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nervous system consists of the BRAIN and the Spinal Cord • The peripheral nervous system consists of the Spinal nerves and the cranial nerves The nervous system is the master controller of the body. Each thought, each emotion, each action—all result from the activity of this system. It then processes that information and decides how the body should respond, if at all.
Finally, if a response is needed, the system sends out electrical signals that spur the body into immediate action.
The central nervous system is made up of the brain and spinal cord. The brain functions to receive nerve impulses from the spinal cord and cranial nerves. The spinal cord contains the nerves that carry messages between the brain and the body. The brain The human brain is a soft, shiny, grayish white, mushroom-shaped structure encased within the skull. Although brain size varies considerably among humans, there is no correlation or link between brain size and intelligence. The brain is composed of lobes• Frontal lobe- personality, memory and motor function • Parietal lobe- sensory function • Temporal lobe- hearing and olfaction and emotion by the limbic system • Occipital lobe- vision
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Test for coordination- rapid alternating movements and finger to nose test ROMBERG test BALANCE TESTS:
B. ROMBERG TEST Ask the person to stand up with feet together and arms at the side. Ask the client to close the eyes and to hold the position for about 20 seconds. Normally, a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur. Positive Romberg sign (loss of balance that occurs when closing the eyes) occurs with cerebellar ataxia, loss of proprioception and loss of vestibular function. • BALANCE TESTS:
A. TANDEM WALKING Ask the person to walk a straight line in a “heel-to-toe” fashion.
The left cerebral hemisphere controls movement of the right side of the body. Depending on the severity, a stroke affecting the left cerebral hemisphere may result in functional loss or motor skill impairment of the right side of the body, and may also cause loss of speech. The right cerebral hemisphere controls movement of the left side of the body. Depending on the severity, a stroke affecting the right cerebral hemisphere may result in functional loss or motor skill impairment of the left side of the body. In addition, there may be impairment of the normal attention to the left side of the body and its surroundings. The thalamus is an important relay station for sensory information coming to the cerebral cortex from other parts of the brain. The thalamus also interprets sensations of pain, pressure, temperature, and touch, and is concerned with some of our emotions and memory. Cerebellum- Is both excitatory and inhibitory actions and responsible for coordination of movement. It controls also fine movements, balance, position sense or proprioception and integration of sensory input. • • The cerebellum is involved in coordination and equilibrium The diencephalon consists of the : • Thalamus- the relay center of all sensory input • Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal, hunger, satiety
Tandem walking decreases the base of support and accentuates problem with coordination. Normally, the person can walk straight and stay balanced. Inability to tandem walk may indicate upper motor neuron lesion such as in multiple sclerosis. • COORDINATION TESTS:
A. RAPID ALTERNATING MOVEMENTS (RAM) Ask the person to pat the knees with both hands, patting alternately with the dorsum and palmar surfaces of the hands. Start slowly then ask the client to do it faster. Ask the person to touch the thumb to each finger on the same hand, starting with the index finger then reverse direction.
STEREOGNOSIS – test the person’s ability to recognize objects by feeling their forms, sizes and weights. Ask the client to close his eyes and identify an object that is placed in his hand. Test a different object in each hand.
Normally, a person will explore the object with the fingers and correctly name it. Testing the left hand assesses right parietal lobe functioning. ASTEREOGNOSIS occurs in sensory cortex lesions. GRAPHESTESIA – ability to read a number by having it trace on the skin. With the client’s eyes closed, use a blunt instrument to trace a number or a letter on the palm.
The cerebellum processes input from other areas of the brain, providing precise timing for coordinated, smooth movements of the skeletal muscular system. A stroke affecting the cerebellum may cause dizziness, nausea, balance and coordination problems. • Test for balance- heel to toe
Ask the person to tell you what the number or letter is. The brainstem is composed of the: MIDBRAIN- for visual and auditory reflexes Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8 Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12
Can't remember the names of the cranial nerves? Here is a handydandy mnemonic for you:
Anosmia (absence of smell)
The Brain stem is the stalk of the brain and is a continuation of the spinal cord. It consists of the medulla oblongata, pons, and midbrain. The medulla oblongata is actually a portion of the spinal cord that extends into the brain. All messages that are transmitted between the brain and spinal cord pass through the medulla. Nerves on the right side of the medulla cross to the left side of the brain, and those on the left cross to the right. The result of this arrangement is that each side of the brain controls the opposite side of the body. Three vital centers in the medulla control heartbeat, rate of breathing, and diameter of the blood vessels. Centers that help coordinate swallowing, vomiting, hiccuping, coughing, sneezing, and other basic functions of life are also located in the medulla. • • • Pons bridge between the two halves of the cerebellum and between medulla cerebrum. It also controls the heart, respiration, blood pressure. CN V, VIII connects in the brain in the pons.
blurred vision; blindness
Pupil constriction, elevation of the upper fixed, dilated pupils lid. Eye movement; controls superior oblique muscle. Controls of muscles of mastication; sensations for the entire face. Nystagmus
Trigeminal Neuralgia (tic douloureux)
Eye movement; controls the lateral rectus muscle.
Diplopia; ptosis of the eyelid.
Controls muscles for facial expression; Bell’s palsy; ageusia (loss of sense of anterior 2/3 of the tongue. taste) of the anterior 2/3 of the tongue. Cochlear branch permits hearing; vestibular branch helps maintain equilibrium. Tinnitus; vertigo
Controls muscles of the throat; taste of Loss of the gag reflex, drooling of the the posterior 1/3 of the tongue. saliva, dysphagia, dysphagia, dysphonia, posterior third ageusia. Controls muscles of the throat, PNS stimulation of thoracic and abdominal organs. Loss of gag reflex, drooling of the saliva, dysphagia, dysarthia, bradycardia, increased HCl secretion.
X. Vagus nerve
Test for the Oculocephalic reflex- doll’s eye • Normal response- eyes appear to move opposite to the movement of the head • Abnormal- eyes move in the same direction What is the spinal cord? The spinal cord is part of the nervous system and is about 45 cm long in men and 43 cm long in women. The length of the spinal cord is much shorter than the length of the bony spinal column. It runs the length of the back, extending from the base of the brain to about the waist. The area within the vertebral column beyond the end of the spinal cord is called the cauda equina. The nervous system is made up of nerve cells or neurons. Neurons have a limited ability to repair themselves. Unlike other body tissues, nerve cells cannot also be repaired if damaged due to injury or disease.
Sen Sen Mo Mo Mi Mo Mi Sen Mi Mi Mo Mo
XI. Spinal Accessory
Controls sternocleidomastoid and trapezius muscles.
EYE OPENING Spontaneous To speech To pain
E 4 3 2 1 M
Movements of the tongue.
No response BEST MOTOR RESPONSE To Verbal Command: Obeys To Painful Stimulus: Localizes pain
5 4 3 2 1 V 5 4 3 2 1
PHYSICAL EXAMINATION • 5 categories: • 1. Cerebral function- LOC, mental status • 2. Cranial nerves • 3. Motor function • 4. Sensory function • 5. Reflexes CATEGORIES OF CONSCIOUSNESS • NORMAL & aware of self & environment. • Spontaneous eye opening
Flexion-withdrawal Flexion-abnormal Extension No response BEST VERBAL RESPONSE Oriented and converse Disoriented Inappropriate words Incomprehensible sounds No response Glasgow Coma Score 8 and Below= severe head injury! Assessing the sensory function • Evaluate symmetric areas of the body • Ask the patient to close the eyes while testing • Use of test tubes with cold and warm water • Use blunt and sharp objects • Use wisp of cotton • Ask to identify objects placed on the hands • Test for sense of position • • • • • • • • • 4+ of disease. 3+ 2+ 1+ 0
LETHARGIC State of drowsiness or inaction which pt. needs an increase stimulus. To be awaken. OBTUNDED Duller indifferences to external stimuli & response is minimally maintained. STUPOR Marked reduction in mental & physical activity, vigorous & continuous stimuli needed. Shows some spontaneous movement. COMA Does not respond to any stimuli, no voluntary movement. Reflexes maybe intact or absent. GLASCOW COMA SCALE to assess these simple three (3) parameters: 1. THE OPENING OF THE EYES; 2. THE USE OF VOICE; 3. and, THE BEST MOVEMENT ( Motor Response).
C5 – The deltoid muscle (abduction of the arm at the shoulder). C6 – The biceps (flexion of the arm at the elbow). C7 – The triceps (extension of the arm at the elbow). C8 – The small muscles of the hand. L4 – The quadriceps (extension of the leg at the knee). L5 – The tibialis anterior (upward flexion of the foot at the ankle). S1 – The gastrocnemius muscle (downward flexion of the foot at the ankle). FOUR POINT SCALE FOR GRADING REFLEXES - very brisk, hyperactive with clonus, indicative - brisker than average, may indicate disease. - average, normal. - diminished, low normal. - no response
The GCS assigned a score to its function: I - As the lowest number ( absence of function ) I5 – As the highest score 8 OR LESS – defines coma ( which indicates less brain function and suggest a higher degree of injury ). Coma represents the last and lowest level of function of the brain prior to death. As a general rule: IF A PATIENT IN COMA SURVIVES FIRST 7 to 10 days following THE INJURY OF THE BRAIN, THEN LONG TERM SURVIVAL CAN BE EXPECTED, HOWEVER THE QUALITY OF THE SURVIVAL REMAINS A SUBJECT OF DEBATE.
Deep tendon reflex • 0- absent • + present but diminished • ++ normal • +++ increased • ++++ hyperactive or clonic Superficial reflex • 0 absent • +present • EEG • Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants Wash hair thoroughly after the procedure
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Surgical complications Subarachnoid hemorrhages Viral infection
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• Definition 1. Measurement and recording of electrical activity of the brain in the form of waves 2. Provides information about seizure disorders, local tumors,infections of the central nervous system, and chemical toxicity With radiation risk If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected Cross-sectional visualization of the brain determined by computer analysis of relative tissue density as an x-ray beam passes through; also known as computerized axial tomography (CAT) scan
Pathophysiology • The cranium only contains the brain substance, the CSF and the blood/blood vessels • MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other • Any increase or alteration in these structures will cause increased ICP • In response Pathologic conditions alter the relationship intracranial volume and ICP • 2. reduction of oxygen will lead to brain damage will lead to edema of the brain and shifting of fluids from the dura and increase ICP. • 3. Increase PaCO2 lead to increase ICP Nursing interventions: Maintain patent airway
CT scan • • •
1. Elevate the head of the bed 30 degrees- to promote venous drainage 2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels◊constricts blood vessels◊reduces edema 3. Administer prescribed medications- usually • Mannitol- to produce negative fluid balance • corticosteroid- to reduce edema • anticonvulsants- to prevent seizures 4. Reduce environmental stimuli 5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning, flexion of the head** 6. Keep head on a neutral position. AVOID- extreme flexion, valsalva 7. monitor for secondary complications • Diabetes insipidus • SIADH
PET scan • Definition • 1. This test registers glucose metabolism in a cross-section of the brain; glucose metabolism increases in areas of the brain that are active • 2. Utilized to diagnose Alzheimer's disease, depression, dementia,and brain tumors MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure This procedure utilizes magnetism and radio waves to produce images of cross-sections of the body Cerebral arteriography / angiography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site Lumbar puncture / Spinal tap Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP*** Keep flat on bed after procedure** Increase fluid intake after procedure Increased Intracranial pressure Brunner= Normal intracranial pressure 10-20 mmHg Causes: • Head injury • Stroke • Inflammatory lesions • Brain tumor
Altered level of consciousness • It is a manifestation of multiple pathophysiologic phenomena • Causes: head injury, toxicity and metabolic derangement • Disruption in the neuronal transmission results to improper function Assessment • Orientation to time, place and person • Motor function • Decerebrate • Decorticate • Sensory function • • 1. 2. 3. 4. 5. 6. • 1. COMA= clinical state of unconsciousness where patient is NOT aware of self and environment Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure ASSESSMENT Behavioral changes initially
Pupils are slowly reactive Then , patient becomes unresponsive and pupils become fixed dilated Glasgow Coma Scale is utilized Nursing Intervention 1. Maintain patent airway • Elevate the head of the bed to 30 degrees • Suctioning 2. Protect the patient • Pad side rails • Prevent injury from equipments, restraints and etc. 3. Maintain fluid and nutritional balance • Input and output monitoring • IVF therapy • Feeding through NGT 4. Provide mouth care • Cleansing and rinsing of mouth • Petrolatum on the lips 5. Maintain skin integrity • Regular turning every 2 hours • 30 degrees bed elevation • Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity • Use of artificial tears every 2 hours 7. Achieve thermoregulation • Minimum amount of beddings • Rectal or tympanic temperature • Administer acetaminophen as prescribed 8. Prevent urinary retention • Use of intermittent catheterization** 9. Promote bowel function • High fiber diet • Stool softeners and suppository 10. Provide sensory stimulation • Touch and communication** • Frequent reorientation Autonomic Dysreflexia/hyperreflexia Seen commonly in spinal cord injury above T6 • An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation*** Trigeminal neuralgia (tic douloureux) • Findings – intense facial pain lasting about one to two minutes along the nerve branches – extreme facial sensitivity • Diagnostics: history and physical exam • Management – expected outcome: to relieve pain – anticonvulsants: phenytoin (dilantin) – help clients to name trigger points with identification of triggering incidents – recommend restful environment with scheduled rest – provide balanced nutrition teach client • medications and side effects • to avoid triggering agents • to chew on the opposite side of the mouth • to avoid very hot or cold foods Facial nerve paralysis (bell's palsy)
Definition/etiology disorder of cranial nerve seven (facial nerve) involves one side only; unilateral etiology unknown Findings often occur suddenly over ten to 30 minutes ptosis cannot close or blink eye with excessive tearing flat nasolabial fold impaired taste lower face paralysis difficulty eating Diagnostics: history and physical exam Management – expected outcome: to restore cranial nerve function – medications » prednisone » analgesics – local comfort measures: heat, massage and electrical nerve stimulation for muscle tone – alternative actions: massage, imagery – – administer drugs as ordered teach client » to chew on opposite side » how to use protective eye wear during risk periods » effects of steroids » the use of eye drugs or ointment to protect the eye from corneal irritation » that once findings disappear their return may occur especially in times of high stress – provide balanced nutrition: soft diet » use of eye patch » Physical Therapy
Traumatic brain injury • AN INJURY TO THE BRAIN OR SCALP AS A RESULT OF TRAUMA. • Occurs when a mechanical force comes in contact with a portion of the brain. (generally the frontal or temporal lobes) directly or indirectly Most common causes • Vehicle accidents compounded by drugs or alcohol use • Acts of violence • Falls • Sports –related injury Occurs most in males between 10-39 yrs old Types: Minor Laceration of the scalp-tearing of the vessels of the scalp that may cause bleeding 2. Contusion- brief loss of consciousness;may also experience amnesia and headaches. • Major: 1. Fractures – comminuted, linear , or depressed Clinical manifestations: Battle’s sign (post-auricular ecchymosis) Racoon’s eye (periorbital edema) Rrhinorrhea (leakage of CSF from nose) Otorrhea – fluid from ear 2. Epidural hematoma – arterial bleed result of temporal bone. 3. Subdural hematoma- venous bleed generally result of a laceration of brain tissue. Findings of head trauma • Degree of neurological damage varies with type and location of injury • • a. 1.
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Restlessness and irritability - initially Decreased LOC - lethargy, difficulty with arousal,amnesia Nausea and vomiting - projectile vomiting indicates increased ICP Cushing’s reflex- severe hypertension and wide pressure is a late sign. Hypovolemic shock Behavioral changes Weakness Ataxia Decreased muscle tone
The real danger lies in possible spinal cord damage. Spinal fractures most commonly occur in the 5th, 6th, and 7th cervical, 12th thoracic, and 1st lumbar vertebrae. Complications: • Spinal shock-occurs immediately following the injury. • Characterized by: • - decreased reflexes • Loss of sensation • Flaccid paralysis below the site of injury Neurogenic shock- loss of vasomotor tone results from the injury characterized by: hypotension, bradycardia. - Occurs with cervical or high thoracic injury Types of injury: Incomplete Central cord syndrome- occurs in older adults in the cervical cord area 2. Anterior cord syndrome- results from flexion injury with motor paralysis and loss of pain and temperature below the site of injury 3. Posterior cord syndrome-rare;loss of proprioception 4. Brown-sequard syndrome-loss of motor function ipsilateral and contralateral pain and temperature remains intact below the level of injury. 5. Conus medullaris and cauda equina- lower limb paralysis,bowel and bladder dysfxn. In th elumbar and sacral area. AUTONOMIC HYPERREFLEXIA /DYSREFLEXIAAutonomic dysreflexia (hyperflexion) Occurs in injury at T6 or above. Most common cause is overdistended bladder or bowel Characterized by hypertension (systolic greater than 300mmHg),bradycardia,diaphoresis and piloerection( body hair erection.), nausea and nasal congestion NURSING INTERVENTIONS 1. Elevate the head of the bed immediately 2. Check for bladder distention and empty bladder with urinary catheter • 3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer • 4. Administer antihypertensive medications- usually hydralazine Spinal Shock Pathophysiology • The sudden depression of reflex activity in the spinal cord below the level of injury • The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions • • • a. 1.
1. CONCUSSION • Involves jarring of head without tissue injury • Temporary loss of neurologic function lasting for a few minutes to hours 2. CONTUSION • Involves structural damage • The patient becomes unconscious for hours 3. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery*** Symptoms develop rapidly** MANIFESTATIONS • 1. Altered LOC • 2. CSF otorrhea • 3. CSF rhinorrhea • 4. Racoon eyes and Battle sign NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway • Elevate bed, suction prn, monitor ABG • Logroll the client 3. Monitor for rhinorhea or otorrhea 4. Administer good skin care 5. Monitor for increase intracranial pressure 6. Provide adequate nutrition 7. Prevent injury • Use padded side rails • Avoid extreme flexion or extension of the neck 8.Elevate the head of the bed to 30 degrees 9.Provide warm or coldcompress to the eyes to dec. periorbital edema 10.. Maintain skin integrity • Prolonged immobility will likely cause skin breakdown • Turn patient every 2 hours • Provide skin care every 4 hours • Avoid friction and shear forces • Prevent complications of immobility 7. Monitor potential complications • Increased ICP • Meningitis** • Post-traumatic seizures • Impaired ventilation Surgical management: Craniotomy:performed to decrease ICP to remove ischemic tissues Spinal Cord Injury • Injury to the spinal cord as a result of an incomplete or complete loss of sensory and motor function. • Caused by MVA, sports injuries or violence and falls. • The greatest at risk is the 16 to 30 yr.old category.
Spinal shock: A rare condition that can occur after spinal cord injury and involves a period of absent reflexes which may be permanent or last for hours to weeks. This period may be followed by a period of excessive reflexes. Signs and symptoms of spinal shock Absence of reflex Paraplegia Atonic paralysis Sensory loss
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The primary treatment after a spinal injury is immediate immobilization to stabilize the spine and prevent cord damage; other measures are supportive. Cervical injuries require immobilization, using a type of cervical immobilization device (CID) on both sides of the patient’s head, a hard cervical collar, or skeletal traction • • Treatment of stable lumbar and dorsal fractures consists of bed rest on firm support (such as a bed board)
Later measures include exercises to strengthen the back muscles and use of a back brace or other device to provide support while walking. • Reorient the patient by calling his name frequently • Provide background information as to date, time, place, environment 3. Use large signs as visual cues 4. Post patient's photo on the door 5. Encourage family members to bring personal articles and place them in the same area • Establish a regular pattern for bowel care • Place the patient on potty every other day • Use of stool softeners • Maintain a dietary intake. Avoid foods that can cause excessive gas production • Elevate the head of the bed 90 degrees during meals and 30 minutes after • Serve foods that are soft and small sized • Keep suction equipment on bedside • Consult with rehabilitation team as to assistive devices that can be utilized Clinical manifestations • 1. Paraplegia • 2. quadriplegia • 3. diplegia • EMERGENCY MANAGEMENT • A-B-C • Immobilization • Immediate transfer to tertiary facility NURSING INTERVENTION • 1. Promote adequate breathing and airway clearance • 2. Improve mobility and proper body alignment*** • 3. Promote adaptation to sensory and perceptual alterations • 4. Maintain skin integrity • • • • • • • • 5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications Thrombophlebitis Orthostatic hypotension Spinal shock Autonomic dysreflexia
Major risk factors » Coronary artery dse. » Hypertension » Age » DM » Previous TIA » transient ischemic attack (TIA), "angina" of the brain » TIA is warning sign of stroke » localized ischemic event » produces neurological deficits lasting only minutes or hours » full functional recovery within 24 to 48 hours » reversible ischemic neurological deficit (RIND) » similar to TIA Two types of stroke by cause – ischemic (also known as occlusive) onset » results from inadequate blood flow infarction » caused by cerebral thrombosis or cerebral blood vessels » most common cause: atherosclerosis – There is disruption of the cerebral obstruction by embolus or thrombus CLINICAL MANIFESTATIONS • 1. Numbness or weakness • 2. confusion or change of LOC • 3. motor and speech difficulties • 4. Visual disturbance • 5. Severe headache – » » » stroke (clot) - slower leading to a cerebral embolism within the blood flow due to
hemorrhagic stroke (bleeding) - abrupt onset ; TYPES blood vessels rupture with a bleed into the brain occurs most often in hypertensive older adults may also result during anticoagulant or thrombolytic therapy » most often caused by rupture of saccular intracranial aneurysms The Circle of Willis is the joining area of several arteries at the bottom (inferior) side of the brain. At the Circle of Willis, the internal carotid arteries branch into smaller arteries that supply oxygenated blood to over 80% of the cerebrum. Middle cerebral artery: • Aphasia – inability to communicate • Dysphagia • HEMIPARESIS on the OPPOSITE side- more severe on the face and arm than on the legs (weakness) Anterior cerebral artery: • Weakness • Numbness on the opposite side • Personality changes • Impaired motor and sensory function Posterior cerebral artery: • Visual field defects • Sensory impairment • Coma • Less likely paralysis RISKS FACTORS Non-modifiable • Advanced age • Gender
CEREBROVASCULAR ACCIDENTS • An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply • Definition: decreased blood supply to the brain • Risk factors • hypertension, uncontrolled • smoking • obesity • increased blood cholesterol and triglycerides • chronic atrial fibrillation
Modifiable • Hypertension • Cardio disease • Obesity • Smoking • Diabetes mellitus • hypercholesterolemia Motor Loss • Hemiplegia – paralysis of one side of the body after a stroke • Hemiparesis - weakness Communication loss • Dysarthria= difficulty in speaking • Aphasia= Loss of speech • Apraxia= inability to perform a previously learned action Perceptual disturbances • Hemianopsia – defective vision or blindness in half of the visual field of one or both eyes. Sensory loss • Paresthesia – any abnormal touch sensation as numbness or tingling in the absence of stimuli NURSING INTERVENTIONS: ACUTE 1. Ensure patent airway 2. Elevate head 3. Monitor VS and GCS, pupil size 4. IVF is ordered but given with caution as not to increase ICP 5. NGT inserted 6. Medications: Heparin, Enoxaparin, t-PA, ASA, Steroids, Mannitol (to decrease edema), Diazepam NURSING INTERVENTIONS: Hospital 1. Improve Mobility and prevent joint deformities • Correctly position patient to prevent contractures • Place pillow under axilla • Hand is placed in slight supination- “C” • Change position every 2 hours 2. Enhance self-care • Carry out activities on the unaffected side • Prevent unilateral neglect- place some items on the affected side!!! • Keep environment organized • Use large mirror 3. Manage sensory-perceptual difficulties • Approach patient on the Unaffected side • Encourage to turn the head to the affected side to compensate for visual loss 4. Manage dysphagia • Place food on the UNAFFECTED side • Provide smaller bolus of food • Manage tube feedings if prescribed 5. Help patient attain bowel and bladder control • Intermittent catheterization is done in the acute stage • Offer bedpan on a regular schedule • High fiber diet and prescribed fluid intake 6. Improve thought processes • Support patient and capitalize on the remaining strengths 7. Improve communication • Anticipate the needs of the patient • Offer support • Provide time to complete the sentence • Provide a written copy of scheduled activities
• Give one instruction at a time 8. Maintain skin integrity • Use of specialty bed • Regular turning and positioning • Keep skin dry and massage NON-reddened areas • Provide adequate nutrition 9. Promote continuing care • Referral to other health care providers 10. Improve family coping 11. Help patient cope with sexual dysfunction Multiple sclerosis Definition demyelination of white matter throughout brain and spinal cord – third most common cause of disability in clients aged 15 to 60 – specific cause unknown – increased incidence in temperate to cool climates – illness improves and worsens unpredictably Findings depend on the location of the demyelination – cranial nerve: blurred vision, dysphagia, diplopia, facial weakness and/or numbness – motor: weakness, paralysis, spasticity, gait disturbances – sensory: paresthesias, decreased proprioception – cerebellar: dysarthria, tremor, incoordination, ataxia, vertigo – – – – – cognitive: decreased short-term memory, difficulty with new information, word-finding difficulty, short attention span urinary retention or incontinence loss of bowel control sexual dysfunction fatigue » » » » » » avoid fatigue and stress conserve energy exercise regularly know drugs and side effects use self-help devices maintain a diet that supports nutrition and energy needs
Guillain Barre Syndrome Definition – acquired inflammatory disease – process: demyelinization of peripheral nerves – precipitating factors include prior bacterial or viral infection within one to two weeks
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muscle weakness: progressive, ascending, bilateral leads to paralysis of voluntary muscles loss of superficial and deep tendon reflexes bulbar weakness dysphagia dysarthria respiratory failure sensory findings: paresthesias, burning pain paralysis may vary from being total to partial of only one-half way up the body expected outcomes: to prevent complications and maintain body functions until any reversal steroids in acute phase care as dictated by areas involved
maintain the care of client on ventilatory support provide for care of the immobilized client
have a safe environment to minimize infection » energy conservation techniques maintain nutrition and fluid balance » medications, expectations and side effects refer families or client to support groups » signs of impending crisis, both myasthenic and supply referrals to therapies such as speech, physical, cholinergic occupational and counseling » to avoid stressors Parkinson's disease Definition: degenerative disorder of the dopamine hydrochloride - producing neurons (substantia nigra Myasthenia Gravis – result: dopamine hydrochloride depletion Definition: – usually occurs in older adults and males more than females – antibodies destroy acetylcholine receptors where nerves join – etiology unknown muscles – two age clusters: women in early adulthood and men in late – resting tremors of the lips, jaw, tongue, and limbs, especially a adulthood resting pill-rolling tremor of one hand that is absent during sleep. – progressive with occurrence of crises This is different from an essential or intention tremor in which the tremor is action related. – progressive fatigue of voluntary muscles, but no muscular – bradykinesia / akinesia atrophy – fatigue – facial – stiffness and cogwheel rigidity with movement » ptosis (drooping eyelid) and reduced eye closure – signs first unilateral, then bilateral » weak smile – mask-like facial expression » diplopia, blurred vision – slow, shuffling walk; gradually more difficult » speech and swallowing disorders – Drooling of saliva » weakness of facial muscles – Dysphagia – signs of restrictive lung disease – Trunk bent forward – sensation remains intact – Microphonia – Micrographia – difficulty rising from sitting position – No intellectual impairment – history and physical exam – No true paralysis – edrophonium (tensilon) test: improved muscle strength after – No loss of sensation tensilon injection indicates a positive test for MG Management DIET: Inc. caloriec, soft diet – expected outcome to improve strength and endurance Position to prevent contractures: – pharmacologic firm beds, no » anticholinesterase agents: pyridostigmine (mestinon),pillows neostigmine (prostigmin) Prone position when lying in bed » corticosteroid therapy – pharmacologic » immunosuppressants: azathioprine (imuran) » anticholinergics - minimize extrapyramidal effects – » dopamine hydrochloridergics-improve muscle myasthenic crisis management flexibility: Levodopa (L-Dopa) » crisis usually follows stressor or during dosage » antiparkinsonian agent: amantadine hcl (Symmetrel) changes reduces rigidity and tremor Avoid the following foods rich in Vit. B6 when on Levodopa therapy;may block the effects of » signs: sudden inability to swallow, speak, or maintain » » » » – patent airway cholinergic crisis may follow over dosage of medication positive edrophonium (tensilon) test signals myasthenia Avoid tyramine if negative endophronium test, client has not rich foods (may cause hepertensive crisis) myasthenic but cholinergic crisis, so treat with chocolate atropine coffee ventilatory support as indicated
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Seizure Definition/etiology • Sudden, transient alteration in brain function • Disorderly transmission of electrical activity in the brain • Causes if client is in crisis: provide care of the client on ventilatory – cerebral lesions support – biochemical alteration give medications as ordered and on time – cerebral trauma help with ADL and feeding as indicated – idiopathic identify aggravating factors, such as: » infection » stress » changes in medication regime provide » emotional support » adequate rest periods » care of the surgical client teach client Types of generalized seizures - one classification system Absence seizures (petit mal seizures) Myoclonic seizures (bilateral massive epileptic myoclonus) Generalized tonic-clonic seizures (grand mal seizures)
Akinetic seizure • •
» techniques to reduce stress » seizure care at home or at work petit mal - called absence seizures » to wear medic-alert jewelry myoclonic » if in public area, after the tonic phase turn client to • sudden, uncontrollable jerking movements of one or side more extremities • usually occurs in the morning clonic In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to • characterized by violent muscle movements cognition and bowel control. be in • hyperventilation Peripheral nerves can regenerate, but nerves in the spinal cord are thought to not be able to • face contortion • excessive salivation During a seizure, do not force anything into the client's mouth. tonic A major problem often associated with a left-sided CVA is an alteration in communication. • first, client loses consciousness suddenly and muscles Clients with CVAs are at a greater risk for aspiration. Initially these clients must be evaluated to contract determine if dysphagia is present. • body stiffens in opisthotonos position The rate, rhythm and depth of a client's respirations are more sensitive indicators of increases in • jaws clenched intracranial pressure than blood pressure and pulse. • may lose bladder control When caring for a comatose client, remember that the hearing is the last sense to be lost. • apnea with cyanosis After a CVA clients often have a loss of memory, emotional lability and a decreased attention span. • pupils dilated and unresponsive Communication difficulties of a client with a CVA usually indicate involvement of the dominant • usually lasts less than a minute hemisphere, usually left, and is associated with right sided hemiplegia or hemiparesis. The client with myasthenia gravis will have more severe muscle weakness in the evening due to grand mal: most common type the fact that muscles weaken with activity - described as progressive muscle weakness - and regain » tonic-clonic movements strength with rest. » lasts two to three minutes » client is unresponsive for about five minutes » arms, legs go limp » breathing returns to normal » possible disorientation or confusion for sometime afterwards atonic: sudden loss of postural muscle tone with collapse status epilepticus » rapid sequence of seizures without interruption » medical and nursing emergency » sometimes occurs if a sudden stop of maintenance doses of anticonvulsants » if cerebral anoxia occurs, brain damage or death can follow
e harmful objects from the patient’s surrounding he client to the floor t the head with a pad ve and note for the duration, parts of body affected, behaviors before and after the
ave the client who is seizing to prevent or break client's fall by assisting him/her to horizontal position on the bed or the
ght clothing around neck and chest objects near the client illow under the client's head if possible and available client's head in a lateral position if possible to maintain airway hing in the client's mouth
type of seizure - describe behavior rather than labeling duration activity during and if incontinence if any precipitating factors client's response - immediate, then at 15 minute intervals until stability is established client » » about medication effects, interactions, and side effects to learn when a seizure may be triggered