WHAT YOU MUST KNOW ABOUT

NEUROLOGICAL DISORDERS
by: Chulou H. Penales, R.N., M.A.N.
ANATOMY AND PHYSIOLOGY
OF THE NERVOUS SYSTEM

CHULOU H. PENALES, RN
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Central nervous system

Brain

Spinal cord
*Autonomic vs. Somatic

Peripheral nervous system

Spinal nerves
Cranial nerves
CHULOU H. PENALES, RN
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Impulse transmission

Acetylcholine

Serotonin
Dopamine

GABA
Sodium-potassium pump
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Myelin sheath

Oligodendrocytes
Schwann cells

Nodes of Ranvier
Neurilemma

CHULOU H. PENALES, RN
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM
The Human Intel Core Duo

3 major divisions

Weight
Basic structures
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

I. Cerebral Hemispheres  4 Lobes

“I’m aware”

“I can talk/understand”
“I can move and sense”

“I can remember”
“I can reason out”
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Cerebral Hemispheres  Other structures

Broca’s Area Basal ganglia

 ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

II. Diencephalon/ III. Brainstem

Interbrain

Midbrain
Thalamus Medulla Oblongata
Epithalamus Hypothalamus Pons RAS
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

IV: Cerebellum Meninges

ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM

Cerebrospinal fluid

Source

Purpose
Contents
Volume/ specific gravity
Blood brain barrier
Assessment
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM
Spinal Cord (***C1-L2) Roots/ Horns
ANATOMY & PHYSIOLOGY: NERVOUS SYSTEM
Brain blood supply

R/L internal carotids

Circle of Willis R/L vertebral arteries
CHULOU H. PENALES, RN
 ANATOMY & PHYSIOLOGY

Sample Question:

An example of integration by the nervous system is:

a. The feeling of a cold breeze
b. The shivering and goose bumps that result
c. The sound of rain
d. The decision to go back for an umbrella

CHULOU H. PENALES, RN
 ANATOMY & PHYSIOLOGY

Sample Question:

What makes up the blood-brain barrier?

a. Large Arteries
b. Small Veins
c. Least permeable capillaries
d. semi-soft bones

CHULOU H. PENALES, RN
 ASSESSING PEOPLE WITH
NEUROLOGICAL DISORDERS

CHULOU H. PENALES, RN
 COMPUTED TOMOGRAPHY SCAN

Need for consent

Position/instructions
Phobia/dye assessment
Sound expectations
Post-procedure
Fluids
Use of narrow x-ray Injection site
beams to scan the head in
successive layers
 POSITRON EMISSION TOMOGRAPHY

Similarity and
differences with CT scan

Radioactive substance
administration

Computer-based nuclear imaging

technique that produces images
of actual organ functioning
 MAGNETIC RESONANCE IMAGING

Metal assessment

Main risks

Use of a powerful magnetic

field to obtain images of
different body areas
 LUMBAR PUNCTURE

Position/instructions

ICP assessment
Bladder instructions
Post-procedure
positions

Insertion of a needle into

the lumbar subarachnoid
space to withdraw CSF
 MYELOGRAM

Purpose

Position/instructions
Meds/dye assessment
Dye types and positions
Post-procedure
X-ray of the Spinal
Subarachnoid Space after Fluids
injection of a contrast Possible
agent into the SSS thru a complications
lumbar puncture
 ELECTROENCEPHALOGRAPHY

Types and duration

Pre-procedure care
Patient assurance

Meds/diet/sleep

Intra-procedure actions
Post-procedure care

EEG represents a record

of electrical brain activity
 ELECTROMYOGRAPHY

What to expect

Post-procedure care

Introduction of a needle into skeletal

muscles to measure changes in the
electrical potential of the muscles &
the nerves leading to them.
 CRANIAL NERVES ASSESSMENT

Graphestesia Stereognosis
Two-point stimulation Extinction phenomenon
 GLASSGOW COMA SCALE
Vital facts:

Motor response

Verbal response
Eye response
Which brain part is likely to be affected if the
patient is in a decerebrate position? Decorticate?

Significance of results
GRADING DEEP TENDON REFLEXES (DTR)
Vital facts:

0 to plus 4

Physiologic vs. pathologic clonus

DOLL’S EYE TEST

Procedure

Significance of results
 ASSESSMENT PROCEDURES

Sample Question:

Which of the following GCS scores indicates a coma?

a. 9 and above
b. 8 and below
c. 2
d. 9 and below

CHULOU H. PENALES, RN
 ASSESSMENT PROCEDURES

Sample Question:

Which of the following is the most important

indicator of neurologic function?
a. Eye opening
b. Verbal response
c. Motor response
d. All are equally important indicators

CHULOU H. PENALES, RN
 ASSESSMENT PROCEDURES

Sample Question:

If increased ICP is suspected in this patient, which

of the following diagnostic tests would most likely
be contraindicated?
a. Intracranial computed tomography scan
b. Skull radiography
c. Lumbar puncture
d. EEG

CHULOU H. PENALES, RN
 NURSING PEOPLE WITH
NEUROLOGICAL DISORDERS
(AUTOIMMUNE PROCESSES, INFECTIONS &
DEGENERATIVE DISORDERS)

CHULOU H. PENALES, RN
MULTIPLE SCLEROSIS
Vital facts:

Risk factors

Pathophysiology
Dx test of choice
Charcot’s triad:SIN
Lhermitte’s sign
Prognosis
 MULTIPLE SCLEROSIS
Types/ Mgt: Symptoms & Tx:

Relapsing-remitting Optic nerves

Primary progressive Cerebrum
Secondary progressive Brain stem/cranial
nerves
Progressive relapsing
Cerebellum
Medications:
Spinal cord
ABC&R,
(Muscle,Elimination,
Steroids,
Muscle relaxants Sensation)
 MULTIPLE SCLEROSIS
Questions:
What bowel problems can you anticipate?
Is there a cure for M.S.?
How do you elicit Lhermitte’s sign?
What are three cardinal findings of patients with
MS?
What emotional state do MS patients usually
display?

CHULOU H. PENALES, RN
GUILLAIN- BARRE SYNDROME

Vital facts:

Risk factors

Pathophysiology
Pattern of paralysis
Sx: Respi, Vagus,Optic
Dangers
Prognosis (2 years)
Management/ Corticosteroids
 GUILLAIN- BARRE SYNDROME

Sample Question:
Ms. May Lasse, 37 years old, complains of
numbness/tingling in the legs that has recently
progressed to the arms. She is suspected to have GBS.
Which of the following questions is important to include
when assessing Ms. May?
a. “Has anyone in your family ever had GBS?”
b. “Did you have an upper respiratory tract infection
lately?
c. “Do you bruise easily?”
d. “Have you been out of the country for the past 4
months? CHULOU H. PENALES, RN
AMYOTROPHIC LATERAL SCLEROSIS
Vital facts:

Risk factors

Pathophysiology
Pattern of paralysis
Sx: Respi, Vagus, Spasms
Dangers
Long-term mgt./ meds.
Prognosis (3 years)
MYASTHENIA GRAVIS
Vital facts:

Risk factors

Pathophysiology
Dx test of choice
Crisis management
Cholinergic medications
Timing and antidote
Other treatments/ diet
 MYASTHENIA GRAVIS

Sample Question:

The teaching plan for a client with Myasthenia

Gravis should include which of the following as a
priority instruction?
a. Exercise to increase peripheral circulation
b. Plan important activities for late afternoon
c. Identify signs and actions during crisis
d. Eat three well-balanced meals per day

CHULOU H. PENALES, RN
TRIGEMINAL NEURALGIA (TIC DOULOREUX)
Vital facts:

Greatest risk factor

Pathophysiology/triggers
Characteristics of attacks
Medications and its s/e
Bone marrow
Dietary instructions
Alternative meds: B-P
BELL’S PALSY
Vital facts:

Risk factors: I H.A.V.E

Ischemia, Herpes, Autoimmune,
Viral & Ear infections

Symptoms
Nursing care/ teachings
Diet, muscle tone, speech

Prognosis
 BELL’S PALSY
Questions:

Can you consider bell’s palsy a minor stroke?

How long does Bell’s palsy usually last?
What pharmacological therapy is usually prescribed for
Bell’s Palsy?
What do you mean by T.E.N.S. and what purpose
does it serve in Bell’s Palsy cases? Who does T.E.N.S.?

CHULOU H. PENALES, RN
PARKINSON’S DISEASE
(a.k.a. PARALYSIS AGITANS)
Vital facts:

Risk factors

Pathophysiology
Triad Sx: R-A-T
Medications: Anticholinergics,
Antiviral & Dopaminergic

Nursing care
Prognosis
Nursing care

Safety: Levodopa s/e

Patience
Diet & lifestyle
OLOF promotion
 PARKINSON’S DISEASE

Sample Question:

The nurse should instruct the patient with

Parkinson’s disease to avoid which of the following?
a. Walking in an indoor shopping mall
b. Sitting on the deck on a cool summer evening
c. Walking to the car on a cold, windy day
d. Sitting in the beach in the sun on a summer day

CHULOU H. PENALES, RN
 HUNTINGTON’S DISEASE
Vital facts:
Genetic transmission (AD)

Probable cause
Pathophysiology
Main Symptom; Sensory vs. motor deficits
Affected structures (Cerebrum, Cerebellum, BG)
Medications
Nursing care: SAFETY
ALZHEIMER’S DISEASE
Vital facts:

Risk factors

Pathophysiology
Confirmatory dx

Medications
Nursing care
Prognosis
ALZHEIMER’S DISEASE
Stages:

Stage 1: “DePART”

Decline in Personal
Appearance

Recent memory loss

Time disorientation
Nursing care
ALZHEIMER’S DISEASE
Stages:
Stage 2: “CACA… PHEW”

Catastrophic reactions
Agnosia (V-A-T)

Confabulation
Agraphia
Perseveration
Hyperorality (Eat),
Wandering
ALZHEIMER’S DISEASE
Stages:
Stage 3: “SHAK”

Sensorimotor deterioration
Hyperetamorphosis

Absence of speech
Kluver-Bucy Syndrome
 ALZHEIMER’S DISEASE (T or F)
Open-ended questions are encouraged for patients
with Alzheimer’s.
A patient’s question may actually be a personal
statement from the patient
Calendars and clocks help the person keep oriented
The patient should be discouraged from talking
about his/her past.
The patient may be restrained if he/she wanders.
Liver enzymes should be monitored when the
patient is on Tacrine therapy
With Alzheimer’s disease, there is an excess Ach.
CHULOU H. PENALES, RN
 ALZHEIMER’S DISEASE
Sample Question:

Mrs. Lee Mott, a 65- years old Alzheimer’s patient,

becomes very restless. The nurse is concerned that she
may harm herself. Which of the following nursing
interventions would best protect the patient?
a. Applying a waist restraint under her gown
b. Placing the patient in a special geriatric chair
c. Distracting the patient with loud music
d. Taking the patient for frequent walks

CHULOU H. PENALES, RN
 NURSING PEOPLE WITH
NEUROLOGICAL DISORDERS
(CNS INJURIES, INFECTIONS and
OTHER CONDITIONS)

CHULOU H. PENALES, RN
 MIGRAINE HEADACHES

Vital facts:

Risk factors: Type A Personality

Vascular theory
Types of headaches

Aura and time of onset

Symptoms & Location
Possible treatments
CHULOU H. PENALES, RN
 MIGRAINE HEADACHES

Scheme of treatment:

Mild migraine
Migraine headache worsens
Arterial walls have
become rigid

Medication facts
 HEADACHES (IDENTIFICATION)
Excruciatingly painful yet of short duration.
Preceded by an aura.
Hunger, fatigue, excitement or alcohol may serve as
its trigger.
Anxiety and depression may serve as triggers.
Bright spots or diplopia may be experienced by the
client.
Believed to be cause by sensitivity to Histamine.
Throbbing, steady pain occurring mostly at night.

CHULOU H. PENALES, RN
 HEADACHES (IDENTIFICATION)
Interventions may be ineffective due to shortness of
episodes.
Relaxation techniques and rest may be enough to
treat the headache.
Crescendo quality headache.
Preventive treatment is possible with Methysergide.

CHULOU H. PENALES, RN
SEIZURES

Vital facts:

Generalized S.: T-A-M-A

Tonic/clonic, Absence,
Myoclonic, Akinetic
Partial S.: Simple, Complex
Priority of care
Medications
Sensations post-seizure
(LOC, speech, aches)
 SEIZURES

Nursing care:

Airway

Injury prevention/ restraints

Privacy

Importance of documentation
 SEIZURES
Sample Question:

Mr. Kerr Rogg is at risk for developing further

seizures. Knowing this, the nurse should:
a. Keep all side rails of the bed down
b. Keep the height of the bed at the highest level
possible
c. Observe the patient frequently
d. Keep a padded tongue blade at the bedside

CHULOU H. PENALES, RN
 INCREASED INTRACRANIAL PRESSURE
Vital facts:

Possible causes: H-I-T-M-A-N

Hemorrhage,Infection,Trauma,
Meningitis, Accidents, Neoplasia
Monroe-Kellie hypothesis; Early Sx

Cerebral Perfusion Pressure (MAP-ICP)

Normal and abnormal values
Cushing’sBradypnea,
response
Increased Bradycardia,
vs.
SystolicCushing’s triad
BP, Widened
Pulse Pressure, Bradycardia
INCREASED INTRACRANIAL PRESSURE

Nursing care:

ABC priorities

Bed position/ neck position

Environment (Avoid chills)

Medications
Things to avoid, inc Morphine
 INCREASED ICP: HEAD INJURIES

Vital facts:

Coup vs. counter coup injuries

Concussion vs. contusion

Epidural vs. subdural hematoma

Ideal position: Modified trendelenburg

Nursing care
INCREASED ICP: HEAD INJURIES

Surgical interventions:
Infratentorial

Supratentorial
Posterior fossa
INCREASED ICP: PITUITARY TUMORS

Hypophysectomy care:
Possible complications

CSF leak: Avoidance

Incision care
Toothbrushing, straw, oral
hygiene, nasal packing
Post-op meds
 INCREASED INTRACRANIAL PRESSURE
Sample Question:

The nurse is teaching the family of a patient with a

concussion about early signs of increased ICP.
Which of the following would she cite as an early
sign of increased ICP?
a. Decreased systolic blood pressure
b. Headache and vomiting
c. Inability to wake patient with a noxious stimuli
d. Dilated pupils that don’t react to light

CHULOU H. PENALES, RN
 INCREASED ICP: PITUITARY TUMORS
Sample Question:
After Transsphenoidal surgery, which of the
following statements by the patient would need
further teaching?
a. “I can expect the packing to be removed in 3-4
days”
b. “I need to perform deep breathing and coughing
exercises to prevent pulmonary complications”
c. “I need to sleep in an elevated position for at
least 2 weeks”
d. “I can drink juice thru a cup or glass”
CHULOU H. PENALES, RN
 SPINAL CORD INJURIES
Vital facts:

Types: Anterior,Posterior,Central,B-S,Conus/Cauda

Symptoms
Touch, pos’n, vibration
Motor function, pain,temp
B-S: Motor--- pain temp

Spinal shock and Autonomic dysreflexia

Symptoms: “Flushed and drenched”
SPINAL CORD INJURIES

Vital facts:

Nursing care for spinal

cord injuries: ABC Safety

Nursing care for autonomic

dysreflexia: “R-S-V-P”
 SPINAL CORD INJURIES
Cervical traction devices:

Skull tongs
Halo Traction
CHULOU H. PENALES, RN
 SPINAL CORD INJURIES
True or False:
Sterile pin site care is needed for both halo traction &
skull tongs.
I can pull on the halo traction device to move the
patient.
The Halo vest must be snugly fitted and must not
allow even one finger under it.
I can insert fleece or foams to relieve pressure points
in the vest/jacket.
Redness, swelling and a slight discharge under the
jacket do not need to be reported.
My patient may have a shower but not a tub bath.
 SPINAL CORD INJURIES
True or False:
The patient may roll onto the side & push with the
arms to get up.
I need to keep a correct-sized wrench available at
the bedside.
I need to use a flashlight in assessing the skin under
the jacket.
If CPR is required, I need not take off the jacket .

CHULOU H. PENALES, RN
 SPINAL CORD INJURIES
Sample Question:
Mr. Pee. Ang, age 25, suffered a cervical fracture
requiring immobilization with a halo traction. When
caring for the patient with a halo traction, the nurse
must:
a. Keep a wrench taped to the halo vest for quick
removal if CPR is necessary
b. Remove the brace once a day to allow the patient to
rest
c. Encourage the patient to use a pillow under the ring.
d. Remove the brace so that the patient can shower
CHULOU H. PENALES, RN
 SPINAL CORD INJURIES
Sample Question:

Although Ms. Kirsten Dunst has a spinal cord injury,

she can still have sexual intercourse. Discharge
teaching should make her aware that:
a. She must remove her indwelling urinary catheter
prior to intercourse
b. She can no longer achieve orgasm
c. Positioning may be awkward
d. She can still get pregnant

CHULOU H. PENALES, RN
CEREBROVASCULAR ACCIDENT

Vital facts:
Types

Significance of TIA
Brain death occurrence
Expressive vs.
receptive aphasia
Nursing care
Warning signs in
HPN people
CEREBROVASCULAR ACCIDENT

Manifestations and related care:

Neglect syndrome

Homonymous hemianopsia
Agnosia

Apraxia
Right brain vs.
left brain CVA
Judgment, speech,
performance, awareness
 ANEURYSM PRECAUTIONS
Bed rest in a private, dark Bed rest in a private, bright
room room
Elevate HOB upto 30 Elevate HOB upto 45
degrees degrees
Perform enemas to prevent Avoid enemas
straining
Administer prescribed stool Avoid prescribed stool
softeners softeners due to possible
laxative abuse
Take rectal temperatures for Avoid rectal temperatures
accurate measurements
Mild fluid restriction to No fluid restricition
minimize ICP
Limit visitors Encourage visitors
 CEREBROVASCULAR ACCIDENT

Sample Question:

Which of the following nursing diagnoses would be

most appropriate for Mr. Friendster (A patient with a
CVA in the right hemisphere)?
a. Impaired verbal communication r/t aphasia
b. Impaired physical mobility r/t right hemiparesis
c. Risk for injury r/t denial of deficits & impulsiveness
d. Decreased cardiac output r/t atrial arrhtyhmias

CHULOU H. PENALES, RN
 CEREBROVASCULAR ACCIDENT
Sample Question:

Immediately following a cerebral aneurysm rupture,

the patient usually complains of:
a. Photophobia
b. Explosive headache
c. Seizures
d. Hemiparesis

CHULOU H. PENALES, RN
MENINGITIS

Vital facts:
Possible causes

Signs and symptoms

Usual drug of choice
CSF changes
Nursing care
 MENINGITIS

Sample Question:
Mel Enjay was diagnosed with pneumococcal
meningitis. What response by the patient indicates
that he understands the precautions necessary with
this diagnosis?
a. “I can’t have visitors for 1 week.”
b. “Thank goodness, I’ll only be in isolation for 1 day”
c. “The nurse told me my urine and stool are also
sources of the meningitis bacteria”
d. “The doctor is a good friend of mine and won’t
keep me in isolation” CHULOU H. PENALES, RN
 You have just completed the
lecture on Neurological
disorders.
THANK YOU VERY MUCH
for your attention!

CHULOU H. PENALES, RN