Summary

17.1 Intracranial Pressure Changes

• In neurology and neurosurgery, the Monro-Kellie doctrine establishes relationships among brain, blood, and cerebrospinal fluid (CSF) volumes within a skull’s rigid confines. Any increase or decrease in one of these components must be counterbalanced with an increase or decrease in one or both other components to maintain a stable intracranial pressure (ICP) in the brain.
• Increased intracranial pressure (IICP) is a serious clinical issue that requires rapid assessment and intervention.
• IICP may be caused by cerebral edema, displacement of brain tissue, impaired blood flow, trauma, or tumors.
• Decreased ICP, a less serious clinical issue (but still in need of treatment), may be due to dehydration, CSF leak, hemorrhage, or brain atrophy.
• Nursing interventions for both increased and decreased ICP include monitoring neurological status and vital sign changes, providing a quiet and calm environment, monitoring and maintaining fluid and electrolyte balance, managing headache pain, oxygenation and ventilation support, recognizing and notifying the provider of any worsening trends, and providing education and support to the patient and their family.
• Nursing care for patients with either increased or decreased ICP must be evaluated to determine efficacy. This is accomplished by using clinical judgment and reviewing nursing interventions to determine if they addressed the patient’s concerns.
• Medical therapies to address increased ICP focus on treating the underlying cause of ICP and may include medications, surgical interventions, and shunt systems.
• Medical therapies to address decreased ICP may include interventions, such as epidural blood patches, to stop fluid leaks in the brain as well as therapies, such as salt tablets, to address dehydration.

17.2 Acute Disorders of the Nervous System

• Brain tumors, Guillain-Barré syndrome (GBS), and meningitis are serious threats to neurological well-being that require prompt medical attention.
• Brain tumors, which are the uncontrolled proliferation of abnormal cells within the brain, may produce symptoms such as headaches, seizures, and neurological deficits.
• Brain tumors are typically diagnosed through imaging studies and tissue biopsies and can be benign or malignant. Treatments for brain tumors include surgery, radiation, and chemotherapy.
• Guillain-Barré syndrome is an autoimmune disorder that causes peripheral nerve inflammation and muscle weakness. Commonly caused by infections, GBS may present with ascending paralysis that can progress rapidly.
• GBS can be diagnosed with lumbar punctures, nerve conduction studies, and EMG. Treatment for GBS may include plasma exchange and immunoglobulin therapy. Nursing care goals are to alleviate symptoms, such as fatigue, numbness, or weakness, and help the patient return to normal peripheral nervous system function.
• Meningitis, which is inflammation of the meninges surrounding the brain and spinal cord, may produce symptoms, such as sudden-onset fever, severe headaches, neck stiffness, skin rashes, and petechiae.
• Meningitis can be diagnosed with blood tests, cerebrospinal fluid lumbar punctures, and CT or MRI imaging. Treatments for meningitis may include antibiotics, skin care, and anti-inflammatory medications. Adequate nursing care can alleviate symptoms and prevent long-term effects.

17.3 Chronic Disorders of the Nervous System

• Multiple sclerosis and myasthenia gravis are both chronic autoimmune neurological disorders.
• MS is caused by inflammation, demyelination, and neurodegeneration of the nerve cells.
• MG is caused by the body’s production of hyperreactive antibodies that block acetylcholine receptors on muscle fibers, prohibiting communication to the nerves.
• MS manifestations include muscle weakness, lack of coordination, vertigo, eyesight and hearing issues, balance issues, bladder and bowel dysfunction, and cognitive issues.
• MG manifestations include difficulty breathing, vision problems, difficulties with swallowing and speaking, facial movement difficulties, and weakness in voluntary muscles.
• MS treatments may include corticosteroids, plasmapheresis, injections, infusions, and oral treatments. Muscle relaxants, pain relievers, and physical therapy may also be useful.
• MG treatments may include corticosteroids and intravenous therapy. Surgery may be needed for patients with MG who have a thymus gland tumor.
• Patients with MG may face a life-threatening situation if their disease causes breathing difficulties. In these circumstances, patients will need immediate medical attention, which may include treatments such as inhaled bronchodilators and/or inhaled steroids, as well as a ventilator.
• Neither MS nor MG is curable, and patients must learn to cope with the disease. Some patients may need mental health support to do this.

17.4 Major Neurocognitive Disorder and Neurodegenerative Diseases

• MND is the decline in cognitive abilities, such as memory and reasoning, in a manner that disrupts patients’ daily lives.
• MND refers to a group of disorders characterized by neurological changes that make it more challenging for patients to continue routine activities.
• MND occurs when the brain’s neurons, or nerve cells, die after they become inactive and lose their connections to other brain cells.
• The symptoms of MND include cognitive problems, such as memory loss and confusion, as well as psychological issues, such as personality changes and feelings of paranoia.
• MND is diagnosed with a physical examination and diagnostic tests, such as lumbar punctures and PET scans. Cognitive and neurological tests that evaluate problem-solving skills, sensory responses, reflexes, and other cognitive abilities provide further evidence of MND.
• MND cannot be cured. But the condition can be managed with medications, such as cholinesterase inhibitors and memantine, as well as treatments, such as occupational therapy and mental health support.
• A neurodegenerative disease is an incurable chronic condition that damages the brain and central nervous system, causing problems with cognitive abilities as well as physical movement. Alzheimer disease, ALS, and Parkinson disease are some of the more common neurodegenerative diseases.
• Amyotrophic lateral sclerosis (ALS) is a disease of the central nervous system that affects the brain and spinal cord’s motor neurons, causing patients to lose control of their muscles.
• ALS typically begins with stiffness and weakness in the muscles that control the limbs, including the legs and arms, before spreading to muscles that control vital functions, such as breathing. The disease also affects cognitive abilities, changing a patient’s behavior and their ability to think.
• Alzheimer disease is a disorder in the brain that gradually destroys patients’ memory and thinking abilities. In addition to being a neurodegenerative disease, Alzheimer disease is the most common form of MND, accounting for at least 60 percent of MND cases.
• Typically, Alzheimer disease affects memory first before spreading to affect other brain functioning. The symptoms often experienced by patients with Alzheimer disease include personality changes, social withdrawal, moodiness, aggressive behavior, delusions, and depression.
• Parkinson disease is an incurable brain disorder that affects the nervous system, causing body parts controlled by nerves to have movements that are unintended and uncontrollable.
• Symptoms of Parkinson may include tremors, stiffness and contractions in muscles, bradykinesia, loss of balance and coordination, difficulty speaking and swallowing, loss of automatic movements such as blinking, constipation and urination issues, blood pressure irregularities, sleep disorders, fatigue, MND, and depression.
• For all patients who have Alzheimer disease, ALS, and Parkinson disease, the overall goal of nursing care is to help the patients manage the disease and improve their quality of life as much as possible.

17.5 Seizures

• A seizure occurs when some of the brain’s neurons experience sudden and uncontrolled electrical activity, sending incorrect messages between brain cells, causing the body to react with involuntary movements and behavior, as well as changes in consciousness and feelings.
• Seizures come in several types and have various causes. Some patients experience seizures because they have epilepsy, an incurable neurological disease that causes recurring seizures.
• Seizures can be triggered by a variety of factors, including high fever, brain tumors, strokes, head trauma, heart attacks, infections, diseases, alcoholism, stress, sleep deprivation, hormonal changes, dehydration, and certain medications.
• Seizures are categorized as either focal, which begin in one area of the brain, or generalized, which affect both sides of the brain at the same time.
• Focal seizures include onset awareness and onset impaired awareness.
• Generalized seizures include absence, atonic, clonic, myoclonic, tonic, and tonic-clonic.
• Seizures may have three phases, including prodrome, which occurs before the seizure actually begins and includes warning signals; ictal, which is the actual seizure; and postictal, which is the recovery period after a seizure ends.
• The symptoms of seizures vary and can be mild or severe. Common symptoms include confusion, staring, uncontrollable twitching or jerking of the arms and legs, body spasms, stiffened and/or weakened muscles, loss of awareness or consciousness, anxiety and fear, and a feeling of déjà vu.
• Nursing care for patients with seizures should focus on identifying the cause of the seizures and curing that cause, if possible, to stop the seizures. If the cause is a condition or disease that cannot be cured, such as epilepsy, nursing care should focus on controlling symptoms and helping patients and their families learn to live with and manage seizures.

17.6 Polyneuropathy

• Polyneuropathy is a peripheral nerve disorder that occurs when multiple peripheral nerves all over the body are damaged and malfunction simultaneously.
• Polyneuropathy can disrupt nerve communication in several ways. For example, lost nerve signals should occur but do not, whereas other nerve signals occur at inappropriate times, and still other signals occur when they should but deliver an error message.
• Polyneuropathy is a serious condition that can disrupt life and cause unpleasant symptoms, such as pain. But generally, polyneuropathy is not life-threatening.
• Polyneuropathy may be caused by health conditions such as infections or tumors, or by alcoholism, vitamin deficiencies, exposure to toxins, and peripheral nerve injuries. The most common cause is diabetes.
• Symptoms vary depending on whether polyneuropathy affects the motor, sensory, or autonomic nerves. Common symptoms include muscle weakness, uncontrolled twitching, loss of reflexes, numbness, feeling of pins and needles, burning sensations, heat intolerance, and gastrointestinal issues. Some patients also experience dizziness from drops in blood pressure and breathing difficulties if the muscles that control the lungs are affected.
• Polyneuropathy is assessed and diagnosed with a physical examination as well as tests, such as blood and urine tests, lumbar puncture, imaging tests, spirometry, EMG, and nerve conduction studies.
• Nursing care for patients with polyneuropathy focuses on identifying the cause of the patient’s condition. If patients cannot be cured of polyneuropathy, nursing care should focus on helping the patient understand polyneuropathy and learn how to control and manage the symptoms.

17.7 Chronic Pain Disorders

• Chronic pain refers to any type of pain, such as a headache or lower back pain, that is ongoing and continues for longer than three months.
• Migraines are a serious neurological disease with headache pain so severe that it disrupts routine activities.
• Migraines may be caused by factors including family genetics, stress, anxiety, tobacco, alcohol, foods such as cheese, low blood sugar, irregular sleep patterns, concussions, hormonal changes, and chemical imbalances in the brain.
• Migraines may progress through four stages—prodrome, aura, attack, and postdrome.
• Prodrome symptoms may include mood changes, food cravings, and uncontrollable yawning. Aura symptoms may include muscle weakness, loss of eyesight, and speaking difficulties. During the attack, the migraine headache may be accompanied by sensitivity to sound, light, touch, and/or smell, as well as nausea. In the postdrome stage, patients may experience exhaustion, confusion, and/or elation.
• Generally, migraines are incurable, but migraines can be treated, and nursing care can help patients learn techniques to prevent migraines and manage them when they do occur.
• Fibromyalgia is a chronic, incurable condition that affects soft tissues and muscles throughout the body, causing musculoskeletal pain and tenderness. It does not damage the body’s muscles or bones, but the pain can disrupt daily routines.
• The cause of fibromyalgia is unknown, but it has been linked to factors such as stress, sleep disorders, migraines, lupus, rheumatoid arthritis, osteoarthritis, chronic back pain, irritable bowel syndrome, anxiety, and depression, as well as endocrine, biochemical, and immune disorders.
• In addition to pain throughout the body, common symptoms of fibromyalgia include fatigue, headaches, restless legs, stiff joints, numbness, tingling, sensitivity to things such as touch and light, fibro fog, constipation, bladder disorders, and painful menstrual periods.
• Fibromyalgia generally is diagnosed with a physical examination and blood tests focused on ruling out other conditions and diseases that cause similar pain, such as rheumatoid arthritis.
• To have a fibromyalgia diagnosis, patients must experience ongoing pain for at least three months in at least four body areas, such as the jaw, neck, shoulders, arms, legs, back, chest, and buttocks.
• Nursing care for patients with fibromyalgia should focus on controlling symptoms and helping patients learn how to manage their condition.

17.8 Spinal Disorders

• Spinal disorders refer to diseases or injuries that affect the spinal cord and back.
• Low back pain refers to any feeling of aching, burning, or stabbing in the muscles of the lower back. When low back pain lasts longer than twelve weeks, it is considered a chronic condition.
• Common causes of low back pain include injuries, strains, and sprains, herniated disks, lumbar spinal stenosis, osteoarthritis, osteoporosis, axial spondyloarthritis, sciatica, scoliosis, and spondylolisthesis.
• Low back pain can be classified as acute, subacute, or chronic.
• Risk factors for low back pain include obesity, lack of exercise, using improper techniques for lifting, age, smoking, anxiety, depression, and arthritis.
• Symptoms of low back pain may include pain that comes and goes, decreased range of motion, difficulty standing straight, weakness in legs and/or feet, bowel and/or bladder issues, fever, and unexplained weight loss.
• Nursing care for patients with low back pain should focus on finding the cause of the pain and treating that cause with the goal of relieving the back pain. For patients with chronic back pain, nursing care should focus on helping patients control and manage the pain.
• Spinal tumors are growths of abnormal tissue inside or encompassing the spinal column or the spinal cord. Spinal tumors can be benign (noncancerous) as well as malignant (cancerous).
• When spinal tumors originate in the spine or the spinal cord, they are considered primary tumors. If they originate elsewhere in the body and spread to the spine, they are considered secondary, or metastatic, tumors.
• Factors that may create a risk for spinal tumors include defective genes, exposure to toxins, a compromised immune system, Von Hippel-Lindau disease, and neurofibromatosis 2.
• Symptoms of spinal tumors may include localized pain at the tumor site, low back pain, muscle weakness, stiff back or neck, difficulty walking, paralysis, loss of sensitivity, and loss of bladder and/or bowel functioning.
• Nursing care for patients with spinal tumors should focus on support when removing the tumor and curing the patient if possible. For benign tumors that cannot be removed, nursing care should focus on helping the patient learn to cope with the condition. For malignant tumors, nursing care should focus on treating the cancer and, if necessary, help the patient prepare for the end of life.

17.9 Neurological Injuries

• Traumatic brain and spinal cord injuries occur when the brain and/or spinal cord are damaged by trauma, typically in an accident.
• Traumatic brain and spinal cord injuries may cause temporary or long-term problems, depending on the nature and severity of the injury.
• Traumatic brain injuries may be penetrating, when the skull is pieced by a sharp object that enters brain tissue, or nonpenetrating, when the skull is not broken.
• The problems caused by traumatic brain injuries may include the inability to think, communicate, and/or struggle to move body parts.
• Primary traumatic brain injuries occur immediately, whereas secondary injuries occur gradually in response to reactive processes in the brain caused by the trauma. Secondary injuries may take days, or even weeks, to appear.
• Traumatic brain injuries can have physical, cognitive and behavioral, and/or perception and sensation symptoms. Typically, symptoms such as headache and confusion tend to occur immediately following a traumatic brain injury, whereas symptoms that involve moods and emotions may take longer to develop.
• Spinal cord injuries may be incomplete, with the spinal cord retaining some capability to communicate with the brain, or complete, with patients losing all functioning, muscle control, and feeling below the injured area.
• Symptoms of a spinal cord injury include the inability to move, pain and/or stinging sensations, muscle weakness, numbness and tingling, balance and coordination difficulties, spasms and/or exaggerated reflexes, loss of bladder and/or bowel control, decreased or lost sensations, and sexual dysfunction.
• Nursing care for traumatic brain and spinal cord injuries should focus on helping the patient recover, if possible. For patients with permanent health issues, nursing care should focus on helping the patient adjust and learn to manage the condition.