Module D

Neurosensory Regulation

Roy Model- Neurosensory Regulation/ Need for Protection

Required Reading (see syllabus for detailed reading assignment)

Lewis, Heitkemper, Dirksen. Medical-Surgical Nursing. current ed, Mosby.

a. General Neurological Assessment and diagnostic tests
b. Acute Intracranial problems- brain trauma, ICP, CPP
c. Stroke- differentiate types and treatments
d. Seizures- Tonic Clonic
e. Peripheral nerve and spinal cord conditions

Recommended Reading

Pathophysiology book for review of neurological system anatomy and physiology

Review critical care concepts with neurologically impaired clients

Theory Objectives
Section 1- Overview of Central Nervous System
1. Review structure and function of the central nervous system
2. Discuss essential components in assessment of neurological function and identify
ineffective behaviors that place clients at risk.
3. Explain the Glasgow Coma Scale as a measure of neurologic status.
4. Describe diagnostic tests used for assessment of neurologic function and related
nursing implications.
5. Discuss changes in neurologic function associated with client’s developmental
level and their impact on neurologic assessment findings.
6. Identify second level assessment (focal, contextual, and residual stimuli)

Section 2- Altered Intracranial Function

1. Explain the pathophysiology underlying signs and symptoms of intracranial
pressure (ICP).
2. Relate the early and late clinical manifestations of increased intracranial pressure
(ICP).
3. Select pertinent and appropriate nursing interventions for ICP.
4. Discuss primary, secondary, and tertiary prevention of head injuries.
5. Differentiate head injuries by types, clinical manifestations and management.
6. Discuss nursing care needs of the unconscious client.
7. Compare types, clinical manifestations and therapeutic management of
intracranial tumors.
8. Discuss nursing care for the client undergoing craniotomy.
9. Compare the primary causes, prognostic outcome, medical and nursing
management of common cerebral inflammatory disorders.
10. Discuss primary, secondary and tertiary prevention of stroke.
 11. Compare and contrast the pathophysiology of strokes caused by thrombosis,
embolism, and intracranial hemorrhage.
12. Describe “subarachnoid precautions” and application to the client with a cerebral
aneurysm.
13. Describe the diagnostic, pharmacological, dietary and therapeutic management of
the acute stroke client.
14. Describe nursing interventions commonly implemented in situations of ineffective
neurologic function in all age groups.
15. Discuss the dosage, action, side effects, and nursing considerations for
pharmacological agents used in the management of neurological disorders.
16. Discuss the physiological, psychosocial, and rehabilitative needs across the age
span following intracranial insult.
17. Develop a care plan utilizing the Roy Model and nursing process to plan care for
clients with neurological dysfunctions

Section 3- Seizures, Spinal Cord

1. Explain the etiology, classification, clinical manifestations, diagnostic evaluation,
complications, medical, surgical and nursing management of clients of various
age groups with seizure disorders.
2. Discuss nursing responsibilities during and after seizure activity.
3. Discuss components of a teaching plan for a client with a seizure disorder across
the life span.
4. Identify the population at risk for spinal cord injuries and primary prevention.
5. Discuss the classification of spinal cord injuries and associated clinical
manifestations.
6. Discuss expected behaviors manifested in the presence of spinal shock.
7. Correlate the clinical manifestations of spinal cord injury with level of disruption
and rehabilitation potential.
8. Describe acute and chronic medical. Surgical and nursing management of the
patient with a spinal cord injury.
9. Discuss the physiological, psychosocial and rehabilitative needs of the patient
with spinal cord injury.
10. Explain the significant effects of spinal cord injury on the older adult population.
11. Discuss the interdisciplinary approach to facilitating rehabilitative needs of clients
with spinal cord injuries.
12. Discuss the etiology, pathophysiology, clinical manifestations, medical, surgical,
and nursing management of spinal cord tumors.

Clinical Component
Objectives
1. Complete a neurological assessment in the clinical setting
2. Provide pre-operative interventions for a neuro-surgical client
3. Identify diagnostic study abnormalities common to the client with a neurologic
dysfunction.
4. Correlate client symptoms with specific pathophysiology in the client with
neurological disorders.
 5. Provide teaching to the client and family
6. Assist with post-operative care in the intensive care unit for clients undergoing
craniotomy or other neuro-surgery.
7. Provide care to a client with spinal surgery, lumbar or cervical
8. Offer emotional support to patients and families of clients with critical neurological
trauma or tumors.

Drugs
Diuretics (Mannitol, Lasix), Anticonvulsants (Dilantin), Barbituates (Pentobarbital),
Dopamine, Decadron

Diet
Assessment of swallow/ gag reflexes prior to diet

Laboratory
General labs, Specific gravity, lumbar puncture

Neurological Diagnostics
See handout

Critical Thinking Question

1. Your patient had symptoms of an ischemic stroke approximately 2 hours ago and is
undergoing a confirmatory CT scan in 30 minutes. You know t-PA must
administered within 3 hours of the symptoms. What actions would you take? What
is your rationale for these actions?
2. After undergoing cranial surgery, your patient has had elevated ICP for 15 minutes.
Mannitol, an osmotic diuretic, was administered, but the ICP remains unchanged.
The patient is receiving sedations and pain medication. Describe some other
interventions that may be initiated.
3. Your patient is admitted with hemorrhagic stroke and exhibits homonymous
hemianopsia. How would you explain this phenomenon to the patient and family?
Describe ways that the patient and family may work together to compensate for this
problem.
 Neurological Outline
Anatomy and Physiology
Review anatomy and physiology, particularly function of the brain

a. Central Nervous System

b. Spinal Cord/ nerves
c. Peripheral Nervous System

Assessment of Neurological Functioning

1. Health Assessment
a. Interview r/t communication, health problems/clinical manifestation
2. Physical Assessment
a. Mental status
b. Cognitive
c. Cranial Nerves
I olfactory sense of smell test w/ familial smells
II optic visual acuity eye chart
III oculomotor eye movement ocular rotations,
IV trochear “ papillary reflex, ptosis
VI abducens “
V trigeminal facial sensation ability to clench jaw
Corneal reflex facial sensation
Mastication corneal reflex
VII facial facial muscle move observe for symmetry
Facial expressions, tear/ saliva secretions
Taste, anterior 2/3
VIII acoustic hearing/ equilibrium whisper & weber test
Rhinne conduction
IX glossopharyngeal taste, posterior 1/3 sugar/ salt
X vagus pharyngeal contract symmetrical move of
Vocal cords, soft palate, thoracic/ abd viscer
XI spinal accessory movement of sternocleidomastoid/ trapezius
XII hypoglossal movement of tongue

d. Sensory function- mostly subjective and requires cooperation of pt

e. Motor function- muscle size, tone, strength, coordination, balance
i. Assess- face-upper/ lower extremities/ comparative data and grade
ii. Evaluate Patterns of movement
f. Cerebellar function- s/sx
g. Reflex assessment
h. Special Neurological Assessments (meningeal irritation)
i. Diagnostic tests – preparation/ rationale for use/ post-procedure
Intracranial Disorders

Increased Intracranial Pressure (IICP)

General-
 Untreated IICP can lead to displacement of brain tissue (herniation)
 Presents as life-threatening situation because of pressure on vital structures in the brain
stem, nerve tracts, and cranial nerves.
 Monitor ICP by ventricular bolt, fiberoptic transducer via fine bore hole.
 Normal ICP is 10-20, <15 mm Hg ideal

Assessment
Use of Glascow coma scale total 15- validates LOC
1. Earliest sign- decrease LOC; progresses from restlessness to confusion to
disorientation to drowsiness to lethargy to coma
a. Confused
b. Lethargic
c. Obtunded
d. Stuporous
e. Comatose
2. Changes in VS- (may be late sign)-
a. Widening pulse pressure
b. Bradycardia
c. Abnormal respirations (Cheyne-Stokes)
d. Elevated temperature
3. Pupillary changes
a. Ipsilateral (same side) dilation w/ sluggish response (CN III)
b. Fixed / dilated pupils
4. Motor abnormalities
a. Contralateral (opposite) hemiparesis
b. Decorticate or Decerebrate rigidity
5. Headache, projectile vomit, papilledema

Early Late
Defects in Mentation
Vasomotor response (slow speech, decrease LOC- comatose
Delay to verbal, disorientation,
Restlessness, increase resp effort)
Headache
Constant, increase intensity projective vomiting esp w/ IICP
Aggrevated by movement
Bradycardia
HR/RR decrease, BP/T elevate
Widening pulse pressure then
Increased HR, cheyne-stokes
Ataxia
Papilledema
Papillary change, impaired loss of pupil change, corneal, gag
Ocular movement, edema of swallow reflex—loss of brain stem
Optic nerve

Nursing Diagnosis
Altered tissue perfusion: cerebral r/t……. m/b (3)
Ineffective airway clearance r/t….. m/b (3)
Risk for injury, aspiration, or disuse syndrome r/t…. m/b (3)
Decreased Adaptive capacity: intracranial r/t brain injury r/t …. m/b (3)
Outcome
Measureable and time sensitive specific to the patient/ nsg dx

Collaborative Management (AIDC model)

Assessment
Priority Assessment to justify nursing dx
Pertinent patient history/ situation that resulted in problem statement
Priority diagnostics
Independent- clustered together based on function
Reduce cellular metabolic demands of the brain
List the nursing actions that will facilitate this
Maintain patient airway and adequate ventilation- ? intubation
Monitor VS w/ special note of temperature, neuro checks frequently
Maintain fluid balance- restriction of 1200-1500 may be indicated
Position client to reduce IICP
Maintain environment conducive to reducing IICP
Medications
Hyperosmotic agents (mannitol) to…..
Corticosteroids (decadron) to…..
Diuretics (Lasix) to…….
Anticonvulsants (dilantin) to…..
EBP- r/t ICP
Monitor the following:
GCS q X, Neuro checks q X
ICP monitoring and prevention of infection

Call MD if
Pupils are fixed and blown, or sudden unequal changes
Cushings Triad
Bradycardia, hypertension, bradypnea w/ widening pulse pressure
Dependent
List the orders from the physician needed to fix the problem i.e. Medications, Surgery,
etc
Collaborative
Who and why
Head Injuries

General
 Usually caused by car accidents, falls, assaults
 Types-
o Concussion
 Severe blow to the head jostles brain, temporary neural dysfx
o Contusion
 Results in more severe blow that bruises the brain and disrupts neural fx
o Hemorrhage
 Epidural
 Subdural
 Subarachnoid
 Intracerebral hematoma
o Fractures
 Linear, depressed, comminuted, or compound

Assessment (depends on type of injury)

1. Concussion
a. H/A, transient loss of consciousness, retrograde or posttraumatic amnesia, nausea,
dizzy, irritable
2. Contusion
a. Neurologic deficits depend on site and extent of damage; decreased LOC,
aphasia, hemiplegia, sensory deficits
3. Hemorrhages
a. Epidural- brief loss of consciousness f/b lucid interval; progression to severe H/A,
vomit, rapid deteriorating LOC, possible seizures, ipsilateral papillary changes
b. Subdural- alterations in LOC, H/A, focal neurologic deficits, personality changes,
ipsilateral papillary dilation
c. Intracerebral- H/A, decreased LOC, hemiplegia, ipsilateral papillary dilation
4. Fractures- H/A to leakage of CSF from site, nose or ear
5. Diagnostics
a. skull x-rays
b. CT scans

Nursing Diagnosis
 Altered thought process r/t pressure damage to brain m/b (cluster of 3)
 Altered tissue perfusion: cerebral r/t effects of IICP or change in perfusion m/b (cluster of
3)
 Sensory/ perceptual alteration r/t pressure damage to sensory centers in brain m/b (cluster
of 3)

Interventions- Organize similar to above

May also be similar to IICP and/ or care of unconscious client
Think about……
 1. Maintain a patient airway/ adequate ventilation
2. Monitor VS, Nuero (watch IICP, shock, seizures, hyperthermia)
3. Observe for CSF leakage
a. Use testape for + glucose, bld spots
b. Never attempt to clean ears/ nose of head injury or use nasal suction
c. If leakage- instruct pt not to blow nose, HOB @ 30, ABtx, sterile gauze
4. Prevent complications of Immobility
5. Prepare for surgery
6. Observe for hemiplegia, aphasia, sensory problems

Intracranial Tumors
Tumors within the cranial cavity; may be benign or malignant
Types
 Primary
 Secondary
Assessment
1. H/A- worse in morning and w/ strain or stoop
2. vomiting
3. papilledema
4. seizures (focal/ generalized)
5. changes in mental status
6. focal neurological deficits (aphasia, sensory problems, blindness)
7. Diagnostics-
a. Skull x-ray, CT, MRI, brain scan
b. Abnormal EEG
c. Brain Biopsy

Nursing Diagnosis
Altered thought process r/t altered circulation or destruction of brain tissue m/b (3)
Anticipatory grieving r/t potential loss of physiosocial- psychosocial well being m/b (3)
Fear r/t threat of life
Sensory/ perceptual alteration; specify (vision, hearing, hearing) r/t tumor growth
compressing brain tissue m/b (3)

Interventions should include at least the following

1. Prepare pt for craniotomy, brain biopsy
2. Radiation therapy and/ or chemotherapy
3. Medications to include- hyperosmotic agents, corticosteroids, diuretics to manage
increased ICP
4. Cont. w/ similar to head injuries

Intracranial Surgery
Types
 Craniotomy
 Craniectomy
 Cranioplasty
Preoperative Nursing
1. Routine preoperative check lists and verifications
2. Provide emotional support as to what to expect ie shaved head, large bandage,
possibly temporary swelling and discoloration around the eyes, poss H/A
3. Preoperative steroids, dilantin levels (if previously taken)

Post-operative Nursing
1. Care for unconscious client
2. Maintain patent airway/ adequate ventilation
a. Instruct conscious pt to breath, no cough or strain
b. HOB 20-45 w/ no head flexion or misalignment of body, turn q 2
3. Monitor VS, neuro’s, LOC, impaired gag/ swallow reflex, seizures, hyperthermia
4. Monitor electrolytes, I/O watching for overhydration and potential for cerebral
edema, s/sx of diabetes insipidus (severe thrist, polyuria, dehydration) and SIADH
(decreased UA output, hunger, thirst, irritability, decreased LOC, muscle weakness)
5. Assess dressing for excessive drainage, CSF, or displacement of catheters and
drainage from catheters
6. Administer Medications (corticosteroids, anticonvulsants, stool softners, mild
analgesics, antihypertensives)

Stroke
General
 Describe pathophysiology, incidence
 Differentiate between thrombosis, embolism, hemorrhage
Risk Factors
Pathophysiology
 Interruption of cerebral blood flow for 5 minutes or more causes death of neurons
in affected area w/ irreversible loss of function
 Modifying factors
o Cerebral edema
 Develops around affected area causing further impairment
o Vasospasm
 Constriction of cerebral bld vessel m/b decreased flow
o Collateral circulation
 May help to maintain cerebral bld flow when there is compromise
of main bld flow
Stages of Development
o Transient Ischemic Attack (TIA)
o Warning sign, lasts from 30 sec to 24 hours w/ complete resolution
o Stroke in evolution
o Progressive development of symptoms from hours to days
o Completed stroke
o Neurological deficit unchanged for at least 2-3 days
Assessment
1. H/A
2. Generalized S/Sx- vomit, seizures, confusion, disorientation, decreased LOC,
nuchal rigidity, fever, HTN, slow bounding pulse, Cheyne-Stokes
3. Focal signs- hemiplegia, sensory loss, aphasia, homonymous hemianopsia
4. Diagnostics
a. CT, brain scan, MRI
b. EEG
c. Cerebral angiography
5. Left Hemispheric Right Hemispheric
Paralysis of Right side Paralysis of Left side
Right visual field defects Left visual field defects
Aphasia (expressive, receptive, Spatial-perceptual
Global deficits)
Altered Intellect Increased distractibility
Slow, cautious behavior Impulsive behavior, poor judgment
Inpatient, lack of awareness –deficit
5. Evaluate clinical manifestations
a. Motor Loss
b. Communication loss
c. Perceptual disturbances
d. Cognitive impairment, psychologic effects
e. Bladder/ bowel dysfunction

Nursing Diagnosis- state correctly with r/t and m/b (3)

Impaired physical mobility r/t loss of balance and coordination
Impaired social interaction r/t limited physical mobility/ communication
Impaired swallowing or Risk for aspiration r/t neuromuscular dysfunction
Sensory/ perceptual alteration: visual, tactile, kinesthetic r/t neuro dysfx

ACUTE - Collaborative Care- usually 48 to 72 hours

“think critical pathway” and EBP- door to final tx of 90 to 180 minutes
1. Medications- (understand rationale)
a. hyperosmotic agents
b. corticosteroids
c. anticonvulsants
d. thrombolytics, antifibrinolytic agents
e. anticoagulants
f. antihypertensives, vasopressors
g. Other- stool softners, analgesics
2. Diagnostics
3. Preparation for surgery if indicated

Rehabilitation – Collaborative Care

1. Hemiplegia
2. Susceptibility to Hazards
 3. Dysphagia
4. Homonymous Hemianopsia
5. Emotional Lability; mood swings; frustration
6. Aphasia (common w/ right hemiplegics)-understand different types
7. Sensory/ perceptual deficits (common w/ left hemiplegics)
8. Apraxia
9. Generalizations/ Geriatric considerations

Seizures
General
Define various types, Incidence
Risk Factors
Genetic predisposition Acute febrile state
Head injury Infection (meningitis/ encephalitis)
Metabolic or endocrine disorders (hypoglycemia/ calcemia/ natremia)
Exposure to toxins Birth injury
Trauma Brain tumors
Hypoxia Drug/ ETOH withdrawal
Fluid/ lyte imbalance Congenital (hydrocephalus)
Vascular (cerebral hemorrhage)

Pathophysiology

Classification
 Generalized-
o Tonic-clonic
o Focal seizure
o Absence seizure (petit mal)
o Myoclonic
o Atonic (drop attacks)
 Partial
o Simple
o Complex
o Status epilepticus
Assessment
1. Evaluation based on classification
2. Evaluate- memory loss during and immediately following, drowsiness or difficulty w/
arousal following, incontinence of urine/ feces, vomiting, hypoxia (severe or
prolonged seizure activity), automatism (lip smacking, repeated swallowing).
3. Diagnostics
a. Blood studies r/o lead poisoning, metabolic imbalance, infection, drug screens
b. LP r/o infection, trauma
c. Skull x-ray, CT, Ultz, brain scan, arteriogram
d. EEG r/o abnormal wave patterns

Nursing Diagnosis
 Risk for injury r/t uncontrolled movements 2* to seizure, falls, drowsiness m/b (3)
Ineffective airway clearance r/t accumulation of secretions during seizure m/b (3)
Anxiety and fear r/t lack of control of body m/b (3)
Ineffective individual coping / social isolation r/t unpredictability of seizure m/b (3)
Knowledge deficit r/t health maintenance, medications, memory m/b (3)

Interventions considerations as you develop an AIDC model

1. Maintain airway and breathing
a. Place in side-lying position to allow excess secretions to escape (aspirate)
b. Loosen tight clothing
2. Prevention of and/ or termination of further seizures
a. Medications- Dilantin, Phenobarbital
b. Surgery to remove tumor, hematoma, or epileptic focus
3. Restoration of cerebral oxygenation
a. Administer oxygen
4. Prevention of complications/ injuries
a. Prevent falling, support head, do not restrain or use tongue blades
5. Observe and record seizure
a. Note preictal aura, ictal phase, and postictal response
6. Provide client teaching and discharge instructions
a. Identify triggers

Spinal Cord Injuries

General
 Occurs most commonly in young adult males betw ages 15 and 25
 Common traumatic causes; MVA, diving in shallow water, falls, industrial, gunshot,
sports injuries
 Nontraumatic causes: tumors, hematomas, aneurysms, congenital defects (spinal bifida)
 May result in complete transaction or partial disruption of nerve tracts and neurons.

Classification based on extent, level, and mechanism

1. Extent of injury
2. Level of injury
3. Mechanism of injury

Risk Factors

Pathophysiology
Hemorrhage and edema cause ischemia, leading to necrosis and destruction of the cord.
Primary injury- initial trauma w/ permanent results vs secondary injury- result of contusion or
tear w/ nerve swelling/ disintegration. Partial damage may be reversed if corticosteroids are
initiated 4-6 * of injury, which can reduce amounts of ischemia and tissue hypoxia which
progresses to necrotic destruction of the cord. Because additional edema will extend the level of
injury beyond the immediate level for 3 to 7 days, the exact extent of the injury cannot be
determined before that time.
Assessment
1. General assessment of respiratory instability, motor/ sensory changes, loss of
reflexes, pain, orthostatic hypotension, hypercalcemia, decreased cough reflex
2. Spinal Shock
a. Occurs immediately after injury r/t insult to CNS
b. Bradycardia, hypotension, flaccid paralysis, loss of reflex activity below the level
of injury, and paralytic ileus
3. Symptoms depend on level
a. Quadriplegia
b. Paraplegia
4. Symptoms depend on extent of injury
a. Complete cord transaction
b. Lesions
c. Incomplete lesions
5. Diagnostics
a. Spinal x-rays, CT, H/P, EMG

Nursing Diagnosis
Body Image disturbance r/t change in body function m/b (3)
Risk for impaired skin integrity r/t immobility, paralysis m/b (3)
Altered health maintenance r/t knowledge deficit regarding self-care w/ spinal cord injury
m/b (3)

Collaborative Care
Emergency/ acute care
1. Assess ABC
a. Do not hyperextend neck to open airway, jaw thrust
b. Cont. to maintain optimum respiratory function, including TCDB & I/S
c. Trach or respirator may be necessary w/ high cervical
d. Circulation
i. Neurogenic shock
ii. Spinal shock
e. Maintain optimum cardiovascular, eval for hypotension, brady, arrhythmia’s, use
of TED’s, change position slowly
2. Perform quick head to toe assessment; LOC, signs of trauma to the Head n’ neck,
leakage of CSF from ears/ nose, signs of motor or sensory
3. Immobilize client in position found until help and able to assess
4. Immobilize/ stabilize neck region on spinal board
5. Have suction available to clear airway and prevent aspiration if client vomits; back
board and client may be turned together
6. Maintain fluid/ lyte/ nutrition
7. Maintain bladder/ bowel elimination
8. Prevention of immobility related issues- thrombosis, ulcer’s, contractures
9. Diagnostics
a. Spinal x-ray, CT scan, MRI
Pharmacological
1. Glucocosteriods (decadron, solumedrol)
2. Vasopressors (dopamine)
3. Muscle relaxants
4. Anti-spasmodics (Dantrium)
5. Analgesics (opioids and non-opioids NSAID’s)
6. Antidepressants (Paxil, Zoloft)
7. Histamine H2 blockers (Zantac)
8. Anticoagulants (Heparin or low molecular weight heparin)
9. Stool softners
10. Vasodilators (hydralazine, nitroglycerin)

Immobilization/ stabilization
1. Horizontal turning frame- Stryker frame
2. Skeletal traction
a. Cervical tongs
b. Halo traction
3. Surgery for decompression laminectomy, spinal fusion

Chronic Care
1. Neurogenic Bladder
2. Spasticity
3. Autonomic Dysreflexia
a. Hypertension, bradycardia, flushed face and neck, severe H/A, nasal stuffiness,
dilated pupils, blurred vision, sweating, and nausea.
4. Rehabilitation
a. Psychological support r/t grieving, sexuality, independence, rehabilitation
program