NEUROLOGIC ASSESSMENT

Teacher: Mrs. Mason – Module: 9 HINKLE 60 & 61, KARCH 23, 26, 29-31, PORTH 13 & 16 – Exam: 5 –
Lecture Notes

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Anatomic and Physiologic Overview

• The nervous system, along with the endocrine system, are types of communication systems
within the body. The nervous system responds quickly with a short duration where the
endocrine system is slow to respond but has a longer duration.
• The nervous system consists of two major parts. Those parts are:
o ____central nervous system_____
o ____peripheral nervous system ________
o The brain and the spinal cord are included in which part of the nervous system?
 __________CNS______________________________
o The cranial nerves, spinal nerves, and autonomic nervous system are included in which
part of the nervous system?
 _____________PNS_________________________
o Function of the nervous system is to control motor, sensory, autonomic, cognitive, and
behavioral activities.

Cells of the Nervous System

• Basic Functional Unit is Neuron

• Neurons are composed of ____dendrites____, __cell body__________, and an ____axon____.
• Which part receives electrochemical messages?
___________dendrites__________________________________
• Which part carries electrical impulses?
_______________axon_______________________________________
o Myelin helps to increase conduction speed. Therefore, anything that interferes with
myelin or the pathway in which it travels, the client will exhibit motor function and
other challenges.
• Clusters of cell bodies with the same function is the center.
• Glial cells help to nourish, protect, and support neurons. If glial cells are damaged, or not
present in the number needed by the body, the neurons are not able to fully function.

Neurotransmitters

• Neurotransmitters (chemical messengers) help to communicate messages from one

neuron to another or from neuron to a _________target cell______________.
• A target cell can be of muscle or endocrine origin. For everything to work properly,
there needs to be sufficient production and release of neurotransmitters along with
adequate number of neurons and target cell receptor sites.
• Neurotransmitters aren’t distributed randomly but are localized to certain groups of
neurons and released in specific pathways.
• Neurotransmitters are manufactured and stored in synaptic vesicles. Its release into
the synapse is stimulated by the electrical impulse which traveled down the axon.

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• Once released, the neurotransmitter must bind to a receptor site on the postsynaptic
cell membrane of another neuron, muscle cell, or endocrine cell.
• Neurotransmitters can either ________excite_______________ or
__________inhibit___________ activity of the target cell. Increased release or production
usually results in excitatory effects whereas a decrease in production or release
results in inhibitory effects.

Neurotransmitters Cont’d

• Imbalances in neurotransmitters result in neurologic dysfunction or disease.

• An example of some neurotransmitters are: acetylcholine, norepinephrine, dopamine,
and serotonin.
• ___Acetylcholine______ is usually thought to give an excitatory result but
parasympathetic stimulation can result in inhibitory responses as frequently seen in
vagal nerve stimulation which can slow the heart rate. Myasthenia Gravis is
associated with this neurotransmitter.
• ___________Serotonin_____________ helps to control mood and sleep and can play a part
in pain pathways. Remember the mental health medications you have learned about.
• ________Dopamine______________ can affect behavior, attention, emotion, and fine
motor movement. This neurotransmitter dysfunction is seen in Parkinson’s Disease.
• _____________Norepi__________________________ gives an excitatory response.
• ______Endorphin________________ & _______enkephalin____________________ are Morphine
like transmitters and play role in pain reduction and pleasure sensation.

Brain

• brain weighs approximately 1400 g, whereas in an average older adult, the brain
weighs approximately 1200 g
• divided into three major areas: the cerebrum, the brain stem, and the cerebellum.
The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus,
and the basal ganglia. The brain stem includes the midbrain, pons, and medulla. The
cerebellum is located under the cerebrum and behind the brain stem
• Cerebrum: The outside surface of the hemispheres has a wrinkled appearance that is
the result of many folded layers or convolutions called gyri (increase the surface area
of the brain)
o The external or outer portion of the hemispheres (the cerebral cortex) is made
up of gray matter
o White matter makes up the innermost layer and is composed of myelinated
nerve fibers
o Cerebral hemispheres are divided into pairs of lobes:
 Frontal Lobe:
 largest lobe, located in the front of the brain
 concentration, abstract thought, information storage or memory,
and motor function
 contains Broca area, which is in the left hemisphere and is critical
for motor control of speech
 also responsible in large part for a person’s affect, judgment,
personality, and inhibitions

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 Parietal:
 predominantly sensory lobe posterior to the frontal lobe
 analyzes sensory information and relays the interpretation of this
information to other cortical areas and is essential to a person’s
awareness of body position in space, size and shape discrimination,
and right–left orientation
 Temporal:
 located inferior to the frontal and parietal lobes
 auditory receptive areas and plays a role in memory of sound and
understanding of language and music
 Occipital:
 posterior to the parietal lobe
 visual interpretation and memory
o Corpus callosum: thick collection of nerve fibers that connects the two
hemispheres of the brain, is responsible for the transmission of information
from one side of the brain to the other
 Information transferred includes sensation, memory, and learned
discrimination.
 Right-handed people and some left-handed people have cerebral
dominance on the left side of the brain for verbal, linguistic, arithmetic,
calculation, and analytic functions.
 The nondominant hemisphere is responsible for geometric, spatial,
visual, pattern, and musical functions. Nuclei for cranial nerves I and II
are also located in the cerebrum
o Thalami:
 lie on either side of the third ventricle and act primarily as a relay station
for all sensation except smell.
 All memory, sensation, and pain impulses pass through this section of
the brain.
 "relay station" for all incoming motor movement and sensory stimulation
except for smell; hearing, sight, taste, touch; plays role in consciousness
(wake, sleep, alert); assists in processing and regulating emotion
o Hypothalamus:
 regulates the pituitary secretion of hormones that influence metabolism,
reproduction, stress response, and urine production
 maintains temperature regulation by promoting vasoconstriction or
vasodilatation
 hunger center: appetite control
 contains centers that regulate the sleep–wake cycle, blood pressure,
aggressive and sexual behavior, and emotional responses (e.g., blushing,
rage, depression, panic, fear)
 links neuro and endocrine system; blood pressure bc it regulates
autonomic nervous system; strongly influences bodies ability to maintain
homeostasis
o Basal ganglia:
 masses of nuclei located deep in the cerebral hemispheres that are
responsible for control of fine motor movements, including those of the
hands and lower extremities.
• Brain Stem: consists of midbrain, pons, and medulla oblongata
o Midbrain: connects the pons and the cerebellum with the cerebral hemispheres
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 contains sensory and motor pathways and serves as the center for
auditory and visual reflexes
 cranial nerves III and IV originate here
o Pons:
 situated in front of the cerebellum between the midbrain and the medulla
 a bridge between the two halves of the cerebellum, and between the
medulla and the midbrain
 Cranial nerves V through VIII originate
 contains motor and sensory pathways. Portions of the pons help regulate
respiration
o Medulla:
 Links brain to spinal cord
 Reflex centers for respiration, blood pressure, heart rate, coughing,
vomiting, swallowing, and sneezing are also located in the medulla
 Cranial nerves IX through XII originate
• Cerebellum:
o posterior to the midbrain and pons, and below the occipital lobe
o integrates sensory information to provide smooth coordinated movement
o controls fine movement, balance, and position (postural) sense or
proprioception (awareness of position of extremities without looking at them)
 motor movement regulation and balance control; coordinates gait,
maintains posture, balance, equilibrium; controls muscle tone and
involuntary muscle reaction
• CSF: that is produced in the choroid plexus of the ventricles and circulates around
the surface of the brain and spinal cord
o Blockage of the flow of CSF anywhere in the ventricular system produces
obstructive hydrocephalus
o produced at a rate of about 500 mL/day; the ventricles and subarachnoid space
contain approximately 125 to 150 mL of fluid
o Normal CSF contains a minimal number of white blood cells and no red blood
cells, some Na and electrolytes, protein and glucose; 1.007 specific gravity

• the brain receives approximately 15% of the cardiac output, or 750 mL per minute of
blood flow.

Bones and Sutures of the Skull

• major bones of the skull are the frontal, temporal, parietal, occipital, and sphenoid
bones
o bones join at the suture lines
• meninges (fibrous connective tissues that cover the brain and spinal cord) provide
protection, support, and nourishment. The layers of the meninges are the dura
mater, arachnoid, and pia mater
o Dura matter: outermost layer; covers the brain and the spinal cord. tough,
thick, inelastic, fibrous, and gray.
o Arachnoid: middle membrane; an extremely thin, delicate membrane that
closely resembles a spider web (hence the name arachnoid)
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has cerebrospinal fluid (CSF) in the space below it, known as the
subarachnoid space
 arachnoid villi, which are unique finger-like projections that absorb CSF
into the venous system
o Pia matter: innermost, thin, transparent layer that hugs the brain closely and
extends into every fold of the brain’s surface

Blood Brain Barrier

• gate keeper; protects from toxins, poisons, some dyes and some meds; can be
damaged from trauma, hypoxia, edema
• barrier is formed by the endothelial cells of the brain’s capillaries
• The blood–brain barrier has a protective function but can be altered by trauma,
cerebral edema, and cerebral hypoxemia

Spinal Cord

• continuous with the medulla, extending from the cerebral hemispheres and serving as
the connection between the brain and the periphery
• cross-sectional view, the spinal cord has an H-shaped central core of nerve cell bodies
(gray matter) surrounded by ascending and descending tracts (white matter)
• anterior horns contain cells with fibers that form the anterior (motor) root and are
essential for the voluntary and reflex activity of the muscles they innervate
• thinner posterior (upper horns) portion contains cells with fibers that enter over the
posterior (sensory) root and thus serve as a relay station in the sensory/reflex
pathway
• Spinal Tracts:
o fiber bundles with a common function are called tracts
o six ascending tracts and eight descending tracts
• Vertebral Column:
o 7 cervical, 12 thoracic, and 5 lumbar vertebrae, as well as the sacrum (a fused
mass of 5 vertebrae) and terminate in the coccyx
o Nerve roots exit from the vertebral column through the intervertebral foramina
(openings)\
o vertebrae are separated by discs (except for C1 and C2)

Cranial Nerves

• Twelve pairs of cranial nerves emerge from the lower surface of the brain and pass
through openings in the base of the skull
• Three sensory (I, II, VIII), five motor (III, IV, VI, XI, and XII), and four mixed sensory and
motor (V, VII, IX, and X)

Spinal Nerves

• 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

• Each spinal nerve has a ventral root and a dorsal root.
• The dorsal roots are sensory and transmit sensory impulses from specific areas of the
body known as dermatomes to the dorsal horn ganglia
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• sensory fiber may be somatic, carrying information about pain, temperature, touch,
and position sense (proprioception) from the tendons, joints, and body surfaces; or
visceral, carrying information from the internal organs.
• The ventral roots are motor and transmit impulses from the spinal cord to the body;
these fibers are also either somatic or visceral.
• The visceral fibers include autonomic fibers that control the cardiac muscles and
glandular secretions.

Autonomic Nervous System

• ANS functions to regulate activities of internal organs (heart, lungs, blood vessels,
digestive organs: stomach and intestines, and glands: salivary and sweat) and to
maintain and restore internal __________homeostasis_________________________.
• Sympathetic nervous system
o _____________excitatory__________________ responses (fight or flight)
o Main neurotransmitter is ________norepi________________
o bronchioles dilate for easier gas exchange; the heart’s contractions are stronger
and faster; the arteries to the heart and voluntary muscles dilate, carrying more
blood to these organs; peripheral blood vessels constrict, making the skin feel
cool but shunting blood to essential organs; the pupils dilate; the liver releases
glucose for quick energy; peristalsis slows; hair stands on end; and perspiration
increases
o A sympathetic discharge releases epinephrine (adrenalin)—hence, the term
adrenergic is often used to refer to this division.
o sympathetic storm is a syndrome associated with changes in level of
consciousness, altered vital signs, diaphoresis, and agitation that may result
from hypothalamic stimulation of the sympathetic nervous system following
traumatic brain injury
• Parasympathetic Nervous System
o Controls mostly _______visceral______________ functions
o functions as the dominant controller for most visceral functions; the primary
neurotransmitter is acetylcholine
• Regulated by centers in the spinal cord, brainstem, and the
_______hypothalamus_______.

Assessment of the Nervous System

• History of present illness or health concern

• Past medical health history
• Family history
• Lifestyle and health practices

Cerebrovascular Risk Factors

• Age
• History of TIA or stroke
• Hypertension
• Smoking/tobacco use
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• Chronic alcohol intake
• History of cardiovascular disease
• High cholesterol
• Sleep apnea
• Diabetes mellitus
• Drug abuse
• Inactivity
• High estrogen levels
• Overweight

Assessing Consciousness and Cognition

• Mental status
• Intellectual function
◦ ask the patient to count backward from 100 or to subtract 7 from 100, then 7
from that, and so forth (referred to as serial 7s)
◦ how are a mouse and dog or pen and pencil alike?
◦ patient arrives home without a house key, what alternatives are there?
• Thought content
• Emotional status
• Language ability
• Impact on lifestyle
• Level of consciousness

Cranial Nerves

• I- Olfactory
• II- Optic
• III- Oculomotor
• IV- Trochlear
• V- Trigeminal
• VI- Abducens
• VII- Facial
• VIII- Acoustic/vestibulcochlear
• IX- Glossopharangeal
• X- Vagus
• XI- Spinal accessory
• XII- Hypoglossal

Motor Function

• Ability- Assessing the condition and movement of muscles. Look for size, shape, and
symmetry.
• Strength and tone- Strong against resistance? Flaccid? Spastic? Rigid? fasciculation’s?
tics? Tremors?
• Gait and balance- Steady and upright. Tandem walking. Safety concern
• Romberg test (Negative vs Positive)

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◦ The patient can be seated or stand with feet together and arms at the side,
first with eyes open and then with both eyes closed for 20 seconds. The
examiner stands close to support the standing patient if they begin to fall.
Slight swaying is normal, but a loss of balance is abnormal and is considered
a positive Romberg test.
• Ataxia
◦ Ataxia is an incoordination of voluntary muscle action, particularly of the
muscle groups used in activities such as walking or reaching for objects
• Finger to nose to test for coordination
◦ Point-to-point testing is accomplished by having the patient touch the
examiner’s extended finger and then their own nose. This is repeated several
times.
• Rapid alternating movements
◦ pat their thigh as fast as possible with each hand separately. Then, the
patient is instructed to alternately pronate and supinate the hand as rapidly
as possible. Last, the patient is asked to touch each of the fingers with the
thumb in a consecutive motion. Speed, symmetry, and degree of difficulty
are noted.
• Heel-to-shin test

Figure Used to Record Muscle Strength

• 5 point scale
o 5- is full power and strength
o 4- active movement against gravity and resistance
o 3- active movement against gravity
o 2-active movement with gravity eliminated
o 1-flicker or trace of movement
o 0- no movement at all

Sensory System

• Light touch, pain, and temperature

◦ Tactile sensation is assessed by lightly touching a cotton wisp or fingertip to
corresponding areas on each side of the body. The sensitivity of proximal
parts of the extremities is compared with that of distal parts, and the right
and left sides are compared.
◦ Pain and temperature sensations are transmitted together in the lateral part
of the spinal cord, so it is unnecessary to test for temperature sense in most
circumstances
◦ differentiate between the sharp and dull ends of a broken wooden cotton
swab or tongue blade; using a safety pin is inadvisable because it breaks the
integrity of the skin
• Anesthesia - absence of ____________________________________ sensation)
• Hypesthesia (decreased _____________________________________ to touch)
• Hyperesthesia (increased sensitivity to _______________________________)
• Analgesia (absence of ______________________________________ sensation)
• Hypalgesia (_______________________________________ sensitivity to pain)
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• Hyperalgesia (_____________________________________ sensitivity to pain)
• Vibratory sensation
◦ use of a low-frequency (128 or 256 Hz) tuning fork; the patient is then
instructed to signal the examiner when the sensation ceases. Common
locations used to test for vibratory sense include the distal joint of the great
toe and the proximal thumb joint
• Sensitivity to position
◦ close both eyes and indicate, as the great toe or index finger is alternately
moved up and down, in which direction movement has taken place.
• Tactile discrimination: Stereognosis; proprioception; point localization; graphesthesia;
two-point discrimination
◦ integration of sensation in the brain is evaluated by testing two-point
discrimination. When the patient is touched with two sharp objects
simultaneously, are they perceived as two or as one? If touched
simultaneously on opposite sides of the body, the patient should normally
report being touched in two places. If only one site is reported, the one not
being recognized is said to demonstrate extinction.

• Agnosia is the general loss of ability to recognize objects through a particular sensory
system. The patient can also be shown a familiar object and asked to identify it by
name; inability to identify a visualized object is known as visual agnosia.
• Vibration and position sense are often lost together, frequently in circumstances in
which all other sensation remains intact.

Examining Reflexes

• Reflex or percussion hammer

• Deep tendon reflexes
o reflex hammer is used to elicit a deep tendon reflex
o handle of the hammer is held loosely between the thumb and index finger,
allowing a full swinging motion
o The extremity is positioned so that the tendon is slightly stretched then struck
briskly
• Reflexes that can be assessed are: Biceps Reflex, Triceps Reflex, Brachioradialis
Reflex, Patellar Reflex, Achilles Reflex
o Biceps Reflex: elicited by striking the biceps tendon over a slightly flexed elbow
 examiner supports the forearm at the elbow with one arm while placing
the thumb against the tendon and striking the thumb with the reflex
hammer
 normal response is flexion at the elbow and contraction of the biceps.
o Triceps Reflex: arm is flexed at the elbow and hanging freely at the side
 supports the patient’s arm and identifies the triceps tendon by palpating
2.5 to 5 cm (1 to 2 inches) above the elbow.
 normally produces contraction of the triceps muscle and extension of the
elbow
o Brachioradialis Reflex:
 patient’s forearm resting on the lap or across the abdomen
 gentle strike of the hammer 2.5 to 5 cm (1 to 2 inches) above the wrist
results in flexion and supination of the forearm
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o Patellar Reflex: striking the patellar tendon just below the patella
 sitting or a lying position
 normal response: contractions of the quadriceps and knee extension
o Achilles Reflex:
 foot is dorsiflexed at the ankle and the hammer strikes the stretched
Achilles tendon
 normal response: plantar flexion
• Ankle clonus: reflexes are hyperactive; if foot is abruptly dorsiflexed, it may continue
to “beat” two or three times before it settles into a position of rest; sometimes with
CNS disease this persists, and foot does not come to rest while tendon is stretched
• Plantar reflex: In a person with an intact CNS, if the lateral aspect of the sole of the
foot is stroked, the toes contract and draw together. In a person who has CNS disease
of the motor system, the toes fan out and draw back

• 0: Absent
• 1+: Present but decreased or hypoactive
• 2+: Normal
• 3+: Increased or brisk but not pathologic. No clonus
• 4+: Hyperactive with clonus

• Clonus is rhythmic involuntary muscle movements or contractions

• Superficial Reflexes: present (+) or absent (−); only the corneal, gag, and plantar
reflexes are commonly tested
o Corneal: carefully using a clean wisp of cotton and lightly touching the outer
corner of each eye on the sclera. The reflex is present if the action elicits a blink
 stroke or brain injury might result in loss of this reflex, either unilaterally
or bilaterally.
 Loss of this reflex indicates the need for eye protection and possible
lubrication to prevent corneal damage.
o Palpebral
o Gag: gently touching the back of the pharynx with a cotton-tipped applicator,
first on one side of the uvula and then the other.
 Positive response is an equal elevation of the uvula and “gag” with
stimulation.
 Absent response on one or both sides can be seen following a stroke
 careful evaluation and treatment of the resultant swallowing dysfunction
to prevent aspiration of food and fluids.
o Upper/lower abdominal
o Cremasteric
o Perianal

Gerontologic Considerations

• Decreased ability to see (presbyopia), hear (presbycusis), taste, or smell: nightlights

and carbon dioxide/smoke detectors
• May have reduced muscle mass from degeneration of muscle fibers
• Slowed coordination and voluntary movements
• Decreased fine motor coordination
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• Older adults may experience intentional tremors
• Slower and less certain gait
• Touch sensations may diminish due to atrophy of peripheral nerve endings
• Decreased light touch and pain sensation
• Vibratory sensation at the ankles may decease after age 70
• May have a decrease in reflex action and unstable balance
• Impaired temperature regulation

Diagnostic Evaluation

• Computed Tomography Scanning (CT Scan)

◦ narrow x-ray beam to scan body parts in successive layers
◦ provides cross-sectional views of the brain, distinguishing differences in
tissue densities of the skull, cortex, subcortical structures, and ventricles
◦ (IV) contrast agent may be used to highlight differences further
◦ Brain lesions have a different tissue density from the surrounding normal
brain tissue
◦ Detects: tumor or other masses, infarction, hemorrhage, displacement of the
ventricles, and cortical atrophy
• Magnetic Resonance Imaging (MRI)
◦ powerful magnetic field to obtain images of different areas of the body
◦ magnetic field causes the hydrogen nuclei (protons) within the body to align
like small magnets in a magnetic field
◦ can identify a cerebral abnormality earlier and more clearly than other
diagnostic tests
◦ particularly useful in the diagnosis of brain tumor, stroke, and multiple
sclerosis and does not involve ionizing radiation
• Positron Emission Tomography (PET Scan)
◦ produces images of actual organ functioning
◦ either inhales a radioactive gas or is injected with a radioactive substance
that emits positively charged particles
◦ measurement of blood flow, tissue composition, and brain metabolism and
thus indirectly evaluates brain function
◦ can detect changes in glucose use.
◦ useful in showing metabolic changes in the brain (Alzheimer’s disease),
locating lesions (brain tumor, epileptogenic lesions), identifying blood flow
and oxygen metabolism in patients with strokes, distinguishing tumor from
areas of necrosis, and revealing biochemical abnormalities associated with
mental illness.
• Single-Photon Emission Computed Tomography (SPECT)
◦ three-dimensional imaging
◦ allows areas behind overlying structures or background to be viewed, greatly
increasing the contrast between normal and abnormal tissue
◦ useful in detecting the extent and location of abnormally perfused areas of
the brain, thus allowing detection, localization, and sizing of stroke (before it
is visible by CT scan); localization of seizure foci in epilepsy; detection of
tumor progression; and evaluation of perfusion before and after
neurosurgical procedures.
◦ Pregnancy and breast-feeding are contraindications to SPECT.
• Cerebral Angiography
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◦ x-ray study of the cerebral circulation with a contrast agent injected into a
selected artery
◦ valuable tool in investigating vascular disease or anomalies, it is used to
determine vessel patency, identify presence of collateral circulation, and
provide detail on vascular anomalies that can be used in planning
interventions
◦ threading a catheter through the femoral artery in the groin or the radial
artery of the wrist and up to the desired vessel
• Myelography
◦ x-ray of the spinal subarachnoid space taken after the injection of a contrast
agent into the spinal subarachnoid space through a lumbar puncture
◦ shows any distortion of the spinal cord or spinal dural sac caused by tumors,
cysts, herniated vertebral discs, or other lesions
◦ patient lies in bed with the head of the bed elevated 30 to 45 degrees. The
patient is advised to remain in bed in the recommended position for 4 to 24
hours after
◦ fluid for rehydration and replacement of CSF may decrease the incidence of
post–lumbar puncture headache
◦ blood pressure, pulse, respiratory rate, and temperature are monitored, as
well as the patient’s ability to void.
◦ Complications: nausea, vomiting, headache, fever, stiff neck, seizures,
paralysis of one side of the body, and changes in level of consciousness
• Noninvasive Carotid Flow Studies
◦ ultrasound imagery and Doppler measurements of arterial blood flow to
evaluate carotid and deep orbital circulation.
• Transcranial Doppler
◦ records the blood flow velocities of the intracranial vessels
• Electroencephalography (EEG)
◦ record of the electrical activity generated in the brain
◦ provides an assessment of cerebral electrical activity
◦ useful for diagnosing and evaluating seizure disorders, coma, or organic
brain syndrome
◦ used in making a determination of brain death
◦ baseline recording, the patient lies quietly with both eyes closed. The patient
may be asked to hyperventilate for 3 to 4 minutes or to look at a bright,
flashing light for photic stimulation
◦ sleep EEG may be recorded after sedation because some abnormal brain
waves are seen only when the patient is asleep
◦ Depth recording of EEG is performed by introducing electrodes
stereotactically (radiologically placed using instrumentation) into a target
area of the brain, as indicated by the patient’s seizure pattern and scalp EEG
◦ sometimes recommended that the patient be deprived of sleep the night
before the EEG. Anticonvulsant agents, tranquilizers, stimulants, and
depressants should be withheld 24 to 48 hours before an EEG, because these
medications can alter the EEG wave patterns or mask the abnormal wave
patterns of seizure disorders
◦ Coffee, tea, chocolate, and cola drinks are omitted from the meal before the
test because of their stimulating effect. However, the meal itself is not
omitted, because an altered blood glucose level can cause changes in brain
wave patterns
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◦ standard EEG takes 45 to 60 minutes; a sleep EEG requires 12 hours
◦ Sedation is not advisable
• Electromyography (EMG)
◦ inserting needle electrodes into the skeletal muscles to measure changes in
the electrical potential of the muscles
◦ useful in determining the presence of neuromuscular disorders and
myopathies. It helps distinguish weakness due to neuropathy (functional or
pathologic changes in the peripheral nervous system) from weakness
resulting from other causes.
◦ muscles examined may ache for a short time after the procedure
• Nerve conduction Studies
◦ stimulating a peripheral nerve at several points along its course and
recording the muscle action potential or the sensory action potential that
results
• Evoked Potential Studies
◦ application of an external stimulus to specific peripheral sensory receptors
with subsequent measurement of the electrical potential generated
◦ In neurologic diagnosis, they reflect nerve conduction times in the peripheral
nervous system.
◦ In visual evoked responses, the patient looks at a visual stimulus (flashing
lights, a checkerboard pattern on a screen).
◦ Brainstem auditory evoked responses (BAERs) are measured by applying an
auditory stimulus (repetitive auditory click) and measuring the transit time
via the brain stem into the cortex.
◦ It is also useful in the diagnosis of demyelinating diseases, such as multiple
sclerosis and polyneuropathies, where nerve conduction is slowed.
• Lumbar Puncture (LP) AKA Spinal Tap
◦ A lumbar puncture (spinal tap) is carried out by inserting a needle into the
lumbar subarachnoid space to withdraw CSF (Schreiber, 2019). The test may
be performed to obtain CSF for examination, to measure and reduce CSF
pressure, to determine the presence or absence of blood in the CSF, and to
administer medications intrathecally (into the spinal canal).
◦ The needle is inserted into the subarachnoid space in the widest
intervertebral spaces; between the second and third, the third and fourth, or
fourth and fifth lumbar vertebrae
◦ A lumbar puncture may be risky in the presence of an intracranial mass
lesion because intraspinal pressure is decreased by removal of CSF, and the
brain may herniate downward through the foramen magnum.
◦ patient who is anxious is tense may artificially alter the pressure reading
◦ CSF should be clear and colorless. Pink, blood-tinged, or grossly bloody CSF
may indicate a subarachnoid hemorrhage. The CSF may be bloody initially
because of local trauma but becomes clearer as more fluid is drained
◦ cell count, culture, glucose, protein, and other tests as indicated
◦ post–lumbar puncture headache: ranging from mild to severe, may occur a
few hours to several days after the procedure; throbbing bifrontal or occipital
headache that is dull and deep in character. It is particularly severe on
sitting or standing but lessens or disappears when the patient lies down.
◦ caused by CSF leakage at the puncture site
◦ fluid continues to escape into the tissues by way of the needle track
from the spinal canal. As a result of a leak, the supply of CSF in the
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 NEUROLOGIC ASSESSMENT
cranium is depleted to a point at which it is insufficient to maintain
proper mechanical stabilization of the brain. When the patient assumes
an upright position, tension and stretching of the venous sinuses and
pain-sensitive structures occur
◦ may be avoided if a small-gauge needle (22 gauge)
◦ usually managed with analgesic agents, encouraging hydration,
ingestion of caffeine, and lying supine
◦ Other complications: Herniation of the intracranial contents, spinal epidural
abscess, spinal epidural hematoma, and meningitis are rare but serious
complications of lumbar puncture. Other complications include temporary
voiding problems, slight elevation of temperature, backache or spasms, and
stiffness of the neck.

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Introduction

• How is the brain protected: skull & CSF

• External versus internal protection
• Brain injuries can be categorized by ____traumatic____ or _____nontraumatic_______
• Brain damage can result from _____ischemia___________, ______cerebral edema____,
and ________increased ICP_____________
• Brain injuries can cause changes in LOC, cognition, motor function, and sensory
function

Altered Level of Consciousness

• Brain injury and disease can lead to altered level of consciousness

• Arousal and wakefulness & content and cognition.
• Our earlier lecture mentioned how level of consciousness exits of a continuum. One
side of the continuum is full consciousness, confusion, lethargy, obtundation, stupor,
and then coma
• Full consciousness
• Confusion: disoriented to time, place, person; some memory or command following
difficulties
• Lethargy: oriented to time, place, person but slow to mentally process, move and
speak; react to pain as normal
• Obtundation or obtunded: similar to lethargy; lessened interest in environment, slow
responses to verbal stimulation, never fully arousable; react to painful stimuli;
increased drowsiness
• Stupor: unresponsive except to vigorous and repeated stimulus, may make
incomprehensible sounds and eye openings
• Coma: clinical state of unarousable unresponsiveness in which there are no
purposeful responses to internal or external stimuli, although nonpurposeful
responses to painful stimuli and brain stem reflexes may be present
• Akinetic mutism: state of unresponsiveness to the environment in which the patient
makes no voluntary movement
• Persistent vegetative state: condition in which the patient who is unresponsive
resumes sleep–wake cycles after coma but is devoid of cognitive or affective mental
function.
• Minimally conscious state: patient has inconsistent but reproducible signs of
awareness
• Locked-in syndrome: results from a lesion affecting the pons and results in paralysis
and the inability to speak, but vertical eye movements and lid elevation remain intact
and are used to indicate responsiveness.
• Altered LOC: patient is not oriented, does not follow commands, or needs persistent
stimuli to achieve a state of alertness, not a disorder but a result of
◦ S/S: initially subtle such as restlessness and increased anxiety; pupils
become sluggish then move to fixed (no response to light)
◦ Glasgow scale to determine: 3 (severe impairment of neurologic function,
brain death, or pharmacologic inhibition of the neurologic response) – 15
(fully responsive)
◦ Abnormal pupillary and motor responses, it is assumed that neurologic
disease is present until proven otherwise. If the patient is comatose but
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 MANAGEMENT OF CLIENTS WITH NEUROLOGIC DYSFUNCTION
pupillary light reflexes are preserved, a toxic or metabolic disorder is
suspected
◦ PATENT AIRWAY first (intubation if needed, mechanical ventilator until ability
to breathe on own is determined); circulatory status monitored (BP,HR), IV
cath, nutritional support asap,

Abnormal Posture Response to Stimuli

Painful stimuli (sternal rub or trapezius squeeze) or ammonia under nose

• Decorticate Posturing: flexion of upper extremities, internal rotation of lower, plantar
flexion
• Decerebrate Posturing: outward: extension of upper extremities, outward rotation of
lower, plantar flexion

Brain Death vs Persistent Vegetative State

• Brain death is defined as the _______irreversible___________________ loss of function of

the brain, including the ________brain stem_____________________
• Brain death confirmation must include cause of irreversibility of the condition,
absence of brain stem reflexes and ________motor_____________ responses to pain,
absence of ______________respirations____________ with a PCo2 of 60 mm Hg or more,
and ______________apnea______________________ is confirmed after ventilation with
oxygen for 10 minutes before withdrawal from the ventilator.
• Persistent vegetative state is characterized by loss of all _______cognitive________
functions and unawareness of __________self_______ and surroundings. There is
spontaneous __eye___ opening without concurrent awareness.
• A diagnosis of persistent vegetative state includes: absence of awareness of self and
____________environment________________ and inability to interact with others; No
reproducible voluntary behavior; No language ____comprehension________.
Incontinence.
• Brain stem and hypothalamic function remains intact. They have Sleep-wake cycles.
• Requires enteral feeding

Glasgow Coma Scale

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Response Scale Score
Eye Opening Response Eyes open spontaneously 4 points
Eyes open to verbal command, speech, shout 3 points
Eyes open to pain (not applied to face) 2 points
No opening eyes 1 point
Verbal Response Oriented 5 points
Confused conversation, but able to answer 4 points
questions
Inappropriate responses, words discernible 3 points
Incomprehensible sounds or speech 2 points
No verbal response 1 point
Motor Response Obeys command for movement 6 points
Purposeful movement to painful stimulus 5 points
Withdraws from pain 4 points
Abnormal (spastic) flexion, decorticate posture 3 points
Extensor (rigid) response, decerebrate posture 2 points
No motor response 1 point
Minor Brain Injury = 13-15 Moderate brain injury = 9-12 points Severe brain injury =
points 3-8 points

Particularly useful in acute stage of injury

Assessment of the Unconscious Client

• LOC
• Respiration
• Eyes
• Corneal reflex
• Facial symmetry
• Swallowing
• Neck
• DTR
• Posturing

Collaborative Problems and Potential Complications of Patients

with Altered Level of Consciousness

• Respiratory distress or failure

◦ Vital signs, CBC, ABGs chest pt, suctioning, oral care
• Aspiration

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◦ Epiglottis and tongue may relax occluding airway, elevate head of bed to 30,
lateral or semiprone (jaw and tongue fall forward promoting secretion
drainage), suctioning, oral hygiene; AUSCULTATE CHEST EVERY 8 HOURS
◦ If intubated: maintain patency of tube, frequent oral care, monitor ABGs,
maintain settings of ventilator
• Pneumonia
• Pressure ulcers
◦ Keep bedding dry, turn and no dragging patient, monitor bony prominences
• DVT/VTE/PE
◦ Turn q2h, passive ROM at least twice a day, hand and feet splints rotating
• Contractures
◦ Passive ROM; splints or foam boots prevent footdrop and eliminates the
pressure of bedding on the toes. Trochanter rolls support the hip joints and
keeps the legs in proper alignment. The arms are in abduction, the fingers
lightly flexed, and the hands in slight supination. The heels of the feet are
assessed for pressure areas. Specialty beds, such as fluidized or low–air-loss
beds, may be used to decrease pressure on bony prominence
• Hydration and nutrition
◦ IV fluids to begin (slowly if intracranial conditions bc too fast can increase
ICP), feeding tube if pt doesn’t recover quickly enough
• Oral care
◦ Inspect mouth for dryness/inflammation/crusting; thin coating of petrolatum
on the lips prevents drying, cracking, and encrustations. If the patient has an
endotracheal tube, the tube should be moved to the opposite side of the
mouth daily to prevent ulceration of the mouth and lip
• Eye care
◦ Some unconscious patients eyes are open which can cause irritation, dryness
and scratches which can cause ulceration, Cleanse with cotton balls
moistened with sterile normal saline to remove debris and discharge.
Artificial tears or methylcellulose may be prescribed to provide lubrication;
eye shields are better than patches; avoid cold compresses touching the
cornea
• Bladder and bowel
◦ often incontinent or has urinary retention; scan or palpate; inspect for
drainage and cleanse routinely; as soon as conscious: bladder training
program
◦ listen for bowel Sunds and measure girth with tape measure; immobility can
cause constipation
• Maintenance of temperature
◦ High temp: infection, drug reactions, damage to regulating center; slightly
elevated: dehydration; minimum amount of bedding used and cool room to
65 degrees, meds to reduce, cool sponge bath, monitor temp frequently
• Family support

• Side rails padded and two are kept up during day and three at night
• Touch the patient, talk to pt but do not make negative comments about status or
prognosis, orient to time and place at least q8h, sounds from daily life through
recordings and reading a favorite book or playing favorite music or tv show,

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• When arousing: period of agitation is a good sign, at this time minimize stimulation
(limit background noise, one person speaking to pt at a time, give longer period to
respond, frequent rest and quiet times

Increased Intracranial Pressure

• The brain, blood, and CSF are inside the skull.

• Brain weighs approximately ________3______________________ pounds.
• Blood and CSF each have a volume of ________75______________________ mL’s.
• Monro-Kellie Hypothesis or doctrine: equilibrium
• Failure to reduce increasing ICP will result in _________ischemia_________________ and
____________necrosis______________ of brain tissue
• Minimal fluctuations on intracranial pressure occur normally secondary to increasing
intrathoracic pressure such as when we _______cough____________, sneeze,
_____________strain____________, or heave. Or bend over
• Brain requires constant supply of _____oxygen_______________ and nutrients, primarily
_____________glucose___________ to maintain function

• ICP: normal = 0-10 mmHg with upper limit of 15; sustained over 20 intracranial HTN
• Compensation typically is accomplished by displacing or shifting CSF, increasing the
absorption or diminishing the production of CSF, or decreasing cerebral blood volume

Pathophysiology & Decreased Cerebral Blood Flow

• Various events can alter the relationship between intracranial volume and intracranial
pressure. Examples would be: ____________head injury______________, brain tumor,
_________hemorrhagic events_______________, viral or bacterial infections and
_____________toxins_____________.
• Anything that increases intracranial pressure results in ______decreased______________
cerebral perfusion, increased cerebral __________edema________________, and then
herniation of the brain tissue.
• As ICP _______increases______ we will see a _________decrease________ in cerebral
blood flow which can cause tissue ____________ischemia_______ or death to the tissue.
o Early ischemic changes then results in the systemic pressure increasing in order
to maintain cerebral perfusion.
• Results: bounding bradycardia, BP changes, and irregular respirations
• As the PaCo2 rises we get cerebral vessel ______dilation_(vasodilation)_____ to
increase cerebral blood flow which increases _________ICP_______________.

Pathophysiology & Cerebral Edema

• Cerebral edema or brain swelling is an abnormal accumulation of water or fluid in the

______intracellular_______________ space, _________extracellular________ space, or both.
This increases the pressure inside the skull. (gray, white, interstitial matter)
• Cerebral autoregulation is the ability of the brain to maintain a constant blood flow
over a wide range of metabolic demands and systemic mean arterial pressures. This
is accomplished through _______vasoconstriction__________ or
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 MANAGEMENT OF CLIENTS WITH NEUROLOGIC DYSFUNCTION
__________vasodilation____________ of the cerebral blood vessels. For example: If
metabolic demands rise, the cerebral blood vessels will vasodilate to increase
cerebral blood flow, _____oxygen_________, and _______glucose________ delivery.
◦ When autoregulation is disrupted cerebral blood flow becomes dependent on
cerebral blood pressure
• Additional compensatory mechanism occurs when cerebral edema is present which is
a decreased production and flow of ___________CSF___________________.

Pathophysiology & Cerebral Response to Increased Intracranial

Pressure

• Cerebral perfusion pressure (CPP) is the pressure gradient that drives oxygen delivery
to the cerebral tissue. CPP is regulated by two opposing forces which are
_____________MAP___________________ and ______ICP____________.
◦ Amount of pressure needed to maintain blood flow to the brain
◦ Difference between MAP and ICP
• Perfusion pressure is maintained if systolic pressure is 50-150 mm Hg, and the ICP is
less than 40 mm Hg.
• The normal CPP is 70-100 mm Hg with the goal being 70-80 mm Hg. If the CPP drops
lower than 50 mm Hg irreversible brain damage ensues. If the MAP is equal to the ICP
there is no cerebral circulation.
o MAP – ICP = CPP
• Cushing's response or reflex will lead to Cushing’s triad. A physiological nervous
system response occurring because cerebral blood flow is decreased due to increased
ICP. Brain is unable to autoregulate effectively.
• Cushing’s response or reflex is a late finding indicating ICP has reached life-
threatening levels. Recovery is possible ONLY if action is taken immediately because
the decline occurs rapidly.
• Cushing’s triad signs are: Increased systolic pressure; widening pulse pressure;
bradycardia which will result in herniation of brain tissue and death.

• As ICP rises and the autoregulatory mechanism of the brain is overwhelmed, the CPP
can increase
• At a certain point, the brain’s ability to autoregulate becomes ineffective and
decompensation (ischemia and infarction) begins. When this occurs: cushings triad
(late finding, ICP is life threatening levels, recovery only possible if action is taken
immediately bc decline will happen rapidly)

Manifestations, Complications, and Management of IIICP

• Clinical manifestations of IICP: LOC change, confusion, behavior change, restlessness,

drowsy, irregular respirations, coma, and posturing.
• Diagnostics: CT, MRI, PET, SPECT, cerebral angiography, or transcranial Doppler.
Caution if LP is ordered
• Complications of IICP: Herniation of the brain stem, diabetes insipidus (DI), and
Syndrome of inappropriate antidiuretic hormone (SIADH)
• DI is a water ______depleting__________ problem. It is secondary to decreased
secretion of ADH which results in _________increased______ U.O., ____decreased___
urine osmolality, and serum hyperosmolarity. (ADH is secreted by posterior pituitary
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 MANAGEMENT OF CLIENTS WITH NEUROLOGIC DYSFUNCTION
at base of brain which is receiving extra pressure due to increased ICP do decreased
ADH secretion)
• DI treatment: fluids, electrolyte replacement, Vasopressors/Desmopressin
• SIADH is a water ______retention__________ problem. It is secondary to increased
secretion of ADH which results ______decreased___________ U.O., volume excess,
____hyponatremia_______, and decreased serum osmolarity.
• SAIDH treatment: fluid restriction of _800_ mL/day and possible IV _3% hypertonic_
saline

Medical Management of IIICP

• Goal: Adequate cerebral blood flow and cerebral perfusion. Decrease intracranial
pressure, decrease cerebral ______edema___, decrease volume of ____CSF_________,
and decrease cerebral ____blood____ volume. (all while being able to maintain
cerbreal perfusion)
• Interventions may include: Osmotic diuretic use, restriction of fluids, draining CSF,
temperature control, maintain systolic pressure, maintaining oxygen-perfusion, and
decreasing metabolic demands.
◦ Mannitol: osmotic diuretic; causes fluid to shift from cells to intravascular
space so cell shrinks and shrivels becoming dehydrated which increases
amount of space in cranium; monitor hourly UO, electrolyte imbalances,
hydration status
◦ IV hypertonic 3% saline to shrink cells
◦ Tumor: steroids (dexamethasone) to decreased edema in area decreasing
ICP
◦ DO NOT WANT PATIENT TO SHIVER (increases temp and bodies metabolic
demands which increases vasocontraction increasing BP and HR). temp rises
= basal metabolic rate rises; must get temp down. antipyretic
(acetaminophen, ibuprofen, aspirin), hypothermia blanket
◦ Maintaining oxygen: ABGs and pulse ox, may be prescribed barbiturates
(depress CNS) (phenobarbital, bella donna) have to monitor cardiac and resp
• Ventriculostomy (intraventricular catheter) monitors the ICP. The goal is to identify
increases in cerebral pressure early so we can intervene to get a positive outcome.
◦ Also: allows CSF to drain, particularly during acute increases in pressure. The
ventriculostomy can also be used to drain blood from the ventricle.
◦ Complications associated with its use include infection, meningitis,
ventricular collapse, occlusion of the catheter by brain tissue or blood, and
problems with the monitoring system.

ICP Monitoring

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Nursing Process- Goal Maintaining Cerebral Perfusion

• Impaired breathing associated with neurologic dysfunction (brain stem compression,

structural displacement)
◦ Irregular respirations = increased ICP; monitor lung sounds and maintain
patent airway; Cheyne stoke respirations (fast shallow breathing followed by
slow heavier with moments of apnea) may be present
◦ Caution if hyperventilating bc can reduce cerebral blood flow without
decreasing ICP
• Risk for ineffective tissue perfusion associated with the effects of increased ICP
◦ Elevation of the head is maintained at 30 to 45 degrees unless
contraindicated.
◦ Extreme rotation of the neck and flexion of the neck are avoided, because
compression or distortion of the jugular veins increases ICP. Impedes venous
circulation. Extreme hip flexion is also avoided, because this position causes
an increase in intra-abdominal and intrathoracic pressures, which can
produce an increase in ICP.
◦ Before suctioning, the patient should be preoxygenated and briefly
hyperventilated using 100% oxygen on the ventilator. Suctioning should not
last longer than 15 seconds.
◦ The Valsalva maneuver, which can be produced by straining at defecation or
even moving in bed, raises ICP and is to be avoided.
◦ When moving or being turned in bed, the patient can be instructed to
exhale (which opens the glottis) to avoid the Valsalva maneuver.
• Hypovolemia associated with fluid restriction
• Risk for infection associated with ICP monitoring system
◦ risk of infection is greatest when ICP is monitored with an intraventricular
catheter and increases with the duration of the monitoring.
◦ Aseptic technique must be used when managing the system and changing
the ventricular drainage bag. The drainage system is also checked for loose
connections, because they can cause leakage and contamination of the CSF
as well as inaccurate readings of ICP.
◦ The patient is monitored for signs and symptoms of meningitis: fever, chills,
nuchal (neck) rigidity, and increasing or persistent headache
• Collaborative Problems: Brain stem herniation, DI, & SIADH
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◦ An output greater than 200 mL/h for 2 consecutive hours may indicate the
onset of diabetes insipidus

• Maintain cerebral perfusion: decompressive hemicraniectomy (remove part of skull)

concerns of infection, ABGs

Intracranial Surgery

• Intracranial surgery may be warranted for removal of a tumor, evacuation of blood or

blood clot, to decrease ICP, and/or to control bleeding.
• There are 3 different methods that can be used: supratentorial (above the tentorium),
infratentorial (below the tentorium), and transphenoid (through the sphenoid sinus
(through mouth and nasal sinuses).
• Burr holes- can be used to relieve _______pressure_____________ on the brain when
there is a build up of fluid, blood, or to evacuate the contents of an
______________abscess_______________.
◦ circular openings made in the skull by either a hand drill or an automatic
craniotome (which has a self-controlled system to stop the drill when the
bone is penetrated)
• Pre-operative considerations: diagnostics, medications, and fluids.
◦ CT scan to demonstrate the lesion and show the degree of surrounding brain
edema, the ventricular size, and the displacement. An MRI scan provides
information similar to that of a CT scan with improved tissue contrast,
resolution, and anatomic definition. Cerebral angiography may be used to
study a tumor’s blood supply or obtain information about vascular lesions.
Transcranial Doppler flow studies are used to evaluate the blood flow within
intracranial blood vessels.
◦ Anticonvulsant (Dilantin, phenytoin, levetiracetam), corticosteroids
(dexamethasone) to decrease cerebral edema, osmotic diuretics (mannitol)
to decrease cerebral swelling, prophylactic antibitoics, diazepam or
lorazepam to decrease anxiety
• Nursing management considerations: baseline assessment, pre-operative teaching, IV
lines, and tubes.
◦ Baseline LOC and responsiveness to stimuli and identifying any neurologic
deficits, such as paralysis, visual dysfunction, alterations in personality or
speech, and bladder and bowel disorders. Baseline distal and proximal motor
strength in both upper and lower extremities is tested and recorded
◦ large head dressing applied after surgery may impair hearing temporarily.
Vision may be limited if the eyes are swollen shut. If a tracheostomy or
endotracheal tube remains in place, the patient will be unable to speak until
the tube is removed, so an alternative method of communication must be
established. Will their hair be shaved in a section?
◦ Seizure precautions, monitor ICP, frequent neurological assessments
• Postoperative management: Goal is to decrease cerebral edema, decrease pain,
prevent seizures, monitor ICP, and neurologic assessment.

Nursing Process- Post Intracranial Surgery

• Risk for ineffective tissue perfusion associated with cerebral edema

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◦ Mannitol; Dexamethasone may be administered IV every 6 hours for 24 to 72
hours; the route is changed to oral as soon as possible, and the dosage is
typically tapered over 5 to 7 days
• Risk for impaired thermoregulation associated with damage to the hypothalamus,
dehydration, and infection.
◦ Moderate temperature elevation can be expected after intracranial surgery
because of the reaction to blood at the operative site or in the subarachnoid
space. Not a problem unless increased ICP is present
◦ monitoring the patient’s temperature and using the following measures to
reduce body temperature: removing blankets, placing ice packs, and
administering prescribed antipyretics to reduce fever
◦ if need to increase temp: SLOWLY to prevent shivering (bc increases cellular
oxygen demands)
• Impaired gas exchange associated with hypoventilation, aspiration, and immobility.
◦ Repositioning the patient every 2 hours helps to mobilize pulmonary
secretions and prevent stasis.
◦ Immobility compromises the respiratory system by causing pooling and
stasis of secretions in dependent areas and the development of atelectasis
◦ Alveoli collapse affecting the exchange of gasses, so secretions
accumulate = good environment for infection. No air leaks out of lung
(that is a pneumothorax)
◦ Prevent atelectasis: IS, deep breathing, reposition, suctioning (no
coughing bc increases ICP)
◦ Oxygen = humidified
• Difficulty coping associated with sensory perception changes due to periorbital
edema, head dressing, endotracheal intubation, and effects of ICP.
◦ Periorbital edema is a common consequence of intracranial surgery, because
fluid drains into the dependent periorbital areas when the patient has been
positioned in a prone position during surgery. A hematoma may form under
the scalp and spread down to the orbit, producing an area of ecchymosis
(black eye).
◦ elevating the head of the bed (if not contraindicated) and applying cold
compresses over the eyes will help reduce the edema. Health care personnel
should announce their presence when entering the room to avoid startling
the patient whose vision is impaired due to periorbital edema or neurologic
deficits.
◦ The surgeon is notified if periorbital edema increases significantly, because
this may indicate that a postoperative clot is developing or that there is
increasing ICP and poor venous drainage.
• Disturbed body image associate with change in appearance or physical disability.
◦ Attention to grooming, the use of the patient’s own clothing, and covering
the head with a turban (and later a wig until hair growth occurs) are
encouraged. Social interaction with close friends, family, and hospital
personnel may increase the patient’s sense of self-worth.
• Watch for complications: IICP, bleeding, hypovolemic shock, ____electrolyte
imbalance____, Cushing's response/triad, elevated ______glucose_________ as a result
of steroid, stress ________ulcers________, DI, SIADH, infection, seizures, and venous
thromboembolism (VTE) or DVT
• Discharge: home, community-based, or transitional care

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Cerebral edema = peak issue at 1-3 days

Transphenoid Approach

• Accomplished via the sphenoid sinus and minimal trauma and bleeding compared to
traditional craniotomy the supratentorial or infratentorial type.
◦ Through nose or mouth
◦ Most common surgery if pituitary gland needs attention
• Complications: transient DI secondary to ______pituitary_____________ gland
manipulation; SIADH, CSF leakage (esp if coughing, using straw, blowing nose,
sneezing), visual disturbances; post-op _________meningitis_______________; and
pneumocephalus (air in intracranial cavity, straw can cause).
◦ More facial swelling
• Preoperative considerations: We may see endocrine studies ordered along with
diagnostics for nose and sinus evaluation; funduscopic eye evaluation;
corticosteroids; and prophylactic antibiotic
• Nursing management considerations: Pre-operative teaching; no vigorous coughing or
blowing of the nose, using a straw, or sneezing as this can increase pressure on the
surgical site and cause CSF leakage.
• Postoperative management: leave nasal packing in place- removed by surgeon;
analgesics; Neuro assessment; HOB 30 degree for 2 weeks; check for CSF leakage;
humidifier or vaporizer; oral hygiene considerations (bc mouth breathing, no
toothbrush and toothpaste bc can cause bacteria to rise to surgical site use warm
saline mouth rinses q4h and petroleum on chapped lips), electrolytes; and I & O

Management of Clients with Neurologic Dysfunction:

Delirium, Seizures, & Headaches

Delirium versus Dementia

• Delirium- acute confusional state. Usually appears over a short period of time from
___hours___ to __________1-2_________ day(s) and is ______reversible______.
• Delirium can be caused by medications, _________infection____, metabolic
disturbances, electrolyte imbalances, surgery, _______nutritional_________ deficiencies
and dehydration.
• Dementia is a chronic disease. It begins very _________subtly______________ and then
progresses, so the signs and symptoms become more obvious.
◦ May have memory impairment, loss of attention, lose enjoyment in things
they previously liked, aphagia, apraxia (inability to move), agnosia
• The most common type of dementia is that of the __________Alzheimer’s___________.
◦ Alzheimer’s: condition diagnosed by ruling out others first
• Other types of dementia can be vascular in nature due to cardiovascular and
______cerebrovascular________ disease. Lewy body or ______parkinsonism______
dementia, which is associated with abnormal deposits of a protein called alpha-
synuclein in the brain. There is also alcohol related dementia- due to
_______chronic________ alcohol abuse and HIV or AIDS related dementia.
• Can clients with dementia experience delirium? Yes
◦ Infection, low blood sugar

Seizure Disorders
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• Seizure- Abnormal episodes of motor, _______sensory______________, autonomic, or
______psychic_________________ activity (or a combination of these) resulting from a
sudden, abnormal, uncontrolled electrical discharge from cerebral neurons.
• Classification of seizures: Focal (originates in one hemisphere); generalized (occur
and engages bilaterally); unknown (epilepsy); or provoked (related to acute reversible
condition: hypoglycemia, hyponatremia, hypoxemia, alc withdrawal, drug withdrawal,
brain tumor, CVA, head injury, febrile, allergies).
• Causes of seizures are varied: CVA or cerebrovascular disease, hypoxemia, fever
related, head injury, withdrawal of alcohol or drugs, and brain tumor.
• Clinical Manifestations can vary from: simple staring, unilateral or bilateral jerking
movements with or without LOC, unintelligible talk, dizzy, unpleasant sights-sounds-
odors-or tastes, incontinence; crying sounds.
• Stages of a seizure: prodromal (aura?), ictal, and _______postictal___________.
• Assessment: Developmental history; head injury; illness, family _______hx________, or
______meds___________.
• Diagnostic: EEG, Video recordings, SPECT scan, CT, MRI, LP, labs such as CBC,
electrolytes, __drug__ levels (epileptic meds therapeutic or not), _____liver______
function, thyroid function, calcium, & possible blood cultures.

Generalized Seizures: Atonic, Absence, and Myoclonic

• Generalized seizures include absence, atonic, tonic, clonic, tonic-clonic, myoclonic,

and febrile seizures.
• Atonic: AKA drop attack or drop seizure. An abrupt loss of muscle tone without
warning. High injury risk to head or face.
• Absence: used to be known as petit mal seizures. More common in children. May
appear as staring spells and can by mistaken for inattentive behavior. No aura and
can be provoked by hyperventilation.
o <30, don’t respond or speak, may not be noticed, may be mistaken as
inattentive, may not remember what happens, no warning
• Myoclonic: Rapid, brief muscular contractions of body usually involving one or more
limbs. Onset can be seen in children.
o Jerking or twitching, 1-2 seconds

Generalized Seizures: Tonic, Clonic, and Tonic-Clonic

• Tonic: during this seizure we only see tonic movement. Here the muscles contract and
stiffen, and the person can lose consciousness. The eyes roll back and the muscles of
the chest, arms, and legs stiffen which causes the back to arch. Impaired respiratory
effort so the client can turn gray or blue.
o May gurgle as struggling to breathe, <1 min
• Clonic: Seizures consists of repeated spasms and jerking of the muscles but there is
no rigidity. They are rare. Most of the time they last only a few seconds. Risk for
injury.
o Loss of bowel or bladder, will fall if standing
• Tonic-Clonic: AKA as Grand Mal. Most common. Usually starts with tonic activity and
then clonic. Breathing is impaired and may cease, be noisy, or labored. Therefore, we
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may see cyanosis (nail beds). Risk for injury-including tongue. Incontinence occurs.
Postictal phase is significant. There may be no memory of the event.
o Accumulation of saliva in mouth (suction); lethargic, resp support may need to
be cont’d

Management During a Seizure

• Observe & document the sequence of events; time of onset and time ended;
circumstances prior to the seizure; aura or not; order and type of movements
(extremities, gaze, head position); automatisms; pupil size; and are the eyes open or
closed.
◦ Did the client lose consciousness? Pupils equal? Automatisms (lip smacking,
chewing, repeated swallowing, clapping hands)?
• Priority- prevent injury! Protect the head; pad side rails; rescue position; bed position;
clothing; do not insert anything in the client’s mouth; oxygen; suction; oral airway;
privacy; and support the client and family.
◦ Loosen clothing around neck
• IV access and medication anticipation.
◦ Seizure could knock out
◦ Meds: diazepam, lorazepam
• Postictal stage.
◦ Positioning for open airway, oxygen, intubation if needed, anticipate another
seizure (seizure precautions)

Generalized Seizures: Febrile

• Most common in children and usually benign but frightening.

• Associated with rapid changing ______temp_________.
• There is a low risk of causing any type of brain damage, nervous system problems,
paralysis, intellectual disability or death.
• Determining source of fever
• History and Physical
• Diagnostics
• Treatment: Control fever; medications

Fam hx and previous seizure increases risk

Focal Seizures

• Focal seizures were also known as partial -electrical discharge happens in one area or
small group of cells.
• They can be simple or complex
• Simple seizures- there is no loss of awareness or consciousness.
o Blank staring, muscle tightening, unusual head movements
• Complex seizures- there is an impaired awareness. Usually lasts 1-2 minutes. May
have an aura. There are involuntary automatisms movements.
o Rubbing hands, lip smacking, chewing

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Status Epilepticus

• Neurologic Emergency!!
• Prolonged or clustered closely together.
◦ 5+ mins, back to back w/in 5 min period
• Can occur with any seizure activity
• Goal: ___stop the seizure, respiratory__________________________.
• Treatment: Support; IV medications; labs (to determine cause)

Vigorous muscular contractions impose a heavy metabolic demand and can interfere
with respirations. Some respiratory arrest at the height of each seizure produces venous
congestion and hypoxia of the brain. Repeated episodes of cerebral anoxia and edema
may lead to irreversible and fatal brain damage.
If the patient remains unconscious and unresponsive, an endotracheal tube is inserted.
IV diazepam, lorazepam, or fosphenytoin is given slowly in an attempt to halt seizures
immediately. Other medications (phenytoin, phenobarbital) are given later to maintain a
seizure-free state.

Rescue position

Epilepsy- Unknown or Unprovoked

• Epilepsy two or more unprovoked seizures. Non-communicable chronic disease.

• Up to 70% of people living with epilepsy could become seizure free with appropriate
use of ______________anticonvulsant_______________________ medication.
• Complications: Falling, drowning, car accidents, pregnancy complications, mental
health issues.
• More serious complications: Status epilepticus and Sudden Unexpected Death in
Epilepsy (SUDEP)
• Gerontology considerations: Leading cause of epilepsy in this age group is
_______cerebrovascular_________ disease; age related interactions due to renal and
_____liver______ function (absorption, distribution, metabolism, & excretion); monitor
for adverse and _______toxic_________ effects; osteoporosis; and medication cost.

Medical Management

• Pharmacological Therapy: Goal is to have seizure control with __minimal____ side

effects.
• Start with single drug or _________monotherapy__________; doses gradually increased;
_______blood levels________ monitored.
• Side effects can vary. Most common side effects that may occur in the first few weeks
are tiredness, stomach upset or discomfort, dizziness, or blurred vision.
• Phenytoin long term use we can see _____________gingival hyperplasia_____________.
◦ Oral care is important
• Other common side effects: CNS Depression, confusion, drowsiness/lethargy,
constipation, dry mouth, anorexia, urinary retention, decreased libido.
• Allergic reaction can be rash or medical emergency of ___stevens johnson
syndrome_____.

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◦ Skin and mucous membrane; flulike to start, then rash, then top layer of skin
peels
• Other more serious effects: cardiac arrhythmias, bone marrow suppression.
• Avoid: Alcohol; CAM
• Surgical treatment: Removal of the cause or we may see vagal nerve stimulator (VNS)
implantation.
◦ vagal nerve stimulator (VNS) may be implanted under the clavicle. The
device is connected to the vagus nerve in the cervical area, where it delivers
electrical signals to the brain to control and reduce seizure activity. The
device can detect changes or the pt or family member can wave a magnet
over it before or during seizure
◦ Complications: infection, cardiac arrhythmias, hoarseness, cough, and
laryngeal spasm
◦ RNS works by interrupting brainwave activity before a clinical seizure can
occur
◦ MRI-guided stereotactic laser interstitial thermal therapy (LiTT) offers a less
invasive treatment option. This treatment involves computer-assisted
placement of a laser probe into the brain and delivery of heat therapy

Antiepileptic Drugs and Therapeutic Ranges

Antiepileptic Plasma Level

(mcg/mL)
Carbamazepine 4-12
Clonazepam 0.02-0.08
Divalproex 50-100
Ethosuximide 40-100
Phenobarbital 15-40
Phenytoin 10-20
Primidone 5-112
Valproic Acid 50-100

DO NOT MEMORIZE

Nursing Diagnosis

• Risk for injury r/t seizure activity

• Fear related to possibility of seizures
• Difficulty coping r/t stresses imposed by epilepsy
• Lack of knowledge r/t epilepsy and anticonvulsant medication

Headaches

• AKA cephalgia is a very common complaint. A headache is not a

_______disease________________, but rather a symptom of an illness or injury.
• Primary versus secondary HA.
• Pathophysiology: Result of a hyper-excitable brain that is prone to a phenomenon
known as cortical spreading depression.
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• Triggers can be foods that contain _________tyramine______________ or nitrates. Food
additives like monosodium glutamate and _________caffeine_________________.
Seasons; weather; hormone fluctuations; activity; bright or flickering lights; odors;
meal schedules; and sleep patterns.
• Persons undergoing HA evaluation require a detailed H & P with detailed
____neurologic___ exam to rule out various physical and psychological causes.
• Headache assessment starts with OPQRST. Any preceding events such as exercise or
trauma? Any associated symptoms such as dizziness, nausea, _____vomitting______, or
__visual___ disturbances? The H & P helps guide what diagnostic may need to be
prescribed.
• Sudden onset HA described as “the worst headache of my life” can signal a possible
____________subarachnoid_______________ hemorrhage.

Primary Headache- Migraines

• Subtypes of migraines: With our without aura; tension; trigeminal autonomic

cephalgia-cluster; cranial arteritis; and other.
• POUND acronym:
◦ P- __pulsating_____________________
◦ O- one to three days
◦ U- __unilateral___________________________________
◦ N- nausea/vomiting may have accompanying photophobia or
___phonophobia_____
◦ D- _disabling intensity___________________________________
• Migraine: Familial link; Women more than men; onset typically around puberty. Aura-
may or may not be present.
• Migraines with aura phases: Premonitory; Aura; headache; Postdrome
◦ Permonitory: hours to days before a migraine headache. Symptoms may
include depression, irritability, feeling cold, food cravings, anorexia, change
in activity level, increased urination, diarrhea, or constipation
◦ Aura: Visual disturbances (i.e., light flashes and bright spots) are most
common and may be hemianopic (affecting only half of the visual field).
Other symptoms that may follow include numbness and tingling of the lips,
face, or hands; mild confusion; slight weakness of an extremity; drowsiness;
and dizziness.
◦ Headache: photophobia (light sensitivity), phonophobia (sound sensitivity),
or allodynia (abnormal perception of innocuous stimuli)
◦ Postdrome: pain gradually subsides, but patients may experience tiredness,
weakness, cognitive difficulties, and mood changes for hours to days. Muscle
contraction in the neck and scalp is common, with associated muscle ache
and localized tenderness. Physical exertion may exacerbate the headache
pain. May sleep for extended periods
• Tension HA: Pain is mild to moderate; steady tight band around the head or on both
the sides and back of the head.
◦ often bandlike or may be described as “a weight on top of my head.”
• Cluster HA: Cyclical pattern or a cluster period; intense pain in or around one eye-
unilateral; strike quickly, usually without warning.

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◦ unilateral and come in clusters of one to eight daily, with excruciating pain
localized to the eye and orbit and radiating to the facial and temporal
regions. The pain is accompanied by watering of the eye and nasal
congestion. Each attack lasts 15 minutes to 3 hours and may have a
crescendo–decrescendo pattern
◦ Alcohol, nitrites, vasodilators, and histamines may precipitate cluster
headaches.
• Diagnostics: H & P including medication and family history; CT; MRI; EMG; cerebral
angiography.

Headache Types

• Tension
• Migraine
• Cluster

Management of the Headache

• Avoidance of triggers and headache journal.

• Encourage healthy lifestyle and health promotion activities.
• Comfort measures include creating a calm environment. Dark and quiet room;
massage; stress reduction; heat and cold.
• Abortive and preventative medication. OTC for mild to moderate pain.
• Abortive medication: Triptans or serotonin receptor agonists; cause vasoconstriction
of cerebral vessels; cause reduction of inflammatory neuropeptides; Examples:
Sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), zolmitriptan
(Zomig), and almotriptan (Axert).
• Abortive medication: Ergotamine is in a class of medications called ergot alkaloids.
Contains small amounts of caffeine. Also causes vasoconstriction.
◦ Cannot take with triptans

Management of the Headache-Continued

• Preventative medications: Beta blockers (propranolol, atenolol); antidepressants

(amitriptyline); antiepileptic (valproic acid); angiotensin converting enzyme (ACE)
inhibitors; angiotensin receptor blockers, and hormone replacement therapy.
• Additional pharmacologic Therapy: NSAIDS, antiemetic, caffeine.
• Goal- pain relief
• Priority is to treat the acute event, start abortive therapy, and institute comfort
measures.
• Secondarily we need to prevent reoccurrences.
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• Client education

Nursing Diagnosis

• Acute pain r/t pathophysiology of HA

• Disturbed sensory perception (visual, auditory, kinesthetic) r/t CNS effects
• Knowledge deficit r/t disease process and drug therapy

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