MEDICAL-SURGICAL NURSING NERVOUS SYSTEM Overview of structures and functions: Central Nervous System

Brain Spinal Cord Peripheral Nervous System Cranial Nerves Spinal Nerves Autonomic Nervous System Sympathetic nervous system Parasympathetic nervous system

Sympathetic Nervous System(ADRENERGIC)

Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC

- Involved in fight or aggression response.- Release of Norepinephrine (cathecolamines)from adrenal glands and causesvasoconstriction.- Increase all bodily activity except GITEFFECTS OF SNS- Dilation of pupils(mydriasis) in order to be aware.- Dry mouth (thickened saliva).- Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.- Increase blood supply tobrain,heart andskeletalmuscles.- SNS

I. Adrenergic Agents- Give Epinephrine.Signs and Symptoms:- SNSContraindication:- Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis, Emphysema, Asthma).II. Beta-adrenergic Blocking Agents- Also called Beta-blockers.- All ending with “lol”-Propranolol, Atenelol, Metoprolol.Effects of Beta-blockersB – roncho spasmE– licits a decrease in myocardial contraction.T – reats hypertension.A – V conduction slows down.

Should be given to patients with Angina Pectoris,Myocardial Infarction, Hypertension.ANTI- HYPERTENSIVE AGENTS1. Beta-blockers – “lol”2. Ace Inhibitors – Angiotensin, “pril” (Captopril,Enalapril)3. Calcium Antagonist – Nifedipine (Calcibloc)

In chronic cases of arrhythmia giveLidocaine(Xylocaine

- Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all bodily activities except GIT.EFFECTS OF PNS- Constriction of pupils (meiosis).- Increase salivation.- Decrease BP and Heart Rate.- Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency.

I. Cholinergic Agents-Mestinon,Neostigmine.Side Effects- PNSII. Anti-cholinergic Agents- To counter cholinergic agents.- Atropine SulfateSide Effects- SN

CENTRAL NERVOUS SYSTEM

Brain and Spinal Cord.I. CELLSA. NEURONS

Basic cells for nerve impulse and conduction.PROPERTIESExcitability – ability of neuron to be affected by changes in external environment.Conductivity – ability of neuron to transmit a wave of excitation from one cell to another.Permanent Cell – once destroyed not capable of regeneration.TYPES OF CELLS BASED ON REGENERATIVE CAPACITY1. Labile

Capable of regeneration. Epidermal cells, GIT cells, GUT cells, cells of lungs.

2. Stable Capable of regeneration with limited time, survival period. Kidney cells, Liver cells, Salivary cells, pancreas.

3. Permanent Not capable of regeneration. Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells.

B. NEUROGLIA Support and protection of neurons.

TYPES1. Astrocytes – maintains blood brain barrier semi-permeable.Majority of brain tumors (90%) arises from calledastrocytoma.2. Oligodendria3. Microglia4. Epindymal

SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER1. Ammonia

Cerebral toxin Hepatic Encephalopathy (Liver Cirrhosis) Ascites Esophageal Varices

Early Signs of Hepatic Encephalopathy asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy Headcahe Dizziness Confusion Fetor hepaticus (ammonia like breath) Decrease LOC

PATHOGNOMONIC SIGNS 1. PTB – low-grade afternoon fever. 2. PNEUMONIA – rusty sputum. 3. ASTHMA – wheezing on expiration. 4. EMPHYSEMA – barrel chest. 5. KAWASAKI SYNDROME – strawberry tongue6. PERNICIOUS ANEMIA – red beefy tongue7. DOWN SYNDROME – protruding tongue8. CHOLERA – rice watery stool9. MALARIA – stepladder like fever with chills10. TYPHOID – rose spots in abdomen11. DIPTHERIA – pseudo membrane formation 12. MEASLES – koplik’s spots.13. SLE – butterfly rashes.14. LIVER CIRRHOSIS – spider like varices.15. LEPROSY – lioning face.16. BULIMIA – chipmunk face. 17. APPENDICITIS – rebound tenderness.18. DENGUE – petechiae or (+) Herman’s sign.19. MENINGITIS – Kernig’s sign (leg pain), Brudzinski sign (neck pain).20. TETANY – HYPOCALCEMIA (+) Trousseau’s sign/carpopedal spasm; Chvostek sign (facial spasm).21. TETANUS – risus sardonicus.

22. PANCREATITIS – Cullen’s sign (ecchymosis of umbilicus); (+) Grey turners spots.23. PYLORIC STENOSIS – olive like mass.24. PDA – machine like murmur.25. ADDISON’S DISEASE – bronze like skin pigmentation.26. CUSHING’S SYNDROME – moon face appearance and buffalo hump.27. HYPERTHYROIDISM/GRAVE’S DISEASE –exopthalmus.28. INTUSSUSCEPTION – sausage shaped mass

2. Carbon Monoxide and Lead Poisoning Can lead to Parkinson’s Disease Epilepsy Treat with ANTIDOTE: Calcium EDTA

3. Type 1 DM (IDDM) Causes diabetic ketoacidosis And increases breakdown of fats And free fatty acids Resulting tocholesterol and (+) toKetones (CNS depressant) Resulting to acetone breath odor/fruity odor KUSSMAUL’S respiration, a rapid shallow respiration Which may lead to diabetic coma

4. Hepatitis Signs of jaundice (icteric sclerae) Caused by bilirubin (yellow pigment)

5. Bilirubin Increase bilirubin in brain (Kernicterus) Causing irreversible brain damage

Astrocites Maintains integrity of blood brain barrier

Oligodendria Produces myelin sheath in CN Act as insulator and facilitates rapid nerve impulse transmission

DEMYELINATING DISORDERS1. ALZHEIMER’S DISEASE

Atrophy of brain tissues.Sign and Symptoms4 A’s of Alzheimera.Amnesia – loss of memory.b.Agnosia – no recognition of inanimate objects.c.Apraxia – no recognition of objects function.d.Aphasia – no speech (nodding).*Expressive aphasia

“motor speech center” Broca’s Aphasia

*Receptive aphasia Inability to understand spoken words Wernicke’s Aphasia General Knowing Gnostic Area or General Interpretative Area

DRUG OF CHOICE: ARICEPT (taken at bedtime) and COGNEX

2. MULTIPLE SCLEROSIS Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain and spinal cord. Characterized by remission and exacerbation Women ages 15-35 are prone Unknown Cause

Slow growing virus Autoimmune disorders Pernicious anemia Myasthenia gravis Lupus Hypothyroidism GBS

Ig G – only antibody that pass placental circulation causing passive immunity- short term protection- Immediate action

Ig A – present in all bodily secretions (tears, saliva, colostrums). Ig M – acute in inflammation.Ig E – for allergic reaction.Ig D – for chronic inflammation* Give palliative or supportive careSigns and Symptoms1. Visual disturbances

blurring of vision (primary)diplopia (double vision)scotomas (blind spots)

2. Impaired sensationto touch, pain, pressure, heat and cold.tingling sensationparesthesianumbness

3. Mood swingseuphoria (sense of well being

4. Impaired motor functionweaknessspasticityparalysis

5. Impaired cerebral functionscanning speech

TRIAD SIGNS OF MS Ataxia

(Unsteady gait, (+) Romberg’s Test

Intentional Tremors Nystagmus 6. Urinary retention/incontinence7. Constipation8. Decrease sexual capacityDIAGNOSTIC PROCEDURE

CSF analysis (increase inIgG andProtein).MRI (reveals site and extent of demyelination).(+) Lhermitte’s sign a continuous and increase contraction of spinal column.

NURSING MANAGEMENT1. Administer medications as ordereda. ACTH (Adreno Corticotropic Hormone)/ Steroids for acute exacerbation to reduce edema at siteof demyelination to prevent paralysis.b. Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) – muscle relaxants.c.Interferons – alter immune response.d.Immunosupresants2. Maintain side rails to prevent injury related to falls.3. Institute stress management techniques.a. Deep breathing exercisesb.Yo g a

4. Increase fluid intake and increase fiber to prevent constipation.5. Catheterization to prevent retentiona.Diureticsb. Bethanicol Chloride (Urecholine)Nursing Management

Only given subcutaneous.Monitor side effects bronchospasm and wheezing.Monitor breath sounds 1 hour after subcutaneous administration.

c. For Urinary IncontinenceAnti spasmodic agenta. Prophantheline Bromide (Promanthene)

Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange.To acidify urine and prevent bacterial multiplication

COMMON CAUSE OF UTIFemale

short urethra (3-5 cm, 1-1 ½ inches)poor perineal hygienevaginal environment is moist

Nursing Managementavoid bubble bath (can alter Ph of vagina).avoid use of tissue papersavoid using talcum powder and perfume.

MaleUrethra (20 cm, 8 inches)urinate after intercourse

MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating),pinocytosis (cell drinking)

MACROPHAGE ORGANMicrogliaMonocytesKupffers cellsHistiocytesAlveolarMacrophagE

BrainBloodKidneySkinLung

EPINDYMAL CELLSSecretes a glue called chemo attractants that concentrate the bacteria.

COMPOSITION OF BRAIN80% brain mass10% blood10% CSF

I. Brain MassPARTS OF THE BRAIN1. CEREBRUM

largest partcomposed of the Right Cerebral Hemisphere and Left Cerebral Hemisphere enclosed in the

Corpus Callosum.Functions of Cerebrum

integrativesensorymotor

Lobes of Cerebrum1. Frontal

higher cortical thinkingcontrols personalitycontrols motor activityBroca’s Area (motor speech area) when damaged results to garbled speech.

2. Temporal hearingshort term memory

3. Parietalfor appreciationdiscrimination of sensory impulses to pain, touch, pressure, heat, cold, numbness.

4. Occipitalfor vision

Insula (Island of Reil)visceral function activities of internal organ like gastric motility.

Limbic System (Rhinencephalon)controls smell and if damaged results toAnosmia (absence of smell).controls libidocontrols long term memory

2. BASAL GAGLIAareas of grey matter located deep within each cerebral hemisphere.release dopamine (controls gross voluntary movement

3. MIDBRAIN/ MESENCEPHALONacts as relay station for sight and hearing.size of pupil is 2 – 3 mm.equal size of pupil isisocoria.unequal size of pupil isanisocoria.hearing acuity is 30 – 40 dB.positive PERRLA

4. INTERBRAIN/ DIENCEPHALONParts of DiencephalonA. Thalamus acts as relay station for sensation.B. Hypothalamus

controls temperature (thermoregulatory center).controls blood pressurecontrols thirstappetite/satietysleep and wakefulnesscontrols some emotional responses like fear, anxiety and excitement.controls pituitary functionsandrogenic hormones promotes secondary sex characteristics.early sign for males are testicular and penile enlargementlate sign is deepening of voice.early sign for females telarche and late sign is menarche.

5. BRAIN STEMlocated at lowest part of brain

Parts of Brain Stem1. Pons

pneumotaxic center controls the rate, rhythm and depth of respiration.2. Medulla Oblongata

controls respiration, heart rate, swallowing, vomiting, hiccup, vasomotor center (dilation andconstriction of bronchioles).3. Cerebellum

smallest part of the brain.lesser braincontrols balance, equilibrium, posture and gait

INTRACRANIAL PRESSURE

Monroe Kellie Hypothesis

Skull is a closed container

NEURO TRANSMITTER DECREASE INCREASE

Acethylcholine Myasthenia Gravis Bi-polar DisorderDopamine Parkinson’s Disease Schizophrenia

Any alteration or increase in one of the intracranial components

Increase intra-cranial pressure (normal ICP is 0 – 15 mmHg)Cervical 1 – also known as ATLAS.Cervical 2 – also known as AXIS.

Foramen Magnum

Medulla Oblongata

Brain Herniation

Increase intra cranial pressure

Alternate hot and cold compress to prevent HEMATOMACSF cushions brain (shock absorber)Obstruction of flow of CSF will lead to enlargement of skull posteriorly calledhydrocephalu s.Early closure of posterior fontanels causes posterior enlargement of skull in hydrocephalus.

NEUROLOGIC DISORDERSNCREASE INTRACRANIAL PRESSURE – increase in intra-cranial bulk brought about by an increase in oneof the 3 major intra cranial components.Causes:

head trauma/injurylocalized abscesscerebral edemahemorrhageinflammatory condition (stroke)hydrocephalustumor (rarely)

Signs and Symptoms (Early)decrease LOCrestlessness/agitationirritabilitylethargy/stuporcoma

Signs and Symptoms (Late)changes in vital signsblood pressure (systolic blood pressure increases but diastolic remains the same).widening of pulse pressure is neurologic in nature (if narrow cardiac in nature).heart rate decreaserespiratory rate decreasetemperature increase directly proportional to blood pressure.projective vomitingheadachepapilledema (edema of optic disc)abnormal posturingdecorticate posturing (damage to cortex and spinal cord).decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and

midbrain).unilateral dilation of pupilscalled uncal herniationbilateral dilation of pupilscalled tentorial herniationresulting to mild headachepossible seizure activity

Nursing Management

1. Maintain patent and adequate ventilation by:a. Prevention of hypoxia and hypercarbiaEarly signs of hypoxia

restlessnessagitationtachycardia

Late signs of hypoxiaBradycardiaExtreme restlessnessDyspneaCyanosis

HYPERCARBIAIncrease CO2 (most powerful respiratory stimulant) retention.In chronic respiratory distress syndrome decrease O2 stimulates respiration.

b. Before and after suctioning hyper oxygenate client 100% and done 10 – 15 seconds only.c. Assist in mechanical ventilation2. Elevate bed of client 30 – 35o angle with neck in neutral position unless contraindicated to promote venousdrainage.3. Limit fluid intake to 1200 – 1500 ml/day (in force fluids 2000 – 3000 ml/day).4. Monitor strictly input and output and neuro check5. Prevent complications of6. Prevent further increase ICP by:

a. provide an comfortable and quite environment.b. avoid use of restraints.c. maintain side rails.d. instruct client to avoid forms of valsalva maneuver like:

straining stoolexcessive vomiting (use anti emetics)excessive coughing (use anti tussive like dextromethorphan)avoid stooping/bendingavoid lifting heavy objects

e. avoid clustering of nursing activity together7. Administer medications like:a. Osmotic diuretic (Mannitol)

for cerebral diuresisNursing Management

monitor vital signs especially BP (hypotension).monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.administered via side dripregulated fast drip to prevent crystal formation.

b. Loop diuretic (Lasix, Furosemide)Drug of choice for CHF (pulmonary edema)Loop of Henle in kidneys.

Nursing Management

Monitor vital signs especially BP (hypotension).monitor strictly input and output every 1 hour notify physician if output is less 30 cc/hr.administered IV push or oral.given early morningimmediate effect of 10 – 15 minutes.maximum effect of 6 hours.

c.CorticosteroidsDexamethasone (Decadron)HydrocortisonePrednisone (to reduce edema that may lead to increase ICP)Mild Analgesics (Codeine Sulfate for respiratory depression)Anti Convulsants (Dilantin, Phenytoin

*CONGESTIVE HEART FAILURESigns and Symptoms

dyspneaorthopneaparoxysmal nocturnal dyspneaproductive coughfrothy salivation

cyanosisrales/cracklesbronchial wheezingpulsus alternansanorexia and general body malaisePMI (point of maximum impulse/apical pulse rate) is displaced laterallyS3 (ventricular gallop)Predisposing Factors/Mitral ValveRHDAging

TREATMENTMorphine SulfateAminophellineDigoxinDiureticsOxygenGases, blood monitorRIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms

jugular vein distention (neck)ascitespitting edemaweight gainhepatosplenomegalyjaundicepruritusesophageal varicesanorexia and general body malaise

Signs and Symptoms of Lasix in terms of electrolyte imbalances1. Hypokalemia

decrease potassium levelnormal valueis 3.4 – 5.5 meq/L

Sign and Symptomsweakness and fatigueconstipationpositive U wave on ECG tracing

Nursing Managementadminister potassium supplements as ordered (Kalium Durule, Oral Potassium Chloride)increase intake of foods rich in potassium

FRUITS VEGETABLESAppleBananaCantalopeOrange

AsparagusBrocolliCarrotsSpinach

2. Hypocalcemia/ Tetanydecrease calcium levelnormal valueis 8.5 – 11 mg/100 ml

Signs and Symptomstingling sensationparesthesianumbness(+) Trousseau’s sign/ Carpopedal spasm(+) Chvostek’s sign

ComplicationsArrhythmiaSeizures

Nursing Management

Calcium Gluconate per IV slowly as ordered* Calcium Gluconate toxicity – results to SEIZURE

Magnesium Sulfate

Magnesium Sulfate toxicity

S/SBPUrine output DECREASERespiratory ratePatellar relfex absent

3. Hyponatremiadecrease sodium levelnormal valueis 135 – 145 meq/L

Signs and Symptomshypotensiondehydration signs (Initial sign in adult isTHIRST, in infantTACHY CARDIA)agitationdry mucous membranepoor skin turgorweakness and fatigue

Nursing Managementforce fluidsadminister isotonic fluid solution as ordered

4. Hyperglycemianormal FBSis 80 – 100 mg/dl

Signs and Symptomspolyuriapolydypsiapolyphagia

Nursing Managementmonitor FBS

5. Hyperuricemiaincrease uric acid (purine metabolism)foods high in uric acid (sardines, organ meats and anchovies)*Increase in tophi deposit leads to Gouty arthritis.

Signs and Symptomsjoint pain (great toes)swelling

Nursing Managementforce fluidsadminister medications as ordered

a. Allopurinol (Zyloprim)Drug of choice for gout.Mechanism of action : inhibits synthesis of uric acid

b. ColchecineAcute goutMechanism of action: promotes excretion of uric acid.

* KIDNEY STONESSigns and Symptoms

renal colicCool moist skin

Nursing Managementforce fluidsadminister medications as ordered

a. Narcotic AnalgesicMorphine SulfateANTIDOTE: Naloxone (Narcan) toxicity leads to tremors.

b. Allopurinol (Zyloprim)Side Effects

Respiratory depression (check for RR)PARKINSON’S DISEASE/ PARKINSONISM

Chronic progressive disorder of CNS characterized by degeneration of dopamine producingcells in the SUBSTANCIA NIGRA of the midbrainand basal ganglia.Predisposing Factors1. Poisoning (lead and carbon monoxide)2. Arteriosclerosis3. Hypoxia4. Encephalitis5. Increase dosage of the following drugsa. Reserpine(Serpasil)b. Methyldopa(Aldomet)AntihypertensiveSc. Haloperidol(Haldol)d. PhenothiazinSIDE EFFECTS RESERPINE Major depression leading to suicide Major depression leading to suicide277direct approach towards the client278close surveillance is a nursing priority279time to commit suicide is on weekends early morningSigns and Symptoms for Parkinson’s280pill rolling tremors of extremities especially the hands.281bradykinesia (slowness of movement)282rigidity (cogwheel type)283stooped posture284shuffling and propulsive gait285over fatigue286mask like facial expression with decrease blinking of the eyes.287difficulty rising from sitting position.288Monotone type speech289mood lability (in state of depression)290increase salivation (drooling type)291autonomic changesa. increase sweatingb. increase lacrimationc. seborrhead. constipatione. decrease sexual capacityNursing Management1. Administer medications as orderedAnti Parkinsonian agents292Levodopa (L-dopa) short acting293Amantadine Hydrochloride (Symmetrel)294Carbidopa (Sinemet)Mechanism of Action295increase level of dopamineSide Effects296GIT irritation (should be taken with meals297orthostatic hypotension298arrhythmia299hallucinationsContraindications300clients with narrow angle closure glaucoma301clients taking MAOI’s (no foods with triptophan and thiamine)302urine and stool may be darkened303no Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa* Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid HydrazideAnti Cholinergic Agents (ARTANE and COGENTIN)- to relieve tremorsMechanism of Action304inhibits action of acethylcholineSide Effects305SNSAnti Histamine (Dipenhydramine Hydrochloride)Side EffectsAdult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed.

Dopamine Agonist- relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side Effects306Respiratory depression2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic Thalamotomy

MAGIC 2’s in Drug Monitoring

DRUG NORMAL RANGE TOXICITY LEVEL INDICATION CLASSIFICATIONDigoxin/ Lanoxin(Increase force ofcardiac output

.5 – 1.5 meq/L 2 CHF Cardiac Glycoside

Lithium/ Lithane(Decrease level ofAch/NE/Serotonin

.6 – 1.2 meq/L 2 Bipolar Anti-Manic Agents

Aminophylline(Dilates bronchial tree

10 – 19 mg/100 m 20 COPD Bronchodilators

Dilantin/ Phenytoin 10 – 19 mg/100 ml 20 Seizures Anti-convulsantAcetaminophen/Tylenol 10 – 30 mg/100 ml 200 Osteoarthritis Non-narcotic Analgesic

2. Maintain side rails to prevent injury3. Prevent complications of immobility4. Decrease protein in morning and increase protein in afternoon to induce sleep5. Encourage increase fluid intake and fiber.6. Assist/supervise in ambulation7. Assist in Stereotaxic ThalamotomyMAGIC 2’s IN DRUG MONITORINGDRUGNORMAL RANGETOXICITYLEVELINDICATIONCLASSIFICATIONDigoxin/ Lanoxin(Increase force ofcardiac output).5 – 1.5 meq/L2CHFCardiac GlycosideLithium/ Lithane(Decrease level ofAch/NE/Serotonin).6 – 1.2 meq/L2

BipolarAnti-Manic AgentsAminophylline(Dilates bronchial tree)10 – 19 mg/100 ml20COPDBronchodilatorsDilantin/ Phenytoin10 – 19 mg/100 ml20SeizuresAnti-ConvulsantAcetaminophen/Tylenol10 – 30 mg/100 ml200OsteoArthritisNon-narcoticAnalgesic1. Digitalis ToxicitySigns and Symptoms307nausea and vomiting308diarrhea309confusion310photophobia311changes in color perception (yellowish spots)Antidote:Dig ib ind2. Lithium ToxicitySigns and Symptoms312anorexia313nausea and vomiting314diarrhea315dehydration causing fine tremors316hypothyroidismNursing Management317force fluids318increase sodium intake to 4 – 10 g% daily3. Aminophylline ToxicitySigns and Symptoms319tachycardia320palpitations321CNS excitement (tremors, irritability, agitation and restlessness)Nursing Management322only mixed with plain NSS or 0.9 NaCl to prevent development of crystals orprecipitate.323administered sandwich method324avoid taking alcohol because it can lead to severe CNS depression325avoid caffeine4. Dilantin ToxicitySigns and Symptoms326gingival hyperplasia (swollen gums)327hairy tongue328ataxia329nystagmusNursing Management330provide oral care331massage gums5. Acetaminophen ToxicitySigns and Symptoms332hepatotoxicity (monitor for liver enzymes)333SGPT/ALT (Serum Glutamic Pyruvate Transaminace)334SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace)

335nephrotoxicity monitor BUN (10 – 20) and Creatinine (.8 – 1)336hypoglycemiaTremors, tachycardiaIrritabilityRestlessnessExtreme fatigueDiaphoresis, depressionAntidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside.MYASTHENIA GRAVIS337neuromuscular disorder characterized by a disturbance in the transmission ofimpulses from nerve to muscle cells at the neuromuscular junction leading todescending muscle weakness.Incidence rate: women 20 – 40 years oldPredisposing factors338unknown339autoimmune: it involves release of cholinesterase an enzyme that destroys Ach.Signs and Symptoms340initial sign isptos is a clinical parameter to determine ptosis is palpebral fissure.341diplipia342mask like facial expression343dysphagia344hoarseness of voice345respiratory muscle weakness that may lead to respiratory arrest346extreme muscle weakness especially during exertion and morningDiagnostic Procedure347Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signsand symptoms for about 5 – 10 minutes and a maximum of 15 minutes.qif there is no effect there is damage to occipital lobe and midbrain and is negative or MGNursing Management1. airway2. aspirationmaintain patent airway and adequate ventilation3. mmobility* assist in mechanical ventilation and monitor pulmonary function test* monitor strictly vital signs, input and output and neuro check* monitor strength or motor grading scale4. maintain side rails to prevent injury related to falls5. institute NGT feeding6. administer medications as ordereda. Cholinergic (Mestinon)b. Anti Cholenisterase (Neostegmin)Mechanism of Actionqincrease level of AchSide EffectsqPNSqCortocosteroids suppress immune responseqmonitor for 2 types of crisis:MYASTHENIC CRISIS CHOLINERGIC CRISISCauses:- under medication- stress- infectionSigns and Symptoms- The client is unable to see, swallow, speak,breatheTreatment- administer cholinergic agents as ordered.

Cause:- over medicationSigns and Symptoms- PNSTreatment- Administer anti cholinergic agents(Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed that the thymus glandis responsible for M.G.8. Assist in plasma paresis and removing auto immune anti bodies9. Prevent complications.

INFLAMMATORY CONDITIONS OF THE BRAIN

MENINGITISMeningesq3 fold membrane that covers brain and spinal cord.qfor support and protectionqfor nourishmentqblood supplyLAYERS OF THE MENINGES1. Dura matter – outer layer2.Ara c hnoid – middle layer3. Pia matter – inner layerqsubdural space between the dura and arachnoidqsubarachnoid space between the arachnoid and pia, CSF aspiration isdone.

A. Etiology1. Meningococcus – most dangerous2. Pneumococcus3. Streptococcus - causes adult meningitis4. Hemophilus Influenzae – causes pediatric meningitisB. Mode of transmission348airborne transmission (droplet nuclei)C. Signs and Symptoms349headache350photophobia351projectile vomiting352fever, chills, anorexia, general body malaise and weight loss353Possible increase in ICP and seizure activity354Abnormal posturing (decorticate and decerebrate)355Signs of meningeal irritation

a. Nuchal rigidity or stiff neckb. Opisthotonus (arching of back)c. (+) Kernig’s sign (leg pain)d. (+) Brudzinski sign (neck pain)

D. Diagnostic Procedures 356Lumbar puncture: a hollow spinal needle is inserted in the subarachnoid space between the L3 – L4 to L5. Nursing Management for LP Before Lumbar Puncture 1. Secure informed consent and explain procedure.2. Empty bladder and bowel to promote comfort.3. Encourage to arch back to clearly visualize L3-L4.Post Lumbar Puncture 1. Place flat on bed 12 – 24o2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities.CSF analysis reveals 1. Increase CHON and WBC2. Decrease glucose3. Increase CSF opening pressure (normal pressure is 50 – 100 mmHg)4. (+) cultured microorganism (confirms meningitis)CBC reveals1. Increase wbc E. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordereda. Broad spectrum antibiotics (Penicillin, Tetracycline)b. Mild analgesicsc. Anti pyretics3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy4. Elevate head 30-45o5. Monitor strictly V/S, input and output and neuro check6. Institute measures to prevent increase ICP and seizure.7. Provide a comfortable and darkened environment.8. Maintain fluid and electrolyte balance.9. Provide client health care and discharge planning concerning:a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings. b. Prevent complications 357mostfe a re d ishy droce pha l us358hearing loss/nerve deafness is second complication359consulta udi ol ogis tc. Rehabilitation for neurological deficit360mental retardation361delayed psychomotor developmentCVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) 362a partial or complete disruption in the brains blood supply. 3632 most common cerebral artery affected by strokea. Mid Cerebral Artery

b. Internal Cerebral Artery – the 2 largest arteryA. Incidence Rate 364men are 2-3 times high risk B. Predisposing Factors 365thrombus (attached) 366embolus (detached and most dangerous because it can go to the lungs and cause pulmonary embolism or the brain and cause cerebral embolismSigns and Symptoms of Pulmonary Embolism367Sudden sharp chest pain368Unexplained dyspnea369Tachycardia370Palpitations371Diaphoresis372Mild restlessnessSigns and Symptoms of Cerebral Embolism373Headache and dizziness374Confusion375Restlessness376Decrease LOC

Fat embolism is the most feared complications after femur fracture.Yellow bone marrow are produced from the medullary cavity of the long bones and produces

fat cells.If there is bone fracture there is hemorrhage and there would be escape of the fat cells in the

circulation.Compartment syndrome (compression of arteries and nerves)

C. Risk Factors1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, ValvularHeartDisease, Post Cardiac Surgery (mitral valve replacement)2. Lifestyle (smoking), sedentary lifestyle3. Obesity (increase 20% ideal body weight)4. Hyperlipidemia more on genetics/genes that binds to cholesterol5. Type A personalitya. deadline drivenb. can do multiple tasksc. usually fells guilty when not doing anything6. Related to diet: increase intake of saturated fats like whole milk7. Related stress physical and emotional8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading toatherosclerosis that will lead to hypertension and eventually CVA.D. Signs and Symptoms377dependent on stages of development1. TIA378Initial sign of stroke or warning signSigns and Symptoms379headache and dizziness380tinnitus381visual and speech disturbances382paresis (plegia)383possible increase ICP2. Stroke in evolution384progression of signs and symptoms of stroke3. Complete stroke385resolution phase characterized by:Signs and Symptoms386headache and dizziness387Cheyne Stokes Respiration388anorexia, nausea and vomiting389dysphagia390(+) Kernig’s sign and Brudzinski sign which may lead to hemorrhagic stroke391focal neurological deficitsa. phlegiab. aphasiac. dysarthria (inability to articulate words)d. alexia (difficulty reading)e. agraphia (difficulty writing)f. homonymous hemianopsia (loss of half of visual field)E. Diagnostic Procedure1. CT Scan – reveals brain lesions

2.Cerebral Arteriography392reveals the site and extent of malocclusion393uses dye for visualization394most of dye are iodine based395check for shellfish allergy396after diagnostic exam force fluids to release dye because it is nephro toxic397check for distal pulse (femoral)398check for hematoma formationF. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. administrate O2 inhalation2. Restrict fluids to prevent cerebral edema that might increase ICP3. Elevate head 30 – 45o4. Monitor strictly vitals signs, I & O and neuro check5. Prevent complications of immobility by:a. turn client to sideb. provide egg crate mattresses or water bedc. provide sand bag or food board.6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and preventcontractures7. Institute NGT feeding8. Provide alternative means of communicationa. non verbal cuesb. magic slate9. If positive to hemianopsia approach client on unaffected side10. Administer medications as ordereda. Osmotic Diuretics (Mannitol)b. Loop Diuretics (Lasix, Furosemide)c. Cortecosteroidsd. Mild Analgesicse. Thrombolytic/Fibrinolytic Agents – dissolves thrombus399Streptokinase

Side Effect: Allergic Reaction400Urokinase401Tissue Plasminogen Activating Factor402Side Effect: Chest Painf. Anti Coagulants403Heparin (short acting)404check for partial thromboplastin time if prolonged there is arisk for bleeding.405give Protamine Sulfate406Comadin/ Warfarin (long acting)407give simultaneously because Coumadin will take effect after3 days408check for prothrombin time if prolonged there is a risk for bleeding409give Vit. K (Aqua Mephyton)g. Anti Platelet410PASA (Aspirin)411Contraindicated for dengue, ulcer and unknown cause of headachebecause it may potentiate bleeding11. Provide client health teachings and discharge planning concerninga. avoidance ofmodifiable risk factors (diet, exercise, smoking)b. prevent complication (subarachnoid hemorrhage is the most feared complication)c.dietary modification (decrease salt, saturated fats and caffeine)d. importance of follow up careGUILLAIN BARRE SYNDROME412a disorder of the CNS characterized by bilateral symmetrical polyneuritis leading toascending muscle paralysis.A. Predisposing Factors1. Autoimmune2. Antecedent viral infections such as LRT infectionsB. Signs and Symptoms1. Clumsiness (initial sign)

2. Dysphagia3. Ascending muscle weakness leading to paralysis4. Decreased of diminished deep tendon reflex5. Alternate hypotension to hypertension** ARRYTHMIA (most feared complication)6. Autonomic symptoms that includesa. increase salivationb. increase sweatingc. constipationC. Diagnostic Procedures1. CSF analysis reveals increase in IgG and proteinD. Nursing Management1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. monitor pulmonary function test2. Monitor strictly the followinga. vital signsb. intake and outputc. neuro checkd. ECG3. Maintain side rails to prevent injury related to fall4. Prevent complications of immobility by turning the client every 2 hours5. Institute NGT feeding to prevent aspiration6. Assist in passive ROM exercise7. Administer medications as ordereda. Corticosteroids – suppress immune responseb. Anti Cholinergic Agents – Atrophine Sulfatec. Anti Arrythmic Agents413Lidocaine, Zylocaine414Bretylium – blocks release of norepinephrineto prevent increase of BP8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies)9. Prevent complicationsa. Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest* Sengstaken Blakemore Tube415for liver cirrhosis416to decompress bleeding esophageal verices (prepare scissor to cut tube incaseof difficulty in breathing to release air in the balloon417for hemodialysis prepare bulldog clips to prevent air embolism.CONVULSIVE DISORDER/ CONVULSION418disorder of CNS characterized by paroxysmal seizure with or without loss of