NURSING MANAGEMENT

OF THE PATIENTS WITH

NEUROLOGICAL
DISORDERS
REVIEW OF ANATOMY OF
NERVOUS SYSTEM
 Nervous System
• Nervous system is the chief controlling and co-ordinating
system of the body.
• The human nervous system is very important in helping to
maintain the homeostasis of the human body.
• Nervous System consists of Central Nervous System which
contains brain and spinal cord and Peripheral Nervous
System
• It is the most complex system of the body.
• A series of sensory receptors work with the nervous system to
provide information about changes in both the external and
internal environments.
• The human nervous system is a complex of interconnected
systems in which larger systems are comprised of smaller
subsystems each of which have specific structures with specific
functions.
• Peripheral nervous system functionally has two components:
– Afferent component which provides sensory information to
CNS
– Efferent component which carries motor information to
muscles glands blood vessels and heart via SOMATIC
NERVOUS SYSTEM to control skeletal muscles and
AUTONOMIC NERVOUS SYSTEM for control of heart smooth
muscles, blood and glands. It is divided into Sympathetic And
Parasympathetic Nervous System
 FOUR PRIMARY FUNCTIONS OF
NERVOUS SYSTEM
1. Sensing the world
 Vision, Hearing, Smell, Taste,
Touch
2. Transmitting information
3. Processing information
4. Producing a response
 NEURONS
• Neurons are the structural and functional unit of brain. It is
divided into 3 parts as cell body, dendrites and axon
 CEREBRUM
• Largest part of the brain
• Also known as “PALLIUM”
• Occupies the anterior, middle cranial fossae and supra-
tentorial part of posterior cranial fossa.
• Made up of outer GRAY MATTER, inner WHITE MATTER and
some neuronal masses called BASAL GANGLIA within the white
matter.
 Spinal Cord
• The spinal cord is the most important structure between the
body and the brain. The spinal cord extends from the foramen
magnum where it is continuous with the medulla to the level of
the first or second lumbar vertebrae.
• It is a vital link between the brain and the body, and from the
body to the brain. The spinal cord is 40 to 50 cm long and 1 cm
to 1.5 cm in diameter. Two consecutive rows of nerve roots
emerge on each of its sides. These nerve roots join distally to
form 31 pairs of spinal nerves.
• The spinal cord is a cylindrical
structure of nervous tissue
composed of white and gray
matter, is uniformly organized
and is divided into four
regions: cervical (C), thoracic
(T), lumbar (L) and sacral (S)
 THE BRAIN STEM

•Brain stem is the part of brain between spinal

cord and diencephalon.
•Brain stem has 3 structures:
–Medulla Oblongata
–Pons
–Midbrain
 Cranial Nerves
• The 12 pairs of cranial nerves arise
from the brain inside the cranial cavity
and pass through various foramina in
the bones of the cranium.
• Divides into 3 functions: Sensory
nerves, Motor nerves and Mixed
nerves.
NEUROLOGICAL
ASSESSMENT
• Neurological disorders invovle the brain,
spinal cord, peripher roots, nerves and
muscles.
• Generally assessment involves two major
steps i.e., Subjective data and Objective
data
 SUBJECTIVE DATA: HISTORY COLLECTION
• Presenting complaint/Present
History
• Past History: Medical and Surgical
• Drug History
• Family History
• Socio Economic History
• Personal History
 OBJECTIVE DATA: PHYSICAL EXAMINATION
• A neurological examination requires to be
systematic.
• It icludes:
– General Physical Examination
– Mental status examination
– Cranial Nerve Assessment
– Reflex testing
– Motor System testing
 GENERAL PHYSICAL EXAMINATION
• Assess for vital signs
• HEAD: Look for any abnormality of the skull.
• SKIN: Rashes, infection, tumors, adenomas, melanomas.
• EYES: Unilateral proptosis, chemosis, keratitis, homonymous
hemianopsia.
• EAR, NOSE AND THROAT:
– EAR: Otitis media, hearing disability, ear infections, tenderness
– NOSE: DNS, infections, polyps
•THROAT: Tonsils, abscess, also assess for
oral cavity for dental infections.
• NECK: Assess for neck vein distention,
palpate for thyroid enlargement, Neck
stiffness, cervical lymphadenopathy.
• Examine Cardiovascular, respiratory,
digestive and renal system assessment.
 MENTAL STATUS EXAMINATION
• LEVEL OF CONSCIOUSNESS
• APPEARENCE
• BEHAVIOUR
• MOOD AND AFFECT
• THOUGHT AND PERCEPTIONS
• INSIGHT AND JUDGEMENT
• COGNITIVE FUNCTIONS
• SPEECH AND LANGUAGE
 CRANIAL NERVE EXAMINATION
ARTICLES REQUIRED:
• Tongue depressor
• Flashlight
• Sugar and salt samples
• Watch
• Cotton-tipped swab
• Snellen chart
• Ophthalmoscope
• Samples of familiar odors
• Tuning fork
 MOTOR ABILITY
• A thorough examination of the motor system includes an
assessment of muscle size and tone as well as strength,
coordination, and balance.
• The patient is instructed to walk across the room, if possible, while the
examiner observes posture and gait. The muscles are inspected, and
palpated if necessary, for their size and symmetry.
• Any evidence of atrophy or involuntary movements (tremors, tics) is
noted.
• Muscle tone (the tension present in a muscle at rest) is evaluated by
palpating various muscle groups at rest and during passive movement.
• Resistance to these movements is assessed and documented.
Abnormalities in tone include spasticity (increased muscle tone),
rigidity (resistance to passive stretch), and flaccidity.
 MUSCLE STRENGTH
• Assessing the patient’s ability to flex or extend the
extremities against resistance tests muscle strength.
• The function of an individual muscle or group of muscles
is evaluated by placing the muscle at a disadvantage.
The quadriceps, for example, is a powerful muscle
responsible for straightening the leg.
• Once the leg is straightened, it is exceedingly difficult for the
examiner to flex the knee. If the knee is flexed and the patient
is asked to straighten the leg against resistance, weakness can
be elicited. The evaluation of muscle strength compares the
sides of the body to each other.
• For example, the right upper extremity is compared to the left
upper extremity. Subtle differences in strength may be
evaluated by testing for drift.
• For example, both arms are out in front of the patient with
palms up; drift is seen as pronation of the palm, indicating a
subtle weakness that may not have been detected on the
resistance examination.
 5-point scale to rate muscle strength.
• 5 indicates full power of contraction against gravity and resistance or normal
muscle strength;
• 4 indicates fair but not full strength against gravity and a moderate amount of
resistance or slight weakness;
• 3 indicates just sufficient strength to overcome the force of gravity or
moderate weakness;
• 2 indicates the ability to move but not to overcome the force of gravity or severe
weakness;
• 1 indicates minimal contractile power (weak muscle contraction can be
palpated but no movement is noted) or very severe weakness;
• 0 indicates no movement.
 COORDINATION
• Cerebellar and basal ganglia influence on the
motor system is reflected in balance control and
coordination.
• Coordination in the hands and upper extremities is
tested by having the patient perform rapid,
alternating movements and point-to- point testing.
• First, the patient is instructed to pat his or her
thigh as fast as possible with each hand
separately.
• Then the patient is instructed to alternately
pronate and supinate the hand as rapidly as
possible.
 COORDINATION
• Last, the patient is asked to touch each of
the fingers with the thumb in a consecutive
motion. Speed, symmetry, and degree of
difficulty are noted.
• Point-to-point testing is accomplished by
having the patient touch the examiner’s
extended finger and then his or her own
nose. This is repeated several times.
 COORDINATION
• Coordination in the lower extremities is tested by
having the patient run the heel down the anterior
surface of the tibia of the other leg. Each leg is
tested in turn.
• Ataxia is defined as incoordination of voluntary
muscle action, particularly of the muscle groups
used in activities such as walking or reaching for
objects.
• Tremors (rhythmic, involuntary movements) noted
at rest or during movement suggest a problem in
the anatomic areas responsible for balance and
coordination.
 BALANCE /ROMBERG TEST
• Ask the clients stand still with their heels
together. Ask the clients to remain still and close
their eyes.
• Result: if the clients loses their balance after
standing still with their eye closed. This is positive
Romberg.
 GAIT TESTING
• To check ability to stand and walk:
• Ask the patient to walk across the room, turn, and come back
towards you. Pay particular attention to, difficult to walk and
indicate upper extremities weakness.
• Difficulty getting up from a chair, Can the patient easily arise from
a sitting position. Problems with this activity might suggest
proximal muscle weakness, a balance problem, or difficulty
initiating movements.
• Ask the clients to walk on heels is the most sensitive way to
test foot dorsiflextion.
 SENSORY FUNCTION

Position or
Temperature kinesthetic
Touch Pain sensation Vibration
sensation sensation (propriocep
tion)
 TOUCH SENSATION
• Tactile sensation is assessed by lightly touching a cotton
wisp or fingertip to corresponding areas on each side
of the body. The sensitivity of proximal parts of the
extremities is compared with that of distal parts, and
the right and left sides are compared.
 PAIN AND TEMPERATURE SENSATION
• Determining the patient’s sensitivity to a sharp object can assess
superficial pain perception.
• The patient is asked to differentiate between the sharp and dull ends of a
broken wooden cotton swab or tongue blade; using a safety pin is
inadvisable because it breaks the integrity of the skin.
• Both the sharp and dull sides of the object are applied with equal
intensity at all times, and the two sides are compared.
• Use the hot and cold object for skin to determine the hot and cold
sensation.
 VIBRATION AND PROPRIOCEPTION
• The handle of the vibrating fork is placed against a bony prominence,
and the patient is asked if he or she feels a sensation and is instructed
to signal the examiner when the sensation ceases.
• Common locations used to test for vibratory sense include the distal
joint of the great toe and the proximal thumb joint.
• If the patient does not perceive the vibrations at the distal bony
prominences, the examiner progresses upward with the tuning fork
until the patient perceives the vibrations.
• As with all measurements of sensation, a side-to-side
comparison is made.
 POSITION AND PROPRIOCEPTION
It is determined by asking the patient to close
both eyes and indicate, as the great toe or index
finger is alternately moved up and down, in
which direction movement has taken place.
Vibration and position sense are often lost
together, frequently in circumstances in which
all other sensation remains intact.
 DIAGNOSTIC PROCEDURES
CT SCAN :
• Computed tomography (CT) scan is a structural
imaging study that uses a computer-based X-ray to
provide a cross-sectional image of the brain.
• A computer calculates differences in tissue absorption
of the X- ray beams. The CT produces a three
dimensional view of structures in the brain and
distinguishes between soft tissues and water. I.V.
contrast dye may be used to examine the integrity of
the blood – brain barrier.
• CT is primarily used to detect tumors and
inflammatory disorders. Spinal CT scan may be used
to evaluate lower back pain due to herniated
intervertebral disk or other spinal lesions.
 Magnetic resonance imaging (MRI)
• Magnetic resonance imaging (MRI) uses computer
generated radio waves and a powerful magnetic field
to produce detailed images of body structures
including tissues, organs, bones, and nerves.
• Neurological uses include the diagnosis of brain and
spinal cord tumors, eye disease, inflammation,
infection, and vascular irregularities that may lead to
stroke.
• MRI can also detect and monitor degenerative
disorders such as multiple sclerosis and can
document brain injury from trauma.
 Single photon emission computed tomography
(SPECT),
• A nuclear imaging test involving blood flow to tissue, is
used to evaluate
certain brain functions.
• The test may be ordered as a follow-up to an MRI to
diagnose tumors, infections, degenerative spinal disease,
and stress fractures.
• As with a PET scan, a radioactive isotope, which binds to
chemicals that flow to the brain, is injected intravenously
into the body, Areas of increased blood flow will collect
more of the isotope.
• As the patient lies on a table, a gamma camera rotates
around the head and records where the radioisotope has
traveled.
• That information is converted by computer into cross-
sectional slices that are stacked to produce a detailed
three-dimensional image of blood flow and activity within
the brain. The test is performed at either an imaging
center or a hospital.
 Angiography
• Angiography is a test used to detect blockages of the arteries or
veins.
• A cerebral angiogram can detect the degree of narrowing or
obstruction of artery or blood vessel in the brain, head, or
neck.
• It is used to diagnose stroke and to determine the location and
size of a brain tumor, aneurysm, or vascular malformation.
• This test is usually performed in a hospital outpatient setting and
takes up to 3 hours, followed by a 9- to 8- hour resting period.
• The patient, wearing a hospital or imaging gown, lies on a table
that is wheeled into the imaging area.
• While the patient is awake, a physician anesthetizes a small area
of the leg near the groin and then inserts a catheter into a major
artery located there.
 Lumbar puncture
• Sampling of cerebrospinal fluid (CSF) via lumbar
puncture is crucial for accurate diagnosis of
meningeal infections and carcinomatosis.
• CSF analysis is also helpful in evaluating patients
with central or peripheral nervous system
demyelinating disorder and with intracranial
hemorrhage particularly when imaging studies are
inconclusive.
 Purpose
• To diagnose central nervous system infections,
subarachnoid hemorrhages, and many other
neurologic pathologies.
 Equipment Needed
• Spinal or lumbar puncture tray (specifically the items listed below)
• Sterile gloves
• Manometer
• Three-way stopcock
• Sterile dressing
• Antiseptic solution with skin swabs
• sterile drape
• 1% Lidocaine
• 3-cc syringe
• 20 – and 25 gauge needle
• 20 – and 22 gauge spinal needle
• Four plastic test tubes, numbered 1 to 4, with caps.
 Technique
• Obtain informed consent from the patient or next of kin.
• Obtain a CT scan of the head or perform a fundoscopic exam
to check for papilledema. It is absolutely necessary to rule out
increased intracranial pressure before proceeding.
• Locate the L3 – L4 space. To do this, find the iliac crests and
move your fingers medially from the crests to the spine.
• Mark the entry site with your thumbnail or a marker.
• Open and prepare the spinal tray in a sterile manner.
 Complications
• Post- spinal puncture headache
• Brain herniation
• Bloody tap (may lead to hematoma)
• meningitis
 Post-procedure care:
• Send the four tubes for the following labs:
a) Tube 1, bacteriology: Gram stain, culture and sensitivity, acid-
fast bacilli, fungal cultures and stains, cell count (compare with
tube 3 to differentiate traumatic tap from subrachnoid
hemorrhage).
b) Tube 2, biochemistry: glucose, protein, and electrophoresis (if
working up for multiple sclerosis to detect oligoclonal banding).
c) Tube 3, hematology: cell count with differential .
d) Tube 4, special studies if needed: VDRL (neurosyphilis), India
ilk (cryptococcus neoformans.)
 Electroencephalgraphy (EEG)
• Eletroencephaloghaphy is the recording and
measurement of scalp potential in orders to evaluate
baseline brain funtioning as well as paroxysmal brain
electrical activity suggestive of a seizure disorder.
• An EEG is performed by securing 20 electrodes to scalp at
prodetrmined locations based on an international system
theta uses standardized percentage of the head
circumferences, the 10-20 .
•
• Each elector is labelled using a letter and a number, the letter
identifying the skull region (FP= Fronttopolar, F=frontal,
P=parietal, T=temporal, O=Occipital, V=vertex) and the number
the specific location, with odd numbers representing the left sided
electrodes.
 Nerve Conduction Study (NCS)
• A Nerve conduction study is the recording the measuring of
the compound nerve and muscle action potentials elicited in
response to an electrical stimulus.
 Repetitive stimulation study
• The repetitive stimulation study is a method of
measuring electrical conduction properties at the
neuromuscular junction. To perform a RSS a surface
recording electrode is placed over a muscle belly
and the nerve innervating that muscle is electrically
stimulated with a superamaximal stimulus at a
certain frequency.
Electromyography
• Electromyography is the
recording and study of
insertional, spontaneous and
voluntary electrical activity
of muscle. This test allows
one to physiologically
evaluate the motor unit,
including the anterior horn
cell, peripheral nerve and
muscle.
 Evoked potentials
• Evoked potentials are ways of measuring conduction
velocities fro sensory pathways in the central nervous
system by means of computer averaging techniques. Three
types of evoked potentials are routinely performed; visual,
brain stem auditory, and somatosensory evoked responses.
1. Pattern reversals visual evoked responses(PVER)
2. Brain stem auditory evoked responses (BAER)