CARE OF CLIENTS WITH

PROBLEMS RELATED TO
NEUROLOGICAL SYSTEM

Earl Francis R. Sumile, RN

Instructor, College of Nursing
University of Santo Tomas
Nursing Assessment

♦ Behavioral changes
♦ Loss of consciousness
♦ Memory loss
♦ Headache
Neurological Examination

♦ Level of Consciousness (LOC) – arousal;

awareness of self or environment
– Alert – fully awake; appropriate responses to
external and internal stimuli; oriented to person,
place and time
– Lethargic – somnolent, drowsy, listless,
indifferent to surroundings, very sleepy, can be
aroused from sleep but when stimulation
ceases, falls back to sleep; may be oriented or
confused
Neurological Examination

– Stuporous – unconscious most of the time but

makes spontaneous movements and response is
evoked only by a strong, continuous, noxious
stimuli; loud noises or sounds, bright light,
pressure to sternum, response is usually a
purposeful attempt to remove the stimulus
– Comatose – absence of voluntary response to
stimuli including painful stimuli; no response,
no eye opening – score of 7 or less on GCS
Glascow Coma Scale
EYE OPENING RESPONSE SPONTANEOUS 4
TO VOICE 3
TO PAIN 2
NONE 1
BEST VERBAL ORIENTED 5
RESPONSE CONFUSED 4
INAPPROPRIATE WORDS 3
INAPPROPRIATE SOUNDS 2
NONE 1
BEST MOTOR RESPONSE OBEYS COMMANDS 6
LOCALIZES PAIN 5
WITHDRAWS (PAIN) 4
FLEXION (PAIN) 3
EXTENSION (PAIN) 2
NONE 1
TOTAL 15
Neurological Examination

♦ Memory
– Recent – ability to recall immediate events
– Remote – ability to remember past events
♦ Speech
– Aphasia – impairment of language function
– Dysarthria – indistinctness of word articulation
or enunciation resulting from inference with
peripheral speech mechanisms
Neurological Examination

– Expressive (Non-fluent) aphasia – loss of

ability to express one’s thoughts in speech and
writing
– Receptive (Fluent) aphasia – impairment of
ability to comprehend spoken or written
language
– Global aphasia – expressive + receptive aphasia
Neurological Examination

♦ Motor
– Decerebrate rigidity – arms stiffly extended and
abducted with hyperpronation of arms
– Decorticate rigidity – arms, wrisht and fingers
are flexed; arms are adducted; in both, legs
fully extended and internally rotated with
plantar flexion of feet
– Paresis – impaired strength or power
– Paralysis – loss of strength
Neurological Examination

– Hemiplegia – paralysis of lateral half

– Paraplegia – paralysis of the legs
– Apraxia – inability to carry out a learned
movement on command without weakness
paralysis
♦ Sensory
– Paresthesia – abnormal sensation; distortion of
sensory stimuli; numbness, tingling sensation
– Anesthesia – absence of sensation or touch
Neurological Examination

– Hyperesthesia – pathologic over-perception of

touch
– Hypoesthesia – reduced sense of touch
– Analgesic – absence of pain
♦ Reflexes – involuntary response which
tends to be specific or fixed pattern for a
given stimuli
– Deep tendon reflexes (DTR’s) – muscle stretch
reflex; uses percussion hammer to check knee
jerk
Neurological Examination

– Patellar reflex – knee jerk

• N = contraction of quardriceps femoris muscle;
extension of the leg
– Corneal reflex (blinking)
• N = eyes blink when hand is passed across eyes
– Pupillary reaction; functioning of brainstem;
observing the size of pupil in relation to light
reflex
• N = pupil constricts when light is flashed
• Normal size of pupil 3-4 mm; <2 mm miosis; >5mm
mydriasis
Neurological Examination

• Anisocoria – unequal pupils

• Ptosis – drooping of eyelids
• Nystagmus – involuntary trembling or oscillation of
eyeball
– Oculocephalic response or doll’s eyes
• Normal if with eyes, open, turn head to right and
eyes deviate to left (conjugate or dysconjugate)
– Babinski
• Extension of great toe and fanning of other toes in
response to stroking of sole of foot; (-) plantar
flexion; (+) dorsiflexion
Neurological Examination

– Brudzinski sign
• Forward flexion of pt’s head by examiner; abn =
flexion of ankle knee or thigh
– Cremasteric = stroke medial surface of upper
thigh = elevation of scrotum and testicle
Diagnostic Procedures or Tests

♦ Cranial nerve testing

– Olfactory – smell
• Anosmia – loss of smell
• Hyposmia – impairment of smell
– Optic – vision
• Retina to brain link
• Papilledema – choked disc – swelling of optic
nerve; increased intraocular pressure
– Oculomotor – movements of eyeball and
eyelids; constriction or dilation of pupils
Diagnostic Procedures or Tests

– Trochlear – movement of eyeball – oblique

– Trigeminal – mastication, sensations of face,
nose, teeth and mouth
– Abducens – movement of eyeball – lateral
rectus
– Facial – contraction of facial and scalpmuscles;
taste
– Vestibulocochlear (auditory)
• Vestibular – equilibrium; cochlear – hearing
Diagnostic Procedures or Tests

– Glossopharyngeal – swallowing, blood

pressure, taste, oral and pharyngeal
– Vagus – pharynx, larynx, thoracic and
abdominal viscera
– Accessory – shoulder and head;
sternocleidomastoid
– Hypoglossal – tongue
♦ Lumbar puncture, spinal tap
– Subarachnoid space of spinal canal (L3-L5)
Diagnostic Procedures or Tests

– Normal opening pressure 60-180 mm H2O

– WBC 0-5 cells/mm
– Cl = 720-750 mg/ 100 ml
– Protein = 15-45 mgs/100 ml
– Glucose = 40-80 mgs/100 ml
– Xanthochromia (bleeding) – yellow color of
CSF from blood or RBC
– Pleocytosis – increased
Diagnostic Procedures or Tests

♦ Romberg test – stand with feet together,

eyes open or close; (+) if unable to maintain
erect posture
♦ X-rays CNS – spine or skull x-rays, CT
Diagnostic Procedures or Tests

♦ Cerebral angiography,
pneumoencephalography, ventriculography
contrast studies
– Cerebral Angiography – visualization of brain’s
vascular system by injection contrast dye into
the circulation blood
– Pneumoencephalography – visualization of
ventricles and subarachnoid spaces by
withdrawal of CSF and injection of air or
oxygen into subarachnoidal space through
lumbar puncture
Diagnostic Procedures or Tests

– Ventriculography – visualization of ventricles

by removal of CSF and injection of air or
oxygen directly into the ventricles through burr
holes in skull
– Myelography – x-ray examination of spinal
cord and vertebral canal following introduction
of contrast media into subarachnoid space
♦ Electroencephalography (EEG) –
– record of electrical activity of the brain
– Prep – no stimulant within 24 hrs before the procedure
– Post – hair shampoo to remove collodia (paste)
Common neurological disorders

♦ Unconsciousness
– State of depressed cerebral function in which
reaction to stimuli is lost and any response, if
present is on the reflex level
– Causes
• A Alcohol
• E Epilepsy
• I Insulin
• O Opiates
• U Urates
Unconsciousness

– Causes
• T Trauma
• I Infection
• P Psychological
• P Poison
• S Shock
– Basic mechanism – interruption of oxygen
supply and glucose supply
Unconsciousness

– Objectives of care:
• A. assess for and maintain patent airway
• B. monitor VS and neurological status
• C. maintain integrity of skin
– Bedsores class:
– Grade 1 – erythema
– 2 – dermis
– 3 – subcutaneous
– 4 – muscle
– 5 – joints and body cavities
Unconsciousness

• D. maintain joint mobility

• E. maintain sensory function
• F. maintain fluid and nutritional status
• G. maintain bladder or bowel function
• H. maintain psychosocial function
Common neurological disorders

♦ Increased intracranial pressure – intracranial

hypertension; cerebral edema
– Causes:
– A. increased inracranial blood volume
– B. increased CSF volume
– C. increased in bulk of brain tissue
– D. intracranial tumors
– E. increased production of CSF or blockage of
ventricles;
– F. decrease in absorption of CSF
Increased intracranial pressure

♦ Nursing Assessment
– A. swelling of optic disk
– B. headache, vomiting projectile
– C. decreasing level of consciousness
– D. pupillary signs – ipsilateral pupil – affected is
dilated
– E. blood pressure – increased systolic and decreased
diastolic (widening pulse pressure)
– F. decreased PR and RR
– G. respiration – cheyne-stokes
– H. temperature regulation – increased temperature
Increased intracranial pressure

♦ Nursing management:
– A. positioning – HOB elevated 15-30o
– B. activites: no coughing, sneezing or straining at stool
valsalva maneuver
– C. avoid hip, waist, neck flexion; avoid rotation of head
especialy to right
– D. space out nursing activities
– E. perform suctioning only PRN
Increased intracranial pressure

– F. IV mannitol and dexamethasone

• Monitor fluid balance
• Restrict fluids
• Urinary output
• Watch for hypotension
– G. Craniectomy to provide room for expansion
Common Neurological Disorders

♦ Seizures (Convulsions)
– Brief cerebral storms associated with sudden
excessive and disorderly electrical discharges
from the brain.
– Nursing observations:
• A. Aura – symptoms that occur during the prodome
of seizure (numbness, dizziness, yawning, smells).
Seizures

• B. During
– Never leave alone
– If standing, lower to floor to prevent injury
– Loosen constrictive clothing
– Do not restrain
– Do not pry jaw open to place padded tongue
blade
– Pad side rails; no pillows
• C. Postictal phase – normally groggy and
confused; deep sleep also follows
Common Neurological Disorders

♦ CVA or stroke or apoplexy

– Disruption in cerebral circulation resulting in motor or
sensory deficit
– Risk factors:
• A. hypertension
• B. heart disease
• C. DM
• D. hypercolesterolemia
• E. oral contraception
• F. obesity
• G. family history
CVA or stroke or apoplexy

♦ Etiology:
– A. Thrombosis – most common cause of cerebral
infarct (atherosclerosis)
– B. Embolism – increased incidence after 40 years
Common Neurological Disorders

♦ Intracerebral hemorrhage
– Within brain substance most common cause –
rupture of arteriosclerotic hypertensive vessels
– most common cause of death in CVA
– Middle cerebral artery – most common site

– Extra or epidural – outside dura mater

– Subdural – beneath dura mater
– Subarachnoid – in subarachnoid space
Intracerebral Hemorrhage

♦ Nursing Assesment:
– A. mental confusion, drowsiness, headache, transient
loss of speech, TIA, hemiplegia or paresthesias to
paralysis
– B. typical headache, vomiting, seizures, coma, nuchal
rigidity, fever, hpn, confusion disorientation
– C. Focal symptoms – weakness, paralysis, sensory loss,
language disorders, reflex changes
– D. Fatal – increased temperature, PR and RR; increased
depth of coma and collapse of vasomotor and heat
regulating centers
Intracerebral Hemorrhage

♦ Nursing management:
– A. Decrease salt diet, oxygen therapy
– B. intubation and mechanical ventilation
– C. GI decomopression, NGT
– D. Semi-fowler’s position
– E. Antacid, anticoagulants, antihpn
– F. Anticonvulsants
Intracerebral Hemorrhage
– G. intracranial surgery
• Craniectomy – portion of cranium is permanently
removed to relieve pressure on brain structures to
provide space for expansion
• Craniotomy – surgical opening into skull
– Position – not in operative site
– Superatentorial – HOB elevated at 30o
– Infratentorial – flat without head elevation to
prevent pressure on brain stem structures
Neurologic Degenerative Diseases
♦ Parkinson’s disease
– Degeneration and destruction of nerve cells of
the basal ganglia throughout the brain (loss of
dopamine – neurotransmitter with
anticholinergic effect)
– Incidence: men and women (50-60 y/o)
– Cause: unknown
– Signs and symptoms: cogwheel rigidity; pill
rolling or resting tremor; masklike appearance
of face; slow monotonous speech
Parkinson’s Disease
– Nursing management:
• Levo-dopa to increase dopamine
• Sinemet to prevent breakdown of dopamine
Neurologic Degenerative Diseases

♦ Multiple Sclerosis
– Multiple patches of demyelination or nerve
degeneration throughout the brain and spinal
cord
– Cause: unknown
– Incidence: women
– Signs and symptoms: Charcot’s triad –
nystagmus, intention tremor, scanning speech,
muscular and gait incoordination
Multiple Sclerosis
– Nursing management:
• Baclofen – to decrease spasms
• Symptomatic
Neurologic Degenerative Diseases

♦ Myasthenia Gravis
– Decreased secretion of acetylcholine or
increase in cholinesterase at the myoneural
junction leading to transmission failure
– Etiology: autoimmunity
– Incidence: young adults (women)
Myasthenia Gravis
– Signs and Symptoms:
• Muscular weakness
• Fatigue
• Ptosis
• Weight loss
• Muscle atrophy

– Diagnostic assessment: Tensilon test – injection of

Tensilon or Prostigmin and muscle weakness
disappears but comes back when medication wears off
Myasthenia Gravis
– Nursing Management:
• Anticholinesterase – prostigmin; mestimon to be
taken at specified time; before meals
– Myasthenic crisis – due to undermedication
(management – anticholenesterase)
– Cholinergic crisis – due to overmedication
(management – atropine sulfate
– Brittle crisis – receptors at neuromuscular
junciton becomes insensitive to
anticholinesterase
Myasthenia Gravis
• Avoid muscle relaxants, barbiturates,
morphine, tranquilizers and neomycin
• Avoid stress, colds and infection
• Never rush, provide rest periods
• Avoid unnecessary muscle activity