0. IICP (Increased Intracranial Pressure)
|• Increased ICP can impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death.
• Increased ICP may be caused by trauma, hemorrhage, growths or tumors, hydrocephalus, edema, or inflammation.
|• altered LOC, which is the most sensitive and earliest indication of IICP
• pupil change
• changes in motor function from weakness to hemiplegia, a positive Babinski reflex, decorticate or decerebrate posturing, seizure
• elevated temperature,
slowing of the pulse,
the rise in BP with widening pulse pressure
|• Monitor respiratory status and prevent hypoxia. Maintain mechanical ventilation as prescribed; maintaining the PaCO2 at 30 to 35 mmHg will result in vasoconstriction of the cerebral blood vessels, decreased blood flow, and therefore decreased ICP. Increased CO2 levels increase cerebral edema.
• Bed rest is needed. For the client with IICP, elevate the head of the bed 30 to 40 degrees, avoid the Trendelenburg position, and prevent flexion of the neck and hip to reduce venous pressure. Position the client so that the head is maintained midline to avoid jugular vein compression, which can increase ICP.
• Monitor vital signs.
• Monitor neurological status. Monitor for decreased responsiveness to pain (a significant sign of altered LOC).
• Assess wounds and dressings for the presence of drainage and monitor for the nose or ear drainage.
• Maintain body temperature. Prevent shivering, which can increase ICP.
• Monitor for pain and restlessness.
• Monitor intake and output. Limit fluid intake to 1200mL/day. Monitor prescribed intravenous fluids carefully to avoid increasing any cerebral edema and to minimize the possibility of overhydration.
• Monitor electrolyte levels and acid-base balance.
• Decrease in environmental stimuli. Instruct the client to avoid straining activities, such as coughing and sneezing. Instruct the client to avoid Valsalva’s maneuver. Keep stimuli to a minimum.
• Avoid the administration of morphine sulfate to prevent the occurrence of hypoxia. Withhold sedating medications during the acute phase of the injury so that changes in LOC can be assessed.
• Initiate seizure precautions.
1. concussion and contusion
|• Concussion is a jarring of the brain within the skull, with no loss of consciousness.|
|• Contusion is a bruising type of injury to the brain tissue.|
|• Hematoma is a collection of blood in the tissues.||• assessment findings depend on the injury
• clinical manifestations usually result from IICP
• The LOC provides the earliest indication of an improvement or deterioration of the neurological condition.
• nausea, vomiting
• headache, visual disturbances
• CSF drainage from the ears or nose
• nuchal rigidity: not tested until spinal cord injury is ruled out
|• care for the client with IICP
• Do not attempt to clean the nose, suction, or allow the client to blow his or her nose if drainage occurs. Avoid suctioning through the nares because of the possibility of the catheter entering the brain through a fracture.
• Do not clean the ear if drainage is noted but apply a loose, dry sterile dressing. Notify the HCP if drainage from the ears or nose is noted and if the drainage tests positive for CSF.
1) EDH (EpiDural Hematoma)
|• Epidural hematoma forms between the dura and skull from a tear in the meningeal artery. The most serious type of hematoma forms rapidly and results from arterial bleeding.||• surgical emergency
• Administer medications.
(단, Mannitol은 뇌 용적 감소로 출혈이 증가할 수 있으므로 뇌간이 눌릴 정도가 아니라면 쓰지 않음)
2) SDH (SubDural hematoma)
|• Subdural hematoma occurs under the dura as a result of tears in the veins crossing the subdural space. Subdural hematoma forms slowly and results from a venous bleed.||• surgery for emergent decompression
• Administer medications. The patient’s BP should be maintained at normal or high levels using isotonic saline or pressor to prevent hypoxia. Mannitol IV bolus for preventing IICP. Administer anticonvulsants. (Do not give steroids.)
• Insert a Foley catheter as prescribed.
3) SAH (SubArachnoid Hemorrhage)
|• A subarachnoid hemorrhage is bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously, such as from a ruptured cerebral aneurysm.||• clipping or coiling
• Administer medications. Administer antihypertensive agents such as CCB (Nimodipine). Administer Mannitol. Administer anticonvulsants.
• Insert a Foley catheter as prescribed.
4) ICH (IntraCerebral Hemorrhage)
|• Intracerebral hemorrhage occurs when a blood vessel within the brain ruptures allowing blood to leak inside the brain.||• craniotomy (evacuation)
• Administer medications. Administer antihypertensive agents such as CCB. Administer Mannitol. Administer anticonvulsants.
• Insert a Foley catheter as prescribed.
3. skull fractures
|• types of skull fractures: linear, depressed, compound, comminuted|
4. SCI (Spinal Cord Injury)
|• Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons. The injury can involve contusion, laceration, or compression of the cord. Spinal cord edema develops; necrosis of the spinal cord can develop as a result of compromised capillary circulation and venous return. Loss of motor function, sensation, reflex activity, and bowel and bladder control may result.
• The most common causes include motor vehicle accidents, falls, sporting, and industrial accidents, and gunshot or stab wounds.
|• dependent on the level of the cord injury||• Emergency management is critical because the improper movement can cause further damage and loss of neurological function.
• Always suspect spinal cord injury when trauma occurs until this injury is ruled out. Immobilize the client on a spinal backboard with the head in a neutral position to prevent an incomplete injury from becoming complete. Prevent head flexion, rotation, or extension. Maintain an extended position. During immobilization, maintain traction and alignment on the head by placing hands on both sides of the head by the ears. Logroll the client. No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position.
• Assess the respiratory pattern and maintain a patent airway.
• Assess neurological status. Assess motor and sensory status to determine the level of injury. Assess motor ability by testing the client’s ability to squeeze hands, spread the fingers, move the toes, and turn the feet. Assess the absence of sensation, hypo-sensation, or hyper-sensation by pinching the skin or pricking it with a pin, starting at the shoulders and working down the extremities. Prevent bowel retention. Prevent urinary retention.
• Assess psychosocial status. Promote rehabilitation with self-care measures, setting realistic goals based on the client’s potential functional level.
- conus medullaris syndrome: Conus medullaris syndrome follows damage to the lumbar nerve roots and conus medullaris in the spinal cord. Client experiences bowel and bladder areflexia and flaccid lower extremities.
- cauda equina syndrome: Cauda equina syndrome occurs from injury to the lumbosacral nerve roots below the conus medullaris. The client experiences areflexia of the bowel, bladder, and slower reflexes.
1) cervical injuries
|• Injury at C2 to C3 is usually fatal.
• C4 is the major innervation of the diaphragm by the phrenic nerve. Involvement above C4 causes respiratory difficulty and paralysis of all four extremities (tetraplegia).
• Client may have movement in the shoulder if the injury is at C5 through C8, and may also have decreased respiratory reserve.
|• Skeletal traction is used to stabilize fractures or dislocations of the cervical or upper thoracic spine. Two types of equipment used for cervical traction are skull tongs and halo traction.
• medications: dexamethasone (Decadron), Dextran, dantrolene (Dantrium)
- skull tongs: Skull tongs are inserted into the outer aspect of the client’s skull, and traction is applied. Weight are attached to the tongs, and the client is used as counteractions.
- halo traction: Halo traction is a static traction device that consists of a headpiece with four pins, two anterior and two posterior, inserted into the client’s skull. The metal halo ring may be attached to a vest or cast when the spine is stable, allowing increased client mobility.
- client education for a halo fixation device: Assess for tightness of the jacket by ensuring that one finger can be placed under the jacket. Assess the skin under the jacket. Notify a HCP if the halo vest or ring bolts loosen. Use fleece or foam inserts to relieve pressure points. Adapt clothing to fit over the halo device. A sponge bath or tube bath is allowed, however showers are prohibited. Clean pins with H2O2 daily. No lotion or powder under the vest. Do not use any products other than shampoo on the hair. When shampooing the hair, cover the vest with plastic. When getting out of bed, roll onto the side and push on the mattress with the arms (전체적으로 움직여야 함). Never use the metal frame for turning or lifting. Use a rolled towel or pillowcase between the back of the neck and bed or next to the cheek when lying on the side, and raise the head of the bed to increase sleep comfort. Eat foods high in protein and calcium to promote bone healing. No driving. No bending. No pulling. No holding.
2) thoracic injuries
|• Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury. Leg paralysis (paraplegia) may occur.
• Autonomic dysreflexia with lesions or injuries above T6 and in cervical lesions may occur.
• Visceral distention from noxious stimuli such as a distended bladder or impacted rectum may cause reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and goose flesh.
|• Bed rest. Immobilization with a body cast if prescribed. Use of a brace or corset when the client is out of bed.
• Assess for respiratory impairment and paralytic ileus, possible complications of the body cast.
• surgical interventions: decompressive laminectomy, spinal fusion
3) lumbar and sacral injuries
|• Loss of movement and sensation of the lower extremities may occur.
• S2 and S3 center on micturition. Therefore, below this level, the bladder will contract but not empty (neurogenic bladder).
• Injury above S2 in males allows them to have an erection, but they are unable to ejaculate because of sympathetic nerve damage.
• Injury between S2 and S4 damages the sympathetic and parasympathetic response, preventing erection or ejaculation.
5. complication of SCI
1) respiratory failure
|• Assess respiratory status because paralysis of the intercostal and abdominal muscles occurs with C4 injuries.
• Monitor ABG levels and maintain mechanical ventilation if prescribed to prevent respiratory arrest, especially with cervical injuries.
• Monitor for signs of infection, particularly pneumonia.
• Encourage deep breathing and the use of an incentive spirometer.
2) spinal shock
|• A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord’s response to the injury. It usually lasts less than 48 hours but can continue for several weeks.||• bradycardia, hypotension
• flaccid paralysis, loss of reflex activity below the level of the injury
• paralytic ileus, flaccid bladder
|• Provide supportive measures as prescribed, based on the presence of symptoms.|
3) neurogenic shock
|• Occurs most commonly in clients with injuries above T6 and usually is experienced a few days after the injury. Massive vasodilation occurs, leading to pooling of the blood in blood vessels, tissue hypoperfusion, and impaired cellular metabolism.||• bradycardia, hypotension|
4) autonomic dysreflexia (autonomic hyperreflexia)
|• Autonomic dysreflexia generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions. It is commonly caused by visceral distention from a distended bladder or an impacted rectum. It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke.||• severe hypertension, bradycardia
• sudden onset, severe throbbing headache
• dilated pupils or blurred vision
• flushing above the level of the injury, pale extremities below the level of the injury
• piloerection, diaphoresis
|• Immediately contact an HCP.
• Raise the head of the bed. Sit the client up in bed in a high Fowler’s position.
• Loosen tight clothing on the client.
• Check for bladder distention or other noxious stimuli. The nurse also should check for fecal impaction and disimpact the client, if necessary.
• Assess the environment to ensure that it is not too cool or too drafty.
• Monitor vital signs, particularly blood pressure, every 15 minutes.
• Administer antihypertensive medications.
• Document the occurrence, treatment, and response.
6. intervertebral disk (herniation)
|• The nucleus of the disk protrudes into the annulus, causing nerve compression.|
1) cervical disk herniation: occurs at the C5 to C6 and C6 to C7 interspaces.
|• pain radiation to shoulders, arms, hands, scapulae, and pectoral muscles
• paresthesia, numbness, weakness of the upper extremities
|• Conservative management is used unless the client develops signs of neurological deterioration.
• Bed rest is prescribed to decrease pressure, inflammation, and pain.
• Immobilize the cervical area with a cervical collar or brace. Maintain head and spine alignment. A cervical collar limits neck movement and holds the head in a neutral or slightly flexed position. Assist and instruct the client in the use of a cervical collar or cervical traction as prescribed. The cervical collar may be worn intermittently or 24 hours daily. Inspect the skin under the collar for irritation. When prescribed and after pain decreases, exercises are done to strengthen the muscles.
• Avoid flexing, extending, and rotating neck. Avoid the prone position and maintain neck, spine, and hips in a neutral position while sleeping. Minimize long periods of sitting.
• Apply heat to reduce muscle spasms and apply ice to reduce inflammation and swelling.
• Prepare the client for a corticosteroid injection into the epidural space if prescribed.
• disk surgery (discectomy, discectomy with fusion, laminectomy, laminotomy): Disk surgery is used when spinal cord compression is suspected, or the client’s symptoms do not respond to conservative treatment.
2) lumbar disk herniation: most often occurs at the L4 to L5 or L5 to S1 interspaces.
|• pain and muscle spasms in the lower back, with radiation of the pain into one hip and down the leg
Pain is relieved by bed rest and aggravated by movement, lifting, straining, and coughing.• muscle weakness, sensory deficits, and diminished tendon reflexes
|• Conservative management is indicated unless neurological deterioration or bowel and bladder dysfunction occur.
• Instruct the client to sleep on the side, with the knees and hips flexed, and place a pillow between the legs.
• Apply pelvic traction as prescribed to relieve muscle spasms and decrease pain. Instruct the client about application techniques for corsets or braces to maintain immobilization and proper spine alignment.
• Begin progressive ambulation as inflammation, edema, and pain subside.
• Apply heat to decrease muscle spasms and apply ice to decrease inflammation and swelling.
• Instruct the client about correct posture while sitting, standing, walking, and working. Instruct the client in the correct technique to use when lifting objects such as bending the knees, maintaining a straight back, and avoiding lifting objects above the elbow level. Instruct in a weight control program as prescribed. Instruct the client in an exercise program to strengthen back and abdominal muscles as prescribed.
• disk surgery: Disk surgery is used when spinal cord compression is suspected or the client’s symptoms do not respond to conservative treatment.
7. cerebral aneurysm
|• dilation of the walls of a weakened cerebral artery
• Aneurysm can lead to rupture.
|• headache, irritability
• diplopia, blurred vision
|• Monitor vital signs. Prevent hypertension.
• Maintain a patent airway, but suction only with an HCP’s prescription. Administer oxygen as prescribed.
• Maintain the client on bed rest in a semi-Fowler’s or a side-lying position. Maintain a darkened room without stimulation. Provide a quiet environment; a telephone in the room is not usually allowed. Reading, watching television, and listening to music are permitted, provided that they do not overstimulate the client. Limit visitors.
• Administer care gently, such as the bath, back rub, range of motion. Limit invasive procedures.
• Prevent any activities that initiate the Valsalva maneuver (straining at stool, coughing, taking temperatures via the rectum)
• Provide stool softeners to prevent straining. Provide pain control. Provide sedation. Administer prophylactic anticonvulsant medications.
• Maintain fluid restriction. Provide a diet as prescribed; avoid stimulants in the diet.
• Provide DVT prophylaxis as prescribed.
8. stroke (brain attack)
|• A stroke is a sudden focal neurological deficit caused by cerebrovascular disease. A stroke is a syndrome in which the cerebral circulation is interrupted, causing neurological deficits.
• TIA (Transient Ischemic Attack) may be a warning sign of an impending stroke.
|• A critical factor in the early intervention and treatment of stroke is the accurate identification of stroke manifestations and establishing the onset. Stroke screening scales (① smile but facial dropping, ② talk but dysarthria, ③ raise both arm but apraxia) may be used to quickly identify stroke manifestations.
• Findings depend on the area of the brain affected. Lesions in the cerebral hemisphere result in manifestations on the contralateral side, which is the side of the body opposite the stroke.
|• Maintain a patent airway and administer oxygen as prescribed.
• Monitor vital signs. Usually, a blood pressure of 150/100mmHg is maintaining to ensure cerebral perfusion.
• Monitor LOC, pupillary response, motor, and sensory response, cranial function, and reflexes.
• Monitor for IICP because the client is most at risk during the first 72 hours following the stroke. Suction secretions as prescribed, but never suction nasally or for longer than 10 seconds to prevent IICP.
• Position the client on the side, with the head of the bed elevated 15 to 30 degrees as prescribed.
• Maintain a quiet environment.
• Administer intravenous fluids as prescribed.
• Insert a Foley catheter as prescribed.
• Prepare to administer anticoagulants, antiplatelets, diuretics, antihypertensives, and anticonvulsants as prescribed.
|Rt brain damage (감각, 공간)
= Rt CVA
= Lt weakness
|Lt brain damage (논리, 언어, 수리)
= Lt CVA
= Rt weakness
• rapid performance
• short attention
• impulsive ⟹ safety 우선순위
• slowness, cautiousness
- intervention in the post-acute phase of a stroke: Continue with interventions from the acute phase. Position the client 2 hours on the unaffected side and 20 minutes on the affected side. Position the client in the prone position if prescribed for 30 minutes three times daily. Perform passive range-of-motion exercises to prevent contractures. Place anti-embolism stockings on the client and remove daily to check the skin. Measure thighs and calves daily for an increase in size. Provide skin, mouth, and eye care. Monitor the gag reflex and the ability to swallow. Provide sips of fluids and slowly advance diet to foods that are easy to chew and swallow. Provide soft and semi-soft foods and flavored, cool, or warm, thickened fluids rather than thin liquids because the stroke client can tolerate these types of food better. Speech therapists may do swallow studies to recommend the consistency of food and fluids. When the client is eating, position the client sitting in a chair, or sitting up in bed, with the head and neck positioned slightly forward and flexed. Place food in the back of the mouth on the unaffected side to prevent trapping of food in the affected cheek.
- interventions in the chronic phase of stroke: Encourage the client to express her or his feelings. Encourage independence in activities of daily living. Increase mobility as tolerated. Provide gait training. Teach transfer technique from bed to chair and from chair to bed. Assess the need for assistive devices such as a cane, walker, splint, or braces. Initiate physical and occupational therapy for assessment and the need for adaptive equipment or other supports for self-care and mobility. Encourage the client and family to contact available community resources.
|① dysphasia||• Provide repetitive directions. Repeat names of objects frequently used. Use a picture board, communication board, or computer technology. Allow time for the client to communicate. Break tasks down to one step at a time.
• Refer the client to a speech and language pathologist as prescribed.
• The client has blindness in half the visual field.
|• Encourage the client to turn the head to scan the complete range of vision. Otherwise, he or she does not see half of the visual field. Place the client’s personal objects within the visual field. Provide eye care for visual deficits. Approach from the unaffected side.
• Place a patch over the affected eye if the client has diplopia.
|③ neglect syndrome
• The client is unaware of the existence of his or her paralyzed side, which places the client at risk for injury.
|• Teach the client to touch as use both sides of the body.
• Approach the client from the unaffected side.
|• Seizures are abnormal, sudden, excessive discharge of electrical activity within the brain. Excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs.
• Epilepsy is a disorder characterized by chronic seizure activity and indicates brain or CNS irritation.
• Status epilepticus involves a rapid succession of epileptic spasms without intervals of consciousness.
|• aura: the sensation that warns the client of the impending seizure
• types of seizure,
occurrence before, during, and after the seizure
• loss of motor activity or bowel and bladder function, or LOC during the seizure.
• occurrences during the postictal state, such as headache, loss of consciousness, sleepiness, and impaired speech or thinking
|• Prevent injury during the seizure. If the client is standing or sitting, place the client on the floor with a side-lying position, and protect the head and body. Place a pillow or folded blanket under the child’s head. If no bedding is available, place your own hands under the child’s head or place the child’s head in your own lap. Do not restrain the client. Loosen restrictive clothing. Remove eyeglasses from the child if present. Raise side rails when the child is sleeping or resting. Place waterproof mattress or pad on bed or crib. Clear the area of any hazards or hard objects.
• Remain with the client.
• Provide privacy, if possible.
• Allow the seizure to proceed and end without interference.
• Support the ABCs; airway, breathing, and circulations.
• Ensure airway patency. Administer oxygen. Prepare to suction secretions. Turn the client to the side to allow secretions to drain while maintaining the airway. Do not force the jaws open or place anything in the client’s mouth. Never place anything, including an airway device or a padded tongue blade, into the mouth of the client experiencing a seizure.
• Administer intravenous medications as prescribed to stop the seizure.
• Note the time and duration of the seizure. Assess behavior at the onset of the seizure. If the client has experienced an aura, if a change in facial expression occurred, or if a sound or cray occurred from the client. Note the type, character, and progression of the movements during the seizure. Monitor behavior following the seizure, such as the state of consciousness, motor ability, and speech ability.
- client education: Instruct the client about the importance of lifelong medication and the need to follow up on the determination of medication blood levels. Instruct the client to avoid alcohol, excessive stress, fatigue, and stroke lights. Instruct the client in precautions to take during potentially hazardous activities. Instruct the client to use a protective helmet and padding when engaged in bicycle riding, skateboarding, and in-line skating. Instruct the client to swim with a companion. Encourage the client to contact available community resources.
1) generalized seizures
|① tonic-clonic||• It may begin with an aura. The tonic phase involves the stiffening or rigidity of the muscles of the arms and legs and usually lasts 10 to 20 seconds, followed by LOC. The clonic phase consists of hyperventilation and jerking of the extremities and usually lasts about 30 seconds. Full recovery from the seizure may take several hours.|
|② myoclonic||• Myoclonic seizures present as a brief generalized jerking or stiffening or extremities. The victim may fall to the ground from the seizure.|
|③ atonic or akinetic||• Atonic seizure is a sudden momentary loss of muscle tone. The victim may fall to the ground as a result of the seizure.|
|④ absence||• A brief seizure that lasts seconds, and the individual may or may not LOC. No loss or change in muscle tone occurs. The victim appears to be daydreaming. Seizures may occur several times during the day.
• This type of seizure is more common in children.
2) partial seizures
|① simple partial||• The client may report an aura. The simple partial seizure produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area. The client remains conscious.|
|② complex partial||• The complex partial seizure is a psychomotor seizure. The area of the brain most usually involved in the temporal lobe. The seizure is characterized by periods of altered behavior of which the client is not aware. The client loses consciousness for a few seconds.|
|• Encephalitis is an inflammation of the brain parenchyma and often of the meninges.||• fever
• nausea, vomiting
• changes in the level of consciousness and mental status
• nuchal rigidity
• positive Kernig’s sign or
positive Brudzinski’s sign
|• Monitor vital signs and neurological signs.
• Assist the client to turn, cough and deep breathe frequently.
• Elevate the head of the bed 30 to 45 degrees.
• Prevent stimulation and restrict visitors.
• Administer acyclovir (Zovirax) as prescribed.
• Initiate rehabilitation as needed for motor dysfunction or neurological deficits.
|• Meningitis is inflammation of the arachnoid and pia mater of the brain and spinal cord.
• Transmission occurs in areas of high population density, crowded living areas such as college dormitories, and prisons. (Transmission of meningitis is by direct contact, including droplet spread.) Meningococcal meningitis can be transmitted by droplets from nasopharyngeal secretions.
• positive Kernig’s sign: inability to extend the leg when the thigh is flexed anteriorly at the hip
• positive Brudzinski’s sign: neck flexion causes adduction and flexion movements of the lower extremities
• CSF, obtained by lumbar puncture, is analyzed to determine the diagnosis and type of meningitis. In meningitis, CSF is cloudy, with increased protein, increased WBC, and decreased glucose counts.
• nuchal rigidity, photophobia
• IICP의 증상으로써 Babinski reflex (+)
|• Maintain isolation precautions as necessary with bacterial meningitis. Maintain respiratory isolation for the client with pneumococcal meningitis. (droplet precaution)
• Administer antibiotics as prescribed.
1) bacterial meningitis
|• Bacterial meningitis can be caused by various organisms, most commonly Haemophilus influenza type b (Hib), group B streptococcal, meningococcal, Streptococcus pneumonia, or Neisseria meningitis.
• most common & acute complication: hydrocephalus
|• drop precaution|
2) viral meningitis
|• Viral meningitis is associated with viruses such as mumps, paramyxovirus, herpesvirus, and enterovirus.|
12. West Nile virus infection
|• West Nile virus infection is a potentially serious illness that affects the CNS.
• 아동보다 성인에게서 흔함.
|• Many individuals will not experience any symptoms. 뇌염 증상
• fever, headache, nausea
• a rash on the chest, stomach, or back
• neck stiffness, disorientation, paralysis, seizures, or coma
|• Interventions are supportive. ex) IICP 낮추기
• prevention: Stay indoors at dusk and dawn when mosquitoes are most active. Use insect repellents when outdoors and wear long sleeves and pants and light-colored clothing. Ensure that mosquito breeding sites are eliminated, such as standing water and water in birdbaths, and keep wading pools empty and on their sides when not in use.
13. Guillain-Barre syndrome
|• Guillain-Barre syndrome is an acute infectious neuronitis of the cranial and peripheral nerves. The immune system overreacts to the infection and destroys the myelin sheath.
• The syndrome usually is preceded by a mild upper respiratory infection or gastroenteritis.
the weakness of lower extremities, gradual progressive weakness of the upper extremities and facial muscles
• possible progression to respiratory failure (major concern),
• The recovery is a slow process and can take years.
|• Monitor respiratory status closely.
• Monitor cardiac status.
• Care is directed toward the treatment of symptoms, including pain management.
14. MG (Myasthenia Gravis)
|• Myasthenia gravis is a neuromuscular disease. A defect in the transmission of nerve impulses at the myoneural junction occurs. (an autoimmune disease)
• Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase, and unresponsiveness of the muscle fibers to acetylcholine.
• Myasthenic crisis: Myasthenic crisis is an acute exacerbation of the disease. The crisis is caused by an inadequate amount of medication.
• Cholinergic crisis: Cholinergic crisis results in depolarization of the motor endplates. The crisis is caused by overmedication with anticholinesterase.
|• characterized by considerable weakness and abnormal fatigue of the voluntary muscles
• difficulty chewing and swallowing
• ptosis, diplopia
• weak and hoarse voice
• difficulty breathing,
• Tensilon test (edrophonium test): This test performed by the neurologist to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis. The client shows improvement in muscle strength after the administration of edrophonium. Edrophonium is administered and, if strength improves, the client needs more medication.
|• Monitor respiratory status.
• Monitor speech and swallowing abilities to prevent aspiration. Encourage the client to sit up when eating.
• Assess muscle status. Instruct the client to conserve strength. Plan short activities that coincide with times of maximal muscle strength.
• Instruct the client to avoid stress, infection, fatigue, and over-the-counter medications.
• Administer anticholinesterase medications as prescribed.
• Prepare to administer the antidote, atropine sulfate, if prescribed.
15. multiple sclerosis
|• Multiple sclerosis is a chronic, progressive, non-contagious, degenerative disease of the CNS characterized by demyelination of the neurons. (an autoimmune disorder)
• Precipitating factors include pregnancy, fatigue, stress, infection, and trauma.
• ataxia, tremor and spasticity of the lower extremities, loss of valance (운동 저하)
• bladder and bowel disturbances
• abnormal reflexes
• blurred vision
• 기억력 저하
|• Protect the client from injury by providing safety measures. Instruct the client in safety measures related to sensory loss, such as regulating the temperature of bathwater and avoiding heating pads. Instruct the client in safety measures related to motor loss, such as avoiding the use of scatter rugs and using assistive devices.
• Provide energy conservation measures during exacerbation. Assist the client to establish a regular exercise and rest program. Instruct the client to balance moderate activity with rest periods.
• Instruct the client to increase fluid intake and eat a balanced diet, including low-fat, high-fiber foods, and foods high in potassium.
• Encourage independence. Assist the need for and provide assistive devices. Initiate physical and speech therapy.
• Instruct the client to avoid stress, infection, fatigue, and over-the-counter medications.
• Instruct the client in the self-administration of prescribed medications.
• Place an eye patch on the eye for diplopia.
• Promote regular elimination by bladder and bowel training.
• 배우자와 성적 문제에 대해 상의한다.
16. ALS (Amyotrophic Lateral Sclerosis, Lou Gehrig’s disease)
|• It is a progressive degenerative disease involving the motor system. The sensory and autonomic systems are not involved, and mental status changes do not result from the disease. As the disease progresses, muscle weakness and atrophy develop until flaccid tetraplegia develops. Eventually, the respiratory muscles become affected, leading to respiratory compromise, pneumonia, and death.||• Care is directed toward the treatment of symptoms.
• Monitor respiratory status.
• Assess for complications of immobility.
• Address advance directives as appropriate.
• Provide the client and family with support.
17. trigeminal neuralgia
|• Trigeminal neuralgia is a sensory disorder of the trigeminal (fifth cranial) nerve.||• The client has severe pain on the lips, gums, or nose, or across the cheeks (along the trigeminal nerve). Situations that stimulate symptoms include cold, washing the face, chewing, or food or fluids, or extreme temperatures.||• Instruct the client to avoid hot or cold foods and fluids. Provide small feedings of liquid and soft foods. Instruct the client to chew food on the unaffected side.
• Administer medications as prescribed.
• surgical interventions
18. Bell’s palsy (facial paralysis)
|• Bell’s palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor.||• paralysis of one side of the face
• recovery usually occurs in a few weeks, without residual effects
|• Encourage facial exercises to prevent the loss of muscle tone.
• Promote the eyes from dryness and prevent injury.
• Promote frequent oral care.
• Instruct the client to chew on the unaffected side.
19. [Pediatric] cerebral palsy
|• Disorder characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system.||• alterations of muscle tone
• delayed developmental milestones
• feeding difficulties
• abnormal posturing
|• The goal of management is early recognition and interventions to maximize the child’s abilities.
• Encourage communication and interaction with the child on his or her developmental level, rather than chronological age level.
• Provide a safe environment by removing sharp objects, using a protective helmet if the child falls frequently, and implementing seizure precautions if necessary.
20. [Pediatric] hydrocephalus
|• an imbalance of CSF absorption or production caused by malformations, tumors, hemorrhage, infections, or trauma
• communicating / non-communicating
• head enlargement
|• The goal of surgical treatment is to prevent further CSF accumulation by bypassing the blockage and draining the fluid from the ventricles to a location where it may be reabsorbed.
( ventriculoperitoneal shunt / ventriculoatrial shunt)
→ Position the child on the unoperated side to prevent pressure on the shunt valve. Keep the child flat as prescribed to avoid the rapid reduction of intracranial fluid.
21. [Pediatric] Reye’s syndrome
|• Reye’s syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver.
• Administration of aspirin and aspirin-containing products is not recommended for children with a febrile illness or children with varicella or influenza because of its association with Reye’s syndrome.
|• history of systemic viral illness 4 to 7 days before the onset of symptoms
• progressive neurological deterioration
• signs of altered hepatic function such as lethargy
|• Monitor for altered LOC and signs of increased ICP.
• Monitor for signs of altering hepatic function and results of liver function studies.
• Provide rest and decrease stimulation in the environment.
22. [Pediatric] neural tube defects
|• This CNS defect results from the failure of the neural tube to close during embryonic development.
• spina bifida occulta, spina bifida cystica, meningocele, myelomeningocele
|• Protect the sac, as prescribed. Cover with a sterile, moist with normal saline, non-adherent dressing to maintain the moisture of the sac and contents. Change the dressing covering the sac on a regular schedule or whenever it becomes soiled because of the risk of infection. Diapering may be contraindicated until the defect has been repaired.
• Place in a prone position to minimize tension on the sac and the risk of trauma. The head is turned to one side for feeding.