neurology part 1

Medical-Surgical NursingA 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

Anatomy and Physiology 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


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=Spontaneous3=To voice2=To pain1=None (No response)

Glasgow Coma Scale

Glasgow Coma Score Verbal Response (V)

5=Normal/oriented4=Disoriented/CONFUSED3=Words, but incoherent/ inappropriate2=Incomprehensible/mumbled words1=None

Glasgow Coma Scale

Glasgow Coma Score Motor Response (M)

6=Normal- obeys command5=Localizes pain4=Withdraws to pain (Flexion)3=Decorticate posture2=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 Function: 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 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

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 Function: Cranial Nerve 11- accessory

Press down the patient’s shoulder while he attempts to shrug against resistance

Cranial Nerve Function: 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

Assessing the motor function 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

Assessing the motor function 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 clonicSuperficial 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 mmHgBrunner= Normal intracranial pressure 10-20

mmHgCauses: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications


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


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


PathophysiologyDecompensatory 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 mmHg2. 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


CLINICAL MANIFESTATIONSEarly manifestations: Changes in the LOC- usually

the earliest Pupillary changes- fixed, slowed

response Headache vomiting


CLINICAL MANIFESTATIONSlate manifestations: Cushing reflex- systolic

hypertension, bradycardia and wide pulse pressure

bradypnea Hyperthermia Abnormal posturing


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 levelsconstricts blood vesselsreduces edema


Nursing interventions 3. Administer prescribed

medications- usually Mannitol- to produce negative fluid

balance corticosteroid- to reduce edema anticonvulsants-p 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.

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

Altered level of consciousness 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 Factors1. Head injury 2. Stroke3. Drug overdose4. Alcoholic intoxication5. Diabetic ketoacidosis6. Hepatic failure


ASSESSMENT1. Behavioral changes initially2. Pupils are slowly reactive 3. Then , patient becomes

unresponsive and pupils become fixed dilated

Glasgow Coma Scale is utilized


Nursing Intervention1. Maintain patent airway Elevate the head of the bed to 30 degrees Suctioning2. Protect the patient Pad side rails Prevent injury from equipments, restraints

and etc.


Nursing Intervention3. Maintain fluid and nutritional

balance Input an output monitoring IVF therapy Feeding through NGT4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips


Nursing Intervention5. Maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by

using trochanter rolls, foot board6. Preserve corneal integrity Use of artificial tears every 2 hours


Nursing Intervention7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as

prescribed8. Prevent urinary retention Use of intermittent catheterization


Nursing Intervention9. Promote bowel function High fiber diet Stool softeners and suppository10. 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 FACTORS1. Idiopathic2. Fever3. Head injury4. CNS infection5. Metabolic and toxic conditions

SEIZURES

Nursing InterventionsDuring 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

Nursing InterventionsDuring seizure 5. loosen constrictive clothing 6. DO NOT restrain, or attempt

to place tongue blade or insert oral airway

SEIZURES

Nursing InterventionsPOST 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

Migraine1. Prodrome stage2. Aura phase3. Headache4. Recovery phase

headache

Nursing Interventions 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


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

Nursing Interventions1. 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

Nursing Interventions4. Use large signs as visual cues5. Post patient's photo on the door6. 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


Non-communicating hydrocephalus results from CSF outflow obstruction

Communicating hydrocephalus results from faulty absorption or increased CSF production


Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head,

thin scalp skin 4. sunset eyes


DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography


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


ASSESSMENT 1. a dimple or tuft of hair in the

vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography


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

CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 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

CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 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 hemorrhageEpidural Hematoma- blood collects

in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal arterySymptoms develop rapidly


4. Intracranial hemorrhageSubdural 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 vesselsSymptoms usually develop slowly


4. Intracranial hemorrhageIntracerebral Hemorrhage and hematoma-

bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalitiesSymptoms 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 MANAGEMENT1. Monitor for declining LOC- use

of Glasgow2. Maintain patent airway Elevate bed, suction prn,

monitor ABG


NURSING MANAGEMENT3. Monitor F and E balance Daily weights IVF therapy Monitor possible development

of DI and SIADH


4. Provide adequate nutrition5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of

intermittent catheter


6. Maintain skin integrity 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


Can be divided into two major categories

1. Ischemic stroke- caused by thrombus and embolus

2. Hemorrhagic stroke- caused commonly by hypertensive bleeding


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 Advanced age Gender race

Modifiable Hypertension Cardio disease 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


DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography


CLINICAL MANIFESTATIONS 1. Numbness or weakness 2. confusion or change of LOC 3. motor and speech

difficulties 4. Visual disturbance 5. Severe headache


Motor Loss Hemiplegia Hemiparesis


Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a

previously learned action


Perceptual disturbances Hemianopsia

Sensory loss paresthesia


NURSING INTERVENTIONS1. 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


NURSING INTERVENTIONS2. Enhance self-care Carry out activities on the

unaffected side Prevent unilateral neglect Keep environment organized Use large mirror


NURSING INTERVENTIONS3. Manage sensory-perceptual

difficulties Approach patient on the

Unaffected side Encourage to turn the head to the

affected side to compensate for visual loss


NURSING INTERVENTIONS4. Manage dysphagia Place food on the UNAFFECTED

side Provide smaller bolus of food Manage tube feedings if

prescribed


NURSING INTERVENTIONS5. 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


NURSING INTERVENTIONS6. Improve thought processes Support patient and capitalize on

the remaining strengths


NURSING INTERVENTIONS7. 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


NURSING INTERVENTIONS8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NON-

reddened areas Provide adequate nutrition


NURSING INTERVENTIONS9. Promote continuing care Referral to other health care

providers


NURSING INTERVENTIONS10. Improve family coping11. 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


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

neurology part 1

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Transcript of neurology part 1