NCM 116 (Lec)

MS 2 (Lec)
PROFESSOR Macoy
______________________________________________________________________________________________________________
PRELIMS

ASSESSING CLIENTS WITH NEUROLOGIC

DISORDERS

Anatomy and Physiology

● Nervous system divided into 2 regions:
1. Central nervous system (CNS): brain PERIPHERAL NERVOUS SYSTEM:
and spinal cord Spinal nerves, cranial nerves and their
2. Peripheral nervous system (PNS): branches
cranial nerves, spinal nerves and
autonomic nervous system
● Function of the nervous system are sensory
input, integration, motor output, homeostasis,
mental activity.

NERVOUS SYSTEM

● Involved in vital body functions such as the

control of HR, BP, and breathing

ORGANIZATION OF NERVOUS SYSTEM

CENTRAL NERVOUS SYSTEM:

BRAIN SPINAL CORD

CENTRAL NERVOUS SYSTEM: Brain

1
 vomiting,
coughing,
sneezing,
balance and
coordination
★ Pons
➢ Immediately
superior to the
medulla
oblongata
● Major regions are: ➢ Means “bridge”
- Diencephalon ➢ CN 5, 6, 7, 8
➔ Thalamus- largest part, ➢ Lower part of
influences mood and registers the pons:
an unlocalized, uncomfortable breathing,
perception of pain swallowing and
➔ Epithalamus- small area balance
superior and posterior to the ➢ Other nuclei in
thalamus, involved in the the pons control
emotional and visceral response functions such
to odors, pineal body (onset of as chewing and
puberty) salivation
➔ Hypothalamus- most inferior ★ Midbrain
part, important in maintaining ➢ Superior to the
homeostasis, plays a central role pons
in the control of body ➢ Smallest region
temperature , hunger and thirst, of the brainstem
plays a major role in controlling ➢ CN 3 and 4
the secretion of hormones from ➢ Found superior
the pituitary gland. and inferior
- Brainstem colliculus
➔ Connects the spinal cord to the ➢ Superior
remainder of the brain colliculi
➔ Consists of the medulla involved in
oblongata, pons, and midbrain visual reflexes,
★ Medulla Oblongata turning the
➢ Most inferior head, a sudden
portion of the loud noise,
brainstem bright flash of
➢ Continuous light
with the spinal ➢ Inferior
cord colliculi major
➢ Extends from relay centers for
the level of the the auditory
foramen nerve pathways
➢ magnum to the in the CNS
pons ➢ General
➢ CN 9, 10, 11, functions :
12 coordination of
➢ Specific eye movements
functions: and in the
regulation of control of pupil
HR and BV diameter and
diameter, lens shape
breathing, ➢ Contains a
swallowing, nuclear black

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 mass called temperature,
Substantia balance and
Nigra taste
➢ Principal
sensory area
(3,1,2)
★ Occipital lobe
➢ Functions in the
reception and
perception of
visual input
➢ Principal visual
cortex (17)
★ Temporal lobe
➢ Involved in
- Cerebrum olfactory
➔ Largest part of the brain (smell) and
➔ Divided into left and right auditory
hemisphere by a longitudinal (hearing)
fissures sensations and
➔ The surface of each hemisphere plays an
is wrinkled by presence of important role
eminences known as Gyri and in memory
furrows called Sulci or Fissures ➢ They associated
➔ Each cerebral hemispheres is in abstract
divided into lobes: thought and
★ Frontal lobes judgment
➢ Principal motor ➢ Primary
area (4) auditory cortex
➢ Important in the (41,42)
control of ➢ Wernicke’s area
voluntary motor (22) wernicke's
functions, aphasia
motivation, (receptive,
aggression, sensory, fluent,
mood, and posterior)
olfactory
(smell)
reception
➢ Broca's area
(44,45) Broca's
aphasia
(executive,
motor,
nonfluent,
anterior)
★ Parietal lobe
➢ Principal center - Cerebellum
for the ➔ Composed of gray matters
reception and ➔ Posterior and inferior to the
conscious cerebrum
perception of ➔ Involved in balance,
most sensory maintenance of muscle tone and
information, coordination of fine motor
such as touch, movements
pain,

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 ➔ Major function of the
cerebellum is that of comparator
➔ Also involves learning motor
skills (riding a bicycle/playing a
piano)

CENTRAL NERVOUS SYSTEM: Spinal Cord

● Spinal cord extends from the foramen magnum
to the 2 nd lumbar vertebra below which is the
cauda equina
● It has a central gray part organized into horns
and a peripheral white part forming nerve tracts
● Roots of spinal nerves extend out of the cord

● Consists of the nerves and ganglia located

outside the brain and spinal cord
● Divided into two groups:
- 12 pairs of CN
- 31 pairs of SN
● C8, T12, I5, S5, C1

PNS: Cranial Nerves

● 12 cranial nerves
● Designated by numerals from I to XII
● General categories:
- Sensory
- Motor
● Cranial nerves
- sensory I,II,VIII
- motor III, IV, VI, XI, XII
- mixed V, VII, IX, X

● Vertebral Column
- surrounds and protects the spinal cord
- 7 cervical, 12 thoracic, 5 lumbar, 5
sacral, coccyx (4 fused vertebra)

PERIPHERAL NERVOUS SYSTEM PNS: Spinal Nerves

● Arise along the spinal cord from the union of the
dorsal and ventral roots

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 AUTONOMIC NERVOUS SYSTEM
● Composed of: Sympathetic (flight or fight)
and Parasympathetic (rest and digest)

ANS: Sympathetic Nervous System

● They contain axons of both sensory and somatic
motor neurons
● Also contain parasympathetic and sympathetic
axons
● Originates from the T1 L2/L3 segments of the
spinal cord (thoracolumbar)
● Utilized by the body for FLIGHT and FIGHT
response
● Neurotransmitter agents are Epinephrine and
Norepinephrine (coming from the adrenal gland)
● ADRENERGIC system

SYMPATHETI PARASYMPATH
C ETIC
RESPONSES: RESPONSES:

HR ↑ ↓

RR ↑ ↓

BP ↑ ↓

Visual Acuity Pupillary Pupillary

(Pupillary Dilation constriction
Dilation)

Smooth Sphincters are Sphincters are

muscle tone contracted relaxed

Vasoconstriction Vasodilation

Metabolism ↑ glucose, ↑ ↓ glucose, ↓ fatty

fatty acids acids

Peristalsis ↓ ↑

Salivary ↓ ↑
secretions

Ejaculation Erection

ANS: Parasympathetic Nervous System

● Categorized by ● CHOLINERGIC system
the region of ● The vegetative system
vertebral column ● Feed and Breed responses
● 31 pairs (c8, t12, ● Cranio-sacral location
l5, s5, c1) ● Cranial nerves 3, 7, 9, 10 and S2 S4
● Organized into 3 ● Neurotransmitter is Acetylcholine
plexuses
UPPER MOTOR LOWER MOTOR

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NEURON LESIONS NEURON LESIONS

Loss of voluntary control Loss of voluntary control

↑ muscle tone ↓ muscle tone

Muscle spasticity Flaccid muscle paralysis

● Cerebrospinal Fluid
No muscle atrophy Muscle atrophy - Bathes the brain and spinal cord
- Protective cushion aound the CNS
Hyperactive and Absent or decreased
- Produced by the Choroid plexus of the
abnormal reflexes reflexes
lateral, third, and fourth ventricles
- Clear, colorless, SG of 1.007
Structures supporting the brain - In normal adult, approximately 500 ml
● Skull of CSF produced each day, all but 125 to
- Frontal bone 150 ml is absorbed by the villi
- Parietal bone - CSF Flow
- Temporal bone
- Occipital bone
● Meninges
- Surround and protect the spinal cord
- 3 layers
1. Dura mater
➢ Dural venous sinuses
➢ Epidural space (SC)

2. Arachnoid
➢ Subdural space (space
between dura mater and
arachnoid, contains
small amount of serous
fluid)

3. Pia Mater
➢ Tightly bound to the
surface of brain and SC ● Cerebral Circulation
➢ Subarachnoid space
(bet. Arachnoid and pia
mater, filled with CSF
and BV)
- Receives approximately 15% of the
cardiac output or 750 ml per minute
- Does not store nutrients and has a high
metabolic demand that requires high
blood flow
- Unique BF bec. It flows against gravity
- Poor collateral BF

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 - Two internal carotid arteries and two
vertebral arteries
- Empty into the dural sinuses

- Dendrite branch type structure with synapses for

receiving electrochemical messages
- Axon long projection that carries impulses away
from the cell body

● Neurotransmitters
- Acetycholine
- Dopamine
- Epinephrine and Norepinephrine
- GABA (inhibitory)
● Blood-Brain Barrier - Serotonin (↓ depression, ↑ manic)
- CNS is inaccessible to many substances - Glutamine (excitatory)
- Many substances cannot reach the
neurons of the CNS
- Formed by the endothelial cells of the
brains capillaries, which form
continuous tight junctions, creating BBB
to macromolecules
- Must filter through the capillary
endothelial cells and astrocytes
- Can be altered by trauma, cerebral
edema and hypoxia
● Neurons
- Basic functional unit of the brain
- Composed of a cell body, dendrite and
an axon

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 - 6=Normal
- obeys command
ASSESSMENT OF THE NEUROLOGIC - 5=Localizes pain
SYSTEM - 4=Withdraws to pain (Flexion)
● Physical Examination: 5 categories - 3=Decorticate posture
1. Cerebral function LOC, mental status - 2=Decerebrate posture
2. Cranial nerves - 1=None (flaccid)
3. Motor function
4. Sensory function CRANIAL NERVE FUNCTION
5. Reflexes
● Neuro check Cranial Nerve 1 Olfactory
- Level of consciousness ● Check first for the patency of the nose
- Pupillary size and response ● Instruct to close the eyes
- Verbal responsiveness ● Occlude one nostrils at a time
- Motor responsiveness ● Hold familiar substance and asks for the
- Vital signs identification
● History ● Repeat with the other nostrils
- A confused client becomes an unreliable ● PROBLEM ANOSMIA --“loss of smell”
source of history
● Physical assessment to collect objective data
Cranial Nerve 2 Optic
a. Unilateral neglect
b. Poor hygiene and grooming ● Check the visual acuity with the use of the
c. Abnormal gait and posture Snellen chart
d. Emotional swings, personality changes ● Check for visual field by confrontation test
e. Mask like appearance on face ● Check for pupillary reflex direct and consensual
f. Apathy ● Fundoscopy to check for papilledema

Cerebral Function Cranial Nerve 3, 4 and 6

● Assess the degree of wakefulness/alertness ● Assess simultaneously the movement of the
● Note the intensity of stimulus to cause a extra ocular muscles
response ● Deviations:
● Apply a painful stimulus over the nailbeds with - Opthalmoplegia inability to move the
a blunt instrument eye in a direction
● Ask questions to assess orientation to person, - Diplopia complaint of double vision
place and time
● Utilize the Glasgow Coma Scale
● An easy method of describing mental status and
abnormality detection
● Tests 3 areas eye opening, verbal response and
motor response
● Scores are evaluated range from 3 15
● No ZERO score
● 8 and Below= COMA!
- Eye Opening (E)
- 4=Spontaneous
- 3=To voice (when told to)
- 2=To pain
- 1=None (No response)
- Verbal Response (V)
- 5=Normal/oriented
Cranial Nerve 5 trigeminal
- 4=Disoriented/ CONFUSED
- 3=Words, but incoherent/ inappropriate ● Sensory portion assess for sensation of the facial
- 2=Incomprehensible/mumbled words skin
- 1=None ● Motor portion assess the muscles of mastication
- Motor Response (M) ● Assess corneal reflex

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 Cranial Nerve 7- Facial
● Sensory portion prepare salt, sugar, vinegar.
Place each substance in the anterior two thirds of
the tongue, rinsing the mouth with water
● Motor portion ask the client to make facial
expressions, ask to forcefully close the eyelids
Cranial Nerve 8 vestibulo auditory
● Test patient’s hearing acuity
● Observe for nystagmus and disturbed balance
Cranial Nerve 9 glossopharyngeal
● Together with Cranial nerve 10 vagus
● Assess for gag reflex
● Watch the soft palate rising after instructing the
client to say “AH”
● The posterior one third of the tongue is supplied
by the glossopharyngeal nerve
Cranial Nerve 11- Accessory
● Press down the patient’s shoulder while he
attempts to shrug against resistance
Cranial Nerve 12- hypoglossal
● Ask patient to protrude the tongue and note for
symmetry
ASSESS MOTOR FUNCTION
● Assess muscle tone and strength by asking
patient to flex or extend the extremities while
the examiner places resistance
● Grading of muscle strength
● Muscle Motor Grading:
- 5/5 normal active movement, full range
of motion against full resistance
- ⅘ active movement, full ROM against
moderate resistance
- ⅗ active movement, full ROM against
gravity
- ⅖ active movement, full ROM w/ gravity
eliminated (horizontal/side to side
- ⅕ palpable or visible contraction
- 0/5 no movement, total paralysis
Assessing the motor function of
the cerebellum
● Test for balance heel to toe
● Test for coordination rapid alternating
movements and finger to nose test
● ROMBERG’s is actually a test for the posterior
spinothalamic tract
Assessing the motor function of
the brainstem
● Test for the Oculocephalic reflex doll’s eye
- Normal response eyes appear to move
opposite to the movement of the head
- Abnormal eyes move in the same
direction
● Test for the Oculovestibular reflex
- Slowly irrigate the ear with cold water
and warm water
- Normal response cOld OppOsite, wArM
sAMe
Assessing the sensory function
● Evaluate symmetric areas of the body
● Ask the patient to close the eyes while testing
● Use of test tubes with cold and warm water
● Use blunt and sharp objects
● Use wisp of cotton
● Ask to identify objects placed on the hands
● Test for sense of position
Assessing the reflexes
● Deep tendon reflexes
- Biceps (C5 C6) Triceps (C6 C8)
Brachioradialis (C5 C6) Patellar
- Assessing the sensory function Achilles
● Superficial reflexes
- Abdominal (T9 T10) Cremasteric (L1
L2) Anal (S3 S5)
● Pathologic reflex
- Babinski stroke the lateral aspect of the
soles doing an inverted “J”
● DORSIFLEXION of the Big toe with fanning
out of the little toes
● Deep tendon reflex
- 0 absent
- + present but diminished
- ++ normal average
- +++ increased but not necessary
abnormal
- ++++ hyperactive or clonic
● Superficial reflex
- 0 absent
- +present
Abnormal Reflex
● Positive Brudzinski’s sign (pain, resistance,
flexion of hips and knees when head flexed to
chest with client supine) indicates meningeal
irritation
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● Positive Kernig’s sign (excessive pain and/or
resistance when examiner attempts to straighten
knees with client supine and knees and hips
Diagnostic Test
flexed) indicates meningeal irritation
a. Skull and spinal x ray
- identify fractures dislocation.
Compression, spinal cord problem
- Nursing Care
- provide nursing support for the confused
or combative patient
- maintain immobilization
- remove metal items
b. CT Scan
- detect intracranial bleeding, space
occupying lesion, cerebral edema.
Hydrocephalus, infarction
- Nursing Care
● Positive Babinski reflex (dorsiflexion of big toe a.) Assess for allergies
with fanning of other toes): UMN diseases of b.) Instruct to lie still and flat
pyramidal tract c. ) Inform pt that there may be hot,
flushed sensation and metallic taste in
the mouth
d.) Treat allergic reaction
c. Magnetic Resonance Imaging
- provides more detailed pictures
- Patients with pacemakers, orthopedic
metal prosthesis and implanted metal
devices cannot undergo this procedure
d. EEG
- Withhold medications that may interfere
with the results anticonvulsants,
● Decorticate posturing (upper arms close to sides, sedatives and stimulants
elbows, wrists and fingers flexes, legs extended - Wash hair thoroughly before procedure
with internal rotation, feet are flexed: body parts
pulled into core of body): lesions of Lumbar Tap
corticospinal tracts ● Contraindications
● Decerebrate posturing (neck extended with jaw - Unstable vital signs or cardiopulmonary
clenched, arms pronated, extended, close to compromise
sides, legs are extended straight out and feet - space occupying lesions
plantar flexed): lesions of midbrain, pons, - infections on the site
diencephalon - hematologic problems
● CSF obtained from LUMBAR Space bet. L4 &
L5
1. skin/superficial fascia
2. Ligaments
3. Epidural Space

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 4. Dura mater
5. Subdural space
6. Archnoid space
7. Subarachnoid space

NURSING CARE FOR CLIENTS WITH

DEGENERATIVE DISORDER & MOTOR
DYSFUNCTION
● Degenerative Disorder
- Demyelinating
➔ Multiple Sclerosis
➔ Guillain-Barre’ Syndrome
- NON-demyelinating
➔ Alzheimer’s disease
➔ Parkinson’s disease
● Motor Dysfunction
- Cranial Nerve
➔ Bell’s Palsy
➔ Trigeminal neuralgia
- Peripheral
➔ Myasthenia gravis
NON-demyelinating: Alzheimer’s Disease
● A progressive, irreversible, degenerative
neurologic disorder that affects the brain
resulting in cognitive impairments.
- Not exclusive in the elderly
- 1-10% occurs in middle age
● 7th decade of life
● Causes:
- Unknown
- Potential factors- amyloid plaques in the
brain, oxidative stress, neurochemical
deficiencies
● 3 stages:
➔ Mild/Early
- Amnesia
- Forgetfulness and have
difficulty retaining
information
- Word finding difficulty
- Poor abstract reasoning
- Perseveration
- “Floating around”
➔ Moderate
- Apraxia
- Aphasia
- Agnosia
- Agraphia
- Wandering
➔ Latent/Severe
- Fragmented memory loss
- Increase irritability
- Urinary and fecal incontinence
- Unresponsiveness or coma
● Clinical Manifestations
1. Forgetfulness
2. Recent memory loss
3. Difficulty learning
4. Deterioration in personal hygiene
5. Inability to concentrate
● Late clinical manifestations
6. Difficulty in abstract thinking
7. Difficulty communicating
8. Severe deterioration in memory,
language and motor function
9. repetitive action
10. personality changes
● Diagnostic Test:
- Health history = Neurologic
examination
- PET scan
- EEG, CT and MRI
- Other tests to rule out Vit B deficiencies
and hypothyroidism
- Autopsy is the most definitive
● Drug Therapy
1. drugs to treat behavioral symptoms-
antipsychotics
2. anxiolytics
3. Tacrine HCL(cognex) – first meds used,
1993
4. Donepezil (Aricept) – 2nd meds, 1997
5. Rivastigmine (Exelon) - 2000
● Nursing Interventions
1. Support cognitive function
new 2. Provide emotional support
3. Establish an effective communication
system with the patient and family
- Use short simple sentences,
words and gestures
- Maintain a calm and consistent
approach
- Attempt to analyze behavior for
meaning
4. protect the patient from injury
- Provide a safe and structured
environment
- Requests a family member to
accompany client if he wanders
around
- Keep bed in low position
- Provide adequate lightning
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 - Assign consistent caregivers =
nightlights are helpful
5. Encourage exercise to maintain mobility
6. Promoting independence in self-care
activities
- simplify daily activities by
organizing them into short,
achievable steps so that the
patient experience a sense of
accomplishment
Demyelinating: Multiple Sclerosis
● An auto-immune mediated progressive
demyelinating disease of the CNS
● The myelin sheath is destroyed and replaced by
sclerotic tissue (sclerosis)
● CAUSE- unknown
● Multiple factors- viral infection, environmental
factors, geographic location and genetic
predisposition
● Exacerbations and remissions
● Common in WOMEN ages 20-40
● Pathophysiology
- Sensitized T cells will enter the brain
and promote antibody production that
damages the myelin sheath
- Plaques of sclerotic tissues appear on
the demyelinated axons interrupting the
neuronal transmission
- The most common areas affected are
➢ Optic nerves and chiasm
➢ Cerebrum
➢ Cerebellum
➢ Spinal cord
- Eventually damage axons thus resulting
to permanent and irreversible damage
● Clinical Manifestations
1. Primary symptoms-
a. fatigue- throughout the course
b. depression – as reaction to
diagnosis
c. weakness, numbness, difficulty
in coordination, loss of balance
d. pain – occurs in 66% due to
demyelination of pain fibers
2. Visual disturbances – lesion in the optic
nerve
a. blurring of vision
b. Diplopia – initial sign
c. patchy blindness (scotoma)
d. total blindness
- CHARCOT’S TRIAD –
- Scanning speech
- Intentional tremors
- Nystagmus
3. Spasticity (muscle hypertonicity) of the
extremities and loss of abdominal
reflexes
4. Ataxia
5. Emotional lability and euphoria
6. Bladder, bowel and sexual dysfunction
● Diagnostic Tests
1. MRI- primary diagnostic study
2. CSF- Immunoglobulin G
● Nursing Interventions
1. Promote physical mobility
- Exercise
- Schedule activity and rest
periods
- Warm packs over the spastic
area
- Swimming and cycling are very
useful
2. Promote physical mobility
- Exercise
- Schedule activity and rest
periods
- Warm packs over the spastic
area
- Swimming and cycling are very
useful
3. Enhance bladder and bowel control
- Set a voiding schedule
- Intermittent bladder
catheterization
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 - Adequate fluids, dietary fibers
and bowel training program
4. Manage speech and swallowing
difficulties
- Careful feeding, proper
positioning, suction machine
availability
- Speech therapist
5. Improve Sensory and Cognitive function
- Vision- use eye patch for
diplopia
- Obtain large printed reading
materials
- Offer emotional support
- Involve the family in the care
6. Strengthen coping mechanism
- Alleviate the stress
- Referral to the appropriate
agencies ● Pathophysiology
7. improve self-care abilities ● Decreased levels of dopamine due to destruction
- Modify activities according to of pigmented neuronal cells in the substantia
physical strength nigra in the basal ganglia
- Provide assistive devices ● Clinical symptoms do not appear until 60% of
8. promote sexual functioning the neurons have disappeared
- Refer to sexual counselor
● Medical Management
❖ Pharmacotherapy
- Interferons beta 1a (Avonex)
and beta 1b (Betaseron),
Glatiramer Acetate (Copaxone),
Rebif
- “ABC and R drugs”
- Immunosuppressants to stabilize
disease process
- Corticosteroids to reduce edema
and inflammatory process
- BACLOFEN for muscle spasms
- NSAIDS for pain
- Antidepressants

NON-demyelinating: Parkinson’s Disease ● CLINICAL MANIFESTATIONS

1. Tremor- resting, pill-rolling, unilateral
● A slowly progressing neurologic movement
(70%)
disorder
2. Rigidity- cog-wheel, lead-pipe
● The degenerative idiopathic form is the most
3. Bradykinesia- abnormally slow
common form
movement
● CAUSATIVE FACTORS: unknown
- Postural Changes
● Potential factors: genetics, atherosclerosis, free
4. Dementia, depression, sleep
radical stress, viral infection, head trauma and
disturbances and hallucinations
environmental factors
5. excessive sweating, paroxysmal
● Parkinsonian symptoms occur in the 5th decade
flushing, orthostatic hypotension
of life
● Medications act by:
- Increasing striatal dopaminergic activity
- Reducing excessive influence of
excitatory cholinergic neurons on the
extrapyramidal tract to restore balance

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 between cholinergic and dopaminergic - Thymoma
activities. - Women suffer at an earlier age (20-40)
- Acting on neurotransmitter pathways compared to men (60-70) and are more
other than the dopaminergic pathway affected
● Medical management ● Pathophysiology:
1. Anti-parkinsonian drugs- Levodopa, 1. Acetylcholine receptor antibodies
Carbidopa interfere with impulse transmission
2. Anticholinergic therapy(Biperiden) 2. Follows an unpredictable course of
3. Antiviral therapy- Amantadine periodic exacerbations and remissions
4. Dopamine Agonists- bromocriptine and ● ASSESSMENT FINDINGS
Pergolide, Ropirinole and Pramipexole 1. Involves the ocular muscles
5. MAOI a. diplopia – double vision
6. Antidepressants b. ptosis – drooping of the eyelids
7. Antihistamine 2. Bulbar symptoms – weakness of the
● Pharmacologic muscles of the face and throat
- Cogentin – tremor and rigidity 3. Generalized weakness
- Artane – tremor and rigidity a. bland facial expression
- Parlodel/Permex useful in postponing b. dysphonia
L-Dopa c. decrease vital capacity
- Akineton ● PURELY MOTOR WITH NO EFFECT ON
- Benadryl - tremors SENSATION OR COORDINATION
- Eldepryl (MAOI) – inhibits dopamine ● DIAGNOSTIC TESTS
breakdown 1. EMG
- L – Dopa 2. TENSILON TEST (Edrophonium)
- S inemet/Symmetrel 3. CT scan
● NURSING INTERVENTIONS 4. Serum anti-AchReceptor antibodies
1. Improve mobility ● MEDICAL THERAPY
2. Enhance Self- care activities - Anticholinesterase drugs-
3. Improve bowel elimination ❖ Tension Pyridostigmine
4. Improve nutrition Neostigmine
5. Enhance swallowing ➔ SHOULD BE GIVEN
6. Encourage the use of assistive devices ON TIME
7. improve communication ➔ 30 MINS. BEFORE
8. Support coping abilities MEALS W/ MILK
9. Proper Diet AND CRACKERS TO
- low protein PREVENT CRISIS
- Excessive vitamin B6 intake - Corticosteroids
(pyridoxine) intake - Immunosuppressants
effectiveness of L-dopa - Plasmapheresis
- Sinemet can discolor urine and - Thymectomy
perspiration ● NURSING INTERVENTIONS
❖ Can increase urine 1. Administer prescribed medication as
glucose intake scheduled
2. Prevent problems with chewing and
MOTOR DYSFUNCTION- PERIPHERAL: swallowing
Myasthenia gravis 3. Promote respiratory function
● A sporadic, but progressive weakness and 4. Encourage adjustments in lifestyle to
abnormal fatigability of striated muscles which prevent fatigue
are exacerbated by exercise and repetitive 5. maximize functional abilities
movements 6. Prepare for complications like
● Autoimmune disorder affecting the myoneural myasthenic crisis and cholinergic crisis
junction 7. prevent problems associated with
● Characterized by varying degrees of weakness impaired vision resulting from ptosis of
of the voluntary muscles eyelids
● ETIOLOGY 8. provide client teaching
- Autoimmune disease 9. promote client and family coping

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 ● NURSING INTERVENTIONS
Demyelinating: Guillain-Barre' Syndrome 1. Maintain respiratory function
● An auto-immune attack of the peripheral nerve - Chest physiotherapy and
myelin incentive spirometry
● Acute, rapid segmental demyelination of - Mechanical ventilator
peripheral nerves and some cranial nerves 2. Enhance physical mobility
producing ascending weakness - Support paralyzed extremities
● POTENTIALLY FATAL! - Provide passive range of motion
● CAUSE: post-infectious polyneuritis of exercise
unknown origin commonly follows viral - Prevent DVT and pulmonary
infection (66%) embolism
● Assoc. with Gastrointestinal infection - Padding over bony prominences
(Campylobacter Jejuni) and respiratory infection 3. Provide adequate nutrition
● PATHOPHYSIOLOGY - IVF
- Cell-mediated immune attack to the - Parenteral nutrition
myelin sheath of the peripheral nerves - Assess frequently return of gag
- Infectious agent may elicit antibody reflex
production that can also destroy the 4. Improve communication
myelin sheath of the PERIPHERAL - Use other means of
NERVES!! communication
5. Decrease fear and anxiety
- Provide Referrals
- Answer questions
- Provide diversional activities
6. Monitor and manage complications
- DVT, Urinary retention,
pulmonary embolism,
respiratory failure
● MEDICAL MANAGEMENT
- ICU admission
- Mechanical Ventilation
- TPN and IVF
- PLASMAPHERESIS
- IV IMMUNOGLOBULIN

● Because this syndrome causes inflammation and
degenerative changes in the posterior and
anterior nerve roots, MOTOR and SENSORY
losses occur SIMULTANEOUSLY!
● CLINICAL MANIFESTATIONS: occurs 2 weeks
before symptoms begins
1. Ascending weakness and paralysis: Leg
affected first (1 month)
2. AREFLEXIA of the lower extremities
3. paresthesia
4. potential respiratory failure
5. blindness
6. bulbar muscle weakness
7. autonomic dysfunction
● Duration of symptoms are variable:complete
functional recovery may take up to 2 yrs.
● LABORATORY EXAMINATION
1. CSF protein level is INCREASED but
the WBC remains normal in the CSF
2. EMG and nerve conduction velocity
studies
MOTOR DYSFUNCTION- CN: Trigeminal
neuralgia
● Also called Tic Douloureux
● Condition of the 5th CN characterized by
paroxysms of pain
● Most commonly occurs in the 2nd and 3rd
branch
● CAUSES: NOT CERTAIN, chronic compression
or irritation of 5th CN
● 400x more common in MS
● Pain is more often cyclic
● Most often in the 5th decade of life
● Paroxsyms can occur with any stimulation of the
affected nerves, such as washing of face,
shaving, brushing the teeth, eating and drinking

15
● ASSESSMENT
1. Pain history (UNILATERAL)
2. Searing or burning jabs of pain lasting
from 1-15 minutes in an area innervated
by the trigeminal nerve
(shooting/stabbing)
● DIAGNOSTIC TESTS
- Skull x-ray or CT scan
● Medical management:
1. Carbamazepine (Tegretol)
- taken w/ meals
- serum levels must be monitored
- S.E. – nausea, dizziness,
drowsiness and aplastic anemia
2. Gabapentin (Neurontin)
● Surgical Management:
1. Microvascular decompression of the
trigeminal nerve
2. Percutaneous radiofrequency trigeminal
gangliolysis
● TRIGEMINAL RHIZOTOMY - surgical
treatment of choice
● NURSING INTERVENTIONS
1. provide emotional support
2. encourage to express feelings
3. provide adequate nutrition in small
frequent meals at room temperature
MOTOR DYSFUNCTION- CN: Bell’s Palsy
● PRESSURE PARALYSIS
● Causes:
1. infection
2. hemorrhage
3. tumor
4. local traumatic injury
● MANIFESTATIONS
1. Unilateral facial weakness
2. Mouth drooping
3. Distorted taste perception
4. Smooth forehead
5. Inability to close eyelid on the affected
side
6. Incomplete eye closure
7. excessive tearing when attempting to
close the eyes
8. Inability to raise eyebrows, puff out the
cheek
● Diagnostic tests
- EMG
● Medical management
1. Prednisone
2. Artificial tears
● Nursing Interventions
1. Apply moist heat to reduce pain
2. Massage the face to maintain muscle
tone
3. Give frequent mouth care
4. protect the eye with an eye patch. Eyelid
can be taped at night
5. instruct to chew on unaffected side
● Reassure that no stroke has occurred and
recovery occurs w/in 3-5 weeks
Huntington’s Disease (chorea)
● Progressive, degenerative inherited neurologic
disease characterized by increasing dementia
and chorea (rapid, jerky involuntary movements)
1. Cause unknown
2. No cure
3. Usually asymptomatic until age of 30 –
40
● Pathophysiology:
- involves destruction of cells in basal
ganglia and other brain areas, decrease
in acetylcholine
● Manifestations
16
 1. Abnormal movement and progressive
dementia
2. Early signs are personality change with
severe depression, memory loss; mood
swings, signs of dementia
3. Increasing restlessness, worsened by
environmental stimuli and emotional
stress; arms and face and entire body
develops choreiform movements,
lurching gait; difficulty swallowing,
chewing, speaking
4. Slow progressive debilitation and total
dependence
5. Death usually results from aspiration
pneumonia or another infectious process
● Collaborative Care: almost always requires
long-term care
● Diagnostic Tests: genetic testing of blood
● Medications
1. Antipsychotic (phenothiazines and
butyrophenones) to restore
neurotransmitters
2. Antidepressants
● Nursing Care
1. Very challenging: physiological,
psychosocial and ethical problems
2. Genetic counseling
● Nursing Diagnoses
1. Risk for Aspiration
2. Imbalanced Nutrition: Less than body
requirements
3. Impaired Skin Integrity
4. Impaired Verbal Communication
● Home Care: Referral to agencies to assist client
and family, support group and organization
Amyotrophic Lateral Sclerosis (ALS)
1. Progressive, degenerative neurologic
disease characterized by weakness and
wasting of muscles without sensory or
cognitive changes
2. Several types of disease including a
familial type; onset is usually between
age of 40 – 60; higher incidence in
males at earlier ages but equally post
menopause
3. Physiologic problems involve
swallowing, managing secretions,
communication, respiratory muscle
dysfunction
4. Death usually occurs in 2 – 5 years due
to respiratory failure
● Pathophysiology
1. Degeneration and demyelination of
motor neurons in anterior horn of spinal
cord, brain stem and cerebral cortex
2. Involves upper and lower motor neurons
3. Reinnervation occurs in the early course
of disease, but fails as disease
progresses
● Manifestations
1. Initial: spastic, weak muscles with
increased DTRs (UMN involvement);
muscle flaccidity, paresis, paralysis,
atrophy (LMN involvement); clients
note muscle weakness and fasciculations
(twitching of involved muscles);
muscles weaken, atrophy; client
complains of progressive fatigue;
usually involves hands, shoulders, upper
arms, and then legs
2. Atrophy of tongue and facial muscles
result in dysphagia and dysarthria;
emotional lability and loss of control
occur
3. 50% of clients die within 2 – 5 years of
diagnosis, often from respiratory failure
or aspiration pneumonia
● Collaborative Care
1. Evaluation to make the diagnosis
2. Referrals for home health support;
3. Client needs to make decisions
regarding gastrostomy tube, ventilator
support
● Diagnostic Test
1. Testing rules out other conditions that
may mimic early ALS such as
hyperthyroidism, compression of spinal
cord, infections, neoplasms
2. EMG to differentiate neuropathy from
myopathy
3. Muscle biopsy shows atrophy and loss
of muscle fiber
4. Serum creatine kinase if elevated
(non-specific)
5. Pulmonary function tests: to determine
degree of respiratory involvement
● Medications: Rilutek (Riluzole) anti glutamate
1. Prescribed to slow muscle degeneration
2. Requires monitoring of liver function,
blood count, chemistries, alkaline
phosphatase
● Nursing Care
1. Help client and family deal with current
health problems
2. Plan for future needs including inability
to communicate
● Nursing Diagnoses
1. Risk for Disuse Syndrome
2. Ineffective Breathing Pattern: may
require mechanical ventilation and
tracheostomy
17
● Home Care: Education regarding disease,
community resources for health care assistance
and dealing with disabilities

Creutzfeldt-Jakob disease (CJD, spongiform

encephalopathy)
● Description
1. Rapid progressive degenerative
neurologic disease causing brain
degeneration without inflammation
2. Transmissible and progressively fatal
3. Caused by prion protein: transmission of
prion is through direct contamination
with infected neural tissue
4. Rare in USA affecting persons 55 - 74
5. Variant form of CJD is “mad cow
disease”: believed transmitted by
consumption of beef contaminated with
bovine form of disease; none identified
in USA as of yet
6. Pathophysiology: spongiform
degeneration of gray matter of brain
● Manifestations
1. Onset: memory changes, exaggerated
startle reflex, sleep disturbances
2. Rapid deterioration in motor, sensory,
language function
3. Confusion progresses to dementia
4. Terminal states: clients are comatose
with decorticate and decerebrate
posturing
● Diagnostic Tests
1. Clinical pictures, suggestive changes on
EEG and CT scan
2. Similar to Alzheimers in early stages
3. Final diagnosis made on postmortem
exam
● Nursing Care
1. Use of standard precautions with blood
and body fluids
2. Support and assistance to client and
family

18

NURSING CARE OF CLIENTS WITH
INTRACRANIAL DISORDERS
Altered Level of Consciousness
● It is a function and symptom of multiple
pathophysiologic phenomena
● Not a disorder
● Causes: head injury, toxicity and metabolic
derangement
● Disruption in the basic functional units or
neurotransmitters results in faulty impulse
transmission
Level of Consciousness
● Awake, alert and responsive?
● Assess different LOCs:
1. Alert
- speak in a normal voice
- patient opens eyes, looks at you
and responds fully
appropriately to stimuli
2. Lethargy
- Speak in a loud voice
- Appears drowsy but opens the eyes
and looks at you, responds to
questions, and then falls asleep
3. Obtunded
- Shake patient gently as if
awakening the sleeper
- Opens the eyes and looks at you,
but responds slowly and is
somewhat confused
- Alertness and interest in the
environment are decreased
4. Stuporous
- Apply a painful stimulus
- Pinching a tendon
- Rubbing the sternum
- Roll a pencil across a nail bed
- Arouses from sleep after a painful
stimulus
- Verbal responses are slow or
absent
- Minimal awareness of self or
environment
5. Coma
- Apply repeated painful stimuli
- Remains unarousable with eyes
closed
- No evident response to inner need
or external
Assessment
● Orientation to time, place and person
● Motor function
● Decerebrate
● Decorticate
● Sensory function
● Patient is not oriented
● Patient does not follow command
● Patient needs persistent stimuli to be awake
1. Coma- clinical state of unconsciousness
where patient is NOT aware of self and
environment
2. Akinetic Mutism – state of
unresponsiveness to the environment in
which the patient makes no movement
and or sound but sometimes opens the eyes
3. Persistent Vegetative – condition in
which the patient is described as
wakeful but devoid of conscious
content, w/o cognitive or affective
mental function
● Behavioral changes initially
● Pupils are slowly reactive
● Then , patient becomes unresponsive and pupils
become fixed dilated
● Glasgow Coma Scale is utilized
Etiologic Factors
● Head injury
● Stroke
● Drug overdose
● Alcoholic intoxication
● Diabetic ketoacidosis
● Hepatic failure
Complications
● Respiratory failure
● Pneumonia
19
 ● Pressure ulcers
● Aspiration
● Deep vein thrombosis
● “ First priority of treatment is to obtain and
maintain a patent airway”
Nursing Interventions
1. Maintain patent airway
- Elevate the head of the bed to 30
degrees
- Suctioning
2. Protect the patient
- Pad side rails
- Prevent injury from equipments,
restraints and etc.
3. Maintain fluid and nutritional balance
- Input an output monitoring
- IVF therapy
- Feeding through NGT
4. Provide mouth care
- Cleansing and rinsing of mouth
- Petrolatum on the lips
5. Maintain skin integrity
- Regular turning every 2 hours
- 30 degrees bed elevation
- Maintain correct body alignment by
using trochanter rolls, foot board
6. Preserve corneal integrity
- Use of artificial tears every 2 hours
7. Achieve thermoregulation
- Minimum amount of beddings
- Rectal or tympanic temperature
- Administer acetaminophen as prescribed
8. Prevent urinary retention
- Use of intermittent catheterization
9. Promote bowel function
- High fiber diet
- Stool softeners and suppository
10. Provide sensory stimulation
- Touch and communication
- Frequent reorientation
Nursing Diagnosis
● Ineffective airway clearance related to altered
LOC
● Risk of injury related to decreased LOC
● Deficient fluid volume related to inability to take
fluids by mouth
● Risk for impaired skin integrity related to
immobility
Headache
● One of the most common ailments
● Generally classified into 3 categories:
a. migraine
b. tension
c. cluster
Causes of Headache are multiple:
1. Acute – SAH, hemorrhagic stroke, meningitis,
seizure, acutely elevated ICP, hypertensive
encephalopathy, post-LP, ocular dse., new
migraine headache
2. Subacute – temporal arteritis, intracranial
tumor, subdural hematoma, pseudotumor
cerebri, trigeminal/glossopharyngeal neuralgia,
postherpetic neuralgia, HTN
3. Chronic/episodic – migraine, cluster headache,
tension headache, sinusitis, dental dse., neck
pain
Evaluation: Headache
● Is the headache new or old?
● Characteristics? Intensity, quality, location,
duration
● Associated symptoms?
● Neurologic symptoms?
● If an SAH is suspected with negative head CT,
LP is mandatory
● CT w/out contrast
Migraine headache
● Most commonly affects women
● (+) family history
● Unknown cause but likely related to vascular
and brain neurotransmitters (serotonin)
● Triggers include: foods, fasting stress, menses,
OCP’s, bright-lights
● Assessment:
a. Gradual onset – severe unilateral
b. throbbing pain that may become
bilateral
c. lasts 4 to 72 hours
d. maybe preceded by sensory, motor, or
mood alterations (AURA)
e. nausea, vomiting and photophobia
Cluster headache
● Men > women
● Pathogenesis: increased histamine
● Assessment:
a. Pain is severe, unilateral, involving the
face, occurs on the same side and on the
same time of the day, sometimes at night
b. Attacks last 20 minutes to 2 hours
20
 c. Occurs in clusters of 2 to 8 weeks A. Supportive Care:
d. Associated with unilateral excessive 1. Reduce environmental stimuli
tearing, redness of the eye, nasal 2. To relieve tension headaches:
congestion, facial swelling, flushing and a. suggest light massage of tight
sweating muscles in neck, scalp, and
back
Tension headache b. apply warm, moist heat to areas of
muscle tension
● Most common type of headache diagnosed in c. teach progressive muscle
adults relaxation
● Result from irritation of sensitive nerve endings 3. Administer abortive and preventive
in the head, jaw and neck caused by prolonged medications as directed
muscle contraction 4. Encourage pt. to lie down and attempt to
sleep
● Assessment:
5. Encourage adequate nutrition, rest and
a. Dull, bandlike pain and pressure in the
relaxation
back of the head and neck, across
6. Review coping mechanisms and strengthen
forehead, bitemporal areas; dull
positive ones
persistent ache; tender spots of head and B. Education and health maintenance
neck 1. Teach proper administration of medications:
a. Sumatriptan – SC with
Collaborative Management: autoinjection for quick relief
or given orally
A. Therapeutic Interventions b. Oral And Nasal Formulations –
1. Non-pharmacologic: Relaxation 5HT agonist
techniques c. Ergotamine – metered dose
2. Avoidance of tyramine containing foods inhaler
(cheese or chocolates) 2. Teach patients about the adverse effects of
3. Identification of other triggers such as headache medications.
skipping of meals, intake of certain a. Ergot derivatives - numbness,
spices and preservatives, withdrawal coldness, paresthesias and
from caffeine pain of extremities
4. Inhalation of 100% o2 to abort cluster b. Sumatriptan – chest pain,
headache wheezing, swelling of lips and
B. Pharmacologic Interventions flushing
1. Aspirin, acetaminophen, nsaid’s c. Beta-adrenergic blocker & Ca
2. Antihistamines and decongestant channel – lightheadedness and
3. Methysergide, ergotamine, sumatriptan hypotension
4. Beta-adrenergic blockers, ca channel
blockers or antidepressants
5. Corticosteroids Intracranial Pressure
6. Opioid analgesics, muscle relaxants and
antianxiety 1. Pressure within cranial cavity measured within
lateral ventricles
Drug Alert: vasoconstrictors and 5HT 2. Transient increases occur with normal activities
agonists are contraindicated in patients coughing, sneezing, straining, bending forward
with uncontrolled HTN, CAD, 3. Sustained increases associated with
hemiplegic migraine and PVD a. Cerebral edema
b. Head trauma
Nursing Diagnosis: c. Tumors
d. Abscesses
● Acute pain e. Stroke
● Disturbed sensory perception f. Inflammation
● Ineffective coping g. Hemorrhage
● Nausea
Clinical Manifestations:
Nursing Interventions:
● Restlessness

21
 ● Headache Cerebral Response To Increased ICP
● n/v
● Altered consciousness ● Steady perfusion up to 40 mmHg
● Diplopia ● Cushing’s response
● Vital signs changes : Cushing Reflex - Vasomotor center triggers rise in BP to
- Systolic hpn increase ICP
- Bradycardia/ bradypnea - Sympathetic response is increased BP but
- Widened bp; elevated temp the heart rate is SLOW
- Respiration becomes SLOW
Monro-Kellie hypothesis
Clinical Manifestations
1. Within skull there are 3 components that maintain
state of dynamic equilibrium ● Early manifestations:
a. Brain (80%) - Changes in the LOC- usually the earliest
b. Cerebrospinal fluid (10%) - Pupillary changes- fixed, slowed response
c. Blood (10%) - Headache
2. If volume of any one increases the volume of others - Vomiting
must decrease to maintain normal pressure ● Late manifestations:
- Cushing reflex- systolic hypertension,
Normal Intracranial Pressure bradycardia and wide pulse pressure
bradypnea
1. 5 – 15 mm Hg, with pressure transducer with head - Hyperthermia
elevated 30 degrees - Abnormal posturing
2. 10-20mmHg (Brunner)
Nursing Interventions:
Background regarding regulation of ICP
● Maintain patent airway
A. Pathophysiology 1. Elevate the head of the bed 15-30 degrees-
- The cranium only contains the brain to promote venous drainage
substance, the CSF and the blood/blood 2. Assists in administering 100% oxygen or
vessels controlled hyperventilation- to reduce the
- Monro-Kellie Hypothesis- an increase in any CO2 blood levels --> constricts blood
one of the components causes a change in vessels --> reduces edema
the volume of the other 3. Administer prescribed medications- usually
- Any increase or alteration in these - Mannitol- to produce negative
structures will cause increased ICP fluid balance
- Compensatory mechanisms: - Corticosteroid- to reduce edema
1. Increased CSF absorption - Anticonvulsants- to prevent
2. Blood shunting seizures
3. Decreased CSF production - Contraindicated drugs:
- Decompensatory mechanisms: a. Opiates/ narcotics –
1. Decreased cerebral perfusion respiratory depression
2. Decreased PO2 leading to brain b. Benzodiazepines –
hypoxia hypotensive effects
3. Cerebral edema 4. Reduce environmental stimuli
4. Brain herniation 5. Avoid activities that can increase ICP like
valsalva, coughing, shivering, and vigorous
Cerebral Edema suctioning, enema, bending or stooping,
rectal examination.
● Abnormal accumulation of fluid in the intracellular 6. Keep head on a neutral position. AVOID-
space, extracellular space or both. extreme flexion, valsalva
7. Monitor for secondary complications
Herniation - Diabetes insipidus- output of >200
mL/hr
● Results from an excessive increase in ICP when the - SIADH
pressure builds up and the brain tissue presses down
on the brain stem.
Seizure Disorder

22
 ● Also known as convulsions, epileptic seizures, and if - Postictal phase: unconscious and
recurrent epilepsy. unresponsive to stimuli (UP TO
● Sudden alterations in normal brain activity that SEVERAL HOURS)
cause distinct behavior and body function
● Pathophysiology: Complications:
- Poorly understood but may be related to
metabolic and electrochemical factors at ● Status Epilepticus
the cellular level (fever, rapid withdrawal - Acute, prolonged, repetitive seizure activity
from alcohol, electrolyte imbalance, brain - Series of generalized seizures w/o return to
pathology) consciousness between attacks
- Continuous clinical or electrical seizures
Predisposing Factors lasting at least 5 minutes, even w/o
impairment of consciousness
1. Head or brain trauma
2. Tumors Febrile Seizures
3. Cranial surgery
4. Metabolic disorders ● Criteria:
5. CNS infections - Age: 9 mos. To 5 yrs.
6. Circulatory disorders - Generalized tonic-clonic lasting not more
7. Drug toxicity/drug withdrawal states than 15 mins
8. Congenital neurodegenerative disorders - Onset of fever > 39°C within hours of the
seizure
Classified as: - Family history of BFC
- No neurologic deficit that would explain the
1. Partial seizures – INVOLVES 1 HEMISPHERE seizure
a. Simple Partial
- Motor, somatosensory an Diagnostic Tests
psychomotor symptoms w/o
impairment of consciousness ● Neurologic exam
- Can progress to complex partial ● EEG to confirm diagnosis and locate lesion
b. Complex Partial Seizures ● X-ray, MRI, CT scan identify any neurologic
- Manifest impairment of abnormalities
consciousness w/ or w/o simple ● Lumbar puncture may be done if infection suspected
partial symptoms ● CBC, electrolytes, BUN, blood glucose
- Can secondarily become ● ECG to determine cardiac dysrhythmias
generalized
2. Generalized seizures: involves both brain Therapeutic Interventions:
hemispheres; consciousness always impaired
a. Absence seizures (petit mal) ● Maintain good nutrition/sleep hygiene/avoid stress
- Characterized by sudden brief ● Ketogenic diet
cessation of all motor activity, a. Precisely calculated portions of CHON and
blank stare and unresponsiveness fats w/o CHO
often with eye fluttering b. IV fluids should be dextrose free, and all
- Lost of contact w/ environment for medications should be in sugar-free
5 to 30 secs. suspensions
- Resumes activity and is not aware
of seizure Pharmacologic:
b. Tonic-clonic seizures (GRAND MAL)
- Most common type in adults a. Antiepileptic drug
- Preceded by aura, sudden loss of 1. Phenobarbital (Luminal) - for partial and
consciousness generalized seizures (tonic-clonic)
- Tonic phase: rigid muscles, - Nursing considerations:
incontinence (LAST 30 TO 60 SECS.) 1.) Encourage good oral
- Clonic phase: altered contraction, hygiene
relaxation; eyes roll back, froths at 2.) Therapeutic range is 10 to
mouth (LAST SEVERAL MINUTES) 20 mcg/ml, administer IV
w/ normal saline

23
 3.) Watch-out SE: rash, - May attempt to excise tissue involved in
nystagmus, ataxia, seizure activity
drug-induced lupus, - EEG done during surgery to identify
anemia epileptogenic focus
2. Valproic Acid (Depakene)/Divalproex Na
(Depakote) – sole therapy for absence Care Of Client During a Seizure
seizures and adjunct therapy for partial and
generalized seizures ● Protect client from injury and maintain airway
- Nursing Considerations: ● Do not force anything into client’s mouth
1.) Liver function test and ● Loosen clothing around neck
platelet count should be
monitored monthly for at Health Promotion:
least 1st 6 months
2.) Take w/ food to minimize ● Stress the following to clients
adverse effect 1. Importance of medical follow-up, taking
3.) Avoid use w/ other CNS prescribed medications
depressants 2. Driving privileges are prohibited in clients
4.) Watchout SE: with seizure disorders; driver’s licenses are
hepatotoxicity, nausea reinstated after seizure free period and
and vomiting, abdominal statement from health care practitioner
pain, anemia, decreased 3. Client needs proper identification
WBC & platelet 4. Family members need to be educated in
3. Carbamazepine (Tegretol) – refractory preventing injury if seizure occurs
partial and generalized seizures
- Nursing Considerations: Nursing Diagnoses
1.) Use cautiously in patients
w/ existing cardiac, renal, ● Risk for Ineffective Airway Clearance
or liver probs. ● Anxiety
2.) Give w/ food
3.) Watch-out SE: dizziness, Home Care
nausea and vomiting, liver
dysfunction, anemia, ● Education of client and family regarding seizure
decreased WBC & platelet disorder; safety measures, avoidance of alcohol and
4. Gabapentin (Neurontin) – adjunct caffeine.
treatment of partial and secondarily ● Referral to support group, national organizations
generalized seizures
- Nursing Considerations:
1.) Serum levels not Trauma
necessary
2.) Watchout SE: somnolence, Mechanism of Trauma
dizziness, ataxia,
headache, tremor, ● Acceleration injury: head struck by moving object
vomiting, nystagmus, ● Deceleration injury: head hits stationary object
fatigue ● Acceleration-deceleration (coup-contrecoup
phenomenon): head hits object and brain rebounds
Nursing Interventions: within skull
● Deformation: force deforms and disrupts body
● Monitor the entire seizure event, including
integrity: skull fracture
prodromal signs, seizure behavior, and postictal state
● Monitor serum levels for therapeutic range of Basilar
medications
● Monitor pt. for adverse reactions of medications ● Involves base of skull and usually involve extension
● Monitor CBC, UA, and liver function of adjacent fractures
● If dura disrupted may have leakage of CSF occurring
Surgery: as:
- Rhinorrhea: through nose
● If all attempts to control seizures are not successful
- Otorrhea: through ear

24
CNS Infections ● Less severe, benign course with short duration
● Intense headache with malaise, nausea, vomiting,
● Most common is bacterial meningitis lethargy
● Mortality rate 25% in adults ● Signs of meningeal irritation
● Meningococcal occurs in epidemics with people
living in close contact Encephalitis
● Pneumococcal effects very young and very old
● Acute inflammation of parenchyma of brain or spinal
RIsk Factors cord
● Usually caused by virus
● High risk for old and young ● Inflammation occurs with manifestations similar to
● High risk for clients with debilitating diseases, or meningitis
immunosuppressed ● LOC deteriorates and client may become comatose
● Pathophysiology ● Arboviruses are agents including West Nile virus
- Pathogens enter CNS and meninges causing
inflammatory process, which leads to Brain abscess
inflammation and increased ICP
- May result in brain damage and ● Infection with a collection of purulent material
life-threatening complications within brain tissue usually in cerebrum
● Causes include open trauma and neurosurgery;
infections of ear, sinuses
● Common pathogens are streptococci, staphylococci,
bacteroids
Meningitis ● Becomes space-occupying lesion
● At risk for infection and increased ICP
● Manifestations
● Inflammation of pia mater, arachnoid, and
- General symptoms associated with acute
subarachnoid space
infectious process
● Spreads rapidly through CNS because of circulation
- Client develops seizures, altered LOC, signs
of CSF around brain and spinal cord
of increased ICP
● May be bacterial, viral, fungal, parasitic in origin
- Specific neurologic symptoms are related to
● Infection enters CNS though invasive procedure or
location
through bloodstream, secondary to another infection
● May be drained surgically, if considered feasible
in body
Collaborative Care
Bacterial Meningitis
● Bacterial meningitis: requires immediate treatment
● Causative organisms: Neisseria meningitis,
and isolation of client
meningoccus, Streptococcus pneumoniae,
● Viral meningitis: supportive treatment and
Haemophilus influenzae, E. Coli
management of client symptoms
● Risk factors: head trauma with basilar skull fracture,
● Brain abscess treatment focuses on antibiotic
otitis media, sinusitis, immunocompromised,
therapy
neurosurgery, systemic sepsis
● Manifestations:
Diagnostic Tests
- Fever chills
- Headache, back and abdominal pain
● Lumbar puncture: definitive test for bacterial
- Nausea and vomiting
meningitis demonstrating infection: turbid cloudy
- Meningeal irritation: nuchal rigidity, positive
appearance, increased WBC, gram stain, culture
Brudzinski’s sign, Kernig’s sign, photophobia
● CT scan, MRI
- Meningococcal meningitis: rapidly
spreading petechial rash of skin and mucous
Medications
membranes
- Increased ICP: decreased LOC, papilledema ● Meningitis: immediate treatment with effective
● Complications antibiotics for 7 – 21 days; according to culture
- Arthritis results; dexamethasone to suppress inflammation
- Cranial nerve damage (deafness) ● encephalitis: viral treated with anti-viral medications
- Hydrocephalus

Viral meningitis

25
 ● Brain abscess: antibiotic therapy, which may include - Vomiting
intraventricular administration; anticonvulsant - Manifestations associated with cerebral
medications, antipyretics edema, increased ICP, cerebral ischemia
leading to brain herniation syndromes
Health Promotion
Collaborative Care
● Vaccinations for meningococcal, pneumococcal,
hemophilic meningitis ● Effective treatment includes chemotherapy, radiation
● Prophylactic rifampin for persons exposed to therapy, and/or surgery
meningococcal meningitis ● Treatment depends on size and location of tumor,
● Mosquito control type of tumor, neurologic deficits, and client’s over
● Prompt diagnosis and treatment of clients with all condition
infections
● Asepsis care for clients with open head injury or Diagnostic Tests
neurosurgery
● CT scan or MRI: determine tumor location and extent
Nursing Diagnoses ● Arteriography
● EEG: information about cerebral function, seizure
● Ineffective Protection data
● Risk for Deficient Fluid Volume ● Endocrine studies if pituitary tumor suspected

Treatment

Home Care ● Medications: Chemotherapy, corticosteroids,

anticonvulsants
● Client education for future prevention ● Surgery
● Complete medications and treatment plan - Purposes include tumor excision, reduction,
or for symptom relief
- Craniotomy: location according to approach
Brain Tumor to tumor
- Radiation: Alone or as adjunctive therapy
● Growths within cranium including tumors of brain Nursing Care
tissue, meninges, pituitary gland, blood vessels
● May be benign or malignant, primary or metastatic ● Support during diagnosis and management through
● May be lethal, due to location (inaccessible to selected treatment
treatment) and capacity to impinge on CNS ● Nursing care involves interventions to deal with
structures altered LOC, increased ICP, and seizures
● In adults most common tumor is glioblastoma
followed by meningioma and cytoma Nursing Diagnoses
● Cause is unknown: factor associated include
heredity, cranial irradiation, exposure to some ● Anxiety
chemicals ● Risk for Infection
● Tumors within brain ● Ineffective Protection
- Compress or destroy brain tissue ● lAcute Pain
- Cause edema in adjacent tissues ● Disturbed Self-esteem
- Cause hemorrhage
- Obstruct circulation of CSF, causing Home Care
hydrocephalus
● Estimated 25% persons with cancer develop brain ● Education, support to client and family
metastasis, often multiple sites throughout the brain ● Instructions for treatment plan and follow-up care
● Referral to home care agencies
Manifestations: ● Referrals to therapies, community resources, support
groups as appropriate
● Multiple depending on location of lesion and rate of
growth
- Changes in cognition and LOC
- Headache usually worse in morning
- Seizures

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 ● The stroke continuum
- TIA- transient ischemic attack, temporary
neurologic loss less than 24 hours duration
- Reversible Neurologic deficits- s/sx last
more the 24 hrs. resolve in days w/o
permanent neurologic deficit
- Stroke in evolution- worsening of neuro s/sx
over several minutes or hours
- Completed stroke- indicates no further
progression of the hypoxic insult
● General manifestations

NURSING CARE OF CLIENTS WITH

CEREBROVASCULAR ACCIDENT Localization

● Anterior cerebral artery:

Cerebrovascular Accidents
- Weakness
- Numbness on the opposite side
● An umbrella term that refers to any functional - Personality changes
abnormality of the CNS related to disrupted blood - Impaired motor and sensory function
supply ● Middle cerebral artery:
● Similaraties between the 2 broad types, overall the - Aphasia
etiology, pathophysiology, medical & surgical - Dysphagia
management, and nursing care differs - HEMIPARESIS on the OPPOSITE side- more
● lCan be divided into two major categories severe on the face and arm than on the legs
- Ischemic stroke- caused by thrombus and ● Posterior cerebral artery:
embolus - Visual field defects
- Hemorrhagic stroke- caused commonly by - Sensory impairment
hypertensive bleeding - Coma
- Less likely paralysis

Cerebrovascular Accidents: Ischemic Strokes

● There is disruption of the cerebral blood flow due to

obstruction by embolus or thrombus

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 - Cardio disease
- Obesity
- Smoking
- Diabetes mellitus
- hypercholesterolemia

Pathophysiology Of Ischemic Stroke

● Disruption of blood supply

● Ischemic cascade (PENUMBRA REGION)
● Anaerobic metabolism ensues
● Decreased ATP production leads to impaired
membrane function
● Cellular injury and death can occur

Diagnostic Test

● CT scan – infarct vs. hge

● MRI- infarct, brainstem vs. cererebellum
● Angiography

Clinical Manifestations (Table 62.2 , p. 1890, 10th Ed.,p.

2208-2209, 11th Ed., p. 1898 12th Ed. Brunner)

● Numbness or weakness
● confusion or change of LOC
● motor and speech difficulties
● Visual disturbance
● Severe headache
● Motor Loss
- Hemiplegia
- Hemiparesis
● Communication loss
- Dysarthria- difficulty in speaking
- Aphasia- loss of speech
- Apraxia- inability to perform a previously
learned action
● Perceptual disturbances
- Hemianopsia
● Sensory loss
- Paresthesia

Comparison:

● Left Hemispheric
- Paralysis/weakness on the right side
- Right visual field deficit
- Aphasia
- Altered intellectual ability
Risks Factors - Slow, cautious behavior
● Right Hemispheric
● Non-modifiable - Paralysis/weakness on the left side
- Advanced age - Left visual field deficit
- Gender - Spatial-perceptual deficits
- Race - Increased distractibility
● Modifiable - Impulsive behaviour and poor judgement
- Hypertension
28
 - Lack of awareness of deficits
Patient Recovering From An Ischemic Stroke
A. Nursing Interventions: Acute
● Ensure patent airway
● Keep patient on LATERAL position
● Monitor VS and GCS, pupil size
● IVF is ordered but given with caution as not
to increase ICP
● NGT inserted
● Medications: Steroids, Mannitol (to
decrease edema), Diazepam
B. Nursing Interventions: Hospital
a. Improve Mobility and prevent joint
deformities
● Correctly position patient to
prevent contractures
● Place pillow under axilla
● Hand is placed in slight supination
● Change position every 2 hours
b. Enhance self-care
● Carry out activities on the
unaffected side
● Prevent unilateral neglect- place
some items on the affected side!!!
● Keep environment organized
● Use large mirror
c. Manage sensory-perceptual difficulties
● Approach patient on the
Unaffected side
● Encourage to turn the head to the
affected side to compensate for
visual loss
d. Manage dysphagia
● Place food on the UNAFFECTED
side
● Provide smaller bolus of food
● Manage tube feedings if prescribed
e. Help patient attain bowel and bladder
control
● Intermittent catheterization is
done in the acute stage
● Offer bedpan on a regular schedule
● High fiber diet and prescribed fluid
intake
f. Improve thought processes
● Support patient and capitalize on
the remaining strengths
g. Improve communication
● Anticipate the needs of the patient
● Offer support
● Provide time to complete the
sentence
● Provide a written copy of
scheduled activities
● Use of communication board
● Give one instruction at a time
h. Maintain skin integrity
● Use of specialty bed
● Regular turning and positioning
● Keep skin dry and massage
NON-reddened areas
● Provide adequate nutrition
i. Promote continuing care
● Referral to other health care
providers
j. Improve family coping
k. Help patient cope with sexual dysfunction
Medical Management
● Pharmacologic:
- Aspirin
- Diazepam to prevent seizures
- Thrombolytics
- Stool softeners
- Antihypertensives
- Analgesics, Muscle relaxants, STEROIDS
1. TIA/Mild stroke
- Non surgical approach
- Platelet inhibiting
medications
2. Thrombolytic therapy
- t-PA administration
- Eligibility criteria for t-PA
administration
- Should be done w/in 3
hrs.
- VS impt
- Bleeding- most common
S.E.
Eligibility Criteria For t-Pa Administration
● Age 18years and above
● Clinical diagnosis of Ischemic stroke
● Time of onset of stroke known and is 3 hours or less
● Systolic BP ≤ 185mmHg, diastolic ≤mmHg
● Not a minor stroke or rapidly resolving stroke
● No seizure at onset of stroke
● Not taking Warfarin (Coumadin)
● PTT ≤ secs. Or INR ≤ 1.7
● Not receiving heparin during the past 48 hrs. w/
elevated partial thromboplastin time
● Platelet ct. ≥ 100,000/mm
● No prior intracranial Hge, neoplasms, AV
malformation, or aneurysms
● No major surgical procedures w/in 14 days
● No stroke, serious head injury or intracranial surgery
w/in 3 mos.
● No gastrointestinal or urinary bleeding w/in 21 days
Ischemic Stroke Not Receiving t-Pa
● Reduce ICP
29
 ● Maintaining PaCO2 (30-35mmHg)
● Proper positioning
● intubation
● Continuous hemodynamic monitoring (<180/100)
● Neurologic assessment
● Anticoagulant
Cerebrovascular Accidents: Hemorrhagic Stroke
● Normal brain metabolism is impaired by interruption
of blood supply, compression and increased ICP
● More sever deficits and longer recovery time
● Pathophysio depends on the cause
● Sudden and severe headache
Same neurologic deficits as ischemic stroke
● Most common cause is a leaking aneurysm in the
area of the circle of Willis or a congenital AVM
Unique Clinical Manifestations:
● Sudden, Unusually Severe Headache And Often Loc
● (+) Meningeal Irritation
● Visual Disturbances – Adjacent Of Oculomotor
Nerve
Diagnostic Tests
● CT scan
● Angiography – confirms the dx of an AVM
● MRI
● Lumbar puncture (only if with no increased ICP) –
causes brain herniation and rebleeding

● Loss of consciousness
● Meningeal irritation
● Visual disturbances

Intracerebral Hemorrhage

● Most common in patients w/ HPN and cerebral

atherosclerosis -causing rupture of the vessels
involve usually ARTERIAL
● Occurs most commonly in the cerebral lobes, basal
ganglia, thalamus and brainstem
● Arterial pathology, brain tumor and the use of meds
(oral anticoagulant, amphetamines, crack and
cocaine)

Intracranial (Cerebral) Aneurysm

Nursing Interventions
● Dilatation of the walls of a cerebral artery that
develops as a result of weakness in the arterial wall ● Optimize cerebral tissue perfusion
● Unknown ● Relieve Sensory deprivation and anxiety
● Usually happens in the bifurcation of the large Artery ● Monitor and manage potential complications
at the circle of willis
Medical Management:
Arteriovenous Malformation (AVM)
● Complete bed rest w/ elastic compression stockings
● Due to an abnormality in embryonal development ● Management of vasospams
that leads to a tangle of arteries and veins in the ● Surgical and medical treatment to prevent
brain w/o capillary bed
rebleeding
● (-) capillary beds leads to dilation of the AV and
eventual RUPTURES Complications:
● Cause of He in young adult
● Rebleeding
Subarachnoid Hemorrhage ● Cerebral hypoxia
● Vasospasms
● May occur as a result of an AVM, intracranial
aneurysms, trauma, or HPN
● Increased ICP
● Systemic HPN

30

Acute Stroke
● Anticoagulant therapy
❖ Ordered for thrombotic stroke during
stroke-in-evolution
❖ Contraindicated in completed stroke
❖ Never used in hemorrhagic stroke
❖ Prevent further extension of clot ; Heparin,
warfarin sodium (Coumadin)
● Thrombolytic therapy: must be given within 3 hours
of onset of manifestations and will dissolve clot;
recombinant altephase (Activase rt-pa)
● Antithrombotic: inhibit platelet phase of clot
formation; contraindicated with hemorrhagic stroke
(aspirin, dipyidamole)
● Calcium channel blockers: reduce ischemic deficits,
death (Nimodipine (Nimotop))
● Corticosteroids: used to treat cerebral edema
● Diuretics: reduce increased intracranial pressure:
mannitol, furosemide
● Anticonvulsants: phenytoin (Dilantin)
Ancillary:
● Surgery
❖ Carotid endarterectomy: in clients who
have had TIAs
❖ Extracranial-intracranial bypass
● Physical therapy: prevents contractures, improves
muscle strength and coordination
● Occupational therapy: provides assistive devices and
plans for regaining lost motor skills
● Speech therapy: improves communication disorder
Nursing Diagnoses
● Ineffective Tissue Perfusion: Cerebral; frequent
monitoring of neurologic status, cardiac status
● Impaired Physical Mobility
● Self-care Deficit
● Impaired Verbal Communication
● Impaired Urinary Elimination and Risk for
Constipation
● Impaired Swallowing
Complications
● Motor Deficits
❖ Affects connections involving motor areas
of cerebral cortex, basal ganglia,
cerebellum, peripheral nerves
❖ Produce effects in contralateral side ranging
from mild weakness to severe limitation
❖ Hemiplegia: paralysis of half of body
❖ Hemiparesis: weakness of half of body
❖ Flaccidity: absence of muscle tone
(hypotonia)
❖ Spasticity: increased muscle tone usually
with some degree of weakness
❖ Affected arm and leg are initially flaccid and
become spastic in 6 – 8 weeks, causes
characteristic body positioning:
1. Adduction of shoulder
2. Pronation of forearm
3. Flexion of fingers
4. Extension of hip and knee
5. Foot drop, outward rotation of leg,
with dependent edema
Sensory-perceptual Deficits
● Hemianopsia: loss of half of visual field on one or
both eyes; homonymous hemianopia: same half
missing in each eye
● Agnosia: inability to recognize one or more subjects
that were previously familiar: includes visual, tactile,
auditory
● Apraxia: inability to carry out some motor pattern
even when strength and coordination is adequate
(e.g. getting dressed)
● Neglect syndrome (unilateral neglect): attention
disorder in which client ignores affected part of
body; client cannot integrate or use perceptions
from affected side of body or from environment on
affected side
Communication Disorders
● Usually result of stroke affecting dominant
hemisphere (left hemisphere dominant in 95%
right-handed persons; 70% left-handed persons)
31
● Aphasia: inability to use or understand language
❖ Expressive: motor speech problem; client
understands what is said but can only
respond verbally in short phases: Broca’s
aphasia
❖ Receptive aphasia: sensory speech problem
in which one cannot understand spoken or
written word; speech may be fluent but
with inappropriate content: Wenicke’s
aphasia
❖ Mixed or global aphasia: language
dysfunction in both understand and
expression
Traumatic Brain Injury
● Concussion
- Involves jarring of head without tissue
injury
- Temporary loss of neurologic function
lasting for a few minutes to hours
● Contusion
- Involves structural damage
- The patient becomes unconscious for hours
● Diffuse Axonal Injury
- Involves widespread damage to the neurons
- Patient has decerebrate and decorticate
posture
● Intracranial Hemorrhage
- Epidural Hematoma- blood collects in the
epidural space between skull and dura
mater. Usually due to laceration of the
middle meningeal artery
❖ Symptoms develop rapidly
- Subdural hematoma- a collection of blood
between the dura and the arachnoid mater
caused by trauma. This is usually due to tear
of dural sinuses or dural venous vessels
❖ Symptoms usually develop slowly
- Intracerebral Hemorrhage And Hematoma-
bleeding into the substance of the brain
resulting from trauma, hypertensive rupture
of aneurysm, coagulopahties, vascular
abnormalities
❖ Symptoms develop insidiously,
beginning with severe headache
and neurologic deficits
32
 Spinal Cord Injury

● The most frequent vertebrae – C5-C7, T12 and L1

● Concussion
● Contusion
● Compression
● Transection

Manifestations

● Altered LOC
● CSF otorrhea
● CSF rhinorrhea
● Racoon eyes and battle sign
- HALO SIGN- blood stain surrounded by a
yellowish stain

Nursing Management

● Monitor for declining LOC- use of Glasgow

● Maintain patent airway
- Elevate bed, suction prn, monitor ABG
● l Monitor F and E balance
- Daily weights
- IVF therapy
- Monitor possible development of DI and
SIADH
● Provide adequate nutrition Clinical Manifestations
● Prevent injury
- Use padded side rails ● Paraplegia
- Minimize environmental stimuli ● Quadriplegia
- Assess bladder ● Spinal shock
- Consider the use of intermittent catheter
● lMaintain skin integrity Diagnostic Test
- Prolonged immobility will likely cause skin
breakdown ● Spinal x-ray
- Turn patient every 2 hours
● CT scan
- Provide skin care every 4 hours
- Avoid friction and shear forces
● MRI
● Monitor potential complications Emergency Management
- Increased ICP
- Post-traumatic seizures
- Impaired ventilation
● A-B-C
● Immobilization
● Immediate transfer to tertiary facility

33
Nursing Intervention

● Promote adequate breathing and airway clearance

● Improve mobility and proper body alignment
● Promote adaptation to sensory and perceptual
alterations
● Maintain skin integrity
● Maintain urinary elimination
● Improve bowel function
● Provide Comfort measures
● Monitor and manage complications
❖ Thrombophlebitis
❖ Orthostatic hypotension
❖ Spinal shock
❖ Autonomic dysreflexia
● Assists with surgical reduction and stabilization of
cervical vertebral column

34