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Assessment Impaired pupillary reaction to light

1. Cerebral Function *normal – sluggish/ brisk

2.Cranial Nerves
3. Motor Function 4. TROCHLEAR (upward eye movn’t)
4. Sensory Function Reflexes Dysconjugate gaze, Weakness, Double
1. Assess the degree of wakefulness and 5. TRIGEMINAL (touch w/ eyes close)
mindfulness. *normal – blink and tear
2. Note intensity of stimulus to cause a Wisp test (cotton): absent corneal reflex,
response. facial numbness, jaw weakness
3. Apply painful stimulus over the nail beds
with blunt instrument. 6. ABDUCENS (lateral eye mov’nt)
4. Assess orientation to person, place and Dysconjugate, Weak, Paralysis, Double
time. vision

GCS - used to assess mental status 7. FACIAL (frown, smile, wrinkle)

15 – highest score Facial weakness.
3 – deep coma Unable to close eyelid and impaired.
<7 – comatose patient
8. AUDITORY (whisper/watch tick)
1. Eye Opening a. Weber Test – tone
4 Spontaneous Symmetrical Center
3 To Speech Sensorineural Better
2 To pain Comductive Poorer
1 No response Decreased hearing
b. Rinne Test
2. Verbal Response – air and bone conduction (25mm yung layo)
5 Oriented to time, person &place Deafness
4 Confused c. Romberg Test
3 Inappropriate words – balance hearing w/ eyes close
2 Incomprehensible sounds Impaired balance
1 No response
Use sugar/salt. Impaired taste
3. Motor Response
Dysphagia - difficulty swallowing
6 Obeys command
5 Localizes pain 10. VAGUS (gag reflex)
4 Withdraws from pain Weak or absent gag reflex
3 Abnormal flexion Dysarthria – defect in speech
2 Abnormal extension Horseness of voice
1 No response
CRANIAL NERVES PROBLEM Normal - Turn head and shrug shoulders

1. OLFACTORY (smell) 12. HYPOGLOSSAL (move tounge)

Cenamon/coffee. Anosmia – walang naamoy Difficulty swallowing
Slurred speech
2. OPTIC (vision)
Hemianopsia – “half blind” SUMMARY:
Decrease Visual Acuity – “bulag” Anosmia – loss of smell
Hemianopsia – “half blind”
3. OCULOMOTOR (movn’t towards nose) Decrease Visual Acuity – blindness
Dysconjugate gaze – d maka duling Dysconjugate gaze – d maka duling
Double vision, Dilated pupil Dysphagia – difficulty swallowing
Dysarthria – defect in speech
(+) Brudzinki Sign 1. Skull & Spinal X-ray
- When neck is flexed, hips and neck will also - To ientify fractures, dislocations,
flex (supine) compression & spinal cord problem.
- Meningitis - Provide support for confused and combative
- (+) pain, resistance, flexion hips & kness patient.
- X METAL items
(+) Kernig’s Sign - Maintain immobilization
- (+) meningeal irritation appendicitis)
- Supine position 2. CT Scan
- Kness & hips are flexed - To detect hemorrhage, cerebral atrophy,
- Pain and resistance tumors, skull fractures, abscesses.
- Check IODINE allergies
Babinski Reflex - Lie on movable table
- Toes fanning out in response to external - Inform for hot, flushed sensation, metallic
stimulation taste on mouth.
- Stroke lateral aspect of foot - Remove hair pins and metal object
- Normal – toes contact
3. MRI
Plantar Reflex - To dx degenerative disease., intra cranial &
- Toes flexing inwards spinal abnormalities
- X bone abnormalities
Decerebrate Posture
- Fingers flexed to side 4. EEG – electroencephalography
- Damage upper brain stem - Graphic recording of electrical activity
- SHAMPOO the night before
Decorticate Posture
- Fingers flexed on chest MRI & EEG
- Damage 1 or both corticospinal tract - Withhold meds (anticonvulsants, sedatives,
- For IV contrast, NSAIDS, metformin,

5. Cerebral Angiography
- To visualize cerebral vessels
- To detect tumors, aneurysm, occlusion,
hematomas, abscesses

Aneurysm - bulge in blood vessels

Hematoma – blood seep out in BV
NEUROLOGIC SYSTEM - Excitatory. Results in neurotoxicity if
- Controls motor, sensory, autonomic, levels are too high.
cognitive & behavioral activities.
1. CNS – brain & spinal cord 1. Frontal
2. PNS – cranial (12 pair), spinal (13 pairs) - Major functions: concentrate, abstract,
nerves & autonomic. though, information storage & memory
function. Contains Broccas area (motor
Nodes of Ranvier control of speech)
- gaps or node in the myelin sheath 2. Parietal
Myelin Sheath - Sensory functions: touch, taste,
- Dense lipid layer which insulates axon to temperature. This is where sensation felt
gray 3. Temporal
Schwann cells - For hearing & smelling. Memory of sound &
- Produce myelin or fat in the PNS understanding language & music.
4. Occipital
NEURON – composed of dendrites & axon - Visual interpretation memory
1. Sensory (afferent – bring messages)
-transmit impulses from receptor to CNS CEREBELLUM
2. Motor (afferent – carry messages) - Controls fine movn’t, balance & position
-transmit impulses from CNS to effector
3. Interneurons MEDULLA
-found within CNS - Contains cardiac, respiratory, vasomotor, &
-transmit sensory/motor impulses reflex centers (cough, sneeze, swallow,
- Communicate message from one neuron to PONS
another - Anterior to cerebellum & superior to medulla.
- Potentiate, terminate/modulate specific 2 respiratory centers (apneustic &
action & excite/inhibit the target cell. pneumotaxic) responsible to produce a
normal breathing rhythm.
- Excitatory. Control complex movnts, MIDBRAIN
motivation, cognition. Regulates - Regulates visual, auditory & righting reflex.
emotional response.
Norepinephrine HYPOTHALAMUS
- Excitatory. Causes changes in attention, - Production of hormones
learning & memory, sleep & wakefulness - Regulation of body temperature
mood. - Regulation of food & fluid intake
Epinephrine - Integration of the functioning of the
- Excitatory. Control fight or fight response. autonomic nervous system.
Serotonin THALAMUS
- Inhibitory. Controls fluid intake, sleep & - Concern with sensation. Suppressing minor
wakefulness, temperature, pain, sexual, & sensations.
-Excitatory/inhibitory. Control sleep &
wakefulness cycle. Signal muscles to become
GABA (Gamma-aminobutyric acid)
- Inhibitory. Modulates other
- Is a symptom - Used beta-blocking agent, Amitriptyline,
- If primary (no organic cause can be Divalproex, Serotonin antagonist
identified) 1. relieved/limit headache
- Pressure, pain and tight feeling in temporal 2. TRIPTAN meds – to treat
and nausea 3. Anti-migraine agent
- reduce inflammation
2. MIGRAINE - cause vasoconstriction
- Periodic/recurrent attack of severe - reduce pain transmission
headache (last 4 to 72hrs)
- Throbbing, boring, viselike and pounding GOALS
pain. Enhance pain relief
Treat acute event of headache
TYPES: Prevent recurrent episodes
1. CLASSIC Quit. Dark environment
- has a pre-headache Head to 30 degrees
- visual disturbance, difficulty w/ speaking, Apply local heat/massage
numbness/tingling Give Analgesic agent
2. COMMON Biofeedback, avoid stress
- x pre headache Exercise Programs
- experience onset or throbbing headache. Medication


1. PRODROME - increase in Brain, CSF or blood component
- Sx is hours to days - 0 – 10 mmHg normal; 15 (upper limit)
- -depressed, irritability, feeling cold, food - IC components: brain abscess, hemorrhage,
cravings, anorexia, change in activity level, edema, hydrocephalus
increased urination, diarrhea/constipation - too much CSF
2. AURA - Meningitis – fluid around the brain
- Last <1 hour - tumor (benign or malignant)
- neurologic syndrome, visual disturbance, - Bleeding in brain (hemorrhagic stroke/
numbness & tingling of lips, face or hands, aneurysm
mild confusion, slightly weak, drows and - Encephalitis – swelling in the brain
dizziness. - Crushing Triad – seen when inc. ICP
3. HEADACHE – dec. cerebral blood flow
- Last 4 to 72 hrs – inc. arterial pressure
- Several hours throbbing, photophobia, N/V - Herniation of the brain stem and occlusion if
4. RECOVERY treatment doesn’t occur
- Aka Termination Postdrome - low CR & RR, high BP (inc. ICP)
- Pain gradually subsides - low BP, high PR & RR (SHOCK)
- Muscle contraction in neck Early - change in LOC & pupil, low speech,
- Localized tenderness restless, confused, inc. drowsiness.
- Exhaustion Late - Decorticate, decerebrate
- CT, MRI, Cerebral angiography, PET scan
Tension type 1. Decreased cerebral edema
- most common, chronic, less severe 2. Decreased volume of CSF
Cluster type 3. Facilitate drainage
- severe form, frequent in men *maintain patent airway
Secondary Headache *head 30-45 degrees
- organic cause symptoms *administer 100% oxygen
- brain tumor, aneurysm *prevent Valsalva maneuver
*meds: mannitol, cortico, anticonvulsant
4.CVA/STROKE - Intracranial aneurysm: dilation of the walls of
- disrupted blood supply to the brain cerebral artery that develops as a result of
weakness in arterial wall
Transient Ischemic Attack - Arteriovenous Malformation: due to an
Neurologic deficit (last <1 hour) abnormality in embryo development that
- confusion leads to a tangle of arteries & veins in the
-CT Scan, MRI, Angiography brain without capillary bed.
- Loss of motor, sensory and visual function - Subarachnoid Hemorrhage: most common
- altered LOC, half blind, peripheral and double cause of leaking aneurysm in the area of the
vision. Loss/decrease in deep tendon reflex. circle of Willis or a congenital AVM of the
Paresthesia, emotional deficit, loss of self brain
control, emotional ability, decreased tolerance to
stressful situations, depression, withdrawal, fear, Left Hemispheric Stroke
hostility, and anger, feelings of isolation. - Paralysis in right
- Communication loss - Right visual field deficit
- Aphasa
Dysarthria – difficulty in speaking - Altered intellect ability
Dysphasia – impaired speech - Slow cautios behavior
Apraxia – inability to perform preveiously
learned actions Right Hemispheric Stroke
Expressive Aphasia - Paralysis on left side
– unable to form words - Left visual field deficit
– speak in single word - Increased distractibility
Rceptive Aphasia - Impulsive behavior & poor judgement
– Can speak but not make sense - Lack of awareness of deficit
Global (mixed) aphasia
– Both receptive & expressive
Hemiplegia – paralysis
Hemiparesis – slight weak
Ataxia – Loss of gait

*Prevent shoulder adduction

*Ensure patent airway
*give 100% O2 (dec. ICP)
*Quit, restful environment
*Monitor VS, GCS, pupil size
*give mouth care before and after
*Manage motor, verbal & cognitive deficits

1. Ischemic Stroke
- Cause by thrombus & embolus
- Large artery thrombotic stoke: due to
atherosclerotic plaques in large BV of brain
- Small penetrating artery: Thrombotic stokes,
affect 1 or more vessels, most common type
of ischemic stroke
- Cardiogenic embolus strokes: associated
with cardiac dysrhythmias, usually atrial
- Cryptogenic stroke: obscure in origin

Hemorrhagic Stroke
- Intra-cerebral Hemorrhage: most common in
patient with hypertension & cerebral
- Inflammation of the lining around the brain & - Degenerative disease
spinal cord - Demyelination of the nerve fibers
Cause: Bacteria (Neisseria Meningitides), - Chronic, slowly progressive
viruses, other microorganisms. - Charaterized by periods of remission &
*Administer large dose of antibiotics IV as exacerbation.
ordered *Promote physical mobility (walking, use of
- enforce respiratory isolation for 24hrs after assistive device).
initiation of antibiotic therapy - warm packs (minimizes spacity & contractures)
- provide bed rest, keep room dark & quite - X hot baths (inc. risk of burn injury)
- administer analgesics for headache as ordered - X strenuous exercises
- maintain fluid & electrolyte balance - instruct to prevent cuts & burns
- monitor VS & neurological assessment - eye patch for diplopia
frequently. Daily body weight.
- high calorie, High protein, small frequent 10. GULLAIN-BARRE SYNDROME
- prevent development of pressure ulcers & - auto immune attack of the peripheral nerve
pneumonia. myolin
- acute, rapid, segmental demyelination of
peripheral nerves and some cranial nerves
6. ENCEPHALITIS - neuromuscular disease
- Acute inflammatory process of the brain - more frequent in males
tissue cause: unknown/post viral infection
*Monitor VS *Mostly supportive
- perform neurological assessment frequently - maintain adequate ventilation
- provide nursing care for confused/ unconscious - incentive spirometry
- pomfort measure to reduce headache: - chest physiotherapy
dim light, limit noise, give analgesics & prevent - perform range of motion
injury. - asses gag reflex before feeding
- monitor VS
7. SEIZURES - check cranial nerves
-Sudden abn & excessive electrical discharge - administer Corticosteroids to suppress immune
from the brain can change motor or autonomic function.
function, consciousness or sensation.
Epilepsy –chronic neuro disorder characterized 11. PARKINSONS DISEASE
by recurrent seizure. - A slowly progressing neurologic movn’t
Status Epilepticus – one or series gran mal disorder that leads to disability
seizures (last >30mins) with out waking interval. - Decreased levels of dopamine
*Before *Improves mobility: walking, riding stationary
- remove harmful objects bicycle, swimming, gardening, provide warm
- ease client to the floor baths & massage.
- protect the head - increased OFI to prevent constipation
- observe & note for duration, parts of the body - aspiration precaution
affected, behavior before & after seizure. - provide semi-solid diet & thick fluids
- loosen constrictive clothing like belt - use of small electronic amplifier to lessen
- do not restrain, or attempt to place tounge hearing defect.
blade or insert oral airway. *Heath Teachings during LEVODOPA therapy
*After - SE: N/V, orthostatic hypotension, insomnia,
- document the events during & after seizure agitation, mental confusion, renal damage
- side-lying position to prevent aspiration - Block the effect: Phenothiazines, reserpine,
- suction equipment should be available pyridoxine (vit.B6)
- place bed in low position - x tuna, pork, dried beans, salmon, beef liver


- Defect in transmission of nerve impulse at - Aka: Lou Gerhig’s Disease
the myoneural junction.
- Progressive & degenerative condition that
affects motor neurons responsible for control
voluntary muscles.
Cause: 5-10% genetics, over excitation of
neurotransmitter glutamate.
*Maximise functional abilities
- prevent compicatins immobility
- promote self care
- maximize effective communication
- promote use of assistive divices
- ensure aequate nutrition
- prevent respiratory complications
- maintain adequate airway
- enhance gas exchange (O2 therapy &
- prevent respiratory infection
- help client & family deal with current prob.

– ICF is low to high (osmosis)
– Pulls water and excretes via urine
– Urine 30ml/hr
– Monitor I&O