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A Review of Neurologic
Concepts
Verbal responsiveness
Motor responsiveness
Vital signs
CEREBRAL FUCTION
Assess the degree of
wakefulness/alertness
Note the intensity of stimulus to
cause a response
Apply a painful stimulus over the
nailbeds with a blunt instrument
Ask questions to assess orientation
to person, place and time
Cerebral function
Utilize the Glasgow Coma Scale
An easy method of describing
mental status and abnormality
detection
Tests 3 areas- eye opening, verbal
response and motor response
Scores are evaluated- range from
3-15
No ZERO score
Glasgow Coma Scale
4=Spontaneous
3=To voice
2=To pain
1=None (No response)
Glasgow Coma Scale
Glasgow Coma Score
Verbal Response (V)
5=Normal/oriented
4=Disoriented/CONFUSED
3=Words, but incoherent/ inappropriate
2=Incomprehensible/mumbled words
1=None
Glasgow Coma Scale
Glasgow Coma Score
Motor Response (M)
vision
Cranial Nerve Function:
Cranial Nerve 5 -trigeminal
Sensory portion- assess for
sensation of the facial skin
Motor portion- assess the muscles
of mastication
Assess corneal reflex
Cranial Nerve Function:
Cranial Nerve 7 -facial
Sensory portion- prepare salt,
sugar, vinegar and quinine. Place
each substance in the anterior two
thirds of the tongue, rinsing the
mouth with water
Motor portion- ask the client to
make facial expressions, ask to
forcefully close the eyelids
Cranial Nerve Function:
Cranial Nerve 8- vestibulo-
auditory
Test patient’s hearing acuity
Observe for nystagmus and
disturbed balance
Cranial Nerve Function:
Cranial Nerve 9-
glossopharyngeal
Together with Cranial nerve 10 –
vagus
Assess for gag reflex
Watch the soft palate rising after
instructing the client to say “AH”
The posterior one-third of the
tongue is supplied by the
glossopharyngeal nerve
Cranial Nerve Function:
Cranial Nerve 11-
accessory
Press down the patient’s shoulder
while he attempts to shrug against
resistance
Cranial Nerve Function:
Cranial Nerve 12-
hypoglossal
Ask patient to protrude the tongue
and note for symmetry
ASSESS Motor function
Assess muscle tone and strength
by asking patient to flex or extend
the extremities while the examiner
places resistance
Grading of muscle strength
Assessing the motor
function of the cerebellum
Test for balance- heel to toe
Test for coordination- rapid
alternating movements and finger
to nose test
direction
Assessing the motor
function of the brainstem
Test for the Oculovestibular reflex
Slowly irrigate the ear with cold
wArM- sAMe
Assessing the sensory
function
Evaluate symmetric areas of the body
Ask the patient to close the eyes while
testing
Use of test tubes with cold and warm
water
Use blunt and sharp objects
Use wisp of cotton
Ask to identify objects placed on the
hands
Test for sense of position
Assessing the reflexes
Deep tendon reflexes
Biceps
Triceps
Brachioradialis
Patellar
Assessing the sensory function
Achilles
Assessing the reflexes
Superficial reflexes
Abdominal
Cremasteric
Anal
Pathologic reflex
Babinski- stroke the lateral aspect of
the soles doing an inverted “J”
(+)- DORSIFLEXION of the Big toe
with fanning out of the little toes
Grading of reflexes
Deep tendon reflex
0- absent
++ normal
+++ increased
Superficial reflex
0 absent
+present
DIAGNOSTIC TESTS
EEG
Withhold medications that may
interfere with the results-
anticonvulsants, sedatives and
stimulants
Wash hair thoroughly before
procedure
DIAGNOSTIC TESTS
CT scan
With radiation risk
seafood
Ensure consent
procedure
Maintain pressure dressing or
to lie still
Contraindicated in patients with
increased ICP
Keep flat on bed after procedure
procedure
Increased Intracranial
pressure
Intracranial pressure more than 15 mmHg
Brunner= Normal intracranial pressure 10-20
mmHg
Causes:
Head injury
Stroke
Inflammatory lesions
Brain tumor
Surgical complications
Increased Intracranial
pressure
Pathophysiology
The cranium only contains the brain
2. Blood shunting
hypoxia
3. Cerebral edema
4. Brain herniation
Decreased cerebral blood
flow
Vasomotor reflexes are stimulated
initially slow bounding pulses
Increased concentration of carbon
dioxide will cause VASODILATION
increased flow increased ICP
Cerebral Edema
Abnormal accumulation of fluid in
the intracellular space,
extracellular space or both.
Herniation
Results from an excessive increase
in ICP when the pressure builds up
and the brain tissue presses down
on the brain stem
Cerebral response to
increased ICP
1. Steady perfusion up to 40 mmHg
2. Cushing’s response
Vasomotor center triggers rise in BP
to increase ICP
Sympathetic response is increased
BP but the heart rate is SLOW
Respiration becomes SLOW
Increased Intracranial
pressure
CLINICAL MANIFESTATIONS
Early manifestations:
Changes in the LOC- usually
the earliest
Pupillary changes- fixed, slowed
response
Headache
vomiting
Increased Intracranial
pressure
CLINICAL MANIFESTATIONS
late manifestations:
Cushing reflex- systolic
Hyperthermia
Abnormal posturing
Increased Intracranial
pressure
Nursing interventions:
Maintain patent airway
1. Elevate the head of the bed 15-
oxygen or controlled
hyperventilation- to reduce the CO2
blood levelsconstricts blood vessels
Increased Intracranial
pressure
Nursing interventions
3. Administer prescribed
medications- usually
Mannitol- to produce negative fluid
balance
corticosteroid- to reduce edema
anticonvulsants-p to prevent seizures
Increased Intracranial
pressure
Nursing interventions
4. Reduce environmental stimuli
person
Motor function
Decerebrate
Decorticate
Sensory function
Altered level of
consciousness
Patient is not oriented
Patient does not follow command
Patient needs persistent stimuli to
be awake
degrees
Suctioning
IVF therapy
Administer acetaminophen as
prescribed
8. Prevent urinary retention
Use of intermittent catheterization
Altered level of
consciousness
Nursing Intervention
9. Promote bowel function
High fiber diet
Frequent reorientation
SEIZURES
Episodes of abnormal motor,
sensory, autonomic activity
resulting from sudden excessive
discharge from cerebral neurons
A part or all of the brain may be
involved
SEIZURES
PATHOPHYSIOLOGY
An electrical disturbance in the
nerve cells in one brain section
EMITS ELECTRICAL IMPULSES
excessively
SEIZURES
ETIOLOGIC FACTORS
2. Idiopathic
3. Fever
4. Head injury
5. CNS infection
6. Metabolic and toxic conditions
SEIZURES
Nursing Interventions
During seizure
1. remove harmful objects from the
patient’s surrounding
2. ease the client to the floor
confused
3. provide care if patient became
regimen
headache
Cephalgia
Primary headache- no organic
cause
Secondary headache- with organic
cause
Migraine headache- periodic
attacks of headache due to
vascular disturbance
Tension headache-the most
common type- due to muscle
headache
Migraine
2. Prodrome stage
3. Aura phase
4. Headache
5. Recovery phase
headache
Nursing Interventions
1. Avoid precipitating factors
2. modify lifestyle
measures
Beta-blockers
Serotonin antagonists- “triptan"
Autonomic
Dysreflexia/hyperreflexia
Seen commonly in spinal cord
injury above T6
An exaggerated response by the
autonomic system resulting from
various stimuli most commonly
distended bladder, impacted feces,
pain, skin irritation
Autonomic
Dysreflexia/hyperreflexia
Clinical MANIFESTATIONS
1. Hypertension
2. Bradycardia
3. severe pounding headache
4. diaphoresis
5. nausea and nasal congestion
Autonomic
Dysreflexia/hyperreflexia
NURSING INTERVENTIONS
1. Elevate the head of the bed
immediately
2. Check for bladder distention and
tissue injury
Temporary loss of neurologic
for hours
Traumatic brain injury
3. Diffuse Axonal injury
Involves widespread damage to
the neurons
Patient has decerebrate and
decorticate posture
Traumatic brain injury
4. Intracranial hemorrhage
Epidural Hematoma- blood collects
in the epidural space between
skull and dura mater. Usually due
to laceration of the middle
meningeal artery
Symptoms develop rapidly
Traumatic brain injury
4. Intracranial hemorrhage
Subdural hematoma- a collection of
blood between the dura and the
arachnoid mater caused by
trauma. This is usually due to
tear of dural sinuses or dural
venous vessels
Symptoms usually develop slowly
Traumatic brain injury
4. Intracranial hemorrhage
Intracerebral Hemorrhage and hematoma-
bleeding into the substance of the
brain resulting from trauma,
hypertensive rupture of aneurysm,
coagulopahties, vascular abnormalities
Symptoms develop insidiously,
beginning with severe headache and
neurologic deficits
Traumatic brain injury
MANIFESTATIONS
1. Altered LOC
2. CSF otorrhea
3. CSF rhinorrhea
monitor ABG
Traumatic brain injury
NURSING MANAGEMENT
3. Monitor F and E balance
Daily weights
IVF therapy
of DI and SIADH
Traumatic brain injury
4. Provide adequate nutrition
5. Prevent injury
Use padded side rails
Assess bladder
intermittent catheter
Traumatic brain injury
6. Maintain skin integrity
Prolonged immobility will likely
hours
Avoid friction and shear forces
Traumatic brain injury
7. Monitor potential
complications
Increased ICP
Post-traumatic seizures
Impaired ventilation
Spinal cord injury
The most frequent vertebrae – C5-
C7, T12 and L1
Concussion
Contusion
Compression
Transection
Spinal cord injury
Clinical manifestations
1. Paraplegia
2. quadriplegia
3. spinal shock
Spinal cord injury
DIAGNOSTIC TEST
Spinal x-ray
CT scan
MRI
Spinal cord injury
EMERGENCY MANAGEMENT
A-B-C
Immobilization
Immediate transfer to tertiary
facility
Spinal cord injury
NURSING INTERVENTION
1. Promote adequate breathing
body alignment
3. Promote adaptation to sensory
3. Stroke in evolution
4. Completed stroke
General manifestations
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
There is disruption of the cerebral
blood flow due to obstruction by
embolus or thrombus
RISKS FACTORS
Non-modifiable Modifiable
Advanced age Hypertension
race Obesity
Smoking
Diabetes mellitus
hypercholesterolemia
Pathophysiology of
ischemic stroke
Disruption of blood supply
Anaerobic metabolism ensues
Decreased ATP production leads to
impaired membrane function
Cellular injury and death can occur
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
DIAGNOSTIC test
1. CT scan
2. MRI
3. Angiography
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
CLINICAL MANIFESTATIONS
1. Numbness or weakness
2. confusion or change of LOC
3. motor and speech
difficulties
4. Visual disturbance
5. Severe headache
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Motor Loss
Hemiplegia
Hemiparesis
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Communication loss
Dysarthria= difficulty in speaking
Aphasia= Loss of speech
Apraxia= inability to perform a
previously learned action
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
Perceptual disturbances
Hemianopsia
Sensory loss
paresthesia
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
2. Improve Mobility and prevent
joint deformities
Correctly position patient to
prevent contractures
Place pillow under axilla
Hand is placed in slight supination-
“C”
Change position every 2 hours
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
2. Enhance self-care
Carry out activities on the
unaffected side
Prevent unilateral neglect
Keep environment organized
Use large mirror
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
3. Manage sensory-perceptual
difficulties
Approach patient on the
Unaffected side
Encourage to turn the head to the
affected side to compensate for
visual loss
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
4. Manage dysphagia
Place food on the UNAFFECTED
side
Provide smaller bolus of food
Manage tube feedings if
prescribed
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
5. Help patient attain bowel and
bladder control
Intermittent catheterization is
done in the acute stage
Offer bedpan on a regular
schedule
High fiber diet and prescribed
fluid intake
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
6. Improve thought processes
Support patient and capitalize on
the remaining strengths
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
7. Improve communication
Anticipate the needs of the patient
Offer support
Provide time to complete the sentence
Provide a written copy of scheduled
activities
Use of communication board
Give one instruction at a time
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
8. Maintain skin integrity
Use of specialty bed
Regular turning and positioning
Keep skin dry and massage NON-
reddened areas
Provide adequate nutrition
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
9. Promote continuing care
Referral to other health care
providers
CEREBROVASCULAR
ACCIDENTS: Ischemic
Stroke
NURSING INTERVENTIONS
10. Improve family coping
11. Help patient cope with sexual
dysfunction
CVA: Hemorrhagic Stroke
Normal brain metabolism is
impaired by interruption of blood
supply, compression and increased
ICP
Usually due to rupture of
intracranial aneurysm, AV
malformation, Subarachnoid
hemorrhage
CVA: Hemorrhagic Stroke
Sudden and severe headache
Same neurologic deficits as
ischemic stroke
Loss of consciousness
Meningeal irritation
Visual disturbances
CVA: Hemorrhagic Stroke
DIAGNOSTIC TESTS
1. CT scan
2. MRI
3. Lumbar puncture (only if with no
increased ICP)
CVA: Hemorrhagic Stroke
NURSING INTERVENTIONS
1. Optimize cerebral tissue
perfusion
2. relieve Sensory deprivation and
anxiety
3. Monitor and manage potential
complications