NCM 216 - CONCEPT

3RD YEAR, SECOND SEM | BATCH 2023 - 2024

SAN PEDRO COLLEGE - BACHELOR IN SCIENCE NURSING

TRANSCRIBED BY:
LECTURER/S: M.J. ADLAWAN
REFERENCES:

ANATOMY AND PHYSIOLOGY OF THE

NERVOUS SYSTEM

NERVOUS SYSTEM
● It is the master controlling and
communicating system of the body
● 10M neurons (basic unit of brain)
● One-way tract
● Brain/Spinal Cord- command system
of CNS
● motor neurons- for moving: somatic
nervous system (voluntary=skeletal), Protection of the CNS
autonomic nervous system ● SKIN/SKULL
(involuntary=cardiac) ○ Major Bones
○ sensory neurons - somatic ○ Fontal
(...) and visceral (pain, ○ Temporal
stretching, nausea, vomiting, ○ Parietal
smell, hunger) sensory ○ Occipital o At 1-2 months,
○ *sympathetic - fight or flight the posterior fontanelle
○ *parasympathetic - rest and closes
digest ○ At 9-18 months, the anterior
fontanelle closes
FUNCTIONS OF THE NERVOUS SYSTEM ● MENINGES
● SENSORY ○ Are connective tissue
○ gathering of information membranes covering and
(stimuli) protecting the CNS.
○ Sensory receptor found in ○ THREE LAYERS
skin and organs receives the ■ Dura Mater- outer
stimuli layer
● INTEGRATION ■ Arachnoid- mid/spider
○ processing and interpret FFweb/contains
sensory input choroid plexus
○ brain and spinal cord responsible for CSF
(interpreted here) production
● MOTOR ■ Pia Matter-
○ output; response in stimuli; inner/nearest layer to
activation of muscle; the brain
secretion of glands ● CEREBROSPINAL FLUID
 ○ Coats the brain and spinal
cord
○ WBC, protein, glucose
○ Formed in the choroid
plexuses
○ Normal Volume: 150 mL
○ Arachnoid villi-site of
absorption of CSF
○ FUNCTIONS OF THE
CEREBROSPINAL FLUID
■ Mechanical
■ Chemical
■ Circulation
Blood-Brain Barrier
● Only water, glucose, essential amino
acids pass through easily the wales
of these capillaries.
● Metabolic waste, such as urea,
toxins, proteins, and most drugs are
prevented from entering the brain
tissue.
● Allows: alcohol, nicotine, heroin
(excess results in CNS disorder) • In
infants (bilirubin)
Cerebral Circulation
● 15% of cardiac output or 750 mL/min
blood
○ any decrease in blood flow
the brain would be directly
affected
○ autoregulation - will
compensate
THE NERVOUS TISSUE
● STRUCTURE AND FUNCTION
○ Neurons- basic unit of a
nerve tissue; transmit
messages from one part of
the body to the another.
● Functional classifications
○ Sensory (Afferent) Neurons-
carry impulses to the brain
○ Motor (efferent) neurons -
carry impulses from the brain
○ Interneurons/association
neurons - found in the brain
and spinal cord
Sensory Neurons
● Carry impulses from the sense
organs (receptors) to the brain and
spinal cord.
● KINDS OF RECEPTORS
○ Naked nerve cells - pain and
temperature
○ Meissner's corpuscle - touch
receptor
○ Pacinian corpuscle - deep
pressure
○ Muscle spindle
(proprioceptor)- respond to a
degree of stretch or tension
 ○ Nodes of Ranvier - interval
Motor Neurons (Efferent)
between/spaces
● Carry impulses from the brain and ○ Schwann cells - made up the
spinal cord to muscles and glands peripheral nervous system.
● Muscles and glands are two types of ○ Oligodendrocytes - made up
effectors. In response to impulses, the central nervous system
muscles contract and glands secrete ● DEFINING TERMS
○ TRACTS - bundle of nerve
Interneurons fibers in the CNS
○ NERVES - PNS
● Connect sensory and motor neurons
○ WHITE MATTER - collection
and carry impulses between them
of myelinated fibers (tracts)
● They are found entirely within the
○ GRAY MATTER - mostly
central nervous system
unmyelinated fiber and cell
● PARTS OF AN INTERNEURON
bodies
○ Cell body- Is the metabolic
center of the neuron
○ Dendrites (Arms)- Conveying
incoming messages toward
the body
○ Axons (Cables)- Generates
nerve impulses and conduct
them away from the cell
body; cable relay nerve
impulses
○ Axon Terminals- gives off
collateral branches; contains
tiny vesicles Neuroglia
(neurotransmitter) ● Provides protection, support and
○ Synapse- separates axon insulation to the delicate neuron
terminals of another neuron ● TYPES OF NEUROGLIA
○ Myelin- insulates the nerve ○ Astrocytes - part of the BBB
fibers and increases the and also covers visceral and
transmission rate of nerve capillaries
impulses. ○ Microglia - … phagocytosis
○ Axon hillock - area of cell ○ Ependymal cells - epithelial
body where axon arises • cells that line the CNS
Axon terminal / axon end - ○ Oligodendrocytes -
tiny membranous sacs responsible for myelin sheath
(sympathetic end bulb)
○ Axon collateral - side Neuron Physiology
branches
○ Myelin sheath - protects thea ● FUNCTIONAL PROPERTIES
xin and increase
transmission of nerves
 ○ Irritability - the ability to
respond to a stimulus and
convert it to a nerve impulse
○ Conductivity - the ability to
transmit impulses; “to travel”
● PHASES OF IRRITABILITY - CEREBRAL CORTEX
Involves the sodium potassium
pump as nerve impulses are being
translated
○ POLARIZATION
■ Inside of neurons are
negatively charged
and the outside is
positively charged.
■ Potassium is
dominant inside the
cell and sodium is
dominant outside the
cell
○ DEPOLARIZATION
■ Stimuli excite
neurons; sodium
diffuse intracellular
and some of the
potassium goes
outside
○ PROPAGATION OF ACTION
POTENTIAL
■ neuron is more
permeable to sodium
○ REPOLARIZATION
(HYPERPOLARIZATION)
■ sodium potassium
pump begins to
functions; sodium is
pumped out of he cell
and brings sodium
back inside the cell
ANATOMY AND PHYSIOLOGY OF THE
BRAIN
● Largest and most complex nervous
tissue in the body
● Subdivided according to its parts
and functions
Functional Anatomy of the Brain
● Speech, memory, logical and
emotional response, as well as
consciousness, interpretation of
sensation and voluntary movements
● LEFT HEMISPHERE
○ Control of muscles on the
Right side of the body
○ Spoken and written language
○ Numerical and Scientific
skills
○ Reasoning
○ Systematic analysis
● RIGHT HEMISPHERE
○ Control of muscles on the L
side of the body
○ Musical and artistic
awareness
○ Space and pattern
perception
○ Insight
○ Imagination
○ Generating mental image to
compare spatial relationship
● FRONTAL LOBE
○ Controls voluntary motor
activity
○ Reasoning, concentration,
abstraction o Memory,
speech motor function
○ Contains the BROCA’S
AREA - speech function
■ Located in the left
hemisphere
■ Broca’s aphasia =
speech disorder (poor
grammar, difficulty
forming sentences,
omits words)
 ○ Voluntary eye movement
○ Access to current and past
information experience
○ Judgment
○ Regulates behavior based
on judgement and foresight
● PARIETAL LOBE
○ Contains Somatic Sensory
Areas (sensation, texture,
size, shape, and spatial
relationship)
○ Pain, coldness, light touch
○ Taste impulses for
interpretation
○ Important for singing, playing
musical instrument, and
processing nonverbal
experiences
● TEMPORAL LOBE
○ Auditory area o Deep inside
the temporal lobe: Olfactory
area
○ Wernicke’s Area - contains
motor neurons in the
comprehension of speech
○ If damaged: Dyslexia or
Wernicke’s aphasia -
problem in understanding
and communicating
■ Note: Global aphasia
- both Broca’s and
Wernicke’s area are
affected - problem in
speech and
comprehension
● OCCIPITAL LOBE
○ Contains the visual area /
visual interpretation
○ Damaged: visual agnosia -
problem in recognition and
identification
DIENCEPHALONS
● THALAMUS
○ The relay station for sensory
impulses passing upward the
sensory cortex
● HYPOTHALAMUS
○ ypothalamus o Regulates
body temperature, water
balance, metabolism, centre
for emotions, and regulates
the pituitary gland
● EPITHALAMUS
○ Pineal Body
■ Probable role in
growth and
development ▪
Regulate the food
getting reflex (hunger)
BRAIN STEM
● Sensory and motor pathway; center
for auditory and visual reflexes
● MIDBRAIN
○ Responsible for motor
coordination o Visual reflex
and auditory relay centers
● PONS - motor and sensory pathway
(controls HR, RR, BP)
○ Contains respiratory center
○ Regulates breathing
○ Pneumotxic - limits duration
of inspiration
○ Apneustic - prolong
inspiration
● MEDULLA OBLONGATA - contains
motor and sensory fibers
○ It contains centers that
control
■ Heart rate
■ Breathing
■ Swallowing
■ Vomiting
○ Cardiac Slowing
● RETICULAR FORMATION
○ Are involved in motor control
of visceral organs
 ○ Reticular activating system - arms, neck and upper
plays a role in consciousness trunk
and the awake/sleep cycles ○ THORACIC NERVE (Nerves
in the upper back)- T1 to T12
CEREBELLUM ■ Supply the trunk and
● Excitatory and inhibitory actions abdomen
● Controls balance and equilibrium ■ Paraplegic
(coordination of movements) ○ LUMBAR AND SACRAL
○ Fine motor, balance, position NERVES (from the lower
sense, integration of sensory back) L1 to L5
input ■ Supply the legs,
● Damaged: cerebellar ataxia bladder, bowel, and
○ Ataxia - abnormal movement sexual organs
or unsteady gait ○ CAUDA EQUINA (S1-S5)
■ Collection spinal
nerves at inferior end
ANATOMY AND PHYSIOLOGY OF THE
LIMBIC SYSTEM of spinal canal

● Medial Site of Temporal Lobe

● Function: Emotions
● The limbic system (or the limbic
areas) is a group of structures that
includes the amygdala, the
hippocampus, mamillary bodies and
cingulate gyrus
● These are areas important for
controlling the emotional response to
a given situation
● The hippocampus is also important
for memory

SPINAL CORD
● Major conduits and reflex center
● Approximately 17-18 inches long
● Major reflex center
● Has 31 pairs of spinal nerves
● C1-C8, T1-T12, L1-L5, S1-S5, C1
● 21 pairs DERMATOMES
○ CERVICAL NERVES ● Is an area of the skin innervated by
(Nerves in the neck)- C1 to all the cutaneous neurons of a single
C7 spinal nerve or cranial nerve V.
■ Supply movement ● Everyone has threshold of pain and
and feelings it varies between individuals
(sensation) to the
 Kinds of Reflexes HEALTH HISTORY
VISCERAL REFLEXES ● Interview- procvides information of
● Reflex that causes smooth or the current condition
cardiac muscle to contract or glands ● Observation
to secrete. Ex: heart rate, respiratory ● Over-all appearance
rate, - Posture, movement,
● Involuntary reflexes hygiene, grooming
● Behavior
SOMATIC REFLEXES - Level of
● Are those that result in the consciousness
contraction of skeletal muscles - Expression
● voluntary reflexes - Body language
● Cognitive Level of
KNEE-JERK REFLEX Functioning
● The knee-jerk-reflex is an ipsilateral - Attention Span
reflex. The receptor and effector - Memory (recent,
organs are on the same side of the remote, immediate)
spinal cord.
● The knee-jerk reflex is also a
MENTAL STATUS EXAM
monosynaptic reflex because it
involves only two neurons and one ● Psychiatric practice; history and
synapse examination
● A structured way of observing and
FLEXOR OR WITHDRAWAL REFLEX describing a patient’s current state of
● Is a polysynaptic reflex and involves mind under the domains:
association neurons in addition to ○ Orientation: knowing person,
sensory and motor neurons; place, and time
instantaneous responses ○ Attention: concentrate on a
mental task (simple
EXTENSOR REFLEX subtractions)
● Causes a reciprocal inhibition if a ○ Registration: listen and
muscles within the opposite repeat back a few words
appendages. This type of reflex ○ Recall: remember words a
inhibition is important in maintaining few minutes later
balance ■ Ask questions that
another person verify
○ Language: speech quality,
DIAGNOSTICS AND ASSESSMENTS rate of production (slow,
stuttered)
○ Constructional or
DIFFERENT TYPES OF ASSESSMENTS visuospatial: copy or draw an
object or diagram (e.g. face
of the clock)
 ○ Abstract thinking: explain the
meaning of a proverb, or to
explain the difference
between two objects (thought
process)
● A snapshot of patient’s condition

GLASGOW COMA SCALE (GCS)

● Level of consciousness
● Overall state of the Central Nervous
System

MOTOR SYSTEM ASSESSMENT

● Muscle size
○ Severe atrophy suggests
denervation of a muscle
(Lower Motor Neuron
damage)
● Muscle tone
○ Rigidity: parkinson's disease
o
○ Resistance to passive stretch
o
○ Spasticity: upper motor
neuron damage; increased
muscle tone o
● Flaccidity: decrease muscle tone •
Strength - tested through applying
resistance
○ 0: complete paralysis
○ 1: weak muscle contraction
○ 2: with ROM if without gravity
○ 3: with ROM with gravity
Note: in checking for pain response, use the ○ 4: with ROM if with moderate
CENTRAL STIMULUS (trapezius pinch, resistance
supraorbital notch, sternal rub) for 10 ○ 5: with ROM if with normal
seconds resistance
● Coordination - tested through
performing a series of movements
 (e.g. tapping of thighs, legs as fast
as possible)
● Balance
○ Romberg’s Test: to check
sense of balance.
ROMBERG’S TEST
● PATIENT IS AT RISK FOR FALL
● Ask the subject to stand erect with
feet together and eyes close
● A positive Romberg test suggest that
ATAXIA (hearing and balance;
damaged in CN VIII) is sensory in
nature. A negative Romberg test
suggest that ataxia is cerebellar in
nature.
○ ATAXIA: incoordination of
voluntary muscle action,
particularly those used in
○ walking, reaching for objects
REFLEXES
● Biceps reflex
● Tricep reflex
● Brachoradialis reflex
● Patellar reflex (Knee-jerk)
● Achilles tendon flex
● Babinski
○ Dorsiflexion of the ankle and
great toe with fanning of the
other toes
○ Fanning is normal in infants
○ Adults: indicate an upper
motor neuron damage
○ N: no fanning of other toes
● Corneal: loss of blink reflex; cranial
nerve V dysfunction
● Gag: loss of gag reflex; cranial nerve
IX and X
SPECIAL NEURO ASSESSMENT
● In meningeal irritation (meningitis):
○ Brudzinski’s Sign
■ Flexion of the head
causes flexion of
thigh at the hips and
knee flexion (+)
○ Kernig’s Sign
■ Flexion of the thigh
and knee at right
angles when the
limbs are extended, it
causes spasm of the
hamstring and pain.
○ Lhermitte’s Sign
■ An electrical
sensation that runs
down the back and
into the limbs, and is
produced by bending
the neck forwards
and/or backward
■ Multiple sclerosis or
herniation
● Uthoff’s Phenomenon
○ visual problems that occur in
persons with MS brought on
during periods of increased
body temperature.
SKULL AND SPINAL RADIOGRAPHY
● Skull- Reveal the size and the shape
of the skull bones, suture separation
in infants, fractures or bony defects
or calcifications
● Spinal- Identify fractures, dislocation,
compression, curvature, erosion,
narrowed spinal cord and
degenerative processes
● Pre-procedure
○ Maintain immobilization of
the neck if spinal fracture is
suspected
 ○ Remove metal items from
body parts
○ Document if the patient has
thick and heavy hair because
it may affect the
interpretation of the x-ray film
● Post-procedure
○ Maintain immobilization until
the results are known
CT SCAN
● A type of brain scanning that may or
may not require an injection of a dye
● Tells the difference in tissue density
● Detect intracranial bleeding, lesions,
edema, infarctions, hydrocephalus
and cerebral atrophy.
Pre-Procedure:
● Informed consent if with dye
● (+) hot, flushed and metallic taste in
the mouth
● Assess for allergies and
claustrophobia
● Instruct to lie still and flat during the
test
● Remove objects from the head
● Inform of the possible mechanical
noises
Post-Procedure:
● Replacement fluids for diuresis (to
excrete dye)
● Allergic reactions to dye
● Assess dye injection site for
bleeding, hematoma, extremity color
and pulses
MAGNETIC RESONANCE IMAGING
● Identifies types of tissues, tumors
and vascular abnormalities
● Similar to CT scan but provides
more detailed picture
● Uses magnetic fields
● Results can show the chemical
changes within a cell
Pre-Procedure:
● Remove all metal objects
● Contraindicated to patients with
pacemakers implanted defibrillator,
metal implants
● Assess for claustrophobia
● Determine if contrast agent will be
given
● Instruct to remain still during the
procedure
Post-Procedure:
● Normal activities; diuresis if with
contrast agent
ELECTROENCEPHALOGRAPHY
● A graphic recording of electrical
activity of the superficial layers of the
cerebral cortex
● Electrodes are placed on the scalp
● Gel is placed to allow the electrodes
to stick on the scalp
● Duration: 45 to 60 minutes
● Overnight EEG: 12 hours
Pre-Procedure:
● Wash hair
● Inform that electrodes are attached
and that electricity DOES NOT enter
● Withhold stimulants (coffee,
chocolate, tea, cola),
antidepressants, tranquilizers,
anticonvulsants for 24-48 hours
before the test
● Premedicate as prescribe (muscle
relaxant if anxious)
Post Procedure:
 ● Wash hair
● Maintain safety if patient was
sedated
POSITION EMISSION TOMOGRAPHY
● A test that uses a special type of
camera and a tracer (radioactive
chemical) to look at organs in the
body
○ Tracer reacts to areas with
metabolic changes
○ Tracer can be injected or
inhaled
● Do not smoke or drink caffeine or
alcohol for 24 hours before this test
● Do not eat or drink for 8 hours
before this test; NPO
● The tracer may make you feel warm
and flushed; dizziness,
lightheadedness, and headache if
tracer was administered through
inhalation
INVASIVE DIAGNOSTIC
EXAMINATIONS
LUMBAR PUNCTURE/SPINAL TAP
● Insertion of a spinal needle through
the L3-L4 interspace into the lumbar
subarachnoid space to obtain CSF,
measure CSF pressure or instill dye
or medications.
● Assess for glucose, protein
● Contraindication
○ Increase ICP due to rapid
decrease of CSF around the
spinal cord = brain herniation
Pre-procedure:
● Informed consent (Physician’s
responsibility)
● Empty bladder
During:
● Lateral recumbent with knees drawn
up to the abdomen and chin onto the
chest (position patient at the edge of
the bed)
● Maintain strict asepsis
○ Usually involves 2 physicians
(one does the procedure, the
other assists and hands the
tube)
Post-procedure:
● Monitor VS and NVS
● Position flat as prescribed - post
lumbar puncture headache (mild to
severe) because of the reduction in
CSF for 4-6 hours
● Monitor I/O, force fluids
MYELOGRAM
● X-ray
● Injection of dye or air into the
subarachnoid space to detect
abnormalities of the spinal cord and
vertebrae
● Detect distortion in spinal cord,
dorsal sac, tumor, cyst
Pre-Procedure:
● Obtain informed consent
● Assess for allergies of iodine
● Premedicate for sedation if
prescribed
Post-Procedure:
● Assess VS and NVS
● Dye
○ Water based: elevate head
15-30 degrees; 6-8 hours
○ Oil based: flat for 6-8 hours
 ○ Air: keep head lower than
trunk 48 hours
● Monitor I/O, bladder distention and
vomiting
CEREBRAL ANGIOGRAPHY
● Injection of a contrast through the
femoral artery into the carotid
arteries to visualize the cerebral
arteries and assess for lesions.
● Contrast dye - help us visualize for
any vascular disease, rysm, AVM,
lesions
● Performed before any craniotomy, to
know if cerebral blood
flow/circulation is adequate and
determine which site
● Usually, femoral artery is used
Pre-Procedure:
● Informed consent
● Assess for allergies
● NPO 4-6 hours prior
● Obtain baseline neurological
assessment
● Mark peripheral pulse
Post Procedure:
● Monitor VS, NVS
● Assess for allergic reaction -
swelling of neck or difficulty
breathing
● Elevate head of bed 15-30 degrees
only if prescribed
● Keep bed flat if femoral artery is
used
● Assess peripheral pulses
● Apply sandbags and pressure
dressing; ice on puncture site
ELECTROMYOGRAPHY
● Test that checks the health of the
muscles and the nerves that control
the muscles; shows impaired muscle
strength.
● A very thin needle electrode will be
inserted through the skin into the
muscle and picks up the electrical
activity which will be displayed on an
oscilloscope
● Muscle response to electrical activity
to nerve stimulation
● Twitching or moving of muscle -
response
SEIZURE DISORDER
● Is a sudden, abnormal electrical
discharge from the brain that results
in charges in sensation, behavior,
movement, perception and
consciousness.
● Excessive electrical discharges from
cerebral neurons.
● Most of seizures are transient
● Epilepsy- is a chronic disorder of
recurrent seizure
● Etiology- pathologically acquired
epilepsy, biochemical epilepsy
(chemical imbalance), posttraumatic,
idiopathic.
Classification
● Partial Seizure
○ localized - affects one part
● Generalized Seizure
○ systemic; no specific area
where it started
Partial Seizure
● Begin in one are or the brain
● Can be caused by any type of focal
injury that leaves scar tangles
● Developmental scars - one that
occurs as part of the fetal and early
 growth of the brain - are common
causes of focal seizures in children
● 1. Simple Partial Seizure - not
accompanied by loss of
consciousness
● 2. Complex Partial Seizure -
automatism (performance of actions
without conscious thought or
intention
Simple-Partial Seizure
● With motor signs - JACKSONIAN
MARCH
● With sensory symptoms - Tingling
sensation, visual, auditory, gustatory
or olfactory (Phantosmia)
phenomena
● With autonomic symptoms or signs
Tachycardia, diaphoresis,
hypo/hypertension
● Psychic symptoms - detachment,
depersonalization, dreamy state
● Memory distortion:
○ Deja vu - feeling that one
has seen something before
○ Deja entendu - feeling that
one has heard something
before
○ Jamais vu - feeling that one
has never heard something
that is familiar
○ Jamais entendu - feeling
that one has never heard
something that is familiar
● Time distortion
Complex-Partial Seizure
● Involves impairment of
consciousness
● “Vacant or “frightened” look
● Types of automatism
○ Alimentary: chewing,
increased salivation,
borborygmi
○ Mimetic: facial expression of
fear, bewilderment,
discomfort, tranquility,
laughter, crying
○ Gestural: repetitive
movements of the hands,
fingers, sexual gestures
○ Ambulatory: wandering,
running
○ Verbal: repeated short
phrases or swearing
Generalized Seizure
● Grandmal seizure (tonic clonic) -
causes a loss of consciousness and
violent muscle contractions
○ Pre-ictal - mood changes,
anxiety, feeling lightheaded,
difficulty sleeping, difficulty
staying focused behavior
changes
○ Aura
○ Ictal Phase:
■ Tonic: muscular
rigidity/ extension of
extremities
■ 10-20 seconds
■ CLONIC: muscular
jerking
■ 2 minutes
○ Post-Ictal Phase: sleep
● PETIT-MAL (absences seizure)
○ Occurs to children ages
4-puberty
○ The victim appears to be
daydreaming
○ 30 seconds
● MYOCLONIC
○ Involves a sudden
uncontrollable jerking
 movements of either a single
muscle group
● ATONIC
○ Associated with total loss of
muscle tone
○ Known as drop attacks
● Febrile Seizures - Convulsion
Complications
● STATUS EPILEPTICUS -
continuous seizure lasting for more
than 30 minutes without full recovery
in between
● Drug treatmemt algorithms for status
epilepticus generally go through
three stages, starting with
benzodiazepines: lorazepam,
midazolam, or diazepam as first
line drugs, moving to levetiracetam,
valporate or fos-phenytoin as
second line drugs, ending, if
necessary, with anesthetics like
propofol or midazolam
Diagnostic Test
● EEG
○ EEG PREPARATION:
■ Clean, dry hair with
no added oils, gels,
hairspray or other
fixatives
■ No weaves, wraps,
braids, or other
attached hairpieces
■ You can eat before
the test, but NO
caffeine on the day of
the test
■ No coffee, colas, or
other caffeinated
products
● MRI
● PET Scan
Medication
● Phenytoin (Dilantin) - it is useful for
the prevention of tonic- clonic
seizure and focal seizure
● Phenobarbital (barbiturate) -
anticonvulsant
● Carbamazepine (Tegretol) -
anticonvulsant
● Ethosuximide (Zarotin) - used to
treat absence seizure
● Valproic Acid - useful for the
prevention of seizures in those with
absence seizure, partial seizure,
generalized seizure
● Diazepam (Valium)
Surgical Management
● Cortical Resection/Corpus
Callostomy
○ Surgical procedure that
disconnects the cerebral
hemisphere, resulting in a
condition called split brain
● Temporal lobectomy - removal of a
lobe
● Hemispherectomy
○ Very rare surgical procedure
where one cerebral
hemisphere (half of the brain)
is removed or disabled
● Vagal nerve Stimulator implants
Nursing Management
● Seizure precaution: Assessment
Preparation
○ Monitor temperature and
respiration
○ Note level of consciousness
○ Provide a quiet, dimly lighted
rooms
 ○ Prepare plastic airways and
suction machine
● Safety
○ Side- rails up (fall precaution)
○ Ease the patient to the floor
(if sitting on a chair)
○ Remove pillow (if in bed)
○ Loosen constrictive clothing
○ Position patient on one side if
possible
○ Do no restrain
● Airway
○ Suctioning
○ Oxygen
● Post-seizure Activity
○ Aspiration prevention -
concern for patient having
seizure
○ Reorient patient
○ Periods of apnea can happen
right after seizure, during or
after
HEADACHE
I. TENSION HEADACHE
● Caused by irritation of pain-sensitive
structures of the brain
○ Structures: trigeminal,
facial,glossopharyngeal, vagus, and cervical
nerves - sensory neurons
● Chronic or Episodic
○ Episodic : fewer 15 days a month
○ Chronic: more than 15 days a month
NOTE:
● Feels like there is tight band due
to fatigue or stress or muscle contraction.
Usually, patient needs rest and muscle
relaxant.
CAUSES:
● Results from muscle contraction
● Fatigue or stress
MANIFESTATION:
● Describe as a tight band-like discomfort
that is unrelenting (pain over forehead going
to temporal and occipital lobe d/t fatigue or
stress)
- Massage can relieve tension
headache

● Also known as CEPHALGIA II. CLUSTER HEADACHE

● Have a cyclical pattern of 1-3 short-lived
Classification attacks of periorbital pain. “alarm clock
headache”
● Ipsilateral pain
● PRIMARY – is one for which no organic
○ One side pain
cause can
● Occurs more often in men
be identified
CAUSES:
○ The main cause or signs and symptoms
● ROH consumption
of
○ Not same with hangover because
the problem
this feels like nabibiak ang ulo
● SECONDARY – is a symptom associated
MANIFESTATION:
with an
● Pain described as deep, boring, intense
organic cause, such as in brain tumor or an
pain of such severity that the client has
aneurysm
difficulty remaining still
○ SE: Sign or symptom of a problem
II. MIGRAINE HEADACHE
Types of Headache
● Considered as “vascular headache”, ● AURA – transient sensory changes prior
vasospasm & ischemia of intracranial vessel to attack
being the cause of pain ○ Blurred vision
○ Nagapitik ang pain (like a pulse) ○ Appearance of floaters (tiny
● Most often unilateral (one sided), specks that float before the eyes)
but pain may occur on alternate ○ Flashes of light or color, or blurry
sides with different attack vision
● ETIOLOGY: Idiopathic ○ A blind spot or even complete
CATEGORIES: blindness in one eye
● With AURA ○ Double vision
● Without aura ○ Numbness or tingling of the hands,
RISK FACTORS: feet,
● Menstrual cycle - because of the changes and/or face (particularly around the
in hormones mouth)
● Stress ○ Stiff neck
● Depression ○ Weakness
● Sleep Deprivation ○ Vertigo or dizziness
● Fatigue ○ Loss of balance
● Overuse of Meds ○ Ringing in the ears
● Tyramine-rich foods ○ Difficulty talking
○ Slow thinking or confusion
○ Problems with concentration
Phases of Migraine Headache
○ Changes in mood and activity level
● HEADACHE – moderate to severe
● PRODOME or aura - symptoms felt by headache that
patient lasts for 4-72 hours
24-48 hrs prior to attack ○ Extreme sensitivity to light, sound
○ Similar to aura pero mas matagal and
ito smell
○ Indicate na magkakaroon ka ng ○ Nausea
migraine attack ○ Vomiting
○ If hindi maagapan, it will lead to an ○ Increased pain with physical
attack activity (such
○ Fatigue as walking or going up or down the
○ Frequent yawning stairs)
○ Fluid retention ○ Throbbing pain and is usually on
○ Increased urination one side
○ Muscle stiffness, especially in the of the head
neck, back and face STATUS MIGRAINOSUS
○ Constipation or diarrhea ● a debilitating migraine attack lasting for
○ Food cravings more than
○ Depression or irritability 72 hours; higher risk for stroke
○ Difficulty concentrating ● Hindi ka makakagalaw kaya kailanagn na
○ Feeling cold pumunta
sa hospital because may possibility na ○ Sumatriptan (Imitrex)
magka ● ERGOTAMINES
storke ka becasue vascular problem ito. ○ Ergotamine tartrate - Can be
● Recovery or Post prodome – may take preventive and abortive because it
hours or causes vasoconstriction
days ● ANTI-EPILEPTICS
- Nanghihina ang patient, sometimes may ○ Topiramate
Confusion ○ Gabapentin
○ Fatigue ○ Preventive type
○ Weakness
○ Irritability
○ Anxiety
○ Depression
○ Difficulty concentrating
○ Scalp tenderness

SECONDARY HEADACHE

● LUMBAR PUNCTURE HEADACHE

○ Loss of CSF volume with LP decreases
the brain supportive cushion
○ If hindi niyo gi lie flat on bed then
magkaka headache.
● POST CONCUSSION HEADACHE
Nursing Management
○ After seemingly trivial head injuries &
particularly after rear-end motor vehicle
collisions
○ Nabagok ka then taod2 nagsakit imong
ulo
DIAGNOSTIC TESTS
● Detailed history taking
● Complete physical & neurological
examination
● CT-scan
● MRI
● Cerebral angiography
MEDICAL MANAGEMENT
● Preventive
○ NSAIDS
● Abortive
○ SEA medications
MEDICATIONS
● SEROTONIN RECEPTOR ANTAGONIST SPINAL CORD INJURY
 ° movement by which the two elements of
any jointed part are drawn away from each
other
E. Axial Loading
° a sudden, excessive compression which
drives the weight of the body against the
head
ex: downward blow to the head, upward
force to the feet
F. Excessive Rotation
° movement of the body about the body’s
axis

Types of Injury
● Complete
° total paralysis (loss of function) below the
level of the injury
● Incomplete
° some function remains on one or both
sides of the body

Causes
● MVA
● FALLS
● VIOLENCE
● SPORTS RELATED
● SURGICAL COMPLICATIONS

Mechanism of Injury
A. Distraction
° the pulling apart of the spine
ex: suicide by hanging, Gunshot wounds
tomthe chest, back, and abdomen
B. Lateral Bending
° the head and neck are bent to one side,
beyond normal limits.
C. Hyperflexion
°the act of bending or the condition of being
bent
D. Hyperextension
 Assessment
● Cardiovascular
° Lesions above T5: bradycardia,
hypotension, postural hypotension, absence
of vasomotor tone
● Gastrointestinal
° decrease or absence of bowel sound

(paralytic ileus in lesions above T5)

Paralysis followingSpinal Cord Injury
° abdominal distention
° constipation
° fecal incontinence
° fecal impaction
● Urinary
° retention for lesions between T1 and L2
°flaccid bladder (acute stage). Loss of nerve
innervations causes atony of the bladder
which causes urine retention.
° spasticity with reflex bladder emptying
(later stage)
● Reproductive

° Priapism (prolonged and painful penile

erection)
° Loss of sexual function
● Neurologic
i.complete
● Flaccid paralysis & anesthesia below
level of injury
● Tetraplegia
 ● Paraplegia ● Spinal RADIOGRAPHY
ii.incomplete ● CT/ MRI
● ECG
● Musculoskeletal
° Muscle arony (in flaccid state
Emergency Management
° Contractures (in spastic state)

1. Immobilize on a spinal back board

Complications 2. Avoid flexion, rotation and extension
1. Spinal Shock of patient’s neck and head
° S/SX: no reflexes, no sensation, no 3. Transport the patient to spinal injury
somatic and visceral distention or trauma centers
° Indication of Recovery:
● Reappearance of reflex activity,
Medical Management
hyperreflexia, spasticity, reflex
emptying of the bladder
2. Neurogenic Shock 1. Pharmacologic Therapy
° develops due to the loss of autonomic 2. Respiratory Therapy
nervous system function below the level of 3. Skeletal Fracture Reduction &
the lesion. Traction
3. Autonomic Dysreflexia
° is a complication with a lesion T4-T6. Surgical Management
° a hypertensive medical emergency
° caused by:
Laminectomy - surgical procedure that
● Overdistended bladder
removes a portion of a vertebra called
● Rectal stimulation
lamina, which is the roof of the spinal canal.
● Impaction
S/SX:
● Piloerection
● Severe HPN
● Headache Nursing Management
● Diaphoresis
● Nasal congestion 1.
2. Promoting adequate breathing &
Management airway
3. Improve mobility
4. Promoting adaptation top sensory &
● Elevate head of the bed
perceptual alterations
● Check the patency of catheter
5. Maintaining skin integrity
● Administer Hydralazine (Apresoline)
6. Maintaining urinary elimination
● Vasodilators
7. Improving bowel function
8. Providing comfort measures
9. Prevention of thrombophlebitis
Diagnostic Tests

NEUROLOGICAL TRAUMA
Head Injury
- The National Head Injury Foundation
defines TBI as a traumatic insult to
the brain capable of causing
physical, intellectual, emotional,
social,,and vocational changes.
- Common in vehicular accident,
violence, fall = TRAUMA (common
cause of death in head injury)
Classifications
● Scalp Injury
- Abrasions, bruising, laceration in the
head
- Minor injury
● Skull Fracture
- A skull fracture is a break in the
continuity of the skull caused by
forceful trauma
TYPES OF SKULL FRACTURE
SIMPLE
- fracture happens in the skull without
breaking the skin
- Blunt trauma
COMMINUTED
- Splintering of the skull
- 2-3 pieces
DEPRESSED
- Depression going inward to the
cranium or into the skull
- Very dangerous injury
BASILAR
- Injury at the base of the skull
- Very dangerous injury
CLINICAL MANIFESTATIONS
- Usually seen in Basilar Skull
Fracture
Battle’s Sign - post-auricular hematoma
Raccoon’s eye - periocular ecchymosis
Subconjunctival Hemorrhage - red patches
in the sclera
Rhinorrhea
- Runny nose
- Important factor to check:
discharges in the nose
- Discharges should be check if it is
CSF or not o How? Use gauze to get
discharge, then weigh
- Observed: HALO SIGN - there's a
development of halo(+)
- Yellowish discharge outside and red
inside = (+) CSF leak (but still need
further testing)
- Otorrhea - halo sign.
BRAIN INJURY
Head Injury
- Injury in the skull, scalp, may lead to
brain injury
Classifications
- Closed trauma or Blunt trauma - no
opening skull/dura
- Open brain injury - (+) opening in
skull/ dura; injury, gunshot
Mechanism of brain injury
- Blunt impact - impact
- Penetrating injury -bullets
- Blast injury - impact/pressure d/t an
explosion
- Accelerating/decelerating force -
sudden/violent motion move tissues
around the brain (e.g. whip lash
injury)
Risk Factors
- Blunt trauma
- Penetrating trauma
- Coup and countercoup
- Coup - moving objects impacting a
stationary head
- Countercoup - brain or head strikes
a stationary object (e.g. fall)
 - Pressure on blood vessels within the
brain causes blood flow to slow
down:
- Compression = decreased blood
flow
- Cerebral hypoxia and ischemia
occurs = autoregulation happens
causing more blood flow to area ->
contribute to increased intracranial
volume -> increased ICP
TYPES OF BRAIN INJURY
CONCUSSION
- Jarring of the brain; alteration in
LOC due to trauma
- Affecting the whole brain.
CONTUSION
- Localized injury or bruising type of
injury to the brain
- Much more can cause mortality
because of the localized or bruising
of the brain that might cause
microtrauma
DIFFUSE AXONAL INJURY
- Axons are injured because of rapid
changing in the skull
- Shearing of the axons
- A micro injury; diffused in nature;
difficult to diagnose
- Anywhere in brain tissue
- Alteration in LOC (manifestation)
- Headache, nausea and vomiting,
drowsiness (depending which part is
the injury
INTRACRANIAL HEMORRHAGE
- Brain bleeds
- Bleeding because of the trauma or
injury subjected to the cranium
affecting the brain
- Subtype:
- Epidural Hematoma (EDH):
meningeal artery affectation;
bleeding in skull and dura
mater
- Subdural Hematoma (SDH):
is a hemorrhage from small
vessel between the dura and
arachnoid
- Subarachnoid Hemorrhage:
result from blunt trauma;
s/sx: nuchal rigidity, (+)
- Kernig’s, (+) Brudzinski —-
Deterioration of LOC,
hemiparesis
- Intracerebral Hematoma
(ICH): bleeding into brain
tissue from contusion or
laceration.
ASSESSMENT
- Headache
- Confusion
- Altered LOC
- Absent corneal reflex
- Pupillary abnormalities
- Vision and hearing impairment
- Sudden Onset of neurological
deficits
- Seizures
- S/sx of increased ICP
- Where did injury occur
- Causes of injury
- What direction?
- GCS
 MANAGEMENT MEDICAL
MANAGEMENT
Treatment of increased ICP (increase
volume - swelling (problem)
- Supportive measures
- Mechanical ventilation
- Seizure prevention
- F&E maintenance
- Nutritional Support
- Pain Management
- Surgical Management
- Goal - decompression
- Craniectomy
- Opening of the
cranium without
putting back the bone
fragment
- Craniotomy
- Bone fragment is
replaced
- Burr Hole
- Decompression, evacuation
of clot and abscess
- Burr holes are small holes
that a neurosurgeon makes
in the skull. Burr holes are
used to help relieve pressure
on the brain when fluid, such
as blood, builds up and starts
to compress brain tissue.
- Cranioplasty - reconstruction of bone
- Surgical Approach
- Supratentorial
- Provide access to the
frontal, temporal,
occipital, and parietal
lobe
- Post-operative:
Position: head
elevated
- Infratentorial
- Provide access to the
lesion in the
brainstem.
- Post-operative: flat on
bed.
NURSING MANAGEMENT
- Maintain Patent Airway (ABCD)
- Neurological assessment
- Treatment of ICP
- Supportive measures
- Electrolyte and Fluid Balance (for
edema and fluid imbalance)
- Adequate Nutrition
- PEG gastrostomy tube
- For patients on
ventilator
- Patients are not
advised to have
prolonged TPN d/t
side effects (irritates
the veins because it’s
a vesicant; hence
central lines need to
be used; central lines
make patients prone
to infection)
- Prevention of Injury
- Maintaining Skin Integrity (patients
are bedbound for a long time)
- Electric pressure sore bed.
ANEURYSM
● An intracranial aneurysm is the
weakness in the tunic media, the
middle layer of the blood vessels -
three layers: tunica intima, tunica
media (middle layer), adventitia
(outer layer)
● The most common type is saccular
or berry aneurysm
● Are found more often in the anterior ○ III- Lethargic or confused,
cerebral circulation mild or focal deficit
○ IV- Stupurous, moderate to
severe hemiparesis, possible
Types of Aneurysm
early decerebrate rigidity.
● Saccular Aneurysms = most ○ V- Deep Coma, decerebrate
common form of aneurysm; Berry rigidity, moribund
● Fusiform Aneurysms - both sides are appearance. ▪
weakened ■ IV and V: POOR
● Dissecting Aneurysm - pair is in the PROGNOSIS
inner most layer, blood will collect in
the tunica media
DIagnostic Tests
● History Taking
Risk Factor
● Physical Assessment
● Smoking • Hypertension (common) ● CT Scan
● Atherosclerosis (common) ● MRI
● Alcohol abuse ● Transcranial Doppler
● Stimulant drug abuse
● Aging process
Management
● SURGICAL MANAGEMENT
CLINICAL MANIFESTATION
○ Aneurysm Clipping
● Asymptomatic ■ Surgical obliteration
○ Ruptured Aneurysm of the aneurysm with
○ Sudden onset of headache, a metal clip to
worst headache eliminate the risk of
○ Vomiting o Generalized rebleeding.
seizure
○ Decreased LOC : confused, ● Endovascular Therapy and
lethargic , coma Embolization
○ S/SX of meningeal irritation ○ Involves obliteration
Nuchal rigidity , photophobia of the aneurysm by
○ Focal motor and sensory means of platinum
deficits coils.
● Important note
HUNT-HESS CLINICAL GRADING ○ Assess the site of
SCALE insertion.
● Used for clients with aneurysmal ○ Presence of
S.A.H. hematoma
○ I- Alert, minimal headache ○ Sandbag for pressure
○ II- Alert, moderate to severe
headache (cranial nerve ● NURSING MANAGEMENT
palsy allowed) ○ A - Assess neurologic status
(ruptured)
 ○ E - Elevate heat at 30
Obesity
degrees
○ U - Uine output monitoring
(ruptured)
○ R - Respi and cardio INITIAL MANIFESTATIONS
monitoring (ruptured)
● Severe
○ Y - You keep patient and
● And sudden headache
family members in a quite
● Trouble in speaking
and comfortable environment
● Right or left hemiparesis
○ S - Surgery preparation
● Ocular disturbances
○ M - Medication administration
● Confusion
● Impairment
STROKE
LEFT AND RIGHT BRAIN FUNCTIONS
● Is a syndrome of a group of sudden
focal neurological deficits resulting LEFT BRAIN
from interruption of cerebral blood ● Right side of body control
flow. ● Number skills
● math/scientific skills
● Written language
CLASSIFICATIONS OF BRAIN ATTACKS ● Spoken language
● Ischemic (Emboli, thrombus) - ● Objectively
blockage in the blood vessels ● Analytical
● Hemorrhagic - rupture of the blood ● Logic
vessels ● Reasoning
● Fister Grading Scale ● Verbal; analytical
○ Grade 1 - no subarachnoid
hemorrhage RIGHT BRAIN FUNCTIONS
○ Grade 2 - <1mm SAH ● Left side of body
○ Grade 3 - >1mm SAH ● 3D shapes
○ Grade 4 - diffuse ● music/art awareness
● Intuition
● Creativity imagination
Non Modifiable Modifiable
● Subjectively
Age Hypertension ● Synthesizing
Gender Heart disease ● Emotion
Race DM ● Face recognition
Family History Sleep Apnea
Blood Cholesterol
Level PRESENTATION
Smoking LEFT HEMISPHERE
Sickle Cell Disease
● Aphasia
Substance Abuse
Intracranial ● Agraphia
Hemorrhage ● Alexia
 ● Acalculia ● Hemipareis
● Dysarthria ● Ataxia
● Hemiplegia ● Dysarthria (can’t control the tongue,
● Homonymous hemianopsia (half of voicebox - slurring of speech)
the visual field problem will only see ● Dysphagia
one side) ● Flaccidity of the muscles associated
● Short term memory with paralysis on the motor neurons
● Depression ● Spasticity
● Frustration
SENSORY DEFICITS
RIGHT HEMISPHERE ● Ptosis
● Spatial-perceptual deficits ● Unilateral neglect syndrome
● Lack of inhibitions (homonymous hemianopia; main
● Inappropriate Social Behavior concern: safety and nutrition)
● Short Attention Span ● Amaurosis fugax (temporary vision
● Poor Judgement loss in one or both eyes due to blood
● Hemiplegia flow)
● Hemiparesis
● Anosognosia (denial of affected
DIAGNOSTIC TESTS
side)
● Apraxia (inability to use objects or ● CT Scan
words) ● MRI
● Cerebral Angiography
● Doppler Flow Studies
ASSESSMENT
COGNITIVE DEFICITS
MEDICAL MANAGEMENT (ABCD)
● Changes In Levels Of
Consciousness ● Maintenance of a patent airway and
● Spatial And Proprioceptive optimal oxygenation
Dysfunction ● Control cerebral edema
● Imapirment in memory ● Control of fluid electrolyte
● Aphasia ● Maintenance of adequate cerebral
● Alexia blood flow and cerebral perfusion
● Agraphia pressure
● Acalculia ● Medications
○ Antihypertensive
SENSORY/PERCEPTUAL DEFICITS ○ Platelet aggregant
● Homonymous Hemianopia ■ Aspirin
● Agnosia ■ Ticlodipine
● Apraxia ○ Anticoagulant
■ Heparin
MOTOR DEFICITS ■ Warfarin
(WEAKNESS/PARALYSIS) ○ Thrombolytics
● Hlegia ■ T-Pa (risk for
bleeding)
 ■ Urokinase
■ Streptokinase
○ Calcium channel blockers
(antihypertensive)
○ Mannitol (decrease edema
and inflammation)
○ Dexamethasone (decrease
edema and inflammation)
or motor nervous system (cranial
nerve VII; facial nerve)
● Focuses only on cranial nerve VII;
specially the lateral side (one side
only)
● One side of the face is moving and
the other is not

SURGICAL MANAGEMENT
● Carotid Endarterectomy
● Transluminal Angioplasty (to dilate
narrowed or obstructed blood
vessels)
● Stenting
● Extra-Intracranial (EC-IC) Bypass
● Craniotomy (evacuation of
hemorrhage)

NURSING MANAGEMENT
● Optimizing cerebral tissue perfusion
● Improving mobility and preventing
joint deformity
● Enhancing self-care
● Managing sensory-perceptual
difficulties
● Assisting with nutrition
● Attaining bowel and bladder control
● Improving communication
● Maintaining skin integrity

CRANIAL NERVE DISORDERS RISK FACTORS

● BELL’S PALSY
● TRIGEMINAL NEURALGIA
BELL'S PALSY
● Is a sudden loss of motor control on
one side of the face.
- Loss of motor control - meaning it is
already in somatic nervous system
● AGE: 20-60 Y.O
- More on the females
● GBS
- Patient with GBS has a big
possibility to develop bell's palsy
although it is quite temporary;
however, others may experience
permanent specially if there's
already damage on the facial nerve
 and neuron will no longer be able to
regenerate
● GENETICS
● VIRAL INFECTION
- Herpes
- Epstein-Barr virus
MANIFESTATIONS
● PAIN BEHIND THE EAR 1-2 DAYS
PRIOR TO PARALYSIS
- Patient will experience pain at the
back of the ear, then later on there is
weakness/numbness on the one
side of the face, until there is already
lose of control
● UNABLE TO:
- Close eyelids,
- Puff out cheeks,
- Close the lips.
● MOUTH DISPLACED
● SALIVA DROOLS
- Especially on the paralysis side
because the paralysis side will also
affect the tongue and the muscles
under the tongue
● CONSTANT TEARING
- Lacrimal duct on the affected side
will continue to secrete lacrimal fluid
to prevent eyes to dry
● LOSS OF TASTE AT THE
ANTERIOR 2/3 OF THE TONGUE.
- Cranial nerve VIl innervates to the
tongue; one of the function of facial
nerve is also for the sense of taste.
DIAGNOSTIC TEST
● EMG (Electromyography)
- To check if ever the neurons or
muscles are still healthy
- for anti-inflammatory
● ANALGESICS
- Some of the pt will experience pain;
specifically in the ear (prior sign)
● WARM OR MOIST APPLICATION
- Hot compress will open up the small
blood vessels for perfusion on the
area
- To prevent drying of the skin
● TENS (TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION)
- To stimulate back the cranial nerve
● CHEW ON UNAFFECTED SIDE
- Due to the innervation of the cranial
nerve on the tongue, there's a
possibility that the patient will
experience dysphagia (mahirapan
sila maglunok)
● ORAL CARE
● ARTIFICIAL TEAR
- We will not be dependent on the
excessive tearing of the eye
because if the patient is lying with
eyes close, it will still open and it will
be exposed to air causing dryness
that would lead to corneal
dystrophies or corneal
problem/lacerations (prone to
blindness)
● SOFT DIET
- Para hindi mahirapan maglunok si pt
TRIGEMINAL NEURALGIA
● Tic douloureux
● Idiopathic CN 5 disorder
characterized by pain along one or
more branches of the CN 5.

MANAGEMENT
● STEROIDS FOR 7 DAYS
 - Tirahin ang vascular system na
RISK FACTORS
nandoon sa trigeminal nerve. If there
● AGE: 50 Y.O is decompression we need to
● GENDER: FEMALE remove or treat it.
● COMPRESSION: ● RADIOFREQUENCY THERMAL
- Arteriosclerosis COAGULATION
- Aneurysm - Use of thermal, this is quite small
- Acoustic neuroma (if there is a and not invasive.
tumor growth in the acoustic - Coagulate to close up vascular
nerve, it will cause Trigeminal system, mawawala ang
Neuralgia) inflammatory process and
- Multiple sclerosis compression
- Infection of the jaw and teeth
CLASSIC FINDING:
● intense, lightning-like pain in NURSING MANAGEMENT
paroxysms about a hundred times ● Provision of therapeutic
daily. environment
- Decrease environmental stimulation
of the trigeminal nerve, room should
DIAGNOSTIC TESTS:
be kept at normal temperature. Kung
● CT - SCAN mainitan ang patient, na mag brush
● MRI off sa ating trigeminal, sa forehead,
sa cheeks or sa mandible may have
an attack of tic douloureux
- Room should be kept at moderate
temperature and free of drafts to
prevent stimulation c n the
MEDICAL MANAGEMENT Trigeminal nerve.
● PHARMACOLOGIC THERAPY ● Avoid jarring the bed or touching
- Anticonvulsants the patient's face that can trigger
- Muscle relaxants (Can help the onset of pain on the three
decrease the stimulation in CN 5) branches of the trigeminal nerve.
● Nerve block (direct giving of - Kung ma jar, gagalaw ang face that
anesthesia to the nerve/temporary) might cause the stimulation of
trigeminal nerves.
● Provide lukewarm water and soft
cloths or cotton saturated
SURGICAL MANAGEMENT solutions not requiring rinsing for
● PERCUTANEOUS cleansing the face.
RADIOFREQUENCY RHIZOTOMY - Dapat hindi malamig, di din
- cut or remove a small portion of the masyadong mainit.
trigeminal nerve to eliminate the ● Use a soft-bristled toothbrush or
nerve. a warm mouthwash during oral
● MICROVASCULAR care.
DECOMPRESSION
 - It might trigger trigeminal nerve
● Avoid extensive conversation Normal tissue
during the acute phase because it growth: tumor
may trigger paroxysms of pain.
- Avoid conversation Abnormal
● Diet must be high in protein and contraction of
calories and easy to chew. muscle:
spasm
- Soft diet

Thermal EXTREME HOT OR

PAIN
COLD

● Unpleasant sensory and emotional Chemical Tissue ischemia,

experience associated with actual or CAD or muscle
potential tissue damage spasm
● Pain threshold is consistent from
one person to the next; HOWEVER,
TYPES OF PAIN
pain tolerance varies greatly.
● Acute Pain
○ Pain is defined as acute
PAIN STIMULI when it lasts the expected
● Central recovery time
➔ Trapezium squeeze ○ Pain may last for 6 months
➔ Supraorbital pressure ● Chronic Pain
➔ Jaw margin pressure ○ Pain lasts for more than 6
➔ Sternal rub months
● Peripheral ● Cancer Pain
➔ Finger pressure ○ Maybe acute or chronic pain
Note: Sternal rub is the least advocated that is associated with an
among pain stimuli underlying malignancy,
diagnostic procedure or
disease treatment.
○ Intractable pain resistant to
TYPES OF NOXIOUS STIMULI treatment

Type Causes PERFORMING THE PAIN

ASSESSMENT
Mechanical Tissue trauma: ● Includes a history, physical
surgery, Laceration
examination
Alteration of tissue: ● Health history
edema ● Biographical data
➔ Age
Obstruction: biliary, ➔ Gender
bowel ➔ Occupation
 ➔ Religion
➔ Ethnicity
Note: Self-Report is the most accurate
indicator of pain.
CURRENT HEALTH STATUS
● When your patient presents with
pain, perform a symptom analysis
Note: Use the PQRST assessment
P: Precipitating/ Palliative/ Provocative
factors
Q: Quality/ Quantity
R: Region/ Radiation/ Related Symptom
S: Severity
T: Timing
1. PRECIPITATING/PALLIATIVE/PRO
VOCATIVE FACTORS
● What were you doing when
the pain started?
● Does anything make it better
such as medication or a
certain position?
● Does anything make it
worse, such as movement or
breathing?
2. QUALITY/ QUANTITY
● What does it feel like?
● How often are you
experiencing it?
● To what degree is the pain
affecting your ability to
perform your usual daily
activities?
3. REGION/ RADIATION/ RELATED
SYMPTOMS
● Can you point to where it
hurts?
● Does the pain occur or
spread anywhere else?
4. SEVERITY
● Use appropriate pain scale
5. TIMING
● When did the pain begin?
➔ How long did it last?
➔ Brief Flash: needle stick
➔ Rhythmic pulsation:
migraine/toothache
➔ Long-duration rhythmic:
intestinal colic
➔ Plateu pain: angina
➔ Paroxysmal: neuropathic
pain
● How often does it occur?
➔ Continuous fluctuating
pain
● Do you have time when you
are pain free?
PAIN SCALES
● Unidimensional Scale
○ Assess the intensity of pain;
useful when assessing acute
pain
Examples of Unidimensional Scale
➔ Numeric Rating Scale
◆ Rates pain on a scale of 0
(no pain) to either 5 or 10
(worst pain) by asking the
patient to rate her current
pain level
➔ Visual Analogue Scale
◆ Utilizes a vertical or
horizontal 10cm line with
anchors
➔ Categorical Scale
◆ Use verbal or visual
descriptors to identify pain
intensity
◆ Verbal description includes:
 ● Mild, discomforting,
distressing, horrible,
excruciating
● No pain, mild pain,
moderate pain,
severe pain, very
severe pain, worst
possible pain
● Multidimensional Scale
○ pain characteristics, effects
of pain in ADL
Examples of Multidimensional Scale
➔ Initial pain assessment inventory
➔ Brief pain inventory
➔ McGill Pain Questionnaire
➔ Neuropathic Pain Scale
➔ Numeric Scale
Note: Multidimensional Scale is useful
in assessing chronic pain

PAIN SCALE FOR CHILDREN

➔ FACES Pain Rating Scale

➔ Poker Chip Tool

➔ Word-Graphic rating Scale
➔ Color Tool

MYASTHENIA GRAVIS (MS)

➔ Oucher
● Is an autoimmune neuromuscular
disorder in which there is chronic,
progressive decreased amplitude of
the nerve impulse at the myoneural
junction (somatic muscle)
● Somatic in response
● Acetylcholine – neurotransmitter
that helps in the dilation of blood
vessels and bodily functions;
contraction of muscles.
○ Acetylcholine can no longer
transfer to somatic muscle
 due to absence of receptor
sites
○ No action potential = no more
contraction of muscles
○ Reception cells are attacked
by the antibodies.
RISK FACTORS
● Gender: Female
● Age: 20-40 y.o
● Thymic Tumor
CLINICAL MANIFESTATIONS
● PTOSIS – other eye is closing or is
drowsy
● Diplopia – double vision
● Dysarthria – slurred speeceh / slow
speech
● Dysphagia – difficulty swallowing
● Respiratory muscle weakness
● Skeletal muscle weakness
CLASSIFICATION
1. OCULAR FORM
- A form of myasthenia gravis
(MG) in which the muscles
that move the eyes and
control the eyelids are easily
fatigued and weakened
2. BULBAR
- Involves breathing,
swallowing, and speech
3. GENERALIZED FORM
- Involves the proximal
muscles of the limbs and
neck, usually with both ocular
and bulbar manifestation
THE MYASTHENIA GRAVIS
FOUNDATION OF
AMERICA (MGFA) CLINICAL
CLASSIFICATION
● Class I:
○ Involves any ocular muscle
weakness, including
weakness of eye closure. All
other muscle groups are
normal
● Class II:
○ Involves mild weakness of
muscles other than ocular
muscles. Ocular muscle
weakness of any severity
may be present
● Class IIa:
○ Involves predominant
weakness of the limb, axial
muscles, or both. It may also
involve the oropharyngeal
muscles to a lesser extent.
● Class IIb:
○ Involves mostly
oropharyngeal, respiratory
muscles, or both. It can have
the involvement of limb, axial
muscles, or both to a lesser
extent.
● Class III:
○ Involves muscles other than
ocular muscles moderately.
Ocular muscle weakness of
any severity can be present.
● ClassIIIa:
○ Involves the limb, axial
muscles, or both
predominantly.
Oropharyngeal muscles can
be involved to a lesser
degree
● Class IIIb:
○ Involves oropharyngeal,
respiratory muscles, or both
predominantly. The limb,
axial muscles, or both can
have lesser or equal
involvement.
● Class IV:
○ Involves severe weakness of
affected muscles. Ocular
muscle weakness of any
severity can be present
● Class IVa:
○ Involves limb, axial muscles,
or both predominantly.
Oropharyngeal muscles can
be involved to a lesser
degree
● Class IVb:
○ involves oropharyngeal,
respiratory muscles, or both
predominantly. The limb,
axial muscles, or both can
have lesser or equal
involvement. It also includes
patients requiring feeding
tubes without intubation
● Class V:
○ Involves intubation with or
without mechanical
ventilation, except when
employed during routine
postoperative management
DIAGNOSTIC TEST
● Edrophonium / Tensilon Testing
- anti-cholinesterase injection
■ If improved.
Possibility of MG
■ Not improved. Muscle
weakness is due to
other reasons.
● Electromyography (EMG)
■ Small electrical
discharges to
determineif there is a
reaction on the
muscles/ muscle
fibers
● Serum Radio
Immunofluorescence
- antibody antigen
MEDICAL MANAGEMENT
1. DRUG THERAPY
● Anticholinesterase Drugs
○ Pyridostigmine
(Mestinon)
○ Neostigmine
(Prostigmin)
● Corticosteroids
○ Prednisone
○ Cyclosporine
● Cytotoxic and
Immunosuppressive Drugs
○ Azathioprine
2. PLASMAPHERESIS
COMPLICATIONS
● MYASTHENIC CRISIS
○ Cause: undermedication,
stress, infection
○ Any infection may precipitate
the condition
○ ACH is a major
neurotransmitter,
Cholinesterase is an enzyme
that breaks down the ACH.
Patients are given
anticholinesterase to prevent
breakdown of ACH.
○ It is life threatening since it
involves the respiratory of the
patients
○ Lack of ACH
● CHOLINERGIC CRISIS
○ Cause: overmedication with
anticholinesterase
○ S/SX: nausea, vomiting,
diarrhea, pallor, cramps,
 sweating, salivation, myelin sheath is damaged
bradycardia with the help of neurilemma it
○ Antidote: Atropine Sulfate regenerate the peripheral
(SO4) nerve myelin sheath

RISK FACTORS

● Viral infection
○ history of upper respiratory
and GI infection
● CMV (Cytomegalovirus)
● EBV (Epstein-Barr virus)
● Hepatitis
● HIV
● Rubella
SURGICAL MANAGEMENT
● Rubeola
● Thymectomy (thymus: maturation ● Varicella
site of T Cells)
○ Abnormal relay of immunity
cells is removed completely
CLINICAL MANIFESTATIONS

NURSING MANAGEMENT
● Bilateral weakness in the legs
● Promote effective breathing pattern ● Respiratory dysfunction
● Improved airway clearance ● Dysphagia
● Ensure adequate nutrition ● CN VII (facial)
● Increased activity tolerance ○ Bell’s palsy like symptoms
● Provision of optimum vision ● Horner’s syndrome ○
○ Ipsilateral ptosis (one side of
GUILLAIN-BARRE SYNDROME (GBS) the body has ptosis)
○ Enophthalmos (pumasok sa
● Ascending paralysis, tingling loob yung eyeball)
sensation on the extremities going ○ Anhidrosis
up, PNS
● Landry's paralysis,
Landry-GBS-Strohl DIAGNOSTIC TESTS
● Is an autoimmune attack of the
peripheral nerve myelin sheath
● CSF analysis ○
○ Schwann cells is the problem
○ Lumbar puncture
of GBS causes
● EMG
demyelination of the
schwann cells
○ Neurilemma is found in
schwann cells if ever the
 ● Abnormalities in T-helper cells,
MEDICAL MANAGEMENT
T-suppressor, B-lymphocytes
○ T-suppressor - stops
● Plasmapheresis antibodies production
● Steroids ○ Hindi nadedeactivate and
● Immunoglobulin infusion B-lymphocytes
○ Para di na mag create ng ● Viral: mumps, measles, rubella
immunoglobulin ang katawan ● Stress
● Ace inhibitors ● Trauma
● Medications: 4A’S ● Pregnancy
○ Antibiotics, ● Age: 20-45 y.o
○ Analgesic, ● Gender: FEMALE
○ Anticoagulants ○ Common usually if
○ Azathripine & autoimmune diseases
Cyclophosphamide (under
neoplastics
● Maintaining Respiratory Function CLINICAL FEATURES

NURSING MANAGEMENT COMMON INITIAL SYMPTOMS:

● TINGLING SENSATION
● NUMBNESS
1. Maintaining Respiratory Function
● SENSORY SYMPTOMS:
2. Enhancing physical mobility
LHERMITTE’S SIGN
3. Providing adequate nutrition
○ If you do flexion, there is
4. Improving communication
sudden jolt of lightning-like
5. Decreasing fear and anxiety
feel
MULTIPLE SCLEROSIS (MS) ● MOTOR SYMPTOMS: UHTHOFF’S
PHENOMENON
● Descending paralysis (from head ○ Inc body temp nagkakaroon
going down) ng blurry vision or loss of
● Progressive, degenerative disease vision
of the CNS. ● CHARCOT’S TRIAD
● Attacks myelin sheaths ○ Scanning of speech -
(oligodendrocytes) - once damaged, stuttering
they are already damaged = loss of ○ Nystagmus - involuntary
functioning/ paralysis is permanent mvmt of the eye
● Goal for treatment - is to slow the ○ Tremors - d/t decrease
progression of the illness, No function of neurons and
Treatment nerve impulses is kahit saan
nalang pumupunta

ETIOLOGY
DIAGNOSTIC TEST

ETIOLOGY: UNKNOWN
● CT-Scan
 ● CSF Analysis
MENINGITIS
● MRI

● Meningitis is an inflammation of the pia

MEDICAL MANAGEMENT
mater, the arachnoid, and the cerebrospinal
fluid-filled subarachnoid space.
PHARMACOLOGIC THERAPY ○ Inflammation of meninges
● DISEASE ○ There is no problem on the brain tissue, if
○ modifying therapies there is a problem on the brain tissue
○ Slows the progression of the affectant it is already encephalitis
disease
● SYMPTOMS MANAGEMENT ● SEPTIC VS ASEPTIC
○ Muscle relaxant, para hindi
mag tremors and weakness
ETIOLOGY
○ Baclofen
○ Valium
○ Symmetrel ● BACTERIA
○ Propranolol ○ Hindi po agad makakalabas sa
○ Anticholinergics, meninges, before the bacteria can transfer
anti-spasmodics, ACE to the brain tissue, the patient is already
inhibitors dead.
● COMPLEMENTARY THERAPIES ● VIRUS
○ Physical therapies ○ Self limiting, mawawala po siya.
○ Diet and exercise - slows the Mas madali siyang matransfer in the brain
progression tissue causing encephalitis. ○ Mostly of
encephalitis is viral infections

NURSING MANAGEMENT
RISK FACTORS

1. Promoting physical mobility - activity

and rest ● HEAD TRAUMA
2. Prevent Injury ○ Opening of the skull, can lead to
3. Enhancing bladder and bowel meningitis
control
4. Enhancing communication ● OTITIS MEDIA
5. Manage feeding difficulties ○ Proximity, ang lapit ng ear paloob.
6. Improve sensory & cognitive function
● SINUSITIS
○ Also proximity
NEURO INFECTION
● MASTOIDITIS
● MENINGITIS
● ENCEPHALITIS ● IMMUNOSUPPRESSION
○ Magandang growth ang bacteria
or virus, if the pt is immunocompromised
● SYSTEMIC SEPSIS ● SKIN LESIONS (N.meningitidis)
○ Microorganism that are spreading
in the blood or any part of the body ● SEIZURE

● INCREASE ICP
MODE OF TRANSMISSION

● BLOOD-STREAM
Meningitis Symptoms in Adults
○ Systemic circulation is the reason why
there is a spread of microorganisms ● Vomiting
towards the meninges ● Headache
● Drowsiness
● DIRECT SPREAD ● Seizures
○ There is trauma or a problem while doing ● High temperature
a procedure ● Joint aching joint pain
○ E.g. was not able to follow the aseptic ● Stiff neck
technique ● Dislike of light (Photophobia)

ASSESSMENT Meningitis Symptoms in Children

● A high-pitch moaning cry whimpering
● HEADACHE ● Dislike of being handled, Fretful (Because
there is neck pain, especially when touched)
● FEVER ● Aching back, neck retraction
(Opisthotonus)
● S/SX OF MENINGEAL IRRITATION: (If ● Blank, staring expression (Absence
there is already a significant inflammation in seizure or Petit-mal)
the meninges, these four symptoms will ● Difficult to wake up or very lethargic
appear) (Stuporous-like mental status; Low NVS)
○ NUCHAL RIGIDITY ● Fever and may have cold hands and feet
○ Stiff neck ● Refusing feeds or vomiting (Usually
○ (+) KERNIG’S SIGN vomits a lot; gina-vomit lahat ng kinain)
○ (+) BRUDZINSKI SIGN ○ ● Pale, blootchy skin color (Skin lesions)
PHOTOPHOBIA
○ There is glare in the light. Masakit sa
mata, that is why gina-dim ang lights sa
COMPLICATIONS
room ng mga meningitis pts

● OPISTHOTONUS ●NON-COMMUNICATING
○ There are uncontrolled contractions of HYDROCEPHALUS
the muscles and arching of the back; The pt ○ There is a problem in producing
is having Tetany (tetanus) ○ More common CSF; there is blockage in the absorption
in children that causes accumulation
 ● Maintenance of Normal Body
● FRIDERICHSEN SYNDROME Temperature-decrease basal metabolic rate
● Preventing Complications

DIAGNOSTIC TEST

● CSF ANALYSIS
○ Sends out CSF for the gram
staining/culture and sensitivity (GS/CS)
○ Gram staining - to identify whether it is
bacterial, viral, or other forms of
microorganisms
○ Culture and sensitivity - to identify which
drug is effective to kill the microorganism

● CT-SCAN

● SKULL RADIOGRAPHY

MEDICAL MANAGEMENT

● PHARMACOLOGIC TREATMENT
○ Penicillin (Antibiotic) - Vancomycin
○ Dexamethasone - To improve the
mental status of the pt because it decreases
the inflammatory process
○ Phenytoin - Anticonvulsant

● RESPIRATORY ISOLATION - If the

meningitis of the pt is bacterial in nature,
mag lock down ang hospital

NURSING MANAGEMENT

● Improve of Cognitive Function-goal is to

decrease ICP and to kill causative agent
● Optimizing Cerebral Tissue
perfusion-oxygenation is needed or intubate
to stabilize O2
● Promotion of Comfort