SPINAL CORD INJURY
 The most frequent vertebrae – C5-C7, T12 and L1
Clinical Manifestations
o
Paraplegia
o
quadriplegia
o
spinal shock
Diagnostic Test
1. Spinal x-ray
2. CT scan
3. MRI
Emergency Management
 A-B-C
 Immobilization
 Immediate transfer to tertiary facility
Nursing Management
 Promote adequate breathing and airway clearance
 Improve mobility and proper body alignment
 Promote adaptation to sensory and perceptual alterations
 Maintain skin integrity
 Maintain urinary elimination
 Improve bowel function
 Provide Comfort measures
 Monitor and manage complications
 Thrombophlebitis
 Orthostatic hypotension
 Spinal shock
 Autonomic dysreflexia
 Assists with surgical reduction and stabilization of cervical vertebral column
AUTONOMIC DYSREFLEXIA/ HYPER REFLEXIA
 Seen commonly in spinal cord injury
 Most often in cervical injuries
 An exaggerated response by the autonomic system resulting from various stimuli
most commonly distended bladder, impacted feces, pain, skin irritation
Clinical Manifestations
o
Hypertension
o
Bradycardia
o
Severe pounding headache
o
o
Diaphoresis – above the lesion
Pilmotor spasm “goose flesh” – below the lesion
o
o
Nausea and nasal congestion
Blurring of vision
Nursing Management
 Elevate the head of the bed immediately. To lower Bp by gravity
 Check for bladder distention and empty bladder with urinary catheter
 Check for Fecal impaction and other triggering factors like skin irritation, pressure
ulcer
Medical Management
Pharmacotherapy
 Administer antihypertensive medications- hydralazine
 Administer Hexamethonium Chloride (a ganglionic blocking agent)
 Nitroprusside (vasodilator)
SPINAL SHOCK
 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
Clinical Manifestations
o Absence of sweating above the level of the lesion
o
Bowel and bladder retention
o
Hypotension, bradycardia
Nursing Management
1. Assist in chest physiotherapy
2. Manage potential complication- DVT, skin breakdown, injury, hypotension
CEREBROVASCULAR ACCIDENT
“Apoplexy”
“stroke”
 An umbrella term that refers to any functional abnormality of the CNS
 Caused by disruption of blood supply to the brain, causing neurologic deficit
 The middle cerebral artery is the most common affected in CVA
 Most common cause of CVA is thrombosis, then followed by embolism, then cerebral
hemorrhage
Can be divided into two major categories:
1. Ischemic stroke- caused by thrombus and embolus
2. Hemorrhagic stroke- caused commonly by hypertensive bleeding
The stroke continuum
1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours
duration
2. Reversible Neurologic deficits
3. Stroke in evolution
4. Completed stroke
Risks factors:
Non-modifiable
Modifiable
Advanced age
Hypertension
Gender
Cardiac diseases
Race
Obesity
Smoking
Diabetes mellitus
Hypercholesterolemia
Table 54. Causes of CVA
CEREBROVASCULAR ACCIDENTS:
Ischemic Stroke
 There is disruption of the cerebral
blood flow due to obstruction by
embolus or thrombus
Hemorrhagic Stroke
 Normal brain metabolism is impaired
by interruption of blood supply,
compression and increased ICP
 Usually due to rupture of
intracranial aneurysm, AV
malformation,
Subarachnoid
hemorrhage
Clinical Manifestations:
Clinical Manifestations:
 Numbness or weakness
 Sudden and severe headache
 Confusion or change of LOC
 Same neurologic deficits as
ischemic stroke
 Motor and speech difficulties
 Visual disturbance
 Severe headache
 Loss of consciousness
 Meningeal irritation
 Visual disturbances
Diagnostic Test
Diagnostic Test
1. CT scan
1. CT scan
2. MRI
2. MRI
3. Angiography
3. Lumbar puncture (only if with no
increased ICP)
Nursing Management
Nursing Management
1. Improve Mobility and prevent joint
deformities
1. Optimize cerebral tissue perfusion
2. Relieve Sensory deprivation and anxiety
2. Enhance self-care
3. Monitor and manage potential
complications
3. Manage sensory-perceptual
difficulties
4. Manage dysphagia
5. Help patient attain bowel and bladder
control
6. Improve thought process
7. Improve communication
8. Maintain skin integrity
9. Improve family coping
10. Help patient cope with sexual
dysfunction
Table 55
DEGENERATIVE DISORDERS– DEMYELINATING
MULITPLE SCLEROSIS





An auto-immune mediated progressive demyelinating disease of the CNS
The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)
Cause- unknown
Age: 20-40 y/o
Multiple factors- viral infection, environmental factors, genetic predisposition,
autoimmune
 With periods of remissions and exacerbation
Risk Factors
 Fatigue
 Infection
 Extreme temperature
 Pregnancy
 Stress – type A personality
Clinical Manifestation
o
Charcot’s triad
S -canning of speech
I -ntentional tremors
N –ystagmus –upward rolling of eyes
Diagnostic Tests
1. MRI- primary diagnostic study
2. CSF Immunoglobulin G
Nursing Management
 Promote physical mobility
 Exercise
 Schedule activity and rest periods
 Prevent injuries
 Wide stance walking
 Use of walking aids
 Enhance bladder and bowel control
 Set a voiding schedule
 Intermittent bladder catheterization
 Use of condom catheter
 Adequate fluids, dietary fibers and bowel training program
 Manage speech and swallowing difficulties
 Careful feeding, proper positioning, suction machine availability
 Speech therapist
 Improve Sensory and Cognitive function
 Vision- use eye patch for diplopia
 Strengthen coping mechanism
 Improve self-care abilities
 Promote sexual functioning
Medical Management
 Corticosteroids
 Immunosuppressant
 Plasmapheresis – method of removing a quantity of plasma from the blood
GULLAIN BARRE’ SYNDROME
 An auto-immune attack of the peripheral nerve myelin
 Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves
 Cause: respiratory and GIT infection
Clinical Manifestations
o Ascending weakness and paralysis (symmetrical)
o diminished reflexes of the lower extremities
o paresthesia
o potential respiratory failure – diaphragm
o paralytic ileus – paralyze GIT
Nursing Management
Focus: Airway
 Maintain respiratory function
02 – 2l/min
Perform deep breathing and coughing exercise
 Enhance physical mobility
 Provide adequate nutrition
 Improve communication
 Decrease fear and anxiety
 Monitor and manage complications
Degenerative disorders- NON-demyelinating
Alzheimer’s disease
 A progressive neurologic disorder that affects the brain resulting in cognitive
impairments
Causes:
 Unknown
 Family History and Down’s Syndrome are very important risk factors!

Potential factors- Amyloid plaques in the brain, Oxidative stress,
neurochemical deficiencies
Pathophysiology



Decreased Acetylcholine
Neurofibrillary tangles
senile neuritic plaques
Clinical Manifestations
o Forgetfulness
o Recent memory loss
o Difficulty learning
o Deterioration in personal hygiene
o Inability to concentrate
Late clinical manifestations
1.
2.
3.
4.
5.
Difficulty in abstract thinking
Difficulty communicating
Severe deterioration in memory, language and motor function
repetitive action- perseveration
personality changes
Remember the “4A’s”




Amnesia
Apraxia
Agnosia
Aphasia
Diagnostic Test
1. Neurologic examination
2. PET scan
3. EEG, CT and MRI
4. Other tests to rule out Vit B deficiencies and hypothyroidism
5. Autopsy is the most definitive test!
Nursing Management
 Support patient’s abilities
 Provide emotional support
 Establish an effective communication system with the patient and family
 Use short simple sentences, words and gestures
 Maintain a calm and consistent approach
 Attempt to analyze behavior for meaning
 Protect the patient from injury by providing a
 Safe , Supervised , Simplified and Structured environment
 Requests a family member to accompany client if he wanders around
 Keep bed in low position
 Provide adequate lightning
 Assign consistent caregivers
 Encourage exercise to maintain mobility
Medical Management
Pharmacotherapy
 drugs to treat behavioral symptoms- antipsychotics
 anxiolytics
 Donepezil
 Tacrine
PARKINSON’S DISEASE
“Parslysis Agitans”
 A slowly progressing neurologic movement disorder
 The degenerative idiopathic form is the most common form
 It affects the extrapyramidal system (EPS). This causes decreased dopamine
production
Pathophysiology
- Decreased levels of dopamine due to destruction of pigmented neuronal cells in the
substantia nigra in the basal ganglia
- Clinical symptoms do not appear until 60% of the neurons have disappeared
Causative factors: unknown
Potential factors: genetics, atherosclerosis, free radical stress, viral infection, head
trauma and environmental factors
Clinical Manifestations
o Tremors- resting, pill-rolling
o Rigidity- cog-wheel, lead-pipe
o Bradykinesia- abnormally slow movement
o Dementia, depression, sleep disturbances and hallucinations
o excessive sweating, paroxysmal flushing, orthostatic hypotension
Nursing Management
 Improve mobility
 Enhance Self- care activities
 Improve bowel elimination
 Improve nutrition
 Enhance swallowing
 Encourage the use of assistive devices
 improve communication
 Support coping abilities
Medical Management
 Anti-parkinsonian drugs- Levodopa, Carbidopa
 Anti-cholinergic therapy
 Antiviral therapy- Amantadine
 Dopamine Agonists- bromocriptine and Pergolide, Ropirinole and
Pramipexole
 MAOI
 Anti-depressants
 Antihistamine
Parkinson’s
Multiple
Sclerosis
Myastenia
Gravis
Degenerativ
e
Autoimmune
Autoimmune
Incidence
Late
elderlymales
Female
young adult
Mechanism
s
Decrease
dopamine
Increase
acetylcholin
e
Demyelinati
on (brainspinal cord)
Descending
s/sx
Bradykinesia
Tremors
Cause
Rigidity
Shuffling
gait
Mask like
face
Monotonous
slow speech
Resting
tremors
Drugs
Levodopa carbidopa
(Sinemet
Charcot’s
triad:
Nystagmus
Scanning of
speech
Amyotropic
Lateral
Sclerosis
Degenerativ
e
Guillain
Bare
Syndrome
Autoimmun
e
Female young
adult
Female
young adult
Female
young
adult
Both sexes
middle adult
Increase
acetylcholines
-terase
Decrease
acetylcholine
Loss of
motor
function
Inflammati
on
Genetically
transmitted
Defect in a
single gene
that is
inherited as an
autosomal
dominant
characteristic
Muscle
fatigue
Ptosisdrooping of
eyes
Sudden
paralysis
In 2 yrs
time patient
dies
Ascending
paralysis
Ascending
paralysis
Intentional
tremors
Huntington’s
chorea
Degenerative
Abnormal
movements
(chorea)
intellectual
decline
emotional
disturbance.
Charcot’s
triad
Steroids
Anticholinest
erase
Neostigmine
Pyridostigmin
e
Give the drug
RTC
Steroids
Steroids
immunosuppr
essants
After meals
Full stomach
to prevent
Haloperidol
Diazepam
Antidepressan
ts
Prevent
myesthenic
and
cholinergic
crisis
gastric
irritation
taken before
meals
Table 56. Comparison between Neurologic Disorders
Nursing care: supportive and symptomatic care not prioritize problem rather the actual
MOTOR DYSFUNCTION- CNS
EPILEPSY
 A group of syndromes characterized by recurring seizures
Causes

Idiopathic

Brain tumors

Birth trauma

head Injury

Perinatal infection

Metabolic disorders

Infectious disease

CVA

Ingestion of toxins
GENERALIZED SEIZURES
PARTIAL SEIZURES
 cause a generalized electrical
abnormality within the brain
 these seizures arise from a localized
part of the brain and cause specific
symptoms
1. General Tonic-Clonic seizure (Grand mal)
- characterized by loss of consciousness
and alternating movements of the
extremities
1. Simple partial seizure- typically limited
to one cerebral hemisphere
2. Absence Seizure (Petit mal)- common in
children, begins with a brief change in the
LOC, indicated by blinking, rolling of eyes
and blank stares
2. Complex partial seizure- begins with an
aura, then with impaired consciousness,
with purposeless behaviors like lipsmacking, chewing movements
3. Myoclonic seizure- characterized by
brief, involuntary muscular jerks of body
extremities
4. Akinetic seizure- general loss of
postural tone and a temporary loss of
consciousness- a drop attack
Table 57. Generalizaed vs. Partial Seizure
Diagnostic Tests
1. EEG
2. CT
3. MRI
4. Lumbar Puncture
5. Angiography
Nursing Management
 During seizure
 Remove harmful objects from the patient’s surrounding
 Ease the client to the floor
 Protect the head with pillows
 Observe and note for the duration, parts of body affected, behaviors
before and after the seizure
 Loosen constrictive clothing
 DO NOT restrain, or attempt to place tongue blade or insert oral airway
 POST seizure
 Place patient to the side to drain secretions and prevent aspiration
 Help re-orient the patient if confused
 Provide care if patient became incontinent during the seizure attack
 Stress importance of medication regimen