CHAPTER 60: ASSESSMENT OF NEUROLOGIC FUNCTION

NERVOUS SYSTEM
2 MAJOR PARTS:
• Central Nervous System – brain and spinal cord
• Peripheral Nervous System – cranial nerves, spinal nerves, and autonomic nervous system
Function: to control motor, sensory, autonomic, cognitive, and behavioral activities

CELLS OF THE NERVOUS SYSTEM

• NEURONS – basic functional unit of the brain

• dendrites, cell body, and an axon
• it is supported, protected, and nourished by glial cells
• controls all motor, sensory, autonomic, cognitive, and behavioral activities
• AXON – long projection that carries electrical impulses away from the cell body (away from the cell body)
• DENDRITES – branch-type structures for receiving electrochemical messages (towards the cell body)
NEUROTRANSMITTERS

• Communicate messages from one neuron to another or to specific target tissue

• It can potentiate, terminate, or modulate a specific action or can excite or inhibit a target cell
• Many neurologic disorders are caused by an imbalance in neurotransmitters
• Inhibitory, excitatory, or both
ACETYLCHOLINE

• Major transmitter of the parasympathetic nervous system

• It is usually excitatory; parasympathetic effects sometimes inhibitory (stimulation of heart by vagal nerve)
SEROTONIN
• Inhibitory; helps control mood and sleep, inhibits pain pathways
DOPAMINE
• Usually inhibitory; affects behavior (attention and emotions) and fine movement
NOREPINEPHRINE
• Major transmitter of the sympathetic nervous system
• It is usually excitatory; affects mood and overall activity
GAMMA-AMINOBURYTIC ACID

• Inhibitory
ENKEPHALIN, ENDORPHIN

• Excitatory; pleasurable sensation, inhibits pain transmission

CENTRAL NERVOUS SYSTEM

BRAIN
3 MAJOR AREAS:
• CEREBRUM
• BRAIN STEM
• CEREBELLUM
CEREBRUM – “largest” section
2 HEMISPHERES: connected by CORPUS CALLOSUM

■ LEFT HEMISPHERE
■ RIGHT HEMISPHERE
GRAY MATTER – outer portion

• It contains billions of neuron cell bodies (gray appearance)

WHITE MATTER – inner portion

• It is composed of myelinated nerve fibers and neuroglia cells that form tracts or pathways connecting various parts of the brain with one another
4 LOBES
 • FRONTAL LOBE
– concentration, abstract thought, information storage or memory, motor function
– Broca area: left hemisphere; critical for motor control of speech
– person’s affect, judgment, personality, and inhibitions
• PARIETAL LOBE
– integrates sensory information
– person’s awareness of body position in space, size and shape discrimination, and right-left orientation

• TEMPORAL LOBE
– auditory information
– play a role in memory of sound and understanding of language and music
• OCCIPITAL LOBE
– visual interpretation and memory
CORPUS CALLOSUM
– thick collection of nerve fibers that connects two hemispheres of the brain
– it is responsible for the transmission of information from one side to another

HYPOTHALAMUS
– plays an important role in endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and
urine production
– it works with pituitary to maintain fluid balance through hormonal release and maintains temperature regulation by promoting vasodilation and vasoconstriction
– it is the site of the HUNGER CENTER (APPETITE CONTROL)
– it contains center that regulate sleep-wake cycle, blood pressure, aggressive and sexual behavior, and emotion responses
– it also controls autonomic nervous system
– it is where OPTIC CHIASM (the point at which the two optic tracts cross) and MAMILLARY BODIES (involved in olfactory reflexes and emotional response to
odors) are found

BRAIN STEM

• MIDBRAIN
– connects the pons and the cerebellum with cerebral hemispheres
– center for auditory and visual reflexes
– cranial III and IV
• PONS
– portions of the pons help regulate respiration
– cranial V and VIII
• MEDULLA OBLONGATA
– reflex centers for respiration, blood pressure, heart rate, coughing, vomiting, swallowing, and sneezing
– cranial IX and XII
– reticular formation (responsible for arousal and sleep-wake cycle) begins in medulla and connects with numerous higher structures

CEREBELLUM
– it controls fine movement, balance, and position sense or proprioception (awareness of position of extremities without looking at them)

STRUCTURES PROTECTING THE BRAIN

Major bones of the skull:
• Frontal
• Temporal
• Parietal
• Occipital
• Sphenoid
Fossae – indentation in the skull base

■ Anterior fossa (frontal lobe)

■ Middle fossa (temporal lobe)
■ Posterior fossa (cerebellum and brain stem)
Meninges
• Fibrous connective tissues that cover the brain and spinal cord
• It provides protection, support, and nourishment
LAYERS:

■ DURA MATER
– outer; covers the brain and spinal cord
– tough, thick, inelastic, fibrous, and gray
3 major extensions:

• falx cerebri – folds between the two hemispheres

• tentorium – folds between occipital lobe and cerebellum to form a tough, membranous shelf
 • falx cerebelli – located between the right and left side of cerebellum

• HERNIATION: brain tissue may be compressed against these dural folds or displaced around when excess pressure occurs
■ ARACHNOID
– middle membrane; an extremely thin, delicate membrane that closely resembles a spider web
– It has CSF in subarachnoid space and arachnoid villi (unique finger-like projections that absorb CSF into the venous system

■ PIA METER
– innermost; thin, transparent layer that hugs the brain closely and extends into every fold of the brain’s surface

CEREBROSPINAL FLUID
– clear and colorless fluid that is produces in the choroid plexus of the ventricles and circulates around the surface of the brain and spinal cord.
– blockage of flow of CSF = obstructive hydrocephalus

BRAIN CIRCULATION

1. Arterial and venous vessels are not paralleled as in other organs in the body
2. The brain has collateral circulation through the circle of Willis, allowing blood flow to be redirected on demand
3. Blood vessels in the brain have two rather than three layers, which may make them more prone to rupture when weakened or under pressure
BLOOD BRAIN BARRIER: protects the brain by forming a highly selective barrier between the bloodstream and the brain's extracellular fluid in the central nervous
system. It is composed of endothelial cells of the brain’s capillaries, the BBB restricts the passage of harmful substances, toxins, and large molecules, preventing them
from entering the brain.

SPINAL CORD
– it serves as a connection between the brain and the periphery
– 45 cm (18 in) extends from the foramen magnum at the base of the skull to the lower border of the first lumbar vertebra, where it tapers to conus medullaris (fibrous
band)
– Below are the second lumbar space are the nerve roots that extend beyond the conus called cauda equina (resembles a horse’s tail)
Meninges: surround the spinal cord

VERTEBRAL COLUMN
8 CERVICAL
12 THORACIC
5 LUMBAR
5 SACRAL
1 COCCYGEAL

PERIPHERAL NERVOUS SYSTEM

Cranial nerves, spinal nerves, autonomic nervous system
CRANIAL NERVES
CRANIAL NERVE ASSESSMENT
IOLFACTORY SENSORY Sense of smell
IIOPTIC SENSORY Sense of vision
III
OCULOMOTOR MOTOR Pupil constriction
IVTROCHLEAR MOTOR Downward, inward eye
(smallest) (down) movement
V TRIGEMINAL SENSORY, (M) Jaw movements – chewing
(largest) (triCHEWminal) MOTOR and mastication
(S) sensation on the face and
neck
VI ABDUCENS MOTOR Lateral movement of the eyes
(at the sides)
VII FACIAL SENSORY, (M) Muscles of the face
MOTOR (S) Sense of taste on the
anterior two thirds of tongue
VIII ACOUSTIC SENSORY Sense of hearing
(VESTIBULOCOCHLEAR)
IX GLOSSOPHARYNGEAL SENSORY, (M) Pharyngeal movement and
MOTOR swallowing
(S) sense of taste on the
posterior one third of tongue
X VAGUS SENSORY, Swallowing and speaking
(longest) (“mavagal”) MOTOR
XI ACCESSORY MOTOR Movement of shoulder muscles
(shoulders)
XII HYPOGLOSSAL MOTOR Movement of the tongue;
strength of the tongue

SPINAL NERVES
31 PAIRS: each has ventral root and dorsal root
ventral root – sensory and transmit sensory impulses from specific areas of the body
dorsal root – motor and transmit impulses from the spinal cord to the body
8 CERVICAL
12 THORACIC
5 LUMBAR
5 SACRAL
1 COCCYGEAL

• Motor pathways
• Corticospinal (pyramidal) tract
• Controls voluntary movement and integrated skilled, complicated, or delicate movements
• Basal ganglia system
• Maintains muscle tone, controls automatic body movements
• Cerebellar system
• Receives sensory and motor input, coordinates motor activity, maintains equilibrium
• Sensory pathways: Spinothalamic tract and posterior columns
• Spinal reflexes: The muscle stretch and deep tendon reflexes
• Reflex: involuntary stereotypical response
• Briskly tap the tendon of partially stretched muscle
• Tapping tendon activates special sensory fibers
• Each deep tendon involves specific spinal segments, can help locate a pathologic lesion
• Spinal reflexes: the deep tendon response
Reflex Spinal Segment
Ankle reflex (Achilles) Sacral 1 primarily
Knee reflex (patellar) Lumbar 2, 3, 4
Supinator (brachioradialis) reflex Cervical 5, 6
Biceps reflex Cervical 5, 6
Triceps reflex Cervical 6, 7

• Cutaneous stimulation reflex

Reflex Spinal Segment

Abdominal reflexes, upper Thoracic 8, 9, 10
Abdominal reflexes, lower Thoracic 10, 11, 12
Cremasteric reflex Lumbar 1, 2
Plantar responses Lumbar 5, Sacral 1
Anal reflex Sacral 2, 3, 4

THE HEALTH HISTORY

TREMORS

• Involuntary movements
• Occur with or without other neurologic manifestations
• Trembling, shakiness, uncontrollable body movements
• Leg restlessness
TREMORS AND INVOLUNTARY MOVEMENTS

• Resting (Static) Tremors

• Postural (Action) Tremors
• Intention Tremors
• Oral-Facial Dyskinesias
• Tics
• Dystonia
• Athetosis
• Chorea
PHYSICAL EXAMINATION EQUIPMENT
CRANIAL NERVE EXAMINATION
• Penlight
• Snellen chart
• Newspaper or hand-held newsprint
• Ophthalmoscope
 • Cotton swab
• Tongue depressor
• Gloves
• Scent stimuli for olfactory (vanilla, cinnamon, coffee, lemon juice, or soap)
• Tuning fork
SENSORY EXAMINATION

• Objects to feel (coin, paper clip)

• Tuning fork
• Hot and cold water in test tubes/glass
• Cotton swab
MUSCLE STRETCH RESPONSE/DEEP TENDON REFLEXES

• Reflex hammer
• Tongue blade
PHYSICAL EXAMINATION
Important areas of examination
• Mental Status
• Cranial nerves I through XII
• Motor system: coordination, gait, balance, stance, muscle strength, bulk, tone
• Sensory system: pain and temperature, position and vibration, light touch, discrimination
• Deep tendon, abdominal and plantar reflexes
Organize approach into five categories:
• Mental status, speech, language
• Cranial nerves
• Motor system
• Sensory system
• Reflexes
If findings are abnormal, group them into patterns of central or peripheral disorders
Integrate neurologic assessment with other parts of the examination
• Mental status and speech during interview
• Cranial nerves during examination of head and neck
• Neurologic abnormalities in the arms and legs while evaluating peripheral vascular and musculoskeletal systems
Think about and describe findings in terms of the nervous system as a unit

GUIDELINES FOR A SCREENING NEUROLOGIC EXAMINATION FROM THE AMERICAN ACADEMY OF NEUROLOGY
• MENTAL STATUS: alertness, appropriateness of responses, orientation to date and place
• CRANIAL NERVES: vision, pupillary light reflex, eye movements, hearing, facial strength
• MOTOR SYSTEM: muscle strength, bulk, and tone, gait, coordination
• SENSORY: light touch, pain/temperature, proprioception
• REFLEXES: muscle stretch response/deep tendon reflexes, plantar response
THE CRANIAL NERVES
CN I: OLFACTORY
• Present patient with familiar and nonirritating odors

• Compress one nostril and ask patient to sniff through the other

• Ask patient to identify odor with eyes closed

• Used different odors for testing smell on each side

• Avoid noxious triggers that might stimulate CN V

CN II: Optic

• Visual acuity
 • Inspect optic fundi with ophthalmoscope
• Test visual fields with confrontation
CN II and III: Optic and Oculomotor
• Size and shape of pupils
➢ Compare one side with the other
• Pupillary reactions to light
• Near response or accommodation
CN III, IV, and VI: Oculomotor, Trochlear, and Abducens
• Extraocular movements
• Convergence of eyes
➢ Nystagmus
• Ptosis
CN V: Trigeminal

• Palpate temporal and masseter muscles

• Clench teeth, move jaw side to side
• Sensory
■ Pain sensation on forehead, cheeks, and chin
• “Sharp” or “dull”
■ Temperature sensation
• “Cold” or “hot”
■ Light touch
■ Corneal reflex
➢ Look up and away
➢ Out of line of vision, touch cornea with fine wisp of cotton
➢ Patient should blink
CN VII: Facial
• Inspect face at rest and during conversation
➢ Asymmetry, abnormal movements
■ Raise both eyebrows
■ Frown, smile
■ Close both eyes, test muscular strength
■ Show both upper and lower teeth
■ Smile
■ Puff out cheeks
TYPES OF FACIAL PARALYSIS

1. Peripheral Lesion
2. Central Lesion
CN VIII: Acoustic

• Whispered voice test, finger rub

• Air and bone conduction test with tuning forks
- Rinne test
- Weber test

CN IX and X: Glossopharyngeal and Vagus

• Voice
• Hoarse? Nasal quality?
• Difficulty swallowing?
 • “Say ‘ah™: movements of soft palate and pharynx?
• Test the gag reflex
CN XI: Spinal accessory

• Atrophy or fasciculations in trapezius muscles

• Shrug both shoulders upward against your hands
• Turn head to each side against hand
CN XII: Hypoglossal
• Listen to articulation of words
• Tongue position in mouth
• When tongue protruded: asymmetry, atrophy, deviation from midline
• Move tongue from side to side, note symmetry of movement
The motor system

• Body position
- During movement and rest
• Involuntary movements
- Tremors, tics, chorea, fasciculations
- Note location, quality, rate, rhythm, amplitude
- Relation to posture, activity, fatigue, emotion,
and other factors

• Muscle bulk, tone, and strength

• Coordination
Requires four areas of the nervous system:

■ Motor system
■ Cerebellar system
■ Vestibular system
■ Sensory system
• Coordination
Observe performance of:

➢ Rapid alternating movements

- Arms
- Legs
➢ Point-to-point movements
- Arms: finger-to-nose test
- Legs: heel-to-shin test
➢ Gait and other related body movements
Stance

- The Romberg test

- Test for pronator drift
➢ Standing in specific ways
ABNORMALITIES OF GAIT AND POSTURE

• Spastic Hemiparesis
• Scissors Gait
• Steppage Gait
• Parkinsonian Gait
• Cerebellar Ataxia
• Sensory Ataxia
The sensory system

• Test the following:

■ Pain and temperature (spinothalamic tracts)
■ Position and vibration (posterior columns)
■ Light touch (both spinothalamic and posterior)
■ Discriminative sensations (cortex, spinothalamic tracts, posterior columns)
• Correlate abnormal findings with motor and reflex activity
• Underlying lesion central or peripheral?
• Sensory loss bilateral or unilateral?
• Pattern suggest dermatomal distribution, a polyneuropathy, or a spinal cord syndrome
• Loss of pain and temperature sensation?
• Intact touch and vibration?
• Patterns of testing
■ Can fatigue patient, producing unreliable results
■ Pay special attention to:
➢ Where there are symptoms such as numbness or pain
➢ Where there are motor or reflex abnormalities
➢ Where there are trophic changes
■ Compare symmetric areas
■ Compare distal with proximal areas
■ Test fingers and toes first for vibration and position
■ Vary the pace of your testing
■ Map out boundaries if sensory loss or hypersensitivity is detected

• Pain
■ Use broken tongue blade/cotton swab
■ Sharp and dull
■ Apply lightest pressure needed for stimulus to feel sharp; do not draw blood
• Temperature
■ Water, tuning fork
• Light touch
■ Cotton, avoid pressure
• Vibration
■ Tuning fork
• Proprioception (joint position)
■ Move big toe up and down

• Discriminative sensations
■ Stereognosis
■ Number identification
■ Two-point discrimination
■ Point localization
■ Extinction
 SCALE FOR FRADING REFLEXES
4+ Very brisk, hyperactive, with clonus (rhythmic oscillations
between flexion and extension)
3+ Brisker than average; possible but not necessarily indicative of
disease
2+ Average; normal
1+ Somewhat diminished; low normal
0 No response

SPECIAL TECHNIQUES
Assessment of the unconscious patient

• ABCDE
• Level of consciousness
➢ GLASGOW COMA SCALE
• Neurologic evaluation – focal or asymmetric findings
• Interview relatives, friends, witnesses
➢ Warning symptoms, precipitating factors, previous episodes, prior appearance, and behavior
• Airway, breathing, and circulation
■ Color and breathing pattern
➢ Rate, rhythm, and pattern of respirations
■ Consider intubating If airway is obstructed
■ Assess circulation by checking the remaining vital signs
➢ If hypotension/hemorrhage present, establish IV access, begin IV fluids

• Level of consciousness
■ Alertness: Alert patient opens eyes, looks at you, and responds fully and appropriately
■ Lethargy: Patient appears drowsy but opens eyes, looks at you, responds to questions, and falls asleep
■ Obtunded: Patient opens eyes, looks at you, responds slowly, and is somewhat confused
■ Stupor: Patient arouses from sleep only after painful stimuli. Verbal responses are slow or absent. Patient lapses into unresponsive state when stimulus
ceases and has minimal awareness of self or environment

■ Coma: Patient is unarousable and eyes are closed. There is no evident response to inner need or external stimuli
GLASGOW COMA SCALE

- Points are determined to assess levels of consciousness and coma in 3 areas:

➢ eye opening
➢ verbal response
➢ motor response
Interpretation:
3 = no response
3-8 = comatose
15 = fully alert and functioning person
EYE OPENING = 4
ACTIVITY RESPONSE SCORE
None 1 = no response, even to supraorbital
pressure
To Pain 2 = pain from sternum/limb/supraorbital
pressure
To speech 3 = nonspecific response, not necessarily
to command
Spontaneous 4 = eyes open, not necessarily aware

MOTOR RESPONSE = 6
ACTIVITY RESPONSE SCORE
None 1 = no response to any pain; limbs flaccid

Extension 2 = shoulder adducted, shoulder and

forearms internally rotated
Flexor response 3 = withdrawal response or assumes of
hemiplegic posture
Withdrawal 4 = arms withdraws to pain, shoulder
adducts
Localizes pain 5 = arm attempts to remove
 supraorbital/chest pressure
Obeys commands 6 = follows simple commands

VERBAL RESPONSE = 5
ACTIVITY RESPONSE SCORE
None 1 = no verbalization of any type

Incomprehensible 2 = moans/groans, no speech

Inappropriate 3 = intelligible, no sustained

sentences
Confused 4 = converse but confused,
disoriented
Oriented 5 = converses and is oriented

PUPILS TO COMATOSE PATIENTS

• Small or pinpoint pupils
• Midposition fixed pupils
• Large pupils
• One large pupil
Assessment of the unconscious patient:

• Neurologic evaluation
➢ Respirations
➢ Pupils
➢ Ocular movement
➢ Oculocephalic reflex
■ Posture and muscle tone
■ If there is no spontaneous movement, apply painful stimuli
■ Classify results:
➢ NORMAL-AVOIDANT
➢ STEREOTYPIC
➢ FLACCID PARALYSIS OR NO RESPONSE
ABNORMAL POSTURES IN COMATOSE PATIENTS

- Hemiplegia
- Decerebrate rigidity
- Decorticate rigidity
• Meningeal signs
■ Neck mobility/Nuchal rigidity
■ Brudzinski sign
■ Kernig sign
• “Don’ts” when assessing the unconscious patient
➢ Don’t dilate the pupils
➢ Don’t flex the neck if there is any question of trauma to the head or neck
ANATOMY OF THE AUTONOMIC NERVOUS SYSTEM
NEUROLOGIC ASSESSMENT: Health History

• Pain
• Seizures
• Dizziness (abnormal sensation of imbalance or movement)
• Vertigo (illusion of movement, usually rotation)
• Visual disturbances
 • Weakness
• Abnormal sensations
• Past health, family, social history
• Consciousness and cognition: mental status, intellectual function, thought content, emotional status, language ability, Impact on lifestyle
• Cranial nerves
■ Motor system: muscle size, muscle tone and strength, coordination and balance, Romberg test
■ Sensory system: tactile sensation, superficial pain, temperature, vibration, and position sense (proprioception)
■ Reflexes: DTRs, biceps, triceps, brachioradialis, patellar Achilles, superficial, pathologic, plantar (Babinski)
GERONTOLOGICAL CONSIDERATIONS

• Important to distinguish normal aging changes from

abnormal changes

• Structural and physiologic changes

• Motor and sensory alterations
• Temperature regulation and pain perception
• Determine previous mental status for comparison
Assess mental status carefully to distinguish delirium from dementia

AUTONOMIC NERVOUS SYSTEM

• It regulates activities of internal organs (heart, lungs, blood vessels, digestive organs, and glands) and to maintain and restore internal homeostasis
• It is regulated by the centers in the spinal cord, brain stem, and hypothalamus (major subcortical center for the regulation of autonomic activities)
2 MAJOR DIVISIONS

■ Sympathetic nervous system (fight-or-flight)

■ Parasympathetic nervous system (rest and digest)
SYMPATHETIC NERVOUS SYSTEM (fight-or-flight response)

• Activated during STRESS

NOREPINEPHRINE: main sympathetic neurotransmitter

• a sympathetic discharge also stimulates the adrenal medulla (the inner part of the adrenal glands) to release epinephrine into the bloodstream

• Bronchioles dilate for easier gas exchange

• Stronger and faster heart contraction
• Arteries to the heart and voluntary muscles dilate
• Peripheral blood vessel constrict
• The pupils dilate
• The liver release glucose for quick energy
• Peristalsis slows
• Hair stands on end
• Increase perspiration
PARASYMPATHETIC NERVOUS SYSTEM (rest and digest)

• dominant controller for most visceral function

• regulated by centers in the spinal cord, brain stem, and hypothalamus
ACETYLCHOLINE: main sympathetic neurotransmitter
• Fibers of the PNS are located in two sections:
• one in the brain stem
• spinal segments below L2
■ referred to CRANIOSACRAL DIVISION (because of the location of the fibers)
 • ↓ HR
↓ BP
↓ PR
Pupil constricts
Bladder contracts
↑ GI motility

DIAGNOSTIC TESTS

• Computed tomography (CT)

• Positron emission tomography (PET)
• Single-photon emission computed tomography (SPECT)
• Magnetic resonance imaging (MRI)
• Cerebral angiography
• Myelography
• Noninvasive carotid flow studies
• Transcranial Doppler
• Electroencephalography (EEG)
• Electromyography (EMG)
• Nerve conduction studies, evoked potential studies
• Lumbar puncture, Queckenstedt test, and analysis of cerebrospinal fluid
CHAPTER 61: MANAGEMENT OF PATIENTS WITH NEUROLOGIC DYSFUNCTION
ALTERED LEVEL OF CONSCIOUSNESS

• Level of responsiveness and consciousness is the most important indicator of the patient’s condition
• An altered level of consciousness is present when the patient is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of
alertness
• LOC is a continuum from normal alertness and full cognition (consciousness) to coma
• Coma: unconsciousness, unarousable unresponsiveness
 • Akinetic mutism: unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes
• Persistent vegetative state: devoid of cognitive function but has sleep-wake cycles
• Minimally conscious state differs from persistent vegetative state in that the patient has inconsistent but reproducible signs of awareness
• Locked-in syndrome: inability to move or respond except for eye movements due to a lesion affecting the pons
• Altered LOC is not the disorder but the result of multiple pathophysiologic phenomena
Cause may be:

• Neurologic (head injury, stroke)

• Toxicologic (drug overdose, alcohol intoxication)

• Metabolic (hepatic or kidney injury, DKA)

ASSESSMENT OF THE PATIENT WITH ALTERED LEVEL OF CONSCIOUSNESS

• Verbal response
• Alertness
• Motor response (posturing)
• Respiratory status
• Eye signs
• Reflexes
NEUROLOGIC EXAMINATION
• Mental status
• Cranial nerve function
• Cerebellar function
• Reflexes
• Motor and sensory function
LOC is a sensitive indicator of neurologic function
• Assessed based on the criteria in the GLASGOW COMA SCALE (GCS)
• Eye opening
• Verbal response
• Motor response
COMMON DIAGNOSTIC PROCEDURES USED TO IDENTIFY UNCONSCIOUSNESS
• Computed tomography (CT) scanning
• Perfusion CT (PCT)
• Magnetic resonance imaging (MRI)
• Magnetic resonance spectroscopy (MRS)
• Electroencephalography (EEG)
• Positron emission tomography (PET)
• Single-photon emission computed tomography (SPECT)
Obtain and maintain a patent airway = first priority of treatment for the patient with altered LOC

Assessment starts with assessing VERBAL RESPONSE

• Determining the patient’s orientation to time, person, and place

Alertness is measured by the patient’s ability to open the eyes spontaneously or in response to a vocal or pressure or pain

• Nurses assesses for preorbital edema or trauma which may prevent the patient from opening the eyes
MOTOR RESPONSE includes spontaneous, purposeful movement, movement only in response to painful stimuli or abnormal posturing

• If the patient is not responding to commands, the motor response is tested by applying a painful stimulus to nailbed or by squeezing a muscle
 • Motor response cannot be elicited or assessed when the patient has been given pharmacologic paralyzing agents

Nurse also monitors respiratory status, eye signs and reflexes

ABNORMAL POSTURE RESPONSE TO STIMULI

• Decorticate posturing
• flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet
• Decerebrate posturing
• Involving extension and outward rotation of the upper extremities and plantar flexion of the feet
COLLABORATIVE PROBLEMS AND POTENTIAL COMPLICATIONS OF PATIENTS WITH ALTERED LOC

• Respiratory distress or failure

• Pneumonia
• Aspiration
• Pressure ulcer
• Deep vein thrombosis (DVT)
• Contractures
PLANNING AND GOALS FOR THE PATIENT WITH ALTERED LEVEL OF CONSCIOUSNESS
Goals may include:

• Maintenance of clear airway

• Protection from injury
• Attainment of fluid volume balance
• Maintenance of skin integrity
• Absence of corneal irritation
• Effective thermoregulation
• Accurate perception of environmental stimuli
• Maintenance of intact family or support system
• Absence of complications
NURSING INTERVENTIONS FOR THE PATIENT WITH ALTERED LOC
• A major nursing goal is to compensate for the patient’s loss of protective reflexes and to assume responsibility for total patient care. Protection also includes
maintaining the patient's dignity and privacy
• Maintaining an airway
• Frequent monitoring of respiratory status including auscultation of lung sounds
• Positioning to promote accumulation of secretion and prevent obstruction of upper airway – head of bed (HOB) elevated 30 degrees; lateral and semi
prone position
• Suctioning, oral hygiene, and CPT

• Maintaining tissue integrity

• Assess skin frequently, especially areas with high potential for breakdown
• Frequent turning; use turning schedule
• Careful positioning in correct body alignment; use of splints, foam boots, trochanter rolls, and specialty beds as needed
• Passive ROM
• Clean eyes with cotton balls moistened with saline
• Use artificial tears as prescribed
• Measured to protect eyes; use eye patched cautiously because the cornea may contact patch
 • Frequent, scrupulous oral care

• Maintaining fluid status

• Assess fluid status by examining tissue turgor and mucosa, laboratory test data, and I&O
• Administer IVs, tube feedings, and fluids via feeding tube as required, monitor ordered care rate of IV fluids carefully
• Maintaining body temperature
• Adjust environment and cover patient appropriately
• If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow
fan to blow over patient to increase cooling
• Monitor temperature frequently and use measures to prevent shivering

• Promote bowel and bladder function

• Assess for urinary retention and urinary incontinence
• May require indwelling or intermittent catheterization
• Bladder training program
• Assess for abdominal distention, potential constipation, and bowel incontinence
• Monitor bowel movements
• Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated
• Diarrhea may result from infection, medications, or hyperosmolar fluids

• Sensory stimulation and communication

• Talk to and touch patient and encourage family to talk to and touch the patient
• Maintain normal day-night pattern of activity; orient the patient frequently
• Note: when arousing from coma, a patient may experience a period of agitation; minimize stimulation at this time
• Programs for sensory stimulation
• Allow family to ventilate and provide support
• Reinforce and provide consistent information to family
• Referral to support groups and services for family
INCREASED INTRACRANIAL PRESSURE
• Pressure in the skull that results from the volume of 3 essential components
1. CSF: 75mL
2. BLOOD VOLUME: 75mL
3. CNS TISSUE: 1400g
• It is usually measured in the lateral ventricles, with the normal pressure being 0 to 10 mmHg, and 15 mmHg being the upper limit of normal
• A syndrome characterized by increase in the amount of CNS tissue, CSF fluid, or blood leading to an ICP greater than 15 mmHg
• Once ICP reaches around 25 mmHg marked elevation in ICP will be noted
• Monro-Kellie hypothesis (Monro-Kellie doctrine)
• Explains the dynamic equilibrium of cranial contents
• Because of a limited space for expansion within the skull, an increase in any of the components causes a change in the volume of the others
• Any increase in one of the elements must be balanced or compensated by a proportional constriction either or both of the other components

TABLE 1: MONRO-KELLIE HYPOTHESIS

1. The brain is enclosed in a nonexpendable case of bone
2. The substance of the rain is nearly incompressible
3. The volume of the blood in the cranial cavity is therefore constant or
nearly constant
4. A continuous outflow of venous blood from the cranial cavity is
required to make a room for the continuous incoming arterial
blood
TRAUMATIC HEAD INJURIES
Head injury is trauma to the skull, resulting in mild to extensive damage to the brain

IMMEDIATE COMPLICATIONS:
• Cerebral bleeding
• Hematomas
• Uncontrolled increased ICP
• Infections, and seizures
• Changes in personality or behavior, cranial nerve deficits, and any other residual deficits depend on the area of the brain damage and the extent of the damage
TREATMENT FOR MILD CONCUSSION:
• Rest
• Increased fluids
• Close monitoring of symptoms
• Pain medication
• Avoid alcohol and illegal drugs
TYPES OF HEAD INJURIES
 1. CONCUSSION
• Jarring of the brain within the skull, with no loss of consciousness
• A mild traumatic brain injury caused by an impact to the head or whiplash
2. COUP & COUNTERCOUP
• A coup injury is the result of a sudden, violent stop that causes the brain to accelerate forward and hit the side of the skull
• A countercoup injury occurs when the brain accelerates forward, hits the side of the skull, and then bounces off the other side of the skull. In both cases, the
brain is damaged as it rubs against the inner ridges of the skull.
• A contusion prevent at both the site of the impact and the exact opposite end of the impact
3. CONTUSION
• A bruising type of injury to the brain tissue
• May occur along with other neurological injuries, such as with subdural or extradural collections of blood
• Blood underneath the skin due to trauma causing a bruise
4. LACERATION
• Tearing of tissues
5. DIFFUSE AXONAL INJURY
• Axons are stretched and damaged
• By high-speed transportation accidents – associated with shaken baby syndrome
• It causes permanent damage to nerves in the brain
• DAI is similar to a concussion, though the brain is shaken much more violently
SKULL FRACTURES

• A break in the continuity of the skull caused by forceful trauma

• It may occur with or without damage to the brain
➢ Simple: a crack in the skull
➢ Comminuted: splintered or multiple fracture line
➢ Depressed: occur when the bones of the skull are forcefully displaced downward
➢ Basilar: fracture of the base of the skull
HEMATOMA
Bleeding in the brain that collects and clots, forming a bump in general, a rapidly developing hematoma even if small, may be fatal, whereas a larger but slowly
developing one may allow compensation for increases in ICP

EPIDURAL HEMATOMA
• The most serious type of hematoma
• It forms rapidly and results from arterial bleeding
• It occurs between the skull and the dura mater
• Extreme emergency
• It is characterized by brief loss of consciousness
• IICP, herniation
SUBDURAL HEMATOMA
• It forms slowly and results from a venous bleed
• Between the dura & the brain
• It is usually due to trauma and ruptured veins
• Symptoms of IICP develops gradually
INTRACEREBRAL HEMORRHAGE
• It occurs when a blood vessel within the brain ruptures allowing blood to leak inside the brain
SUBARACHNOID HEMORRHAGE

• It is bleeding into the subarachnoid space

• It may occur as a result of head trauma or spontaneously, such as from a ruptured cerebral aneurysm
TRAUMATIC HEAD INJURIES
Common causes:

1. Falls
2. Motor vehicle crashes
3. Being struck by objects
4. Physical assaults
5. Accidents at work, home and outdoors
6. While playing sports
Highest risk of TBI: 15-19 age group (Males)

PRIMARY AND SECONDARY INJURIES

• Primary injury
- Initial damage to the brain that results from the traumatic event includes contusions, lacerations, and torn blood vessels
• Secondary injury
- It evolves over the ensuing hours and days after the initial injury
- It results from inadequate delivery of nutrients and oxygen to the cells
CLINICAL MANIFESTATIONS
In any serious head trauma, always assume the spinal cord is also injured

• Chronic or severe headaches

• Nausea & vomiting
• Signs and symptoms of IICP
• Hemorrhage/fluid draining from the nose, pharynx, ears, conjunctiva
• Weakness & paralysis
• Decreasing LOC
• Decreased sensation, visual disturbances, seizure
• Memory loss, personality & behavior changes
• Battle’s sign
• CSF otorrhea, CSF rhinorrhea
PATHOPHYSIOLOGY
Brain suffers traumatic injury
↓
Brain swelling/bleeding increase intracranial volume
↓
Rigid cranium allow no room for expansion
↓
Slow blood flow to brain due to increased pressure
↓
Cerebral hypoxia & ischemia occur
↓
Intracranial pressure continues to rise
Brain may herniate
↓
Cerebral blood flow ceases
• HALO SIGN
• RACOON’S EYE
• BATTLE’S SIGN
ASSESSMENT AND DIAGNOSTIC TESTS
• Neurologic history
• X-ray
 • CT Scan
• MRI
• Cerebral angiography
MEDICAL MANAGEMENT

• Close observation of the patient

• Monitor LOC, respiratory status & maintain patent airway
• Notify the physician if drainage from the ears or nose is noted
• Maintain head elevation
• Assess cranial nerve function
• Monitor for IICP
• Do not take aspirin, ibuprofen, anti-inflammatory medications
• Diuretics
• Anti-seizure medications
SURGICAL MANAGEMENT
• CRANIOTOMY
- Surgical procedure that involves an incision through the cranium to remove accumulated blood or a tumor
• STEREOTACTIC RADIOSURGERY (SRS)
- It may be an alternative to traditional surgery and is usually used to treat tumors and arteriovenous malformations
PREVENTION
• Always use safety equipment during activities that could result in head injury
• Obey traffic signals when riding a bicycle
• Be visible
• Use age-appropriate car seats or boosters for babies and young children
• Make sure that children have a safe area in which to play
• Do not drink & drive
FIRST AID
FOR MILD HEAD INJURY
• No specific treatment is needed
• Close monitoring is needed
• When person is sleeping, wake him/her every 2-3 hours and ask simple questions
FOR MODERATE TO SEVERE

• Treat as if there is spinal injury

• Stop any bleeding by firmly pressing a clean cloth on the wound
• If with skull fracture, do not apply pressure
• If the person vomits, roll the head, neck, and body as one unit to prevent choking
• Apply ice packs to swollen areas

SEIZURE DISORDERS
• Seizure are an abnormal, sudden, excessive discharge of electrical activity within the brain
GENERALIZED SEIZURE: both hemisphere of the brain is affected + LOC
• Tonic – muscles are stiff or flexed
 • Atonic – muscles are relaxed
• Clonic – violent muscle contractions (convulsions)
• TONIC-CLONIC (MOST COMMON)
• Myoclonic – short muscle twitches
• Absence – lose and regain consciousness “Spaced out”
PARTIAL SEIZURE: one hemisphere of the brain or lobe is affected
• SIMPLE PARTIAL
➢ Awake and alert (aura)
➢ Small area of the brain
➢ Jerking movements
➢ Starts in a specific area and spreads to other group (Jacksonian March)
• COMPLEX PARTIAL: impaired consciousness/LOC
STATUS EPILEPTICUS
• It involves a rapid succession of epileptic spasms without intervals of consciousness; it is a potential complication that can occur with any type of seizure, and
brain damage may result.
• SEIZURES LAST LONGER THAN 5 MINUTES
• Usually tonic-clonic
• MEDICAL EMERGENCY
➢ Treated with BENZODIAZEPINES (enhances GABA)
RISK FACTORS:
• Genetic factors
• Trauma
• Tumors
• Circulatory or metabolic disorders
• Toxicity
• Infections
GENERALIZED SEIZURES:

1. GRAND MAL
• May be preceded by AURA; tonic and clonic phase involve both hemispheres of the brain
■ TONIC PHASE: limbs contract or stiffen; pupils dilate and eyes roll up to one side; glottis closes; may be incontinent; occurs at the dame time as loss of
consciousness; lasts 20-40 seconds

■ CLONIC PHASE: repetitive movement (elbows, legs, and head will flex then relax, increased mucus production
Characteristic EPILEPTIC CRY – wild, harsh sounds
Tongue is often chewed, incontinent of urine and feces
Patient relaxes and lies in deep coma, breathing nosily
Seizure ends with post-ictal period of confusion and drowsiness
Many patients report headache, sore muscles, fatigue & depression

2. PETIT MAL (Little seizure)

• Not preceded by an aura
• Little or no tonic-clonic seizures
• There is sudden cessation of ongoing physical activities by blank facial expression, automatism like lip-chewing, lip smacking

3. MYOCLONIC SEIZURES
• Associated with brain damage
• Generalized jerking or stiffening of extremities (arms and shoulders)
• “jumps” – sudden muscle jerks
 • Non-rhythmic jerks resulting from involuntary muscle twitching that normally target the upper extremities, and after an episode, patients may describe the
perceived sensation as momentary electrical shocks

4. AKINETIC SEIZURES (drop attack, astatic, atonic)

• Related to organic brain damage
• Sudden brief loss of postural tone, and temporary loss of consciousness

5. FEBRILE SEIZURE
• Seizure occur only when fever is rising
• Common among 6 months to 5 years
PARTIAL/FOCAL SEIZURES

1. SIMPLE PARTIAL SEIZURES

• It produces sensory symptoms accompanied by motor symptoms that are localized or confined to a specific area only a finger or hand may shake, or the mouth
may jerk uncontrollably
• Person may talk unintelligibly, dizzy, experience of unusual or unpleasant sights, sounds, odors, or tastes
• No loss of consciousness
2. COMPLEX PARTIAL SEIZURE/PYSCHOMOTOR SEIZURES
• May follow trauma, hypoxia, drug use
• It is characterized by periods of altered behavior that the client is not aware of
• Aura present; dreamlike state
• The client loses consciousness for a few seconds; the person either remains motionless or moves automatically but inappropriately for time and place
• May experience excessive emotions of fear, anger, elation, or irritability
ABDOMINAL SEIZURE (ABDOMINAL EPILEPSY)
• These seizures are accompanied by autonomic symptoms or signs, such as abdominal discomfort or nausea which may rise into the throat (epigastric rising),
stomach pain, the rumbling sounds of gas moving in the intestines (borborygmi), belching, flatulence, and vomiting.

SPECIFIC CAUSES:

■ IDIOPATHIC
■ ACQUIRED
➢ Cerebrovascular disease
➢ Hypoxemia of any cause
➢ Fever
➢ Head injury
➢ Hypertension
➢ CNS infection
➢ Metabolic & toxic conditions
➢ Brain tumor
➢ Drug & alcohol withdrawal
➢ Allergies
NURSING MANAGEMENT:
Before & during a seizure
Observe & record the sequence of signs
• The circumstances before the seizure
• Occurrence of an AURA
• The first thing the patient does in the seizure
 • Type of movements in the body involved
• Pupil size & if the eyes are open
• AUTOMATISMS
• Incontinence of urine or stool
• Duration of each phase of seizure
• Duration of unconsciousness
• Obvious paralysis or weakness
• Inability to speak after the seizure
• Cognitive status
NURSING CARE DURING SEIZURE

• Prevent injury & support not only physically but also psychologically
• Provide privacy & protect the patient
• Place patient on the floor if possible
• Protect the head with a pad
• Loosen constrictive clothing
• Push aside any furniture
• If the patient is in bed, raise side rails
• If an aura precedes the seizure, insert oral airway equipment
• Don’t attempt to open jaws clenched during spasm or insert anything
• Don’t restrain the patient during seizure
• If possible, place the patient on one side with head flexed forward
CAUSE:
• Inherited
• Idiopathic
➢ Birth trauma
➢ Asphyxia neonatorum
➢ Head injuries
➢ Some infectious diseases
➢ Toxicity
➢ Circulatory problems, fever, metabolic & nutritional disorders, drug, or alcohol intoxication
➢ Brain tumors, abscesses, congenital malformations
PATHOPHYSIOLOGY:
NEURONS carry messages from the body
↓
Impulses occur in bursts whenever a nerve cell has a task to perform
↓
Permanent changes occur in brain tissue
↓
Brain becomes too excitable or jumpy
↓
Brain sends out abnormal, recurring, uncontrolled signals
↓
Repeated & unpredictable seizure

CLINICAL MANIFESTATIONS:
• Simple staring spells
• Violent shaking and loss of alertness
• The type of seizure depends on the part of the brain affected and cause of epilepsy
• Strange sensation
DIAGNOSTIC TESTS
• EEG
• Blood chemistry
• Kidney function tests (electrolytes)
• Head CT & MRI
• Lumbar puncture
• Tests for infectious diseases
MEDICAL MANAGEMENT:
Pharmacologic therapy
• Objective: to achieve seizure control with minimal side effects
• Medication therapy controls rather than cure seizures
• Major antiseizure medications:
➢ Carbamazepine
➢ Clonazepam
➢ Gabapentin
➢ Phenobarbital
➢ Phenytoin
➢ Valproate
PHENYTOIN
• Therapeutic ranges: 10-20 mcg/dl
BELOW 10 = seizure risk (report to HCP)
OVER 20 = toxic risk (Hold Med and Notify HCP)
TAKE MEDICATION AT THE SAME TIME, DAILY

PHENYTOIN TOXICITY
• Early signs to report to HCP
1. ATAXIA
2. HAND TREMORS
3. SLURRED SPEECH
• Other adverse effects:
➢ Suicidal ideation
➢ Skin rash that are NEW and PAINFUL
PATIENT TEACHING
• NO ORAL CONTRACEPTIVES
• DO NOT STOP MEDICATION ABRUPTLY
• TAKE FOLIC ACID, CA, AND VITAMIN D
• NO TUBE FEEDING 1-2 HOURS BEFORE AND AFTER FEEDING
• FLUSH 30-50 ML
• (NORMAL SALINE FOR IV)
SURGICAL MANAGEMENT
• Indicated for patients whose epilepsy results from intracranial tumors, abscesses, cysts, or vascular anomalies
STATUS EPILEPTICUS

• Acute prolonged seizure activity

• A series of generalized seizures that occur without full recover of consciousness between attacks
• A medical emergency
 • A tonic-clonic seizure lasting longer than 5 minutes
• Repeated episodes of cerebral anoxia & edema may lead to irreversible & fatal brain damage
MANAGEMENT:
• Stop the seizures as quickly as possible
• Airway & adequate oxygenation
• IV Diazepam (Valium), Lorazepam (Ativan)
• IV line is established and blood samples are obtained
• EEG monitoring
• VS & neurologic signs are monitored
• Cardiac & respiratory depression should be monitored