NCM 116: Neurologic Dysfunctions

Joyce Bernadette P. Andot – Anna Delle Nicole P. Aranding, BSN-III

CONTENTS
Definition
ALTERED LEVEL OF
Risk Factors
CONSCIOUSNESS
Complications
Review of Systems
INCREASED Review of Affected
INTRACRANIAL Systems
PPRESSURE Signs & Symptoms
Pathophysiology
Management
SEIZURES Nursing Management
Medical Management
HEADACHES Surgical Management
ALTERED LEVEL OF CONSCIOUSNESS
DEFINITION
Altered Level of Consciousness (LOC) is present when the patient is not oriented, does not follow com
mands, or needs persistent stimuli to achieve a state of alertness. LOC is gauge to a continuum, with a nor
mal state of alertness and full cognition (consciousness) on one end and coma on the other end.

TYPES TERMS
• Coma • Alert or conscious – attends to environment and responds appropriately to commands and quest
ions with minimal stimulations.
• Akinetic mutism
• Confused – disoriented to surroundings, may have impaired judgements, may needs cues to res
• Persistent vegetative state pond to commands.
• Minimally conscious state
• Lethargic – drowsy, needs gentle verbal or touch stimulation to initiate response.
• Locked-in syndrome
• Obtunded – responds slowly to external stimulation, may only moan as a verbal response.

• Comatose – no observable response to any external stimuli.

CAUSES HALLMARK SIGNS
1. structural • Confusion

• trauma
• Lethargy
• vascular diseases • Delirium
• infections • Dementia
• Neoplasms
• encephalopathy
• Organic brain syndrome
2. Metabolic

• systematic metabolic derangement COMPLICATIONS

• hypoxic encephalopathies • Respiratory failure
• Toxicity • Pneumonia
• Pressure ulcers
• extremes of body temperature
• Aspirations
• seizures
 Risk Factors
• Brain infections
• Drug overdose
• Toxicity
• Korsakoff Syndrome
• Wernicke syndrome
• Wilson disease
PATHOPHYSIOLOGY
NURSING & MEDICAL MANAGEMENT
Priority • Antibiotics
• Maintaining the airway • Hypertonic saline and mannitol
• Medication to Control blood sugar
Reducing risk such as rapid-acting insulins (insul
in aspart, insulin glulisine, insulin
Maintaining fluid balance lispro), short acting insulins (regul
Providing mouth care ar insulin), Electrolyte supplement
s (potassium Chloride), and Alkali
Maintaining skin and joint integrity nizing agents (sodium bicarbonat
Promoting bowel functions e).
Preserving corneal integrity
Abnormal posture response to stimuli:

1. Decorticate posturing - flexion of the

upper extremities, internal rotation of
the lower extremities, and plantar
flexion of the feet.

2. Decerebrate posturing – involving

extension and outward rotation of the
upper extremities and plantar flexion
of the feet.
INCREASED INTRACRANIAL PRESSURE
DEFINITION
Increased intracranial pressure - is a medical term that refers to growing pressure inside a person's skull. This pressure
 can affect the brain functions.

Monro – killie hypothesis

Explain the dynamic equilibrium of cranial contents. the hypothesis states that because of the limited spac
e for expansion within the skull, an increased in any one of the components causes a change in the volume of t
he others. because brain tissue has limited space to expand, compensation is typically accomplished by displaci
ng or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral bloo
d volume.
 Key points about increased intracranial pressure (ICP)

 ICP is a dangerous condition.

 It is an emergency and requires immediate medical attention.

 Increased intracranial pressure from bleeding in the brain, a tumor, stroke, aneurysm, high bl
ood pressure, brain infection, etc. can cause a headache and other symptoms.

 Treatment includes relieving the brain of the increased pressure.

 ICP has serious complications including death.

SIGNS & RISK FACTORS

SYMPTOMS
body temperature
 oxygen status, especially the CO2 and O2 levels
 Headache
 body position
 Blurred vision
 arterial and venous pressure
 Feeling less alert than usual  anything that increases intra - abdominal/ thoracic pressure.


Vomiting

Changes in your behavior

COMPLICATIONS
• Seizures
 Weakness or problems with moving or talkin • Stroke
g
• Neurological damage
 Lack of energy or sleepiness • Death
PATHOPHYSIOLOGY
 NURSING, MEDICAL, & SURGICAL
MANAGEMENT  Craniotomy – involves the
 Priority • Corticosteroids (dexona) opening of the skull
• Preventing ICP • Barbiturates (Thiopental, pentobarbital) surgically to gain access to
• Maintaining Airway • Antiepileptics (phenytoin) intracranial structures. This
Achieving adequate breathing pattern • H2 receptor antagonist or proton pump inhibit procedure is to performed to
ors remove a tumor, relived
Maintaining fluid balance
elevated ICP, evacuate blood
Preventing infections clot, or control hemorrhage.
 Surgical approaches/skill:

1. above the tentorium (supratentorial

craniotomy) into the supratentorial
compartment

2. below the tentorium into the infratentorial

(posterior fossa) compartment.

3. Transsphenoidal approach (through the

mouth and nasal sinuses)
SEIZURES
DEFINITION
Seizures are a sudden, uncontrolled electrical disturbance in the brain. They are episodes of
abnormal motor, sensory, autonomic, or psychic activity (or a combination of these) that result
from sudden excessive discharge from cerebral neurons.

PHASES
- Aura
- Seizure
- Post-ictal
LEVELS
 Seizures
 
 Epilepsies
 Group of syndromes characterized by unprovoked, recurring seizures.
 Classified by specific patterns of clinical features, including age at onset, family history, and seizure type.
 Include electroclinical syndromes (a complex of clinical features, signs, and symptoms) and other epilepsies.
 Can be primary (idiopathic) or secondary (when the cause is known and the epilepsy is a symptom of another
underlying condition, such as a brain tumor).
 Affects an estimated 3% of people during their lifetime, and most forms of epilepsy occur in children and older adults.
 
 Status Epilepticus
 Acute prolonged seizure activity
 Series of generalized seizures that occur without full recovery of consciousness between attacks.
 Single seizure lasting more than five minutes or two or more seizures within a five-minute period without the person
returning to normal between them
TYPES
 Focal-onset Seizures (Partial Seizures)
Focal seizures can start in one part of the brain and spread to other areas, causing symptoms that are mild or severe, depending on how
much of the brain becomes involved. These seizures are also called partial seizures.
- Simple Partial Seizures
 Sometimes called focal aware seizures
 Remain in one sensory or motor area of the brain.
 Person is aware of what is happening, and may notice unusual sensations and movements..
 
- Complex Partial Seizures
 Sometimes called focal unaware seizures
 Seizure spreads across the brain
 More symptoms appear
 Person may feel confused or dazed, or experience minor shaking, muscle stiffening, or fumbling or chewing motions. 
 
- Secondary Generalized Seizures
 Begin in one part of the brain, but then spread to both sides of the brain.
 Person first has a focal seizure, followed by a generalized seizure.
TYPES
 Generalized-onset Seizures
Seizures that appear to involve all areas of the brain are called generalized seizures. Different types of generalized seizures include:
 
- Absence Seizures
 Previously known as petit mal seizures
 Often occur in children
 Characterized by staring into space or by subtle body movements, such as eye blinking or lip smacking
 Usually last for 5 to 10 seconds but may happen up to hundreds of times / day
 Occurs in clusters and cause a brief loss of awareness
 
- Tonic Seizures. 
 Cause stiffening of your muscles
 Usually affect muscles in the back, arms and legs and may cause to lose consciousness and fall to the ground.
 
- Atonic Seizures
 Also known as drop seizures
 Cause a loss of muscle control, which may cause to suddenly collapse, fall down or drop the head.
 
- Clonic Seizures
 Associated with repeated or rhythmic, jerking muscle movements
 Usually affect the neck, face and arms on both sides of the body.
 
- Myoclonic Seizures
 Usually appear as sudden brief jerks or twitches of the arms and legs.
 There is often no loss of consciousness.
 
- Tonic-Clonic Seizures
 Previously known as grand mal seizures, are the most dramatic type of epileptic seizure
 Can cause an abrupt loss of consciousness, body stiffening and shaking, and sometimes loss of bladder control or biting tongue
 May last for several minutes.
TYPES
 Unknown-Onset
 
Sometimes no one sees the beginning of a seizure. For example, someone may wake up in the middle of the night and observe their
partner having a seizure. These are called unknown onset seizures. They are unclassified because of insufficient information about how they
started.
RISK FACTORS
 Alcohol misuse (withdrawal, intoxication)
 An electrolyte imbalance, Kidney or liver failure
 Autoimmune disorders, including systemic lupus erythematosus and multiple sclerosis
 Brain disorders (congenital defect, infection, injury, tumor), Vascular abnormality in the brain
 Choking
 Drug abuse & withdrawal
 Electric shock
 Extremely high blood pressure
 Flashing lights, moving patterns or other visual stimulants
 Head trauma, High fever
 Low blood glucose levels, Low blood sodium (hyponatremia), which can happen with diuretic therapy
 Medications, such as certain pain relievers, antidepressants or smoking cessation therapies, that lower the seizure threshold
 Stroke
 
COMPLICATIONS
If untreated, symptoms can become worse and progressively longer in duration. Extremely long seizures can lead to coma
or death. Seizures also can lead to injury, such as falls or trauma to the body.
SIGNS & SYMPTOMS
You can experience both focal and generalized seizures at the same time, or one can happen before the other. The
symptoms can last anywhere from a few seconds to 15 minutes per episode.
 
Sometimes, symptoms occur before the seizure takes place. These can include:
 sudden feeling of fear or anxiousness
 feeling of being sick to your stomach
 dizziness
 change in vision
 jerky movement of the arms and legs that may cause you to drop things
 an out of body sensation
 headache
 
Symptoms that indicate a seizure is in progress include:
SIGNS & SYMPTOMS
Symptoms that indicate a seizure is in progress include:
 losing consciousness, followed by confusion
 having uncontrollable muscle spasms
 drooling or frothing at the mouth
 falling
 having a strange taste in mouth
 clenching teeth, biting tongue
 sudden, rapid eye movements
 making unusual noises, such as grunting
 losing control of bladder or bowel function
 sudden mood changes
 Apnea, cyanosis
PATHOPHYSIOLOGY
PATHOPHYSIOLOGY
NURSING MANAGEMENT
Patient safety is one of the main considerations during seizure activity. It is important to remember DRSABCD:
 Danger;
 Response;
 Send for help;
 Airway;
 Breathing;
 CPR; and
 Defibrillation.
NURSING MANAGEMENT
• Stay with the patient and call for help
• Time the seizure and note its characteristics.
• Protection must be given to the patient’s head, place something soft under their head and shoulders. Clear the area.
• Do not try to physically restrict the movement of the patient’s limbs as this can cause musculoskeletal damage.
• Do not put anything in the patient’s mouth or attempt to move them.
• Roll the patient onto their side in the recovery position to prevent aspiration due to excessive saliva production and ensure
their airway remains patent.
• Suction and oxygen must be available. Monitoring of vital signs is imperative, especially respiratory function.
• Continue to monitor the patient’s airway, using suction as needed, and do not disturb the patient if they fall sleep.
• When they wake, calmly tell them where they are and that they are safe.
• Provide reassurance, as this can understandably be quite distressing for the patient
• Frequent monitoring of vital signs and neurological observations to monitor the patient’s condition.
 
NURSING MANAGEMENT
MEDICAL MANAGEMENT &
TREATMENT
Not everyone who has one seizure has another one. Because a seizure can be an isolated incident, your doctor may not start
treatment until you've had more than one. Treatment usually involves the use of anti-seizure medications.
Many medications are used in the treatment of epilepsy and seizures, including:
 Carbamazepine (Carbatrol, Tegretol, others)
 Phenytoin (Dilantin, Phenytek)
 Valproic acid (Depakene)
 Oxcarbazepine (Oxtellar, Trileptal)
 Lamotrigine (Lamictal)
 Gabapentin (Gralise, Neurontin)
 Topiramate (Topamax)
 Phenobarbital
 Zonisamide (Zonegran)
SURGICAL MANAGEMENT
If other treatments aren't effective, surgery may be an option. The goal of surgery is to stop seizures from happening. Surgery
works best for people who have seizures that always originate in the same place in the brain. There are several types of surgery,
including:
 
 Lobectomy (lesionectomy). 
 Multiple subpial transection.
 Corpus callosotomy.  
 Hemispherectomy (hemispherotomy). 
 Thermal ablation (laser interstitial thermal therapy).  
Electrical stimulation
 Vagus nerve stimulation.  
 Responsive neurostimulation.
 Deep brain stimulation. 
HEADACHES
DEFINITION
Headache, or cephalalgia, is one of the most common of all human physical complaints. Headache is a symptom rather than a
disease entity: it may indicate organic disease (neurologic or other disease), a stress response, vasodilation (migraine), skeletal
muscle tension (tension headache), or a combination of factors.

TYPES
A primary headache is one for which no organic cause can be identified. Primary causes of headaches are causes that
aren’t related to separate medical conditions. This type of head- ache includes migraine, tension-type, and cluster headaches.
 
A secondary headache is a symptom associated with o causes, such as a brain tumor, and aneurysm, or lumbar puncture.
Although the headaches do not indicate serious disease, persistent he aches require further investigation Serious disorders
related to headache include brain tumors, subarachnoid hemorrhage stroke, severe hypertension, meningitis, and head injuries
TYPES
Primary Headaches
 Tension Headaches
Tend to be chronic, less severe, and probably the most common type of headache. Anyone can get a tension headache,
and they’re often triggered by stress.
 
 Cluster Headaches
Cluster headaches are characterized by severe burning and piercing pain. They occur around or behind one eye or on
one side of the face at a time.
 
These headaches occur in a series. Each individual headache can last from 15 minutes to three hours. Most people
experience one to four headaches a day, usually around the same time each day, during a cluster. After one headache
resolves, another will soon follow.
 
A series of cluster headaches can be daily for months at a time. In the months between clusters, individuals are
symptom-free. Cluster headaches are more common in the spring and fall. They are also three times more common in
men.
 
TYPES 
 Migraine Headaches
Migraine pain is an intense pulsing from deep within your head. This pain can last for days. The headache significantly
limits your ability to carry out your daily routine. Migraine is throbbing and usually one-sided. Migraine is a complex of
symptoms characterized by periodic and recurrent attacks of severe headache lasting from hours to days in adults. People
with migraine headaches are often sensitive to light and sound.
 
The migraine with aura can be divided into four phases: premonitory, aura, the headache and recovery (headache
termination and postdrome).

Premonitory Phase
The premonitory phase is experienced by more than 80% adult migraine sufferers, with symptoms that occur hours to days
before a migraine headache. Patients may experience the same prodrome with each migraine headache, A current theory
regarding premonitory symptoms is that they involve the neurotransmitter dopamine.
 
Aura Phase
TYPES
 Aura Phase Secondary Headaches
An aura may be a variable feature for patients  Allergy or Sinus Headaches
who experience migraines An aura is  Hormone Headaches
characterized by focal neurologic symptoms.
 Caffeine Headaches
 Exertion Headaches
Headache Phase
 Hypertension Headaches
Migraine headache is severe and
incapacitating.  Rebound Headaches

   Post-Traumatic Headaches

Postdrome Phase
In the postdrome phase, the pain gradually
subsides, but patients may experience other
symptoms.
TYPES
RISK FACTORS COMPLICATIONS
 Skipping meals.  Chronic migraine.
 Too much or too little sleep.  Migraine-triggered seizures.
 Stressful events.  Migrainous infarction (stroke with migraine)
 Smoking.
 Depression or anxiety.
 Drinking too much alcohol.
 Loud or sudden noises.
 Hypoxia
 Caffeine Withdrawal
 Hypertension
SIGNS & SYMPTOMS
Cluster Headache
 Swelling, redness, flushing, and sweating can occur on the side that’s affected by the headache. Nasal congestion and eye tearing also often occur on the same
side as the headache.
 

Migraine
Premonitory Phase
 Depression, irritability, feeling cold, food cravings, anorexia, change in activity level, increased urination, diarrhea, or constipation.
Aura Phase
 Visual disturbances (i.e., light flashes and bright spots) are most common and may be hemianopic (affecting only half of the visual field). Other symptoms that
may follow include numbness and tingling of the lips, face, or hands; mild confusion; slight weakness of an extremity; drowsiness; and dizziness.
Headache Phase
 Photophobia (light sensitivity), phonophobia (sound sensitivity), or allodynia (abnormal perception of innocuous stimuli).
Postdrome Phase
 Tiredness, weakness, cognitive difficulties, and mood changes for hours to days. Muscle contraction in the neck and scalp is common, with associated muscle
ache and localized tenderness. Physical exertion may exacerbate the headache pain. During this post-headache phase, patients may sleep for extended periods.
PATHOPHYSIOLOGY
NURSING & MEDICAL MANAGEMENT
• Individualized treatment depends on the type of headache. Nursing care is directed toward treatment of the acute episode.
• A migraine or a cluster headache in the early phase requires abortive medication therapy instituted as soon as possible.
• Comfort measures such as a quiet, dark environment; elevation of the head of the bed to 30 degrees; and symptomatic
treatment
• Symptomatic pain relief for tension headache may be obtained by application of local heat or massage.
• Additional strategies may include administration of analgesic agents, antidepressant medications, and muscle relaxants.
 
If OTC pain relievers don’t reduce your migraine pain during an attack, your doctor might prescribe triptans. Triptans are drugs
that decrease inflammation and change the flow of blood within your brain. They come in the form of nasal sprays, pills, and
injections. Popular options include:
 sumatriptan (Imitrex)
 rizatriptan (Maxalt)
 rizatriptan (Axert)
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