Page 2 Musculoskeletal/Neurological/Psychosocial Study Guide for the CCRN®
Ischemic strokes occur when blood flow to the brain (or a part of the brain) is obstructed or interrupted. When blood flow cannot reach the distal structures of the vessels, tissue death quickly occurs. Approximately 80% of strokes are due to ischemia. The other 20% are generally a result of hemorrhage.
Symptoms and Diagnosis
Ischemic strokes generally occur due to thrombus. Thrombus that occurs in large arteries is usually a result of atherosclerosis. The elderly are most at risk for a large thrombus ischemic stroke. Thrombosis that penetrates into smaller arteries, also known as lacunar infarct, are most common in patients with diabetes mellitus and hypertension. Another type of ischemic stroke may occur due to embolism that lodges in the brain after traveling through the arterial system. This type of stroke often happens without warning and can be fatal quickly. Occasionally, ischemic stroke occurs with an unidentified cause. This is known as cryptogenic.
Treatment of ischemic stroke must be initiated as quickly as possible to restore perfusion, or at least prevent progression of ischemia, to the distal areas of the blockage. Patients diagnosed with this condition should have tissue plasminogen activator (tPA, Activase®) initiated within 3 hours of symptom onset. This medication is used to dissolve fibrin clots and is given intravenously at a dose of 0.9 mg/kg up to 90 mg. Nurses should administer this medication by injecting 10% of the dose as an initial bolus. The rest of the dose should then be administered over the next 60 minutes.
Patients should also be placed on antihypertensive medications if their MAP exceeds 130 mmHg or systolic blood pressure exceeds 220. Osmotic diuretics such as mannitol, hypertonic saline, loop diuretics (generally Lasix®), and corticosteroids may be initiated to decrease cerebral edema and intracranial pressure. If the patient’s symptoms are due to embolism, aspirin and anticoagulation may be initiated.
Additional measures of care include cooling the patient to avoid hyperthermia and increased metabolic demand; treating hyperglycemia; and surgical intervention to manually remove the obstruction if all else fails. Nursing interventions during this time include reducing factors that may increase the patient’s ICP, such as maintaining a neutral head/body position, elevating the patient’s head to 30 degrees, reducing external stimulation, reducing pain, and closely monitoring the patient’s vital signs.
Neurologic Infectious Disease
Infectious disease, when involving the neurologic system, can have a series of devastating effects for the patient. Early identification of any suspected neurologic infection is imperative to best long-term outcomes. Neurologic infection can be from viral, bacterial, or fungal components. Neurologic involvement can also be secondary to an infection elsewhere in the body. The most common sources of neurologic infection are within the spinal cord and meninges surrounding the brain. Rarely, brain abscesses will form and present similarly to a space-occupying lesion, as described later in this guide.
When a patient has viral neurologic infectious disease, the patient often has symptoms due to effects such as inflammation or auto-immune activation that react because of the viral presence. Two of the more common conditions related to this event are Guillain-Barre՛ syndrome and transverse myelitis.
An autoimmune disorder, Guillain-Barre՛ syndrome generally occurs when a viral illness activates the attack of myelinated structures in the peripheral nervous system. This condition may also occur due to idiopathic causes. The autoimmune reaction to the nervous system causes both ascending and descending paralysis.
Symptoms of this condition include generalized numbness and tingling, increasing weakness of lower extremities, loss of deep tendon reflexes, and progressing loss of sensation leading to possible complete paralysis and inability to breathe. Patients may also lose the ability to move their eyes and experience facial weakness. Diagnosis may be made via lumbar puncture, electromyography, and nerve conduction studies.
Treatment for Guillain-Barre՛ is typically supportive. Patients should have their airways maintained with artificial ventilation as needed. Some evidence has shown shorter duration of symptoms when IVIG and plasma exchange are implemented. Overall prognosis of Guillain-Barre՛ is good. Most patients will start to regain function around 2-4 weeks after initial symptoms. Recovery involves intensive therapy services, as patients will be required to relearn and strengthen many motor skills.
Transverse myelitis is a condition when one or both sides of the spinal cord in one or more sections becomes inflamed and damages the myelin sheaths of the nerve cell fibers. This causes interruption of the nerve transmissions throughout the body. It can be due to viral, bacterial, myelin disorders, or immune responses to illness.
Symptoms of transverse myelitis include muscle weakness, paralysis, decreased sensation, pain, and bladder and bowel dysfunction. Symptoms may develop over the course of a few hours to few days. Usually, with aggressive rehabilitation and therapy, partial to all function is restored after the spinal cord swelling subsides. Diagnosis of transverse myelitis may be determined with MRI, lumbar puncture, and lab work.
Treatment of transverse myelitis includes supportive therapy, maintaining the patient’s airway, intravenous steroids, plasma exchange therapy, antiviral medication, immunosuppressants, and pain management. Patients will need extensive physical therapy, occupational therapy, and psychotherapy.
Bacterial infection of the nervous system is known as bacterial meningitis. Streptococcus pneumoniae and Neisseria meningitidis are two of the most common offenders in meningeal infection. Infection of the spinal cord or meninges can be from distal infection, surgical site wounds, invasive devices, nasal colonization, or invasive traumas. Bacteria then raise havoc in the nervous system by releasing toxins that cause inflammation, WBC accumulation, and exudate. The bacteria and their toxins may quickly cause brain cell damage if not treated.
Meningitis spreads quickly among the central nervous structures and causes headache, nuchal rigidity, decreasing level of consciousness, agitation, irritability, and seizures. Diagnosis is usually made via lumbar puncture, blood cultures, CT, and/or MRI.
Treatment of bacterial meningitis includes supportive therapy, IV antibiotics, corticosteroids, and pain management. Patients should be monitored closely for changes in neurologic status, signs of increased ICP (unequal pupils, coma, etc.), and hemodynamic instability. Mortality of this condition may reach up to 34%.
Fungal meningitis is a fungal infection of the meninges and surrounding nervous system structures. It is relatively uncommon and can only occur when a fungal organism enters the subarachnoid spaces or cerebrospinal fluid. Patients with immune deficiencies (HIV, cancer, autoimmune) are at highest risk of developing fungal meningitis. Patients with ventricular shunts are also at increased risk for fungal infection after shunt placement or revision.
The most common organisms that cause this type of fungal infection include Candida albicans and Cryptococcus neoformans. Candida albicans is seen more often in patients who have recently undergone spinal/spinal cord surgery, lumbar puncture, or brain surgery. Cryptococcus neoformans is usually seen in patients with HIV/AIDS.
Symptoms and Diagnosis
Symptoms of fungal meningitis are similar to bacterial meningitis symptoms. These include headache, stiff neck, photophobia, fever, nausea and vomiting, and mental changes. Diagnosis can be obtained with a culture of cerebrospinal fluid obtained by a lumbar puncture, blood cultures, and CT.
Treatment of fungal meningitis includes long-term antifungal medications such as amphotericin B, flucytosine, and fluconazole. Patients should be monitored closely for decline in respiratory function, increased ICP, and seizures. Anticonvulsants may also be administered to prevent seizure activity due to the inflamed and infected tissues.
Neurosurgery is a vast category of surgical interventions that can be performed on any part of the nervous system. Most commonly, neurosurgery involves surgical intervention of the skull, brain, and/or spinal column and cord.
Neurosurgery will likely be indicated in patients with head trauma or increased intracranial pressure due to infection or cerebral edema. Patients may need to undergo a craniotomy to decompress a swelling brain or a have a resection of a tumor that is disrupting the brain structures. Intracranial pressure may be monitored through a ventricular drain or transducer placed into the brain. Patients with hydrocephalus may require an internalized ventricular-peritoneal (VP) shunt.
Spinal injuries, and some congenital conditions, may result in spinal cord damage and scarring. Neurosurgery may be indicated to provide detethering of the cord to improve motor skills, gait, bowel and bladder continence, and flexibility.
Several nursing interventions are expected following a neurosurgical event. After brain surgery or placement of an ICP monitor, nurses should maintain neutral patient positioning with head of bed elevated between 30-45 degrees. After a lumbar puncture, patients will need to be on bed rest for several hours and have activity restrictions to prevent complications following the procedure. Patients should be monitored closely for infection.
Avoidance of increased stimulus can help to reduce increased cranial pressure. Administration of medications such as corticosteroids, anticoagulants, antibiotics, and antiepileptics may be indicated to reduce complications from the surgery or preceding event. Patient intake and output should be monitored closely. Frequent monitoring of arterial blood gasses, pulse oximetry, and lab work (CBC, electrolyte panels, etc.) would also be expected.
Seizure disorders are some of the most common neurologic conditions. Epilepsy can be diagnosed based on a patient’s history of seizure activity with supporting electroencephalogram (EEG) evidence. Several seizure types exist including generalized, partial, absence, atonic, myoclonic, tonic-clonic, and individually tonic and clonic seizures. Seizures may be congenital, infantile, or acquired. Patients with head trauma and severe illness with electrolyte imbalances are at high risk for seizure activity. Febrile seizures often occur in young childhood. Many seizures are preceded by an aura.
Treatment of seizures generally involves medications. Treatment must be individualized to each person. Medications are often added one at a time so that appropriate doses and management can be maintained. Some medications, such as phenobarbital, require close monitoring of drug levels to optimize therapeutic effects. Patients will also have rescue medications, which are additional, stronger antiepileptics that can be used in the event of breakthrough seizure activity. Barbiturates, such as rectal diazepam (Diastat®) and lorazepam (Ativan®), are most commonly administered in an epileptic emergency. Review the common epileptic medications and their effects for this exam.
Medication education regarding common side effects and possible interactions should be provided to patients. Antiepileptic medications may cause symptoms of allergic reactions, skin irritations, severe rash, and hepatotoxicity. Women of childbearing age should understand that most antiepileptic medications are teratogenic. Women may need to prove two types of birth control while on these medications.
Patients in the intensive care unit may be admitted due to breakthrough seizures or develop seizures due to their other conditions. Chronic seizure activity can cause permanent brain changes. Status epilepticus is a medical emergency. It is defined as a seizure lasting more than 30 minutes or two or more seizures without a break between them. This condition is dangerous and often deadly if not treated in a short period of time. Patients may need to be sedated and intubated in the event of uncontrollable status epilepticus.
Nursing interventions for patients with seizures should prioritize patient safety. Patients should have bed alarms notifying nurses of falls. Padding on side rails and flooring surrounding the patient’s bed may be necessary to prevent injury. If a patient begins to convulse, nurses should immediately place the patient on his or her side to prevent aspiration of oral secretions or vomitus. This allows for the protection of the patient’s airway as well. Nurses should note the exact time a seizure occurs and how long it lasts. Often seizures lasting greater than 5 minutes will need pharmacologic intervention.
Space-occupying lesions in the brain are most likely the result of a brain tumor. Brain tumors may be benign or malignant. Primary and secondary brain tumors exist. Primary brain tumors result when the lesion begins in the brain or brain stem. Secondary lesions are usually due to metastasis of other lesions in the body.
There are several types of brain tumors that occur in adults. These include: astrocytoma, glioblastoma, brain stem glioma, craniopharyngioma, meningioma, ganglioglioma, medulloblastoma, oligodendroglioma, and optic nerve glioma. The slow-growing tumors include astrocytoma, brain stem glioma, craniopharyngioma (congenital and recurrent), meningioma (most often in women ages 40-70), ganglioglioma (usually benign), oligodendroglioma (most often in ages 40-60), and optic nerve glioma (often occurs with neurofibromatosis type I, NFI). Tumors that are typically fast-growing tumors include glioblastoma (the most common malignant brain tumor, adults age 45-70), brain stem glioma, and medulloblastoma.
Diagnosis and Testing
Diagnosis for brain tumors is classically made with imaging, particularly CT or MRI. Patients will also have several lab tests run to determine the type of cancer and possible malignancies. CBC, tumor marker labs, and electrolyte panels are among the many tests that can be run in the event of suspected brain tumor.
Treatment of these space-occupying lesions involves a variety of measures. If possible, many tumors are resected or debulked to reduce the amount of space they occupy and to help treat the lesion. Chemotherapy, immunotherapy, and radiation are used to treat metastatic lesions to prevent or treat the spread of cancer cells.