EMILIO AGUINALDO COLLEGE - CAVITE

~THE NERVOUS
SYSTEM~
Common Health Problem and Disorders

JHOANNE D. DUERO
7/18/2009
 NERVOUS SYSTEM
1. Central Nervous System
• Brain
• Spinal Cord
2. Peripheral Nervous System
• Cranial Nerves
• Spinal Nerves

Neuron

BRAIN

The Brain is divided into 3 major areas:

1. Cerebrum
2. Brain Stem
3. Cerebellum
External surface of the brain
CEREBRUM
• The largest part of the brain.
• Composed of: 2 hemispheres- the right and left, and the basal ganglia.
• The hemisphere is connected by corpus callosum, a band of fibers.
• Each hemisphere is divided into 4 lobes.

Structure of the Brain

The 4 Lobes of the Cerebrum

1. Frontal Lobe
 • Largest lobe
• Location: front of the skull.
• Contains the primary motor cortex and responsible for functions related to motor
activity.
• The left frontal lobe contains Broca’s area (control the ability to produce spoken
words)
• The frontal lobe controls higher intellectual function, awareness of self, and
autonomic responses related to emotions

2. Parietal Lobe
• Sensory lobe
• Location: near the crown of the head.
• Contains the primary sensory cortex.
• One of its major functions is to process sensory input such as position sense,
touch, shape, and consistency of objects.
3. Temporal Lobe
• Location: around the temples.
• Contains the primary auditory cortex.
• Wernicke’s area is located on left temporal lobe.
• Contains the interpretative area where auditory, visual and somatic input are
integrated into thought and memory

4. Occipital Lobe
• Location: lower back of the head
• Contains the primary visual cortex
• Function: responsible for visual interpretation.

THE 4 LOBES
• Frontal- motor /controls higher intellectual function, awareness of self and autonomic
responses related to emotions.
• Parietal- sensory
• Temporal- auditory (Wernicke’s); Contains the interpretative area where auditory, visual
and somatic input are integrated into thought and memory
• Occipital- visual
Ventricles of the Brain
Diencephalon
• Lies on the top of the brain-stem
• Contains the thalamus, hypothalamus, epithalamus, and subthalamus.

1. Thalamus
• Lies on the either side of the third ventricle
• “Relay station” for all sensation except smell.
• All memory, sensation and pain impulses pass through this section.

2. Hypothalamus
• Located anterior and inferior to the thalamus.
• Has a variety of function and plays an important role in maintaining homeostasis.
• Regulation of body temperature, hunger and thirst; formation of autonomic
nervous system responses; and storage and secretion of hormones from the
pituitary gland.

3. Epithalamus
• Contains pineal gland.

4. Subthalamus
• Part of the extrapyramidal system of the autonomic nervous system and the basal
ganglia.
The Basal Ganglia
• Are masses of nuclei located deep in the cerebral hemispheres.
• Responsible for fine motor movements, including those of the hands and lower
extremities.
• Several motor disorders are associated with basal ganglia damage including
Huntington’s chorea and Parkinson’s disease.

BRAIN STEM
• Consist of the midbrain, pons, and medulla oblongata.
• Midbrain
➢ connects the pons and the cerebellum with the cerebral hemisphere, it contains
sensory and motor pathways
➢ center for auditory and visual reflexes
• Pons
➢ connects the two halves of the cerebrum
 ➢ involved in the integration of movements in the right and left sides of the body,
and the transmission of motor information from the higher brain areas and the
spinal cord to the cerebellum.
• Medulla oblongata
➢ involved in the respiration, circulation, gastrointestinal functioning, coughing,
sneezing, and swallowing.

CEREBELLUM
• Location: base of the brain.
• Responsible for coordination, balance and posture.
• Damage to the cerebellum can result in ataxia, a condition characterized by drunken-like
movements, severe tremors, and loss of balance.

Structures Protecting the Brain

• The brain is contained in the rigid skull, which protects it from injury.
• The meninges (fibrous connective tissues that cover the brain and the spinal cord)
provide protection, support and nourishment to the brain and the spinal cord.
• Layers of the meninges:
a. Dura mater
b. Arachnoid
c. Pia mater

CSF – Cerebrospinal Fluid

• Provide a cushion, provide nutrition, maintain normal ICP, remove metabolic waste.
 • Composition – colorless, odorless fluid containing glucose, electrolytes, oxygen, water,
small amount of carbon monoxide and few leukocytes.
• Produced in the choroid plexus of the ventricles.

SPINAL CORD

• Approximately 45 cm long (18 inches) long.

• Acts as a passageway for condition of sensory information from the periphery of the
body to the brain (via afferent nerve fibers).
• Serve as the connection between the brain and the periphery.
• Mediates the reflexes.

a. Cervical C1-4
b. Brachial plexus C5-8, T1
c. Intercostal T2-T12
d. Lumbar L1-L4
e. Sacral L4-L5, S1-S3
f. Pudendal S4

Blood Supply to the CNS

• 1/3 of the cardiac output
• From 2 vertebral artery and one internal carotid arteries
• Circle of Willis

Peripheral Nervous System –

Cranial Nerves & Spinal Nerves
CRANIAL NERVES
• 12 pairs
• Emerge from the undersurface of the brain.
• Cranial nerve conducts impulses (motor and sensory information) between the brain and
various structures of the head, neck, thoracic cavity and abdominal cavity.

➢ I Olfactory nerve
➢ II Optic nerve
➢ III Oculomotor nerve
➢ IV Trochlear nerve
➢ V Trigeminal nerve
➢ VI Abducens nerve
➢ VII Facial nerve
➢ VIII Acoustic/Vestibulocochlear
➢ IX Glossopharyngeal nerve
➢ X Vagus nerve
➢ XI Accessory nerve
➢ XII Hypoglossal nerve

Cranial Nerves Function Assessment

I. Olfactory Sensory: Assess nose for Smell.

smell reception and ➢ Have the client close eyes and

interpretation properly identify common
aromatic substance held under the
nose; test one nostril at a time.
(ex. coffee, toothpaste, orange)

II. Optic Sensory: Assess eyes for Visual Acuity and

Peripheral Vision.
visual acuity and visual fields
➢ Vision and visual field tested with
an eye chart and by testing point
at which person sees an object
(finger) moving into visual fields;
inside of the eye is viewed with
ophthalmoscope to observe blood
vessels.

III. Oculomotor Motor: Assess eyes for Extraocular Movement.

raise eyelids, most extraocular ➢ The CN III, CN IV, and CN VI

movements nerves are tested together since
they control muscles that provide
eye movement. Test the
Parasympathetic: movement of the eyes in the six
cardinal fields of gaze.
pupillary constriction, change
lens shape Assess eyes for Pupillary Constriction and
Accommodation.

➢ To test pupillary reaction and

accommodation, shine a light into
the eye to note whether the iris

constricts, making the pupil

smaller.

➢ Accommodation is tested by
observing pupillary constriction
when the client changes gaze
from a distant object to a near
object.

IV. Trochlear Motor: Assess eyes for Extraocular Movement

downward, inward eye

movement.
V. Trigeminal Motor: Assess face for Movement and Sensation

jaw opening and clenching, ➢ Test motor function by having the

chewing and mastication
Sensory:
sensation to cornea, iris,
lacrimal glands, conjunctiva
eyelids, forehead, nose, nasal
and mouth mucosa, teeth,
tongue, ear, facial skin
client clenches his/her teeth, then
palate the temporal and masseter
muscles.
➢ To test light sensation, have the
client close his/her eyes, then
wipe a cotton wisp lightly over
the anterior scalp, paranasal
sinuses, and jaw.
➢ To test deep sensation, use
alternating blunt and sharp ends
of a paper clip over the client’s
forehead and paranasal sinus.

VI. Abducens Motor:

lateral eye movement

VII. Facial Motor: ➢ Inspect the face both at rest and

movement of facial expression
muscles except jaw, close eyes,
labial speech sounds.
Sensory:
taste- anterior two third of
tongue, sensation to Pharynx
Parasympathetic:
secretion of saliva and tears.
during conversation.
➢ Have the client raise the
eyebrows, frown, close the eyes
tightly and show the teeth, smile
and puff out the cheeks.
Assess mouth for Taste
➢ Instruct the client to stick out the
tongue and leave it out during the
testing process. Use a cotton
applicator to place quantities of
salt, sugar, and lemon to client’s
tongue.

VIII. Acoustic Sensory: ➢ Hearing initially can be screened

while taking the history.
hearing and equilibrium.

IX. Glossopharyngeal Motor: Assess mouth for Gag Reflex and

Movement of Soft Palate.
voluntary muscle for
swallowing and phonation. ➢ Evaluate CN IX and CN X
 together for movement and gag
reflex.
Parasympathetic:
➢ Instruct the client to say “ah”;
secretion of salivary gland, there should be bilateral equal
carotid reflex upward movement of the soft
palate and uvula; gagging will
occur; and speech should be
smooth.

X. Vagus Motor: Assess mouth for Gag Reflex and

Movement of Soft Palate
voluntary muscle of phonation
and swallowing

Sensory:

sensation behind ear and part of

external ear canal.

Parasympathetic:

secretion of digestive enzymes;

peristalsis; carotid reflex;
involuntary action of the
heart, lungs and digestive tract.

XI. Spinal Accessory Motor: Assess shoulder and neck muscles for
Strength and Movement
turn head, shrug shoulders,
some actions for phonation ➢ Have the client shrug his/her
shoulders upward against your
hands.

➢ Have the client turn his/her head

to the side against your hand,
repeat on the other side.
XII. Hypoglossal Motor: Assess mouth for Tongue Movement,
Symmetry, Strength, and Absence of
tongue movement for speech Tumors
sound articulation and
swallowing ➢ client protrudes tongue. Note
symmetry, atrophy, and absence
of tumors

➢ Then ask the client to move

 tongue toward nose, chin, and
side to side.

➢ Strength of the tongue can be

tested by pressing it against your
gloved index finger.

SPINAL NERVES
• 31 pairs
• 8 cervical, 12 thoracic, 5 lumbar
• 5 sacral, 1 coccygeal
• Two roots
➢ Dorsal and Ventral - Each spinal nerve has a ventral root (motor) and a dorsal root
(sensory)
• Dermatome distribution

 The dorsal roots contains sensory fibers that relay information from sensory receptors to
the spinal cord
 The ventral root contains motor fibers that relay information from the spinal cord to the
body’s glands and muscles.
Dermatome distribution

AUTONOMIC NERVOUS SYSTEM

 • Regulates the activities of the internal organs (heart, lungs, blood vessels, digestive
organs, and glands)
• Responsible for maintenance and restoration of internal homeostasis.

2 Components of ANS
1. Sympathetic Nervous System
2. Parasympathetic Nervous System

Sympathetic Nervous System

• Expenditure of energy
• Catecholamines: Epinephrine; norepinephrine; dopamine
• “Fight or flight” response.
 Pupil dilates
 Increased HR
 Increased BP
 Increased RR
 Constipation
 Dry mouth
 Urinary retention

Parasympathetic Nervous System

• Conserving energy.
➢ Acetylcholine
 Pupil constricts
 Decreased HR
 Decreased BP
 Decreased RR
 Diarrhea
 Increased salivation
 Urinary frequency
 Assessment
THE NEUROLOGIC EXAMINATION

General Assessment for Neurological Disorders

Health History
 Past Health History
 Injuries and surgeries
 Use of alcohol, medications, and illicit drugs
 Onset of symptoms.
 Duration of current complain
 Recent trauma
 The disorders involving neurologic system impairment are headache, dizziness or vertigo,
seizures, change in consciousness, altered sensation and visual disturbances.

Physical Examination
 The brain and spinal cord cannot be examined directly as other system of the body.
 V/S - abnormal respiration
 breathing pattern
 Pupillary reaction/pupillary changes
 Eye movement & reflex response
 Change in balance

Neurological Assessment
 Recognition of change
 Helps assess the patient’s ability to engage in self-care activities.
 Neurologic assessment is divided to into 5 components:
 Cerebral function
 Cranial nerves
 Motor system
 Sensory system
 Reflexes

1. Cerebral Function
 Mental status: observe patient’s appearance, behavior, dressing, grooming and
personal hygiene.
a. Posture, gestures, movements, facial expression, motor activity, the
patient’s manner of speech and LOC are also assessed.
b. Level of Consciousness (LOC) – awareness of self and environment and
level of arousal (alert, lethargic, obtunded, stuporous, coma).
Altered Level of Consciousness (LOC) - can result from destruction of the brain stem or
its reticular formation of ascending nerves, or from other structural, metabolic, or
psychogenic disturbances.
Confusion • Impaired ability to think clearly
• Disturbed ability to perceive,
respond to, and remember current
stimuli
• Disorientation
• Functional in activities of daily
living (ADLs)

Delirium • Motor restlessness

• Increased disorientation
• Transient hallucinations
• Delusions possible
• Requires some assistance with
ADLs

Obtundation • Decreased alertness

• Psychomotor retardation
• Requires complete assistance with
ADLs

Stupor • Arousable but not alert

• Severe disorientation
• Little or no spontaneous activity

Coma • Unarousable
• Unresponsive to external stimuli or
internal needs
• Determination commonly
documented using Glasgow Coma
Scale score

Altered Movement
  Involves certain neurotransmitters (ex. dopamine)
○ Hyperkinesia- excessive movement
○ Hypokinesia- decreased movement
 Marked by paresis- partialloss of motor function and muscle power; commonly
described as weakness; can result from destruction of upper & lower motor
neurons

2. Cranial Nerve Function

 Assess cranial nerve function.

3. Motor System Function

 Assess muscle size (inspect and palpate) tone, and strength; assess symmetry
differences between right and left side; balance and coordination.
○ Altered Muscle Tone
○ Hypotonia- severely reduced degree of tension or resistance to movement
in a muscle
○ Hypertonia- marked increase in a muscle tension and decreased ability of
a muscle to stretch

4. Sensory Function
 Test for:
○ superficial tactile sensation superficial and deep pressure pain
○ thermal sensitivity
○ sensitivity to vibration
○ point localization

5. Reflexes
 Evaluate deep and superficial reflexes (biceps, triceps, patellar, ankle reflexes)
and abnormal reflexes (Babinski’s reflex).

Diagnostic Tests

Diagnostic Procedure Nursing Interventions

Computed Tomography Scanning
➢ Visualize sections of the spinal cord as ✔ Teaching the client about the need to lie
well as intracranial contents quietly throughout the procedure.
➢ The injection of a water-soluble
 iodinated contrast into the subarachnoid
space through lumbar puncture helps
➢ noninvasive and painless
➢ has a high degree of sensitivity for
detecting lesions.
✔ Relaxation technique maybe helpful for
clients with claustrophobia.
✔ Assess for iodine/shellfish allergy.

✔ Secure patent IV line.

Use of x-ray beams cross section
➢ Use: to identify intracranial tumor,
✔ NPO if with contrast medium, for 4 hrs.
hemorrhage, cerebral atrophy,
calcification, edema, infarction,
congenital abnormality.
✔ Monitor for allergic reaction: flushing,
nausea and vomiting.
Magnetic Resonance Imaging

Diagnostic Procedure Nursing Interventions

Magnetic Resonance Imaging
➢ Uses a powerful magnetic field to ✔ Obtain history of metal implants.
obtain images of different areas of the Remove all metal objects.
body.
✔ Inform the client that the procedure last
➢ Can be performed with or without a for 30 to 90 mins.
contrast agent and can identify a
 cerebral abnormality earlier and more
clearly than other diagnostic tests.
➢ Useful in diagnosis of multiple
sclerosis and can describe the activity
and the extent of disease in the brain
and spinal cord.
Cerebral Angiography
➢ Is an x-ray study of the cerebral
circulation with a contrast agent
injected into a selected artery (femoral)
Visualize aneurysm
Myelography
➢ Contrast agents are injected into spinal
subarachnoid space to permit
visualization of spinal cord.
➢ Shows any distortion of the spinal cord
or spinal dural sac caused by tumors,
cysts, herniated vertebral disks or other
lesions.
✔ Patient preparation should include
teaching relaxation technique.
✔ Inform the client that a narrow, tunnel
like machine will enclose him/her
during the procedure.
✔ Sedation may be needed for
claustrophobic client.
✔ Obtain a signed consent.
✔ Hydrate the client, clear liquids are
usually permitted.
✔ Instruct the client to void before the
procedure.
✔ Instruct the patient to remain immobile
during the test.
✔ Tell the client to expect a brief feeling
of warmth in the face, behind the eyes
or in the jaw, teeth, tongue, and lips,
and a metallic taste when the contrast is
injected.
✔ After the procedure check LOC, and
injection site should be observed.
✔ Explain the procedure.
✔ Obtain a signed consent.
✔ Withhold oral intake 4-6 hours before
the test.
✔ After the procedure:
 For pantopaque myelogram
(oil-based) pt lies flat for 6-24
hours.

Electroencephalography
➢ Graphic record of the electrical activity
generated in the brain.
➢ EEG is a useful test for diagnosing and
evaluating seizure disorders, coma, or
organic brain syndrome.
➢ A sleep EEG may be recorded after
sedation because some abnormal brain
waves are seen only when the patient is
asleep.
For metrizamide myelogram

(water-based), HOB is elevated
at 30 degrees for at least 8
hours.
✔ Encourage fluid intake.
✔ Explain the procedure; assure the client
he/she will not receive electrical shock.
✔ The nurse needs to check doctor’s order
regarding the administration of anti-
seizure medication prior to testing.
✔ Withhold tranquillizer and stimulants
for 24 to 48 hours.
✔ Inform the client that the standard EEG
takes 45 to 60 minutes and 12 hours for
sleep EEG.

Electroencephalography

• Measurement of the electrical activity of the brain done during:

○ Relax
○ Hyperventilate
○ Sleeping
○ Flickering lights

Lumbar Puncture
 • Insertion of needle in the Subarachnoid Space
• Assess the CSF
Lumbar Puncture
➢ Is carried out by inserting a needle into
the lumbar subarachnoid space to
withdraw CSF for diagnostic or
therapeutic purposes.
➢ The needle is usually inserted between
L4 and L5.
Electromyography
➢ Obtain by inserting needle electrodes
into the skeletal muscles.
➢ Measure changes in the electrical
potential of the muscles and the nerves
leading to them.
➢ Useful in determining neuromuscular
disorders and myopathies.
✔ Maintain position, usually lateral
horizontal with knees to chest, chin on
chest.
✔ Obtain signed consent.
✔ Explain the procedure.
✔ Observe for complication following the
procedure.
✔ Keeping the patient in prone position
overnight may reduce the incidence of
headache.
✔ Explain the procedure.
✔ The patient is warned to expect a
sensation similar to that of an
intramuscular injection and the muscle
examined may ache for a short time
after the procedure.
 Electromyogram

• Measures electrical potential/ activity of the muscles

Pneumoencephalography
➢ Special contrast study of the ventricular
and cisternal system using air as
contrast medium.
➢ Permits accurate localization of brain
lesions by spinal or cisternal puncture
with x-ray examination.
✔ Secure written consent.
✔ Sedate as ordered. GA may be used.
✔ Inform the client that the procedure
takes 2 hours.
✔ Inform the client that he/she may
experience discomfort, N/V, after the
procedure.
✔ After the procedure keep the client flat
in bed for 24 to 48 hours.
✔ Monitor VS and neurologic checks.
 Common Health Problem of the Neonate and Infant

Nervous System Developmental Disorders

1. Cranial
 Hydrocephalus
2. Spinal Cord
 Meningocele

HYDROCEPHALUS
• Is an excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain.
• Reasons for excess:
○ over production of fluid by the choroid plexus in the 1st or 2nd ventricle
○ obstruction of the passageway of fluid somewhere between the point of origin and
the point of absorption
○ interference with the absorption of fluid from the subarachnoid space
• Classifications:
a. Congenital
b. Acquired
• The cause of congenital hydrocephalus is unknown.
• Incidence: 3 to 4 per 1000 live births
• In older child infections such as meningitis and encephalitis may leave adhesion that lead
to obstruction.
Nursing Assessment
 Enlarged head
 Prominent scalp vein.
 Enlarged or full fontanels
 Separated suture line
 Increased head circumference
 Sunset eyes
 Shrill cry
 Hyperactive reflexes
 Signs of increased ICP
 Decreased pulse
 Increased temperature
 Decreased respiration
 Increased BP
Diagnostic Test
 Sonogram, CT scan, MRI
 Skull x-ray film will reveal the separating sutures and thinning of the skull bones.
 Transillumination will reveal skull filled with fluid rather than solid brain substance.

Nursing Goals and Interventions

 Assess neurologic status closely.
 Measure and plot occipital-frontal baseline measurement, then measure head
circumference once a day.
 Check for fontanelle for bulging and sutures for widening.
 Assist with head ultrasound and Transillumination.
 Maintain skin integrity: change position frequently.
 Clean skin creases after feeding or vomiting.
 Postoperatively, position head off operative site.
 Watch for signs of infection.
MYELOMENINGOCELE
• The spinal cord and the meninges protrude through the vertebrae.
• This result in lower motor neuron damage.
○ The child will have flaccidity and lack of sensation of the lower extremities and
loss of bowel and bladder control.
• Hydrocephalus accompanies Myelomeningocele in as many as 80% of infant due to lack
of subarachnoid membrane.

Diagnostic Test
 Neural tube defects can be discovered during intrauterine life by sonography, fetoscopy,
amniocentesis, or analysis of AFP in maternal serum.
 When infants are detected having Myelomeningocele, they may born by cesarean
birth to avoid pressure and injury to the spinal cord.

Nursing Assessment
 Saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar
area.
 Myelomeningocele directly connects to subarachnoid space so hydrocephalus often
associated.
 No response or varying response to sensation below level of sac.
 May have constant dribbling of urine.
 Retention of stool.
Nursing Goals and Interventions
 Prevent trauma and infection.
 Position on abdomen or on side and restrain.
 Meticulously clean buttocks and genitals after each voiding and defecation.
 May put protective covering over sac.
 Observe sac for oozing of fluid or pus.
 Crede bladder (apply downward pressure on bladder with thumbs, moving urine toward
the urethra) as ordered to prevent urinary stasis.
 Assess amount of sensation and movement below defect.
 Observe for complications.
 Obtain occipital-frontal circumference baseline measurement, then measure head
circumference once a day (to detect hydrocephalus).
 Check fontanelle for bulging.

Common Health Problems of the Child and Adolescent

CEREBRAL PALSY
• Group of non-progressive disorders of upper motor neuron impairment that result in
motor dysfunction.
• A child may also have speech or ocular difficulty, seizures, cognitive challenges, or
hyperactivity.
• Exact cause is unknown, but the disorder is associated with low birth weight, prebirth, or
birth injury.
• Occurs in approximately 2 in 1000 live births, occurring most frequently in very-low-
birth-weight infants
• It apparently occurs when brain anoxia leads to cell destruction of the motor tracts.

Types of Cerebral Palsy

1. Spastic Type
 Spasticity is excessive tone in the voluntary muscles (loss of upper motor
neurons)
 The child with spastic CP has hypertonic muscle, abnormal clonus, exaggeration
of deep tendon reflexes, abnormal reflexes such as tonic neck reflex.
 Spastic movement may affect both extremities on one side (hemiplegia), all four
extremities (quadriplegia), or primarily the lower extremities (paraplegia)
 2. Dyskinetic or Athetoid Type
 Involves abnormal involuntary movement.
 Athetoid means “wormlike”.
 The child is limp and flaccid.
 The child makes slow, writhing motions. This may involve all four extremities,
plus the face, neck, and tongue.
 The child drools and speech is difficult to understand.

3. Ataxic Type
 Children with ataxic involvement have an awkward, wide-base gait.
 On neurologic examination, they are unable to perform finger-to-nose test or
perform rapid, repetitive movements (tests of cerebral function).

4. Mixed Type
 Symptoms of both spasticity and athetoid movements are present together.

Nursing Assessment
 Diagnosis is based on history and physical assessment.
 On history, an episode of possible anoxia during prenatal life or at birth is documented.
 Neurologic exam in infant is difficult. In all forms of CP may have sensory alteration.

REYE’S SYNDROME
• Is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs,
pancreas, and skeletal muscle.
• 1 to 18 years of age regardless of gender.
• The cause is unknown, but it generally occurs after a viral infection such as varicella or
influenza if the child is treated with salicylate.
• Avoiding the use of aspirin during viral infection has led to almost total prevention of the
syndrome.

Nursing Assessment
 Children: Lethargic, vomiting, agitation, anorexia, confusion, and combativeness.
 Laboratory diagnosis of Reye's syndrome is confirmed by:
 Elevated Liver Enzyme Levels
 Elevated Serum Ammonia
 Normal Direct Bilirubin
 Delayed Prothrombin Time and Partial Thromboplastin Time
  Decreased Blood Glucose
 Elevated BUN
 Elevated Serum Amylase
 Elevated Short-chain Fatty Acid
 Elevated WBC Count

Common Health Problems of the Young Adult

Neuromuscular Disorders
 Multiple Sclerosis
 Myasthenia Gravis

MULTIPLE SCLEROSIS
• Chronic, degenerative disease of the central nervous system that is characterized by
demyelination of the nerve fibers of the brain and spinal cord
• Gen. characterized by exacerbations and remissions (relapsing-remitting type)
• Although the cause of MS is unknown, it appears to be related to autoimmune disorder
and viral infections
• Commonly appears during adulthood (ages 20 to 40)
• W>M
• Areas of the CNS most commonly affected brainstem, cerebrum, cerebellum, optic
nerves, and the spinal cord.
Process of Demylination
Assessment
 Sign and symptoms of MS is characterized by remissions and exacerbation of symptoms.
 Symptoms vary depending on the area of the CNS involved, but generally include:
 Visual disturbances (diplopia, partial or total loss of vision, nystagmus)
 Scanning speech (slow, monotonous, slurred)
 Tremors
 Weakness/numbness of the extremities
 Fatigue
 Increased susceptibility to URTI
 Dysphagia
 Ataxic gait

Diagnostic Test
 Lumbar Puncture-total CSF protein is normal; IgG (gamma globulin is elevated- IgG
reflects hyperactivity of the immune system due to chronic demyelination)
 EEG-abnormalities in brain waves
 CT scan/ MRI reveals multifocal white matter lesion
 Myelogram
 Skull x-ray

Nursing Diagnoses
 Risks: Ineffective breathing pattern; airway clearance
 Impaired—swallowing, physical mobility, skin integrity; altered nutrition; urinary
incontinence; constipation

Interventions
 There is no specific treatment for MS.
 Treatment includes:
• Physical therapy- to assist with motor dysfunction, such as problem with
balance, strength, and motor coordination.
• Speech therapy- to manage dysarthria
• Drug therapy
a. Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)- to
reduce edema of the myelin sheet; sppeds recovery from attack
 b. Muscle relaxant (Baclofen)- to treat spasticity
c. Amantadine, Ritalin, or antidepressants– to manage fatigue
d. Low-dose TCAs- to manage sensory symptoms such as pains,
numbness, burning, and tingling sensationsAntihistamines with
vision therapy & exercises to minimize vertigo

Nursing Responsibilities/Considerations
 Provide regular activity, rest, and relaxation.
 Assist with physical therapy: muscle stretching, relaxation and coordination exercise,
walking exercise.
 Encourage well balanced, high fiber diet.
 Force fluids to prevent constipation.
 Avoid hot baths.
 Provide skin care to prevent skin breakdown.
 Patient and family teaching to promote emotional stability
 Help patient establish daily routine, and help family understand patient’s changes
in personality and physical capabilities.
 Inform the pt that exacerbations are unpredictable, necessitating physical &
emotional adjustments in lifestyle
• eye patch
• Speech therapy
• Medicate and watch for adverse effects
Evaluate
 Respiration; nutrition; ADLs; skin; bowel elimination; urinary incontinence

MYASTHENIA GRAVIS
• Progressive neuromuscular disorder that results in the failure to transmit nerve impulses
at the MYONEURAL JUNCTION causing extreme weakness
• Failure of transmission is due to decreased acetylcholine
• Women > Men; 3 times more common in w
• Young adults 20-30
• Secretion and increased cholinesterase at the nerve ending
• Autoimmune disease
• Characterized by progressive weakness and abnormal fatigability of the skeletal muscles
• Commonly affects muscles innervated by the cranial nerves (face, lips, tongue, neck, and
throat)
• Exacerbated by exercise & repetitive movement
 • Occurs along with thymic abnormalities in 75% of pts

Pathophysiology
 Transmission of nerve impulses at the neuromuscular junction FAILS.
 Anti-receptor antibodies block, weaken, or reduce the number of acetylcholine Ach
receptors available at each neuromuscular junction, thereby impairing the muscle
depolarization necessary for movement

Cause
 Autoimmune response leading to ineffective acetylcholine release and inadequate muscle
fiber response to Ach.

Complications
 Aspiration
 Pneumonia
 Respiratory distress

Assessment
 S&S
○ Skeletal muscle weakness, fatigue
○ Weak eye closure,ptosis, diplopia,
○ “snarl smile” (smiles slowly)
○ Masklike facial expression; Impaired speech; drooling
○ Weakened respiratory muscles
○ Muscles are usually strongest in the morning but become progressively weaker
during the day and following an exercise.

Rationale/Pathophysiologic Basis
 Impaired neuromuscular transmission
 Impaired neuromuscular transmission to the cranial nerves supplying the eye muscles
 Impaired transmission of the cranial nerves innervating the facial muscles
 Impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in
the appropriate junctions
 Skeletal muscle weakness

Diagnostic Test
 Tensilon Test (Edrophonium Chloride Test)
 Short acting cholinergic is administered.
 Reveals increased muscle strength is observed (+ Tensilon Test) within 30-60 secs
after IV injection of Edrophonium (Tensilon) or Neostigmine (Prostigmin) lasting
up to 30 mins.
 Single fiber electromyography with neural stimulation at the specific muscle fiber-
progressive decrease in muscle fiber contraction
 Chest x-ray- reveals thymoma in 15% of pts

Treatment of Myasthenia Gravis

 Anticholinesterase drugs, such as neostigmine and pyridostigmine- to counteract fatigue
and muscle weaknes and allow for about 80% of normal muscle
 Immunosuppresive therapy with corticosteroids, azathioprine (Imuran) – to decrease the
immune response toward Ach receptors at the neuromuscular junction
 IgG during acute relapses- to suppress the immune system
 Thymectomy- to remove thymomas
 Tracheostomy- suctioning to remove secretions
Nursing Goals and Interventions
 Establish neurologic and respiratory baselines
 Assess swallowing / gag reflex before feeding the client.
 Plan exercise, meals, patient care & activities to make the most of energy peaks.
Ex.,administer medications 20-30 minutes before meal to facilitate chewing or
swallowing.
 Start meal with cold beverage.
 Administer medication at precise time to prevent relapses.
 Protect the client from falls.
 Provide adequate ventilation.
 Avoid exposure to infection, stree, strenous exercise, and needless exposure to the sun or
cold.
 Frequent rest periods.
 Be prepared to give atropine for anticholinesterase overdose or toxicity
 Avoid aminoglycoside antibiotics, which can exacerbate myasthenia gravis
 Aerosol, pesticides/cleaners should also be avoided,
 Avoid alcohol, tonic water, and cigarette smoke.
 Pharmacotherapy
 Cholinergics (Anticholinesterase)
✔ Neostigmine (Postigmin)
✔ Pyridostigmin (Mestinon)
✔ Ambenomium (Mytelase)
 Glucocorticoids
 Antacids

Common Health Problem of the Middle-aged Adult

Cranial Nerve Disorder: TRIGEMINAL NEURALGIA (TIC DOULOUREUX)

• Neurologic disorder affecting the 5th cranial nerve. Possible fifth cranial nerve root
compression
• Manifested by excruciating, recurrent paroxysms of sharp, stabbing facial pain along the
trigeminal nerve.
 Areas innervated by the three branches of the trigeminal nerve

Management
 Narcotic analgesics; anticonvulsants
○ Tegretol
○ Dilantin
 Alcohol injection of the nerve
 Avoid extremes of heat and cold.
 Correction of dental malocclusion
 Surgical Management
○ Surgical division of the trigeminal nerve (neurectomy)

Nursing Management
 Assessment
○ Complete history
○ Affected area; oral cavity
○ Record weight and ability to eat food
 Diagnosis, Planning, and Interventions
○ Acute pain
 Evaluate:
○ Pain; client cooperation

Cranial Nerve Disorder: BELL’S PALSY

 • Disease of the cranial nerve VII (facial nerve that produces unilateral or bilateral facial
weakness or paralysis
• Resolves spontaneously in 80% of pts with complete recovery in 18 weeks
• Recover may be delayed in the elderly
• If recovery is partial, contractures may developed on the paralyzed side of the face

Causes
 Hemorrhage
 Herpes simplex or herpes zoster
 Infection
 Local trauma
 Meningitis
 Tumor
 Viral disease

Pathophysiology
 An inflammatory reaction occurs around cranial nerve VII, usually at the internal
auditory meatus, where the nerves leave bony tissue
 The inflammatory reaction produces a conduction block that inhibits appropriate neural
stimulation to the muscle by the motor fibers of the facial nerve, resulting in the
characteristic unilateral or bilateral facial weakness.

Pathophysiologic Changes/S & S

 Unilateral facial weakness
 Drooping mouth & drooling saliva
 Lose of taste
 Smooth forehead appearance
 Impaired ability to close the eye on the weak side
 Bell’s phenomenon-Upward rolling of the eyes when attempting to close them
 Excessive tearing
 Ringing in the ear

Complications of Bell’s Palsy

○ Corneal abrasion
○ Infection (masked by steroid use)
○ Poor functional recovery

Diagnostic Tests
 based on clinical presentation
  MRI-rules out tumor
 Electromyography- 10 days after the onset of S/S

Treatment
 Analgesics- to relieve pain
 Steroids- to reduce facial nerve edema & improve edema & improve nerve conduction &
blood flow
 Possible electrotherapy
 Surgery for persistent paralysis

Nursing Considerations
 Watch for adverse effects of steroids use
 Apply moist heat to the affected side of the face-to reduce pain
 Help the pt maintain muscle tone:
○ massaging the face with a gentle upward motion 2-3xdaily x 5-10mins
○ exercise by grimacing in front of a mirror
 Protect eyes, have pt cover eye w/ an eye patch
 Prevent excessive wt loss:
○ have him chew on unaffected side of his mouth
○ provide a soft, nutritionally balanced diet, eliminating hot foods & fluids
○ apply a facial sling to improve lip alignment
 Provide frequent & complete mouth care
 Offer psychological support

Common Health Problems of the Older Adult

CEREBRO-VASCULAR DISORDER : Stroke/Cerebrovascular Accident (CVA)

• Disruption of the Blood Supply to the Brain.

• Sudden loss of neurologic function
• Note: Middle Cerebral Artery is commonly affected.
The second most frequently affected is the internal carotid artery.

Classification
1. ischemic (a thrombus or embolus blocks circulation)
2. hemorrhagic (a blood vessel ruptures)

Risk factors
 Increased alcohol intake or cocaine
  Cardiac disease
 Cigarrette smoking
 DM
 Familial hyperlipidemia
 Family history of stroke
 Hx of TIA
 HPN
 Obesity,sedentary lifestyle
 Sickle cell disease
 Use of hormonal contraceptive

Causes of Stroke
Ischemic
 Thrombosis- occluded blood flow caused by thrombosis of the cerebral arteries
supplying the brain or the intracranial vessels
○ The most frequent cause of CVA
○ The most common cause of cerebral thrombosis is atherosclerosis; usually
affecting elderly persons.
○ Tends to occur during sleep or soon after arising.
○ This may tend to occur among clients with DM, and hypertension.

 Embolism- from thrombus outside the brain, such as in the heart, aorta, or common
carotid artery.
○ The second most common cause of CVA.
○ Most commonly affecting younger people.
○ Most frequently caused by Rheumatic Heart Disease and MI.
○ Symptoms occur at any time and progress rapidly.

Hemorrhagic Stroke – Hemorrhage

 Impaired cerebral perfusion from hemorrhage causes infarction, & the blood itself as a
space-occupying mass, exerting pressure on the brain tissues
 Hemorrhage from an intracranial artery or vein, such as HPN, ruptured aneurysm,
trauma, hemorrhagic disorder, or septic embolism

Transient Ischemic Attacks

 Refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction.
 Manifestation includes contralateral weakness of the lower portion of the face, fingers,
hands, arms, and legs; dysphagia, and sensory impairment.
 Stoke in evolution refers to development of a neurologic deficit over several hours to
days
Pathophysiologic Changes in CVA: specific manifestations are determined by the cerebral artery
affected, the brain tissue supply by that vessel, and the adequacy of the collateral circulation

• Aphasia, dysphasia; visual fields deficits; and hemiparesis of affected side (more
severe in face & arms)- resulting from thrombosis or hemorrhage of middle cerebral
artery
• Weakness, paralysis, numbness; sensory changes; altered LOC; bruits over carotid artery;
and headache caused by thrombosis or hemorrhage of carotid artery
• Weakness, paralysis, numbness around lips & mouth; visual field deficits, diplopia,
nystagmus; poor coordination, dizziness, dysphagia, slurred speech; amnesia, and ataxia
resulting from thrombosis or hemorrhage of vertebrobasilar artery.
• Confusion, weakness, numbness; urinary incontenece; impaired motor & sensory
functions; and personality changes caused by thrombosis or hemorrhage of anterior
cerebral artery.
• Visual field deficits; sensory impairments; dyslexia; cortical blindness and coma resulting
from thrombosis or hemorrhage of posterior cerebral artery.
Assessment of CVA
• check for:
 S&S of increased ICP.
 Perceptual defects
 Aphasia
 Unstable respiration
 Severe headache
 Diagnostic procedure results
 Unilateral neglect
Diagnostic Findings
• CT scan- identifies an ischemic stroke within the first 72 hours of symptom onset or
evidence of a hemorrhagic stroke (lesions >1 cm immediately)
• MRI-assists in identifying areas of ischemia or infarction and cerebral swelling
• Others: angiography, carotid duplex scan, EEG

Complications
• Hemiplegia – weakness/paralysis of half the body
• Cognitive impairment - Aphasia – maybe expressive or receptive; the partial or total
inability to produce & understand speech
• Apraxia – can move but cannot do the purpose; inability to perform complex movements
• Sensory impairement - Visual changes – Homonymous Hemianopsia; Agnosia – loss of
sense of smell
• Dysarthria - difficulty in speech articulation due to lack of muscle control
• Kinesthesia – loss of sensation (of bodily movement)
• Incontinence – maybe fecal/urine; inability to control urination or defecation
 • Shoulder pain
• Contractures
• Fluid imbalances
• Cerebral edema
• Aspiration
• Altered LOC
• Infections such as pneumonia

Nursing Considerations
 Maintain a patent airway and oxygenation:
○ If the pt is unconscious; vomiting- lateral position to prevent aspiration of saliva
 Check v/s & neurologic status:
○ Monitor BP, LOC, pupillary changes, motor and sensory functions, speech, skin,
color, temp.
○ Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity
 Watch for s/s of pulmonary emboli:
○ Chest pain, shortness of breath, dusky color, tachycardia, fever, and change in
sensorium
 If the pt is unresponsive, monitor ABG as ordered
 Monitor F & E balance:
○ Monitor I and O.
○ Administer IVF as ordered
○ Offer bedpan /urinal
 Ensure adequate nutrition:
○ Check for gag reflex before offering small oral feedings of semisolid food
○ Teach the client to chew on the unaffected side.
○ If oral feeding is not possible, TPN, NGT feeding, gastrostomy feeding
 Turn the patient frequently, at least q 2 hrs to prevent pneumonia.
 Perform ROM exercises for affected & unaffected sides.
 Massage if not contraindicated.
 Provide meticulous eye care- Instill meds as ordered; patch the affected eye if the pt can’t
close eyelid.
 Compensate for perceptual difficulties.
○ Care of the client with Hemianopsia.
○ Approach from the unaffected side.
○ Place articles on the unaffected side.
 Promote communication
○ Care for the client with aphasia.
○ Say one word at time.
○ Give simple commands.
○ Allow the client to verbalize, no matter how long it takes him
 Give medications as ordered- Tell the pt to watch out for side effects. (ex. Aspirin-GI
bleeding)

Assist with rehab

  Teach the pt to comb hair, to dress, & to wash
 Obtain assistive devices ( through the aid of PT/OT) such as walkers, hand bars by the
toilet, and ramps as needed
 Be aware that the pt has a unilateral neglect, in which he fails to recognize that he ha a
paralyzed side- show him how to protect his body from harm
 Emphasize importance of regular ff-up visits

PARKINSON’S DISEASE
 Slowly progressive degenerative disorder of basal ganglia function that results in variable
combinations of tremor, rigidity, and bradykinesia
 Onset usually after age 40
 men>women
Parkinson’s Disease: deficient in dopamine

Causes
 Exact cause unknown
 Possible causes:
○ Dopamine deficiency, which prevents affected brain cells from performing their
nomal inhibitory function in the CNS
○ Exposure to toxins( manganese dust or carbon monoxide)
 ○ Repeated trauma to the brain
○ Stroke
○ Brain tumors

Pathophysiology
 Dopamine neurons degenerate, causing loss of available dopamine
 Dopamine deficiency prevents affected brain cells from performing their normal
inhibitory function
 Excess excitatory Ach occurs at the synapses
 Nondopamineric receptors are also involve
 Motor neurons are depressed

Pathophysiologic changes/ S&S

 Muscle rigidity, akinesia, and insidious tremor beginning in the fingers (UNILATERAL
PILL_ROLL TREMOR) secondary to loss of inhibitory dopamine activity at the synapse-
increase during stress or anxiety; decreases with purposeful movement & sleep
 Muscle rigidity with resistance to passive
 Mask-like appearance
 Gait disturbance-lacks normal parallel motion; may be retropulsive or propulsive
 Oily skin- secondary to inappropriate regulation of androgen production by hypothalmic-
pituitary axis
 Dysphagia, dysarthria; excessive sweating; decreased GI motility and genitourinary
smooth muscle-from impaired autonomic transmission
 Voice changes
 Small handwriting
 Poor judgment, endogenous depression, dementia- from impaired dopamine metabolism,
and neurotransmitter dysfunction

Common Health Problem that occur Across the Life Span

SEIZURE DISORDER
• Sudden explosive and disorderly discharge of cerebral neurons
• Abnormal and excessive discharge of neurons in the brain
• Types of seizures:
a. grand mal
b. petit mal
c. febrile seizures
d. status epilepticus

Petit mal
 No aura
 10-20 seconds
 Common to children as well as adult
 Little tonic-clonic movements
 Cessation of ongoing physical activities
Jacksonian
 With aura
 With organic lesion
 Group of muscle affectation

Psychomotor Seizure
 With aura
 With psychiatric involvement
 Characterized with mental clouding
 Violence, antisocial acts

Febrile Seizure
 Related to temperature
 Present among children

Status epilepticus
 Prolonged seizure state
 Can occur in any type of seizure
 Rapid successions with no full consciousness in between
 Brain damage can occur; most life threatening in tonic-clonic seizures
 Common to clients who are in coma
 Related to medication
a) Primary Seizure Disorder (Epilepsy)
○ Idiopathic
○ No apparent structural changes in the brain
b) Secondary Epilepsy
○ Characterized by structural changes or metabolic alterations of the
neuronal membranes that caused increased automacity

Causes of Seizures
 Idiopathic- two-thirds of all seizure disorders
 Anoxia
 Birth trauma (inadequate supply of O2 supply to the brain, blood incompatibility,
hemorrhage)
 Brain tumors
 Drug or alcohol abuse or rapid withdrawal from abused drugs
 Febrile illness
 Genetic predisposition
 Head injury or trauma
 Infectious diseases
 Ingestions of toxins( lead, mercury, or carbon monoxide)
  Metabolic disorders, such as hypoglycemia or hyperparathyroidism
 Perinatal infections

Pathophysiology
 Some neurons of the brain may depolarize easily or hyperexcitable
 On stimulation, these neurons fires locally or throughout the cerebrum and spreads
electric current to surrounding cells.
 Cells fire in turn and the impulses cascades to one side of the brain (a partial seizure),
both sides of the brain (a generalized seizure), or the cortical, subcortical, and brain stem
areas.

Pathophysiologic changes
 Recurring seizures, possibly of more than one type ( hallmark of epilepsy)
 Visual, olfactory, or auditory hallucinations; sweating or flushing; dream states; anger, or
fear reactions resulting from simple partial seizures
 Altered consciousness , such as amnesia for events around the time of the seizure,
resulting from complex partial seizures
 Movement and muscle involvement resulting from tonic-clonic or myoclonic seizures
 Brief changes in LOC without motor involvement due to absence seizures

Complications
 Hypoxia or anoxia from airway occlusion
 Traumatic injury
 Brain damage
 Depression and anxiety

Diagnostic Tests
 CT scan or MRI- reveals abnormalities
 EEG- reveals paroxysmal abnormalities
➢ in tonic-clonic seizures, high, fast voltage spikes are present in all leads
➢ In absence seizures, rounded spike wave complexes are present
➢ Note: a negative EEG doesn’t rule out epilepsy because the abnormalities occur
intermittently
 Skull x-ray may show evidence of fractures or shifting of the pineal gland, bony erosion,
or separated sutures
 Serum chemistry blood studies may reveal hypoglycemia, electrolyte imbalances, and
elevated liver enzyme & alcohol level

Treatment
 Drug Therapy-
➢ Ex. Phenytoin (Dilantin) carbamazepine (Tegretol), phenobarbital (Barbita,
Luminal) –for generalized tonic clonic seizures and complex partial seizures
 ➢ Valproic acid (Depakene), clonazepam (Klonopin) for absence seizures
 If drug therapy is ineffective, surgery to remove a demonstrated focal lesion, or to
remove the underlying cause (tumor, abscess)
 I.V. diazepam ( valium), lorazepam (Ativan) phenytooin, or phenobarbital for status
epilepticus
 Dextrose- for hypoglycemia
 Thiamine-for chronic alcoholism or withdrawal

Nursing Considerations
 Patent airway
 Oxygenate as needed
 Raise side rails
 Ensure safety-during seizure:
➢ Avoid restraining the pt
➢ Help the pt to a lying position
➢ Loosen any tight clothing
➢ Clear the area of hard objects
➢ Don’t place anything into the pt’s mouth to prevent lacerating the mouth & lips or
displace teeth
➢ If vomiting occurs, turn the head to provide an open airway
 After the seizure subsides, reorient the patient to time & place; inform him that he had a
seizure
 Companion at bedside
 Meds as ordered

INCREASED INTRACRANIAL PRESSURE

• ICP- the pressure exerted within the intact skull by the intracranial volume - about 10%
blood,10% CSF, & 80% brain tissue
• Causes
 head injury
 CVA
 tumors
 HPN
• Pathophysiology
 ICP- the brain will compensate by:
○ limiting bld flow to the head
○ displaces CSF into the spinal canal
○ increases absorption or decreases production
 If ICP remains high, there will be loss of autoregulatory mechanism which will
lead to passive dilation, increased cerebral flow, and venous congestion. Further
increase in ICP will result to cellular hypoxia and eventually, brain death.
 Major Types of Herniation

• S&S
 Increased HA
 Nausea &Vomiting
 Cushing’s triad
 Restlessness
 Eye involvement
 Altered LOC
 Sensory dysfunction
 Elimination problem
 Decorticate/decerebrate
 • Nursing Management
 Determine airway patency
 Elevate HOB
 Check VS/Neuro assessment
 Record I&O
 Enema restriction
 Avoid coughing, vomiting, restraints, stress ulcer, suctioning
 Seizure precaution
 Edema reduction
 Diuretics

CRANIOCEREBRAL TRAUMA (HEAD INJURY)

• Involves injury to the scalp, skull, and/or brain tissues.

• Types of Brain Injury
 Concussions. Jarring of the brain and its sudden, forceful contact with the rigid
skull. There is transient period of unconsciousness.
 Contusion (bruising). A structural alteration characterized by extravasion of blood
cells.
 Laceration. Tearing of tissue caused by sharp fragment or object or shearing
force.
 Compression of the Brain. Result from depressed fracture causing edema and
hemorrhage.

Assessment
 Sign and symptoms of increased ICP.
 CSF leakage from ears and nose.
 Battle’s sign (hematoma at the mastoid process) in basilar head trauma.

Management
 Care for the client with increased ICP.
 Monitor drainage from ears and nose.
 Monitor for signs and symptoms of meningitis, atelectasis, pneumonia, UTI.

INTRACRANIAL TUMORS
• Intracranial tumors may be classified as: gliomas, meningiomas, neuromas,
hemangiomas.
• Gliomas account for about 50% of all brain tumors.
Assessment
 Frontal lobe
○ Personality disturbance
○ Inappropriate affect
○ Indifference of bodily functions
 Precental gyrus
○ Jacksonian seizures
 Occipital lobe
○ Visual disturbances preceeding convulsions.

 Temporal lobe
○ Olfactory, visual or gustatory hallucinations.
○ Psychomotor seizures with automatic behavior.
 Parietal lobe
○ Inability to replicate pictures.
○ Loss of right-left discrimination

Management
 Care for the client with increase ICP.
 Surgery
○ Supratentorial craniotomy (post-op)
 Semi-fowler’s position
○ Infratentorial craniotomy
 Flat position; turn to sides, avoid supine position for the first 48 hours.
Avoid neck flexion.
 Report immediately for presence of yellowish drainage on the head
dressing.
 An increase in urine output may herald onset of diabetes insipidus.
 Test the urine for glucose and acetone when steroids are administered.

SPINAL CORD INJURY

• complete or partial disruption of nerve tracts and neurons
• Causes
 infection
 trauma
 injury
• Signs and symptoms
 Cervical –respiratory diff, quadriplegia
 Thoracic- paraplegia
  Lumbar – flaccid paralysis
 Sacral – loss of erection, ejaculation

Nursing Assessment
 Injury; treatment given at scene
 Neurologic assessment: Document findings
 Vital signs; respiratory status
 Movement and sensation below injury level
 Signs
○ Worsening neurologic damage
○ Respiratory distress
○ Spinal shock

Nursing Diagnoses
 Ineffective breathing pattern
 Ineffective airway clearance
 Neuropathic pain
 Impaired physical mobility
 Anxiety
 Risks
○ Impaired gas exchange
○ Disuse syndrome
○ Ineffective coping

Medical Management
 Cervical collar; cast or brace; traction; turning frame
 IV; stabilization of vital signs
 Corticosteroids
 Surgical intervention

Surgical Management
 Surgery to
○ Remove bone fragments
○ Repair dislocated vertebrae
○ Stabilize the spine

Management
 Maintain airway patency
 Immobilize
 Suction PRN
 Position
 Nutrition
  Elimination hygiene
 Drugs

Evaluation
 Adequate breathing
 Pain relief
 Mobility using minimal assistive devices
 Reduced complications from inactivity
 Coping with the challenge of rehabilitation

INFECTIOUS NEUROLOGIC DISORDERS

• Meningitis
• Brain Abscess
• Herpes Simplex Virus Encephalitis
• Arthropod-Borne Virus Encephalitis
• Fungal Encephalitis
• Creutzfeldt-Jakob and New-Variant Creutzfeldt-Jakob Disease

BRAIN INJURIES
• Closed (blunt) Brain Injury
• Open Brain Injury
• Concussion
• Contusion
• Diffuse Axonal Injury
• Intracranial Hemorrhage
 Epidural Hematoma
 Subdural Hematoma
• Intracerebral Hemorrhage and Hematoma

Pathophysiology