NEUROLOGICAL SYSTEM 2.

Glial cells – protective cells in the CNS; responsible for

Physiology of the Neurologic System the formation of the myelin.
Space Occupying Lesions 3. Myelin sheath.
Interruption of Cerebral circulation a. Dense membrane or insulator around the axon.
Inflammatory Problems b. Facilitates function of the neuron,
Spinal Cord Injury c. Contributes to the blood-brain barrier to protect the
Neuromuscular Disorders central nervous system against harmful molecules.
Peripheral Nerve Disorders
C. Nerve regeneration – entire neuron is unable to undergo
The neurologic or nervous system is composed of two primary complete regeneration.
areas; the central nervous system which includes the brain and the 1. The axons of the PNS may regenerate via the connective tissue
spinal cord, and the peripheral nervous system which includes all neurilemma, providing the cell body of the neuron remains viable.
the network of nerves extending from the central system. In order 2. Neuron regeneration in the CNS is very limited, possibly due to
to enhance the understanding of a very complex system, common the lack of neurilemma.
disorders and conditions are categorized according to the 3. Scar tissue is a major deterrent to successful cellular
physiological origin of the problem, as well as to similarities regeneration.
involved in nursing care. The concept of increased intracranial
pressure is presented, followed by a discussion of common D. Impulse conduction.
conditions involved. Neuromuscular degenerative diseases, 1. Reflex arc.
inflammatory conditions, spinal cord injuries and problems of a. Reflex are is the functional unit which provides pathways over
cerebral circulation are broad categories under which specific which nerve impulses travel.
conditions are addressed. b. Passage of impulses over a reflex arc is called a reflex act or a
reflex.
PHYSIOLOGY OF THE NEUROLOGIC SYSTEM c. Reflex arc – The afferent neuron carries the stimulus to the
Organization of the Nervous System spine; integrates it into and through the spine (CNS) to the efferent
neuron; crosses the synapse with the message from the CNS to
A. Central nervous system (CNS). the organ or muscle which responds to the stimuli. This is the
1. Brain sequence of events when testing the deep tendon reflexes.
2. Spinal Cord 2. Synaptic transmission.
B. Peripheral nervous system (PNS). a. A chemical synapse maintains a one-way communication link
1. Twelve pairs of cranial nerves between neurons.
2. Thirty-one pairs of spinal nerves b. Chemical neurotransmitters (neuro-mediators) facilitate the
3. Autonomic nervous system transmission of the impulse across the synapse.
a. Sympathetic system 1). Acetylcholine.
b. Parasympathetic system. 2). Norepinephrine.
3). Dopamine.
CELLS OF THE NERVOUS SYSTEM 4). Histamine.
A. Neuron-the functional cell of the nervous system. c. Impulses pass in only one direction.
1. Common characteristics.
a. Responds or reacts to stimuli CENTRAL NERVOUS SYSTEM
b. Conducts impulses The brain and the spinal cord within the vertebral column
c. Influences other neurons. make up the central nervous system.
2. Structure.
a. Cell body-contains the cell nucleus which controls cellular A. The brain and the spinal column are protected
activity. by the rigid bony structure of the skull and the
b. Axon-conducts impulses away from the cell body vertebral column.
c. Dendrites-receive incoming stimuli and transmit them to the B. Meninges –protective membranes that cover
axon of another neuron. the brain and are continuous with those of the
3. Function/classification. spinal cord.
a. Afferent neurons (sensory) transmit information away from the 1. Pia mater-a delicate vascular connective
CNS. tissue layer that covers the surfaces of the
b. Efferent neurons (motor) transmit information away from the brain barrier.
CNS. 2. Arachnoid-a delicate nonvascular, waterproof
c. Somatic system membrane that encases the entire CNS; the
1). Afferent are sensory neurons that transmit impulses from the subarachnoid space contains the cerebral
skeletal muscles and skin to the CNS. spinal fluid.
2). Efferent are motor neurons that transmit impulses that lead to 3. Dura mater-a tough membrane immediately
contraction and control of skeletal muscle. outside the arachnoid; provides protection to
d. Visceral system. the brain and spinal cord.
1). Afferent are sensory neurons that transmit impulses from C. Cerebral spinal fluid (CSF).
smooth muscle and cardiac muscle to the CNS. 1. Serves to cushion and protect the brain and
2) Efferent are motor neurons that transmit impulses to the glands, spinal cord; brain literally floats in CSF.
cardiac muscle, and smooth muscle. 2. CSF is clear, colorless, watery fluid;
e. Synapse or synaptic terminals are areas of chemical approximately 100 to 200 cc total volume, with
transmission of an impulse from the axon of one neuron to the a normal fluid pressure of 70 to 150 mm of
dendrites of another neuron. water 9average-125 cm water pressure).
3. Formation and circulation of CSF.
B. Supporting cells provide support, nourishment, and protection to a. Fluid is secreted by the choroids plexus
the neuron. located in the ventricles of the brain.
b. CSF flows through the lateral ventricles into
1. Neurilemma – protective cells which surround the axons the third ventricle, flows through the Aqueduct
in the PNS. of Sylvius into the fourth ventricle where the
a. Provide for effective regeneration of PNS nerve fibers. central of the spinal column opens.
b. From the myelin sheath in the PNS. c. From the fourth ventricle, there are openings
c. No neurilemma present in the CNS. into the cranial subarachnoid space; CSF
flows around the spinal cord ad brain.

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d. Since CSF is formed continuously, it is
reabsorbed at a comparable rate by the
arachnoid villi.
D. Brain.
1. Cerebrum – the largest portion of the brain is
separated into hemispheres; the cerebral
cortex is the surface layer of each hemisphere.
2. Major lobes of the central cortex.
a. Frontal.
1). Coordination of voluntary skeletal muscle
movement.
2). Abstract thinking, morals, judgment.
3). Speech area, motor speech area (Broca’s area)
located in only one hemisphere.
b. Parietal.
1. Interprets sensory nerve impulses (pain,
temperature, touch).
2. Maintains proprioception.
3. Recognition of size, texture, and shape of
objects.
c. Temporal.
1. Auditory area- interprets meaning of certain
sounds.
2. Wernicke’s area- comprehension and formulation
of speech.
d.Occipital area-interprets vision and controls ability
to understand written words.
3. Motor areas of the cerebral cortex.
a. Primary function is coordination and control of
skeletal muscle activity.
b. Corticospinal tracts (pyramidal tracts).
1. Descending tract from the motor area of the
cerebral cortex to the spinal cord.
2. Majority of nerves cross in the medulla to
the opposite side before descending into the spinal
cord.
3. These pathways do not cross over.
c. Brain cells and the nerve fibers in the descending
tracts of the central nervous system are called
upper motor neurons.
d. Basal ganglia (cerebral nuclei) – regulate and
program muscle activity coming from the cerebral
cortex.
4. Movements is controlled by:
a. Cerebral cortex – voluntary initiation of motor
activity.
b. Basal ganglia-assist to maintain posture.
c. Cerebellum-coordinates muscle movement.
5. Cerebellum-attached to the medulla and the
pons.
a. Primarily concerned with coordination of
muscular activity and maintenance of equilibrium.
b. Nerve fibers spread upward to the cerebrum and
downward to the pons, medulla, and spinal cord.
1). Visual reflexes-pupillary constriction and
movement of the eyeball.
2). Auditory reflexes-turning of the head toward
sound.
6. Brain stem – consists of the pons and the
medulla.
a. Pons-contains the reticular formation, which is
responsible for alertness.
b. Medulla oblongata-a continuation of the spinal
cord as it enters into the cranial vault in the brain.
1. Conduction center and crossing center for the
upper motor neurons.
2. Maintains control of cardiac rate.
3. Vasomotor center for constriction and dilation of
vessels.
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4. Respiratory center for changes in rate and depth
of breathing.
5. Vomiting reflex center.
6. Swallowing reflex center.
c. Thalamus.
1. Organization and distribution of incoming
sensory impulses.
2. Activities related to consciousness.
d. Hypothalamus.
1. Regulation of visceral activities-body
temperature, motility and secretions of the GI tract,
arterial blood pressure.
2. Nerve connections with the thalamus and
the cerebral cortex make it possible for our
emotions to influence visceral activity.
3. Regulation of endocrine glands via influence
on the pituitary gland.
4. Neurosecretion of antidiuretic hormone
(ADH) which is stored in the pituitary.
7. Cerebral circulation.
a. The internal carotid arteries enter the cranial
vault at the temporal area; the main branches are:
b. Vertebral arteries arise from the subclavian artery
and enter the brain at the foramen magnum.
c. The Circle of Willis is an arterial anastomosis at
the base of the brain. The circle ensures continued
circulation if one of the main vessels is disrupted.
E. Spinal Cord.
1. The spinal cord is continuous with the medulla
and extends down the vertebral columns to the
level of the first and second lumbar vertebra.
2. Each column is divided into functional groups of
nerve fibers.
a. Ascending tracts – transmit impulses to the brain
(sensory pathway).
b. Descending tracts – transmit impulses from the
brain to the various levels of the spinal cord (motor
pathways).
4. Structure.
a. Closely approximately vertebrae provide
protection from the spinal cord and nerve roots.
b. Intervertebral discs lie between each vertebra to
provide flexibility to the spinal column.
c. Nucleus pulposus is a gelatin substance in the
vertebral disc.
5. Upper motor neurons-originate in the brain,
transmit impulses to the muscles and organs.
These neurons from the reflex arc.
6. Lower motor neurons – originate in the spinal
cord, transmit impulses to the muscles and organs.
These neurons form the reflex arc:
7. Reflex activity.
a. The reflex arch must be intact, the spinal cord
serves as the connection between the afferent
pathway (sensory), and the efferent pathway
(motor).
b. By testing the reflex arc (deep tendon reflexes),
the lower motor neuron and the sensory/motor
fibers from the spinal column can be evaluated.
For example, if the biceps reflex is normal, then the
lower motor neurons and the nerve fibers at C5 and
C6 are intact.
c. Babinski reflex- normal up to one year, should
not be positive in clients over one year of age.
PERIPHERAL NERVOUS SYSTEM (PNS)
The cranial and spinal nerves which connect
the CNS with the body parts continue the PNS. The
peripheral nervous system is further divided into
subdivisions based on the destination of the nerves
 which compromise the cranial and spinal nerves. Muscle of the eyelid (ability
The autonomic nervous system is part of the to close the eye)
subdivision.
A. Cranial nerves
1. Twelve pairs of cranial
nerves. VIII. Acoustic Reception of hearing and
2. Originate from under maintenance of equilibrium
the surface of the brain. IX. Glossopharyngeal Sense of taste on posterior
B. Spinal nerves. tongue
1. Each pair of nerves is numbered Salivation
according to the level of the spinal X. Vagus nerve Swallowing or gag reflex
cord from which it originates. Assists in swallowing
action
Motor fibers to larynx for
2. Each spinal nerve is connected to speech
the cord by two roots. Innervation of organs in
a. Dorsal (posterior root)- XI. Accessory (Spinal) thorax and abdomen
a sensory nerve Important in respiratory,
carrying messages to XII. Hypoglossal cardiac, and circulatory
the CNS. reflexes
b. Ventral (anterior root) – Ability to rotate the head
a motor nerve carrying and raise the shoulder
neuron messages to Muscles of the tongue
glands and to the
peripheral area. b. Norepinephrine released primarily by the
sympathetic division.
3. The roots fuse at the exit from the vertebra to 1. Adrenergic fibers – those fibers releasing
form a mixed spinal nerve. norepinephrine.
C. Somatic nervous system – fibers which connect 2. Effects are widespread and augmented by
the CNS with the structures of the body wall. secretions from the adrenal medulla.
D. autonomic nervous system – regulates 3. Norepinephrine is inactivated by monoamine
involuntary activity (cardiovascular, respiratory, oxidase (MAO) medications.
metabolic, body temperature, etc.)
1. Consists of two divisions that have antagonistic System Assessment
activity.
2. Parasympathetic division – maintains normal A. History.
body functions. 1. Neurologic history.
3. Sympathetic division-prepares the body to meet a. Avoid suggesting symptoms to the client.
a challenge or an emergency (preparation for b. The manner in which the problems began and
“fight/flight”). the overall course of the illness are very
4. Most of the organs of the body receive important.
innervation from both the Parasympathetic and the c. Mental status must be assessed before
sympathetic divisions. The divisions are usually assuming the history data from the client is
antagonistic, the other relaxes. accurate.
5. Chemical mediators – facilitate transmission of 2. Medical history.
impulses in the autonomic nervous system. a. Chronic, concurrent medical problems.
a. Acetylcholine is released by the fibers in both b. Medications (especially tranquilizers,
divisions of the autonomic nervous system. sedatives, narcotics, etc).
1. Cholinergic fibers – those fibers releasing c. Pregnancy and delivery history of infants and
acetylcholine. young children.
2. Acetylcholine is destroyed by the enzyme d. Sequence of growth and development.
cholinesterase. 3. Family history-presence of hereditary or
congenital problems.
CRANIAL NERVES 4. Personal history-activities of daily living, any
change in routine.
NUMBER NAME FUNCTION 5. History and symptoms of current problem.
I. Olfactory Sense of smell a. Paralysis or paresthesia.
II. Optic Vision-conducts information b. Syncope, dizziness
from the retina c. Headache.
III. Oculomotor Down and outward d. Speech problems.
movement of the eye e. Visual problems.
Pupillary constriction and f. Changes in personality.
accommodation g. Memory loss.
Muscle of the upper eyelid h. Nausea, vomiting.
IV. Trochlear (ability to keep the eye
V. Trigeminal: open)
Opthalmic Movement of the eye AUTONOMIC NERVOUS SYSTEM
Macillary Area Affected Sympathetic Parasympathetic
Mandibular Corneal reflex Pupil Dilates Constricts
Sensory fibers of the face
VI. Abducens Motor nerves for chewing Bronchi Dilates Constricts
VII. Facial and swallowing
Inward movement of the eye Heart Increases rate Decreases rate
Facial expression
Sense of taste on anterior Gastrointestinal Inhibits peristalsis Stimulates peristalsis
tongue

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 Stimulates sphincter Inhibits sphincters e. deep tendon reflexes (simple stretch reflex).
6. Assess vital signs and correlate with other data; changes often
Bladder Relaxes bladder Contracts bladder occur slowly and the overall trend needs to be evaluated.
muscle muscle a. Blood pressure and pulse-intracranial problems precipitate
changes, blood pressure may increase and pulse rate may
Constricts sphincter Relaxes sphincter decrease.
Adrenal glands b. Respirations – rate, depth, and rhythm are sensitive indicators of
Increases secretion intracranial problems.
of epinephrine and 1. Cheyne Stokes – periodic breathing in which hyperpnea
norepinephrine alternates with apnea, rapid, deep hyperpnea.
2. Neurogenic hyperventilation-regular, rapid, deep hyperpnea.
B. Physical Assessment. 3. Ataxic – completely irregular pattern with random deep and
1. General observation of client. shallow respirations.
a. Posture, gait..
b. Position of rest for the infant or young child. c. Temperature – evaluate changes in temperature as related to a
c. Personal hygiene, grooming. neurological control versus infection.
d. Evaluate speech and ability to communicate.
1. Pace of speech-rapid, slow, halting. >Nursing Alert< Bedside neuro checks-evaluate level of
2. Clarity – slurred or distinct. consciousness; respiratory patterns; papillary signs; eye
3. Tone – high pitched, rough. movements; motor responses; vital signs.
4. Vocabulary – appropriate choice of words.
e. Facial features may suggest specific syndromes in children. C. Neuro checks – parameters for frequent nursing evaluation of
2. mental status 9must take into consideration the client’s culture neurological symptoms.
and educational background). 1. Assess level of consciousness (LOC).
a. General appearance and behavior. a. Verbal and motor response to command.
b. Level of consciousness. b. Appropriate conversation and speech.
1. Oriented to time, person, place. c. Presence of delayed response to stimuli, from lethargic to
2. Appropriate response to verbal and tactile stimuli. unresponsive.
3. Memory, problem-solving abilities. d. Appropriate behavior in infants and young children.
c. Mood. e. Be explicit in describing LOC; may utilize a specific coma scale
d. Thought content and intellectual capacity. (Glasgow).
3. Assess papillary status and eye movements.
a. Size of pupils should be equal.
b. Reaction of pupils. 2. Respiratory patterns – evaluate current respiratory pattern and
1. Accommodation– papillary constriction to assess for changes in pattern.
accommodate near visions.
2. Direct light reflex – constriction of pupil when light is 3. Pupillary response.
shown directly into eye. a. Equality of pupils.
3. Consensual reflex – constriction of the opposite eye b. Presence of consensual, direct, and accommodation reflexes.
for the direct light reflex. c. Position of pupils at rest.
c. Evaluate ability to move eye.
1. Note nystagmus-fine, jerking eye movement. 4. Motor function.
2. Ability of eyes to move together. a. Ability to move all extremities with equal strength.
3. Resting position should be at mid position of the eye b. Presence of posturing.
socket. c. Basins reflex.
d. Presence of seizure activity.
e. Presence of gag and cough reflex.
d. PERRLA – indicates that pupils are equal, round, reactive to
light and accommodation is present. 5. Vital signs.
a. Correlate blood pressure and pulse changes.
4. Evaluate motor function. b. Assess respiratory pattern.
a. Assess face and upper extremities for equality of movement and c. Assess temperature in regard to overall condition.
sensation.
b. Evaluate appropriateness of motor movement, spontaneous and 6. Assess for presence of pain, headache.
on command.
c. Movement of extremities should always be evaluated bilaterally, 7. Presence of projective vomiting not associated with nausea.
comparing tone, strength, and muscle movement of each side.
d. Presence of inappropriate, non-purposeful movement, i.e., 8. Infants-assess fontanel and suture lines.
posturing. a. Size of fontanel for growth and development level.
1.Decerebrate – extension and adduction of the arms, b. Fontanel should be soft to touch with slight pulsations.
hyperextension of the leg. c. Normal approximation of cranial suture lines.
2. Decorticate-flexion, internal rotation of the arms,
extension of the leg. SPACE OCCUPYING LESIONS
3. Presence of non-purposeful involuntary movements Concept of Increased Intracranial Pressure (IICP)
such as tremors, jerking,
twitching. An increase in intracranial pressure occurs any time there is an
increase in the size of the intracranial contents.
e. Ability of an infant to suck and to swallow.
f. Asymmetrical contraction of facial muscles. A. The cranial vault is rigid, and there is
5. Evaluate reflexes. minimal area for expansion of the
a. Gag or cough reflex. intracranial components.
b. Swallow reflex. B. An increase in any one of the
c. Corneal reflex. components necessitates a
d. Babinski reflex– normal is negative in adults and children over reciprocal change in other cranial
one year, positive sign is dorsal flexion of the foot and large toe contents; this frequently results in
with fanning of the other toes. ischemia of brain tissue. An increase

4
 in ICP results from one of the 1. Cushing’s triad – increasing systolic pressure, decreased
following: pulse rate, and irregular respirations. Increased pressure
1. Increased intracranial blood volume is established when this occurs.
(vasodilation). 2. Alteration in respiratory pattern (Cheyne-Stokes,
2. Increased CSF fluid. hyperventilation).
3. Increase in the bulk of the brain 3. Temperature usually increases.
tissue (edema). c. Pupillary changes.
C. Cerebral edema. 1. Ipsilateral – papillary changes occurring on the same
1. Vasogenic edema occurs when side as the lesion.
there is an increase in the volume of 2. Contralateral – papillary changes occurring on the
brain tissue caused by increase in opposite side of the lesion.
the permeability of the walls of the 3. Unilateral dilatation of pupils.
cerebral vessels. Protein-rich fluid 4. Pupillary response to light may be from slow, sluggish
leaks into the extra cellular space. reaction to fixed, dilated with no response.
Most often the cause of IICP in d. Papilledema – edema of the optic nerve is evaluated
adults. when examining the retinal area with an opthalmoscope.
2. Cytotoxic (cellular) edema occurs as e. Doll’s eyes phenomena is abnormal when it is present
a result of hypoxia. This results in and may occur as the client begins to experience a
abnormal accumulation of fluid decrease in the level of consciousness.
within the cell (intracellular) and a 1. Eyes normally move from side to side when the head is
decrease of extra cellular fluid. tuned.
D. Cerebral arteries dilate with a 2. “Doll’s eyes” occur when the client’s head is moved from
decrease in the delivery of side to side and the eyes remain in a fixed, midline
oxygenated blood. position.
1. Increase in PCO2 and accumulation f. Decrease in motor and sensory function.
of lactic acid precipitates an acidotic 1) Weakness.
state. 2) Hemiplegia.
2. An acidotic state increases cerebral 3) Failure to withdraw from painful stimuli.
vascular dilatation which, in turn, 4) Posturing.
increases cerebral vascular blood 5) Seizure activity.
flow and increases intracranial g. Headache.
pressure. 1) Constant with increasing intensity.
E. Regardless of the cause, IICP will 2) Aggravated by movement.
result in progressive neuro h. Vomiting – projectile vomiting.
deterioration; the specific i. Infants.
deficiencies seen are determined by 1). Tense, bulging fontanel.
the area of compression of brain 2). Separated cranial sutures.
tissue. 3). Increasing frontal occipital circumference.
F. In infants where the cranial suture 4). High-pitched cry.
lines are open, increased ICP will
cause further separation of the 3. Diagnostics
suture lines and increased the a. CAT scan.
circumference of the head. b. Cerebral angiogram.
c. Direct intracranial pressure monitoring.
ASSESSMENT d. Electroencephalogram (EEG).
e. Caloric testing – test is performed at bedside by
1. Risk factors/etiology. introducing cold water into the external auditory canal. If
a. Cerebral edema secondary to the initial damage. the eighth cranial nerve is stimulated, nystagmus occurs,
b. Brain tumors. pathology is present.
c. Intracranial hemorrhage due to closed head injuries. f. Lumbar puncture is generally not performed; decrease in
d. Intracranial hemorrhage due to ruptured vessels. CSF pressure could precipitate herniation of the brain
e. Cerebral embolism resulting in necrosis and edema of stem.
areas supplied by the involved vessel.
f. Cerebral thrombosis resulting in necrosis and edema TREATMENT
and leading to edema and congestion of affected area.
g. Hydrocephalus. 1. Treatment of the underlying cause of
2. Clinical manifestations. increasing pressure.
2. Fluid restrictions (fluids may be increased in
It is essential for the safe care of the neurologically impaired the client with vascular damage to decrease
client that the nurse be able to rapidly evaluate the client and the problem of vascular spasm).
recognize changes in the neuro signs that indicate an 3. Medications.
increase in the intracranial pressure. a. Osmotic diuretics.
b. Corticosteroids.
a. Assess for changes in level of consciousness. c. Anticonvulsants.
4. Maintain adequate ventilation.
NURSING PRIORITY: The first sign of a change in the level
of intracranial pressure is alteration in level of consciousness. Complications

1. Any alteration in level of consciousness (early sign for 1. Tentorial herniation – the shifting of the intracranial
both adults and children) irritability, restlessness, contents from one compartment to another. Most often
confusion, lethargy, difficult to arouse, etc. may be involves supratentorial herniation through the tentorial
significant. notch.
2. As the client loses consciousness, hearing is the last a. Brain compression occurs.
sense to the lost. b. Distortion of other brain structures.
c. Compromise in the vascular bed.
b. Changes in vital signs. d. Obstruction of the cerebrospinal fluid.

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e. Irreversible brain damage.
2. Lateral transtentorial herniation (uncal ) occurs as a
result of a laterally expanding mass (hematoma).
3. Central herniation occurs as a result of a centrally
expanding mass that shifts the brain stem downward.
NURSING INTERVENTION
 Goal: to identify and decrease problem of IICP.
1. Neuro checks as indicated by client status.
2. maintain semi-Fowler’s position to promote venous
drainage and respiratory function.
NURSING ALERT > If the client with IICP develops
hypovolemic shock, do not place client in Trendelenburg’s
position, elevate the lower extremities to enhance venous
return.
NURSING DIAGNOSES:
Increased Intracranial Pressure
Impaired Gas Exchange related to decreased level of
consciousness.
Alteration in Sensory Perception related to increased
pressure.
Alteration in Fluid Volume, Excess related to cerebral edema.
Alteration in Tissue Perfusion related to IICP, and shock.
Alteration in Nutrition, Less Than Body Requirements related
to decreased level of consciousness and tendency toward
aspiration.
Alteration in Comfort related to headache.
Potential for Injury related to change in level of
consciousness.
Fear related to severity and prognosis of condition.
3. Change client’s position slowly and gently; avoid
jerky movements.
4. Maintain fluid restriction.
5. Evaluate intake and output.
a. In response to diuretics.
b. As correlated with changes in daily weight.
c. For complications of diabetes insipidus.
6. Maintain intake evenly over twenty-four hour time
period.
7. Sedatives and narcotics can depress respiration
and mask symptoms indicating increasing ICP.
8. Client should avoid strenuous coughing, Valsalva’s
maneuver, and isometric muscle exercises.
9. In infants, measure frontal occipital circumference
to evaluate increase in size of the head.
10. Control hyperthermia as indicated.
 Goal: to maintain respiratory function.
NURSING PRIORITY > Airway is one of the most common
problems in the unconscious client, position them to maintain
patent airway or use airway adjuncts.
1. Prevent respiratory problems of immobility.
2. Evaluate patency of airway frequently; as level of
consciousness decreases, client is at an increased risk
for respiratory obstruction by the tongue and
accumulating secretions.
3. Keep PCO2 levels within normal to low range.
4. Suction as necessary, but in short duration with rest
periods.
5. Client may require intubation and control on a volume
ventilator.
Nursing Diagnoses:
Unconscious Client
Self Care Deficit related to unresponsive condition
Potential for infection related to immobility and invasive
procedures.
6
Potential Impaired Tissue Integrity: Corneal related to
ulcerations and drying.
Anxiety/Fear (Family) related to uncertain state of client and
prognosis.
Incontinence related to unconsciousness state.
Potential for ineffective Airway Clearance related to
unconscious state.
 Goal: to protect from injury.
1. Take seizure precautions.
2. Restrain client only if absolutely necessary; struggling
against restraints will increase ICP.
3. Do not clean the ears or nasal passages of a head
injury, or neuro surgery client. If bleeding or drainage
occurs from these areas, evaluate carefully as it may be
cerebral spinal fluid.
4. Aspiration is a major problem in the unconscious client.
Carefully assess the swallow reflex in clients who are not
fully conscious; position the client in Semi-Fowler’s for
tube feeding.
5. Maintain quiet, nonstimulating environment if condition is
unstable.
6. Inspect eyes and prevent corneal ulceration.
a. Protective closing of eyes if the eyes remain open.
b. Normal saline irrigation or methylcellulose drops to
restore moisture.
 Goal: to maintain psychological equilibrium.
1. Neuro checks are a continuous reminder of potential
problem.
2. Encourage verbalization of fears regarding condition.
3. Give simple explanation of procedures to client and family.
4. Altered states of consciousness will cause increased
anxiety and confusion; maintain reality orientation.
5. If client is unconscious, continue to talk to him/her, describe
procedures and treatments; always assume that client can
hear.
6. Assist parents and family to work through feelings of guilt
and anger.
 Goal: to prevent complications of immobility.
 Goal: to maintain elimination.
1. Urinary incontinence – may use condom catheter or
indwelling bladder catheter.
2. Keep perineal area free from excoriation.
3. Monitor bowel function; evaluate for fecal impaction.
BRAIN TUMORS
A. Classification of tumors.
1. Tumors arising from the protective covering of the brain-
i.e., dural meningiomas.
2. Tumors developing I or around cranial nerves-i.e.,
acoustic neuromas.
3. Tumors originating in the brain tissue-i.e., gliomas.
4. Metastatic tumors originating elsewhere in the body;
frequently, metastasis is from the lung or the breast.
B. Gliomas are the most common tumors; frequently are
malignant.
C. Brain tumors may be benign, malignant, or metastatic;
malignant brain tumors rarely metastasize outside the
CNS.
D. Supratentorial – tumors occurring within the anterior two-
thirds of the brain, primarily the cerebrum.
E. Infratentorial – tumors occurring in the posterior third of
the brain (or below the tentorium); primarily in the
cerebellum or the brain stem.
F. Regardless of the origin, site, or presence of malignancy,
problems of increased intracranial pressure occur
because of the limited area in the intracranial contents.
Assessment
1. Risk factors/etiology.
a. Adults-highest incidence between 55 and 70 years of
age.
b. Prognosis is generally poorer in the infant than in older
children.  Goal: to provide appropriate preoperative nursing
c. Presence of metastatic cancer of the lung or breast. intervention.
2. Clinical manifestations – symptoms correlate with the 1. General preoperative care with exceptions as noted.
area of the brain initially involved. 2. Shave the head, save the hair and return it to the family, or
a. Headache. dispose of its indicated by institutional policy.
1). Recurrent. 3. If there is increased ICP, generally do not administer an
2). Progressive. enema.
3). More severe in the morning. 4. Prepare client, family, and parents for appearance of the
4). Affected by position. client postoperatively.
5). Headache in infant may be identified by persistent, irritated 5. Encourage verbalization regarding concerns of surgery.
crying and head rolling.
b. Vomiting – initially with or without nausea; progressively  Goal: to maintain homeostasis and monitor
becomes projectile. changes increased intracranial pressure
c. Coordination disturbances (ataxia, staggering gait). postoperative craniotomy.
d. Hypotonia, hyporeflexia. 1. Neuro checks as necessary.
2. Maintain pulmonary function and hygiene.
a. Patent airway.
e. Visual changes due to localizing effects. b. Prevent aspiration.
1. Nystagmus. c. Increase respiratory excursion by deep breathing.
2. Diplopia. d. Antiemetics to decrease vomiting and possibility of
3. Decrease in visual acuity. aspiration.
4. Visual field deficits. e. Discourage vigorous coughing.
f. Head tilt- child may tilt the head due to damage to extra 3. Careful evaluation of the level of consciousness; regression
ocular muscles; may be first indication of a decrease in to more lethargic or irritable state may be indicative of
visual acuity. increasing ICP.
g. Behavioral changes. 4. Evaluate dressing.
1) Obvious personality changes. a. Location and amount of drainage.
2) Decreasing level of consciousness. b. Evaluate for CSF leak through the incision.
3) Decreasing activity, increased sleep periods in c. Do not change dressing initially, but reinforce it.
the infant. 5. Position in low to semi-Fowler’s if there is a spinal fluid leak
h. Decrease in muscle strength or loss of specific areas of from ears or nose.
movement. 6. Position postoperatively for infratentorial surgery.
i. Changes in vital signs indicative of increasing ICP. a. Bed should be flat.
j. Seizures (focal or generalized). b. Position client on either side; keep off back.
k. Cranial enlargement in the infant under eighteen months c. Maintain head and neck in midline and slightly extended.
old. 7. Position postoperatively for supratentorial surgery-semi to
l. Papilledema (edema of the optic disc). low Fowler’s.
m. Dizziness and vertigo. 8. Trendelenburg position is contraindicated in both types of
NURSING DIAGNOSES: surgery.
Brain Tumor 9. Maintain fluid regulation.
a. Begin clear liquids PO after swallow and gag reflexes
Injury: High Risk related to gait disorders, vertigo, visual return and client is awake.
disturbances, or compression/displacement of brain tissue. b. Maintain IV fluid until client tolerates fluids.
Anxiety related to implications of condition and uncertain c. Closely monitor intake and output.
future. d. Client may be on fluid restriction.
Self-care Deficit related to inability to perform ADL’s 10. Evaluate neuro status in response to fluid balance and
secondary to sensory-motor impairment. diuretics.
Altered Family Processes related to the nature of the 11. Carefully evaluate changes in temperature-may be due to
condition, role disturbances, and uncertain future. respiratory complications or to alteration in the function of
the hypothalamus.
3. Diagnostics. 12. Provide appropriate pain relief.
a. Clinical manifestations exhibited in the neurological a. Avoid narcotic analgesics.
exam. b. Aspirin or TYLENOL is frequently used.
b. EEG. c. Maintain quiet, dim atmosphere.
c. CAT scan. d. Avoid sudden movements.
d. Brain scan. 13. Prevent complications of immobility.
e. Cerebral angiogram. 14. Maintain seizure precautions.

Treatment
1. Medical. HEAD INJURY
a. Dexamethasone
b. Anticonvulsants Trauma to the cranium and its contents.
c. Radiation and chemotherapy if malignant.
2. Surgical excision-craniotomy. A. Classification.
1. Closed – no fracture present.
Complications 2. Open-simple skull fracture to compound deep skull fracture.
Meningitis, respiratory aspiration, brain stem herniation; B. Children and infants are more capable or absorbing direct
diabetes insipidus, inappropriate ADH secretion. impact due to pliability of the skull.
C. Coup-Contrecoup injury-damage to the site of impact
Nursing Intervention (coup) and damage on the opposite side of the injury
See Nursing Diagnosis for Increased Intracranial (contrecoup).
Pressure. D. Injury to the brain occurs by compression, tearing and
shearing stresses on vessels and nerves.
Preoperative management – see nursing goals for
increased intracranial pressure.

7
E. Although brain volume remains unchanged, cerebral contributes to the cerebral edema; close observation and prompt
edema occurs in response to the injury and frequently recognition of IICP.
precipitates an increase in intracranial pressure.
F. Types of head injuries. 1. majority of clients who experience concussion
1. Concussion. are treated agt home.
a. Immediate brief period of unconsciousness. 2. A period of unconsciousness or presence of
b. Generally followed by amnesia from the moment of injury seizures are considered serious indications of
impact and short period afterward. injury.
2. Contusion (bruising). 3. Surgical intervention
a. Produces small hemorrhages along the surface of the brain a. Burr holes to evacuate the hematoma
without penetration of the brain tissue. b. Craniotomy
b. May cause focal disturbances.
c. Blood supply is altered in the area of injury, swelling, NURSING INTERVENTION
ischemia, and occurrence of IICP. See Nursing Diagnosis for Increased Intracranial
3. Intracranial hemorrhage. Pressure.
a. Epidural (extradural) hematoma- a large vwessel (generally
an artery) in the dura mater is damaged; a hematoma rapidly  Goal: to provide instruction for care of the client in the
forms between the dura and the skull precipitating an increase in home environment.
intracranial pressure. 1. Problems frequently do not occur until twenty four
1. Momentary loss of consciousness then free of symptoms hours or more after the initial injury.
(lucid period). 2. Observe the client for increased periods of sleep; if
2. Within minutes to hours, symptoms of increasing intracranial client is asleep, awaken every two to three hours to
pressure (ipsilateral papillary symptoms, contra lateral weakness see if he can be aroused normally.
or paralysis). 3. Maintain contact with physician for re-evaluation if
3. Symptoms of increasing ICP may develop after the lucid complications occur.
interval. 4. doctor should be notified for:
4. Tentorial herniation may occur without immediate intervention. a. Any changes in LOC (increased drowsiness,
b. Subdural hematoma –bleeding between the dura and confusion).
arachnoid area, usually due to the rupture of veins in the b. Unable to arouse client.
subdural space.
c. Seizures occur.
1) Develops more slowly – may be acute, subacute, or d. Bleeding or watery drainage from the ears or nose.
chronic. e. Loss of feeling or sensation in any extremity.
2) Subacute may not become symptomatic for several f. Blurred vision
days to weeks. g. Slurring speech.
3) Acute injury is manifested within 24 hours of the injury. h. Vomiting
4) Symptoms of increasing intracranial pressure develop
gradually. NURSING PRIORITY: Instructions should be given to the
client and to the family in writing. Frequently clients have
Assessment increased anxiety in the emergency room and do not
comprehend verbal directions.
1. Risk factors/etiology.
a. Falls  Goal: to maintain homeostasis; monitor and identify
b. Motor vehicle accidents early symptoms of increased intracranial pressure in
c. Epidural hematomas are uncommon in children under four the hospitalized client.
years of age.
d. Subdural hematomas are common in infants and may be the 1. Generally on bed rest and clear liquids initially.
result of birth trauma. 2. Frequent neuro checks for increased ICP.
2. Clinical manifestations-see individual types of injury. a. Decreased level of consciousness frequently the first
3. Diagnostics. indication.
a. Neurologic history. b. Instruct head injury clients not to cough, sneeze or
b. Skull X-ray blow his nose.
c. Cerebral angiogram 3. Evaluate drainage from nose, ears and mouth.
d. CAT scan a. Do not clean out the ears-place loose cotton in the
Nursing Diagnoses: auditory canal and changes as soiled.
Head Injury b. Check continuous clear drainage from the nose with a
dextrose stix; if glucose is present, it is indicative of
Impaired Physical Mobility related to motor, sensory, or CSF.
proprioceptive deficits, depressed level of consciousness. 4. Seizure precautions
Injury: High Risk related to restlessness and confusion. 5. Maintain adequate fluid intake via IV or PO; do not
Sleep Pattern Disturbance related to frequent assessments and over hydrate.
loss of REM sleep. 6. Assess for other undetected injuries.
Altered Thought Processes related to memory deficit, impaired
reasoning ability, altered LOC, confusion, speech impairment, or  Goal: to provide appropriate nursing
sensory deprivation. intervention for the client experiencing an
Seizures: High Risk related to brain injury or hypoxia. increase in intracranial pressure.

Complications HYDROCEPHALUS
Increased intracranial pressure, meningitis, diabetes
insipidus, permanent brain damage. A condition caused by an imbalance in the production and
absorption of CSF in the ventricles of the brain.
Treatment
Classification
Nursing Priority: the initial treatment of the head injury client is to
maintain adequate respiratory function to prevent hypoxia and
hypercapnia resulting in acidosis which causes vasodilation and

8
 1. Noncommunicating-circulation of CSF is blocked problem with children who are having a shunt
within the ventricular system of the brain; may also be revision, they have not had an increase in
referred to as obstructive. ventricular pressure.
2. Communicating – CSF flows freely within the 3. Monitor for increasing ICP and compare data with
ventricular system but is not adequately absorbed. previous data.
3. Frequently associated with meningomyelocele in the 4. Monitor for infection, a common problem.
newborn.
Goal: to assists family and child to understand
Assessment implications of the problem and measures to maintain
and promote health post shunt procedure.
1. Risk factors/etiology.
a. Neonate. 1. Teach parents symptoms of increasing ICP.
1) Non communicating usually the result of a 2. Have parents participate in care of the shunt prior to
congenital malformation. client’s discharge.
2) Intrauterine infection 3. Encourage parents and family to ventilate feelings
3) Perinatal hemorrhage regarding client’s condition.
4) Neonatal meningoencephalitis 4. Refer client to appropriate community agencies.
b. Other child,adult.
1) Space occupying lesion.
2) Pre-existing developmental defects. INTERRUPTION OF CEREBRAL CIRCULATION

2. Clinical manifestations-infant. Cerebral Vascular Accident (CVA)

a. Head enlargement, increasing circumference.
b. Separation of cranial suture lines. Also known as a stroke, CVA is the disruption of the blood supply
c. Fontanel becomes tense and bulging to an area of the brain resulting in tissue necrosis and sudden loss
d. Dilated scalp veins. of brain function.
e. Frontal enlargement, bulging “sunset eyes”.
f. Symptoms of increasing ICP. A. Atherosclerosis – resulting in cerebral vascular disease,
frequently precedes the development of a CVA.
3. Clinical manifestations – older child, adult. B. Types of stroke.
a. Symptoms of increasing ICP. 1. Thrombosis-formation of a clot which results in the
b. Specific manifestations related to site of the lesion. narrowing of a vessel lumen and eventual occlusion.
a. Associated with hypertension and diabetes (i.e.,
4. Diagnostics. conditions which accelerate atherosclerotic process).
a. Same as for brain tumor b. Associated with atherosclerotic disease of the carotid,
b. Increasing head circumference is diagnostic in infants. subclavian, and vertebral arteries.
c. Generally a condition of the elderly.
Treatment 2. Embolism – occlusion of a cerebral artery by an
1.Non communicating and communicating. embolus.
a. Ventriculoatrial shunt-CSF is shunted into the right a. common site of origin is the endocardium.
atrium. b. May effect any age group; frequently associated with
b. Ventriculoperitoneal shunt- CSF is shunted into the rheumatic heart disease and atrial fibrillation.
peritoneum (preferred).
3. Cerebral hemorrhage.
2. Obstructive-removal of the obstruction (cyst, hematoma, a. Rupture of a cerebral artery secondary to hypertension,
tumor). trauma, or aneurysm.
b. Blood leaks into the brain tissue and the subarachnoid
NURSING DIAGNOSES: space; creates a mass that displaces the brain.
Hydrocephalus
C. The area of edema resulting from tissue damage may
Nursing Diagnosis for Increased Intracranial Pressure. precipitate more damage than the vascular damage
Potential for Altered Growth and Development related to itself.
brain damage. D. Transient ischemic attack (TIA).
Alteration in Family Process related to acute illness of 1. Brief episode of neurological dysfunction.
infant. 2. Frequently indicative of advanced atherosclerotic
disease of the cerebral vessels.
Nursing Intervention 3. Should be considered a warning symptom of an
impending CVA.
Goal: to monitor for the development of increasing ICP. 4. Neurologic dysfunction is present for minutes to hours,
1. Daily measurement of the frontal but no permanent neurological deficit remains.
occipital circumference of the head in
infants. E. Neuromuscular deficits resulting from a stroke are due to
2. Assess for symptoms of increasing damage of motor neurons of the pyramidal tract.
ICP.
3. Infants is often difficult to feed; RISK FACTORS ASSOCIATED WITH CEREBRAL
administer small feedings at frequent VASCULAR ACCIDENT
intervals.
4. Evaluate LOC. It is frequently the first Reversible:
symptom of increasing ICP. • Smoking
• Obesity
Goal: to maintain patency of the shunt and monitor • Increased salt intake
intracranial pressure post shunt procedure. • Sedentary life style
1. Position on the unoperative side to prevent • Oral contraceptives
pressure on the shunt valve.
2. may be positioned flat immediately after surgery to Partially Reversible:
prevent too rapid depletion of CSF. This is not a
• Hypertension
9
 • Cardiac valve disease Treatment
• Dysrhythmias 1. Prophylactic.
• Diabetes mellitus a. Aspirin.
• Hypercholesterolemia b. Persantine
c. Antihypertensives.
Nonreversible: 2. Medical
• Sex (increased incidence in men) a. Medications to decrease cerebral edema.
1. Osmotic diuretics
• Age
2. Corticosteroids (dexamethasone).
• Increased incidence in the black b. Medical measurements to maintain homeostasis.
• Hereditary predisposition 3. Surgical.
a. Carotid endarterectomy.
1. Damage to the left side of the brain will result in paralysis b. Cerebral revascularization.
of the right side of the body (hemiplegia-paralysis of one
side of the body). Nursing Intervention
2. Both upper and lower extremities of the involved side are Goal: to prevent CVA through client education.
affected.
1. Identification of individuals with reversible risk factors
Assessment: and measures to reduce them.
1. Risk factors/Etiology: (see previous table) 2. Appropriate medical attention for control of chronic
2. Clinical Manifestations: conditions conducive to the development of CVA (Partial
a. TIA reversible risk factors).
1. Temporary loss of vision in one eye
2. Transient hemiparesis Goal: to maintain patent airway and adequate cerebral
3. Tinnitus oxygenation.
4. Vertigo 1. Position side-lying with head elevated.
5. Confusion 2. Assess for symptoms of hypoxia; ET intubation and
6. Nosebleeds(epistaxis) mechanical ventilation may be necessary.
b. Completed CVA (occurs suddenly with an embolism 3. Maintain patent airway; use oropharyngeal airway to
more gradually in hemorrhage or thrombosis) prevent airway obstruction by the tongue.
1. Hemiplegia – loss of voluntary movement, damage to 4. Client is prone to obstructed airway and pulmonary
the right side of the infection; have/her cough and deep breathe as indicated.
brain will result in left-sided weakness
and paralysis Goal: to assess for and implement measures to decrease
2. Aphasia – defect in using and interpreting the symbols intracranial pressure
of language, may
include written, printed or spoken words, Goal: to maintain adequate nutritional intake.
may be partial or 1. Administer PO feedings with caution; check presence of
complete. gag reflex and swallowing before feeding.
3. Problem of neuromuscular control of respiration. 2. Place food on the unaffected side of the mouth.
4. Problem of neuromuscular control over swallowing and 3. Select foods that are easy to control in the mouth and
cough reflex. swallow; liquids often promote coughing as client is
5. Initially may be incontinent. unable to control them.
6. Agnosia- a perceptual defect that causes a disturbance in 4. Maintain high Fowler’s position for feeding.
interpreting sensory information, client may not be able to 5. Maintain privacy and unrushed atmosphere.
recognize previously familiar objects. 6. If client is unable to tolerate PO intake, tube feedings
7. Emotional lability. may be initiated.
8. Impairment of judgment and memory.
9. Hypotonia (flaccidity) for days to weeks followed by Goal: to preserve function of the musculoskeletal system to
hypertonia (spasticity). prevent joint contraction and muscle atrophy.
10. Visual defects homonymous hemianopsia, the loss of
vision in one half of the visual field. 1. Passive ROM on affected side.
11. Perceptual defects. 2. Active ROM on unaffected side.
12. Apraxia inability to carry out learned movements. 3. Utilize footboard to keep at right angles and prevent foot
drop.
Nursing Diagnosis: 4. Legs should be maintained in a neutral position; prevent
Cerebral Vascular Accident (CVA) external rotation of affected hip by placing a trochanter
roll or sandbag at the thigh.
Ineffective Airway Clearance related to neurological deficits 5. Position every two hours but limit the period of time
inability to cough. spent on the affected side.
Altered Tissue Perfusion related to interrupted cerebral 6. Assess for adduction and internal rotation of the affected
vascular blood supply. arm; maintain arm in a neutral (slightly flexed) position
Impaired Verbal Communications related to visual and speech with each joint slightly higher than the preceding one.
impairment. 7. Restraints should be avoided, they often increase
Potential for Injury related to seizures and neurological deficits. agitation.
Alteration In Nutrition: Less Than Body Requirements related 8. Maintain joints in position of normal function to prevent
difficulty in swallowing and potential for aspiration. flexion contractures.
Impaired Physical Mobility related to severe weakness and
paralysis. Goal: to maintain homeostasis through continued nursing
Knowledge Deficit related to prognosis. assessment and appropriate nursing intervention.
3. Diagnostics 1. Evaluate adequacy of cardiac output.
a. Clinical manifestations elicited in the neurological exam. 2. Monitor hydration status-prevent fluid
b. Cerebral arteriogram. overload.
c. Lumbar puncture a. Carefully regulate IV intake.
d. CAT and brain scan. b. Evaluate response to diuretics.

10
 c. Assess for the development of peripheral b. Atherosclerosis resulting in
edema. weakness of the vessel wall.
d. Restrict fluid intake as indicated. c. Hypertension; head trauma may
e. Assess respiratory parameters indicative of enhance the problem.
fluid overload (rales, dyspnea, etc.) d. Most often occurs in middle life.
3. Maintain and promote normal elimination. 2. Clinical manifestations.
a. Avoid urinary catheter if possible; if catheter is a. A Rupture may be
necessary, remove as soon as possible. preceded by:
b. Offer bedpan or urinal every two hours; help 1) Severe
establish a schedule. headache.
c. Prevent constipation- increase bulk in the diet, 2) Intermittent
stool softeners, etc. nausea.
d. Provide privacy and decrease emotional b. Rupture frequently
trauma related to incontinence. occurs without warning.
4. Prevent problems of skin breakdown through 1) Severe headache.
proper positioning and good skin hygiene. 2) Seizures.
5. Maintain psychological homeostasis 3) Nuchal rigidity
a. Client is very anxious due to the flack of 4) Hemiparesis.
understanding of what has happened to 5) Loss of
him/her and the inability to communicate. consciousness.
b. Speak slowly, clearly, and explain what has 6) Overall symptoms
happened. depends on the
c. Assess client’s communication abilities and site and amount of
identify methods to promote communication. bleeding; overall
prognosis is poor.
Goal: to assist client to become independent in 3. Diagnostics.
activities of daily living as rehabilitation phase a. Lumbar puncture, revealing blood in
progresses. the spinal fluid.
b. Cerebral angiogram.
1. Encourage self-feeding c. CAT scan.
2. Provide clothing easy to get in and out of. Treatment
3. Active participation in ROM; do his/her own 1. Osmotic diuretics.
ROM on affected side. 2. Antihypertensive medications.
4. Physical therapy for retraining of lost function. 3. Surgical intervention-ligation or “clipping” of the
5. When in the sitting position, assist client to aneurysm.
maintain sense of balance; client will
frequently fall to the affected side. Nursing Intervention
6. Encourage participation in carrying out daily Goal: to prevent further increase in intracranial pressure and
personal hygiene. possible rupture.
7. Assist/teach client safe transfer from bed to
wheelchair. 1. Immediate, strict bed rest.
8. Maintain bowel and bladder training program. 2. Prevent Valsalva’s maneuver.
9. Promote urinary continence. 3. Client should avoid straining, sneezing, pulling up in bed,
10. Encourage social interaction.
acute flexion of the neck, cigarette smoking.
a. Speech therapy
4. Elevate head of the bed 15˚ to 30˚.
b. Frequent and meaningful verbal stimuli.
5. Quiet, dim, nonstimulating environment.
c. Allow client plenty of time to respond.
d. Speak slowly and clearly; do not give too 6. Constant monitoring of condition to identify occurrence of
many directions at one time. bleeding as evidenced by symptoms of increasing
e. Do not “talk down to” or treats as a child. intracranial pressure.
f. Mental status may be normal; do not assume it 7. Administer analgesics cautiously, the client should
is impaired. continue to be easily aroused in order to perform neuro
checks.
CEREBRAL ANEURYSM, SUBARACHNOID
HEMORRHAGE Nursing Priority: If the client survives the rupture of the
aneurysm, it is most likely to rebleed within the next 24 to 48
A dilation of the wall of a cerebral artery (Berry aneurysm) most hours.
often arises from an arterial junction in the Circle of Willis.
Goal: to assess for and implement nursing measures to
A. An aneurysm frequently ruptures decrease intracranial pressure.
and bleeds into the subarachnoid
space. Goal: to provide appropriate preoperative nursing intervention.
B. Symptoms occur when aneurysm
enlarges and exerts pressure on the Goal: to maintain homeostasis and monitor changes in
brain tissue, or when it ruptures. intracranial pressure postoperative craniotomy.
C. Frequently the vasopasm that
accompanies the rupture causes a INFLAMMATORY PROBLEMS
significant increase in the area of Meningitis
damage.
Meningitis is an inflammatory condition of the meningeal
tissue covering the brain.

Assessment A. Types.

1. Risk factors/etiology. 1. Bacterial.

a. Congenital deformities of the vessel. 2. Fungal.

11
3. Viral (aseptic).
4. Parasitic. Treatment
1. Respiratory isolation for at least twenty-four hours after
B. Infectious process of inflammation, exudation, and initiation of treatment or until positive organism identified.
accumulation of white blood cells and tissue damage. 2. IV antibiotics.
3. Optimum hydration.
C. Inflammatory process results in the development of 4. Anticonvulsant medications
cerebral edema. 5. Maintain ventilation.

Assessment Complications
1. Increasing ICP resulting in permanent brain damage.
1. Risk factors/etiology. 2. Respiratory complications.
a. Pathogenic organism most often gains entry from an 3. Damage to senses-blindness and hearing loss.
infection elsewhere in the body. 4. Meningococcal infection.
b. Organisms. a. Adrenal damage.
1) Hemophilus influenza. b. Peripheral circulatory collapse (Water-House-
2) Streptococcus pneumoniae. Friedeichsen syndrome, frequently fatal)
3) Neisseria meningitis (meningococcus). 5. Inappropriate secretion of ADH (SIADH)
4) Staphylococcus aureus.
5) Mycobacterium tuberculosis.
c. Meningococcic meningitis is the only form readily
contagious. Nursing Intervention
Goal: to identify the organism, control spread, and initiate
1. Transmitted by direct contact, especially by droplet therapy.
infection from nasopharyngeal secretions. 1. Maintain respiratory isolation as indicated.
2. Occurs predominately in the school-age child 2. Initiate IV antibiotics after lumbar puncture and fluid
sample are obtained.
d. Increased mortality in infants. 3. Establish IV infusion as indicated.
4. Identify family contacts who may require prophylactic
2. Clinical manifestations-older child, adult. treatment.
a. Nuchal rigidity.
b.Chills and fever Goal: to identify the organism, control spread, and initiate
c. Headache. therapy.
d. Increasing irritability, changes in LOC. 1. Maintain respiratory isolation as indicated.
e. Respiratory distress. 2. Initiate IV antibiotics after lumbar puncture and
f. Generalized seizures. fluid sample are obtained.
g. Vomiting 3. Establish IV infusion as indicated.
h. Postive Kernig’s sign-resistance or pain at the knee and the 4. Identify family contacts who may require
hamstring muscles when attempting to extend the leg after prophylactic treatment.
thigh flexion.
i. Positive Brudzinski’s sign-reflex flexion of the hips when the Goal: to monitor course of infection and prevent
neck is flexed. complications.
j. Photophobia. 1. Frequent nursing assessment for increased ICP.
k. Petechiae, purpuric rash (especially in meningococcal 2. Maintain adequate hydration; may be on fluid restriction
meningitis). if increased ICP present.
3. Clinical manifestations-neonate and infant. 3. Monitor infusion site for complications of IVPB
a. Fever. antibiotics.
b. Apneic episodes. 4. Assess for side effects of high dosage of antibiotics.
c. Bulging fontanel 5. Decrease stimuli in environment-dim lights, quiet
d. Seizures. environment, no loud noises.
e. High-pitched cry. 6. Avoid movement or positioning that increases
f. Opisthotonos positioning-a dorsal arched position. discomfort; client generally assumes a sidelying position.
g. Petechiae, purpuric rash (especially in meningococcal 7. Seizure precautions.
meningitis). 8. Prevent complications of immobility.
h. Changes in sleep pattern, increasing irritability. 9. Good respiratory hygiene.
i. Poor sucking, may refuse feedings. 10. Measures to decrease fever.
j. Poor muscle tone, diminished movement. 11. Assess for increased ICP.
Nursing Diagnoses:
Meningitis ENCEPHALITIS

Potential for Infection Transmission related to presence of This is an inflammatory process of the CNS.
meningococcal bacteria in spinal fluid.
Potential for alteration in Fluid Volume: Deficit related to loss Assessment
of body fluid from temperature elevation. 1. Risk factors/etiology
Potential for Ineffective Airway Clearance related to a. May occur as a complication following a viral infection
complication of IICP. (measles, chicken pox, mumps)
b. May be transmitted by a vector – mosquito and ticks
4. Diagnostics. c. Causative organism may be herpes simplex virus

a. Lumbar puncture – reveals increasing 2. Clinical Manifestations (similar to meningitis but

spinal fluid pressure. generally less severe}
b. Examination of the spinal fluid. a. onset generally more gradual than with meningitis
1. Culture and stain-infective organism b. headache
present. c. fever
2. Increased protein content. d. seizures
3. Cloudy yellow fluid. e. change in LOC

12
 f. motor involvement 3. Condition may mask symptoms of hemorrhage in the trauma
client.
3. Diagnostics – examination of the spinal fluid, specific E. Autonomic dysreflexia (AD) occurs in clients with an injury at T-6
viral studies to isolate the virus. or higher.
1. A noxious stimuli below the level of injury triggers the
Treatment: sympathetic nervous system which causes a release of
1. Vidarabine for herpes simplex encephalitis catecholamines resulting in bnypertension.
2. Anticonvulsants 2. Spinal injury blocks the normal transmission of sensory impulses
3. Treatment to decrease ICP and the impulses cannot reach the brain, but they rebound and
4. Hydration stimulate the sympathetic nervous system.
3. there is an exaggerated response to the sensory stimuli, most
Nursing Intervention: common stimuli causing the response are a full bladder, fecal
Generally the same as for meningitis with the exception of impaction, and skin stimulation.
antibiotic therapy (encephalitis is caused by a viral agent and is not 4. Severe hypertension, pounding headache, bradycardia,
responsive to antibiotic therapy; antibiotic therapy may be done to restlessness, skin flushed and warm are not uncommon body
prevent bacterial infection). Give emphasis or focus on client safety responses.
and seizure precautions. 5. Treatment is directed identifying and removing noxious stimuli.
E. Bladder dysfunction will occur as a result of the injury. Normal
SPINAL CORD INJURY bladder control is dependent on both the sensory and motor
pathways, and the lower motor neurons being intact.
Generally occurs as a result of direct trauma to the head or neck 1. Reflex neurogenic bladder (spastic, autonomous)occurs in
area. clients with cord lesions above the level of lower lumbar and
A. Initially after the injury, the nerve fibers swell and circulation to caudal area of the spine. The lower motor neuron pathway remains
the spinal cord is decreased; hemorrhage and edema occur intact below the level of the injury.
causing an increase in the ischemic process which progresses to a.There is loss of voluntary muscle control, and depending on the
necrotic destruction of the spinal cord. level of the injury, there is loss or decreased sensation.
b. Bladder will retain a volume of urine, then reflexive involuntary
Nursing Priority: Within twenty-four hours of the injury, edema voiding will occur.
secondary to the inflammatory process results in compression of c. Bladder empties autonomically in response to stretching of the
the cord; the edema extends above and below the area of injury detrusor muscles.
and increases the area of ischemic damage. 2. Nonreflexic neurogenic bladder (flaccid) occurs in clients will
cord lesions at the lower lumbar and caudal area of the spine. The
B. Consequences of cord injury depend on the extent of damage lower motor neurons are damaged.
as well as the level of cord injury. a. The sensory function may remain unimpaired, there is loss of
1. The higher the lesion, the more severe the sequela. bladder tone and voluntary control.
2. Complete transaction (complete cord dissolution, complete b. Bladder retains a volume of urine, becomes distended and
lesion)-paralysis below the level of injury; minimum, if any, return of overflows.
function. c. There is no bladder muscle contraction or forceful emptying.
a. Loss of sensory function. F. Long-term rehabilitation potential depends on the amount of
b. Loss of voluntary motor activity damage done to the cord which may not be evident for several
c. Loss of sense of position (proprioception). weeks after the injury.
d. Minimum, if any return of function. Assessment
3. Incomplete. 1. Risk factors/etiology-accidents.
a. Central cord syndrome-center of cord is damaged, results 2. Clinical manifestations-depend on level of
primarily in impairment in upper extremities. cord injury.
b. Damage to one side of the cord (Brown-Sequard syndrome)- a. C1-C3-usually fatal at the scene of the
motor function and position sense may be present on one side, accident due to respiratory arrest.
temperature and sensation may be lost on the opposite side. b. Flaccid paralysis and sensory loss below the
c. Anterior cord damage-disruption of blood flow results in a mixed level of injury.
loss of sensory and motor function below the level of injury. c. Spinal shock.
C. Spinal Cord Shock (areflexia)-occurs predominantly in complete 1) Generally occurs within seventy-
cord lesions. Because of the loss of communication with the higher two hours and may last for several
centers of control, the muscles below the level of injury will become weeks.
flaccid and all functional control will cease. 2) Flaccid paralysis.
1. Spinal cord injury interrupts the sympathetic nerve impulse 3) Loss of sensation and absence of
transmission, the parasympathetic impulses are not counter reflexes.
checked and vasodilation occurs; this results in hypovolemia and 4) Bowel and bladder dysfunction.
hypotension. 5) Hypotension and bradycardia.
6) After spinal shock, reflexes, and
autonomic activity return as
evidenced by development of
spasticity.
d. Neurogenic shock
2. There is loss of the hypothalamus to control body temperature 1) Hypotension from vasodilation.
by vasoconstriction and dilation. 2) Bradycardia from increased vagal tone.
3. Condition may persist for several weeks and reverse 3) Skin remains warm and dry.
spontaneously, resolution of spinal shock will be evident by the 4) May require vasoactive medications
return of reflexes. (dopamine and dobutamine) for
4. Spasticity will occur as recovery progresses. Spastic movements hypotension and bradycardia.
may be precipitated by emotion and cutaneous stimulation. e. Autonomic dysreflexia in clients with injuries
D. Neurogenic shock. at T6 or higher.
1. Dominance of the parasympathetic nervous system results in 1) Severe hypertension.
loss in vasomotor tone and increased vagal tone leading to 2) Severe bradycardia.
hypotension and bradycardia. 3) Complaints of headache.
2. skin stays warm and dry due to loss of sympathetic response of 4) Flushing and diaphoresing above level
vasoconstriction. of injury.

13

Nursing Diagnosis:
Spinal Cord Injury
Potential for Aspiration related to inability to cough.
Alteration in Elimination, bowel and Bladder related
to level of injury.
Impaired Physical Mobility related to level of injury.
Disturbance in Body Image related to dependency
on others and change in body function.
Self Care Deficit related to anticipated losses.
Grieving related to anticipated losses.
Altered Family Process related to adjustment of
family member to permanent disability.
3. Diagnostics
a. History of accident
b. clinical manifestations.
c. X-rays to determine level of damage.
d. MRI.
e. CT scan.
d) Maintain extremities in neutral, functional position.
3. Appropriate nursing intervention when surgery is indicated
for stability of the injury.
Goal: to maintain ongoing assessment to identify level of
damage and changes in neurological status.
1. Motor and sensory evaluation.
a. Ability to move all extremities; strength of extremities.
b. Sensory examination including touch and pain.
c. Presence of deep tendon reflexes.
2. Ongoing assessment and status of:
a) Bladder function.
b) Gastric function.
c) Respiratory and cardiovascular systems.
d) Bowel function.
e) Psychological adjustment to the injury.

Treatment
1. Immobilization of the vertebral column in cervical Goal: to maintain respiratory function.
fracture. 1. Frequent assessment of respiratory function during first
a. Stryker frame. forty-eight hours.
b. Circular electric bed. a) Evaluate for changes in breathing pattern.
c. Cervical tongs (Crutchfield) for cervical b) Evaluate client’s complaints of increasing difficulty
immobility. in breathing; utilization of sternocleidomastoid and
2. Respiratory support as indicated. intercostals muscles for respiration.
3. Immobilization of spinal column by bed rest in c) Evaluate ABG.
lumbar fracture. d) Evaluate for presence of increasing hypoxia.
4. Stabilization of spinal column by surgical 2. Maintain adequate respiratory function as indicated.
procedures. a) Chest physiotherapy.
5. Corticosteroids to decrease cord edema. b) Incentive spirometry.
c) Changing position within limits of injury.
d) Assess for complications of atelectasis, pulmonary
emboli, and pneumonia
e) Nasopharyngeal or endotracheal suctioning
suctioning as indicated.
Goal: to maintain cardiovascular stability.
Nursing Intervention 1. Neurogenic shock.
Goal: to maintains stability of the vertebral column a) Monitor vital signs closely for first 24 hours post
and prevent further cord damage. injury.
b) Carefully titrate IV fluids as client is at high risk for
1. Emergency care and treatment. fluid overload.
a. Suspect spinal cord injury if there is any evidence c) Assess other client parameters for evidence of
of direct trauma to the head or neck area (contact hemorrhage and other injuries.
sports, diving accidents, MVA). 1) Abdominal muscles will remain flaccid in
b. Immobilize and place on spinal board with the presence of abdominal injuries.
head and neck in a neutral position; do not allow 2) With the loss of vascular tone the
the neck to flex. symptoms of hemorrhage will be masked.
2. Spinal shock.
Nursing Priority: Do not hyperextend the neck in the a) Monitor vital signs and
client with a suspected cervical injury. Airways evaluate changes with
should be opened by the jaw lift method. Improper regard to development of
handling of the client at the scene of the accident neurogenic shock and
often results in extension of the damaged area. hemorrhage.
b) Vagal stimulation,
c. Maintain in extended position with no twisting or turning; hypothermia, and hypoxia
do not remove from the spinal board until area of injury is may precipitate spinal shock.
identified. c) Development of spasticity of
d. Maintain patent airway during transportation. muscles below the level of
2. Maintain stability of the vertebral column as indicated by injury indicates resolution of
the level of injury. spinal shock.
a) Bed rest on firm mattress with supportive devices 3. Assess for developmental of autonomic dysreflexia, if it
(sandbags,skin traction, etc.); maintain alignment in occurs:
the supine position; logroll without any flexion or a) Elevate the head of the bed (if possible).
twisting. b) Assess for sources of stimuli-distended bladder,
b) Maintain cervical traction-tongs are inserted into the fecal impaction, or constipation.
skull with traction and weights applied; do not c) Relieve the stimuli and frequently dysreflexia will
remove weights; logroll to maintain spinal subside.
immobility. d) Maintain cardiovascular support during period of
c) Stryker frame or circle bed permit change of hypertension.
position from prone to supine; frequently utilized in 4. Evaluate cardiovascular responses when or suctioning.
conjunction with cervical traction; maintain safety 5. If turning on a circular electric bed, evaluate for postural
precautions when turning. hypotension.

14
6. Antiembolism stockings or elastic wraps to the legs to 9. Assist client to set realistic short-term goals.
facilitate venous return. (Lack of muscle tone and loss of
sympathetic tone in the peripheral vessels results in a NEUROMUSCULAR DISORDERS
decrease in venous tone and in venous return predisposing The neuromuscular disorders have many common
the client to the development of deep vein thrombosis). nursing implications. The nursing diagnoses for the
conditions are essentially the same and are
Goal: to maintain adequate fluid and nutritional status. included at the beginning of this section.
1. During the first forty-eight hours, evaluate GI
function frequently; decrease in function may
necessitate utilization of a nasogastric tube to
decrease distention. MYASTHENIA GRAVIS
2. Prevent complications of nausea and vomiting. A neuromuscular disease characterized by a
3. Evaluate bowel sounds and client’s ability to decrease in acetylcholine at the receptor sites in the
tolerate PO fluids. neuromuscular junction; precipitates a disturbance
4. Increase protein and calories in diet; may need in the transmission of nerve impulses.
to decrease calcium intake.
5. Evaluate for presence of paralytic ileus. Assessment
6. Increase roughage in diet to promote bowel 1. Risk factors/etiology.
function. a) Condition has been associated with
Goal: to prevent complications of immobility. dysfunction of the thymus gland.
Goal: to promote bowel and bladder function b) Autoimmune in origin.
1. Urine is retained due to the loss of autonomic c) More common in women.
and reflexive control of the bladder. d) Peak incidence between 20 and 30.
a. Intermittent catheterization or indwelling 2. Clinical manifestations.
catheter initially to prevent bladder distention. a. Primary problem is skeletal muscle fatigue;
b. Nursing intervention to prevent urinary tract symptoms are predominantly bilateral.
infection. 1) Muscular fatigue increases with
2. Determine type of bladder dysfunction and activity.
assist client to determine appropriate method 2) Ptosis(drooping of the eyelids) and
of bladder emptying. diplopia (double vision) are
3. Assess client’s awareness of bladder function. frequently the first symptoms.
4. Initiate measures to institute bladder control. 3) Impairment of facial mobility and
a. Establish a schedule for voiding; have client expression.
attempt voiding every two hours. 4) Impairment of chewing and
b. Utilize the Créde method for manual swallowing.
expression of urine. 5) Speech impairment (dysarthria).
c. May be necessary to teach client self- 6) No sensory deficit, loss of reflexes,
catheterization. or muscular atrophy.
d. Record output and evaluate for residual urine. b. Course is variable.
5.Evaluate bowel functioning. 1) May be progressive.
a. Incontinence and paralytic ileus frequently occur 2) May stabilize.
with spinal shock. 3) May be characterized by short remissions
b. Incontinence and impaction are common later. and exacerbations
6. Initiate measures to promote bowel control (after c. Myasthenic crisis-an acute exacerbation of
spinal shock is resolved). symptoms of the condition characterized by
a) Identify client’s bowel habits prior to weakness of the muscles controlling
injury. swallowing and breathing (dysphagia,
b) Maintain sufficient fluid intake and dysarthria, dyspnea). Occurs as a result of
adequate bulk in the diet. insufficient acetylcholine
c) Establish specific time each day for bowel (anticholinesterase)or exacerbation of disease
evacuation. state.
d) Assess client’s awareness of need to d. Cholinergic crisis is a toxic response to the
defecate. anticholinesterase medications.
e) Teach client effective utilization of the e. The symptoms of a myasthenic crisis and a
Valsalva maneuver to induce defecation. cholinergic crisis are essentially the same.
f) Induce defecation by digital stimulation, 1. Difficulty breathing, swallowing, chewing, or
suppository or as a last resort, enema. speaking.
Goal: To maintain psychological equilibrium. 2. Increased secretions (saliva, bronchial).
1. Simple explanation of all procedures. 3. Restlessness and apprehension.
2. Anticipate outburst of anger and hostility as 4. Tensilon test to differentiate crisis.
client begins to work through the grieving 3. Diagnostics.
process and adjustments in body image. a. Clinical manifestations.
3. Anticipate and accept periods of depression in b. Electromyography-shows a decreasing response
client. of muscles to stimuli.
4. Encourage independence whenever possible; c. TENSILON test- utilized for diagnostics and
allow client to participate in decisions differentiating types of crisis ( cholinergic crisis
regarding care and to gain control over versus myasthenic crisis).
environment.
5. Encourage family involvement in identifying
appropriate diversional activities.
6. Avoid sympathy and emphasize client’s
potential.
7. Initiate frank, open discussion regarding
sexual functioning.
8. Assist client family to identify community
resources. Treatment

15
1. Anticholinesterase (cholinergic) medications Goal: to assist client to understand implications of
2. Steroids disease process and measures to maintain health.
3. Plasma electrophoresis. 1. Importance of taking medication on
4. Immunosuppressive therapy. a regular basis; peak effect of the
5. Surgical removal of the thymus (thymectomy). medication should coincide with
mealtimes.
Nursing Intervention 2. If ptosis becomes severe, client may
( Client generally hospitalized for acute myasthenic need to wear an eye patch to protect
crisis or for respiratory infection). cornea (alternate eye patches if
Goal: to maintain respiratory function. problem is bilateral).
1. Assess for increasing problems of difficult 3. Emotional upset, severe fatigue,
breathing. infections, and exposure to extreme
2. Determine client’s medication schedule; when temperatures may precipitate
was medication last taken? myasthenic crisis.
3. Assess ability to swallow; prevent problems of
aspiration. MULTIPLE SCLEROSIS
4. Evaluate effectiveness of cough reflex.
5. Have emergency tracheotomy set available. The disease is characterized by multiple areas of
demyelinization of the neurons in the brain and
Nursing Priority: Do not give the client in spinal cord (CNS).
myasthenic crisis anything to eat or drink, there is
significant increased risk for aspirating during this A. Initially the myelin sheath is demyelinized, but
time. with no effect on the transmission of nerve
impulses. The myelin regenerates and
Goal: to distinguish between myasthenic crisis and symptoms disappear.
cholinergic crisis. B. The progression of the disease results in total
1. Maintain adequate ventilatory support during destruction of the myelin and the nerve fibers
crisis. become involved.
2. Assist in administration of TENSILON to 1. Damaged myelin is replaced by scar tissue.
differentiate crisis 2. Loss of myelin sheath causes decreased
a) Myasthenic crisis-client’s condition impulse conduction, destruction of the nerve
will improve. axon, and a blockage of the impulse
b) Cholinergic crisis-client’s condition conduction.
will improve. 3. The demyelinization occurs in irregular
3. If myasthenic crisis, neostigmine may be scattered patches throughout the CNS.
administered. C. The condition is chronic with unpredictable
4. If cholinergic crisis, atropine may be remissions and exacerbations; with repeated
administered and all cholinergic medications exacerbations there is a progressive scarring
discontinued. and deterioration of the neurological function.
5. Avoid use of sedatives and tranquilizers which
cause respiratory depression. Assessment
6. Provide psychological support during crisis. 1. Risk factors/etiology.
a. Autoimmune disorder.
Nursing Diagnosis: 1) Associated with a defect in the T-
Neuromuscular Disorders lymphocytes.
2) Correlated with previous viral
Potential Complications: Respiratory failure, Renal infections.
failure, Pneumonia b. Increased incidence in women.
Potential for Ineffective Breathing Patterns related c. Considered a disease of young adults, onset
to neurological deficits and immobility. generally between ages 20 and 40.
Disturbance In Self Confidence related to d. Familial tendency.
debilitating condition. 2. Clinical manifestations (vary from person to
Potential for Injury related to loss of coordination of person as well as within the same individual
movement, visual disturbances. depending on the area of involvement).
Impaired Verbal communication secondary to a. Onset is usually gradual; symptoms may occur
cranial nerve damage. intermittently over several years.
Potential Alteration In Nutrition: Less Than
Body Requirements related to difficulty eating and
chewing. b. Cerebellar dysfunction.
Activity Intolerance related to fatigue. 1) Nystagmus.
Potential for Disuse Syndrome related to effects of 2) Ataxia.
immobility. 3) Dysarthria.
Alteration In Elimination: Urinary related to sensory 4) Dysphagia.
motor deficit. c. Motor dysfunction.
1) Weakness progressing to paralysis of
extremities.
Alteration in Growth and Development related to 2) Spasticity of the muscles of the involved
onset of debilitation and inability of client to meet extremities.
developmental milestones. 3) Diplopia.
Sexual dysfunction related to changes in libido, or d. Sensory.
neurosensory deficits. 1) Vertigo.
Potential for Injury related to decreased sensory 2) Blurred vision.
perception of pain, and touch. 3) Decreased hearing, tinnitus.
Altered Family Process related to family member e. Bowel and bladder dysfunction.
with chronic debilitating disease. 1) Urinary retention, loss of sensation to
void.

16
 2) Uninhibited spastic bladder. c. Gait training and devices to maintain
3) Constipation. ambulation.
f. Impotency. 3. Measures to maintain voiding.
1) Physiological impotence in the male. a. Participation in bladder retraining.
2) Decreased sensation prevents normal b. Créde method of voiding
sexual response in males and females. c. Intermittent self-catheterization as indicated-
g. Psychosocial. residual urine should be less than 150 cc.
1) Intellectual functioning remains intact. 4. Safety measures due to decreased sensation.
2) Emotional lability-increased excitability a. Check bath water temperature.
and inappropriate euphoria. b. Wear protective clothing in the winter.
3) Emotional effects of the chronic illness c. Avoid heating pads and clothing that is
and changes in body image. constrictive.
3. Diagnostics. 5. Client should understand that relapses are
a. No definitive diagnostic test. frequently associated with an increase in
b. Diagnostics based on history and clinical physiological and psychological stress.
manifestations.
GUILLAIN-BARRÉ SYNDROME
Treatment
1. No cure; medical treatment is directed toward This condition involves segmental demyelination of
treatment of the disease process and nerve root in the spinal cord and medulla.
symptoms. Demyelination occurs, leading to inflammation,
2. Medications to decrease edema and edema and nerve root compression which causes
inflammation of the nerve site. decreased nerve conduction and rapidly ascending
a. Anti-inflammatory. paralysis. Both sensory and motor impairment, also
b. Antispasmodic. called polyradiculitis.
c. Immunosuppressive.
d. Anticholinergic and cholinergic. Assessment
e. Interferons. 1. Risk factors/etiology.
a) Possibly autoimmune in origin.
Nursing Intervention b) May effect any age group, more common
(Client hospitalized generally for diagnostic workup in ages 20 to 50.
or for acute exacerbation and complications). c) May be associated with swine flu
immunizations.
Goal: to maintain homeostasis and prevent d) Frequently preceded by mild respiratory
complications in an acute exacerbation of disease of intestinal infection.
symptoms. 2. Clinical manifestations.
a) Begins in the lower extremities and
1. Maintain adequate respiratory function. ascends bilaterally.
a. Prevent respiratory infection. 1. Weakness.
b. Good pulmonary hygiene. 2. Ataxia.
c. Prevent aspiration; sitting position for eating. 3. Bilateral paresthesia progressing to
d. Evaluate adequacy of cough reflex. complete paralysis.
2. Maintain urinary tract function. b). paralysis ascends the body symmetrically
a. Prevent urinary tract infection. and produces problems of the lower brain
b. Increase fluid intake. stem.
c. Evaluate voiding-assess for retention and 1) Paralysis of respiratory
incontinence. muscles.
d. Provide good perineal care. 2) Difficulty talking and
3. Maintain nutrition. swallowing.
a. Evaluate coughing and swallowing reflex. 3) Cranial nerve involvement.
b. Provide food that is easy to chew. c). Loss of sensation and function of bowel and
c. If client is experiencing difficulty swallowing, bladder.
observe closely with fluid intake. d). Manifestations may progress rapidly or occur
over two to three weeks.
Goal: to prevent complications of immobility. e). Muscle atrophy is minimum.

Goal: to promote psychological well being. Nursing Priority: Of the neuromuscular disorders,
1. Focus on remaining capabilities. Guillain-Barre is the most rapidly developing and
2. Encourage independence and assist client to progressive condition. It is potentially fatal if
gain control over environment. unrecognized.
3. If impotence is a problem, initiate sexual
counseling. 3. Diagnostics – based primarily on the clinical
4. Assist client to work through the grieving manifestations.
process.
5. Identify community resources available. Treatment
(Supportive).
Goal: to assist client to understand implications of 1. Corticosteroids.
the disease process and measures to maintain 2. Maintain respiratory function;
health. may require mechanical
1. Medical regimen and side effects of the ventilation.
medications.
2. Physical therapy to maintain muscle function Nursing Intervention
and decrease spasticity. Goal: to evaluate progress of paralysis and initiate
a. Water exercises. actions to prevent complications.
b. Stretching exercises. 1. Evaluate rate of progress of paralysis; careful
assessment of changes in respiratory pattern.

17
2. Frequent evaluation of cough and swallow Treatment
reflex. No definitive therapy.
a) Remain with client while eating;
have suction equipment available. Nursing Intervention
b) NPO if reflexes are involved. (Child is frequently cared for at home; hospitalized
3. If paralysis is rapid, prepare for ET intubation only for complications).
and respiratory assistance.
4. Prevent complications of immobility during Goal: to maintain function as long as possible.
period of paralysis.
1. Maintain child’s independence in ADL and maintain
Goal: To prevent complications of hypoxia if social contact with peers as long as possible.
respiratory muscles become involved. 2. Assist parents to identify resources for assistance
with physical therapy and exercise program at home.
3. Assist family to identify resources to adapt to
physiological barriers within the home and to promote
mobility of the child in a wheelchair.
4. Assist family to identify methods of preventing
Goal: to maintain psychological homeostasis. respiratory infection and to assess for increasing
1. Simple explanation of respiratory problems.
procedures.
2. Generally complete recovery is Goal: to assist parents and child to maintain
anticipated; residual problems psychological equilibrium and to adapt to chronic long-
are not common. term illness.
3. provide psychological support
during period of assisted 1) Assist parents to understand importance of
ventilation. independence and self-help skills;
4. Keep client and family aware of frequently parents are overprotective of the
progress of disease. child.
2) Counseling to assist parents and family
MUSCULAR DYSTROPHY members to identify family activities that can
be modified to meet child’s needs.
The term pseudohypertrophy describes 3) Mother may feel particularly guilty because
characteristic muscle enlargement due to fatty of transmission of disease to her son.
infiltration which occurs in muscular dystrophy. 4) Identify community resources available.
5) Counseling to assist family and child with
A. Muscular dystrophy is the most significant chronic long-term illness and child’s
group of childhood diseases of the muscles. eventual death.
B. Duchenne’s is the most common type and is
also the most severe. CEREBRAL PALSY (CP)
C. Condition is characterized by gradual
degeneration of muscle fibers and progressive A non progressive abnormality in the pyramidal
symmetrical weakness and wasting of skeletal system (motor cortex, basal ganglia, and cerebellum)
muscle. resulting in impairment of muscle control. May be
classified according to the specific area of brain
Assessment involvement and to the resulting clinical
1. Risk factors/etiology. manifestations.
a. Genetic-sex linked disorder primarily affecting
males. Assessment
b. Onset generally between 1 to 5 years. 1. Risk factors/etiology.
2. Clinical manifestations. a. Associated with cerebral anoxia during
a. History of delay in motor development, pregnancy or perinatal period.
particularly in walking. b. Prenatal.
b. Abnormal waddling gait. 1) Maternal anemia, metabolic
1. Falls frequently and develops characteristic disturbances.
manner of rising. 2) Intrauterine infection.
2. Gower’s sign-from sitting or squatting position, 3) Blood incapatabilities.
the child assumes a kneeling position and 4) Toxemia.
pushes his/her torso up by walking his/her c. Perinatal.
hands up the thighs. 1) Prematurity.
c. Progressive muscle weakness and atrophy. 2) Trauma during delivery.
1) Deformities of the joints. 3) Hyperbilirubinemia.
2) Ambulation frequently impossible by d. Postnatal.
age 12. 1) Cerebral trauma.
3) Ultimately destroys essential 2) CVA
muscles of respiration; death occurs 3) Infection.
from respiratory infection or cardiac
failure.
3. Diagnostics.
a. Electromyography (EMG). 2. Clinical manifestations.
b. Muscle biopsy. a) Delayed achievement of
c. Serum enzymes. developmental milestones.
1) Increases SGOT in the first 2 years b) Neuromotor dysfunction in motor
of life before the onset of symptoms. performances.
2) Increased creatinine phosphokinase c) Increased or decreased resistance to
and aldolase. passive movement.
d) Abnormal posture.

18
 e) Presence of infantile reflexes (tonic c) Encourage recreation and educational
neck reflex, exaggerated moro). activities, especially those involving other
f) Associated disabilities include: cerebral palsy children.
1. Mental retardation; d) Encourage child to express feelings
approximately 1/3 of the children regarding his/her disorder.
affected are of normal or e) Do not “talk down” to child; communicate at
superior intelligence. appropriate mental level..
2. Seizures f) Assists parents in problem solving in home
3. Attention-deficit problems. environment.
4. Vision and hearing sensory g) Identify community resources available.
impairments
3. Diagnostics. PARKINSON’S DISEASE (PARALYSIS AGITANS)
a. Neurological examination
and contributing history. - a progressive disorder causing destruction
b. Diagnostics tests to rule and degeneration of nerve cells in the basal
out other neurological ganglia resulting in damage to the
dysfunction. extrapyramidal system difficulty in control
c. Frequently difficult to and regulation of movement.
diagnose in early months;
condition may not be A. Dopamine a neurotransmitter is responsible for
evident until child attempts normal functioning of the extrapyramidal system.
to walk. B. The condition is correlated with a depletion of, or
Treatment imbalance in, dopamine and an increased activity
(Generally supportive). of acetylcholine.

1. Maintain and promote mobility wit orthopedic Assessment:

devices and physical therapy. 1. Risk factors/etiology:
2. Skeletal muscle relaxant. a. No sexual, economical or cultural
3. Anticonvulsant as indicated. preferences
b. General onset is after age 50
Nursing Intervention: c. Rarely occurs in the black population
(Child is frequently cared for a home and on an
outpatient basis unless complications occur.) 2. Clinical Manifestations:
a. Tremor
Goal: to assist child to become as independent and 1) Generally affects the arms and hands
self sufficient as possible. bilaterally – often the first sign
a) Physical therapy program designed to assist 2) Tremors may be increased or decreased with
individual child to gain maximum function. purposeful movement
b) Assist child to progress according to 3) Described as “pill rolling” tremor
developmental level and functional abilities; 4) Aggravated by emotional stress and
encourage crawling, sitting and balancing increased concentration
appropriate to developmental, level.
c) Assist child to carry out activities of daily b. Muscle rigidity
living as age and capacities permit (feeding, 1) Increased resistance to passive movement
dressing and personal hygiene). 2) Movement may be described as “cog wheel
d) Speech therapy is indicated. rigidity” due to jerky
e) Encourage play appropriate for age. movement of extremities
f) Encourage appropriate educational 3) Precipitates slowlessness of movement
activities.
g) Bowel and bladder training may be difficult c. Bradykinesia
due to poor control. 1) Decreased blinking of the eyelids
2) Loss of ability to swallow saliva
Goal: to maintain physiological homeostasis. 3) Facial expression is blank or “mask like”
a) Maintain adequate nutrition 4) Loss of normal arm swing while walking
1. may experience difficulty eating 5) Difficulty initiating movement
due to spasticity; may drool
excessively. d. Stood posture
2. encourage independence in e. Shuffling propulsive gait
eating; utilize self help devices f. Onset usually gradual
3. provide a balanced diet with
increased caloric intake to meet 3. Diagnostic – no specific diagnostic test
extra energy demands.
b) Maintain safety and precautions to prevent Treatment:
injury. 1. Medication to enhance dopamine secretion
c) Increased susceptibility to infections, a. Levodopa (L-DOPA)
especially respiratory infectio0ns due to poor b. Sinemet
control of intercostals muscle and diaphragm.
d) Increased incidence of dental problems; 2. Anticholinergic medications to decrease
frequent dental check up. effects of acetylcholine
a. Artane
Goal: to promote a positive self- image I the child and b. Cogentin
provide support to the
family. Nursing Intervention:
a) Use positive reinforcement Goal: to maintain homeostasis
b) Assist parents to set realistic goals. 1. Encourage independence in ADL utilizing
self help devices

19
 2. Maintain nutrition: Goal: to control pain.
a. Increase calories, protein and
easily chewed foods 1. Assess the nature of a painful attack.
b. Frequent small meals 2. Identify triggering factors; adjust environment to
c. Allow ample time for eating decrease factors.
d. Monitor weight loss a. Keep room at an even, comfortable temperature.
e. Provide pleasant atmosphere at b. Avoid touching client.
mealtime; client frequently c. Avoid jarring the bed.
prefers to eat alone due to d. Allow client to carry out own ADL as necessary.
difficulty swallowing and inability 3. Administer analgesics to decrease pain.
to control saliva
f. Increase fluid intake with
increased bulk in the diet to
decrease problem with
constipation
3. Maintain muscle function
a. Full range of motion to extremities to prevent
contracture Nursing Diagnosis:
b. Decrease effects of tremors Trigeminal Neuralgia
c. Encourage activity
d. Physical Therapy as indicated Alteration In Comfort: Acute Pain related to condition.
Knowledge Deficit related to inadequate knowledge regarding
Goal: to promote a positive self-image condition, precipitating factors, and treatment.
1. Encourage diversional activities Potential for Self Harm related to inability to cope with pain.
2. Assist client to set realistic goals
3. Explore reasons for depression; Nursing Priority: Due to the severe pain of the condition,
encourage client to discuss changes clients are susceptible to severe depression and suicide.
occurring in life style.
4. Assist client in gaining control of Goal: to maintain nutrition.
environment. 1. Frequently client does not eat due to
5. Assist client to identify and avoid reluctance to stimulate the pain.
activities that increase frustration levels. 2. Provide lukewarm food which is easily
6. Encourage good personal hygiene. chewed.
3. Increase protein and calories.
Goal: to evaluate residual effects and prevent complications
postoperative surgical intervention.

1. Identify presence of corneal reflex; provide protective

eye care if reflex is absent.
2. If there is loss of sensation to the side of the face client
PERIPHERAL NERVE DISORDERS should:
Trigeminal Neuralgia a. Chew on the unaffected side.
b. Avoid temperature extremes in foods.
A Cranial nerve disorder affecting the sensory branches of the c. Check the mouth after eating to remove remaining
trigeminal (cranial nerve V). particles of food.
d. Maintain meticulous oral hygiene.
Assessment e. Have frequent dental checkups.
Risk factors/etiology.
a. Onset generally between 20 and 40 years of age. BELL’S PALSY
b. Increasing frequency with aging. A cranial nerve disorder affecting the facial nerve (cranial
2. Clinical manifestations. nerve VII),characterized by a disruption of the motor branches
a. Abrupt onset of paroxysmal pain in the lower and upper jaw, on one side of the face. The disruption of the motor branches
cheek, and lips. results in muscle flaccidity of the affected side of the face.
1) Tearing of the eyes and frequent blinking.
2) Facial twitching and grimacing. Assessment
3) Pain usually brief; ends as abruptly as it begins. 1. Risk factors/etiology.
b. Recurrence of pain is unpredictable. a. Can affect any age group; increased incidence between
c. Pain is initiated by cutaneous stimulation of the affected nerve ages 20 and 40.
area. b. Current theories suggest the inflammation and
1) Chewing. demyelinization of the nerve is precipitated by a viral
2) Washing the face. agent, possibly herpes simplex.
3) Extremes of temperature-either on the face or in food. 2. Clinical manifestations.
4) Brushing teeth. a. Lag or inability to close eyelid on affected side.
3. Diagnostics. b. Drooping of the mouth.
a. clinical manifestations. c. Decreased taste sensation.
b. Test to rule out other neurologic dysfunctions. d. May experience pain behind the ear of the affected side.
3. Diagnostics-no specific diagnostic test.
Treatment
1. Medical management of pain. Treatment
a. DILANTIN. 1. Corticosteroids.
b. TEGRETOL. 2. Vasodilators.
2. Surgical intervention.
a. Local nerve block.
b. Surgical intervention to interrupt nerve impulse transmission.
Nursing Intervention
Nursing Intervention Goal: to assess nerve function and prevent complications.

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 1. Analgesics to decrease pain.
2. Evaluate ability of client to eat.
3. Meticulous oral hygiene.
4. Prevent drying of the cornea on the affected
side.
a. Instill methylcellulose drops frequently during
the day.
b. Ophthalmic ointment and eye patches may be
required at night.
5. As function returns, active facial exercises.
Goal: to assist client to maintain a positive self-image.
1. Changes in physical appearance may be dramatic.
2. Discuss with client that the condition is usually self-
limiting with minimum, If any, residual effects.
3. Client may require counseling if facial appearance is
permanent.
Nursing Diagnosis:
Bell’s Palsy
Disturbance in Body Image related to facial deficits.
Potential for Injury: Eye related to loss of normal blink reflex.
Potential for alteration in Nutrition: Less Than
Normal Body Requirements related to difficulty eating.
SPINA BIFIDA
Spina Bifida – refers to a malformation of the spine in which the
posterior portion of the larrinae of the vertebrae fails to close. It
affects approximately 1 out of every l,000 babies born in U.S.A.,
malformation of the neural tube a cylinder of embryonic tissue that
develops into the brain and Spinal cord during the 1st month of
gestation. It’s the most common developmental defect of the
Central Nervous System.
MOST COMMON TYPES
1. SPINA BIFIDA OCCULTA, in which the defect is only in
the vertebrae. The spinal cord and meninges are normal.
2. MENINGOCELE, in which the meninges protrude
through the opening in the spinal canal, forming a cyst
filled with Cerebro Spinal Fluid and covered with skin.
3. MENINGOMYELOCELE OR MYELOMENINGOCELE –-
in which both the spinal cord and cord membranes
protrude through the defect in the laminae of the spinal
canal. Meningomyeloceles are covered by a thin
membrane.
Rachischisis neural tube defect extends the length of the
spine which is always fatal. Spina bifida cystica is also
another term used to describe Meningomyelocele.
ETIOLOGY:
1. unknown, but generally thought to result from genetic
predisposition triggered by something in the
environment.
2. It involves an arrest in the orderly formation of the
vertebral arches and spinal cord that occurred between
the 4th and 6th week of embryogenesis.
THEORIES CAUSATION:
A). There is incomplete closure of the neural tube during the
4th week of embryonic life.
B). The neural tube forms adequately but then ruptures.
INCIDENCE:
1. Geographical distribution and incidence vary widely.
2. Condition occurs in approximately 1 per 1,000 live births
in the U.S.
3. most common developmental defect of / CNS.
4. more common in Caucasians than in non white
population specially those of celtic ancestry and those
living in South Eastern U.S.
5. condition may have other congenital anomalies
associated with it.
6. Women who have spina bifida and parents who have
one affected child have an increased risk of producing
children with neural tube defects.
ALTERED PHYSIOLOGY AND CLINICAL
MANIFESTATIONS:
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A. SPINA BIFIDA OCCULTA
1. Most common type, may occur in as many as 25% of
otherwise normal children.
2. The bony defect may range from a very thin slit
separating one lamina from the spinous process to a
complete absence of spine and laminae.
3. A thin, fibrous membrane sometimes covers the defect.
4. The spinal cord and its meninges may be connected with
a fistulous tract extending to and opening onto the
surface of the skin.
5. Most patients have no symptoms:
a. They may have a dimple on the skin or a growth of hair
over the malformed vertebra.
b. There is no externally visible sac.
c. With growth, the child may develop foot weakness or
bowel and bladder sphincter disturbances.
B. MENINGOCELE
1. An external cystic defect can be seen in the spinal cord,
usually in the center line.
a. The sac is composed only of meninges and is filled with
CSF.
b. The cord and nerve roots are usually normal.
2. The defect may occur anywhere in the cord. Higher
defect (from the thorax and up) are usually
meningoceles.
3. There is seldom evidence of weakness of the legs or
lack of sphincter control.
4. Surgical correction is necessary to prevent rupture of the
sac and subsequent infection.
5. Hydrocephalus may be an associated findings and may
be aggravated after surgery for a meningocele.
a. Occurs in about 9% of patients
b. Usually not associated with the Arnold-Chiari
malformation
6. Prognosis is good with surgical correction.
C. MENINGOMYELOCELE ( MYELOMENINGOCELE)
1. most common type of open spinal defect – occurs 4-5
times more frequently than meningocele.
2. A round, raised, and poorly epithelialized area may be
noted at any level of the spinal column. However, the
highest incidence of the lesion occurs in the lumbosacral
area.
3. The lesion contains both the spinal cord and cord
membranes. A bluish area may be evident on the top
because of exposed neural tissue.
4. The sac may leak in utero and may rupture after birth
allowing free drainage of CSF. This renders the child
highly susceptible to meningitis.
5. Prognosis.
a. Influenced by the site of the lesion and the presence and
degree of associated hydrocephalus. Generally, the
higher the defect, the greater the extent of neurologic
deficit and the greater the likelihood of hydrocephalus.
b. In the absence of treatment, most infants with
meningomyelocele die early in infancy.
c. Surgical intervention is most effective if it’s done early in
the neonatal period, preferably within the 1st few days of
life.
d. Even with surgical intervention, infants can be expected
to manifest associated neurosurgical, orthopedic and or
urologic problems.
e. New techniques of treatment, intensive research and
improved services have increased life expectancy and
have greatly enhanced the quality of life for most
children who received treatment for the defect.
CLINICAL PROBLEMS COMMONLY ASSOCIATED WITH
MENINGOMYELOCELE
A. Neurologic Problems.
1. Arnold-Chiari malformation
a). associated malformation involving the brain stem and
cerebellum
b). causes block-flow-CSF thru the ventricles and leads
to failure n the reabsorption mechanism of CSF
 c). Produces significant hydrocephalus in approximately POST OPERATIVE CARE:
2/3 of children wit meningomyelocele Take vital signs and monitor the infant’s ability to feed. In
2. Loss of motor control and sensation below the level of the addition to a flat diaper under the infant, put a piece of sterile
lesion. plastic above the anus to deflect feces away from the surgical site.
B. Mobility and Orthopedic Problems Watch for fever, signs of infection
1. Contractures Watch for leakage of CSF at the closure site, and
2. Clubfeet evidence of hydrocephalus.
3. Scoliosis Do a complete orthopedic and urinary assessment.
4. Ambulation and ability to be upright.
C. Urologic Problems - sacral nerves innervate the bladder.
D. Bowel Problems – poor innervation of the anal sphincter and
bowel musculature.
E.Skin Problems – areas of decreased sensation have a
tendency to break down.

F. Dietary Problems – children become overweight because of

activity limitations.
Dietary control to prevent obesity.
G. Developmental Problems – average intellectual ability despite
hydrocephalus.
DIAGNOSTICS – prenatal screening for neural tube defects. A
blood test may reveal high levels of maternal AFP – serum
alphafetoprotein indicating a break in the neural tube that is
allowing too much of this protein to seep into amniotic fluid and
subsequently into the mother’s blood. The results must be
confirmed by ultrasound and amniocentesis, although these tests
can’t determine the severity of the defect.

TREATMENT AND NURSING INTERVENTIONS:

Depends on the extent of the neurologic deficit, level of the lesion,
and any complication she may have – most commonly
hydrocephalus and UTI.
A number of interventions have significantly increased the survival
rate and quality of life; Early surgical repair of the defect, antibiotic
therapy to reduce the incidence of: meningitis and ventriculitis ,
shunting to relieve hydrocephalus, and early management of
urinary problems.
In caring for a newborn of spina bifida, the nurse’s major concern is
preventing infection.
Screening - indentation or tuft of hair may be the only visible sign
of mild forms of spina bifida.
In more severe cases - the defect is obvious: a portion of the spinal
cord protrudes from the infant’s back. Tissues and nerves are
either completely exposed or covered by a thin membrane of skin.
Cover the protruding sac – whether open or closed – right away
with a non adherent, sterile gauze dressing soaked with sterile
saline. Keeping it moist will help prevent infection before referring
her to a neurosurgeon. Surgery to repair the sac with intact tissue
and skin grafts within the next 48 to 72 hrs. (others within 24 hrs.)
Before surgery: Nurses do complete physical examination - Since
musculoskeletal problems such as dislocated hips and clubfeet
frequently accompany myelomeningocele – pay particular attention
to the lower extremities.
To keep the spine aligned and to avoid pressure on the baby’s
back, place her on her abdomen on an elevated wooden box
covered with sheepskin. The baby stays in this position during
feedings. Do range of motion exercises gently every hour to
prevent pressure sores.
Urine and feces - that remain for any length of time in the baby’s
diaper increase the risk of infection. So instead of diapering simply
place one underneath her.
A foley cathether is inserted before surgery.
To further protect against infection – start a continuous IV infusion
of Gentamycin (Garamycin) or Ampicillin ( Polycillin – N) as per
Doctor’s order.
Change the gauze dressing at least once a shift and right before
surgery.

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