Neuro Concepts

Medical-Surgical Nursing
__________________________________________________________ Professional Review Strategies for

Nurses
MEDICAL SURGICAL NURSING

I. NEUROLOGICAL PROBLEMS
A.
CONCEPTS:
1. The RAS is the center of wakefulness.

Injury to RAS unconsciousness
2. Brain requires 15-20% of total circulating blood at all times for proper functioning.
Problems: Hypoxia/Hypoglycemia
800 ml blood flow per minute
Blood supply: Right & Left internal carotid and
Right & Left vertebral arteries Circle of Willis
3. Glucose metabolism supplies most energy requirement of brain tissue
Brain has minute capacity to store glucose
Brain consumes 65% of the bodys glucose on a daily basis
Failure of supply neutron failure seizures unconsciousness
Death
4. Blood vessels in the brain dilate and constrict in response to alteration in pH,
PaCO2, PaO2.
Acidosis vasodilatation
Alkalosis vasoconstriction
Therapy to decrease ICP is largely influenced by respiratory responses

Mechanical ventilation control brain edema
5. Brain and spinal cord are constantly bathed in about 120-150 ml of CSF which is
produced, circulated and reabsorbed on a dynamic basis.
CSF - acts as protective cushion and aids in the exchange of nutrients and waste.
6. Normal brain consumes oxygen at an approximate rate of 3.3 ml/100g brain
tissue/minute. Twenty (20%) percent of total oxygen consumption of the body. It
has only a 10-second reserve supply of oxygen.
7. A blood-brain barrier prevents certain substances from passing between the
blood and CSF.
Water, glucose, blood gases move freely
Certain steroids, antibiotics, catecholamines do not move
3 types: Blood-brain barrier
Blood-CSF barrier
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Brain-CSF barrier
8. The neurotransmitters of the brain are: acetylcholine, norepinephrine, dopamine,
serotonin, amino acids & polypeptides.
9. Nerve cells are called neurons. Neurons do not reproduce after an axon or
dendrite is damaged, it will die & be slowly replaced only if the neurolemma is
intact & the cell body has not died.
a. Sensory neurons carry impulses to CNS
b. Motor neurons carry impulses away from CNS
B. ASSESSMENT
1. Health History
a. Family history
b. History of problem
c. Headaches
d. Seizures
e. Medications
f. Change in behavior and personality
2. Physical examination
a. Cognitive function
behavior, emotional status
level of consciousness
attention span
ability to follow commands
memory
arithmetic ability
abstract thinking
language/speech
a. motor aphasia (expressive)
b. sensory aphasia (receptive)
i. auditory spoken
ii. visual written
b. Cerebellar function
balance
coordination
c. Motor function
muscle size, tone, strength
involuntary movements
coordination
motor integration
bowel and bladder function
Nurses
d. Seizures
e. Blood or fluid leakage Nose & Ears
f.
Posturing
Decorticate (cortico-spinal tract)

Decerebrate (midbrain & pons)
g. Sensory function
Touch, pressure, pain, position, sense, temperature
Vision (amount of sight, distortion: halos, floaters, diplopia,
floaters)
Hearing (amount of hearing, deafness [conductive
impairment of outer & middle ear conduction, problem of
perception of volume, not discrimination, can benefit from
hearing aid]; [sensorineural imparment of inner ear nerve
conduction, loss of sensitivity to & discrimination of sounds,
hearing aid not beneficial]
Reflexes
Cranial nerves
3. Important parameters for on-going neuro checks:
I. Level of Consciousness
Note: Arousal & Content (Cognition) 2 components that need to be present at
all times
Levels:
I Conscious
II Lethargy (also includes delirium, confused state)
III Stupor
IV Coma
Use Glasgow Coma scale (Eye

opening, Verbal response &
Motor response)
II. Respiratory pattern

Assessment of Respirations
CHEYNE-STOKES: rhythmical with periods of apnea; can indicate a metabolic
dysfunction or dysfunction in the cerebral hemisphere or basal ganglia
NEUROGENIC HYPERVENTILATION: regular rapid and deep sustained respirations;
indicates a dysfunction in the low midbrain and middle pons
APNEUSTIC: irregular respirations with pauses at the end of inspiration and expiration;
indicates a dysfunction in the middle or caudal pons
ATAXIC: totally irregular in rhythm and depth; indicates a dysfunction in the medulla
CLUSTER: clusters of breaths with irregularly spaced pauses indicates a dysfunction in
the medulla and pons
Nurses
III. Pupillary Size and Reaction

Normal: 2 4 mm; brisk and reactive
Alterations: Midposition, small, reactive beginning uncal herniation
Anisocoric impending uncal herniation
Pathology on
side of bigger
pupil.
Midposition, fixed, dilated: poor prognosis (midbrain injury)

Fixed, pinpoint: midbrain injury
IV. Brain stem reflex (Oculocephalic reflex; Dolls eye reflex)
(+) intact brain stem; (-) brain stem affection DO
NOT
CONSCIOUS
INDIVIDUALS!
PERFORM
ON
V. Motor response and muscle function

a. Hemiparesis apply pain stimuli
b. Posturing indicates deteriorating condition
I Decerebrate brain stem lesion
II Decorticate non-functioning cortex
*Note muscle tone, strength &

equality.
*Note for nonpurposeful, involuntary
movements.
VI. Vital signs: note changes in increased ICP

VII. Assessment of reflexes
BABINSKI REFLEX: dorsiflexion of the ankle and great toe with fanning of the
other toes
CORNEAL REFLEX: loss of the blink reflex; indicates a dysfunction of CN V
GAG REFLEX: loss of the gag reflex; indicates a dysfunction of CN IX and X
VIII. Assessment of meningeal irritation
BRUDZINSKIS SIGN: flexion of the head causes flexion of both thighs at the hips
and knee flexion
KERNIGS SIGN: flexion of the thigh and knee to right angles, and when extended,
causes spasm of hamstring and pain
UPPER MOTOR NEURON Lesion:
Signs and symptoms: Hyperreflexia; Hypertonia; Paralysis or Paresis in
hemiplegic distribution; Atrophy (late sign due to non-use).
a. Above medulla deficits contralateral to lesion demonstrate as hemiplegia
b. Distal to medulla deficits ipsilateral to lesion
c. Cerebral lesion alteration in sensation contralateral to the lesion
Nurses
d. Spinal cord transaction total bilateral sensory loss distal to lesion

EXTRAPYRAMIDAL TRACT Lesion:
Signs and symptoms: Rigidity; Bradykinesis; Loss of strength; Involuntary rest
tremors
LOWER MOTOR NEURON Lesion:
Signs and symptoms: Flaccidity; Hypotonia; Areflexia; Muscle atrophy from
denervation; Muscle weakness of individual muscles or sets of muscles in the
spinal root of PN distribution.
C. COMMON NURSING PROBLEMS

I. ALTERED LEVEL OF CONSCIOUSNESS
Nursing Care of Client with Altered LOC
Causes: head injury; drug overdose; diffuse cerebral disease; metabolic
dysfunction
Assessment:
check LOC use GCS

motor function for strength and symmetry
check brain stem reflexes (pupils: size, reaction, symmetry;
oculocephalic response)
respiration and pattern
swallowing reflex; DTR
note for signs of trauma of head; leakage of CSF from ears or
nose
neuro check
Interventions:
1. Maintain effective airway
a. position (semi-Fowlers)
b. artificial airway (as needed)
c. suction; oxygen
Nurses
2. Attain/Maintain fluid and electrolyte balance

a. check for dehydration
b. check gag & swallowing reflexes before resuming diet
c. check IVF
d. TPN
e. NGT feeding
f. check intake and output; urine specific gravity
3. Maintain healthy oral mucous membrane
a. oral hygiene
b. lip emollient
4. Maintain skin integrity
a. turn to sides every 2 hours
b.
c.
d.
e.
meticulous skin care

extremities in ROM
avoid restraints
assess for edema
5. Maintain corneal integrity

a. irrigate eyes with prescribed solution
b. instill ointment
c. instill artificial tears
d. cover eyes with eye patches
6. Reduce fever
a. check for cause
b. hydro therapeutic measures
c. hypothermia blanket
7. Promote bowel function/urinary elimination
a. constipation - stool softeners & glycerine suppository
- rectal exam to check for fecal impaction
b. diarrhea
c. note for abdominal distention
d. urinary retention indwelling catheter; initiative bladder training
program
II. INCREASED INTRACRANIAL PRESSURE

1. Increased Intracranial pressure secondary to:
MASS
-
Blood
NO MASS
- Hydrocephalus
Nurses
Abscess
Tumor glioma
Granuloma
- Meningitis
(clogs CSF pathway with CHON)
Intracranial contents:
Brain 1200 cc space
CSF 150 cc space
Blood 100 cc space
Meninges 50 cc space
2. What happens when ICP rises:
Intracranial pressure (ICP) is the pressure exerted within the intact

skull by the intracranial volume (about 10% blood, 10% CSF and
80% brain tissue). The skull has little space for expansion of these
substances.
The brain compensates for increases in ICP by regulating the
volume of the three substances in the following ways:
1. limiting blood flow to the head
2. displacing CSF into the spinal canal
3. increasing absorption or decreasing production of CSF
(withdrawing water from brain tissue and excreting it through
the kidneys)
When compensatory mechanisms become overworked, small
changes in the volume lead to large changes in pressure. Figure 1
will help you understand increased ICP pathophysiology.
3. Signs of Increasing Intracranial Pressure (ICP):

1. Change in level of consciousness
ALERT: One of the earliest and most sensitive signs of rising ICP
is restlessness
2. Pupillary signs
Pressure on the oculomotor nerve
Slower response, pupil inequality, of fixed dilated pupils
3. Blood Pressure and pulse
Increasing systolic pressure with stable or falling diastolic
pressure
Widening pulse pressure
Slowing of the pulse rate from pressure on the vagus nerve
4. Respirations
Changes are usually quite late
Slowing of rate and an irregular breathing pattern
Nurses
5. Temperature
Failure of thermoregulatory center occurs late
High uncontrolled temperature
6. Focal signs
Muscle weakness or paralysis
Decreasing response to pain stimulus in comatose patients
Positive Babinskis sign
Decerebrate or decorticate posture
7. Visceral
Decreasing visual activity
Papilledema
8. Headache and vomiting
4. Nursing care of client with Increased Intracranial Pressure (ICP):
SIGNS AND SYMPTOMS:
Neuro
Headache
Altered level of consciousness
Behavioral changes
Irritability
Loss of oculomotor control
Double vision
Hemiparesis
Seizures
Cardiovascular/Respiratory
Increased systolic BP
Decreased HR (early)
Increased HR (late)
Decreased RR
Other
Photophobia
Papilledema (edema of the optic disc)
Vomiting
Bulging fontanel in infants
MANAGEMENT
Nurses
Nursing
Elevate the head 15 30 degrees

Keep head in neutral alignment
Avoid flexion/rotation of neck
Restrict fluids
Closely monitor vital signs
Check neurological status
Monitor fluid and electrolytes
Keep environment quiet
Schedule procedures to coincide with periods of sedation
Avoid activities that elicit a vasovagal response
Establish IV access
Insert Foley catheter
Medication
may
include
sedatives,
osmotic
diuretics,
corticosteroids, barbiturates (to decrease cerebral metabolic rate)
Ventricular drainage of CSF
Neuromuscular blocking agents
Anticonvulsants
Hyperventilation with mechanical ventilator with result in
decreased PaCO2, causing vasoconstriction which produces a
decrease in ICP
Perform invasive ICP monitoring
Medical
III. NURSING INTERVENTIONS FOR APHASIA

General:
Establish a relaxed environment.

Encourage persistence and the desire to communicate.
Control and limit the amount of stimuli in the environment
Sensory (Receptive):
Sit down and establish eye contact.

Face patient and speak simply and slowly.
Reword the message if misunderstood.
Use appropriate gestures to supplement words.
Use a normal tone of voice.
Nurses
Motor (Expressive):
Avoid interrupting and rushing patient.

Emphasize simple concrete words used for daily care.
Discuss topics of interest to patient.
Encourage use of other means of communication.
Convey acceptance and encourage patient to talk.
Dont speak for the patient.
IV. HYPERTHERMIA
D. COMMON DISORDERS
1. Cranio-cerebral Trauma
Damage of brain tissue due to trauma

Type of Injury
Characteristics
Concussion
Immediate and transitory impairment of neurologic function

Caused by the mechanical force.
Contusion
Likened to bruising with extravasation of blood cells.
Laceration
Tearing of tissues caused by sharp fragment or a shearing force.
Intracranial
Hemorrhage
Bleeding into the epidural, subdural, subarachnoid spaces or into

the brain or ventricles.
Epidural
Hematoma
Rupture of a large vessel that lies above the dura mater; tear is usually
in an artery (middle meningeal is the most common site).
Subdural
Hematoma
Usually results from venous bleeding below the dura mater; bleeding
may produce acute, subacute or chronic hematoma formation.
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2. Tumors
SPECIFIC BRAIN LOBES, SYMPTOMS OF TUMORS FOUND IN SPECIFIC BRAIN LOBES
FRONTAL LOBE
Personally disturbances (range from the subtle personality changes to

obvious
psychotic behavior)
Inappropriate affect
Indifference bodily functions
PRECENTRAL GYRUS
Jacksonian seizures
OCCIPITAL LOBE
Visual disturbances preceding convulsions
TEMPORAL LOBE
Olfactory, visual, or gustatory hallucinations

Psychomotor seizures with automatic behavior
PARIETAL LOBE
Inability to replicate pictures

Loss of right-left discrimination
3. Cerebrovascular Accident
Destruction of brain cells due to sudden decreased in cerebral blood flow decreased O 2
Incidence: Men more than women
Increased with age
Causes:
o Thrombosis
o Embolism
o Hemorrhage
Risk Factor:
o HTN, DM, arteriosclerosis/atherosclerosis, cardiac disease (MI, AF, Valvular
defect)
o Life style: obesity, smoking, inactivity stress, oral contraceptive use
Stages of Development:
o T/ A
warning sign of impending CVA
brief neuro-deficit:
Visual loss
slurred speech
aphasia
hemiparesis
vertigo
last 30 sec to 24 hours with complete return to normal
Nurses
Stroke in Evolution
Progressive neuro impairment over a period of several hrs. or days
Complete Stroke
Neuro deficit remains unchanged for
Right Brain Damage

(stroke on the right side of the brain)
Left Brain Damage

(stroke on left side of the brain)
Paralyzed left side: hemiplegia

Left sided neglect
Spatial-perceptual deficits
Tends to deny or minimize problems
Rapid performance, short attention span
Impulsice, safety problems
Impaired judgment
Impaired concepts
ONSET
Signs and Symptoms
Paralyzed right side: hemiplegia

Impaired speech/language aphasia
Impaired right/left discrimination
Slow performance, cautious
Impaired speech/language
Aware of deficits: depression, anxiety
Impaired comprehension related to
language , math
HEMORRHAGIC
THROMBOTIC/EMBOLIC
SUDDEN
GRADUAL
Severe HA
Nausea and vomiting
SX of meningeal irritations
Increased restlessness
Confusion
Early instability
Signs & Symptoms of Cerebral

Insufficiency:
- blurred vision
- dizziness
- light headedness
- speech disturbance
Focal signs (related to site of infarction):

Hemiplegia
Sensory loss
Homonymous Hemianopsia
Aphasia (common with left cerebral infarct & right
handedness)
Control HTN
Control hemorrhage:
Vitamin K
Cerebral Vasodilators
- Dypiridamole (Persantin)
- Nicotinyl tartrate(Roniacol)
Nurses
AMICAR antifibrinolytic
Control increased ICP
- Isoxuprine HCL (Vasodilan)

- Carbogen inhalation
- Papaverine
Antithrombotics
- Anticoagulants
- Platelet Deaggregators
- Aspirin
- Dypiridamole
- Fibrinolytics
4. Convulsions
-
Transitory disturbances in consciousness and motor, sensory or automatic functioning die to

uncontrolled electrical discharges in the brain.
Last from a few seconds to as long as 5 minutes
Assessment:
S History of seizure disorders medications & degree of compliance aura
experience & post-ictal feelings social adjustment to disorder
O Sequence & duration of seizure observed behavior before seizure side effects
medications
Common types of Seizures:
1. Generalized
bilaterally symmetrical, with no local onset
A. Grandmal
- Most common
- Progression:
1. Aura changes in sensation or affect maybe numbness, odors, lights,
dizziness.
2. Cry caused by spasms of thorax expelling air through glottis.
3. Loss of consciousness
4. Tonic-Clonic Seizures
Bilateral tonic cessation of respiration & cyanosis clonic
contractions return of shallow respiration.
Incontinence may occur
Nurses
5. Postical
Partial return of consciousness to a groggy confused state,
headache, muscle pain, deep sleep may follow
B. Petitmal
- Common during childhood
- Progression:
Loss of consciousness with little or no motor movement
- Duration: 10-20 seconds
- may occur many times in a day
2. Partial Seizures
A. Psychomotor Temporal lobe
- Sudden change in awareness or consciousness
- May have complex hallucination aura
- May engage in antisocial behavior or repetitive meaningless activities
Observations to be made about a person having a seizure:
Aura
Presence or absence; nature id present; ability of patient

to describe it (somatic, visceral, psychic)
Cry
Presence or absence
Onset
Site of initial body movements; deviation of head

and eyes; chewing and salivation; posture of body;
sensory changes
Tonic and Clonic
Movement of body as to progression; skin color and

airway; papillary changes; incontinence; duration of
each phase
Relaxation (sleep)
Duration and behavior
Postical Phase
Duration; general behavior; ability to remember

anything about the seizure; orientation: papillary
changes; headache; injuries present
Duration of entire
Seizure
Measure by clock
Level of consciousness length of unconsciousness if present

DRUG TO PREVENT SEIZURES
1. Phenytoin Na (Dilantin)
SE: Ataxia, vomiting, nystagmus, Drowsiness, rash, fever
Nurses
2. Phenobarbital (Luminal)
SE: drowsiness, rash
3. Carbamazepine (Tegretol)
SE: rash, drowsiness, ataxia
4. Mephenytoin (Mesantoin)
SE: ataxia, nystagmus, pancytopenia
5. Valium
SE: drowsiness, ataxia
NURSING CARE DURING SEIZURE
Never leave patient alone during seizure,

If patient is upright, lower to bed or floor and clear immediate environment to prevent injury.
Loosen constrictive clothing, especially around the neck.
Turn head to side if feasible to help keep airway open.
Cushion head.
Provide privacy.
No effort tongue blade or oral airway may be inserted to protect tongue and mouth if jaws are not
already clenched. Never attempt to pry open the mouth once jaws are clenched.
Record sequence and progression of seizure accurately, and provide for post-ictal rest and sleep.
5. Cranial Nerve Disorders
A. Bells Palsy
Cranial nerve VII paralysis
Assessment:
facial paralysis
painful sensation
eye problems: epiphora (overflow of tears); lagophthalmos (unable to
close eyes); decreased tears
speech difficulty
Management:
artificial tears; eye protection
steroids (prednisone)
physical therapy
non-narcotic analgesic
facial exercises
keep face warm and free from draft
Nurses
B. Trigeminal Neuralgia
Cranial Nerve V
Sudden episode of sharp, stabbing, excruciating pain along the branches of
cranial Nerve V
Management:
- medications: tegretol & phenytoin (relieve pain)
- surgery: alcohol or phenol lock
: microvascular decompression of Trigeminal Neuralgia
- nutrition: food and fluids at room temperature
: chew on unaffected side
E. CARE OF THE NEUROSURGICAL PATIENT

Specific nursing interventions for the craniotomy patient
Preoperative
Assess baseline neurologic status.

Encourage patient and family to verbalize fears and concerns.
Provide detailed teaching about procedures; postoperative care; movement and activity
restrictions and equipment to be used.
Prepare family for the patients appearance after the operation: head dressing, shaved
scalp, edema and bruising, temporary decrease in mental status
Postoperative
Complete or perform nursing interventions for monitoring neurologic status dealing with
rising ICP and preventing complications of immobility.
Positioning:
Supratentorial surgery:
HOB elevated 15-45 degrees.
patient turned only between back and unaffected side to prevent shift of brain tissues
Infratentorial surgery:
Nurses
HOB flat or elevated 20-30 degrees

avoid positioning patient on back to prevent shift of brain tissues downward
avoid neck flexion
Observe for the following side effects of high-dose glucocorticosteroid therapy: elevated
blood glucose, glycosuria, stress ulcer.
Check urinary output and specific gravity for Diabetes Insipidus (increased output;
decreased specific gravity) and Syndrome of Inappropriate ADH (decreased output)
Assist and support patient and family in dealing with residual effects of the tumor or
surgery.
Precautions for care of Neurological patient.

1. Do not lower head in Trendelenburg or supine position.
2. Do not suction through nose unless there is specific order.
3. Be careful when administering sedatives and narcotics (it may cause respiratory
depression and it is difficult to evaluate neurologic status).
4. No oral fluids unless fully awake.
5. No enemas or cathartics.
6. Do not place on operative side.

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Medical-Surgical Nursing

__________________________________________________________ Professional Review Strategies for

MEDICAL SURGICAL NURSING

1. The RAS is the center of wakefulness.

Therapy to decrease ICP is largely influenced by respiratory responses

Decorticate (cortico-spinal tract)

Use Glasgow Coma scale (Eye

II. Respiratory pattern

III. Pupillary Size and Reaction

Midposition, fixed, dilated: poor prognosis (midbrain injury)

V. Motor response and muscle function

*Note muscle tone, strength &

VI. Vital signs: note changes in increased ICP

d. Spinal cord transaction total bilateral sensory loss distal to lesion

C. COMMON NURSING PROBLEMS

check LOC use GCS

2. Attain/Maintain fluid and electrolyte balance

meticulous skin care

5. Maintain corneal integrity

II. INCREASED INTRACRANIAL PRESSURE

Intracranial pressure (ICP) is the pressure exerted within the intact

3. Signs of Increasing Intracranial Pressure (ICP):

Elevate the head 15 30 degrees

III. NURSING INTERVENTIONS FOR APHASIA

Establish a relaxed environment.

Sit down and establish eye contact.

Avoid interrupting and rushing patient.

Damage of brain tissue due to trauma

Immediate and transitory impairment of neurologic function

Likened to bruising with extravasation of blood cells.

Tearing of tissues caused by sharp fragment or a shearing force.

Bleeding into the epidural, subdural, subarachnoid spaces or into

Personally disturbances (range from the subtle personality changes to

Visual disturbances preceding convulsions

Olfactory, visual, or gustatory hallucinations

Inability to replicate pictures

Right Brain Damage

Left Brain Damage

Paralyzed left side: hemiplegia

Paralyzed right side: hemiplegia

Signs & Symptoms of Cerebral

Focal signs (related to site of infarction):

- Isoxuprine HCL (Vasodilan)

Transitory disturbances in consciousness and motor, sensory or automatic functioning die to

Presence or absence; nature id present; ability of patient

Site of initial body movements; deviation of head

Tonic and Clonic

Movement of body as to progression; skin color and

Duration and behavior

Duration; general behavior; ability to remember

Level of consciousness length of unconsciousness if present

Never leave patient alone during seizure,

5. Cranial Nerve Disorders

E. CARE OF THE NEUROSURGICAL PATIENT

Assess baseline neurologic status.

HOB flat or elevated 20-30 degrees

Precautions for care of Neurological patient.

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