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Handouts in Perception and Coordination

By: France A. Turiano-Caayao
Management of Patients with Neurologic Trauma
Clinical Manifestations of Metabolic and Structural Causes of Coma(Huether)

Manifestations Metabolically Induced Coma Structurally Induced Coma

Blink to threat(CNII,VII)
Extraocular movement
Pupils (CNII,III)
Equal Asymmetric
Roving eye movt’s Gaze paresis, nerve palsy
Equal and reactive, may be Asymmetric or nonreactive;
dilated, pinpoint, or may be midposition(mid-brain
midposition and fixed injury), pinpoint(pons injury)

Corneal reflex symmetric response Asymmetric response

(CN V, VII)
Grimace to pain (CN VII) symmetric response Asymmetric response
Motor function movt symmetric response Asymmetric response
tone symmetric response Paratonic, spastic, flaccid,
asymmetric response
posture symmetric response Decorticate, esp if symmetric;
decerebrate, esp if asymmetric
Deep tendon reflexes symmetric Asymmetric
Babinski’s sign Absence or symmetric present
responses
sensation symmetric symmetric

Head Injury
• A broad classification that includes injury to the scalp, skull, or brain
• 1.4 million people in the U.S. receive head injuries every year
• Head injury is the most common cause of death from trauma
• Most common cause of brain trauma is MVA
• Group at highest risk group for brain trauma are males age 15 to 24
• Those younger than 5 years and the elderly are also at increased risk
• Prevention: see Chart 63-1

Pathophysiology of Brain Damage

• Primary injury: due to the initial damage
– Contusions, lacerations, damage to blood vessels, acceleration/deceleration injury, or
foreign object penetration
• Secondary injury: damage evolves after the initial insult
– Due to cerebral edema, ischemia, or chemical changes associated with the trauma
• Manifestations depend upon the severity and location of the injury
– Scalp wounds
 Tend to bleed heavily; scalp wounds are also portals for infection
– Skull fractures
 Usually have localized, persistent pain
 Fractures of the base of the skull
• Bleeding from nose, pharynx, or ears
• Battle’s sign: ecchymosis behind the ear /over the mastoid
• CSF leak—halo sign—ring of fluid around the blood stain from drainage

Manifestations of Brain Injury

• Altered level of consciousness
• Pupillary abnormalities
• Sudden onset of neurological deficits and neurological changes; changes in sense, movement,
and reflexes
• Changes in vital signs
• Headache
• Seizures
• See Chart 63-2
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Initial Management of the Severe Head Injury Patient (see chart in your MS)
• Types of Brain Injury
– Closed brain injury (blunt trauma): acceleration/ deceleration injury occurs when the
head accelerates then rapidly decelerates, damaging brain tissue.
– Open brain injury: object penetrates the brain or trauma is so severe that the scalp and
skull are opened
– Concussion: a temporary loss of consciousness with no apparent structural damage
– Contusion: more severe injury with possible surface hemorrhage
 Symptoms and recovery depend upon the amount of damage and associated cerebral edema
 Longer period of unconsciousness with more symptoms of neurologic deficits and changes in
vital signs.
– Diffuse axonal injury: widespread axon damage in the brain seen with head trauma;
patient develops immediate coma.
– Intracranial bleeding
 Epidural hematoma
 Subdural hematoma
• Acute and subacute
• Chronic
 Intracerebral hemorrhage and hematoma

Concussion
• Patient may be admitted for observation or sent home
• Observation of patients after head trauma; report immediately
– Observe for any changes in level of consciousness
– Difficulty in awakening, lethargy, dizziness, confusion, irritability, and anxiety
– Difficulty in speaking or moving
– Severe headache
– Vomiting
• Patient should be aroused and assessed frequently
• Location of Subdural, Intracerebral, and Epidural Hemorrhages

Epidural Hematoma
• Blood collection in the space between the skull and the dura
• Patient may have a brief loss of consciousness with return of lucid state; then, as hematoma
expands, increased ICP will often suddenly reduce LOC
• An emergency situation
• Treatment includes measures to reduce ICP, remove the clot, and stop bleeding—burr holes or
craniotomy
• Patient will need monitoring and support of vital body functions and respiratory support

Subdural Hematoma
• Collection of blood between the dura and the brain
• Acute/subacute
– Acute: symptoms develop over 24 to 48 hours
– Subacute: symptoms develop over 48 hours to 2 weeks
– Requires immediate craniotomy and control of ICP
• Chronic
– Develops over weeks to months
– Causative injury may be minor and forgotten
– Clinical signs and symptoms may fluctuate
– Treatment is evacuation of the clot

Intracerebral Hemorrhage
• Hemorrhage occurs into the substance of the brain
• May be due to trauma or a nontraumatic cause
Treatment
– Supportive care
– Control of ICP
– Administration of fluids, electrolytes, and antihypertensive medications
– Craniotomy or craniectomy to remove clot and control hemorrhage
 May not be possible due to the location or lack of circumscribed area of hemorrhage

Diagnostic Evaluation
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• Physical and neurologic exam

• Skull and spinal x-rays
• CT scan
• MRI
• PET scan

Management of the Patient With a

Head Injury
• Assume cervical spine injury until this is ruled out
• Therapy to preserve brain homeostasis and prevent secondary damage
– Treat cerebral edema
– Maintain cerebral perfusion; treat hypotension, hypovolemia, and bleeding; monitor and
manage ICP
– Maintain oxygenation as well as cardiovascular and respiratory function
– Manage fluid and electrolyte balance

Supportive Measures
• Respiratory support; intubation and mechanical ventilation
• Seizure precautions and prevention
• NG to manage reduced gastric motility and prevent aspiration
• Fluid and electrolyte maintenance
• Pain and anxiety management
• Nutrition

Nursing Process—Assessment of the Patient With Brain Injury

• Health history with focus upon the immediate injury, time, cause, and the direction and force of
the blow
• Baseline assessment
• LOC: Use Glasgow Coma Scale
• Frequent and ongoing neurologic assessment
• Multisystem assessment: see Table 63-1
• Glasgow Coma Scale

Nursing Process—Diagnosis of the

Patient With Brain Injury
• Ineffective airway clearance and impaired gas exchange
• Ineffective cerebral perfusion
• Deficient fluid volume
• Imbalanced nutrition
• Risk for injury
• Risk for imbalanced body temperature
• Risk for impaired skin integrity
• Disturbed thought patterns
• Disturbed sleep pattern
 Interrupted family process
 Deficient knowledge

Collaborative Problems/Potential Complications

• Decreased cerebral perfusion
• Cerebral edema and herniation
• Impaired oxygenation and ventilation
• Impaired fluid, electrolyte, and nutritional balance
• Risk of post-traumatic seizures

Nursing Process—Planning the Care of the Patient With a Brain Injury

• Major goals include maintenance of patent airway, adequate CPP, fluid and electrolyte balance,
adequate nutritional status, prevention of secondary injury, maintenance of normal
temperature,
• maintenance of skin integrity, improvement of cognitive function, prevention of sleep
deprivation, effective family coping, increased knowledge about rehabilitation process, and
absence of complications

Interventions
• Provide ongoing assessment and monitoring is vital
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• Maintain airway
– Positioning to facilitate drainage of oral secretions with HOB usually elevated 30° to
decrease venous pressure
– Suctioning with caution
– Prevention of aspiration and respiratory insufficiency
– Monitor ABGs, ventilation, and mechanical ventilation
• Monitor I&O and daily weights
• Monitor blood and urine electrolytes, osmolality and blood glucose
• Implement measures to promote adequate nutrition
• Implement strategies to prevent injury
– Assess oxygenation
– Assess bladder and urinary output
– Assess for constriction due to dressings and casts
– Pad side rails
– Use mittens to prevent self-injury; avoid restraints
– Reduce environmental stimuli
– Use adequate lighting to reduce visual hallucinations
– Implement measures to minimize disruption of sleep–wake cycles
– Provide skin care
– Implement measures to prevent infection
• Posey Mitt Used to Prevent Self-Injury
• Maintain body temperature
– Maintain appropriate environmental temperature
– Use coverings: sheets, blankets as per patient needs
– Administer acetaminophen for fever
– Use cooling blankets or cool baths; prevent shivering
• Support cognitive function: see Table 63-2
• Support family
– Provide and reinforce information
– Implement measures to promote effective coping
– Set realistic, well-defined, short-term goals
– Refer patient for counseling
– Refer patient to support groups
• Patient and family teaching: see Chart 63-6

• Management of Patients with Neurologic Trauma

• Ms. France A. Turiano-Caayao, RN,RM,MN
Spinal Nerves
Spinal Nerves Functions
C1, C2, C3 Head, neck and diaphragm
C4,C5 diaphragm
C6, C7, C8 Deltoids, biceps, wrist, triceps
T1, T2 Upper extremities (hand)
T3, T4, T5, T6 Chest muscles
T7, T8, T9, T10, T11, T12 Abdominal muscles
L1, L2, L3, L4, L5 Leg muscles
S1, S3 Bowel/ bladder function
S4, S5 Sexual function

Spinal Cord Injury (SCI)

• A major health problem
• 200,000 persons in the U.S. live with disability from SCI
• Causes include MVAs (35%), violence (24%), falls (22%), and sports injuries (8%)
• Males account for 82% of SCIs
• Young people ages 16 to 30 account for more than half of all new SCIs
• African Americans are at higher risk
• Risk factors include alcohol and drug use
• Prevention: see Chart 63-1

Spinal Cord Injury (SCI) (cont.)

• The result of concussion, contusion, laceration, or compression of the spinal cord
• Primary injury is the result of the initial trauma
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• Secondary injury is usually the result of ischemia, hypoxia, and hemorrhage which destroys the
nerve tissues
• Secondary injuries are thought to be reversible/ preventable during the first 4 to 6 hours after
injury
• Treatment is needed to prevent partial injury from developing into more extensive, permanent
damage
Note: Correct management at the time of injury is crucial because moving the client incorrectly can
permanently damage the spinal cord.

Complications of an SCI
 Spinal and Neurogenic Shock
• Spinal shock
– A sudden depression of reflex activity below the level of spinal injury
– Muscular flaccidity and lack of sensation and reflexes
• Neurogenic shock
– Due to the loss of function of the autonomic nervous system
– Blood pressure, heart rate decrease, and cardiac output decrease
– Venous pooling occurs due to peripheral vasodilation
– Paralyzed portions of the body do not perspire
 Autonomic Dysreflexia
• Acute emergency
• Occurs after spinal shock has resolved and may occur years after the injury
• Occurs in persons with a SC lesion above T6
• Autonomic nervous system responses are exaggerated

Common Causes of AD
– Full bladder
– Abdominal distention
– impacted feces
– Skin pressure or breakdown
– Overstretched muscles
– Sexual intercourse
– Labor and delivery
• Symptoms include severe pounding headache, sudden increase in blood pressure, profuse
diaphoresis, nausea, nasal congestion, and bradycardia
• Triggering stimuli include distended bladder (most common cause), distention or contraction
of visceral organs (such as constipation), or stimulation of the skin

Diagnostic Procedures:
• Neurologic examination
• Radiography
• Myelography
• MRI
• CT Scan

MEDICAL MANAGEMENT
• Cervical collar/back support
– Immobilizes head and back.
• IV line
– Provides access to a vein if shock develops
• V/S are stabilized
• Corticosteroids
– Reduces Spinal cord edema
• Cast or brace or traction
– Additional weight is added over the next few days to increase space between the
vertebrae and move them in correct alignment.

Surgical management
• Spinal fusion
• laminectomy

Nursing Interventions(AD)
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• Place patient in seated position to lower BP

• Impose rapid assessment to identify and eliminate cause
– Empty the bladder using a urinary catheter and irrigate/change indwelling catheter
– Examine rectum for fecal mass
– Examine skin
– Examine for any other stimulus
• Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV
• Label chart or medical record that patient is at risk for autonomic dysreflexia
• Instruct patient in prevention and management

Nursing Process—Assessment of the Patient With SCI

• Monitor respirations and breathing pattern
• Assess lung sounds and cough
• Monitor for changes in motor or sensory function; report immediately
• Assess for spinal shock
• Monitor for bladder retention or distention, gastric dilation, and ileus
• Take temperature; assess for potential hyperthermia
• See Chart 63-7

Nursing Process—Diagnosis of the

Patient With SCI
• Ineffective breathing pattern
• Ineffective airway clearance
• Impaired physical mobility
• Disturbed sensory perception
• Risk for impaired skin integrity
• Impaired urinary elimination
• Constipation
• Acute pain
Collaborative Problems/Potential Complications
• DVT
• Orthostatic hypotension
• Autonomic dysreflexia
Nursing Process—Planning the Care of the Patient With SCI
• Major goals include improved breathing pattern and airway clearance, improved mobility,
improved sensory and perceptual awareness, maintenance of skin integrity, promotion of
comfort, and absence of complications
• Promotion of Effective Breathing and Airway Clearance
• Monitor carefully to detect potential respiratory failure
– Pulse oximetry and ABGs
– Lung sounds
• Early and vigorous pulmonary care to prevent and remove secretions
• Suctioning with caution
• Breathing exercises
• Assisted coughing
• Humidification and hydration
• Improving Mobility
• Maintain proper body alignment
• Turn only if spine is stable and as indicated by physician
• Monitor blood pressure with position changes
• PROM at least 4 times a day
• Use neck brace or collar, as prescribed, when patient is mobilized
• Move gradually to erect position
Interventions
• Implement strategies to compensate for sensory and perceptual alterations
• Implement measures to maintain skin integrity
• Provide temporary indwelling catherization or intermittent catherization
• Use NG tube to alleviate gastric distention
• Implement high-calorie, high-protein, high-fiber diet
• Implement bowel program and use of stool softeners
• Implement traction pin care
• Provide hygiene and skin care related to traction devices

Handouts in Perception & Coordination

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By: France A. Turiano-Caayao, RN,RM,MN

SKULL/SPINAL X-RAYS
Definition
• Non-invasive
• Radiographic picture of head and neck bones
• Taken from two-angles: anteroposterior (AP) and lateral.
• Helps detect:
– Fractures
– Bony tumors
– Vascular abnormalities
– Spinal fracture
– Structural abnormalities
– Congenital abnormalities

Nursing Intervention (before)

• Explain the procedure to the patient
• Determine the patient’s ability to lie still during the procedure
• Explain the events that will occur during the procedure.

Spine Films
• Remove metallic item from around the neck/body.
• Avoid flexion/rotation of spine when fracture is suspected.

CT SCAN
• Combines radiology and computer analysis of tissue density to study intracranial
structures.
• Non invasive scan
• Contrast dye maybe be used
• Uses x-rays and computer analysis to produce 3-dimensional views of thin cross-
sections, or “slices” of the body.
• Narrow xray beam rotates around the client and the results are analyzed by a computer.
• Extremely sensitive to differences in tissue densities, allowing differentiation between
intracranial tumors, cysts, edema and hemorrhage.
• Client is exposed to the same amount of radiation as in a conventional x-ray.

N. Intervention (CT Scan): before

• Explain the procedure to the patient
• Obtain signed informed consent per facility policy.
• Note for allergies to iodine, seafood and radiopaque dyes.
• Allay patient’s anxiety(sedation may be used)
• Explain to the patient that he may feel flushed or noticed a metallic taste in his
mouth(when contrast medium is injected).
• Tell him that the CT scanner will circle around him for 10 to 30 minutes and that he
must lie still during the test.
• Inform patient about possible side effects of dye (throat irritation and flushing of face).
• Remove metallic objects from hair.
• Sedation if unable to remain still.
• NPO 4-6 hrs if contrast medium is used.
• Observe for allergic reaction to iodinated contrast material.
• Encourage to resume normal activities and a regular diet after the test.
• Encourage to resume normal activities and a regular diet after the test.

MAGNETIC RESONANCE IMAGING

• Generates detailed pictures of body structures.
• Involves the use of a contrast medium such as gadolinium.
• Non-invasive scan using magnetic and radio waves.
• Provides superior contrast of soft tissues, sharply differentiating healthy, benign, and
cancerous tissue and clearly revealing blood vessels.
• Permits imaging in multiple planes.
• Detects structural and biochemical abnormalities associated with such conditions as
tumors, cerebral edema and hydrocephalus.
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Nursing Intervention
• Obtain history or metal implants (client with metal implants are not eligible for MRI
scans).
• Procedure lasts up to 1 ½ hours and client should remain.
• Reassure client that procedure is painless.
• Assess for claustrophobia.
• Inform client that machine makes drum-like sounds.
• Request client to remove credit cards, watches which may be demagnetized or any
metal items.
• Determine the ability to lie still
• Administer sedation as prescribed.
• Encourage client to resume normal activities as ordered.

POSITRON EMISSION TOMOGRAPHY SCAN

• Provides colorimetric information about the brain’s metabolic activity.
• Detect how quickly tissues consume radioactive isotopes.
• Helps reveal cerebral dysfunction associated with tumors, seizures, head trauma, some
mental illnesses.
• Detect how quickly tissues consume radioactive isotopes.
• Helps evaluate the effect of drug therapy and neuro surgery.
• Help determine the presence of attention deficit hyperactivity disorder.
• Client either inhales or is injected with a radioactive substance with positively charged
particles that combine with negatively charged particles found normally in the body.
• Used less frequently than CT or MRI because the equipment is available only in major
medical research centers.

Nursing Intervention
• Explain
• Determine patient’s ability to lie still.
• Withhold alcohol, tobacco and caffeine for 24 hours before the procedure.
• Withhold meds as ordered before the procedure.
• Check injection site for bleeding after the procedure.

ELECTROENCEPHALOGRAPHY
• Definition and purpose
• Non-invasive test of the brain
• Graphic representation of the brain’s electrical activity.
• Records the electrical impulses generated by the brain. Electrodes are placed on the
scalp and electrical activity is recorded on the graph.

Nursing Intervention
• Position comfortably in a reclining chair or on a bed.
• Explain – apply paste and attach electrodes to areas of the skin on the patient’s head
and neck.
• Determine the patient’s ability to lie still
• Reassure patient that electrical shock won’t occur.
• Explain that the patient will be subjected to stimuli, such as lights and sound
• Hair shampoo to remove oil/sprays
• No caffeine and other stimulants, anticonvulsants for at least 24 - 48 hours.
• Wash hair after the procedure to remove EEG paste.
• Use acetone to remove any remaining paste from the patient’s skin.
• Encourage him to resume his normal activities, as ordered.

ECHOENCEPHALOGRAPHY
Definition and purpose
• Ultrasound examination of the structures of the brain.
• Detects abnormalities in the ventricles and the location of intracranial bleeding

ELECTROMYOGRAPHY
(EMG)
• Definition and purpose
• Studies the changes in the electrical potential of muscles and the nerves supplying the
muscles.
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• Needle electrodes are place into one or more skeletal muscles and the results recorded
on an oscilloscope.
• Useful in determining the presence of neuromuscular disorders.
• Noninvasive test of muscles
• Graphic recording of the electrical activity of a muscle at rest and during contraction.

N. Interventions
• Explain that the patient must flex and relax his muscles during the procedure.
• Stress the importance of cooperation during the procedure.
• Explain that the patient will feel some discomfort, but not pain.
• Administer analgesics as prescribed, after the procedure.

NERVE CONDUCTION VELOCITY (NCV)

• Measures the speed with which nerve impulses travel along a peripheral nerve fiber
when a specific nerve is electrically stimulated.
• Aids diagnosis of nerve injury and compression or neurologic disorders affecting
peripheral nerves.
• Explain
• May be with mild discomfort.
• Time is appro. 45 minutes for one muscle.

BRAIN SCAN
Definition and Purpose
• Procedure that involves injection of a radiopaque dye.
• Visual imaging of blood flow and distribution and brain structures.
• Identifies tumors, hematomas in or around the brain, cerebral abscesses, cerebral
infractions, or displaced ventricles.
• The length of this procedure varies from a few minutes to 1 hour.
• CT Scans and MRI are replacing this procedures

N. Interventions
• Explain the procedure to the patient.
• Note the patient’ s allergies to iodine, seafood, and radiopaque dyes.
• Determine the patient’s ability to lie still during the procedure.

N. Interventions (before)
• Reassure client: radiation hazard is negligible.
• Time is about 45 minutes; procedure is painless.
• Inform the patient about possible throat irritation and flushing of the face.

CEREBRAL ANGIOGRAPHY
• Fluoroscopic procedure using a radiopaque dye into the brachial artery or the femoral
artery.
• Examination of the cerebral arteries
• Detects stenosis or occlusion associated with a thrombi or spasms
• Identify aneurysms
• Locate vessels displacements associated with tumors, cerebral edema, hematoma or
herniation

N. Interventions (before)
• Explain the procedure to the patient.
• Obtain signed informed consent.
• Note the patient’s allergies to iodine, seafood or radiopaque dyes.
• Inform the patient about possible throat irritation, flushing of the face and a metallic
taste in the mouth.
• Hot, flushing sensation
• Contrast material injected into femoral, brachial or carotid arteries.
• Remove metallic clips from hair.
• NPO 4-6 hours
• IVF to ensure adequate hydration
• Premedicate as ordered

After
• Monitor vital signs.
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• Observe arterial puncture site for bleeding or hematoma;

• Apply pressure dressing or ice pack to the area.
• Maintain affected extremity in straight alignment for 6 hours, or as ordered to prevent a
hematoma.
• Observe pulse distal to the puncture site; diminished or absent pulse may indicate
blockage of vessel by thrombus or by hematoma.
• Monitor neurovital signs.
• Supplements the routine measurement of temperature, pulse rate and respirations by
• Evaluating the:
• LOC
• Pupillary activity
• Orientation to place, time and date and person.
• Provides a simple, indispensable tool for quickly checking the patient’s neurologic status

Nsg. Consideration:
• Observe affected limb for color and temperature.
• Assess for motor or sensory deficits.
• Observe for bradycardia and hypotension which may occur due to vagal irritation in
carotid artery
• Observe for any change in neurological status, risk of stroke or ischemia following
angiography secondary to embolus, thrombus or vasospasm.
• Bed rest (may have head elevated) for 12 to 24 hours; if femoral puncture, must keep
leg extended and immobile for several hours to prevent dislodgement of clot.
• Provide adequate hydration orally or IV., as indicated.
• Allay patient’s anxiety.

LUMBAR PUNCTURE(Pls. see Medical-Surgical Nursing Book)

• Spinal tap
• Performed to obtain the specimen sample of CSF from the subarachnoid space for
laboratory examination and to measure CSF pressure
• Bacteriologic tests on specimens of CSF reveal the presence of pathogenic
microorganisms.
• Therapeutic
o to inject a drug into the subarachnoid space (intrathecal injection),
o to administer a spinal anesthetic,
o to withdraw CSF for the relief of ICP, or
o to inject air, gas or dye for a neurologic procedure.
• Strict aseptic technique is required
• CSF –normally clear ; 80-180 mmH20 or 100 – 150 mmH20.
• A pressure over 200 mm H20 is considered abnormal.

Nursing Considerations: Lumbar Puncture

• Before and during
o Encourage client to void.
o Assist client to assume “fetal position” (flexed, lateral, recumbent position)
• Local anesthetic is used to numb lumbar area.
• Label the specimen collected.
• After
• Lie flat in the prone position for 2 hrs
• then flat in the side lying position for 2 to 3 hours,
• then in the prone or supine position for 6 or more hours.
• Encourage fluids if not contraindicated, to offset CSF leakage.
• Administer analgesics as prescribed.
• Check the puncture site for bleeding.
• Monitor neurovital signs
• Headache may develop due to CSF leakage; treated with bedrest; analgesics and ice to
head.
• Observe for change in neurological.

• Normal Values of CSF

• Pressure – 75 to 180 mmH20
• Glucose -50 to 80 mg/dl
• Protein – 20 to 50 mg/dl
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CSF ANALYSIS
• Definition
• Laboratory test of CSF obtained via LP
• Microscopic examination of CSF for blood, white blood cells, immunoglobulins(Igs),
bacteria, protein, glucose, specific gravity, pH, and electrolytes.

N. Interventions
• Label specimens properly and send to the laboratory immediately.
• Adhere to nursing interventions after a LP.

MYELOGRAPHY
• Definition and purpose:
• Injection of radiopaque water-based dye by LP.
• Visualization of the subarachnoid space, spinal cord and vertebrae under fluoroscopy.
Before
• Explain
• Consent
• Premedicate client is ordered
• Inform client that time is appro 2 hrs.
• Note the patient’s allergies to iodine, seafood and radiopaque dyes.
• Inform the patient about possible throat irritation and flushing of the face.

After
• Keep patient flat in bed for at least 3 hours, with the head of the bed raised 30 to 45
degrees.
• For pantopaque myelogram (oil-based), patient lies flat for 6 to 24 hours to prevent
spinal headache.
• For metrizamide myelogram (water-based), HOB is elevated at 30 degrees for at least 8
hrs. to prevent meningeal irritation.
• Encourage fluids to enhance excretion of dye.
• Observe for any change in neurologic status – confusion, disorientation, nausea and
vomiting
• Observe for generalized seizures.
• Avoid administration of phenothiazines.
• Check puncture site for bleeding.
• Assess for photophobia.

BLOOD CHEMISTRY
• Definition and purpose:
• Laboratory test of a blood sample.
• Analysis for potassium, sodium, calcium, phosphorus, protein, albumin, osmolality,
glucose, bicarbonate, blood urea nitrogen(BUN), and creatinine.

Nursing Intervention
• Explain
• Monitor site for bleeding after the procedure.

HEMATOLOGIC STUDIES
• Definition and purpose
• Laboratory test of a blood sample.
• Analysis from WBCs. RBCs, erythrocyte sedimentation rate(ESR), prothrombin time(PT),
partial thromboplastin time(PTT), platelets, hemoglobin(hgb), and hematocrit(HCT)

Nursing Intervention
• Explain
• Note current drug therapy before the procedure
• Check the venipuncture site for bleeding after the procedure.
Ventriculography
• Before
• Secure surgical permit
• Prepare client as if for surgery
• Inform client that general anesthesia will be used.
• After
• Flat in bed 24 to 48 hours.
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• Monitor VS and neurologic checks

• Severe headache lasts 48 hours.
• Observe seizure precaution.
• Observe for respiratory difficult
Assessment Findings
A. History
• Memory impairment
• Inability to recognize objects(agnosia)
• Numbness and tingling
• Muscle weakness, twitching and spasm
• Ringing in the ears.
• Difficulty chewing, swallowing, talking and walking.
• Headache
• Dizziness
• Fainting
• Loss of balance and coordination
• Nausea and vomiting
• Pain
• Mental confusion or excitement
• Emotional lability
• Blurred or double vision
• Changes in vision
• Change in bowel and bladder patterns
• Sexual dysfunction
• Tremors
• Stiff neck
• Drooping eyelids
• Seizures
• Trauma
B. Physical Examination

KEY FINDINGS IN A CLIENT WITH NS DISORDER:

• Paresthesia
• Loss of sensation
• Altered LOC
• Ataxic gait
• Dyskinesia
• Tinnitus
• dysphagia
• Aphasia
• Seizures
• Diplopia
• Papilledema
• Change in visual fields
• Loss of vision
• Abnormal temperature
• Pulse changes
• Abnormal respirations
• Hypertension
• Weakness
• Spasticity, rigidity, flaccidity
• Abnormal pupil size and reaction
• Abnormal reflexes:
• Babinski’s
• Plantar response
• Changes in muscle reflexes
• Loss of cough, gag, corneal, oculocephalic, and oculovestibular reflexes.
• Ptosis

THE CLIENT UNDERGOING NEUROLOGIC TESTING

Assessment
• Determine the client’s understanding of the diagnostic procedures.
• Make sure a consent form has been signed and witnessed.
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• Check the client’s history for previous allergic reactions to radiographic dyes, iodine or
seafood.
• Obtains baseline data.
• Observe the client for any mental or physical deviations.

Diagnosis, Planning and Intervention

• Deficient Knowledge related to unfamiliarity with diagnostic testing process.
• Clarify the physician’s explanation
• Answer the client’s questions.
• Describe the procedure to the client as well as what the procedure requires, such as the
position required.
• Discuss the preparation for the diagnostic test.
• Explain that hair will be shampooed before an EEG.
• Inform the patient that he or she will be able to shampoo after the procedure.
• Tell the client about some discomforts during the procedure.

Allergic Reaction
• Report the allergy history to the physician.
• Document allergy information.
• Attach allergy band to the client’s wrist.
• Admin. antihistamines accdg to the physician’s order.

• Monitor client for severe hypotension, tachycardia, profuse diaphoresis, sudden change
in LOC, dyspnea, hives or itching.
• Obtain the E-cart that contains drugs and resuscitation equipments.

Meningeal Irritation or CNS changes

• Observe closely for any neurologic abnormalities .
• Assess for changes in v/s, restlessness, and mental changes in orientation and thought
processes.
• Report the onset of a headache and sudden or severe pain in any area of the body to
the physician immediately.
• Inspect injection sites, esp. those made with lumbar puncture, for signs of a hematoma
(collection of Blood).
• Position the client for at least 3 hours as directed by the physician after a lumbar
puncture or myelogram.
• Encourage a liberal fluid intake.
• Keep the room dark and quiet after a lumbar puncture or myelogram.
• Administer a prescribed analgesic if with headache.
• Clients who are allergic to iodine cannot receive radiopaque dyes. Seafoods suggests an
allergy to iodine.

General Considerations
• Clients who are allergic to iodine cannot receive radiopaque dyes.
• Seafoods suggests an allergy to iodine.
• Pharmacologic Considerations
• Morphine and other Narcotic depressants for pain affect the response to light, making
them pinpoint in size.
• The use of morphine, heroine or other narcotics or CNS depressants affects the results
of a neurologic exam.

Gerontologic Considerations
• Diseases that are more common in adults (like dementia)often make it difficult to
perform neurologic assessment.
• Pupillary response is more sluggish.
• If with cataract – no pupillary response.
• Possibility of drug toxicity should be considered.
• Older adults who have difficulty following instructions need brief directions, one step at
a time.
• Obtain facts necessary for a health history from a family member.
 Page 14 of 26

Handouts in Perception and Coordination

By: France A. Turiano-Caayao, RN,RM,MN

Cerebrovascular Accident
A. General Information
1. Destruction(infarction) of brain cells caused by a reduction in cerebral blood flow and oxygen
2. Affects men more than women; incidence increases with age.
3. Caused by thrombosis, embolism, hemorrhage, vasospasm
4. Risk Factors
a. Age: increased risk after age 55
b. Family history
c. Race: African Americans at higher risk
d. Gender: men at higher risk
e. Prior stoke, transient ischemic attack(TIA), or heart attack
f. Hypertension
g. Cigarette smoking
h. Diabetes mellitus
i. Atherosclerosis
j. Atrial fibrillation
k. Lifestyle: High blood cholesterol level, High fat diet, Obesity, Physical inactivity, Use of
hormonal contraceptives
5. Pathophysiology:
a. Interruption of cerebral blood flow for 5 minutes or more causes death of neurons in
affected area with irreversible loss of function.
b. Modifying factors
i. Cerebral edema: develops around affected area causing further impairment
ii. Vasospasm: constriction of cerebral blood vessel may occur, causing further decrease in
blood flow.
iii. Collateral circulation: may help to maintain cerebral blood flow when there is
compromise of main blood supply.
6. Stages of development
a. Transient Ischemic Attack(TIA)
i. Warning sign of impending CVA
ii. Brief period of neurologic deficit: visual loss, hemiparesis, slurred speech, aphasia, vertigo
iii. May last less than 30 seconds, but no more than 24 hours with complete resolution of
symptoms
b. Stroke in evolution: progressive development of stroke symptoms over a period of hours to
days
c. Completed stroke: neurologic deficit remains unchanged for a 2-3 day period.
7. Assessment findings
1. Headache
2. Generalized signs: vomiting, seizures, confusion, disorientation, decreased LOC, nuchal
rigidity, fever, hypertension, slow bounding pulse, Cheyne stokes
3. Focal signs (related to site of infarction)
a. Hemiplegia, sensory loss, aphasia, homonymous hemianopsia
4. Diagnostic tests
a. CT and brain scan: reveal lesion
b. EEG: abnormal changes
c. Cerebral arteriography: may show occlusion or malformation of blood vessels
8. Nursing Interventions :
Acute Stage
a. Maintain patent airway and adequate ventilation.
b. Monitor vital signs and neuro checks and observe for signs of increased ICP, shock,
hyperthermia and seizures
c. Provide complete bed rest as ordered.
d. Maintain fluid and electrolyte balance and ensure adequate nutrition.
i. IV therapy for the first few days
 Page 15 of 26

ii. NGT feedings if client is unable to swallow

iii. Fluid restriction as ordered to decrease cerebral edema
e. Maintain proper positioning and body alignment
i. Head of bed may be elevated 300 to 450 to decrease ICP.
ii. Turn and reposition every 2 hours(only 20 minutes on the affected side)
iii. Passive ROM exercises every 4 hours
f. Promote optimum skin integrity: turn client and apply lotion every 2 hours.
g. Maintain adequate elimination
i. Offer bedpan or urinal every 2 hours, catheterize only if absolutely necessary.
ii. Administer stool softeners and suppositories as ordered to prevent constipation and fecal
impaction.
h. Provide a quiet, restful environment
i. Establish a means of communicating with the client.
j. Administer medications as ordered.
i. Hyperosmotic agents, corticosteroids to decrease cerebral edema
ii. Anticonvulsants to prevent or treat seizures
iii. Thrombolytics given to dissolve clot(hemorrhage must be ruled out)
1. Tissue plasminogen activator
2. Streptokinase, urokinase
3. Must be given within 2 hours of episode
iv. Anticoagulants for stroke in evolution or embolic stroke (hemorrhage must be ruled out)
1. Heparin
2. Warfarin(Coumadin) for long-term therapy
3. Aspirin and dipyridamole(persantine) to inhibit platelet aggregation in
treating TIAs
v. Antihypertensives if indicated for elevated blood pressure
9. Nursing Interventions:
Rehabilitation
a. Hemiplegia: results from injury to cells in the cerebral motor cortex or to corticospinal
tracts(causes contralateral hemiplegia since tracts cross in medulla)
i. Turn every 2 hours (20 minutes only on affected side)
ii. Use proper positioning and repositioning to prevent deformities (foot drop, external
rotation of hip, flexion of fingers, wrist drop, abduction of shoulder and arm.)
iii. Support paralyzed arm on pillow or use sling while out of bed to prevent subluxation of
shoulder.
iv. Elevate extremities to prevent dependent edema
v. Provide active and passive ROM exercises every 4 hours.
b. Susceptibility to hazards
i. Keep side rails up at all times.
ii. Institute safety measures
iii. Inspect body parts frequently for signs of injury.
c. Dysphagia(difficulty swallowing)
i. Check gag reflex before feeding client.
ii. Maintain a calm, unhurried approach.
iii. Place client in upright position.
iv. Place food in unaffected side of mouth.
v. Offer soft foods
vi. Give mouth care before and after meals.
d. Homonymous hemianopsia: loss of half of each visual field.
i. Approach client on unaffected side.
ii. Place personal belongings, food, etc., on unaffected side.
iii. Gradually teach client to compensate by scanning, i.e., turning the head to see things on
affected side.
e. Emotional lability: mood swings, frustration
i. Create a quiet, restful environment with a reduction in excessive sensory stimuli.
ii. Maintain a calm, nonthreatening manner;
iii. Explain to family that the client’s behavior is not purposeful.
f. Aphasia: most common in right hemiplegics; may be receptive/expressive
i. Receptive aphasia
1. Give simple, slow directions
2. Give one command at a time; gradually shift topics
3. Use nonverbal techniques of communication(e.g., pantomime, demo)
4. Expressive aphasia
 Page 16 of 26

a. Listen and watch very carefully when client attempts to speak.

b. Anticipate client’s needs to decrease frustration and feelings of helplessness.
c. Allow sufficient time for client to answer.
g. Sensory/perceptual deficits: more common in left hemiplegics; characterized by
impulsiveness , unawareness of disabilities, visual neglect (neglect of affected side and visual
space on affected side)
i. Assist with self-care
ii. Provide safety measures
iii. Initially, arrange objects in environment on unaffected side.
iv. Gradually client to take care of the affected side and to turn frequently and look at
affected side.
h. Apraxia: loss of ability to perform purposeful, skilled acts
i. Guide client through intended movement (e.g., take object such as washcloth and guide
client through movement of washing).
ii. Keep repeating the movement.
i. Generalizations about clients with left hemiplegia versus right hemiplegia and nursing care.
i. Left hemiplegia
1. Perceptual, sensory deficits; quick and impulsive behavior
2. Use safety measures, verbal cues, simplicity in all areas of care.
ii. Right hemiplegia
1. Speech-language deficits; slow and cautious behavior
2. Use pantomime and demonstrations

Cerebral Aneurysm

A. General Information
a. Dilation of the walls of a cerebral artery, resulting in a sac-like outpouching of vessel
b. Caused by congenital weakness in the vessel, trauma, arteriosclerosis, hypertension
c. Pathophysiology
i. Aneursym compresses nearby cranial nerves or brain substance, producing
dysfunction
ii. Aneursym may rupture, causing subarachnoid hemorrhage or intracerebral
hemorrhage
iii. Initially a clot forms at the site of rupture, but fibrinolyisis (dissolution of the clot)
tends to occur within 7-10 days and may cause rebleeding.
B. Assessment Findings
a. Severe headache and pain in the eyes
b. Diplopia, tinnitus, dizziness
c. Nuchal rigidity, ptosis, decreasing LOC, hemiparesis, seizures

C. Nursing Interventions
a. Maintain a patent airway and adequate ventilation.
i. Instruct client to take deep breaths but to avoid coughing.

ii. Suction only with a specific order.

b. Monitor vital signs and neuro checks and observe for signs of vasospasm, increased ICP,
hypertension, seizures and hyperthermia.
c. Enforce strict bed rest and provide complete care.
d. Keep head of bed flat or elevated to 20 o -30o as ordered
e. Maintain a quiet, darkened environment.
f. Avoid taking temperature rectally and instruct client to avoid sneezing, coughing, and
straining at stool.
g. Enforce fluid restriction as ordered; maintain accurate I & O.
h. Administer medications as ordered.
i. Antihypertensive agents to maintain normotensive levels.
ii. Corticosteroids to prevent increased ICP.
iii. Anticonvulsants to prevent seizures
iv. Stool softeners to prevent straining.
v. Aminocaproic acid (Amicar) to decrease fibrinolysis of the clot(administered IV).
i. Prevent complications of immobility.
j. Institute seizure precations.
k. Provide nursing care for the unconscious client if needed.
l. Prepare the client for surgery if indicated(craniotomy).
 Page 17 of 26

Degenerative Diseases

Parkinson’s Disease

A. General Information
a. A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting
in generalized decline in muscular function; disorder of the extrapyramidal system.
b. Usually occurs in older population
c. Cause unknown; predominantly idiopathic, but sometimes disorder is postencephalitic,
toxic, arterioscleriotic, traumatic, or drug induced(reserpine, methyldopa(Aldomet),
haloperidol(Haldol), Phenothiazines)
d. Pathophysiology
i. Disorder causes degeneration of the dopamine-producing neurons in the substantia
nigra in the midbrain
ii. Dopamine influences purposeful movement
iii. Depletion of dopamine results in degeneration of the basal ganglia.
B. Assessment Findings
a. Tremor: mainly of the upper limb, “pill-rolling,” resting tremors,; most common initial
symptom
b. Rigidity
c. Bradykinesia: slowness of movement
d. Fatigue
e. stooped posture; shuffling, propulsive gait – head held forward, mouth open and
inability to stand
f. difficulty rising form sitting position
g. masklike face with decreased blinking of eyes
h. quiet monotone speech
i. emotional lability, depression
j. increased salivation, drooling
k. cramped, small handwriting
l. autonomic symptoms: excessive sweating, seborrhea, lacrimation, constipation;
decreased sexual capacity
C. Nursing Interventions
a. Administer medications as ordered.
i. Levodopa(L-dopa)
1. Increases level of dopamine in the brain: relieves tremor, rigidity and bradykinesia.
2. Side effects: anorexia, nausea and vomiting; postural hypotension; mental changes
such as confusion, agitation, and hallucinations; cardiac arrhythmias;dyskinesias
3. Contraindications: glaucoma, clients taking MAO inhibitors, reserpine,
guanethidine, methyldopa, antipsychotics, acute psychoses.
4. Avoid multiple vitamin preparations containing B6(Pyridoxine) and foods high in
Vitamin B6
5. Be aware of any worsening of symptoms with prolonged high dose therapy: “on-
off” syndrome.
6. Administer food or snack to decrease GI irritation.
7. Inform client that urine and sweat may be darkened.
ii. Carbidopa-Levodopa(Sinemet):
1. Prevents breakdown of dopamine in the periphery and causes fewer side effects.
iii. Amantadine(Symmetrel): used in mild cases or in combination L-dopa to reduce
rigidity, tremor and bradykinesia.
iv. Anticholinergic drugs; benztropine mesylate (Cogentin), procyclidine (Kemadrin),
Trihexyphenidyl(Artane)
1. Inhibit action of acetylcholine
2. Used in mild cases or in combination with L-dopa
3. Relieve tremor and rigidity
4. Side effects: dry mouth, blurred vision, constipation, urinary retention, confusion,
hallucinations, tachycardia
v. Antihistamines:diphenhydramine(Benadryl)
1. Decrease tremor and anxiety
2. Side effect: drowsiness
vi. Bromocriptine(Parlodel)
1. Often employed when L-dopa losses effectiveness
 Page 18 of 26

vii. Eldepryl(Selegilene) a MAO inhibitor inhibits dopamine breakdown and slows

progression of disease
viii. Tricyclic antidepressants given to treat depression commonly seen in Parkinson’s
disease
b. Provide a safe environment
1. Side rails on bed; rails and handlebars in toilet, bathtub and hallways; no scatter
rugs
2. Hard-back or spring-loaded chair to make getting up easier
c. Provide measure to increase mobility
1. PT: active and passive ROM exercises; stretching exercise; warm baths.
2. Assistive devices
3. If client “freezes,” suggest thinking of something to walk over.
d. Encourage independence in self-care activities; alter clothing for ease in dressing; use
assistive devices; do not rush client.
e. Improve communication abilities: instruct client to practice reading aloud, to listen to
own voice, and enunciate each syllable clearly.
f. Refer for speech therapy when indicated.
g. Maintain adequate nutrition
1. Cut food into bite-sized pieces
2. Provide small, frequent feedings
3. Allow sufficient time for meals, use warming tray.
h. Avoid constipation, and maintain adequate bowel elimination.
i. Provide psychologic support to client/ significant others; depression is common due to
changes in body image and self-concept.
j. Provide client teaching and discharge concerning.
1. Nature of the disease.
2. Use of prescribed medications and side effects.
3. Importance of daily exercise: walking, swimming, gardening as tolerated; balanced
activity and rest.
4. Activities/ methods to limit postural deformities; keep head and neck as erect as
possible; use broad-based gait; raise feet while walking
5. Promotion of active participation in self-care activities.

AUTOIMMUNE DISEASES
I. MULTIPLE SCLEROSIS

A. General Information
a. Chronic, intermittently progressive disease of the CNS, characterized by scattered patches of
demyelination within the brain and spinal cord.
b. Incidence
i. Affects women more than men
ii. Usually occurs from 20-40 years of age
iii. More frequent in cool or temperate climates
c. Cause unknown; may be a slow-growing virus or possibly of autoimmune origin
d. Signs and symptoms are varied and multiple, reflecting the location of demyelination within
the CNS
e. Characterized by remissions and exacerbations
B. Assessment Findings
a. Visual disturbances: blurred vision, scotomas(blind spots), diplopia
b. Impaired sensation: touch, pain, temperature, or position sense; paresthesias such as
numbness, tingling
c. Euphoria, or mood swings
d. Impaired cerebellar function: scanning speech, ataxic gait, nystagmus, dysarthria, intention
tremor
e. Bladder: retention or incontinence
f. Constipation
g. Sexual impotence in the male
h. Diagnostic tests:
i. CSF studies: increased protein and IgG (immunoglobulin)
ii. Visual evoked response
iii. CT scan: increased density of white matter
C. Nursing Interventions
 Page 19 of 26

a. Assess the client for specific deficits related to location of demyelinization.

b. Promote optimum mobility.
i. Muscle-stretching and strengthening exercises.
ii. Walking exercises to improve gait: use wide-based gait.
iii. Assistive devices as necessary.
c. Administer medications as ordered.
i. For acute exacerbations: corticosteroids(ACTH (IV)), prednisone) to reduce edema at
sites of demyelinization.
ii. For spasticity: Baclofen(Lioresal), Dantrolene(Dantrium), diazepam(Valium)
iii. Beta interferon (Betaseron) to alter immune response.
d. Encourage independence in self-care activities.
e. Prevents complication of immobility.
f. Institute bowel program
g. Maintain urinary elimination.
i. Urinary retention
1. Administer bethanecol chloride(Urecholine) as ordered.
2. Perform Intermittent catheterization as ordered.
ii. Urinary Incontinence
1. Establish voiding schedule
2. Administer propantheline bromide(Pro-Banthine) if ordered.
iii. Force fluids to 3000ml/day
iv. Promote use of acid-ash foods to acidify urine like cranberry or grape juice, prune juice,
meat, eggs, poultry, fish, grapes, whole grain.
h. Prevent injury related to sensory problems.
i. Test bath water with thermometer.
ii. Avoid heating pads, hot-water bottles.
iii. Inspect body parts frequently for injury.
iv. Make frequent position changes.
i. Prepare client for plasma exchange (to remove antibodies) if indicated.
j. Provide psychologic support to client/ significant others.
i. Encourage positive attitude and assist client in setting realistic goals.
ii. Provide compassion in helping client adapt to changes in body image and self-concept.
iii. Do not encourage false hopes during remission.
iv. Refer to multiple sclerosis societies and community agencies.
k. Provide client teaching and discharge planning concerning;
i. General measure to ensure optimum health.
1. Balance between activity and rest
2. Regular exercise such as walking, swimming, biking in mild cases.
3. Use of energy conservation techniques
4. Well-balanced diet
5. Fresh air and sunshine
6. Avoiding fatigue, overheating or chilling, stress, infection.
ii. Use of medications and side effects
iii. Alternative methods for sexual gratification; refer to sexual counseling if indicated.

II. Guillain-Barre’ Syndrome

A. General Information
a. Symmetrical, bilateral, peripheral polyneuritis characterized by ascending paralysis
b. Can occur at any age; affects women and men equally.
c. Cause unknown; may be an autoimmune process
d. Precipitating factors: antecedent viral infection, immunization
e. Progression of disease is highly individual; 90% of clients stop progression in 4 weeks;
recovery is usually from 3-6 months; may have residual deficits.
B. Pathophysiology:
a. Preceding infection synthesizes lymphocytes, which attack the myelin sheath, causing
demyelination.
b. Demyelination is followed by inflammation around nerve roots, veins and capillaries
c. Inflammatory process compresses nerve roots.
C. Medical Management
a. Mechanical ventilation if respiratory problems present
i. Plasmepheresis to reduce circulating antibodies
ii. Continuous ECG monitoring to detect alteration in heart rate and rhythm
 Page 20 of 26

iii. Propanolol to prevent tachycardia

iv. Atropine may be given to prevent episodes of bradycardia during endotracheal
suctioning and physical therapy.
D. Assessment findings
a. Mild sensory changes; in some clients severe misinterpretation of sensory stimuli resulting
in extreme discomfort
b. Clumsiness: usually first symptom
c. Progressive motor weakness in more than one limb(classically is ascending and
symmetrical)- initiating in the lower extremities
d. Cranial nerve involvement(dysphagia)
e. Ventilatory insufficiency if paralysis ascends to respiratory muscles.
f. Absence of deep tendon reflexes.
g. Ptosis, visual disturbance
h. Facial weakness
i. Dysphagia
j. dysarthria
k. Diagnostic tests
i. CSF studies: increased protein
ii. EMG: slowed nerve function

E. Nursing Interventions
a. Maintain adequate ventilation.
i. Monitor rate and depth of respirations; serial vital capacities.
ii. Observe for ventilator insufficiency.
iii. Maintain mechanical ventilation as needed; keep airway free of secretions and
prevent pneumonia.
b. Assess cranial nerve function; check gag reflex and swallowing ability; ability to handle
secretions; voice.
c. Monitor vital signs and observe for signs of autonomic dysfunction such as acute periods
of hypertension fluctuating with hypotension, tachycardia, arrhythmias
d. Administer antiarrythmic agents as ordered.
e. Prevent complications of immobility.
f. Promote comfort (especially in clients with sensory changes); foot cradle; sheepskin;
guided imagery; relaxation techniques.
g. Promote optimum nutrition
i. Check gag reflex before feeding
ii. Start with pureed foods.
iii. Assess need for NGT feedings if unable to swallow.
h. Provide psychologic support and encouragement to client/ signifcant others.
i. Refer for rehabilitation to regain strength and to treat any residual deficits.

III. Myasthenia Gravis

A. General Information
a. A neuromuscular disorder in which there is a disturbance in the transmission of impulses
from nerve to muscle cells at the neuromuscular junction, causing extreme muscle weakness.
b. Incidence
1. Highest between ages 15-35 for women, over 40 for men
2. Affects women more than men
c. Cause: thought to be autoimmune disorder whereby antibodies destroy acetycholine
receptor sites on the postsynaptic membrane of the neuromuscular junction
d. Voluntary muscles are affected, especially those muscles innervated by the cranial nerves.
B. Pathophysiology
a. Antibodies attach to the AH receptor sites.
b. Antibodies block, destroy and weaken these sites, leaving them insensitive to
Acetycholine(ACh), thereby blocking neuromuscular transmission.
c. Normal Physiology; during normal neuromuscular transmission, a motor nerve impulse
travels to a motor nerve terminal, stimulating the release of a chemical neurotransmitter
called acetylcholine(ACh). When ACh diffuses across the synapse, receptor sites in the
motor end plate react and depolarize the muscle fiber. The depolarization spreads
through the muscle fiber, causing muscle contraction.
C. Medical Management
 Page 21 of 26

1.Drug therapy

a.Anticholinesterase drugs: ambenomium (Mytelase), Neostigmine(Prostigmin),

Pyridostigmine (Mestinon)
i.block action of cholinesterase and increase levels of acetycholine at the neuromuscular
junction
ii. side effects: excessive salivation and sweating, abdominal cramps, nausea and
vomiting, diarrhea, fasciculations(muscle twitching)
b.Surgery(thymectomy)
i.Surgical removal of the thymus gland(thought to be involved in the production of
acetylcholine receptor antibodies)
ii. May cause remission in some clients especially if performed early in the disease.

c.Plasma Exchange
i.Removes circulating acetycholine receptor antibodies
ii.Use in clients who do not respond to other types of therapy

C. Assessment Findings
a. diplopia, dysphagia
b. extreme muscle weakness, increased with activity and reduced with rest
c. ptosis, masklike facial expression
d. weak voice, hoarseness
e. Diagnostic tests
a. Tensilon test: IV injection of Edrophonium or Neostigmine(Tensilon) provides spontaneous
relief of symptoms (lasts 5-10 minutes). This test also differentiates a myasthenic crisis from
a cholinergic crisis.
b. Electromyography (EMG): amplitude of evoked potentials decreases rapidly. It helps
differentiate nerve disorders from muscle disorders.
c. Presence of antiacetycholine receptor antibodies in the serum.
D. Nursing Interventions
1. Administer anticholinesterase drugs Neostigmine(Prostigmine) and
Pyridostigmine(Mestinon) as ordered.
a. This will counteract fatigue and muscle weakness and enable about 80% of normal
muscle function.Give medication exactly on time.
b. Give with milk and crackers to decrease GI upset
c. Monitor effectiveness of drugs; assess muscle strength and vital capacity before and
after medication.
d. Avoid use of the following drugs: morphine and strong sedatives (respiratory depressant
effect), quinine curare, procainamide, neomycin, streptomycin, kanamycin, and other
aminoglycosides(skeletal muscle blocking effects)
e. Observe for side effects
2. Promote optimal nutrition
a. Mealtimes should coincide with the peak effects of the drugs: give medications 30
minutes before meals.
b. Check gag reflex and swallowing ability before feeding
c. If the client has difficulty chewing and swallowing, do not leave alone at mealtimes; keep
emergency airway and suction equipment nearby.
d. Monitor respiratory status frequently: rate, depth; vital capacity; ability to deep breath
and cough.
e. Assess muscle strength frequently; plan activity to take advantage of energy peaks and
provide frequent rest periods.
f. Observe for signs of myasthenic or cholinergic crisis.
a. Myasthenic crisis
1. Abrupt onset of severe, generalized muscle weakness with inability to swallow,
speak, or maintain respirations.
2. Caused by undermedication, physical or emotional stress, infection.
3. Symptoms will improve temporarily with Tensilon test
b. Cholinergic crisis
1. Symptoms similar to myasthenic crisis and, in addition, the side effects of
anticholinesterase drugs(e.g., excessive salivation and sweating, abdominal
cramps, nausea and vomiting, diarrhea, fasciculations)
2. Caused by overmedication with the cholinergic (anticholinesterase) drugs.
 Page 22 of 26

3. Symptoms worsen with tensilon test; keep atropine sulfate and emergency
equipment on hand.
c. Nursing care in crisis
1. Maintain tracheostomy or endotracheal tube with mechanical ventilation as
indicated.
2. Monitor arterial blood gases and vital capacities.
3. Administer medications as ordered.
a. Myasthenic crisis: increase doses of anticholinesterase drugs as ordered.
b. Cholinergic crisis: discontinue anticholinesterase drugs as ordered.
4. Establish a method of communication.
5. Provide support and reassurance.
g. Provide nursing care for the client with a thymectomy.
h. Provide client teaching and discharge planning concerning
a. Nature of disease
b. Medications, side effects and toxicity
c. Check with physician before taking any new medications including OTC drugs.
d. Importance of planning activities to take advantage peaks and of scheduling
frequent rest periods.
e. Need to avoid fatigue, stress, people with upper-respiratory infections
f. Use of eye patch for diplopia
g. Need to wear Medic-alert bracelet

IV. Huntington’s Chorea

A. General Information
a. Or Huntington’s disease.
b. It is a hereditary disease that causes degeneration in the cerebral cortex and basal ganglia.
c. Degeneration leads to chronic progressive chorea and mental deterioration that ends in
dementia.
d. Cause is unknown. Thought to be transmitted as an autosomal dominant trait.

B. Pathophysiology

a. HC involves a disturbance in neurotransmitter substances, primarily gamma aminobutyric

acid(GABA) and dopamine.
b. GABA neurons in the basal ganglia, frontal cortex and cerebellum are destroyed and replaced
with glial cells.
c.The deficiency of GABA (an inhibitory neurotransmitter) causes an excess of dopamine and
abnormal neuro transmission along the affected pathways.
C. Assessment Findings
a. Severe choreic movements(involuntary, rapid, usually violent and purposeless movements)
initially unilateral and more prominent in the face and arms than in the legs.
b. Dementia, typically mild at first and then growing more severe until it disrupts the
personality.
c. dysarthria
d. Loss of musculoskeletal control
D. Diagnostic Findings
a. PET scan
b. Deoxyribonucleic acid analysis can detect HD.
c. CT scan and MRI reveal brain atrophy
E. Medical Management
a. No known cure.
b. Focus: safety of patient, support, preventing symptoms
c. Tranquilizers and drugs such as Chlorpromazine(thorazine), Haloperidol, and
Imipramine(Tofranil) – controls choreic movement and alleviate discomfort and depression.
However, they can stop mental deterioration. Tranquilizers increases rigidity.
d. To control choreic movements without rigidity, Choline(Tricosal) is given.
F. Nursing Intervention
a. Attend to the patient’s needs
i. Hygiene
ii. Skin care
iii. Bowel and bladder care
iv. Nutrition
 Page 23 of 26

b. Increase support as his mental and physical deterioration becomes more pronounced.
c. Provide emotional support.
d. Be alert for signs of suicide, and make sure the patient’s environment is free from
instruments that could permit self-inflicted injury.
e. Evaluate the patient’s mobility and level of function.
f. Help family to identify resources that can help them cope with the patient’s illness.

Specific Disorders of the Peripheral Nervous System

I. Bells’ Palsy
A.General Information
a. Disorder of cranial nerve VII resulting in the loss of ability to move the muscles on one side
of the face.
b. Cause unknown: may be viral or autoimmune
c. Complete recovery in 305 weeks in majority of clients.
B. Assessment Findings
a. Loss of taste over anterior two-thirds of tongue on affected side.
b. Complete paralysis of one side of face.
c. Loss of expression, displacement of mouth toward unaffected side, and inability to close
eyelid(all on affected side)
d. Pain behind the ear.
C. Nursing Interventions
a. Assess facial nerve function regularly
b. Administer medications as ordered
i. Corticosteroids: to decrease edema and pain
ii. Mild analgesics as necessary
c. Provide soft diet with supplementary feedings as indicated
d. Instruct to chew on unaffected side, a void hot fluids/foods, and perform mouth care after
each meal.
e. Provide special eye care to protect the cornea.
i. Dark glasses (cosmetic and protective) or eyeshield
ii. Artificial tears to prevent drying of the cornea.
iii. Ointment and eye patch at night to keep eyelid closed.
f. Provide support and reassurance.
g. Include in the health teaching that children have a 50% chance of inheriting the disease and
that genetic counseling is a good idea before starting a family.

III.Trigeminal Neuralgia (Tic Douloureux)

A. General Information
a. Disorder of the Cranial Nerve V causing disabling and recurring attacks of severe pain along
the sensory distribution of one or more branches of the trigeminal nerve.
b. Incidence increased in elderly women
c. Cause unknown
B. Medical Management
a. Anticonvulsant drugs: Carbamazepine (Tegretol), Phenytoin(Dilantin)
b. Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve;
temporary effect, lasts 6-18 months.
c. Surgery
a. Peripheral: avulsion of peripheral branches of trigeminal nerve
b. Intracranial
i. Retrogasserian Rhizotomy: total severance of the sensory root of the trigeminal nerve
intracranially; results in permanent anesthesia, numbness, heaviness, and stiffness in
affected part; loss of corneal reflex
ii. Microsurgery: uses more precise cutting and may preserve facial sensation and corneal
reflex
iii. Percutaneous radio-frequency trigeminal gangliolysis: current surgical procedure of
choice; thermally destroys the trigeminal nerve in the area of the ganglion; provides
permanent pain relief with preservation of sense of touch, proprioception, and
corneal reflex; done under local anesthesia
iv. Microvascular decompression of trigeminal nerve decompresses the trigeminal nerve;
provides permanent pain relief while preserving facial sensation.
C. Assessment findings
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a. Sudden paroxysms of extremely severe shooting pain in one side of the face
b. Attacks may be triggered by a cold breeze, foods/fluids of extreme temperature,
toothbrushing, chewing, talking, or touching the face.
c. During attack: twitching, grimacing, and frequent blinking/tearing of the eye.
d. Poor eating and hygiene habits
e. Withdrawal from interactions with others
f. Diagnostics tests: x-rays of the skull, teeth and sinuses may identify dental or sinus infection
as an aggravating factor.
D. Nursing Interventions
a. Assess characteristics of the pain including triggering factors, trigger points, and pain
management techniques.
b. Administer as ordered; monitor response
c. Maintain room at an even, moderate temperature, free from drafts
d. Provide small, frequent feedings of lukewarm, semiliquid, or soft foods that are easily
chewed.
e. Provide the client with a soft washcloth and lukewarm water and perform hygiene during
periods when pain is decreased.
f. Prepare the client for surgery if indicated
g. Provide client teaching and discharge planning concerning
a. Need to avoid outdoor activities during cold, windy or rainy weather
b. Importance of good nutrition and hygiene
c. Use of medications, side effects and signs of toxicity
d. Specific instructions following surgery for residual effects of anesthesia and loss of
corneal reflex.
i. Protective eye care
ii. chew on unaffected side only
iii. avoid hot fluids/foods
iv. mouth care after meals to remove particles
v. good oral hygiene; visit dentist every 6 months
vi. protect the face during extremes of temperature

III. Amyotrophic Lateral Sclerosis

(Lou Gehrig’s Disease)

A. General Information
a. Progressive motor neuron disease which usually leads to death in 2-6 years.
b. Onset usually between ages 40-70; affects men more than women.
c. Cause unknown: In some cases, genetic predisposition, viral infection.
d. There is no cure or specific treatment; death usually occurs as a result of respiratory
infection secondary to respiratory insufficiency.
B. Pathophysiology
a. Myelin sheaths are destroyed and replaced with scar tissue, resulting in distorted or
blocked nerve impulses.
b. Degeneration of upper motor neurons in the medulla oblongata and lower motor
neurons in the spinal cord.
c. Nerve cells die and muscle fibers have atrophic changes.
C. Assessment Findings
a. Progressive weakness and atrophy of the muscles of the arms, trunk or legs.
b. Dysarthria, dysphagia
c. Fasciculations
d. Spasticity
e. Emotional lability
f. Muscle incoordination
g. Respiratory insufficiency
h. Diagnostic tests: EMG and muscle biopsy can rule out other diseases; laboratory values:
elevated creatinine kinase.
D. Medical Management
a. Mechanical ventilation: negative-pressure ventilators
b. Antispasmodics: Baclofen(Lioresal), Tizanidine(Zanaflex)
c. Physical therapy
E. Nursing Interventions
a. Provide nursing measures for muscle weakness and dysphagia.
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b. Promote adequate ventilator function.

c. Prevent complications of immobility
d. Encourage diversional activities; spend time with the client.
e. Provide compassion and intensive support to client/significant others.
f. Provide or refer for physical therapy as indicated
g. Promote independence for as long as possible.

INTERVERTBERAL DISK HERNIATION

A. General Information
a. All or part of the nucleus pulposus is forced through the disk’s outer ring (annulus fibrosus)
b. Causes: degenerative disk changes, trauma, physical stress, scoliosis/kyphosis, spondylosis
B. Pathophysiology
a. The extruded disk may impinge on spinal nerve roots as they exit from the spinal canal or on the
spinal cord itself.
C. Assessment Findings

a. In lumbosacral area
i. acute, intermittent pain in the lower back radiating across the buttock and down the leg.
ii. Pain on ambulation
i. weakness, numbness and tingling of the foot and leg.
ii. Diminished reflexes of the affected extremity.
b.In cervical area
i. weakness of the affected upper extremity
ii.neck pain that radiates down the arm to the hand.
iii.sensory loss of the hand

iv.diminished or absent reflexes of the arm.

c.In thoracic area
i. bandlike pain around chest

D. Diagnostic Findings
a. MRI: herniation of the affected area of spine, degenerative changes and condition of the canal
and nerve root.
b. Myelogram: degree of injury and level of herniation
c. CT scan: outlines bone and soft tissue structures
d. Lasegue’s sign and straight –leg raising test: positive
E. Medical Management
a. Heating pad and moist, warm compress
b. Analgesics: Propoxyphene(Darvon), Oxycodone and Acetaminophen(Percocet, Tylox)
c. Nonsteroidal and anti-inflammatory drugs: Indomethacin(Indocin), Ibuprofen(Motrin),
Sulindac(Clinoril), Piroxicam(Feldene), Diclofenac(Voltaren), Diazepam(Valium)
d. Physical therapy
e. Orthopedic devices: back brace, cervical collar, traction
f. Transcutaneous electrical nerve stimulation(TENS)
F. Nursing Intervention
a. Monitor neurovascular status, vital signs, I/O and laboratory values
b. Assess level of pain and administer analgesics as necessary
c. Maintain traction, braces and cervical collar
d. Encourage fluids
e. Maintain bed rest with proper body alignment
f. Encourage patient to verbalize feelings
g. Reposition patient every 2 hours using logrolling technique
h. Promote independence in ADLs.
i. Health teaching should include:
i.nature of disease
ii. medications
iii. exercise regularly per PT’s advise
iv. avoid heavy lifting
v. avoid flexion, extension or rotation of the neck, if cervical
vi. use a back brace or cervical collar
vii. practice relaxation techniques
viii. use proper body mechanics.
G. Surgical Interventions
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a. Microdisectomy
b. Percutaneous discectomy
c. Laminotomy or discectomy with or without use of instrumentation