NCM 104- Nervous System
-
Upload
babeepny807076 -
Category
Documents
-
view
111 -
download
9
Transcript of NCM 104- Nervous System
EMILIO AGUINALDO COLLEGE - CAVITE
~THE NERVOUS SYSTEM~
Common Health Problem and Disorders
JHOANNE D. DUERO7/18/2009
NERVOUS SYSTEM
1. Central Nervous System Brain Spinal Cord
2. Peripheral Nervous System Cranial Nerves Spinal Nerves
Neuron
BRAIN
The Brain is divided into 3 major areas:1. Cerebrum 2. Brain Stem3. Cerebellum
External surface of the brain
CEREBRUM The largest part of the brain. Composed of: 2 hemispheres- the right and left, and the basal ganglia. The hemisphere is connected by corpus callosum, a band of fibers. Each hemisphere is divided into 4 lobes.
Structure of the Brain
The 4 Lobes of the Cerebrum
1. Frontal Lobe Largest lobe Location: front of the skull. Contains the primary motor cortex and responsible for functions related to motor
activity. The left frontal lobe contains Broca’s area (control the ability to produce spoken
words) The frontal lobe controls higher intellectual function, awareness of self, and
autonomic responses related to emotions
2. Parietal Lobe Sensory lobe Location: near the crown of the head. Contains the primary sensory cortex. One of its major functions is to process sensory input such as position sense,
touch, shape, and consistency of objects.3. Temporal Lobe
Location: around the temples. Contains the primary auditory cortex. Wernicke’s area is located on left temporal lobe. Contains the interpretative area where auditory, visual and somatic input are
integrated into thought and memory
4. Occipital Lobe Location: lower back of the head Contains the primary visual cortex Function: responsible for visual interpretation.
THE 4 LOBES Frontal- motor /controls higher intellectual function, awareness of self and autonomic
responses related to emotions. Parietal- sensory Temporal- auditory (Wernicke’s); Contains the interpretative area where auditory, visual
and somatic input are integrated into thought and memory Occipital- visual
Ventricles of the Brain
Diencephalon Lies on the top of the brain-stem Contains the thalamus, hypothalamus, epithalamus, and subthalamus.
1. Thalamus Lies on the either side of the third ventricle “Relay station” for all sensation except smell. All memory, sensation and pain impulses pass through this section.
2. Hypothalamus Located anterior and inferior to the thalamus. Has a variety of function and plays an important role in maintaining homeostasis. Regulation of body temperature, hunger and thirst; formation of autonomic
nervous system responses; and storage and secretion of hormones from the pituitary gland.
3. Epithalamus Contains pineal gland.
4. Subthalamus Part of the extrapyramidal system of the autonomic nervous system and the basal
ganglia.The Basal Ganglia
Are masses of nuclei located deep in the cerebral hemispheres.
Responsible for fine motor movements, including those of the hands and lower extremities.
Several motor disorders are associated with basal ganglia damage including Huntington’s chorea and Parkinson’s disease.
BRAIN STEM Consist of the midbrain, pons, and medulla oblongata. Midbrain
connects the pons and the cerebellum with the cerebral hemisphere, it contains sensory and motor pathways
center for auditory and visual reflexes Pons
connects the two halves of the cerebrum involved in the integration of movements in the right and left sides of the body,
and the transmission of motor information from the higher brain areas and the spinal cord to the cerebellum.
Medulla oblongata involved in the respiration, circulation, gastrointestinal functioning, coughing,
sneezing, and swallowing.
CEREBELLUM Location: base of the brain. Responsible for coordination, balance and posture. Damage to the cerebellum can result in ataxia, a condition characterized by drunken-like
movements, severe tremors, and loss of balance.
Structures Protecting the Brain The brain is contained in the rigid skull, which protects it from injury. The meninges (fibrous connective tissues that cover the brain and the spinal cord)
provide protection, support and nourishment to the brain and the spinal cord. Layers of the meninges:
a. Dura materb. Arachnoid c. Pia mater
CSF – Cerebrospinal Fluid Provide a cushion, provide nutrition, maintain normal ICP, remove metabolic waste. Composition – colorless, odorless fluid containing glucose, electrolytes, oxygen, water,
small amount of carbon monoxide and few leukocytes. Produced in the choroid plexus of the ventricles.
SPINAL CORD
Approximately 45 cm long (18 inches) long. Acts as a passageway for condition of sensory information from the periphery of the
body to the brain (via afferent nerve fibers). Serve as the connection between the brain and the periphery. Mediates the reflexes.
a. Cervical C1-4b. Brachial plexus C5-8, T1c. Intercostal T2-T12d. Lumbar L1-L4e. Sacral L4-L5, S1-S3f. Pudendal S4
Blood Supply to the CNS 1/3 of the cardiac output From 2 vertebral artery and one internal carotid arteries Circle of Willis
Peripheral Nervous System –Cranial Nerves & Spinal Nerves
CRANIAL NERVES 12 pairs Emerge from the undersurface of the brain. Cranial nerve conducts impulses (motor and sensory information) between the brain and
various structures of the head, neck, thoracic cavity and abdominal cavity.
I Olfactory nerve II Optic nerve III Oculomotor nerve IV Trochlear nerve V Trigeminal nerve VI Abducens nerve VII Facial nerve VIII Acoustic/Vestibulocochlear IX Glossopharyngeal nerve X Vagus nerve XI Accessory nerve XII Hypoglossal nerve
Cranial Nerves Function Assessment
I. Olfactory Sensory: smell reception and interpretation
Assess nose for Smell. Have the client close eyes and
properly identify common aromatic substance held under the nose; test one nostril at a time. (ex. coffee, toothpaste, orange)
II. Optic Sensory: visual acuity and visual fields
Assess eyes for Visual Acuity and Peripheral Vision.
Vision and visual field tested with an eye chart and by testing point at which person sees an object (finger) moving into visual fields; inside of the eye is viewed with ophthalmoscope to observe blood vessels.
III. Oculomotor Motor: raise eyelids, most extraocular movements
Parasympathetic: pupillary constriction, change lens shape
Assess eyes for Extraocular Movement. The CN III, CN IV, and CN VI
nerves are tested together since they control muscles that provide eye movement. Test the movement of the eyes in the six cardinal fields of gaze.
Assess eyes for Pupillary Constriction and Accommodation.
To test pupillary reaction and accommodation, shine a light into the eye to note whether the iris
constricts, making the pupil smaller.
Accommodation is tested by observing pupillary constriction when the client changes gaze from a distant object to a near object.
IV. Trochlear Motor: downward, inward eye movement.
Assess eyes for Extraocular Movement
V. Trigeminal Motor: jaw opening and clenching, chewing and mastication
Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin
Assess face for Movement and Sensation Test motor function by having the
client clenches his/her teeth, then palate the temporal and masseter muscles.
To test light sensation, have the client close his/her eyes, then wipe a cotton wisp lightly over the anterior scalp, paranasal sinuses, and jaw.
To test deep sensation, use alternating blunt and sharp ends
of a paper clip over the client’s forehead and paranasal sinus.
VI. Abducens Motor: lateral eye movement
VII. Facial Motor: movement of facial expression muscles except jaw, close eyes, labial speech sounds.
Sensory: taste- anterior two third of tongue, sensation to Pharynx
Parasympathetic: secretion of saliva and tears.
Inspect the face both at rest and during conversation.
Have the client raise the eyebrows, frown, close the eyes tightly and show the teeth, smile and puff out the cheeks.
Assess mouth for Taste Instruct the client to stick out the
tongue and leave it out during the testing process. Use a cotton applicator to place quantities of salt, sugar, and lemon to client’s tongue.
VIII. Acoustic Sensory: hearing and equilibrium.
Hearing initially can be screened while taking the history.
IX. Glossopharyngeal Motor: voluntary muscle for swallowing and phonation.
Parasympathetic: secretion of salivary gland, carotid reflex
Assess mouth for Gag Reflex and Movement of Soft Palate.
Evaluate CN IX and CN X together for movement and gag reflex.
Instruct the client to say “ah”; there should be bilateral equal upward movement of the soft palate and uvula; gagging will occur; and speech should be smooth.
X. Vagus Motor: voluntary muscle of phonation and swallowing
Sensory: sensation behind ear and part of external ear canal.
Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of the heart, lungs and digestive tract.
Assess mouth for Gag Reflex and Movement of Soft Palate
XI. Spinal Accessory Motor: turn head, shrug shoulders, some actions for phonation
Assess shoulder and neck muscles for Strength and Movement
Have the client shrug his/her shoulders upward against your hands.
Have the client turn his/her head
to the side against your hand, repeat on the other side.
XII. Hypoglossal Motor: tongue movement for speech sound articulation and swallowing
Assess mouth for Tongue Movement, Symmetry, Strength, and Absence of Tumors
client protrudes tongue. Note symmetry, atrophy, and absence of tumors
Then ask the client to move tongue toward nose, chin, and side to side.
Strength of the tongue can be tested by pressing it against your gloved index finger.
SPINAL NERVES 31 pairs 8 cervical, 12 thoracic, 5 lumbar 5 sacral, 1 coccygeal Two roots
Dorsal and Ventral - Each spinal nerve has a ventral root (motor) and a dorsal root (sensory)
Dermatome distribution
The dorsal roots contains sensory fibers that relay information from sensory receptors to the spinal cord
The ventral root contains motor fibers that relay information from the spinal cord to the body’s glands and muscles.
Dermatome distribution
AUTONOMIC NERVOUS SYSTEM Regulates the activities of the internal organs (heart, lungs, blood vessels, digestive
organs, and glands) Responsible for maintenance and restoration of internal homeostasis.
2 Components of ANS1. Sympathetic Nervous System2. Parasympathetic Nervous System
Sympathetic Nervous System Expenditure of energy Catecholamines: Epinephrine; norepinephrine; dopamine “Fight or flight” response.
Pupil dilates Increased HR Increased BP Increased RR Constipation Dry mouth Urinary retention
Parasympathetic Nervous System Conserving energy.
Acetylcholine Pupil constricts Decreased HR Decreased BP
Decreased RR Diarrhea Increased salivation Urinary frequency
AssessmentTHE NEUROLOGIC EXAMINATION
General Assessment for Neurological Disorders
Health History Past Health History
Injuries and surgeries Use of alcohol, medications, and illicit drugs Onset of symptoms. Duration of current complain Recent trauma
The disorders involving neurologic system impairment are headache, dizziness or vertigo, seizures, change in consciousness, altered sensation and visual disturbances.
Physical Examination The brain and spinal cord cannot be examined directly as other system of the body.
V/S - abnormal respiration breathing pattern Pupillary reaction/pupillary changes Eye movement & reflex response Change in balance
Neurological Assessment Recognition of change Helps assess the patient’s ability to engage in self-care activities. Neurologic assessment is divided to into 5 components:
Cerebral function
Cranial nerves Motor system Sensory system Reflexes
1. Cerebral Function Mental status: observe patient’s appearance, behavior, dressing, grooming and
personal hygiene.a. Posture, gestures, movements, facial expression, motor activity, the
patient’s manner of speech and LOC are also assessed.b. Level of Consciousness (LOC) – awareness of self and environment and
level of arousal (alert, lethargic, obtunded, stuporous, coma).
Altered Level of Consciousness (LOC) - can result from destruction of the brain stem or its reticular formation of ascending nerves, or from other structural, metabolic, or psychogenic disturbances.
Confusion Impaired ability to think clearly Disturbed ability to perceive,
respond to, and remember current stimuli
Disorientation Functional in activities of daily
living (ADLs)
Delirium Motor restlessness Increased disorientation Transient hallucinations Delusions possible Requires some assistance with
ADLs
Obtundation Decreased alertness Psychomotor retardation Requires complete assistance with
ADLs
Stupor Arousable but not alert Severe disorientation Little or no spontaneous activity
Coma Unarousable Unresponsive to external stimuli or
internal needs Determination commonly
documented using Glasgow Coma
Scale score
Altered Movement Involves certain neurotransmitters (ex. dopamine)
o Hyperkinesia- excessive movement
o Hypokinesia- decreased movement
Marked by paresis- partial loss of motor function and muscle power; commonly described as weakness; can result from destruction of upper & lower motor neurons
2. Cranial Nerve Function Assess cranial nerve function.
3. Motor System Function Assess muscle size (inspect and palpate) tone, and strength; assess symmetry
differences between right and left side; balance and coordination.o Altered Muscle Tone
o Hypotonia - severely reduced degree of tension or resistance to movement
in a muscleo Hypertonia - marked increase in a muscle tension and decreased ability of
a muscle to stretch
4. Sensory Function Test for:
o superficial tactile sensation superficial and deep pressure pain
o thermal sensitivity
o sensitivity to vibration
o point localization
5. Reflexes Evaluate deep and superficial reflexes (biceps, triceps, patellar, ankle reflexes)
and abnormal reflexes (Babinski’s reflex).
Diagnostic Tests
Diagnostic Procedure Nursing InterventionsComputed Tomography Scanning
Visualize sections of the spinal cord as well as intracranial contents
The injection of a water-soluble iodinated contrast into the subarachnoid space through lumbar puncture helps
noninvasive and painless has a high degree of sensitivity for
detecting lesions.
Use of x-ray beams cross section Use: to identify intracranial tumor,
hemorrhage, cerebral atrophy, calcification, edema, infarction, congenital abnormality.
Teaching the client about the need to lie quietly throughout the procedure.
Relaxation technique maybe helpful for clients with claustrophobia.
Assess for iodine/shellfish allergy.
Secure patent IV line.
NPO if with contrast medium, for 4 hrs.
Monitor for allergic reaction: flushing, nausea and vomiting.
Magnetic Resonance Imaging
Diagnostic Procedure Nursing InterventionsMagnetic Resonance Imaging
Uses a powerful magnetic field to obtain images of different areas of the body.
Can be performed with or without a contrast agent and can identify a cerebral abnormality earlier and more clearly than other diagnostic tests.
Useful in diagnosis of multiple sclerosis and can describe the activity and the extent of disease in the brain and spinal cord.
Obtain history of metal implants. Remove all metal objects.
Inform the client that the procedure last for 30 to 90 mins.
Patient preparation should include teaching relaxation technique.
Inform the client that a narrow, tunnel like machine will enclose him/her during the procedure.
Sedation may be needed for claustrophobic client.
Cerebral Angiography Is an x-ray study of the cerebral Obtain a signed consent.
circulation with a contrast agent injected into a selected artery (femoral)
Visualize aneurysm
Myelography Contrast agents are injected into spinal
subarachnoid space to permit visualization of spinal cord.
Shows any distortion of the spinal cord or spinal dural sac caused by tumors, cysts, herniated vertebral disks or other lesions.
Hydrate the client, clear liquids are usually permitted.
Instruct the client to void before the procedure.
Instruct the patient to remain immobile during the test.
Tell the client to expect a brief feeling of warmth in the face, behind the eyes or in the jaw, teeth, tongue, and lips, and a metallic taste when the contrast is injected.
After the procedure check LOC, and injection site should be observed.
Explain the procedure. Obtain a signed consent. Withhold oral intake 4-6 hours before
the test. After the procedure:
For pantopaque myelogram (oil-based) pt lies flat for 6-24 hours.
For metrizamide myelogram (water-based), HOB is elevated at 30 degrees for at least 8 hours.
Encourage fluid intake.Electroencephalography
Graphic record of the electrical activity generated in the brain.
EEG is a useful test for diagnosing and evaluating seizure disorders, coma, or organic brain syndrome.
A sleep EEG may be recorded after sedation because some abnormal brain waves are seen only when the patient is asleep.
Explain the procedure; assure the client he/she will not receive electrical shock.
The nurse needs to check doctor’s order regarding the administration of anti-seizure medication prior to testing.
Withhold tranquillizer and stimulants for 24 to 48 hours.
Inform the client that the standard EEG takes 45 to 60 minutes and 12 hours for sleep EEG.
Electroencephalography
Measurement of the electrical activity of the brain done during:o Relax
o Hyperventilate
o Sleeping
o Flickering lights
Lumbar Puncture
Insertion of needle in the Subarachnoid Space Assess the CSF
Lumbar Puncture Is carried out by inserting a needle into
the lumbar subarachnoid space to withdraw CSF for diagnostic or therapeutic purposes.
The needle is usually inserted between L4 and L5.
Maintain position, usually lateral horizontal with knees to chest, chin on chest.
Obtain signed consent. Explain the procedure. Observe for complication following the
procedure. Keeping the patient in prone position
overnight may reduce the incidence of headache.
Electromyography Obtain by inserting needle electrodes Explain the procedure.
into the skeletal muscles. Measure changes in the electrical
potential of the muscles and the nerves leading to them.
Useful in determining neuromuscular disorders and myopathies.
The patient is warned to expect a sensation similar to that of an intramuscular injection and the muscle examined may ache for a short time after the procedure.
Electromyogram
Measures electrical potential/ activity of the muscles
Pneumoencephalography Special contrast study of the ventricular
and cisternal system using air as contrast medium.
Permits accurate localization of brain lesions by spinal or cisternal puncture with x-ray examination.
Secure written consent. Sedate as ordered. GA may be used. Inform the client that the procedure
takes 2 hours. Inform the client that he/she may
experience discomfort, N/V, after the procedure.
After the procedure keep the client flat in bed for 24 to 48 hours.
Monitor VS and neurologic checks.
Common Health Problem of the Neonate and Infant
Nervous System Developmental Disorders
1. Cranial Hydrocephalus
2. Spinal Cord Meningocele
HYDROCEPHALUS Is an excess of cerebrospinal fluid in the ventricles and subarachnoid spaces of the brain. Reasons for excess:
o over production of fluid by the choroid plexus in the 1st or 2nd ventricle
o obstruction of the passageway of fluid somewhere between the point of origin and
the point of absorptiono interference with the absorption of fluid from the subarachnoid space
Classifications:a. Congenital b. Acquired
The cause of congenital hydrocephalus is unknown. Incidence: 3 to 4 per 1000 live births In older child infections such as meningitis and encephalitis may leave adhesion that lead
to obstruction.
Nursing Assessment Enlarged head Prominent scalp vein. Enlarged or full fontanels Separated suture line Increased head circumference Sunset eyes Shrill cry Hyperactive reflexes Signs of increased ICP
Decreased pulse Increased temperature Decreased respiration Increased BP
Diagnostic Test Sonogram, CT scan, MRI Skull x-ray film will reveal the separating sutures and thinning of the skull bones.
Transillumination will reveal skull filled with fluid rather than solid brain substance.
Nursing Goals and Interventions Assess neurologic status closely. Measure and plot occipital-frontal baseline measurement, then measure head
circumference once a day. Check for fontanelle for bulging and sutures for widening. Assist with head ultrasound and Transillumination. Maintain skin integrity: change position frequently. Clean skin creases after feeding or vomiting. Postoperatively, position head off operative site. Watch for signs of infection.
MYELOMENINGOCELE The spinal cord and the meninges protrude through the vertebrae. This result in lower motor neuron damage.
o The child will have flaccidity and lack of sensation of the lower extremities and
loss of bowel and bladder control. Hydrocephalus accompanies Myelomeningocele in as many as 80% of infant due to lack
of subarachnoid membrane.
Diagnostic Test Neural tube defects can be discovered during intrauterine life by sonography, fetoscopy,
amniocentesis, or analysis of AFP in maternal serum. When infants are detected having Myelomeningocele, they may born by cesarean
birth to avoid pressure and injury to the spinal cord.
Nursing Assessment Saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar
area. Myelomeningocele directly connects to subarachnoid space so hydrocephalus often
associated. No response or varying response to sensation below level of sac. May have constant dribbling of urine. Retention of stool.
Nursing Goals and Interventions Prevent trauma and infection. Position on abdomen or on side and restrain. Meticulously clean buttocks and genitals after each voiding and defecation. May put protective covering over sac.
Observe sac for oozing of fluid or pus. Crede bladder (apply downward pressure on bladder with thumbs, moving urine toward
the urethra) as ordered to prevent urinary stasis. Assess amount of sensation and movement below defect. Observe for complications. Obtain occipital-frontal circumference baseline measurement, then measure head
circumference once a day (to detect hydrocephalus). Check fontanelle for bulging.
Common Health Problems of the Child and Adolescent
CEREBRAL PALSY Group of non-progressive disorders of upper motor neuron impairment that result in
motor dysfunction. A child may also have speech or ocular difficulty, seizures, cognitive challenges, or
hyperactivity. Exact cause is unknown, but the disorder is associated with low birth weight, prebirth, or
birth injury. Occurs in approximately 2 in 1000 live births, occurring most frequently in very-low-
birth-weight infants It apparently occurs when brain anoxia leads to cell destruction of the motor tracts.
Types of Cerebral Palsy1. Spastic Type
Spasticity is excessive tone in the voluntary muscles (loss of upper motor neurons)
The child with spastic CP has hypertonic muscle, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as tonic neck reflex.
Spastic movement may affect both extremities on one side (hemiplegia), all four extremities (quadriplegia), or primarily the lower extremities (paraplegia)
2. Dyskinetic or Athetoid Type Involves abnormal involuntary movement. Athetoid means “wormlike”. The child is limp and flaccid. The child makes slow, writhing motions. This may involve all four extremities,
plus the face, neck, and tongue. The child drools and speech is difficult to understand.
3. Ataxic Type Children with ataxic involvement have an awkward, wide-base gait. On neurologic examination, they are unable to perform finger-to-nose test or
perform rapid, repetitive movements (tests of cerebral function).
4. Mixed Type Symptoms of both spasticity and athetoid movements are present together.
Nursing Assessment Diagnosis is based on history and physical assessment. On history, an episode of possible anoxia during prenatal life or at birth is documented. Neurologic exam in infant is difficult. In all forms of CP may have sensory alteration.
REYE’S SYNDROME Is acute encephalitis with accompanying fatty infiltration of the liver, heart, lungs,
pancreas, and skeletal muscle. 1 to 18 years of age regardless of gender. The cause is unknown, but it generally occurs after a viral infection such as varicella or
influenza if the child is treated with salicylate. Avoiding the use of aspirin during viral infection has led to almost total prevention of the
syndrome.
Nursing Assessment Children: Lethargic, vomiting, agitation, anorexia, confusion, and combativeness. Laboratory diagnosis of Reye's syndrome is confirmed by:
Elevated Liver Enzyme Levels Elevated Serum Ammonia Normal Direct Bilirubin Delayed Prothrombin Time and Partial Thromboplastin Time Decreased Blood Glucose Elevated BUN Elevated Serum Amylase Elevated Short-chain Fatty Acid Elevated WBC Count
Common Health Problems of the Young Adult
Neuromuscular Disorders Multiple Sclerosis Myasthenia Gravis
MULTIPLE SCLEROSIS Chronic, degenerative disease of the central nervous system that is characterized by
demyelination of the nerve fibers of the brain and spinal cord Gen. characterized by exacerbations and remissions (relapsing-remitting type) Although the cause of MS is unknown, it appears to be related to autoimmune disorder
and viral infections Commonly appears during adulthood (ages 20 to 40) W>M Areas of the CNS most commonly affected brainstem, cerebrum, cerebellum, optic
nerves, and the spinal cord.
Process of Demylination
MS
CausesUnknown
Viral infectionAutoimmune disease
Multiple foci of dmyelination in the white matter(brainstem, spinal cord, optic nerves, cerebrum)
Then later the gray matter.
Destruction of the myelin sheath(SCHWANN’S CELLS)
INTERRUPTION/DISTORTION OF IMPULSE(SLOWED/BLOCKED)
Assessment Sign and symptoms of MS is characterized by remissions and exacerbation of symptoms. Symptoms vary depending on the area of the CNS involved, but generally include:
Visual disturbances (diplopia, partial or total loss of vision, nystagmus) Scanning speech (slow, monotonous, slurred) Tremors Weakness/numbness of the extremities Fatigue Increased susceptibility to URTI Dysphagia Ataxic gait
Diagnostic Test Lumbar Puncture-total CSF protein is normal; IgG (gamma globulin is elevated- IgG
reflects hyperactivity of the immune system due to chronic demyelination) EEG-abnormalities in brain waves CT scan/ MRI reveals multifocal white matter lesion Myelogram Skull x-ray
Nursing Diagnoses Risks: Ineffective breathing pattern; airway clearance Impaired—swallowing, physical mobility, skin integrity; altered nutrition; urinary
incontinence; constipation
Interventions There is no specific treatment for MS.
Treatment includes: Physical therapy- to assist with motor dysfunction, such as problem with
balance, strength, and motor coordination. Speech therapy- to manage dysarthria Drug therapy
a. Glucocorticoids (Prednisone, Dexamethasone, Corticotropin)- to reduce edema of the myelin sheet; sppeds recovery from attack
b. Muscle relaxant (Baclofen)- to treat spasticityc. Amantadine, Ritalin, or antidepressants– to manage fatigued. Low-dose TCAs- to manage sensory symptoms such as pains,
numbness, burning, and tingling sensationsAntihistamines with vision therapy & exercises to minimize vertigo
Nursing Responsibilities/Considerations
Provide regular activity, rest, and relaxation. Assist with physical therapy: muscle stretching, relaxation and coordination exercise,
walking exercise. Encourage well balanced, high fiber diet. Force fluids to prevent constipation. Avoid hot baths. Provide skin care to prevent skin breakdown. Patient and family teaching to promote emotional stability
Help patient establish daily routine, and help family understand patient’s changes in personality and physical capabilities.
Inform the pt that exacerbations are unpredictable, necessitating physical & emotional adjustments in lifestyle
eye patch Speech therapy Medicate and watch for adverse effects
Evaluate Respiration; nutrition; ADLs; skin; bowel elimination; urinary incontinence
MYASTHENIA GRAVIS Progressive neuromuscular disorder that results in the failure to transmit nerve impulses
at the MYONEURAL JUNCTION causing extreme weakness Failure of transmission is due to decreased acetylcholine Women > Men; 3 times more common in w Young adults 20-30 Secretion and increased cholinesterase at the nerve ending Autoimmune disease Characterized by progressive weakness and abnormal fatigability of the skeletal muscles Commonly affects muscles innervated by the cranial nerves (face, lips, tongue, neck, and
throat) Exacerbated by exercise & repetitive movement Occurs along with thymic abnormalities in 75% of pts
Pathophysiology Transmission of nerve impulses at the neuromuscular junction FAILS. Anti-receptor antibodies block, weaken, or reduce the number of acetylcholine Ach
receptors available at each neuromuscular junction, thereby impairing the muscle depolarization necessary for movement
Cause
Autoimmune response leading to ineffective acetylcholine release and inadequate muscle fiber response to Ach.
Complications Aspiration Pneumonia Respiratory distress
Assessment S&S
o Skeletal muscle weakness, fatigue
o Weak eye closure,ptosis, diplopia,
o “snarl smile” (smiles slowly)
o Masklike facial expression; Impaired speech; drooling
o Weakened respiratory muscles
o Muscles are usually strongest in the morning but become progressively weaker
during the day and following an exercise.
Rationale/Pathophysiologic Basis Impaired neuromuscular transmission Impaired neuromuscular transmission to the cranial nerves supplying the eye muscles Impaired transmission of the cranial nerves innervating the facial muscles Impaired neuromuscular transmission to the diaphragm due to loss of ACh receptors in
the appropriate junctions
Skeletal muscle weakness
Diagnostic Test Tensilon Test (Edrophonium Chloride Test)
Short acting cholinergic is administered. Reveals increased muscle strength is observed (+ Tensilon Test) within 30-60
secs after IV injection of Edrophonium (Tensilon) or Neostigmine (Prostigmin) lasting up to 30 mins.
Single fiber electromyography with neural stimulation at the specific muscle fiber- progressive decrease in muscle fiber contraction
Chest x-ray- reveals thymoma in 15% of pts
Treatment of Myasthenia Gravis Anticholinesterase drugs, such as neostigmine and pyridostigmine- to counteract fatigue
and muscle weaknes and allow for about 80% of normal muscle Immunosuppresive therapy with corticosteroids, azathioprine (Imuran) – to decrease the
immune response toward Ach receptors at the neuromuscular junction IgG during acute relapses- to suppress the immune system Thymectomy- to remove thymomas Tracheostomy- suctioning to remove secretions
Nursing Goals and Interventions
Establish neurologic and respiratory baselines Assess swallowing / gag reflex before feeding the client. Plan exercise, meals, patient care & activities to make the most of energy peaks.
Ex.,administer medications 20-30 minutes before meal to facilitate chewing or swallowing.
Start meal with cold beverage. Administer medication at precise time to prevent relapses. Protect the client from falls. Provide adequate ventilation. Avoid exposure to infection, stree, strenous exercise, and needless exposure to the sun or
cold. Frequent rest periods. Be prepared to give atropine for anticholinesterase overdose or toxicity Avoid aminoglycoside antibiotics, which can exacerbate myasthenia gravis Aerosol, pesticides/cleaners should also be avoided, Avoid alcohol, tonic water, and cigarette smoke. Pharmacotherapy
Cholinergics (Anticholinesterase) Neostigmine (Postigmin) Pyridostigmin (Mestinon) Ambenomium (Mytelase)
Glucocorticoids Antacids
Common Health Problem of the Middle-aged Adult
Cranial Nerve Disorder: TRIGEMINAL NEURALGIA (TIC DOULOUREUX) Neurologic disorder affecting the 5th cranial nerve. Possible fifth cranial nerve root
compression Manifested by excruciating, recurrent paroxysms of sharp, stabbing facial pain along the
trigeminal nerve.
Areas innervated by the three branches of the trigeminal nerve
Management Narcotic analgesics; anticonvulsants
o Tegretol
o Dilantin
Alcohol injection of the nerve Avoid extremes of heat and cold. Correction of dental malocclusion Surgical Management
o Surgical division of the trigeminal nerve (neurectomy)
Nursing Management Assessment
o Complete history
o Affected area; oral cavity
o Record weight and ability to eat food
Diagnosis, Planning, and Interventions o Acute pain
Evaluate:o Pain; client cooperation
Cranial Nerve Disorder: BELL’S PALSY Disease of the cranial nerve VII (facial nerve that produces unilateral or bilateral facial
weakness or paralysis Resolves spontaneously in 80% of pts with complete recovery in 18 weeks Recover may be delayed in the elderly
If recovery is partial, contractures may developed on the paralyzed side of the face
Causes Hemorrhage Herpes simplex or herpes zoster Infection Local trauma Meningitis Tumor Viral disease
Pathophysiology An inflammatory reaction occurs around cranial nerve VII, usually at the internal
auditory meatus, where the nerves leave bony tissue The inflammatory reaction produces a conduction block that inhibits appropriate neural
stimulation to the muscle by the motor fibers of the facial nerve, resulting in the characteristic unilateral or bilateral facial weakness.
Pathophysiologic Changes/S & S Unilateral facial weakness Drooping mouth & drooling saliva Lose of taste Smooth forehead appearance Impaired ability to close the eye on the weak side Bell’s phenomenon-Upward rolling of the eyes when attempting to close them Excessive tearing Ringing in the ear
Complications of Bell’s Palsyo Corneal abrasion
o Infection (masked by steroid use)
o Poor functional recovery
Diagnostic Tests based on clinical presentation MRI-rules out tumor Electromyography- 10 days after the onset of S/S
Treatment Analgesics- to relieve pain
Steroids- to reduce facial nerve edema & improve edema & improve nerve conduction & blood flow
Possible electrotherapy Surgery for persistent paralysis
Nursing Considerations Watch for adverse effects of steroids use Apply moist heat to the affected side of the face-to reduce pain Help the pt maintain muscle tone:
o massaging the face with a gentle upward motion 2-3xdaily x 5-10mins
o exercise by grimacing in front of a mirror
Protect eyes, have pt cover eye w/ an eye patch Prevent excessive wt loss:
o have him chew on unaffected side of his mouth
o provide a soft, nutritionally balanced diet, eliminating hot foods & fluids
o apply a facial sling to improve lip alignment
Provide frequent & complete mouth care Offer psychological support
Common Health Problems of the Older Adult
CEREBRO-VASCULAR DISORDER : Stroke/Cerebrovascular Accident (CVA) Disruption of the Blood Supply to the Brain. Sudden loss of neurologic function Note: Middle Cerebral Artery is commonly affected.
The second most frequently affected is the internal carotid artery.
Classification1. ischemic (a thrombus or embolus blocks circulation)2. hemorrhagic (a blood vessel ruptures)
Risk factors Increased alcohol intake or cocaine Cardiac disease Cigarrette smoking DM Familial hyperlipidemia Family history of stroke Hx of TIA HPN Obesity,sedentary lifestyle
Sickle cell disease Use of hormonal contraceptive
Causes of StrokeIschemic
Thrombosis- occluded blood flow caused by thrombosis of the cerebral arteries supplying the brain or the intracranial vessels
o The most frequent cause of CVAo The most common cause of cerebral thrombosis is atherosclerosis; usually
affecting elderly persons.o Tends to occur during sleep or soon after arising.o This may tend to occur among clients with DM, and hypertension.
Embolism- from thrombus outside the brain, such as in the heart, aorta, or common carotid artery.
o The second most common cause of CVA.o Most commonly affecting younger people.o Most frequently caused by Rheumatic Heart Disease and MI.o Symptoms occur at any time and progress rapidly.
Hemorrhagic Stroke – Hemorrhage Impaired cerebral perfusion from hemorrhage causes infarction, & the blood itself as a
space-occupying mass, exerting pressure on the brain tissues Hemorrhage from an intracranial artery or vein, such as HPN, ruptured aneurysm,
trauma, hemorrhagic disorder, or septic embolism
Transient Ischemic Attacks Refers to transient cerebral ischemia with temporary episodes of neurologic dysfunction. Manifestation includes contralateral weakness of the lower portion of the face, fingers,
hands, arms, and legs; dysphagia, and sensory impairment. Stoke in evolution refers to development of a neurologic deficit over several hours to
days
Pathophysiologic Changes in CVA: specific manifestations are determined by the cerebral artery affected, the brain tissue supply by that vessel, and the adequacy of the collateral circulation
Aphasia, dysphasia; visual fields deficits; and hemiparesis of affected side (more severe in face & arms)- resulting from thrombosis or hemorrhage of middle cerebral artery
Weakness, paralysis, numbness; sensory changes; altered LOC; bruits over carotid artery; and headache caused by thrombosis or hemorrhage of carotid artery
Weakness, paralysis, numbness around lips & mouth; visual field deficits, diplopia, nystagmus; poor coordination, dizziness, dysphagia, slurred speech; amnesia, and ataxia resulting from thrombosis or hemorrhage of vertebrobasilar artery.
Confusion, weakness, numbness; urinary incontenece; impaired motor & sensory functions; and personality changes caused by thrombosis or hemorrhage of anterior cerebral artery.
Visual field deficits; sensory impairments; dyslexia; cortical blindness and coma resulting from thrombosis or hemorrhage of posterior cerebral artery.
Assessment of CVA check for:
S&S of increased ICP. Perceptual defects Aphasia Unstable respiration Severe headache Diagnostic procedure results Unilateral neglect
Diagnostic Findings CT scan- identifies an ischemic stroke within the first 72 hours of symptom onset or
evidence of a hemorrhagic stroke (lesions >1 cm immediately) MRI-assists in identifying areas of ischemia or infarction and cerebral swelling Others: angiography, carotid duplex scan, EEG
Complications Hemiplegia – weakness/paralysis of half the body Cognitive impairment - Aphasia – maybe expressive or receptive; the partial or total
inability to produce & understand speech Apraxia – can move but cannot do the purpose; inability to perform complex movements Sensory impairement - Visual changes – Homonymous Hemianopsia; Agnosia – loss of
sense of smell Dysarthria - difficulty in speech articulation due to lack of muscle control Kinesthesia – loss of sensation (of bodily movement) Incontinence – maybe fecal/urine; inability to control urination or defecation
Shoulder pain Contractures Fluid imbalances Cerebral edema Aspiration Altered LOC Infections such as pneumonia
Nursing Considerations Maintain a patent airway and oxygenation:
o If the pt is unconscious; vomiting- lateral position to prevent aspiration of saliva Check v/s & neurologic status:
o Monitor BP, LOC, pupillary changes, motor and sensory functions, speech, skin, color, temp.
o Monitor pt for s/s of increased ICP and nuchal rigidity or flaccidity Watch for s/s of pulmonary emboli:
o Chest pain, shortness of breath, dusky color, tachycardia, fever, and change in sensorium
If the pt is unresponsive, monitor ABG as ordered Monitor F & E balance:
o Monitor I and O.o Administer IVF as orderedo Offer bedpan /urinal
Ensure adequate nutrition: o Check for gag reflex before offering small oral feedings of semisolid foodo Teach the client to chew on the unaffected side. o If oral feeding is not possible, TPN, NGT feeding, gastrostomy feeding
Turn the patient frequently, at least q 2 hrs to prevent pneumonia. Perform ROM exercises for affected & unaffected sides. Massage if not contraindicated. Provide meticulous eye care- Instill meds as ordered; patch the affected eye if the pt can’t
close eyelid. Compensate for perceptual difficulties.
o Care of the client with Hemianopsia.o Approach from the unaffected side.o Place articles on the unaffected side.
Promote communicationo Care for the client with aphasia.o Say one word at time.o Give simple commands.o Allow the client to verbalize, no matter how long it takes him
Give medications as ordered- Tell the pt to watch out for side effects. (ex. Aspirin-GI bleeding)
Assist with rehab Teach the pt to comb hair, to dress, & to wash Obtain assistive devices ( through the aid of PT/OT) such as walkers, hand bars by the
toilet, and ramps as needed Be aware that the pt has a unilateral neglect, in which he fails to recognize that he ha a
paralyzed side- show him how to protect his body from harm Emphasize importance of regular ff-up visits
PARKINSON’S DISEASE Slowly progressive degenerative disorder of basal ganglia function that results in variable
combinations of tremor, rigidity, and bradykinesia Onset usually after age 40 men>women
Parkinson’s Disease: deficient in dopamine
Causes Exact cause unknown Possible causes:
o Dopamine deficiency, which prevents affected brain cells from performing their nomal inhibitory function in the CNS
o Exposure to toxins( manganese dust or carbon monoxide)
o Repeated trauma to the braino Strokeo Brain tumors
Pathophysiology Dopamine neurons degenerate, causing loss of available dopamine Dopamine deficiency prevents affected brain cells from performing their normal
inhibitory function Excess excitatory Ach occurs at the synapses Nondopamineric receptors are also involve Motor neurons are depressed
Pathophysiologic changes/ S&S Muscle rigidity, akinesia, and insidious tremor beginning in the fingers (UNILATERAL
PILL_ROLL TREMOR) secondary to loss of inhibitory dopamine activity at the synapse- increase during stress or anxiety; decreases with purposeful movement & sleep
Muscle rigidity with resistance to passive Mask-like appearance Gait disturbance-lacks normal parallel motion; may be retropulsive or propulsive Oily skin- secondary to inappropriate regulation of androgen production by hypothalmic-
pituitary axis Dysphagia, dysarthria; excessive sweating; decreased GI motility and genitourinary
smooth muscle-from impaired autonomic transmission Voice changes Small handwriting Poor judgment, endogenous depression, dementia- from impaired dopamine metabolism,
and neurotransmitter dysfunction
Common Health Problem that occur Across the Life Span
SEIZURE DISORDER Sudden explosive and disorderly discharge of cerebral neurons Abnormal and excessive discharge of neurons in the brain Types of seizures:
a. grand malb. petit malc. febrile seizuresd. status epilepticus
Petit mal No aura 10-20 seconds Common to children as well as adult
Little tonic-clonic movements Cessation of ongoing physical activities
Jacksonian With aura With organic lesion Group of muscle affectation
Psychomotor Seizure With aura With psychiatric involvement Characterized with mental clouding Violence, antisocial acts
Febrile Seizure Related to temperature Present among children
Status epilepticus Prolonged seizure state Can occur in any type of seizure Rapid successions with no full consciousness in between Brain damage can occur; most life threatening in tonic-clonic seizures Common to clients who are in coma Related to medication
a) Primary Seizure Disorder (Epilepsy)o Idiopathic
o No apparent structural changes in the brain
b) Secondary Epilepsyo Characterized by structural changes or metabolic alterations of the
neuronal membranes that caused increased automacity
Causes of Seizures Idiopathic- two-thirds of all seizure disorders Anoxia Birth trauma (inadequate supply of O2 supply to the brain, blood incompatibility,
hemorrhage) Brain tumors Drug or alcohol abuse or rapid withdrawal from abused drugs Febrile illness
Genetic predisposition Head injury or trauma Infectious diseases Ingestions of toxins( lead, mercury, or carbon monoxide) Metabolic disorders, such as hypoglycemia or hyperparathyroidism Perinatal infections
Pathophysiology Some neurons of the brain may depolarize easily or hyperexcitable On stimulation, these neurons fires locally or throughout the cerebrum and spreads
electric current to surrounding cells. Cells fire in turn and the impulses cascades to one side of the brain (a partial seizure),
both sides of the brain (a generalized seizure), or the cortical, subcortical, and brain stem areas.
Pathophysiologic changes Recurring seizures, possibly of more than one type ( hallmark of epilepsy) Visual, olfactory, or auditory hallucinations; sweating or flushing; dream states; anger, or
fear reactions resulting from simple partial seizures Altered consciousness , such as amnesia for events around the time of the seizure,
resulting from complex partial seizures Movement and muscle involvement resulting from tonic-clonic or myoclonic seizures Brief changes in LOC without motor involvement due to absence seizures
Complications Hypoxia or anoxia from airway occlusion Traumatic injury Brain damage Depression and anxiety
Diagnostic Tests CT scan or MRI- reveals abnormalities EEG- reveals paroxysmal abnormalities
in tonic-clonic seizures, high, fast voltage spikes are present in all leads In absence seizures, rounded spike wave complexes are present Note: a negative EEG doesn’t rule out epilepsy because the abnormalities occur
intermittently Skull x-ray may show evidence of fractures or shifting of the pineal gland, bony erosion,
or separated sutures Serum chemistry blood studies may reveal hypoglycemia, electrolyte imbalances, and
elevated liver enzyme & alcohol level
Treatment Drug Therapy-
Ex. Phenytoin (Dilantin) carbamazepine (Tegretol), phenobarbital (Barbita, Luminal) –for generalized tonic clonic seizures and complex partial seizures
Valproic acid (Depakene), clonazepam (Klonopin) for absence seizures If drug therapy is ineffective, surgery to remove a demonstrated focal lesion, or to
remove the underlying cause (tumor, abscess) I.V. diazepam ( valium), lorazepam (Ativan) phenytooin, or phenobarbital for status
epilepticus Dextrose- for hypoglycemia Thiamine-for chronic alcoholism or withdrawal
Nursing Considerations Patent airway Oxygenate as needed Raise side rails Ensure safety-during seizure:
Avoid restraining the pt Help the pt to a lying position Loosen any tight clothing Clear the area of hard objects Don’t place anything into the pt’s mouth to prevent lacerating the mouth & lips or
displace teeth If vomiting occurs, turn the head to provide an open airway
After the seizure subsides, reorient the patient to time & place; inform him that he had a seizure
Companion at bedside Meds as ordered
INCREASED INTRACRANIAL PRESSURE ICP- the pressure exerted within the intact skull by the intracranial volume - about 10%
blood,10% CSF, & 80% brain tissue Causes
head injury CVA tumors HPN
Pathophysiology ICP- the brain will compensate by:
o limiting bld flow to the head
o displaces CSF into the spinal canal
o increases absorption or decreases production
If ICP remains high, there will be loss of autoregulatory mechanism which will lead to passive dilation, increased cerebral flow, and venous congestion. Further increase in ICP will result to cellular hypoxia and eventually, brain death.
Major Types of Herniation
S&S Increased HA Nausea &Vomiting Cushing’s triad Restlessness Eye involvement Altered LOC Sensory dysfunction Elimination problem Decorticate/decerebrate
Nursing Management Determine airway patency Elevate HOB Check VS/Neuro assessment Record I&O Enema restriction Avoid coughing, vomiting, restraints, stress ulcer, suctioning Seizure precaution Edema reduction Diuretics
CRANIOCEREBRAL TRAUMA (HEAD INJURY)
Involves injury to the scalp, skull, and/or brain tissues. Types of Brain Injury
Concussions. Jarring of the brain and its sudden, forceful contact with the rigid skull. There is transient period of unconsciousness.
Contusion (bruising). A structural alteration characterized by extravasion of blood cells.
Laceration . Tearing of tissue caused by sharp fragment or object or shearing force.
Compression of the Brain . Result from depressed fracture causing edema and hemorrhage.
Assessment
Sign and symptoms of increased ICP. CSF leakage from ears and nose. Battle’s sign (hematoma at the mastoid process) in basilar head trauma.
Management Care for the client with increased ICP. Monitor drainage from ears and nose. Monitor for signs and symptoms of meningitis, atelectasis, pneumonia, UTI.
INTRACRANIAL TUMORS Intracranial tumors may be classified as: gliomas, meningiomas, neuromas,
hemangiomas. Gliomas account for about 50% of all brain tumors.
Assessment Frontal lobe
o Personality disturbance
o Inappropriate affect
o Indifference of bodily functions
Precental gyrus o Jacksonian seizures
Occipital lobeo Visual disturbances preceeding convulsions.
Temporal lobeo Olfactory, visual or gustatory hallucinations.
o Psychomotor seizures with automatic behavior.
Parietal lobeo Inability to replicate pictures.
o Loss of right-left discrimination
Management Care for the client with increase ICP. Surgery
o Supratentorial craniotomy (post-op)
Semi-fowler’s positiono Infratentorial craniotomy
Flat position; turn to sides, avoid supine position for the first 48 hours. Avoid neck flexion.
Report immediately for presence of yellowish drainage on the head dressing.
An increase in urine output may herald onset of diabetes insipidus. Test the urine for glucose and acetone when steroids are administered.
SPINAL CORD INJURY complete or partial disruption of nerve tracts and neurons Causes
infection trauma injury
Signs and symptoms Cervical –respiratory diff, quadriplegia Thoracic- paraplegia Lumbar – flaccid paralysis Sacral – loss of erection, ejaculation
Nursing Assessment Injury; treatment given at scene Neurologic assessment: Document findings Vital signs; respiratory status Movement and sensation below injury level Signs
o Worsening neurologic damage
o Respiratory distress
o Spinal shock
Nursing Diagnoses Ineffective breathing pattern Ineffective airway clearance Neuropathic pain Impaired physical mobility Anxiety Risks
o Impaired gas exchange
o Disuse syndrome
o Ineffective coping
Medical Management
Cervical collar; cast or brace; traction; turning frame IV; stabilization of vital signs Corticosteroids Surgical intervention
Surgical Management Surgery to
o Remove bone fragments
o Repair dislocated vertebrae
o Stabilize the spine
Management Maintain airway patency Immobilize Suction PRN Position Nutrition Elimination hygiene Drugs
Evaluation Adequate breathing Pain relief Mobility using minimal assistive devices Reduced complications from inactivity Coping with the challenge of rehabilitation
INFECTIOUS NEUROLOGIC DISORDERS Meningitis Brain Abscess Herpes Simplex Virus Encephalitis Arthropod-Borne Virus Encephalitis Fungal Encephalitis Creutzfeldt-Jakob and New-Variant Creutzfeldt-Jakob Disease
BRAIN INJURIES Closed (blunt) Brain Injury
Open Brain Injury Concussion Contusion Diffuse Axonal Injury Intracranial Hemorrhage
Epidural Hematoma Subdural Hematoma Intracerebral Hemorrhage and Hematoma
Pathophysiology