Neurology.. | Stroke | Multiple Sclerosis

Medical-Surgical Nursing A Review of Neurologic Concepts

Nurse Licensure Examination Review

Key to Success! 
   



Confidence Test taking strategies Ample test preparation and study habits Review of frequent board examination topics Focus on your goals Above all- PRAYERS

Outline of Our Review 


Brief review of Anatomy and Physiology Application of the Nursing process in the approach of neurologic problems:  

  

ASSESSMENT relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Outline of the review 

Trauma and related accidents 


Traumatic brain injury Spinal cord injury 

Cerebrovascular Accidents

Outline of the review 

Degenerative disorders- demyelinating 


Multiple sclerosis Guillain-Barre syndrome 

Degenerative disordersNON-demyelinating 


Alzheimer s disease Parkinson s disease

Outline of the review 

Motor dysfunction- CNS 

Epilepsy Bell s palsy Trigeminal neuralgia Myasthenia gravis 

Motor dysfunction- cranial nerve 
 

Motor dysfunction- peripheral 

Outline of the review 

Infectious Disease 
 

Meningitis Brain abscess Encephalitis 

Neoplastic disease

IMPLEMENTATION PHASE 
     

Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence

IMPLEMENTATION PHASE 
 

Impaired physical mobility Impaired swallowing Disturbed sensory perception

Anatomy and Physiology 

Gross anatomy   

The nervous system is divided into the central and peripheral nervous system The Central nervous system consists of the BRAIN and the Spinal Cord The peripheral nervous system consists of the Spinal nerves and the cranial nerves

Anatomy and Physiology
The brain is composed of lobes Frontal lobe- personality, memory and motor function  Parietal lobe- sensory function  Temporal lobe- hearing and olfaction and emotion by the limbic system  Occipital lobe- vision

Anatomy and Physiology  

The cerebellum is involved in coordination and equilibrium The diencephalon consists of the :  

Thalamus- the relay center of all sensory input Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response

Anatomy and Physiology 
  

The brainstem is composed of the: MIDBRAIN- for visual and auditory reflexes Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8 Medulla oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12

ASSESSMENT OF THE NEUROLOGIC SYSTEM 


HISTORY A confused client becomes an unreliable source of history

ASSESSMENT OF THE NEUROLOGIC SYSTEM
PHYSICAL EXAMINATION 

5 categories: 

   

1. 2. 3. 4. 5.

Cerebral function- LOC, mental status Cranial nerves Motor function Sensory function Reflexes

ASSESSMENT OF THE NEUROLOGIC SYSTEM
Neuro Check  Level of consciousness  Pupillary size and response  Verbal responsiveness  Motor responsiveness  Vital signs

CEREBRAL FUCTION    

Assess the degree of wakefulness/alertness Note the intensity of stimulus to cause a response Apply a painful stimulus over the nailbeds with a blunt instrument Ask questions to assess orientation to person, place and time

Cerebral function 
  



Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor response Scores are evaluated- range from 3-15 No ZERO score

Glasgow Coma Scale

Glasgow Coma Score  Eye Opening (E)  Verbal Response (V)  Motor Response (M)

Glasgow Coma Scale
Glasgow Coma Score  Eye Opening (E) 4=Spontaneous 3=To voice 2=To pain 1=None (No response)

Glasgow Coma Scale
Glasgow Coma Score  Verbal Response (V) 5=Normal/oriented 4=Disoriented/CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None

Glasgow Coma Scale
Glasgow Coma Score  Motor Response (M) 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=Decerebrate posture 1=None (flaccid)

Cranial Nerve Function: Cranial Nerve 1- Olfactory 
   



Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- loss of smell

Cranial Nerve Function: Cranial Nerve 2- Optic    

Check the visual acuity with the use of the Snellen chart Check for visual field by confrontation test Check for pupillary reflex- direct and consensual Fundoscopy to check for papilledema

Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6
Assess simultaneously the movement of the extra-ocular muscles Deviations:  Opthalmoplegia- inability to move the eye in a direction  Diplopia- complaint of double vision 

Cranial Nerve Function: Cranial Nerve 5 -trigeminal   

Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess corneal reflex

Cranial Nerve Function: Cranial Nerve 7 -facial  

Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory 


Test patient s hearing acuity Observe for nystagmus and disturbed balance

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal 
  

Together with Cranial nerve 10 vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say AH The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 11- accessory 

Press down the patient s shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 12- hypoglossal 

Ask patient to protrude the tongue and note for symmetry

ASSESS Motor function  

Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance Grading of muscle strength

Assessing the motor function of the cerebellum 


Test for balance- heel to toe Test for coordination- rapid alternating movements and finger to nose test ROMBERG s is actually a test for the posterior spinothalamic tract 

Assessing the motor function of the brainstem
Test for the Oculocephalic reflex- doll s eye  Normal response- eyes appear to move opposite to the movement of the head  Abnormal- eyes move in the same direction

Assessing the motor function of the brainstem
Test for the Oculovestibular reflex  Slowly irrigate the ear with cold water and warm water  Normal response- cOld- OppOsite, wArM- sAMe

Assessing the sensory function 
     

Evaluate symmetric areas of the body Ask the patient to close the eyes while testing Use of test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to identify objects placed on the hands Test for sense of position

Assessing the reflexes 

Deep tendon reflexes 
   

Biceps Triceps Brachioradialis Patellar Assessing the sensory function Achilles

Assessing the reflexes 

Superficial reflexes 
 

Abdominal Cremasteric Anal Babinski- stroke the lateral aspect of the soles doing an inverted J 

Pathologic reflex  

(+)- DORSIFLEXION of the Big toe with fanning out of the little toes

Grading of reflexes
Deep tendon reflex  0- absent  + present but diminished  ++ normal  +++ increased  ++++ hyperactive or clonic Superficial reflex  0 absent  +present

DIAGNOSTIC TESTS 

EEG  

Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants Wash hair thoroughly before procedure

DIAGNOSTIC TESTS
CT scan  With radiation risk  If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

DIAGNOSTIC TESTS
MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices cannot undergo this procedure

DIAGNOSTIC TESTS
Cerebral arteriography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

DIAGNOSTIC TESTS
Lumbar puncture Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP Keep flat on bed after procedure Increase fluid intake after procedure

Increased Intracranial pressure
Intracranial pressure more than 15 mmHg Brunner= Normal intracranial pressure 10-20 mmHg Causes:  Head injury  Stroke  Inflammatory lesions  Brain tumor  Surgical complications

Increased Intracranial pressure
Pathophysiology  The cranium only contains the brain substance, the CSF and the blood/blood vessels  MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other  Any increase or alteration in these structures will cause increased ICP

Increased Intracranial pressure
Pathophysiology  Compensatory mechanisms:  1. Increased CSF absorption  2. Blood shunting  3. Decreased CSF production

Increased Intracranial pressure
Pathophysiology Decompensatory mechanisms:  1. Decreased cerebral perfusion  2. Decreased PO2 leading to brain hypoxia  3. Cerebral edema  4. Brain herniation

Decreased cerebral blood flow  

Vasomotor reflexes are stimulated initially slow bounding pulses Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP

Cerebral Edema 

Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Herniation 

Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Cerebral response to increased ICP
1. 2. 

Steady perfusion up to 40 mmHg Cushing s response
Vasomotor center triggers rise in BP to increase ICP Sympathetic response is increased BP but the heart rate is SLOW Respiration becomes SLOW  

Increased Intracranial pressure
CLINICAL MANIFESTATIONS Early manifestations:  Changes in the LOC- usually the earliest  Pupillary changes- fixed, slowed response  Headache  vomiting

Increased Intracranial pressure
CLINICAL MANIFESTATIONS late manifestations:  Cushing reflex- systolic hypertension, bradycardia and wide pulse pressure  bradypnea  Hyperthermia  Abnormal posturing

Increased Intracranial pressure
Nursing interventions: Maintain patent airway  1. Elevate the head of the bed 15-30 degrees- to promote venous drainage  2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levels constricts blood vessels reduces edema

Increased Intracranial pressure
Nursing interventions  3. Administer prescribed medicationsusually 
 

Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants-p to prevent seizures

Increased Intracranial pressure
Nursing interventions  4. Reduce environmental stimuli  5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

Increased Intracranial pressure 
 

Nursing interventions 6. Keep head on a neutral position. ACOID- extreme flexion, valsalva 7. monitor for secondary complications 


Diabetes insipidus- output of >200 mL/hr SIADH

Altered level of consciousness   

It is a function and symptom of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic derangement Disruption in the neuronal transmission results to improper function

Altered level of consciousness
Assessment  Orientation to time, place and person  Motor function 


Decerebrate Decorticate 

Sensory function

Altered level of consciousness 
 

Patient is not oriented Patient does not follow command Patient needs persistent stimuli to be awake COMA= clinical state of unconsciousness where patient is NOT aware of self and environment 

Altered level of consciousness 

1. 2. 3. 4. 5. 6.

Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure

Altered level of consciousness
ASSESSMENT 1. Behavioral changes initially 2. Pupils are slowly reactive 3. Then , patient becomes unresponsive and pupils become fixed dilated Glasgow Coma Scale is utilized 

Altered level of consciousness
Nursing Intervention 1. Maintain patent airway  Elevate the head of the bed to 30 degrees  Suctioning 2. Protect the patient  Pad side rails  Prevent injury from equipments, restraints and etc.

Altered level of consciousness
Nursing Intervention 3. Maintain fluid and nutritional balance  Input an output monitoring  IVF therapy  Feeding through NGT 4. Provide mouth care  Cleansing and rinsing of mouth  Petrolatum on the lips

Altered level of consciousness
Nursing Intervention 5. Maintain skin integrity  Regular turning every 2 hours  30 degrees bed elevation  Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity  Use of artificial tears every 2 hours

Altered level of consciousness
Nursing Intervention 7. Achieve thermoregulation  Minimum amount of beddings  Rectal or tympanic temperature  Administer acetaminophen as prescribed 8. Prevent urinary retention  Use of intermittent catheterization

Altered level of consciousness
Nursing Intervention 9. Promote bowel function  High fiber diet  Stool softeners and suppository 10. Provide sensory stimulation  Touch and communication  Frequent reorientation

SEIZURES  

Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved

SEIZURES 


PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively

SEIZURES 

1. 2. 3. 4. 5.

ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions

SEIZURES
Nursing Interventions During seizure  1. remove harmful objects from the patient s surrounding  2. ease the client to the floor  3. protect the head with pillows  4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES
Nursing Interventions During seizure  5. loosen constrictive clothing  6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES
Nursing Interventions POST seizure  1. place patient to the side to drain secretions and prevent aspiration  2. help re-orient the patient if confused  3. provide care if patient became incontinent during the seizure attack  4. stress importance of medication regimen

headache 
   

Cephalgia Primary headache- no organic cause Secondary headache- with organic cause Migraine headache- periodic attacks of headache due to vascular disturbance Tension headache-the most common type- due to muscle tension

headache 

1. 2. 3. 4.

Migraine Prodrome stage Aura phase Headache Recovery phase

headache
Nursing Interventions  1. Avoid precipitating factors  2. modify lifestyle  3. relieve pain by pharmacologic measures 


Beta-blockers Serotonin antagonists- triptan"

Autonomic Dysreflexia/hyperreflexia  

Seen commonly in spinal cord injury above T6 An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation

Autonomic Dysreflexia/hyperreflexia 
    

Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion

Autonomic Dysreflexia/hyperreflexia
NURSING INTERVENTIONS  1. Elevate the head of the bed immediately  2. Check for bladder distention and empty bladder with urinary catheter  3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer  4. Administer antihypertensive medicationsusually hydralazine

Spinal Shock
Pathophysiology  The sudden depression of reflex activity in the spinal cord below the level of injury  The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions

Spinal Shock 
 

Nursing Interventions 1. Assist in chest physical therapy 2. Manage potential complication- DVT

Cognitive Impairment
Nursing Interventions 1. Assist or encourage the patient to use eyeglass, hearing aid or assistive devices 2. Reorient the patient by calling his name frequently 3. Provide background information as to date, time, place, environment

Cognitive Impairment
Nursing Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area

Bowel and Bladder incontinence  

Establish a regular pattern for bowel care Maintain a dietary intake. Avoid foods that can cause excessive gas production

CONGENITAL DISORDERS: Hydrocephalus  



Excessive CSF accumulation in the brain s ventricular system In infants, head enlarges In children and adults- brain compression

CONGENITAL DISORDERS: Hydrocephalus  

Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production

CONGENITAL DISORDERS: Hydrocephalus 
   

Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes

CONGENITAL DISORDERS: Hydrocephalus 
 

DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography

CONGENITAL DISORDERS: Hydrocephalus 
 

Nursing Intervention 1. monitor neurologic status 2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows

CONGENITAL DISORDERSpinal cord defects   

1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges 2. Spina bifida with meningocele- a sac contains meninges and CSF 3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF

CONGENITAL DISORDER: Spinal cord defects 
   

Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic

CONGENITAL DISORDER: Spinal cord defects 
 

  

ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography

CONGENITAL DISORDER: Spinal cord defects 
  

NURSING INTERVENTION 1. cover the defect with sterile dressing moistened with sterile saline 2. position the patient on prone or side to protect the fragile sac 3. place a diaper under the infant and change it often

CONGENITAL DISORDER: Spinal cord defects 
   

 

NURSING INTERVENTION 4. avoid the use of lotion 5. avoid frequent handling 6. Measure the child s head circumference daily 7. check anal reflex 8. support family members 9. prepare the parents for the possible outcome of eh defect

CONGENITAL DISORDER: Spinal cord defects 
      

NURSING INTERVENTION 10. Post-operative care Position on abdomen Check post-operative dressings Place infant s hips in abduction and feet in neutral position Monitor intake and output Check for urine retention Asess infant frequently as he recovers from the surgery

Traumatic brain injury
1. CONCUSSION  Involves jarring of head without tissue injury  Temporary loss of neurologic function lasting fore a few minutes to hours

Traumatic brain injury
2. CONTUSION  Involves structural damage  The patient becomes unconscious for hours

Traumatic brain injury
3. Diffuse Axonal injury  Involves widespread damage to the neurons  Patient has decerebrate and decorticate posture

Traumatic brain injury
4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly

Traumatic brain injury
4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly

Traumatic brain injury
4. Intracranial hemorrhage Intracerebral Hemorrhage and hematomableeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits

Traumatic brain injury
MANIFESTATIONS  1. Altered LOC  2. CSF otorrhea  3. CSF rhinorrhea  4. Racoon eyes and battle sign 

HALO SIGN- blood stain surrounded by a yellowish stain

Traumatic brain injury
NURSING MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway  Elevate bed, suction prn, monitor ABG

Traumatic brain injury
NURSING MANAGEMENT 3. Monitor F and E balance  Daily weights  IVF therapy  Monitor possible development of DI and SIADH

Traumatic brain injury
4. Provide adequate nutrition 5. Prevent injury  Use padded side rails  Minimize environmental stimuli  Assess bladder  Consider the use of intermittent catheter

Traumatic brain injury
6. Maintain skin integrity  Prolonged immobility will likely cause skin breakdown  Turn patient every 2 hours  Provide skin care every 4 hours  Avoid friction and shear forces

Traumatic brain injury
7. Monitor potential complications  Increased ICP  Post-traumatic seizures  Impaired ventilation

Spinal cord injury  

  

The most frequent vertebrae T12 and L1 Concussion Contusion Compression Transection

C5-C7,

Spinal cord injury
Clinical manifestations  1. Paraplegia  2. quadriplegia  3. spinal shock

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

Spinal cord injury
NURSING INTERVENTION  1. Promote adequate breathing and airway clearance  2. Improve mobility and proper body alignment  3. Promote adaptation to sensory and perceptual alterations  4. Maintain skin integrity

Spinal cord injury 
  

5. 6. 7. 8. 
  

Maintain urinary elimination Improve bowel function Provide Comfort measures Monitor and manage complications
Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia

Spinal cord injury 

9. Assists with surgical reduction and stabilization of cervical vertebral column

CEREBROVASCULAR ACCIDENTS 

An umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply

CEREBROVASCULAR ACCIDENTS   

Can be divided into two major categories 1. Ischemic stroke- caused by thrombus and embolus 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

CEREBROVASCULAR ACCIDENTS
The stroke continuum  1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration  2. Reversible Neurologic deficits  3. Stroke in evolution  4. Completed stroke

General manifestations

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke 

There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

RISKS FACTORS
Non-modifiable  Advanced age  Gender  race Modifiable  Hypertension  Cardio disease  Obesity  Smoking  Diabetes mellitus  hypercholesterolemia

Pathophysiology of ischemic stroke 
  

Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to impaired membrane function Cellular injury and death can occur

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke 
  

DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
CLINICAL MANIFESTATIONS  1. Numbness or weakness  2. confusion or change of LOC  3. motor and speech difficulties  4. Visual disturbance  5. Severe headache

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Motor Loss  Hemiplegia  Hemiparesis

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Communication loss  Dysarthria= difficulty in speaking  Aphasia= Loss of speech  Apraxia= inability to perform a previously learned action

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
Perceptual disturbances  Hemianopsia Sensory loss  paresthesia

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 1. 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

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 2. Enhance self-care  Carry out activities on the unaffected side  Prevent unilateral neglect  Keep environment organized  Use large mirror

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 3. Manage sensory-perceptual difficulties  Approach patient on the Unaffected side  Encourage to turn the head to the affected side to compensate for visual loss

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 4. Manage dysphagia  Place food on the UNAFFECTED side  Provide smaller bolus of food  Manage tube feedings if prescribed

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
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

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 6. Improve thought processes  Support patient and capitalize on the remaining strengths

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 7. 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

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 8. Maintain skin integrity  Use of specialty bed  Regular turning and positioning  Keep skin dry and massage NONreddened areas  Provide adequate nutrition

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 9. Promote continuing care  Referral to other health care providers

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke
NURSING INTERVENTIONS 10. Improve family coping 11. Help patient cope with sexual dysfunction

CVA: Hemorrhagic Stroke  

Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage

CVA: Hemorrhagic Stroke 
 

 

Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

CVA: Hemorrhagic Stroke 
  

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)

CVA: Hemorrhagic Stroke 
  

NURSING INTERVENTIONS 1. Optimize cerebral tissue perfusion 2. relieve Sensory deprivation and anxiety 3. Monitor and manage potential complications

DEMYELINATING DISEASES
Nurse Licensure Examination Review

MULTIPLE SCLEROSIS  

An auto-immune mediated progressive demyelinating disease of the CNS The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)

MULTIPLE SCLEROSIS 


CAUSE- unknown Multiple factors- viral infection, environmental factors,geographic location and genetic predisposition Common in WOMEN ages 20-40 

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY  Sensitized T cells will enter the brain and promote antibody production that damages the myelin sheath  Plaques of sclerotic tissues appear on the demyelinated axons interrupting the neuronal transmission

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY  The most common areas affected are 
  

Optic nerves and chiasm Cerebrum Cerebellum Spinal cord

MULTIPLE SCLEROSIS
CLINICAL MANIFESTATIONS  1. visual problems such as diplopia, blurred vision and nystagmus  2. motor dysfunction  3. Fatigue  4. Mental changes like mood swings, depression  5. spasticity

MULTIPLE SCLEROSIS 
 

DIAGNOSTIC TESTS 1. MRI- primary diagnostic study 2. CSF Immunoglobulin G

MULTIPLE SCLEROSIS
NURSING INTERVENTIONS 1. Promote physical mobility  Exercise  Schedule activity and rest periods  Warm packs over the spastic area  Swimming and cycling are very useful

MULTIPLE SCLEROSIS
NURSING INTERVENTIONS 2. Prevent injuries  Wide stance walking  Use of walking aids  Wheelchair

MULTIPLE SCLEROSIS
3. Enhance bladder and bowel control  Set a voiding schedule  Intermittent bladder catheterization  Use of condom catheter  Adequate fluids, dietary fibers and bowel training program

MULTIPLE SCLEROSIS
4. Manage speech and swallowing difficulties  Careful feeding, proper positioning, suction machine availability  Speech therapist

MULTIPLE SCLEROSIS
5. Improve Sensory and Cognitive function  Vision- use eye patch for diplopia  Obtain large printed reading materials  Offer emotional support  Involve the family in the care

MULTIPLE SCLEROSIS
6. Strengthen coping mechanism  Alleviate the stress  Referral to the appropriate agencies

MULTIPLE SCLEROSIS
7. improve self-care abilities  Modify activities according to physical strength  Provide assistive devices

MULTIPLE SCLEROSIS
8. promote sexual functioning  Refer to sexual counselor

MULTIPLE SCLEROSIS
MEDICAL MANAGEMENT Pharmacotherapy 
   

Interferons Immunomodulators Corticosteroids BACLOFEN for muscle spasms NSAIDS for pain

Guillian-Barre Syndrome  

An auto-immune attack of the peripheral nerve myelin Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves

Guillian-Barre Syndrome 

CAUSE: post-infectious polyneuritis of unknown origin commonly follows viral infection

Guillian-Barre Syndrome 

PATHOPHYSIOLOGY  

Cell-mediated imune attack to the myelin sheath of the peripheral nerves Infectious agent may elicit antibody production that can also destroy the myelin sheath

Guillian-Barre Syndrome
CLINICAL MANIFESTATIONS  1. Ascending weakness and paralysis  2. diminished reflexes of the lower extremities  3. paresthesia  4. potential respiratory failure

Guillian-Barre Syndrome
NURSING INTERVENTIONS 1. Maintain respiratory function  Chest physiotherapy and incentive spirometry  Mechanical vetnilator

Guillian-Barre Syndrome
NURSING INTERVENTIONS  2. Enhance physical mobility 
  

Support paralyzed extremities Provide passive range of motion exercise Prevent DVT and pulmonary embolism Padding over bony prominences

Guillian-Barre Syndrome
NURSING INTERVENTIONS  3. Provide adequate nutrition 
 

IVF Parenteral nutrition Assess frequently return o gag refelx

Guillian-Barre Syndrome
NURSING INTERVENTIONS  4. Improve communication 

Use other means of communication

Guillian-Barre Syndrome
NURSING INTERVENTIONS  5. Decrease fear and anxiety 
 

Provide Referrals Answer questions Provide diversional activities DVT, Urinary retention, pulmonary embolism, respiratory failure 

6. Monitor and manage complications 

Guillian-Barre Syndrome
MEDICAL MANAGEMENT  ICU admission  Mechanical Ventilation  TPN and IVF  PLASMAPHERESIS  IV IMMUNOGLOBULIN

ALZHEIMER S disease 

A progressive neurologic disorder that affects the brain resulting in cognitive impairments

ALZHEIMER S disease
CAUSES:  Unknown  Potential factors- Amyloid plaques in the brain, Oxidative stress, neurochemical deficiencies

ALZHEIMER S disease 
    

CLINCAL MANIFESTATIONS 1. Forgetfulness 2. Recent memory loss 3. Difficulty learning 4. Deterioration in personal hygiene 5. Inability to concentrate

ALZHEIMER S disease 
   



LATE CLINICAL MANIFESTATIONS 6. Difficulty in abstract thinking 7. Difficulty communicating 8. Severe deterioration in memory, language and motor function 9. repetitive action- perseveration 10. personality changes

ALZHEIMER S disease
DIAGNOSTIC TEST  Neurologic examination  PET scan  EEG, CT and MRI  Other tests to rule out Vit B deficiencies and hypothyroidism  Autopsy is the most definitive

ALZHEIMER S disease
Drug therapy  1. drugs to treat behavioral symptoms- antipsychotics  2. anxiolytics  3. Donepezil  4. Tacrine

ALZHEIMER S disease
Nursing Interventions  1. Support patient s abilities  2. Provide emotional support

ALZHEIMER S disease
Nursing Interventions 3. Establish an effective communication system with the patient and family  Use short simple sentences, words and gestures  Maintain a calm and consistent approach  Attempt to analyze behavior for meaning

ALZHEIMER S disease
4. protect the patient from injury  Provide a safe and structured environment  Requests a family member to accompany client if he wanders around  Keep bed in low position  Provide adequate lightning  Assign consistent caregivers

ALZHEIMER S disease
5. Encourage exercise to maintain mobility

PARKINSON s Disease  

A slowly progressing neurologic movement disorder The degenerative idiopathic form is the most common form

PARKINSON s Disease
CAUSATIVE FACTORS: unknown  Potential factors: genetics, atherosclerosis, free radical stress, viral infection, head trauma and environmental factors

PARKINSON s Disease
Pathophysiology  Decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia  Clinical symptoms do not appear until 60% of the neurons have disappeared

PARKINSON s Disease
CLINICAL MANIFESTATIONS  1. Tremor- resting, pill-rolling  2. Rigidity- cog-wheel, lead-pipe  3. Bradykinesia- abnormally slow movement  4. Dementia, depression, sleep disturbances and hallucinations  5. excessive sweating, paroxysmal flushing, orthostatic hypotension

PARKINSON s Disease
Medical management  1. Anti-parkinsonian drugs- Levodopa, Carbidopa  2. Anti-cholinergic therapy  3. Antiviral therapy- Amantadine  4. Dopamine Agonists- bromocriptine and Pergolide, Ropirinole anmd Pramipexole

PARKINSON s Disease 
  

Medical management 5. MAOI 6. Anti-depressants 7. Antihistamine

PARKINSON s Disease 
     

NURSING INTERVENTIONS 1. Improve mobility 2. Enhance Self- care activities 3. Improve bowel elimination 4. Improve nutrition 5. Enhance swallowing 6. Encourage the use of assistive devices

PARKINSON s Disease 
 

NURSING INTERVENTIONS 7. improve communication 8. Support coping abilities

EPILEPSY 

A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins

EPILEPSY   

Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms

GENERALIZED SEIZURES  

1. General Tonic-Clonic seizure- (Grand mal) characterized by loss of consciousness and alternating movements of the extremities 2. Absence Seizure (Petit mal)- common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares

GENERALIZED SEIZURES  

3. Myoclonic seizure- characterized by brief, involuntary muscular jerks of body extremities 4. Akinetic seizure- general loss of postural tone and a temporary loss of consciousness- a drop attack

PARTIAL SEIZURES  

1. Simple partial seizure- typically limited to one cerebral hemisphere 2. Complex partial seizure- begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements

Epilepsy 
    

DIAGNOSTIC TESTS 1. EEG 2. CT 3. MRI 4. LP 5. Angiography

Epilepsy 
  

Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery

Epilepsy 
  

Nursing Intervention 1. Care of patients during seizure 2. care of patients after seizures 3. patient teaching

BELL S PALSY 
   

Causes 1. infection 2. hemorrhage 3. tumor 4. local traumatic injury

BELL S PALSY 
       

MANIFESTATIONS 1. Unilateral facial weakness 2. Mouth drooping 3. Distorted taste perception 4. Smooth forehead 5. Inability to close eyelid on the affected side 6. Incomplete eye closure 7. excessive tearing when attempting to close the eyes 8. Inability to raise eyebrows, puff out the cheek

BELL S palsy 
   

Diagnostic tests EMG Medical management 1. Prednisone 2. Artificial tears

BELL S palsy 
  

 

Nursing Interventions 1. Apply moist heat to reduce pain 2. Massage the face to maintain muscle tone 3. Give frequent mouth care 4. protect the eye with an eye patch. Eyelid can be taped at night 5. instruct to chew on unaffected side

Trigeminal neuralgia 


Also called Tic Douloureux Painful disorder that affects one or more branches of the fifth cranial nerve CAUSES: repetitive pulsation of an artery as it exits the pons is the usual cause 

Trigeminal neuralgia 
  

ASSESSMENT 1. Pain history 2. Searing or burning jabs of pain lasting from 1-15 minutes in an area innervated by the trigeminal nerve DIAGNOSTIC TESTS Skull x-ray or CT scan

Trigeminal neuralgia 
  

NURSING INTERVENTIONS 1. provide emotional support 2. encourage to express feelings 3. provide adequate nutrition in small frequent meals at room temperature

Myasthenia gravis 

A sporadic, but progressive weakness and abnormal fatigability of striated muscles which are exacerbated by exercise and repetitive movements

Myasthenia gravis
ETIOLOGY  Autoimmune disease  Thymoma Women suffer at an earlier age and are more affected

Myasthenia gravis
Pathophysiology:  1. Acetylcholine receptor antibodies interfere with impulse transmission  2. Follows an unpredictable course of periodic exacerbations and remissions

Myasthenia gravis
CAUSE: autoimmune disorder that impairs transmission of nerve impulses ASSESSMENT FINDINGS 1. Gradually progressive skeletal muscle weakness and fatigue 2. Weakness that worsens during the day 3. Ptosis, diplopia and weak eye closure 4. Blank, mask-like facies 5. Difficulty chewing and swallowing 6. Respiratory difficulty 

Myasthenia gravis
DIAGNOSTIC TESTS  1. EMG  2. TENSILON TEST  3. CT scan  4. Serum anti-AchReceptor antibodies

Myasthenia gravis
MEDICAL THERAPY  Anticholinesterase drugspyridostigmine and neostigmine  Corticosteroids  Immunosuppresants  Plasmapheresis  Thymectomy

Myasthenia gravis
NURSING INTERVENTIONS  1. Administer prescribed medication as scheduled  2. Prevent problems with chewing and swallowing  3. Promote respiratory function  4. Encourage adjustments in lifestyle to prevent fatigue  5.maximize functional abilities

Myasthenia gravis   



6. Prepare for complications like myasthenic crisis and cholinergic crisis 7. prevent problems associated with impaired vision resulting from ptosis of eyelids 8. provide client teaching 9. promote client and family coping

Meningitis  

Infection or inflammation of the meninges covering the brain and spinal cord. Caused by bacterial, viral and fungal agents

Brain Abscess  

A free or encapsulated collection of pus in the brain parenchyma Causes: usually secondary to another infection like- sinusitis, meningitis, dental abscess, mastoiditis, bacteremia and trauma

Encephalitis 

Intense inflammation of the brain tisssue with lymphocytic infiltration, cerebral edema, degeneration of brain cells and diffuse nerve cell destruction

CNS infections 
     

ASSESSMENT FINDINGS Meningitis 1. fever, headache, vomiting 2. positive meningeal sings Brain abscess 1. headache, N/V, seizures, changes in LOC 2. Focal neurologic deficits

CNS infections 
      

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. EEG MEDICAL TREAMENT 1. Antibiotics 2. Surgical drainage 3. Drugs to reduce increased ICP

CNS infections 
 

  

NURSING INTERVENTIONS 1. Frequent monitoring of neurologic status 2. Monitor intake and output 3. Administer antibiotics 4. Administer mild laxative to prevent constipation 5. maintain quiet environment

Neoplastic diseases  

A brain tumor is a localized intracranial lesion that occupies space within the skull Primary brain tumors originate from cells and structures within the brain.

Neoplastic disease 


The cause of brain tumors is unknown The only risk factor accepted is radiation exposure to ionization rays

Neoplastic disease 


CLINICAL MANIFESTATIONS 1. increased ICP 
  

Vomiting Headache. Especially early in the morning Vomiting Visual disturbances

Neoplastic disease 
  

2. Localized symptoms Hemiparesis Seizures Mental status changes

Neoplastic disease 
   

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. PET 4. EEG

Neoplastic disease 
  

MEDICAL MANAGEMENT Surgery Chemotherapy Radiotherapy

Neoplastic disease 
     

NURSING INTERVENTIONS 1. promote self-care independence 2. improve nutrition 3. relieve anxiety 4. enhance family processes 5. provide pre-operative and post-operative care 6. manage pain

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