Transcript Common Disorders of the Neurological System

Chapter 54
Care of the Patient with a
Neurological Disorder
- Complete Slides
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Overview of Anatomy and Physiology
• Nervous System
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Responsible for communication and control within the
body
Interprets and processes information received and
sends in to the appropriate area of brain and spinal
cord where response is generated
Body’s link to the environment
Works with endocrine to maintain homeostasis
• NS reacts in a split second
• Endocrine works more slowly to secrete hormones
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Slide 2
Overview of Anatomy and Physiology
• Structural divisions
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2 Main Structural division:
1. Central nervous system (CNS)
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Brain and spinal cord
Occupies a medial position in the body
Responsible for interpreting incoming sensory
information and issuing instructions based on past
experiences
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Slide 3
Overview of Anatomy and Physiology

2 main structural divisions – cont’d
2. Peripheral nervous system (Lies Outside the
CNS), divided into 2 main divisions:
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Somatic nervous system
o
Sends messages from the CNS to the skeletal
muscles
o
Voluntary muscles
o
Sensory (Afferent) and Motor (Efferent) Neuron
Autonomic nervous system
o
Transmits messages from the CNS to the smooth
muscle, cardiac muscle and certain glands
o
Involuntary
o
Known as involuntary nervous system
Actions takes place without conscious control
o
Sensory (Afferent) and Motor (Efferent) Neuron
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Slide 4
Overview of Anatomy and Physiology
-cells of the nervous system
•
Cells of the Nervous system
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•
2 Broad Category:
1. Neurons, transmitter cells as they carry messages to and from the
brain and spinal cord.
2. Neuroglial or glial cells, support and protect the neurons while
producing cerebrospinal fluid (CSF), which continuously bathes the
structures of the CNS.
Neuron (nerve cell)
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Basic nerve cell of nervous system
Separate unit compose of:
• Cell body, the axon and the dendrites
Cell body
• Contains a nucleus surrounded by cytoplasm
Axon
• Cylindrical extension of a nerve cell
• Conducts impulses away from the neuron cell body
Dendrites
• Branching structures that extend from a cell body and receive
impulses
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Slide 5
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neuron (nerve cell) – cont’d

Synapse
• A gap (space) between each neuron
• Defined as region surrounding the point of contact
between two neurons
• Between a neuron and an effectors organ, across which
nerve impulses are transmitted through the action of a
neurotransmitter
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Governed by “all or none” law
• Never a partial transmission of a message
• Impulse is either strong enough to elicit a response or
too weak to generate the message
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neuromuscular junction
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Area of contact between ends of a large myelinated
nerve fiber and a fiber of skeletal muscle
 Necessary for functioning of the body
 Neurotransmitters act to make sure the neurological
impulse passes from nerve to muscle
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Slide 8
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neurotransmitters
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It modify or result in transmission of impulses between synapses
Best known neurotransmitter are: Acetylcholine,
Norepinephrine, dopamine and serotonin.
Acetylcholine (Ach)
• Role in nerve impulse transmission
• Spills into synapse area and speed transmission of impulse
• Cholinesterase (enzyme)
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Deactivate Ach once message or impulse has been sent
• Happens rapidly and continuously as each impulse is relayed
Norepinephrine
• Effects on maintaining arousal (awakening from deep sleep)
and dreaming
• Regulation of mood (i.e. happiness and sadness)
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Slide 9
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neurotransmitters
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Dopamine
• Primarily affects motor function
• Involved in gross subconscious movements of skeletal
muscles
• Role in emotional responses
• In Parkinson’s disease
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There is a decrease in dopamine, that’s why the person suffers
from tremors or involuntary, trembling muscle movements
Serotonin
• Induces sleep
• Affects sensory perception
• Controls temperature
• Role in control of mood
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Slide 10
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neuron coverings
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Myelin
• White, waxy, fatty material
• Increases rate of transmission of impulses
• Protects and insulate fibers
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nodes of Ranvier
• Wraps the axon leaving the CNS in layers of myelin
with indentation
• Further increase rate of transmission, because impulse
can jump from node to node
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Slide 11
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
• Neuron coverings
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Peripheral nervous system
• Myelin is produced by Schwann cells
• Outer membrane gives rise to another layer which is
very important in regeneration of cells called
neurilemma, functions of neurilemma:
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Helps to regenerate injured axons
Regeneration of nerve cell occurs only in peripheral
nervous system
• Cells damaged in CNS results permanently (paralysis)
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Do not have neurilemma, so no regeneration occurs.
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Slide 12
Overview of Anatomy and Physiology
-cells of the nervous system (cont’d)
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Slide 13
Figure 54-1
(A, C, from Thibodeau, G.A., Patton, K.T. [2003]. Anatomy and physiology. [5th ed.]. St. Louis: Mosby.
B, Courtesy of Brenda Russell, PhD, University of Illinois at Chicago.)
A, Diagram of a typical neuron. B, Scanning electron micrograph of
a neuron. C, Myelinated axon.
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Slide 14
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Central Nervous System
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One of two main divisions of nervous system
Composed of brain and spinal cord
Functions somewhat like a computer but is much
more complex
Cranium protects the brain
Vertebral column protects the spinal cord
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Slide 15
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain
Specialized cells in the brain’s mass of convoluted,
soft, gray or white tissue coordinate and regulate the
functions of CNS
 Largest organ weighing about 3 pounds
 Divided into four parts
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•
•
•
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Cerebrum
Diencephalon
Cerebellum
Brain stem
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Midbrain; pons; medulla oblongata; coverings of the brain
and spinal cord; ventricles
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Slide 16
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain
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Cerebrum
• Largest part of the brain
• Divided into left and right hemispheres
• Outer portion is gray matter
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Called - Cerebral cortex
• Arrange into folds called gyri (convolutions)
• Grooves are called sulci (fissures
• Corpus callosum
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Connecting structure or bridge
Divides two hemispheres into for lobes
o Frontal lobe, parietal lobe, temporal lobe, occipital
lobe
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Slide 17
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain
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Cerebrum
• Fissure is a natural division between the left and right
hemispheres
• Controls initiation of movement on opposite side of body
• Specific areas of cerebral cortex are associated with
specific functions:
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Frontal Lobe
o Written speech (ability to write)
o Motor speech (ability to speak)
o Motor ability – directs movements of body; left side controls
the right side of the body and the right side of the brain
controls the left side of the body.
o Intellectualization – the ability to form concepts
o Judgment formation
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Slide 18
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain.. cont
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Cerebrum.. cont
• Specific areas of cerebral cortex are associated with
specific functions.. cont:
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Parietal Lobe
o Interpretation of sensory impulses from the skin such as
touch, pain, and temperature
o Recognition of body parts
o Determination of left from right
o Determination of shapes, sizes and distances
Temporal Lobe
o Memory storage
o Integration of auditory stimuli
Occipital Lobe
o Interpretation of visual impulses from the retina
o Understanding of the written word
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Slide 19
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain
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Diencephalon
• Called interbrain
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It lies beneath the cerebrum
• Contains: thalamus and hypothalamus
• Thalamus
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Relay station for some sensory impulses while interpreting other
sensory messages (i.e. pain, touch, pressure)
• Hypothalamus
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Lies beneath the thalamus
Role in control of body temperature, fluid balance, appetite,
emotions (i.e. fear, pleasure, pain)
Controls sympathetic and parasympathetic divisions of
autonomic system as is the pituitary glands
Influences heartbeat, contraction and relaxation of walls of
blood vessels, hormone secretion, and other vital body
functions
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Slide 20
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Brain
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Cerebellum
• Lies posterior and inferior to cerebrum
• Second largest portion of brain
• Contains two hemispheres with convoluted surface much like
cerebrum
• Responsible for coordination of voluntary movement and
maintenance of balance, equilibrium, and muscle tone
• Sensory messages from semicircular canals in inner ear
sends messages to cerebellum
Brain stem
• Located at the base of the brain
• Consist of: Midbrain; pons; medulla oblongata;
• Connect spinal cord and cerebrum
• Carries all nerve fibers between spinal cord and cerebrum
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Slide 21
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
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Brainstem..cont
• Midbrain
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Superior portion of brain stem
Responsible for motor movement, relay of impulses,
auditory and visual reflexes
Origin of Cranial Nerves (CN) III and IV
• Pons
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Connects midbrain to medulla oblongata
“Pons” means “bridge”
Origin of CN V through VIII
Composed of myelinated nerve fibers and is responsible
for sending impulses to structures that are inferior and
superior to it
Contains a respiratory center that compliments
respiratory centers located in medulla
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Slide 22
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
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Brainstem.. cont
• Medulla oblongata
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Distal portion of brainstem
Origin of CN IX and XII
Controls heart beat, rhythm of breathing, swallowing,
coughing, sneezing, vomiting, and hiccups (singultus)
Vasomotor center regulates diameter of blood vessels,
helps aid in BP control
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Slide 23
Figure 54-2
(From Thibodeau, G.A., Patton, K.T. [1987]. Anatomy and physiology. St. Louis: Mosby.)
Sagittal section of the brain (note position of midbrain).
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Slide 24
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Coverings of brain and spinal cord
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Three protective coverings called meninges
• 1. Dura mater
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Outer most layer
• 2. Arachnoid membrane
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Second layer
• 3. Pia mater
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Inner most layer
Provides oxygen and nourishment to nervous tissue
• These layers also bathe Spinal Cord and brain in
cerebrospinal fluid (CSF)
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Slide 25
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
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Slide 26
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Ventricles
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Four in all: 3rd, 4th, left and right lateral ventricle
Spaces or cavities located in brain
CSF
• Clear and resembles plasma
• Flows into subarachnoid spaces around brain and
spinal cord and cushions them
• Contains protein, glucose, urea, and salts
• Contains substances that forms a protective barrier (the
Blood-Brain Barrier)

Prevents harmful substances to enter the Brain and SC
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Slide 27
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
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Slide 28
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
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Slide 29
Overview of Anatomy and Physiology
-Central Nervous System (CNS)
• Spinal Cord
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17 to 18 inch cord extending from brainstem to
second lumbar vertebra
Two main functions:
• Conducting impulses to and from the brain
• Serving as a center for reflex actions
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Responsible for certain reflex activity such as knee
jerk
• Sensory neuron sends information to cord, a central
neuron (within the cord) interprets impulse, and a
motorneuron sends message back to muscle or organ
involved
• Message is sent, interpreted, and acted upon without
traveling to brain
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Slide 30
Figure 54-3
(From Thibodeau, G. A., Patton, K. T. [1990]. Anthony’s textbook of anatomy and physiology. [13th ed.]. St. Louis: Mosby.)
Neural pathway involved in the patellar reflex.
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Slide 31
Another example
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Slide 32
Overview of Anatomy and Physiology
- Peripheral nervous system
• Peripheral nervous system

Comprise motor nerves, sensory nerves, and ganglia
outside brain and SC
 31 pairs of spinal nerves
 12 pairs of cranial nerves
 Autonomic nervous system
• Sympathetic nervous system
• Parasympathetic nervous system
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Slide 33
Overview of Anatomy and Physiology
- Peripheral nervous system
• Spinal Nerves
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31 pairs and all are mixed nerves
Transmit sensory information to SC through afferent
neurons and motor information from CNS to areas of
body through efferent neurons
Named according to the corresponding vertebra (e.g
C1, C2)
See next figure
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Slide 34
Overview of Anatomy and Physiology
- Peripheral nervous system
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Slide 35
Overview of Anatomy and Physiology
- Peripheral nervous system
• Cranial Nerves
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12 pairs
Attach to posterior surface of brain, mainly brainstem
Conduct impulses between head, neck, and brain, excluding vagus
nerve (CN X), which also serves organs in thoracic and abdominal
cavities
List of CN, impulses sent and functions:
• CN I, Olfactory – nose to brain – sense of smell
• CN II, Optic – eye to brain – vision
• CN III, Oculomotor – brain to eye muscles – eye movements,
pupillary control
• CN IV, Trochlear – brain to external eye muscles – eye movements
• CN V, Trigeminal (opthalmic, maxillary, mandibular branch) – skin &
mucus membrane of head to brain; teeth to brain; brain to chewing
muscles – sensation of face, scalp and teeth; chewing movements
• CN VI, Abducens – brain to external eye muscles – turning eyes
outward
• CN VII, Facial – taste buds of tongue to brain; brain to facial
muscles – sense of taste; contraction of muscles of facial expression
• CN VIII, Acoustic (vestibulocochlear) – ear to brain – hearing; sense
of balance
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Slide 36
Overview of Anatomy and Physiology
- Peripheral nervous system
• Cranial Nerves.. cont

List of CN, impulses sent and functions..cont:
• CN IX, Glossopharyngeal – throat and taste buds of tongue to
brain; brain to throat muscle and salivary glands – sensations
of throat, taste, swallowing, movements, secretion of saliva
• CN X, Vagus – throat, larynx & organs in thoracic &
abdominal cavities to brain; brain to muscles of throat & to
organs in thoracic & abdominal cavities – sensation of throat,
larynx & of thoracic & abdominal organs; swallowing, voice
production, slowing heartbeat, acceleration of peristalsis
• CN XI, Spinal accessory – brain to certain shoulder & neck
muscles – shoulder movements & turning movements of
head
• CN XII, Hypoglossal – brain to muscles of tongue – tongue
movements
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Slide 37
Overview of Anatomy and Physiology
- Peripheral nervous system
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Slide 38
Overview of Anatomy and Physiology
- Peripheral nervous system
• Autonomic Nervous System

Controls activities of smooth muscle, cardiac muscle,
and all glands
 Subdivision of peripheral nervous system
 Primary function is to maintain internal homeostasis
• Strives to maintain a normal heartbeat, constant body
temperature, and normal respiratory pattern

Two divisions:
• Sympathetic nervous system
• Parasympathetic nervous system
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Slide 39
Overview of Anatomy and Physiology
- Peripheral nervous system
• Autonomic Nervous System
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Two divisions
• Antagonistic
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One slows an action, and the other accelerates the action
Note: function simultaneously, but have the ability to
dominate each other as the need arises
• Stress
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Sympathetic takes over to prepare body for “fight or flight”
Heartbeat accelerates, BP increases, adrenal glands
increase secretions
• To calm the body
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
Parasympathetic dominates
Slowing heartbeat and decreasing BP and adrenal
hormones
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Slide 40
Overview of Anatomy and Physiology
- Peripheral nervous system
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Slide 41
Overview of Anatomy and Physiology
• Effects of Normal Aging on the Nervous System
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Loss of brain weight
Loss of neurons (1% a year after age 50)
Cortex losing cells faster than the brainstem
Remaining cells undergo structural changes
General decline in interconnections of dendrites
Reduction in cerebral blood flow
Decrease in brain metabolism and oxygen utilization
Neurons may contain senile plaques, neurofibrillary tangles &
age pigment lifofuscin
Altered sleep/ wakefulness ratio
Decrease in ability to regulate body temperature
Decrease in velocity of nerve impulses
Decreased blood supply to spinal cord causes decreased
reflexes
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Slide 42
Overview of Anatomy and Physiology
Older Adult Consideration Box
• Neurological Disorder
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As neuron are lost with aging, there is a deterioration in neurological
function, resulting in slowed reflex and reaction time
Tremors that increase with fatigue are commonly observed in adults
The sense of touch & the ability for fine motor coordination diminish with
aging
Most older people possess the ability to learn, but the speed of learning
is slowed. Short-term memory is more affected by aging than long-term
memory
The incidence of physiologic dementia or organic brain syndromeincluding Alzheimer’s disease, Pick’s disease & multiinfarct dementiaincreases with aging
Incidence of stroke increases with age. Prognosis is affected by the
location & extent of the cerebral damage. Rehab potential after a stroke
is often reduced by advanced age & coexisting medical problem
Nerve irritation resulting from arthritis, joint injuries or spinal-cord
compression can cause chronic pain or weakness
Dementia is not a normal consequence of aging but may be result of
may reversible conditions, including anemia, fluid & electrolyte
imbalance, malnutrition, hypothyroidism, metabolic disturbances, drug
toxicity, a drug reaction/idiosyncrasy & hypotension.
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Slide 43
Overview of Anatomy and Physiology
• Prevention of neurological problems

Avoid drug and alcohol use
• Smoking increases lung cancer and lung CA
metastasizes to the brain

Safe use of motor vehicles
 Safe swimming practices
 Safe handling and storage of firearms
 Use of hardhats in dangerous construction areas
 Use of protective padding as needed for sports
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Slide 44
Assessment of the Neurological System
• History
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Essential for diagnosing neurological disease
Includes specifics about symptoms experienced
Asses patient understanding & perception of what is happening.
Obtain info from family members/ significant others may be
helpful
Make sure information is complete
For patients with suspected neurological conditions presence of
many symptoms of subjective data may be significant. These
include the following:
• Headaches, especially those that first occur after middle age
or those that change in character; headaches that are worse
in the morning or awaken a person from sleep are especially
significant
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Slide 45
Assessment of the Neurological System
• History..cont

For patients with suspected neurological conditions
presence of many symptoms of subjective data may
be significant. These include the following..cont:
•
•
•
•
•
•
•
Clumsiness or loss of function in an extremity
Change in visual acuity
Any new or worsened seizure activity
Numbness or tingling in one or more extremities
Pain in an extremity or other part of the body
Personality changes or mood swings
Extreme fatigue or tiredness
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Slide 46
Assessment of the Neurological System
• Mental Status
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Assessment of patient neurological mental status is
important
Examination generaly includes orientation (person,
place, time, and purpose), mood and behavior,
general knowledge (such as names of U.S.
presidents), and short- and long-term memory.
The patient’s attention span and ability to concentrate
may also be assessed
Note actual patient statement & note actual level of
orientation (name, date, time & purpose), always try
different approach cause patient my learn the correct
answer through repetition
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Slide 47
Assessment of the Neurological System
• Level of consciousness
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Level of consciousness (LOC) is the earliest and most sensitive
indicator that something is changing.
A decreasing level of consciousness is the earliest sign of
increased intracranial pressure.
LOC has two components
• Arousal (or wakefulness) and
• Awareness.
Wakefulness is the most fundamental part of LOC. If the patient
can open the eyes spontaneously to voice or to pain, it says that
the wakefulness center in the brainstem is still functioning.
Awareness, a higher function controlled by the reticular activating
system in the brainstem.
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Slide 48
Assessment of the Neurological System
• Level of consciousness
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Awareness has four components:
1. Orientation: person, place, time, purpose
2. Memory: assess short-term memory; do not ask yes
or no questions.
3. Calculation: example, “If you have $2 and your apple
costs $1.25, how many quarters would you get back?”
4. Fund of knowledge: Ask the patient to name the
president and to tell you what’s on the national news
(Lower, 2002).

Restlessness, disorientation, and lethargy may be
seen first.
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Slide 49
Assessment of the Neurological System
• LEVELS OF CONSCIOUSNESS

Alert, Disorientation, Stupor, Semicomatose, Comatose, level &
description below:
• Alert: Responds appropriately to auditory, tactile, and visual
stimuli
• Disorientation: Disoriented; unable to follow simple
commands, thinking slowed, inattentive, flat affect.
• Stupor: Responds to verbal commands with moaning or
groaning, if at all
• Semicomatose: Impaired state of consciousness
characterized by obtundation and stupor, from which a patient
can be aroused only by energetic stimulation
• Comatose: Unable to respond to painful stimuli; cornea and
papillary reflexes are absent. The patient cannot swallow or
cough. The patient is incontinent of urine and feces. The EEG
pattern demonstrates decreased or absent neuronal activity.
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Slide 50
Assessment of the Neurological System
• Glasgow Coma Scale
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Quick, practical & standardized system for assessing
the degree of consciousness impairment in the
critically ill and for predicting the duration and ultimate
outcome of coma, particularly head injury.
Neurologic evaluation uses the Glasgow Coma scale
as an indicator of the severity of brain injury.
The highest possible number of 15 indicates that the
individual has no impairment, while a score of 3
indicates brain death.
A score of 6 – 8 is associated with a coma state
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Slide 51
Assessment of the Neurological System
• Glasgow Coma Scale
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E: Eye opening
• Spontaneous
• To verbal stimuli
• To pain stimuli
• None
=4
=3
=2
=1
M: motor response
• Obeys commands
• Localizes pain
• Normal withdrawal flexion
• Decorticate flexion
• Decerebrate extension
• Flaccid
=6
=5
=4
=3
=2
=1
V: verbal response
• Oriented
• Confused conversation
• Inappropriate words
• Incomprehensible sounds
• None
=5
=4
=3
=2
=1
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 52
Assessment of the Neurological System
• LANGUAGE AND SPEECH



Speech is a function of the dominant hemisphere, which is on the
left side of the brain for all right-handed people and most lefthanded people.
Aphasia
• An abnormal neurological condition in which the language
function is defective or absent because of an injury to certain
areas of the cerebral cortex-Broca’s area in the frontal lobe
and Wernicke’s area in the posterior part of the temporal
lobe.
Aphasia includes all areas of language, including speech,
reading, writing, and understanding. Aphasia has been
subdivided as follows:
• Sensory aphasia or receptive aphasia: inability to
comprehend the spoken word or written word.
• Motor aphasia: inability to use symbols of speech (also
called expressive aphasia).
• Global aphasia: inability to understand the spoken word or to
speak.
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Slide 53
Assessment of the Neurological System
• LANGUAGE AND SPEECH

Anomia
• A form of aphasia characterized by the inability to name
objects.

Dysarthria
• Defined as difficult, poorly articulated speech that
usually results from interference in the control over the
muscles of speech. The general cause is damage to a
central or peripheral nerve.
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Slide 54
Assessment of the Neurological System
• The cranial nerves classification












I (olfactory) - Identification of common odors
II (optic) - Testing of visual acuity and visual fields
III (oculomotor) - Testing of ability of eyes to move together in all
directions, testing pupillary response
IV (trochlear) - Tested with oculomotor; testing eye movements
V (trigeminal) - Jaw strength and sensation of face corneal reflex
VI (abducens) - Tested with oculomotor; testing eye movements
VII (facial) - Ability of face to move in symmetry, identification of
tastes
VIII (acoustic, or vestibulocochlear) - Testing of hearing through
whisper or other means and checking equilibrium and balance.
IX (glossopharyngeal) - Identification of taste
X (vagus) - Gag reflex, movement of uvula and soft palate
XI (spinal accessory) - Shoulder and neck movement
XII (hypoglossal) - Tongue motion
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Slide 55
Assessment of the Neurological System
MOTOR FUNCTION
• Motor function disturbances are the most commonly encountered
neurological symptom
• In general, the parts of the motor status examination include gait and
stance, muscle tone, coordination, involuntary movements, and the
muscle stretch reflexes.
• Reflexes that are usually tested include the biceps, triceps,
brachioradialis, quadriceps, gastrocnemius, and soleus muscles.
The examiner taps briskly over the muscle with a reflex hammer. The
response is noted and graded on a scale, usually from 0 to 4+, with
4+ being hyperreflexic
• The most important feature of any reflex pattern is not the absolute
value on the scale, but the comparison of one side of the body with
the other.
• Stick figures are commonly used to record the bilateral values.
• Damage to the nervous system often causes a serious problem in
mobility. A loss of function is called paralysis; a lesser degree of
movement deficit from partial or incomplete paralysis is called
paresis.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 56
Assessment of the Neurological System
MOTOR FUNCTION..cont
• Muscles may be flaccid (weak, soft, and flabby
and lacking normal muscle tone), with absent
deep tendon reflexes, or spastic (involuntary,
sudden movement or muscular contraction), with
increased reflexes.
• With some muscle problems, the affected muscle
shows small, localized, spontaneous, and
involuntary contractions called fasciculations.
With other problems, clonus (a forced series of
alternating contractions and partial relaxation of
a muscle) may occur.
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Slide 57
Assessment of the Neurological System
SENSORY AND PERCEPTUAL STATUS
• The sensory examination is the most common
difficult part of the neurological evaluation. Specific
alterations in sensation that should be assessed
include pain; touch; temperature; and
proprioception, the sensation pertaining to spatialposition and muscular-activity stimuli originating from
within the body or to the sensory receptors that
those stimuli activate.

This sensation gives one the ability to know
the position of the body without looking at it
and the ability to know objects by the sense of
touch.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 58
Assessment of the Neurological System
SENSORY AND PERCEPTUAL STATUS..cont
• Unilateral neglect, a condition in which an
individual is perceptually unaware of and inattentive
to one side of the body
• Another perceptual problem is hemianopia or
hemianopsia, which is characterized by defective
vision or blindness in half of the visual field
of one or both eyes.
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Slide 59
Assessment of the Neurological System
SENSORY AND PERCEPTUAL STATUS..cont
• It is usually not feasible or necessary to complete the total
neurological examination during shift-to-shift assessments of
the patient.
• In intensive care units, the neurological checks may be done
as frequently as every 15 minutes.

Factors that are the most important include
1. orientation,
2. level of consciousness,
3. bilateral muscle strength,
4. speech ability,
5. involuntary movements,
6. ability to follow commands, and
7. any abnormal posturing.
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Slide 60
Laboratory and Diagnostic Exam
BLOOD AND URINE TESTS
• Urine culture may rule out infection involving the urinary tract.
• Other urine testing may indicate the presence of diabetes
insipidus
• Urine drug screens may be done to rule out drug use as a
cause of lethargy or to identify specific drugs ingested
• Arterial blood gas values may be an important diagnostic tool
in monitoring the oxygen content of the blood
• Gases may be altered with neurological diseases suc as
Guillain-Barre syndrome where breathing pattern were altered
• Blood test that are routinely done may help narrow the Dx of
neurological disorder
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Slide 61
Laboratory and Diagnostic Exam
CEREBROSPINAL FLUID
• Normally there are up to 10 lymphocytes per milliliter of
spinal fluid. An increase in the number of cells may indicate
an infection.
• Infections such as Tuberculosis meningitis often lower the
CSF glucose level
• Bacterial infection such as TB meningitis often lower the
CSF glucose level as well as the chloride levels (culture or
smear exam is done to determine the causative organism in
meningitis)
• Spinal-fluid protein is elevated when degenerative disease
or a brain tumor is present
• Blood in the spinal fluid indicates hemorrhage from
somewhere in the ventricular system
• A protein electrophoresis eval may give evidence of
neurological diseases such as Multiple Sclerosis (MS)
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Slide 62
Laboratory and Diagnostic Exam
CEREBROSPINAL FLUID..cont
• Normal Characteristic of CSF



Spec Gravity
pH
Chloride
Glucose
Pressure
Total vol

Total protein

Gamma globulin



Cell count
RBC
WBC


Culture & sensitivity
Serology for syphilis



1.007
7.35-7.45
120-130 mEq/L
50-75 mg/dl
80-200 mm water
80-200 ml (15ml in
ventricle)
15-45 mg/dl – lumbar
10-25 mg/dl – cisternal
5-15 mg/dl – ventricular
6-13% of total protein
count
None
0-10 cells (all lymphocytes n
monocytes)
No organism present
Negative
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Slide 63
Laboratory and Diagnostic Exam
Other Tests
• Routine skull radiographs of the head and vertebral
column, used in ruling out fractures of the skull and
cervical vertebrae.
• Since the development of the computed tomography
(CT) scan, skull radiographs are not used as
extensively as before.
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Slide 64
Laboratory and Diagnostic Exam
Computed Tomography (CT) Scan
• The purpose of the CT scan, also called the CAT scan, is to
detect pathologic conditions of the cerebrum and spinal cord
using a technique of scanning without radioisotopes
• If contrast medium is used, it is important for the nurse to
document and report to the physician any history of allergy to
iodine and seafood because iodine is present in the contrast
medium
• No special physical preparation on the patient, takes about
20-30 min without contrast medium and 60 min with contrast
medium.
• Painless except discomfort when IV is started for contrast
medium and claustrophobic feeling as head will be placed on
a holder while laying still
• Each image appears specific brain tissue, computer will
display areas of increased densities (e.g tumors or thrombi)
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Slide 65
Laboratory and Diagnostic Exam
Brain Scan
• The brain scan’s purpose is detecting pathologic conditions of
the cerebrum. It uses radioactive isotopes and a scanner.
• No special physical preparation, patient lay still as the scanner
passes over the brain area
• Procedure takes 45 min for the scanning
• The patient is injected with radioisotope, minimal discomfort
may occur when IV is started for radioisotope
• If mercury is used as isotope, meralluride (mercuhydrin) is
administered several hours before to allow greater
concentration of mercury to circulate the brain tissue, coz it
minimizes uptake of mercury by kidney
• Brain scan is being used less frequently than in the past
because of the excellent results obtained from CT scan and
magnetic resonance imaging (MRI)
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Slide 66
Laboratory and Diagnostic Exam
Magnetic Resonance Imaging (MRI) Scan
• MRI uses magnetic forces to image body structures.
• Used to detect pathologic conditions of the cerebrum and
spinal cord, as in detection of stroke, multiple sclerosis,
tumors, trauma, herniation & seizures
• MRI is the diagnostic test of choice for many neurological
diseases because it yields greater contrast in the images of
soft-tissue structures than does the CT scan
• The scan involves a magnetic force, hence, the patient is
cautioned to remove watches and any metal from body or
clothing before entering the scanning room.
• Painless procedure takes about 45-60min, minimal discomfort
for lying still and claustrophobia feeling, patient must be
warned that machine may makes loud noises during
procedure
• New advanced in MRI techniques include diffusion weighted
imaging and magnetic resonance spectroscopy
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Slide 67
Laboratory and Diagnostic Exam
Magnetic Resonance Angiography (MRA)
• Magnetic resonance angiography (MRA) uses
differential signal characteristic of flowing blood to
evaluate extracranial and intracranial blood vessels.
It provides both anatomic and hemodynamic
information.
• MRA is rapidly replacing cerebral angiography for
use in diagnosing cerebrovascular disease
• Also called cMRA (contrast enhanced MRA) if used
in conjuction with contrast media
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Slide 68
Laboratory and Diagnostic Exam
Positron Emission Tomography (PET) Scan
• In this procedure the patient receives an injection of
deoxyglucose with radioactive fluorine.
• The area in question is scanned, and a color composite
picture is obtained. Shades of color give an indication of
the level of glucose metabolism; this then can be
translated into indications of a pathologic state.
• PET scan provide non invasive means of determining
biochemical processes that occur in the brain
• There is increased clinical use of PET scan to monitor
select patients following stroke, Alzheimer’s disease,
tumors, epilepsy, and Parkinson’s disease
• Discomfort is minimal, patient must be aware the need to
lie still during scanning, approx 45 min.
Slide 69
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Laboratory and Diagnostic Exam
The gray outer surface is the surface of
the brain from MRI and the inner
colored structure is cingulate gyrus,
part of the brain's emotional system
visualized with PET.
Photo by Monte S. Buchsbaum, M.D.
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Slide 70
Laboratory and Diagnostic Exam
Lumbar Puncture
• Performed as part of the Dx workup of the patient who may have a
neurological problem
• A lumbar puncture is done to obtain CSF for examination, to relieve
pressure, or to introduce dye or medication
• It is contraindicated in patients with increased intracranial pressure, because
the withdrawal of fluid may cause the medulla oblongata to herniate
downward into the foramen magnum
• Procedure takes 10-15min, commonly done in patient’s room or the imaging
department, slight pain & pressure may be felt as the dura is entered, sharp
shooting pain down one leg may occur, caused by needle coming close to a
nerve
• Done in side positioned with knee and head flexed at acute angle allowing
lumber flexion & separation of the interespinous spaces. Anesthetized the
area with local aesthesis then needle inserted at L4-L5 or L5-s1 interspace.
Removed inner needle for drainage & measure the spinal fluid.
• Manometer is used to measure the pressure
• After the procedure the patient lies flat in bed for several hours.
• Headache is fairly common and is thought to be caused by the loss of spinal
fluid.
• If a headache develops, bed rest, analgesics, and ice to the head may help.
Opioids are usually not helpful
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Slide 71
Laboratory and Diagnostic Exam
LUMBAR
PUNCTURE
(BETWEEN L3–L4)
Position and angle of
the needle when
lumbar puncture is
performed.
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Slide 72
Laboratory and Diagnostic Exam
Electroencephalogram
• The electroencephalogram (EEG) is used to provide evidence
•
•
•
•
of focal or generalized disturbances of brain function by
measuring the electrical activity of the brain.
Among the cerebral diseases assessed by the EEG are
epilepsy, mass lesions (e.g, tumors, abscess, hematoma),
cerebrovascular lesions, and brain injury.
No special preparation, only rest & quite surrounding before
procedure.
Usually done first thing in the morning, takes about 1hr to
complete
After procedure patient must rest and assisted to wash the
patient hair to remove the collodion from scalp.
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Slide 73
Laboratory and Diagnostic Exam
Myelogram
• The myelogram is commonly used to identify lesions in the
•
•
•
•
•
•
intradural or extradural compartments of the spinal canal by
observing the flow of radioppaque dye through the
subarachnoid space.
The most common lesion for which this test is used is a
herniated or protruding intervertebral disk. Other lesions
include spinal tumors, adhesions, bony deformations, and
arteriovenous malformations.
Procedure takes about 2 hrs, will be slight discomfort as dura
entered and may be asked to assume variety position during
procedure
Preparation are the same as the lumbar puncture aside from
the injection of dye (ask patient for allergic reaction)
Patient usually undergoes CT scan 4-6hrs after myelogram
Headaches are common after the procedure, might be
accompanied by N&V.
Patient must lay flat for few hours.
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Slide 74
Laboratory and Diagnostic Exam
Angiograms
• The angiograms (cerebral arteriography) is a procedure used to
•
•
•
•
•
•
•
•
•
visualize the cerebral arterial system by injecting to visualize the
cerebral system by injecting radiopaque material.
It allows the detection of arterial aneurysms, vessel anomalies,
ruptured vessels, and displacement of vessels by tumors or masses.
Clear liquid only before procedure, some other facility require NPO
Asses allergic reaction to iodine
Takes about 2-3hrs, may experience discomfort lying still for that
time period. Supine position on radiograph table
When dye injected may experience feeling or extremely hot and
seeing flashes of light.
After procedure bed rest is ordered for 4-6hrs, VS checked every
15mins, neurological assesment every VS check, asses puncture
site for hematoma
Patient may be at risk for cerebral vascular accident as well as
increase in intracranial pressure.
Any changes in LOC must be reported promptly
MRA is replacing cerebral ateriography in some facility
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Slide 75
Laboratory and Diagnostic Exam
CAROTID DUPLEX
• Combined ultrasound & Doppler technology
• Amplified response & graphic record & sound
registers blood flow velocity indicating stenosis of a
vessel
• Non invasive studies that evaluates carotid occlusive
disease
• Usually ordered on Transient Ischemic Attack patient
to determine the pathology of the carotid
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Slide 76
Laboratory and Diagnostic Exam
ELECTROMYOGRAM
• Used to measure the contraction of a muscle in
response to electrical stimulation
• Provide evidence of lowere motoneuron disease;
primary muscle disease; defects in transmission of
electrical impulses at NMJ, such as in Myasthenia
gravis
• Takes 45min for muscle study, there will be
discomfort when electrode inserted into muscle &
when electrical current is used. Muscle may ache
afterwards
• Asses signs of bleeding after procedure at the
injection sites.
• May need analgesic for discomfort & rest period
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Slide 77
Laboratory and Diagnostic Exam
Echoencephalogram
• Uses ultrasound to depict the intracranial structures
of the brain
• Helpful in detecting ventricular dilation & major shift
of midline structures in the brain as result of
expanding lesion
• Procedure is similar to brain scan
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Slide 78
Common Disorders of the Neurological
System
• Headaches

Etiology/pathophysiology
• The exact mechanism of head pain is not known. Although
the skull and brain tissues are not able to feel sensory pain,
pain arises from the scalp, its blood vessels and muscles,
and from the dura mater and its venous sinuses.
• Pain also arises from the blood vessels at the base of the
brain and from cervical cranial nerves. Blood vessels may
dilate and become congested with blood
• Headaches can be classified as vascular, tension, and
traction-inflammatory
1.
2.
3.
Vascular headache, include migraine, cluster, and hypertensive
headaches
Tension headache, arise from medical problems such as
cervical arthritis.
Traction-inflammatory headaches include
those caused by
infection, intracranial or extracranial causes, occlusive vascular
structures, and temporal arteritis.
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Slide 79
Common Disorders of the Neurological
System
•
Headaches (continued)

Clinical manifestations
• Headache pain may be worse by stress or tension.
• Knowledge of the patient’s perception of the effect of stress
on the pain is important in planning effective interventions.
• Migraine headaches

Prodromal (early s/s ofsigns and symptoms that occur
before the acute attack. These may include any of the
following:
1.
Visual field defects
2.
Experiencing unusual smells or sounds
3.
Disorientation
4.
Paresthesias and,
5.
In rare cases, paralysis of a part of the body.
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Slide 80
Common Disorders of the Neurological System
• Headaches (continued)

Clinical manifestations...cont
• During a migraine headache s/s may include:


N&V, sensitivity to light, chilliness, fatigue, irritability,
diaphoresis, edema & other signs of autonomic dysfunction
• Abnormal metabolism of serotonin, a vasoactive
neurotransmitter found in platelets & cells of the brain, plays a
major role.
Assessment
• Include the patient’s understanding of the headache, possible
causes and any precipitating factors
• Important to determine what measures relieve the symptoms
as well as the location, frequency, pattern & character of the
pain
• Includes the site of return f the headache, time of day,
intervals between headaches
• Initial onset of the headache, presence of any symptoms that
occur before the headache or associated symptoms, the
presence of allergies and any family history of similar
headache patterns are also important to asses
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Slide 81
Common Disorders of the Neurological System
• Headaches (continued)

Assessment..cont
• Objective date include any behavior indicating stress,
anxiety and pain
• Changes in ADL, as abnormally raised temperature n
presence of sinus drainage may be important
• Document abnormality during physical exam of
neurological assessment

Diagnostic test
• Usual testing includes neuro exam, a CT scan (MRI or
PET), brain scan, skull radiograph and lumbar pucture
• Lumbar pucture is contraindicated if increased
intracranial pressure exist, or if brain tumor is suspected
as it may cause brain herniation. CT scan is the
preferable test in this situation.
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Slide 82
Common Disorders of the Neurological
System
• Headaches (continued)

Medical management
• Diet: limit MSG, vinegar, chocolate, yogurt, alcohol,
fermented or marinated foods, ripened cheese, cured
sandwich meat, caffeine, and pork
• Psychotherapy
• Medications

Migraine headaches
o Aspirin, acetaminophen, ibuprofen
o Ergotamine tartrate
o Codeine
o Inderal
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Slide 83
Common Disorders of the Neurological System
• Medical management...cont


Acetylsalicylic acid (aspirin) may help relieve migraine pain.
Ergotamine tartrate preparations taken early in the attack may
prevent progression of the headache. These drugs act by
constricting cerebral blood vessel walls and reducing cerebral
blood flow.
• Reduces inflammation and may reduce pain transmission
• Given orally, sublingually, rectally or by injection
• Can be combined with caffeine, phenobarbital & belladona
• Side effects of ergot preparations include nausea,
vomiting, numbness and tingling, muscle pain, and
changes in heart rate
• They cannot be taken by pregnant women because
they stimulate contractions of the uterine smooth
muscle
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Slide 84
Common Disorders of the Neurological System
• Medical management…cont

Drugs that are Classified as selective serotonin receptor
agonists, these drugs are all indicated to treat acute migraine
(with or without aura) in adults:
•
•
•
•
•
•
•
Eletriptan (Relpax)
Almotriptan (Axert),
Frovatriptan (Frova),
Naratriptan (Amerge),
Rizatriptan (maxalt),
Sumatriptan (Imitrex), and
Zolmigriptan (Zomig)
The Triptan are thought to act on receptors in the extracerebral,
intracranial vessels that become dilated during a migraine attack.
Stimulating this receptor constricts cranial vessels, inhibit
neuropeptide release and reduces nerve impulse transmission
along trigeminal pain pathways.
 Triptans relieve N&V and photphobia assicuated with acute
migrane attack
Slide 85
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Common Disorders of the Neurological System
• Medical management ..cont






Other drugs that maybe used include nonopioid analgesics such
as phenacetin, acetaminophen (Darvocet N).
Propranolol (Inderal) has been used in the prophylactic treatment
of migraine and other vascular headaches.
Intranasal lidocaine has been used with some relief.
Tension headaches
• Non-narcotic analgesics
Traction-inflammatory headaches
• Treat cause
Comfort measures
• Cold packs to forehead or base of skull
• Pressure to temporal arteries
• Dark room; limit auditory stimulation
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Slide 86
Common Disorders of the Neurological
System
• Nursing Interventions and Patients Teaching


Because stress and emotional upsets may precipitate
some headaches and worsen others, relaxation and
rest should be facilitated. This includes relaxation
techniques, planned sleeping hours, and regular rest
periods.
Alcohol should not be used to relieve tension because
it may become addicting and has been found to be a
significant cause of cluster headaches, especially
ones caused by tension.
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Slide 87
Common Disorders of the Neurological System
• Nursing Interventions and Patients Teaching

Comfort measures.
• Other treatments that may be helpful for a
patient with a headache include cold packs
applied to the forehead or base of the skull.
• Pressure applied to the temporal arteries may
be helpful.
• People with migraine headaches, especially,
are usually most comfortable lying in a dark
room with minimal auditory stimulation.
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Slide 88
Common Disorders of the Neurological System
• Education and Teaching:
1.
2.
3.
4.
5.
Avoidance of factors that trigger headaches,
Relaxation techniques including biofeedback,
Importance of maintaining regular sleep patterns,
Medications to be used (including dose, actions, and side
effects), and
The importance of follow-up care.
• Prognosis



With proper treatment the person with headaches can expect to
live a normal life.
Changes in lifestyle may need to occur, especially during acute
episodes of headache pain.
The person may have to adjust to periodic headaches and will
need to rest until the headache resolves.
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Slide 89
Common Disorders of the Neurological System
• Neurological Pain

Etiology/pathophysiology
• Neurological pain other than headache is common. The
transmission of pain is not fully understood, but patients may
experience disabling pain either caused by a disorder within
the nervous system (lesion in nerve roots, thalamus, central
pain tract [lateral spinothalamic]) or caused peripherally at a
distant part of the body
• Pain receptor can be activated by cellular damage certain
chemicals such as histamine, heat, ischemia, muscle spasm
& sensation of cold & pruritus that go beyond specific level of
intensity.
• Pain that is described as unbearable and does not respond to
treatment is classified as intractable. It is chronic and often
debilitating, and may prevent the patient from functioning in
ADLs.
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Slide 90
Common Disorders of the Neurological System
• Neurological Pain..cont

Assessment
• Subjective:






Perception of pain is highly subjective
Asses patient understanding of pain
Any precipitating factors
Measures to relieve stress, including medication & Usual coping
patterns of the patient when under stress
Site, quality, frequency & nature of the pain
Presence of associated symptoms & measures that makes it
worse are important too
• Objective:






Any behavioral signs indicating pain or stress
Change in ADLs
Muscle weakness or wasting
Vasomotor responses (flushing)
Abnormalities in spinal reflexes
Abnormalities noted during the sensory examination
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Slide 91
Common Disorders of the Neurological System
• Neurological Pain..cont


Diagnostic Test
• Diagnostic tests for the patient in pain may include electrical
stimulation used to define the pain to a greater degree.
Psychological testing may be part of the workup.
• If back or neck pain is present, a myelogram is usually
performed.
Medical management
• Nonsurgical methods of pain control include


Transcutaneous electrical nerve stimulation (TENS)
Spinal cord stimulation.

Both techniques use electrodes applied near the site of
pain or on or around the spine.

Acupuncture has also been used to treat patients with
neurological pain.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 92
Common Disorders of the Neurological System
• Neurological Pain..cont

Medical management..cont
• Nerve block used to control intractable pain
• By injecting local anesthetic, alcohol or phenol close
enough to a nerve to block the conduction of impulses
• Sources of pain treated include trigeminal neuralgia,
cancer, or pheripheral vascular disease
• Duration of effect is from months to years
• Epidural catheter is used to control pain & spacticity
• Continued Meds are given
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 93
Common Disorders of the Neurological System
• Neurological Pain..cont

Medical management..cont
• Medications are often used to treat patients with
neurological pain.



Gabapentin (Neurontin) to control neurological pain
Nonopioid analgesics such as acetaminophen,
propoxyphene (Darvon), phenacetin, and acetylsalicylic
acid.
Opioids may be prescribed, as well as muscle relaxants,
but these drugs may led to abuse.
• The emphasis should be on helping the patient learn
other measures to control the pain.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 94
Common Disorders of the Neurological System
• Neurological Pain..cont

Medical management..cont
• Surgical methods of pain control
 In cases of intractable pain that does not
respond to more conservative measures,
surgery may be necessary to reduce or abolish
pain.
 Neurosurgical procedures that may be done
include neurectomy, rhizotomy, cordotomy, and
percutaneous cordotomy.
o
Side effects of the procedures (cordotomy) include
postural hypotension, inability to feel hot or cold, and
possibly motor and bowel dysfunction function.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 95
Common Disorders of the Neurological System
• Neurological Pain..cont

Nursing Interventions and Patient Teaching
• Comfort measures.



The patient assumes the most comfortable position.
Nurse should help the patient to find a comfortable
position and may need to actively assist the patient in
turning or moving
Straining may intensify pain, so stool softener may be
needed. Offer prune juice & high fiber diet with 2000ml/
day fluid or more
• Promotion of rest and relaxation.


As with headache, stress and emotional upsets may
precipitate or exacerbate neurological pain. Rest and
relaxation should be facilitated, with planned sleeping
hours and rest periods as needed.
Some patients with pain, especially intractable pain, may
respond well to psychotherapy.
Slide 96
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Common Disorders of the Neurological System
• Neurological Pain..cont

Prognosis
• As with headache pain, neurological pain can in most
cases be treated adequately. Lifestyle changes may be
helpful in allowing the person to live a full life.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 97
Common Disorders of the Neurological
System
• Increased intracranial pressure

Etiology/pathophysiology
• Complex grouping of events that occurs because of
multiple neurological conditions
• Occurs suddenly, can progress rapidly, often requires
surgical intervention
• Considered as an increase in any content of the
cranium
• Space-occupying lesions, cerebrospinal problems,
cerebral edema
• Since cranial vault is rigid and nonexpandable, buildup
pressure may occur in weeks, or rapidly depending on
cause.
• Usually involved one side of the brain, but both will
eventually involved
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 98
Common Disorders of the Neurological System
• Increased intracranial
pressure

Etiology/pathophysiology..c
ont
• Normal ICP = 4 – 13
mmHg
• Any sustained increase
in ICP is dangerous
hence early detection
and treatment are vital
before complications
occur
• Neuron tissue death will
begin within 4 – 6
minutes if oxygen is not
supplied
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 99
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Etiology/pathophysiology..cont
• How it happened:


Increased pressure in cranial cavity compensated by
venous compression & cerebrospinal displacement. As
pressure increased the cerebral blood flow decreases
causing inadequate perfusion to the brain, starting a
vicious cycle that causes PCO2 to increase and PO2 &
pH decrease. These causing vasodilation and cerebral
edema causing further increased intracranial pressure
and even greater increase in pressure as compression of
neural tissue increased.
When pressure is greater than the ability to compensate,
pressure is exerted on surrounding structure where the
pressure is lower, this movemenet of pressure is called
supratentorial shift, which can result in herniation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 100
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Etiology/pathophysiology..cont
• How it happened..cont


Brainstem is compressed at various levels, which in turn
compresses the vasomotor center, posterior cerebral
artery, oculomotor nerve, corticospinal nerve pathway
and the fibers of the ascending reticular activating system
as a result of herniation of the brain
Rise in systolic pressure and an unchanged diastolic
pressure, resulting in a widening pulse pressure,
bradycardia & abnormal respiration are late sign of
increased ICP and indicating that brain is about to
herniate.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 101
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Assessment
• Subjective







Presence of any visual changes such as diplopoa or
double vision
Change in patient personality
Change in the ability to think
Presence of nausea or pain, especially headache is
important
Headache thought resulting from venous congestion &
tension in the intracranial blood vessels as the cerebral
pressure rises
Increase intensity with coughing, straining at stool or
stooping
Usually present early mornings and may awaken patient
from sleep
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Slide 102
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Assessment..cont
• Objective








Change of LOC (earliest sign of increased ICP)
o Disorientation, restlessness or lethargy
It’s important to chart what is seen not what is inferred
Pupillary sign may change responsiveness as it’s controlled by
cranial nerve III (oculomotor nerve)
As the brain herniates, the nerve is being compressed-with the
top part of the nerve being affected first. The ipsilateral pupil
(when lesion in one hemisphere) remains dilated & incapable of
constricting
Once both halves of the brain become affected bilateral pupil
dilation and fixation occur
Pupil that is fixed & dilated is called blown pupil, an ominous
sign that must be reported to the MD immediately
BP & pulse will increase in increased ICP, causing systolic BP
to rise
If pressure continues widening pulse pressure will occur
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Slide 103
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Assessment..cont
• Objective..cont






Pressure will increased parasympathetic transmission of
impulses through the vagus nerve to the heart, causing slowing
of the pulse
Cushing’s response will exist, it is a widened pulse pressure,
increase systolic BP and bradycardia. Cushing’s is considered
and important Dx sign of late stage brain herniation
Breathing pattern may be deep & stertorous (snorelike) or
periodic (Cheyne-Stokes) respiration
Ataxic breathing may occur (an irregular & unpredictable
breathing pattern with random, shallow, and deep breath &
occasional pauses)
As Intracranial pressure increases to fatal levels, respiratory
paralysis occur
Seen in patient with damage to medulla oblongata
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Slide 104
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Assessment..cont
• Objective..cont



High, uncontrolled temperature occur due to a failure of
the thermoregulatory center
Presence of Babinski’s reflex, hyperflexia, rigidity &
seizures are additional signs of decreased motor function
due to compression of the upper motoneuron pathway
(corticospinal tract) interrupting transmission of impulses
to the lower motoneuron
Herniation of the upper part of the brainstem may
produce characteristic posturing when patient is
stimulated (see picture left)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 105
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Assessment..cont
• Objective..cont







Vomiting & singultus are two objective sign.
Vomiting is often projectile in nature & usually not
preceded by nausea (called unexpected vomiting)
Singultus is caused by compression of the vagus nerve
(CN X) when brainstem herniation occur.
Papilledema, can be detected by using ophtalmoscope
(done by MD’s) as optic disk becomes edematous, reitna
is also compressed, damaged retina cannot detect light
rays as blind spot enlarges as visual acuity lessened.
Papilledema is also called choked disk
Urinary incontinence
Bulging fontanelles
Leakage of CSF (clear yellow or pinkish fluid) from the
nose (rhinorrhea) or ear (otorrhea).
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 106
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Herniation of the Brain
• When Inc. ICP exerts enough pressure to displace a
portion of the brain, herniation can occur. The brain
would herniate through a large foramen in the occipital
bone, which lies between the cranial and spinal cavities.
• Herniation causes severe injury to the brain because of
prolonged hypoxia to parts of the brain that control the
vital functions of the body, such as breathing and blood
circulation. The result is brain death and death of the
patient.
• When ICP is elevated, lumbar puncture is
contraindicated , because it can cause the brain to
herniate.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 107
Common Disorders of the Neurological System
• Increased intracranial
pressure..cont

Diagnostic Test
• CT or MRI scan, shows
structural herniation &
shifting of the brain
• Most of the time acute
increased intracranial
pressure is an emergency
there is little time for Dx
test
• Dx must be based on
frequent & careful
observation & neurological
testing
• Presence of even subtle
changes may be very
significant
• Internal measuring device
used to Dx increased
intracranial pressure (see
right pic)
ICP Monitoring
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Slide 108
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Medical management
• Treat cause if possible
• Mechanical decompression



Craniotomy, bone flap is removed then replaced
Craniectomy, bone flap is removed & not replaced
(often done when pressure is high)
Drainage of the ventricles or any subdural
hematoma may be beneficial as well
• Internal monitoring devices
• Endotracheal intubation may be necessary
• ABG analysis to guide O2 therapy (to maintain
PAO2 @ 100mmHg)
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 109
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Medical management
• Three types of medications are usually administered to
patients with increased intracranial pressure:


Osmotic Diuretics, Corticosteroids & Anticonvulsants.
Example of drugs:
1.
2.
3.
4.
Osmotic diuretics (mannitol), Loop diuretics
(furosemide (Lasix), bumetanide (Bumex), and
ethacrynic acid (Edecrin)
Midazolam (sedative, hypnotic, antianxiety) and
atracurium besylate (neuromuscular blocker)
Corticosteroids – Dexamethasone – to control edema
surrounding cerebral tumors and abcesses (monitor
glucose level).
Anticonvulsants - Phenytoin (Dilantin), Fosphenytoin
(Cerebyx) through IV for better absorbtion– To
prevent seizures
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Slide 110
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Nursing Interventions and Patients Teaching
• Therapeutic measures to reduce venous volume may
be implemented.





Elevate the head of the bed to 30 to 45 degrees to
promote venous return.
Place the neck in a neutral position (not flexed or
extended) to promote venous drainage.
Position the patient to avoid flexion of the hips, waist, and
neck as well as rotation of the head, especially to the
right. Extreme hip flexion is avoided because this position
causes an increase in intraabdominal and intrathoracic
pressures, which can produce a rise in ICP.
Instruct the patient to avoid isometric or resistive
exercises.
Restrict fluid intake.
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Slide 111
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Nursing Interventions and Patients Teaching
• Therapeutic measures to reduce venous volume may be
implemented.





Implement measures to help the patient avoid Valsalva’s
maneuever (any forced expiratory effort against a closed airway,
such as straining to have a stool). Enemas and laxatives should
be avoided if possible.
Have a Foley catheter in place if the patient is not alert because
of the large amount of urine that is produced
Perform suctioning only as necessary and for no longer than 10
seconds with admission of 100% oxygen before and after to
prevent decreases in the PaO2.
Administer oxygen via mask or cannula to improve cerebral
perfusion.
Use a hypothermia blanket to control body temperature
(increased body temperature increases brain damage).
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Slide 112
Common Disorders of the Neurological System
• Increased intracranial pressure..cont

Prognosis
• The prognosis for the patient with increased intracranial
pressure depends on the cause and how rapid with
which it is treated.
• The nurse assumes a very important role in monitoring
the patient for signs and symptoms of increased
pressure.
• After herniation of the brain has begun as a result of
pressure, there is little chance for complete reversal
without significant brain damage.
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Slide 113
Common Disorders of the Neurological System
• Increased intracranial pressure

Clinical manifestations/assessment
•
•
•
•
Diplopia
Headache
Decreased level of consciousness
Pupillary signs
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 114
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Slide 115
Common Disorders of the Neurological
System
• Increased intracranial pressure (continued)

Clinical manifestations/assessment (continued)
•
•
•
•
•
•
•
•
•
Widening pulse pressure
Bradycardia
Respiratory problems
High, uncontrolled temperatures
Positive Babinski’s reflex
Seizures
Posturing
Vomiting
Singultus
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Slide 116
Common Disorders of the Neurological
System
• Increased intracranial pressure (continued)

Medical management/nursing interventions
• Treat cause if possible
• Mechanical decompression


Craniotomy
Craniectomy
• Internal monitoring devices
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Slide 117
Common Disorders of the Neurological
System
• Disturbances in muscle tone and motor function

Etiology/pathophysiology
• Damage to the nervous system causes serious
problems in mobility

Clinical manifestations/assessment
• Flaccid or hyperreflexic muscle tone
• Clumsiness or incoordination
• Abnormal gait
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Slide 118
Common Disorders of the Neurological
System
• Disturbances in muscle tone and motor function
(continued)

Medical management/nursing interventions
•
•
•
•
•
•
•
Muscle relaxants
Protect from falls
Assess skin integrity
Positioning
Sit up and tuck chin when eating
Encourage patient to assist with ADLs
Emotional support
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Slide 119
Other Disorders of the Neurological
System
• Epilepsy or seizures

Etiology/pathophysiology
• Transitory disturbance in consciousness or in motor,
sensory, or autonomic function due to sudden,
excessive, and disorderly discharges in the neurons of
the brain; results in sudden, violent, involuntary
contraction of a group of muscles
• Types: grand mal; petit mal; psychomotor; Jacksonianfocal; myoclonic; akinetic
• Status epilepticus
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Slide 120
Other Disorders of the Neurological
System
• Epilepsy or seizures (continued)

Clinical manifestations/assessment
• Depends on type of seizure
• Aura
• Postictal period

Medical management/nursing interventions
• During seizure: protect from aspiration and injury
• Anticonvulsant medications
• Surgery

Removal of brain tissue where seizure occurs
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Slide 121
Other Disorders of the Neurological
System
• Epilepsy or seizures (continued)

Medical management/nursing interventions
(continued)
•
•
•
•
Adequate rest
Good nutrition
Avoid alcohol
Avoid driving, operating machinery, and swimming until
seizures are controlled
• Good oral hygiene
• Medical alert tag
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Slide 122
Degenerative Diseases
• Multiple sclerosis

Etiology/pathophysiology
• Degenerative neurological disorder with demyelination
of the brain stem, spinal cord, optic nerves, and
cerebrum
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Slide 123
Figure 54-13
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Pathogenesis of multiple sclerosis.
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Slide 124
Degenerative Diseases
• Multiple sclerosis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Visual problems
Urinary incontinence
Fatigue
Weakness
Incoordination
Sexual problems
Swallowing difficulties
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Slide 125
Degenerative Diseases
• Multiple sclerosis (continued)

Medical management/nursing interventions
•
•
•
•
•
•
•
•
No specific treatment
Adrenocorticotropic hormone (ACTH)
Steroids
Valium
Betaseron (interferon beta-1b)
Avonex (interferon beta-1a)
Pro-banthine; urecholine
Bactrim, Septra, and Macrodantin
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Slide 126
Degenerative Diseases
• Parkinson’s disease

Etiology/pathophysiology
• Deficiency of dopamine

Clinical manifestations/assessment
•
•
•
•
•
•
Muscular tremors; bradykinesia
Rigidity; propulsive gait
Emotional instability
Heat intolerance
Decreased blinking
“Pill-rolling” motions of fingers
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 127
Figure 54-14
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Nigrostriatal disorders produce parkinsonism.
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Slide 128
Degenerative Diseases
• Parkinson’s disease (continued)

Medical management/nursing interventions
• Medications





Levodopa
Sinemet
Artane
Cogentin
Symmetrol
• Surgery

Pallidotomy
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Slide 129
Degenerative Diseases
• Alzheimer’s disease

Etiology/pathophysiology
• Impaired intellectual functioning
• Degeneration of the cells of the brain
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Slide 130
Degenerative Diseases
• Alzheimer’s disease (continued)

Clinical manifestations/assessment
• Early stage

Mild memory lapses; decreased attention span
• Second stage

Obvious memory lapses
• Third stage


Total disorientation to person, place, and time
Apraxia; wandering
• Terminal stage

Severe mental and physical deterioration
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Slide 131
Degenerative Diseases
• Alzheimer’s disease (continued)

Medical management/nursing interventions
• Medications


Agitation: lorazepam; Haldol
Dementia: Cognex; Aricept
• Nutrition

Finger foods; frequent feedings; encourage fluids
• Safety



Remove burner controls at night
Double-lock all doors and windows
Constant supervision
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 132
Degenerative Diseases
• Myasthenia gravis

Etiology/pathophysiology
• Neuromuscular disorder; nerve impulses fail to pass at
the myoneural junction; causes muscular weakness

Clinical manifestations/assessment
•
•
•
•
Ptosis; diplopia
Skeletal weakness; ataxia
Dysarthria; dysphagia
Bowel and bladder incontinence
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Slide 133
Degenerative Diseases
• Myasthenia gravis (continued)

Medical management/nursing interventions
• Anticholinesterase drugs


Prostigmin
Mestinon
• Corticosteroids
• May require mechanical ventilation
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Slide 134
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS)

Etiology/pathophysiology
• Motor neurons in the brain stem and spinal cord
gradually degenerate
• Electrical and chemical messages originating in the
brain do not reach the muscles to activate them
• Lou Gehrig’s disease
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Slide 135
Degenerative Diseases
• Amyotrophic lateral sclerosis (ALS) (continued)

Clinical manifestations/assessment
•
•
•
•

Weakness of the upper extremities
Dysarthria; dysphagia
Muscle wasting
Compromised respiratory function
Medical management/nursing interventions
• No cure
• Rilutec (Riluzole)
• Multidisciplinary ALS teams; emotional support
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Slide 136
Degenerative Diseases
• Huntington’s disease

Etiology/pathophysiology
• Overactivity of the dopamine pathways
• Genetically transmitted

Clinical manifestations/assessment
• Abnormal and excessive involuntary movements
(chorea)
• Ataxia to immobility
• Deterioration in mental functions
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Slide 137
Degenerative Diseases
• Huntington’s disease (continued)

Medical management/nursing interventions
•
•
•
•
•
•
•
No cure; palliative treatment
Antipsychotics
Antidepressants
Antichoreas
Safe environment
Emotional support
High-calorie diet
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Slide 138
Vascular Problems
• Stroke (cerebrovascular accident)

Etiology/pathophysiology
• Abnormal condition of the blood vessels of the brain:
thrombosis; embolism; hemorrhage
• Results in ischemia of the brain tissue

Clinical manifestations/assessment
•
•
•
•
Headache
Sensory deficit
Hemiparesis; hemiplegia
Dysphasia or aphasia
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Slide 139
Figure 54-16
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Three types of stroke.
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Slide 140
Vascular Problems
• Stroke (cerebrovascular accident) (continued)

Medical management/nursing interventions
• Thrombosis or embolism


•
•
•
•
Thrombolytics
Heparin and Coumadin
Decadron
Neurological checks
Feeding tube
Physical, occupational, and/or speech therapy
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Slide 141
Cranial and Peripheral Nerve Disorders
• Trigeminal neuralgia

Etiology/pathophysiology
• Degeneration of or pressure on the trigeminal nerve; tic
douloureux

Clinical manifestations/assessment
• Excruciating, burning facial pain

Medical management/nursing interventions
• Tegretol
• Surgical resection of the trigeminal nerve
• Avoid stimulation of face on affected side
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Slide 142
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis)

Etiology/pathophysiology
• Inflammatory process involving the facial nerve

Clinical manifestations/assessment
•
•
•
•
•
•
Facial numbness or stiffness
Drawing sensation of the face
Unilateral weakness of facial muscles
Reduction of saliva
Pain behind the ear
Ringing in ear or other hearing loss
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 143
Cranial and Peripheral Nerve Disorders
• Bell’s palsy (peripheral facial paralysis) (continued)

Medical management/nursing interventions
•
•
•
•
•
Electrical stimulation
Moist heat
Steroids
Massage of the affected area
Facial exercises
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Slide 144
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome

Etiology/pathophysiology
• Inflammation and demyelination of the peripheral
nervous system
• Possibly viral or autoimmune reaction
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Slide 145
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome (continued)

Clinical manifestations/assessment
• Symptoms are progressive
• Paralysis usually starts in the lower extremities and
moves upward; may stop at any point
• Respiratory failure if intercostal muscles are affected
• May have difficulty swallowing, breathing, and speaking
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Slide 146
Cranial and Peripheral Nerve Disorders
• Guillain-Barré syndrome (continued)

Medical management/nursing interventions
•
•
•
•
•
•
Adrenocortical steroids
Apheresis
Mechanical ventilation
Gastrostomy tube
Meticulous skin care
Range-of-motion exercises
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 147
Cranial and Peripheral Nerve Disorders
• Meningitis

Etiology/pathophysiology
• Acute infection of the meninges
• Bacterial or aseptic
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 148
Cranial and Peripheral Nerve Disorders
• Meningitis (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
Headache; stiff neck
Irritability; restlessness
Malaise
Nausea and vomiting
Delirium
Elevated temperature, pulse, and respirations
Kernig’s and Brudzinski’s signs
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 149
Cranial and Peripheral Nerve Disorders
• Meningitis (continued)

Medical management/nursing interventions
• Antibiotics



Massive doses
Multiple types
IV or intrathecal
• Steroids
• Anticonvulsants
• Dark, quiet room
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 150
Cranial and Peripheral Nerve Disorders
• Intracranial tumors

Etiology/pathophysiology
• Benign or malignant
• Primary or metastatic
• May affect any area of the brain
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 151
Cranial and Peripheral Nerve Disorders
• Intracranial tumors (continued)

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Headache
Hearing loss
Motor weakness
Ataxia
Decreased alertness and consciousness
Abnormal pupil response and/or unequal size
Seizures
Speech abnormalities
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 152
Cranial and Peripheral Nerve Disorders
• Intracranial tumors (continued)

Medical management/nursing interventions
• Surgical removal of tumor


Craniotomy
Intracranial endoscopy
• Radiation
• Chemotherapy
• Combination of above
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 153
Trauma
• Craniocerebral trauma

Etiology/pathophysiology
• Motor vehicle and motorcycle accidents, falls, industrial
accidents, assaults, and sports trauma
• Direct trauma: head is directly injured
• Indirect trauma: tension strains and shearing forces
• Open head injuries
• Closed head injuries
• Hematomas
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 154
Trauma
• Craniocerebral trauma

Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Headache
Nausea
Vomiting
Abnormal sensations
Loss of consciousness
Bleeding from ears or nose
Abnormal pupil size and\or reaction
Battle’s sign
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 155
Trauma
• Craniocerebral trauma (continued)

Medical management/nursing interventions
•
•
•
•
•
Maintain airway
Oxygen
Mannitol and dexamethasone
Analgesics
Anticonvulsants
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 156
Trauma
• Spinal cord trauma

Etiology/pathophysiology
• Automobile, motorcycle, diving, surfing, other athletic
accidents, and gunshot wounds
• Fracture of vertebra
• Complete cord injury
• Incomplete cord injury
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 157
Figure 54-22
(From Lewis, S.M., Heitkemper, M.M., Dirksen, S.R. [2004]. Medical-surgical nursing: assessment and
management of clinical problems. [6th ed.]. St. Louis: Mosby.)
Mechanisms of spinal injury.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 158
Trauma
• Spinal cord trauma (continued)

Clinical manifestations/assessment
•
•
•
•
Loss of muscle function depends on level of injury
Spinal shock
Autonomic dysreflexia
Sexual dysfunction
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Slide 159
Trauma
• Spinal cord trauma (continued)

Medical management/nursing interventions
• Realignment of bony column for fractures or
dislocations: immobilization; skeletal traction

Surgery for spinal decompression
• Methylprednisolone
• Mobility: slowly increase sitting up
• Urinary function: Foley catheter; bladder training

Intermittent catheterization
• Bowel program
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 160
Nursing Process
• Nursing diagnoses

Autonomic dysreflexia
 Communication, impaired
 Coping, compromised family
 Disuse syndrome, risk for
 Grieving
 Infection, risk for
 Knowledge, deficient
 Memory, impaired
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 161
Nursing Process
• Nursing diagnoses (continued)

Mobility, impaired physical
 Nutrition, imbalanced: less than body requirements
 Pain, acute, chronic
 Self-care deficit
 Swallowing, impaired
 Thought process, disturbed
 Tissue perfusion (cerebral), ineffective
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 162