UNIT XV

Neurological Problems of
the Adult Client
ALEJANDRA MARTINEZ
RN, BSN, IBCLC
Anatomy and
Physiology of the
Brain and Spinal
Cord
CHAPTER 58

PAGE 2003
Cerebrum

The cerebrum consists of the right and

left hemispheres.
Each hemisphere receives sensory
information from the opposite side of
the body and controls the skeletal
muscles of the opposite side.
The cerebrum governs sensory and
motor activity and thought and
learning.
Cerebral
cortex
The cerebral cortex is the
outer gray layer; it is
divided into 5 lobes.
It is responsible for the
conscious activities of the
cerebrum.
Cerebral cortex

Frontal Lobe Parietal Lobe

Broca’s area for production of Interpretation of taste, pain,
speech touch, temperature, and pressure
Morals, emotions, reasoning and Spatial perception
judgment, concentration, and
abstraction.
Cerebral cortex

Occipital Lobe
Temporal Lobe Visual area

Auditory center
Wernicke’s area for Limbic System
comprehension of speech
Emotional and visceral patterns
for survival
Learning and memory
Basal ganglia

Cell bodies in white

matter that help the
cerebral cortex produce
smooth voluntary
movements
 Diencephalon

Thalamus

Relays sensory impulses

to the cortex
Provides a pain gate
Part of the reticular
activating system
Diencephalon

Hypothalamus

Regulates autonomic responses of the sympathetic and

parasympathetic nervous systems
Regulates the stress response, sleep, appetite, body
temperature, fluid balance, and emotions
Responsible for the production of hormones secreted by the
pituitary gland and the hypothalamus
 Brainstem
(Tronco encefálico)

Midbrain (mesencéfalo)

Responsible for motor

coordination
Contains the visual
reflex and auditory relay
centers
Brainstem

Pons:
Contains the respiratory centers and regulates breathing

Medulla oblongata (bulbo):

Contains all afferent and efferent tracts and cardiac,
respiratory, vomiting, and vasomotor centers
Controls heart rate, respiration, blood vessel diameter,
sneezing, swallowing, vomiting, and coughing
 Cerebellum

Coordinates muscle
movement, posture,
equilibrium, and muscle
tone
Spinal cord

Provides neuron and synapse networks to produce involuntary

responses to sensory stimulation
Controls body movement and regulates visceral function
Carries sensory information to and motor information from the
brain
Extends from the first cervical to the second lumbar vertebra
Protected by the meninges, cerebrospinal fluid (CSF), and
adipose tissue
Spinal cord

Horns
Inner column of gray matter;
contains 2 anterior and 2
posterior horns
Posterior horns connect with
afferent (sensory) nerve
fibers.
Anterior horns contain
efferent (motor)nerve fibers.
Spinal cord

Nerve tracts

White matter contains the

nerve tracts.
Ascending tracts (sensory
pathway)
Descending tracts (motor
pathway)
Meninges

Dura mater is a tough and

fibrous membrane.
Arachnoid membrane is a
delicate membrane and
contains CSF.
Pia mater is a vascular
membrane.
The subarachnoid space is
formed by the arachnoid
membrane and the pia mater.
Cerebrospinal
fluid
Secreted in the ventricles; circulates in the subarachnoid
space and through the ventricles to the subarachnoid space of
the meninges, where it is reabsorbed
Acts as a protective cushion; aids in the exchange of nutrients
and wastes
Normal pressure is 50 to 175 mm H2O.
Normal volume is 125 to 150 mL.
Ventricles

Four ventricles
The ventricles
communicate between
the subarachnoid
spaces and produce and
circulate CSF.
Blood supply

Right and left internal

carotid arteries
Right and left vertebral
arteries
These arteries supply the
brain via an anastomosis
at the base of the brain
called the circle of Willis.
Neurotransmitters

1. Acetylcholine: Motor, neurons, parasympathetic nervous system

2. Norepinephrine: Mobilize the brain and body for action
3. Dopamine: motivational component of reward-motivated behavior,
motor control and release of various hormones, inhibits norepinephrine
4. Serotonin: modulating mood, cognition, reward, learning, memory,
and physiological processes such as vomiting and vasoconstriction
5. Amino acids
6. Polypeptides
Neurons

The neuron consists of the cell body, axon, and dendrites.

The cell body contains the nucleus.
Neurons carrying impulses from the peripheral nervous system to
the central nervous system (CNS) are called sensory neurons.
Neurons carrying impulses away from the CNS are called motor
neurons.
Synapse is the chemical transmission of impulses from 1 neuron to
another.
Axons and
dendrites
The axon conducts impulses from the cell body.
The dendrites receive stimuli from the body and transmit them to
the axon.
The neurons are protected and insulated by Schwann cells.
The Schwann cell sheath is called the neurolemma.
Neurons do not reproduce after the neonatal period.
If an axon or dendrite is damaged, it will die and be replaced slowly
only if the neurolemma is intact and the cell body has not died.
Spinal nerves

There are 31 pairs of spinal nerves.

Mixed nerve fibers are formed by
the joining of the anterior motor
and posterior sensory roots.
Posterior roots contain afferent
(sensory) nerve fibers.
Anterior roots contain efferent
(motor) nerve fibers.
Autonomic
nervous system
Sympathetic (adrenergic) fibers
dilate pupils, increase heart rate
and rhythm, contract blood
vessels, and relax smooth
muscles of the bronchi.
Parasympathetic (cholinergic)
fibers produce the opposite
effect.
Diagnostic
Tests
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Skull and spinal
radiography

Radiographs of the skull reveal the size and shape of the skull
bones, suture separation in infants, fractures or bony defects,
erosion, and calcification.
Spinal radiographs identify fractures, dislocation,
compression, curvature, erosion, narrowed spinal cord, and
degenerative processes.
Skull and spinal Preprocedure
radiography interventions

Provide nursing support for the confused, combative, or

ventilator dependent client.
Maintain immobilization of the neck if a spinal fracture is
suspected.
Remove metal items from the client.
If the client has thick and heavy hair, this should be documented
because it could affect interpretation of the x-ray film.
Skull and spinal
radiography

Maintain immobilization
until results are known.
Always check with the
client about the possibility
of pregnancy before any
radiographic procedures.
Computed
tomography (CT)

Brain scanning that may or may not require injection of a dye.

It is used to detect intracranial bleeding, space-occupying
lesions, cerebral edema, infarctions, hydrocephalus, cerebral
atrophy, and shifts of brain structures.
An informed consent is needed for any invasive procedure,
including those that use a contrast medium (dye).
Computed Preprocedure
tomography (CT) interventions

Assess for allergies to iodine, contrast dyes, if a dye is used.

Assess renal function and verify contrast dose with the pharmacy.
Instruct the client of the need to lie still and flat during the test.
Instruct the client to hold her or his breath when requested.
Initiate an intravenous line with the appropriate gauge size if prescribed.
Remove objects from the head (wigs, barrettes, earrings, hairpins).
Assess for claustrophobia.
Computed Preprocedure
tomography (CT) interventions
Inform the client of possible mechanical noises as the scanning occurs.
That there may be a hot, flushed sensation and a metallic taste in the
mouth when the dye is injected.
Note that some clients may be given the dye even if they report an allergy;
they may be treated with an antihistamine and corticosteroids before the
injection to reduce the severity of a reaction.
Assess the need to withhold metformin if iodinated contrast dye is used for
a diagnostic procedure because of the risk for metformin-induced lactic
acidosis.
Computed Postprocedure
tomography (CT) interventions

Provide replacement fluids, because diuresis from the dye is

expected.
Monitor for an allergic reaction to the dye.
Assess the dye injection site for bleeding or hematoma, and
monitor the extremity for color, warmth, and the presence of
distal pulses.
Magnetic
resonance imaging
(MRI)

A noninvasive procedure that

identifies tissues, tumors, and
vascular abnormalities.
It is similar to CT scanning but
provides more detailed
pictures.
Magnetic
resonance imaging Preprocedure
(MRI) interventions

Remove all metal objects from the client.

Determine whether the client has a pacemaker, implanted
defibrillator, or other metal implants such as a hip prosthesis or
vascular clips, because these clients cannot have this test
performed.
Insert an intermittent infusion device (saline lock) to all intravenous
accesses prior to the procedure (intravenous fluid pumps are not
allowed in the MRI room).
Magnetic
resonance imaging Preprocedure
(MRI) interventions

Provide precautions for the client who is attached to a pulse

oximeter, because it can cause a burn during testing if coiled around
the body or a body part.
Provide an assessment of the client with claustrophobia (may not
be necessary if an open MRI machine is used).
Administer medication as prescribed for the client with
claustrophobia.
Magnetic
resonance imaging Preprocedure
(MRI) interventions

Determine whether a contrast agent is to be used and follow the

prescription related to the administration of food, fluids, and
medications. Verify allergies and renal function prior to
administration.
Instruct the client that she or he will need to remain still during the
procedure.
Magnetic
resonance imaging Postprocedure
(MRI) interventions

The client may resume normal activities.

Increase fluid intake and expect diuresis if a contrast agent is used.

Contraindicated in a pregnant woman, because the increase in amniotic

fluid temperature that occurs during the procedure may be harmful to the
fetus.
Lumbar puncture

Insertion of a spinal needle through the L3–L4 interspace into the lumbar
subarachnoid space to obtain CSF; measure CSF fluid or pressure; or instill
air, dye, or medications
The test is contraindicated in clients with increased intracranial pressure
(ICP), because the procedure will cause a rapid decrease in pressure in the
CSF around the spinal cord, leading to brain herniation.

Before: Have the client empty the bladder.

Lumbar puncture During the
procedure

Position the client in a lateral recumbent position and have the client
draw the knees up to the abdomen and the chin onto the chest; the
prone position may be required for radiologically guided punctures.
Assist with the collection of specimens (label the specimens in
sequence).
Maintain strict asepsis.
Lumbar puncture Postprocedure
interventions

Monitor vital signs and neurological signs to check for the presence of
leakage of CSF and also monitor for headache.
Position the client flat as prescribed.
Encourage fluids to replace CSF obtained from the specimen collection
or from leakage.
Monitor intake and output.
Cerebral
angiography

Injection of a contrast material

usually through the femoral artery
(or another artery) into the carotid
arteries to visualize the cerebral
arteries and assess for lesions
Cerebral Preprocedure
angiography
interventions

Assess the client for allergies to iodine and shellfish. Assess renal
function.
Assess for a medication history of anticoagulation therapy; withhold the
anticoagulant medication prior to the procedure as prescribed.
Encourage hydration for 2 days before the test.
Maintain the client on NPO (nothing by mouth) status 4 to 6 hours before
the test as prescribed.
Cerebral Preprocedure
angiography
interventions

Perform a neurological assessment, which will serve as a

baseline for postprocedure assessments.
Mark the peripheral pulses.
Remove metal items from the hair.
Administer premedication as prescribed.
Cerebral Postprocedure
angiography
interventions

Monitor neurological status, vital signs, and neurovascular status of

the affected extremity frequently until stable.
Monitor for swelling in the neck and for difficulty swallowing; notify a
primary health care provider (PHCP) if these symptoms occur.
Maintain bed rest for 12 hours as prescribed.
Elevate the head of the bed 15 to 30 degrees only if prescribed.
Cerebral Postprocedure
angiography
interventions

Keep the bed flat, as prescribed, if the femoral artery is used.

Assess peripheral pulses.
Apply sandbags or another device to immobilize the limb and a
pressure dressing to the injection site to decrease bleeding as
prescribed.
Place ice on the puncture site as prescribed.
Encourage fluid intake.
Electro-
encephalography

Graphic recording of
the electrical activity
of the superficial
layers of the cerebral
cortex
Electro- Preprocedure
encephalography
interventions

Wash the client’s hair.

Inform the client that electrodes are attached to the head and that
electricity does not enter the head.
Withhold stimulants such as coffee, tea, and caffeine beverages;
antidepressants; tranquilizers; and possibly antiseizure medications
for 24 to 48 hours before the test as prescribed.
Allow the client to have breakfast if prescribed.
Premedicate for sedation as prescribed.
Electro- Postprocedure
encephalography
interventions

Wash the client’s

hair.
Maintain safety
precautions, if the
client was sedated.
Caloric testing
(oculovestibular
reflex)

Provides information
about the function of
the vestibular portion of
cranial nerve VIII and
aids in the diagnosis of
cerebellar and
brainstem lesions.
Caloric testing
(oculovestibular
reflex)

Patency of the external auditory canal is confirmed.

The client is positioned supine with the head of the bed elevated 30
degrees.
Water that is warmer or cooler than body temperature is infused into
the ear.
A normal response is the onset of vertigo and nystagmus (involuntary
eye movements) within 20 to 30 seconds.
Absent or disconjugate eye movements indicate brainstem damage.
Neurological
Assessment
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PAGE 2011
Assessment of risk
factors

1. Trauma 8. Hypertension
2. Hemorrhage 9. Cigarette smoking
3. Tumors 10. Stress
4. Infection 11. Aging process
5. Toxicity 12. Chemicals, either
6. Metabolic disorders ingestion or environmental
7. Hypoxic conditions exposure
Subjective data

Headaches, dizziness or vertigo, tremors, weakness, incoordination,

numbness or tingling in any area of the body, difficulty speaking or
swallowing, medications being taken, history of seizures, history of
head injury or surgery, exposure to environmental or occupational
hazards (e.g., chemicals, alcohol, drugs)
Objective data:

Assessment of cranial nerves, level of consciousness, pupils, motor

function, cerebellar function, coordination, sensory function, and
reflexes.

Note mental and emotional status, behavior and appearance,

language ability, and intellectual functioning, including memory,
knowledge, abstract thinking, association, and judgment.
Assessment of
cranial nerves
Assessment of
cranial nerves
Assessment of
cranial nerves
Assessment of
cranial nerves
Assessment of
cranial nerves
Level of
consciousness

Assess the client’s behavior to determine level of consciousness

(e.g., alertness, confusion, delirium, unconsciousness, stupor,
coma); assessment becomes increasingly invasive as the client
is less responsive. Use the Glasgow Coma Scale as appropriate
Speak to client.
Assess appropriateness of behavior and conversation.
Lightly touch the client (as culturally appropriate).
Glasgow scale
Assessment of vital
signs

Monitor for blood pressure or pulse changes, which may indicate increased
ICP.

Assessment of temperature

An elevated temperature increases the metabolic rate of the brain.

Rapid elevation may indicate a dysfunction of the hypothalamus or
brainstem.
A slow rise may indicate infection.
Assessment of vital signs:
Respirations

Cheyne-Stokes Neurogenic Hyperventilation

Rhythmic, with periods of apnea Regular rapid and deep sustained
respirations
Metabolic dysfunction, head
injuries, tumors, heart failure, Indicates a dysfunction in the low
strokes, low sodium levels midbrain and middle pons, tumor in
brainstem
Assessment of vital signs:
Respirations

Apneustic Ataxic - Biot

Irregular respirations, Totally irregular in rhythm and
with pauses at the end of depth
inspiration and expiration Dysfunction in the medulla,
Dysfunction in the pons or end of life
vagus nerve
Assessment of
pupils

Unilateral pupil dilation

indicates compression of
cranial nerve III.
Midposition fixed pupils
indicate midbrain injury.
Pinpoint fixed pupils
indicate pontine damage.
Assessment for
posturing

Flexor (decorticate posturing)

Client flexes 1 or both arms on the chest and may extend the legs stiffly.
Flexor posturing indicates a nonfunctioning cortex.
Assessment for
posturing

Extensor (decerebrate posturing)

Client stiffly extends 1 or both arms and possibly the legs.
Extensor posturing indicates a brainstem lesion.
Assessment of
reflexes

Babinski’s Reflex

Dorsiflexion of the big toe and fanning of the other toes; elicited
by firmly stroking the lateral aspect of the sole of the foot
Is a pathological or abnormal reflex in anyone older than 2
years and represents the presence of central nervous system
(CNS) disease
Assessment of
reflexes

Corneal (Blink) Reflex

▪ Involuntary closure of the eyelids in response to stimulation of

the cornea
▪ Loss of the blink reflex indicates a dysfunction of cranial nerve V.
Assessment of
reflexes

Gag Reflex
▪ Contraction of pharyngeal muscle, elicited by touching the back
of the throat
▪ Loss of the gag reflex indicates a dysfunction of cranial nerves IX
and X.
Assessment of
Meningeal Irritation

General Findings
▪ Nausea and vomiting
▪ Irritability ▪ Fever and chills
▪ Nuchal rigidity ▪ Tachycardia
▪ Severe, unrelenting ▪ Photophobia
headaches ▪ Nystagmus
▪ Generalized muscle aches ▪Abnormal pupil reaction
and pains and eye movement
Assessment of
Meningeal Irritation

Brudzinski’s Sign
Involuntary flexion of the
hip and knee when the neck
is passively flexed;
indicates meningeal
irritation
Assessment of
Meningeal Irritation

Kernig’s Sign
Loss of the ability of a supine
client to straighten the leg
completely when it is fully
flexed at the knee and hip;
indicates meningeal irritation
Assessment of
Meningeal Irritation

Motor Response Memory Changes

Hemiparesis, hemiplegia, and Short attention span
decreased muscle tone Personality and behavioral
Cranial nerve dysfunction, changes
especially cranial nerves III, Bewilderment
IV, VI, VII, and VIII
Assessment of the
autonomic system

Sympathetic functions, adrenergic responses

Increased pulse and blood pressure

Dilated pupils
Decreased peristalsis
Increased perspiration
Assessment of the
autonomic system

Parasympathetic function, cholinergic responses

Decreased pulse and blood pressure
Constricted pupils
Increased salivation
Increased peristalsis
Dilated blood vessels
Bladder contraction
The Unconscious
Client

A state of depressed cerebral functioning with unresponsiveness to stimulation

of sensory and motor function. Some causes include head trauma, cerebral
toxins, shock, hemorrhage, tumor, and infection.

1. Unarousable
2. Primitive or no response to painful stimuli
3. Altered respirations
4. Decreased cranial nerve and reflex activity
Care of the
Unconscious Client

▪ Assess patency of the airway and keep airway and emergency equipment
readily available.
▪ Monitor blood pressure, pulse, and heart sounds.
▪ Assess respiratory and circulatory status.
▪ Do not leave the client unattended if unstable.
▪ Maintain a patent airway and ventilation, because a high carbon dioxide
(CO2) level increases intracranial pressure.
▪ Assess lung sounds for the accumulation of secretions; suction as needed.
Care of the
Unconscious Client

▪ Assess neurological status, including level of consciousness, pupillary

reactions, and motor and sensory function, using a coma scale.
▪ Place the client in a semi-Fowler’s position.
▪ Change position of the client every 2 hours, avoiding injury when turning.
▪ Avoid Trendelenburg’s position.
▪ Use side rails unless contraindicated or according to agency protocol.
▪ Assess for edema.
▪ Monitor for dehydration.
Care of the
Unconscious Client

▪ Monitor intake and output and daily weight.

▪ Maintain NPO (nothing by mouth) status until consciousness returns.
▪ Maintain nutrition as prescribed (intravenous or enteral feedings), and
monitor fluid and electrolyte balance (when consciousness returns, check the
gag and swallow reflex before resuming a diet).
▪ Assess bowel sounds.
▪ Monitor elimination patterns.
▪ Monitor for constipation, impaction, and paralytic ileus.
Care of the
Unconscious Client

▪ Maintain urinary output to prevent stasis, infection, and calculus formation.

▪ Monitor the status of skin integrity.
▪ Initiate measures to prevent skin breakdown.
▪ Provide frequent mouth care.
▪ Remove dentures and contact lenses.
▪ Assess the eyes for the presence of a corneal reflex and irritation, and instill
artificial tears or cover the eyes with eye patches.
▪ Monitor drainage from the ears or nose for the presence of cerebrospinal
fluid.
Care of the
Unconscious Client

▪ Assume that the unconscious client can hear.

▪ Avoid restraints.
▪ Initiate seizure precautions if necessary.
▪ Provide range-of-motion exercises to prevent contractures.
▪ Use a footboard or high-topped sneakers to prevent footdrop.
▪ Use splints to prevent wrist deformities.
▪ Initiate physical therapy as appropriate.
Increased
Intracranial
Pressure

Caused by trauma, hemorrhage, growths or tumors,

hydrocephalus, edema, or inflammation.

Can impede circulation to the brain, absorption of CSF, affect the

functioning of nerve cells, and lead to brainstem compression and
death.
Assessment

Altered level of consciousness (the most sensitive and earliest

indication of increasing ICP)
Headache, abnormal respirations
Rise in blood pressure with widening pulse pressure
Slowing of pulse, elevated temperature, vomiting, pupil changes
Late signs: increased systolic blood pressure, widened pulse
pressure, and slowed heart rate, changes in motor function from
weakness to hemiplegia, a positive Babinski’s reflex, decorticate or
decerebrate posturing, seizures.
 Elevate the head of
Interventions the bed 30 - 40º,
avoid Trendelenburg
and flexion of the
neck and hips.

Monitor respiratory status, prevent hypoxia.

Avoid the administration of morphine sulfate (prevent hypoxia)
Maintain mechanical ventilation as prescribed; maintaining the PaCO2 at 30
to 35 mm Hg, will result in vasoconstriction of the cerebral blood vessels,
decreased blood flow, and decreased ICP.
Maintain body temperature, prevent shivering. Decrease stimuli.
Monitor electrolyte levels and acid–base balance
Intake and output: Limit fluid intake to 1200 mL/day.
Avoid straining activities, such as coughing and sneezing, Valsalva’s
maneuver.
Ventriculoperitoneal
Shunt

Diverts cerebrospinal fluid from the ventricles into the peritoneum.

▪ Position the client supine and turn from the back to the
nonoperative side.
▪ Monitor for signs of increasing intracranial pressure resulting
from shunt failure.
▪ Monitor for signs of infection.
Medications

Antiseizure Antipyretics and Muscle Relaxants

Seizures increase metabolic Temperature reduction decreases
requirements and cerebral blood metabolism, cerebral blood flow,
flow and volume, increasing and ICP. Muscle relaxants prevent
intracranial pressure (ICP). shivering.
Medications

Blood Pressure Medication Corticosteroids

May be required to maintain Stabilize the cell membrane, reduce
cerebral perfusion at a normal leakiness of the bloodbrain barrier.
level. Notify the PHCP if the Decrease cerebral edema. Histamine
systolic blood pressure is lower blocker may counteract the excess gastric
than 100 or higher than 150 mm. secretion. Withdrawn slowly.
Medications

Intravenous Fluids Hyperosmotic Agent

Monitored closely because of the Increases intravascular pressure by
risk of promoting additional drawing fluid from the interstitial spaces
cerebral edema and fluid and from the brain cells. Monitor renal
overload. function. Diuresis is expected.
Hyperthermia

Temperature higher than 105° F (40.6° C), which increases the

cerebral metabolism and the risk of hypoxia. Shivering, nausea
and vomiting.

Causes: infection, heat stroke, exposure to high environmental

temperatures, and dysfunction of the thermoregulatory center.
Interventions

Maintain a patent airway. Initiate seizure precautions.

Monitor intake and output and assess the skin and mucous
membranes for signs of dehydration.
Monitor lung sounds. Monitor for dysrhythmias.
Assess peripheral pulses for systemic blood flow.
Induce normothermia with fluids, cool baths, fans, or a
hypothermia blanket.
Inducement of
normothermia

Prevent shivering. Administer medications as prescribed.

Monitor neurological status and cardiac dysrhythmias.
Monitor for infection and respiratory complications because hyperthermia
may mask the signs of infection.
Monitor intake and output and fluid balance.
Prevent trauma to the skin and tissues. Apply lotion to the skin frequently.
Inspect for frostbite if a hypothermia blanket is used.
Traumatic Head
Injury

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.
Hematoma

A collection of blood in the tissues that can occur as a result of a

subarachnoid hemorrhage or an intracerebral hemorrhage.
CSF can be distinguished from other fluids by the presence of
concentric rings (halo sign) when placed on a white sterile
background, such as a gauze pad. CSF also tests positive for
glucose.
Types of head injuries

Open Closed Skull Fractures

Scalp lacerations Concussions Linear
Fractures in the skull Contusions Depressed
Interruption of the Fractures Compound
dura mater Comminuted
Types of head injuries

Concussion Contusion
Jarring of the brain within the Bruising type of injury to the brain
skull; there may or may not tissue. May occur along with other
be a loss of consciousness. neurological injuries (subdural or
extradural collections of blood)
Types of head injuries

Epidural Hematoma Subdural Hematoma

Most serious type, forms rapidly and results Forms slowly and results from a
from arterial bleeding. Forms between the venous bleed. It occurs under the
dura and skull, often associated with dura as a result of tears in the veins
temporary loss of consciousness, followed by crossing the subdural space.
a lucid period that then rapidly progresses to
coma. Is a surgical emergency.
Types of head injuries

Intracerebral Hemorrhage Subarachnoid Hemorrhage

Occurs when a blood vessel Bleeding into the subarachnoid
within the brain ruptures, space. Result of head trauma or
allowing blood to leak inside spontaneously, such as from a
the brain. ruptured cerebral aneurysm.
Assessment:
Hematoma

Depend on the injury, usually result from increased ICP.

Changing neurological signs in the client, changes in level of consciousness
Airway and breathing pattern changes, vital signs changes.
Headache, nausea, and vomiting, visual disturbances, pupillary changes,
and papilledema, nuchal rigidity (not tested until spinal cord injury ruled out)
CSF drainage from the ears or nose
Weakness and paralysis, posturing, decreased sensation or absence of
feeling, reflex activity changes, seizure activity
Interventions

Monitor respiratory status and maintain a patent airway, because

increased carbon dioxide (CO2) levels increase cerebral edema.
Monitor neurological status and vital signs, including temperature.
Monitor for increased ICP. Maintain head elevation to reduce venous
pressure. Prevent neck flexion.
Initiate normothermia measures for increased temperature.
Assess cranial nerve function, reflexes, and motor and sensory
function.
Initiate seizure precautions. Monitor for pain and restlessness.
Interventions

Morphine sulfate or opioids may decrease agitation and control

restlessness caused by pain; administer with caution because it is a
respiratory depressant and may increase ICP.
Monitor for drainage from the nose or ears, because this fluid may be
CSF. Do not attempt to clean the nose, suction, or allow the client to
blow her or his nose if drainage occurs.
Do not clean the ear if drainage is noted, but apply a loose, dry sterile
dressing. Check drainage for the presence of CSF.
Interventions

Notify the PHCP if drainage from the ears or nose is noted and if the
drainage tests positive for CSF.
Instruct the client to avoid coughing.
Monitor for signs of infection, prevent complications of immobility.
Inform the client and family about the possible behavior changes that
may occur, including those that are expected and those that need to be
reported.
Craniotomy

Surgical procedure that involves an incision through the cranium to remove

accumulated blood or a tumor
Complications: increased ICP from cerebral edema, hemorrhage, or
obstruction of the normal flow of CSF.
Hematomas, hypovolemic shock, hydrocephalus, respiratory and neurogenic
complications, pulmonary edema, and wound infections.
Fluid and electrolyte imbalances: diabetes insipidus (antidiuretic hormone)
Stereotactic radiosurgery (SRS): an alternative to traditional surgery, usually
used to treat tumors and arteriovenous malformations.
Preoperative
interventions

Explain the procedure to the client and family.

Prepare to shave the client’s head as prescribed (usually done in
the operating room) and cover the head with an appropriate
covering.
Stabilize the client before surgery.
Postoperative
interventions

▪ Monitor vital signs and neurological status every 30 to 60 minutes.

▪ Monitor for increased intracranial pressure (ICP).
▪ Monitor for decreased level of consciousness, motor weakness or paralysis,
aphasia, visual changes, and personality changes.
▪ Maintain mechanical ventilation and slight hyperventilation for the first 24
to 48 hours as prescribed to prevent increased ICP.
▪ Assess the PHCP’s prescription regarding client positioning.
▪ Avoid extreme hip or neck flexion, and maintain the head in a midline
neutral position
Postoperative
interventions

▪ Provide a quiet environment, monitor the head dressing frequently for signs
of drainage.
▪ Mark any area of drainage at least once each nursing shift for baseline
comparison. Monitor the drain, which may be in place for 24 hours; maintain
suction on the drain as prescribed.
▪ Measure drainage from the drain every 8 hours, and record the amount and
color.
▪ Notify the PHCP if drainage is more than the normal amount of 30 to 50 mL
per shift.
Postoperative
interventions

▪ Record strict measurement of hourly intake and output.

▪ Maintain fluid restriction at 1500 mL/day as prescribed. Electrolyte levels.
▪ Monitor for dysrhythmias (may occur for fluid or electrolyte imbalance.)
▪ Apply ice packs or cool compresses as prescribed; expect periorbital edema
and ecchymosis of 1 or both eyes.
▪ Provide range-of-motion exercises every 8 hours. Place antiembolism stockings
on the client as prescribed.
▪ Administer antiseizure medications, antacids, corticosteroids, and antibiotics as
prescribed.
▪ Administer analgesics such as codeine sulfate or acetaminophen as prescribed
for pain.
 Client Positioning Following Craniotomy

Removal of a Bone Flap for Posterior Fossa Surgery

Decompression

To facilitate brain expansion, the To protect the operative site from

client should be turned from the back pressure and minimize tension on the
to the nonoperative side, but not to suture line, position the client on the
the side on which the operation was side, with a pillow under the head for
performed. support, and not on the back.
 Client Positioning Following Craniotomy

Infratentorial Surgery Supratentorial Surgery

Flat position without head elevation or Head of the bed be elevated at 30

that the head of the bed be elevated degrees to promote venous outflow
at 30 to 45 degrees. through the jugular veins. Do not lower
Do not elevate the head of the bed in the head of the bed in the acute phase
the acute phase of care following of care following surgery without a
surgery without an PHCP’s prescription. PHCP’s prescription.
Cerebral
Aneurysm

Dilation of the walls of a weakened cerebral artery; can lead to rupture

1. Headache and pain

2. Irritability
3. Visual changes
4. Tinnitus
5. Hemiparesis
6. Nuchal rigidity
7. Seizures
Interventions

Maintain a patent airway (suction only with an PHCP’s prescription).

Administer oxygen as prescribed. Monitor vital signs and for hypertension
or dysrhythmias. Avoid taking temperatures via the rectum.

Aneurysm precautions:
Maintain the client on bed rest in a semi-Fowler’s or a side-lying position.
Maintain a darkened room (subdued lighting and avoid direct, bright,
artificial lights) without stimulation (a private room is optimal).
Interventions

Provide a quiet environment. Reading, watching television, and listening to

music are permitted, provided that they do not overstimulate the client.
Limit visitors. Maintain fluid restrictions. Avoid stimulants in the diet.
Prevent any activities that initiate the Valsalva maneuver (straining at stool,
coughing); provide stool softeners to prevent straining. Administer care
gently (such as the bath, back rub, range of motion).
Limit invasive procedures. Maintain normothermia. Prevent hypertension.
Provide sedation and pain control. Administer antiseizure medications.
Provide deep vein thrombosis (DVT) prophylaxis
Seizures
Seizures

Abnormal, sudden, excessive discharge of electrical activity within the brain.

Epilepsy: chronic seizure activity, indicates brain or CNS irritation.
Causes include genetic factors, trauma, tumors, circulatory or metabolic
disorders, toxicity, and infections.
Status epilepticus 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.
 Types of Seizures: Generalized Seizures

Tonic-Clonic Absence
May begin with an aura. Tonic phase involves A brief seizure that lasts seconds, and
the stiffening or rigidity of the muscles of the the individual may or may not lose
arms and legs and usually lasts 10 to 20 consciousness. No loss or change in
seconds, followed by loss of consciousness. muscle tone occurs. Seizures may occur
Clonic phase consists of hyperventilation several times during a day. The victim
and jerking of the extremities and usually appears to be daydreaming. This type of
lasts about 30 seconds. Full recovery may seizure is more common in children.
take several hours.
 Types of Seizures: Generalized Seizures

Myoclonic Atonic or Akinetic (Drop Attacks)

Myoclonic seizures present as a brief An atonic seizure is a sudden momentary
generalized jerking or stiffening of loss of muscle tone. The victim may fall
extremities. The victim may fall from the as a result of the seizure.
seizure.
 Types of Seizures: Partial Seizures

Simple Partial Complex Partial

Produces sensory symptoms accompanied Psychomotor seizure. The area of the
by motor symptoms that are localized or brain most usually involved is the
confined to a specific area. temporal lobe.
The client remains conscious and may Periods of altered behavior of which the
report an aura. client is not aware. The client loses
consciousness for a few seconds.
Assessment

Seizure history, type of seizure

Occurrences before, during, and after the seizure; prodromal signs, such as
mood changes, irritability, and insomnia
Aura: Sensation that warns the client of the impending seizure
Loss of motor activity or bowel and bladder function or loss of consciousness
during the seizure
Occurrences during the postictal state, such as headache, loss of
consciousness, sleepiness, and impaired speech or thinking
 Maintain a patent
Interventions airway, do not force
the jaws open or
place anything in
the client’s mouth

Note time and duration, assess behavior at the onset of the seizure: aura,
change in facial expression, sound or cry.
If standing or sitting, place the client on the floor and protect head and body.
Support airway, breathing, and circulation. Administer oxygen.
Prepare to suction secretions. Turn the client to the side to allow secretions
to drain while maintaining the airway.
Prevent injury during the seizure. Remain with the client.
Do not restrain the client. Loosen restrictive clothing.
 Maintain a patent
Interventions airway, do not force
the jaws open or
place anything in
the client’s mouth

Note the type, character, and progression of movements. Monitor incontinence.

Administer IV medications as prescribed to stop the seizure.
Provide privacy. Monitor behavior following the seizure (state of consciousness,
motor and speech ability.
Instruct about the importance of lifelong medication and the need for follow-up
determination of medication blood levels. Avoid alcohol, excessive stress,
fatigue, and strobe lights.
Encourage the client to contact available community resources.
Wear a MedicAlert bracelet.
 Stroke
(Brain Attack)
Stroke

Sudden focal neurological deficit, caused by cerebrovascular disease.

Cerebral anoxia lasting longer than 10 minutes causes cerebral
infarction with irreversible change.
Cerebral edema and congestion cause further dysfunction.
Diagnosis is determined by a CT scan, electroencephalography,
cerebral arteriography, and MRI. In most facilities, the type of stroke
needs to be determined within a certain time frame after arrival in
order for timely treatment to be initiated.
Stroke

Transient ischemic attack may be a warning sign of an impending stroke. The

permanent disability cannot be determined until cerebral edema subsides.
The order in which function may return is facial, swallowing, lower limbs,
speech, and arms.
Carotid endarterectomy: stroke management; it is targeted at stroke
prevention, especially in clients with symptomatic carotid stenosis.
The NINDS developed the Know Stroke: Know the Signs. Act in Time campaign
devised to help educate the public about the symptoms of stroke and the
importance of getting to the hospital quickly
Causes

Thrombosis, embolism: classified as ischemic strokes.

Hemorrhage from rupture of a vessel: classified as a hemorrhagic
stroke
Manifestations of different types of stroke are similar and, therefore it
is critical to determine the type of stroke occurring; the type cannot
be determined solely based on manifestations, and the correct and
appropriate treatment for the stroke type must be initiated.
Risk factors

Atherosclerosis
Hypertension
Anticoagulation therapy
Diabetes mellitus
Stress
Obesity
Oral contraceptives
Assessment

Findings depend on the area of the brain affected. Lesions in the cerebral
hemisphere result in manifestations on the contralateral side.

Airway patency is always a priority. Pulse (slow and bounding). Respirations

(Cheyne-Stokes), blood pressure (hypertension)
Headache, nausea, and vomiting, facial drooping, nuchal rigidity
Visual changes, ataxia, dysarthria, dysphagia, speech changes
Decreased sensation to pressure, heat, and cold, bowel and bladder
dysfunctions paralysis
 Clinical Manifestations Based on Type

Thrombotic Stroke Embolic Stroke Hemorrhagic Stroke

Typically, no decreased Sudden, severe Sudden onset of
level of consciousness symptoms. Warning symptoms
within the first 24 hours. signs are less common. Symptoms progress
Symptoms get Client remains over minutes to hours
progressively worse as conscious and may due to ongoing bleeding
the infarction and have a headache.
edema increase.
 Clinical Manifestations Based on Type

Agnosia Apraxia Hemianopsia

Inability to recognize Dyspraxia if the Blindness in half the
familiar objects or persons condition is mild. Loss of visual field
ability to execute or
carry out skilled
Neglect Syndrome movements or gestures, Proprioception Alterations
despite having the
Client unaware of the desire and physical With visual problems, the
existence of her or his ability to perform them client must turn the head to
paralyzed side scan the complete range of
vision
Aphasia

Expressive: Broca’s area of the frontal brain. The client

understands what is said but is unable to communicate verbally
Receptive: Wernicke’s area in the temporoparietal area. The
client is unable to understand the spoken and often the written
word.
Global or mixed: Language dysfunction occurs in expression and
reception.
Interventions
for aphasia

Provide repetitive directions.

Break tasks down to 1 step at a time.
Repeat names of objects frequently used.
Allow time for the client to communicate.
Use a picture board, communication board, or computer
technology.
Interventions:
acute phase of
stroke
Maintain a patent airway and administer oxygen as prescribed.
Monitor vital signs, blood pressure of 150/100 mm Hg is maintained to
ensure cerebral perfusion.
Suction secretions to prevent aspiration as prescribed, but never suction
nasally or for longer than 10 seconds to prevent increased ICP.
Monitor for increased ICP, more risk during first 72 hours following the
stroke.
Position the client on the side, with the head of the bed elevated 15 to 30º
Monitor level of consciousness, pupillary response, motor and sensory
response, cranial nerve function, and reflexes.
Interventions:
acute phase of
stroke

Maintain a quiet environment.

Insert a urinary catheter as prescribed.
Administer intravenous fluids as prescribed.
Maintain fluid and electrolyte balance.
Prepare to administer anticoagulants, antiplatelets, diuretics,
antihypertensives, and antiseizure medications as prescribed depending
on the type of stroke that has been diagnosed.
Establish a form of communication.
Interventions:
postacute phase

Position the client 2 hours on the unaffected side and 20 minutes on

the affected side; the prone position may also be prescribed.
Skin, mouth, and eye care. Perform passive range-of-motion
exercises.
Antiembolism stockings on the client; remove daily to check skin.
Monitor the gag reflex and ability to swallow. Provide sips of fluids
and slowly advance diet to foods that are easy to chew and swallow.
Interventions:
postacute phase

Soft and semisoft foods and flavored, cool or warm, thickened fluids
rather than thin; speech therapists may do swallow studies to
recommend consistency of food and fluids.
When the client is eating, position the client sitting in a chair or sitting
up in bed, with the head and neck positioned slightly forward and
flexed.
Place food in the back of the mouth on the unaffected side to prevent
trapping of food in the affected cheek.
Interventions:
chronic phase

Neglect syndrome: Client is unaware of the existence of her or his

paralyzed side (unilateral neglect), risk for injury. Teach the client to
touch and use both sides of the body.
Hemianopsia: Blindness in half of the visual field. Encourage to turn the
head to scan the complete range of vision.
Approach the client from the unaffected side.
Place the client’s personal objects within the visual field. Provide eye
care for visual deficits. Place a patch over the affected eye if the client
has diplopia.
Interventions:
chronic phase

Increase mobility as tolerated. Encourage fluid intake, high-fiber diet.

Administer stool softeners as prescribed. Encourage the client to
express her or his feelings, independence in activities of daily living.
Assess the need for assistive devices (cane, walker, splint, or braces)
Teach transfer technique from bed to chair and from chair to bed.
Provide gait training. Initiate physical and occupational therapy.
Refer client to a speech and language pathologist, community
resources.
Multiple
Sclerosis
Multiple
Sclerosis

Chronic, progressive, noncontagious, degenerative disease of the CNS

characterized by demyelinization of the neurons.
Occurs between the ages of 20 and 40 years and consists of periods of
remissions and exacerbations.
Causes unknown, but the disease is thought to be the result of an
autoimmune response or viral infection.
Precipitating factors: pregnancy, fatigue, stress, infection, and trauma.
Electroencephalographic findings are abnormal.
Lumbar puncture: increased gamma globulin level, but the serum
globulin level is normal.
Assessment

Fatigue and weakness, ataxia and vertigo

Tremors and spasticity of the lower extremities, paresthesias
Blurred vision, diplopia, and transient blindness, nystagmus, dysphasia
Decreased perception to pain, touch, and temperature
Bladder and bowel disturbances (urgency, retention, incontinence)
Abnormal reflexes, including hyperreflexia, absent, reflexes, positive
Babinski’s reflex
Emotional changes (apathy, euphoria, irritability, depression)
Memory changes and confusion
Interventions

Provide energy conservation measures during exacerbation.

Protect the client from injury by providing safety measures.
Place an eye patch on the eye for diplopia.
Monitor for potential complications such as urinary tract infections,
calculi, pressure ulcers, respiratory tract infections, and contractures.
Promote regular elimination by bladder and bowel training.
Encourage independence. assist the client to establish a regular exercise
and rest program and to balance moderate activity with rest periods.
Interventions

Assess the need for and provide assistive devices. Initiate physical and
speech therapy. Instruct the client to avoid fatigue, stress, infection,
overheating, and chilling.
Increase fluid intake and eat a balanced diet, including low-fat, high-
fiber foods and foods high in potassium.
Instruct the client in safety measures related to sensory loss, such as
regulating the temperature of bath water and avoiding heating pads.
Safety measures related to motor loss.
Self-administration of medications.
Myasthenia
Gravis
Myasthenia
Gravis

Neuromuscular disease characterized by considerable weakness and

abnormal fatigue of the voluntary muscles
A defect in the transmission of nerve impulses at the myoneural
junction.
Causes include insufficient secretion of acetylcholine, excessive
secretion of cholinesterase, and unresponsiveness of the muscle
fibers to acetylcholine.
Assessment

Weakness and fatigue

Difficulty chewing and swallowing
Dysphagia
Ptosis, diplopia
Weak, hoarse voice
Difficulty breathing
Diminished breath sounds
Respiratory paralysis and failure
Interventions

Monitor respiratory status and ability to cough and deep-breathe

adequately. Monitor for respiratory failure.
Maintain suctioning and emergency equipment at the bedside.
Monitor vital signs.
Monitor speech and swallowing abilities to prevent aspiration.
Encourage the client to sit up when eating.
Assess muscle status. Instruct the client to conserve strength.
Interventions

Plan short activities that coincide with times of maximal muscle

strength.
Monitor for myasthenic and cholinergic crises.
Administer anticholinesterase medications as prescribed.
Instruct the client to avoid stress, infection, fatigue, and over-the-
counter medications.
Instruct the client to wear a MedicAlert bracelet.
Myasthenic crisis

Acute exacerbation of the disease, caused by a rapid, unrecognized

progression of the disease, inadequate amount of medication, infection,
fatigue, or stress.

Increased pulse, respirations, and blood pressure

Dyspnea, anoxia, and cyanosis, bowel and bladder incontinence,
decreased urine output, absent cough and swallow reflex
Increase anticholinesterase medication, as prescribed.
Cholinergic crisis

Caused by overmedication with anticholinesterase.

Abdominal cramps, nausea, vomiting, and diarrhea, blurred vision,

pallor, facial muscle twitching, hypotension, pupillary miosis
Withhold anticholinesterase medication. Prepare to administer the
antidote, atropine sulfate, if prescribed.
Edrophonium
(Tensilon) test

This test is performed to diagnose myasthenia gravis and to

differentiate between myasthenic crisis and cholinergic crisis.
The test places the client at risk for ventricular fibrillation and cardiac
arrest; emergency equipment needs to be available.
Edrophonium injection is administered to the client.
Positive: Client shows improvement in muscle strength after the
administration of edrophonium.
Negative for myasthenia gravis: Client shows no improvement in
muscle strength, and strength may even deteriorate after injection.
Edrophonium
(Tensilon) test

To differentiate crisis

Myasthenic crisis: Edrophonium is administered and, if strength

improves, the client needs more medication.
Cholinergic crisis: Edrophonium is administered and, if weakness is
more severe, the client is overmedicated; prepare to administer
atropine sulfate, the antidote, as prescribed.
Parkinson’s
Disease
Parkinson’s
Disease

Degenerative disease caused by the depletion of dopamine, which

interferes with the inhibition of excitatory impulses, resulting in a
dysfunction of the extrapyramidal system.
It is a slow, progressive disease that results in a crippling disability.
The debilitation can result in falls, self-care deficits, failure of body
systems, and depression.
Mental deterioration occurs late in the disease.
Assessment

Bradykinesia, sluggishness of physical and mental responses

Akinesia, monotonous speech, handwriting becomes smaller
Tremors in hands and fingers at rest (pill rolling), increasing when
fatigued and decreasing with purposeful activity or sleep
Rigidity with jerky movements, restlessness and pacing
Blank facial expression; mask-like faces, drooling
Difficulty swallowing and speaking, loss of coordination and balance
Shuffling steps, stooped position, and propulsive gait
Interventions

Assess neurological status, ability to swallow and chew.

Provide high-calorie, protein, fiber soft diet; small, frequent feedings.
Increase fluid intake to 2000 mL/day. monitor for constipation.
Promote independence along with safety measures.
Avoid rushing the client with activities.
Assist with ambulation and provide assistive devices.
Instruct the client to rock back and forth to initiate movement, wear
low-heeled shoes, lift the feet when walking, avoid prolonged sitting.
Interventions

Provide a firm mattress and position the client prone, without a pillow, to
facilitate proper posture.
Instruct in proper posture by teaching to hold the hands behind the back
to keep the spine and neck erect.
Promote physical therapy and rehabilitation. Administer antiparkinsonian
medications to increase the level of dopamine.
Avoid foods high in vitamin B6, because they block the effects of
antiparkinsonian medications.
Avoid IMAOS, they will precipitate hypertensive crisis.
Trigeminal
Neuralgia
Trigeminal
Neuralgia

A sensory disorder of the trigeminal (fifth cranial) nerve.

Severe pain on the lips, gums, or nose, or across the cheeks.
Situations that stimulate symptoms include cold, washing the face,
chewing, or food or fluids of extreme temperatures.
Instruct the client to avoid hot or cold foods and fluids, small feedings of
liquid and soft foods.
Chew food on the unaffected side, administer medications as prescribed
Surgical
interventions

1. Microvascular decompression: Surgical relocation of the artery that

compresses the trigeminal nerve as it enters the pons, which may relieve pain
without compromising facial sensation
2. Radiofrequency waveforms: Create lesions that provide relief of pain without
compromising touch or motor function
3. Rhizotomy: Resection of the root of the nerve to relieve pain
4. Glycerol injection: Destroys the myelinated fibers of the trigeminal nerve
(may take up to 3 weeks for pain relief to occur)
Bell’s Palsy
(Facial
Paralysis)
Bell’s Palsy
(Facial Paralysis)

Lower motor neuron lesion of cranial nerve VII that may result from infection,
trauma, hemorrhage, meningitis, or tumor. Paralysis of 1 side of the face. Recovery
usually occurs in a few weeks, without residual effects.

Flaccid facial muscles

Inability to raise the eyebrows, frown, smile, close the eyelids, or puff out the
cheeks
Upward movement of the eye when attempting to close the eyelid
Loss of taste
Interventions

Encourage facial exercises to prevent the loss of muscle tone (a face

sling may be prescribed to prevent stretching of weak muscles).
Protect the eyes from dryness and prevent injury.
Promote frequent oral care.
Instruct the client to chew on the unaffected side.
Guillain-Barré
Syndrome
Guillain-Barré
Syndrome

An acute infectious neuronitis of the cranial and peripheral nerves. The immune
system destroys the myelin sheath. Usually preceded by a mild upper respiratory
infection or gastroenteritis. The recovery is a slow process and can take years.

Paresthesias, pain and/or hypersensitivity such as with the weight of bed

sheets or other items touching the body. Weakness of lower extremities
Gradual progressive weakness of the upper extremities and facial muscles,
possible progression to respiratory failure. Cardiac dysrhythmias, CSF that
reveals an elevated protein level, abnormal electroencephalogram
Interventions

Care is directed toward the treatment of symptoms, including pain

management.
Monitor respiratory status closely.
Provide respiratory treatments.
Prepare to initiate respiratory support.
Monitor cardiac status.
Assess for complications of immobility.
Provide the client and family with support.
Amyotrophic
Lateral
Sclerosis
Amyotrophic
Lateral Sclerosis

Progressive degenerative disease involving the motor system. Sensory and

autonomic systems are not involved, mental status changes do not result from
the disease.
Cause: excess of glutamate, a chemical responsible for relaying messages
between the motor neurons.
Muscle weakness and atrophy develop until a flaccid tetraplegia develops.
Respiratory muscles become affected, leading to respiratory compromise,
pneumonia, and death. No cure is known, and the treatment is symptomatic.
Assessment

Respiratory difficulty
Fatigue while talking
Muscle weakness and atrophy
Tongue atrophy
Dysphagia
Weakness of the hands and arms
Fasciculations of the face
Nasal quality of speech
Dysarthria
Interventions

Care is directed toward the treatment of symptoms.

Monitor respiratory status and institute measures to prevent aspiration.
Provide respiratory treatments.
Prepare to initiate respiratory support.
Assess for complications of immobility.
Address advance directives as appropriate.
Provide the client and family with psychosocial support.
Encephalitis
Encephalitis

An inflammation of the brain parenchyma and often of the meninges.

It affects the cerebrum, brainstem, and cerebellum.
It most often is caused by a viral agent, although bacteria, fungi, or
parasites also may be involved.
Viral encephalitis is almost always preceded by a viral infection.
Transmission

Arboviruses can be transmitted to human beings through the bite of an

infected mosquito or tick.
Echovirus, coxsackievirus, poliovirus, herpes zoster virus, and viruses
that cause mumps and chickenpox.
Herpes simplex type 1 virus can cause viral encephalitis.
The organism that causes amebic meningoencephalitis can enter the
nasal mucosa of persons swimming in warm fresh water, such as a
pond or lake.
Assessment

Cold sores, lesions, or ulcerations of the oral cavity

History of insect bites and swimming in fresh water
Exposure to infectious diseases
Travel to areas where the disease is prevalent, fever
Nausea and vomiting, nuchal rigidity
Changes in level of consciousness and mental status
Signs of increased ICP
Motor dysfunction and focal neurological deficits
Interventions

Monitor vital and neurological signs, Glasgow Coma Scale

Assess for mental status, personality and behavior changes.
Assess for signs of increased ICP, nuchal rigidity and a positive Kernig’s
sign or Brudzinski’s sign.
Assist the client to turn, cough, and deep-breathe frequently.
Elevate the head of the bed 30 to 45 degrees.
Assess for muscle and neurological deficits.
Administer acyclovir as prescribed (herpes encephalitis).
Initiate rehabilitation as needed.
Meningitis
Meningitis

Inflammation of the arachnoid and pia mater

Caused by an infection.
Predisposing factors: skull fractures, brain or spinal surgery, sinus or upper
respiratory infections, the use of nasal sprays, and a compromised
immune system.
CSF is analyzed to determine the diagnosis and type of meningitis. In
meningitis, CSF is cloudy, with increased protein, increased white blood
cells, and decreased glucose counts.
Transmission is by direct contact, including droplet spread.
Assessment

Mild lethargy
Photophobia
Deterioration in the level of consciousness
Signs of meningeal irritation, such as nuchal rigidity and a positive
Kernig’s sign and Brudzinski’s sign
Red, macular rash with meningococcal meningitis
Abdominal and chest pain with viral meningitis
Interventions

Monitor vital and neurological signs, signs of increased ICP.

Initiate seizure precautions, monitor for seizure activity.
Monitor for signs of meningeal irritation.
Assess peripheral vascular status (septic emboli may block circulation).
Maintain urine and stool precautions with viral meningitis.
Maintain respiratory isolation for the client with pneumococcal meningitis.
Elevate the head of the bed 30 degrees, avoid neck flexion and extreme hip
flexion.
Prevent stimulation and restrict visitors.
Administer analgesics and/or antibiotics as prescribed.