NEURO NURSINGBy: JOHN MARK B. POCSIDIOGIVEN FREE BY THE LECTURER

THE NERVOUS SYSTEMThe function of the nervous system is to control all motor, sensory, autonomic, cognitive, and behavioral activities.The nervous system has approximately 10 million sensory neurons500,000 motor neurons that control the muscles and glands.The brain itself contains more than 20 billion nerve cells

Nervous SystemCNSbrain and spinal cordPNScranial nerve and spinal nerveANSsympa and para

The NeuronFUNCTIONAL UNITdendrites – receive neural msgs & transmit towards cell bodyaxon – transmits neural msgs away from cell bodycell body – contains nucleus, mitochondria, & other organellesmyelin & cellular sheath produced by Schwann cellsnodes of Ranvier

TYPES OF NEURONS

Sensory neurons typically have a long dendrite and short axon, carry messages from sensory receptors central nervous system. Motor neurons have a long axon and short dendrites, transmit messages from central nervous system muscles (or to glands).

Interneurons are found only in the central nervous system where they connect neuron to neuron. Afferent neurons

From tissues and organs into the CNS (sensory neurons.)

Efferent neurons From CNS to the effector cells (motor neurons)

NEUROTRANSMITTERS

Neurotransmitters communicate messages from one neuron to another or from a neuron to a specific target tissueNeurotransmitters are manufactured and stored in synaptic vesicles. They enable conduction of impulses across the synaptic cleft.When released, the neurotransmitter crosses the synaptic cleft and binds to receptors in the postsynaptic cell membraneThe action of a neurotransmitter is to potentiate, terminate, or modulate a specific action and can either excite or inhibit the target cell’s activity

NeurotransmittersAcetycholineDopamineEpi and Nor EGABA Serotonin (↓ depression, ↑ manic)Glutamine (excitatory)

CEREBRUMfrontaloccipitalparietaltemporal

Anatomy and Physiology Central lobe- controls visceral fx

- activities of internal organ

Rhinencephalon/ Limbec- Smell, libido, long-term memory

Cerebellum

-Sensory perception and motor outputDisorder = in fine movement, equilibrium, posture and motor

learning -Coordinates sm muscle mov’t-coordinates, posture, equilibrium and muscle tone- It controls fine movements, balance, position sense. (awareness of where each part of the body is)

CNSThalamusHypothalamus

Pituitary Gland

The ThalamusAfferent neurons coming from all sense organs (except olfactory) & motor neurons synapse with nuclei found within the thalamus cerebrumThe thalamus also helps one associate feelings of pleasantness or unpleasantness with sensory impulsesRelays sensory impulses to the cortexProvides a pain gate

HYPOTHALAMUSlocated anterior and inferior to the Thalamus. the hypothalamus lies immediately beneath and lateral to the lower portion of the wall of the third ventricle. It includes the optic chiasm (the point at which the two optic tracts cross) and the mamillary bodies.

HYPOTHALAMUSThe hypothalamus plays an important role in the endocrine system because it regulates the pituitary secretion of hormones that influence metabolism, reproduction, stress response, and urine production. It works with the pituitary to maintain fluid balance and maintains temperature regulation by promoting vasoconstriction or vasodilatation.BrainStem

Mid BrainPonsMedulla

The MidbrainMotor coordinationVisual reflex and auditory relay center

PonsRegulates breathing- resp. center Medulla oblongataContains efferent/afferent fibersCardiac, respiratory, vomiting and vasomotor center( bld. vessel diameter)

MedullaVital reflex centers within the medulla:

Cardiac centers – control heart rateVasomotor centers – control blood pressureRespiratory centers – regulate breathingCenters for vomiting, sneezing, coughing, & swallowingCenters for reflexes mediated by CNs IX-XII

Meningespiaarachnoiddura

Meninges = DAP1. Dura Mater = outermost

Tough, white fibrous connective tissueSubdural space = potential space

2. Arachnoid = Middle Thin, delicate, cobweb-like membrane

Subarachnoid space Filled with CSF & blood vessels

3. Pia Mater = Innermost Thin, vascular membrane tightly bound to the brain

CNS

Spinal Cordmotor and sensory pathways

PNSSpinal Nerves 31 pairsCranial Nerves 12

Spinal Nerves

C- 8T- 12L- 5S- 5C- 1Autonomic Nervous SystemSympathetic

Parasympathetic

DIAGNOSTIC EXAMBy: JOHN MARK B. POCSIDIO, RN, USRN, MSNASSESSMENT OF THE NEUROLOGIC SYSTEMPHYSICAL EXAMINATION

5 categories:1. Cerebral function- LOC, mental status2. Cranial nerves3. Motor function4. Sensory function5. ReflexesCEREBRAL FUNCTIONAssess the degree of wakefulness/alertnessNote the intensity of stimulus to cause a responseApply a painful stimulus over the nailbeds with a blunt instrumentAsk questions to assess orientation to person, place and time

Cerebral functionUtilize the Glasgow Coma ScaleAn easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor responseScores are evaluated- range from 3-15No ZERO scoreGlasgow Coma ScaleGlasgow Coma ScoreEye Opening (E)Verbal Response (V)Motor Response (M)Glasgow Coma ScaleGlasgow Coma Score7 and Below= COMA!Glasgow Coma ScaleGlasgow Coma Score

Eye Opening (E)4=Spontaneous3=To voice (when told to)2=To pain1=None (No response)

Verbal Response (V)5=Normal/oriented4=Disoriented/CONFUSED3=Words, but incoherent/ inappropriate2=Incomprehensible/mumbled words1=None

Motor Response (M)6=Normal- obeys command5=Localizes pain4=Withdraws to pain (Flexion)3=Decorticate posture2=Decerebrate posture 1=None (flaccid)

Cranial Nerve Function: Cranial Nerve 1- Olfactory Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- “loss of smell”

Cranial Nerve Function: Cranial Nerve 2- Optic Check the visual acuity with the use of the Snellen chart Check for visual field by confrontation test Check for pupillary reflex- direct and consensual

Snellen chart

Cranial Nerve Function: Cranial Nerve 3, 4 and 6Assess simultaneously the movement of the extra-ocular musclesDeviations:Opthalmoplegia- inability to move the eye in a directionDiplopia- complaint of double visionCranial Nerve Function: Cranial Nerve 5 -trigeminal Sensory portion- assess for sensation of the facial skin (touch

cotton to forehead, chick & jaw) Motor portion- assess the muscles of mastication ( ask to clench

and move jaw side to side) Assess corneal reflex ( wisp of cotton on temporal surface of

cornea)

Cranial Nerve Function: Cranial Nerve 7 -facial Sensory portion- prepare salt, sugar, vinegar and quinine. Place

each substance in the anterior two thirds of the tongue, rinsing the mouth with water

Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditoryTest patient’s hearing acuityObserve for nystagmus and disturbed balanceTest for lateralization (Weber)Test for air and bone conduction (Rinne)

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal Together with Cranial nerve 10 –vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say

“AH” The posterior one-third of the tongue is supplied by the

glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 11- accessory Press down the patient’s shoulder while he attempts to shrug

against resistance

Cranial Nerve Function: Cranial Nerve 12- hypoglossal Ask patient to protrude the tongue and note for symmetry

Assessing the motor function of the cerebellumTest for balance- heel to toeTest for coordination- rapid alternating movements and finger to nose test

ROMBERG’s is actually a test for the posterior spinothalamic tractAbnormal Reflex• Positive Brudzinski’s sign (pain, resistance, flexion of hips

and knees when head flexed to chest with client supine) indicates meningeal irritation

Positive Kernig’s sign (excessive pain and/or resistance when examiner attempts to straighten knees with client supine and knees and hips flexed) indicates meningeal irritation

d. Positive Babinski reflex (dorsiflexion of big toe with fanning of other toes): UMN diseases of pyramidal tract

Decorticate posturing (upper arms close to sides, elbows, wrists and fingers flexes, legs extended with internal rotation, feet are flexed: body parts pulled into core of body): lesions of corticospinal tracts

Decerebrate posturing (neck extended with jaw clenched, arms pronated, extended, close to sides, legs are extended straight out and feet plantar flexed): lesions of midbrain, pons, diencephalon

Diagnostic Test• Skull and spinal x-ray - identify fractures dislocation. Compression, spinal cord problem Nursing Care - provide nursing support for the confused or combative patient- No to pregnant-CBQ - maintain immobilization

- remove metal items

b. CT Scan- skull/ spinal cord are scanned in successive layers by a narrow beam of X-rays. A computer uses information obtained to construct a picture of the internal structure of the brain

- detect intracranial bleeding, space occupying lesion, cerebral edema. Hydrocephalus, infarction

Nursing CareAssess for allergies - CBQ Instruct to lie still and flat-CBQ Inform pt that there may be hot, flushed sensation and metallic

taste in the mouth-CBQ Treat allergic reaction-CBQ Remove hairpins etc.-CBQ

MAGNETIC RESONANCE IMAGING -Computer-drawn, detailed pictures of structures of the body through use of large magnet, radio waves.- Used to detect intracranial and spinal abnormalities associated with disorders such as CVA, tumors, abscesses, cerebral edema, hydrocephalus, multiple sclerosis

NURSING INTERVENTIONS1.) Instruct client to remove jewelry, hairpins, glasses, wigs,( with metal clips), and other metallic objects-CBQ2.) Patients with orthopedic hardware, intrauterine devices, pacemaker, internal surgical clips or other fixed metallic objects in the body cannot undergo the procedure-CBQ3.) Inform client to remain still during the procedure ( last 45-60 mins)4.) Teach relaxation techniques to assist client & help prevent claustrophobia5.) Warn the client of normal audible humming and thumping noises from the scanner during test6.) Have client void before test-CBQ7.) Sedate client if ordered

EEG -graphic recording of electrical activity of the brain by several small electrodes placed on the scalp.NURSING INTERVENTIONS

Withhold medications that may interfere with the results- anticonvulsants, sedatives and stimulants

Wash hair thoroughly before procedure Instruct adult client to sleep no more than 5 hrs the night before. Instruct child client to sleep no more than 5-7 hrs the night before

Lumbar tapInsertion of spinal needle through the L3 and L4 into the subarachnoid spacePURPOSES1.) Measures CSF pressure ( normal opening pressure 60-150mmH2O)2.) Obtain specimens for lab analysis( protein normally not present), sugar ( normally present), cytology, C&S3.) Check color of CSF ( normally clear) and check for blood4.) Inject air, dye, or drugs into the spinal canal

NURSING CARE PRE-TEST1.) Have client empty bladder2.) Position client in a lateral recumbent position with head and neck flexed onto the chest and knees pulled up.3.) Explain the need to remain still during the procedureNURSING CARE POST-TEST1.) Ensure labeling of CSF specimens in proper sequence2.) Keep client flat for 12-24 hours as ordered3.) Force fluids4.) Check puncture site for bleeding, leakage of CSF5.) Assess sensation and movement in lower extremities6.) Monitor vital signs7.) Administer analgesics for headache as orderedCONTRAINDICATION TO LUMBAR TAP INCREASED ICP COAGULOPATHY & DECREASED PLATELETS SPINAL DEFORMITIES ( SCOLIOSIS, KYPHOSIS)

CEREBRAL ANGIOGRAPHYInjection of radiopaque substance into the cerebral circulation via carotid, vertebral, femoral , or brachial artery followed by x-raysUsed to visualize cerebral vessels and detect tumors, aneurysm, occlusion, hematomas, or abscessesNURSING CARE PRE-TEST1.) Check allergy to iodine2.) Keep NPO after midnight or offer clear liquid breakfast only3.) Explain that the client may have warm, flushed feeling and salty taste in mouth during procedure4.) Take baseline vital signs and neuro check 5.) Administer sedation if orderedNURSING CARE POST-TEST1.) Maintain pressure dressing over site if femoral or brachial artery used; apply ice as ordered

2.) Maintain bed rest until next morning as ordered3.) Monitor vital signs, neuro checks frequently; report any changes immediately4.) Check site frequently for bleeding or hematoma; if carotid artery used; assess for swelling of neck, difficulty swallowing or breathing5.) Check pulse, color, and temperature of extremity distal to site used.6.) Keep extremity extended and avoid flexion

NEUROLOGICAL DISODERSHEADACHEHeadache is pain affecting the front, top, or sides of the head. Often occurring in the middle of the day, the pain may have these characteristics: Mild to moderate. Constant.

ASSESSMENT S/SX. PRESSURE PAIN, & TIGHT FEELING IN THE TEMPORAL AREA PAIN NAUSEA HEADACHE WITH SENSITIVITY TO LIGHTDIAGNOSTICSHEALTH HISTORYPHYSICAL EXAMINATIONCT SCANMRITreatments include: Depends on the type of headache and whether it is acute or chronic. Quiet, dark room especially for migraines. Antiemetics such as phenergan if vomiting. Opiate analgesics. Meds like sumatriptan ( SSRI)can be given to abort the headache

but the cardiovascular risk must be weighed against the benefit. These are reserved for clients who are having two or more migraines per month.-cgfns

Ergot derivatives ( bromocriptine) ( stimulate dopamine receptors)are also given to abort the headache but can also cause spontaneous abortion (miscarriage).-NCLEX!!!!!

Chronic migraines may be treated prophylactically with propranolol (beta-blocker), amitriptyline, clonidine, verapamil (calcium-

channel blocker), cyproheptadine (Periactin), as well as various

antidepressants.

Opioid analgesics such as Demerol mixed with phenergan for severe attacks.

Nonsteroidal, antiinflammatory drugs (NSAIDs) PO or IM such as Toradol, Decadron

Increase Intracranial pressureAn increase in intracranial bulk due to increase in any of the major intracranial components: brain tissue, CSF, or BloodCaused by: Brain abscesses, hemorrhage, edema, hydrocephalus, inflammationIf left in treated it can lead to brain herniation

CLINICAL MANIFESTATIONSEarly manifestations:Changes in the LOC- usually the earliest -CBQPupillary changes- fixed, slowed responseHeadachevomitingIncreased Intracranial pressure

CLINICAL MANIFESTATIONSlate manifestations:Cushing reflex- systolic hypertension , bradycardia and wide pulse pressurebradypneaHypothermiaAbnormal posturing

Increased Intracranial pressureNursing interventions: Maintain patent airway1. Elevate the head of the bed 15-30 degrees- to promote venous drainage2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levelsconstricts blood vesselsreduces edema

Increased Intracranial pressureNursing interventions3. Administer prescribed medications- usually

Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants-p to prevent seizures

Increased Intracranial pressureNursing interventions4. Reduce environmental stimuli

5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

CEREBROVASCULAR ACCIDENTSAn umbrella term that refers to any functional abnormality of the CNS related to disrupted blood supply

CEREBROVASCULAR ACCIDENTSCan be divided into two major categories1. Ischemic stroke- caused by thrombus and embolus2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

CEREBROVASCULAR ACCIDENTSThe stroke continuum1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration2. Reversible Neurologic deficits3. Stroke in evolution4. Completed stroke

CEREBROVASCULAR ACCIDENTS: Ischemic StrokeDIAGNOSTIC test1. CT scan2. MRI3. AngiographyCLINICAL MANIFESTATIONS1. Numbness or weakness2. confusion or change of LOC3. motor and speech difficulties4. Visual disturbance5. Severe headache

Motor Loss Hemiplegia Hemiparesis Communication loss Dysarthria= difficulty in speaking Aphasia= Loss of speech Apraxia= inability to perform a previously learned action Perceptual disturbances Hemianopsia

Sensory loss paresthesia

NURSING INTERVENTIONS: ACUTE Ensure patent airway Give 100% oxygen to the patient to dec ICP

Keep patient on LATERAL position ( initially) Then if stable position low fowlers with neck aligned Monitor VS and GCS, pupil size IVF is ordered but given with caution as not to increase ICP NGT inserted Medications: Steroids, Mannitol (to decrease edema), Diazepam,

Thrombolytics

NURSING INTERVENTION -REHABCARE FOR HEMIPLEGIA1. ) Turn every 2 hours ( 20 mins only on affected side)2.)Use proper positioning and repositioning to prevent deformities 3.) Support paralyzed arm on pillow or use sling while out of bed to prevent subluxation of shoulder4.) Elevate extremities to prevent dependent edema5.) Provide active and passive ROM excercises evry 4 hoursSAFETY1.) Keep side rails up at all times2.) Institute safety measures3.) Inspect body parts frequently for signs of injuryDYSPHAGIA1.) Check gag reflex before feeding client2.) Maintain calm unhurried approach3.) Place client upright position4.) Place food in unaffected side of mouth5.) Offer soft foods6.)Give mouth care before and after mealsHOMONYMOUS HEMIANOPSIA1.) Approach client on unaffected side2.) Place personal belongings, food, etc. on unaffected side3.) Teach scanning techniques EMOTIONAL LABILITY: MOOD SWINGS 1.) Create a quiet, restful environment with a reduction in excessive sensory stimuli 2.) Maintain a calm , non threatening manner 3.) Explain to family that the client’s behavior is not purposefulAPHASIARECEPTIVE APHASIA1.) Give simple, slow directions2.) Give one command at a time ; gradually shift topics3.) Use non verbal techniques in communication ( pantomine)- CBQEXPRESSIVE APHASIA1.) Listen & watch carefully when the client attempts to speak2.) Anticipate the clients needs to decrease frustrations3.)Give magic slate- CBQAPRAXIA – loss of ability to perform purposeful skilled acts1.) Guide the client through intended movement 2.) Keep repeating the movement

MENINGITISInflammation of the meninges of the brain and spinal cordCaused by: BACTERIA, VIRUSES or other microorganismsMay reach the brain via: Blood, CSF By direct extension from adjacent cranial structures ( nasal

sinuses, mastoid bone, ear, skull fracture) By oral or nasopharyngeal routeASSESSMENT FINDINGS Headache, photophobia, malaise, irritability Fever and chills Signs of meningeal irritation Nuchal rigidity: stiff neck Kernig’s sign: contraction or pain in the hamstring muscle when

attempting to extend the leg when hip is flexed Opisthotonus: head and heals bent backward and body arched

forward Brudzinski sign: flexion at the hip and knee in response to

forward flexion of the neckCont.4. vomiting5. possible seizures and decreasing LOC

DIAGNOSTIC TEST: LUMBAR PUNCTURECSF shows: elevated WBC, protein, decreased glucose and culture positive for specific microorganisms

NURSING INTERVENTIONS1. Administer large doses of antibiotics IV as ordered2. Enforce respiratory isolation for 24 hours after initiation of antibiotic therapy3. Provide bed rest; keep room dark and quiet4. Administer analgesics for headache as ordered5. Maintain fluid and electrolyte balance6. Monitor vital signs and neuro checks frequently7 DIET? High calorie, high protein, small frequent feedingREFER? AUDIOLOGIST

ENCEPHALITISInflammation of the brain caused by a virus, E.g herpes simplex or arbovirus ( transmitted by mosquito or tick)May occur as a sequela of other diseases such as measles, mumps, chickenpox

ASSESMENT1. Headache2. Fever, chills, vomiting3. Signs of meningeal irritation4. Possibly seizures

5. Alteration in LOC

NURSING INTERVENTIONS1. Monitor vital signs and neurochecks frequently2. Provide nursing measures for increased ICP3. Provide nursing care for confused or unconscious client as needed

CEREBRAL ANEURYSMDilation of the walls of a cerebral artery resulting in a sac-like out pouching of the vesselCaused by: congenital weakness in the vessel, trauma, arteriosclerosis , hypertension

PATHOPHYSILOGY:Aneurysms compress nearby cranial nerves or brain substance , producing dysfunction Aneurysms may rupture , causing intracerebral hemorrhage

ASSESSMENT1. Severe headache, and pain in the eyes2.Diplopia, tinnitus, dizziness3. Nuchal rigidity, ptosis, decreasing LOC, hemiparesis, seizures

NURSING INTERVENTIONS1. Maintain a patent airway and adequate ventilation-instruct client to take deep breaths but to avoid coughing-suction only with a specific order2. Monitor vital signs and neuro checks and observe signs of vasospasm, increased ICP, hypertension, seizures, and hyperthermia3. Institute seizure precaution4. Enforce bed rest and provide complete care5. Keep head of bed flat or elevated to 20-30 degrees as ordered6. Maintain a quiet and darkened environment7. Avoid taking rectal temperature, avoid sneezing, coughing, and straining at stool8. Enforce fluid restriction as ordered; maintain accurate I&OGive meds: antihypertension. Corticosteriods, anticonvulsant, stoolsofteners

SEIZURESEpisodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neuronsA part or all of the brain may be involvedEPILEPSYNeurologic disorder in which the patient experiences recurrent seizures consisting of transient disturbances of cerebral function due to paroxysmal neuronal discharge

PATHOPHYSIOLOGY

An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessivelyEtiologic Factors Often idiopathic Cerebral trauma, infection, vascular disease, neoplasms,

degenerative disease (Alzheimer) Drugs, chemical poisons Metabolic disorders Children, high fever Others: lack of sleep, alcohol

CLASSIFICATION OF SEIZURESSIMPLE PARTIAL- symptoms confined to one hemisphere, may have motor ( change in posture), sensory ( hallucinations), or autonomic ( flushing, tachycardia) symptoms ; no loss of consciousness

COMPLEX PARTIAL – begins in one focal area but spreads to both hemispheres ( more common in adults), there is loss of consciousness; aura of visual disturbances, postictal symptoms

Generalized: entire cerebral cortex is involved

Absence (petit mal): sudden onset, lat 5-10 seconds; can have 100 daily, precipitated by stress, hypoglycemia, fatigue, hyperventilation , there is loss of responsiveness but continued ability to maintain posture control and not fall, twitching of the eyelids, lip smacking , no postictal symptoms

Tonic-clonic (grand mal): victim becomes rigid, cries out, loses consciousness, falls & stops breathing (tonic phase); muscular jerking, may bite tongue or lips, may be incontinent (clonic phase); after awakening, subject is drowsy & amnesic

Cyclonic: repeated shock like, often violent contractions in one or more muscle groups Status epilepticus: one or a series of grand mal seizures lasting more than 30 minutes w/o waking intervals

DIAGNOSTICSEEG shows focal abnormalities in the rate, rhythm or relative intensity of cerebral cortical rhythmsOthers: CT scan, MRISEIZURESNursing InterventionsDuring seizure1. remove harmful objects from the patient’s surrounding

2. ease the client to the floor3. protect the head with pillows4. Observe and note for the duration, parts of body affected, behaviors before and after the seizureSEIZURESNursing InterventionsDuring seizure5. loosen constrictive clothing6. DO NOT restrain, or attempt to place tongue blade or insert oral airway PharmacologyDILANTINCBQ- used to prevent siezure. - given in the ward not in the ER (EXPLAIN) - causes brownish urine - never abruptly stop ( can cause rebound siezure) - can cause gingival hyperplasia ( massage gums) NCLEX??? LETHAL FATAL; EFFECT? APLASTIC ANEMIA

BENZODIAZEPINECBQ Major indications. Anxiety, insomnia, and siezure( skeletal muscle relaxationNCLEX– Should be started on low dosage and gradually increased to achieved desired clinical response.NO TO PREGNANT MOTHER!!!-Monitor client for drowsiness, lightheadedness, and dizziness periodically during treatment, these usually disappear as therapy progresses- NCLEX---- restrict amount of drug available or the client. May

cause physical dependence if prolonged therapy.- NO TO ACUTE ASTHMA OR COPD ATTACK!!!!!! ( may cause respiratory

depression)- ANTIDOTE: FLUMAZENILMEDSPHENYTOIN DILANTIN -often used with phenobarbital for its potentiating effect. -inhibits spread of electrical discharge S.e gum hyperplasia, hirsutism, ataxia, gas distress, nystagmus,

sedation Best taken with food to enhance absorption Massage gums May turn urine reddish brown (explain to client) Can cause aplastic anemia( watch out) Do NOT ABRUPTLY STOP!!!!

Trigeminal Neuralgia (Tic Douloureux)

Is an intensely painful neurologic condition affecting the 5th CN (trigeminal)Patient may experience lancinating or electric shock-like facial painPain can be triggered when talking, shaving, eating, touching the face, brushing teeth, or when exposed to cold and wind. Trigeminal Neuralgia

Avoid too hot or too cold food or liquidsRoom temp for food and water for bathingChewing on the unaffected side is recommendedNo massageProvide water jet device for mouth careTegretol for painPhenol Injection in the Gasserian ganglia ( loss of temporary facial sensation)Rhizotomy (surgical intervention)Percutaneous radio-frequency trigeminal gangliolysis

BELL’S PALSYAffects the 7th cranial nerve ( facial)Produces unilateral facial weakness, or paralysisOnset is rapidOccurs in persons under age 60

Bell’s PalsyNamed after Scottish anatomist Charles Bell Acute peripheral facial paralysis of the 7th CN (facial) Self-limiting that usually improves in 4-6 months.Cause is unknownInflammation Vascular ischemiaAutoimmune demyelination

ASSESSMENT Inability to close eye completely on the affected side Pain around the jaw or ear Ringing in the ear Taste distortion on the anterior portion of the tongue on the

affected side Unilateral facial weakness Eye roll upward and tears excessively when the patient attempts to

close it

Interventions Artificial tears is recommended and dark glasses- CBQ Apply warm packs to the affected Inadequate eyelid closure

Exercise (grimacing, wrinkling, whistling, puffing the cheeks, blowing out air)

Provide soft diet-CBQ Instruct to chew on unaffected side, avoid hot fluids/ food-CBQ

MULTIPLE SCLEROSISDegenerative diseaseDemyelination of the (myelin sheath) nerve fibers (brain and spinal cord)Hypofunction of oligodendroglial cells and schwann cells(responsible for reproduction of the myelin sheath)Chronic slowly progressiveCharacterized by remission and exacerbation

Maybe triggered by:pregnancy fatigue stress infection and traumaMay worsen in extreme temperaturesLesions are scatteredCommon among womenCause: UnknownAutoimmune (post viral infection)

Diagnostic test: CT scan, MRI, CSF (IgG), EEG

Manifestations

Eye problem (early manifestation)vision is impaired, blurring, diplopia, scotoma (patch blindness), nystagmus, total blindnessDisruption of sensory nerveParesthesia and painFrontal lobe problemmemory loss, concentration, poor abstract reasoning

Cerebellum and basal ganglia involvementAtaxia (uncoordinated muscle movementTremorWeakness of muscle in throat and face (3 D’s)Sacral cord problemImpotence, bowel and bladder dysfunctionCharcot’s triad (nystagmus, tremors and scanning speech)DIAGNOSTIC TEST:CSF- IGg in CSF

Management

Avoid fatigue, stress and infectionPromote safety and restVisual disturbance (scanning vision) eye patch for diplopiaSensory problem (caution for cuts and burns), avoid hot tubs ( heat increases weakness)Motor problem (fall and slip)Bowel and bladder programSteroids, Immunosuppressive, Antibiotics, baclofen ,Plasmapheresis, ThymectomyRespiratory Distress precautions

Guillian-Barre’ SyndromeAn auto-immune attack of the peripheral nerve myelinAcute, rapid segmental demyelination of peripheral nerves and some cranial nerves

Neuromuscular diseaseAscending paralysis(Schwan cells) Demylinating polyneuropathy of motor and sensory nervesCause: UnknownAutoimmune (post viral infection)Diagnostic test: EMG, CSF and ECG

PATHOPHYSIOLOGYCell-mediated imune attack to the myelin sheath of the peripheral nervesInfectious agent may elicit antibody production that can also destroy the myelin sheath

Manifestations

Clumsiness (initial symptom)Muscle weakness or paralysis of the feet or legs that goes upward

HyporeflexiaDistention to incontinenceParalysis of the diaphragmDysphagia and drooling

Respiratory depressionBlurred vision (CN II)

NURSING INTERVENTIONmostly supportive 1. Maintain adequate ventilation 2. Check individual muscle groups every 2 hours in acute phase to check progression of weakness3. Check cranial nerve function, assess gag reflex and swallowing ability, give pureed foods.4. Monitor vital signs5.administer corticosteroids to suppress immune function

Myasthenia GravisNeuromuscular diseaseMarked weakness and fatigue of voluntary muscles acetylcholine or – communication of nerve cells acetylcholinesterase – inactive form sensitivity to acetylcholine by the receptor siteDefect in transmission of nerve impulse at the myoneural junctionCause:

UnknownAutoimmune (post viral infection)

Diagnostic Test: Tensilon Test (Edrophonium)

Short acting cholinergic is administeredIncreased muscle strength is observe ( + tensilon)

EMG

Manifestations

Ptosis, diplopia and eye squint (early sign)May start from ocular to oropharyngeal, facial and to respiratory muscle paralysisMuscle weakness more pronounce in the evening3 D’s dysphagia, dysphonia, dysarthriaDrooping faciesRespiratory paralysis (cause of death)

NURSING INTERVENTIONS Supportive Assess gag reflex before feeding Administer meds 20-30 mins. Before meals to prevent aspiration Administer meds at precise time to prevent respiratory distress

which may cause death Protect from falls due to weakness Start meal with cold beverages to improve ability to swallow

Avoid exposure to infection8. Adequate rest and activity9.Plasmapharesis- involves removal of antibodies from the plasma to inhibit immune responseMyasthenic crisis – caused by undermedicationCholinergic crisis – caused by overmedication

MEDSNeostigminePyridostegmine

MEDS TO AVOID!!!!!!!( increases muscle weakness): Muscle relaxant Barbiturates Morphine sulfate Tranquilizers Neomycin

Parkinson’s Disease Degeneration of the substantia nigra

PATHOPHYSIOLOGYUnknownMay be due to:

Parkinson’s Disease

Older people greatly affected Depletion of dopamine Cause: Unknown CVA Post encephalitic, arteriosclerotic Drug Induced: Methyldopa Haldol Phenothiazine

Manifestations

Triad (bradykinesia, resting tremors and rigidity [Cogwheel])Pill rolling (fingers)Stooped postureMasklike faceMonotone speechDrooling of salivaFestinating gait

NURSING INTERVENTIONS1.Supportive2. Aspiration precaution3. Increase fluid intake to prevent constipation4. Position the patient to prevent contractures Firm bed, no pillows Hold hands folded at the back when walking5. Give meds as ordered.

ANTICHOLINERGIC: To reduce tremors -cogentin Artane AkinetonSIDE EFFECT: Blurring of vision Dryness of mouth/throat Constipatin Urinary retention Dysarthia Mental disturbanceANTIPARKINSONIAN DRUGS LEVODOPA CARBIDOPAANTIVIRAL

AMANTADINE BROMOCRIPTINEANTISPASMODICS PROCYCLIDINEANTIHISTAMINE BENADRYL- to decrease tremors and anxiety

AVOID THE FOLLOWING DRUGS WHEN ON LEVODOPA THERAPY1. Phenothiazines, reserpine, pyridoxine( vit B6) these blocks the effects of levodopa.FOODS TO AVOID!!! TUNA, PORK, DRIED BEANS, SALMON, BEEF LIVER ( Blocks effect of levodopa)-CBQSIDEFFECT OF LEVODOPA: Nausea and vomiting Orthostatic hypotension Insomia Agitation Mental confusion Renal damage

Amyotrophic Lateral SclerosisProgressive, debilitating, degenerative and eventually fatal neurologic disease involving degeneration of motor neurons in the anterior horn of the spinal cord and the motor nuclei of the lower brainstem - Characterized by weakness and muscle wasting without sensory or cognitive changesMaybe caused by an excess of GLUTAMATE a chemical responsible for relaying messages between the motor neurons.

Amyotrophic Lateral Sclerosis- cause is unknown, 5-10% GENETICS- onset: age of 40 – 60; males > females- Physiologic problems involve swallowing, managing secretions, communication, respiratory muscle dysfunction - Death usually occurs in 2 – 5 years due to respiratory failure

ETIOLOGY: DEGENERATION OF MOTOR NEURON Familial Heavy metal intoxication Tumors Onset - midlife

Amyotrophic Lateral sclerosisFATIGUEMUSCLE WEAKNESS & WASTINGINCOORDINATIONDYSARTHRIA

RESPIRATORY DIFFICULTY (BRAINSTEM INVOLVEMENT)UNILATERAL DISABILITY OF UPPER AND LOWER EXTREMITIESFASCICULATIONS

Diagnostic Test1. Testing to rule - out hyperthyroidism, compression of spinal cord, infections, neoplasms 2. EMG - differentiates neuropathy from myopathyAmyotrophic Lateral sclerosis3. Muscle biopsy - atrophy and loss of muscle fiber4. Serum creatine kinase - elevated (non- specific)5. Pulmonary function tests - determine degree of respiratory involvement

Medical Management: 1. Riluzole (Rilutek) - glutamate antagonist medication that slows down muscle degeneration

- requires monitoring of liver function, blood count, chemistries, alkaline phosphatase

2. muscle relaxants: a. Baclofen (Lioresal) b. Dantrolene sodium (Dantrium) c. Diazepam (Valium)

Nursing Management 1. Maximize functional abilities a. Prevent complications of immobility b. Promote self-care c. Maximize effective communication

2. Ensure adequate nutrition 3. Prevent respiratory complications a. promote measures to maintain adequate airway b. promote measures to enhance gas exchange – O2 therapy &

ventilatory assistance c. promote measures to prevent respiratory infection

4. Help client and family deal with current health problems 5. Plan for future needs including inability to communicate

HUNTINGTON’S CHOREAIs a hereditary disease in which degeneration in the cerebral cortex and basal ganglia causes chronic progressive chorea ( involuntary & irregular movements ) and cognitive deterioration , ending in dementia

Huntington’s disease usually strikes people between ages 25-55

Death usually results 10-15 years after onset of from suicide, heart failure, or pneumonia

CAUSESAUTOSOMAL DOMINANT GENETIC TRANSMISSION

ASSESSMENTCHOREIC MOVEMENTS: rapid, often violent and purposeless that becomes progressively severe and may include fidgeting , tongue smacking , dysarthria( indistinct speech), athetoid movements ( slow sinuous writhing movements, especially the hands and torticollis ( twisting of the neck)

Dementia ( mild at first but eventually disrupts the patients personality)Gradual loss of musculoskeletal control, eventually leading to total dependencePersonality changes , carelessness, untidiness, moodiness, apathy, loss of memory and paranoia

DIAGNOSTICSPOSITRON EMISSION TOMOGRAPHY (PET)Detects the diseaseDEOXYRIBONUCLEIC ACID analysis detects the diseaseCT scan reveals brain atrophyMRI reveals brain atrophy

TREATMENTSDISEASE HAS NO CURE!! TREATMENT IS SUPPORTIVE, PROTECTIVE, AND AIMED AT RELEIVING SYMPTOMSDRUG THERAPYANTIPSYCHOTICS: chlorpromazine( thorazine) and haloperidol ( Haldol)- to help control choreic movementsANTIDEPRESSANT: imipramine ( Tofranil) –to help control choreic movements)

NURSING INTERVENTIONS1. Provide physical support by attending to patient’s needs ( hygiene, skin care, bowel & bladder care) etc.2. Stay alert for possible suicide3. Pad the side rails of the bed but avoid restraints4. Provide emotional support5. Assist in designing behavioral plan that deals with disruptive and aggressive behavior and impulse control problem

SPINAL CORD INJURYOccurs most commonly in young adult males between ages 15-25Common causes: motor vehicle accidents, diving in a shallow water, falls, sports injuriesEffects :

Paralysis Loss of reflexes Loss of sensory function Loss of motor function Autonomic dysfunctionCERVICAL SCI Above C4 is fatal Quadriplegia ( paralysis of all four extremities) Respiratory muscle paralysis Bowel/ bladder retentionTHORACIC SCI Paraplegia Poor control of upper trunk Bowel/bladder retentionLUMBAR SCI Paraplegia(flaccid) Bowel/ bladder retentionSACRAL SCI Above S2 With erection No ejaculationS2-S4 No erection No ejaculation Bowel and bladder incontinenceSpinal cord injuryDIAGNOSTIC TESTSpinal x-rayCT scanMRI

MANAGEMENT1. Respiratory function is the first priority especially in cervical SCI2. Immobilize in a flat, firm surface3. Cervical collar if cervical injury is suspected4. Transport client as a unit5. Do not attempt to realign body partsTRACTIONCASTSURGERY

AUTONOMIC DYSREFLEXIAReflex response to stimulation of the sympathetic nervous system Rise in blood pressure, sometimes to fatal level due to over distended bladder and bowelOccurs in clients with cord lesion above T6 and most commonly in clients with cervical injuries

ASSESSMENT Bradycardia Hypertension—CVA, blindness Sweating above lesion “ Goose flesh” Severe headache Blurring of vision Nasal stuffinessMANAGEMENT Position the patient in a sitting position to decrease BP Check bladder distention, fecal impaction Remove offending stimulus ( catheterize) Monitor blood pressure Administer antihypertensives (Hydralazine HCL Apresoline) as

orderedAlzheimer’s Disease- Form of dementia characterized by progressive, irreversible deterioration of general neurological functioning- begins insidiously - characterized by gradual losses of cognitive function and disturbances in behavior and affectPATHOPHYSIOLOGYcharacterized by cortical atrophy and loss of neurons, particularly in the parietal and temporal lobes . With significant atrophy, there is ventricular enlargement (i.e., hydrocephalus) from the loss of brain tissue.There is presence of amyloid-containing neuritic plaques and neurofibrillary tanglesThese plaques are found in areas of the cerebral cortex that are linked to intellectual function.Neurochemically, Alzheimer’s disease has been associated with a decrease in the level of choline acetyltransferase activity in the cortex and hippocampus

Warning signs includea. Memory loss affecting ability to function in jobb. Difficulty with familiar tasksc. Problems with language, abstract thinkingd. Disorientation, changes in mood and personality

Alzheimer’s DiseaseASESSMENT:SUBTLE RECENT MEMORY LOSS--- PROGRESSIVEDeath usually due to malnutrition and secondary infectionDuration 8-10 yrs.Clinical Manifestations:1. Stage I

a. Appears healthy and alertb. Cognitive deficits are undetected

c. Subtle memory lapses and forgetfulnessd. Personality changes - depressione. Seems restless and uncoordinated

2. Stage IIa. Memory deficits - more apparent

(1) may lose ability to recognize familiar places, faces and objects

(2) may get lost in a familiar environment(3) conversation becomes difficult(4) word-finding difficultiesb. ability to formulate concepts and to think abstractly

disappears – concrete thinking predominatesc. impulsive behaviord. Less able to behave spontaneouslye. Wandering behaviorf. Changes in sleeping patternsg. Agitation and stressh. Trouble with simple decisionsi. Sundowning: increased agitation, wandering, disorientation in afternoon and evening hours

j. Language problems:(1) Echolalia(2) scanning speech(3) total aphasia at times(4) apraxia(5) astereognosis(6) inability to write

k. frustration and depression

3. Stage IIIa. Increasing dependence - inability to communicate &

loss of continenceb. Progressive loss of cognitive abilitiesc. delusion, hostility, paranoid reactions, combativenessd. prone to falls

Diagnostic TestsEEG - slow pattern in later stages of diseaseMRI and CT scanPositron emission tomography (PET)Folstein Mini-Mental StatusCerebral Biopsy – confirms the diagnosis

Medications1. Acetylcholinesterase inhibitors - mild to moderate dementia

- enhances Acetylcholine uptake in the braina. Tacrine hydrochloride (Cognex)b. Donezepil hydrochloride (Aricept)c. Rivastigmine (Exelon)

2. Antidepressants3. Tranquilizers – for severe agitation

a. Thioridazine (Mellaril)b. Haloperidol (Haldol)

4. Antioxidants: vitamin E5. anti-inflammatory agent6. estrogen replacement therapy in women

Nursing Management:1. Support cognitive function

a. Provide a calm, predictable environmentb. Speak in a quiet and pleasant manner c. Use memory aids and cues - gives a sense

of securityd. Color-code the doorwaye. Encourage active participation

2. Promote physical safetya. Remove all obvious hazardsb. monitor patient’s intake of food and medicationsc. wandering behavior – use gentle persuasion or distracting

the patientd. avoid restraints – increases agitatione. secure doors leading from the housef. supervise all activities outside the home – let patient

wear identification bracelet or neck chain

3. Reduce anxiety and agitationa. provide constant emotional support b. keep the environment uncluttered, familiar and noise-freec. structure activities

d. familiarize oneself with the px’s predicted responses to certain stressors

4. Improve communicationa. nurse uses clear, easy-to-understand sentencesb. list simple written instructions – serve as remindersc. px may use nonverbal communicationd. tactile stimuli – hug or hand pat – signs of affection, concern & security

5. promote independence in self-care activitiesa. simplify daily activitiesb. collaborate with occupational therapistc. direct px supervision d. encourage px to make decisions

6. provide for socialization and intimacy needsa. encourage socialization b. encourage px to enjoy simple recreational activities

(1) walking(2) exercising(3) socializing

c. encourage px to care for a pet – provides an outlet for energy

7. promote adequate nutritiona. keep mealtime simple and calmb. one dish is offered at a timec. cut food into small piecesd. hot food and beverages are served warme. provide familiar foods that look appetizing and tastes goodf. provide adaptive equipment if necessary

END OF NEURO!!!!THANKS!!!!