Hizon, Dan Melton Anthony A.

BSN3B

Assessment of Neurologic Function

I. Interpretation, Completion, and Comparison

MULTIPLE CHOICE
Read each question carefully. Circle your answer.

1. A neurotransmitter that helps control mood and sleep is:

a. acetylcholine. c. enkephalin.
b. dopamine. d. serotonin.

2. Parkinson's disease is caused by an imbalance in the neurotransmitter known as:

a. acetylcholine.c. GABA.
b. dopamine. d. endorphin.
3. A person's personality and judgment are controlled by that area of the brain known as the:
a. frontal lobe. c. parietal lobe.
b. occipital lobe. d. temporal lobe.
4. The lobe of the cerebral cortex that is responsible for the understanding of language and
music is the:
a. frontal lobe. c. parietal lobe.
b. occipital lobe. d. temporal lobe.

5. Voluntary muscle control is governed by a vertical band of "motor cortex" located in the:
a. frontal lobe. c. parietal lobe.
b. occipital lobe. d. temporal lobe.
6. The sleep—wake cycle regulator and the site of the hunger center is known as
the:
a. hypothalamus. c. pituitary gland.
b. medulla oblongata. d. thalamus.
 7. The overall regulation of the autonomic nervous system is the function of the: a.
cerebellum.
c. pons.
b. hypothalamus.
d. temporal lobe of the cerebral cortex.
8. The "master gland" is also known as the: a.
adrenal gland.
c. pineal gland.
b. thyroid
gland.
d. pituitary gland.
9. The major receiving and communication center for afferent sensory nerves
is the: a. medulla oblongata.
b. pineal body. c. pituitary gland.
d. thalamus.

10. The normal adult produces about 150 ml. of cerebrospinal fluid daily from
the:
a. ventricles.
b.dura mater. c. circle of Willis. d. corpus callosum.
11. The spinal cord tapers off to a fibrous band of tissue at the level of the:
a. coccygeal nerve.
b. first lumbar vertebra. c. lateral ventricle.
d. medulla oblongata.
12. The preganglionic fibers of the sympathetic neurons are located in those
segments of the spinal cord identified as: a. Cl to Tl.
b. C3 to Ll. c. C8 to L3.
d. Tl to SS.
13. The parasympathetic division of the autonomic nervous system yields impulses
that are mediated by the secretion of: a. acetylcholine.
c. norepinephrine.
b. epinephrine. d. all of the above.

14. Motor axons form pyramidal tracts that cross to the opposite side. This cfossed
pyramidal tract occurs in the brain in the area of the:
a. frontal cerebrum. c. medulla oblongata.
b. lateral portion of the cerebellum. d. pons.

15. The brain center responsible for balancing and coordination is the:
 a. cerebellum. c. first sacral nerve.
b. second lumbar vertebra. d. sacrum.
16. The Romberg test is used to assess:
a. balance and coordination. c. biceps reflex.
b. muscle strength. d. muscle tone.

17. The Babinski reflex is used to assess: c. central nervous system disease.
a. muscle strength. d. optical nerve damage.
b.coordination.
18. To reduce leakage of cerebrospinal fluid after myelography with an oil-based
medium, the patient lies down for 12 to 24 hours in what position? c. Prone
a. In high-Fowler's position d. Recumbent
b.In bed with head elevated 30 to 45 degrees
19. Patient preparation for electroencephalography includes omitting, for 24 hours
before the test, all of the following except: c. stimulants.
a. coffee and tea. d. tranquilizers.
b.solid foods.
20. For a lumbar puncture, the nurse should assist the patient to flex his or her head
and thighs while lying on the side so that the needle can be inserted between the:c.
third and fourth lumbar vertebrae.
a. fourth and fifth cervical vertebrae. d. first and second sacral vertebrae.
b.fifth and sixth thoracic vertebrae.
MATCHING
Match the neurologic dysfunction in column Il with its associated nursing intervention
found in column I. An answer may be used more than once.
Il Column I Column
Assist with daily active or passive range of motion.F a. Footdrop
Elevate the head of the bed 30 degrees.E b. Incontinence
c. Impaired cough
Institute a bowel-training program.B reflex
d. Keratitis
Maintain dorsiflexion to affected area.A e. Paralyzed
diaphragm
Place the patient in a lateral positionC. f. Paralyzed
extremity
Il. Thinking Questions and Exercises

DISCUSSION AND ANALYSIS

Discuss the following topics with your classmates.
1. Describe several nursing interventions for maintaining the airway for
a patient with an altered level of consciousness.

2. Discuss 6 of 12 major goals for a patient with an altered level of

consciousness.

3. Describe Cushing's reflex, in neurological a phenomenon monitoring:

seen when microdialysis cerebral blood and cerebral flow decreases
oxygenation significantly.monitoring.

4. Explain two trends

5. Distinguish between the early and late signs of ICP that a nurse would
be responsible for assessing.

6. Explain the rationale for regulating body temperature in patients with

cerebral disorders.

7. Describe the nursing management of a patient during a seizure.

8. Describe the role of the nurse after a seizure has occurred.

9. Describe the pathophysiology, clinical manifestations, and

medical/nursing interventions for epilepsy

10. Describe the clinical manifestations of a migraine headache from

prodrome phase to the recovery phase

.II. Critical Thinking Exercises

 1. Describe several nursing interventions for maitaining the airway for patient with an
alter level of conscious

Nursing interventions

 Monitor frequent neurological status and maintain hourly neurological chart

 Institute measures to minimize risk for increased ICP, cerebral edema, seizures.)
Minimizing secondary brain injury
 Monitor lab data if indicated (Blood glucose, CSF, CBC etc.)
 Institute measures to minimize risk for increased ICP, cerebral edema, seizures.)
 Monitoring temperature status; maintain normothermia, institute cooling procedures if
indicated. Minimizing secondary brain injury
 The most important aspect in managing the patient with ALOC is to establish an
adequate airway and ensure ventilation.
 Keep the airway freeform secretions with adequate suctioning
 If client need endotracheal intubation and mechanical ventilation should be assist.
Maintaining an effective airway
 Monitor prescribed IV fluids carefully for e.g. monitor hourly intake and output
 Assess hydration status by examining skin turgor & mucous membranes
 Monitor Pulse, BP
 Monitor fluid over load and pulmonary edema carefully. Attaining & Maintaining fluid
& electrolyte balance
 Respiratory tract infection and UTI is most common complications in a patient with
prolong ALOC status
 Ventilator associated pneumonia (VAP) and aspiration pneumonia can be associated with
prolong endotracheal intubation and Mechanical ventilation.
 Adequate oral care and anticipate prevention of aspiration such as proper position and
suctioning is essential to prevent respiratory tract infection Prevent infection
 Respiratory therapies such as CPT and PD
 Follow proper aseptic technique maintain adequate urinary catheter care
 Monitor signs &symptoms of infection (Elevation body temp, increase WBC etc.)
Prevent infection
 Maintain hydration and prevent dryness Maintaining healthy oral mucus membranes and
oral hygiene
 Use oxygen therapy if indicated. ∗ Refer to Chest physical therapy such as Postural
drainage, chest percussion etc. Frequently monitor respiratory status such as rate,
rhythm, pattern etc., Maintaining an effective airway
 Maintaining of skin integrity is quite challenging in a patient with ALOC because of long
term immobility, negligence of providing frequent positioning and nutritional factors can
affect level of skin integrity. Frequent turn the client from side to side and provide
positioning on a regular schedule to relive pressure areas and help clear lungs by
mobilizing secretions Maintain skin integrity
 Perform ROM exercise of extremities at least four times per day
 Use water bed and air bed to prevent pressure ulcer
 Maintain adequate nutritional status.
 Keep the skin clean and moisture, well lubricated Maintain skin integrity
 Some clients who are unconscious have their eyes open and have inadequate or absent
corneal reflexes. The cornea may become infected, irritated, dry, or scratched and
leading to ulcerations. Maintain corneal integrity
 Protect the eyes from corneal irritation as the cornea functions as shield. Care full
inspect the condition of the eyes with penlight. Remove the any contact lenses if worn
Irrigate the eyes with sterile water. Instill prescribed ophthalmic ointments and drops
Apply eye patches when indicated Maintain corneal integrity
 Hypothermia & Hyperthermia is common in unconscious clients in case of damage of
thermo regulating Centre of the brain (hypothalamus) and also may be caused by
respiratory and urinary tract infections. Monitor client body temperature
  Take appropriate interventions to manage thermo imbalance Maintain thermoregulation
functions
 An Indwelling Urinary Catheter may be used for short –term management, Use
intermittent bladder catheterization. Monitor cloudy urine and fever
 Auscultate for bowel sounds; palpate and measure lower abdomen for distention. Treat
constipation promptly if present. Monitor for diarrhea caused by infection & antibiotics
Promote manage urinary and bowel function
 Always beds slide rails should be used
 Care taken invasive IV lines and tubes
 Frequent neurological assessment and frequent orientation is essential
 Develop a supportive and trusting relationship with the family members of the patient.
Provide information and frequent updates on the client’s condition and progress.
Demonstrate and teach some of procedure esp. procedure carried out in home setting
such as feeding technique, position change etc. Family education and support

2. Discuss 6 to 12 major goals for patient with an altered level of conscious

 Maintaining Fluid Balance And Managing Nutritional Needs
 Maintaining Skin And Joint Integrity
 Preserving Corneal Integrity
 Achieving Thermoregulation 
 Preventing Urinary Retention
 Promoting Bowel Function 
 Providing Sensory Stimulation

3. Describe Cushing’s reflex, a phenomenon seen when cerebral blood flow decreases
significantly.

Cushing reflex is a physiological nervous system response to acute elevations of intracranial

pressure (ICP) resulting in the Cushing triad of widened pulse pressure (increasing systolic,
decreasing diastolic), bradycardia, and irregular respirations. Brain edema usually results from
increased capillary pressure or actual damage to the capillary walls that allows them to leak. As
the brain starts to swell, two things begin to occur. Edema begins to compress the blood vessels
supplying the brain. This compression results in reduced blood flow to the brain and ultimately
brain ischemia. The ischemia will then cause the arteries leading to the brain to dilate, causing
an additional increase in capillary pressure and a further increase in intracranial pressure. The
increased capillary pressure worsens edema. Then it decreased cerebral blood flow to the brain
subsequently decreases oxygen delivery to the sensitive brain tissues. This reduces the ability of
the capillaries in the brain to function normally and results in increased capillary permeability
and leakage. When the cells of the brain lose their energy supplies, the intracellular pumps
(sodium/potassium pumps) start to fail. This allows sodium to enter the cells of the brain,
causing cellular edema and ultimately cell death. Blood flow to the brain is directly related to
cerebral perfusion pressure (CPP).

4. Explain two trends in neurological monitoring: micro dialysis and cerebral

oxygenation monitoring

Cerebral microdialysis
The technique of micro dialysis enables the monitoring of neurotransmitters and other
molecules in interstitial tissue fluid. This method is widely used for sampling and quantifying
neurotransmitters, neuropeptides, and hormones in the brain and periphery. Depending on the
availability of an appropriate analytical assay, virtually any soluble molecule in the interstitial
space fluid can be measured by micro dialysis.

It measures changes at the cellular level and it has the potential to detect ischemia or
mitochondrial dysfunction before changes can be detected in the patient’s neurological status or
by more conventional monitoring techniques such as ICP measurement.

Cerebral oxygenation monitoring

The most important function of blood flow is oxygenation, and extreme ischemia results
in a drastic drop in oxygen supply. The resulting chain of events may result in cell membrane
loss and necrosis in some cells, but cells in the surrounding tissue region, which is less affected
by hypoxia, survive to form the ischemic penumbra. Although the exact timing of these events is
unknown, these cells have enough oxygen to sustain membrane ion pump functions but not
enough to produce action potentials and therefore behave as neurons. Based on the essence of
clinical recovery, the presence of such areas has been assumed for some time, but. The existence
of such areas has been suspected for some time based upon the nature of clinical recovery, but
has now been demonstrated by SPECT imaging with a high plasma oxygen concentration under
hyperbaric conditions as a tracer. A course of hyperbaric oxygen therapy frequently results in a
permanent improvement in both flow and metabolism. These changes apparently represent a
reversal of the changes that render neurones dormant and the activity of cells, previously
undetectable by standard electrophysiological methods, can now be demonstrated. 

5. Distinguish between the early and late signs of ICP that a nurse would be
responsible for assessing.

By closely monitoring patients who may be at risk of raised ICP, we can detect any changes
promptly and therefore improve patient outcomes with early treatment interventions.

The nurse must monitor and report any early signs and symptoms of increasing ICP, which can
be done by regularly attending to neurological observations on the patient.

These signs include:

 Disorientation, restlessness, mental confusion and purposeless movements;

 Pupillary changes and impaired extraocular movements;
 Weakness in one extremity or hemiplegia; and
 Headache, constant in nature, increasing in intensity and aggravated by movement or
straining.

If the patient’s condition progresses, the symptoms may worsen to:

 Deterioration in level of consciousness;

  Cushing’s triad;
 Altered respiratory patterns including Cheyne-Stokes breathing;
 Vomiting;
 Hemiplegia; and
 Loss of brain stem reflexes (pupillary, corneal, gag and swallowing reflexes)
6. Explain the rationale for regulating body temperature in patients with cerebral
disorder.
Temperature management in neurosurgical intensive care units (ICUs) has become an
integral part of patient care. Although moderate cooling can be used to target secondary
injury pathways, ICU treatment procedures must also provide measures to prevent cycles
of reactive hyperthermia. Early cooling has been shown in some clinical trials to
decrease mortality and increase functional outcome in particular patient groups with
traumatic brain injury and spinal cord injury, for example. Temperature has been shown
to target a number of pathophysiological pathways implicated in systemic damage and
long-term cognitive deficits in experiments. While mild cooling reduces many of these
pathophysiological events, mild elevations in temperature aggravate some of these
processes.
7. Describe the nursing management of a patient during seizure.

Patient safety is one of the main considerations during seizure activity. It is important to
remember DRSABCD:

 Danger;
 Response;
 Send for help;
 Airway;
 Breathing;
 CPR; and
 Defibrillation.
The nurse must stay with the patient when calling for assistance. It's vital to keep track of the
seizure's duration and characteristics. The patient's head must be covered, especially if
convulsive motions occur that could harm the patient. Place something gentle under the patient's
head and shoulders to save them from hurting themselves. To reduce the chance of injuries,
make the surrounding environment as visible as possible; however, do not attempt to actively
limit the patient's limb mobility as this will result in musculoskeletal damage. Place nothing in
the patient's mouth and don't want to move them.

Roll the patient onto their side in the recovery position as quickly as possible to prevent
aspiration from increased saliva output and to ensure their airway stays patent. It is important to
do something immediately whether the patient has vomited or has food or liquid in their mouth.

Suction and oxygen must be available. Monitoring of vital signs is imperative, especially
respiratory function.

Manage any injuries that arise as a result of the seizure. Continue to control the patient's
airway, suctioning if appropriate, and don't wake them up if they fall asleep. Asking them what
they're doing and that they are healthy when they wakes. Provide reassurance to the patient,
since it is understandably distressing.

Frequent monitoring of vital signs and neurological observations will need to be

performed in order to monitor the patient’s condition.

8. Describe the role of the nurse after a seizure has occurred.

Continue to control the patient's airway, suctioning if appropriate, and don't wake them up if
they fall asleep. Asking them where they are and that they are healthy when they wake up.
Provide reassurance to the patient, since this is understandably distressing. In order to maintain
track of the patient's health, vital signs and neurological observations will need to be tracked on
a daily basis..

9. Describe the pathophysiology, clinical manifestations, and medical/nursing

interventions for epilepsy.
 Pathophysiology
Seizures start with the excitation of susceptible cerebral neurons, which leads to synchronous
discharges of progressively larger groups of connected neurons. Neurotransmitters are
undoubtedly involved. Glutamate is the most common excitatory neurotransmitter, and gamma-
aminobutyric acid (GABA) is an important inhibitory neurotransmitter. An imbalance of excess
excitation and decreased inhibition initiates the abnormal electrical activity. These electrical
paroxysmal depolarization shifts (PDS) seem to trigger epileptiform activity. Increased
activation or decreased inhibition of such discharges could result in seizures. The part of the
brain affected often reflects in the clinical signs or symptoms of the seizure. Systemic
modifications such as lactic acidosis, elevated catecholamine levels, hyperthermia, respiratory
compromise, and other systemic alterations follow generalized convulsive status epilepticus. The
brain is damaged by the continuous excessive electrical activity that occurs in status epilepticus.
Generalized convulsive status epilepticus progresses from continuous or isolated seizures to a
state of little to no motor function. EEG reflects electrical activity that changes over time. A
form of nonconvulsive generalized status epilepticus may result as a result.

Clinical Manifestations

The clinical diagnosis of seizures is based on the history obtained from the patient and, most
importantly, the observers.

 Aura. An aura (unusual sensations) precedes seizures in about 20% of people who have
a seizure disorder.
 Short duration. Almost all seizures are relatively brief, lasting from a few seconds to a
few minutes; most seizures last 1 to 2 minutes.
 Postictal state. When a seizure stops, people may have a headache, sore muscles,
unusual sensations, confusion, and profound fatigue; these after-effects are called the
postictal state.
  Todd paralysis. In some people, one side of the body is weak, and the weakness lasts
longer than the seizure (a disorder called Todd paralysis).
 Visual hallucinations. Visual hallucinations (seeing unformed images) occur if the
occipital lobe is affected.
 Convulsions. A convulsion (jerking and spasms of muscles throughout the body) occur
if large areas on both sides of the brain are affected.

Nursing Interventions

 Prevent trauma/injury. Teach SO to determine and familiarize warning signs and how to

care for patient during and after seizure attack; avoid using thermometers that can cause
breakage; use tympanic thermometer when necessary to take temperature; uphold strict
bedrest if prodromal signs or aura experienced; turn head to side and suction airway as
indicated; support head, place on soft area, or assist to floor if out of bed; do not attempt
to restrain; monitor and document AED drug levels, corresponding side effects, and
frequency of seizure activity.
 Promote airway clearance. Maintain in lying position, flat surface; turn head to side
during seizure activity; loosen clothing from neck or chest and abdominal areas; suction
as needed; supervise supplemental oxygen or bag ventilation as needed postictally.
 Improve self-esteem. Determine individual situation related to low self-esteem in the
present circumstances; refrain from over protecting the patient; encourage activities,
providing supervision and monitoring when indicated; know the attitudes or capabilities
of SO; help an individual realize that his or her feelings are normal; however, guilt and
blame are not helpful.
 Enforce education about the disease. Review pathology and prognosis of condition and
lifelong need for treatments as indicated; discuss patient’s particular trigger factors;
know and instill the importance of good oral hygiene and regular dental care; review
 medication regimen, necessity of taking drugs as ordered, and not discontinuing therapy
without physician supervision; include directions for missed dose.

10. Describe the clinical manifestations of a migraine headache from prodrome phase
to recovery phase.

Migraine attack stages or phases

It is often difficult to predict when a migraine attack is going to happen. However, you can often
predict the pattern of each attack as there are well defined stages.  It is these stages and their
symptoms which distinguish a migraine from a headache.

In adults, we can divide a migraine attack into four or five stages that lead on from each other:

 Premonitory or warning phase

 Aura (not always present)
 The headache or main attack stage
 Resolution
 Recovery or postdrome stage

Learning to recognise the different phases of a migraine attack can be useful. You might get one,
all, or a combination of these stages, and the combination of stages may vary from attack to
attack. Each phase can vary in length and severity.

Recognising different symptoms at different times during your headache attack can give a doctor
information which may help diagnosis. Also, taking medication before the symptoms have fully
developed may reduce the effect of an attack. A child’s migraine attack is often much shorter
than an adult’s attack, and it may therefore not be possible to fully make out the different
headache phases.

Premonitory stage

This describes certain physical and mental changes such as tiredness, craving sweet foods, mood
changes, feeling thirsty and a stiff neck. These feelings can last from 1 to 24 hours.

Aura

The aura of migraine includes a wide range of neurological symptoms. This stage can last from
5 to 60 minutes, and usually happens before the headache. Migraine without aura does not
include this stage.

In some people, changes in the cortex area of the brain cause changes in their sight, such as dark
spots, coloured spots, sparkles or ‘stars’, and zigzag lines. Numbness or tingling, weakness, and
dizziness or vertigo (the feeling of everything spinning) can also happen. Speech and hearing
can also be disturbed, and people with migraine have reported memory changes, feelings of fear
and confusion, and more rarely, partial paralysis or fainting. These neurological symptoms are
called the ‘aura’ of migraine. In adults, they usually happen before the headache itself, but in
children, they may happen at the same time as the headache. It is possible to have the aura
symptoms without the headache.  

The headache or main attack stage

This stage involves head pain which can be severe, even unbearable. The headache is typically
throbbing, and made worse by movement. Some people describe a pressing or tightening pain.
The headache is usually on one side of the head, especially at the start of an attack. However, it
is not uncommon to get pain on both sides, or all over the head. Nausea (sickness) and vomiting
(being sick) can happen at this stage, and the person with migraine may feel sensitive to light or
sound, or both.

Resolution

Most attacks slowly fade away, but some stop suddenly after the person with migraine is sick, or
cries a lot. Sleep seems to help many people, who find that even an hour or two can be enough to
end an attack. Many children find that sleeping for just a few minutes can stop their attack.

Recovery or postdrome stage

This is the final stage of an attack, and it can take hours or days for a ‘hangover’ type feeling to
disappear. Symptoms can be similar to those of the first stage, and often they are mirrored
symptoms. For example, if you lost your appetite at the beginning of the attack, you might be
very hungry now. If you were tired, now you might feel full of energy.

INTERPRETING PATTERNS
Complete the following analogies by inserting the word that reflects the association.

I. Craniotomy : surgery involving entry into the cranial vault Craniectomy

:Removing a small portion of skull
2. Cushing's response : increased arterial pressure in response to increased ICP :
: Cushing's triad:
3. Decerebration : extreme extension of the upper and lower extremities the upper
extremities : abnormal flexion of upper extrimites