Nervous SystemOVERVIEW OF THE STRUCTURES & FUNCTIONS

Central NS PNS ANS-Brain & spinal cord -31 spinal & cranial -sympathetic NS

-Parasypathatic NS

Somatic NSC- 8T- 12L- 5S- 5C- 1

ANS or adrenergic of parasympathetic/parasympatholitic response

1. SYMPATHETIC NS: FIGHT OR FLIGHT/AGGRESSION RESPONSE Release of norepinephrine (adrenaline – cathecolamine)Adrenal medulla (potent vasoconstrictor)Increases body activitiesExcept 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 oxygen VS = Increase4. RR increased5. Constipation & urinary retention

I. Adrenergic Agents – Epinephrine (adrenaline)

SE: SNS effectII. 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, MetopanololSE:

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 heart

Anti HPN Agents:1. Beta blockers (-lol)

Ex. Propanolol, Metopanolol2. Ace inhibitors (-pril)

Ex Enalapril, Captopril3. Calcium antagonist

Ex Calcibloc or NefedipineSide Effects:

orthostatic hpntransient headache dizziness

Management: - Rise slowly. Assist in ambulation.

2. PERIPHERAL NERVOUS SYSTEM: CHOLINERGIC/ VAGAL OR SYMPATHOLITIC RESPONSE Involved in fly or withdrawal responseRelease of acetylcholine (ACTH)Decrease all bodily activities except GIT (diarrhea)

EFFECTS OF PNS (CHOLINERGIC) 1. Meiosis – contraction of pupils2. Increase salivation3. BP & HR decreased VS decrease4. RR decrease – broncho constriction5. Diarrhea – increased GI motility6. Urinary frequency

I.Cholinergic Agents - anticholinesterase agents

Ex (Pyridostigmine) MestinonAntidote – anti cholinergic agents Ex Atropine Sulfate

SE: SNS effect

CNS (BRAIN & SPINAL CORD)I. Cells – A. neurons

PROPERTIES AND CHARACTERISTICSa. 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 CAPACITYA. Labile – once destroyed cant regenerate

- Epidermal cells, GIT cells, resp (lung cells). GUTB. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cellsC. Permanent cells – retina, brain, heart, osteocytes can’t regenerate.3.) Neuroglia – attached to neurons. 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.ASTROCYTE – maintains integrity of blood brain barrier (BBB).BBB – semi permeable / selective-Toxic substance that destroys astrocyte & destroy BBB.Toxins that can pass in BBB:

1. Ammonia-liver cirrhosis. 2. 2. Carbon Monoxide – seizure & parkinsons. 3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia. 4. 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

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: 0-15mmHgBrain mass

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

Rt cerebral hemisphere, Lt cerebral hemisphereFUNCTION:

1. Sensory2. Motor3. Integrative

LOBES:1.) 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 impulse - Pain, touch, pressure, heat & cold4.) Occipital - vision5.) Insula/island of reil/ Central lobe - controls visceral function

Function: - activities of internal organ6.) Rhinencephalon/ Limbec

- Smell, libido, long-term memory

Basal Ganglia – areas of gray matte located deep within a cerebral hemisphereExtra pyramidal tractReleases dopamineControls gross voluntary unit

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

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

DIENCEPHALON- between brain Thalamus – acts as a relay station for sensationHypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses, controls pituitary function.

BRAIN STEM- a. Pons – or pneumotaxic center – controls respirationCranial 5 – 8 CNS

MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutusVasomotor center, spinal decussation termination , CN 9, 10, 11, 12

CEREBELLUM – lesser brain

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 HypothesisSkull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

Normal ICP – 0 – 15 mmHgForamen Magnum C1 – atlasC2 – axis

(+) Projectile vomiting = increase ICPObserve for 24 - 48 hrsCSF – cushions the brain, shock absorber Obstruction of flow of CSF = increase ICPHydrocephalus – posteriorly due to closure of posterior fontanelCVA – 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

Signs & Symptoms:Earliest Symptoms:a.) Change or decrease LOC – Restlessness to confusion

- Disorientation to lethargy - 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 EFFECT Decrease RR Increase RR Increase Temp Decrease temp

change in VS = always late symptomsWide pulse pressure: Increased ICPNarrow pp: Cardiac disorder, shock

b.) HeadacheProjectile vomitingPapilledima (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. (Bilateral dilation of pupil – tentorial herniation.)

d.) Possible seizure.

NURSING PRIORITY:1.) Maintain patent a/w & adequate ventilationa. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention). Hypoxia – cerebral edema - increase ICP Hypoxia – inadequate tissue oxygenation Early symptoms – R – restlessness

A – agitation T – tachycardia

Late symptoms of hypoxia – B – bradycardia E – extreme restlessness D – dyspnea C – cyanosis

Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICPMost powerful respiratory stimulant increase in CO2Hyperventilate decrease CO2 – excrete CO2

Respiratory Distress Syndrome (RDS) – decrease OxygenSuctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.Ambu bag – pump upon inspiration

b. Assist in mechanical ventilation1. Maintain patent a/w 2. 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

(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:

-Valsalva maneuver or bearing down, avoid straining of stool (give laxatives/ stool softener Dulcolax/ Duphalac)

- Excessive cough – antitussive (Dextrometorpham)

-Excessive vomiting anti emetic (Plasil – Phil only)/ Phenergan

- Lifting of heavy objects - Bending & stoopinge. Avoid clustering of nursing activities

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

Nursing considerations: Mannitol1. Monitor BP – SE of hypotension2. Monitor I&O every hr. report if < 30cc out put3. Administer via side drip 4. Regulate fast drip – to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide) Nursing considerations: Lasix Same as Mannitol except:

Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15

Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm) Side effects of Lasix:

1.) HYPOKALEMIA (normal K-3.5 – 5.5 meg/L)Signs & symptoms:

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

Nursing Management:Administer K supplements – ex Kalium Durule, K chloridePotassium Rich food:

ABC’s of KVegetables FruitsA - asparagus A – apple B – broccoli (highest) B – banana – greenC – carrots C – cantalope/ melon O – orange (highest) –for digitalis toxicity also.

2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or TetanySigns & symptoms:

weaknessParesthesia(+) Trousseau sign – pathognomonic sign carpopedal spasm. Put bp cuff on arm=hand spasm.(+) Chevostek’s signArrhythmiaLaryngospasm

Nursing Management:Administer Ca gluconate – IV slowly

CA GLUCONATE TOXICITY: Sx seizure administer Mg SO4

MG SO4 TOXCICITYSX B – BP decrease U – urine output decrease R – RR decrease P – patellar reflexes absentNursing Management:– administer Ca gluconate

3). Hyponatremia – Normal Na level = 135 – 145 meg/L Signs & symptoms:

HypotensionSigns of Dehydration: -dry skin, poor skin turgor, gen body malaise. Early signs – Adult: thirst and agitation - Child: tachycardia

Nursing Management:- force fluid- Administer isotonic fluid soluton

4.) Hyperglycemia – increase blood sugar levelSigns & symptoms: P – polyuria P – polyphagia P – polydipsiaNursing Management:

a. Monitor FBS (N=80 – 120 mg/dl)

5.) Hyperurecemia increase serum uric acid. Tophi- urate crystals in joint.

Hyperurecemia

Gouty arthritis kidney stones- renal colic (pain)

Sx joint pain & swelling usually at great toe. Cool moist skin

Nursing Management of Gouty Arthritis a.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO) b.) Force fluid c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid drug of choice for gout - Colchicene – excretes uric acid. ACUTE GOUT drug of choice.Nursing Management of Kidney Stones

a.) Force fluidb.) Meds – narcotic analgesic - Morphine SO4

Side effects Morphine SO4 toxicity Respiratory depression (check RR 1st)Antidote for morphine SO4 toxicity –Narcan (NALOXONE)Naloxone toxicity – tremors

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?a. Administer Mannitol as orderedb. Elevate head 30 – 45 degreesc. Restrict fluidd. Avoid use of restraints

Nsg Priority – ABC & safety

Pt suffering from epiglotitis. What is nsg priority?a. Administer steroids – least priorityb. Assist in ET – temp, a/wc. 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-

MAGIC 2’S OF DRUG MONITORING

Drug N range Toxicity Classification IndicationD – digoxinL – lithiumA – aminophyllineD – DilantinA – acetaminophen

.5 – 1.5 meq/L

.6 – 1.2 meq/L10 – 19 mg/100ml10 -19 mg/100 ml10 – 30 mg/100ml

22

2020

200

cardiac glycosidesantimanic

bronchodilatoranticonvulsant

narcotic analgesic

CHFBipolarCOPD

SeizuresOsteoarthritis

DIGITALIS increase cardiac contraction = increase CONursing Management

- Check PR, HR (if HR below 60bpm, don’t give Digoxin)

DIGITALIS TOXICITY Signs & symptoms:

a. Anorexia b. n/v initial sxc. Diarrhea

d. Confusione. Photophobiaf. Changes in color perception – yellow

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

Antidote - Digivine

LITHIUM (lithane) decrease levels of norepinephrine, serotonine, acetylcholineAntimanic agent

LITHIUM TOXICITYSigns & symptoms:

a.) Anorexiab.) n/sc.) Diarrhead.) Dehydration – force fluid, maintain Na

intake 4 – 10g dailye.) Hypothyroidism

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

AMINOPHYLINE (theophylline) dilates bronchioles.

AMINOPHYLLINE TOXICITYSigns & symptoms:

a. Tachycardiab. Hyperactivity – restlessness, agitation, tremors

Nursing ManagementTake bp before giving aminophylline.

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

- Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa

MAOI – antidepressantm AR plann AR dil can lead to CVA orp AR nate hypertensive crisis

Nursing Management3 – 4 weeks - before MAOI will take effect

DILATIN (Phenytoin) – anti convulsant/seizureNursing Management

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: Signs & symptoms: G – gingival hyperplasia – swollen gums

i. Oral hygiene – soft toothbrushii. Massage gums

H – hairy tongue A – ataxia N – nystagmus – abnormal movement of eyeballs

ACETAMINOPHEN (Tylenol )– non-opoid analgesic & antipyretic – febrile pts

ACETAMINOPHEN TOXICITY Signs & symptoms:

Acetaminophen toxicity can lead to hypoglycemia T – tremors, TachycardiaI – irritabilityR – restlessnessE – extreme fatigueD – depression (nightmares) , Diaphoresis

Nursing Management:1. Hepato toxicity - complication2. Monitor liver enzymes

SGPT (ALT) – Serum Glutamic Piruvate TyranaseSGOT- Serum Glutamic Acetate Tyranase

3. Monitor BUN (10 – 20)Crea (.8-1)

ANTIDOTE Acetylcesteine = causes outporing of secretions. Suction.

Prepare suctioning apparatus.

Question: The following are symptoms of hypoglycemia except:a. Nightmaresb. Extreme thirst – hyperglycemia symptomsc. Weakness d. Diaphoresis

PARKINSONS DISEASE (parkinsonism)chronic, progressive disease of CNS characterize by degeneration of dopamine producing cells in substancia nigra at mid brain & basal gangliaPalliative, SupportiveFunction of dopamine: controls gross voluntary motors.

Predisposing factors:1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA2. Hypoxia3. Arteriosclerosis4. Encephalitis5. High doses of the ff:

a. Reserpine (serpasil) anti HPN, S/E – 1.) depression - suicidal b. Methyldopa (aldomet) - promote safety 2.) breast cancerc. Haloperidol (Haldol)- anti psychoticd. Phenothiazide - anti psychotic

SIDE EFFECTS OF ANTI PSYCHOTIC DRUGS – Extra Pyramidal Symptom Over meds of anti psychotic drugs – neuroleptic malignant syndrome tremors (severe)

Sign & Symptoms Parkinsonism:1. Pill rolling tremors of extremities – early sign2. Bradykinesia – slow movement3. Over fatigue4. Rigidity (cogwheel type)

a. Stooped postureb. Shuffling gait – 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 sweatingIncrease lacrimationSeborrhea (increase sebaceous gland)ConstipationDecrease sexual activity

Nursing Management:1.) Anti parkinsonian agents Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)

Mechanism Of Action:- Increase levels of dopa – relieving tremors & bradykinesia

Side Effects Of Anti Parkinsonian:Orthostatic hypotensionAnorexian/vConfusionHallucinationArrhythmia

Contraindication:1. Narrow angled closure glaucoma2. Pt taking MAOI (Parnate, Marplan, Nardil)

NSG. MGT When giving anti-parkinsonian1. Take with meals – to decrease GIT irritation2. Inform pt – urine/ stool may be darkened3. Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green

leafy vegetables cause B6 reverses therapeutic effects of levodopaGive INH (Isoniazide-Isonicotene acid hydrazide.) S/E of INH-Peripheral neuritis.

2.) Anti cholinergic agents – relieves tremors

1. Artane 2. Cogentin

Mechanism Of Action: - inhibits acetylcholine action

Side Effects: - SNS

3.) Antihistamine Diphenhydramine Hcl (Benadryl) – take at bedtime

Side Effects:1. adult– drowsiness,– avoid driving & operating heavy equipt. 2. Child – hyperactivity CNS excitement for kids.

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

Nursing Management: Parkinsonism1.) Maintain siderails2.) Prevent complications of immobility

- Turn pt every 2h- Turn pt every 1 h – elderly

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

CHON – in am CHON – 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) Chronic intermittent disorder of CNSWhite patches of demyelenation in brain & spinal cord.

Remission & exacerbation Common – women, 15 – 35 yo

Cause – unknownPredisposing factor:

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

Normal Resident Antibodies:IgG – can pass placenta – passive immunity. Short acting.IgA – body secretions – saliva, tears, colostrums, sweatIgM – acute inflammationIgE – allergic reactionsIgD – chronic inflammation

Sign & Symptoms of MS: (everything down)

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

2. Impaired sensation to touch, pain, pressure, heat, colda. Numbnessb. Tinglingc. Paresthesia

3. Mood swings – euphoria (sense of elation )4. Impaired motor function:

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

5. Impaired cerebellar functionTRIAD Signs OF MS

I – intentional tremors N – nystagmus – abnormal rotation of eyes Charcots triadA – Ataxia S - scanning speech

6. Urinary retention or incontinence7. Constipation8. Decrease sexual ability

Diagnosis of MS:1. 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.

Nursing Management: MS1. Supportive mgt2. Meds

a. ACTH – adenocorticotopicb. Steroids – to reduce edema at the site of Acute exacerbation

demyelination to prevent paralysis

SPINAL CORD INJURY (SCI)

1. Administer drug to prevent paralysis due to edema a. Give ACTH – steroids

b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)To decrease muscle spasticity

c. Interferone – to alter immune response

d. Immunosuppresants2. Maintain siderails3. Assist passive ROM exercises – 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

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 y/ounknown cause or idiopathic Autoimmune release of cholenesterase enzyme

Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholineDescending muscle weakness(Ascending muscle weakness – Guillain Barre Syndrome)

Sign & Symptoms:1.) Ptosis – drooping of upper lid ( initial sign)

Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.2.) Diplopia – double vision3.) Mask like facial expression4.) Dysphagia – risk for aspiration!5.) Weakening of laryngeal muscles – hoarseness of voice6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set7.) Extreme muscle weakness during activity especially in the morning.

Diagnosis1. Tensilon test (Edrophonium Hcl)

– temporarily strengthens muscles for 5 – 10 mins. – Short term- cholinergic. PNS effect.

Nursing Management:1. Maintain patent a/w & adequate vent by:

a.) Assist in mechanical vent – attach to ventilatorb.) Monitor pulmonary function test. Decrease vital lung capacity.

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 6. Administer meds –

a.) Cholinergics or anticholinesterase agents Mestinon (Pyridostigmine)Neostignine (prostigmin) – Long term- Increase acetylcholines/e – PNS

b.) Corticosteroids – to suppress immune resp Decadron (dexamethasone)

MONITOR FOR 2 TYPES OF CRISIS: MYASTINIC CRISIS CHOLINERGIC CRISISA cause – 1. Under medication 2. Stress 3. InfectionB S&Sx 1. Unable to see – Ptosis & diplopia 2. Dysphagia- unable to swallow. 3. Unable to breath C Mgt – adm cholinergic agents

Cause: 1 over medsS/Sx - PNS

Mgt. adm anti-cholinergic

Mestinon (Pyridostigmine)Neostignine (prostigmin) – Long term

- Atropine SO4- SNS – dry mouth

7. Assist in surgical procedure – thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.8. Prepare tracheostomy set at bedside.9. Assist in plasmaparesis – filter blood10. Prevent complication – respiratory arrest

GUILLAIN BARRE SYNDROME (GBS)- Disorder of CNS- Bilateral symmetrical polyneuritis- Ascending paralysisunknown cause or idiopathic Auto immuner/t antecedent viral infectionImmunizations

Sign & Symptoms : Initial :

1. Clumsiness2. Ascending muscle weakness lead to paralysis

- Decrease or diminished DTR (deep tendon reflexes)3. Dysphagia4. Alternate HPN to hypotension lead to arrhythmia - complication5. Autonomic changes – increase sweating increase salivation.

Increase lacrimation6. Constipation

Diagnosis:Important

1. CSF analysis thru lumbar puncture- Reveals increase CHON & IgG (same with MS)

Nursing Management:1. 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 complication – immobility5. Assist in passive ROM exercises6. Institute NGT feeding – due dysphagia7. Administer meds as ordered: 1. Anti cholinergic – Atropine So4

2. Corticosteroids – to suppress immune response 3. Anti arrhythmic agents

a.) Lidocaine /Xylocaine –S/E confusion = VTachb.) Bretylliumc.) Quinines/Quinidine – anti malarial agent. Give with meals.

- Toxic effect – cinchonismQuinidine toxicityS/E – anorexia, n/v, headache, vertigo,

visual disturbances8. Assist in plasmaparesis (MG. GBS)9. Prevent complicatio – arrhythmias, respiratory arrest10. Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAINMeninges – 3-fold membrane – cover brain & spinal cordFx: Protection & support

Nourishment Blood supply3 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:MeningococusPneumococcusHemophilous influenza – childStreptococcus – adult meningitis

Mode of Transmission – direct transmission via droplet nuclei

Sign & Symptoms : - meningeal irritation- 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

Opisthotonus- rigid arching of back

Pathognomonic sign of Meningitis (+) Kernig’s & Brudzinski sign

Leg pain Neck pain

Diagnosis::1. Lumbar puncture Aspirate CSF

lumbar/ spinal tapLumbar / spinal tapuse of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5

Nursing Management: lumbar tap- invasive

Pre-Op1. Consent / explain procedure to pt- RN – dx procedure (lab)- MD – operation procedure 2. Empty bladder, bowel – promote comfort3. Arch back – to clearly visualize L3, L4

Post-Op1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF2. Force fluid3. Check punctured site for drainage, discoloration & leakage to

tissue4. Assess for movement & sensation of extremeties

RESULT:1. CSF analysis:

- Confirms bacterial meningitisContent of CSF:

a. increase CHON & WBC Chon, wbc, glucose

b. Decrease glucose c. increase CSF opening pressure

N 50 – 160 mmHgd. (+) Culture microorganism

2. Complete blood count CBC – reveals increase WBC

Nursing Management::1. Administer meds

a.) Broad-spectrum antibiotic penicillin S/E

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

Sx of superinfection of penicillin = diarrheab.) Antipyretic c.) Mild analgesic

2. Strict respiratory isolation 24h after start of antibiotic therapyCushing’s Syndrome

– reverse isolation due to increased corticosteroid in body.Aplastic anemia

– reverse isolation due to bone marrow depression.Cancer anytype

– reverse isolation immunocompromised.Post liver transplant

– reverse isolation takes steroids lifetime.Prolonged use steroids

– reverse isolationMeningitis

– strict respiratory isolation safe after 24h of antibiotic thrpyAsthma

– not to be isolated3. 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 feeding b. Prevent complication hydrocephalus, hearing loss or nerve deafness.8. Prevent seizure.

Where to bring 2 yo 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 (CVA)stroke, brain attack or cerebral thrombosis, apoplexy Partial or complete disruption in the brains blood supply2 largest & common artery in stroke

- Middle cerebral artery- Internal carotid artery

Common to male – 2 – 3x high risk

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

S/Sx: pulmo embolism Sudden sharp chest pain

Unexplained dyspnea, SOB Tachycardia, palpitations, diaphoresis & mild restlessness

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

Femur fracture – complications: fat embolism – most feared complication w/in 24hrsYellow 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 replacementLifestyle:

1. Smoking – nicotine potent vasoconstrictor 2. Hyperlipidemia – genetic

3. Prolonged use of oral contraceptives- Macro pill – has large amt estrogen- Mini pill – has large amt of progestin- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis, HPN, stroke

5. Type A personalitya. Deadline driven personb. 2 – 5 things at the same timec. Guilty when not dong anything

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

Sign & Symptoms : 1. TIA- 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 Respc.) Anorexia, n/vd.) Dysphagiae.) Increase BPf.) (+) Kernig’s & Brudzinski – sx of hemorrhagic strokeg.) Focal & neurological deficit

1. Phlegia2. Dysarthria – inability to vocalize, articulate words 3. Aphasia4. Agraphia diff writing5. Alesia – diff reading6. Homoninous hemianopsia – loss of half of field of vision

Left sided hemianopsia – approach Right side of pt – the unaffected side

Diagnosis::1. CT Scan – reveals brain lesion2. Cerebral arteriography – site & extent of mal occlusion- Invasive procedure due to inject dye - Allergy testAll – graphy – invasive due to iodine dye

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

Nursing Management: CVA 1. Maintain patent a/w & adequate vent

- Assist mechanical ventilation

- Administer O22. 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. Administer medsa. Osmotic diuretics – Mannitolb. Loop diuretics – Lasix/ Furosemidec. Corticosteroids – dextamethazoned. Mild analgesic e. Thrombolytic/ fibrolitic agents – dissolves clot.

S/E -Urticaria, pruritus-caused by foreign subs.

Streptokinase Urokinase

Tissue plasminogen activating10. Monitor bleeding time

a. Anticoagulants – Heparin & Coumadin” sabay”Coumadin will take effect after 3 days

*Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.

*Coumadin –Long term. monitor PT prothrombin time if prolonged - bleeding give Vit K – Aquamephyton- antidote.

*Antiplatelet – PASA – aspirin paraanemo aspirin - don’t give to dengue, ulcer, and unknown headache.

Nursing Management: 1. Avoidance modifiable lifestyle

- Diet, smoking2. Dietary modification

- Avoid caffeine, decrease Na & saturated fatsComplications:

Subarachnoid hemorrhageRehab for focal neurological deficit – physical therapy

1. Mental retardation2. Delay in psychomotor development

CONVULSIVE Disorder (CONVULSIONS) - disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attackFebrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizurePathologic if > 5 yo

Predisposing Factor:Head injury due birth traumaToxicity of carbon monoxideBrain tumorGenetics

Nutritional & metabolic deficitPhysical stressSudden withdrawal to anticonvulsants will bring about status epilepticusStatus epilepticus – drug of choice: Diazepam & glucose

Sign & Symptoms : I. Generalized Seizure –

a.) Grand mal / tonic clonic seizuresWith or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory, tactile, visual, auditory sensory experience

- Epileptic cry – fall- Loss of consciousness 3 – 5 min- Tonic clonic contractions- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC - Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic

b.) Petimal seizure – (same as daydreaming!) or absence seizure.- Blank stare- Decrease blinking eye- Twitching of mouth- no loss of consciousness (aware of his surroundings

II. Localized/partial seizurea.) Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to shoulder & - 1 sideof the body with janksonian marchb.) Psychomotor/ focal motor - seizure

-Automatism – stereotype repetitive & non-purposive behavior- Clouding of consciousness – not in control with environment- Mild hallucinatory sensory experience

HALLUCINATIONS1. Auditory – schitzo – paranoid type2. Visual – korsakoffs psychosis – chronic alcoholism3. Tactile – addict – substance abuse; alcohol withdrawal

III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – death

Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.Tx:Diazepam (drug of choice), glucoseDx-Convulsion- get health history!

1. CT scan – brain lesion2. EEG electroencephalography- Hyperactivity brain waves

Nursing Management: Priority – Airway & safety

1. Maintain patent a/w & promote safetyBefore seizure:

1. Remove blunt/sharp objects2. Loosen clothing3. Avoid restraints4. Maintain siderails5. Turn head to side to prevent aspiration6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can

use spoon at home.7. Avoid precipitating stimulus – bright glaring lights & noises8. Administer medsa. Dilantin (Phenytoin) –( toxicity level – 20 )

SE Gingival hyperplasia H-hairy tongue

A-ataxia N-nystagmus

A-acetaminophen- febrile ptMix with NSS- Don’t give alcohol – lead to CNS depression

b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmiac. Phenobarbital (Luminal)- SE: hallucinations

2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside3. Monitor onset & duration

- Type of seizure - Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!

4. Assist in surgical procedure. Cortical resection 5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal – immediate nursing action = a/w & safetya. Mouthpiece – 1 yr old – little teeth onlyb. Adm o2 inhalation – post!c. Give pillow – safety (answer)d. Prepare suction

NEUROLOGICAL ASSESSMENT1. Comprehensive neuro exam2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check

3 Components Of ECSM – motor 6V – verbal 5E – eye opening 4

15

15 – 14 – conscious13 – 11 – lethargy10 – 8 – stupor 7 – coma 3 – deep coma – lowest score

Survey of mental status & speech (Comprehensice Neuro Exam):1.) LOC & test of memory2.) Levels of orientation3.) CN assessment4.) Motor assessment5.) Sensory assessment6.) Cerebral test – Rhomberg, finger to nose7.) DTR8.) Autonomics

LEVELS OF CONSCIOUSNESS (LOC)1. Conscious (conscious) – awake – levels of wakefulness2. Lethargy (lethargic) – drowsy, sleepy, obtunded3. Stupor (stuporous) – awakened by vigorous stimulation

Pt has gen body weakness, decrease body reflex4. Coma (Comatose) light – (+) all forms of painful stimulations

Deep – (-) to painful stimulation

Question: Describe a conscious pt ?a. Alert – not all pt are alert & oriented to time & placeb. Coherentc. Awake- answerd. Aware

DIFFERENT TYPES OF PAIN STIMULATION:

- Don’t prick1. Deep sternal stimulation/ pressure 3x– fist knuckle

With response – light comaWithout response – deep coma

2. Pressure on great toe – 3x3. Orbital pressure – pressure on orbits only – below eye4. Corneal reflex/ blinking reflex

Wisp of cotton – used to illicit blinking reflex among conscious patientsInstill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma

5. Test of memory – considered educational backgrounda.) Short term memory – - What did you eat for breakfast?

Damage to temporal lobe – (+) antero grade amnesiab.) Long term memory(+) Retrograde amnesia – damage to limbic system

6. Levels of orientationTime Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.

CN ASSESSMENTI – Olfactory sII – Optic sIII – Oculomotor mIV – Trocheal m smallest CNV – Trigeminal b largest CNVI – Abducens mVII – Facial bVIII – Acustic/auditory sIX – Glassopharyngeal bX – Vagus b longest CNXI– Spinal accessory mXII – Hypoglossal m

I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar

- Hyposmia – decrease sensitivity to smell- Diposmia – distorted sense of smell- Anosmia – absence of sense of smell

* Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition – sinusitis

II Optic- test of visual acuity

1. Snellens chart – central or distance vision Snellens E chart – used for illiterate chart

N 20/20 vision distance by w/c person can see letters- 20 ft Numerator – distance to snellens chartDenominator – distance the person can see the lettersOD – Rt eye 20/20 20/200 – blindness – cant read E – biggestOS – left eye 20/20OU – both eye 20/20

2. Test of peripheral vision/ visual fielda. Superiorityb. Bitemporallyc. Inferiorlyd. Nasally

Common Disorders:1. Glaucoma – Normal 12 – 21 mmHg pressure

- Increase IOP - Loss of peripheral vision – “tunnel vision” 2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision”3. Retinal detachment – curtain veil – like vision & floaters4. Macular degeneration – black spots

III, IV, VI – tested simultaneously

c.) Innervates the movementt of extrinsic ocular muscle6 cardinal gaze EOM

Right eye n left eyeIO SO o

s LR MR e

SR

3 – 4 EOM IV – sup obliqueVI – lateral rectusNormal response – PERRLA (isocoria – equal pupil)Anisocoria – unequal pupil

Oculomotor 1. Raising of eyelid – Ptosis2. Controls pupil size 2 -3 cm or 1.5 – 2 mm

V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex

Unconscious – instill drop of saline solutionMotor – controls muscles of chewing/ muscles of masticationTrigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended

Question: Trigeminal neuralgia, RN should give

a. Hot milk, butter, raisinsb. Cereals c. Gelatin, toast, potato – all correct butd. Potato, salad, gelatin – salad easier to chew

VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar. -Put applicator with sugar to tip to tongue. -Start of taste insensitivity: Age group – 40 yrs old

Motor- controls muscles of facial expression, smile frown, raise eyebrowDamage – Bells palsy – facial paralysis

Cause – bells palsy pedia – R/T forcep deliveryTemporary only

Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense) d.) Movement & orientation of body in spacee.) Organ of Corti – for hearing – true sense organ of hearing

Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumenMiddle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media

f.) Eustachean earInner ear- meniere dse, sensory hearing loss (research parts! & dse)Remove vestibule – meniere’s dse – disease inner ear

Archimedes law – buoyancy (pregnancy – fetus)Daltons law – partial pressure of gases Inertia – law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest

- Movement of air in & out of lungs is carried by what principle?- Diffusion – Dalton’s law

2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid- Archimedes

3.) Severe vertigo due- Inertia

Test for acoustic nerve:g.) Repeat words uttered

IX – Glossopharyngeal – controls taste – posterior 1/3 of tongueX – Vagus – controls gag reflex

Test 9 – 10Pt say ah – check uvula – should be midline Damage cerebral hemisphere is L or R Gag reflex – place tongue depression post part of tongue

i. Don’t touch uvula

XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)

h.) Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegiaXII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline

L or R deviation- Push tongue against cheek- Short frenulum lingue – Tongue tied – “bulol”