Medical-Surgical Nursing A Review of Neurologic Concepts Philippine Nurse Licensure Examination 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 Apply the Nursing process in the approach of neurologic problems: ASSESSMENT relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION Outline of the review Congenital disorders Hydrocephalus Spinal cord defects Trauma and related accidents Traumatic brain injury Spinal cord injury Cerebrovascular Accidents Outline of the review Degenerative disorders- demyelinating Multiple sclerosis Amyotrophic lateral sclerosis Guillain-Barre syndrome Degenerative disorders- NON-demyelinating Alzheimers disease Parkinsons disease Outline of the review Motor dysfunction- CNS Epilepsy Motor dysfunction- cranial nerve Bells palsy Trigeminal neuralgia Motor dysfunction- peripheral Myasthenia gravis Outline of the review Infectious Disease

Meningitis Encephalitis Neoplastic disease

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 Anatomy and Physiology 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 Anatomy and Physiology 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 nerves5,6,7,8 Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12 ASSESSMENT OF THE NEUROLOGIC SYSTEM HISTORY A confused client becomes an unreliable source of history ASSESSMENT OF THE NEUROLOGIC SYSTEM PHYSICAL EXAMINATION 5 categories: 1. Cerebral function- LOC, mental status 2. Cranial nerves 3. Motor function 4. Sensory function 5. Reflexes ASSESSMENT OF THE NEUROLOGIC SYSTEM Neuro Check Level of consciousness

Pupillary size and response Verbal responsiveness Motor responsiveness Vital signs

CEREBRAL 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 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 Cranial Nerve Function: Cranial Nerve 3, 4 and 6 Assess simultaneously the movement of the extraocular 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 patients hearing acuity Observe for nystagmus and disturbed balance Webers test

Rinnes test 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 patients 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

ROMBERGs is actually a test for the posterior spinothalamic tract Assessing the motor function of the brainstem Test for the Oculocephalic reflex- dolls eye Normal response- eyes appear to move opposite to the movement of the head Abnormal- eyes move in the same direction Test for the Oculovestibular reflex Slowly irrigate the ear with cold water and warm water Normal response- cold- same side , warm- opposite side

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 Grading of reflexes Deep tendon reflex 0- absent + present but diminished ++ normal +++ increased ++++ hyperactive or clonic Superficial reflex 0 absent +present 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 DIAGNOSTIC TESTS EEG Withhold medications that may interfere with the resultsanticonvulsants, 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 Periodically check peripheral pulses distal to 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 Periodically check peripheral pulses distal to site Increased Intracranial pressure Intracranial pressure more than 15 mmHg Causes: Head injury Stroke Inflammatory lesions Brain tumor Surgical complications Increased Intracranial pressure Pathophysiology The cranium only contains the brain substance, the CSF and the blood/blood vessels MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other Any increase or alteration in these structures will cause increased ICP Increased Intracranial pressure Pathophysiology Compensatory mechanisms: 1. Increased CSF absorption 2. Blood shunting 3. Decreased CSF production Increased Intracranial pressure Pathophysiology Decompensatory mechanisms: 1. Decreased cerebral perfusion 2. Decreased PO2 leading to brain hypoxia 3. Cerebral edema

4. Brain herniation Increased Intracranial pressure CLINICAL MANIFESTATIONS Early manifestations: Changes in the LOC- usually the earliest other early indicator: slow speech Pupillary changes- fixed, slowed response Headache vomiting Increased Intracranial pressure CLINICAL MANIFESTATIONS late manifestations: Changes in VS Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure bradypnea hyperthermia

Increased Intracranial pressure Shock VS ICP Decreased BP Increased BP-systolic Inc HR Dec HR PP narrow PP wide Inc RR Dec RR Increased Intracranial pressure Nursing interventions 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 Increased Intracranial pressure Nursing interventions 3. Administer prescribed medications- usually Mannitol, corticosteroid and anticonvulsants, stool softeners 4. Reduce environmental stimuli 5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning Increased Intracranial pressure Nursing interventions 6. monitor for secondary complications Diabetes insipidus SIADH

Altered level of consciousness It is a function and symptom of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic derangement PATHOPHYSIOLOGY Disruption in the neuronal transmission results to improper function Altered level of consciousness 1. Awake- alert, oriented to 3 spheres 2. Drowsy- sleepy, wakes up and stays awake 3. Lethargic- sleepy, wakes up and goes back to sleep 4. Stuporous- sleepy, infrequently wakes up 5. Comatose- unresponsive most of the time Altered level of consciousness Assessment Orientation to time, place and person Motor function Decerebrate Decorticate Sensory function Altered level of consciousness Nursing Intervention 1. maintain patent airway Elevate the head of the bed Suctioning 2. protect the patient Pad side rails Prevent injury from equipments, restraints and etc. Altered level of consciousness Nursing Intervention 3. Maintain fluid and nutritional balance Input an output monitoring IVF therapy Feeding through NGT 4. Provide mouth care Cleansing and rinsing of mouth Petrolatum on the lips Altered level of consciousness Nursing Intervention 5. maintain skin integrity Regular turning every 2 hours 30 degrees bed elevation

Maintain correct body alignment by using trochanter rolls, foot

board 6. Preserve corneal integrity Use of artificial tears Altered level of consciousness Nursing Intervention 7. Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature Administer acetaminophen as prescribed 8. prevent urinary retention Use of intermittent catheterization Altered level of consciousness Nursing Intervention 9. promote bowel function High fiber diet Stool softeners and suppository 10. provide sensory stimulation Touch and communication Frequent reorientation SEIZURES Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved SEIZURES Nursing Interventions During seizure 1. remove harmful objects from the patients 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 SEIZURES Nursing Interventions POST seizure 1. place patient to the side to drain secretions and prevent aspiration 2. help re-orient the patient if confused

3. provide care if patient became incontinent during the seizure attack 4. stress importance of medication regimen

headache Cephalgia Primary headache- no organic cause Secondary headache- with organic cause Migraine headache- periodic attacks of headache due to vascular disturbance Tension headache- the most common type- due to muscle tension headache Nursing Intervention 1. Avoid precipitating factors 2. modify lifestyle 3. relieve pain by pharmacologic measures Autonomic Dysreflexia/hyperreflexia Seen commonly in spinal cord injury above T6 An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation Autonomic Dysreflexia/hyperreflexia Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion Autonomic Dysreflexia/hyperreflexia 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, skin breakdown, injury, hypotention Cognitive Impairment Nursing Interventions Assist or encourage the patient to use eyeglass, hearing aid or assistive devices Reorient the patient by calling his name frequently Provide background information as to date, time, place, environment Cognitive Impairment Nursing Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area CONGENITAL DISORDERS: Hydrocephalus Excessive CSF accumulation in the brains ventricular system In infants- head enlarges In children and adults- brain compression CONGENITAL DISORDERS: Hydrocephalus Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production CONGENITAL DISORDERS: Hydrocephalus Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes CONGENITAL DISORDERS: Hydrocephalus DIAGNOSTIC TESTS 1. Skull x-ray 2. Ventriculography Surgical Management CONGENITAL DISORDERS: Hydrocephalus Nursing Intervention 1. monitor neurologic status

2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows CONGENITAL DISORDER- Spinal cord defects 1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges 2. Spina bifida with meningocele- a sac contains meninges and CSF 3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF

CONGENITAL DISORDER: Spinal cord defects Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic CONGENITAL DISORDER: Spinal cord defects ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 1. cover the defect with sterile dressing moistened with sterile saline 2. position the patient on prone or side to protect the fragile sac 3. place a diaper under the infant and change it often CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 4. avoid the use of lotion 5. avoid frequent handling 6. Measure the childs head circumference daily 7. check anal reflex 8. support family members 9. prepare the parents for the possible outcome of defect CONGENITAL DISORDER: Spinal cord defects NURSING INTERVENTION 10. Post-operative care Position on abdomen Check post-operative dressings Place infants 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 Traumatic brain injury 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 Traumatic brain injury 4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly Traumatic brain injury 4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly Traumatic brain injury 4. Intracranial hemorrhage Intracerebral Hemorrhage and hematoma- bleeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits Traumatic brain injury Traumatic brain injury 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 Traumatic brain injury NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway Elevate bed, suction prn, monitor ABG

3. Monitor F and E balance Daily weights IVF therapy Monitor possible development of DI and SIADH Traumatic brain injury 4. Provide adequate nutrition 5. Prevent injury Use padded side rails Minimize environmental stimuli Assess bladder Consider the use of intermittent catheter Traumatic brain injury 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 Traumatic brain injury 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 Thromboplebitis 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 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 There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus CLINCAL MANIFESTATIONS: 1. Numbness or weakness 2. confusion or change of LOC 3. motor and speech difficulties 4. Visual disturbance 5. Severe headache RISKS FACTORS

Non-modifiable Advanced age Gender race

Modifiable Hypertension Cardiac diseases Obesity Smoking Diabetes mellitus hypercholesterolemia CEREBROVASCULAR ACCIDENTS: Ischemic Stroke DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS Improve Mobility and prevent joint deformities Enhance self-care Manage sensory-perceptual difficulties Manage dysphagia Help patient attain bowel and bladder control CEREBROVASCULAR ACCIDENTS: Ischemic Stroke NURSING INTERVENTIONS 7. Improve thought process 8. Improve communication 9. Maintain skin integrity 10. Improve family coping 11. Help patient cope with sexual dysfunction CVA: Hemorrhagic Stroke Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage CVA: Hemorrhagic Stroke

Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

CVA: Hemorrhagic Stroke DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP) CVA: Hemorrhagic Stroke NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications Sample Board Question Ashley went into seizure. To protect a child from injury during a seizure, the nurse should: A. Restrain the childs arms and legs B. Place a tongue blade in the childs mouth C. Place a pillow on the childs head D. Provide a waterproof pad for the bed Sample Board question You have to observe for increased intracranial pressure. Which of the following is not a SIGN of increased ICP? A. Headache B. Vomiting C. Vertigo D. Changes in the LOC Sample Board Question Which of the following drugs maybe given to reduce increased intracranial pressure? A. Scopolamine B. Lanoxin C. Coumadin D. Mannitol Sample Board Question Since she was medicated to reduce increased ICP, what nursing measure must be done to prevent further complication? A. Encourage her to observe bed rest B. Check BP every shift C. Observe complete bed rest

D. Measure intake and output Sample Board Question STAT lumbar puncture was ordered. Finding reveals bloody spinal fluid. This would indicate that he is suffering from: A. Cerebral edema B. Cerebral contusion C. Cerebral hematoma D. Cerebral hemorrhage Sample board question Manies situation is probably the result of a rupture of a branch of the: A. Posterior cerebral artery B. Anterior cerebral artery C. Middle cerebral artery D. Vertebral artery Sample Board Question Upon awakening from coma, he would likely demonstrate which type of paralysis? A. Periodic B. Spastic C. Bilateral D. Flaccid