EMILIO AGUINALDO COLLEGE - CAVITE

~THE NERVOUS SYSTEM~

Common Health Problem and Disorders

JHOANNE D. DUERO7/18/2009

NERVOUS SYSTEM

1. Central Nervous System Brain Spinal Cord

2. Peripheral Nervous System Cranial Nerves Spinal Nerves

Neuron

BRAIN

The Brain is divided into 3 major areas:1. Cerebrum 2. Brain Stem3. Cerebellum

External surface of the brain

CEREBRUM The largest part of the brain. Composed of: 2 hemispheres- the right and left, and the basal ganglia. The hemisphere is connected by corpus callosum, a band of fibers. Each hemisphere is divided into 4 lobes.

Structure of the Brain

The 4 Lobes of the Cerebrum

1. Frontal Lobe Largest lobe Location: front of the skull. Contains the primary motor cortex and responsible for functions related to motor

activity. The left frontal lobe contains Broca’s area (control the ability to produce spoken

words) The frontal lobe controls higher intellectual function, awareness of self, and

autonomic responses related to emotions

2. Parietal Lobe Sensory lobe Location: near the crown of the head. Contains the primary sensory cortex. One of its major functions is to process sensory input such as position sense,

touch, shape, and consistency of objects.3. Temporal Lobe

Location: around the temples. Contains the primary auditory cortex. Wernicke’s area is located on left temporal lobe. Contains the interpretative area where auditory, visual and somatic input are

integrated into thought and memory

4. Occipital Lobe Location: lower back of the head Contains the primary visual cortex Function: responsible for visual interpretation.

THE 4 LOBES Frontal- motor /controls higher intellectual function, awareness of self and autonomic

responses related to emotions. Parietal- sensory Temporal- auditory (Wernicke’s); Contains the interpretative area where auditory, visual

and somatic input are integrated into thought and memory Occipital- visual

Ventricles of the Brain

Diencephalon Lies on the top of the brain-stem Contains the thalamus, hypothalamus, epithalamus, and subthalamus.

1. Thalamus Lies on the either side of the third ventricle “Relay station” for all sensation except smell. All memory, sensation and pain impulses pass through this section.

2. Hypothalamus Located anterior and inferior to the thalamus. Has a variety of function and plays an important role in maintaining homeostasis. Regulation of body temperature, hunger and thirst; formation of autonomic

nervous system responses; and storage and secretion of hormones from the pituitary gland.

3. Epithalamus Contains pineal gland.

4. Subthalamus Part of the extrapyramidal system of the autonomic nervous system and the basal

ganglia.The Basal Ganglia

Are masses of nuclei located deep in the cerebral hemispheres.

Responsible for fine motor movements, including those of the hands and lower extremities.

Several motor disorders are associated with basal ganglia damage including Huntington’s chorea and Parkinson’s disease.

BRAIN STEM Consist of the midbrain, pons, and medulla oblongata. Midbrain

connects the pons and the cerebellum with the cerebral hemisphere, it contains sensory and motor pathways

center for auditory and visual reflexes Pons

connects the two halves of the cerebrum involved in the integration of movements in the right and left sides of the body,

and the transmission of motor information from the higher brain areas and the spinal cord to the cerebellum.

Medulla oblongata involved in the respiration, circulation, gastrointestinal functioning, coughing,

sneezing, and swallowing.

CEREBELLUM Location: base of the brain. Responsible for coordination, balance and posture. Damage to the cerebellum can result in ataxia, a condition characterized by drunken-like

movements, severe tremors, and loss of balance.

Structures Protecting the Brain The brain is contained in the rigid skull, which protects it from injury. The meninges (fibrous connective tissues that cover the brain and the spinal cord)

provide protection, support and nourishment to the brain and the spinal cord. Layers of the meninges:

a. Dura materb. Arachnoid c. Pia mater

CSF – Cerebrospinal Fluid Provide a cushion, provide nutrition, maintain normal ICP, remove metabolic waste. Composition – colorless, odorless fluid containing glucose, electrolytes, oxygen, water,

small amount of carbon monoxide and few leukocytes. Produced in the choroid plexus of the ventricles.

SPINAL CORD

Approximately 45 cm long (18 inches) long. Acts as a passageway for condition of sensory information from the periphery of the

body to the brain (via afferent nerve fibers). Serve as the connection between the brain and the periphery. Mediates the reflexes.

a. Cervical C1-4b. Brachial plexus C5-8, T1c. Intercostal T2-T12d. Lumbar L1-L4e. Sacral L4-L5, S1-S3f. Pudendal S4

Blood Supply to the CNS 1/3 of the cardiac output From 2 vertebral artery and one internal carotid arteries Circle of Willis

Peripheral Nervous System –Cranial Nerves & Spinal Nerves

CRANIAL NERVES 12 pairs Emerge from the undersurface of the brain. Cranial nerve conducts impulses (motor and sensory information) between the brain and

various structures of the head, neck, thoracic cavity and abdominal cavity.

I Olfactory nerve II Optic nerve III Oculomotor nerve IV Trochlear nerve V Trigeminal nerve VI Abducens nerve VII Facial nerve VIII Acoustic/Vestibulocochlear IX Glossopharyngeal nerve X Vagus nerve XI Accessory nerve XII Hypoglossal nerve

Cranial Nerves Function Assessment

I. Olfactory Sensory: smell reception and interpretation

Assess nose for Smell. Have the client close eyes and

properly identify common aromatic substance held under the nose; test one nostril at a time. (ex. coffee, toothpaste, orange)

II. Optic Sensory: visual acuity and visual fields

Assess eyes for Visual Acuity and Peripheral Vision.

Vision and visual field tested with an eye chart and by testing point at which person sees an object (finger) moving into visual fields; inside of the eye is viewed with ophthalmoscope to observe blood vessels.

III. Oculomotor Motor: raise eyelids, most extraocular movements

Parasympathetic: pupillary constriction, change lens shape

Assess eyes for Extraocular Movement. The CN III, CN IV, and CN VI

nerves are tested together since they control muscles that provide eye movement. Test the movement of the eyes in the six cardinal fields of gaze.

Assess eyes for Pupillary Constriction and Accommodation.

To test pupillary reaction and accommodation, shine a light into the eye to note whether the iris

constricts, making the pupil smaller.

Accommodation is tested by observing pupillary constriction when the client changes gaze from a distant object to a near object.

IV. Trochlear Motor: downward, inward eye movement.

Assess eyes for Extraocular Movement

V. Trigeminal Motor: jaw opening and clenching, chewing and mastication

Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin

Assess face for Movement and Sensation Test motor function by having the

client clenches his/her teeth, then palate the temporal and masseter muscles.

To test light sensation, have the client close his/her eyes, then wipe a cotton wisp lightly over the anterior scalp, paranasal sinuses, and jaw.

To test deep sensation, use alternating blunt and sharp ends

of a paper clip over the client’s forehead and paranasal sinus.

VI. Abducens Motor: lateral eye movement

VII. Facial Motor: movement of facial expression muscles except jaw, close eyes, labial speech sounds.

Sensory: taste- anterior two third of tongue, sensation to Pharynx

Parasympathetic: secretion of saliva and tears.

Inspect the face both at rest and during conversation.

Have the client raise the eyebrows, frown, close the eyes tightly and show the teeth, smile and puff out the cheeks.

Assess mouth for Taste Instruct the client to stick out the

tongue and leave it out during the testing process. Use a cotton applicator to place quantities of salt, sugar, and lemon to client’s tongue.

VIII. Acoustic Sensory: hearing and equilibrium.

Hearing initially can be screened while taking the history.

IX. Glossopharyngeal Motor: voluntary muscle for swallowing and phonation.

Parasympathetic: secretion of salivary gland, carotid reflex

Assess mouth for Gag Reflex and Movement of Soft Palate.

Evaluate CN IX and CN X together for movement and gag reflex.

Instruct the client to say “ah”; there should be bilateral equal upward movement of the soft palate and uvula; gagging will occur; and speech should be smooth.

X. Vagus Motor: voluntary muscle of phonation and swallowing

Sensory: sensation behind ear and part of external ear canal.

Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of the heart, lungs and digestive tract.

Assess mouth for Gag Reflex and Movement of Soft Palate

XI. Spinal Accessory Motor: turn head, shrug shoulders, some actions for phonation

Assess shoulder and neck muscles for Strength and Movement

Have the client shrug his/her shoulders upward against your hands.

Have the client turn his/her head

to the side against your hand, repeat on the other side.

XII. Hypoglossal Motor: tongue movement for speech sound articulation and swallowing

Assess mouth for Tongue Movement, Symmetry, Strength, and Absence of Tumors

client protrudes tongue. Note symmetry, atrophy, and absence of tumors

Then ask the client to move tongue toward nose, chin, and side to side.

Strength of the tongue can be tested by pressing it against your gloved index finger.

SPINAL NERVES 31 pairs 8 cervical, 12 thoracic, 5 lumbar 5 sacral, 1 coccygeal Two roots

Dorsal and Ventral - Each spinal nerve has a ventral root (motor) and a dorsal root (sensory)

Dermatome distribution

The dorsal roots contains sensory fibers that relay information from sensory receptors to the spinal cord

The ventral root contains motor fibers that relay information from the spinal cord to the body’s glands and muscles.

Dermatome distribution

AUTONOMIC NERVOUS SYSTEM Regulates the activities of the internal organs (heart, lungs, blood vessels, digestive

organs, and glands) Responsible for maintenance and restoration of internal homeostasis.

2 Components of ANS1. Sympathetic Nervous System2. Parasympathetic Nervous System

Sympathetic Nervous System Expenditure of energy Catecholamines: Epinephrine; norepinephrine; dopamine “Fight or flight” response.

Pupil dilates Increased HR Increased BP Increased RR Constipation Dry mouth Urinary retention

Parasympathetic Nervous System Conserving energy.

Acetylcholine Pupil constricts Decreased HR Decreased BP

Decreased RR Diarrhea Increased salivation Urinary frequency

AssessmentTHE NEUROLOGIC EXAMINATION

General Assessment for Neurological Disorders

Health History Past Health History

Injuries and surgeries Use of alcohol, medications, and illicit drugs Onset of symptoms. Duration of current complain Recent trauma

The disorders involving neurologic system impairment are headache, dizziness or vertigo, seizures, change in consciousness, altered sensation and visual disturbances.

Physical Examination The brain and spinal cord cannot be examined directly as other system of the body.

V/S - abnormal respiration breathing pattern Pupillary reaction/pupillary changes Eye movement & reflex response Change in balance

Neurological Assessment Recognition of change Helps assess the patient’s ability to engage in self-care activities. Neurologic assessment is divided to into 5 components:

Cerebral function

Cranial nerves Motor system Sensory system Reflexes

1. Cerebral Function Mental status: observe patient’s appearance, behavior, dressing, grooming and

personal hygiene.a. Posture, gestures, movements, facial expression, motor activity, the

patient’s manner of speech and LOC are also assessed.b. Level of Consciousness (LOC) – awareness of self and environment and

level of arousal (alert, lethargic, obtunded, stuporous, coma).

Altered Level of Consciousness (LOC) - can result from destruction of the brain stem or its reticular formation of ascending nerves, or from other structural, metabolic, or psychogenic disturbances.

Confusion Impaired ability to think clearly Disturbed ability to perceive,

respond to, and remember current stimuli

Disorientation Functional in activities of daily

living (ADLs)

Delirium Motor restlessness Increased disorientation Transient hallucinations Delusions possible Requires some assistance with

ADLs

Obtundation Decreased alertness Psychomotor retardation Requires complete assistance with

ADLs

Stupor Arousable but not alert Severe disorientation Little or no spontaneous activity

Coma Unarousable Unresponsive to external stimuli or

internal needs Determination commonly

documented using Glasgow Coma

Scale score

Altered Movement Involves certain neurotransmitters (ex. dopamine)

o Hyperkinesia- excessive movement

o Hypokinesia- decreased movement

Marked by paresis- partial loss of motor function and muscle power; commonly described as weakness; can result from destruction of upper & lower motor neurons

2. Cranial Nerve Function Assess cranial nerve function.

3. Motor System Function Assess muscle size (inspect and palpate) tone, and strength; assess symmetry

differences between right and left side; balance and coordination.o Altered Muscle Tone

o Hypotonia - severely reduced degree of tension or resistance to movement

in a muscleo Hypertonia - marked increase in a muscle tension and decreased ability of

a muscle to stretch

4. Sensory Function Test for:

o superficial tactile sensation superficial and deep pressure pain

o thermal sensitivity

o sensitivity to vibration

o point localization

5. Reflexes Evaluate deep and superficial reflexes (biceps, triceps, patellar, ankle reflexes)

and abnormal reflexes (Babinski’s reflex).

Diagnostic Tests

Diagnostic Procedure Nursing InterventionsComputed Tomography Scanning

Visualize sections of the spinal cord as well as intracranial contents

The injection of a water-soluble iodinated contrast into the subarachnoid space through lumbar puncture helps

noninvasive and painless has a high degree of sensitivity for

detecting lesions.

Use of x-ray beams cross section Use: to identify intracranial tumor,

hemorrhage, cerebral atrophy, calcification, edema, infarction, congenital abnormality.

Teaching the client about the need to lie quietly throughout the procedure.

Relaxation technique maybe helpful for clients with claustrophobia.

Assess for iodine/shellfish allergy.

Secure patent IV line.

NPO if with contrast medium, for 4 hrs.

Monitor for allergic reaction: flushing, nausea and vomiting.

Magnetic Resonance Imaging

Diagnostic Procedure Nursing InterventionsMagnetic Resonance Imaging

Uses a powerful magnetic field to obtain images of different areas of the body.

Can be performed with or without a contrast agent and can identify a cerebral abnormality earlier and more clearly than other diagnostic tests.

Useful in diagnosis of multiple sclerosis and can describe the activity and the extent of disease in the brain and spinal cord.

Obtain history of metal implants. Remove all metal objects.

Inform the client that the procedure last for 30 to 90 mins.

Patient preparation should include teaching relaxation technique.

Inform the client that a narrow, tunnel like machine will enclose him/her during the procedure.

Sedation may be needed for claustrophobic client.

Cerebral Angiography Is an x-ray study of the cerebral Obtain a signed consent.

circulation with a contrast agent injected into a selected artery (femoral)

Visualize aneurysm

Myelography Contrast agents are injected into spinal

subarachnoid space to permit visualization of spinal cord.

Shows any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks or other lesions.

Hydrate the client, clear liquids are usually permitted.

Instruct the client to void before the procedure.

Instruct the patient to remain immobile during the test.

Tell the client to expect a brief feeling of warmth in the face, behind the eyes or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast is injected.

After the procedure check LOC, and injection site should be observed.

Explain the procedure. Obtain a signed consent. Withhold oral intake 4-6 hours before

the test. After the procedure:

For pantopaque myelogram (oil-based) pt lies flat for 6-24 hours.

For metrizamide myelogram (water-based), HOB is elevated at 30 degrees for at least 8 hours.

Encourage fluid intake.Electroencephalography

Graphic record of the electrical activity generated in the brain.

EEG is a useful test for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome.

A sleep EEG may be recorded after sedation because some abnormal brain waves are seen only when the patient is asleep.

Explain the procedure; assure the client he/she will not receive electrical shock.

The nurse needs to check doctor’s order regarding the administration of anti-seizure medication prior to testing.

Withhold tranquillizer and stimulants for 24 to 48 hours.

Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.

Electroencephalography

Measurement of the electrical activity of the brain done during:o Relax

o Hyperventilate

o Sleeping

o Flickering lights

Lumbar Puncture

Insertion of needle in the Subarachnoid Space Assess the CSF

Lumbar Puncture Is carried out by inserting a needle into

the lumbar subarachnoid space to withdraw CSF for diagnostic or therapeutic purposes.

The needle is usually inserted between L4 and L5.

Maintain position, usually lateral horizontal with knees to chest, chin on chest.

Obtain signed consent. Explain the procedure. Observe for complication following the

procedure. Keeping the patient in prone position

overnight may reduce the incidence of headache.

Electromyography Obtain by inserting needle electrodes Explain the procedure.

into the skeletal muscles. Measure changes in the electrical

potential of the muscles and the nerves leading to them.

Useful in determining neuromuscular disorders and myopathies.

The patient is warned to expect a sensation similar to that of an intramuscular injection and the muscle examined may ache for a short time after the procedure.

Electromyogram

Measures electrical potential/ activity of the muscles

Pneumoencephalography Special contrast study of the ventricular

and cisternal system using air as contrast medium.

Permits accurate localization of brain lesions by spinal or cisternal puncture with x-ray examination.

Secure written consent. Sedate as ordered. GA may be used. Inform the client that the procedure

takes 2 hours. Inform the client that he/she may

experience discomfort, N/V, after the procedure.

After the procedure keep the client flat in bed for 24 to 48 hours.

Monitor VS and neurologic checks.

Common Health Problem of the Neonate and Infant

Nervous System Developmental Disorders

1. Cranial Hydrocephalus

2. Spinal Cord Meningocele

HYDROCEPHALUS Is an excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain. Reasons for excess:

o over production of fluid by the choroid plexus in the 1st or 2nd ventricle

o obstruction of the passageway of fluid somewhere between the point of origin and

the point of absorptiono interference with the absorption of fluid from the subarachnoid space

Classifications:a. Congenital b. Acquired

The cause of congenital hydrocephalus is unknown. Incidence: 3 to 4 per 1000 live births In older child infections such as meningitis and encephalitis may leave adhesion that lead

to obstruction.

Nursing Assessment Enlarged head Prominent scalp vein. Enlarged or full fontanels Separated suture line Increased head circumference Sunset eyes Shrill cry Hyperactive reflexes Signs of increased ICP

Decreased pulse Increased temperature Decreased respiration Increased BP

Diagnostic Test Sonogram, CT scan, MRI Skull x-ray film will reveal the separating sutures and thinning of the skull bones.

Transillumination will reveal skull filled with fluid rather than solid brain substance.

Nursing Goals and Interventions Assess neurologic status closely. Measure and plot occipital-frontal baseline measurement, then measure head

circumference once a day. Check for fontanelle for bulging and sutures for widening. Assist with head ultrasound and Transillumination. Maintain skin integrity: change position frequently. Clean skin creases after feeding or vomiting. Postoperatively, position head off operative site. Watch for signs of infection.

MYELOMENINGOCELE The spinal cord and the meninges protrude through the vertebrae. This result in lower motor neuron damage.

o The child will have flaccidity and lack of sensation of the lower extremities and

loss of bowel and bladder control. Hydrocephalus accompanies Myelomeningocele in as many as 80% of infant due to lack

of subarachnoid membrane.

Diagnostic Test Neural tube defects can be discovered during intrauterine life by sonography, fetoscopy,

amniocentesis, or analysis of AFP in maternal serum. When infants are detected having Myelomeningocele, they may born by cesarean

birth to avoid pressure and injury to the spinal cord.

Nursing Assessment Saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar

area. Myelomeningocele directly connects to subarachnoid space so hydrocephalus often

associated. No response or varying response to sensation below level of sac. May have constant dribbling of urine. Retention of stool.

Nursing Goals and Interventions Prevent trauma and infection. Position on abdomen or on side and restrain. Meticulously clean buttocks and genitals after each voiding and defecation. May put protective covering over sac.

Observe sac for oozing of fluid or pus. Crede bladder (apply downward pressure on bladder with thumbs, moving urine toward

the urethra) as ordered to prevent urinary stasis. Assess amount of sensation and movement below defect. Observe for complications. Obtain occipital-frontal circumference baseline measurement, then measure head

circumference once a day (to detect hydrocephalus). Check fontanelle for bulging.

Common Health Problems of the Child and Adolescent

CEREBRAL PALSY Group of non-progressive disorders of upper motor neuron impairment that result in

motor dysfunction. A child may also have speech or ocular difficulty, seizures, cognitive challenges, or

hyperactivity. Exact cause is unknown, but the disorder is associated with low birth weight, prebirth, or

birth injury. Occurs in approximately 2 in 1000 live births, occurring most frequently in very-low-

birth-weight infants It apparently occurs when brain anoxia leads to cell destruction of the motor tracts.

Types of Cerebral Palsy1. Spastic Type

Spasticity is excessive tone in the voluntary muscles (loss of upper motor neurons)

The child with spastic CP has hypertonic muscle, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as tonic neck reflex.

Spastic movement may affect both extremities on one side (hemiplegia), all four extremities (quadriplegia), or primarily the lower extremities (paraplegia)

2. Dyskinetic or Athetoid Type Involves abnormal involuntary movement. Athetoid means “wormlike”. The child is limp and flaccid. The child makes slow, writhing motions. This may involve all four extremities,

plus the face, neck, and tongue. The child drools and speech is difficult to understand.

3. Ataxic Type Children with ataxic involvement have an awkward, wide-base gait. On neurologic examination, they are unable to perform finger-to-nose test or

perform rapid, repetitive movements (tests of cerebral function).

4. Mixed Type Symptoms of both spasticity and athetoid movements are present together.

Nursing Assessment Diagnosis is based on history and physical assessment. On history, an episode of possible anoxia during prenatal life or at birth is documented. Neurologic exam in infant is difficult. In all forms of CP may have sensory alteration.

REYE’S SYNDROME Is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs,

pancreas, and skeletal muscle. 1 to 18 years of age regardless of gender. The cause is unknown, but it generally occurs after a viral infection such as varicella or

influenza if the child is treated with salicylate. Avoiding the use of aspirin during viral infection has led to almost total prevention of the

syndrome.

Nursing Assessment Children: Lethargic, vomiting, agitation, anorexia, confusion, and combativeness. Laboratory diagnosis of Reye's syndrome is confirmed by:

Elevated Liver Enzyme Levels Elevated Serum Ammonia Normal Direct Bilirubin Delayed Prothrombin Time and Partial Thromboplastin Time Decreased Blood Glucose Elevated BUN Elevated Serum Amylase Elevated Short-chain Fatty Acid Elevated WBC Count

Common Health Problems of the Young Adult

Neuromuscular Disorders Multiple Sclerosis Myasthenia Gravis

MULTIPLE SCLEROSIS Chronic, degenerative disease of the central nervous system that is characterized by

demyelination of the nerve fibers of the brain and spinal cord Gen. characterized by exacerbations and remissions (relapsing-remitting type) Although the cause of MS is unknown, it appears to be related to autoimmune disorder

and viral infections Commonly appears during adulthood (ages 20 to 40) W>M Areas of the CNS most commonly affected brainstem, cerebrum, cerebellum, optic

nerves, and the spinal cord.

Process of Demylination

MS

CausesUnknown

Viral infectionAutoimmune disease

Multiple foci of dmyelination in the white matter(brainstem, spinal cord, optic nerves, cerebrum)

Then later the gray matter.

Destruction of the myelin sheath(SCHWANN’S CELLS)

INTERRUPTION/DISTORTION OF IMPULSE(SLOWED/BLOCKED)

Assessment Sign and symptoms of MS is characterized by remissions and exacerbation of symptoms. Symptoms vary depending on the area of the CNS involved, but generally include:

Visual disturbances (diplopia, partial or total loss of vision, nystagmus) Scanning speech (slow, monotonous, slurred) Tremors Weakness/numbness of the extremities Fatigue Increased susceptibility to URTI Dysphagia Ataxic gait

Diagnostic Test Lumbar Puncture-total CSF protein is normal; IgG (gamma globulin is elevated- IgG

reflects hyperactivity of the immune system due to chronic demyelination) EEG-abnormalities in brain waves CT scan/ MRI reveals multifocal white matter lesion Myelogram Skull x-ray

Nursing Diagnoses Risks: Ineffective breathing pattern; airway clearance Impaired—swallowing, physical mobility, skin integrity; altered nutrition; urinary

incontinence; constipation

Interventions There is no specific treatment for MS.

Treatment includes: Physical therapy- to assist with motor dysfunction, such as problem with

balance, strength, and motor coordination. Speech therapy- to manage dysarthria Drug therapy

a. Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)- to reduce edema of the myelin sheet; sppeds recovery from attack

b. Muscle relaxant (Baclofen)- to treat spasticityc. Amantadine, Ritalin, or antidepressants– to manage fatigued. Low-dose TCAs- to manage sensory symptoms such as pains,

numbness, burning, and tingling sensationsAntihistamines with vision therapy & exercises to minimize vertigo

Nursing Responsibilities/Considerations

Provide regular activity, rest, and relaxation. Assist with physical therapy: muscle stretching, relaxation and coordination exercise,

walking exercise. Encourage well balanced, high fiber diet. Force fluids to prevent constipation. Avoid hot baths. Provide skin care to prevent skin breakdown. Patient and family teaching to promote emotional stability

Help patient establish daily routine, and help family understand patient’s changes in personality and physical capabilities.

Inform the pt that exacerbations are unpredictable, necessitating physical & emotional adjustments in lifestyle

eye patch Speech therapy Medicate and watch for adverse effects

Evaluate Respiration; nutrition; ADLs; skin; bowel elimination; urinary incontinence

MYASTHENIA GRAVIS Progressive neuromuscular disorder that results in the failure to transmit nerve impulses

at the MYONEURAL JUNCTION causing extreme weakness Failure of transmission is due to decreased acetylcholine Women > Men; 3 times more common in w Young adults 20-30 Secretion and increased cholinesterase at the nerve ending Autoimmune disease Characterized by progressive weakness and abnormal fatigability of the skeletal muscles Commonly affects muscles innervated by the cranial nerves (face, lips, tongue, neck, and

throat) Exacerbated by exercise & repetitive movement Occurs along with thymic abnormalities in 75% of pts

Pathophysiology Transmission of nerve impulses at the neuromuscular junction FAILS. Anti-receptor antibodies block, weaken, or reduce the number of acetylcholine Ach

receptors available at each neuromuscular junction, thereby impairing the muscle depolarization necessary for movement

Cause

Autoimmune response leading to ineffective acetylcholine release and inadequate muscle fiber response to Ach.

Complications Aspiration Pneumonia Respiratory distress

Assessment S&S

o Skeletal muscle weakness, fatigue

o Weak eye closure,ptosis, diplopia,

o “snarl smile” (smiles slowly)

o Masklike facial expression; Impaired speech; drooling

o Weakened respiratory muscles

o Muscles are usually strongest in the morning but become progressively weaker

during the day and following an exercise.

Rationale/Pathophysiologic Basis Impaired neuromuscular transmission Impaired neuromuscular transmission to the cranial nerves supplying the eye muscles Impaired transmission of the cranial nerves innervating the facial muscles Impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in

the appropriate junctions

Skeletal muscle weakness

Diagnostic Test Tensilon Test (Edrophonium Chloride Test)

Short acting cholinergic is administered. Reveals increased muscle strength is observed (+ Tensilon Test) within 30-60

secs after IV injection of Edrophonium (Tensilon) or Neostigmine (Prostigmin) lasting up to 30 mins.

Single fiber electromyography with neural stimulation at the specific muscle fiber- progressive decrease in muscle fiber contraction

Chest x-ray- reveals thymoma in 15% of pts

Treatment of Myasthenia Gravis Anticholinesterase drugs, such as neostigmine and pyridostigmine- to counteract fatigue

and muscle weaknes and allow for about 80% of normal muscle Immunosuppresive therapy with corticosteroids, azathioprine (Imuran) – to decrease the

immune response toward Ach receptors at the neuromuscular junction IgG during acute relapses- to suppress the immune system Thymectomy- to remove thymomas Tracheostomy- suctioning to remove secretions

Nursing Goals and Interventions

Establish neurologic and respiratory baselines Assess swallowing / gag reflex before feeding the client. Plan exercise, meals, patient care & activities to make the most of energy peaks.

Ex.,administer medications 20-30 minutes before meal to facilitate chewing or swallowing.

Start meal with cold beverage. Administer medication at precise time to prevent relapses. Protect the client from falls. Provide adequate ventilation. Avoid exposure to infection, stree, strenous exercise, and needless exposure to the sun or

cold. Frequent rest periods. Be prepared to give atropine for anticholinesterase overdose or toxicity Avoid aminoglycoside antibiotics, which can exacerbate myasthenia gravis Aerosol, pesticides/cleaners should also be avoided, Avoid alcohol, tonic water, and cigarette smoke. Pharmacotherapy

Cholinergics (Anticholinesterase) Neostigmine (Postigmin) Pyridostigmin (Mestinon) Ambenomium (Mytelase)

Glucocorticoids Antacids

Common Health Problem of the Middle-aged Adult

Cranial Nerve Disorder: TRIGEMINAL NEURALGIA (TIC DOULOUREUX) Neurologic disorder affecting the 5th cranial nerve. Possible fifth cranial nerve root

compression Manifested by excruciating, recurrent paroxysms of sharp, stabbing facial pain along the

trigeminal nerve.

Areas innervated by the three branches of the trigeminal nerve

Management Narcotic analgesics; anticonvulsants

o Tegretol

o Dilantin

Alcohol injection of the nerve Avoid extremes of heat and cold. Correction of dental malocclusion Surgical Management

o Surgical division of the trigeminal nerve (neurectomy)

Nursing Management Assessment

o Complete history

o Affected area; oral cavity

o Record weight and ability to eat food

Diagnosis, Planning, and Interventions o Acute pain

Evaluate:o Pain; client cooperation

Cranial Nerve Disorder: BELL’S PALSY Disease of the cranial nerve VII (facial nerve that produces unilateral or bilateral facial

weakness or paralysis Resolves spontaneously in 80% of pts with complete recovery in 18 weeks Recover may be delayed in the elderly

If recovery is partial, contractures may developed on the paralyzed side of the face

Causes Hemorrhage Herpes simplex or herpes zoster Infection Local trauma Meningitis Tumor Viral disease

Pathophysiology An inflammatory reaction occurs around cranial nerve VII, usually at the internal

auditory meatus, where the nerves leave bony tissue The inflammatory reaction produces a conduction block that inhibits appropriate neural

stimulation to the muscle by the motor fibers of the facial nerve, resulting in the characteristic unilateral or bilateral facial weakness.

Pathophysiologic Changes/S & S Unilateral facial weakness Drooping mouth & drooling saliva Lose of taste Smooth forehead appearance Impaired ability to close the eye on the weak side Bell’s phenomenon-Upward rolling of the eyes when attempting to close them Excessive tearing Ringing in the ear

Complications of Bell’s Palsyo Corneal abrasion

o Infection (masked by steroid use)

o Poor functional recovery

Diagnostic Tests based on clinical presentation MRI-rules out tumor Electromyography- 10 days after the onset of S/S

Treatment Analgesics- to relieve pain

Steroids- to reduce facial nerve edema & improve edema & improve nerve conduction & blood flow

Possible electrotherapy Surgery for persistent paralysis

Nursing Considerations Watch for adverse effects of steroids use Apply moist heat to the affected side of the face-to reduce pain Help the pt maintain muscle tone:

o massaging the face with a gentle upward motion 2-3xdaily x 5-10mins

o exercise by grimacing in front of a mirror

Protect eyes, have pt cover eye w/ an eye patch Prevent excessive wt loss:

o have him chew on unaffected side of his mouth

o provide a soft, nutritionally balanced diet, eliminating hot foods & fluids

o apply a facial sling to improve lip alignment

Provide frequent & complete mouth care Offer psychological support

Common Health Problems of the Older Adult

CEREBRO-VASCULAR DISORDER : Stroke/Cerebrovascular Accident (CVA) Disruption of the Blood Supply to the Brain. Sudden loss of neurologic function Note: Middle Cerebral Artery is commonly affected.

The second most frequently affected is the internal carotid artery.

Classification1. ischemic (a thrombus or embolus blocks circulation)2. hemorrhagic (a blood vessel ruptures)

Risk factors Increased alcohol intake or cocaine Cardiac disease Cigarrette smoking DM Familial hyperlipidemia Family history of stroke Hx of TIA HPN Obesity,sedentary lifestyle

Sickle cell disease Use of hormonal contraceptive

Causes of StrokeIschemic

Thrombosis- occluded blood flow caused by thrombosis of the cerebral arteries supplying the brain or the intracranial vessels

o The most frequent cause of CVAo The most common cause of cerebral thrombosis is atherosclerosis; usually

affecting elderly persons.o Tends to occur during sleep or soon after arising.o This may tend to occur among clients with DM, and hypertension.

Embolism- from thrombus outside the brain, such as in the heart, aorta, or common carotid artery.

o The second most common cause of CVA.o Most commonly affecting younger people.o Most frequently caused by Rheumatic Heart Disease and MI.o Symptoms occur at any time and progress rapidly.

Hemorrhagic Stroke – Hemorrhage Impaired cerebral perfusion from hemorrhage causes infarction, & the blood itself as a

space-occupying mass, exerting pressure on the brain tissues Hemorrhage from an intracranial artery or vein, such as HPN, ruptured aneurysm,

trauma, hemorrhagic disorder, or septic embolism

Transient Ischemic Attacks Refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction. Manifestation includes contralateral weakness of the lower portion of the face, fingers,

hands, arms, and legs; dysphagia, and sensory impairment. Stoke in evolution refers to development of a neurologic deficit over several hours to

days

Pathophysiologic Changes in CVA: specific manifestations are determined by the cerebral artery affected, the brain tissue supply by that vessel, and the adequacy of the collateral circulation

Aphasia, dysphasia; visual fields deficits; and hemiparesis of affected side (more severe in face & arms)- resulting from thrombosis or hemorrhage of middle cerebral artery

Weakness, paralysis, numbness; sensory changes; altered LOC; bruits over carotid artery; and headache caused by thrombosis or hemorrhage of carotid artery

Weakness, paralysis, numbness around lips & mouth; visual field deficits, diplopia, nystagmus; poor coordination, dizziness, dysphagia, slurred speech; amnesia, and ataxia resulting from thrombosis or hemorrhage of vertebrobasilar artery.

Confusion, weakness, numbness; urinary incontenece; impaired motor & sensory functions; and personality changes caused by thrombosis or hemorrhage of anterior cerebral artery.

Visual field deficits; sensory impairments; dyslexia; cortical blindness and coma resulting from thrombosis or hemorrhage of posterior cerebral artery.

Assessment of CVA check for:

S&S of increased ICP. Perceptual defects Aphasia Unstable respiration Severe headache Diagnostic procedure results Unilateral neglect

Diagnostic Findings CT scan- identifies an ischemic stroke within the first 72 hours of symptom onset or

evidence of a hemorrhagic stroke (lesions >1 cm immediately) MRI-assists in identifying areas of ischemia or infarction and cerebral swelling Others: angiography, carotid duplex scan, EEG

Complications Hemiplegia – weakness/paralysis of half the body Cognitive impairment - Aphasia – maybe expressive or receptive; the partial or total

inability to produce & understand speech Apraxia – can move but cannot do the purpose; inability to perform complex movements Sensory impairement - Visual changes – Homonymous Hemianopsia; Agnosia – loss of

sense of smell Dysarthria - difficulty in speech articulation due to lack of muscle control Kinesthesia – loss of sensation (of bodily movement) Incontinence – maybe fecal/urine; inability to control urination or defecation

Shoulder pain Contractures Fluid imbalances Cerebral edema Aspiration Altered LOC Infections such as pneumonia

Nursing Considerations Maintain a patent airway and oxygenation:

o If the pt is unconscious; vomiting- lateral position to prevent aspiration of saliva Check v/s & neurologic status:

o Monitor BP, LOC, pupillary changes, motor and sensory functions, speech, skin, color, temp.

o Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity Watch for s/s of pulmonary emboli:

o Chest pain, shortness of breath, dusky color, tachycardia, fever, and change in sensorium

If the pt is unresponsive, monitor ABG as ordered Monitor F & E balance:

o Monitor I and O.o Administer IVF as orderedo Offer bedpan /urinal

Ensure adequate nutrition: o Check for gag reflex before offering small oral feedings of semisolid foodo Teach the client to chew on the unaffected side. o If oral feeding is not possible, TPN, NGT feeding, gastrostomy feeding

Turn the patient frequently, at least q 2 hrs to prevent pneumonia. Perform ROM exercises for affected & unaffected sides. Massage if not contraindicated. Provide meticulous eye care- Instill meds as ordered; patch the affected eye if the pt can’t

close eyelid. Compensate for perceptual difficulties.

o Care of the client with Hemianopsia.o Approach from the unaffected side.o Place articles on the unaffected side.

Promote communicationo Care for the client with aphasia.o Say one word at time.o Give simple commands.o Allow the client to verbalize, no matter how long it takes him

Give medications as ordered- Tell the pt to watch out for side effects. (ex. Aspirin-GI bleeding)

Assist with rehab Teach the pt to comb hair, to dress, & to wash Obtain assistive devices ( through the aid of PT/OT) such as walkers, hand bars by the

toilet, and ramps as needed Be aware that the pt has a unilateral neglect, in which he fails to recognize that he ha a

paralyzed side- show him how to protect his body from harm Emphasize importance of regular ff-up visits

PARKINSON’S DISEASE Slowly progressive degenerative disorder of basal ganglia function that results in variable

combinations of tremor, rigidity, and bradykinesia Onset usually after age 40 men>women

Parkinson’s Disease: deficient in dopamine

Causes Exact cause unknown Possible causes:

o Dopamine deficiency, which prevents affected brain cells from performing their nomal inhibitory function in the CNS

o Exposure to toxins( manganese dust or carbon monoxide)

o Repeated trauma to the braino Strokeo Brain tumors

Pathophysiology Dopamine neurons degenerate, causing loss of available dopamine Dopamine deficiency prevents affected brain cells from performing their normal

inhibitory function Excess excitatory Ach occurs at the synapses Nondopamineric receptors are also involve Motor neurons are depressed

Pathophysiologic changes/ S&S Muscle rigidity, akinesia, and insidious tremor beginning in the fingers (UNILATERAL

PILL_ROLL TREMOR) secondary to loss of inhibitory dopamine activity at the synapse- increase during stress or anxiety; decreases with purposeful movement & sleep

Muscle rigidity with resistance to passive Mask-like appearance Gait disturbance-lacks normal parallel motion; may be retropulsive or propulsive Oily skin- secondary to inappropriate regulation of androgen production by hypothalmic-

pituitary axis Dysphagia, dysarthria; excessive sweating; decreased GI motility and genitourinary

smooth muscle-from impaired autonomic transmission Voice changes Small handwriting Poor judgment, endogenous depression, dementia- from impaired dopamine metabolism,

and neurotransmitter dysfunction

Common Health Problem that occur Across the Life Span

SEIZURE DISORDER Sudden explosive and disorderly discharge of cerebral neurons Abnormal and excessive discharge of neurons in the brain Types of seizures:

a. grand malb. petit malc. febrile seizuresd. status epilepticus

Petit mal No aura 10-20 seconds Common to children as well as adult

Little tonic-clonic movements Cessation of ongoing physical activities

Jacksonian With aura With organic lesion Group of muscle affectation

Psychomotor Seizure With aura With psychiatric involvement Characterized with mental clouding Violence, antisocial acts

Febrile Seizure Related to temperature Present among children

Status epilepticus Prolonged seizure state Can occur in any type of seizure Rapid successions with no full consciousness in between Brain damage can occur; most life threatening in tonic-clonic seizures Common to clients who are in coma Related to medication

a) Primary Seizure Disorder (Epilepsy)o Idiopathic

o No apparent structural changes in the brain

b) Secondary Epilepsyo Characterized by structural changes or metabolic alterations of the

neuronal membranes that caused increased automacity

Causes of Seizures Idiopathic- two-thirds of all seizure disorders Anoxia Birth trauma (inadequate supply of O2 supply to the brain, blood incompatibility,

hemorrhage) Brain tumors Drug or alcohol abuse or rapid withdrawal from abused drugs Febrile illness

Genetic predisposition Head injury or trauma Infectious diseases Ingestions of toxins( lead, mercury, or carbon monoxide) Metabolic disorders, such as hypoglycemia or hyperparathyroidism Perinatal infections

Pathophysiology Some neurons of the brain may depolarize easily or hyperexcitable On stimulation, these neurons fires locally or throughout the cerebrum and spreads

electric current to surrounding cells. Cells fire in turn and the impulses cascades to one side of the brain (a partial seizure),

both sides of the brain (a generalized seizure), or the cortical, subcortical, and brain stem areas.

Pathophysiologic changes Recurring seizures, possibly of more than one type ( hallmark of epilepsy) Visual, olfactory, or auditory hallucinations; sweating or flushing; dream states; anger, or

fear reactions resulting from simple partial seizures Altered consciousness , such as amnesia for events around the time of the seizure,

resulting from complex partial seizures Movement and muscle involvement resulting from tonic-clonic or myoclonic seizures Brief changes in LOC without motor involvement due to absence seizures

Complications Hypoxia or anoxia from airway occlusion Traumatic injury Brain damage Depression and anxiety

Diagnostic Tests CT scan or MRI- reveals abnormalities EEG- reveals paroxysmal abnormalities

in tonic-clonic seizures, high, fast voltage spikes are present in all leads In absence seizures, rounded spike wave complexes are present Note: a negative EEG doesn’t rule out epilepsy because the abnormalities occur

intermittently Skull x-ray may show evidence of fractures or shifting of the pineal gland, bony erosion,

or separated sutures Serum chemistry blood studies may reveal hypoglycemia, electrolyte imbalances, and

elevated liver enzyme & alcohol level

Treatment Drug Therapy-

Ex. Phenytoin (Dilantin) carbamazepine (Tegretol), phenobarbital (Barbita, Luminal) –for generalized tonic clonic seizures and complex partial seizures

Valproic acid (Depakene), clonazepam (Klonopin) for absence seizures If drug therapy is ineffective, surgery to remove a demonstrated focal lesion, or to

remove the underlying cause (tumor, abscess) I.V. diazepam ( valium), lorazepam (Ativan) phenytooin, or phenobarbital for status

epilepticus Dextrose- for hypoglycemia Thiamine-for chronic alcoholism or withdrawal

Nursing Considerations Patent airway Oxygenate as needed Raise side rails Ensure safety-during seizure:

Avoid restraining the pt Help the pt to a lying position Loosen any tight clothing Clear the area of hard objects Don’t place anything into the pt’s mouth to prevent lacerating the mouth & lips or

displace teeth If vomiting occurs, turn the head to provide an open airway

After the seizure subsides, reorient the patient to time & place; inform him that he had a seizure

Companion at bedside Meds as ordered

INCREASED INTRACRANIAL PRESSURE ICP- the pressure exerted within the intact skull by the intracranial volume - about 10%

blood,10% CSF, & 80% brain tissue Causes

head injury CVA tumors HPN

Pathophysiology ICP- the brain will compensate by:

o limiting bld flow to the head

o displaces CSF into the spinal canal

o increases absorption or decreases production

If ICP remains high, there will be loss of autoregulatory mechanism which will lead to passive dilation, increased cerebral flow, and venous congestion. Further increase in ICP will result to cellular hypoxia and eventually, brain death.

Major Types of Herniation

S&S Increased HA Nausea &Vomiting Cushing’s triad Restlessness Eye involvement Altered LOC Sensory dysfunction Elimination problem Decorticate/decerebrate

Nursing Management Determine airway patency Elevate HOB Check VS/Neuro assessment Record I&O Enema restriction Avoid coughing, vomiting, restraints, stress ulcer, suctioning Seizure precaution Edema reduction Diuretics

CRANIOCEREBRAL TRAUMA (HEAD INJURY)

Involves injury to the scalp, skull, and/or brain tissues. Types of Brain Injury

Concussions. Jarring of the brain and its sudden, forceful contact with the rigid skull. There is transient period of unconsciousness.

Contusion (bruising). A structural alteration characterized by extravasion of blood cells.

Laceration . Tearing of tissue caused by sharp fragment or object or shearing force.

Compression of the Brain . Result from depressed fracture causing edema and hemorrhage.

Assessment

Sign and symptoms of increased ICP. CSF leakage from ears and nose. Battle’s sign (hematoma at the mastoid process) in basilar head trauma.

Management Care for the client with increased ICP. Monitor drainage from ears and nose. Monitor for signs and symptoms of meningitis, atelectasis, pneumonia, UTI.

INTRACRANIAL TUMORS Intracranial tumors may be classified as: gliomas, meningiomas, neuromas,

hemangiomas. Gliomas account for about 50% of all brain tumors.

Assessment Frontal lobe

o Personality disturbance

o Inappropriate affect

o Indifference of bodily functions

Precental gyrus o Jacksonian seizures

Occipital lobeo Visual disturbances preceeding convulsions.

Temporal lobeo Olfactory, visual or gustatory hallucinations.

o Psychomotor seizures with automatic behavior.

Parietal lobeo Inability to replicate pictures.

o Loss of right-left discrimination

Management Care for the client with increase ICP. Surgery

o Supratentorial craniotomy (post-op)

Semi-fowler’s positiono Infratentorial craniotomy

Flat position; turn to sides, avoid supine position for the first 48 hours. Avoid neck flexion.

Report immediately for presence of yellowish drainage on the head dressing.

An increase in urine output may herald onset of diabetes insipidus. Test the urine for glucose and acetone when steroids are administered.

SPINAL CORD INJURY complete or partial disruption of nerve tracts and neurons Causes

infection trauma injury

Signs and symptoms Cervical –respiratory diff, quadriplegia Thoracic- paraplegia Lumbar – flaccid paralysis Sacral – loss of erection, ejaculation

Nursing Assessment Injury; treatment given at scene Neurologic assessment: Document findings Vital signs; respiratory status Movement and sensation below injury level Signs

o Worsening neurologic damage

o Respiratory distress

o Spinal shock

Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Neuropathic pain Impaired physical mobility Anxiety Risks

o Impaired gas exchange

o Disuse syndrome

o Ineffective coping

Medical Management

Cervical collar; cast or brace; traction; turning frame IV; stabilization of vital signs Corticosteroids Surgical intervention

Surgical Management Surgery to

o Remove bone fragments

o Repair dislocated vertebrae

o Stabilize the spine

Management Maintain airway patency Immobilize Suction PRN Position Nutrition Elimination hygiene Drugs

Evaluation Adequate breathing Pain relief Mobility using minimal assistive devices Reduced complications from inactivity Coping with the challenge of rehabilitation

INFECTIOUS NEUROLOGIC DISORDERS Meningitis Brain Abscess Herpes Simplex Virus Encephalitis Arthropod-Borne Virus Encephalitis Fungal Encephalitis Creutzfeldt-Jakob and New-Variant Creutzfeldt-Jakob Disease

BRAIN INJURIES Closed (blunt) Brain Injury

Open Brain Injury Concussion Contusion Diffuse Axonal Injury Intracranial Hemorrhage

Epidural Hematoma Subdural Hematoma Intracerebral Hemorrhage and Hematoma

Pathophysiology