Neurological

Emergencies
REVIEW OF THE SYSTEM
Central Nervous System (CNS)
REVIEW OF THE SYSTEM
1 Central Nervous System (CNS)

2 Brain

3 Cerebrospinal Fluid (CSF)

4 Cranial Nerves

5 Peripheral Nervous System (PNS)

6 Spinal Cord

7 Autonomic Nervous System

 DISCUSSION OF CLINICAL EMERGENCY
NEUROLOGICAL EMERGENCIES
Mental well-being is a vital component of a person’s overall health
condition. Neurology diseases are one of the common reasons for
admissions to emergency wards in hospitals. Neurological disorders are
characterized by disturbances in thinking, emotional instability and
abnormal behaviour which negatively affect daily life. The major
emergencies are stroke, seizures, brain aneurysms, and Guillain Barre
Syndrome.
CHAPTER 1: GENERAL STRATEGY
A. Assessment
1. Primary and secondary assessment/resuscitation
2. Focused assessment

a. Subjective data collection

1. History of present illness/chief
complaint
a) Chronologic sequence of onset and
development of neurologic symptoms
b) Consciousness
c) Mentation
d) Alteration in personality
e) Emotional lability or mood swings,
irritability
CHAPTER 1: GENERAL STRATEGY
A. Assessment
a. Subjective data collection
f) Alteration in health or personal habits, activities
of daily living (ADLs)
g) Alteration in communication
h) Alteration in motor ability
i) Alteration in sensation
j) Alteration in sexual performance
k) Alteration in vision
l) Injury or fall
m) Pain
n) Headache
o) Seizures
CHAPTER 1: GENERAL STRATEGY
A. Assessment
a. Subjective data collection
p) Vomiting
q) Incontinence
r) Efforts to relieve symptoms

2. Past medical history

a) Current or preexisting diseases/illness
b) Smoking history
c) Substance and/or alcohol use/abuse
d) Last normal menstrual period: female
patients of childbearing age
e) Current medications
f) Allergies: food or drug
g) Immunization status
CHAPTER 1: GENERAL STRATEGY
A. Assessment

a. Subjective data collection

3. Psychological/social/environmental
factors related to neurologic
emergencies
a) Stress factors
b) Personal habits/grooming changes
CHAPTER 1: GENERAL STRATEGY
A. Assessment

b. Objective data collection

1. General appearance
a) Level of consciousness, behavior,
affect
b) Vital signs
c) Odors
d) Gait: balance and coordination
e) Hygiene
f) Level of distress/discomfort
CHAPTER 1: GENERAL STRATEGY
A. Assessment
b. Objective data collection

2. Inspection
a) Surface trauma
b) Symmetry of movements: facial
c) Cerebrospinal fluid (CSF) leaks: otorrhea
and/or rhinorrhea
d) Seizure activity
e) Abnormal positioning: flexion/extension

3. Auscultation
a) Heart sounds
b) Breath sounds
c) Carotid bruits: present or absent
CHAPTER 1: GENERAL STRATEGY
A. Assessment

b. Objective data collection

4. Palpation/percussion
a) Areas of tenderness
b) Deep tendon reflexes
c) Muscle strength and sensation

5. Neurologic examinations
a) Cranial nerve assessment
b) Glasgow Coma Scale (GCS): adult or pediatric
c) National Institutes of Health Stroke Scale (NIHSS)
CHAPTER 1: GENERAL STRATEGY
A. Assessment

b. Objective data collection

d) Oculocephalic reflex (doll’s eyes)

(1) Present when eyes move in the direction

opposite that which the head is moving
(2) Occurs with an intact brainstem but damaged
cerebral cortex
(3) Failure of the eyes to make the movement
indicates severe brainstem damage
(4) Should not be performed if neck injury
suspected
CHAPTER 1: GENERAL STRATEGY
A. Assessment
b. Objective data collection
e) Oculovestibular reflex (caloric testing)
(1) Present when eyes move toward the ear
stimulated with cold water
(2) Occurs with intact brainstem but damaged
cerebral hemispheres
(3) Absent caloric reflex indicates severe
brainstem damage
(4) Usually preserved longer than the
oculocephalic reflex
f) Apnea test: allow carbon dioxide (CO2) to build up to
stimulate the respiratory system, then determine
whether patient will breathe spontaneously
g) Loss of brainstem reflexes (pupils, gag, cough,
corneal reflexes)
CHAPTER 1: GENERAL STRATEGY
A. Assessment
b. Objective data collection

6. Meningeal signs
a) Stiff neck, photophobia, pain on neck
flexion
b) Positive Brudzinski’s sign (involuntary
flexion of knees/hips when neck is flexed)
c) Positive Kernig’s sign (supine patient
cannot completely straighten leg when
hip is fully flexed to a 90-degree angle)
CHAPTER 1: GENERAL STRATEGY
B. Analysis: Nursing Diagnosis

1. Risk for ineffective airway clearance

2. Impaired gas exchange
3. Decreased cardiac output
4. Ineffective tissue perfusion: cerebral
5. Acute/chronic pain
6. Anxiety/fear
7. Impaired verbal communication
8. Risk for injury
9. Deficient knowledge
10.Noncompliance
CHAPTER 1: GENERAL STRATEGY
C. Planning

1.No further complications related to

any disease
2.Maintain a stable neurological status
within baseline parameters
3.Relieve anxiety/apprehension
4.Demonstrate appropriate adaptation
to any residual deficits
CHAPTER 1: GENERAL STRATEGY
D. Intervention/ Implementation
1. Determine priorities of care
a) Maintain airway, breathing, and circulation
a) Provide supplemental oxygen as indicated
b) Establish intravenous (IV) access for administration of
crystalloid fluid/medications as needed
c) Obtain and set up equipment and supplies
d) Prepare for/assist with medical interventions
e) Administer pharmacologic therapy as ordered
2. Allow significant others to remain with patient if
supportive
3. Educate patient and significant others
CHAPTER 1: GENERAL STRATEGY
E. Evaluation and Ongoing Monitoring

1. Continuously monitor and treat as

indicated
2. Monitor patient response/outcomes, and
modify nursing care plan as appropriate
3. If positive patient outcomes are not
demonstrated, reevaluate assessment
and/or plan of care
 Stroke
Stroke or Cerebral Vascular Accident
(CVA) sometimes called a brain attack,
occurs when something blocks blood
supply to part of the brain or when a blood
vessel in the brain bursts.
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
A. Nursing Assessment

1. Primary Assessment
a) Remember that your first priority is to look for and
treat life-threatening conditions
b) Form a general impression
c) Airway and breathing
(1) Stroke patients may have difficulty swallowing
and are at risk for choking on their own saliva
(2) Evaluate the airway of an unresponsive patient
to make sure it is patent
(3) Check for foreign body obstruction
(4) Assess the patient’s breathing
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
A. Nursing Assessment

1. Primary Assessment
d) Circulation
(1) Begin by checking the pulse if the patient is unresponsive
(2) If no pulse is found, immediately begin CPR
(3) If the patient is responsive, determine if the pulse is fast or
slow, weak or strong
(4) Evaluate the patient quickly for external bleeding
e) Level of Consciousness
(1) Use of AVPU
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
A. Nursing Assessment

2. History Taking
a. Investigate the chief complaint
(1) If the patient is unresponsive, gather any history of the present illness from family or
bystanders
(2) If no one is around, quickly look for explanations for the AMS
(3) In a responsive patient, ask him or her what happened
(4) Evaluate the patient’s speech
(5) Gather a SAMPLE history
(i) Remember that time can be critical in a neurologic emergency
(ii) Make a special effort to determine the exact time that the patient last appeared to
be healthy
(iii) Collect or list all medications the patient has taken
(iv) Patients who have had a stroke may appear to be unconscious and
unable to speak, but they may still be able to hear and understand what is taking place
(v) Try to establish effective communication
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
A. Nursing Assessment
3. Secondary Assessment

a. Physical examinations
b. Stroke assessment
(1) Stroke scales evaluate the face, arms, and speech
(2) All patients with an AMS should also have a Glasgow Coma
Scale (GCS) score calculated

c. Vital signs
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
B. Diagnostic Test

1. Physical Exam
2. Blood Test
3. Computerized tomography (CT) scan
4. Magnetic resonance imaging (MRI)
5. Carotid ultrasound
6. Cerebral angiogram
7. Echocardiogram
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
C. Emergency Nursing Management
1. Airway management/ventilator management
2. Assessment and evaluation of neurologic status to detect
patient deterioration
3. Blood pressure management
4. General supportive care and prevention of complications
associated with: dysphagia, HTN, hyperglycemia,
dehydration, malnourishment, fever, cerebral edema,
infection, and DVT, immobility, falls, skin care, bowel and
bladder dysfunction.
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
D. Emergency Medical and Surgical Management

ISCHEMIC STROKE

- Recognition and Rapid Assessment

- Immediate Transportation to Hospital
- Diagnostic Imaging
- Thrombolytic Therapy
- Supportive Care
CHAPTER 2: SPECIFIC EMERGENCIES
STROKE
D. Emergency Medical and Surgical Management

HEMORRHAGIC STROKE

- Recognition and Rapid Assessment

- Immediate Transportation to Hospital
- Diagnostic Imaging
- Neurosurgical Intervention
- Blood Pressure Management
 Seizure
Seizure is a burst of uncontrolled electrical
activity between brain cells (also called neurons
or nerve cells) that causes temporary
abnormalities in muscle tone or movements
(stiffness, twitching or limpness), behaviors,
sensations or states of awareness.
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
A. Nursing Assessment

1. Primary Assessment
a) Remember that your first priority is to look for and treat life-threatening
conditions
b) Form a general impression
(1) You should be able to tell if a seizure is still taking place
c) Airway and breathing
(1) Evaluate the airway of an unresponsive patient to make sure it
is patent.
(2) Check for foreign body obstruction
(3) Assess the patient’s breathing
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
A. Nursing Assessment

1. Primary Assessment
d) Circulation
(1) Begin by checking the pulse if the patient is unresponsive
(2) If no pulse is found, immediately begin CPR
(3) If the patient is responsive, determine if the pulse is fast or
slow, weak or strong
(4) Evaluate the patient quickly for external bleeding
e) Level of Consciousness
(1) Use of AVPU
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
A. Nursing Assessment

2. History Taking
a) Investigate the chief complaint
(1) If the patient is unresponsive, gather any history of the
present illness from family or bystanders
(2) If no one is around, quickly look for explanations for the
AMS
(3) In a responsive patient, ask him or her what happened
(4) Gather a SAMPLE history
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
A. Nursing Assessment

2. Secondary Assessment
a) Physical examinations
(1) Your assessment should continue with a full-body scan
b) Vital signs
(1) Patients with significant intracranial bleeding may have a great
deal of pressure in the skull that is compressing the brain
(2) If the patient has an AMS, you should check the glucose level if
you have the equipment available
(3) During most active seizures, it is impossible to evaluate vital
signs
(4) Unless the situation is unusual, vital signs in a postictal state will
approximate normal
(5) Monitoring devices
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
B. Diagnostic Test

Test may include:

1. Neurological Exam
2. Blood Test
3. Lumbar Puncture
4. Electroencephalogram (EEG)
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
B. Diagnostic Test

Imaging Test may include:

1. Magnetic Resonance Imaging (MRI)

2. Computerized tomography (CT)
3. Positron emission tomography (PET)
4. Single-photon emission computed tomography
(SPECT)
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
C. Emergency Nursing Management
1. The nursing goal is to prevent injury to the patient. This includes not only
physical support but psychological support as well
2. Provide privacy
3. Ease the patient on the floor, if possible
4. Protect the head with a pad to prevent injury
5. Loosen constrictive clothing
6. If aura precedes the seizure, place a padded tongue blade between the teeth
7. Do not attempt to pry open jaws that are clenched in a spasm to insert
anything
8. No attempt should be made to restrain the patient during the seizure
9. Place the patient on one side with head flexed forward
10. The patient should be reoriented to the environments and happening upon
awakening
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
D. Emergency Medical and Surgical Management
Broad-spectrum antiseizure drugs (which are effective for focal-onset seizures and various types
of generalized-onset seizures) include:
• Lamotrigin
• Levetiracetam
• Topiramate
• Valproate
• Zonisamide

Epileptic (formerly, infantile) spasms, atonic seizures, and myoclonic seizures are difficult to treat.
Valproate or vigabatrin is preferred, followed by clonazepam.

For juvenile myoclonic epilepsy, life-long treatment with valproate or another antiseizure drug is
usually recommended. Carbamazepine, oxcarbazepine, or gabapentin can exacerbate the
seizures. Lamotrigine can be used as second-line monotherapy (eg, for women of childbearing
age) or adjunctive therapy for juvenile myoclonic epilepsy
CHAPTER 2: SPECIFIC EMERGENCIES
SEIZURE
D. Emergency Medical and Surgical Management

There are several types of surgery, including:

1.Lobectomy
2.Thermal ablation
3.Multiple subpial transection
4.Corpus callosotomy
5.Hemispherotomy
 Guillain-Barré
Syndrome
Guillain-Barré syndrome (GBS) is a rare
disorder where the body's immune system
damages nerve. The damage to the nerves
causes muscle weakness and sometimes
paralysis.
CHAPTER 2: SPECIFIC EMERGENCIES
GUILLAIN-BARRE SYNDROME
A. Nursing Assessment
1. Subjective Data
a) Proximal and distal weakness
b) Areflexia or Hyporeflexia
c) Patients can develop diplegia due to the involvement of
both facial cranial nerves.
d) Problems with balance and coordination
2. Objective Data
a) Slurred speech
b) Dysphagia
c) Ophthalmoplegia
d) Apraxia
e) Abnormal gait, heart rate, and blood pressure
disturbance
CHAPTER 2: SPECIFIC EMERGENCIES
GUILLAIN-BARRE SYNDROME
B. Diagnostic Test

1. Electromyography (EMG)
2. Nerve Conduction Studies
(NCS)
3. Lumbar puncture
CHAPTER 2: SPECIFIC EMERGENCIES
GUILLAIN-BARRE SYNDROME
C. Emergency Nursing Management

• Recognize and assess signs and symptoms of Guillan-

Barre Syndrome
• Provide supportive care to manage pain and discomfort
• Educate patients and families on the course of GBS,
expected recovery timeline, and strategies for managing
residual symptoms
• Schedule regular follow-up appointments to monitor
progress and address any ongoing needs or concerns
CHAPTER 2: SPECIFIC EMERGENCIES
GUILLAIN-BARRE SYNDROME
D. Emergency Medical and Surgical Management
There’s no known cure for Guillan-Barre syndrome. But
some therapies can lessen the severity of the condition and
shorten your recovery time. The main medical management
for GBS includes:

1. Plasma exchange
2. Intravenous immunoglobulin therapy (IVIG)
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
A. Nursing Assessment

1. Subjective data collection

a. History of present illness/chief complaint
1. Onset and Description of Symptoms
2. Headache
3. Nausea and vomiting
4. Visual Disturbances
5. Neck Pain and Stiffness
6. Focal Neurological Deficits
7. Mental Status and Altered Consciousness
8. Family History
9. Past Medical History
10. Social and Lifestyle Factors
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
A. Nursing Assessment

2. Objective data collection

a. Vital Signs
b. Neurological Examination
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
B. Diagnostic Test

1. Medical history and Physical exam

including neurological exam

2. Spinal Tap
3. Computed tomography or CT scan
4. Magnetic resonance imaging or MRI
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
C. Emergency Nursing Management
1. Secure the airway maintaining adequate oxygenation and
ventilation and providing circulatory support as needed.
2. Rapidly assess the patient's level of consciousness vital
signs and neurological status using the Glasgow coma scale or
GCS.
3. Monitor for signs of increased ICP including headache
altered mental status pupillary changes and focal neurological
deficits. -Raise the head of the bed to 30-degree angle to
facilitate venous drainage from the brain and reduced ICP.
4. Administer antihypertensive medications or adjust the rate of
intravenous fluids to maintain the blood pressure within the
prescribed target range.
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
D. Emergency Medical and Surgical Management

-Quickly assess the patient's level of consciousness

neurological status and pain intensity.
- Identify and address any immediate life-threatening
issues such as airway compromise or severe bleeding.
- Continuously monitor vital signs including blood
pressure heart rate respiratory rate and oxygen
saturation
-Evaluate the patient's pain using a pain scale or
assessment tool to quantify pain intensity and location
CHAPTER 2: SPECIFIC EMERGENCIES
BRAIN ANEURYSM
D. Emergency Medical and Surgical Management
- Decompressive craniotomy in cases of severe
intracranial hypertension decompressive craniotomy
may be necessary to relief pressure within the skull.
- Evacuation of hematomas is elevated ICP is due to
a hematoma for example subdural or epidural
hematoma surgical evacuation may be required.
- -Ventricular to me in cases of elevated ICP with
hydrocephalus even three colostomy or external
ventricular drain EVD maybe place to drain excess
cerebrospinal fluid and reduced ICP
 CHAPTER 3: NURSING CARE PLAN
STROKE
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective data: Impaired Short Term Goal: Independent: After 8 hours of
physical nursing
“Bigla nalang siyang After 3 hours of -evaluation for airway, breathing, and circulation -most acute ischemic stroke clients arrive to the
mobility may be intervention the
nahirapang humawak ng mga intervention the ED hemodynamically stable; however, clients with
related to client would be
bagay, hindi niya mapwersa decrease in client will able to: decreased level of consciousness may require airway able to:
ang kamay niya sa kaliwa at management
muscle control
ganon din sa kanyang paa -maintain the
or strength as -rapid neurological examination -to determine focal neurological deficits using a
tuwing sinusubukan niyang -demonstrate stable usual/improved
evidence by validated scale such as FAST (Face, Arm, Speech,
maglakad, hindi niya kayang vital signs level of
decrease in Time)
maipwersa dahil ang kalahati consciousness,
fine and gross - assessment of heart rate and rhythm, blood pressure,
ng kanyang katawan ay -for early detection and control of two major risk cognition, and
motor skills temperature, oxygen saturation, point-of-care glucose, and
namamanhid kaya inaalalayan factors for stroke: hypertension and diabetes motor
Long Term Goal: presence of seizure activity
ko siya” as verbalized by
the relative After 8 hours of -Assess - Identifies strengths and deficiencies and may -will improve
functional ability and extent of impairment
nursing intervention initially and on a regular basis provide information regarding recovery mobility
the client will be
-Maintain neutral position of the head. -Flaccid paralysis may interfere with client’s
Objective Data: able to:
ability to support the head, whereas spastic
Vital signs as follows: paralysis may lead to deviation of the head to one
side.
BP- 180/120 mmHg -maintain the - Set goals with client/significant other (SO) for increasing
usual/improved level participation in activities, exercise, and position changes - Promotes a sense of expectation of progress and
PR- 87 bpm of consciousness, Dependent: improvement and provides some sense of control and
cognition, and motor independence
RR- 22 bpm
-Administer oxygen via nasal cannula
-will improve -giving oxygen to reduce the potential damage may
Temp- 36.7 °C
mobility -conduct initial blood work include electrolytes, random appear to make sense
02 sat: 94% glucose, complete blood count (CBC)
-blood tests to learn the cause of your stroke
-Dysphagia - Administer muscle relaxants and antispasmodics as symptoms.
indicated, such as baclofen (Lioresal) and dantrolene
-Confused - May be required to relieve spasticity in affected
(Dantrium)
extremities
-Drowsy -Administer medicine for antihypertensive drug therapy as
-effective for primary and secondary prevention of
-Having a slurred speech indicated
stroke
when talking Collaboration:
-loss of sensation on one - Consult with physical therapist regarding passive, active,
side - An individualized program can be developed to
resistive exercises and client mobilization meet particular needs and deal with deficits in
-weak muscle tone balance, coordination, and strength
Diagnostic Test
-Hand grasp: left hand is
weak - Physical Exam, blood test, CT scan
 CHAPTER 3: NURSING CARE PLAN
SEIZURE
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Risk for Short Term Goal: Independent: -The client or
trauma caregiver
“Bigla nalang nanginig After 1 hour of -Explore with the client the various stimuli that - Lack of sleep, flashing lights and
related to recognized the
ang anak ko” (suddenly nursing may precipitate seizure activity prolonged television viewing may increase
loss of large need for
my daughter started interventions the brain activity that may cause potential
muscle assistance to
shaking uncontrollably) seizure episode seizure activity.
coordination prevent accidents
as verbalized by the will be lessened -Discuss seizure warning signs and usual seizure
as evidenced -Enables the client to protect self from or injuries.
mother. and the client pattern.
by body injury.
will be more -The client or
weakness and
comfortable. -Minimizes injury should seizure occur caregiver
facial
Objective Data: -Keep padded side rails up with the bed in the while client is in bed. verbalized
grimace. Long Term Goal:
lowest position. understanding of
-V/S taken as follows: -Use of helmet may provide added protection
After 8 hours of the disorder and
-Evaluate need for protective head gear. for individuals during seizure activity.
T: 37.3 degree celcius nursing various stimuli
interventions the Dependent: that may increase
PR: 110 bpm potentiate
client will
-Clear the area around the person or anything hard -To prevent injury.
RR: 18 bpm demonstrate seizure activity
behaviors, or sharp.
BP: 130/90 mmHg -The client or
lifestyle changes -Administer oral fast acting medicines as
-Diazepam can be used as a rescue medicines caregiver
O2 sat: 85% to reduce risk prescribed by the physician.
to stop seizures. identified and
factors and
-Weakness corrected
protect self from
potential risk
-Facial grimace injury Collaborative:
- to find out whether an area of your brain factors in the
-Epileptologist: To diagnose and manage various is functioning abnormally environment.
kinds of seizures.
- In this test electrodes attached to your
-Physical Therapist: To treat muscle weakness and scalp record electrical activity of your
atrophy brain

Diagnostic Test

Neurological Exam
Electroencephalogram (EEG)