MEDICAL-SURGICAL NURSING NERVOUS SYSTEM

Overview of structures and functions:

Central Nervous System
Brain
Spinal Cord Peripheral Nervous System
Cranial Nerves
Spinal Nerves Autonomic Nervous System
Sympathetic nervous system
Parasympathetic nervous system

Sympathetic Nervous System Parasympathetic Nervous System

(ADRENERGIC) (CHOLINERGIC, VAGAL, SYMPATHOLYTIC

- Involved in fight or aggression response. - Involved in fight or withdrawal response.

- Release of Norepinephrine (cathecolamines) - Release of Acetylcholine.
from adrenal glands and causes - Decreases all bodily activities except GIT.
vasoconstriction. EFFECTS OF PNS
- Increase all bodily activity except GIT - Constriction of pupils (meiosis).
EFFECTS OF SNS - Increase salivation.
- Dilation of pupils(mydriasis) in order to be aware. - Decrease BP and Heart Rate.
- Dry mouth (thickened saliva). - Bronchoconstriction, Decrease RR.
- Increase BP and Heart Rate. - Diarrhea
- Bronchodilation, Increase RR - Urinary frequency.
- Constipation.
- Urinary Retention.
- Increase blood supply tobrain,heart andskeletal
muscles.
- SNS

I. Adrenergic Agents I. Cholinergic Agents

- Give Epinephrine. -Mestinon,Neostigmine.
Signs and Symptoms: Side Effects
- SNS - PNS
Contraindication: II. Anti-cholinergic Agents
- Contraindicated to patients suffering from COPD - To counter cholinergic agents.
(Broncholitis, Bronchoectasis, Emphysema, Asthma). - Atropine Sulfate
II. Beta-adrenergic Blocking Agents Side Effects
- Also called Beta-blockers. - SN
- 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.
Should 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)
In chronic cases of arrhythmia give
Lidocaine(Xylocaine

CENTRAL NERVOUS SYSTEM

  Brain and Spinal Cord.
I. CELLS
A. NEURONS
 Basic cells for nerve impulse and conduction.
PROPERTIES
Excitability – ability of neuron to be affected by changes 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 REGENERATIVE CAPACITY
1. Labile
 Capable of regeneration.
 Epidermal cells, GIT cells, GUT cells, cells of lungs.

2. Stable
 Capable of regeneration with limited time, survival period.
 Kidney cells, Liver cells, Salivary cells, pancreas.
3. Permanent
 Not capable of regeneration.
 Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA
 Support and protection of neurons.
TYPES
1. Astrocytes – maintains blood brain barrier semi-permeable.
Majority of brain tumors (90%) arises from calledastrocytoma.
2. Oligodendria
3. Microglia
4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER

1. Ammonia
 Cerebral toxin
 Hepatic Encephalopathy (Liver Cirrhosis)
 Ascites
 Esophageal Varices

Early Signs of Hepatic Encephalopathy

 asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy

 Headcahe
 Dizziness
 Confusion
 Fetor hepaticus (ammonia like breath)
 Decrease LOC

PATHOGNOMONIC SIGNS
1. 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), Brudzinski sign (neck pain).
20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).
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 skin pigmentation.
26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.
27. HYPERTHYROIDISM/GRAVE’S DISEASE –exopthalmus.
28. INTUSSUSCEPTION – sausage shaped mass

2. Carbon Monoxide and Lead Poisoning

 Can lead to Parkinson’s Disease
 Epilepsy
 Treat with ANTIDOTE: Calcium EDTA

3. Type 1 DM (IDDM)
 Causes diabetic ketoacidosis
 And increases breakdown of fats
 And free fatty acids
 Resulting tocholesterol and (+) toKetones (CNS depressant)
 Resulting to acetone breath odor/fruity odor
 KUSSMAUL’S respiration, a rapid shallow respiration
 Which may lead to diabetic coma

4. Hepatitis
 Signs of jaundice (icteric sclerae)
 Caused by bilirubin (yellow pigment)

5. Bilirubin
 Increase bilirubin in brain (Kernicterus)
 Causing irreversible brain damage

Astrocites
 Maintains integrity of blood brain barrier

Oligodendria
 Produces myelin sheath in CN
 Act as insulator and facilitates rapid nerve impulse transmission

DEMYELINATING DISORDERS
1. ALZHEIMER’S DISEASE
 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
 “motor speech center”
 Broca’s Aphasia
*Receptive aphasia
 Inability to understand spoken words
 Wernicke’s Aphasia
 General Knowing Gnostic Area or General Interpretative Area
DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX
2. MULTIPLE SCLEROSIS
 Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord.
 Characterized by remission and exacerbation
 Women ages 15-35 are prone
 Unknown Cause
 Slow growing virus
 Autoimmune disorders
 Pernicious anemia
 Myasthenia gravis
 Lupus
 Hypothyroidism
 GBS
Ig G – only antibody that pass placental circulation causing 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 Symptoms
1. Visual disturbances
blurring of vision (primary)
diplopia (double vision)
scotomas (blind spots)
2. Impaired sensation
to touch, pain, pressure, heat and cold.
tingling sensation
paresthesia
numbness
3. Mood swings
euphoria (sense of well being
4. Impaired motor function
weakness
spasticity
paralysis
5. Impaired cerebral function
scanning speech

TRIAD SIGNS OF MS
Ataxia

(Unsteady gait, (+) Romberg’s Test

Intentional Tremors Nystagmus

6. Urinary retention/incontinence
7. Constipation
8. Decrease sexual capacity
DIAGNOSTIC PROCEDURE
CSF analysis (increase inIgG andProtein).
MRI (reveals site and extent of demyelination).
(+) Lhermitte’s sign a continuous and increase contraction of spinal column.
NURSING MANAGEMENT
1. Administer medications as ordered
a. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at site
of demyelination to prevent paralysis.
b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.
c.Interferons – alter immune response.
d.Immunosupresants
2. Maintain side rails to prevent injury related to falls.
3. Institute stress management techniques.
a. Deep breathing exercises
b.Yo g a
4. Increase fluid intake and increase fiber to prevent constipation.
5. Catheterization to prevent retention
a.Diuretics
b. Bethanicol Chloride (Urecholine)
Nursing Management
Only given subcutaneous.
Monitor side effects bronchospasm and wheezing.
Monitor breath sounds 1 hour after subcutaneous administration.
c. For Urinary Incontinence
Anti spasmodic agent
a. Prophantheline Bromide (Promanthene)
Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.
To acidify urine and prevent bacterial multiplication
COMMON CAUSE OF UTI
Female
short urethra (3-5 cm, 1-1 ½ inches)
poor perineal hygiene
vaginal environment is moist
Nursing Management
avoid bubble bath (can alter Ph of vagina).
avoid use of tissue papers
avoid using talcum powder and perfume.
Male
Urethra (20 cm, 8 inches)
urinate after intercourse
MICROGLIAstationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating),
pinocytosis (cell drinking)

MACROPHAGE ORGAN
Microglia Brain
Monocytes Blood
Kupffers cells Kidney
Histiocytes Skin
Alveolar Lung
MacrophagE

EPINDYMAL CELLS
Secretes a glue called chemo attractants that concentrate the bacteria.
COMPOSITION OF BRAIN
80% brain mass
10% blood
10% CSF
I. Brain Mass
PARTS OF THE BRAIN
1. CEREBRUM
largest part
composed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the
Corpus Callosum.
Functions of Cerebrum
integrative
sensory
motor
Lobes of Cerebrum
1. Frontal
higher cortical thinking
controls personality
controls motor activity
Broca’s Area (motor speech area) when damaged results to garbled speech.
2. Temporalhearing
short term memory
3. Parietal
for appreciation
discrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.
4. Occipital
for vision
Insula (Island of Reil)
visceral function activities of internal organ like gastric motility.
Limbic System (Rhinencephalon)
controls smell and if damaged results toAnosmia (absence of smell).
controls libido
controls long term memory
2. BASAL GAGLIA
areas of grey matter located deep within each cerebral hemisphere.
release dopamine (controls gross voluntary movement

NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar Disorder
Dopamine Parkinson’s Disease Schizophrenia

3. MIDBRAIN/ MESENCEPHALON
acts as relay station for sight and hearing.
size of pupil is 2 – 3 mm.
equal size of pupil isisocoria.
unequal size of pupil isanisocoria.
hearing acuity is 30 – 40 dB.
positive PERRLA
4. INTERBRAIN/ DIENCEPHALON
Parts of Diencephalon
A. Thalamusacts as relay station for sensation.
B. Hypothalamus
controls temperature (thermoregulatory center).
controls blood pressure
controls thirst
appetite/satiety
sleep and wakefulness
controls some emotional responses like fear, anxiety and excitement.
controls pituitary functions
androgenic hormones promotes secondary sex characteristics.
early sign for males are testicular and penile enlargement
late sign is deepening of voice.
early sign for females telarche and late sign is menarche.
5. BRAIN STEM
located at lowest part of brain
Parts of Brain Stem
1. Pons
pneumotaxic center controls the rate, rhythm and depth of respiration.
2. Medulla Oblongata
controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation and
constriction of bronchioles).
3. Cerebellum
smallest part of the brain.
lesser brain
controls balance, equilibrium, posture and gait

INTRACRANIAL PRESSURE
 Monroe Kellie Hypothesis

Skull is a closed container

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure

(normal ICP is 0 – 15 mmHg)
Cervical 1 – also known as ATLAS.
Cervical 2 – also known as AXIS.
Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

Alternate hot and cold compress to prevent HEMATOMA

CSF cushions brain (shock absorber)
Obstruction of flow of CSF will lead to enlargement of skull posteriorly calledhydrocephalu s.
Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERS
NCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in one
of the 3 major intra cranial components.
Causes:
head trauma/injury
localized abscess
cerebral edema
hemorrhage
inflammatory condition (stroke)
hydrocephalus
tumor (rarely)

Signs and Symptoms (Early)

decrease LOC
restlessness/agitation
irritability
lethargy/stupor
coma

Signs and Symptoms (Late)

changes in vital signs
blood pressure (systolic blood pressure increases but diastolic remains the same).
widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).
heart rate decrease
respiratory rate decrease
temperature increase directly proportional to blood pressure.
projective vomiting
headache
papilledema (edema of optic disc)
abnormal posturing
decorticate posturing (damage to cortex and spinal cord).
decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and
midbrain).
unilateral dilation of pupilscalled uncal herniation
bilateral dilation of pupilscalled tentorial herniation
resulting to mild headache
possible seizure activity
Nursing Management
1. Maintain patent and adequate ventilation by:
a. Prevention of hypoxia and hypercarbia
Early signs of hypoxia
restlessness
agitation
tachycardia
Late signs of hypoxia
Bradycardia
Extreme restlessness
Dyspnea
Cyanosis
HYPERCARBIA
Increase CO2 (most powerful respiratory stimulant) retention.
In chronic respiratory distress syndrome decrease O2 stimulates respiration.
b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only.
c. Assist in mechanical ventilation
2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venous
drainage.
3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).
4. Monitor strictly input and output and neuro check
5. 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 maneuver like:
straining stool
excessive vomiting (use anti emetics)
excessive coughing (use anti tussive like dextromethorphan)
avoid stooping/bending
avoid lifting heavy objects
e. avoid clustering of nursing activity together
7. Administer medications like:
a. Osmotic diuretic (Mannitol)
for cerebral diuresis
Nursing Management
monitor vital signs especially BP (hypotension).
monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered via side drip
regulated fast drip to prevent crystal formation.
b. Loop diuretic (Lasix, Furosemide)
Drug of choice for CHF (pulmonary edema)
Loop of Henle in kidneys.
Nursing Management

Monitor vital signs especially BP (hypotension).

monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.
administered IV push or oral.
given early morning
immediate effect of 10 – 15 minutes.
maximum effect of 6 hours.
c.Corticosteroids
Dexamethasone (Decadron)
Hydrocortisone
Prednisone (to reduce edema that may lead to increase ICP)
Mild Analgesics (Codeine Sulfate for respiratory depression)
Anti Convulsants (Dilantin, Phenytoin
*CONGESTIVE HEART FAILURE
Signs and Symptoms
dyspnea
orthopnea
paroxysmal nocturnal dyspnea
productive cough
frothy salivation
cyanosis
rales/crackles
bronchial wheezing
pulsus alternans
anorexia and general body malaise
PMI (point of maximum impulse/apical pulse rate) is displaced laterally
S3 (ventricular gallop)
Predisposing Factors/Mitral Valve
RHD
Aging
TREATMENT
Morphine Sulfate
Aminophelline
Digoxin
Diuretics
Oxygen
Gases, blood monitor
RIGHT CONGESTIVE HEART FAILURE (Venous congestion)
Signs and Symptoms
jugular vein distention (neck)
ascites
pitting edema
weight gain
hepatosplenomegaly
jaundice
pruritus
esophageal varices
anorexia and general body malaise
Signs and Symptoms of Lasix in terms of electrolyte imbalances
1. Hypokalemia
decrease potassium level
normal valueis 3.4 – 5.5 meq/L
Sign and Symptoms
weakness and fatigue
constipation
positive U wave on ECG tracing
Nursing Management
administer potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)
increase intake of foods rich in potassium

FRUITS VEGETABLES
Apple Asparagus
Banana Brocolli
Cantalop Carrots
eOrange Spinach

2. Hypocalcemia/ Tetany
decrease calcium level
normal valueis 8.5 – 11 mg/100 ml
Signs and Symptoms
tingling sensation
paresthesia
numbness
(+) Trousseau’s sign/ Carpopedal spasm
(+) Chvostek’s sign
Complications
Arrhythmia
Seizures
Nursing Management
Calcium Gluconate per IV slowly as ordered
* Calcium Gluconate toxicity – results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicity

S/S
BP
Urine output DECREASE
Respiratory rate
Patellar relfex absent

3. Hyponatremia
decrease sodium level
normal valueis 135 – 145 meq/L
Signs and Symptoms
hypotension
dehydration signs (Initial sign in adult isTHIRST, in infantTACHY CARDIA)
agitation
dry mucous membrane
poor skin turgor
weakness and fatigue
Nursing Management
force fluids
administer isotonic fluid solution as ordered
4. Hyperglycemia
normal FBSis 80 – 100 mg/dl
Signs and Symptoms
polyuria
polydypsia
polyphagia
Nursing Management
monitor FBS
5. Hyperuricemia
increase uric acid (purine metabolism)
foods high in uric acid (sardines, organ meats and anchovies)
*Increase in tophi deposit leads to Gouty arthritis.
Signs and Symptoms
joint pain (great toes)
swelling
Nursing Management
force fluids
administer medications as ordered
a. Allopurinol (Zyloprim)
Drug of choice for gout.
Mechanism of action : inhibits synthesis of uric acid
b. Colchecine
Acute gout
Mechanism of action: promotes excretion of uric acid.
* KIDNEY STONES
Signs and Symptoms
renal colic
Cool moist skin
Nursing Management
force fluids
administer medications as ordered
a. Narcotic Analgesic
Morphine Sulfate
ANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.
b. Allopurinol (Zyloprim)
Side Effects
Respiratory depression (check for RR)
PARKINSON’S DISEASE/ PARKINSONISM
Chronic progressive disorder of CNS characterized by degeneration of dopamine producing
cells in the SUBSTANCIA NIGRA of the midbrainand basal ganglia.
Predisposing Factors
1. Poisoning (lead and carbon monoxide)
2. Arteriosclerosis
3. Hypoxia
4. Encephalitis
5. Increase dosage of the following drugs
a. Reserpine(Serpasil)
b. Methyldopa(Aldomet)
AntihypertensiveS
c. Haloperidol(Haldol)
d. Phenothiazin
SIDE EFFECTS RESERPINE Major depression leading to suicide Major depression leading to suicide
277direct approach towards the client
278close surveillance is a nursing priority
279time to commit suicide is on weekends early morning
Signs and Symptoms for Parkinson’s
280pill rolling tremors of extremities especially the hands.
281bradykinesia (slowness of movement)
282rigidity (cogwheel type)
283stooped posture
284shuffling and propulsive gait
285over fatigue
286mask like facial expression with decrease blinking of the eyes.
287difficulty rising from sitting position.
288Monotone type speech
289mood lability (in state of depression)
290increase salivation (drooling type)
291autonomic changes
a. increase sweating
b. increase lacrimation
c. seborrhea
d. constipation
e. decrease sexual capacity
Nursing Management
1. Administer medications as ordered
Anti Parkinsonian agents
292Levodopa (L-dopa) short acting
293Amantadine Hydrochloride (Symmetrel)
294Carbidopa (Sinemet)
Mechanism of Action
295increase level of dopamine
Side Effects296GIT irritation (should be taken with meals
297orthostatic hypotension
298arrhythmia
299hallucinations
Contraindications
300clients with narrow angle closure glaucoma
301clients taking MAOI’s (no foods with triptophan and thiamine)
302urine and stool may be darkened
303no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa
* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid Hydrazide
Anti Cholinergic Agents (ARTANE and COGENTIN)- to relieve tremors
Mechanism of Action
304inhibits action of acethylcholine
Side Effects
305SNS
Anti Histamine (Dipenhydramine Hydrochloride)
Side Effects
Adult: drowsiness
Children: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.
Dopamine Agonist- relieves tremor rigidity
Bromocriptene Hydrochloride (Parlodel)
Side Effects306Respiratory depression
2. Maintain side rails to prevent injury
3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy
MAGIC 2’s in Drug Monitoring

DRUG NORMAL RANGE TOXICITY LEVEL INDICATION CLASSIFICATION

Digoxin/ Lanoxin .5 – 1.5 meq/L 2 CHF Cardiac Glycoside
(Increase force of
cardiac output
Lithium/ Lithane .6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents
(Decrease level of
Ach/NE/Serotonin
Aminophylline 10 – 19 mg/100 m 20 COPD Bronchodilators
(Dilates bronchial tree

Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-convulsant

Acetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis Non-narcotic Analgesic

2. Maintain side rails to prevent injury

3. Prevent complications of immobility
4. Decrease protein in morning and increase protein in afternoon to induce sleep
5. Encourage increase fluid intake and fiber.
6. Assist/supervise in ambulation
7. Assist in Stereotaxic Thalamotomy
MAGIC 2’s IN DRUG MONITORING
DRUG
NORMAL RANGE
TOXICITY
LEVEL
INDICATION
CLASSIFICATION
Digoxin/ Lanoxin
(Increase force of
cardiac output)
.5 – 1.5 meq/L
2
CHF
Cardiac Glycoside
Lithium/ Lithane
(Decrease level of
Ach/NE/Serotonin)
.6 – 1.2 meq/L
2
Bipolar
Anti-Manic Agents
Aminophylline
(Dilates bronchial tree)
10 – 19 mg/100 ml
20
COPD
Bronchodilators
Dilantin/ Phenytoin
10 – 19 mg/100 ml
20
Seizures
Anti-Convulsant
Acetaminophen/Tylenol
10 – 30 mg/100 ml
200
Osteo
Arthritis
Non-narcotic
Analgesic
1. Digitalis Toxicity
Signs and Symptoms
307nausea and vomiting
308diarrhea
309confusion
310photophobia
311changes in color perception (yellowish spots)
Antidote:Dig ib ind
2. Lithium Toxicity
Signs and Symptoms
312anorexia
313nausea and vomiting
314diarrhea
315dehydration causing fine tremors
316hypothyroidism
Nursing Management
317force fluids
318increase sodium intake to 4 – 10 g% daily
3. Aminophylline Toxicity
Signs and Symptoms
319tachycardia
320palpitations
321CNS excitement (tremors, irritability, agitation and restlessness)
Nursing Management
322only mixed with plain NSS or 0.9 NaCl to prevent development of crystals or
precipitate.
323administered sandwich method
324avoid taking alcohol because it can lead to severe CNS depression
325avoid caffeine
4. Dilantin Toxicity
Signs and Symptoms
326gingival hyperplasia (swollen gums)
327hairy tongue
328ataxia
329nystagmus
Nursing Management
330provide oral care
331massage gums
5. Acetaminophen Toxicity
Signs and Symptoms
332hepatotoxicity (monitor for liver enzymes)
333SGPT/ALT (Serum Glutamic Pyruvate Transaminace)
334SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)
335nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)
336hypoglycemia
Tremors, tachycardia
Irritability
Restlessness
Extreme fatigue
Diaphoresis, depression
Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.
MYASTHENIA GRAVIS
337neuromuscular disorder characterized by a disturbance in the transmission ofimpulses from nerve to muscle cells at the neuromuscular junction leading
todescending muscle weakness.
Incidence rate: women 20 – 40 years old
Predisposing factors
338unknown
339autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.
Signs and Symptoms
340initial sign isptos is a clinical parameter to determine ptosis is palpebral fissure.
341diplipia
342mask like facial expression
343dysphagia
344hoarseness of voice
345respiratory muscle weakness that may lead to respiratory arrest
346extreme muscle weakness especially during exertion and morning
Diagnostic Procedure
347Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs
and symptoms for about 5 – 10 minutes and a maximum of 15 minutes.
q
if there is no effect there is damage to occipital lobe and midbrain and is negative or MG
Nursing Management
1. airway
2. aspiration
maintain patent airway and adequate ventilation
3. mmobility
* assist in mechanical ventilation and monitor pulmonary function test
* monitor strictly vital signs, input and output and neuro check
* monitor strength or motor grading scale
4. maintain side rails to prevent injury related to falls
5. institute NGT feeding
6. administer medications as ordered
a. Cholinergic (Mestinon)
b. Anti Cholenisterase (Neostegmin)
Mechanism of Action
qincrease level of Ach
Side Effects
qPNS
qCortocosteroids suppress immune response
qmonitor for 2 types of crisis:
MYASTHENIC CRISIS CHOLINERGIC CRISIS
Causes: Cause:
- under medication - over medication
- stress Signs and Symptoms
- infection - PNS
Signs and Symptoms Treatment
- The client is unable to see, swallow, speak, - Administer anti cholinergic agents
breathe (Atropine Sulfate)
Treatment
- administer cholinergic agents as ordered.
7. Assist in surgical procedure known as thymectomy because it is believed that the thymus gland
is responsible for M.G.
8. Assist in plasma paresis and removing auto immune anti bodies
9. Prevent complications.

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITIS
Meninges
q3 fold membrane that covers brain and spinal cord.
qfor support and protection
qfor nourishment
qblood supply
LAYERS OF THE MENINGES
1. Dura matter – outer layer2.Ara c hnoid – middle layer3. Pia matter – inner layer
qsubdural space between the dura and arachnoid
qsubarachnoid space between the arachnoid and pia, CSF aspiration is
done.

A. Etiology
1. Meningococcus – most dangerous
2. Pneumococcus
3. Streptococcus - causes adult meningitis
4. Hemophilus Influenzae – causes pediatric meningitis
B. Mode of transmission
348airborne transmission (droplet nuclei)
C. Signs and Symptoms
349headache
350photophobia
351projectile vomiting
352fever, chills, anorexia, general body malaise and weight loss
353Possible increase in ICP and seizure activity
354Abnormal posturing (decorticate and decerebrate)
355Signs of meningeal irritation
a. Nuchal rigidity or stiff neck
b. Opisthotonus (arching of back)
c. (+) Kernig’s sign (leg pain)
d. (+) Brudzinski sign (neck pain)
D. Diagnostic Procedures 356Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Nursing Management for LP
Before Lumbar Puncture 1. Secure informed consent and explain procedure.
2. Empty bladder and bowel to promote comfort.
3. Encourage to arch back to clearly visualize L3-L4.
Post Lumbar Puncture 1. Place flat on bed 12 – 24o
2. Force fluids
3. Check punctured site for any discoloration, drainage and leakage to tissues.
4. Assess for movement and sensation of extremities.
CSF analysis reveals 1. Increase CHON and WBC
2. Decrease glucose
3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)
4. (+) cultured microorganism (confirms meningitis)
CBC reveals
1. Increase wbc E. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered
a. Broad spectrum antibiotics (Penicillin, Tetracycline)
b. Mild analgesics
c. Anti pyretics
3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy
4. Elevate head 30-45o
5. Monitor strictly V/S, input and output and neuro check
6. Institute measures to prevent increase ICP and seizure.
7. Provide a comfortable and darkened environment.
8. Maintain fluid and electrolyte balance.
9. Provide client health care and discharge planning concerning:
a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings. b. Prevent complications 357mostfe a re d ishy droce pha l us
358hearing loss/nerve deafness is second complication
359consulta udi ol ogis t
c. Rehabilitation for neurological deficit
360mental retardation
361delayed psychomotor development
CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) 362a partial or complete disruption in the brains blood supply. 3632 most common cerebral
artery affected by stroke
a. Mid Cerebral Artery
b. Internal Cerebral Artery – the 2 largest artery
A. Incidence Rate 364men are 2-3 times high risk B. Predisposing Factors 365thrombus (attached) 366embolus (detached and most dangerous because it can go to
the lungs and cause pulmonary embolism or the brain and cause cerebral embolism
Signs and Symptoms of Pulmonary Embolism
367Sudden sharp chest pain
368Unexplained dyspnea
369Tachycardia
370Palpitations
371Diaphoresis
372Mild restlessness
Signs and Symptoms of Cerebral Embolism
373Headache and dizziness
374Confusion
375Restlessness
376Decrease LOC
Fat embolism is the most feared complications after femur fracture.
Yellow bone marrow are produced from the medullary cavity of the long bones and produces
fat cells.
If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the
circulation.
Compartment syndrome (compression of arteries and nerves)
C. Risk Factors
1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, ValvularHeart
Disease, Post Cardiac Surgery (mitral valve replacement)
2. Lifestyle (smoking), sedentary lifestyle
3. Obesity (increase 20% ideal body weight)
4. Hyperlipidemia more on genetics/genes that binds to cholesterol
5. Type A personality
a. deadline driven
b. can do multiple tasks
c. usually fells guilty when not doing anything
6. Related to diet: increase intake of saturated fats like whole milk
7. Related stress physical and emotional
8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to
atherosclerosis that will lead to hypertension and eventually CVA.
D. Signs and Symptoms
377dependent on stages of development
1. TIA
378Initial sign of stroke or warning sign
Signs and Symptoms
379headache and dizziness
380tinnitus
381visual and speech disturbances
382paresis (plegia)
383possible increase ICP
2. Stroke in evolution
384progression of signs and symptoms of stroke
3. Complete stroke
385resolution phase characterized by:
Signs and Symptoms
386headache and dizziness
387Cheyne Stokes Respiration
388anorexia, nausea and vomiting
389dysphagia
390(+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke
391focal neurological deficits
a. phlegia
b. aphasia
c. dysarthria (inability to articulate words)
d. alexia (difficulty reading)
e. agraphia (difficulty writing)
f. homonymous hemianopsia (loss of half of visual field)
E. Diagnostic Procedure
1. CT Scan – reveals brain lesions
2.Cerebral Arteriography
392reveals the site and extent of malocclusion
393uses dye for visualization
394most of dye are iodine based
395check for shellfish allergy
396after diagnostic exam force fluids to release dye because it is nephro toxic
397check for distal pulse (femoral)
398check for hematoma formation
F. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. administrate O2 inhalation
2. Restrict fluids to prevent cerebral edema that might increase ICP
3. Elevate head 30 – 45o
4. Monitor strictly vitals signs, I & O and neuro check
5. Prevent complications of immobility by:
a. turn client to side
b. provide egg crate mattresses or water bed
c. provide sand bag or food board.
6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent
contractures
7. Institute NGT feeding
8. Provide alternative means of communication
a. non verbal cues
b. magic slate
9. If positive to hemianopsia approach client on unaffected side
10. Administer medications as ordered
a. Osmotic Diuretics (Mannitol)
b. Loop Diuretics (Lasix, Furosemide)
c. Cortecosteroids
d. Mild Analgesics
e. Thrombolytic/Fibrinolytic Agents – dissolves thrombus
399Streptokinase
Side Effect: Allergic Reaction
400Urokinase
401Tissue Plasminogen Activating Factor
402Side Effect: Chest Pain
f. Anti Coagulants
403Heparin (short acting)
404check for partial thromboplastin time if prolonged there is a
risk for bleeding.
405give Protamine Sulfate
406Comadin/ Warfarin (long acting)
407give simultaneously because Coumadin will take effect after
3 days
408check for prothrombin time if prolonged there is a risk for bleeding
409give Vit. K (Aqua Mephyton)
g. Anti Platelet
410PASA (Aspirin)
411Contraindicated for dengue, ulcer and unknown cause of headache
because it may potentiate bleeding
11. Provide client health teachings and discharge planning concerning
a. avoidance ofmodifiable risk factors (diet, exercise, smoking)
b. prevent complication (subarachnoid hemorrhage is the most feared complication)
c.dietary modification (decrease salt, saturated fats and caffeine)
d. importance of follow up care
GUILLAIN BARRE SYNDROME
412a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to
ascending muscle paralysis.
A. Predisposing Factors
1. Autoimmune
2. Antecedent viral infections such as LRT infections
B. Signs and Symptoms
1. Clumsiness (initial sign)
2. Dysphagia
3. Ascending muscle weakness leading to paralysis
4. Decreased of diminished deep tendon reflex
5. Alternate hypotension to hypertension
** ARRYTHMIA (most feared complication)
6. Autonomic symptoms that includes
a. increase salivation
b. increase sweating
c. constipation
C. Diagnostic Procedures
1. CSF analysis reveals increase in IgG and protein
D. Nursing Management
1. Maintain patent airway and adequate ventilation by:
a. assist in mechanical ventilation
b. monitor pulmonary function test
2. Monitor strictly the following
a. vital signs
b. intake and output
c. neuro check
d. ECG
3. Maintain side rails to prevent injury related to fall
4. Prevent complications of immobility by turning the client every 2 hours
5. Institute NGT feeding to prevent aspiration
6. Assist in passive ROM exercise
7. Administer medications as ordered
a. Corticosteroids – suppress immune response
b. Anti Cholinergic Agents – Atrophine Sulfate
c. Anti Arrythmic Agents
413Lidocaine, Zylocaine
414Bretylium – blocks release of norepinephrineto prevent increase of BP
8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)
9. Prevent complications
a. Arrythmia
b. Paralysis or respiratory muscles/Respiratory arrest
* Sengstaken Blakemore Tube
415for liver cirrhosis
416to decompress bleeding esophageal verices (prepare scissor to cut tube incase
of difficulty in breathing to release air in the balloon
417for hemodialysis prepare bulldog clips to prevent air embolism.
CONVULSIVE DISORDER/ CONVULSION
418disorder of CNS characterized by paroxysmal seizure with or without loss of