Medical-Surgical Nursing A Review of Neurologic Concepts: Nurse Licensure Examination Review

Medical-Surgical Nursing
A Review of Neurologic Concepts
Nurse Licensure Examination

Review
Key to Success!
 Confidence
 Test taking strategies
 Ample test preparation and study habits
 Review of frequent board examination
topics
 Focus on your goals
 Above all- PRAYERS
Outline of Our Review
 Brief review of 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 review
 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
 Neoplastic disease
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
Anatomy and Physiology
 Gross anatomy
 The nervous system is divided into the
central and peripheral nervous system
 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
The brain 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 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 is composed of the:
 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
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
 HISTORY
 A confused client becomes an unreliable
source of history
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
PHYSICAL EXAMINATION
 5 categories:
 1. Cerebral function- LOC, mental status
 2. Cranial nerves
 3. Motor function
 4. Sensory function
 5. Reflexes
ASSESSMENT OF THE
NEUROLOGIC SYSTEM
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 (Flexion)
3=Decorticate posture
2=Decerebrate posture
1=None (flaccid)
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”
Cranial Nerve 2- 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 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 5 -trigeminal
 Sensory portion- assess for sensation of
the facial skin
 Motor portion- assess the muscles of
mastication
 Assess corneal reflex
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
Cranial Nerve Function: Cranial
Nerve 9- glossopharyngeal
 Together with Cranial nerve 10 –vagus
 Assess for gag reflex
 Watch the soft palate rising after
instructing the client to say “AH”
 The posterior one-third of the tongue is
supplied by the glossopharyngeal nerve
Cranial Nerve 11- accessory
 Press down the patient’s shoulder while
he attempts to shrug against resistance
Cranial Nerve 12- hypoglossal
 Ask patient to protrude the tongue and
note for symmetry
ASSESS Motor function
 Assess muscle tone and strength by
asking patient to flex or extend the
extremities while the examiner places
resistance
 Grading of muscle strength
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
of the brainstem
Test for the Oculocephalic reflex- doll’s
eye
 Normal response- eyes appear to move
opposite to the movement of the head

 Abnormal- eyes move in the same
direction
of the 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 reflexes
 Biceps
 Triceps
 Brachioradialis
 Patellar
 Assessing the sensory function Achilles
Assessing the reflexes
 Superficial reflexes
 Abdominal
 Cremasteric
 Anal
 Pathologic reflex
 Babinski- stroke the lateral aspect of the
soles doing an inverted “J”
 (+)- DORSIFLEXION of the Big toe with
fanning out of the little toes
Grading of reflexes
Deep tendon reflex
 0- absent
 + present but diminished
 ++ normal
 +++ increased
 ++++ hyperactive or clonic
Superficial reflex
 0 absent
 +present
DIAGNOSTIC TESTS
 EEG
 Withhold medications that may interfere
with the results- anticonvulsants, sedatives
and stimulants
 Wash hair thoroughly before procedure
DIAGNOSTIC TESTS
CT scan
 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
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
 Ensure consent, determine ability to lie
still
 Contraindicated in patients with
increased ICP
 Keep flat on bed after procedure
 Increase fluid intake after procedure

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
pressure
Pathophysiology
 The cranium only contains the brain
substance, the CSF and the blood/blood

vessels
 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

pressure
Pathophysiology
 Compensatory mechanisms:
 1. Increased CSF absorption
 2. Blood shunting
 3. Decreased CSF production

pressure
Pathophysiology
Decompensatory mechanisms:
 1. Decreased cerebral perfusion
 2. Decreased PO2 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
pressure
CLINICAL MANIFESTATIONS
Early manifestations:
 Changes in the LOC- usually the
earliest
 Pupillary changes- fixed, slowed
response
 Headache
 vomiting
pressure
late manifestations:
 Cushing reflex- systolic hypertension,
bradycardia and wide pulse pressure

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

 2. assists in administering 100%
oxygen or controlled hyperventilation- to

reduce the CO2 blood levelsconstricts
blood vesselsreduces edema
pressure
Nursing interventions
 3. Administer prescribed medications-
usually
 Mannitol- to produce negative fluid balance
 corticosteroid- to reduce edema
 anticonvulsants-p to prevent seizures
pressure
Nursing interventions
 4. Reduce environmental stimuli
 5. Avoid activities that can increase ICP
like valsalva, coughing, shivering, and

vigorous suctioning
pressure
 Nursing interventions
 6. Keep head on a neutral position.
ACOID- 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
 COMA= clinical state of

unconsciousness where patient is NOT
aware of self and environment
 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 an output monitoring
 IVF therapy
 Feeding through NGT
4. Provide mouth care

 Cleansing and rinsing of mouth
 Petrolatum on the lips

5. Maintain skin integrity
 Regular turning every 2 hours
 30 degrees bed elevation
 Maintain correct body alignment by using
trochanter rolls, foot board

6. Preserve corneal integrity
 Use of artificial tears every 2 hours
7. Achieve thermoregulation
 Minimum amount of beddings
 Rectal or tympanic temperature
 Administer acetaminophen as prescribed
8. Prevent urinary retention

 Use of intermittent catheterization
9. Promote bowel function
 High fiber diet
 Stool softeners and suppository
10. Provide sensory stimulation

 Touch and communication
 Frequent reorientation
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
SEIZURES
 ETIOLOGIC FACTORS
1. Idiopathic
2. Fever
3. Head injury
4. CNS infection
5. Metabolic and toxic conditions
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
 Primary headache- no organic cause
 Secondary headache- with organic
cause
 Migraine headache- periodic attacks of
headache due to vascular disturbance
 Tension headache-the most common
type- due to muscle tension
headache
 Migraine
1. Prodrome stage
2. Aura phase
3. Headache
4. Recovery phase
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
above T6
 An exaggerated response by the
autonomic system resulting from
various stimuli most commonly
distended bladder, impacted feces,
pain, skin irritation
Autonomic
 Clinical MANIFESTATIONS
 1. Hypertension
 2. Bradycardia
 3. severe pounding headache
 4. diaphoresis
 5. nausea and nasal congestion
Autonomic
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
 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
Hydrocephalus
 DIAGNOSTIC TESTS
 1. Skull x-ray
 2. ventriculography
Hydrocephalus
 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
CONGENITAL DISORDER-
Spinal cord defects
 1. Spina bifida occulta- incomplete closure of
one or more vertebrae without protrusion of
the spinal cord or meninges
 2. Spina bifida with meningocele- a sac
contains meninges and CSF
 3. Spina bifida with meningomyelocele- a sac
contains spinal cord substance, meninges and
CSF
CONGENITAL DISORDER:
Spinal cord defects
 Causes
 1. environmental factors
 2. radiation
 3. folic acid deficiency in a pregnant
woman
 4. possibly genetic
Spinal cord defects
 ASSESSMENT
 1. a dimple or tuft of hair in the
vertebral area
 2. external sac
 DIAGNOSIS
 1. Spinal x-ray
 2. myelography
Spinal cord defects
 NURSING INTERVENTION
 1. cover the defect with sterile dressing
moistened with sterile saline
 2. position the patient on prone or side
to protect the fragile sac
 3. place a diaper under the infant and
change it often
Spinal cord defects
 4. avoid the use of lotion
 5. avoid frequent handling
 6. Measure the child’s head circumference
daily
 7. check anal reflex
 8. support family members
 9. prepare the parents for the possible
outcome of eh defect
Spinal cord defects
 10. Post-operative care
 Position on abdomen
 Check post-operative dressings
 Place infant’s hips in abduction and feet in
neutral position
 Monitor intake and output
 Check for urine retention
 Asess infant frequently as he recovers from
the surgery
Traumatic brain injury
1. CONCUSSION
 Involves jarring of head without tissue
injury
 Temporary loss of neurologic function
lasting fore 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
Spinal cord injury
Clinical manifestations
 1. Paraplegia
 2. quadriplegia
 3. spinal shock
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
CEREBROVASCULAR
ACCIDENTS
 An umbrella term that refers
to any functional abnormality
of the CNS related to
disrupted blood supply
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
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
General manifestations
CEREBROVASCULAR ACCIDENTS:
Ischemic Stroke
 There is disruption of the cerebral blood
flow due to obstruction by embolus or
thrombus
RISKS FACTORS
Non-modifiable Modifiable
 Advanced age  Hypertension
 Gender  Cardio disease
 race  Obesity
 Smoking
 Diabetes mellitus
 hypercholesterolemia
Pathophysiology of ischemic
stroke
 Disruption of blood supply
 Anaerobic metabolism ensues
 Decreased ATP production leads to
impaired membrane function
 Cellular injury and death can occur
CEREBROVASCULAR
ACCIDENTS: Ischemic Stroke
 DIAGNOSTIC test
 1. CT scan
 2. MRI
 3. Angiography
CEREBROVASCULAR
 1. Numbness or weakness
 2. confusion or change of LOC
 3. motor and speech difficulties
 4. Visual disturbance
 5. Severe headache
CEREBROVASCULAR
Motor Loss
 Hemiplegia
 Hemiparesis
CEREBROVASCULAR
Communication loss
 Dysarthria= difficulty in speaking
 Aphasia= Loss of speech
 Apraxia= inability to perform a
previously learned action
CEREBROVASCULAR
Perceptual disturbances
 Hemianopsia
Sensory loss
 paresthesia
CEREBROVASCULAR
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
CEREBROVASCULAR
2. Enhance self-care
 Carry out activities on the unaffected
side
 Prevent unilateral neglect
 Keep environment organized
 Use large mirror
CEREBROVASCULAR
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
CEREBROVASCULAR
4. Manage dysphagia
 Place food on the UNAFFECTED side
 Provide smaller bolus of food
 Manage tube feedings if prescribed
CEREBROVASCULAR
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
CEREBROVASCULAR
6. Improve thought processes
 Support patient and capitalize on the
remaining strengths
CEREBROVASCULAR
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
CEREBROVASCULAR
 Use of specialty bed
 Regular turning and positioning
 Keep skin dry and massage NON-
reddened areas
 Provide adequate nutrition
CEREBROVASCULAR
9. Promote continuing care
 Referral to other health care providers
CEREBROVASCULAR
10. Improve family coping
11. Help patient cope with sexual
dysfunction
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
 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
DEMYELINATING DISEASES
Nurse Licensure Examination

Review
MULTIPLE SCLEROSIS
 An auto-immune mediated
progressive demyelinating disease
of the CNS
 The myelin sheath is destroyed and
replaced by sclerotic tissue
(sclerosis)
MULTIPLE SCLEROSIS
 CAUSE- unknown
 Multiple factors- viral infection,
environmental factors,geographic
location and genetic predisposition
 Common in WOMEN ages 20-40

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY
 Sensitized T cells will enter the brain
and promote antibody production that

damages the myelin sheath
 Plaques of sclerotic tissues appear on
the demyelinated axons interrupting the

neuronal transmission
MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY
 The most common areas affected are
 Optic nerves and chiasm

 Cerebrum
 Cerebellum
 Spinal cord
MULTIPLE SCLEROSIS
 1. visual problems such as diplopia,
blurred vision and nystagmus

 2. motor dysfunction
 3. Fatigue
 4. Mental changes like mood swings,
depression
 5. spasticity
MULTIPLE SCLEROSIS
 1. MRI- primary diagnostic study
 2. CSF Immunoglobulin G
MULTIPLE SCLEROSIS
1. Promote physical mobility
 Exercise
 Schedule activity and rest periods
 Warm packs over the spastic area
 Swimming and cycling are very useful

MULTIPLE SCLEROSIS
2. Prevent injuries
 Wide stance walking
 Use of walking aids
 Wheelchair
MULTIPLE SCLEROSIS
3. Enhance bladder and bowel
control
 Set a voiding schedule
 Intermittent bladder catheterization
 Use of condom catheter
 Adequate fluids, dietary fibers and
bowel training program

MULTIPLE SCLEROSIS
4. Manage speech and swallowing
difficulties
 Careful feeding, proper positioning,
suction machine availability

 Speech therapist
MULTIPLE SCLEROSIS
5. Improve Sensory and Cognitive
function
 Vision- use eye patch for diplopia
 Obtain large printed reading materials
 Offer emotional support
 Involve the family in the care

MULTIPLE SCLEROSIS
6. Strengthen coping mechanism
 Alleviate the stress
 Referral to the appropriate agencies

MULTIPLE SCLEROSIS
7. improve self-care abilities
 Modify activities according to physical
strength
 Provide assistive devices
MULTIPLE SCLEROSIS
8. promote sexual functioning
 Refer to sexual counselor
MULTIPLE SCLEROSIS
MEDICAL MANAGEMENT
Pharmacotherapy
 Interferons
 Immunomodulators
 Corticosteroids
 BACLOFEN for muscle spasms
 NSAIDS for pain
Guillian-Barre’ Syndrome
 An auto-immune attack of the
peripheral nerve myelin
 Acute, rapid segmental
demyelination of peripheral nerves
and some cranial nerves
 CAUSE: post-infectious polyneuritis
of unknown origin commonly
follows viral infection
 PATHOPHYSIOLOGY
 Cell-mediated imune attack to the
myelin sheath of the peripheral
nerves
 Infectious agent may elicit antibody
production that can also destroy the
myelin sheath
 1. Ascending weakness and
paralysis
 2. diminished reflexes of the lower
extremities
 3. paresthesia
 4. potential respiratory failure

1. Maintain respiratory function
 Chest physiotherapy and incentive
spirometry
 Mechanical vetnilator
 2. Enhance physical mobility
 Support paralyzed extremities

 Provide passive range of motion exercise
 Prevent DVT and pulmonary embolism
 Padding over bony prominences
 3. Provide adequate nutrition
 IVF
 Parenteral nutrition
 Assess frequently return o gag refelx
 4. Improve communication
 Use other means of communication

 5. Decrease fear and anxiety
 Provide Referrals
 Answer questions
 Provide diversional activities
 6. Monitor and manage complications
 DVT, Urinary retention, pulmonary
embolism, respiratory failure
MEDICAL MANAGEMENT
 ICU admission
 Mechanical Ventilation
 TPN and IVF
 PLASMAPHERESIS
 IV IMMUNOGLOBULIN
ALZHEIMER’S disease
 A progressive neurologic disorder
that affects the brain resulting in
cognitive impairments
CAUSES:
 Unknown
 Potential factors- Amyloid plaques
in the brain, Oxidative stress,

neurochemical deficiencies
 CLINCAL MANIFESTATIONS
 1. Forgetfulness
 2. Recent memory loss
 3. Difficulty learning
 4. Deterioration in personal hygiene
 5. Inability to concentrate
 LATE CLINICAL MANIFESTATIONS
 6. Difficulty in abstract thinking
 7. Difficulty communicating
 8. Severe deterioration in memory,
language and motor function
 9. repetitive action- perseveration
 10. personality changes
DIAGNOSTIC TEST
 Neurologic examination
 PET scan
 EEG, CT and MRI
 Other tests to rule out Vit B deficiencies
and hypothyroidism
 Autopsy is the most definitive
Drug therapy
 1. drugs to treat behavioral
symptoms- antipsychotics
 2. anxiolytics
 3. Donepezil
 4. Tacrine
 1. Support patient’s abilities
 2. Provide emotional support

3. Establish an effective communication
system with the patient and family
 Use short simple sentences, words and
gestures
 Maintain a calm and consistent approach
 Attempt to analyze behavior for meaning

4. protect the patient from injury
 Provide a safe and structured environment
 Requests a family member to accompany
client if he wanders around

 Keep bed in low position
 Provide adequate lightning
 Assign consistent caregivers

5. Encourage exercise to maintain
mobility
PARKINSON’s Disease
 A slowly progressing neurologic
movement disorder
 The degenerative idiopathic form is
the most common form
CAUSATIVE FACTORS: unknown
 Potential factors: genetics,
atherosclerosis, free radical stress,

viral infection, head trauma and
environmental factors
Pathophysiology
 Decreased levels of dopamine due to
destruction of pigmented neuronal cells

in the substantia nigra in the basal
ganglia
 Clinical symptoms do not appear until
60% of the neurons have disappeared

 1. Tremor- resting, pill-rolling
 2. Rigidity- cog-wheel, lead-pipe
 3. Bradykinesia- abnormally slow movement
 4. Dementia, depression, sleep disturbances
and hallucinations
 5. excessive sweating, paroxysmal flushing,
orthostatic hypotension
Medical management
 1. Anti-parkinsonian drugs- Levodopa,
Carbidopa
 2. Anti-cholinergic therapy
 3. Antiviral therapy- Amantadine
 4. Dopamine Agonists- bromocriptine
and Pergolide, Ropirinole anmd

Pramipexole
 Medical management
 5. MAOI
 6. Anti-depressants
 7. Antihistamine
 1. Improve mobility
 2. Enhance Self- care activities
 3. Improve bowel elimination
 4. Improve nutrition
 5. Enhance swallowing
 6. Encourage the use of assistive devices
 7. improve communication
 8. Support coping abilities
EPILEPSY
 A group of syndromes characterized by
recurring seizures
CAUSES
1. idiopathic 6. brain tumors
2. Birth trauma 7. head Injury
3. perinatal infection 8. metabolic disorders
4. infectious disease 9. CVA
5. ingestion of toxins
EPILEPSY
 Recurring seizures may be classified as
GENERALIZED or PARTIAL SEIZURES
 Generalized Seizures- cause a
generalized electrical abnormality within
the brain
 Partial seizures- these seizures arise
from a localized part of the brain and
cause specific symptoms
GENERALIZED SEIZURES
 1. General Tonic-Clonic seizure- (Grand
mal) characterized by loss of
consciousness and alternating
movements of the extremities
 2. Absence Seizure (Petit mal)- common
in children, begins with a brief change
in the LOC, indicated by blinking, rolling
of eyes and blank stares
GENERALIZED SEIZURES
 3. Myoclonic seizure- characterized by
brief, involuntary muscular jerks of
body extremities
 4. Akinetic seizure- general loss of
postural tone and a temporary loss of
consciousness- a drop attack
PARTIAL SEIZURES
 1. Simple partial seizure- typically
limited to one cerebral hemisphere
 2. Complex partial seizure- begins with
an aura, then with impaired
consciousness, with purposeless
behaviors like lip-smacking, chewing
movements
Epilepsy
 1. EEG
 2. CT
 3. MRI
 4. LP
 5. Angiography
Epilepsy
 Medical treatment
 1. Anticonvulsants- most commonly
phenytoin, phenobarbital and
carbamazepine
 Ethosuximide and valproic acid for
absence seizure
 2. surgery
Epilepsy
 Nursing Intervention
 1. Care of patients during seizure
 2. care of patients after seizures
 3. patient teaching
BELL’S PALSY
 Causes
 1. infection
 2. hemorrhage
 3. tumor
 4. local traumatic injury
BELL’S PALSY
 MANIFESTATIONS
 1. Unilateral facial weakness
 2. Mouth drooping
 3. Distorted taste perception
 4. Smooth forehead
 5. Inability to close eyelid on the affected side
 6. Incomplete eye closure
 7. excessive tearing when attempting to close the
eyes
 8. Inability to raise eyebrows, puff out the cheek
BELL’S palsy
 Diagnostic tests
 EMG
 Medical management
 1. Prednisone
 2. Artificial tears
BELL’S palsy
 Nursing Interventions
 1. Apply moist heat to reduce pain
 2. Massage the face to maintain muscle
tone
 3. Give frequent mouth care
 4. protect the eye with an eye patch.
Eyelid can be taped at night
 5. instruct to chew on unaffected side
Trigeminal neuralgia
 Also called Tic Douloureux
 Painful disorder that affects one or
more branches of the fifth cranial nerve
 CAUSES: repetitive pulsation of an

artery as it exits the pons is the usual
cause
 ASSESSMENT
 1. Pain history
 2. Searing or burning jabs of pain
lasting from 1-15 minutes in an area
innervated by the trigeminal nerve
Skull x-ray or CT scan
 1. provide emotional support
 2. encourage to express feelings
 3. provide adequate nutrition in small
frequent meals at room temperature
Myasthenia gravis
 A sporadic, but progressive
weakness and abnormal
fatigability of striated muscles
which are exacerbated by exercise
and repetitive movements
Myasthenia gravis
ETIOLOGY
 Autoimmune disease
 Thymoma
Women suffer at an earlier age and are

more affected
Myasthenia gravis
Pathophysiology:
 1. Acetylcholine receptor antibodies
interfere with impulse transmission

 2. Follows an unpredictable course of
periodic exacerbations and remissions

Myasthenia gravis
 CAUSE: autoimmune disorder that impairs
transmission of nerve impulses
ASSESSMENT FINDINGS
1. Gradually progressive skeletal muscle
weakness and fatigue
2. Weakness that worsens during the day
3. Ptosis, diplopia and weak eye closure
4. Blank, mask-like facies
5. Difficulty chewing and swallowing
6. Respiratory difficulty
Myasthenia gravis
DIAGNOSTIC TESTS
 1. EMG
 2. TENSILON TEST
 3. CT scan
 4. Serum anti-AchReceptor antibodies

Myasthenia gravis
MEDICAL THERAPY
 Anticholinesterase drugs-
pyridostigmine and neostigmine

 Corticosteroids
 Immunosuppresants
 Plasmapheresis
 Thymectomy
Myasthenia gravis
 1. Administer prescribed medication as
scheduled
 2. Prevent problems with chewing and
swallowing
 3. Promote respiratory function
 4. Encourage adjustments in lifestyle to
prevent fatigue
 5.maximize functional abilities
Myasthenia gravis
 6. Prepare for complications like
myasthenic crisis and cholinergic crisis
 7. prevent problems associated with
impaired vision resulting from ptosis of
eyelids
 8. provide client teaching
 9. promote client and family coping
Meningitis
 Infection or inflammation of the
meninges covering the brain and spinal
cord.
 Caused by bacterial, viral and fungal
agents
Brain Abscess
 A free or encapsulated collection of pus
in the brain parenchyma
 Causes: usually secondary to another
infection like- sinusitis, meningitis,
dental abscess, mastoiditis, bacteremia
and trauma
Encephalitis
 Intense inflammation of the brain
tisssue with lymphocytic infiltration,
cerebral edema, degeneration of brain
cells and diffuse nerve cell destruction
CNS infections
 ASSESSMENT FINDINGS
 Meningitis
 1. fever, headache, vomiting
 2. positive meningeal sings
 Brain abscess
 1. headache, N/V, seizures, changes in LOC
 2. Focal neurologic deficits
CNS infections
 1. CT scan
 2. MRI
 3. EEG
 MEDICAL TREAMENT
 1. Antibiotics
 2. Surgical drainage
 3. Drugs to reduce increased ICP
CNS infections
 1. Frequent monitoring of neurologic
status
 2. Monitor intake and output
 3. Administer antibiotics
 4. Administer mild laxative to prevent
constipation
 5. maintain quiet environment
Neoplastic diseases
 A brain tumor is a localized intracranial
lesion that occupies space within the
skull
 Primary brain tumors originate from
cells and structures within the brain.
Neoplastic disease
 The cause of brain tumors is unknown
 The only risk factor accepted is
radiation exposure to ionization rays
Neoplastic disease
 CLINICAL MANIFESTATIONS
 1. increased ICP
 Vomiting
 Headache. Especially early in the morning
 Vomiting
 Visual disturbances
Neoplastic disease
 2. Localized symptoms
 Hemiparesis
 Seizures
 Mental status changes
Neoplastic disease
 1. CT scan
 2. MRI
 3. PET
 4. EEG
Neoplastic disease
 MEDICAL MANAGEMENT
 Surgery
 Chemotherapy
 Radiotherapy
Neoplastic disease
 1. promote self-care independence
 2. improve nutrition
 3. relieve anxiety
 4. enhance family processes
 5. provide pre-operative and post-operative
care
 6. manage pain

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Medical-Surgical Nursing

A Review of Neurologic Concepts

Nurse Licensure Examination

 Trauma and related accidents

 Temporal lobe- hearing and olfaction

and emotion by the limbic system

 Pupillary size and response

 Verbal Response (V)

 Motor Response (M)

6=Normal- obeys command

 ROMBERG’s is actually a test for the

opposite to the movement of the head

and warm water

 + present but diminished

 ++++ hyperactive or clonic

 If contrast medium will be used- ensure

consent, assess for allergies to dyes

 Patients with pacemakers, orthopedic

metal prosthesis and implanted metal

 Keep patient at rest after procedure

 Maintain pressure dressing or sandbag

over punctured site

 Increase fluid intake after procedure

substance, the CSF and the blood/blood

any one of the components causes a change

will cause increased ICP

 1. Increased CSF absorption

 3. Decreased CSF production

 2. Decreased PO2 leading to brain

bradycardia and wide pulse pressure

degrees- to promote venous drainage

oxygen or controlled hyperventilation- to

 5. Avoid activities that can increase ICP

like valsalva, coughing, shivering, and

 COMA= clinical state of

2. Protect the patient

 Prevent injury from equipments, restraints

 Feeding through NGT

4. Provide mouth care

 Petrolatum on the lips

 30 degrees bed elevation

 Maintain correct body alignment by using

trochanter rolls, foot board

 Rectal or tympanic temperature

 Administer acetaminophen as prescribed

8. Prevent urinary retention

 Stool softeners and suppository

10. Provide sensory stimulation

 3. protect the head with pillows

 4. Observe and note for the duration, parts

of body affected, behaviors before and after

 6. DO NOT restrain, or attempt to

place tongue blade or insert oral

secretions and prevent aspiration

 3. provide care if patient became

incontinent during the seizure attack

 3. relieve pain by pharmacologic

bladder with urinary catheter

triggering factors like skin irritation, pressure