NCM II6j: NEUROLOGICAL SYSTEM REVIEWER

Medical Surgical Nursing

2nd Semester, Finals
For BSN III – B ONLY

NEUROLOGIC SYSTEM DISORDERS

SEIZURE DISORDERS Pathophysiology

Seizures Altered Physiology

1. Pathophysiology (unknown)
o Brain has metabolic needs for
oxygen and glucose.
o Neurons have permeability
gradients and voltage
gradients affected by changes in
the chemical and humoral
• Sudden uncontrolled burst of environment.
electrical activity in the brain. 2. Changes in the permeability of the cell
• CAUSES CHANGES IN: population (ischemia, hemorrhage) and
o Consciousness ion concentration (Na+, K+) can produce
o Behavior sensations neurons that are hyperexcitable and
o Muscular activities (movements) demonstrate hypersynchrony, producing
o Feelings beyond voluntary abnormal discharge.
control 3. Factors affecting cell permeability can
make a person susceptible to seizure.
• Produced by excessive neuronal
These includes:
discharge.
a. Medications
• A symptom of an underlying pathology.
b. Genetic factors
• Normally neurons send out messages in
c. Electrolyte imbalances
electrical impulses periodically.
d. Infections
o With seizures, many more
e. Brain inflammation
neurons than normal fire in a
f. Injury
synchronous fashion in a
particular area of the brain.
Cellular Level
• Seizures may be symptomatic or
acquired (sudden excessive disorderly • SEIZURES
electrical discharges of the neurons). o Starts with the excitation of
o INCIDENCE: Higher with susceptible cerebral neurons
family history of seizures. which leads to synchronous
• Also known as epileptic seizures if discharges of progressive larger
recurrent. group connected neurons.
• EPILEPSY – has 2 or more seizures
(recurrent) with no known cause. Neurotransmitters
o INCIDENCE: Higher in those TYPES
with family history of idiopathic Glutamate Most common
seizures. excitatory
o CAUSE: Unknown in 75% of neurotransmitter
epilepsy Gamma – Aminobutyric Important
cases. Acid (GABA) inhibitory
neurotransmitter.

• An imbalance of excess excitation and

decreased inhibition initiates electrical
activity.
• Increased activation or decreased
inhibition of discharges = results in
seizure.

Prepared by: Elianna Marisse A. Verar 1

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Causes Note: Déjà vu is a temporal lobe epilepsy; a
feeling like you have been there before.
• Tumors to the head/brain
• Brain tumor 3. Ictal Stage
• Circulatory disorder • Seizure itself.
• Stroke • Here you can already see the signs of
• Subdural hematoma symptoms of seizure.
• METABOLIC:
o Hypoglycemia SIGNS & SYMPTOMS
o Hypocalcemia Tonic – stiffness
o Hyponatremia Clonic – jerking movements of arms and legs
o Cerebral anoxia PRIORITY
• Drug/alcohol toxicity Airway, suction secretions
• INFECTION:
o Meningitis 4. Post Ictal Stage
o Encephalitis • Recovery phase.
• ENCEPHALOPATHY: • After the attack; after effects.
o Lead poisoning
o Hepatic SIGNS & SYMPTOMS
• CONGENITAL: Generalized body weakness
o Hydrocephalus Recovery position
• VASCULAR:
o Intracranial hemorrhage

4 Stages of Seizure

1. Prodromal
2. Aura
3. Ictal
4. Post Ictal

1. Prodromal Stage
• Happens few days or hours prior to
seizure.
SIGNS & SYMPTOMS
Mood changes
Agitation
Irritability
Depression

2. Aura Stage
• Change of activity few minutes or
seconds prior to seizure.
• WARNING SIGN!
o In any seconds, the seizure will
follow such as:
▪ Flashes of light
▪ Dark spots
▪ Nausea
▪ Numbness
▪ Tingling of the limbs
SIGNS & SYMPTOMS
Olfactory: smelling of burning wires
Optic: photosensitivity
Déjà vu, migraine

Prepared by: Elianna Marisse A. Verar 2

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Classification of Seizures B. Clonic
TYPES • CLONIC = contractions
1. Generalized a. Tonic • Violent muscle contraction known as
Seizure b. Clonic convulsions.
c. Petit • Elbow, legs, head will flex & then relax
Mal/Absence rapidly at first but the frequency of the
Seizure spasms will gradually subside until they
d. Akinetic Seizure cease altogether.
e. Myoclonic • As the jerking stops, it is common for the
f. Tonic-Clonic person to let out a deep sigh after which
(Grand Mal) normal breathing resumes.
2. Partial Seizure a. Psychomotor
Seizure
b. Simple Partial
Seizure
c. Complex Partial
Seizure
3. Status Epilepticus

1. Generalized Seizure
• Occurs when the abnormal electrical
activity causing a seizure begins in both
halves (hemispheres) of the brain at the
same time.
• INITIAL onset in both hemisphere;
affects both sides of the brain. Involves
loss of consciousness and bilateral
motor activity.
• Types of Seizures:
o Tonic • Tonic-clonic seizures – most common
o Clonic type of generalized seizure.
o Petit Mal/Absence Seizure
o Akinetic Seizure
Tonic Phase Muscles become tense
o Myoclonic
and rigid.
o Tonic-Clonic (Grand Mal) Clonic Phase Muscles rapidly
contract and relax.
A. Tonic
• Muscles suddenly become stiff and C. Petit Mal / Absence Seizure
flexed arms, or trunk. • Nonorganic brain damage.
• Lasts about 20 seconds • Sudden onset, with twitching or rolling
• May cause person to fall if he is standing. of eyes ; lasts a few seconds.
• After seizure he may feel tired and • Minimal or no alteration in muscle tone.
confused. o When walking they suddenly
stand still, may loss and regain
consciousness "spaced out."
• Brief LOC with or without movement of
the eyes, head and extremities.
• Regain of consciousness is rapid and
lasts for 10-20 seconds.
• They may go unrecognized because the
behavior changes very little.

Prepared by: Elianna Marisse A. Verar 3

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 D. Akinetic Seizure (Atonic) A. Psychomotor Seizure

• Atonic – “drop attacks or drop seizures.” • May follow: trauma, hypoxia, drug
o Loss of muscle tone abuse.
o LOC may be brief • Purposeful but inappropriate, repetitive
• Related to organic brain damage. motor acts.
• Sudden loss of muscle strength, tone, • Aura present; dreamlike state.
person is relaxed.
• Can cause person to fall.
• Persons eyes rolls back into their head. B. Simple Partial Seizure
• Patient remains conscious and may not
always fall. • Seizure confined to one hemisphere of
brain.
E. Myoclonic • No loss of consciousness (does not
affect awareness).
• Associated with brain damage, • May be motor, sensory or autonomic
precipitated tactile or visual sensations. symptoms
• Brief transient rigidity or jerking of • Simple partial seizures can be:
extremities, arm extension, trunk o Motor – affecting the muscles of
flexion. the body.
• Single group of muscles affected; o Sensory – affecting the senses.
involuntary muscle contractions;
myoclonic jerks.
C. Complex Partial Seizure
F. Tonic-Clonic (Grand Mal)
• Begins in focal area but spreads to both
• Tonic-Clonic: person experiences tonic hemisphere.
phase and clonic phase. • Associated with impairment in
• LOC lasts 2-5 minutes. consciousness
• Rigidity followed by tonic-clonic • “Focal impaired awareness seizure or
movements. Focal onset impaired awareness
• Loss of bowel and bladder control. seizure.”
• Preceded by an aura.

2. Partial (Focal Seizure)

• Begins in focal (specific) area of brain
(simple, complex).
• Symptoms are appropriate to a
dysfunction of that area.
• May progress to generalized seizure.
• Subdivided into simple partial or
complex partial.
• Classification of seizures depends on the
area involved.
• Smaller area of the brain is affected.
• Able to interact and remembers the
event afterwards.
• May affect or not affect LOC.
• May recall the presence of an AURA.

Prepared by: Elianna Marisse A. Verar 4

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 3. Status Epilepticus 2. Jacksonian • Common among
Seizure (Focal clients with brain
Seizure) lesion.
• Aura is present.
• Commonly occur
during sleep.
• Begin with tonic
contractions of
the fingers in the
hand that
progress into
tonic-clonic
movements that
proceed up the
muscles of the
left side of the
• Generalized grand mal seizures. body, ending in
• MEDICAL EMERGENCY. Grand Mal
• LIFE THREATENING. seizure.
• Seizure is prolonged (repetitive without • Common:
regaining consciousness between childhood and
attacks). adolescence.
• Unresponsive to treatment. 3. Psychomotor • Has a psychiatric
• Brain damage may occur secondary to Seizure component
prolonged hypoxia and exhaustion (hallucinations
which can lead to death. and illusions).
• Can result in decreased oxygen supply • Aura is present.
and possible cardiac arrest. • Manifested by
• Last AT LEAST 30 minutes. confusion,
• It can be more than 30 minutes of a amnesia.
continuous seizure or two or more • Patient may
sequential seizures WITHOUT full commit violent
recovery of consciousness. social acts like:
• In clinical practice, a single seizure of going naked in
more than 5 minutes (in adults and public, running
children more than 5 years of age) should amok.
be considered as status epilepticus. • May loss
• TREATMENT: consciousness.
o Benzodiazepines to enhance
GABA neurotransmitter. Clinical Manifestation of Seizures
▪ Diazepam (Valium)
▪ Alprazolam (Xanax) • Related to area of brain involved in the
seizure activity.
Other Types of Seizures o Single abnormal sensations
o Aberrant (deviating) motor
TYPES
activity
1. Febrile Seizure • Common in 5%
o Altered
under 5 years old
consciousness/personality to
population.
loss of consciousness
• Nonprogressive o Convulsive movements
• Does not result in ▪ Sudden, violent,
brain damage. irregular movement of a
• Occurs only when limb or body, caused by
fever is rising. involuntary contraction.
• EEG: normal 2 o Confusion
weeks after
seizure.

Prepared by: Elianna Marisse A. Verar 5

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Diagnostic Tests Side Effects of Phenytoin
Blood Studies • Gum hyperplasia
• Hirsutism – a
• Rule out lead
condition in
poisoning ,
women where
hypoglycemia,
excessive growth
infection, electrolyte
of dark or coarse hair in a male-like
imbalances.
pattern.
Lumbar Puncture • Ataxia – no muscle coordination.
• Gastric distress
• Rule out infection. • Nystagmus – uncontrolled eye
movements.
• Anemia
• Sedation
• Bone marrow depression
• Causes pinkish red to brown
Skull X-Rays, CT-Scan, & MRI discoloration of urine (HARMLESS).
• Detect pathologic • Drug is withdrawn GRADUALLY to
defects. prevent status epilepticus.

Nursing Interventions on Phenytoin Therapy

• Monitor CBC.
o May cause bone marrow
Electroencephalogram (EEG)
depression.
• Rule out • Monitor serum drug levels to prevent
infection. toxicity.
• Child may be o Especially to diabetic patients as
awake or the drug inhibits the release of
asleep. insulin (lowers blood sugar
• Sedation is ordered. levels), causing hyperglycemia.
• May be sleep deprived the night before. • Instruct the client to take
• Stimulation: flashing strobe light, anticonvulsant everyday with food or
clicking sounds. milk.
• NPO (6- 8 hours) o To prevent GI bleeding.
• Consent • Avoid driving or strenuous activity.
• Shampoo head – to remove grease. • Withdraw the drug gradually.
• No stimulants 24-48 hours BEFORE o To prevent status epilepticus.
procedure • Contraindicated in pregnancy:
• Avoid 3 C’s: caffeine, cola, chocolate o Causes fetal anomalies (cardiac
defects, cleft lip and palate)
• Maintain serum drug levels.
Medical Management
Therapeutic serum level: 10-20 mcg/ml
1. Hydantoin More than 20 mcg/ml = Toxicity
a. Phenytoin (Dilantin) Less than 10 mcg/ml = Prone to seizure
b. Mephenytoin (Mesantoin)
c. Ethotoin • Toxic Effects:
o Difficulty speaking
o Drowsiness
Phenytoin
o Lethargy (LOC)
• Often used with phenobarbital for its o Rapid eye movements
potentiating effect. • Ensure adequate nutrition.
• Inhibits spread of electrical discharge. o Causes anorexia, N/V
• Avoid driving and performing
hazardous activities.

Prepared by: Elianna Marisse A. Verar 6

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 • Avoid alcohol and CNS depressant.
3. Iminostilbenes: Antiseizure Agent
o Lowers threshold of the
medication. Carbamazepine (Tegretol)
• Prevent gum hyperplasia.
o Ensure good oral hygiene. • Adverse Effects
o Use smooth toothbrush. o Agranulocytosis
o Massage the gums. ▪ A serious condition that
occurs when there is an
extremely low number
Drug Administration of Phenytoin of granulocytes (a type
• Anticonvulsant: Phenytoin. of white blood cell) in
o IM injection: the blood.
▪ Causes tissue irritations • Used for:
o IV infusion: o Tonic-clonic seizures
▪ Causes hypotension and o Bipolar disease
o Partial seizure
cardiac dysrhythmias
o Grand mal seizures.
• Should be injected slowly and directly
into a large vein through a large gauge 4. Benzodiazepines: Sedative Medications
needle or Intravenous catheter.
• IV administration: Should NOT exceed Diazepam (Valium)
50 mg/min in adults.
• Administered IV.
• Oral dosage: At first 100mg TID or 300
• For status epilepticus.
mg OD.
• NOTE: If PHENYTOIN is used, it is
Lorazepam (Ativan)
administered ONLY with NORMAL
SALINE and administer it slowly. • An antianxiety and anticonvulsant
o Rationale: Because it drug.
precipitates when mixed with • For status epilepticus.
glucose.
• Infusion rate: Should
NOT exceed 2mg/min.
2. Barbiturates
• PHENOBARBITAL
o Elevates the seizure threshold 5. Valproate
and inhibits the spread of
electrical discharge. • Valproic Acid (Depakene)
o Grand mal, petit mal, status o Indicated for grand mal, petit
epilepticus. mal, and mixed type of seizures.
• Barbiturates are o Is hepatotoxic, liver enzymes
CNS Depressants. should be monitored.

BARBITURATES (BARBITAL)
1. Amobarbital • Status Epilepticus
(Amytal)
2. Mephobarbital • Grand Mal
(Mebaral) • Petit Mal
3. Phenobarbital • Grand Mal • Divalproex Na (Depakote)
(Luminal) • Petit Mal o Used for treatment of manic
• Status Epilepticus associated with bipolar
4. Primidone • Grand Mal disorder.
(Mysoline) • Psychomotor
Seizures
Watch Out For: Respiratory Depression

Prepared by: Elianna Marisse A. Verar 7

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Surgery Corpus Callosotomy

• Resective and palliative operations.

• To remove the tumor, hematoma, or • Corpus callosotomy is surgery to treat
epileptic focus. epilepsy seizures when antiseizure
medications don't help.
Temporal Lobectomy
• The procedure involves cutting a band of
fibers (the corpus callosum) in the
brain.
• Afterwards, the nerves can't send
seizure signals between the brain's two
halves.

Hemispherectomy

• Temporal lobectomy is the most

common type of surgery for people with
temporal lobe epilepsy.
• It removes a part of the anterior
temporal lobe along with the amygdala
and hippocampus.
• A temporal lobectomy leads to a • A hemispherectomy is a radical surgical
significant reduction or complete seizure procedure where the diseased half of the
control about 70% to 80% of the time. brain is completely removed, partially
removed and fully disconnected or just
Extratemporal Resection
disconnected from the normal
hemisphere.
• This is one of the most successful
operations at stopping seizures in
carefully selected patients.

Collaborative Management

• An extratemporal resection is one type 1. Stay with the patient

of focal resection which is an operation 2. Protect the patient/person from injury.
to remove a small part of the brain. a. PROMOTE SAFETY.
• An extratemporal resection removes a b. Put up padded side rails.
part of either the occipital lobe, the c. If the client is standing/sitting,
parietal lobe or the frontal lobe or a ease him onto the floor with a
combination of these. pillow under the head.

Prepared by: Elianna Marisse A. Verar 8

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 d. Protect head with small pillow or
place head onto lap.
e. DO NOT apply restraints.
▪ This increases the
chance of them
suffering an injury such
as a broken bone or
dislocated shoulder.
f. DO NOT insert tongue blade
during tonic-clonic movements.
▪ A person may bite down
during a seizure if their
jaw and face muscles
tighten.
▪ If something is in their
mouth, they could break
and swallow the object,
or break their teeth.
Hence, it can injure the
teeth and jaw.
▪ Remember, a person
can't swallow their
tongue during a seizure. Seizure Management
▪ Contrary to popular
belief, it is not true that
a. Floor
a person having a
b. Bed
seizure can swallow his
tongue. c. Anticonvulsants
3. Promote patent AIRWAY.
a. Turn the client on his side. Floor
b. Loosen constricting clothing • Face on the side
especially around the neck. • Loosen clothing
c. Nothing should be force into the • Observe head protection
mouth because this may occlude • Over pillow / rolled towel
the airway.
• Remove nearby objects
4. Observe the seizure activity.
• Discharge instructions: wear helmet
5. Provide privacy.
6. Avoid any stimulus to the patient.
Bed
• Side- lying
• Oxygen
• Suction
• Airway
• Padded siderails
• Remove pillow
• IV anticonvulsant (administer slowly)
• Loosen clothing

Prepared by: Elianna Marisse A. Verar 9

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Nursing Interventions TRAUMATIC HEAD INJURY

a. Maintaining cerebral perfusion

b. Preventing injury
c. Strengthening coping

Maintaining Cerebral Perfusion

1. Maintain patent airway.
2. Provide oxygen inhalation. • Also known as brain injury.
3. Stress importance of taking • Involves injury to the:
medications regularly. o Scalp
4. Monitor therapeutic levels of o Skull
medications. o Brain tissues
5. Monitor toxic/side effects of • Disruption of normal brain function due
medications. to trauma-related injury resulting in
6. Monitor platelet/liver function test for compromised neurologic function.
drug toxicity. 1. Head injury is trauma to the
skull, resulting in mild to
Preventing Injury extensive damage to the brain.
1. Provide safe environment by padding 2. Immediate complications
side rails. include:
2. Place bed in low position. a. Cerebral bleeding
3. Do not restrain during a seizure. b. Hematomas
4. Do not put anything in patient's mouth c. Uncontrolled increased
during a seizure to prevent aspiration. ICP
5. Protect patient's head during a seizure. d. Infections
6. Manage the patient in status epilepticus. e. Seizures
• Can cause:
Strengthening Coping o Changes in personality or
behavior
1. Consult social worker for community o Cranial nerve deficits
resources for vocational rehabilitation, o Other residual deficits depend on
counselors, support groups. the area of the brain damage and
2. Teach stress reduction techniques. the extent of the damage.
3. Initiate appropriate consultation of
behaviors related to personality Classification
disorders.
Mild Brain Injury
Evaluation • GCS: 13 to 15
• Loss of consciousness of 0-15 minutes
• Taking medications as ordered.
• Drug level within normal range. Moderate Brain Injury
• No injuries observed. • GCS: 9 to 12
• Uses stress management techniques. • Loss of consciousness for up to 6
hours.
Severe Brain Injury
• GCS: 3 to 8
• Loss of consciousness greater than 6
hours.

Prepared by: Elianna Marisse A. Verar 10

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Causes of TBI B. Skull Fracture

Causes depend on the type of head injury:

• Falls
• Sports injury
• Being struct by an object
• Child abuse
• Blast injuries due to explosions
• PENETRATING INJURY
o Being hit by a bullet/shrapnel
Linear Skull Fracture
o Being hit by a weapon: hammer,
baseball bat, knife
o Head injury that causes a bone
fragment to penetrate the skull

Types of Head Injury

TYPES
1. Open Head a. Scalp Lacerations
Injuries b. Skull Fractures • Break in a cranial bone resembling a thin
• Linear line.
• Depressed • Without splintering, depression or
• Diastatic distortion
• Basilar
• Comminuted Depressed Skull Fracture
2. Closed Head a. Concussions
Injuries b. Cerebral Contusions
c. Brain Stem
Contusions
3. Compression
of the Brain
4. Hemorrhage/ a. Hematoma • Break in cranial bone or crushed portion
Hematoma • Epidural of the bone in toward the brain.
• Subdural
b. Hemorrhage Diastatic Skull Fracture
• Intracerebral
• Subarachnoid

1. Open Head Injuries

A. Scalp Lacerations

• Occurs when there is a separation of the

cranial sutures.
• Most common with the lambdoid
suture.
• Growing fracture: herniation of the
brain through the dura following a skull
fracture (often diastatic).

• Tearing of tissues caused by sharp

object.
• Hemorrhage may cause hematoma.

Prepared by: Elianna Marisse A. Verar 11

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Basilar Skull Fracture • PRIORITY:
o Assess Halos or Concentrix
rings in 4x4 gauze:
▪ (+) for Glucose
HALO OR RING SIGN
It occurs when
cerebrospinal fluid
(CSF) mixes with blood
• Caused by substantial blunt force on an absorbent surface.
trauma, involve at least one of the The blood forms a spot
bones that compose the base of the skull. in the center and a
• Involves the: lightly stained ring
o Temporal bones forms a halo around it.
o Occipital The halo sign is reliable
o Sphenoid for detecting CSF but
o Ethmoid not exclusive.
o Orbital plate of the frontal bone
Comminuted Skull Fracture

BATTLE’S SIGN
A crescent-shaped
• Break is an incomplete fracture and the
bruise that appears
broken bone is not completely separated.
behind one or both ears
• Comminuted: The break is in three or
(mastoid process). It is
more pieces.
retroauricular or mastoid
ecchymosis that is 2. Closed Head Injuries
typically the result of
head trauma. A. Concussions
RACOON’S EYES
Pooling of blood
around the eyes.
Periorbital ecchymosis
is a sign of basal skull
fracture.

• Jarring of the brain against the skull

• Fracture at the base of the skull
with TRANSIENT PERIOD (no loss)
• CAUSE: Trauma of unconsciousness.
• SIGNS AND SYMPTOMS: • Acceleration-deceleration injury
o Leak of CSF to:
• Caused by:
Eyes o A blow to the head.
• Racoon’s Eyes o Violently shaking of the head
Nose and upper body.
• Epistaxis (Nose bleeding)
• Rhinorrhea (CSF leak through nose)
Ears
• Battle’s Sign
• Otorrhea (CSF leak through ears)

Prepared by: Elianna Marisse A. Verar 12

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 B. Cerebral Contusions 4. Hemorrhage or Hematoma
A. Hematoma
Epidural Hematoma

• Bruising or extravasation of blood

cells/brain tissue.
• Causes bleeding and swelling inside of
the brain around the area where the head • Collection of blood that forms rapidly
was struck. between your skull and the dura mater,
• Contusions may occur with: the outermost protective membrane
o Skull fractures covering your brain.
o Other blood clots such as a • CAUSE:
subdural, extradural, or epidural o Usually from an arterial
hematoma. bleeding (artery torn) by a skull
C. Brain Stem Contusions fracture.
• Forms between the dura and skull from a
tear in the meningeal artery.
• Associated with temporary loss of
consciousness, followed by a lucid
period, that rapidly progresses to coma.
o Lucid interval period between
regaining consciousness after a
short period of unconsciousness,
resulting from a head injury and
• Condition in which a vertebra (bone) at deteriorating after the onset of
the top of the spine moves up and back, neurologic signs and symptoms.
toward the base of the skull. • IT IS A SURGICAL EMERGENCY.
• In this abnormal position, the bone may
Subdural Hematoma
compress the brain stem and spinal cord.

3. Compression of the Brain

• Forms slowly and results from a venous

• Results from depressed fracture of the
bleed.
skull.
• Occurs under the dura as a result of tears
• Causes hemorrhage and edema.
in the veins crossing the subdural space.
• Blood vessel in the space between the
skull and the brain is damaged.
• Blood escapes from the blood vessel,
leading to the formation of blood clot
(hematoma) that places pressure on the
brain and damages it.

Prepared by: Elianna Marisse A. Verar 13

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 • Sudden onset of neurologic deficit
B. Hemorrhage
• Signs of Basilar Head Injury
Intracerebral Hemorrhage o CSF leak from the ears
(otorrhea) and nose
(rhinorrhea)
o Raccoon's Eye
o Battle's Sign

• Multiple hemorrhages occur around a • Weakness and paralysis

contused area. • Posturing
• Decreased sensation or absence of
Subarachnoid Hemorrhage feeling
• Reflex activity changes
• Seizure activity

Primary Assessment
Airway
Assess for:
• Vomitus
• Bleeding occurs directly into the brain, • Bleeding
ventricles, or subarachnoid space. • Foreign objects
Pathophysiology or Etiology of TBI Breathing
Assess for:
• Caused by blunt or penetrating injury. • Abnormally slow or shallow
respirations
Blunt Trauma
• Elevated partial pressure of carbon
• Injury of the brain / body by forceful
dioxide (PCO2) can worsen cerebral
impact, falls, or physical attack.
edema.
Penetrating Injury
Circulation
• Object piercing the skin causing open
wound Assess for:
• Pulse
• Neurologic deficits result in shearing of • Bleeding
white matter, ischemia and mass effect
from hemorrhage, cerebral edema of
surrounding brain tissue. Diagnostic Evaluation

Assessment CT Scan
• Identifies and localize lesions, edema,
• Disturbance in consciousness:
bleeding.
o CONFUSION TO COMA
o Signs and symptoms of
Skull and Cervical Spine Films
increased ICP
• Changing neurological signs in the client • Identifies fracture, displacements.
• Changes in level of consciousness
• Airway and breathing pattern changes Neuropsychologic Tests During
• Vital signs changes reflecting increased Rehabilitation
ICP Headache, nausea, and vomiting
• To determine cognitive defects.
• Visual disturbances, pupillary changes,
and papilledema
Test Fluid for Glucose
• Nuchal rigidity (not tested until spinal
cord injury is ruled out) • CSF is positive for glucose.

Prepared by: Elianna Marisse A. Verar 14

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 insipidus and inappropriate secretion
General Management
of antidiuretic hormone (SIADH).
Management of Increased ICP
Preoperative Interventions
• Antibiotics:
o Prevents infection with open 1. Explain the procedure to the client and
skull fracture or penetrating family.
wounds. 2. Prepare to shave the client’s head as
• Surgery: prescribed;
o Evacuation of intracranial o Usually done in the operating
hematomas room and cover the head with an
o Debridement of penetrating appropriate covering.
3. Stabilize the client before surgery.
wounds
o Elevation of skull fractures
Postoperative Interventions
o Repair of CSF leaks
1. Client positioning following craniotomy
Surgical Management a. Removal of a Bone Flap for
Decompression.
• CRANIOTOMY ▪ To facilitate brain
• Indication: Hematoma expansion:
o Removal of a section of the o Client should be
skull to drain the hematoma. turned from the
o Allows the brain, if it is swollen, back to the
to bulge out of the skull and nonoperative
reduce intracranial pressure. side, but not to
the side
Craniotomy operated on.
2. Posterior Fossa Surgery
a. To protect the operative site
from pressure and minimize
tension on the suture line:
▪ Position the client on the
side, with a pillow under
the head for support and
not on the back.
3. Post-operative position
• A surgical procedure that involves an a. Lie FLAT (supine) for a few
incision through the cranium to remove days.
accumulated blood or a tumor. ▪ The head of the bed may
Complications of Craniotomy be raised to prevent
swelling of the face and
• Includes: head.
o Increased ICP from cerebral ▪ Some swelling is
edema normal.
o Hemorrhage ▪ Early ambulation:
o Obstruction of the normal flow Patient is encouraged
of CSF to move while in bed.
• Additional complications include: As the strength
o Hematomas improves, patient is
o Hypovolemic shock assisted to get out of
o Hydrocephalus bed and walk around
o Respiratory and Neurogenic under supervision.
complications,
o Pulmonary edema, and wound
infections
• Complications related to fluid and
electrolyte imbalances include diabetes

Prepared by: Elianna Marisse A. Verar 15

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Pharmacologic Interventions General Interventions

• Disturbance in consciousness: Head Injuries

MEDICATIONS • Keep head in neutral position with
1. Diazepam • To control cervical spine immobilized.
(Valium) seizures. • Hyperventilation to reduce intracranial
2. Steroids • To reduce pressure
swelling and • Establish an IV line of NSS or ringer's
brain cell lactate solution.
oxygenation o Fluid volume should be
requirements. restricted.
3. Mannitol • To reduce and • Manage seizures.
(Osmitrol) decrease cerebral o If it occur, manage immediately.
edema. • Maintain normothermia.
4. Barbiturate • To medically o NORMOTHERMIA - a core
Coma induce coma temperature between 36 and 38
brought on by a degrees Celsius and an
controlled dose acceptable level of warmth.
of an anesthetic
drug. Nursing Interventions
5. Antibiotics • To fight Maintaining Adequate Cerebral Perfusion
infections
Prepare for immediate surgical intervention • Maintain patent airway.
if patient shows evidence of neurological • Monitor:
deterioration. o ICP
o Serial serum
o Urine electrolyte
Management
o Central Venous Pressure (CVP)
Head Trauma • Restrict fluid intake.
• Administer IV solutions slowly to avoid
Care of Client with Increased ICP
dehydration and cerebral edema.
• Monitor the client for the drainage from
ears and nose. Maintaining Respiration
• Monitor the client for signs and
• Monitor:
symptoms of:
o Respiratory rate
o Meningitis
o Depth
o Pneumonia
o Patterns
o Urinary Tract Infection (UTI)
o Cheyne-stokes respiration
• Monitor signs of:
▪ Alternating apnea and
o ICP hyperventilation during
o Altered LOC
sleep.
o Abnormal pupil responses
• Assist with intubation and ventilatory
o Vomiting
assistance.
o Increased pulse pressure
• Turn patient every 2 hours.
o Bradycardia
• Assist with coughing and deep breathing.
o Hyperthermia
• Observe CSF leak.
Meeting Nutritional Needs
• Note contusions around eyes (Racoon
Sign) and ears (Battle’s Sign). • Provide NGT feedings
• Perform cranial nerve, motor, sensory, • Prevent aspiration
and reflex assessment. • Administer IV hyperalimentation
(artificial supply of nutrients) as ordered.

Prepared by: Elianna Marisse A. Verar 16

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN
 Promoting Cognitive Function Risk Factors
• Provide stimulation of sensory function. • Things that may raise the risk of this
• Use meaningful stimulation. problem are:
• Involve family. o Having health problems that
• Refer patient for cognitive retraining. increase the risk of falls
o Alcohol use disorder
Evaluation o Substance use disorder
o Being in a violent setting
• ICP stable.
o Playing high impact sports
• Respirations 24, regular
o Being in a motor vehicle
• Tube feedings tolerated well without accident
residual
• Oriented to person, place and time Symptoms
• Less agitated
• Siderails maintained • Heavy bleeding from the head
• Bleeding from the ears
PENETRATING BRAIN INJURY • Problems breathing
• Seizure
• Loss of bowel and bladder function
• Problems moving
• Loss of feeling in the limbs
• Loss of consciousness

Diagnosis
• Traumatic brain injuries other than blunt • X-rays
head trauma. • CT Scan
• A wound in which a projectile breaches • MRI
the cranium but does not exit it. o Only used when the penetrating
• MOST SEVERE form of traumatic object is not made of metal
brain injuries.
• SIGNIFICANT CAUSE of mortality in Treatment
young individuals.
o The morbidity and mortality • Surgery done to:
associated with this condition o Remove skull pieces that broke
remain high. off.
o Remove any objects, such as
Causes bullets.
o Remove part of the skull to ease
• Being hit by a bullet/shrapnel. pressure from swelling.
• Being hit by a weapon: hammer, baseball o Make holes in the scalp and
bat, knife. skull to drain blood.
• Head injury that causes a bone fragment o Place a tube into the brain to
to penetrate the skull. drain fluid.
• The injury may be from any object or
outside force, such as: Medications
o A fall, which could cause a piece
of the skull to break off and enter • Anticonvulsants
the brain. • Antibiotics
o Motor vehicle accident • Mannitol
o Gunshot
o Stab wound
o Sports injury
o Abuse, such as being struck on
the head with an object.

Prepared by: Elianna Marisse A. Verar 17

Clinical Instructor: Mrs. Mary Ann F. Rubio, RN MN