Shalom H. Jaco BSN MEDICAL SURGICAL

Overview of the Structures & Functions of Nervous SystemCentral NS PNS ANSBrain & spinal cord 31 spinal & cranial sympathetic NS

Parasypathatic NS

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

ANS (or adrenergic of parasympatholitic response)

SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)1. Dilate pupil – to aware of surroundings

Release of norepinephrine (adrenaline – cathecolamine) - medriasisAdrenal medulla (potent vasoconstrictor) 2. Dry mouthIncreases body activities VS = Increase 3. BP & HR= increasedExcept GIT – decrease GITmotility bronchioles dilated to take more oxygen

4. RR increased* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retentionIncrease blood flow to skeletal muscles, brain & heart.

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, Metopanolol

SE: 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)2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL3. Calcium antagonist

ex CALCIBLOC or NEFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)- 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 1. Mestinon 6. Urinary frequencyAntidote – anti cholinergic agents Atropine Sulfate – S/E – SNS S/E- of anti-hpn drugs:

1. orthostatic hpn2. transient headache & dizziness.

-Mgt. Rise slowly. Assist in ambulation.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 another

c. 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

DEMYELLENATING DSE 1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:A – amnesia – loss of memoryA – apraxia – unable to determine function & purpose of objectA – agnosia – unable to recognize familiar objectA – aphasia –

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

Common to Alzheimer – receptive aphasiaDrug 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: 0-15mmHgBrain mass

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

Rt cerebral hemisphere, Lt cerebral hemisphereFunction:

1. Sensory2. Motor3. Integrative

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 - vision5.) Insula/island of reil/ Central lobe- controls visceral fx

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

- Smell, libido, long-term memory

Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere- Extra pyramidal tract- Releases dopamine- - Controls gross voluntary unit

Decrease 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

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 decuissation 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 Hypothesis- Skull 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

B. S&Sx change in VS = always late symptomsEarliest Sx: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 EFFECT Decrease RR Increase RR Increase Temp Decrease temp

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 ICPHypoxia – inadequate tissue oxygenationLate symptoms of hypoxia – B – bradycardia

E – extreme restlessness D – dyspnea C – cyanosis

Early symptoms – R – restlessness A – agitation T – tachycardia

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

c. 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 environment

b. 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 & stooping

e. Avoid clustering of nursing activities7. 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 Mgt: 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)

S/E of Lasix Hypokalemia (normal K-3.5 – 5.5 meg/L)

S&Sx 1. Weakness & fatigue2. Constipation3. (+) “U” wave in ECG tracing

Nursing Mgt:1.) Administer K supplements – ex Kalium Durule, K chloride

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.Vit A – squash, carrots yellow vegetables & fruits, spinach, chesaIron – raisins, Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretionsDon’t give grapes – may choke

S/E of Lasix:1.) Hypokalemia2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:

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

Administer – Ca gluconate – IV slowly

Ca gluconate toxicity: Sx – seizure – administer Mg SO4Mg 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: tachycardiaMgt: force fluidAdminister isotonic fluid sol

4.) Hyperglycemia – increase blood sugar levelP – polyuriaP – polyphagiaP – polydipsia

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

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

Gouty arthritis kidney stones- renal colic (pain)Cool moist skin

Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritisa.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO)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.Kidney stones – renal colic (pain). Cool moist skinMgt:

1.) Force fluid2.) Meds – narcotic analgesic

Morphine SO4

SE of Morphine SO4 toxicityRespiratory 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 – digoxin .5 – 1.5 meq/L 2 cardiac glycosides CHFL - lithium .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 narcotic analgesic osteoarthritis

Digitalis – increase cardiac contraction = increase CO

Nursing Mgt1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)

Digitalis toxicity – antidote - Digivinea. Anorexia -initial sx.b. n/v GITc. 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, acetylcholineAntimanic agent

Lithium toxicityS/Sx -

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)

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 - c. Hot chocolate & tea – caffeine – CNS stimulant tachycardiad. Organ meat/ box cereals – anti parkinsonian

MAOI – antidepressantm AR plann AR dil can lead to CVA or hypertensive crisisp AR nate

3 – 4 weeks - before MAOI will take effect 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 i. Oral hygiene – soft toothbrush

ii. Massage gums H – hairy tongue A - ataxia N – nystagmus – abnormal movement of eyeballs

A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile ptsAcetaminophen toxicity :

1. Hepato toxicity2. Monitor liver enzymes

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

3. Monitor BUN (10 – 20)Crea (.8-1)

Acetaminophen toxicity can lead to hypoglycemia T – tremors, TachycardiaI – irritability

R – restlessnessE – extreme fatigueD – depression (nightmares) , Diaphoresis

Antidote for acetaminophen toxicity – 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 DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia

- Palliative, SupportiveFunction of dopamine: controls gross voluntary motors.

Predisposing Factors:1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA2. Hypoxia3. Arteriosclerosis4. Encephalitis

High doses of the ff:a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancerb. Methyldopa (aldomet) - promote safetyc. 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- Seborrhea (increase sebaceous gland)- Constipation- Decrease sexual activity

Nsg Mgt1.) Anti parkinsonian agents

- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)Mechanism of actionIncrease levels of dopa – relieving tremors & bradykinesia

S/E of anti parkinsonian- Anorexia- n/v- Confusion- Orthostatic hypotension- Hallucination- Arrhythmia

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 veg- Cause B6 reverses therapeutic effects of levodopa

Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.2.) Anti cholinergic agents – relieves tremors

Artane mech – inhibits acetylcholineCogentin action , S/E - SNS

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

Child – hyperactivity CNS excitement for kids. 4.) Dopamine agonist

Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR.

Nsg Mgt – Parkinson1.) 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 amCHON – 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 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. 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 Sx of MS

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

6. Urinary retention or incontinence7. Constipation8. 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.) Meds

a. Acute exacerbationACTH – adenocorticotopicSteroids – to reduce edema at the site of demyelination to prevent paralysis

Spinal Cord InjuryAdminister 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 responsed. Immunosuppresants

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

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

Nsg priority: 1) a/w 2) aspiration 3) immobility

S/ Sx: 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.

Dx test1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.

Nsg Mgt1. 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 Administer meds –

a.) Cholinergics or anticholinesterase agentsMestinon (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

Cause: 1 over medsS/Sx - PNS

2. Dysphagia- unable to swallow. 3. Unable to breath C Mgt – adm cholinergic agents Mgt. adm anti-cholinergic

- Atropine SO4- SNS – dry mouth

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- Disorder of CNS- Bilateral symmetrical polyneuritis- Ascending paralysisCause – 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 lacrimationConstipationDx 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

7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4 2. Corticosteroids – to suppress immune response 3. Anti arrhythmic agents

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

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

8. Assist in plasmaparesis (MG. GBS)9. Prevent comp – arrhythmias, respiratory arrest

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 – Meningococcus Pneumococcus Hemophilous influenza – child Streptococcus – adult meningitis

MOT – direct transmission via droplet nuclei

S&Sx - 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 seizureSx of meningeal irritation – nuchal rigidity or stiffness

Opisthotonus- rigid arching of back

Pathognomonic sign – (+) Kernig’s & Brudzinski sign

Leg pain neck pain

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

Aspirate CSF for lumbar puncture.Nsg Mgt for lumbar puncture – invasive

1. 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

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 tissue4. 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 WBCMgt:1. Adm meds

a.) Broad-spectrum antibiotic penicillinS/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 resp isolation 24h after start of antibiotic therapyA – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.B – Aplastic anemia – reverse isolation - due to bone marrow depression.C – Cancer anytype – 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 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 – 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

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

2.) Hemorrhage3.) 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 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

S & Sx 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 Resp

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 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

Dx 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 dyePost 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. MedsOsmotic diuretics – MannitolLoop diuretics – Lasix/ FurosemideCorticosteroids – dextamethazoneMild analgesicThrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.

StreptokinaseUrokinase

Tissue plasminogen activatingMonitor bleeding timeAnticoagulants – Heparin & Coumadin” sabay”

Coumadin will take effect after 3 daysHeparin – 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.

Health Teaching1. 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 FactorHead injury due birth traumaToxicity of carbon monoxideBrain tumorGeneticsNutritional & metabolic deficitPhysical stressSudden withdrawal to anticonvulsants will bring about status epilepticusStatus epilepticus – drug of choice: Diazepam & glucose

S & Sx 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 absent seizure.- Blank stare- Decrease blinking eye- Twitching of mouth- Loss of consciousness – 5 – 10 secs (quick & short)

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

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

Nsg MgtPriority – 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 Ginguial 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 assessment:1. Comprehensive neuro exam2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check

3 components of ECSM – motor 6V – verbal resp 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 – Romhberg, 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 stimulationQuestion: 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 assessment:I – 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 smellEither 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 – Snellens chart – central or distance visionSnellens E chart – used for illiterate chartN 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 – see page 85-87 for more info on glaucoma, etc.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 - Innervates the movementt of extrinsic ocular muscle

6 cardinal gaze EOM

Rt eye N left eyeIO SO O

SLR MR E SR

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

Oculomotor 1. Raising of eyelid – Ptosis

2. 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 givea. 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) - Movement & orientation of body in space- 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

- 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:- 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

Don’t touch uvula

XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia

XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midlineL or R deviation

- Push tongue against cheek- Short frenulum lingue – Tongue tied – “bulol”