Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.

N, MAN Clinical Instructor

Decreased HR and BP Decresead RR Diarrhea Urinary Frequency Seizures

MEDICAL-SURGICAL NURSING

Neurologic Nursing
Lecturer: Mark Fredderick Abejo RN, MAN ________________________________________________________ OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE NERVOUS SYSTEM I. Divisions a. CNS brain and spinal cord b. PNS 12 pairs of cranial nerves and 31 pairs of spinal nerves 1. Spinal nerves: Cervical 8 Thoracic 12 Lumbar 5 Sacral 5 Coccygeal - 1 c. ANS sympathetic and parasympathetic systems

II. SNS a. Adrenergic Agents 1. Epinephrine (Adrenaline) 2. Note: Side Effects (SE) normal drug expectancies b. Beta-Adrenergic Agents (Beta-Blockers) 1. Propanolol, metoprolol, atenolol 2. Bronchospasm, Elicits decreased cardiac contractions, Treats HPN, AV conduction slows down (BETA) 3. Anti-HPN Management Beta-blockers -olol ACE inhibitors -pril Ca-Antagonist nifedipine Transient headache and dizziness Orthostatic hypotension Assist in ambulation Pt. to rise slowly from sitting position 4. BP = CO x PR 5. CO = HR x SV 6. (N) HR = 60-100 bpm 7. (N) SV = 60-70 ml of H2O TOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARIER: (BLACK) Bilirubin yellow pigment Lead Antidote: Ca+ EDTA Ammonia cerebral toxin; present in hepatic encephalopathy (liver cirrhosis) Carbon Monoxide in Parkinsons and Epilepsy Ketones cerebral depressant III. CNS

a.

Sympathetic flight or aggression response release of norepinephrine increase in all bodily activity except GI (constipation); adrenergic; parasympatholytic response. REMEMBER: GIT is the least important area during stress decreased blood flow in the area; Increased blood flow in the brain, heart and skeletal muscles Mydriasis (dilat-ation) Dry mouth Increase in HR and BP Tachypnea Constipation Urinary retention Parasympathetic flight or withdrawal response release of Acetylcholine decrease in all bodily activity except GI (diarrhea); chonlinergic/ vagal/ sympatholytic response Meiosis Increased salivation MS

b.

Cells 1. Neurons Excitability Conductivity Permanence 2. Neuroglia majority of tumors arise from here; about 40% from astrocytes Astrocytes maintains integrity of BBB Oligodendrocytes production of myelin Myelin sheath insulates axons; for rapid impulse transmission Microglia STATIONARY cells which carry on phagocytosis (cell eating) Ependymal cells produces chemoattractants which concentrates bacteria Composition 1. 80% brain mass CEREBRUM divided into two hemispheres, the left and right and is bridged by the corpus callosum Motor, sensory, integrative function Lobes: Frontal controls higher cortical thinking, personality development, motor activity, contains BROCAs are or the motor-speech center. (Expressive Aphasia) Occipital vision Parietal appreciation and discrimination of sensory impulses (pain, touch, pressure, heat and cold) Abejo

Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

Temporal hearing, short term memory, contains the general interpretative area Wernickes aphasia Insula (Island of Reil) visceral function (internal area) Limbic System (Rhinencephalon) sense of smell, libido or sexual urge control, long term memory

CI Atlas; C2 Axis CSF shock absorber, cushions brain altered when there is obstruction in CSF drainage HYDROCEPHALUS posteriorly growth of the head d/t early closure of fontanels

Types of Cells: Labile (regenerative) Epidermal, GIT, Respiratory, GUT Stable regenerative but limited survival period: liver, pancreas, salivary glands, kidneys Permanent cardiac, neurons, osteocytes, retinal

NEUROLOGIC ASSESSMENT I. COMPREHENSIVE NEUROLOGIC EXAM A. Purpose 1. To know exact neuro deficit 2. To localize lesion 3. For rehabilitation 4. For guidance in nursing care B. Survey of Mental Status 1. LOC Conscious awake Lethargy sleepy/drowsy/obtunded Stupor only awakened by vigorous stimulation General body weakness Decreased body defenses Coma Light (+) to all painful stimuli Deep (-) to all painful stimuli PAINFUL STIMULATION Deep Sternal Stimulation/Pressure Orbital Pressure Pressure on Great Toes Nail bed pressure Corneal/Blinking Reflex Conscious wisp of cotton Unconscious institute/drop of saline solution (coma if positive reaction, deep coma if negative) 2. Test of memory (consider educational background) Short term memory (ask what the pt ate for breakfast) (+) anterograde amnesia temporal lobe damage Long term memory (ask birthday) (+) retrograde amnesia damage to Rhinencephalon (Limbic system) C. Levels of Orientation (time, person and place) D. CN Assessment E. Motor Assessment

BASAL GANGLIA areas of gray matter located deep within each cerebral hemisphere; involved in the extrapyramidal tract; produces DOPAMINE (controls gross voluntary movement) MIDBRAIN (Mesencephalon) acts as a relay station for sight and hearing particularly helps in size and reaction of pupils and hearing acuity N hearing acuity : 30-40dB N pupil constriction: 2-3 mm N pupil finding: PERRLA Isocoria vs. Anisocoria DIENCEPHALON (Interbrain) Thalamus acts as a relay station for sensation Hypothalamus controls temperature, BP, sleep and wakefulness, thirst, appetite (satiety), some emotional responses like fear, anxiety and excitement, controls pituitary functions BRAIN STEM Pons (Pneumotaxic center) controls rate, rhythm and depth of respiration Medulla Oblongata lowest part; damage: most life threatening; controls respiration, HR, swallowing, vomiting, hiccups, vasomotor center CEREBELLUM smallest part; lesser brain; balance, equilibrium, gait and posture.

F.

2. 3.

10 % CSF 10% Blood

MONROE KELLY HYPOTHESIS the skull is a closed vault, any increase in one component will bring about increases in ICP NORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAY NORMAL CSF OPENING PRESSURE: 60-150 MMHG NORMAL CSF CONTENTS: GLUCOSE, PROTEINS, WBCS FORAMEN MAGNUM - The large opening in the basal part of the occipital bone through which the spinal cord becomes continuous with the medulla oblongata. 2

Sensory Assessment 1. PAIN - Gingerbread test 100% very painful 75% tolerable pain 25% moderate pain 0% no pain 2. TOUCH Stereognosis Identifying familiar object placed on clients hands Astereognosis if patient cannot identify object; damage in parietal lobe 3. PRESSURE AND TOUCH Graphesthesia Identify numbers or letters written on clients palm Agraphesthesia if (-), damage to parietal lobe

G.

Cerebellar Test Abejo

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

H. I.

Rombergs Test Instruct patient to close eyes, assume a normal anatomical position for 5-15 minutes; two nurses at right and left side Normal is (-) If (+) ataxia 2. Finger-to-nose Test 3. Alternate Pronation and Supination Dysmetria inability of a client to stop a movement at a desired point DTRs Autonomics 1.

2. 3.

Dysosmia distorted sense of smell Anosmia absence of smell

II. Glasgow Coma Scale A. objective measurement of LOC; B. quick neuro check 1. Motor 6 2. Verbal 5 3. Eye Opening 4 C. Normal: 14-15 conscious 1. lethargy 13-11 2. Stupor 10-8 3. Coma = 7 4. deep coma = 3 II. OPTIC A. Sensory Vision B. Tests 1. Test of Visual Acuity/Central or Distance Vision Materials Snellens Chart Alphabet literate E chart illiterate Animal chart pedia, since shorter attention span 20 feet distance (67 cm) 20 feet/6-7 m; constant normal 20/20 numerator distance to snellen chart denominator distance the person can see the letters Abnormal findings 20/200 blindness OD: oculus dexter OS: oculus sinister OU: oculus uritas 2. Visual Fields/Peripheral vision Superiorly Bitemporally Nasally Inferiorly Sensory Sensory Motor Motor Sensory, motor Motor Sensory, motor Sensory Sensory, motor Sensory, motor Motor Motor Some Say Marry Money But My Brother Says Bad Business Marry Money C. COMMON VISUAL DISORDERS 1. Glaucoma 40 yo, obese hereditary Loss of peripheral vision tunnel vision Increased IOP (N = 12-21 mm Hg) Signs and symptoms: Headache Nausea and vomiting Halos around lights Steamy cornea Acute angle closure glaucoma most dangerous, may lead to blindness Diagnostics: Tonometry increased IOP Gonioscopy obstruction in anterior chamber Perimetry decreased visual fields Drugs (for lifetime) Timolol maleate Pilocarpine drug of choice (miotic) Epinephrine decrease in aqueous humor Carbonic Anhydrase Diamox (Acetazolamide) Decrease in aqueous humor (maintains IOP); promotes drainage Monitor I/O Abejo

CRANIAL NERVE ASSESSMENT I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. I. Olfactory Optic Oculomotor Trochlear (smallest) (down) Trigeminal (largest) (triCHEWminal) Abducens (at the sides) Facial Acoustic (Vestibulocochlear) Glossopharyngeal Vagus (longest) (mavagal) Accessory (shoulders) Hypoglossal

OLFACTORY A. Sensory smell B. Use coffee, bar soap, vinegar, cigarette tar C. Abnormal findings Indication of: Head trauma damaging the cribriform plate of ethmoid bone where olfactory cells are located Sinusitis give antibiotics to prevent meningitis 1. Hyposmia decreased sensitivity to smell 3

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

NO ATROPINE: may lead to increased IOP Surgery Trabeculectomy Peripheral iridectomy Uveitis inflammation of the iris Keratitis inflammation of the cornea

Trauma Nasolabial folds most evident sign of facial symmetry

I.

2.

3.

Cataract Loss of central vision Glaring or hazy vision Opacity of lens, milky white appearance of cornea, decreased perception to colors Due to aging Prolonged UV rays exposure Congenital disorder very rare DM Dx: Ophthalmoscopic examination Tx: Mydriatics, cycloplegics (cyclogil) paralyzes ciliary muscles Surgery: lens extraction ECLE partial removal of cataract ICLE capsule included, total removal of cataract Retinal Detachment most common complication following lens extraction Curtain veil like vision Leads to blindness Severe myopia common cause Emetropia normal refraction of eyes Presbyopia loss of lens elasticity due to aging (+) floaters d/t seepage of RBCs Surgery: Scleral Buckling, Diathermy (heat application), Cryosurgery (cold application) Macular degeneration degeneration of macula lutea (yellowish spots in center of retina) Black spots Yellowish spots in center of retina or the macula lutea It innervates movt of EOMs

ACOUSIC/VESTIBULOCOCHLEAR A. Controls balance or kinesthesia (position sense/ movement and correlation of body in space) 1. Organ of corti (true sense organ for hearing) for hearing 2. Cochlea snail-shaped organ in middle ear B. Disorders 1. Conductive hearing loss 2. Otitis Media 3. Menieres disease Archimedes Principle buoyancy (pregnancyfetus) Daltons Law of Partial Pressure Inertia - Kinesthesia

II. III. IV.

V.

GLOSSOPHARYNGEAL taste; posterior 1/3 tongue VAGUS gag reflex, decreased vital signs, eyes constrict, mouth moist PNS SPINAL/ACCESSORY controls 2 muscles: A. Sternocleidomastoid (neck) B. Trapezius (Shoulder) HYPOGLOSSAL tongue movement; frenulum linguae anchors tongue (tongue tied short frenulum)

DEMYELINATING DISEASES I. ALZHEIMERS DISEASE - atrophy of the brain tissue characterized by: a. Amnesia b. Agnosia (-) sense of smell c. Apraxia (-) purposive movements d. Aphasia 1. Expressive/Brocas problem in speaking 2. Receptive/Wernickes problem in understanding; USUAL FOR ALZHEIMERS 3. Brocas area motor speech center; frontal 4. Wernickes area general interpretative area; temporal e. ARICEPT drug of choice, given at HS COGNEX also given

4.

III. OCULOMOTOR IV. TROCHLEAR V. ABDUCENS

SR (Abducens) LR IR

IO (trochlear) MR SO

A. B. C.

Normal response PEBRTLA/ PERRLA (isocoria) Anisocoria unequal pupils Nystagmus Rhythmical oscillation of the eyeballs, either pendular or jerky; can be seen in MS, dilantin toxicity.

VI. TRIGEMINAL largest cranial nerve with 3 branches; sensory and motor. A. Ophthalmic branch B. Maxillary branch C. Mandibular branch D. Sensory controls sensation of face and teeth, mucous membrane and corneal reflex E. Motor Mastication or chewing F. Trigeminal Neuralgia characterized by severe pain upon chewing, dysphagia 1. avoid foods with extreme temperature 2. DOC: carbamazepine (Tegretol) VII. FACIAL A. Sensory anterior 2/3 of tongue; identify taste without swallowing B. Motor facial expression control 1. instruct patient to smile, frown or raise eyebrows Bells palsy or (temporary) facial paralysis damage to facial nerve caused by: Forceps delivery - #1 cause Autoimmune Stress 4

PICKS Disease: a form of dementia wherein there is damage in the frontoparietal area II. MULTIPLE SCLEROSIS chronic, intermittent disorder of the CNS characterized by white patches of demyelination of the brain and spinal cord. IDIOPATHIC, AUTOIMMUNE A. B. INCIDENCE RATE: 15-35 yo, females PREDISPOSING FACTOR 1. Slow growing virus 2. Autoimmune body produces antibodies which attacks normal cells 3. REVIEW: ANTIBODIES IgG passes placenta (gestational) IgA found in bodily secretions, colostrums Abejo

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

IgM acute infections (mabilis) IgE allergic reactions IgD Chronic infections (dalas)

Brought about by increase in the three intracranial components A. PREDISPOSING FACTORS a. Head injury b. Tumor c. Localized abscesses d. Cerebral edema e. Hydrocephalus f. Hemorrhage g. Inflammatory conditions 1. Meningitis 2. Encephalitis SIGNS AND SYMPTOMS a. Early signs 1. Decreased or change in LOC 2. Restlessness to confusion 3. Disorientation 4. Lethargy to stupor 5. Stupor to coma b. Late signs 1. Changes in the vital signs Elevated BP (SBP rising, DBP constant) N Pulse Pressure: 40 mmHG HR decreased RR decreased (Cheyne-Stokes respiration: normal rhythmic respiration followed by periods of apnea) Elevated temperature 2. Headache, papilledema, projectile vomiting 3. Abnormal posturing- decorticate (flexion) damage to corticospinal tract (spinal cord and cerebral cortex) remember: deCORDThreecate OR decerebrate (extension): upper brain stem damage pons, midbrain, cerebellum 4. Unilateral dilation of pupil (ANISOCORIA) indicates uncal brain herniation; if bilateral dilatation: tentorial herniation 5. possible seizures 6. Cushings reflex (hypertension with bradycardia) o o C. SHOCK inadequate tissue perfusion HYPOXIA inadequate tissue oxygenation

B.

C.

CLINICAL MANIFESTATION 1. Visual disturbances Blurring of vision Diplopia Scotoma (blind spot) 2. Impaired sensation to touch, pain, pressure, heat and cold Tingling sensation Paresthesia Numbness 3. Mood swings Euphoria sense of well-being 4. Impaired motor activity Weakness Spasticity Paralysis 5. Impaired cerebellar function CHARCOTS TRIAD: ataxia (unsteady gait), nystagmus, intentional tremors Scanning speech 6. Urinary retention or incontinence 7. Constipation 8. Decrease in sexual capacity DIAGNOSTIC PROCEDURE 1. CSF Analysis LT: reveals increased CHON and IgG 2. MRI site and extent of demyelination NURSING MANAGEMENT: Palliative 1. Administer medications as ordered Acute Exacerbation ACTH (Adrenocorticotropic hormone) reduces edema at site of demyelination thereby preventing paralysis; compression of spinal cord will lead to paralysis Baclofen (Lioresal), Dantrolene Na to reduce muscle spasticity Interferons Immunosuppressives Diuretics PROPHANTHELENE BROMIDE (PRO-BANTHENE) anti-cholinergic for urinary incontinence 2. Provide for Relaxation DBE, biofeedback, yoga 3. Retain side rails 4. Prevent complications of immobility TTS Q2h, Q1 h for elderly, 20 minutes only on affected side 5. Increase OFI, high fiber diet (for constipation), acidash in diet to acidify urine to prevent bacterial multiplication (cranberry juice, prunes, grape juice, vitamin c, plums, orange and pineapple juice.) 6. Provide catheterization for urinary retention

D.

F.

NURSING MANAGEMENT 1. maintain patent airway and adequate ventilation by: prevention of hypoxia ( cerebral edema increased ICP) and hypercarbia (CO2 retention) cerebral vasodilation increased ICP decreased tissue perfusion possible shock Early signs of hypoxia Restlessness Agitation Tachycardia Late signs of hypoxia Bradycardia Extreme restlessness Dyspnea Cyanosis Increased CO2 most potent respiratory stimulant in the normal person (irritates medulla oblongata) Decreased O2 stimulates respiration in CRDS Suctioning should only last for 10 -15 seconds and application of suction should be done upon withdrawal of catheter in a circular fashion. 2. 3. Assist in mechanical ventilation Elevate head of bed 30-45 degrees with neck in neutral position when contraindicated to promote venous drainage Limit fluid intake to 1.2-1.5 l per day (Forced fluids = 2-3 L/day) Monitor VS, NVS, I/O strictly Prevent complications of immobility Prevent further increase in ICP Provide comfortable environment Avoid use of restraints fractures Keep side rails up Abejo

4. 5. 6. 7.

INCREASED INTRACRANIAL PRESSURE MS 5

8.

Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

9.

Avoid valsalva maneuver Straining of stools (give laxatives/stool softeners) Excessive vomiting (give Metoclopramide (plasil) anti-emetic) Lifting of heavy objects Bending or stooping 10. Administer medications as ordered Osmotic Diuretics Mannitol (Osmitol) cerebral diuresis Monitor VS especially BP (SE: Hypotension resulting from hypovolemia) Monitor I/O qH Given via side drip, fast drip to avoid precipitate formation Instruct client that a flushing sensation will be felt as drug is introduced Loop Diuretics via IV push Furosemide BP Monitor 1/0 q1, notify if <30cc/hr IV push Lasix effect in 10-15 minutes, max 6 hours; best given in AM to prevent sleep interruption Corticosteroids Dexamethasone (decadron) Steroids administered 2/3 in AM to mimic diurnal rhythm Hydorcortisone Prednisone Mild Analgesic Codeine sulfate Anti-Convulsant Pheytoin (Dilantin) Benadryl is given at HS because it causes drowsiness Levothyroxine is given in AM to prevent insomnia

SE: major depression suicidal ideation Linked to Breast Ca development SBE is done 7 days after menstruation Breast Ca - #1 Ca in women Cervical Ca - #2 Ca in women 1. multiple sex partners 2. early pregnancy Ovarian Ca - #3 Ca in women mammography lasts for 10-20 minutes Methyldopa (Aldomet) has anti HPN properties Haloperidol (Haldol) anti-psychotic NEUROLEPTIC MALIGNANT SYNDROME (NMS) Tremors, tachycardia, tachypnea, fever Phenothiazides anti-psychotic PHENERGAN only anti-psychotic with antiemetic properties

B.

CLINICAL MANIFESTATION 1. PILL ROLLING TREMORS of the extremities first sx 2. Bradykinesia second sx 3. Rigidity (cogwheel type) third sx 4. Stooped posture, SHUFFLING GAIT, propulsive gait 5. Overfatigue 6. Mask-like facial expression, decreased blinking of the eyelids 7. Difficulty in rising from sitting position 8. Quiet monotone speech 9. Mood lability depression suicide 10. Increased salivation, drooling type 11. Autonomic changes Increased sweating and lacrimation Seborrhea Constipation Decreased sexual capacity

III.

PARKINSONS DISEASE (degenerative disease) chronic progressive disorder of the CNS characterized by degeneration of the dopamine producing cells in the substantia nigra of the midbrain and basal ganglia (areas of gray matter in both hemispheres which is involved in the extrapyramidal tract) IRREVERSIBLE, IDIOPATHIC

C.

A.

PREDISPOSING FACTORS 1. Poisoning Lead (ANTIDOTE: Ca EDTA heavy metal antagonist) Carbon Monoxide decreased capacity of hemoglobin to carry oxygen cherry red skin color 2. Arteriosclerosis 3. Hypoxia inadequate tissue perfusion 4. Encephalitis 5. Drugs Reserpine (Serpasil) Has anti HPN properties Promote safety when giving this drug 6

NURSING MANAGEMENT (palliative) 1. Administer medications as ordered Anti-Parkinsonian Agents increase dopamine relieves rigidity (CAPABLES!) Levodopa (L-dopa) short acting dopaminergic Amantadine HCl (Symmetrel) long acting dopaminergic Carbidopa (Sinemet) long acting dopaminergic SE: (GIT) anorexia, nausea and vomiting, orthostatic hypotension, hallucination, arrhythmia Contraindications: narrow angle closure glaucoma loss of peripheral vision tunnel vision halos in light; normal IOP = 12-21 mmHg

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

2. 3. 4.

5. 6. 7. 8.

Also contraindicated in patients taking MAOIs (Avoid tryptophan and tyramine in pts taking MAOIs) Administer with food or snack to lessen GIT irritation Inform client that stools/urine maybe darkened INSTRUCT CLIENT TO AVOID FOODS RICH IN VITAMIN B6--PYRIDOXINE (Cereals, organ meat, green leafy vegetables) reverses therapeutic effect of levodopa Anti-cholinergics relieves tremors Relieves tremors Artane and Cogentin Mode of action: increases dopamine SE: SNS Antihistamine relieves tremors Diphenhydramine HCl (Benadryl) SE: Drowsiness adult CNS excitement and hyperactivity children Dopamine Agonists relieves tremors and rigidity Bromocriptine HCl (Parlodel) SE: CNS Depression No OCPs decreased effect Maintain side rails to prevent injuries related to falls Prevent complications of immobility Maintain good nutrition. Provide dietary intake that is low in protein in AM and high protein at night to induce sleep TRYPTOPHAN induces sleep Assists in passive ROM exercises to prevent contractures. Q4h for proper body alignment. Increased OFI is encouraged and increased Fiber in the diet for constipation Ambulate with assistance Assist in STEROTAXIC THALAMOTOMY COMPLICATIONS: SUBARACHNOID HEMORRHAGE, ENCEPHALITIS, CEREBRAL ANEURYSM

C.

CLINICAL MANIFESATION 1. PTOSIS INITIAL SIGN Check palpebral fissure drooping of upper eyelids 2. Double vision 3. Mask like facial expression 4. Weakened laryngeal muscles dysphagia (difficulty of swallowing, without food); odynophagia ang with food 5. Hoarseness of voice 6. Respiratory muscle weakness respiratory arrest; prepare trache set at bedside 7. Extreme muscle weakness especially during activity or exertion in AM DIAGNOSTICS 1. TENSILON TEST (EDROPHONIUM HCL) Temporary relief of symptoms Strengthens muscles temporarily Pt, temporarily can open eyelids, increased muscle strength 5-10 minutes after admin

D.

E.

IV.

MYASTHENIA GRAVIS (MG) neuromuscular disorder characterized by a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction (or motor end plate site of exchange of neurotransmitters) IDIOPATHIC; DECENDING MUSCLE WEAKNESS

NURSING MANAGEMENT Airway Aspiration Immobility 1. Maintain patent airway and adequate ventilation Assist in mechanical ventilation Assess PFT (decreased Vital Lung Capacity) 2. Monitor Strictly VS, IO, NVS, motor grading scale (muscle strength) 3. Maintain side rails 4. institute NGT feeding to prevent aspiration 5. prevent complications of immobility q2 turning, q1 for elderly 6. Administer meds as ordered Corticosteroids for immunosuppression Cholinergic/Anticholinergic agents Mestinol (Pyridostigmine) Neostigmine (Prostigmin) Monitor for the two types of crisis Cholinergic Crisis Cause: overmedication S/sx: PNS, increased salivation aspiration Tx: anticholinergic agents, atropine sulfate

Myasthenic Crisis Causes: undermedication, stress, infection S/sx: (-) seeing, swallowing, speaking, breathing Tx: admin cholinergic agents as ordered

Monitor for BRITTLE CRISIS: characterized by severe respiratory muscle weakness and exertioal discomfort. Prepare trache set. 7. Assist in THYMECTOMY removal of thymus which is believed to produce autoimmunity Plasmaparesis filtering of blood; removal of autoimmune antibodies in the blood Prevent complications respiratory arrest Prepare trache set in pts with MG

8. 9.

V.

A.

INCIDENCE RATE 1. Women aged 20-40 years old PREDISPOSING FACTORS 1. Autoimmune Involves release of CHOLINESTERASE an enzyme which destroys Ach descending muscle weakness 7

B.

MENINGITIS inflammation of the meninges of the brain and spinal cord Meninges 3fold membrane that covers the brain and spinal cord For support and protection For blood supply For nourishment Dura mater - outermost Subdural space between dura and arachnoid Arachnoid mater - middlemost Subarachnoid space where CSF circulates; location where aspirate is taken during LT (puncture either bet l3-l4 or l4-l5 because it is above these areas where the spinal cord terminates) Pia mater gentle mater Abejo

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

VI. A. ETIOLOGIC AGENTS 1. MENINGOCOCCUS MOST DANGEROUS 2. Pneumococcus 3. Streptococcus adult 4. Hemophilus influenzae pedia MODE OF TRANSMISSION airborne transmission via droplet infection CLINICAL MANIFESTATION 1. Headache, photophobia, projectile vomiting 2. Fever, chills, anorexia, generalized body malaise, weight loss 3. decorticate (deCORDthreecate) and or decerebrate 4. Possible seizure and increased ICP 5. Signs of meningeal irritation Nucchal rigidity Opisthotonus rigid arching of the head (+) kernigs sign leg pain (+) brudzinksis sign neck pain DIAGNOSTICS 1. Lumbar puncture (lumbar or spinal tap) Nursing management for before LT Obtain informed consent Explain procedure to client Empty bowel and bladder for comfort Encourage client to arch back to clearly visualize spinal columns Nursing management post LT Flat on bed for 12-24 hours to prevent spinal headaches and CSF leakage Forced fluids Check puncture site for any discoloration, drainage and leakage to tissues ASSESS FOR MOVEMENT AND SENSATION OF EXTREMITIES (MOST IMPORTANT) CSF analysis will reveal Increased CHON and WBC Decreased Glucose Increased CSF opening pressure N = 50-160 mmHg (+) cultured microorganisms These confirm presence of meningitis 2. CBC Reveals Increased WBC NURSING MANAGEMENT 1. Complete bed rest 2. Administer medications as ordered Broad Spectrum Antibiotics Penicillin alteration in the N flora of the GI superinfection diarrhea Analgesics Antipyretics 3. Institute strict respiratory isolation after initiation of antibiotic therapy 4. Institute ICP monitoring 5. Dim environment d/t photophobia 6. Monitor strictly VS, IO and NVS 7. Maintain F and E balance 8. Prevent complications of immobility: turn to sides q2 9. Health Teaching and D/C planning Dietary intake increased in calories with small frequent feedings (increase carbohydrates) Prevent complications HYDROCEPHALUS HEARING LOSS (NERVE DEAFNESS) Visit audiologist for audiometric screening after resolution of meningitis Rehabilitation for residual deficits Mental retardation or delay and psychomotor development Singit lang to: pag post repair ng myelomeningocoele checkup with urologist baka na-hit ung bladder

CEREBROVASCULAR ACCIDENTS (Stroke, brain attack, cerebral thrombosis, apoplexy) partial or total disruption in the blood supply of the brain, usually in the MCA or ICA (2 largest cerebral arteries) A. B. INCIDENCE RATE 2-3x higher in males than in females PREDISPOSING FACTORS 1. Thrombosis attached clot, #1 cause of stroke 2. Emboli detached/wandering thrombosis Pulmonary embolism Sudden sharp chest pain Unexplained dyspnea Tachycardia Palpitation Diaphoresis Cerebral embolism Headache Dizziness Disorientation Change in LOC that may lead to coma 3. Hemorrhage

B. C.

D.

C.

E.

RISK FACTORS 1. HPN 2. DM 3. Atherosclerosis MI 4. Valvular heart disease, Mitral/post-cardiac surgery/mitral valve replacement mlt CVA 5. Lifestyle Smoking Sedentary lifestyle Obesity (more than 20% ideal body weight) Diet rich in saturated fats Hyperlipidemia genetic; (+) genes that easily binds to cholesterol Type A personality Deadline driven person Does several things at the same time Feels guilty when not doing anything Prolonged use of oral contraceptives Macropil estrogen Minipil progestin Increases lipolysis breakdown of lipids atherosclerosis HPN CVA CLINICAL MANIFESTATION 1. TRANSIENT ISCHEMIC ATTACK initial sign of CVA Headache, dizziness, tinnitus, visual and speech disturbances, paresis to plegia, increase in ICP possible, cheyne-stokes respirations 2. Stroke in evolution progression of S/sx 3. Complete Stroke resolution phase characterized by still dizziness and headache Cheyne-stokes respirations Anorexia Nausea and vomiting Dysphagia (+) Kernigs and Brudzinksis Focal Neurological Deficits Plegia Aphasia Abejo

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Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

E.

Dysarthria speaking difficulty Alexia reading difficulty Agraphia writing difficulty Homonymous hemianopsia loss of vision field Unilateral neglect

VII.

GUILLAINE-BARRE SYNDROME (GBS) CNS disorder characterized by bilateral, symmetrical, polyneuritis leading to ascending muscle weakness/paralysis. A. B. Cause IDIOPATHIC PREDISPOSING FACTORS 1. Autoimmune 2. antecedent viral infection 3. immunizations such as your flu vaccine CLINICAL MANIFESTATION 1. CLUMSINESS INITIAL SIGN 2. Dysphagia 3. Ascending muscle weakness paralysis 4. Decreased DTRs 5. Alternate hypertension and hypotension; MOST FEARED COMPLICATION: ARRHYTHMIAS 6. Autonomic changes Increased sweating and lacrimation Increased salivation Constipation DIAGNOSTICS 1. CSF Analysis : reveals elevated CHON and IgG CSF is produced in the choroid plexus NURSING MANAGEMENT 1. Maintain patent airway and ventilation Assist in mechanical ventilation 2. Maintain side rails (paralysis) 3. prevent complications of immobility 4. institute NGT feeding 5. Administer medications as ordered Anticholinergics Atropine Sulfate Corticosteroids to suppress immune response Anti-arrhythmic agents Lidocaine (Xylocaine) Bretyllium Blocks norepinephrine Quinidines anti-arrhythmic, anti-malarial (Malaria king of tropical diseases kaya ang meds ay queen = quinines) Common SE: QUINCHONISM : Female anopheles malaria, night biting, lay eggs in the morning Female aegis egyptis dengue, day biting, lay eggs at night, 4 oclock habit Plasmodium falciparum most dangerous form of malaria hemorrhage 6. Assist in plasmaparesis 7. Prevent complications ARRHYTHMIAS RESPIRATORY ARREST

DIAGNOSTICS 1. CAT scan 2. Cerebral Arteriography reveals site of lesion Informed consent Allergies to seafood Post-dx: forced fluids and check for presence of hematoma NURSING MANAGEMENT 1. Maintain patent airway and adequate ventilation Assist in mechanical ventilation Administer oxygen as ordered 2. Restrict Fluids 3. Elevate head of bed, 30-40 degrees to promote venous drainage 4. Avoid activities that cause valsalva maneuver 5. Prevent complications of immobility Prevent bed sores and hypostatic pneumonia TTS q2 Use of egg crate mattress or water bed Sand bag/foot board to prevent foot lag 6. Institute NGT feeding 7. ROM exercises q4h to prevent contractures and promote proper body alignment 8. Alternative means of communication Non verbal cues Magic slate or picture board 9. If positive for hemianopsia, approach client on unaffected side 10. Administer meds as ordered Osmotic diuretics Mannitol (Osmitrol) Corticosteroids Dexamethasone (Decadron) Mild Analgesics Codeine Sulfate Thrombolytics Streptokinase Urokinase Tissue Plasminogen Activity Factor (TPAF) Monitor for bleeding Anti-coagulants as ordered. Heparin check PTT if prolonged, indicates bleeding give protamine sulfate when overdosed Coumadin check PT if prolonged, indicates bleeding vitamin K (aquamephyton) as antidote Given together because coumadin will take effect after 3 days still Loop-diuretics Lasix (okay to administer in DM pts but monitor CBG) Anti-platelets ASA anti-thrombotic Contraindicated in dengue, ulcers and unknown cause of headache potentiates bleeding 11. Health Teaching Avoid modifiable risk factors Avoid / prevent complications: Sub-arachnoid hemorrhage Diet modification: low saturated fat, sodium and caffeine Rehabilitation for focal neurologic weakness Importance of ffup care and strict compliance to medications

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VIII.

CONVULSIVE DISORDERS A disorder of the CNS characterized by paroxysmal seizures with or without loss of consciousness, alternation in sensation and perception, abnormal motor activity and changes in behavior; IDIOPATIHIC Febrile seizures are normal for children below 5 years only; can be outgrown Febrile seizures in children >5 yo = abnormal SEIZURE first convulsive attack EPILEPSY series of seizure activity

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Abejo

Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor

A.

PREDISPOSING FACTORS 1. Head injury secondary to birth trauma 2. Lead poisoning 3. Genetics 4. Brain tumor 5. Nutritional and metabolic deficiencies 6. Sudden withdrawal of anti-convulsive drugs Causes STATUS EPILEPTICUS DOC: diazepam, glucose 7. Physical and emotional stress TYPES OF SEIZURES 1. Generalized Grand Mal (Tonic-Clonic) With or without an aura Epigastric pain initial sign of an aura (aura is an initial sign of seizures) Visual auditory olfactory tactile sensory experience Epileptic cry Fall Loss of consciousness for 3-5 minutes Tonic-clonic contractions Direct symmetrical extension of extremities Shaking/convulsive activity Post-ictal sleep (unresponsive sleep) Petit Mal (Absence Seizure) S/sx: Blank stare Decreased blinking of the eyes Twitching of the mouth and loss of consciousness for 5-10 seconds Partial Seizures Jacksonian seizure (focal seizures) characterized by tingling and jerky movements of index finger and thumb spreads to shoulders Psychomotor seizure (focal-motor seizures) characterized by: Automatism stereotype, non-repetitive and non-purposive behavior Clouding of consciousness not in contact with reality Mild hallucinating sensory experience Status Epilepticus continuous uninterrupted seizure activity that if left untreated may lead to hyperpyrexia coma death Increased electrical activity in brain increased metabolism increased glucose and oxygen use, increased temperature coma death DOC: Valium, Glucose

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Diazepam (Valium) for status epilepticus Carbamazepine (Tegretol) Also used for Trigeminal neuralgia (Tic Dolor) Phenobarbitals (Luminal) Institute seizure and safety precautions Post-seizure: O2 inhalation Suction apparatus Monitor and document the following Onset and duration Type of seizure Duration of post-ictal sleep increased length of sleep can lead to status epilepticus Assist in CORTICAL RESECTION

For a one year old client suffering grand mal seizures: NOT Mouthpiece Eh onte lang teeth ng one year old eh Give pillows support for the head (For banging of head during seizure activity)

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C.

DIAGNOSTICS 1. CT-SCAN brain lesion d/t head trauma 2. EEG hyperactivity of brain waves (all elevated) Alpha, beta, delta, theta waves NURSING MANAGEMENT 1. Maintain patent airway and promote safety before seizure activity Clear the site of sharps, harmful objects Loosen clothing of the patient Avoid use of restraints fractures Maintain side rails Turn head to side to prevent aspiration Tongue guard is between mouth and teeth to prevent biting of the tongue 2. Avoid precipitating stimulus Bright/glaring lights Noise 3. Administer medications as ordered Phenytoin (Dilantin) Gingival Hyperplasia Use soft-bristled toothbrush Ataxia Nystagmus Hirsutism 10 Abejo

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