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Medical Surgical Nursing Notes


									Three Common signs and symptoms present among patients with neurologic deficit:
    1. Seizure
    2. Unconsciousness
    3. Intracranial Hypertension

INTRACRANIAL HYPERTENSION – CSF pressure > 15 mmHg. Roots from hemorrhage or bleeding,
CSF and brain tissue.


   1.   Head injury or hematoma – bleeding is evident
   2.   Cerebral edema, stroke
   3.   Abscess, infection – meningitis, encephalitis
   4.   Hemorrhage – impending aneurismal attack
   5.   Brain tumor – neuroblastoma
   6.   Intracranial surgery – S/P craniotomy


   1. Changes in Level of Responsiveness – lethargy, drowsy, stupor, coma
   2. Changes in vital signs – increased BP, bradycardia, tachycardia, tachypnea, widened pulse
   3. Papillary changes – unilateral change in visual acuity, hemiplegia, hemiparesis
   4. Others : headache, vomiting, subtle changes, papilledema – headache is exemplified by
      moving, check for cloudiness in terms of subtle changes in CSF, vomiting is projective


   1. Airway – Oxygen therapy
   2. Osmotic dieresis – manitol, watch for dieresis or polyuria. Expect for catheterization. Check
      patency of the tube.
   3. Steroids – reduces swelling. Dexamethasone (Decadron)
   4. Hyperventilation with a volume ventilator – for respiratory alkalosis. Check for oxygenation.
   5. Ventricular drainage of CSF – check for output
   6. Treatment of fever – TSB or hypothermic blanket, administer antipyretic agents
   7. Barbiturates and anesthetic agents – barbiturates are anticonvulsants, anesthetics have
      relaxing effect

Nursing Interventions:

       Reduce ICP pressure and prevent irreversible brain damage

   1. Continuous assessment of the LOC – check for ICP (suctioning is contraindicated). Jugular
      vein should be well rested (position the client in such a way that the jugular vein is not
   2. Maintain neurologic observation record
   3. Monitor patient’s temperature – fever increases the metabolic demand for oxygen. May be
      indicative of an infectious disease
   4. Avoid activities or positions that produce a rise in ICP – e.g. valsalva maneuver or straining
      upon defacation
   5. Prepare for surgical intervention – secure cardiopulmonary clearance. For pediatric patients,
      provide psychological preparations and avoid terminologies that involve body mutilations like
SEIZURES – episodes of abnormal motor, sensory, autonomic or psychic activity (or a combination of
these) as a consequence of sudden excessive discharge from cerebral neurons ; sudden increase of
nerve impulse transmission


   1.    Description of the circumference before the attack
   2.    The first thing the patient does in an attack
   3.    Type of movement of the part involved
   4.    Parts involved
   5.    Size of both pupils
   6.    Whether or not automatisms are observed – involves frequent swallowing, involuntary motor
         activity and lip smacking
   7.    Incontinence of urine or feces
   8.    Did the patient bite his tongue?
   9.    Duration of each phase of the attack
   10.   Unconsciousness
   11.   Any obvious paralysis or weakness of arms or legs after the attack
   12.   Inability to speak after the attack
   13.   Movements at the end of seizure
   14.   Whether or not the patient sleeps afterwards
   15.   Whether or not the pat is confused following the attack

Types of Seizure:

   1.    Grand mal – generalized body seizure
   2.    Petite mal – brief loss of awareness
   3.    Jacksonian – involves one body part
   4.    Status Epilepticus – continuous clonic or contraction

Stages of Seizure:

   1. Prodromal – symptoms or manifestations include tingling sensation, coldness of extremities,
   2. Aura – flashes of light before or after the attack
   3. Epileptic cry – exemplified as the patient shouts
   4. Convulsions – involves tonic (flaccidity, rigidity or relaxation as patient is out of clonic) and
      clonic (muscle contraction)

Nursing Interventions:

   1. Ensure adequate airway
   2. Protrect from injury
   3. Others: privacy, stay with the patient, reorient, handle calmly, summon medical assistance

                                   CRANIAL NERVE DISORDERS

   1. Bell’s palsy (idiopathic facial paralysis) – an acute peripheral facial paralysis involving
      cranial nerve number 7 on one side producing weakness or paralysis of the facial muscle.
      May be a cause of viral or upper respiratory tract infection and autoimmune disorders

Clinical Manifestations:

   1. Distortion of face – due to paralysis
   2. Facial numbness, diminished taste and numbness of the tongue – initiate nutritional intake
   3. Painful sensation in the face, behind the ear and in the eye – administer antibiotic and
      narcotic analgesics, prone to dryness dryness of eye, laxity in lower lid
   4. Eye problems
               Epiphora – involuntary outflow of tears
               Logopthalmus – inability to close eyes
   5. Speech difficulties – communication, adjuncts

Diagnostic Evaluations:

   1. Test for cranial function and corneal sensation
   2. Electrophysiologic testing – assessment facial testing by low voltage electrical current


   1. Protection of involved eye – methylcellulose solution or artificial tears. Beer or softdrinks may
      also be used because they are fermented
   2. Steroid therapy
   3. Physical therapy or physiotherapy
   4. Non-narcotic analgesics – for pain
   5. Surgery – oral and maxillofacial surgery

Nursing Interventions:

   1.    Reassure the patient that a stroke is not involved and that recovery will probably occur
   2.    Protect involved eye
   3.    Keep cornea for moist
   4.    Avoid drying of cornea from sun, wind or air conditioning
   5.    Avoid eye irritants
   6.    Ensure eye protection during sleep
   7.    Report eye pain immediately
   8.    Continue to use facial massage
   9.    Keep face warm
   10.   Facial exercises – smiling, frowning or puffing
   2. Trigeminal Neuralgia (tic douloureux) – condition of the 5 cranial nerve characterized by
      sudden paroxysms of sharp, stabbing, excruciating pain in the distribution of one or more
      branches of the trigeminal nerve.

Branches of Trigeminal Nerve:

   1. Sensory
   2. Motor

Distribution of Sensory Branch:

   1. Opthalmic – vision
   2. Maxillary
   3. Mandibular

Clinical Manifestations:

   1. Sudden and severe pain
   2. Numerous individual flashes of pain
   3. Attacks predicted


   1. Carbamazepine (Tegretol) or Phenytoin (Dilantin) – establishes neural membranes. Take
      note for drowsiness and requiring attention
   2. Alcohol or phenol block
   3. Percutaneous radiofrequency trigeminal gangliolysis – low voltage control electrical current to
      relieve pain
   4. Microvascular decompression of cranial nerve 5 – removes pressure within peripheral nerves
   5. Open surgical retrogasserian rhizotomy – transaction of the nerve root
Nursing Interventions:

   1. Recognize that certain factors may aggravate excruciating pain – refer to dentist dental
      management of caries
   2. Be aware that anxiety, depression and insomnia may accompany chronic, painful conditions
   3. Post- operative intervention – for protection agains keratitis, provide artificial tears
      a. Atherosclerosis
      b. Use of anticoagulants
      c. Embolus
      d. Platelet aggregation
      e. History of precipitating surgical intervention

CEREBROVASCULAR DISEASE – any functional abnormality of the CNS caused by interference
with normal blood supply to the brain

Cerebrovascular diseases from impairment of cerebral circulation:

   1. Transient ischemic attacks (TIA’s) – transient episodes of cerebral dysfunction commonly
      manifested by a sudden loss of motor, sensory or visual function lasting minutes up to an
      hour or more, but not more than 24 hours. Can cause stroke
   2. Reversible ischemic neurologic deficit (RIND) – episodes producing neurologic deficits longer
      than 24 hours but followed by a return to normal state
   3. Cerebral thrombosis – from cerebral arteriosclerosis and slowing of cerebral circulation.
      Alteration in speech and vision
   4. Cerebral embolism – caused by heart disease, pulmonary emboli, arteriosclerosis, plaque in
      carotid artery

Cerebrovascular diseases from hemorrhage:

   1.    Extradural hemorrhage – hemorrhage occurring outside the dura matter
   2.    Subdural hemorrhage – hemorrhage occurring beneath the dura matter
   3.    Subarachnoid hemorrhage – hemorrhage occurring in the subarachnoid space
   4.    Intracranial hemorrhage – hemorrhage occurring within the brain structure

STROKE (Cerebrovascular Accident) – the onset of neurologic dysfunction resulting in interruption
of the blood supply to the brain


   1.    Thrombosis – blood clot
   2.    Cerebral Embolism
   3.    Ischemia – decreased blood flow
   4.    Cerebral hemorrhage – intermittent pressure caused by bleeding
   5.    Elevated cholesterol
   6.    Diabetes mellitus
   7.    Obesity
   8.    Red blood cell disorder – hematopoietic
   9.    Cigarette smoking – precipitates thrombosis and embolism
   10.   Substance abuse and drug intoxication

Clinical Manifestations:

   1. Sudden severe headache – aggravated by movement
      Frozen shoulder – sublaxation of the shoulder with painful shoulder-hand dystrophy
   2. Numbness, weakness or motor loss
   3. Difficulty in speaking and or swallowing
   4. Visual fields deficits
      Homonymes hemianopnia – inability to see passed the midline where patient encounters
      depth of perception
   5. Impairment of sensations
   6. Impairment of mental activity and physiological effect


   1.   Close observation and monitoring of hemodynamic parameters
   2.   Management of increased ICP
   3.   Support of vital functions
   4.   Management of post stroke rehabilitation program
   5.   Anti spasmodic medications – diazepam, baclopen, diantrolene
   6.   Treatment of post stroke depression – tricyclics anti depressants and psychotherapy

Nursing Interventions:

   1.   Positioning
   2.   Measures to avoid contractures
   3.   Preventing shoulder pain
   4.   Others
        4.1. Achieving self care
        4.2. Developing compensating skills for sensory dysfunction
        4.3. Attaining bladder control
        4.4. Compensating for altered thought processes
        4.5. Achieving communication
        4.6. Helping family cope – respite care

APHASIA – is an acquired disorder of communication resulting in brain damage. It may involve
impairment of the ability to speak, understand the speech of others, read, write, calculate and
understand gestures.


   1. Stroke
   2. Head injury
   3. Brain tumor

Aphasic Syndromes:

   1. Fluent aphasia – patient retains verbal fluency but may have difficulty in understanding
      speech. Involves the posterior language area
      Wernicke’s – lacks content of info
      Conduct – with comprehension but has difficulty of repeating words
      Anomic or amnesic – speech is almost normal but patient finds difficulty in finding appropriate
   2. Non-fluent aphasia – sparse speech produced slowly and with efferent and poor articulation
      usually has a relative preservation of auditory compression. Involves the anterior language
   3. Global aphasia – severe disruption of all aspects of speech (both posterior and anterior
      language areas)


   1. Speech therapy – compensatory measure of communication
   2. Dopamine antagonist – theory states that an increase in dopamine results in an increased
      chance of aphasia
      Bronchocriptine – drug of choice

Nursing Interventions:

   1. Improving communication
      1.1. Encourage the patient to listen
      1.2. Give patient plenty of time to speak and respond
      1.3. Keep the environment relaxed
      1.4. Keep distractions at a minimum
      1.5. Use as many sensory channels as possible
   2. Enhancing self concept
      2.1 Give patient as much as psychological security as possible
      2.2 Give support by assuring the patient that there is nothing wrong with his intelligence
      2.3 Maintain a calm, accepting and deliberate manner, especially during periods of
           environmental lability
      2.4 Encourage the patient to socialize with his family and friends
      2.5 Watch the patient for clues and gestures if his speech is unintelligence or jargon lire
      2.6 Observe patient during the course of his daily schedule for clues to evaluate and assess
           his progress
   3. Promoting family education
      3.1. Fatigue will have an adverse effect on patient’s speech
      3.2. Ignore swearing and abusive languages
      3.3. Some persons cannot express themselves but can comprehend
      3.4. Seek support group

INTRACRANIAL ANEURYSM – is the dilation of the walls of a cerebral artery. Rupture of an
intracranial aneurysm leads to subarachnoid hemorrhage


   1.   Atherosclerosis
   2.   Intracranial arteriovenous
   3.   Hypertensive vascular disease
   4.   Head trauma
   5.   Unknown

Clinical Manifestations:

   1.   Sudden onset of a new atypical headache – patient can experience eye pain
   2.   LOC
   3.   Visual disturbances – diplopia, photophobia and blurred vision
   4.   Fever and neck stiffness
   5.   Dizziness, nausea and vomiting
   6.   Hemiparesis


   1.   Bed rest with sedation – LOC monitoring
   2.   Manage increased ICP
   3.   Control of hypertension
   4.   Anti-fibrinolytic therapy – inhibits clotlysis
   5.   Plasma volume expansion and vasopressor
   6.   Calcium channel blockers
   7.   Prophylactic anti seizure therapy
   8.   Surgical intervention – craniotomy


   1.   Bleeding or rupture
   2.   Cerebral vasospasm – mentation and gait
   3.   Hydrocephalus
   4.   Epilepsy
   5.   Psychiatric problems – anxiety and phobias

Nursing Interventions:

   1. Modifying activities to prevent recurrent bleeding
   1.1. Immediate and also lute bed rest – elevate head of the bed 30 to 35 degrees
   1.2. Avoid activity that increases blood pressure or obstruct venous return
   1.3. Dim lights
   1.4. Instruct to exhale through moth during voiding and defacation
   1.5. Eliminate caffeinated beverages
   1.6. Avoid activities that cause a sudden increase in arterial blood
   1.7. Use appropriate psychological interventions and reassurance
2. Monitor for complications
   2.1. Recognize neurologic deterioration and determine optimum time for surgery
   2.2. Monitor bladder disturbances – inappropriate dosage of anti diuretic hormone

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