NSG210 Hinkle Ch. 65: Management of Patients with Oncologic or Degenerative Neurologic Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 65, pp. 2112-2141 (textbooks/HINKLE_MS_CH65.pdf, also in textbooks/exam04/). Week 11 reading (Parkinson disease); Exam 4 content (the course calendars end Exam 3 content with the October 28 OB lecture). Numbering note: the syllabus lists “Ch. 66” (16th edition); this is Ch. 65 in the 15th edition (see nsg210-textbook-chapter-crosswalk). Craniotomy, transsphenoidal surgery, ICP, and seizure care are in nsg210-hinkle-ch61-neurologic-dysfunction.

Learning Outcomes

1. Describe brain and spinal cord tumors: classification, pathophysiology, manifestations, diagnosis, and management.
2. Use the nursing process for the patient with nervous system metastases or primary brain tumor.
3. Explain the pathophysiology of neurodegenerative disorders.
4. Apply the nursing process to the patient with Parkinson disease (PD) or the patient who has had a cervical discectomy.

Key Terms

• Bradykinesia: abnormally slow voluntary movement and speech
• Chorea: rapid, jerky, involuntary, purposeless movements of extremities or face, including grimacing
• Dementia: general decline in higher brain function with eventual loss of basic ADLs
• Dyskinesia: impaired ability to execute voluntary movements
• Dysphonia: voice impairment
• Neurodegenerative: deterioration of nervous system cells or function
• Papilledema: optic nerve edema, usually from increased ICP
• Paresthesia: numbness, tingling, “pins and needles”
• Sciatica: pain and tenderness along the sciatic nerve through thigh and leg
• Spondylosis: degenerative changes in a disc and adjacent vertebral bodies

I. Brain Tumors

A. Overview

• Effects from inflammation, compression, and infiltration: increased ICP and cerebral edema, focal signs, seizures, hydrocephalus, altered pituitary function. Death results from rising ICP impairing vital functions such as respiration.
• About 78,000 new cases per year (25,000 malignant, 53,000 nonmalignant); over 100 types.
• Primary tumors: arise from brain cells, most from glial cells and supratentorial in adults; rarely metastasize outside CNS; 5-year survival 33.4 percent.
• Only known modifiable risk factor: ionizing radiation. Genetic syndromes (neurofibromatosis) increase risk.
• Secondary (metastatic) tumors are twice as common as primary: from lung, breast, lower GI, pancreas, kidney, skin (melanoma).
• Peak incidence ages 50s-70s; slight male predominance for malignant tumors. About 70 percent are benign, but benign tumors in vital areas can still be serious.

B. Classification (Chart 65-1)

• Intracerebral: gliomas (astrocytoma grades I-II; glioblastoma grades III-IV; oligodendroglioma; ependymoma; medulloblastoma).
• Supporting structures: meningioma, neuromas (acoustic neuroma, schwannoma), pituitary adenoma.
• Developmental: angiomas, dermoid, epidermoid, teratoma, craniopharyngioma.
• Metastatic lesions.

C. Types

• Gliomas: most common intracerebral neoplasm; astrocytomas about 25 percent of symptomatic primary tumors; infiltrate surrounding tissue, so cannot be totally removed. Oligodendrogliomas (1.4 percent of gliomas; ages 50-60; more sensitive to chemotherapy). Ependymomas more common in children.
• Meningiomas: 37 percent of primary brain tumors; benign, encapsulated, slow growing; middle-aged; more common in women; near venous sinuses; symptoms from compression. Surgery preferred.
• Acoustic neuroma: 16 percent; CN VIII tumor; hearing loss, tinnitus, vertigo, staggering gait; later facial pain from CN V compression. Conservative management, surgery, or stereotactic radiotherapy.
• Pituitary adenomas: about 16 percent; more in older adults and women of childbearing age; rarely malignant.
  • Pressure effects: headache, visual dysfunction (optic chiasm), hypothalamic disorders (sleep, appetite, temperature, emotion), increased ICP, sella turcica erosion.
  • Hormonal (about 50 percent secrete): prolactin (women: amenorrhea, galactorrhea; men: impotence, hypogonadism); GH (acromegaly: enlarged hands and feet, facial distortion, nerve entrapment); ACTH (Cushing disease: central obesity, hypertension, purple striae, osteoporosis, hyperglycemia, emotional disorders).
• Older adults: early signs (personality change, confusion, speech or gait problems) may be mistaken for normal aging; frailty predicts longer stays and long-term care discharge.

D. Clinical Manifestations

• Increased ICP (Monro-Kellie): headache, nausea with or without vomiting, papilledema; personality changes; focal motor, sensory, cranial nerve deficits.
• Headache: early in one third; worst in early morning; worse with coughing, straining, sudden movement; becomes bifrontal or bioccipital as edema increases.
• Vomiting: seldom related to food; from vagal center irritation; may be projectile; may relieve headache.
• Visual: papilledema, diplopia, hemianopsia, blindness.
• Seizures: common; greatest risk with frontal, parietal, temporal tumors; unusual with brainstem or cerebellar tumors. Best evidence drugs: levetiracetam, carbamazepine, phenytoin, zonisamide.
• Localizing signs:
  • Frontal (motor cortex): contralateral hemiparesis and partial seizures; emotional and behavior change, apathy, impulsiveness, inappropriate speech and behavior.
  • Parietal: decreased contralateral sensation, generalized seizures.
  • Temporal: seizures, psychological disorders.
  • Occipital: contralateral homonymous hemianopsia, visual hallucinations.
  • Cerebellar: dizziness, ataxic staggering gait with falls toward the lesion side, incoordination, horizontal nystagmus.
  • Cerebellopontine angle (acoustic nerve sheath): tinnitus and vertigo, then progressive nerve deafness (CN VIII); facial and tongue numbness (CN V); then facial weakness (CN VII); then motor abnormalities.
  • Brainstem: cranial nerve deficits with complex motor and sensory impairment.

E. Diagnosis

• History and time course; neuro exam.
• Contrast CT (number, size, density, edema). MRI most helpful (small lesions, brainstem, pituitary); also monitors treatment.
• Computer-assisted stereotactic biopsy for deep tumors; brain mapping.
• PET: low-grade tumors hypometabolic, high-grade hypermetabolic. EEG for temporal lobe seizures. CSF cytology.

F. Medical and Surgical Management

• Surgery, chemotherapy, external beam radiation, alone or combined. Tumor-treating fields (worn on head) for glioblastoma; side effect skin irritation.
• Secreting tumors: hormone-suppressing drugs; hormone replacement if pituitary function lost.
• Surgery: remove as much tumor as possible without increasing deficit; craniotomy for meningiomas, acoustic neuromas, cerebellar cystic astrocytomas, colloid cysts; malignant glioma cannot be cured (resection relieves ICP, removes necrotic tissue, reduces bulk). Most pituitary adenomas: transsphenoidal removal.
• Radiation: cornerstone; external beam fractions; brachytherapy; stereotactic radiosurgery (linear accelerator or gamma knife) for deep tumors in a single session, no incision, but delayed effect and radiation necrosis risk.
• Chemotherapy: blood-brain barrier is the main challenge. Malignant glioma: temozolomide (oral, crosses BBB) for 6 weeks with radiation, then 6 to 12 months; low-grade glioma 6 months alone. Autologous bone marrow transplant to rescue from high-dose therapy.
• Medications: dexamethasone (reduces edema; relieves headache and LOC changes); mannitol or hypertonic saline (decrease ICP); anticonvulsants.

G. Nursing Management

• Assess headache; upright positioning and analgesics.
• Teach seizure possibility and adherence to prophylactic anticonvulsants.
• Aspiration risk from cranial nerve dysfunction: check gag and swallow; direct food to unaffected side, sit upright, semisoft diet, suction available; antiemetics.
• Neuro checks, VS, space interventions to avoid ICP spikes, reorient.
• Corticosteroids: monitor for hyperglycemia, electrolyte abnormalities, muscle weakness.
• Cognitive changes: reorientation, orienting objects, supervised self-care, injury prevention. Seizure precautions. Motor deficits: PT/OT. Protect numb areas. Alternative communication. Fatigue: conserve energy. Include caregivers.

II. Cerebral Metastases

• More common than primary brain tumors; 2-year survival under 10 percent.
• Headache, gait disturbance, visual impairment, personality change, memory loss and confusion, focal weakness, paralysis, aphasia, seizures. Leptomeningeal metastases: headache, isolated cranial nerve deficits.
• Treatment is palliative: whole brain radiation (foundation) for multiple metastases; stereotactic radiosurgery for up to three sites; surgery for a single symptomatic lesion; chemotherapy that crosses BBB; intrathecal chemotherapy.
• Pain: stepped analgesics; epidural or subarachnoid morphine for severe pain.

Nursing Process: Nervous System Metastases or Primary Brain Tumor

• Assess baseline neuro function, distressing symptoms (pain, respiratory, bowel, bladder, sleep, skin, fluids, temperature), nutrition (cachexia, anorexia-cachexia syndrome; dietary history, BMI, labs), family impact.
• Diagnoses: self-care deficits; impaired nutrition (cachexia or increased intake with steroids); anxiety; interrupted family processes. Complications: seizures, headaches.
• Self-care: independence as long as possible; plan each day; exercise program; eventually home or hospice.
• Nutrition: manage nausea, pain, dyspnea; meals when rested; clean, comfortable, pain-free, pleasant setting; oral hygiene before meals; remove offensive odors; daily weights and calorie counts; supplements; preferred foods; tube feeding or parenteral nutrition only if consistent with end-of-life wishes; do not overemphasize eating. Steroids increase appetite: monitor weight and glucose.
• Anxiety: patient may be restless, depressed, euphoric, paranoid; allow control; spend time; touch; reassure they will not be abandoned; refer to spiritual advisor, social worker, mental health.
• Family: reassurance about care; home health, hospice; caregiver education and resources.
• Discuss hospice early, not when death is imminent.

III. Spinal Cord Tumors

• Intramedullary (within cord: astrocytoma, ependymoma), extramedullary-intradural (meningioma), extramedullary-extradural (outside dura; usually metastatic, far more common).
• Symptoms: localized or shooting pain, weakness, loss of reflexes below tumor, progressive motor loss and paralysis; sharp pain in the region’s root distribution; sensory deficits below lesion; loss of bowel and bladder function.
• MRI is most sensitive (epidural cord compression, metastases).
• Surgery primary treatment, then chemo and radiation.
• Extramedullary-extradural cord compression: 5 to 7 percent of cancer deaths; neurologic emergency. Metastatic compression (breast, prostate, lung): high-dose dexamethasone plus radiation.
• Sudden decrease or loss of motor, sensory, bowel, or bladder function: emergent surgery.
• Preop nursing: assess weakness, wasting, spasticity, sensory change, bowel and bladder, respiratory status (cervical tumor); coagulation and anticoagulant history; teach breathing exercises and pain plan.
• Postop: frequent VS and neuro checks of extremities; sudden new deficit is ominous (cord ischemia or infarction); sensory level by pinching arms, legs, trunk.
• Pain: pain is the hallmark of spinal metastasis; give adequate doses on schedule.
• Position: bed flat initially; logroll (shoulders and hips aligned); side-lying most comfortable; pillow between knees.
• Complications: cervical tumor: respiratory compromise from edema (asymmetric chest movement, abdominal breathing); ET tube stays until respiratory function adequate. Bladder scan for retention; incontinence signals cord decompensation; bowel sounds; dressing staining or incision bulging = CSF leak (pseudomeningocele).
• Teaching: avoid temperature extremes and heating devices (sensory loss); daily skin checks; ADL training and assistive devices.

IV. Parkinson Disease

A. Overview and Pathophysiology

• Slowly progressive movement disorder; more men than women; symptoms usually first in the 50s (as early as 30).
• Idiopathic most common; secondary form has a known cause. Multifactorial (age, environment, heredity); 15 percent of early cases linked to genetic mutations.
• Degeneration of dopamine-storing cells in the substantia nigra (basal ganglia); less dopamine (inhibitory) relative to acetylcholine (excitatory) in the corpus striatum, so voluntary movement is impaired. Extrapyramidal tracts affected; pyramidal tracts spared.
• Symptoms appear only after 60 percent of pigmented neurons are lost and striatal dopamine falls 80 percent.

B. Clinical Manifestations

• Cardinal signs: tremor, rigidity, bradykinesia/akinesia, postural instability. Subtypes: tremor dominant and non-tremor dominant (akinetic-rigid, postural instability).
• Tremor: slow, unilateral, resting tremor; disappears with purposeful movement and sleep; pill-rolling; pronation-supination of forearm.
• Rigidity: resistance to passive movement; lead-pipe or cogwheel; early shoulder pain.
• Bradykinesia: slowing of movement; difficulty initiating (rising from chair, turning in bed).
• Postural instability: head bent forward, flexed posture, propulsive and shuffling gait, trouble pivoting, propulsion or retropulsion; high fall risk.
• Autonomic: excessive sweating, drooling, flushing, orthostatic hypotension (neurogenic, 30 to 50 percent), gastric and urinary retention, constipation, sexual dysfunction.
• Dysphagia: over 50 percent report choking; vision and smell changes.
• Psychiatric and cognitive: depression, anxiety, dementia (over 80 percent after 20 years), delirium, hallucinations, psychosis; decreased executive function and word finding.
• Hypokinesia; freezing (transient inability to move); decreased arm swing; micrographia; masklike face, decreased blinking; dysphonia (soft, monotone voice); drooling; aspiration risk.
• Complications: respiratory and urinary infections, skin breakdown, falls; medication side effects (dyskinesia, orthostatic hypotension).

C. Diagnosis

• Clinical: history plus two of four cardinal signs; often confirmed by positive response to a levodopa trial. Labs and imaging not diagnostic. MDS-UPDRS tracks progression.

D. Medical Management

• No therapy stops progression; treat symptoms and maintain independence; usually managed at home.
• Levodopa: most effective, mainstay; converted to dopamine in basal ganglia; carbidopa added to prevent peripheral breakdown. Best effect in first 1-2 years; within 5 to 10 years most develop dyskinesia (grimacing, jerking, head bobbing, chewing and smacking) and on-off syndrome (sudden immobility then sudden return of effect). Other effects: nausea, vomiting, anorexia, low BP, dystonia, confusion. Current practice: delay levodopa as long as possible.
• Table 65-1, other drugs:
  • Anticholinergics (trihexyphenidyl, benztropine): tremor in early disease; blurred vision, flushing, rash, constipation, urinary retention, confusion; contraindicated in narrow-angle glaucoma.
  • Amantadine (antiviral): reduces rigidity, tremor, bradykinesia early; psychiatric effects, leg edema, nausea, urinary retention, headache, vision changes.
  • Dopamine agonists: bromocriptine (early or after levodopa loses effect; nausea, hypotension, psychiatric effects); nonergot ropinirole and pramipexole (early; drowsiness, dizziness).
  • MAO-B inhibitors (selegiline, rasagiline): inhibit dopamine breakdown; agitation, dizziness, orthostatic hypotension, insomnia.
  • COMT inhibitors (entacapone, tolcapone): extend carbidopa-levodopa action; reduce motor fluctuations in advanced PD.
• Surgery: thalamotomy and pallidotomy (ablative, rarely used now). Deep brain stimulation (DBS): electrode in globus pallidus or subthalamic nucleus with subclavicular or abdominal pulse generator; improves tremor and rigidity; may allow lower levodopa dose. Candidates: levodopa responsive but disabled by dyskinesias, disease at least 5 years, disabling tremor; usually 10 to 13 years after diagnosis; dementia and atypical PD excluded. Complications: weakness, paresthesias, confusion, hemorrhage, infection, lead problems.
• Neural transplantation is investigational.

E. Nursing Process: Parkinson Disease

• Assess ADLs, function through the day, response to medications; ask about stiffness, jerking, freezing, drooling, grimacing, falls. Observe speech, facial expression, swallowing, tremor, posture, rigidity, mental slowness. Fall risk assessment.
• Diagnoses: impaired mobility; self-care deficits; constipation; impaired nutrition; impaired verbal communication; difficulty coping. Complications: sleep and psychiatric disturbances.
• Mobility: daily progressive exercise (walking, stationary bike, swimming, gardening); stretch-hold-relax, ROM; postural exercises; warm baths and massage for spasm. Walking: stay erect, watch the horizon, wide-based gait, swing arms, raise feet, heel-toe with long strides; march to music or metronome; breathing exercises while walking; rest periods.
• Self-care: adaptive devices (hospital bed with rails, trapeze, rope at foot of bed); OT.
• Bowel: regular time, increased fluids, moderate fiber; avoid laxatives (psyllium may obstruct); raised toilet seat; allow extra time.
• Nutrition: weekly weights; supplements; NG or PEG later.
• Swallowing: sit upright; semisolid diet with thick liquids, avoid thin liquids; think through swallow sequence; chew on alternating sides; hold head upright and swallow saliva consciously; massage face and neck before meals. Warming tray, stabilized plate, nonspill cup, built-up utensils.
• Communication: speak slowly, face listener, exaggerate words, short sentences, deep breaths before speaking; speech therapist; amplifier.
• Coping: active participation; achievable goals; do not do tasks for patient to save time.
• Complications: planned daytime activity to prevent excessive daytime sleep; limit evening caffeine; assess nocturia; screen for depression; late-stage psychosis managed with low-dose antipsychotics and avoiding dopamine-depleting drugs.
• Teaching (Chart 65-3): medication adherence and side effects, fall prevention, home safety, dysphagia and aspiration prevention, speech exercises, constipation, urinary problems, immobility prevention, daily exercise. Caregiver stress and respite.

V. Huntington Disease

• Chronic progressive hereditary disease: chorea and dementia; about 1 in 10,000; onset usually 35 to 45 (10 percent children). Autosomal dominant: each child has 50 percent risk. CAG repeat in HTT gene; genetic testing predicts disease but not timing; genetic counseling crucial.
• Premature death of striatal cells (caudate, putamen), cortex, and cerebellum.
• Triad: motor (chorea; writhing; facial tics and grimaces; slurred, explosive, then unintelligible speech; choking and aspiration; chorea diminished but persists during sleep; gait fails, wheelchair then bed; loss of bladder and bowel control), cognitive (early attention and emotion recognition problems; later dementia), behavioral (apathy, blunted affect, irritability, anger, suicidal depression, psychosis). Behavioral changes may be more devastating than movements.
• Ravenous appetite yet emaciation; death in 10 to 20 years (heart failure, pneumonia, infection, falls, choking).
• Diagnosis: clinical, family history, genetic marker; CT or MRI striatal atrophy.
• Treatment: no cure. Tetrabenazine is the only FDA-approved drug for chorea; benzodiazepines and neuroleptics also used. Akathisia from overmedication can be mistaken for disease restlessness. Levodopa for rigid forms. SSRIs, tricyclics for psychiatric symptoms; suicide risk especially early; antipsychotics for psychosis.
• Nursing (Chart 65-4): pad bed sides and head, padded heel and elbow protectors, meticulous skin care, padding, assisted ambulation; restraints only if necessary and padded. Feeding: chlorpromazine before meals if prescribed; upright; stabilize head; long-handled spoon on middle of tongue; small bites; thick foods; between-meal feedings (high calorie needs); do not interpret head turning as refusal; learn abdominal thrust. Communication: picture or word cards before speech is lost; keep talking to the patient. Orientation aids, medical ID, social inclusion. PEG later. Plan end-of-life care early; Huntington Disease Society of America.

VI. Amyotrophic Lateral Sclerosis (ALS)

• Loss of motor neurons in anterior horns and lower brainstem motor nuclei (upper and lower motor neurons); possibly glutamate overexcitation. Lou Gehrig disease.
• Onset 40 to 60; slightly more men; 5 to 10 percent familial (autosomal dominant; onset about 10 years earlier, shorter survival).
• Risk factors (Chart 65-5): age, autoimmune disease, toxins, family history, smoking, viral infections.
• Manifestations: fatigue, progressive weakness, cramps, fasciculations, incoordination, atrophy, spasticity, brisk reflexes. Anal and bladder sphincters usually spared.
• About 25 percent start with bulbar weakness: trouble talking, swallowing, breathing; nasal regurgitation of liquids; nasal voice; aspiration risk. Emotional lability; some cognitive impairment.
• Death from infection, respiratory insufficiency, or aspiration.
• Diagnosis by signs and symptoms; EMG and muscle biopsy; MRI.
• No cure. Riluzole and edaravone are disease-modifying. Baclofen, dantrolene, diazepam for spasticity; modafinil for fatigue; treat pain, depression, drooling, constipation.
• Hospitalized mainly for dehydration, malnutrition, pneumonia, respiratory failure.
• Ventilation: noninvasive positive-pressure ventilation (especially at night) postpones tracheostomy decision; negative-pressure ventilators.
• PEG placed before forced vital capacity drops below 50 percent of predicted.
• Advance directives and life-support decisions early. ALS Association.

VII. Muscular Dystrophies

• Inherited, incurable progressive weakness and wasting of skeletal muscle; about 30 types. Duchenne: most common and severe, 1 in 3500 male births.
• Muscle fiber degeneration replaced by connective tissue; elevated serum muscle enzymes; possible decreased respiratory reserve and cardiomyopathy (common in all forms).
• Management supportive: individualized exercise, night splints, stretching to delay contractures (ankles, knees, hips), braces; orthotic jacket for spinal deformity, later spinal fusion; treat respiratory infections and fractures with minimal immobilization.
• Facial weakness affects dental hygiene, speech, swallowing; GI issues (gastric dilation, rectal prolapse, impaction).
• Genetic counseling. Muscular Dystrophy Association.
• Nursing: respect family caregiving strategies during hospitalization; transition from pediatric to adult care; job training and sex education; respiratory infection and cardiac failure are the leading causes of death, so monitor and plan ventilatory support (home ventilators, wheelchair mobility); ROM to prevent contractures; assistive devices; address grief, depression, end-of-life decisions.

VIII. Degenerative Disc Disease

• Low back pain: second most common neurologic disorder; one quarter of adults report recent back pain; linked to depression, anxiety, smoking, alcohol, obesity, stress; most common reason for missed work. Acute under 3 months; chronic 3 months or more. About 90 percent recover spontaneously in 4 to 6 weeks.
• Herniation: nucleus pulposus protrudes into annulus and compresses nerve root; preceded by aging changes (water loss, annular cracks) and trauma. Radiculopathy: pain and sensitivity in the nerve’s distribution; later sensation and reflex changes.
• Older adults: age alone should not exclude spinal fusion; similar complication rates except more UTIs after age 70; more often discharged to rehab or skilled care.
• Diagnosis: rule out fracture, tumor, infection, cauda equina syndrome; MRI is the tool of choice; CT or myelography if inconsistent; EMG to localize roots.
• Usually conservative (medications, PT, exercise). Surgery for progressing neurologic deficit (weakness, atrophy, sensory or motor loss, loss of sphincter control) or radicular pain unresponsive to conservative care.
• Procedures: microdiscectomy, laminectomy, hemilaminectomy, partial laminectomy or laminotomy, discectomy with fusion (bone graft from iliac crest or bank), foraminotomy.

A. Cervical Disc Herniation

• Usually C5-C6 or C6-C7; unilateral root compression: neck, shoulder, scapular pain and stiffness (may be mistaken for heart trouble or bursitis); arm and hand pain and paresthesia.
• Central herniation: Lhermitte sign (electric shock with neck flexion) and myelopathy (bilateral arm and leg weakness, decreased fine motor skills, gait, bowel and bladder problems, respiratory impairment if high).
• Conservative: rest and immobilize (cervical collar, traction, brace); collar may be worn 24 hours a day in acute phase, inspect skin; isometric neck exercises once pain-free; firm mattress.
• Medications: analgesics (NSAIDs, acetaminophen/oxycodone, acetaminophen/hydrocodone); sedatives for anxiety; muscle relaxants (cyclobenzaprine, methocarbamol, metaxalone) for less than 1 week; NSAIDs or corticosteroids, epidural steroid injection; NSAIDs with food. Hot moist compresses 10 to 20 minutes several times daily.
• Surgery: cervical discectomy with or without fusion. Anterior approach complications: carotid or vertebral artery injury, recurrent laryngeal nerve dysfunction, esophageal perforation, airway obstruction. Posterior approach: nerve root or cord damage. Endoscopic microdiscectomy: less trauma, shorter stay.

B. Nursing Process: Cervical Discectomy

• Assess prior neck injuries (whiplash), onset, location, radiation of pain, paresthesias, function of neck, shoulders, arms; bilateral symptoms suggest cord compression; palpate; ROM; mood and stress.
• Diagnoses: acute pain, impaired mobility, lack of knowledge. Complications: hematoma at site with cord compression; recurrent or persistent pain.
• Pain: incisional pain expected; radicular pain improves over time; iliac crest donor site pain (watch for hematoma). Sudden increase in pain may mean graft extrusion: report promptly. Sore throat, hoarseness, dysphagia from edema: lozenges, voice rest, humidification, pureed diet.
• Mobility: collar; turn the body, not the neck; neck neutral; support neck and shoulders when sitting up; shoes when walking; no lifting more than 10 pounds.
• Complications: swelling, excessive neck pressure, or severe incision pain = bleeding or hematoma; serosanguineous drainage suggests dural leak (meningitis risk); evaluate headache; check swallowing and extremity strength (cord compression can cause rapid or delayed paralysis); sudden return of radicular pain after anterior discectomy may mean spinal instability; respiratory difficulty from recurrent laryngeal nerve injury (hoarseness, weak cough). Report severe unrelieved pain or any neuro change promptly.
• Home (Chart 65-6): collar usually about 6 weeks, worn at all times until told otherwise; wash neck under collar twice daily lying flat with a helper, keeping neck still; avoid sitting or standing more than 30 minutes; avoid twisting, flexing, extending, rotating neck; no prone sleeping, minimal pillows; low-heeled shoes; silk scarf under collar; shave without moving neck; report fever, redness, drainage, increased pain.

C. Lumbar Disc Herniation

• Most at L5-S1. Low back pain with muscle spasm and sciatica; worse with bending, lifting, straining, sneezing, coughing; usually relieved by bed rest; postural deformity; positive straight-leg raising test; weakness, reflex changes, sensory loss.
• Diagnosis: history, exam, MRI, CT, myelography.
• Medical: relieve pain, slow progression, improve function. Bed rest discouraged (weakens muscles) but avoid aggravating activities. Muscle relaxants; NSAIDs and systemic corticosteroids; moist heat and massage; weight reduction, PT, biofeedback; strengthening exercises.
• Surgery: lumbar disc excision via posterolateral laminotomy; microdiscectomy (2.5 cm incision, about 30 minutes, short stay); percutaneous discectomy. Herniation may recur at same or other levels. Arachnoiditis: insidious diffuse burning low back pain radiating to buttocks. Failed disc syndrome: recurrent sciatica after discectomy.
• Preop: reassure surgery will not weaken the back; baseline pain, paresthesia, spasm, extremity movement, bladder and bowel; teach logrolling, deep breathing, coughing, muscle-setting exercises. Motivational interviewing improves self-care confidence (Chart 65-7).
• Postop: frequent VS and wound checks (vascular injury); lower extremity sensation, strength, color, temperature, toe sensation; urinary retention is a sign of neurologic deterioration. Fusion adds a donor incision and longer recovery.
• Positioning: pillow under head, knee rest slightly elevated; avoid extreme knee flexion when side-lying; reassure that moving side to side is safe; to turn, bed flat, pillow between legs, logroll without twisting. To get up: lie on side, push up to sitting while legs are eased over the edge, one smooth motion. Most walk to the bathroom the day of surgery. Sitting discouraged except for defecation.
• Home: increase activity gradually; ligaments take up to 6 weeks to heal; avoid flexion strain (driving) until healed; heat for spasm; rest periods; no heavy work for 2 to 3 months; abdominal and erector spinae strengthening; brace or corset if pain persists.

IX. Post-Polio Syndrome

• New weakness, fatigue, and musculoskeletal pain at least 15 years after polio; 15 to 20 million worldwide; men and women equally. Likely from aging or overuse of surviving neurons and their axon sprouts.
• Diagnosis by history (paralytic polio, recovery, plateau, new symptoms) and exclusion; no specific test.
• No specific treatment; IVIG may improve pain and weakness.
• Nursing: energy conservation, planned rest, assistive devices; schedule important activities in the morning (fatigue worsens later); heat and cold for pain (older adults may not tolerate medications); balance nutrition and avoid obesity; pulmonary hygiene and fluids; sleep hygiene (limit caffeine, assess nocturia, evaluate for sleep apnea, CPAP); bone density testing, fall prevention, osteoporosis treatment.

High-Yield Numbers

Priority Nursing Actions and Red Flags

• Brain tumor: morning headache worse with straining, projectile vomiting, papilledema = increased ICP.
• Steroid therapy: check glucose, electrolytes, muscle weakness.
• Spinal cord tumor or postop: sudden loss of motor, sensory, bowel, or bladder function is an emergency.
• After spinal surgery: logroll; check extremity strength and sensation; urinary retention may mean neuro decline; clear or serosanguineous drainage or incision bulging = CSF leak.
• After anterior cervical discectomy: neck swelling, pressure, severe pain = hematoma with airway or cord compression risk; hoarseness and weak cough from laryngeal nerve injury; sudden increase in pain = graft extrusion.
• PD: aspiration (thick liquids, upright), falls (wide-based gait), orthostatic hypotension; anticholinergics contraindicated in narrow-angle glaucoma.
• Huntington: suicide risk early; akathisia from overmedication can mimic disease restlessness.
• ALS: monitor respiratory function; plan PEG before FVC falls below 50 percent; advance directives early.
• Muscular dystrophy: respiratory infection and cardiac failure are leading causes of death.

Medications

Related

• nsg210-hinkle-ch60-neurologic-assessment
• nsg210-hinkle-ch61-neurologic-dysfunction
• nsg210-hinkle-ch63-neurologic-trauma
• nsg210-hinkle-ch64-neuro-infections-autoimmune
• nsg210-hinkle-ch45-endocrine-disorders (pituitary tumors, Cushing)
• INDEX