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GOOD morning!

Come Holy Spirit


Replace the tension within us
with a holy relaxation.
Replace the turbulence within
us with a sacred calm.
Replace the anxiety within us
with a quiet confidence.
Replace the fear within us with
a strong faith.

Replace the bitterness within us


with the sweetness of grace.
Replace the darkness within us
with a gentle light.
Replace the coldness within us
with a loving warmth.
Replace the night within us
with your light.

Straighten our crookedness.


Fill our emptiness.
Dull the end of our pride.
Sharpen the edge of our
humility.
Light the fires of our love.
Quench the flames of our lust.
Let us see ourselves as you see
us.

That we may see you as you


have promised,
And be fortunate according to
your word;

Blessed are the pure of heart

For they shall see God. (Mt. 5:8)


AMEN.

Medical-Surgical Nursing
Enrichment Class

MERCEDITAS L. DE BELEN-CRISTOBAL, RN, MD


UST COLLEGE OF NURSING

NERVOUS SYSTEM
DISORDERS

PRE-TEST
1.

A.
B.
C.

D.

Which of the following nursing actions would


be contraindicated when performing mouth
care to an unconscious client?
Brush the teeth with a small toothbrush.
Position the patient to one side or the other.
Use an alcohol-based product for better
cleansing.
Dry the mouth with gauze-covered tongue
depressor.

2. A client is scheduled for an


electroencephalogram early in the
morning. The nurse working the night
shift prior the procedure should do which
of the ff. measures?
A. Instruct the client not to wash his hair.
B. Hold the daily dose of the anticonvulsant.
C. Place the patient on NPO.
D. Reinforce client teaching that the test is
only mildly uncomfortable.

3. A client newly-diagnosed with trigeminal


neuralgia asks you to explain why it hurts so
much when an episode occurs. You would
explain that the pain of trigeminal neuralgia
is the result of which of the following?
A. Stimulation of the nerve by temperature or
pressure.
B. Irritation due to cellular effects of
hypoglycemia.
C. Release of epinephrine during stress.
D. An immune system reaction to cold and
influenza.

4. The nurse monitoring a client who has


sustained a head injury would determine
that the intracranial pressure is rising if
which of the ff. vital sign trends is noted
during the course of the shift?
A. temp, pulse, RR, BP
B. temp, pulse, RR, BP
C. temp, pulse, RR, BP
D. temp, pulse, RR, BP

5. A client is displaying decerebrate


posturing in response to pressure on the
trapezius muscle. It is exhibited as
A. extension of the lower and upper
extremities
B. extension of the lower and flexion of the
upper extremities
C. flexion of the lower and upper extremities
D. flexion of the lower extremities and
extension of the upper extremities

NERVOUS SYSTEM: Anatomy and


Physiology

Coordinates and organizes the functions of


all body systems
3 main divisions
- CNS- (brain and spinal cord)
- PNS- motor and sensory nerves
- ANS- regulates the involuntary functions of
the internal organs

NERVOUS SYSTEM: Anatomy and


Physiology

Brain
Cerebrum- right and left hemispheres
- governs sensory and motor activity
- divided into 4 lobes (frontal, parietal,
temporal and occipital)
Cerebral cortex- outer gray area
Basal ganglia
- cell bodies in white matter
- smooth voluntary movements

NERVOUS SYSTEM: Anatomy and


Physiology

Frontal
- primary motor area; voluntary eye movement
- Brocas area
- access to past info, behavior, judgment, reasoning, affective
response
Parietal
- sensation, texture, size, spatial relationships , body position
awareness
Temporal
- auditory center, complicated memory patterns, Wernickes
area
Occipital primary visual center

NERVOUS SYSTEM: Anatomy and


Physiology

Diencephalon
- thalamus- relays sensory impulses to the
cortex- part of the RAS
- hypothalamus- regulates ANS, sleep and
wake cycles, appetite, body temperature,
emotions, pituitary secretions and emotions
Limbic system: hunger, aggression, sexual
and emotional arousal
RAS: stimulates wakefulness

NERVOUS SYSTEM: Anatomy and


Physiology

Cerebellum
- coordinates smooth muscle movement;
posture, equilibrium and muscle tone
Brain Stem
Pons- contains respiratory center
Midbrain- motor coordination; visual and auditory
relay center
Medulla oblongata
- contains all afferent and efferent tracts
- regulates vomiting, cardiac, vasomotor and
respiratory function

NERVOUS SYSTEM: Anatomy and


Physiology

Spinal cord
- carries sensory to, and motor information
from, the brain
- inner portion of gray matter
dorsal and ventral horns
- outer portion of white matter
ascending and descending nerve tracts

NERVOUS SYSTEM: Anatomy and


Physiology

Cerebrospinal fluid
- secreted in ventricles, circulates in
subarachnoid space then reabsorbed
- protective cushion and assists in exchange
of wastes and nutrients
- normal pressure- 50-175mm H2O
- normal volume- 125-150ml

NERVOUS SYSTEM: Anatomy and


Physiology

Blood supply
- internal carotids, vertebral arteries, circle of
Willis
Internal carotid arteries
-

MCA- lateral surface of the cerebrum (hearing and


upper body motor and sensory neurons
ACA- medial aspect of the same area

CIRCLE OF WILLIS

What kind of brain do you


have?

Diagnostic Tests
1. X-Ray (skull and spine)
2. Computerized Tomography (CT
Scan)
3. Electroencephalography (EEG)
4. Electromyography and Nerve
Conduction
Velocity studies
(EMG-NCV)

Diagnostic Tests
5. Cerebral Arteriogram
- assess patency of the cerebral arteries
- femoral artery, monitor for hemorrhage
6. Lumbar Puncture (tap)
- L3-L4; spinal headache and hypotension
- contraindicated in a patient with increased ICPbrain herniation
7. Magnetic Resonance Imaging (MRI)
- remove electrical devices and prosthesis

Neurologic Assessment

Mental status - orientation and memory


Level of Consciousness
levels of consciousness
Glasgow Coma Scale (EVM)
Sensory Functioning
Motor Functioning
Cranial Nerve Testing

Neurologic Assessment

Language and Speech


Bowel and Bladder Function

Sample Neuro Exam

Mental status: oriented to 3 spheres


CN: CN I-XII intact
Gait, Station: normal
Motor: MMT 5/5
Coordination/ involuntary movt: FTNT, APST,
heel to shin
Sensory: no sensory deficit
Reflexes: ++, no pathologic reflexes
Meninges: (-) nuchal rigidity, (-) Kernigs, (-)
Brudzinskis

Decorticate posturing

The result of lesions of


internal capsule or
cerebral hemispheres
Patient has flexion and
internal rotation of arms
and wrists and
extension internal
rotation of plantar
flexion of feet

Decerebrate posturing

The result of lesion of


the midbrain
Patient has extension
and external rotation of
the arms and wrists and
extension plantar
flexion of feet

Neurologic System: Physical


Examination

Cranial nerves

Olfactory nerve (CNI): smell

Optic nerve (CNII): vision; PERLA

Oculomotor (CNIII), trochlear (CNIV),


abducens (CNVI): ocular movements

Trigeminal nerve (CNV): sensation on the


face, movement of the mouth

Facial nerve (CNVII): facial muscles

Neurologic System: Physical


Examination (cont.)

Cranial nerves

Acoustic nerve (CNVIII): hearing and balance

Glossopharyngeal (CNIX): palate, uvula

Vagus (CNX)

Spinal accessory nerve (CNXI): muscles of the


shoulders and neck

Hypoglossal nerve (CNXII): tongue

Neurological Assessment

Assessment of Reflexes
Babinski reflex
Corneal reflex- loss of blink reflex; CN V
Gag reflex- loss of gag reflex; CN IX and X
Assessment of meningeal irritation
Brudzinskis sign- flexion of the head causes flexion
of the both thighs to the hip and knee flexion
Kernigs sign- flexion of the thigh and knee to right
angles and when extended causes spasm and
pain of hamstring

Question:
Two days after admission a stroke client has
a steady rise in temperature accompanied by
slow pulse and labile respiration. What do
these symptoms likely suggest?
A. absorption of the clot
B. injury to the vital centers in the brainstem
C. development of pneumonia
D. bacterial infection of the CNS

Increased Intracranial
Pressure
Increase in one content will increase pressure

(Brain tissue, blood and CSF)


Signs of increased ICP
restlessness
headache, nausea and vomiting, diplopia
change in the level of sensorium
vital signs changes : Cushings triad
elevated BP (systolic); slowed PR; slowed
RR; widened pulse pressure; temperature
change

Increased Intracranial
Pressure

Pupillary changes- pressure on


oculomotor nerve
Papilledema- edema of the optic nerve

Nursing management

Position - Semi-fowlers, lateral position


Oxygenation
Safety
Rest- keep environment quiet
Avoid factors that may increase ICP: vasovagal responses

nausea and vomiting


sneezing/ coughing

rectal examinations, enemas are CI


over suctioning- limit to 10-15 seconds
restraints
positional changes ( hip,waist or neck
flexion)

Control fever; prevent shivering


(predisposes to seizures)

Control HPN
Restrict fluid intake- if IV, slow infusion
pharmacotherapy
diuretics (mannitol, furosemide)
dexamethasone
anticonvulsants (diazepam, phenytoin,
phenobarbital)

Management for Increased


ICP

CSF blockage is corrected by surgical


placement of shunts; tumor or hematoma is
removed surgically; craniectomy or burr holes
may be required for decompression (craniotomy)

Place pads loosely around ears and under nose


to absorb leaking CSF (Halo sign)

Use aseptic technique in cleaning post-op


wound

Sample Question

A patient is admitted to the hospital with a closed


head injury. The nurse observes a yellow ring
encircling a clear moist area on the patients
pillow. The nurse should recognize this finding as:
a. an indication of a decrease in cranial pressure
b. an indication that the patient had an emesis
prior to admission
c. a sign of CSF fluid drainage
d. an indication of an emergency situation
requiring the physician to be notified

Sample Questions

When planning for the care of a patient with


increased ICP, a nurse should give priority to
which of the following measures?
a. limiting environmental stimuli
b. increasing fluid intake
c. suctioning nasotracheally
d. keeping the patient in a recumbent position

Which type of seizure is frequently preceded


by an aura?
A. jacksonian (focal)
B. petit mal (absence)
C. grand mal (tonic-clonic)
D. myoclonus

Seizures
Abnormal electrical activity
Effects altered loc
motor, sensory and autonomic dysfunction
Types
Grand mal (tonic-clonic)
Petit mal (absence or little sickness)
Jacksonian/ Focal
Febrile
Status epilepticus
Epilepsy

Seizures

Three Phases
- Prodromal phase: produces an aura
(sensory signals) - flash of light, mood or
behavior changes, sudden sensation of
smell or taste; cry
- Ictal phase: seizure itself
- Postictal phase: after the seizure;
amnesia, confusion, inability to be
aroused, sleepiness

Nursing management

Promote a safe environment

padded side rails

loosen constrictive clothings


turn to sides
no restraints and no tongue blades
observe and document

characteristic and duration

Health education :

medications taken regularly


- Dilantin- gingival hyperplasia
- Barbiturates: Phenobarbital
- Benzodiazepines: Diazepam

avoid alcohol
active lifestyle with adequate rest
avoid hazardous activities

The most likely cause of a comatose


condition with a history of hypertension,
headache and unequal pupils is
A. meningitis
B. intracranial aneurysm
C. diabetic ketoacidosis
D. cerebral concussion

Cerebrovascular Accidents

Stroke
Destruction of brain cells due to sudden
decrease in cerebral blood flow (cerebral
infarct)
Cerebral anoxia lasting more than 610minutes causes cerebral infarction with
irreversible damage
TIA: temporary interruption of blood supply
to the brain; symptoms disappear in 124hours; warning signal that a CVA can
occur

Cerebrovascular
Accidents
Maybe an ischemic or hemorrhagic
Causes :
thrombosis
embolism
hypertension
subarachnoid hemorrhage

Manifestations include :
Increased ICP
Symptoms will depend upon what lobe was
affected
Frontal (speech, motor movementhemiplegia, facial drooping, judgment,
personality, thinking and cognition)
Parietal- sensory
Temporal- hearing, speech
Occipital- visual

Nursing Management

Care of client with increased ICP


promote nutrition (aspiration precautions)
activity (rehabilitation)
elimination
communication (alternate means)
compensate for deficits
provide emotional support
provide health teachings

CVA Treatment

Carotid endarterectomy- scraping of plaque)


Surgical evacuation of clot or hematoma
Anticoagulants for non-hemorrhagic strokes
TPA (tissue plasminogen activator)- improves
neurologic functioning for thrombotic stroke used
within 3-4hours
Anticonvulsants, diuretics, antihypertensives and
analgesics
Physical and occupational therapy to maintain
muscle and joint function

Rehabilitation

prevent complications of immobility (pressure


ulcers, muscle atrophy, pneumonia)
correction of deformities
restoration of function for maximum independence
limitation of disability

HEAD TRAUMA
CONSIDERATIONS:
1. obtain thorough hx
2. monitor VS & check for additional injuries
3. check LOC & pupil reaction & observe closely.
4. note for increasing ICP, increasing headache,
vomiting, signs of ear bleed, or CSF leak
5. wake patient up at intervals during the night
6. With serious head injury:
- establish & maintain patent airway
- is CSF leaks from the nose:
- NO nasal airway >>> intubate
- avoid nose blowing

- Check for other CSF leaks: ears &mouth


- Ear leaks: cover lightly with sterile gauze, do not put
packs
- No spinal injury: elevate HOB 30 degrees
- Seizure precaution; no restraints
- No narcotics or sedatives
- May give acetaminophen for pain
- Restrict fluids
- Prepare for possible OR.

Parkinsons Disease

Decreased dopamine levels in CNS


idiopathic
acetylcholine predominates
signs
pill-rolling tremors
rigidity (cogwheel rigidity)
bradykinesia

Pathology of Parkinsons
Disease

MANIFESTATIONS
Mask-like facies
drooling of saliva
dysphagia
Shuffling and propulsive gait
Stooped posture
no sensory deficits
diagnostic test : clinical observation

Nursing Management

Maintain adequate diet


proper positioning to prevent contractures
Aspiration precautions
pharmacotherapy

anticholinergics (biperiden, diphenhydramine)


dopaminergics (levodopa, carbidopa)
dopamine agonists(amantadine, bromocriptine)

Myasthenia Gravis
Autoimmune disorder
Myoneural junction problem
Acetylcholine- skeletal muscle contraction
Theories
Imbalance of acetylcholine and acetylcholinesterase
Formation of autoantibodies that destroy
acetylcholine receptors (thymus gland)

Signs
Muscle weakness (including dysphagia and
dyspnea)
Easy fatigability
Ptosis and diplopia
Impaired speech
Mask-like facies with snarl smile
Drooling
Progressive respiratory difficulty
Diagnostic test
Tensilon Test (Edrophonium Chloride Test)
short acting acetylcholine (5-20mins)

Nursing management

Aspiration precautions
accident preventions
medications should be timely given
Cholinergic drugs (neostigmine,
pyridostigmine)
adequate ventilation
adequate rest periods
avoid exposures to infections

Plasmapheresis- remove autoantibodies


Surgery: ____________
myasthenia crisis and cholinergic crisis
- Same symptom: Extreme muscle weakness
- To differentiate: _______________

Sample Question

a.
b.
c.
d.

The nurse is aware that the teaching about


myasthenic and cholinergic crisis is
understood when a client with Myasthenia
Gravis states that a symptom common to
both is:
Diarrhea
difficulty breathing
salivation
abdominal cramping

Sample question

a.
b.
c.
d.

The nurse should explain to the client that


the diagnosis of Myasthenia gravis will be
confirmed if the administration of Tensilon
produces a:
brief exaggeration of symptoms
prolonged symptomatic improvement
rapid but brief symptomatic improvement
symptomatic improvement of just the ptosis

MULTIPLE SCLEROSIS
Autoimmune; characterized by exacerbations
and remissions (aggravated by fatigue and
emotional disturbances)
Demyelinating disease of the CNS inflammation and destruction of the myelin
sheath > sclerotic plaque (scar tissue) >
irritation of nerves and slowing down of
impulses

MULTIPLE SCLEROSIS

signs
diplopia, scotoma, blindness (optic
nerve)
muscle spasms, weakness and
numbness, fatigue
dysphagia

Nursing management

Eye patch for diplopia


well-balanced diet
force fluids
avoid hot baths
physical and speech therapy
Plasmapharesis
Pharmacotherapy

muscle relaxants (baclofen)


glucocorticoids

prednisone
dexamethasone
corticotropin

Sample Questions

a.
b.
c.
d.

The nurse reminds a group of students about


the aspects of the pathophysiology of multiple
sclerosis (MS) which is:
damage occurs primarily to the dendrites
once damaged, myelin cannot regenerate
plaques occur anywhere in the white matter of
the PNS
Schwann cells are destroyed

The nurse might expect a client with Multiple


sclerosis to complain about the most
common initial symptom which is:
a. Diarrhea
b. Skin infections
c.
Headache
d. Visual disturbances

Autoimmune: Guillain-Barr
Syndrome
An autoimmune attack of the peripheral nerve

myelin (Schwann cells- produce myelin in PNS)


Resolves about a month after onset of
symptoms due to regeneration of myelin sheath
Also known as: post-infectious polyneuritis
Characterized by ascending paralysis

Autoimmune: GuillainBarr Syndrome

Clinical Manifestations
muscle weakness
diminished reflexes of the lower extremities
quadriplegia
neuromuscular respiratory failure
paresthesias of the hand and feet
blindness
inability to swallow or clear secretions
instability of the cardiovascular system

Autoimmune: GuillainBarr Syndrome


Nursing and Medical management
medical emergency: ICU
assess changes in motor weakness and
respiratory function
respiratory therapy / mechanical ventilation
prevent the complications of immobility: elastic
stockings
plasmapheresis
steroids

MENINGITIS- inflammation of the meninges, the


protective membrane lining the brain and spinal
cord
CLASSIFICATION:
ASEPTIC/ VIRAL MENINGITIS- the cause is viral
(mumps virus, measles, HSV and herpes zoster) or
secondary to lymphoma, leukemia, or brain abscess
- Self- limiting
SEPTIC MENINGITIS- caused by bacteria, most
commonly Neisseria meningitides and
Streptococcus pneumoniae are also causative
agents.
.

Infectious: Meningitis
Diagnostic exam:
Lumbar puncture

CSF pressure
cloudy or milky white (clear- viral)
protein level
glucose concentration (normal in viral)
(+) Gram stain, C & S (except in viral)
CBC leukocytosis
CT Scan / skull X-ray to rule out underlying cause
Cultures of blood, urine, nose & throat secretions

Infectious: Meningitis

Initial Manifestations:
Headache, fever
Classical Manifestations:
nuchal rigidity, (+) Kernigs sign, (+) Brudzinskis sign,
photophobia
Others:
- rash; skin lesions (ranging from petechial rash with
purpuric lesions to large areas of ecchymosis)
- disorientation and memory impairment
- behavioral manifestations
- seizures (sec. to focal areas of cortical irritability )
- increased ICP (sec. to accumulation of purulent exudates);
as manifested by decrease LOC and focal motor deficits)

Infectious: Meningitis

Prevention: vaccination
Nursing Management:
- Neurologic status and VS continually
assessed
- Protect client from injury (seizure or
altered LOC)
- Preventing complications
- Instituting droplet precaution until 24 hrs.
after the initiation

Infectious: Meningitis

Medications:
Early administration of antibiotic
( penicillin e.g. ampicillin and piperacillin;
cephalosporin e.g. ceftriaxone sodium and
cefotaxime sodium,)
( Vancomycin HCL)
anti-fungal = (Amphotericin B)
Adjunctive therapy (Dexamethasone)
Seizures are controlled with phenytoin (Dilantin)

Cranial Nerve Disorder :


Trigeminal Neuralgia (Tic
Douloureux)
A condition of the 5th cranial nerve

characterized by unilateral paroxysms of pain


in the area innervated by any of the 3
branches, but it most commonly occurs in the
2nd and 3rd branches of the trigeminal nerve
Trigeminal nerves controls:
- corneal reflex
- facial sensation
- mastication muscles

Trigeminal Neuralgia (Tic


Douloureux)
Pathophysiology
Suggested causes:
- chronic irritation of the trigeminal nerve
Diagnostic Method
- based on characteristic behavior:
avoiding stimulating trigger points

Trigeminal Neuralgia
(Tic Douloureux)
Clinical manifestations:
Pain felt on skin (more severe over lip, chin,
nostrils, in the teeth)
Paroxysms are aroused by stimulation of
affected nerve endings (washing the face,
shaving, brushing teeth, eating, drinking)
Drafts of cold air and direct pressure against
the nerve may cause pain

Trigeminal Neuralgia
(Tic Douloureux)
Nursing management
Assist patient to recognize the factors that
trigger facial pain- use cotton pads and room
temperature water
Rinse mouth if toohbrushing causes pain
Take food and fluids at room temperature , chew
on unaffected side, ingest soft foods
Perform personal hygiene during pain free
interval

Trigeminal Neuralgia (Tic


Douloureux)

Medical management
Anticonvulsive agents

carbamazepine (Tegretol)
phenytoin (Dilantin)

Surgery:
microvascular decompression of the
trigeminal nerve

Bells Palsy

A disease of the 7th cranial nerve (Facial) that


produces unilateral or bilateral facial
weakness or paralysis
Cause unknown but may result from
infection, hemorrhage, tumor, meningitis,
local trauma
Usually resolves after 3 to 4 weeks

Cranial Nerve Disorder : Bells


Palsy

Clinical manifestations
- distortion of the face
- increased lacrimation
- painful sensations : face, behind the ear, in the eye
- diminished blink reflex
- speech difficulties
- may be unable to swallow

Cranial Nerve Disorder : Bells


Palsy
Nursing and medical management
Maintain facial muscle tone
Eye care
Steroid therapy (prednisone)
Analgesic
Heat therapy
Electrical stimulation
Surgical exploration of the facial nerve

1.
2.
3.

4.

You are working with a client who is in the


convalescent phase after a cerebrovascular
accident. Which statement by the client indicates
that further teaching on bowel training is needed?
I find the need for an enema almost every day.
I am drinking 6 to 8 glasses of fluid per day.
My husband helps me use the toilet around 9am
every day.
I have increased the fiber in my diet.

1.
2.
3.

4.

In planning nursing care for the client with a left


hemisphere stroke, you develop the following
interventions. Which one addresses the problem of
unilateral neglect?
Face client, speak slowly and distinctly.
Place objects within clients visual field.
Teach the client to monitor position of the right
side.
Verbally cue the patient at his left side.

A.
B.
C.
D.

A client with myasthenia gravis has difficulty


chewing and has received a prescription for
pyridostimine (Mestinon). You plan to check
to see that the client understands to take
the medication at which of the following?
Just after meals
Between meals
With meals
30 minutes before meals

A client with Parkinsons disease has begun


therapy with levo-dopa. You determine that the
client understands the action of the medication if
the client verbalizes that results may not be
apparent for which of the following amounts of
time?
A. 24 hours
B. 2-3 days
C. 1 week
D. 2-3 weeks

You are providing instructions to the client with Bells


palsy regarding treatment measures for the disorder.
Which of the following statements by the client
indicates a need for further teaching?
A. I am staying on a liquid diet.
B. I should eat small meals and soft foods frequently.
C. I should protect my affected eye by using an eye
patch.
D. I should place artificial tears into my eye four times
daily.