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Michael r. enciso
Anatomy and Physiology (NERVOUS SYSTEM) Assessment Diagnostic Exam Disorders
Nervous System CNS brain and spinal cord PNS cranial nerve and spinal nerve ANS sympa and para .
Afferent neurons From tissues and organs into the CNS (sensory neurons.) Efferent neurons From CNS to the effector cells (motor neurons) .
CNS Brain NEURON .
The Neuron 1. mitochondria. axon – transmits neural msgs away from cell body 4. myelin & cellular sheath produced by Schwann cells 5. nodes of Ranvier . dendrites – receive neural msgs & transmit towards cell body 2. & other organelles 3. cell body – contains nucleus.
Neurotransmitters Acetycholine Dopamine Epi and Nor E GABA (inhibitory) Serotonin (↓ depression. ↑ manic) Glutamine (excitatory) .
CEREBRUM frontal occipital parietal temporal .
1. Where primitive reflexes are inhibited d. Hearing b. Wernickes area – gen interpretative or knowing Gnostic area 3. heat & cold 4. pressure. Controls personality development c.vision . Controls motor activity b.) Occipital .) Parietal lobe – appreciation & discrimation of sensory impulses . touch.) Temporal a.Pain. Brocca’s area – speech center 2. Site of development of sense of umor e.) Frontal a. Short term memory c.
) Rhinencephalon/ Limbec .Smell.activities of internal organ 6. long-term memory .controls visceral fx .) Central lobe. libido.5.
equilibrium. posture and motor learning .Cerebellum Little Brain Sensory perception and motor output Disorder = in fine movement.
CNS Thalamus Hypothalamus Pituitary Gland .
The Thalamus Afferent neurons coming from all sense organs (except olfactory) & motor neurons synapse with nuclei found within the thalamus cerebrum The thalamus also helps one associate feelings of pleasantness or unpleasantness with sensory impulses .
Mechanisms of the hypothalamus that maintain homeostasis: 1. 3. 5. Connects the cerebral cortex & the lower autonomic centers. 6. Influences sexual behavior & the affective (emotional) aspects of sensory input. ( ADH & presence of thirst center) 4. The appetite & satiety centers within regulate food intake. Link bet the nervous & endocrine systems. Body temperature is regulated. Helps maintain fluid balance. . 2.
BrainStem – Mid Brain – Pons – Medulla .
The Midbrain AKA mesencephalon Relay station for sight & hearing Controls size & reaction of pupil 2 – 3 mm Controls hearing acuity CN 3 – 4 Isocoria – normal size (equal) Anisocoria – uneven size – damage to mid brain PERRLA – normal reaction .
just above the medulla Acts as a bridge/link connecting various parts of the brain Contains one of the respiratory centers & centers for reflexes mediated by the CNs V-VII .The Pons A bulge on the anterior (ventral) surface of the brain stem.
Medulla Vital reflex centers within the medulla: – – – – Cardiac centers – control heart rate Vasomotor centers – control blood pressure Respiratory centers – regulate breathing Centers for vomiting. coughing. sneezing. & swallowing – Centers for reflexes mediated by CNs IX-XII .
Ventricles of the Brain Choroid plexus CSF
Meninges pia arachnoid dura
Arachnoid = Middle Thin. white fibrous connective tissue Subdural space = potential space 2. delicate. Pia Mater = Innermost Thin. Dura Mater = outermost Tough.Meninges = DAP 1. vascular membrane tightly bound to the brain . cobweb-like membrane Subarachnoid space Filled with CSF & blood vessels 3.
CNS Spinal Cord motor and sensory pathways .
PNS Spinal Nerves 31 pairs Cranial Nerves 12 .
Spinal Nerves .
5 S.8 T.12 L.C.1 .5 C.
Autonomic Nervous System Sympathetic Parasympathetic .
Comparison of Sympathetic and Parasympathetic Actions on Selected Effectors Sympathetic Action Effector Heart Bronchial tubes Iris of eye Increases rate and strength of contraction Dilates Dilates (pupil becomes larger) Decreases rate. ejaculation Generally constricts Stimulates Inhibits motility Stimulates glycogen breakdown Stimulates free fatty acid release from fat cells Stimulates secretion of Dilates blood vessels. erection No innervation for many No innervation Stimulates motility and secretion No effect No effect No effect . no direct effect on strength of contraction Constricts Constricts (pupil becomes smaller) Parasympathetic Action Sex organs Blood vessels Sweat glands Intestine Liver metabolism Adipose tissue Adrenal Constricts blood vessels.
highest 15 CN assessment Reflex Sensory and Motor ↑ ICP (normal = 0-14 mm Hg) minute neuro exam .Assessment LOC GCS Motor =6 Verbal =5 Eye =4 ↑7 good. ↓7 poor. lowest 3.
Diagnostic and Lab CT scan with or without c. media MRI PET EEG Lumbar Tap CSF analysis Electromyography DIAGNOSTIC PROCEDURES IN NEUROLOGY .
Disorders Trigeminal Neuralgia Bell’s Palsy Hydrocephalous Seizures CVA Spinal cord Injury Multiple Sclerosis Guillain-Barre Syndrome Amyotrophic Lateral Sclerosis Myasthenia Gravis Parkinson’s Disease Dementia .
touching the face. eating. or when exposed to cold and wind. . shaving.Trigeminal Neuralgia (Tic Douloureux) Is an intensely painful neurologic condition affecting the 5th CN (trigeminal) Patient may experience lancinating or electric shock-like facial pain Pain can be triggered when talking. brushing teeth.
Trigeminal Neuralgia Avoid too hot or too cold food or liquids Room temp for food and water for bathing Chewing on the unaffected side is recommended No massage Provide water jet device for mouth care Tegretol for pain Phenol Injection in the Gasserian ganglia ( loss of temporary facial sensation) Rhizotomy (surgical intervention) Percutaneous radio-frequency trigeminal gangliolysis .
Bell’s Palsy Named after Scottish anatomist Charles Bell Acute peripheral facial paralysis of the 7th CN (facial) Self-limiting that usually improves in 4-6 months. Cause is unknown Inflammation Vascular ischemia Autoimmune demyelination .
Interventions Artificial tears is recommended Apply warm packs to the affected Inadequate eyelid closure Exercise (grimacing, wrinkling, whistling, puffing the cheeks, blowing out air)
Enlargement of the head by excessive fluid pressure within the ventricular system evident at birth or within the first few weeks of life
Cause: obstruction of the normal outflow of CSF from the ventricular system due to a congenital defect Abnormally large head circumference at birth CT scan and ultrasonography confirms the ventricular enlargement .
If without treatment damage to the cerebral hemispheres may be expected Treatment is surgical insertion of shunt either through the: – Right atrium – Peritoneal cavity .
sensory.SEIZURES Episodes of abnormal motor. autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved .
EPILEPSY Neurologic disorder in which the patient experiences recurrent seizures consisting of transient disturbances of cerebral function due to paroxysmal neuronal discharge .
SEIZURES PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively .
Etiologic Factors Often idiopathic Cerebral trauma. neoplasms. alcohol . infection. high fever Others: lack of sleep. chemical poisons Metabolic disorders Children. degenerative disease (Alzheimer) Drugs. vascular disease.
CLASSIFICATION OF SEIZURES A. perception of flashing lights or other abnormal sensory phenomenon . Partial: one part of the cerebral cortex is involved B. Simple (no unconsciousness): local twitching or jerking.
Absence (petit mal): brief loss of attention & perception.Common in Children . Complex (impaired alertness or unconsciousness): sometimes with psychic symptoms or automatisms D. Generalized: entire cerebral cortex is involved E.C.
Tonic-clonic (grand mal): victim becomes rigid. falls & stops breathing (tonic phase). cries out. may bite tongue or lips. may be incontinent (clonic phase). F. loses consciousness. after awakening. muscular jerking. subject is drowsy & amnesic .
Status epilepticus: one or a series of grand mal seizures lasting more than 30 minutes w/o waking intervals . often violent contractions in one or more muscle groups H. Cyclonic: repeated shock like.G.
DIAGNOSTICS EEG shows focal abnormalities in the rate. MRI . rhythm or relative intensity of cerebral cortical rhythms Others: CT scan.
remove harmful objects from the patient’s surrounding 2. behaviors before and after the seizure . Observe and note for the duration. parts of body affected.SEIZURES Nursing Interventions During seizure 1. protect the head with pillows 4. ease the client to the floor 3.
loosen constrictive clothing 6. or attempt to place tongue blade or insert oral airway . DO NOT restrain.SEIZURES Nursing Interventions During seizure 5.
place patient to the side to drain secretions and prevent aspiration 2. provide care if patient became incontinent during the seizure attack 4. help re-orient the patient if confused 3.SEIZURES Nursing Interventions POST seizure 1. stress importance of medication regimen .
Seizure Precautions Provide a safe environment Place an oral airway at the bedside Keep bed in a low elevation Provide a dimly lit and quiet room Prepare a padded tongue blade O2 on Bedside Place side rails Pad the side rails Prn Sedatives as ordered .
ethosuximide) Avoid triggering factors . phenobarbital. carbamazepine.TREATMENT Anticonvulsant medicine (phenytoin. valproic acid.
CVA Cerebrovascular Accident Cerebrovascular Disease Stroke Cerebral Infarction Apoplexy .
Due to or absent cerebral blood flow from: Thrombosis Mural Thrombi Embolism Hemorrhage Tumor .
Brain circulation: The circle of Willis .
Risk Factors HPN Heart Disease DM Obesity Vascular Disease Cigarette Smoking Age Sex or Gender Genetics .
Manifestations of TIA .
Manifestations TIA early signal Will depend on the affected blood vessel (usually multiple s/sx) Severe headache may be a sign of SAH ICP and cerebral edema Critical conditions ( CTP and airway patency) .
HPN.cheynestokes Focal signs(related to site of infarction) Hemiplegia.seizures.rigidity.sensory loss.fever.dec LOC.nuchal.S/Sx HA Generalized signs: vomiting.aphasia.homonymous hemianopsia .
CEREBROVASCULAR ACCIDENTS Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech or comprehension Apraxia= inability to perform a previously learned action .
PET.Diagnostic History CT. UTZ (carotid) arteriography Other test to rule out risk factors . MRI.
Interventions ABC NEURO VS CBR Maintain adequate F &E.Nutrition Proper positioning and alignment Establish means of communication .
Monitor VS and GCS. IVF is ordered but given with caution as not to increase ICP 5. pupil size 4. Keep patient on LATERAL position 3. Ensure patent airway 2. Mannitol (to decrease edema).CEREBROVASCULAR ACCIDENTS NURSING INTERVENTIONS: ACUTE 1. Medications: Steroids. NGT inserted 6. Diazepam .
Improve Mobility and prevent joint deformities Correctly position patient to prevent contractures – Place pillow under axilla – Hand is placed in slight supination―C‖ – Change position every 2 hours .NURSING INTERVENTIONS: Hospital 1.
NURSING INTERVENTIONS 2. Enhance self-care Carry out activities on the unaffected side Prevent unilateral neglect.place some items on the affected side!!! Keep environment organized Use large mirror .
Manage sensory-perceptual difficulties Approach patient on the Unaffected side Encourage to turn the head to the affected side to compensate for visual loss .NURSING INTERVENTIONS 3.
Manage dysphagia Place food on the UNAFFECTED side Provide smaller bolus of food Manage tube feedings if prescribed .NURSING INTERVENTIONS 4.
NURSING INTERVENTIONS 5. Help patient attain bowel and bladder control Intermittent catheterization is done in the acute stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake .
NURSING INTERVENTIONS 6. Improve thought processes Support patient and capitalize on the remaining strengths .
Improve communication Anticipate the needs of the patient Offer support Provide time to complete the sentence Provide a written copy of scheduled activities Use of communication board Give one instruction at a time .NURSING INTERVENTIONS 7.
Maintain skin integrity Use of specialty bed Regular turning and positioning Keep skin dry and massage NONreddened areas Provide adequate nutrition .NURSING INTERVENTIONS 8.
STEROIDS . Muscle relaxants.MEDICAL MANAGEMENT 1. Pharmacologic: – – – – – – Aspirin (anticoagulant) Diazepam to prevent seizures Thrombolytics (Heparin.Warfarin) Stool softeners Antihypertensives Analgesics.
Coagulation studies Purpose PT 12-16 seconds PTT 60-70 seconds Measures the effectiveness of Warfarin The BEST single screening test for coagulation disorders aPTT 30-40 seconds Bleeding time 1-9 minutes Same as PTT. measures effectiveness of HEPARIN (more specific than PTT) Measures Platelet function .
T12 and L1 Concussion Contusion Compression Transection .Spinal cord injury The most frequent vertebrae – C5-C7.
Causes MVA Diving accidents Falls Sports injury GSW .
Spinal cord injury Clinical manifestations 1. spinal shock . Paraplegia 2. quadriplegia 3.
Spinal cord injury DIAGNOSTIC TEST Spinal x-ray CT scan MRI .
Spinal cord injury EMERGENCY MANAGEMENT A-B-C Immobilization Immediate transfer to tertiary facility .
Maintain skin integrity . Promote adaptation to sensory and perceptual alterations 4. Promote adequate breathing and airway clearance 2. Improve mobility and proper body alignment 3.Spinal cord injury NURSING INTERVENTION 1.
Improve bowel function 7.Spinal cord injury 5. Monitor and manage complications – Thromboplebhitis – Orthostatic hypotension – Spinal shock – Autonomic dysreflexia . Provide Comfort measures 8. Maintain urinary elimination 6.
Assists with surgical reduction and stabilization of cervical vertebral column .Spinal cord injury 9.
MULTIPLE SCLEROSIS Degenerative disease Demyelination of the (myelin sheath) nerve fibers (brain and spinal cord) Hypofunction of oligodendroglial cells and schwann cells(responsible for reproduction of the myelin sheath) Chronic slowly progressive Characterized by remission and exacerbation .
Multiple Sclerosis .
Maybe triggered by: pregnancy fatigue stress infection and trauma May worsen in extreme temperatures Lesions are scattered Common among women
MRI. CSF (IgG). EEG .Cause: Unknown Autoimmune (post viral infection) Diagnostic test: CT scan.
total blindness Disruption of sensory nerve Paresthesia and pain Frontal lobe problem memory loss. blurring. scotoma (patch blindness). nystagmus. concentration. diplopia. poor abstract reasoning .Manifestations Eye problem (early manifestation) vision is impaired.
Cerebellum and basal ganglia involvement Ataxia (uncoordinated muscle movement Tremor Weakness of muscle in throat and face (3 D’s) Sacral cord problem Impotence. bowel and bladder dysfunction Charcot’s triad (nystagmus. tremors and scanning speech) .
Plasmapheresis.Management Avoid fatigue. Thymectomy Respiratory Distress precautions . Antibiotics. Immunosuppressive. stress and infection Promote safety and rest Visual disturbance (scanning vision) Sensory problem (caution for cuts and burns) Motor problem (fall and slip) Bowel and bladder program Steroids.
Guillain-Barre’ Syndrome .
CSF and ECG .Guillain-Barre Syndrome Neuromuscular disease Ascending paralysis (Schwan cells) Demylinating polyneuropathy of motor and sensory nerves Cause: Unknown Autoimmune (post viral infection) Diagnostic test: EMG.
Manifestations Clumsiness (initial symptom) Muscle weakness or paralysis of the feet or legs that goes upward Hyporeflexia Distention to incontinence Paralysis of the diaphragm Dysphagia and drooling Respiratory depression Blurred vision (CN II) Adrenergic crisis .
ETT. Plasmapheresis. Immunosuppressive. O2 therapy . Thymectomy NGT.Management Watchout ascending paralysis DTR I and O Vital Signs ABG Analysis Aspiration Precautions Steroids. Antibiotics.
Amyotrophic Lateral Sclerosis LOU GEHRIG’S DISEASE .
Neuromuscular disease Progressive degeneration of motor neurons glutamate nerve atrophy transmission of nerve impulse is blocked muscle paralysis 2-3 years life expectancy .
Cause: Unknown Autoimmune (post viral infection) Diagnostic test: EMG Muscle Biopsy CHON. CSF Analysis .
Stage I Weakness of the hands with thenar eminence Clawhand with footdrop and fasciculation Stage II Bulbar involvement 3 D’s dysarthria. bowel and bladder and intellect will be affected on the latent part . dysphagia and dysphonia (leads to aspiration) Aphagia (late manifestation) Outburst laughing and crying (tourette’s syndrome) HALDOL Stage III DTR spasticity weakness paralysis cane or crutches walker wheelchair bedridden Note: sensory.
Thymectomy Respiratory precautions Glutamate inhibitor: Riluzole (Rilutek) . Antibiotics. Immunosuppressive.Management Monitor the progression of the disease Symptomatic care Steroids. Plasmapheresis.
Myasthenia Gravis Neuromuscular disease Marked weakness and fatigue of voluntary muscles acetylcholine or – communication of nerve cells acetylcholinesterase – inactive form sensitivity to acetylcholine by the receptor site Defect in transmission of nerve impulse at the myoneural junction .
Cause: Unknown Autoimmune (post viral infection) Diagnostic Test: Tensilon Test (Edrophonium) –Acetylcholinesterase inhibitor EMG .
facial and to respiratory muscle paralysis No muscle atrophy and degeneration Muscle weakness more pronounce in the evening 3 D’s dysphagia. diplopia and eye squint (early sign) May start from ocular to oropharyngeal. dysarthria Drooping facies Respiratory paralysis (cause of death) .Manifestations Ptosis. dysphonia.
Myasthenia Gravis .
Thymectomy NGT. maintain patent airway Steroids. Antibiotics.give Atropine and stop anticholenesterase. ETT. O2 therapy . Immunosuppressive. Plasmaphoresis.Management Myasthenic crisis .give anticholenesterase and maintain patent airway Cholinergic crisis .
Parkinson’s Disease Degeneration of the substantia nigra .
Parkinson’s Disease Older people greatly affected Depletion of dopamine Cause: Unknown CVA Post encephalitic. arteriosclerotic Drug Induced: Methyldopa Haldol Phenothiazine .
resting tremors and rigidity [Cogwheel]) Pill rolling (fingers) Stooped posture Masklike face Monotone speech Drooling of saliva Festinating gait .Manifestations Triad (bradykinesia.
Management Provide safe environment mobility Improve communication Nutrition support Psychologic support .
rashes and constipation Dopamine Agonist (Levodopa-Carbidopa) Converted into dopamine Action: stimulates dopamine production Side Effects: orthostatic hypotension. depression and anorexia Avoid vit B6 it counteract the effects of LDopa .Drugs Anticholinergic (Trihexyphenidyl and Benztropine) Action: tremors and rigidity Side Effects: BP.
confusion Reduces tremors.bradykinesia . MAOI (Selegiline) Action: inhibits breakdown of dopamine Side Effects: orthostatic hypotension.rigidity. depression and anorexia Slows progression Antiviral (Amantadine HCl-Symmetrel) Action: fights influenzae A virus Side Effects: insomnia.
Exact cause is still unknown blood supply that leads to amyloid plaque and neurofibrillary tangles (twisted nerve filaments) causing nerve destruction and cerebral atrophy . behavioral and cognitive changes.Dementia Progressive organic mental disorder characterized by affect.
Alzheimer’s type Pathophysiology: Chronic and irreversible .
Low level of Acetylcholine is also noted due to high cholinesterase .Characterized by mild cognitive deficits in the area of short-term memory and accomplishment of goal directed activity to the final stage in which profound impairment occurs in the areas of cognition and self care abilities.
g. severe memory loss.inability to perform instrumental ADLs .recent memory loss.formulate concepts. Early-subtle changes such as forgetfullness.think abstractly.inability to hold a conversation.poor hygiene and poor grooming.inappropriate dress. poor concentration Late-More overt signs of impaired cognition (e.forgetfulness.
Depression. Behavioral changes (e.g.withdrawal .catastrophic reaction.imitation.mandering.impulsive behavior.emotional lability. anxiety.
Huntingtons Chorea Rare genetic disorder Hereditary Onset: earlier than DAT (25-35 y/o) Choreiform movements Personality changes Memory loss Language problem Another type of DEMENTIA .
MRI and SPECT single-photon emission computed tomography Neuropsychological test (to determine impaired to intact areas) Orientation Attention span Recent memory Remote memory Depression ADL .Diagnostic CT.
Manifestations Mild Moderate Severe recent memory remote memory and 4 A ↓ acetylcholine .
Mild or early Amnesia (recent memory loss) Forgetfulness and have difficulty retaining new information Word-finding difficulty Poor abstract reasoning Perseveration (repetitive actions) .
“floating around” .
Apraxia (impaired purposeful activity) Aphasia (inability to speak) Agnosia (person or object unfamaliarity) Agraphia (inability to write) Memory loss (remote) Loss of social inhibition Delusions, hallucination, aggressions and wandering With disease progression frontal lobe dysfunction will occur
Latent or Advanced stage
Urinary and fecal incontinence Emaciation Increased irritability Remote memory is loss Decreased acetylcholine Unresponsiveness or coma Respiratory paralysis
Nursing Diagnosis Altered thought process Impaired verbal communication Knowledge deficit High risk for injury Sleep pattern disturbance Ineffective ADL .
Management Intervene based on the nursing diagnosis Anticholinesterase: Tacrine (Cognex) Donepezil (Aricept) acetylcholine uptake in the brain: Rivastigmine (Exelon) .
Increased Intracranial Pressure ↑ 14 mm Hg It is the pressure of the intracranial contents exerted against the cranial vault. abscesses. Intracranial contents = brain tissue. tumors and fluid surrounding injured area (edema) If the intracranial contents expand. blood and CSF and may include hematoma. ICP rises. compressing the brain and .
hemiplegia. facial paralysis. slurred speech and abnormal posturing) .Manifestations ICP decreasing LOC dilated pupils (2-6 mm=normal size) or fails to react to light widening pulse pressure Increased systolic BP and temp Slow bounding pulse Altered respiratory pattern neurologic deficit (hemiparesis.
Management and Prevention ICP Prevent hypercapnea and hypoxia Limit fluid intake as ordered Avoid neck flexion (foramen magnum contents may be compressed) No valsalva’s maneuver Avoid activity that may increase intrathoracic and intraabdominal pressure Complete bed rest Control fever and avoid noise .
Treatment ICP Restriction of fluids Steroids (dexamethasone) to reduce inflammation Hyperventilate (decreases CO2 = increases the venous return) Osmotic diuretics (mannitol/osmitrol) to reduce brain swelling Barbiturates (Phenobarbital/luminal) to combat seizures Withdraw CSF via lumbar tap. cisternal puncture or ventricular catheter Surgical removal of skull or bone flap .
with periods of apnea (DKA) Apneustic breathing—prolonged inspiratory followed by 2-3 seconds apnea (Medulla Oblongata dysfunction) Cluster breathing—clusters of irregular breaths with apnea at irregular intervals (Medulla Oblongata dysfunction) Biot’s or Ataxic breathing—completely irregular breathing pattern (Medulla Oblongata dysfunction) .Respiratory Patterns Cheyne-Stokes—↑ and ↓ depth.
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