NCLEX: Caring for the Client with Disorders of the Neurological System

Terms you’ll need to understand:
Areflexia
Aura
Automaticism
Burr holes
Cheyne Stokes respirations
Clonic movements
Craniotomy
Decerebrate posture
Decorticate posture
Doll’s eye phenomena
Hypocapnia
Piloerection
Post-ictal
Pulse pressure
Rinne test
Tonic movements
Webber test

Nursing skills you’ll need to master:
Performing neurological assessments
Performing log roll turning technique
Bowel and bladder training

Seizures
Seizures are episodes of abnormal motor, sensory, or autonomic activity that result from the excessive discharge of electrical impulses from cerebral neurons. All seizures affect the level of consciousness; however, the degree is dependent on the type of seizure. Most seizures occur without a cause. Any abnormality in the central nervous system (CNS) can cause seizure activity.
The significant causes of seizure you need to know for the NCLEX® exam are
- Abrupt withdrawal of barbiturates
- Brain tumors
- Central nervous system infections
- Head injuries
- High fevers
- Hypertension
- Hypoglycemia

Types of Seizures
There are two main categories for classifying seizure: the generalized seizure and the partial, or focal, seizure. The following sections describe these two seizure categories more fully.

Generalized Seizures
With this type of seizure, the whole brain is involved in the seizure activity.
Within this category, two types of seizures are identified. The first type is the tonic-clonic, or grand mal, seizure; the second is the absence, or petit mal, seizure.

Tonic-Clonic Seizures
Tonic-clonic seizures can last for up to 5 minutes. The following highlights the signs and symptoms of tonic-clonic seizures you need to know:
- Aura prior to seizure activity
- Brief episodes of apnea
- Chewing of the tongue
- Incontinence
- Loss of consciousness
- Loss of motor function
- Tonic (muscle tension) and clonic (alternating muscle contraction and relaxation) movements

Aura can be any type of sensory sensation, such as a smell or flashing lights, that signals to the client that the seizure is about to occur. Children usually do not have an aura.

There is a risk for injury for any client involved in this type of seizure activity. You must become familiar with nursing care required for the general safety and physiological care of the client before and after the seizure. You also need to know how to accurately document the seizure because this will assist the physician with the diagnosis. You should gain knowledge of the following aspects of care and expect to see them on your exam:
- Assess the client’s behavior and surroundings prior to the seizure.
- Loosen his clothing.
- Maintain a patent airway (oxygen, suction).
- Note any loss of consciousness, aura, or incontinence.
- Provide client safety (place padding under the client’s head and move objects out of reach of the client to prevent self-injury).
- Time and document the seizure activity.
- Turn the client on his side.

Don’t
- Put anything in the client’s mouth after a seizure has begun.
- Restrain the client.

Nursing care after a tonic/clonic seizure includes
- Allow the client to sleep.
- Keep the client side-lying.
- Orient the client to the environment.
- Be prepared for the client to be confused and disoriented because he’s in the post-ictal phase after the seizure.

Absence Seizures
The second type of generalized seizure is absence, or petit mal, seizure. This type is more common in children and might improve by adolescence. There is no loss of consciousness, and it can be mistaken for daydreaming. Other clinical manifestations you need to know are:
- Blank stare
- Smacking of the lips
- Twitching of the mouth

Partial Seizures
The second category of seizures is called partial, or focal, seizures. These seizure types affect one cerebral hemisphere. Mostly found in adults, these seizures respond unfavorably to medical regimens. Focal seizures are further divided into two classifications. The first type is the simple partial seizure, and the second is known as the complex partial seizure.

Simple Partial
With simple partial seizure, the client’s finger or hand might shake or she might have unusual sensations. The client often has an aura but does not lose consciousness.

Complex Partial
The second type of focal seizure is the complex partial. One of the major differentiating factors is that these clients do lose consciousness, whereas in simple partial they do not. The seizure can last for up to 3 minutes. Some characteristics you need to know for the exam include:
- Automaticisms (behaviors that the person is not aware of, such as hand movements and picking at clothes) might occur.
- These seizures are common in adults.
- The client has amnesia of episode.
- The client is in a trancelike state.

Treatment of Seizure Clients
The treatment of clients with seizures concentrates on stopping the seizure activity. This goal is most often accomplished by the use of anticonvulsant medications. Another method of treatment involves the insertion of a vagal nerve stimulator. In this procedure, an electrode is placed on the vagal nerve and gives intermittent stimulation to the nerve, preventing seizures. Clients who continue to have seizures with treatment might require surgical removal of the section of the brain causing the seizure; however, this is a last resort.

Status Epilepticus
A person in status epilepticus has a continuation of grand mal seizures without a normal recovery period. The client does not regain consciousness between attacks, despite medical intervention. Any one seizure that lasts longer than 10 minutes or repeated seizures longer than 30 minutes are classified as status epilepticus. This disorder is life-threatening if not corrected.
Possible causes of status epilepticus include sudden noncompliance of anticonvulsant medications, head trauma, and alcohol withdrawal.
Clients experiencing status epilepticus are treated as a neurological emergency. Interventions important for the nurse candidate to know are administration of oxygen, initiation of IV access, and establishment and maintenance of a patent airway (intubation by an anesthetist or a physician might be required). Medications need to be given to stop the seizure, as well as drugs to prevent another seizure. If the seizure activity continues despite efforts, general anesthesia might be required. The following highlights the drugs you need to know for this disorder: IV diazepam (Valium) or lorazepam (Ativan) to stop the seizure activity, followed by phenobarbital and diphenyldantion (Dilantin) or fosphenytoin (Cerebyx).

Brain Injuries
Brain injuries occur when a force is applied to the brain, causing damage.
The age group most affected is 18–34. An injury of this type can cause extreme emotional adjustments and disability.
Several types of brain injuries can occur. They are classified according to the area in the brain that’s affected. The information that follows discusses the three hematomas that can develop from an injury.

Epidural Hematomas
The first type of hematoma is the epidural. It usually develops from an arterial bleed, which makes it more acute. An epidural hematoma occurs when there is a collection of blood between the skull and dura. The symptoms indicating an epidural hematoma involve a pattern of consciousness, a lucid interval, followed by the client being critical and then comatose.

Subdural Hematoma
The second type of hematoma is a subdural hematoma. It is usually venous in origin and occurs when a collection of blood is between the dura and above the arachnoid space. Subdural hematomas are subdivided into three classifications that are identified by their time of development after the injury. The following highlights these terms and how they are identified:
- Acute—Occurs within the first 2 days of injury
- Subacute—Occurs 2–14 days after the injury
- Chronic—Occurs from 14 days to several months after the injury

Treatment of Epidural and Subdural Hematomas
Clients with hematomas are treated depending on the amount of space occupied by the hematoma. If the client has increased intracranial pressure, measures included in the following section on increased ICP are used. Surgical interventions include insertion of burr holes and a craniotomy to evacuate the hematoma.

Increased Intracranial Pressure
Increased intracranial pressure (ICP) can result from any alteration that increases tissue or fluid volume within the cranium. The skull is rigid with no flexibility; therefore, there is no room for any additional fluid or blood, or a space-occupying lesion. The causes of increased ICP are as follows:
- Accumulation of cerebral spinal fluid in the ventricles
- Brain tumors
- Central nervous system infections
- Cerebral edema
- Intracranial bleeding

The client with increased ICP exhibits specific signs and symptoms that you need to be able to recognize and report to the physician for early intervention. These clinical manifestations include
- Blurred vision
- Changes in cognition
- Changes in the level of consciousness
- Cheyne stokes respirations
- Coma
- Decerebrate posturev(Decerebrate posture indicates brain stem dysfunction.)
- Decorticate posture
- Decreased motor responsiveness
- Diplopia
- Doll’s eye phenomena
- Headache
- Nausea and vomiting (usually projectile)
- Papillary changes
- Personality and behavior changes
- Seizures
- Vital signs changes (also called Cushing’s triad):
- Increased BP with a widening pulse pressure
- Decreased pulse rate
- Decreased respirations

Note that these vital sign changes are actually the opposite of shock—so if you know one, you know the other, and vice versa.

It is important for the nurse candidate to be aware of the differences of symptoms that can occur in infants. The following focuses on the clinical manifestations of increased ICP you need to know for the infant:
- Bulging fontanels
- A high-pitched cry
- Irritability
- Restlessness

Decerabrate posturing


Decorticate posturing


Treatment of ICP
Treatment of increased ICP is directed toward paths that will both prevent further increases in intracranial pressure and help in the recognition of it, so that early intervention is possible. The following interventions are important for you to know for the exam:
- Frequent neurological assessment.
- Strict intake and output to prevent overhydration.
- Prevent seizures by administering anticonvulsants when due for blood level maintenance.
- Treat nausea and vomiting.
- Maintain the client in a barbiturate coma to decrease metabolic demands.
- Maintain hypocapnia to constrict cerebral blood vessels and decrease

ICP.
- Pharmacological interventions, including
- Decadron
- Mannitol (observe for signs of congestive heart failure due to a pos- sible alteration of cardiac enzymes).
- Anticonvulsants.
- Avoid aspirin, narcotics, or medications that depress respirations.
Pain medications can mask symptoms, which can make assessments inaccurate.

Neurological Assessment
The client assessment is a major component of nursing care. Early recognition of a deficit in neurological status can mean a more favorable outcome in the client’s condition. The following information offers insight into three forms of assessment techniques: cranial nerve assessment, Glasgow coma scale, and intracranial pressure monitors that can be used to identify deficits in a client.

Cranial Nerve Assessment

Assessment of Cranial Nerves
The 12 cranial nerves, their names, functions, and the assessment methods.


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Glasgow Coma Scale
The Glasgow coma scale assesses neurologic status based on the client’s motor, verbal, and eye-opening responses. Lower responses indicate central nervous system impairment, while higher responses indicate central nervous system functioning. The scale is a universal tool, which makes it a popular screening tool. The candidate should be aware of the following information for the nursing exam:

Eye Opening:
Spontaneous opening = 4
To speech = 3
To pain = 2
No response = 1

Best Motor Response:
Obeys = 6
Localizes pain = 5
Withdraws = 4
Abnormal flexion = 3
Extends = 2
No response = 1

Verbal Response:
Oriented = 5
Confused conversation = 4
Inappropriate words = 3
Incomprehensible words = 2
No response = 1
Total Points = 3–15

Intracranial Pressure Monitors
The third assessment tool is the most invasive and accurate of the ones mentioned. An intracranial pressure monitor is inserted by the physician.
This is a sensing device inside the skull that is attached to a transducer. This device gives an electronic recording of intracranial pressure. The normal
ICP reading is 10–20 mm Hg. The monitoring device can also be used to drain cerebrospinal fluid.
The cerebral perfusion pressure (CPP) can also be used to evaluate the client. Cerebral perfusion pressure is calculated by subtracting the ICP reading from the mean arterial pressure (MAP). A CPP above 70 is needed to have adequate brain viability. It is important for you to have the knowledge required for clients with ICP monitors in place:
- Assess for complications or problems with the ICP monitor.
- Interpret and report results to the physician.
- Utilize sterile technique when handling the equipment.

Care of the Client with Intracranial Surgery (Craniotomy)

Neuro assessments might indicate to the physician that surgery is required.
If a client has a craniotomy, post-operative care is of particular importance.
The following post-operative craniotomy interventions are important for you to know:
- Monitor vital signs and neurological assessments.
- Monitor cardiac rhythm.
- Perform passive range of motion exercises on the client.
- Assist the client to turn, cough, and deep breathe every 2–3 hours. B. careful with coughing exercises because they can increase intracranial pressure.
- Use cold application for periorbital edema and bruising.
- Prevent deep vein thrombosis by compression stocking application.
- Use the following positioning:
- Supratentorial surgery—Elevate the head of the bed 30°
- Infratentorial surgery—Flat on either side
- Assess head dressing and drainage from wound suction devices.
- Monitor ABGs.
- Assess urinary output (note: excessive urinary output could indicate the complication of diabetes insipidous).
- Use the following pharmacological interventions:
- Anticonvulsants
- Steroids
- Histamine blockers
- Prophylactic antibiotics

Spinal Cord Injury
Spinal cord injuries occur most often in young men between the ages of 15 and 30. Most cord injuries occur at the 5th, 6th, or 7th cervical, or at the 12th thoracic or the 1st lumbar. These areas are weaker due to the range of mobility needed.
A spinal cord injury is classified as complete (no function below the level of injury) or incomplete (partial function remains). These injuries can occur from diseases—for example, tumors causing compression and damage—but the most frequent causes are trauma and falls. These clients display the following characteristics:
- Acute respiratory failure
- Compromised respiratory function
- Loss of bowel and bladder tone
- Loss of sweating and vasomotor tone
- Marked reduction in BP due to loss of peripheral vascular resistance
- Sensory and motor paralysis below the level of injury
Acute respiratory failure is the primary cause of death in high-level cord injuries.

Treatment of Spinal Cord Injuries
Treatment of spinal cord injuries follows the paths of stabilization, monitoring and assessing, and preventing further damage. The following measures are important aspects of care:
- Stabilize respiratory and cardiovascular systems.
- Transport the client on a spinal board to prevent further damage.
- Medication administration of high-dose steroids within 8 hours of injury is the front-line treatment.
- Perform surgical reduction and alignment. The client might be placed in traction after reduction with the use of skeletal tongs. Three types of tongs are
- Crutchfield
- Gardner-Wells
- Vinke

Clients in tong traction must be moved carefully and as a unit (log roll). You will need a physician’s instruction for turning.

A halo vest is another type of alignment immobilization device that provides immobilization of the bone with ambulation allowed. These clients, as well as clients with tongs, require pin care per protocol with H202 or normal saline and an antibiotic cream.

Potential Complications with SCI Clients
Because of the damage to the spinal cord and autonomic nervous system, clients with SCIs can develop two main complications. The first complication is spinal shock, which occurs because of the sudden failure in the communication of the upper and lower neurons. Spinal shock can last for 3–6 weeks. Clients exhibit the following symptoms:
- Decreased heart rate
- Flaccid paralysis
- Low blood pressure

Another complication from this syndrome is autonomic hyperreflexia, or dysreflexia. Most often seen in injuries higher that T6, this disorder usually occurs later after the spinal shock has resolved. You need to be familiar with clinical manifestations, which include
- Bradycardia
- Headache
- Hypertension
- Nasal congestion
- Piloerection
- Profuse sweating

The treatment plan for autonomic dysreflexia focuses on removing the trigger or cause and lowering the blood pressure. The immediate interventions you will need to know are
- Remove the triggering stimuli.
- Elevate the head.
- Empty the bladder.
- Administer antihypertensive medications.
- Check for impaction after the episode has resolved.

Guillain-Barré
Guillain-Barré is a rapidly ascending progressive paralysis or weakness. It can also be descending but is uncommon by this progression, and it is an acute inflammatory process. Respiratory complications are the usual cause of death, although the exact cause is unknown. It has been shown to be related to a para-infection or post-infection immune response. It frequently develops 1–3 weeks following an upper respiratory or gastrointestinal infection. It has also been linked to clients with a history of a recent immunization or allergy. A client with Guillain-Barré displays the following symptoms:
- Diminished or absent tendon reflexes
- Low-grade fever
- Muscle weakness that gradually moves up the arms, trunk, and face
- Numbness, pain, and tingling in the lower extremities

Treating Clients with Guillian-Barré
The treatment phase for Guillian-Barré is directed toward performing indepth assessments, paying particular attention to the need for assisted ventilation. Emotional support and adequate nutrition are also used. You also need to be aware of other treatment modalities, including medications such as steroids to decrease the immune response and IV immunoglobulin and plasmopheresis. Plasmopheresis is used to remove circulating antibodies and speed the healing process.

Degenerative Neurological Disorders
Several neuro-disorders have similar pathophysiological features: there is a deficit in a neurotransmitter or an impairment of nerve conduction.

Degenerative Neurological Disorders
Keep in mind that the medications for treatment in several of the disorders are used to replace the deficiencies listed in the pathophysiology section. You should study and learn this table and expect some of this information to be on the exam.


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Diagnostic Tests for Review
A part of the neurological assessment includes diagnostic exams. Routine laboratory work, such as the CBC, chest x-ray, and urinalysis will also be done. Blood cultures are also required to identify the causative agent in CNS infections. Clients with head injuries and spinal cord injuries need skull x-rays, CT scans, and MRIs to identify defects. When reviewing the diagnostic exams that follow, remember which tests are commonly done for a specific disorder. For example, the electroencephalogram is used for epilepsy and seizure activity:
- Cerebral arteriogram
- Electroencephalogram
- Magnetic resonance angiography (MRA)
- Magnetic resonance imaging (MRI)
- Positron emission tomography (PET)
- Skull x-rays

Pharmacology for Review
Pharmacological interventions are used in most types of neurological problems. Some drug classifications are used in several disorders. For example, steroids are used in clients with multiple sclerosis, but also in head injuries and spinal cord injuries. While reviewing the drug classifications, you should recognize the most common ones, such as anticonvulsants, and realize that these drugs have a higher probability of being tested. Continue to look for the commonality in side effects of the drugs you are reviewing and focus on nursing considerations and adverse drug effects:
- Antianxiety
- Anticonvulsants
- Antimyasthenics
- Anti-Parkinson’s
- Cholinesterase inhibitor
- Corticosteroids
- Diuretics
- Gamma globulins
- Immunosuppressives
- Interferons
- Muscle relaxers
- Osmotic diuretics