Medical Surgical Nursing:
Neurology Handout
I.
Anatomy of the Nervous system
a. Consists of
i. _________________________
ii. ______________________ cord
iii. ______________________ nerves
b. Divided into …
_____________________ Nervous System
_________________________ Nervous System
______________________
_________________________
______________________ cord
(Peripheral & _______________________)
c. Function
i. _____________________ and ______________________ all parts of the body
1. By transmission of _________________________________________
ii. ________________________________
iii. ________________________________ of movement
d. Purpose
i. ________________________ homeostasis along with the _________________
e. Basic functional unit: ____________________________
i. Connect to each other _____________ to __________________
1. __________________________ junction / _______________________
f.
Central Nervous System
i. _______________________ center for the entire system
ii. Protections
1. Brain: ______________within the ___________________________
2. Spinal Cord: Encased in the ________________________________
iii. Meninges
Document1
1
1. Function:
a. ______________________
b. ______________________
c. ______________________
2. _____________ mater
3. Arachnoid
a. CSF________________________________________
4. _______________ mater
II.
Brain
a. 3 Main areas
i. __________________________: coordination of ________________
ii. __________________________: Control ________________________
1. “_______________________ brain”
iii. __________________________:
1.
________________ reflexes
2. Relay for ______________________ & ___________________
3. _______________________________ tracts
iv.
III.
Spinal Cord
a. Continuous with brain _____________________
b. Extends to ________________
c. Lumbar punctures _____________________
IV.
Peripheral Nervous System
a. Contains ___________________ & ___________________ nerves
b. Location: ______________________________________________
c. Function:
i. Sensory impulses from _____________  __________________
ii. Motor responses from _____________  __________________
d. Key Word: _________________________________________
e. PNS is divided into ______________ systems
i. ______________________ nervous system
1. ______________________________ movement
Document1
2
ii. ______________________ nervous system
1. Connects _____________ to _____________________ organs
2. __________________________ activities
3. Divided
a. ______________________________ nervous system
i. __________________ or __________________
b. ______________________________ nervous system
i. __________________ & ___________________
V.
Subjective
a. History
i. ______________________ member present
ii. Vaccination
iii. Major _________________________
iv. _______________________ illnesses
v. __________________
vi. _______________________ illness
b. Complaint of…
i. Pain (The 5th _______________ sign)
1. _____________________
2. _____________________
3. _____________________
4. _____________________
5. Precipitating ____________________
6. _____________________ symptoms
7. Exacerbation / diminishes
8. ______________________
ii. _________________________________
1. Multiple ________________________
2. _________________ a good indicator of neuro trouble
iii. ____________________________: Sensation of __________________________
in space or objects _______________________________ them.
iv. Paresthesia: _________________________ sensation
Document1
3
1. E.G.
a. __________________________________
b. __________________________________
c. __________________________________
2. Farther Assessment
a. ____________________________
b. _________________________ or constant
v. ________________________ dysfunction
1. _________________________: __________________________ vision
2. _________________________
3. Nystagmus: _______________________________________________
vi. Disturbance in…
1. ______________________
2. ______________________
3. ______________________
vii. N&V: ____________________________________
VI.
Assessment
i. Areas of assessment: ____________________ status ___________________
function, thought content, emotional status, perception, __________________
ability _____________________ability
b. LOC
i. _______________________: Opens eyes ______________________________
ii. _______________________: opens eyes to ____________________________
1. _____________ to respond but _______________________________
iii. _______________________: Responds to _____________________________
1. With _______________________ & ___________________
iv. Semi- __________________: Responds to _____________________________
v. _______________________: Unresponsive except to ____________________
1. Absent ________________________________ reflexes
c. Types of stimuli  response
i. __________________________
ii. __________________________
Document1
4
iii. __________________________
iv. Voice + ____________________________
v. Noxious / __________________________ stimuli
d. Natures of response
i. __________________ opens
ii. Remove _________________________
iii. Abnormal ________________________
iv. ________________________ response
e. Glasgow Coma Scale
_____________ opening
Best _____________ response
__________________ response
Spontaneous
To speech
To pain
Nil
Obeys
Localized
Withdraws
Abnormal flexion response
Abnormal extension response
Nil
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
Nil
i. Strong predictor of outcome
1. >__________: ___________________ brain injury
2. ___________: ___________________ brain injury
3. <__________: ___________________ brain injury
f.
Orientation X 3
i. ________________________________________________________________
g. General Appearance: How do they look?
i. __________________________, dress, ______________, eye deviation, skin
h. Vital Signs:
i. Temperature: __________ with head trauma
ii. Pulse: ________________ with increased intracranial pressure (ICP)
iii. Respirations:
Document1
5
1. Ataxic: Damage to _______________________ oblongata
2. Cheyne-stokes: Lesion deep in _________ cerebral cortex
3. Hyperventilation: ________________________ problems
iv. Blood Pressure
1. Orthostatic __________________ > ________mmHg = Cerebral ______
2. Pulse Pressure: ____________________ - ____________________
a. Normal: _____________________________
b. Widening Pulse pressure= ______________________________
i.
Neuro Checks:
i. _____________________
ii. Pupils
1. ___________________________
2. Anisocoria: Inequality in the _____________________ of the pupils
3. Nystagmus: _____________________________________________
4. Progressive dilation: ______________________________________
5. Fixed and dilated: ___________________ prognosis
VII.
Diagnostic Testing
a. Computer __________________________ Scan (CT)
i. __________________
ii. Distinguishes tissue ____________________________: ________________
iii. Nursing Considerations:
1. Explain procedure:
a. Duration: ___________________________________
b. ___________________________________________
2. If contrast medium is used:
a. Check for __________________________________ allergies
b. ________________________
c. ________________________ after procedure
d. Watch for S&S of _______________________
b. _________________________ Resonance Imaging: MRI
i. Magnetic field + _____________________ waves
ii. Used to Identify: _________________________________________________
Document1
6
iii. Nursing Considerations
1. Remove all ______________________
2. ________________________ techniques / _____________________
3. Duration: _______________________
4. Lay flat and _________________________
c. Electroencephalography (_________)
i. Measures ____________________ impulses of the brain: _________________
ii. Electrodes applied to ________________________
iii. Used to diagnose: __________________________________________________
iv. Procedure:
1. Baseline: ___________________________________________
2. Stimulation: ________________________________________
v. Nursing Considerations:
1. Durations: ____________________________
2. ____ seizures
a. ___________________________________
3. Hold Meds:
a. Anti _________________________
b. Tranquilizers
c. ______________________ or ___________________________
4. No ________________________________
5. _______________ eat
d. ___________________ puncture
i. Into ______________________________ space
ii. @L __________________
iii. Used to
1. Extract ________________________
2. Test spinal fluid _____________________________
3. Introduce
a. _________________________
b. _________________________
c. _________________________
Document1
7
iv. Nursing Considerations
1. Pre-procedure
a. __________ lying with ____________ pulled close to chin
b. Do Not ______________________
c. Painful: _______________________
i. Shooting pain down __________________
d. Duration: _____________________
2. Post procedure
a. Bed _______________________
b. ________ fluids
c. Observe for ________________
VIII.
Increased Intracranial Pressure
a.
-ICP cycle
i. ________ pressure  ________ cerebral perfusion  __________________ 
_________ edema  ____________________
b. Early S&S
i. #1: __________________: ______________________ or _________________
ii. __________________
iii. __________________ changes
iv. __________________ on one side
c. Late S&S
i. __________________  ____________________
ii. Pulse _____________
iii. Respirations ______________ & ___________________
iv. BP: ____________________
v. Temp __________________
vi. _______________________ vomiting
vii. Abnormal _______________________________
viii. Loss of protective _________________
d. Goal: __________ the pressure   ________________
e. Medical Management:
i. Osmotic _____________________________
Document1
8
ii. Corticosteroids: __________________________________
iii. Fluids_________________
iv. HOB___________________
IX.
Seizures
a. Abnormal motor, sensory autonomic or psychic activity resulting from sudden excessive
___________________________ from cerebral neurons
b. Partial
i. Seizure that begins in ___________________ of the brain
ii. Simple
1. Awareness, _______________________ consciousness
iii. Complex
1. _________ of awareness, memory or consciousness
c. Generalized
i. Seizure that involves electrical discharges in the _________________ brain
ii. Absence Seizure: Period of _________________________
iii. Tonic-Clonic Seizure
1. Tonic = ___________________________
2. Clonic = ___________________________
d. Post-seizure / ________________________: _______________ period / deep ________
e. Medical Management
i. ____________-convulsants
f.
Nursing management: Anti-convulsants
i. Do not _______________ meds abruptly  ________________
ii. Monitor_____________________
iii. Take _______________________
iv. ___________________________ only in moderation
g. Seizure precaution: At risk for injury: Before the seizure
i. ______________________ side rails
ii. ______________________ machine in room
h. At risk for injury: During a seizure
i. _______________ to the floor – protect the _____________________
ii. _______________ to the side – Loosen _________________________
Document1
9
iii. Bed: Remove __________________ - Side/rails up
iv. DONOT
1. Insert anything in their ____________________
2. ______________________
v. Support client: _______________________
i.
Observe & Document:
i. First: ____________________________
ii. Movement: ___________________________
iii. Duration: _____________________________
iv. Unconsciousness? _____________________
v. ______________ seizure behavior:______________________
j.
After seizure: At risk for aspiration
i. _____________________
ii. V/S
iii. Check ________________________
iv. ____________________ client
v. Allow to ________________________________________
1. Position: _________________________________
2. ___________________________ side rails
3. _____________ stimulation
X.
Cerebrovascular Accident: AKA ______________, _______________, Brain ______________
a. Pathophysiology
i. Disruption of ______________ flow to part of the brain  _______________ 
Infarction  _____ ICP
b. Common Causes:
i. Ischemic: _________________________ or Emboli
ii. Hemorrhage: ________________ of the cerebral blood vessel
1. D/T ___________________________
c. Risk Factors
Changeable
Document1
Non-changable
10
d. S&S
i. Depends on: ______________________ & size
ii. Alt ___________________
iii. ______________________
iv. Aphasia: __________________________________
v. ______________________
vi. ______________________ disturbance
vii. Labile _____________________________
viii. Hemiparesis ____________________/ Hemiplegia_______________________
e. Hemorrhagic Stroke
i. Usually _____________severe with a _____________recovery period than
ischemic stroke
ii. Common Cause: __________________
f.
Diagnostic Exams: ____________________________________
g. Medical Management
i. #1 cause: _____________________:
1. Medications: Anti-_______________________
a. _____________ blockers
b. Block ________________________ response
2. Diet
a. Sodium ___________________
b. Fat _____________________
Document1
11
c. Potassium ________________
d. Stimulants _______________
e. Fluids ____________________
ii. Prevent slots
1. Medications: Anti______________________________
2. Non-Rx
a. ______________ hose
b. __________________
c. __________________ exercises
iii. Break down clots
1. Medications: ___________________________ agents
a. S/E _________________________________
iv. Prevent Seizures
1. Medications: Anti-_____________________________
a. Seizure _______________________________
b. ________ stimuli
v. Increase ICP protocol
1. __________ oxygen
2. Position: _______________________________
3. Activity: _______________________________
4. Medications: ___________________________ & __________________
5. Monitor: _____________
vi. Nutrition: ________________
vii. Monitor for complications
1. ____________________
2. ____________________
3. Labs:
a. ____________ & _______________
b. _____________________________
c. PT/PTT: ___________________________
4. _____________________ oximetry
viii. Prevent Complications
Document1
12
1. _________________________
2. _________________________ exercises
3. _________________________ control
h. Nursing Dx: Risk for Injury
i. _______________________ side rails
ii. _____________ light within reach
iii. Assist with ________________
iv. _________________________
v. Items within _______________
vi. Clear _____________________
vii. ______________ temp
viii. _______________ & reposition
i.
Nursing Dx: Altered nutrition
i. ___________ Speech therapist
ii. Swallow ____________________
iii. HOB _______________________
iv. Straws:_____________________
v. ________________ liquids
vi. Swallow ___________________
vii. Check for pocketed ______________
viii. Talking and eating: ________________
ix. Plase food on ____________________ side of tongue
x. Check for _______________
xi. __________________ meals
xii. _______________ textured food
j.
Nursing Dx: Altered mobility
i. Rehab begins ________________________________
ii. Turn __________________
iii. ______________________
iv. Splints
v. ________ boards
vi. Built-up _____________________
Document1
13
vii. Raised ______________________
viii. ____________________________
k. Nursing Dx: Impaired Communication
i. ____________________
ii. Give the client __________________
iii. Anticipate ________________
iv. Call _____________ within reach
v. Slow & clear
vi. _____________ patient
vii. ____________contact
viii. Yes/No _______________________
ix. ___________ methods
x. Gestures / Visual aids
l.
Nursing Dx: Self – Care Deficit
i. Eating
1. Non-skid mats, stabilizer____________ , plate guards, wide grip utensils
ii. Bathing & Grooming
1. _____________handle sponge, grab _____________ Non-skid mats,
Hand held showers, Electric razor, Shower seat
iii. Toileting
1. _________________ seat & Grab bars
iv. Dressing
1. _____________________ , Elastic shoelaces, Long-handle shoehorn
v. Mobility
1. _____________, walkers, wheelchairs, transfers devices
m. Nursing Dx: Unilateral neglect
i. ____________________ side: Personal items, Approach, Door face
XI.
TIA: _______________________________ ischemic Attack
a. Short __________________________ischemic event
b. Duration
c. ____________________permanent neuro deficit = _____________________!
Document1
14