MEDICAL SURGICAL REVIEWER

Nervous SystemCentral NS Peripheral NS Autonomic NSBrain & spinal cord 31 spinal sympathetic NS

Parasympathatic NS

Somatic NSC- 8 ex. Breakfast 8am – diaphragm, chest wall muscles, shoulder’s & armsT- 12 ex. Lunch 12nn – upper body, GI functionsL- 5 ex. Dinner 5pm (napaa aga haha) – lower body, bladder, bowelS- 5 ex. Dinner ulit kasi matakawC- 1 ex. Midnight snack 1am

SNS (involved in fight or aggression response / LABAN) Release of norepinephrine (adrenaline –

cathecolamine) Adrenal medulla (potent vasoconstrictor) Increases body activities Except GIT – decrease GIT motility Why GIT is not increased = GIT is not important! Increase blood flow to skeletal muscles, brain &

heart.

Effects of SNS (anti-cholinergic/adrenergic)1. Dilate pupil – to aware of surroundings

- medriasis2. Dry mouth3. BP & HR= increased

- bronchioles dilated to take more oxygen4. RR increased5. Constipation & urinary retention

I. Adrenergic Agents – Epinephrine (adrenaline)SE: SNS effect

II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’) Blocks release of norepinephrine. Decrease body activities except GIT (diarrhea)

Ex. Propanolol, MetopanololSie effects:

B – broncho spasm (bronchoconstriction)E – elicits a decrease in myocardial contractionT – treats HPNA – AV conduction slows down

- Given to angina & MI – beta-blockers to rest heartAnti HPN agents:

1. Beta blockers (-lol)2. Ace inhibitors (-pril)

Ex. ENALAPRIL, CAPTOPRIL3. Calcium antagonist

Ex. CALCIBLOC or NEFEDIPINE

S/E- of Anti-HPN drugs:1. orthostatic hpn2. transient headache & dizziness.

Mgt. Rise slowly. Assist in ambulation.

Parasympathetic Nervous System: (Cholinergic / BAWI) Effect of PNS: (cholinergic/ opposite ng SNS) Involved in fly or withdrawal response 1. Meiosis – contraction of pupils Release of acetylcholine (ACTH) 2. Increase salivation Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased

4. RR decrease – broncho constrictionI. Cholinergic agents 5. Diarrhea – increased GI motility Ex. Mestinon 6. Urinary frequency

Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS

CENTRAL NS (brain & spinal cord)1

I. Cells – A. Neurons – 10 billiono Properties and characteristics

a. Excitability – ability of neuron to be affected in external environment. b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to anotherc. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)

Regenerative capacity Labile – once destroyed cant regenerate Epidermal cells, GIT cells, resp (lung cells). GUT Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells Permanent cells – retina, brain, heart, osteocytes can’t regenerate.

*Neuroglia – attached to neurons. o Supports neurons. Where brain tumors are found.

Types: 1. Astrocyte2. Oligodendria

Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte, most common.

*Astrocyte – maintains integrity of blood brain barrier (BBB). BBB – semi permeable / selective

Toxins that can pass in BBB: 1. Ammonia - liver cirrhosis. 2. Carbon Monoxide – seizure & parkinsons. 3. Bilirubin - jaundice, hepatitis, kernicterus/hyperbilirubenia. 4. Ketones –DM.

*OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission. No myelin sheath – degenerates neurons Damage to myelin sheath – demyellenating disorders

**DEMYELLENATING DISEASES

1. ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.S/S: FOUR A’s

A – amnesia – loss of memory A – apraxia – unable to determine function & purpose of object A – agnosia – unable to recognize familiar object A – aphasia –

o Expressive – brocca’s aphasia – unable to speak o Receptive – wernickes aphasia – unable to understand spoken words

Common to Alzheimer – receptive aphasia Drug of choice – ARICEPT (taken at bedtime) & COGNEX. Mgt: Supportive & palliative.

*MICROGLIA – stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord80% - brain mass10% - CSF10% - blood

*MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP. Normal ICP: 0-15mmHg

BRAIN MASS

2

1. Cerebrum – largest part Corpus collusum - connects R & L cerebral hemisphere.

Function:1. S - Sensory2. I - Integrative3. M – Motor4.

**LOBES1.) Frontal

a. Controls motor activityb. Controls personality development

c. Where primitive reflexes are inhibitedd. Site of development of sense of umore. Brocca’s area – speech center

Damage - expressive aphasia2.) Temporal –

a. Hearingb. Short term memoryc. Wernickes area – gen interpretative or knowing Gnostic area

Damage – receptive aphasia3.) Parietal lobe – appreciation & discrimation of sensory imp

- Pain, touch, pressure, heat & cold4.) Occipital - vision6.) Rhinencephalon/ Limbec

- Smell, libido, long-term memory

2. BASAL GANGLIA – areas of gray matteR located deep within a cerebral hemisphere Extra pyramidal tract Releases dopamine Controls gross voluntary unit

**TRIVIADecrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse.Decrease acetylcholine – Myasthenia Gravis & Alzheimer’sIncreased neurotransmitter = psychiatric disorder Increase dopamine – schizo

Increase acetylcholine – bipolar

3. MID BRAIN – relay station for sight & hearing Controls size & reaction of pupil 2 – 3 mm Controls hearing acuity CN 3 – 4 Isocoria – normal size (equal) Anisocoria – uneven size – damage to mid brain PERRLA – normal reaction

4. DIENCEPHALON - between brain Thalamus – acts as a relay station for sensation Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional

responses, controls pituitary function.

5. BRAIN STEM – a. Pons – or pneumotaxic center – controls respiration

Cranial 5 – 8 CNS

b. Medulla Oblangata - controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutusVasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

6. CEREBELLUM – lesser brain

3

- Controls posture, gait, balance, equilibrium**Cerebellar Tests:a.) R – Romberg’s test- needs 2 RNs to assist

- Normal anatomical position 5 – 10 min(+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.

b.) Finger to nose test –(+) To FTNT – dymetria – inability to stop a movement at a desired point

c.) Alternate pronation & supinationPalm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium

**Composition of brain - based on Monroe Kellie Hypothesis Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

o Normal ICP – 0 – 15 mmHgo Foramen Magnum o C1 – atlaso C2 – axiso (+) Projectile vomiting = increase ICP

o Observe for 24 - 48 hrso CSF – cushions the brain, shock absorber o Obstruction of flow of CSF = increase ICPo Hydrocephalus – posteriorly due to closure of

posterior fontanelo CVA – partial/ total obstruction of blood supply

---------------------------------------------------------------------------------------------------------------------------------------------------------------INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.Predisposing factors:

1.) Head injury2.) Tumor3.) Localized abscess4.) Hemorrhage (stroke)5.) Cerebral edema6.) Hydrocephalus7.) Inflammatory conditions - Meningitis, encephalitis

S&Sx **change in VS = always LATE symptoms** Earliest Sx : (vision changes, change in LOC, headache)a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP

- Disorientation to lethargy Narrow pp: Cardiac disorder, shock - Stupor to coma

Late sign – change in V/S 1. BP increase (systolic increase, diastole- same)2. Widening pulse pressure

Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure)Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide)

3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)4. Temp increaseIncreased ICP: Increase BP Shock – decrease BP –

Decrease HR Increase HR CUSHINGS TRIAD (opposite ng inceased ICP) Decrease RR Increase RR

b.) Headache Projectile vomiting Papilledima (edema of optic disk – outer surface of retina) Decorticate (abnormal flexion) = Damage to cortico spinal tract / Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation – unilateral dilation of pupil. (**kapag Bilateral dilation of pupil = tentorial herniation.)d.) Possible seizure.

4

Nursing priority:1.) Maintain patent a/w & adequate ventilation

a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

o Hypoxia – cerebral edema - increase ICPo Hypoxia – inadequate tissue oxygenation

Late symptoms of hypoxia ----------- B – bradycardiaE – extreme restlessnessD – dyspneaC – cyanosis

**Early symptoms --------- R – restlessnessA – agitationT – tachycardia

Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP Most powerful respiratory stimulant increase in CO2 ----- remember this! Hyperventilate decrease CO2 – it excretes CO2 kaya nga dapat i-“brown bag” to retain CO2

Respiratory Distress Syndrome (RDS) – decrease Oxygen*Suctioning – 10-15 seconds, max 15 seconds.

o Suction upon withdrawal*Ambu bag – pump upon inspiration

**Assist in mechanical ventilation1. Maintain patent airway2. Monitor VS & I&O3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage4. Limit fluid intake 1,200 – 1,500 ml/day (side note: FORCE FLUID means = Increase fluid intake/day – 2,000 – 3,000 ml/day) - not for inc ICP.5. Prevent complications of immobility6. Prevent increase ICP by:

a. Maintain quiet & comfy environmentb. Avoid use of restraints – lead to fracturesc. Siderails upd. Instruct patient to avoid the ff:

* Avoid valsalva maneuver or bearing down, avoid straining of stool(give laxatives/ stool softener Dulcolax/ Duphalac)

* Avoid Excessive cough – antitussiveEx. Dextrometorpham

* Avoid Excessive vomiting – anti emetic (Plasil – brand name sa pinas) / Phenergan* Avoid Lifting of heavy objects* Avoid Bending & stooping* Avoid clustering of nursing activities

7. Administer MEDS as ordered:1.) Osmotic diuretic – Mannitol./Osmitrol - promotes cerebral diuresis by decompressing brain tissue Nursing considerations:

o Monitor BP – SE of hypotensiono Monitor I&O every hr. report if < 30cc out puto Administer via side drip o Regulate fast drip – to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide) Nursing Mgt:o Same as Mannitol except o Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15o Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm)

**S/E of Lasix

5

1. Hypokalemia (normal K-3.5 – 5.5 meg/L)S&Sx

Weakness & fatigue Constipation (+) “U” wave in ECG tracing

Nursing Mgt:o Administer K supplements – ex Kalium Durule, K chlorideo Potassium Rich food:

ABC’s of K Vegetables FruitsA - asparagus A – apple B – broccoli (highest) B – banana – greenC – carrots C – cantalope/ melon

O – orange (highest) –for digitalis toxicity also.

o Vit A – squash, carrots yellow vegetables & fruits, spinach, chesao Iron – raisins o Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretionso Don’t give grapes – may choke

2. Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:S&Sx

weakness Paresthesia (+) Trousseau sign – pathognomonic – or carpopedal spasm. [Put bp cuff on arm = hand spasm.] (+) Chevostek’s sign - nerve hyperexcitability (tetany) [FACE will contract or twitch kapag haplusin mo] Arrhythmia Laryngospasm

Administer – Ca gluconate – IV slowly *Ca gluconate toxicity: Sx – seizure – administer Mg SO4 *Mg SO4 toxcicity– administer Ca gluconate

B – BP decreaseU – urine output decreaseR – RR decreaseP – patellar reflexes absent

3. Hyponatremia – (Normal Na level = 135 – 145 meg/L)S/Sx

Hypotension Signs of Dehydration: dry skin, poor skin turgor, gen body malaise. Early signs – Adult: thirst and agitation / Child: tachycardia Mgt: force fluid Administer isotonic fluid solution

4. Hyperglycemia – increase blood sugar level P – polyuria P – polyphagia P – polydipsia

Nsg Mgt:Monitor FBS (N=80 – 120 mg/dl)

5.) Hyperurecemia – increase serum uric acid.

6

- Tophi- urate crystals in joint.- kidney stones- renal colic (pain), cool moist skin- Gouty arthritis - Sx: joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritisa.) Cheese - dairy products may lower your risk. (Not good if pt taking MAOI – tyramine may lead to HTN crisis)b.) Force fluidc.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout

Colchicene – excretes uric acid. Acute gout drug of choice.d.) Avoid sardines, anchovies, organ meat

**Kidney stones – renal colic (pain). Cool moist skinMgt:

o Force fluido Meds – narcotic analgesic o Morphine SO4

SE of Morphine SO4 toxicityo Respiratory depression (check RR 1st)o Antidote for morphine SO4 toxicity –Narcan (NALOXONE)o Naloxone toxicity – tremors

**BALIK TAYO INCREASE ICP ------------------------------------------------------------------------------------------------------------------

Increase ICP meds:3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone)4.) Mild analgesic – codeine SO4. For headache.5.) Anti consultants – Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action? Administer Mannitol as ordered --- mannitol kagad basta ordered Elevate head 30 – 45 degrees Restrict fluid Avoid use of restraints

Question: Pt suffering from epiglotitis. What is nsg priority?a. Administer steroids – least priorityb. Assist in ET – n/ac. Assist in tracheotomy – permanent (Answer)d. Apply warm moist pack? Least priority

Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only

-----------------------------------------------------------------------------------------------------------------------------------------------------------Drug Monitoring

Drug N range Toxicity Classification IndicationD – digoxin 0.5 – 1.5 meq/L 2 cardiac glycosides CHFL - lithium 0.6 – 1.2 meq/L 2 antimanic bipolarA – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPDD – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizuresA – acetaminophen 10 – 30 mg/100ml 200 analgesic osteoarthritis

Digitalis – increase cardiac contraction = increase CO // Digitalis toxicity – antidote - DigivineNursing Mgt

1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)

a. Anorexia -initial sx. GIT

7

b. nausea/vomitingc. Diarrhead. Confusione. Photophobiaf. Changes in color perception – yellow spots

(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L – lithium (lithane) - decrease levels of norepinephrine, serotonine, acetylcholine Antimanic agent

S/Sx - a.) Anorexiab.) Diarrheac.) Dehydration – force fluid, maintain Na intake 4 – 10g dailyd.) Hypothyroidism

(CRETINISM– the only endocrine disorder that can lead to mental retardation)

A – Aminophyline (theophylline) – dilates bronchioles.Take bp before giving aminophylline.

S/Sx : Aminophylline toxicity:1. Tachycardia2. Hyperactivity – restlessness, agitation, tremors

Question: Avoid giving food with Aminophyllinea. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI b. Beer/ wine - Hot chocolate & tea – caffeine – CNS stimulant, can cause tachycardiac. Organ meat/ box cereals – anti parkinsonian

**MAOI – antidepressant // 3 – 4 weeks - before MAOI will take effectm AR plann AR dil Avoid tyramine rich foods, can lead to CVA or hypertensive crisisp AR nate

Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa

D – dilatin (Phenytoin) – anti convulsant/seizureNursing Mgt:

1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate Do sandwich method Give NSS then Dilantin, then NSS! 2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity: S/Sx: G – gingival hyperplasia – swollen gums Oral hygiene – soft toothbrushMassage gums H – hairy tongue A - ataxia N – nystagmus – abnormal movement of eyeballs A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts

Acetaminophen toxicity :Hepato toxicityMonitor liver enzymes**SGPT (ALT) – Serum Glutamic Piruvate Tyranase

**SGOT- Serum Glutamic Acetate TyranaseMonitor BUN (10 – 20)Creatinine (.8-1)

8

Acetaminophen toxicity can lead to hypoglycemia T – tremors, TachycardiaI – irritabilityR – restlessnessE – extreme fatigue

D – depression (nightmares) , DiaphoresisAntidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction.

Prepare suctioning apparatus.

-------------------------------------------------------------------------------------------------------------------------------PARKINSONS (parkinsonism)

chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia

Function of dopamine: controls gross voluntary motors.Predisposing Factors:

o Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTAo Hypoxiao Arteriosclerosiso Encephalitiso High doses of the ff:

a. Reserpine (serpasil) anti HPN, Side Effect – 1.) depression 2.) breast cancerb. Methyldopa (aldomet) c. Haloperidol (Haldol)- anti psychoticd. Phenothiazide - anti psychotic

**SE of anti psychotic drugs – Extra Pyramidal Symptom Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)

S/Sx: Parkinsonism – 1. Pill rolling tremors of extremities – early sign2. Bradykinesia – slow movement3. Over fatigue4. Rigidity (cogwheel type)

a. Stooped postureb. Shuffling – most commonc. Propulsive gait

5. Mask like facial expression with decrease blinking eyes6. Monotone speech7. Difficulty rising from sitting position8. Mood labilety – always depressed – suicide

Nsg priority: Promote safety9. Increase salivation – drooling type10. Autonomic signs:

Increase sweating Increase lacrimation – iyakin! Seborrhea (increase sebaceous gland) – oily! Constipation Decrease sexual activity

**Nsg Mgt:1. Anti parkinsonian agents

Levodopa (L-Dopa) – short acting Carbidopa (Sinemet) – long acting Amantadine Hcl (Symmetrel) – eto hindi ko alam haha

Mechanism of actionIncrease levels of dopa – relieving tremors & bradykinesia

*S/E of anti parkinsoniano Anorexiao n/v

o Confusiono Orthostatic hypotension

o Hallucinationo Arrhythmia

*Contraindication:o Narrow angled closure glaucoma o Pt taking MAOI (Parnate, Marplan, Nardil)

9

*Nsg Mgt when giving anti-parkinsonian: Take with meals – to decrease GIT irritation Inform pt – urine/ stool may be darkened Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg Cause B6 reverses therapeutic effects of levodopa Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.

2. Anti cholinergic agents – relieves tremorso Artaneo Cogentin

3. Antihistamine – Diphenhydramine Hcl (Benadryl)S/E: Adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime.

Child – hyperactivity CNS excitement for kids.

4. Dopamine agonistBromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR.

**Nsg Mgt – Parkinson1.) Maintain siderails2.) Prevent complications of immobility

o Turn pt every 2ho Turn pt every 1 h – elderly

3.) Assist in passive ROM exercises to prevent contractures4.) Maintain good nutrition

CHON (protein) – in am CHON (protein) – in pm – to induce sleep – due Tryptopan – Amino Acid

5.) Increase fluid in take, high fiber diet to prevent constipation6.) Assist in surgery – Sterotaxic Thalamotomy

Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis----------------------------------------------------------------------------------------------------------------------------------------------------------------MULTIPLE SCLEROSIS (MS) - myelin sheathChronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord.

Remission & exacerbation Common – women, 15 – 35 yo cause – unknown

Predisposing factor:1. Slow growing virus2. Autoimmune – (supportive & palliative treatment only)

*Normal Resident Antibodies:Ig G – can pass placenta – passive immunity. Short acting.Ig A – body secretions – saliva, tears, colostrums, sweatIg M – acute inflammationIg E – allergic reactionsIgD – chronic inflammation

**S & Sx of MS: ( everything down )

1. Visual disturbances a. Blurring of visionb. Diplopia/ double visionc. Scotomas (blind spots) – initial sx

2. Impaired sensation to touch, pain, pressure, heat, colda. Numbnessc. Paresthesia – tingling sensation

3. Mood swings – euphoria (sense of elation )

4. Impaired motor function:

a. Weaknessb. Spasiticity –“ tigas”c. Paralysis –major problem

5. Impaired cerebellar functionTriad Sx of MS aka (Charcot’s triad)

I – intentional tremors N – nystagmus – abnormal rotation of eyes A – Ataxia & Scanning speech

6. Urinary retention or incontinence7. Constipation

10

8. Decrease sexual ability

**Dx – MS1. CSF analysis thru lumbar puncture

- Reveals increase CHON & IgG2. MRI – reveals site & extent of demyelination3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.

Nsg Mgt MS Supportive mgt

1.) Medsa. Acute exacerbationACTH – adenocorticotopicSteroids – to reduce edema at the site of demyelination to prevent paralysis

2. Maintain siderails3. Assist passive ROMexercises – promote proper body alignment4. Prevent complications of immobility5. Encourage fluid intake & increase fiber diet – to prevent constipation6. Provide catheterization die urinary retention7. Give diuretics Urinary incontinence – give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication

Ex. Grape, Cranberry, Orange juice, Vit C-------------------------------------------------------------------------------------------------------------------------------------------------------------------

MYASTHENIA GRAVIS (MG) disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction. Common in Women, 20 – 40 yo, unknown cause or idiopathic Autoimmune – release of cholenesterase – enzyme [REMEMBER! Lumabas sa boards yan.] Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine Descending muscle weakness

Nsg priority: o a/w o aspiration o immobility

S/ Sx: Ptosis – drooping of upper lid of the eye ( initial sign) Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG. Diplopia – double vision Mask like facial expression Dysphagia – risk for aspiration!!! Weakening of laryngeal muscles – hoarseness of voice Resp muscle weakness – leads to respiratory arrest. [Prepare at bedside tracheostomy set] Extreme muscle weakness during activity especially in the morning.

Dx test Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.

o Remember ung aso sa video dati, ung biglang lumakas – meaning nun (+) sya for MGNsg Mgt1. Maintain patent a/w & adequate vent by:

*Assist in mechanical vent – attach to ventilator*Monitor pulmonary function test.

= kasi decreased vital lung capacity ung pt.2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)

3. Siderails4. Prevent complications of immobility.

Adult - every 2 hrs. // Elderly - every 1 hr.5. NGT feeding

11

**Administer meds Cholinergics or anticholinesterase agents Mestinon (Pyridostigmine) Neostignine (prostigmin) – Long term

Increase acetylcholine Corticosteroids – to suppress immune response

o Ex. Decadron (dexamethasone)

**Monitor for 2 types of Crisis: Myastinic Crisis Cholinergic crisisCause – 1. Under medication 2. Stress 3. InfectionS/S 1. Unable to see – Ptosis & diplopia 2. Dysphagia- unable to swallow. 3. Unable to breath

Mgt – administer cholinergic agents

Cause: 1 over medsS/Sx - PNS

Mgt. - adm anti-cholinergic Atropine SO4

7. Assist in surgical proc – thymectomy - Removal of thymus gland. [Thymus secretes auto immune antibody.]8. Assist in plasmaparesis – filter blood9. Prevent complication – respiratory arrest – [Prepare tracheostomy set at bedside.]

------------------------------------------------------------------------------------------------------------------------------------------------GBS – Guillain Barre Syndrome aka Acute inflammatory demyelinating polyneuropathy (AIDP)

Disorder of CNS Bilateral symmetrical polyneuritis Ascending paralysis

Cause – unknown, idiopathic Auto immune r/t antecedent viral infection Immunizations

**S&Sx Initial :

1. Clumsiness2. Ascending muscle weakness – lead to paralysis3. Dysphagia4. Decrease or diminished DTR (deep tendon reflexes)

Paralysis5. Alternate HPN to hypotension – lead to arrhythmia - complication6. Autonomic changes

increase sweating, increase salivation. Increase lacrimation

Dx most important : CSF analysis - thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt1. Maintain patent a/w & adequate vent

a. Assist in mechanical ventb. Monitor pulmonary function test

2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia3. Siderails4. Prevent compl – immobility5. Assist in passive ROM exercises6. Institute NGT feeding – due dysphagia

12

7. Adm meds (GBS) as ordered: Anti cholinergic – atropine SO4 Corticosteroids – to suppress immune response Anti arrhythmic agents

o Lidocaine /Xylocaine –SE confusion = VTacho Bretylliumo Quinines/Quinidine – anti malarial agent. Give with meals. // Toxic effect – cinchonism

8. Assist in plasmaparesis (MG. GBS)9. Prevent comp – arrhythmias, respiratory arrest – [Prepare tracheostomy set at bedside.]

-------------------------------------------------------------------------------------------------------------------------------------------------------------------Meninges – 3-fold membrane – cover brain & spinal cordFunctions:

Protection & support Nourishment Blood supply

**3 layers:1. Duramater sub dural space2. Arachmoid matter3. Pia matter sub arachnoid space where CSF flows L3 & L4. [Site for lumbar puncture.]

MENINGITIS – inflammation of meningitis & spinal cord

Etiology – Meningococcus- Pneumococcus- Hemophilous influenza – child- Streptococcus – adult meningitis

Transmission – direct transmission via droplet nuclei

S/S: Stiff neck or nuchal rigidity (initial sign) Headache Projectile vomiting – due to increase ICP Photophobia Fever chills, anorexia Gen body malaise Wt loss Decorticate/decerebration – abnormal posturing Possible seizure**Signs of meningeal irritation – nuchal rigidity or stiffness

Opisthotonus- rigid arching of back

Pathognomonic sign – (+) Kernig’s [leg pain] & Brudzinski sign [neck pain]

Dx:1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5**Nsg Mgt for lumbar puncture – invasive

1. Consent / explain procedure to pto RN – diagnostic procedure (lab)o MD – operation procedure

2. Empty bladder, bowel – promote comfort3. Arch back – to clearly visualize L3, L4 [sim’s, shrimp position]

**Nsg Ngt post lumbar1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF2. Force fluid3. Check punctured site for drainage, discoloration & leakage to tissue

13

4. Assess for movement & sensation of extremeties

Result 1. CSF analysis: a. increase CHON & WBC Content of CSF: CHON, WBC, Glucose

b. Decrease glucose Confirms meningitis c. increase CSF opening pressure

N 50 – 160 mmHgd. (+) Culture microorganism

2. Complete blood count CBC – reveals increase WBC

Management:1. Adm meds

a.) Broad-spectrum antibiotic penicillin**Side effects:

1. GIT irritation – take with food2. Hepatotoxicity, nephrotoxcicity3. Allergic reaction4. Super infection – alteration in normal bacterial flora Normal flora sa throat – streptococcus Normal flora sa intestine – e coli

**Sign of superinfection of penicillin = diarrheab.) Antipyretic c.) Mild analgesic

2. Strict respiratory isolation 24h after start of antibiotic therapy **Side note:

A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.B – Aplastic anemia – reverse isolation - due to bone marrow depression.C – Cancer any type – reverse isolation – immunocompromised.D – Post liver transplant – reverse isolation – takes steroids lifetime.E – Prolonged use steroids – reverse isolationF – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapyG – Asthma – not to be isolated

3. Comfy & dark room – due to photophobia & seizure 4. Prevent complications of immobility 5. Maintain F & E balance6. Monitor vs, I&O, neuro check7. Provide client health teaching & discharge plan

a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feedingb. Prevent complication hydrocephalus, hearing loss or nerve deafness.

8. Prevent seizure.Where to bring 2 y/o post meningitis Audiologist - due to damage to hearing- post repair myelomeningocele Urologist - Damage to sacral area – spina bifida – controls urination

9. Rehab for neurological deficit. [Can lead to mental retardation or a delay in psychomotor development.]

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy Partial or complete disruption in the brains blood supply 2 largest & common artery in stroke

Middle cerebral arteryInternal carotid artery

Common to male – 2 – 3x high risk

14

Predisposing factor:1. Thrombosis – clot (attached) – [stationary]2. Embolism – dislodged clot – pulmo embolism [circulating]

S/Sx: pulmo embolism Sudden sharp chest pain Unexplained dyspnea, SOB Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism Headache, disorientation, confusion & decrease in LOC

[Femur fracture – complications: fat embolism – most feared complication w/in 24hrs]Yellow bone marrow – produces fat cells at meduallary cavity of long boneRed bone marrow – provides WBC, platelets, RBC found at epiphisis

3.) Hemorrhage4.) Compartment syndrome – compression of nerves/ arteries

**Risk factors of CVA: HPN DM MI artherosclerosis

valvular heart dse Post heart surgery mitral valve replacement

**Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor2. Sedentary lifestyle3. Hyperlipidemia – genetic 4. Prolonged use of oral contraceptives

- Macro pill – has large amount of estrogen- Mini pill – has large amt of progestin- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke

5. Type A personality – [punong Abala! – gusto laging busy]a. Deadline driven personb. 2 – 5 things at the same timec. Guilty when not dong anything

6. Diet – increase saturated fats7. Emotional & physical stress8. Obesity

S /S: 1. TIA- [Transient inschemic attack] - warning signs of impending stroke attacks

Headache (initial sx) dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia – 1 extreme) Increase ICP

2. Stroke in evolution – progression of S & Sx of stroke3. Complete stroke – resolution of stroke

a.) Headacheb.) Cheyne-Stokes Resp - progressively deeper and sometimes faster breathing, followed by a gradual decrease**c.) Anorexia, n/vd.) Dysphagiae.) Increase BPf.) (+) Kernig’s & Brudzinski – sx of hemorrhagic strokeg.) Focal & neurological deficit

1. Phlegia2. Dysarthria – inability to vocalize, articulate words – hirap magsalita! D:3. Aphasia4. Agraphia difficulty writing5. Alesia – difficulty reading6. Homoninous hemianopsia – loss of half of field of vision – half bulag! ._o

**Ex. Left sided hemianopsia – approach Right side of pt – the unaffected side - [always approach unaffected side]

15

Dx:1. CT Scan – reveals brain lesion2. Cerebral arteriography – site & extent of mal occlusion

Invasive procedure due to inject dye Allergy test

**REMEMBER!!! -- All – graphy = invasive due to iodine dye- [lahat ng GRAPHY = invasive!]**Post [after]

1.) Force fluid – to excrete dye is nephrotoxic2.) Check peripheral pulses - distal

**Nsg Mgt:1. Maintain patent a/w & adequate vent

- Assist mechanical ventilation- Administer O2

2. Restrict fluids – prevent cerebral edema3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.4. Monitor vs., I&O, neuro check5. Prevent compl of immobility by:

a. Turn client q2h Elderly q1h

To prevent decubitus ulcer To prevent hypostatic pneumonia – after prolonged immobility.

b. Egg crate mattress or H2O bedc. Sand bag or foot board- prevent foot drop

6. NGT feeding – if pt can’t swallow7. Passive ROM exercise q4h8. Alternative means of communication

- Non-verbal cues- Magic slate. Not paper and pen. Tiring for pt.- (+) To hemianopsia – approach on unaffected side

9. Medso Osmotic diuretics – Mannitolo Loop diuretics – Lasix/ Furosemideo Corticosteroids – dextamethazoneo Mild analgesico Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.

Streptokinase Urokinase Tissue plasminogen activating

o Monitor bleeding timeo Anticoagulants – Heparin & Coumadin” sabay”

Coumadin will take effect after 3 days o Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.o Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote.o Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.

Health Teaching1. Avoidance modifiable lifestyle - Diet, smoking2. Dietary modification - Avoid caffeine, decrease Na & saturated fats

Complications:Subarachnoid hemorrhageRehab for focal neurological deficit – physical therapy

1. Mental retardation2. Delay in psychomotor development

16