Neurology

Part I:
Anatomy & Physiology
Cells of the Nervous System
● Neuron
○ Transmits and receives electrical and chemical impulses
○ Cell body, dendrites, axon
○ Myelin sheath
■ Insulates and allows quick impulses

Synaptic Transmission
Lobes of the brain Occipital: Vision

Temporal: Memory, understanding language

Parietal: Perception, math, spelling, logic

Frontal: Thinking, planning, organizing, problem

solving, emotions, behavioral control, personality

Cerebellum: Balance

Medulla: HR, BP, reflexes (swallowing, vomiting)

*Language centers:
Broca’s area: expressive language
Wernicke’s area: receptive language
 Spinal Cord

Meninges
Connective tissue covering the CNS
Cerebrospinal fluid
A clear, odorless liquid found in your brain and spinal cord.
Cranial Nerves
T r a ve l e d And
I - Olfactory (smell)
, O h, O h , They Very
Oh rt Gu a rd i n g
II - Optic (vision)

V ol d e m o
III - Oculomotor (pupil constriction)
Found n t) H o r c r uxes
cie
Secret (An
IV - Trochlear (downward movement of eyes)

V - Trigeminal (jaw movement, sensation of face and neck)

VI - Abducens (lateral movement of eyes)

VII - Facial (facial movement, taste on anterior 2/3 of tongue)

VIII - Vestibulocochlear (hearing and balance)

IX - Glossopharyngeal (swallowing, taste on posterior 1/3 of tongue)

X - Vagus (swallowing, speaking)

XI - Spinal/Accessory (flexion and rotation of head)

XII - Hypoglossal (tongue movements)

Autonomic Nervous System

Neurologic Assessments
+ Symptoms
Cerebral Perfusion
● Blood flow to the brain
● Blood pressure in the body is what send blood up to the brain
● We MUST have a high enough BP to get blood to the brain…..
○ ….or it will not have oxygen!
○ ….and brain cells will start to die!

MAP > 60!

(for adults)

Intracranial Pressure
● The pressure inside of the skull
● Normal = 5-15
● Monro-Kellie hypothesis
○ The skull is a rigid container filled with: blood, brain, and CSF. If one of those three increases,
another must decrease.
● Causes of increased ICP:
○ Cerebral edema
○ Hemorrhage
○ Tumor growth
○ Excess CSF
● Works against BP…. pushing blood away from the brain!
○ High ICP = Less blood to the brain
Herniation
Protrusion of an organ through a
natural opening in a covering,
muscle, or bone.

There is SO much pressure, that

the brain tissue pushes through
the skull.
Posturing
Hydrocephalus
● Increased accumulation of cerebrospinal fluid
● Increases ICP
● Causes:
○ Tumor
○ Hemorrhage
○ Infection
○ Congenital

External Ventricular Drain (EVD)

VP Shunt

○ Ventricle - Space in the brain

○ Peritoneum - Serous membrane
lining the abdominal
compartment
○ Shunt that drains extra CSF
from brain to the abdomen,
where it can then be excreted
as urine.

Alterations in muscles
● Hypotonia ● Where is it happening?
● Hypertonia ○ Hemi
■ One side of the body
○ Para
● Paresis ■ Only the legs
○ Weakness in muscles ○ Quad
○ Also called ‘incomplete paralysis’ ■ All four extremities
● Paralysis
○ Inability to move muscles
Altered Movement
● Hyperkinesia
● Ataxia
○ Tremors
○ Poor muscle control causes clumsy
● Dyskinesias voluntary movements
○ Spasms
● Dyspraxia
○ Involuntary movements
○ Partial inability to perform purposeful
○ Tardive dyskinesia
or skilled motor acts
● Hypokinesia
● Apraxia
○ Bradykinesia: slow
○ Complete inability to perform
○ Akinesia: Absence
purposeful or skilled motor acts

Alterations in speech & language

● Dysphasia / Aphasia
○ Impairment in comprehension or production of language
■ Comprehension → Receptive → Wernicke's area
■ Production → Expressive → Broca’s area
■ Global = receptive + expressive
● Dysphagia
○ Difficulty swallowing
● Aphagia
○ Inability to swallow
Seizures
● Seizures are not a disease in themselves
● They are a symptom of an underlying disorder.
● Epilepsy
○ “A neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of
consciousness, or convulsions, associated with abnormal electrical activity in the brain.”
○ No other underlying disorder

Seizure Classifications/Terminology
Location:
● Partial - limited to a specific area of the brain
● Generalized - Involves the entire brain
● Simple - No loss of consciousness.
● Complex - Impaired consciousness ranging from confusion to non responsive

Movements:
● Tonic/Clonic - Phases of tonic and clonic spasm
● Myoclonic - sudden, brief contractions of a muscle or group of muscles
● Atonic
● Infantile spasms
● Petit Mal
● Absence - Loss of consciousness; staring off into space.
Treatment
● Anticonvulsants
○ Rapid acting - lorazepam
○ Long acting - phenytoin
● Very important to monitor for therapeutic levels
● Never stop taking suddenly - can cause a seizure

Seizure Precautions
NCLEX Question
Seizure precautions have been ordered for a client admitted to the psychiatric
unit. Which of the following nursing interventions is not appropriate when
initiating seizure precautions? Select all that apply.

A. Pad the side rails of the bed

B. Lower side rails while the client sleeps
C. Remove hard or sharp objects from the bed
D. Use four point restraints to prevent injury
E. Adhere a fall risk bracelet to the seizure prone client
F. Ask the family to monitor the client 24/7.

Answers: B, D, + F
The correct answers are B, D, and F. Padded bed rails should remain up while the client
sleeps. clients should be provided with a call light so that they may call for help if needed.
Four-point restraints are not appropriate for the seizing client and could result in injury. It is
not appropriate to ask the family to monitor the client 24/7

Choice A is incorrect. When initiating seizure precautions, the nurse should ensure that the
side rails are padded.

Choice C is incorrect. All sharp objects should be removed from a client's bed when
instituting seizure precautions.

Choice E is incorrect. clients prone to seizures should wear a fall risk bracelet to alert
members of the health care team to the client's need for increased supervision.
 Part II:
Neuro Pharmacology

Antianxiety Agents - Benzodiazepines

Short acting

● Midazolam | onset: rapid | duration 1-2 hours - quick on/ quick off

Intermediate acting

● Alprazolam | onset: intermediate | duration: 6-12 hours

● Clonazepam | onset: intermediate | duration: 18-50 hours
● Lorazepam | onset: rapid IV, intermediate PO| duration: 2-6 hours - medium on/long off

Long acting

● Diazepam| onset: rapid | duration: 20-50 hours - quick on/ long off
Anticonvulsants
● Phenytoin (Dilantin)
● Gabapentin
● Levetiracetam

Phenytoin
Therapeutic class: Anticonvulsant

Indication: Seizures

Action: blocks sustained high frequency repetitive firing of action potentials

Nursing Considerations:

● Therapeutic level: 10-20 mcg/mL

● Side effect: gingival hyperplasia
○ Regular dental check-ups
○ Use soft bristle toothbrush
● Antacids can reduce the effect of phenytoin and should be avoided.
Non-opioid Analgesics
● Acetaminophen
● NSAIDS
○ Acetylsalicylic Acid
○ Ibuprofen
○ Naproxen

Acetaminophen
Therapeutic class: antipyretic, non-opioid analgesic

Indication: Pain, fever

Action: Inhibit the synthesis of prostaglandins which play a role in transmission of

pain signals and fever response

Nursing Considerations:

● Max daily dose = 4g

○ For long term use - the maximum daily dose is only 3 grams per day!!
● Monitor liver function
● Antidote = n-acetylcysteine
NSAIDS - Non-steroidal anti-inflammatory drugs
Examples: Aspirin, ibuprofen, ketoprofen, naproxen

Indication: Pain, inflammation, fever

Action: Block prostaglandins which causes inflammation, pain, and fever.

Nursing Considerations:

● Can cause prolonged bleeding

○ Typically avoided in trauma and surgical clients
● Can cause peptic ulcers

Acetylsalicylic Acid (Aspirin)

Therapeutic class: Antipyretic, non-opioid analgesic

Indication: Pain - arthritis. Stroke and MI prophylaxis

Action: Inhibits the production of prostaglandins which leads to a reduction of

fever and inflammation, decreases platelet aggregation leading to a decrease in
ischemic diseases

Nursing Considerations:
● Risk of bleeding
○ Don’t administer with other anticoagulants
○ D/c 5-7 days prior to surgery
● Caution with pediatric clients
○ Reye’s syndrome can occur with viral infections
○ Only time it is commonly used in peds is in Kawasaki's disease
Opioids
● Morphine
● Fentanyl
● Hydromorphone
● Oxycodone

Morphine
Therapeutic class: Opioid analgesic

Indication: Pain

Action: Binds to opiate receptors in the CNS and alters perception of pain while
producing a general depression of the CNS.

Nursing Considerations:

● Common side effect: constipation

● CNS depressant
○ Decreased respiration, decreased heart rate, etc.
○ Monitor respiratory rate
● Antidote = naloxone
 Part III:
Neurological Disorders

Central Nervous System

Disorders
 Traumatic Brain Injury (TBI)
● Alteration in brain function caused
by an external source
● Fractures
○ Open
○ Closed
● Bleeds
○ Epidural
○ Subdural
○ Intracerebral
● Contusion
○ Coup
○ Contrecoup

Skull Fracture
● Open fracture → Torn dura
● Closed fracture → Dura is intact

● Basilar skull fracture

○ Battle’s sign → Bruising over the mastoid process
○ Raccoon eyes → Periorbital bruising
○ Cerebrospinal rhinorrhea
■ Test drainage for CSF
● Halo test
● Glucose
○ NEVER INSERT AN NG TUBE IN A CLIENT WITH A BASILAR SKULL FRACTURE
Dwayne Reed at English Wikipedia, Parasagittal MRI of human head in patient with benign familial macrocephaly prior to brain injury (ANIMATED), Modified by Morgan
Taylor, CC BY-SA 3.0
 Spinal Cord Injury
● Damage to the spinal cord causes permanent changes in strength, sensation and other
body functions below the site of the injury.
● Symptoms depend on location of the injury
● The higher the injury - the more function that is lost.
● Injuries above T6:
○ Monitor for autonomic dysreflexia

Autonomic dysreflexia
● Syndrome characterized by
○ Sudden severe hypertension
○ Bradycardia
○ Headache
○ Nasal stuffiness
○ Flushing
○ Sweating
○ Blurred vision
○ Anxiety
Treatment
1. Sit the client up to lower their BP
2. Antihypertensives
a. Hydralazine
3. Find the cause and treat
a. Full bladder? Cath
b. Constipated? Remove impaction
c. Pressure injury? Reposition
d. Painful stimuli? Remove stimuli
e. Cold room? Change the temperature
 Stroke

What is a stroke?
“A disease that affects the arteries leading to and within the brain. It is the No. 5 cause of death and a
leading cause of disability in the United States. A stroke occurs when a blood vessel that carries
oxygen and nutrients to the brain is either blocked by a clot or bursts”

…..There is a lack of oxygen to the brain, and that causes damage!

This lack of oxygen can be:

● Hemorrhagic
● Ischemic
○ Embolic
○ Thrombotic
Pathophysiology - Hemorrhagic stroke
● A vessel ruptures and bleeds
into the brain.
● As the blood accumulates, there
is increased pressure on the
brain
● The rupture can be caused by a
weakened vessel, such as in an
aneurysm.

“Worst headache of my life”

Pathophysiology - Ischemic stroke

● Blood flow to the brain is blocked by
a blood clot.
○ Thrombotic - a blood clot (thrombus) in an
artery going to the brain. Onset in a stepwise
fashion.
○ Embolic - a clot that’s formed elsewhere
(usually in the heart or neck arteries) travels in
the bloodstream and clogs a blood vessel in or
leading to the brain. Sudden onset!
● There is a loss of blood circulating to
this area of the brain.
● The lack of blood leads to a lack of
oxygen, causing ischemia and
damage.
Assessment
● Warning signs:
○ Balance
■ Dizzy → loss of balance
○ Eyes
■ Blurry vision
■ Abnormal pupil response
■ Hemianopia
● Facial droop
○ Unilateral
● Arms
○ Arm drift or weakness
● Speech
○ Aphasia
○ Dysphagia
○ Altered LOC/Confusion
NCLEX Question
You are working in the Emergency Department when a client with a suspected
stroke arrives. Which of the following essential nursing actions should the nurse
perform? Select all that apply.

A. Activate the stroke team

B. Check and treat the glucose
C. Order an immediate CT or MRI of the brain
D. Administer tPA
E. Administer morphine

Answers: A, B, and C
According to the AHA, the immediate general assessment and stabilization
should include: assess the ABCs and vital signs, provide oxygen as needed,
obtain an IV, check glucose and treat as needed, perform an essential neurologic
screening, activation of the stroke team, order an immediate CT or MRI of the
brain, and obtain an ECG. All of these actions should be included within the first
10 minutes after arrival at the ED. The decision of whether or not to give tPA will
depend on the results of the CT scan or MRI. If the provider determines that there
is no brain hemorrhage, the team should complete the fibrinolytic checklist before
deciding whether or not to give rtPA. Administering morphine is not a priority in a
suspected stroke.
Meningitis
● Inflammation of the spinal cord or brain
● Caused by a virus or bacteria
○ Bacterial is more dangerous

Assessment
● Nuchal rigidity
● Photophobia
● Kernig’s sign
● Brudzinski’s sign
 Kernig’s Sign

Brudzinski’s Sign

Treatment
● Steroids
● Analgesics
● Antibiotics - only if bacterial!!
● Isolation precautions
○ Viral - standard
○ Bacterial - standard
○ Hib or meningococcal - Droplet
● Prevention
○ Hib vaccine
○ Recommended for college students due to living in close quarters in dorms
Encephalitis
● Inflammation of the brain tissue
● Due to a viral infection
○ HSV most common
● Causes edema and necrosis
● Meninges are also inflamed

What is Multiple Sclerosis?

● Autoimmune disorder
● CNS inflammation
● Damages and degrades the myelin sheath surrounding neurons
○ Demyelination
Interventions
● No cure
● Corticosteroids
○ Decrease inflammation
● Plasmapheresis
Guillain-Barré
● Antibody and cell mediated immunologic reaction precipitated by a viral or
bacterial illness
● Immune system switches to attacking the nerves and demyelinates
peripheral nerves
● Causes ascending weakness and paralysis
● If ascends to the diaphragm can cause respiratory arrest

Assessment Findings
● Recent illness or infection
○ Ask about a GI bug…. Campylobacter jejuni is responsible for many GBS cases!
● Weakness or tingling in the lower extremities
● Increases in severity and moves up symmetrically
● As severity increases
○ Paralysis
○ Absent reflexes
○ Loss of muscle tone
○ Respiratory distress - requires intubation or trach
● Peaks in about 2 weeks
● Slow recovery
Treatment
● Client will gradually recover as antibodies clear
● Plasmapheresis
○ Filter blood and remove antibodies attacking the nerves
○ Helps symptoms
● Immunoglobulin therapy
○ Stops the antibodies that are attacking the myelin sheath

Peripheral Nervous System

Disorders
Neuropathy
“Weakness, numbness, and pain from nerve damage”

● There has been injury to the peripheral nerve

○ Injuries
○ Infections
○ Toxin exposure
○ Diabetes

Pain is often described as “pins and needles”, numbness, or weakness.

Botulism
● Botulinum toxin released by Clostridium botulinum
○ Found in soil and dust
○ Can contaminate honey
■ Children under 1 year old should never have honey
● Inhibits acetylcholine release at the junction between peripheral nerves and
muscles
● This causes life-threatening flaccid paralysis.
● Treatment: Antitoxin
Assessment Findings
● Blurry vision
● Difficulty breathing
● Respiratory failure
● Symmetric, descending flaccid paralysis

Myasthenia Gravis
● Autoimmune disorder
● Communication between nerves and muscles destroyed
● Diagnosis
○ Tensilon Test
Assessment
● Weak muscles
● Ptosis
○ Drooping eyelid

Interventions
● Cholinesterase inhibitors
● Corticosteroids
● Immunosuppressants
What is Parkinson's Disease?
● Progressive nervous system disorder.
● Caused by degeneration of dopamine neurons

Assessment findings
● Tremor
○ Usually starts on one side
● Rigidity
● Hypophonia
● Mask-like faces
● Akinesia: loss or impairment in power of voluntary movement
○ Bradykinesia
○ Dyskinesia
● Stooped posture
● Difficulty balancing
● Orthostatic hypotension
Interventions
● Fall risk
● No cure
● Therapy
○ PT
○ OT
SLP
● Carbidopa-levodopa.
○ Increase dopamine in the brain