NURS 370 Module 12: MANAGEMENT OF NEUROLOGIC FUNCTIONS

Acute Neurological Pain

• often presents suddenly and is sometimes severe; for example, a thunderclap headache may indicate bleeding in the brain.​

• May result from sudden events such as brain hemorrhage, spinal disc diseases, or trigeminal neuralgia.

Chronic Neurological Pain

• May be persistent or recurrent and can seriously impact daily function and quality of life.​

• Related to long-standing degenerative and neurologic conditions such as multiple sclerosis, migraines, or neuropathies.

Seizure Causes

Occur due to abnormal electrical discharge in the cerebral cortex, high fever, drug or alcohol withdrawal, or hypoglycemia.

Seizure Features

• Seizure episodes can involve changes in sensation, behavior, movement, perception, or consciousness.

• Duration can range from brief seconds to several minutes; some seizures are subtle and may only cause momentary lapses in attention.

Seizure Associated Symptoms

Uncontrollable movements (jerking of arms or legs), sudden loss of awareness, temporary confusion, or even persistent emotional changes (e.g., inexplicable fear or anxiety).​

Permanent Muscle Weakness

Weakness resulting from stroke, often affecting one side of the body, limb, or face, and may impact daily activities such as walking, lifting, or speaking.

Progressive Muscle Weakness

Neuromuscular diseases like amyotrophic lateral sclerosis (ALS) cause muscle weakness that worsens over time, often starting subtly and advancing to more severe disability involving swallowing, breathing, or speech.

Neurological Visual Disturbance

• Description:

  • Sudden blindness may occur in acute conditions such as glaucoma, but other disturbances include double vision or loss of vision related to neurological disease or eye nerve damage.

• Associated Findings:

  • Can be accompanied by headache, confusion, or rapid changes in visual clarity—often a sign to seek urgent evaluation.​

Neurological Caused Abnormal Sensation

• Central and Peripheral Nervous System:

  • May present as numbness, tingling (paresthesia), burning, or loss of sensation, depending on which nerves or brain areas are affected.

  • Such symptoms often start in the extremities and can spread, indicating nerve dysfunction from stroke, multiple sclerosis, diabetes, or peripheral neuropathy.​

Physical Assessment of Neuro Status: Indirect Assessment

Physical assessment of neurological status is often indirect, meaning findings are interpreted based on observed or elicited responses rather than direct visualization of pathology.​

Five Key Components of Physical Neuro Status Assessment

• Consciousness and Cognition

• Cranial Nerve Assessment (I-XII)

• Motor System

• Sensory System

• Reflexes

Physical Neuro Status Assessment: Consciousness and Cognition

• Assesses the patient’s level of alertness, orientation, attention span, memory, language skills, and reasoning abilities.

• Typical methods include asking questions about time, place, and person (orientation); testing both short-term and long-term memory; and having the patient follow commands or perform simple calculations and drawings.

• Changes may indicate diffuse or focal brain dysfunction, metabolic derangements, or psychiatric conditions.

Physical Neuro Status Assessment: Cranial Nerve Assessment (I-XII)

• Evaluates function of twelve cranial nerves:

  • Sensory Only:

    • Nerve I (Olfactory): Smell

    • Nerve II (Optic): Vision

    • Nerve VII (Facial): Taste for anterior tongue

  • Motor Only:

    • Nerve III (Oculomotor), IV (Trochlear), VI (Abducens): Eye movement

    • Nerve XI (Accessory): Shoulder/head muscles

    • Nerve XII (Hypoglossal): Tongue movement

  • Mixed (Sensory and Motor):

    • V (Trigeminal): Facial sensation, chewing

    • VIII (Vestibulocochlear): Hearing, balance

    • IX (Glossopharyngeal): Taste, swallowing

    • X (Vagus): Sensation/motor to heart, gut, etc.​

• Testing involves sensory evaluation (e.g., smell, visual fields), motor function (e.g., eye movement, facial muscle strength), and reflexes specific to cranial nerves (e.g., corneal reflex for V, gag reflex for IX/X).

Physical Neuro Status Assessment: Motor System

• Evaluates muscle bulk, strength, tone, and any abnormal movements.

• Assessment may include inspection and palpation of muscles, having the patient perform movements against resistance, and observing for tremors or involuntary movements.

• Weakness can indicate injury or disease in the motor cortex, spinal cord, peripheral nerves, or neuromuscular junction.​

Physical Neuro Status Assessment: Sensory System

• Examines the ability to perceive stimuli such as light touch, pain (sharp/dull), temperature, vibration, and proprioception (position sense).​

• Methods include touching the skin lightly, applying hot/cold objects, vibrating tuning forks, and checking position sense in extremities.

• Abnormalities help localize lesions to nerve roots, peripheral nerves, spinal cord, or brain.

Physical Neuro Status Assessment: Reflexes

• Assesses involuntary responses to stimulation, including deep tendon reflexes (e.g., knee jerk), superficial reflexes (e.g., abdominal), and pathological reflexes (e.g., Babinski).​

• Reflexes are graded (0-4+), and asymmetry or abnormal responses may point to lesions in the central or peripheral nervous system.

• Reflex testing helps differentiate between upper and lower motor neuron disorders and may suggest specific sites of injury (e.g., spinal cord, nerve root).

Level of Consciousness (LOC)

Equals wakefulness plus ability to respond to the environment.

• Wakefulness refers to the patient's level of alertness or arousal.

• Ability to respond includes how well the patient follows commands and interacts meaningfully, both verbally and physically.​​

Most sensitive indicator of neurologic function:

• LOC is considered the earliest and most sensitive clinical sign of neurological deterioration or recovery.​​

Clinical Red Flag:

• Any change in LOC, even subtle (such as increased drowsiness, new confusion, slower response, or inability to follow commands as before), must be treated as a serious warning and immediately reported to medical staff.​​

• Such changes may signal new or worsening injury, stroke, hypoxia, infection, metabolic disorder, or drug effect.

LOC Assessment

• The assessment of LOC includes evaluating both components:

  • Level of alertness: How awake or aware a person is. Can be documented as alert, drowsy, lethargic, stuporous, or comatose.​

  • Ability to respond: Assessed by observing whether the patient can reliably follow commands, give appropriate answers, and interact purposefully.​​

• If a patient becomes less responsive or shows new difficulty in interacting (for example, they are slow to answer questions or cannot follow instructions they could before), this suggests possible worsening of the underlying neurological condition and prompts urgent evaluation.​

Upper Motor Neuron Lesions ("HIGH Signs")

• UMN = "HIGH"

  • High muscle tone (spasticity)

  • High (exaggerated) reflexes

• Loss of voluntary muscle control (paralysis or weakness)

• Increased muscle tone (spasticity): muscles feel stiff or tight

• Hyperactive or abnormal reflexes (such as exaggerated knee-jerk or pathological Babinski reflex)

• Muscle spasticity and possible mild disuse atrophy over time

• Classic causes include stroke, multiple sclerosis, or traumatic brain/spinal cord injury.​​

Lower Motor Neuron Lesions ("LOW Signs")

• LMN = "LOW"

  • Low muscle tone (flaccidity)

  • Low (reduced/absent) reflexes

  • Low muscle mass (atrophy)

• Loss of voluntary control (paralysis or weakness)

• Decreased muscle tone (flaccidity): muscles feel soft or limp

• Flaccid muscle paralysis; muscle atrophy develops rapidly

• Absent or decreased reflexes (hyporeflexia/areflexia)

• May see fasciculations (twitches) in affected muscles

• Direct nerve, spinal root, or peripheral nerve diseases—examples include amyotrophic lateral sclerosis, polio, peripheral neuropathy.​​

Neurological DIAGNOSTIC EVALUATION: CT (Computed Tomography), MRI (Magnetic Resonance Imaging)

• CT uses X-rays and computers to create images; ideal for acute emergency assessment—bleeding, stroke, trauma, tumors, structural changes, and bone injuries.​

• MRI employs magnets and radio waves; provides more detailed images of nerves, soft tissue, and brain/spinal cord; preferred for chronic disease, tumors, multiple sclerosis, and spinal cord diseases.​

Neurological DIAGNOSTIC EVALUATION: Cerebral Angiography, Myelography, Electroencephalography (EEG)

• Cerebral angiography: Visualizes brain blood vessels using contrast dye, useful for detecting aneurysms, blockages, or malformations, planning vascular surgery, and stroke evaluation.​

• Myelography: Injects contrast dye into spinal fluid to outline spinal cord and nerve roots; used when more detail is needed than MRI or CT, such as spinal tumors or disc disease.​

• EEG: Records electrical activity of the brain from scalp electrodes; essential for diagnosing seizures, epilepsy, sleep disorders, brain injury, and altered mental status.​

Neurological DIAGNOSTIC EVALUATION: Doppler Studies

• Uses ultrasound waves to evaluate blood flow in arteries and veins, most commonly for carotid arteries (blood supply to the brain), to assess risk of stroke, blockages, or narrowing.​

• Transcranial Doppler also images flow within brain vessels.

Neurological DIAGNOSTIC EVALUATION: Non-Invasive Carotid Flow Studies

Similar technique to Doppler; sometimes called carotid ultrasound. Assesses blood flow to the brain and determines risk of stroke or need for surgical intervention.

Neurological DIAGNOSTIC EVALUATION: Lumbar Puncture and Cerebrospinal Fluid (CSF) Examination

• Lumbar puncture (spinal tap) collects CSF from the lower spine; fluid is analyzed for infection, inflammation, bleeding, or diseases like multiple sclerosis.​

• Can help diagnose meningitis, subarachnoid hemorrhage, and autoimmune disorders; also used to measure intracranial pressure.

Lumbar Puncture Temporary Problems

(Most Common, Usually Mild)

• Low grade fever: Mild fever may occur after the procedure but resolves on its own in most cases.​

• Back pain or spasm: Soreness, discomfort, or muscle spasm at the site or down the back; usually mild and temporary.​

• Neck stiffness: Some patients may develop stiffness or mild discomfort in the neck, often related to headache or procedure positioning.​

• Headache: One of the most frequent side effects; results from spinal fluid leakage. Typically starts hours to days after, and improves with rest and fluids.​

Lumbar Puncture Complications

(Rare but More Serious)

• Herniation of intracranial contents: Sudden drop in pressure during fluid removal may cause brain tissue to shift (“herniate”), which can be life-threatening, especially if there is already increased pressure in the skull (e.g., brain swelling, tumor, abscess). This is why careful assessment is needed before the procedure, and imaging may be performed first in high-risk cases.​

• Spinal epidural abscess: Infection introduced during the procedure could lead to an abscess (collection of pus) in the spinal epidural space. This is extremely rare but serious; requires prompt treatment.​

• Spinal epidural hematoma: Bleeding in the epidural space can occur, especially in people with clotting problems or on anticoagulant medications. May lead to nerve compression and requires urgent care.​

• Meningitis: Introduction of bacteria during the procedure can cause infection of the membranes covering the brain and spinal cord. Risk is minimized by using sterile technique.​

Nursing Care Post-Lumbar Puncture Headache: Monitor pain response to interventions.

• Regularly assess headache severity, response to medications, hydration, and lying position.​

• Track associated symptoms (nausea, vomiting, fever, changes in neurological status).

• Document effectiveness of each intervention and alert providers if pain or symptoms persist or worsen.​​

Nursing Care Post-Lumbar Puncture Headache: Keep the patient lying flat if headache occurs.

• The classic post-lumbar puncture headache is positional: it is worse when sitting or standing and improves when lying down.

• Lying flat (supine) for several hours can help relieve symptoms and promote closure of the puncture site by stabilizing spinal fluid pressure.​

Nursing Care Post-Lumbar Puncture Headache: Educate the patient about reporting positional headaches early.

• Patients should be taught the signs of spinal headache (worsening with upright posture, improvement when flat, often throbbing frontal or occipital pain), and encouraged to notify staff immediately if these symptoms develop.​​

• Early reporting can help ensure timely intervention—analgesics, hydration, or, in severe cases, blood patch procedure.

Post-Lumbar Puncture Headache Cause

CSF leakage at the puncture site leads to depletion of CSF in the cranium.

Post-Lumbar Puncture Headache Symptoms

• Throbbing bifrontal or occipital headache

• Dull and deep pain

• Severe when sitting or standing up

• Disappears when lying down

Post-Lumbar Puncture Headache Management

• Analgesic agents

• Hydration

• Ingestion of caffeineNursing care

Post-Lumbar Puncture Headache Nursing care & Prevention

• Maintain patient’s lying position

• Avoid using small-gauge needles (such as 22 gauge)

The meninges

are the protective membranes surrounding the brain and spinal cord.

Consist of three layers:

• Dura mater (outer)

• Arachnoid mater (middle; produces cerebrospinal fluid/CSF via granulations)

• Pia mater (inner)

Cerebrospinal fluid (CSF)

• Is produced in the arachnoid layer and fills the subarachnoid space, providing cushioning and protection for the brain and spinal cord.

• CSF leakage can occur as clear, watery drainage from the nose (rhinorrhea) or ear (otorrhea), as depicted in the images.

Nursing Notes & Emergency Actions CSF Leakage

• Any clear, watery drainage from the nose or ear should be treated as possible CSF.

  • This can indicate traumatic injury or post-surgical leaks, signifying an opening in meninges and risk of infection/neurological harm.

• Test drainage with glucose or “halo” test if ordered.

  • CSF has elevated glucose compared to typical nasal secretions; the "halo" sign involves blood-stained fluid separating into clear rings on filter paper.

• Do NOT pack the ear or nose—allow it to drain freely.

  • Packing can increase intracranial pressure or force pathogens into the intracranial space.

• Notify provider immediately; this is a neurological emergency.

  • CSF leak increases risk for meningitis and may be a sign of basilar skull fracture or post-neurosurgical complication.

Clinical Connections:

• CSF leakage is always considered urgent, as breaches in meningeal layers expose the central nervous system to infection and further injury.

• The combination of anatomical knowledge (meningeal layers, CSF physiology) and careful clinical practice (drainage recognition, emergency escalation) is critical for neurological nursing care.

Brain Injuries: Key Concepts

• Head injuries: Always ask—is the brain itself injured? Not all head trauma causes brain injury, but injury must be excluded.

• Blood supply is critical: Disruption, even for a few minutes, can cause brain cell death and irreversible damage.

Types of brain injuries

• Closed or open injuries: Trauma can occur with or without a break in the skull.

  • Contusions: Bruises of the brain tissue.

  • Intracranial hemorrhage: Bleeding within the skull (e.g., epidural, subdural, intracerebral).

  • Concussion: Temporary dysfunction, usually no structural damage, but LOC and amnesia possible.

  • Diffuse axonal injury: Widespread damage to brain cells, often coma, poor prognosis.

Brain Injury: LOC Changes

Is the first sign of brain deterioration.

• Most sensitive for increased intracranial pressure (ICP).

• Even mild confusion should be reported immediately.

Brain Injury: Cushing’s Triad (late ICP sign)

• ↑ Systolic BP / widened pulse pressure

• ↓ Heart rate (bradycardia)

• Irregular respirations

• → Signals impending brain herniation. Requires urgent intervention.

Brain Injury: CSF Leak (from nose/ears)

• Test with halo sign or glucose test.

• Never pack nose/ears; position patient upright.

• Increases risk for meningitis.

Brain Injury: Concussion Red Flags (Need ED evaluation)

• Worsening headache

• Repeat vomiting

• Increasing confusion

• Unequal pupils

• Weakness/seizure

Brain Injury: Epidural Hematoma (rapid)

Classic NCLEX Pattern: 

• Brief Loss of Consciousness

• lucid interval

• sudden decline.

• Emergency surgery is required.

Brain Injury: Subdural Hematoma (slower)

• Venous bleed.

• Symptoms may develop over hours/days.

• Common in elderly or alcohol users.

Brain Injury: Prevent ICP elevation

• Teach: No coughing, straining, hip flexion, unnecessary suctioning.

• Keep HOB at 30°, neck neutral.

Brain Injury: Post-Lumbar Puncture Headache

• Worse sitting/standing, better lying flat.

• Nursing Care: Lie flat, fluids, caffeine, analgesics.

Brain Injury: Diffuse Axonal Injury

• Usually coma

• Very poor prognosis.

• Minimal or Lucid Interval

• Often occurs from a high-speed Motor Vehicle Crash

• NCLEX Pearl: Decerebrate/decorticate posturing (classic finding).

Brain Injury: Concussion

NO narcotics: They Mask Neurological Changes. 

• Use acetaminophen only, monitor LOC.

Brain Injury: Battle Sign & Raccoon Eyes

Basilar Skull Fracture Indicators:

• Periorbital ecchymosis

• Mastoid bruising.

• No NG tubes (risk of brain insertion).

Brain Injury: Brain Herniation Danger Signs

• Dilated, non-reactive pupils.

• Loss of brainstem reflexes (gag, cough, corneal).

• Abnormal breathing pattern.

• Requires immediate intervention.