Medical-Surgical Nursing The Neurologic Concepts: Jimmellee Ellen P. Olilang, RN

Medical-Surgical Nursing
The Neurologic Concepts
JIMMELLEE ELLEN P. OLILANG, RN

References:
BRUNNER & SUDDARTH’S

TEXTBOOK OF MEDICAL-
SURGICAL NURSING
Learning Objectives
on the completion of this chapter, the learner will be
able to:
 Describe the structure and functions of the central and peripheral
nervous systems.
 Differentiate between pathologic changes that affect motor
control and those that affect sensory pathways.
 Compare the functioning of the sympathetic and parasympathetic
nervous systems.
 Describe the significance of physical assessment to the diagnosis
of neurologic dysfunction.
 Describe changes in neurologic function associated with aging
and their impact on neurologic assessment findings.
 Describe diagnostic tests used for assessment of suspected
neurologic disorders and the related nursing implications.
Outline of Our Lecture
 Anatomy and Physiology

 Application of the Nursing process in the
approach of neurologic problems:
 ASSESSMENT – relevant techniques and lab
procedures
 DIAGNOSIS
 PLANNING
 IMPLEMENTATION
 EVALUATION
Outline of the lecture
 Trauma and related accidents

 Traumatic brain injury
 Spinal cord injury
 Cerebrovascular Accidents
 Degenerative disorders- demyelinating

 Multiple sclerosis
 Guillain-Barre’ syndrome
Degenerative disorders-
NON-demyelinating
 Alzheimer’s disease
 Parkinson’s disease
 Motor dysfunction- CNS

 Epilepsy
 Motor dysfunction- cranial nerve
 Bell’s palsy
 Trigeminal neuralgia
 Motor dysfunction- peripheral

 Myasthenia gravis
Infectious Disease
Meningitis
Brain abscess
Encephalitis
IMPLEMENTATION PHASE
 Increased Intracranial pressure

 Altered level of consciousness
 Seizures
 Autonomic dysreflexia / hyperreflexia
 Spinal shock
 Cognitive impairment
 Bowel incontinence
IMPLEMENTATION PHASE
Impaired physical mobility

Impaired swallowing
Disturbed sensory
perception
A. CEREBRAL DISORDERS C. PERIPHERAL NERVOUS SYSTEM
 Epilepsy DISORDERS
 Seizures  Lower Back Pain
 Brain Tumors  Trigeminal Neuralgia
 Cerebrovascular Disease  Bell’s Palsy
 Brain Infections  Vascular Spinal Cord Lesions
 Headaches  Disorders of the Peripheral Nerves
B. DEGENERATIVE NEUROLOGIC
DISORDERS
 Dementia (Alzheimers)
D. NEUROLOGIC TRAUMA
 Parkinson’s Disease  Spinal Cord Injury
 Creutzfeldt-Jakob Disease  Head Injury
 Huntington’s Disease
 Multiple Sclerosis
 Guillain Barre Syndrome
 Myasthenia Gravis
 Amyotrophic Lateral Sclerosis
Anatomy and Physiology
 Gross anatomy
 The nervous system is divided into the central and peripheral nervous
system
 Control all motor, sensory, autonomic, cognitive and behavioral activities.
 The Central nervous system consists of the BRAIN and the SPINAL
CORD
 The peripheral nervous system consists of the SPINAL NERVES and
the CRANIAL NERVES

 Can be further divided into the: SOMATIC OR VOLUNTARY NERVOUS SYSTEM
AND THE AUTONOMIC OR INVOLUNTARY NERVOUS SYSTEM
BRAIN - it collects, integrates, and interprets all stimuli
- it initiates & monitors voluntary & involuntary motor activity
 CEREBRUM (cerbral cortex)

 BRAIN STEM
 CEREBELLUM
Cerebrum
-Gives us the ability to think & reason

-enclosed in 3 membrane layers called meninges
is composed of lobes-
 Frontal lobe- personality, memory and motor
function
 Parietal lobe- sensory function
 Temporal lobe- hearing and olfaction and emotion by

the limbic system
 Occipital lobe- vision
 The cerebellum is involved in coordination and

equilibrium
 The diencephalon (a part of the cerebellum)
consists of the :
 Thalamus- the relay center of all sensory input
 Hypothalamus- center for endocrine regulation,
sleep, temperature, thirst, sexual arousal and

emotional response
 The brainstem (beneath the diencephalon)
 Relays messages between the cerebrum & diencephalon &
spinal cord
 Regulates automatic body fxns e.g. HR, RR, swallowing, &
coughing
 is composed of:
 midbrain- for visual and auditory reflexes
 Pons- respiratory apneustic center, nucleus of cranial nerves-

5,6,7,8
 Medulla oblongata- respiratory and cardiovascular centers,
nucleus of cranial nerves 9,10,11,12
Peripheral Nervous System
 Includes:
 Peripheral sensory nerves transmit stimuli from
sensory receptors in the skin, muscles, sensory
organs, & the viscera to the dorsal horn of the spinal
cord
 The upper motor neurons of the brain & the lower
motor neurons of cell bodies in the ventral horn of
the spinal cord carry impulses that affect the
movement
Autonomic Nervous System
 Contains motor neurons that

regulate visceral organs & innervate
( supply nerves to ) smooth &
cardiac muscles & the glands
TWO PARTS OF ANS
 1. sympathetic nervous system

 Controls the fight or flight response
 2. parasympathetic nervous systrem

 Maintains the baseline of the body
functions
 Resposible for the rest & digest response
 or nervous system is the body’s communication network
 it coordinates and organizes the functions of all other body systems
NERVOUS SYSTEM
Central Nervous System Peripheral Nervous System
Brain Spinal Cord Motor (Efferent) Sensory (Afferent )

Neurons Neuron
Sympathetic Nervous
Somatic Nervous Autonomic Nervous System
System System
Parasympathetic
Nervous System
 the NEURON or NERVE CELL is the nervous system’s
fundamental unit
this highly specialized conductor cell receives and
transmits electrochemical nerve impulses
 delicate, threadlike nerve fibers called

AXONS & DENDRITES extend from the
cell body & transmit signals
 Axons carry impulses away from the

cell body;dendrites carry impulses to the
cell body
 this intricate network of interlocking

receptors & transmitters, along with
the brain & spinal cord, forms a living
computer that controls & regulates every
mental and physical function
Each neuron communicates with each
other to a specific target tissue through
neurotransmitters
 These neurotransmitters are produced

& stored in the synaptic vesicles;they
enable conduction of impulses across the
synaptic cleft
MAJOR NEUROTRANSMITTERS:
 The action of neurotransmitters is to
1. Acetycholine potentiate, terminate or modulate a
2. Serotonin specific action & can either excite or
3. Dopamine inhibit the target cell’s activity.
4. Norepinephrine
5. Gamma-aminobutyric acid (GABA)
6. Enkephalin,endorphin
Major Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION
ACETYLCHOLINE Many areas of the brain; Usually excitatory;

autonomic Nervous System parasympathetic effects
- (major transmitter sometimes inhibitory
of the (simulation of heart by
parasympathetic vagal nerve)
nervous system)
SEROTONIN Brain stem, hypothalamus, Inhibtory, helps control
dorsal horn of the spinal mood and sleep, inhibits
cord pain pathways
DOPAMINE Substantia Nigra and basal Usually inhibits, affects

ganglia behavior (attention,
emotions, fine movements)
Major Neurotransmitters
NEUROTRANSMITTER SOURCE ACTION
ACETYLCHOLINE Many areas of the Usually excitatory;

parasympathetic effects
- (major transmitter of brain; autonomic sometimes inhibitory (simulation
the parasympathetic Nervous System of heart by vagal nerve)
nervous system)
SEROTONIN Brain stem, hypothalamus, dorsal Inhibtory, helps control mood
horn of the spinal cord and sleep, inhibits pain pathways
DOPAMINE Substantia Nigra and basal Usually inhibits, affects behavior

ganglia (attention, emotions, fine
movements)
ENKEPHALIN, Nerve terminals in the spine, Excitatory; pleasurable

brain stem, thalamus and sensation, inhibits pain
ENDORPHIN hypothalamus, pituitary gland transmission
 consists of the brain & the spinal cord
that are protected by the bony skull and
vertebrae, cerebrospinal fluid (CSF) and
three membranes: the dura mater, the
arachnoid membrane and the pia mater
The brain is contained in the rigid
skull, which protects it from injury;the
major bones of the skull are the frontal,
temporal, parietal & occipital bones;
These bones join at the suture lines
 The bones of the vertebral column

surround & protect the spinal cord &
normally consists of 7 cervical, 12
thoracic, 5 lumbar vertebrae,sacrum &
coccyx.
Scalp skin
Inner /Outer layers of the Skull
Dura mater (2 layers)
 is a tough,fibrous, leatherlike tissue

Composed of two layers:
1. Endosteal dura:forms the periosteum Of

the skull & is continuous with the Lining of
the vertebral canal
2. Meningeal dura: a thick membrane
covers the brain, dipping between the
brain tissue & providing support &
protection
Arachnoid mater: is a thin, fibrous

membrane that hugs the brain &
spinal cord
Pia mater: is a continuous layer of

Connective tissue that covers &
Contours the spinal tissue & brain
 The epidural space lies between
the skull & the dura mater
 Between the dura mater & the

arachnoid membrane is the subdural
space
 Between the arachnoid membrane

& the pia mater is the subarachnoid
space
 Within the subarachnoid space &
the brain’s four ventricles is CSF, a
liquid composed of water & traces
of organic materials (especially CHON)
glucose and minerals;this fluid
protects
the brain & spinal tissue from jolts &
blows
ASSESSMENT OF THE NEUROLOGIC SYSTEM
 HISTORY
 Initial interview provides excellent opportunity
to explore the current condition and events
while observing appearance, mental status,
posture, movement and affect.
 A confused client becomes an unreliable
source of history
PHYSICAL EXAMINATION
 5 categories:
 1. Cerebral function- LOC, mental status
 2. Cranial nerves
 3. Motor function
 4. Sensory function
 5. Reflexes
Neuro Check
 Level of consciousness
 Pupillary size and response
 Verbal responsiveness
 Motor responsiveness
 Vital signs
CEREBRAL FUCTION
 Assess the degree of

wakefulness/alertness
 Note the intensity of stimulus to cause a
response
 Apply a painful stimulus over the nailbeds
with a blunt instrument
 Ask questions to assess orientation to
person, place and time
Cerebral function
 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
Glasgow Coma Scale
Glasgow Coma Score

Eye Opening (E)
Verbal Response (V)
Motor Response (M)

Glasgow Coma Scale
Glasgow Coma Score

Eye Opening (E)
4=Spontaneous
3=To voice
2=To pain
1=None (No response)
Glasgow Coma Scale
Glasgow Coma Score

 Verbal Response (V)
5=Normal/oriented
4=Disoriented/CONFUSED
3=Words, but incoherent/ inappropriate
2=Incomprehensible/mumbled words
1=None
Glasgow Coma Scale
Glasgow Coma Score
 Motor Response (M)
6=Normal- obeys command

5=Localizes pain
4=Withdraws to pain
3=Decorticate posture
2=Decerebrate posture
1=None (flaccid)
GLASGOW COMA SCALE
 CONSCIOUS glasgow coma of 12 – 15

 LIGHT STUPOROUS 9 – 11
 DEEP STUPOROUS 7– 8
 LIGHT COMA 4–6
 DEEP COMA 3
PUPILLARY CHANGES
Unilateral dilated (4mm) uncal herniation

Fixed non-reactive Brain stem compression
Subdural / epidural hematoma
Tentorial / herniation
Bilateral dilated (4mm) Severe midbrain damage

Fixed non-reactive CP arrest
Bilateral mid-sized Midbrain involvement caused by
(2mm) edema, hemorrhage, infarction,
Fixed non-reactive lacerations, contusions
Pipillary Changes
Bilateral Pinpoint (<1mm) Lesions of the pons

Non-reactive
Unilateral, small (1.5mm) Disruption of the SNS

Non-reactive supply to the head due to
spinal card lesion above T1
CRANIAL NERVES
Cranial
Nerves
I olfactory smell
II optic vision
III oculomotor Most eye mov’t, pupillary constriction,
upper eyelid elevation
IV trochlear Down & in down mov’t
V trigeminal Chewing, corneal reflex, face & scalp
sensations
VI
CRANIAL NERVES
Cranial
Nerves
VI abducent Lateral eye movement
VII
facial Expressions in forehead
VIII
acoustic Hearing & balance
IX
glossopha Swallowing, salivating, taste
ryngeal
X Swallowing, gag reflex, talking, sensations of the throat,
vagus larynx & abd’l viscera, activities of thoracic & abd’l
viscera, e.g. HR, & peristalsis
XI accessory Shoulder mov’t, head rotation
Cranial Nerve Function: Cranial Nerve 1-
Olfactory
 Check first for the patency of the nose

 Instruct to close the eyes
 Occlude one nostrils at a time
 Hold familiar substance and asks for the
identification
 Repeat with the other nostrils
 PROBLEM- ANOSMIA- “loss of smell”

Optic
 Check the visual acuity with the use of the

Snellen chart
 Check for visual field by confrontation test
 Check for pupillary reflex- direct and

consensual
 Fundoscopy to check for papilledema
Snellen chart
Cranial Nerve Function: Cranial Nerve 3, 4
and 6
 Assess simultaneously the movement

of the extra-ocular muscles
Deviations:
 Opthalmoplegia- inability to move the
eye in a direction
 Diplopia- complaint of double vision
Cranial Nerve Function: Cranial Nerve 5 -
trigeminal
 Sensory portion- assess for sensation

of the facial skin
 Motor portion- assess the muscles of
mastication
 Assess corneal reflex
Cranial Nerve Function: Cranial Nerve 7 -
facial
 Sensory portion- prepare salt, sugar,

vinegar and quinine. 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 Function: Cranial Nerve 8- vestibulo-
auditory
 Test patient’s hearing acuity

 Observe for nystagmus and disturbed
balance
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
accessory
 Press down the patient’s shoulder

while he attempts to shrug against
resistance
hypoglossal
Ask patient to protrude the

tongue and note for
symmetry
NEUROLOGIC ASSESSMENT
 CEREBRAL FUNCTION
 Includes level of consciousness,
intellectual function, speech, speech,
memory, patterns of emotional
behavior, balance & coordination
DESCRIBING LEVEL OF CONCIOUSNESS
 AWAKE – alert & completely oriented

- responds to verbal & painful stimuli
 SLEEP – becomes alert & oriented when awakened
- responds to stimuli
 CONFUSION – has short attention span & misinterpret
information
- disoriented to time, place, person & has trouble
following commands, but still responds to stumuli
DESCRIBING LEVEL OF CONSCIOUSNESS
 DELIRIUM – disoriented, agitated, & perhaps may have

hallucinations, & responds to stimuli
 OBTUNDED – remains drowsy when awakened, disoriented &
confused
- stays awake only if he’s continously stimulated
 LIGHT STUPOR – does not respond to stimuli, withdraws
quickly & forcefully from moderate pain which he can localize
 DEEP STUPOR – responds only to a strong stimulus, when he
can’t localize
- may note decerebrate posture
DESCRIBING LEVEL OF CONSCIOUSNESS
COMA – doesn’t responds to any stimuli

- vital signs may be stable
- may note brain stem & spinal cord reflexes
- EEG shows activity
CEREBRAL DEATH – vital signs must be maintained
artificially
- has reflexes & no EEG activity
- doesn’t responds to stimuli
ASSESS Motor function
 Assess muscle tone and strength by

asking patient to flex or extend the
extremities over resistance
 Grading of muscle strength
GRADING SCALE FOR MOTOR STRENGTH
5/5 movement against gravity with strong

resistance
4/5 movement against gravity with some
resistance
3/5 movement against gravity with out resistance
2/5 movement not against gravity
1/5 trace movement
0/5 no movement
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
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
brainstem
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/muscle-stretch reflexes
– assymetrical – indicate paralysis

- brisk response – indicate localizing value
- absent – deep coma
 Biceps
 Triceps
 Brachioradialis
 Patellar
 Assessing the sensory function Achilles

Assessing the reflexes
 Superficial /cutaneous reflexes
 Abdominal
 Cremasteric
 Anal
 Pathologic/primitive 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
 Brudzinski & kernig’s sign – meningeal irritation in meningitis
Grading of reflexes
Deep tendon reflex
 0- absent
 + present but diminished
 ++ normal
 +++ increased
 ++++ hyperactive or clonic
Superficial reflex
 0 absent
 +present
DIAGNOSTIC TESTS
 EEG (electroencephalogram) – represents a record of

electrical activity generated in the brain.
 It provides physiologic assessment of cerebral activity and
determining brain death
 Test diagnosing and evaluating Sz disorders, coma, or
organic brain syndrome

 Withhold medications that may interfere with the results-
anticonvulsants, sedatives and stimulants

 Wash hair thoroughly before procedure
 It takes 45 to 60 mins
Nursing interventions to patient undergoing
EEG
 Recommend the patient not to sleep the

night before the procedure to increase the
chances of recording Sz activities.
 Anti Sz agents, tranquilizers, stimulants
and depressants shld be withheld 24 to 48
hours before the test
DIAGNOSTIC TESTS
CT scan – makes use of a narrow x-ray beam to scan the

body part in successive layers
 With radiation risk
 If contrast medium will be used- ensure consent, assess
for allergies to dyes and iodine or seafood, flushing and

metallic taste are expected as the dye is injected.
 The injection of the water soluble iodinated contrast agent
into the subarachnoid space through the lumbar puncture
improves the visualization of the spinal and intracranial
contents on these images.
Nursing interventions for patient undergoing
CT scan
 Teach the patient the need to lie quietly throughout the
procedure
 Sedation could be used if agitation and restlessness interfere
with the successful study
 For patient is to be using a contrast agent:
 Assess the patient for allergy to iodine and shellfish because the agent
is iodine based
 IV line is needed for the contrast flushing
 A period of fasting for 4 hours is needed
 Assess for the S/Sx of allergy like flushing, nausea & vomiting
DIAGNOSTIC TESTS
MRI
Uses magnetic waves
Patients with pacemakers, orthopedic
metal prosthesis and implanted metal

devices cannot undergo this procedure
DIAGNOSTIC TESTS
Cerebral arteriography
Note allergies to dyes, iodine and
seafood
Ensure consent
Keep patient at rest after procedure
Maintain pressure dressing or sandbag

over punctured site
DIAGNOSTIC TESTS
Lumbar puncture and examination of CSF
 Ensure consent, determine ability to lie still
 Contraindicated in patients with increased ICP
 Keep flat on bed after procedure
 Increase fluid intake after procedure
 CSF pressure with the patient in lateral position is

normally 70 – 200 mmH20.
 > 200 mm H20 = abnormal
Lumbar puncture (spinal tap)
 It is performed to obtain CSF for examination, to measure and

reduce CSF pressure, to determine presence or absence of
blood in the CSF, to detect subarachnoid block, & to
administer antibiotics intrathecally (into the spinal canal)
 Queckenstedt’s Test – lumbar manometric test – compress the
jugular veins on each side of the neck during the lumbar

puncture
 Normal- CSF pressure is increased
 Slow rise and fall in pressure- indicates a partial block due to a lesion
compressing the spinal arachnoid pathways

Lumbar puncture (spinal tap)
 Cerebrospinal Analysis
 Normal – clear & colorless
 Cerebral contusion, laceration,
subarachnoid hemorrhage - Pink,

blood-tinged, or bloody CSF
Increased Intracranial pressure
Intracranial pressure more than 15 mmHg
Brunner= Normal intracranial pressure 10-20 mmHg
Causes:
 Head injury
 Stroke
 Inflammatory lesions
 Brain tumor
 Surgical complications
Pathophysiology
 The cranium only contains the brain substance (1400g), the
CSF (75mL) and the blood/blood vessels (75 ml)
 MONRO-KELLIE hypothesis- an increase in any one of the
components causes a change in the volume of the other
 Any increase or alteration in these structures will cause
increased ICP
 Increased ICP from any cause decrease cerebral perfusion,
stimulates further swelling and may shift brain tissue through
openings in the rigid dura, resulting herniation
Pathophysiology
Decompensatory mechanisms:
 1. Decreased cerebral perfusion
 2. Decreased O2 leading to brain hypoxia
 3. Cerebral edema
 4. Brain herniation
Decreased cerebral blood flow
 Vasomotor reflexes are stimulated initially

slow bounding pulses
 Increased concentration of carbon dioxide
will cause VASODILATION  increased
flow increased ICP
Cerebral Edema
 Abnormal accumulation of fluid in the

intracellular space, extracellular space or
both.
Herniation
 Results from an excessive increase in ICP when the pressure
builds up and the brain tissue presses down on the brain
stem
Cerebral response to increased ICP
1. Steady perfusion up to 40 mmHg

2. Cushing’s response
 Vasomotor center triggers rise in BP to increase ICP
 Sympathetic response is increased BP but the heart
rate is SLOW
 Respiration becomes SLOW
Increased intracranial pressure
CLINICAL PICTURE:
 Subtle to dramatic changes in LOC; restlessness,
confusion, drowsiness, stupor, coma
 Double or blurred vision, headache, nausea\ and
vomiting, photosensitivity
 Decreased motor function
 Late findings: Changes in vital signs (widening of
pulse pressure, bradycardia, tachypnea)

CLINICAL MANIFESTATIONS
Early manifestations:
 Changes in the LOC- usually the earliest
 Pupillary changes- fixed, slowed response
 Headache
 vomiting
CLINICAL MANIFESTATIONS
late manifestations:
 Cushing reflex- systolic hypertension, bradycardia
and wide pulse pressure

 bradycardia
 Hyperthermia
 Abnormal posturing
Nursing interventions:
Maintain patent airway
 1. Elevate the head of the bed 15-30 degrees- to
promote venous drainage

 Assess VS
 2. assists in administering 100% oxygen or controlled

hyperventilation- to reduce the CO2 blood levelsconstricts
blood vesselsreduces edema
 Notify physicians of findings
 Keep head in neutral alignment
 Avoid flexion of the neck or hips

Increased Intracranial Pressure
minimize environmental stimuli

 document patient’s status, phone call to
physician and physician response
thereafter
Increased intracranial pressure
 FOCUSED ASSESSMENT
 Assess neuro status
 Assess cranial nerves as condition allows
 Asses Oxygen saturation, cardiac rhythm
 Assess for signs of decreased oxygenation
 STABILIZING & MONITORING

 Monitor neuro status & V/S
 Keep SBP bet. 100mmHg-160mmHg (check AP for parameters)g
 Limit suctioning (<10secs in duration, adm. O2 before hand; limit
to 2 passes
 Maintain O2 sat at 100%
Increased ICP
 Maintain & assess I&O

 Monitor ABG & electrolytes
 Insert oral / nasal airway if neccesary
 Maintain quiet environment; protect from injury
 Provide education/reassurance/comfort measures
 Document all findings & communicate to physicians
 Obtain/perform chest physiotherapy as needed;

assess nutritional status; obtain consult as needed
Nursing interventions
 3. Administer prescribed medications- usually
Mannitol- to produce negative fluid balance

 corticosteroid- to reduce edema
 anticonvulsants- to prevent seizures

Nursing interventions
 4. Reduce environmental stimuli
 5. Avoid activities that can increase ICP like
valsalva, coughing, shivering, and vigorous

suctioning
 Nursing interventions
 6. Keep head on a neutral position. AvOID-
extreme flexion, valsalva
 7. monitor for secondary complications
 Diabetes insipidus- output of >200 mL/hr

 SIADH
Altered level of consciousness
 It is a function and symptom of

multiple pathophysiologic phenomena
 Causes: head injury, toxicity and
metabolic derangement
 Disruption in the neuronal transmission
results to improper function

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
 Inability to speak
 Confused, lethargic, obtunded,

stuporous, or comatose
 Etiologic Factors
1. Head injury
2. Stroke
3. Drug overdose
4. Alcoholic intoxication
5. Diabetic ketoacidosis
6. Hepatic failure
 ASSESSMENT
1. Behavioral changes initially
2. Pupils are slowly reactive
3. Then , patient becomes unresponsive and
pupils become fixed dilated

Glasgow Coma Scale is utilized
Nursing Intervention
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 and 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
SEIZURES
 Episodes of abnormal motor, sensory,

autonomic activity resulting from
sudden excessive discharge from
cerebral neurons
 A part or all of the brain may be
involved
SEIZURES
 PATHOPHYSIOLOGY
 An electrical disturbance in the nerve cells in one brain section
EMITS ELECTRICAL IMPULSES excessively
 CLINICAL PICTURE
 Repetitive, jerky mov’t of all extremities
 Extreme muscle rigidity
 LOC or disorientation
 Tongue or eye deviation
 Cyanosis/apnea
 Urinary or fecal incontinence
 Blinking or repetitive behaviors (playing buttons)

SEIZURE
 CLINICAL PICTURE
Difficulty in arousing
Aura ( warning or recognition that
seizures may occur)

SEIZURES
 ETIOLOGIC FACTORS
1. Idiopathic
2. Fever
3. Head injury
4. CNS infection
5. Metabolic and toxic conditions
SEIZURE
 6 types of seizures:
 Simple partial-sensory symptoms (flashing lights, smells,
auditory hallucinations)
 Autonomic symptoms (sweating, flushing, pupil dilation)
 Psych symptoms ( dream states, anger, fear)
 Complex partial seizure
 Altered LOC
 Amnesia
 Absence seizure
 A brief change in LOC indicated by blinking or rolling of the eyes,
a blank stare, and a slight mouth mov’t
SEIZURE
 Myoclonic seizure
 Brief involutary muscular jerks of the body or extremities
 Generelized tonic-clonic seizure

 Typically beginning with a loud cry
 Change in LOC
 Body stiffening, alternating between muscle spasm & relaxation
 Tongue biting, incontinence, labored breathing, apnea, cyanosis,
 Upon wakening, possible confusion & difficulty talking
 Drowsiness, fatigue, headache, muscle soreness, weakness
 Atonic seizure
 General loss of postural tone
 Temporary loss of consciousness
SEIZURES
Nursing Interventions
During seizure
 1. remove harmful objects from the patient’s
surrounding
 2. ease the client to the floor
 3. protect the head with pillows
 4. Observe and note for the duration, parts of

body affected, behaviors before and after the
seizure
SEIZURES
During seizure
 5. loosen constrictive clothing
 6. DO NOT restrain, or attempt to
place tongue blade or insert oral

airway
SEIZURES
POST seizure
 1. place patient to the side to drain
secretions and prevent aspiration
 2. help re-orient the patient if confused
 3. provide care if patient became

incontinent during the seizure attack
 4. stress importance of medication
regimen
HEADACHE
 Cephalgia-pain in the head
 90% is caused by muscle contraction & vascular abnormalities
 Indicates underlying intracranial, systemic, psychological disorder
TYPES OF HEADACHE:
1. Primary headache- no organic cause
2. Secondary headache- with organic cause
3. Migraine headache/throbbing vascular headache-periodic attacks of
headache due to vascular disturbance
 Affect 10% of Americans
 Begin in childhood or adolescence & recur throughout adulthood
 Tend to run in families w/c are common in women than men
4. Tension headache-the most common type- due to muscle tension
CAUSES OF HEADACHE
 Emotional stress or fatigue
 Menstruation
 Environmental stimuli (crowds, noise, bright lights)
 Glaucoma
 Inflammation of the eyes or nasal/paranasal sinus mucosa
 Disease of the scalp, teeth, external/middle ear
 Vasodilators (nitrates, alcohol, histamine)
 Systemic disease
 HPN
 Head trauma/tumor
 Intracranial bleeding
headache
 Migraine-unilateral pulsating pain w/c become more

generalized overtime lasting up to 2days
 Stages of migraine
1. Prodrome stage – symptom indicating the onset
2. Aura phase – a sensation that forewarns of an attack
- Usually affects the patient’s eyesight with brilliant
flickering lights or blurring of vision, but may also
result from numbness or weakness of limbs
3. Headache
4. Recovery phase
OTHER TYPES OF
HEADACHE
HEADACHE
 Muscular contraction & traction-

inflammatory vascular headache
 Dull, persistent ache or severe, unrelenting pain
 Tender spots on the head & neck
 Feeling of tightness around the head with a characteristic
“hatband” distribution
HEADACHE
 INTRACRANIAL BLEEDING
 Neuro deficits, such as paresthesia & muscle weakness
 Unrelieved by opiods
HEADACHE
 TUMOR
 Pain that’s most severe when the patient is awake
headache
 1. Avoid precipitating factors
 2. modify lifestyle
 3. relieve pain by pharmacologic measures
 Beta-blockers
 Serotonin antagonists- “triptan"
Autonomic Dysreflexia/hyperreflexia
 Seen commonly in spinal cord injury
 An exaggerated response by the
autonomic system resulting from

various stimuli most commonly
distended bladder, impacted feces,
pain, skin irritation
SKELETAL SPINE
 Clinical MANIFESTATIONS
 1. Hypertension
 2. Bradycardia
 3. severe pounding headache
 4. diaphoresis
 5. nausea and nasal congestion
NURSING INTERVENTIONS
 1. Elevate the head of the bed immediately
 2. Check for bladder distention and empty bladder with urinary

catheter
 3. Check for Fecal impaction and other triggering factors like skin
irritation, pressure ulcer
 4. Administer antihypertensive medications- usually hydralazine
Spinal Shock
Pathophysiology
 The sudden depression of reflex activity in the spinal cord
below the level of injury
 The muscles below the lesion are flaccid, the skin without
sensation and the reflexes are absent including bowel and
bladder functions
Spinal Shock
 Nursing Interventions
 1. Assist in chest physical therapy
 2. Manage potential complication- DVT
Cognitive Impairment
1. Assist or encourage the patient to use eyeglass, hearing aid
or assistive devices
2. Reorient the patient by calling his name frequently
3. Provide background information as to date, time, place,
environment
Cognitive Impairment
4. Use large signs as visual cues
5. Post patient's photo on the door
6. Encourage family members to bring personal articles and
place them in the same area
Bowel and Bladder incontinence
 Establish a regular pattern for bowel care
 Maintain a dietary intake. Avoid foods that can cause
excessive gas production
CONGENITAL DISORDERS:
Hydrocephalus
 Excessive CSF accumulation in the brain’s ventricular system
leading to their enlargement and swelling
 In infants- head enlarges
 In children and adults- brain compression
Hydrocephalus
 Non-communicating hydrocephalus results from CSF outflow
obstruction
 Communicating hydrocephalus results from faulty absorption
or increased CSF production
Hydrocephalus
 Assessment
 1. irritability
 2. change in LOC
 3. infants- enlargement of the head, thin scalp skin
 4. sunset eyes – or setting sun; sclera is above the iris; depressed
eyes
Hydrocephalus
 DIAGNOSTIC TESTS
 1. Skull x-ray
 2. ventriculography – x ray exam of the ventricles of the
brain after the introduction of the introduction of the contrast
medium, such as air or radiopaque material; has been
replaced by ct scan & MRI
Hydrocephalus
 GOAL OF Treatment: to minimize & prevent

brain damage by improving CSF flow
 Nursing Intervention
 1. monitor neurologic status
 2. teach parents to watch for signs of shunt

malfunction, and periodic surgery to lengthen
the shunt as child grows
hydrocephalus
 Shunting-surgical intervention to primary treat hydrocephalus
 It includes the direct removal of the obstruction with in the brain
so as to allow CSF to bypass the obstructed area, if the obstructed
cannot be removed
 Shunting of CSF to an outside of the brain
 Right atrium of the heart
 Abdominal peritoneum
 Cautery – destruction by burning or removal of the parts of
the ventricles that produce CSF may reduce CSF production
Traumatic brain injury
1. CONCUSSION
 Involves jarring of head without tissue injury
 Temporary loss of neurologic function lasting for a few
minutes to hours
2. CONTUSION
 Involves structural damage
 The patient becomes unconscious for hours

3. Diffuse Axonal injury
 Involves widespread damage to the neurons
 Patient has decerebrate and decorticate posture

4. 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
MANIFESTATIONS
 1. Altered LOC
 2. CSF otorrhea
 3. CSF rhinorrhea
 4. Racoon eyes and battle sign
 HALO SIGN- blood stain surrounded by a yellowish stain

NURSING MANAGEMENT
1. Monitor for declining LOC- use of Glasgow
2. Maintain patent airway
 Elevate bed, suction prn, monitor ABG
NURSING MANAGEMENT
3. Monitor F and E balance
 Daily weights
 IVF therapy
 Monitor possible development of DI and SIADH

4. Provide adequate nutrition
5. Prevent injury
 Use padded side rails
 Minimize environmental stimuli
 Assess bladder
 Consider the use of intermittent catheter

 Prolonged immobility will likely cause skin breakdown
 Turn patient every 2 hours
 Provide skin care every 4 hours
 Avoid friction and shear forces

7. Monitor potential complications
 Increased ICP
 Post-traumatic seizures
 Impaired ventilation
Spinal cord injury
 The most frequent vertebrae – C5-C7, T12 and L1
 Concussion
 Contusion
 Compression
 Transection
 is trauma to the spinal cord which results
In complete (transection) or partial disruption
Nerve tracts & neurons
 The level of cord involved dictates the
consequences of spinal cord injury
 most frequently vertebrae involved are:

• 5th,6th, 7th cervical
• 12th thoracic
•1st lumbar
 injuries may involve contusions, laceration,

Or compression of the spinal cord
 majority of spinal cord injury occur from

car accidents, falls or sports injuries
 Risk factors:
• male
• High risk lifestyle activities
• Active in sports
• Age (teen to early 20’s)
• Alcohol and/or drug abuse
After an injury
Petechial hemorrhages in the

Central gray matter of the cord
Spinal Shock: decrease reflexes
flaccid paralsis
ischemia
Neurogenic Shock: Sudden disruption of

Edema results to sympathetic nervous system
Permanent damage
Hypotension
Spinal cord loses function bradycardia

Below the level of lesion
Hypothermia
Warm/dry extremities
Peripheral vasodilation that lead venous pooling
Decrease cardiac output

Spinal cord injury
Clinical manifestations
 1. Paraplegia
 2. quadriplegia
 3. spinal shock
 are classified according to cause, level of injury and degree of disruption produced
Central cord syndrome
•Characteristics: Motor deficits (in the

upper extremities compared to the lower
extremities; sensory loss varies but is
more pronounced in the upper
extremities); bowel/bladder dysfunction
is variable, or function may be completely
preserved.
•Cause: Injury or edema of the central
cord, usually of the cervical area.
Anterior cord syndrome
•Characteristics: Loss of pain,

temperature, and motor function is
noted below the level of the lesion;
light touch, position, and vibration
sensation remain intact.
•Cause: The syndrome may be caused
by acute disk herniation or hyperflexion
injuries associated with fracture-
dislocation of vertebra. It also may
occur as a result of injury to the anterior
spinal artery, which supplies the anterior
two-thirds of the spinal cord.
Brown-Séquard syndrome
(lateral cord syndrome)
•Characteristics: Ipsilateral paralysis

or paresis, together with ipsilateral loss
of touch, pressure, and vibration and
contralateral loss of pain & temperature.
•Cause: The lesion is caused by a
transverse hemisection of the cord
(half of the cord is transected from
north to south), usually as a result of
a knife or missile injury, fracture/
dislocation of a unilateral articular
process, or possibly an acute ruptured
disk.
PHARMACOLOGY
1. Glucocorticoids: Decadron
DIAGNOSTIC TESTS/LABORATORY 2. Vasopressors:
1. History & physical examination Norepinephrine,dopamine
2. X-rays 3. Muscle relaxants: methocarbamol
3. MRI 4. Anti-spasmodics:dantrolene
4. CT Scan sodium
5. Electromyography 5. Analgesics:opioid & non opioid
COMPLICATION
NSAIDS
1. Paralysis 6. Antidepressants
2. Autonomic dysreflexia 7. Histamine H2 receptor antagonists
3. Neurogenic shock (spinal shock) 8. Anticoagulant
4. Contractures 9. Stool softeners
5. Muscle atrophy 10. vasodilators
6. Pressure ulcers
7. Stool impaction
8. Death
NURSING MANAGEMENT
1. Assess/Monitor: 2. Nursing activities:

a.Vital signs a.Maintain patent airway
b.Neurological status b. Maintain mechanical ventilation as
c. For signs of thrombophlebitis Prescribed
d. For spinal shock c. Perform passive exercises
e. For autonomic dysreflexia: d. Encourage deep breathing exercises
hypertension,bradycardia,flushed face e. Encourage active exercises
& neck,severe headache,nasal stuffiness, f. Maintain skin integrity
dilated pupils,Blurred vision, sweating, g. Assist with turning as needed
nausea) h. Maintain adequate fluid intake
f. Oxygen saturation levels i.Teach self-catheterization
g. For bladder distention j.Institute bowel retraining as needed
h. For indications of altered body image/ k.Teach regarding sexual function/
Self concept dysfunction
Spinal cord injury
 DIAGNOSTIC TEST
 Spinal x-ray
 CT scan
 MRI
Spinal cord injury
 EMERGENCY MANAGEMENT
 A-B-C
 Immobilization
 Immediate transfer to tertiary facility
Spinal cord injury
NURSING INTERVENTION
 1. Promote adequate breathing and airway clearance
 2. Improve mobility and proper body alignment
 3. Promote adaptation to sensory and perceptual alterations
 4. Maintain skin integrity

Spinal cord injury
 5. Maintain urinary elimination
 6. Improve bowel function
 7. Provide Comfort measures
 8. Monitor and manage complications
 Thromboplebhitis
 Orthostaic hypotension
 Spinal shock
 Autonomic dysreflexia
Spinal cord injury
 9. Assists with surgical reduction and stabilization of cervical
vertebral column
is an umbrella term that refers to any functional
abnormality of the CNS that occurs when the normal blood
supply to the brain is disrupted
Modifiable risk factors include:

A.Hypertension: major risk factor is the key to preventing stroke
B.Cardiovascular disease: cerebral emboli may originate in the
heart;atrial fibrillation, coronary artery disease, heart failure, left
ventricular hypertrophy, MI, RHD
C.High cholesterol levels
D.Obesity
E. Elevated hematocrit:increases the risk of cerebral infarction
F. Diabetes mellitus
G. Oral contraceptive use
H. Smoking
I. Drug abuse
J. Excessive alcohol consumption
CEREBROVASCULAR ACCIDENTS
 Can be divided into two major categories
 1. Ischemic stroke- caused by thrombus and embolus
 2. Hemorrhagic stroke- caused commonly by
hypertensive bleeding
It can be divided into two major categories:
1. Ischemic: vascular occlusion and significant hypoperfusion occur;causes: are large

artery thrombosis, small penetrating artery thrombosis, cardiogenic embolic, cryptogenic
(no known cause)
CEREBROVASCULAR ACCIDENTS: Ischemic
Stroke
 There is disruption of the cerebral blood flow due to
obstruction by embolus or thrombus
Pathophysiology of ischemic stroke
 Disruption of blood supply
 Decreased ATP production leads to impaired membrane
function
 Cellular injury and death can occur
Stroke
Motor Loss
 Hemiplegia
 Hemiparesis
Stroke
Communication loss
 Dysarthria= difficulty in speaking
 Aphasia= Loss of speech
 Apraxia= inability to perform a previously learned action
Stroke
Perceptual disturbances
 Hemianopia
Sensory loss
 paresthesia
RISKS FACTORS
Non-modifiable Modifiable
 Advanced age  Hypertension
 Gender  Cardio disease
 race  Obesity
 Smoking
 Diabetes mellitus
 hypercholesterolemia
Stroke
 DIAGNOSTIC test
 1. CT scan
 2. MRI
 3. Angiography
Stroke
1. Improve Mobility and prevent joint deformities
 Correctly position patient to prevent contractures
 Place pillow under axilla
 Hand is placed in slight supination- “C”
 Change position every 2 hours
Stroke
2. Enhance self-care
 Carry out activities on the unaffected side
 Prevent unilateral neglect
 Keep environment organized
 Use large mirror
Stroke
3. Manage sensory-perceptual difficulties
 Approach patient on the Unaffected side
 Encourage to turn the head to the affected side to
compensate for visual loss
Stroke
4. Manage dysphagia
 Place food on the UNAFFECTED side
 Provide smaller bolus of food
 Manage tube feedings if prescribed
Stroke
5. 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
Stroke
6. Improve thought processes
 Support patient and capitalize on the remaining strengths
Stroke
7. 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
Stroke
 Use of specialty bed
 Regular turning and positioning
 Keep skin dry and massage NON-reddened areas
 Provide adequate nutrition
Stroke
9. Promote continuing care
 Referral to other health care providers
Stroke
10. Improve family coping
11. Help patient cope with sexual dysfunction
2. Hemorrhagic: there is extravasation of blood in the brain; causes: are
intracerebral hemorrhage, subarachnoid hemorrhage,cerebral aneurysm &
arteriovenous malformation
CVA: Hemorrhagic Stroke
 Normal brain metabolism is impaired by interruption of blood
supply, compression and increased ICP
 Usually due to rupture of intracranial aneurysm, AV
malformation, Subarachnoid hemorrhage
 Sudden and severe headache
 Same neurologic deficits as ischemic stroke
 Loss of consciousness
 Meningeal irritation
 Visual disturbances
 Destruction (infarction) of brain cells caused by a reduction in
oxygen supply.
 Symptoms depend on the area of the brain involved and extent of damage; may be
masked or delayed because of compensatory collateral circulation through the circle of
Willis.
 DIAGNOSTIC TESTS
 1. CT scan
 2. MRI
 3. Lumbar puncture (only if with no increased ICP)
 NURSING INTERVENTIONS
 1. Optimize cerebral tissue perfusion
 2. relieve Sensory deprivation and anxiety
 3. Monitor and manage potential complications
General manifestations
CEREBROVASCULAR ACCIDENTS
The stroke continuum
 1. TIA- transient ischemic attack, temporary neurologic loss
less than 24 hours duration
 2. Reversible Neurologic deficits
 3. Stroke in evolution
 4. Completed stroke
 Classified using the time course in the following manner:
1. Transient Ischemic Attack (TIA)
 Temporary episode of neurologic dysfunction manifested by a

sudden loss of motor, sensory or visual function
It may last a few seconds or minutes but no longer 24 hours
Complete recovery usually occurs between attacks
Serve as a warning of impending stroke which has its greatest
incidence in the first month after the first attack
2. Reversible Ischemic Neurologic Deficits (RIND)

Signs & symptoms are consistent with but more pronounced
than a TIA and last more than 24 hours
Symptoms resolve in days with no permanent neurologic deficits
3. Stroke in evolution
 Worsening of neurologic signs & symptoms over several minutes

or hours;
 This is a progressing stroke
4. Complete Stroke
 Stabilization of the neurologic signs and symptoms
This indicates no further progression of the hypoxic insult to the brain from this particular ischemic
attack
CLINICAL FINDINGS OF CVD:
1. Subjective: syncope; headache; changes in level of consciousness; transient paresthesias (with

TIAs); mood swings.
2. Objective:
a.Convulsions
b.Hemiplegia on side opposite the lesion (initially flaccid then spastic)
COMPARISON OF LEFT AND RIGHT HEMISPHERIC STROKES
Left Hemispheric Stroke Right Hemispheric Stroke
Paralysis /weakness on R side Paralysis/weakness on L side of the body
of the body Left visual field deficit
Right visual field deficit Spatial-perceptual deficits
Aphasia (expressive,receptive, Increased distractibility
Or global) Impulsive behavior and poor judgment
Altered intellectual ability Lack of awareness of deficits
Slow, cautious behavior
c. Aphasia: brain unable to fulfill its communicative functions because of damage to input,
integrative, or output centers.
1.Expressive (motor or Broca’s) aphasia: difficulty

making thoughts known to others; speaking and
writing is most affected.
2. Receptive (sensory or Wernicke’s) aphasia:

difficulty understanding what others is trying to
communicate; interpretation of speech and reading is
most affected.
3. Global aphasia: affects both expression and

reception
d.Dysphagia
e.Sensory changes; hemianopia

(loss of half of visual field)
f. Alterations in reflexes
g. Altered bladder and bowel function
h. CSF is bloody if cerebral or

subarachnoid hemorrhage is present.
i. Abnormal EEG, CT scan, MRI

j.Cerebral Angiography may reveal
vascular abnormalities such as
aneurysms, narrowing or occlusions.
k.Signs of increased intracranial pressure

THERAPEUTIC INTERVENTIONS FOR CVD:
1.Complete bed rest with sedation as needed.
2.Maintenance of oxygenation by oxygen therapy or mechanical
ventilation.
3. Maintenance of nutrition by parenteral route or nasogastric feedings if
the client is unable to swallow.
4. Anticoagulant therapy if thrombus or embolus is present; antiplatelet
therapy.
5. Antihypertensives and anticonvulsants if indicated.
6. Glucocorticoids may be used to reduce cerebral edema and intacranial
pressure.
7.Surgical intervention.
a.To relieve pressure and control bleeding if hemorrhage is present.
b.Carotid endarterectomy to improve cerebral blood flow when carotid arteries are narrowed by
arteriosclerotic patches
NURSING CARE OF CLIENTS WITH CVD:
1. Assessment of:
a.Adequacy of airway and respiratory function.
b.Neurologic status
c.Presence of signs of increased ICP.
2.Assist with lumbar puncture if performed; may be performed if subarachnoid hemorrhage is
suspected.
3. Monitor vital signs; avoid using affected extremity for BP because it may produce falsely lowered
readings.
4.Maintain patency of the airway by positioning, suctioning, and inserting an artificial airway.
5.Provide for drainage and expansion of lungs with head turned to side; provide oxygen as necessary.
6.Encouraged deep breathing; utilize mechanical ventilation if ordered.
7.Involve all members of the health team when planning care.
8. Assist client and family to set realistic goals; provide encouragement and praise.
9.Accept and explore feelings of fear, anger, and depression; accept mood swings and emotional
outburst.
10.Provide frequent oral hygiene; use artificial tears if blink reflex is
absent.
11.Institute seizure precautions.
12.Provide elastic or pneumatic stockings for both legs.

13.Prevent pressure ulcers.
14.Prevent muscle atrophy and contractures.
a.Provide passive range- of- motion exercises; active range
of motion and other exercises may be instituted later.
b.Use devices to prevent footdrop, flexion of fingers, external rotation of hips, adduction of
shoulders and arms.
15.Provide tube feedings if swallowing and gag reflexes are depressed or absent.
16.Provide food in a form that is easily swallowed (mechanical soft, puree, thickening products);
encourage intake of nutrient- dense foods; when client is capable of chewing, introduce dietary fiber
to promote normal bowel function.
17. Assist with feeding (e.g. use a padded spoon handle; feed on the unaffected side of mouth; fed in
as close to a sitting position as possible)
18.Encourage the client with speech difficulties to communicate.
a.Be aware of own reactions to the speech difficulty.

b.Evaluate extent of the client’s ability to understand and express self.
a. Reinforce what has been learned in speech therapy.
b. Convey that there is a problem with communication, not with
intelligence, try to eliminate anxiety related to communication attempts.
c. Avoid pushing to point of frustration.
d. Keep distractions at a minimum, since they interfere with the reception
and integration of messages.
e. Speak slowly, clearly, and in short sentences, and do not raise voice.
f. Use alternate means of communication.
g. Involve client in a social interactions.
Be alert for clues and gestures when speech is garbled.
19.Make a definite transition between tasks to prevent or reduce confusion.

20.Attempt to prevent fecal impaction and/or urinary tract problems.
a.Provide adequate fluid intake.
b.Provide a diet with enough roughage for sufficient quantity of bowel content and
proper consistency for evacuation; avoid straining at stool because it can
raise ICP; administer stool softeners as ordered.
c.Avoid preoccupation with elimination; avoid encouragement of incontinence.
d.Stimulate normal elimination by exercise and activity.
e.Help develop regular bowel and bladder patterns.
f.Respect the individual; provide for privacy and individually of routine.
g.Utilize physical and psychologic techniques to stimulate elimination.
21.Create environment that keeps sensory monotony to a minimum; orient to time and place,
increase social contacts, provide visual stimuli, extend environment.
22. Provide for self-esteem; encourage wearing own clothes, doing self-care activities, making
decisions.
23.Help with adjustment to altered body image and self-esteem.
THANK YOU!

Medical-Surgical Nursing The Neurologic Concepts: Jimmellee Ellen P. Olilang, RN

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Medical-Surgical Nursing The Neurologic Concepts: Jimmellee Ellen P. Olilang, RN

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Medical-Surgical Nursing

The Neurologic Concepts

JIMMELLEE ELLEN P. OLILANG, RN

 Anatomy and Physiology

 Trauma and related accidents

 Degenerative disorders- demyelinating

 Motor dysfunction- CNS

 Motor dysfunction- peripheral

 Increased Intracranial pressure

 Autonomic dysreflexia / hyperreflexia

Impaired physical mobility

the CRANIAL NERVES

 CEREBRUM (cerbral cortex)

-Gives us the ability to think & reason

 Temporal lobe- hearing and olfaction and emotion by

 The cerebellum is involved in coordination and

sleep, temperature, thirst, sexual arousal and

 midbrain- for visual and auditory reflexes

 Pons- respiratory apneustic center, nucleus of cranial nerves-

 Contains motor neurons that

 1. sympathetic nervous system

 2. parasympathetic nervous systrem

Central Nervous System Peripheral Nervous System

Brain Spinal Cord Motor (Efferent) Sensory (Afferent )

 delicate, threadlike nerve fibers called

 Axons carry impulses away from the

 this intricate network of interlocking

 These neurotransmitters are produced

ACETYLCHOLINE Many areas of the brain; Usually excitatory;

DOPAMINE Substantia Nigra and basal Usually inhibits, affects

ACETYLCHOLINE Many areas of the Usually excitatory;

DOPAMINE Substantia Nigra and basal Usually inhibits, affects behavior

ENKEPHALIN, Nerve terminals in the spine, Excitatory; pleasurable

 The bones of the vertebral column

Inner /Outer layers of the Skull

Dura mater (2 layers)

 is a tough,fibrous, leatherlike tissue

1. Endosteal dura:forms the periosteum Of

Arachnoid mater: is a thin, fibrous

Pia mater: is a continuous layer of

 Between the dura mater & the

 Between the arachnoid membrane

 Pupillary size and response

 Assess the degree of

 Utilize the Glasgow Coma Scale

status and abnormality detection

Glasgow Coma Score

Verbal Response (V)

Motor Response (M)

Glasgow Coma Score

Glasgow Coma Score

6=Normal- obeys command

 CONSCIOUS glasgow coma of 12 – 15

Unilateral dilated (4mm) uncal herniation

Bilateral dilated (4mm) Severe midbrain damage

Bilateral Pinpoint (<1mm) Lesions of the pons

Unilateral, small (1.5mm) Disruption of the SNS

 Check first for the patency of the nose

 Occlude one nostrils at a time

 Hold familiar substance and asks for the

 PROBLEM- ANOSMIA- “loss of smell”

 Check the visual acuity with the use of the

 Check for pupillary reflex- direct and