You are on page 1of 20

 tiny gap at this junction is called

Care of CLIENT with neurologic problems the synaptic gap or clef


gudecena Neurotransmitters
 chemical messengers that
Major Divisions of the Nervous System traverse the synaptic gaps
A. CENTRAL NERVOUS SYSTEM (CNS), consisting between neurons
of the brain and spinal cord,  when released by the sending
B. PERIPHERAL NERVOUS SYSTEM (PNS), the neuron, neuro-transmitters
vast network of spinal and cranial nerves linking travel across the synapse and
the body to the brain and spinal cord. bind to receptor sites on the
receiving neuron, thereby
The PNS is subdivided into: influencing whether it will
AUTONOMIC NERVOUS SYSTEM generate a neural impulse
involuntary control of: Neurotransmitters
• internal organs There are approximately 50 neurotransmitters
• blood vessels, identified
• smooth and cardiac muscle are chemicals located and released in the brain
A. SYMPATHETIC NERVOUS SYSTEM to allow an impulse from one nerve cell to pass
B. PARASYMPATHETIC NERVOUS SYSTEM to another nerve cell.
Nerve cells communicate messages by secreting
Structures Protecting the Brain neurotransmitters.
1. Meninges Neurotransmitters can excite or inhibit neurons
covers the brain
provides protection, support and nourishment Cranial Nerves
to the brain and spinal cord are composed of twelve pairs of nerves that
LAYERS: emanate from the nervous tissue of the brain.
1. Dura Mater
2. Arachnoid- contains the choroid plexus Neurodiagnostic Studies
3. Pia Mater 1. Lumbar Puncture/Spinal Tap- for CSF
2. CerebroSpinal Fluid analysis
- CSF should be clear and colorless
a clear and colorless fluid produced in the - Obtained for cell count, culture, glucose
choroid plexus at the lateral 3rd & 4th ventricles and protein testing
Contains minimal wbc and no RBC - Also used to measure CSF fluid or
3. Blood-Brain Barrier pressure, or instill air, dye or meds
Formed by the endothelial cells of the brain - A spinal needle is inserted into the
capillaries subarachnoid space between 3rd and 4th
All substances entering the CSF must filter or 4th and 5th lumbar vertebrae
through these barriers
Dyes, medications and anitibiotics are examples Nursing Management in Assisting with Spinal
of substances that cannot reach the CNS Tap/Lumbar Puncture
PreProcedure
Synapse [SIN-aps] - Signed consent
 junction between the axon tip - Explain procedure and clarify
of the sending neuron and the misconceptions
dendrite or cell body of the
receiving neuron
During the Procedure - Image is displayed on an oscilloscope or
- Position: Back of patient towards MD, TV monitor and is photographed
lateral recumbent have client draw knees to digitally
abdomen and chin to chest - Performed FIRST without contrast
- Pillows on patient’s head and between legs before imaging with contrast
- Maintain position to prevent trauma
resulting to a bloody tap CT Scan Nursing Intervention
During Procedure Patient needs to lie still during the entire
- Instruct patient to breathe normally and procedure; essential to be instructed to patient
relax; hyperventilation may lower an Teach relaxation techniques
elevated pressure altering accurate Sedation maybe necessary if patient is
pressure reading confused, agitated or restless
- Assist in cleansing lumbar area with Will require monitoring all through out
betadine sol’n and draping (observe If a contrast agent/dye will be used:
strict aseptic technique) Assess allergy to iodine/shellfish
- MD will inject a local anesthetic to 4hour fasting is required prior to test
numb puncture site Monitor post procedure dye reaction such as
- A specimen is collected usually in 3 vomiting, nausea, flushing
tubes; MUST be labeled in order of Assess dye injection site for bleeding or
collection. Pressure reading may also be hematoma, and monitor presence of distal
obtained. pulses
Post Procedure Provide fluid replacement because diuresis from
Patient must lie PRONE for 2-3 hours to reduce dye is expected
leakage of CSF
Monitor for complications of Lumbar tap 3. Magnetic Resonance Imaging
Force fluid intake to prevent post-procedure Uses magnetic field to create an image
headache Provides info about chemical changes w/in the
Monitor intake and output cell to monitor an organ’s response to
Post Lumbar Tap Complications treatment
Post Lumbar Puncture Headache Maybe used with or without dye
Temporary voiding problems MRI Nursing Intervention
Slight elevation of temperature Assess patient for claustrophobia
Backache or spasms Patient instructions: relaxation technique;
Stiff neck microphone is provided inside the scanner so
Rare but serious: herniation of spinal patient may speak to staff
intracranial contents, spinal epidural abscess,
meningitis 4. Cerebral Angiogram
Injection of contrast through the femoral artery
Radiographic into carotid arteries to visualize arteries and
1. Skull and Spinal Radiography assess for lesions
- X-ray of the skull reveal the size and shape of Used to investigate vascular disease, aneurysms
the skull bones, suture separation in infants, Frequently performed before craniotomy to
fracture or bony defects, erosion or calcification assess patency and adequacy of cerebral
2. CT Scan circulation
- Images provide cross-sectional view of May use brachial artery to inject dye or a direct
the brain, distinguish differences in puncture of carotid or vertebral artery
tissue densities of the skull, cortex, sub alternatively
cortical structures and ventricles
Angiography Nursing Intervention - Stupor- Awakens to vigorous shake or
Preprocedure painful stimuli but returns to
Signed Consent unresponsive sleep
4-6hours NPO - Coma- Remains unresponsive to all
Obtain baseline neuro assessment stimuli; eyes stay closed; decorticate or
Patient must be well hydrated 2days prior to the decerebrate
exam. Patient will be asked to void before going
to the x-ray department GLASGOW COMA SCALE:
Explain procedure to patient. - Developed to predict recovery from a
Patient has to be immobile during the entire head injury
procedure. - Used also to assess the LEVEL OF
A brief feeling of warmth in the face, behind the CONCIOUSNESS (LOC)
eyes, or the jaw, teeth, tongue, lips will be felt. a. EYE RESPONSE
A metallic taste after the injection of the b. MOTOR RESPONSE
contrast agent will be experienced. c. VERBAL RESPONSE
Mark peripheral pulses Maximum points/score: 15
Angiography Nursing Intervention Lowest possible score: 3
During Procedure State of coma: 7 and below
The groin will be shaved and prepared, injected Mental Status Assessment
with a local anesthetic to numb as catheter is B. Appearance and Mood
inserted Posture
Catheter will be flushed with heparinized saline Gait- smooth, coordinated
Post Procedure Motor Movements
- Observe for Dress; hygiene
signs of altered cerebral blood Facial Expression- good eye contact
flow due to minor or major arterial Speech- clear with moderate pace
blockage caused by thrombosis, Mental Status Assessment
embolism or hemorrhage producing C. Mood
neurologic deficits such as: Observe mood when asked, “How are you
 a. Altered feeing?” or “What are your plans for the
level of responsiveness and future?”
 Expression
consciousness D. Thought Processes & Perceptions
b. Hemiparesis - Clarity and content
c. Speech disturbances - Perceptions- follows directions
Angiography Nursing Intervention accurately
Post Procedure - Judgment- answers to questions are
Monitor Neuro status and V/S until stable based on
Monitor for swelling in the neck and for - sound rationale
dysphagia and NOTIFY MD if these occur Mental Status Assessment
Maintain bed rest for 12hrs as prescribed E. Cognitive Abilities
Mental Status Assessment Orientation
A. Level of Consciousness Length of concentration
- Awake– oriented to time, place and Memory
person Abstract reasoning
- Obtunded- opens eyes to loud voice, Ability to make sound judgment
responds slowly with confusion Ability to identify similarities
Sensory perception and coordination
CSF Circulation/ Pathway B. Supratentorial Surgery
CSF is produced in the choroid plexus (approx. Head of bed elevation 30 degrees to promote
50-70%), and the remainder is formed around venous outflow through the jugular vein
blood vessels and along ventricular walls. Do not lower head of bed w/o MDs order
It circulates from the lateral ventricles to the
foramen of Monro Common Neurologic Manifestations
third ventricle, aqueduct of Sylvius (Cerebral Headache
aqueduct), fourth ventricle, foramen of (cephalgia),
Magendie (Median aperture) and foramina of is one of the most common of all human
Luschka (Lateral apertures) physical complaints.
subarachnoid space over brain and spinal cord symptom rather than a disease entity
CSF is reabsorbed into venous sinus blood via it may indicate organic disease (neurologic or
arachnoid granulations. other disease), a stress response, vasodilation
Surgical Intervention (migraine), skeletal muscle tension (tension
Craniotomy headache), or a combination of factors
Complications: Primary headache
- Increased ICP from cerebral edema Include migraine, tension-type, and cluster
- Hemorrhage headaches
- obstruction of the normal flow of CSF
Surgical Intervention Migraine
Preoperative Intervention is a symptom complex characterized by periodic
Explain procedure to client and family and recurrent attacks of severe headache.
Ensure informed consent has been obtained Caused by primarily a vascular disturbance that
Prepare to shave clients head as prescribed occurs more commonly in women and has a
Stabilize client before surgery strong familial tendency.
Surgical Intervention
Avoid neck or hip flexion and maintain head in Clinical Manifestations
midline neutral position MIGRAINE
Provide quiet environment The migraine with aura can be divided into four
Monitor head dressing frequently for signs of phases: prodrome, aura, the headache, and
drainage recovery (headache termination and
Mark areas of drainage at least once/shift postdrome).
If on ventriculostomy maintain suction of drain, 1. Prodrome
record amount and color; notify MD if drainage Symptoms include depression, irritability,
is greater than 30-50ml feeling cold, food cravings, anorexia, change in
Record strict measurement of I&O hourly activity level, increased urination, diarrhea, or
Monitor electrolyte values constipation.
Apply ice pack or cool compresses as prescribed 2. Aura Phase
for periorbital edema and ecchymosis characterized by focal neurologic symptoms,
Positioning of Patient after Craniotomy visual disturbances (ie, light flashes and bright
varies spots) are common and may be hemianopic
Incorrect positioning may cause serious and (affecting only half of the visual field).
possibly fatal complications Other symptoms that may follow include
A. Infratentorial Surgery numbness and tingling of the lips, face, or
Flat position without head elevation or may hands; mild confusion; slight weakness of an
order head of bed at 40-35 degrees extremity; drowsiness; and dizziness.
Do not elevate the head in the acute phase of 3. Headache Phase.
care after surgery w/o MD order
occur, a throbbing headache intensifies over Sometimes a tender, swollen, or nodular
several hours. temporal artery is visible.
This headache is severe and incapacitating and
is often associated with photophobia, nausea, Medical Management
and vomiting. Triptans
4. Recovery Phase Cause vasoconstriction, reduce inflammation,
- In the recovery phase (termination and and may reduce pain transmission.
postdrome), the pain gradually The five triptans in routine clinical use include
subsides. sumatriptan (Imitrex)
- Muscle contraction in the neck and naratriptan (Amerge)
scalp is common, with associated rizatriptan (Maxalt)
muscle ache and localized tenderness, zolmitriptan (Zomig)
exhaustion, and mood changes. almotriptan
- Any physical exertion exacerbates the
headache pain. Nursing Management
Relieving pain
Tension headaches comfort measures
is characterized by a steady, constant feeling of application of local heat or massage.
pressure that usually begins in the forehead, Additional strategies may include the use of
temple, or back of the neck. analgesic agents, antidepressant medications,
It is often bandlike or may be described as “a and muscle relaxants as prescribed.
weight on top of my head.” Increased Intracranial Pressure
The rigid cranial vault contains brain tissue
Cluster headaches (1,400 g), blood (75 mL), and CSF (75 mL)
are unilateral and come in clusters of one to It can result from head injury, brain tumor,
eight daily, with excruciating pain localized to hydrocephaly, meningitis, encephalitis, or
the eye and orbit and radiating to the facial and intracerebral hemorrhage.
temporal regions. Increased ICP should be treated as a medical
The pain is accompanied by watering of the eye emergency
and nasal congestion.
Each attack lasts 30 to 90 minutes and may have MANIFESTATIONS OF INCREASED ICP
a crescendo–decrescendo pattern Headache
often described as penetrating and steady Change in level of consciousness
Irritability
Secondary Headache Increased systolic BP
Associated with an organic cause, such as a Decreased HR (early)
brain tumor or an aneurysm. Increased HR (late)
Serious disorders related to headache include Decreased RR
brain tumors, subarachnoid hemorrhage, stroke, Hemiparesis
severe hypertension, meningitis, and head Loss of oculomotor control
injuries. Photophobia (light sensitivity)
Vomiting (with subsequent decreased
Other type of headache headache)
Cranial arteritis Diplopia (double vision)
often begins with general manifestations, such Decreased RR
as fatigue, malaise, weight loss, and fever. Hemiparesis
Clinical manifestations Loss of oculomotor control
MANAGEMENT OF INCREASED ICP Diagnostics
1. Elevate head of bed 15 to 30 degrees. Amniocentesis (to det increased levels of alpha-
Keep head in neutral alignment. Do not fetoprotein
flex or rotate neck. alpha-fetoprotein level – increase suggests a
2. Establish IV access. NTD)
3. Insert Foley catheter. Urine estriol level
4. Meds that may be used include osmotic Pre-pregnancy serum folic acid
diuretics, sedatives, neuromuscular Fetal ultrasound
blocking agents, corticosteroids, and MRI
anticonvulsants. CT scan
5. Restrict fluids.
6. Closely monitor vital signs and perform Types:
neuro checks. A. Anencephaly– large skull defect with
7. Monitor fluids and electrolytes no cortex. many are stillborn and other
8. Schedule all procedures (including bathing die within days of birth
and especially suctioning) to coincide with
periods of sedation. B. Encephalocele– projections of cranial
9. Discourage patient activities that result in use content through a bony skull defects, usually
of Valsalva’s maneuver. occipital region.
10. Keep environment as quiet as possible. C. Spina Bifida - CNS defect that occurs as a
11. Ventilator may be used to maintain PaCO2 result of incomplete closure of one or more
between 35-45. vertebrae.

Neurological Dysfunctions TYPES OF SPINA BIFIDA


• Depends on the spinal cord
Neural Tube Defects involvement
Closure of the neural tube occurs during the 3 rd • Visible spinal defect
and 4th week AOG. • Flaccid paralysis of the legs
Etiology • Altered bladder and bowel function
It is UNKNOWN, only associated with the • Hip and joint deformities
following Nursing Management:
Inadequate folic acid • Evaluate sac and measure lesion
Medications – antimetabolites of folic acid, • Perform neurological assessment
anticonvulsant • Monitor increase in ICP
Pregestational IDDM • Protect sac, using, use aseptic
Maternal hyperthermia technique
Genetics • Place in prone position, head turned to
Amniotic band disruption sequence one side for feeding
Teratogens • Assess for early signs of infection
radiation • Administer medication as ordered
Risk Factors: ( antibiotics, a
Maternal malnutrition
Drug exposure CEREBRAL PALSY
Low socioeconomic group • Non progressive disorder of movement
Older maternal age and posture that results from lesion of
the immature brain
Risk factors:
• Prematurity
• Birth asphyxia Diagnostic Methods
• Early infection or trauma • A. MRI
Clinical Manifestations • to visualize small plaques, evaluate
• Tones remains relatively constant cause & effect of treatment.
regardless of activity and level of • B. Electrophoresis
arousal • - used to study the CSF, abnormal IgG
• Significant Hyperreflexia appears in the CSF
• Stiff and rigid arms or legs • - a technique widely used to separate &
• Persistence of Primitive and pathologic identify serum proteins & other
reflexes substances up to 95% of patients.
• Extreme irritability and crying C. Fluid- Attenuated-Inversion-Recovery
• Feeding difficulties ( FLAIR)
• Delayed gross development - able to detect two to three times the number
• Opisthotonus posture of lesions seen in MRI
D. Magnetic Resonance Spectroscopy
Management - decreased level of N- Acetylaspartate
Prosthetics/Orthotics (NAA) suggest presence of axonal
Surgery damage
Hyperbaric Oxygen - N- Acetylaspartate - is the second-most-
Therapies: speech, physical, occupational concentrated molecule in the brain after
 Botulinum Toxin A: Botox the amino acid glutamate
 Massage Medical Management:
1. Immunomodulating Drugs- slows
Nursing Management disease progression, reduces relapse
Assess child’s developmental level and Eg. Interferon beta-1a ( Avonex)
intelligence 2. Immunosuppresant Drugs – same as #1
Encourage early intervention and participation Eg. Mitoxantrone ( Novantrone)
in school programs 3. Corticosteroid Drugs- exacerbations
Prepare for using mobilizing devices to prevent Eg. Corticotropin (ACTH), Prednisone Deltasone
deformities 4. Muscle Relaxants- spasticity
Communicate with the child on a functional Eg. Diazepam (Valium), Baclofen(Lioresal)
level, not on chronological age level Antiepileptic Drugs –neuropathic pain
Provide safe environment Eg. Carbamazepine ( Tegretol)
Provide safe, appropriate toys for age and Anti depressants- depression
developmental level Eg. Amitriptyline (Elavil)
Position upright after meals Stimulant Drugs- fatigue
Eg. Amantadine ( Symmetrel)
Degenerative Neurological Dysfunctions Cholinergic- urinary retention
Eg Neostigmine (Prostigmin)
MULTIPLE SCLEROSIS Anti cholinergic- urinary frequency
• characterized by small patches of Eg. Probantin ( Pro- Banthine)
demyelination in the brain & spinal Surgical Management:
cord. Nursing Management
• Aka: Disseminated Sclerosis Regular exercise
Immune-mediated progressive demyelinating Warm packs
disease of the CNS Muscle stretching
A chronic degenerative progressive disease of Stretch-hold-relax routine, swimming,
the CNS stationary bicycling, progressive weight bearing
Activity and rest - surgical implantation of adrenal medullary
Minimizing effects of immobility tissue in the corpus striatum to establish normal
Safety dopamine release
Enhancing bladder and bowel control 4. Deep Brain Stimulation
Enhancing communication • electrode placed in the
Managing swallowing difficulties thalamus and connected to
Suction apparatus pulse generator, blocks nerve
pathways that cause tremors
PARKINSON’S DISEASE Nursing Care
Discovered by Dr. James Parkinson in the 1800 Improving mobility
Another name for this illness is Paralysis Enhancing self care activities
Agitans Latin translation of "shaking palsy.” Improving bowel eliminations
Is a slowly progressing neurologic movement Improving nutrition
disorder that eventually leads to disability Enhancing swallowing
Most common is the idiopathic or Encouraging the use of assistive device
degenerative form Improving communication
a movement disorder often characterized by Supporting coping abilities
muscle rigidity, tremor, a slowing of physical
movement Trigeminal neuralgia
The interaction of Dopamine and Acetylcholine - (TIC DOULOUREUX)
 Acetylcholine stimulates muscle - is a condition of the fifth cranial nerve
contraction. characterized by paroxysms of pain in
 Dopamine inhibits muscle contraction the area innervated by any of the three
 The primary symptoms are due to branches
excessive muscle contraction, normally - most commonly occurs in the second
caused by the insufficient formation and and third branches of the trigeminal
action of dopamine which is produced nerve
in the dopaminergic neurons of the Causes/ risk factors
brain. Multiple sclerosis
 occurs when the effect of dopamine is Swollen blood vessels or tumor
less than that of acetylcholine. Most often before 35 years old
 The level of dopamine tends to More common in women
continue to fall slowly over time, with Manifestations
an attendant worsening of symptoms. pain that ends as abruptly as it starts and is
described as a unilateral shooting and stabbing
Surgical Management sensation.
1. Thalamotomy Associated involuntary contraction of the facial
- stereotactic electrical stimulator destroys part muscles can cause sudden closing of the eye or
of the ventrolateral portion of the thalamus in a twitch of the mouth
an attempt to reduce tremors Factors that trigger
2. Pallidotomy Paroxysms can occur with any stimulation of the
- involves destroying part of the ventral aspect terminals of the affected nerve branches such
of the medial globus pallidus through electrical as washing the face, shaving, brushing the
stimulation teeth, eating, and drinking.
3. Neural Transplantation
Medical Management
PHARMACOLOGIC THERAPY
1. Antiseizure agents, such as The patient is cautioned not to chew on the
carbamazepine (Tegretol) affected side until numbness has diminished.
relieve pain by reducing the transmission of The patient is observed carefully for any
impulses at certain nerve terminals. difficulty in eating and swallowing foods of
 S/E: nausea, dizziness, different consistency.
drowsiness, and aplastic
anemia. MYASTHENIA GRAVIS
 Monitor for bone marrow Medical Management
depression during long term 1. Anti cholinesterase
therapy. • increase the relative
2. Gabapentin (Neurontin) and baclofen concentration of available
(Lioresal) - used for pain control. acetylcholine at the neuro
3. Phenytoin (Dilantin) may be used as muscular junction
adjunctive therapy • Eg. Pyridostigmine bromide
Surgical Management (Mestinon)
Microvascular Decompression of the Neostigmine bromide (Prostigmin)
Trigeminal Nerve. 2. Immunosuppressive therapy
used to decompress the trigeminal nerve. • Eg. Corticosteroid
relieves facial pain while preserving normal 3. Cyto toxic medications
sensation, but it is a major procedure, involving • decrease the circulating anti
a craniotomy. acetylcholine receptor
Percutaneous Radiofrequency Trigeminal • Eg. Cyclophosphamide
Gangliolysis. (cytoxan )
radiofrequency interruption of the gasserian Surgical Management
ganglion, in which the small unmyelinated and Nursing Care
thinly myelinated fibers that conduct pain are Improving respiratory function
thermally destroyed Increasing physical mobility
Improving communication
Nursing Management Providing eye care
Preventing Pain Preventing aspiration
Providing cotton pads and room-temperature ALZHEIMER’S DISEASE
water for washing the face Epidemiology
Instruct to rinse with mouthwash after eating - 4 million affected in the US
when tooth-brushing causes pain, and - Statistics will double by 2020
performing personal hygiene during pain-free - Women and men are affected
intervals equally
Instruct to take food and fluids at room - 10% of the population older
temperature, to chew on the unaffected side, than 65 are affected
and to ingest soft foods.  a neurodegenerative disease
PROVIDING POSTOPERATIVE CARE  most common cause of dementia
Postoperative neurologic assessments  characterized clinically by progressive
If the surgery results in sensory deficits to the cognitive deterioration together with
affected side of the face, the patient is declining activities of daily living and
instructed not to rub the eye, because pain will neuropsychiatric symptoms or
not be felt if there is injury. behavioral changes.
The eye is assessed for irritation or redness. ETIOLOGY
Artificial tears may be prescribed to prevent A. Brain atropy
dryness in the affected eye. B. Distortions in cortical neurofibrils
(Alzheimer's fibrils) Assist in ADLs
C. Aluminum toxins Nsg. Mgt
D. Alteration in acetylcholine Sing and dance, as necessary
E. Reduction in norepinephrine, GABA Engage in reminiscing activities (look at old
F. Altered immune functionining photos, allow to share stories of the past)
G. Genetics Call the person by name and always introduce
yourself at the start
Pathophysiology Actively involve the person in activities and
Assessment Findings: simple decision making
 History of progressive degeneration of Redirect inappropriate behavior like anger
mental, emotional & physical abilities CEREBROVASCULAR DISORDERS
 History of progressive memory loss & Stroke is the primary cerebrovascular disorder
regressive behavior, physical & in the United States and in the world.
emotional status in relation to needs 2nd leading cause of death.
associated with nutrition, fluid &
electrolyte status, & safety CEREBROVASCULAR DISORDER
 History of premorbid personality from Types:
family members A. Ischemic - damage to brain due
 History of medications used by the to a clogged artery
client B. Hemorrhagic-blood vessel burst
Pharmacological Management leaking blood into brain tissues
Nursing Management Pathophysiology
Exercise and Physical Therapy NEUROLOGIC DEFICIT- MANIFESTATION
Decision making process Visual Field Deficits
Speech Therapy 1. Homonymous hemianopsia (loss of
 Health teaching half of the visual field)
 Address physical, emotional • Unaware of persons or objects on side
and social aspect of visual loss
 Medication regimen • Neglect of one side of the body
 Safety measures • Difficulty judging distances
 Signs and symptoms of 2. Loss of peripheral vision
disease progression Difficulty seeing at night
 Nutrition Unaware of objects or the borders of objects
 Supplemental feedings may 3. Diplopia - Double vision
be required NEUROLOGIC DEFICIT- MANIFESTATION
 Monitor weight Motor Deficits
 Consider difficulty in 1. Hemiparesis
swallowing Weakness of the face, arm, and leg on the same
Nsg Mgt side (due to a lesion in the opposite
Do not push too fast or pressure elderly (threat hemisphere)
to self-image, new environment, or direct 2. Hemiplegia
confrontation). This will result in combative Paralysis of the face, arm, and leg on the same
behavior. side (due to a lesion in the opposite hemisphere
Provide basic human needs and SAFETY NEUROLOGIC DEFICIT- MANIFESTATION
Listen to what the person is NOT saying (NON- 3. Ataxia
VERBAL CUES) Staggering, unsteady gait
Encourage periodic rest and sleep Unable to keep feet together;
needs a broad base to stand
4. Dysarthria - The remaining dose is administered
Difficulty in forming words over 1 hour via an infusion pump.
5. Dysphagia - After the infusion is completed, the line
Difficulty in swallowing is flushed with 20 mL of normal saline
NEUROLOGIC DEFICIT- MANIFESTATION solution to ensure that all the
Sensory Deficits medication is administered
Paresthesia (occurs on the side opposite the Side Effects
lesion) Bleeding - most common side effect of t-PA
Numbness and tingling of extremity administration
Difficulty with proprioception Nsg. Responsibilities
NEUROLOGIC DEFICIT- MANIFESTATION cardiac monitoring
Verbal Deficits Vital signs are obtained every 15 minutes for
1. Expressive aphasia the first 2 hours, every 30 minutes for the next 6
Unable to form words that are understandable; hours, then every hour for 16 hours.
may be able to speak in single-word responses Blood pressure should be maintained with the
2. Receptive aphasia systolic pressure less than 180 mm Hg and the
Unable to comprehend the spoken word; can diastolic pressure less than 100 mm Hg.
speak but may not make sense Airway management is instituted based on the
3. Global (mixed) aphasia patient’s clinical condition and arterial blood gas
Combination of both receptive and expressive values.
aphasia Medical and Surgical Management
NEUROLOGIC DEFICIT- MANIFESTATION 2. Anticoagulant (IV heparin or low-
Cognitive Deficits molecularweight heparin) for ischemic strokes
Short- and long-term memory loss 3. careful maintenance of cerebral
Decreased attention span hemodynamics to maintain cerebral perfusion.
Impaired ability to concentrate 4. Reduce ICP by administering an osmotic
Poor abstract reasoning diuretic (eg, mannitol), maintaining PaCO2
Altered judgment within the range of 35 to 45 mm Hg, and
NEUROLOGIC DEFICIT- MANIFESTATION positioning to avoid hypoxia
Emotional Deficits Other treatment measures include the
Loss of self-control following:
Emotional lability Elevation of the head of the bed to promote
Decreased tolerance to stressful situations venous drainage and to lower increased ICP
Depression Intubation with an endotracheal tube to
Withdrawal establish a patent airway, if necessary
Fear, hostility, and anger Continuous hemodynamic monitoring
Feelings of isolation Systolic pressure should be maintained at less
Time Course in Stroke than 180 mm Hg, diastolic pressure at less than
Diagnostic Tests 100 mm Hg to reduce the potential for
Medical and Surgical Management additional bleeding or further ischemic damage
Meds: Neurologic assessment
1. Thrombolytic Therapy – Recombinant t- Medical and Surgical Management
PA Endarterectomy
• minimum dose is 0.9 mg/kg; the surgical reopening of an artery obstructed by
maximum dose is 90 mg. ATHEROMA.
• The loading dose is 10% of the Nursing Management
calculated dose and is administered Improving mobility and preventing joint
over 1 minute. deformity
Changing positions, maintaining skin integrity Clinical Manifestations
Establishing exercise program Fatigue
Enhancing Self care, activities of daily living progressive weakness and atrophy of the
Managing Sensory-Perceptual Difficulties muscles of the arms, trunk, or legs, cramps,
Nursing Management Muscle fasciculations (twitching)
Attaining bowel and bladder control Muscle incoordination
Improving thought process Muscle spasticity
Improving communication brisk and overactive deep tendon stretch
Improving family coping reflexes
Helping pt cope with sexual dysfunction Clinical Manifestations
Continuing care difficulty talking, swallowing, and ultimately
Hemorrhagic Stroke breathing.
Clinical Manifestations Weakness of the posterior tongue and palate
Surgical and Medical Management impairs the ability to laugh, cough, or even blow
Analgesics the nose
Bed rest with sedation The voice assumes a nasal sound, and
Surgical Evacuation (Craniotomy) articulation becomes so disrupted that the
if cerebellar hemorrhage diameter exceeds 3 speech is unintelligible.
cm Some emotional lability may be present, but
Glasgow Coma Scale score is below 14 intellectual function is not impaired.
Aneurysm Clipping Medical Management
Craniectomy  riluzole (Rilutek), a glutamate
Craniotomy Procedure antagonist, slows the deterioration of
Aneurysm Clipping motor neurons (dose of 100 mg riluzole
Nursing Management per day)
Monitor for neurologic deterioration  Symptomatic treatment and
Implement aneurysm precaution rehabilitative measures are employed to
Monitor and manage complications: support the patient and improve the
 Vasospasm quality of life.
 Seizure  Baclofen (Lioresal), dantrolene sodium
 Hydrocephalus (Dantrium), or diazepam (Valium) may
 Rebleeding be useful for patients troubled by
Teaching patient self care spasticity, which causes pain and
Continuing care interferes with self-care.
DYSFUNCTIONS Medical Management
OF THE PERIPHERAL NERVOUS SYSTEM  A patient experiencing problems with
Amyotrophic Lateral Sclerosis aspiration and swallowing may require
is a disease of unknown cause in which there is enteral feeding.
a loss of motor neurons (nerve cells controlling  Mechanical ventilation (using negative-
muscles) in the anterior horns of the spinal cord pressure ventilators) is an option when
and the motor nuclei of the lower brain stem. alveolar hypoventilation develops.
 Several theories exist regarding the
cause of ALS, including autoimmune BELL’S PALSY
disease and free radical damage. Pathophysiology
 The leading theory held by researchers Clinical Manifestations
is that overexcitation of nerve cells by Management
the neurotransmitter glutamate leads to Nursing Considerations
cell injury and neuronal degeneration
• explain to the client that in most cases, The eye is the organ of sight, a nearly spherical
recovery occurs within 2 to 8 weeks. hollow globe filled with fluids (humors)
• teach client to prevent corneal - The outer layer or tunic is fibrous and
irritation by using artificial tears, protective (sclera, or white, and cornea)
manually closing the eye & applying an - The middle tunic layer is vascular in
eye shield nature (choroid, ciliary body and the
• teach client to keep the face warm iris)
• teach the client to massage face gently - The innermost layer – light-sensitive
& perform simple exercises such as layer that lines the interior of the eye
blowing and is sensory in nature. (the retina)
• encourage ventilation of feelings • The fluids in the eye are divided
because self image may be affected. by the lens into the vitreous
• support client’s nutritional status by humor (behind the lens) and
providing privacy & small, frequent the aqueous humor (in front of
feedings & encourage the client to the lens).
favor the unaffected side while eating. The lens
• allow it to change shape to focus light
Guillain-Barre Syndrome on the retina, which is composed of
Medical Management sensory neurons.
• Plasmapheresis (IVIG) - trials • The eye is like a
have proven the effectiveness camera.
of this form of treatment. • Light comes in through the cornea, a
• Support of vital function: NGT clear cover that is like the glass of a
insertion, intermittent camera's aperture.
catheterization, intubation or • The amount of light coming in is
ventilatory support controlled by the pupil, an opening that
• Steroids opens and closes a little like a camera
Nursing Management shutter.
Monitor vital signs, vital capacity, breath sounds • The light focuses on the retina, a series
& ABG of light-sensitive cells lining the back of
Keep airway & tracheostomy set at bedside the eye.
Suction, provide fluid replacement therapy, & • The retina acts like camera film, reacting
monitor functioning of the respirator as to the incoming light and sending a
required record of it via the optic nerve to the
Provide emotional support to the client & brain.
family Other parts of the eye support the main
Provide explanations of disease process & care activity of sight:
Refer client & family to a support group or • Some carry fluids (such as tears and
foundation for additional information & blood) to lubricate or nourish the eye.
resources • Others are muscles that allow the eye
Prevent complications of Immobility to move.
Skin care, apply antiembolic stockings • Some parts protect the eye from injury
Range of motion exercise, position changes (such as the lids and the epithelium of
Coughing & deep breathing the cornea).
• And some are messengers, sending
The Eye and Vision sensory information to the brain (such
• EYES as the pain-sensing nerves in the cornea
and the optic nerve behind the retina).
• Vision increasing numbers of letters that
Is the passage of rays of light from an object decrease in size.
through the cornea, aqueous humor, lens and • The smallest row that can be read
vitreous humor to the retina, and its accurately indicates the patient's visual
appreciation in the cerebral cortex. acuity in that eye.
• Accommodation • The fraction 20/20
The adjustment of the lens to change the focus • The numerator represents the test
of the eye. distance, 20 feet.
• Types of Refractive Errors • The denominator represents the
• EMMETROPIA distance that the average eye can see
(normal) the letters on a certain line of the eye
• Rays coming from an object at a chart.
distance of 6 meters (20 ft) or more are • The biggest letter on an eye chart often
brought to a focus on the retina by the represents an acuity of 20/200, the
lens value that is considered “legally blind”
• AMETROPIA • A legally blind person is one who can
(abnormal) read the E with the best possible
Rays of light coming from an object at a distance glasses.
of 6 meters B. Ishihara Test - Color Blindness Test
(20 ft) or more are brought to a focus in front of • People who are "color blind" cannot
the retina distinguish red from green or blue from
Correction yellow.
Concave Lens • composed of a series of colored cards
• AMETROPIA on which numbers or lines of equal
(abnormal) shade can be read by a person with
• AMETROPIA(abnormal) normal color vision but not by someone
• Astigmatism occurs when an abnormal with defective color vision.
curvature of the cornea can cause two • Diagnostic Findings
focal points to fall in two different C. Ophthalmoscope
locations; makes both near and far • Ophthalmoscopy requires dilating the
objects appear blurry pupils with drops to give the doctor the
• Presbyopia is caused when the center best view of the inside of the eye.
of the lens in the eye hardens so that it Purpose:
is unable to focus up close; this • To view the eye’s fundus
condition generally affects those over • To detect changes in the retina
the age of 40. due to eye disease
• Correction • Types of Opthalmoscope
Bifocals (two corrective lenses; one for • Diagnostic Procedures
near vision or reading, the other for far D. Eye Irrigation
vision) • irrigating the eye to help relieve
• Corrective Lenses irritation, discomfort and burning by
• Diagnostic Findings removing loose foreign material , air
A. Snellen Chart - measures visual acuity. pollutants (smog or pollen), or
• The traditional Snellen chart is printed chlorinated water.
with eleven lines of block letters. COMMON EYE PROBLEMS
• The first line consists of one very large CATARACT
letter, an E. Subsequent rows have Congenital Cataract
• A congenital
cataract involves • seems to develop because the eye
clouding of the lens of muscles are uncoordinated and do not
the eye that is present move the eyes together
at birth. • acquired strabismus can occasionally
Management occur because of a problem in the brain,
• Surgical cataract removal an injury to the eye socket, or thyroid
• Followed by placement of an intraocular eye disease.
lens (IOL). • Signs & Symptoms
• Patching Children:
• Treatment for any underlying disorder - may hold their heads to one side if they
may be needed. can use their eyes together in that
Surgical Management position.
A. Intracapsular Cataract Extraction (ICCE) - may close or cover one eye when it
• Involves removing the lens, the entire deviates, especially at first.
lens capsule and its attachments from Adults
the eye. - have more symptoms
• Surgical Management - double vision (see a second image)
B. Extracapsular Cataract Extraction (ECCE) - may lose depth perception.
• refers to a surgery in which the entire • Treatment
cataract is removed through a small • patch the good eye and wear glasses
hole made in the lens capsule. before treating the strabismus.
• The rest of the lens capsule and all its • Surgery to get the eyes close enough to
attachments are left intact. perfectly straight that it is hard to see
C. Kelman Phaco Emulsification any residual deviation.
• the use of high frequency sound waves • Prisms and Botox injections of the eye
to liquefy the contents of the lens which muscles are alternatives to surgery in
can then be safely remove from the eye some cases.
using suction through a 3 mm incision
• Nursing Considerations GLAUCOMA
• Health Teachings • is a condition where pressure inside the
• STRABISMUS eye rises to the point of causing damage
• refers to misaligned eye to the optic nerve with associated loss
• can be subtle or obvious of vision
• intermittent (occurring occasionally) or
constant • It usually affects both eyes, and it is the
• It can affect one eye only or shift leading cause of blindness in the world.
between the eyes • Pathophysiology
TYPES: There are two accepted theories regarding how
1. Esotropia increased IOP damages the optic nerve in
2. Exotropia glaucoma.
3. Hyperropia 1. The direct mechanical theory
4. Hyporopia • suggests that high IOP damages the
Causes retinal layer as it passes through the
• do not have a well-understood cause optic nerve head.
• Usually begins in infancy or childhood 2. The indirect ischemic theory
• need glasses for farsightedness - Suggests that high IOP compresses the
microcirculation in the optic nerve head,
resulting in cell injury and death.
• stages • Types of Laser Surgery
1. Initiating events: precipitating factors 1. Laser Peripheral Iridotomy
include illness, emotional stress, - used for treating acute angle glaucoma
congenital narrow angles, long-term use - The procedure makes an opening in the
of corticosteroids, and mydriatics (ie, iris, which lets the fluid drain more
medications causing pupillary dilation). 2. Argon Laser Trabeculoplasty
2. Structural alterations in the aqueous - used for the open angle glaucoma and
outflow system: tissue and cellular when doctor do this they aim the laser
changes caused by factors that affect at the opening of the canal, helping the
aqueous humor dynamics lead to drainage system work by making it a
structural alterations little bigger
• stages - 3. Microsurgery
3. Functional alterations: conditions such as - - conventional surgery and it is used for
increased IOP or impaired blood flow create acute, chronic, congenital, and
functional changes that lead to the fourth stage. secondary glaucoma.
4. Optic nerve damage: atrophy of the optic 3. Selective Laser Trabeculoplasty
nerve is characterized by loss of nerve fibers and - It is a combination of very low frequencies that
blood supply, and this fourth stage inevitably treat specific cells and leave the mesh-like
progresses to the fifth stage. drainage canals intact.
5. Visual loss: progressive loss of vision is 4. Laser Cyclophotocoagulation
characterized by visual field defects. -. used for severe glaucoma cases that can’t be
For all glaucoma cases: treated with minor surgery, that helps decrease
- blurred vision the amount of fluid made
- eye pain Nursing Management
- red eye • Explain the importance of continued
- dilated pupils use of eye medication
- severe pain in the head • Explain the need for continued medical
- seeing halos around lights supervision
Diagnostic Procedure • Teach the client to avoid activities that
• Diagnostic Procedure can increase intraocular pressure.
• Diagnostic Procedure • Instruct client to report severe eye or
Types of Glaucoma brow pain & nausea to the physician.
1. Open Angle Glaucoma
- most common type and comprises RETINAL DETACHMENT
about 90% of all cases of glaucoma. • four types of retinal detachment
- no symptoms for this glaucoma 1. Rhegmatogenous detachment
• TYPES • is the most common form.
3. Pigmentary • In this condition, a hole or tear develops
- which occurs when pigment from the iris flakes in the sensory retina, allowing some of
off and blocks the drainage canal. the liquid vitreous to seep through the
4. Secondary Glaucoma sensory retina and detach it from the
- can develop only from specific things like a RPE
tumor, diabetes, and a medical condition most • People at risk for this type of
likely having something to do with your eye. detachment include those with high
5. Congenital Glaucoma. (born with) – myopia or after cataract
- symptoms, which include cloudy eyes, surgery
excessive tearing, and sensitivity to light – Trauma
• Treatment 2. traction retinal detachment
- Cause is Tension, or a pulling force ANATOMY OF THE MIDDLE EAR
- patients with this condition have an air-filled cavity, includes the tympanic
developed fibrous scar tissue from membrane laterally and the otic capsule
conditions such as diabetic retinopathy, medially
vitreous hemorrhage, or the connected by the eustachian tube to the
retinopathy of prematurity nasopharynx and is continuous with air-filled
3. a combination of rhegmatogenous and cells in the adjacent mastoid portion of the
traction temporal bone.
4. Exudative retinal detachments are the result
of the production of a serous fluid under the Tympanic Membrane
retina from the choroid. The tympanic membrane (ie, eardrum), about 1
• Signs & Symptoms cm in diameter and very thin, is normally pearly
• Management gray and translucent.
• Photocoagulation protects the middle ear and conducts sound
laser beam through the pupil produces vibrations from the external canal to the
retinal burn, which causes scarring of ossicles
the involved area. consists of three layers of tissue (ectoderm,
• Scleral buckling entoderm, and mesoderm)
shortening of the sclera to force the Ossicles
choroid closer to the retina. The middle ear contains the three smallest
• Nursing Intervention bones (ie, ossicles) of the body: malleus, incus,
• Provide accurate information; alleviate and stapes.
anxiety assist in the transmission of sound
• Provide a call bell for the client &
answer promptly ANATOMY OF THE INNER EAR
• Explain: normal occupational activity is housed deep within the temporal bone
will return after 3 weeks & to a more The organs for hearing (ie, cochlea) and balance
active job in 6-8 weeks (ie, semicircular canals), as well as cranial
• Instruct client to avoid activities that nerves VII (ie, facial nerve) and VIII (ie,
increase IOP vestibulocochlear nerve)
• Keep the client on bed rest in a position Membranous Labyrinth
as ordered The membranous labyrinth is composed of the
• Maintain protective eye patch utricle, the saccule, the cochlear duct, the
• Diminish lights in the room\Observe for semicircular canals, and the organ of Corti.
hemorrhage, postoperatively The three semicircular canals—posterior,
superior, and lateral contain sensory receptor
Auditory Problems organs, arranged to detect rotational
ANATOMY OF THE EXTERNAL EAR movement.
The auricle The utricle and saccule are involved with linear
attached to the side of the head by skin movements.
collects the sound waves and directs vibrations Organ of Corti
into the external auditory canal. is located in the cochlea,
The external auditory canal is located on the basilar membrane stretching
ends at the tympanic membrane from the base to the apex of the cochlea.
The skin of the canal contains hair, sebaceous transforms mechanical energy into neural
glands, and ceruminous glands, which secrete a activity and separates sounds into different
brown, waxlike substance called cerumen (ie, frequencies
ear wax).
Enlarged adenoids can, because of their size,
Common health problems of Infants & Child interfere with the Eustachian tube opening.
Otitis Media In addition, adenoids may themselves become
Mastoiditis infected, and the infection may spread into the
Foreign Bodies Eustachian tube.
interventions
Otitis Media Systemic antibiotics
75% of children experience at least one episode Antibiotic eardrops
of otitis media by their third birthday. Symptomatic relief w/ analgesics,
Almost half of these children will have three or antihistamines & decongestants
more ear infections during their first three Gentle irrigation to cleanse the ear
years. Myringotomy
Causes/Diagnosis Nursing intervention
Otitis media usually results from a bacterial or Obtain specimen of exudate for culture &
viral infection secondary to a cold, sore throat sensitivity
or other respiratory problem. Administer antibiotics & other drugs as
Signs & symptoms prescribed
unusual irritability, Instruct client to administer eardrops
difficulty sleeping, Monitor temperature, drainage, pain & hearing
tugging or pulling at one or both ears, acuity to evaluate effective effectiveness of
fever, therapy
fluid draining from the ear, Teach client to avoid others with respiratory
loss of balance, infections & delay air travel when infection is
or unresponsiveness to quiet sounds or other present
signs of hearing difficulty such as sitting too Face client, minimize distractions, enunciate
close to the television or being inattentive. clearly, provide written communication if
diagnostic hearing is diminished
Otoscopy Instruct client to report headache or stiff neck
Inflammation of the eardrum indicates an immediately, since this may indicate
infection. complications of meningitis.
There are several ways that a physician checks
for middle ear fluid. Mastoiditis
pneumatic otoscope It is rarely seen today because of the use of
allows the physician to blow a puff of air onto antibiotics to treat ear infections.
the eardrum to test eardrum movement. This child has noticeable swelling and redness
An eardrum with fluid behind it does not move behind his right ear.
as well as an eardrum with air behind it. Causes & risk factors
Reasons why more children usually a consequence of a middle ear infection
are affected than adults (acute otitis media).
immune systems are still developing. The infection may spread from the ear to the
child's Eustachian tube is shorter and straighter mastoid bone of the skull.
than adult. The mastoid bone fills with infected materials
adenoids in children are larger than they are in and its honeycomb-like structure may
adults. deteriorate.
Adenoids are composed largely of cells Symptoms & Signs
(lymphocytes) that help fight infections. ear pain or discomfort
positioned in the back of the upper part of the earache
throat near the Eustachian tubes. pain behind the ear
redness of the ear or behind the ear Assessment:
fever, may be high or spike (have sudden high 1. Rinne Test
increases) Rinne Test
headache Management
drainage from the ear Medical:
diagnostics 1. Well-fitting hearing aid
An examination of the head Stapedectomy -involves removing the stapes
A skull X-ray superstructure and part of the footplate and
head CT scan inserting a tissue graft and a suitable prosthesis.
CT of the ear
may show an abnormality in the mastoid bone. Nursing care (post-op)
A culture of drainage from the ear may show Position pt in the first 24 hr. post-op as desired
bacteria. by the physician
interventions Antimotion medication and sedatives for
Antibiotics: eardrop or systemic vertigo, nystagmus or nausea
Cleansing of the ear Assist pt in ambulation
Surgical intervention Pain medication
Mastoidectomy Observe for:
Tympanoplasty 1. Fever
Eardrum repair 2. Headache
Nursing intervention 3. Vertigo
Obtain specimen for culture & sensitivity 4. Ear Pain
Instruct client to seek treatment for ear Patient Education
infection Advise pt that there maybe temporary hearing
Observe for facial paralysis loss for a few weeks after surgery due to tissue
Instruct client to report headache & stiff neck, edema and packing
this may indicate meningitis. Packing to be removed by the surgeon in 5-6
Utilize safety precautions to prevent injury for days post-op.
those who are experiencing vertigo Protect ear by placing cotton ball in outer ear
Position on unaffected side post operatively and changing it BID
Common health problems of adults Instruct pt to:
Otosclerosis a. Avoid sudden pressure changes in the
Meniere’s disease ear
OTOSCLEROSIS 1. Do not blow nose
A term applied to a form of progressive
deafness caused by the formation of new Patient Education
spongy bone in the labyrinth which locks the 2. Do not wet head (in showers or swimming)
footplate of the stapes in a fixed position for about 6 wks.
preventing sound transmission by the vibrating 3. Avoid sudden head movements
ossicles to the inner ear fluids. 4. Avoid flying for several mos.
S/Sx: 5. Stay away from people with URTI
Insidious hearing loss b. Do not smoke.
Ringing or buzzing in the ear c. Protect ear when going outdoor for the first
Own voice sounds unusually loud wk
Inability to hear a whisper or somebody talking d. Advise pt to report s/sx of complications:
@ a distance - Return of tinnitus, vertigo
Can hear fairly well on telephone and in noisy - Fluctuation of hearing ability
environment.
Meniere’s Syndrome - Butter, cream, honey, jellies, jam,
A chronic disease involving the middle ear sugar and candy (except chocolates) as desired
characterized by fluid distention of the Foods to be avoided:
endolymphatic spaces of the labyrinth - Salted meats and fish
accompanied by destruction of cochlear hair - Bread, crackers and butter prepared
cells. with salt
DIAGNOSTIC EVALUATION - Carrots, Spinach, Clams, Oysters,
1. Caloric Test - “nystagmus test” Raisins,Cheese, condensed milk
Instillation of water @ 30 degrees Foods that can be taken no more than twice
Celsius or ice water weekly:
2. Electronystagmography (ENG) -Pumpkin, Cauliflower, Radish, Strawberries,
A graphical record of the labyrinthine Limes, Peaches, Dried coconut, Buttermilk,
function measuring the electropotential of the Peanuts, Mustard
eye movements when nystagmus is produced.
3. MRI/CT Scan
Caloric Test
Electronystagmography (ENG)
Management
Surgery
1. Cryosurgery
2. Endolymphatic Shunt
3. Total labyrinthectomy
4. Cochlear implantation
Medical:
1. Low-salt diet for 2-3 mos. (Furstenberg
Diet)
2. Vasodilating Drugs for tinnitus
- Nicotinic Acid
- Tolazoline Hydrochloride
- Methantheline Bromide
3. Antivertiginous
- Dymendydrinate (Benadryl and
Dramamine)
- Phenobarbital
Furstenberg Diet
1. Fluids not restricted, however excessive
quantities of water is discouraged
2. Proteins unrestricted or forced; calories
permitted as indicated; Na allowance
low
3. Foods to be eaten daily (2-3 mos.)
- Eggs, meat, fish as desired
- Bread as desired, cereal
- Potato and at least one of the ff:
macaroni, spaghetti, rice, corn, plums, prunes or
cranberries
- Milk as desired