The Nervous System

 The body’s most organized and complex structural and functional system
 The body’s information gather, storage center and control system
 The function of the nervous system is to control all motor, sensory, autonomic, cognitive, and behavioral activities

2 divisions of the Nervous System

 Central Nervous System (CNS)

 Includes the brain and the spinal cord
 Peripheral Nervous System
 Consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves
 Divided into Somatic And Autonomic Nervous System

2 types of cells in the Nervous System

1. Neurons
2. Neuroglia

Parts of Neurons

1. Dendrites – a branch type structure with synapses for receiving electrochemical messages
2. Axon – long projection that carries impulses away from the cell body
3. Cell body – it contains the nucleus
4. Myelin Sheath – protects and insulates nerve fibers

Types of neurons according to function:

1. Sensory (afferent) – sends information from the sensory organs through the nerves into the CNS
2. Motor (efferent) – carry messages from CNS, through nerves, to operate muscles and glands
3. Interneuron – They carry messages from 1 set of neurons to the other

Types of neurons according to structure:

1. Bipolar (Interneuron)
2. Unipolar (Sensory)
3. Multipolar (Motoneuron)

Neuroglia

 Non-neuronal cells that maintain homeostasis, form myelin, and provide support and protection for the neurons
 4 main function of glial cells:

o Hold neurons in place

o Supply nutrients and oxygen
o Insulate neurons from one another
o Remove dead neurons

Types of Neuroglial cells

1. Astroglial cells (star-shaped)

o Provide the physical support for the neurons

o Regulate the physical environment
o Nourish the neurons
2. Ependymal cells

o Form the lining of the ventricles & the central canal of the spinal cord
o A part of the blood-brain barrier
o Help regulate the composition of the CSF

3. Oligodendrocytes

o Form myelin sheaths around the axon

o Insulate axons

4. Microglial cells

o Scavenger roles
o Resident macrophages of the brain and spinal cord
o Responds to infection in the CNS or trauma to the CNS

Neurotransmitters

 Communicate messages from one neuron to another or from a neuron to a specific target tissue
 Manufactured and stored in synaptic vesicles
 The action of a neurotransmitter is to potentiate, or modulate a specific action and can either excite or inhibit the
target cell’s activity

Major Neurotransmitters

Acetylcholine  Controls the flow of information from other areas of

the brain
 Major transmitter of the parasympathetic nervous
system Norepinephrine
 The neurotransmitter that is released by stimulation
of the vagus nerve, which alters heart muscle  Usually excitatory; affects mood and overall activity
contractions  Important for attentiveness, emotions, sleeping,
 Used by motor neurons as dreaming, and learning
an excitatoryneurotransmitter that triggers muscle
contraction Gamma-aminobutyric acid (GABA)
 Controls brain activity in brain areas connected with
attention, learning and memory  An inhibitoryneurotransmitter that is very widely
distributed in the neurons of the cortex
Serotonin  Contributes to motor control, vision, and also
regulates anxiety
 Neurons which use serotonin are distributed  Acts like a brake to the excitatory neurotransmitters
throughout the brain and spinal cord that lead to anxiety
 Restraining, helps control mood and  A low level of GABA can have an association
sleep, inhibitspain pathways with anxiety disorders
 Used to regulate intestinal movements
 Low serotonin level is found to be associated with Endorphin
conditions like depression, suicidal thoughts and OCD
 Has pain-relieving properties similar to morphine
Dopamine  It is involved in pain reduction and pleasure
 Also thought to be connected to be connected to
 Generally involved in regulatory motor activity physiological processes including euphoric feelings,
 Involved in mood, sensory perception, and attention appetite modulation, and the released sex hormones
 Also involved in controlling movement and posture
Cranial Nerves

Peripheral Nervous System

1. Somatic nervous system

o Associated with VOLUNTARY control of the body movement

o Consists of efferent nerves responsible for sensing brain signals for muscle contraction

2. Autonomic nervous system

o Associated with INVOLUNTARY control

o Responsible for maintaining and restoring internal homeostasis

Parasympathetic VS Sympathetic Effect

Parasympathetic Sympathetic

§ Usually when sleeping “Fight or Flight”

§ Bronchoconstriction § Pupillary dilation

§ Urinary bladder emptying § Bronchodilation

§ Increased peristalsis § Urinary retention

§ Glycolysis (glucose converted to § Decreased peristalsis

glycogen)
§ Gluconeogenesis (glucose is
§ Bradycardia derived from other sources)

§ Tachycardia

Central Nervous system

Brain

 Divided into three major areas: the cerebrum, the brain stem, and the cerebellum
 Semi-solid organ weighs about 3 lbs or more than a kilo

Meninges

 System of membranes which encloses the CNS

 Made of fibrous connective tissues
 3 layers:

1. Dura mater

o Thick durable, outside fibrous layer that protects the brain

o Closest to the skull
o Restricts and anchors the movement of the brain within the skull

** Epidural space– between skull and outer layer of the dura; epidural hematoma(accumulation of blood in epidural space)
1. Arachnoid

o Middle later of the meninges

**Contains arachnoid villi – aids in absorption of CSF

** Subdural space– between inner dura and arachnoid; subdural hematoma(accumulation of blood in subdural space)

1. Pia mater

o Innermost layer of the meninges

o Closely adheres to the brain

** Subarachnoid hemorrhage, not hematoma, because blood mixes with CSF and becomes pinkish instead of clear

Cerebrum

 The largest part of the human brain

 Associated with higher brain functions
 Divided into L and R hemispheres
 Contains billions of neurons
 Outer layer -> gray matter, inner layer -> white matter

Left Brain Functions Right Brain Functions

§ Logic § Emotional expression

§ Right hand control § Left hand control

§ Visual cortex (R eye) § Creativity

§ Auditory cortex (R ear) § L eye

§ Analysis § L ear

§ Science/scientific skills § Intuition

§ Number skills § Playfulness

§ Written language § Insight

§ Reasoning § 3-D forms

§ Spoken language § Art awareness

§ Imagination

§ Music awareness

Frontal Lobe

 The largest lobe

 The major functions of this lobe are concentration, abstract thought, information storage or memory, cognition, and
motor function
 Contains the Broca’s areawhich is critical for motor control of speech
Parietal lobe

 Predominantly sensory lobe

 Processing of sensory input, sensory discrimination
 Analyzes sensory information and relays the interpretation of this information to the thalamus and other cortical
areas

Temporal lobe

 Involved in auditory perception and is home to the primary auditory cortex

 Auditory receptive area and association areas
 Contains Wernicke’s area

Occipital Lobe

 The visual processing center

 For visual interpretation

Corpus Callosum

 Large fiber tract that connects the right and left hemispheres of the cerebrum, coordinating the functions of the
halves

Basal ganglia

 Regulate & integrate motor activity originating in the cerebrum or cerebral cortex
 Responsible for control of fine motor movements, including those of the hands and lower extremities

Thalamus

 Lies on either side of the third ventricle and acts primarily as a relay station for all sensation except smell
 Also passes through are memory, sensation, and pain impulses

Hypothalamus

 Plays a major role in regulation of vital functions such as: BP, sleep, food & water intake, body temp
 Acts as control center for pituitary gland
 Anterior Hypothalamus: parasympathetic activity (maintenance function).
 Posterior Hypothalamus: sympathetic activity (“Fight” or “Flight”, stress response)

Brain Stem

 Lower extension of the brain where it connects to the spinal cord

 Consists of the midbrain, pons, and medulla oblongata
 In charge of all the functions your body needs to stay alive, like breathing air, digesting food, and circulating blood

Mid Brain

 CN III & IV
 Serves as the nerve pathway of the cerebral hemispheres and contains auditory and visual reflex centers

Pons

 CN V, VI, VII, VIII

 Contains motor and sensory pathways
 Contains the respiratory center
Medulla Oblongata

 CN IX, X, XI, XII

 Contains motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to the brain
 Contains the respiratory, vasomotor & cardiac centers, as well as many mechanisms for controlling reflex activities
such as coughing, gagging, swallowing and vomiting

Cerebellum

 The little brain

 Only 1/8 of the size of the cerebrum
 Has both excitatory and inhibitory actions and is largely responsible for coordination of movement
 Important in maintaining balance, posture, and equilibrium
 Unlike the cerebrum, the left cerebellum controls the left side of the body, and the right cerebellum controls the right
side of the body

Spinal Cord

 A continuous structure extending from the cerebral hemispheres and serving as the connection between the brain
and the periphery
 Approximately 45 cm (18 in) long and about the thickness of a finger
 Surrounded CSF that acts as a cushion to protect the delicate nerve tissues against damage from banging against the
inside of the vertebrae

Functions of the Cord:

 Conducts sensory informationfrom the peripheral nervous systems to the brain

 Conducts motor informationfrom the brain to our various effectors

o Skeletal muscle
o Cardiac muscle
o Smooth muscle
o Glands

4 Main groups of Spinal nerves:

 Cervical Nerves: (nerves in the neck) supply movement and feeling to the arms, neck and upper trunk
 Thoracic Nerves: (nerves in the upper back) supply the trunk and abdomen
 Lumbar Nerves and Sacral Nerves: (nerves in the lower back) supply the legs, bladder, bowel and sexual organs

Other Structures

 The point at which the spinal cord ends is called the Conus medullaris, and is the terminal end of the spinal cord
 It occurs near lumbar nerves L1 and L2

Ventricular system

 Set of structures containing cerebrospinal fluid in the brain. It is continuous with the central canal of the spinal cord

Pathway of the CSF fluid:

Choroid plexus of the lateral ventricles àforamen of Monro àthird ventricle àaqueduct of Sylvius/Cerebral
aqueduct àfourth ventricle àthen separates into 2 pathways:

1àforamen of Magendie (middle)àspinal cord; OR

2àForamen of Luschka (lateral) àbrain’s subarachnoid space (absorbed by arachnoid villi) àcirculation

** Hydrocephalus– increased volume of CSF

Two types:

 Communicating – CSF reaches the brain butdecreased absorption

o Meningitis, tumor of the meninges

 Non-communicating – there is obstructionin the pathway of CSF

o Cerebellar tumor

Signs and symptoms:

 In children, there is enlargement of the head since the suture lines are still open

o Anterior fontanel closes at more or less 18 months

 In adult, there is no enlargement of head; increased ICP:

o Headache, vomiting, visual disturbances, ataxia (esp. if with cerebellar tumor)

Management:

 Ventriculoatrial (VA) shunt– to the heart

 Ventriculoperitoneal (VP) shunt– to the peritoneum
 Ventriculostomy– one end is outside

o Nursing Responsibility: Drainage bottle or bag should be placed just slightly below the head (or else, you will
drain all of the CSF)
o Number 1 complication is infection (encephalitis)!

CSF

 Clear and colorless fluid that is produced in the ventricles and is circulated around the brain and the spinal cord
through the ventricular system
 Contains a minimum number of the white blood cells and no red blood cells
 Specific gravity is 1.007

Blood supply to the brain

 Receives approximately 15% of the cardiac output

 Comes from four vessels: the right and left internal carotid and vertebral arteries
 The vertebral arteriesenter the skull through the foramen magnum and unite to supply blood to the brainstem
 The internal carotid arteriestraverse the skull in the carotid canal and the cavernous sinus
 Main arteries to each hemispheres of the brain:

o Anterior
o Middle
o Posterior cerebral arteries

 Arteries communicate at the base of the brain through the Circle of Willis

Assessing Neurological Function

History

 Demographic data
 Past medical history
 o Client’s medical history
o Family’s medical history
o Pervious injuries
o Chronic diseases: HPN, DM or lung disease
o Previous neurologic problems: headaches, seizures, head or spine trauma, eye problems

 Current history

o Current symptoms: blurred vision, headache, speech or swallowing difficulties, numbness, tingling, weakness,
clumsiness, bowel or bladder difficulties, N&V
o Allergies: in food, medication
o Pain tolerance: meds taken for pain
o Medications: prescribed, illicit, otc
o ADL

 Social History

o Usual recreational activities

o Level of physical activity each day
o Hobbies
o Alcohol consumption & use of recreational drugs
o Smoking
o Sleep habits: changes in pattern, duration or intensity

 Work History

o Exposure to toxic agents

o Educational background
o Handedness R or L handed

 (the client may somewhat be stronger on the dominant side, which is expected, & the effects of cerebral
injury or disease are more pronounced if the dominant hemisphere is involved)

Level of Consciousness

 A term used to describe a person’s awareness and understanding of what is happening in his or her surroundings
 The single most important assessment:

o Evaluation of level of consciousness (LOC) and mentation are the most important parts of the neuro exam
o A change in either is usually the first clueto deteriorating condition

Pupil Assessment

 Pupils are another important component of the neuro exam

 Assessing them is especially important in a patient with impaired LOC.
 Like a change in LOC, a change in pupil size, shape, or reactivity can indicate increasing intracranial pressure (ICP) from
a mass or fluid.
 Late signs of deterioration

o Pinpoint or dilated & nonreactive pupils

o Decerebration

 Is abnormal posturing
 Characterized by:

 Rigid extension of 4 extremities

 Hyperpronation of arms
 Plantar flexion of feet
  Opisthotonos (back arched)
 Associated with dysfunction of brainstem

 Decortication

 Abnormal posturing
 Characterized by:

 Internal rotation & adduction of arms

 Flexion of elbows; wrists & fingers
 Extension of leg

 Seen in client with lesions that interrupt the corticospinal pathways (pathway between the brain & the
spinal cord)

Diagnostic Assessment

Computed Tomography Scanning

 Makes use of a narrow x-ray beam to scan the head in successive layers
 The image is displayed on an oscilloscope or TV monitor and is photographed and stored digitally
 The images provide cross sectional views of the brain, with distinguishing differences in tissue densities

Nursing Responsibilities:

 Secure consent
 Fasting 4 hours before the test
 Inform the patients to remain as still as possible
 Ask client to remove any metallic objects
 If a contrast agent will be used, assess the client for iodine/shellfish allergies
 Sedation if pt is agitated, restless or confused

Positron Emission Tomography

 A computer-based nuclear imaging technique that produces images of actual organ functioning
 Patienteither inhales a radioactive gas or is injected with a radioactive substance that emits positively charged
particles
 Provides information about the function of the brain specifically glucose, O2 metabolism and cerebral blood flow
 The test involves injecting a very small dose of a radioactive chemical called a radiotracer, into the vein of the arm
 Useful in showing metabolic changes in the brain (Alzheimer’s disease), locating lesions (brain tumor, epileptogenic
lesions), etc.
 Client is placed on a stretcher
 IV line is started to inject isotope (Fluorodeoxyglucose)
 Isotope emits activity in the form of positron which are scanned & converted into a color image by computer
 More active a given part of the brain = the greater the glucose uptake
 Client is asked to perform certain mental functions to activate different areas of the brain

Magnetic Resonance Imaging (MRI)

 Uses a powerful magnetic field to obtain images of different areas of the body
 Provides much greater contrast between the different soft tissues of the body than computed tomography
 It can provide information about the chemical changes within the cells, allowing the clinician to monitor a tumor’s
response to treatment
 Useful in the diagnosis of multiple sclerosis and can describe the activity and extent of a disease in the brain and
spinal cord

Nursing Responsibilities:
 Signed consent form
 Remove jewelry, glasses & other metals
 Contraindicated to:

o Anyone with orthopedic hardware

o Pacemaker
o Internal surgical clips
o Other fixed metallic object in the body

 Warn client of normal audible humming & thumping noises during the scan

Cerebral Angiography (Arteriography/Arteriogram)

 An x-ray study of the cerebral circulation with a contrast agent injected into a selected artery
 Done by injection of radio opaque substance into the cerebral circulation via carotid, vertebral, femoral, brachial
artery followed by x-rays
 Used to visualize cerebral vessels & detect tumors, aneurysms, occlusions, hematomas, abscesses

Nursing responsibilities:

 Ice collar
 Pressure dressing

Myelography/Myelogram

 An x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid
space through a lumbar puncture
 Outlines the spinal subarachnoid space and shows any distortion of the spinal cord or spinal dural sac caused by
tumors, cysts, herniated vertebral disks or lesions

Nursing Responsibilities:

 Explain the procedure and secure consent

 Solid foods are avoided
 Assess for allergies to contrast agents, iodine or shellfish
 After the procedure, the patient lies in bed with the head of the bed elevated 30 to 45 degrees
 Increase fluid intake and check v/s

Non-invasive Carotid Flow

 Use ultrasound imagery and Doppler measurements of arterial blood flow to evaluate carotid and deep orbital
circulation
 Increased blood velocity can indicate stenosis or partial obstruction
 Carotid Doppler, carotid ultrasonography, are the common noninvasive vascular techniques

Transcranial Doppler

 Same noninvasive techniques as carotid flow studies except that it records the blood flow velocities of the intracranial
vessels
 Helpful in assessing vasospasm (a complication following subarachnoid hemorrhage), altered cerebral blood flow
found in occlusive vascular disease or stroke, and other cerebral pathology

Electroencephalography

 Recording of electrical activity along the scalp produced by the firing of neurons within the brain
 Obtained through electrodes applied on the scalp or through microelectrodes placed within the brain tissue
 Useful test for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome
** Electrical activity; seizures, epilepsy

Nursing Responsibilities:

 Withhold sedatives, tranquilizers, stimulants for 2-3 days

 Not to consume caffeine before the test
 Avoid using hair styling products (hairspray or gel) on the day of the exam
 For sleep EEG, client may be asked to stay awake the night before the exam

Electromyography

 Obtained by introducing needle electrodes into the skeletal muscles

 It tests the electrical activity or the muscles
 Useful in determining the presence of a neuromuscular disorder and myopathies

Lumbar Puncture

 Carried out by inserting a needle into the lumbar subarachnoid space to withdraw CSF
 Performed to obtain CSF for examination, to measure and reduce CSF for examination to determine the presence or
absence of blood in the CSF, to detect spinal subarachnoid block, and to administer antibiotics intrathecally in certain
cases of infection
 Client is usually placed in the left fetal position
 Area in the lower back is prepared aseptically.
 Once the appropriate location is located (to prevent puncture of spinal cord), a spinal needle is inserted

Nursing Responsibilities:

 Maintain flat on bed without head pillows (about 4 hours) in order to prevent spinal headache
 Maintain on NPO
 Increase fluid after procedure (if diagnostic); if therapeutic purpose, limit fluid intake.
 Assess ability to void.

Increased Intracranial Pressure

 Means an ↑ in intracranial bulk due to an ↑ in any of the intracranial components : brain tissue, CSF or blood

o If one or more of these components increase in size, intracranial pressure rises

o ICP measured in the lateral ventricles, NORMAL PRESSURE = 10-20 mmHg

**Compensations of the brain with increased ICP:

 Decreased production of CSF

 Increased absorption of CSF
 Shunting of fluid into the spinal canal

Causes:

 Trauma
 Hemorrhage
 Growths or tumors
 Edema or inflammation
 Decreased cerebral blood flow

Monro-Kellie Hypothesis

 States that the cranial compartment is incomprehensible, and the volume inside the cranium is fixed volume. The
cranium and its constituents (blood, CSF, and brain tissue) create a state of volume equilibrium, such that any
increase in volume of one of the cranial constituents must be compensated by a decrease in volume of another
Assessment

 History
 Assessment tests: Mental status, LOC, cranial nerve function, cerebellar function reflexes, and motor and sensory
function
 Diagnostic evaluation: CT scanning, MRI, or PET. Transcranial Doppler for blood velocity, evoked potential monitoring
measures the electrical potentials produced by nerve tissue in response to external stimulation.
 Earliest sign: Deterioration in the level of consciousness

o Early: confusion, restlessness, lethargy, and disorientation first to time, then to place and then to person
o Later: stupor then coma

 Pupillary dysfunction relative to size, shape, and reaction to light

o Early: gradual dilation, a slightly ovoid shape, and a sluggish response to light ipsilateral to the lesion
o Later: signs are dilation of the ipsilateral pupil and a non-reactivity to light (from compression of CN III)
o Final: bilateral dilation and fixation

 Motor weakness and sensory deficits

o Early: monoparesis, contralateral hemiparesis, and decreased visual acuity, such as blurred vision & diplopia
(double vision)
o Later: hemiplegia, decortication or decerebration (either unilateral or bilateral)

 Headache, possible seizures, projectile vomiting, (+) Babinski’s reflex

 Late sign: Changes in vital signs

o Hypertension: systolic BP rises while diastolic pressure remains the same (widening pulse pressure a difference of
more than 50 mmHg)
o Bradycardia
o Bradypnea
o Elevated temperature
o Cushing’s triad

 Very late presentation of brain stem dysfunction

Nursing Interventions

 Maintain patent airway

o Elevated head of bed to 15-30 degrees as prescribed

o Monitor respiratory status and prevent hypoxia.

 Leads to brain swelling and ischemia

o Coughing is discouraged because it also increase ICP

o Suction with care

 Achieve adequate breathing pattern

o Maintain mechanical ventilation as prescribed.

o PaCO2 at 30-35 mmHg àvasoconstriction of cerebral blood vessels àdecreased blood flow = decreased ICP
o Avoid the administration of morphine sulfate to prevent the occurrence of hypoxia

 Optimizing cerebral tissue perfusion

o Elevation of the head is maintained at 15 to 30 degrees to aid in venous drainage unless otherwise prescribed
o Prevent flexion of the neck and hips
 o Instruct the client to avoid Valsalva’s maneuver
o Decrease environmental stimuli

 Maintaining fluid balance

o Monitor I&O
o Skin turgor, mucous membranes, and serum and urine osmolality are monitored to assess fluid status

Medications

 Corticosteroids (dexamethasone)

o Stabilize the cell membrane & reduce the leakiness in the blood-brain barrier
o Reduces cerebral edema

 Antipyretics

o Prevents temp. elevation & shivering

o reduction à↓ metabolism, cerebral blood flow + ICP

 Osmotic diuretics (Mannitol)

o Given to dehydrate the brain tissue and reduce cerebral edema

 Blood Pressure Medications (beta blockers [Propanolol])

o To maintain cerebral perfusion at a normal level

o Notify physician if BP is <100 or > than 150 mmHg systolic

Seizures

 Episodes of abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) resulting from
sudden excessive discharge from cerebral neurons
 Can generally be classified as either “simple” (no change in level of consciousness) or “complex” (change in level of
consciousness). Or “generalized” (whole body affected) or “focal” (only one part or side of the body is affected)

Epilepsy

 A chronic disorder characterized by recurrent, unprovoked seizure activity

 Cause unknown in 75% of epilepsy cases
 The normal pattern of neuronal activity becomes disturbed, causing strange sensations, emotions, and behavior or
sometimes convulsions, muscle spasms, and loss of consciousness

Causes

 Any condition that results in abnormal electrical excitation of the brain may result in a seizure, including:

o Epilepsy
o Injury or trauma to the head
o Infection (brain abscess, meningitis)
o Brain tumor
o Stroke

 Also, any medical condition that irritates brain cells may result in a seizure. Common medical conditions that
commonly cause seizures include:

o Hypoglycemia (low blood sugar) o Alcohol withdrawal

o Drug use (especially cocaine or stimulants) o Very high fever (fever convulsions in children)
 Type of Seizure Clinical Findings

I. Generalized seizures

- May be preceded by aura

- Tonic and clonic phases

Tonic phase:limbs contract or stiffen, pupils dilate and eyes roll up and to one side; glottis
Major motor seizure closes, causing noise on exhalation; may be incontinent; occurs at same time as loss of
(grand mal) consciousness; lasts 20-40 seconds

Clonic Phase:repetitive movements, increased mucus production; Seizure ends with post-
ictal period of confusion, drowsiness

Related to organic brain damage. Also known as Drop seizure.

Akinetic Seizure
Sudden brief loss of postural tone, and temporal loss of consciousness.

Associated with brain damage, may be precipitated by tactile or visual sensations.

May be generalized or local.

Myoclonic seizure
Brief flexor muscle spasm; may have arm extension, trunk flexion.

Single group of muscle affection, involuntary muscle contractions = myoclonic jerks

Absence seizure (petit Must be differentiated from daydreaming.

mal) Sudden onset, with twitching or rolling of eyes; lasts a few seconds.

Common in 5% of population under 5, familial, nonprogressive; does not generally result in

brain damage.
Febrile seizure
Typically tonic-clonic.

Seizures occurs only when fever is rising. EEG is normal 2 weeks after seizure.

II. Partial seizures

Seizure confined to one hemisphere of brain.

Simple partial seizure No loss of consciousness.

May be motor, sensory, or autonomic symptoms.

Begins in focal area (anterior temporal lobe) but spreads to both hemispheres.

Complex partial seizure Impairs consciousness.

May be preceded by aura.

Status Epilepticus

 Usually refers to generalize grand mal seizures.

 A series of generalized seizures that occur without full recovery of consciousness between attacks or a seizure of
more than 15 mins.
 Vigorous muscular contractions impose a heavy metabolic demand and can interfere with respirations
 Factors that precipitate status epilepticus include withdrawal of antiseizure medication, fever, and concurrent
infection

Diagnostic Tests

 Blood studies to rule out lead poisoning, hypoglycemia, infection, or electrolyte imbalances
 Lumbar puncture to rule out infection or trauma
 Skull x-rays, CT scan, or ultrasound of the head, brain scan, arteriogram to detect any pathologic defects
 EEG may detect abnormal wave patterns, characteristic of different types of seizures

Medical Management

 Drug Therapy

o Phenytoin [Dilantin]

 It is one of the drugs of choice for: generalized tonic-clonic seizures; partial seizures
 Common side effects of phenytoin include: swollen, tender gums– gum hyperplasia, growth of facial and
body hair damage or rough facial features, acne, skin rash

o Carbamazepine (Tegretol)

 It is used alone or in combination with other medications to treat certain types of seizures in patients with
epilepsy
 It works by reducing abnormal excitement in the brain
 Common side-effects: fatigue, dizziness, N&V, decreases WBC (leukopenia)

o Diazepam (Valium)

 It slows the central nervous system and is used to treat anxiety related disorders and conditions that cause
severe muscle spasms and convulsions.
 Valium is administered rectally. Liquid valium is absorbed fast from the rectum
 Valium should not be used on a daily basis because it can cause withdrawal.

o Phenobarbital (Luminal)

 for tonic clonic seizures

o Clonazepam (Klonopin)

 Absence and myoclonic seizures

o Ethosuximide (Zarontin)

 Absence seizures

o Surgical Management

 Remove intracranial tumors, abscess, cysts, hematoma

 o First Aid for Seizures

 Cushion head
 Loosen tight neckwear
 Turn on side
 Nothing in mouth
 Look for I.D. (noting if they have a seizure disorder)
 Don’t hold down
 As seizure ends, offer help

In the hospital setting:

 Document: duration, is there an aura? Rolling of eyeballs?

 Provide privacy
 Prevent injury
 Administer anticonvulsants

Cerebrovascular Accident

Stroke

 Destruction (infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen
 Two major categories: ischemicin which vascular occlusion and significant hypoperfusion occur, and hemorrhagicin
which there is extravasation of blood into the brain
 Caused by thrombosis, embolism, hemorrhage

Types of Stroke

 Ischemic Stroke

o A thrombus or embolus blocks blood flow to part of the brain

o A clot blocks blood flow in an area of the brain

 Hemorrhagic Stroke

o Blood spills out from break in blood vessel in brain

o Bleeding occurs inside or around brain tissue

Risk Factors

 Hypertension
 Diabetes mellitus
 Atherosclerosis
 Cardiac disease (valvular disease/replacement, MI)
 Life-style (obesity, smoking, inactivity, stress)

1. Transient ischemic attack (TIA)

 Warning sign of impending CVA

 Brief period of neurologic deficit (visual loss, hemiparesis, slurred speech, aphasia, vertigo)
 May last less than 30 seconds, but no more than 24 hours with complete resolution of symptoms

** What blood tests to be done: CBC, lipid profile, blood sugar

1. Reversible ischemic neurologic deficits

 Signs and symptoms are consistent with but more pronounced than TIA
 Last more than 24 hours

1. Stroke in evolution

 Progressive development of stroke symptoms over a period of hours to days

1. Complete stroke

 Neurologic deficit remains unchanged for a 2- to 3-day period

Assessment

 Headache
 Generalized signs:
 Vomiting
 Seizures
 Confusion
 Disorientation
 Altered LOC
 Fever
 Hypertension & slow bounding pulse
 Cheyne-Stokes respirationsàirregular breathing
 Nuchal rigidity
 Focal signs (related to site of infarction)
 Hemiplegiaàfrontal lobe
 Sensory lossàparietal lobe
 Aphasiaàfrontal and temporal
 Homonymous hemianopsia
 Diagnostic tests

o CT and brain scan: reveal lesion

o EEG: abnormal changes
o Cerebral arteriography: may show occlusion or malformation of blood vessels

Nursing Interventions

 Acute stage

1. Maintain patent airway and adequate ventilation

2. Monitor VS, neuro checks, observe for signs of increased ICP, shock, hyperthermia, and seizures.
3. Provide complete bed rest as ordered.
4. Maintain F&E balance and ensure adequate nutrition.

 IV therapy for the first few days

 NGT feedings – if unable to swallow
 Fluid restriction as ordered – to decrease cerebral edema

Maintain proper positioning and body alignment.

 Head of bed may be elevated 30°-45° to decrease ICP

 Turn and reposition every 2 hours (only 20 minutes on the affected side)
 Passive ROM exercises every 4 hours

5. Promote optimum skin integrity: turn client and apply lotion every 2 hours.
6. Maintain adequate elimination.
  Offer bedpan or urinal every 2 hours, catheterize only if absolutely necessary.

** Best time to offer bed pan is in the morning.

 Administer stool softeners and constipation and fecal impaction

1. Provide a quiet, restful environment.

2. Establish a means of communicating with the client.
3. Administer medication as ordered.

 Hyperosmotic agents, corticosteroids to decrease cerebral edema

 Anticonvulsants to prevent or treat seizures
 Tissue plasminogen activator (t-PA) given to dissolve clot (hemorrhage must be ruled out)

Medications

 Anticoagulants – stroke in evolution or embolic stroke

o Heparin

 PTT (60-70 secs)

o Warfarin (Coumadin) for long-term therapy

 PT (11-17 secs)

o Aspirin and Dipyridamole (Persantin)

 To inhibit platelet aggregation in treating TIAs

o Antihypertensive – if indicated for elevated blood pressure

Management of Patients with Neurologic Trauma

Head Injury

 A broad classification that includes injury to the scalp, skull, or brain

 Can result to mild to extensive damage to the brain
 The most common cause of traumatic brain injury are motor vehicle crashes, violence, and falls.
 Immediate complications: cerebral bleeding, hematomas, uncontrolled IICP, infections and seizures

Types of Head Injury

1. Open 2. Closed

 A scalp injury  Concussion

 Fractures of the skull  Contusion

Scalp injury

 Generally classified as a minor head injury

 Bleeds profusely because the blood vessels constrict poorly
 Scalp wounds are potential portals of entry of organisms that cause intracranial infections
Skull fractures

 A break in the continuity of the skull caused by forceful trauma

 Skull fractures are classified as linear, comminuted, depressed or basilar

o Linear/Hairline

 A break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone

o Comminuted

 A fracture of many relatively small fragments

o Depressed

 A break in a cranial bone (or “crushed” portion of skull) with depression of the bone in toward the brain

o Compound

 A break in or loss of skin and splintering of the bone

o Basilar

 Breaks in bones at the base of the skull

 Raccoon eyes – ecchymosis around the eyes

 Battle’s sign/Mastoid ecchymosis
 Otorrhea (CSF flows out of the ears)

Concussion

 A temporary loss of neurologic function with no apparent structural damage

o Sudden loss of consciousness

Contusion

 A more severe injury in which the brain is bruised, with possible surface hemorrhage

Assessment

 Clinical manifestations usually from IICP

o Changes in LOC
o Visual disturbances, pupillary changes and papilledema
o Airway & breathing pattern changes
o Headache, N&V
o Weakness & paralysis
o Posturing
o V/S changes

 CSF drainage: Nose/ears

Nursing Interventions

 Maintain patent airway & ventilation; V/S, neuro checks, monitor signs of IICP, seizures, hyperthermia
 Observe CSF leak

o Check discharge for glucose (strip test), bloody spot encircled by watery, pale ring on pillowcase or sheet.
o Never attempt to clean the ears or nose; never use nasal suction unless ordered.

Maintaining Patent Airway

 Elevated head of bed about 30 degrees to decrease intracranial venous pressure

 Suction with care

Monitor fluid and Electrolyte balance

 Assess tissue turgor, mucous membrane, I&0

 Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be
accompanied by disorders of sodium regulation

Promoting adequate nutrition

 Parenteral nutrition via a central line

 Enteral feedings administered via a nasogastric or nasojejunal feeding tube

Prevent Injury (esp. fall injury)

 Minimize environmental stimuli by keeping the room quiet, limiting visitors, speaking calmly, and providing frequent
orientation information
 Lubricate the skin with oil or emollient lotion to prevent irritation due to rubbing against the sheet

Maintain body temperature

 TSB
 Acetaminophen as ordered

Maintain Skin integrity

 Assess all body surfaces and document skin integrity at least every 8 hours
 Turn and reposition the patient every 2 hours
 Provide skin care every 4 hours
 Signed consent
 NPO
 Shaving is done in the OR, not in the ward
Spinal Cord Injury

 Trauma to the spinal cord which causes partial or complete disruption of the nerve tracts & neurons
 Cause damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain
 Causes: motor vehicle accidents, diving in shallow water, falls, industrial accidents, sports injuries, gunshot or stab
wound

Medical Management

 Immobilization & maintenance of normal spine alignment

o To promote fracture healing

 Horizontal turning frame/Stryker frame  Cervical tongs (Crutchfield)

 Skeletal traction  Halo traction
 Garner-Wells Tongs
 Surgery is performed to reduce the spinal fracture or dislocation or to decompress the cord

 Laminectomy

 Surgical procedure in which the surgeon removes a portion of the bony arch, or lamina for relief of
pain

 Spinal fusion

 Surgery to join together two bone in the spine

 May use bone graft or metal implants

Assessment

 Spinal Shock

o Occurs immediately after the injury as a result of the insult to the CNS
o Temporary condition lasting from several days to 3 months
o Characterized by:

 Absence of reflexes below the level of lesion

 Flaccid paralysis
 Lack of temperature control
 Hypotension w/ bradycardia
 Retention of urine and feces àatonic bladder

o Level of injury

 Quadriplegia

 Cervical injuries (C1-C8) àparalysis of all 4 extremities

** Most common injury, and most fatal

 Paraplegia

o Thoracolumbar injuries (T1-L4) àparalysis of the lower half of the body involving both legs

 Extent of injury

o Complete cord transection

  Loss of all voluntary movement and sensation below the level of injury

o Incomplete lesions

 Varying degrees of motor or sensory loss between the level of the lesion depending on which neurologic
tracts are damaged & which are spared.

Nursing Interventions

 Emergency care

o Assess ABC

 Do not move the patient during assessment

 If airway obstruction or inadequate ventilation exists, do not hyperextend neck to open airway, use jaw
thrust

o Perform a quick head to toe assessment; check for LOC, signs of trauma; check for leakage of fluid from ear
o Immobilize client
o Assist in immobilizing head and neck with cervical collar & place on spinal board; avoid flexion of the spinal
column

 Promote adequate breathing and airway clearance

 Improve mobility and proper body alignment

o Supine position
o Turn every 2 hours. If not on a rotating bed, the patient should not be turned unless the spine is stable and the
physician has indicated that it is safe to do so.

 Promote adaptation to sensory and perceptual alterations.

 Maintain skin integrity
 Maintain urinary elimination
 Improve bowel function
 Monitor and manage complications

o DVT
o Orthostatic hypotension
o Autonomic dysreflexia

Chronic care

 Neurogenic bladder

o Nonreflexive/Areflexive or lower motor neuron bladder/LMN bladder

 Spinal shock: when reflex arc is not functioning due to initial trauma
 No reflex activity of the bladder occurs, resulting in urine retention with overflow
 Failure to empty
 Lesion: Complete destruction of Sacral Micturition Center (S2-S4) at S2 or below

o Management:

 Intermitted catheterization every 6 hours

 Crede’s maneuver – contract the bladder manually by applying pressure
 Regulate intake to 1800-2000 ml/day àto prevent over distention of bladder

o Reflex or upper motor neuron bladder/UMN bladder

  Reflex activity of the bladder may occur after spinal shock resolves
 Bladder is unable to store urine very long and empties voluntarily
 Failure to store (Incontinence)
 Lesion: Above sacral Micturition Center (above S2)
 Management:

 Intermittent catheterization every 4 hours and gradually progresses to every 6 hours

 Regulate fluid intake to 1800-2000 ml/day
 Bladder taps àto cause reflex emptying of the bladder

 Autonomic dysreflexia

 Rise in blood pressure; sometimes to fatal levels

 Reflex response to stimulation of the sympathetic nervous system
 Occurs in clients with cord lesions above T6
 Symptoms: severe headache, hypertension, bradycardia, sweating, goose bumps, nasal congestion,
blurred vision, convulsions.
 Interventions:

 Raise client to sitting position to decrease BP

 Check for source of stimulus (bladder, bowel, skin)
 Remove offending stimulus (e.g reposition client, catheterize client, digitally remove impacted feces)
 Monitor BP
 Administer hypertensive as ordered

Meningitis

 Inflammation of the meninges, the protective membrane that surround the brain and spinal cord
 Classified as Aseptic or Septic
 Complications include visual impairment, deafness, seizures, paralysis, hydrocephalus (communicating), and septic
shock
 Aseptic Meningitis

o Bacteria are not the cause of the inflammation

o Causes – blood, or brain abscess

 Septic meningitis

o Meningitis caused by bacteria

o Causes: Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae

Clinical Manifestations:

 Initial signs: Headache & fever

 Nuchal rigidity (stiff neck)

o Flexion of the head are difficult because of spasms in the muscles of the neck

 Positive Kernig’s sign

o When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended

 Positive Brudzinski’s sign

o When the patient’s neck is flexed, flexion of the knees and hips is produced; when passive flexion of the lower
extremity of one side is made, a similar movement is seen in the opposite extremity
 Photophobia

o Extreme sensitivity to light

 Rash

o Striking feature of the meningitidis infection

 Disorientation and memory impairment

 Lethargy, unresponsiveness, and coma may develop as illness progresses
 Seizures and increased intracranial pressure
 Opisthotonos:

o Head and heels bent backward and body arched forward. Sign of meningeal irritation.

Diagnostic tests

 Lumbar puncture for CSF analysis

Nursing Interventions

 Monitor vital signs and neuro checks frequently

 Provide nursing care for increased ICP, seizures, and hyperthermia if they occur
 Protect the patient from injury secondary to seizure activity or altered level of consciousness
 Provide bed rest; keep room quiet and dark if client has headache or photophobia
 Maintain fluid and electrolyte balance
 Prevent complication of immobility
 Penicillin antibiotics (e.g. ampicillin, piperacillin) or cephalosporins (eg. Ceftriaxone sodium, cefotaxime sodium) IV as
ordered
 Dexamethasone for acute bacterial meningitis and pneumococcal meningitis
 Prevention: Rifampicin, ciprofloxacin, or ceftriaxone sodium

Degenerative Diseases

 Drug induced, trauma, toxins, atherosclerosis and arteriosclerosis, autoimmune, viral infection

Multiple Sclerosis

 An immune-mediated progressive demyelinating disease of CNS

 Demyelination refers to the destruction of myelin, the fatty and protein material that surrounds certain nerve fibers in
the brain and spinal cord
 Typically present in young adults 20-40
 Affects women more than men

Diagnostic Test

 CSF studies: increased protein and IgG (immunoglobulin)

 MRI: shows areas of demyelination

Manifestations:

 1stsx: visual disturbances: blurred vision, scotomas  Impaired cerebellar function: ataxic gait, nystagmus,
(patchy blindness), diplopia dysarthria
 Impaired sensation: touch, pain, temperature, or  Euphoria or mood swings
position sense; Paresthesia  Bladder: retention or incontinence
 Impaired motor function: weakness, paralysis,  Constipation
spasticity  Sexual impotence in the male
Nursing Interventions

 Promote optimum mobility

o Muscle stretching and strengthening exercises

o Walking exercises to improve gait: use wide-based gait
o Assistive devices: cane, walker, rails, wheelchair as necessary

 Prevent injury related to sensory problems

o Test bath water with thermometer

o Avoid heating pads, hot-water baths
o Inspect body parts frequently for injury
o Make frequent position changes.

Medications

 Immunosuprpesant and corticosteroids!

 ABC and R drugs

o Avonex (Beta 1a)

 Given by intramuscular injection once a week; reduce T-cell proliferation

o Betaseron (Beta 1b)

 Administered subcutaneously every other day; reduce T-cell proliferation

o Copaxone (Glatiramer acetate)

 Administered by subcutaneous injection everyday; reduces the relapse rate

o Rebif

 Administered subcutaneously three times a week; for the treatment of relapsing MS

o For acute exacerbations: corticosteroids

 To reduce edema at sites of demyelinization

 For spasticity: baclofen (Lioresal), dantrolene (Dantrium), diazepam (Valium)

Myasthenia Gravis

 An autoimmune disorder affecting the myoneural junction, is characterized by varying degrees of weakness of the
voluntary muscles
 Women are affected more frequently
 Wome (20-40 years of age)
 Men (60-70 years of age)

Assessment Findings:

 The first noticeable symptoms of myasthenia gravis may be weakness of the eye muscles, difficulty of swallowing, or
slurred speech.
 Weakness of the muscles of the face and throat
 Ptosis (drooping of eyelids), diplopia (double vision), dysphagia (inability to swallow)
 The hallmark of myasthenia gravis is muscle weakness that increases during periods of activity and improves after
periods of rest
 Blank facial expression
 Laryngeal involvement produces dysphonia (voice impairment)

Diagnostic Test

 Tensilon test: IV injection of Tensilon (Edrophonium chloride) 2 mg at a time to a total of 10 mg provides spontaneous
relief of symptoms 30 seconds after injection (lasts about 5 mins)

Medications

 Anticholinesterase drugs

o Neostigmine bromide (Prostigmin), pyridostigmine bromide (Mestinon)

o Block action of cholinesterase and increase levels of acethylcholine at the neuromuscular junction
o Side effects: excessive salivation, abdominal cramps, nausea and vomiting, diarrhea, fasciculations (muscle
twitching)

 Corticosteroids: prednisone

o Used if other drugs are not effective

o Suppress autoimmune response

Plasmapheresis

 A technique used to treat exacerbations

 The patient’s plasma and plasma components are removed through a centrally placed large-bore double-lumen
catheter.
 The blood cells and antibody-containing plasma are separated; then the cells and a plasma substitute are reinfused.

Thymectomy

 Surgical removal of the thymus gland

 Can produce antigen-specific immunosuppression and result in clinical improvement
 Thymus glands plays an important role in the development of the immune system

Nursing Interventions:

 Administer anticholinesterase drugs as ordered.

 Give medications exactly on time
 Give with milk and crackers to decrease GI upset
 Monitor effectiveness of drugs: assess muscle strength and vital capacity before and after medication.
 Observe for side effects
 Promote optimal nutrition.
 Meal times should coincide with the peak effects of the drugs: give medications 30 minutes before meals.
 Check gag reflex and swallowing ability before feeding.
 If the client has difficulty chewing and swallowing, do not leave alone at mealtimes
 Keep emergency airway and suction equipment nearby
 Monitor respiratory status frequently: rate, depth; vital capacity; ability to deep breathe and cough
 Observe for signs of myasthenic or cholinergic crisis

Myasthenic Crisis

 Abrupt onset of severe, generalized muscle weakness with inability to swallow, speak, or maintain respirations
 Caused by undermedication, physical or emotional stress, infection
 Symptoms will improve temporarily with Tensilon test
Cholinergic crisis

 Symptoms similar to myasthenic crisis and, in addition, the side effects of anticholinesterase drugs (e.g. excessive
salivation and sweating, abdominal cramps, nausea and vomiting, diarrhea, fasciculations)
 Caused by overmedication with the cholinergic/anticholinesterase drugs
 Symptoms worsen with Tensilon test

Guillain Barre Syndrome

 An autoimmune attack of the peripheral nerve myelin

 Usually triggered by an acute infectious process

Clinical Manifestations

 Begins with muscle weakness and diminished reflexes of the lower extremities
 May result in quadriplegia (paralysis of all limbs)
 Demyelination of the nerves that innervate the diaphragm and intercostal muscles results in neuromuscular
respiratory failure
 Paresthesias of the hands and feet and pain
 Dyskinesia (inability to execute voluntary movements)
 Optic nerve demyelination may result in blindness
 Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in an inability to
swallow or clear secretions.
 Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system.

Nursing interventions

 Maintain respiratory function

 Enhance physical mobility

o Prevent DVT
o Position and paddings over bony prominences

 Monitor for life-threatening complications

Parkinson’s Disease

 A slow progressive neurologic movement disorder that eventually leads to disability

 Affects men more frequently than women
 Neurons that make a chemical called dopamine die or do not work properly

Assessment

 Tremor  Masklike face with decreased blinking of eyes

 Mainly of the upper limbs  Soft, slurred, low-pitched, and less audible speech
 “pill-rolling” (Dysphonia)
 Resting tremor; most common initial symptom  Depression, dementia
 Increased salivation, drooling
 Rigidity: cogwheel type  Shrinking, slow handwriting (micrographia)
 Bradykinesia: slowness of movement  Autonomic symptoms:
 Fatigue
 Stooped posture; shuffling, propulsive gait  Excessive sweating
 Difficulty rising from sitting position  Constipation
 Decreased sexual capacity
Medications:

 Antiparkinsonian: Levodopa (Dopar, Larodopa)

 Increases level of dopamine in the brain; relieves tremor, rigidity, and bradykinesia
 The beneficial effects of levodopa are most pronounces in the first few years of treatment
 Confusion, hallucinations, depression, and sleep alterations are associated with prolonged use
 Administer with food or snack to decrease GI irritation
 Usually given in combination with carbidopa
 Carbidopa (Sinemet)
 Prevents breakdown of dopamine in the periphery and causes fewer side effects
 Antiviral: Amantadine (Symmetrel)
 Used in early/mild cases to reduce rigidity, tremor, and bradykinesia
 Act by releasing dopamine from neuronal storage sites
 Anticholinergic: Benztropine mesylate (Cogentin); procyclidine (Kemadrin)
 Inhibit action of acetylcholine
 Used in mild cases or in combination with Levodopa
 Relieve tremor and rigidity
 Dopamine agonist: Bromocriptine mesylate (Parlodel)
 Stimulates release of dopamine in the substantia nigra
 Often employed when Levodopa loses
 Tricyclic antidepressants
 Given to treat depression
 Typically prescribed because of its anticholinergic and antidepressant effect
 Antihistamines
 Have mild central anticholinergic & sedative effects & may reduce tremors

Nursing Interventions

 Provide a safe environment

 Side rails on bed; rails and handlebars in toilet, bathtub, and hallways
 No scatter rugs
 Hard-back or spring-loaded chair to make getting up easier
 Provide measures to increase mobility
 Physical therapy: active and passive ROM exercises; stretching exercises; warm baths
 Assistive devices
 Improve communication abilities: instruct client to practice reading aloud to listen to own voice and enunciate each
syllable clearly
 Maintain adequate nutrition
 Cute food into bite-sized pieces
 Provide small frequent feedings.
 Allow sufficient time for meals; use warming tray