended periods.

Clinical Manifestations: Other Headache Types

1. The tension-type headache is characterized by a steady, constant feeling of pressure that usually
begins in the forehead, temple, or back of the neck. It is often bandlike or may be described as
“a weight on top of my head.”

2. Cluster headaches are unilateral and come in clusters of one to eight daily, with excruciating
pain localized to the eye and orbit and radiating to the facial and temporal regions. The pain is
accompanied by watering of the eye and nasal congestion. Each attack lasts 15 minutes to 3
hours and may have a crescendo–decrescendo pattern (Hickey, 2014). The headache is often
described as penetrating.

Assessment and Diagnostic Findings

• The health history focuses on assessing the headache itself, with emphasis on the factors that
precipitate or provoke it.

• The patient is asked to describe the headache in their own words.

• Diagnostic testing often is not helpful in the investigation of headache, because usually there
are few objective findings.

• In patients who demonstrate abnormalities on the neurologic examination, CT scan, cerebral

angiography, or MRI scan may be used to detect underlying causes, such as tumor or aneurysm.

• Electromyography (EMG) may reveal a sustained contraction of the neck, scalp, or facial
muscles.

• Laboratory tests may include complete blood count, erythrocyte sedimentation rate,
electrolytes, glucose, creatinine, and thyroid hormone levels.
Prevention

• Prevention begins by having the patient avoid specific triggers that are known to initiate the
headache syndrome.

• Preventive medical management of migraine involves the daily use of one or more agents that
are thought to block the physiologic events leading to an attack.

• Treatment regimens vary greatly, as do patient responses; therefore, close monitoring is

indicated.

• Alcohol, nitrites, vasodilators, and histamines may precipitate cluster headaches.

• Elimination of these factors helps prevent the headaches.

Medical Management

• The triptans, which are serotonin receptor agonists, are the most specific antimigraine agents
available.

• These agents cause vasoconstriction, reduce inflammation, and may reduce pain transmission.

• The five triptans in routine clinical use include sumatriptan (Imitrex), naratriptan (Amerge),
rizatriptan (Maxalt), zolmitriptan (Zomig), and almotriptan (Axert).

• The triptans are considered first-line treatment of the management of moderate to severe
migraine pain.

• Best results are achieved with early use of triptans; oral dosing takes effect within 20 to 60
minutes of taking the drug and if needed may be repeated in 2 to 4 hours.

• Triptans are contraindicated in patients with ischemic heart disease.

• The medical management of an acute attack of cluster headaches may include 100% oxygen by
facemask for 15 minutes, subcutaneous sumatriptan, or intranasal zolmitriptan.

Nursing Management

• Relieving Pain

• Symptomatic pain relief for tension headache may be obtained by application of local heat or
massage.

• Additional strategies may include administration of analgesic agents, antidepressant

medications, and muscle relaxants.
 CONVULSIVE DISORDERS

(Convulsion)

- seizure – 1st convulsive attack

- epilepsy – 2nd and with history of seizure

- febrile seizure

: normal if < 5 y/o

- pathologic if > 5 y/o

Seizures management:

C- Counselling

Calm – maintain a calm environment

A- Anti-coagulant

Phenobarbital (Phenytoin)

-gingival hyperplasia

- monitor for apnea and cyanosis

- don’t force anything into the client’s mouth if jaws are clenched

- place airway on mouth after seizure

- no artificial ventilation during tonic-clonic

E- Evaluate changes in LOC after seizure

S- Safety – protect from injury

- bed rails always up, loose clothing do not restrain during seizure activity

A- Avoid alcohol

Activities – know what occurred prior to seizure attack

R- Reduce Stimuli

Remain with client during seizure. Note the time began and duration lasted
Predisposing factors:

- head injury due to birth trauma (#1 cause of seizure)

- Carbon monoxide poisoning

- Brain tumor

- Genetics

- Physical stress

- Sudden withdrawal to anticonvulsants will bring about status epilepticus

- Diazepam – relaxant

S/Sx:

1. Generalized Seizures

a. Grandmal / tonic clonic seizures (most common type)

- with or without AURA

- epigastric pain or flashes of lights, noise, etc

 - epileptic cry – fall

- loss of consciousness – 3-5 mins

- tonic-clonic contractions

- post-ictal sleep – state of lethargy or drowsiness

b. Petit mal seizure

- same as day dreaming or absence seizure

- blank stare

- decrease blinking eye, staring into space

- pausing amidst of conversation

- loss of consciousness – 5-10 secs

- typically, under 20 y/o

Diagnostics:

1. Convulsion – get health history

2. CT scan – brain lesion

3. EEG

– considerations: no caffeine and shampoo patient

- hyperactivity of brain waves

4. Neurologic assessment:

- comprehensive neuro exam

- GCS

SPINAL CORD INJURY

- injuries at C4 – paralysis of respiratory muscles

Nsg Mgt:

- supportive and palliative only

1. medication as ordered to prevent paralysis because of edema

a. ACTH – Adrenocorticotropic hormone

b. Baclofen (Lioresol) or Dantrolene Na (Natrene) - for spasticity

c. Interferon – alter immune response

2. Maintain Side rails

3. Assist passive ROM exercises every 4 hours

4. Prevent complications of immobility

5. Increase fluid intake and high fiber diet

6. Diuretic therapy

7. Emphasize the need to avoid stress, infections