Chapter 42
Nursing Care of Patients with Intracranial Disorders
Learning Outcomes
1. Describe the pathophysiology and manifestations of altered level of consciousness, and
outline the interprofessional care and nursing care of patients with this condition.
2. Describe the pathophysiology and manifestations of increased intracranial pressure, and
outline the interprofessional care and nursing care of patients with this condition.
3. Describe the pathophysiology and manifestations of seizures, and outline the
interprofessional care and nursing care of patients with seizures.
4. Describe the pathophysiology and manifestations of stroke, and outline the
interprofessional care and nursing care of patients with stroke.
5. Describe the pathophysiology and manifestations of intracranial vascular disorders, and
outline the interprofessional care and nursing care of patients with these disorders.
6. Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the
interprofessional care and nursing care of patients with this condition.
7. Describe the pathophysiology and manifestations of brain tumors, and outline the
interprofessional care and nursing care of patients with brain tumors.
8. Describe the pathophysiology and manifestations of headaches, and outline the
interprofessional care and nursing care of patients with headache.
Key Concepts
I. Altered Level of Consciousness
A. Consciousness
1. Aware of self and environment, appropriate response to stimuli
2. Arousal/alertness: Depends on the RAS, a diffuse system of neurons in the thalamus and
upper brainstem
3. Cognition: Complex process involving all mental activities controlled by the cerebral
hemispheres including thought processes, memory, perception, problem solving, and
emotion
4. Changing LOC corresponds to patterns of respiration, pupillary, oculomotor responses, and
motor function (Table 42.1)
5. Altered level of consciousness (LOC) (Table 42.2)
a) Full consciousness, confusion, disorientation, obtundation, stupor, semicomatose,
coma, and deep coma
b) Major causes of altered consciousness
(1) A-E-I-O-U = Alcohol, Epilepsy, Insulin, Opium, Uremia
(2) TIPSS = Tumor, Injury, Psychiatric, Stroke, Sepsis
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
B. The Patient with Altered Level of Consciousness
1. Pathophysiology
a) Arousal and cognition
(1) Reticular formation: Most important part of the reticular activating system (RAS)
(a) Mass of nerve cells and fibers making up the core of the brainstem
(b) Neurons pass impulses through the thalamic relays, stimulating wakefulness
(2) Damage to RAS
(a) Most commonly caused by stroke
(b) Other causes: Demyelinating diseases (multiple sclerosis, tumors, abscesses,
and head injury)
(3) May be difficult to assess cognitive functioning when RAS damage is due to
impairment of arousal
(4) Cerebral hemisphere (dis)functioning
(a) Any process that affects the flow of blood, oxygen, and glucose to the brain
or alters cell membranes can also alter LOC
(5) Progression of deterioration of brain functioning
b) Patterns of respiration
(1) Normal respirations: Maintained pons and medulla responding to oxygen and
carbon dioxide levels
(2) Damage can result in lower brainstem regulation of breathing, which only
responds to changes in carbon dioxide
(3) Yawning and sighing: Initial manifestations of deteriorating brain functioning
(4) Progressive respiratory changes include:
(a) Cheyne-Stokes respirations (damage to diencephalon)
(b) Neurogenic hyperventilation (damage to the midbrain)
(c) Apneustic respirations (damage to the pons)
(d) Ataxic/apneic respirations (damage to the medulla)
c) Pupillary and oculomotor responses
(1) Localized damage to brain (ipsilateral pupil) vs. generalized or systemic process
entire pupil
(2) Small pupils, equally reactive: Metabolic processes
(3) Pupils oval or eccentric: Compression of CN III
(4) Pupils become increasingly fixed and dilated
(5) Blown pupils: Sudden appearance of fixed and dilated pupils
(6) Ocular movement: Spontaneous eye movement is lost and reflexive movements
are altered
(a) Cranial nerve nuclei injury impairs normal movement
(b) Doll’s eye movement: Oculocephalic reflex, lessens to fixation with
deterioration
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
d) Motor responses
(1) Most accurate identifier of changes in mental status
(2) As function declines, movements become more generalized (withdrawal,
grimacing) and less purposeful
(3) Reflexive responses: Decorticate posturing, then decerebrate posturing,
eventually flaccid
e) Coma states and brain death
(1) Full recovery or recovery with residual damage including learning deficits,
emotional difficulties, impaired judgment, and cerebral death
(2) Persistent vegetative state (PVS)
(a) Permanent unawareness of self and environment and loss of all cognitive
functions
(b) Caused by severe brain trauma or global ischemia
(c) Death of cerebral hemispheres with continued function of brainstem and
cerebellum
(d) Sleep–wake cycles, chew, swallow, and cough
(e) Eyes may wander but cannot track objects or people
(f) Diagnosis requires that the condition lasts for 1 month
(3) Locked-in syndrome
(a) Intact cognitive abilities, alert and fully aware of environment
(b) Unable to communicate through speech or movement because of blocked
efferent pathways from the brain
(c) Patient may be able to communicate through eye movements and blinking
(4) Brain death
(a) Cessation and irreversibility of all brain functions, including the brainstem
(b) Criteria for establishing brain death varies state to state (usually 6–24 hours)
(i) Unresponsive coma with absent motor and reflex movements
(ii) No spontaneous respirations, apnea test performed
(iii) Pupils fixed (unresponsive to light) and dilated
(iv) Absent ocular responses to head turning and caloric stimulation
(v) Flat electroencephalogram (EEG) in patient who is not hypothermic or
under the influence of drugs that depress the central nervous system
(vi) No cerebral blood flow on angiography
(vii) Persistence of manifestations for 30 minutes to 1 hour and 6 hours
after onset of coma and apnea
(5) Prognosis
(a) Varies with underlying cause and pathologic process
(b) Poor when pupillary reaction or reflex eye movements are lacking 6 hours
after the onset of coma
2. Interprofessional care
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
a) Diagnosis
(1) Patient history and physical exam
(2) Diagnostic tests
(a) CT and MRI scanning: Hemorrhage, tumor, cyst, edema, myocardial
infarction, brain atrophy, and displacement of brain structures
(b) Radioisotope brain scan: Abnormal lesions in the brain and evaluate cerebral
blood flow
(c) Cerebral angiography: Radiographic visualization of the vascular system
(i) Aneurysms, occluded vessels, or tumors
(ii) Cessation of cerebral blood flow and brain death
(d) Transcranial Doppler: Assess cerebral blood flow
(e) Lumbar puncture with cerebrospinal fluid (CSF) analysis: Infection or
meningitis are suspected
(f) EEG: Electrical activity of the brain
(3) Laboratory tests
(a) Blood glucose: Suspected hypoglycemia
(b) Serum electrolytes
(c) Serum osmolality (hyperosmolality, hypo-osmolality)
(d) Arterial blood gases (ABGs)
(e) Liver function tests
(f) Toxicology screening
b) Medications
(1) Fluid balance is maintained via intravenous catheter using isotonic or slightly
hypertonic solutions (e.g., normal saline or lactated Ringer’s solution)
(2) Response to fluid administration is monitored for evidence of increased cerebral
edema
(3) Hypoglycemia: 50% glucose is administered
(4) Hyperglycemia: Insulin is administered
(5) Narcotic overdose: Naloxone is administered
(6) Thiamine administered if patient is malnourished or known to abuse alcohol
(Wernicke’s encephalopathy)
(7) Fluid and electrolyte imbalance is corrected by administering medications or
appropriate electrolytes
(8) Hyponatremic, low-serum osmolality: Furosemide (Lasix) or an osmotic diuretic
such as mannitol may be administered
(9) Meningitis: Antibiotics are administered
c) Nutrition: Long-term alterations in consciousness
(1) Enteral feedings
(2) Total parenteral nutrition (TPN)
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
d) Surgery
(1) If coma is caused by intracerebral tumor, hemorrhage, or hematoma
(2) When there is a risk of IICP, the patient is monitored continuously
e) Other treatments
(1) Support of the airway and respirations: Oral pharyngeal airway, endotracheal
intubation, mechanical ventilation
(2) AGBs monitored to determine adequacy of ventilation
3. Nursing care
a) Support of the family
b) Assessment
(1) Assess for manifestations or LOC
(2) Interprofessional care for the assessment of the patient with altered LOC
c) Diagnoses, outcomes, and interventions
(1) Maintain adequate airway clearance
(a) Monitor breath sounds, rate and depth of respirations, dyspnea, pulse
oximeter, and the presence of cyanosis
(b) If patient is unconscious of does not have an intact cough reflex: Maintain an
open airway by periodic suctioning, to clear mucus, blood, etc.
(2) Reduce risk for aspiration
(a) Drainage, mucus, or blood may obstruct the airway, interfering with
oxygenation
(b) Secretions may pool in lungs, increasing risk of pneumonia
(3) Reduce risk for impaired skin integrity
(a) Ischemia and pressure ulcers
(b) Interventions for skin, lips, and mucous membranes
(4) Promote physical mobility
(a) Passive ROM exercises; collaborate with a physical therapist
(b) Support devices to maintain functional positions of extremities
(5) Promote adequate nutritional intake
(6) Assess the need for alternative methods of nutrition with collaboration with
dietitian
(a) Increased nutritional needs during trauma or infection recovery
4. Transitions of care
a) Reinforce teaching
b) Explain the purpose of tubes and drains
c) Encourage family self-care
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
II. Increased Intracranial Pressure
A. Increased intracranial pressure (IICP)
1. Results in ischemia and damage to neural tissue
2. Cerebral edema is most frequent cause, other causes: Head trauma, tumors, abscesses,
stroke, inflammation, and hemorrhage
3. Dynamic equilibrium: Brain (80%), cerebrospinal fluid (8%), and blood (12%)
B. The Patient with Increased Intracranial Pressure
1. Pathophysiology
a) Autoregulation
(1) Increase in intracranial contents: Space-occupying lesion, hydrocephalus,
cerebral edema, excess cerebrospinal fluid, and intracranial hemorrhage
(2) Compensatory mechanisms: CSF is displaced and absorbed, low-pressure venous
system is compressed, and cerebral arteries constrict
(3) Compliance: Relationship between the volume of components and pressure
(4) Autoregulation can fail, then cerebrovascular tone is reduced, and blood flow
becomes dependent on changes in blood pressure
b) Cerebral edema
(1) Vasogenic edema: Extracellular edema of the white matter; brain tumors
(locally), cerebral trauma and meningitis (globally)
(2) Cytotoxic edema: Increase in fluid in neurons, glia, and endothelial cells; events
causing anoxia or hypoxia (e.g., cardiac arrest), hypo-osmolar conditions
(hyponatremia)
c) Hydrocephalus: Abnormal overproduction, circulation, or reabsorption of CSF
(1) Noncommunicating: Drainage from ventricular system is obstructed
(2) Communicating: CSF not reabsorbed through the arachnoid villi
d) Brain herniation: Displacement of brain tissue
(1) Supratentorial herniation
(a) Cingulate herniation
(b) Central or transtentorial herniation
(c) Uncal or lateral transtentorial herniation
(d) Infratentorial
2. Manifestations
a) Changes in LOR
b) Motor responses
c) Vision and pupils
d) Vital signs
(1) Other manifestations
(2) Headache
(3) Papilledema
(4) Vomiting
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
3. Interprofessional care
a) Diagnosis: Identifying presence of IICP and underlying cause
(1) CT or MRI
(2) Serum osmolality
(3) ABGs
(4) Additional tests used for altered LOC
b) Medications
(1) Chemical restraints
(2) Osmotic diuretics
(a) Nursing responsibilities
(i) Monitor vital signs, urinary output, central venous pressure (CVP), and
pulmonary artery pressures (PAP)
(ii) Assess for manifestations of dehydration, muscle weakness, numbness,
tingling, paresthesia, confusion, and excessive thirst
(iii) Assess for pulmonary edema while administering the medication
(iv) Monitor neurologic status and intracranial pressure readings
(v) Monitor renal function and serum electrolytes throughout therapy
(vi) Check medication solution for crystals, use an in-line filter, and observe
site frequently for infiltration
(vii) Do not administer mannitol solution with blood
(3) Loop diuretics
(a) Nursing responsibilities
(i) Monitor vital signs and electrolyte values closely
(ii) Assess fluid status throughout therapy
(iii) Monitor blood pressure and pulse before and during administration
(iv) Monitor renal laboratory studies closely
(v) Use infusion pump to ensure accurate dosage
(4) Intravenous fluids
(a) Nursing responsibilities
(i) Monitor fluid and neurologic status closely
(ii) Avoid administering solutions that become hypo-osmolar
(5) Other pharmacologic interventions for ICP
(a) Antipyretics are used in conjunction with a hypothermia blanket to reduce
hyperthermia
(b) Antiulcer drugs are used in patients with ICP to decrease the development of
stress ulcers
(c) Antihypertensive agents and vasopressors may be used to adjust high and
low MAP
(d) Vasopressors may be used if the mean arterial pressure is low
(e) Anticonvulsants may be given to prevent or treat seizures
c) Surgery
(1) Infarcted or necrotic tissue may be resected
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(2) Drainage catheter or shunt for CSF
d) ICP monitoring
(1) Measure cerebral blood flow, cerebral perfusion pressure, and oxygen levels
(2) In general, patients who are comatose and have a Glasgow Coma Score of 8 or
less should be monitored
e) Basic monitoring systems
(a) Epidural probe
(b) Subarachnoid bolt or screw
(c) Intraventricular catheter
(d) Transcranial Doppler studies (TCD)
(e) Cerebral perfusion pressure (CPP)
(f) Jugular bulb oxygen saturation monitor
(g) LICOX system: Oxygen and temperature status within brain tissue
(h) Cerebral microdialysis catheters
f) Mechanical ventilation
4. Nursing care
a) Diagnoses, outcomes, and interventions
(1) Maintain normal ICP
(a) Maintain patency of the airway for the patient on a ventilator
(b) Monitor ABGs
(c) Elevate head to 30 degrees or keep flat, as prescribed; maintain alignment of
head and neck
(d) Teach the patient to avoid actions that increase ICP: Coughing, blowing nose,
and muscle contracting exercises
(e) Monitor bladder distention and bowel constipation
(f) Assist patient to move up in bed to prevent the initiation of the Valsalva
maneuver
(g) Schedule nursing care to provide rest between procedures
(h) Provide a quiet environment, limiting stimuli both physical and emotional
(i) Maintain fluid limitations if prescribed
(2) Reduce risk for infection
(a) Keep dressings over catheter dry
(b) Monitor the insertion site for leaking CSF, drainage, or infection, and monitor
for physical and vital signs of infection
(c) Use strict aseptic technique when in contact with the device
5. Transitions of care
a) Encourage the family to talk to the patient, but to maintain low stimuli in environment
b) Family must carry out decisions about treatment if patient is unable to give informed
consent
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
III. Seizures
A. Pathophysiology
1. Seizure: “A single event of abnormal electrical discharge in the brain resulting in an abrupt
and temporary altered state of cerebral function” (Hickey, 2013)
a) Precipitating factors for seizures are unknown in 70% of all cases
2. Epilepsy: A chronic disorder of abnormal, recurring, excessive, and self-terminating
electrical discharge from neurons
a) Affects people of all ages, races, and ethnic background
b) Fourth most common neurological disorder in the United States; affects 2.2 million
people in the United States
3. Excessive imbalance in excitation and inhibition in cerebral cortex
4. Alterations in membrane potentials that increase the risk of hypersensitive neurons
responding abnormally to changes in the cellular environment
5. Epilepsy in older adults
a) By age 75, 3% of the population will have been diagnosed with epilepsy, 10% will have
experienced a seizure
b) Caused by arteriosclerosis of the cerebrovascular system and stroke
c) Complex partial seizure is most common type
d) Longer postseizure manifestations than young adults
e) Epilepsy beginning in older adults is often easier to control with antiepileptic drugs
(AEDs)
6. Seizure thresholds
7. Epileptogenic focus: Neurons that initiate seizure activity
8. Triggers: Music, odors, lights, fatigue, hypoglycemia, fever, alcohol, menstruation,
constipation, and hyperventilation
B. Risk factors
1. Birth defects, trauma, brain tumors, IICP, metabolic disorders, Alzheimer’s disease, and
cardiovascular diseases
2. Cause is unknown in 70% of all cases
3. Isolated seizure episodes may occur in otherwise because of fever, infection, metabolic or
endocrine disorder, or exposure to toxins
C. Manifestations
1. Seizure types
a) Focal seizures
(1) Simple partial seizures: Manifestations depend on involved area of the brain
(2) Complex partial seizure: Consciousness is impaired, may be preceded by an aura
b) Generalized seizures
(1) Absence seizures: Brief cessation of motor activity, automatisms
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
2.
3.
4.
5.
(2) Tonic–clonic seizures: Most common type in adults, aura may precede, loss of
consciousness, tonic phase, opisthotonic posture, clonic phase, and postictal
period
c) Unknown Onset
(1) Seizures when the onset is not determined
Epilepsy types
a) Focal
b) Generalized
c) Combined generalized and focal
d) Unknown
Epilepsy syndrome
a) Cluster of features including seizure type, EEG, and imaging features
Terms no longer used in epilepsy classification
a) Simple partial seizures
b) Complex partial seizures
c) Partial seizures
d) Psychic seizures
e) Dyscognitive seizures
f) Secondarily generalized tonic–clonic seizures
Status epilepticus: Repetitive seizures, usually tonic–clonic
a) Cumulative effect, can interfere with respirations, requires immediate intervention
b) Airway is a priority
D. The Patient with Seizures
1. Interprofessional care
a) Diagnosis
(1) MRI or CT scan: Determine abnormalities in brain
(2) Skull x-ray: Bony abnormalities
(3) EEG: Helps localize brain lesions and confirm diagnosis
(4) Lumbar puncture: CNS infections (increased WBCs) or tumors (increased protein
levels)
(5) Blood studies: Blood count, electrolytes, blood urea, and blood glucose
b) Medication administration
c) Antiseizure drugs
(1) Potentiate GABA Action (Barbiturates, Benzodiazepines, and Other Drugs)
(a) clonazepam (Klonopin)
(b) diazepam (Valium)
(c) gabapentin (Neurontin)
(d) lorazepam (Ativan)
(e) phenobarbital (Luminol)
(f) pregabalin (Lyrica)
(g) primidone (Mysoline)
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(h) topiramate (Topramax)
(2) Suppress Sodium Influx (Hydantoins and Related Drugs)
(a) carbamazepine (Tegretol)
(b) fosphenytoin (Cerebrex)
(c) lamotrigine (Lamictal)
(d) levetiracetam (Keppra)
(e) phenytoin (Dilantin)
(f) valproic acid (Depakene)
(g) zonisamide (Zonegran)
(3) Suppress Calcium Influx
(a) ethosuximide (Zarontin)
(b) methsuximide (Celontin)
(4) Nursing Responsibilities
(a) Monitor blood pressure, pulse, and respirations
(b) Note evidence of CNS side effects: Blurred vision, dimmed vision, slurred
speech, nystagmus, or confusion
(c) Prolonged therapy may require a diet rich in vitamin D
(d) Monitor the serum calcium level as ordered; phenytoin can contribute to
demineralization of bone
(e) When administering anticonvulsants intravenously, monitor closely for
respiratory depression and cardiovascular collapse
(f) Administer gabapentin 2 hours after antacids
(g) Administer tiagabine HCL with food
(5) Health education for the patient and family
(a) Take exact dosage to avoid convulsions
(b) Avoid hazardous tasks until drug has been regulated
(c) Maintain good oral hygiene with Dilantin
(d) Obtain liver function studies
(e) Carry identification indicating the type of seizures
(f) Do not take gabapentin 1 hour before or less than 2 hours after an antacid
(g) Tell provider if you develop a rash when on lamotrigine
(h) Take tiagabine HCL with food
d) Surgery
(1) Resective surgery: Removal of the epileptogenic focus
(2) Responsive Neurostimulator System: Electrodes implanted in the brain suppress
seizure; currently in clinical trials
e) Vagal nerve stimulation therapy: Sends regular small pulses of electrical energy to the
brain via the vagus nerve
2. Nursing care
a) Assessment
(1) Health history
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(2) Physical assessment
b) Diagnosis, outcomes, and interventions
(1) Maintain adequate airway clearance
(a) Provide interventions to maintain a patent airway
(b) Teach interventions to family members
(2) Relieve anxiety
(a) Provide support by explaining that concerns are normal
(b) Help identify safe leisure activities
(c) Provide information about sources and support groups
(d) Provide accurate information about hiring practices and legal limitations on
driving or operating heavy or dangerous machinery
(3) Provide special instructions for women
(a) Encourage discussion with the woman’s healthcare provider about the
increased probability of seizures at the time of menses
(b) Discuss the effects of AEDs; effectiveness of oral contraceptives and
breakthrough bleeding, and birth defects
3. Transitions of care
(1) Seizure management for family members: Care and observations are both
necessary before and during seizure
(2) The importance of wearing a MedicAlert band or carrying a medical alert card at
all times
(3) Avoiding alcoholic beverages and limiting coffee intake
IV. Stroke
A. Pathophysiology
1. Ischemic stroke
a) Transient ischemic attack
b) Large vessel (thrombotic) stroke
c) Small vessel stroke (lacunar infarct)
d) Cardiogenic embolic stroke
2. Hemorrhagic stroke
B. Risk factors
1. Modifiable
a) Hypertension: Treat it
b) Cigarette smoking: Quit it
c) Heart disease: Manage it
d) Diabetes: Control it
e) TIAs: Seek help
2. Act fast
a) Face: Ask the person to smile. Does one side of the face droop?
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
b) Arm: Ask the person to raise both arms. Does one arm drift downward?
c) Speech: Ask the person to repeat a simple sentence. Does the speech sound slurred or
strange?
d) Time: Call 911
C. Manifestations
1. Manifestations of a stroke by involved cerebral vessel
a) Internal carotid artery
(1) Contralateral paralysis of the arm, leg, and face
(2) Contralateral sensory deficits of the arm, leg, and face
(3) If the dominant hemisphere is involved: Aphasia
(4) If the nondominant hemisphere is involved: Apraxia, agnosia, unilateral neglect
(5) Homonymous hemianopia (see Figure 42.5c)
b) Middle cerebral artery
(1) Drowsiness, stupor, coma
(2) Contralateral hemiplegia of the arm and face
(3) Contralateral sensory deficits of the arm and face
(4) Global aphasia (if dominant hemisphere is involved)
(5) Homonymous hemianopia
c) Anterior cerebral artery
(1) Contralateral weakness or paralysis of the foot and leg
(2) Contralateral sensory loss of the toes, foot, and leg
(3) Loss of ability to make decisions or act voluntarily
(4) Urinary incontinence
d) Vertebral artery
(1) Pain in face, nose, or eye
(2) Numbness and weakness of the face on involved side
(3) Problems with gait
(4) Dysphagia
2. Complications
a) Sensoriperceptual deficits
(1) Hemianopia: The loss of half of the visual field of one or both eyes; when the
same half is missing in each eye, the condition is called homonymous
hemianopia (refer to Figure 42.5)
(2) Agnosia: The inability to recognize one or more subjects that were previously
familiar; agnosia may be visual, tactile, or auditory
(3) Apraxia: The inability to carry out some motor pattern (e.g., drawing a figure,
getting dressed) even when strength and coordination are adequate.
(4) Neglect syndrome
b) Cognitive and behavioral changes
c) Communication disorders
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(1) Aphasia: The inability to use or understand language; aphasia may be expressive,
receptive, or mixed (global)
(2) Expressive aphasia: A motor speech problem in which one can understand what
is being said but can respond verbally only in short phrases; also called Broca’s
aphasia
(3) Receptive aphasia: A sensory speech problem in which one cannot understand
the spoken (and often written) word. Speech may be fluent but with
inappropriate content; also called Wernicke’s aphasia
(4) Mixed or global aphasia: Language dysfunction in both understanding and
expression
(5) Dysarthria: Any disturbance in muscular control of speech
d) Motor deficits
(1) Hemiplegia: Paralysis of the left or right half of the body (Figure 42.6)
(2) Hemiparesis: Weakness of the left or right half of the body
(3) Flaccidity: Absence of muscle tone (hypotonia)
(4) Spasticity: Increased muscle tone (hypertonia), usually with some degree of
weakness
e) Elimination disorders
D. The Patient with a Stroke
1. Interprofessional care
a) Diagnosis
(1) Imaging tests
(2) Lumbar puncture
b) Medications
(1) Prevention
(a) Antiplatelet agents
(2) Acute stroke
(a) Fibrinolytic therapy
c) Nutrition
(1) Healthy diet
d) Surgery
(1) Carotid endarterectomy
(i) Postoperative care
(ii) Assess respirations and oxygen saturation
e) Rehabilitation
(1) Physical therapy
(2) Occupational therapy
(3) Speech therapy
2. Nursing care
a) Assessment
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(1) Health history
(2) Physical assessment
b) Diagnosis, outcomes, and interventions
(1) Maintain adequate cerebral perfusion
(a) Monitor respiratory status
(b) Suction as necessary
(c) Place in a side-lying position
(d) Administer oxygen as prescribed
(e)
(2) Promote physical mobility
(a) Encourage ROM exercises and perform passive ROM exercises
(b) Turn every 2 hours
(3) Promote self-care
(a) Screen for executive cognitive function
(b) Encourage use of unaffected arm
(c) Teach patient to dress
(d) Collaborate with the occupational therapist
(4) Assist with communication
(a) Treat patient as an adult
(b) Do not assume they cannot hear if they don’t respond, allow time for patient
to respond, face patient and speak slowly, using simple statements and
questions, do not use a raised voice; use alternate methods of
communication
(c) Accept frustration and anger as normal reactions to loss of functions
(5) Promote normal urinary and bowel elimination
(a) Assess for urinary frequency, urgency, incontinence, nocturia, and patient’s
ability to respond to the void
(b) Assess for distended bladder, encourage bladder training using schedule, and
teach Kegel exercises
(c) Discuss prestrike bowl habits, and post-stroke patterns
(d) Increase physical activity, fluids, fiber, prescribed stool softeners
(6) Prevent aspiration and ensure adequate nutrition
(a) Monitor results of swallowing studies prior to providing food and fluids
(b) Eating: Upright sitting position, neck slightly flexed, soft foods, teach to eat
with unaffected side of mouth
(c) Suction equipment in case of choking or aspiration
(d) Check affected area of mouth for pocketing of food
(e) Monitor lung sounds
3. Transitions of care
(1) Self-care
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(2) Physical care, medications, physical therapy, occupational therapy, and speech
therapy
(3) Home environment modifications
(4) Home health services, community resources, and organizational resources
V. Intracranial Vascular Disorders
A. The Patient with an Intracranial Aneurysm
1. Introduction
a) Intracranial aneurysm: Saccular outpouching of a cerebral artery that occurs at the site
of a weakness in the vessel wall
b) Most common cause of a hemorrhagic stroke
c) Most often in adults over the age of 50, a ruptured intracranial aneurysm often results
in death or severe disability in those who survive
2. Pathophysiology
a) Tend to occur at the bifurcations in the circle of Willis
b) Enlarge over time, increasing the probability of rupture
3. Risk factors
a) Inherited
b) Lifestyle
4. Manifestations
a) Rupture causes subarachnoid hemorrhage: Sudden explosive headache, neck pain,
nausea, vomiting, photophobia, nerve deficits, and stroke syndrome
b) Hypertension and cardiac dysrhythmias may occur
c) Fibrin and platelets seal bleeding point, escaped blood forms irritating clot that causes
inflammation
d) IICP
e) Pituitary gland: Diabetes insipidus and hyponatremia
5. Complications
a) Rebleeding: 70% of patients with rebleeding will die
b) Cerebral vasospasm: Narrows the lumen of one or more cerebral vessels, causing
ischemia and infarction of brain tissue supplied by affected vessels
c) Hypothalamic dysfunction, hydrocephalus, and seizures
6. Interprofessional care
a) Diagnosis
(1) CT scan: Detect hemorrhage
(2) Spiral computer tomography angiogram (CTA): Identifies the arterial anatomy
(3) Angiograms: Visualization of all four major cerebral vessels and their branches
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(4) Lumbar puncture: Blood-tinged spinal fluid
b) Medications
(1) Calcium channel blockers [e.g., nimodipine (Nimotop)]: Improve neurologic
deficits due to vasospasm
(2) Anticonvulsants [e.g., phenytoin (Dilantin)]: Prevent seizures in patients with IICP
(3) Analgesics: Headache
(4) Antacids and H2-receptor antagonist [e.g., ranitidine (Xanax)]: Gastric irritation
(5) Stool softeners: Prevent constipation and straining
c) Treatment
(1) Surgery as soon as possible, depends on patient’s neurologic status
(a) Neck of aneurysm may be clipped
(b) Balloon embolization
(c) Platinum coil electrothrombosis
7. Nursing care
a) Rebleeding prevention and needs resulting from neurologic deficits
b) Priority interventions in acute stage focus on ineffective cerebral tissue perfusion
B. The Patient with an Arteriovenous Malformation
1. Introduction
a) Arteriovenous (AV) malformation: Congenital intracranial lesion, formed by a tangled
collection of dilated arteries and veins that allows blood to flow directly from the
arterial into the venous system, bypassing the normal capillary network
b) Rupture in malformations account for 2% of strokes, manifestations develop before age
40, affects men and women equally, 90% are in cerebral hemispheres
2. Pathophysiology
a) Transfers higher arterial pressure into lower pressure venous system, causing
spontaneous bleeding or rupture
b) Blood flow through malformation is diverted from normal cerebral circulation, causing
tissue ischemia, sometimes called vascular steal phenomenon
3. Risk factors
a) Before 40 years of age
b) Affects men and women equally
4. Manifestations
a) Large malformations are usually initially manifested by seizure activity
b) Small malformations are more often due to a hemorrhage
5. Interprofessional care
a) Diagnosis: Same tests used for intracranial aneurysms
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
b) Treatments: Surgical excision, vascular occlusion, and radiosurgery
6. Nursing care
a) Depends on condition of malformation
b) If hemorrhage has not occurred, teach patient to avoid risky activities
c) Medications: Usually given to control blood pressure and prevent seizures
d) If ruptured and causes hemorrhage, care is same as stroke
VI. Traumatic Brain Injury
A. Introduction
1. TBI (also called craniocerebral trauma): Any injury of the scalp, skull, or brain
2. Penetrating or closed head injury; focal or diffuse
3. May cause problems with cognition, movement, sensation, and emotions
4. Mild injuries repeated over time result in cumulative deficits
5. Leading cause of death and disability: Crashes, falls (over 75), violence, sports injury, war;
at least half involve alcohol or drug use
6. TBI
a) Mechanism, nature, and location of injury determine damage
(1) Contact phenomena injury
(2) Acceleration–deceleration injury
(3) Rotational injury
b) Craniocerebral trauma: Skull, brain (concussion, contusion), hematomas, and
hemorrhage
B. Focal or Diffuse Traumatic Brain Injury
1. Pathophysiology
a) Focal brain injuries: Specific brain lesions, including contusions and
hemorrhage/hematomas
(1) Occur when brain strikes inner skull, coup and contrecoup lesions (Figure 42.8)
(2) Contusion: Bruise on brain’s surface, usually accompanied by small, diffuse
hemorrhages
(a) Edema can follow, resulting in IICP
(b) Contusions, hemorrhages, and brain swelling peak 12–24 hours after injury
(c) Initial loss of consciousness, LOC may remain altered, behavior changes may
persist
(d) Intracranial hematomas (Table 42.6)
(e) Epidural hematoma: Develops in potential space between the dura and the
skull, pulling dura away from skull
(i) Usually results from a skull fracture that tears an artery (meningeal),
develop rapidly
(ii) Headache, vomiting, fixed dilated ipsilateral pupil, contralateral
hemiparesis or hemiplegia, and seizures
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(f) Subdural hematoma: Blood collects between dura and arachnoid matter
(i) More common, top of head, develops within 48 hours of injury
(ii) Drowsiness, confusion, enlargement of ipsilateral pupil, unilateral
headache, hemiparesis, and respiratory changes
(iii) Chronic type: Occurs spontaneously in older adults or patients with
bleeding disorders
(g) Intracerebral hematoma: Closed head trauma, contusion or shearing of small
blood vessels deep within hemispheres, usually in frontal or temporal lobes
(i) More common in older adults whose blood vessels are more fragile
(ii) Manifestations vary according to location
b) Diffuse cerebral injury: Concussion and diffuse axonal injury
(1) Caused by shaking motion with twisting movement (rotational injury)
(2) Number of damaged axons increase, astrocytosis (scarring), and demyelation
(3) Mild concussion: Temporary axonal disturbances
(a) Classic cerebral concussion: Diffuse cerebral disconnection from the
brainstem RAS
(4) Diffuse axonal injury (DAI): High-speed acceleration–deceleration injury, causing
widespread disruption of axons in white matter (many focal lesions)
2. Manifestations
a) Short loss of consciousness, amnesia, headache, drowsiness, confusion, dizziness, visual
disturbances, and possibly seizure
b) Postconcussion syndrome: Persistent headache, dizziness, irritability, insomnia,
impaired memory and concentration, and learning problems
3. Interprofessional care
a) Concussion
(1) Observe patient for 1–2 hours in emergency department
(2) Discharge with instructions to observe and detect secondary injury
manifestations
b) Acute TBI
(1) Morbidity and mortality increase with hypotension and hypoxia (hypertonic
saline is given)
(2) Assessment of airway, breathing, and circulation (ABCs)
(3) Intracranial pressure monitor probe
(4) Osmotic diuretics, oxygenation
(5) ICU: Central venous pressure (CVP) catheter, arterial line, pulmonary catheter,
ventriculostomy, ICP monitor, retrograde jugular catheter, endotracheal tube,
bilateral sequential pressure boots, and rectal temperature probe
c) Diagnosis
(1) X-rays: Skull fractures, penetrating objects
(2) CT or MRI: Contusions, lacerations (diffuse axonal injury)
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(3) ABGs: Especially oxygen and carbon dioxide levels
d) Managing IICP
(1) Airway management, hyperventilation, fluid resuscitation, positioning, and
temperature regulation
(2) Medications (neuroprotectants): Lipid peroxidase inhibitors, free radical
scavengers, receptor antagonists, calcium channel blockers, and gangliosides
e) Surgery
(1) Epidural and large acute subdural hematomas (burr holes)
(2) Rebleeding especially in older adults and patients with alcoholism, chronic
subdural hematomas (craniotomy)
4. Nursing care
a) Assessment
(1) Health history
(a) Understand the nature of the craniocerebral trauma, knowledge about loss of
consciousness
(2) Physical examination
(a) Neurologic assessment, pupils, LOC, Glasgow Coma Scale, brainstem reflexes,
spontaneous movement, response to pain, vital signs, skull and face, and
movement of extremities
b) Diagnoses, outcomes, and interventions
(1) Monitor intracranial pressure
(a) Patient should experience fewer than five episodes of disproportionate IICP
in 24 hours
(b) Monitor for manifestations of IICP, changes in vitals, vomiting, headache,
lethargy, restlessness, purposeless movements, and changes in mentation
(c) Temperature, hyperthermia may increase ICP, and hypothermia treatment
(d) Monitor fluid stats
(2) Maintain adequate airway clearance
(a) Maintain airway clearance through interventions and suctioning
(b) Monitor neurologic manifestations on regular schedule
(c) Maintain head and neck in neutral alignment, immobilizing until injury is
determined
(d) Clear nose and mouth of mucus and blood: Do not suction nose until dural
tear has been ruled out
(3) Promote effective breathing pattern
(a) Ineffective breathing is related to IICP, if ICP increases dramatically tentorial
herniation may occur leading to sudden respiratory arrest
(b) Patient must utilize techniques to promote adequate ventilation: Deep
breathing and slowed respirations
5. Transitions of care
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
a) Inform patient and family about postconcussion syndrome
b) Long-term physical care and rehabilitation
c) Realities of possibility of residual deficits in self-care, emotional responses, cognition,
communication, and movement
VII. Brain Tumors
A. The Patient with a Brain Tumor
1. Pathophysiology
a) Classification
(1) Malignant: Lack of cell differentiation and invasive nature of the tumor
(2) Benign (surgically inaccessible = herniation)
(3) Primary: Arise from cells and structures found within the brain
(4) Metastatic: Originate outside the brain, lungs, breasts, and prostate gland
b) Damage: Focal disturbances, vasogenic edema, and altered electrical potential from
plasma
2. Manifestations, classifications of primary brain tumors (Table 42.7)
a) Changes in cognition or consciousness, headache that is worse in the morning, seizures,
vomiting
b) Changes seen with cerebral edema and IICP are seen due to compression and invasion
of brain tissue by tumor
c) Cerebral blood supply diminishes as tumor compresses vessels
d) Primary tumors
(1) Glioma: Astrocytoma, glioblastoma multiforme, ependymoma,
oligodendroglioma, and astroblastoma
e) Extracerebral tumor
(1) Medulloblastoma, meningioma, and acoustic neuroma (neurofibromatosis)
(2) Arise from supporting structures of nervous system, rare
f) Congenital tumors
(1) Hemangioblastoma and craniopharyngioma
g) Pituitary adenomas
(1) Chromophobic, eosinophilic, and basophilic
3. Manifestations of brain tumors by location
a) Frontal lobe: Inappropriate behavior, recent memory loss, personality changes,
headache, inability to concentrate, expressive aphasia, impaired judgment, and motor
dysfunctions
b) Parietal lobe tumors: Sensory deficits (paresthesia, loss of two-point discrimination,
visual field)
c) Temporal lobe tumors: Psychomotor seizures
d) Occipital lobe tumors: Visual disturbances
e) Cerebellum tumors: Disturbances in coordination and equilibrium
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
f) Pituitary tumors: Endocrine dysfunction, visual deficits, and headache
4. Interprofessional care
a) Diagnosis
(1) History and physical: Fundus of the eye, visual fields, neurologic assessment, and
EEG
(2) MRI with gadolinium enhancement: Defines size, shape, associated edema, and
distortions of anatomy
(3) Arteriogram: Stretching or displacement of vessels, presence of tumor vascularity
(4) Endocrine studies: Pituitary gland involvement
b) Chemotherapy (blood–brain barrier)
(1) Intraventricular administration: Ommaya reservoir surgically implanted into
lateral ventricle of brain
(2) Convection-enhanced delivery (CED): Continuous injection of chemotherapy
directly to tumor site through a catheter with positive pressure
(3) Biodegradable anhydrous wafer: Impregnated with drug and implanted into
tumor at time of surgery
c) Surgery: Preferred treatment for primary tumors
(1) Burr hole: Removal of clots, series of holes for craniotomy
(2) Craniotomy: Bone flap removed and returned
(a) Tumors, defects from TBIs, repair cerebral aneurysm
(b) Awake craniotomy
(3) Craniectomy: Complete removal of bone flap, to remove pressure
(4) Cranioplasty: Plastic repair to the skull
d) Radiation therapy: Alone or as adjunctive therapy, surgically inaccessible tumors, or to
decrease size before surgery
e) Specialty procedures: Special instruments, stereotaxic techniques, laser beam,
microsurgery, and gamma knife
5. Nursing care
a) Diagnoses, outcomes, and interventions
(1) Relieve anxiety:
(a) Provide emotional and educational support, explain routine procedures,
review patient and family strengths and coping skills, etc.
(2) Reduce risk for infection
(a) Monitor for leakage of CSF, prevent contamination of leakage areas
(b) Nose leakage: Keep bed elevated 20 degrees, do not clean nose or suction,
and do not touch
(c) Ear: Position patient on side of leakage, do not clean or touch or insert
packing
(d) Place sterile dressing over area of drainage and change often
(e) Monitor and report manifestations of infection
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
(f) Implement interventions to prevent infection
(3) Reduce risk of ICPP and bleeding
(a) Patient with intracranial surgery does not have normal defenses against
changes in ICP
(b) Internal shunts: Avoid pressure on shunt, reservoir, or tubing
(c) External shunts: Avoid kinks in tubing, maintain the drainage collecting device
(4) Relieve acute pain
(a) Assess location, duration, and intensity of pain
(b) Implement interventions: Raise head of bed, reduce noise and lights, loosen
head dressing if allowed, use narcotic analgesics with caution
(5) Promote acceptance and independence
(a) Patient should demonstrate that self-perceptions are accurate given physical
capabilities
(b) Assess for verbal and nonverbal manifestations of negative self-esteem
6. Transitions of care
a) Assess family members for ability to cope with stress of surgery
b) Family may assist with ADLs
c) Encourage patient to take an active role in care
d) Discharge planning: Medication, wound care, wigs, turbans, hats, scarves, follow-up
visits, reporting manifestations: Stiff neck, increased headache, elevated temperature,
new motor or sensory deficits, vision changes, and seizures
VIII. Headache
A. Pathophysiology
1. Migraine headache: A recurring primary headache, triggered by an event, and
accompanied by a neurologic dysfunction
a) Classic migraine with aura (15%): Sensory manifestation occurs prior to manifestations
b) Cause not understood, relationships between serotonin and migraines
c) Vessels narrow, reducing blood flow, followed by vasodilation, swelling, and pain
d) Triggers: Menstruation, rapid changes in glucose levels, stress, emotional excitement,
fatigue, alcohol intake, stimuli to bright lights, food high in tyramine, and other
vasoactive substances (aged cheese, nuts, chocolate)
e) Pain is unilateral and throbbing, may become bilateral; chills, nausea, vomiting, fatigue,
sensitivity to light, sound, and odor
f) Other manifestations: Blurred vision, anorexia, hunger, diarrhea, abdominal cramping,
facial pallor, sweating, and stiffness or tenderness of neck
2. Cluster headache: Severe, unilateral, and burning pain behind or around eyes
a) Predominantly experienced by men between 20 and 40 years
b) Occur in clusters of one to eight each day for several weeks or months
c) Physiologic mechanism is not well understood, involves vascular disorder, a disturbance
of serotonin mechanisms, a sympathetic defect, or dysregulation of the hypothalamus
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
d) Triggers: Alcohol, certain foods, smoking, high altitude, and sleep cycle disturbances
e) Eye pain is accompanied by shinorrhea, lacrimation, flushing, sweating, facial edema,
and possible miosis or ptosis
B. The Patient with a Headache
1. Interprofessional care
a) Diagnosis
(1) History, identifying triggering events, and type of headache
(2) Neurodiagnostic testing rules out structural disease
(3) Brain scan, MRI, x-ray, EEG, lumbar puncture, serum metabolic screens, and
hypersensitivity testing
b) Medications
(1) Prophylactic therapy: Beta blockers, SSRIs, calcium channel antagonists
(2) Once in progress: Narcotic analgesic
(3) Inhalation of 100% oxygen at onset of attack
(4) Preventive treatment: Calcium channel blockers, lithium carbonate, topiramate,
and baclofen
(5) Integrative therapies
(a) Acupuncture
(b) Biofeedback
(c) Massage
(d) Relaxation
(e) Spinal manipulation
(f) Herbs: Butterbur while feverfew, magnesium, and riboflavin coenzyme Q10
c) Suggestions to Decrease Incidence of Migraine Headaches
(1) Wake up at the same time every morning
(2) Eat your meals and exercise on a regular schedule
(3) No smoking or caffeine after 3:00 p.m.
(4) No artificial sweeteners or MSG
(5) Reduce or eliminate red wine, cheese, alcohol, chocolate, and caffeine.
(6) Practice relaxation techniques, such as yoga, meditation, or biofeedback
C. Nursing care
1. Teach for self-care at home
2. Suggest strategies to control pain
3. Suggest diary of duration, onset, location, relation to menstruation or food intake, and any
precipitating triggers
4. Methods of stress reduction
Chapter Highlights
A. Altered level of consciousness (LOC) is a common response to intracranial disorders and is
an early manifestation of deterioration of the function of the cerebral hemispheres. The
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
alteration in cerebral function occurs in a sequential pattern, with characteristic changes in
LOC, respiratory patterns, pupillary and oculomotor responses, and motor function.
Coma states include persistent vegetative state and locked-in syndrome. Increased
intracranial pressure (IICP) is a sustained elevated pressure (greater than 10 mmHg) within
the cranial cavity. IICP may result from cerebral edema, hydrocephalus, head trauma,
tumors, abscesses, inflammation, hemorrhage, or stroke.
The manifestations of IICP include a decreasing LOC, abnormal motor weakness and
responses, altered vision, altered vital signs, headache, papilledema, and projectile
vomiting. If untreated, IICP causes a displacement (herniation) of cerebral tissue and
herniation of the cerebellum through the tentorium, followed by herniation of the
brainstem through the foramen magnum. This is a lethal complication of IICP because it puts
pressure on the vital centers in the medulla. IICP is primarily managed with osmotic
diuretics and monitored with continuous intracranial pressure monitors.
A seizure is a single event of abnormal electrical discharge.
Epilepsy is a chronic seizure disorder of abnormal, recurring, excessive, and self-terminating
electrical discharges from neurons.
Seizures are categorized into those that affect only a part of the brain (partial seizures) and
those that affect all of the brain (generalized). The most common type of seizure in adults is
a tonic–clonic generalized seizure.
A stroke is a condition in which neurologic deficits result from a sudden decrease in blood
flow to a localized area of the brain. Strokes may be ischemic or hemorrhagic. Ischemic
strokes result from a blockage of a cerebral artery by formation of a blood clot or by a clot
or foreign substance lodging in a blood vessel; they include transient ischemic attacks,
thrombotic strokes, or embolic strokes. Hemorrhagic strokes occur when a cerebral blood
vessel ruptures. Depending on the size and location of cerebral tissue damage, strokes may
cause cognitive and behavior changes, sensory–perceptual deficits, language disorders, and
motor deficits. Treatment of an ischemic stroke with fibrinolytic therapy within 3 hours of
the onset of manifestations may reverse damage to cerebral neurons. Nursing care is
directed toward both prevention of a stroke through community-based educational
programs and interventions to promote recovery and decrease complications.
Intracerebral hemorrhage may follow rupture of an intracranial aneurysm or arteriovenous
malformation. Intracranial aneurysms occur at the site of a weakness in a cerebral blood
vessel. AV malformations are a tangled collection of dilated arteries and veins.
An epidural hematoma develops in the potential space between the dura and the skull. A
subdural hematoma collects between the dura mater and the arachnoid mater. Diffuse brain
injuries include contusions, concussions, and diffuse axonal injury. Patients with an acute TBI
must have immediate transport and treatment in an ED, followed by care in an ICU. They will
require long-term physical care and rehabilitation.
Arteriovenous malformations are a tangled collection of dilated arteries and veins,
increasing the risk for rupture.
Traumatic brain injury (TBI) refers to any injury of the scalp, skull, or brain and is a leading
cause of death and disability.
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
L. Traumatic brain injuries can include focal or diffuse brain injury. An acute brain injury affects
all body systems and carries the risk of secondary injury to the brain from hypoxia and
ischemia.
M. Brain tumors are growths within the cranium, including on or in brain tissue, the meninges,
the pituitary gland, or blood vessels.
N. Brain tumors may be benign or malignant, primary or metastatic, and intracerebral or
extracerebral.
O. Regardless of the type or location, brain tumors are potentially lethal because they displace
or impinge on CNS structures within a closed bony system.
P. Headaches, a common type of intracranial pain, are categorized as tension, migraine, and
cluster.
Q. A classic migraine is characterized by an aura; a common migraine does not have an aura.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME ONE
Discuss levels of consciousness and increased intracranial pressure. Discuss the pathophysiologic
findings and the manifestations as they apply to changes in cerebral tissue perfusion.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME ONE
Assign students, if possible, to care for a client with an altered level of consciousness.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME TWO
Have students research the diagnosis of persistent vegetative state and brain death. Look for
differences between and among states. Look for differences in definition between children and
adults.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME TWO
Assign students to care for/observe the care of client with increased intracranial pressure.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME THREE
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of seizures. Share the group
findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME THREE
Assign students to care for a client with a seizure disorder.
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FOUR
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of a stroke. Share the group
findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FOUR
Assign students to care for a client recovering from a stroke. This could be in acute care or home
care setting.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME FIVE
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of intracranial vascular
disorders. Share the group findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME FIVE
Assign students to care for and observe the surgery to correct an intracranial vascular disorder.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SIX
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of traumatic brain injuries.
Share the group findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SIX
Assign students to observe/participate in the care of a client recovering from a traumatic brain
injury.
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME SEVEN
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of brain tumors. Share the
group findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME SEVEN
Assign students to observe/participate in the care of a client with a brain tumor.
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition
SUGGESTION FOR CLASSROOM ACTIVITY—LEARNING OUTCOME EIGHT
Divide the students into small groups. Have the group investigate the pathophysiology,
manifestations, complications, and interdisciplinary and nursing care of headaches. Share the group
findings.
SUGGESTION FOR CLINICAL ACTIVITY—LEARNING OUTCOME EIGHT
Assign students to assess a client with a headache. Have the students create a teaching tool to
share with the client to assist with reducing the frequency of headaches.
Copyright © 2020 by Pearson Education, Inc.
Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing:
Clinical Reasoning in Patient Care, 7th Edition