COLLEGE OF NURSING

EAST COAST INSTITUTE OF MEDICAL SCIENCES

KEY NOTES ON
NURSING MANAGEMENT OF PATIENTS WITH NEUROLOGICAL DISORDERS
Neurological disorders involve the brain, spinal cord, peripheral roots, nerves and the muscles.
1. ALTERED LEVEL OF CONSCIOUSNESS
(UNCONSCIOUSNESS/ COMA)
DEFINITION
Unconsciousness or coma is defined as persistent loss of consciousness in which subject lies with eyes
closed and shows no understandable response to external stimulus.
Obtunded consciousness or clouding of consciousness means just reduced wakefulness or alertness.
Stupor is defined as coma-like (sleep-like) state in which the patient responds to external stimuli and shows
symptoms of resentment when stimulated by pin-prick or loud noise, such as clapping of hands.
Drowsiness means sleep-like state from which patient can be aroused easily by noise or touch.
Confusion is a state of reduced mental clarity.
Disorientation has been called ‘acute confusion’.
CAUSES
i) Metabolic disturbance
 Drug over dosage and poisoning
 Diabetes mellitus
 Hyponatremia, hypernatremia, hypocalcaemia, hypercalcemia
 Metabolic acidosis
 Hypopituitarism, hypothyroidism
 Renal failure, hepatic failure, respiratory failure
 Hypothermia, hyperpyrexia
ii) Trauma head
 Brain haemorrhage or hematoma
iii) Cerebrovascular disease
 Hypertensive encephalopathy
 Brain haemorrhage
 Cerebrovascular accident (CVA)
iv) Infections of brain
 Meningitis
 Cerebral abscess
 Encephalitis
v) Other causes
Example: status epilepticus, brain tumour
vi) Psychogenic
Example: hysteria
DIAGNOSTIC TEST
 Skull X-ray
 EEG

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  Cerebral angiogram
 MRI
NURSING MANAGEMENT
a) Nursing assessment
 Glasgow coma scale
 Vital signs
 General physical examination
 Neurological examination
 Brainstem reflexes- doll’s head reflex
 Caloric test
b) Nursing first-aid
EXAMINE ACTION
 Airway Clear, intubate, if necessary
 Pulse Perform CPR, if appropriate
 Pupils (fixed, dilated) Look for signs of brain death
 Drug over dosage or poisoning Induce vomiting, if appropriate
 For presence of head injury If head injury present, anticipate
deterioration
 Place the client in semi-prone position.
 Loosen clothing around neck, waist and chest. Turn the head to one side to prevent fall of tongue
and risk of asphyxia. In case of neck injury, keep the neck straight, chin forward, clean the mouth
and remove artificial denture, if any.
 Give nothing by mouth to prevent aspiration.
 Disperse the crowd around the patient so that patient breathes fresh air.
 Observe the level of consciousness after every 15 minutes.
 Summon the doctor or shift the patient to hospital.

c) Nursing management in hospital

 An oropharyngeal airway and IV access are done to maintain breathing & to administer fluids
and drugs
 Keep extremities and joints in functional position to prevent foot drop, wrist drop, contractures.
Passive exercises & turning to either side after every 2 hours are necessary to prevent
complications
 Care of the skin: sponging, frequent turning of the patient, removal of rings & other belongings
and avoidance of pressure sores by special mattresses
 Mouth care (oral hygiene): frequent mouth cleaning, teeth brushing & suction. Remove
dentures if worn.
 Care of the eyes: tapping of the lids, prevention of ulceration by eye cover, irrigation
 Feeding and fluids: given through Ryle’s tube/ IV fluids. Maintain intake & output chart.
Lateral position (with lower leg straight & upper leg flexed) to prevent aspiration
 Diet: liquid diet through Ryle’s tube
 Care of the bladder & bowel: catheterization/condom drainage to avoid bed wetting; enema
or evacuation by rectum to avoid constipation, if necessary
 Monitor vital signs

2. INCREASED/RAISED INTRACRANIAL PRESSURE (ICP)

Increased intracranial pressure is a rise in the pressure inside the skull.

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The normal CSF pressure is 50-200mm of H2O.
Normal intracranial pressure is 5 to 15 mm Hg, more than this is called raised intracranial pressure.
ETIOLOGY

Space-
Cerebral Hydrocephalus
occupying
oedema
lesions

CAUSES
1) Venous obstruction
 Intracranial infection (example- meningitis)
 Head trauma, cerebrovascular accidents (CVA)
2) Haematological disorders
 Iron deficiency anaemia, pernicious anaemia
 Thrombocytopenia
3) Endocrine & metabolic dysfunction
 Diabetic coma
 Hepatic coma
 Menarche/ pregnancy
 Obesity
 Oral contraceptives
 Withdrawal of steroids
4) Drug induced
 Tetracycline
 Nalidixic acid
 Penicillin

5) Miscellaneous
 Benign raised ICP
 Hypervitaminosis A
 Galactosaemia
CLINICAL FEATURES
 Headache- frequent & severe in early morning
 Vomiting- projectile, not associated with nausea & relieves headache
 Papilledema- in severe cases, causes blurring of vision & blindness
 Deterioration of consciousness- apathy, clouding of consciousness, stupor & coma
 Disturbed breathing- initially there is slow & deep breathing. Later, it becomes cheyne-stokes
breathing
INVESTIGATIONS
1. Skull x-ray
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 2. CT scan of skull
3. MRI scan
4. Intracranial pressure measurement & monitoring
TREATMENT
i. Treat underlying cause
 find the cause & remove it, example- CSF diversion for hydrocephalus, drainage of an abscess,
removal of clot or cyst or a tumour
ii. Symptomatic medical treatment
 IV infusion of mannitol (20%)
OR
Frusemide (20-40 mg IV)
 Corticosteroids (dexamethasone 10-20mg/day) provide relief from brain edema
 Oral glycerol (thrice a day) or IV glycerol (10%)
 Emergent treatment of increased ICP is intubation & hyperventilation which causes
vasoconstriction & reduces cerebral blood volume
 Carbonic anhydrase inhibitor (acetazolamide)
 Finally, high dose barbiturate or hypothermia are sometimes used for refractory cases
iii. Surgical measures
 Ventricular drainage- (lumbar drainage)
 Long- term drainage procedure- example: ventriculo-peritoneal shunt (VP shunt)
NURSING MANAGEMENT

GOAL: IDENTIFY AND TREAT THE CAUSE OF INCREASED ICP

 Nursing assessment- Glasgow coma scale, signs of trauma/drug over dosage/diabetes, meningitis,
encephalitis
 The initial emergency nursing management includes-
 Patent airway, give O2 through mask
 Procure IV line and start fluids
 Elevate the head of the bed or position the patient to one side to prevent aspiration
 Emergency biochemical investigations (urea, sugar, electrolytes, blood gas analysis, etc.)
 Treat the cause:
Diabetes IV insulin
Narcotic over dosage Naloxone
Wernicke’s encephalopathy Thiamine
 Monitor vital signs, level of consciousness, O2 saturation, ECG, pupils (size & reaction)
& blood gas analysis
 Plan gastric lavage if poisoning is suspected
 Anticipate the need for intubation if there is respiratory depression and gag reflex is absent
Ongoing nursing management-

GOALS
 Maintenance of airway, breathing, fluid & electrolyte balance, nutrition,
normothermia, etc.
 Lowering of ICP
 ICP monitoring

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 Optimal position of the head (elevation of the head to 30o with head in neutral position to reduce
cerebral edema)
Monitoring- vital signs, level of consciousness, intake & output, oximetry, pupils (size & reaction)
& blood gas analysis
Monitor signs of symptoms of cerebral edema
Promote rest & comfort
o Calm & quiet environment
o Bed with side rails
o Medication for pain, seizures
Maintain normothermia
o Maintain room temperature
o Tepid sponging for hyperthermia
o Give fluids at normal temperature
Adequate ventilation/respiration
o Patent airway & O2 therapy
o Head end elevation to 30o
o Frequent suctioning
Maintain fluid & electrolyte balance
o Intake, output chart
o Give fluids slowly monitoring Central Venous Pressure (CVP). Avoid dehydration/ over
hydration
o Correct & monitor electrolytes
o Keep the systolic BP between 100-160mm Hg
Reduce ICP and cerebral edema
o Avoid precipitating factors- violent coughing, sneezing, straining at stools or urination, etc.
o Drug therapy- diuretics, mannitol, steroids & glycerol
o Hyperventilation, hypothermia can be used
o Diversion of CSF
3. INTRACRANIAL SURGERY
A surgical opening into the skull is known as craniotomy.
INDICATIONS
i. Brain abscess
ii. Hydrocephalus
iii. Intracranial tumours
iv. Intracranial bleed
v. Fractures of the skull
vi. Arteriovenous malformation
vii. Intracranial aneurysm
TYPES
1. Burr hole: it is a hole made in the cranium with the help of a drill. It is employed to drain fluid or
blood beneath the duramater
2. Craniotomy: it is defined as opening of the cranium surgically with the help of bone flap & dura is
opened. This is used to remove tumour, foreign body, for debridement of damaged area, drain blood
& to relieve raised ICP
3. Craniectomy: excision of portion of cranium

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 4. Cranioplasty: repair of cranial defect
5. Shunt procedures: these are diversional procedures done to divert CSF from one area to another
using a tube or device (example- VP shunt)
NURSING MANAGEMENT
A. Preoperative management
Preoperative assessment
 History collection
 Physical examination
 Baseline investigations
 Ask and record the clinical features, vital signs, level of consciousness, mental status, orientation,
pupils (size & reaction), ocular movements & cranial nerve function
 Examination of muscle power, tone, reflexes & sensations will also be recorded
Reassurance
 Encourage patient and family to verbalise fears
 Explain the procedure fully to gain confidence of the patient
Shaving of the part
Antiseptic shampoo- night before surgery
Clarifications
 All the doubts of the patient must be clarified before the surgery (example- appearance after
surgery, dressing, etc.)
 Do not give empty promises about recovery
Completion of the record
 Complete the case file completely
 Written consent must be obtained
Premedication is to be given if advised
B. Postoperative management
 Assess neurological status & vital signs frequently
 Elevate head of bed to 30o
 Head & neck- neutral alignment
 Avoid straining- stools, coughing, etc.
 Monitor intake & output
 Monitor pulse oximetry & ABG analysis, O2 therapy
 Quiet & calm environment
 Medications- steroids, antiepileptic, analgesics, sedatives as prescribed
 Allow patient to verbalise fears
 Early ambulation is encouraged to prevent thrombophlebitis
 Observe for signs of postural hypotension such as syncope, light-headedness
4.HEADACHE
It means all aches and pain localised to the head. It is a symptom of an underlying disorder rather than a
disease itself.
TYPES
Mainly two types:

PRIMARY SECONDARY
HEADACHE HEADACHE

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1. Primary headache
It is of three types
a) Tension headache
b) Migraine or vascular headache
c) Cluster headache

a) Tension headache: it is due to emotional and physical stress. It occurs mostly in the temporal
area, forehead and backside of the head. It is also known as muscle contraction headache.
Treatment
 Narcotic analgesics
 NSAIDs
 Muscle relaxant
 Antidepressant and tranquilizers
Nursing management
 Provide reassurance to the patient
 Provide behavioural therapy to the patient
b) Migraine (Vascular Headache): a recurrent throbbing headache that characteristically affects
one side of the head. Due to spasm and over dilation of certain arteries in the brain
o Women are more susceptible than men
o It occurs in supraorbital, retro-orbital or temporal area
Signs & symptoms
 Pain on one side of the head
 Periodic attack of pain
 Photophobia
 Visual disturbance
 Nausea
 Vomiting
Treatment
 Analgesic e.g., acetaminophen
 5HT1 agonist e.g., sumatriptan (it rapidly reverses the dilation of blood vessels)
Prophylactic measures
o Restrict chocolate, alcohol, coffee, cheese, etc.
o Avoid precipitating factors such as noise, sunlight, tension, etc.
c) Cluster headache: It occurs mainly in men. It starts from eye orbit and then radiates to facial
and temporal region.
Signs and symptoms
 Throbbing pain
 Watery eyes
 Nasal congestion
Treatment
o Cold application
o Analgesics
o Antidepressants
2. Secondary headache: it occurs in case of brain tumour, meningitis, subarachnoid haemorrhage,
hypertension, etc.

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 Treatment
Treatment with secondary disease management which causes headache.
5.EPILEPSY/SEIZURES
DEFINITION
Seizure is defined as an episode of neurological dysfunction.
Epilepsy is a chronic seizures disorder with recurrent and unprovoked seizures.
Convulsions are seizures accompanied by motor manifestations (limb jerking, incontinence, etc.)
CLASSIFICATION
1. PARTIAL / FOCAL SEIZURES
The seizures starting in localised area of the brain are called partial or focal seizures

❖ Simple: they remain localised and awareness is preserved

❖ Complex: activity spreads and awareness is lost

2. GENERALISED SEIZURES
Seizures spread throughout the brain producing unconsciousness

❖ Myoclonic: muscle jerking

❖ Absence (petit mal): during an absence attack, a child stops working, looks confused, may blink or roll
up the eyeballs and fails to respond to verbal commands.

❖ Tonic-clonic (grand mal): tonic contraction of the muscles, flexion of arms, extension of legs lasting for
10-30 seconds followed by a clonic phase where there is frothing of the mouth, violent jerking of face and
limbs, biting of the tongue and incontinence of urine and faeces. This phase lasts for 1-5 minutes.
CAUSES
 CNS infection- encephalitis, meningitis, brain abscess
 Head injury/ trauma
 Brain tumour
 Idiopathic
 Familial
 Hypoglycaemia
 Cerebral palsy
PRECIPITATING FACTORS
 Insomnia
 Flashes of bright light
 Loud noise
 Stress
 Pyrexia
 Infection
 Alcohol ingestion or withdrawal
 Drugs
 Physical or mental fatigue

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PHASES
a. Prodromal phase: This phase usually starts a few hours or even days before the actual seizure.
Symptoms include insomnia, headache, irritability, ill-temper, increased agitation and depression.
b. Aura: It is the beginning of the seizure, usually lasts a few seconds to a few minutes. There may be
feelings of extreme fear, sensations in the stomach, dreamlike experiences, unpleasant smells.
c. Ictal stage: This is the actual seizure.
d. Post ictal stage: This is the phase following a seizure. This phase may be brief or last several hours or
even days. There may be severe tiredness, irritability, vomiting, confusion and balance problems.
Speech, behaviour, and emotions may be altered.
CLINICAL FEATURES
 Jerky movements of limbs
 Head ache, vertigo
 Restlessness
 Biting of tongue during seizure
 Urine and faecal incontinence
INVESTIGATIONS
 Liver function tests for hepatic encephalopathy
 EEG
 CT scan
 MRI scan
MANAGEMENT
First aid treatment of a seizure:
 Move the patient to a safer place
 Loosen clothes around the neck
 Prevent tongue biting by putting the tightly rolled handkerchief or a piece of cloth into the mouth
 After a convulsion ceases, turn the patient into semi-prone position and make the air passage clear
Drug therapy:
 Valproate
 Phenytoin
 Carbamazepine
 Clonazepam
Precaution for epileptics:
 Work or recreation near open fires or operation of dangerous machinery should be avoided
 Patient should not lock the bathroom doors
 Cycling, swimming, mountaineering should be discouraged until at least 6 months seizure free
period has been achieved with treatment. Later on, these activities may be allowed in the company of
someone
 Patient is allowed if he/she has not experienced any fit for the last one year (on or off medicines)

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NURSING CARE PLAN

6.STATUS EPILEPTICUS
It is a condition in which a seizure that lasts longer than 5 minutes or having more than one seizure within a
5-minute period without returning to a normal level of consciousness between episodes
CAUSES
 CNS infection- encephalitis, meningitis, brain abscess
 Head injury/ trauma
 Brain tumour
 Idiopathic
 Familial
 Hypoglycaemia
 Cerebral palsy
PRECIPITATING FACTORS
 Insomnia
 Flashes of bright light
 Loud noise
 Stress
 Pyrexia
 Infection
 Alcohol ingestion or withdrawal
 Drugs
 Physical or mental fatigue
CLINICAL FEATURES
 Jerky movements of limbs
 Head ache, vertigo
 Restlessness

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  Biting of tongue during seizure
 Urine and faecal incontinence
INVESTIGATIONS
o Liver function tests for hepatic encephalopathy
o EEG
o CT scan
o MRI scan
MANAGEMENT
A. Immediate:
▪ Move the patient to a safer place
▪ Loosen clothes around the neck
▪ Prevent tongue biting by putting the tightly rolled handkerchief or a piece of cloth into the mouth
▪ After a convulsion ceases, turn the patient into semi-prone position and make the air passage clear
▪ Secure intravenous access
▪ Give diazepam 10mg IV OR lorazepam 4mg IV
▪ Transfer the patient to intensive care unit for monitoring
B. Pharmacological treatment
Regardless of the response to diazepam/ lorazepam:
 Phenytoin IV infusion o
 Phenytoin IV infusion OR fosphenytoin IV infusion OR phenobarbitone IV infusion
If seizures continue:
 Start treatment with intubation and ventilation
 General anaesthesia using propofol or thiopental
HEALTH EDUCATION

❖ Use relaxation therapy to reduce seizures

❖ Avoid alcohol intake, fatigue and insomnia

❖ Avoid precipitating/provoking factors

❖ Educate the patient about the first aid treatment and its importance

❖ Advice the patient and family to follow do’s and dont’s in epilepsy

❖ Advice to shift the patient to the hospital if status epilepticus develops

❖ Advice regular follow up

Do’s:
• Regular physical exercise
• Regular medication
• Regular follow-up

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• Consult the doctor
• Precaution to prevent seizure
Dont’s:
o Stress/fatigue
o Alcohol/substance abuse
o Activities that provoke seizure
o Fire/fire works
7.CEREBROVASCULAR ACCIDENT (CVA) / STROKE
DEFINITION
CVA or stroke is an infarction of a specific portion of the brain due to insufficient blood supply.
This is due to the blockage of the major vessels supplying the brain because of haemorrhage, embolus or
thrombus. It could be an ischemic stroke or a haemorrhagic stroke.
TRANSIENT ISCHEMIC ATTACK
 It is a neurologic dysfunction that lasts for a few seconds or minutes and not more than 24 hours with
complete recovery in between.
 This is due to temporary impairment of blood flow to specific regions of the brain.
 It is a warning of occurrence of stroke
TYPES
i. Ischemic stroke - caused by a blockage of blood vessels in the brain
ii. Haemorrhagic stroke – caused by rupture of blood vessels in the brain
CAUSES
 Cerebral thrombosis
 Cerebral embolism
 Hypertension
 Trauma
 Anticoagulants
 Bleed in a brain tumour
RISK FACTORS
 Hypertension
 Smoking
 Alcohol
 Oral contraceptives
 Old age
 Diabetes mellitus
 Obesity
 Sedentary lifestyle
 Hyperlipidaemia
CLINICAL MANIFESTATIONS
o Headache
o Seizure

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 o Retinal haemorrhage
o Vertigo
o Fever
o Disorientation
o Weakness
o Reflex changes
o Depression
o Vomiting
o Epistaxis
o Motor and sensory disturbances
o Stiff neck
o Confusion
o Memory impairment
o Language disorder
o Numbness

DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 CT scan
 PET scan
 CSF examination
 MRI
 Echoencephalography
MANAGEMENT
The management is done with the following aims:
1) To save life and speed up recovery
2) Minimising deformity
3) Reducing ICP
4) To prevent recurrence
5) To remove the cause, if possible
GENERAL MEASURES
 Ventilation:
o Maintain airway to prevent aspiration
o Suction secretions
o O2 administration if necessary
 Fluid & electrolyte balance
Restriction of fluid intake during first 2-3 days or even a negative balance is beneficial to reduce
cerebral oedema
 Reduction of cerebral oedema / ICP
IV mannitol or glycerol is used
PHARMACOLOGICAL MANAGEMENT
 Mild analgesics, example- ibuprofen
 Osmotic diuretics (for oedema), example- mannitol
 Anticoagulant, example- heparin
 Antihypertensive agents, example- verapamil

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  Antiepileptic, example- phenytoin
DIETARY MANAGEMENT
 Fluid diet is given because patient is unable to swallow.
SURGICAL MANAGEMENT
 If ICP is above 30-40 mm Hg, then only surgery will be performed.
NURSING MANAGEMENT
 Emergency:
 To make the patient lie comfortably
 Ensure patient airway and O2 therapy
 Remove the dentures
 Procure IV line and start normal saline infusion. Monitor the BP
 Elevate head end of the bed to 30o. Ensure to use the side rails.
 Emergency decongestive therapy, example: mannitol or glycerol
 Monitoring of vital signs, O2 saturation, ECG, Glasgow coma scale
 Take all the measures for coma management if patient is in coma
NURSING DIAGNOSIS
 Altered cerebral tissue perfusion related to increased ICP
 Impaired physical mobility related to paralysis
 Self-care deficit related to paralysis
 Risk for injury related to paralysis
 Imbalanced nutrition less than body requirement related to inability to swallow
 Impaired verbal communication related to aphasia
PREVENTION
Managing hypertension, avoiding smoking and excessive alcohol intake.
8.HEAD INJURY
DEFINITION
Head injury is defined as trauma limited to the skull, scalp and brain tissue either singly or collectively
ETIOLOGY
 Motor vehicle accidents
 Fall
 Sports related injuries
 Gun-shot wounds, arrows
TYPES
1. Primary head injury
o Due to direct impact of trauma to the skull leading to skull fracture and injury to the brain
2. Acceleration and deceleration injuries
o Acceleration- when head is fixed and objects move
o Deceleration- when head is moving and objects are fixed

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3. Rotational injuries
o It is the result of a rapid change of the rotational velocity of the head
4. Coup-contracoup injuries
o Dual injuries- at the point of injury and opposite to direct force of impact
5. Penetrating injuries
o Foreign bodies (knives or bullets)
6. Scalp injuries
o These injuries can cause brain injuries (contusion, laceration, hematoma formation)
o Scalp injuries are associated with profuse bleeding due to rich blood supply
7. Skull injuries
o Fracture of the skull- linear, depressed, simple or comminuted
CLINICAL MANIFESTATION
 CSF or blood draining from the ear or nose
 Loss of sense of smell, visual and hearing loss, change in pupils, vertigo, nystagmus
 Periorbital ecchymosis (bruising around the eyes)
 Increased intra cranial pressure- Headache, Vomiting, Blurred vision
9.BRAIN INJURY
Traumatic brain injury (TBI) also known as head injury, is the disruption of normal brain function due to
trauma-related injury
TYPES
I. Minor brain injury/ concussion:
 There is no break in the skull or dura
 There is a sudden jolt to the brain structure leading to disturbance of neural activity resulting in loss
of consciousness for few minutes to hours
 The CT scan and MRI scan are normal
II. Major brain injury/ contusion:
 Contusions and lacerations of the brain are major injuries that result from blunt trauma
 There is bruising of the brain tissue
Clinical manifestation
i. Concussion:
 Nausea
 Vomiting
 Headache
 Dizziness
 Loss of consciousness
ii. Contusion:
 Headache
 Agitation

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  Confusion
 Hemiplegia
 Aphasia
 Alteration in level of consciousness
 Abnormal breathing
 Pupillary abnormalities
 Abnormal posturing (flexion/extension)
 Abnormal vital functions (high temperature, rapid pulse rate and respirations, abnormal sweating,
etc.)
III. Focal injuries:
Subdural hematoma- collection of blood between dura mater and arachnoid mater
Extradural hematoma- collection of blood in between skull and dura mater
Clinical manifestation
 Drowsiness
 Unconsciousness
 Headache
 Confusion
 Disorientation
 Stupor or coma
MANAGEMENT
 Airway and ventilation
 Circulation and cerebral perfusion
 Control of intracranial pressure
MEDICATIONS
o Osmotic diuretics (mannitol)
o Anticonvulsants (phenytoin)
SURGICAL MANAGEMENT
No surgical intervention if collection is less than 10 ml
Indications for surgery:
- The GCS score decreases by 2 or more points between the time of injury and hospital evaluation
- The patient presents with fixed and dilated pupils
- The intracranial pressure (ICP) exceeds 20 mm Hg
Types:
o Burr hole
o Craniotomy
o Craniectomy
o Cranioplasty
NURSING MANAGEMENT
 Nursing assessment
ABC
GCS Score

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 Neurologic examination
Signs of elevated ICP
Signs of CSF leakage

Nursing Diagnosis:
 Altered cerebral tissue perfusion related to increased ICP
 Acute pain (headache) related to trauma/cerebral oedema
 Risk for injury related to decreased level of consciousness
10.SPINAL CORD INJURY
Spinal column is a vertebral column containing bony rings through which spinal cord passes.
The vertebral column protects the spinal cord from injury.
CAUSES & MECHANISMS OF INJURY
1. Flexion injury
2. Hyperextension injury
3. Compression injury
4. Rotational injury
CLINICAL MANIFESTATION
 Paralysis of the skeletal muscle below the level of injury- paraplegia, quadriplegia
 Loss of bowel and bladder tone
 Sensory loss below the level of injury as loss of sensation to pain, loss of temperature control
MANAGEMENT
 Stabilizing the spinal column by surgical or non- surgical means
 Surgical: traction, immobilization
 Non-surgical: hard cervical collar, complete immobilization of the head and neck without flexion,
extension or rotation movements
NURSING MANAGEMENT
i. Care of respiration: artificial ventilation, monitoring oxygen saturation, maintaining airway clearance
by suction
ii. Nutrition: feeding through Ryles tube to prevent aspiration
iii. Care of the bladder & bowel: catheterization, constipation & faecal impaction must be avoided by
increasing fluids through Ryles tube, laxatives or stool softeners as needed
iv. Skin care: care of the pressure points, use of air or water mattress, use of comfort devices such as
pillows, foot board to prevent foot drop and splints to prevent wrist drop
v. Prevention of injury: use side-rails, call bell system, keep personal items within the reach of the
patient
vi. Promote physical mobility: range of motion 3-4 times a day
vii. Prevent thrombophlebitis & deep vein thrombosis (DVT): use of anti-embolism stockings,
administer heparin subcutaneously, assess for signs of clot formation (redness, swelling, warmth) in
the lower extremities
viii. Promote comfort & reduce pain: administer analgesics
11.MENINGITIS
It is defined as the inflammation of the protective membranes covering the brain & spinal cord collectively
known as meninges

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CAUSES
 Neisseria meningitides
 Haemophilus influenza
 Pneumococci
 Streptococcus pneumonia
CLINICAL MANIFESTATIONS
 Brudzinski’s sign: when the patient is in supine position and on lifting the head rapidly, a forward
neck flexion leads to flexion of hips, knees and ankles
 Kernig’s sign: severe stiffness of the hamstring muscles causes an inability to straighten the leg when
the hip is flexed to 90 degrees.
 Other manifestations: fever, headache, chills, nausea and vomiting, irritability, confusion, semi-
comatose
DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 Lumbar puncture
 CT scan
 MRI
MANAGEMENT
Medical management:
 Antimicrobial therapy- ceftriaxone, cefotaxime
 Antibiotics- penicillin, ampicillin
 Antiviral- acyclovir
 Symptomatic drugs- antipyretics, analgesics, anti-emetics, anticonvulsants
Nursing management:
o Reduce fever
o Monitor the level of consciousness
o Monitor fluid and electrolyte balance
o Nutritional status is promoted and maintained by intravenous fluids
o Condom drain or catheter to promote voiding
o Risk for seizures and injury are managed by continuous monitoring of the patient foe signs of
increased intracranial pressure (ICP)
o Provide rest by avoiding noise and stimuli that increase ICP, administering injection mannitol
o Administer tablet eptoin to reduce the risk of seizures
12.BRAIN ABSCESS
A brain abscess is a collection of pus enclosed in the brain tissue, caused by a bacterial or fungal infection.
ETIOLOGY
 Penetrating or traumatic brain injury
 Intracranial surgery that can lead to infection
CLINICAL MANIFESTATIONS
 Headache
 Lethargy
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  Fever
 Chills
 Drowsiness
 Confusion
 Depressed mental status
 Increased ICP
INVESTIGATIONS
o CT scan
o MRI scan
MANAGEMENT
 Penicillin
 Corticosteroids to decrease cerebral oedema
13.ENCEPHALITIS
Encephalitis is the inflammation of the brain parenchyma
CAUSES
 Lead, arsenic or carbon monoxide toxicity
 Infection- typhoid, measles, chickenpox
 Viral- arbo virus, herpes simplex
SIGNS AND SYMPTOMS
 Fever
 Confusion
 Aphasia
 Involuntary movement
 Nausea
 Vomiting
 Stiffness of neck
 Motor weakness
 Memory loss
 Seizures
 Stupor & coma
 Headache
 Photophobia
 Increased ICP
 Ataxia
INVESTIGATIONS
- CSF examination
- EEG
- CT scan
- MRI scan
- Serology test
MANAGEMENT
 Antiviral drug- acyclovir
 Diuretics to reduce ICP

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  Anticonvulsant for seizures
Nursing intervention:
 Assess level of consciousness, vital signs and neurological parameters frequently.
 Maintain a quiet, calm environment to prevent agitation, which may cause an increased ICP.
 Injury prevention and safety in case of seizures
 Provide psychotherapy
 Provide health education
 Other general care which are required in neurological disease
14.MULTIPLE SCLEROSIS
It is a progressive degenerative disease that affects the myelin sheath of neurons in the central nervous
system.

CAUSES
 Unknown
 Autoimmune dysfunction
 Infectious process
SIGNS & SYMPTOMS
 Fatigue and weakness
 Tingling sensation (paresthesia)
 Vision loss
 Incoordination
 Bowel and bladder dysfunction
 Impaired speech
 Abnormal reflexes
DIAGNOSTIC EVALUATION
 Physical examination
 MRI
 Electrophoresis study
MANAGEMENT
 Corticosteroids therapy
 Alkylating agents (example- Cyclophosphamide)

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  Use of interferon beta-1a (avonex) and interferon beta-1b (betaseron)
15.MYASTHENIA GRAVIS
It is an autoimmune disease with muscular weakness and fatigue that worsens with exercise and improved
with rest

ETIOLOGY
 Unknown
 Loss of acetylcholine receptors in the post synaptic neurons of the neuromuscular junction
 Ageing factors
CLINICAL MANIFESTATIONS
o Drifting (slow or aimless movements)
o Ocular symptoms (ptosis, diplopia)
o Facial muscle weakness
o Dysphonia
o Chewing and swallowing muscles weakness
o Dysphagia
o Respiratory muscles weakness

DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 Electromyography
 Serum test for acetylcholine receptor antibodies
 CT scan
MANAGEMENT
 Anticholinesterase agents
 Corticosteroids
Surgical management:
Thymectomy: removal of the thymus gland
Nursing diagnosis:
 Fatigue related to disease process
 Risk for aspiration related to muscle weakness of face and tongue
 Social isolation related to diminished speech capabilities
16.GUILLAIN-BARRE SYNDROME
Guillain-Barre syndrome (GBS) is an acute rapid disease with progressing, ascending, inflammatory
demyelinating polyneuropathy of peripheral sensory and motor nerves
ETIOLOGY
 Unknown
 Upper respiratory tract infection
 Gastro-intestinal infection
 HIV

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CLINICAL MANIFESTATION
 Weakness
 Paresthesia
 Dyskinesia
 Quadriplegia
 Areflexia
 Ascending weakness
 Pupillary disturbances
 Difficulty in talking, chewing and swallowing
DIAGNOSTIC EVALUATION
o History collection
o Physical examination
o CSF examination
o Electromyography
o Nerve conduction studies

MANAGEMENT
 There is no cure
 Supportive care
 Oxygen administration
 Prevention of infection
 Analgesics and muscle relaxants
17.PARKINSON’S DISEASE
Parkinsonism is a chronic, progressive neurologic disease affecting the basal ganglia of the brain that leads
to deficiency of neurotransmitter dopamine. It is characterized by muscle weakness, rigidity, tremors and
bradykinesia.
RISK FACTORS
 Age factors
 Deficiency of dopamine
 Atherosclerosis (cerebral)
 Diabetes
 Hyperlipidaemia
SIGNS & SYMPTOMS
 Tremor
 Rigidity
 Bradykinesia
Others:
 Mask-like facial expression
 Dysphagia
 Decreased sexual capacity
 Gait changes
 Sleeplessness
 Salivation
 Sweating

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  Mental disturbances
 Dementia
 Depression
 Dysarthria
 Head bent forward

DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 CT scan
 MRI scan
 Mental status examination
MANAGEMENT
Pharmacological:
 Levodopa
 Carbidopa with levodopa
 Anticholinergic drugs
 Avoid vitamin B6
Nursing management:
- Health assessment
- Provide stool softeners
- Provide ROM exercises daily
- Maintain fluid intake
- Provide emotional support to family
- Physical therapy
- Rehabilitation technique
Nursing diagnosis:
 Impaired physical mobility related to akinesia
 Self-care deficit related to muscle weakness
 Altered nutrition related to dysphagia
18.ALZHEIMER’S DISEASE
It is a chronic, irreversible disease that affects the cells of the brain and causes impairment of intellectual
functioning.
It usually affects people above 85 years of age
ETIOLOGY & RISK FACTORS
 Unknown
 Down’s syndrome
 Family history
 Chronic hypertension
 Head injury
 Smoking and drinking
SIGNS & SYMPTOMS

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 - Memory loss
- Difficulty in performing familiar tasks
- Language problems
- Disoriented to time and place
- Misplacing things
- Confusion
- Disturbance in short-term memory
- Mood swings
DIAGNOSTIC EVALUATION
o Mental status examination
o CT scan
o MRI scan
o PET scan
o CSF examination
o EEG
MANAGEMENT
Pharmacological:
 Cholinesterase inhibitors
 Antidepressant drugs
 Antipsychotic drugs
 Haloperidol
Non-pharmacological measures:
 Aromatherapy
 Music therapy
 Exercise
19.TRIGEMINAL NEURALGIA
It is an uncommon cranial nerve disorder in which the fifth cranial nerve (trigeminal nerve) is involved.
CAUSES
o Nerve compression
o Infection of the teeth and jaw
o Herpes virus infection
CLINICAL MANIFESTATIONS
 Sudden onset of excruciating pain that may be burning, knife-like, lightning-like shock in the lips,
upper or lower gums, cheeks, forehead or side of the nose.
 Twitching
 Grimacing
 Frequent blinking
 Tearing of the eye
The pain is due to triggering factors as chewing, brushing teeth, a hot or cold blast of air on the face,
washing the face, yawning or even talking.
DIAGNOSTIC EVALUATION

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  Neurological examination
 CT scan
 MRI
MANAGEMENT
Medical:
 Anti-seizure agents as carbamazepine, phenytoin and valproate to prevent acute attacks
 Nerve blocking agents and local anaesthetics for pain relief
Surgical:
 Percutaneous radiofrequency rhizotomy by placing a needle into the trigeminal rootlets adjacent to
the pons and destroying the area by radiofrequency current.
 Micro vascular decompression (MVD) of the trigeminal nerve by displacing and repositioning blood
vessels that compress the nerve at the root.
 Glycerol rhizotomy injection
 Gamma knife radio surgery
20.BELL’S PALSY
Bell’s palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial
nerve) that results in the inability to control facial muscles on the affected side.
ETIOLOGY
- Herpes simplex virus infection
- HIV infection
- Middle ear infection
CLINICAL MANIFESTATIONS
 Pain
 Fever
 Tinnitus
 Hearing deficit
 Drooping of the mouth
 Drooling
 Inability to close the eyelids
 Inability to smile or whistle
 Loss of taste
 Inability to chew
 Loss of tears or excessive tear production
DIAGNOSTIC EVALUATION
 History collection
 Physical examination
 Electromyography (EMG)
MANAGEMENT
 Corticosteroids: prednisolone to reduce oedema and pain
 Mild analgesics
 Acyclovir for herpes simplex virus infection
 Moist heat application
 Massage
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21.PERIPHERAL NEUROPATHY
Peripheral neuropathy results when trauma or a disease process interferes with innervation of the peripheral
nerves
CAUSES AND RISK FACTORS
o Hereditary
o Idiopathic
o Diabetes
o Alcohol abuse
o Autoimmune diseases
o Age
CLINICAL MANIFESTATIONS
 Depends on the affected nerves
 Commonly paraesthesia
 Weakness in arms/legs
 Pain
DIAGNOSTIC EVALUATIONS
 EMG
 Nerve biopsy
MANAGEMENT
Medical:
- Pain relievers
- Anticonvulsant drugs
- Anti-depressants
Surgery:
- Removal of tumours
Nursing:
- Physiotherapy
- Occupational therapy
22.BRAIN TUMOUR
Brain tumour is a collection or mass of abnormal cells in the brain.
CLASSIFICATION
1) Benign tumours
2) Malignant tumours
 Primary: malignancy arising from the CNS
 Secondary: malignancy metastasize to the brain
ETIOLOGY
o Age
o Family history
o Chemical exposure
o Electromagnetic fields
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 o Infections
o Head injury
CLINICAL MANIFESTATIONS
 Headache
 Seizures
 Personality/memory changes
 Nausea, vomiting
 Fatigue
 Drowsiness
 Sleep problems
 Loss of balance
 Partial or complete loss of vision
 Changes in speech, hearing, etc.
DIAGNOSTIC EVALUATIONS
o CT scan
o PET scan
o MRI scan
o Biopsy
o Lumbar puncture
o Myelogram
o Cerebral angiogram
o EEG
MANAGEMENT
 Chemotherapy
 Radiotherapy
 Surgery: removal of the mass
 Decongestive therapy (mannitol)
 Anticonvulsants for epilepsy
Nursing management:
 Implement medical treatment
 Patient teaching
 Pre-operative & post-operative management
23.SPINAL CORD TUMOURS
It is an abnormal growth (mass) of cells within or surrounding the spinal cord
TYPES
Intramedullary tumours
Intradural extramedullary tumours
Extradural spinal tumours

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CLINICAL MANIFESTATIONS
Pressure on the spinal cord may cause the following:
 Back and neck pain that progressively worsens
 Numbness, tingling and weakness or paralysis
 Decreased sensation
 Erectile dysfunction
 Loss of bladder/bowel control
 Difficulty in walking
 Muscle spasms
DIAGNOSTIC EVALUATION
- CT scan
- MRI
- Biopsy
MANAGEMENT
Goal: to reduce/prevent any nerve damage from pressure on the spinal cord
A) Surgery: removal of tumours
B) Radiotherapy
C) Chemotherapy
D) Steroids
24.HUNTINGTON’S CHOREA/DISEASE
DEFINITION
It is a progressive disorder characterized by abnormal movements (chorea), behavioural changes and
dementia.
It is an inherited neurological condition that causes breakdown of nerve cells in the brain.
CAUSES
 Unknown
 Ageing factor
 Genetic
 Increased concentration of dopamine
CLINICAL MANIFESTATIONS
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  Involuntary jerky movements (chorea)
 Emotional disturbance
 Difficulty in chewing and swallowing
 Abnormal gait
 Hallucination
 Delusions
DIAGNOSTIC EVALUATION
 CT
 MRI
 Genetic testing

MANAGEMENT
Medical:
o Haloperidol (blocks dopamine)
o Antidepressants for depression
o Anticonvulsants (valproate)

Nursing:
o Soft diet (nutritional therapy)
o Psychotherapy
o Speech therapy
o Health education to patient and family members

25.MUSCULAR DYSTROPHIES
DEFINITON
The muscular dystrophies are a group of inherited genetic conditions that gradually cause the muscles to
weaken, leading to an increasing level of disability.
DUCHENNE’S MUSCULAR DYSTROPHY
Muscles are wasted and replaced by fat, especially in calf muscles
Signs and symptoms
 Common in boys below the age of 5 years
 Falls frequently
 Wheel chair bound
Diagnostic evaluation
 EMG
Treatment
- No treatment
- Passive physiotherapy
26.HERNIATION OF THE INTERVERTEBRAL DISC
It is a protrusion of the nucleus of the disc into the annulus with subsequent nerve compression.

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CAUSES
 90% of herniated disc involve the lumbar and lumbosacral spine
 The most common site is the L4 and L5 disc space
 Flexion injury
RISK FACTORS
 Ageing
 Trauma
 Genetic
 Sedentary occupation
 Obesity
 Smoking
CLINICAL MANIFESTATIONS
 Symptoms depend on location, size
 Cervical manifestations:
- Pain and stiffness in the neck, top of shoulders and scapula
- Pain in upper extremities and head
- Paraesthesia and numbness of upper extremities
- Weakness of upper extremities
 Lumbar manifestations:
- Lower back pain
- Pain radiating from the lower back into the buttocks and down the leg (sciatica)
- Paraesthesia, weakness, reflex impairment
DIAGNOSTIC EVALUATION
 X-ray of cervical/lumbar spine
 CT contrast
 MRI
MANAGEMENT
Medical:
 Analgesics or NSAIDs for pain
Surgical:

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  Surgical decompression
Nursing:
 Physiotherapy
 Bed rest on firm mattress
 Cervical collar/immobilise the lower part of the spine (jacket) for 3 months or longer

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