NEUROMUSCULAR

Acetylcholine
contract muscle cholinergic
- act as a neurotransmitter
- aid for muscle contraction
- hold to “receptor”
- cholinesterase:
a. destry acetylcholine
b. relax contracted muscle

Myasthenia Gravis
- means “muscle weakness”: usually found in afternoon
- means “Grave” (fatal)
- no muscle contraction
- with muscle relaxation weakness death
- Cause: unknown
- Theory: autoimmune thymus disorder

produce antibodies

attack receptors

decrease receptors
- S/Sx:
ptosis
diplopia: uncoordination of the eyes
blank facial expression
open mouth:
- action: close with your hand
dysphagia: inability to swallow
- WOF: airway obstruction
- complication: aspiration
- intervention:
a. flex the neck
b. give thick liquids (e.g. fruit shake)
shallow breathing: complications
a. pneumonia
b. atelectasis
c. respiratory arrest
d. respiratory acidosis: accumulation of oxygen
- Diagnostic test: Tensilon Test
- use of drug called Endrophonium Chloride:
a. given via IV
b. short-acting (up to 5mins.)
c. anticholinesterase
- DOC: anticholinesterase
a. increase acetylcholine
b. contract the muscle; increases strenght
- with cholinergic effect: increase secretion
- all ending in “stigmine”
a. Pyridostigmine
b. Neostigmine
- must give on time before eating in AM
- SE: GIT disturbances
- Management: give with snacks
- Management of thymus disorder:
1. Surgery: Thymectomy
 - Plasmapheresis: removal of antibodies
- effective: patient consume the entire meal (lumalakas na sya)
2. Immunosuppressant:
a. steroid
b. cyclosporine
- Management:
1. Avoid muscle relaxant:
a. Baclofen
b. Soma
c. Dantrolene
d. Flexeril
2. Avoid hot bath

Myasthenic Crisis Cholinergic Crisis

- under medication - over medication
- triggers infection - increase secretion, peristalsis & urine output
- (+) weakness - complication: aspiration (airway obstruction)
- Tensilon test: with improvement - Tensilon test: no improvement
- DOC: all “stigmine” - DOC: Atropine SO4 (anti-cholinergic)

Nervous System
Central Nervous System Peripheral Nervous System
- consist of brain & spinal cord - consist of cranial nerves and spinal nerves

Autonomic Nervous System

SNS PNS
(flight/ fight) (relax)

Brain:
- Cerebellum: balance & coordination
Lobes of the Brain:
1. Frontal: motor & cognition
2. Parietal: sensation & spatial
3. Occipital: vision
4. Temporal: hearing
Spinal Cord:
> C1-C7
a. C4: innervation of diaphragm
- injury needs mechanical ventilator
b. C5, C6, C7 & T1: innervation of arms
- damage: cannot write
> T1-T2
a. T2-T8: innervation of chest
b. T9-T12: innervation of abdomen
> Lumbar: legs
> Sacral: sex organ, bowel, bladder
Cranial Nerves:
Cranial Nerve Functions
Olfactory Nose
Optic Eyes
Occulomotor Eyes opening
Trochlear Eyes up
 Trigeminal Sensation of face
Motor of the mouth
Abducens Eyes gaze (R/L)
Peripheral movement
Facial Make faces
Acoustic Hearing & balance
Glossopharyngeal Swallowing
Vagus Cholinergic effect; decrease HR
Spinal accesory Movement of the shoulder
Hypoglossal Tongue movement

* O, O, O, To, Touch, And, Feel, A, Girl, Vagina, So, Heaven

SNS PNS
Blood Presure
Cardiac Contraction
Heart Rate
Glucose
dilation Bronchus constriction

* Beta Blocker: example of with PNS effect

* Myelin sheath: fast impulse conduction
* Saltatutory leap: faster impulse
- impulse jump on myelin sheath
* Demyelination: slow impulse conduction
a. CNS: Multiple Sclerosis
b. PNS: Guillain Barre Syndrome

Multiple Sclerosis
- dymelination of CNS; slower impulse in CNC
- cause: unknown
- theory: autoimmune
- DOC: Immunosuppresant
a. steroid
b. cyclosporine
- common: women 20-40 years old (young woman)
- characterized by remission & exacerbation
a. remission: no S/Sx
b. exacerbation: triggers
a. stress/ infection
b. humid
c. emotion/ fatigue
- S/Sx:
1. Brain
a. visual disturbances (CN1)
- early sign of exacerbaton: diplopia scotoma (blind spots)
b. dysphagia (CN9)
2. Cerebellum
- incoordination result to:
a. ataxia
b. Charcot's triad:
 1. scanning speech
2. intentional tremors (seen if may ginagawa)
3. nystagmus (uncoordinated movement of the eyes)
3. Spinal Cord
a. sensory: numbness
- lesser pain medication
- no hot bath
b. Motor: spastic paralysis (stiffness)
- DOC: muscle relaxant
- complication:
a. contracture: walking- allowed; running-not allowed
b. chronic fatigue: need rest periods
- air condition room
c. Bowel: constipation
d. Bladder: neurogenic bladder
- decrease urine output
- complication: UTI
- prevention: provide acid ash diet
- Management:
1. Avoid stress
2. Avoid infection: #1 stressor
3. No extreme emotion/ fatigue
4. Avoid extreme temperature
- rest or conditioned room (controlled environment)
5. Avoid humid

Guillain Barre Syndrome

- demyelination of PNS
- slow impulse in PNS
- cause: unknown
- theory: autoimmune
- trigger:
Virus
GIT
URTI
Vaccine
- S/Sx:
1. Cranial nerve: C9
- dysphagia
- complication: aspiration
2. Spinal nerve
a. sensory
- paresthesia: parang tinutusok ng karayom
- flaccid: nanlalambot
b. motor
- ascending paralysis (from lower extremities and up)
- DTR
3. ANS
- cardiac dysrhythmia
- constipation
> nerogenic bladder
- Management:
1. Aspiration risk
- flex the neck
- give thick fluid
2. Breathing
3. Cardiac monitor
- Recovery: 6 months-2 years
 - self-limiting (kusang gumagaling)
- descending ( pababa ung recovery)

Parkinson's Drugs

Dopaminergic Anti-cholinergic COMT Inhibitor

(increase dopamine) (inaalagaan yung dopamine)
Amantadine Benztropine Tolcapone
Bromocriptine Procylidine Entacapone
Ropinirole Biperidon
Pramipexole
Seleginine

Parkinson's Disease
- destruction of dopamine producing cells in substantia nigra (found in basal ganglia)
- decrease in dopamine; increase in dopamine

Neurotransmitters:
Acetylcholine Dopamine
Excitatory Inhibitory
Cholinergic Adrenergic
* Acetylcholine is greater than dopamine

- DOC:
a. Anticholinergic drugs
b. Dopaminergic
c. COMT Inhibitor
- Sinemet/ Levodopa: * Dopamine: cannot cross the blod-brain barrier
a. contains Levodopa and Carbidopa * Decarboxylase: convert Levodopa to Dopamine in the brain
b. crosses blood-brain barrier * Carbidopa: inactivate decarboxylase outside the brain
- Side Effects of Levodopa:
a. dark urine
b. anti-cholinergic effect
1. decrease secretion: dry mouth
2. decrease peristalsis: constipation
3. decrease urine output
4. orthostatic hypotension
- Complication of Levodopa:
a. psychosis
b. dyskinesia
- Management of Levodopa:
a. Avoid MAOI for 14 days before
- can cause hypertensive crisis
b. Avoid Tyramine
aged cheese red wine
fermented (soy sauce) preservative
c. Low protein diet
- protein increase interfere with the absorption of dopamine
d. Avoid excess Vit. B6
e. Teratogenic
- S/Sx:
a. shaking tremors at rest (resting tremors)
- pill rolling sensation
- HT: “dapat laging may ginagawa”
b. spastic with passive movement
 - cog wheel rigidity
c. slow movement/ bradykinesia
- difficulty in standing
- HT:
1. rock back & forth
2. hard surface
- Other S/Sx:
a. swallowing problem (dysphagia): Risk for Aspiration

drooling
b. small handwriting (micrographia)
c. slow peristalsis/ constipation
- include high fiber diet
d. stoope posture/ flex posture
e. swing arms move
f. small steps
g. shuffling gait

Trigeminal Neuralgia/ Tic Doloureux

- problem with cranial nerve #5 (trigeminal nerve): sensory of the face
- increase in impulses
- S/Sx:
excruciating facial pain
unilateral pain
altered nutrition
exhaustion
- Management:
1. Avoid triggers: cause pain
a. pressure
b. hard food
c. extreme temperature
2. Diet:
a. increase calorie
b. soft & warm food
3. Position: supine
4. DOC: anticonvulsant/ mild tranquilizer (decreases impulses)
a. Tegretol
b. Dilantin
c. Diazepam
- Medical Management:
a. Direct nerve injection; anesthesia
b. Rhizotomy: removal of the nerve

Bell's Palsy
- problem with cranial nerve #7 (facial nerve)
a. function: face & closing of eyes
b. responsible for motor
c. located behind the ear
- unilateral inflammation
- half paralysis of the face
- S/Sx:
Half of the face is NO: (FACE)
F- Facial expression
- Management: exercise; massge if not in pain
A- Affected side chewing
- Management: oral care
C- Closure of the eye
 - Management: provide safety ( protect the eye)
E- Eye lacrimation
- provide artificial tears
- Self-limited: full recovery in a few weeks with residual effects
- DOC: Steroids
* eyes: most important to protect part in Bell's Palsy
* ear operation: possible for Bell's Palsy

Cerebrovascular Accident/ Stroke

Types of Stroke:
1. Ischemic
a. Thrombus: cause by ruptured atherosclerosis reutl to blood vessel blockage
b. Emboli: form from other part, move into the brain blood vessel causing blockage
- Management:
a. Positioning: flat
- increase blood flow to the brain
b. Drugs:
1. antithrombus
2. antiplatelet
3. anticoagulant
4. thrombolytic
2. Hemmorhagic
- most fatal/ deadliest
- Cause: cerebral aneurysm rupture
- S/Sx:
sudden severe headache: sign of ruptured aneurysm
bleeding
- Management:
a. Position: Semi-fowlers
- prevent increase ICP
- to drain blood
b. Avoid anti-thrombus
c. Drug of Choice: Aminocaproic acid
- promote clot formation

Stroke

Brain Ischemia

Irreversible damage
within 4-6 mins.

S/Sx: neurologic deficits

Transcient Ischemic Attack

- less than 24 hours of neurological deficit

- Cause: atherosclerosis in the artery
- Artherosclerosis surgery: Carotid Endarterectomy
- Post-procedure:
a. flat on bed
b. monitor BP
c. Monitor neurological deficit

Hemispheres of the Brain:

Right Side Judgement - Impulsive: lack of judgement
Spatial - Deficit: problem with space
- Management: provide safety
Left Side Intellect
Language - Aphasia: inability to communicate
1. Expressive: problem with speaking
- damage with Broca's area
- Broca's area: frontal lobe of the brain; motor of the brain\
- management:
a. writing
b. point
2. Receptive: impaired hearing
- damage with Wernicke's area
- management:
a. talk slowly
b. pantomime
3. Global: combination of expressive & receptive

Neurological Deficits

1. Dysphagia:
- problem with cranial nerve #9: glossopharyngeal
- management:
a. thick liquid
b. flex the neck
2. Dysarthria:
- problem with cranial nerve #12: hypoglossal
- agnosia: inability to recognize an object
- management: provide safety
3. Homonymous Hemianopia:
- half part of an eye is blind
- can see half of the visual field
- management:
a. scan the environment
b. turn to good side: approach to good side
4. Hemiplegia:
- half side paralysis
- right side CVA: left lower part is paralyze
- left side CVA: right lower part is paralyze
- manifestations:
a. arm & leg: flexor if greater than extensor
b. shoulder: internal rotation
c. hip: external rotation
d. hands & feet: pronation
e. feet: plantar flexion
- management:
a. avoid the aboven manifestations
b. avoid flexion contractures
5. Unilateral Neglect
- neglect one side of the face
- management:
a. early: focus on good side
- put things on good side
b. late: focus on bad side
- put things on bad side
- S/Sx: Horner's Syndrome
 a. inability the pupil to dilate
b. ptosis

Increasing Intracranial Pressure

- Intra:
a. Brain: 84%
b. Blood: 12 %
c. CSF: 14%
- Crania: skull
- Cranial pressure
a. pressure inside the brain
b. normal: 0 to 20 mmhg
c. increased ICP by: Avoid the following
- cough
- smoking
- Valsalva
- Cerebral Perfusion Pressure (CPP)
- normal: 60 to 90
- increase blood flow to the brain increase ICP hypertension
- Monroe Kellis Hypothesis: Theory
a. increase in volume of 1 content = decrease of volume in the other content
b. cranium
c. closed vault
- Cause of Increase ICP: cerebral edema trauma
- Complication:
a. Brain herniation death
- S/Sx: fixed dilated pupils
b. Altered LOC
- most sensitive indicator of increase ICP
- due to decrease blood in the brain
- Management:
1. Position: Semi-fowlers
2. Avoid:
Valsalva sneezing
coughing vasodilator
3. Contraindication:
a. Vasodilator
- nitroglycerin
- acidosis
b. morphine: decreases RR
4. Drug of choice: Codeine + Acetaminophen
a. Codeine
- SE: constipation
b. Acetaminophen
- SE: decrease RR
5. Hyperventilate the patient
- can lead to alkalosis ischemia
6. Drug of chice: Mannitol
- decrease edema/ fluid in the brain
7. Fluid restriction: 1.2 L/day
8. Dexamethasone
- S/Sx:
a. Early (BRAIN)
B- Blurring of vission
R- Restless
A- Alered LOC: most sensitive
I- increase in confusion
 N- note for headache
b. Late (ICP)
I- Increase temperature
Increase systolic BP
C- Cushing's triad:
a. increase BP
b. decrease HR
c. decrease RR
P- Pulse pressure widening
Projectile vomiting
Papilledema (edema of the eye)
- check with use of opthalmoscope
- problem with optic disk
Posturing: damage with spinal cord tract
a. Decorticate
- flexion; 1st seen
- “mummy”
b. Decerebrate: damage with cerebellum
- extension; 2nd seen
- more fatal
* “Party: decorate before celebrate
* Increase ICP S/Sx: opposite of Shock S/Sx

Head Injury

Epidural Hematoma Subdural Hematoma

- “ emergency” or more fatal
- above the dura (artery)
- can bleed first
- (+) in and out of consciousness
- below the dura (vein)
- slow accumulation of blood
- Managment:
increase ICP 1. monitor increase in ICP
2. time to increase ICP: ?

Basilar Skull Fracture

- Complication:
a. Increase in ICP
b. CSF leak: thru the ears & nose
- Otorrhea: fluid in the ears
- Rhinorrhea: fluid in the nose
- (+) Halo's sign
a. Pink: blood
b. Yellow: CSF
- Management: Monitor increase in ICP & CSF leak

Craniotomy

Supratentorial Infratentorial
- Post procedure: monitor increase in ICP - Position: flat on bed
- Position: semi-fowlers - Complication: brain herniation

Transphenoidal Hypophysectomy
- no external incison; incision is made underneath the upper lip
- removal of the pituitary gland
- Post procedure:
1. Avoid:
 - tooth brush for 2 weeks
- use straw
2. Position: semi-fowlers
- prevent increase ICP
- Complication:
a. Increase ICP
b. CSF leak
c. Diabetes Insipidus: check for urine specific gravity

Meningitis
- damage in brain, CSF anf spinal cord
- Cause:
a. Bacterial: fatal
- transmission: droplet
- precaution: droplet precaution
- Streptococcus Pneumonae: most common cause
- Neisseria Meningitidis: deadliest
- characteristic sign: petechiae
- Management: isolation
b. Viral: self-limiting
- Enterovirus (Coxsackie)
- transmission: enteric
- S/Sx:
URTI
high fever
CSF sample:
- increase CHON & WBC
- decrease glucose
- cloudy
increase ICP seizure
Spinal cord compression:
a. Brudzinski sign: nape flex
- examiner flex the neck (passive) result to flex of the hip (active)
b. Kernig's sing: knee flexion
- knee flex in 90º angle
- the examiner try to extend the knee results to hamstring spasm & pain
c. nuchal rigidity/ stiffneck
d. headache
e. photophobia
f. nausea & vomiting
- Management:
1. Isolation:
a. droplet
b. dark room
c. quiet
d. place away nurse station
2. CSF sample
3. Antibiotic:
a. Vancomycin
- complication: Red Man Syndrome
- (+) allergic reaction
- cause: fast infusion
- management: slow infusion more than 60 mins.
b. Ceftriaxone
4. 24 hours stable