chapter 54 care of the patient with a neurological disorder - complete slides

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Chapter 54

Care of the Patient with a Neurological Disorder

- Complete Slides

Chapter 54

Care of the Patient with a Neurological Disorder

- Complete Slides


Overview of Anatomy and PhysiologyOverview of Anatomy and Physiology

• Nervous System Responsible for communication and control within the

body Interprets and processes information received and

sends in to the appropriate area of brain and spinal cord where response is generated

Body’s link to the environment Works with endocrine to maintain homeostasis

• NS reacts in a split second

• Endocrine works more slowly to secrete hormones



• Structural divisions 2 Main Structural division:

1. Central nervous system (CNS) Brain and spinal cord Occupies a medial position in the body Responsible for interpreting incoming sensory

information and issuing instructions based on past experiences



2 main structural divisions – cont’d2. Peripheral nervous system (Lies Outside the CNS),

divided into 2 main divisions: Somatic nervous system

o Sends messages from the CNS to the skeletal muscles

o Voluntary muscleso Sensory (Afferent) and Motor (Efferent) Neuron

Autonomic nervous systemo Transmits messages from the CNS to the smooth

muscle, cardiac muscle and certain glandso Involuntary o Known as involuntary nervous system

Actions takes place without conscious control

o Sensory (Afferent) and Motor (Efferent) Neuron


Overview of Anatomy and Physiology-cells of the nervous system

Overview of Anatomy and Physiology-cells of the nervous system

• Cells of the Nervous system 2 Broad Category:

1. Neurons, transmitter cells as they carry messages to and from the brain and spinal cord.

2. Neuroglial or glial cells, support and protect the neurons while producing cerebrospinal fluid (CSF), which continuously bathes the structures of the CNS.

• Neuron (nerve cell) Basic nerve cell of nervous system Separate unit compose of:

• Cell body, the axon and the dendrites Cell body

• Contains a nucleus surrounded by cytoplasm Axon

• Cylindrical extension of a nerve cell• Conducts impulses away from the neuron cell body

Dendrites• Branching structures that extend from a cell body and receive

impulses


Overview of Anatomy and Physiology-cells of the nervous system (cont’d)


• Neuron (nerve cell) – cont’d Synapse

• A gap (space) between each neuron

• Defined as region surrounding the point of contact between two neurons

• Between a neuron and an effectors organ, across which nerve impulses are transmitted through the action of a neurotransmitter

Governed by “all or none” law• Never a partial transmission of a message

• Impulse is either strong enough to elicit a response or too weak to generate the message




• Neuromuscular junction Area of contact between ends of a large myelinated

nerve fiber and a fiber of skeletal muscle Necessary for functioning of the body Neurotransmitters act to make sure the neurological

impulse passes from nerve to muscle




• Neurotransmitters It modify or result in transmission of impulses between synapses Best known neurotransmitter are: Acetylcholine,

Norepinephrine, dopamine and serotonin. Acetylcholine (Ach)

• Role in nerve impulse transmission• Spills into synapse area and speed transmission of impulse• Cholinesterase (enzyme)

Deactivate Ach once message or impulse has been sent

• Happens rapidly and continuously as each impulse is relayed Norepinephrine

• Effects on maintaining arousal (awakening from deep sleep) and dreaming

• Regulation of mood (i.e. happiness and sadness)




• Neurotransmitters Dopamine

• Primarily affects motor function• Involved in gross subconscious movements of skeletal

muscles• Role in emotional responses• In Parkinson’s disease

There is a decrease in dopamine, that’s why the person suffers from tremors or involuntary, trembling muscle movements

Serotonin• Induces sleep• Affects sensory perception• Controls temperature• Role in control of mood




• Neuron coverings Myelin

• White, waxy, fatty material

• Increases rate of transmission of impulses

• Protects and insulate fibers nodes of Ranvier

• Wraps the axon leaving the CNS in layers of myelin with indentation

• Further increase rate of transmission, because impulse can jump from node to node




• Neuron coverings Peripheral nervous system

• Myelin is produced by Schwann cells

• Outer membrane gives rise to another layer which is very important in regeneration of cells called neurilemma, functions of neurilemma:

Helps to regenerate injured axons Regeneration of nerve cell occurs only in peripheral

nervous system

• Cells damaged in CNS results permanently (paralysis) Do not have neurilemma, so no regeneration occurs.


Figure 54-1Figure 54-1

A, Diagram of a typical neuron. B, Scanning electron micrograph of a

neuron. C, Myelinated axon.

(A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby. B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.)


Overview of Anatomy and Physiology-Central Nervous System (CNS)


• Central Nervous System One of two main divisions of nervous system Composed of brain and spinal cord Functions somewhat like a computer but is much

more complex Cranium protects the brain Vertebral column protects the spinal cord




• Brain Specialized cells in the brain’s mass of convoluted,

soft, gray or white tissue coordinate and regulate the functions of CNS

Largest organ weighing about 3 pounds Divided into four parts

• Cerebrum• Diencephalon• Cerebellum• Brain stem

Midbrain; pons; medulla oblongata; coverings of the brain and spinal cord; ventricles




• Brain Cerebrum

• Largest part of the brain

• Divided into left and right hemispheres

• Outer portion is gray matter Called - Cerebral cortex

• Arrange into folds called gyri (convolutions)

• Grooves are called sulci (fissures

• Corpus callosum Connecting structure or bridge Divides two hemispheres into for lobes

o Frontal lobe, parietal lobe, temporal lobe, occipital lobe




• Brain Cerebrum

• Fissure is a natural division between the left and right hemispheres

• Controls initiation of movement on opposite side of body• Specific areas of cerebral cortex are associated with

specific functions: Frontal Lobe

o Written speech (ability to write)o Motor speech (ability to speak)o Motor ability – directs movements of body; left side controls

the right side of the body and the right side of the brain controls the left side of the body.

o Intellectualization – the ability to form conceptso Judgment formation




• Brain.. cont Cerebrum.. cont

• Specific areas of cerebral cortex are associated with specific functions.. cont:

Parietal Lobeo Interpretation of sensory impulses from the skin such as

touch, pain, and temperatureo Recognition of body partso Determination of left from righto Determination of shapes, sizes and distances

Temporal Lobeo Memory storageo Integration of auditory stimuli

Occipital Lobeo Interpretation of visual impulses from the retinao Understanding of the written word




• Brain Diencephalon

• Called interbrain It lies beneath the cerebrum

• Contains: thalamus and hypothalamus• Thalamus

Relay station for some sensory impulses while interpreting other sensory messages (i.e. pain, touch, pressure)

• Hypothalamus Lies beneath the thalamus Role in control of body temperature, fluid balance, appetite,

emotions (i.e. fear, pleasure, pain) Controls sympathetic and parasympathetic divisions of

autonomic system as is the pituitary glands Influences heartbeat, contraction and relaxation of walls of

blood vessels, hormone secretion, and other vital body functions




• Brain Cerebellum

• Lies posterior and inferior to cerebrum• Second largest portion of brain• Contains two hemispheres with convoluted surface much like

cerebrum• Responsible for coordination of voluntary movement and

maintenance of balance, equilibrium, and muscle tone• Sensory messages from semicircular canals in inner ear

sends messages to cerebellum Brain stem

• Located at the base of the brain• Consist of: Midbrain; pons; medulla oblongata; • Connect spinal cord and cerebrum • Carries all nerve fibers between spinal cord and cerebrum




Brainstem..cont• Midbrain

Superior portion of brain stem Responsible for motor movement, relay of impulses,

auditory and visual reflexes Origin of Cranial Nerves (CN) III and IV

• Pons Connects midbrain to medulla oblongata “Pons” means “bridge” Origin of CN V through VIII Composed of myelinated nerve fibers and is responsible

for sending impulses to structures that are inferior and superior to it

Contains a respiratory center that compliments respiratory centers located in medulla




Brainstem.. cont• Medulla oblongata

Distal portion of brainstem Origin of CN IX and XII Controls heart beat, rhythm of breathing, swallowing,

coughing, sneezing, vomiting, and hiccups (singultus) Vasomotor center regulates diameter of blood vessels,

helps aid in BP control



Sagittal section of the brain (note position of midbrain).

(From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.)




• Coverings of brain and spinal cord Three protective coverings called meninges

• 1. Dura mater Outer most layer

• 2. Arachnoid membrane Second layer

• 3. Pia mater Inner most layer Provides oxygen and nourishment to nervous tissue

• These layers also bathe Spinal Cord and brain in cerebrospinal fluid (CSF)




• Ventricles Four in all: 3rd, 4th, left and right lateral ventricle Spaces or cavities located in brain CSF

• Clear and resembles plasma

• Flows into subarachnoid spaces around brain and spinal cord and cushions them

• Contains protein, glucose, urea, and salts

• Contains substances that forms a protective barrier (the Blood-Brain Barrier)

Prevents harmful substances to enter the Brain and SC


• Spinal Cord 17 to 18 inch cord extending from brainstem to

second lumbar vertebra Two main functions:

• Conducting impulses to and from the brain• Serving as a center for reflex actions

Responsible for certain reflex activity such as knee jerk

• Sensory neuron sends information to cord, a central neuron (within the cord) interprets impulse, and a motorneuron sends message back to muscle or organ involved

• Message is sent, interpreted, and acted upon without traveling to brain





Neural pathway involved in the patellar reflex.

(From Thibodeau, G. A., Patton, K. T. [1990]. Anthony’s textbook of anatomy and physiology. [13th ed.]. St. Louis: Mosby.)


Another exampleAnother example


Overview of Anatomy and Physiology- Peripheral nervous system


• Peripheral nervous system Comprise motor nerves, sensory nerves, and ganglia

outside brain and SC 31 pairs of spinal nerves 12 pairs of cranial nerves Autonomic nervous system

• Sympathetic nervous system

• Parasympathetic nervous system




• Spinal Nerves 31 pairs and all are mixed nerves Transmit sensory information to SC through afferent

neurons and motor information from CNS to areas of body through efferent neurons

Named according to the corresponding vertebra (e.g C1, C2)

See next figure




• Cranial Nerves 12 pairs Attach to posterior surface of brain, mainly brainstem Conduct impulses between head, neck, and brain, excluding vagus

nerve (CN X), which also serves organs in thoracic and abdominal cavities

List of CN, impulses sent and functions:• CN I, Olfactory – nose to brain – sense of smell• CN II, Optic – eye to brain – vision• CN III, Oculomotor – brain to eye muscles – eye movements,

pupillary control• CN IV, Trochlear – brain to external eye muscles – eye movements• CN V, Trigeminal (opthalmic, maxillary, mandibular branch) – skin &

mucus membrane of head to brain; teeth to brain; brain to chewing muscles – sensation of face, scalp and teeth; chewing movements

• CN VI, Abducens – brain to external eye muscles – turning eyes outward

• CN VII, Facial – taste buds of tongue to brain; brain to facial muscles – sense of taste; contraction of muscles of facial expression

• CN VIII, Acoustic (vestibulocochlear) – ear to brain – hearing; sense of balance




• Cranial Nerves.. cont List of CN, impulses sent and functions..cont:

• CN IX, Glossopharyngeal – throat and taste buds of tongue to brain; brain to throat muscle and salivary glands – sensations of throat, taste, swallowing, movements, secretion of saliva

• CN X, Vagus – throat, larynx & organs in thoracic & abdominal cavities to brain; brain to muscles of throat & to organs in thoracic & abdominal cavities – sensation of throat, larynx & of thoracic & abdominal organs; swallowing, voice production, slowing heartbeat, acceleration of peristalsis

• CN XI, Spinal accessory – brain to certain shoulder & neck muscles – shoulder movements & turning movements of head

• CN XII, Hypoglossal – brain to muscles of tongue – tongue movements




• Autonomic Nervous System Controls activities of smooth muscle, cardiac muscle,

and all glands Subdivision of peripheral nervous system Primary function is to maintain internal homeostasis

• Strives to maintain a normal heartbeat, constant body temperature, and normal respiratory pattern

Two divisions: • Sympathetic nervous system

• Parasympathetic nervous system




• Autonomic Nervous System Two divisions

• Antagonistic One slows an action, and the other accelerates the action Note: function simultaneously, but have the ability to

dominate each other as the need arises

• Stress Sympathetic takes over to prepare body for “fight or

flight” Heartbeat accelerates, BP increases, adrenal glands

increase secretions

• To calm the body Parasympathetic dominates Slowing heartbeat and decreasing BP and adrenal

hormones



• Effects of Normal Aging on the Nervous System Loss of brain weight Loss of neurons (1% a year after age 50) Cortex losing cells faster than the brainstem Remaining cells undergo structural changes General decline in interconnections of dendrites Reduction in cerebral blood flow Decrease in brain metabolism and oxygen utilization Neurons may contain senile plaques, neurofibrillary tangles &

age pigment lifofuscin Altered sleep/ wakefulness ratio Decrease in ability to regulate body temperature Decrease in velocity of nerve impulses Decreased blood supply to spinal cord causes decreased

reflexes


Overview of Anatomy and PhysiologyOlder Adult Consideration BoxOverview of Anatomy and PhysiologyOlder Adult Consideration Box

• Neurological Disorder As neuron are lost with aging, there is a deterioration in neurological

function, resulting in slowed reflex and reaction time Tremors that increase with fatigue are commonly observed in adults The sense of touch & the ability for fine motor coordination diminish with

aging Most older people possess the ability to learn, but the speed of learning

is slowed. Short-term memory is more affected by aging than long-term memory

The incidence of physiologic dementia or organic brain syndrome-including Alzheimer’s disease, Pick’s disease & multiinfarct dementia-increases with aging

Incidence of stroke increases with age. Prognosis is affected by the location & extent of the cerebral damage. Rehab potential after a stroke is often reduced by advanced age & coexisting medical problem

Nerve irritation resulting from arthritis, joint injuries or spinal-cord compression can cause chronic pain or weakness

Dementia is not a normal consequence of aging but may be result of may reversible conditions, including anemia, fluid & electrolyte imbalance, malnutrition, hypothyroidism, metabolic disturbances, drug toxicity, a drug reaction/idiosyncrasy & hypotension.



• Prevention of neurological problems Avoid drug and alcohol use

• Smoking increases lung cancer and lung CA metastasizes to the brain

Safe use of motor vehicles Safe swimming practices Safe handling and storage of firearms Use of hardhats in dangerous construction areas Use of protective padding as needed for sports


Assessment of the Neurological SystemAssessment of the Neurological System

• History Essential for diagnosing neurological disease Includes specifics about symptoms experienced Asses patient understanding & perception of what is happening. Obtain info from family members/ significant others may be

helpful Make sure information is complete For patients with suspected neurological conditions presence of

many symptoms of subjective data may be significant. These include the following:• Headaches, especially those that first occur after middle

age or those that change in character; headaches that are worse in the morning or awaken a person from sleep are especially significant



• History..cont For patients with suspected neurological conditions

presence of many symptoms of subjective data may be significant. These include the following..cont:

• Clumsiness or loss of function in an extremity

• Change in visual acuity

• Any new or worsened seizure activity

• Numbness or tingling in one or more extremities

• Pain in an extremity or other part of the body

• Personality changes or mood swings

• Extreme fatigue or tiredness



• Mental Status Assessment of patient neurological mental status is

important Examination generaly includes orientation (person,

place, time, and purpose), mood and behavior, general knowledge (such as names of U.S. presidents), and short- and long-term memory.

The patient’s attention span and ability to concentrate may also be assessed

Note actual patient statement & note actual level of orientation (name, date, time & purpose), always try different approach cause patient my learn the correct answer through repetition



• Level of consciousness Level of consciousness (LOC) is the earliest and most sensitive

indicator that something is changing. A decreasing level of consciousness is the earliest sign of

increased intracranial pressure. LOC has two components

• Arousal (or wakefulness) and

• Awareness. Wakefulness is the most fundamental part of LOC. If the patient

can open the eyes spontaneously to voice or to pain, it says that the wakefulness center in the brainstem is still functioning.

Awareness, a higher function controlled by the reticular activating system in the brainstem.



• Level of consciousness Awareness has four components:

1. Orientation: person, place, time, purpose

2. Memory: assess short-term memory; do not ask yes or no questions.

3. Calculation: example, “If you have $2 and your apple costs $1.25, how many quarters would you get back?”

4. Fund of knowledge: Ask the patient to name the president and to tell you what’s on the national news (Lower, 2002).

Restlessness, disorientation, and lethargy may be seen first.



• LEVELS OF CONSCIOUSNESS Alert, Disorientation, Stupor, Semicomatose, Comatose, level &

description below:• Alert: Responds appropriately to auditory, tactile, and visual

stimuli• Disorientation: Disoriented; unable to follow simple

commands, thinking slowed, inattentive, flat affect.• Stupor: Responds to verbal commands with moaning or

groaning, if at all• Semicomatose: Impaired state of consciousness

characterized by obtundation and stupor, from which a patient can be aroused only by energetic stimulation

• Comatose: Unable to respond to painful stimuli; cornea and papillary reflexes are absent. The patient cannot swallow or cough. The patient is incontinent of urine and feces. The EEG pattern demonstrates decreased or absent neuronal activity.



• Glasgow Coma Scale Quick, practical & standardized system for assessing

the degree of consciousness impairment in the critically ill and for predicting the duration and ultimate outcome of coma, particularly head injury.

Neurologic evaluation uses the Glasgow Coma scale as an indicator of the severity of brain injury.

The highest possible number of 15 indicates that the individual has no impairment, while a score of 3 indicates brain death.

A score of 6 – 8 is associated with a coma state



• Glasgow Coma Scale E: Eye opening

• Spontaneous = 4• To verbal stimuli = 3• To pain stimuli = 2• None = 1

M: motor response• Obeys commands = 6• Localizes pain = 5• Normal withdrawal flexion = 4• Decorticate flexion = 3• Decerebrate extension = 2• Flaccid = 1

V: verbal response• Oriented = 5• Confused conversation = 4• Inappropriate words = 3• Incomprehensible sounds = 2• None = 1



• LANGUAGE AND SPEECH Speech is a function of the dominant hemisphere, which is on the

left side of the brain for all right-handed people and most left-handed people.

Aphasia • An abnormal neurological condition in which the language

function is defective or absent because of an injury to certain areas of the cerebral cortex-Broca’s area in the frontal lobe and Wernicke’s area in the posterior part of the temporal lobe.

Aphasia includes all areas of language, including speech, reading, writing, and understanding. Aphasia has been subdivided as follows:

• Sensory aphasia or receptive aphasia: inability to comprehend the spoken word or written word.

• Motor aphasia: inability to use symbols of speech (also called expressive aphasia).

• Global aphasia: inability to understand the spoken word or to speak.



• LANGUAGE AND SPEECH Anomia

• A form of aphasia characterized by the inability to name objects.

Dysarthria • Defined as difficult, poorly articulated speech that

usually results from interference in the control over the muscles of speech. The general cause is damage to a central or peripheral nerve.



• The cranial nerves classification I (olfactory) - Identification of common odors II (optic) - Testing of visual acuity and visual fields III (oculomotor) - Testing of ability of eyes to move together in all

directions, testing pupillary response IV (trochlear) - Tested with oculomotor; testing eye movements V (trigeminal) - Jaw strength and sensation of face corneal reflex VI (abducens) - Tested with oculomotor; testing eye movements VII (facial) - Ability of face to move in symmetry, identification of

tastes VIII (acoustic, or vestibulocochlear) - Testing of hearing through

whisper or other means and checking equilibrium and balance. IX (glossopharyngeal) - Identification of taste X (vagus) - Gag reflex, movement of uvula and soft palate XI (spinal accessory) - Shoulder and neck movement XII (hypoglossal) - Tongue motion



MOTOR FUNCTION• Motor function disturbances are the most commonly encountered

neurological symptom• In general, the parts of the motor status examination include gait and

stance, muscle tone, coordination, involuntary movements, and the muscle stretch reflexes.

• Reflexes that are usually tested include the biceps, triceps, brachioradialis, quadriceps, gastrocnemius, and soleus muscles. The examiner taps briskly over the muscle with a reflex hammer. The response is noted and graded on a scale, usually from 0 to 4+, with 4+ being hyperreflexic

• The most important feature of any reflex pattern is not the absolute value on the scale, but the comparison of one side of the body with the other.

• Stick figures are commonly used to record the bilateral values.• Damage to the nervous system often causes a serious problem in

mobility. A loss of function is called paralysis; a lesser degree of movement deficit from partial or incomplete paralysis is called paresis.



MOTOR FUNCTION..cont

• Muscles may be flaccid (weak, soft, and flabby and lacking normal muscle tone), with absent deep tendon reflexes, or spastic (involuntary, sudden movement or muscular contraction), with increased reflexes.

• With some muscle problems, the affected muscle shows small, localized, spontaneous, and involuntary contractions called fasciculations. With other problems, clonus (a forced series of alternating contractions and partial relaxation of a muscle) may occur.



SENSORY AND PERCEPTUAL STATUS• The sensory examination is the most common

difficult part of the neurological evaluation. Specific alterations in sensation that should be assessed include pain; touch; temperature; and proprioception, the sensation pertaining to spatial-position and muscular-activity stimuli originating from within the body or to the sensory receptors that those stimuli activate. This sensation gives one the ability to know

the position of the body without looking at it and the ability to know objects by the sense of touch.



SENSORY AND PERCEPTUAL STATUS..cont

• Unilateral neglect, a condition in which an individual is perceptually unaware of and inattentive to one side of the body

• Another perceptual problem is hemianopia or hemianopsia, which is characterized by defective vision or blindness in half of the visual field

of one or both eyes.



SENSORY AND PERCEPTUAL STATUS..cont

• It is usually not feasible or necessary to complete the total neurological examination during shift-to-shift assessments of the patient.

• In intensive care units, the neurological checks may be done as frequently as every 15 minutes. Factors that are the most important include

1. orientation,

2. level of consciousness,

3. bilateral muscle strength,

4. speech ability,

5. involuntary movements,

6. ability to follow commands, and

7. any abnormal posturing.


Laboratory and Diagnostic ExamLaboratory and Diagnostic Exam

BLOOD AND URINE TESTS

• Urine culture may rule out infection involving the urinary tract.

• Other urine testing may indicate the presence of diabetes insipidus

• Urine drug screens may be done to rule out drug use as a cause of lethargy or to identify specific drugs ingested

• Arterial blood gas values may be an important diagnostic tool in monitoring the oxygen content of the blood

• Gases may be altered with neurological diseases suc as Guillain-Barre syndrome where breathing pattern were altered

• Blood test that are routinely done may help narrow the Dx of neurological disorder



CEREBROSPINAL FLUID• Normally there are up to 10 lymphocytes per milliliter of

spinal fluid. An increase in the number of cells may indicate an infection.

• Infections such as Tuberculosis meningitis often lower the CSF glucose level

• Bacterial infection such as TB meningitis often lower the CSF glucose level as well as the chloride levels (culture or smear exam is done to determine the causative organism in meningitis)

• Spinal-fluid protein is elevated when degenerative disease or a brain tumor is present

• Blood in the spinal fluid indicates hemorrhage from somewhere in the ventricular system

• A protein electrophoresis eval may give evidence of neurological diseases such as Multiple Sclerosis (MS)



CEREBROSPINAL FLUID..cont• Normal Characteristic of CSF

Spec Gravity 1.007 pH 7.35-7.45 Chloride 120-130 mEq/L Glucose 50-75 mg/dl Pressure 80-200 mm water Total vol 80-200 ml (15ml in

ventricle) Total protein 15-45 mg/dl – lumbar

10-25 mg/dl – cisternal5-15 mg/dl – ventricular

Gamma globulin 6-13% of total protein count

Cell count RBC None WBC 0-10 cells (all lymphocytes n

monocytes) Culture & sensitivity No organism present Serology for syphilis Negative



Other Tests

• Routine skull radiographs of the head and vertebral column, used in ruling out fractures of the skull and cervical vertebrae.

• Since the development of the computed tomography (CT) scan, skull radiographs are not used as extensively as before.



Computed Tomography (CT) Scan• The purpose of the CT scan, also called the CAT scan, is to

detect pathologic conditions of the cerebrum and spinal cord using a technique of scanning without radioisotopes

• If contrast medium is used, it is important for the nurse to document and report to the physician any history of allergy to iodine and seafood because iodine is present in the contrast medium

• No special physical preparation on the patient, takes about 20-30 min without contrast medium and 60 min with contrast medium.

• Painless except discomfort when IV is started for contrast medium and claustrophobic feeling as head will be placed on a holder while laying still

• Each image appears specific brain tissue, computer will display areas of increased densities (e.g tumors or thrombi)



Brain Scan• The brain scan’s purpose is detecting pathologic conditions of

the cerebrum. It uses radioactive isotopes and a scanner.• No special physical preparation, patient lay still as the scanner

passes over the brain area• Procedure takes 45 min for the scanning• The patient is injected with radioisotope, minimal discomfort

may occur when IV is started for radioisotope• If mercury is used as isotope, meralluride (mercuhydrin) is

administered several hours before to allow greater concentration of mercury to circulate the brain tissue, coz it minimizes uptake of mercury by kidney

• Brain scan is being used less frequently than in the past because of the excellent results obtained from CT scan and magnetic resonance imaging (MRI)



Magnetic Resonance Imaging (MRI) Scan• MRI uses magnetic forces to image body structures. • Used to detect pathologic conditions of the cerebrum and

spinal cord, as in detection of stroke, multiple sclerosis, tumors, trauma, herniation & seizures

• MRI is the diagnostic test of choice for many neurological diseases because it yields greater contrast in the images of soft-tissue structures than does the CT scan

• The scan involves a magnetic force, hence, the patient is cautioned to remove watches and any metal from body or clothing before entering the scanning room.

• Painless procedure takes about 45-60min, minimal discomfort for lying still and claustrophobia feeling, patient must be warned that machine may makes loud noises during procedure

• New advanced in MRI techniques include diffusion weighted imaging and magnetic resonance spectroscopy



Magnetic Resonance Angiography (MRA)

• Magnetic resonance angiography (MRA) uses differential signal characteristic of flowing blood to evaluate extracranial and intracranial blood vessels. It provides both anatomic and hemodynamic information.

• MRA is rapidly replacing cerebral angiography for use in diagnosing cerebrovascular disease

• Also called cMRA (contrast enhanced MRA) if used in conjuction with contrast media



Positron Emission Tomography (PET) Scan

• In this procedure the patient receives an injection of deoxyglucose with radioactive fluorine.

• The area in question is scanned, and a color composite picture is obtained. Shades of color give an indication of the level of glucose metabolism; this then can be translated into indications of a pathologic state.

• PET scan provide non invasive means of determining biochemical processes that occur in the brain

• There is increased clinical use of PET scan to monitor select patients following stroke, Alzheimer’s disease, tumors, epilepsy, and Parkinson’s disease

• Discomfort is minimal, patient must be aware the need to lie still during scanning, approx 45 min.



The gray outer surface is the surface of the brain from MRI and the inner colored structure is cingulate gyrus, part of the brain's emotional system visualized with PET.Photo by Monte S. Buchsbaum, M.D.



Lumbar Puncture• Performed as part of the Dx workup of the patient who may have a

neurological problem• A lumbar puncture is done to obtain CSF for examination, to relieve

pressure, or to introduce dye or medication• It is contraindicated in patients with increased intracranial pressure, because

the withdrawal of fluid may cause the medulla oblongata to herniate downward into the foramen magnum

• Procedure takes 10-15min, commonly done in patient’s room or the imaging department, slight pain & pressure may be felt as the dura is entered, sharp shooting pain down one leg may occur, caused by needle coming close to a nerve

• Done in side positioned with knee and head flexed at acute angle allowing lumber flexion & separation of the interespinous spaces. Anesthetized the area with local aesthesis then needle inserted at L4-L5 or L5-s1 interspace. Removed inner needle for drainage & measure the spinal fluid.

• Manometer is used to measure the pressure• After the procedure the patient lies flat in bed for several hours. • Headache is fairly common and is thought to be caused by the loss of spinal

fluid. • If a headache develops, bed rest, analgesics, and ice to the head may help.

Opioids are usually not helpful



LUMBAR LUMBAR PUNCTURE PUNCTURE (BETWEEN L3–L4)(BETWEEN L3–L4)

Position and angle of the needle when lumbar puncture is performed.



Electroencephalogram• The electroencephalogram (EEG) is used to provide evidence

of focal or generalized disturbances of brain function by measuring the electrical activity of the brain.

• Among the cerebral diseases assessed by the EEG are epilepsy, mass lesions (e.g, tumors, abscess, hematoma), cerebrovascular lesions, and brain injury.

• No special preparation, only rest & quite surrounding before procedure.

• Usually done first thing in the morning, takes about 1hr to complete

• After procedure patient must rest and assisted to wash the patient hair to remove the collodion from scalp.



Myelogram• The myelogram is commonly used to identify lesions in the

intradural or extradural compartments of the spinal canal by observing the flow of radioppaque dye through the subarachnoid space.

• The most common lesion for which this test is used is a herniated or protruding intervertebral disk. Other lesions include spinal tumors, adhesions, bony deformations, and arteriovenous malformations.

• Procedure takes about 2 hrs, will be slight discomfort as dura entered and may be asked to assume variety position during procedure

• Preparation are the same as the lumbar puncture aside from the injection of dye (ask patient for allergic reaction)

• Patient usually undergoes CT scan 4-6hrs after myelogram• Headaches are common after the procedure, might be

accompanied by N&V.• Patient must lay flat for few hours.



Angiograms• The angiograms (cerebral arteriography) is a procedure used to

visualize the cerebral arterial system by injecting to visualize the cerebral system by injecting radiopaque material.

• It allows the detection of arterial aneurysms, vessel anomalies, ruptured vessels, and displacement of vessels by tumors or masses.

• Clear liquid only before procedure, some other facility require NPO• Asses allergic reaction to iodine• Takes about 2-3hrs, may experience discomfort lying still for that

time period. Supine position on radiograph table• When dye injected may experience feeling or extremely hot and

seeing flashes of light.• After procedure bed rest is ordered for 4-6hrs, VS checked every

15mins, neurological assesment every VS check, asses puncture site for hematoma

• Patient may be at risk for cerebral vascular accident as well as increase in intracranial pressure.

• Any changes in LOC must be reported promptly• MRA is replacing cerebral ateriography in some facility



CAROTID DUPLEX

• Combined ultrasound & Doppler technology

• Amplified response & graphic record & sound registers blood flow velocity indicating stenosis of a vessel

• Non invasive studies that evaluates carotid occlusive disease

• Usually ordered on Transient Ischemic Attack patient to determine the pathology of the carotid



ELECTROMYOGRAM• Used to measure the contraction of a muscle in

response to electrical stimulation• Provide evidence of lowere motoneuron disease;

primary muscle disease; defects in transmission of electrical impulses at NMJ, such as in Myasthenia gravis

• Takes 45min for muscle study, there will be discomfort when electrode inserted into muscle & when electrical current is used. Muscle may ache afterwards

• Asses signs of bleeding after procedure at the injection sites.

• May need analgesic for discomfort & rest period



Echoencephalogram

• Uses ultrasound to depict the intracranial structures of the brain

• Helpful in detecting ventricular dilation & major shift of midline structures in the brain as result of expanding lesion

• Procedure is similar to brain scan


Common Disorders of the Neurological SystemCommon Disorders of the Neurological System

• Headaches Etiology/pathophysiology

• The exact mechanism of head pain is not known. Although the skull and brain tissues are not able to feel sensory pain, pain arises from the scalp, its blood vessels and muscles, and from the dura mater and its venous sinuses.

• Pain also arises from the blood vessels at the base of the brain and from cervical cranial nerves. Blood vessels may dilate and become congested with blood

• Headaches can be classified as vascular, tension, and traction-inflammatory

1. Vascular headache, include migraine, cluster, and hypertensive headaches

2. Tension headache, arise from medical problems such as cervical arthritis.

3. Traction-inflammatory headaches include those caused by infection, intracranial or extracranial causes, occlusive vascular structures, and temporal arteritis.



• Headaches (continued) Clinical manifestations

• Headache pain may be worse by stress or tension.• Knowledge of the patient’s perception of the effect of stress

on the pain is important in planning effective interventions.• Migraine headaches

Prodromal (early s/s ofsigns and symptoms that occur before the acute attack. These may include any of the following:

1. Visual field defects

2. Experiencing unusual smells or sounds

3. Disorientation

4. Paresthesias and,

5. In rare cases, paralysis of a part of the body.



• Headaches (continued) Clinical manifestations...cont

• During a migraine headache s/s may include: N&V, sensitivity to light, chilliness, fatigue, irritability,

diaphoresis, edema & other signs of autonomic dysfunction• Abnormal metabolism of serotonin, a vasoactive

neurotransmitter found in platelets & cells of the brain, plays a major role.

Assessment• Include the patient’s understanding of the headache, possible

causes and any precipitating factors• Important to determine what measures relieve the symptoms

as well as the location, frequency, pattern & character of the pain

• Includes the site of return f the headache, time of day, intervals between headaches

• Initial onset of the headache, presence of any symptoms that occur before the headache or associated symptoms, the presence of allergies and any family history of similar headache patterns are also important to asses



• Headaches (continued) Assessment..cont

• Objective date include any behavior indicating stress, anxiety and pain

• Changes in ADL, as abnormally raised temperature n presence of sinus drainage may be important

• Document abnormality during physical exam of neurological assessment

Diagnostic test• Usual testing includes neuro exam, a CT scan (MRI or

PET), brain scan, skull radiograph and lumbar pucture• Lumbar pucture is contraindicated if increased

intracranial pressure exist, or if brain tumor is suspected as it may cause brain herniation. CT scan is the preferable test in this situation.



• Headaches (continued) Medical management

• Diet: limit MSG, vinegar, chocolate, yogurt, alcohol, fermented or marinated foods, ripened cheese, cured sandwich meat, caffeine, and pork

• Psychotherapy

• Medications Migraine headaches

o Aspirin, acetaminophen, ibuprofeno Ergotamine tartrateo Codeineo Inderal



• Medical management...cont Acetylsalicylic acid (aspirin) may help relieve migraine pain. Ergotamine tartrate preparations taken early in the attack may

prevent progression of the headache. These drugs act by constricting cerebral blood vessel walls and reducing cerebral blood flow.

• Reduces inflammation and may reduce pain transmission• Given orally, sublingually, rectally or by injection• Can be combined with caffeine, phenobarbital & belladona

• Side effects of ergot preparations include nausea, vomiting, numbness and tingling, muscle pain, and changes in heart rate

• They cannot be taken by pregnant women because they stimulate contractions of the uterine smooth muscle



• Medical management…cont Drugs that are Classified as selective serotonin receptor

agonists, these drugs are all indicated to treat acute migraine (with or without aura) in adults:

• Eletriptan (Relpax) • Almotriptan (Axert), • Frovatriptan (Frova), • Naratriptan (Amerge),• Rizatriptan (maxalt), • Sumatriptan (Imitrex), and • Zolmigriptan (Zomig)

The Triptan are thought to act on receptors in the extracerebral, intracranial vessels that become dilated during a migraine attack. Stimulating this receptor constricts cranial vessels, inhibit neuropeptide release and reduces nerve impulse transmission along trigeminal pain pathways.

Triptans relieve N&V and photphobia assicuated with acute migrane attack



• Medical management ..cont Other drugs that maybe used include nonopioid analgesics such

as phenacetin, acetaminophen (Darvocet N). Propranolol (Inderal) has been used in the prophylactic treatment

of migraine and other vascular headaches. Intranasal lidocaine has been used with some relief. Tension headaches

• Non-narcotic analgesics Traction-inflammatory headaches

• Treat cause Comfort measures

• Cold packs to forehead or base of skull• Pressure to temporal arteries• Dark room; limit auditory stimulation



• Nursing Interventions and Patients Teaching Because stress and emotional upsets may precipitate

some headaches and worsen others, relaxation and rest should be facilitated. This includes relaxation techniques, planned sleeping hours, and regular rest periods.

Alcohol should not be used to relieve tension because it may become addicting and has been found to be a significant cause of cluster headaches, especially ones caused by tension.



• Nursing Interventions and Patients Teaching Comfort measures.

• Other treatments that may be helpful for a patient with a headache include cold packs applied to the forehead or base of the skull.

• Pressure applied to the temporal arteries may be helpful.

• People with migraine headaches, especially, are usually most comfortable lying in a dark room with minimal auditory stimulation.



• Education and Teaching: 1. Avoidance of factors that trigger headaches,

2. Relaxation techniques including biofeedback,

3. Importance of maintaining regular sleep patterns,

4. Medications to be used (including dose, actions, and side effects), and

5. The importance of follow-up care.

• Prognosis With proper treatment the person with headaches can expect to

live a normal life. Changes in lifestyle may need to occur, especially during acute

episodes of headache pain. The person may have to adjust to periodic headaches and will

need to rest until the headache resolves.



• Neurological Pain Etiology/pathophysiology

• Neurological pain other than headache is common. The transmission of pain is not fully understood, but patients may experience disabling pain either caused by a disorder within the nervous system (lesion in nerve roots, thalamus, central pain tract [lateral spinothalamic]) or caused peripherally at a distant part of the body

• Pain receptor can be activated by cellular damage certain chemicals such as histamine, heat, ischemia, muscle spasm & sensation of cold & pruritus that go beyond specific level of intensity.

• Pain that is described as unbearable and does not respond to treatment is classified as intractable. It is chronic and often debilitating, and may prevent the patient from functioning in ADLs.



• Neurological Pain..cont Assessment

• Subjective: Perception of pain is highly subjective Asses patient understanding of pain Any precipitating factors Measures to relieve stress, including medication & Usual coping

patterns of the patient when under stress Site, quality, frequency & nature of the pain Presence of associated symptoms & measures that makes it

worse are important too• Objective:

Any behavioral signs indicating pain or stress Change in ADLs Muscle weakness or wasting Vasomotor responses (flushing) Abnormalities in spinal reflexes Abnormalities noted during the sensory examination



• Neurological Pain..cont Diagnostic Test

• Diagnostic tests for the patient in pain may include electrical stimulation used to define the pain to a greater degree. Psychological testing may be part of the workup.

• If back or neck pain is present, a myelogram is usually performed.

Medical management• Nonsurgical methods of pain control include

Transcutaneous electrical nerve stimulation (TENS) Spinal cord stimulation. Both techniques use electrodes applied near the site of

pain or on or around the spine. Acupuncture has also been used to treat patients with

neurological pain.



• Neurological Pain..cont Medical management..cont

• Nerve block used to control intractable pain

• By injecting local anesthetic, alcohol or phenol close enough to a nerve to block the conduction of impulses

• Sources of pain treated include trigeminal neuralgia, cancer, or pheripheral vascular disease

• Duration of effect is from months to years

• Epidural catheter is used to control pain & spacticity

• Continued Meds are given




• Medications are often used to treat patients with neurological pain.

Gabapentin (Neurontin) to control neurological pain Nonopioid analgesics such as acetaminophen,

propoxyphene (Darvon), phenacetin, and acetylsalicylic acid.

Opioids may be prescribed, as well as muscle relaxants, but these drugs may led to abuse.

• The emphasis should be on helping the patient learn other measures to control the pain.




• Surgical methods of pain control In cases of intractable pain that does not

respond to more conservative measures, surgery may be necessary to reduce or abolish pain.

Neurosurgical procedures that may be done include neurectomy, rhizotomy, cordotomy, and percutaneous cordotomy.

o Side effects of the procedures (cordotomy) include postural hypotension, inability to feel hot or cold, and possibly motor and bowel dysfunction function.



• Neurological Pain..cont Nursing Interventions and Patient Teaching

• Comfort measures. The patient assumes the most comfortable position. Nurse should help the patient to find a comfortable

position and may need to actively assist the patient in turning or moving

Straining may intensify pain, so stool softener may be needed. Offer prune juice & high fiber diet with 2000ml/ day fluid or more

• Promotion of rest and relaxation. As with headache, stress and emotional upsets may

precipitate or exacerbate neurological pain. Rest and relaxation should be facilitated, with planned sleeping hours and rest periods as needed.

Some patients with pain, especially intractable pain, may respond well to psychotherapy.



• Neurological Pain..cont Prognosis

• As with headache pain, neurological pain can in most cases be treated adequately. Lifestyle changes may be helpful in allowing the person to live a full life.



• Increased intracranial pressure Etiology/pathophysiology

• Complex grouping of events that occurs because of multiple neurological conditions

• Occurs suddenly, can progress rapidly, often requires surgical intervention

• Considered as an increase in any content of the cranium

• Space-occupying lesions, cerebrospinal problems, cerebral edema

• Since cranial vault is rigid and nonexpandable, buildup pressure may occur in weeks, or rapidly depending on cause.

• Usually involved one side of the brain, but both will eventually involved



• Increased intracranial pressure Etiology/

pathophysiology..cont• Normal ICP = 4 – 13

mmHg• Any sustained increase

in ICP is dangerous hence early detection and treatment are vital before complications occur

• Neuron tissue death will begin within 4 – 6 minutes if oxygen is not supplied



• Increased intracranial pressure..cont Etiology/pathophysiology..cont

• How it happened: Increased pressure in cranial cavity compensated by

venous compression & cerebrospinal displacement. As pressure increased the cerebral blood flow decreases causing inadequate perfusion to the brain, starting a vicious cycle that causes PCO2 to increase and PO2 & pH decrease. These causing vasodilation and cerebral edema causing further increased intracranial pressure and even greater increase in pressure as compression of neural tissue increased.

When pressure is greater than the ability to compensate, pressure is exerted on surrounding structure where the pressure is lower, this movemenet of pressure is called supratentorial shift, which can result in herniation



• Increased intracranial pressure..cont Etiology/pathophysiology..cont

• How it happened..cont Brainstem is compressed at various levels, which in turn

compresses the vasomotor center, posterior cerebral artery, oculomotor nerve, corticospinal nerve pathway and the fibers of the ascending reticular activating system as a result of herniation of the brain

Rise in systolic pressure and an unchanged diastolic pressure, resulting in a widening pulse pressure, bradycardia & abnormal respiration are late sign of increased ICP and indicating that brain is about to herniate.



• Increased intracranial pressure..cont Assessment

• Subjective Presence of any visual changes such as diplopoa or

double vision Change in patient personality Change in the ability to think Presence of nausea or pain, especially headache is

important Headache thought resulting from venous congestion &

tension in the intracranial blood vessels as the cerebral pressure rises

Increase intensity with coughing, straining at stool or stooping

Usually present early mornings and may awaken patient from sleep



• Increased intracranial pressure..cont Assessment..cont

• Objective Change of LOC (earliest sign of increased ICP)

o Disorientation, restlessness or lethargy It’s important to chart what is seen not what is inferred Pupillary sign may change responsiveness as it’s controlled by

cranial nerve III (oculomotor nerve) As the brain herniates, the nerve is being compressed-with the

top part of the nerve being affected first. The ipsilateral pupil (when lesion in one hemisphere) remains dilated & incapable of constricting

Once both halves of the brain become affected bilateral pupil dilation and fixation occur

Pupil that is fixed & dilated is called blown pupil, an ominous sign that must be reported to the MD immediately

BP & pulse will increase in increased ICP, causing systolic BP to rise

If pressure continues widening pulse pressure will occur




• Objective..cont Pressure will increased parasympathetic transmission of

impulses through the vagus nerve to the heart, causing slowing of the pulse

Cushing’s response will exist, it is a widened pulse pressure, increase systolic BP and bradycardia. Cushing’s is considered and important Dx sign of late stage brain herniation

Breathing pattern may be deep & stertorous (snorelike) or periodic (Cheyne-Stokes) respiration

Ataxic breathing may occur (an irregular & unpredictable breathing pattern with random, shallow, and deep breath & occasional pauses)

As Intracranial pressure increases to fatal levels, respiratory paralysis occur

Seen in patient with damage to medulla oblongata




• Objective..cont High, uncontrolled temperature occur due to a failure of

the thermoregulatory center Presence of Babinski’s reflex, hyperflexia, rigidity &

seizures are additional signs of decreased motor function due to compression of the upper motoneuron pathway (corticospinal tract) interrupting transmission of impulses to the lower motoneuron

Herniation of the upper part of the brainstem may produce characteristic posturing when patient is stimulated (see picture left)




• Objective..cont Vomiting & singultus are two objective sign. Vomiting is often projectile in nature & usually not

preceded by nausea (called unexpected vomiting) Singultus is caused by compression of the vagus nerve

(CN X) when brainstem herniation occur. Papilledema, can be detected by using ophtalmoscope

(done by MD’s) as optic disk becomes edematous, reitna is also compressed, damaged retina cannot detect light rays as blind spot enlarges as visual acuity lessened. Papilledema is also called choked disk

Urinary incontinence Bulging fontanelles Leakage of CSF (clear yellow or pinkish fluid) from the

nose (rhinorrhea) or ear (otorrhea).



• Increased intracranial pressure..cont Herniation of the Brain

• When Inc. ICP exerts enough pressure to displace a portion of the brain, herniation can occur. The brain would herniate through a large foramen in the occipital bone, which lies between the cranial and spinal cavities.

• Herniation causes severe injury to the brain because of prolonged hypoxia to parts of the brain that control the vital functions of the body, such as breathing and blood circulation. The result is brain death and death of the patient.

• When ICP is elevated, lumbar puncture is contraindicated , because it can cause the brain to herniate.



• Increased intracranial pressure..cont Diagnostic Test

• CT or MRI scan, shows structural herniation & shifting of the brain

• Most of the time acute increased intracranial pressure is an emergency there is little time for Dx test

• Dx must be based on frequent & careful observation & neurological testing

• Presence of even subtle changes may be very significant

• Internal measuring device used to Dx increased intracranial pressure (see right pic)

ICP Monitoring



• Increased intracranial pressure..cont Medical management

• Treat cause if possible• Mechanical decompression

Craniotomy, bone flap is removed then replaced Craniectomy, bone flap is removed & not replaced

(often done when pressure is high) Drainage of the ventricles or any subdural

hematoma may be beneficial as well• Internal monitoring devices• Endotracheal intubation may be necessary• ABG analysis to guide O2 therapy (to maintain

PAO2 @ 100mmHg)



• Increased intracranial pressure..cont Medical management

• Three types of medications are usually administered to patients with increased intracranial pressure:

Osmotic Diuretics, Corticosteroids & Anticonvulsants. Example of drugs:

1. Osmotic diuretics (mannitol), Loop diuretics (furosemide (Lasix), bumetanide (Bumex), and ethacrynic acid (Edecrin)

2. Midazolam (sedative, hypnotic, antianxiety) and atracurium besylate (neuromuscular blocker)

3. Corticosteroids – Dexamethasone – to control edema surrounding cerebral tumors and abcesses (monitor glucose level).

4. Anticonvulsants - Phenytoin (Dilantin), Fosphenytoin (Cerebyx) through IV for better absorbtion– To prevent seizures



• Increased intracranial pressure..cont Nursing Interventions and Patients Teaching

• Therapeutic measures to reduce venous volume may be implemented.

Elevate the head of the bed to 30 to 45 degrees to promote venous return.

Place the neck in a neutral position (not flexed or extended) to promote venous drainage.

Position the patient to avoid flexion of the hips, waist, and neck as well as rotation of the head, especially to the right. Extreme hip flexion is avoided because this position causes an increase in intraabdominal and intrathoracic pressures, which can produce a rise in ICP.

Instruct the patient to avoid isometric or resistive exercises.

Restrict fluid intake.



• Increased intracranial pressure..cont Nursing Interventions and Patients Teaching

• Therapeutic measures to reduce venous volume may be implemented.

Implement measures to help the patient avoid Valsalva’s maneuever (any forced expiratory effort against a closed airway, such as straining to have a stool). Enemas and laxatives should be avoided if possible.

Have a Foley catheter in place if the patient is not alert because of the large amount of urine that is produced

Perform suctioning only as necessary and for no longer than 10 seconds with admission of 100% oxygen before and after to prevent decreases in the PaO2.

Administer oxygen via mask or cannula to improve cerebral perfusion.

Use a hypothermia blanket to control body temperature (increased body temperature increases brain damage).



• Increased intracranial pressure..cont Prognosis

• The prognosis for the patient with increased intracranial pressure depends on the cause and how rapid with which it is treated.

• The nurse assumes a very important role in monitoring the patient for signs and symptoms of increased pressure.

• After herniation of the brain has begun as a result of pressure, there is little chance for complete reversal without significant brain damage.



• Increased intracranial pressure Clinical manifestations/assessment

• Diplopia

• Headache

• Decreased level of consciousness

• Pupillary signs



• Increased intracranial pressure (continued) Clinical manifestations/assessment (continued)

• Widening pulse pressure

• Bradycardia

• Respiratory problems

• High, uncontrolled temperatures

• Positive Babinski’s reflex

• Seizures

• Posturing

• Vomiting

• Singultus



• Increased intracranial pressure (continued) Medical management/nursing interventions

• Treat cause if possible

• Mechanical decompression Craniotomy Craniectomy

• Internal monitoring devices



• Disturbances in muscle tone and motor function Etiology/pathophysiology

• Damage to the nervous system causes serious problems in mobility

Clinical manifestations/assessment• Flaccid or hyperreflexic muscle tone

• Clumsiness or incoordination

• Abnormal gait



• Disturbances in muscle tone and motor function (continued) Medical management/nursing interventions

• Muscle relaxants

• Protect from falls

• Assess skin integrity

• Positioning

• Sit up and tuck chin when eating

• Encourage patient to assist with ADLs

• Emotional support


Other Disorders of the Neurological SystemOther Disorders of the Neurological System

• Epilepsy or seizures Etiology/pathophysiology

• Transitory disturbance in consciousness or in motor, sensory, or autonomic function due to sudden, excessive, and disorderly discharges in the neurons of the brain; results in sudden, violent, involuntary contraction of a group of muscles

• Types: grand mal; petit mal; psychomotor; Jacksonian-focal; myoclonic; akinetic

• Status epilepticus



• Epilepsy or seizures (continued) Clinical manifestations/assessment

• Depends on type of seizure

• Aura

• Postictal period Medical management/nursing interventions

• During seizure: protect from aspiration and injury

• Anticonvulsant medications

• Surgery Removal of brain tissue where seizure occurs



• Epilepsy or seizures (continued) Medical management/nursing interventions

(continued)• Adequate rest

• Good nutrition

• Avoid alcohol

• Avoid driving, operating machinery, and swimming until seizures are controlled

• Good oral hygiene

• Medical alert tag


Degenerative DiseasesDegenerative Diseases

• Multiple sclerosis Etiology/pathophysiology

• Degenerative neurological disorder with demyelination of the brain stem, spinal cord, optic nerves, and cerebrum



Pathogenesis of multiple sclerosis.

(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and management of clinical problems. [6th ed.]. St. Louis: Mosby.)



• Multiple sclerosis (continued) Clinical manifestations/assessment

• Visual problems

• Urinary incontinence

• Fatigue

• Weakness

• Incoordination

• Sexual problems

• Swallowing difficulties



• Multiple sclerosis (continued) Medical management/nursing interventions

• No specific treatment

• Adrenocorticotropic hormone (ACTH)

• Steroids

• Valium

• Betaseron (interferon beta-1b)

• Avonex (interferon beta-1a)

• Pro-banthine; urecholine

• Bactrim, Septra, and Macrodantin



• Parkinson’s disease Etiology/pathophysiology

• Deficiency of dopamine Clinical manifestations/assessment

• Muscular tremors; bradykinesia

• Rigidity; propulsive gait

• Emotional instability

• Heat intolerance

• Decreased blinking

• “Pill-rolling” motions of fingers



Nigrostriatal disorders produce parkinsonism.




• Parkinson’s disease (continued) Medical management/nursing interventions

• Medications Levodopa Sinemet Artane Cogentin Symmetrol

• Surgery Pallidotomy



• Alzheimer’s disease Etiology/pathophysiology

• Impaired intellectual functioning

• Degeneration of the cells of the brain



• Alzheimer’s disease (continued) Clinical manifestations/assessment

• Early stage Mild memory lapses; decreased attention span

• Second stage Obvious memory lapses

• Third stage Total disorientation to person, place, and time Apraxia; wandering

• Terminal stage Severe mental and physical deterioration



• Alzheimer’s disease (continued) Medical management/nursing interventions

• Medications Agitation: lorazepam; Haldol Dementia: Cognex; Aricept

• Nutrition Finger foods; frequent feedings; encourage fluids

• Safety Remove burner controls at night Double-lock all doors and windows Constant supervision



• Myasthenia gravis Etiology/pathophysiology

• Neuromuscular disorder; nerve impulses fail to pass at the myoneural junction; causes muscular weakness

Clinical manifestations/assessment• Ptosis; diplopia

• Skeletal weakness; ataxia

• Dysarthria; dysphagia

• Bowel and bladder incontinence



• Myasthenia gravis (continued) Medical management/nursing interventions

• Anticholinesterase drugs Prostigmin Mestinon

• Corticosteroids

• May require mechanical ventilation



• Amyotrophic lateral sclerosis (ALS) Etiology/pathophysiology

• Motor neurons in the brain stem and spinal cord gradually degenerate

• Electrical and chemical messages originating in the brain do not reach the muscles to activate them

• Lou Gehrig’s disease



• Amyotrophic lateral sclerosis (ALS) (continued) Clinical manifestations/assessment

• Weakness of the upper extremities

• Dysarthria; dysphagia

• Muscle wasting

• Compromised respiratory function Medical management/nursing interventions

• No cure

• Rilutec (Riluzole)

• Multidisciplinary ALS teams; emotional support



• Huntington’s disease Etiology/pathophysiology

• Overactivity of the dopamine pathways

• Genetically transmitted Clinical manifestations/assessment

• Abnormal and excessive involuntary movements (chorea)

• Ataxia to immobility

• Deterioration in mental functions



• Huntington’s disease (continued) Medical management/nursing interventions

• No cure; palliative treatment

• Antipsychotics

• Antidepressants

• Antichoreas

• Safe environment

• Emotional support

• High-calorie diet


Vascular ProblemsVascular Problems

• Stroke (cerebrovascular accident) Etiology/pathophysiology

• Abnormal condition of the blood vessels of the brain: thrombosis; embolism; hemorrhage

• Results in ischemia of the brain tissue Clinical manifestations/assessment

• Headache

• Sensory deficit

• Hemiparesis; hemiplegia

• Dysphasia or aphasia



Three types of stroke.



Vascular ProblemsVascular Problems

• Stroke (cerebrovascular accident) (continued) Medical management/nursing interventions

• Thrombosis or embolism Thrombolytics Heparin and Coumadin

• Decadron

• Neurological checks

• Feeding tube

• Physical, occupational, and/or speech therapy


Cranial and Peripheral Nerve DisordersCranial and Peripheral Nerve Disorders

• Trigeminal neuralgia Etiology/pathophysiology

• Degeneration of or pressure on the trigeminal nerve; tic douloureux

Clinical manifestations/assessment• Excruciating, burning facial pain

Medical management/nursing interventions• Tegretol

• Surgical resection of the trigeminal nerve

• Avoid stimulation of face on affected side



• Bell’s palsy (peripheral facial paralysis) Etiology/pathophysiology

• Inflammatory process involving the facial nerve Clinical manifestations/assessment

• Facial numbness or stiffness

• Drawing sensation of the face

• Unilateral weakness of facial muscles

• Reduction of saliva

• Pain behind the ear

• Ringing in ear or other hearing loss



• Bell’s palsy (peripheral facial paralysis) (continued) Medical management/nursing interventions

• Electrical stimulation

• Moist heat

• Steroids

• Massage of the affected area

• Facial exercises



• Guillain-Barré syndrome Etiology/pathophysiology

• Inflammation and demyelination of the peripheral nervous system

• Possibly viral or autoimmune reaction



• Guillain-Barré syndrome (continued) Clinical manifestations/assessment

• Symptoms are progressive

• Paralysis usually starts in the lower extremities and moves upward; may stop at any point

• Respiratory failure if intercostal muscles are affected

• May have difficulty swallowing, breathing, and speaking



• Guillain-Barré syndrome (continued) Medical management/nursing interventions

• Adrenocortical steroids

• Apheresis

• Mechanical ventilation

• Gastrostomy tube

• Meticulous skin care

• Range-of-motion exercises



• Meningitis Etiology/pathophysiology

• Acute infection of the meninges

• Bacterial or aseptic



• Meningitis (continued) Clinical manifestations/assessment

• Headache; stiff neck

• Irritability; restlessness

• Malaise

• Nausea and vomiting

• Delirium

• Elevated temperature, pulse, and respirations

• Kernig’s and Brudzinski’s signs



• Meningitis (continued) Medical management/nursing interventions

• Antibiotics Massive doses Multiple types IV or intrathecal

• Steroids

• Anticonvulsants

• Dark, quiet room



• Intracranial tumors Etiology/pathophysiology

• Benign or malignant

• Primary or metastatic

• May affect any area of the brain



• Intracranial tumors (continued) Clinical manifestations/assessment

• Headache

• Hearing loss

• Motor weakness

• Ataxia

• Decreased alertness and consciousness

• Abnormal pupil response and/or unequal size

• Seizures

• Speech abnormalities



• Intracranial tumors (continued) Medical management/nursing interventions

• Surgical removal of tumor Craniotomy Intracranial endoscopy

• Radiation

• Chemotherapy

• Combination of above


TraumaTrauma

• Craniocerebral trauma Etiology/pathophysiology

• Motor vehicle and motorcycle accidents, falls, industrial accidents, assaults, and sports trauma

• Direct trauma: head is directly injured

• Indirect trauma: tension strains and shearing forces

• Open head injuries

• Closed head injuries

• Hematomas


TraumaTrauma

• Craniocerebral trauma Clinical manifestations/assessment

• Headache

• Nausea

• Vomiting

• Abnormal sensations

• Loss of consciousness

• Bleeding from ears or nose

• Abnormal pupil size and\or reaction

• Battle’s sign


TraumaTrauma

• Craniocerebral trauma (continued) Medical management/nursing interventions

• Maintain airway

• Oxygen

• Mannitol and dexamethasone

• Analgesics

• Anticonvulsants


TraumaTrauma

• Spinal cord trauma Etiology/pathophysiology

• Automobile, motorcycle, diving, surfing, other athletic accidents, and gunshot wounds

• Fracture of vertebra

• Complete cord injury

• Incomplete cord injury



Mechanisms of spinal injury.



TraumaTrauma

• Spinal cord trauma (continued) Clinical manifestations/assessment

• Loss of muscle function depends on level of injury

• Spinal shock

• Autonomic dysreflexia

• Sexual dysfunction


TraumaTrauma

• Spinal cord trauma (continued) Medical management/nursing interventions

• Realignment of bony column for fractures or dislocations: immobilization; skeletal traction

Surgery for spinal decompression

• Methylprednisolone

• Mobility: slowly increase sitting up

• Urinary function: Foley catheter; bladder training Intermittent catheterization

• Bowel program


Nursing ProcessNursing Process

• Nursing diagnoses Autonomic dysreflexia Communication, impaired Coping, compromised family Disuse syndrome, risk for Grieving Infection, risk for Knowledge, deficient Memory, impaired


Nursing ProcessNursing Process

• Nursing diagnoses (continued) Mobility, impaired physical Nutrition, imbalanced: less than body requirements Pain, acute, chronic Self-care deficit Swallowing, impaired Thought process, disturbed Tissue perfusion (cerebral), ineffective

chapter 54 care of the patient with a neurological disorder - complete slides

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