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Neurological nursing INTRODUCTION a.

The nervous system can be thought of as having three major subdivisions: (1) The central nervous system (CNS), which consists of the brain and spinal cord. (2) The peripheral nervous system (PNS), which consists of those nerves which pass from the CNS to the periphery of the body (the cranial nerves and the spinal nerves). (3) The autonomic nervous system (ANS), also referred to as the "involuntary" nervous system. Outside of the CNS and considered to be part of the PNS, the autonomic nervous system is sufficiently different in function to be studied as a separate division. Body functions that are not under conscious control are regulated by the ANS. b. Neurological conditions are disorders that involve some portion of the nervous system. These conditions may result from infections, deranged physiology, or trauma. In all cases, the normal function of the nervous system has been altered, and the patient is not in control of the alterations. THE CENTRAL NERVOUS SYSTEM The CNS consists of the brain and the spinal cord, which share a continuous, protective, fibrous membrane cover called the meninges. The meninges consist of three separate membranes, which are separated by spaces. a. Dura Mater. (1) The dura mater is a tough fibrous layer that serves as the outer layer of meninges and the inner lining of the cranial bones. (2) Between the dura mater and the next layer of meninges is a potential space called the subdural space. b. Arachnoid Mater.

(1) The arachnoid mater is a fine, membranous layer of spider-web-like threads that extend from the dura mater, through the subarachnoid space, to the innermost layer of meninges. (2) The subarachnoid space is filled with cerebrospinal fluid (CSF). c. Pia Mater.

(1) The pia mater is the delicate, transparent membrane that directly covers the surface of the brain and spinal cord. (2) The pia mater contains a network of blood vessels. d. Cerebrospinal Fluid

(1) Cerebrospinal fluid, circulating within the network of the subarachnoid space, provides the brain and spinal cord with protection. It acts as a cushion, or shock-absorber, against injury. (2) CSF is manufactured from blood in networks of capillaries called choroid plexuses. It circulates through the ventricles (cavities inside the brain) and subarachnoid space of the meninges.

THE BRAIN The human brain has three major subdivisions--the brainstem, the cerebellum, and the cerebrum.

Figure 2-1. The brainstem. a. The Brainstem. The brainstem (figure 2-1) is the basal portion of the brain. It is continuous with the spinal cord. Exiting from the sides of the brainstem are 12 pairs of nerves known as the cranial nerves. The brainstem is divided into 3 major portions. (1) Forebrain stem (diencephalon), consisting of: (a) Thalamus--a sensory relay station for impulses conveyed upward from the spinal cord. (b) Hypothalamus--concerned with regulation of autonomic functions. (2) Midbrain stem (mesencephalon) consisting of: (a) Corpora quadrigemina--concerned with vision and hearing. (b) Cerebral peduncles--connecting the brainstem to the cerebrum. (3) Hindbrainstem, consisting of: (a) Pons--concerned with transmission of impulses between the left and right hemispheres of the cerebellum. (b) Medulla--contains nerve centers for cardiac, vasomotor, and respiratory functions. Also influences sneezing, coughing, hiccoughing, and vomiting. b. The Cerebellum. The cerebellum (figure 2-2) is a spherical mass of nervous tissue attached to and covering the hindbrainstem. It is attached to the brainstem by three pairs of cerebellar peduncles. The cerebellum consists of three lobes; the right hemisphere, left hemisphere, and a central portion called the vermis.

(1) The outer layer, or cortex, of the cerebellum is composed of "gray matter." Gray matter is actually the cell bodies of neurons. Many folds (gyri) and grooves (sulci) in the surface of the cortex give it a wrinkled appearance.

Figure 2-2. Human brain, lateral view. (2) More centrally located within the cerebellum is the "white matter." White matter is actually the myelin covered processes of the neurons. (3) The cerebellum is concerned with coordination of nerve impulses to the voluntary muscles and with the equilibrium of the body. c. The Cerebrum. The cerebrum (figure 2-2) is the largest part of the brain. The outer layer of the cerebrum is called the cerebral cortex. It is composed of the cell bodies of neurons and is often referred to as the "gray matter." Many folds (gyri) and grooves (sulci) increase the surface area of this layer. Beneath the cortex lies the "white matter," actually the myelin covered processes of the neurons. The cerebrum is divided into right and left hemispheres by a longitudinal fissure. A band of nerve fibers called the corpus callosum connects the hemispheres and provides for communication between them. Each cerebral hemisphere is further divided into lobes, which are named after the overlying cranial bones (frontal, parietal, temporal, and occipital). (1) Frontal lobe. (a) The frontal lobe is located beneath the frontal bones of the skull. It is divided from the parietal lobes by the central sulcus and from the temporal lobes by the lateral fissure. (b) The functions of the frontal lobe include personality, behavior, intellectual functioning, creative thinking, morals, ethics, and level of consciousness. (c) The precentral gyrus, within the frontal lobe and directly in front of the central sulcus, initiates and controls voluntary muscle movements (motor function). Impulses originating here travel along motor pathways through the spinal cord and stimulate skeletal muscles on the opposite side of the body. (This is

important to remember when correlating clinical symptoms with associated cerebral damage.) The percentral gyrus also contains Broca's speech center, which is involved in the motor activities necessary for speech. (2) Parietal lobes. (a) The parietal lobes are located beneath the parietal bones of the skull. They are posterior to the central sulcus and superior to the lateral fissure. (b) The functions of the parietal lobes include comprehension of written and spoken language, discrimination of fine touch, and stereogenesis. Sterogenesis is the ability to recognize, by touch alone, the size, shape, texture, and consistency of objects. (c) The postcentral gyrus, within the parietal lobes and directly behind the central sulcus, controls and interprets sensations from the opposite side of the body. These sensations include pain, heat, cold, and pressure. (3) Temporal lobes. (a) The temporal lobes are located beneath the temporal bones of the skull and inferior to the lateral fissure. (b) The functions of the temporal lobes include taste, smell, balance, and hearing. (The perception of sound as well as the interpretation of sound as words.) (c) The area of the brain concerned with the comprehension of both written and spoken language (Wernicke's area) is located in both the parietal and temporal lobes. (4) Occipital lobe. (a) The occipital lobe is located beneath the occipital bone of the skull, at the posterior of the cerebrum behind the parietal lobes. (b) The occipital lobe receives and interprets visual stimuli. THE SPINAL CORD a. The spinal cord, located within the vertebral canal of the spine, is continuous with the brainstem. (Together, the brain and spinal cord are referred to as the neuraxis.) The spinal cord extends from the foramen magnum of the skull to the level of the first lumbar vertebrae, at which point it tapers to fine threads of tissue. b. The spinal cord has two enlargements along its length that are due to an increase in the mass of nervous tissue required to serve the limbs. (1) The cervical enlargement is associated with the nerves of the upper extremities. (2) The lumbosacral enlargement is associated with the nerves of the lower extremities. c. The spinal cord is composed of a central mass of gray matter (cell bodies of neurons) surrounded by white matter (myelinated processes of the neurons). The areas of gray and white matter are referred to as columns.

these pathways cross to the opposite side of the cord and continue their path. (Each crossing is called a decussation. A very narrow canal. called the central canal. (1) Tracts conducting impulses from the brain are called motor tracts. or the PNS. grouped together. Each arm of the H is called a horn. Thirty-one pairs of spinal nerves exit from the spinal cord. b. (Neuron processes.) Nerves outside the CNS are referred to as peripheral nerves. This central canal is continuous with the fourth ventricle of the brain and contains CSF. g.Figure 2-3. the right cerebral hemisphere of the brain communicates with the left half of the body. The PNS is made up of a large number of nerves arranged in pairs. A nerve is a collection of neuron processes. The spinal cord. f. the gray matter appears to be H-shaped. and inside the CNS are the fiber tracts of the spinal cord. e. Each pair includes one nerve for the left side of the body and one nerve for the right side. grouped together. resulting in two anterior horns and two posterior horns. (2) Tracts conducting impulses to the brain are called sensory tracts.) Thus. . (3) At some specific point along the neuraxis. d. cross-section. The connecting middle portion is called the gray commissure. and located outside of the CNS. is located in the center of the spinal cord. THE PERIPHERAL NERVOUS SYSTEM a. Connecting the CNS to all parts of the body are nerves. In a cross-section of the spinal cord (figure 2-3). The processes of the neurons that compose the surrounding white matter are grouped into pathways called fiber tracts. and the left cerebral hemisphere communicates with the right half of the body. These nerves connect the CNS to the periphery of the body.

(2) Contracts eyeball muscles. (2) Contracts the eyeball muscles. THE CRANIAL NERVES a.(1) Peripheral nerves connected to the brainstem are called cranial nerves. (3) Contracts the muscles of chewing (motor function). touch. and a number representing the sequence within the region. (2) Contracts the eyeball muscles. d. Trigeminal Nerve (V). (2) Transmits visual impulses from the eye to the brain. Abducens Nerve (VI). g. They are numbered from I through XII and have individual names. e. L-5 is the fifth spinal nerve in the lumbar region. (1) Sensory nerve. h. Oculomotor Nerve (III). They are identified by a letter. Optic Nerve (II). Vestibulocochlear Nerve (VIII). (1) Mixed nerve. c. (2) Peripheral nerves connected to the spine are called spinal nerves. Facial Nerve (VII). Olfactory Nerve (I). (2) Transmits hearing and balance impulses from the inner ear to the brain. (1) Sensory nerve. b. . (1) Motor nerve. (2) Transmits taste impulses from the tongue to the brain (sensory function). and temperature impulses from the face and head to the brain (sensory function). representing the corresponding region of the vertebral column. (1) Mixed nerve. For example. (1) Motor nerve. f. Trochlear Nerve (IV). (2) Transmits pain. (1) Motor nerve. (3) Contracts the muscles of facial expression and stimulates secretion of salivary and lacrimal glands (motor function). (2) Transmits smell impulses from receptors in the nasal mucosa to the brain. (1) Sensory nerve.

(3) Contracts the muscles of the pharynx. (2) Transmits taste impulses and general sensations from the tongue and pharynx (sensory function) to the brain. Spinal Accessory Nerve (XI). . contracts the swallowing muscles of the pharynx and larynx.i. and the neck. (1) Mixed nerve. and larynx to the brain. There are 31 pairs of spinal nerves. (1) Mixed nerve. (2) Transmits sensory impulses from the viscera (heart. j. l. (2) Transmits sensory impulses from the pharynx and larynx to the brain. (1) Motor nerve. identified as follows: (1) Cervical nerves (8) (C-1 through C-8). smooth muscles. pharynx. Vagus Nerve (X). (1) Mixed nerve. and modifies muscular contraction of smooth muscles. THE SPINAL NERVES a. (3) Lumbar nerves (5) (L-1 through L-5). abdominal organs). k. (2) Contracts the muscles of the tongue. Glossopharyngeal Nerve (IX). (4) Sacral nerves (5) (S-1 through S-5). (2) Thoracic nerves (12) (T-1 through T-12). slows down the heart rate. larynx. Hypoglossal Nerve (XII). (5) Coccygeal nerve (1). (3) Contracts the swallowing muscles in the pharynx and stimulates secretions of the salivary glands. (3) Secrets digestive juices.

The spinal nerve trunk of each spinal nerve is located in the appropriate intervertebral foramen of the vertebral column. These processes may belong to different types of neurons--afferent (sensory). b. and branches (rami) (figure 2-4).) (3) Where the spinal nerve trunk emerges laterally from the intervertebral foramen. singular). the trunk divides into two major branches. outside the CNS. These branches are called the anterior (ventral) and posterior (dorsal) primary rami (ramus. efferent (motor). you can understand the anatomy of all spinal nerves. (2) An efferent neuron carries motor commands from the CNS to the periphery of the body. The posterior primary rami go to the back. By learning the anatomy of one spinal nerve. (The ANS will be discussed separately.) (2) Laterally. NERVE ACTION a. (An intervertebral foramen is a passage found on both sides of a vertebrae. A stimulus acts upon a sensory receptor. Like a tree. (A ganglion is a collection of neuron cell bodies. An enlargement on the posterior root is the posterior root ganglion. The information is carried . The anterior primary rami go the sides and front of the body and also to the upper and lower extremities. or the visceral motor neurons of the autonomic nervous system.Figure 2-4. A nerve has been defined as a collection of neuron processes. a typical spinal nerve has roots. It is formed by the columnar alignment of the vertebrae. together. every spinal nerve has essentially the same structure and components. c. Spinal nerve.) (1) An afferent neuron carries sensory information from the periphery to the CNS. The information is carried by an afferent (sensory) neuron through the merging branches of the spinal nerve that has been affected. a trunk. the posterior and anterior roots of the spinal nerve join to form the spinal nerve trunk. (1) Coming off of the posterior and anterior sides of the spinal cord are the posterior (sensory) and anterior (motor) roots of the spinal nerve. In the human body.

through the posterior root ganglion and posterior root to the spinal cord. Once the information reaches the spinal cord. The pathway from the receptor organ to the reacting muscle is called a reflex arc (figure 2-5). mental status. The axon of the efferent neuron carries the information to the effector organ. c. Reflex arc. sensory function. d. the afferent neuron synapses with a special connecting neuron called the internuncial neuron (or interneuron). and level of consciousness. A reflex is an automatic reaction to a stimulus. motor function. The effector organ receives the command to act. Figure 2-5. The efferent (motor) neurons carry the command from the spinal cord to the effector organ. e. a. The stimulus is received by a receptor organ specific to that stimulus. it ascends the appropriate fiber tract to the designated area of the brain. . The pathway of a reflex arc contains five components. b. In turn. the internuncial neuron synapses with the efferent neuron's cell body. Neurological assessment A thorough neurological assessment is one that accurately and completely evaluates the patient's vital signs. Motor information (commands) from the brain will descend along the appropriate fiber tract within the spinal cord until the appropriate spinal nerve is innervated. b. REFLEX ARC The simplest reaction of the human nervous system is the reflex. Within the spinal cord. The information is transmitted to the CNS by the afferent neuron of the appropriate peripheral nerve.

Temperature. The terms used to describe state of consciousness are often subjective and ambiguous. Do not ask for the date. Cognition. auditory. c. This is a poor indication of orientation. (3) Stuporous--partial unconsciousness. described in paragraph 2-16. state. Note respiratory changes. Blood pressure. MENTAL STATUS a. b.     Orientation. The patient can be aroused and will respond to commands. Terms used to describe state of consciousness include: (1) Conscious (alert)--the patient responds immediately. When assessing a patient who is other than "awake and alert." it is best to use a standardized assessment scale. For this reason. Orientation is determined by questioning the patient about person. The patient can be aroused with painful stimuli and will attempt to respond with purposeful withdrawal from the stimulus. Radial pulses. (4) Comatose--complete unconsciousness.VITAL SIGNS a. (3) Ask the patient to tell you the year. month. Note temperature elevations. bilaterally. and time-of-day (mid-morning. fully. city. He may be asked to name the hospital. and time. such terms should not be used in nursing documentation unless they are qualified with an explanatory statement. Affect. Note any changes in pulse rate or rhythm. especially when it occurs with a widening pulse pressure. Vital signs should be evaluated as follows:      Compare current vital signs with baseline and previous vital signs. or recite his address. One such scale is the Glasgow Coma Scale (GCS). (2) Somnolent--unnatural drowsiness. and other stimuli. The patient may be restless or combative as well. and so on. but will fall asleep again as soon as he is left alone. late afternoon. Note elevation of blood pressure. no purposeful response to any stimulus. Apical heart rate and rhythm. and so forth). Respiratory rate and rhythm. Does the patient know who he is? Does the patient know who others are? (2) Ask the patient to tell you where he is. (Mood) Memory. Vital signs should include:       b. . Mental status assessment should evaluate the following areas: State of consciousness. Femoral pulses. (1) Ask the patient to spell his name. name his children. and appropriately to visual. bilaterally. place. Most people cannot tell you the exact date when questioned.

term memory). Cognition is tested by asking the patient to perform calculations. Evaluate: (1) Size in millimeters (do not use subjective terms such as dilated or pinpoint. (1) Discussing past events or questioning the patient about his medical history will test his ability for remote recall (long-term memory). For example:    Does the patient laugh when talking about serious or sad subjects? Is the patient easily startled by loud noises? Does the patient respond to stimuli in a normal manner? Does the patient display excessive anger. (3) Observe patient's facial expression for signs of any pain/discomfort. elbows. Beginning with upper extremities. Grasp one of the patient's digits (thumb. and so forth? e. b. Ask the patient to tell you which direction the digit is pointing. . Sensory function is evaluated by testing perception of pain. (2) Touch--ask the patient to close his eyes. and position. (2) Note strength of both hands and compare strength of one to the other. Position the patient comfortably so that you can observe both upper and lower extremities. SENSORY FUNCTION a. ask patient to put each joint (wrist. Affect. Do not exert any pressure with your grasp that will indicate which direction you are moving the digit. touch the skin as lightly as possible to elicit a sharp sensation.) (2) Equality in size of the pupils. shoulders) through active range of motion. great toe) and move it up or down. fear. ask the patient what he ate for breakfast that morning. confusion. a. (1) Observe smoothness of movement. ask the patient to count backward from 100 by 7s. For example. Extend your index and middle fingers of each hand and ask patient to grip firmly. c. b. (3) Position--ask the patient to close his eyes. Use a piece of cotton or gauze to gently brush the skin on the patient's arms. and feet. Pupillary response is another sensory function indicator. MOTOR FUNCTION Evaluate motor function by testing muscle strength. Long and short term memory should be evaluated by asking questions. and coordination. (1) Pain--using a safety pin. (2) Questions about daily events will test recent recall (short. legs. For example. (2) Note inability to move any body part. (3) Response to light. mobility.d. Ask the patient to tell you when and where he feels a touch. or mood. touch. (1) Dominant hand will usually be slightly stronger. is evaluated by observing the patient's verbal and nonverbal behavioral responses for appropriateness. f.

Recording and/or graphing the scores on a flow sheet permits easy tracking of the patient's status. c. (1) Ask the patient to run his left heel along his right shin (while standing) and vice versa. and time. (c) 3 points--the patient speaks in a disorganized manner. and eye). and touch his index finger to his nose.d Instruct patient to put each lower extremity joint (ankles. Patient responses are graded by the degree of dysfunction. place. Response scale. f. Observe coordination. The scale measures three areas of observable behavioral responses (verbal. b. (d) 1 point--eyes do not open in response to any stimuli. reliable instrument for the assessment of level of consciousness.) (d) 2 points--the patient's response is moaning or groaning sounds. objective. Observe posture and balance. hips) through active range of motion. (Inappropriate speech. (1) Note the strength that the patient exerts against your resistance and compare right to left.) (e) 1 point--the patient does not respond. (Incomprehensible sounds. (b) 3 points--eyes open in response to sound. The patient's best response in each of the three areas is recorded. forward and backward. (1) Observe smoothness of movement. (2) If muscle group is weak. knees. d. (2) Note inability to move any body part. . (b) 5 points--the patient "localizes" to the stimulus (pain). (Explanation) (1) Eye response. Ask the patient to alternately flex and extend his feet while you provide resistance with your hands. (3) Motor response. (a) 6 points--the patient obeys commands appropriately and moves all extremities equally and spontaneously. (3) Observe patient's facial expression for signs of any pain/ discomfort. (2) Ask the patient to close his eyes. (2) Verbal response. (a) 5 points--the patient is oriented to person. extend his arms. (3) Ask the patient to walk in a straight line. (c) 2 points--eyes open in response to painful stimuli. The combined score of the three areas is the "consciousness level" score. LEVEL OF CONSCIOUSNESS a The Glasgow Coma Scale (GCS) is a standardized. motor. (a) 4 points--eyes open spontaneously. lessen your resistance or provide no resistance to permit more accurate observation. Attempts to locate the source of the pain and move the limb away from the stimulus. (b) 4 points--the patient is confused but is able to communicate. e.

Because of complex anatomy of the skull. (1) Review the patient's clinical record to determine the reason (purpose) for the specific scheduled skull x-rays. (2) Approach and identify the patient. b. which make up the skull.) (e) 2 points--the patient extends an extremity abnormally. a series of films is usually required for a complete evaluation. tumors. bleeding. c. (Decerebrate response.) (f) 1 point--the patient has no motor response. (4) To detect congenital anomalies.) e. (4) As indicated. Nursing implications. (Decorticate response. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient. and infection. (3) To aid diagnosis of pituitary tumors. 6 5 4 3 2 1 3 through 15 5 4 3 2 1 4 3 2 1 . explain to the patient the specific purpose of the skull x-rays in his/her situation. (Flexor withdrawal. Skull X-rays are the oldest.) (d) 3 points--the patient flexes an extremity abnormally.(c) 4 points--the patient attempts to withdraw from the source of the (painful) stimuli in a less than purposeful movement. Abbreviated Response Scale. Diagnostic uses for skull X-rays: (1) To detect fractures in patient's with head trauma. (Flaccid. (2) To help detect and assess increased intracranial pressure. non-invasive neurological test used to evaluate the bones. (3) Interview the patient to determine his/her knowledge of the purpose of the skull x-rays. Eye Opening Spontaneous To sound To pain None Best Verbal Response Oriented Confused Inappropriate words Incomprehensible sounds None Best Motor Response Obeys commands Localizes stimulus Withdrawal from stimulus Abnormal flexion (decorticate) Abnormal extension (decerebrate) Flaccid TOTAL SCORE POSSIBLE SKULL X-RAYS a.

(1) Review the patient's clinical record to determine the reason for the patient's scheduled lumbar puncture procedure and what the patient has been told about the procedure. It is performed therapeutically to administer drugs or anesthetics and to relieve intracranial pressure. Betaine solution. or sandbags may be used to immobilize the patient's head and increase patient comfort.(5) Explain to the patient the events which will occur prior to the skull x-rays. (7) Explain to the patient events. .      Sterile gloves. (a) Patient is not required to restrict food and fluids before x-rays. (6) Explain to the patient events which will occur during the skull x-ray procedure. foam pads. (b) All jewelry and other metal objects must be removed from patient's head and neck and placed in safekeeping. Labels. (a) Patient will be returned to his/her room. This test requires sterile technique and careful patient positioning. Laboratory request slips. (3) Approach and identify the patient. to reach the cerebral spinal fluid. (b) Physician will report the results of the x-rays to the patient when they are available. (2) To detect increased intracranial pressure. or seated in a chair. (5) As indicated. and instructed to remain still. (3) To detect presence of blood in the cerebral spinal fluid which indicates cerebral hemorrhage. (4) To obtain cerebral spinal fluid specimens for laboratory analysis. (6) Explain the procedure to the patient. Overbed table. which will occur after the procedure. b. Lumbar puncture is the insertion of a sterile needle into the subarachnoid space of the spinal canal. explain to the patient the specific purpose of the lumbar puncture procedure. Sterile disposable lumbar tray. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient. LUMBAR PUNCTURE a. Diagnostic uses for lumbar puncture: (1) To determine the pressure of the cerebral spinal fluid. (c) Tell the patient where and when the x-rays will be performed. Nursing implications. (4) Interview the patient to determine his/her knowledge of the purpose of the lumbar puncture procedure. c. (c) Tell the patient that several (usually five) x-ray films of the skull will be taken from various angles. (a) Patient will be placed in a supine position on a radiographic table. usually between the third and fourth vertebra. ( 2) Assemble the necessary equipment. Local anesthetic. (d) Reassure patient that the procedure will cause no discomfort. (b) A headband. (e) Films will be developed and checked before patient leaves the x-ray department.

(2) Position the patient. An electroencephalogram (EEG) is a recording of brain wave activity. sensitivity. tinnitus. Procedure. (8) When the needle is in place. (10) When there is approximately 2 or 3 ml of fluid in each tube. (5) Inform the patient that the physician will report the results of the lumbar puncture as soon as they are available. apply pressure to the area briefly. (Much the same as an electrocardiogram. Remove equipment from bedside and dispose of properly. stopper them securely. the physician will hand them to the assistant. the physician will attach a manometer with stopcock to the needle hub to read CSF pressure. (b) To help the patient maintain this position. (6) The physician will insert the spinal needle. (12) The entire procedure will last approximately 15 minutes. (4) The physician will drape the area with a fenestrated drape to provide a sterile field. (4) Give the patient increased fluids for at least 24 hours after the procedure. (1) Electrodes are attached to specific areas of a patient's scalp. and apply a band-aid or small dressing. (3) The physician will clean the puncture site area with sterile applicators from the lumbar puncture tray. e. meningitis. as such: (a) Gram stain. syncope. (a) Lateral recumbent. nausea. (2) Instruct the patient to lie flat for several hours to reduce chance of headache. (7) If the procedure is being performed to administer contrast media for radiologic studies or spinal anesthetic. respiratory distress. the physician will inject the dye or anesthetic. (d) Protein and glucose. (5) The physician will inject local anesthetic into the planned needle puncture site. and chin tucked to chest. Record the procedure in the patient's chart. change in vital signs. (1) Ask the patient to empty his/her bladder. and fever should be reported to the professional nurse. ELECTROENCEPHALOGRAM a.    Ensure the comfort and safety of the patient. (c) Cell count. vertigo. (11) The physician will remove the spinal needle.) . at the edge of the bed. The patient will feel some pressure at this time. who will mark the tubes in sequence. which magnifies the impulses and records them on moving strips of paper.d. (2) Electrical impulses are received and transmitted to a machine called an electroencephalograph. knees drawn up to abdomen. Adverse reactions including headache. (3) Monitor the patient carefully following the procedure. and label them properly. (The patient may need to extend his legs to provide a more accurate pressure reading.) (9) The physician will detach the manometer and allow the fluid to drain from the needle hub into four collection tubes. (b) Culture. (1) Send the CSF specimens to the laboratory immediately. Follow-up. the nursing paraprofessional places one hand behind the patient's neck and the other behind patient's knees to help support the patient's position throughout the procedure.

(5) As indicated. the patient is instructed to relax with the eyes closed and remain still. (c) Barbiturates. Diagnostic uses for EEG. (4) Interview the patient to determine his/her knowledge of the purpose of the electroencephalogram procedure. and electrodes will be attached to the scalp. explain to the patient the specific purpose of the electroencephalogram. (a) Patient will be asked to relax in a reclining chair or lie on a bed. (a) Anticonvulsants. (1) Review the patient's clinical record to determine the reason for the patient's scheduled electroencephalography and what the patient has been told about the procedure. BRAIN SCAN a. the patient will feel pricking sensations when they are inserted. (c) If needle electrodes are used. (a) Food or fluids need not be restricted. and encephalitis. (b) Physician will report the results of the electroencephalogram to the patient when they are available. (8) Explain to the patient events which will occur after the electroencephalogram procedure.V. (b) Assure the patient that the electrodes will not cause electrical shocks. head injury. injection of a radionucleotide. (6) Explain to the patient events which will occur prior to the electroencephalogram. (2) Check the patient's medication history for drugs that may interfere with test results. (c) Patient will be transported to electroencephalogram clinic. c. and report positive findings to charge nurse. (2) Aid in diagnosis of intracranial lesions. meningitis. (a) Patient will return to his/her room. (3) To evaluate the brain's electrical activity in metabolic disease. (7) Explain to the patient events that will occur during the procedure. the radionucleotide cannot permeate the blood-brain barriers. (d) Before the recording procedure starts. (1) To determine the presence and type of epilepsy. Nursing implications. (b) Tranquilizers. and who will do it. Brain scanning is the use of a specialized camera to provide images of the brain after an I. Normally. (d) Other sedatives. but if .b. (4) To confirm brain death. (b) Tell the patient when and where the test will be performed. (3) Approach and identify the patient.

(a) Patient will be transported back to his/her room. arterial spasm. (a) Patient will not have to restrict food or fluids before test. (a) The patient will be transported to the nuclear medicine department. (6) Explain to the patient events that will occur during the brain scanning procedure. CEREBRAL ANGIOGRAPHY a. or hemorrhage. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient. (b) Films will be taken of the brain at various time intervals. (2) To locate areas of ischemia. . c. (3) To locate surgical clips applied to blood vessels during surgery and to evaluate the postoperative status of the vessels. the radionucleotide may concentrate in the abnormal area. and femoral arteries. (f) A radioactive drug will be injected intravenously at least one hour before the scan begins. b. (b) Physician will report the results of the brain scan to the patient when available. b. hematoma. (e) Explain that the procedure is painless and that the radiation poses no danger to the patient or visitors. explain to the patient the specific purpose of the brain scan. brachial. (2) To study vascular displacement caused by tumor. Nursing implications. (2) Approach and identify the patient. (c) The patient can expect to be in the nuclear medicine department at least an hour and a half. (4) As indicated. Diagnostic uses for cerebral angiography. cerebral infarction. (1) To detect cerebrovascular abnormalities. (3) Interview the patient to determine his/her knowledge of the purpose of the brain scanning procedure. Nursing implications. (b) Patient will be asked to empty his/her bladder prior to the procedure. (7) Explain to the patient events that will occur after the brain scan. edema. (c) All jewelry or metal in the x-ray field will be removed and placed in safe keeping. (1) Review the patient's clinical record to determine the reason (purpose) for the specific patient's scheduled brain scanning procedure and what the patient has been told about the procedure. (3) To evaluate the course of certain lesions postoperatively and during chemotherapy. Diagnostic uses: (1) To detect an intracranial mass or vascular lesion. or increased intracranial pressure. Common injection sites are the carotid. A cerebral angiogram is a radiographic examination of the cerebral vasculature after injection of a contrast medium. (5) Explain to the patient events that will occur prior to the brain scanning procedure. (d) Describe the scanning machine and explain it will move back and forth close to the patient's head. c.pathologic changes have destroyed the barrier.

(3) Brain tumor. (b) Physician will report the results of the cerebral angiography test to the patient. (3) Approach and identify the patient. The basic principle to remember is that the unconscious patient is completely dependent on others for all of his needs. (b) All jewelry. (d) Patient will be asked to empty his/her bladder prior to the procedure. (2) Check the patient's medication history for hypersensitivity to iodine. medication such as a sedative may be administered prior to the test. when they are available. b. . (9) Document the completion of the examination and the patient's return to the nursing unit. Unconsciousness means that the patient is unaware of what is going on around him and is unable to make purposeful movement. (b) The patient will be placed in a supine position on the x-ray table and asked to remain still. Explain purpose in a manner consistent with that offered by the physician to avoid confusing the patient. or nauseated after injection of the contrast medium. warm. which will occur after the cerebral angiography. and report significant findings to the Professional Nurse. (a) Patient will be required to fast 8-10 hours before test. (c) Contrast medium will be injected intravenously. seafoods. or the dyes used for other local tests. (4) Interview the patient to determine his/her knowledge of the purpose of the cerebral antiography procedure. and hair pins will be removed and placed in safekeeping. General nursing considerations: (1) Always assume that the patient can hear. (f) The test will take approximately two hours. (g) If ordered. (d) The patient may experience a transient burning sensation at the injection site during the injection. c.(1) Review the patient's clinical record to determine the reason (purpose) for the specific patient's scheduled cerebral angiography and what the patient has been told about the procedure. explain to the patient the specific purpose of the cerebral angiography in his/her situation. (2) Head injury. (7) Explain to the patient events that will occur during the cerebral angiography procedure. (8) Explain to the patient events. (e) The patient may become flushed. (c) Patient will wear a hospital gown. (5) As indicated. (e) Patient (or responsible family member) must sign a consent form. A transient headache or salty taste in the mouth may also be experienced. dentures. Any omissions in basic nursing care or any failure to protect the unconscious patient in his helpless state may inhibit recovery or greatly prolong his convalescence because of complications that might have been prevented. (4) Drug overdose. even though he makes no response. The most common causes of prolonged unconsciousness include: (1) Cerebrovascular accident (CVA). (a) Patient will be transported to the x-ray department. Care of the unconscious patient GENERAL ASSESSMENT a. (a) Patient will be returned to his/her room. (6) Explain to the patient events that will occur prior to the cerebral angiography procedure.

it is best to place the patient in a sitting position (Fowler's or semi-Fowlers) and support with pillows. c. Reposition the patient from side-to-side to prevent pooling of mucous and secretions in the lungs. d.(2) Always address the patient by name and tell him what you are going to do. (This prevents drying of the skin. (1) Always take a rectal temperature. b Suction the mouth. e." (2) It is the safest position for a patient who is left unattended. A patient who is unconscious is normally fed and medicated by gavage. NUTRITIONAL NEEDS a. (2) Report changes in vital signs to the professional nurse.) The patient's face and perineal area should be bathed daily. Regularly observe and record the patient's vital signs and level of consciousness. (a) This permits gravity to help move the feeding or medication. d. water. (3) Keep accurate records of all intake. (Feeding formula. (3) Refrain from any conversation about the patient's condition while in the patient's presence. position the patient on his side with the chin extended. (1) Keep accurate records of IV intake and urine output. and trachea as often as necessary to prevent aspiration of secretions. Whenever possible. Maintain a patent airway by proper positioning of the patient. (2) Observe the patient for signs of dehydration or fluid overload. This prevents the tongue from obstructing the airway. e. The unconscious patient should be given a complete bath every other day. Always have suction available to prevent aspiration of vomitus. (4) Note the return of protective reflexes such as blinking the eyelids or swallowing saliva. Fluids are maintained by IV therapy. AIRWAY AND BREATHING a. Check the patient's skin temperature by feeling the extremities for warmth or coolness. (1) This lateral recumbent position is often referred to as the "coma position. Adjust the room temperature if the patient's skin is too warm or too cool. pharynx. Administer oxygen as ordered. SKIN CARE a. (2) Do not leave the patient unattended while gavage feeding. liquid medications. b.) (4) When gavage feeding an unconscious patient. (1) Always observe the patient carefully when administering anything by gavage. Keep the patient's room at a comfortable temperature. . (3) Note changes in response to stimuli. (b) The chance of aspiration of feeding into the airway is reduced.

Small. Check the eyes frequently for signs of irritation or infection. (2) Keep accurate intake and output records. This causes saliva to dry and adhere to the mouth and tooth surfaces. color. (1) Adequate fluids should be given to prevent dehydration. the perineal area must be washed and dried thoroughly after each incident. or water-soluble lubricant. and consistency. Prevent drying with a light coat of lotion. The bowel should be evacuated regularly to prevent impaction of stool. e. f. amount. (2) Apply lotion. (3) Gently massage the skin to stimulate circulation. ELIMINATION a. (4) If enemas are ordered. The bladder should be emptied regularly to prevent infection or stone formation. (1) Change the bed linen if damp or soiled. One such solution.(1) The skin should be lubricated with moisturizing lotion after bathing. (2) The nails should be kept short. frequent. all tooth surfaces. Keep the nostrils free of crusted secretions. (1) Examine the skin for areas of irritation or breakdown. Provide oral hygiene at least twice per shift. Include the tongue. as many patients will scratch themselves. and all soft tissue areas. use proper technique to ensure effective administration and effective return of feces and solution. prn. b. The unconscious patient is often a mouth breather. b. Skin care should be provided each time the patient is turned. Use only cleansing solutions and eye drops ordered by the physician. (3) Assess for fecal impaction. c. (1) Keep accurate record of bowel movements. If the patient is incontinent. methyl cellulose (referred to as "artificial tears") may be ordered for instillation at frequent intervals to prevent irritation. POSITIONING . It is generally administered once per day. (2) Apply petrolatum to the lips to prevent drying. d. (2) Observe the skin for evidence of skin breakdown. Note time. Neglect can result in permanent damage to the cornea since the normal blink reflex and tear-washing mechanisms may be absent. (2) A liquid stool softener may be ordered by the physician to prevent constipation or impaction. (4) Provide catheter care at least once per shift to prevent infection in catheterized patients. The patient may be incontinent of stool. (3) Report low urine output to professional nurse. (1) Always have suction apparatus immediately available when giving mouth care to the unconscious patient. petrolatum. loose stools may be the first signs of an impaction as the irritated bowel forces liquid stools around the retained feces. yet never completely evacuate the rectum.

(2) Change the patient's position at least every two hours. (3) Change the patient's position to a new weight-bearing surface every two hours. MENINGITIS . Caring for a patient with an infectious neurological condition provides a challenge for the health care team in terms of bedside clinical skills and intensive planning for discharge and rehabilitation. (a) Physical therapy personnel will not always be available. forming what is known as a contracture. (1) Limbs must be supported in a position of function. Protect the patient from injury. Precautions must be taken to prevent the development of pressure sores. (4) Use draw sheets for easier turning. orthostatic pneumonia. d. e. (2) When turning the patient. This decreases the likelihood of complications such as decubitus ulcers. When joints are not exercised in their full range of motion each day. (3) Unless contraindicated. and thrombophlebitis.) (3) The restless. (4) Utilize a foot board at the end of the bed to decrease the possibility of foot drop. (4) Take precautions to prevent restraint from becoming restricting.a. his hair. (b) It is a nursing care responsibility to maintain the patient's range of motion. Do not allow flaccid limbs to rest unsupported. confused patient will actively resist restraint and thrash about more when not permitted some freedom of movement of the arms and legs. Infectious Nervous System Disorders Infectious neurological diseases usually render the patient acutely ill. (2) Nursing personnel must be proficient in ROM exercises. the muscles will gradually shrink. (1) Utilize a protective mattress such as a flotation mattress. (1) Use restraints only with physician's order. supportive chair. (1) Exercises with a range of motion (ROM) are performed under the direction of the physical therapist. Do not cut-off circulation. Restraints. (3) Keep stray objects out of the bed. (2) Use "mitten" restraints to prevent the patient from pulling at catheters. (Patients not in deep coma may scratch or pick at themselves. or eggcrate mattress. b. IV lines. alternating pressure mattress. (5) Keep suction equipment available at the bedside for emergencies. and so on. Passive exercises must be provided for the unconscious patient to prevent contractures. The unconscious patient cannot tell you that he is uncomfortable or is experiencing pressure on a body part. pay particular attention to maintaining proper body alignment. When positioning the unconscious patient. (1) Keep siderails up. c. get the patient out of bed and into a cushioned. maintain alignment and do not allow the arms to be caught under the torso. Do not irritate the skin. (2) Pad the rails with pillows or folded blankets.

(1) Administer intravenous fluids and medications. . (b) Streptococcus. (b) Corticostertoids may be used for the critically ill patient. Signs and Symptoms. (5) Nuchal rigidity (stiffness of the neck). d. (a) Antibiotics should be started immediately. (3) If isolation measures are required. the presence of other neurological disorders. the speed of diagnosis. vomiting. 3) Infected shunt. and administration of ordered antipyretics. c. inform family members and ensure staff compliance of isolation procedures in accordance with (IAW) standard operating procedures (SOP). The severity of the disease is dependent upon the specific microorganism involved. (2) Chills. (3) Headache (often severe). Nursing Management. (d) Pneumococcus. Diagnostic Evaluation Techniques. (d) Record intake and output carefully and observe patient closely for signs of dehydration due to insensible fluid loss. Utilize GCS for accuracy and consistency. (1) Travel of infectious microorganisms to the meninges via the bloodstream or through direct extension from an infected area (such as the middle ear or paranasal sinuses). the general health of the patient. (4) Contaminated lumbar puncture. (c) Staphylococcus. provide for cooling measures such as a cooling mattress. cooling sponge baths. (a) Level of consciousness. (7) Opisthotonos (extreme hyperextension of the head and arching of the back due to irritation of the meninges). (2) Monitor patient's vital signs and neurological status and record. (3) Physical examination.a. as ordered by the physician. (6) Photophobia. Causes of Meningitis. (1) Elevated temperature. b. Definition. Meningitis is inflammation of the meninges. (b) Monitor rectal temperature at least every 4 hours and. (9) Multiple petechiae on the body. (2) Blood cultures. (4) Nausea. and the initiation of treatment. e. (c) Drug therapy may be continued after the acute phase of the illness is over to prevent recurrence. (1) Lumbar puncture to identify the causative organism in the cerebrospinal fluid. (2) Contaminated head injury. if elevated. Common microorganisms include: (a) Meningococcus. (8) Altered level of consciousness.

(c) Possible follow-up with the community health nurse. (2) Severe headache. (5) Altered level of consciousness. Pathophysiological changes associated with encephalitis include: (1) Severe. Signs and Symptoms. d. Causes of Encephalitis. (5) Provide discharge planning information to the patient and family. medical treatment is symptomatic. c. lethargy. arsenic. (4) Vomiting. highly infectious viral disease characterized by fever. ENCEPHALITIS a.(4) Provide basic patient care needs. (b) Discharge medication instruction. Infection is transmitted through oral and nasal secretions or through the oral-fecal route. (1) Because no specific antiviral measure has yet been developed. (2) Chemical toxins (lead. especially around cerebral blood vessels. b. paralysis. (3) As a complication of infectious childhood diseases (measles. carbon monoxide). Definition. (2) Specific supportive nursing measures which apply to the patient with meningitis should be followed. (8) Visual disturbances (photophobia. (2) Intense lymphocytic infiltration. b. muscular weakness. If patient is not fully conscious. Poliomyelitis is an acute. (Onset of symptoms is usually very sudden. POLIOMYELITIS a. Management. follow the guidelines for care of the unconscious patient (Part 5). (6) Seizures. (1) Microorganisms. rubella. chicken pox). Signs and Symptoms. (a) The patient's level of consciousness will dictate whether the patient requires only assistance with activities of daily living or total care. and muscle atrophy.) (1) Fever. . Definition. Encephalitis is an infectious disease of the central nervous system characterized by pathological changes in the gray and white matter of the cord and brain. (3) Nuchal rigidity. (7) Incoordination. diffuse inflammation of the brain. (b) Maintain dim lighting in the patient's room to reduce photophobic discomfort. The incidence of polio has been greatly reduced with childhood immunization using the Sabin and Salk polio vaccines. diplopia). (a) Follow up appointments with the physician. (3) Possible extensive nerve cell destruction.

(1) Treatment is nonspecific and symptomatic. Medical and Nursing Management. (6) Residual effects are rare. (6) Continually observe family interactions to determine long-term effect of polio on family resources and dynamics. (2) Lethargy. over a period of several hours to one week. numbness. Cause. (5) Determine the degree to which patient and family can participate in care. (2) Weakness usually progresses (ascends). (2) Utilize supportive nursing measures. (3) Sensory disturbances.(1) Headache. Guillain-Barre Syndrome is a disorder of the nervous system that affects peripheral nerves and spinal nerve roots. talking. especially in the extremities. stiffness. Additionally. (6) Paralysis. Diagnosis is made on the basis of the history and symptoms. d. GUILLAIN-BARRE SYNDROME a. Anorexia. Vomiting. (3) Consult infection control for recommendations regarding enteric (4) Involve physical therapy for a formal evaluation and instruction. Degenerative Nervous System Disorders MULTIPLE SCLEROSIS . (7) Seek assistance from Community Health Nurse for discharge planning and community assistance. (3) Continuous EKG monitoring. c. and (5) Diminished or absent deep tendon reflexes. The exact cause of Guillain-Barre syndrome is unknown. c. b. especially of the upper respiratory tract. (5) In several weeks. Nursing Management. (5) Muscle weakness. Definition. (1) Motor weakness. (4) Supportive nursing care measures indicated by the patient's degree of paralysis. (3) Muscle pain. (4) Cranial nerve involvement resulting in difficulty chewing. to the upper areas of the body. and tingling. usually starting from the head and moving downward. paralysis will begin to disappear. but prolonged flaccid paralysis may lead to muscle atrophy requiring rehabilitation and physical therapy. There is also evidence of a connection with the Swine flu vaccination. Many patients give a history of a recent infection. lumbar puncture will reveal increased protein in the CSF. Low grade fever. is often the first symptom. (2) Patient must be continuously observed for adequacy of respiratory effort. Signs and Symptoms. It is also called infectious polyneuritis. (1) Monitor patient's level of consciousness. where muscles of respiration may be affected. (4) Loss of deep tendon reflexes. Fever.

Signs and Symptoms. wrist and finger flexors. (1) Weakness. (7) Paraplegia. (8) Urinary and bowel incontinence/retention. Research is investigating the possibilities of infection by slow virus. (1) The cause of MS is unknown. . hesitating speech. as ordered. Multiple Sclerosis (MS) is a chronic. (a) To keep the patient as active and functional as possible in order to lead a purposeful life. Medical and Nursing Management. (5) Assist the patient to establish a routine of regular bowel evacuation. (b) Patient may need to be taught self-catheterization. (a) Observe patient closely for retention and catheterize. progressive disease of the central nervous system characterized by the destruction of myelin. walkers when necessary to keep patient ambulatory. (3) Slurred. (2) Instruct patient to perform muscle stretching exercises to minimize join contractu res. (9) Emotional lability. (d) Support the patient with bladder incontinence by initiating a bladder training program. (e) Meticulous skin care is required for the incontinent patient. as ordered during periods of exacerbation. (4) Support the patient with bladder disturbances. (3) Avoid skin pressure and immobility. crutches. biceps. (1) Objectives of care. (e) Administer muscle relaxants as ordered. (b) Instruct family about passive range of motion exercises for patients with severe spasticity. (5) Abnormal reflexes (absent or hyperactive). (b) Change patient's position every 2 hours even if patient is in wheelchair. (6) Administer corticosteroids. Myelin is the fatty and protein material that covers certain nerve fibers in the brain and spinal cord. (c) Give careful attention to sacral and perineal hygiene. (2) Multiple Sclerosis primarily affects adults between 20 and 40 years of age. b. (b) To relieve the patient's symptoms and provide him/her with continued support. (6) Ataxia.a. hip adductors. c. blindness). canes. (4) Intention tremor. Definition. (depressed. blurred vision. and genetic factors. alteration in the immune system. (f) Utilize braces. (d) Instruct patient to participate in walking exercises to improve gait affected by loss of position sense in legs. as ordered. (c) Advise patient to prevent muscle fatigue with frequent rest periods. (a) Particular emphasis on hamstrings. (a) Pressure sores will accompany severe spasticity in an immobile patient due to sensory loss. gastrocnemius. (2) Visual disturbances (nystagmus. (c) Administer urinary antiseptics. euphoric).

(3) Utilize braces. Definition. speech may be nasal and unintelligible. and forgetfulness. Amyotrophic lateral sclerosis is commonly known as Lou Gehrig's Disease. depression. etc. (a) Eye patch to block vision impulses for patient with diplopia. canes. to keep patient mobile as long as possible. (c) Use soft cervical collar if patient has difficulty holding head up. (b) Obtain services of speech therapist. (5) Muscle twitching. (a) Instruct patient and family in activities of daily living using assistive and self-help aids. (5) Give patient and family compassionate and caring support. (6) Mental facilities are not affected. (a) Allow expressions of feelings and frustrations about losses and eventual outcome. (e) Keep in mind that patient may have frequent outbursts of laughing and crying. (b) Assist the patient and family to cope with the stress of multiple sclerosis. denial. c. b Signs and Symptoms. (7) Death usually occurs 3-5 years after onset. (b) Encourage bedrest during the acute stage as activity seems to worsen attack.(a) May reduce severity of exacerbation by reducing edema and inflammation. splints. (1) Symptoms vary. depending upon the location of affected motor neurons. Medical and Nursing Management (1) Objective--to support the patient and improve quality of life. intelligence. (c) The patient with MS will experience behavioral changes such as euphoria. AMYOTROPHIC LATERAL SCLEROSIS a. (4) Excessive drooling. as aspiration is a constant danger. trunk. (b) Instruct patient to drink and eat in an upright position with the neck flexed. incapacitating. ocular movement. (c) Keep in mind that the residual effects of the disease may increase with each exacerbation. (3) Progressive difficulty in speaking and swallowing. and consciousness even though he/she is paralyzed. It is characterized by loss of motor neurons in the anterior horns of the spinal cord and lower brain stem. (2) Progressive weakness and atrophy of muscles of arms. or legs. (a) Keep suction apparatus at bedside. and fatal disease of unknown cause.. Avoid easily-aspirated pureed foods and mucous producing foods (milk). (f) Develop communication system when speech is lost. Amyotrophic lateral sclerosis (ALS) is a progressive. (d) Avoid physical and emotional stress as they may worsen symptoms. (8) Discharge planning considerations. (e) Assist patient to accept his new identity as a handicapped person. (d) Give semi-soft foods. (4) Assist the patient to prevent complications that may result from symptoms. (7) Support the patient with optic and speech defects. . (b) Remember that the patient is alert and retains vision. (2) Instruct the patient to perform active exercises and range of motion exercises to strengthen uninvolved muscles and prevent disuse atrophy.

In normal individuals. (5) Encourage patient to be an active participant in his/her therapy and in social and recreational events. swallowing. . (a) Emphasize importance of a daily exercise program. (8) Dementia. (1) Primary degenerative changes of the basal ganglia and their connections prevent motor transmission of automatic movements (blinking. chemical toxicity. and cerebrovascular disease. (2) The exact cause of Parkinson's is unknown. Signs and Symptoms. muscle tone). particularly of large joints. Medical and Nursing Management. (6) Inform patient about American Parkinson's Disease Foundation for patient education and group support. encephalitis. (6) Mask-like facial expression with unblinking eyes. Parkinson's disease is a progressive neurological disorder affecting the brain centers that are responsible for control of movement. and drug effects. PARKINSON'S DISEASE a. (b) Instruct patient in postural exercises and walking techniques to offset shuffling gait and tendency to lean forward. (3) Instruct patient to establish a regular bowel routine with a high fiber diet and plenty of fluids. (c) Rehabilitation techniques. facial expressions. transmission of impulses from the nerve to the motor end plate of the muscle is accomplished by the transmitter substance acetylcholine. (4) Classic shuffling gait. (b) Physical therapy.(c) Advise patient's family of helping services of ALS Society of America. which usually becomes the most disabling symptom. (c) Encourage warm baths and showers to help relax muscles and relieve spasms. (4) Eat a well-balanced diet. viruses. Suspected causes include genetic factors. (7) Depression. Constipation is a problem due to muscle weakness. (5) Muscle weakness which affects eating. Definition. Myasthenia Gravis is an autoimmune disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body. MYASTHENIA GRAVIS a. b. speaking. (d) Patient and family education. as Parkinsonism tends to lead to withdrawal and depression. c. (2) Encourage patient to participate in physical therapy and an exercise program to improve coordination and dexterity. (1) Bradykinesia. Nutritional problems develop from difficulty chewing and swallowing and dry mouth from medications. (1) Treatment is based on a combination of the following: (a) Drug therapy. Definition. (3) Rigidity. lack of exercise. (2) Tremor which tends to decrease or disappear on purposeful movements. chewing. writing.

b. (2) Acetylcholine is then broken down into acetate and choline by the substance cholinesterase. and acetylcholine is destroyed too quickly. resulting in inadequate depolarization of the motor end plate. (6) Difficulty swallowing. (3) Abnormal muscle weakness.(1) Acetylcholine is released at the nerve ending and moves to the muscle end plate. (1) Diplopia (double vision). Medical and Nursing Management. mask-like facial expression with difficulty smiling. Actions. Symptoms of overdosage and actions to take should crisis occur. aspiration of food. (d) . Signs and Symptoms. (b) There may be too little acetylcholine released from the nerve fiber. (3) In myasthenia gravis. causing muscle contraction. (b) After initial medication adjustments are made. patient learns to take his medication according to his/her needs. (4) Sleepy. c. (5) Speech weakness (high-pitched nasal voice). (a) Drug must be given exactly on time to control symptoms. characteristically worse after effort and improved by rest. (c) The motor end plate is not sensitive to the action of acetylcholine. Dosage adjustment. (7) Choking. Reasons for timing. (2) Ptosis (dropping of one or both eyelids). one of three physiological abnormalities may exist: (a) There may be too much cholinesterase present. (1) Primary drug therapy (anticholinesterase drugs to enhance the action of acetylcholine at the myoneural junction). (2) Patient needs explicit instructions regarding medications.

as patient is still alert. Signs and Symptoms. Complications associated with Bell's palsy include facial weakness. endotracheal intubation. (5) Wear an eyepatch over one eye (alternating from side to side) if diplopia occurs. mechanical ventilation. (8) Instruct patient to inform dentist of myasthenia condition since Novocaine is usually poorly tolerated. surgery.(3) Have mealtimes coincide with peak effect of anticholinergics. (5) Provide ventilatory assistance. but the majority of patient's have experienced a viral upper respiratory infection 1 to 3 weeks prior to the onset of symptoms. . (6) Control factors which lead to fatigue. and blindness. if required. Management of the Crises of Myasthenia. when ability to swallow is best. since these conditions could be devastating to the myasthenic patient. Peripheral involvement of the 7th cranial nerve (facial nerve) produces weakness or paralysis of the facial muscles. (1) Myasthenic crisis may result from natural deterioration of the disease. (3) Cholinergic crisis may result from overmedication with anticholinergic drugs. (7) Support patient's fluid and nutritional needs. The cause of this condition is unknown. Numbness of face and tongue. as determined by patient's status and cause of the crisis. (6) Administer appropriate medications.    Distortion of face. (4) Patient must be placed in an intensive care unit for continuous monitoring of the patient's respiratory status. Cranial Nerve Disorders BELL'S PALSY a. Definition. upper respiratory infection. corneal ulceration. facial spasm with contracture. (9) Instruct patient to rest at frequent intervals and avoid fatigue. (2) Patient may be temporarily resistant to anticholinesterase drugs or need increased dosage. (7) Emphasize importance of avoiding contact with individuals with colds or respiratory infections. emotional upset. (8) Give continued psychological support during crisis period. Bell's Palsy is a cranial nerve disorder characterized by facial paralysis. d. as ordered and indicated by patient's condition. (4) Obtain medic alert bracelet signifying that patient has myasthenia gravis. or steroid therapy. Overflow of tears down the cheek from keratitis caused by drying of cornea and lack of blink reflex. b.

particles. Trigeminal neuralgia. is a disorder of the 5th cranial nerve (trigeminal nerve).) (f) Instruct patient to wear protective glasses to further protect eye and decrease normal evaporation of moisture from eye. (5) Facial massage may be prescribed to help maintain muscle tone. Decreased tear production that may predispose to infection. (c) Increase environmental humidity. severe pain appearing without warning. (a) If blink reflex is absent.  c.) (4) Provide for pain relief with analgesics and local application of heat. (3) Attacks provoked by pressure on a "trigger point" (the terminals of the affected branches of the trigeminal nerve). (2) Prevent or minimize denervation. (b) Surgical correction of eyelid deformities. also known as Tic Douloureux. b.) (2) Numerous individual flashes of pain. (1) Sudden. eye is vulnerable to dust and foreign (b) Instill artificial tears (methylcellulose) to protect the cornea. Speech difficulty secondary to facial paralysis. as ordered. Definition. Such triggers include: . (6) Surgical intervention may be necessary. Signs and Symptoms. ending abruptly and usually on one side of the face only. TRIGEMINAL NEURALGIA a. (1) Maintain muscle tone of the face. (d) Instruct patient to close affected eye frequently using accessory (e) Instruct patient to wear a protective patch at night. (May reduce inflammation and edema and restore normal blood circulation to the nerve. (Along one or more branches of trigeminal nerve. (a) Decompression of facial nerve. Nursing Care Considerations. (Keep in mind that patch may eventually abrade cornea as paralyzed eyelids are difficult to keep closed. The pain alternates with periods of complete comfort. (7) Protect the involved eye. (3) Administer steroid therapy. facial muscles. It is characterized by sudden paroxysms of burning pain along one or more of the branches of the trigeminal nerve.

(b) Talking. (d) Chewing gum. They may cause compression of brain tissue." They may be dangerous if they overlie vascular structures. . Head injuries are generally categorized as direct and indirect. A direct blow to one side of the skull causes the brain to be jarred inside the skull. Head and Spine Injuries HEAD INJURIES a. (b) Avoids drafts and breezes. c. (b) Cold wind. For example. Brain Damage. (c) Yawning. (2) The type of impact. Brain damage resulting from a head injury is dependent upon: (1) The force of impact. In either case. (3) Linear skull fractures are "cracks. (3) Surgical procedures to sever the affected nerve provide optimum pain relief with minimum impairment. (1) Instruct patient to avoid exposing affected cheek to sudden cold if this is known to trigger the nerve. the underlying brain tissue may be damaged. d. b. (2) Depressed skull fractures may be open or closed. (4) Instruct patient in methods to prevent environmental stimulation of pain. as ordered.(a) Shaving. Hematomas are a result of bleeding within the closed compartment of the skull. c. (c) Swimming in cold water. avoid: (a) Iced drinks. Hematomas. (3) The location of impact. (e) Cold wind. Direct and Indirect Head Injuries.    (1) Direct injuries result from a direct blow to the head. (b) Serum blood levels of drug are monitored in long term use. (3) Coup-contrecoup. (1) Basilar skull fractures are potentially serious injuries due to the proximity of the brain stem. (2) Indirect injuries result from the brain being jarred against the interior of the skull. (a) Tegretol or Dilantin--relieves and prevents pain in some patients. causing an indirect injury on the side opposite the direct blow. Care Considerations. (2) Administer drug therapy. (a) Eat foods that are easily chewed and are served at room temperature. Skull Fractures. This phenomenon is a combination of direct and indirect injury. A skull fracture is a break in the continuity of the skull bones or a separation of the sutures.

the foramen magnum). (a) May occur over a period of minutes. (d) Confusion. or days. Rapid or prolonged increases in an intracranial pressure present a serious threat to life. Irreversible neurological damage or death will result. (b) Pupil on the affected side may be nonreactive. c. The cranium is a closed cavity filled with contents that are virtually noncompressible. Signs and Symptoms of Increased Intracranial Pressure. position the patient on his side to decrease the possibility of airway occlusion. or space-occupying lesions. (e) Decreased pulse rate (may be increased initially). (2) Headache--increases in severity with coughing.) Permanent damage may result. Concussion. (f) Decreased respiratory rate (may be irregular). (d) Elevation of blood pressure with a widened pulse pressure. (a) Accurately assess and document neurological status. (3) Subarachnoid hemorrhage/hematoma is caused by bleeding into the subarachnoid space. (b) If patient is not intubated. (c) Pupils may be unequal. prn. headache. (1) Monitor vital signs closely. and irritability. use oral or nasopharyngeal airway. pinpoint.(1) Epidural hematoma is caused by bleeding between the skull and the dura. (a) Intubation and hyperventilation may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm. The patient experiences a brief loss of consciousness followed by confusion. This increased pressure may result from edema. dilated. or straining at stool. Nursing Management. (c) Responsiveness ranges from alert and oriented to no response to stimuli. (b) Evaluation of alterations of consciousness is crucial since symptoms progress rapidly. (2) Maintain patent airway. disorientation. Definition. (1) Change in level of consciousness. Contusion. Concussion results from violent jarring of the brain against the interior of the skull. Once the pressure exceeds the accommodation point. or nonreactive. sneezing. e. (3) Vomiting. bleeding. f. (b) Characterized by a diminished response to environmental stimuli. INCREASED INTRACRANIAL PRESSURE a. the brain will herniate through weak points (for example. (4) Papilledema/pupil changes. hours. . b. (This bruising is the result of blood vessel rupture. Complete recovery is usual. (2) Subdural hematoma is caused by bleeding between the dura and the arachnoid membrane. The severe jarring of the brain causes bruising of the brain. restlessness. This injury is more serious than a concussion. and drowsiness may be signs of an impending change. (a) Edema and pressure of both the optic nerve and the oculomotor nerve at the point at which they enter the globe is caused by venous congestion resulting from increased intracranial pressure. trauma.

Family members of patients who return home following injury to the head should be instructed to return the patient to the hospital if any of the following problems occur. (6) Blurred or double vision.(c) Be aware that stimulation of coughing when suctioning increases intracranial pressure and may precipitate seizure activity.V. (c) Dilantin (as a precautionary measure to prevent seizure activity). (7) Maintain normal body temperature. (b) Under no circumstances should patient's head be lower than the body. (11) Convulsions. d. to decrease cerebral edema). solutions as ordered. Facts about Spinal Cord Injuries. (a) Promotes return of venous blood. (4) Slurred speech. (b) Secure a tongue blade to the head of the bed for easy access. (3) Administer medications as ordered. (6) Protect patient from injury should seizures occur. for temperature over 102ºF. (12) Unconsciousness SPINAL CORD INJURIES a. (b) Fluids will be restricted to reduce intracranial pressure. . (d) Antibiotics. (b) Corticosteroids (to reduce cerebral edema). (b) Monitor rectal temperature frequently. (4) Elevate head of bed (30º). (7) Unequal pupil size. (a) Dextrose in water (hypotonic) crosses the blood-brain barrier and increase cerebral edema and intracranial pressure. (3) Vomiting. (a) Mannital (osmotic diuretic. (9) Increased sleepiness. (2) Pulse less than 50 beats per minute. as ordered. (5) Administer hypertonic I. (8) Blood or fluid discharge from ears or nose. (a) Pad side rails. (10) Inability to move extremities. (1) Fever greater than 100ºF. (c) Accurate intake and output records must be kept. Patient Education. (c) Place patient on hypothermia blanket. (a) Intracranial bleeding is frequently accompanied by increases in body temperature that are resistant to antipyretic agents. (5) Dizziness.

(1) Objectives of care: (a) Reduce the fracture/dislocation and obtain immobilization of the spine as soon as possible to prevent further cord damage. (2) Maintain patient on a turning frame or Circo-lectric bed to maintain spinal alignment. hard-contact sports). (a) Damage to the cord may be a concussion. (2) Common locations of spinal cord injuries. (3) Patient with cervical spine injury will have some form of skeletal traction. (e) Industrial accidents. (4) Loss of sweating and vasomotor tone below the level of the cord injury. (a) Flexion-extension injuries are commonly located at C4 . seen with rapid deceleration injuries. T12. (a) Flexion-extension: whiplash. painful erection of the penis. (4) Continuously observe patient's breathing pattern. (3) Loss of bowel and bladder control. (b) T11. stab wounds. or complete transection of the cord. contusion. (c) Falls. (6) Neck/back pain. (b) Athletic injuries (diving. (4) Pathophysiological changes associated with spinal cord injuries. (b) Injuries to the thoracic spinal cord below the level of T 1 will produce paraplegia--paralysis of the lower extremities. (c) Torsion: twisting of the spinal cord. (7) Priapism--persistent. c. (b) Subluxation: incomplete or partial dislocation.C7 ("whiplash"). (b) Observe strength of cough effort. (d) Gunshot wounds. (b Observe for symptoms of progressive neurological damage. (2) There will be total sensory loss and motor paralysis below level of the injury. (d) Compression. laceration. . (a) Cervical spinal cord injuries will produce quadriplegia--loss of function of all four extremities. ischemia. Maintain traction and provide nursing care IAW local policy. Medical and Nursing Management. (a) Patients with injuries at high levels are at risk for respiratory failure. and edema. compression. (1) Patient's symptoms will mirror the level of the cord injury. (5) Marked reduction of blood pressure due to loss of peripheral vascular resistance. (3) Mechanisms of spinal cord injury. usually urinary retention and bladder distention. b. and L1 are frequent sites of spinal cord injury resulting rom falls.(1) Common causes of spinal cord injuries include: (a) Automobile accidents. Signs and Symptoms. (b) Cord's response to injury includes hemorrhage.

(11) Provide constant encouragement and psychological support to the patient with a spinal cord injury. (2) Cerebral embolism. d. spinal shock may last for several weeks. resulting in neurological dysfunction. (1) Highly dependent upon size and site of lesion. shrug shoulders. Risk Factors Associated with Cerebral Vascular Accidents. (a) Spinal shock represents a sudden loss of continuity between the spinal cord and higher nerve centers. and autonomic activity below the level of the injury. (a) Program is designed according to neurological deficit. b. report changes in patient's motor/sensory level immediately to professional nurse. (9) Patient will require passive range of motion exercises. depending upon the injury and pathological findings. reflex. (d) Carefully record findings in patient's clinical record. (3) Cardiac disease (atherosclerosis. (b) It is characterized by a complete loss of motor. (7) If turning is allowed and patient is not on a turning frame or turning bed. (a) Test patient's motor ability by asking him/her to spread fingers. (2) Previous transient ischemic attacks. (b) Test sensory level by gently pinching the skin at shoulders and progressing down sides. valvular heart disease). c. etc. which may further compromise cord function. Disorders of the Brain CEREBRAL VASCULAR ACCIDENT a. grip your hands. (6) Be alert for signs of spinal shock and report immediately. may have to be performed to stabilize the spine before rehabilitation can begin. depending upon level of injury. Causes of Cerebral Vascular Accidents. Definition. (1) Hypertension. (8) Surgery. Signs and Symptoms. . (3) Stenosis of an artery supplying the brain. (4) Advanced age. arrhythmias. ascertain level at which patient can no longer feel pinch. (4) Cerebral hemorrhage--rupture of a cerebral blood vessel with bleeding/pressure into brain tissue. (c) Note presence/absence of sweating.(5) Continuously observe patient for motor and sensory changes due to cord edema or hemorrhage. (10) Assist with active rehabilitation procedures when patient is stable. (1) Thrombosis--blood clot within a blood vessel in the brain or neck. (b) Usually involves 6 weeks of gradual mobilization with brace or cast. (c) Though temporary. sensory. Cerebral vascular accident (CVA) (stroke) is the disruption of the blood supply to the brain. (5) Diabetes. the patient must be carefully log-rolled with the spine maintained in alignment.

(5) Maintain proper positioning/body alignment. (4) Continually reorient patient to person. then nasogastric tube feedings or oral feedings are begun depending upon patient's abilities. (2) Support airway. (e) Patient's vital signs--BP. (d) Place air mattress or alternating pressure mattress on bed and turn patient every two hours to maintain skin integrity. . pulse. headache with nausea and vomiting. the longer the coma. trochanter rolls. sand bags. e. (9) Increased intracranial pressure is a frequent complication resulting from hemorrhage or ischemia and subsequent cerebral edema. (c) Keep head of bed elevated 30º. the poorer the prognosis. (b) Intravenous fluids are maintained until patient's condition stabilizes. (a) Receptive aphasia (inability to understand the spoken word). (7) Impairment of mental activity. (a) Level of consciousness may vary from lethargy. and then recover. (8) In most instances onset of symptoms is very sudden. Deterioration could indicate progression of the CVA. (c) Patient may experience sudden. (1) Objectives of care during the acute phase: (a) Keep the patient alive. month) even if patient remains in a coma. (f) Be particularly aware of changes in any of the above. (e) Generally. as ordered. (c) Patient's response to commands. or may be due to a neurological deficit. (3) Communication loss. (a) Fluids may be restricted in an attempt to reduce intracranial pressure (ICP). (6) Ensure adequate fluid and electrocyte balance. (b) Blood pressure may be severely elevated due to increased intracranial pr e ssure. (d) Patient may remain comatose for hours. (7) Administer medications. respirations. Confusion may be a result of simply regaining consciousness. and splints as necessary. (b) Expressive aphasia (inability to speak). (d) Movement and strength. and circulation. to deep coma. or as ordered. (b) Apply foot board. (3) Maintain neurological flow sheet with frequent observations of the following: (a) Level of consciousness. place. (b) Minimize cerebral damage by providing adequately oxygenated blood to the brain. to mental confusion. severe. (a) Prevent complications of bed rest. Medical and Nursing Management during the Acute Phase of Cerebral Vascular Accidents. breathing. and temperature. (b) Pupil size and reaction to light. to reduce increased intracranial pressure.(2) Motor loss--hemiplegia (paralysis on one side of the side) or hemiparesis (motor weakness on one side of the body). days. (6) Bladder impairment. or even weeks. (5) Sensory loss. and time (day. (4) Vision loss.

(6) Speech therapy. Rehabilitation of the Patient after a Cerebral Vascular Accidents. or outbursts of temper. (2) Process of setting goals for rehabilitation must include the patient. encouragement. as indicated by patient's condition. eating). (b) Instruct family to expect some emotional lability such as inappropriate crying. They must avoid doing things for the patient that he can do for himself. This increases the likelihood of the goals being met. if necessary. (b) Provide stool softeners to prevent constipation. (5) Individualized exercise program involving both affected and unaffected extremities is required.     Taking prescribed medications. Definition. Stopping smoking. (d) Anticoagulants. (b) Learning to become independent in activities of daily living (bathing. Reducing day-to-day stress. may be necessary. (a) Allow them to assist with care when feasible. (8) Counseling and support to family is an integral part of the rehabilitation process. (e) Sedatives and tranquilizers are not given because they depress the respiratory center and obscure neurological observations. (b) Antibiotics. bladder retraining is begun during rehabilitation. (c) Developing behavior patterns that are likely to prevent the recurrence of symptoms. (3) General rehabilitative tasks faced by the patient include: (a) Learning to use strength and abilities that are intact to compensate for impaired functions. (c) Seizure control medications. (9) Include patient's family and significant others in plan of care to the maximum extent possible. (7) Continuous revaluation of goals and patient's ability to meet the goals is required to maintain a realistic plan of care. (1) Multidisciplinary team is most frequently utilized. EPILEPSY a. and support are needed.(a) Anti hypertensives. An estimated 2 to 4 million persons in the United States are afflicted with epilepsy and more that half of those are under 20 years of age. Epilepsy is an abnormal electrical disturbance in one or more areas of the brain. (4) Specific teaching. (8) Maintain adequate elimination. Modifying diet. (c) Instruct family to be supportive and optimistic. but firm as well. f. dressing. . (b) Keep them informed and help them to understand the patient's condition. (a) A Foley catheter is usually inserted during the acute phase. (a) Both family and patient need direction and support in coping with intellectual and personality impairment. laughing. Straining at stool will increase intracranial pressure.

or olfactory hallucinations may also occur. (c) Urinary and fecal incontinence usually occur. It is related to the anatomical origin of the seizure. b. uncontrolled electrical discharges that produce a seizure or convulsion. . (2) Last only a few moments and individual has no recall of behavior. fatigue. causing jerking movements of the arms and legs. (e) Drug/alcohol toxicity. (3) Factors that may predispose a patient to epilepsy/seizures. (d) Preictal phase may or may not be present in all patients. visual. (c) Circulatory disorder. (3) Auditory. physiological. c. recurrent. (2) The underlying disorder may be structural. or cerebral anoxia). and warns the patient that a seizure is imminent. (c) Patient may experience headache. (e) Tonic activity is characterized by rigid contraction of the muscles. (a) Trauma to the head/brain. (4) May occur dozens of times per day. and nausea.) (1) Preictal phase.(1) The basic problem is thought to be an electrical disturbance in the nerve cells in one section of the brain. (d) Metabolic disorder (such as hypoglycemia. (1) Characterized by brief loss of consciousness. (a) Phase will vary in symptoms. Grand Mal Seizure. Followed by an "aura. jaws are tightly clenched. Psychomotor Seizure. (a) Loss of consciousness. (3) Postictal phase. (a) Consists of vague emotional changes (depression. (b) Skin may become cyanotic. (1) Different forms of seizure activity often appearing as irrational or odd behavior. confusion. (f) Clonic activity is characterized by alternate contraction and relaxation of muscles. eyelids may flutter. (f) Infection (meningitis/brain abscess). anxiety. breathing is spasmodic. (b) Brain tumor. hypocalcemia. (b) Lasts for minutes to hours. numbness). (Characterized by three phases. stroke. and there is slight movement of head and extremities. chemical. (b) Many patients fall into a deep sleep which may last for several hours." (2) Individual stares blankly. causing them to give off abnormal. Petit Mal Seizure. (2) Tonic-clonic phase. and tongue and inner teeth may be bitten. or a combination of all three. (d) Phase may last one or more minutes. or "blank spells. (3) More common in children. nervousness)." (c) Aura is usually a sensory "cue" (odor or sound) or sensation "cue" (weakness. d. such as removing one's clothing or purposeless behaviors such as smacking one's lips.

time. (b) Use during or after a seizure to clear the patient's airway. tongue.) (1) Seizures may start in one part of the body and move to another. (b) Initially. it is not a cure. (f) If patient is incontinent. (e) Check lips. Consciousness may not be lost. (5) Place a padded tongue blade and oral airway at the patient's bedside. (1) Objectives of care: (a) Determine and treat underlying cause of seizures if possible. (2) Extreme neurological emergency. g. (1) Series of grand mal seizures experienced by the patient without regaining consciousness. (3) Instruct patient to keep record of events surrounding his/her seizures (number. Tape them to the headboard or wall above the bed. (2) Institute and reinforce the importance of anticonvulsant drug therapy: (a) Drug therapy is a means of controlling the condition. (c) Loosen restrictive clothing (if not done during seizure).e. (Also called focal or marching seizures. change clothing and bedding with as little disturbance as possible. Medical and Nursing Management. (b) Do not forcibly restrain patient during seizure. (2) May be followed by a grand mal seizure. (b) Room lighting should be dim and noise kept to a minimum. Jacksonian Seizure. This provides easy emergency access. etc. (8) Essential steps necessary to protect the patient during a seizure. (6) Take the seizure prone patient's temperature with a rectal thermometer. blanket. (a) Keep bed flat and patient turned on his side until he is alert. (d) Check vital signs immediately following seizure and every 30 minutes (or as ordered) until patient is alert. sleep/eating patterns). (9) Essential steps necessary to ensure safety of the patient following a seizure. prevents possibility of patient biting an oral thermometer if a seizure should occur. dosage will have to be monitored and altered to provide maximum control with minimum side effects. (a) Check the equipment daily to be sure it is working properly. emotional. and inside of mouth for injuries. duration. (b) Prevent recurrence of seizures and therefore allow patient to live a normal life. (7) Set up suction equipment at the patient's bedside. . (c) Remove objects that may obstruct breathing or cause injury to patient. f. (d) Protect patient's head from injury with pillow. (4) Use of multidisciplinary approach to cope with social. and vocational pressures of the person with epilepsy. Status Epilipticus. (a) Turn patient on his side to provide for drainage of oral secretions. (3) May occur spontaneously or if anticonvulsant medications are suddenly stopped.

(f) Visual field defects. (1) Meticulous nursing management and care aimed at prevention of postoperative complications are imperative for the patient's survival. (b) Withholding of antiepileptic agents frequently precipitates seizure. (2) Monitor and record vital signs and neurological status accurately q2-4h. Lethargy. then experience a decrease in level of consciousness during this time. Confusion. (a) Postoperative cerebral edema peaks between 48 and 60 hours following surgery. or as ordered. and vital signs. (Tongue blade airway. length of seizure activity. Definition. Documentation. (7) Surgery (craniotomy) is performed to remove neoplasm and alleviate symptoms. (d) Alterations in mentation. (1) Document all precautions taken. Signs and Symptoms. (6) Administer all doses of steroids and antiepileptic agents on time. (3) Institute measures to prevent inadvertent increases in intracranial pressure. (1) A brain tumor is usually characterized by a progressive course of symptoms over a period of time. BRAIN TUMOR a. (2) Symptoms depend primarily on the location of the mass within the (3) Symptoms related to increased intracranial pressure will occur. (b) Patient may be lucid during first 24 hours. (c) Papilledema--edema of optic nerve. (a) Elevate head of bed 30º.h. location. (a) Decrease in level of consciousness. Seizures. circumstances. (4) Institute seizure precautions at patient's bedside. hearing). (1) Instruct patient and family about the necessity and importance of diagnostic tests to determine the exact location of the tumor. (2) Accurately monitor and record all vital signs and neurological signs. Aphasia. Post Operative Nursing Care Considerations. (b) Stool softeners to prevent straining at stool (which increases intracranial pressure). Vomiting. b. . Report changes to professional nurse immediately. (e) Hemiparesis. (2) Document all activity observed during a seizure. (3) Document any injury sustained during a seizure. (b) Headache. c.) (5) Supportive nursing care is given depending upon the patient's symptoms and ability to perform activities of daily living. A brain tumor is a localized intracranial lesion which occupies space with the skull and tends to cause a rise in intracranial pressure. (g) Sensory defects (smell. to include the time. d. Preoperative Medical and Nursing Management. (a) Withholding steroids can result in adrenal crisis.

.(3) Administer artificial tears (eye drops) as ordered. airway. and time. turning patient to the affected side. (b) Perform gentle chest percussion. (a) Increases of body temperature in the neurosurgical patient may be due to cerebral edema around the hypothalamus. as ordered. (12) Continuously talk to the patient while providing care. with the patient in the lateral decubitus position. (c) Place patient on hypothermia blanket.) (10) Maintain accurate record of intake and output. (9) Institute seizure precautions at patient's bedside. to prevent corneal ulceration in the comatose patient. if the flap has been removed. (8) Maintain body temperature. (b) Monitor rectal temperature frequently. place. if tolerated. (a) Cough and deep breath every 2 hours. (5) Bone flap may not have been replaced over surgical site. (Tongue blade. reorienting him to person. (11) Prevent pulmonary complications associated with bedrest. (4) Maintain skin integrity. (6) Maintain head of bed at 30ºelevation. can cause irreversible damage in the first 72 hours. (7) Perform passive range of motion exercises to all extremities every 2-4 hours.

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