Nervous System

Overview of the Structures & Functions

Central NS PNS ANS
Brain & spinal cord 31 spinal & cranial sympathetic NS
Parasypathatic NS

Somatic NS
C- 8
T- 12
L- 5
S- 5
C- 1

ANS (or adrenergic of parasympatholitic response)

SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)

1. Dilate pupil – to aware of surroundings
Release of norepinephrine (adrenaline – cathecolamine) - medriasis
Adrenal medulla (potent vasoconstrictor) 2. Dry mouth
Increases body activities VS = Increase 3. BP & HR= increased
Except GIT – decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased
* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention
Increase blood flow to skeletal muscles, brain & heart.

I. Adrenergic Agents – Epinephrine (adrenaline)

SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’)
- Blocks release of norepinephrine.
- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol

SE:
B – broncho spasm (bronchoconstriction)
E – elicits a decrease in myocardial contraction
T – treats HPN
A – AV conduction slows down

Given to angina & MI – beta-blockers to rest heart

Anti HPN agents:
1. Beta blockers (-lol)
2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL
3. Calcium antagonist
ex CALCIBLOC or NEFEDIPINE

Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic)
- Involved in fly or withdrawal response 1. Meiosis – contraction of pupils
- Release of acetylcholine (ACTH) 2. Increase salivation
- Decrease all bodily activities except GIT (diarrhea) 3. BP & HR decreased
4. RR decrease – broncho constriction
I Cholinergic agents 5. Diarrhea – increased GI motility
ex 1. Mestinon 6. Urinary frequency
Antidote – anti cholinergic agents Atropine Sulfate – S/E – SNS

S/E- of anti-hpn drugs:

1. orthostatic hpn
2. transient headache & dizziness.
-Mgt. Rise slowly. Assist in ambulation.
CNS (brain & spinal cord)
I. Cells – A. neurons
Properties and characteristics
a. Excitability – ability of neuron to be affected in external environment.
b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
A. Labile – once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUT
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B. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
C. Permanent cells – retina, brain, heart, osteocytes can’t regenerate.

3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria

Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.
Astrocyte – maintains integrity of blood brain barrier (BBB).
BBB – semi permeable / selective
-Toxic substance that destroys astrocyte & destroy BBB.
Toxins that can pass in BBB:
1. Ammonia-liver cirrhosis.
2. 2. Carbon Monoxide – seizure & parkinsons.
3. 3. Bilirubin- jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. 4. Ketones –DM.

OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse
transmission.
No myelin sheath – degenerates neurons

Damage to myelin sheath – demyellenating disorders

DEMYELLENATING DSE
1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.

S&Sx:
A – amnesia – loss of memory
A – apraxia – unable to determine function & purpose of object
A – agnosia – unable to recognize familiar object
A – aphasia –
- Expressive – brocca’s aphasia – unable to speak
- Receptive – wernickes aphasia – unable to understand spoken words
Common to Alzheimer – receptive aphasia
Drug of choice – ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.

Microglia – stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord

80% - brain mass
10% - CSF
10% - blood
MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg
Brain mass

1. Cerebrum – largest - Connects R & L cerebral hemisphere

- Corpus collusum
Rt cerebral hemisphere, Lt cerebral hemisphere
Function:
1. Sensory
2. Motor
3. Integrative
Lobes
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Brocca’s area – speech center
Damage - expressive aphasia
2.) Temporal –
a. Hearing
b. Short term memory
c. Wernickes area – gen interpretative or knowing Gnostic area
Damage – receptive aphasia
3.) Parietal lobe – appreciation & discrimation of sensory imp

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 - Pain, touch, pressure, heat & cold
4.) Occipital - vision
5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory

Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere
- Extra pyramidal tract
- Releases dopamine-
- Controls gross voluntary unit

Decrease dopamine – (Parkinson’s) pin rolling of extremities & Huntington’s Dse.

Decrease acetylcholine – Myasthenia Gravis & Alzheimer’s
Increased neurotransmitter = psychiatric disorder Increase dopamine – schizo
Increase acetylcholine – bipolar

MID BRAIN – relay station for sight & hearing

Controls size & reaction of pupil 2 – 3 mm
Controls hearing acuity
CN 3 – 4
Isocoria – normal size (equal)
Anisocoria – uneven size – damage to mid brain
PERRLA – normal reaction

DIENCEPHALON- between brain

Thalamus – acts as a relay station for sensation
Hypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional
responses, controls pituitary function.

BRAIN STEM- a. Pons – or pneumotaxic center – controls respiration

Cranial 5 – 8 CNS

MEDULLA OBLONGATA- controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12

CEREBELLUM – lesser brain

- Controls posture, gait, balance, equilibrium

Cerebellar Tests:
a.) R – Romberg’s test- needs 2 RNs to assist
- Normal anatomical position 5 – 10 min
(+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test –
(+) To FTNT – dymetria – inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium

Composition of brain - based on Monroe Kellie Hypothesis

- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP

Normal ICP – 0 – 15 mmHg

Foramen Magnum
C1 – atlas
C2 – axis

(+) Projectile vomiting = increase ICP

Observe for 24 - 48 hrs
CSF – cushions the brain, shock absorber
Obstruction of flow of CSF = increase ICP
Hydrocephalus – posteriorly due to closure of posterior fontanel
CVA – partial/ total obstruction of blood supply

INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus

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 7.) Inflammatory conditions - Meningitis, encephalitis

B. S&Sx change in VS = always late symptoms

Earliest Sx:
a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign – change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP Shock – decrease BP –
Decrease HR Increase HR CUSHINGS EFFECT
Decrease RR Increase RR
Increase Temp Decrease temp
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk – outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/

c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.)
d.) Possible seizure.

Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).

Hypoxia – cerebral edema - increase ICP

Hypoxia – inadequate tissue oxygenation
Late symptoms of hypoxia – B – bradycardia
E – extreme restlessness
D – dyspnea
C – cyanosis
Early symptoms – R – restlessness
A – agitation
T – tachycardia

Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP

Most powerful respiratory stimulant increase in CO2
Hyperventilate decrease CO2 – excrete CO2

Respiratory Distress Syndrome (RDS) – decrease Oxygen

Suctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.
Ambu bag – pump upon inspiration

c. Assist in mechanical ventilation

1. Maintain patent a/w
2. Monitor VS & I&O
3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote
venous drainage
4. Limit fluid intake 1,200 – 1,500 ml/day
(FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP.

5. Prevent complications of immobility

6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints – lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
-Valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
- Excessive cough – antitussive
Dextrometorpham
-Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan
- Lifting of heavy objects
- Bending & stooping

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 e. Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic – Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue

Nursing considerations: Mannitol

1. Monitor BP – SE of hypotension
2. Monitor I&O every hr. report if < 30cc out put
3. Administer via side drip
4. Regulate fast drip – to prevent formation of crystals or precipitate

2.) Loop diuretic - Lasix (Furosemide)

Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the
morning. If given at 7am. Pt will urinate at 7:15
Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm)

S/E of Lasix
Hypokalemia (normal K-3.5 – 5.5 meg/L)
S&Sx
1. Weakness & fatigue
2. Constipation
3. (+) “U” wave in ECG tracing

Nursing Mgt:
1.) Administer K supplements – ex Kalium Durule, K chloride
Potassium Rich food:
ABC’s of K
Vegetables Fruits
A - asparagus A – apple
B – broccoli (highest) B – banana – green
C – carrots C – cantalope/ melon
O – orange (highest) –for digitalis toxicity
also.
Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa
Iron – raisins,
Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions
Don’t give grapes – may choke

S/E of Lasix:
1.) Hypokalemia
2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:
S&Sx
weakness
Paresthesia
(+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on
arm=hand spasm.
(+) Chevostek’s sign
Arrhythmia
Laryngospasm
Administer – Ca gluconate – IV slowly

Ca gluconate toxicity: Sx – seizure – administer Mg SO4

Mg SO4 toxcicity– administer Ca gluconate
B – BP decrease
U – urine output decrease
R – RR decrease
P – patellar reflexes absent

3.) Hyponatremia – Normal Na level = 135 – 145 meg/L

S/Sx – Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs – Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid sol

4.) Hyperglycemia – increase blood sugar level

P – polyuria
P – polyphagia
P – polydipsia

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 Nsg Mgt:
a. Monitor FBS (N=80 – 120 mg/dl)
5.) Hyperurecemia – increase serum uric acid. Tophi- urate crystals in joint.

Gouty arthritis kidney stones- renal colic (pain)

Cool moist skin
Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis

a.) Cheese (not sardines, anchovies, organ meat)
(Not good if pt taking MAO)
b.) Force fluid
c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for
gout
Colchicene – excretes uric acid. Acute gout drug of choice.
Kidney stones – renal colic (pain). Cool moist skin
Mgt:
1.) Force fluid
2.) Meds – narcotic analgesic
Morphine SO4

SE of Morphine SO4 toxicity

Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity –Narcan (NALOXONE)
Naloxone toxicity – tremors

Increase ICP meds:

3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone)
4.) Mild analgesic – codeine SO4. For headache.
5.) Anti consultants – Dilantin (Phenytoin)

Question: Increase ICP what is the immediate nsg action?

a. Administer Mannitol as ordered
b. Elevate head 30 – 45 degrees
c. Restrict fluid
d. Avoid use of restraints

Nsg Priority – ABC & safety

Pt suffering from epiglotitis. What is nsg priority?

a. Administer steroids – least priority
b. Assist in ET – temp, a/w
c. Assist in tracheotomy – permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only-

Magic 2’s of drug monitoring

Drug N range Toxicity Classification Indication

D – digoxin .5 – 1.5 meq/L 2 cardiac glycosides CHF
L - lithium .6 – 1.2 meq/L 2 antimanic bipolar
A – aminophylline 10 – 19 mg/100ml 20 bronchodilator COPD
D – Dilantin 10 -19 mg/100 ml 20 anticonvulsant seizures
A – acetaminophen 10 – 30 mg/100ml 200 narcotic analgesic osteoarthritis

Digitalis – increase cardiac contraction = increase CO

Nursing Mgt
1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin)
Digitalis toxicity – antidote - Digivine
a. Anorexia -initial sx.
b. n/v GIT
c. Diarrhea
d. Confusion
e. Photophobia
f. Changes in color perception – yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L – lithium (lithane) decrease levels of norepinephrine, serotonine, acetylcholine

Antimanic agent

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 Lithium toxicity
S/Sx -
a.) Anorexia
b.) n/s
c.) Diarrhea
d.) Dehydration – force fluid, maintain Na intake 4 – 10g daily
e.) Hypothyroidism
(CRETINISM– the only endocrine disorder that can lead to mental retardation)

A – aminophyline (theophylline) – dilates bronchioles.

Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity – restlessness, agitation, tremors

Question: Avoid giving food with Aminophylline

a. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI
b. Beer/ wine -
c. Hot chocolate & tea – caffeine – CNS stimulant tachycardia
d. Organ meat/ box cereals – anti parkinsonian

MAOI – antidepressant
m AR plan
n AR dil can lead to CVA or hypertensive crisis
p AR nate
3 – 4 weeks - before MAOI will take effect
Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa

D – dilatin (Phenytoin) – anti convulsant/seizure

Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
- Do sandwich method
- Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression

Dilantin toxicity:
S/Sx:
G – gingival hyperplasia – swollen gums
i. Oral hygiene – soft toothbrush
ii. Massage gums
H – hairy tongue
A - ataxia
N – nystagmus – abnormal movement of eyeballs
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts
Acetaminophen toxicity :
1. Hepato toxicity
2. Monitor liver enzymes
SGPT (ALT) – Serum Glutamic Piruvate Tyranase
SGOT- Serum Glutamic Acetate Tyranase
3. Monitor BUN (10 – 20)
Crea (.8-1)
Acetaminophen toxicity can lead to hypoglycemia
T – tremors, Tachycardia
I – irritability
R – restlessness
E – extreme fatigue
D – depression (nightmares) , Diaphoresis
Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction.
Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:
a. Nightmares
b. Extreme thirst – hyperglycemia symptoms
c. Weakness d. Diaphoresis

PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine
producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, Supportive
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA

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2. Hypoxia
3. Arteriosclerosis
4. Encephalitis

High doses of the ff:

a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancer
b. Methyldopa (aldomet) - promote safety
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic

SE of anti psychotic drugs – Extra Pyramidal Symptom

Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism –
1. Pill rolling tremors of extremities – early sign
2. Bradykinesia – slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling – most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety – always depressed – suicide
Nsg priority: Promote safety
9. Increase salivation – drooling type
10. Autonomic signs:
- Increase sweating
- Increase lacrimation
- Seborrhea (increase sebaceous gland)
- Constipation
- Decrease sexual activity
Nsg Mgt
1.) Anti parkinsonian agents
- Levodopa (L-Dopa), Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)
Mechanism of action
Increase levels of dopa – relieving tremors & bradykinesia
S/E of anti parkinsonian
- Anorexia
- n/v
- Confusion
- Orthostatic hypotension
- Hallucination
- Arrhythmia
Contraindication:
1. Narrow angled closure glaucoma
2. Pt taking MAOI (Parnate, Marplan, Nardil)

Nsg Mgt when giving anti-parkinsonian

1. Take with meals – to decrease GIT irritation
2. Inform pt – urine/ stool may be darkened
3. Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2.) Anti cholinergic agents – relieves tremors
Artane mech – inhibits acetylcholine
Cogentin action , S/E - SNS

3.) Antihistamine – Diphenhydramine Hcl (Benadryl) – take at bedtime

S/E: adult– drowsiness,– avoid driving & operating heavy equipt. Take at bedtime.
Child – hyperactivity CNS excitement for kids.
4.) Dopamine agonist
Bromotriptine Hcl (Parlodel) – respiratory depression. Monitor RR.

Nsg Mgt – Parkinson

1.) Maintain siderails
2.) Prevent complications of immobility
- Turn pt every 2h
Turn pt every 1 h – elderly
3.) Assist in passive ROM exercises to prevent contractures
4.) Maintain good nutrition

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 CHON – in am
CHON – in pm – to induce sleep – due Tryptopan – Amino Acid
5.) Increase fluid in take, high fiber diet to prevent constipation
6.) Assist in surgery – Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis

MULTIPLE SCLEROSIS (MS)

Chronic intermittent disorder of CNS – white patches of demyelenation in brain & spinal cord.
- Remission & exacerbation
- Common – women, 15 – 35 yo cause – unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune – (supportive & palliative treatment only)
Normal Resident Antibodies:
Ig G – can pass placenta – passive immunity. Short acting.
Ig A – body secretions – saliva, tears, colostrums, sweat
Ig M – acute inflammation
Ig E – allergic reactions
IgD – chronic inflammation

S & Sx of MS: (everything down)

1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) – initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
b. Tingling
c. Paresthesia
3. Mood swings – euphoria (sense of elation )
4. Impaired motor function:
a. Weakness
b. Spasiticity –“ tigas”
c. Paralysis –major problem
5. Impaired cerebellar function
Triad Sx of MS
I – intentional tremors
N – nystagmus – abnormal rotation of eyes Charcots triad
A – Ataxia
& Scanning speech
6. Urinary retention or incontinence
7. Constipation
8. Decrease sexual ability
Dx – MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI – reveals site & extent of demyelination
3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
- Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH – adenocorticotopic
Steroids – to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord Injury
Administer drug to prevent paralysis due to edema
a. Give ACTH – steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)
To decrease muscle spasticity
c. Interferone – to alter immune response
d. Immunosuppresants
2. Maintain siderails
3. Assist passive ROMexercises – promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet – to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence – give Prophantheline bromide (probanthene)

Antispasmodic anti cholinergic

8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication

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 Grape, Cranberry, Orange juice, Vit C

MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at neuro muscular
junction.
Common in Women, 20 – 40 yo, unknown cause or idiopathic
Autoimmune – release of cholenesterase – enzyme
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
(Ascending muscle weakness – Guillain Barre Syndrome)
Nsg priority:
1) a/w
2) aspiration
3) immobility
S/ Sx:
1.) Ptosis – drooping of upper lid ( initial sign)
Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.
2.) Diplopia – double vision
3.) Mask like facial expression
4.) Dysphagia – risk for aspiration!
5.) Weakening of laryngeal muscles – hoarseness of voice
6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set
7.) Extreme muscle weakness during activity especially in the morning.
Dx test
1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS
effect.
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent – attach to ventilator
b.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)
3. Siderails
4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.
5. NGT feeding
Administer meds –
a.) Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) – Long term
- Increase acetylcholine
s/e – PNS
b.) Corticosteroids – to suppress immune resp
Decadron (dexamethasone)

Monitor for 2 types of Crisis:

Myastinic crisis Cholinergic crisis
A cause – 1. Under medication Cause: 1 over meds
2. Stress S/Sx - PNS
3. Infection
B S&Sx 1. Unable to see – Ptosis &
diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath Mgt. adm anti-cholinergic
C Mgt – adm cholinergic agents - Atropine SO4
- SNS – dry mouth
7. Assist in surgical proc – thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.
8. Assist in plasmaparesis – filter blood
9. Prevent complication – respiratory arrest
Prepare tracheostomy set at bedside.

GBS – Guillain Barre Syndrome

- Disorder of CNS
- Bilateral symmetrical polyneuritis
- Ascending paralysis
Cause – unknown, idiopathic
- Auto immune
- r/t antecedent viral infection
- Immunizations

S&Sx
Initial :
1. Clumsiness
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 2. Ascending muscle weakness – lead to paralysis
3. Dysphagia
4. Decrease or diminished DTR (deep tendon reflexes)
- Paralysis
5. Alternate HPN to hypotension – lead to arrhythmia - complication
6. Autonomic changes – increase sweating, increase salivation.
Increase lacrimation
Constipation
Dx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)

Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl – immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding – due dysphagia

7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4

2. Corticosteroids – to suppress immune response
3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine –SE confusion = VTach
b.) Bretyllium
c.) Quinines/Quinidine – anti malarial agent. Give with meals.
- Toxic effect – cinchonism
Quinidine toxicity
S/E – anorexia, n/v, headache, vertigo, visual disturbances
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp – arrhythmias, respiratory arrest
Prepare tracheostomy set at bedside.

INFL CONDITONS OF BRAIN

Meninges – 3-fold membrane – cover brain & spinal cord
Fx:
Protection & support
Nourishment
Blood supply
3 layers
1. Duramater sub dural space
2. Arachmoid matter
3. Pia matter sub arachnoid space where CSF flows L3 & L4. Site for lumbar puncture.

MENINGITIS – inflammation of meningitis & spinal cord

Etiology – Meningococcus
Pneumococcus
Hemophilous influenza – child
Streptococcus – adult meningitis
MOT – direct transmission via droplet nuclei

S&Sx
- Stiff neck or nuchal rigidity (initial sign)
- Headache
- Projectile vomiting – due to increase ICP
- Photophobia
- Fever chills, anorexia
- Gen body malaise
- Wt loss
- Decorticate/decerebration – abnormal posturing
- Possible seizure
Sx of meningeal irritation – nuchal rigidity or stiffness
Opisthotonus- rigid arching of back

Pathognomonic sign – (+) Kernig’s & Brudzinski sign

Leg pain neck pain

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Dx:
1. Lumbar puncture – lumbar/ spinal tap – use of hallow spinal needle – sub arachnoid space L3 & L4 or L4 & L5
Aspirate CSF for lumbar puncture.
Nsg Mgt for lumbar puncture – invasive
1. Consent / explain procedure to pt
- RN – dx procedure (lab)
- MD – operation procedure
2. Empty bladder, bowel – promote comfort
3. Arch back – to clearly visualize L3, L4

Nsg Ngt post lumbar

1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue
4. Assess for movement & sensation of extremeties

Result
1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 – 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC – reveals increase WBC
Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
S/E
1. GIT irritation – take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection – alteration in normal bacterial flora
- N flora throat – streptococcus
- N flora intestine – e coli
Sx of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapy
A – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.
B – Aplastic anemia – reverse isolation - due to bone marrow depression.
C – Cancer anytype – reverse isolation – immunocompromised.
D – Post liver transplant – reverse isolation – takes steroids lifetime.
E – Prolonged use steroids – reverse isolation
F – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapy
G – Asthma – not to be isolated

3. Comfy & dark room – due to photophobia & seizure

4. Prevent complications of immobility
5. Maintain F & E balance
6. Monitor vs, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 yo post meningitis
- Audiologist due to damage to hearing- post repair myelomeningocele
- Urologist -Damage to sacral area – spina bifida – controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.

CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy

- Partial or complete disruption in the brains blood supply
- 2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
- Common to male – 2 – 3x high risk

Predisposing factor:

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 1. Thrombosis – clot (attached)
2. Embolism – dislodged clot – pulmo embolism
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness

S/Sx: cerebral embolism

Headache, disorientation, confusion & decrease in LOC

Femur fracture – complications: fat embolism – most feared complication w/in 24hrs
Yellow bone marrow – produces fat cells at meduallary cavity of long bone
Red bone marrow – provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage
3.) Compartment syndrome – compression of nerves/ arteries

Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral valve replacement

Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor

2. Sedentary lifestyle
3. Hyperlipidemia – genetic
4. Prolonged use of oral contraceptives
- Macro pill – has large amt estrogen
- Mini pill – has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke
5. Type A personality
a. Deadline driven person
b. 2 – 5 things at the same time
c. Guilty when not dong anything
6. Diet – increase saturated fats
7. Emotional & physical stress
8. Obesity
S & Sx
1. TIA- warning signs of impending stroke attacks
- Headache (initial sx), dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia
(monoplegia – 1 extreme)
Increase ICP
2. Stroke in evolution – progression of S & Sx of stroke
3. Complete stroke – resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernig’s & Brudzinski – sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria – inability to vocalize, articulate words
3. Aphasia
4. Agraphia diff writing
5. Alesia – diff reading
6. Homoninous hemianopsia – loss of half of field of vision
Left sided hemianopsia – approach Right side of pt – the unaffected side

Dx
1. CT Scan – reveals brain lesion
2. Cerebral arteriography – site & extent of mal occlusion
- Invasive procedure due to inject dye
- Allergy test
All – graphy – invasive due to iodine dye
Post
1.) Force fluid – to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal

Nsg Mgt
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids – prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:

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 a. Turn client q2h
Elderly q1h
- To prevent decubitus ulcer
- To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding – if pt can’t swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia – approach on unaffected side
9. Meds
Osmotic diuretics – Mannitol
Loop diuretics – Lasix/ Furosemide
Corticosteroids – dextamethazone
Mild analgesic
Thrombolytic/ fibrolitic agents – tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
Monitor bleeding time
Anticoagulants – Heparin & Coumadin” sabay”
Coumadin will take effect after 3 days
Heparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.
Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton-
antidote.
Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.

Health Teaching
1. Avoidance modifiable lifestyle
- Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit – physical therapy
1. Mental retardation
2. Delay in psychomotor development

CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of
consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.

Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attack
Febrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizure
Pathologic if > 5 yo

Predisposing Factor
Head injury due birth trauma
Toxicity of carbon monoxide
Brain tumor
Genetics
Nutritional & metabolic deficit
Physical stress
Sudden withdrawal to anticonvulsants will bring about status epilepticus
Status epilepticus – drug of choice: Diazepam & glucose

S & Sx
I. Generalized Seizure –
a.) Grand mal / tonic clonic seizures
With or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with
olfactory, tactile, visual, auditory sensory experience
- Epileptic cry – fall
- Loss of consciousness 3 – 5 min
- Tonic clonic contractions
- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC
- Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure – (same as daydreaming!) or absent seizure.
- Blank stare

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 - Decrease blinking eye
- Twitching of mouth
- Loss of consciousness – 5 – 10 secs (quick & short)

II. Localized/partial seizure

a.) Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to shoulder &
1 sideof the body with janksonian march
b.) Psychomotor/ focal motor - seizure
-Automatism – stereotype repetitive & non-purposive behavior
- Clouding of consciousness – not in control with environment
- Mild hallucinatory sensory experience

HALLUCINATIONS
1. Auditory – schitzo – paranoid type
2. Visual – korsakoffs psychosis – chronic alcoholism
3. Tactile – addict – substance abuse

III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – death
Seizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose,
dec O2.
Tx:Diazepam (drug of choice), glucose
Dx-Convulsion- get health history!
1. CT scan – brain lesion
2. EEG electroencephalography
- Hyperactivity brain waves
Nsg Mgt
Priority – Airway & safety
1. Maintain patent a/w & promote safety
Before seizure:
1. Remove blunt/sharp objects
2. Loosen clothing
3. Avoid restraints
4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.
7. Avoid precipitating stimulus – bright glaring lights & noises
8. Administer meds
a. Dilantin (Phenytoin) –( toxicity level – 20 )

SE Ginguial hyperplasia
H-hairy tongue
A-ataxia
N-nystagmus
A-acetaminophen- febrile pt
Mix with NSS
- Don’t give alcohol – lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmia
c. Phenobarbital (Luminal)- SE: hallucinations

2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside
3. Monitor onset & duration
- Type of seizure
- Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status
epilepticus!
4. Assist in surgical procedure. Cortical resection
5. Complications: Subarachnoid hemorrhage and encephalitis

Question: 1 yo grand mal – immediate nursing action = a/w & safety

a. Mouthpiece – 1 yr old – little teeth only
b. Adm o2 inhalation – post!
c. Give pillow – safety (answer)
d. Prepare suction

Neurological assessment:
1. Comprehensive neuro exam
2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check
3 components of ECS
M – motor 6
V – verbal resp 5
E – eye opening 4
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 15 – 14 – conscious
13 – 11 – lethargy
10 – 8 – stupor
7 – coma
3 – deep coma – lowest score

Survey of mental status & speech (Comprehensice Neuro Exam)

1.) LOC & test of memory
2.) Levels of orientation
3.) CN assessment
4.) Motor assessment
5.) Sensory assessment
6.) Cerebral test – Romhberg, finger to nose
7.) DTR
8.) Autonomics

Levels of consciousness (LOC) –

1. Conscious (conscious) – awake – levels of wakefulness
2. Lethargy (lethargic) – drowsy, sleepy, obtunded
3. Stupor (stuporous) – awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex
4. Coma (Comatose) light – (+) all forms of painful stimulations
Deep – (-) to painful stimulation
Question: Describe a conscious pt ?
a. Alert – not all pt are alert & oriented to time & place
b. Coherent
c. Awake- answer
d. Aware

Different types of pain stimulation

- Don’t prick
1. Deep sternal stimulation/ pressure 3x– fist knuckle
With response – light coma
Without response – deep coma
2. Pressure on great toe – 3x
3. Orbital pressure – pressure on orbits only – below eye
4. Corneal reflex/ blinking reflex
Wisp of cotton – used to illicit blinking reflex among conscious patients
Instill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma
5. Test of memory – considered educational background
a.) Short term memory –
- What did you eat for breakfast?
Damage to temporal lobe – (+) antero grade amnesia
b.) Long term memory
(+) Retrograde amnesia – damage to limbic system
6. Levels of orientation
Time Place Person

Graphesthesia- can identify numbers or letters written on palm with a blunt object.
Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.

CN assessment:
I– Olfactory s
II – Optic s
III – Oculomotor m
IV – Trocheal m smallest CN
V– Trigeminal b largest CN
VI – Abducens m
VII – Facial b
VIII – Acustic/auditory s
IX – Glassopharyngeal b
X– Vagus b longest CN
XI– Spinal accessory m
XII – Hypoglossal m

I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar
- Hyposmia – decrease sensitivity to smell
- Diposmia – distorted sense of smell
- Anosmia – absence of sense of smell
Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are
located or indicate inflammation condition – sinusitis

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II optic- test of visual acuity – Snellens chart – central or distance vision
Snellens E chart – used for illiterate chart
N 20/20 vision distance by w/c person can see letters- 20 ft
Numerator – distance to snellens chart
Denominator – distance the person can see the letters
OD – Rt eye 20/20 20/200 – blindness – cant read E – biggest
OS – left eye 20/20
OU – both eye 20/20

2. Test of peripheral vision/ visual field

a. Superiority
b. Bitemporally
c. Inferiorly
d. Nasally

Common Disorders – see page 85-87 for more info on glaucoma, etc.
1. Glaucoma – Normal 12 – 21 mmHg pressure
- Increase IOP - Loss of peripheral vision – “tunnel vision”
2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision”
3. Retinal detachment – curtain veil – like vision & floaters
4. Macular degeneration – black spots

III, IV, VI – tested simultaneously

- Innervates the movementt of extrinsic ocular muscle
6 cardinal gaze EOM

Rt eye N left eye

IO SO O
S
LR MR E
SR

3 – 4 EOM
IV – sup oblique
VI – lateral rectus
Normal response – PERRLA (isocoria – equal pupil)
Anisocoria – unequal pupil

Oculomotor
1. Raising of eyelid – Ptosis
2. Controls pupil size 2 -3 cm or 1.5 – 2 mm

V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular

Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex

Unconscious – instill drop of saline solution

Motor – controls muscles of chewing/ muscles of mastication
Trigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended

Question: Trigeminal neuralgia, RN should give

a. Hot milk, butter, raisins
b. Cereals
c. Gelatin, toast, potato – all correct but
d. Potato, salad, gelatin – salad easier to chew

VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar.
-Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group – 40 yrs old
Motor- controls muscles of facial expression, smile frown, raise eyebrow
Damage – Bells palsy – facial paralysis
Cause – bells palsy pedia – R/T forcep delivery
Temporary only
Most evident clinical sign of facial symmetry: Nasolabial folds

VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense)
- Movement & orientation of body in space
- Organ of Corti – for hearing – true sense organ of hearing

Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumen

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 Middle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
- Eustachean ear
Inner ear- meniere dse, sensory hearing loss (research parts! & dse)
Remove vestibule – meniere’s dse – disease inner ear

Archimedes law – buoyancy (pregnancy – fetus)

Daltons law – partial pressure of gases
Inertia – law of motion (dizziness, vertigo)

1.) Pt with multiple stab wound - chest

- Movement of air in & out of lungs is carried by what principle?
- Diffusion – Dalton’s law
2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid
- Archimedes
3.) Severe vertigo due- Inertia

Test for acoustic nerve:

- Repeat words uttered

IX – Glossopharyngeal – controls taste – posterior 1/3 of tongue

X – Vagus – controls gag reflex

Test 9 – 10
Pt say ah – check uvula – should be midline
Damage cerebral hemisphere is L or R
Gag reflex – place tongue depression post part of tongue
 Don’t touch uvula

XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)
- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midline
L or R deviation
- Push tongue against cheek
- Short frenulum lingue –
Tongue tied – “bulol”

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