Editing Medical-Surgical Nursing (section)

== Neurologic Disorders ==

=== Increased Intracranial Pressure ===

The skull is a fixed space, so any increase in brain tissue, blood, or cerebrospinal fluid raises pressure. The earliest and most sensitive sign of increased intracranial pressure is a change in level of consciousness, including restlessness, irritability, or confusion. Additional findings are headache, vomiting that may be projectile, pupillary changes with a sluggish or fixed and dilated pupil, and papilledema.

Cushing triad is a late and ominous sign of impending herniation: rising systolic blood pressure with a widening pulse pressure, bradycardia, and irregular respirations.

Nursing interventions: elevate the head of the bed about thirty degrees unless contraindicated, keep the head in neutral midline alignment to promote venous drainage, avoid hip flexion and neck flexion, prevent Valsalva by treating constipation and avoiding straining, cluster care to limit stimulation, keep suctioning brief and preoxygenate, control fever and pain, and administer osmotic diuretics such as mannitol as ordered. Avoid hypotonic fluids.

=== Stroke ===

Ischemic stroke results from thrombosis or embolism and accounts for most strokes; hemorrhagic stroke results from rupture of a vessel, often from hypertension or aneurysm. Findings include sudden unilateral weakness or numbness, facial droop, speech difficulty, vision loss, and sudden severe headache, which is more characteristic of hemorrhage. A subarachnoid hemorrhage classically presents as the worst headache of the patient's life with nuchal rigidity.

The first diagnostic priority is a noncontrast computed tomography scan to distinguish ischemic from hemorrhagic stroke, because thrombolytic therapy is life-saving in one and lethal in the other. Intravenous alteplase is given for eligible ischemic stroke patients generally within three hours and up to four and a half hours from the time the patient was last known well.

Left hemisphere stroke typically produces right-sided weakness, aphasia, and slow cautious behavior. Right hemisphere stroke typically produces left-sided weakness, unilateral neglect, impulsivity, and poor safety judgment.

Nursing application: keep the patient nothing by mouth until a swallow screen is passed, because aspiration pneumonia is a leading complication. When feeding is resumed, position upright at ninety degrees, use thickened liquids if prescribed, place food in the unaffected side of the mouth, and check for pocketing. Approach a patient with neglect from the unaffected side initially for safety, then teach scanning toward the neglected side.

=== Seizures ===

During a seizure, protect the patient rather than restrain the patient: stay with the patient, ease them to the floor or lower the bed, turn the head or body to the side to protect the airway, remove nearby objects, loosen restrictive clothing, pad the side rails, and time the event. Never insert anything into the mouth and never restrain limbs. Afterward assess airway, vital signs, neurologic status, and injuries, and allow the patient to rest through the postictal period.

Status epilepticus is continuous or repeated seizure activity without recovery and is a medical emergency treated with airway support, oxygen, and intravenous benzodiazepines followed by a longer-acting anticonvulsant.

Phenytoin teaching includes meticulous oral hygiene because of gingival hyperplasia, avoiding abrupt discontinuation, and awareness of numerous drug interactions. Phenytoin is mixed only with normal saline, never with dextrose solutions, which cause precipitation.

=== Neuromuscular and Degenerative Disorders ===

Myasthenia gravis is an autoimmune attack on acetylcholine receptors, producing descending weakness that worsens with activity and improves with rest, ptosis, diplopia, difficulty chewing and swallowing, and respiratory muscle weakness. Myasthenic crisis is undermedication or a trigger causing severe weakness and respiratory failure; cholinergic crisis is overmedication with anticholinesterase drugs and adds salivation, lacrimation, diarrhea, and muscle fasciculations. Both threaten the airway, so respiratory support is the immediate priority in either case.

Guillain-Barre syndrome produces ascending symmetric weakness and paralysis, often after a viral or gastrointestinal illness. The nursing priority is serial monitoring of respiratory status, particularly vital capacity and negative inspiratory force, because ascending paralysis can reach the diaphragm. Recovery is usually descending and gradual.

Multiple sclerosis is demyelination in the central nervous system producing variable fatigue, visual disturbance, weakness, spasticity, paresthesia, and bladder dysfunction with relapses and remissions. Teach avoidance of heat, which temporarily worsens symptoms, along with energy conservation and fall prevention.

Parkinson disease results from dopamine deficiency in the basal ganglia and produces resting tremor, cogwheel rigidity, bradykinesia, a shuffling festinating gait, masked facies, and postural instability. Teach the patient to consciously lift the feet, to use a wide stance, to allow extra time, and to eat soft, high-calorie foods safely.

=== Spinal Cord Injury ===

Immediately after injury, spinal shock produces flaccid paralysis, loss of reflexes, and loss of sensation below the level of injury. Injuries at or above C4 threaten diaphragm function and may require ventilatory support.

Nursing application: autonomic dysreflexia is an emergency in patients with injury at or above the sixth thoracic vertebra. A noxious stimulus below the injury level, most commonly a distended bladder or impacted bowel, triggers severe hypertension with a pounding headache, bradycardia, flushing and sweating above the injury, and pallor and coolness below it. Act in this order: place the patient in a sitting position immediately to lower blood pressure, loosen constrictive clothing, then find and remove the stimulus by checking for kinked catheter tubing or bladder distention and then for impaction, and notify the provider. Untreated, it causes stroke, seizure, or death.