NEUROLOGICAL DISORDERS

VE RLE N CA B A LTICA , RN
HEADACHE (cephalgia)

Classification:
o PRIMARY HEADACHE
o a symptom NOT associated with an
organic cause
o No known underlying cause

o SECONDARY HEADACHE
o symptom associated with an organic cause
or underlying medical condition
o A symptom of another disorder
o Ex: brain tumor, aneurysm
Questions specific for
Headache

W H E R E WA S T H E H E A D AC H E
H U RT, A N D W H AT W E R E YO U
D O I N G W H E N T H E H E A D AC H E
S TA RT E D ?

H OW L O N G D O T H E Y U S U A L LY
L A S T, A N D D O T H E H E A D AC H E
RECUR?

D O YO U H AV E T RO U B L E W I T H
YO U R V I S I O N B E F O R E ?

D O YO U TA K E A N Y OT C M E D S ?

H AV E YO U B E E N D E P R E S S E D ?

D O YO U H AV E A N Y F A M I LY
M E M B E R W I T H H I S TO RY O F
H E A D AC H E ?
 • TTH (TENSION-TYPE HEADACHE)
• Etiology: multifactorial
• Triggered/worsened by stress, depression, anxiety
• More common in women
TENSION
• Characteristic:
HEADACHE
• band-like pressure; tightness that affects the forehead, temples,
back of head

Types:

Episodic:
>1 but <15 episodes per month for 3 or more months

Chronic:
>15 episodes per month for 3 or more months; (+) nausea
 • Rare; extremely painful
• Occur multiple times a day for weeks-months
• Etiology is unknown but originate form hypothalamus
• More common to MEN
• Triggered/worsened with ALCOHOL/TOBACCO
(vasodilation)
CLUSTER HEADACHE
• Characteristic:
• intense; severe pain around/above/behind one eye
with redness, swelling, tearing
• knife-like/icepick pain
• (+) runny nose, facial sweating, restless
 • Recurrent, throbbing/pulsing pain on one side of the head
• Preceded by symptoms of “aura”; vision difficulties, fatigue,
weakness/numbness of limbs
• Etiology: unknown but multifactorial;
• STRESSORS (emotional, environmental)
• insomnia

MIGRAINE • diet (tyramine containing – aged cheese, soy beans,

smoked/processed meat)
HEADACHE
• exercise habits
• medications
• alcohol intake (vasoconstriction)
• hormonal imbalance (serotonin)
• More common in women (familial)
 CATEGORIES OF MIGRAINE H/A

• With Aura / classic migraine

• Without Aura
• “Aura” is a warning sign; affects eyesight
• Headache lasts 1-2 days
(blind spots, flashing lights, tingoling in hand or
aggravated by physical activity
face)
• With nausea and vomiting
• Recuring headache that strikes after or at the
• Photophobia same time aura occurred
• phonophobia
 4 PHASES OF MIGRAINE:

Headache Recovery
Prodrome Aura
phase Phase
 PRODROME AURA HEADACHE RECOVERY
24-48 HRS PRIOR ATTACK 48-72 HOURS

Fatigue Blurred vision Extreme sensitivity to light and sound Fatigue

Frequent yawning
Fluid retention
Increased urination
Muscle stiffness(neck, back, face)
Constipation or diarrhea
Food cravings
Depression or irritability
Difficulty concentrating
Feeling cold
Appearance of floaters (tiny specks and smell Weakness
that float before the eyes) Nausea Irritability
Flashes of light or color, or blurry vision Vomiting Anxiety
A blind spot or even complete Increased pain with physical activity Depression
blindness in one eye (such as walking or going up or down Difficulty concentrating
Numbness or tingling of the hands, stairs) Scalp tenderness
feet, and/or face (particularly around
the mouth) Status migrainosus - debilitating
Stiff neck migraine attack lasting for more than
Weakness 72 hours.
Vertigo or Dizziness Risk for stroke
Loss of balance
Ringing in the ears
Double vision
Difficulty talking
Slow thinking or confusion
Problems with concentration
Changes in mood and activity level
SPINAL/LUMBAR TAP PUNCTURE HEADACHE
Caused by leakage of CSF through a puncture hole in the dura mater that
surrounds the spinal cord.
loss of CSF volume with LP decreases the pressure exerted by the spinal
fluid on the brain and spinal cord w/c leads to headche

POST CONCUSSION HEADACHE

may vary and may feel like tension-type headache/migraine
may be associated with neck injury that happened at the same time as
the head injury
a type of TBI caused by bump, blow, jolt to the head or by a hit to the
body that causes head and brain to move rapidly back and forth
 DIAGNOSTIC TESTS:
NURSING
• CT-Scan
INTERVENTIONS
• MRI
• Cerebral Angiography H-eat application or massage
E-ducate on prevention
A-nti-emetic medications
D-im or dark environment
ME D IC A L MA NA GE ME NT A-dminister analgesics
C-oach on habit and lifestyle changes
Approaches:
H-ead elevation
• Abortive (symptomatic) – who suffers less frequent E-xercise programs
attacks
• Preventive – who suffers more frequent attacks

Medications:
Serotonin receptor antagonist: Sumatriptan (Imitrex)
Ergotamines: Ergotamine tartrate
Anti-epileptics: Divalproex sodium, Topiramate, Gabapentin
 SEIZURE DISORDER
sudden, abnormal electrical discharge
from the brain that results in changes in 5’s that can trigger seizure…
sensation, behavior, movements,
perception and consciousness • Stress
• Etiology:
• Idiopathic
• Sleep deprivation à fatigue
• Epilepsy- chronic disorder of recurrent • Strobe lights/ flashing lights
seizure; abnormal firing of neuron
• Trauma damage: TBI, concussion • Stimulants: high in caffeine à tea, coffee, soda
• Abnormality in the brain: increase ICP,
hemorrhage, infarction
• Sugar and sodium that is low à hypoglycemia
• Infectious disease: meningitis (<70), hyponatremia (<135)
• Alcohol or drug withdrawal
• fever
 INTERNATIONAL
CLASSIFICATION OF SEIZURES
qGeneralized Seizures
qTonic-clonic seizures (Grand mal)
qAbsence seizures (Petit mal)
qMyoclonic seizures
qAtonic seizures
qPartial Seizures
qSimple partial seizures
qComplex partial seizures
 PARTIAL SEIZURE
SIMPLE - PARTIAL
Involves focal area of the brain
No impairment in consciousness; patient
is aware and awake throughout the
seizure
Only one finger/hand may shake or
mouth jerking uncontrollably, dizzy,
experiences unpleasant sights, sounds,
odor, taste
JACKSONIAN MARCH -
tingling/twitching begins in small area and
the marches or spreads to a larger area
of the body
COMPLEX - PARTIAL
There is impairment in consciousness
Seizure starts in one area and travel to
another
Patient either remains motionless or
moves automatically but inappropriately
for time and place or may experience
excessive emotions (fear, anger, elation,
irritability)
Cannot remember the episode post
seizure (amnestic)
If frontal lobe is involved: patient may see
bicycling movements of the leg or pelvic
thrusting
 COMPLEX-PARTIAL
SIMPLE-PARTIAL Involves impairment of
consciousness

Psychic symptoms "vacant" or "frightened" look

• Detachment, depersonalization
Five types of automatisms:
• Dreamy state

Memory distortion • Alimentary: chewing, increased salivation,

• deja vu (feeling that one has seen something before), borborygmi
• deja entendu (feeling that one has heard something before) • Mimetic: facial expressions of fear,
• jamais vu (feeling that one has never seen something that is familiar),
bewilderment, discomfort, tranquility, laughter,
crying
• jamais entendu (feeling that one has never heard something that is
familiar), • Gestural: repetitive movements of the hands,
fingers, sexual gestures
• panoramic vision (rapid recall of past events)
• Ambulatory: wandering, running
Time distortion • Verbal: repeated short phrases or swearing
• Time appears fast or slow
 GENERALIZED SEIZURE

1. GRAND MAL SEIZURE(generalized tonic-clonic)

Causes LOC and violent muscle contractions; abnormal
electrical activity throughout the brain
v PHASES:
v Pre-ictal/prodrome – warning sign before aura phase; lasts from mins to
days
v Aura - sensory disturbance
v Ictal Phase/ active seizure; FOCUS: SAFETY, NOTE THE DURATION AND
TYPE
v 2 phases:
v TONIC- muscular rigidity/ extension of extremities; 10-20 secs
v CLONIC- muscular jerking; 2 minutes
v Post-ictal Phase: hangover phase: confused, disoriented, major headache,
sleepy
2.) PETIT-MAL (absence seizure)
• Occurs to children ages 4- puberty (8-14 y.o.)
• The victim appears to be day dreaming.
• 30 sec
3.) MYOCLONIC
• Involve a sudden uncontrollable jerking movements of either a single muscle group.
4.) ATONIC
• Associated with total loss of muscle tone.
• Known as drop attack
5.) FEBRILE SEIZURE
• a convulsion in a child that's caused by a fever
• The fever is often from an infection
• Febrile seizures occur in young, healthy children who have normal development and haven’t
had any neurological symptoms before.
• It can be frightening when your child has a febrile seizure.
STATUS EPILEPTICUS SUCTION AS NEEDED

continuous or more than 1 seizure lasting for more than 5 minutes DIAGNOSTIC TEST:
without full recovery in between;
EEG – BRAIN ACTIVITY
a medical emergency that can lead to permanent brain damage or
death FOR 12-24 HRS:
NO CAFFEINATED DRINKS
Management: NO SEIZURE MEDS
priority: AIRWAY MRI/CT/PET SCAN – FOR POSSIBLE TUMORS
TURN TO SIDE
SUCTION SECTIONS PHARMA MGT:
NEVER: insert anything in the mouth, restrain ANTICONVULSANTS/ANTI EPILEPTIC/ANTISEIZURE DRUGS
STAY WITH THE PATIENT; RECORD TIME AND - symptomatic treatment only
SEIZURE4 CHARACTERISTIC
Phenytoin (Dilantin)/ Diazepam (Valium) – seizure
LOOSEN RESTRICTIVE CLOTHING
Phenobarbital (Luminal)/ Valproic Acid (Valproate - epilepsy
SAFETY
Carbamazepine (Tegretol) - anticonvulsant
CLEAR THE AREA
Ethosuximide (Zarontin) – absence seizures
RAISE SIDERAILS
MEDICATION:
DIAZEPAM/VALIUM
POST SEIZURE:
ASSESS LOC/ VS AND NVS
 S TAT U S E P I L E P T I C U S :
S U R G I C A L M A N A G E M E N T:
DISEASE PART(CAUSING SEIXURE) CUT/REMOVED
Corpus Callosotomy/Split brain surgery
control generalized seizures in pediatrics by
cutting the corpus callosum
Temporal Lobectomy
removal of a portion of a lobe
Hemispherectomy
very rare surgical procedure where one cerebral
hemisphere (half of the brain/cerebrum) is removed,
disconnected or disabled
treat variety of seizure disorders where the source of
epilepsy is localized to a broad area of a single brain
hemisphere (RASMUSSEN’S ENCEPHALITIS)
Vagus Nerve stimulator Implants
prevents seizures by sending regular, mild pulses of
electrical energy to the brain via vagus nerve;
”pacemaker for the brain”
implanted under the skin in the chest
S TAT U S E P I L E P T I C U S :
N U R S I N G M A N A G E M E N T:
Seizure precautions:
ü Monitor temperature & Respirations
ü Note level of consciousness
ü Provide a quiet, dimly lighted rooms.
ü Prepare plastic airways and suction
machine
5’s triggering seizure
• Stress
• Sleep deprivation à fatigue
• Strobe lights/ flashing lights
• Stimulants à Tea, coffee, soda
• Sugar and sodium that is low à
hypoglycemia, hyponatremia
 INTRACRANIAL PRESSURE

CSF PRESSURE
• the pressure within craniospinal
compartment; comprises a fixed • Intrathoracic pressure during coughing,
volume of neural tissue, blood, CSF sneezing (intra-abdominal pressure)
• Normal pressure:
• Valsalva maneuver
• 10–20 mm/ Hg
Monro-Kellie hypothesis • Venous and arterial systems
because of the limited space for • BP
expansion within the skull, an increase in
any one of the components causes a
change in the volume of the others.
 INCREASED ICP
> 20 MMHG

• Causes:
• Head trauma
• Infection - meningitis
• Aneurysm
• Tumor, mass lesions in the brain
• Cerebral edema
• Brain surgery
• Obstruction to CSF flow and/or
absorption
• Decreased venous outflow
 Ealy Signs Late/ Deadly Signs
• Altered LOC: Irritability, Restless
• Lungs – irregular respiration; Cheyne
• Decreased Mental Status Stokes respiration
• Sleepiness
• Neck – nuchal rigidity (stiffed neck);
• Flat affect and drowsiness
cannot flex towards chest
Moderate Signs
Brain stem affected:
INCREASED • Headache – constant
• Projectile vomiting/ Sudden vomiting
• Eyes: Pupils: fixed and dilated, 8 mm

ICP “emesis” WITHOUT nausea (Report to

HCP)
(n:2-6 mm), sometimes unequal;
Negative Doll’s Eye Reflex

SIGNS Late/ Deadly Signs

• Cushing Triad
• Foot:
• Positive Babinski reflex (toes fan
AND • High SBP with widened pulse pressure
(wide difference between the
out)

SYMPTOMS systolic and diastolic pressure)

• Bradycardia
• Seizure and coma;
• GCS <8/15 (Intubate)
• Irregular respiration/ bradypnea
• Abnormal posturing: decorticate and
decerebrate (worst).
 DIAGNOSTICS NURSING INTERVENTION
• Immobilize head “C-Spine”; head in neutral
• Imaging: CT Scan (1st); quick and easy with fast result position; log roll as one unit.
showing root cause.
• CO2 Low; Hyperventilate to blow out CO2
• No lumbar puncture/spinal tap - precipitate (Mechanical Ventilator)
brainstem herniation
• Positioning; HOB 30-35 degrees or higher;
no flexion or bending; no coughing, sneezing
or blowing of nose, No Valsalva maneuver
(holding breath/ bearing down)
MANAGEMENT • Suctioning; 10 sec or less or as needed;
hyperoxygenate with 100% O2 before and
after suction.
R- educing CSF & Intracranial Blood volume
E- dema decrement
D- ecrease of metabolic demand
U- pright position
C-ontrolling fever
E-nsure oxygenation
D-rug administration
 MEDICAL SURGIC AL
MANAGEMENT MANAGEMENT

Focus: relieve increased ICP by:

• Decreasing cerebral edema
• Lowering the volume of CSF Craniotomy
• Decreasing cerebral blood volume while
maintaining cerebral perfusion

Mannitol – osmotic diuretic; s/e Decompressive

edema & s/s of heart failure
Craniectomy
Phenytoin to prevent seizure

Steroids: Dexamethasone for

swelling Cranioplasty
Phenobarbital to decrease brain
activity
aka “Brain attack”
a syndrome of a group of Non-Modifiable: Modifiable:
sudden focal neurological
qAge: 18-50 YO q Hypertension (1st)
deficit resulting from qGender: MEN q Heart Disease
interruption of cerebral blood qRace: AFRICAN AMERICANS q DM
flow qFamily History q Sleep apnea
q Blood Cholesterol level
q Smoking
Classification: q Sickle Cell Disease
q Substance abuse
Non-hemorrhagic: Ischemic
q Intracranial haemorrhage
(embolic, Thrombotic) q Obesity
Hemorrhagic
TIA
CVA: INITIAL MANIFESTATIONS

S-evere & sudden headache

T-trouble in speaking
R-ight or left hemiparesis
O-cular disturbances
K-onfusion
E-mpairement in
coordination
 Left Hemisphere Right Hemisphere

§Aphasia §Spatial-perceptual deficits

§Agraphia §Lack of inhibitions
§Alexia §Inappropriate social behavior
§Acalculia §Short attention span
§ Dysarthria §Poor judgment
§Hemiplegia §Hemiplegia
§Homonymous hemianopia §Hemiparesis
§Short-term memory §Anosognosia (Denial of affected
§Depression Side)
§frustration §Apraxia (Inability to use objects or
words)
• CT Scan
• MRI
• Cerebral Angiography
• Doppler Flow studies
• NIH Stroke Scale
Maintenance of a patent airway and optimal oxygenation
Control cerebral edema
Control of fluid and electrolyte balance CVA BLEED INFARCTION
Maintenance of adequate cerebral blood flow and No aspirin or clopidogrel • Thrombolytics within 4.5 hours
cerebral perfusion pressure No heparin & enoxaparin of onset of symptoms
No warfarin • tPA – tissue plasminogen
No thrombolytics activator
• Streptokinase

oCraniotomy
oCraniectomy
q Optimizing cerebral tissue perfusion
q Improving Mobility and Preventing Joint Deformity
q Enhancing Self-Care
q Managing Sensory-Perceptual Difficulties
q Assisting with Nutrition
q Attaining Bowel and Bladder Control
q Improving Communication
q Maintaining Skin Integrity
• An intracranial aneurysm is the weakness in the tunica
media, the middle layer of the blood vessels.

• The most common type is saccular or berry aneurysm.

• Are found more often in the anterior cerebral circulation

RISK FACTORS:
CLINICAL MANIFESTATIONS:
oSmoking
Asymptomatic
oHypertension Ruptured Aneurysm:
oAtherosclerosis • Sudden onset of headache “Worst
headache of my life”
oAlcohol abuse
• Vomiting
oStimulant drug abuse • Generalized seizure
oAging process • Decrease LOC: confused, lethargic, coma
• S/sx of Meningeal Irritation( Nuchal
rigidity, photophobia)
• Focal motor & Sensory Deficits
 DIAGNOSTIC TESTS:

• CT Scan MEDICAL MANAGEMENT

• MRI § Neurologic Assessment

• Transcranial § Maintain a patent Airway

Doppler § Continuous hemodynamic monitoring

§ Nimodipine administration

§ Morphine administration

§ I & O monitoring
 SURGICAL MANAGEMENT
§ ANEURYSM CLIPPING
§ Surgical obliteration of the
aneurysm with a metal clip to
NURSING MANAGEMENT
eliminate the risk of rebleeding.
A-ssess neurologic status

§ ENDOVASCULAR E-levate head at 30 degrees

THERAPY & U- rine output monitoring
EMBOLIZATION
R-espi and cardio monitoring
§ Involves obliteration of the
aneurysm by means of platinum Y-ou keep patient & family members in a quiet and comfortable environment
coils.
S-urgery preparation
M-edication administration
 HEAD INJURIES
• Injury to the scalp, skull or brain
• Traumatic brain injury (TBI) – is the most serious form of head injury

TRAUMATIC BRAIN INJURY (TBI)

A damage to the brain from an external mechanical force and

not caused by neurodegenerative or congenital conditions.
TBI can lead to temporary and permanent impairment of
cognitive, physical, and psychosocial functions.
 CLOSED HEAD INJURY

• Concussion CONCUSSION
• Cerebral Contusion • A jarring of the brain within the skull with temporary
• Diffuse Axonal Injury loss of consciousness/ neurologic function with no
apparent structural damage to the brain
• Intracranial Hemorrhage
• Epidural
CEREBRAL CONTUSION
• Subdural • A bruising of the brain surface.
• Subarachnoid
• Intracerebral DIFFUSE (WIDESPREAD) AXONAL INJURY
• Injury to axons, corpus callosum, white matter and the
brain stem.
4. INTRACRANIAL HEMMORHAGE
1.) EPIDURAL HEMATOMA
• Meningeal artery affectation.

2.) SUBDURAL HEMATOMA

• Is a hemorrhage from small vessel
between the dura and arachnoid.
3.) SUBARACHNOID HEMORRHAGE
• Results from blunt trauma.
• S/S: nuchal rigidity, (+) Kernig’s,
(+) Brudzinski
• Deterioration of LOC, hemiparesis
4.) INTRACEREBRAL HEMATOMA
• Bleeding into brain tissue from
contusion or laceration.
 OPEN HEAD INJURY

• Linear Fracture
• Depressed Fracture
• Open fracture
• Comminuted fracture
• Basilar skull fracture
 Basilar Fracture
Battle's sign - a bruise that indicates a fracture at the bottom of
the skull; it is a medical emergency.

Raccoon eyes - most often caused by a basal skull fracture -

- The basal part of skull is the bottom portion where the
brain rests; can occur from car accidents, falls, sports injuries, and
other sources of head trauma.

Rhinorrhea/ Otorrhea – Clear fluid discharges from nose and

ears – may indicate CSF leakage

halo sign - a blood stain surrounded by a yellowish stain – CSF

Leak

Subconjunctival hemorrhage - when one or more blood spots

appear on the white of your eye.
RISK FACTORS:

Blunt Trauma
ASSESSMENT :

qHeadache
Penetrating qConfusion
Trauma qAltered LOC
qAbsent corneal reflex
qPupillary abnormalities
Coup & qVision & hearing impairment
Countrecoup qSudden Onset of neurological deficits
qSeizures
qS/S of Increased ICP
 DIAGNOSTIC TESTS
1. Skull X-ray
2. CT-Scan
Treatment of Increased ICP
3. MRI
Supportive Measures:
4. Cerebral Angiography
Mechanical ventilation
Seizure Prevention
F & E Maintenance
Nutritional support
Pain Management
 SURGICAL
MANAGEMENT

Goal: Decompression
BURR HOLE - decompression,
evacuation of clot & abscess.

CRANIECTOMY
excision of the cranial
bone without replacing it.

CRANIOTOMY
Opening to the cranium
 NURSING MANAGEMENT

Maintain Neurological Treatment of

Patent Airway assessment ICP

Supportive Electrolyte & Adequate

measures Fluid Balance Nutrition

Prevention of Maintaining
Injury Skin integrity
generally the result of trauma to the vertebral
column.

CAUSES: C AT E G O R I E S

Primary
• MVA
• result of the initial insult or
• FALLS trauma, usually permanent
Secondary
• VIOLENCE • result of a contusion or injury in
which the fibers begin to swell
• SPORT RELATED and disintegrate (break up/
deteriorate)
• a secondary chain of events
produces edema, hypoxia,
ischemia and hemorrhagic lesions,
which in turn result in destruction
of myelin and axons.
 MECHANISM OF INJURY
Hyperextension
Distraction movement by which the two elements of any
jointed part are drawn away from each other
the pulling apart of the spine
Axial Loading
ex: suicide by hanging, Gunshot wounds
to the chest, back, and abdomen a sudden, excessive compression which drives
the weight of the body against the head
Lateral Bending ex; downward blow to the head, upward force to

the head and neck are bent to one side, the feet
beyond normal limits. Excessive Rotation
Hyperflexion movement of the body about
the act of bending or the condition of being
the body's axis
bent
Complete Cord Involvement
no functioning nerves
remain below the level of
injury.
Incomplete Cord
Involvement of some
function remains below
the level of injury
 CERVIC AL INJURY

LEVEL AFFECTED FUNCTION

C1-C2 LOSS OF BREATHING

C3 ABOVE RESULTS IN LOSS OF DIAPHRAGM FUNCTION

C4 LOSS OF FUNCTION AT THE BICEPS AND

SHOULDERS
C5 LOSS OF FUNCTION AT THE SHOULDERS AND
BICEPS, AND COMPLETE LOSS OF FUNCTION AT
THE WRISTS AND HANDS.
C6 LIMITED WRIST CONTROL, AND COMPLETE LOSS
OF HAND FUNCTION
C7 AND T1 LACK OF DEXTERITY IN THE HANDS AND FINGERS,
BUT ALLOWS FOR LIMITED USE OF ARMS
 THORACIC INJURY

LEVEL AFFECTED FUNCTION

T1-T8 INABILITY TO CONTROL THE

ABDOMINAL MUSCLES
T9-T12 PARTIAL LOSS OF TRUNK AND
ABDOMINAL MUSCLE CONTROL

LUMBOSACRAL INJURY

Dysfunction of bowel, bladder and sexual function

 SPINAL SHOCK NEUROLOGIC AUTONOMIC
SHOCK DYSREFLEXIASIGNS
definition Loss of sensation Develops d/t loss of Complication w a lesion above T4-
T6 (UPPER BACK)
accompanied by motor autonomic NS; involuntary
paralysis w initial loss but fxn below the level of A hypertensive medical
gradual recovery of lesion emergency
reflexes
cause SCI SCI Overdistended
bladder
TBI Rectal stimulation
Impaction/
constipation

SIGNS & SYMPTOMS NO REFLEX Low BP INCREASE BP

NO SENSATION Low HR LOW HR
NO SOMATIC AND FACIAL FLUSHING
VISCERAL DISTENTION DIAPHORESIS ABOVE
THE INJURY
GOOSEBUMPS
 DIAGNOSTIC
TESTS EMERGENCY MANAGEMENT
Spinal RADIOGRAPHY
üImmobilize on a spinal back
CT/MRI
board
ECG
üAvoid flexion, rotation and
extension of patient’s neck and
head
Laminectomy üTransport the patient to spinal
-creates space by removing the lamina; the back
part of a vertebra that covers your spinal canal.
injury or trauma centers
-enlarges your spinal canal to relieve pressure on
the spinal cord or nerves.
o Pharmacologic Therapy
o Respiratory Therapy
o Skeletal Fracture Reduction & Traction

ü Promoting adequate breathing & airway

ü Improve Mobility
ü Promoting adaptation top sensory & Perceptual alterations
ü Maintaining skin integrity
ü Maintaining urinary elimination
ü Improving bowel function
ü Providing comfort measures
ü Prevention of thrombophlebitis
AUTOIMMUNE PROCESSES
 MYASTHENIA GRAVIS

MUSCLE – MY
WEAKNESS – ASTHENIA
GRAVE – GRAVIS
There is chronic, progressive decreased amplitude of the nerve impulse at the myoneural junction.
Affects: skeletal(somatic/voluntary) muscle; extraocular muscles of the eye that controls the eye lid (diplopia/ptosis).
• muscles of the eyelids: Levator palpebræ superioris, Orbicularis oculi, Corrugator
• Function:
• levator palpebrae superioris muscle - raise and maintain the upper eyelid position;
• origin is the periosteum of the lesser wing of the sphenoid bone, superior to the optic foramen.

“Wakes up in the morning fine but at the end of the day feels week.”
No cure; only treat the progression.
 MYASTHENIA GRAVIS

• RISK FACTORS:
• FEMALE; 20-40 YO; CHILD BEARING AGE
• THYMONA (THYMIC TUMOR) – tumor in the
thymus gland (anterior mediastinum) 10-15%
pts

CLINICAL FEATURES:
• Ptosis - drooping of upper eyelid either in one
or both the eyes
• Diplopia – double vision
• Dysarthria - Difficulty in speech due to weakness
of speech muscles.
• Dysphagia - ability to eat and drink is disrupted.

• ALL s/s gets worst with activity!

 MYASTHENIA GRAVIS: CLASSIFICATION

OCCULAR FORM

the muscles that move the eyes and control the eyelids are easily GENERALIZED FORM
fatigued and weakened
Involves the proximal muscles of the limbs and neck, usually with
both ocular and bulbar manifestations; ALL SKELETAL MUSCLES
including respi muscles
BULBAR FORM
STAGES:
involves breathing, swallowing, and speech
• Mild
bulbar weakness - named for the nerves that originate from the
bulblike part of the brainstem; can cause difficulty with talking • Moderate
(dysarthria), chewing, swallowing (dysphagia), and holding up the
• Acute Fulminating - occurs suddenly and escalates quickly,
head.
intense and severe to the point of lethality; explosive
character

• Late Severe
 MYASTHENIA GRAVIS: DIAGNOSTIC TESTS
• EMG • To r/o thymoma/thymic carcinoma (thymus)
• Normal in MG but repetitive stimulation of nerve may • TENSILON/EDROPHONIUM TEST
demonstrate decrements of muscle action potential
• High false positive rate
• Muscle action potential triggers a sequence of action
that results in contraction and relaxation of muscle • Route: IV
fiber; it is called EXCITATION-CONTRACTION- • Symptoms improve rapidly after administration
RELAXATION CYCLE of a short-acting acetylcholinesterase inhibitor;
no improvement? Rule out MG à Cholinergic
• ACETYLCHOLINE RECEPTOR ANTIBODY TEST crisis
• Most specific test; 80-90% pts w/ MG have antibodies
• achr receptor antibodies-an autoantibody directed
against the acetylcholine receptor; along with
antibodies against muscle-specific tyrosine kinase, can
cause myasthenia gravis.; can also be detected in some
patients with a thymoma (100%)
• CHEST CT SCAN
 MYASTHENIA GRAVIS: COMPLICATIONS

Cholinergic crisis - no improvement or worsening of weakness when edrophonium is

administered
• Tx:
• hold all anticholinesterase medication
• mechanical ventilation if required
• atropine for muscarinic effects of the overdose (The neuromuscular block is a nicotinic
effect and will be unchanged by atropine.)
Myasthenic crisis - when there is improvement with a small dose of edrophonium.

Both can lead to respiratory failure.

 MG: MEDICAL MANAGEMENT
• PLASMAPHERESIS (plasma exchange)
• filtering plasma from whole blood.
• used to remove harmful substances (autoantibodies/
toxins)
• The plasma may be returned after purification or replaced
with donor plasma or albumin solution.
• IV IG
• For severe/rapidly worsening symptoms of MG
• Altering immune system and neutralizing or destroying
damaging antibodies
• Iv ig stops antibodies from attacking itself
• Acts like a bait instead of attacking the nerves it attacks
this substance
• STEROIDS (ex: glucocorticoids)
• To reduce symptoms
• Taken along with acetylcholinesterase inhibitors
• Alert: suppresses immune system; risk for infection and
bleeding; bone marrow suppression
• ANTICHOLINESTERASE (ex: Pyro/Neo-stigmine)
• Give pre meals
• Improve swallowing and chewing
• Indication of effectiveness: absence of muscle cramps and
w/o diplopia
• R: stigmine means secretion (bosy becomes wet and wild
which leads to cholinergic crisis
 MG: SURGICAL
MANAGEMENT

• surgical removal of the thymus gland; which has been

shown to play a role in the development of
myasthenia gravis.
• Roughly 10 percent of patients with myasthenia
gravis have a thymoma, or a tumor on the thymus
gland.

• Robotic thymectomy
• much less invasive.
• no long incision and the chest does not have to be
opened
• patients experience: A shorter hospital stay – usually
going home the day after surgery.
 MG: NURSING MANAGEMENT

Airway protection & safety with swallowing
intubation set at bedside
Encourage semi-solid foods
Remember: dry esophagus and weak
muscle; risk for choking/aspiration
Triggers: Avoid this 4a’s àLead to Myasthenic
Crisis
Stress – over exercise, surgery and
pregnancy
Sun – avoid hot temperatures
Avoid crowds during flu season
Get vaccines (flu and pneumonia)
Fever – indicator of infection
Smoking
Wear medic alert bracelet at all times
Patient education:
No cure but only treat this condition (it goes with
ALL autoimmune diseases)

Sickness or sepsis (infection – especially

respiratory)
 • In affected patients, cross-reactive autoantibodies
GUILLAINE-B ARRE SYNDROME attack the host's own axonal antigens, resulting in
inflammatory and demyelinating polyneuropathy.
OR

ACUTE INFLAMMATORY • Ascending paralysis, from leg to head; inability to

DEMYELINATING cough and lift head
POLYRADICULONEUROPATHY • if with neurolemma, chance of regeneration) à
temporary or permanent
OR • Landry's paralysis
ACUTE POSTINFECTIOUS • form of peripheral polyneuritis characterized by pain
and weakness and sometimes paralysis of the limbs;
POLYNEUROPATHY cause is unknown.
 • Bacterial/Viral infection
• CYTOMEGALOVIRUS
• EPSTEIN BARR VIRUS
• Hepatitis E Virus
• HIV
• Rubella & rubeola
GBS: RISK FACTORS • Varicella

• Postinfectious autoimmune reaction that generates cross-reactive

antibodies (molecular mimicry)
• Infection triggers humoral response; formation of autoantibodies
against gangliosides
 Bilateral, symmetrical ascending flaccid
weakness/paralysis – nerve associated
Absent DTR
Neuromuscular respiratory failure
early signs:: inability to cough, lift head, eyebrows,
shallow respirations, dyspnea, hypoxia
priority: AIRWAY
Dysphagia
GBS:
CN VII (facial) – most affected
MANIFESTATIONS
HORNER’S SYNDROME
a combination of s/s caused by the disruption of a
nerve pathway from the brain to the face and eye
on one side of the body.
results in a decreased pupil size, a drooping
eyelid and decreased sweating on the affected
side of your face.
• Enophthalmos
• posterior displacement of the eye;
• The anterior projection of the eye is most commonly measured
relative to the outer edge of the orbit, the orbital rim, but may also
be assessed relative to the frontal and maxillary prominences, or the
contralateral eye.
• Exophthalmos/proptosis
• for bulging or protruding eyeballs.
• It can affect 1 or both eyes and is most often caused by thyroid eye
disease.

• Anhidrosis
• the inability to sweat normally.
• When you don't sweat (perspire), your body can't cool itself, which
can lead to overheating and sometimes to heatstroke — a
potentially fatal condition.
• sometimes called hypohidrosis — can be difficult to diagnose. Mild
anhidrosis often goes unrecognized.
 • CSF analysis:
• albuminocytologic dissociation,
characterized by elevated protein
levels and normal cell counts in
cerebrospinal fluid (CSF), is a
GBS: hallmark finding of GBS.
DIAGNOSTIC
TESTS • EMG
• muscle and nerve electrophysiology
are used to diagnose demyelinating
processes
 GBS: MEDICAL MANAGEMENT

• INTUBATION
• AVOID GLUCOCORTICOSTIROIDS
• DVT PREVENTION
• ANTICOAGULANTS
• IV IG
• Stops attacking self and start attacking ivig
• PLASMAPHERESIS
• Filters blood to remove antibodies that contributes to the destruction of neurons
 ü Maintaining Respiratory Function
ü Enhancing physical mobility
GBS: NURSING ü Providing adequate nutrition
MANAGEMENT ü Improving communication
ü Decreasing fear and anxiety
A chronic, progressive, degenerative Etiology:
and autoimmune disease that attacks UNKNOWN
the myelin sheath; Genetics: Female
Leads to muscle spasm and stiffness Environmental factors
Viral: mumps, measles, rubella
Vitamin D deficiency
Abnormalities in T-helper cells, T-
suppressor, B-lymphocytes
Stress
Trauma
Pregnancy
Age: 20-45 y.o.
Common initial symptoms:
• Burning, numbness and tingling sensation
• Numbness and weakness of extremities
• Muscle Tremors
• Sensory symptoms: Lhermitte’s sign
• electric shock like condition
• Occurs when neck is moved/flexed in a wrong way
• Motor Symptoms: Uhthoff’s phenomenon/sign/syndrome
• A transient worsening of neuro symptoms r/t demyelinating
disorder
• Body becomes overheated in hot weather, exercise, fever, saunas

• Charcot’s Triad
• Scanning of speech
• Nystagmus
• Muscle Tremors
MS: DIAGNOSTIC TEST
MRI/ CT-Scan
CSF Analysis PHARMACOLOGIC THERAPY
First line – IV glucocorticoids
Second line - plasmapheresis
Disease –modifying therapies
Symptoms management
Baclofen, Valium, Symmetrel, Propranolol
Anticholinergics, anti-spasmodics, ACE
inhibitors
Immunosuppressants - cyclosporine
1. Promoting physical mobility
2. Prevent Injury
3. Enhancing bladder and bowel
control
4. Enhancing communication
5. Manage feeding difficulties
6. Improve sensory & cognitive
function
• sudden loss of • pain behind the ear 1-2 days prior to paralysis,
motor control on • unable to (one side of the face)

one side of the face. • smile,

• frown,
• close eyelids,
• puff out cheeks,
• close the lips.

Age: 20-60 y.o • Mouth displaced

GBS • Saliva drools

Genetics • Constant tearing

• Loss of taste at the anterior 2/3 of the tongue.
Viral infection
Herpes
Epstein-Barr virus
 • Steroids for 7 days
DIAGNOSTIC • Analgesics
TEST: • Warm or moist
application
EMG • TENS Unit
• Chew on unaffected side
• Oral care
• Artificial tear
• Soft diet
CN 5 disorder
characterized by pain
along one or more
branches of the CN 5. q Age: 50 y.o
q Gender: Female
Tic douloureux q Compression:
q Arteriosclerosis
Severe sharp pain
describe as electrical shocks q Aneurysm
to one side of the face due q Acoustic neuroma
to irritation of the fifth q Multiple sclerosis
cranial nerve, the trigeminal
nerve. q Infection of the jaw and teeth
q Tumor
Classic Finding:
intense, lightning-like pain is paroxysms q Vascular compression
about hundred times daily.
DIAGNOSTIC TESTS:
CT SCAN
MRI
DIAGNOSTIC TESTS: MEDICAL MANAGEMENT
CT SCAN
MRI
R/O TUMOR
Pharmacologic Therapy
Anti-convulsant (slows
SURGICAL MANAGEMENT firing
carbamazepine
q PERCUTANEOUS RADIOFREQUENCY
RHIZOTOMY Muscle relaxants
baclofen
q MICROVASCULAR DECOMPRESSION
Nerve block (reduce
q RADIOFREQUENZY THERMAL COAGULATION
pain)
botox injections
 NURSING MANAGEMENT
ü Provision of therapeutic environment
ü Room should be kept at moderate temperature and free of drafts to prevent stimulation on
Trigeminal nerve.
ü Avoid jarring the bed or touching the patient’s face that can trigger the onset of pain on the
three branches of trigeminal nerve.
ü Provide lukewarm water and soft cloths or cotton saturated solutions not requiring rinsing for
cleansing the face.

ü Use soft-bristled toothbrush or a warm mouthwash during oral care.

ü Avoid extensive conversation during the acute phase because it may trigger paroxysms of pain.

ü Diet must be high protein and calories and easy to chew.

inflammation of the pia mater, the arachnoid, and the
cerebrospinal fluid-filled subarachnoid space.

SEPTIC VS ASEPTIC
Aseptic meningitis is when something other than a
bacterial infection causes meningitis. Most often, it is
the result of a virus.

Bacterial (septic) meningitis à considered medical

emergency
ETIOLOGY:
ASSESSMENT:
Bacterial(most contagious)
o Headache
Viral
o Fever
o S/sx of meningeal Irritation:
RISK FACTORS: o Nuchal rigidity
• Head trauma o (+) Kernig’s Sign
• Otitis media o (+) Brudzinski Sign
• Sinusitis o Photophobia
• Mastoiditis o Opisthotonos

• Immunosuppression o Skin Lesions (Neisseria meningitidis)

o Seizure
• Systemic sepsis
o Increase ICP

MOT:
BLOOD STREAM/DIRECT SPREAD
Non-communicating hydrocephalus
Friderichsen syndrome
qPharmacologic Treatment
q Penicillin
q Dexamethasone
q Phenytoin

qRespiratory isolation
 Encephalitis is an
inflammation of the
brain parenchyma
(brain tissue) and
often the meninges.
• Etiology: Viral Infection
• Mumps
• Measles

MOT: Direct qChanges in LOC

Invasion
qNuchal Rigidity
qFocal neurologic deficits
qMotor Dysfunction
qS/sx of Increased ICP
Lumbar Puncture
MRI qImprove Tissue cerebral
EEG perfusion

q Adequate oxygenation

q Treatment of Increased ICP

q Intubation & mechanical ventilation qPromotion of comfort

q Pharmacologic Management
q Dexamethasone
qAttain Normal Body
q Acyclovir (Zovirax) temperature
q Anti-pyretic
q Analgesics
q Anticonvulsants
qImprove Tissue cerebral perfusion

q Adequate oxygenation

qPromotion of comfort

qAttain Normal Body temperature

Is a chronic, progressively degenerative disease of the basal
ganglia.
• Cause: Unknown
• RISK FACTORS:
• Age: >30 y.o
• Gender: Male
• Genetics
• Atherosclerosis
• Free radicals
• Viral infections
• Head trauma
• Chronic use of anti-psychotic medications
qAge: >30 y.o
qGender: Male
qGenetics
qAtherosclerosis
qFree radicals
qViral infections
qHead trauma
qChronic use of anti-psychotic
medications
 DIAGNOSTIC TEST:
3 CARDINAL SIGNS PET SCAN
1. Tremors at rest CSF ANALYSIS
2. Rigidity: Cogwheel
3. Bradykinesia

• Micrographia
• Masked-like facial
expression
• Short-shuffling gait.
MEDICATIONS:
1.) Anti-Cholinergic
• Trihexyphenidyl (Artane)
• Benztropine Mesylate (Cogentin)

2.) Anti-histamine: Benadryl

3.) Dopaminergic Agent
• Carbidopa/Levodopa (Sinemet)
• Bromocriptine

4.) Anti-viral: Amantadine

5.) Anti-depressants
6.) Monoamine oxidase Inhibitors:
Selegiline
THALAMOTOMY & PALLIDOTOMY

NEURAL
TRANSPLANTATION
DEEP BRAIN
STIMULATION
qImproving mobility
qEnhancing self-care activities
qImproving bowel elimination
qImproving nutrition
qEnhance swallowing
qImproving communication
qSupporting coping abilities