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Nervous System

J. Concepcion

Neuron

Central Nervous System
Brain Cerebrum Cerebellum Brain stem Midbrain Pons Medulla oblongata Spinal cord

Nervous System
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Central Nervous System Brain Spinal Cord

2. Peripheral Nervous System  Cranial Nerves  Spinal Nerves

ƥBRAI BRAIN
The Brain is divided into 3 major areas: 1. Cerebrum 2. Brain Stem 3. Cerebellum

External surface of the brain

BRAINN- 1. Cerebrum 

The largest part of the brain.  Composed of:  2 hemisphereshemispheres- 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

Frontal Lobe  Largest lobe   location: front of the skull.The 4 Lobes of the CEREBRUM 1. memory & abstract thought . C Con oncentration. contains the primary motor cortex and responsible for functions related to motor activity. awareness of self. and autonomic responses related to emotions. The left frontal lobe contains Brocaƍs area (control the ability to produce spoken words)    The frontal lobe controls higher intellectual function.

and consistency of objects. visual and somatic input are integrated into thought and memory  .2. Parietal Senso Sensory lobe    location: near the crown of the head. Contains the prim ma ary ry auditory cortex. shape. One of its major function is to process sensory input such as position sense. cortex. Temporal   Wernickeƍs area is located on left temporal lobe. touch.  Contains the interpretative area where auditory. Also spatial relations Location: around the temples. Contains the primary sensory cortex. 3.

Occipital Location: lower back of the head  Contains the primary visual cortex  Function: responsible for visual interpretation.LobesLobes -cont. 4.  .

Contains the interpretative area where auditory. and autonomic responses related to emotions. Parietal.sensory Temporalauditory (Wernickeƞs).    Frontalrontal. awareness of self.motor /controls higher intellectual function. Wernickeƞs). visual and somatic input are integrated into thought and memory Occipital-visual THE 4 LOBES .

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epithalamus .  . hypothalamus. epithalamus.BRAIN. subthalamus. and subthalamus Thalamus  Lies on the either side of the third ventricle  ƏRelay stationƐ for all sensation except smell. sensation and pain impulses pass through this section.DIENCEPHALON   Lies on the top of the brainbrain-stem contains the thalamus. .  All memory.

formation of autonomic nervous system responses.DIENCEPHALON     Hypothalamus  Located anterior and inferior to the thalamus. Epithalamus  Contains pineal gland.  Has a variety of function and plays an important role in maintaining homeostasis.  regulation of body temperature. and storage and secretion of hormones from the pituitary gland. Subthalamus  Part of the extrapyramidal system of the autonomic nervous system and the basal ganglia. .BRAIN. hunger and thirst.

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Several motor disorders are associated with basal ganglia damage including Huntingtonƍs chorea and Parkinsonƍs disease. responsible for fine motor movements.The Basal Ganglia    Are masses of nuclei located deep in the cerebral hemispheres. including those of the hands and lower extremities. .

.BRAINN-2. and medulla oblongata. pons pons. Brain Stem  Consist of the midbrain.  Midbrain -connects the pons and the cerebellum with the cerebral hemisphere. it contains sensory and motor pathways -center for auditory and visual reflexes .

medulla oblongata involved in the respiration. sneezing. Brain Stem  Pons -connects the two halves of the cerebrum . circulation. and swallowing. and the transmission of motor information from the higher brain areas and the spinal cord to the cerebellum.BRAINN-2.involved in the integration of movements in the right and left sides of the body.   . coughing. gastrointestinal functioning.

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a condition characterized by drunkendrunken-like movements. ia. Separated by a fold of dura mater mater.tentorium cerebelli  Damage to the cerebellum can result in ataxia.  FTNT  . balance and posture. Cerebellum   Location: base of the brain.BRAINN-3. brain. Responsible for coordination. and loss of balance. severe tremors.

PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT CEREBRAL FUNCTION ASSESSMENT FingerFinger -to to-Nose Test ‡ abduct and extend the arms at shoulder height and then rapidly touch the nose alternately with one index finger and then the other .

PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT CEREBRAL FUNCTION ASSESSMENT Finger-to Fingerto-Nose & to the Nurse͛s Finger touch the nose and then the index finger of the nurse held at a rapid and increasing rate .

 The meninges (fibrous connective tissues that cover the brain and the spinal cord) provide protection. which protects it from injury. . support and nourishment to the brain and the spinal cord.dura mater 2.arachnoid 3.  Layers of the meninges: meninges: 1.Structures Protecting the Brain  The brain is contained in the rigid skull.pia mater.

Meninges and Related Structures .

maintain normal ICP. .provide a cushion. electrolytes. small amount of carbon monoxide and few leukocytes. water. oxygen. provide nutrition. odorless fluid containing glucose.   Composition ƛ colorless.CS F  CSF . remove metabolic waste.(SG ƛ 1.007) Produced in the choroid plexus of the ventricles.

Lumbar Tap  spinal needle into subarachnoid space at L3-L4. intervertebral space Normal Value of CSF ‡ Pressure ƛ 75-180 mmH20 or 0 to 15 mmHg ‡ Glucose ƛ 50. head and knees flexed on chest) to widen intervertebral spaces .80 mg/dl ‡ Protein ƛ 20 ƛ 50 mg/dl Nursing Considerations Before and During the Procedure  encourage client to void  assist client to assume a Əfetal positionƐ (lateral recumbent position with back arched.L4-L5 & L5-S1.

analgesics and ice to head  observe for changes in neurologic status .After the Procedure  lie flat in bed for 6-8 hours (may turn to sides)  encourage fluids if not contraindicated  headache may develop due to CSF leakage. treated w/ bed rest.

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  Serve as the connection between the brain and the periphery. Acts as a passageway for condition of sensory information from the periphery of the body to the brain (via afferent nerve fibers). .ƥSpinal Cord   Approximately 45 cm long (18 inches) long. Mediates the reflexes.

T1 T2T2-T12 L1L1-L4 L4L4-L5. S1S1-S3 S4 .Spinal Cord cervical brachial plexus intercostal lumbar sacral pudendal C11-4 C55-8.

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BLOOD SUPPLY TO THE CNS  1/3 of the cardiac output From 2 vertebral artery and one internal carotid arteries Circle of Willis ƛ provide collateral circulation   .

Arterial Blood Supply of the Brain .

Peripheral Nervous System Cranial Nerves & Spinal Nerves ƛ .

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ƥCranial 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.          IƜOlfactory nerve IIƜ IIƜOptic nerve IIIƜ III ƜOculomotor nerve IVƜTrochlear nerve VƜTrigeminal nerve VIƜ IƜAbducens nerve VIIƜ IIƜFacial nerve VIIIAcoustic/Vestibuloc ochlear IXƜ IXƜGlossopharyngeal nerve XƜVagus nerve XIƜ XIƜAccessory nerve XIIƜ XII ƜHypoglossal nerve . neck. thoracic cavity and abdominal cavity.

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Vision and visual field tested with an eye chart and by testing point at which person sees an object (finger) moving into visual fields. coffee. inside of the eye is viewed with ophthalmoscope to observe blood vessels. Have the client close eyes and properly identify common aromatic substance held under the nose. II. Olfactory Function Sensory: smell reception and interpretation Assessment Assess nose for Smell.Cranial Nerves Cranial Nerves I. (ex. toothpaste. orange) Assess eyes for Visual Acuity and Peripheral Vision. test one nostril at a time. Optic Sensory: visual acuity and visual fields .

shine a light into the eye to note whether the iris Parasympathetic: pupillary constriction. Test the movement of the eyes in the six cardinal fields of gaze. most extraocular movements Assessment Assess eyes for Extraocular Movement. and CN VI nerves are tested together since they control muscles that provide eye movement. change lens shape . To test pupillary reaction and accommodation. CN IV.Cranial Nerves III. Movement . The CN III. Assess eyes for Pupillary Constriction and Accommodation. Oculomotor Function Motor: raise eyelids.

facial skin V. iris. Assess eyes for Extraocular Movement IV. Accommodation is tested by observing pupillary constriction when the client changes gaze from a distant object to a near object. Trigeminal Assess face for Movement and Sensation Test motor function by having the client clench his/her teeth. forehead. tongue. To test light sensation.Cranial Nerves Function Assessment constricts. have the client close his/ . lacrimal glands. nasal and mouth mucosa. the temporal and masseter muscles. conjunctiva eyelids. nose. making the pupil smaller. Motor: jaw opening and clenching. teeth. inward eye movement. ear. chewing and mastication Sensory: sensation to cornea. Trochlear Motor: downward. then palate.

ptosis of eyelid Inspect the face both at rest and during conversation. close the eyes tightly and show the teeth. paranasal sinuses. close eyes. use alternating blunt and sharp ends of a paper clip over the clientƞs forehead and paranasal sinus. Abducens VII. frown. Diplopia. To test deep sensation. VI. and jaw. labial speech sounds. then wipe a cotton wisp lightly over the anterior scalp.Cranial Nerves Function Assessment her eyes. Facial Motor: lateral eye movement Motor: movement of facial expression muscles except jaw. . Have the client raise the eyebrows.

sensation to pharynx Parasympathetic: secretion of saliva and tears. and lemon to clientƞs tongue. 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.Cranial Nerves Function Assessment Smile and puff out the cheeks. while taking the history. VIII. Acoustic Sensory: hearing and Hearing initially can be screened equilibrium. Sensory: tastetasteanterior two third of tongue. sugar. .

Cranial Nerves
IX. Glossopharyngeal

Function
Motor: voluntary muscle for swallowing and phonation.

Assessment
Assess mouth for Gag Reflex and Movement of Soft Palate. Evaluate CN IX and CN X together for movement and gag reflex. Instruct the client to say Ơahơ; there should be bilateral equal upward movement of the soft palate and uvula; gagging will occur; and speech should be smooth. Assess mouth for Gag Reflex and Movement of Soft Palate

Parasympathetic: secretion of salivary gland, carotid reflex

X. Vagus

Motor: voluntary muscle of phonation and swallowing Sensory: sensation behind ear and part of

Cranial Nerves

Function
external ear canal. Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of the heart, lungs and digestive tract. Motor: turn head, shrug shoulders, some actions for phonation

Assessment

XI. Spinal accessory

Assess shoulder and neck muscles for Strength and Movement 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.

Cranial Nerves
XII. Hypoglossal

Function
Motor: tongue movement for speech sound articulation and swallowing

Assessment
Assess mouth for Tongue Movement, Symmetry, Strength, and Absence of Tumors  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.

ƥSpinal Nerves 

Spinal nerves  31 pairs  8 cervical, 12 thoracic, 5 lumbar  5 sacral, 1 coccygeal  Two roots  Dorsal and ventralventral-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 bodyƞs glands and muscles.

Dermatome distribution .

d dige igestive organs. blood ve vessels. lungs. Sympathetic Nervous System 2.Autonomic Nervous System   Regulates the activities of the internal organs (heart. 2 Components of ANS 1. Parasympathetic Nervous System . and glands) Responsible for maintenance and restoration of internal homeostasis.

norepinephrine. dopamine   ƏFight or flightƐ response.  Pupil dilates  Increased HR  Increased BP  Increased RR  Constipation  Dry mouth  Urinary retention .Sympathetic Nervous System Expenditure of energy  Catecholamines: atecholamines: Epinephrine.

 Acetylcholine        Pupil constricts Decreased HR Decreased BP Decreased RR Diarrhea Increased salivation Urinary frequency .Parasympathetic Nervous System  conserving energy.

Assessment The Neurologic Examination .

disturbances. seizures. and illicit drugs Onset of symptoms. Duration of current complain Recent trauma  The disorders involving neurologic system impairment are headache. change in consciousness.General Assessment for Neurological Disorders Health History  Past Health History      Injuries and surgeries Use of alcohol. dizziness or vertigo. medications. 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/ reaction/pupillary pupillary changes Eye movement & reflex response Change in balance .

Neurologic assessment is divided to into 5 components:      Cerebral function Cranial nerves Motor system Sensory system Reflexes .Neurological Assessment    recognition of change helps assess the patientƞs ability to engage in selfself-care activities.

the patientƞs manner of speech and LOC are also assessed. dressing. coma). stuporous stuporous.  most sensitive indicator of the changes in neurologic status of the client . motor activity. Cerebral Function  Mental status: observe patientƞs appearance. . obtunded.  Posture. facial expression. gestures. movements. behavior.  Level of Consciousness (LOC) ƛ awareness of self and environment and level of arousal (alert. lethargic.1. grooming and personal hygiene.

time & place Memory Immediate recall . or historical events that can be answered by the general population .ask client to repeat your question  Recent memory ƛ ask client about events that occurred few minutes or few hours ago  Remote memory ƛ ask the client about events in the remote past. Recent memory.Mental Status  Orientation to 3 spheres: people. Remote memory  Immediate recall .

 Confusion     Impaired ability to think clearly Disturbed ability to perceive. or from other structural. or psychogenic disturbances. system). and remember current stimuli Disorientation Functional in activities of daily living (ADLs) ARAS ƛ (ascending reticular activating system).Altered Level of Consciousness (LOC)C)can result from destruction of the brain stem or its reticular formation of ascending nerves. metabolic. respond to. center for wakefulness .

 Delirium      Motor restlessness Increased disorientation Transient hallucinations Delusions possible Requires some assistance with ADLs . or psychogenic disturbances. or from other structural.can result from destruction of the brain stem or its reticular formation of ascending nerves. metabolic.Altered Level of Consciousness (LOC)C).

 Obtundation    Decreased alertness Psychomotor retardation Requires complete assistance with ADLs Arousable but not alert Severe disorientation Little or no spontaneous activity Unarousable Unresponsive to external stimuli or internal needs Determination commonly documented using Glasgow Coma Scale score  Stupor     Coma    .Altered Arousal/Level of Consciousness (LOC) cont.

cognitive. somnolent  Level 3 ƛ stuporous. coherent  Level 2 ƛ confused. responds only to noxious or strong/intense stimuli (sternal pressure. trapezius pinch. drowsy.Level of Consciousness  Level 1 ƛ conscious. pressure at the base of the nail or supraorbital area. obtunded. very strong light or sound)  Level 4 ƛ Coma  Light Coma ƛ response is only by grimace or withdrawing limb from pain  Deep Coma ƛ absence of response to even the most painful stimuli GCS (Glassgow Coma Scale) . lethargic.

spontaneous. decorticate. flexion withdrawal. confused in content. localizes painful stimuli. decerebrate. no response Motor Response (6) Ɗ obeys command. no response . on request. no opening Verbal Response (5) Ɗ oriented.GCS (Glassgow Coma Scale)  Eye Opening (4) . groans on evoked pain. to painful stimuli. engages in conversation. words spoken but conversation not sustained.

6 grades 1. Abnormal flexor response to pain pain: ‡ Pressure on the nail bed causes abnormal flexion of limbs ʹ DECORTICATE POSTURE 4. Withdraws to pain pain: ‡ Pulls limb away from painful stimulus. Best Motor Response (M) . 2. No response to pain. internal rotation of shoulder. Extensor posturing to pain pain: ‡ The stimulus causes limb extension (adduction. ‡ Infant: withdraws from pain. . pronation of forearm) ʹ DECEREBRATE POSTURE 3.PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 1.

internal rotation of shoulder. Extensor posturing to pain pain: ‡ The stimulus causes limb extension (adduction. pronation of forearm) ʹ DECEREBRATE POSTURE 3. . 2. Abnormal flexor response to pain pain: ‡ Pressure on the nail bed causes abnormal flexion of limbs ʹ DECORTICATE POSTURE 4. ‡ Infant: withdraws from pain. Withdraws to pain pain: ‡ Pulls limb away from painful stimulus.6 grades 1. No response to pain. Best Motor Response (M) .PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 1.

Obeying command command: ‡ The patient does simple things you ask (beware of accepting a grasp reflex in this category).6 grades 5. ‡ Infant: moves spontaneously or purposefully . ‡ Infant: withdraws from touch 6. Best Motor Response (M) . Localizing response to pain pain: ‡ Put pressure on the patient's finger nail bed with a pencil then try supraorbital and sternal pressure:  purposeful movements towards changing painful stimuli is a 'localizing' response.PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 1.

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2. but no conversational exchange. Incomprehensible speech speech: ‡ Moaning but no words. If patient is intubated. a "derived verbal score" is calculated via a linear regression prediction. .PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 2. Best Verbal Response (V) . agitated. 3. 1.5 grades Record best level of speech. No verbal response. Inappropriate speech: ‡ Random or exclamatory articulated speech. ‡ Infant: Inconsistantly inconsolable. ‡ Infant: Inconsolable. moaning.

and month. Confused conversation conversation: ‡ Patient responds to questions in a conversational manner but some disorientation and confusion. Orientated Orientated: ‡ Patient 'knows who he is. season.PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 2. interacts. where he is and why. the year. orientated to sounds. ‡ Infant: Cries but consolable. follows objects.5 grades 4. Best Verbal Response (V) . 5. . inappropriate interactions. ‡ Infant: Smiles.

Opening to response to pain to limbs as above 3. not necessarily request to open eyes). 4. Eye opening in response any speech (or shout. Spontaneous eye opening. Interpretation of Symptoms: ‡ Severe: less than 8 ‡ Moderate: 9-12 ‡ Mild: 13-15 . 2. Best eye response (E) . No eye opening.PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT SENSORY FUNCTION Glasgow Coma Scale (GCS) 3.4 grades 1.

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

.2. Cranial Nerve Function  Assess cranial nerve function.

assess symmetry differences between right and left side.3.    Altered Muscle Tone Hypotonia. balance and coordination. and strength. Motor System Function Assess muscle size (ins (inspect and palpate) tone.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 .

Motor Function Motor Center ƛ Frontal Lobe  Apraxia ƛ inability to perform fine motor activities  Agraphia ƛ inability to write Cerebellum ƛ Rombergƞs Test  client stands w/ both feet together. posture & regulates locomotion . eyes closed  Ataxia ƛ uncoordinated movements. wide base stance And swaying manner of walking Extrapyramidal System ƛ maintains balance.

PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT CEREBRAL FUNCTION ASSESSMENT Romberg test: test: ͻtests position sense. note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds .

ankle reflexes) and abnormal reflexes (Babinskiƞs reflex). (biceps. . patellar.Sensory Function Test for: (Parietal lobe)  superficial tactile sensation superficial and deep pressure pain  thermal sensitivity  sensitivity to vibration  point localization.   Stereognosis ƛ ability to perceive sensory stimuli Agnosia ƛ inability to perceive sensory stimuli Reflexes  Evaluate deep and superficial reflexes (biceps. triceps.

documented as "positive for ___" Babinski reflex (Plantar) (L4-S2): ‡ stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average) .PHYSICAL ASSESSMENT NEUROLOGICAL ASSESSMENT PATHOLOGIC REFLEXES in adults .

Reflexes to Assess Meningeal Irritation .

pain is experienced Brudzinskiƍs reflex ƛ client is placed in supine postion. (more accurate indicator of meningeal irritation) . passively flex the neck. spontaneous flexion of the hips occur. flex the knee. attempt to extend the leg.Kernigƍs sign ƛ client is placed in supine position.

Diagnostic Tests .

NPO if with contrast medium. hemorrhage. infarction.      teaching the client about the need to lie quietly throughout the procedure. Secure patent IV line. Use of xray beams cross section Use : to identify intracranial tumor.Diagnostic Procedure Computed Tomography Scanning Visualize Nursing Interventions  sections of the spinal cord as well as intracranial contents The injection of a waterwater-soluble iodinated contrast into the subarachnoid space through lumbar puncture helps noninvasive and painless  has a high degree of sensitivity for detecting lesions. cerebral atrophy. edema. nausea and vomiting. Relaxation technique maybe helpful for clients with claustrophobia. remove metallic objects from hair . congenital abnormality. Assess for iodine/shellfish allergy. Monitor for allergic reaction: flushing. calcification. for 4 Ɗ 6 hrs.

Magnetic Resonance Imaging .

Useful in diagnosis of multiple sclerosis and can describe the activity and the extent of disease in the brain and spinal cord. Inform the client that the procedure last for 30 to 90 mins.Diagnostic Procedure Magnetic Resonance Imaging Uses a powerful magnetic field to obtain images of different areas of the body. Instruct the client to void before the procedure. Inform the client that a narrow. a signed consent. Obtain Obtain . Cerebral Angiography Is an x-ray study of the cerebral circulation with a contrast agent injected into a selected artery (femoral) Visualize aneurysm Nursing Interventions history of metal implants. Sedation may be needed for claustrophobic client. tunnel like machine will enclose him/her during the procedure. clear liquids are usually permitted. Hydrate the client. Remove all metal objects. Can be performed with or without a contrast agent and can identify a cerebral abnormality earlier and more clearly than other diagnostic tests. Patient preparation should include teaching relaxation technique.

Explain . and lips. Shows any distortion of the spinal cord or spinal dural sac caused by tumors. Tell the client to expect a brief feeling of warmth in the face. and injection site should be observed. behind the eyes or in the jaw. After the procedure check LOC. cysts. Instruct Myelography Contrast agent are injected into spinal subarachnoid space to permit visualization of spinal cord. Obtain a signed consent. After the procedure: For pantopaque myelogram (oil(oilbased) pt lies flat for 66-24 hours. the procedure. Withhold oral intake 44-6 hours before the test. teeth. tongue. and a metallic taste when the contrast is injected.Diagnostic Procedure Nursing Interventions the patient to remain immobile during the test.

A sleep EEG may be recorded after sedation because some abnormal brain waves are seen only when the patient is asleep. Withhold tranquillizer and stimulants for 24 to 48 hours. Encourage fluid intake For Electroencephalography Graphic record of the electrical activity generated in the brain. assure the client he/she will not receive electrical shock. the procedure. Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.Diagnostic Procedure herniated vertebral disks or other lesions. Explain . HOB is elevated at 30 degrees for at least 8 hours. or organic brain syndrome. EEG is a useful test for diagnosing and evaluating seizure disorders. coma. Nursing Interventions metrizamide myelogram (water(waterbased). The nurse needs to check doctorƞs order regarding the administration of antiseizure medication prior to testing.

Electroencephalography Measurement of the electrical activity Of the brain done during: ‡Relax ‡Hyperventilate ‡Sleeping ‡Flickering lights Hair shampoo to remove oil/sprays .

Lumbar puncture ‡Insertion of needle in the sub arachnoid space ‡Assess the csf .

usually lateral horizontal with knees to chest.  Keeping the patient in prone position overnight may reduce the incidence of headache.  The needle is usually inserted between L4 and L5.Lumbar Puncture Lumbar Puncture  Is carried out by inserting a needle into the lumbar subarachnoid space to withdraw CSF for diagnostic or therapeutic purposes.  Obtain signed consent.  . chin on chest. Maintain position.  Observe for complication following the procedure.  Explain the procedure.

. Measure changes in the electrical potential of the muscles and the nerves leading to them.Electromyography Nursing Interventions Obtain by inserting needle electrodes into the skeletal muscles. Useful in determining neuromuscular disorders and myopathies myopathies. . 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. Explain the procedure.

Electromyogram .

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

Common Health Problems of the Young Adult .

NEUROMUSCULAR DISORDERS Sclerosis Myasthenia Gravis Multiple .

     . characterized by exacerbations and remmissions (relapsing(relapsing -remitting type) Although the cause of MS is unknown. cerebellum. and the spinal cord.Multiple Sclerosis   MS is: chronic. it appears to be related to autoimmune disorder and viral infections. cerebrum. degenerative disease of the central nervous system that is characterized by demyelination of the nerve fibers of the brain and spinal cord. optic nerves. Gen. commonly appears during adulthood (ages 20 to 40). W>M Areas of the CNS most commonly affected brainstem.

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Process of Demylination .

Pathophysiology MS Causes Unknown Viral infection Autoimmune disease Multiple foci of dmyelination in the white matter (brainstem. spinal cord. optic nerves. cerebrum) Then later the gray matter. Destruction of the myelin sheath (SCHWANN¶S CELLS) INTERRUPTION/DISTORTION OF IMPULSE (SLOWED/BLOCKED) .

Symptoms vary depending on the area of the CNS involved. . partial or total loss of vision. monotonous.Assessment   Sign and symptoms of MS is characterized by remissions and exacerbation of symptoms. but generally include:  Visual disturbances (diplopia (diplopia. slurred)  Tremors  Weakness/numbness of the extremities  Fatigue  Increased susceptibility to URTI  Dysphagia  Ataxic gait . nystagmus)  Scanning speech (slow.

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

impairedƜswallowing. skin integrity. altered nutrition.Nursing Diagnoses for MS:  Risks: Ineffective breathing pattern. constipation . urinary incontinence. physical mobility. airway clearance.

Interventions for MS:
There is no specific treatment for MS. Treatment includes:  physical therapy rapy- to assist with motor dysfunction, such as problem with balance, strength, and motor coordination.  speech therapyrapy- to manage dysarthria  drug therapy  

 

Glucocorticoids (Prednisone, Dexamethasone, amethasone, Corticotropin)to reduce edema of the myelin sheet; speeds recovery from attack Muscle relaxant (Baclofen)- to treat spasticity Amantadine, mantadine, Ritalin, or antidepressants ƛto manage fatigue Low-dose TCAss- to manage sensory symptoms such as pains, numbness, burning, and tingling sensations Antihistamines with vision therapy & exercises to minimize vertigo

Nursing Responsibilities/ Considerations for MS: 

Provide regular activity, rest 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 s. . Provide skin care to prevent skin breakdown.  

  

Nursing Responsibilities/ Considerations for MS cont.: 

Patient and family teaching to promote emotional stability
Help patient establish daily routine, and help family understand patientƞs 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

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Evaluate 

Respiration; nutrition; ADLs; skin; bowel elimination; urinary incontinence

Autoimmune disease. Commonly affects muscles innervated by the cranial nerves (face. Characterized by progressive weakness and abnormal fatigability of the skeletal muscles.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. neck. lips. tongue. and throat) Exacerbated by exercise & repetitive movement Occurs along with thymic abnormalities in 75% of pts . 3 times more common in w Young adults 2020-30 secretion and increased cholinesterase at the nerve ending.

weaken.Pathophysiology:   Transmission of nurve impulses at the neuromuscular junction FAILS. or reduce the number of acetylcholyne Ach receptors available at each neuromuscular juction.thereby impairing the muscle depolarization necessary for movement . Antireceptor antibodies block.

Myasthenia Gravis Cause:  Autoimmune response leading to ineffective acetylcholine release and inadequate muscle fiber response to Ach. Complications:  Aspiration  Pneumonia  Respiratory distress .

closure. Ơsnarl smileơ (smiles slowly) Masklike facial expression. fatigue Weak eye closure.Assessment  S&S    Skeletal muscle weakness.ptosis . diplopia.ptosis. drooling Weakened respiratory muscles Muscle are usually strongest in the morning but become progressively weaker during the day and following an exercise. Impaired speech. Rationale/ Pathophysiologic Basis due to impaired neuromuscular transmission due to impaired neuromuscular transmission to the cranial nerves supplying the eye muscles Impaired transmission of the cranial nerves innervating the facial muscles         Due to impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in the appropriate junctions .

Myasthenia Gravis Skeletal muscle weakness .

lasting up to 30 mins mins.  Reveals Increased muscle strength is observed (+ Tensilon Test) within 3030-60 secs after IV injection of edrophonium (tensilon) or Neostigmine (Prostigmin).Diagnostic Test  Tensilon Test (Edrophonium Chloride Test)  Short acting cholinergic is administered.progressive decrease in muscle fiber contraction Chest xx-rayray. Single Single fiber electromyography with neural stimulation at the specific muscle fiberfiber.reveals thymoma in 15% of pts . .

such as neostigmine and pyridostigminepyridostigmine . y. suctioning to remove secretions     .Treatment of Myasthenia Gravis  Anticholinesterase drugs.to remove thymomas Tracheostomy.to counteract fatigue and muscle weaknes and allow for about 80% of normal muscle Immunosuppresive therapy with corticosteroids. azathioprine (Imuran) ƛ to decrease the immune response toward Ach receptors at the neuromuscular junction IgG during acute relapsesrelapses.to suppress the immune system Thymectomy y.

Nursing Goals and Interventions            Establish neurologic and respiratory baselines Assess swallowing / gag reflex before feeding the client. Frequent rest periods. Start meal with cold beverage. Ex. Plan exercise. Be prepared to give atropine for anticholinesterase overdose or toxicity Avoid aminoglycoside antibiotics. patient care & activities to make the most of energy peaks. strenous exercise.administer medications 20-30 minutes before meal to facilitate chewing or swallowing.. meals. Administer medication at precise time to prevent relapses. which can exacerbate myasthenia gravis . Protect the client from falls. and needless exposure to the sun r cold. stress. Avoid exposure to infection. Provide adequate ventilation.

pesticides/cleaners should also be avoided.Aerosol. and cigarette smoke.  Avoid alcohol. tonic water.  Pharmacotherapy  Cholinergics (Anticholinesterase)   Neostigmine (Postigmin)  Pyridostigmin (Mestinon)  Ambenomium (Mytelase)   Glucocorticoids Antacids .

Common Health Problem of the Middleiddle-aged Adult .

recurrent paroxysms of sharp. nerve . stabbing facial pain along the trigeminal nerve. sharp. . Possible fifth cranial nerve root compression  Manifested by excruciating.CRANIAL NERVE DISORDER: Trigeminal Neuralgia (Tic Douloureux)  Neurologic disorder affecting the 5th cranial nerve.

Areas innervated by the three branches of the trigeminal nerve .

Correction of dental malocclusion Surgical Management  Surgical division of the trigeminal nerve (neurectomy) y)  Protect eye if surgery is done     . anticonvulsants  Tegretol  Dilantin Alcohol injection of the nerve Avoid extremes of heat and cold.Management Narcotic analgesics.

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

contractures may developed on the paralyzed side of the face. with complete recovery in 18 weeks  Recover may be delayed in the elderly  If recovery is partial. Causes:  Hemorrhage  Herpes simplex or herpes zoster  Infection  Local trauma  Meningitis  Tumor  Viral disease .CRANIAL NERVE DISORDER: Bellƍs Palsy D De efinition: Disease of the cranial nerve VII (facial nerve that produces unilateral or bilateral facial weakness or paralysis of one side of the face  Resolves spontaneously in most pts.

resulting in the characteristic unilateral or bilateral facial weakness. usually at the internal auditory meatus s. . .Bellƞs Palsy    Pathophysiology: athophysiology: An inflammatory reaction occurs around cranial nerve VII. 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.

Pathophysiologic Chanes/ S & S:          Unilateral facial weakness Drooping mouth & drooling saliva Loss of taste Smooth forehead appearance Impaired ability to close the eye on the weak side (P (Ptosis) tosis) Bellƞs phenomenonphenomenon-Upward rolling of the eyes when attempting to close them Excessive tearing Ringing in the ear Painful sensations in the face .

Complications of Bellƍs Palsy  Corneal abrasion  Infection (masked by steroid use)  Poor functional recovery Diagnostic Tests: -based on clinical presentation MRI-rules out tumor Electromyographylectromyography.10 days after the onset of S/S .

to relieve pain Steroids.to reduce facial nerve edema & Steroidsimprove edema & improve nerve conduction & blood flow Possible electrotheraphy Surgery for persistent paralysis    .Treatment  Analgesicsnalgesics.

Nursing Considerations Watch for adverse effects of steroids use  Apply moist heat to the affected side of the faceface-to reduce pain  Help the pt maintain muscle tone: -massaging the face with a gentle upward motion 22-3xdaily x 5510mins Exercise by grimacing in front in front of a mirror  Protect eyes. eliminating hot foods & fluids -apply a facial sling to improve lip alignment  Provide frequent & complete mouth care  Offer psychological support  . 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.

Common Health Problems of the Older Adult .

Classification: 1. The second most frequently affected is the internal arotid artery.CEREBRO-VASCULAR DISORDER:Stroke/ :Stroke/Cerebrovascular Accident (CVA) Definition: Disruption of the Blood Supply to the Brain rain-sudden loss of neurologic funtion Note: Middle Cerebral Artery is commonly affected. ischemic (a thrombus or embolus blocks circulation 2.sedentary lifestyle  Sickle cell disease  Use of hormonal contraceptives . 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.

.Causes of Stroke: Ischemic  Thrombosis.from thrombus outside the brain. or common carotid artery.  This may tend to occur among clients with DM.  The second most common cause of CVA.  Tends to occur during sleep or soon after arising.  Most frequently caused by Rheumatic Heart Disease and MI. and hypertension.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.  Embolism.  Most commonly affecting younger people. aorta.  Symptoms occur at any time and progress rapidly. usually affecting elderly persons. such as in the heart.

or septic embolism. & the blood itself as a spacespace-occupying mass.Hemorrhagic Stroke  Impaired cerebral perfusion from hemorrhage causes infarction. exerting pressure on the brain tissues Hemorrhage from an intracranial artery or vein. ruptured aneurysm. hemorrhagic disorder. trauma.Causes of Stroke: Hemorrhagic Stroke  Hemorrhage age. such as HPN.AV malformation  ..

  Stoke in evolution refers to development of a neurologic deficit over several hours to days Completed stroke refers to a permanent neurologic deficit  . dysphagia.Transient Ischemic Attacks Refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction. fingers. agia. and legs.  Manifestation include contralateral weakness of the lower portion of the face. hands. and sensory impairment. arms.

dysphagia. altered LOC. . and headache caused by thrombosis or hemorrhage of carotid artery Weakness. and hemiparesis of affected side (more severe in face & arms). the brain tissue supply by that of that vessel. poor coordination. diplopia. dysphagia.resulting from thrombosis or hemorrhage of middle cerebral artery Weakness. slurred speech.Pathophysiologic Changes in CVA: :-specific manifestations are determined by the cerebral artery affected. paralysis.   . dizziness. sensory changes. visual field deficits. and the adequacy of the collateral circulation  Aphasia. paralysis. diplopia. amnesia. numbness. nystagmus nystagmus. numbness around lips & mouth. and ataxia resulting from thrombosis or hemorrhage of vertebrobasilar artery. visual fields deficits. dysphasia. bruits over carotid artery.

numbness.  . urinary incontenece. sensory impairments. Confusion. impaired motor & sensory functions. and personality changes caused by thrombosis or hemorrhage of anterior cerebral artery. cortical blindness and coma resulting from thrombosis or hemorrhage of posterior cerebral artery. dyslexia. weakness. Visual field deficits. incontenece .

 Perceptual defects  Aphasia ƛ inability to comprehend or use words  Unstable respiration  Severe headache  Diagnostic procedure results  Unilateral neglect  Hemianopsia ƛ loss of half of the visual field .Assessment of CVA: check for:  S&S of increased ICP.

carotid duplex scan. EEG   .Diagnostic Findings:  CT scanan.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.

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

lateral position to prevent aspiration of saliva  Check v/s & neurologic status s: : Monitor BP. color. speech. monitor ABG as ordered    Monitor F & E balance balance: : Monitor I and O. dusky color. and changes in sensorium If the pt is unresponsive. shortness of breath. tachycardia. LOC. fever.Nursing Considerations:CVA  Maintain a patent airway and oxygenation: oxygenation: If the pt is unconscious. pupillary changes. temp. Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity Watch for s/s of pulmonary emboli: boli: chest pain. vomitingvomiting. Administer IVF as ordered Offer bedpan /urinal . motor and sensory functions. skin.

If oral feeding is not possible. . at least q 2 hrs to prevent pneumonia. patch the affected eye if the pt canƞt close eyelid.     Turn the patient frequently. gastrostomy feeding. NGT feeding.Nursing Considerations:CVA  Ensure adequate nutrition: trition: Check for gag reflex before offering small oral feedings of semi solid food Teach the client to chew on the unaffected side. Provide meticulous eye carecare.Instill meds as ordered. Massage if not contraindicated. Perform ROM exercises for affected & unaffected sides. contraindicated. TPN.

Aspirinspirin-GI bleeding)  .  Care of the client with Hemianopsia Hemianopsia.  Approach from the unaffected side.  Say one word at time.  Allow the client to verbalize. (ex.  Place articles on the unaffected side.Nursing Considerations:CVA  Compensate for perceptual difficulties. Promote communication  Care for the client with aphasia. no matter how long it takes him Give medications as orderedordered. .  Give simple commands.Tell the pt to watch out for side effects.

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

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40. rigidity.Parkinson·s Disease Also called Paralysis Agitans  Slowly progressive degenerative disorder of basal ganglia function that results in variable combinations of tremor. and bradykinesia  Onset usually after age 40. first appears in the 5th decade of life  men>wo n>women  .

Parkinsonƞs Disease: deficient in dopamine .

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  Drugs ƛ phenothiazines. . phenothiazines.Causes: Exact cause unknown  Possible causes:  Dopamine deficiency. reserpine reserpine. haloperidol & methyldopa .

Pathophysiology of Parkinsonƞs Disease .

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 Current theory ƛ caused by oxidative stress in portion of the neuron known as Lewy bodies Maybe caused by protein aggregation .

Pathophysiologic changes/ S&S:  Muscle rigidity. and insidious tremor beginning in the fingers (UNILATERAL PILL_ROLL TREMOR) secondary to loss of inhibitory dopamine activity at the synapsesynapseincrease during stress or anxiety. bradykinesia bradykinesia. decreases with purposeful movement & sleep Muscle rigidity with resistance to passive limb movement bradykinesia/ bradykinesia /akinesia Cogwheel rigidity absence of arm swing in normal rhythmic gait     . .

pt.Pathophysiologic changes/ S&S:     Mask-like appearance MaskGait disturbancee-lacks normal parallel motion. may be retropulsive or propulsive ² head bent forward Shuffling. may walk faster & faster. unable to stop until obstruction is met Oily skinskin. festinating gait ² walking in tiptoe.secondary to inappropriate regulation of androgen production by hypothalamic-pituitary axis .

dysarthria.from impaired dopamine metabolism.Pathophysiologic changes/ S&S:       Dysphagia. gement. and neurotransmitter dysfunction No intellectual impairment Drooling of saliva . excessive sweating. endogenous depression. decreased GI motility and genitourinary smooth muscle e-from impaired autonomic transmission Voice changes Small handwriting (Micrographia) ia) Poor judgement. dementia.

caloric. no pillows  prone position when lying in bed  hold hands folded at the back when walking Aspiration precaution Inc. fluid intake ƛ prevent constipation . residue.Collaborative Management Diet  inc. soft diet (well-balanced diet) Position to prevent contractures  firm bed. inc.

dryness of mouth/throat. urinary retention. constipation.Medications Anticholinergics ƛ to reduce tremors  Cogentin (Benztropine Mesylate)  Artane (Trihexyphenydil)  Akineton (Biperiden) o Side effects: blurring of vision. dysarthria. mental disturbance o IOP must be monitored o contraindicated in patients w/ narrow-angle glaucoma .

Reserpine.Anti Ɗ Parkinsonian Agents (Dopaminergics) Ɗ improve muscle flexibility Levodopa ƛ converted to dopamine in the basal ganglia. stupor & hyperthermia Carbidopa w/ Levodopa (Sinemet) ƛ aa decarboxylase inhibitor. Pyridoxine (vit. reduces destruction of levodopa at periphery . good in the 1st few years of tx  avoid Phenothiazines.B6)  w/in 5-10 years px develops dyskinesia (abnormal involuntary movements)  neuroleptic malignant syndrome ƛ characterized by rigidity.

Antiviral Amantadine HCl (Symmetrel) Dopamine Agonists Ɗ added to medication regimen after carbidopa or levodopa loses effectiveness Bromocriptine (Parlodel) Pergolide (Permax) Antispasmodics Procyclidine HCl (kemadrin) .

reduces tremors MAOI Ɗ inhibits dopamine breakdown Selegiline (Eldepryl)  enhances norepinephine activity  hypertensive crisis may occur  methyldopa ƛ potentiates effects of levodopa .Antihistamines Diphenhydramine HCl (Benadryl) ƛ sedative effects.

vomiting. cream. red wine. renal damage Patient teaching:  gradual change of position. pork. yeast. beer. bananas. dried beans. agitation. italian green beans (hypertensive crisis) Side effects of Levodopa:  nausea. soy sauce.Avoid when on levodopa:  B6 rich foods ƛ tuna. orthostatic hypotension. wear elastic stockings to prevent postural hypotension  reddish brown urine . pickled herring. insomnia. sausage. liver. raisins. yogurt. beef liver tyramine rich foods ƛ cheese. mental confusion. coffee. salmon. chocolate.

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: grand mal petit mal febrile seizures status epilepticus Jacksonian/fo n/focal psychomotor .

3.Grand Mal  the most common type of seizure Phases: Aura Tonic-clonic phase Postost-ictal phase  1. . 2.

Tonic Ɗ clonic phase  Characerized by contractions ƛ tonic  Jerking movements ƛ clonic  Accompanied by dyspnea.I. Aura  flashing lights. urinary incontinence III. drowsiness. deep sleep of 1-2 hours  disorientation . headache. drooling of saliva. spots before eyes. smells. Post Ɗ ictal phase  cessation of tonic-clonic movements  characterized by exhaustion. dizziness  shout/cry  fall II.

cheekcheek-smacking regains consciousness occurs during childhood & adolescence . automatism like liplipchewing.Petit mal          Absence seizure or Little Sickness No aura 10-20 seconds Common to children as well as adult Little tonictonic-clonic movements Sudden cessation of ongoing physical activities blank facial expression.

frontal lobe tumor Group of muscle affectation e. hands.g.g. tingling.Jacksonian      Focal seizure With aura (numbness. crawling feeling) With organic lesion ƛ e. foot or face Proceeds to grand mal seizure .

Psychomotor Seizure       With aura (hallucinations or illusions) With psychiatric involvement Characterized with mental clouding (out of touch w/ environment) Violence. By ongoing physical activity during time of loss of consciousness . antisocial acts Appears intoxicated Char.

Febrile Seizure   Related to temperature Present among children under five years of age .

Status epilepticus       Prolonged seizure state Can occur in any type of seizure Rapid successions with no full consciousness in between seizures Brain damage can occur due to hypoxia & exhaustion. most life threatening in tonic tonicclonic seizures Common to clients who are in coma Related to failure to take medication .

Primary Seizure Disorder (Epilepsy)  Idiopathic  No apparent structural changes in the brain Secondary Epilepsy  Characterized by structural changes or metabolic alterations of the neuronal membranes that caused increased automacity  .

mercury. such as hypoglycemia or hypoparathyroidism Perinatal infections . 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. or carbon monoxide) Metabolic disorders.twoo-thirds of all seizure disorders Anoxia Birth trauma (inadequate supply of O2 supply to the brain.Causes of Seizures:             Idiopathic. blood incompatibility.

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

sweating or flushing. or fear reactions resulting from simple partial seizures Altered consciousness . 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     . such as amnesia for events around the time of the seizure.Pathophysiologic changes:  Recurring seizures. dream states. anger. or auditory hallucinations. olfactory. possibly of more than one type (hallmark of epilepsy) Visual.

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

electrolyte imbalances. high.reveals paroxysmal abnormalities in tonictonic-clonic seizures. and elevated liver enzyme & alcohol level    . rounded spike wave complexes are present Note: a negative EEG doesnƞt rule out epilepsy because the abnormalities occur intermittently Skull x-ray may show evidence of fractures or shifting of the pineal gland. or separated sutures Serum chemistry blood studies may reveal hypoglycemia.Diagnostic Tests:  CT scan or MRI. fast voltagespikes are present in all leads In absence seizures.reveals abnormalities EEGG. bony erosion.

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

turn the head to provide an open airway  After the seizure subsides. reorient the patient to time & place.Nursing Considerations Patent airway  Oxygenate as needed  Raise side rails ƛ pad side rails  Ensure safetysafety-during seizure: Avoid restraining the pt Help the pt to a sideside.lying position Loosen any tight clothing Clear the area of hard objects Donƍt place anything into the ptƍs mouth to prevent lacerating the mouth & lips or displace teeth If vomiting occurs. inform him that he had a seizure  Companion at bedside  Avoid alcohol  Meds as ordered  Make documentation  .

the brain will compensate by: limiting blood flow to the head displaces CSF into the spinal canal increases absorption or decreases production If ICP remains high.the pressure exerted within the intact skull by the intracranial volumeme-about 10% blood.10% CSF. Causes : head injury CVA tumors H PN Overproduction of CSF due to tumor Pathophysiology: ^ICP. & 80% brain tissue. Further increase in ICP will result to cellular hypoxia and eventually. . venous congestion. there will be loss of autoregulatory mechanism which will lead to passive dilation.Increased Intracranial Pressure ICP. brain death. increased cerebral flow.

Monroƍs Theory Brain Ⱥ Bony Skull Ⱥ No Room for Expansion Ⱥ Increase in the Bulk of the Brain Ⱥ Compression of Brain Structures and Blood Supply Ⱥ Cerebral Ischemia Ⱥ Cerebral Hypoxia Ⱥ Necrosis (Cerebral infarction) Ⱥ Inflammation Ⱥ Cerebral edema Ⱥ Increase Intracranial Pressure  Box Theory Ɗ MONRO-KELLIE HYPOTHESIS  an inc. in any one of the contents of the cranium is usually accompanied by a reciprocal change in volume of one of the others .

Major Types of Herniation .

brainstem  Cushingƍs response/reflex ƛ inc SBP. diplopia  Altered LOC Ɗ earliest sign  Sensory dysfunction  Elimination problem ƛ bowel/bladder  Decorticate ƛ above midbrain  Decerebrate .Increased Intracranial Pressure S&S:  Restlessness ƛ initial sign  Increased HA  Nausea & Vomiting ƛ pressure at medulla  Cushingƍs triad ƛ bradycardia.. hypertension & bradypnea  Eye involvement ƛ CN VI. RR is dec. bradycardia. reflex slowing of the heart.. late sign .widening of PP. dec.

g. left brain affected ƛ R hemiplegia right brain affected ƛ L hemiplegia .Cont. S/S  Pupillary Changes ƛ Anisocoria due to CN III compression ƛ ipsilateral pupil dilatation  Fixed dilated pupils indicate uncal herniation ƛ compression of the brainstem ƛ respiratory arrest  Papilledema ƛ compression of the optic nerve ƛ ƠChoked discƐ  Lateralizing sign ƛ contralateral loss of motor function due to decussation of fibers at medulla e.

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bending control HPN Seizure precaution Edema reduction Diuretics . restraints. vomiting. rectal exam. stress ulcer. suctioning. sneezing. vasalva maneuver.NURSING MANAGEMENT OF INCREASED ICP:           Determine airway patency Elevate HOB ƛ SemiSemi-Fowlerƞs Check VS/neuro VS/neuro assessment Record I&O Enema restriction Avoid coughing.

massage  Phenobarbital (Na Luminal) ƛ sedation in adults. reduce cerebral edema  Lasix  Decadron (Dexamethasone) ƛ reduce cerebral edema. only steroid that can pass through the blood-brain barriers  Anticonvulsants : Valium (Diazepam)  Dilantin (Phenytoin Sodium) ƛ give after meals to prevent GI upset  prep. ataxia.10 ml NSS to flush IV line before/after admin.  gum hyperplasia ƛ soft bristled tooth brush.Pharmacotherapy  Mannnitol ƛ osmotic diuretic. paradoxical active reaction in children. habituation  Tegretol (Carbamazepine) ƛ rash. drowsiness .

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

CSF leakage from ears and nose. atelectasis. UTI. . Management    Care for the client with increased ICP. Monitor drainage from ears and nose. (CSF ƛ positive for glucose) Monitor for signs and symptoms of meningitis.Assessment    Sign and symptoms of increased ICP. Battleƍs sign (hematoma at the mastoid process) in basilar head trauma. atelectasis. pneumonia.

meningiomas.Intracranial Tumors  Intracranial tumors may be classified as: gliomas. as. as. hemangiomas. neuromas.  . Gliomas account for about 50% of all brain tumors. as.

and vertigo with acoustic neuroma .Brain Tumors Symptoms are dependent upon the location and size of the lesion and the compression of associated structures Manifestations: Localized or generalized neurologic symptoms Symptoms of increased ICP Headache Vomiting Visual disturbances Hormonal effects with pituitary adenoma Loss of hearing. tinnitus.

Common Brain Tumor Sites .

Diagnostic Evaluation Neurologic examination CT scan MRI PET scan EEG Cytologic study of cerebral spinal fluid Biopsy .

 Occipital lobe  . Frontal lobe  Assessment Personality disturbance  Inappropriate affect  Indifference of bodily functions  Precental gyrus  Jacksonian seizures Visual disturbances preceeding convulsions.

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

turn to sides.Management   Care for the client with increase ICP( (preop preop & post op) Surgery  Supratentorial craniotomy (postpost-op)  Semi Semi-fowlerƞs position  Infratentorial craniotomy  Flat position. avoid supine position for the first 48 hours. . Pressure on neurohypophysis  Test the urine for glucose and acetone when steroids are administered. 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.

Spinal Cord Injury complete or partial disruption of nerve tracts and neurons infection Causes : trauma injury - .

quadriplegia.paraplegia. poor control of upper trunk Lumbar ² flaccid paralysis Sacral ² loss of erection. ejaculation.Signs and symptoms     Cervical ²respiratory diff. bowel/bladder incontinence . bowel/bladder retention Thoracic.

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 Asessment:      Injury.

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. turning frame IV. stabilization of vital signs Corticosteroids Surgical intervention Surgery to  Remove bone fragments  Repair dislocated vertebrae  Stabilize the spine  Surgical Management  . cast or brace. traction.

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  Arthropodrthropod-Borne Virus Encephalitis  Fungal Encephalitis  Creutzfeldtreutzfeldt-Jakob and New-Variant Creutzfeldtreutzfeldt-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 .