NEURO NURSING

By: JOHN MARK B. POCSIDIO

GIVEN FREE BY THE LECTURER

THE NERVOUS SYSTEM

The function of the nervous system is to control all motor, sensory,
autonomic, cognitive, and behavioral activities.
The nervous system has approximately 10 million sensory neurons
500,000 motor neurons that control the muscles and glands.
The brain itself contains more than 20 billion nerve cells

Nervous System
CNS
brain and spinal cord
PNS
cranial nerve and spinal nerve
ANS
sympa and para

The Neuron
FUNCTIONAL UNIT
dendrites – receive neural msgs
& transmit towards cell body
axon – transmits neural msgs
away from cell body
cell body – contains nucleus,
mitochondria, & other organelles
myelin & cellular sheath
produced by Schwann cells
nodes of Ranvier

TYPES OF NEURONS

Sensory neurons typically have a long dendrite

and short axon, carry messages from
sensory receptors  central nervous system.

Motor neurons have a long axon and short dendrites, transmit messages from
central nervous system muscles (or to glands).

Interneurons are found only in the central nervous system where they connect
neuron to neuron.
Afferent neurons
From tissues and organs into the CNS (sensory neurons.)

Efferent neurons
From CNS to the effector cells (motor neurons)
NEUROTRANSMITTERS

Neurotransmitters communicate messages from one neuron to another or from a

neuron to a specific target tissue
Neurotransmitters are manufactured and stored in synaptic vesicles. They
enable conduction of impulses across the synaptic cleft.
When released, the neurotransmitter crosses the synaptic cleft and binds to
receptors in the postsynaptic cell membrane
The action of a neurotransmitter is to potentiate, terminate, or modulate a
specific action and can either excite or inhibit the target cell’s activity

Neurotransmitters
Acetycholine
Dopamine
Epi and Nor E
GABA
Serotonin (↓ depression, ↑ manic)
Glutamine (excitatory)

CEREBRUM
frontal
occipital
parietal
temporal

Anatomy and Physiology

Central lobe- controls visceral fx
- activities of internal organ

Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Cerebellum

-Sensory perception and motor output

Disorder = in fine movement, equilibrium, posture and motor learning
-Coordinates sm muscle mov’t
-coordinates, posture, equilibrium and muscle tone
- It controls fine movements, balance, position sense. (awareness of where
each part of the body is)

CNS
Thalamus
Hypothalamus
Pituitary Gland
The Thalamus
Afferent neurons coming from all sense organs (except olfactory) & motor
neurons synapse with nuclei found within the thalamus  cerebrum
The thalamus also helps one associate feelings of pleasantness or
unpleasantness with sensory impulses
Relays sensory impulses to the cortex
Provides a pain gate

HYPOTHALAMUS
located anterior and inferior to the Thalamus. the hypothalamus lies
immediately beneath and lateral to the lower portion of the wall of the third
ventricle. It includes the optic chiasm (the point at which the two optic
tracts cross) and the mamillary bodies.

HYPOTHALAMUS
The hypothalamus plays an important role in the endocrine system because it
regulates the pituitary secretion of hormones that influence metabolism,
reproduction, stress response, and urine production. It works with the
pituitary to maintain fluid balance and maintains temperature regulation by
promoting vasoconstriction or vasodilatation.
BrainStem
Mid Brain
Pons
Medulla
The Midbrain
Motor coordination
Visual reflex and auditory relay center

Pons
Regulates breathing- resp. center
Medulla oblongata
Contains efferent/afferent fibers
Cardiac, respiratory, vomiting and vasomotor center( bld. vessel diameter)

Medulla
Vital reflex centers within the medulla:
Cardiac centers – control heart rate
Vasomotor centers – control blood pressure
Respiratory centers – regulate breathing
Centers for vomiting, sneezing, coughing, & swallowing
Centers for reflexes mediated by CNs IX-XII
 Meninges
pia
arachnoid
dura

Meninges = DAP
1. Dura Mater = outermost
 Tough, white fibrous connective tissue
Subdural space = potential space
2. Arachnoid = Middle
Thin, delicate, cobweb-like membrane
Subarachnoid space
Filled with CSF & blood vessels
3. Pia Mater = Innermost
Thin, vascular membrane tightly bound to the brain
CNS

Spinal Cord
motor and sensory pathways

PNS
Spinal Nerves 31 pairs
Cranial Nerves 12

Spinal Nerves

C- 8
T- 12
L- 5
S- 5
C- 1
Autonomic Nervous System
Sympathetic

Parasympathetic
Comparison of Sympathetic and Parasympathetic Actions on Selected Effectors

Sympathetic Action Parasympathetic Action

Effector
Heart Increases rate and strength of Decreases rate; no direct effect
contraction on strength of contraction
Bronchial Dilates Constricts
tubes
Iris of eye Dilates (pupil becomes larger) Constricts (pupil becomes
smaller)
Sex organs Constricts blood vessels; Dilates blood vessels; erection
ejaculation
Blood vessels Generally constricts No innervation for many
Sweat glands Stimulates No innervation
Intestine Inhibits motility Stimulates motility and
secretion
Liver Stimulates glycogen breakdown No effect
metabolism
Adipose tissue Stimulates free fatty acid release No effect
from fat cells
Adrenal Stimulates secretion of No effect
medulla epinephrine and norepinephrine
Salivary Stimulates thick, viscous Stimulates profuse, water

DIAGNOSTIC EXAM
By: JOHN MARK B. POCSIDIO, RN, USRN, MSN
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
CEREBRAL FUNCTION
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
7 and Below= COMA!
Glasgow Coma Scale
Glasgow Coma Score

Eye Opening (E)

4=Spontaneous
3=To voice (when told to)
2=To pain
1=None (No response)

Verbal Response (V)

5=Normal/oriented
4=Disoriented/CONFUSED
3=Words, but incoherent/ inappropriate
2=Incomprehensible/mumbled words
1=None

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 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

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 (touch cotton
to forehead, chick & jaw)
 Motor portion- assess the muscles of mastication ( ask to clench and
move jaw side to side)
 Assess corneal reflex ( wisp of cotton on temporal surface of cornea)

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
Test for lateralization (Weber)
Test for air and bone conduction (Rinne)

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

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

Abnormal Reflex
• Positive Brudzinski’s sign (pain, resistance, flexion of hips and
knees when head flexed to chest with client supine) indicates
meningeal irritation

Positive Kernig’s sign (excessive pain and/or resistance when examiner

attempts to straighten knees with client supine and knees and hips flexed)
indicates meningeal irritation

d. Positive Babinski reflex (dorsiflexion of big toe with fanning of other

toes): UMN diseases of pyramidal tract

Decorticate posturing (upper arms close to sides, elbows, wrists and fingers
flexes, legs extended with internal rotation, feet are flexed: body parts
pulled into core of body): lesions of corticospinal tracts

Decerebrate posturing (neck extended with jaw clenched, arms pronated,

extended, close to sides, legs are extended straight out and feet plantar
flexed): lesions of midbrain, pons, diencephalon

Diagnostic Test
• Skull and spinal x-ray
- identify fractures dislocation. Compression, spinal cord problem
Nursing Care
- provide nursing support for the confused or combative patient
- No to pregnant-CBQ
- maintain immobilization
- remove metal items
b. CT Scan- skull/ spinal cord are scanned in successive layers by a narrow
beam of X-rays. A computer uses information obtained to construct a
picture of the internal structure of the brain
- detect intracranial bleeding, space occupying lesion, cerebral edema.
Hydrocephalus, infarction
Nursing Care
Assess for allergies - CBQ
 Instruct to lie still and flat-CBQ
 Inform pt that there may be hot, flushed sensation and metallic taste
in the mouth-CBQ
 Treat allergic reaction-CBQ
 Remove hairpins etc.-CBQ

MAGNETIC RESONANCE IMAGING

-Computer-drawn, detailed pictures of structures of the body through use of
large magnet, radio waves.
- Used to detect intracranial and spinal abnormalities associated with
disorders such as CVA, tumors, abscesses, cerebral edema, hydrocephalus,
multiple sclerosis

NURSING INTERVENTIONS
1.) Instruct client to remove jewelry, hairpins, glasses, wigs,( with metal
clips), and other metallic objects-CBQ
2.) Patients with orthopedic hardware, intrauterine devices, pacemaker,
internal surgical clips or other fixed metallic objects in the body cannot
undergo the procedure-CBQ
3.) Inform client to remain still during the procedure ( last 45-60 mins)
4.) Teach relaxation techniques to assist client & help prevent
claustrophobia
5.) Warn the client of normal audible humming and thumping noises from the
scanner during test
6.) Have client void before test-CBQ
7.) Sedate client if ordered

EEG -graphic recording of electrical activity of the brain by several small

electrodes placed on the scalp.
NURSING INTERVENTIONS
 Withhold medications that may interfere with the results- anticonvulsants, sedatives
and stimulants
 Wash hair thoroughly before procedure
  Instruct adult client to sleep no more than 5 hrs the night before.
 Instruct child client to sleep no more than 5-7 hrs the night before

Lumbar tap
Insertion of spinal needle through the L3 and L4 into the subarachnoid space
PURPOSES
1.) Measures CSF pressure ( normal opening pressure 60-150mmH2O)
2.) Obtain specimens for lab analysis( protein normally not present), sugar (
normally present), cytology, C&S
3.) Check color of CSF ( normally clear) and check for blood
4.) Inject air, dye, or drugs into the spinal canal

NURSING CARE PRE-TEST

1.) Have client empty bladder
2.) Position client in a lateral recumbent position with head and neck flexed
onto the chest and knees pulled up.
3.) Explain the need to remain still during the procedure
NURSING CARE POST-TEST
1.) Ensure labeling of CSF specimens in proper sequence
2.) Keep client flat for 12-24 hours as ordered
3.) Force fluids
4.) Check puncture site for bleeding, leakage of CSF
5.) Assess sensation and movement in lower extremities
6.) Monitor vital signs
7.) Administer analgesics for headache as ordered
CONTRAINDICATION TO LUMBAR TAP
 INCREASED ICP
 COAGULOPATHY & DECREASED PLATELETS
 SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)

CEREBRAL ANGIOGRAPHY
Injection of radiopaque substance into the cerebral circulation via carotid,
vertebral, femoral , or brachial artery followed by x-rays
Used to visualize cerebral vessels and detect tumors, aneurysm, occlusion,
hematomas, or abscesses
NURSING CARE PRE-TEST
1.) Check allergy to iodine
2.) Keep NPO after midnight or offer clear liquid breakfast only
3.) Explain that the client may have warm, flushed feeling and salty taste in
mouth during procedure
4.) Take baseline vital signs and neuro check
5.) Administer sedation if ordered
NURSING CARE POST-TEST
1.) Maintain pressure dressing over site if femoral or brachial artery used;
apply ice as ordered
2.) Maintain bed rest until next morning as ordered
3.) Monitor vital signs, neuro checks frequently; report any changes
immediately
4.) Check site frequently for bleeding or hematoma; if carotid artery used;
assess for swelling of neck, difficulty swallowing or breathing
5.) Check pulse, color, and temperature of extremity distal to site used.
6.) Keep extremity extended and avoid flexion

NEUROLOGICAL DISODERS
HEADACHE
Headache is pain affecting the front, top, or sides of the head. Often
occurring in the middle of the day, the pain may have these characteristics:
Mild to moderate.
Constant.
ASSESSMENT S/SX.
 PRESSURE PAIN, & TIGHT FEELING IN THE TEMPORAL AREA
 PAIN
 NAUSEA
 HEADACHE WITH SENSITIVITY TO LIGHT
DIAGNOSTICS
HEALTH HISTORY
PHYSICAL EXAMINATION
CT SCAN
MRI
Treatments include:
 Depends on the type of headache and whether it is acute or
 chronic.
 Quiet, dark room especially for migraines.
 Antiemetics such as phenergan if vomiting.
 Opiate analgesics.
 Meds like sumatriptan ( SSRI)can be given to abort the headache but
the cardiovascular risk must be weighed against the benefit. These are
reserved for clients who are having two or more migraines per month.-
cgfns
 Ergot derivatives ( bromocriptine) ( stimulate dopamine receptors)are
also given to abort the headache but can also cause spontaneous abortion
(miscarriage).-NCLEX!!!!!
 Chronic migraines may be treated prophylactically with propranolol
 (beta-blocker), amitriptyline, clonidine, verapamil (calcium-channel
 blocker), cyproheptadine (Periactin), as well as various
antidepressants.
 Opioid analgesics such as Demerol mixed with phenergan for severe
attacks.
 Nonsteroidal, antiinflammatory drugs (NSAIDs) PO or IM such as Toradol,
Decadron

Increase Intracranial pressure

An increase in intracranial bulk due to increase in any of the major
intracranial components: brain tissue, CSF, or Blood
Caused by: Brain abscesses, hemorrhage, edema, hydrocephalus, inflammation
If left in treated it can lead to brain herniation

CLINICAL MANIFESTATIONS
Early manifestations:
Changes in the LOC- usually the earliest -CBQ
Pupillary changes- fixed, slowed response
Headache
vomiting
Increased Intracranial pressure

CLINICAL MANIFESTATIONS
late manifestations:
Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure
bradypnea
Hypothermia
Abnormal posturing

Increased Intracranial 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

Increased Intracranial pressure

Nursing interventions
3. Administer prescribed medications- usually
Mannitol- to produce negative fluid balance
corticosteroid- to reduce edema
anticonvulsants-p to prevent seizures

Increased Intracranial pressure

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

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke

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 INTERVENTIONS: ACUTE
 Ensure patent airway
 Give 100% oxygen to the patient to dec ICP
 Keep patient on LATERAL position ( initially)
 Then if stable position low fowlers with neck aligned
 Monitor VS and GCS, pupil size
 IVF is ordered but given with caution as not to increase ICP
 NGT inserted
 Medications: Steroids, Mannitol (to decrease edema), Diazepam,
Thrombolytics

NURSING INTERVENTION -REHAB

CARE FOR HEMIPLEGIA
1. ) Turn every 2 hours ( 20 mins only on affected side)
2.)Use proper positioning and repositioning to prevent deformities
3.) Support paralyzed arm on pillow or use sling while out of bed to prevent
subluxation of shoulder
4.) Elevate extremities to prevent dependent edema
5.) Provide active and passive ROM excercises evry 4 hours
SAFETY
1.) Keep side rails up at all times
2.) Institute safety measures
3.) Inspect body parts frequently for signs of injury
DYSPHAGIA
1.) Check gag reflex before feeding client
2.) Maintain calm unhurried approach
3.) Place client upright position
4.) Place food in unaffected side of mouth
5.) Offer soft foods
6.)Give mouth care before and after meals
HOMONYMOUS HEMIANOPSIA
1.) Approach client on unaffected side
2.) Place personal belongings, food, etc. on unaffected side
3.) Teach scanning techniques
EMOTIONAL LABILITY: MOOD SWINGS
1.) Create a quiet, restful environment with a reduction in excessive
sensory stimuli
2.) Maintain a calm , non threatening manner
3.) Explain to family that the client’s behavior is not purposeful
APHASIA
RECEPTIVE APHASIA
1.) Give simple, slow directions
2.) Give one command at a time ; gradually shift topics
3.) Use non verbal techniques in communication ( pantomine)- CBQ
EXPRESSIVE APHASIA
1.) Listen & watch carefully when the client attempts to speak
2.) Anticipate the clients needs to decrease frustrations
3.)Give magic slate- CBQ
APRAXIA – loss of ability to perform purposeful skilled acts
1.) Guide the client through intended movement
2.) Keep repeating the movement

MENINGITIS
Inflammation of the meninges of the brain and spinal cord
Caused by: BACTERIA, VIRUSES or other microorganisms
May reach the brain via:
 Blood, CSF
 By direct extension from adjacent cranial structures ( nasal
sinuses, mastoid bone, ear, skull fracture)
 By oral or nasopharyngeal route
ASSESSMENT FINDINGS
 Headache, photophobia, malaise, irritability
 Fever and chills
 Signs of meningeal irritation
 Nuchal rigidity: stiff neck
 Kernig’s sign: contraction or pain in the hamstring muscle when
attempting to extend the leg when hip is flexed
 Opisthotonus: head and heals bent backward and body arched forward
 Brudzinski sign: flexion at the hip and knee in response to forward
flexion of the neck
Cont.
4. vomiting
5. possible seizures and decreasing LOC

DIAGNOSTIC TEST: LUMBAR PUNCTURE

CSF shows: elevated WBC, protein, decreased glucose and culture positive for
specific microorganisms

NURSING INTERVENTIONS
1. Administer large doses of antibiotics IV as ordered
2. Enforce respiratory isolation for 24 hours after initiation of antibiotic
therapy
3. Provide bed rest; keep room dark and quiet
4. Administer analgesics for headache as ordered
5. Maintain fluid and electrolyte balance
6. Monitor vital signs and neuro checks frequently
7 DIET? High calorie, high protein, small frequent feeding
REFER? AUDIOLOGIST

ENCEPHALITIS
Inflammation of the brain caused by a virus,
E.g herpes simplex or arbovirus ( transmitted by mosquito or tick)
May occur as a sequela of other diseases such as measles, mumps, chickenpox

ASSESMENT
1. Headache
2. Fever, chills, vomiting
3. Signs of meningeal irritation
4. Possibly seizures
5. Alteration in LOC

NURSING INTERVENTIONS
1. Monitor vital signs and neurochecks frequently
2. Provide nursing measures for increased ICP
3. Provide nursing care for confused or unconscious client as needed
CEREBRAL ANEURYSM
Dilation of the walls of a cerebral artery resulting in a sac-like out
pouching of the vessel
Caused by: congenital weakness in the vessel, trauma, arteriosclerosis ,
hypertension

PATHOPHYSILOGY:
Aneurysms compress nearby cranial nerves or brain substance , producing
dysfunction
Aneurysms may rupture , causing intracerebral hemorrhage

ASSESSMENT
1. Severe headache, and pain in the eyes
2.Diplopia, tinnitus, dizziness
3. Nuchal rigidity, ptosis, decreasing LOC, hemiparesis, seizures

NURSING INTERVENTIONS
1. Maintain a patent airway and adequate ventilation
-instruct client to take deep breaths but to avoid coughing
-suction only with a specific order
2. Monitor vital signs and neuro checks and observe signs of vasospasm,
increased ICP, hypertension, seizures, and hyperthermia
3. Institute seizure precaution
4. Enforce bed rest and provide complete care
5. Keep head of bed flat or elevated to 20-30 degrees as ordered
6. Maintain a quiet and darkened environment
7. Avoid taking rectal temperature, avoid sneezing, coughing, and straining
at stool
8. Enforce fluid restriction as ordered; maintain accurate I&O
Give meds: antihypertension
. Corticosteriods, anticonvulsant, stoolsofteners

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
EPILEPSY
Neurologic disorder in which the patient experiences recurrent seizures
consisting of transient disturbances of cerebral function due to paroxysmal
neuronal discharge

PATHOPHYSIOLOGY
An electrical disturbance in the nerve cells in one brain section EMITS
ELECTRICAL IMPULSES excessively
Etiologic Factors
 Often idiopathic
 Cerebral trauma, infection, vascular disease, neoplasms, degenerative
disease (Alzheimer)
 Drugs, chemical poisons
 Metabolic disorders
 Children, high fever
 Others: lack of sleep, alcohol

CLASSIFICATION OF SEIZURES
SIMPLE PARTIAL- symptoms confined to one hemisphere, may have motor ( change
in posture), sensory ( hallucinations), or autonomic ( flushing, tachycardia)
symptoms ; no loss of consciousness

COMPLEX PARTIAL – begins in one focal area but spreads to both hemispheres
( more common in adults), there is loss of consciousness; aura of visual
disturbances, postictal symptoms

Generalized: entire cerebral cortex is involved

Absence (petit mal): sudden onset, lat 5-10 seconds; can have 100 daily,
precipitated by stress, hypoglycemia, fatigue, hyperventilation , there is
loss of responsiveness but continued ability to maintain posture control and
not fall, twitching of the eyelids, lip smacking , no postictal symptoms

Tonic-clonic (grand mal): victim becomes rigid, cries out, loses

consciousness, falls & stops breathing (tonic phase); muscular jerking, may
bite tongue or lips, may be incontinent (clonic phase); after awakening,
subject is drowsy & amnesic

Cyclonic: repeated shock like, often violent contractions in one or more

muscle groups
Status epilepticus: one or a series of grand mal seizures lasting more than
30 minutes w/o waking intervals

DIAGNOSTICS
EEG shows focal abnormalities in the rate, rhythm or relative intensity of
cerebral cortical rhythms
Others: CT scan, MRI
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
Nursing Interventions
During seizure
5. loosen constrictive clothing
6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

Pharmacology
DILANTIN
CBQ- used to prevent siezure.
- given in the ward not in the ER (EXPLAIN)
- causes brownish urine
- never abruptly stop ( can cause rebound siezure)
- can cause gingival hyperplasia ( massage gums)
NCLEX??? LETHAL FATAL; EFFECT? APLASTIC ANEMIA

BENZODIAZEPINE
CBQ Major indications. Anxiety, insomnia, and siezure( skeletal muscle
relaxation
NCLEX– Should be started on low dosage and gradually increased to achieved
desired clinical response.
NO TO PREGNANT MOTHER!!!
-Monitor client for drowsiness, lightheadedness, and dizziness periodically
during treatment, these usually disappear as therapy progresses
- NCLEX---- restrict amount of drug available or the client. May cause
physical dependence if prolonged therapy.
- NO TO ACUTE ASTHMA OR COPD ATTACK!!!!!! ( may cause respiratory
depression)
- ANTIDOTE: FLUMAZENIL
MEDS
PHENYTOIN DILANTIN
 -often used with phenobarbital for its potentiating effect.
 -inhibits spread of electrical discharge
 S.e gum hyperplasia, hirsutism, ataxia, gas distress, nystagmus,
sedation
 Best taken with food to enhance absorption
 Massage gums
 May turn urine reddish brown (explain to client)
 Can cause aplastic anemia( watch out)
 Do NOT ABRUPTLY STOP!!!!

Trigeminal Neuralgia
(Tic Douloureux)

Is an intensely painful neurologic condition affecting the 5th CN

(trigeminal)
Patient may experience lancinating or electric shock-like facial pain
Pain can be triggered when talking, shaving, eating, touching the face,
brushing teeth, or when exposed to cold and wind.
Trigeminal Neuralgia
Avoid too hot or too cold food or liquids
Room temp for food and water for bathing
Chewing on the unaffected side is recommended
No massage
Provide water jet device for mouth care
Tegretol for pain
Phenol Injection in the Gasserian ganglia ( loss of temporary facial
sensation)
Rhizotomy (surgical intervention)
Percutaneous radio-frequency trigeminal gangliolysis

BELL’S PALSY
Affects the 7th cranial nerve ( facial)
Produces unilateral facial weakness, or paralysis
Onset is rapid
Occurs in persons under age 60

Bell’s Palsy
Named after Scottish anatomist Charles Bell
Acute peripheral facial paralysis of the 7th CN (facial)
Self-limiting that usually improves in 4-6 months.
Cause is unknown
Inflammation
Vascular ischemia
Autoimmune demyelination

ASSESSMENT
 Inability to close eye completely on the affected side
 Pain around the jaw or ear
 Ringing in the ear
 Taste distortion on the anterior portion of the tongue on the affected
side
 Unilateral facial weakness
 Eye roll upward and tears excessively when the patient attempts to close
it

Interventions
 Artificial tears is recommended and dark glasses- CBQ
 Apply warm packs to the affected
 Inadequate eyelid closure
 Exercise (grimacing, wrinkling, whistling, puffing the cheeks, blowing
out air)
 Provide soft diet-CBQ
 Instruct to chew on unaffected side, avoid hot fluids/ food-CBQ
MULTIPLE SCLEROSIS
Degenerative disease
Demyelination of the (myelin sheath) nerve fibers (brain and spinal cord)
Hypofunction of oligodendroglial cells and schwann cells(responsible for
reproduction of the myelin sheath)
Chronic slowly progressive
Characterized by remission and exacerbation

Maybe triggered by:

pregnancy
fatigue
stress
infection and trauma
May worsen in extreme temperatures
Lesions are scattered
Common among women
Cause:
Unknown
Autoimmune (post viral infection)

Diagnostic test: CT scan, MRI, CSF (IgG), EEG

Manifestations

Eye problem (early manifestation)

vision is impaired, blurring, diplopia, scotoma (patch blindness), nystagmus,
total blindness
Disruption of sensory nerve
Paresthesia and pain
Frontal lobe problem
memory loss,  concentration, poor abstract reasoning

Cerebellum and basal ganglia involvement

Ataxia (uncoordinated muscle movement
Tremor
Weakness of muscle in throat and face (3 D’s)
Sacral cord problem
Impotence, bowel and bladder dysfunction
Charcot’s triad (nystagmus, tremors and scanning speech)
DIAGNOSTIC TEST:
CSF- IGg in CSF

Management

Avoid fatigue, stress and infection

Promote safety and rest
Visual disturbance (scanning vision) eye patch for diplopia
Sensory problem (caution for cuts and burns), avoid hot tubs ( heat increases
weakness)
Motor problem (fall and slip)
Bowel and bladder program
Steroids, Immunosuppressive, Antibiotics, baclofen ,Plasmapheresis,
Thymectomy
Respiratory Distress precautions

Guillian-Barre’ Syndrome
An auto-immune attack of the peripheral nerve myelin
Acute, rapid segmental demyelination of peripheral nerves and some cranial
nerves

Neuromuscular disease
Ascending paralysis
(Schwan cells) Demylinating polyneuropathy of motor and sensory nerves
Cause:
Unknown
Autoimmune (post viral infection)
Diagnostic test: EMG, CSF and ECG

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

Manifestations

Clumsiness (initial symptom)

Muscle weakness or paralysis of the feet or legs that goes upward
Hyporeflexia
Distention to incontinence
Paralysis of the diaphragm
Dysphagia and drooling
Respiratory depression
Blurred vision (CN II)

NURSING INTERVENTION
mostly supportive
1. Maintain adequate ventilation
2. Check individual muscle groups every 2 hours in acute phase to check
progression of weakness
3. Check cranial nerve function, assess gag reflex and swallowing ability,
give pureed foods.
4. Monitor vital signs
5.administer corticosteroids to suppress immune function

Myasthenia Gravis
Neuromuscular disease
Marked weakness and fatigue of voluntary muscles
 acetylcholine or – communication of nerve cells
 acetylcholinesterase – inactive form
 sensitivity to acetylcholine by the receptor site
Defect in transmission of nerve impulse at the myoneural junction
Cause:
Unknown
Autoimmune (post viral infection)
Diagnostic Test:
Tensilon Test (Edrophonium)
Short acting cholinergic is administered
Increased muscle strength is observe ( + tensilon)
EMG

Manifestations

Ptosis, diplopia and eye squint (early sign)

May start from ocular to oropharyngeal, facial and to respiratory muscle
paralysis
Muscle weakness more pronounce in the evening
3 D’s dysphagia, dysphonia, dysarthria
Drooping facies
Respiratory paralysis (cause of death)

NURSING INTERVENTIONS
 Supportive
 Assess gag reflex before feeding
 Administer meds 20-30 mins. Before meals to prevent aspiration
 Administer meds at precise time to prevent respiratory distress which
may cause death
 Protect from falls due to weakness
 Start meal with cold beverages to improve ability to swallow
 Avoid exposure to infection
8. Adequate rest and activity
9.Plasmapharesis- involves removal of antibodies from the plasma to inhibit
immune response
Myasthenic crisis – caused by undermedication
Cholinergic crisis – caused by overmedication
MEDS
Neostigmine
Pyridostegmine

MEDS TO AVOID!!!!!!!( increases muscle weakness):

 Muscle relaxant
 Barbiturates
 Morphine sulfate
 Tranquilizers
 Neomycin

Parkinson’s Disease
Degeneration of the substantia nigra

PATHOPHYSIOLOGY
Unknown
May be due to:

PATHOPHYSIOLOGY

 Unknown
 May be due to:

DECREASES
DESTROYS DOPAMINE THAT
EXPOSURE TO
CELLS IN THE RESULTS TO
TOXINS, MANGANESE
SUBSTANTIA APPEARANCE OF
DUST,
NIGRA OF THE S/SX OF
CARBONMONOXIDE
BRAIN PARKINSONS

Parkinson’s Disease

 Older people greatly affected

 Depletion of dopamine
 Cause:
 Unknown
 CVA
 Post encephalitic, arteriosclerotic
 Drug Induced:
 Methyldopa
 Haldol
 Phenothiazine

Manifestations

Triad (bradykinesia, resting tremors and rigidity [Cogwheel])

Pill rolling (fingers)
Stooped posture
Masklike face
Monotone speech
Drooling of saliva
Festinating gait

NURSING INTERVENTIONS
1.Supportive
2. Aspiration precaution
3. Increase fluid intake to prevent constipation
4. Position the patient to prevent contractures
 Firm bed, no pillows
 Hold hands folded at the back when walking
5. Give meds as ordered.

ANTICHOLINERGIC: To reduce tremors

 -cogentin
 Artane
 Akineton
SIDE EFFECT:
 Blurring of vision
 Dryness of mouth/throat
 Constipatin
 Urinary retention
 Dysarthia
 Mental disturbance
ANTIPARKINSONIAN DRUGS
 LEVODOPA
 CARBIDOPA
ANTIVIRAL
 AMANTADINE
 BROMOCRIPTINE
ANTISPASMODICS
 PROCYCLIDINE
ANTIHISTAMINE
 BENADRYL- to decrease tremors and anxiety
AVOID THE FOLLOWING DRUGS WHEN ON LEVODOPA THERAPY
1. Phenothiazines, reserpine, pyridoxine( vit B6) these blocks the effects of
levodopa.
FOODS TO AVOID!!!
TUNA, PORK, DRIED BEANS, SALMON, BEEF LIVER ( Blocks effect of levodopa)-CBQ
SIDEFFECT OF LEVODOPA:
 Nausea and vomiting
 Orthostatic hypotension
 Insomia
 Agitation
 Mental confusion
 Renal damage

Amyotrophic Lateral Sclerosis

Progressive, debilitating, degenerative and eventually fatal neurologic
disease involving degeneration of motor neurons in the anterior horn of the
spinal cord and the motor nuclei of the lower brainstem
- Characterized by weakness and muscle wasting without sensory or
cognitive changes
Maybe caused by an excess of GLUTAMATE a chemical responsible for relaying
messages between the motor neurons.

Amyotrophic Lateral Sclerosis

- cause is unknown, 5-10% GENETICS
- onset: age of 40 – 60; males > females
- Physiologic problems involve swallowing, managing secretions,
communication, respiratory muscle dysfunction
- Death usually occurs in 2 – 5 years due to respiratory failure

ETIOLOGY:
 DEGENERATION OF MOTOR NEURON
 Familial
 Heavy metal intoxication
 Tumors
 Onset - midlife

Amyotrophic Lateral sclerosis

FATIGUE
MUSCLE WEAKNESS & WASTING
INCOORDINATION
DYSARTHRIA
RESPIRATORY DIFFICULTY (BRAINSTEM INVOLVEMENT)
UNILATERAL DISABILITY OF UPPER AND LOWER EXTREMITIES
FASCICULATIONS

Diagnostic Test
1. Testing to rule - out hyperthyroidism, compression of spinal cord,
infections, neoplasms
2. EMG - differentiates neuropathy from myopathy
Amyotrophic Lateral sclerosis
3. Muscle biopsy - atrophy and loss of muscle fiber
4. Serum creatine kinase - elevated (non- specific)
5. Pulmonary function tests - determine degree of respiratory
involvement

Medical Management:
1. Riluzole (Rilutek) - glutamate antagonist medication
that slows down muscle degeneration
- requires monitoring of liver function, blood count,
chemistries, alkaline phosphatase

2. muscle relaxants:
a. Baclofen (Lioresal)
b. Dantrolene sodium (Dantrium)
c. Diazepam (Valium)

Nursing Management
1. Maximize functional abilities
a. Prevent complications of immobility
b. Promote self-care
c. Maximize effective communication

2. Ensure adequate nutrition

3. Prevent respiratory complications
a. promote measures to maintain adequate airway
b. promote measures to enhance gas exchange – O2 therapy &
ventilatory assistance
c. promote measures to prevent respiratory infection

4. Help client and family deal with current health problems

5. Plan for future needs including inability to communicate

HUNTINGTON’S CHOREA
Is a hereditary disease in which degeneration in the cerebral cortex and
basal ganglia causes chronic progressive chorea ( involuntary & irregular
movements ) and cognitive deterioration , ending in dementia

Huntington’s disease usually strikes people between ages 25-55

Death usually results 10-15 years after onset of from suicide, heart failure,
or pneumonia

CAUSES
AUTOSOMAL DOMINANT GENETIC TRANSMISSION

ASSESSMENT
CHOREIC MOVEMENTS: rapid, often violent and purposeless that becomes
progressively severe and may include fidgeting , tongue smacking ,
dysarthria( indistinct speech), athetoid movements ( slow sinuous writhing
movements, especially the hands and torticollis ( twisting of the neck)

Dementia ( mild at first but eventually disrupts the patients personality)

Gradual loss of musculoskeletal control, eventually leading to total
dependence
Personality changes , carelessness, untidiness, moodiness, apathy, loss of
memory and paranoia

DIAGNOSTICS
POSITRON EMISSION TOMOGRAPHY (PET)
Detects the disease
DEOXYRIBONUCLEIC ACID analysis detects the disease
CT scan reveals brain atrophy
MRI reveals brain atrophy

TREATMENTS
DISEASE HAS NO CURE!! TREATMENT IS SUPPORTIVE, PROTECTIVE, AND AIMED AT
RELEIVING SYMPTOMS
DRUG THERAPY
ANTIPSYCHOTICS: chlorpromazine( thorazine) and haloperidol ( Haldol)- to help
control choreic movements
ANTIDEPRESSANT: imipramine ( Tofranil) –to help control choreic movements)

NURSING INTERVENTIONS
1. Provide physical support by attending to patient’s needs ( hygiene, skin
care, bowel & bladder care) etc.
2. Stay alert for possible suicide
3. Pad the side rails of the bed but avoid restraints
4. Provide emotional support
5. Assist in designing behavioral plan that deals with disruptive and
aggressive behavior and impulse control problem

SPINAL CORD INJURY

Occurs most commonly in young adult males between ages 15-25
Common causes: motor vehicle accidents, diving in a shallow water, falls,
sports injuries
Effects :
 Paralysis
 Loss of reflexes
 Loss of sensory function
 Loss of motor function
 Autonomic dysfunction
CERVICAL SCI
 Above C4 is fatal
 Quadriplegia ( paralysis of all four extremities)
 Respiratory muscle paralysis
 Bowel/ bladder retention
THORACIC SCI
 Paraplegia
 Poor control of upper trunk
 Bowel/bladder retention
LUMBAR SCI
 Paraplegia(flaccid)
 Bowel/ bladder retention
SACRAL SCI
 Above S2
 With erection
 No ejaculation
S2-S4
 No erection
 No ejaculation
 Bowel and bladder incontinence
Spinal cord injury
DIAGNOSTIC TEST
Spinal x-ray
CT scan
MRI

MANAGEMENT
1. Respiratory function is the first priority especially in cervical SCI
2. Immobilize in a flat, firm surface
3. Cervical collar if cervical injury is suspected
4. Transport client as a unit
5. Do not attempt to realign body parts
TRACTION
CAST
SURGERY

AUTONOMIC DYSREFLEXIA
Reflex response to stimulation of the sympathetic nervous system
Rise in blood pressure, sometimes to fatal level due to over distended
bladder and bowel
Occurs in clients with cord lesion above T6 and most commonly in clients with
cervical injuries
ASSESSMENT
 Bradycardia
 Hypertension—CVA, blindness
 Sweating above lesion
 “ Goose flesh”
 Severe headache
 Blurring of vision
 Nasal stuffiness
MANAGEMENT
 Position the patient in a sitting position to decrease BP
 Check bladder distention, fecal impaction
 Remove offending stimulus ( catheterize)
 Monitor blood pressure
 Administer antihypertensives (Hydralazine HCL Apresoline) as ordered

Alzheimer’s Disease
- Form of dementia characterized by progressive, irreversible
deterioration of general neurological functioning
- begins insidiously
- characterized by gradual losses of cognitive function and disturbances
in behavior and affect
PATHOPHYSIOLOGY
characterized by cortical atrophy and loss of neurons, particularly in the
parietal and temporal lobes . With significant atrophy, there is ventricular
enlargement (i.e., hydrocephalus) from the loss of brain tissue.
There is presence of amyloid-containing neuritic plaques and neurofibrillary
tangles
These plaques are found in areas of the cerebral cortex that are linked to
intellectual function.
Neurochemically, Alzheimer’s disease has been associated with a decrease in
the level of choline acetyltransferase activity in the cortex and hippocampus

Warning signs include

a. Memory loss affecting ability to function in job
b. Difficulty with familiar tasks
c. Problems with language, abstract thinking
d. Disorientation, changes in mood and personality

Alzheimer’s Disease
ASESSMENT:
SUBTLE RECENT MEMORY LOSS--- PROGRESSIVE
Death usually due to malnutrition and secondary infection
Duration 8-10 yrs.
Clinical Manifestations:
1. Stage I
a. Appears healthy and alert
b. Cognitive deficits are undetected
c. Subtle memory lapses and forgetfulness
d. Personality changes - depression
e. Seems restless and uncoordinated
2. Stage II
a. Memory deficits - more apparent
(1) may lose ability to recognize familiar places, faces and objects
(2) may get lost in a familiar environment
(3) conversation becomes difficult
(4) word-finding difficulties
b. ability to formulate concepts and to think abstractly disappears –
concrete thinking predominates
c. impulsive behavior
d. Less able to behave spontaneously
e. Wandering behavior
f. Changes in sleeping patterns
g. Agitation and stress
h. Trouble with simple decisions
i. Sundowning: increased agitation, wandering, disorientation in afternoon
and evening hours
j. Language problems:
(1) Echolalia
(2) scanning speech
(3) total aphasia at times
(4) apraxia
(5) astereognosis
(6) inability to write
k. frustration and depression

3. Stage III
a. Increasing dependence - inability to communicate &
loss of continence
b. Progressive loss of cognitive abilities
c. delusion, hostility, paranoid reactions, combativeness
d. prone to falls

Diagnostic Tests
EEG - slow pattern in later stages of disease
MRI and CT scan
Positron emission tomography (PET)
Folstein Mini-Mental Status
Cerebral Biopsy – confirms the diagnosis

Medications
1. Acetylcholinesterase inhibitors - mild to moderate dementia
- enhances Acetylcholine uptake in the brain
a. Tacrine hydrochloride (Cognex)
b. Donezepil hydrochloride (Aricept)
c. Rivastigmine (Exelon)
2. Antidepressants
3. Tranquilizers – for severe agitation
a. Thioridazine (Mellaril)
b. Haloperidol (Haldol)
4. Antioxidants: vitamin E
5. anti-inflammatory agent
6. estrogen replacement therapy in women

Nursing Management:
1. Support cognitive function
a. Provide a calm, predictable environment
b. Speak in a quiet and pleasant manner
 c. Use memory aids and cues - gives a sense of
security
d. Color-code the doorway
e. Encourage active participation

2. Promote physical safety

a. Remove all obvious hazards
b. monitor patient’s intake of food and medications
c. wandering behavior – use gentle persuasion or distracting the
patient
d. avoid restraints – increases agitation
e. secure doors leading from the house
f. supervise all activities outside the home – let patient wear
identification bracelet or neck chain

3. Reduce anxiety and agitation

a. provide constant emotional support
b. keep the environment uncluttered, familiar and noise-free
c. structure activities
d. familiarize oneself with the px’s predicted responses to
certain stressors

4. Improve communication
a. nurse uses clear, easy-to-understand sentences
b. list simple written instructions – serve as reminders
c. px may use nonverbal communication
d. tactile stimuli – hug or hand pat – signs of affection, concern &
security

5. promote independence in self-care activities

a. simplify daily activities
b. collaborate with occupational therapist
c. direct px supervision
d. encourage px to make decisions

6. provide for socialization and intimacy needs

a. encourage socialization
b. encourage px to enjoy simple recreational activities
(1) walking
(2) exercising
(3) socializing
c. encourage px to care for a pet – provides an outlet for energy

7. promote adequate nutrition

a. keep mealtime simple and calm
b. one dish is offered at a time
c. cut food into small pieces
d. hot food and beverages are served warm
e. provide familiar foods that look appetizing and tastes good
f. provide adaptive equipment if necessary
END OF NEURO!!!!
THANKS!!!!