NEUROLOGICAL SYSTEM

Lecturer: MS. Louradel M. Ulbata, RN

PHYSIOLOGY OF THE NEUROLOGIC
SYSTEM
Organization of the Nervous System
A. Central nervous system (CNS).
1. Brain
2. Spinal Cord
B. Peripheral nervous system (PNS).
1. Twelve pairs of cranial nerves
2. Thirty-one pairs of spinal nerves
B.1. Autonomic nervous system
a. Sympathetic system
b. Parasympathetic system.
B.2. SOMATIC NERVOUS SYSTEM
a. Afferent Nerves
b. Efferent Nerves

Irritability ability to respond to stimuli

Conductivity ability to transmit an
impulse
NERVE FUNCTION is NERVE
CONDUCTION

ACTION POTENTIAL
Nerve Cell undergoes:
1. Resting Membrane Potential
2. Action Potential / Depolarization
3. Repolarization / Restabilization
1. RESTING MEMBRANE POTENTIAL
Sodium predominates outside the cell,
potassium inside the cell.
Inside of the cell is relatively negative
with the presence of potassium and
large amounts of negative ions.
2. Action Potential / Depolarization
When a cell is stimulated, cell
membranes become permeable to
sodium ions.
Sodium moves inside the cell and
potassium moves out.
Inside of the cell becomes positively
charged.
Sudden change in the charge of the cell
from negative to positive is called
action potential.

CELLS OF THE NERVOUS SYSTEM

A. Neuron-the functional cell of the nervous
system.
1. Common characteristics.
a. Responds or reacts to stimuli
b. Conducts impulses
c. Influences other neurons.
2. Structure
a. Cell body-contains the cell nucleus which
controls cellular activity.
b. Axon-conducts impulses away from the cell
body
c. Dendrites-receive incoming stimuli and
transmit them to the axon of another neuron.

3. REPOLARIZATION
The sodium-potassium pump restores
the original configuration
This action requires ATP
Sodium is pumped out of the cell
and potassium back into the cell.
B. Supporting cells provide support,
nourishment, and protection to the neuron.
1. Neurilemma protective cells which
surround the axons in the PNS.
a. Provide for effective regeneration of
PNS nerve fibers.
b. Form the myelin sheath in the PNS.
c. No neurilemma present in the CNS.

3. Function/classification.
a. Afferent neurons (sensory) transmit
information away from the CNS.
b. Efferent neurons (motor) transmit
information away from the CNS.
REMEMBER: SAME
Sensory = Afferent; Motor =
Efferent

2. Glial cells protective cells in the CNS;

responsible for the formation of the
myelin.

c. Somatic system
1). Afferent are sensory neurons that transmit
impulses from the skeletal muscles and skin to
the CNS.
2). Efferent are motor neurons that transmit
impulses that lead to contraction and control
of skeletal muscle.
d. Visceral system.
1). Afferent are sensory neurons that transmit
impulses from smooth muscle and cardiac
muscle to the CNS.
2) Efferent are motor neurons that transmit
impulses to the glands, cardiac muscle, and
smooth muscle.
e. Synapse or synaptic terminals are areas of
chemical transmission of an impulse from the
axon of one neuron to the dendrites of another
neuron.

3. Myelin sheath.
a. Dense membrane or insulator around
the axon.
b. Facilitates function of the neuron,
c. Contributes to the blood-brain barrier to
protect the central nervous system
against harmful molecules.
4. nodes of Ranvier
- Intermittent gaps between the
myelin sheath
that
allow
communication
between nerve
fibers.
- Signals jumping from node to
node
travel hundreds of times
faster than
signals traveling
along the surface of
the axon.
D. Impulse conduction.
SALTATORY CONDUCTION

Functional Properties of Neurons

An action potential excites one section

of the nerve membrane and electrical
impulse then SKIPS from one node to
the next generating an action potential.
These node-to-node mode of
conduction is termed SALTATORY OR
LEAPING TRANSMISSION

- neurotransmitters are reabsorbed by

the
presynaptic nerve to
reuse/recycle
2. Inactivation by an enzyme
3. Broken down by enzymes in the area
4. Diffusion out of the synaptic cleft and
removal by the vascular system
d. Nerve regeneration entire neuron is
unable to undergo complete regeneration.

ADVANTAGES OF SALTATORY Of
LEAPING TRANSMISSION
Membranes are forming fewer action
potentials so:
1. The speed of conduction is much faster
2. The nerve is protected from exhaustion
or using up energy to form multiple
action potentials

1. The axons of the PNS may regenerate via

the connective tissue neurilemma, providing
the cell body of the neuron remains viable.
2. Neuron regeneration in the CNS is very
limited, possibly due to the lack of
neurilemma.
3. Scar tissue is a major deterrent to successful
cellular regeneration.

Synaptic transmission:
TRANSMISSION OF ELECTRICAL
IMPULSES FROM ONE NEURON TO
ANOTHER

CENTRAL NERVOUS SYSTEM

The brain and the spinal cord within the
vertebral column make up the central nervous
system.

a. A chemical synapse maintains a oneway communication link between

neurons

A. The brain and the spinal column

are protected by the rigid bony
structure of the skull and the
vertebral column.
B. Meninges protective
membranes that cover the brain
and are continuous with those of
the spinal cord. (DAP)

synapse - junction between two

neurons.

NERVE SYNAPSE IS MADE UP OF:

1. presynaptic nerve -ends BEFORE
specific
synapse
2. synaptic cleft -separates synapse
by a tiny
gap (less than onemillionth of an
inch)
3. Post synaptic Nerve - begins
AFTER
synapse
b. Chemical neurotransmitters (neuromediators) facilitate the transmission of
the impulse across the synapse.
1). Acetylcholine.
2). Norepinephrine.
3). Dopamine.
4). Histamine.
c. Impulses pass in only one direction.
Impulses are able to cross the synapse
to another nerve
Neurotransmitter is released
from a nerves axon terminal
The dendrite of the next neuron
has receptors that are
stimulated by the
neurotransmitter
An action potential is started in
the dendrite

1. Dura mater-a tough membrane

immediately outside the
arachnoid; provides protection
to the brain and spinal cord.
2. Arachnoid-a delicate
nonvascular, waterproof
membrane that encases the
entire CNS; the subarachnoid
space contains the cerebral
spinal fluid.
3. Pia mater-a delicate vascular
connective tissue layer that
covers the surfaces of the brain
barrier.
C. Cerebral spinal fluid (CSF).
1. Serves to cushion and protect
the brain and spinal cord; brain
literally floats in CSF.
2. CSF is clear, colorless, watery
fluid; approximately 100 to 200
cc total volume, with a normal
fluid pressure of 70 to 150 mm
of water 9average-125 cm water
pressure).
3. Formation and circulation of CSF.
a. Fluid is secreted by the choroids
plexus located in the ventricles
of the brain.
b. CSF flows through the lateral
ventricles into the third
ventricle, flows through the
Aqueduct of Sylvius into the
fourth ventricle where the
central of the spinal column
opens.

To return the effector to a resting

state so that it can be stimulated
again, the actions of these
neurotransmitter must be stopped by
one or more of these processes:
1. Reuptake by the presynaptic nerve

c. From the fourth ventricle, there

are openings into the cranial
subarachnoid space; CSF flows
around the spinal cord ad brain.
d. Since CSF is formed
continuously, it is reabsorbed at
a comparable rate by the
arachnoid villi.
D.

motility and secretions of the GI

tract, arterial blood pressure.
2. Nerve connections with the
thalamus and
the cerebral
cortex make it possible for our
emotions to influence visceral
activity.
3. Regulation of endocrine
glands via influence
on the
pituitary gland.
4. Neurosecretion of antidiuretic
hormone (ADH) which is stored in
the pituitary

Brain.
I. FOREBRAIN
Prosencephalon - "Pro Die & Tell
Diencephalon => Thalamus,
Hypothalamus
Telencephalon => Cerebrum

3. Motor areas of the cerebral

cortex.
a. Primary function is coordination
and control of
skeletal muscle
activity.
b. Corticospinal tracts
(pyramidal tracts).
1. Descending tract from the
motor
area of the
cerebral
cortex to the
spinal cord.
2. Majority of nerves cross in the
medulla to
the opposite side
before descending into the
spinal cord.
3. These pathways do not cross
over.
c. Brain cells and the nerve fibers in
the descending tracts of the central
nervous system are called upper
motor neurons.

1. Cerebrum seat of
consciousness
- convolutions or gyri & grooves:
sulci
or fissures which expands
or increases the surface area of
the
brain
- is divided into left and right
hemispheres connected
to each
other by the corpus
callosum
- the cerebral cortex is the
surface
layer of
each
hemisphere.
A. Major lobes of the
central cortex.
a. Frontal.
1). Coordination of voluntary
skeletal muscle movement.
2). Abstract thinking, morals,
judgment.
3). Speech area, motor speech area
(Brocas area) located in only one
hemisphere.
b. Parietal.
1. Interprets sensory nerve impulses
(pain, temperature,
touch).
2. Maintains proprioception.
3. Recognition of size, texture, and
shape
of
objects.
c. Temporal.
1. Auditory area- interprets meaning
of
certain
sounds.
2. Wernickes area- comprehension
and formulation
of speech.

II. MIDBRAIN (MESENCEPHALON)

- Consists of 4 rounded bodies, the corpora
quadrigemina:
Paired upper bodies: serve as
visual reflex centers for head &
eyeball movements
Paired lower bodies: serve as
relay centers for auditory
information
III. HINDBRAIN (RHOMBENCEPHALON)
Brainstem
Pons
Medulla oblongata
Cerebellum
A.. Pons- respiratory apneustic center,
nucleus of cranial nerves5,6,7,8
B. Medulla oblongata-a continuation of
the spinal cord as it enters into the cranial
vault in the
brain.
- respiratory and cardiovascular
centers, nucleus of cranial nerves
9,10,11,12
1. Conduction center and crossing
center for the upper motor neurons.
2. Maintains control of cardiac rate.
3. Vasomotor center for constriction
and dilation of vessels.
4. Respiratory center for changes in
rate and depth of breathing.
5. Vomiting reflex center.
6. Swallowing reflex center.
C. The Cerebellum
2nd largest part of the brain w/c
consists of 2 hemispheres & a
connecting portion, the vermis

d.Occipital area-interprets vision

and controls ability to understand
written words.
e.
The limbic lobe is
thought to be a link bet emotional &
cognitive (thought) mechanisms.
f.
The central lobe
(insula) is thought to be involved in
both autonomic & somatic activities.
2. Thalamus.
1. relay station for all sensory
information
2. Activities related to
consciousness.
3. . Hypothalamus.
1. Regulation of visceral
activities-body
temperature,

responsible for coordination of muscle

movements
functions:
1. helps make muscular movement
smooth instead of jerky &
trembling
2. helps maintain muscle tone &
posture
3. impulses from the vestibular
apparatus are continuously
delivered to the cerebellum to
help maintain equilibrium

b. Intervertebral discs lie between each

vertebra to provide flexibility to the
spinal column.
c. Nucleus pulposus is a gelatin
substance in the vertebral disc.
5. Upper motor neurons-originate in the
brain, transmit impulses to the
muscles and organs.
6. Lower motor neurons originate in
the spinal
cord, transmit impulses
to the muscles and organs.
4. Reflex activity.
a. The reflex arch must be intact, the
spinal cord serves as the connection
between the afferent pathway
(sensory),
and the efferent pathway (motor).
b. By testing the reflex arc (deep
tendon reflexes), the
lower motor
neuron and the sensory/motor fibers from
the spinal column can be evaluated.

RETICULAR FORMATION
Nerve fibers arising from the central
core of the medulla and lower pons
Reticular Activating System
- arises from reticular formation.
- essential for arousing from
sleep
and remaining alert.
- Injury to RAS can cause
anesthesia
and coma
Basal ganglia (cerebral nuclei)
regulate and program muscle
activity coming from the cerebral
cortex.

Reflex arc
a. Reflex are is the functional unit
which provides pathways over which nerve
impulses travel.
b. Passage of impulses over a reflex arc
is
called a reflex
act or a reflex.
c. Reflex arc The afferent neuron
carries
the stimulus to the spine;
integrates it into
and through the spine
(CNS) to the efferent neuron; crosses
the synapse with
the
message from the
CNS to the organ or muscle which responds
to the stimuli. This is the sequence of events
when testing the deep tendon reflexes.

Movement is controlled by:

a. Cerebral cortex voluntary
initiation of motor
activity.
b. Basal ganglia-assist to maintain
posture.
c. Cerebellum-coordinates muscle
movement.

PERIPHERAL NERVOUS SYSTEM

(PNS)
Cranial nerves
1.
Twelve pairs of
cranial nerves.
2.
Originate from
under the surface of the brain.
A. Spinal nerves.
1. Each pair of nerves is
numbered according to
the level of the spinal
cord from which it
originates.
2. Each spinal nerve is connected
to the cord by two roots.
A.
DORSAL
(PoSterior) root- receives
SENSORY input from sensory
receptors throughout the
body.
B. Ventral (anterior root)
a motor nerve carrying
neuron messages to glands
and to the peripheral area.

CEREBRAL CIRCULATION
a. The internal carotid arteries enter the
cranial
vault at the temporal area
b. Vertebral arteries arise from the
subclavian
artery and enter the
brain at the foramen
magnum.
c. The Circle of Willis is an arterial
anastomosis
at the base of the brain.
The circle ensures continued circulation if
one of
the
main vessels is
disrupted.
THE SPINAL CORD
1. The spinal cord is continuous with the
medulla and extends down the vertebral
columns to the level of the first and
second lumbar vertebra.
2. Each column is divided into functional
groups of nerve fibers.
a. Ascending tracts transmit impulses
to the brain (sensory pathway).
b. Descending tracts transmit
impulses from the brain to the various
levels of the spinal cord (motor
pathways).
3. Structure.
a. Closely approximately vertebrae
provide protection from the spinal cord
and nerve roots.

REMEMBER!
DORSAL ROOT/ POSTERIOR
=SENSORY
VENTRAL ROOT/ ANTERIOR =
MOTOR

3. The roots fuse at the exit from

the vertebra to form a mixed
spinal nerve.
4.
SPINAL NERVE
PLEXUSES
- network of interwoven spinal
nerves

Lacrimation
Salivation

MAJOR PLEXUSES:
A. CERVICAL PLEXUSES
a. sends motor impulses to the
NECK
muscles
b. Sends out PHRENIC nerve,
activating the
diaphragm
c. Receives sensory impulses from
neck
snd back of the head
B. BRACHIAL PLEXUSES
- Innervates shoulder, arm,
forearm,
wrist and hand

CRANIAL NERVES

c. LUMBOSACRAL PLEXUS
- Innervates the lower
extremities.
- Sends out the large SCIATIC
NERVE
C. Somatic nervous system associated
with the voluntary control of body movements
via skeletal muscles, and with sensory
reception of external stimuli (e.g., touch,
hearing, and sight
D. autonomic nervous system regulates
involuntary activity (cardiovascular,
respiratory, metabolic, body temperature, etc.)
1. Consists of two divisions that have
antagonistic activity.
2. Parasympathetic division maintains
normal body functions.
- REST & DIGEST
3. Sympathetic division-prepares the
body to
meet a
challenge or an
emergency
(preparation for fight/flight).

Function:
Control
Neurotransm
itter

are nerves which start directly from the

brainstem instead of the spinal cord.

Only the first and the second pair

emerge from the cerebrum; the
remaining 10 pairs emerge from the
brainstem.

NUMBER
I.
II.

NAME
Olfactory
Optic

III.

Oculomotor

IV.
V.

Trochlear
Trigeminal:
Opthalmic
Macillary
Mandibular

VI.
VII.

Abducens
Facial

FUNCTION
Sense of smell
Vision-conducts
information from
the retina
Down and outward
movement of the
eye
Pupillary
constriction and
accommodation
Muscle of the
upper eyelid
(ability to keep the
eye open)
Movement of the
eye
Corneal reflex
Sensory fibers of
the face
Motor nerves for
chewing and
swallowing
Inward movement
of the eye
Facial expression
Sense of taste on
anterior tongue
Muscle of the
eyelid (ability to
close the eye)

SYMPATHETIC VS PARASYMPATHETIC
Parasympathe
tic:
REST AND
DIGEST
=> slows stuff
down
Craniosacral:
brain + below
the belt
ACETYLCHOLI
NE
"DUMBBELS":
Diarrhea
Urination
Miosis
"constrict"
Bradycardia
Bronchoconstric
t
Erection "point"

Tachycardia
Bronchodilate
Ejaculation
"shoot"
Xerophthalmia
(dry eyes)
Xerostomia (dry
mouth)

Sympathetic:
FIGHT &
FLIGHT
=> speed
stuff up
Thoracolumba
r: above the
belt
EPINEPHRINE
& NE
Opposite of
Parasympatheti
cs:
Constipation
Urinary
retention
Mydriasis "eyes
wide with
fright"

VIII.

Acoustic

IX.

Glossopharyngeal

X.

Vagus nerve

XI.

Accessory (Spinal)

XII.

Hypoglossal

Reception of
hearing and
maintenance of
equilibrium
Sense of taste on
posterior tongue
Salivation
Swallowing or gag
reflex
Assists in
swallowing action
Motor fibers to
larynx for speech
Innervation of
organs in thorax
and abdomen
Important in
respiratory,
cardiac, and
circulatory

b. Position of rest for the infant or young child.

c. Personal hygiene, grooming.
d. Evaluate speech and ability to
communicate.
1. Pace of speech-rapid, slow, halting.
2. Clarity slurred or distinct.
3. Tone high pitched, rough.
4. Vocabulary appropriate choice of
words.
e. Facial features may suggest specific
syndromes in children.
2. mental status must take into consideration
the clients culture and educational
background).
a. General appearance and behavior.
b. Level of consciousness.
1. Oriented to time, person,
place.
2. Appropriate response to
verbal and tactile
stimuli.
3. Memory, problem-solving
abilities.
c. Mood.
d. Thought content and intellectual
capacity.
3. Assess papillary status and eye movements.
a. Size of pupils should be equal.
b. Reaction of pupils.
1. Accommodation papillary
constriction to
accommodate
near visions.
2. Direct light reflex constriction of
pupil when light is
shown directly into eye.
3. Consensual reflex constriction of
the opposite eye
for the direct light reflex.
c. Evaluate ability to move eye.
1. Note nystagmus-fine, jerking eye
movement.
2. Ability of eyes to move together.
3. Resting position should be at mid
position of the eye socket.
d. PERRLA indicates that pupils are
equal, round, reactive to light and
accommodation is present.
4. Evaluate motor function.
a. Assess face and upper
extremities for
equality of
movement and sensation.
b. Evaluate appropriateness of
motor
movement, spontaneous
and on command.
c. Movement of extremities
should always be
evaluated
bilaterally, comparing tone, strength,
and muscle movement of each side.
d. Presence of inappropriate,
non-purposeful
movement, i.e.,
posturing.
e. Ability of an infant to suck and
to swallow.
f. Asymmetrical contraction of
facial muscles.
5. Evaluate reflexes.
a. Gag or cough reflex.
b. Swallow reflex.
c. Corneal reflex.
d. Babinski reflex normal is
negative in adults
and children over
one year, positive sign is
dorsal
flexion of the foot and large toe with
fanning of the other toes.

reflexes
Ability to rotate
the head and
raise the shoulder
Muscles of the
tongue

Neurological Examination
NEUROLOGICAL ASSESSMENT:
Three Components:
1. Interview
- psychosocial assessment
- extensive neurologic history
2. Physical assessment
- neurologic examination
3. General and Special Neurologic
diagnostic studies
System Assessment
A. History.
1. Neurologic history.
a. Avoid suggesting symptoms to
the client.
b. The manner in which the
problems began and the overall
course of the illness are very
important.
c. Mental status must be assessed
before assuming the history data
from the client is accurate.
2. Medical history.
a. Chronic, concurrent medical
problems.
b. Medications (especially
tranquilizers, sedatives,
narcotics, etc).
c. Pregnancy and delivery history
of infants and young children.
d. Sequence of growth and
development.
3. Family history-presence of
hereditary or congenital
problems.
4. Personal history-activities of
daily living, any change in
routine.
5. History and symptoms of
current problem.
a. Paralysis or paresthesia.
b. Syncope, dizziness
c. Headache.
d. Speech problems.
e. Visual problems
f. Changes in personality.
g. Memory loss.
h. Nausea, vomiting.
B. Physical Assessment.
1. General observation of client.
a. Posture, gait..

e. deep tendon reflexes (simple

stretch reflex).

c. Normal approximation of cranial suture lines.

ASSESSMENT OF LEVEL OF
CONSCIOUSNESS

6. Assess vital signs and correlate with other

data; changes often occur slowly and the
overall trend needs to be evaluated.
a. Blood pressure and pulse-intracranial
problems
precipitate
changes, blood
pressure may increase and pulse rate may
decrease.
b. Respirations rate, depth, and rhythm are
sensitive
indicators of intracranial
problems.
1. Cheyne Stokes periodic breathing
in which
hyperpnea alternates with
apnea, rapid, deep hyperpnea.
2. Neurogenic hyperventilation-regular,
rapid, deep hyperpnea.
3. Ataxic completely irregular pattern
with random deep
and shallow respirations.
c. Temperature evaluate changes in
temperature as related to a neurological
control versus infection.

Consciousness is defined as the state of

being aware of physical events or
mental concepts.
First and most important observation
made in people with neuro d/o.
Levels of Consciousness:
Alert and Oriented
Disoriented
Lethargic - slight reduction in
alertness

Obtunded
Drowsy/somnolent
Clouded consciousness
Slow thought, movement, and
speech
Stuporous
Marked reduction in mental and
physical activity
Vigorous stimuli needed to
provoke a response
Comatose
Completely unconscious
Cannot be aroused by painful
stimuli
Absence of voluntary movement
+/- reflexes

>Nursing Alert< Bedside neuro checksevaluate level of consciousness; respiratory

patterns; papillary signs; eye movements;
motor responses; vital signs.
C. Neuro checks parameters for frequent
nursing evaluation of
neurological
symptoms.
1. Assess level of consciousness (LOC).
a. Verbal and motor response to
command.
b. Appropriate conversation and
speech.
c. Presence of delayed response to
stimuli,
from lethargic to unresponsive.
d. Appropriate behavior in infants and
young children.
e. Be explicit in describing LOC; may
utilize a
specific coma scale (Glasgow).
2. Respiratory patterns evaluate current
respiratory pattern and assess for changes in
pattern.
3. Pupillary response.
a. Equality of pupils.
b. Presence of consensual, direct, and
accommodation reflexes.
c. Position of pupils at rest.
4. Motor function.
a. Ability to move all extremities with
equal strength.
b. Presence of posturing.
c. Presence of seizure activity.
d. Presence of gag and cough reflex.
5. Vital signs.
a. Correlate blood pressure and pulse
changes.
b. Assess respiratory pattern.
c. Assess temperature in regard to
overall
condition.
6. Assess for presence of pain, headache.
7. Presence of projective vomiting not
associated with
nausea.
8. Infants-assess fontanel and suture lines.
a. Size of fontanel for growth and development
level.
b. Fontanel should be soft to touch with slight
pulsations.

GLASGOW COMA SCALE (GCS)

a neurological scale that aims to give a
reliable, objective way of recording the
conscious state of a person
Tests 3 areas- eye opening, verbal
response and motor response
Scores are evaluated- range from 3-15
No ZERO score
patients with scores of 3-8 are usually
said to be in a coma.
Tests 3 areas:

Eye Opening (E) 4 points

points

Verbal Response (V) 5

Motor Response (M)- 6

points

ASSESSMENT OF SPEECH AND LANGUAGE

Dysarthria
- difficulty in articulation
- lesions of tongue & palate
Dysphonia
- difficulty in phonation
- lesions of palate & vocal cords
Agnosia
- inability to recognize objects or
symbols
by means of senses

Aphasia
- inability use and understand written
and spoken words

 CN III pupil constriction & elevation of

eyelid
- assess pupil (PERRLA)
- assess for ptosis

TYPES:
1. Expressive (motor, nonfluent, or
Broca's) aphasia:
- The ability to create words is
impaired, but comprehension and
ability to
conceptualize are relatively
preserved.
.
- It often causes agraphia (loss of the
ability to write) and impairs oral reading.
2. Receptive (sensory, fluent, or
Wernicke's) aphasia:
- Patients cannot comprehend words or
recognize auditory, visual, or tactile
symbols.
- Often, alexia (loss of the ability to
read
words) is also present.
REMEMBER:
BEWARE:
Broca's area: Expressive dysphasia.
Wernicke's Area: REceptive dysphasia

CN III, IV, VI control eye movement

- SO4 , LR 6 = CN 4 controls the
superior
oblique muscle and CN 6
controls the lateral
rectus muscle
- Assess simultaneously the
movement
Deviations:
Opthalmoplegia- inability to move the
eye in a direction
Diplopia- complaint of double vision

Pupil Abnormalities:
Asymmetry of pupil size of >1mm
suggests CN III compression
Bilateral dilation
anoxia
drug Effect
Unilateral constriction
sympathetic dysfunction (Horner
syndrome)
carotid artery dissection
Bilateral constriction
PinPoint oPiods & Pontine d/o

CRANIAL NERVE ASSESSMENT

I. Cranial Nerve 1- Olfactory
Check first for the patency of the nose
PROBLEM: ANOSMIA- loss of smell
II. Cranial Nerve 2- Optic
Papilledema
- optic disc swelling that is caused by
increased
intracranial pressure.

Argyll Robertson pupil

- bilateral small pupils that constrict
when the patient
focuses on a near
object (they
accommodate), but do
not constrict
when exposed to bright
light (they do not react to light).
- formerly known as "Prostitute's
Pupils"
because of
their association
with tertiary
syphilis
- Prostitute's Pupils : Prostitutes
accommodate but do not react
Anisocoria
>2mm difference in size
Adies (Tonic) pupil
sluggish response

Hemianopsia
- is loss of vision in one-half of the
normal visual field
(usually the right
or left half) of one or both eyes.

IV. Cranial Nerve 5 -trigeminal

Sensory portion- assess for sensation of
the facial skin
Motor portion- assess the muscles of
mastication
Assess corneal reflex
V. CRANIAL NERVE 7 Facial
Sensory portion- prepare salt, sugar,
vinegar and quinine. Place each
substance in the anterior two thirds of
the tongue, rinsing the mouth with
water
Motor portion- ask the client to make
facial expressions, ask to forcefully
close the eyelids
Facial nerve (CN VII) palsy: Bells Palsy
VI. Cranial Nerve 8 Vestibulocochlear
nerve

1) Ipsilateral blindness: Optic nerve lesion

2) Bitemporal Hemianopsia: Optic chiasm
lesion
3) Homonymous Hemianopsia (Right or
Left): Optic tract lesion

Test patients hearing acuity

Observe for nystagmus and disturbed
balance

III. CRANIAL NERVE III, IV,VI

VII. Cranial Nerve 9- glossopharyngeal

Together with Cranial nerve 10 vagus

 Assess for gag reflex

Watch the soft palate rising after
instructing the client to say AH
The posterior one-third of the tongue is
supplied by the glossopharyngeal nerve

inappropriately varying in
speed, force, & direction

B. GAIT
1. Ataxic
- staggering and unsteady
2. SPASTIC GAIT
- stiff, short steps, toes catch and drag,
legs
are held together and hips and
kness are
flexed
3. SCISSORS GAIT
- legs cross while walking with short,
slow steps
4. STEPPAGE GAIT
- foot and toes lifted high, heels come
down heavily
5. WADDLING GAIT
- a broad-based gait with a duck-like
waddle
to the swing phase
6. festinating gait
- a gait in which the patient
involuntarily moves with short,
accelerating steps, often on tiptoe, as in
parkinsonism.

VIII. Cranial Nerve 11- accessory

Press down the patients shoulder while
he attempts to shrug against resistance
IX. Cranial Nerve 12- hypoglossal
- Ask patient to protrude the
tongue and note for symmetry
- Unilateral cortical lesions causes
the protruded tongue to deviate
toward the affected side
SENSORY ASSESSMENT
1. DISCRIMINATION
- Tests the integrative functions of
sensation and memory in the brains
parietal lobe
- Includes:

C. ABNORMAL MOVEMENTS
1. AKINESIA
- reduced body movement in the
absence of
weakness or paralysis
2. ATHETOSIS
- gross, writhing, worm-like movement
of
body, face or extremities

a. STEREOGNOSIS
- discernment of the form or
configuration of
objects
felt
b. GRAPESTHESIA
- recognition of the form of
written
symbol
2. SENSATION ABNORMALITIES
a. DYSESTHESIAS
- well localized irritating sensations ; warmth,
cold, itching, tickling
b. PARESTHESIAS
- distortion of sensory stimuli ; light
touch may
be interpreted as burning or
painful sensation
c. ANESTHESIA
- absence of sense of touch
d. HYPERESTHESIA
- pathologic over perception of touch
e. HYPALGESIA
- reduced sensation to pai
f. HYPERALGESIA
- increased sensation to pain
g. ANALGESIA
- absence of pain sensation

3. BRADYKINESIA
- slow movement
D. POSTURING
1. DECORTICATE RIGIDITY
Abnormal flexor response
Characterized by rigidity, flexion of the
arms, clenched fists, and extended legs
the arms are bent inward toward
the body with the wrists and
fingers bent and held on the
chest
Destructive lesion of Corticospinal
tracts
2. DECEREBRATE RIGIDITY
Abnormal Extensor Response
Characterized by rigid extension of the
arms and legs, downward pointing of
the toes, and backward arching of the
head
Typicall caused by deterioration of the
structures of the nervous system,
particularly the upper brain stem
lesion in diencephalon, midbrain,
pons
metabolic disorders

h. ASTEREOGNOSIS
- loss of sense of three dimensional
discrimination
MOTOR SYSTEM ASSESSMENT
Praxis = ability to perform a motor
activity
Apraxia = inability to perform voluntary
movement in the absence of deficits
Dyspraxia = difficulty performing an
activity
A. Coordination:
Cerebellar disease
incoordination is worse with
eyes closed

Assessing the motor function of the

brainstem
1. Test for the Oculocephalic reflex- dolls
eye
- head is moved rapidly from side to
side
Normal response- eyes appear to move
opposite to the movement of the head

dysmetria
point-to-point
movements are clumsy,
unsteady,

 Abnormal- eyes move in the same

direction with suspected cervical spine
injury

Deep Tendon Reflexes: Grading

Grade

NOTE:

Do not use the Dolls eye test on

people with suspected cervical spine injury.

with

2. Test for the Oculovestibular reflex

Slowly irrigate the ear with cold water
and warm water
Normal response- COWS
Cold = Opposite : Warm =
Same
Nystagmus - Involuntary eye
movements usually triggered by inner
ear stimulation

DTR Response
4+

Very brisk, hyperactive,

clonus
Brisker than average,

slightly

hyperreflexic
2
Average, expected
response;
normal
1
Somewhat diminished,
low
normal
0
No response, absent
PATHOLOGICAL REFLEXES
- do not normally occur
- presence indicates neurologic
d/o
1. CLONUS
- Rhythmic Oscillation
2. BABINSKI REFLEX
- stroke the lateral aspect of the soles
doing an inverted
(+)-DORSIFLEXION of the Big toe with
fanning out of
the little toes

REFLEXES ASSESSMENT
TWO (2) REFLEXES:
1. SUPERFICIAL (CUTANEOUS)
- elicited by superficial or cutaneous
stimulation
- stimulus is produced by stroking a
sensory
zone with an object that will
not cause
damage
2. DEEP TENDON REFLEX (MUSCLE
STRETCH)
- reflex muscle contraction results from
rapidly
stretching the muscle
- produced rapidly by striking a
muscles
tendon of
insertion sharply
with a sudden, brief blow using a reflex
hammer

DIAGNOSTIC EXAMINATION
1. LUMBAR PUNCTURE
- NEEDLE IS INSERTED BETWEEN L4-L5
- BELOW THE LEVEL OF THE SPINAL
CORD
L4 & L5 will keep the spinal cord alive

SUPERFICIAL (CUTANEOUS) REFLEXES

1. ABDOMINAL REFLEX
- scratching the skin on an abdominal
quadrant normally contracts the
abdominal
muscle in that
quadrant.
2. CORNEAL REFLEX
- gentle stroking of cornea with a wisp
of
cotton causes
reflex
blinking
3. PHARYNGEAL / GAG REFLEX
- gentle stimulation with a tongue blade
at
the back of
the throat and
pharynx
normally produce gagging.
4. CREMASTERIC REFLEX
- stroking the inner thigh of a male
normally elevates the ipsilateral
testicle.

Complications:
HEADACHE
HYPOTENSION
MENINGITIS
SUBARACHNOID HEMATOMA
NORMAL CSF CHARACTERISTICS:
PRESSURE : 6-13 mmHg
APPEARANCE : clear & colorless
RBC : none
WBC : 0-5 cells/mm
Protein: very little
Glucose: 40-80 mg /dl
Chlorides: 720-750 mg/dl
NURSING CARE FOR CLIENTS WITH
NEUROLOGICAL DISORDER

DEEP TENDON REFLEX (MUSCLE

STRETCH)
1. ANKLE JERK (plantar flexion of the foot)
- produced by tapping the Achilles
tendon
2. KNEE JERK (leg extension)
- produced by tapping the quadriceps
femoris
tendon just below the patella
3. BICEPS JERK (forearm flexion)
- produced by tapping the biceps
brachii
tendon
4. TRICEPS JERK (forearm extension)
- is produced by tapping the triceps
brachii
tendon at the elbow

Client with Headache

Headaches may be due to benign or
pathological condition
Pathophysiology: multiple pain sensitive
structures within cranial vault, face, and scalp
are stimulated and cause pain perception
Types:
Tension-characterized by sensation of
tightness around head and may have specific

10

localized painful areas; areas caused by

sustained contraction of muscles and head and
neck; precipitated by stress and anxiety

1. Aspirin, Ibuprofen-suppress prostaglandin

that dilates and sensitizes nerve fibers
2. Acetaminophen-tension headache; works in
CNS to reduce pain without effect on
prostaglandin (safe for gastritis)
3. Triptans-anti-migraine; activates serotonin
receptors decreasing inflammation of blood
vessels
4. Botox (purified botulinum bacteria)
-small dosages allow it to be localized;
paralyses muscles locally and is not absorbed
into the blood stream (may cause nerve
paralysis if given in large doses)
5. Indomethacin-for cluster headaches; with
pain killers
Nonpharmacological:
1. Biofeedback
2. Acupuncture
3. Massage
4. Yoga
5. Herbal remedies

Migraine (more common in women)

-recurring vascular headache often initiated by
triggering event and accompanied by
neurologic dysfunction; or increase release of
sensory substances (e.g. serotonin); triggers
include stress, fluctuating glucose levels,
fatigue, hormones, bright lights
Cluster (common in men)
-typically awakens client with unilateral pain
around eye accompanied by rhinorrhea,
lacrimation, flushing; attacks occur in clusters
of 1-8 days for weeks
HEADACHE
1. Tension headache-90%; noise, stress
sustained contraction of muscles
2. Sinus Headache
Virus, allergen, bacteria, temp

Nerves in sinuses swell

Headache
e.g. brain freeze due to swallowing of cold
substances rapidly

SYNCOPE/FAINTING
TRANSIENT LOSS OF CONSCIOUSNESS
INADEQUATE BRAIN PERFUSION
MANAGEMENT:
DANGLE FEET FOR 30 SEC BEFORE
STANDING
SPIRITS OF AMMONIA
VERTIGO

3. Hang-over headache
Alcohol blocks hormonal mechanisms

Dehydration

SENSATION OF:
ROTATING SURROUNDINGS
CLIENT IS ROTATING

4. Wine headache
Increases histamine/tyramine

Dilate blood vessels

Pressure on nerves

SEEN IN:
NEURO DSE
OTOLOGIC DSE
CARDIOVASC DSE
NEUROLOGIC PAIN

5. Migraine headache: 1:4 household

Women 3x more than men: 3days a week
May be caused by:
Light
Noise
Irregular eating and sleep
Chocolate
Strong smell
Peanut butter

Electrical impulse altered and triggers

trigeminal nerve

Trigeminal nerve=vasodilation and nerve

irritation

ARISE FROM NEUROLOGIC LESIONS

CONCERNING PAIN SENSATION
SURGERY:
NEURECTOMY 5TH NERVE
RESECTON
IN TRIGEMINAL
NEURALGIA
RHIZOTOMY- RESECTION OF
THE
POSTERIOR NERVE ROOT

Increased I C P
Increased blood volume, increased brain
volume, increased CSF volume

6. Cluster Headache
Excruciating pain
6 x more in men, 30 min to 2 hours
Nerves irritated

Pain signals

Tension Headache
Management:
Pharmacological

Normal pressure: 6-13mmHg, with pressure

transducer with head elevated 30;
60-180 cmH20, water manometer with client
lateral recumbent
3 essential components of skull:
1. Brain tissue-78%
2. Blood -12 %
3. CSF-10%

11

D. In infants where the cranial suture lines are

open, increased ICP will cause further
separation of the suture lines and
increased the circumference of the head.

Monroe-Kellie Hypothesis:
The skull is a CLOSED CONTAINER
and contains a fixed volume.
An increase in any one of the
components causes a change in
the volume of the other
Normal Compensatory Adaptations:
Initial:
o Increased CSF absorption
o Displacement of CSF into the spinal
subarachnoid spacespace between
arachnoid and pia mater)
o Collapse of the cerebral veins and dural
sinuses
Other mechanisms:
o Distensibility of the dura
o Increased venous outflow
o Decreased CSF production
o Constriction and vasodilation
o Slight compression of brain tissue

Schematic Diagram
Cranial insult

Tissue edema

Increased ICP

Compression of blood vessels

Decreased cerebral blood flow

Decreased oxygen with brain cell death

Edema around necrotic tissue

Increased ICP with brainstem and respiratory

center compression

Carbon dioxide accumulation

Vasodilation

Increased ICP

DEATH

Sustained increases associated with:

a. Cerebral edema
b. Head trauma
c.Tumors
d. Abscesses
e. Stroke
f. Inflammation
g. Hemorrhage

Factors that Increase ICP

Hypercapnea, hypoxemia
Cerebral vasodilating agents
Valsalva maneuver; coughing or sneezing
Body positioning
(prone, neck flexion, extreme hip flexion)
Isometric muscle contraction
Emotional upset; noxious stimuli
Arousal from sleep
Clustering of activities
Pain and agitation

Pathophysiology:
pressure results to lack of oxygen and blood
supply
MANIFESTATIONS:
1. HEADACHE
- TENSION ON INTRACRANIAL
VESSELS
NURSING CARE:
KEEP HOB ELEVATED
POST: NO TRENDELENBERG
ASPIRIN AS ORDERED
NO NARCOTICS

( PUPILLARY CHANGES)
2. VOMITING
- UNRELATED TO MEALS
OR NAUSEA
PROJECTILE
PRESSURE STIMULATION OF
MEDULLA OBLONGATA
NURSING CARE:
I&O
WITHHOLD ORAL FLUIDS
SUCTION IF NEEDED
3. WIDENING PULSE PRESSURE

- REFLEX EFFECT OF
CEREBRAL ANOXIA
NURSING CARE:
MONITOR VS HOURLY
REPORT WIDENING OF

A. Cerebral edema.
1. Vasogenic edema occurs when there is an
increase in the volume of brain tissue
caused by increase in the permeability
of the walls of the cerebral vessels.
Protein-rich fluid leaks into the extra
cellular space. Most often the cause of
IICP in adults.
2. Cytotoxic (cellular) edema occurs as a
result of hypoxia. This results in abnormal
accumulation of fluid within the cell
(intracellular) and a decrease of extra
cellular fluid.
B. Cerebral arteries dilate with a decrease in
the delivery of oxygenated blood.
1. Increase in PCO2 and accumulation of
lactic acid precipitates an acidotic state.
2. An acidotic state increases cerebral
vascular dilatation which, in turn, increases
cerebral vascular blood flow and increases
intracranial pressure.
C. Regardless of the cause, IICP will result in
progressive neuro deterioration; the
specific deficiencies seen are determined
by the area of compression of brain tissue.

12

PULSE PRESSURE
4. SLOWING OF RESPIRATION
- PRESSURE & ANOXIA
OF MEDULLA
- UNCAL HERNIATION
NURSING CARE:
MONITOR VS HOURLY
RR IN 1 FULL MIN
5. FALLING PULSE RATE
- REFLEX EFFECT OF RISING BP
NURSING CARE:
MONITOR VS HOURLY
PULSE IN 1 FULL MIN
6. PAPILLEDEMA
- due to the compression of optic disc
- UNCAL HERNIATION
NURSING CARE:
PUPILLARY CHECKS : EQUALITY
& REACTION TO LIGHT
7. LOSS OF MOTOR FUNCTION
- DECORTICATE
- DECEREBRATE
- PRESSURE ON MOTOR
CENTERS
NURSING CARE:
RECORD HEMIPARESIS
CN CXS
CHECK REFLEXES
8. SEIZURE
- INTRACRANIAL
- STIMULATION TO BRAIN
NURSING CARE:
CARRYOUT SEIZURE
PRECAUTION
9. LOSS OF SPHINCTER CONTROL
- CEREBRAL PRESSURE
- INTERFERE WITH SPHINCTER
INHIBITORY CONTROL

CUSHINGS TRIAD: HYPERBRADYBRADY

Hypertension
Bradycardia
Bradypnea
Late signs:
coma
apnea
unilateral pupil changes
TREATMENT:
CONSERVATIVE:
1. HYPERBARRIC O2 / HYPERVENTILATION
2. ELEVATE HOB
3. MEDICATIONS

Medications for Increased ICP:

Osmotic diuretics increases osmolarity of
blood and
draw fluid from edematous brain
and tissue
into vascular bed
- Mannitol
Loop diuretics such as furosemide
* STEROIDS- DECADRON ONLY STEROID
THAT CAN CROSS THE BBB
Antipyretics or hypothermia blanket:
used to control
increases in cerebral
metabolic rate
Anticonvulsants to manage seizure activity
Histamine H2 receptors to decrease risk of
stress ulcers
Barbiturates: may be given as continuous
infusion to
induce coma and decrease
metabolic
demands of injured brain
Vasoactive medicine may be given to
maintain blood
pressure to cerebral
perfusion
4.

NURSING CARE:
RECORD I & O
CHECK DISTENTION/
INCONTINENCE
CATHETERIZE
10.TEMPERATURE VARIATIONS
- DAMAGE TO HYPOTHALAMUS
- METABOLIC CHANGES
- DEVELOPMENT Of MENINGITIS
NURSING CARE:
ANTIPYRETICS
ICE BAG
REMOVE EXCESSIVE CLOTHING
PREVENT CHILLS
11.CHANGES IN LOC
- LETHARGY EARLIEST SIGN
OF INCREASED ICP
- PRESSURE ON CEREBRAL
CORTEX & RAS
NURSING CARE:
NOTE RESTLESSNESS
EVALUATE CONSCIOUSNESS
RECORD DISORIENTATION
& HALLUCINATIONS
12.BULGING OF FONTANELS
- MECHANICAL PRESSURE
NURSING CARE:
REPORT CSF LEAKAGE
REINFORCE WITH DRESSINGS

FLUID RESTRICTION

AGGRESSIVE treatment:
MECHANICAL DECOMPRESSION
1. CRANIOTOMY
- BRAIN TISSUE EXPANSION
- Surgery includes removal of brain
tumors, burr holes
2. VENTRICULAR DRAINAGE
- insertion of drainage catheter or
shunt to drain excessive CSF
ICP monitoring
Continuous intracranial pressure monitor is
used for continual assessment of ICP and to
monitor effects of medical therapy and nursing
interventions
Risk of infection exists with invasive
procedure
Nursing Diagnoses
1. Ineffective Tissue perfusion
2. Risk for infection: open head wounds and
intracranial monitor device requires meticulous
aseptic technique
3. Anxiety (family)

NURSING INTERVENTION

13

4. Aspiration is a major problem in the

unconscious client. Carefully assess the
swallow reflex in clients who are not
fully conscious; position the client in
Semi-Fowlers for tube feeding.
5. Maintain quiet, nonstimulating
environment if condition is unstable.
6. Inspect eyes and prevent corneal
ulceration.
a. Protective closing of eyes if the eyes
remain open.
b. Normal saline irrigation or
methylcellulose drops to restore
moisture.

Goal: to identify and decrease

problem of IICP.
1. Neuro checks as indicated by client
status.
2. maintain semi-Fowlers position to
promote venous drainage and
respiratory function.

NURSING ALERT > If the client with

IICP develops hypovolemic shock, do
not place client in Trendelenburgs
position, elevate the lower extremities
to enhance venous return.

Goal: to maintain psychological

equilibrium.
1. Neuro checks are a continuous reminder
of potential problem.
2. Encourage verbalization of fears
regarding condition.
3. Give simple explanation of procedures to
client and family.
4. Altered states of consciousness will cause
increased anxiety and confusion;
maintain reality orientation.
5. If client is unconscious, continue to talk to
him/her, describe procedures and
treatments; always assume that client
can hear.
6. Assist parents and family to work through
feelings of guilt and anger.
Goal: to prevent complications of
immobility.
Goal: to maintain elimination.
1. Urinary incontinence may use condom
catheter or indwelling bladder catheter.
2. Keep perineal area free from
excoriation.
3. Monitor bowel function; evaluate for
fecal impaction.

3. Change clients position slowly and

gently; avoid jerky movements.
4. Maintain fluid restriction.
5. Evaluate intake and output.
a. In response to diuretics.
b. As correlated with changes in daily
weight.
c. For complications of diabetes
insipidus.
6. Maintain intake evenly over twentyfour hour time period.
7. Sedatives and narcotics can
depress respiration and mask
symptoms indicating increasing ICP.
8. Client should avoid strenuous
coughing, Valsalvas maneuver,
and isometric muscle exercises.
9. In infants, measure frontal occipital
circumference to evaluate increase
in size of the head.
10. Control hyperthermia as indicated.

Goal: to maintain
respiratory function.

NURSING PRIORITY > Airway is one of

the most common problems in the
unconscious client, position them to
maintain patent airway or use airway
adjuncts.

COMPLICATION OF INCREASED ICP:

BRAIN HERNIATION
ABNORMAL BODY TEMPERATURE

1. Prevent respiratory problems of

immobility.
2. Evaluate patency of airway frequently;
as level of consciousness decreases,
client is at an increased risk for
respiratory obstruction by the tongue
and accumulating secretions.
3. Keep PCO2 levels within normal to low
range.
4. Suction as necessary, but in short
duration with rest periods.
5. Client may require intubation and
control on a volume ventilator.

HYPERTHERMIA/ HYPERPYREXIA
> or = 41o C or 106 o F
The temperature-regulatory center in
the hypothalamus can be disturbed by:
CEREBRAL EDEMA
CEREBROVASCULAR DISEASE
INTRACRANIAL SURGERY
HEAD INJURY
BRAIN TUMORS
NOTE:
EACH OC OF RISE IN TEMP = 13 % INCREASE
IN O2 REQIREMENTOF BODY TISSUESBRAIN
TISSUE IS HIGHLY SUSCEPTIBLE TO HYPOXIA

Goal: to protect from injury.

1. Take seizure precautions.

2. Restrain client only if absolutely
necessary; struggling against restraints
will increase ICP.
3. Do not clean the ears or nasal passages
of a head injury, or neuro surgery client.
If bleeding or drainage occurs from
these areas, evaluate carefully as it
may be cerebral spinal fluid.

NURSING MANAGEMENT:
MAINTAIN ROOM TEMP
INCREASE FLUIDS 3000 ML/DAY
ANTIPYRETICS
COMFORT MEASURES
MONITOR VS
ICE BAGS TO GROIN, AXILLA

14

APHASIA OR DYSPHASIA

2. Client at risk to develop hypoxia, acidosis,

hypoglycemia, hyperthermia, exhaustion
3. Life threatening medical emergency
requiring immediate treatment:
a. Establish and maintain airway
b. Diazepam (Valium) and Lorazepam
(Ativan) intravenously at
c.50% Dextrose IV
d. Phenytoin (Dilantin) IV-increase seizure
threshold
e. Pentobarbital-lessen nervous irritation
Medications:
a. Manage but do not cure seizures
b. Raise seizure threshold
c. Carbamezepine & Lamotrigine
- associated with Stevens-Johnson
syndrome (SJS) or toxic epidermal
necrolysis (TEN).
- very dangerous skin reactions
- These problems start out as skin
rashes but can progress to permanent
disfigurement or even loss of life.
d.Phenytoin
- most common SE is GINGIVAL
HYPERLASIA
NSG Care: ORAL HYGIENE
e. Valproic acid

NURSING CARE:
REHAB 6-12 WKS AFTER STROKE
FORMAL SPEECH THERAPY
VERBAL STIMULATION
TALK SLOWLY & IN A NATURAL TONE
SIMPLE WORDS & PHRASES
USE CARDS, PICTURES, SLATE BOARDS
SEIZURES
Seizures
-alteration in consciousness, sensory and
motor
Paroxysmal motor, sensory, or cognitive
manifestations of spontaneous abnormal
discharges from neurons in cerebral cortex
May involve all or part of brain consciousness,
autonomic function, motor function and
sensation
Epilepsy
: any disorder characterized by recurrent
seizures

1.
2.
3.
4.
5.

ETIOLOGIC FACTORS
Idiopathic
Fever
Head injury
CNS infection
Metabolic and toxic conditions

Key Interventions:
1. Protect client from injury and maintain
airway
2. Do not force anything into the clients mouth
3. Loosen clothing around neck

Categorization of seizures:

Nursing Diagnoses:
1. Risk for Ineffective airway clearance
2. Anxiety

Partial seizures: activation of part of one

cerebral hemisphere
a. Simple partial seizure: no altered
consciousness, recurrent muscle contraction;
motor portion of cortex affected
b. Complex partial seizure: impaired
consciousness; may engage in automatisms
(repetitive nonpurposeful activity such as lip
smacking, preceded by aura, originates in the
temporal lobe)

Interventions:
1. Assess for signs and symptoms of seizure
activity such as report of aura or twitching of
muscle groups
2. Have an oral airway oxygen and suction
readily available
3. Stay with client to protect him from injury
and observe seizure activity. If he is in bed,
remove pillows, raise side rails, and put bed on
flat position. Loosen any restrictive clothing
4. After seizure, assess respiration and pulse. If
they present and he is unresponsive turn him
onto his side to keep his airway patent
5. Cover him with a blanket for warmth and
privacy
6. Observe and document characteristics of
the seizure

Generalized seizures:
Involves both brain hemispheres;
consciousness always impaired
Absence seizures (petit mal): characterized
by sudden brief cessation of all motor activity,
blank stare and unresponsiveness often with
eyes fluttering
MYOCLONIC SEIZURE
SUDDEN INVOLUNTARY CONTRACTION
OF A SINGLE OR SMALL GROUPS OF
MUSCLE
MAY OCCUR DURING PETIT MAL
Tonic-clonic seizures
Preceded by aura, sudden loss of
consciousness
Tonic phase: rigid muscles, incontinence (as
muscle contracts, bladder relax)
Clonic phase: altered contraction, relaxation,
eyes roll back, froths at mouth
Post-ictal phase: unconscious and
unresponsive to stimuli

THE UNCONSCIOUS CLIENT

Coma
Irreversible coma - vegetative state
Permanent condition of complete
unawareness of self and environment, death of
cerebral hemispheres with continued function
of brain stem and cerebellum
Client does not respond meaningfully to
environment but has sleep-wake cycles and
retains ability to chew, swallow and cough
Eyes may wander but cannot track objects

Status Epilepticus
1. Continuous seizure activity, generally tonicclonic type

15

Minimally conscious state: client aware of

environment, can follow simple commands,
indicates yes/no responses; make meaningful
movements (blink, smile)
Often results from severe head injury or
global anoxia

DEGENERATIVE DISEASES
I. PARKINSONS DISEASE

Degeneration of dopamine-providing cells

in the substantia nigra, which leads to
degeneration of neurons in the basal
ganglia; usually develops after 60 age
Associated with decreased levels of
dopamine due to destruction of pigmented
neuronal cells in the substantia nigra in the
basal ganglia of the brain (Smeltzer &
Bare, 2004, p. 1979)
Imbalance between dopamine and
acetylcholine
Three cardinal features:
1. Tremors at rest
e.g. rhythmic, slow turning motion (pronationsupination) of the forearm and the hand and a
motion of the thumb against the fingers as if
rolling a pill
tremor is present while at rest, increases
when the patient is walking, concentrating,
feeling anxious (Smeltzer & Bare, 2004, p.
1980).
2. Rigidity-resistance to passive limb
movement
3. Bradykinesia-most common features;
patients take longer to complete most
activities and have difficulty initiating
movement

Locked-in syndrome
1. Client is alert and fully aware of
environment; intact cognitive abilities but
unable to communicate through speech or
movement because of blocked efferent
pathways from brain
2. Motor paralysis but cranial nerves may be
intact allowing client to communicate through
eye movement and blinking
3. Occurs with hemorrhage or infarction of
pons, disorders of lower motor neurons or
muscles

Brain Death
1. Cessation and irreversibility of all brain
functions
2. General criteria:
a. Absent motor and reflex movements
b. Apnea
c. Fixed and dilated pupils
d. No ocular responses to head turning and
caloric stimulation
e. Flat EEG

Clinical Manifestations:
Generalized feelings of stiffness
Mild, diffuse muscular pain
Hand tremor at rest (pill rolling)
Akinesia
Gait changes shuffling gait
Characteristic stance-stooped posture
Masklike-facial expression
Speech pattern-slow, low volume monotonous
in tone with poor articulation
Involuntary drooling
Decreased lacrimation; constipation,
incontinence
Heat intolerance; excessive perspiration
Lack of spontaneous swallowing

NURSING DIAGNOSES
Ineffective airway clearance: limit suctioning
to <10-15 seconds, hyperoxygenate
Risk for aspiration
Risk for impaired skin integrity: preventive
measures, continual inspection
Impaired physical mobility: maintain
functionality of joints, physical therapy
Risk for Imbalanced Nutrition: Less than body
requirements
Anxiety (of family)
NEUROLOGICAL DISORDERS
1. DEGENERATIVE DISEASES
- PREMATURE SENESCENCE OF CELLS
- Parkinsons disease
- Huntingtons Chorea
- ALS
- Alzheimers
2. AUTOIMMUNE DISEASE
- Multiple Sclerosis
- MG
- GBS
3. CEREBROVASCULAR DISEASES
- ARTERIOSCLEROSIS
- ANEURYSM, HEMORRHAGE
- INFARCTION
- CVA
4. TRAUMATIC INJURIES
- HEAD INJURY
- SPINAL INJURY
5. NEUROPATHIES
- TRIGEMINAL NEURALGIA
- BELLS PALSY
6. NEOPLASMS
-

Medical Management
Levodopa-Carbidopa T-synthetic precursor of
dopamine for basal ganglia (Sinemet)
Anticholinergic-to control symptoms
(Cogentin, Artane, Symmetrel); anticholinergic
drugs act at central sites to inhibit cerebral
motor impulses that cause rigidity of the
musculature
MAOI-Bomcriptine; inhibit breakdown of
dopamine
Physiotherapy-reduces rigidity of muscles and
prevents contractures
Surgical intervention-to destroy globus
pallidus (to relieve rigidity) and/or thalamus
(relieve tremors)
Nursing Management
Provide safe environment
Nutrition
Small bite pieces of food to prevent
choking
Small frequent meals for easy
mastication

16

Adequate intake of roughage to prevent

constipation
Encourage diet rich in nutrient-dense
foods such as fruits, vegetables, whole
grains
Positioning and activity
Limit postural activities
Maintain gait as normal as possible: may
utilize cane or wheel chair
Encourage daily physical therapy to limit
rigidity and prevent contractions
Medication compliance; report side
effects
Avoid rushing client as he is unable to work
under pressure
Assist client in setting achievable goals to
improve self-esteem
Total body function support in advanced
stages (respiratory elimination)

Ineffective Breathing Pattern: may

require mechanical ventilation and
tracheostomy
Nursing Management:
1. Improving Respiratory Function
2. Preventing Aspiration
- assess for drooling, regurgitation
through
the nose and choking while
attempting to
swallow
- provide standby suction
- encourage rest before meals; place
patient
in an upright position to
facilitate swallowing
- provide soft foods that are easily
swallowed
3. Increasing Physical Mobility
- emphasize importance of taking
medications on time to improve
strength and endurance
4. Improving Communication

II. AMYOTROPIC LATERAL SCLEROSIS

(ALS)
is a progressive,fatal,
neurodegenerative disease caused by
the degeneration of motor neurons, the
nerve cells in the central nervous
system that control voluntary muscle
movement
Progressive, degenerative neurologic
disease characterized by weakness and
wasting of muscles without sensory
or cognitive changes
onset is usually between age of 40 60
higher incidence in males at earlier
ages but equally post menopause
Death usually occurs in 2 5 years due
to respiratory failure

III. HUNTINGTONS DISEASE

is a neurodegenerative genetic disorder
that affects muscle coordination and
leads to cognitive decline and dementia
Cause unknown
Autosomal dominant genetic disorder
- each children of a parent with
Huntingtons disease has a 50% risk of
inheriting the disorder
No cure
Usually asymptomatic until age of 30
40
a significant reduction (volume and
activity) of acetylcholine and nerve cell
degeneration
Clinical manifestations:
1. Movement
Chorea abnormal involuntary
movements
Clumsiness
Jaw clenching (bruxism)
Loss of coordination and balance
Slurred speech
Swallowing and/or eating
difficulty
Uncontrolled continual muscular
contractions (dystonia)
Walking difficulty, stumbling,
falling

Clinical Manifestations :
depends on the location of the affected
motor neurons
Chief symptoms:
fatigue
progressive muscle weakness
cramps
fasciculation (twitching)
incoordination
Difficulty lifting the front part of the foot
and toes (footdrop)
Weakness in the leg, feet or ankles
Hand weakness or clumsiness
Slurring of speech or trouble swallowing
Medical Management
no specific treatment for ALS
Supportive and Rehabilitative
Measures
Baclofen, dantrolen sodium,
or diazepam for spasticity
Quinine for muscle cramps
Riluzole a glutamate
antagonist, to slow muscle
degeneration
Enteral Feedings
(percutaneous endoscopic
gastrotomy [PEG]) for patients
with aspiration or swallowing
difficulties
Nursing Diagnoses
Risk for Disuse Syndrome

2. Cognitive:
Cognitive function is usually affected
with dementia usually occurring.
Impaired judgment and memory
Slowing of thought processes to control
muscle.
3. Psychiatric Symptoms
A. Depression
b. Psychotic symptoms
- Delusions
- Hallucinations
- Paranoia
Management::
NO treatment that halts or
reverses
Medications to reduced chorea:
a) Dopamine receptor blockers

17

- improve the chorea in many

patients
- Thiothixene Hydrochloride

Stage

(Navane)
- Haloperidol Decanoate (Haldol)
b) Riluzole (Rilutek)
- showed to reduce chorea
c.) Antidepressants
- for patients with emotional
disturbances, particularly
depression.
d.) Antipsychotic medications
- (in low doses) for patients with
psychotic symptoms.
Nursing Diagnoses :
Risk for injury
Risk for Aspiration
Imbalanced Nutrition: Less than body
requirements
Impaired Skin Integrity
Impaired Verbal Communication
Disturbed thought processes

Stage

Stage

Nursing Care :
Focus on:
1. Mobility
2. Personal hygiene
3. Communication
4. Nutrition
5. Elimination
6. Genetic counseling

>Forgetfulness
>Mild memory lapses
>Short attention span
>Decrease interest in personal affairs
>subtle behavior changes
#2
>short term memory Lapses
>hesitant speech
>confabulation to hide memory
problems
>misplace item
>repetitive behavior
#3
>Disoriented to person,place,time
>wanders
>Apraxia-impairment in the ability to
perform purposeful acts or to
manipulate objects
#4
>Terminal Stage
>severe physical and mental
deterioriation
>No recognition of self/others
>completely dependent
>incontinent
>Aphasia
>Dysphagia

Medical Management
Medication to treat symptoms
Memory:Cognex, Aricept
Agitation: Mellaril, Haldol
Supplements
Folic Acid & Vitamin B12
Low fat diet
NSAIDS
Nursing Diagnosis
ALTERED THOUGHT PROCESS
NURSING INTERVENTIONS:
1. Support patients abilities
2. Provide emotional support
3. Establish an effective communication
system with the patient and family
Use short simple sentences,
words and gestures
Maintain a calm and consistent
approach
Attempt to analyze behavior for
meaning
4. protect the patient from injury
Provide a safe and structured
environment
Requests a family member to
accompany client if he wanders
around
Keep bed in low position
Provide adequate lightning
Assign consistent caregivers

2 key points for all care:

IV. ALZHEIMERS disease

A progressive neurologic disorder that
affects the brain resulting in cognitive
impairments
CAUSES:
Unknown
Potential factors- Amyloid plaques in
the brain, Oxidative stress,
neurochemical deficiencies
Very common; risk increases with age
Brain changes:
plaques
tangled neurons
blood vessel degeneration
chemical changes
Autopsy is the most definitive

Ten warning signs of Alzheimer's disease

Memory loss
Difficulty performing familiar tasks
Problems with language
Disorientation to time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood or behavior
Changes in personality
Loss of initiative

Prevent overstimulation
Provide structured, orderly
environment
4 Cs in Alzheimers
Use of:
1. Calendar
2. Clock
3. Colors
4. Consistency of caregivers

4 STAGES OF Alzheimer's DISEASE

Stage # 1

18

2. Optic nerve involvement: blurred vision,

haziness
3. Brain stem involvement: nystagmus,
dysarthria (scanning speech); cognitive
dysfunction, vertigo, deafness
4. Weakness, numbness in legs, spastic
paresis, bladder and bowel dysfunction
5. Cerebellar involvement: nystagmus,
ataxia, hypotonia
6. Blindness

Creutzfeldt-Jakob disease
- Rapid progressive degenerative neurologic
disease causing brain degeneration without
inflammation
Transmissible and progressively fatal
Variant form of CJD is mad cow
disease: believed transmitted by
consumption of beef contaminated with
bovine form of disease
Pathophysiology: spongiform
degeneration of gray matter of brain
No definitive treatment. Outcome is
fatal.

CHARCOTS TRIAD -> NYSTAGMUS

INTENTIONAL TREMOR
SCANNING SPEECH
TREATMENT:
1.
No cure; medical treatment is
directed toward
treatment
of
the
disease process and
symptoms.
2.
Medications to decrease edema
and
inflammation of the nerve site.
a.
Anti-inflammatory.
b.
Antispasmodic.
c.
Immunosuppressive.
d.
Anticholinergic and cholinergic.
e.
Interferons.

Manifestations:
Personality changes
Anxiety
Depression
Memory loss
Impaired thinking
Blurred vision
Insomnia
Difficulty speaking
Difficulty swallowing
Sudden jerky movements
Terminal states: clients are comatose
with decorticate and decerebrate
posturing

Nursing Intervention:
Goal: to maintain homeostasis and
prevent complications in an acute
exacerbation of disease symptoms.
1. Maintain adequate respiratory function.
a.
Prevent respiratory infection.
b.
Good pulmonary hygiene.
c.
Prevent aspiration; sitting
position for
eating.
d.
Evaluate adequacy of cough
reflex.
2.
Maintain urinary tract function.
a.
Prevent urinary tract infection.
b.
Increase fluid intake.
c.
Evaluate voiding-assess for
retention
and
incontinence.
d.
Provide good perineal care.
3. Maintain nutrition.
a.
Evaluate coughing and
swallowing
reflex.
b.
Provide food that is easy to
chew.
c.
If client is experiencing difficulty
swallowing, observe closely with
fluid intake.

Nursing Care :
Use of standard precautions with blood
and body fluids
Support and assistance to client and
family
AUTOIMMUNE DISEASES
I. MULTIPLE SCLEROSIS
An auto-immune mediated progressive
demyelinating disease of the CNS
The myelin sheath is destroyed and
replaced by sclerotic tissue (sclerosis)
Periods of exacerbations and
remissions
CAUSE- unknown
Multiple factors- viral infection,
environmental factors,geographic
location and genetic predisposition
Incidence is highest in young adults
(20 40); onset between 20 50
Affects females more than males (MS
feminine title)
More common in temperate climates

4. Prevent
1.
2.
assist

complications of immobility.
Focus on remaining capabilities.
Encourage independence and
client to
gain control over
environment.
3.
If impotence is a problem,
initiate sexual counseling.
4.
Assist client to work through the
grieving process.
5.
Identify community resources
available.

PATHOPHYSIOLOGY
Sensitized T cells will enter the brain
and promote antibody production that
damages the myelin sheath
Plaques of sclerotic tissues appear on
the demyelinated axons interrupting
the neuronal transmission

5. Assist client to understand implications of

the disease process and measures to
maintain health.
1.
Medical regimen and side effects
of
the medications.

Manifestations
1. Fatigue- initial manifestation

19

2.
muscle
A.
B.
C.

Physical therapy to maintain

function and decrease spasticity.
Water exercises.
Stretching exercises.
Gait training and devices to
maintain ambulation.
6. Measures to maintain voiding.
a. Participation in bladder
retraining.
b. Crde method of voiding
c. Intermittent self-catheterization
as indicated-residual urine
should be less than 150 cc.
7. Safety measures due to decreased
sensation.
a. Check bath water temperature.
b. Wear protective clothing in the
winter.
c. Avoid heating pads and clothing
that is constrictive.
d. Client should understand that
relapses are frequently
associated with an increase in
physiological and psychological
stress.

3) May be characterized by
short remissions and
exacerbations
a. Myasthenic crisis-an acute
exacerbation of symptoms of
the condition characterized by
weakness of the muscles
controlling swallowing and
breathing (dysphagia,
dysarthria, dyspnea). Occurs as
a result of
insufficientacetylcholine
(anticholinesterase)or
exacerbation of disease state.
b. Cholinergic crisis is a toxic
response to the
anticholinesterase medications.
c. The symptoms of a myasthenic
crisis and a cholinergic crisis are
essentially the same.
1. Difficulty breathing, swallowing,
chewing, or speaking.
2. Increased secretions (saliva,
bronchial).
3. Restlessness and apprehension.
4. Tensilon test to differentiate
crisis.
3. Diagnostics.
a. Clinical manifestations.
b. Electromyography-shows a
decreasing response of muscles to
stimuli.
c. TENSILON test- edrophonium
chloride (Tensilon)
administered and
client with
myasthenia will show
significant improvement lasting 5
minutes
Treatment:
1. Anticholinesterase (cholinergic)
medications
a. to improve impulse
transmission (Mestinon)
2. Steroids
a. to suppress immune
system (steroids,
Cytoxan)
3. Plasmapheresis
a. Used to remove
antibodies
4. Immunosuppressive therapy.
5. Surgical removal of the thymus
(thymectomy).

II. MYASTHENIA GRAVIS

A neuromuscular disease
characterized by a decrease in
acetylcholine at the receptor sites in
the neuromuscular junction;
precipitates a disturbance in the
transmission of nerve impulses.
Assessment
1. Risk factors/etiology.
a) Condition has been
associated with dysfunction
of the thymus gland.
b) Autoimmune in origin.
c) More common in women.
d) Peak incidence between 20
and 30.
2. Clinical manifestations.
a. Primary problem is skeletal
muscle fatigue; symptoms are
predominantly bilateral.
1) Muscular fatigue
increases with activity.
2) Ptosis(drooping of the
eyelids) and diplopia
(double vision) are
frequently the first
symptoms.
3) Impairment of facial
mobility and expression.
4) Impairment of chewing
and swallowing.
5) Speech impairment
(dysarthria).
6) No sensory deficit, loss of
reflexes, or muscular
atrophy.
b. Course is variable.
1) May be progressive.
2) May stabilize.

Nursing Intervention:
( Client generally hospitalized for
acute myasthenic crisis or for
respiratory infection).
Goal: to maintain respiratory
function.
1. Assess for increasing problems
of difficult breathing.
2. Determine clients medication
schedule; when was medication
last taken?
3. Assess ability to swallow;
prevent problems of aspiration.
4. Evaluate effectiveness of cough
reflex.
5. Have emergency tracheotomy
set available.

20

Nursing Priority: Do not give the

client in myasthenic crisis
anything to eat or drink, there
is significant increased risk for
aspirating during this time.

2. Clinical manifestations.
a) Begins in the lower
extremities and ascends
bilaterally
1. Weakness.
2. Ataxia.
3. Bilateral paresthesia
progressing to complete
paralysis.
b). paralysis ascends the
body symmetrically and
produces problems of the lower
brain stem.
1) Paralysis of
respiratory muscles.
2) Difficulty talking and
swallowing.
3) Cranial nerve
involvement.
c). Loss of sensation and function
of bowel and bladder.
d). Manifestations may progress
rapidly or occur over two to
three
weeks.
e). Muscle atrophy is minimum.

Goal: to distinguish between

myasthenic crisis and cholinergic
crisis.
1. Maintain adequate ventilatory
support during crisis.
2. Assist in administration of
TENSILON to differentiate crisis
a) Myasthenic crisis-clients
condition will improve.
b) Cholinergic crisis-clients
condition will improve.
3. If myasthenic crisis, neostigmine
may be administered.
4. If cholinergic crisis, atropine may
be administered and all
cholinergic medications
discontinued.
5. Avoid use of sedatives and
tranquilizers which cause
respiratory depression.
6. Provide psychological support
during crisis.
Goal: to assist client to understand
implications of disease process and
measures to maintain health.
1. Importance of taking
medication on a regular
basis; peak effect of the
medication should
coincide with mealtimes.
2. If ptosis becomes severe,
client may need to wear
an eye patch to protect
cornea (alternate eye
patches if problem is
bilateral).
3. Emotional upset, severe
fatigue, infections, and
exposure to extreme
temperatures may
precipitate myasthenic
crisis.

Nursing Priority: Of the

neuromuscular disorders,
Guillain-Barre is the most
rapidly developing and
progressive condition. It is
potentially fatal if
unrecognized.
3. Diagnostics based primarily on
the clinical manifestations.
Treatment:
(Supportive).
1. Corticosteroids.
2. Maintain respiratory
function; may require
mechanical
ventilation.
Nursing Intervention:
Goal: to evaluate progress of
paralysis and initiate actions to
prevent complications.
1. Evaluate rate of progress of
paralysis; careful assessment of
changes in respiratory pattern.
2. Frequent evaluation of cough
and swallow reflex.
a) Remain with client while
eating; have suction
equipment available.
b) NPO if reflexes are
involved.
3. If paralysis is rapid, prepare for
ET intubation and respiratory
assistance.
4. Prevent complications of
immobility during period of
paralysis.

III. GUILLAIN-BARR SYNDROME

This condition involves segmental
demyelination of nerve root in the
PNS. Demyelination occurs, leading to
inflammation, edema and nerve root
compression which causes decreased nerve
conduction and rapidly ascending paralysis.
Both sensory and motor impairment, also
called polyradiculitis.
Assessment
1. Risk factors/etiology.
a) Possibly autoimmune in
origin.
b) May effect any age group,
more common in ages 20 to
50.
c) May be associated with
swine flu immunizations.
d) Frequently preceded by mild
respiratory of intestinal
infection.

Goal: To prevent complications of

hypoxia if respiratory muscles
become involved.
Goal: to maintain psychological
homeostasis.

21

1. Simple explanation of
procedures.
2. Generally complete
recovery is
anticipated; residual
problems are not
common.
3. provide psychological
support during period
of assisted
ventilation.
4. Keep client and family
aware of progress of
disease.

2. Frequently indicative of advanced

atherosclerotic disease of the cerebral
vessels.
3. Should be considered a warning
symptom of an impending CVA.
4. Neurologic dysfunction is present for
minutes to hours, but no permanent
neurological deficit remains.
RISK FACTORS ASSOCIATED WITH
CEREBRAL VASCULAR ACCIDENT
Reversible:
Smoking
Obesity
Increased salt intake
Sedentary life style
Oral contraceptives

Cerebral Vascular Accident (CVA)

Also known as a stroke, CVA is the disruption of
the blood supply to an area of the brain
resulting in tissue necrosis and sudden loss of
brain function.
BRAIN:
2% of the body's weight
20% of the oxygen supply
gets 20% of the blood flow.
Consumes 70% of the glucose in the
body
If brain cells do not get oxygen for 3 to
5 minutes, they begin to die.
CEREBRAL ANOXIA:

Partially Reversible:
Hypertension
Cardiac valve disease
Dysrhythmias
Diabetes mellitus
Hypercholesterolemia
Nonreversible:
Sex (increased incidence in men)
Age
Increased incidence in the black
Hereditary predisposition

4-6 Minutes REVERSIBLE

> 10 Minutes IRREVERSIBLE

1. Damage to the left side of the brain will

result in paralysis of the right side of
the body (hemiplegia-paralysis of one
side of the body).
2. Both upper and lower extremities of the
involved side are affected.

A. Atherosclerosis resulting in cerebral

vascular disease, frequently precedes
the development of a CVA.
B. Types of stroke.
1. Thrombosis-formation of a clot which
results in the narrowing of a vessel
lumen and eventual occlusion.
a.
Associated with hypertension
and diabetes (i.e., conditions which
accelerate atherosclerotic process).
b.
Associated with atherosclerotic
disease of the
carotid,
subclavian, and vertebral arteries.
c.
Generally a condition of the
elderly.
2. Embolism occlusion of a cerebral
artery by an embolus.
a. common site of origin is the
endocardium.
b. May effect any age group; frequently
associated with rheumatic heart
disease and atrial fibrillation.

Assessment:
1. Risk factors/Etiology: (see previous
table)
2. Clinical Manifestations:
a. TIA
1. Temporary loss of vision in one
eye
2. Transient hemiparesis
3. Tinnitus
4. Vertigo
5. Confusion
6. Nosebleeds(epistaxis)
b. Completed CVA (occurs suddenly
with an embolism
more gradually in
hemorrhage or thrombosis)
1. Hemiplegia loss of voluntary
movement, damage to the right side of
the brain will result in left-sided
weakness and paralysis
2. Aphasia defect in using and
interpreting the symbols of language,
may include written, printed or spoken
words, may be partial or complete.
3. Problem of neuromuscular control of
respiration.
4. Problem of neuromuscular control over
swallowing and cough reflex.
5. Initially may be incontinent.

3. Cerebral hemorrhage.
a. Rupture of a cerebral artery secondary
to hypertension, trauma, or aneurysm.
b. Blood leaks into the brain tissue and
the subarachnoid space; creates a mass
that displaces the brain.
C. The area of edema resulting from tissue
damage may precipitate more damage
than the vascular damage itself.
Transient ischemic attack (TIA).
1. Brief episode of neurological
dysfunction.

22

6. Agnosia- a perceptual defect that

causes a disturbance in interpreting
sensory information, client may not be
able to recognize previously familiar
objects.
7. Emotional lability.
8. Impairment of judgment and memory.
9. Hypotonia (flaccidity) for days to weeks
followed by hypertonia (spasticity).
10. Visual defects homonymous
hemianopsia, the loss of vision in one
half of the visual field.
11. Perceptual defects.
12. Apraxia inability to carry out learned
movements.

2. Appropriate medical attention for

control of chronic conditions conducive
to the development of CVA (Partial
reversible risk factors).
Goal: to maintain patent airway and
adequate cerebral oxygenation.
1. Position side-lying with head elevated.
2. Assess for symptoms of hypoxia; ET
intubation and mechanical ventilation
may be necessary.
3. Maintain patent airway; use
oropharyngeal airway to prevent airway
obstruction by the tongue.
4. Client is prone to obstructed airway and
pulmonary infection; have/her cough
and deep breathe as indicated.

Nursing Diagnosis:
- Ineffective Airway Clearance related to
neurological deficits
inability to cough.
- Altered Tissue Perfusion related to
interrupted cerebral
vascular blood
supply.
- Impaired Verbal Communications related
to visual and
speech impairment.
- Potential for Injury related to seizures and
neurological
deficits.
- Alteration In Nutrition:
Less Than Body Requirements related
difficulty in swallowing and potential for
aspiration.
- Impaired Physical Mobility related to
severe weakness and
paralysis.
- Knowledge Deficit related to prognosis.
3. Diagnostics
a. Clinical manifestations elicited in the
neurological exam.
b. Cerebral arteriogram.
c. Lumbar puncture
d. CAT and brain scan.
Treatment
1. Prophylactic.
a. Aspirin.
b. Persantine
c. Antihypertensives.
2. Medical
a. Medications to decrease cerebral
edema.
1. Osmotic diuretics
2. Corticosteroids (dexamethasone).
b. Medical measurements to maintain
homeostasis.
3. Surgical.
a. Carotid endarterectomy.
b. Cerebral revascularization.

Goal: to assess for and implement

measures to decrease intracranial pressure
Goal: to maintain adequate nutritional
intake.
1. Administer PO feedings with caution;
check presence of gag reflex and
swallowing before feeding.
2. Place food on the unaffected side of the
mouth.
3. Select foods that are easy to control in
the mouth and swallow; liquids often
promote coughing as client is unable to
control them.
4. Maintain high Fowlers position for
feeding.
5. Maintain privacy and unrushed
atmosphere.
6. If client is unable to tolerate PO intake,
tube feedings may be initiated.
Goal: to preserve function of the
musculoskeletal system to prevent joint
contraction and muscle atrophy.
1. Passive ROM on affected side.
2. Active ROM on unaffected side.
3. Utilize footboard to keep at right angles
and prevent foot drop.
4. Legs should be maintained in a neutral
position; prevent external rotation of
affected hip by placing a trochanter roll
or sandbag at the thigh.
5. Position every two hours but limit the
period of time spent on the affected
side.
6. Assess for adduction and internal
rotation of the affected arm; maintain
arm in a neutral (slightly flexed)
position with each joint slightly higher
than the preceding one.
7. Restraints should be avoided, they
often increase agitation.
8. Maintain joints in position of normal
function to prevent flexion contractures.

Unilateral Neglect/ Neglect Syndrome

- neuropsychological condition in which,
after
damage to one hemisphere of
the brain, a
deficit in attention to and
awareness of
one
side
of space is
observed.
- is very commonly seen contralateral
to the
damaged
hemisphere

Goal: to maintain homeostasis through

continued nursing assessment and
appropriate nursing intervention.

Nursing Intervention
Goal: to prevent CVA through client
education.

1. Evaluate adequacy of cardiac

output.
2. Monitor hydration status-prevent
fluid overload.

1. Identification of individuals with

reversible risk factors and measures to
reduce them.

23

a. Carefully regulate IV intake.

b. Evaluate response to diuretics.
c. Assess for the development of
peripheral edema.
d. Restrict fluid intake as indicated.
e. Assess respiratory parameters
indicative of fluid overload
(rales, dyspnea, etc.)
3. Maintain and promote normal
elimination.
a. Avoid urinary catheter if
possible; if catheter is
necessary, remove as soon as
possible.
b. Offer bedpan or urinal every two
hours; help establish a schedule.
c. Prevent constipation- increase
bulk in the diet, stool softeners,
etc.
d. Provide privacy and decrease
emotional trauma related to
incontinence.
4. Prevent problems of skin
breakdown through proper
positioning and good skin
hygiene.
5. Maintain psychological
homeostasis
a. Client is very anxious due to the
flack of understanding of what
has happened to him/her and
the inability to communicate.
b. Speak slowly, clearly, and
explain what has happened.
c. Assess clients communication
abilities and identify methods to
promote communication.

e. Do not talk down to or treats

as a child.
f. Mental status may be normal; do
not assume it is impaired.
NIH STROKE SCALE
Standardized stroke severity scale to
describe neurological deficits in acute
stroke patients
Allows to:
Quantify our clinical exam
Determine if the patients
neurological status is improving
or deteriorating
Provide for standardization
Communicate patient status
11 item scoring system
Integrates components of neurological
exam
Includes testing of LOC, select cranial
nerves, motor, sensory, cerebellar
function, language, inattention
(neglect)
Maximum score: 42, minimum score: 0
NIHSS tests the following items:

Goal: to assist client to become

independent in activities of daily
living as rehabilitation phase
progresses.

LOC
Best gaze
Visual field testing
Facial paresis
Arm & leg motor function
Limb ataxia
Sensory
Best language
Dysarthria
Extinction & inattention

NIHSS and Patient Outcomes

Total scores range from 0-42 with
higher values representing more severe
infarcts
>25 Very severe neurological
impairment
15-24 Severe impairment
5-14
Moderately severe
impairment
<5
Mild impairment

1. Encourage self-feeding
2. Provide clothing easy to get in
and out of.
3. Active participation in ROM; do
his/her own ROM on affected
side.
4. Physical therapy for retraining of
lost function.
5. When in the sitting position,
assist client to maintain sense of
balance; client will frequently fall
to the affected side.
6. Encourage participation in
carrying out daily personal
hygiene.
7. Assist/teach client safe transfer
from bed to wheelchair.
8. Maintain bowel and bladder
training program.
9. Promote urinary continence.
10. Encourage social interaction.
a. Speech therapy
b. Frequent and meaningful verbal
stimuli.
c. Allow client plenty of time to
respond.
d. Speak slowly and clearly; do not
give too many directions at one
time.

A 2-point (or greater) increase on the

NIHSS administered serially indicates
stroke progression. It is advisable to
report this increase.
When to Communicate NIHSS Results

Neurological decline
New focal deficit
Advancing neurological deficit
Other concern

CEREBRAL ANEURYSM, SUBARACHNOID

HEMORRHAGE

24

A dilation of the wall of a cerebral artery

(Berry aneurysm) most often arises from an
arterial junction in the Circle of Willis.

Nursing Priority: If the client survives

the rupture of the aneurysm, it is
most likely to rebleed within the next
24 to 48 hours.

a. An aneurysm frequently ruptures and bleeds

into the subarachnoid space.
b. Symptoms occur when aneurysm enlarges
and exerts pressure on the brain tissue, or
when it ruptures.
c. Frequently the vasopasm that accompanies
the rupture causes a significant increase in the
area of damage.

Goal: to assess for and implement nursing

measures to decrease intracranial
pressure.
Goal: to provide appropriate preoperative
nursing intervention.
Goal: to maintain homeostasis and monitor
changes in intracranial pressure
postoperative craniotomy.

Assessment

TRAUMATIC INJURIES

1. Risk factors/etiology.
a.
Congenital deformities of
the vessel.
b.
Atherosclerosis resulting
in weakness of the vessel
wall.
c.Hypertension; head trauma may
enhance the problem.
d.
Most often occurs in
middle life.
2. Clinical manifestations.
a. A Rupture may be preceded by:
a. Severe headache.
b. Intermittent nausea.
c. Rupture frequently occurs without
warning.
1. Severe headache.
2. Seizures.
3. Nuchal rigidity
4. Hemiparesis.
5. Loss of consciousness.
6. Overall symptoms depends on
the site and
amount of
bleeding; overall prognosis is poor.
3. Diagnostics.
a. Lumbar puncture, revealing blood in the
spinal fluid.
b. Cerebral angiogram.
c. CAT scan.
Treatment
1. Osmotic diuretics.
2. Antihypertensive medications.
3. Surgical intervention-ligation or
clipping of the aneurysm.

Head

Injury
Laceration
Hematoma
Contusion
Bleeding

Sources:
1. Scalp injury
2. Skull fracture
3. Brain injury

Risk factors:
a. Motor vehicle accidents
b. Elevated blood alcohol levels
c. Greatest risk: male aged 15-30 and those
over 75
Mechanism of trauma:
1. Acceleration injury: head struck by
moving object
2. Deceleration injury: head hits stationary
object
3. Acceleration-deceleration (coupcountercoup phenomena) head hits objects
and brain rebounds within skull
Diffuse axonal injury-most severe form of
brain injury also called shearing injury
Types of brain Injury:
a. Open head injuries (dura)
b. Closed head injuries blunt trauma
c. Concussions caused by sudden blow to the
head or rapid acceleration-deceleration
results in retrograde amnesia and loss
of consciousness for 5 minutes
No break in skull or dura
May have headache, nausea or
vomiting
d. Contusions-cause more damage, damage to
brain itself involve cortical bruising and
laceration of vessels and brain tissues

Nursing Intervention
Goal: to prevent further increase in intracranial
pressure and possible rupture.
1. Immediate, strict bed rest.
2. Prevent Valsalvas maneuver.
3. Client should avoid straining, sneezing,
pulling up in bed, acute flexion of the
neck, cigarette smoking.
4. Elevate head of the bed 15 to 30.
5. Quiet, dim, nonstimulating
environment.
6. Constant monitoring of condition to
identify occurrence of bleeding as
evidenced by symptoms of increasing
intracranial pressure.
7. Administer analgesics cautiously, the
client should continue to be easily
aroused in order to perform neuro
checks.

Complications of Brain Injury

A. Post concussion syndrome:
Manifestations:
Headache, dizziness
Nervousness, irritability
Changes in intelligence, poor
concentrating, poor memory
Fatigability
Insomnia
Traumatic Brain Injury

25

Epidural
Subdural
Intracerebral

Glucose reagent strip: If positive indicates

CSF
Interventions:
a. Keep nasopharynx and external ear clean
b. No blowing nose, coughing or hard sneezing
c. Prophylactic antibiotic

B. Hematoma Formation:
1. Subdural hematoma (slower progression)veins, poor prognosis due to late diagnosis;
occurs within 24-48 hours of injury in acute, 214 days in subacute; can occur up to several
months in chronic
Manifestations:
Acute
Progressive and marked depression of
consciousness
Headache, drowsiness, agitation and
confusion
Pupillary and motor changes

Nursing Management for head injuries:

Immediately following surgery:
Immobilize head and neck until cervical injury
is ruled out
Avoid flexion: hyperextension and rotation of
the neck
Jaw thrust maneuver
-Patent airway and support ventilatory function
-Document baseline neurological assessment

Chronic
Increasing severe headache
Slow cerebration and drowsiness
Papilledema and ipsilateral pupil
dilatation

After initial stabilization:

Monitor neurological status every hour until
stable
-LOC, responsiveness
-Pupillary size, position, direct and consensual
response
-Assess extraocular movements
-Note verbal and motor changes

Systemic-Bilateral
2. Epidural (extradural) Hematoma
Immediate loss of consciousness, lucid
interval lasting for few minutes or hours; lapse
into unconsciousness
Severe, headache, seizures, vomiting,
hemiparesis, fixed, dilated ipsilateral pupils

Monitor for complications

-Hematoma formation
-Infection
-Acute hydrocephalus
-ARDS
Monitor temperature and maintain
normothermia (decrease metabolism)
Report high urine output (over 200 ml/hr for 2
consecutive hours)
Monitor osmolality and serum electrolytes
CBC
ROM exercises
Eye/ear care
Nutrition-NGT (high glucose-brain functioning;
protein-tissue repair)
Elimination-laxatives, increase fiber

3. Intracerebral Hematoma
Contained well-defined blood clot; usually at
frontal and temporal lobes
Coup-Contrecoup injury-damage to the site
of impact (coup) and damage on the
opposite side of the injury (contrecoup).
Management: Craniotomy
C. Cerebral edema and Increased ICP
Skull fracture
break in continuity of skull usually resulting in
brain trauma
a. Linear: dura remains intact; subdural or
epidural hematoma may occur underneath
b. Comminuted and depressed skull
fractures: increase risk for direct injury to
brain tissue from contusion (bruise) and bone
fragment: risk for infection
c. Basilar: involves base of skull (softer) and
usually involves extension of adjacent
fractures

Craniotomy-surgical opening of the skull

Craniectomy permanent removal of the
cranium to relieve pressure on the brain by
providing space for expansion
Nursing management
Preoperative
Parenteral corticosteroids
Scalp preparation
Antiembolism stockings
Postoperative
1. Neurological assessment
2. Head dressings: monitor for CSF leaks
3. Control ICP
Assess for signs of increasing ICP
Positioning to prevent increase in ICP
- Supratentorial surgery-elevate head
of bed 30 degrees
- Infratentorial-keep flat, turn every 2
hours, but never onto the back (to
prevent brain hernation)
- Posterior fossa surgery-either side
but never on the back
- Bone flap-on the unoperated side

Assessment:
Rhinorrhea: through nose
Otorrhea: through
May appear on x-ray
Hemotympanum: blood behind tympanic
membrane (purple or dark color)
Normal: pearly gray
Battles sign: blood over mastoid process
Raccoon eyes: bilateral periorbital
ecchymosis

Spinal Cord Injury

26

Generally occurs as a result of direct trauma to

the head or neck area.
A. Initially after the injury, the nerve fibers
swell and circulation to the spinal cord is
decreased; hemorrhage and edema occur
causing an increase in the ischemic process
which progresses to necrotic destruction of the
spinal cord.

2. There is loss of the hypothalamus to control

body temperature by vasoconstriction and
dilation.
3. Condition may persist for several weeks and
reverse spontaneously, resolution of spinal
shock will be evident by the return of reflexes.
4. Spasticity will occur as recovery progresses.
Spastic movements may be precipitated by
emotion and cutaneous stimulation.

Nursing Priority: Within twenty-four hours of

the injury, edema secondary to the
inflammatory process results in compression
of the cord; the edema extends above and
below the area of injury and increases the area
of ischemic damage.

D. Neurogenic shock.
1. Dominance of the parasympathetic nervous
system results in loss in vasomotor tone and
increased vagal tone leading to hypotension
and bradycardia.
2. skin stays warm and dry due to loss of
sympathetic response of vasoconstriction.
3. Condition may mask symptoms of
hemorrhage in the trauma client.

B. Consequences of cord injury depend on the

extent of damage as well as the level of cord
injury.

E. Autonomic dysreflexia (AD) occurs in

clients with an injury at T-6 or higher.

Mechanisms of spinal cord injury.

with

(a) Flexion-extension: whiplash, seen

rapid deceleration injuries.
(b) Subluxation: incomplete or partial
dislocation.
(c) Torsion: twisting of the spinal cord.
(d) Compression

1. A noxious stimuli below the level of injury

triggers the sympathetic nervous system
which causes a release of catecholamines
resulting in bnypertension.
2. Spinal injury blocks the normal transmission
of sensory impulses and the impulses cannot
reach the brain, but they rebound and
stimulate the sympathetic nervous system.
3. there is an exaggerated response to the
sensory stimuli, most common stimuli causing
the response are a full bladder, fecal
impaction, and skin stimulation.
4. Severe hypertension, pounding headache,
bradycardia, restlessness, skin flushed and
warm are not uncommon body responses.
5. Treatment is directed identifying and
removing noxious stimuli.

1. The higher the lesion, the more severe the

sequela.
2. Complete transaction (complete cord
dissolution, complete lesion)-paralysis below
the level of injury; minimum, if any, return of
function.
a. Loss of sensory function.
b. Loss of voluntary motor activity
c. Loss of sense of position (proprioception).
d. Minimum, if any return of function.
3. Incomplete.
a. Central cord syndrome-center of cord
is
damaged, results primarily in
impairment in upper extremities.
b. Damage to one side of the cord
(BrownSequard syndrome)-motor
function and position sense may be
present on one side, temperature and
sensation may be
lost
on the opposite
side.
c. Anterior cord damage-disruption of
blood flow results in a mixed loss of sensory
and
motor function below the level of
injury.

F. Bladder dysfunction will occur as a result of

the injury. Normal bladder control is dependent
on both the sensory and motor pathways, and
the lower motor neurons being intact.

1. Reflex neurogenic bladder (spastic,

autonomous)occurs in clients with cord lesions
above the level of lower lumbar and caudal
area of the spine. The lower motor neuron
pathway remains intact below the level of the
injury.
a.There is loss of voluntary muscle
control,
and
depending on the level of
the injury,
there is loss or
decreased
sensation.
b. Bladder will retain a volume of urine,
then reflexive involuntary voiding will occur.
c. Bladder empties autonomically in
response
to stretching of the detrusor
muscles.

C. Spinal Cord Shock (areflexia)-occurs

predominantly in complete cord lesions.
Because of the loss of communication with the
higher centers of control, the muscles below
the level of injury will become flaccid and all
functional control will cease.
1. Spinal cord injury interrupts the sympathetic
nerve impulse transmission, the
parasympathetic impulses are not counter
checked and vasodilation occurs; this results in
hypovolemia and hypotension.

2. Nonreflexic neurogenic bladder

(flaccid) occurs in clients will cord lesions at
the lower lumbar and caudal area of the spine.
The lower motor neurons are damaged.
a. The sensory function may remain
unimpaired, there is loss of bladder
tone and voluntary control.

27

b. Bladder retains a volume of urine,

becomes distended and overflows.
c. There is no bladder muscle
contraction or
forceful
emptying.
G. Long-term rehabilitation potential depends
on the amount of damage done to the cord
which may not be evident for several weeks
after the injury.

- Altered Family Process related to

adjustment of
family member to
permanent disability.
3. Diagnostics
a. History of accident
b. clinical manifestations.
c. X-rays to determine level of
damage.
d. MRI.
e. CT scan.

Assessment
1. Risk factors/etiology-accidents.
2. Clinical manifestations-depend
on level of cord injury.
a. C1-C3-usually fatal at the scene
of the accident due to
respiratory arrest.
b. Flaccid paralysis and sensory
loss below the level of injury.
c. Spinal shock.
1) Generally occurs within
seventy-two hours and
may last for several
weeks.
2) Flaccid paralysis.
3) Loss of sensation and
absence of reflexes.
4) Bowel and bladder
dysfunction.
5) Hypotension and
bradycardia.
6) After spinal shock,
reflexes, and autonomic
activity return as
evidenced by
development of
spasticity.
d. Neurogenic shock
1) Hypotension from
vasodilation.
2) Bradycardia from increased
vagal tone.
3) Skin remains warm and dry.
4) May require vasoactive
medications (dopamine and
dobutamine) for
hypotension and
bradycardia.
e. Autonomic dysreflexia in
clients with injuries at T6 or
higher.
1) Severe hypertension.
2) Severe bradycardia.
3) Complaints of headache.
4) Flushing and diaphoresing
above level of injury.
Nursing Diagnosis:
Spinal Cord Injury
- Potential for Aspiration related to
inability to
cough.
- Alteration in Elimination, bowel
and Bladder
related to level of
injury.
- Impaired Physical Mobility related
to level of injury.
- Disturbance in Body Image related
to dependency
on others and
change in body function.
- Self Care Deficit related to
anticipated losses.
- Grieving related to anticipated
losses.

Treatment
1. Immobilization of the vertebral
column in cervical
fracture.
a. Stryker frame.
b. Circular electric bed.
c. Cervical tongs (Crutchfield) for
cervical
immobility.
2. Respiratory support as indicated.
3. Immobilization of spinal column
by bed
rest in lumbar fracture.
4. Stabilization of spinal column by
surgical
procedures.
5. Corticosteroids to decrease cord e
dema.
Nursing Intervention:
Goal: to maintains stability of the
vertebral column and prevent
further cord damage.
1. Emergency care and treatment.
a. Suspect spinal cord injury if there
is any evidence of direct trauma to
the head or neck area (contact
sports, diving accidents, MVA).
b. Immobilize and place on spinal
board with the head and neck in a
neutral position; do not allow the
neck to flex.
Nursing Priority: Do not hyperextend
the neck in the client with a
suspected cervical injury. Airways
should be opened by the jaw lift
method. Improper handling of the
client at the scene of the accident
often results in extension of the
damaged area.
a. Maintain in extended position
with no
twisting or turning; do
not remove from
the spinal board
until area of injury is identified.
b. Maintain patent airway during
transportation.
2. Maintain stability of the vertebral column
as
indicated by the level of injury.
a) Bed rest on firm mattress with
supportive devices (sandbags,skin
traction, etc.); maintain alignment
in the supine position; logroll
without any flexion or twisting.
b) Maintain cervical traction-tongs are
inserted into the skull with traction
and weights applied; do not remove

28

weights; logroll to maintain spinal

immobility.
c) Stryker frame or circle bed permit
change of position from prone to
supine; frequently utilized in
conjunction with cervical traction;
maintain safety precautions when
turning.
d) Maintain extremities in neutral,
functional position.

2) With the loss of vascular

tone the symptoms of
hemorrhage will be masked.
2. Spinal shock.
a)
Monitor vital signs
and evaluate
changes with regard
to development of
neurogenic shock
and hemorrhage.
b)
Vagal stimulation,
hypothermia, and
hypoxia may
precipitate spinal
shock.
c)
Development of
spasticity of
muscles below the
level of injury
indicates resolution
of spinal shock.
3. Assess for developmental of autonomic
dysreflexia, if it occurs:
a) Elevate the head of the bed (if
possible).
b) Assess for sources of stimulidistended bladder, fecal impaction,
or constipation.
c) Relieve the stimuli and frequently
dysreflexia will subside.
d) Maintain cardiovascular support
during period of hypertension.

3. Appropriate nursing intervention when

surgery is indicated for stability of the
injury.
Goal: to maintain ongoing assessment
to identify level of damage and
changes in neurological status.
1. Motor and sensory evaluation.
a. Ability to move all extremities;
strength of extremities.
b. Sensory examination including touch
and pain.
c. Presence of deep tendon reflexes.
2. Ongoing assessment and status of:
a) Bladder function.
b) Gastric function.
c) Respiratory and cardiovascular
systems.
d) Bowel function.
e) Psychological adjustment to the
injury.
Goal: to maintain respiratory function.
1. Frequent assessment of respiratory
function during first
forty-eight hours.
a) Evaluate for changes in breathing
pattern.
b) Evaluate clients complaints of
increasing difficulty in breathing;
utilization of sternocleidomastoid
and intercostals muscles for
respiration.
c) Evaluate ABG.
d) Evaluate for presence of increasing
hypoxia.
2. Maintain adequate respiratory function
as indicated.
a) Chest physiotherapy.
b) Incentive spirometry.
c) Changing position within limits of
injury.
d) Assess for complications of
atelectasis, pulmonary emboli, and
pneumonia
e) Nasopharyngeal or endotracheal
suctioning suctioning as indicated.

4. Evaluate cardiovascular responses when

or suctioning.
5. If turning on a circular electric bed,
evaluate for postural hypotension.
6. Antiembolism stockings or elastic wraps
to the legs to facilitate venous return. (Lack
of muscle tone and loss of sympathetic
tone in the peripheral vessels results in a
decrease in venous tone and in venous
return predisposing the client to the
development of deep vein thrombosis).
Goal: to maintain adequate fluid and
nutritional status.
1. During the first forty-eight hours,
evaluate GI function frequently;
decrease in function may
necessitate utilization of a
nasogastric tube to decrease
distention.
2. Prevent complications of nausea
and vomiting.
3. Evaluate bowel sounds and
clients ability to tolerate PO
fluids.
4. Increase protein and calories in
diet; may need to decrease
calcium intake.
5. Evaluate for presence of
paralytic ileus.
6. Increase roughage in diet to
promote bowel function.
Goal: to prevent complications of
immobility.
Goal: to promote bowel and bladder
function

Goal: to maintain cardiovascular

stability.
1. Neurogenic shock.
a) Monitor vital signs closely for first
24 hours post injury.
b) Carefully titrate IV fluids as client is
at high risk for fluid overload.
c) Assess other client parameters for
evidence of hemorrhage and other
injuries.
1) Abdominal muscles will
remain flaccid in presence of
abdominal injuries.

29

1. Urine is retained due to the loss

of autonomic and reflexive
control of the bladder.
d. Intermittent catheterization or
indwelling catheter initially to
prevent bladder distention.
e. Nursing intervention to prevent
urinary tract infection.
2. Determine type of bladder
dysfunction and assist client to
determine appropriate method
of bladder emptying.
3. Assess clients awareness of
bladder function.
4. Initiate measures to institute
bladder control.
a. Establish a schedule for voiding;
have client attempt voiding
every two hours.
b. Utilize the Crde method for
manual expression of urine.
c. May be necessary to teach client
self-catheterization.
d. Record output and evaluate for
residual urine.
5.Evaluate bowel functioning.
a. Incontinence and paralytic ileus
frequently occur with spinal shock.
b. Incontinence and impaction are
common later.
6. Initiate measures to promote
bowel control (after spinal shock is
resolved).
a) Identify clients bowel habits
prior to injury.
b) Maintain sufficient fluid
intake and adequate bulk in
the diet.
c) Establish specific time each
day for bowel evacuation.
d) Assess clients awareness of
need to defecate.
e) Teach client effective
utilization of the Valsalva
maneuver to induce
defecation.
f) Induce defecation by digital
stimulation, suppository or
as a last resort, enema.

8. Assist client family to identify

community resources.
9. Assist client to set realistic shortterm goals.
Medical Management
ImmobilizationGardner well tongs, halo
external fixation
Maintenance of heart rate (Atropine) and BP
(dopamine) vasopressors
Methylprednisolone therapy
Insertion of NGT
Intubation, if needed
Indwelling urinary catheter
Stress ulcer prophylaxis (Proton-pump
inhibitos, H2 blockers)
Physical therapy
CLIENTS IN TRACTIONS
CERVICAL TRACTIONS:
1. Skull Tongs/ Crutchfield Tong
Nsg Mgt: PETAM
- Provide pin care.
- Ensure wt is hanging freely.
- Turn to sides q2H
- Assess insertion site for infection.
- Massage the occiput.
2. Halo Traction
A. Avoid putting powder inside the vest.
B. Turn the pt as a unit, do not use the
halo vest to lift
the pt.
C. Assess for tightness of the vest by
ensuring that 1
finger can be placed
under the jacket.
D. Have the correct-size wrench
available at all times for
emergency.
E. Provide pin care.

CNS INFECTIONS
I. Meningitis
Inflammation of pia matter, arachnoid and
subarachnoid space
Spreads rapidly through CNS because of
circulation of CSF around brain and spinal cord
May be bacterial, viral, fungal, parasitic in
origin
Infection enters CNS though invasive
procedure or through bloodstream, secondary
to another infection in body

Goal: To maintain psychological

equilibrium.
1. Simple explanation of all
procedures.
2. Anticipate outburst of anger and
hostility as client begins to work
through the grieving process
and adjustments in body image.
3. Anticipate and accept periods of
depression in client.
4. Encourage independence
whenever possible; allow client
to participate in decisions
regarding care and to gain
control over environment.
5. Encourage family involvement in
identifying appropriate
diversional activities.
6. Avoid sympathy and emphasize
clients potential.
7. Initiate frank, open discussion
regarding sexual functioning.

Bacterial Meningitis
Causative organism:
Neisseria meningitides, Streptococcus
pneumonia, Haemophilus influenza,
Escherichia coli
Manifestations
a. Fever, chills
b. Headache, back and abdominal pain
c. Nausea and vomiting
d. Meningeal irritation:
Nuchal rigidity (stiff neck)-early sign
* Opisthotonos

30

Positive Kernigs sign

Positive Brudzinskis sign-when the
patients neck is flexed, flexion of the
knees and hips is produced
Photophobia extreme sensitivity to
light
e. Meningococcal meningitis: rapidly
spreading petechial rash of skin and mucous
membrane
f. Increased ICP: decreased LOC, papilledema
edema of optic disc due to increased ICP

b. Test to rule out other neurologic

dysfunctions.
Treatment
1. Medical management of pain.
a. DILANTIN.
b. TEGRETOL.

Viral Meningitis
Less severe, benign course with short
duration, intense headache with malaise,
nausea, vomiting, lethargy, signs of meningeal
irritation

Nursing Intervention
Goal: to control pain.

2. Surgical intervention.
a. Local nerve block.
b. Surgical intervention to interrupt nerve
impulse transmission.

1. Assess the nature of a painful attack.

2. Identify triggering factors; adjust
environment to decrease factors.
a. Keep room at an even, comfortable
temperature.
b. Avoid touching client.
c. Avoid jarring the bed.
d. Allow client to carry out own ADL as
necessary.
3. Administer analgesics to decrease pain.

Encephalitis
1. Acute inflammation of parenchyma of brain
or spinal cord
2. Usually caused by virus
Medications
1. Meningitis: immediate treatment of effective
antibodies for 7-21 days according to culture
results; dexamethasone to suppress
inflammation

Nursing Diagnosis:
Trigeminal Neuralgia

DilantinIncrease seizure threshold

Alteration In Comfort: Acute Pain related to

condition.
Knowledge Deficit related to inadequate
knowledge regarding condition,
precipitating factors, and treatment.
Potential for Self Harm related to inability
to cope with pain.

Health Promotion
1. Vaccinations for meningococcal,
pneumococcal, haemophilus meningitis
2. Prophylactic rifampins for persons exposed
to meningococcal meningitis
3. Mosquito control
4. Prompt diagnosis
5. Asepsis care for clients with open head
injury or neurosurgery

Nursing Priority: Due to the severe

pain of the condition, clients are
susceptible to severe depression and
suicide.

NEUROPATHIES

Goal: to maintain nutrition.

1. Frequently client does not eat
due to reluctance to stimulate
the pain.
2. Provide lukewarm food which is
easily chewed.
3. Increase protein and calories.
Goal: to evaluate residual effects and
prevent complications postoperative
surgical intervention.

I. Trigeminal Neuralgia
A Cranial nerve disorder affecting the sensory
branches of the trigeminal (cranial nerve V).
Assessment
1. Risk factors/etiology.
a. Onset generally between 20 and 40
years of age.
b. Increasing frequency with aging.
2. Clinical manifestations.
a. Abrupt onset of paroxysmal pain in the lower
and upper jaw, cheek, and lips.
1) Tearing of the eyes and frequent
blinking.
2) Facial twitching and grimacing.
3) Pain usually brief; ends as abruptly as it
begins.
b. Recurrence of pain is unpredictable.
c. Pain is initiated by cutaneous stimulation of
the affected nerve area.
1) Chewing.
2) Washing the face.
3) Extremes of temperature-either on the
face or in food.
4) Brushing teeth.
3. Diagnostics.
a. clinical manifestations.

1. Identify presence of corneal reflex;

provide protective eye care if reflex is
absent.
2. If there is loss of sensation to the side
of the face client should:
a. Chew on the unaffected side.
b. Avoid temperature extremes in foods.
c. Check the mouth after eating to remove
remaining particles of food.
d. Maintain meticulous oral hygiene.
e. Have frequent dental checkups.
II. BELLS PALSY
A cranial nerve disorder affecting the facial
nerve (cranial nerve VII),characterized by a
disruption of the motor branches on one
side of the face. The disruption of the

31

motor branches results in muscle flaccidity

of the affected side of the face.

3. Tumors originating in the brain tissuei.e., gliomas.

4. Metastatic tumors originating elsewhere
in the body; frequently, metastasis is
from the lung or the breast.
B. Gliomas are the most common tumors;
frequently are malignant.
C. Brain tumors may be benign,
malignant, or metastatic; malignant
brain tumors rarely metastasize outside
the CNS.
D. Supratentorial tumors occurring within
the anterior two-thirds of the brain,
primarily the cerebrum.
E. Infratentorial tumors occurring in the
posterior third of the brain (or below the
tentorium); primarily in the cerebellum
or the brain stem.
F. Regardless of the origin, site, or
presence of malignancy, problems of
increased intracranial pressure occur
because of the limited area in the
intracranial contents.

Assessment
1. Risk factors/etiology.
a. Can affect any age group; increased
incidence between ages 20 and 40.
b. Current theories suggest the
inflammation and demyelinization of
the nerve is precipitated by a viral
agent, possibly herpes simplex.
2. Clinical manifestations.
a. Lag or inability to close eyelid on
affected side.
b. Drooping of the mouth.
c. Decreased taste sensation.
d. May experience pain behind the ear of
the affected side.
3. Diagnostics-no specific diagnostic test.
Treatment
1. Corticosteroids.
2. Vasodilators.
Nursing Intervention
Goal: to assess nerve function and prevent
complications.
1. Analgesics to decrease pain.
2. Evaluate ability of client to eat.
3. Meticulous oral hygiene.
4. Prevent drying of the cornea on
the affected side.
a. Instill methylcellulose drops
frequently during the day.
b. Ophthalmic ointment and eye
patches may be required at
night.
5. As function returns, active facial
exercises.

Assessment
1. Risk factors/etiology.
a. Adults-highest incidence between 55
and 70 years of age.
b. Prognosis is generally poorer in the
infant than in older children.
c. Presence of metastatic cancer of the
lung or breast.
2. Clinical manifestations symptoms
correlate with the area of the brain
initially involved.
a. Headache.
1). Recurrent.
2). Progressive.
3). More severe in the morning.
4). Affected by position.
5). Headache in infant may be identified by
persistent, irritated crying and head rolling.
b. Vomiting initially with or without
nausea; progressively becomes
projectile.
c. Coordination disturbances (ataxia,
staggering gait).
d. Hypotonia, hyporeflexia.
e. Visual changes due to localizing effects.
1. Nystagmus.
2. Diplopia.
3. Decrease in visual acuity.
4. Visual field deficits.
f. Head tilt- child may tilt the head due to
damage to extra ocular muscles; may
be first indication of a decrease in
visual acuity.
g. Behavioral changes.
1) Obvious personality changes.
2) Decreasing level of
consciousness.
3) Decreasing activity, increased
sleep periods in the infant.
h. Decrease in muscle strength or loss of
specific areas of movement.
i. Changes in vital signs indicative of
increasing ICP.
j. Seizures (focal or generalized).
k. Cranial enlargement in the infant under
eighteen months old.
l. Papilledema (edema of the optic disc).

Goal: to assist client to maintain a positive

self-image.
1. Changes in physical appearance may
be dramatic.
2. Discuss with client that the condition is
usually self-limiting with minimum, If
any, residual effects.
3. Client may require counseling if facial
appearance is permanent.
Nursing Diagnosis:
Bells Palsy
Disturbance in Body Image related to facial
deficits.
Potential for Injury: Eye related to loss of
normal blink reflex.
Potential for alteration in Nutrition: Less
Than
Normal Body Requirements related to
difficulty eating.
NEOPLASMS
I. BRAIN TUMORS
A. Classification of tumors.
1. Tumors arising from the protective
covering of the brain-i.e., dural
meningiomas.
2. Tumors developing I or around cranial
nerves-i.e., acoustic neuromas.

32

m. Dizziness and vertigo.

NURSING DIAGNOSES: Brain Tumor

3. Careful evaluation of the level of

consciousness; regression to more
lethargic or irritable state may be
indicative of increasing ICP.
4. Evaluate dressing.
a. Location and amount of drainage.
b. Evaluate for CSF leak through the
incision.
c. Do not change dressing initially, but
reinforce it.
5. Position in low to semi-Fowlers if there is
a spinal fluid leak from ears or nose.
6. Position postoperatively for infratentorial
surgery.
a. Bed should be flat.
b. Position client on either side; keep off
back.
c. Maintain head and neck in midline and
slightly extended.
7. Position postoperatively for supratentorial
surgery-semi to low Fowlers.
8. Trendelenburg position is contraindicated
in both types of surgery.
9. Maintain fluid regulation.
a. Begin clear liquids PO after swallow and
gag reflexes return and client is awake.
b. Maintain IV fluid until client tolerates
fluids.
c. Closely monitor intake and output.
d. Client may be on fluid restriction.
10. Evaluate neuro status in response to fluid
balance and diuretics.
11. Carefully evaluate changes in
temperature-may be due to respiratory
complications or to alteration in the
function of the hypothalamus.
12. Provide appropriate pain relief.
a. Avoid narcotic analgesics.
b. Aspirin or TYLENOL is frequently used.
c. Maintain quiet, dim atmosphere.
d. Avoid sudden movements.
13. Prevent complications of immobility.
14. Maintain seizure precautions.

Injury: High Risk related to gait disorders,

vertigo, visual disturbances, or
compression/displacement of brain tissue.
Anxiety related to implications of condition
and uncertain future.
Self-care Deficit related to inability to
perform ADLs secondary to sensory-motor
impairment.
Altered Family Processes related to the
nature of the condition, role disturbances,
and uncertain future.
3. Diagnostics.
a. Clinical manifestations exhibited in the
neurological exam.
b. EEG.
c. CAT scan.
d. Brain scan.
e. Cerebral angiogram.
Treatment
1. Medical.
a. Dexamethasone
b. Anticonvulsants
c. Radiation and chemotherapy if
malignant.
2. Surgical excision-craniotomy.
Complications
Meningitis, respiratory aspiration, brain
stem herniation; diabetes insipidus,
inappropriate ADH secretion.
Nursing Intervention
See Nursing Diagnosis for Increased
Intracranial Pressure.
Preoperative management see
nursing goals for increased intracranial
pressure.
Goal: to provide appropriate
preoperative nursing intervention.
General preoperative care with
exceptions as noted.
Shave the head, save the hair and return
it to the family, or dispose of its indicated
by institutional policy.
If there is increased ICP, generally do not
administer an enema.
Prepare client, family, and parents for
appearance of the client postoperatively.
Encourage verbalization regarding
concerns of surgery.

CEREBRAL PALSY (CP)

1.
2.
3.
4.
5.

A non progressive abnormality in the

pyramidal system (motor cortex, basal ganglia,
and cerebellum) resulting in impairment of
muscle control. May be classified according to
the specific area of brain involvement and to
the resulting clinical manifestations.
Assessment
1. Risk factors/etiology.
a. Associated with cerebral anoxia
during pregnancy or perinatal
period.
b. Prenatal.
1) Maternal anemia,
metabolic disturbances.
2) Intrauterine infection.
3) Blood incapatabilities.
4) Toxemia.
c. Perinatal.
1) Prematurity.
2) Trauma during delivery.
3) Hyperbilirubinemia.
d. Postnatal.
1) Cerebral trauma.
2) CVA
3) Infection.

Goal: to maintain homeostasis and

monitor changes increased
intracranial pressure
postoperative craniotomy.
Neuro checks as necessary.
Maintain pulmonary function and
hygiene.
Patent airway.
Prevent aspiration.
Increase respiratory excursion by deep
breathing.
Antiemetics to decrease vomiting and
possibility of aspiration.
Discourage vigorous coughing.

1.
2.
a.
b.
c.
d.
e.

33

dressing and personal

hygiene).
d) Speech therapy is indicated.
e) Encourage play appropriate for
age.
f) Encourage appropriate
educational activities.
g) Bowel and bladder training
may be difficult due to poor
control.

2. Clinical manifestations.
a) Delayed achievement of
developmental milestones.
b) Neuromotor dysfunction in
motor performances.
c) Increased or decreased
resistance to passive
movement.
d) Abnormal posture.
e) Presence of infantile
reflexes (tonic neck reflex,
exaggerated moro).
f) Associated disabilities
include:
1. Mental retardation;
approximately 1/3 of
the children affected
are of normal or
superior intelligence.
2. Seizures
3. Attention-deficit
problems.
4. Vision and hearing
sensory impairments
3. Diagnostics.
a. Neurological
examination and
contributing
history.
b. Diagnostics tests
to rule out other
neurological
dysfunction.
c. Frequently difficult
to diagnose in
early months;
condition may not
be evident until
child attempts to
walk.
Treatment
(Generally supportive).

Goal: to maintain physiological

homeostasis.
a) Maintain adequate nutrition
1. may experience
difficulty eating due to
spasticity; may drool
excessively.
2. encourage
independence in eating;
utilize self help devices
3. provide a balanced diet
with increased caloric
intake to meet extra
energy demands.
b) Maintain safety and precautions
to prevent injury.
c) Increased susceptibility to
infections, especially respiratory
infectio0ns due to poor control
of intercostals muscle and
diaphragm.
d) Increased incidence of dental
problems; frequent dental check
up.
Goal: to promote a positive self- image
I the child and provide support to the
family.
a) Use positive reinforcement
b) Assist parents to set realistic
goals.
c) Encourage recreation and
educational activities,
especially those involving other
cerebral palsy children.
d) Encourage child to express
feelings regarding his/her
disorder.
e) Do not talk down to child;
communicate at appropriate
mental level..
f) Assists parents in problem
solving in home environment.
g) Identify community resources
available.

1. Maintain and promote mobility wit

orthopedic devices and physical
therapy.
2. Skeletal muscle relaxant.
3. Anticonvulsant as indicated.
Nursing Intervention:
(Child is frequently cared for a home
and on an outpatient basis unless
complications occur.)
Goal: to assist child to become as
independent and self sufficient as
possible.
a) Physical therapy program
designed to assist individual
child to gain maximum
function.
b) Assist child to progress
according to developmental
level and functional abilities;
encourage crawling, sitting
and balancing appropriate to
developmental, level.
c) Assist child to carry out
activities of daily living as age
and capacities permit (feeding,

Hydrocephalus
Increase in volume of CSF within ventricular
system, which becomes dilated
Common Causes:
1. Noncommunicating: obstruction in CSF
drainage from ventricular system
2. Communicating: CSF is not effectively
reabsorbed through arachnoid villi
3. Normal pressure hydrocephalus: occurs
in persons>60 in which ventricles enlarge
causing cerebral tissue compression
Manifestations
depend on rate of onset:

34

 progressive cognitive dysfunction

gait disruptions
urinary incontinence
Visual changes
Increase in head size
Increase ICP

celtic ancestry and those living in South

Eastern U.S.
5. condition may have other congenital
anomalies associated with it.
6. Women who have spina bifida and
parents who have one affected child
have an increased risk of producing
children with neural tube defects.

Treatment/Management
1. Diuretics
2. Surgery
3. Protect from injury from altered LOC and
immobility

ALTERED PHYSIOLOGY AND CLINICAL

MANIFESTATIONS:
A. SPINA BIFIDA OCCULTA
1. Most common type, may occur in as
many as 25% of otherwise normal
children.
2. The bony defect may range from a very
thin slit separating one lamina from the
spinous process to a complete absence
of spine and laminae.
3. A thin, fibrous membrane sometimes
covers the defect.
4. The spinal cord and its meninges may
be connected with a fistulous tract
extending to and opening onto the
surface of the skin.
5. Most patients have no symptoms:
a. They may have a dimple on the skin or
a growth of hair over the malformed
vertebra.
b. There is no externally visible sac.
c. With growth, the child may develop foot
weakness or bowel and bladder
sphincter disturbances.

SPINA BIFIDA
Spina Bifida refers to a malformation of the
spine in which the posterior portion of the
laminae of the vertebrae fails to close. Its the
most common developmental defect of the
Central Nervous System.
MOST COMMON TYPES
1. SPINA BIFIDA OCCULTA, in which the
defect is only in the vertebrae. The
spinal cord and meninges are normal.
2. MENINGOCELE, in which the meninges
protrude through the opening in the
spinal canal, forming a cyst filled with
Cerebro Spinal Fluid and covered with
skin.
3. MENINGOMYELOCELE OR
MYELOMENINGOCELE - in which both
the spinal cord and cord membranes
protrude through the defect in the
laminae of the spinal canal.
Meningomyeloceles are covered by a
thin membrane.
Rachischisis neural tube defect extends
the length of the spine which is always
fatal. Spina bifida cystica is also
another term used to describe
Meningomyelocele.
ETIOLOGY:
1. unknown, but generally thought to
result from genetic predisposition
triggered by something in the
environment.
2. It involves an arrest in the orderly
formation of the vertebral arches and
spinal cord that occurred between the
4th and 6th week of embryogenesis.
THEORIES CAUSATION:
A). There is incomplete closure of the
neural tube during the 4th week of
embryonic life.
B). The neural tube forms adequately but
then ruptures.
INCIDENCE:
1. Geographical distribution and incidence
vary widely.
2. Condition occurs in approximately 1 per
1,000 live births in the U.S.
3. most common developmental defect
of / CNS.
4. more common in Caucasians than in
non white population specially those of

B. MENINGOCELE
1. An external cystic defect can be seen in
the spinal cord, usually in the center
line.
a. The sac is composed only of meninges
and is filled with CSF.
b. The cord and nerve roots are usually
normal.
2. The defect may occur anywhere in the
cord. Higher defect (from the thorax
and up) are usually meningoceles.
3. There is seldom evidence of weakness
of the legs or lack of sphincter control.
4. Surgical correction is necessary to
prevent rupture of the sac and
subsequent infection.
5. Hydrocephalus may be an associated
findings and may be aggravated after
surgery for a meningocele.
a. Occurs in about 9% of patients
b. Usually not associated with the ArnoldChiari malformation
6. Prognosis is good with surgical
correction.
C. MENINGOMYELOCELE
( MYELOMENINGOCELE)
1. most common type of open spinal
defect occurs 4-5 times more
frequently than meningocele.
2. A round, raised, and poorly
epithelialized area may be noted at any
level of the spinal column. However, the
highest incidence of the lesion occurs in
the lumbosacral area.
3. The lesion contains both the spinal cord
and cord membranes. A bluish area

35

may be evident on the top because of

exposed neural tissue.
4. The sac may leak in utero and may
rupture after birth allowing free
drainage of CSF. This renders the child
highly susceptible to meningitis.
5. Prognosis.
a. Influenced by the site of the lesion and
the presence and degree of associated
hydrocephalus. Generally, the higher
the defect, the greater the extent of
neurologic deficit and the greater the
likelihood of hydrocephalus.
b. In the absence of treatment, most
infants with meningomyelocele die
early in infancy.
c. Surgical intervention is most effective if
its done early in the neonatal period,
preferably within the 1st few days of life.
d. Even with surgical intervention, infants
can be expected to manifest
associated neurosurgical, orthopedic
and or urologic problems.
e. New techniques of treatment, intensive
research and improved services have
increased life expectancy and have
greatly enhanced the quality of life for
most children who received treatment
for the defect.
CLINICAL PROBLEMS COMMONLY
ASSOCIATED WITH
MENINGOMYELOCELE
A. Neurologic Problems.
1. Arnold-Chiari malformation
a). associated malformation involving
the brain stem and cerebellum
b). causes block-flow-CSF thru the
ventricles and leads to failure n the
reabsorption mechanism of CSF
c). Produces significant hydrocephalus
in approximately 2/3 of children wit
meningomyelocele
2. Loss of motor control and sensation
below the level of the lesion.
B. Mobility and Orthopedic Problems
1. Contractures
2. Clubfeet
3. Scoliosis
4. Ambulation and ability to be
upright.
C. Urologic Problems - sacral nerves
innervate the bladder.
D. Bowel Problems poor innervation of the
anal sphincter and bowel musculature.
E.Skin Problems areas of decreased
sensation have a tendency to break down.

TREATMENT AND NURSING

INTERVENTIONS:
- Depends on the extent of the neurologic
deficit, level of the lesion, and any
complication she may have most commonly
hydrocephalus and UTI.
- In caring for a newborn of spina bifida,
the nurses major concern is preventing
infection.
a. Screening - indentation or tuft of hair may
be the only visible sign of mild forms of spina
bifida.
In more severe cases - the defect is obvious: a
portion of the spinal cord protrudes from the
infants back. Tissues and nerves are either
completely exposed or covered by a thin
membrane of skin.
Cover the protruding sac whether open or
closed right away with a non adherent, sterile
gauze dressing soaked with sterile saline.
Keeping it moist will help prevent infection
before referring her to a neurosurgeon.
Surgery to repair the sac with intact tissue and
skin grafts within the next 48 to 72 hrs. (others
within 24 hrs.)
Before surgery: Nurses do complete physical
examination - Since musculoskeletal problems
such as dislocated hips and clubfeet frequently
accompany myelomeningocele pay particular
attention to the lower extremities.
To keep the spine aligned and to avoid
pressure on the babys back, place her on
her abdomen on an elevated wooden box
covered with sheepskin. The baby stays in this
position during feedings. Do range of motion
exercises gently every hour to prevent
pressure sores.
Urine and feces - that remain for any length
of time in the babys diaper increase the risk of
infection. So instead of diapering simply place
one underneath her.
A foley cathether is inserted before surgery.
To further protect against infection start
a continuous IV infusion of Gentamycin
(Garamycin) or Ampicillin ( Polycillin N) as per
Doctors order.
Change the gauze dressing at least once a
shift and right before surgery.

F. Dietary Problems children become

overweight because of activity limitations.
Dietary control to prevent obesity.
G. Developmental Problems average
intellectual ability despite hydrocephalus.
DIAGNOSTICS prenatal screening for neural
tube defects. A blood test may reveal high
levels of maternal AFP serum
alphafetoprotein indicating a break in the
neural tube that is allowing too much of this
protein to seep into amniotic fluid and
subsequently into the mothers blood. The
results must be confirmed by ultrasound and
amniocentesis, although these tests cant
determine the severity of the defect.

POST OPERATIVE CARE:

Take vital signs and monitor the infants
ability to feed. In addition to a flat diaper under
the infant, put a piece of sterile plastic above
the anus to deflect feces away from the
surgical site.

36

site,

Watch for fever, signs of infection

Watch for leakage of CSF at the closure
and evidence of hydrocephalus.
Do a complete orthopedic and urinary
assessment.

bonne chance
Lmulbata@2011

37