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MEDICAL-SURGICAL NURSINGNERVOUS SYSTEM
Overview of structures and functions:
Central Nervous System
11 Brain12 Spinal Cord
Peripheral Nervous System
13 Cranial Nerves14 Spinal Nerves
Autonomic Nervous System
15 Sympathetic nervous system16 Parasympathetic nervous system
AUTONOMIC NERVOUS SYSTEMSympathetic Nervous System(ADRENERGIC)-
Involved in fight or aggression response.- Release of Norepinephrine (cathecolamines)from
adrenal glands
and causes
vasoconstriction.
- Increase all bodily activity except GIT
EFFECTS OF SNS
- Dilation of pupils(
mydriasis
) in order to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.- Increase blood supply to
brain
,
heart
and
skeletalmuscles
.- SNS
I. Adrenergic Agents
- Give
Epinephrine.Signs and Symptoms:
- SNS
Contraindication:
- Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis, Emphysema, Asthma).
II. Beta-adrenergic Blocking Agents
- Also called
Beta-blockers
.- All ending with “
lol
”-
Propranolol
,
Atenelol
,
Metoprolol
.
Effects of Beta-blockers
B
– roncho spasm
E
– licits a decrease in myocardial contraction.
T
– reats hypertension.
A
– V conduction slows down.q1Should be given to patients with
Angina Pectoris
,
Myocardial Infarction
,
Hypertension
.
ANTI- HYPERTENSIVE AGENTS
1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril,Enalapril)3. Calcium Antagonist – Nifedipine (Calcibloc)q1 In chronic cases of arrhythmia give
Lidocaine
(
Xylocaine
)
Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC)-
Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all bodily activities except GIT.
EFFECTS OF PNS
- Constriction of pupils (
meiosis
).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency.
I. Cholinergic Agents
-
Mestinon
,
Neostigmine
.
Side Effects
- PNS
II. Anti-cholinergic Agents-
 To counter cholinergic agents.- Atropine Sulfate
Side Effects
- SNS
CENTRAL NERVOUS SYSTEM
17 Brain and Spinal Cord.
I. CELLSA. NEURONS
18 Basic cells for nerve impulse and conduction.
PROPERTIESExcitability
– ability of neuron to be affected bychanges in external environment.
Conductivity
– ability of neuron to transmit a wave of excitation from one cell to another.
Permanent Cell
– once destroyed not capable of regeneration.
TYPES OF CELLS BASED ON REGENERATIVECAPACITY 1. Labile
19 Capable of regeneration.20 Epidermal cells, GIT cells, GUT cells, cells of lungs.
2. Stable
21 Capable of regeneration with limited time, survivalperiod.22 Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
23 Not capable of regeneration.24 Myocardial cells, Neurons, Bone cells, Osteocytes,Retinal Cells.
B. NEUROGLIA
25 Support and protection of neurons.
TYPES1. Astrocytes –
maintains blood brain barrier semi-permeable.26 Majority of brain tumors (90%) arises from called
astrocytoma
.
2. Oligodendria3. Microglia4. EpindymalSUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER1. Ammonia
27 Cerebral toxin28 Hepatic Encephalopathy (Liver Cirrhosis)29 Ascites30 Esophageal Varices
Early Signs of Hepatic Encephalopathy
31
asterixis
(flapping hand tremors).
Late Signs of Hepatic Encephalopathy
32 Headache33 Dizziness34 Confusion35
Fetor hepaticus
(ammonia like breath)36 Decrease LOC
PATHOGNOMONIC SIGNS1. PTB –
low-grade afternoon fever.
2. PNEUMONIA –
rusty sputum.
3. ASTHMA –
wheezing on expiration.
4. EMPHYSEMA
– barrel chest.
5. KAWASAKI SYNDROME –
strawberry tongue.
6. PERNICIOUS ANEMIA –
red beefy tongue.
7. DOWN SYNDROME –
protruding tongue.
8. CHOLERA –
rice watery stool.
9. MALARIA –
stepladder like fever with chills.
10. TYPHOID –
rose spots in abdomen.
11. DIPTHERIA –
pseudo membrane formation
12. MEASLES –
koplik’s spots.
13. SLE –
butterfly rashes.
14. LIVER CIRRHOSIS –
spider like varices.
15. LEPROSY –
lioning face.
16. BULIMIA –
chipmunk face.
17. APPENDICITIS –
rebound tenderness.
18. DENGUE –
petechiae or (+) Herman’s sign.
19. MENINGITIS –
Kernig’s sign (leg pain), Brudzinskisign (neck pain).
20. TETANY –
HYPOCALCEMIA (+)
Trousseau’ssign/carpopedal spasm; Chvostek sign
(facialspasm).
21. TETANUS –
risus sardonicus.
22. PANCREATITIS –
Cullen’s sign (ecchymosis of umbilicus); (+)
Grey turners spots
.
23. PYLORIC STENOSIS –
olive like mass.
24. PDA –
machine like murmur.
25. ADDISON’S DISEASE –
bronze like skinpigmentation.
26. CUSHING’S SYNDROME –
moon faceappearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE –
exopthalmus.
28. INTUSSUSCEPTION –
sausage shaped mass
2. Carbon Monoxide and Lead Poisoning
37 Can lead to
Parkinson’s Disease.
38 Epilepsy
1
 
39 Treat with
ANTIDOTE
:
Calcium EDTA.3. Type 1 DM (IDDM)
40 Causes diabetic ketoacidosis.41 And increases breakdown of fats.42 And free fatty acids43 Resulting to
cholesterol
and (+) to
Ketones
(CNSdepressant).44 Resulting to acetone breath odor/fruity odor.45
KUSSMAUL’S respiration,
a rapid shallowrespiration.46 Which may lead to diabetic coma.
4. Hepatitis
47 Signs of jaundice (icteric sclerae).48 Caused by bilirubin (yellow pigment)
5. Bilirubin
49 Increase bilirubin in brain (
Kernicterus
).50 Causing irreversible brain damage.
DEMYELINATING DISORDERS1. ALZHEIMER’S DISEASE
51 Atrophy of brain tissues.
Sign and Symptoms
 4 A’s of Alzheimer 
a.
Amnesia
– loss of memory.b.
Agnosia
– no recognition of inanimate objects.c.
Apraxia
– no recognition of objects function.d.
Aphasia
– no speech (nodding).
*Expressive aphasia
52 “motor speech center”53 Broca’s Aphasia
*Receptive aphasia
54 inability to understand spoken words.55 Wernicke’s Aphasia56 General Knowing Gnostic Area or GeneralInterpretative Area.
DRUG OF CHOICE: ARICEPT (
taken at bedtime
)and COGNEX.2. MULTIPLE SCLEROSIS
57 Chronic intermittent disorder of CNS characterizedby white patches of demyelination inbrain and spinal cord.58 Characterized by remission and exacerbation.59 Women ages 15-35 are prone60 Unknown Cause61 Slow growing virus62 Autoimmune disorders63 Pernicious anemia64 Myasthenia gravis65 Lupus66 Hypothyroidism67 GBS
Ig G –
only antibody that pass placental circulationcausing
passive immunity.-
short term protection.- Immediate action.
Ig A
– present in all bodily secretions (tears, saliva,colostrums).
Ig M
– acute in inflammation.
Ig E
– for allergic reaction.
Ig D
– for chronic inflammation.
* Give palliative or supportive care.
Signs and Symptoms1. Visual disturbances
68 blurring of vision (primary)69 diplopia (double vision)70
scotomas
(blind spots)
2. Impaired sensation
71 to touch, pain, pressure, heat and cold.72 tingling sensation73 paresthesia74 numbness
3. Mood swings
75 euphoria (sense of well being)
4. Impaired motor function
76 weakness77 spasticity78 paralysis
5. Impaired cerebral function
79 scanning speech
TRIAD SIGNS OF MSAtaxia
(Unsteady gait,
(+) Romberg’s test
)
Intentional tremors Nystagmus6. Urinary retention/incontinence7. Constipation8. Decrease sexual capacityDIAGNOSTIC PROCEDURE
80 CSF analysis (increase in
IgG
and
Protein
).81 MRI (reveals site and extent of demyelination).82 (+)
Lhermitte’s sign
a continuous and increasecontraction of spinal column.
NURSING MANAGEMENT1.
Administer medications as ordereda.
ACTH (Adreno Corticotropic Hormone)/Steroids
for acute exacerbation to reduceedema at siteof demyelination to prevent paralysis.b.
Baclofen (Dioresal)/ Dantrolene Sodium(Dantrene)
– muscle relaxants.c.
Interferons
– alter immune response.d.
Immunosupresants2.
Maintain side rails to prevent injury related to falls.
3.
Institute stress management techniques.a.
Deep breathing exercises
b.
 Yoga4.
Increase fluid intake and increase fiber to preventconstipation.
5.
Catheterization to prevent retention.a.
Diuretics
b.
Bethanicol Chloride (Urecholine)Nursing Management
83 Only given subcutaneous.84 Monitor side effects bronchospasm and wheezing.85 Monitor breath sounds 1 hour after subcutaneousadministration.c.
For Urinary IncontinenceAnti spasmodic agent
a.
Prophantheline Bromide (Promanthene)
86 Acid ash diet like cranberry juice, plums, prunes,pineapple, vitamin C andorange.87 To acidify urine and prevent bacterialmultiplication.
COMMON CAUSE OF UTIFemale
88 short urethra (3-5 cm, 1-1 . inches)89 poor perineal hygiene90 vaginal environment is moist
Nursing Management
91 avoid bubble bath (can alter Ph of vagina).92 avoid use of tissue papers93 avoid using talcum powder and perfume.
Male
94 Urethra (20 cm, 8 inches)95 urinate after intercourse
MICROGLIA
96 stationary cells that carry on phagocytosis(engulfing of bacteria or cellulardebris, eating), pinocytosis (cell drinking).
MACROPHAGE ORGANMicrogliaMonocytesKupffers cellsHistiocytesAlveolarMacrophageBrainBloodKidneySkinLungEPINDYMAL CELLS
97 Secretes a glue called
chemo attractants
thatconcentrate the bacteria.
COMPOSITION OF BRAIN
98 80% brain mass99 10% blood10010% CSF
I. Brain MassPARTS OF THE BRAIN1. CEREBRUM
101largest part102composed of the Right Cerebral Hemisphere andLeft Cerebral Hemisphereenclosed in the Corpus Callosum.
Functions of Cerebrum
103integrative104sensory105motor
Lobes of Cerebrum1. Frontal
106higher cortical thinking
2
 
107controls personality108controls motor activity109Broca’s Area (motor speech area) when damagedresults to garbled speech.
2. Temporal
110hearing111short term memory
3. Parietal
112for appreciation113discrimination of sensory impulses to pain, touch,pressure, heat, cold,numbness.
4. Occipital
114for vision
Insula (Island of Reil)
115visceral function activities of internal organ likegastric motility.
Limbic System (Rhinencephalon)
116controls smell and if damaged results to
Anosmia
(absence of smell).117controls libido118controls long term memory
2. BASAL GAGLIA
119areas of grey matter located deep within eachcerebral hemisphere.120release dopamine (controls gross voluntarymovement.
NEURO TRANSMITTER DECREASE INCREASEAcethylcholine Myasthenia Gravis Bi-polarDisorderDopamine Parkinson’s Disease Schizophrenia3. MIDBRAIN/ MESENCEPHALON
121acts as relay station for sight and hearing.122size of pupil is
2 – 3 mm
.123equal size of pupil is
isocoria
.124unequal size of pupil is
anisocoria
.125hearing acuity is
30 – 40 dB
.126positive PERRLA
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamus
127acts as relay station for sensation.
B. Hypothalamus
128controls temperature (thermoregulatory center).129controls blood pressure130controls thirst131appetite/satiety132sleep and wakefulness133controls some emotional responses like fear,anxiety and excitement.134controls pituitary functions135
androgenic hormones
promotes secondary sexcharacteristics.136early sign for males are testicular and penileenlargement137late sign is deepening of voice.138early sign for females telarche and late sign ismenarche.
5. BRAIN STEM
139located at lowest part of brain
Parts of Brain Stem
1. Pons
140pneumotaxic center controls the rate, rhythm anddepth of respiration.
2. Medulla Oblongata
141controls respiration, heart rate, swallowing,vomiting, hiccup, vasomotor center(dilation and constriction of bronchioles).
3. Cerebellum
142smallest part of the brain.143lesser brain.144controls balance, equilibrium, posture and gait.
INTRA CRANIAL PRESSURE
Monroe Kellie HypothesisSkull is a closed containerAny alteration or increase in one of the intracranialcomponentsIncrease intra-cranial pressure(
normal ICP is 0 – 15 mmHg
)
Cervical 1
– also known as ATLAS.
Cervical 2
– also known as AXIS.Foramen MagnumMedulla OblongataBrain HerniationIncrease intra cranial pressure
* Alternate hot and cold compress to prevent HEMATOMA
145CSF cushions brain (shock absorber)146Obstruction of flow of CSF will lead to enlargementof skull posteriorly called
hydrocephalus
.147Early closure of posterior fontanels causesposterior enlargement of skull inhydrocephalus.
NEUROLOGIC DISORDERSINCREASE INTRACRANIAL PRESSURE
– increase inintra-cranial bulk brought about by anincrease in one of the 3 major intra cranialcomponents.
Causes:
q1 head trauma/injury148localized abscess149cerebral edema150hemorrhage151inflammatory condition (stroke)152hydrocephalus153tumor (rarely)
Signs and Symptoms (Early)
154decrease LOC155restlessness/agitation156irritability157lethargy/stupor158coma
Signs and Symptoms (Late)
159changes in vital signs160blood pressure (
systolic blood pressureincreases but diastolic remains thesame
).161widening of pulse pressure is neurologic in nature(if narrow cardiac in nature).162heart rate decrease163respiratory rate decrease164temperature increase directly proportional toblood pressure.165projective vomiting166headache167
papilledema
(edema of optic disc)168abnormal posturing169
decorticate posturing
(damage to cortex andspinal cord).170
decerebrate posturing
(damage to upper brainstem that includes pons,cerebellum and midbrain).171
unilateral dilation of pupils
called
uncalherniation
172
bilateral dilation of pupils
called
tentorialherniation
173resulting to mild headache174possible seizure activity
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia
175restlessness176agitation177tachycardia
Late signs of hypoxia
178
B
radycardia179
E
xtreme restlessness180
D
yspnea181
C
yanosis
HYPERCARBIA
182Increase CO2 (most powerful respiratorystimulant) retention.183In chronic respiratory distress syndrome
decrease O2
stimulates respiration.
b. Before and after suctioning hyper oxygenateclient 100% and done 10 – 15seconds only.c. Assist in mechanical ventilation
2. Elevate bed of client 30 – 35o angle with neck inneutral position unless contraindicated topromote venous drainage.3. Limit fluid intake to 1200 – 1500 ml/day (in forcefluids 2000 – 3000 ml/day).4. Monitor strictly input and output and neuro check5. Prevent complications of 6. Prevent further increase ICP by:a. provide an comfortable and quite environment.b. avoid use of restraints.c. maintain side rails.d. instruct client to avoid forms of valsalva maneuverlike:184straining stool
3
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