INCREASED INTRACRANIAL PRESSURE
(Cerebral Perfusion Pressure)
DEFINITION:
● Pressure in the skull increases
○ It is a medical emergency
PHYSIOLOGY:
● Intracranial pressure is created by
the following
○ Brain Tissue
○ Cerebrospinal Fluid (CSF)
○ Blood
● Normal ICP
○ 5-15 mmHg (RN.com)
○ 0-15 mmHg (Book)
● Emergency!
○ >20 mmHg
○ Need immediate treatment
3 Structure that can alter Intracranial
Pressure:
● Brain
● CSF
● Blood
Monro-Kellie Hypothesis:
● How ICP is affected by CSF brain’s
blood & tissue to maintain cerebral
perfusion pressure (CPP)
○ So if there is an increased
volume in any of those
structures (Brain tissue, CSF,
and blood) the other
structure will try to
compensate by decreasing
its volume to help alleviate it
■ Moving structure in
the spinal cords
■ The cerebral artery
will be compressed
and constrict and
decrease its blood
flow- the tissue will
be deprived of blood
Cerebral Perfusion Pressure
● It is the pressure that pushed the
blood to the brain. Hence, influences
the cerebral blood flow (CBF)
Normal CPP is 60-100 mmHg
● When CPP falls too low the brain is
not perfused and brain tissue DIE
CPP CALCULATIONS:
● CPP=MAP (Mean Arterial pressure)
- ICP (intracranial pressure)
● MAP [(Diastolic x 2) + Systolic
pressure] / 3
Example
● BP: 90/42, ICP: 19
● MAP: [(42 x 2 = 84) + 90] / 3
○ MAP=58
● CPP(39)=58-19 - It’s very very bad
(meaning that it’s Fatal)
CAUSE:
● Traumatic Brain Injury (Trauma)
● High amount/volume CSF (A
condition)
● Bleeding (hemorrhage)
● Hematoma
● Hydrocephalus
● Tumor
● Encephalitis/Meningitis
FACTOR:
● Body Temperature
● Oxygenation status, especially CO2
and O2 Level
○ Hypoxic
○ CARBON can dilate the
blood vessel and increase
Blood pressure
● Body position
○ Keeping neck midline not flex
○ Keeping in 30-45 degrees
● Arterial and Venous pressure
● Anything that increases intra-
abdominal/thoracic pressure
(vomiting and bearing down)
PATHOPHYSIOLOGY: “M-I-N-D C-R-U-S-H”
● The human skull is very hard and
has limited space within its cavity M MENTAL STATUS CHANGES
○ Limits expansion of the brain ● Earliest: Restless, confused,
whenever there’s a responding to question NLE Tips
swelling/increase in I IRREGULAR BREATHING:
intracranial pressure ● Cheyne-StokesNLE Tips
○ Hyperventilation then Apnea
Increase ICP= Ischemia due to decrease (Late)
CPP ○ Occurs when the PONS is
| compressed or displaced
Its gonna cut of the Blood supply of the N NERVE CHANGES TO OPTIC &
Brain (Decrease CBF leads to the limitation OCULOMOTORNLE Tips
of nutrient to the brain) ● Double vision
| ● Swelling of Optic Nerve
The body will try to compensate for it by “Papilledema”NLE Tips
increasing the systolic blood pressure- and ● Unequal Pupils
it will push more blood there because the ● Abnormal Doll’s eyes
body thinks that the brain is not receiving ○ “Oculocephalic reflex”NLE
enough blood Tips
*But pressure still continuously increases ○ Indicates that there is
| damage in the brainstem
The Increase Systolic Blood pressure will ■ Side to side of they
add up with the existing pressure and will move in the opposite
lead to: side
● Swelling/Edema ■ If not (DANGEROUS)
● Arteries dilate due to the increase in D DECEREBRATE AND DECORTICATE
CO2 POSTURING OR FLACCID
○ Limitation of venous floor ● Decerebrate is the worstNLE Tips
○ Draining of CSF will be ○ Extension type of posturing
stagnant/obstructed ○ There will be adduction of the
■ Increase more arm and Extension of the
swelling arms with pronation
| ○ The feel will be just flexed
Displacement of Brain ○ A lot of E meaning a lot of
Compression of Brainstem, medulla Extensions
oblongata, and Pons ● DecorticateNLE Tips
| ○ Arms adducted to the body
Respiratory depression, Alteration of and Leg internally with feet
Cardiac system and Neuro alteration flex
| ○ Look at that arm and see if
Death it’s close to the core of the
SIGNS AND SYMPTOMS body
○ Core in the body where are
 P POSITION HOB (Head Over Bed)
C CUSHING’S TRIAD (LATE) ● 30-34 degrees
● Increase Systolic Pressure ● Head Mid Line
○ Widening of Pulse Pressure ● No Flexion of Neck and Hips
○ Increase SBP and decrease ○ Can impede blood flow and
DBP obliterate the venous
● Decrease Heart Rate, Decrease return/draining of blood
Respiratory Rate (Abnormal) ○ Can also increase intra-
Normal: 40 mmHg abdominal pressure
*If High meaning widening
R REFLEX (Late) R RESPIRATORY:
● (+) Babinski Reflex (Toes Fanout) ● Prevent Hypoxia (low oxygen level)
● Baroreceptor Reflex and Hypercapnia (too high CO2)
○ The parasympathetic has Normal Values:
been stimulated because of ○ CO2 (35-43)
that high Systolic blood ○ Too much can cause
pressure Vasodilation= Increase ICP
■ To decrease that SBP O2 Saturation
down ○ 95-100%
U UNCONSCIOUS (Late) ○ Monitor ABGs
S SEIZURE ○ Suction PRN (no more than
H HEADACHE 15 sec)
E EMESIS (Vomiting) w/out nausea ■ Because suctioning
● Projectile Vomiting itself can increase
D DETERIORATION ICP
● Hemiplegia ■ Hyperventilate them
○ Motor Deteriation before and after
○ One side paralysis ○ Mechanical Ventilation
DIAGNOSTIC PROCEDURE: ■ The PaCO2 Level
● There is a device that will measure must be kept (30-35)
the Intracranial pressure because f we keep it
○ Lateral ventricle low to prevent
○ Subarachnoid space vasodilation
MEDICATION: ■ Keep PEEP low
● Barbituates & Anticonvulsants because if this too
● For Supportive Meds: Anti-emetic high it can increase
and Laxatives intrathoracic pressure
NURSING INTERVENTION that can lead to
increased ICP
Goal: PReventing Progressive increase of
ICP and Monitoring of ICP & PROVIDING E ELEVATED TEMPERATURE PREVENT!
routine care for the unconscious ● Increased ICP can also increase
metabolic needs
“P-R-E-S-S-U-R-E” ● Monitor temperature
 ○ If Unconscious (Rectally, Ventriculostomy
tympanic, temporal)
○ Avoid oral and axillary route
● Antipyretics, Tepid Sponge bath/cool
bath, remove extra blankets,
decrease room temperature and
cool blanket
● The reason for that increased in
temperature
○ Is due to damage to the
hypothalamus, infection
dehydration and etc
.

S SYSTEMS TO MONITOR
● Round the clock assess NeuroVitals,
Glasgow Coma Scale ● A.k. A External Ventricular Drain
● It monitors the ICP and has a
catheter inserted in the area of the
Behavior Response
lateral ventricle and drains the CSF
4- Spontaneously during increase pressure reading
3- To Speech ○ >20 mmHg call M.D
2- To pain REMEMBER THEY ARE NOT GOOD
1- No response CANDIDATES FOR LUMBAR PUNCTURE
Verbal Response 5- Oriented to time,
person, and place S STRAINING ACTIVITIES AVOIDED
4- Confused ● Vomiting
3- Inappropriate ○ antiemetic may be prescribed
words ● Sneezing
2- ● Valsalva maneuver
Incomprehensible
sounds ○ Laxative
1- No response ● Kepp environment calm anf avoid
restraint
Motor Response 6- Obeys command U UNCONSCIOUS PATIENT CARE
5- Moves to ● Avoid over sedating
localized pain ○ It can mask the early S&S of
4- Flex to withdraw
from pain increase intracranial
3- Abnormal flexion pressure
2- Abnormal ● Assess Lung sound
Extension ○ They can have pooling of
1- No response secretions
● Best Score: 15 ○ Move them every 2 hours
● Comatose: Less than 8 ○ Suction as needed (not more
● Unresponsive: 3 than 15 sec)
 ● Skincare for immobile
● GI Tube
○ Check residual
● The risk for renal stone development
○ Foley catheter
● Contractures
● Eyes Care
● Constipation
● Blood Blots (PT and INR)
● Treat them as a conscious patient
Rx/MEDICATION
● Barbiturates
○ Decrease Brain metabolism
and Decrease BP and ICP
○ Vasopressor/IVF if they have
too much Mannitol
● Antihypertensive medication
○ To decrease MAP (SBP)
● Mannitol
E EDEMA MANAGEMENT:
● Hyperosmotic Drugs
○ Dehydrating brain
○ Done very carefully and
○ Monitor BP and renal
Functions
Mannitol
● Concentrated sugar
● Draws water that is pooling in the
brain into the blood
● Filtered through Glomerulus and Not
reabsorbed by the renal tubules
○ Water remove = Na+
+Chloride
● The risk for Fluid Volume Overload
○ The risk for Heart Failure
○ The risk for Pulmonary
Edema
● The risk for Fluid Depletion
○ S&S: Thirst and dry
○ Dehydration
○ Monitor Renal Function,
○ UOP (urinary output),
○ Electrolytes
Loop Diuretics and Corticosteroids
(protein starts leaking in a breakdown on
the Blood-Brain Barriers, and corticosteroids
can help with that)
1. Select the main structures below that play a role with altering
intracranial pressure:
A. Brain
B. Neurons
C. Cerebrospinal Fluid
D. Blood
E. Periosteum
F. Dura mater
The answers are A, C, and D. Inside the skull are three structures
that can alter intracranial pressure. They are the brain, cerebrospinal
fluid (CSF), and blood.
2. The Monro-Kellie hypothesis explains the compensatory
relationship among the structures in the skull that play a role with
intracranial pressure. Which of the following are NOT compensatory
mechanisms performed by the body to decrease intracranial pressure
naturally? Select all that apply:
A. Shifting cerebrospinal fluid to other areas of the brain and spinal
cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier
The answers are B and D. These are NOT compensatory
mechanisms, but actions that will actually increase intracranial
pressure. Vasoconstriction (not dilation) decreases blood flow and
helps lower ICP. Leaking of protein actually leads to more swelling of
the brain tissue. Remember water is attracted to protein (oncotic
pressure).
3. A patient is being treated for increased intracranial pressure.
Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees
The answers are A, B, D, and E. These activities can increase ICP.
4. A patient is experiencing hyperventilation and has a PaCO2 level
of 52. The patient has an ICP of 20 mmHg. As the nurse you know
that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP
The answer is C. An elevated carbon dioxide level in the blood will
cause vasodilation (NOT constriction), which will increase ICP
(normal ICP 5 to 15 mmHg). Therefore, many patients with severe
ICP may need to be mechanical ventilated so PaCO2 levels can be
lowered (30-35), which will lead to vasoconstriction and decrease ICP
(with constriction there is less blood volume and flow going to the
brain and this helps decrease pressure)....remember Monro-Kellie
hypothesis.
5. You're providing education to a group of nursing students about
ICP. You explain that when cerebral perfusion pressure falls too low
the brain is not properly perfused and brain tissue dies. A student
asks, "What is a normal cerebral perfusion pressure level?" Your
response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg
The answer is B. This is a normal CPP. Option A represents a normal
intracranial pressure.
6. Which patient below is at MOST risk for increased intracranial
pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.
The answer is B. Remember head trauma, cerebral hemorrhage,
hematoma, hydrocephalus, tumor, encephalitis etc. can all increase
ICP.
7. A patient with increased ICP has the following vital signs: blood
pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14,
oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these
findings you would?
A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning
The answer is C. It is important to monitor the patient for
hyperthermia (a fever). A fever increases ICP and cerebral blood
volume, and metabolic needs of the patient. The nurse can
administer antipyretics per MD order, remove extra blankets,
decrease room temperature, give a cool bath or use a cooling
system. Remember it is important to prevent shivering (this also
increases metabolic needs and ICP).
The answer is A. LPs are avoided in patients with ICP because they
can lead to possible brain herniation.
11. You're collecting vital signs on a patient with ICP. The patient has
a Glascoma Scale rating of 4. How will you assess the patient's
temperature?
A. Rectal
B. Oral
C. Axillary
The answer is A. This GCS rating demonstrates the patient is
unconscious. If a patient is unconscious the nurse should take the
patient’s temperature either via the rectal, tympanic, or temporal
method. Oral and axillary are not reliable.
12. A patient who experienced a cerebral hemorrhage is at risk for
developing increased ICP. Which sign and symptom below is the
EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size
The answer is C. Mental status changes are the earliest indicator a
patient is experiencing increased ICP. All the other signs and
symptoms listed happen later.
13. Select all the signs and symptoms that occur with increased ICP:
A. Decorticate posturing
B. Tachycardia
C. Decrease in pulse pressure
D. Cheyne-stokes
E. Hemiplegia
F. Decerebrate posturing
The answers are A, D, E, and F. Option B is wrong because
bradycardia (not tachycardia) happens in the late stage along with an
INCREASE (not decrease) in pulse pressure.

14. You're maintaining an external ventricular drain. The ICP

8. A patient has a ventriculostomy. Which finding would you readings should be?
immediately report to the doctor? A. 5 to 15 mmHg
A. Temperature 98.4 'F B. 20 to 35 mmHg
B. CPP 70 mmHg C. 60 to 100 mmHg
C. ICP 24 mmHg D. 5 to 25 mmHg
D. PaCO2 35 The answer is A. Normal ICP should be 5 to 15 mmHg.
The answer is C. A ventriculostomy is a catheter inserted in the area
of the lateral ventricle to assess ICP. It will help drain CSF during
increase pressure readings and measure ICP. The nurse must 15. Which patient below with ICP is experiencing Cushing's Triad? A
monitor for ICP levels greater than 20 mmHg and report it to the patient with the following:
doctor. A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
9. External ventricular drains monitor ICP and are inserted where? D. BP 80/40, HR 49, RR 12
A. Subarachnoid space The answer is C. These vital signs represent Cushing's triad. There is
B. Lateral Ventricle an increase in the systolic pressure, widening pulse pressure of 140
C. Epidural space (200-60=140), bradycardia, and bradypnea.
D. Right Ventricle
The answer is B. External ventricular drains (also called
ventriculostomy) are inserted in the lateral ventricle. 16. The patient has a blood pressure of 130/88 and ICP reading of
12. What is the patient's cerebral perfusion pressure, and how do you
interpret this as the nurse?
10. Which of the following is contraindicated in a patient with A. 90 mmHg, normal
increased ICP? B. 62 mmHg, abnormal
A. Lumbar puncture C. 36 mmHg, abnormal
B. Midline position of the head D. 56 mmHg, normal
C. Hyperosmotic diuretics The answer is A. CPP is calculated by the following formula:
D. Barbiturates medications CPP=MAP-ICP. The patient’s CPP is 90 and this is normal. A normal
CPP is 60-100 mmHg.
 C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved
17. According to question 16, the patient's blood pressure is 130/88. side to side.
What is the patient's mean arterial pressure (MAP)? The answer is D. This is known as a negative doll's eye and
A. 42 represents brain stem damage. It is a very bad sign.
B. 74
C. 102
D. 88 21. A patient is receiving Mannitol for increased ICP. Which
The answer is C. MAP is calculated by taking the DBP (88) and statement is INCORRECT about this medication?
multiplying it by 2. This equals 176. Then take this number and add A. Mannitol will remove water from the brain and place it in the blood
the SBP (130). This equals 306. Then take this number and divide by to be removed from the body.
3, which equal 102. B. Mannitol will cause water and electrolyte reabsorption in the renal
tubules.
C. When a patient receives Mannitol the nurse must monitor the
18. During the assessment of a patient with increased ICP, you note patient for both fluid volume overload and depletion.
that the patient's arms are extended straight out and toes pointed D. Mannitol is not for patients who are experiencing anuria.
downward. You will document this as: The answer is B. All the other options are correct. Mannitol will
A. Decorticate posturing PREVENT (not cause) water and electrolytes (specifically sodium
B. Decerebrate posturing and chloride) from being reabsorbed....hence it will leave the body as
C. Flaccid posturing urine.
The answer is B.

22. What assessment finding requires immediate intervention if found

19. While positioning a patient in bed with increased ICP, it important while a patient is receiving Mannitol?
to avoid? A. An ICP of 10 mmHg
A. Midline positioning of the head B. Crackles throughout lung fields
B. Placing the HOB at 30-35 degrees C. BP 110/72
C. Preventing flexion of the neck D. Patient complains of dry mouth and thirst
D. Flexion of the hips The answer is B. Mannitol can cause fluid volume overload that leads
The answer is D. Avoid flexing the hips because this can increase to heart failure and pulmonary edema. Crackles in the lung fields
intra-abdominal/thoracic pressure, which will increase ICP. represent pulmonary edema and require immediate intervention.
Option A is a normal ICP reading and shows the mannitol is being
effective. BP is within normal limits, and dry mouth/thirst will occur
20. During the eye assessment of a patient with increased ICP, you with this medication because remember we are trying to dehydrate
need to assess the oculocephalic reflex. If the patient has brain stem the brain to keep edema and intracranial pressure decreased.
damage what response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved
side to side.
STROKE (CEREBROVASCULAR ● Brains cells are super sensitive
ACCIDENTS) ○ They cannot go without a
minutes without blood rich
DEFINITION: oxygen
● Blood rich in oxygen can not reach ○ Cells affected within 5
brain cells and cells begin to die minutes
○ Blockage or Bleeding ■ The longer it goes the
● Types of Strokes: more cell death can
○ Ischemic Stroke occur
○ Hemorrhagic Stroke ● Hemisphere of the Brain
○ Transient Ischemic Attack ○ Right
■ Creativity
ANATOMY AND PHYSIOLOGY: ■ Music and Arts
● Blood Supply: ■ Attention Span
○ Carotid and Vertebral ■ Showing emotions
Arteries ■ Ability to solve
■ Each areas of the everyday problems by
brain has specific making
function decision/plans
 ■ Reasoning
the body
(understanding
jokes… read in
between the line) ● Parts of the brain and function:
■ Making judgement ○ Frontal:
calls ■ Decision making
■ Memory Recall ■ Thinking
■ Music/Art Awareness ■ Speaking
■ Control the left side ■ Memory
of the body ■ Movement
○ Left (Logic) ■ Broca’s Area
■ Logical ○ Parietal Lobe
■ Reading Writing and ■ Language
speaking ■ Touch
■ Speaking ○ Temporal Lobe:
■ writing ■ Hearing
■ Reading ■ Learning
■ Math skills ■ Feeling
■ Analyzing info ■ Weicken’s Area
■ Planning ○ Occipital
■ Vision Acuity
■ Color perception
Right Side of the Left Side of the ○ Cerebellum
Brain Brain
■ Ballance
- Attention - Speaking ■ Coordination
span - Writing ○ Brain Stem
- Showing - Reading ■ Breathing
Emotions - Math skills ■ Heart Rate
- Ability to - Analyzing ■ Temperature
solve info
CAUSE
everyday - Planning
problems by - Controls the ● Blockage:
making left side of ○ Atherosclerosis
decisions/pl the body ○ Clots
an ○ Embolism
- Reasoning ○ Thrombi
{understandi ● Bleeding
ng jokes,
○ AMD
reading in
between the ○ Cerebral Aneurysm
lines} PATHOPHYSIOLOGY
- Memory ● Ischemic Stroke
Recall ○ Blockage of Blood Vessel/
- Music/Art Stenosis or artery
awareness ■ Not be able to feed
- Controls the
the brain tissue
left side of
 ○ Results to a lack of blood
flow in affected area
○ Can Happen due to
■ Embolism: A clot has
left a part of the body
(example the heart:
heart valve problem
or atrial fibrillation) nd
travelled to the brain,
which stops blood
flow
■ Thrombosis: Clot
form within the
arterial wall within the
neck or rain
● Seen in
patient with
Hyperlipidem
ia and SIGNS AND SYMPTOMS
atherosclero
sis
● Hemorrhagic Stroke:
○ Happen due to
■ Bleeding in the
Brain due to a break
in blood vessel
■ Leads to no blood to
perfuse the brain cells
and excessive blood
in the brain
■ Cause: a brain
aneurysm bursts.
Uncontrolled
hypertension, old age
(vessels are not as
resilient)
○ Can cause excessive
swelling and increase
intracranial pressure
● Transient Ischemic Attack:
○ This is an ischemia type of
stroke on its origin
■ There is some type of
blockage on that
vein/arteries that
prevents blood from
coming in
■ It’s a mini type of
stroke
■ It’s not a full blown
stroke yet
■ Usually its a sign that
something’s big is
about to happen
○ Signs and Symptoms last
few minutes to hours and
will resolve
○ It's a Warning signs
○ Bloodakege of of the vessel
○ Mini type stroke NOT A
FULL BLOWN STROKE
● Physical Examination reveals
○ Happen suddenly
■ Need to act FAST to
save brain cells
○ Call rapid response of 911
○ NOTE the time
■ tPA might be
administered before 3
hours of onset stoke
● Aphasia- unable to speak and
comprehension it or producing
○ Types
■ Receptive- unable to
comprehend speech
{wernicke’s area at
the temporal lobe
■ Expressive
comprehends speech
but can’t respond
back with speech
{Broca’s area at the
frontal lobe
■ Mixed: both
combination of two
 ■ Global: complete repeat
inability to understand something
speech or produce it ● Slurred
● Dysarthria: unable to speak clearly speech
due to weak muscle {hard to ■ T for tome
understand} ● Act fast if
● Apraxia: Can’t perform voluntary someone is
movement even though muscles experiencing
function is normal stroke
● Agraphia: loss the ability to write symptoms
● Alexia: loss the ability to read {does
Right Brain Injury Left Brain Injury
not understand or see the words
● Agnosia: doesn’t understand
sensations or recognize known
objects or people
○ They can’t call pencil a pencil
● Dysphagia: issue swallowing
○ Major risk for pneumonia
● Hemianopia: limited vision in half of
the visual fields
● Learn to recognize the Signs of a Findings: Findings:
Stroke - Left side ● Right side
○ Act “FAST” weakness: Hemiplegia
■ F for Face Hemiparesis ● Aphasia
● Drooping of and {trouble
Hemiplegia formulating
the face
- Impairment in words and
● Uneven smile creativity: Arts comprehendin
■ A for Arms and music g them}
● Arm - Confused on ● Aware of their
numbness or date, time, limits {they
weakness place often
● Ask the - Cannot experience
recognize depression,
person to
faces or the anger,
raise their person’s name frustration}
arms - Loss of depth ○ They
{however it perception know what
the arms still - Trouble they feel
drops down staying on ● Trouble
and isn’t topic understanding
- Can’t see written text
ready} things on left issues with
■ A for speech side: writing
difficulty - LEFT SIDE {agraphia}
● Ask the NEGLECT: ● Memory intact
person to Ignores left side ● Issues with
 ■ Risk for developing
of the body seeing on the
- Trouble with right side atherosclerosis
maintaining ■ Hyperlipidemia
proper ○ S-enior Citizens
grooming ○ H-ypertension
- Emotionally: not ○ A-therosclerosis
going to think ○ P-hysical Inactivity
things through-
○ P-revious TIA
very impulsive
- Poor ability to ○ E-levated glucose
make decisions ■ Diabetes Mellitus
and assessing ■ The sugarry blood
spatial can irritate the blood
elements...sha vessel and stick to
pes vessel and form a
- Denial about
their thrombi and
limitations eventually leads to
- Not able to emboli and stoke
interpret ○ a-N-eurysm brain
nonverbal ■ Outpouching of
language or vessel
understand the
DIAGNOSTIC AND LABORATORY TEST
hidden meaning
of things ● Remember prompt diagnosis is the
- Very short key
attention span ● CT scan and MRI
○ They want to rule out if there
is bleeding or stroke
RISK FACTOR:
○ Because if they do, they are
● “S.T.R.O.K.E.S H.A.P.P.E.N”
not candidate for t-PA tissue
○ S-moking
plasminogen activator
○ T-hinners {anticoagulant}
■ A medication
■ When blood gets too
indicated only for
thin the pressure
Ischemic Stroke and
increases which will
not Hemorrhagic
lead to bursting of
○ tPA dissolved the clot by
fragile vessel
activating the protein that
○ R-hythm Changes {Atrial
causes fibrinolysis
Fibrillation}
■ Given within 3 hours
■ Clot can form and
from onset signs and
lead to TIA or stoke
symptoms
○ O-ral Contraceptives
■ 3-4.5 hours if meets
■ Estrogen
the criteria
○ K-in
● Criteria for tPA
■ Family
○ CT scan negative
○ E-xcessive weight
○ Labs within normal limit
 ■ Glucose ■ During 1st 14 hours
■ INR after administration of
■ Platelets the medication
○ BP is controlled
■ <180/110
○ Hasn’t received any blood
thinners and other
anticoagulants like heparin
TREATMENT
● tPA
NURSING INTERVENTION
● NURSING INTERVENTION FOR
tPA
○ Check for bleeding
○ Neuro checks around the
clock
■ NIH stroke scale
● Assess 11
level areas of
their body
● Scores ranges
from 0-42
● 0: no stroke
● Worst score
21-42

○ Blood pressure medication if

needed for hypertension
○ VItal signs
○ Labs
■ INR
○ Monitor Glucose
○ Prevent injury
■ Promote bed rest
■ Fall can increase
ecchymosis and
bleeding
○ Avoid unnecessary
venipunctures
○ Avoid IM injection
○ Most patient will go to ICU to
be monitored
 ○ V/S: Increase BP, Decrease
HR, and Decrease RR
■ Because they are
high at risk of
developing increased
intracranial pressure
especially for
Hemorrhagic Stroke
■ Increase
ICP=Nauseas and
vomiting, decrease
Level of
Consciousness
■ No pupil response
○ Airway: issue swallowing
■ Suction at bedside
can provided
○ Cranial Nerves: pupil.
Swallowing, facial gaze, gag
reflex and etc
○ Bladder and Bowel Function
■ Bedpan
■ Foley - bladder scan
● For urine
retention
○ Maintain Skin and Limb
integrity
■ Reposition them
every 2 hours
■ Maintain proper body
alignment
■ Perform passive
motion technique
■ Watch out for
Neglect Syndrome/
Unilateral neglect
● Right side
injury and
ignore the left
side
● Teach patient
to always do a
conscious
● Monitor: effort to touch
 and feel the ■ Short phrases and
left side of the simple details
body ■ Use gestures and
■ Always scan the point
environment and ■ Be patient
surrounding to ■ Remove distractions
prevent injury of the ■ Repeat and repeat
affected side and rephrase
○ Hemianopia: Half od the ○ Expressive Aphasia: They
visual field is gone can comprehend but trouble
■ Increase risk for injury responding
■ Prevent injury by ■ Be patient and let
● Always turn them speak
head side to ● Don't rush and
side to see all fill out what
vision fields they say
○ Diet: Evaluated by SLP ■ Ask one question at a
■ Problems like time and let those
difficulty swallowing question be direct
occurs ■ Use communication
■ Thickened Liquid, board
crushed meds with
applesauce, our Grade: C
mechanical soft foods Percentage of What you Got Right: 71
○ Always assist patient with
eating Go Here for More Quizzes
■ Assess Pouching
food in cheeks can Your Answers & what you got Right &
increase risk for Wrong:
aspiration
■ Always assess risk 1. A patient is admitted with uncontrolled
for Aspiration atrial fibrillation. The patient’s medication
■ To prevent aspiration history includes vitamin D supplements and
TUCK IN CHIN TO calcium. What type of stroke is this patient
CHEST WHILE at MOST risk for?
SWALLOWING A. Ischemic thrombosis
● Communication: Aphasia B. Ischemic embolism
○ Always note that they don’t C. Hemorrhagic
have mental deficits D. Ischemic stenosis
○ They just can’t properly The answer is B. If a patient is in
communicate like they used uncontrolled a-fib they are at risk for clot
to be formation within the heart chambers. This
○ For Receptive aphasia: clot can leave the heart and travel to the
brain. Hence, an ischemic embolism type
stroke can occur. An ischemic thrombosis
type stroke is where a clot forms within the
artery wall of the neck or brain.
2. Which patient below is at most risk for a
hemorrhagic stroke?
A. A 65 year old male patient with carotid
stenosis.
B. A 89 year old female with
atherosclerosis.
C. A 88 year old male with uncontrolled
hypertension and a history of brain
aneurysm repair 2 years ago.
D. A 55 year old female with atrial flutter.
The answer is C. A hemorrhagic stroke
occurs when bleeding in the brain happens
due to a break in a blood vessel. Risk
factors for a hemorrhagic stroke is
uncontrolled hypertension, history of brain
aneurysm, old age (due to aging blood
vessels.) All the other options are at risk for
an ischemic type of stroke.
3. You're educating a patient about transient
ischemic attacks (TIAs). Select all the
options that are incorrect about this
condition:
A. TIAs are caused by a temporary
decrease in blood flow to the brain.
B. TIAs produce signs and symptoms that
can last for several weeks to months.
C. A TIAs is a warning sign that an
impending stroke may occur.
D. TIAs don't require medical treatment.
The answers are B and D. Options A and C
are CORRECT statements about TIAs.
However, option B is wrong because TIAs
produce signs and symptoms that can last a
few minutes to hours and resolve (NOT
several weeks to months). Option D is
wrong be TIAs do require medical
treatment.
4. A patient who suffered a stroke one
month ago is experiencing hearing
problems along with issues learning and
showing emotion. On the MRI what lobe in
the brain do you expect to be affected?
A. Frontal lobe
B. Occipital lobe
C. Parietal lobe
D. Temporal
The answer is D. The temporal lobe is
responsible for hearing, learning, and
feelings/emotions.
5. A patient's MRI imaging shows damage
to the cerebellum a week after the patient
suffered a stroke. What assessment
findings would correlate with this MRI
finding?
A. Vision problems
B. Balance impairment
C. Language difficulty
D. Impaired short-term memory
The answer is B. The cerebellum is
important for coordination and balance.
6. A patient is demonstrating signs and
symptoms of stroke. The patient reports
loss of vision. What area of the brain do you
suspect is affected based on this finding?
A. Brain stem
B. Hippocampus
C. Parietal lobe
D. Occipital lobe
The answer is D. The occipital lobe is
responsible for vision and color perception.
7. A patient has right side brain damage
from a stroke. Select all the signs and
symptoms that occur with this type of
stroke:
A. Right side hemiplegia
B. Confusion on date, time, and place
C. Aphasia
D. Unilateral neglect
E. Aware of limitations
F. Impulsive
G. Short attention span
H. Agraphia
The answers are B, D, F, and G. Patients
who have right side brain damage will have
LEFT side hemiplegia (opposite side),
confused on date, time, and place, unilateral
neglect (left side neglect), DENIAL about
limitations, be impulsive, and have a short
attention span. Agraphia, right side
hemiplegia, aware of limitations, and
aphasia occur in a LEFT SIDE brain injury.
8. You're educating a group of nursing
students about left side brain damage.
Select all the signs and symptoms noted
with this type of stroke:
A. Aphasia
B. Denial about limitations
C. Impaired math skills
D. Issues with seeing on the right side
E. Disoriented
F. Depression and anger
G. Impulsive
H. Agraphia
The answers are A, C, D, F, and H. Patients
who have left side brain damage will have
aphasia, be AWARE of their limitations,
impaired math skills, issues with seeing on
the right side, no deficit in memory,
depression/anger, cautious, and agraphia.
All the other options are found in right side
brain injury.
9. During discharge teaching for a patient
who experienced a mild stroke, you are
providing details on how to eliminate risk
factors for experiencing another stroke.
Which risk factors below for stroke are
modifiable?
A. Smoking
B. Family history
C. Advanced age
D. Obesity
E. Sedentary lifestyle
The answers are A, D, and E. These risk
factors are modifiable in that the patient can
attempt to change them to prevent another
stroke in the future. The other risk factors
are NOT modifiable.
10. Your patient who had a stroke has
issues with understanding speech. What
type of aphasia is this patient experiencing
and what area of the brain is affected?
A. Expressive; Wernicke's area
B. Receptive, Broca's area
C. Expressive; hippocampus
D. Receptive; Wernicke's area
The answer is D.
11. Your patient has expressive aphasia.
Select all the ways to effectively
communicate with this patient?
A. Fill in the words for the patient they can't
say.
B. Don't repeat questions.
C. Ask questions that require a simple
response.
D. Use a communication board.
E. Discourage the patient from using words.
The answers are C and D. Patients with
expressive aphasia can understand spoken
words but can't respond back effectively or
at all. Therefore be patient, let them speak,
be direct and ask simple questions that
require a simple response, and
communicate with a dry erase board etc.
12. While conversing with a patient who had
a stroke six months ago, you note their
speech is hard to understand and slurred.
This is known as:
A. Dysarthria
B. Apraxia
C. Alexia
D. Dysphagia
The answer is A.
13. You're reading the physician’s history
and physical assessment report. You note
the physician wrote that the patient has
apraxia. What assessment finding in your
morning assessment correlates with this
condition?
A. The patient is unable to read.
B. The patient has limited vision in half of
the visual field.
C. The patient is unable to wink or move his
arm to scratch his skin.
D. The patient doesn't recognize a pencil or
television.
The answer is C.
14. You need to obtain informed consent
from a patient for a procedure. The patient
experienced a stroke three months ago. The
patient is unable to sign the consent form
because he can't write. This is known as
what:
A. Agraphia
B. Alexia
C. Hemianopia
D. Apraxia
The answer is A.
15. You're assessing your patient's pupil
size and vision after a stroke. The patient
says they can only see half of the objects in
the room. You document this finding as:
A. Hemianopia
B. Opticopsia
C. Alexia
D. Dysoptic
The answer is A.
16. A patient who has hemianopia is at risk
for injury. What can you educate the patient
to perform regularly to prevent injury?
A. Wearing anti-embolism stockings daily
B. Consume soft foods and tuck in chin
while swallowing
C. Scanning the room from side to side
frequently
D. Muscle training
The answer is C. Hemianopia is limited
vision in half of the visual field. The patient
needs to scan the room from side to side to
prevent injury.
17. You receive a patient who is suspected
of experiencing a stroke from EMS. You
conduct a stroke assessment with the NIH
Stroke Scale. The patient scores a 40.
According to the scale, the result is:
A. No stroke symptoms
B. Severe stroke symptoms
C. Mild stroke symptoms
D. Moderate stroke symptoms
The answer is B. Scores on the NIH stroke
scale range from 0 to 42, with 0 (no stroke
symptoms) and 21-42 (severe stroke
symptoms).
18. In order for tissue plasminogen activator
(tPA) to be most effective in the treatment of
stroke, it must be administered?
A. 6 hours after the onset of stroke
symptoms
B. 3 hours before the onset of stroke
symptoms
C. 3 hours after the onset of stroke
symptoms
D. 12 hours before the onset of stroke
symptoms
The answer is C. tPA dissolves the clot
causing the blockage in stroke by activating
the protein that causes fibrinolysis. It should
be given within 3 hours after the onset of
stroke symptoms. It can be given 3 to 4.5
hours after onset IF the patient meets strict
criteria. It is used for acute ischemia stroke,
NOT hemorrhagic!!
19. Which patients are NOT a candidate for
tissue plasminogen activator (tPA) for the
treatment of stroke?
A. A patient with a CT scan that is negative.
B. A patient whose blood pressure is
200/110.
C. A patient who is showing signs and
symptoms of ischemic stroke.
D. A patient who received Heparin 24 hours
ago.
The answers are B and D. Patients who are
experiencing signs and symptoms of a
hemorrhagic stroke, who have a BP for
>185/110, and has received heparin or any
other anticoagulants etc. are NOT a
candidate for tPA. tPA is only for an
ischemic stroke.
20. You're assisting a patient who has right
side hemiparesis and dysphagia with eating.
It is very important to:
A. Keep the head of bed less than 30'.
B. Check for pouching of food in the right
cheek.
C. Prevent aspiration by thinning the liquids.
D. Have the patient extend the neck upward
away from the chest while eating.
The answer is B. Because the patient has
weakness on the right side and dysphagia
the nurse should regularly check for
pouching of food in the right cheek.
Pouching of food in the cheek can lead to
aspiration or choking. The HOB should be
>30', liquids thickened per MD order, and
the patient should tuck in the chin to the
chest while swallowing.
21. A patient has experienced right side
brain damage. You note the patient is
experiencing neglect syndrome. What
nursing intervention will you include in the
patient's plan of care?
A. Remind the patient to use and touch both
sides of the body daily.
B. Offer the patient a soft mechanical diet
with honey thick liquids.
C. Ask direct questions that require one
word responses.
D. Offer the bedpan and bedside commode
every 2 hours.
The answer is A. It is important to watch for
neglect syndrome. This tends to happen in
right side brain damage. The patient ignores
the left side of the body in this condition.
The nurse needs to remind the patient to
use and touch both sides of the body daily
and that the patient must make a conscious
effort to do so.
EPILEPSY (SEIZURES)
DEFINITION:
● Abnormal electrical signals in the
brain being fired from neurons:
Two Category:
○ Generalize (both side of the
brain)
○ Focal (partial seizure and
only target specific parts of
the brain)
PHYSIOLOGY
● Neurons
○ Their task is handling and
transmitting information and
impulses STAGES OF A SEIZURE:
2 Types of Neuron
● Excitatory PRODROMAL
○ Whenever they are
stimulated they will cause a
response
○ They will release a
neurotransmitter glutamate
● Inhibitory
○ They will inhibit a response
they will decrease it
○ They will release a
neurotransmitter GABA
There is an equilibrium for a patient who
does not have a seizure
Problem: Damage in inhibitory neuron will AURA
be damage then there won’t be an inhibiting
excessive excitatory neurotransmitter
release by the excitatory muscle--
overstimulation of the brain
● For example, the Barbituates- will
stimulate the GABA receptors that
will decrease the excitatory
CAUSE
● Affects Anyone due to an acute
illness
○ Hugh fever
○ CNS infection
○ Hypoglycemia
○ EtOH withdrawal
○ Acid-base imbalances
○ Hypoxia
○ Brain tumor
● But some patient Epilepsy frequent
seizures activity due to Chronic
condition
○ Traumatic brain injury (TBI)
○ congenital birth defect
○ Massive Stroke
○ Idiopathic
○ Effects of an illness
● When symptoms start to appear
prior to the big event (hence the
seizure)
○ Depression
○ Anger
○ Issue sleeping
○ Anxiety
○ GI and Urinary issue
● Can start days before a seizure
happens
● Intervention: Pro;ong betablockes &
calcium blocker can e utilize to
prepare themselves for the seizure
● It does NOT happen with all type
○ Focal seizures or tonic-clonic
types
● Happens at the very beginning of a
seizure (Serve as a warning signs) a
bigger seizure is expected
○ Altered vision or hearing
○ Anxiety or dread
○ Deja Vu
○ Sudden weird taste or smell
○ Dizziness
 ○ Inability to speak
● Happens within hour, second or
minute
● Intervention: They can immediately
render care by administering
phenobarbital and etc to prevent
seizure
ICTUS/THE SEIZURE
● The actual seizure
● It last about 1-3 minutes
○ Nursing Responsibility TIME
THE SEIZURE
● Greater than 5 minutes or starts to
have seizures back to back:
○ May indicate Status
Epilepticus
○ Caused by medication, brain
trauma etc.
○ They may need intermediate
medical treatment to make
seizure stops
POST-ICTUS
● After the seizure
● Recovery
● Time for the brain to recover
● Takes hours to days (tonic-clonic) or
Immediate (absence)
○ Very tired that they want to
sleep
○ Confused
○ Headache
○ Injury (tongue, cheek, body)
● Allow them to rest
TYPES
Generalized:Whole Brain
○ Tonic-clonic (grand mal)
○ Most common type
○ Usually 1-3 minutes
■ If >5 mins treat
immediately
(EMERGENCY)
○ Has Aura
■ Warning signs (Ask
on that: Lie them on
their side to prevent
aspiration on their
own tongue and to
facilitate secretions
out the mouth, put
pillows as well to
prevent injury to the
head)
○ Lost of Consciousness: They
are risk for Injury
|
○ Tonic: Body stiffened
■ Groan/crying
(respiratory muscles
are stiffened)
■ Bite Tongue
■ Foaming apnea
■ Cyanosis
|
○ Clonic: Recurrent Jerking of
extremities relax-spas-relax
■ Experience
Incontinence (Urinary
and Bowel)
○ Time the Seizure:
■ N: 1-3 mis
■ >5 mins (Status
Epilepticus)
○ Post Ictus:
■ Sore from the
stiffening of the body
■ Sleepy
■ Headache
■ Can’t remember the
event
Types of Generalized Seizures:
● Tonic: Body stiffened
○ Groan/crying (respiratory
muscles are stiffened)
○ Bite Tongue
○ Foaming apnea
○ Cyanosis
 ● Clonic: Recurrent Jerking of
extremities relax-spas-relax
○ Experience Incontinence
(Urinary and Bowel)
● Absence Seizure (Petit-mal)
○ Most common in Pediatrics
○ Hallmark: Staring (Appear
to be daydreaming)
■ May Go unnoticed
■ Won’t response to
you
■ They will stop doing
their current activity
and just stare
○ Very short (Seconds)
○ Post-Ictus
■ Immediate
■ They won’t remember
event
○ Atonic (Drop Attacks)
■ Without Muscle tone
■ Goes limps falls
(when their standing)
● Risk for
Cerebral injury
because our
head is heavy)
● Wear helmet
for children
■ Sumps Over (sitting)
● Helmet may
be advised
■ Not aware during the
event
■ Post-Ictus:
● Immediate
● They can
regain
consciousnes
s smells
Focal: Partial/Specific Area
Two types
● Focal Onset Aware
○ Simple partial
○ Symptoms vary (location and
dependent
○ Small area of the lobe
■ (Occipital: Changes in
Vision)
○ Patient is Aware ( Also refer
as to the Aura because they
are Short <2 mins)
● Focal Impaired Awareness
○ Complex Partial
○ Unaware
■ Motor Symptoms
■ Automatisms
● Its the activity
that they’re
doing without
them noticing
that they’re
doing it
● Lips smacking
■ Normally align with
the temporal lobe
CAUSE (SEIZURE TRIGGERS)
● “S-T-O-P--S-E-I-Z-U-R-E”
S Stress
T Trauma (cerebral)
O Overexertion
P Period, Pregnancy
● Hormone Shift and Ovulation
S Sleep Loss
E Electrolyte & Metabolic imbalance/Issue
● Hypoglycemia
● Hypernatremia
● Acidosis
● Dehydration
I Illness (Meningitis, Encephalopathy)
VisualiZation disturbances, Sounds or
U Undermedicated
R Recreational Drug
E ETOH
DIAGNOSTIC AND LABORATORY TEST
EEG ■ Monitor Rash
● Painless Procedures ● Steven
● No caffeine prior to the test Johnson
● Hold Seizure medications and other syndrome
stimulants ● Refer to the
● Can eat before the test doctor
● Wash and Dry hair ■ Don’t give with milk or
○ Oily hair will slip the antacids
electrodes ● It can alter the
● Sleep absorption
○ It depends on the technicians ■ Drug Level:
● Breathing, Light ● 10-20 mcg/mL
● Benzodiazepines:
MEDICATION ○ Used for absence, tonic-
● Barbiturates: Phenobarbital clonic or focal seizures
○ Used for tonic clonic or focal ○ For Status Epilepticus
seizures and status ■ Diazepam and
epilepticus Lorazepam
○ Mechanism of Action: ■ Fast Acting for Status
Stimulate GABA receptors & Epilepticus
this helps inhibitory ○ Side Effect:
neurotransmission of ■ Very drowsy
Glutamate ■ Tolerance (not as
○ Side effects: Drowsiness, effective)
Ataxia ■ Impairment of liver
○ Monitor: ○ Antidote: Flumazenil
■ Respiratory ● Valproates: Valproic Acids
depression & ○ Used for all types
hypotension ○ Side Effects:
● Hydantoins (Phenytoin) ■ Monitor Liver, WBCs,
○ Used for Tonic clonic or focal Platelets and GI
seizures issues
○ Side Effects TREATMENTS:
■ Monitor Gums (It can ● Surgery:
cause gingival ○ To removes an area of the
hyperplasia) brain that is causing the
Enlargement and seizure
bleeding of gums ■ Example: Focal
■ Bone marrow Seizure (Removal of
suppression (Risk for Temporal lobe)
Fractures) Temporal Lobectomy
● Watch ● Vagus Nerve Stimulator
platelets and
WBC
 ○Electrical device that sends
electrical signals to the vagus
nerve
● For Pediatric Patient (KETOGENIC
DIET)
○ Used in pediatric patient
whose epilepsy is not
controlled by medication
■ High in Fats and
Protein
■ Low in Carbs
■ 5% Carbs
■ 30% Protein
■ 65% Fats
NURSING INTERVENTION
Assess Risk Factors:
● Seizures precautions
● O2 and suction (not more than 15
seconds)
● IV access panned bed rails
● Bed (Lowest position)
● Pillow
● No restrictive clothing
Assess Seizure History
● Prodromal?
● Signs and Symptoms of Aura
○ How fast?
● How long do they last?
○ Is it Drugs Illicit?
○ When they take their Drug
Level?
During the Seizure
● Put Patient on their side
○ Standing or sitting lay down
with pillow underneath the
head
● Do not restrain/Try to open their
mouth
● Do not insert anything in their mouth
● Remove restrictive items or glasses
● Time seizures
○ Status Epilepticus
● Note Characteristics:
○ Cry out?
○ Stiffening?
○ Jerking?
○ Blood in the mouth?
○ Incontinence
● Before and During
Characteristics/Signs and Symptoms
● Be calm and reassure patient
After the Seizures
● Vital signs and Neurological
assignment
● How is your patient behaving
● Drawing blood, Medication, EEG
(assess brain activity)
EEG
● Painless Procedures
● No caffeine prior to the test
● Hold Seizure medications and other
stimulants
● Can eat before the test
● Wash and Dry hair
○ Oily hair will slip the
electrodes
● Sleep
○ It depends on the technicians
● Breathing, Light
Your Answers & what you got Right &
Wrong:
1. Neurons in the brain are tasked with
handling and transmitting information. There
are different types of neurons, such as
excitatory and inhibitory. Excitatory neurons
release the neurotransmitter
_____________, while inhibitory neurons
release the neurotransmitter
________________.
A. GABA, glutamate
B. Norepinephrine, GABA
C. Glutamate, GABA
D. Dopamine, glutamate
The answer is C. Excitatory neurons release
glutamate and inhibitory neurons release
GABA.
2. You’re assessing your patient load for the
patients who are at MOST risk for seizures.
Select all the patients below that are at risk:
A. A 32-year-old with a blood glucose of 20
mg/dL.
B. A 63-year-old whose CT scan shows an
ischemic stroke.
C. A 72-year-old who is post opt day 5 from
open heart surgery.
D. A 16-year-old with bacterial meningitis.
E. A 58-year-old experiencing ETOH
withdrawal.
The answers are A, B, D, and E. All the
patients are at risk except option C.
Remember all the risk factors: illness
(especially CNS types like bacterial
meningitis), fever, electrolyte/metabolic
issues (low blood sugar, acidosis etc),
ETOH (alcohol) withdraw, brain injury,
STROKE, congenital brain defects, tumors
etc.
3. A patient with a history of epilepsy is
taking Phenytoin. The patient’s morning
labs are back, and the patient’s Phenytoin
level is 7 mcg/mL. Based on this finding, the
nurse will?
A. Assess the patient for a rash
B. Initiate seizure precautions
C. Hold the next dose of Phenytoin
D. Continue to monitor the patient
The answer is B. A normal Phenytoin level
is 10 to 20 mcg/mL. The patient’s level is
low; therefore, the patient is at risk for
seizures. The nurse should initiate seizure
precautions. Remember a patient being
under medicated is a trigger for developing
a seizure.
4. You’re educating a 25-year-old female
about possible triggers for seizures. Which
statement requires you to re-educate the
patient about the triggers?
A. “I’m at risk for seizure activity during my
menstrual cycle.”
B. “I will limit my alcohol intake to 2 glasses
of wine per day.”
C. “It’s important I get plenty of sleep.”
D. “I will be sure to stay hydrated, especially
during hot weather.”
The answer is B. The patient should avoid
all alcohol because it can lead to a seizure.
Hormone shifts (menstrual cycle, ovulation,
pregnancy) sleep deprivation, and
dehydration can lead to a seizure.
5. True or False: A patient who is
experiencing a tonic-clonic seizure is
experiencing a focal (partial) seizure.
True
False
Answer FALSE: A patient who is
experiencing a tonic-clonic seizure is
experiencing a GENERLAIZED seizure.
This type of seizure affects both sides of the
brain.
6. A 7-year-old male patient is being
evaluated for seizures. While in the child’s
room talking with the child’s parents, you
notice that the child appears to be
daydreaming. You time this event to be 10
seconds. After 10 seconds, the child
appropriately responds and doesn’t recall
the event. This is known as what type of
seizure?
A. Focal Impaired Awareness (complex
partial)
B. Atonic
C. Tonic-clonic
D. Absence
The answer is D. This is an absence seizure
and is most common in children. The
hallmark of it is staring that appears to be
like a daydreaming state. It is very short and
the post ictus stage of this type of seizure is
immediate.
7. Your patient has a history of epilepsy.
While helping the patient to the restroom,
the patient reports having this feeling of déjà
vu and seeing spots in their visual field.
Your next nursing action is to?
A. Continue assisting the patient to the
restroom and let them sit down.
B. Initiate the emergency response system.
C. Lay the patient down on their side with a
pillow underneath the head.
D. Assess the patient’s medication history.
The answer is C. The patient is reporting
signs and symptoms of an aura (this is a
warning sign before a seizure event). Lay
the patient down on their side with a pillow
underneath the head and remove any
restrictive clothing. Also, time the seizure. If
the seizure lasts more than 5 minutes or if
the patient starts to have seizures back-to-
back activate the emergency response
system.
8. Keeping the previous question in mind,
the patient is now experiencing
characteristics of a tonic-clonic seizure. The
seizure started at 1402 and it is now 1408,
and the patient is still experiencing a
seizure. The nurse should?
A. Continue to monitor the patient
B. Suction the patient
C. Initiate the emergency response system
D. Restrain the patient to prevent further
injury
The answer is C. Tonic-clonic seizures
should last about 1-3 minutes. If the seizure
lasts MORE than 5 minutes, the patient
needs medical treatment FAST to stop the
seizure….this is known as status
epilepticus.
9. Your patient has entered the post ictus
stage for seizures. The patient’s seizure
presented with an aura followed by body
stiffening and then recurrent jerking. The
patient had incontinence and bleeding in the
mouth from injury to the tongue. What is an
expected finding in this stage based on the
type of seizure this patient experienced?
A. Crying and anxiety
B. Immediate return to baseline behavior
C. Sleepy, headache, and soreness
D. Unconsciousness
The answer is C. Based on the findings
during the seizure the patient experienced a
tonic-clonic seizure. In the post ictus stage
(after the seizure) the patient is expected to
be sleepy (very tired), have soreness, and a
headache. The nurse should let the patient
sleep.
10. You’re developing discharge instructions
to the parents of a child who experiences
atonic seizures. What information below is
important to include in the teaching?
A. “This type of seizure is hard to detect
because the child may appear like he or she
is daydreaming.”
B. “Be sure your child wears a helmet daily.”
C. “It is common for the child to feel
extremely tired after experiencing this type
of seizure.”
D. “Avoid high fat and low carbohydrate
diets.”
The answer is B. This type of seizure leads
to a sudden loss of muscle tone. The patient
will go limp and fall, which when this
happens the head is usually the first part of
the body to hit the floor or an object nearby.
It is important the child wears a helmet daily
to protect their head from injury. Option A is
a characteristic of an absence seizure.
Option C is a characteristic of a tonic-clonic
seizure during the post ictus stage. And
option D is wrong because some patients
benefit from this type of diet known as the
ketogenic diet.
11. You’re assessing a patient who recently
experienced a focal type seizure (partial
seizure). As the nurse, you know that which
statement by the patient indicates the
patient may have experienced a focal
impaired awareness (complex partial)
seizure?
A. “My friend reported that during the
seizure I was staring off and rubbing my
hands together, but I don’t remember doing
this.”
B. “I remember having vision changes, but it
didn’t last long.”
C. “I woke up on the floor with my mouth
bleeding.”
D. “After the seizure I was very sleepy, and I
had a headache for several hours.”
The answer is A. The patient will experience
an alternation in consciousness (hence the
name focal IMPAIRED awareness) AND will
perform an action without knowing they are
doing it called automatism like lip-smacking,
rubbing the hands together etc. With a focal
onset AWARE seizure (also called partial
simple seizure) the patient is aware and will
remember what happens (like vision
changes etc.).
12. You have a patient who has a brain
tumor and is at risk for seizures. In the
patient’s plan of care you incorporate
seizure precautions. Select below all the
proper steps to take in initiating seizure
precautions:
A. Oxygen and suction at bedside
B. Bed in highest position
C. Remove all pillows from the patient’s
head
D. Have restraints on stand-by
E. Padded bed rails
F. Remove restrictive objects or clothing
from patient’s body
G. IV access
The answers are A, E, F, and G. The bed
needs to be in the LOWEST position
possible, a pillow should be underneath the
patient’s head to protect it from injury,
AVOID using restraints (this can cause
musculoskeletal damage).
13. You’re patient is scheduled for an EEG
(electroencephalogram). As the nurse you
will:
A. Keep the patient nothing by mouth.
B. Hold seizure medications until after the
test.
C. Allow the patient to have coffee, milk,
and juice only.
D. Wash the patient’s hair prior to the test.
E. Administer a sedative prior to the test.
The answers are B and D. An EEG is a
painless procedure that will assess the
patient’s brain activity (if a seizure occurs
during the test this can allow the physician
to determine what type of seizure it is).
Therefore, the nurse would hold seizure
medications (this can affect the test) and
would NOT allow the patient to have
caffeine like coffee or stimulant drugs (the
patient can eat prior to the test just NO
caffeine). The patient’s hair should be
cleaned prior to the test so the technician
can apply the electrodes and get them to
stick to the scalp easily. A sedative is not
needed before this test.
14. A patient is taking Phenytoin for
treatment of seizures. Which statement by
the patient requires you to re-educate the
patient about this medication?
A. “Every morning I take this medication
with a full glass of milk with my breakfast.”
B. “I know it is important to have my drug
levels checked regularly.”
C. “I will report a skin rash immediately to
my doctor.”
D. “This medication can lower my body’s
ability to clot and fight infection.”
The answer is A. This medication should
NOT be taken with milk products or antacids
because it affects absorption. All the other
options are correct.
15. The nurse is ordered to administer
Lorazepam to a patient experiencing status
epilepticus. As a precautionary measure,
the nurse will also have what reversal agent
on standby?
A. Narcan
B. Flumazenil
C. Calcium Chloride
D. Idarucizumab
The answer is B. Flumazenil is the reversal
agent for Lorazepam, which is a
benzodiazepine.
16. A patient who is having a tonic-clonic
seizure is prescribed Phenobarbital. During
administration of this drug, it is important the
nurse monitors for:
HEADACHE
DEFINITION:
A. Respiratory depression
B. Hypertension
C. Disseminated intravascular clotting
D. Hypotension
E. Fever
The answers are A and D. This medication
stimulates the GABA receptors and helps
with inhibitory neurotransmission. It can
lead to respiratory depression and
hypotension, therefore, it is very important
the nurse monitors the patient for this.
17. An 8-year-old child, who is not
responding to anti-seizure medications, is
prescribed to start a ketogenic diet. This diet
will include:
A. High carbohydrates and high fat
B. Low fat, high salt, and high
carbohydrates
C. High fat and low carbohydrates
D. High glucose, high fat, and low
carbohydrates
The answer is C. This is a type of diet used
in the pediatric population with epilepsy
whose seizures cannot be controlled by
medication. It is a high fat and low carb diet.
● Headache can be Divided into TWO
MAIN TYPES
● Cephalalgia
PRIMARY:
 ● Main and common type of ■ Pressure or tightened
headaches which waxes and
○ Unilateral Headache wanes
(Migraine) ○ Duration:
○ Tightness of the Head ■ Variable
Headache (Tension type ○ Associated Symptoms:
Headache) ■ None
○ Orbit area headaches ● Cluster Headache
(Cluster Headache) ○ Group of Idiopathic
○ Sinus Headache headache that is associated
○ Hormonal Headache with trigeminal neuralgia
SECONDARY: ○ Location:
● Pretty Bad Headaches ■ Always unilateral
● These are the Red Flag Headaches (around the eyes)
PRIMARY HEADACHE ○ Characteristics:
PATHOPHYSIOLOGY ■ Pain begins quickly
● Migraine: ■ Deep continuous pain
○ Disorder of recurrent attacks ■ Excruciating and
○ Location: Unilateral (70%) explosive in quality
○ Characteristics: ○ Durations:
■ Gradual Onset ■ 1o mins to 1 hour
■ Crescendo Pattern ○ Associated Symptoms:
■ Moderate to severe ■ Horner's Symptoms
intensity ● Ptosis
○ Duration: ● Miosis
■ 4-72 hours ● Pain
○ Associated Symptoms: ■ Lacrimation
■ Nausea ■ Nasal Discharge
■ Vomiting ○ Function of Trigeminal
■ Photophobia Nerve:
■ Phenophobia ■ Important for the
■ Aura sensation around
● Tension Headache your forehead which
○ More muscular is supplied by the
■ Most ambiguous ophthalmic branch of
headache headache the trigeminal (V1)
■ Its the most common ■ Maxillary Branch (V2)
reason why OTC ■ Mandibular Branch
analgesia are (V3)
purchased ● Sinus Headache:
○ Location: ○ Associated with Sinusitis
■ Bilateral ● Hormonal Headache:
○ CHaracteristics: ○ Associated with Low
estrogen concentration
 ■ Beginning of ○ N Neurological symptoms or
menstrual cycle abnormal signs
■ Withdrawal of ○ O Onset is new (Age >40) or
Hormone Therapy sudden (Thunderclaps)
TREATMENT Stroke
● Migraine: ○ O Other associated condition
○ NSAIDs/ Aspirin + Antiemetic or features
○ Hydration ○ P Precious Headache History
● Tension Headache: with headache progression
○ OTC paracetamol or change in attack character
● Cluster Headache: *The Head is very abnormal, it indicates a
○ Subcutaneously very serious problem
Sumatroptophan or Oxygen
○ Triptants are Intracranial Hemorrhage
Contraindicated in patient ● Subdural
with CAD, PVD, or ● Epidural
Cerebrovascular Disease ● Subarachnoid
● Sinusitis Headache:
● Supportive Therapy
○ Analgesic/Anti
Inflammatory
○ Antibiotics

SECONDARY HEADACHE
PATHOPHYSIOLOGY
● It is a result of an underlying
disease/conditions
● Warning signs and symptoms
○ S Systemic Symptoms
(Illness or conditions like
cancer)
○ Their task is handling and
transmitting information and
DEFINITION: impulses
● Abnormal electrical signals in the 2 Types of Neuron
brain being fired from neurons: ● Excitatory
Two Category: ○ Whenever they are
○ Generalize (both side of the stimulated they will cause a
brain) response
○ Focal (partial seizure and ○ They will release a
only target specific parts of neurotransmitter glutamate
the brain) ● Inhibitory
PHYSIOLOGY ○ They will inhibit a response
● Neurons they will decrease it
 ○ They will release a ○ Hugh fever
neurotransmitter GABA ○ CNS infection
There is an equilibrium for a patient who ○ Hypoglycemia
does not have a seizure ○ EtOH withdrawal
○ Acid-base imbalances
Problem: Damage in inhibitory neuron will ○ Hypoxia
be damage then there won’t be an inhibiting ○ Brain tumor
excessive excitatory neurotransmitter ● But some patient Epilepsy frequent
release by the excitatory muscle-- seizures activity due to Chronic
overstimulation of the brain condition
● For example, the Barbituates- will ○ Traumatic brain injury (TBI)
stimulate the GABA receptors that ○ congenital birth defect
will decrease the excitatory ○ Massive Stroke
○ Idiopathic
CAUSE ○ Effects of an illness
● Affects Anyone due to an acute
illness
GUILLAIN-BARRE SYNDROME ○ It receives and transmit
signals so some type of
DEFINITION: action can occur
● Autoimmune condition ○ For sensory and motor
● The immune system attacks nerves ■ The nerve receives
in the body specifically in impulses at the
○ Peripheral Nervous system dendrites
■ Nerves located ■ Then to the stoma
outside the spinal ■ And go through the
cords Axon with Myelin
○ Cranial Nerves sheaths
● Immune system attacking ● Purpose of Myelin Sheath
○ Myelin Sheath ○ It serves as an insulator that
○ Demyelination is occurring can allow smooth passage of
● If the GBS is severe enough it can signals without being
extends to the autonomic nervous interrupted
system ○ Then allows it to reach to the
● GBS=Gradual block axon terminal
RISK FACTOR: PATHOPHYSIOLOGY
● If a defect was found in the Nerve
ANATOMY AND PHYSIOLOGY: ○ Sensory and Nerve function
● Peripheral Nervous System: will not be effective
○ Somatic: control voluntary ○ Can lead to Respiratory
functions Failure as the disease
○ Autonomic: Controls ● There is an existing condition that
involuntary functions triggers this condition
● Purpose of Nerve:
 ○ May ask the patient’s history
extensively
● GBS can affect anyone at any age,
any gender and any race
● There is no cure to this disease
If illness does exist
● The immune system usually fights
the illness but somewhere along the
way it got confuse and attacked the
Myelin sheath
● Gradual Block of Sensation
Different Type of Guillain Barre
Syndrome
❏ Miller Fisher Syndrome:
❏ MFS originates in the eyes,
adversely affecting the
manner in which the
individual walks. It is more
prevalent in Asia compared
to North America.
❏ Acute Motor Axonal Neuropathy
(AMAN)/Acute Motor-Sensory
Axonal Neuropathy (AMSAN):
AMSAN and AMAN
❏ affect more people in Asian
countries in comparison to
the USA.
❏ Acute Inflammatory
Demyelinating
Polyradiculoneuropathy (AIDP):
❏ It is the most widespread
form of GBS, characterized
by muscular weakness and
numbness that develops
from the lower extremity and
shoots upward. Majority of
affected Americans are
diagnosed with the AIDP
WHAT HAPPENS:
● .It tends to start in the feet
○ Feeling of paresthesia
{tingling, numbness
● It migrates upward/ ascends
○ It is symmetrical
● This can lead to paralysation of the
body
● The myelin sheath is destroyed and
won’t get any signal
WHY?
● Report illness
○ 1-3 weeks of upper
respiratory disease or an
Gastrointestinal Disease
■ Caused by a
Campylobacter
Jejuni
○ “As many as 40 percent of
GBS cases in the United
stated are thought to be
triggered by Campylobacter
infection” +
○ Also link with patient with
Epstein Barr Virus {EBV}
○ Also link with HIV and AIDS
○ Also link with recent
vaccination
■ Swine flu
■ Influenza
PATHOPHYSIOLOGY
● If a defect was found in the Nerve
○ Sensory and Nerve function
will not be effective
○ Can lead to Respiratory
Failure as the disease
● Lower extremities they felt
numbness and tingling and they
have trouble walking
○ They reported that they have
severe GI illness caused by
Campylobacter Jejuni
● Peripheral nerves starts
demyelination downwards then
ascends
● .After 2 weeks
 ○ Work signs and symptoms ■ And patient will start
occur experiencing Difficulty
● After the worst scenario breathing
○ Remyelination occurs ○
○ The symptoms starts SIGNS AND SYMPTOMS
subsiding ● Paresthesia at the lower extremities
○ They start to get better ● Migration upward/ Ascending
● After 1 to 2 years Numbness and tingling
○ The symptoms will reoccur symmetrically
● Paralysis on the waist down
Worst case scenario ● Absent Reflexes
● Cranial: Migrates to brain stem ● Loss Muscle Time
○ Face paralysis ● Patient will complain difficulty
○ Difficulty Swallowing breathing
○ Difficulty Speaking ○ Ineffective cough
○ Vissium issue ○ So Always prepare Airway
● Severe Pain at the cramps of muscle management kit at the
○ Odd paradox bedside
● Involvement of Autonomic nervous ● Difficult swallowing
system ○ They can aspirate and can
○ Heart: develop pneumonia
■ Dysrhythmias ○ Always assess swallowing
■ Orthostatic activity
Hypotension ● They can’t speak and articulate
■ Paroxysmal words
Hypertension ○ Always provide a
● GI system: communication boards
○ Constipation ○ Always provide they
■ Feeding tube and assurance that this is
always be alerted that temporary and they can
if bowel sound is regain their sensation back
present- paralytic DIAGNOSTIC AND LABORATORY TEST
ileus ● electromyography and Nerve
■ Always check Conduction Studies
Residuals ○ Assess the demyelination of
■ the nerves by determining
○ Renal muscle’s ability to response
■ Urinary Retention to nerve stimulation
● As disease progresses and ascends ● Lumbar Puncture:
in the chest ○ Elevated Protein without
○ Muscle wall responsible for elevated white blood cell
drawing air in and out will ■ Before: Empty
start to paralyze Bladder
 ■ During: Position
lateral recumbent with
knee up to abdomen
and bend chin to
chest
■ After: Lie flat needs
to consume a lot of
fluids to prevent
headache and to
replace loss CSF
TREATMENT
● TReatment can not CURE
● They can only decrease recovery
time and Improves Signs and
Symptoms
○ Decrease signs and
symptoms
● They have to be administered 2
weeks from the onset of symptoms
MEDICATION
● Immunoglobulin Therapy:
○ IV immunoglobulin from a
donor given to the patient to
stop the antibodies that are
damaging the nerves
● Plasmapheresis
○ Machine that will filter the
blood to remove the
antibodies from the plasma
that are attacking the myelin
sheth
NURSING INTERVENTION
● Immobility and Paralysis can lead to
Increase risk for infection, blood
clots, pressure injuries UTIs, Weight
loss
○ They can be Intubated
○ Anticoagulants and monitor
SCDs
○ Turning them frequently
○ Physical therapy and
p[reventing contractures
○ Maintain muscle Integrity
○ Monitor Weights daily
Your Grade: B
Percentage of What you Got Right: 82
Go Here for More Quizzes
Your Answers & what you got Right &
Wrong:
1. True or False: Guillain-Barré Syndrome
occurs when the body's immune system
attacks the myelin sheath on the nerves in
the central nervous system.
True
False
FALSE: Guillain-Barré Syndrome is an
autoimmune neuro condition where the
immune system attacks the nerves (myelin
sheath) in the PERIPHERAL NERVOUS
SYSTEM and cranial nerves. This condition
does NOT occur in the central nervous
system (CNS).
2. During nursing report you learn that the
patient you will be caring for has Guillain-
Barré Syndrome. As the nurse you know
that this disease tends to present with:
A. signs and symptoms that are unilateral
and descending that start in the lower
extremities
B. signs and symptoms that are symmetrical
and ascending that start in the upper
extremities
C. signs and symptoms that are
asymmetrical and ascending that start in the
upper extremities
D. signs and symptoms that are
symmetrical and ascending that start in the
lower extremities
The answer is D. GBS signs and symptoms
will most likely start in the lower extremities
(ex: feet), be symmetrical, and will gradually
spread upward (ascending) to the head.
There are various forms of Guillain-Barré
Syndrome. Acute inflammatory
demyelinating polyradiculoneuropathy
(AIDP) is the most common type in the U.S.
and this is how this syndrome tends to
present.
3. You're assessing a patient's health
history for risk factors associated with
developing Guillain-Barré Syndrome. Select
all the risk factors below:
A. Recent upper respiratory infection
B. Patient's age: 3 years old
C. Positive stool culture Campylobacter
Jejuni
D. Hyperthermia
E. Epstein-Barr
F. Diabetes
G. Myasthenia Gravis
The answers are: A, C, and E. Risk factors
for developing Guillain-Barré Syndrome
include: experiencing upper respiratory
infection, GI infection (especially from
Campylobacter Jejuni), Epstein-Barr
infection, HIV/AIDS, vaccination (flu or
swine flu) etc.
4. A 25 year-old presents to the ER with
unexplained paralysis from the hips
downward. The patient explains that a few
days ago her feet were feeling weird and
she had trouble walking and now she is
unable to move her lower extremities. The
patient reports suffering an illness about 2
weeks ago, but has no other health history.
The physician suspects Guillain-Barré
Syndrome and orders some diagnostic
tests. Which finding below during your
assessment requires immediate nursing
action?
A. The patient reports a headache.
B. The patient has a weak cough.
C. The patient has absent reflexes in the
lower extremities.
D. The patient reports paresthesia in the
upper extremities.
The answer is B. The patient’s signs and
symptoms in this scenario are typical with
Guillain-Barré Syndrome. The syndrome
tends to start in the lower extremities (with
paresthesia that will progress to paralysis)
and migrate upward. The respiratory system
can be affected leading to respiratory
failure. Therefore, the nurse should assess
for any signs and symptoms that the
respiratory system may be compromised
(ex: weak cough, shortness of breath,
dyspnea...patient says it is hard to breath
etc.). The nurse should immediately report
this to the MD because the patient may
need mechanical ventilation. Absent
reflexes is common in GBS and paresthesia
can extend to the upper extremities as the
syndrome progresses. A headache is not
common.
5. A patient with Guillain-Barré Syndrome
has a feeding tube for nutrition. Before
starting the scheduled feeding, it is essential
the nurse? Select all that apply:
A. Assesses for bowel sounds
B. Keeps the head of bed less than 30'
degrees
C. Checks for gastric residual
D. Weighs the patient
The answers are A and C. Some patients
who experience GBS will need a feeding
tube because they are no longer able to
swallow safely due to paralysis of the
cranial nerves that help with swallowing.
GBS can lead to a decrease in gastric
motility and paralytic ileus. Therefore,
before starting a scheduled feeding the
nurse should always assess for bowel
sounds and check gastric residual.
6. You’re educating a patient about
treatment options for Guillain-Barré
Syndrome. Which statement by the patient
requires you to re-educate the patient about
treatment?
A. "Treatments available for this syndrome
do not cure the condition but helps speed
up recovery time."
B. "Plasmapheresis or immunoglobin
therapies are treatment options available for
this syndrome but are most effective when
given within 4 weeks of the onset of
symptoms."
C. "When I start plasmapheresis treatment
a machine will filter my blood to remove the
antibodies from my plasma that are
attacking the myelin sheath."
D. "Immunoglobulin therapy is where IV
immunoglobulin from a donor is given to a
patient to stop the antibodies that are
damaging the nerves.
The answer is B. This statement is
incorrect. Plasmapheresis and
immunoglobin therapies are treatment
options available for GBS, BUT they are
only really effective when given within 2
weeks from the onset of symptoms (not 4
weeks).
7. Which tests below can be ordered to help
the physician diagnose Guillain-Barré
Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test
C. Lumbar puncture
D. Electromyography
E. Nerve Conduction Studies
The answers are C, D, and E. These are the
tests that can be ordered to help the MD
determine if the patient is experiencing
GBS.
8. You're teaching a group of nursing
students about Guillain-Barré Syndrome
and how it can affect the autonomic nervous
system. Which signs and symptoms
verbalized by the students demonstrate they
understood the autonomic involvement of
this syndrome? Select all that apply:
A. Altered body temperature regulation
B. Inability to move facial muscles
C. Cardiac dysrhythmias
D. Orthostatic hypotension
E. Bladder distension
The answers are A, C, D, and E. All these
are some signs and symptoms that can
present in severe cases of GBS when the
autonomic nervous system is involved.
9. You're about to send a patient for a
lumbar puncture to help rule out Guillain-
Barré Syndrome. Before sending the patient
you will have the patient?
A. Clean the back with antiseptic
B. Drink contrast dye
C. Void
D. Wash their hair
The answer is C. The patient will need to
void and empty the bladder before going for
a LP. This will help decrease the chances of
the bladder becoming punctured during the
procedure.
10. Your patient is back from having a
lumbar puncture. Select all the correct
nursing interventions for this patient?
A. Place the patient in lateral recumbent
position.
B. Keep the patient flat.
C. Remind the patient to refrain from eating
or drinking for 4 hours.
D. Encourage the patient to consume liquids
regularly.
The answers are B and D. The patient will
need to stay flat after the procedure for a
prescribed amount of time to prevent a
headache, and the nurse will need to
encourage the patient to drink fluids
regularly to help replace the fluid lost during
the lumbar puncture.
11. The patient's lumbar puncture results
are back. Which finding below correlates
with Guillain-Barré Syndrome?
A. high glucose with normal white blood
cells
B. high protein with normal white blood cells
C. high protein with low white blood cells
D. low protein with high white blood cells
The answer is B.

MULTIPLE SCLEROSIS ○ They receives to create

some types of action
DEFINITION ● Soma/Body:
● Autoimmune disease that affects the ○ Helps pass the signal receive
Myelin sheath of the neuron on on the Dendrites and help it
the CNS pass to the rest of the bodies
● MS=Myelin Sheath=Multiple ● Axon Hillock
sclerosis ○ Axon connect
○ Neuron can become inflamed ● Axon:
and scar ○ It takes impulses away from
○ It decreases the nerve signal the neuron
transmission ○ Myelin sheath
○ Lead in many motor sensory ■ What protect the
problem Axon
QUICK FACTS ■ What allows easy
● This disease is immune related passage of the
● Symptoms Vary signals
○ Because it can affect ■ Serves as an
different parts of the neurons insulator
and lobes in the brain ■ They are made up of
○ Example Cerebellar: tremor, Schwann Cells: fats
dysarthria, ataxia, cognition and proteins
○ Occipital Lobe: Eye problems ● There is good synapse- nerve
● Women 20-40 years old signal is passed
● Cause is unknown ○ Because the myelin sheath
● No cure facilitates the impulses for it
○ Lifestyle change and to restructure that permits a
medication are needed to neuron (or nerve cell) to pass
improve signs and symptoms an electrical or chemical
● Appear and Disappear signal to another neuron or to
○ Relapsing remitting MS the target effector cells the
ANATOMY Axon terminal
● Dendrites: ○
pATHOPHYSIOLOGY ● Remember that symptoms may vary
● Demyelination in progress depending on the lobe and structure
○ Damage of the myelin it will affects
sheaths ● And * can indicated early
● When an impulse/signal is symptoms
transferred down to this neuron Emotions and Cognitive
○ Not gonna happen correctly ● Drained/fatigues*
○ Not strong enough ○ Even though they didn’t do
● There won’t have stimulation of the anything
muscle/organ that it supplies ● Depressed
● They is no synapse/ signal ● Speech issues *
stimulation ○ Dysarthria-Cerebellar lesions
○ The signal received in the ○ Swallowing problem*
axon terminal is not enough ■ Dysphagia
○ There is none signal received ● Mood swings
● Multiple sclerosis Concept: ● Trouble thinking -cerebellar problem
○ We are talking of the nerve cells ○ Focus
in the CNS ○ Problem solving problem
■ Brain and spinal cord ○ Thinking problem
○ Sensory problems and motor
Sensation issues:
● Remors
problems
● Spasms*
■ Touch and vision
○ Can be very painful
■ Emotional and cognitive
● Clumsiness*
position
○ They may feel drunk
■ Coordination an bladder
○ Can lead to injury
symptoms
● Numbness*
○ Tingling on the face and
extremities
● Dizziness/vertigo*
● Coordination*
● + Romberg signs
○ Patient stand with their eyes
close and feet together
○ + they have lesion on
cerebellar area
■ Proprioceptors
■ Loss of balance and
sway
● + Lhermitte’s signs
RISK FACTORS
○ It is where the patient
● SDASASD
whenever they move their
SIGNS AND SYMPTOMS
head in various motion they
 can experience electric
shock down in their body
■ Electric shock
sensation
■ L-Lighting shock
VISION
● Nystagmus
● Optic Neuritis*
● It is where the optic nerve that
supplies the eyes gets inflamed and
scarred because of the
demyelination of myelin sheaths
○ Double vision
○ Blurry
○ Dull/gray vision
○ Pain moving eyes
○ Dark spot vision
ELIMINATION*
● Can’t hold urine:
○ Nocturia-peeing alot at night
○ overactive bladder
● Problems with contracting to coid
○ Urinary retention .
○ At risk for
■ UTIs and renal stones
● Bowel:
○ constipation
○ Diarrhea
○ Can’t hold stool
UHTHOFF’s SIGN
● Heat makes signs and symptoms
worst
DIAGNOSTIC PROCEDURE
● It really takes time
● Neurologist assess various things:
○ There is no single test to rule
out MS
● Patient’s signs and symptoms:
○ They must be assessed
thoroughly because the S
and S may mimic other
disease
● MRI
○ In the brain and Spinal cord
○ This allows viewing of the
Inflammation of the brain and
spinal cord
● Lumbar puncture:
○ CSF oligoclonal bands
○ High amount of proteins and
Oligoclonal bands
● Evoked potential studies
○ They will evoked an electrical
signet to the CNS to create a
response
TREATMENT
● SDASASD
MEDICATION
● Beta Interferon:
○ Decreases the number of
relapses of symptoms by
decreasing inflammation and
the immune response
towards the Myelin sheath
■ Can be High risk for
infection
■ It can decrease
WBCs
○ Drug Names: ANOVEX
{Interferon beta 1a}, Rebif,
Betaferon
● Corticosteroids:
○ For those who’s already
having relapse of MS
○ Ordered to decrease the
inflammation and to
decrease that immune
response
○ Drug Names:
Methylprednisolone,
prednisone
For Bladder issue: Medication includes
● OXYBUTYNIN
○ Anticholinergic
○ It helps with overactive
bladder by relaxing the
bladder muscle to prevent
contraction
 ● BETHANECHOL:
○ Cholinergic
○ Helps with emptying the
bladder by helping with
bladder contraction
Medication for Fatigue:
● Amantadine
○ Antiviral and antiparkinsonian
○ It has CNS effects that helps
improve fatigue in patient
with MS
● Modafinil
○ CNS stimulant
Spasms:
● Baclofen:
○ Skeletal muscle relaxants
that acts centrally
● Diazepam
Tremors:
● Propranolol
○ Beta Blockers
○ Warn the patient with DM
that if they take this
medication
■ They when they go
Hypo can cause
tremors
● Isoniazid:
○ Antibiotic used for infection
○ Especially with TB
○ Helps with certain tremors in
MS
NURSING INTERVENTION
● Safety {Vision, coordination,
decrease reception pain,
bowel/bladder issue, Remitting
Relapse MS RRMS prevention,
Medication}
Preventing the increase ef Signs and
Symptoms:
● Stress.
○ Provide and nice,
comfortable, and non
stressful environment
○ Provide stress relief
techniques
● Infection
○ Avoid infection
● Overexertion
○ Exercise is needed to
improve tolerance
○ BUT DONT DO IT OVERLY
■ Relax
○ Swimming exercise is good
■ Because water is cool
● Remember UHTHOFF's Sign
○ Avoid Heat
■ No heating pads,
warming blankets,
keeping room and
temp hot
ASSISTIVE DEVICES:
● Showering is difficult and standing is
a problem
○ Provide shower chair
○ Railing
● Creating a clutter free room
○ Eyes problem
● Scan the environment before they
get up
Speech language pathology
● Speech problem
○ For Dysarthria patient
● Swallowing problems
○ Dysphagia
○ Aspiration
■ Assess lung sound
Physical therapist
● Exercise and regimens
● Help them us assistive devices
Support groups
● Support to one another
Bower Problems
● Constipation
 ○ Increase fiber
○ Stool softer
● Incontinent stool
○ Skin care
Bladder Problems
● Overactive bladder
○ Always assure easy access ti
the comfort room that are
clutter free
● Incontinence:
○ Foley catheter
○ Assess for skin break down
○ Provide clean pads
○ Self Catheter
● Skin problem:
○ Provide skin care
○ 1-2 fluids a day to prevent
concentration
our Grade: D
Percentage of What you Got Right: 67
Go Here for More Quizzes
Your Answers & what you got Right &
Wrong:
1. Select all the TRUE statements about the
pathophysiology of multiple sclerosis:
A. "The dendrites on the neuron are
overstimulated leading to the destruction of
the axon."
B. "The myelin sheath, which is made up of
Schwann cells, is damaged along the axon."
C. "This disease affects the insulating
structure found on the neuron in the central
nervous system."
D. "The dopaminergic neurons in the part of
the brain called substantia nigra have
started to die."
The answers are B and C. In multiple
sclerosis the myelin sheath (which is the
insulating and protective structure made up
of Schwann cells that protects the axon) is
damaged. MS affects the CNS (central
nervous system) and when the myelin
sheath becomes damaged it leads to a
decrease in nerve transmission.
2. True or False: Multiple Sclerosis tends to
affect men more than women and occurs
during the ages of 50-70 years.
True
False
False: MS affects WOMEN more than men
and shows up during the ages of 20-40
years.
3. True or False: Patients with multiple
sclerosis have different signs and symptoms
because this disease can affect various
areas of the peripheral nervous system.
True
False
False: Yes, patients with MS have different
signs and symptoms because lesions can
present at different locations in the
CENTRAL NERVOUS SYSTEM....hence
the brain and spinal cord (not the peripheral
nervous system).
4. A patient is suspected of having multiple
sclerosis. The neurologist orders various
test. The patient's MRI results are back and
show lesions on the cerebellum and optic
nerve. What signs and symptoms below
would correlate with this MRI finding in a
patient with multiple sclerosis?
A. Blurry vision
B. Pain when moving eyes
C. Dysarthria
D. Balance and coordination issues
E. "Pill rolling" of fingers and hands
G. Heat intolerance
H. Dark spots in vision
I. Ptosis
The answers are A, B C, D, and H. If lesions
are present on the optic nerves, optic
neuritis can occurs which can lead to blurry
vision, pain when moving the eyes, and
dark spots in the vision. If cerebellar lesions
are found, this can affect movement,
speech, and some cognitive abilities. This
would present as dysarthria (issues
articulating words), and
balance/coordination issues. "Pill rolling" of
the fingers and hands is found in
Parkinson's disease. Ptosis is common in
myasthenia gravis, and heat intolerance in
thyroid issues.
5. You're performing a head-to-toe
assessment on a patient with multiple
sclerosis. When you ask the patient to move
the head and neck downward the patient
reports an "electric shock" sensation that
travels down the body. You would report
your finding to the doctor that the patient is
experiencing:
A. Romberg's Sign
B. Lhermitte's Sign
C. Uhthoff's Sign
D. Homan's Sign
The answer is B. This finding is known as
Lhermitte's Sign.
6. Which finding below represents a positive
Romberg Sign in a patient with multiple
sclerosis?
A. The patient report dark spots in the visual
fields during the confrontation visual field
test.
B. When the patient closes the eyes and
stands with their feet together they start to
lose their balance and sway back and forth.
C. The patient's sign and symptoms
increase when expose to hot temperatures.
D. The patient reports an electric shock
feeling when the head and neck are moved
downward.
The answer is B. This is an example of a
positive Romberg's Sign.
7. Your patient is scheduled for a lumbar
puncture to help diagnose multiple
sclerosis. The patient wants clarification
about what will be found in the
cerebrospinal fluid during the lumbar
puncture to confirm the diagnosis of MS.
You explain that ____________ will be
present in the fluid if MS is present.
A. high amounts of IgM
B. oligoclonal bands
C. low amounts of WBC
D. oblong red blood cells and glucose
The answer is B. These specific proteins,
oligoclonal bands, which are
immunoglobulins will be found in the CSF.
This demonstrates there is inflammation in
the CNS and is a common finding in
multiple sclerosis.
8. You're developing a plan of care for a
patient with multiple sclerosis who presents
with Uhthoff's Sign. What interventions will
you include in the patient's plan of care?
Select all that apply:
A. Avoid movements of the head and neck
downward
B. Keep room temperature cool
C. Encourage patient to use warm packs
and heating pads for symptoms
D. Educate the patient on three ways to
avoid overheating during exercise
The answers are B and D. Uhthoff's Sign is
where when the patient experiences too
much heat their symptoms increase and get
worst. Therefore, it is important the patient
stays cool and doesn't overheat
(overheating can come from outside
temperatures, exercise, emotional events
etc.). The room should be cool and the
patient should be encouraged to exercise
but to avoid overheating.
9. During your discharge teaching to a
patient with multiple sclerosis, you educate
the patient on how to avoid increasing
symptoms and relapses. You tell the patient
to avoid:
A. Cold temperatures
B. Infection
C. Overexertion
D. Salt
F. Stress
The answer is B, C, and F. The patient
should also avoid extreme heat, which can
increase symptoms.
The answer is A. This medication is a
cholinergic medication that will help with
bladder emptying.
11. A patient is receiving Interferon Beta for
treatment of multiple sclerosis. As the nurse
you will stress the importance of?
A. Physical exercise to improve fatigue
B. Low fat diet
C. Hand hygiene and avoiding infection
D. Reporting ideation of suicide
The answer is C. Interferon Beta decreases
the number of relapses of symptoms in MS
patients by decreasing the immune system
response, but it lowers the white blood cells
count. Hence, there is a risk of infection. It is
very important the nurse stresses the
importance of hand hygiene and avoiding
infection.

10. A patient with multiple sclerosis has 12. Which medications below can help treat
issues with completely emptying the muscle spasms in a patient with multiple
bladder. The physician orders the patient to sclerosis? Select all that apply:
take ___________, which will help with A. Propranolol
bladder emptying. B. Isoniazid
A. Bethanechol C. Baclofen
B. Oxybutynin D. Diazepam
C. Avonex E. Modafinil
D. Amantadine The answers are C and D. These
medications treat muscle spasms in patients
with MS.
MYASTHENIA GRAVIS ■ Drooping of the eyes
■ Diplopia/Lazy eyes
DEFINITION ■ Strabismus
● Autoimmune Condition ○ Throat: Another common
● Body attacks the muscle receptors signs
that controls the voluntary muscles ■ Weakens muscle on
Can lead to : throat
● Muscle weakness ■ Dysphasia
Organs Involves: ■ Hoarseness of voice
● Voluntary Muscles: ■ Chewing is an effort
○ Eyes: Most likely 1st signs ○ Arms and Legs
 ○ Respiratory ○ And they bind with
■ Severe case Nicotinic Acetylcholine
QUICK FACTS receptors {nAChRs}
● This disease is immune related ○ Acetylcholinesterase
● Symptoms Vary {AChE}
○ Because it can affect ■ Enzymes that Break
different Down acetylcholine
RISK FACTORS into two pieces
● This disease is immune related ● It allows the motor neuron to
● Symptoms Var transmit a signal to the muscle fiber,
ANATOMY causing muscle contraction.
● Muscles require innervation to
function—and even just to maintain
muscle tone, avoiding atrophy. In the
neuromuscular system nerves from
the central nervous system and the
peripheral nervous system are linked
and work together with muscles.
PATHOPHYSIOLOGY
● Key player:
○ Neuromuscular Junction
■ Nicotinic
● Key player: Acetylcholine
○ Neuromuscular Junction Receptors
■ Nicotinic ■ Function of Muscle
Acetylcholine Specific Kinase
Receptors ■ Acetylcholine
■ Function of Muscle ■ Immune system
Specific Kinase ● Produces
■ Acetylcholine antibodies
■ Immune system against
● Produces receptors
antibodies ● Thymus gland
against ● The Immune system build up an
receptors antibody that destroys the Nicotinic
● Thymus gland Acetylcholine receptors {nAChRs}
● A neuromuscular junction (or ● Alot of them won’t be available and
myoneural junction) is a chemical working meaning that they are not
synapse between a motor neuron functioning well
and a muscle fiber. ○ They won’t be able to receive
○ Cholinergic fibers initiates the the Acetylcholine
release of acetylcholine ○ Muscle fibers won’t be
contracting like they
should
 ■ WEAKNESS
● Antiacetylcholinesterase are
administer
○ Like Pyridosestigmy
○ To prevent breakdown
○ So more acetylcholine can
be made available to these
limited receptors
○ To increase muscle strength
● Thymus Gland
○ Location: Anterior at the
upper part of the body
■ Behind the sternum
and between the
lungs
○ Provides a very important
role on our immune system
and health
○ Creator or T cells
■ Fighting against
viruses and bacteria
and cell
○ This tends to be enlarge at
children than an adult
■ By puberty the
thymus gland has
usually produce a
lifelong supply of t
cells that we are
going to need
○ ABut as person ages usually
in the older age the thymus
gland will actually turn into
fatty tissue
● People with Myasthenia Gravis the
thymus gland is still enlarge
○ They are not small like they
should be
○ They have tumors
○ A Lot of immune cell has
congregate together
○ The thymus is actually
erroneously creating this
antibodies to attracts the
receptor site of
neuromuscular junction
○ Making acetylcholine not
reaching the tissue site
■ To create voluntary
contraction
SIGNS AND SYMPTOMS
● ****Hallmark:
○ Muscle weakness gets worse
with activity
■ Especially repetitive
activity
■ Because the
receptors are very
limited and remaining
acetylcholine is very
abundant but can be
destroyed later on
when enzyme breaks
them down
○ But will improve after resting
the muscle
● “W.E.A.K.N.E.S.S”
○ Weakness of the neck, face,
arms and legs “hemiplegia”
○ Eyelid drooping “Ptosis”
○ Appearance mask like
■ Very sleepy
expression
○ Keep on choking/gagging
when eating
■ Risk for aspiration
○ No Energy
■ Do it in the morning
when they have
enough rest
■ When patient has
more energy to do
stuff
○ Extraocular Muscle
Involvement
■ Strabismus
■ Diplopia
○ Slurred speech
 Shortness of breath
○ the receptors and
COMPLICATION wear them out
● Myasthenic Crisis ■ This will result a
○ Disease can go to remission decrease in the
{no signs and number of nicotinic
symptoms1]BUT can Acetylcholine
experience acute receptors available
exacerbation ■ They can be tolerant
■ THIS occurs because ○ Severe muscle weakness
they are not receiving and respiratory depression
acetylcholine like they ○ Making Acetylcholine
should abundant in the synapses
● Because LABORATORY AND DIAGNOSTIC
Cholinesteras PROCEDURE
e an enzyme ● Tensilon Test
will ○ A medication Edrophonium
continuously is given
breakdown ○ Used to diagnose and
acetylcholine differentiate myasthenic and
● Making cholinergic crisis in
acetylcholine myasthenia gravis
not available ○ It’s an anticholinesterase:
for the ■ Prevents breakdown
receptors acetylcholine more
■ Muscle can’t contract available at
○ Severe muscle weakness neuromuscular
and respiratory failure junction and makes it
■ Need for intubation more available to the
and mechanical site
ventilator Result:
○ Cause? ● Myasthenia gravis or crisis:
■ Not enough ○ They will get better
Anticholinesterase ○ Strength is improved
Medication ● Cholinergic Crisis
■ Stress ○ Strength becomes worst
■ Respiratory infection ○ Weaker
● Frequent use ○ Provide antidote:
of muscle ■ Physostigmine
■ Surgery ■ Atropine
● Cholinergic Crisis: {anticholinergic}
○ Too much medication TREATMENT and MEDICATION
■ Where a lot a ● NO CURE
acetylcholine will ● Anticholinesterase
continuously bombard “Pyridostigmine”
 ○Take 30 minutes to 1 hours
before meal-peak
● Complication: Myasthenic Crisis
{inadequate medication} and
● Complication: Cholinergic Crisis
{Too much medication}
○ Signs and Symptom: Similar
to over stimulation of the
parasympathetic system
“Rest and digest”
■ Bradycardia
■ Pupil constriction
■ Bronchospasm
■ Increase salivation
and Mucous
■ GI: cramping and
diarrhea
■ Bladder incontinence
■ Muscle weakness
and respiratory failure
● Corticosteroid:
○ To decrease inflammatory
response
● IV immunoglobulins
● Plasmapheresis
○ Dialysis
○ Blood is filtered and removes
antibodies
● Thymectomy
○ Improves signs and
symptoms
NURSING INTERVENTION
● Note improvement, cardiac monitor,
make atropine available, have the
crash cart at the bedside
● Monitor respiratory status:
○ Effort of breathing
○ Respiratory rate
○ Suction must be provided to
prevent aspiration
● Neuromuscular functions
○ Assess cranial nerves
○ Vision, sound of voice
○ Speech, facial appearance
○ Strength of arms and legs
● Determine swallowing function
○ Before eating and
administration of PO
medication
● Speech Langage pathologist must
be referred to patient
● Always secure safety
○ Always assess any risk for
fall
■ Weak arms and leg
■ Low rr-they might
pass out
■ Vission problem
● Aspiration
○ Speech Pathologist
○ Evaluate swallowing
○ During feeding the head over
bed mus be raised at >30
degree
● Educating of Eating:
○ Larger meals in the morning
because they have energy to
chew
■ Then small meal later
in day
○ Schedule medication 30 mins
to 1 hour after taking
anticholinesterase
■ It is the peak time of
the medication
○ Thicken liquid
○ Small bites, soft foods
○ Perform most activities in the
morning
■ Ambulating
■ Leg rolling
■ And other procedure
Your Grade: A
Percentage of What you Got Right: 90
Go Here for More Quizzes
Your Answers & what you got Right &
Wrong:
1. Myasthenia gravis occurs when
antibodies attack the __________ receptors
at the neuromuscular junction leading to
____________.
A. metabotropic; muscle weakness
B. nicotinic acetylcholine; muscle weakness
C. dopaminergic adrenergic; muscle
contraction
D. nicotinic adrenergic; muscle contraction
The answer is B. In myasthenia gravis,
either the nicotinic acetylcholine receptors
are attacked by antibodies created by the
immune system (hence why this disease is
considered autoimmune) or antibodies are
inhibiting the function of muscle-specific
kinase (which is a receptor tyrosine kinase
that helps with maintaining and building the
neuromuscular junction). Either way this
leads to the neurotransmitter acetylcholine
from being able to communicate with the
muscle fiber to make it contract.
2. You're educating a patient about the
pathophysiology of myasthenia gravis.
While explaining the involvement of the
thymus gland, the patient asks you where
the thymus gland is located. You state it is
located?
A. behind the thyroid gland
B. within the adrenal glands
C. behind the sternum in between the lungs
D. anterior to the hypothalamus
The answer is C. The thymus is located
anteriorly in the upper part of the chest
behind the sternum in between the lungs.
3. A patient with myasthenia gravis will be
eating lunch at 1200. It is now 1000 and the
patient is scheduled to take Pyridostigmine.
At what time should you administer this
medication so the patient will have the
maximum benefit of this medication?
A. As soon as possible
B. 1 hour after the patient has eaten (at
1300)
C. 1 hour before the patient eats (at 1100)
D. at 1200 right before the patient eats
The answer is C. Pyridostigmine is an
anticholinesterase medication that will help
improve muscle strength. It is important the
patient has maximum muscle strength while
eating for the chewing and swallowing
process. Therefore, the medication should
be given 1 hour before the patient eats
because this medication peaks (has the
maximum effect) at approximately 1 hour
after administration. How does the
medication improve muscle strength? It
does this by preventing the breakdown of
acetylcholine. Remember the nicotinic
acetylcholine receptors are damaged and
the patient needs as much acetylcholine as
possible to prevent muscle weakness.
Therefore, this medication will allow more
acetylcholine to be used...hence improving
muscle strength.
4. The neurologist is conducting a Tensilon
test (Edrophonium) at the bedside of a
patient who is experiencing unexplained
muscle weakness, double vision, difficulty
breathing, and ptosis. Which findings after
the administration of Edrophonium would
represent the patient has myasthenia
gravis?
A. The patient experiences worsening of the
muscle weakness.
B. The patient experiences wheezing along
with facial flushing.
C. The patient reports a tingling sensation in
the eyelids and sudden ringing in the ears.
D. The patient experiences improved
muscle strength.
The answer is D. During a Tensilon test
Edrophonium is administered. This
medication prevents the breakdown of
acetylcholine, which will allow more of the
neurotransmitter acetylcholine to be present
at the neuromuscular junction....hence
IMPROVING muscle strength IF myasthenia
gravis is present. Therefore, if a patient with
MG is given this medication they will have
improved muscle strength.
5. You're preparing to help the neurologist
with conducting a Tensilon test. Which
antidote will you have on hand in case of an
emergency?
A. Atropine
B. Protamine sulfate
C. Narcan
D. Leucovorin
The answer is A. Atropine will help reverse
the effects of the drug given during a
Tensilon test, which is Edrophonium, in
case an emergency arises. Edrophonium is
a short-acting cholinergic drug, while
atropine is an anticholinergic.
6. Which patient below is MOST at risk for
developing a cholinergic crisis?
A. A patient with myasthenia gravis is who
is not receiving sufficient amounts of their
anticholinesterase medication.
B. A patient with myasthenia gravis who
reports not taking the medication
Pyridostigmine for 2 weeks.
C. A patient with myasthenia gravis who is
experiencing a respiratory infection and
recently had left hip surgery.
D. A patient with myasthenia gravis who
reports taking too much of their
anticholinesterase medication.
The answer is D. Remember patients who
experience a cholinergic crisis are most
likely to because they’ve received too much
of their anticholinesterase medications
(example Pyridostigmine). However, on the
other hand, patients who have received
insufficient amount of their
anticholinesterase medication or have
experienced an illness/stress/surgery are
most likely to experience a myasthenia
crisis. Both conditions will lead to muscle
weakness and respiratory failure but from
different causes, which is why a Tensilon
test is used to help differentiate between the
two conditions.
7. Which meal option would be the most
appropriate for a patient with myasthenia
gravis?
A. Roasted potatoes and cubed steak
B. Hamburger with baked fries
C. Clam chowder with mashed potatoes
D. Fresh veggie tray with sliced cheese
cubes
The answer is C. Patients with MG have
weak muscles and this can include the
muscles that are used for chewing and
swallowing. The patient should choose meal
options that require the least amount of
chewing and that are easy to swallow.
Option C is a thick type of soup and the
mashed potatoes are soft....both are very
easy to eat and swallow compared to the
other options.
8. Select all the signs and symptoms below
that can present in myasthenia gravis:
A. Respiratory failure
B. Increased salivation
C. Diplopia
D. Ptosis
E. Slurred speech
F. Restlessness
G. Mask-like appearance of looking sleepy
H. Difficulty swallowing
The answers are A, C, D, E, F (restlessness
from hypoxia, which is experienced with
respiratory failure), G, and H.
9. You're providing teaching to a group of
patients with myasthenia gravis. Which of
the following is not a treatment option for
this condition?
A. Plasmapheresis
B. Cholinesterase medications
C. Thymectomy
D. Corticosteroids
The answer is B. These medications are not
used to treat MG, but ANTIcholinesterase
medications (like Pyridostigmine) are used
to treat this condition.
10. You're a home health nurse providing
care to a patient with myasthenia gravis.
Today you plan on helping the patient with
bathing and exercising. When would be the
best time to visit the patient to help these
tasks?
A. Mid-afternoon
B. Morning
C. Evening
D. Before bedtime
The answer is B. Patients with MG tend to
have the best muscle strength in the
morning after sleeping or resting rather than
at the end of the day....the muscles are tired
from being used and the muscle become
weaker as the day progresses etc.
Therefore any rigorous activities are best
performed in the morning or after the patient
has rested.

Cholinergic Crisis vs Myasthenic Crisis

{acetylcholine} junction by ACh
{acetylcholine}
● Key player:
○ Neuromuscular Junction Can lead to severe Overdrive in
■ Nicotinic muscle weakness and cholinergic
respiratory failure response, severe
Acetylcholine
muscle weakness
Receptors and respiratory
■ Function of Muscle failure
Specific Kinase
■ Acetylcholine Cause: Cause:
■ Immune system
Insufficiency Too much
● Produces anticholinesterase anticholinesterase
antibodies medication or medication
against respiratory infection,
receptors stress and acute It stops the
● Thymus gland exacerbation breakdown of ACh
mare at the
junction
Myasthenic Crisis Cholinergic Crisis
Great for MG
Happens due to low to Happens due to treat,emt but too
no stimulation at the excessive much cholinergic
neuromuscular stimulation at the
junction by ACh neuromuscular Signs and Symptoms: Signs and
 Symptoms:
● Dilated pupils Go Here for More Quizzes
● Increased Similar to “Rest
Heart rate and and digest” Your Answers & what you got Right &
BP Wrong:
● No cough and ● GI:
gag vomiting, 1. __________________ happens due to
● aspiration / no diarrhea,
excessive stimulation of the receptors at the
swallowing cramping
reflex ● Pupil neuromuscular junction by acetylcholine,
● Incontinence constriction which eventually leads to muscle weakness
bowel and ● Increase and respiratory failure.
bladder salivation A. Myasthenic crisis
and tears B. Cholinergic crisis
● Increase The answer is B.
respiratory
secretions
● Muscle
fasciculatio 2. _________________ happens due to
n minimal to no stimulation of the receptors at
“twitching” the neuromuscular junction site by
due to acetylcholine because there is damage to
constantly
the receptor sites, which leads to muscle
stimulation
● Decrease weakness and respiratory failure.
HR and BP A. Myasthenic crisis
B. Cholinergic crisis
Tensilon test: Tensilon Test: The answer is A.

● Medication ● Medication
Edrophonium= Edrophoniu
Anticholinester m=Anticholi 3. A patient is experiencing unexplained
ase nesterase muscle weakness and respiratory failure.
Medication Medication The neurologist conducts a Tensilon test to
Adds More ACh at the Adding more ACh differentiate between myasthenic crisis or
junction at the junction- cholinergic crisis. During the test the patient
experiences improved muscle strength.
Improvement of Worsening of
Based on this finding the patient has:
signs and symptoms signs and
symptoms A. Myasthenic Crisis
Positive test result B. Cholinergic Crisis
Negative test C. Neither
Treatment per MD result The answer is A. During a Tensilon test the
Order medication Edrophonium is given, which is
Anticholinesterase Treatment: an cholinesterase medication. This will
Antidote Atropine
increase the availability of acetylcholine at
hold further dose
the neuromuscular junction. If the patient
had a cholinergic crisis the problem is not
our Grade: D with the availability of acetylcholine, but
Percentage of What you Got Right: 67
because there is TOO MUCH of it at the
receptor site. Therefore, during this test the
patient would experience worsening of
symptoms NOT improvement.
4. You're examining a patient’s health
history and find that the patient experienced
a cholinergic crisis last year. As the nurse
you know that the most common cause of a
cholinergic crisis is?
A. Over usage of adrenergic blocker
medications
B. Stress
C. Respiratory infections
D. Overmedication of an anticholinesterase
medication
The answer is D. The most common cause
of a cholinergic crisis is overmedication of
an anticholinesterase medication. However,
on the other hand, the cause of a
myasthenic crisis is NOT enough of an
anticholinesterase medication or having a
respiratory infection or experiencing stress
of some type.
5. While assisting with a Tensilon test you
will have what antidote on hand?
A. Narcan
B. Atropine
C. Flumazenil
D. Glucagon
The answer is B. Atropine is the antidote for
Edrophonium, which is given during a
Tensilon test.
6. Select all the signs and symptoms
associated with a myasthenic crisis:
A. Pupil dilation
B. Muscle fasciculation
C. Miosis
D. Bowel and bladder incontinence
E. Negative gag or cough reflex
F. Respiratory failure
G. Bradycardia
The answers are A, D, E, and F.
7. During a Tensilon test the patient has
worsening of muscle weakness. The nurse
anticipates that the physician will give the
following order?
A. Administer Atropine along with an
anticholinesterase medication.
B. Administer Atropine and hold any further
doses of Pyridostigmine.
C. Administer Pyridostigmine and hold
Atropine.
D. Administer Edrophonium along with
Atropine.
The answer is B. If a patient experiences
worsening of muscle weakness during a
Tensilon test the patient has cholinergic
crisis. Therefore, the nurse could anticipate
that the physician will order Atropine (to
reverse the signs and symptoms...because
remember this drug is the antidote for
Edrophonium which is given during the test)
and to HOLD any further doses of
Pyridostigmine (this is an anticholinesterase
drug).
8. Select all the signs and symptoms
associated with cholinergic crisis:
A. Miosis
B. Dry mouth
C. Blurred vision
D. Constipation
E. Muscle fasciculation
F. Diarrhea and abdominal cramping
G. Respiratory failure
The answers are A, C, E, F, and G.
9. You're patient is recovering from a
myasthenic crisis and you are providing
education to the patient about the causes of
this condition. Which statement by the
patient demonstrates they understood the
teaching about how to prevent this
condition?
A. "I will make sure I don't take too much of
my anticholinesterase medication because it
can lead to this condition."
B. "I will avoid milk products while taking
Pyridostigmine because it increases the
chances of toxicity."
C. "I will avoid taking over-the-counter
supplements that contain aconite."
D. "I will avoid people who are sick with
respiratory infections and be sure not to
miss my scheduled doses of
Pyridostigmine."
The answer is D. Myasthenic crisis is
caused by not enough anticholinesterase
medication (pyridostigmine) or respiratory
infection/stress etc. The other options are
NOT causes of this condition.
PARKINSON'S DISEASED SYMPTOMS
DEFINITION:
● Its is a neurological disease that
affects the movement
● Dopaminergic Neurons DIE in
substantia nigra
○ Location of Substantia Nigra
○ This area is part of the Basal
ganglia which is a part of part
of the MidBrain that overall
plays a huge role in our
movement
● The substantia Nigra is black
○ Dopaminergic Neurons is the
part of the brain called
Substantia Nigra has started
to die
■ They release
Dopamine
{neurotransmitter}
● Leading to: Less Dopamine
○ Dopamine provides us an
accuracy with MOVEMENT
● The receptors are find and waiting
for the Dopamine to come

RISK FACTORS
● Tends of Affects Older adults 60+
● Cause is Unknown
ANATOMY
● Dopamine provides us an
accuracy with
● MOVEMENTBalance Between
○ ACh {Excitatory}
■ This causes
cholinergic activity
○ Dopamine {Inhibitory}
What Happen when Dopamine is Less
● There is an imbalances between
ACh and Dopamine
○ Causing Overstimulation of
neurons ACh to produce a
cholinergic action:
Tremors, Rigidity, etc
Medication involves:
● Administration of Anticholinergic
Medication
○ Younger people are
common users of this
medication
PATHOPHYSIOLOGY
● "cogwheel" rigidity ), is
SIGNS AND SYMPTOMS:
● Subtle at 1st but it may VARY
● But as time goes on
○ May worsen-they will realize
the problems in movement
○ It may affect one side of the
extremities and progresses
● Tremors at Rest:
○ Most common
○ It involves Hands, legs, lips,
tongue
○ *Pill-Rolling*-tremors of the
finger and hand
■ Improves with
purposeful movement
● Stiffness of the extremities
○ Arms Don’t swing with gait
● Akinesia
○ Lose the ability to do
movement voluntarily
○ Example when they’re
walking they tend to freeze
up
○ No voluntary movement of
Muscle
■ Freeze up
● Shuffling of gait
○ They won’t be able to pick up
their feel very well
● Posture
○ Forward bent
● Cogwheel Rigidity
○ muscular rigidity in which
passive movement of the
limbs (as during a physical
examination) elicits ratchet-
like start-and stop
movements through the
range of motion of a joint (as
of the elbow) and that occurs
especially in individuals
affected with Parkinson's
disease The third major sign,
rigidity (sometimes called
peculiar to Parkinson's
○ The hands will just jerk back
as you move them
● Bradykinesia:
○ Movement is Slow
○ Swallowing issue: drooling
○ Expressionless face “mask
like”
 ○ Chewing issue ■ Take up to 3 weeks to
○ Speech is slowed and notice decrease signs
slurred and symptoms
● Compensation for that ■ Body fluids turn dark
○ Coordination problems- color
steap to compensate ■ Long term use “weak
● Non Motor off” before next dose
○ Loss of smell ● COMT
○ Constipation inhibitors:
○ Depression Entacapone
“Comtan”
■ Entacopanoe
● Not be taken
with MAOIs
■ NO High vitamin B6
can decrease the
effects
■ Not taking food with
HIGH protein
● They compete
in the small
LABORATORY AND DIAGNOSTIC intestine
TESTING: ● Ropinirole “Requip”
● ○ Stimulates dopamine
TREATMENT receptors to increase
● There is NO CURE improvement
● But medication can be given to ○ Side Effects:
decrease the signs and symptoms ■ Drowsiness
MEDICATION ○ They might abruptly sleep
● Carbidopa with Levodopa ● Amantadine:
“sinemet” ○ Antiviral in treatment of
○ Adds more dopamine to influenza A
brain ○ Stimulates dopamine in CNS
○ Carbidopa: prevents ● Anticholinergic
levodopa from breaking ○ Benztropine “Cogentin”
down in the blood more ○ Blocks ACh
enters in the brain and turn ■ Decrease rigidity
into dopamine ■ Decrease salivation
○ Side Effects ■ Decrease signs and
■ Nausea and symptoms
involuntary movement ○ Not for glaucoma patient
○ Patient education: ○ Don't Abruptly quit
○ NO ETOH
 ○ They will experience Dry
mouth
● MAO inhibitors Type B
● Rasagiline “Azilect”
● Increase dopamine by
stopping MAO activity
● NO FOODS with Tyramine
○ Aged cheese
○ Smoked/cured meats
○ Fermented food
○ Beers
● COMT “Catechol-O-
methyltransferase”
○ Used with Sinemet
○ It can decrease wearing off
phase
○ Block COMT enzyme that will
breakdown Levodopa in the
blood to make it last longer
NURSING INTERVENTION
Areas of Intervention:
● Safety
○ Cogwheel
○ Freeze Up
● Psychosocial
○ Depression
○ Loss of Self Care
○ Loss of autonomy
● Medication side effects
○ Mediation
● Digestion and nutrition
○ Constipation
● Education
Safety:
● Assistive Devices
○ Hand rail
○ Cane, walkers,
○ Keeping rubs off the floor
○ Pets must be trained
● Balance: More slowly with position
changes
○ They can use Rubber tip
cane single point
● Shoes ware: Low heel shoes without
rubber sole
○ The rubber sole can stick to
the floor and end up tripping
Education: Freeze up
● When they are normally walking
and suddenly their foot is stuck
on the ground, can lead to
increase risk for fall
○ Change Direction of
movement
■ As you move forward
you’re foot suddenly
stops
■ Try to move to the
side
○ Laser patient cane or walker
○ Ass they walk and Freeze up
happen
■ They must
consciously make an
effort to Lift legs off
the floor walking like
their marching
○ Don’t try to push through it
Psychosocial Part
● Autonomy problem
○ Make sure that you allow
them to take care of
themselves-like feeding,
dressing and etc
● Special cookware and utensils
● Dressings: Shirt without buttons and
zipper
○ Velcros
● Shoes without tie
○ Velcros shoes
● Support groups
● Exercise
● Don’t try to stress them up
○ Hurrying them and etc
 ○ This can increase Signs and
symptoms and might
exacerbate symptoms
Digestion/Nutrition
● Soft easy to chew foods
● Speech language Pathologist
● High fiber foods and 2 liter of water
● Stool softer
● Always assess digestion
● Watch protein rich foods with
medication
○ They will compete with the
medications
Parkinson's Disease
NCLEX Questions
This quiz will test your knowledge on
Parkinson's Disease in preparation for
the NCLEX exam.
1. As the nurse you know that
Parkinson's Disease tends to
affect the _____________ of the
midbrain, which leads to the
depletion of the
neurotransmitter
________________.*
○ A. red nucleus, acetylcholine
○ B. leminisci, norepinephrine
○ C. substantia nigra, dopamine
○ D. tectum nigra, dopamine
2. True or False: Parkinson's
Disease most commonly
affects patients in young
adulthood, and there is
currently no cure for the
disease.*
○ A. True
○ B. False
3. You're caring for a patient
with Parkinson's Disease that
has tremors. Select the option
that is INCORRECT about
tremors experienced in this
disease:*
○ A. The tremors are most likely
to occur with purposeful
movements.
○ B. A common term used to
describe the tremors in the
hands and fingers is called
"pill-rolling".
○ C. Tremors are one of the
most common signs and
symptoms in Parkinson's
Disease.
○ D. Tremors in this disease can
occur in the hands, fingers,
arms, legs and even the lips
and tongue.
4. While assessing a patient
with Parkinson's Disease, you
note the patient's arms slightly
jerk as you passively move
them toward the patient's
body. This is known as:*
○ A. Lead Pipe Rigidity
○ B. Cogwheel Rigidity
○ C. Pronate Rigidity
○ D. Flexor Rigidity
5. A patient with Parkinson's
Disease has slow movements
that affects their swallowing,
facial expressions, and ability
to coordinate movements. As
the nurse you will document
the patient has:*
○ A. Akinesia
○ B. "Freeze up" tremors
○ C. Bradykinesia
○ D. Pill-rolling
6. You're providing free
education to a local community
group about the signs and
symptoms of Parkinson's
Disease. Select all the signs
and symptoms a patient could
experience with this disease:*
○ A. Increased Salivation
○ B. Loss of smell
○ C. Constipation
○ D. Tremors with purposeful
movement
○ E. Shuffling of gait
○ F. Freezing of extremities
○ G. Euphoria
○ H. Coordination issues
7. You're providing diet
education to a patient with
Parkinson's Disease. Which
statement below demonstrates
the patient understood your
teaching? Select all that
apply:*
○ A. "I will limit foods high in
fiber like fruits and vegetables
in my diet."
○ B. "I will be sure to drink 2
Liter of fluid per day."
○ C. "It is very common for me
to experience diarrhea with
this disease."
○ D. "I will avoid taking
Carbidopa/Levodopa with a
protein rich meal."
8. A patient with Parkinson
Disease is experiencing weight
loss due to difficulty chewing
and swallowing. Which meal
option below is the best for
this patient?*
○ A. Scrambled eggs with a side
of cottage cheese
○ B. Grilled cheese with apple
slices
○ C. Baked chicken with bacon
slices
○ D. Tacos with refried beans
9. As the home health nurse
you are helping a patient with
Parkinson's Disease get
dressed. What item gathered
by the patient to wear should
NOT be worn?*
○ A. Velcro pants
○ B. Pull over sweatshirt
○ C. Non-slip socks
○ D. Rubber sole shoes
10. A spouse of a husband who
has Parkinson's Disease
explains to you that her
husband experiences episodes
while walking where he freezes
and can't move. She asks what
can be done to help with these
types of episodes to prevent
injury. Select all the options
that are correct:*
○ A. Have the husband try to
change direction of movement
by moving in the opposite
direction when the freeze ups
occur.
○ B. Use a cane with a laser
point while walking.
○ C. Have the husband try to
push through the freeze ups.
○ D. Encourage the husband to
consciously lift the legs while
walking (as with marching).
11. A patient is prescribed to
take Carbidopa/Levodopa
(Sinemet). As the nurse you
know that which statement is
incorrect about this
medication:*
○ A. It can take up to 3 weeks
for the patient to notice a
decrease in signs and
symptoms when beginning
treatment with this medication.
 ○ B. Body fluids can turn a dark
color and stain clothes.
○ C. This medication is most
commonly prescribed with a
vitamin B6 supplement.
○ D. Carbidopa helps to prevent
Levodopa from being broken
down in the blood before it
enters the brain. Hence,
levodopa is able to enter the
brain.
12. You're patient with
Parkinson's Disease has been
taking Carbidopa/Levodopa for
several years. The patient
reports that his signs and
symptoms actually become
worse before the next dose of
medication is due. As the
nurse, you know what
medication can be prescribed
with this medication to help
decrease this for happening?*
○ A. Anticholinergic
(Benztropine)
○ B. Dopamine agonists
(Ropinirole)
○ C. COMT Inhibitor
(Entacapone)
○ D: Beta blockers (Metoprolol)
13. While providing discharge
teaching to a patient
prescribed Ropinirole (Requip),
you make it priority to teach
AUTONOMIC DYSREFLEXIA
{HYPERREFLEXIA}
DEFINITION:
the patient about what side
effect?*
○ A. Drowsiness
○ B. Dry mouth
○ C. Coughing
○ D. Dark sweat or saliva
14. A physician orders a
patient to take Benztropine
(Cogentin). The patient has
never taken this medication
before and is due to take the
first dose at 1000. What
statement by the patient
requires you to hold the dose
and notify the physician?*
○ A. "I forgot to tell the doctor I
take eye drops for my
glaucoma."
○ B. "I had a PET scan last
week."
○ C. "I take aspirin once day."
○ D. "My hands are experiencing
tremors at rest."
15. A patient is taking
Rasagiline "Azilect" for
treatment of Parkinson's
Disease. What foods do the
patient want to limit in their
diet? Select all that apply:*
○ A. Liver
○ B. Aged Cheese
○ C. Sweetbread
○ D. Beer
○ E. Fermented foods
○ F. Shellfish
● Exaggerated reflex response by the
autonomic nervous system due to
an irritating stimulus BELOW the site
of spinal injury.
 ○ It affects the SYMPATHETIC 3 BIG B’S
NERVOUS SYSTEM “Fight or
Flight” system
○ Result of SEVERE ● BLADDER* {MOST COMMON}
HYPERTENSION ○ Urinary retention
● If this is uncontrolled ○ Full and distended bladder
○ It can lead to STROKE, ● BOWEL
SEIZURE AND CAN BE ○ Harden stool
FATAL ○ Impaction
● IT IS A MEDICAL EMERGENCY ● BREAKDOWN OF SKIN
○ Preventing AD ○ Pressure injury
○ Detecting AD ○ Ingrown toenail
○ ACTon AD appropriately

RISK FACTOR

● All patient that has a spinal cord

injury are high risk of developing
Autonomic Dysreflexia
○ All injury T6 high

ANATOMY

Role of AUTONOMIC NERVOUS SYSTEM: it

controls the Sympathetic and
Parasympathetic Nervous system

CAUSE:

● All patient that has a spinal cord

injury are high risk of developing Sympathetic Parasympathetic
Autonomic Dysreflexia Nervous System Nervous System
○ All injury T6 high “Fight or Flight” “Rest and Digest”
● They recieve that irritating stimulus ● Vasoconstriction ● Vasodilation
they can trigger that reflex response ● Sweat glands ● Decrease HR
by the sympathetic nervous response stimulation ● Salivation
● Bronchodilation ● Bronchoconstricti
● Increase HR on
● Dilates Pupils ● Constrict Pupils
* These system works beautifully together but
they oppose each other to check balance
between each other BUT NUMBER ONE
REQUIREMENT: They must have a good
spinal cord structure and functioning
PATHOPHYSIOLOGY
● What is that requirement?
○ They must have that irritating
stimulus and destroyed or
injured T6 and above spinal
cord
IRRITATING STIMULUS
1. Irritating Bladder
a. Its ascending irritating stimulus
to our body
b. Causing our nerves to send an
impulse that something is
wrong
c. However since we have an
injured Spinal Cord T6 and
Higher the stimulus can be
blong creating no response
2. It will create Exaggerated
Sympathetic Reflex Response
a. This is excessive and
Exaggerated
3. Vasoconstriction
a. Vasoconstriction and
narrowing of vessel BELOW
THE INJURED SPINE
b. Increase blood pressure
c. It's going to cause a veryPale
cool clammy
i. Because we are
constricting vessel to
the non-vital organs
4. The body will sense it specifically
Baroreceptors Sense
a. It doesn't know what’s going
on Or if there is an existing
issue below T6
b. So the Increase BP will cause
the Baroreceptors to Stimulate
PARASYMPATHETIC
ACTIVITY
i. VASODILATION {
ii. Flushing
iii. Decrease HR less than
60
iv. Bradycardia
c. However these Baroreceptor
response really can’t bring
change the BP below T6
i. Instead it will cause
Vasodilation Up there
and vasoconstriction
Down there
5. The compensatory mechanism is NOT
effective due to vasoconstriction
Goal: Remove the irritating response and treat
patient appropriately
SIGNS AND SYMPTOMS:
 ● Nitropaste: Topical
administration
○ Do not administer if a patient
has taken
phosphodiesterase
inhibitors in the past 24
hours….. Sildenafil or
Tadalafil
○ Other medications:
Nifedipine {CCBs}

● Throbbing Headache
○ Due to increase blood
pressure
● Hypertension NURSING INTERVENTION
○ Systolic 20-40 mmHg higher
than BASELINE
○ Example 106/78 to 149/92
● P-prevention
● Flushing
○ Think of the 3 Big B’s
○ Above T6 or Above injury ■ Bladder
○ Vasodilation above the injury ■ Bowel
● Pale, cool, clammy ■ Breakdown of Skin
○ Below the T6 or sight of Injury ○ Irritating response must be
eliminated
○ Vasoconstriction below the
injury
● Bradycardia
○ Below 60
● Sweating
● Dilated pupils Bladder {most common cause}
● Stuffy nose
● Anxiety
● Goosebumps ● Keep Bladder EMPTY
● Assess I and O’s
● Routine Bladder Scans
● Prevent UTIs
MEDICAL ● Foley draining
MANAGEMENTS/SURGERY/MEDICATION ○ Determine if its kink or
blocked
● Use anesthetic jelly if need
catheterized

Medication to help treat AD

Bowel
● Check for impaction
● down on those leg and
● Assess bowel sounds
● Palpate for distention
● Assess last Bowel movement
● For impacted always use
○ Use anesthetic jelly, prior to
stool removal
● Position the patient at 90 degrees
with legs lowered
○ This will allow gravity to pool
decrease the blood pressure
● Assess BP every 2-5 minutes
● Removed Binding devices or
clothing
● Investigate 3 Big B’s and correct it
● Start w/ bladder, then proceed to
bowel, and the skin

LAST RESORT

Breakdown of the skin

Medication to help treat AD
● Remove binding devices
● Reposition every Hours ● Nitropaste: Topical
● Asses skin regularly administration
● Protect from injury ○ Do not administer if a patient
has taken
phosphodiesterase
inhibitors in the past 24
hours….. Sildenafil or
Tadalafil
○ Other medications:
Nifedipine {CCBs}
● D-detection and A-action
○ Patient w/ T6 Or higher are at
the HIGHEST
○ Always assess blood
Your Grade: A
pressure and monitor for:
■ Any elevation of a
systolic pressure 20-
40 mmHg more than
Percentage of What you Got Right: 91
baseline
■ If patient reports
HEADACHE, always
check BP immediately
■ Assess for signs and
symptoms of AD
■ What to do if signs and
symptoms present?
Go Here for More Quizzes
● A-action

It is a MEDICAL EMERGENCY
● Call a rapid response and get
help
Your Answers & what you got Right &
Wrong:
1. Which patient below is at MOST risk for
developing a condition called autonomic
dysreflexia?
A. A 24-year-old male patient with a
traumatic brain injury.
B. A 15-year-old female patient with a
spinal cord injury at C7.
C. A 35-year-old male patient with a spinal
cord injury at L6.
D. A 42-year-old male patient recovering
from a hemorrhagic stroke.
The answer is B. Patients who are at MOST
risk for developing autonomic dysreflexia
are patients who've experienced a spinal
cord injury at T6 or higher...this includes
C7. L6 is below T6, and traumatic brain
injury and hemorrhagic stroke does not
increase a patient risk of AD.
2. Your patient, who has a spinal cord
injury at T3, states they are experiencing a
throbbing headache. What is your NEXT
nursing action?
A. Perform a bladder scan
B. Perform a rectal digital examination
C. Assess the patient's blood pressure
D. Administer a PRN medication to
alleviate pain and provide a dark, calm
environment.
The answer is C. This is the nurse's NEXT
action. The patient is at risk for developing
autonomic dysreflexia because of their
spinal cord injury at T3 (remember patients
who have a SCI at T6 or higher are at
MOST risk). If a patient with this type of
injury states they have a headache, the
nurse should NEXT assess the patient's
blood pressure. If it is elevated, the nurse
would take measures to check the bladder
(a bladder issue is the most common
cause of AD), bowel, and skin for
breakdown.
3. You're performing a head-to-toe
assessment on a patient with a spinal cord
injury at T6. The patient is restless,
sweaty, and extremely flushed. You assess
the patient's blood pressure and heart rate.
The patient’s blood pressure is 140/98 and
heart rate is 52. You look at the patient's
chart and find that their baseline blood
pressure is 106/76 and heart rate is 72.
What action should the nurse take FIRST?
A. Reassess the patient’s blood pressure.
B. Check the patient's blood glucose.
C. Position the patient at 90 degrees and
lower the legs.
D. Provide cooling blankets for the patient.
The answer is C. Based on the patient
findings and how the patient has a spinal
cord injury at T6, they are experiencing
autonomic dysreflexia. Patients with this
condition may have a blood pressure that
is 20-40 mmHg higher than their baseline
and may experience bradycardia (heart
rate less than 60). The FIRST action the
nurse should take when AD is suspected is
to position the patient at 90 degree (high
Fowler's) and lower the legs. This will
allow gravity to cause the blood to pool in
the lower extremities and help decrease
the blood pressure. Then the nurse should
try to find the cause of the autonomic
dysreflexia, which could be a full bladder,
impacted bowel, or skin break down.
4. You’re providing an in-service to a
group of new nurse graduates on the
causes of autonomic dysreflexia. Select all
the most common causes you will discuss
during the in-service:
A. Hypoglycemia
B. Distended bladder
C. Sacral pressure injury
D. Fecal impaction
E. Urinary tract infection
The answers are B, C, D, and E. Anything
that can cause an irritating stimulus below
the site of the spinal injury (T6 or higher)
can lead to autonomic dysreflexia, which
causes an exaggerated sympathetic reflex
response and the parasympathetic system
is unable to oppose it. This will lead to
severe hypertension. The most common
cause of AD is a bladder issue
(full/distended bladder, urinary tract
infection etc). Other common causes are
due to a bowel issue like fecal impaction or
skin break down (pressure injury/ulcer,
cut, infection etc.).

5. After taking all the necessary steps for a
patient who has developed autonomic
dysreflexia, what should the nurse assess
FIRST as a possible cause of this
condition?
A. Skin break down
B. Blood glucose
C. Possible bladder irritant
D. Last bowel movement
The answer is C. A bladder issue is usually
the most common cause of AD. If this isn’t
the issue the nurse should assess the
bowel and then the skin for break down.
6. The physician orders Nitropaste for a
patient who has developed autonomic
dysreflexia. Which finding would require
the nurse to hold the ordered dose of
Nitropaste and notify the physician?
A. The patient’s blood pressure is 130/80.
B. The patient reports a throbbing
headache.
C. The patient’s lower extremities are pale
and cool.
D. The patient states they took Sildenafil
12 hours ago.
The answer is D. A patient should not
receive a dose of Nitropaste if they have
taken a phosphodiesterase inhibitor within
the past 24 hours (Sildenafil or Tadalafil).
This will cause major vasodilation and
severe hypotension that will not respond
to medication. Another medication should
be used. All the other findings are
expected with autonomic dysreflexia.
7. A patient is receiving treatment for a
complete spinal cord injury at T4. As the
nurse you know to educate the patient on
the signs and symptoms of autonomic
dysreflexia What signs and symptoms will
you educate the patient about? Select all
that apply:

8. What is the BEST position for a patient

A. Headache experiencing autonomic dysreflexia?

B. Low blood glucose A. High Fowler's with legs lowered

C. Sweating B. Low Fowler's with legs lowered

D. Flushed below site of injury C. Semi-Fowler's with legs at heart level

E. Pale and cool above site of injury D. Prone

F. Hypertension The answer is A. The patient should be in

high Fowler's (90 degrees) with the legs
lowered. This will allow gravity to cause
G. Slow heart rate blood to pool in the lower extremities and
help decrease blood pressure.

H. Stuffy nose

The answers are A, C, F, G and H. All of

these are signs and symptoms of
autonomic dysreflexia. The patient will
have flushing above site of injury due to
vasodilation from parasympathetic 9. In autonomic dysreflexia, the nurse
activity, BUT will be pale and cool below would expect what finding below the site
site of injury due to vasoconstriction of the spinal cord injury?
occurring below the site of injury for the
sympathetic response reflex.
A. Flushed lower body

B. Pale and cool lower extremities

C. Low blood pressure
D. Absent reflexes
The answer is B. The lower extremities
would be cool and pale due to
vasconstriction caused by the exaggerated
reflex response of the sympathetic
nervous system from an irritating stimulus.
The sympathetic reflex can NOT be
unopposed by the parasympathetic
nervous system due to the spinal injury,
which is blocking the nerve impulse. The
areas found ABOVE the site of injury
would be flushed due to vasodilation from
parasympathetic stimulation.
10. Which statements are TRUE about
autonomic dysreflexia? Select all that
apply:
A. "Autonomic dysreflexia is an
exaggerated reflex response by the
parasympathetic nervous system that
results in severe hypertension due to a
spinal cord injury."
B. "Autonomic dysreflexia causes a slow
heart rate and severe hypertension."
C. "Autonomic dysreflexia is less likely to
occur in a patient who has experienced a
lumbar injury."
D. "The first-line of treatment for
autonomic dysreflexia is an
antihypertensive medication."
The answers are B and C. Option A is
false, it should say: Autonomic dysreflexia
is an exaggerated reflex response by the
SYMPATHETIC (NOT parasympathetic)
nervous system that results in severe
hypertension due to a spinal cord injury.
Option D is false because medications are
used only if the blood pressure is not
decreasing or the cause cannot be
determined.
11. The nurse is about to assess for bowel
impaction in a patient who has developed
autonomic dysreflexia. The nurse makes it
priority to?
A. Avoid using lubricants
B. Stimulate the bowel with rectal
manipulation
C. Slowly administer a saline solution prior
to assessment
D. Instill an anesthetic jelly prior to
assessment
The answer is D. To avoid increasing
autonomic dysreflexia symptoms by
increasing the sympathetic reflex due to an
irritating stimulus, the nurse should instill
an anesthetic jelly before assessing the
rectum for hardened stool. This is also
important prior to catheterization to check
the bladder for urine.

ANATOMY OF CRANIAL NERVES: 12 PAIR CRANIAL NERVE FOUND IN

HUMAN BRAIN

MID BRAIN ORIGIN

● SENSORY
○ I, II, VIII {1,2,8
I. OLFACTORY NERVE {SENSORY} ● MOTOR
II. OPTIC NERVE {sENSORY} ○ III, IV, VI, XI, XII {3,4,6,11,12}
III. OCULOMOTOR {MOTOR} ● MIXED
IV. TROCHLEAR {MOTOR} ○ V, VII, IX, X {5,7,9,10}.

PONS ORIGIN FACTS:

V. TRIGEMINAL {MIX} ● Smallest Cranial Nerve

VI. ABDUCENS {MOTOR} ○ 4th cranial nerve i.e. trochlear
VII. FACIAL {MIX} nerve
VIII. AUDITORY/ACOUSTIC/VESTIBULO ● Shortest Cranial nerve
COCHLEAR {SENSORY} ○ 1st cranial nerve i.e. Olfactory
nerve
● Largest Cranial nerve
○ 5th Trigeminal Nerve
MEDULLA OBLONGATA ● Longest Cranial Nerve
○ 10th vagus nerve
● Highest number of branches
IX. GLOSSOPHARYNGEAL {MIX} ○ 10th Vagus nerve
X. VAGUS {MIX} ● Dentist Nerve
XI. ACCESSORY SPINAL {MOTOR} ○ Trigeminal {mandibular}
XII. HYPOGLOSSAL {MOTOR}. ● Cranial Nerve Arise/Insertion
○ From brain to stem
● Only Nerve that arise from Dorsal
aspect of brain stem is
 ○ Trochlear Cranial nerve
● Most commonly cranial nerves Origin Nasal-
involved/affected in diabetes {Diabetic Mucosa
Neuropathy} Insertion Midbrain to
○ 3th- Most affected temporal
○ 4th
○ 6th Function Smell
● Most commonly cranial nerve
involved/affected in shingles {caused II- Optic
Nerves
by Herpes Zosters} Nature Sensory
○ 5th Nerve
{Afferent}
○ 7th
○ 9th Origin Retina
○ 10th
○ 7th Insertion Lateral
Geniculate
○ Affected mostly {called as
Nuclei of
Ramsay Hunt disease} thalamus to
○ Most Common SIgns of Occipital
Shingles area of
■ Tingling Brain
■ Pain
Function Vision
■ Rashes
■ Numbness
III-
Oculomotor
Nature Motor
Nerves
{efferent}

Origin Midbrain

Insertion Muscles of the

● Herpes Zosters most commonly {56 eyeball
percent} affecting thoracic spinal {superior
rectus, Medial
nerve ganglia rectus, inferior
rectus, inferior
oblique}

Function * Eyeball
movement
* Pupil
Cranial Information Movement
Nerve {iris}
*{compression
I-Olfactory of III nerve
Nerves causes
Nature Sensory unilateral pupil
Nerve dilation}
{afferent} *Upper eyelid
 Movement mucosa.
{levator * Muscle of
palpebrae} mastication
and sense of
IV-Trochlear lower jaw,
Nerve lower lips,
Nature Motor {efferent} chin, teeth,
hums
Origin Midbrain

Insertion Muscle of
eyeball
{superior
oblique
muscle}

Function * Eyeball
Movement
* Outward VI-Abducens
downward Nerves
Nature Motor
movement {efferent}

V-Trigeminal Origin PONS

Nerves
Nature Mix Insertion Muscle of
a. Ophthalmic eyeballs
Largest
{S} {Lateral rectus
Nerve
b.Maxillary {S} muscles}
C. Mandibular
{M} Function * Eyeball
movement
Origin PONS * Outward
movement
Insertion Around the
eyes, facem
nose, lips, VII- Facial
maxilla, Nerves
Nature Mix
mandible a. Sensory
Facial
Function * Sense from B. Motor Facial
upper eye lid,
eye brow, Origin PONS
forehead,
anterior part Insertion Face skin and
of scalp Facial Muscle
* Sense from
upper lip, Function * Anterior 2/3rd
upper jaw, of tongue
gums, teeth, {taste}
hard and soft * Touch,
palate, nose, temperature of
skin, oral facial area
 * Facial B. Motor GP-
Expression movement of
muscle of
Paralysis of swallowing
7th cranial
nerves X- VAGUS
causes NERVE
BELL’S Nature Mix
FACIAL Longest
PALSY a. Sensory
nerve
Vagus
B. Motor Vagus
VIII- Has many
VESTIBULO branching Origin Medulla
Nature Sensory Nerve
COCHLEAR nerve Oblongata
{afferent}
NERVE
a. Vestibular
branch-sensory
balance Insertion Trachea,
b. Cochlear Heart,
branch-sensory Digestive tract
hearing {Parasympathe
tic branch}
Origin Inner ear
Function * Pain
Insertio PONS sensation from
n visceral organs
{Heart,
Functio * Vestibular digestive,
n Branch-sensory respiratory,
balance kidney}
* Cochlear
branch- sensory *
hearing Parasympathet
ic supply to
IX- visceral organs
GLOSSOPH
Nature Mix
ARYNGEAL Vagal Maneuver:
a. Sensory GP
NERVES ● Is an act that used to
B. Motor GP
slow down the heart
Origin Medulla rate {Sinus
Oblongata tachycardia} by
stimulating the
Insertion Posterior ⅓ Vagus nerves
part of the ○ Straining
tongue {taste} ○ Bearing
down
Muscle of
swallowing
XI-
Function a. Sensory GP- ACCESSOR
Nature Motor
taste Y SPINAL
{efferent}
NERVES
 Origin Medulla
Oblingate

Insertion Accessory
Muscle of
Respiration
{Sternocleido
mastoid SCM,
scalene,
trapezius}

Function Neck
movement

XII- ● Also called “

Hypoglossal ○ Tic Douloureux”,
Nature Motor
Nerves ○ “Prosoplagia” or
{efferent}
○ “Forthergill’s disease”
Origin Medulla ● It involve 5th cranial Nerve
Oblongata compression that causes sharp
intense, pin-like pain on face
Insertion Muscles of {EPISODIC PAIN}
tongue ● It is sudden, severe facial pain
● It is a sharp shooting pain or like
Function Tongue having an electric shock in the jaw,
movement teeth, or gums
during chewing ● It usually last from a few seconds to
and speech about 2 minutes
● The attacks stop as suddenly as they
start

LINK REFLEX {CORNEAL REFLEX}

Sleep can provide some relief from the pain
so patient sleep most of the time

● Loss of blink indicate dysfunction of

Naso-cillary branch of OPTHALMIC
TWO MAIN TYPES:
BRANCH OF TRIGEMINAL NERVE
{levator palpebrae muscle}
● It can be tested by cotton wisp if
patient is conscious or by a sterile
drop if patient is unconscious
○ Sterile drops of NS is safest
method
CRANIAL NERVE THAT SUPPLY TO
EYEBALL MUSCLES
● Typical Trigeminal Neuralgia
○ Episodes of severe sudden,
shock-like pain in one side of
the face
○ Last for seconds to a few
minutes
○ Groups of these episodes can
occur over a few hours
● Atypical trigeminal neuralgia
 ○ It is a constant burning pain
that is less severe
○ Episodes may be triggered by
any touch to the face

CAUSES:

● Main Cause of trigeminal Neuralgia:

Blood vessel Compressing on the root
of the trigeminal nerve
● Pressure on the Trigeminal Nerve may
be cause vy
○ Tumor
○ Multiple sclerosis
○ Trauma
○ Stroke

Management:
● Paralysis/weakness of one side
face
○ Caused by damage of lower
● Carbamazepines {Drug of choice} motor neuron of 7th cranial
○ Reduce transmission of nerve {Facial nerve}
impulses ○ Bell’s palsy usually resolves
● Oxcarbazepine on its own within six months
● Nerve Blocks {local anesthetics} ○ Physiotherapy can help
● Radiofrequency/Rhizotomy prevent muscle permanently
○ Resection of nerve roots contracting
● Glycerol injection
○ Demyelinating nerve, effective
for 3 weeks
● Avoid Cold/Hold food and fluids

Characterized by:

BELL’S PALSY ○ Muscles weakness that

causes one half of the face to
droop

Cause:
 ● Unknown

NEURO
Risk Factors:

CNS PNS
● Diabetes
● Upper respiratory tract infection
● Some viruses Multiple Parkinso Myasthe Amyotro
○ Varicella zoster sclerosis n’s nia phic
○ Epstein Barr Virus Disease Gravis Lateral
○ Herpes zoster
Sclerosi
● Familial Inheritance
s (ALS)

SYMPTOMS:
PATHOPHYSIOLOGY OF CNS DISEASE:

● FLACCID FACIAL MUSCLES and CNS IS OUR CMP {Central Nervous

numbness System, Multiple Sclerosis, Parkinons}
○ Drooling and Dry eyes
● Drooping {ptosis}
○ On affected side MS=Myelin Sheath
○ Loss of ability to taste SPECIFIC SIGNS AND SYMPTOMS OF
MS:
● Numbness
Treatment: ● Cramping
● Muscle weakness

● Facial exercise
Parkinson’s Disease: decrease of amount
○ It is a self limiting disease of DOPE in the PARK
○ It starts to improve generally in ● Less Dopamine
14 days and recovers in 6-15 ● Dopamine Helps Regulates
week ○ BP {when patient gets to a
● Eye Moisturizer
○ Prevent eye dryness
CODE or HYPOTENSION-
● Mouth care and eye care DOPE release to
○ Priority of Nursing care Vasoconstriction}
● Corticosteroid ○ CNS and Ability to Move
○ prednisone ■ They Move slowly
■ Shuffling Gait
● Someone barely learning how to
park a car
○ They walk so slowly, they
Neurological Disorders: Parkinson's, MS, shuffling the feet
MG, ALS ○ Pill Rolling

PATHOPHYSIOLOGY OF CNS DISEASE:
PNS
● They are more on motor function
M.G= Disney Waltz Movie Show white
{Sleepy} was dedicated for his friend that
has Myasthenia Gravis
● A disease that inhibits you from a
producing a chemical called
Acetylcholine
○ Acetylcholine- help body and
neuron to contract at the
Myoneural Junction
○ If lacking it can cause severe
muscle weakness
● You have
○ Ptosis “drooping eyes”
○ Extremely fatigue
○ Severe muscle weakness
■ Dysphagia “fail to
swallow perfectly
■ Aspiration
Precaution, Airway
issue and
diaphragm issue
■ Not a progressive
disease
● Myasthenia Gravis: Gravity
○ Gravity pulling down your
eyelid
○ Making you very sleepy and
TIIIIIIIRRREDDD
○ Can get you dead within 5
years
● Motor Neurons will get Sclerotic
and can get Stiff
○ Motor Neurons: Grip, Push,
Pull, contract and still
○ You get a prisoner of the
body
■ Not dementia
■ No Loss of Sensation
■ No Irrationality
○ You’re just in bed but you
can’t just move
■ Very sad
● 3 D’s of ALS
○ Dysarthria- difficulty moving
○ Dysphagia-Difficulty
Swallowing
○ Drooling
● Can get you killed with a pneumatic
disease
○ Because even the lung
muscles that helps your lung
breath starts to fail
○ Mech vent is need

‘
ALS: Amyotrophic Lateral Sclerosis
(ALS).
● This is by far the worst neurological
disease you can get
○ Incurable
○ No remission