Neurological

• Sensory


  Relating to the senses, especially sight and hearing
• Types of hearing loss


  • Conductive - outer due to wax or otitis media
  • Sensorineural - inner due to damage to cochlea or vestibulocochlear nerve
• Tinnitus


  Ringing or buzzing in the ears
• Causes of tinnitus


  • Hearing loss
  • Circulatory issues
  • Injury
  • Side effect of medications (ASA, furosemide)
• Meniere's Disease


  Disorder of the inner ear that causes vertigo, tinnitus, nausea, pressure in the ear, balance issues, hearing loss
• Management of Meniere's Disease


  Diet of avoiding salt, sugar, caffeine, alcohol, and tobacco, or medication
• Communicating with a hearing impaired patient


  1. Use a low tone, normal, slowly and distinctly

  2. Face the person

  3. Speak into less impaired ear

  4. Use gestures and facial expressions

  5. Write out information

  6. Announce yourself when entering the room
• Cerebrovascular Disorders


  Disorders related to the blood vessels in the brain
• Types of stroke


  • Ischemic - blocked blood flow
  • Hemorrhagic - burst blood vessel
• Ischemic stroke


  • Types: large artery thrombosis, cardiogenic
  • Symptoms: numbness of face, arm, or leg on one side of body, confusion, trouble speaking or understanding speech, difficulty walking, sudden severe headache, perceptual disturbances
• Hemorrhagic stroke


  • Brain metabolism disrupted by blood, increased cranial pressure
  • Causes: spontaneous rupture of small vessels primarily related to hypertension, subarachnoid hemorrhage, anticoagulant use
  • Symptoms: severe headache, early and sudden changes in level of consciousness, vomiting, widened pulse pressure (signs of increased intracranial pressure)
• Medical management of stroke

  1. Control of hypertension

  2. CT scan

  3. Cerebral angiography

  4. Lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage

  5. Supportive care, oxygen
• Nursing management of stroke


  Aneurysm precautions: bed rest, elevate HOB 30 degrees, avoid activity that may increase ICP or BP, Valsalva maneuver, no flexion or rotation of neck or head, exhale through mouth when voiding and defecating, provide personal care, nonstimulating nonstressful environment, restrict visitors
• Transient Ischemic Attack (TIA)


  Temporary neurologic deficit resulting from temporary impairment of blood flow, same symptoms as stroke, warning of an impending stroke
• BEFAST stroke symptoms

  • Balance
  • Eyes
  • Face
  • Arms
  • Speech
  • Time
• Glasgow Coma Scale


  Assesses eye, verbal, and motor response, 15 is normal, 13-15 is mild, 9-12 is moderate, less than 8 is a coma or death
• Stroke-related deficits


  • Hemiplegia - paralysis on half of the body
  • Hemiparesis - weakness on half of the body
  • Dysarthria - difficulty speaking
  • Aphasia - difficulty understanding and/or expressing language
  • Brocas area - language production, patient has a hard time speaking but no issue understanding
  • Wernickes area - language comprehension, patient can speak but can't comprehend
  • Hemianopsia - loss of half of visual field (on side of paralysis), can be permanent or temporary
  • Agnosia - can't recognize previously familiar objects
• Acute phase of stroke management


  1. Prompt diagnosis and treatment - stat CT scan

  2. Ongoing monitoring of all systems and neurological assessment

  3. Monitor for potential complications including musculoskeletal problems, swallowing issues, respiratory issues, signs and symptoms of increased intracranial pressure and meningeal irritation
• Post-stroke management


  Focus on patient function, self-care ability, coping, teaching, needs to facilitate rehabilitation
• NIHSS assessment tool


  Looks at level of consciousness, visual, sensory, motor, speech, rated 0-42 (42 is bad)
• tPA (thrombolytic therapy)


  • Must have ischemic stroke, within 3-4.5 hours of onset, no anticoagulant use, no prior history of aneurysm, recent stroke, surgery, GI bleed, head trauma in previous 3 months, arterial puncture at non-compressible site in previous 7 days, elevated BP of sys over 185 dia over 110, anticoagulant use with INR of 1.7
  • Side effects can kill if not in eligibility criteria
• Risk factors for stroke


  • Hypertension
  • Cardiovascular disease
  • Obesity
  • Diabetes
  • Oral contraceptive use
  • Smoking and drug and alcohol abuse
  • Age over 55
  • Male
  • African American
• Preventative treatments for stroke


  • Health maintenance
  • Treatment of periodontal disease
  • Exercise
  • Anticoagulant therapy
  • Antiplatelet therapy (Plavix, Ticlid, Persantine)
  • Statins
  • Antihypertensive medications
• Carotid endarterectomy


  Removal of plaque from carotid artery
• Potential complications of stroke


  • Vasospasm - decreased level of consciousness, aphasia, partial paralysis, leading cause of morbidity, can occur 3-14 days after initial hemorrhage
  • Seizures
  • Hydrocephalus - drowsiness, behavioral changes, ataxic gait, blood in subarachnoid space impedes circulation
  • Rebleeding - sudden severe headache
  • Hyponatremia - confusion, seizure, 30% of patients
  • Increased intracranial pressure
• Management of stroke complications


  1. Vasospasm - treat with calcium channel blocker (nimodipine)

  2. Seizures - precautions, prevent dilantin

  3. Hydrocephalus - treat with shunt

  4. Rebleeding - keep BP low

  5. Hyponatremia - treat with 3% saline hypertonic

  6. Increased intracranial pressure - CSF drainage
• Meningitis


  Inflammation of the membranes and fluid space surrounding the brain and spinal cord
• Types of meningitis


  • Septic - due to bacteria
  • Aseptic - due to viral infection, lymphoma, leukemia, or brain abscess
• Transmission of N. Meningitis


  Transmitted by secretion or aerosol contamination in dense community groups
• Manifestations of meningitis


  • Headache
  • Fever
  • Rash
  • Changes in level of consciousness
  • Behavioral changes
  • Nuchal rigidity (stiff neck)
  • Positive Kernig's sign
  • Positive Brudzinski's sign
  • Photophobia
• Brudzinski's sign


  Severe neck stiffness causes a patient's hips and knees to flex when neck is flexed
• Kernig's sign


  Severe stiffness of hamstrings causes an inability to straighten leg when hip is flexed to 90 degrees
• Diagnostic tests for meningitis


  1. CT to rule out shift in brain contents

  2. Spinal tap - low glucose, high protein, high white count

  3. Gram stain, bacterial culture of CSF and blood
• Medical management of meningitis


  1. Prevention by vaccination for children and at-risk adults

  2. Early administration of high doses of IV antibiotics

  3. Dexamethasone - steroid

  4. Treatment of dehydration, shock and seizures

  5. Treat those in close contact with rifampin, ciprofloxacin, ceftriaxone

  6. Protect against seizures, infection, mobility precautions

  7. Monitor daily weight, electrolytes, urine volume, specific gravity, and osmolarity
• Encephalitis


  Acute inflammatory process of brain tissue
• Causes of encephalitis


  • Viral infections (herpes)
  • Vector-borne virus (West Nile)
  • Fungal
• Manifestations of encephalitis


  • Headache
  • Fever
  • Confusion
  • Changes in level of consciousness
  • Vector-borne - rash, flaccid paralysis, Parkinson-like movements
• Medical management of encephalitis

  1. Acyclovir for HSV

  2. Amphotericin and antifungal agents for fungal infection
• Nursing management of encephalitis


  1. Frequent and ongoing assessment - level of consciousness, mentation

  2. Supportive care
• Trigeminal Neuralgia


  Condition of the 5th cranial nerve characterized by paroxysms of pain (comes and goes)