NCLEX Review Nervous System
An Overview of Neurological Assessments and Anatomy of the Brain
Neurological exams are an essential part of diagnosing and monitoring neurological conditions. The Glasgow Coma Scale (GCS) is a standard measure of a patient's level of consciousness. It is based on three parameters: eye-opening response, verbal response, and motor response. The scores for each parameter are added to give a total score that ranges from 3 to 15. The higher the score, the better the neurological function.
Other aspects of the neurological exam include PERRLA (pupils equal, round, reactive to light, and accommodation), CSMT (color, sensory, motor, and temperature), and vital signs. Changes in a patient's level of consciousness are the best indicators of mental status.
Elevated Intracranial Pressure (ICP):
Elevated ICP is a serious condition that can result in permanent neurological damage. Signs and symptoms include changes in level of consciousness, headache, increased blood pressure with widening pulse pressure, bradycardia, fever, and pupil changes. Nursing interventions for elevated ICP include elevating the head of the bed to promote drainage, maintaining proper fluid volumes, setting up a quiet environment to minimize sensory stimulation, avoiding suctioning, and administering stool softeners to prevent straining.
Cerebrospinal Fluid (CSF) Assessment:
CSF is a clear, colorless fluid that circulates around the brain and spinal cord. The normal volume of CSF is 125-150 mL, and normal pressure is 60-150 mmH2O. A CSF assessment may be necessary to diagnose neurological conditions. Normal CSF has little protein and glucose, no white blood cells, no red blood cells, and no microorganisms. A bloody fluid surrounded by a yellow stain when placed on a white backdrop, known as a halo sign, may indicate a serious condition.
Anatomy of the Brain:
The brain is a complex organ responsible for controlling and coordinating bodily functions. It is divided into four main regions: the frontal lobe, the parietal lobe, the temporal lobe, and the occipital lobe. Each region has a specific function.
The frontal lobe controls emotions, judgments, the motor aspects of speech, and the primary motor cortex for voluntary muscle activation. The Broca's area is responsible for speech. The parietal lobe receives fibers with sensory information about touch, proprioception, temperature, and pain from the other side of the body. It is also responsible for spatial perception. The temporal lobe processes auditory information and language comprehension. The Wernicke's area is responsible for language comprehension. The occipital lobe is the center for visual information.
Other areas of the brain include the cerebellum, which is responsible for the coordination of muscle function, the brainstem, which contains the respiratory and cardiac centers, and the diencephalon, which contains the thalamus and hypothalamus.
The nervous system is a complex system that controls and coordinates the body's functions. The autonomic nervous system is responsible for regulating bodily functions such as heart rate, respiratory rate, and blood pressure. The sympathetic nervous system is responsible for the "fight or flight" response, which includes dilated pupils, elevated heart rate and respiratory rate, sweating, epinephrine and norepinephrine secretion, increased blood pressure, and constriction of skin and abdominal arterioles. The parasympathetic nervous system is responsible for the "rest and digest" response, which includes constricted pupils, lowered heart rate and respiratory rate, increased peristalsis, acetylcholine secretion, decreased blood pressure, and relaxation of skin and abdominal arterioles.
Medical Diagnosis with Nursing Interventions:
CVA, Stroke: A stroke can occur due to a blockage of blood flow, causing issues with brain tissue perfusion or due to a bleed in the brain because of blood vessel ruptures. The risk factors include diabetes, atherosclerosis, hypertension, cardiac disease, and transient ischemic attacks. Three types of strokes are an anterior cerebral stroke, a posterior cerebral stroke, and a middle cerebral artery stroke. Nursing intervention priority for a stroke patient includes giving TPA 3-4 hours from onset of S/S, which is contraindicated in thrombocytopenia, uncontrolled hypertension, head trauma within the past three months, and major surgery within the past 14 days. Other interventions include NPO, neuro assessment, preventing activities that increase ICP or BP, stool softeners, and bed rest with body midline. Anticoagulants are contraindicated. Seizures can occur due to high ICP and dysphagia.
Cerebral Aneurysm: A cerebral aneurysm can lead to a rupture and brain bleed, and its signs and symptoms include headache, irritability, vision changes, tinnitus, nuchal rigidity, and seizures. Nursing interventions include avoiding rectal temperatures, limiting visitors, maintaining a dark and calm environment, keeping the head of bed between 30-45 degrees, preventing hypertension and pain, and avoiding Valsalva’s maneuver.
Seizures: Seizures occur due to various reasons such as epilepsy or excessive and sudden discharge of cerebral cortical neurons, and they can be tonic-clonic (Grand Mal), absence seizures (Petit Mal), simple seizures, and complex seizures. Nursing intervention priorities include assisting the patient to lie down, positioning the patient on their side to maintain patent airway and prevent tongue from occluding airway, loosening restrictive clothing, giving O2 as needed, recording the time and duration of the seizure, not abruptly stopping antiseizure meds, providing good oral care to prevent gingival hyperplasia (from Phenytoin), using suction after seizure, and not using a tongue blade when a patient has a seizure during most interventions, allowing free movement in a safe environment.
Wernicke’s Encephalopathy: Wernicke’s encephalopathy can be due to low thiamine intake (Vitamin B1), and severe alcoholism can cause low absorption of B1. Its signs and symptoms include altered mental status, oculomotor dysfunction, and ataxia.
Autonomic Dysreflexia/Hyperreflexia: Autonomic dysreflexia/hyperreflexia is caused by sympathetic nervous system stimulation after an injury at T6 or higher, a lesion in the high thoracic or cervical cord, or a blockage of the urinary catheter. Its signs and symptoms include severe hypertension, sweating above the level of injury, flushing, headaches, bradycardia, piloerection, and nausea. Nursing intervention priorities include monitoring BP and providing antihypertensives if needed, monitoring bladder distention, assessing for bowel impaction, removing restrictive clothing, and keeping HOB at 45 degrees.
Meningitis: Meningitis is inflammation of the meninges of the spinal cord and brain caused by bacteria, and its signs and symptoms include Brudzinski’s sign, Kernig’s sign, a stiff/tight neck, fever, and confusion. Nursing intervention priorities include droplet/contact precautions if bacterial or meningococcal meningitis, assessing for signs of increased ICP, keeping HOB at 30 degrees and avoiding flexion of body, seizure precautions, and preparing for lumbar puncture.
Multiple Sclerosis: Is an autoimmune disorder resulting nerve damage disrupts communication between the brain and the body. Nursing Interventions include Provide a calm, supportive environment Encourage adequate rest and sleep Help the patient develop a regular exercise program Assess for depression and anxiety and provide support as needed Encourage the patient to engage in activities that promote socialization and self-esteem.
Parkinson's Disease: Progressive degenerative disorder of the nervous system characterized by tremors, rigidity, bradykinesia, and postural instability. Interventions: Encourage activity and exercise to help improve mobility and balance Assist with ADLs as needed Provide emotional support and encourage participation in support groups Monitor for adverse effects of medications and adjust dosage as needed Encourage a healthy, balanced diet
Alzheimer's Disease A progressive disorder that affects memory, thinking, and behavior. Nursing Interventions: Provide a safe, structured environment to help minimize confusion and agitation Encourage socialization and engagement in meaningful activities Assist with ADLs as needed Monitor for signs of depression and anxiety and provide support as needed Provide education and support to family members and caregivers
In conclusion, nursing interventions for neurological disorders can vary widely depending on the specific disorder and its symptoms. It is important for nurses to have a thorough understanding of the pathophysiology and manifestations of these disorders, as well as the most effective interventions to promote optimal patient outcomes. With proper care and management, patients with neurological disorders can achieve improved quality of life and functional ability.