1. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Decreased HR and BP
Decresead RR
Diarrhea
Urinary Frequency
Seizures
II. SNS
a. Adrenergic Agents
1. Epinephrine (Adrenaline)
2. Note: Side Effects (SE) – normal drug expectancies
b. Beta-Adrenergic Agents (Beta-Blockers)
MEDICAL-SURGICAL NURSING 1. Propanolol, metoprolol, atenolol
2. Bronchospasm, Elicits decreased cardiac contractions,
Treats HPN, AV conduction slows down (BETA)
Neurologic Nursing 3. Anti-HPN Management
Beta-blockers – ―-olol‖
Lecturer: Mark Fredderick Abejo RN, MAN ACE inhibitors – ―-pril‖
________________________________________________________ Ca-Antagonist – nifedipine
Transient headache and dizziness
OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE Orthostatic hypotension
NERVOUS SYSTEM Assist in ambulation
Pt. to rise slowly from sitting position
I. Divisions 4. BP = CO x PR
a. CNS – brain and spinal cord 5. CO = HR x SV
b. PNS – 12 pairs of cranial nerves and 31 pairs of spinal 6. (N) HR = 60-100 bpm
nerves 7. (N) SV = 60-70 ml of H2O
1. Spinal nerves:
TOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN
Cervical – 8
BARIER: (BLACK)
Thoracic – 12
Bilirubin – yellow pigment
Lumbar – 5
Lead – Antidote: Ca+ EDTA
Sacral – 5
Ammonia – cerebral toxin; present in hepatic encephalopathy
Coccygeal - 1
(liver cirrhosis)
c. ANS – sympathetic and parasympathetic systems
Carbon Monoxide – in Parkinson’s and Epilepsy
Ketones – cerebral depressant
III. CNS
a. Cells
1. Neurons
Excitability
Conductivity
Permanence
2. Neuroglia – majority of tumors arise from here; about
40% from astrocytes
Astrocytes – maintains integrity of BBB
Oligodendrocytes – production of myelin
Myelin sheath – insulates axons; for rapid
impulse transmission
Microglia – STATIONARY cells which carry on
phagocytosis (cell eating)
Sympathetic – flight or aggression response release of Ependymal cells – produces chemoattractants
norepinephrine increase in all bodily activity except GI which concentrates bacteria
(constipation); adrenergic; parasympatholytic response. b. Composition
1. 80% brain mass
REMEMBER: GIT is the least important area during stress CEREBRUM – divided into two hemispheres, the
decreased blood flow in the area; Increased blood flow in the brain, left and right and is bridged by the corpus
heart and skeletal muscles callosum
Mydriasis (―dilat‖-ation) Motor, sensory, integrative function
Dry mouth Lobes:
Increase in HR and BP Frontal – controls higher cortical thinking,
Tachypnea personality development, motor activity,
Constipation contains BROCA’s are or the motor-speech
Urinary retention center. (Expressive Aphasia)
Parasympathetic – flight or withdrawal response release of Occipital – vision
Acetylcholine decrease in all bodily activity except GI (diarrhea); Parietal – appreciation and discrimination
chonlinergic/ vagal/ sympatholytic response
of sensory impulses (pain, touch, pressure,
Meiosis heat and cold)
Increased salivation
MS 1 Abejo
2. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Temporal – hearing, short term memory, CI – Atlas; C2 – Axis
contains the general interpretative area— CSF – shock absorber, cushions brain altered when there is
Wernicke’s aphasia obstruction in CSF drainage
Insula (Island of Reil) – visceral function HYDROCEPHALUS – posteriorly growth of the head d/t early
(internal area) closure of fontanels
Limbic System (Rhinencephalon) – sense
of smell, libido or sexual urge control, long Types of Cells:
term memory Labile (regenerative) – Epidermal, GIT, Respiratory, GUT
Stable – regenerative but limited survival period: liver, pancreas,
salivary glands, kidneys
Permanent – cardiac, neurons, osteocytes, retinal
NEUROLOGIC ASSESSMENT
I. COMPREHENSIVE NEUROLOGIC EXAM
A. Purpose
1. To know exact neuro deficit
2. To localize lesion
3. For rehabilitation
4. For guidance in nursing care
B. Survey of Mental Status
1. LOC
Conscious – awake
Lethargy – sleepy/drowsy/obtunded
Stupor – only awakened by vigorous stimulation
BASAL GANGLIA – areas of gray matter General body weakness
located deep within each cerebral hemisphere; Decreased body defenses
involved in the extrapyramidal tract; produces Coma
DOPAMINE (controls gross voluntary movement) Light – (+) to all painful stimuli
MIDBRAIN (Mesencephalon) – acts as a relay Deep – (-) to all painful stimuli
station for sight and hearing particularly helps in PAINFUL STIMULATION
size and reaction of pupils and hearing acuity Deep Sternal Stimulation/Pressure
N hearing acuity : 30-40dB Orbital Pressure
N pupil constriction: 2-3 mm Pressure on Great Toes
N pupil finding: PERRLA Nail bed pressure
Isocoria vs. Anisocoria Corneal/Blinking Reflex
DIENCEPHALON (Interbrain)
Conscious – wisp of cotton
Thalamus – acts as a relay station for
sensation Unconscious – institute/drop of saline
Hypothalamus – controls temperature, BP, solution (coma if positive reaction, deep
sleep and wakefulness, thirst, appetite coma if negative)
(satiety), some emotional responses like fear, 2. Test of memory (consider educational background)
anxiety and excitement, controls pituitary Short term memory (ask what the pt ate for
functions breakfast)
BRAIN STEM (+) anterograde amnesia temporal lobe
Pons (Pneumotaxic center) – controls rate, damage
rhythm and depth of respiration Long term memory (ask birthday)
Medulla Oblongata – lowest part; damage: (+) retrograde amnesia damage to
most life threatening; controls respiration, Rhinencephalon (Limbic system)
HR, swallowing, vomiting, hiccups, C. Levels of Orientation (time, person and place)
vasomotor center D. CN Assessment
CEREBELLUM – smallest part; ―lesser brain‖; E. Motor Assessment
balance, equilibrium, gait and posture.
F. Sensory Assessment
1. PAIN - Gingerbread test
100% very painful
75% tolerable pain
25% moderate pain
0% no pain
2. 10 % CSF 2. TOUCH – Stereognosis
3. 10% Blood Identifying familiar object placed on clients hands
Astereognosis – if patient cannot identify object;
MONROE KELLY HYPOTHESIS – the skull is a closed damage in parietal lobe
vault, any increase in one component will bring about increases 3. PRESSURE AND TOUCH – Graphesthesia
in ICP Identify numbers or letters written on client’s
NORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAY palm
NORMAL CSF OPENING PRESSURE: 60-150 MMHG Agraphesthesia if (-), damage to parietal lobe
NORMAL CSF CONTENTS: GLUCOSE, PROTEINS, WBCS
FORAMEN MAGNUM - The large opening in the basal part of
the occipital bone through which the spinal cord becomes
continuous with the medulla oblongata. G. Cerebellar Test
MS 2 Abejo
3. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
1. Romberg’s Test 2. Dysosmia – distorted sense of smell
Instruct patient to close eyes, assume a normal 3. Anosmia – absence of smell
anatomical position for 5-15 minutes; two nurses
at right and left side
Normal is (-)
If (+) ataxia
2. Finger-to-nose Test
3. Alternate Pronation and Supination
Dysmetria – inability of a client to stop a
movement at a desired point
H. DTRs
I. Autonomics
II. Glasgow Coma Scale
A. objective measurement of LOC;
B. quick neuro check
1. Motor – 6
2. Verbal – 5
3. Eye Opening – 4
C. Normal: 14-15 – conscious
1. lethargy 13-11
2. Stupor 10-8
3. Coma = 7
4. deep coma = 3
II. OPTIC
A. Sensory – Vision
B. Tests
1. Test of Visual Acuity/Central or Distance Vision
Materials
Snellen’s Chart
Alphabet – literate
E chart – illiterate
Animal chart – pedia, since shorter
attention span
20 feet distance (67 cm) 20 feet/6-7 m; constant
normal 20/20
numerator – distance to snellen chart
denominator – distance the person can see the
letters
Abnormal findings
20/200 blindness
OD: oculus dexter
OS: oculus sinister
OU: oculus uritas
2. Visual Fields/Peripheral vision
Superiorly
Bitemporally
Nasally
CRANIAL NERVE ASSESSMENT Inferiorly
I. Olfactory Sensory Some C. COMMON VISUAL DISORDERS
1. Glaucoma
II. Optic Sensory Say 40 yo, obese
III. Oculomotor Motor Marry hereditary
IV. Trochlear (smallest) (―down‖) Motor Money Loss of peripheral vision tunnel vision
V. Trigeminal (largest) Sensory, But Increased IOP (N = 12-21 mm Hg)
(―triCHEWminal‖) motor Signs and symptoms:
VI. Abducens (―at the sides‖) Motor My Headache
VII. Facial Sensory, Brother Nausea and vomiting
motor Halos around lights
Steamy cornea
VIII. Acoustic (Vestibulocochlear) Sensory Says
Acute angle closure glaucoma – most
IX. Glossopharyngeal Sensory, Bad dangerous, may lead to blindness
motor Diagnostics:
X. Vagus (longest) (―mavagal‖) Sensory, Business Tonometry – increased IOP
motor Gonioscopy – obstruction in anterior
XI. Accessory (―shoulders‖) Motor Marry chamber
XII. Hypoglossal Motor Money Perimetry – decreased visual fields
Drugs (for lifetime)
I. OLFACTORY Timolol maleate
A. Sensory – smell Pilocarpine – drug of choice (miotic)
B. Use coffee, bar soap, vinegar, cigarette tar Epinephrine – decrease in aqueous humor
C. Abnormal findings Carbonic Anhydrase Diamox
Indication of: (Acetazolamide)
Head trauma damaging the cribriform plate of Decrease in aqueous humor (maintains
ethmoid bone where olfactory cells are located IOP); promotes drainage
Sinusitis – give antibiotics to prevent meningitis Monitor I/O
1. Hyposmia – decreased sensitivity to smell
MS 3 Abejo
4. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
NO ATROPINE: may lead to increased IOP Trauma
Surgery Nasolabial folds – most evident sign of facial
Trabeculectomy symmetry
Peripheral iridectomy
Uveitis – inflammation of the iris I. ACOUSIC/VESTIBULOCOCHLEAR
Keratitis – inflammation of the cornea A. Controls balance or kinesthesia (position sense/ movement
and correlation of body in space)
2. Cataract 1. Organ of corti (true sense organ for hearing) for
Loss of central vision Glaring or hazy vision hearing
Opacity of lens, milky white appearance of cornea, 2. Cochlea – snail-shaped organ in middle ear
decreased perception to colors B. Disorders
Due to aging 1. Conductive hearing loss
Prolonged UV rays exposure 2. Otitis Media
Congenital disorder – very rare 3. Meniere’s disease
DM
Dx: Ophthalmoscopic examination Archimedes Principle – buoyancy (pregnancyfetus)
Tx: Mydriatics, cycloplegics (cyclogil) – paralyzes Dalton’s – Law of Partial Pressure
ciliary muscles Inertia - Kinesthesia
Surgery: lens extraction
ECLE – partial removal of cataract II. GLOSSOPHARYNGEAL – taste; posterior 1/3 tongue
ICLE – capsule included, total removal of III. VAGUS – gag reflex, decreased vital signs, eyes constrict, mouth
cataract moist PNS
3. Retinal Detachment – most common complication IV. SPINAL/ACCESSORY controls 2 muscles:
following lens extraction A. Sternocleidomastoid (neck)
Curtain veil like vision B. Trapezius (Shoulder)
Leads to blindness V. HYPOGLOSSAL – tongue movement; frenulum linguae –
Severe myopia – common cause anchors tongue (tongue tied – short frenulum)
Emetropia – normal refraction of eyes
Presbyopia – loss of lens elasticity due to
aging DEMYELINATING DISEASES
(+) floaters – d/t seepage of RBCs
Surgery: Scleral Buckling, Diathermy (heat I. ALZHEIMER’S DISEASE - atrophy of the brain tissue
application), Cryosurgery (cold application) characterized by:
a. Amnesia
4. Macular degeneration – degeneration of macula lutea b. Agnosia – (-) sense of smell
(yellowish spots in center of retina) c. Apraxia – (-) purposive movements
Black spots d. Aphasia
Yellowish spots in center of retina or the macula 1. Expressive/Broca’s – problem in speaking
lutea 2. Receptive/Wernickes – problem in understanding;
USUAL FOR ALZHEIMER’S
III. OCULOMOTOR 3. Broca’s area – motor speech center; frontal
IV. TROCHLEAR It innervates mov’t of EOMs 4. Wernickes’ area – general interpretative area;
V. ABDUCENS temporal
e. ARICEPT – drug of choice, given at HS
COGNEX also given
SR IO (trochlear)
(Abducens) LR MR
IR SO
A. Normal response – PEBRTLA/ PERRLA (isocoria)
B. Anisocoria – unequal pupils
C. Nystagmus – Rhythmical oscillation of the eyeballs, either
pendular or jerky; can be seen in MS, dilantin toxicity.
VI. TRIGEMINAL – largest cranial nerve with 3 branches; sensory
and motor.
A. Ophthalmic branch
B. Maxillary branch
C. Mandibular branch
D. Sensory – controls sensation of face and teeth, mucous
membrane and corneal reflex
E. Motor – Mastication or chewing
F. Trigeminal Neuralgia – characterized by severe pain upon PICK’S Disease: a form of dementia wherein there is damage in the
chewing, dysphagia frontoparietal area
1. avoid foods with extreme temperature
2. DOC: carbamazepine (Tegretol) II. MULTIPLE SCLEROSIS – chronic, intermittent disorder of
the CNS characterized by white patches of demyelination of the
VII. FACIAL brain and spinal cord. IDIOPATHIC, AUTOIMMUNE
A. Sensory – anterior 2/3 of tongue; identify taste without
swallowing A. INCIDENCE RATE: 15-35 yo, females
B. Motor – facial expression control B. PREDISPOSING FACTOR
1. instruct patient to smile, frown or raise eyebrows 1. Slow growing virus
Bell’s palsy or (temporary) facial paralysis – 2. Autoimmune – body produces antibodies which attacks
damage to facial nerve caused by: normal cells
Forceps delivery - #1 cause 3. REVIEW: ANTIBODIES
Autoimmune IgG – passes placenta (gestational)
Stress IgA – found in bodily secretions, colostrums
MS 4 Abejo
5. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
IgM – acute infections (mabilis) Brought about by increase in the three intracranial components
IgE – allergic reactions
IgD – Chronic infections (dalas) A. PREDISPOSING FACTORS
a. Head injury
b. Tumor
c. Localized abscesses
d. Cerebral edema
e. Hydrocephalus
f. Hemorrhage
g. Inflammatory conditions
1. Meningitis
2. Encephalitis
B. SIGNS AND SYMPTOMS
a. Early signs
1. Decreased or change in LOC
2. Restlessness to confusion
3. Disorientation
4. Lethargy to stupor
5. Stupor to coma
b. Late signs
C. CLINICAL MANIFESTATION 1. Changes in the vital signs
1. Visual disturbances Elevated BP (SBP rising, DBP constant)
Blurring of vision N Pulse Pressure: 40 mmHG
Diplopia HR decreased
Scotoma (blind spot) RR decreased (Cheyne-Stokes respiration: normal
2. Impaired sensation to touch, pain, pressure, heat and rhythmic respiration followed by periods of apnea)
cold Elevated temperature
Tingling sensation 2. Headache, papilledema, projectile vomiting
Paresthesia 3. Abnormal posturing- decorticate (flexion) – damage to
Numbness corticospinal tract (spinal cord and cerebral cortex)
3. Mood swings remember: deCORDThreecate OR decerebrate
Euphoria – sense of well-being (extension): upper brain stem damage – pons, midbrain,
4. Impaired motor activity cerebellum
Weakness 4. Unilateral dilation of pupil (ANISOCORIA) –
Spasticity indicates uncal brain herniation; if bilateral dilatation:
Paralysis tentorial herniation
5. Impaired cerebellar function 5. possible seizures
CHARCOT’S TRIAD: ataxia (unsteady gait), 6. Cushing’s reflex (hypertension with bradycardia)
nystagmus, intentional tremors
Scanning speech o SHOCK – inadequate tissue perfusion
6. Urinary retention or incontinence o HYPOXIA – inadequate tissue oxygenation
7. Constipation
8. Decrease in sexual capacity C. NURSING MANAGEMENT
1. maintain patent airway and adequate ventilation by:
D. DIAGNOSTIC PROCEDURE prevention of hypoxia ( cerebral edema
1. CSF Analysis LT: reveals increased CHON and IgG increased ICP) and hypercarbia (CO2 retention)
2. MRI – site and extent of demyelination cerebral vasodilation increased ICP
decreased tissue perfusion possible shock
F. NURSING MANAGEMENT: Palliative Early signs of hypoxia
1. Administer medications as ordered Restlessness
Acute Exacerbation Agitation
ACTH (Adrenocorticotropic hormone) – Tachycardia
reduces edema at site of demyelination Late signs of hypoxia
thereby preventing paralysis; compression of Bradycardia
spinal cord will lead to paralysis Extreme restlessness
Baclofen (Lioresal), Dantrolene Na – to reduce Dyspnea
muscle spasticity Cyanosis
Interferons Increased CO2 – most potent respiratory
Immunosuppressives stimulant in the normal person (irritates medulla
Diuretics oblongata)
PROPHANTHELENE BROMIDE (PRO-BANTHENE) – Decreased O2 – stimulates respiration in CRDS
anti-cholinergic for urinary incontinence Suctioning should only last for 10 -15 seconds and
2. Provide for Relaxation application of suction should be done upon
DBE, biofeedback, yoga withdrawal of catheter in a circular fashion.
3. Retain side rails
4. Prevent complications of immobility – TTS Q2h, Q1 h 2. Assist in mechanical ventilation
for elderly, 20 minutes only on affected side 3. Elevate head of bed 30-45 degrees with neck in neutral
5. Increase OFI, high fiber diet (for constipation), acid- position when contraindicated to promote venous
ash in diet to acidify urine to prevent bacterial drainage
multiplication (cranberry juice, prunes, grape juice, 4. Limit fluid intake to 1.2-1.5 l per day (Forced fluids =
vitamin c, plums, orange and pineapple juice.) 2-3 L/day)
6. Provide catheterization for urinary retention 5. Monitor VS, NVS, I/O strictly
6. Prevent complications of immobility
7. Prevent further increase in ICP
Provide comfortable environment
Avoid use of restraints fractures
INCREASED INTRACRANIAL PRESSURE 8. Keep side rails up
MS 5 Abejo
6. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
9. Avoid valsalva maneuver SE: major depression suicidal ideation
Straining of stools (give laxatives/stool softeners) Linked to Breast Ca development
Excessive vomiting (give Metoclopramide (plasil) SBE is done 7 days after menstruation
– anti-emetic) Breast Ca - #1 Ca in women
Lifting of heavy objects Cervical Ca - #2 Ca in women
Bending or stooping 1. multiple sex partners
10. Administer medications as ordered 2. early pregnancy
Osmotic Diuretics – Mannitol (Osmitol) –
Ovarian Ca - #3 Ca in women
cerebral diuresis
Monitor VS especially BP (SE: Hypotension mammography lasts for 10-20 minutes
resulting from hypovolemia) Methyldopa (Aldomet) – has anti HPN properties
Monitor I/O qH Haloperidol (Haldol) – anti-psychotic
Given via side drip, fast drip to avoid NEUROLEPTIC MALIGNANT SYNDROME
precipitate formation (NMS)
Instruct client that a flushing sensation will Tremors, tachycardia, tachypnea, fever
be felt as drug is introduced Phenothiazides – anti-psychotic
Loop Diuretics via IV push – Furosemide PHENERGAN – only anti-psychotic with anti-
BP emetic properties
Monitor 1/0 q1, notify if <30cc/hr
IV push Lasix effect in 10-15 minutes, B. CLINICAL MANIFESTATION
max 6 hours; best given in AM to prevent 1. PILL ROLLING TREMORS of the extremities – first sx
sleep interruption 2. Bradykinesia – second sx
Corticosteroids 3. Rigidity (―cogwheel type‖) – third sx
Dexamethasone (decadron) 4. Stooped posture, SHUFFLING GAIT, propulsive gait
Steroids administered 2/3 in AM to 5. Overfatigue
mimic diurnal rhythm 6. Mask-like facial expression, decreased blinking of the
Hydorcortisone eyelids
Prednisone 7. Difficulty in rising from sitting position
Mild Analgesic 8. Quiet monotone speech
Codeine sulfate 9. Mood lability depression suicide
Anti-Convulsant 10. Increased salivation, drooling type
Pheytoin (Dilantin) 11. Autonomic changes
Increased sweating and lacrimation
Seborrhea
Benadryl is given at HS because it causes drowsiness
Constipation
Levothyroxine is given in AM to prevent insomnia
Decreased sexual capacity
III. PARKINSON’S DISEASE – (degenerative disease) chronic
progressive disorder of the CNS characterized by degeneration of
the dopamine producing cells in the substantia nigra of the
midbrain and basal ganglia (areas of gray matter in both
hemispheres which is involved in the extrapyramidal tract)
IRREVERSIBLE, IDIOPATHIC
C. NURSING MANAGEMENT (palliative)
1. Administer medications as ordered
Anti-Parkinsonian Agents increase dopamine
relieves rigidity (CAPABLES!)
Levodopa (L-dopa) – short acting
A. PREDISPOSING FACTORS dopaminergic
1. Poisoning Amantadine HCl (Symmetrel) – long acting
Lead (ANTIDOTE: Ca EDTA – heavy metal dopaminergic
antagonist) Carbidopa (Sinemet) – long acting
Carbon Monoxide decreased capacity of dopaminergic
hemoglobin to carry oxygen cherry red skin
SE: (GIT) anorexia, nausea and vomiting,
color
orthostatic hypotension, hallucination,
2. Arteriosclerosis
arrhythmia
3. Hypoxia – inadequate tissue perfusion
4. Encephalitis Contraindications: narrow angle closure
5. Drugs glaucoma loss of peripheral vision
Reserpine (Serpasil) tunnel vision halos in light; normal IOP =
Has anti HPN properties 12-21 mmHg
Promote safety when giving this drug
MS 6 Abejo
7. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Also contraindicated in patient’s taking C. CLINICAL MANIFESATION
MAOI’s (Avoid tryptophan and tyramine in 1. PTOSIS – INITIAL SIGN
pts taking MAOI’s) Check palpebral fissure drooping of upper
Administer with food or snack to lessen GIT eyelids
irritation 2. Double vision
Inform client that stools/urine maybe 3. Mask like facial expression
darkened 4. Weakened laryngeal muscles dysphagia (difficulty
INSTRUCT CLIENT TO AVOID FOODS RICH IN of swallowing, without food); odynophagia ang with
VITAMIN B6--PYRIDOXINE (Cereals, organ food
meat, green leafy vegetables) – reverses 5. Hoarseness of voice
therapeutic effect of levodopa 6. Respiratory muscle weakness respiratory arrest;
Anti-cholinergics – relieves tremors prepare trache set at bedside
Relieves tremors 7. Extreme muscle weakness especially during activity or
Artane and Cogentin exertion in AM
Mode of action: increases dopamine
SE: SNS D. DIAGNOSTICS
Antihistamine – relieves tremors 1. TENSILON TEST (EDROPHONIUM HCL)
Diphenhydramine HCl (Benadryl) Temporary relief of symptoms
SE: Strengthens muscles temporarily
Drowsiness – adult Pt, temporarily can open eyelids, increased muscle
CNS excitement and hyperactivity – children strength 5-10 minutes after admin
Dopamine Agonists – relieves tremors and
rigidity
Bromocriptine HCl (Parlodel) E. NURSING MANAGEMENT
Airway
SE: CNS Depression
Aspiration
No OCP’s decreased effect Immobility
2. Maintain side rails to prevent injuries related to falls 1. Maintain patent airway and adequate ventilation
3. Prevent complications of immobility Assist in mechanical ventilation
4. Maintain good nutrition. Provide dietary intake that is Assess PFT (decreased Vital Lung Capacity)
low in protein in AM and high protein at night to 2. Monitor Strictly VS, IO, NVS, motor grading scale
induce sleep (muscle strength)
TRYPTOPHAN – induces sleep 3. Maintain side rails
5. Assists in passive ROM exercises to prevent 4. institute NGT feeding to prevent aspiration
contractures. Q4h for proper body alignment. 5. prevent complications of immobility – q2 turning, q1
6. Increased OFI is encouraged and increased Fiber in the for elderly
diet for constipation 6. Administer meds as ordered
7. Ambulate with assistance Corticosteroids – for immunosuppression
8. Assist in STEROTAXIC THALAMOTOMY Cholinergic/Anticholinergic agents
COMPLICATIONS: SUBARACHNOID HEMORRHAGE,
Mestinol (Pyridostigmine)
ENCEPHALITIS, CEREBRAL ANEURYSM Neostigmine (Prostigmin)
Monitor for the two types of crisis
IV. MYASTHENIA GRAVIS (MG) – neuromuscular disorder
characterized by a disturbance in the transmission of impulses
Myasthenic Crisis Cholinergic Crisis
from nerve to muscle cells at the neuromuscular junction (or
motor end plate – site of exchange of neurotransmitters) Causes: undermedication, stress, Cause: overmedication
infection
IDIOPATHIC; DECENDING MUSCLE WEAKNESS
S/sx: (-) seeing, swallowing, speaking, S/sx: PNS, increased
breathing salivation aspiration
Tx: admin cholinergic agents as ordered Tx: anticholinergic agents,
atropine sulfate
Monitor for BRITTLE CRISIS: characterized by severe respiratory
muscle weakness and exertioal discomfort. Prepare trache set.
7. Assist in
THYMECTOMY – removal of thymus which is
believed to produce autoimmunity
Plasmaparesis – filtering of blood; removal of
autoimmune antibodies in the blood
8. Prevent complications respiratory arrest
9. Prepare trache set in pts with MG
V. MENINGITIS – inflammation of the meninges of the brain and
spinal cord
Meninges – 3fold membrane that covers the brain and
spinal cord
For support and protection
For blood supply
A. INCIDENCE RATE
For nourishment
1. Women aged 20-40 years old
Dura mater - outermost
Subdural space – between dura and arachnoid
B. PREDISPOSING FACTORS
Arachnoid mater - middlemost
1. Autoimmune
Subarachnoid space where CSF circulates; location
Involves release of CHOLINESTERASE an
where aspirate is taken during LT (puncture either bet l3-l4
enzyme which destroys Ach descending muscle
or l4-l5 because it is above these areas where the spinal cord
weakness
terminates)
Pia mater – ―gentle mater‖
MS 7 Abejo
8. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
VI. CEREBROVASCULAR ACCIDENTS (Stroke, brain attack,
A. ETIOLOGIC AGENTS cerebral thrombosis, apoplexy) – partial or total disruption in the
1. MENINGOCOCCUS – MOST DANGEROUS blood supply of the brain, usually in the MCA or ICA (2 largest
2. Pneumococcus cerebral arteries)
3. Streptococcus – adult
4. Hemophilus influenzae – pedia A. INCIDENCE RATE – 2-3x higher in males than in females
B. MODE OF TRANSMISSION – airborne transmission via B. PREDISPOSING FACTORS
droplet infection 1. Thrombosis – attached clot, #1 cause of stroke
C. CLINICAL MANIFESTATION 2. Emboli – detached/wandering thrombosis
1. Headache, photophobia, projectile vomiting Pulmonary embolism
2. Fever, chills, anorexia, generalized body malaise, Sudden sharp chest pain
weight loss Unexplained dyspnea
3. decorticate (deCORDthreecate) and or decerebrate Tachycardia
4. Possible seizure and increased ICP Palpitation
5. Signs of meningeal irritation Diaphoresis
Nucchal rigidity Cerebral embolism
Opisthotonus – rigid arching of the head Headache
(+) kernig’s sign – leg pain Dizziness
(+) brudzinksi’s sign – neck pain Disorientation
Change in LOC that may lead to coma
D. DIAGNOSTICS 3. Hemorrhage
1. Lumbar puncture (lumbar or spinal tap)
Nursing management for before LT
Obtain informed consent
Explain procedure to client
Empty bowel and bladder for comfort
Encourage client to arch back to clearly
visualize spinal columns
Nursing management post LT
Flat on bed for 12-24 hours to prevent spinal
headaches and CSF leakage
Forced fluids
Check puncture site for any discoloration,
drainage and leakage to tissues
ASSESS FOR MOVEMENT AND SENSATION OF
EXTREMITIES (MOST IMPORTANT)
CSF analysis will reveal
Increased CHON and WBC
Decreased Glucose C. RISK FACTORS
Increased CSF opening pressure 1. HPN
N = 50-160 mmHg 2. DM
(+) cultured microorganisms 3. Atherosclerosis MI
These confirm presence of meningitis 4. Valvular heart disease, Mitral/post-cardiac
2. CBC Reveals surgery/mitral valve replacement mlt CVA
Increased WBC 5. Lifestyle
Smoking
E. NURSING MANAGEMENT Sedentary lifestyle
1. Complete bed rest Obesity (more than 20% ideal body weight)
2. Administer medications as ordered Diet rich in saturated fats
Broad Spectrum Antibiotics Hyperlipidemia – genetic; (+) genes that easily
Penicillin alteration in the N flora of the binds to cholesterol
GI superinfection diarrhea Type A personality
Analgesics Deadline driven person
Antipyretics Does several things at the same time
3. Institute strict respiratory isolation after initiation of Feels guilty when not doing anything
antibiotic therapy Prolonged use of oral contraceptives
4. Institute ICP monitoring Macropil estrogen
5. Dim environment d/t photophobia Minipil progestin
6. Monitor strictly VS, IO and NVS Increases lipolysis breakdown of lipids
7. Maintain F and E balance atherosclerosis HPN CVA
8. Prevent complications of immobility: turn to sides q2
9. Health Teaching and D/C planning D. CLINICAL MANIFESTATION
Dietary intake increased in calories with small 1. TRANSIENT ISCHEMIC ATTACK – initial sign of CVA
frequent feedings (increase carbohydrates) Headache, dizziness, tinnitus, visual and speech
Prevent complications disturbances, paresis to plegia, increase in ICP
HYDROCEPHALUS possible, cheyne-stokes respirations
HEARING LOSS (NERVE DEAFNESS) 2. Stroke in evolution – progression of S/sx
Visit audiologist for audiometric screening 3. Complete Stroke – resolution phase characterized by
after resolution of meningitis still dizziness and headache
Rehabilitation for residual deficits Cheyne-stokes respirations
Mental retardation or delay and psychomotor Anorexia
development Nausea and vomiting
Singit lang to: pag post repair ng Dysphagia
myelomeningocoele checkup with (+) Kernigs and Brudzinksi’s
urologist baka na-hit ung bladder Focal Neurological Deficits
Plegia
Aphasia
MS 8 Abejo
9. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Dysarthria – speaking difficulty VII. GUILLAINE-BARRE SYNDROME (GBS) – CNS disorder
Alexia – reading difficulty characterized by bilateral, symmetrical, polyneuritis leading to
Agraphia – writing difficulty ascending muscle weakness/paralysis.
Homonymous hemianopsia –loss of ½ vision
field A. Cause – IDIOPATHIC
Unilateral neglect B. PREDISPOSING FACTORS
1. Autoimmune
E. DIAGNOSTICS 2. antecedent viral infection
1. CAT scan 3. immunizations such as your flu vaccine
2. Cerebral Arteriography – reveals site of lesion
Informed consent C. CLINICAL MANIFESTATION
Allergies to seafood 1. CLUMSINESS – INITIAL SIGN
Post-dx: forced fluids and check for presence of 2. Dysphagia
hematoma 3. Ascending muscle weakness paralysis
4. Decreased DTRs
F. NURSING MANAGEMENT 5. Alternate hypertension and hypotension; MOST FEARED
1. Maintain patent airway and adequate ventilation COMPLICATION: ARRHYTHMIAS
Assist in mechanical ventilation 6. Autonomic changes
Administer oxygen as ordered Increased sweating and lacrimation
2. Restrict Fluids Increased salivation
3. Elevate head of bed, 30-40 degrees to promote venous Constipation
drainage
4. Avoid activities that cause valsalva maneuver D. DIAGNOSTICS
5. Prevent complications of immobility 1. CSF Analysis : reveals elevated CHON and IgG
Prevent bed sores and hypostatic pneumonia CSF is produced in the choroid plexus
TTS q2
Use of egg crate mattress or water bed E. NURSING MANAGEMENT
Sand bag/foot board to prevent foot lag 1. Maintain patent airway and ventilation
6. Institute NGT feeding Assist in mechanical ventilation
7. ROM exercises q4h to prevent contractures and 2. Maintain side rails (paralysis)
promote proper body alignment 3. prevent complications of immobility
8. Alternative means of communication 4. institute NGT feeding
Non verbal cues 5. Administer medications as ordered
Magic slate or picture board Anticholinergics – Atropine Sulfate
9. If positive for hemianopsia, approach client on Corticosteroids – to suppress immune response
unaffected side Anti-arrhythmic agents
10. Administer meds as ordered Lidocaine (Xylocaine)
Osmotic diuretics Bretyllium – Blocks norepinephrine
Mannitol (Osmitrol) Quinidines – anti-arrhythmic, anti-malarial
Corticosteroids (Malaria –king of tropical diseases kaya ang
Dexamethasone (Decadron) meds ay queen = quinines) Common SE:
Mild Analgesics QUINCHONISM :
Codeine Sulfate Female anopheles – malaria, night biting, lay
Thrombolytics eggs in the morning
Streptokinase Female aegis egyptis – dengue, day biting,
Urokinase lay eggs at night, 4 o’clock habit
Tissue Plasminogen Activity Factor (TPAF) Plasmodium falciparum – most dangerous
Monitor for bleeding form of malaria hemorrhage
Anti-coagulants as ordered. 6. Assist in plasmaparesis
Heparin check PTT – if prolonged, 7. Prevent complications
indicates bleeding give protamine sulfate ARRHYTHMIAS
when overdosed RESPIRATORY ARREST
Coumadin check PT – if prolonged,
indicates bleeding vitamin K VIII. CONVULSIVE DISORDERS
(aquamephyton) as antidote A disorder of the CNS characterized by paroxysmal
Given together because coumadin will take seizures with or without loss of consciousness, alternation in
effect after 3 days still sensation and perception, abnormal motor activity and
Loop-diuretics changes in behavior; IDIOPATIHIC
Lasix (okay to administer in DM pts but Febrile seizures are normal for children below 5 years only;
monitor CBG) can be outgrown
Anti-platelets Febrile seizures in children >5 yo = abnormal
ASA – anti-thrombotic SEIZURE – first convulsive attack
Contraindicated in dengue, ulcers and EPILEPSY – series of seizure activity
unknown cause of headache potentiates
bleeding
11. Health Teaching
Avoid modifiable risk factors
Avoid / prevent complications: Sub-arachnoid
hemorrhage
Diet modification: low saturated fat, sodium and
caffeine
Rehabilitation for focal neurologic weakness
Importance of ffup care and strict compliance to
medications
MS 9 Abejo
10. Lecture Notes on Neurologic Nursing
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
A. PREDISPOSING FACTORS Diazepam (Valium) – for status epilepticus
1. Head injury secondary to birth trauma Carbamazepine (Tegretol)
2. Lead poisoning Also used for Trigeminal neuralgia (Tic
3. Genetics Dolor)
4. Brain tumor Phenobarbitals (Luminal)
5. Nutritional and metabolic deficiencies 4. Institute seizure and safety precautions
6. Sudden withdrawal of anti-convulsive drugs Post-seizure:
Causes STATUS EPILEPTICUS O2 inhalation
DOC: diazepam, glucose Suction apparatus
7. Physical and emotional stress 5. Monitor and document the following
Onset and duration
B. TYPES OF SEIZURES Type of seizure
1. Generalized Duration of post-ictal sleep increased length of
Grand Mal (Tonic-Clonic) sleep can lead to status epilepticus
With or without an aura 6. Assist in CORTICAL RESECTION
Epigastric pain – initial sign of an aura (aura
is an initial sign of seizures) For a one year old client suffering grand mal seizures:
Visual auditory olfactory tactile NOT Mouthpiece Eh onte lang teeth ng one year
sensory experience old eh
Epileptic cry Give pillows support for the head (For banging of
Fall head during seizure activity)
Loss of consciousness for 3-5 minutes
Tonic-clonic contractions
Direct symmetrical extension of extremities
Shaking/convulsive activity
Post-ictal sleep (unresponsive sleep)
Petit Mal (Absence Seizure)
S/sx:
Blank stare
Decreased blinking of the eyes
Twitching of the mouth and loss of
consciousness for 5-10 seconds
2. Partial Seizures
Jacksonian seizure (focal seizures) –
characterized by tingling and jerky movements of
index finger and thumb spreads to shoulders
Psychomotor seizure (focal-motor seizures) –
characterized by:
Automatism – stereotype, non-repetitive and
non-purposive behavior
Clouding of consciousness – not in contact
with reality
Mild hallucinating sensory experience
3. Status Epilepticus – continuous uninterrupted seizure
activity that if left untreated may lead to hyperpyrexia
coma death
Increased electrical activity in brain increased
metabolism increased glucose and oxygen use,
increased temperature coma death
DOC: Valium, Glucose
C. DIAGNOSTICS
1. CT-SCAN – brain lesion d/t head trauma
2. EEG – hyperactivity of brain waves (all elevated)
Alpha, beta, delta, theta waves
D. NURSING MANAGEMENT
1. Maintain patent airway and promote safety before
seizure activity
Clear the site of sharps, harmful objects
Loosen clothing of the patient
Avoid use of restraints fractures
Maintain side rails
Turn head to side to prevent aspiration
Tongue guard is between mouth and teeth to
prevent biting of the tongue
2. Avoid precipitating stimulus
Bright/glaring lights
Noise
3. Administer medications as ordered
Phenytoin (Dilantin)
Gingival Hyperplasia
Use soft-bristled toothbrush
Ataxia
Nystagmus
Hirsutism
MS 10 Abejo