Neuro Comprehensive Lect

8/8/2019 Neuro Comprehensive Lect

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NERVOUS SYSTEM


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Outline of Our ReviewBrief review of Anatomy and PhysiologyApplication of the Nursing process in theapproach of neurologic problems:

ASSESSMENT relevant techniques and labproceduresDIAGNOSISPLANNINGIMPLEMENTATIONEVALUATION


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Outline of the review

Trauma and related accidents

Traumatic brain injurySpinal cord injury

Cerebrovascular Accidents


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Outline of the reviewDegenerative disorders-demyelinating

Multiple sclerosisGuillain-Barre syndrome

Degenerative disorders-NON- demyelinating

Alzheimers diseaseParkinsons disease


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Outline of the reviewMotor dysfunction- CNS

Epilepsy

Motor dysfunction- cranial nerveBells palsyTrigeminal neuralgia

Motor dysfunction- peripheralMyasthenia gravis


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Outline of the reviewInfectious Disease

Meningitis

Brain abscessEncephalitis

Neoplastic disease


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F UNCTIONS O F THE NERVOUS

SYSTEMSensory InputIntegration

HomeostasisMental ActivityControl of muscles and glands


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Nervous system

PNS CNS

BRAINSPINAL CORDEFFERENT AFFERENT

somatic

autonomic

somatic

visceral

sympa parasympa


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Divisions of the Nervous

SystemCentral Nervous System consists of thebrain and spinal cordPeripheral Nervous System consists of nerves and ganglia

Two Subdivisions of PNS:1. Sensory Divisions conducts action

potentials from sensory receptors to the

CNS2. Motor Division conducts action potentials

from the CNS to effector organs


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Motor DivisionSomatic Motor Nervous System transmit action potentials from the

CNS to skeletal musclesAutonomic Nervous System (ANS) transmits action potentials from theCNS to cardiac muscle, smoothmuscle and glands; subdivided intosympathetic, parasympathetic andenteric portions


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G roomp!G roomp!

Psst!


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0

Hmmm?

stimulus


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Cells of the Nervous System

Neurons or nerve cells receive stimuli and transmitaction potentials to other neurons or to effectororgansParts of Neuron:

1. Cell body contains a single nucleus which is thesource of information for protein synthesis; containsextensive rough ER (Nissl bodies), Golgi apparatus,mitochondria, neurofilaments and microtubules

2. Dendrites short, often highly branching cytoplasmicextensions that are tapered from their bases at the

neuron cell body to their tips; function to receiveinformation from other neurons or sensory receptorsand transmit the information toward the neuron cellbody


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Parts of Neuron

Axon a long cell process extendingfrom the neuron cell body; axon of motor neurons conduct actionpotentials away from the CNS andaxon of sensory neurons conductaction potentials toward the CNS;could also conduct action potentialsfrom one part of the brain or spinalcord to another part; surrounded bySchwann cells

Axon


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U NIPOLAR


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Bipolar


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Multipolar


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NeurogliaAlso known as glial cellsAre nonneuronal cells of the CNS and PNSRetain the ability to divideF ive types of Neuroglia:

1. Astrocytes star-shaped; providestructural support; form a layer aroundblood vessels, contribute to blood-brain

barrier2. Ependymal cells squamous epithelial-

like; line ventricles of brain, circulatecerebrospinal fluid (CS F ); some formchoroid plexus which produce CS F


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Types of Neuroglia3. Microglia small mobile cells; protect CNS from

infection; become phagocytic in response toinflammation

4. Oligodendrocytes cells with processes that can

surround several axons; cell processes form myelinsheaths around axons, or enclose unmyelinatedaxons, I the CNS

5. Schwann cells or Neurolemmocytes/neurolemmacells; single cells surrounding axons; form myelinsheaths around axons, or enclose unmyelinated axonsin the PNS


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Myelin SheathsUnmyelinated axons rest in indentationsof the oligodendrocytes in the CNS and theSchwann cells in PNS

Myelinated axons have specializedsheaths, called myelin sheaths wrappedaround themMyelin is an excellent insulator, whichprevents almost all electrical current flowthrough the cell membraneNodes of Ranvier gaps in myelin sheath;current flows easily between theextracellular fluid and the axon, and actionpotentials can develop


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Organization of Nervous TissueGray matter groups of neuron cell bodies and theirdendrites where there is very little myelinCortex gray matter on the surface of the brainNuclei clusters of gray matter located deeper within

the brainGanglion cluster of neuron cell bodies in the PNSWhite matter whitish, bundle of parallel axons withtheir myelin sheathsPathways or Nerve tracts white matter of the CNSwhich propagate action potentials from one area inthe CNS to anotherNerves bundles of axons and their connective tissue


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Resting Membrane PotentialCharge difference across the membrane of anunstimulated cell or polarized cellResults from differences in the concentration of ionsacross the cell membrane and the permeabilitycharacteristics of the cell membraneHigher concentration of sodium ions immediatelyoutside the cell membrane than inside and a higherconcentration of potassium ions immediately insidethe cell membrane than outsideConcentration of ions are maintained by sodium-potassium exchange pumpPoint of equilibrium is when potassium stops movingout of the cell


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Na

Na

Na

Charged


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Action PotentialsConsists of depolarization and repolarizationLocal current movement of sodium into a cellDepolarization sodium influx cause the inside of thecell membrane to become more positive; results to

local potentialThreshold valueAll-or-none if threshold is reached, the chargereversal is completeSaltatory conduction flow of action potential in a

jumping manner

Medium-diameter, lightly myelinated axons conductaction potentials at the rate of about 3-15 m/swhereas large-diameter, heavily myelinated axonsconduct action potentials at the rate of 15-120 m/s


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How does it happen

At rest, the inside of the neuron isslightly negative due to a higherconcentration of positively chargedsodium ions outside the neuron.


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When stimulated past threshold, sodiumchannels open and sodium rushes intothe axon, causing a region of positivecharge within the axon.


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nearby sodium channels to open. Justafter the sodium channels close, the

potassium channels open wide, andpotassium exits the axon.


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This process continues as a chain-reaction along the axon. The influx of sodium depolarizes the axon, and theourflow of potassium repolarizes the axon


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The SynapseSynapse a junction where the axonof one neuron interacts with anotherneuron or an effector organPresynaptic terminalPostsynaptic membraneSynaptic cleft

Synaptic vesicleNeurotransmitters


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acetylcholine Acetylcholinesterase


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choline acetate

acethylcholine


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F ive Basic Components of aReflex Arc

Sensory ReceptorSensory Neuron

InterneuronsMotor NeuronEffector Organ


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Central Nervous SystemSPINAL CORD extends from the foramenmagnum at the base of the skull to thesecond lumbar vertebraCross section reveals a peripheral whitematter portion and a central gray matterportionThree columns of white matter dorsal,ventral and lateralAscending tracts consists of axons thatconduct action potentials toward the brainDescending tracts consists of axons thatconduct action potential away from thebrain


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Gray matter

Shaped like letter HPosterior, Anterior and lateral horns

Central canal a fluid-filled space inthe center of the cord


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Spinal Nerves

Ventral root formed by combinationof ventral rootlets arising from theventral side of the spinal cordDorsal root formed by combinationof dorsal rootlets on the dorsal side of the cord; contains dorsal root

ganglionDorsal root ganglion - contains thecell bodies of unipolar sensoryneurons


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Spinal Cord ReflexesStretch reflex a reflex in which musclescontract in response to a stretching forceapplied to themKnee-jerk reflex used to determine if thehigher CNS centers that normally influencethis reflex are functionalDescending neurons within the spinal cordsynapse with the neurons of the stretchreflex and modulate their activity; activityis important in maintaining posture and incoordinating muscular activity


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Withdrawal Reflex

Withdrawal or F lexor reflex thefunction is to remove a limb or otherbody part from a painful stimulusPain receptors stimulated actionpotential conducted through thedorsal root to the spinal cord

synapse with interneuron synapsewith motor neurons flexing of muscle


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Spinal NervesArise along the spinal cord from the unionof the dorsal roots and the dorsal roots;mixed nervesCategorized by the region of the vertebralcolumn from which they emerge cervical(C), thoracic (T), lumbar (L), sacral (S),and coccygeal (Cx)31 pairs of spinal nerves C1-C8, T1-T12,L1-L5, S1-S5 and CoThree plexuses: Cervical plexus, Brachialplexus and the lumbosacral plexus


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1. Brainstem

- connects the spinal cord to theremainder of the brain

Consists of the medulla oblongata,pons and midbrain and containsseveral nuclei

Majority of the cranial nerves arisein brainstem except CN 1 and 2


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a. Medulla OblongataMost inferior portion of the brainstem and iscontinuous with spinal cordContains ascending and descending tracts with somenuclei with specific functions such as regulation of

heart rate and blood vessel diameter, breathing,swallowing, vomiting, coughing, sneezing, balanceand coordinationPyramids prominent enlargements consisting of descending tracts, which transmit action potentialsfrom the brain to motor neurons of the spinal cordand are involved in the conscious control of skeletalmuscles


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b. Pons

Means bridge; located superior to themedulla oblongata

Contains ascending and descendingnerve tracts and several nucleiNuclei are responsible for breathing,swallowing, balance, chewing andsalivation


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2. Cerebellum

Means little brainAttached to the brainstem bycerebellar pedunclesConnections provide routes of communication between thecerebellum and other parts of theCNS


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3. Diencephalon

The part of the brain between thebrainstem and the cerebrumMain components are the thalamus,epithalamus and hypothalamus


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a. Thalamus

The largest part of the diencephalonConsists of a cluster of nuclei withtwo large lateral parts connected inthe center by a small interthalamicadhesionsInfluences mood and registers an

unlocalized, uncomfortable perceptionof pain


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b. EpithalamusA small area superior and posterior to thethalamusConsists of a few small nuclei that are

involved in the emotional and visceralresponse to odors and the pineal bodyPineal body an endocrine gland that mayinfluence the onset of puberty; play a rolein controlling some long-term cycles thatare influenced by the light-dark cycleKnown to influence annual behaviors suchas migration in birds as well as changes infur color and density in some mammals


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c. HypothalamusMost inferior part of the diencephalon and containsseveral small nuclei which are very important inhomeostasisPlay a central role in the control of body temperature,

hunger and thirst; also sexual pleasure, feelingrelaxed and good after meal, rage and fear; plays amajor role in controlling the secretion of hormonesfrom the pituitary glandContains the infundibulum and mamillary bodyMamillary body is involved in emotional responses toodors and in memory


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4. CerebrumThe largest part of the brainDivided into right and left hemispheres by alongitudinal fissureContains gyri which greatly increase the surface areaof the cortex and intervening grooves called sulciCerebral hemispheres are divided into lobes namedfor the skull bones overlying themF rontal lobe control of voluntary motor functions,motivation, aggression, mood and olfactoryperceptionParietal lobe principal center for the reception andconscious perception of most sensory informationsuch as touch, pain, temperature, balance and tasteCentral sulcus separates frontal and parietal lobes


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CerebrumOccipital lobe functions in the receptionand perception of visual input and is notdistinctly separate from the other lobesTemporal lobe involved in olfactory andauditory sensations and plays an importantrole in memoryPsychic cortex consists of the anterior andinferior portions of temporal lobe which isinvolved in abstract thought and judgmentLateral fissure separates temporal lobefrom cerebrum


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Brain circulation: The circle of

Willis


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The spinal cord

A long cylindrical structure

extending from the foramenmagnum to the L1 in adult,L3/L4 in pedia


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The spinal cord

Each spinal nerve is formed by thedorsal root (sensory) and the

ventral root (motor)Cervical segments= 8 pairsThoracic segments=12 pairs

Lumbar= 5 pairsSacral=5 pairsCoccygeal=1 pair


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The Meninges

1. DURA MATER- the superficial,thickest layer. The area above thedura mater is called epidural space2. ARACHNOID- second layer, thinand wispy.3. PIA MATER- the deepest layer,adhered to the brain and spinal cordsubstance


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The CS F

This is the fluid found inside theventricles that bathe the brain and

spinal cordF unction: provides protective cushionaround the CNS

Produced by the choroid plexus in theventriclesAbsorbed by the arachnoid

granulations


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ASSESSMENT OF THE


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ASSESSMENT OF THENEUROLOGIC SYSTEM

HISTORYA co nfused cl ient b e co mes an unre lia bl e s o ur c e o f h ist o ry

ASSESSMENT OF THE


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ASSESSMENT OF THENEUROLOGIC SYSTEM

N eur o-PHYSICAL EXAMINATION5 categories:

1. C ere b ra l fun c ti o n - LOC, menta lstatus

2 . C rania l nerves

3 . Mo t o r fun c ti o n4 . S ens o ry fun c ti o n5 . R ef lexes


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CERE BRAL FUNCTION

Assess t h e degree o f w akefu lness/a lertness

No te t h e intensity o f stimu lus t oc ause a resp o nseApp ly a painfu l stimu lus o ver t h e nai l-b eds w it h a bl unt instrumentA sk questions to assess orientation to

person, place and time


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Gl asg ow Co ma Sc a le

Gl a sgow Com a Score

Ey e Opening ( E)Verb a l Response ( V)

Motor Response ( M)


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7 a nd Be low= CO MA!


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Eye Opening (E)4 =Spont a neous3 =To voice (when to ld to )

2 =To p a in1 =None (No response)


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Gl asg ow Co ma Sc a leGl a sgow Com a ScoreV erbal Response ( V )

5=Norm a

l/ORIENTED4 =Disoriented /CONFUSED

3 =Words, but incoherent/ INAPPROPRIATE 2 =INCOMPREHENSIBLE /mumb led words

1 =None


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Gl a sgow Com a ScoreMotor Response ( M)

6 =Norm a l- obe ys comm a nd5 =Loc a lizes p a in4 =Withdr a ws to p a in (Flexion)

3 =Decortic a te posture2 =Decerebr a te posture1 =None (f la ccid )


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Level of consciousness

Awake/alertDrowsy sleepy, wake ups and staysawake for longLethargic/Stuporous sleepy, wakesup and goes back to sleepComatose


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Crania l N erve 1- Ol fa c t o ry

Ch e c k first f o r t h e paten c y o f t h e n o se

I nstru c t t o clo se t h e eyesOccl ude o ne n o stri ls at a timeHol d fami liar su b stan c e and asks f o r

t h e identifi c ati o nR epeat w it h t h e o t h er n o stri lsPRO BLEM- ANO SMI A- lo ss o f sme ll


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Crania l N erve 2 - O pti c

Ch e c k t h e visua l a c uity w it h t h e use o f t h e Snellen chart

Ch e c k f o r visua l fie ld b y co nfr o ntati o n testCh e c k f o r pupi ll ary ref lex - dire c t and co nsensua lFund o s co py t o ch e c k f o r papi ll edema


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S ne ll en ch art


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Crania l N erve 7 - fa c ia l

S ens o ry p o rti o n - prepare sa lt , sugar ,vinegar and q uinine . Pl a c e ea ch

su b stan c e in t h e anteri o r t wo t h irds o f t h e t o ngue , rinsing t h e m o ut hw it h w aterMo t o r p o rti o n - ask t h e cl ient t omake fa c ia l expressi o ns , ask t of o r c efu ll y clo se t h e eye lids


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N erve 8- vesti b u lo- audit o ry

Test patients hearing a c uityOb serve f o r nystagmus and distur b ed b a lan c e


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N erve 9- g lo ss o p h aryngea l

T ogether with Cranial nerve 10 vagus

Assess f o r gag ref lexWat ch t h e s o ft pa late rising after instru c ting t h e cl ient t o say AH

Th e p o steri o r o ne - t h ird o f t h e t o ngue is supp lied b y t h e g lo ss o-p h aryngea l nerve


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Crania l N erve 11- a cc ess o ry

P ress d ow n t h e patients s ho u lder wh ile h e attempts t o s h rug against resistan c e


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ASSESS Mo t o r fun c ti o n

Assess mus cl e t o ne and strengt hb y asking patient t o f lex o r extend t h e extremities wh ile t h e examiner p la c es resistan c eGrading o f mus cl e strengt h

Assessing t h e m o t o r


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fun c ti o n o f t h e c ere b e ll um

Test f o r b a lan c e - h ee l t o t o eTest f o r coo rdinati o n - rapid a lternating m o vements and finger t o n o se test

R O MBERGs is actually a test for

the posterior spinothalamic tract


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fun c ti o n o f t h e b rainstem

Test f o r t h e Oc u loc ep h a lic ref lex -d oll s eye

No rma l resp o nse - eyes appear t om o ve o pp o site t o t h e m o vement o f t h e h eadAb n o rma l- eyes m o ve in t h e same dire c ti o n



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fun c ti o n o f t h e b rainstem

Test f o r t h e Oc u lo vesti b u lar ref lex

Slowl y irrigate t h e ear w it h col d w ater and w arm w ater

No rma l resp o nse - cOl d - O pp O site ,wA r M- s AM e

Assessing t h e sens o ry


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fun c ti o n

Eva luate symmetri c areas o f t h e bo dyAsk t h e patient t o clo se t h e eyes wh ile testing

U se o f test tu b es w it h col d and w arm w aterU se bl unt and s h arp obj e c tsU se w isp o f co tt o nAsk t o identify obj e c ts p la c ed o n t h e h andsTest f o r sense o f p o siti o n


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Assessing t h e ref lexes

Deep tend o n ref lexesBi c eps

Tri c epsBra ch io radia lisP ate ll arAssessing t h e sens o ry fun c ti o n Ach ill es


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Assessing t h e ref lexes

S uperfi c ia l ref lexesAb d o mina lAna lCremasteri c

P at holo gi c ref lexBa b inski - str o ke t h e latera l aspe c t o f t h e s ol es d o ing an inverted J

(+)- D ORSIFLEXION o f t h e Big t o e w it hfanning o ut o f t h e litt le t o es


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G rading o f ref lexesDeep tend o n ref lex

0 - a b sent+ present b ut diminis h ed++ n o rma l+++ in c reased++++ h ypera c tive o r clo ni c

S uperfi c ia l ref lex0 a b sent+ present


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Wala Lang Relax lang


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D IAGNOSTIC TESTS

EEGWit hhol d medi c ati o ns t h at may interfere w it h t h e resu lts -

anti co nvu lsants , sedatives and stimu lantsWas h h air t ho r o ug hl y b ef o re pr oc edure


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F ig . 8. 33


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D IAGNOSTIC TESTS

CT s c anWit h radiati o n riskI f co ntrast medium w ill b e used -ensure co nsent , assess f o r a ll ergies t o dyes and io dine o r seaf oo d , f lus h ing and meta ll ic

taste are expe c ted as t h e dye is in j e c ted


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D IAGNOSTIC TESTS

MRIUses magneti c w avesP atients w it h pa c emakers ,o rt ho pedi c meta l pr o st h esis and imp lanted meta l devi c es c ann o t underg o t h is pr oc edure


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D IAGNOSTIC TESTS

Cere b ra l arteri o grap h yNo te a ll ergies t o dyes , io dine and seaf oo dEnsure co nsentKeep patient at rest after pr oc edure

Maintain pressure dressing o r sand b ag o ver pun c tured site


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D IAGNOSTIC TESTS

Lum b ar pun c tureEnsure co nsent , determine a b ility t o

lie sti llCo ntraindi c ated in patients w it hin c reased ICPKeep f lat o n b ed after pr oc edureI n c rease f luid intake after pr oc edure


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I n c reased I ntra c rania l


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pressure

I ntra c rania l pressure morethan 15 mmHg

Brunner= N ormal

intracranial pressure 10 -2 0mmHg



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pressure

Causes:H ead in j ury

S tr o keI nf lammat o ry lesi o nsBrain tum o rS urgi c a l co mp lic ati o ns



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pressure

P at ho p h ysi olo gyTh e c ranium o n ly co ntains

t h e b rain su b stan c et h e CSF

t h e bloo d/ bloo d vesse ls



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pressure

P at ho p h ysi olo gyM ON R O-K ELLIE hypothesis - an

in c rease in any o ne o f t h e co mp o nents c auses a ch ange in t h e v ol ume o f t h e o t h erAny in c rease o r a lterati o n in t h ese stru c tures w ill c ause in c reased ICP



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pressure

P at ho p h ysi olo gy

Co mpensat o ry me ch anisms:

1. I n c reased CSF a b sorption2 . B loo d s h unting blood

3 . De c reased CSF production production



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pressure

P at ho p h ysi olo gyD ecompensatory mechanisms

1. De c reased c ere b ra l perfusi o n2 . De c reased PO 2 hypoxia3 . C ere b ra l edema

4 . Brain herniation

De c reased c ere b ra l bloo d f lo


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f low

V asomotor reflexes are stimulated initially slow b ounding pulses

I n c reased co n c entrati o n o f c ar bo n di o xide w ill c ause VASO D ILATIONin c reased f low increased ICP

Cere b ra l resp o nse t oin c reased ICP


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in c reased ICP

1. Steady perfusion up to 40mmHg

2 . Cushings responseVas o m o t o r c enter triggers rise in BP t o in c rease ICP

( HYPER T E N SI ON)S ympat h eti c resp o nse is in c reased BP b ut t h e h eart rate is SLO WR espirati o n b e co mes SLO W

I n c reased I ntra c rania lpressure


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pressure

CLINICAL MANIFESTATIONSEarly manifestations :

Changes in the L O C - usually theearliest P upi ll ary ch anges - fixed , s low ed resp o nse

H eada ch eVo miting



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pressure

CLINICAL MANIFESTATIONSlate manifestations

Cushing reflex - systolic hypertension, b radycardia and wide

pulse pressureb radypneaH ypert h ermiaAb n o rma l p o sturing



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pressure

N ursing interventionsN ursing interventions1 . Maintain patent airway

2 . Elevate the head of the b ed 15 -3 0degrees - to promote venous drainageto promote venous drainage

3 . A ssists in administering 100%oxygen o r co ntr oll ed h yperventi lati o n - t o redu c e t h e CO 2 bloo d leve ls co nstri c ts bloo d vesse ls redu c es edema


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pressure

N ursing interventi o ns5 . R edu c e envir o nmenta l stimu li

6. A v o id a c tivities t h at c an in c rease ICP l ike va lsa lva , co ug h ing ,s h ivering , and vig o r o us su c ti o ning



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pressure

N ursing interventi o ns7. Keep h ead o n a neutra l p o siti o n .

AVOI D - extreme f lexi o n , va lsa lva

8. Mo nit o r f o r se co ndary co mp lic ati o ns

Dia b etes insipidus - o utput o f > 200 m L/ h r



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pressure

HEA D SH= HO B e levate

E= E va luate ICPA=A ir w ay maintainD = Drainage pr o m o te

S= S afety ensure


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Al tered leve l o f co ns c io usness


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I t is a fun c ti o n and sympt o m o f mu ltip le pat ho p h ysi olo gi cp h en o mena

Disrupti o n in t h e neur o na ltransmissi o n resu lts t o impr o per fun c ti o n


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co ns c io usness

Eti olo gi c F a c t o rs1. H ead in j ury

2 . S tr o ke3 . Drug o verd o se4 . Alcohol ic int o xi c ati o n

5 . Dia b eti c ket o a c id o sis6. H epati c fai lure



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co ns c io usness

AssessmentO rientati o n t o time , p la c e and

pers o nMo t o r fun c ti o n

De c ere b rateDe co rti c ate

S ens o ry fun c ti o n


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co ns c io usness

ASSESSMENT1. Be h avi o ra l ch anges initia ll y

2 . P upi ls are s lowl y rea c tive 3 . Th en , patient b e co mes

unresp o nsive and pupi ls b e co me fixed di latedGl asg ow Co ma Sc a le is uti lized



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co ns c io usness

N ursing I nterventi o n1. Maintain patent airway

El evate t h e h ead o f t h e b ed t o 3 0 degreesS u c ti o ning

2 . Protect the patient P ad side rai ls

P revent in j ury fr o m e q uipments , restraints and et c.



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co ns c io usness

N ursing I nterventi o n3 . Maintain fluid and nutritional

b alanceI nput an o utput m o nit o ringIVF t h erapyFeeding t h r o ug h NGT

4. Provide mouth careCl eansing and rinsing o f m o ut hP etr ol atum o n t h e lips



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co ns c io usness

N ursing I nterventi o n5. Maintain skin integrity

R egu lar turning every 2 ho urs30 degrees b ed e levati o nMaintain co rre c t bo dy a lignment b y using tr och anter r oll s , f oo t bo ard

6 . Preserve corneal integrity U se o f artifi c ia l tears every 2 ho urs



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co ns c io usness

N ursing I nterventi o n7 . Achieve thermoregulation

M inimum am o unt o f b eddingsR e c ta l o r tympani c temperatureAdminister a c etamin o p h en as pres c ri b ed

8 . Prevent urinary retention

U se o f intermittent c at h eterizati o n


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SEIZURES


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SEIZURES

Epis o des o f a b n o rma l m o t o r ,sens o ry , aut o n o mi c a c tivity resu lting fr o m sudden ex c essive dis ch arge fr o m c ere b ra l neur o ns

A part o r a ll o f t h e b rain may b e inv ol ved

SEIZURES


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SEIZURES

PATHOPHYSIOLOGYAn e le c tri c a l distur b an c e in t h e

nerve c e ll s in o ne b rain se c ti o nEMI T S ELEC T RIC AL IMP U LSES excessively


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EPILEPSY


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A gr o up o f syndr o mes ch ara c terized b y re c urring seizures

CAUSES1. idi o pat h ic 6. b rain tum o rs2 . Birt h trauma 7. h ead I n j ury3 . perinata l infe c ti o n 8. meta bol ic ds o

4 . infe c ti o us disease 9. CVA5 . ingesti o n o f t o xins


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EPILEPSY


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Recurring seizures may be classifiedas GENERALIZED or PARTIALSEIZURES

Generalized Seizures- cause ageneralized electrical abnormalitywithin the brainPartial seizures- these seizures arise

from a localized part of the brain andcause specific symptoms

GENERALIZED SEIZURES


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1. General Tonic-Clonic seizure-( Grand mal ) characterized by loss of consciousness and alternating

movements of the extremities2. Absence Seizure ( Petit mal )-common in children, begins with abrief change in the LOC, indicated byblinking, rolling of eyes and blankstares


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PARTIAL SEIZURES


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1. Simple partial seizure- typicallylimited to one cerebral hemisphere2. Complex partial seizure- begins

with an aura, then with impairedconsciousness, with purposelessbehaviors like lip-smacking, chewingmovements

Epilepsy


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p p y

DIAGNOSTIC TESTS1. EEG2. CT3. MRI4. Lumbar P5. Angiography


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Epilepsy


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p p y

Nursing Interventions1. Care of patients during seizure2. care of patients after seizures3. patient teaching

SEIZURES and Epi lepsy


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N ursing Interventions: During seizure1. rem o ve h armfu l obj e c ts fr o m t h e

patients surr o unding2 . ease t h e cl ient t o t h e f loo r3 . pr o te c t t h e h ead w it h pi llow s4 . Ob serve and n o te f o r t h e durati o n , parts o f bo dy affe c ted ,b e h avi o rs b ef o re and after t h e seizure

SEIZURES and epi lepsy


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N ursing I nterventi o ns During seizure5 . loo sen co nstri c tive clo t h ing

6. D O NOT restrain , o r attempt t op la c e t o ngue bl ade o r insert o ra lair w ay

SEIZURES and epi lepsy


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N ursing I nterventi o ns: POST seizure1. p la c e patient t o t h e side t o drain

se c reti o ns and prevent aspirati o n2 . h e lp re -o rient t h e patient if co nfused3 . pr o vide c are if patient b e c ame

in co ntinent during t h e seizure atta c k4 . stress imp o rtan c e o f medi c ati o n

regimen


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S pina l Shoc k


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Th e sudden depressi o n o f ref lex a c tivity in t h e spina l co rd b e low t h e leve l o f in j ury

S pina l Shoc k


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P at ho p h ysi olo gy: Lo ss o f SC fun c ti o n T he muscles b elow the lesion areflaccid,the skin without sensationthe reflexes are a b sent includingb owel and b ladder functions

S pina l Shoc k


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N ursing I nterventi o ns1. S upp o rtive measures

2 . A ssist in Ch est p h ysi c a l t h erapy ,bow e l and bl adder e liminati o n 3 . M anage p o tentia l co mp lic ati o n -D VT


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Aut o n o mi c Dysref lexia


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S een co mm o n ly in spina l co rd in j ury a b ove T6

O ccurs SE V ER AL weeks after spinal cord injury


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Aut o n o mi cDysref lexia/ h yperref lexia


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Cl ini c a l MANIFESTATIONSArea a bo ve w ill VASO D ILATE

Area b e low w ill VASOCONSTRICT

Aut o n o mi cDysref lexia/ h yperref lexia


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NURSING INTERVENTIONS1. Elevate the head of the b ed immediately 2 . Ch e c k f o r bl adder distenti o n and empty

bl adder w it h urinary c at h eter3 . Ch e c k f o r Fe c a l impa c ti o n and o t h er

triggering fa c t o rs like skin irritati o n ,pressure u lc er

4 . A dminister anti h ypertensive medi c ati o ns - usua ll y h ydra lazine

Co gnitive I mpairment


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N ursing I nterventi o ns1. Assist o r en co urage t h e patient t o

use eyeg lass , h earing aid o r assistive devi c es

2 . R e o rient t h e patient b y c a ll ing h is name fre q uent ly

3 . P r o vide b a c kgr o und inf o rmati o n as t o date , time , p la c e , envir o nment

Co gnitive I mpairment


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N ursing I nterventi o ns4 . U se large signs as visua l c ues

5 . Po st patient's p ho t o o n t h e d oo r6. E n co urage fami ly mem b ers t o b ring

pers o na l arti cl es and p la c e t h em in t h e same area


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Bow e l and B ladder in co ntinen c e


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Bladder training b y esta bl is h ing a s ch edu le f o r urinati o n I n t h e ho spita l intermittent c at h eterizati o nAt ho me SELF-c at h eterizati o n

I mpaired Sw a llow ing


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Elevate the head of the b e 9 0degrees during meals and 3 0minutes after S erve f oo ds t h at are s o ft and sma llsizedKeep su c ti o n e q uipment o n b edside

Co nsu lt w it h re h a b ilitati o n team as t o assistive devi c es t h at c an b e uti lized

In summary


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I nterventi o ns f o r Cere b ra lFun c ti o n

Maintain ne c k mid line , neutra l

1 5 - 30 degrees e levati o nS upp lementa l o xygenMedi c ati o ns like mannit ol and ster o ids


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Traumati c b rain in j ury


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1. CONCUSSIONI nv ol ves j arring o f h ead w it ho ut tissue in j uryTemp o rary lo ss o f neur olo gi cfun c ti o n lasting f o re a fe wminutes t o ho urs


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2 . CONTUSIONI nv ol ves stru c tura l damage

Th e patient b e co mes un co ns c io us f o r ho urs


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3 . I ntra c rania l h em o rr h age

Epidura l h emat o ma

S u b dura l h emat o ma

I ntra -c ere b ra l h em o rr h age


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3 . I ntra c rania l h em o rr h ageI ntra c ere b ra l H em o rr h ageB leeding int o t h e su b stan c e o f t h e b rain

resu lting fr o m trauma , h ypertensive rupture of aneurysm , co agu lo pa h ties ,vas c u lar a b n o rma litiesS ympt o ms deve lo p insidi o us ly ,b eginning w it h severe h eada ch e and neur olo gi c defi c its


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M AN IFES TAT I ON S of b rain injury 1. Al tered LOC

2 . CSF o t o rr h ea3 . CSF r h in o rr h ea4 . R a coo n eyes and b att le sign

H ALO SIG N- b lood stain surrounded b y a yellowish stain



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NURSING MANAGEMENT1. Mo nit o r f o r de cl ining LOC- use o f

Gl asg ow

2 . Maintain patent airway El evate b ed , su c ti o n prn , m o nit o r ABG



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NURSING MANAGEMENT3 . Mo nit o r F and E b a lan c e

Dai ly w eig h tsIVF t h erapyMo nit o r p o ssi bl e deve lo pment o f D Iand SIA D H


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7. Mo nit o r p o tentia l co mp lic ati o nsI n c reased ICP

Po st - traumati c seizuresI mpaired venti lati o n


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S pina l co rd in j ury


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Cl ini c a l manifestati o ns1. P arap legia2 . q uadrip legia

3 . spina l s hoc k


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NURSING INTERVENTION1. P r o m o te ade q uate b reat h ing and air w ay cl earan c e2 . I mpr o ve m ob ility and pr o per bo dy a lignment3 . P r o m o te adaptati o n t o sens o ry and per c eptua l a lterati o ns4 . M aintain skin integrity



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5 . M aintain urinary e liminati o n6. I mpr o ve bow e l fun c ti o n7. P r o vide Co mf o rt measures8. Mo nit o r and manage co mp lic ati o ns

Th r o m bo p le bh itisO rt ho stai c h yp o tensi o nS pina l s hoc kAut o n o mi c dysref lexia



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9. A ssists w it h surgi c a l redu c ti o n and sta b ilizati o n o f c ervi c a lverte b ra l col umn


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CERE BROVASCULAR ACCI D ENTS


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An um b re ll a term t h at refers t o any fun c ti o na l a b n o rma lity

o f t h e CNS re lated t odisrupted bloo d supp ly



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Can b e divided int o t wo ma jo r c ateg o ries1. Ischemic stroke - c aused b y t h r o m b us and em bol us2 . Hemorrhagic stroke - c aused co mm o n ly b y h ypertensive bl eeding


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Th t k ti


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Th e str o ke co ntinuum1. TIA- transient is ch emi c atta c k ,temp o rary neur olo gi c lo ss less

than 2 4 hours duration2 . R eversi bl e N eur olo gi c defi c its3 . S tr o ke in ev ol uti o n

4 . Co mp leted str o ke

Genera l manifestati o ns


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Loc a lizati o n

Midd l b l t


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Midd le c ere b ra l artery:A phasiaD ysphagia

HEMIP ARESIS on the O PP O SI T E side - more severe on the face and arm than on the legs

Loc a lizati o n

Anteri o r c ere b ra l arter :


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Anteri o r c ere b ra l artery:WeaknessN um b ness o n t h e o pp o site side

P ers o na lity ch angesI mpaired m o t o r and sens o ry fun c ti o n

Loc a lizati o n

Po steri o r c ere b ra l artery:


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Po steri o r c ere b ra l artery:Visua l fie ld defe c tsS ens o ry impairment

Co maLess like ly para lysis


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RIS KS FACTORS

No n m o difia bl e


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No n - m o difia bl eAdvan c ed ageGenderra c e

Mo difia bl eH ypertensi o nCardi o disease

Ob esityS m o kingDia b etes me ll itush yper chol ester ol emia

P at ho p h ysi olo gy o f str o ke


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Disrupti o n o f bloo d supp ly

Anaer ob ic meta bol ism ensues

De c reased ATP pr o du c ti o n leads t o impaired mem b rane fun c ti o n

Ce ll u lar in j ury and deat h c an occ ur

CERE BROVASCULAR ACCI D ENTS : S tr o ke

D IAGNOSTIC test


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D IAGNOSTIC test1. CT s c an2 . MRI

3 . A ngi o grap h y


CLINICAL MANIFESTATIONS


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CLINICAL MANIFESTATIONS1. N um b ness o r w eakness2 . co nfusi o n o r ch ange o f LOC

3 . m o t o r and spee ch diffi c u lties4 . V isua l distur b an c e5 . S evere h eada ch e


Mo t o r Lo ss


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Mo t o r Lo ssH emip legiaH emiparesis



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Co mmuni c ati o n lo ssDysart h ria = diffi c u lty in speakingAp h asia = Lo ss o f spee chApraxia = ina b ility t o perf o rm a previ o us ly learned a c ti o n



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P er c eptua l distur b an c esH emian o psia

S ens o ry lo ssparest h esia



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NURSING INTERVENTIONS : ACUTE1. Ensure patent air w ay2 . Keep patient o n L AT ER AL position3 . Mo nit o r VS and GCS, pupi l size4 . IVF is o rdered b ut given w it h c auti o n as

n o t t o in c rease ICP5 . NGT inserted6. Medi c ati o ns: S ter o ids , M annit ol ( t o

de c rease edema ), Diazepam


NURSING INTERVENTIONS H i l


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NURSING INTERVENTIONS : Ho spita l1. I mpr o ve Mob ility and prevent jo int

def o rmities

Correctly position patient to prevent contractures

Place pillow under axillaHand is placed in slight supination - C Change position every 2 hours


NURSING INTERVENTIONS


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NURSING INTERVENTIONS2 . E n h an c e se lf -c are

Carry out activities on theunaffected sideP revent uni latera l neg le c t - p la c e s o me items o n t h e affe c ted side!!!Keep envir o nment o rganizedUse large mirr o r



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NURSING INTERVENTIONS3 . M anage sens o ry - per c eptua l

diffi c u ltiesA pproach patient on the U naffected

sideEn co urage t o turn t h e h ead t o t h e

affe c ted side t o co mpensate f o r visua l lo ss




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NURSING INTERVENTIONS4 . M anage dysp h agia

Pl a c e f oo d o n t h e UNAFFECTE D sideP r o vide sma ll er bol us o f f oo dU se o f purred f oo ds o r t h ic kened f oo dsManage tu b e feedings if pres c ri b ed




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NURSING INTERVENTIONS5 . H e lp patient attain bow e l and

bl adder co ntr olI ntermittent c at h eterizati o n is d o ne in t h e a c ute stageO ffer b edpan o n a regu lar s ch edu le

H ig h fi b er diet and pres c ri b ed f luid intake




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NURSING INTERVENTIONS6. I mpr o ve t ho ug h t pr oc esses

S upp o rt patient and c apita lize o n

t h e remaining strengt h s




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NURSING INTERVENTIONS7. I mpr o ve co mmuni c ati o n

Anti c ipate t h e needs o f t h e patient

O ffer supp o rtP r o vide time t o co mp lete t h e senten c eP r o vide a w ritten co py o f s ch edu led a c tivitiesU se o f co mmuni c ati o n bo ardG ive o ne instru c ti o n at a time




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NURSING INTERVENTIONS8. M aintain skin integrity

Use o f spe c ia lty b edR egu lar turning and p o siti o ningK eep skin dry and massage NON-reddened areasP r o vide ade q uate nutriti o n


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PAR KINSONS D SE (parkinsonism) - chronic,progressive disease of CNS char bydegeneration of dopamineproducing cells in substancia nigra at midbrain & basal ganglia


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g gPalliative, SupportiveF unction of dopamine: controls grossvoluntary motors.

Predisposing F actors:1. Poisoning (lead & carbon monoxide).Antidote for lead = Calcium EDTA2. Hypoxia

3. Arteriosclerosis4. Encephalitis

SE of anti psychotic drugs Extra P yramida l S ympt o mOver meds of anti psychotic drugs neuroleptic malignant syndrome charby tremors (severe)S/Sx: Parkinsonism Pill rolling tremors of extremities early signBradykinesia slow movementOver fatigue

Rigidity (cogwheel type)Stooped postureh ffl


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Shuffling most commonPropulsive gait

Mask like facial expression with decrease blinking eyesMonotone speechDifficulty rising from sitting positionMood labilety always depressed suicide

Nsg priority: Promote safetyIncrease salivation drooling type

Autonomic signs:Increase sweatingIncrease lacrimationSeborrhea (increase sebaceous gland)

ConstipationDecrease sexual activity

Nsg MgtAnti parkinsonian agentsLevodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl(Symmetrel)

Mechanism of actionIncrease levels of dopa relieving tremors & bradykinesia


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S/E of anti parkinsonianAnorexian/v

ConfusionOrthostatic hypotensionHallucinationArrhythmia

Contraindication:

Narrow angled closure glaucomaPt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonianTake with meals to decrease GIT irritationInform pt urine/ stool may be darkenedInstruct pt- dont take food Vit B6 (Pyridoxine) cereals,organ meats, green leafy vegCause B6 reverses therapeutic effects of levodopaGive INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis


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Peripheral neuritis.

Anti cholinergic agents relieves tremorsArtane mech inhibits acetylcholineCogentin action , S/E - SNS

Antihistamine Diphenhydramine Hcl (Benadryl) take atbedtimeS/E: adult drowsiness, avoid driving & operating heavyequipt. 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 elderly3.) Assist in passive ROM exercises to prevent


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) p pcontractures4.) Maintain good nutritionCHON in am

CHON in pm to induce sleep dueTryptopan Amino Acid5.) Increase fluid in take, high fiber diet to preventconstipation6.) Assist in surgery Sterotaxic ThalamotomyComplications in sterotaxic thalmotomy- 1.)Subarachnoid hemorrhage 2.) aneurism 3.)encephalitis

MULTIPLE SCLEROSIS (MS)Chronic intermittent disorder of CNS white patchesof demyelenation in brain & spinal cord.Remission & exacerbationCommon women, 15 35 yo cause unknown

Predisposing factor:


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Predisposing factor:Slow growing virusAutoimmune (supportive & palliative treatmentonly)

Normal Resident Antibodies:Ig G can pass placenta passive immunity. Shortacting.Ig A body secretions saliva, tears, colostrums,sweat

Ig 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, cold

a. Numbnessb. Tingling


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c. Paresthesia3. 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 tremorsN nystagmus abnormal rotation of eyes

Charcots A Ataxia

& Scanning speech6. Urinary retention or incontinence7. Constipation8. Decrease sexual ability

Dx MS1. CS F analysis thru lumbar puncture

- Reveals increase CHON & IgG2. MRI reveals site & extent of demyelination

3 Lh i i ( )


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3. Lhermittes response is (+).Introduce electricity at the back. Theresspasm & paralysis at spinal cord.Nsg Mgt MSSupportive mgt1.) Meds

a. Acute exacerbationACTH adenocorticotopicSteroids to reduce edema at the site of

demyelination to prevent paralysis

MYASTHENIA GRAVIS (MG) disturbancein transmission of

impulses from nerve tomuscle cell at neuro muscular junction.Common in Women, 20 40 yo, unknown

cause or idiopathicAutoimmune release of cholenesterase


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Autoimmune release of cholenesterase enzymeCholinesterase destroys ACH(acetylcholine) = Decrease acetylcholine

Descending muscle weakness(Ascending muscle weakness GuillainBarre Syndrome)

Nsg priority:a/waspirationimmobility

S/ Sx:Ptosis drooping of upper lid ( initial sign)Check Palpebral fissure opening of upper& lower lids = to know if (+) of MG.Diplopia double vision


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p pMask like facial expressionDysphagia risk for aspiration!

Weakening of laryngeal muscles hoarseness of voiceResp muscle weakness lead respiratoryarrest. Prepare at bedside tracheostomysetExtreme muscle weakness during activityespecially in the morning.

Dx testTensilon test (Edrophonium Hcl) temporarily strengthensmuscles 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 ventilator

b.) Monitor pulmonary function test. Decrease vital lungcapacity.2 M i VS I&O h k l h


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2. Monitor VS, I&O neuro check, muscle strength or motorgrading scale (4/5, 5/5, etc)3. Siderails4. Prevent complications of immobility. Adult-every 2 hrs. Elderly-every 1 hr.

5. NGT feedingAdminister meds Cholinergics or anticholinesterase agents

Mestinon (Pyridostigmine)Neostignine (prostigmin) Long term- Increase acetylcholines/e PNS

Corticosteroids to suppress immune respDecadron (dexamethasone)

Monitor for 2 types of Crisis:Myastinic crisis Cholinergic crisisA cause 1. Under medication 2. Stress3. InfectionB S&Sx 1. Unable to see Ptosis & diplopia 2. Dysphagia- unable to swallow.3. Unable to breath C Mgt adm cholinergicagentsCause: 1 over medsS/Sx - PNSMgt. adm anti-


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agentsCause: 1 over medsS/Sx PNSMgt. adm anticholinergic Atropine SO4SNS dry mouth7. Assist insurgical proc thymectomy. Removal of thymusgland. Thymus secretes auto immune antibody.8. Assist in plasmaparesis filter blood9. Prevent complication respiratory arrest

Prepare tracheostomy set at bedside.

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