1

MEDICAL SURGICAL REVIEWER


Nervous System
Central NS Peripheral NS Autonomic NS
Brain & spinal cord 31 spinal sympathetic NS
Parasympathatic NS


Somatic NS
C- 8 ex. Breakfast 8am – diaphragm, chest wall muscles, shoulder’s & arms
T- 12 ex. Lunch 12nn – upper body, GI functions
L- 5 ex. Dinner 5pm (napaa aga haha) – lower body, bladder, bowel
S- 5 ex. Dinner ulit kasi matakaw
C- 1 ex. Midnight snack 1am

SNS (involved in fight or aggression response / LABAN)
 Release of norepinephrine (adrenaline –
cathecolamine)
 Adrenal medulla (potent vasoconstrictor)
 Increases body activities
 Except GIT – decrease GIT motility
 Why GIT is not increased = GIT is not important!
 Increase blood flow to skeletal muscles, brain &
heart.

Effects of SNS (anti-cholinergic/adrenergic)
1. Dilate pupil – to aware of surroundings
- medriasis
2. Dry mouth
3. BP & HR= increased
- bronchioles dilated to take more oxygen
4. RR increased
5. Constipation & urinary retention

I. Adrenergic Agents – Epinephrine (adrenaline)
SE: SNS effect

II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’)
 Blocks release of norepinephrine.
 Decrease body activities except GIT (diarrhea)
 Ex. Propanolol, Metopanolol
Sie effects:
B – broncho spasm (bronchoconstriction)
E – elicits a decrease in myocardial contraction
T – treats HPN
A – AV conduction slows down
- Given to angina & MI – beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril)
Ex. ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
Ex. CALCIBLOC or NEFEDIPINE

S/E- of Anti-HPN drugs:
1. orthostatic hpn
2. transient headache & dizziness.
 Mgt. Rise slowly. Assist in ambulation.

Parasympathetic Nervous System: (Cholinergic / BAWI) Effect of PNS: (cholinergic/ opposite ng SNS)
 Involved in fly or withdrawal response 1. Meiosis – contraction of pupils
 Release of acetylcholine (ACTH) 2. Increase salivation
 Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease – broncho constriction
I. Cholinergic agents 5. Diarrhea – increased GI motility
Ex. Mestinon 6. Urinary frequency
 Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS


CENTRAL NS (brain & spinal cord)
2
I. Cells – A. Neurons – 10 billion
o Properties and characteristics
a. Excitability – ability of neuron to be affected in external environment.
b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
 Labile – once destroyed cant regenerate
 Epidermal cells, GIT cells, resp (lung cells). GUT
 Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
 Permanent cells – retina, brain, heart, osteocytes can’t regenerate.

*Neuroglia – attached to neurons.
o Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria
 Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte, most common.

*Astrocyte – maintains integrity of blood brain barrier (BBB).
 BBB – semi permeable / selective
Toxins that can pass in BBB:
1. Ammonia - liver cirrhosis.
2. Carbon Monoxide – seizure & parkinsons.
3. Bilirubin - jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. Ketones –DM.

*OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission.
 No myelin sheath – degenerates neurons
 Damage to myelin sheath – demyellenating disorders

**DEMYELLENATING DISEASES
1. ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.
S/S: FOUR A’s
 A – amnesia – loss of memory
 A – apraxia – unable to determine function & purpose of object
 A – agnosia – unable to recognize familiar object
 A – aphasia –
o Expressive – brocca’s aphasia – unable to speak
o Receptive – wernickes aphasia – unable to understand spoken words
 Common to Alzheimer – receptive aphasia
 Drug of choice – ARICEPT (taken at bedtime) & COGNEX.
 Mgt: Supportive & palliative.

*MICROGLIA – stationary cells, engulfs bacteria, engulfs cellular debris.


II. Compositions of Cord & Spinal cord
80% - brain mass
10% - CSF
10% - blood
*MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
 Normal ICP: 0-15mmHg



BRAIN MASS
3
1. Cerebrum – largest part
 Corpus collusum - connects R & L cerebral hemisphere.
Function:
1. S - Sensory
2. I - Integrative
3. M – Motor
4.
**LOBES
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Brocca’s area – speech center
Damage - expressive aphasia
2.) Temporal –
a. Hearing
b. Short term memory
c. Wernickes area – gen interpretative or knowing Gnostic area
Damage – receptive aphasia
3.) Parietal lobe – appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory

2. BASAL GANGLIA – areas of gray matteR located deep within a cerebral hemisphere
 Extra pyramidal tract
 Releases dopamine
 Controls gross voluntary unit
**TRIVIA
Decrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse.
Decrease acetylcholine – Myasthenia Gravis & Alzheimer’s
Increased neurotransmitter = psychiatric disorder Increase dopamine – schizo
Increase acetylcholine – bipolar

3. MID BRAIN – relay station for sight & hearing
 Controls size & reaction of pupil 2 – 3 mm
 Controls hearing acuity
 CN 3 – 4
 Isocoria – normal size (equal)
 Anisocoria – uneven size – damage to mid brain
 PERRLA – normal reaction

4. DIENCEPHALON - between brain
 Thalamus – acts as a relay station for sensation
 Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional
responses, controls pituitary function.

5. BRAIN STEM –
a. Pons – or pneumotaxic center – controls respiration
Cranial 5 – 8 CNS

b. Medulla Oblangata - controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

6. CEREBELLUM – lesser brain
4
- Controls posture, gait, balance, equilibrium
**Cerebellar Tests:
a.) R – Romberg’s test- needs 2 RNs to assist
- Normal anatomical position 5 – 10 min
(+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test –
(+) To FTNT – dymetria – inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium

**Composition of brain - based on Monroe Kellie Hypothesis
 Skull is a closed container.
 Any alteration in 1 of 3 intracranial components = increase in ICP

o Normal ICP – 0 – 15 mmHg
o Foramen Magnum
o C1 – atlas
o C2 – axis
o (+) Projectile vomiting = increase ICP
o Observe for 24 - 48 hrs
o CSF – cushions the brain, shock absorber
o Obstruction of flow of CSF = increase ICP
o Hydrocephalus – posteriorly due to closure of
posterior fontanel
o CVA – partial/ total obstruction of blood supply
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INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis

S&Sx **change in VS = always LATE symptoms
**Earliest Sx: (vision changes, change in LOC, headache)
a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign – change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP Shock – decrease BP –
Decrease HR Increase HR CUSHINGS TRIAD (opposite ng inceased ICP)
Decrease RR Increase RR

b.) Headache
 Projectile vomiting
 Papilledima (edema of optic disk – outer surface of retina)
 Decorticate (abnormal flexion) = Damage to cortico spinal tract /
 Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation – unilateral dilation of pupil. (**kapag Bilateral dilation of pupil = tentorial herniation.)
d.) Possible seizure.


5
Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

o Hypoxia – cerebral edema - increase ICP
o Hypoxia – inadequate tissue oxygenation
Late symptoms of hypoxia ----------- B – bradycardia
E – extreme restlessness
D – dyspnea
C – cyanosis
**Early symptoms --------- R – restlessness
A – agitation
T – tachycardia

 Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP
 Most powerful respiratory stimulant increase in CO2 ----- remember this!
 Hyperventilate decrease CO2 – it excretes CO2 kaya nga dapat i-“brown bag” to retain CO2

Respiratory Distress Syndrome (RDS) – decrease Oxygen
*Suctioning – 10-15 seconds, max 15 seconds.
o Suction upon withdrawal
*Ambu bag – pump upon inspiration

**Assist in mechanical ventilation
1. Maintain patent airway
2. Monitor VS & I&O
3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 – 1,500 ml/day
(side note: FORCE FLUID means = Increase fluid intake/day – 2,000 – 3,000 ml/day) - not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints – lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
* Avoid valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
* Avoid Excessive cough – antitussive
Ex. Dextrometorpham
* Avoid Excessive vomiting – anti emetic (Plasil – brand name sa pinas) / Phenergan
* Avoid Lifting of heavy objects
* Avoid Bending & stooping
* Avoid clustering of nursing activities
7. Administer MEDS as ordered:
1.) Osmotic diuretic – Mannitol./Osmitrol - promotes cerebral diuresis by decompressing brain tissue
 Nursing considerations:
o Monitor BP – SE of hypotension
o Monitor I&O every hr. report if < 30cc out put
o Administer via side drip
o Regulate fast drip – to prevent formation of crystals or precipitate
2.) Loop diuretic - Lasix (Furosemide)
 Nursing Mgt:
o Same as Mannitol except
o Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15
o Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm)

**S/E of Lasix
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1. Hypokalemia (normal K-3.5 – 5.5 meg/L)
S&Sx
 Weakness & fatigue
 Constipation
 (+) “U” wave in ECG tracing

Nursing Mgt:
o Administer K supplements – ex Kalium Durule, K chloride
o Potassium Rich food:
ABC’s of K
Vegetables Fruits
A - asparagus A – apple
B – broccoli (highest) B – banana – green
C – carrots C – cantalope/ melon
O – orange (highest) –for digitalis toxicity also.

o Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa
o Iron – raisins
o Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions
o Don’t give grapes – may choke

2. Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:
S&Sx
 weakness
 Paresthesia
 (+) Trousseau sign – pathognomonic – or carpopedal spasm. [Put bp cuff on arm = hand spasm.]
 (+) Chevostek’s sign - nerve hyperexcitability (tetany) [FACE will contract or twitch kapag haplusin mo]
 Arrhythmia
 Laryngospasm
Administer – Ca gluconate – IV slowly

*Ca gluconate toxicity: Sx – seizure – administer Mg SO4
*Mg SO4 toxcicity– administer Ca gluconate
B – BP decrease
U – urine output decrease
R – RR decrease
P – patellar reflexes absent

3. Hyponatremia – (Normal Na level = 135 – 145 meg/L)
S/Sx
 Hypotension
 Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
 Early signs – Adult: thirst and agitation / Child: tachycardia
 Mgt: force fluid
 Administer isotonic fluid solution

4. Hyperglycemia – increase blood sugar level
 P – polyuria
 P – polyphagia
 P – polydipsia
Nsg Mgt:
Monitor FBS (N=80 – 120 mg/dl)



5.) Hyperurecemia – increase serum uric acid.
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- Tophi- urate crystals in joint.
- kidney stones- renal colic (pain), cool moist skin
- Gouty arthritis - Sx: joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis
a.) Cheese - dairy products may lower your risk. (Not good if pt taking MAOI – tyramine may lead to HTN crisis)
b.) Force fluid
c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout
Colchicene – excretes uric acid. Acute gout drug of choice.
d.) Avoid sardines, anchovies, organ meat

**Kidney stones – renal colic (pain). Cool moist skin
Mgt:
o Force fluid
o Meds – narcotic analgesic
o Morphine SO4

SE of Morphine SO4 toxicity
o Respiratory depression (check RR 1
st
)
o Antidote for morphine SO4 toxicity –Narcan (NALOXONE)
o Naloxone toxicity – tremors

**BALIK TAYO INCREASE ICP ------------------------------------------------------------------------------------------------------------------

Increase ICP meds:
3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone)
4.) Mild analgesic – codeine SO4. For headache.
5.) Anti consultants – Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?
 Administer Mannitol as ordered --- mannitol kagad basta ordered
 Elevate head 30 – 45 degrees
 Restrict fluid
 Avoid use of restraints

Question: Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids – least priority
b. Assist in ET – n/a
c. Assist in tracheotomy – permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only

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Drug Monitoring

Drug N range Toxicity Classification Indication
D – digoxin 0.5 – 1.5 meq/L 2 cardiac glycosides CHF
L - lithium 0.6 – 1.2 meq/L 2 antimanic bipolar
A – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPD
D – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A – acetaminophen 10 – 30 mg/100ml 200 analgesic osteoarthritis

Digitalis – increase cardiac contraction = increase CO // Digitalis toxicity – antidote - Digivine
Nursing Mgt
1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)

a. Anorexia -initial sx. GIT
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b. nausea/vomiting
c. Diarrhea
d. Confusion
e. Photophobia
f. Changes in color perception – yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L – lithium (lithane) - decrease levels of norepinephrine, serotonine, acetylcholine
 Antimanic agent
S/Sx -
a.) Anorexia
b.) Diarrhea
c.) Dehydration – force fluid, maintain Na intake 4 – 10g daily
d.) Hypothyroidism
(CRETINISM– the only endocrine disorder that can lead to mental retardation)

A – Aminophyline (theophylline) – dilates bronchioles.
Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity – restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline
a. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI
b. Beer/ wine -
 Hot chocolate & tea – caffeine – CNS stimulant, can cause tachycardia
c. Organ meat/ box cereals – anti parkinsonian

**MAOI – antidepressant // 3 – 4 weeks - before MAOI will take effect
m AR plan
n AR dil Avoid tyramine rich foods, can lead to CVA or hypertensive crisis
p AR nate

Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa


D – dilatin (Phenytoin) – anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
 Do sandwich method
 Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity:
S/Sx:
G – gingival hyperplasia – swollen gums
Oral hygiene – soft toothbrush
Massage gums
H – hairy tongue
A - ataxia
N – nystagmus – abnormal movement of eyeballs
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts

Acetaminophen toxicity :
Hepato toxicity
Monitor liver enzymes
**SGPT (ALT) – Serum Glutamic Piruvate Tyranase
**SGOT- Serum Glutamic Acetate Tyranase
Monitor BUN (10 – 20)
Creatinine (.8-1)
9
Acetaminophen toxicity can lead to hypoglycemia
T – tremors, Tachycardia
I – irritability
R – restlessness
E – extreme fatigue
D – depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity – Acetylcesteine =
causes outporing of secretions. Suction.
 Prepare suctioning apparatus.
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PARKINSONS (parkinsonism)
 chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain &
basal ganglia
 Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
o Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
o Hypoxia
o Arteriosclerosis
o Encephalitis
o High doses of the ff:
a. Reserpine (serpasil) anti HPN, Side Effect – 1.) depression 2.) breast cancer
b. Methyldopa (aldomet)
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic

**SE of anti psychotic drugs – Extra Pyramidal Symptom
Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism –
1. Pill rolling tremors of extremities – early sign
2. Bradykinesia – slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling – most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety – always depressed – suicide
Nsg priority: Promote safety
9. Increase salivation – drooling type
10. Autonomic signs:
 Increase sweating
 Increase lacrimation – iyakin!
 Seborrhea (increase sebaceous gland) – oily!
 Constipation
 Decrease sexual activity
**Nsg Mgt:
1. Anti parkinsonian agents
 Levodopa (L-Dopa) – short acting
 Carbidopa (Sinemet) – long acting
 Amantadine Hcl (Symmetrel) – eto hindi ko alam haha
Mechanism of action
Increase levels of dopa – relieving tremors & bradykinesia

*S/E of anti parkinsonian
o Anorexia
o n/v
o Confusion
o Orthostatic hypotension
o Hallucination
o Arrhythmia
*Contraindication:
o Narrow angled closure glaucoma o Pt taking MAOI (Parnate, Marplan, Nardil)

10
*Nsg Mgt when giving anti-parkinsonian:
 Take with meals – to decrease GIT irritation
 Inform pt – urine/ stool may be darkened
 Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
 Cause B6 reverses therapeutic effects of levodopa
 Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.

2. Anti cholinergic agents – relieves tremors
o Artane
o Cogentin

3. Antihistamine – Diphenhydramine Hcl (Benadryl)
S/E: Adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime.
Child – hyperactivity CNS excitement for kids.

4. Dopamine agonist
Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR.

**Nsg Mgt – Parkinson
1.) Maintain siderails
2.) Prevent complications of immobility
o Turn pt every 2h
o Turn pt every 1 h – elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition
CHON (protein) – in am
CHON (protein) – in pm – to induce sleep – due Tryptopan – Amino Acid
5.) Increase fluid in take, high fiber diet to prevent constipation
6.) Assist in surgery – Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
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MULTIPLE SCLEROSIS (MS) - myelin sheath
Chronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord.
 Remission & exacerbation
 Common – women, 15 – 35 yo cause – unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune – (supportive & palliative treatment only)
*Normal Resident Antibodies:
Ig G – can pass placenta – passive immunity. Short acting.
Ig A – body secretions – saliva, tears, colostrums, sweat
Ig M – acute inflammation
Ig E – allergic reactions
IgD – chronic inflammation

**S & Sx of MS: (everything down)

1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) – initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
c. Paresthesia – tingling sensation
3. Mood swings – euphoria (sense of elation )

4. Impaired motor function:
a. Weakness
b. Spasiticity –“ tigas”
c. Paralysis –major problem
5. Impaired cerebellar function
Triad Sx of MS aka (Charcot’s triad)
I – intentional tremors
N – nystagmus – abnormal rotation of eyes
A – Ataxia & Scanning speech
6. Urinary retention or incontinence
7. Constipation
11
8. Decrease sexual ability

**Dx – MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI – reveals site & extent of demyelination
3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.

Nsg Mgt MS
 Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH – adenocorticotopic
Steroids – to reduce edema at the site of demyelination to prevent paralysis
2. Maintain siderails
3. Assist passive ROMexercises – promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet – to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence – give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication
Ex. Grape, Cranberry, Orange juice, Vit C
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MYASTHENIA GRAVIS (MG)
 disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction.
 Common in Women, 20 – 40 yo, unknown cause or idiopathic
 Autoimmune – release of cholenesterase – enzyme [REMEMBER! Lumabas sa boards yan.]
 Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
 Descending muscle weakness
Nsg priority:
o a/w o aspiration o immobility

S/ Sx:
 Ptosis – drooping of upper lid of the eye ( initial sign)
 Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.
 Diplopia – double vision
 Mask like facial expression
 Dysphagia – risk for aspiration!!!
 Weakening of laryngeal muscles – hoarseness of voice
 Resp muscle weakness – leads to respiratory arrest. [Prepare at bedside tracheostomy set]
 Extreme muscle weakness during activity especially in the morning.

Dx test
 Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.
o Remember ung aso sa video dati, ung biglang lumakas – meaning nun (+) sya for MG
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
*Assist in mechanical vent – attach to ventilator
*Monitor pulmonary function test.
= kasi decreased vital lung capacity ung pt.
2. Monitor VS, I&O neuro check, muscle strength or motor
grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility.
Adult - every 2 hrs. // Elderly - every 1 hr.
5. NGT feeding
12
**Administer meds
 Cholinergics or anticholinesterase agents
 Mestinon (Pyridostigmine)
 Neostignine (prostigmin) – Long term
 Increase acetylcholine
 Corticosteroids – to suppress immune response
o Ex. Decadron (dexamethasone)

**Monitor for 2 types of Crisis:
Myastinic Crisis Cholinergic crisis
Cause – 1. Under medication
2. Stress
3. Infection
S/S
1. Unable to see – Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath
Mgt – administer cholinergic agents
Cause: 1 over meds
S/Sx - PNS



Mgt. - adm anti-cholinergic
 Atropine SO4

7. Assist in surgical proc – thymectomy - Removal of thymus gland. [Thymus secretes auto immune antibody.]
8. Assist in plasmaparesis – filter blood
9. Prevent complication – respiratory arrest – [Prepare tracheostomy set at bedside.]
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GBS – Guillain Barre Syndrome aka Acute inflammatory demyelinating polyneuropathy (AIDP)
 Disorder of CNS
 Bilateral symmetrical polyneuritis
 Ascending paralysis
Cause – unknown, idiopathic
 Auto immune
 r/t antecedent viral infection
 Immunizations

**S&Sx
Initial :
1. Clumsiness
2. Ascending muscle weakness – lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
 Paralysis
5. Alternate HPN to hypotension – lead to arrhythmia - complication
6. Autonomic changes
 increase sweating, increase salivation.
 Increase lacrimation

Dx most important: CSF analysis - thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl – immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding – due dysphagia
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7. Adm meds (GBS) as ordered:
 Anti cholinergic – atropine SO4
 Corticosteroids – to suppress immune response
 Anti arrhythmic agents
o Lidocaine /Xylocaine –SE confusion = VTach
o Bretyllium
o Quinines/Quinidine – anti malarial agent. Give with meals. // Toxic effect – cinchonism
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp – arrhythmias, respiratory arrest – [Prepare tracheostomy set at bedside.]
----------------------------------------------------------------------------------------------------------------------------- --------------------------------------
Meninges – 3-fold membrane – cover brain & spinal cord
Functions:
 Protection & support
 Nourishment
 Blood supply
**3 layers:
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF flows L3 & L4. [Site for lumbar puncture.]

MENINGITIS – inflammation of meningitis & spinal cord

Etiology – Meningococcus
- Pneumococcus
- Hemophilous influenza – child
- Streptococcus – adult meningitis
Transmission – direct transmission via droplet nuclei

S/S:
 Stiff neck or nuchal rigidity (initial sign)
 Headache
 Projectile vomiting – due to increase ICP
 Photophobia
 Fever chills, anorexia
 Gen body malaise
 Wt loss
 Decorticate/decerebration – abnormal posturing
 Possible seizure
**Signs of meningeal irritation – nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign – (+) Kernig’s [leg pain] & Brudzinski sign [neck pain]

Dx:
1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5
**Nsg Mgt for lumbar puncture – invasive
1. Consent / explain procedure to pt
o RN – diagnostic procedure (lab)
o MD – operation procedure
2. Empty bladder, bowel – promote comfort
3. Arch back – to clearly visualize L3, L4 *sim’s, shrimp position+
**Nsg Ngt post lumbar
1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
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4. Assess for movement & sensation of extremeties

Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: CHON, WBC, Glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 – 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC – reveals increase WBC

Management:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
**Side effects:
1. GIT irritation – take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection – alteration in normal bacterial flora
 Normal flora sa throat – streptococcus
 Normal flora sa intestine – e coli
**Sign of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic

2. Strict respiratory isolation 24h after start of antibiotic therapy
**Side note:
A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
B – Aplastic anemia – reverse isolation - due to bone marrow depression.
C – Cancer any type – reverse isolation – immunocompromised.
D – Post liver transplant – reverse isolation – takes steroids lifetime.
E – Prolonged use steroids – reverse isolation
F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
G – Asthma – not to be isolated

3. Comfy & dark room – due to photophobia & seizure
4. Prevent complications of immobility
5. Maintain F & E balance
6. Monitor vs, I&O, neuro check
7. Provide client health teaching & discharge plan
a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 y/o post meningitis
 Audiologist - due to damage to hearing- post repair myelomeningocele
 Urologist -Damage to sacral area – spina bifida – controls urination
9. Rehab for neurological deficit. [Can lead to mental retardation or a delay in psychomotor development.]
----------------------------------------------------------------------------------------------------------------------------- --------------------------------------

CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy
 Partial or complete disruption in the brains blood supply
 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
 Common to male – 2 – 3x high risk


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Predisposing factor:
1. Thrombosis – clot (attached) – [stationary]
2. Embolism – dislodged clot – pulmo embolism [circulating]
S/Sx: pulmo embolism
 Sudden sharp chest pain
 Unexplained dyspnea, SOB
 Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism
 Headache, disorientation, confusion & decrease in LOC

[Femur fracture – complications: fat embolism – most feared complication w/in 24hrs]
Yellow bone marrow – produces fat cells at meduallary cavity of long bone
Red bone marrow – provides WBC, platelets, RBC found at epiphisis
3.) Hemorrhage
4.) Compartment syndrome – compression of nerves/ arteries
**Risk factors of CVA:
 HPN
 DM
 MI
 artherosclerosis
 valvular heart dse
 Post heart surgery
 mitral valve replacement
**Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor
2. Sedentary lifestyle
3. Hyperlipidemia – genetic
4. Prolonged use of oral contraceptives
- Macro pill – has large amount of estrogen
- Mini pill – has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke
5. Type A personality – [punong Abala! – gusto laging busy]
a. Deadline driven person
b. 2 – 5 things at the same time
c. Guilty when not dong anything
6. Diet – increase saturated fats
7. Emotional & physical stress
8. Obesity
S /S:
1. TIA- [Transient inschemic attack] - warning signs of impending stroke attacks
 Headache (initial sx)
 dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia – 1 extreme)
 Increase ICP
2. Stroke in evolution – progression of S & Sx of stroke
3. Complete stroke – resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp - progressively deeper and sometimes faster breathing, followed by a gradual decrease**
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria – inability to vocalize, articulate words – hirap magsalita! D:
3. Aphasia
4. Agraphia difficulty writing
5. Alesia – difficulty reading
6. Homoninous hemianopsia – loss of half of field of vision – half bulag! ._o
**Ex. Left sided hemianopsia – approach Right side of pt – the unaffected side - [always approach unaffected side]
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Dx:
1. CT Scan – reveals brain lesion
2. Cerebral arteriography – site & extent of mal occlusion
 Invasive procedure due to inject dye
 Allergy test
**REMEMBER!!! -- All – graphy = invasive due to iodine dye- [lahat ng GRAPHY = invasive!]
**Post [after]
1.) Force fluid – to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal

**Nsg Mgt:
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids – prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
 To prevent decubitus ulcer
 To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding – if pt can’t swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia – approach on unaffected side
9. Meds
o Osmotic diuretics – Mannitol
o Loop diuretics – Lasix/ Furosemide
o Corticosteroids – dextamethazone
o Mild analgesic
o Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
 Streptokinase
 Urokinase
 Tissue plasminogen activating
o Monitor bleeding time
o Anticoagulants – Heparin & Coumadin” sabay”
 Coumadin will take effect after 3 days
o Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.
o Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote.
o Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.

Health Teaching
1. Avoidance modifiable lifestyle - Diet, smoking
2. Dietary modification - Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit – physical therapy
1. Mental retardation
2. Delay in psychomotor development

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