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NEURO ASSESSMENT DISORDERS

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MAJOR CLASSIFICATION OF NEUROLOGIC DISORDERS

1.CEREBRAL DISORDERS

A. EPILEPSY

DEFINITION
Epilepsy is a common condition that causes repeated seizures. The
seizures are caused by bursts of electrical activity in the brain that are not normal.
Seizures may cause problems with muscle control, movement, speech, vision, or
awareness. They usually don't last very long, but they can be scary. The good
news is that treatment usually works to control and reduce seizures.
Epilepsy is not a type of mental illness or retardation. It generally does
not affect how well you think or learn. You can't catch epilepsy from someone
else (like a cold), and they can't catch it from you.

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SYMPTOMS
The main symptom of epilepsy is repeated seizures that happen without
warning. Without treatment, seizures may continue and even become worse and
more frequent over time.
There are different kinds of seizures. You may have only one type of
seizure. Some people have more than one type. Depending on what kind of
seizure you have:
Your senses may not work right. For example, you may notice strange
smells or sounds.
You may lose control of your muscles.
You may fall down, and your body may twitch or jerk.
You may stare off into space.
You may faint (lose consciousness).

Not everyone who has seizures has epilepsy. Sometimes seizures happen
because of an injury, illness, or another problem. In these cases, the seizures stop
when that problem improves or goes away.

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MEDICAL/SURGICAL MANAGEMENT

The list of treatments mentioned in various sources for Epilepsy includes

the following list.
Always seek professional medical advice about any treatment or change
in treatment plans.

Anticonvulsant medications
Phenytoin
Primidone
Methoin
Clonazepam
Sodium valproate
Carbamazepine
Brain surgery
Lifestyle changes
Avoid alcohol
Avoid driving

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B. SEIZURES
DEFINITION

Seizures are caused by abnormal electrical discharges in the brain.

Symptoms may vary depending on the part of the brain that is involved, but
seizures often cause unusual sensations, uncontrollable muscle spasms, and
loss of consciousness.
Some seizures may be the result of a medical problem. Low blood sugar,
infection, a head injury, accidental poisoning, or drug overdose can cause a
seizure. A seizure may also be due to a brain tumor or other health problem
affecting the brain. In addition, anything that results in a sudden lack of oxygen to
the brain can cause a seizure. In some cases, the cause of the seizure is never
discovered.

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SYMPTOMS
Sensory/thought: Emotional:
Black out Fear/Panic
Confusion
Deafness/Sounds •Physical:
Electric Shock Chewing Lip smacking
Feeling movements Making sounds
Loss of Convulsion Shaking
consciousness Difficulty talking Staring
Smell Drooling Stiffening
Spacing out Eyelid fluttering Swallowing
Out of body Eyes rolling up Sweating
experience Falling down Teeth
Visual loss or Foot stomping clenching/grinding
blurring Hand waving Tongue biting
Inability to move Tremors
Incontinence Twitching movements
Breathing difficulty
Heart racing
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MEDICAL/SURGICAL MANAGEMENT

The first step toward getting treatment for seizures is to see a doctor! The
doctor may make a diagnosis of epilepsy (the doctor might call it a seizure
disorder). This step usually will involve some diagnostic tests.
Then comes the treatment. There are many seizure medicines. Each one
tends to work better for certain kinds of seizures than for others. The doctor
chooses one based on the type of seizure, the person's age, and whether the
person has any other medical conditions. The doctor then will usually discuss
how to take the medicine, what side effects to look for, and when to come back
for a follow-up visit.

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C. BRAIN TUMORS
DEFINITION
Brain tumor is a growth or tumor that develops in the tissues of the brain
in adults. The tumor can be benign or malignant.

SYMPTOMS
The symptoms of brain tumors depend on tumor size, type, and location.
Symptoms may be caused when a tumor presses on a nerve or damages a certain
area of the brain. They also may be caused when the brain swells or fluid builds
up within the skull.

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These are the most common symptoms of brain tumors:

Headaches (usually worse in the morning)
•Nausea or vomiting
•Changes in speech, vision, or hearing
•Problems balancing or walking
•Changes in mood, personality, or ability to
concentrate
•Problems with memory
•Muscle jerking or twitching (seizures or convulsions)
•Numbness or tingling in the arms or legs
These symptoms are not sure signs of a brain tumor. Other conditions
also could cause these problems. Anyone with these symptoms should see a
doctor as soon as possible. Only a doctor can diagnose and treat the problem.

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If a person has symptoms that suggest a brain tumor, the doctor may
perform one or more of the following procedures:
1. Physical exam - The doctor checks general signs of health.
2. Neurologic exam - The doctor checks for alertness, muscle strength,
coordination, reflexes, and response to pain. The doctor also examines the
eyes to look for swelling caused by a tumor pressing on the nerve that
connects the eye and brain.
3. CT scan - An x-ray machine linked to a computer takes a series of detailed
pictures of the head. The patient may receive an injection of a special dye so
the brain shows up clearly in the pictures. The pictures can show tumors in
the brain.
4. MRI - A powerful magnet linked to a computer makes detailed pictures of
areas inside the body. These pictures are viewed on a monitor and can also
be printed. Sometimes a special dye is injected to help show differences in
the tissues of the brain. The pictures can show a tumor or other problem in
the brain.

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D. CEREBROVASCULAR DISEASE

INTRODUCTION
Cerebrovascular disease is a group of brain dysfunctions related to
disease of blood vessels supplying the brain. Hypertension is the most important
cause that damages the blood vessel lining endothelium exposing the underlying
collagen where platelets aggregate to initiate a repairing process which is not
always complete and perfect. Sustained hypertension permanently changes the
architecture of the blood vessels making them narrow, stiff, deformed and uneven
which are more vulnerable to fluctuations of blood pressure. A fall in blood
pressure during sleep can lead to marked reduction in blood flow in the narrowed
blood vessels causing ischemic stroke in the morning whereas a sudden rise in
blood pressure can cause tearing of the blood vessels causing intracranial
hemorrhage during excitation at daytime. Primarily people who are elderly,
diabetic, smoker, or have ischemic heart disease, have cerebrovascular disease.
All diseases related to artery dysfunction can be classified under a disease as
known as Macrovascular disease.

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SYMPTOMS
A cerebrovascular accident is apparent if the victim displays the following
symptoms: dizziness, nausea, vomiting, severe headaches, head pressure, and
the numbness within the limbs, slurred speech, vision loss, loss of coordination
and the ability to walk. Hemorrhagic strokes may require surgery to relieve the
pressure within the brain. Another treatment, endovascular treatment, requires
inserting a tube into the major artery.

MEDICAL/SURGICAL MANAGEMENT
1. Physical examination
Pulse and blood pressure
Cranial nerve examination including visual acuity and visual fields,
pupils and eye movements, facial muscles and facial sensation,
hearing, gag reflex and tongue
Examine gait
Examine upper and lower limbs noting tone, power, reflexes, co-
ordination and sensation
Listen to carotid arteries for bruits (sign of reduced blood flow to
brain)
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2. Blood tests
Full blood count to detect polycythaemia, infection or inflammation
Electrolytes and renal function tests
Blood glucose
Syphilis serology to detect possible neurosyphilis
Clotting screen if appropriate (antithrombin III deficiency, protein C
or S deficiency, lupus anticoagulant)
Lupus erythematosus serology e.g. antinuclear antibodies, double
stranded DNA, cardiolipin antibodies
Blood cultures if any chance of bacterial endocarditis

3. Electrocardiogram - to detect atrial fibrillation.

4. Radiological tests
CT Scan Brain
MRI Brain can detect changes of stroke within a few hours
Chest X-Ray
Carotid Doppler
Echocardiogram and Cerebral angiogram

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E. BRAIN INFECTIONS

DEFINITION
Any infection of the brain is usually called encephalitis, though
meningitis is closely related.

SYMPTOMS
Patients with encephalitis suffer from fever, headache and photophobia
with weakness and seizures also common. Less commonly, stiffness of the neck
can occur with rare cases of patients also suffering from stiffness of the limbs,
slowness in movement and clumsiness depending on which specific part of the
brain is involved. The symptoms of encephalitis are caused by the brain's defense
mechanisms activating to get rid of the infection.

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MEDICAL/SURGICAL MANAGEMENT
Treatment is usually symptomatic. Reliably tested specific antiviral
agents are available only for a few viral agents (e.g. acyclovir for herpes simplex
virus) and are used with limited success for most infection except herpes simplex
encephalitis. In patients who are very sick, supportive treatment, such as
mechanical ventilation, is equally important.

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F. HEADACHES

DEFINITION
A headache is a pain in the head with the pain being above the eyes or
the ears, behind the head (occipital), or in the back of the upper neck. Headache,
like chest pain or back ache, has many causes.

SYMPTOMS
The list of signs and symptoms mentioned in various sources for
Headache includes the 4 symptoms listed below:
Confusion
Memory problems
Headaches
Vision problems

Note that Headache symptoms usually refers to various symptoms known

to a patient, but the phrase Headache signs may refer to those signs only
noticable by a doctor.

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MEDICAL/SURGICAL MANAGEMENT
Not all headaches require medical attention, and many respond with
simple analgesia (painkillers) such as paracetamol/acetaminophen or members of
the NSAID class (such as aspirin/acetylsalicylic acid or ibuprofen).
In recurrent unexplained headaches, healthcare professionals may
recommend keeping a "headache diary" with entries on type of headache,
associated symptoms, precipitating and aggravating factors. This may reveal
specific patterns, such as an association with medication, menstruation or
absenteeism or with certain foods. It was reported in March 2007 by two separate
teams of researchers that stimulating the brain with implanted electrodes appears
to help ease the pain of cluster headaches.

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2. DEGENERATIVE NEUROLOGIC DISORDERS

A. DEMENTIA (ALZHEIMERS)

DEFINITION
Alzheimer's disease (AD) affects the mental abilities including memory,
language, and cognition. Progressively it leads to dementia and death. AD usually
arises in late middle age or the elderly but there is a rare familial subtype that
occurs earlier. Because AD is so well-known, other causes of dementia or
memory loss may be overlooked. Other possible diagnoses include normal aging
(if very mild symptoms), emotional problems, fatigue, depression, and certain
medical conditions such as thyroid disease, brain tumors, multi-infarct disease, or
Huntington's disease. In its early stages, a correct diagnosis of AD can also be
overlooked itself and misdiagnosed as other conditions such as depression,
dementia, simple forgetfulness, or senility.

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SYMPTOMS
Early symptoms Later symptoms
Forgetfulness Indifferent attitude Depression
Loss of concentration Anxiety Aggression
Forgetting names Apathy Wandering
Cognition Normal motor
Progressing symptoms disintegration function - AD
Memory loss Personality affects the brain
Forgetting how to do disintegration but not the body
everyday tasks Suspicion
Thinking difficulty Hostility
Difficulty speaking Aggression
Difficulty reading Inability to function
Language deterioration Loss of speech
Impaired visual skills Difficulty swallowing
Impaired spatial skills Drooling
Poor judgment Incontinence
Confusion
Disorientation
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MEDICAL/SURGICAL MANAGEMENT
Neuropsychological screening tests, such as the mini-mental state
examination (MMSE), are widely used to evaluate the cognitive impairments
needed for diagnosis. More comprehensive test arrays are necessary for high
reliability of results, particularly in the earliest stages of the disease. Neurological
examination in early AD will usually provide normal results, except for obvious
cognitive impairment, which may not differ from standard dementia. Further
neurological examinations are crucial in the differential diagnosis of AD and other
diseases. Interviews with family members are also utilised in the assessment of
the disease. Caregivers can supply important information on the daily living
abilities, as well as on the decrease, over time, of the person's mental function. A
caregiver's viewpoint is particularly important, since a person with AD is
commonly unaware of his own deficits. Many times, families also have difficulties
in the detection of initial dementia symptoms and may not communicate accurate
information to a physician. Supplemental testing provides extra information on
some features of the disease or is used to rule out other diagnoses. Blood tests
can identify other causes for dementia than AD—causes which may, in rare cases,
be reversible. Psychological tests for depression are employed, since depression
can either be concurrent with AD or be the cause of cognitive impairment.

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B. PAKINSON’S DISEASE

DEFINITION
Parkinson's disease (also known as Parkinson disease or PD) is a
degenerative disorder of the central nervous system that often impairs the
sufferer's motor skills, speech, and other functions.
Parkinson's disease belongs to a group of conditions called movement
disorders. It is characterized by muscle rigidity, tremor, a slowing of physical
movement (bradykinesia) and, in extreme cases, a loss of physical movement
(akinesia). The primary symptoms are the results of decreased stimulation of the
motor cortex by the basal ganglia, normally caused by the insufficient formation
and action of dopamine, which is produced in the dopaminergic neurons of the
brain. Secondary symptoms may include high level cognitive dysfunction and
subtle language problems. PD is both chronic and progressive.

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SYMPTOMS
Fixed facial expression
• Lack of blinking
• Tremor or trembling - various uncontrolled movements typically occuring in
fingers, hands, arms, legs, jaw, and face
Tremor in one little finger - a common early symptom
Hand tremor
Tremor in one hand
Tremor in one leg
Tremor in one arm
Tremor in one side of the body
Involuntary head nodding

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Walking symptoms
Rigidity - stiffness of the limbs
Difficulty walking
and trunk
Stooping posture
Loss of postural reflexes • Bradykinesia - slowness of
Rigid back movement
Shuffling gait • Difficulty swallowing
Postural instability
Impaired balance • Speech changes
Impaired coordination Difficulty talking
Falls Voice changes
Falling forwards Softer voice
Falling backwards Monotonous voice
Stammering

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Facial symptoms
Facial expression changes
Fixed mask-like expression
Tight facial muscles
Facial muscle spasm

Intellectual symptoms - usually late in the progression of symptoms; most

people suffer physical symptoms without early mental changes.

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MEDICAL/SURGICAL MANAGEMENT
Typically, the diagnosis is based on medical history and neurological
examination conducted by interviewing and observing the patient in person using
the Unified Parkinson's Disease Rating Scale. A radiotracer for SPECT scanning
machines called DaTSCAN and made by General Electric is specialized for
diagnosing Parkinson's disease, but it is only marketed in Europe. Due to this, the
disease can be difficult to diagnose accurately, especially in its early stages. Due
to symptom overlap with other diseases, only 75% of clinical diagnoses of PD are
confirmed to be idiopathic PD at autopsy. Early signs and symptoms of PD may
sometimes be dismissed as the effects of normal aging. The physician may need
to observe the person for some time until it is apparent that the symptoms are
consistently present. Usually doctors look for shuffling of feet and lack of swing
in the arms. Doctors may sometimes request brain scans or laboratory tests in
order to rule out other diseases. However, CT and MRI brain scans of people with
PD usually appear normal.

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C. CREUTZFELDT-JAKOB DISEASE

DEFINITION
Creutzfeldt-Jakob disease (CJD) is the dementing form of the human
prion diseases (also known as spongiform transmissible encephalopathies or
infectious amyloidoses). A prion is an unconventional, transmissible agent (not a
virus or a bacterium). Prions are special proteins that can be transmitted from
animal to animal to cause a group of degenerative diseases of the nervous
system. These diseases can be manifest as sporadic, infectious, or inherited
disorders.
CJD is characterized by forgetfulness and nervousness; jerky, trembling
hand movements; unsteady gait; myoclonus; chronic dementia; severe balance
disturbance; and muscular rigidity. Patients can have characteristic brain
electrical changes referred to as periodic electroencephalogram (EEG) complexes.
Brain biopsy (pathology under the microscope) includes typical tissue changes
referred to as status spongiosus, diffuse nerve cell degeneration, and glial
proliferation. There is no known treatment or cure for CJD. Bovine spongiform
encephalopathy (BSE) represents another, similar disease of cattle.

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SYMPTOMS

The first symptom of CJD is rapidly progressive dementia, leading to

memory loss, personality changes and hallucinations. This is accompanied by
physical problems such as speech impairment, jerky movements (myoclonus),
balance and coordination dysfunction (ataxia), changes in gait, rigid posture, and
seizures. The duration of the disease varies greatly, but sporadic (non-inherited)
CJD can be fatal within months or even weeks (Johnson, 1998). In some people,
the symptoms can continue for years. In most patients, these symptoms are
followed by involuntary movements and the appearance of a typical diagnostic
electroencephalogram tracing.
The symptoms of CJD are caused by the progressive death of the brain's
nerve cells, which is associated with the build-up of abnormal prion proteins.
When brain tissue from a CJD patient is examined under a microscope, many tiny
holes can be seen where whole areas of nerve cells have died. The word
'spongiform' in 'transmissible spongiform encephalopathies' refers to the
'spongy' appearance of the brain tissue.

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MEDICAL/SURGICAL MANAGEMENT
There is currently no cure for CJD, a fatal disease, and the search for
viable treatments continues. An experimental treatment was given to a Northern
Irish teenager, Jonathan Simms, beginning in January 2003. The medication,
called pentosan polysulphate (PPS) and used to treat interstitial cystitis, is
infused into the patient's lateral ventricle within the brain. PPS does not seem to
stop the disease from progressing, and both brain function and tissue continue to
be lost. However, the treatment is alleged to slow the progression of the
otherwise untreatable disease, and may have contributed to the longer than
expected survival of the seven patients that were studied. The CJD Therapy
Advisory Group to the UK Health Departments advises that data are not sufficient
to support claims that pentosan polysulphate is an effective treatment and
suggests that further research in animal models is appropriate. A 2007 review of
the treatment of 26 patients with PPS finds no proof of efficacy because of the
lack of accepted objective criteria.

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D. HUNTINGTON’S DISEASE

DEFINITION
Huntington's disease, also called Huntington's chorea, chorea major, or
HD, is a genetic neurological disorder characterized after onset by uncoordinated,
jerky body movements called chorea and a decline in some mental abilities, which
can lead to affected aspects of behavior. As the disorder progresses, these
symptoms can cause complications that significantly reduce life expectancy.

SYMPTOMS
Physical symptoms are usually the first to cause problems and to be
noticed, but at this point they are usually accompanied by cognitive and
psychiatric ones that are often not recognized. Almost everyone with Huntington's
disease eventually exhibits all physical symptoms, but cognitive and psychiatric
symptoms vary significantly between individuals.

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MEDICAL/SURGICAL MANAGEMENT

The list of treatments mentioned in various sources for Huntington's

Disease includes the following list.
Prenatal chorionic villus sampling
Medications
Anti-chorea medications
Anti-agitation medications
Physiotherapy
Exercise

Always seek professional medical advice about any treatment or change

in treatment plans.

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E. MULTIPLE SCLEROSIS

DEFINITION
Multiple sclerosis (MS) is a disease in which the nerves of the central
nervous system (brain and spinal cord) degenerate. Myelin, which provides a
covering or insulation for nerves, improves the conduction of impulses along the
nerves and also is important for maintaining the health of the nerves. In multiple
sclerosis, inflammation causes the myelin to eventually disappear. Consequently,
the electrical impulses that travel along the nerves decelerate, that is, become
slower. In addition, the nerves themselves are damaged. As more and more
nerves are affected, a patient experiences a progressive interference with
functions that are controlled by the nervous system such as vision, speech,
walking, writing, and memory.

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SYMPTOMS
Symptoms of MS usually appear in episodic acute periods of worsening
(relapses, exacerbations, bouts or attacks), in a gradually-progressive
deterioration of neurologic function, or in a combination of both.
The most common presentation of MS is the clinically isolated syndrome
(CIS). In CIS, a patient has an attack suggestive of demyelination, but does not
fulfill the criteria for multiple sclerosis.Only 30 to 70% of persons experiencing
CIS later develop MS. The disease usually presents with sensorial (46% of cases),
visual (33%), cerebellar (30%) and motor (26%) symptoms. Many rare initial
symptoms have also been reported, including aphasia, psychosis and epilepsy.
Patients first seeking medical attention commonly present with multiple
symptoms. The initial signs and symptoms of MS are often transient, mild, and
self-limited. These signs and symptoms often do not prompt a person to seek
medical attention and are sometimes identified only retrospectively once the
diagnosis of MS has been made. Cases of MS are sometimes incidentally
identified during neurological examinations performed for other causes. Such
cases are referred to as subclinical MS.

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The person with MS can suffer almost any neurological symptom or sign,
including changes in sensation (hypoesthesias and paraesthesias), muscle
weakness, muscle spasms, or difficulty in moving; difficulties with coordination
and balance (ataxia); problems in speech (dysarthria) or swallowing (dysphagia),
visual problems (nystagmus, optic neuritis, or diplopia), fatigue, acute or chronic
pain, and bladder and bowel difficulties. Cognitive impairment of varying degrees
and emotional symptoms of depression or unstable mood are also common. The
main clinical measure of disability progression and symptom severity is the
Expanded Disability Status Scale or EDSS.

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MEDICAL/SURGICAL MANAGEMENT
There are many issues for the patient and physician to consider in
treating multiple sclerosis. Goals may include reducing the number of attacks,
improving recovery from attacks, and attempting to slow further progression of
the disease (treatment with disease-modifying drugs). An additional goal is relief
from complications due to the loss of function of affected organs (treatment with
drugs aimed at specific symptoms). Most neurologists will consider treatment
with disease-modifying drugs once the diagnosis of multiple sclerosis is
established. Many will begin treatment at the time of the first multiple sclerosis
attack, since clinical trials have suggested that patients in whom treatment is
delayed may not benefit as much as patients who are treated early. Finally,
utilizing support groups or counseling may be helpful for patients and their
families whose lives may directly be affected by multiple sclerosis.

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Once goals have been set, initial therapy may include medications to
manage attacks, symptoms, or both. An understanding of the potential side
effects of drugs is critical for the patient because sometimes side effects alone
deter patients from drug therapy. Patients may choose to avoid drugs altogether
or choose an alternative drug that may offer relief with fewer side effects. A
continuous dialogue between the patient and physician about the medications is
important in determining the needs for treatment.
Drugs known to affect the immune system have become the primary
focus for managing multiple sclerosis. Initially, corticosteroids, such as
prednisone (Deltasone, Liquid Pred, Deltasone, Orasone, Prednicen-M) or
methylprednisolone (Medrol, Depo-Medrol), were widely used. However, since
their effect on the immune system is non-specific and their use may cause
numerous side effects, corticosteroids now tend to be used to manage only
sudden, severe multiple sclerosis attacks.

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F. GUILLAIN BARRE SYNDROME

DEFINITION
Guillain-Barré syndrome (often misspelled Guillain-Barre) is a disorder in
which the body's immune system attacks part of the peripheral nervous system.
The first symptoms of this disorder include varying degrees of weakness or
tingling sensations in the legs. In many instances the weakness and abnormal
sensations spread to the arms and upper body. These symptoms can increase in
intensity until certain muscles cannot be used at all and, when severe, the patient
is almost totally paralyzed. In these cases the disorder is life threatening -
potentially interfering with breathing and, at times, with blood pressure or heart
rate - and is considered a medical emergency. Such a patient is often put on a
respirator to assist with breathing and is watched closely for problems such as an
abnormal heart beat, infections, blood clots, and high or low blood pressure. Most
patients, however, recover from even the most severe cases of Guillain-Barré
syndrome, although some continue to have a certain degree of weakness.

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SYMPTOMS
Symptoms of Guillain-Barré Syndrome include weakness, typically
beginning in the legs and progressing upward. The weakness is accompanied by
decreased feeling (paresthesia). Reflexes are lost, for example, the hammer to the
front of the knee will not induce a kick. In severe cases breathing can be affected
enough to require a ventilator and rarely the heart can be affected. The maximal
degree of weakness usually occurs within the first 2-3 weeks.

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MEDICAL/SURGICAL MANAGEMENT
There is no known cure for Guillain-Barré syndrome. However, there are
therapies that lessen the severity of the illness and accelerate the recovery in
most patients. There are also a number of ways to treat the complications of the
disease.
Currently, plasma exchange (sometimes called plasmapheresis) and high-
dose immunoglobulin therapy are used. Both of them are equally effective, but
immunoglobulin is easier to administer. Plasma exchange is a method by which
whole blood is removed from the body and processed so that the red and white
blood cells are separated from the plasma, or liquid portion of the blood. The
blood cells are then returned to the patient without the plasma, which the body
quickly replaces. Scientists still don't know exactly why plasma exchange works,
but the technique seems to reduce the severity and duration of the Guillain-Barré
episode. This may be because the plasma portion of the blood contains elements
of the immune system that may be toxic to the myelin.

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In high-dose immunoglobulin therapy, doctors give intravenous

injections of the proteins that, in small quantities, the immune system uses
naturally to attack invading organisms. Investigators have found that giving high
doses of these immunoglobulins, derived from a pool of thousands of normal
donors, to Guillain-Barré patients can lessen the immune attack on the nervous
system. Investigators don't know why or how this works, although several
hypotheses have been proposed.
The use of steroid hormones has also been tried as a way to reduce the
severity of Guillain-Barré, but controlled clinical trials have demonstrated that this
treatment not only is not effective but may even have a deleterious effect on the
disease.
The most critical part of the treatment for this syndrome consists of
keeping the patient's body functioning during recovery of the nervous system.
This can sometimes require placing the patient on a respirator, a heart monitor, or
other machines that assist body function. The need for this sophisticated
machinery is one reason why Guillain-Barré syndrome patients are usually treated
in hospitals, often in an intensive care ward. In the hospital, doctors can also look
for and treat the many problems that can afflict any paralyzed patient -
complications such as pneumonia or bed sores.
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G. MYASTHENIA GRAVIS

DEFINITION
Myasthenia gravis is a chronic autoimmune neuromuscular disease
characterized by varying degrees of weakness of the skeletal (voluntary) muscles
of the body. The name myasthenia gravis, which is Latin and Greek in origin,
literally means "grave muscle weakness." With current therapies, however, most
cases of myasthenia gravis are not as "grave" as the name implies. In fact, for the
majority of individuals with myasthenia gravis, life expectancy is not lessened by
the disorder.

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SYMPTOMS
Although myasthenia gravis may affect any voluntary muscle, muscles
that control eye and eyelid movement, facial expression, and swallowing are most
frequently affected. The onset of the disorder may be sudden. Symptoms often
are not immediately recognized as myasthenia gravis.
In most cases, the first noticeable symptom is weakness of the eye
muscles. In others, difficulty in swallowing and slurred speech may be the first
signs. The degree of muscle weakness involved in myasthenia gravis varies
greatly among patients, ranging from a localized form, limited to eye muscles
(ocular myasthenia), to a severe or generalized form in which many muscles -
sometimes including those that control breathing - are affected. Symptoms, which
vary in type and severity, may include a drooping of one or both eyelids (ptosis),
blurred or double vision (diplopia) due to weakness of the muscles that control
eye movements, unstable or waddling gait, weakness in arms, hands, fingers,
legs, and neck, a change in facial expression, difficulty in swallowing and
shortness of breath, and impaired speech (dysarthria).

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MEDICAL/SURGICAL MANAGEMENT
Immunosuppressive drugs such as prednisone, cyclosporine, and
azathioprine may also be used. These medications improve muscle strength by
suppressing the production of abnormal antibodies. They must be used with
careful medical followup because they may cause major side effects.
Thymectomy, the surgical removal of the thymus gland (which often is
abnormal in myasthenia gravis patients), reduces symptoms in more than 70
percent of patients without thymoma and may cure some individuals, possibly by
re-balancing the immune system. Other therapies used to treat myasthenia gravis
include plasmapheresis, a procedure in which abnormal antibodies are removed
from the blood, and high-dose intravenous immune globulin, which temporarily
modifies the immune system and provides the body with normal antibodies from
donated blood. These therapies may be used to help individuals during especially
difficult periods of weakness. A neurologist will determine which treatment option
is best for each individual depending on the severity of the weakness, which
muscles are affected, and the individual's age and other associated medical
problems.

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H. AMYOTROPHIC LATERAL SCLEROSIS

DEFINITION
Amyotrophic lateral sclerosis (also called ALS or "Lou Gehrig's disease")
is a classic motor neuron disease. Motor neuron diseases are progressive chronic
diseases of the nerves that come from the spinal cord responsible for supplying
electrical stimulation to the muscles. This stimulation is necessary for the
movement of body parts.

SYMPTOMS
All forms of ALS cause progressive muscle weakness and wasting.
Spontaneous tiny local areas of muscle twitching, called fasciculations, are
characteristic in most patients. These may be sensed by the patient as muscle
cramping. Lower extremity muscle wasting (atrophy) and weakness generally
follows wasting of the arms, hands, and shoulders. Spastic muscles can be
present.
Other muscles diseases are considered in the evaluation of patients.
Blood testing and muscle electrical testing with electromyography (EMG) and
nerve conduction velocities (NCV) can be helpful for a diagnosis.
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MEDICAL/SURGICAL MANAGEMENT
Treatment measures in patients with motor neuron diseases are largely
supportive, treating the complications, such as infections and general health. The
treatment of ALS is also directed toward suppressing the immune inflammation
felt to play a role in the degeneration of the nervous system of these patients.
While there is no cure for ALS or a proven therapy that will prevent or
reverse the course of the disorder, the U.S. Food and Drug Administration (FDA)
has approved riluzole (RILUTEK), the first drug that has been shown to prolong
the survival of ALS patients. Patients may also receive supportive treatments that
address the symptoms of the disease.

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3. PERIPHERAL NERVOUS SYSTEM DISORDERS

A. LOWER BACK PAIN

DEFINITION
Low back pain (sometimes referred to generally as lumbago) is a
common musculoskeletal disorder causing back pain in the lumbar vertebrae. It
can be either acute, subacute or chronic in its clinical presentation. Typically, the
symptoms of low back pain do show significant improvement within two to three
months from its onset. In a significant number of individuals, low back pain tends
to be recurrent in nature with a waxing and waning quality to it. In a small
proportion of sufferers this condition can become chronic. Population studies
show that back pain affects most adults at some stage in their life and accounts
for more sick leave and disability than any other single medical condition.

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CAUSES
Common causes of low back pain include lumbar strain, nerve irritation,
lumbar radiculopathy, bony encroachment, and conditions of the bone and joints.

MEDICAL/SURGICAL MANAGEMENT
The McKenzie Method or Mechanical Diagnosis and Treatment (MDT) of the
pain. This is based on a set of repeated movements or statically held postures to
determine if symptoms can be changed (better or worse). Treatment is then
based on avoiding postures or movements that aggravate symptoms, as well as
performing or adhering to postures to assist in symptom reduction. Robin
McKenzie, Founder of the McKenzie Institute, originally based his premise for
treatment on a intervertebral disc model. Hence, he believes this type of
assessment and treatment is beneficial for degenerative disc disease including
disc herniation. The McKenzie Institute, along with Robin, expanded it's scope of
treatment to any mechanical origin of spine pain. Health care professionals such
as Doctors, Physical Therapists and Chiropractors can follow a postgraduate
study in the McKenzie Method.

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Analgesics (pain medications), such as NSAIDs or acetaminophen.
•Arch support
•The Alexander Technique was shown in a UK clinical trial to have long term
benefits for patients with chronic back pain.
•Spinal manipulation for acute or chronic pain. A clinical prediction rule can
guide who is most likely to respond to manipulation.
•Muscle relaxants for acute or chronic pain.
•Antidepressants for chronic low back pain.
•Stay physically active.
•Exercise for chronic pain.
•Intensive multidisciplinary treatment programs may help subacute or chronic
low back pain.
•Behavioral therapy
•Acupuncture may help chronic pain; however, a more recent randomized
controlled trial suggested insignificant difference between real and sham
acupuncture

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B. TRIGEMINAL NEURALGIA

DEFINITION
Trigeminal neuralgia (TN), or Tic Doloureux, (also known as prosopalgia)
is a neuropathic disorder of the trigeminal nerve that causes episodes of intense
pain in the eyes, lips, nose, scalp, forehead, and jaw. It is estimated that 1 in
15,000 people suffer from trigeminal neuralgia, although those numbers may be
significantly higher due to frequent misdiagnosis. TN usually develops after the
age of 50, more commonly in females, although there have been cases with
patients being as young as three years of age.

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SYMPTOMS
The episodes of pain may occur paroxysmally. To describe the pain
sensation, patients describe a trigger area on the face, so sensitive that touching
or even air currents can trigger an episode of pain. It affects lifestyle as it can be
triggered by common activities in a patient's daily life, such as eating, talking,
shaving and toothbrushing. The attacks are said to feel like stabbing electric
shocks, burning, pressing or shooting pain that becomes intractable. Individual
attacks affect one side of the face at a time, last several seconds, hours or longer,
and repeat up to hundreds of times throughout the day.
The pain also tends to occur in cycles with complete remissions lasting
months or even years. 10-12% of cases are bilateral, or occurring on both sides.
This normally indicates problems with both trigeminal nerves since one serves
strictly the left side of the face and the other serves the right side. Pain attacks
typically worsen in frequency or severity over time. A great deal of patients
develop the pain in one branch, then over years the pain will travel through the
other nerve branches.

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MEDICAL/SURGICAL MANAGEMENT
There is no cure for trigeminal neuralgia, but most people find relief from
medication, from one of the five surgical options or sometimes from one of the
many complementary or alternative therapies. Atypical trigeminal neuralgia, which
involves a more constant and burning pain, is more difficult to treat, both with
medications and surgery. Surgery may result in varying degrees of numbness to
the patient and lead occasionally to "anesthesia dolorosa," which is numbness
with intense pain. However, some people do find dramatic relief with minimal side
effects from the various surgeries that are now available.
There are some things that a patient can do to minimize the frequency
and intensity of TN attacks:
Apply ice packs or any readily available source of cold to the area of
pain. Cold often numbs the area and will reduce the pain.
•Warming packs, wrapped in a towel to protect one's skin, can also
provide relief as they stimulate blood flow to the area they are placed
upon.

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Get adequate rest in normal rest cycles.

•Manage your stress well and keep stress levels low. When you feel a TN
attack coming on, try to relax immediately.
•Practice healthy living principles such as diet and exercise.
•Avoid foods that may act as nerve stimulants, such as coffee, tea, and
foods that are high in sugar.
•Maintain adequate hydration and electrolyte levels at all time.

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C. BELL’S PALSY

DEFINITION
Bell's palsy is a paralysis of the facial nerve resulting in inability to
control facial muscles on the affected side. Several conditions can cause a facial
paralysis, e.g., brain tumor, stroke, and Lyme disease. However, if no specific
cause can be identified, the condition is known as Bell's Palsy. Named after
Scottish anatomist Charles Bell, who first described it, Bell's palsy is the most
common acute mononeuropathy (disease involving only one nerve), and is the
most common cause of acute facial nerve paralysis.
Bell's palsy is defined as an idiopathic unilateral facial nerve paralysis,
usually self-limiting. The trademark is rapid onset of partial or complete palsy,
usually in a single day.

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SYMPTOMS
Although defined as a mononeuritis (involving only one nerve), patients
diagnosed with Bell’s palsy may have "myriad neurological symptoms" including
"facial tingling, moderate or severe headache/neck pain, memory problems,
balance problems, ipsilateral limb paresthesias, ipsilateral limb weakness, and a
sense of clumsiness" that are "unexplained by facial nerve dysfunction". This is
yet an enigmatic facet of this condition.

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MEDICAL/SURGICAL MANAGEMENT
Treatment of Bell's palsy is a matter of controversy. Two Cochrane
reviews from 2004 underlined the need for larger, properly designed clinical trials
to evaluate antiviral drugs or corticosteroids for Bell's palsy. The effect of
treatment is difficult to evaluate experimentally because spontaneous recovery
(without any treatment) is common. In patients presenting with incomplete facial
palsy, where the prognosis for recovery is very good, treatment may be
unnecessary. Patients presenting with complete paralysis, marked by an inability
to close the eyes and mouth on the involved side, are usually treated. Early
treatment (within 3 days after the onset) seems to be necessary for therapy to be
effective.
Prednisolone, a corticosteroid, if used early in treatment of Bell's palsy,
significantly improves the chances of complete recovery at 3 and 9 months when
compared to treatment with the anti-viral drug acyclovir or no treatment at all.

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D. VASCULAR SPINAL CORD LESIONS

E. DISORDERS OF THE PERIPHERAL NERVES

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4. NEUROLOGIC TRAUMA

A. SPINAL CORD INJURY

DEFINITION
Spinal cord injury causes myelopathy or damage to white matter or
myelinated fiber tracts that carry sensation and motor signals to and from the
brain. It also damages gray matter in the central part of the spinal, causing
segmental losses of interneurons and motorneurons. Spinal cord injury can occur
from many causes, including:
Trauma such as automobile crashes, falls, gunshots, diving
accidents, war injuries, etc.
• Tumor such as meningiomas, ependymomas, astrocytomas, and
metastatic cancer.
• Ischemia resulting from occlusion of spinal blood vessels, including
dissecting aortic aneurysms, emboli, arteriosclerosis.

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Developmental disorders, such as spina bifida, meningomyolcoele,

and other.
•Neurodegenerative diseases, such as Friedreich's ataxia,
spinocerebellar ataxia, etc.
•Demyelinative diseases, such as Multiple Sclerosis.
Transverse myelitis, resulting from spinal cord stroke,
inflammation, or other causes.

Vascular malformations, such as arteriovenous malformation (AVM),

dural arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and
aneurysm.

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SYMPTOMS
Paralysis
Loss of sensation
Loss of reflex function
Loss of autonomic activity
Breathing difficulty
Loss of bowel control
• Pain
• Sensitivity to stimuli
• Muscle spasms
• Sexual dysfunction
• Loss of bladder control

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MEDICAL/SURGICAL MANAGEMENT
Treatment for acute traumatic spinal cord injuries have consisted of
giving a high dose methylprednisolone if the injury occurred within 8 hours. The
recommendation is primarily based on the National Acute Spinal Cord Injury
Studies (NASCIS) II and III. Some of the claims of the studies have been
challenged as being from faulty interpretation of the data.

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B. HEAD INJURY

DEFINITION
Head injury is a trauma to the head, that may or may not include injury to
the brain (see also brain injury). However, 'brain injury' and 'head injury' are often
used interchangeably in the medical literature.
The incidence (number of new cases) of head injury is 300 per 100,000 per year
(0.3% of the population), with a mortality of 25 per 100,000 in North America and 9
per 100,000 in Britain. Head trauma is a common cause of childhood
hospitalization.

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SYMPTOMS
Leaking cerebrospinal fluid (a clear fluid drainage from nose, mouth or
ear) may be and is strongly indicative of basilar skull fracture and the
tearing of sheaths surrounding the brain, which can lead to secondary
brain infection.
•Visible deformity or depression in the head or face; for example a
sunken eye can indicate a maxillar fracture
•An eye that cannot move or is deviated to one side can indicate that a
broken facial bone is pinching a nerve that innervates eye muscles
•Wounds or bruises on the scalp or face.
•Basilar skull fractures, those that occur at the base of the skull, are
associated with Battle's sign, a subcutaneous bleed over the mastoid,
hemotympanum, and cerebrospinal fluid rhinorrhea and otorrhea.

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MEDICAL/SURGICAL MANAGEMENT

Unfortunately, once the brain has been damaged by trauma, there is no

quick fix. However, there are some steps that can be taken to prevent secondary
damage. If left untreated many patients with head injury will rapidly develop
complications which may lead to death or permanent disability. Prompt medical
treatment may prevent the worsening of symptoms and lead to a better outcome.
Medical treatment should begin at the scene of the trauma. Paramedics will
generally immobilize the patient to ensure no further damage to the spine or
nervous system, insert an airway to ensure uninterrupted breathing and perform
endotracheal intubation if indicated. One or more IVs will be inserted to maintain
perfusion status.

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In some cases medications may be administered to sedate or paralyze the

patient to prevent additional movement which may worsen the brain injury. The
patient should be delivered promptly to a hospital with neurosurgical capabilities.
The management of brain injury requires the involvement of subspecialists who
are generally available only at larger hospitals. Primary treatment involves
controlling elevated intracranial pressure. This can include sedation, paralytics,
cerebrospinal fluid diversion. Second line alternatives include decompressive
craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in
pediatric patients), barbiturate coma, hypertonic saline and hypothermia.
Although all of these methods have potential benefits, there has been no
randomized study that has shown unequivocal benefit.

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CEREBRAL VASCULAR DISEASE

DEFINITION
It is an umbrella term that refers to any functional abnormality of the CNS that
occurs when the normal blood supply to the brain is disrupted.

MODIFIABLE RISK FACTORS INCLUDES

hypertension
cardiovascular disease
High cholesterol
obesity
elevated hematocrit
diabetes mellitus
Oral contraceptive use
smoking
Drug abuse
excessive alcohol consumption

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TWO MAJOR CATEGORIES

• Ischemic - vascular occlusion and significant hypoperfusion occur
• Hemorrhagic - there is extravasion of blood in the brain.

CLASSIFIED USING THE TIME COURSE IN THE FOLLOWING MANNER

• Transient ischemic attack (TIA) - temporary episode of neurologic
dysfunction manifested by a sudden loss of motor, sensory or visual
function.
• Reversible ischemic neurologic deficit - signs and symptoms are consistent
with but more pronounced than a TIA and last more then 24 hours.
• Stroke in evolution - worsening of neurologic signs and symptoms over
several minutes or hours.
• Complete stroke - stabilization of the neurologic signs and symptoms.

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CLINICAL FINDING OF CVD

1. Subjective:
syncope
Headache
changes in level of consciousness
transient paresthesias (with TIAs)
mood swings
2. Objective:
Convulsions
Hemiplegia
aphasia
3. Expressive (motor or broca’s)aphasia
4. Receptive (sensory or wernike’s)aphasia

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5. Global aphasia
CSF is bloody if cerebral or subarachnoid hemorrhage
is present
Abnormal EEG, CT scan ,MRI
Cerebral angiography may reveal vascular abnormalities such as
aneurysms, narrowing or occlusions.
Signs of increased intracranial pressure
Dysphagia
Sensory changes:hemianopia
Alterations in reflexes
Altered bladder and bowel function

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SURGICAL INTERVENTIONS
• To relieved pressure control bleeding if hemorrhage is present.
• Carotid endarterectomy to improve cerebral blood flow when
carotid arteries are narrowed by arteriosclerotic

THERAPUETIC INTERVENTIONS FOR CVD:

• Complete bed rest with sedation as needed.
• maintenance of oxygenation by oxygen therapy or mechanical
ventilation
• Maintenance of nutrition by parenteral route or nasogastric
feedings if the client is unable to swallow.
• Anticoagulant therapy if thrombus or embolus is present; anti
platelet therapy.
• Antihypertensives and anticonvulsants if indicated.
• Glucocorticoids may be used to reduce cerebral edema and
intracranial pressure.

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