Medical Surgical Nursing – Nervous System

PENTAGON REVIEW / SIR VALDEZ

COVERAGE o Personality development

I. Composition of Brain & Spinal o Judgement / Logic / Rationality
Cord o Primitive reflexes are inhibited
II. Neurological Trauma / Injury o Motor activity
o Cerebral Perfusion Pressure o Site of Broca’s area or “motor speech
(CPP) center”  damage could lead to
o Factors affecting ICP (+) Expressive Aphasia – Alz/Stroke
A. Increased Intracranial Pressure - Inability to speak
(ICP) - (+) nodding
B. Cerebrovascular Accident (CVA) - Damage to frontal lobe
C. Convulsive Disorder Nursing Care:
> Use of picture board

I. COMPOSITION OF BRAIN & SPINAL  Temporal Lobe

CORD o Hearing
- 80% brain mass, 10% blood, 10% CSF o Short term memory
o Site of Wernicke’s area or
1. Cerebrum – largest “language center”
o Damage could lead to
A. Parts (+) Receptive Aphasia – Alz/Stroke
> 2 – right & left hemisphere - Inability to understand
> Corpus callosum – largest commissural spoken words
tract / fiber / pathways - (+) illogical / irrational
thoughts
B. Functions - Damage to temporal lobe
> Sensory Nursing Care:
> Motor > Use of gestures / Pantomime
> Integrative > Repeat instructions
C. Basal Ganglia * Mixed type / Global Aphasia – Stroke
> Produce neurotransmitter - inability to speak & inability to
> Areas of grey matter located deep understand spoken words
within each cerebral hemisphere
 Parietal Lobe
Neurotransmitters: - Responsible for appreciation
1. Dopamine Parkinsons Schizophrenia
and discrimination of sensory
- Controls voluntary impulses like pain, touch,
movement pressure, heat & cold
- Relaxes muscles
- Responsible for  Occipital Lobe
muscle coordination o Vision
- Facilitates mood, pleasure,
reward, and memory  Central lobe / Insula / Island of Reil
o Visceral – GIT motility,
2. Acetylcholine contraction & relaxation of
MG
- Excitatory Bipolar
heart muscles,
Disorder
bronchoconstriction / dilation
D. Lobes
 Rhinencephalon / Limbic System
 Frontal Lobe – larges
It controls:

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o Smell – uses coffee granules, o Controls depth & respiration

bar soap, vinegar, cigarette
(upos)
o Long term memory
o Libido / Sexual urge c. Medulla Oblongata
o Lowest part of the brain
Abnormal Findings: (smell) o RR
1. Anosmia – absence of smell o HR
2. Hyposmia – decrease sensitivity to o Swallowing
smell o Vomiting
3. Dysosmia – distorted sense of smell o Sneezing
o Coughing
o Salivation
2. Diancephalon o Site of spinal decussation
a. Hypothalamus - Criss cross
o Temperature (thermoregulation
center) 4. Cerebellum – smallest
o Thirst o Control balance, posture,
o Appetite (Satiety center) equilibrium & gait
o Blood pressure
o Sleep & wakefulness Cerebellar Tests:
o Some emotional responses 1. Romberg’s Test
(excitement, fear, anxiety) o 2 RN’s ; R/L
b. Thalamus o Assume normal anatomical
- relay station for sensation position
o 5-10 mins ; (+) Romberg’s Test /
3. Brainstem Ataxia / Unsteady gait
a) Midbrain (Mesencephalon)
b) Pons 2. Alternate supination & pronation
c) Medulla Oblongata o (+) AS&P – Dymetria

a. Midbrain 3. Finger to Nose Test (FTNT)

- acts as relay center for site & hearing o (+) FTNT – Dymetria
- control size and response of pupil (center of > Inability to stop a
iris) & hearing activity movement at a desired point
 Normal size of pupil:
o Daylight – 2-4mm
o Dimlight – 4-6mm II. NEUROLOGICAL TRAUMA / INJURY
o Average – 2-3mm 1. Increased ICP
o Fully dilated – 9-10mm 2. CVA
 Isocoria – equal size 3. Convulsive Disorder
 Anisocoria – unequal size
 Normal reponse: PERRLA Cerebral Perfusion Pressure (CPP)
- Pupil equal round reactive to o N – 60-100 mmHg
light & accommodation o It is the pressure that pushes
blood into the brain hence the
b. Pons CPP is influenced by cerebral
o Pneumoraxic center – limiting blood flow
inspiration  limits the burst of Findings:
action potentials in the phrenic nerve 1. Hyperperfusion - >100mmHg
 decreasing the tidal volume and 2. Hypoperfusion – 4-60 mmHg
regulating RR 3. Brain death – 0-40 mmHg

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

> If CPP is <50mmHg  irreversible b) Irritability & agitation

neurological deficit c) Lethargy to stupor
= MAP – ICP = CPP ; MAP = S + 2(D) d) Disorientation to 3 spheres
3 (time, place, person)
Factors affecting ICP e) Does not respond to
1. Body temperature; Hyperthermia / questions
Pyrexia 2. Late signs:
- Increase in body metabolism o Changes in VS:
 increase glucose & O2 a) Hypertension (SBP rises,
consumption  Inc ICP DBP remains the same)
2. Oxygenation Status Cushing’s b) Widening of pulse
a. Hypoxia  Inc ICP Triad pressure
b. Hypercapnia / Hypercarbia c) Bradycardia
- Inc in CO2 retention  Inc d) Bradypnea
ICP
3. Body position
o Flexion of the neck  Inc ICP Stages of Shock: ICPR
4. Arterial & Venous pressure 1. Initial
5. Activities that inc intraabdominal & 2. Compensatory – RAAS
intrathoracic pressure = Valsalva 3. Progressive
Maneuver  Inc ICP 4. Refractory – multisystem organ
failure
A. Increased ICP
- N: 0-15 mmHg
- An increase in the intracranial bulk o Headache
brought about by “an increased in one o Projectile vomiting
of the intracranial components” o Papilledema – edema of the
- Monroe – Kellie Hypothesis optic disc that could lead to
> states that the skull is a closed blindness if left untreated
container, therefore, any increase in one o Possible seizure
of the intracranial components could o Unilateral dilation of pupil
lead to increased ICP (Uncal Herniation)
a. Blood (10%) = stroke  Inc ICP o Abnormal doll’s eye
b. Brain (10%) = Hydrocephalus  movement (oculocephalic
Inc ICP reflex) indicates drug to
c. Brain Mass (80%) = Head Injury  brainstem; tested or elicited
Inc ICP among unconscious client

A. Predisposing Factors C. Nursing Management

1. Head injury 1. Maintain patent airway and
2. Brain tumor – Astrocytoma (most adequate ventilation by:
common) o Prevention of hypoxia and
3. Brain abscess hypercarbia
4. Meningitis o Assist in mechanical
5. Hydrocephalus ventilation  promoting
6. Cerebral edema constriction of cerebral veins
7. Hemorrhage (stroke) thereby decreasing ICP
o Before and after suctioning,
B. Signs & symptoms hyperventilate the pt 100% to
1. Early signs “blow off” CO2 (CO2 dilates
o Changes / Alteration in LOC
a) Confusion to restlessness

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Medical Surgical Nursing – Nervous System
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blood vessels) suction pt 10- B. Cerebrovascular Accident (CVA)

15 secs ABC’S of CVA:
2. Place client semi fowlers / elevate - Apoplexy
HOB 30-45 degrees with neck in - Brain attack
neutral position, unless - Cerebral thrombosis
contraindicated to promote venous - Stroke
drainage
3. Limit fluid intake (1200-1500ml/day) A. Incidence Rate
4. Monitor strictly VS & neuro check o Common among men
5. Prevent complications of immobility o Increases as men age
- Decubitus ulcer and o May be preventable if causes
hypostatic pneumonia discovered early
6. Prevent further increase in ICP by ff
measures: B. Types
a. Provide comfortable and quiet 1. Ischemic – caused by blood clots /
environment stenosis; easy to treat
b. Avoid use of restraints a. Thrombosis – blood clot
c. Maintain padded rails (attached)
d. Instruct client to avoid activities b. Embolus – detached
 Valsalva Maneuver thrombus
o Avoid straining of stool
 Dulcolax / Assessment Guide: Nasolabial Fold
Duphalac o Balance is lost – most impt

o Avoid excessive o Eyes (blurring) parameter to

indicate facial
coughing o Face symmetry symmetry
 Adm antitussive o Arm movement
as ordered o Speech (slurred)
 Dextrometorph o Time the onset of s/sx
an
o Avoid excessive Bring client to the nearest
vomiting Hospital/healthcare facility
 Give antiemetics
 Plasil / Phenergan Thrombolytics / Fibrinolytics
o Avoid lifting heavy (only given 3-4 hours from the onset)
objects
o Avoid stooping / bending
Examples:
Administer meds as ordered: a. Streptokinase – SE allergic
1. Osmotic diuretic: Mannitol reaction
(Osmitrol) b. Urokinase – SE HPN
2. Loop diuretics: Furosemide c. (TPAF) Altaplase – SE Chest pain
3. Corticosteroids: Dexamethasone - Most common
(Decadron)
4. Mild analgesic: Codeine SO4 Thrombolytic is given if the client
5. Anti convulsant:Dilantitn meets the ff criteria:
(Phenytoin) 1. If the CT Scan is (-)
2. Labs is within normal limits
(glucose / platelets)
3. BP is controlled or less thank
185/110
4. Hasn’t received heparin or other
anticoagulants

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

2. Hemorrhagic – caused by ruptured Right Brain injury  Left Left Brain injury  Brain
aneurysm, uncontrollable hypertension, Side Affected Side Affected
old age (vessels are not anymore Signs & symptoms: Signs & symptoms:
resilient) o Left side weakness o Right side weakness
o Caused by vascular disruption (paresis) or paralysis (paresis) or paralysis
e.g. aneurysm, arteriovenous (phlegia) (phlegia)
malformation (AVM) o Loss of depth o Cannot recognize
o Surgical decompression – if brain perception faces or the person’s
cells (neurons) is not properly o Confused on time, name
supported by enough blood date & place o Impaired math skills
within 3-5 mins, it could lead to o Trouble staying on o Aware of their limits,
irreversible brain damage one topic expression,
o Impaired creativity: depression, anger &
C. Risk factors – STROKES HAPPEN arts & music frustration
1. Smoking o Cannot recognize o Trouble
2. Thinners (Blood) faces of the person’s understanding written
3. Rhythm – arrhythmia (A. Fib) name test
4. Oral contraceptives o Agraphia – inability to
a. Macropill – contains large write
amount of estrogen o Issues on being on the
b. Minipill – contains large right side only:
amount of progesterone Unilateral neglect
5. Kin (family history o Aphasia – expressive
6. Excessive weight (Obese) & receptive
7. Senior citizen
8. Hypertension D. Signs & symptoms
9. Atherosclerosis - narrowing Based on the stages of stroke:
10. Physical inactivity (sedentary 1. Transient Ischemic Attack – also
lifestyle) called as “silent stroke”
11. Previous TIA o Mini stroke (it only lasts for about 30
12. Elevated blood glucose (DM) mins to resolve)
13. aNeurysm (brain) o Warning sign of an impending stoke
attack characterized by:
Cerebrum – 2 parts a) Headache
Right Side Left Side b) Dizziness
Hemisphere Hemisphere c) Numbness
o Left side of the o Math skills d) Tinnitus
body o Reading e) Speech & visual disturbances
o Music / art o Writing f) Possible increase in ICP
appreciation o Speaking g) Paresis / phlegia
o Memory recall o Analyzing h) Temporary loss of memory
o Reasoning information 2. Stroke in evolution
o Showing of o planning o Progression of the s/sx of stoke
emotions 3. Complete Stroke
o Attention span o Resolution characterized by:
o Ability to solve a) Headache
everyday b) Dizziness
problems by c) Cheyne-strokes respiration
making decision d) Anorexia
/ planning e) Nausea & vomiting
o Corpus Callosum – connects the 2 f) Dysphagia

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

g) (+) Kernig’s & Brudzinki’s

 Indicates G. Nursing Management
hemorrhagic stroke 1. Maintain patent airway and
adequate ventilation by:
📌 Signs of meningeal irritation: o Assist in mech ventilation
1. Nuchal rigidity (stiff neck) o Adm O2 inhalation
2. Opisthotomus 2. Restrict fluids to prevent cerebral
3. Kernig’s sign edema
4. Brudzinkis’s sign 3. Place client on semi fowlers position /
elevate HOB 30-45 degrees
4. Prevent complications of immobility
h) (+) focal neurological deficits: by:
 Aphasia o Turning client to sides q 2h
 Dysarthria – inability o Provide “egg crate”
to articulate words mattresses or water bed
 Agraphia – inability o Provide sandbag & footboard
to write to prevent foot drop
 Alexia – inability to 5. Institute NGT feeding via gastrict
read gavage to prevent aspiration
 Amaurosis Fugax – 6. Assist in passive ROM q 4hrs to
temporary / transient prevent contractures or to promote
loss of vision in one proper body alignment or prevent
eye (last for seconds disuse syndrome  deterioration or
to minutes)  stiffening of muscles due to
ischemic to carotid prolonged inactivity
system 7. Provide alternative means of
 (+) homonymous communication:
hemianopsia – loss or o Use of non-verbal cues
blindness in one of o Provide” magic slate”
half of the visual field) 8. If positive to hemianopsia, approach
o Always SCAN client to unaffected
the 9. Encourage client to scan the
environment. environment to prevent injury
10. Monitor strictly VS, I&O, neuro check
E. Diagnostiv Procedure 11. Maintain padded rails
1. Baseline CT Scan – revelas brain 12. Instruct client to avoid activities
lesion =  MRI even better (if want to leading to Valsalva maneuver or
ensure that the stroke is not bearing down
hemorrhagic) 13. Administer meds as ordered:
2. Cerebral myelography – reveals the o Osmotic diuretics – Mannitol
site & event of malocclusion (Osmitrol)
o Corticosteroids:
F. Nursing Priority / Diagnosis Dexamethasone (Decadron)
1. Cerebral perfusion (altered) o Mild analgesics: Codeine SO4
2. Physical mobility o Thrombolytics / Fibrinolytics
3. Verbal communication (impaired)  Streptokinase
4. Sensory perception  Urokinase
5. Safety/injury  TPAF (Alteplase) 
6. Aspiration should be given 3 hours
upon onset

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o Anticoagulants o Prevent complications:

 Heparin  Subarachnoid
 Warfarin / Coumadin hemorrhage
 Brain herniation
📌
 Heparin (short acting) ; IV/SC  Hypostatic
 Monitor PTT – 30-40 secs pneumonia
 INR (International normalized  Deep vein thrombosis
ratio); 1.2-2.5 x within normal  Depression & mood
(therapeutic) but if around 60- changes
80 secs  prone to bleeding  o Dietary modifications:
administer antidote: Protamine  Provide a general
Sulfate liquid to soft diet
 Warfarin / Coumadin (long acting) ; that is low in
2-3 / 3-4 days effect; orally saturated fats,
 Monitor for PT – 10-12 secs sodium, avoid
 INR: 2-3x (normal / therapeutic), caffeine & gas
if more than 36 secs  prone to forming foods
bleeding  administer antidote:
Vit K (Aquamephyton) Gas Forming Foods
o Popcorn
o Antiplatelet o Onion
- Paraamino salicylic acid o Soda
(PASA) – Aspirin
- Persantine Odor Forming Foods - FACES
- Toclopidine (Ticlid) o Fish
o Asparagus
SE of Aspirin: o Cheese
1. Hemolytic anemia o Egg
2. Dyspepsia (indigestion) o Spicy foods
3. GIT irritation
4. Bilateral tinnitus o Rehabilitation for local
Contraindications: neurological deficits
1. Dengue
2. Hemophilia C. Convulsive Disorder
3. Unknown cause of - Disorder characterized by seizure with
headache or without loss of consciousness,
abnormal motor activity, alteration in
o Antihypertensive agents sensation and perception and changes
- Calcium channel blockers in behavior
- Nifedipine (Procardia)
- Cardizem (Diltiazem) A. Predisposing Factors
- Verapamil (Isoptin) 1. Head injury secondary to birth
o Peripheral vasodilators trauma
- Papavarine HCL (Pavabid) 2. Brain tumor (Astrocytoma)
o Stool softener 3. CO poisoning
- Dulcolax (Duphalac) 4. Nutritional & metabolic disorders
5. Genetics
14. Provide client health teaching and 6. ETOH withdrawal / alcohol
discharge planning concerning: 7. Stroke
o Avoid modifiable risk factors: 8. Acid base imbalance
lifestyle / diet / exercise 9. CNS infections

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

10. Cerebral hypoxia remember events that

happened to him
B. Stages - PAIP
1. Prodromal  Petit Mal / Absence Seizure
o When symptoms start appear - Common among children
prior to the big event - Characterized by:
o Characterized by depression, o Blank stare
anger, unable to sleep o Twitching of the mouth
o Anxiety, GIT and urinary o Lip smacking
problems o Loss of consciousness for
2. Aura 5-10 secs
o Warning sign of an impending
seizure attack  Atonic Seizure (Drop Fall)
o Subjective in nature - Provide helmet
o Characterized by altered vision,
taste, hearing, feels dizzy, sudden 2. Partial / Localized Seizure:
weird taste
3. Ictus / Ictal  Focal / Jacksonian Seizure:
o Actual seizure usually lasts for 1-3 o Characterized by jerky
minutes movement of the index finger &
o Time the actual seizure because that spreads to the shoulder & to
a seizure that lasts for about 5 the other side of the body
minutes or more, indicates:  Psychomotor / Focal Motor Seizure:
Status Epilepticus or Back to o Automatism: stereotyped,
back seizure repetitive and non-purposive
4. Post Ictal / Ictus behavior (such as finger rubbing,
o After the seizure / recovery, lip smacking, chewing)
unresponsive, sleep o Mild hallucinatory sensory
characterized by: experience
o Very tired and wants to o Clouding of consciousness: the
sleep; obtunded client is not in contact with the
o (+) confused, body sores environment

c. Classification 3. Status Epilepticus

1. Generalized Seizure: o Major cause: sudden withdrawal
o affects the whole brain to ani convulsants
o Continuous and uninterrupted
 Grand mal / Tonic Clonic Seizure seizure activity
- Most common type o If left untreated could lead to
- Characterized by: hyperpyrexia  could lead to
o With or without aura COMA
o Epileptic cry o Can also lead to hypoxia /
 Fall hypotension / hypoglycemia,
 Loss of consciousness arrhythmias & lactic acidosis
for about 1-3 minutes o Drug of Choice:
o Tonic  direct symmetrical  Benzodiazepines  rapid
extension of extremeties or onset of action & long
stretching duration of action; ANTIDOTE:
o Clonic  body stiffening FLUMAZENIL
o Post ictal sleep   Diazepam (Valium)
unresponsive sleep / can’t  Lorazepam (Ativan)

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

 Midazolam (Versed)  Indication: used for grand

 IV glucose: D50W mal / focal seizures & status
epilepticus
D. Nursing priority  MOA: it stimulates GABA
1. Airway receptors & this helps
2. Trauma / Suffocation inhibitor transmission
3. Safety  SE: ataxia, drowsiness,
hypotension, respiratory
E. Diagnostic Procedures depression
1. CT Scan – reveals brain lesion o Anti convulsants: Hydantoins
2. Electroencephalography (EEG) –  Dilantin (Phenytoin)
reveals hyperactivity of brain waves  Toxicity level: 20 mg/ 100 ml
Nursing care:  Normal range: 10-19
o Shampoo the hair of the mg/100ml
client  MOA: decreases
o No NPO hyperactivity of brain waves
o Avoid caffeine because it  SE:
could alter the result of EEG  Gingival hyperplasia
(swollen gums) –
F. Nursing Management
provide oral care, use
1. Maintain patent airway & promote
soft bristled
safety, before seizure activity:
toothbrush
o Clear the site of blunt / sharp
 Hairy tongue
objects
 Ataxia
o Loosen clothing of client
 Nystagmus
o Avoid use of restraints
 Bone marrow
o Maintain padded rails
depression
o Turn clients head to side to
 Nursing care:
prevent aspiration
- It is only mixed with
o Place mouthpiece, tongue guard
plain NSS / .9NaCl
on the clients mouth to prevent
to prevent
biting of the tongue
development of
2. Avoid precipitating stimulation such
crystals or
as:
precipitate
o Trauma
- Given via
o Stress
“sandwich method”
o Overexertion
- Instruct the client
o Loss of sleep
to avoid taking
o Visual stimulation (bright, glaring
alcohol because it
lights or noises)
could lead to
3. Institute seizure and safety
severe CNS
precautions, post seizure activity:
depressant
o Suction apparatus
o Benzodiaxepines
o O2 inhalation
o Diazepam (Valium)
4. Monitor and document the ff:
o Lorazepam (Ativan)
o Onset and duration
o Midazolam (Versed)
o Type of seizure
 Indications: used for petit mal
o Duration of post ictal sleep
& grand mal seizure
5. Administer meds as ordere:
 Fast acting agent to treat
o Phenobarbital (Luminal)
status epilepticus
 Drug level: 15-40 mcg/ml
 SE:

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o Drowsiness
o Hepatotoxic (liver
impairment);
antidote: Flumazenil
o Valproates
 Valproic acid
 Indication: all types of seizure
 SE:
 Hepatotoxic
 Blood dyscrasias
 GIT irritation
6. Assists in surgical procedure:
o Cortical resection: a portion of
the cortex is excised to relieved
seizure
o Vagus nerve stimulator
7. Ketogenic diet: used for pediatric
client
o Whose seizure is not
controlled by meds
o High fats & low carbs
o Fats – 65%
o CHON – 30%
o CHO – 5%

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