Nervous System

J. Concepcion

Neuron

Central Nervous System

Brain Cerebrum Cerebellum Brain stem Midbrain Pons Medulla oblongata Spinal cord

Nervous System
1.  

Central Nervous System Brain Spinal Cord

2. Peripheral Nervous System  Cranial Nerves  Spinal Nerves

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

External surface of the brain

BRAINBRAIN- 1. Cerebrum


The largest part of the brain.  Composed of:  2 hemispheres- the right and left, and hemispheresthe basal ganglia.  The hemisphere is connected by corpus callosum, a band of fibers. callosum,  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. Concentration, memory & abstract thought

2. Parietal Sensory lobe


 

location: near the crown of the head. Contains the primary sensory cortex. One of its major function is to process sensory input such as position sense, touch, shape, and consistency of objects. Also spatial relations Location: around the temples. Contains the primary auditory cortex. cortex.

3. Temporal
 

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


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


 

FrontalFrontal- motor /controls higher intellectual function, awareness of self, and autonomic responses related to emotions. Parietal- sensory ParietalTemporalTemporal auditory (Wernicke s); s); Contains the interpretative area where auditory, visual and somatic input are integrated into thought and memory OccipitalOccipital-visual

THE 4 LOBES

BRAINBRAIN- DIENCEPHALON
 

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

BRAINBRAIN- DIENCEPHALON
 

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. Epithalamus  Contains pineal gland. 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, 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.

BRAINBRAIN-2. Brain Stem



Consist of the midbrain, pons, and pons, 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

BRAINBRAIN-2. Brain Stem



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.

 

BRAINBRAIN-3. Cerebellum



Location: base of the brain. brain. Responsible for coordination, balance and posture.
Separated by a fold of dura mater- tentorium cerebelli mater-

Damage to the cerebellum can result in ataxia, a ataxia, condition characterized by drunken-like drunkenmovements, severe tremors, and loss of balance.  FTNT


PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
CEREBRAL FUNCTION ASSESSMENT

Finger-toFinger-to-Nose Test abduct and extend the arms at shoulder height and then rapidly touch the nose alternately with one index finger and then the other

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
CEREBRAL FUNCTION ASSESSMENT

Finger-toFinger-to-Nose & to the Nurse s Finger touch the nose and then the index finger of the nurse held at a rapid and increasing rate

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 cord) and nourishment to the brain and the spinal cord.  Layers of the meninges: meninges: 1.dura mater 2.arachnoid 3.pia mater.

Meninges and Related Structures

CSF
 CSF

- 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.(SG 1.007) Produced in the choroid plexus of the ventricles.

Lumbar Tap
 spinal needle into subarachnoid space at L3-L4,L4-L5 & L5-S1, intervertebral space

Normal Value of CSF Pressure 75-180 mmH20 or 0 to 15 mmHg Glucose 50- 80 mg/dl Protein 20 50 mg/dl Nursing Considerations Before and During the Procedure
 encourage client to void  assist client to assume a fetal position (lateral recumbent position with back arched, head and knees flexed on chest) to widen intervertebral spaces

After the Procedure  lie flat in bed for 6-8 hours (may turn to sides)  encourage fluids if not contraindicated  headache may develop due to CSF leakage; treated w/ bed rest, analgesics and ice to head  observe for changes in neurologic status

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.

Spinal Cord
cervical brachial plexus intercostal lumbar sacral pudendal C1C1-4 C5C5-8, T1 T2-T12 T2L1-L4 L1L4-L5, S1-S3 L4S1S4

BLOOD SUPPLY TO THE CNS



1/3 of the cardiac output From 2 vertebral artery and one internal carotid arteries Circle of Willis circulation provide collateral

Arterial Blood Supply of the Brain

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 VIIIAcoustic/Vestibuloc ochlear IX Glossopharyngeal nerve X Vagus nerve XI Accessory nerve XII Hypoglossal nerve

Cranial Nerves
Cranial Nerves
I. Olfactory

Function
Sensory: smell reception and interpretation

Assessment
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) 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.

II. Optic

Sensory: visual acuity and visual fields

Cranial Nerves
III. Oculomotor

Function
Motor: raise eyelids, most extraocular movements

Assessment
Assess eyes for Extraocular Movement. 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

Parasympathetic: pupillary constriction, change lens shape

Cranial Nerves

Function

Assessment
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. Assess eyes for Extraocular Movement

IV. Trochlear

Motor: downward, inward eye movement. 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

V. Trigeminal

Assess face for Movement and Sensation Test motor function by having the client clench his/her teeth, then palate, the temporal and masseter muscles. To test light sensation, have the client close his/

Cranial Nerves

Function

Assessment
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 VII. Facial

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

of eyelid Inspect the face both at rest and during conversation. Have the client raise the eyebrows, frown, close the eyes tightly and show the teeth,
Diplopia,ptosis

Cranial Nerves

Function

Assessment
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.

Sensory: tastetasteanterior two third of tongue, sensation to pharynx Parasympathetic: secretion of saliva and tears.

VIII. Acoustic

Sensory: hearing and Hearing initially can be screened equilibrium. while taking the history.

Cranial Nerves
IX. Glossopharyngeal

Function
Motor: voluntary muscle for swallowing and phonation.

Assessment
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. Assess mouth for Gag Reflex and Movement of Soft Palate

Parasympathetic: secretion of salivary gland, carotid reflex

X. Vagus

Motor: voluntary muscle of phonation and swallowing Sensory: sensation behind ear and part of

Cranial Nerves

Function
external ear canal. Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of the heart, lungs and heart, digestive tract. Motor: turn head, shrug shoulders, some actions for phonation

Assessment

XI. Spinal accessory

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.

Cranial Nerves
XII. Hypoglossal

Function
Motor: tongue movement for speech sound articulation and swallowing

Assessment
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


Spinal nerves  31 pairs  8 cervical, 12 thoracic, 5 lumbar  5 sacral, 1 coccygeal  Two roots  Dorsal and ventral-Each spinal nerve has a ventralventral 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 homeostasis. internal homeostasis.

2 Components of ANS 1. Sympathetic Nervous System 2. Parasympathetic Nervous System

Sympathetic Nervous System

Expenditure of energy  Catecholamines: Catecholamines: Epinephrine; norepinephrine; dopamine norepinephrine;
 

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

Assessment
The 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. 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 reaction/pupillary Eye movement & reflex response Change in balance

Neurological Assessment
 

recognition of change helps assess the patient s ability to engage in self-care activities. selfNeurologic assessment is divided to into 5 components:
    

Cerebral function Cranial nerves Motor system Sensory system Reflexes

1. Cerebral Function


Mental status: observe patient s status: appearance, behavior, dressing, grooming and personal hygiene.


Posture, gestures, movements, facial expression, motor activity, the patient s manner of speech and LOC are also assessed.

Level of Consciousness (LOC)

awareness of self and environment and level of arousal (alert, lethargic, obtunded, stuporous, stuporous, coma).  most sensitive indicator of the changes in neurologic status of the client

Mental Status
 Orientation to 3 spheres: people, time & place Memory Immediate recall , Recent memory, Remote memory  Immediate recall - ask client to repeat your question  Recent memory ask client about events that occurred few minutes or few hours ago  Remote memory ask the client about events in the remote past, or historical events that can be answered by the general population

Altered Level of Consciousness (LOC)(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)

ARAS (ascending reticular activating system); center for system); wakefulness

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

Delirium

    

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

Altered Arousal/Level of Consciousness (LOC) cont.



Obtundation

  

Decreased alertness Psychomotor retardation Requires complete assistance with ADLs Arousable but not alert Severe disorientation Little or no spontaneous activity Unarousable Unresponsive to external stimuli or internal needs Determination commonly documented using Glasgow Coma Scale score

Stupor

  

Coma

 

Level of Consciousness  Level 1

 Level 2

conscious, cognitive, coherent confused, drowsy, lethargic, obtunded, somnolent

 Level 3 stuporous, responds only to noxious or strong/intense stimuli (sternal pressure, trapezius pinch, pressure at the base of the nail or supraorbital area, very strong light or sound)  Level 4 Coma  Light Coma response is only by grimace or withdrawing limb from pain  Deep Coma absence of response to even the most painful stimuli GCS (Glassgow Coma Scale)

GCS (Glassgow Coma Scale)

 Eye Opening (4) - spontaneous, on request, to painful stimuli, no opening Verbal Response (5) oriented, engages in conversation, confused in content, words spoken but conversation not sustained, groans on evoked pain, no response Motor Response (6) obeys command, localizes painful stimuli, flexion withdrawal, decorticate, decerebrate, no response

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

1. Best Motor Response (M) - 6 grades 1. No response to pain. 2. Extensor posturing to pain pain: The stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) DECEREBRATE POSTURE 3. Abnormal flexor response to pain pain: Pressure on the nail bed causes abnormal flexion of limbs DECORTICATE POSTURE 4. Withdraws to pain pain: Pulls limb away from painful stimulus. Infant: withdraws from pain.

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

1. Best Motor Response (M) - 6 grades 1. No response to pain. 2. Extensor posturing to pain pain: The stimulus causes limb extension (adduction, internal rotation of shoulder, pronation of forearm) DECEREBRATE POSTURE 3. Abnormal flexor response to pain pain: Pressure on the nail bed causes abnormal flexion of limbs DECORTICATE POSTURE 4. Withdraws to pain pain: Pulls limb away from painful stimulus. Infant: withdraws from pain.

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

1. Best Motor Response (M) - 6 grades 5. Localizing response to pain pain: Put pressure on the patient's finger nail bed with a pencil then try supraorbital and sternal pressure:  purposeful movements towards changing painful stimuli is a 'localizing' response. Infant: withdraws from touch 6. Obeying command command: The patient does simple things you ask (beware of accepting a grasp reflex in this category). Infant: moves spontaneously or purposefully

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

2. Best Verbal Response (V) - 5 grades Record best level of speech. If patient is intubated, a "derived verbal score" is calculated via a linear regression prediction. 1. No verbal response. 2. Incomprehensible speech speech: Moaning but no words. Infant: Inconsolable, agitated. 3. Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange. Infant: Inconsistantly inconsolable, moaning.

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

2. Best Verbal Response (V) - 5 grades 4. Confused conversation conversation: Patient responds to questions in a conversational manner but some disorientation and confusion. Infant: Cries but consolable, inappropriate interactions. 5. Orientated Orientated: Patient 'knows who he is, where he is and why, the year, season, and month. Infant: Smiles, orientated to sounds, follows objects, interacts.

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
SENSORY FUNCTION
Glasgow Coma Scale (GCS)

3. Best eye response (E) - 4 grades 1. No eye opening; 2. Opening to response to pain to limbs as above 3. Eye opening in response any speech (or shout, not necessarily request to open eyes); 4. Spontaneous eye opening.

Interpretation of Symptoms: Severe: less than 8 Moderate: 9-12 Mild: 13-15

Altered Movement
Involves certain neurotransmitters (ex. dopamine) Hyperkinesia- excessive movement HyperkinesiaHypokinesia- decreased movement Hypokinesia Marked by paresis- partial loss of motor paresisfunction and muscle power; commonly described as weakness; can result from destruction of weakness; upper & lower motor neurons  Plegia - paralysis


2. Cranial Nerve Function



Assess cranial nerve function.

3. Motor System Function

Assess muscle size (inspect and palpate) tone, and (inspect palpate) strength; assess symmetry differences between right and left side; balance and coordination.
 

Altered Muscle Tone HypotoniaHypotonia- severely reduced degree of tension or resistance to movement in a muscle HypertoniaHypertonia- marked increase in a muscle tension and decreased ability of a muscle to stretch

Motor Function
Motor Center Frontal Lobe  Apraxia inability to perform fine motor activities  Agraphia inability to write Cerebellum Romberg s Test  client stands w/ both feet together, eyes closed  Ataxia uncoordinated movements; wide base stance And swaying manner of walking Extrapyramidal System regulates locomotion maintains balance, posture &

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
CEREBRAL FUNCTION ASSESSMENT

Romberg test: test: tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds

Sensory Function
Test for: (Parietal lobe) (Parietal lobe)  superficial tactile sensation superficial and deep pressure pain  thermal sensitivity  sensitivity to vibration  point localization.
 

Stereognosis ability to perceive sensory stimuli Agnosia inability to perceive sensory stimuli

Reflexes  Evaluate deep and superficial reflexes (biceps, (biceps, triceps, patellar, ankle reflexes) and abnormal reflexes) reflexes (Babinski s reflex). (Babinski reflex).

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT
PATHOLOGIC REFLEXES

in adults - documented as "positive for ___"

Babinski reflex (Plantar) (L4-S2): stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average)

Reflexes to Assess Meningeal Irritation

Kernig s sign client is placed in supine position; flex the knee, attempt to extend the leg, pain is experienced Brudzinski s reflex client is placed in supine postion; passively flex the neck, spontaneous flexion of the hips occur; (more accurate indicator of meningeal irritation)

Diagnostic Tests

Diagnostic Procedure Computed Tomography Scanning

Visualize

Nursing Interventions


sections of the spinal cord as well as intracranial contents The injection of a water-soluble wateriodinated contrast into the subarachnoid space through lumbar puncture helps noninvasive and painless  has a high degree of sensitivity for detecting lesions. Use of xray 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 6 hrs. Monitor for allergic reaction: flushing, nausea and vomiting. remove metallic objects from hair

Magnetic Resonance Imaging

Diagnostic Procedure
Magnetic 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. Cerebral Angiography Is an x-ray study of the cerebral xcirculation with a contrast agent injected into a selected artery femoral) (femoral) Visualize aneurysm

Nursing Interventions
history of metal implants. Remove all metal objects. Inform the client that the procedure last for 30 to 90 mins. 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.
Obtain

a signed consent. Hydrate the client, clear liquids client, are usually permitted. Instruct the client to void before the procedure.
Obtain

Diagnostic Procedure

Nursing Interventions
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.
Instruct

Myelography Contrast agent 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,

the procedure. Obtain a signed consent. Withhold oral intake 4-6 hours 4before the test. After the procedure: For pantopaque myelogram (oil(oilbased) pt lies flat for 6-24 hours. 6Explain

Diagnostic Procedure
herniated vertebral disks or other lesions.

Nursing Interventions
metrizamide myelogram (water(waterbased), HOB is elevated at 30 degrees for at least 8 hours. Encourage fluid intake
For

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.

the procedure, assure the client he/she will not receive electrical shock. The nurse needs to check doctor s order regarding the administration of antiseizure 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.
Explain

Electroencephalography

Measurement of the electrical activity Of the brain done during: Relax Hyperventilate Sleeping Flickering lights Hair shampoo to remove oil/sprays

Lumbar puncture
Insertion of needle in the sub arachnoid space Assess the csf

Lumbar Puncture
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

Nursing Interventions

by inserting needle electrodes 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. myopathies.
Obtain

the procedure. 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.
Explain

Electromyogram

Pneumoencephalography

Nursing Intervention

Special

contrast study of the Secure written consent. ventricular and cisternal system using Sedate as ordered. GA may be air as contrast medium. used. used. Permits accurate localization of Inform the client that the procedure brain lesions by spinal or takes 2 hours. xcisternal puncture with x-ray Inform the client that he/she may examination. 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 Problems of the Young Adult

NEUROMUSCULAR DISORDERS

Sclerosis Myasthenia Gravis

Multiple

Multiple Sclerosis
 

MS is: 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 remmissions (relapsing(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

Pathophysiology
MS
Causes Unknown Viral infection Autoimmune 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 (SCHWANNS 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 (diplopia, vision, nystagmus) 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 elevatedimmune system due to chronic demyelinaton) demyelinaton)

EEGEEG-abnormalities in brain waves  CT scan/ MRI reveals multifocal white matter lesion  Myelogram  Skull x-ray x

Nursing Diagnoses for MS:



Risks: Ineffective breathing pattern; airway clearance; impaired swallowing, physical mobility, skin integrity; altered nutrition; urinary incontinence; constipation

Interventions for MS:

There is no specific treatment for MS. Treatment includes:  physical therapy- to assist with motor dysfunction, therapysuch as problem with balance, strength, and motor coordination.  speech therapy- to manage dysarthria therapy drug therapy


  

Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)Dexamethasone, Corticotropin) to reduce edema of the myelin sheet; speeds recovery from attack Muscle relaxant (Baclofen)- to treat spasticity (Baclofen) Amantadine, Amantadine, Ritalin, or antidepressants to manage fatigue LowLow-dose TCAs- to manage sensory symptoms such as TCAspains, numbness, burning, and tingling sensations Antihistamines with vision therapy & exercises to minimize vertigo

Nursing Responsibilities/ Considerations for MS:



Provide regular activity, rest, and relaxation. rest, Assist with physical therapy: muscle stretching, therapy: relaxation and coordination exercise, walking exercise. Encourage well balanced, high fiber diet. Force fluids to prevent constipation. Avoid hot baths. baths. Provide skin care to prevent skin breakdown.

 

Nursing Responsibilities/ Considerations for MS cont.:



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 20secretion 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 nurve impulses at the neuromuscular junction FAILS. Antireceptor antibodies block, weaken, or reduce the number of acetylcholyne Ach receptors available at each neuromuscular juction,thereby impairing the muscle depolarization necessary for movement

Myasthenia Gravis
Cause:  Autoimmune response leading to ineffective acetylcholine release and inadequate muscle fiber response to Ach. Complications:  Aspiration  Pneumonia  Respiratory distress

Assessment


S&S

 

Skeletal muscle weakness, fatigue Weak eye closure,ptosis, closure,ptosis, diplopia, snarl smile (smiles slowly) Masklike facial expression; Impaired speech; drooling Weakened respiratory muscles
Muscle are usually strongest in the morning but become progressively weaker during the day and following an exercise.

Rationale/ Pathophysiologic Basis due to impaired neuromuscular transmission due to impaired neuromuscular transmission to the cranial nerves supplying the eye muscles Impaired transmission of the cranial nerves innervating the facial muscles

 

Due to impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in the appropriate junctions

Myasthenia Gravis

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 30edrophonium (tensilon) or Neostigmine (Prostigmin), tensilon) Prostigmin), lasting up to 30 mins. mins. Single fiber electromyography with neural stimulation at the specific muscle fiber- progressive decrease in fibermuscle fiber contraction Chest x-ray- reveals thymoma in 15% of pts x-ray-

Treatment of Myasthenia Gravis



Anticholinesterase drugs, such as neostigmine and pyridostigminepyridostigmine- to counteract fatigue and muscle weaknes and allow for about 80% of normal muscle Immunosuppresive therapy with corticosteroids, azathioprine (Imuran) to decrease the immune Imuran) response toward Ach receptors at the neuromuscular junction IgG during acute relapses- to suppress the immune relapsessystem Thymectomy- to remove thymomas ThymectomyTracheostomy, 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 20minutes 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, stress, strenous exercise, and needless exposure to the sun r cold. Frequent rest periods. Be prepared to give atropine for anticholinesterase overdose or toxicity Avoid aminoglycoside antibiotics, which can exacerbate antibiotics, myasthenia gravis

Aerosol, pesticides/cleaners should also be avoided,  Avoid alcohol, tonic water, and cigarette smoke.  Pharmacotherapy  Cholinergics (Anticholinesterase) Anticholinesterase)

 Neostigmine

(Postigmin) Postigmin)  Pyridostigmin (Mestinon) Mestinon)  Ambenomium (Mytelase) Mytelase)

 

Glucocorticoids Antacids

Common Health Problem of the MiddleMiddle-aged Adult

CRANIAL NERVE DISORDER: Trigeminal Neuralgia (Tic Douloureux)



Neurologic disorder affecting the 5th cranial nerve. nerve. Possible fifth cranial nerve root compression  Manifested by excruciating, recurrent paroxysms of sharp, stabbing facial pain sharp, along the trigeminal nerve.

Areas innervated by the three branches of the trigeminal nerve

Management
Narcotic analgesics; anticonvulsants  Tegretol  Dilantin Alcohol injection of the nerve Avoid extremes of heat and cold. Correction of dental malocclusion Surgical Management  Surgical division of the trigeminal nerve (neurectomy) neurectomy)  Protect eye if surgery is done

   

Nursing Management


Assessment
  

Complete history Affected area; oral cavity Record weight and ability to eat food Acute pain Pain; client cooperation

Diagnosis, Planning, and Interventions



Evaluate:


CRANIAL NERVE DISORDER: Bell s Palsy

Definition: Disease of the cranial nerve VII (facial nerve that produces unilateral or bilateral facial weakness or paralysis of one side of the face  Resolves spontaneously in most 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

Bell s Palsy
 

Pathophysiology: Pathophysiology: An inflammatory reaction occurs around cranial nerve VII, usually at the internal auditory meatus, where the nerves leave bony tissue meatus, 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 Chanes/ S & S:

    

  

Unilateral facial weakness Drooping mouth & drooling saliva Loss of taste Smooth forehead appearance Impaired ability to close the eye on the weak side (Ptosis) (Ptosis) Bell s phenomenon-Upward rolling of the eyes phenomenonwhen attempting to close them Excessive tearing Ringing in the ear Painful sensations in the face

Complications of Bell s Palsy  Corneal abrasion  Infection (masked by steroid use)  Poor functional recovery Diagnostic Tests: -based on clinical presentation MRIMRI-rules out tumor ElectromyographyElectromyography- 10 days after the onset of S/S

Treatment


AnalgesicsAnalgesics- to relieve pain SteroidsSteroids- to reduce facial nerve edema & improve edema & improve nerve conduction & blood flow Possible electrotheraphy 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 face Help the pt maintain muscle tone: -massaging the face with a gentle upward motion 2-3xdaily x 52510mins Exercise by grimacing in front in front of a mirror  Protect eyes, have pt cover eye w/ an eye patch  Prevent excessive wt loss: -have him chew on unaffected side of his mouth -provide a soft, nutritionally balanced diet, eliminating hot foods & fluids -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 CEREBRODISORDER:Stroke/ Accident (CVA)

Definition: Disruption of the Blood Supply to the BrainBrain-sudden loss of neurologic funtion Note: Middle Cerebral Artery is commonly affected. The second most frequently affected is the internal arotid artery. artery. Classification: 1. 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 contraceptives

Causes of Stroke: Ischemic



Thrombosis- occluded blood flow caused by thrombosis of the

cerebral arteries supplying the brain or the intracranial vessels  The most frequent cause of CVA  The most common cause of cerebral thrombosis is atherosclerosis; atherosclerosis; usually affecting elderly persons.  Tends to occur during sleep or soon after arising.  This may tend to occur among clients with DM, and hypertension.

Embolism- from thrombus outside the brain, such as in the Embolismheart, aorta, or common carotid artery. artery.  The second most common cause of CVA.  Most commonly affecting younger people. people.  Most frequently caused by Rheumatic Heart Disease and MI.  Symptoms occur at any time and progress rapidly. rapidly.

Causes of Stroke: Hemorrhagic Stroke

Hemorrhage- Hemorrhagic Stroke Hemorrhage

Impaired cerebral perfusion from hemorrhage causes infarction, & the blood itself as a space-occupying infarction, spacemass, exerting pressure on the brain tissues Hemorrhage from an intracranial artery or vein, such as HPN, ruptured aneurysm, trauma, hemorrhagic disorder, or septic embolism.,AV malformation

Transient Ischemic Attacks

Refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction.  Manifestation include contralateral weakness of the lower portion of the face, fingers, hands, arms, and legs; dysphagia, and sensory impairment. dysphagia,
 

Stoke in evolution refers to development of a neurologic deficit over several hours to days Completed stroke refers to a permanent neurologic deficit

Pathophysiologic Changes in CVA:-specific manifestations CVA:are determined by the cerebral artery affected, the brain tissue supply by that of 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 arms)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, diplopia, nystagmus; dizziness, dysphagia, slurred speech; amnesia, and ataxia dysphagia, resulting from thrombosis or hemorrhage of vertebrobasilar artery. artery.

Confusion, Confusion, weakness, numbness; urinary incontenece; incontenece; impaired motor & sensory functions; and personality changes caused by thrombosis or hemorrhage of anterior cerebral artery. artery. Visual field deficits; sensory impairments; dyslexia; cortical blindness and coma resulting from thrombosis or hemorrhage of posterior cerebral artery. artery.

Assessment of CVA: check for:



S&S of increased ICP.  Perceptual defects  Aphasia inability to comprehend or use words  Unstable respiration  Severe headache  Diagnostic procedure results  Unilateral neglect  Hemianopsia loss of half of the visual field

Diagnostic Findings:


CT scan- identifies an ischemic stroke within scanthe first 72 hours of symptom onset or evidence of a hemorrhagic stroke (lesions >1 cm immediately) MRIMRI-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 impairementimpairementAphasia 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 impairementimpairementVisual changes homonymous hemianopsia; 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:CVA


Maintain a patent airway and oxygenation: oxygenation: If the pt is unconscious; vomiting- lateral position to prevent aspiration of vomitingsaliva

Check v/s & neurologic status: status: Monitor BP, LOC, pupillary changes, motor and sensory functions, speech, skin, color, temp. Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity Watch for s/s of pulmonary emboli: emboli: chest pain, shortness of breath, dusky color, tachycardia, fever, and changes in sensorium If the pt is unresponsive, monitor ABG as ordered

Monitor F & E balance: balance: Monitor I and O. Administer IVF as ordered Offer bedpan /urinal

Nursing Considerations:CVA


Ensure adequate nutrition: nutrition:

Check for gag reflex before offering small oral feedings of semi solid food Teach the client to chew on the unaffected side. If oral feeding is not possible, TPN, NGT feeding, gastrostomy feeding.
   

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

Nursing Considerations:CVA


Compensate for perceptual difficulties.  Care of the client with Hemianopsia. Hemianopsia.  Approach from the unaffected side.  Place articles on the unaffected side. Promote communication  Care for the client with aphasia.  Say one word at time.  Give simple commands.  Allow the client to verbalize, no matter how long it takes him Give medications as ordered- Tell the pt to watch orderedout for side effects. (ex. Aspirin-GI bleeding) Aspirin-

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 has a paralized side- show sidehim how to protect his body from harm Emphasize importance of regular ff-up visits ff-

Parkinsons Disease
Also called Paralysis Agitans  Slowly progressive degenerative disorder of basal ganglia function that results in variable combinations of tremor, rigidity, and bradykinesia  Onset usually after age 40; first appears in 40; the 5th decade of life  men>women men>women


Parkinson s Disease: deficient in dopamine

Causes:
Exact cause unknown  Possible causes:  Dopamine deficiency, which prevents affected deficiency, brain cells from performing their nomal inhibitory function in the CNS  Exposure to toxins( manganese dust or carbon toxins( monoxide)  Repeated trauma to the brain  Stroke  Brain tumors  Drugs phenothiazines, reserpine, haloperidol phenothiazines, reserpine, & methyldopa

Pathophysiology of Parkinson s Disease

Pathophysiology:


 

Dopamine neurons degenerate, causing loss degenerate, of available dopamine Dopamine deficiency prevents affected brain cells from performing their normal inhibitory function Excess excitatory Ach occurs at the synapses Current theory caused by oxidative stress in portion of the neuron known as Lewy bodies Maybe caused by protein aggregation

Pathophysiologic changes/ S&S:



Muscle rigidity, bradykinesia, and insidious bradykinesia, tremor beginning in the fingers (UNILATERAL (UNILATERAL PILL_ROLL TREMOR) secondary to loss of TREMOR) inhibitory dopamine activity at the synapsesynapseincrease during stress or anxiety; decreases with purposeful movement & sleep Muscle rigidity with resistance to passive limb movement bradykinesia/ bradykinesia/akinesia Cogwheel rigidity absence of arm swing in normal rhythmic gait

  

Pathophysiologic changes/ S&S:

 

MaskMask-like appearance Gait disturbance-lacks normal parallel motion; disturbancemay be retropulsive or propulsive head bent forward Shuffling, festinating gait walking in tiptoe, pt. may walk faster & faster; unable to stop until obstruction is met Oily skin- secondary to inappropriate skinregulation of androgen production by hypothalamic-pituitary axis hypothalamic-

Pathophysiologic changes/ S&S:



  

 

Dysphagia, dysarthria; excessive sweating; Dysphagia, dysarthria; decreased GI motility and genitourinary smooth muscle-from impaired autonomic muscletransmission Voice changes Small handwriting (Micrographia) Micrographia) Poor judgement, endogenous depression, judgement, dementia- from impaired dopamine dementiametabolism, and neurotransmitter dysfunction No intellectual impairment Drooling of saliva

Collaborative Management
Diet  inc. residue, inc. caloric, soft diet (well-balanced diet) Position to prevent contractures  firm bed, no pillows  prone position when lying in bed  hold hands folded at the back when walking Aspiration precaution Inc. fluid intake prevent constipation

Medications
Anticholinergics to reduce tremors

 Cogentin (Benztropine Mesylate)  Artane (Trihexyphenydil)  Akineton (Biperiden) o Side effects: blurring of vision, dryness of mouth/throat, constipation, urinary retention, dysarthria, mental disturbance o IOP must be monitored o contraindicated in patients w/ narrow-angle glaucoma

Anti Parkinsonian Agents (Dopaminergics) improve muscle flexibility

Levodopa converted to dopamine in the basal ganglia; good in the 1st few years of tx  avoid Phenothiazines, Reserpine, Pyridoxine (vit.B6)  w/in 5-10 years px develops dyskinesia (abnormal involuntary movements)  neuroleptic malignant syndrome characterized by rigidity, stupor & hyperthermia Carbidopa w/ Levodopa (Sinemet) aa decarboxylase inhibitor; reduces destruction of levodopa at periphery

Antiviral Amantadine HCl (Symmetrel) Dopamine Agonists added to medication regimen after carbidopa or levodopa loses effectiveness Bromocriptine (Parlodel) Pergolide (Permax) Antispasmodics Procyclidine HCl (kemadrin)

Antihistamines Diphenhydramine HCl (Benadryl) reduces tremors MAOI sedative effects;

inhibits dopamine breakdown

Selegiline (Eldepryl)  enhances norepinephine activity  hypertensive crisis may occur  methyldopa potentiates effects of levodopa

Avoid when on levodopa:  B6 rich foods tuna, pork, dried beans, salmon, beef liver
tyramine rich foods cheese, cream, yogurt, coffee, chocolate, bananas, raisins, liver, pickled herring, sausage, soy sauce, yeast, beer, red wine, italian green beans (hypertensive crisis)

Side effects of Levodopa:

 nausea, vomiting, orthostatic hypotension, insomnia, agitation, mental confusion, renal damage

Patient teaching:
 gradual change of position; wear elastic stockings to prevent postural hypotension  reddish brown urine

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:

grand mal petit mal febrile seizures status epilepticus Jacksonian/focal Jacksonian/focal psychomotor

Grand Mal


the most common type of seizure Phases: Aura TonicTonic-clonic phase PostPost-ictal phase

1. 2. 3.

I. Aura  flashing lights, smells, spots before eyes, dizziness  shout/cry  fall II. Tonic clonic phase  Characerized by contractions tonic  Jerking movements clonic  Accompanied by dyspnea, drooling of saliva, urinary incontinence III. Post ictal phase  cessation of tonic-clonic movements  characterized by exhaustion, headache, drowsiness, deep sleep of 1-2 hours  disorientation

Petit mal
      

 

Absence seizure or Little Sickness No aura 1010-20 seconds Common to children as well as adult Little tonic-clonic movements tonicSudden cessation of ongoing physical activities blank facial expression, automatism like lipexpression, lipchewing, cheek-smacking cheekregains consciousness occurs during childhood & adolescence

Jacksonian
 

Focal seizure With aura (numbness, tingling, crawling feeling) With organic lesion e.g. frontal lobe tumor Group of muscle affectation e.g. hands, foot or face Proceeds to grand mal seizure

Psychomotor Seizure
  

  

With aura (hallucinations or illusions) With psychiatric involvement Characterized with mental clouding (out of touch w/ environment) Violence, antisocial acts Appears intoxicated Char. By ongoing physical activity during time of loss of consciousness

Febrile Seizure
 

Related to temperature Present among children under five years of age

Status epilepticus
  

 

Prolonged seizure state Can occur in any type of seizure Rapid successions with no full consciousness in between seizures Brain damage can occur due to hypoxia & exhaustion; most life threatening in tonictonicclonic seizures Common to clients who are in coma Related to failure to take medication

Primary Seizure Disorder (Epilepsy)  Idiopathic  No apparent structural changes in the brain Secondary Epilepsy  Characterized by structural changes or metabolic alterations of the neuronal membranes that caused increased automacity


Causes of Seizures:
           

Idiopathic- twoIdiopathic- 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 toxins( monoxide) Metabolic disorders, such as hypoglycemia or hypoparathyroidism Perinatal infections

Pathophysiology:


Some neurons of the brain may depolarize easily or hyperexcitable. hyperexcitable. On stimulation, these neurons fire locally or throughout the cerebrum and spreads electric current to surrounding cells. Cells fire in turn and the impulses cascades to seizure), one side of the brain ( a partial seizure), both seizure), sides of the brain (a generalized seizure), or the cortical, subcortical, and brain stem areas. subcortical,

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 tonictonic-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 MRIEEGEEG- reveals paroxysmal abnormalities in tonic-clonic seizures, high, fast voltagespikes are tonicpresent 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 xthe 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), Dilantin) Tegretol), phenobarbital (Barbita, Luminal) for generalized tonic Barbita, Luminal) clonic seizures and complex partial seizures Valproic acid (Depakene), clonazepam (Klonopin) for (Depakene), Klonopin) absence seizures If drug therapy is inefective, surgery to remove a inefective, demonsrated focal lesion, or to remove the underlying cause (tumor, abscess) I.V. I.V. diazepam ( valium), lorazepam (Ativan) phenytoin, Ativan) phenytoin, or phenobarbital for status epilepticus DextroseDextrose- for hypoglycemia ThiamineThiamine-for chronic alcoholism or withdrawal

  

Nursing Considerations
Patent airway  Oxygenate as needed  Raise side rails pad side rails  Ensure safety-during seizure: safetyAvoid restraining the pt Help the pt to a side- lying position sideLoosen 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  Avoid alcohol  Meds as ordered  Make documentation


Increased Intracranial Pressure

ICPICP- the pressure exerted within the intact skull by the intracranial volumevolume-about 10% blood,10% CSF, & 80% brain tissue. Causes : head injury CVA tumors HPN Overproduction of CSF due to tumor Pathophysiology: Pathophysiology: ^ICP- the brain will compensate by: ^ICPlimiting blood flow to the head displaces CSF into the spinal canal 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, venous congestion. Further increase in ICP will result to cellular hypoxia and eventually, brain death.

Monro s Theory Brain Bony Skull No Room for Expansion Increase in the Bulk of the Brain Compression of Brain Structures and Blood Supply Cerebral Ischemia Cerebral Hypoxia Necrosis (Cerebral infarction) Inflammation Cerebral edema Increase Intracranial Pressure


Box Theory

MONRO-KELLIE HYPOTHESIS

 an inc. in any one of the contents of the cranium is usually

accompanied by a reciprocal change in volume of one of the others

Major Types of Herniation

Increased Intracranial Pressure

S&S:  Restlessness initial sign  Increased HA  Nausea & Vomiting pressure at medulla  Cushing s triad bradycardia, hypertension & bradycardia, bradypnea  Eye involvement CN VI; diplopia  Altered LOC earliest sign  Sensory dysfunction  Elimination problem bowel/bladder  Decorticate above midbrain  Decerebrate - brainstem  Cushing s response/reflex inc SBP,widening of PP, reflex slowing of the heart; RR is dec.; late sign dec.;

Cont. S/S  Pupillary Changes Anisocoria due to CN III compression ipsilateral pupil dilatation  Fixed dilated pupils indicate uncal herniation compression of the brainstem respiratory arrest  Papilledema compression of the optic nerve Choked disc  Lateralizing sign contralateral loss of motor function due to decussation of fibers at medulla e.g. left brain affected R hemiplegia right brain affected L hemiplegia

NURSING MANAGEMENT OF INCREASED ICP:

     

   

Determine airway patency Elevate HOB Semi-Fowler s SemiCheck VS/neuro assessment VS/neuro Record I&O Enema restriction Avoid coughing, sneezing, vomiting, restraints, stress ulcer, suctioning, rectal exam, vasalva maneuver, bending control HPN Seizure precaution Edema reduction Diuretics

Pharmacotherapy  Mannnitol osmotic diuretic; reduce cerebral edema

 Lasix  Decadron (Dexamethasone) reduce cerebral edema; only steroid that can pass through the blood-brain barriers  Anticonvulsants : Valium (Diazepam)  Dilantin (Phenytoin Sodium) give after meals to prevent GI upset  prep- 10 ml NSS to flush IV line before/after admin.  gum hyperplasia soft bristled tooth brush; massage  Phenobarbital (Na Luminal) sedation in adults; paradoxical active reaction in children; habituation  Tegretol (Carbamazepine)

rash, ataxia, drowsiness

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, Concussions. forceful contact with the rigid skull. There is transient period of unconsciousness. Contusion (bruising). A structural alteration characterized by extravasion of blood cells. Laceration. Laceration. Tearing of tissue caused by sharp fragment or object or shearing force. Compression of the Brain. Result from depressed Brain. 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. (CSF positive for nose. glucose) Monitor for signs and symptoms of meningitis, atelectasis, atelectasis, pneumonia, UTI.

Intracranial Tumors


Intracranial tumors may be classified as: gliomas, meningiomas, neuromas, gliomas, meningiomas, neuromas, hemangiomas. hemangiomas. Gliomas account for about 50% of all brain tumors.

Brain Tumors
Symptoms are dependent upon the location and size of the lesion and the compression of associated structures Manifestations:

Localized or generalized neurologic symptoms Symptoms of increased ICP Headache Vomiting Visual disturbances
Hormonal effects with pituitary adenoma Loss of hearing, tinnitus, and vertigo with acoustic neuroma

Common Brain Tumor Sites

Diagnostic Evaluation
Neurologic examination CT scan MRI PET scan EEG Cytologic study of cerebral spinal fluid Biopsy

Frontal lobe


Assessment

Personality disturbance  Inappropriate affect  Indifference of bodily functions



Precental gyrus


Jacksonian seizures Visual disturbances preceeding convulsions.

Occipital lobe


Temporal lobe
Olfactory, visual or gustatory hallucinations.  Psychomotor seizures with automatic behavior.


Parietal lobe
Inability to replicate pictures.  Loss of right-left discrimination right

Management
 

Care for the client with increase ICP(preop & post op) ICP(preop Surgery  Supratentorial craniotomy (post-op) (post Semi-fowler Semi-

s position

Infratentorial craniotomy
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. Pressure on neurohypophysis insipidus.  Test the urine for glucose and acetone when steroids are administered.
 Flat

Spinal Cord Injury

complete or partial disruption of nerve tracts and neurons infection Causes : trauma injury
-

Signs and symptoms



 

Cervical respiratory diff, quadriplegia; bowel/bladder retention Thoracic- paraplegia, poor control of Thoracicupper trunk Lumbar flaccid paralysis Sacral loss of erection, ejaculation; bowel/bladder incontinence

Nursing Asessment:
    

Injury; treatment given at scene Neurologic assessment: Document findings Vital signs; respiratory status Movement and sensation below injury level Signs
Worsening neurologic damage  Respiratory distress  Spinal shock


Nursing Diagnoses:
     

Ineffective breathing pattern Ineffective airway clearance Neuropathic pain Impaired physical mobility Anxiety Risks
Impaired gas exchange  Disuse syndrome  Ineffective coping


Medical Management
   

Cervical collar; cast or brace; traction; turning frame IV; stabilization of vital signs Corticosteroids Surgical intervention Surgery to  Remove bone fragments  Repair dislocated vertebrae  Stabilize the spine

Surgical Management


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 Arthropod Fungal Encephalitis  Creutzfeldt-Jakob and New-Variant CreutzfeldtNewCreutzfeldtCreutzfeldt-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