NEUROLOGICAL

Neurological Anatomy and Physiology

A.Central nervous system (CNS) -
coordinates and controls body functions
1.Brain
a. cerebrum (illustration )
i. hemispheres right and left
ii. frontal lobe - higher intellectual
functions, social behavior,
personality
iii. parietal lobe - perceives and
interprets sensory input
iv. temporal lobe - emotional
response, memory, language,
organization of sensory input
(hearing, taste and smell)
 v. occipital lobe - vision

b.cerebellum -

c.brain stem - midbrain, pons and medulla

oblongata; controls basic body functions
and relays impulses to and from spinal
cord; the connection between the brain
and spinal cord
brain stem
2.Spinal cord

a.descending tract - anterior portion of cord

carrying motor information; associate
"d"escending to "d"own impulses are carried
to peripheral nerves

b.ascending tract
i. the posterior portion of cord that
carries sensory information up to the brain
ii. 31 segments

• eight cervical: neck and upper extremities

• 12 thoracic: thoracic and abdomen
• five lumbar: lower extremities
• five sacral: lower extremities, urine and
bowel control
• one coccygeal
 Peripheral nervous system - carries
information to and from the CNS

 Motor nerves
 Sensory nerves
 Autonomic nervous system - regulates
body's internal environment
 Sympathetic - prepares body for fight or
flight; used only as needed when scared or
excessively happy
 Parasympathetic - controls normal body
functioning for day to day activities, e.g.,
increases muscle tone, maintains
secretions with moist mucous membranes;
maintains heart rate within normal limits;
maintains GI and GU peristalsis
 Cranial nerves
 These nerves are the vital bridges
between the brain and the rest of the body.
E. Physiology - nervous system coordinates
and controls all activities of the body

1.Receives internal and external stimuli

2.Processes information to determine
appropriate response
3.Transmits information over varied motor
pathways to effector organs
F. Findings for increased intracranial pressure
(ICP)
1.Early
a. change in level of consicousness
(LOC): restlessness, agitation, irritability,
disorientation, confusion, lethargy, stupor
b. pupils: dilated ipsilaterally, react
slowly to light
c. abnormal motor activity: contralateral
hemiparesis
d. abnormal reflexes - hyper or hypo
e. signs within normal parameters
2.Late
a. LOC: semicomatose, coma
b. pupils: dilated bilaterally and fixed; no
reaction to light
c. motor function: decorticate posture
then decerebrate posture; flaccid muscles at
end stage
d. vital signs - increased systolic
pressure to result in a widened pulse
pressure, decreased respirations with
bradycardia (Tip: heart and lungs go in
similar directions - both increase or
decrease), temperature initially may rise
then fall below normal parameters
Degenerative Disorders
Degenerative Disorders
A. Parkinson's disease
1. Definition: degenerative disorder of the
dopamine hydrochloride - producing
neurons
a. result: dopamine hydrochloride
depletion
b. usually occurs in older adults and
males more than females
c. etiology unknown
2.Findings: first unilateral, then bilateral
movements
a. resting tremors of the lips, jaw, tongue,
and limbs, especially a resting pill-rolling
tremor of one hand that is absent during
sleep. This tremor is often labeled - "non
intention" tremor. This is different from an
essential or intention tremor in which the
tremor is action related and labeled
"intention" tremor.
b. bradykinesia
c. fatigue
d. stiffness and rigidity with movement
e.mask-like facial expression often
accompanied with drooling
f. slow, shuffling walk in a stooped-over
posture; gradually more difficulty with
walking
g.difficulty rising from sitting position
h.ultimately confined to a wheelchair
i. mind stays intact unless other aggravating
conditions
j. echolalia in most cases
• Diagnostics
a.based on findings with history
b.EEG
c. MRI
d.computerized tomogram (CT scan)
(illustration
• Management
a.expected outcomes: palliative and to
postpone dependence
b.pharmacologic
i. anticholinergics - minimize
extrapyramidal effects
• benzotropine mesylate (Cogentin)
• procyclidine (Kemadrin)
ii. dopamine hydrochloridergics:
Levodopa (L-Dopa)
iii. antiparkinsonian agent: amantadine
HCl (Symmetrel)
c. therapies
i. physical
ii. occupational
iii. speech
 surgery: to decrease tremor
 stereotaxic thalamotomy
 pallidotomy - pinpoint the areas to be treated
surgically
 deep brain stimulation
Nursing interventions
a.maintain safety of client
b.prevent effects of immobility
c. foster independence in activities of daily
living (ADL)
d.reinforce the use of assistive devices for
ambulation as indicated
e.promote good nutrition
i. small, frequent meals
ii. soft foods
iii. roughage with sufficient fluids to
decrease constipation
f. monitor effectiveness or ineffectiveness of
administered medications
g.provide emotional support to client and
family members
h.teach client
i. when and what side effects of the
drugs to report
ii. the benefits of daily exercise
iii. the benefits of "drug holidays"
Huntington's disease
1.Definition
a. progressive atrophy of basal ganglia
and some parts of cerebral cortex
b. etiology - genetic disorder, autosomal
dominant
2.Findings: usually occurs in middle age,
increased involuntary movements,
progressive decline in cognitive function
a.motor function
i. impaired chewing and swallowing
ii. chorea
iii. dystonic posture
iv. gradually becomes bedridden
b.cognitive function: less able to organize,
plan and sequence behavior
c. mental function: personality changes,
depression, even psychosis
3.Diagnostics: history and physical exam

4.Management
a.expected outcome: postpone dependence
b.supportive care for findings
c. therapies: speech, physical
d.genetic counseling
5.Nursing interventions
a. foster independence in ADL
b. reinforce the use of assistive devices for
ambulation as needed
c. teach client to
i. maintain good nutrition
ii. get emotional support from support
groups, friends
iii. seek genetic counseling
Amyotrophic lateral sclerosis (ALS, Lou
Gehrig's disease)
Amyotrophic lateral sclerosis (ALS, Lou
Gehrig's disease)
1.Definition
a. progressive atrophy of spinal muscle;
bulbar palsy
b. progressive degeneration of the motor
neurons of the anterior horn cells of the
spinal cord, brainstem, and motor cortex
c. onset in later middle age; more in men
than in women
d. clients with ALS usually die within two to
six years
e. etiology unknown
 Upper motor neurons are motor neurons
that originate in of the cerebral cortex or the
brain stem and carry motor information down
to the final common pathway, that is, any
motor neurons that are not directly
responsible for stimulating the target muscle.
 Lower motor neurons (LMNs) are the motor
neurons connecting the brainstem and spinal
cord to muscle fibers, bringing the nerve
impulses from the upper motor neurons out to
the muscles
2.Findings
a. usually beginning in the upper body - the
head and arms, the distal portion first
b. mild clumsiness progressing to total
incapacity
c. muscle wasting, atrophy, spasticity
d. speech disorders
e.no change in sensation or autonomic
system
f. death most often from complications:
respiratory failure, urinary or pulmonary
infections for stasis
g.mind usually intact while client has loss of
voluntary and eventually involuntary muscle
functions

3.Diagnostics: history and physical exam

• Management
a.expected outcome: keep functional
independence as much as possible
b.no cure
c. management of findings
i. muscle relaxants for spasticity
ii. therapies:
• speech
• physical
• respiratory support
• nutritional support
• Nursing interventions
a.provide for respiratory care and referrals
b.maintain a safe environment focused toward
infection prevention
c. prevent complications of immobility
especially pulmonary and urinary stasis
d.postpone dependence
e.promote balanced nutrition
f. provide emotional support and referrals to
support groups
Dementia
1.Etiology
a. characterized by irreversible,
progressive cerebral dysfunction
b. Alzheimer's disease - most common
cause of dementia
i. characterized by brain atrophy
ii. development of senile plaques and
neurofibrillary tangles in the
cerebral hemispheres
iii. etiology unknown
2.Findings
a. initially characterized by decreased
intellectual functioning
b. Alzheimer's disease has three stages
i. early stage
• memory loss
• subtle personality changes
• difficulty with abstract thinking
ii. middle stage
• impaired judgment
• impaired language
• difficulty with motor activity and object
recognition
• wandering
• inability to carry out ADL
iii. final stage
• complete loss of language function
• loss of bowel and bladder control
c. prognosis - poor, incurable

3.Management - expected outcome:

maintenance of functional capacity
4.Nursing interventions
a. meet client's physical needs
b. promote client's independence
c. promote contact with reality
d. assist client/family to establish a routine
e. provide emotional support or caregiver
support with appropriate referrals
E. Organic brain syndrome
1.Definition - a general term used to
categorize physical conditions that can
cause decreased mental function
2.Etiology
a. degenerative disorders
b. drug and alcohol related conditions
c. infections
d. repiratory conditions
e. trauma-induced brain injury
f. cardiovascular disorders
g. dementia from metabolic disorders
3.Findings
a. findings vary with the specific disease
b. in general, organic brain syndromes
cause varying degrees of confusion
c. delirium - severe often sudden short
term loss of brain function as with high
temperatures, drug withdrawal
d. agitation
e. dementia - long term loss of brain
function
f. aggression - typical of some of the
conditions contributing to this diagnosis
4.Management
a.therapy varies with the specific disorder
b.many of the disorders have nonspecific
treatments
c. the priority in many instances is supportive
care to assist the person in areas where
brain function is lost
d.medications may be needed to reduce
aggressive behaviors typical of some of the
conditions in this category
5.Nursing interventions
a.assist to meet the client's physical needs
b.refer family to support systems
c. monitor the effectiveness of medication
therapy
d.evaluate changes to where the client is
unable to maintain independence with ADL
Cerebrovascular Accident (CVA, Stroke,
Cerebral Infarction) (illustration )
A. Definition: decreased blood supply to the
brain
1. Risk factors
a. hypertension, uncontrolled
b. smoking
c. obesity
d. increased blood cholesterol and
triglycerides
e. chronic atrial fibrillation
2.Five classes of stroke: by "severity" - least
to most severe

a.transient ischemic attack (TIA)

i. TIA is warning sign of stroke
ii. localized ischemic event
iii. produces neurological deficits lasting
only minutes or hours
iv. full functional recovery within 24 to 48
hours
b.reversible ischemic neurological deficit
(RIND)
i. similar to TIA
ii. findings last between 24 hours and three
weeks
iii. usual full functional recovery within three
to four weeks

c. partial, nonprogressing stroke: some

neurological deficit, but stabilized
d.progressing stroke (stroke in evolution)

i. deterioration of neurological status often

with grand mal seizure activity
ii. has residual neurological deficits that
last indefinitely

e.completed stroke - results from a stroke in

evolution
Two types of stroke by "cause"

a.ischemic (also known as occlusive) stroke

(clot) - slower onset
i. results from inadequate blood flow
leading to a cerebral infarction
ii. caused by cerebral thrombosis or
embolism within the cerebral blood
vessels
iii. most common cause: atherosclerosis
b.hemorrhagic stroke (bleeding) - abrupt
onset
i. intracerebral hemorrhagic stroke
• blood vessels rupture with a bleed
into the brain
• occurs most often in hypertensive
older adults
• may also result during
anticoagulant or thrombolytic
therapy
ii. subarachnoid hemorrhage (SAH)

• most often caused by rupture of saccular

intracranial aneurysms
• more than 90% are congenital aneurysms
iii. epidural bleeds

• cerebral arterial vessels are involved

• often a loss of consciousness for a short
period of time called transient
unconsciousness
• recall clue: associate that "e" in epidural and
"a" in artery are together at the top of the
alphabet
iv. subdural bleeds

• veins are involved

• may not be evident until months after an
initial trauma
• recall clue: associate that "s" in subdural
and "v" in vein are together at the bottom of
the alphabet
v. Findings (depends on the location of the
lesion)
Diagnostics
1.History and physical exam
2.Computerized tomogram (CT) scan
(illustration )
3.Magnetic resenance imaging (MRI)
(illustration )
4.Doppler echocardiography flow analysis
5.Carotid artery duplex doppler
ultrasonography
6.EEG (illustration ) - shows abnormal
electrical activity
7.Lumbar puncture (illustration ) - shows if
blood is found in the cerebral spinal fluid as
a result of a cerebral bleed
8.Cerebral angiography - shows blood flow in
cerebral arteries

a. may be done with or without contrast

Management - to prevent or minimize the
damaging effects of stroke; dependent on
the type of CVA
1.Expected outcomes
a. prevent or minimize the damaging
effects of stoke
b. depends on the type of CVA
2.Occlusive stroke
a. pharmacologic
i. thrombolytics
ii. anticoagulant therapy: heparin,
coumadin
iii. antiplatelet therapy: aspirin,
dipyridamole (Persantine)
• platelet aggregation inhibitor: clopidogrel
(Plavix), ticlopidine HCL (Ticlid)
iv. steroids: dexamethasone (Decadron)
b. surgery - bypass - carotid endarterectomy
3.Hemorrhagic stroke
a.pharmacologic
i. antihypertensive agents
ii. systemic steroids: dexamethasone
(Decadron)
iii. osmotic diuretics: mannitol
iv. antifibrinolytic agents: aminocaproic acid
(Amicar)
v. vasodilators
vi. alpha-blockers and beta-blockers
vii. anticonvulsants

b.surgical excision of aneurysm

4.Common to both types of stroke
a. care based on findings
b. therapies
i. nutritional support
ii. physical
iii. speech
iv. behavioral
v. occupational
Nursing interventions
1.In acute stage of stroke
a. maintain airway patency; if grand mal
seizure activity note time, length,
behaviors
b. monitor neuro status and vital signs
c. maintain adequate fluids
d. position with head of bed elevated 15 to
30 degrees with client turned or tilted to
unaffected side
e. provide activity as ordered
f. perform passive and/or active range of
motion exercises
g.maintain client's proper body alignment
h.administer medications as ordered
i. care for post op client as indicated
j. provide care for client with increased
intracranial pressure
CARE OF CLIENT WITH INCREASED
INTRACRANIAL PRESSURE

1.Institute seizure precautions

2.Administer oxygen as ordered
3.Monitor for changes in intracranial pressure
4.Monitor neuro vital signs as ordered
5.Maintain fluid restriction as ordered
6.Observe for herniation syndrome
7.Raise head of bed at 30-45 degrees; avoid
90 degrees since pressure in hip area
increases ICP
8.Prevent any activities that increase ICP
such as: laughing, straining at stool,
coughing, vomiting, any restrictive clothing
around neck, anxiety, pushing up in bed
with heels, pulling on rails when turning,
neck rotation, flexion or extension
9.Provide for the care of the unconscious
clients if decreased LOC
2.Long-term care of client with stroke
a. monitor to facilitate normal elimination
patterns
b. teach/evaluate the use of supportive
devices
c. maintain client in a safe environment
d. prevent the effects of immobility
e.support the maintenance of adequate
nutrition in light of feeding and swallowing
problems
f. assist with eating and ADL as indicated
g.provide emotional support
h.provide methods of communication for client
with aphasia
1. After a stroke, a 75-year-old client is
admitted to the facility. The client has left-
sided weakness and an absent gag reflex.
He’s incontinent and has a tarry stool. His
blood pressure is 90/50 mm Hg, and his
hemoglobin is 10 g. which of the following is
a priority for this client?
a. Checking the stools for occult blood
b. Performing ROM exercises to the left side
c. Keeping skin clean and dry
d. Elevating the head of the bed to 30 degrees
Correct answer: D
2. If a client experienced a stroke that damaged
the hypothalamus, the nurse would
anticipate that the client has problems with:
a. Body temperature control

b. Balance and equilibrium

c. Visual acuity
d. Thinking and reasoning
Correct answer: A
Infectious Inflammatory Disorders

A. Meningitis

1.Definition/course
a. acute or chronic inflammation of the
meninges
b. average length of illness is four months
2.Types
a. bacterial: mostly contagious; requires
isolation
i. mostly common meningococcal
• the covering of the brain and
spinal cord are involved
• in children 2 to 18 years-old
• in high risk groups
o infants
o adults with weakened or suppressed
immune systems

o 10 – 15% of cases are fatal

o 10 – 15 % of cases result in brain
damage or other serious side effects
ii. Haemophilus influenzae; those at risk are
• children in child care settings
• children with no access to vaccine

iii. Pneumococcal; those at risk are

• children under the age of 2 years-old
• adults with weakened or suppressed
immune systems
b.viral
i. isolation is not required
ii. aseptic meningitis is the most common
form in the USA

c. cryptococcal fungal
i. often from bird droppings
ii. organism is found in dirt
iii. common in clients with AIDS
3.Findings

a.severe headache
b.sudden fever
c. altered LOC – decreased
d.photophobia
e.nuchal rigidity – severe pain in the back of
neck when the chin is moved toward the
chest with the client resisting movement
4.Diagnostics
a. history and physical exam
b. positive Kernig's sign: 90-degree flexion
of hip and knee with extension of knee
causes pain
c. positive Brudzinski's sign: flexion of neck
causes flexion of hip and knee
d. lumbar puncture (illustration ) for
characteristics of cerebral spinal fluid -
decreased glucose in bacterial or fungal
infections
e. CT or MRI with and without contrast
f. EEG
Management
a.expected outcomes: to cure the infection
and prevent complications
b.pharmacologic
i. antibiotic therapy depends on the type
of pathogen
ii. preventive therapy for people exposed
to those with meningococcal or
haemophilus influenzae (H flu) meningitis:
rifampin (rifadin)
 iii. H flu vaccine
iv. antifungals if fungus
v. anticonvulsants to prevent seizures
c. actions to minimize fever
d.prevention of increased intracranial
pressure or seizures
Nursing interventions
a. care of client with increased ICP
b. seizure precautions
c. administer drugs as ordered
d. provide comfort measures for pain
e. reduce external stimuli and lighting if
photophobia
 CARE OF CLIENT WITH INCREASED
INTRACRANIAL PRESSURE
 Institute seizure precautions
 Administer oxygen as ordered
 Monitor for changes in intracranial pressure
 Monitor neuro vital signs as ordered
 Maintain fluid restriction as ordered
 Observe for herniation syndrome
 Raise head of bed at 30-45 degrees; avoid
90 degrees since pressure in hip area
increases ICP
 Prevent any activities that increase ICP
such as: laughing, straining at stool,
coughing, vomiting, any restrictive clothing
around neck, anxiety, pushing up in bed
with heels, pulling on rails when turning,
neck rotation, flexion or extension
 Provide for the care of the unconscious
clients if decreased LOC
 SEIZURE PRECAUTIONS

Before seizure
 Bed rest with padded side rails
 Suction available at the bedside
 Oxygen available at bedside
 During seizures
 Loosen any tight or restrictive clothing.
 If clients are falling, gently help them to the
ground and position clients on their side.
 Do not place anything in the mouth.
 Observe the seizure as it runs its course.
 If it lasts longer than 5 minutes, notify
health care provider immediately.
 Note the activity and the time it begun and
ended.
 Daily life precautions
 For children discourage climbing over 10
feet high.
 Recommend for clients not to lock
bathroom or shower doors.
 If swimming, clients are to have someone
with them who can rescue.
 If old enough to drive, clients should be
seizure free for six months. The time may
vary in some states.
Parameningeal infections
 Definition
 localized collection of exudate in the brain or in
the spinal cord
 a recurrent aseptic meningitis
 considered noninfectious
 Findings
 similar to meningitis
 headache, fever, stiff neck, altered
consciousness - decreased
 Diagnostics
 NO lumbar puncture; may cause herniation
 computerized tomogram (CT) scan
 Management
 expected outcomes: to cure infection and
prevent complications
 surgical decompression of abscess
 symptomatic and preventive treatment as with
meningitis
 drugs: antibiotics
 Nursing interventions: same as meningitis
except that infectious precautions are not
required
Encephalitis
 Definition
 acute viral or less commonly bacterial
inflammation, irritation and swelling on the
brain tissue
 can occur as epidemics or sporadically
 death rate ranges up to 70%
 may follow a systemic viral illness such as
chicken pox
Encephalitis
 Findings
 adult
 sudden fever
 severe headache
 altered LOC – decreased progressing to stupor then
coma with seizure activity
 nuchal rigidity
 speech or hearing de
 change in personality
 mild flu-like complaints
 infant
 vomiting
 body stiffness
 constant crying that worsens when child picked up
 constant full or bulging anterior fontanel
 Diagnostics
 history and physical exam
 CT scan, MRI, EEG
 brain biopsy
 cerebral spinal fluid – decreased glucose
suggests bacterial or fungal infection
 Management
 expected outcomes: to cure infection and prevent
infections
 uncomplicated cases require supportive and
preventive care
 bed or chair rest
 support nutritional needs
 monitor for fluid balance maintenance
 herpes simplex calls for antivirals: vidarabine
(viraA), acyclovir (Zovirax) (illustration )
 prevention of increased ICP
 antivirals such as acyclovir or ganciclovir
 anticonvulsants - prevent seizures
 · Nursing interventions
 comfort measures for fever
 administer drugs as ordered
 seizure precautions
 care of the client with increased ICP
 when needed, ensure isolation and
airborne-droplet precautions
Various Disorders of the Neurologic System
 Multiple sclerosis
 Definition
 demyelination of white matter throughout brain and
spinal cord
 third most common cause of disability in clients aged
15 to 60
 specific cause unknown
 increased incidence in temperate to cool climates
 illness improves and worsens unpredictably
 Findings depend on the location of the
demyelination
 cranial nerve: blurred vision, dysphagia,
diplopia, facial weakness and/or
numbness
 motor: weakness, paralysis, spasticity, gait
disturbances
 sensory: paresthesias, decreased
proprioception
 cerebellar: dysarthria, tremor,
incoordination, ataxia, vertigo
 cognitive: decreased short-term memory,
difficulty with new information, word-
finding difficulty, short attention span
 urinary retention or incontinence
 loss of bowel control
 sexual dysfunction
 fatigue
Guillain-Barre syndrome
 Definition
 acquired inflammatory disease
 process: demyelinization of peripheral nerves
 precipitating factors include prior bacterial or
viral infection within one to two weeks

 Findings
 muscle weakness: progressive, ascending,
bilateral
 leads to paralysis of voluntary muscles

 loss of superficial and deep tendon reflexes

 bulbar weakness
 dysphagia
 dysarthria
 respiratory failure
 sensory findings: paresthesias, burning pain
 paralysis may vary from being total to partial
of only one-half way up the body
 Diagnostics
a. history and physical exam
b. lumbar puncture will show
c. increased protein in CSF
d. electromyography (EMG)
 Management
a. expected outcomes: to prevent
complications and maintain body
functions until any reversal
b. steroids in acute phase
c. care as dictated by areas
involved
 Nursing interventions
 maintain the care of client on ventilatory
support
 provide for care of the immobilized client

 have a safe environment to minimize

infection
 maintain nutrition and fluid balance

 refer families or client to support groups

 supply referrals to therapies such as

speech, physical, occupational and
counseling
1. The nurse is assessing a 38-year-old client
diagmosed with multiple sclerosis. Which of
the following symptoms would the nurse
expect to find?
a. Vision changes

b. Absent deep tendon reflexes

c. Tremors at rest
d. Flaccid muscles
Correct answer: A
 CARE OF THE CLIENT ON VENTILATOR

Nutrition
 Administer as ordered
 IV fluids, meds
 Enteral feedings
 Evaluate for
 balanced fluid intake and output
 adequate and balanced nutrition
Hygiene
 Provide
 a rigorous, scheduled mouth care � prevents
ventilator acquired pneumonia
 bed baths and skin care as necessary
 eye care if client has decreased LOC
 meticulous perineal care to prevent yeast
infections
 for the initiation of a bowel regimen with stool
softeners with expected bowel movements at
least every three days
Skin and Muscle Integrity
 Prevent the effects of immobility by routine
passive or active range of motion exercises
or get client OOB as tolerated
 Minimize decubitus ulcers by avoidance of
rubbing or massaging reddened areas
 Reposition client every hour if bed ridden
Safety
 Apply bilateral splints as ordered to prevent footdrop
and wristdrop
 Provide a safe environment - bed in low position,
side rails up, call light within reach
 Initiate seizure precautions if indicated

Sensory Stimulation
 Provide appropriate stimulation which means to
schedule groups of tasks to prevent overstimulation
 Talk to clients before and during procedures or when
any direct care or when in the room for other
reasons
 Explain procedures before beginning them
 Encourage family members to talk with
clients about usual family activities
 Enhance stimulation by
 insertion of hearing aids
 a check of glasses for cloudy smeared lens then
clean and put them nearby or on client
 a change of lighting in the room to mimic natural
light changes
 promotion of the use of electronic battery
devices such as CD � DVD � MP3 players,
radio, television. Have maintenance check for
leakage of currents before use.
Management
 expected outcomes: to improve strength
and endurance
 pharmacologic
 anticholinesterase agents: pyridostigmine
(mestinon), neostigmine (prostigmin)
 corticosteroid therapy
 immunosuppressants: azathioprine (imuran)
 thymectomy
 plasma exchange
 myasthenic crisis management
 crisis usually follows stressor or during dosage
changes usually when being increased
 signs: sudden inability to swallow, speak, or
maintain patent airway
 cholinergic crisis may follow over dosage of
medication
 positive edrophonium (tensilon) test signals
myasthenia
 if negative endophronium test, client has not
myasthenic but cholinergic crisis, so treat with
atropine
 ventilatory support as indicated
Nursing interventions

 identify aggravating factors, such as:

 infection
 stress
 changes in medication regime - especially when
increasing dose
 if client is in crisis: provide care of the client
on ventilatory support
 give medications as ordered and on time
 help with ADL and feeding as indicated
 provide
 emotional support
 adequate rest periods
 care of the post-surgical client
 teach client
 energy conservation techniques
 expectations, side effects and medications
 signs of impending crisis, both myasthenic and
cholinergic along with what actions to take
 to avoid stressors or how to minimize stressors
Seizure Disorders
 Definition/etiology

 Sudden, transient alteration in brain function

 Disorderly transmission of electrical activity in
the brain
 Causes
 cerebral lesions
 biochemical alteration
 cerebral trauma
 idiopathic
 A classification of seizure types: partial,
simple, complex, generalized
SEIZURE CLASSIFICATIONS
 Types of generalized seizures - one
classification system
 Absence seizures (petit mal seizures)
 Myoclonic seizures (bilateral massive epileptic
myoclonus)
 Generalized tonic-clonic seizures (grand mal
seizures)
 Akinetic seizure
 Proposed international classification of
epilepsies and epileptic syndromes
 Idiopathic
 Benign childhood epilepsy
 Primary reading epilepsy
 Symptomatic
 chronic progressive epilepsia partialis continua of
childhood
 syndromes characterized by seizures with specific
triggers
 Cryptogenic
 presumed to be symptomatic but etiology is unknown
 differs from Symptomatic by lack of etiologic evidence
 Partial seizures
 focal motor
 seizure activity only in specific parts of the brain
 usually client remains conscious
 Simple with findings associated with
 motor activity
 special sensory feelings
 autonomic activity
 psychic issues
 psychomotor actions
 no loss of consciousness
 Complex
 impairment of consciousness
 secondarily generalized
 progressing to generalized tonic-clonic
Generalized seizures: eight types
 petit mal - called absence seizures
 myoclonic
 sudden, uncontrollable jerking movements of
one or more extremities
 usually occurs in the morning
 clonic
 characterized by violent bilateral muscle
movements
 hyperventilation
 face contortion
 excessive salivation
 diaphoresis
 tachycardia
 tonic
 first, client loses consciousness suddenly and
muscles contract bilaterally
 body stiffens in opisthotonos position
 jaws clenched
 may lose bladder control
 apnea with cyanosis
 pupils dilated and unresponsive
 usually lasts less than a minute
 grand mal: most common type
 tonic-clonic movements bilaterally
 may be preceded by prodromal
 lasts two to three minutes
 often incontinent of bowel/bladder
 after clonic phase, client is unresponsive for
about five minutes
 arms and legs go limp
 breathing returns to normal
 possible disorientation or confusion for
sometime afterwards
 possible headache and fatigue afterwards
 atonic: sudden loss of postural muscle tone
with collapse
 unclassified seizures
 status epilepticus
 rapid sequence of seizures without interruption
or pauses
 medical and nursing emergency
 client in postictal state when next seizure begins
 sometimes occurs if a sudden stop of
maintenance anticonvulsants
 if cerebral anoxia occurs, brain damage or death
can follow
 risk for severe organ and muscle hypoxia
 Diagnostics
 by the event itself - see above

 history and physical exam

 electroencephalogram (EEG)

 computerized tomogram (CT) scan

 Management
 expected outcomes: to control or minimize
the seizure activity and prevent
complications
 correction of underlying problem
 medications
 benzodiazepines, I.V. such as diazepam
(valium), lorazepam (ativan) for active seizures
 hydantoin anticonvulsants such as phenytoin
(dilantin) - maintenance
 barbiturates such as phenobarbitol -
maintenance
 succinimides such as ethosuximide (zarontin) -
maintenance
Nursing interventions
 administer medications as ordered
 seizure care
SEIZURE CARE
 Do not leave the client who is seizing
 Attempt to prevent or break client's fall by
assisting him/her to horizontal position on the
bed or the floor
 Loosen tight clothing around neck and chest
 Remove objects near the client
 Place a pillow under the client's head if
possible and available
 Place the client's head in a lateral position if
possible to maintain airway
 Place nothing in the client's mouth
 Cover the client if possible
 Document
 type of seizure - describe behavior rather
than labeling
 duration

 activity during and if incontinence

 if any precipitating factors

 client's response - immediate, then at 15

minute intervals until stability is
established
 seizure precautions
 teach client
 to wear MedicAlert jewelry
 about medication effects, interactions, and side
effects
 to learn when a seizure may be triggered
 techniques to reduce stress
 seizure care at home or at work
 if in public area, after the tonic phase turn client
to side
Headache
Definition
 Pain located in the upper region of the head
 One of the most common neurologic
complaints

 Classifications
 Recurrent migraine headache

 onset during adolescence or early

adulthood
 familial

 involves unilateral, throbbing pain

  subtypes
 classic migraine

 common migraine

 cluster headache

 hemiplegic headache

 ophthalmoplegic headache

 Recurrent muscular-contraction headache

(pressure, tension headache)
 most common form of headache

 may be direct result of stress, anxiety,

depression, drastic changes in caffeine
consumption
 Nonrecurrent headaches
 occur with systemic infections and are
usually associated with fever
 occur as the result of a lesion, after an
invasive spinal cord procedure such as a
lumbar puncture, or subarachnoid bleed
 caused by increased intracranial pressure
 Findings
 Vary by type of headache
 May include throbbing, nausea, vomiting,
visual disturbance, tenderness, neck
stiffness, and focal neurological signs
  Diagnostics
 History and physical exam

 Computing tomogram (CT) scan

 Magnetic resonance imaging (MRI)

 Management of headaches
 Expected outcomes: to alleviate pain and treat
underlying cause
 Vasoconstriction by pressure or cold
 Management of migraine
 nonnarcotic analgesics usually when onset
noted: aspirin, acetaminophen (Tylenol),
ibuprofen
 narcotic analgesics: codeine, meperidine
(Demerol), morphine
 alpha-adrenergic blocking agentblocker:
ergotamine tartrate (Ergostat) without or with
caffeine
 steroids: dexamethasone (Decadron)

 prophylactic treatment with beta-adrenergic

blocking agents, serotonin antagonists,
antidepressants, imipramine (Tofranil)
 avoid headache-precipitating foods such as
MSG, tyramine, or milk products, or sudden
stopping of caffeinated drinks
 Management of cluster headaches - a type of
migraine
 narcotic analgesics: codeine sulfate
 alpha-adrenergic blocking agentblocker:
ergotamine tartrate (Ergostat)
 prophylactically with serotonin antagonists
 Management of tension headaches
 nonnarcotic analgesics
 muscle relaxants
 prophylactically: antidepressants and/or
doxepin (Sinequan)
Nursing interventions

 Suggest a quiet, dark environment

 Manage pain by prompt medication
administration or other comfort measures
 Help client identify precipitating factors and
actions for prevention
 Keep NPO until nausea and vomiting subside
 Teach client
 to keep a headache diary

 expected medication actions and side

effects
 alternatives for pain relief including

referrals for alternative approaches

 to avoid or minimize trigger factors
Head Trauma
 Classifications
 Closed versus open injury
 closed is nonpenetrating; no break in the integrity of
the skull
 open injury: skull is broken with the brain exposed
 Severity
 mild: only momentary loss of consciousness with no
neurological sequelae
 moderate: momentary loss of consciousness with a
change afterwards in neurological function which is
usually not permanent
 severe: decreased LOC with serious neurological
impairment and sequelae
Types of skull fractures

 Linear: simple break in the bone; no

displacement of the skull
 Depressed: part of skull is pushed in
 Basilar: at base of skull; may extend into orbit
or ear; ear or nose may leak CSF; most
difficult to verify by x-ray
 Concussion: temporary loss of neurologic
function with complete recovery
Types of bleeding or hematomas

 Epidural
 usually something lacerates the blood vessels
(arteries) of the middle meninges
 since this is arterial bleeding, the risk of death is
greatest
 client commonly looses consciousness after injury
then is lucid; then LOC drops quickly with the next
24 hours
 Subdural
 something has lacerated the blood vessels
(veins) crossing the subdural space
 acute: findings surface in 24 to 72 hours after
injury with rapid neurologic deterioration
 subacute: findings surface 72 hours to 2
weeks after injury with a slower progression
of deterioration
 chronic: gradual clot formation over time,
possibly months with minimal deterioration
 Progression of skull fracture injury
 Onset: contusions and lacerations of
nerve cells
 Neuron death: gradual demyelinization of
affected nerve fibers
 Scarring: meninges adheres to injured
area of brain
Complications
 Cerebral edema
 results in increased intracranial pressure
 results directly from cerebral ischemia, anoxia,
and hypercapnia
 Diabetes insipidus (DI)
 DI results from a decrease release of antidiuretic
hormone (ADH) and body excretes too much fluid
 the increase in urinary output results in a low
specific gravity
 more common in the initial acute phase of head
injury
 Stress ulcer
 head injuries activate both the sympathetic and
parasympathetic systems
 stimulation of sympathetic system leads to gastric
ischemia from vasoconstriction
 stimulation of parasympathetic system leads to
increased release of hydrochloric acid (HCL) into the
stomach
 steroid therapy may contribute to the development of
ulcers since steroids increase HCL acid
 Syndrome of inappropriate anitdiuretic
hormone (SIADH)
 too much ADH is produced
 water is excessively retained - hemodilution
 urinary output decreases; urine specific granity
increases effect
 more common in the chronic phase of care after a
head injury
 Seizure disorders
 Infection: brain, lungs, urinary system from
immobility
 Hyperthermia or hypothermia
Findings of head trauma
 Degree of neurological damage varies with
type and location of injury
 Restlessness and irritability - initially
 Decreased LOC - lethargy, difficulty with
arousal
 Headache
 Nausea and vomiting - projectile vomiting
indicates increased ICP
Diagnostics

 History and physical exam

 Computerized tomogram (CT) scan
 Magnetic resonance imaging (MRI)
 Electroencephalogram (EEG)
Management
 Expected outcomes: to reduce or minimize
increases in intracranial pressure and protect
the nervous system
 Medications for increased ICP
 osmotic diuretics; mannitol (osmitrol) - IV drip or
push
 steroids: dexamethasone (decadron) - IV push
 barbiturate coma may be induced to treat
refractory increased intracranial pressure
 Surgical correction of underlying cause
 Treatment for evident findings: seizures,
fever, infection
 Therapy
 nutritional support

 physical

 speech

 behavioral

 occupational
 Nursing interventions
 Provide care of the client with increased
intracranial pressure
 seizure precautions
 seizure care

 care of the client on ventilator

 Monitor for balanced nutrition and fluids

 Assist with ADL as indicated
 Prevent complications of immobility
 Monitor neuro vital signs
 Give medications as ordered
 Provide emotional support with appropriate
referrals
 Manage pain within agency's guidelines
Brain Tumors

 Growth of tissue within the brain tissue

enclosed by the skull
 May be cancerous or benign

 Classified according to tissue type

 May be primary or metastatic

 Findings
 Depend on the size and the location of tumor

 Locations and findings

 frontal lobe: personality changes - classic,

focal seizures, visual disturbances,
hemiparesis, aphasia
 occipital lobe: visual hallucinations, focal
seizures
 temporal lobe: headache, seizures

 parietal lobe: visual losses, seizures

 cerebellum: coordination or mobility

difficulties
 Increased intracranial pressure as tumor
enlarges
 Diagnostics
 History and physical exam
 CT scan
 Magnetic resonance imaging (MRI)
 Management
 Expected outcome: removal of the tumor with
minimal harm to the nervous system
 Depends on the location and size of the tumor
 Treatment for associated increased intracranial
pressure from tumors
 surgery

 craniotomy to remove tumor

 stereotactic laser surgery

 radiation therapy for malignancy

 Medications for malignant tumors: chemotherapy

Nursing interventions
 Provide:
 care of the client with increased intracranial
pressure from tumors
 care of the client undergoing
 surgery
 radiation therapy
 chemotherapy
 seizure precautions
 seizure care
 balanced nutrition and fluid
 Facilitate emotional support with referrals to
support groups for the client and family
Peripheral Nerve and Cranial Nerve
Disorders

 Trigeminal neuralgia (tic douloureux)

 Syndrome of paroxysmal facial pain
 occurs more often in middle age and older
adults
 affects cranial nerve five (trigeminal nerve)
 has unknown etiology
 involves one side only
 is triggered by harmless events such as a
breeze, hot or cold liquids
 Findings
 intense facial pain lasting about one to
two minutes along the nerve branches
 extreme facial sensitivity

 pain may be described as "burning" or

"shooting"
 Diagnostics: history and physical exam
Management
 expected outcomes: to relieve pain and to
minimize frequency
 anticonvulsants: carbamazepine (tegretol),
phenytoin (dilantin)
 surgery
 minor
 radio-frequency gangliolysis: heat destroys
trigeminal ganglion
 glycerol gangliolysis: glycerol injected into
subarachnoid space around gasserian ganglion
 major - microvascular compression: move
arterial loop away from posterior trigeminal root
Nursing interventions
 help clients to name trigger points with
identification of triggering incidents
 recommend restful environment with scheduled
rest periods
 reinforce the need for balanced nutrition
 provide appropriate care of the client undergoing
surgery
 teach client
 about medications and side effects
 to avoid triggering agents
 to chew on the opposite side of the mouth
 to avoid drafts
 to avoid very hot or cold foods or fluids
Facial nerve paralysis (bell's palsy)

 Definition/etiology
 is a disorder of cranial nerve seven (facial
nerve)
 involves one side only; unilateral

 has an unknown etiology

 often occurs during periods of high stress

 Findings often occur suddenly over ten to
30 minutes
 ptosis
 cannot close or blink eye with excessive
tearing
 flat nasolabial fold
 impaired taste
 lower face paralysis
 difficulty eating - impaired mastication of food
and difficulty swallowing
 Diagnostics: history and physical exam
 Management
 expected outcome: to restore cranial nerve
function
 medications
 prednisone

 analgesics

 local comfort measures: heat, massage and

electrical nerve stimulation for muscle tone
 alternative therapies: reiki, massage,
imagery
 Nursing interventions
 reinforce balanced nutrition with a soft diet
 administer drugs as ordered
 teach client
 to chew on the opposite side
 how to use protective eye wear during
risk periods - patch or glasses over eye
 effects of steroids
 the use of eye drugs or ointment to
protect the eye from corneal irritation
 that once findings disappear their return
may occur especially in times of high
stress