NCLEX: Neurologic disorders

Neurologic disorders: Diagnostic tests

Focus topic: Neurologic disorders

Neurologic disorders: Feel the burn

Focus topic: Neurologic disorders

  • Explain to the patient that he’ll probably feel a flushed sensation in his face as the dye is injected.
  • Maintain bed rest, as ordered, and monitor his vital signs and LOC.
  • Monitor the catheter injection site for signs of bleeding.
  • Monitor vital signs frequently for signs of internal bleeding.
  • As ordered, maintain pressure over the injection site.
  • Monitor the patient’s peripheral pulse in the arm or leg used for catheter insertion (mark the site).
  • Unless contraindicated, encourage the patient to drink more fluids to help flush the dye from his system.
  • Monitor the patient for neurologic changes and such complications as hemiparesis, hemiplegia, aphasia, and impaired LOC.
  • Monitor for an adverse reaction to the contrast medium, which may include restlessness, tachypnea and respiratory distress, tachycardia, facial flushing, urticaria, and nausea and vomiting.

Digital subtraction angiography
Like cerebral angiography, DSA highlights cerebral blood vessels. Using a special type of computerized fluoroscopy, a technician takes an image of the selected area, which is then stored in the computer’s memory. After administering a contrast medium, the technician takes several more images. By manipulating the two sets of images, the computer produces high-resolution images for interpretation. Although arterial DSA requires more contrast medium than cerebral angiography, because it’s injected I.V., DSA doesn’t increase the patient’s risk of stroke and can be performed on an outpatient basis.

 

Neurologic disorders: Nursing considerations

Focus topic: Neurologic disorders

  • Confirm that the patient isn’t allergic to iodine or shellfish. (A patient with these allergies may have an adverse reaction to the contrast medium and require premedication with corticosteroids.)
  • Determine if the patient is taking any anticoagulant or antiplatelet medications; he’ll need to stop taking these drugs for a period of time before the procedure.
  • Restrict the patient’s consumption of solid foods for 4 hours before the test.
  • Explain that the test requires insertion of an I.V. catheter.
  • Tell him that he must remain still during the test.
  • Explain that he’ll probably feel a flush or have a metallic taste in his mouth as the contrast medium is injected.
  • Tell the patient to alert the doctor immediately if he feels discomfort or shortness of breath.
  • After the catheter is removed, encourage the patient to resume his normal activities.
  • Encourage him to drink more fluids for the rest of the day to help flush the contrast medium out of his system.

Neurologic disorders: Electrophysiologic studies

Focus topic: Neurologic disorders

Electrophysiologic studies are commonly performed and include EEG and electromyography.

Electroencephalography
By recording the brain’s continuous electrical activity, EEG can help identify seizure disorders, head injuries, intracranial lesions (such as abscesses and tumors), TIAs, stroke, or brain death. In EEG, electrodes attached to standard areas of the patient’s scalp record a portion of the brain’s activity. These electrical impulses are transmitted to an electroencephalogram, which magnifies them 1 million times and records them as brain waves on moving strips of paper.

Neurologic disorders: Nursing considerations

Focus topic: Neurologic disorders

  • Tell the patient that during the EEG, he’ll be positioned comfortably in a reclining chair or on a bed.
  • Explain that a technician will apply paste and attach electrodes to areas of skin on the patient’s head and neck after these areas have been lightly abraded to ensure good contact.
  • Explain that he must remain still throughout the test. Discuss any specific activity that the patient will be asked to perform, such as hyperventilating for 3 minutes or sleeping, depending on the purpose of the EEG.
  • Use acetone to remove any remaining paste from the patient’s s kin.
  • Encourage him to resume his normal activities, as ordered.

Electromyography
Electromyography records a muscle’s electrical impulses to help distinguish lower motor neuron disorders from muscle disorders — for example, amyotrophic lateral sclerosis (ALS) frommuscular dystrophy. It also helps evaluate neuromuscular disorders such as myasthenia gravis. In this test, a needle electrode is inserted percutaneously into a muscle. The muscle’s electrical discharge is then displayed and measured on an oscilloscope screen.

Neurologic disorders: Nursing considerations

Focus topic: Neurologic disorders

  • Tell the patient that the test may take 1 hour to complete and that he may be asked to sit or lie down during the procedure.
  • Warn him that he’ll probably feel some discomfort when the doctor inserts a needle attached to an electrode into his muscle and when a mild electrical charge is delivered to the muscle.
  • Explain that he must remain still during the test except when asked to contract or relax a muscle.
  • Explain that an amplifier may emit crackling noises whenever his muscle moves.
  • Encourage him to resume his normal activities, as ordered.
  • Explain why he shouldn’t take any stimulants, depressants, or sedatives for 24 hours before the test.

Neurologic disorders: Treatments

Focus topic: Neurologic disorders

The most common treatments for neurologic disorders are drug therapy and surgery.

Neurologic disorders: Drug therapy

Focus topic: Neurologic disorders

Drug therapy is a common and important treatment for neurologic disorders. When caring for a patient undergoing drug therapy, you’ll need to be alert for severe adverse reactions and for interactions with other drugs. Some drugs, such as barbiturates, also carry a high risk of toxicity.
Keep in mind that drug therapy’s success hinges on the patient’s strict adherence to his medication schedule. Compliance is especially critical for drugs that require steady-state blood levels for therapeutic effectiveness, such as anticonvulsants, or for drugs used prophylactically such as beta-adrenergic blockers.

Neurologic disorders: Surgery

Focus topic: Neurologic disorders

Surgical procedures typically used to treat neurologic disorders include cerebral aneurysm repair, craniotomy, and intracranial hematoma aspiration. As a medical-surgical nurse, you should prepare to handle the patient’s preoperative assessment and preparation and postoperative care.

Neurologic disorders: Questions, concerns, fears

Focus topic: Neurologic disorders

When confronted with surgery, the patient and his family usually have questions, concerns, and fears that require compassionate attention. Keep in mind that a patient requiring surgery to address a neurologic disorder may be left with deficits that can be frustrating for him and his family. A positive, caring attitude and support can help them cope with their ordeal.

Neurologic disorders

Cerebral aneurysm repair
Surgical intervention is the standard method for preventing rupture or rebleeding of a cerebral aneurysm. First, a craniotomy is performed to expose the aneurysm. Then, there are several corrective techniques the surgeon may use, depending on the shape and location of the aneurysm. He can clamp the affected artery, wrap the aneurysm wall with a biological or synthetic material, or clip or ligate the aneurysm.
Newer surgical approaches use a combination of therapies to repair an aneurysm. For instance, interventional radiology may be used in conjunction with endovascular balloon therapy to occlude the aneurysm or vessel and treat arterial vasospasm with cerebral angiography.

Neurologic disorders

Neurologic disorders: Don’t flip your lid yet

Focus topic: Neurologic disorders

Another less invasive technique that has been successful for some patients is electrothrombosis, or coiling. This endovascular technique doesn’t require open surgery; instead, the surgeon uses a catheter to thread a platinum coil into the aneurysm sac and, through electrolysis, seal off the aneurysm to prevent further bleeding.

Neurologic disorders: Patient preparation

Focus topic: Neurologic disorders
Before the procedure, take these steps:

  • Tell the patient and his family that he’ll be monitored in the intensive care unit (ICU) after surgery, where he’ll be observed for signs of vasospasm, bleeding, and elevated intracranial pressure.
  • Explain that he’ll return to the medical-surgical unit for further care when his condition is stable.

Neurologic disorders: Monitoring and aftercare

Focus topic: Neurologic disorders
After the procedure, take these steps:

  • Gradually increase the patient’s level of activity, as ordered.
  • Monitor the incision for signs of infection or drainage.
  • Monitor the patient’s neurologic status and vital signs, and report acute changes immediately. Watch for increased ICP: pupil changes, weakness in extremities, headache, and a change in LOC.
  • Provide the patient and his family with emotional support as they cope with residual neurologic deficits.

Neurologic disorders

Neurologic disorders: Home care instructions

Focus topic: Neurologic disorders
Before discharge, give the patient these instructions:

  • Teach the patient or family member proper dressing change and wound care techniques and how to evaluate the incision regularly for redness, warmth, or tenderness, and to report any occurrence to the practitioner immediately.

Neurologic disorders: Dazed and confused

Focus topic: Neurologic disorders

  • Remind the patient to continue taking prescribed anticonvulsant medications to minimize the risk of seizures. Depending on the type of surgery performed, he may need to continue anticonvulsant therapy for up to 12 months after surgery. Also, tell him to notify his practitioner of any adverse drug reactions such as excessive drowsiness or confusion.
  • Emphasize the importance of returning for scheduled follow-up examinations and tests.
  • Refer the patient and his family for appropriate home care or support groups.

Craniotomy
Craniotomy involves creation of a surgical incision into the skull to expose the brain for various treatments, such as ventricular shunting, excision of a tumor or abscess, hematoma aspiration, and aneurysm clipping. Craniotomy has many potential complications, including infection, hemorrhage, respiratory compromise, and increased ICP. The degree of risk depends on the patient’s condition and the surgery’s complexity.

Neurologic disorders: Patient preparation

Focus topic: Neurologic disorders
Before the procdedure, take these steps:
• Answer questions the family may have about the procedure to help reduce confusion and anxiety and help them cope.
• Explain to the patient that his hair will be clipped or shaved.
• Discuss the recovery period so the patient understands what to expect. Explain that he’ll awaken with a dressing on his head to protect the incision and may have a surgical drain as well.
• Tell him to expect a headache and facial swelling for 2 to 3 days after surgery, and reassure him that he’ll receive pain medication.
• Perform and document a baseline neurologic assessment.
• Explain that the patient will go to the ICU after surgery for close monitoring.

Neurologic disorders: Monitoring and aftercare

Focus topic: Neurologic disorders
After the procedure, take these steps:
• Gradually increase the patient’s level of activity, as ordered.
• Monitor the incision site for signs of infection or drainage.
• Monitor the patient’s neurologic status and vital signs, and report any acute change immediately. Watch for signs of increased ICP, such as pupil changes, weakness in extremities, headache, and change in LOC.
• Provide the patient and his family with emotional support as they cope with residual neurologic deficits.

Neurologic disorders: Home care instructions

Focus topic: Neurologic disorders
Before discharge, take these steps:
• Teach the patient or family member proper wound care techniques and how to evaluate the incision regularly for redness, warmth, or tenderness and report occurrences to the practitioner.
• Remind the patient to continue taking prescribed anticonvulsant medications to minimize the risk of seizures. Depending on the type of surgery performed, he may need to continue anticonvulsant therapy for up to 12 months after surgery. Also, remind him to report any adverse drug reactions, such as excessive drowsiness or confusion.

Neurologic disorders

  • Emphasize the importance of returning for scheduled follow-up examinations and tests.
  • Refer the patient and his family for home care or support groups as appropriate.
  • Provide written copies of home care instructions and a list of medications for the patient and family members.

Intracranial hematoma aspiration
In intracranial hematoma aspiration, an epidural, subdural, or intracerebral hematoma is aspirated with a small suction tip. This suction tip is inserted through burr holes in the skull (for a fluid hematoma) or through a craniotomy (for a solid clot or a liquid one that can’t be aspirated through burr holes).

Neurologic disorders: It’s complicated

Focus topic: Neurologic disorders

Patients undergoing hematoma aspiration risk severe infection and seizures as well as physiologic problems associated with immobility during the prolonged recovery period. Even if hematoma removal proves successful, associated head injuries and other complications, such as cerebral edema, can produce permanent neurologic deficits, coma, or even death.

Neurologic disorders: What you can do

Focus topic: Neurologic disorders

Patient preparation, monitoring and aftercare, and home care instructions are the same as those for cerebral aneurysm repair.

Neurologic disorders: Nursing diagnoses

Focus topic: Neurologic disorders

When caring for patients with neurologic disorders, certain nursing diagnoses are commonly used. When developing your care plan, keep in mind interventions to prevent the three most common complications in patients with neurologic disorders: respiratory infection, urinary tract infection (UTI), and infected pressure ulcers.

Neurologic disorders: Impaired physical mobility

Focus topic: Neurologic disorders

Impaired physical mobility can occur in ALS, cerebral palsy, stroke, MS, muscular dystrophy, myasthenia gravis, Parkinson’s disease, poliomyelitis, or spinal cord injury.

Expected outcomes

  • The patient will show no evidence of complications, such as contractures, venous stasis, thrombus formation, or skin breakdown.
  • The patient will achieve the highest level of mobility possible.
  • The patient will maintain muscle strength and joint ROM.

Nursing interventions and rationales

  • Have the patient perform ROM exercises at least once every shift, unless contraindicated. Progress from passive to active exercises, as tolerated. This prevents joint contractures and muscular atrophy.
  • Turn and position the dependent patient every 2 hours. Establish a turning schedule, post this schedule at the bedside, and monitor the frequency of turning. Turning prevents skin breakdown by relieving pressure.
  • Place joints in functional positions (use hand splints if needed and available), use a trochanter roll along the thigh, abduct the thighs, use high-top sneakers, and put a small pillow under the patient’s head. These measures maintain joints in a functional position and prevent musculoskeletal deformities.
  • Identify the patient’s level of functioning using a functional mobility scale. Communicate the patient’s skill level to all staff members to provide continuity and preserve a specific level of independence.
  • Encourage mobility independence by helping the patient use a trapeze and side rails to reposition himself; use his good leg to move his affected leg; and perform self-care activities, such as feeding and dressing, to increase muscle tone and build self-esteem.

Neurologic disorders: Declaration of independence

Focus topic: Neurologic disorders

  • If one-sided weakness or paralysis is present, place items within reach of the patient’s unaffected arm to promote independence.
  • Monitor and record evidence of immobility complications (such as contractures, venous stasis, thrombus, pneumonia, skin breakdown, and UTI) each day. The patient with a history of a neuromuscular disorder or dysfunction may be prone to complications.
  • Promote progressive mobilization to the degree possible in light of the patient’s condition (bed mobility to chair mobility to ambulation) to maintain muscle tone and prevent complications.
  • Refer the patient to physical and occupational therapists for development of a mobility regimen to help rehabilitate the patient’s musculoskeletal deficits. Request written mobility plans and use these as references.
  • Teach the patient and his family how to perform ROM e xercises, transfers, and skin inspection and explain the mobility regimen to prepare the patient for discharge.
  • Demonstrate the mobility regimen, and have the patient and his caregivers do a return demonstration and note the dates of both. This ensures continuity of care and correct completion.
  • Help identify resources that will help the patient carry out the mobility regimen, such as Strokesurvivors International, the United Cerebral Palsy Associations, and the National Multiple Sclerosis Society, to help provide a comprehensive approach to rehabilitation.

Neurologic disorders: Impaired skin integrity

Focus topic: Neurologic disorders

Impaired skin integrity is a potential (and common) problem for anyone with a lower than normal level of activity. However, it can be deadly for a patient who can’t turn or move by himself. Infected pressure ulcers are one of the primary causes of death in a patient with neurologic disease. Even when not infected, pressure ulcers still cause prolonged distress and adversely affect the patient’s ability to function and his quality of life.

Expected outcomes

  • The patient will maintain intact skin integrity.
  • The patient won’t develop complications, should skin breakdown occur.
  • The patient will maintain the optimal nutrition needed to prevent skin breakdown.

Nursing interventions and rationales

  • Turn and move the patient at least every 2 hours if he’s unable to do so. Teach wheelchair patients to shift position several times each hour; provide help if needed. Pressure reduces skin circulation very quickly, which is a precursor to breakdown.

Neurologic disorders: Steering clear of breakdowns

Focus topic: Neurologic disorders

  • Use appropriate support surfaces, such as 4 convoluted foam mattresses or gelmats. If the patient develops pressure ulcers, consult established guidelines and protocols to determine the proper supportive surfaces for the patient. Repositioning and proper support surfaces reduce pressure on skin and help prevent skin breakdown.
  •  Consult with an enterostomal therapist and published guidelines to determine preventive measures and interventions.
  • Encourage optimal food and fluid intake to maintain skin health.

Neurologic disorders: Impaired urinary elimination

Focus topic: Neurologic disorders

Impaired urinary elimination is another of the major complications affecting patients with neurologic disorders. Many of these patients have bladder spasticity or are unable to empty their bladders fully or properly. UTIs are common and can lead to prolonged hospitalization or even death.

Expected outcomes
• The patient will empty his bladder completely and regularly.
• The patient won’t develop a UTI.

Nursing interventions and rationales

  • Use appropriate strategies for assessing adequacy of output and bladder emptying. Although regular emptying is essential to urinary tract health, the patient may be unable to do so or may be unable to sense whether or not he’s completely emptying his bladder.
  • Encourage the patient to drink plenty of fluids each day. Fluid intake is essential to the production of urine to clean the urinary tract and bladder.
  • If the patient can’t empty his bladder alone, use the least invasive strategies to improve bladder emptying. Start with such techniques as Credé’s maneuver, in which the patient bends forward and presses on the bladder while urinating. Intermittent self-catheterization is more invasive, but less likely to cause infection than an indwelling urinary catheter.
  • If the patient voids adequately but is incontinent, a condom catheter will help keep his skin dry, while being less likely than intermittent or indwelling urinary catheterization to cause infection.
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Neurologic disorders: Impaired gas exchange

Focus topic: Neurologic disorders

Impaired gas exchange relates to the third most common complication for patients with neurologic disorders: respiratory infection.

Expected outcomes

  • The patient won’t develop a respiratory infection.
  • The patient will maintain optimal oxygen saturation levels.

Nursing interventions and rationales

  • If the patient is immobile or has impaired respiratory muscle function, encourage the use of incentive spirometry, deep breathing, and coughing several times per day. Deep breathing and coughing help prevent atelectasis, which can become a respiratory infection as secretions accumulate.
  • Encourage fluid intake. Fluids keep respiratory secretions thin and easy to cough up.
  • Discourage smoking and exposure to second-hand smoke that impair respiration and the body’s ability to clear the lungs.
  • Encourage adequate rest, exercise, and nutrition, which will help maintain the strength of respiratory muscles.
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