Medical Surgical Nursing 2

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➔ Communication occurring between
CARE FOR CLIENTS WITH NEUROLOGIC DISORDERS brain cells is happening at the
Neurosensory System synapse.
The Nervous system consists of two divisions
the central nervous system (CNS) including Dendrites Specializes extension
the brain and spinal cord, and the of the cell body and
peripheral nervous system (PNS) which they function to
includes the cranial and spinal nerves. obtain information
➔ Function: control motor, sensory, from other cells and
autonomic, cognitive, and behavioral carry that
activities. information to the
cell body.
Major Parts: Axons Neuron processes
• CNS that transmit nerve
• Brain impulses away from
• Spinal Cord the cell body.
• Meninges
• Nerves ➔ Axons carry impulses away from the
• Nerve Frac cell body. Dendrites carry impulses
• Reflex towards the cell.

PARTS OF A NERVE Central Nervous System

Neurons Basic unit of nerves
and tissues
composed of cell
body and nerve
fibers such as axons
and the dendrites.

PARTS OF CENTRAL NERVOUS SYSTEM

Brain “ encephalon” , is divided
Afferent Sensory Nerves into cerebrum, spinal cord,
Efferent Motor Nerves and the meninges.
Myelin Sheath Allows electrical Cerebrum Divided into two
impulses to transmit hemispheres (thalamus.
quickly and Hypothalamus and the
efficiently along the basal ganglia) and further
nerve cells. divided into four main
Synapse Connect neurons in lobes. These are the (1)
the brain to the Frontal Lobe, Parietal
neurons of the rest of Lobe, Temporal and
the body. Occipital Lobe.
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Spinal Cord Consists of 31 segments extremely thin,
and these are the eight (8) delicate membrane
cervical, twelve (12) where the sub-
thoracic, five (5) lumbar, arachnoid spaces or
five (5) sacral, and one (1) CSF is located.
coccyx area. Cerebrospinal fluid A clear liquid that
(CSF) circulates in the
subarachnoid space.
Pia Matter Innermost layer
which contains the
blood vessels.

Functional Areas of the Brain

The skull is the cranial vault that protects

our brain. After the skull, we have the
meninges which covers the brain. There are
three layers;

Medulla oblongata – where the respiratory,

cardiac, and vasomotor centers are located.
LAYERS OF THE MENINGES This is one of the vital functions of the brain.
Meninges Fibrous connective ➔ An injury to the medulla oblongata
tissues that cover the can lead to death.
brain and the spinal
cord; provides DIFFERENT LOBES OF THE BRAIN
protection, support Frontal Lobe The largest lobe. It
and nourishment to also contains the
the brain and the Broca’s area, which
spinal cord. is located in the left
Dura Matter The outermost, hemisphere and is
thickest, and critical for the
toughest covering of language and motor
the brain. function or control of
Arachnoid Matter The middle speech, problem
membrane is an solving, reasoning,
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memory and visual processing.
executive function of Occipital Lobe Visual processing.
the brain. The posterior lobe is
responsible for visual
➔ For example, an individual’s inability interpretation and
to perform a simple mathematical memory.
problem is a sign of a problem in the Parietal Lobe Integrates sensory
frontal lobes of the brain. information taste,
touch, pain, and
Temporal Lobe This is where the temperature.
Wernicke’s area can
Lobes & their Specific Functions
be located. Contains
the auditory
receptive areas. It
takes responsibility
in the memory,
hearing, perception,
and recognition of
the individual.
Wernicke’s area is a critical language area
in the posterior superior temporal lobe
connects to Broca’s area via a neural
pathway. It is primarily involved in the
comprehension.
Brain Stem Located at the base
of the brain. It’s
function is related to
the heartbeat and
breathing process.
Cerebellum Little brain. It has
the responsibility in
the coordination,
timing of movements
and the motor
learning of the Thalamus Plays an important
individuals. role as it maintains
Midbrain Not located in the water balance. It
cerebellum. The acts primarily as a
pressure here is relay station for all
accompanied by the sensations except
loss of pupil response smell. All memory,
since it functions on sensation and pain
the motor movement impulses pass
of the eye, the through this section
auditory and the of the brain.
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Hypothalamus Controls and will take about 20 minutes if without
regulates the contrast medium and 60 minutes if
Autonomic Nervous with contrast medium.
System (ANS) and is ➔ Incase if the patient cannot remain
located anterior and still, it is necessary to sedate the
inferior of the patient.
thalamus. It is ➔ NPO for 4 to 6 hours if contrast
connected in medium is used.
regulating our body ➔ Since a contrast medium is used,
temperature likewise observe for allergic reactions on
it takes responsibility iodinated contrast material.
in the functioning of Electroencephalography (EEG) – graphical
our energy through recording of spontaneous electrical impulses
drinking and eating. of the brain from skull electrodes.
Hippocampus Store long term Nursing Responsibilities:
memories. Involved ➔ Explain the procedure to the client.
in the spatial ➔ Use of hair shampoo to remove oils.
processing and ➔ No caffeine and other stimulants or
navigation. anticonvulsants for
Amygdala Part of the brain that at least 24 hours
drives the fight or before the
flight response. procedure.
Olfactory bulb Receive input on the ➔ Wash hair
odor detected. after the procedure
Frontal Cortex The frontal lobe of to remove the
the brain. paste/glue placed in
the hair for EEG.
Electromyography (EMG) – records the
Diagnostic Workups electrical activity in muscles at rest during
NEURODIAGNOSTIC TESTS voluntary contraction and in response to
Skull x-ray Spine x-ray electrical stimulation.
Nursing Responsibilities: Nerve Conduction Test – records speed of
➔ Remove metallic items from the hair conduction in motor and sensory fibers of
or from around the neck and body as peripheral nerves.
the presence of these items will not EMG and Nerve Conduction test are done
give accurate results. to detect neuromuscular disorders like
➔ Specifically for spine x-ray - Avoid Myasthenia gravis (MG) and Parkinson’s
flexion or rotation of spine when disease.
fracture is suspected. Nursing Responsibilities:
CAT or CT Scan (Computed Tomography) ➔ Explain procedure to the client that
Nursing Responsibilities: small electrode needles will be
➔ Remove metallic objects from hair. inserted into the muscles. The patient
➔ Reinstruct the patient to remain will most likely to experience
absolutely still during the procedure. discomfort so, we need the patient to
➔ Inform the patient that the procedure be aware of this and that the
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procedure will take about 45 minutes
for one muscle.
➔ If the muscles will be tested more
than one, this will mean that the
procedure will take longer period of
time.
Cerebral Angiography – is a very important
procedure. This arteriogram is an intra-
arterial injection of contrast medium with
simultaneous radiographs of head and neck
to visualize intracranial and extracranial
vessels.
Nursing Responsibilities:
Before the Procedure
➔ Explain the procedure to the patient.
➔ The client may experience hot,
flushing sensation.
➔ The contrast material can be injected
in the femoral, brachial, or carotid
arteries.
➔ Remove metallic clips from hair.
➔ Check allergy to iodine/seafoods.
➔ NPO 4 to 6 hours.
➔ IVF to ensure adequate hydration.
➔ Premedicate as ordered.
After Procedure
➔ Observe puncture site for bleeding or
hematoma; apply pressure dressing
or ice pack to the area.
➔ Observe pulse distal to the puncture
site. Any diminished or absent pulse
may indicate blockage of vessels by
thrombus or hematoma.
➔ Observe affected limb for color and
temperature. Remember, a cold and
clammy skin is an indication of
circulatory insufficiency.
➔ Observe for bradycardia and
hypotension which may happen due
to vagal irritation in the carotid
artery.
➔ Observe for any change in
neurological status. Risk of stroke or
ischemia following angiography
secondary to embolus, thrombus, or
vasospasm.
➔ Bed rest should be emphasized
(must have head elevated) for 12 to
24 hours; if the site used is the
femoral area/femoral puncture is
done, must keep leg extended and
immobile for several hours to prevent
dislodgement of clot.
➔ A clot that can go with the circulation
may land in the cerebral arteries and the
patient may have stroke. While it can also
land in the respiratory system and the
patient may cause respiratory arrest.
Lumbar Puncture (Lumbar Tap) – also
called as the “ spinal tap” . This is the
introduction of needle into spinal
subarachnoid space usually at L3–4, L4–5,
L5–S1, intervertebral space, to assess
cerebrospinal fluid (CSF).
Nursing Responsibilities:
Before and During the Procedure
➔ Encourage the patient to void.
➔ Assist client to assume “ fetal
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position” . This is the Lateral
recumbent position with the back
arched, head and neck flexed on
chest. This is to widen the
intervertebral space.
➔ Local anesthetic is used to numb the
lumbar area.
➔ Prepare three (3) specimen bottles
and label them as to: pressure,
glucose, and protein.
➔ Queckenstedt’ s test may be done to
test for the subarachnoid
obstruction; the jugular veins are
compressed for 10 seconds. First on
one side and then on the other side.
(Note for any change of pressure of
the spinal fluid).
After Procedure
➔ Flat on bed for 6 to 8 hours or turn
the patient on sides.
➔ Encourage fluid intake if not
contraindicated.
➔ Headache may be experienced by
the patient this is due to CSF leakage
this can be relieved with bedrest,
analgesic and cold or ice compress.
➔ Observe neurological status.
(Confusion, drowsiness and etc.)
Normal Values of CSF
• Pressure – 75 to 180 mmH20 or 0 to
15 mmHg.
• Glucose – 50 to 80 mg/dL
• Protein – 20 to 50 mg/dL
Myelography – introduction of a radiopaque
solution, oil-based or water-based, into the
spinal subarachnoid space with fluoroscopic
and radiographic observation.
Detects vertebral disk disease, spinal
cord tumors.
Nursing Responsibilities:
Before the Procedure
➔ Consent must be taken/signed by the
patient/SO since this is an invasive
procedure.
➔ Requires lumbar puncture.
➔ Premedicate client as ordered.
➔ Inform the client that procedure may
take for approximately 2 hours.
After the Procedure
➔ For pant opaque myelogram (oil-
based) patient lies flat for 6 to 24
hours to prevent spinal headache.
➔ For metrizamide myelogram (water-
based), HOB is elevated to 30
degrees for at least 8 hours to
prevent meningeal irritation.
➔ Encourage fluids to enhance
excretion of dye. To remove the dye
from the blood vessels.
➔ Observe for any changes in
neurological status such as
confusion, disorientation, nausea,
and vomiting.
➔ Observe for generalized seizures.
➔ Avoid administration of
phenothiazines because of lower
seizure threshold.
Magnetic Resonance Imaging (MRI) – uses
a very strong magnet combined with radio
frequency waves and a computer to
produce x-ray like images of body
chemistry.
Nursing Responsibilities:
➔ Obtain history of metal implants.
Because clients with metal implants
are not eligible for MRI scan.
➔ Procedure lasts from 30 to 90
minutes.
➔ Reassure client that procedure is
painless.
➔ Assess claustrophobia.
➔ Inform client that machine makes
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drum-like sounds.
➔ Request the client to remove credit
cards, watches, or any metal items
that would affect the machine, thus it
has to be removed.
Pneumoencephalography – special contrast
study of the ventricular and cisternal
systems using air as contrast medium.
Permits accurate localization of brain
lesions by spinal or cisternal puncture with
x-ray examination.

Nursing Responsibilities:
Before the Procedure
Just like how we take care of a patient pre-
operatively:
➔ Secure surgical permit/consent.
➔ Prepare the client as is for surgery.
➔ Inform client that general anesthesia
will be used.
Nursing Responsibilities:
After the Procedure
Before the Procedure
➔ After care is similar to a patient who
➔ Secure a written consent.
have undergone
➔ Sedative as ordered.
Pneumoencephalography.
➔ General anesthesia may be used.
➔ Time of the procedure is about 2
hours.
➔ May experience discomfort,
headache, nausea, and vomiting
after the procedure (Take note,
contraindicated in increased ICP)
After the Procedure
➔ Place the client flat in bed for 24 to 48
hours.
➔ Monitor VS and neurologic
checks/status.
➔ Severe headache lasts 48 hours.
Render nursing measures to relieve
headache.
➔ Observe seizure precaution. Positive Emission Tomography (PET Scan) –
➔ Observe for respiratory difficulty. involves uses of radioactive – substances
Ventriculography – air is introduced directly that emit positive electrons (positrons) while
into the lateral ventricles through trephine CT scanning is performed.
openings (burr holes) into the skull, x-ray Provides metabolized profile by
films are taken. revealing the rate at which tissues
Performed in the Operating Room metabolize glucose.
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BASIC CONCEPTS IN NORMAL NEUROLOGIC
FUNCTION
NORMAL NEUROLOGIC FUNCTIONS
Oxygen Supply 20% of the oxygen
Glucose Supply 65% to 70% of the glucose
Blood Supply 1/3 of the cardiac output
Acid-base balance
Acidosis Cerebral Vasodilation
CNS Depressant – Coma
Alkalosis Cerebral
Vasoconstriction
CNS Stimulant – Muscular
Contractions or Seizures
Blood Brain Soldiers of the brain.
Barriers Protects the brain from
certain drugs, chemicals,
and microorganisms.
Layer of least semi
permeable capillaries.
Cerebrospinal Cushions the brain. It
Fluid nourishes the brain and
determines the ICP, Part
of the brain that produces
CSF is the Choroid Flexus
located in the lateral
ventricles.
100 – 150 mL at a time –
normal CSF volume.
Average of 120 mL.
Cerebral vasodilation Hypoxemia (low
can be connected to blood oxygen)
Intracranial Pressure
Cerebral Vasodilation Cerebral blood
loss such as
Hypocapnea (low
PCO2) which
results the patient
to Hyperventilate.
Patient exhales
more than
inhaling.
NEUROLOGIC ASSESSMENT
MENTAL STATUS
➔ Orientation to three spheres; people,
time, and place.
➔ Memory; immediate recall, recent
memory, and remote memory.
Immediate Recall This can be tested by
asking the client to
repeat your
question.
Recent Memory Ask the clients about
the events that
occurred few
minutes or few hours
ago.
Remote Memory Ask the client about
events in the remote
past, or historical
events that can be
answered by the
general population
or the SO who will
confirm the answer
of the client.
LEVEL OF CONSCIOUSNESS
A very important part of the neurologic
assessment. It is the most sensitive indicator
of the changes in neurologic status of the
client (the level of consciousness).
➔ The center for wakefulness is
ascending reticular activating system
(ARAS) or reticular formation.
➔ Asses both wakefulness and content
of thought.
Level I If the client is
conscious, cognitive,
and coherent (3 C’s).
Level II Patient is confused,
drowsy, lethargic,
obtunded, and
somnolent. (e.g.,
Patients coming
from the operating
theater)
Level III Stuporous; respond
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only to noxious, 3 – Abnormal Flexion
strong, or intense 2 – Abnormal Extension
stimuli, (e.g., apply 1 – Flaccid/No response
sternal pressure, SENSORY FUNCTION
trapezius pinch, The center for sensory perception is located
pressure at the base in the parietal lobe. This enables us to
of the nail or perceive pressure, temperature, texture, and
supraorbital area; pain.
the patient will ➔ The ability to perceive sensory stimuli
respond either very is stereognosis.
strong light or very ➔ Inability to perceive sensory stimuli is
loud sound). agnosia.
Level IV Stereognosis The ability to
Light Coma Response is only by perceive sensory
grimace or withdrawing stimuli. For example,
limb from pain: primitive patient can identify
and disorganized response an object based in
to painful stimuli. the head with eyes
Deep Coma Absence of response to closed.
even the most painful Agnosia Inability to perceive
stimuli. sensory stimuli.
Glasgow Coma Monitor the level of
Scale (GCS) consciousness. MOTOR FUNCTION
Perfect score for this The regulating mechanism for Motor
is 15. Objective function are as follows:
measure to describe Motor Center Responsible for
NOC, it is based on (Frontal Lobe) voluntary, purposeful
the client’s response and coordinated
to the areas (eye movements.
opening, motor, and Apraxia The inability to
verbal response). perform fine motor
Eye 4 - Spontaneous activities
Opening 3 - On request Agraphia The inability to write.
2 – Painful stimuli Cerebellum Responsible for
1 – No opening equilibrium, the
Verbal 5 – Oriented (Oriented with sense of posture, and
Response time and place) direction. Roberg
4 – Confused (Engages in test is conducted to
conversations) assess sense of
3 – Inappropriate words equilibrium.
2 – Incomprehensible Words Roberg Test The patient will be
1 – No response asked to stand with
Motor 6 – Obeys Commands feet together, eyes
Response 5 – Localized Pain closed and hands on
4 – Flexion withdrawal the side. If the
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patient was able to muscle volume. increase in muscle
do this, the patient volume.
has a negative Movement
Roberg’s test Bradykinesia is slow Akinesia is absence
(normal response) muscle movement of muscle
but when the patient not associated with movement.
immediately starts to weakness.
sway moves his feet Coordination
further apart this Assesses by FTNT HKT (heel to knee to
gives a positive (finger-to-nose-test) toe test).
Roberg’s test. Station and Gait
Station is posture Gait is manner of
Assess the walking
vestibular apparatus For example, Parkinson’s disease (PD) is
and the posterior characterized by stooped posture and
column of the spinal shuffling, festinating gait; multiple sclerosis is
cord. characterized by ataxic gait.
Ataxia Uncoordinated
movement, MORE NEUROLOGIC EXAMINATIONS
characterized by
Kinesthesia Awareness of
wide-base stance
position and sense of
and swaying manner joint movement.
of walking.
For example,
Extrapyramidal It maintains balance, we ask the patient to
system posture and close his eyes then
regulates you move the
locomotion. patient’s finger up
and down so the
CLIENTS WHO CONDUCT NEUROLOGICAL patient was able to
ASSESSMENT identify the direction
General Presence of of movement
Appearance involuntary, not (normal result).
purposeful, and Graphesthesia Ability to perceive
uncoordinated writing on the skin.
movements; Topognosis Ability to identify an
asymmetry of the area of the body that
face; muscle has been touched.
dystrophy. Fasciculation or also known as
Muscle Power twitch is the rapid
Weakness (paresis) Paralysis (plegia) muscle contraction
Muscle Tone of the quadriceps
Flaccidity Rigidity muscles.
(hypotonicity) (Hypertonicity) Tremors Rhythmic or
Muscle Volume alternating
Atrophy is loss of Hypertrophy is involuntary
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movements caused of the pupils.
by the contraction of Consensual Light This result in
opposing muscles. Reflex simultaneous
Myoclonus Continual, rapid, constriction of both
short spasm pupils even if light is
involving one or applied to one pupil
group of muscles. only.
This
frequently occurs in Accommodation This result to
an extremity of an Reflex (PERRLA) constriction of
individual who is pupils when gaze is
falling asleep. shifted from a
Tic Sudden, repetitive distant object to a
non-rhythmic motor near object.
movements. The
Pupillary Reflexes
REFLEX TESTING are presented by
➔ The center for reflex act is the spinal PERRLA.
cord. Pupils
➔ The cerebral cortex determines the Equally Round
motor response. Reactive to Light
TYPES OF REFLEXES Accommodation.
Superficial Reflexes Pupillary reflexes ➔ A fix and dilated pupil/s in the client
who has previously had reactive pupils is a
DTR’s
neurologic emergency. You have to refer the
Reflexes to assess meningeal irritation
client immediately to the physician.
Oculocephalic reflex
Corneal Reflex Elicited by touching
Oculovestibular reflex
the cornea with a
Plantar Reflex Plantar flexion of
use of a cotton as
the foot. This is
the client moves
assessment of
towards the
adult’s plantar
opposite direction
reflex. Normal
so, there will be
reflux when there is
blinking of the eyes.
plantar flexion of
Abdominal Reflex Contraction of the
the foot where the
site of the abdomen
toes curl towards
stroked with blunt
the sole of the foot.
object.
Direct Light Reflex As part of the
Pupillary Reflexes.
This is elicited by Cremasteric Reflex Elicited by
applying light downward stroking
stimulus, then move of the inner thigh of
side to side into the the male then there
pupil and this result would be elevation
to the constriction of the scrotum on
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the same side. This REFLEXES TO ASSESS MENINGEAL IRRITATION
test is only done
among unconscious
male patients.
Anal Reflex Similarly, must be
done to an
unconscious client.
This results to the
contraction of the
anus when it is
stroked with blunt
object.
Babinski Reflex This is elicited by Kernig’s sign Client is placed in
Testing stroking the sole of supine position with
the foot from the hip flexed 90
heel upwards so, degrees. Knee
there would be a cannot be fully
plantar flexion. extended.
Negative Brudzinski’s Neck Client is places in a
Babinski is a Sign (Neck rigidity) supine position with
normal result passive flexion of
among adults. neck causes
Remember! The Babinski response is spontaneous flexion
considered abnormal in an adult and may of hips, both legs and
indicate upper motor neuron disease. thighs. This is a more
How to interpret the results of the accurate indication
superficial reflexes? This is where you can of meningeal
see in some of the patient’s chart wherein irritation than
there is 0 written which means there is Kernig’s sign.
absence of reflexes, (+) normally active, (-)
slightly present Oculocephalic Demonstrated by
Deep Tendon Knee jerk (Patellar Reflex (Dolls Eye holding the person’s
Reflexes Knees) and Ankle Phenomenon) eyelids open and
jerk. rotating the head
Knee Jerk (Patellar Ankle Jerk Reflex – from side to side.
Knees) – is produced is produced by Positive or normal
by tapping the tapping the tendon Dolls Eye is
quadriceps femoris. of Achilles and there demonstrated by
The quadriceps would be plantar conjugate
femoris is just below flexion of the foot. movements of the
the patella. Two-leg eye towards the
extension. opposite side.
Oculovestibular This is done by
Reflex (Caloric Ice irrigating the semi-
Water Test or circular canals of the
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Caloric Reflex Test) ears with iced water. Blurring of the
This will cause vision and
conjugate eye blindness.
movements or (44:17)
nystagmus Oculomotor (CN-III) Regulation of eye
(repetitive, movements.
uncontrolled Connected to pupil
movements). This is constriction to light
an accurate method elevation of the
of assessing brain upper lid.
stem functioning. ➔ Abnormal
OTHER REFLEXES findings:
Tricep Reflex Extension of the arm Pinpoint fix and
at the elbow and dilated pupils.
contraction of the Trochlear (CN-IV) Regulation of eye
biceps tendon. movements and
Brachioradialis Supination of the controls superior
hand oblique muscles.
Bicep Reflex Flexion of the arm at ➔ Abnormal
the elbow findings:
Nystagmus
Trigeminal (CN-V) Facial sensation,
corneal reflex, and
mastication.
➔ Abnormal
findings: A
patient with tic
douloureux or
Trigeminal
Neuralgia.
Abducens (CN-VI) Regulation of eye
movements.
Controls the lateral
rectus muscle.
12 CRANIAL NERVES ➔ Abnormal
Olfactory (CN-1) Sense of smell. findings:
➔ Abnormal presence of
findings: the closes of
Absence of smell the eyelid or
Optic (CN-II) Visual Acuity. Diplopia
➔ Abnormal (double
findings: vision, 2
Papilledema images of a
(swelling of the single object).
optic nerve due
to raised ICP),
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Facial (CN-VII) Facial muscle saliva,
movement, facial dysphagia, or
expression, tear, and dystonia
saliva secretion. (muscles
Symmetry of facial contract
expressions like involuntarily).
smiling, frowning, Vagus (X) Pharyngeal
and puffing of the Contraction:
cheeks. It also Movement of vocal
controls the anterior chords and soft
2/3 of the tongue. palate; movement
➔ Abnormal and secretion of
Findings: thoracic and
presence of a abdominal viscera.
flattened ➔ Abnormal
nasolabial folds, findings:
drooling of the Increased
mouth, Bell’s Hydrochloric
Palsy or acid secretion,
Ageusia (loss of bradycardia,
sense of taste). dysphagia, loss
Vestibulocochlear Hearing (cochlear of gag reflex,
(CN-VIII) branch) and and drooling of
equilibrium saliva.
(vestibular branch). Spinal Accessory Movement of
Also known as (CN-XI) sternocleidomastoid
acoustic. and trapezius
➔ Abnormal muscle.
findings: If the ➔ Abnormal
patient findings: Inability
experiences of the patient to
tinnitus, they will rotate head.
complain about Hypoglossal (CN- Movement of tongue.
the hearing and XII) ➔ Abnormal
ringing noises findings:
and vertigo. Protrusion of the
Glossopharyngeal Taste: Posterior third tongue,
(CN-IX) of tongue. Control deviation of the
muscle of the throat. tongue to one
➔ Abnormal side of the
findings: Injury mouth we
of the CN-IX can reassess the
imply any of the cranial nerve XII.
following; loss of
gag reflex,
drooling of
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ASSESSMENT OF SENSORY FUNCTIONS aphasia which is
Hypoalgesia or Decrease pain inability to
Hypalgesia sensation. understand sounds
Analgesia Absence of pain or language.
sensation. Global aphasia is the inability to use and
Anesthesia Inability to perceive understand language. This occurs from
the sense of touch. impairment of both the Broca’s and
Hypoesthesia Decreased but not Wernicke’s area.
absent of touch Visual speech center in the occipital lobe.
sensation. This enables a person to read or interpret
symbols. Impairment of the visual speech
LANGUAGE AND SPEECH center results to Alexia, which is inability to
The speech centers are as follows: read.
Broca’s Area In the left frontal Meningeal Irritation
lobe. This is the
motor speech BOWEL AND BLADDER FUNCTION
center. This enables Sympathetic Originates from the
a person to speak Nervous System thoracolumbar
and make gestures. (SNS) segment of the
Impairment spinal cord. This is
of the Broca’s area the inhibitory
results to expressive impulse.
or motor aphasia Impairment
which is inability to of the SNS leads to
speak and make bowel and bladder
gestures. retention.
Nursing Responsibilities: (As part of the Parasympathetic Originates from the
long-range plan of the nurse, the nurse Nervous System cranial sacral
should;) (PNS) segment of the
➔ Provide positive feedback when the spinal cord. This is
client uses a word correctly. This is the motor impulse.
due to the fact that damaged Broca’s Impairment
area will make the client difficult to of the PNS leads to
speak. If the client was able to do so, bowel and bladder
we have to compliment the client. incontinence.
Wernicke’s Area In the temporal The client is unable to control elimination
lobes. This is the because individual loses voluntary control of
auditory speech the sphincter surrounding urethra and anus.
center. This enables
a person to interpret CARE OF THE CLIENT WITH INCREASED
sounds or language. INTRACRANIAL PRESSURE
Impairment
of the Wernicke’s ➔ Increase in the bulk of the brain (↑ ICP)
area results to Brain tissues Space occupying
receptive auditory (space-occupying lesions such as
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lesions) tumors, abscess, and medulla oblongata
edema. and is more of a
Blood Supply Thrombosis, projectile vomiting.
embolism, Diplopia is
aneurysm, and AV result from the
(arteriovenous) pressure in the
malformation. Cranial Nerve 6
Cerebrospinal Fluid Obstruction to the (Abducens) which is
(CSF) flow cause by a brain the longest cranial
tumor or nerve therefore, it is
overproduction of very vulnerable to
CSF due to the tumor compression.
in choroid plexus Abducens controls
(plica choroidea). the lateral rectus
Box Theory An increase in any muscle of the eyes.
one of contents of Decrease in level of This is due to
the cranium usually consciousness affectation of
is accompanied by a ascending reticular
reciprocal change in activating system or
the volume of one of the ARAS.
the others. Vital signs changes / Cerebral Hypoxia
Normal ICP 12 mmHg Cushing Triad
Vital Signs (Blood Blood pressure is
MONRO’S THEORY pressure) rising specifically the
(Pathophysiology of ICP) systolic is elevated
Brain → Bony Skull → No Room for due to increased
expansion → Increase in the bulk of the force of cardiac
brain → Compression of brain structures contractility and
and blood supply → Cerebral Ischemia → diastolic remains
Cerebral Hypoxia (can also lead to → normal or decrease
Necrosis) → Cerebral Edema → Increase in due to a longer time
Intracranial Pressure (terminal output) → required for the
Compression of Brain structures and blood heart to relapse.
supply. If you attain the difference between the
systolic and diastolic bp, the reading will be
ASSESSMENT IN ↑ INTRACRANIAL PRESSURE the pulse pressure. In ICP there will be a
Restlessness widening of pulse pressure, the pulse
Headache / nausea Headache is pressure is more than 40mmHg.
and vomiting / due to traction on Vital Signs (Pulse Pulse Rate is slow
diplopia the pain sensitive Rate) and bounding.
brain structure and Vital Signs Respiratory Rate is
on cranial nerves. (Respiratory Rate) also slow due to the
Vomiting is involvement of the
the result from the medulla oblongata
pressure in the and pons.
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Vital Signs (Body Body Temperature is ➔ Brainstem Function Impairment
Temperature) increased usually, Decorticate Midbrain
sometimes sub-
normal. This is due
to the involvement of Decerebrate Brainstem
the hypothalamus.
Pupillary Changes Anisocoria
due to cranial nerve Oculovestibular Test
straight compression (Caloric Ice Water
there is tipsy lateral Test)
pupil dilatation. ➔ In ICP there would be alterations in:
Pinpoint
Sensory function
pupils indicates
Motor function
pons involvement.
Language and Speech
Fixed dilated
Bowel and Bladder function
pupils indicate
ample coordination
this causes COLLABORATIVE MANAGEMENT
compression of the Position Head of Bed (HOB)
brain stem that 15 to 30 degrees,
results to respiratory lateral position to
arrest hence a client facilitate drainage of
with fixed dilated the CSF from the
pupils should be subarachnoid space
referred to a of the brain will also
physician promote maximum
immediately. lung expansion, no
Papilledema results It is also known as Trendelenburg.
from the choked disc. Adequate oxygenation
comprehension of Safety Seizure precautions
the optic nerve. Rest Prevent or avoid any
Lateralizing Sign This is the occurrence of any
contralateral loss of stimuli that may
motor function due trigger another
to decussation seizure attack that
(crossover) of motor will leave to ICP.
fibers at the level of Avoid factors that Prevention from
medulla oblongata. increase ICP having nausea,
For example, there is left brain affectation vomiting, sneezing,
that leads to right hemiplegia while the right coughing, or the
brain affectation will lead to left hemiplegia. conduct of valsalva
Likewise, the patient will be in a stuporous maneuver such as
position (sitting or lying motionless in bed, straining the stool,
arms outstretched in the position of over suctioning
crucifixion). should not be done
and restraint should
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not be applied as reduces cerebral
well as rectal edema by inducing
examination. Lastly, diuresis.
we should assume Nursing Roles/Responsibilities
that client can hear ➔ Check the BP of the patient
hence, sensitive ➔ Hourly checking of urine output
issues should not be during the administration of mannitol
discussed beside the as well as the BP again afterwards.
client, this can be Lasix (Furosemide) Also a diuretic,
one of the triggering reduce cerebral
factors to ↑ ICP. edema.
Enema and Decadron Corticosteroid.
flexion of waist, hip, (Dexamethasone) Reduces cerebral
neck such as edema as an anti-
bending, or stooping inflammatory agent.
should be This is the drug of
prevented. These choice by many of
are factors that the physician since
leads to ICP. this is the only
Controlling This reduces corticosteroid that
Hypertension cerebral tissue could pass through
perfusion. blood brain barriers.
Restrict fluid intake. Limit fluid intake to Nursing Roles/ Responsibilities:
(as prescribed by 1,200 to 1,500 ➔ While the client is receiving
the physician) ml/day to reduce Decadron, the nurse should check
CSF production. the client’s blood glucose level.
Formula for Cerebral Perfusion Rationale: The drug has the ability to
ICP – Intracranial Pressure mobilize the liver’s source of
MAP – Mean Arterial Pressure glycogen hence, hyperglycemia will
SBP – Systolic Blood Pressure also be manifested by the patient.
DBP – Diastolic Blood Pressure ➔ In the event where the patient’s
condition has been stabilized, explain
The ICP is subtracted from the MAP. that the Decadron dosage will be
The MAP is calculated by adding the SBP gradually reduced to continue at a
plus 2 times the DBP, divided by 3. lower maintenance dosage to allow
Example: return of the cortisol production by
BP: 120/90, ICP is 12mmHg the adrenal gland.
130 + 160 = 290 Anticonvulsants To prevent seizures
290 / 3 = 97 - Valium
The ICP is 12, so 97 – 12 = 85 - Diazepam
The cerebral perfusion is 85. - Dilantin
Pharmacotherapy (phenytoin
Mannitol No.1 drug for ICP. Sodium)
This is an osmotic Nursing Roles/ Responsibilities:
diuretic drug. This ➔ If orally, must be given after meals to
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prevent GI abscess. Side Effects of Phenobarbital (luminal)
➔ If intravenously, introduce 10 ml of Sedation In adults, besides
NSS to flush the IV line before and sedation it can also
after administration of Dilantin lead to habituation.
(Phenytoin) since it crystalizes in the Paradoxical active
veins so we have to dissolve these reaction in children
crystals by the usage of NSS solution. Side Effects of Tegretol (carbamazepine)
➔ Pre- warn the patient on the side Rashes, Ataxia, Drowsiness
effects. Antacids In giving
➔ Patients in Dilantin should be given Dexamethasone to
Folic Acid because of Aplastic prevent Gi irritation,
Anemia especially for female clients you can also give
who has the plan of getting pregnant Antacids to the
or a pregnant lady. patient.
Histamine – H2 To prevent stress
Folic Acid during pregnancy will also prevent receptor antagonist ulcer (Cushing’s
congenital disorders/defect on the newborn. ulcer).
Side Effects of Dilantin: Anticoagulants To prevent
Gum or gingival Good oral care has thromboembolism.
Hyperplasia to be provided to Opiates and These drugs are
the patient. Oral Sedatives contraindicated to
care should use a the client with
soft-bristle increased ICP
toothbrush and because they cause
afterwards, respiratory
massage the gums. depression and
Sedation acidosis.
Hirsutism Condition in women Ventriculostomy This is a
that results in neurosurgical
excessive growth of procedure that
dark or coarse hair involves creating a
in a male-like hole (stoma) within a
pattern (face, chest cerebral ventricle for
and back). Excess drainage. This is
male hormones done to drain the
(androgens). cerebral perfusion
Ataxia Caused by damage bleeding.
to the cerebellum.
Slurred speech, CARE OF CLIENT WITH SEIZURE DISORDER
stumbling, falling
and incoordination. Seizures are sudden excessive, disorderly
GI abscess electrical discharges of the neurons. A
Aplastic Anemia Patient should have chronic disorder of seizures are referred to
intake of folic acid. as epilepsy.
Reddish urine
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EFFECTS OF SEIZURES chewing or cheek
Mental Status Motor Function (Loss smacking. Patient
or Excessive will regain
LOC Autonomic Function consciousness as
Sensory and Special Motor Function (Loss rapid as it was lost
Senses or Excessive and this type of
seizure will last for
TYPES OF SEIZURES 10-20 seconds.
Grand Mal – common type of seizures Common during
Phase 1 Aura (flashing lights, smells, childhood and
spots before eyes, dizziness) adolescent.
Phase 2 Alter a shout or cry and fall to Jacksonian or Focal Very common
the ground. While on the ground Seizure among patients with
the patient will manifest the organic drainage
following: lesion like frontal
➔ Tonic phase is lobe tumor. Aura is
characterized by present such as
contractions. numbness, tingling
➔ Clonic phase is and crawling feeling.
characterized by jerking This is characterized
movements. by tonic-clonic
➔ Accompanied by dyspnea, movements of group
drooling of saliva, urinary of muscles like the
incontinence. hands, feet or face
Post-ictal Cessation of tonic-clonic then it proceeds to
phase movements. Characterized by Grand Mals’
exhaustion, headache, seizures.
drowsiness, deep sleep of 1 to 2 Psychomotor It has a psychiatric
hours, disorientation. Seizures component. Aura is
Petit Mal (Absence This is not preceded present in the form
Seizure or Little by an Aura, no of hallucinations or
Sickness) warning signs. Little illusions. It is
or no tonic-clonic characterized by
movements. There is mental clouding
a sudden cessation being out of touch
of ongoing physical with the
activity. environment. Patient
Characterized by will appear
blank facial intoxicated and this
expressions, is characterized by
automatism (non- ongoing physical
purposeful, activity during the
stereotyped, and the time of loss of
repetitive behaviors) consciousness.
such as by lip Patient will manifest
confusion, amnesia
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and the need for Dilantin is actually
sleep. May commit increased with
violence or antisocial growth.
acts such as Sudden withdrawal Emphasize that
examples of going of Anticonvulsant withdrawal will elicit
naked in public or Drug another seizure
running naked. attack.
Febrile Seizure Common among
children under 5 COLLABORATIVE MANAGEMENT
years of age when Do not leave the Safety – clear the
temperature is rising. client alone environment,
Status Epilepticus A type of seizure remove the chairs
occurring in rapid and furniture that
succession and full could harm the
consciousness is not patient. If the patient
regained between is in bed, put the side
seizures. Brain rails up and locked. If
damage may occur the seizures
secondary to happened while the
prolonged hypoxia client is sitting down,
and exhaustion. The assist the client to lie
client is often in on the floor.
coma for 12 to 24 Protect from injury
hours or longer Loosen constricting clothing
during which time Turn to sides If its difficult for the
the current seizures nurse to turn the
has occurred. The patient on sides, turn
attack is usually the head only to side
related to failure to to facilitate drainage
take prescribed of the secretions.
anticonvulsants. Also, the tongue
Tonic-clonic If you have a should fall forward
Seizures teenager client who so that it will not
has been taking obstruct the airway
Dilantin for quite patency.
some time and then Do not apply Restraint will lead to
suddenly manifest restraints. bone and soft tissue
another seizure injury since two
attack, educate the opposing force is
client or the SO that applied when the
this happens due to patient is having
the cross in seizures.
adolescence. The Do not insert tongue Even when using soft
dosage of the blade during tonic- materials, during
maintenance drug of clonic movements. seizures the patient
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may bite the orally, Dilantin
material in half. can be given IV.
Side rails should be padded. Encourage A ketogenic diet is a
Make relevant Take note of the ketogenic diet high fat and low
observations and frequency, duration carbohydrate diet. A
documentations of the seizures and ketogenic diet
from what part of decreases the
the body did the excitability of the
muscle spasm start neurons.
Patient Education ➔ Remind take Instruct that drugs are taken for lifetime and
medication at taken with meals to control nausea and
regular basis. vomiting.
➔ Avoid Alcohol as Folic Acid should be given to pregnant
this lowers women.
seizure Drugs
threshold. Phenytoin Sodium Controls nerve
➔ Adequate rest. (Dilantin) impulses originating
➔ Well-balanced in the motor cortex;
diet. Some if positive for
doctors will nystagmus,
specify a confusion and
ketogenic diet. ataxia, the dosage is
➔ Advice the decreased.
patient to avoid Phenobarbital Side Effects:
driving, (Luminal) drowsiness, loss of
operating appetite, fatigue
machines, An 80-year-old
swimming until patient side effects –
seizures are well Osteomalacia.
controlled. To enhance
➔ Live an active coagulation - green
lifestyle. leafy vegetable and
➔ Incase there is a organ meats.
situation that Diazepam Relaxes peripheral
will prohibit the muscles
patient to take Folic Acid For patients on
the drugs orally Dilantin because
should be absorption from food
reported to the is inhibited by
doctor since Dilantin
drugs can’t be
stop without
doctors order-
other routes if
cannot be taken
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✓ Support family/ maintain psychosocial
CARE OF CLIENT WITH ALTERED LEVEL OF functioning.
CONSCIOUSNESS
CARE OF THE CLIENT WITH HEADACHE OR
Altered level of consciousness as the most CEPHALALQIA
sensitive indicator of increased intracranial
pressure. Take note of consciousness, is the Causes:
patient arousable and aware? • Expanding masses
• Intracranial bleeding
CAUSES OF DECREASED LEVEL OF CONSCIOUNESS • Inflammation of meninges
Primary Brain Injury Trauma, vascular • Infections of the brain and spinal
or Disease disease, infections, cord
neoplasm, and • Dilatation of a cerebral vessels
seizures • Head trauma
Systemic Conditions Metabolic • Stress
encephalopathies, • Eye, ear, or sinus diseases
Hypoxic
encephalopathies, TYPES OF HEADACHES
toxicity, physical Migraine Strongly hereditary and more
causes, deficiency Headaches common in women. Tends to
state. occur with stress or life crisis.
Usually last to hours or days.
LEVELS OF CONSCIOUSNESS Affects one side of the head
3 C’s Conscious, Coherent, caused by dilatation of blood
Cognitive vessels. Aura of acute attack
Confused, drowsy, obtunded, somnolent includes visual field,
Stuporous Arousal only to confusion, paresthesia,
vigorous stimuli paralysis in extreme cases.
Coma
Associated symptoms:
Guidelines for Nursing Intervention for persons ➔ Nausea and vomiting
with Decrease Level of Consciousness or Coma ➔ Chills
✓ Maintain patent airway. ➔ Fatiguability
✓ Monitor vital signs and neurological ➔ Irritability
status. ➔ Perspiration
✓ Maintain integrity of the skin. ➔ Edema
✓ Maintain joint mobility/promote
activity. Treatment:
✓ Maintain sensory function/maintain ➔ Ergotamine Tartrate
stimulation. ➔ Propranolol
✓ Promote safety. ➔ NSAIDs
✓ Maintain fluids and nutritional status. ➔ Relaxation
✓ Maintain bowel and bladder Techniques
functioning.
✓ Maintain good hygiene. Avoid chocolates, nuts, onion,
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and food seasonings. Vertigo
Cluster Very common in older men.
Headaches This is precipitated by alcohol
or nitrate. Episodes cluster
together in quick succession
for few days or weeks or with
emissions that last for
months. There will be intense
throbbing deep often
unilateral pain that will begin
in the intra-orbital regions
and spread to head and
neck.

Associated symptoms:
➔ Flushing
➔ Tearing of eyes
➔ Nasal stuffiness
➔ Sweating
➔ Swelling of temporal
vessels.

Treatment:
➔ Narcotic analgesic
➔ Usually
intramuscularly given
during the acute
phase.
Tension Muscle Contractions
Headaches Headache.
It is episodic, vary with stress,
usually bilateral, involves the
neck and shoulders.

Associated Symptoms:
➔ Sustained
contractions of head
and neck muscles.

Treatment:
➔ Non-narcotic
analgesics such as
acetaminophen or
ASA.
➔ Relaxation technique
➔ Amitriptyline or Elavil