Neurological
Priority concept: Perfusion, cognition, mobility, sensory perception
Acute ischemic stroke can be warned by a transient ischemic attack (TIA)
Common causes: carotid stenosis with atherosclerotic plaque and a-fib.
S/S of TIA:
Visual:
 Blurred vision
 Doubled vision (diplopia)
 Blindness of one or both eyes (hemianopsia)
 Tunnel vision (loss of peripheral vision)
Speech:
 Problem with speech (Aphasia)
 Slurred speech caused by muscle weakness (dysarthria)
Mobility:
 Weakness (facial droop, can’t lift arms, weak hand grasp)
 Ataxia (lack of muscle control, impaired gait, balance, and ability to walk)
Sensory perception:
 Numbness (face, extremities)
 Dizziness
Diagnostic tests:
National Institutes of Health Stroke Scale (NIHSS)
Lab – PT, INR, aPTT, and lipids
ECG
Head CT, MRI of brain w/o contrast, CTA (CT angiography), MRA of brain and neck.
ABCD assessment tool:
Age>60
BP>140/90
Clinical TIA features (unilateral weakness)
Duration of symptoms
Collaborative intervention:
 Surgery to remove plaque
 Carotid angioplasty
 Antiplatelet drug
 Antihypertensives
 Control DM
 Promoting lifestyle changes
1. Identify common changes in the neurological system associated with aging.
2. Discuss the components of a neurological assessment.
3. Perform a rapid neurological assessment and interpret findings.
4. Identify clinical manifestations of increased intracranial pressure.
 ALOC (earliest sign)
 Behavior changes: restlessness, irritability, and confusion
 Headache
 Nausea and vomiting
 Dysarthria (changes in speech pattern)
 Aphasia (problem with speech)
 Change in sensorimotor status:
o Pupillary: dilated/constricted and nonreactive pupils
o Cranial nerve dysfunction
 Ataxia (lack of muscle control, impaired gait, balance and ability to walk)
 Seizures (usually within first 24 hr after stroke)
 Crushing triad (very late sign):
o Severe HTN/irregular respiration
o Widened pulse pressure
o Bradycardia
 Abnormal posturing (very late sign):
o Decerebrate (with the arms extended at the sides)
o Decortibrate (with the arms flexed over the chest)
5. Identify the common types of stroke and related risk factors.
Ischemic stroke (caused by the blockage of a cerebral or carotid artery by a thrombus or
embolus):
 Thrombotic: a clot associated with the development of atherosclerosis (fatty plaque
buildup on the inner wall) in intracranial or extracranial arteries (usually carotid arteries)
 Embolic: caused by an embolus (dislodged clot) that traveled from one area of the body
to the cerebral arteries via the carotid arteries or vertebrobasilar system.
Hemorrhagic stroke: (caused by bleeding occurs into the brain tissue or the subarachnoid space
from a ruptured vessel)
 Intracerebral hemorrhage (ICH): bleeding into the brain tissue from severe HTN
 Subarachnoid hemorrhage (SAH): bleeding into the subarachnoid space (the space
between the pia mater and arachnoid layers of meninges covering the brain) that is
usually caused by a ruptured aneurysm (an abnormal ballooning or blister along a normal
artery commonly developing in a weak spot on the artery wall) or arteriovenous
malformation (AVM, an angled collection of malformed, thin-walled, dilated vessels w/o
a capillary network)
6. Describe the typical manifestations of stroke.
 Numbness or weakness in the face (drooping), arm (difficult to lift), or leg, especially on
one side of the body.

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
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Sudden confusion, trouble speaking, or difficulty understanding speech (Aphasia &
dysarthria)
Trouble seeing in one or both eyes (blurred vision, doubled vision, and tunnel vision)
Trouble walking, dizziness, loss of balance, or lack of coordination (Ataxia)
Sudden severe headache with no known cause.
7. Identify and discuss diagnostic testing and nursing responsibilities related to stroke.
 National Institutes of Health Stroke Scale (NIHSS)
 Lab – PT, INR, aPTT, and lipids
 ECG
 Head CT, MRI of brain w/o contrast, CTA (CT angiography), MRA of brain and neck
8. Identify collaborative management options and drug therapy used to treat patients with
stroke.
 Surgery to remove plaque
 Carotid angioplasty
 Antiplatelet drug
 Antihypertensives
 Control DM
 Promoting lifestyle changes
9. Prioritize nursing problems, expected outcomes and nursing care for a patient with stroke.
10. Discuss the eight core measures associated with the care of stroke patients.
 VTE prophylaxis
 Discharge with antithrombotic therapy
 Discharge with anticoagulant therapy for a-fib/flutter
 Thrombolytic therapy as indicated
 Antithrombotic therapy re-evaluated by end of hospital day 2
 Discharge on statin medication
 Stroke education provided and documented
 Assessment for rehabilitation
11. Discuss the common types of seizures, precipitating factors, and clinical manifestations.
12. Explain the nursing interventions required when caring for a patient at risk for or having a
seizure.
13. Provide patient and family education for the patient with epilepsy.
Seizures
Excitatory – Glutamate vs Inhibitory – GABA
Medication – barbiturates (stimulate the GABA receptor and help decrease the excitation in the
brain)
Causes:
 High fever
 Acute illness
 CNS infection (such as bacterial meningitis)
 Hypoglycemia
 Alcohol withdrawal
 Acid-base imbalance, hypoxia
 Brain tumor
Epilepsy - frequent chronic seizure activity due to chronic conditions such as traumatic brain
injury, stroke, congenital)
Stages of seizures:
Prodromal – when symptoms start to appear before the big event hence the seizure
 Depression
 Anger
 Sleeping issues
 Anxiety
 GI and urinary issues
Tend to start days before a seizure starts
Aura – does not happen with all types of seizures, usually partial or generalized tonic-clonic
seizures. It happens at the very beginning of a seizure – A BIGGER SEIZURE IS EXPECTED
 Altered vision or hearing (seeing spots or hearing voices)
 Sudden anxiety
 DÉJÀ VU
 Sudden weird taste or smell
 Dizziness
 Inability to speak
Happens within seconds or minutes
Ictus – actual seizure that lasts about 1-3 minutes, TIME THE SEIZURE (more than 5 mins or
back-to-back seizures cause Status epilepticus – dangerous, require immediate treatment to stop
the seizure)
Post Ictus – after the seizure, recovery. It takes hours to days (tonic-clonic) or immediate
(absence) for the brain to recover
 Very tired – allow rest
 Confused
 Headache

Injury (tongue, cheek, body)
Generalize (both hemispheres):
TONIC-CLONIC (grand mal) – most common, aura, loss of consciousness, injury, stiffening
muscle and arhythmic jerking (recurrent spasm and relaxation)
When aura occurs: prepare patient, turn on the side to promote airway and drainage, cushion the
head
During Tonic: may bite tongue, apnea, cyanosis
During Clonic: incontinence
TIME THE SEIZURE; CALL FOR HELP IF LONGER THAN 5 MINS
Absence – (petit mal) more common in Peds, STARING (appears to be daydreaming)
 Go unnoticed
 Won’t respond – they can stop in the middle of an activity and resume after the seizure
 Very short – seconds
 Recovers immediately but will not recall
Atonic (drop attack) – without muscle tone leads to FALL (risk for head trauma)
 Wear helmet to prevent head
 Patient unaware surrounding
 Post ictus immediately
Partial or local (one hemisphere, specific area):
Focal onset awareness (simple partial): patient is aware of the surroundings, <2 mins – aura
Focal impaired awareness (complex partial): patient is not aware, motor symptoms occur,
automatism – such as lip smacking, hand rubbing, grasping things that are not there
Nursing interventions:
Assess risk factors:
Seizure precautions
 O2 and suction ready – clear airway
 IV access – medication administration
 Padded side rails (debatable)
 Bed at its lowest position
 Pillow for head protection
 No restraint
Access seizure history:
 Prodromal
 Aura – signs and symptoms, how fast it happens after
 How long it lasts
 What types of seizures
 Last med dose (undermedicated?)
 Drug level (lab draw)
During the seizure:
 Patient on side lying – clear airway, promote drainage
 Pillow under head
 No restraint
 No mouth insertion
 Remove objects (glasses)
 TIME THE SEIZURE
 Seizure characteristics – aura? Cry out? Stiffening? Jerking? Blood? incontinence?
After the seizure:
 Vital signs and neuro assessment
 How is the patient behaving
 Lab draw, medication
 EEG for assessing brain activity
o Painless procedure
o No caffeine 8 hr before the test
o Hold seizure med and other stimulants
o Can eat before
o Hair is clean and dry
o Allowing sleep before test??
STOP SEIZURE:
Stress
Trauma
Overexertion
Period, pregnancy
Sleep loss
Electrolyte and metabolic disorder
Illness
visualization disturbances, sounds or smells
Undermedicated
Recreational drug
Ethanol
Stroke
Oxygenated blood cannot reach brain cells, and cells begin to die due to bleeding or blockage
Ischemic stroke (caused by the blockage of a cerebral or carotid artery by a thrombus or embolus
– could be artery stenosis):
 Thrombotic: a clot associated with the development of atherosclerosis (fatty plaque
buildup on the inner wall) in intracranial or extracranial arteries (usually carotid arteries)
 Embolic: caused by an embolus (dislodged clot) that traveled from one area of the body
to the cerebral arteries via the carotid arteries or vertebrobasilar system.
Hemorrhagic stroke (caused by bleeding occurs into the brain tissue or the subarachnoid space
from a ruptured vessel- no blood to perfuse the brain cells and excessive swelling from the
leakage of blood in the brain)
 Intracerebral hemorrhage (ICH): bleeding into the brain tissue from severe HTN
 Subarachnoid hemorrhage (SAH): bleeding into the subarachnoid space (the space
between the pia mater and arachnoid layers of meninges covering the brain) that is
usually caused by a ruptured aneurysm (an abnormal ballooning or blister along a normal
artery commonly developing in a weak spot on the artery wall) or arteriovenous
malformation (AVM, an angled collection of malformed, thin-walled, dilated vessels w/o
a capillary network)
TIA mini-stroke, a warning sign for a bigger stroke, shares the same symptoms of stroke, only
lasts a few minutes but cannot be ignored, and needs evaluation.
Visual:
 Blurred vision
 Doubled vision (diplopia)
 Blindness of one or both eyes (hemianopsia)
 Tunnel vision (loss of peripheral vision)
Speech:
 Problem with speech (Aphasia)
 Slurred speech caused by muscle weakness (dysarthria)
Mobility:
 Weakness (facial droop, can’t lift arms, weak hand grasp)
 Ataxia (lack of muscle control, impaired gait, balance, and ability to walk)
Sensory perception:
 Numbness (face, extremities)
 Dizziness
Frontal lobe: thinking, speaking memory, movement
Parietal lobe: language, touch
Temporal lobe: hearing, learning, feelings
Occipital lobe: vision, color perception
Cerebellum: balance and coordination
Brain stem: breathing, HR, temperature
Right side of brain – creativity
 Attention span
 Emotions
 Vision
 Music/art awareness
 Balance
 Control the left side of body
Findings: left side weakness (hemiplegia), impairment in creativity, confused on date, time and
place, cannot recognize faces or the person’s name, loss of depth perception, trouble staying on
topic when talking, cannot see on the left side, denial about limitation.
Left side of brain -- logical
 Speaking
 Thinking
 Writing
 Reding
 Math skills
 Analyzing info
 planning
 Control the right side of body
Findings: right side hemiplegia, aphasia, aware of the limits, depression, anger, frustration,
trouble understanding written text, impaired math skills, memory intact, trouble seeing on the
right side
Risk factors:
Non-modifiable: age, genetic, DM, HTN, CVD
Modifiable: obesity, smoking, exercise
Diagnosed:
CT scan – r/o hemorrhage
MRI – to know the area of the stroke
tPA therapy (IV fibrinolytic, NOT FOR HEMORRHAGE)
within 3 – 4.5 hr if:
 CT scan – negative
 Labs WNL (glucose, INR, platelet)
 BP < 185/110
 No recent anticoagulant
Nursing interventions for tPA:
 Check for bleeding
 Neuro checks around the clock
 BP medication if needed
 VS
 Labs
 Glucose
 Bedrest to prevent injury
 Avoid unnecessary venipunctures
 Avoid IM injections
 Most patients will go to ICU to be monitored
NIHSS assessment
Monitor:
 VS: increased BP, decreased HR, decreased RR = increased intracranial pressure
 N+V and ALOC
 Airway: issue swallowing – suctioning @bedside
 Cranial nerves: pupils, swallowing, facial gaze, gag reflux
 Bladder & bowel: (for incontinence or retention) – bedpan, foley
 Skin & limb integrity
 Neglect syndrome: unilateral neglect - remind pt to check and touch the affected side
 Hemianopia: prevent injury, turn head side to side to scan the environment
 Diet: difficulty swallowing by SLP – thickened liquid, crushed meds, mechanical soft
food
 Assist with eating: pouching food in cheek
 Communication – aphasia, be patient, use gestures, repeat