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NERVOUS SYSTEM
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Outline of Our ReviewBrief review of Anatomy and PhysiologyApplication of the Nursing process in theapproach of neurologic problems:
ASSESSMENT relevant techniques and labproceduresDIAGNOSISPLANNINGIMPLEMENTATIONEVALUATION
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Outline of the review
Trauma and related accidents
Traumatic brain injurySpinal cord injury
Cerebrovascular Accidents
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Outline of the reviewDegenerative disorders-demyelinating
Multiple sclerosisGuillain-Barre syndrome
Degenerative disorders-NON- demyelinating
Alzheimers diseaseParkinsons disease
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Outline of the reviewMotor dysfunction- CNS
Epilepsy
Motor dysfunction- cranial nerveBells palsyTrigeminal neuralgia
Motor dysfunction- peripheralMyasthenia gravis
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Outline of the reviewInfectious Disease
Meningitis
Brain abscessEncephalitis
Neoplastic disease
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F UNCTIONS O F THE NERVOUS
SYSTEMSensory InputIntegration
HomeostasisMental ActivityControl of muscles and glands
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Nervous system
PNS CNS
BRAINSPINAL CORDEFFERENT AFFERENT
somatic
autonomic
somatic
visceral
sympa parasympa
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Divisions of the Nervous
SystemCentral Nervous System consists of thebrain and spinal cordPeripheral Nervous System consists of nerves and ganglia
Two Subdivisions of PNS:1. Sensory Divisions conducts action
potentials from sensory receptors to the
CNS2. Motor Division conducts action potentials
from the CNS to effector organs
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Motor DivisionSomatic Motor Nervous System transmit action potentials from the
CNS to skeletal musclesAutonomic Nervous System (ANS) transmits action potentials from theCNS to cardiac muscle, smoothmuscle and glands; subdivided intosympathetic, parasympathetic andenteric portions
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G roomp!G roomp!
Psst!
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0
Hmmm?
stimulus
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Cells of the Nervous System
Neurons or nerve cells receive stimuli and transmitaction potentials to other neurons or to effectororgansParts of Neuron:
1. Cell body contains a single nucleus which is thesource of information for protein synthesis; containsextensive rough ER (Nissl bodies), Golgi apparatus,mitochondria, neurofilaments and microtubules
2. Dendrites short, often highly branching cytoplasmicextensions that are tapered from their bases at the
neuron cell body to their tips; function to receiveinformation from other neurons or sensory receptorsand transmit the information toward the neuron cellbody
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Parts of Neuron
Axon a long cell process extendingfrom the neuron cell body; axon of motor neurons conduct actionpotentials away from the CNS andaxon of sensory neurons conductaction potentials toward the CNS;could also conduct action potentialsfrom one part of the brain or spinalcord to another part; surrounded bySchwann cells
Axon
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U NIPOLAR
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Bipolar
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Multipolar
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NeurogliaAlso known as glial cellsAre nonneuronal cells of the CNS and PNSRetain the ability to divideF ive types of Neuroglia:
1. Astrocytes star-shaped; providestructural support; form a layer aroundblood vessels, contribute to blood-brain
barrier2. Ependymal cells squamous epithelial-
like; line ventricles of brain, circulatecerebrospinal fluid (CS F ); some formchoroid plexus which produce CS F
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Types of Neuroglia3. Microglia small mobile cells; protect CNS from
infection; become phagocytic in response toinflammation
4. Oligodendrocytes cells with processes that can
surround several axons; cell processes form myelinsheaths around axons, or enclose unmyelinatedaxons, I the CNS
5. Schwann cells or Neurolemmocytes/neurolemmacells; single cells surrounding axons; form myelinsheaths around axons, or enclose unmyelinated axonsin the PNS
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Myelin SheathsUnmyelinated axons rest in indentationsof the oligodendrocytes in the CNS and theSchwann cells in PNS
Myelinated axons have specializedsheaths, called myelin sheaths wrappedaround themMyelin is an excellent insulator, whichprevents almost all electrical current flowthrough the cell membraneNodes of Ranvier gaps in myelin sheath;current flows easily between theextracellular fluid and the axon, and actionpotentials can develop
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Organization of Nervous TissueGray matter groups of neuron cell bodies and theirdendrites where there is very little myelinCortex gray matter on the surface of the brainNuclei clusters of gray matter located deeper within
the brainGanglion cluster of neuron cell bodies in the PNSWhite matter whitish, bundle of parallel axons withtheir myelin sheathsPathways or Nerve tracts white matter of the CNSwhich propagate action potentials from one area inthe CNS to anotherNerves bundles of axons and their connective tissue
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Resting Membrane PotentialCharge difference across the membrane of anunstimulated cell or polarized cellResults from differences in the concentration of ionsacross the cell membrane and the permeabilitycharacteristics of the cell membraneHigher concentration of sodium ions immediatelyoutside the cell membrane than inside and a higherconcentration of potassium ions immediately insidethe cell membrane than outsideConcentration of ions are maintained by sodium-potassium exchange pumpPoint of equilibrium is when potassium stops movingout of the cell
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Na
Na
Na
Charged
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Action PotentialsConsists of depolarization and repolarizationLocal current movement of sodium into a cellDepolarization sodium influx cause the inside of thecell membrane to become more positive; results to
local potentialThreshold valueAll-or-none if threshold is reached, the chargereversal is completeSaltatory conduction flow of action potential in a
jumping manner
Medium-diameter, lightly myelinated axons conductaction potentials at the rate of about 3-15 m/swhereas large-diameter, heavily myelinated axonsconduct action potentials at the rate of 15-120 m/s
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How does it happen
At rest, the inside of the neuron isslightly negative due to a higherconcentration of positively chargedsodium ions outside the neuron.
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When stimulated past threshold, sodiumchannels open and sodium rushes intothe axon, causing a region of positivecharge within the axon.
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nearby sodium channels to open. Justafter the sodium channels close, the
potassium channels open wide, andpotassium exits the axon.
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This process continues as a chain-reaction along the axon. The influx of sodium depolarizes the axon, and theourflow of potassium repolarizes the axon
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The SynapseSynapse a junction where the axonof one neuron interacts with anotherneuron or an effector organPresynaptic terminalPostsynaptic membraneSynaptic cleft
Synaptic vesicleNeurotransmitters
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acetylcholine Acetylcholinesterase
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choline acetate
acethylcholine
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F ive Basic Components of aReflex Arc
Sensory ReceptorSensory Neuron
InterneuronsMotor NeuronEffector Organ
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Central Nervous SystemSPINAL CORD extends from the foramenmagnum at the base of the skull to thesecond lumbar vertebraCross section reveals a peripheral whitematter portion and a central gray matterportionThree columns of white matter dorsal,ventral and lateralAscending tracts consists of axons thatconduct action potentials toward the brainDescending tracts consists of axons thatconduct action potential away from thebrain
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Gray matter
Shaped like letter HPosterior, Anterior and lateral horns
Central canal a fluid-filled space inthe center of the cord
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Spinal Nerves
Ventral root formed by combinationof ventral rootlets arising from theventral side of the spinal cordDorsal root formed by combinationof dorsal rootlets on the dorsal side of the cord; contains dorsal root
ganglionDorsal root ganglion - contains thecell bodies of unipolar sensoryneurons
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Spinal Cord ReflexesStretch reflex a reflex in which musclescontract in response to a stretching forceapplied to themKnee-jerk reflex used to determine if thehigher CNS centers that normally influencethis reflex are functionalDescending neurons within the spinal cordsynapse with the neurons of the stretchreflex and modulate their activity; activityis important in maintaining posture and incoordinating muscular activity
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Withdrawal Reflex
Withdrawal or F lexor reflex thefunction is to remove a limb or otherbody part from a painful stimulusPain receptors stimulated actionpotential conducted through thedorsal root to the spinal cord
synapse with interneuron synapsewith motor neurons flexing of muscle
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Spinal NervesArise along the spinal cord from the unionof the dorsal roots and the dorsal roots;mixed nervesCategorized by the region of the vertebralcolumn from which they emerge cervical(C), thoracic (T), lumbar (L), sacral (S),and coccygeal (Cx)31 pairs of spinal nerves C1-C8, T1-T12,L1-L5, S1-S5 and CoThree plexuses: Cervical plexus, Brachialplexus and the lumbosacral plexus
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1. Brainstem
- connects the spinal cord to theremainder of the brain
Consists of the medulla oblongata,pons and midbrain and containsseveral nuclei
Majority of the cranial nerves arisein brainstem except CN 1 and 2
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a. Medulla OblongataMost inferior portion of the brainstem and iscontinuous with spinal cordContains ascending and descending tracts with somenuclei with specific functions such as regulation of
heart rate and blood vessel diameter, breathing,swallowing, vomiting, coughing, sneezing, balanceand coordinationPyramids prominent enlargements consisting of descending tracts, which transmit action potentialsfrom the brain to motor neurons of the spinal cordand are involved in the conscious control of skeletalmuscles
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b. Pons
Means bridge; located superior to themedulla oblongata
Contains ascending and descendingnerve tracts and several nucleiNuclei are responsible for breathing,swallowing, balance, chewing andsalivation
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2. Cerebellum
Means little brainAttached to the brainstem bycerebellar pedunclesConnections provide routes of communication between thecerebellum and other parts of theCNS
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3. Diencephalon
The part of the brain between thebrainstem and the cerebrumMain components are the thalamus,epithalamus and hypothalamus
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a. Thalamus
The largest part of the diencephalonConsists of a cluster of nuclei withtwo large lateral parts connected inthe center by a small interthalamicadhesionsInfluences mood and registers an
unlocalized, uncomfortable perceptionof pain
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b. EpithalamusA small area superior and posterior to thethalamusConsists of a few small nuclei that are
involved in the emotional and visceralresponse to odors and the pineal bodyPineal body an endocrine gland that mayinfluence the onset of puberty; play a rolein controlling some long-term cycles thatare influenced by the light-dark cycleKnown to influence annual behaviors suchas migration in birds as well as changes infur color and density in some mammals
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c. HypothalamusMost inferior part of the diencephalon and containsseveral small nuclei which are very important inhomeostasisPlay a central role in the control of body temperature,
hunger and thirst; also sexual pleasure, feelingrelaxed and good after meal, rage and fear; plays amajor role in controlling the secretion of hormonesfrom the pituitary glandContains the infundibulum and mamillary bodyMamillary body is involved in emotional responses toodors and in memory
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4. CerebrumThe largest part of the brainDivided into right and left hemispheres by alongitudinal fissureContains gyri which greatly increase the surface areaof the cortex and intervening grooves called sulciCerebral hemispheres are divided into lobes namedfor the skull bones overlying themF rontal lobe control of voluntary motor functions,motivation, aggression, mood and olfactoryperceptionParietal lobe principal center for the reception andconscious perception of most sensory informationsuch as touch, pain, temperature, balance and tasteCentral sulcus separates frontal and parietal lobes
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CerebrumOccipital lobe functions in the receptionand perception of visual input and is notdistinctly separate from the other lobesTemporal lobe involved in olfactory andauditory sensations and plays an importantrole in memoryPsychic cortex consists of the anterior andinferior portions of temporal lobe which isinvolved in abstract thought and judgmentLateral fissure separates temporal lobefrom cerebrum
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Brain circulation: The circle of
Willis
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The spinal cord
A long cylindrical structure
extending from the foramenmagnum to the L1 in adult,L3/L4 in pedia
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The spinal cord
Each spinal nerve is formed by thedorsal root (sensory) and the
ventral root (motor)Cervical segments= 8 pairsThoracic segments=12 pairs
Lumbar= 5 pairsSacral=5 pairsCoccygeal=1 pair
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The Meninges
1. DURA MATER- the superficial,thickest layer. The area above thedura mater is called epidural space2. ARACHNOID- second layer, thinand wispy.3. PIA MATER- the deepest layer,adhered to the brain and spinal cordsubstance
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The CS F
This is the fluid found inside theventricles that bathe the brain and
spinal cordF unction: provides protective cushionaround the CNS
Produced by the choroid plexus in theventriclesAbsorbed by the arachnoid
granulations
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ASSESSMENT OF THE
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ASSESSMENT OF THENEUROLOGIC SYSTEM
HISTORYA co nfused cl ient b e co mes an unre lia bl e s o ur c e o f h ist o ry
ASSESSMENT OF THE
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ASSESSMENT OF THENEUROLOGIC SYSTEM
N eur o-PHYSICAL EXAMINATION5 categories:
1. C ere b ra l fun c ti o n - LOC, menta lstatus
2 . C rania l nerves
3 . Mo t o r fun c ti o n4 . S ens o ry fun c ti o n5 . R ef lexes
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CERE BRAL FUNCTION
Assess t h e degree o f w akefu lness/a lertness
No te t h e intensity o f stimu lus t oc ause a resp o nseApp ly a painfu l stimu lus o ver t h e nai l-b eds w it h a bl unt instrumentA sk questions to assess orientation to
person, place and time
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Gl asg ow Co ma Sc a le
Gl a sgow Com a Score
Ey e Opening ( E)Verb a l Response ( V)
Motor Response ( M)
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Gl asg ow Co ma Sc a le
Gl a sgow Com a Score
7 a nd Be low= CO MA!
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Gl asg ow Co ma Sc a le
Gl a sgow Com a Score
Eye Opening (E)4 =Spont a neous3 =To voice (when to ld to )
2 =To p a in1 =None (No response)
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Gl asg ow Co ma Sc a leGl a sgow Com a ScoreV erbal Response ( V )
5=Norm a
l/ORIENTED4 =Disoriented /CONFUSED
3 =Words, but incoherent/ INAPPROPRIATE 2 =INCOMPREHENSIBLE /mumb led words
1 =None
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Gl asg ow Co ma Sc a le
Gl a sgow Com a ScoreMotor Response ( M)
6 =Norm a l- obe ys comm a nd5 =Loc a lizes p a in4 =Withdr a ws to p a in (Flexion)
3 =Decortic a te posture2 =Decerebr a te posture1 =None (f la ccid )
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Level of consciousness
Awake/alertDrowsy sleepy, wake ups and staysawake for longLethargic/Stuporous sleepy, wakesup and goes back to sleepComatose
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Crania l N erve 1- Ol fa c t o ry
Ch e c k first f o r t h e paten c y o f t h e n o se
I nstru c t t o clo se t h e eyesOccl ude o ne n o stri ls at a timeHol d fami liar su b stan c e and asks f o r
t h e identifi c ati o nR epeat w it h t h e o t h er n o stri lsPRO BLEM- ANO SMI A- lo ss o f sme ll
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Crania l N erve 2 - O pti c
Ch e c k t h e visua l a c uity w it h t h e use o f t h e Snellen chart
Ch e c k f o r visua l fie ld b y co nfr o ntati o n testCh e c k f o r pupi ll ary ref lex - dire c t and co nsensua lFund o s co py t o ch e c k f o r papi ll edema
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S ne ll en ch art
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Crania l N erve 7 - fa c ia l
S ens o ry p o rti o n - prepare sa lt , sugar ,vinegar and q uinine . Pl a c e ea ch
su b stan c e in t h e anteri o r t wo t h irds o f t h e t o ngue , rinsing t h e m o ut hw it h w aterMo t o r p o rti o n - ask t h e cl ient t omake fa c ia l expressi o ns , ask t of o r c efu ll y clo se t h e eye lids
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N erve 8- vesti b u lo- audit o ry
Test patients hearing a c uityOb serve f o r nystagmus and distur b ed b a lan c e
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N erve 9- g lo ss o p h aryngea l
T ogether with Cranial nerve 10 vagus
Assess f o r gag ref lexWat ch t h e s o ft pa late rising after instru c ting t h e cl ient t o say AH
Th e p o steri o r o ne - t h ird o f t h e t o ngue is supp lied b y t h e g lo ss o-p h aryngea l nerve
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Crania l N erve 11- a cc ess o ry
P ress d ow n t h e patients s ho u lder wh ile h e attempts t o s h rug against resistan c e
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ASSESS Mo t o r fun c ti o n
Assess mus cl e t o ne and strengt hb y asking patient t o f lex o r extend t h e extremities wh ile t h e examiner p la c es resistan c eGrading o f mus cl e strengt h
Assessing t h e m o t o r
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fun c ti o n o f t h e c ere b e ll um
Test f o r b a lan c e - h ee l t o t o eTest f o r coo rdinati o n - rapid a lternating m o vements and finger t o n o se test
R O MBERGs is actually a test for
the posterior spinothalamic tract
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Assessing t h e m o t o r
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fun c ti o n o f t h e b rainstem
Test f o r t h e Oc u loc ep h a lic ref lex -d oll s eye
No rma l resp o nse - eyes appear t om o ve o pp o site t o t h e m o vement o f t h e h eadAb n o rma l- eyes m o ve in t h e same dire c ti o n
Assessing t h e m o t o r
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fun c ti o n o f t h e b rainstem
Test f o r t h e Oc u lo vesti b u lar ref lex
Slowl y irrigate t h e ear w it h col d w ater and w arm w ater
No rma l resp o nse - cOl d - O pp O site ,wA r M- s AM e
Assessing t h e sens o ry
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fun c ti o n
Eva luate symmetri c areas o f t h e bo dyAsk t h e patient t o clo se t h e eyes wh ile testing
U se o f test tu b es w it h col d and w arm w aterU se bl unt and s h arp obj e c tsU se w isp o f co tt o nAsk t o identify obj e c ts p la c ed o n t h e h andsTest f o r sense o f p o siti o n
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Assessing t h e ref lexes
Deep tend o n ref lexesBi c eps
Tri c epsBra ch io radia lisP ate ll arAssessing t h e sens o ry fun c ti o n Ach ill es
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Assessing t h e ref lexes
S uperfi c ia l ref lexesAb d o mina lAna lCremasteri c
P at holo gi c ref lexBa b inski - str o ke t h e latera l aspe c t o f t h e s ol es d o ing an inverted J
(+)- D ORSIFLEXION o f t h e Big t o e w it hfanning o ut o f t h e litt le t o es
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G rading o f ref lexesDeep tend o n ref lex
0 - a b sent+ present b ut diminis h ed++ n o rma l+++ in c reased++++ h ypera c tive o r clo ni c
S uperfi c ia l ref lex0 a b sent+ present
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Wala Lang Relax lang
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D IAGNOSTIC TESTS
EEGWit hhol d medi c ati o ns t h at may interfere w it h t h e resu lts -
anti co nvu lsants , sedatives and stimu lantsWas h h air t ho r o ug hl y b ef o re pr oc edure
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F ig . 8. 33
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D IAGNOSTIC TESTS
CT s c anWit h radiati o n riskI f co ntrast medium w ill b e used -ensure co nsent , assess f o r a ll ergies t o dyes and io dine o r seaf oo d , f lus h ing and meta ll ic
taste are expe c ted as t h e dye is in j e c ted
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D IAGNOSTIC TESTS
MRIUses magneti c w avesP atients w it h pa c emakers ,o rt ho pedi c meta l pr o st h esis and imp lanted meta l devi c es c ann o t underg o t h is pr oc edure
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D IAGNOSTIC TESTS
Cere b ra l arteri o grap h yNo te a ll ergies t o dyes , io dine and seaf oo dEnsure co nsentKeep patient at rest after pr oc edure
Maintain pressure dressing o r sand b ag o ver pun c tured site
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D IAGNOSTIC TESTS
Lum b ar pun c tureEnsure co nsent , determine a b ility t o
lie sti llCo ntraindi c ated in patients w it hin c reased ICPKeep f lat o n b ed after pr oc edureI n c rease f luid intake after pr oc edure
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I n c reased I ntra c rania l
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pressure
I ntra c rania l pressure morethan 15 mmHg
Brunner= N ormal
intracranial pressure 10 -2 0mmHg
I n c reased I ntra c rania l
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pressure
Causes:H ead in j ury
S tr o keI nf lammat o ry lesi o nsBrain tum o rS urgi c a l co mp lic ati o ns
I n c reased I ntra c rania l
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pressure
P at ho p h ysi olo gyTh e c ranium o n ly co ntains
t h e b rain su b stan c et h e CSF
t h e bloo d/ bloo d vesse ls
I n c reased I ntra c rania l
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pressure
P at ho p h ysi olo gyM ON R O-K ELLIE hypothesis - an
in c rease in any o ne o f t h e co mp o nents c auses a ch ange in t h e v ol ume o f t h e o t h erAny in c rease o r a lterati o n in t h ese stru c tures w ill c ause in c reased ICP
I n c reased I ntra c rania l
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pressure
P at ho p h ysi olo gy
Co mpensat o ry me ch anisms:
1. I n c reased CSF a b sorption2 . B loo d s h unting blood
3 . De c reased CSF production production
I n c reased I ntra c rania l
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pressure
P at ho p h ysi olo gyD ecompensatory mechanisms
1. De c reased c ere b ra l perfusi o n2 . De c reased PO 2 hypoxia3 . C ere b ra l edema
4 . Brain herniation
De c reased c ere b ra l bloo d f lo
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f low
V asomotor reflexes are stimulated initially slow b ounding pulses
I n c reased co n c entrati o n o f c ar bo n di o xide w ill c ause VASO D ILATIONin c reased f low increased ICP
Cere b ra l resp o nse t oin c reased ICP
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in c reased ICP
1. Steady perfusion up to 40mmHg
2 . Cushings responseVas o m o t o r c enter triggers rise in BP t o in c rease ICP
( HYPER T E N SI ON)S ympat h eti c resp o nse is in c reased BP b ut t h e h eart rate is SLO WR espirati o n b e co mes SLO W
I n c reased I ntra c rania lpressure
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pressure
CLINICAL MANIFESTATIONSEarly manifestations :
Changes in the L O C - usually theearliest P upi ll ary ch anges - fixed , s low ed resp o nse
H eada ch eVo miting
I n c reased I ntra c rania lpressure
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pressure
CLINICAL MANIFESTATIONSlate manifestations
Cushing reflex - systolic hypertension, b radycardia and wide
pulse pressureb radypneaH ypert h ermiaAb n o rma l p o sturing
I n c reased I ntra c rania lpressure
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pressure
N ursing interventionsN ursing interventions1 . Maintain patent airway
2 . Elevate the head of the b ed 15 -3 0degrees - to promote venous drainageto promote venous drainage
3 . A ssists in administering 100%oxygen o r co ntr oll ed h yperventi lati o n - t o redu c e t h e CO 2 bloo d leve ls co nstri c ts bloo d vesse ls redu c es edema
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I n c reased I ntra c rania lpressure
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pressure
N ursing interventi o ns5 . R edu c e envir o nmenta l stimu li
6. A v o id a c tivities t h at c an in c rease ICP l ike va lsa lva , co ug h ing ,s h ivering , and vig o r o us su c ti o ning
I n c reased I ntra c rania lpressure
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pressure
N ursing interventi o ns7. Keep h ead o n a neutra l p o siti o n .
AVOI D - extreme f lexi o n , va lsa lva
8. Mo nit o r f o r se co ndary co mp lic ati o ns
Dia b etes insipidus - o utput o f > 200 m L/ h r
I n c reased I ntra c rania lpressure
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pressure
HEA D SH= HO B e levate
E= E va luate ICPA=A ir w ay maintainD = Drainage pr o m o te
S= S afety ensure
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Al tered leve l o f co ns c io usness
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Al tered leve l o f co ns c io usness
I t is a fun c ti o n and sympt o m o f mu ltip le pat ho p h ysi olo gi cp h en o mena
Disrupti o n in t h e neur o na ltransmissi o n resu lts t o impr o per fun c ti o n
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Al tered leve l o f co ns c io usness
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co ns c io usness
Eti olo gi c F a c t o rs1. H ead in j ury
2 . S tr o ke3 . Drug o verd o se4 . Alcohol ic int o xi c ati o n
5 . Dia b eti c ket o a c id o sis6. H epati c fai lure
Al tered leve l o f co ns c io usness
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co ns c io usness
AssessmentO rientati o n t o time , p la c e and
pers o nMo t o r fun c ti o n
De c ere b rateDe co rti c ate
S ens o ry fun c ti o n
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Al tered leve l o f co ns c io usness
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co ns c io usness
ASSESSMENT1. Be h avi o ra l ch anges initia ll y
2 . P upi ls are s lowl y rea c tive 3 . Th en , patient b e co mes
unresp o nsive and pupi ls b e co me fixed di latedGl asg ow Co ma Sc a le is uti lized
Al tered leve l o f co ns c io usness
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co ns c io usness
N ursing I nterventi o n1. Maintain patent airway
El evate t h e h ead o f t h e b ed t o 3 0 degreesS u c ti o ning
2 . Protect the patient P ad side rai ls
P revent in j ury fr o m e q uipments , restraints and et c.
Al tered leve l o f co ns c io usness
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co ns c io usness
N ursing I nterventi o n3 . Maintain fluid and nutritional
b alanceI nput an o utput m o nit o ringIVF t h erapyFeeding t h r o ug h NGT
4. Provide mouth careCl eansing and rinsing o f m o ut hP etr ol atum o n t h e lips
Al tered leve l o f co ns c io usness
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co ns c io usness
N ursing I nterventi o n5. Maintain skin integrity
R egu lar turning every 2 ho urs30 degrees b ed e levati o nMaintain co rre c t bo dy a lignment b y using tr och anter r oll s , f oo t bo ard
6 . Preserve corneal integrity U se o f artifi c ia l tears every 2 ho urs
Al tered leve l o f co ns c io usness
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co ns c io usness
N ursing I nterventi o n7 . Achieve thermoregulation
M inimum am o unt o f b eddingsR e c ta l o r tympani c temperatureAdminister a c etamin o p h en as pres c ri b ed
8 . Prevent urinary retention
U se o f intermittent c at h eterizati o n
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SEIZURES
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SEIZURES
Epis o des o f a b n o rma l m o t o r ,sens o ry , aut o n o mi c a c tivity resu lting fr o m sudden ex c essive dis ch arge fr o m c ere b ra l neur o ns
A part o r a ll o f t h e b rain may b e inv ol ved
SEIZURES
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SEIZURES
PATHOPHYSIOLOGYAn e le c tri c a l distur b an c e in t h e
nerve c e ll s in o ne b rain se c ti o nEMI T S ELEC T RIC AL IMP U LSES excessively
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EPILEPSY
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A gr o up o f syndr o mes ch ara c terized b y re c urring seizures
CAUSES1. idi o pat h ic 6. b rain tum o rs2 . Birt h trauma 7. h ead I n j ury3 . perinata l infe c ti o n 8. meta bol ic ds o
4 . infe c ti o us disease 9. CVA5 . ingesti o n o f t o xins
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EPILEPSY
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Recurring seizures may be classifiedas GENERALIZED or PARTIALSEIZURES
Generalized Seizures- cause ageneralized electrical abnormalitywithin the brainPartial seizures- these seizures arise
from a localized part of the brain andcause specific symptoms
GENERALIZED SEIZURES
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1. General Tonic-Clonic seizure-( Grand mal ) characterized by loss of consciousness and alternating
movements of the extremities2. Absence Seizure ( Petit mal )-common in children, begins with abrief change in the LOC, indicated byblinking, rolling of eyes and blankstares
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PARTIAL SEIZURES
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1. Simple partial seizure- typicallylimited to one cerebral hemisphere2. Complex partial seizure- begins
with an aura, then with impairedconsciousness, with purposelessbehaviors like lip-smacking, chewingmovements
Epilepsy
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p p y
DIAGNOSTIC TESTS1. EEG2. CT3. MRI4. Lumbar P5. Angiography
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Epilepsy
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p p y
Nursing Interventions1. Care of patients during seizure2. care of patients after seizures3. patient teaching
SEIZURES and Epi lepsy
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N ursing Interventions: During seizure1. rem o ve h armfu l obj e c ts fr o m t h e
patients surr o unding2 . ease t h e cl ient t o t h e f loo r3 . pr o te c t t h e h ead w it h pi llow s4 . Ob serve and n o te f o r t h e durati o n , parts o f bo dy affe c ted ,b e h avi o rs b ef o re and after t h e seizure
SEIZURES and epi lepsy
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N ursing I nterventi o ns During seizure5 . loo sen co nstri c tive clo t h ing
6. D O NOT restrain , o r attempt t op la c e t o ngue bl ade o r insert o ra lair w ay
SEIZURES and epi lepsy
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N ursing I nterventi o ns: POST seizure1. p la c e patient t o t h e side t o drain
se c reti o ns and prevent aspirati o n2 . h e lp re -o rient t h e patient if co nfused3 . pr o vide c are if patient b e c ame
in co ntinent during t h e seizure atta c k4 . stress imp o rtan c e o f medi c ati o n
regimen
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S pina l Shoc k
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Th e sudden depressi o n o f ref lex a c tivity in t h e spina l co rd b e low t h e leve l o f in j ury
S pina l Shoc k
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P at ho p h ysi olo gy: Lo ss o f SC fun c ti o n T he muscles b elow the lesion areflaccid,the skin without sensationthe reflexes are a b sent includingb owel and b ladder functions
S pina l Shoc k
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N ursing I nterventi o ns1. S upp o rtive measures
2 . A ssist in Ch est p h ysi c a l t h erapy ,bow e l and bl adder e liminati o n 3 . M anage p o tentia l co mp lic ati o n -D VT
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Aut o n o mi c Dysref lexia
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S een co mm o n ly in spina l co rd in j ury a b ove T6
O ccurs SE V ER AL weeks after spinal cord injury
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Aut o n o mi cDysref lexia/ h yperref lexia
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Cl ini c a l MANIFESTATIONSArea a bo ve w ill VASO D ILATE
Area b e low w ill VASOCONSTRICT
Aut o n o mi cDysref lexia/ h yperref lexia
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NURSING INTERVENTIONS1. Elevate the head of the b ed immediately 2 . Ch e c k f o r bl adder distenti o n and empty
bl adder w it h urinary c at h eter3 . Ch e c k f o r Fe c a l impa c ti o n and o t h er
triggering fa c t o rs like skin irritati o n ,pressure u lc er
4 . A dminister anti h ypertensive medi c ati o ns - usua ll y h ydra lazine
Co gnitive I mpairment
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N ursing I nterventi o ns1. Assist o r en co urage t h e patient t o
use eyeg lass , h earing aid o r assistive devi c es
2 . R e o rient t h e patient b y c a ll ing h is name fre q uent ly
3 . P r o vide b a c kgr o und inf o rmati o n as t o date , time , p la c e , envir o nment
Co gnitive I mpairment
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N ursing I nterventi o ns4 . U se large signs as visua l c ues
5 . Po st patient's p ho t o o n t h e d oo r6. E n co urage fami ly mem b ers t o b ring
pers o na l arti cl es and p la c e t h em in t h e same area
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Bow e l and B ladder in co ntinen c e
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Bladder training b y esta bl is h ing a s ch edu le f o r urinati o n I n t h e ho spita l intermittent c at h eterizati o nAt ho me SELF-c at h eterizati o n
I mpaired Sw a llow ing
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Elevate the head of the b e 9 0degrees during meals and 3 0minutes after S erve f oo ds t h at are s o ft and sma llsizedKeep su c ti o n e q uipment o n b edside
Co nsu lt w it h re h a b ilitati o n team as t o assistive devi c es t h at c an b e uti lized
In summary
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I nterventi o ns f o r Cere b ra lFun c ti o n
Maintain ne c k mid line , neutra l
1 5 - 30 degrees e levati o nS upp lementa l o xygenMedi c ati o ns like mannit ol and ster o ids
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Traumati c b rain in j ury
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1. CONCUSSIONI nv ol ves j arring o f h ead w it ho ut tissue in j uryTemp o rary lo ss o f neur olo gi cfun c ti o n lasting f o re a fe wminutes t o ho urs
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Traumati c b rain in j ury
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2 . CONTUSIONI nv ol ves stru c tura l damage
Th e patient b e co mes un co ns c io us f o r ho urs
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Traumati c b rain in j ury
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3 . I ntra c rania l h em o rr h age
Epidura l h emat o ma
S u b dura l h emat o ma
I ntra -c ere b ra l h em o rr h age
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Traumati c b rain in j ury
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3 . I ntra c rania l h em o rr h ageI ntra c ere b ra l H em o rr h ageB leeding int o t h e su b stan c e o f t h e b rain
resu lting fr o m trauma , h ypertensive rupture of aneurysm , co agu lo pa h ties ,vas c u lar a b n o rma litiesS ympt o ms deve lo p insidi o us ly ,b eginning w it h severe h eada ch e and neur olo gi c defi c its
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Traumati c b rain in j ury
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M AN IFES TAT I ON S of b rain injury 1. Al tered LOC
2 . CSF o t o rr h ea3 . CSF r h in o rr h ea4 . R a coo n eyes and b att le sign
H ALO SIG N- b lood stain surrounded b y a yellowish stain
Traumati c b rain in j ury
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NURSING MANAGEMENT1. Mo nit o r f o r de cl ining LOC- use o f
Gl asg ow
2 . Maintain patent airway El evate b ed , su c ti o n prn , m o nit o r ABG
Traumati c b rain in j ury
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NURSING MANAGEMENT3 . Mo nit o r F and E b a lan c e
Dai ly w eig h tsIVF t h erapyMo nit o r p o ssi bl e deve lo pment o f D Iand SIA D H
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Traumati c b rain in j ury
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7. Mo nit o r p o tentia l co mp lic ati o nsI n c reased ICP
Po st - traumati c seizuresI mpaired venti lati o n
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S pina l co rd in j ury
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Cl ini c a l manifestati o ns1. P arap legia2 . q uadrip legia
3 . spina l s hoc k
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S pina l co rd in j ury
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NURSING INTERVENTION1. P r o m o te ade q uate b reat h ing and air w ay cl earan c e2 . I mpr o ve m ob ility and pr o per bo dy a lignment3 . P r o m o te adaptati o n t o sens o ry and per c eptua l a lterati o ns4 . M aintain skin integrity
S pina l co rd in j ury
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5 . M aintain urinary e liminati o n6. I mpr o ve bow e l fun c ti o n7. P r o vide Co mf o rt measures8. Mo nit o r and manage co mp lic ati o ns
Th r o m bo p le bh itisO rt ho stai c h yp o tensi o nS pina l s hoc kAut o n o mi c dysref lexia
S pina l co rd in j ury
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9. A ssists w it h surgi c a l redu c ti o n and sta b ilizati o n o f c ervi c a lverte b ra l col umn
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CERE BROVASCULAR ACCI D ENTS
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An um b re ll a term t h at refers t o any fun c ti o na l a b n o rma lity
o f t h e CNS re lated t odisrupted bloo d supp ly
CERE BROVASCULAR ACCI D ENTS
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Can b e divided int o t wo ma jo r c ateg o ries1. Ischemic stroke - c aused b y t h r o m b us and em bol us2 . Hemorrhagic stroke - c aused co mm o n ly b y h ypertensive bl eeding
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CERE BROVASCULAR ACCI D ENTS
Th t k ti
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Th e str o ke co ntinuum1. TIA- transient is ch emi c atta c k ,temp o rary neur olo gi c lo ss less
than 2 4 hours duration2 . R eversi bl e N eur olo gi c defi c its3 . S tr o ke in ev ol uti o n
4 . Co mp leted str o ke
Genera l manifestati o ns
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Loc a lizati o n
Midd l b l t
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Midd le c ere b ra l artery:A phasiaD ysphagia
HEMIP ARESIS on the O PP O SI T E side - more severe on the face and arm than on the legs
Loc a lizati o n
Anteri o r c ere b ra l arter :
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Anteri o r c ere b ra l artery:WeaknessN um b ness o n t h e o pp o site side
P ers o na lity ch angesI mpaired m o t o r and sens o ry fun c ti o n
Loc a lizati o n
Po steri o r c ere b ra l artery:
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Po steri o r c ere b ra l artery:Visua l fie ld defe c tsS ens o ry impairment
Co maLess like ly para lysis
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RIS KS FACTORS
No n m o difia bl e
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No n - m o difia bl eAdvan c ed ageGenderra c e
Mo difia bl eH ypertensi o nCardi o disease
Ob esityS m o kingDia b etes me ll itush yper chol ester ol emia
P at ho p h ysi olo gy o f str o ke
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Disrupti o n o f bloo d supp ly
Anaer ob ic meta bol ism ensues
De c reased ATP pr o du c ti o n leads t o impaired mem b rane fun c ti o n
Ce ll u lar in j ury and deat h c an occ ur
CERE BROVASCULAR ACCI D ENTS : S tr o ke
D IAGNOSTIC test
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D IAGNOSTIC test1. CT s c an2 . MRI
3 . A ngi o grap h y
CERE BROVASCULAR ACCI D ENTS : S tr o ke
CLINICAL MANIFESTATIONS
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CLINICAL MANIFESTATIONS1. N um b ness o r w eakness2 . co nfusi o n o r ch ange o f LOC
3 . m o t o r and spee ch diffi c u lties4 . V isua l distur b an c e5 . S evere h eada ch e
CERE BROVASCULAR ACCI D ENTS : S tr o ke
Mo t o r Lo ss
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Mo t o r Lo ssH emip legiaH emiparesis
CERE BROVASCULAR ACCI D ENTS : S tr o ke
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Co mmuni c ati o n lo ssDysart h ria = diffi c u lty in speakingAp h asia = Lo ss o f spee chApraxia = ina b ility t o perf o rm a previ o us ly learned a c ti o n
CERE BROVASCULAR ACCI D ENTS : S tr o ke
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P er c eptua l distur b an c esH emian o psia
S ens o ry lo ssparest h esia
CERE BROVASCULAR ACCI D ENTS : S tr o ke
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NURSING INTERVENTIONS : ACUTE1. Ensure patent air w ay2 . Keep patient o n L AT ER AL position3 . Mo nit o r VS and GCS, pupi l size4 . IVF is o rdered b ut given w it h c auti o n as
n o t t o in c rease ICP5 . NGT inserted6. Medi c ati o ns: S ter o ids , M annit ol ( t o
de c rease edema ), Diazepam
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS H i l
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NURSING INTERVENTIONS : Ho spita l1. I mpr o ve Mob ility and prevent jo int
def o rmities
Correctly position patient to prevent contractures
Place pillow under axillaHand is placed in slight supination - C Change position every 2 hours
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS2 . E n h an c e se lf -c are
Carry out activities on theunaffected sideP revent uni latera l neg le c t - p la c e s o me items o n t h e affe c ted side!!!Keep envir o nment o rganizedUse large mirr o r
CERE BROVASCULAR ACCI D ENTS : S tr o ke
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NURSING INTERVENTIONS3 . M anage sens o ry - per c eptua l
diffi c u ltiesA pproach patient on the U naffected
sideEn co urage t o turn t h e h ead t o t h e
affe c ted side t o co mpensate f o r visua l lo ss
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS4 . M anage dysp h agia
Pl a c e f oo d o n t h e UNAFFECTE D sideP r o vide sma ll er bol us o f f oo dU se o f purred f oo ds o r t h ic kened f oo dsManage tu b e feedings if pres c ri b ed
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS5 . H e lp patient attain bow e l and
bl adder co ntr olI ntermittent c at h eterizati o n is d o ne in t h e a c ute stageO ffer b edpan o n a regu lar s ch edu le
H ig h fi b er diet and pres c ri b ed f luid intake
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS6. I mpr o ve t ho ug h t pr oc esses
S upp o rt patient and c apita lize o n
t h e remaining strengt h s
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS7. I mpr o ve co mmuni c ati o n
Anti c ipate t h e needs o f t h e patient
O ffer supp o rtP r o vide time t o co mp lete t h e senten c eP r o vide a w ritten co py o f s ch edu led a c tivitiesU se o f co mmuni c ati o n bo ardG ive o ne instru c ti o n at a time
CERE BROVASCULAR ACCI D ENTS : S tr o ke
NURSING INTERVENTIONS
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NURSING INTERVENTIONS8. M aintain skin integrity
Use o f spe c ia lty b edR egu lar turning and p o siti o ningK eep skin dry and massage NON-reddened areasP r o vide ade q uate nutriti o n
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PAR KINSONS D SE (parkinsonism) - chronic,progressive disease of CNS char bydegeneration of dopamineproducing cells in substancia nigra at midbrain & basal ganglia
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g gPalliative, SupportiveF unction of dopamine: controls grossvoluntary motors.
Predisposing F actors:1. Poisoning (lead & carbon monoxide).Antidote for lead = Calcium EDTA2. Hypoxia
3. Arteriosclerosis4. Encephalitis
SE of anti psychotic drugs Extra P yramida l S ympt o mOver meds of anti psychotic drugs neuroleptic malignant syndrome charby tremors (severe)S/Sx: Parkinsonism Pill rolling tremors of extremities early signBradykinesia slow movementOver fatigue
Rigidity (cogwheel type)Stooped postureh ffl
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Shuffling most commonPropulsive gait
Mask like facial expression with decrease blinking eyesMonotone speechDifficulty rising from sitting positionMood labilety always depressed suicide
Nsg priority: Promote safetyIncrease salivation drooling type
Autonomic signs:Increase sweatingIncrease lacrimationSeborrhea (increase sebaceous gland)
ConstipationDecrease sexual activity
Nsg MgtAnti parkinsonian agentsLevodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl(Symmetrel)
Mechanism of actionIncrease levels of dopa relieving tremors & bradykinesia
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S/E of anti parkinsonianAnorexian/v
ConfusionOrthostatic hypotensionHallucinationArrhythmia
Contraindication:
Narrow angled closure glaucomaPt taking MAOI (Parnate, Marplan, Nardil)
Nsg Mgt when giving anti-parkinsonianTake with meals to decrease GIT irritationInform pt urine/ stool may be darkenedInstruct pt- dont take food Vit B6 (Pyridoxine) cereals,organ meats, green leafy vegCause B6 reverses therapeutic effects of levodopaGive INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis
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Peripheral neuritis.
Anti cholinergic agents relieves tremorsArtane mech inhibits acetylcholineCogentin action , S/E - SNS
Antihistamine Diphenhydramine Hcl (Benadryl) take atbedtimeS/E: adult drowsiness, avoid driving & operating heavyequipt. Take at bedtime.
Child hyperactivity CNS excitement for kids.4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression.Monitor RR.
Nsg Mgt Parkinson1.) Maintain siderails2.) Prevent complications of immobility- Turn pt every 2h
Turn pt every 1 h elderly3.) Assist in passive ROM exercises to prevent
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) p pcontractures4.) Maintain good nutritionCHON in am
CHON in pm to induce sleep dueTryptopan Amino Acid5.) Increase fluid in take, high fiber diet to preventconstipation6.) Assist in surgery Sterotaxic ThalamotomyComplications in sterotaxic thalmotomy- 1.)Subarachnoid hemorrhage 2.) aneurism 3.)encephalitis
MULTIPLE SCLEROSIS (MS)Chronic intermittent disorder of CNS white patchesof demyelenation in brain & spinal cord.Remission & exacerbationCommon women, 15 35 yo cause unknown
Predisposing factor:
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Predisposing factor:Slow growing virusAutoimmune (supportive & palliative treatmentonly)
Normal Resident Antibodies:Ig G can pass placenta passive immunity. Shortacting.Ig A body secretions saliva, tears, colostrums,sweat
Ig M acute inflammationIg E allergic reactionsIgD chronic inflammation
S & Sx of MS: (everything down)1. Visual disturbances
a. Blurring of visionb. Diplopia/ double visionc. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbnessb. Tingling
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c. Paresthesia3. Mood swings euphoria (sense of elation )4. Impaired motor function:
a. Weaknessb. Spasiticity tigas c. Paralysis major problem
5. Impaired cerebellar functionTriad Sx of MS
I intentional tremorsN nystagmus abnormal rotation of eyes
Charcots A Ataxia
& Scanning speech6. Urinary retention or incontinence7. Constipation8. Decrease sexual ability
Dx MS1. CS F analysis thru lumbar puncture
- Reveals increase CHON & IgG2. MRI reveals site & extent of demyelination
3 Lh i i ( )
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3. Lhermittes response is (+).Introduce electricity at the back. Theresspasm & paralysis at spinal cord.Nsg Mgt MSSupportive mgt1.) Meds
a. Acute exacerbationACTH adenocorticotopicSteroids to reduce edema at the site of
demyelination to prevent paralysis
MYASTHENIA GRAVIS (MG) disturbancein transmission of
impulses from nerve tomuscle cell at neuro muscular junction.Common in Women, 20 40 yo, unknown
cause or idiopathicAutoimmune release of cholenesterase
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Autoimmune release of cholenesterase enzymeCholinesterase destroys ACH(acetylcholine) = Decrease acetylcholine
Descending muscle weakness(Ascending muscle weakness GuillainBarre Syndrome)
Nsg priority:a/waspirationimmobility
S/ Sx:Ptosis drooping of upper lid ( initial sign)Check Palpebral fissure opening of upper& lower lids = to know if (+) of MG.Diplopia double vision
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p pMask like facial expressionDysphagia risk for aspiration!
Weakening of laryngeal muscles hoarseness of voiceResp muscle weakness lead respiratoryarrest. Prepare at bedside tracheostomysetExtreme muscle weakness during activityespecially in the morning.
Dx testTensilon test (Edrophonium Hcl) temporarily strengthensmuscles for 5 10 mins. Short term- cholinergic. PNS effect.Nsg Mgt1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lungcapacity.2 M i VS I&O h k l h
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2. Monitor VS, I&O neuro check, muscle strength or motorgrading scale (4/5, 5/5, etc)3. Siderails4. Prevent complications of immobility. Adult-every 2 hrs. Elderly-every 1 hr.
5. NGT feedingAdminister meds Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)Neostignine (prostigmin) Long term- Increase acetylcholines/e PNS
Corticosteroids to suppress immune respDecadron (dexamethasone)
Monitor for 2 types of Crisis:Myastinic crisis Cholinergic crisisA cause 1. Under medication 2. Stress3. InfectionB S&Sx 1. Unable to see Ptosis & diplopia 2. Dysphagia- unable to swallow.3. Unable to breath C Mgt adm cholinergicagentsCause: 1 over medsS/Sx - PNSMgt. adm anti-
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agentsCause: 1 over medsS/Sx PNSMgt. adm anticholinergic Atropine SO4SNS dry mouth7. Assist insurgical proc thymectomy. Removal of thymusgland. Thymus secretes auto immune antibody.8. Assist in plasmaparesis filter blood9. Prevent complication respiratory arrest
Prepare tracheostomy set at bedside.