Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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CHAPTER 5 Nervous System
TREATMENT
•
Administer corticosteroids to decrease inflammation (unclear if there is a
definitive benefit):
•
prednisone in divided doses for first few days, then taper down
•
Administer artificial tears to maintain moisture within eyes.
NURSING DIAGNOSES
•
Disturbed sensory perception
•
Disturbed body image
NURSING INTERVENTION
•
Monitor for pain control.
•
Monitor for visual changes—dryness of eye can lead to irritation of cornea.
•
Monitor patient for reaction to medications.
•
Provide meals in private—patient may have difficulty keeping food in mouth
and may not feel food or liquid that is drooling out side of mouth.
•
Explain to patient:
•
How to properly instill artificial tear drops.
•
How to use eye patch.
Brain Abscess
WHAT WENT WRONG?
Collection of pus creates a space-occupying area within the brain. Symptoms are
similar to any other space-occupying lesion. The infection may be a primary site
within the brain or may have traveled from nearby sites such as the ear or sinuses
through bone erosion. It may also enter the brain via the systemic circulation from
any infected site in the body, such as the lungs in bronchiectasis. The organism
causes a local inflammatory reaction; there is pus and liquification of the affected
tissue. Cerebral edema of the surrounding tissue occurs. The area becomes en-
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capsulated within 10 to 14 days from the onset of the infection. The infections are
typically streptococci, staphylococci, anaerobes, or mixed-organism infections.
Immunocompromised patients may have fungal or yeast present in the abscess. Up
to 20 percent of the patients may have more than one abscess.
PROGNOSIS
Identification of the organism and appropriate treatment is imperative to resolution
of the infection. There is a significant mortality rate in these patients.
HALLMARK SIGNS AND SYMPTOMS
•
Drowsiness due to increased intracranial pressure
•
Headache due to increased intracranial pressure
•
Confusion or inattention
•
Seizures due to irritation of brain tissue
•
Increasing intracranial pressure
•
Widened pulse pressure and bradycardia due to increased intracranial pressure
•
Focal neurologic deficit, depending on location of abscess
•
Nystagmus with cerebral abscess
•
Aphasia with frontal lobe abscess
•
Loss of coordination (ataxia) with a cerebellar abscess
INTERPRETING TEST RESULTS
•
CBC elevated white blood cell count due to bacterial presence.
•
CT scan shows area of abscess site differentiated from surrounding tissue.
•
MRI shows area of abscess site possibly earlier than CT scan.
•
Biopsy to positively identify organism.
TREATMENT
•
Surgically drain (aspiration or open) the abscess to relieve intracranial
pressure.
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•
Administer antibiotic intravenously, depending on organism:
•
nafcillin sodium (penicillinase-resistant penicillin)
•
penicillin G benzathine
•
chloramphenicol
•
metronidazole
•
vancomycin
•
Administer corticosteroids in divided doses to decrease inflammation:
•
dexamethasone—taper dose down before stopping
•
Administer anticonvulsants to reduce seizure risk; watch for drug interactions:
•
phenytoin
•
phenobarbital
•
Administer osmotic diuretics to decrease cerebral edema:
•
mannitol
NURSING DIAGNOSES
•
Risk for disturbed thought process
•
Risk for falls
NURSING INTERVENTION
•
Assess the patient’s ability to think, reason, and remember.
•
Assess the patient’s speech capabilities.
•
Assess the patient’s movement and senses.
•
Assess the patient’s cranial nerve function.
•
Monitor vital signs.
•
Monitor fluid intake and output.
•
Monitor for signs of infection in post-operative patients.
•
Monitor for side effects of medications.
•
Explain to the patient:
•
Need for continued antibiotic treatments.
•
How to administer IV antibiotics at home, how to monitor IV access, and
when to call for problems.
•
Need for follow up CT scan or MRI imaging for monitoring.
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Brain Tumor
WHAT WENT WRONG?
A brain tumor is a growth of abnormal cells within the brain tissue. The tumor may
be a primary site that originated in the brain or a secondary site that has metastasized
from a cancer site elsewhere in the body. Because the tumor is growing within the
confined space of the skull, the patient will eventually develop signs of increased
intracranial pressure. Some cell types grow faster than others; the patients with the
more aggressive, fast-growing cancers will develop symptoms more quickly.
PROGNOSIS
Meningiomas are typically benign tumors that begin from the meninges (covering
the brain). They are more common in women and in people as they age. Treatment
is surgical removal, but the growth tends to recur.
Gliomas are malignant brain tumors of the neuroglial cells that tend to be fast-
growing. Patients have nonspecific symptoms of increased intracranial pressure.
Treatment typically includes surgical debulking of the tumor; complete removal is
often not possible at the time of diagnosis. Surgery is followed by radiation and
chemotherapy. Astrocytoma is the most common glioma and has a variable progno-
sis. Oligodendroglioma is more slow-growing and may be calcified. Glioblastoma is
a poorly differentiated glioma with a poor prognosis.
HALLMARK SIGNS AND SYMPTOMS
•
Cerebellum or brain stem:
•
Lack of coordination—cerebellum helps coordinate gross movements
•
Hypotonia of limbs
•
Ataxia
•
Frontal lobe:
•
Inability to speak (expressive aphasia)
•
Slowing of mental activity
•
Personality changes
•
Anosmia (loss of sense of smell)
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•
Occipital lobe:
•
Impaired vision—defect in visual fields; patient may deny or be unaware
of defect
•
Prosopagnosia (patient is unable to recognize familiar faces)
•
Change in color perception
•
Parietal lobe:
•
Seizures
•
Sight disturbances result in visual field defect
•
Sensory loss—unable to identify object placed in hand without looking
•
Temporal lobe:
•
Seizures
•
Taste or smell hallucinations
•
Auditory hallucinations
•
Depersonalization
•
Emotional changes
•
Visual field defects
•
Receptive aphasia
•
Altered perception of music
INTERPRETING TEST RESULTS
•
MRI with gadolinium (contrast) defines tumor location, size.
•
CT scan shows characteristic appearance of meningioma.
•
Angiography will show blood flow to the area; some tumors will displace
vessels as they grow
.
TREATMENT
•
Chemotherapeutic agents alone or in combination with radiation and surgery.
May be given orally, intravenously or through an Ommaya reservoir. Drugs
are chosen based on cell type:
•
carmustine, lomustine, procarbazine, vincristine, temozolomide, erlotinib,
gefitinib
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•
Irradiation of the area to decrease tumor size.
•
Craniotomy to remove the tumor if appropriate; this depends on location,
size, primary site of cancer, and number of tumors. Some patients may have
several small, scattered tumors, making surgery impractical.
•
Administer glucocorticoid to reduce swelling or inflammatory response
within confined space inside skull (no room to expand, bone does not give):
•
dexamethasone
•
Administer osmotic diuretic to reduce cerebral edema:
•
mannitol
•
Administer anticonvulsant to reduce chance of seizure activity:
•
phenytoin, phenobarbital, carbamazepine, divalproex sodium, valproic
acid, levetiracetam, lamotrigine, clonazepam, topiramate, ethosuximide
•
Administer mucosal barrier fortifier to reduce risk of gastric irritation:
•
sucralfate
•
Administer H2 receptor antagonists to reduce risk of gastric irritation:
•
ranitidine, famotidine, nizatidine, cimetidine
•
Administer proton pump inhibitors (PPIs) to reduce risk of gastric irritation:
•
lansoprazole, omeprazole, esomeprazole, rabeprazole, pantoprazole
NURSING DIAGNOSES
•
Disturbed sensory perception
•
Risk for injury
NURSING INTERVENTION
•
Monitor neurologic function.
•
Check for side effects to medications.
•
Seizure precautions per institution protocol.
•
Assess for pain control.
•
Explain to the patient:
•
Home care needs.
•
Possible need for hospice.
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CHAPTER 5 Nervous System
Cerebral Aneurysm
WHAT WENT WRONG?
A cerebral aneurysm is a balloon-like out-pouching caused by a congenital or
developed weakness in a cerebral artery. Trauma, infection, or vessel wall lesions
due to atherosclerosis can all lead to the development of an aneurysm. Increased
pressure within the vessel lumen may cause the aneurysm to rupture, causing sig-
nificant intracranial bleeding.
PROGNOSIS
Patients are often asymptomatic with the aneurysm, until the time of the rupture.
Some patients have the aneurysm identified on a radiological study as an inciden-
tal finding. The decision can then be made to monitor or treat the aneurysm. If an
arterial aneurysm ruptures without warning, the patient will have significant bleed-
ing—a hemorrhagic stroke. The blood may need to be evacuated from the intracra-
nial area to relieve pressure. The rupture of the aneurysm may be fatal, or the patient
may have long-term disability following the event.
HALLMARK SIGNS AND SYMPTOMS
•
Asymptomatic until rupture
•
Very bad headache due to hemorrhage and increased intracranial pressure
•
Decreased level of consciousness due to increased intracranial pressure from
blood accumulating within the brain
INTERPRETING TEST RESULTS
•
Angiogram highlights the aneurysm due to structural abnormality.
•
CT scan shows the aneurysm unless it is very small.
•
Digital subtraction angiography shows the detail of the vasculature—abnor-
mal structure.
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Diffusion/perfusion MRI or MRA (magnetic resonance angiography) shows
vessel structure.
•
Single photon emission computed tomography (SPECT) shows the perfu-
sion of blood flow to a specific area of the brain.
TREATMENT
•
Surgical repair of the aneurysm.
•
Monitor level of consciousness and neurologic status.
•
Administer corticosteroid drugs to reduce inflammation:
•
dexamethasone
•
Administer anticonvulsant drugs to reduce seizure risk due to irritation of
brain:
•
phenytoin, phenobarbital
•
Administer stool-softener drugs to decrease need to strain (straining increases
intracranial pressure):
•
docusate sodium
•
Bed rest until otherwise ordered by physician, nurse practitioner, or physi-
cian assistant.
•
Elevate head of bed 30 degrees.
NURSING DIAGNOSES
•
Ineffective tissue perfusion
•
Decreased intracranial adaptive capacity
NURSING INTERVENTION
•
Monitor the patient’s neurological function for changes—typically use
Glasgow Coma Scale or similar tool to grade response to stimuli (highest
score 15).
•
Eye-opening response spontaneous 4
to sound 3
to pain 2
none 1
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•
Motor responses obeys commands 6
localizes pain 5
withdrawal (normal) 4
abnormal flexion 3
extension 2
none 1
•
Verbal responses oriented 5
confused conversation 4
inappropriate words 3
incomprehensible sounds 2
none 1
•
Monitor vital signs for changes—widened pulse pressure with bradycardia
indicative of increased intracranial pressure.
•
Explain to the patient:
•
Needs for homecare.
•
When to call healthcare provider.
Encephalitis
WHAT WENT WRONG?
Encephalitis is the inflammation of the brain tissue, most often caused by a virus,
although it can also be due to bacteria, fungus, or protozoa. In the case of viral
encephalitis, the patient typically will have had viral symptoms prior to the current
illness. The virus enters the central nervous system via the bloodstream and begins
to reproduce. Inflammation in the area follows, causing damage to the neurons.
Demyelination of the nerve fibers in the affected area and hemorrhage, edema, and
necrosis occur, which create small cavities within the brain tissue. Herpes simplex
virus 1, cytomegalovirus, echovirus, Coxsackie virus, and herpes zoster can all
cause encephalitis. Some forms of encephalitis can be transmitted by insects (such
as mosquitoes or ticks) to humans, such as West Nile virus, St. Louis encephalitis,
or equine encephalitis.
PROGNOSIS
Identification of the organism is important in order to individualize the treatment
for the patient. The earlier that symptoms are recognized and the earlier the patient
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enters the healthcare system the better. Some patients will incur permanent dis-
ability from the irreversible damage that occurs to the brain. These patients may
be in need of long-term custodial care.
HALLMARK SIGNS AND SYMPTOMS
•
Fever due to infection
•
Nausea and vomiting due to increased intracranial pressure
•
Stiff neck due to meningeal irritation
•
Drowsiness, lethargy, or stupor due to increased intracranial pressure
•
Altered mental status—irritability, confusion, disorientation, personality change
•
Headache due to increased intracranial pressure
•
Seizure activity possible due to irritation of brain tissue
INTERPRETING TEST RESULTS
•
Blood cultures used to help identify organism when patient is febrile.
TREATMENT
•
Monitor respiratory status for compromise.
•
Monitor vital signs for widened pulse pressure and bradycardia—signs of
increased intracranial pressure.
•
Monitor neurologic function for change.
•
Administer corticosteroid to decrease inflammation:
•
dexamethasone
•
Administer antipyretics to reduce fever:
•
acetaminophen
•
Administer anticonvulsants to decrease chance of seizure activity:
•
phenytoin, phenobarbital
•
Administer diuretics to decrease cerebral edema, if indicated: