NEUROLOGY
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KOMUNITAS BLOGGER UNIVERSITAS SRIWIJAYA
Gross anatomy The nervous system is divided into the central and peripheral nervous
system The Central nervous system consists of the BRAIN and the Spinal Cord The
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 brain The 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
function Parietal lobe- sensory function Temporal lobe- hearing and olfaction and emotion by
the limbic system Occipital 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 equilibrium The diencephalon consists of the : Thalamus- the relay center of all sensory
input Hypothalamus- 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: 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. - 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 reflexdoll’s eye Normal response- eyes appear to move opposite to the movement of the
head Abnormal- 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: Sen Sen Mo Mo Mi Mo Mi Sen Mi Mi Mo Mo XI. Spinal Accessory
Controls sternocleidomastoid and trapezius muscles. Inability to rotate the head and move
the shoulders. XII. Hypoglossal Movements of the tongue. Protrusion of the tongue, deviation
of the tongue to one side of the mouth. PHYSICAL EXAMINATION 5 categories: 1. Cerebral
function- LOC, mental status 2. Cranial nerves 3. Motor function 4. Sensory function 5.
Reflexes CATEGORIES OF CONSCIOUSNESS NORMAL 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 Score 8 and Below= severe head injury! Assessing the sensory function
Evaluate symmetric areas of the body Ask the patient to close the eyes while testing Use of
test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to
identify objects placed on the hands Test 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 reflex 0- absent + present but diminished ++ normal
+++ increased ++++ hyperactive or clonic Superficial reflex 0 absent +present EEG Withhold
medications that may interfere with the results- anticonvulsants, sedatives and stimulants
Wash hair thoroughly after the procedure Definition 1. Measurement and recording of
electrical activity of the brain in the form of waves 2. Provides information about seizure
disorders, local tumors,infections of the central nervous system, and chemical toxicity CT
scan With radiation risk If 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 scan Definition 1. This test registers glucose metabolism in a cross-section
of the brain; glucose metabolism increases in areas of the brain that are active 2. Utilized to
diagnose Alzheimer\'s disease, depression, dementia,and brain tumors MRI q Uses magnetic
waves q Patients with pacemakers, orthopedic metal prosthesis and implanted metal devices
cannot undergo this procedure This procedure utilizes magnetism and radio waves to
produce images of cross-sections of the body Cerebral arteriography / angiography q Note
allergies to dyes, iodine and seafood q Ensure consent q Keep patient at rest after procedure
q Maintain pressure dressing or sandbag over punctured site Lumbar puncture / Spinal tap q
Ensure consent, determine ability to lie still q Contraindicated in patients with increased
ICP*** q Keep flat on bed after procedure** q Increase fluid intake after procedure Increased
Intracranial pressure Brunner= Normal intracranial pressure 10-20 mmHg Causes: Head
injury Stroke Inflammatory lesions Brain tumor Surgical complications Subarachnoid
hemorrhages Viral infection Pathophysiology The cranium only contains the brain substance,
the CSF and the blood/blood vessels MONRO-KELLIE hypothesis- an increase in any one of
the components causes a change in the volume of the other Any increase or alteration in
these structures will cause increased ICP In response Pathologic conditions alter the
relationship intracranial volume and ICP 2. 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 drainage 2. assists in administering 100%
oxygen or controlled hyperventilation- to reduce the CO2 blood levelsàconstricts
blood vesselsàreduces edema 3. Administer prescribed medications- usually
Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsantsto prevent seizures 4. Reduce environmental stimuli 5. 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, valsalva 7. monitor for secondary
complications Diabetes insipidus SIADH Altered level of consciousness It is a manifestation
of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic
derangement Disruption in the neuronal transmission results to improper function
Assessment Orientation to time, place and person Motor function Decerebrate Decorticate
Sensory function COMA= clinical state of unconsciousness where patient is NOT aware of
self and environment Etiologic Factors 1. Head injury 2. Stroke 3. Drug overdose 4. Alcoholic
intoxication 5. Diabetic ketoacidosis 6. Hepatic failure ASSESSMENT 1. Behavioral changes
initially 2. Pupils are slowly reactive 3. Then , patient becomes unresponsive and pupils
become fixed dilated Glasgow Coma Scale is utilized Nursing Intervention 1. Maintain patent
airway Elevate the head of the bed to 30 degrees Suctioning 2. Protect the patient Pad side
rails Prevent injury from equipments, restraints and etc. 3. Maintain fluid and nutritional
balance Input and output monitoring IVF therapy Feeding through NGT 4. Provide mouth
care Cleansing and rinsing of mouth Petrolatum on the lips 5. Maintain skin integrity Regular
turning every 2 hours 30 degrees bed elevation Maintain correct body alignment by using
trochanter rolls, foot board 6. Preserve corneal integrity Use of artificial tears every 2 hours 7.
Achieve thermoregulation Minimum amount of beddings Rectal or tympanic temperature
Administer acetaminophen as prescribed 8. Prevent urinary retention Use of intermittent
catheterization** 9. Promote bowel function High fiber diet Stool softeners and suppository
10. Provide sensory stimulation Touch and communication** Frequent reorientation
Autonomic Dysreflexia/hyperreflexia Seen commonly in spinal cord injury above T6 An
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;
unilateral etiology 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 injury AN 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 causes Vehicle accidents
compounded by drugs or alcohol use Acts of violence Falls Sports –related injury
Occurs most in males between 10-39 yrs old Types: a. Minor 1. Laceration of the scalptearing of the vessels of the scalp that may cause bleeding 2. Contusion- brief loss of
consciousness;may also experience amnesia and headaches. Major: 1. Fractures –
comminuted, linear , or depressed Clinical manifestations: Battle’s sign (post-auricular
ecchymosis) Racoon’s eye (periorbital edema) Rrhinorrhea (leakage of CSF from
nose) Otorrhea – fluid from ear 2. 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,amnesia Nausea and vomiting - projectile vomiting indicates increased ICP
Cushing’s reflex- severe hypertension and wide pressure is a late sign. Hypovolemic
shock Behavioral changes Weakness Ataxia Decreased muscle tone 1. CONCUSSION
Involves jarring of head without tissue injury Temporary loss of neurologic function lasting for
a few minutes to hours 2. CONTUSION Involves structural damage The patient becomes
unconscious for hours 3. Intracranial hemorrhage Epidural 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 LOC 2. CSF
otorrhea 3. CSF rhinorrhea 4. Racoon eyes and Battle sign NURSING MANAGEMENT 1.
Monitor for declining LOC- use of Glasgow 2. Maintain patent airway Elevate bed, suction
prn, monitor ABG Logroll the client 3. Monitor for rhinorhea or otorrhea 4. Administer good
skin care 5. Monitor for increase intracranial pressure 6. Provide adequate nutrition 7.
Prevent injury Use padded side rails Avoid extreme flexion or extension of the neck 8.Elevate
the head of the bed to 30 degrees 9.Provide warm or coldcompress to the eyes to dec.
periorbital edema 10.. Maintain skin integrity Prolonged immobility will likely cause skin
breakdown Turn patient every 2 hours Provide skin care every 4 hours Avoid friction and
shear forces Prevent complications of immobility 7. Monitor potential complications Increased
ICP Meningitis** Post-traumatic seizures Impaired 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 reflexes Loss of sensation Flaccid 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.
Incomplete 1. Central cord syndrome- occurs in older adults in the cervical cord area 2.
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 proprioception 4.
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 equinalower 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 INTERVENTIONS 1. Elevate
the head of the bed immediately 2. Check for bladder distention and empty bladder with
urinary catheter 3. Check for Fecal impaction and other triggering factors like skin irritation,
pressure ulcer 4. Administer antihypertensive medications- usually hydralazine Spinal Shock
Pathophysiology The sudden depression of reflex activity in the spinal cord below the level of
injury The muscles below the lesion are flaccid, the skin without sensation and the reflexes
are absent including bowel and bladder functions Spinal 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 shock Absence of reflex Paraplegia Atonic paralysis
Sensory 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 frequently Provide background information as to date, time, place,
environment 3. Use large signs as visual cues 4. Post patient\'s photo on the door 5.
Encourage family members to bring personal articles and place them in the same area
Establish a regular pattern for bowel care Place the patient on potty every other day Use of
stool softeners Maintain a dietary intake. Avoid foods that can cause excessive gas
production Elevate the head of the bed 90 degrees during meals and 30 minutes after Serve
foods that are soft and small sized Keep suction equipment on bedside Consult with
rehabilitation team as to assistive devices that can be utilized Clinical manifestations 1.
Paraplegia 2. quadriplegia 3. diplegia EMERGENCY MANAGEMENT A-B-C Immobilization
Immediate transfer to tertiary facility NURSING INTERVENTION 1. Promote adequate
breathing and airway clearance 2. Improve mobility and proper body alignment*** 3. Promote
adaptation to sensory and perceptual alterations 4. Maintain skin integrity 5. Maintain urinary
elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage
complications Thrombophlebitis Orthostatic hypotension Spinal shock Autonomic dysreflexia
CEREBROVASCULAR ACCIDENTS An umbrella term that refers to any functional
abnormality of the CNS related to disrupted blood supply Definition: 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 MANIFESTATIONS 1. Numbness or weakness 2. confusion or change
of LOC 3. motor and speech difficulties 4. Visual disturbance 5. 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 communicate Dysphagia HEMIPARESIS
on the OPPOSITE side- more severe on the face and arm than on the legs (weakness)
Anterior cerebral artery: Weakness Numbness on the opposite side Personality changes
Impaired motor and sensory function Posterior cerebral artery: Visual field defects Sensory
impairment Coma Less likely paralysis RISKS FACTORS Non-modifiable Advanced age
Gender race Modifiable Hypertension Cardio disease Obesity Smoking Diabetes mellitus
hypercholesterolemia Motor Loss Hemiplegia – paralysis of one side of the body after
a stroke Hemiparesis - weakness Communication loss Dysarthria= difficulty in speaking
Aphasia= Loss of speech Apraxia= inability to perform a previously learned action Perceptual
disturbances Hemianopsia – defective vision or blindness in half of the visual field of
one or both eyes. Sensory loss Paresthesia – any abnormal touch sensation as
numbness or tingling in the absence of stimuli NURSING INTERVENTIONS: ACUTE 1.
Ensure patent airway 2. Elevate head 3. Monitor VS and GCS, pupil size 4. IVF is ordered
but given with caution as not to increase ICP 5. NGT inserted 6. Medications: Heparin,
Enoxaparin, t-PA, ASA, Steroids, Mannitol (to decrease edema), Diazepam NURSING
INTERVENTIONS: Hospital 1. Improve Mobility and prevent joint deformities Correctly
position patient to prevent contractures Place pillow under axilla Hand 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 organized Use large mirror 3. Manage sensory-perceptual
difficulties Approach patient on the Unaffected side Encourage to turn the head to the
affected side to compensate for visual loss 4. Manage dysphagia Place food on the
UNAFFECTED side Provide smaller bolus of food Manage tube feedings if prescribed 5.
Help patient attain bowel and bladder control Intermittent catheterization is done in the acute
stage Offer bedpan on a regular schedule High fiber diet and prescribed fluid intake 6.
Improve thought processes Support patient and capitalize on the remaining strengths 7.
Improve communication Anticipate the needs of the patient Offer support Provide time to
complete the sentence Provide a written copy of scheduled activities Give one instruction at
a time 8. Maintain skin integrity Use of specialty bed Regular turning and positioning Keep
skin dry and massage NON-reddened areas Provide adequate nutrition 9. Promote
continuing care Referral to other health care providers 10. Improve family coping 11. 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 teach client to: » 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 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 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 Diagnostics – 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) Management – 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 Nursing interventions
– 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 Findings – 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 diet Position to prevent
contractures: Ø firm beds, no pillows Ø Prone position when lying in bed
– pharmacologic » anticholinergics - minimize extrapyramidal effects
(Cogentin,artane, akineton) » 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. Ø Tuna Ø pork Ø Dried beans Ø
Avoid tyramine rich foods (may cause hepertensive crisis) Ø Cream chocolate
Ø Cheese coffee Seizure Disorders 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 tonicclonic 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
Nursing Interventions During seizure 1. remove harmful objects from the patient’s
surrounding 2. ease the client to the floor 3. protect the head with a pad 4. Observe and note
for the duration, parts of body affected, behaviors before and after the seizure Do 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 Document 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 seizure
precautions :teach client » 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 REMINDERS: 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. DOWNLOAD