  

Decreased HR and BP
  
Decresead RR
  
Diarrhea
  
Urinary Frequency
 
Seizures

II. SNS
a. Adrenergic Agents
1. Epinephrine (Adrenaline)
2. Note: Side Effects (SE) – normal drug expectancies
b. Beta-Adrenergic Agents (Beta-Blockers)
MEDICAL-SURGICAL NURSING 1. Propanolol, metoprolol, atenolol
2. Bronchospasm, Elicits decreased cardiac contractions,
Neurologic Nursing Treats HPN, AV conduction slows down (BETA)
3. Anti-HPN Management
________________________________________________________   
Beta-blockers – ―-olol‖
  
ACE inhibitors – ―-pril‖
OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE   
Ca-Antagonist – nifedipine
NERVOUS SYSTEM   
Transient headache and dizziness

Orthostatic hypotension
 
I. Divisions Assist in ambulation
a. CNS – brain and spinal cord  
Pt. to rise slowly from sitting position
b. PNS – 12 pairs of cranial nerves and 31 pairs of spinal 4. BP = CO x PR
nerves 5. CO = HR x SV
1. Spinal nerves: 6. (N) HR = 60-100 bpm
  
Cervical – 8 7. (N) SV = 60-70 ml of H2O
  
Thoracic – 12 TOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN
  
Lumbar – 5 BARIER: (BLACK)
    
Sacral – 5 
  Bilirubin – yellow pigment
 Coccygeal - 1  
 Lead – Antidote: Ca+ EDTA
c. ANS – sympathetic and parasympathetic systems

 
Ammonia – cerebral toxin; present in hepatic encephalopathy (liver cirrhosis)

 
Carbon Monoxide – in Parkinson’s and Epilepsy
 
Ketones – cerebral depressant

III. CNS

a. 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)
  
Sympathetic – flight or aggression response release of norepinephrine Ependymal cells – produces chemoattractants which
increase in all bodily activity except GI (constipation); adrenergic;  concentrates bacteria
parasympatholytic response. b. Composition
1. 80% brain mass

REMEMBER: GIT is the least important area during stress 
decreased blood flow in the area; Increased blood flow in the brain, CEREBRUM – divided into two hemispheres, the 
heart and skeletal muscles  left and right and is bridged by the corpus callosum
     
Mydriasis (―dilat‖-ation) Motor, sensory, integrative function
    
Dry mouth  Lobes:
  

Increase in HR and BP

Frontal – controls higher cortical thinking,
 Tachypnea personality development, motor activity,
  
Constipation contains BROCA’s are or the motor-speech
 
Urinary retention  center. (Expressive Aphasia) 
  Occipital – vision 
Parasympathetic – flight or withdrawal response release of Acetylcholine 
decrease in all bodily activity except GI (diarrhea); chonlinergic/ vagal/ Parietal – appreciation and discrimination
sympatholytic response
   of sensory impulses (pain, touch, pressure,

Meiosis

heat and cold) 
Increased salivation
 
 
Temporal – hearing, short term memory, CI – Atlas; C2 – Axis
 
contains the general interpretative area— CSF – shock absorber,
 cushions brain altered when there is obstruction in
 CSF drainage
Wernicke’s aphasia

Insula (Island of Reil) – visceral function 
HYDROCEPHALUS – posteriorly growth of the head d/t early closure of
(internal area) fontanels

Limbic System (Rhinencephalon) – sense

of smell, libido or sexual urge control, long Types of Cells:

 
term memory 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

BASAL GANGLIA – areas of gray matter   
located deep within each cerebral hemisphere; Decreased body defenses
involved in the extrapyramidal tract; produces    
 DOPAMINE (controls gross voluntary movement) 
Coma
 
Light – (+) to all painful stimuli
  
Deep – (-) to all painful stimuli

MIDBRAIN (Mesencephalon) – acts as a relay  
for sight and hearing particularly  
 station
and reaction of pupils and hearing acuity
helps in size PAINFUL STIMULATION
 
 Deep Sternal Stimulation/Pressure
  
N hearing acuity : 30-40dB   
Orbital Pressure
    
N pupil constriction: 2-3 mm  Pressure on Great Toes
    
N pupil finding: PERRLA  Nail bed pressure
    
Isocoria vs. Anisocoria  Corneal/Blinking Reflex
  
DIENCEPHALON (Interbrain)  Conscious – wisp of cotton
  Thalamus – acts as a relay station for sensation
 Unconscious – institute/drop of saline
solution (coma if positive reaction, deep
  coma if negative) 
Hypothalamus – controls temperature, BP,
sleep and wakefulness, thirst, appetite 2. Test of memory (consider educational background)
(satiety), some emotional responses like fear,
  
 anxiety and excitement, controls pituitary Short term memory (ask what the pt ate for breakfast)
functions
    
BRAIN STEM  (+) anterograde amnesia temporal lobe damage
   
Pons (Pneumotaxic  center) – controls rate, rhythm and Long term memory (ask birthday)
 depth of respiration  
(+) retrograde amnesia  damage to
  Rhinencephalon (Limbic system)
Medulla Oblongata – lowest part; damage:
most life threatening; controls respiration, C. Levels of Orientation (time, person and place)
 HR,  vomiting, hiccups,
swallowing, D. CN Assessment
vasomotor center E. Motor Assessment

CEREBELLUM – smallest  part; ―lesser brain‖; balance,
equilibrium, gait and posture.

F. Sensory Assessment
1. PAIN - Gingerbread test
 100% very painful
 75% tolerable pain
 25% moderate pain
 0% no pain
2. 10 % CSF 2. TOUCH – Stereognosis
3. 10% Blood  Identifying familiar object placed on clients hands

 Astereognosis – if patient cannot identify object;
MONROE KELLY HYPOTHESIS – the skull is a closed damage in parietal lobe
vault, any increase in one component will bring about increases 3. PRESSURE AND TOUCH – Graphesthesia
in ICP  Identify numbers or letters written on client’s

NORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAY palm

NORMAL CSF OPENING PRESSURE: 60-150 MMHG  Agraphesthesia if (-), damage to parietal lobe
 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. G. Cerebellar Test
 1. Romberg’s Test 2. Dysosmia – distorted sense of smell
 3. Anosmia – absence of smell
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
H. DTRs
I. Autonomics

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
 
 Snellen’s 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
 
CRANIAL NERVE ASSESSMENT Inferiorly


I. Olfactory Sensory Some C. COMMON VISUAL DISORDERS

1. Glaucoma
II. Optic Sensory Say   
40 yo, obese
III. Oculomotor Motor Marry   
hereditary
  
IV. Trochlear (smallest) (―down‖) Motor Money Loss of peripheral vision tunnel vision
  
V. Trigeminal (largest) Sensory, But Increased IOP (N = 12-21 mm Hg)
  
(―triCHEWminal‖) motor Signs and symptoms:
  
VI. Abducens (―at the sides‖) Motor My Headache
  
VII. Facial Sensory, Brother Nausea and vomiting
  
motor Halos around lights
  
Steamy cornea
VIII. Acoustic (Vestibulocochlear) Sensory Says

IX. Glossopharyngeal Sensory, Bad  glaucoma – most dangerous, may
Acute angle closure
lead to blindness
motor   
Diagnostics:
X. Vagus (longest) (―mavagal‖) Sensory, Business   
Tonometry – increased IOP
motor
XI. Accessory (―shoulders‖) Motor Marry   
Gonioscopy – obstruction in anterior chamber
  
XII. Hypoglossal Motor Money Perimetry – decreased visual fields
  
Drugs (for lifetime)
  
I. OLFACTORY Timolol maleate
  
A. Sensory – smell Pilocarpine – drug of choice (miotic)
  
B. Use coffee, bar soap, vinegar, cigarette tar Epinephrine – decrease in aqueous humor

C. Abnormal findings Carbonic Anhydrase

Diamox
    (Acetazolamide) 
Indication of:
 Decrease in aqueous humor (maintains
 plate of ethmoid bone
Head trauma damaging the cribriform
 IOP); promotes drainage 
where olfactory cells are located
 
Sinusitis – give antibiotics to prevent meningitis Monitor I/O 
1. Hyposmia – decreased sensitivity to smell
   
NO ATROPINE: may lead to increased IOP Trauma
  
Surgery
 
 
 Nasolabial folds – most evident sign of facial symmetry

Trabeculectomy
 
 Peripheral iridectomy
 Uveitis – inflammation of the iris  I. ACOUSIC/VESTIBULOCOCHLEAR
Keratitis – inflammation of the cornea  A. Controls balance or kinesthesia (position sense/ movement
 and correlation of body in space)
2. Cataract 
   1. Organ of corti (true sense organ for hearing) for hearing
 Loss of central vision Glaring or hazy vision
 2. Cochlea – snail-shaped organ in middle ear
 Opacity of lens, milky white  appearance of cornea, B. Disorders
decreased perception to colors
   1. Conductive hearing loss
Due to aging
   2. Otitis Media
Prolonged UV rays exposure
   3. Meniere’s disease
Congenital disorder – very rare
 
DM
 
  Archimedes Principle – buoyancy (pregnancy fetus)
 Dx: Ophthalmoscopic examination
 Dalton’s – Law of Partial Pressure
 
Tx: Mydriatics, cycloplegics (cyclogil) – paralyzes ciliary Inertia - Kinesthesia
muscles
  
Surgery: lens extraction
 
ECLE – partial removal of cataract
 II. GLOSSOPHARYNGEAL – taste; posterior 1/3 tongue
III. VAGUS – gag reflex, decreased vital signs, eyes constrict, mouth
  
 ICLE – capsule included, total removal of cataract moist PNS
3. Retinal Detachment – most common complication IV. SPINAL/ACCESSORY controls 2 muscles:
following lens extraction A. Sternocleidomastoid (neck)
   B. Trapezius (Shoulder)
Curtain veil like vision
 
Leads to blindness
 V. HYPOGLOSSAL – tongue movement; frenulum linguae –
 
Severe myopia – common cause
 anchors tongue (tongue tied – short frenulum)
  
Emetropia – normal refraction of eyes
 
Presbyopia – loss of lens elasticity due to aging DEMYELINATING DISEASES
  
(+) floaters – d/t seepage of RBCs
 I. ALZHEIMER’S DISEASE - atrophy of the brain tissue

Surgery: Scleral Buckling, Diathermy (heat application),
Cryosurgery (cold application) characterized by:

a. Amnesia
4. Macular degeneration – degeneration of macula lutea b. Agnosia – (-) sense of smell
(yellowish spots in center of retina) c. Apraxia – (-) purposive movements
  
Black spots d. Aphasia
  1. Expressive/Broca’s – problem in speaking
Yellowish spots in center of retina or the macula lutea
 2. Receptive/Wernickes – problem in understanding;
USUAL FOR ALZHEIMER’S
III. OCULOMOTOR 3. Broca’s area – motor speech center; frontal
IV. TROCHLEAR It innervates mov’t of EOMs 4. Wernickes’ area – general interpretative area;
V. ABDUCENS temporal

e. ARICEPT – drug of choice, given at HS
COGNEX also given
SR IO (trochlear)
(Abducens) LR MR
IR SO

A. Normal response – PEBRTLA/ PERRLA (isocoria)

B. Anisocoria – unequal pupils
C. 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 PICK’S Disease: a form of dementia wherein there is damage in the
chewing, dysphagia frontoparietal area
1. avoid foods with extreme temperature
2. DOC: carbamazepine (Tegretol) II. MULTIPLE SCLEROSIS – chronic, intermittent disorder of
the CNS characterized by white patches of demyelination of the
VII. FACIAL brain and spinal cord. IDIOPATHIC, AUTOIMMUNE
A. Sensory – anterior 2/3 of tongue; identify taste without
swallowing A. INCIDENCE RATE: 15-35 yo, females
B. Motor – facial expression control B. PREDISPOSING FACTOR
1. instruct patient to smile, frown or raise eyebrows 1. Slow growing virus

Bell’s palsy or (temporary) facial paralysis – 2. Autoimmune – body produces antibodies which attacks
damage to facial nerve caused by: normal cells
 Forceps delivery - #1 cause 3. REVIEW: ANTIBODIES

 Autoimmune IgG – passes placenta (gestational)

 Stress IgA – found in bodily secretions, colostrums
   
IgM – acute infections (mabilis) Brought about by increase in the three intracranial components
  
IgE – allergic reactions
 
IgD – Chronic infections (dalas) 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

B. 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
C. CLINICAL MANIFESTATION 1. Changes in the vital signs
1. Visual disturbances   
Elevated BP (SBP rising, DBP constant)
     
Blurring of vision N Pulse Pressure: 40 mmHG
    
Diplopia  HR decreased
 
 Scotoma (blind spot) 
2. Impaired sensation to touch, pain, pressure, heat and
RR decreased (Cheyne-Stokes respiration: normal rhythmic
respiration followed by periods of apnea)
cold   
Elevated temperature
  
Tingling sensation 2. Headache, papilledema, projectile vomiting
  
Paresthesia 3. Abnormal posturing- decorticate (flexion) – damage to
  
Numbness corticospinal tract (spinal cord and cerebral cortex)
3. Mood swings remember: deCORDThreecate OR decerebrate
  
Euphoria – sense of well-being (extension): upper brain stem damage – pons, midbrain,
4. Impaired motor activity cerebellum
  
Weakness 4. Unilateral dilation of pupil (ANISOCORIA) –
  
Spasticity indicates uncal brain herniation; if bilateral dilatation:
  
Paralysis tentorial herniation
5. Impaired cerebellar function 5. possible seizures
 6. Cushing’s reflex (hypertension with bradycardia)
 CHARCOT’S TRIAD : ataxia (unsteady gait), nystagmus,
intentional tremors
   o SHOCK – inadequate tissue perfusion
Scanning speech
6. Urinary retention or incontinence o HYPOXIA – inadequate tissue oxygenation
7. Constipation
8. Decrease in sexual capacity C. NURSING MANAGEMENT
1. maintain patent airway and adequate ventilation by:
D. DIAGNOSTIC PROCEDURE   
 prevention of hypoxia ( cerebraledema increased ICP)
1. CSF Analysis LT: reveals increased CHON and IgG  and hypercarbia (CO2 retention)
  
2. MRI – site and extent of demyelination cerebral vasodilation increased ICP decreased tissue
 
perfusion possible shock
F. NURSING MANAGEMENT: Palliative   
Early signs of hypoxia
1. Administer medications as ordered   
Restlessness
    
Acute Exacerbation  Agitation
  
Tachycardia

ACTH (Adrenocorticotropic hormone) –   
Late signs of hypoxia
reduces edema at site of demyelination  

 
thereby preventing paralysis; compression of
 
Bradycardia

spinal cord will lead to paralysis Extreme restlessness
   
Baclofen  (Lioresal), Dantrolene Na – to reduce muscle Dyspnea
spasticity   
Cyanosis
 
 Interferons 
   Increased CO2 – most potent respiratory

Immunosuppressives
  stimulant inthe normal person (irritates medulla
 Diuretics oblongata)
 
PROPHANTHELENE BROMIDE (PRO-BANTHENE) –    
Decreased O2 – stimulates respiration in CRDS
anti-cholinergic for urinary incontinence  
2. Provide for Relaxation Suctioning should only last for 10 -15 seconds and
   application of suction should be done  upon
DBE, biofeedback, yoga
 withdrawal of catheter in a circular fashion.
3. Retain side rails
4. Prevent complications of immobility – TTS Q2h, Q1 h 2. Assist in mechanical ventilation
for elderly, 20 minutes only on affected side 3. Elevate head of bed 30-45 degrees with neck in neutral
5. Increase OFI, high fiber diet (for constipation), acid-ash position when contraindicated to promote venous
in diet to acidify urine to prevent bacterial drainage
multiplication (cranberry juice, prunes, grape juice, 4. Limit fluid intake to 1.2-1.5 l per day (Forced fluids =
vitamin c, plums, orange and pineapple juice.) 2-3 L/day)
6. Provide catheterization for urinary retention 5. Monitor VS, NVS, I/O strictly
6. Prevent complications of immobility
7. Prevent further increase in ICP
  
Provide comfortable environment
  
Avoid use of restraints fractures
INCREASED INTRACRANIAL PRESSURE 8. Keep side rails up
   
9. Avoid valsalva maneuver SE: major depression suicidal ideation
    
Straining of stools (give laxatives/stool softeners) Linked to Breast Ca development
  
Excessive vomiting (give Metoclopramide (plasil) SBE is done 7 days after menstruation

– anti-emetic) Breast Ca - #1 Ca in women
  
Lifting of heavy objects Cervical Ca - #2 Ca in women
  
Bending or stooping 1. multiple sex partners
10. Administer medications as ordered 2. early pregnancy
  Ovarian Ca - #3 Ca in women
 Osmotic Diuretics – Mannitol (Osmitol) – cerebral diuresis
 mammography lasts for 10-20 minutes
 BP (SE: Hypotension resulting
Monitor VS especially   
from hypovolemia) Methyldopa (Aldomet) – has anti HPN properties
   

Haloperidol (Haldol) – anti-psychotic

Monitor I/O qH
  
NEUROLEPTIC MALIGNANT SYNDROME
Given via side drip, fast drip to avoid precipitate 
 formation
 (NMS)
  Tremors, tachycardia, tachypnea, fever 
Instruct client that
a flushing sensation will be felt as drug
 is introduced  
Phenothiazides – anti-psychotic

 
Loop Diuretics via IV push – Furosemide
 
PHENERGAN– only anti-psychotic with anti-emetic
 
BP properties
   
Monitor 1/0 q1, notify if <30cc/hr
  
IV push Lasix effect in 10-15 minutes, max 6
B. CLINICAL MANIFESTATION
hours; best given in AM to prevent sleep 1. PILL ROLLING TREMORS of the extremities – first sx
 interruption 2. Bradykinesia – second sx
   3. Rigidity (―cogwheel type‖) – third sx
Corticosteroids
  4. Stooped posture, SHUFFLING GAIT, propulsive gait
Dexamethasone (decadron)
Steroids administered 2/3 in AM to 5. Overfatigue
mimic diurnal rhythm 6. Mask-like facial expression, decreased blinking of the
   eyelids
Hydorcortisone
   7. Difficulty in rising from sitting position
Prednisone
   8. Quiet monotone speech
Mild Analgesic
   
 Codeine sulfate 9. Mood lability depression suicide
   10. Increased salivation, drooling type
Anti-Convulsant
  11. Autonomic changes
Pheytoin (Dilantin)
  
Increased sweating and lacrimation
  
Benadryl is given at HS because it causes drowsiness Seborrhea
  
Levothyroxine is given in AM to prevent insomnia Constipation
 
Decreased sexual capacity

III. PARKINSON’S 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. NURSING MANAGEMENT (palliative)

1. Administer medications as ordered
 
Anti-Parkinsonian Agents increase dopamine

relieves rigidity (CAPABLES!)

A. PREDISPOSING FACTORS   
Levodopa (L-dopa) – short acting dopaminergic
1. Poisoning 
  Amantadine  HCl (Symmetrel) – long acting
  dopaminergic
Lead (ANTIDOTE: Ca EDTA – heavy metal antagonist)
   
Carbon Monoxide decreased capacity of Carbidopa (Sinemet) – long acting dopaminergic
   SE: (GIT) anorexia, nausea and vomiting,
hemoglobin to carry oxygen cherry red skin color
2. Arteriosclerosis orthostatic hypotension, hallucination,
arrhythmia
3. Hypoxia – inadequate tissue perfusion
4. Encephalitis Contraindications: narrow angle closure
5. Drugs  
glaucoma loss of peripheral vision tunnel vision
  
Reserpine (Serpasil) 
   halos in light; normal IOP = 12-21 mmHg
Has anti HPN properties
 
Promote safety when giving this drug
 Also contraindicated in patient’s taking
MAOI’s (Avoid tryptophan and tyramine in
pts taking MAOI’s) C. CLINICAL MANIFESATION
  1. PTOSIS – INITIAL SIGN
 Administer with food or snack to lessen GIT irritation
  
   Check palpebral fissure drooping of upper eyelids
Inform client that stools/urine maybe darkened 2. Double vision

 RICH IN
INSTRUCT CLIENT TO AVOID FOODS VITAMIN B6- 3. Mask like facial expression
 -PYRIDOXINE (Cereals, organ

meat, green leafy vegetables) 
– reverses 4. Weakened laryngeal muscles dysphagia (difficulty of
therapeutic effect of levodopa swallowing, without food); odynophagia ang with food
  
Anti-cholinergics – relieves tremors 5. Hoarseness of voice
  
Relieves tremors 
   6. Respiratory muscle weakness respiratory arrest; prepare trache
Artane and Cogentin set at bedside
  
Mode of action: increases dopamine 7. Extreme muscle weakness especially during activity or
  
SE: SNS exertion in AM
  
Antihistamine – relieves tremors
  
Diphenhydramine HCl (Benadryl) D. DIAGNOSTICS
 
SE: 1. TENSILON TEST (EDROPHONIUM HCL)
Drowsiness – adult   
Temporary relief of symptoms
CNS excitement and hyperactivity – children   
Strengthens muscles temporarily
  
 Dopamine Agonists – relieves tremors and rigidity
Pt, temporarily can open 
5-10 minutes after admin
eyelids, increased muscle strength
 
Bromocriptine HCl (Parlodel) SE:
 
CNS Depression
   E. NURSING MANAGEMENT
No OCP’s decreased effect

2. Maintain side rails to prevent injuries related to falls Airway
3. Prevent complications of immobility  
Aspiration
4. Maintain good nutrition. Provide dietary intake that is Immobility
low in protein in AM and high protein at night to 1. Maintain patent airway and adequate ventilation
  
induce sleep Assist in mechanical ventilation
    
 TRYPTOPHAN – induces sleep Assess PFT (decreased Vital Lung Capacity)
5. Assists in passive ROM exercises to prevent 2. Monitor Strictly VS, IO, NVS, motor grading scale
contractures. Q4h for proper body alignment. (muscle strength)
6. Increased OFI is encouraged and increased Fiber in the 3. Maintain side rails
diet for constipation 4. institute NGT feeding to prevent aspiration
7. Ambulate with assistance 5. prevent complications of immobility – q2 turning, q1
8. Assist in STEROTAXIC THALAMOTOMY for elderly
 6. Administer meds as ordered
COMPLICATIONS: SUBARACHNOID HEMORRHAGE,   
ENCEPHALITIS, CEREBRAL ANEURYSM Corticosteroids – for immunosuppression
  
Cholinergic/Anticholinergic agents
  
IV. MYASTHENIA GRAVIS (MG) – neuromuscular disorder 
Mestinol (Pyridostigmine)

characterized by a disturbance in the transmission of impulses Neostigmine (Prostigmin)
from nerve to muscle cells at the neuromuscular junction (or Monitor for the two types of crisis
motor end plate – site of exchange of neurotransmitters)
IDIOPATHIC; DECENDING MUSCLE WEAKNESS Myasthenic Crisis Cholinergic Crisis
Causes: undermedication, stress, Cause: overmedication
infection
S/sx: (-) seeing, swallowing, speaking, S/sx: PNS, increased

breathing salivation aspiration
Tx: admin cholinergic agents as ordered Tx: anticholinergic agents,
atropine sulfate

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

8. Prevent complications respiratory arrest
9. Prepare trache set in pts with MG

V. MENINGITIS – inflammation of the meninges of the brain and

spinal cord
 
Meninges – 3fold membrane that covers the brain and spinal cord
A. INCIDENCE RATE
1. Women aged 20-40 years old For support and protection
For blood supply
B. PREDISPOSING FACTORS For nourishment
  
1. Autoimmune Dura mater - outermost
  
 
Subdural space – between dura and arachnoid

Involves release of CHOLINESTERASE an enzyme 
  Arachnoid mater - middlemost
which destroys Ach descending muscle weakness  
Subarachnoid space where CSF circulates; location
where aspirate is taken during LT (puncture either bet l3-l4
  it is above these areas where the spinal cord
or l4-l5 because
terminates)
 
Pia mater – ―gentle mater‖
 VI. CEREBROVASCULAR ACCIDENTS (Stroke, brain attack,
A. ETIOLOGIC AGENTS cerebral thrombosis, apoplexy) – partial or total disruption in the
1. MENINGOCOCCUS – MOST DANGEROUS blood supply of the brain, usually in the MCA or ICA (2 largest
2. Pneumococcus cerebral arteries)
3. Streptococcus – adult
4. Hemophilus influenzae – pedia A. INCIDENCE RATE – 2-3x higher in males than in females

B. MODE OF TRANSMISSION – airborne transmission via B. PREDISPOSING FACTORS

droplet infection 1. Thrombosis – attached clot, #1 cause of stroke
C. CLINICAL MANIFESTATION 2. Emboli – detached/wandering thrombosis
1. Headache, photophobia, projectile vomiting   
Pulmonary embolism
  
2. Fever, chills, anorexia, generalized body malaise, Sudden sharp chest pain
weight loss   
Unexplained dyspnea
3. decorticate (deCORDthreecate) and or decerebrate   
Tachycardia
4. Possible seizure and increased ICP   
Palpitation
5. Signs of meningeal irritation   
Diaphoresis
    
Nucchal rigidity  Cerebral embolism
     
Opisthotonus – rigid arching of the head Headache
     
(+) kernig’s sign – leg pain Dizziness
    
(+) brudzinksi’s sign – neck pain Disorientation
  
 Change in LOC that may lead to coma
D. DIAGNOSTICS 3. Hemorrhage
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

 to arch back to clearly visualize
Encourage client
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 C. RISK FACTORS
 
Increased CSF opening pressure 1. HPN
N = 50-160 mmHg 2. DM
   
(+) cultured microorganisms 3. Atherosclerosis MI
   4. Valvular heart disease, Mitral/post-cardiac surgery/mitral valve
These confirm presence of meningitis

2. CBC Reveals replacement mlt CVA
  5. Lifestyle
Increased WBC
   
Smoking
   
E. NURSING MANAGEMENT Sedentary lifestyle
  
1. Complete bed rest Obesity (more than 20% ideal body weight)
 
2. Administer medications as ordered  Diet rich in saturated fats
   
Broad Spectrum Antibiotics
   – genetic; (+) genes that easily binds to
Hyperlipidemia
Penicillin alteration in the N flora of the GI cholesterol
     
superinfection diarrhea Type A personality
     
Analgesics Deadline driven person
    
 Antipyretics Does several things at the same time
  
3. Institute strict respiratory isolation after initiation of Feels guilty when not doing anything
antibiotic therapy   
Prolonged use of oral contraceptives
  
4. Institute ICP monitoring Macropil estrogen
    
5. Dim environment d/t photophobia Minipil progestin
6. Monitor strictly VS, IO and NVS   
Increases lipolysis breakdown of lipids
7. Maintain F and E balance
   
8. Prevent complications of immobility: turn to sides q2 atherosclerosis HPN CVA
9. Health Teaching and D/C planning D. CLINICAL MANIFESTATION
 1. TRANSIENT ISCHEMIC ATTACK – initial sign of CVA
 with small frequent
Dietary intake increased in calories

feedings (increase carbohydrates)
  Headache, dizziness, tinnitus, visual and speech
 Prevent complications
 
 
disturbances, paresis to plegia, increase in ICP
 HYDROCEPHALUS possible, cheyne-stokes respirations

HEARING LOSS (NERVE DEAFNESS)  2. Stroke in evolution – progression of S/sx
Visit audiologist for audiometric screening 3. Complete Stroke – resolution phase characterized by
after resolution of meningitis still dizziness and headache
    
 Rehabilitation for residual deficits Cheyne-stokes respirations
 
  Anorexia
Mental retardation
 or delay and psychomotor   
 development Nausea and vomiting
 
  Dysphagia
Singit lang to: pag post repair ng myelomeningocoele   
(+) Kernigs and Brudzinksi’s
    
checkup with urologist baka na-hit ung bladder Focal Neurological Deficits
  
Plegia
 
Aphasia
  
Dysarthria – speaking difficulty
  
Alexia – reading difficulty
 
 Agraphia – writing difficulty
VII. GUILLAINE-BARRE SYNDROME (GBS) – CNS disorder
  characterized by bilateral, symmetrical, polyneuritis leading to
Homonymous hemianopsia –loss of ½ vision field
Unilateral neglect ascending muscle weakness/paralysis.

A. Cause – IDIOPATHIC
E. DIAGNOSTICS
B. PREDISPOSING FACTORS
1. CAT scan
1. Autoimmune
2. Cerebral Arteriography – reveals site of lesion
   2. antecedent viral infection
Informed consent
  3. immunizations such as your flu vaccine
 Allergies to seafood
  C. CLINICAL MANIFESTATION
Post-dx: forced fluids and check for presence of hematoma
 1. CLUMSINESS – INITIAL SIGN
2. Dysphagia
F. NURSING MANAGEMENT 
3. Ascending muscle weakness paralysis
1. Maintain patent airway and adequate ventilation
   4. Decreased DTRs
Assist in mechanical ventilation
   5. Alternate hypertension and hypotension; MOST FEARED
Administer oxygen as ordered
COMPLICATION: ARRHYTHMIAS
2. Restrict Fluids
6. Autonomic changes
3. Elevate head of bed, 30-40 degrees to promote venous   
Increased sweating and lacrimation
drainage   
Increased salivation
4. Avoid activities that cause valsalva maneuver  
Constipation
5. Prevent complications of immobility 
 
Prevent
 bed sores and hypostatic pneumonia TTS D. DIAGNOSTICS
 q2
  1. CSF Analysis : reveals elevated CHON and IgG
Use of egg crate mattress or water  
  bed Sand CSF is produced in the choroid plexus
bag/foot board to prevent foot lag 
6. Institute NGT feeding
E. NURSING MANAGEMENT
7. ROM exercises q4h to prevent contractures and
promote proper body alignment 1. Maintain patent airway and ventilation
  
8. Alternative means of communication Assist in mechanical ventilation
   2. Maintain side rails (paralysis)
Non verbal cues
   3. prevent complications of immobility
Magic slate or picture board
4. institute NGT feeding
9. If positive for hemianopsia, approach client on
unaffected side 5. Administer medications as ordered
  
10. Administer meds as ordered Anticholinergics – Atropine Sulfate
    
 Corticosteroids – to suppress immune response
Osmotic diuretics  
   Anti-arrhythmic agents
Mannitol (Osmitrol)  
  
 Corticosteroids
Lidocaine (Xylocaine)
    
Dexamethasone (Decadron) Bretyllium – Blocks norepinephrine
 
Mild Analgesics
 
  Quinidines – anti-arrhythmic, anti-malarial

Codeine Sulfate

(Malaria –king of tropical diseases kaya ang
 Thrombolytics meds ay queen =  quinines) Common SE:
  QUINCHONISM :
Streptokinase
 Urokinase  Female anopheles – malaria, night biting, lay
 eggs in the morning
Tissue Plasminogen Activity Factor (TPAF)
Monitor for bleeding  Female aegis egyptis – dengue, day biting,
   lay eggs at night, 4 o’clock habit
Anti-coagulants as ordered.
  Plasmodium falciparum – most dangerous form of
Heparin check PTT – if prolonged, indicates bleeding 
  malaria hemorrhage
 give protamine sulfate when overdosed 6. Assist in plasmaparesis
  7. Prevent complications
Coumadin check PT – if prolonged, indicates
 
  ARRHYTHMIAS
 bleeding vitamin K (aquamephyton) as antidote 
RESPIRATORY ARREST 
Given together because coumadin will take
 
effect after 3 days still VIII. CONVULSIVE DISORDERS
 
 Loop-diuretics 
 
A disorder of the CNS characterized by paroxysmal seizures
 Lasix (okay to administer in DM pts but monitor CBG) with or without loss of consciousness, alternation in
   sensation and perception, abnormal motor activity and
Anti-platelets changes in behavior; IDIOPATIHIC
  
ASA – anti-thrombotic 
 
Febrile seizures are normal for children below 5 years only; can be
Contraindicated in dengue, ulcers and unknown outgrown
 
 
 Febrile seizures in children >5 yo = abnormal
cause of headache potentiates bleeding   
 SEIZURE – first convulsive attack
 
EPILEPSY – series of seizure activity
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
   
A. PREDISPOSING FACTORS Diazepam (Valium) – for status epilepticus
  
1. Head injury secondary to birth trauma Carbamazepine (Tegretol)
2. Lead poisoning  
3. Genetics Also used for Trigeminal neuralgia (Tic Dolor)
  
4. Brain tumor Phenobarbitals (Luminal)
5. Nutritional and metabolic deficiencies 4. Institute seizure and safety precautions
  
6. Sudden withdrawal of anti-convulsive drugs Post-seizure:
    
 Causes STATUS EPILEPTICUS O2 inhalation
    
 DOC: diazepam, glucose Suction apparatus
7. Physical and emotional stress 5. Monitor and document the following
  
Onset and duration
  
B. TYPES OF SEIZURES Type of seizure
 
1. Generalized  Duration of post-ictal sleep
 increased length of sleep can
   lead to status epilepticus
Grand Mal (Tonic-Clonic)

With or without an aura
 6. Assist in CORTICAL RESECTION
Epigastric pain – initial sign of an aura (aura
is an initial sign of seizures) For a one year old client suffering grand mal seizures:
     
Visual auditory olfactory tactile  NOT Mouthpiece Eh onte lang teeth ng one year old eh
sensory experience  
 Give pillows  for the head (For banging of head
support
Epileptic cry
  during seizure activity)
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
2. 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
3. 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


C. DIAGNOSTICS 
1. CT-SCAN – brain lesion d/t head trauma
2. EEG – hyperactivity of brain waves (all elevated)
 
Alpha, beta, delta, theta waves

D. 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