Neuro

• Nervous system


  Enables the body to react to continuous changes in its internal and external environments, controls and integrates the various activities of the body, such as circulation and respiration
• Nervous system


  • Structurally into the central nervous system (CNS), consisting of the brain and spinal cord, and the peripheral nervous system (PNS), the remainder of the nervous system outside of the CNS
  • Functionally into the somatic nervous system (SNS) and the autonomic nervous system (ANS)
• The central nervous system is estimated to contain 80-100 billion neurons
• Motor part of the nervous system

  Controls the contraction of skeletal muscles, smooth muscle in internal organs, and secretion of active chemical substances by exocrine and endocrine glands
• Levels of the central nervous system that can control skeletal muscles

  • Spinal cord
  • Reticular substance of the medulla, pons, and mesencephalon
  • Basal ganglia
  • Cerebellum
  • Motor cortex
• Headache


  Common complaint that can occur for many different reasons
• Common primary headache syndromes


  • Migraine
  • Tension-type headache
  • Cluster headache
• Important secondary causes of headache to consider

  • Intracranial lesions
  • Head injury
  • Cervical spondylosis
  • Dental or ocular disease
  • Temporomandibular joint dysfunction
  • Sinusitis
  • Hypertension
  • Depression
  • A wide variety of general medical disorders
• Migraine


  Headache, usually pulsatile, lasting 4 – 72 hours, pain is typically unilateral, accompanied by nausea, vomiting, photophobia, and phonophobia, aggravated with routine physical activity, may be preceded by an aura of transient neurologic symptoms
• Migrainous headache


  • Lateralized throbbing headache that occurs episodically following its onset in adolescence or early adult life, may be lateralized or generalized, dull or throbbing, associated with anorexia, nausea, vomiting, photophobia, phonophobia, osmophobia, cognitive impairment, and blurring of vision, usually builds up gradually and lasts several hours or longer, focal disturbances of neurologic function (migraine aura) may precede or accompany the headaches
• Symptomatic therapy for migraine

  1. Rest in a quiet, darkened room until symptoms subside

  2. Take a simple analgesic (e.g. aspirin, acetaminophen, ibuprofen, or naproxen) immediately

  3. Limit use of simple analgesics to 15 days or less per month, and other medications to no more than 10 days per month
• Preventive therapy/nursing considerations for migraine


  1. Preventive treatment may be necessary if migraine headaches occur more frequently than two or three times a month or significantly disability is associated with attacks

  2. Avoidance of triggers and maintenance of homeostasis with regular sleep, meals, and hydration

  3. Use of a headache diary may be useful to identify triggers
• Tension-type headache


  The most common type of primary headache disorder, characterized by pericranial tenderness, poor concentration, and other nonspecific symptoms, headaches are often vise-like or tight in quality but not pulsatile, exacerbated by emotional stress, fatigue, noise, or glare, usually generalized, most intense about the neck or back of the head, not associated with focal neurologic symptoms
• Cluster headache


  Affects predominantly middle-aged men, pathophysiology may relate to activation of cells in the ipsilateral hypothalamus, triggering the trigeminal autonomic vascular system, often no family history of headache or migraine, episodes of severe unilateral periorbital pain occur daily for several weeks, accompanied by ipsilateral nasal congestion, rhinorrhea, lacrimation, redness of the eye, and Horner syndrome, patients are often restless and agitated, episodes typically occur at night, awaken the patient, and last between 15 minutes and 3 hours, spontaneous remission then occurs, and the patient remains well for weeks or months before another bout of closely spaced attacks
• Posttraumatic headache


  Variety of nonspecific symptoms may follow closed head injury, headache usually appears within a day or so following injury, may worsen over the ensuing weeks, and then gradually subsides, usually a constant dull ache, with superimposed throbbing that may be localized, lateralized, or generalized, sometimes accompanied by nausea, vomiting, and may respond to simple analgesics
• Transient ischemic attacks (TIAs)


  Focal neurologic deficit of acute onset that resolves completely within 24 hours, risk factors for vascular disease often present
• Transient ischemic attacks (TIAs)

  • Characterized by focal ischemic cerebral neurologic deficits that last for less than 24 hours (usually less than 1–2 hours), about 30% of patients with stroke have a history of TIAs and 5–10% of patients with TIAs will have a stroke within 90 days, the risk of stroke is high in the first 3 months after an attack, particularly in the first month and especially within the first 48 hours, symptoms or signs of weakness, speech impairment, or gait disturbance, carotid ischemic attacks are more liable than vertebrobasilar ischemic attacks to be followed by stroke
• Imaging for TIAs


  CT or MRI scan is indicated within 24 hours of symptom onset, in part to exclude the possibility of a small cerebral hemorrhage or a cerebral tumor masquerading as a TIA
• Treatment for TIAs


  Medical treatment is aimed at preventing further attacks and stroke, treat diabetes mellitus, hematologic disorders, and hypertension, preferably with an ACE inhibitor or ARB, start atorvastatin 80 mg orally once daily if LDL greater than 100 mg/dL, add ezetimibe if necessary to lower LDL to less than 70 mg/dL, start an antiplatelet or anticoagulant as soon as imaging has established the absence
• Nursing interventions for TIAs

  Cigarette smoking should be stopped, cardiac sources of embolization should be treated appropriately, weight reduction and regular physical activity should be encouraged when appropriate, an antiplatelet or anticoagulant should be started as soon as imaging has established the absence
• Stroke


  Sudden onset of neurologic deficit of cerebrovascular origin, patient often has hypertension, diabetes mellitus, tobacco use, atrial fibrillation, or atherosclerosis, distinctive neurologic signs reflect the region of the brain involved
• Stroke


  • Onset is usually abrupt, and there may then be little progression except that due to brain swelling
• Imaging for stroke


  A CT scan of the head (without contrast) should be performed immediately, before the administration of aspirin or other antithrombotic agents, to exclude cerebral hemorrhage, CT is relatively insensitive to acute ischemic stroke within the first 6–12 hours, and subsequent MRI with diffusion-weighted sequences helps define the distribution and extent of infarction as well as exclude tumor or other differential considerations
• Treatment for stroke


  Management is first aimed at minimizing disability and the second at preventing recurrent stroke, a combination of thrombolysis and endovascular therapies is available to patients who present within 24 hours of stroke onset, determined by when the patient was last normal, once hemorrhage has been excluded by CT, aspirin (325 mg orally daily) is started immediately unless the patient received thrombolysis, in which case aspirin is initiated after a follow-up CT has ruled out thrombolytic-associated hemorrhage at 24 hours, dual antiplatelet therapy should be used for 21 days in patients with minor stroke, anticoagulant medications are started when indicated
• Nursing interventions for stroke

  Physical therapy has an important role in the management of patients with impaired motor function, passive movements at an early stage will help prevent contractures, as cooperation increases and some recovery begins, active movements will improve strength and coordination, early mobilization and active rehabilitation are important, occupational therapy may improve morale and motor skills, speech therapy may help expressive aphasia or dysarthria, access to food and drink is typically restricted until an appropriate swallowing evaluation, the head of the bed should be kept elevated to prevent aspiration