parietal lobe

receives sensory input

frontal lobe
Controls higher-order processing, such as executive function and personality. Injury to the frontal lobe
often results in behavioral changes.

temporal lobe
integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand
verbal or written language.

occipital lobe
registers visual images. Injury to the occipital lobe could result in a deficit with vision.

medulla oblongata
regulates the rate and depth of respirations

cerebellum
Involved in coordination of voluntary movements and maintenance of balance and posture. Balance is
assessed with heel-to-toe gait testing. Coordination is assessed with finger tapping, rapid alternating
movements, finger-to-nose testing, and heel-to-shin testing.

stroke
Risk factors include diabetes, high cholesterol, hypertension, smoking, obesity (particularly in the
abdomen), older age, and genetic susceptibility. The single most important modifiable risk factor
is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of
hypertension. Because clients often experience side effects from the antihypertensive medications and
don't feel bad with untreated hypertension, they may not realize that it is essential to continue the
medications. The nurse should therefore emphasize this point.
Supraglottic swallow
Clients are instructed to:
1. Inhale deeply
2. Hold breath tightly to close the vocal cords
3. Place food in mouth and swallow while continuing to hold breath
4. Cough to dispel remaining food from vocal cords
5. Swallow a second time before breathing

Coup-contrecoup
Injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions
(bruising) of brain tissue as the brain moves back and forth within the skull.
Usually affect the frontal and occipital lobes. When the forward collision occurred, the frontal lobe most
likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and
voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital
lobe, where vision is processed.
Quadriplegia (tetraplegia)
occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the
upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury
and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is
the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory
muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed).

Huntington disease
is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs
movement, swallowing, speech, and cognitive abilities. The onset of active disease is usually at age 30-
50. Death from neuromuscular and respiratory complications typically occurs within 20 years. Clients
who have a parent with this disease should receive genetic counseling, especially when planning to start a
family.

St. John's wort

Herbal product commonly used by many clients to treat depression. However, it may interact with
medications used to treat depression or other mood disorders, including tricyclic antidepressants, selective
serotonin and/or norepinephrine receptor inhibitors (SSRIs/SNRIs), and monoamine oxidase inhibitors
(MAOIs). Taking St. John's wort with these medications tends to increase side effects and could
potentially lead to a dangerous condition called serotonin syndrome.
Excessive serotonin causes symptoms that can range from mild (shivering and diarrhea) to severe (muscle
rigidity, fever, and seizures). Severe serotonin syndrome can be fatal if it is not treated.
Serotonin Syndrome- Agitation, Diaphoresis, Tachycardia, Autonomic instability & hypertensive,
Diarrhea & hyperactive bowel sounds, clonus, tremor, hyperreflexia, mydriasis (dilated pupils)

Levetiracetam (Keppra)
a medication often used to treat seizures in various settings. It has minimal drug-drug interactions
compared to phenytoin and is often the preferred antiepileptic medication.

Dexamethasone
a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing
inflammation.

Malignant hyperthermia (MH)

a rare but life-threatening inherited muscle abnormality that is triggered by specific, inhaled anesthetic
agents and the depolarizing muscle relaxant succinylcholine (Anectine) used to induce general anesthesia.
the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle
contraction and rigidity (usually of the jaw and upper body [early sign]), increased oxygen demand and
metabolism, and dangerously high temperature (later sign).
As MH is an inherited condition, proper screening and a thorough preoperative nursing assessment and
health history can help minimize the client's risk

Parkinson Disease
Caused by low levels of dopamine in the brain. S&S- stooped posture, rigidity, flexed elbows & wrists,
trembling of extremities, masked facial expression, forward tilt of trunk, reduced arm swing, slightly
flexed hips & knees, shuffling, short stepped gait.
Anticholinergic medications (eg, benztropine, trihexyphenidyl) are used to treat Parkinson disease
tremor. However, they can precipitate acute glaucoma and urinary retention and are therefore
contraindicated in susceptible clients (eg, those with glaucoma or benign prostatic hyperplasia).
Carbidopa-levodopa
combination medication most helpful for treating bradykinesia in Parkinson disease and can also improve
tremor and rigidity to some extent. It is started in low doses to prevent orthostatic hypotension and
neuropsychiatric adverse effects. Carbidopa-levodopa once started should never be stopped suddenly as
doing so can lead to akinetic crisis (complete loss of movement).
Orthostatic hypotension and neuropsychiatric disturbances (eg, confusion, hallucinations, delusions,
agitation, psychosis) are serious and important adverse effects of carbidopa-levodopa. Health care
providers usually start the medications at low doses and gradually increase them to prevent these effects.

Myasthenia gravis
an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular
junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented
as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles
are stronger in the morning and become weaker with the day's activity as the supply of available
acetylcholine is depleted.
Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before
meals so that the client's ability to swallow is strongest during the meal
Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles
involved in chewing and swallowing) or liquids (aspiration risk)
should receive the annual flu vaccine. It is especially important in clients with myasthenia gravis as the
flu (or pneumonia) would tax the already compromised respiratory muscles
Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis

Myasthenia gravis is an autoimmune disease of the neuromuscular junction resulting in fluctuating

muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are
available for acetylcholine to bind. It is treated with pyridostigmine (Mestinon), which increases the
amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving
muscle strength.

Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is
characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's
infection and increasing difficulty swallowing indicate the need for immediate intervention.

Phenytoin (Dilantin)
an anticonvulsant drug, is used to treat generalized tonic-clonic seizures
The therapeutic serum phenytoin reference range is 10-20 mcg/mL
Signs of toxicity (eg, ataxia, nystagmus, slurred speech, decreased mentation).
Can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily),
especially in high doses. Discuss the need to perform good oral hygiene with a soft-bristle toothbrush and
to visit the dentist regularly. Folic acid supplementation can also reduce this side effect.
The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and
decreased bone density (osteoporosis).
Administration of phenytoin concurrent with certain drugs (eg, antacids, calcium) and/or enteral feedings
can affect the absorption of phenytoin. Stop enteral feeding for 1 to 2 hours before and after administering
phenytoin

Rigid extension of the arms and legs is seen in the tonic phase of a tonic-clonic seizure. During this
time, muscles become stiff, the jaw becomes clenched, and pupils can be fixed and dilated.

Increased ICP
Clients with should avoid anything that increases intrathoracic or intraabdominal pressure as these also
indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory
interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing.
The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid
drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli,
including no bright lights or multiple visitors.
Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is
often projectile, associated with headache, and gets worse with lowering the head position.

Cushing's triad
related to increased intracranial pressure (ICP). Early signs include change in level of
consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse
pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes)
respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some
time. It indicates brain stem compression.

Serial neurologic assessments

Are important as neurologic abnormalities are often initially subtle, making it important to note the
trend. Clients must be awakened for a prescribed, necessary neurologic assessment.
Interventions for neurologic issues are most effective when made early. A neurologic assessment
includes:
1. Glasgow Coma Scale (GCS)—best eye, verbal, and motor responses. Best verbal response
assesses orientation to person, place, and time (time is the most sensitive).
2. Pupils—equal, round, response to light, and accommodate (PERRLA)
3. Motor—strength and movement in all four extremities
4. Vital signs—especially any signs of Cushing's triad of bradycardia, bradypnea/abnormal
breathing pattern and widening pulse pressure (the difference between systolic and diastolic blood
pressure readings). The nurse is assessing for signs of increased intracranial pressure (ICP).
-The neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up
due to possible meningeal irritation related to infection (eg, meningitis)
- Pupil dilation can be the result of medication use or neurological causes (eg, increased intracranial
pressure, brain herniation) Normal pupils are 3-5 mm in diameter
- Oculocephalic reflex (doll's eyes) is an expected finding indicating an intact brainstem. It is tested by
rotating the head and watching for the eyes to move simultaneously in the opposite direction. The test is
not performed if spinal trauma is suspected.
- The normal finding in adults is an absent Babinski reflex (ie, toes point downward with stimulus to the
sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in
infants up to age 1, but in an adult may indicate a brain or spinal cord lesion.

Trigeminal neuralgia
sudden, sharp pain along the distribution of the trigeminal nerve.
symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may
experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods
without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or
talking. Pain is severe, intense, burning, or electric shock-like. The primary intervention for trigeminal
neuralgia is consistent pain control with medications and lifestyle changes. The drug of choice
is carbamazepine. It is a seizure medication but is highly effective for neuropathic pain. Carbamazepine
is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any
fever or sore throat.
Behavioral interventions include the following:
1. Oral care – use a small, soft-bristled toothbrush or a warm mouth wash
 2. Use lukewarm water; avoid beverages or food that are too hot or cold
3. Room should be kept at an even and moderate temperature
4. Avoid rubbing or facial massage. Use cotton pads to wash the face if necessary.
5. Have a soft diet with high calorie content; avoid foods that are difficult to chew. Chew on the
unaffected side of the mouth.

Tissue plasminogen activator (tPA)

dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3-
to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for
contraindications to tPA due to the risk of hemorrhage.
The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within
the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical
site.
cranial nerve (CN) VIII, the vestibulocochlear (or auditory) nerve
Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which
place the client at a high risk for falls.

Autonomic dysreflexia (autonomic hyperreflexia)

a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal
injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS
stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations
include severe hypertension, throbbing headache, marked diaphoresis above the level of injury,
bradycardia, piloerection (goose bumps), and flushing. This is an emergency condition requiring
immediate intervention. Management includes raising the head of the bed and then treating the cause.
Clients with a spinal cord injury should have their blood pressure checked when they report a headache
The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed.
Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive
clothing should be removed to decrease skin stimulation
The primary health care provider should be notified. An alpha-adrenergic blocker or an arteriolar
vasodilator (eg, nifedipine) may be prescribed.
head of the bed elevated 45 degrees or high Fowler's to lower blood pressure.

Guillain-Barré syndrome (GBS)

an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle
weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or
GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and
cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication.
Early signs indicating impending respiratory failure include:
 Inability to cough
 Shallow respirations
 Dyspnea and hypoxia
 Inability to lift the head or eye brows
Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement
of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates
impending respiratory arrest requiring endotracheal intubation.
at risk for paralytic ileus, developing deep venous thrombosis due to lack of ambulation and should
receive pharmacologic prophylaxis (heparin) and support stockings.

Bell's palsy
an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are
usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In
Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal
abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some
clients. Facial muscle weakness results in poor chewing and food retention.
Symptoms include the following: Inability to completely close the eye on the affected side, Flattening of
the nasolabial fold on the side of the paralysis, Inability to smile or frown symmetrically, Alteration in
tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to lower eyelid
muscle weakness, Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the
tongue.
Client teaching should include the following:
1. Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the
exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea
2. Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is
recommended. Maintain good oral hygiene after every meal to prevent problems from
accumulated residual food (eg, parotitis, dental caries)

Tricyclic antidepressants
(amitriptyline, nortriptyline, desipramine, imipramine) are commonly used for neuropathic pain. Side
effects are especially common in elderly clients.
The most common side effects include dizziness, drowsiness, dry mouth, constipation, photosensitivity,
urinary retention, and blurred vision. The priority nursing action is to teach caution in changing positions
due to the increased risk for falls from dizziness and orthostatic hypotension, especially in elderly clients.

Due to the increased risk of falling, the priority nursing action is to teach the client to get up
slowly from the bed or a sitting position.
Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg,
elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease),
include the following:
 Swallowing 2 times before taking another bite of food. This clears food from the pharynx.
 Thickening liquids to assist swallowing
 Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also
have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia)
production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to
facilitate swallowing.
 Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid
through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for
aspiration.
 Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial
count before eating because bacteria as well as food can be aspirated. After-meal use removes
particles of food that can be aspirated later.
 Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in
the mouth.

Multiple sclerosis (MS)

a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing
a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of
balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking
with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a
cane or walker, are usually required as demyelination of the nerve fibers progresses.
Fatigue is a common symptom with MS. Clients should balance exercise with rest. Clients should also
exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause
symptom exacerbation.

Concussion
considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration
head injury. Typical signs of concussion include:
1. A brief disruption in level of consciousness
2. Amnesia regarding the event (retrograde amnesia)
3. Headache
These clients should be observed closely by family members and not participate in strenuous or athletic
activities for 1–2 days. Rest and a light diet are encouraged during this time.
not expected with simple concussion:
 Worsening headaches and vomiting (indicate high intracranial pressure)
 Sleepiness and/or confusion (indicate high intracranial pressure)
 Visual changes
 Weakness or numbness of part of the body

Aphasia
refers to a neurological impairment of communication. Clients may have impaired speech and writing,
impaired comprehension of words, or a combination of both.
Broca (expressive) aphasia
a nonfluent aphasia resulting from damage to the frontal lobe.
can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short,
limited phrases that make sense but display great effort and frequent omission of smaller words (eg,
"and," "is," "the")
aware of their deficits and can become frustrated easily
Wernicke (receptive) aphasia
damage to the temporal portion of the brain
unaware of their speech impairment
the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech
pattern.
Global aphasia
inability to read, write, or understand speech. This is the most severe form of aphasia.

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase)

Often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive
pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic
system and dissolve thrombi.
Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm,
arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood
pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for
clarification. Administering alteplase in the presence of these conditions can cause hemorrhage,
including life-threatening intracerebral hemorrhage

Transsphenoidal hypophysectomy
surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones
(eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone).
at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels.
Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum
osmolality, and decreased urine specific gravity.

Seizures
Manifestations generally are classified into 4 phases:
1. The prodromal phase is the period with warning signs that precede the seizure (before the aural
phase).
2. The aural phase is the period before the seizure when the client may experience visual or other
sensory changes. Not all clients experience or can recognize a prodromal or aural phase before
the seizure.
3. The ictal phase is the period of active seizure activity.
4. During the postictal phase, the client may experience confusion while recovering from the
seizure. The client may also experience a headache. Postictal confusion can help identify clients
by differentiating seizures from syncope. In syncope, there will be only a brief loss of
consciousness without prolonged post-event confusion.

Seizure precautions
 Raising the upper side rails on the bed to prevent the client from falling to the floor during a
seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails
during a seizure
 During a seizure, a client may be unable to control secretions, increasing the risk for an impaired
airway. Suction equipment and oxygen equipment are set up at the bedside


Lumbar puncture
Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and
colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and
no microorganisms. Normal CSF pressure is 60–150 mm H2O. Abnormal CSF pressure or contents can
help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or
ventriculostomy.
Prior to a lumbar puncture, clients are instructed as follows:
1. Empty the bladder before the procedure
2. The procedure can be performed in the lateral recumbent position or sitting upright. These
positions help widen the space between the vertebrae and allow easier insertion of the needle
3. A sterile needle will be inserted between the L3/4 or L4/5 interspace
4. Pain may be felt radiating down the leg, but it should be temporary
After the procedure, instruct the client as follows:
1. Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant
headache
2. Increase fluid intake for at least 24 hours to prevent dehydration
A headache after the procedure is an expected finding. The symptom is treated and is normally self-
limiting.

Mannitol (Osmitrol)
an osmotic diuretic used to treat cerebral edema (increased intracranial pressure) and acute glaucoma.
Normal kidney function and adequate urine output are crucial while administering this medication as
mannitol accumulation can result in significant volume expansion, dilutional hyponatremia, and
pulmonary edema.
An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs.
To prevent these complications, clients require frequent monitoring of serum osmolarity, input and
output, serum electrolytes, and kidney function.

Melatonin
supplement thought to help the body adjust quickly to new surroundings and time zones (jet lag). Most
practitioners agree that the lowest possible dose should be used and should be taken only for a short time.

Evening primrose
may be used for eczema or skin irritations.

Ginseng
used to promote mental alertness and enhance the immune system.

Head injury
discharging a client
ensuring that a responsible adult will check on the client as the level of consciousness can change
client should return to the emergency department or notify the primary care provider if any of the
following signs/symptoms are present in the next 2-3 days:
 Change in level of consciousness (eg, increased drowsiness, difficulty arousing, confusion)
 Worsening headache or stiff neck, especially if unrelieved by over-the-counter analgesics
 Visual changes (eg, blurring)
 Motor problems (eg, difficulty walking, slurred speech)
 Sensory disturbances
 Seizures
 Nausea/vomiting or bradycardia (indicates IICP)
The client is also to abstain from alcohol, check before taking medications that can affect level of
consciousness (eg, muscle relaxants, opioids), and avoid driving or operating heavy machinery.
Clients should avoid opioid pain medications and CNS depressants (eg, alcohol) when recovering from a
head injury. They should also avoid driving, using heavy machinery, playing contact sports, or taking hot
baths for 1-2 days.

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal
immobilization is NSAIDs:
N - Neurological examination. Focal deficits include numbness and decreased strength.
S - Significant traumatic mechanism of injury
A - Alertness. The client may be disoriented or have an altered level of consciousness
I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain
D - Distracting injury. Another significant injury could distract the client from spinal pain.
S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline
tenderness) may be present

Ischemic stroke
a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and
permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to
the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not
require treatment unless the hypertension is extreme (systolic blood pressure >220 mm Hg or diastolic
blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict
blood pressure control (eg, active ischemic coronary disease, heart failure, aortic dissection). "mild"
lowering is required, usually to a systolic pressure that is not below 170 mm Hg. Treatment would be
indicated for blood pressure >220/120 mm Hg or for hemorrhagic strokes.
Nicardipine (Cardene) is a prototype of nifedipine and is a potent calcium channel blocking
vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood
pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can
occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex
tachycardia occurs.

Status epilepticus
a serious and life-threatening emergency in which a client has been seizing for 5 minutes or
longer. Grunting and a dazed appearance are 2 common signs.
Stopping seizure activity is the first nursing priority. IVbenzodiazepines (diazepam or lorazepam) are
used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is
unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to
administer a dose before bringing a child to the emergency department.

Ruptured cerebral aneurysm

a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless
they rupture; they are often called "silent killers" as they may go undetected for many years before
rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt
onset of "the worst headache of my life" that is different from previous headaches (including
migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing
a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures,
vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance
for survival.

Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by
severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting.
The client with uncontrolled migraine headaches requires a change in treatment regimen (eg, ergotamine).
Meningitis
an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of
bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other
symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure
(ICP).
In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood
pressure
In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and
meningitis may include:
 Administer vasopressors.
 Obtain relevant labs and blood cultures prior to administering antibiotics.
 Administer empiric antibiotics, preferably within 30 minutes of admission. This client will
continue to decline without antibiotic therapy.
 Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions may
contraindicate a LP due to the risk of brain herniation
 Assist with a LP for cerebrospinal fluid (CSF) examination and cultures. CSF is usually purulent
and turbid in clients with bacterial meningitis. CSF cultures will allow for targeted antibiotic
therapy.
Hemorrhagic stroke
occurs when a blood vessel ruptures in the brain and causes bleeding. Seizure activity may occur due to
increased intracranial pressure (ICP). During the acute phase, a client may develop dysphagia. To prevent
aspiration, the client must remain NPO until a swallow function screen reveals no deficits.
perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and
report any acute changes.
Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse
should: Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors,
Administer stool softeners to reduce strain during bowel movements, Reduce exertion, maintain strict bed
rest, assist with activities of daily living, Maintain head in midline position to improve jugular venous
return to the heart
Arteriovenous malformation
A congenital deformity of tangled blood vessels often occurring in the brain. These vessels may weaken
and rupture, causing an intracranial hemorrhage. Any neurologic changes and severe headache need to be
addressed immediately as these may indicate hemorrhage.
Epidural hematoma
An accumulation of blood between the skull bone and dura mater
The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the
time of impact. The client then regains consciousness quickly and feels well for some time after the
injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in
mental function that can progress into coma and death.
** Codeine is a derivative of natural opiates (eg, morphine), whereas fentanyl is completely synthetic.
** Dysphagia refers to difficulty swallowing. The term dysphagia is often confused with
dysphasia. Clients with motor deficits after a stroke may have dysphagia, which requires swallowing
precautions to prevent aspiration.
** Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are
affected. Comprehension and the meaning of words are intact, but speech is difficult to understand (eg,
mumble, lisp).
** Apraxia refers to loss of the ability to perform a learned movement (eg, whistling, clapping, dressing)
due to neurological impairment.