Module 3: Caring for Clients with Common Neurological

Health Challenges
Introduction (I) - Part A
Overview
Registered nurses in many types of practice settings encounter patients with altered neurologic
function. Disorders of the nervous system can occur at any time during the lifespan and can vary
from mild, self-limiting symptoms to devastating, life-threatening disorders.

In Module 3 we will explore the role of the registered nurse (RN) when providing safe and
competent care for persons experiencing common neurological health challenges. Specifically,
this module will focus on the role of the RN associated with the following:
 Assessment of the nervous system.
 Altered LOC
 Increased ICP
 Headaches
 Seizures
 Epilepsy
 Cerebrovascular disorders - Stroke
 Delirium
 Alzheimer’s disease and other dementias

Learning Outcomes
 Review the major structures and function of the nervous system.
 Summarize the role of the registered nurse when performing a neurological system health
assessment and physical examination.
 Explain the role of the registered nurse when caring for a client having common
diagnostic studies associated with the nervous system.
 Review the pathophysiology of common health challenges involving the nervous system.
 Formulate a plan of nursing care, using the nursing process, for persons experiencing
common neurological health challenges.
 Examine the role of the registered nurse when providing client education for persons
experiencing common neurological problems.
 Discuss the mechanism of action, indications, dosage forms, application techniques,
adverse effects, cautions, contraindications, and drug interactions of selected drugs
relevant to the health challenges in this module.
Required Readings
Lewis text
 Chapter 58 – Nervous System
 Chapter 59 – Acute Intracranial Problems
 pp. 1474-1486
 Chapter 60 – Stroke
 Chapter 61 – Chronic Neurological Problems
 pp. 1534-1546
 Chapter 62 – Delirium, Alzheimer’s Disease, and Other Dementias.
Jarvis text
 Chapter 25 – Neurological System

Lilley text
 Chapter 15 – Antiepileptic Drugs
 Chapter 21 – Cholinergic Drugs
 pp. 409-417
 Chapter 27 – Coagulation Modifier Drugs
 pp. 529-531
Other
Registered Nurses’ Association of Ontario. (2011). Clinical best practice guideline: Stroke
assessment across the continuum of care. Toronto, ON: Author. Retrieved
from https://rnao.ca/sites/rnao-ca/files/Stroke_with_merged_supplement_sticker_2012.pdf

Registered Nurses’ Association of Ontario. (2016). Clinical best practice guideline: Delirium,
dementia, and depression in older adults (2nd ed.). Toronto, ON: Author. Retrieved
from https://rnao.ca/sites/rnao-ca/files/bpg/RNAO_Delirium_Dementia_Depression_Older_Adul
ts_Assessment_and_Care.pdf

Library Streaming Videos

Please find below the link to log in to the Nipissing University Library. Following this step,
students will be able to view the available Health Sciences e-resources, specifically the library
streaming videos. After selecting the URL provided, scroll down to the ‘Jarvis Physical
Examination and Health Assessment Series’ and/ or the ‘Taylor’s Video Guide to Clinical
Nursing Skills’ to view the applicable video assigned for the weekly module.
Link: https://secure-nucc-eclibrary-ca.roxy.nipissingu.ca/site/content/health-sciences

Jarvis Physical Examination and Health Assessment Series:

 Part 9, Neurologic system: Motor system and reflexes.
 Part 10, Neurologic system: Cranial nerves and sensory system.

Taylor’s Video Guide to Clinical Nursing Skills:

 Module 2- Physical Assessment- Chapter 15, Assessing the Musculoskeletal and
Neurological Systems.

Concepts and Theory (C)- Part A

The module ‘Concepts and Theory Worksheet’ outlines the main concepts and important theory
for each module. The worksheet below can be filled in when completing the required readings
and saved as a study resource for the NSGD 2117 course, future clinical courses, and as well
when preparing to write the final NCLEX-RN exam. There are no requirements for learners to
submit the module concepts and theory worksheet.

Concepts and Theory Worksheet

1. Review the major structures and function of the nervous system.
The human nervous system is a highly specialized system responsible for the control and
integration of the body's many activities. The nervous system has two main divisions: the central
nervous system (CNS) and the peripheral nervous system (PNS). The CNS consists of the brain,
the spinal cord, and cranial nerves I and II. The PNS consists of cranial nerves III to XII, the
spinal nerves, and the peripheral components of the autonomic nervous system (ANS).
The major structural components of the CNS are the cerebrum (cerebral hemispheres), brain
stem, cerebellum, and spinal cord. The PNS includes all of the neuronal structures that lie outside
the CNS. It consists of the spinal and cranial nerves, their associated ganglia (groupings of cell
bodies), and portions of the ANS.

2. Summarize the role of the registered nurse when performing a neurological system
health assessment and physical examination.
 Mental Status: Assessment of mental status (cerebral functioning) gives an indication of
how the patient is functioning. It involves determination of complex and high-level
cerebral functions that are governed by many areas of the cerebral cortex. Much of the
mental status examination can be conducted during the routine history and may not need
to be evaluated further. For example, language and memory can be assessed when the
patient is asked for details of the illness and significant past events. The patient's cultural
and educational background should be considered when mental status is evaluated.
 Assess level of consciousness: This is the most sensitive indicator of changes in
neurological status. LOC concerns arousal and wakefulness and the ability to respond to
the environment. The Glasgow Coma Scale is often used to assess a patient's response to
stimuli.
 General appearance and behaviour: This component includes motor activity, body
posture, dress and hygiene, facial expression, and speech.
 Cognition: The nurse should note the patient's orientation to time, place, person, and
situation. Further assessment of memory, intellectual ability, insight, judgement, problem
solving, and calculation may be warranted. The nurse should consider whether the
patient's plans and goals match the patient's physical and mental capabilities. Problems
with memory may have implications for retention of new information, and impaired
judgement and insight may jeopardize the patient's safety.
 Mood and affect: The nurse should note restlessness, agitation, anger, depression, or
euphoria and the appropriateness of these states. The nurse should also note whether the
patient's affect is appropriate for the situation.
 Thought content: The nurse should note the presence or report of illusions, hallucinations,
delusions, or paranoia.
 Cranial Nerves:

Assessing Cranial Nerve Function

Cranial Nerve Nursing Clinical Examination

Olfactory After determining that both nostrils are patent, the olfactory nerve (CN I)
is tested by asking the patient to close one nostril, close both eyes, and
sniff from a bottle containing coffee, spice, soap, or some other readily
recognized odour. The same procedure is done for the other nostril. In
general, olfaction is not tested unless the patient has some disturbance
 with smell.

Optic Visual fields and visual acuity are assessed to test the function of the
optic nerve (CN II). Visual fields are assessed by gross confrontation. The
nurse, positioned directly opposite the patient, asks the patient to close
one eye, look directly at the bridge of the nurse's nose, and indicate when
an object (finger, pencil tip, head of pin) presented from the periphery of
each of the four visual field quadrants becomes visible (Figure 58-16).
The same test is repeated for the other eye. To test visual acuity, the
patient reads a Snellen chart from 6 metres away. The nurse records the
number of the lowest line that the patient can read accurately. The patient
who wears glasses should wear them during testing unless they are used
only for reading. The eyes should be tested individually and together.

Oculomotor The patient is asked to keep the head steady and to follow the nurse's
(tested together finger only with the eyes. The nurse should keep the finger back about 30
with Trochlear cm so that the patient can focus on it comfortably. The nurse moves the
and Abducens) finger to each of the six positions (right and up, right, right and down, left
and up, left, left and down), holds it momentarily, and then moves back to
the centre. To test pupillary constriction, the nurse shines a light into the
pupil of one eye and looks for ipsilateral (same side) constriction of the
same pupil and contralateral (consensual) constriction of the opposite
eye. To test convergence and accommodation, the patient focuses on the
nurse's finger as it moves toward the patient's nose. Another function of
the oculomotor nerve is to keep the eyelid open.

Trochlear Same as Oculomotor

Trigeminal To test the sensory component of the trigeminal nerve (CN V), the patient
is asked to identify light touch (cotton) and pinprick in each of the three
divisions (ophthalmic, maxillary, and mandibular) of the nerve on both
sides of the face. The patient's eyes should be closed during this part of
the examination. To test the motor component, the patient clenches the
teeth, and the masseter muscles, just above the mandibular angle, are
palpated. The corneal reflex test, in which CN V and CN VII are
evaluated simultaneously, involves applying a cotton wisp strand to the
cornea. The sensory component of this reflex (corneal sensation) is
innervated by the ophthalmic division of CN V. The motor component
(eye blink) is innervated by the facial nerve (CN VII). This reflex is not
normally tested in patients who are awake and alert because other tests
are used to evaluate these two nerves. However, for patients with a
decreased level of consciousness, the corneal reflex test provides an
opportunity to evaluate the integrity of the brain stem at the level of the
 pons because the fibres of CN V and CN VII have connections in this
area.

Abducens Same as Oculomotor

Facial The facial nerve (CN VII) innervates the muscles of facial expression. To
test its function, the patient raises the eyebrows, closes the eyes tightly,
purses the lips, draws back the corners of the mouth in an exaggerated
smile, and frowns. The nurse should note any asymmetry in the facial
movements because this can indicate damage to the facial nerve.
Although taste discrimination of salt and sugar in the anterior two-thirds
of the tongue is a function of this nerve, it is not routinely tested unless a
peripheral nerve lesion is suspected.

Acoustic To test the cochlear portion of the acoustic (vestibulo-cochlear) nerve

(CN VIII), the patient closes the eyes and indicates when a ticking watch
or the rustling of the nurse's fingertips is heard as the stimulus is brought
closer to the patient's ear. Each ear is tested individually, and the distance
from the patient's ear to the sound source when first heard is recorded.
This test identifies only gross deficits in hearing. For more precise
assessment of hearing, an audiometer (or tuning forks) can be used.

Glossopharyngeal The glossopharyngeal nerve (CN IX) is primarily sensory. In the gag
(tested together reflex (bilateral contraction of the palatal muscles initiated by stroking or
with Vagus) touching either side of the posterior pharynx or soft palate with a tongue
blade), the sensory component is mediated by CN IX and the major motor
component by the vagus nerve (CN X). It is important to assess the gag
reflex in patients who have a decreased level of consciousness, a brain
stem lesion, or a disease involving the throat musculature. If the reflex is
weak or absent, the patient may be at risk of aspirating food or secretions.
The strength and efficiency of swallowing are important to test in these
patients for the same reason. In another test for an awake, cooperative
patient, the patient phonates by saying “ah” and the nurse notes the
bilateral symmetry of elevation of the soft palate. Any asymmetry can
indicate weakness or paralysis. To assess swallowing, the nurse's hands
are held lightly on either side of the patient's throat while the patient
swallows.

Vagus Same as Glossopharyngeal

Spinal Accessory To test the spinal accessory nerve (CN XI), the patient shrugs the
shoulders against resistance and turns the head to either side against
 resistance. The contraction of the sternocleidomastoid and trapezius
muscles should be smooth. Symmetry, atrophy, or fasciculation of the
muscle should also be noted. A fasciculation is a small, local involuntary
muscular contraction.

Hypoglossal To test the hypoglossal nerve (CN XII), the patient sticks out the tongue.
It should protrude in the midline. The patient should also be able to push
the tongue to either side against the resistance of a tongue blade. Again,
any asymmetry, atrophy, or fasciculation should be noted.

 Motor Function: Muscle size - inspect all muscle groups for size. Compare the right side
with the left. Muscle groups should be within the normal size limits for age and
symmetric bilaterally, strength - To test strength, the patient pushes and pulls against the
resistance of the nurse's arm as it opposes flexion and extension of the patient's muscle.,
tone -To test tone, the limbs are passively moved through their range of motion; there
should be a slight resistance to these movements., Gait & Balance - A good screening
test for both balance and muscle strength is to observe the patient's stance (posture while
standing) and gait. The nurse should note the pace and rhythm of the gait and observe the
arm swing., Coordination - Coordination can be easily tested in several ways. In the
finger-to-nose test, the patient alternately touches the nose with the index finger and then
touches the nurse's finger. The nurse repositions the finger while the patient is touching
the nose so that the patient must adjust to a new distance each time the nurse's finger is
touched.
 Sensory Function: Superficial pain -Pain is tested by touching the skin with the sharp
end of a safety pin. This stimulus is irregularly alternated with a simple touch stimulus
with the dull end of the pin to determine whether the patient can distinguish the two
stimuli., temperature - The sensation of temperature is tested by applying tubes of warm
and cold water to the skin and asking the patient to identify the stimuli with the eyes
closed., light touch - The sensation of light touch is usually tested first. The nurse gently
strokes each of the four extremities with a cotton wisp and asks the patient to indicate
when the stimulus is felt by saying “touch.”, Vibration -To assess vibration sense, a
vibrating C128 tuning fork is applied to the patient's fingernails and the bony
prominences of the hands, the legs, and the feet while the patient's eyes are closed. The
nurse asks the patient whether the vibration or “buzz” is felt. The nurse then asks the
patient to indicate when the vibration ceases. The nurse stops the vibration with the hand
as desired., Position - To assess position sense, the nurse's thumb and forefinger are
placed on either side of the patient's forefinger or great toe and gently move the patient's
digit up or down. The patient is asked to indicate the direction in which the digit is
moved. Another test of position sense of the lower extremities is the Romberg test. The
patient is asked to stand with the feet together and then to close his or her eyes. If the
patient is able to maintain balance with the eyes open but sways or falls with the eyes
closed (i.e., a positive result of the Romberg test), disease may be present in the posterior
columns of the spinal cord or the cerebellum. It is important for the nurse to ensure the
patient's safety during this test., Graphesthesia - To test graphesthesia (ability to feel
 writing on skin), the patient is asked to identify numbers traced on the palm of the hands.,
Stereognosis -To test stereognosis (ability to perceive the form and nature of objects), the
patient is asked to identify the size and shape of easily recognized objects (e.g., coins,
keys, a safety pin) placed in the hands., To evaluate sensory extinction or inattention, the
nurse touches both sides of the patient's body simultaneously. An abnormal response
occurs when the patient perceives the stimulus only on one side. The other stimulus is
“extinguished.” Extinction - Simultaneously touch both sides of the body at the same
point. Ask the person to state how many sensations are felt and where they are. Normally
both sensations are felt. Point Location - Touch the skin and withdraw the stimulus
promptly. Tell the person, “Put your finger where I touched you.” You can perform this
test simultaneously with light touch sensation.
 Reflexes: Tendons attached to skeletal muscles have receptors that are sensitive to stretch.
A reflex contraction of the skeletal muscle occurs when the tendon is stretched. A simple
muscle stretch reflex is initiated by briskly tapping the tendon of a stretched muscle,
usually with a reflex hammer.
 Pupillary Response: PERRLA. Note the size, shape, and symmetry of both pupils. Shine
a light into each pupil, and note the direct and consensual light reflex. Both pupils should
constrict briskly.
 Vital Signs: Define Cushing's triad - consisting of increasing systolic pressure (widening
pulse pressure), bradycardia with a full and bounding pulse, and irregular respiratory
pattern, may be present but often do not appear until ICP has been increased for some
time or suddenly and markedly increases (e.g., head trauma). Cushing reflex. Measure the
temperature, pulse, respiration, and BP as often as the person's condition warrants.
Although they are vital to the overall assessment of the critically ill person, pulse and BP
are notoriously unreliable parameters of CNS deficit. Any changes are late consequences
of rising intracranial pressure.
 Glasgow Coma Scale: Quantitative tool to assess level of consciousness. The scale is
divided into three areas: eye opening, verbal response, and motor response. Each area is
rated separately, and a number is given for the person's best response. The three numbers
are added; the total score reflects the functional level of the brain. A fully alert, normal
person has a score of 15, whereas a score of 7 or less reflects coma.
 Abnormal posturing: Decorticate posture consists of internal rotation and adduction of
the arms, with flexion of elbows, wrists, and fingers as a result of interruption of
voluntary motor tracts. Extension of the legs may also be seen. A decerebrate posture
may indicate more serious damage and results from disruption of motor fibres in the
midbrain and brain stem. In this position, the arms are stiffly extended, adducted, and
hyper pronated. There is also hyperextension of the legs, with plantar flexion of the feet.
3. Construct questions independently that would gather the following subjective data when
taking a client history:
 Headaches - Any unusually frequent or severe headaches? When did they start? How
often do they occur? Where in your head do you feel the headaches? Do they seem to be
associated with anything?
 Head Injury - Ever had any head injury? Please describe. What part of your head was hit?
• Did you have a loss of consciousness? For how long? Do you remember details of the
event?
 Dizziness - Ever feel light-headed, a swimming sensation, like feeling faint? When have
you noticed this? How often does it occur? Does it occur with activity, change in
position?
 Vertigo - Do you ever feel a sensation called vertigo, a rotational spinning sensation?
(NOTE: Distinguish vertigo from dizziness.) Do you feel as if the room spins (objective
vertigo)? Or do you feel that you are spinning (subjective vertigo)? Did this come on
suddenly or gradually?
 Seizures - Ever had convulsions? When did they start? How often do they occur?
• Course and duration—When a seizure starts, do you have any warning sign? What type
of sign?
• Motor activity—Where in your body do the seizures begin? Do they travel through your
body? On one side or both? Does your muscle tone seem tense or limp?
• Any associated signs—Color change in face or lips, loss of consciousness (for how
long), automatisms (eyelid fluttering, eye rolling, lip smacking), incontinence?
• Postictal phase—After the seizure, are you told that you spent time sleeping or had any
confusion? Do you have weakness, headache, or muscle ache?
• Precipitating factors—Does anything seem to bring on the seizures: activity,
discontinuing medication, fatigue, stress? Do you take any medication?
• Coping strategies—How have the seizures affected daily life, occupation?
 Tremors - Any shakes or tremors in the hands or face? When did they start? • Do they
seem to grow worse with anxiety, intention, or rest? • Are they relieved with rest, activity,
alcohol? Do they affect daily activities?
 Weakness - Any weakness or problem moving any body part? Is it generalized or local?
Does weakness occur with any particular movement (e.g., with proximal or large muscle
weakness, it is hard to get up out of a chair or reach for an object; with distal or small
muscle weakness, it is hard to open a jar, write, use scissors, or walk without tripping)?
 Coordination - Any problem with coordination? Any problem with balance when
walking? Do you list to one side? Any falling? Which way? Do your legs seem to give
way? Any clumsy movement?
 Numbness or Tingling - Any numbness or tingling in any body part? Does it feel like pins
and needles? When did it start? Where do you feel it? Does it occur with activity?
 Difficulty Swallowing - Any problem swallowing? Occur with solids or liquids? Have
you experienced excessive saliva, drooling?
 Difficulty Speaking - Any problem speaking: with forming words or with saying what
you intended to say? When did you first notice this? How long?
 Significant Past History (Stroke, Spinal cord injury, Meningitis, etc.) - Past history of
stroke, spinal cord injury, meningitis or encephalitis, congenital defect, or alcohol use
problem?
 Environmental and Occupational Hazards Are you exposed to any
environmental/occupational hazards: insecticides, organic solvents, lead? (Lead, etc.) -
 Additional History for Older Adults –
1. Any problem with dizziness? Does it occur when you first sit or stand up, when you
move your head, when you get up and walk just after eating? Does it occur with any of
your medications? Any recent falls? • (For men) Do you ever get up at night and then feel
faint while standing to urinate? • How does dizziness affect your daily activities? Are you
 able to drive safely and maneuver within your house safely? • Which safety modifications
have you applied at home?
2. Have you noticed any decrease in memory, change in mental function? Have you felt
any confusion? Did it seem to come on suddenly or gradually?
3. Have you ever noticed any tremor? Is it in your hands or face? Is it worse with anxiety,
activity, rest? Does it seem to be relieved with alcohol, activity, rest? Does it interfere
with daily or social activities?
4. Have you ever had any sudden vision change, fleeting blindness? Did it occur along
with weakness? Did you have any loss of consciousness?
(Littlejohns, 2019).

4. Explain briefly the role of the registered nurse when caring for a client having the
following diagnostic studies associated with the nervous system:

Diagnostic Test Nursing Role

Lumbar Puncture Help patient assume and maintain lateral recumbent position with
knees flexed. Ensure maintenance of strict aseptic technique. Ensure
labelling of CSF specimens in proper sequence. Encourage patient to
drink fluids. Monitor neurological and VS. Administer analgesia as
needed.

Cerebral Angiography Assess for risk for stroke because thrombi may be dislodged during
procedure. Withhold preceding meal. Explain that patient will
experience hot flush of head and neck when contrast medium is
injected. Explain need to be absolutely still during procedure.
Monitor neurological and VS every 15–30 min for first 2 hr, every
hour for next 6 hr, then every 2 hr for 24 hr. Maintain pressure
dressing and ice on injection site. Maintain bed rest until patient is
alert and VS are stable. Report any signs of change in neurological
status.

Computed Tomography Explain that procedure is non-invasive (if no contrast medium is

(CT) used). Observe for allergic reaction, and note puncture site (if
contrast medium is used). Explain appearance of scanner. Instruct
patient to remain absolutely still during procedure.

Magnetic Resonance Screen patient for joint replacements and pacemaker in body. Instruct
Imaging (MRI) patient to lie very still for up to 1 hr. Sedation may be necessary if
patient is claustrophobic.

Positron Emission Explain procedure to patient. Explain that two IV lines will be
 Tomography (PET) inserted. Instruct patient not to take sedatives or tranquilizers and to
empty bladder before procedure. Patient may be asked to perform
different activities during test.

Electroencephalography Inform patient that procedure is painless and without danger of

(EEG) electric shock. Withhold stimulants. Inform patient that he or she
may be asked to perform various activities such as hyperventilation
during test. Determine whether any medications (e.g., tranquilizers,
anticonvulsant drugs) should be withheld. Resume medications after
test. Assist patient in washing electrode paste out of hair.

Electromyography Inform patient of slight discomfort associated with insertion of

(EMG) and Nerve needles.
Conduction Studies

Transcranial Doppler Explain procedure to patient.

Sonography

5. a) Formulate a plan of nursing care for a simulated client with epilepsy, using the
information from the readings and posted project assignment.

Care plan: Epilepsy Description and Rationale

Pathophysiology Epilepsy results from abnormal and excessive neuronal discharges in the
cerebral cortex. It is diagnosed when two or more unprovoked seizures
occur more than 24 hours apart. There are different types of seizures,
including idiopathic, cryptogenic, symptomatic, acute symptomatic, and
remote symptomatic seizures

Nursing assessments Conduct a thorough assessment to gather relevant information:

 Detailed medical history, including seizure type, frequency,
triggers, and duration.
 Physical examination to identify any neurological deficits.
 Medication history, allergies, and comorbidities.
 Psychosocial assessment to understand the impact of epilepsy on
the patient’s life.

Nursing diagnoses  Risk for injury related to seizures.

  Ineffective airway clearance related to altered consciousness
during seizures.
 Anxiety related to fear of seizures.
 Deficient knowledge about epilepsy management.
 Social isolation related to stigma associated with epilepsy.

Planning and goals  Collaborate with the patient, family, and healthcare team to set
realistic goals:
o Prevent injury during seizures.
o Optimize medication adherence.
o Enhance self-esteem and coping skills.
o Educate the patient and family about epilepsy
management.
o Promote social support and community resources.

Nursing interventions  Preventing Injuries and Suffocation:

o Educate the patient and family on safety measures during
seizures (e.g., cushioning the head, removing harmful
objects).
o Encourage the use of medical alert bracelets.
 Maintaining Patent Airway Clearance and Preventing
Aspiration:
o Position the patient on their side during a seizure.
o Administer oxygen if needed.
 Enhancing Self-Esteem:
o Provide emotional support and address stigma.
o Encourage participation in support groups.
 Promoting Adherence to Therapeutic Management:
o Teach the patient about antiepileptic medications (AEDs),
side effects, and the importance of consistent dosing.
o Monitor AED levels and adjust doses as necessary.
 Initiating Patient Education and Health Teachings:
o Educate the patient and family about epilepsy, triggers,
and lifestyle modifications.
o Discuss seizure first aid and emergency action plans

Teaching self-care/  Teach the patient and family to recognize warning signs of
Continuing care seizures.
 Encourage regular follow-up appointments with the neurologist.
 Discuss the importance of maintaining a healthy lifestyle (e.g.,
 sleep, stress management, avoiding alcohol).
 Provide resources for ongoing support and education.

Evaluation Get family or patient to teach back to check for understanding.

Allow patient to talk about triggers and how they can eliminate them to
reduce frequent seizures.
Observe patient when its time for medications and allow patient to
describe their effects.

b) Formulate a plan of nursing care for a simulated client with an acute stroke, using the
information from the readings and posted project assignment.

Care plan: Acute Description and Rationale

Stroke

Pathophysiology  Acute stroke (cerebrovascular accident or CVA) occurs due to

impaired cerebral circulation caused by thrombosis, embolism,
or hemorrhage.
 Blood flow disruption leads to ischemia or bleeding in the brain,
resulting in neurological deficits.

Nursing assessments  Conduct thorough assessments:

o Neurological Assessment:
 Level of consciousness (LOC), orientation, and
cognition.
 Motor strength, sensation, and reflexes.
 Cranial nerve function.
o Vital Signs Monitoring:
 Blood pressure, heart rate, respiratory rate, and
oxygen saturation.
o Swallowing Assessment:
 Evaluate for dysphagia and risk of aspiration.
o Functional Assessment:
 Assess mobility, ADLs, and self-care abilities.

Nursing diagnoses  Potential nursing diagnoses include:

o Risk for impaired mobility related to stroke-induced
weakness.
o Impaired verbal communication related to aphasia.
o Risk for aspiration related to dysphagia.
 o Disturbed sensory perception related to neurological
deficits.

Planning and goals  Collaborate with the patient, family, and healthcare team to set
goals:
o Improve mobility and prevent complications.
o Enhance communication.
o Ensure safe swallowing.
o Promote self-care and independence.

Nursing interventions  Mobility Enhancement:

o Encourage early mobilization.
o Use assistive devices as needed.
 Communication Support:
o Use alternative communication methods (e.g., picture
boards).
o Involve speech therapy.
 Swallowing Management:
o Modify diet consistency (soft, pureed, thickened liquids).
o Monitor for signs of aspiration.
 Safety Measures:
o Fall prevention strategies.
o Pressure ulcer prevention.
 Pain Management:
o Administer pain medications as prescribed.
 Emotional Support and Coping:
o Address anxiety and emotional distress.
o Involve family in coping strategies.

Teaching self-care/  Educate the patient and family about:

Continuing care o Stroke prevention (e.g., managing hypertension,
diabetes).
o Medication adherence.
o Follow-up appointments with healthcare providers.
o Community resources and support groups.

Evaluation Evaluate all assessments and intervention by nurse

c) Formulate a plan of nursing care for a simulated client with Alzheimer’s Disease, using
the information from the readings and posted project assignment.
Care plan: Description and Rationale
Alzheimer’s Disease

Pathophysiology  Alzheimer’s disease (AD) is a progressive and irreversible

degenerative disorder, and it is the most common form of
dementia among older individuals.
 Dementia significantly impairs a person’s ability to carry out
daily activities and usually begins after age 60.
 The risk of AD increases with age and is higher if there is a
family history of the disease.
 Pathologically, AD involves the loss of neurons in multiple brain
areas, brain atrophy, and the presence of plaques and
neurofibrillary tangles.
 Symptoms result from neuronal destruction in the hippocampus
and cerebral cortex, leading to impaired cognitive function.

Nursing assessments  Neurological Assessment:

o Evaluate level of consciousness, cognition, and
orientation.
o Assess motor strength, sensation, reflexes, and cranial
nerve function.
 Vital Signs Monitoring:
o Regularly measure blood pressure, heart rate, respiratory
rate, and oxygen saturation.
 Swallowing Assessment:
o Evaluate for dysphagia and risk of aspiration.
 Functional Assessment:
o Assess mobility, activities of daily living (ADLs), and
self-care abilities.

Nursing diagnoses  Common nursing diagnoses related to Alzheimer’s Disease

include:
o Risk for impaired mobility due to weakness.
o Impaired verbal communication related to aphasia.
o Risk for aspiration due to dysphagia.
o Disturbed sensory perception related to neurological
deficits.

Planning and goals  Collaborate with the patient, family, and healthcare team to set
goals:
o Improve mobility and prevent complications.
o Enhance communication abilities.
 o Ensure safe swallowing practices.
o Promote self-care and independence.

Nursing interventions  Mobility Enhancement:

o Encourage early mobilization.
o Use assistive devices as needed.
 Communication Support:
o Utilize alternative communication methods (e.g., picture
boards).
o Involve speech therapy.
 Swallowing Management:
o Modify diet consistency (soft, pureed, thickened liquids).
o Monitor for signs of aspiration.
 Safety Measures:
o Implement fall prevention strategies.
o Prevent pressure ulcers.
 Pain Management:
o Administer pain medications as prescribed.
 Emotional Support and Coping:
o Address anxiety and emotional distress.
o Involve family members in coping strategies.

Teaching self-care/  Educate the patient and family about:

Continuing care o Alzheimer’s prevention strategies (e.g., managing
hypertension, diabetes).
o Medication adherence.
o Follow-up appointments with healthcare providers.
o Community resources and support groups.

Evaluation Evaluate the progression of the disease. Cognition through assessments.

6. Complete the following chart for the selected drugs relevant to this module:

Drug & Mechanism Indications & Adverse Effects Nursing

Classification of Action Contraindications Considerations

Carbamazepin Appears to Used for tonic- Drowsiness, Nausea, Assess:

e decrease clonic seizures, Constipation, • Renal studies,
polysynaptic trigeminal Diarrhea, Rash. including BUN,
responses neuralgia, bipolar creatinine,
and block disorder. serum uric acid,
post tetanic urine creatinine
potential. Contraindications clearance
in pregnancy, before and
hypersensitivity, during therapy •
MAOI therapy, Blood studies:
bone marrow RBC, Hct, Hgb,
suppression. reticulocyte
counts weekly
for 4 wk then
monthly •
Hepatic studies:
AST, ALT,
bilirubin,
creatinine •
Mental status,
including mood,
sensorium,
affect,
behavioral
changes; if
mental status
changes, notify
prescriber • Eye
problems,
including need
for ophthalmic
exam before,
during, and
after treatment
(slit lamp,
fundoscopy,
tonometry) •
Allergic
reactions,
including red,
raised rash; if
this occurs,
product should
be discontinued
• Blood
dyscrasia,
including fever,
sore throat,
bruising, rash,
 jaundice •
Toxicity,
including bone
marrow
depression,
nausea,
vomiting,
ataxia, diplopia,
CV collapse,
Stevens-
Johnson
syndrome

Phenobarbital Works to Anticonvulsant in CNS: hangover, Monitor signs

depress the tonic-clonic delirium, depression, of
central (grand mal), drowsiness, excitation, hypersensitivity
nervous partial, and febrile lethargy, vertigo. Resp: reactions,
system. seizures in respiratory depression. including skin
Increases children. IV: problems, fever,
activity of Preoperative LARYNGOSPASM, swelling in the
GABA sedative and in bronchospasm. CV: face, difficulty
receptors, other situations in IV: hypotension. GI: breathing,
which which sedation constipation, diarrhea, muscle aches
reduce may be required. nausea, vomiting. (myalgia), and
neural Derm: joint pain
impulses in Contraindications photosensitivity, (arthralgia).
the brain, : rashes, urticaria. Assess
while Local: phlebitis at IV symptoms of
decreasing site. MS: arthralgia, bronchospasm
activity of myalgia, neuralgia. and
glutamate Misc: laryngospasm
receptors, HYPERSENSITIVIT (wheezing,
which excite Y REACTIONS, coughing,
and increase INCLUDING tightness in
neuronal ANGIOEDEMA AND chest),
activity. This SERUM SICKNESS, especially after
reduces physical dependence, IV
hyperactivity psychological administration.
in neurons, dependence. Monitor
preventing drowsiness,
seizures blood studies,
hypersensitivity
.
Phenytoin Inhibits Used for general The most common Assess: for
spread of tonic-clonic side effects are GI hypersensitivity
seizure seizures, status symptoms. CNS for long use,
activity in epilepticus, effects such as serious skin
motor cortex nonepileptic nystagmus, ataxia, disorders,
by altering seizures. slurred speech, and toxicity levels,
ion mental confusion. blood studies,
transport; Contraindications mental status,
increases AV in pregnancy, cardio heart
conduction. hypersensitivity, studies ECG,
bradycardia, SA Beers in older
and AV block, adults.
stroke adams
syndrome.

Topiramate May prevent Used for partial Most common side Assess: seizure
seizure seizures in adults effects include activity, moods,
spread as and children, dizziness, fatigue, renal studies,
opposed to migraines. anxiety, memory loss, hepatic studies,
an elevation tremors, SI, vision blood studies,
of seizure Contraindications abnormality, anorexia, migraines,
threshold, : hypersensitivity, nausea, dyspepsia. mental status,
increase metabolic eating
GABA acidosis, disorders,
activity. pregnancy. weight loss.

Valproic Acid Increases Used for simple, Sedation, drowsiness, Assess: mental
levels of y- complex, absence, N/V/D, constipation, status, seizure
aminobutyri and mixed dyspepsia, rash. activity,
c acid seizures, bipolar migraine
(GABA) in disorders and activity, blood
the brain, migraines, studies,
which ADHD, tonic- hepatoxicity,
decreases clonic, myoclonic blood levels,
seizure seizures. Beers in older
activity. adults.
Contraindications
: hypersensitivity,
urea cycle
disorders, hepatic
disease,
mitochondrial
disease.
Donepezil HCl Elevates Uses: mild to Insomnia, headache, Assess: BP, HR,
acetylcholin severe dementia N/V/D, AV block, afib, mental status,
e with Alzheimer’s GI bleed, seizures. GI status,
concentrates disease urinary status,
(cerebral ambulation
cortex) by Contraindications (may need
slowing : hypersensitivity, assistance).
degradation pregnancy, sick
of sinus syndrome,
acetylcholin Hx of ulcers, GI
e released in bleeding, hepatic
cholinergic disease, bladder
neurons; obstruction,
does not asthma, seizures,
alter COPD, abrupt
underlying discontinuation,
dementia. AV block, GI
obstruction,
Parkinson’s
disease.

Alteplase Produces Uses: lysis of Surface bleeding, Assess: Vital

fibrin obstructing bradycardia. signs, bleeding,
conversion thrombi dysrhythmias,
of associated with monitor heart,
plasminogen acute MI, breath sounds,
to plasmin; ischemic neurological
able to bind conditions that status,
to fibrin, require hypersensitivity
convert thrombolysis (PE, . Blood studies.
plasminogen unclotting
in thrombus arteriovenous
to plasmin, shunts, acute
which leads ischemic CVA)
to local central venous
fibrinolysis, catheter occlusion
limited (cathflo).
systemic
proteolysis. Contraindications
: active bleeding,
Hx of CVA,
hypertension,
aneurysm, brain
tumor,
 hemorrhage,
seizure at onet of
stroke.

Apply (A)- Part B

Online Learning Activities:
The course instructor/ professor will provide the learning activities to apply and critically
analyze the module theory, concepts, and relevant best practice guidelines.

Reflect (R)- Part B

A. Independent Reflection Activity
1. What are your thoughts about specific training for health care providers on how to
manage agitation for patients with Alzheimer’s disease? I think the more training is
provided to health care providers the better equipped they can be to handle agitation for
patients with Alzheimer’s.
2. What areas would you focus on as a registered nurse when designing and delivering an
education session to the public on the prevention and identification of cerebrovascular
accidents (CVA)?
3. What specific information would be important for the registered nurse to consider when
caring for an expectant mother who has a history of epilepsy? The information most
important to focus on would be safety for mother and baby during an episode.
B. Review the sample NCLEX-style questions:
1. Which of the following are nursing responsibilities for lumbar puncture?
a) Ensuring the client has a full bladder.
b) Placing the client in the lateral recumbent position.
c) Straightening the client’s legs just before the puncture.
d) Having the client cough when the needle has been inserted.
2. A nurse caring for a client with increased intracranial pressure knows that the best way to
position the client is which of the following.
a) Keep the head of the bed flat.
b) Elevate the head of the bed to 30 degrees.
c) Maintain the client on the left side with head supported on a pillow.
d) Use a continuous-rotation bed to continuously change the client’s position.
3. Which of the following pieces of information provided by the client would help differentiate a
hemorrhagic stroke from an ischemic stroke?
a) Sensory disturbance.
b) A history of hypertension.
c) Presence of motor weakness.
d) Sudden onset of severe headache.
4. For a client who is suspected to have had a stroke, what is one of the most important pieces of
information that the nurse can obtain?
a) Time of the client’s last meal.
b) Time at which stroke symptoms first appeared.
c) Client’s hypertension history and management.
d) Family history of stroke and other cardiovascular diseases.
5. Which of the following symptoms are the hallmarks of delirium?
a) Inattention, fluctuating course, hyperactivity, and altered level of consciousness.
b) Disorganized thinking, insidious onset, inattention, and altered level of consciousness.
c) Acute onset, fluctuating course, memory loss, and altered level of consciousness.
d) Acute onset, fluctuating course, inattention, or disorganized thinking, and altered level of
consciousness.
6. On which of the following findings is the clinical diagnosis of dementia made?
a) Brain biopsy.
b) Electroencephalography.
c) Patient history and cognitive assessment.
d) Computed tomography or MRI.
7. The nurse is caring for a client who begins to experience seizure activity while in bed. Which
actions should the nurse take? Select all that apply.
a) Loosening restrictive clothing.
b) Restraining the client’s limbs.
c) Removing the pillow and raising padded rails.
d) Positioning the client to the side, if possible, with the head flexed forward.
e) Keeping the curtain around the client and the room door open so when help arrives, they
can quickly enter to assist.
8. The nurse is preparing to give medications. Which of the following is the most appropriate
nursing action for intravenous (IV) phenytoin (Dilantin)?
a) Give IV doses via rapid IV push.
b) Administer in normal saline solutions. (with special microfilter)
c) Administer in dextrose solutions.
d) Ensure continuous infusion of drug.
9. The nurse is administering an antiepileptic drug and will follow which guidelines? Select all
that apply.
a) Monitor the patient for drowsiness.
b) Stop medications if seizure activity disappears.
c) Give the medication at the same time every day.
d) Give the medication on an empty stomach.
e) Notify the prescriber if the patient is unable to take the medication.

Extend (E)- Part B

Alzheimer Society Ontario. (2018). About dementia. Retrieved
from http://www.alzheimer.ca/en/on/About-dementia

Centers for Disease Control and Prevention. (2017). What you need to know about
concussion [Audio podcast]. Retrieved from http://www2c.cdc.gov/podcasts/player.asp?
f=858437

Epilepsy Ontario. (2018a). Types of seizures. Retrieved from http://epilepsyontario.org/types-of-

seizures/

Epilepsy Ontario. (2018b). Tonic-clonic seizures [Video]. Retrieved

from http://epilepsyontario.org/tonic-clonic-seizures/
Heart and Stroke Foundation. (2018). Canadian stroke best practices: Acute stroke
management. Retrieved from http://www.strokebestpractices.ca/acute-stroke-management/

Registered Nurses’ Association of Ontario. (2016). Delirium, dementia, and depression in older
adults: Assessment and care. Toronto, ON: Registered Nurses’ Association of Ontario. Retrieved
from https://rnao.ca/sites/rnao-ca/files/3Ds_BPG_WEB_FINAL.pdf