Lecture Notes on Neurologic Nursing

Prepared By: Mark Fredderick R Abejo R.N, MAN

Clinical Instructor

Decreased HR and BP
Decresead RR
Diarrhea
Urinary Frequency
Seizures

II.SNS
a. Adrenergic Agents
1. Epinephrine (Adrenaline)
2. Note: Side Effects (SE) – normal drug expectancies
b. Beta-Adrenergic Agents (Beta-Blockers)
MEDICAL-SURGICAL NURSING 1. Propanolol, metoprolol, atenolol
2. Bronchospasm, Elicits decreased cardiac contractions,
Treats HPN, AV conduction slows down (BETA)
Neurologic Nursing 3. Anti-HPN Management
Beta-blockers – ―-olol‖
Lecturer: Mark Fredderick Abejo RN, MAN ACE inhibitors – ―-pril‖
________________________________________________________ Ca-Antagonist – nifedipine
Transient headache and dizziness
OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE Orthostatic hypotension
NERVOUS SYSTEM Assist in ambulation
Pt. to rise slowly from sitting position
I. Divisions 4. BP = CO x PR
a. CNS – brain and spinal cord 5. CO = HR x SV
b. PNS – 12 pairs of cranial nerves and 31 pairs of spinal 6. (N) HR = 60-100 bpm
nerves 7. (N) SV = 60-70 ml of H2O
1. Spinal nerves:
TOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN
Cervical – 8
BARIER: (BLACK)
Thoracic – 12
Bilirubin – yellow pigment
Lumbar – 5
Lead – Antidote: Ca+ EDTA
Sacral – 5
Ammonia – cerebral toxin; present in hepatic encephalopathy
Coccygeal - 1
(liver cirrhosis)
c. ANS – sympathetic and parasympathetic systems
Carbon Monoxide – in Parkinson’s and Epilepsy
Ketones – cerebral depressant

III. CNS

a. Cells
1. Neurons
Excitability
Conductivity
Permanence
2. Neuroglia – majority of tumors arise from here; about
40% from astrocytes
Astrocytes – maintains integrity of BBB
Oligodendrocytes – production of myelin
Myelin sheath – insulates axons; for rapid
impulse transmission
Microglia – STATIONARY cells which carry on
phagocytosis (cell eating)
Sympathetic – flight or aggression response release of Ependymal cells – produces chemoattractants
norepinephrine increase in all bodily activity except GI which concentrates bacteria
(constipation); adrenergic; parasympatholytic response. b. Composition
1. 80% brain mass
REMEMBER: GIT is the least important area during stress CEREBRUM – divided into two hemispheres, the
decreased blood flow in the area; Increased blood flow in the brain, left and right and is bridged by the corpus
heart and skeletal muscles callosum
Mydriasis (―dilat‖-ation) Motor, sensory, integrative function
Dry mouth Lobes:
Increase in HR and BP Frontal – controls higher cortical thinking,
Tachypnea personality development, motor activity,
Constipation contains BROCA’s are or the motor-speech
Urinary retention center. (Expressive Aphasia)
Parasympathetic – flight or withdrawal response release of Occipital – vision
Acetylcholine decrease in all bodily activity except GI (diarrhea); Parietal – appreciation and discrimination
chonlinergic/ vagal/ sympatholytic response
of sensory impulses (pain, touch, pressure,
Meiosis heat and cold)
Increased salivation
MS 1 Abejo
 SYMPATHETIC PARASYMPATHETIC
• Alpha, beta receptors • Muscarinic, nicotinic receptors

• NE, dopamine • Acetylcholine

• FIGHT OR FLIGHT • REST & DIGEST
RESPONSE RESPONSE
• INCREASE IN VS • DECREASE IN VS
(increase in BP; (Decrease in BP;
tachypnea; tachycardia; bradypnea; bradycardia;
increase in body temp) decrease in body temp)
• Urinary retention; • Urination;
constipation
diarrhea
• Mydriasis = pupillary • Miosis = pupillary
dilatation
constriction
• Bronchodilation
• Bronchoconstriction
• Dry eyes & dry mouth • Lacrimation & salivation
• Relaxation of skeletal • Excitation of skeletal
muscles muscles

• Vasoconstriction • Vasodilation
• Ejaculation • Erection
Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor

Temporal – hearing, short term memory, CI – Atlas; C2 – Axis

contains the general interpretative area—
Wernicke’s aphasia
Insula (Island of Reil) – visceral function
(internal area)
Limbic System (Rhinencephalon) – sense
of smell, libido or sexual urge control, long
term memory
CSF – shock absorber, cushions brain altered when there is
obstruction in CSF drainage
HYDROCEPHALUS – posteriorly growth of the head d/t early
closure of fontanels
Types of Cells:
Labile (regenerative) – Epidermal, GIT, Respiratory, GUT
Stable – regenerative but limited survival period: liver, pancreas,
salivary glands, kidneys
Permanent – cardiac, neurons, osteocytes, retinal

NEUROLOGIC ASSESSMENT

I. COMPREHENSIVE NEUROLOGIC EXAM

A. Purpose
1. To know exact neuro deficit
2. To localize lesion
3. For rehabilitation
4. For guidance in nursing care
B. Survey of Mental Status
1. LOC
Conscious – awake
Lethargy – sleepy/drowsy/obtunded
Stupor – only awakened by vigorous stimulation
BASAL GANGLIA – areas of gray matter General body weakness
located deep within each cerebral hemisphere; Decreased body defenses
involved in the extrapyramidal tract; produces Coma
DOPAMINE (controls gross voluntary movement) Light – (+) to all painful stimuli
MIDBRAIN (Mesencephalon) – acts as a relay Deep – (-) to all painful stimuli
station for sight and hearing particularly helps in PAINFUL STIMULATION
size and reaction of pupils and hearing acuity Deep Sternal Stimulation/Pressure
N hearing acuity : 30-40dB Orbital Pressure
N pupil constriction: 2-3 mm Pressure on Great Toes
N pupil finding: PERRLA Nail bed pressure
Isocoria vs. Anisocoria Corneal/Blinking Reflex
DIENCEPHALON (Interbrain)
Conscious – wisp of cotton
Thalamus – acts as a relay station for
sensation Unconscious – institute/drop of saline
Hypothalamus – controls temperature, BP, solution (coma if positive reaction, deep
sleep and wakefulness, thirst, appetite coma if negative)
(satiety), some emotional responses like fear, 2. Test of memory (consider educational background)
anxiety and excitement, controls pituitary Short term memory (ask what the pt ate for
functions breakfast)
BRAIN STEM (+) anterograde amnesia temporal lobe
Pons (Pneumotaxic center) – controls rate, damage
rhythm and depth of respiration Long term memory (ask birthday)
Medulla Oblongata – lowest part; damage: (+) retrograde amnesia damage to
most life threatening; controls respiration, Rhinencephalon (Limbic system)
HR, swallowing, vomiting, hiccups, C. Levels of Orientation (time, person and place)
vasomotor center D. CN Assessment
CEREBELLUM – smallest part; ―lesser brain‖; E. Motor Assessment
balance, equilibrium, gait and posture.

F. Sensory Assessment
1. PAIN - Gingerbread test
100% very painful
75% tolerable pain
25% moderate pain
0% no pain
2. 10 % CSF 2. TOUCH – Stereognosis
3. 10% Blood Identifying familiar object placed on clients hands
Astereognosis – if patient cannot identify object;
MONROE KELLY HYPOTHESIS – the skull is a closed damage in parietal lobe
vault, any increase in one component will bring about increases 3. PRESSURE AND TOUCH – Graphesthesia
in ICP Identify numbers or letters written on client’s
NORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAY palm
NORMAL CSF OPENING PRESSURE: 60-150 MMHG Agraphesthesia if (-), damage to parietal lobe
NORMAL CSF CONTENTS: GLUCOSE, PROTEINS, WBCS
FORAMEN MAGNUM - The large opening in the basal part of
the occipital bone through which the spinal cord becomes
continuous with the medulla oblongata. G. Cerebellar Test
MS 2 Abejo
Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor

1. Romberg’s Test 2. Dysosmia – distorted sense of smell

Instruct patient to close eyes, assume a normal 3. Anosmia – absence of smell
anatomical position for 5-15 minutes; two nurses
at right and left side
Normal is (-)
If (+) ataxia
2. Finger-to-nose Test
3. Alternate Pronation and Supination
Dysmetria – inability of a client to stop a
movement at a desired point
H. DTRs
I. Autonomics

II. Glasgow Coma Scale

A. objective measurement of LOC;
B. quick neuro check
1. Motor – 6
2. Verbal – 5
3. Eye Opening – 4
C. Normal: 14-15 – conscious
1. lethargy 13-11
2. Stupor 10-8
3. Coma = 7
4. deep coma = 3
II. OPTIC
A. Sensory – Vision
B. Tests
1. Test of Visual Acuity/Central or Distance Vision
Materials
Snellen’s Chart
Alphabet – literate
E chart – illiterate
Animal chart – pedia, since shorter
attention span
20 feet distance (67 cm) 20 feet/6-7 m; constant
normal 20/20
numerator – distance to snellen chart
denominator – distance the person can see the
letters
Abnormal findings
20/200 blindness
OD: oculus dexter
OS: oculus sinister
OU: oculus uritas
2. Visual Fields/Peripheral vision
Superiorly
Bitemporally
Nasally
CRANIAL NERVE ASSESSMENT Inferiorly

I. Olfactory Sensory Some C. COMMON VISUAL DISORDERS

1. Glaucoma
II. Optic Sensory Say 40 yo, obese
III. Oculomotor Motor Marry hereditary
IV. Trochlear (smallest) (―down‖) Motor Money Loss of peripheral vision tunnel vision
V. Trigeminal (largest) Sensory, But Increased IOP (N = 12-21 mm Hg)
(―triCHEWminal‖) motor Signs and symptoms:
VI. Abducens (―at the sides‖) Motor My Headache
VII. Facial Sensory, Brother Nausea and vomiting
motor Halos around lights
Steamy cornea
VIII. Acoustic (Vestibulocochlear) Sensory Says
Acute angle closure glaucoma – most
IX. Glossopharyngeal Sensory, Bad dangerous, may lead to blindness
motor Diagnostics:
X. Vagus (longest) (―mavagal‖) Sensory, Business Tonometry – increased IOP
motor Gonioscopy – obstruction in anterior
XI. Accessory (―shoulders‖) Motor Marry chamber
XII. Hypoglossal Motor Money Perimetry – decreased visual fields
Drugs (for lifetime)
I. OLFACTORY Timolol maleate
A. Sensory – smell Pilocarpine – drug of choice (miotic)
B. Use coffee, bar soap, vinegar, cigarette tar Epinephrine – decrease in aqueous humor
C. Abnormal findings Carbonic Anhydrase Diamox
Indication of: (Acetazolamide)
Head trauma damaging the cribriform plate of Decrease in aqueous humor (maintains
ethmoid bone where olfactory cells are located IOP); promotes drainage
Sinusitis – give antibiotics to prevent meningitis Monitor I/O
1. Hyposmia – decreased sensitivity to smell
MS 3 Abejo
Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor

NO ATROPINE: may lead to increased IOP Trauma

Surgery Nasolabial folds – most evident sign of facial
Trabeculectomy symmetry
Peripheral iridectomy
Uveitis – inflammation of the iris I. ACOUSIC/VESTIBULOCOCHLEAR
Keratitis – inflammation of the cornea A. Controls balance or kinesthesia (position sense/ movement
and correlation of body in space)
2. Cataract 1. Organ of corti (true sense organ for hearing) for
Loss of central vision Glaring or hazy vision hearing
Opacity of lens, milky white appearance of cornea, 2. Cochlea – snail-shaped organ in middle ear
decreased perception to colors B. Disorders
Due to aging 1. Conductive hearing loss
Prolonged UV rays exposure 2. Otitis Media
Congenital disorder – very rare 3. Meniere’s disease
DM
Dx: Ophthalmoscopic examination Archimedes Principle – buoyancy (pregnancy fetus)
Tx: Mydriatics, cycloplegics (cyclogil) – paralyzes Dalton’s – Law of Partial Pressure
ciliary muscles Inertia - Kinesthesia
Surgery: lens extraction
ECLE – partial removal of cataract II. GLOSSOPHARYNGEAL – taste; posterior 1/3 tongue
ICLE – capsule included, total removal of III. VAGUS – gag reflex, decreased vital signs, eyes constrict, mouth
cataract moist PNS
3. Retinal Detachment – most common complication IV. SPINAL/ACCESSORY controls 2 muscles:
following lens extraction A. Sternocleidomastoid (neck)
Curtain veil like vision B. Trapezius (Shoulder)
Leads to blindness V. HYPOGLOSSAL – tongue movement; frenulum linguae –
Severe myopia – common cause anchors tongue (tongue tied – short frenulum)
Emetropia – normal refraction of eyes
Presbyopia – loss of lens elasticity due to
aging DEMYELINATING DISEASES
(+) floaters – d/t seepage of RBCs
Surgery: Scleral Buckling, Diathermy (heat I. ALZHEIMER’S DISEASE - atrophy of the brain tissue
application), Cryosurgery (cold application) characterized by:
a. Amnesia
4. Macular degeneration – degeneration of macula lutea b. Agnosia – (-) sense of smell
(yellowish spots in center of retina) c. Apraxia – (-) purposive movements
Black spots d. Aphasia
Yellowish spots in center of retina or the macula 1. Expressive/Broca’s – problem in speaking
lutea 2. Receptive/Wernickes – problem in understanding;
USUAL FOR ALZHEIMER’S
III. OCULOMOTOR 3. Broca’s area – motor speech center; frontal
IV. TROCHLEAR It innervates mov’t of EOMs 4. Wernickes’ area – general interpretative area;
V. ABDUCENS temporal
e. ARICEPT – drug of choice, given at HS
COGNEX also given
SR IO (trochlear)
(Abducens) LR MR
IR SO

A. Normal response – PEBRTLA/ PERRLA (isocoria)

B. Anisocoria – unequal pupils
C. Nystagmus – Rhythmical oscillation of the eyeballs, either
pendular or jerky; can be seen in MS, dilantin toxicity.

VI. TRIGEMINAL – largest cranial nerve with 3 branches; sensory

and motor.
A. Ophthalmic branch
B. Maxillary branch
C. Mandibular branch
D. Sensory – controls sensation of face and teeth, mucous
membrane and corneal reflex
E. Motor – Mastication or chewing
F. Trigeminal Neuralgia – characterized by severe pain upon PICK’S Disease: a form of dementia wherein there is damage in the
chewing, dysphagia frontoparietal area
1. avoid foods with extreme temperature
2. DOC: carbamazepine (Tegretol) II. MULTIPLE SCLEROSIS – chronic, intermittent disorder of
the CNS characterized by white patches of demyelination of the
VII. FACIAL brain and spinal cord. IDIOPATHIC, AUTOIMMUNE
A. Sensory – anterior 2/3 of tongue; identify taste without
swallowing A. INCIDENCE RATE: 15-35 yo, females
B. Motor – facial expression control B. PREDISPOSING FACTOR
1. instruct patient to smile, frown or raise eyebrows 1. Slow growing virus
Bell’s palsy or (temporary) facial paralysis – 2. Autoimmune – body produces antibodies which attacks
damage to facial nerve caused by: normal cells
Forceps delivery - #1 cause 3. REVIEW: ANTIBODIES
Autoimmune IgG – passes placenta (gestational)
Stress IgA – found in bodily secretions, colostrums
MS 4 Abejo