Gross anatomyThe nervous system is divided into the central and peripheral nervous systemThe Central nervous system consists of the BRAIN and the Spinal CordThe peripheral nervous system consists of the Spinal nerves and the cranial nerves

The nervous system is the master controller of the body. Each thought, each emotion, each action—all result from the activity of this system. It then processes that information and decides how the body should respond, if at all.

Finally, if a response is needed, the system sends out electrical signals that spur the body into immediate action.

The central nervous system is made up of the brain and spinal cord. The brain functions to receive nerve impulses from the spinal cord and cranial nerves.

The spinal cord contains the nerves that carry messages between the brain and the body.

The brainThe human brain is a soft, shiny, grayish white, mushroom-shaped structure encased within the skull.

Although brain size varies considerably among humans, there is no correlation or link between brain size and intelligence.

The brain is composed of lobes-Frontal lobe- personality, memory and motor functionParietal lobe- sensory functionTemporal lobe- hearing and olfaction and emotion by the limbic systemOccipital lobe- vision

The left cerebral hemisphere controls movement of the right side of the body. Depending on the severity, a stroke affecting the left cerebral hemisphere may result in functional loss or motor skill impairment of the right side of the body, and may also cause loss of speech.

The right cerebral hemisphere controls movement of the left side of the body. Depending on the severity, a stroke affecting the right cerebral hemisphere may result in functional loss or motor skill impairment of the left side of the body. In addition, there may be impairment of the normal attention to the left side of the body and its surroundings.

The thalamus is an important relay station for sensory information coming to the cerebral cortex from other parts of the brain.

The thalamus also interprets sensations of pain, pressure, temperature, and touch, and is concerned with some of our emotions and memory.

Cerebellum- Is both excitatory and inhibitory actions and responsible for coordination of movement. It controls also fine movements, balance, position sense or proprioception and integration of sensory input.

The cerebellum is involved in coordination and equilibriumThe diencephalon consists of the :

Thalamus- the relay center of all sensory inputHypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal, hunger, satiety

The cerebellum processes input from other areas of the brain, providing precise timing for coordinated, smooth movements of the skeletal muscular system.

A stroke affecting the cerebellum may cause dizziness, nausea, balance and coordination problems.

Test for balance- heel to toe

Test for coordination- rapid alternating movements and finger to nose test

ROMBERG test

BALANCE TESTS:

B. ROMBERG TEST- Ask the person to stand up with feet together and arms at

the side.- Ask the client to close the eyes and to hold the position for

about 20 seconds.

Normally, a person can maintain posture and balance even with the visual orienting information blocked, although slight swaying may occur.

Positive Romberg sign (loss of balance that occurs when closing the eyes) occurs with cerebellar ataxia, loss of proprioception and loss of vestibular function.

BALANCE TESTS:

A. TANDEM WALKING

- Ask the person to walk a straight line in a “heel-to-toe” fashion.

Tandem walking decreases the base of support and accentuates problem with coordination.

Normally, the person can walk straight and stay balanced.

Inability to tandem walk may indicate upper motor neuron lesion such as in multiple sclerosis.

COORDINATION TESTS:

A. RAPID ALTERNATING MOVEMENTS (RAM)

- Ask the person to pat the knees with both hands, patting alternately with the dorsum and palmar surfaces of the hands.

- Start slowly then ask the client to do it faster.

- Ask the person to touch the thumb to each finger on the same hand, starting with the index finger then reverse direction.

STEREOGNOSIS – test the person’s ability to recognize objects by feeling their forms, sizes and weights.

- Ask the client to close his eyes and identify an object that is placed in his hand.

- Test a different object in each hand.

Normally, a person will explore the object with the fingers and correctly name it.

Testing the left hand assesses right parietal lobe functioning. ASTEREOGNOSIS occurs in sensory cortex lesions.

GRAPHESTESIA – ability to read a number by having it trace on the skin.

- With the client’s eyes closed, use a blunt instrument to trace a number or a letter on the palm.

- Ask the person to tell you what the number or letter is.

- The brainstem is composed of the:- MIDBRAIN- for visual and auditory

reflexes- Pons- respiratory apneustic center,

nucleus of cranial nerves- 5,6,7,8- Medulla oblongata- respiratory and

cardiovascular centers, nucleus of cranial nerves 9,10,11,12

The Brain stem is the stalk of the brain and is a continuation of the spinal cord.

It consists of the medulla oblongata, pons, and midbrain. The medulla oblongata is actually a portion of the spinal cord that extends into the brain.

All messages that are transmitted between the brain and spinal cord pass through the medulla. Nerves on the right side of the medulla cross to the left side of the brain, and those on the left cross to the right.

The result of this arrangement is that each side of the brain controls the opposite side of the body.

Three vital centers in the medulla control heartbeat, rate of breathing, and diameter of the blood vessels.

Centers that help coordinate swallowing, vomiting, hiccuping, coughing, sneezing, and other basic functions of life are also located in the medulla.

Pons bridge between the two halves of the cerebellum and between medulla cerebrum.It also controls the heart, respiration, blood pressure.CN V, VIII connects in the brain in the pons.

Test for the Oculocephalic reflex- doll’s eyeNormal response- eyes appear to move opposite to the movement of the headAbnormal- eyes move in the same direction

What is the spinal cord?The spinal cord is part of the nervous system and is about 45 cm long in men and 43 cm long in women.

The length of the spinal cord is much shorter than the length of the bony spinal column. It runs the length of the back, extending from the base of the brain to about the waist.

The area within the vertebral column beyond the end of the spinal cord is called the cauda equina.

The nervous system is made up of nerve cells or neurons. Neurons have a limited ability to repair themselves. Unlike other body tissues, nerve cells cannot also be repaired if damaged due to injury or disease.

Can't remember the names of the cranial nerves? Here is a handy-dandy mnemonic for you:

SenSenMoMoMiMoMiSenMiMiMoMo

CRANIAL NERVES FUNCTIONS ABNORMAL FINDINGS

I. Olfactory Smell Anosmia (absence of smell)

II. Optic Vision blurred vision; blindness

III. Oculomotor Pupil constriction, elevation of the upper lid.

fixed, dilated pupils

IV. Trochlear Eye movement; controls superior oblique muscle.

Nystagmus

V. Trigeminal Controls of muscles of mastication; sensations for the entire face.

Trigeminal Neuralgia (tic douloureux)

VI. Abducens Eye movement; controls the lateral rectus muscle.

Diplopia; ptosis of the eyelid.

VII. Facial Controls muscles for facial expression; anterior 2/3 of the tongue.

Bell’s palsy; ageusia (loss of sense of taste) of the anterior 2/3 of the tongue.

VIII. Acoustic Cochlear branch permits hearing; vestibular branch helps maintain equilibrium.

Tinnitus; vertigo

IX. Glossopharyngeal Controls muscles of the throat; taste of the posterior 1/3 of the tongue.

Loss of the gag reflex, drooling of the saliva, dysphagia, dysphagia, dysphonia, posterior third ageusia.

X. Vagus nerve Controls muscles of the throat, PNS stimulation of thoracic and abdominal organs.

Loss of gag reflex, drooling of the saliva, dysphagia, dysarthia, bradycardia, increased HCl secretion.

XI. Spinal Accessory Controls sternocleidomastoid and trapezius muscles.

XII. Hypoglossal Movements of the tongue.

PHYSICAL EXAMINATION5 categories:

1. Cerebral function- LOC, mental status2. Cranial nerves3. Motor function4. Sensory function5. Reflexes

CATEGORIES OF CONSCIOUSNESSNORMAL Spontaneous eye opening & aware of self &

environment.

LETHARGIC State of drowsiness or inaction which pt. needs an increase stimulus. To be awaken.

OBTUNDED Duller indifferences to external stimuli &

response is minimally maintained.

STUPOR Marked reduction in mental & physical activity, vigorous & continuous stimuli needed. Shows

some spontaneous movement.

COMA Does not respond to any stimuli, no voluntary movement. Reflexes maybe intact or absent.

GLASCOW COMA SCALE to assess these simple three (3) parameters:

1. THE OPENING OF THE EYES;2. THE USE OF VOICE;

3. and, THE BEST MOVEMENT ( Motor Response).

The GCS assigned a score to its function:

I - As the lowest number ( absence of function ) I5 – As the highest score 8 OR LESS – defines coma ( which indicates less brain function and suggest a higher degree of injury ).

Coma represents the last and lowest level of function of the brain prior to death. As a general rule: IF A PATIENT IN COMA SURVIVES FIRST 7 to 10 days following THE INJURY OF THE BRAIN, THEN LONG TERM SURVIVAL CAN BE EXPECTED, HOWEVER THE QUALITY OF THE SURVIVAL REMAINS A SUBJECT OF DEBATE.

EYE OPENING E

Spontaneous 4

To speech 3

To pain 2

No response 1

BEST MOTOR RESPONSE M

To Verbal Command:  

Obeys 6

To Painful Stimulus:  

Localizes pain 5

Flexion-withdrawal 4

Flexion-abnormal 3

Extension 2

No response 1

BEST VERBAL RESPONSE V

Oriented and converse 5

Disoriented 4

Inappropriate words 3

Incomprehensible sounds 2

No response 1

Glasgow Coma Score8 and Below= severe head injury!

Assessing the sensory function Evaluate symmetric areas of the bodyAsk the patient to close the eyes while testingUse of test tubes with cold and warm waterUse blunt and sharp objectsUse wisp of cottonAsk to identify objects placed on the handsTest for sense of position

C5 – The deltoid muscle (abduction of the arm at the shoulder).C6 – The biceps (flexion of the arm at the elbow).C7 – The triceps (extension of the arm at the elbow).C8 – The small muscles of the hand. L4 – The quadriceps (extension of the leg at the knee).L5 – The tibialis anterior (upward flexion of the foot at the ankle).S1 – The gastrocnemius muscle (downward flexion of the foot at the ankle).FOUR POINT SCALE FOR GRADING REFLEXES

4+ - very brisk, hyperactive with clonus, indicative of disease.

3+ - brisker than average, may indicate disease.

2+ - average, normal.

1+ - diminished, low normal.

0 - no response

Deep tendon reflex0- absent+ present but diminished++ normal+++ increased++++ hyperactive or clonic

Superficial reflex0 absent+present

EEGWithhold medications that may interfere with the results- anticonvulsants, sedatives and stimulantsWash hair thoroughly after the procedure

Definition1. Measurement and recording of electrical activity of the brain in the form of waves2. Provides information about seizure disorders, local tumors,infections of the central nervous system, and chemical toxicity

CT scanWith radiation riskIf contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected Cross-sectional visualization of the brain determined by computer analysis of relative tissue density as an x-ray beam passes through; also known as computerized axial tomography (CAT) scan

PET scanDefinition1. This test registers glucose metabolism in a cross-section of the brain; glucose metabolism increases in areas of the brain that are active2. Utilized to diagnose Alzheimer's disease, depression, dementia,and brain tumors

MRI Uses magnetic waves Patients with pacemakers, orthopedic metal prosthesis and

implanted metal devices cannot undergo this procedureThis procedure utilizes magnetism and radio waves to produce images of cross-sections of the body

Cerebral arteriography / angiography Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

Lumbar puncture / Spinal tap Ensure consent, determine ability to lie still Contraindicated in patients with increased ICP*** Keep flat on bed after procedure** Increase fluid intake after procedure

Increased Intracranial pressureBrunner= Normal intracranial pressure 10-20 mmHgCauses:

Head injuryStrokeInflammatory lesionsBrain tumor

Surgical complicationsSubarachnoid hemorrhagesViral infection

PathophysiologyThe cranium only contains the brain substance, the CSF and the blood/blood vesselsMONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the otherAny increase or alteration in these structures will cause increased ICPIn response Pathologic conditions alter the relationship intracranial volume and ICP2. reduction of oxygen will lead to brain damage will lead to edema of the brain and shifting of fluids from the dura and increase ICP.3. Increase PaCO2 lead to increase ICP

Nursing interventions: Maintain patent airway

1. Elevate the head of the bed 30 degrees- to promote venous drainage2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levelsàconstricts blood vesselsàreduces edema3. Administer prescribed medications- usually

Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants- to prevent seizures

4. Reduce environmental stimuli5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning, flexion of the head**

6. Keep head on a neutral position. AVOID- extreme flexion, valsalva7. monitor for secondary complications

Diabetes insipidusSIADH

Altered level of consciousnessIt is a manifestation of multiple pathophysiologic phenomenaCauses: head injury, toxicity and metabolic derangementDisruption in the neuronal transmission results to improper function

AssessmentOrientation to time, place and personMotor function

DecerebrateDecorticate

Sensory function

COMA= clinical state of unconsciousness where patient is NOT aware of self and environment

Etiologic Factors1. Head injury 2. Stroke3. Drug overdose4. Alcoholic intoxication5. Diabetic ketoacidosis6. Hepatic failure

ASSESSMENT1. Behavioral changes initially2. Pupils are slowly reactive

3. Then , patient becomes unresponsive and pupils become fixed dilated

Glasgow Coma Scale is utilized

Nursing Intervention1. Maintain patent airway

Elevate the head of the bed to 30 degreesSuctioning

2. Protect the patientPad side railsPrevent injury from equipments, restraints and etc.

3. Maintain fluid and nutritional balanceInput and output monitoringIVF therapyFeeding through NGT

4. Provide mouth careCleansing and rinsing of mouthPetrolatum on the lips

5. Maintain skin integrityRegular turning every 2 hours30 degrees bed elevationMaintain correct body alignment by using trochanter rolls, foot board

6. Preserve corneal integrityUse of artificial tears every 2 hours

7. Achieve thermoregulationMinimum amount of beddingsRectal or tympanic temperatureAdminister acetaminophen as prescribed

8. Prevent urinary retentionUse of intermittent catheterization**

9. Promote bowel functionHigh fiber dietStool softeners and suppository

10. Provide sensory stimulationTouch and communication**Frequent reorientation

Autonomic Dysreflexia/hyperreflexiaSeen commonly in spinal cord injury above T6An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation***

Trigeminal neuralgia (tic douloureux) Findings

– intense facial pain lasting about one to two minutes along the nerve branches – extreme facial sensitivity

Diagnostics: history and physical exam Management

– expected outcome: to relieve pain – anticonvulsants: phenytoin (dilantin) – help clients to name trigger points with identification of triggering incidents – recommend restful environment with scheduled rest – provide balanced nutrition

teach client medications and side effects to avoid triggering agents to chew on the opposite side of the mouth to avoid very hot or cold foods

Facial nerve paralysis (bell's palsy)Definition/etiology

disorder of cranial nerve seven (facial nerve)involves one side only; unilateraletiology unknown

Findings often occur suddenly over ten to 30 minutes ptosis cannot close or blink eye with excessive tearing flat nasolabial fold impaired taste lower face paralysis difficulty eating Diagnostics: history and physical exam Management

– expected outcome: to restore cranial nerve function – medications

» prednisone » analgesics

– local comfort measures: heat, massage and electrical nerve stimulation for muscle tone

– alternative actions: massage, imagery

– administer drugs as ordered – teach client

» to chew on opposite side » how to use protective eye wear during risk periods » effects of steroids » the use of eye drugs or ointment to protect the eye from corneal irritation » that once findings disappear their return may occur especially in times of high stress – provide balanced nutrition: soft diet » use of eye patch» Physical Therapy

Traumatic brain injuryAN INJURY TO THE BRAIN OR SCALP AS A RESULT OF TRAUMA.Occurs when a mechanical force comes in contact with a portion of the brain. (generally the frontal or temporal lobes) directly or indirectly

Most common causesVehicle accidents compounded by drugs or alcohol useActs of violenceFallsSports –related injury

Occurs most in males between 10-39 yrs oldTypes:

a. Minor1. Laceration of the scalp-tearing of the vessels of the scalp that

may cause bleeding2. Contusion- brief loss of consciousness;may also experience

amnesia and headaches.Major:

1. Fractures – comminuted, linear , or depressedClinical manifestations:Battle’s sign (post-auricular ecchymosis)Racoon’s eye (periorbital edema)Rrhinorrhea (leakage of CSF from nose)Otorrhea – fluid from ear2. Epidural hematoma – arterial bleed result of temporal bone.3. Subdural hematoma- venous bleed generally result of a laceration of brain tissue.

Findings of head trauma

Degree of neurological damage varies with type and location of injury

Restlessness and irritability - initially Decreased LOC - lethargy, difficulty with arousal,amnesiaNausea and vomiting - projectile vomiting indicates increased ICP Cushing’s reflex- severe hypertension and wide pressure is a late

sign.Hypovolemic shockBehavioral changesWeaknessAtaxiaDecreased muscle tone

1. CONCUSSIONInvolves jarring of head without tissue injuryTemporary loss of neurologic function lasting for a few minutes to hours

2. CONTUSIONInvolves structural damageThe patient becomes unconscious for hours

3. Intracranial hemorrhageEpidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery***

Symptoms develop rapidly**MANIFESTATIONS

1. Altered LOC2. CSF otorrhea3. CSF rhinorrhea4. Racoon eyes and Battle sign

NURSING MANAGEMENT1. Monitor for declining LOC- use of Glasgow2. Maintain patent airway

Elevate bed, suction prn, monitor ABGLogroll the client

3. Monitor for rhinorhea or otorrhea4. Administer good skin care5. Monitor for increase intracranial pressure6. Provide adequate nutrition7. Prevent injury

Use padded side railsAvoid extreme flexion or extension of the neck

8.Elevate the head of the bed to 30 degrees9.Provide warm or coldcompress to the eyes to dec. periorbital edema10.. Maintain skin integrity

Prolonged immobility will likely cause skin breakdownTurn patient every 2 hoursProvide skin care every 4 hoursAvoid friction and shear forcesPrevent complications of immobility

7. Monitor potential complicationsIncreased ICPMeningitis**Post-traumatic seizuresImpaired ventilation

Surgical management:Craniotomy:performed to decrease ICP to remove ischemic tissues

Spinal Cord Injury Injury to the spinal cord as a result of an incomplete or complete loss of sensory and motor function.Caused by MVA, sports injuries or violence and falls.

The greatest at risk is the 16 to 30 yr.old category.The real danger lies in possible spinal cord damage. Spinal fractures most commonly occur in the 5th, 6th, and 7th cervical, 12th thoracic, and 1st lumbar vertebrae.

Complications:Spinal shock-occurs immediately following the injury.

Characterized by:- decreased reflexesLoss of sensationFlaccid paralysis below the site of injury

Neurogenic shock- loss of vasomotor tone results from the injury characterized by: hypotension,bradycardia.- Occurs with cervical or high thoracic injury

Types of injury:a. Incomplete1. Central cord syndrome- occurs in older adults in the cervical

cord area2. Anterior cord syndrome- results from flexion injury with

motor paralysis and loss of pain and temperature below the site of injury

3. Posterior cord syndrome-rare;loss of proprioception4. Brown-sequard syndrome-loss of motor function ipsilateral and contralateral pain and temperature remains intact below the level of injury.5. Conus medullaris and cauda equina- lower limb paralysis,bowel and bladder dysfxn. In th elumbar and sacral area.

AUTONOMIC HYPERREFLEXIA /DYSREFLEXIA- Autonomic dysreflexia (hyperflexion)

- Occurs in injury at T6 or above.- Most common cause is overdistended bladder or bowel- Characterized by hypertension (systolic greater than

300mmHg),bradycardia,diaphoresis and piloerection( body hair erection.), nausea and nasal congestion

NURSING INTERVENTIONS1. Elevate the head of the bed immediately2. Check for bladder distention and empty bladder with urinary catheter3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer4. Administer antihypertensive medications- usually hydralazine

Spinal ShockPathophysiology

The sudden depression of reflex activity in the spinal cord below the level of injuryThe muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functionsSpinal shock: A rare condition that can occur after spinal cord injury and involves a period of absent reflexes which may be permanent or last for hours to weeks. This period may be followed by a period of excessive reflexes.

Signs and symptoms of spinal shockAbsence of reflexParaplegiaAtonic paralysisSensory loss

Nursing Interventions

The primary treatment after a spinal injury is immediate immobilization to stabilize the spine and prevent cord damage; other measures are supportive. Cervical injuries require immobilization, using a type of cervical immobilization device (CID) on both sides of the patient’s head, a hard cervical collar, or skeletal traction

Treatment of stable lumbar and dorsal fractures consists of bed rest on firm support (such as a bed board)

Later measures include exercises to strengthen the back muscles and use of a back brace or other device to provide support while walking.Reorient the patient by calling his name frequentlyProvide background information as to date, time, place, environment

3. Use large signs as visual cues4. Post patient's photo on the door5. Encourage family members to bring personal articles and place them in the same area

Establish a regular pattern for bowel carePlace the patient on potty every other dayUse of stool softeners

Maintain a dietary intake. Avoid foods that can cause excessive gas productionElevate the head of the bed 90 degrees during meals and 30 minutes afterServe foods that are soft and small sizedKeep suction equipment on bedsideConsult with rehabilitation team as to assistive devices that can be utilized

Clinical manifestations1. Paraplegia2. quadriplegia3. diplegiaEMERGENCY MANAGEMENTA-B-CImmobilizationImmediate transfer to tertiary facility

NURSING INTERVENTION1. Promote adequate breathing and airway clearance2. Improve mobility and proper body alignment***3. Promote adaptation to sensory and perceptual alterations4. Maintain skin integrity

5. Maintain urinary elimination6. Improve bowel function7. Provide Comfort measures8. Monitor and manage complications

ThrombophlebitisOrthostatic hypotensionSpinal shockAutonomic dysreflexia

CEREBROVASCULAR ACCIDENTSAn umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supplyDefinition: decreased blood supply to the brain Risk factors

hypertension, uncontrolled smoking obesity increased blood cholesterol and triglycerides

chronic atrial fibrillation

Major risk factors» Coronary artery dse.» Hypertension» Age» DM» Previous TIA

» transient ischemic attack (TIA), "angina" of the brain

» TIA is warning sign of stroke » localized ischemic event » produces neurological deficits lasting only minutes or hours » full functional recovery within 24 to 48 hours» reversible ischemic neurological deficit (RIND) » similar to TIA

Two types of stroke by cause – ischemic (also known as

occlusive) stroke (clot) - slower onset » results from

inadequate blood flow leading to a cerebral infarction » caused by

cerebral thrombosis or embolism within the cerebral blood vessels

» most common cause: atherosclerosis

– There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

CLINICAL MANIFESTATIONS1. Numbness or weakness2. confusion or change of LOC3. motor and speech difficulties4. Visual disturbance5. Severe headache

– hemorrhagic stroke (bleeding) - abrupt onset ; TYPES» blood vessels rupture with a bleed into the brain » occurs most often in hypertensive older adults » may also result during anticoagulant or thrombolytic therapy » most often caused by rupture of saccular intracranial

aneurysms The Circle of Willis is the joining area of several arteries at the bottom (inferior) side of the brain.

At the Circle of Willis, the internal carotid arteries branch into smaller arteries that supply oxygenated blood to over 80% of the cerebrum.

Middle cerebral artery:Aphasia – inability to communicateDysphagiaHEMIPARESIS on the OPPOSITE side- more severe on the face and arm than on the legs (weakness)

Anterior cerebral artery:WeaknessNumbness on the opposite sidePersonality changesImpaired motor and sensory function

Posterior cerebral artery:Visual field defectsSensory impairmentComaLess likely paralysis

RISKS FACTORS

Non-modifiableAdvanced ageGenderrace

ModifiableHypertensionCardio diseaseObesitySmokingDiabetes mellitushypercholesterolemia

Motor LossHemiplegia – paralysis of one side of the body after a strokeHemiparesis - weakness

Communication lossDysarthria= difficulty in speakingAphasia= Loss of speechApraxia= inability to perform a previously learned action

Perceptual disturbancesHemianopsia – defective vision or blindness in half of the visual field of one or both eyes.

Sensory lossParesthesia – any abnormal touch sensation as numbness or tingling in the absence of stimuli

NURSING INTERVENTIONS: ACUTE1. Ensure patent airway2. Elevate head3. Monitor VS and GCS, pupil size4. IVF is ordered but given with caution as not to increase ICP5. NGT inserted6. Medications: Heparin, Enoxaparin, t-PA, ASA, Steroids,

Mannitol (to decrease edema), DiazepamNURSING INTERVENTIONS: Hospital1. Improve Mobility and prevent joint deformities

Correctly position patient to prevent contracturesPlace pillow under axillaHand is placed in slight supination- “C”Change position every 2 hours

2. Enhance self-care Carry out activities on the unaffected side

Prevent unilateral neglect- place some items on the affected side!!!Keep environment organizedUse large mirror

3. Manage sensory-perceptual difficultiesApproach patient on the Unaffected sideEncourage to turn the head to the affected side to compensate for visual loss

4. Manage dysphagiaPlace food on the UNAFFECTED sideProvide smaller bolus of foodManage tube feedings if prescribed

5. Help patient attain bowel and bladder controlIntermittent catheterization is done in the acute stageOffer bedpan on a regular scheduleHigh fiber diet and prescribed fluid intake

6. Improve thought processesSupport patient and capitalize on the remaining strengths

7. Improve communicationAnticipate the needs of the patient

Offer supportProvide time to complete the sentenceProvide a written copy of scheduled activitiesGive one instruction at a time

8. Maintain skin integrityUse of specialty bedRegular turning and positioningKeep skin dry and massage NON-reddened areasProvide adequate nutrition

9. Promote continuing careReferral to other health care providers

10. Improve family coping11. Help patient cope with sexual dysfunction

Multiple sclerosis Definition demyelination of white matter throughout brain and spinal cord

– third most common cause of disability in clients aged 15 to 60 – specific cause unknown – increased incidence in temperate to cool climates – illness improves and worsens unpredictably

Findings depend on the location of the demyelination – cranial nerve: blurred vision, dysphagia, diplopia, facial weakness

and/or numbness – motor: weakness, paralysis, spasticity, gait disturbances – sensory: paresthesias, decreased proprioception – cerebellar: dysarthria, tremor, incoordination, ataxia, vertigo

– cognitive: decreased short-term memory, difficulty with new information, word-finding difficulty, short attention span

– urinary retention or incontinence – loss of bowel control – sexual dysfunction – fatigue

» avoid fatigue and stress » conserve energy » exercise regularly » know drugs and side effects » use self-help devices » maintain a diet that supports nutrition and energy needs

Guillain Barre Syndrome Definition

– acquired inflammatory disease – process: demyelinization of peripheral nerves – precipitating factors include prior bacterial or viral infection within

one to two weeks – muscle weakness: progressive, ascending, bilateral – leads to paralysis of voluntary muscles – loss of superficial and deep tendon reflexes – bulbar weakness – dysphagia – dysarthria – respiratory failure – sensory findings: paresthesias, burning pain – paralysis may vary from being total to partial of only one-half way

up the body

– expected outcomes: to prevent complications and maintain body functions until any reversal

– steroids in acute phase – care as dictated by areas involved

Nursing interventions – maintain the care of client on ventilatory support   – provide for care of the immobilized client – have a safe environment to minimize infection – maintain nutrition and fluid balance – refer families or client to support groups – supply referrals to therapies such as speech, physical, occupational

and counseling

Myasthenia Gravis Definition:

– antibodies destroy acetylcholine receptors where nerves join muscles

– two age clusters: women in early adulthood and men in late adulthood

– progressive with occurrence of crises

– progressive fatigue of voluntary muscles, but no muscular atrophy – facial

» ptosis (drooping eyelid) and reduced eye closure » weak smile » diplopia, blurred vision » speech and swallowing disorders » weakness of facial muscles

– signs of restrictive lung disease – sensation remains intact

– history and physical exam – edrophonium (tensilon) test: improved muscle strength after tensilon injection indicates a positive test for MG

Management – expected outcome to improve strength and endurance – pharmacologic

» anticholinesterase agents: pyridostigmine (mestinon), neostigmine (prostigmin)

» corticosteroid therapy » immunosuppressants: azathioprine (imuran)

– myasthenic crisis management » crisis usually follows stressor or during dosage changes » signs: sudden inability to swallow, speak, or maintain

patent airway » cholinergic crisis may follow over dosage of medication » positive edrophonium (tensilon) test signals myasthenia » if negative endophronium test, client has not myasthenic

but cholinergic crisis, so treat with atropine » ventilatory support as indicated

– identify aggravating factors, such as: » infection » stress » changes in medication regime

– if client is in crisis: provide care of the client on ventilatory support   – give medications as ordered and on time – help with ADL and feeding as indicated

– provide » emotional support » adequate rest periods » care of the surgical client

– teach client » energy conservation techniques

» medications, expectations and side effects » signs of impending crisis, both myasthenic and

cholinergic » to avoid stressors

Parkinson's disease Definition: degenerative disorder of the dopamine hydrochloride - producing neurons (substantia nigra of the basal ganglia)

– result: dopamine hydrochloride depletion – usually occurs in older adults and males more than females – etiology unknown

– resting tremors of  the lips, jaw, tongue, and limbs, especially a resting pill-rolling tremor of one hand that is absent during sleep. This is different from an essential or intention tremor in which the tremor is action related. 

– bradykinesia / akinesia– fatigue – stiffness and cogwheel rigidity with movement – signs first unilateral, then bilateral – mask-like facial expression – slow, shuffling walk; gradually more difficult – Drooling of saliva– Dysphagia– Trunk bent forward– Microphonia– Micrographia– difficulty rising from sitting position – No intellectual impairment– No true paralysis– No loss of sensation

DIET: Inc. caloriec, soft dietPosition to prevent contractures:firm beds, no pillowsProne position when lying in bed

– pharmacologic » anticholinergics - minimize extrapyramidal effects

» dopamine hydrochloridergics-improve muscle flexibility: Levodopa (L-Dopa)

» antiparkinsonian agent: amantadine hcl (Symmetrel) reduces rigidity and tremor

Avoid the following foods rich in Vit. B6 when on Levodopa therapy;may block the effects of levodopa.

TunaporkDried beans

Avoid tyramine rich foods (may cause hepertensive crisis)Cream chocolateCheese coffee

Seizure Definition/etiology Sudden, transient alteration in brain function Disorderly transmission of electrical activity in the brain Causes

– cerebral lesions – biochemical alteration – cerebral trauma – idiopathic

Types of generalized seizures - one classification system Absence seizures (petit mal seizures) Myoclonic seizures (bilateral massive epileptic myoclonus)

Generalized tonic-clonic seizures (grand mal seizures) Akinetic seizure petit mal - called absence seizures myoclonic

sudden, uncontrollable jerking movements of one or more extremities

usually occurs in the morning clonic

characterized by violent muscle movements hyperventilation face contortion excessive salivation

tonic first, client loses consciousness suddenly and muscles

contract body stiffens in opisthotonos position jaws clenched may lose bladder control apnea with cyanosis pupils dilated and unresponsive usually lasts less than a minute

– grand mal: most common type » tonic-clonic movements » lasts two to three minutes » client is unresponsive for about five minutes » arms, legs go limp » breathing returns to normal » possible disorientation or confusion for sometime

afterwards

– atonic: sudden loss of postural muscle tone with collapse – status epilepticus

» rapid sequence of seizures without interruption » medical and nursing emergency » sometimes occurs if a sudden stop of maintenance doses

of anticonvulsants

» if cerebral anoxia occurs, brain damage or death can follow

1. remove harmful objects from the patient’s surrounding2. ease the client to the floor3. protect the head with a pad4. Observe and note for the duration, parts of body affected,

behaviors before and after the seizureDo not leave the client who is seizing Attempt to prevent or break client's fall by assisting him/her to

horizontal position on the bed or the floor Loosen tight clothing around neck and chest Remove objects near the client Place a pillow under the client's head if possible and available Place the client's head in a lateral position if possible to maintain

airway Place nothing in the client's mouth

type of seizure - describe behavior rather than labeling duration activity during and if incontinence if any precipitating factors client's response - immediate, then at 15 minute intervals until

stability is established

» about medication effects, interactions, and side effects » to learn when a seizure may be triggered » techniques to reduce stress » seizure care at home or at work » to wear medic-alert jewelry » if in public area, after the tonic phase turn client to side

In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition and bowel control.

Peripheral nerves can regenerate, but nerves in the spinal cord are thought to not be able to regenerate.

During a seizure, do not force anything into the client's mouth. A major problem often associated with a left-sided CVA is an

alteration in communication. Clients with CVAs are at a greater risk for aspiration. Initially these

clients must be evaluated to determine if dysphagia is present.

The rate, rhythm and depth of a client's respirations are more sensitive indicators of increases in intracranial pressure than blood pressure and pulse.

When caring for a comatose client, remember that the hearing is the last sense to be lost.

After a CVA clients often have a loss of memory, emotional lability and a decreased attention span.

Communication difficulties of a client with a CVA usually indicate involvement of the dominant hemisphere, usually left, and is associated with right sided hemiplegia or hemiparesis.

The client with myasthenia gravis will have more severe muscle weakness in the evening due to the fact that muscles weaken with activity - described as progressive muscle weakness - and regain strength with rest.