THE NERVOUS SYSTEM

- system of regulation

1. Central Nervous System (CNS)

 Is like the CPU of a computer
 It controls, regulates, integrates every function
of your body
 It Consist of:
a. Nerve Cells – basic communication unit of
the brain and SC/ functional unit.
-neurons or nerve cells are the only unit that do
not regenerate. Supporting cells for nerve cells are
called NEUROGLIA (NERVE GLUE)

b. Brain
c. Spinal Cord

2. Peripheral Nervous System (PNS)-

- 31 prs spinal nerves and 12 prs cranial nerves

 Is like the cables of a computer

 It transmits/distributes electrical impulses
 The PNS include sensory receptors, sensory
and motor neurons:
a. Sensory PNS – Afferent Pathway
 Afferent - ―upward movement‖ or
ascending movement going to the
brain‖
 Transmits signals from the skin (i. e. pain), muscles, and internal organs to the brain.
 Example: If you sense a hot/warm surface it goes through the afferent pathway
b. Motor PNS – Efferent Pathway
 Efferent– meaning ―effect‖ –  The peripheral nervous system includes sensory
downward movement or descending receptors, sensory neurons, and motor neurons.
from the brain Sensory receptors are activated by a stimulus
 It sends commands from the brain to (change in the internal or external environment).
the body to control the muscles The stimulus is converted to an electronic signal
(locomotion) and to supervise the and transmitted to a sensory neuron. Sensory
autonomic nervous system, which is neurons connect sensory receptors to the CNS. The
in charge of controlling the heart, CNS processes the signal, and transmits a message
intestines and other organs. back to an effector organ (an organ that responds to
 Further divided into 2: a nerve impulse from the CNS) through a motor
 PNS Is Consist of: neuron.

a. Somatic – voluntary NS
 Soma = prefix for muscles, thus the target is our muscles, skeletons
ligaments and tendons
 Voluntary meaning = conscious, under your will

c. Autonomic – involuntary NS (ANS)/ automatic

 you cannot see it but it is working, doing its job
 Example: Visceral organs like your heart is constantly pumping.,kidneys,
internal organs, git,lungs,etc.
 Further divided into 2:
a. Sympathetic NS
 is activated during stress- everything is UP, except GIT and
URINARY
 UP – pupils dilated, inc. PR,RR, dry mouth (git down)
 Fight/Flight response
  Why UP? Coz ADRENALIN/ EPINEPHRINE (catecholamine
of PNS-gasoline) is stimulated (adrenergic drugs-same effect,
activates SNS) DOPAMINE- same effect (dopaminergic drugs)
 MAO – MONOAMINE OXIDASE –will stop the actions of
adrenalin/epinephrine and dopamine once stress is stopped.

b. Parasympathetic NS
 Is activated during rest and relaxation
 Normal or slightly depressed internal organs, EXCEPT GIT
AND URINARY
 Eg; salivating, pupils constricted
 ACETYLCHOLINE – the catecholamine of PNS, so
adrenergic drugs have same effect PNS effect
 CHOLINESTERASE- will stop the actions of acetylcholine to
normalize the organs

a. Spinal Nerves (SN) – 31 pairs

8 Cervical
12 Thoracic
5 Lumbar
5 Sacral
1 Coccygeal
b. Cranial Nerves (CN) – 12 pairs

NERVE CELL/NEURONS-functional unit of the nervous system

2 Types of Nerve Cell:

a. Neuroglia (―Nerve Glue‖)

 A supporting cell
 it is non-functioning as far as transmitting impulses is concerned

b. Neuron (the ―star‖)

 Is the functional unit of the nerve cell (NC)
 It transmits and relays impulses and messages

A.**Neuroglia
1. Astrocytes (letter B) – star-shaped
Cell body

Capillaries

 It is connected to your neuron (cell body) and the other part to your capillaries
 It’s function is part of your ―blood-brain-barrier‖:
 only certain substances or nutrients can enter your cell body
 harmful substances are off limits
 it maintains the chemical environment of your neuron
 acts like a regulator

2. Microglia (letter D)- also part of the immune system (WBC)

 Acts as phagocytes, eating the harmful substances in the cell

3. Ependymal CELLS(letter A)
 Is like the ―cushion‖ in your neuron
 It is located in the crevices of your
neuron

4. Oligodendrocyte (letter C) cytes- cells

 Forms part of myelin sheath (the axon’s
insulator) –just like the outer covering of
an electrical wire
 In the CNS the oligodendrocyte cells
form part of the myelin sheath, while in the PNS the Schwann cells form part of myelin sheath
 Oligodendrocytes = does not regenerate
 Schwann cells = may regenerate

Neuron –NERVOUS SYSTEM is composed of billions of neurons

The neuron consists of:

1.) Cell Body Nodes of

* Center of activity Ranvier
* Metabolic process of
the neuron

2.) Dendrites- a lot of

dendrites in one neuron
 -carries transmission to cell body
* The impulses carried by the dendrites are moving towards the cell body

3.) Axon – only ONE axon in one neuron Axon

* The impulses carried by the axon are moving away from the cell body terminals
* A = away (clubbed-
* 1 axon per neuron shaped)
* covered by myelin sheath

4.) Axon Terminal Junction

 at the axon terminal (at the end of the neuron)
 NEUROMYO JUNCTION/ NEUROMUSCULAR JUNCTION – where
acetylcholine is stored. So acetylcholine serves as a bridge from the axon terminal
towards the organ (eg muscle) though a gap or synapse is present.

1.) Nodes of Ranvier (BOARD QUESTION)

* it allows for the impulses to have staltutory leaps (faster)

2.) Synapse
 means “gap”
 it is where chemicals (neurotransmitters) are stored

THE BRAIN
- CENTER OF ALL FUNCTIONS

The brain (also called encephalon) has 4 major parts:

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TIFF (Uncompressed) decompressor
are needed to see this picture.

1) Cerebrum – largest part of the brain, controls most activities of the brain
* Has 2 hemispheres the left & right hemispheres
* Joined by the corpus callosum
* Each hemisphere has 4 lobes:

a. Frontal Lobe (pinaka bright)

 The largest lobe
 Responsible for: FXNS: * Anything Intellectual (BOARD QUESTION)
 Judgment
 Abstract thinking  contains the BROCA’S area which is said to
be responsible for the MOTOR part of
 Memory storage
articulated SPEECH (expressive speech)
 Behavior
 Aphasia = absence of speech
 Emotions
 Broca’s Aphasia is deficit in speech production
 Artistic traits

b. Temporal Lobe
  It controls, regulates and integrates hearing or reception of sound
 Auditory reception

BOARD QUESTION:
 It contains the WERNICKE’S AREA which is essential for formulating
coherent and proportional speech (receptive area-SOUND RECEPTION)
 A patient with Wernicke’s Aphasia may be able to talk and say that he
wants to eat, but if asked ―what he wants to eat‖ he cannot understand what
you are saying.
 Probably because he cannot hear you, or there is a problem in reception.

c. Parietal Lobe
 Is purely sensory (para-i-touch; para-i-taste) SENSE OF TOUCH AND TASTE
 It controls, regulates and integrates sensory: warm, painful, cold, salty, sweet, etc.

d. Occipital Lobe
 Is for the control, regulation and integration of the sense of sight.

BASAL GANGLIA
 Located at the base of the cerebrum
 Which refines/coordinates our movements (FXN)
 Here there would be a balance of neurotransmitters which are stored in the substantia nigra
 Neurotransmitters-chemical substances in transmitting impulses:(secreted by SUBSTANCIA
NIGRA)
 Dopamine
 Acetylcholine
 GABA (+GAMMA-aminobutyric acid)
 Diseases affecting basal ganglia refer to movements

2) Diencephalon
Consist of:
a. Thalamus
 a relay center (HUB) for the transmission of impulses for all senses (hearing, touch, taste,
etc.) except olfactory (smell)

 Impulses for olfactory (smelling) passes through your hypothalamus, where all
mamillary bodies are present.

b. Hypothalamus
 For olfactory (smell) senses
 It plays a big part of the endocrine system because –HEART OF ENDOCRINE SYSTEM
1. this is where the pituitary gland hangs from and
2. because it regulates the release of pituitary hormones
 It also secretes its own hormones such as: ( O/A)
1. ADH (antidiuretic hormone) also called VASOPRESIN
2. Oxytocin (for milk ejection and contraction of pregnant uterus)
 These 2 hormones are stored in the posterior pituitary gland
 Other functions:
1. hunger and appetite control
2. temperature regulation
3. water and fluid balance (coz of ADH)
4. autonomic nervous system
5. Since it is enveloped by your limbic system, it regulates your primitive emotions
such as rage, anger, blushing, etc.
 Vital Centers - responsible for
3) Brain Stem respiration, blood pressure, heart rate,
vomiting centers and reflexes such as
gag and swallowing reflex
  Vital Centers (PR, RR, BP,VOMITING CTR)
 Also controls GAG AND SWALLOWING
 REFLEXES
 Where cranial nerves Originate
 It consist of the:
1. Mid Brain
 CN 3 and 4 originates  CN 1 and 2 originate
2. Pons from your cerebral
 CN 5 to 8 originates hemisphere

3. Medulla Oblongata
- Also the first area to be impinged in the foramen magnum if there is brain trauma
and the brain herniates in the foramen magnum.
 CN 9 to 12 originates
 This is where the cranial nerves decussate (crosses) forming an X pattern of travel
of nerve impulses.

4) Cerebellum (cauliflower like)

 Balance and position sense (where you are in time and space)-proprioception

SPINAL CORD

 17 TO 18 inches long
 It starts from the foramen magnum to L1 TO L2

 Foramen magnum = is the hole (buslot) you see when you turn a skull
upside-down
 Intrathecal (intraspinal) meds/drugs are injected in L3 to L5 – below the
spinal cord.

Gray Matter
Cell bodies and fibers
Posterior Horn (dorsal)
Sensory
(PAS – posterior, ascending tract, sensory)

White Matter Lateral Horn (middle)

(Tracks) Autonomic NS (Parasympathetic NS)

Anterior Horn (ventral)

Motor
(ADM – anterior, descending tract, motor)
Components of the Spinal Cord (SC):

I. Gray Matter
 Contains cell bodies and fibers

1. Anterior Horn (Ventral)

2. Posterior Horn (Dorsal)
3. Lateral Horn (middle)

II. White Matter

 The fibers will form into bundles called tract

 Two major systems of nerve cells operate in the spinal cord to relay information from the
brain to the body and vice versa.
 Tract are bundle of neuro fibers

1. Ascending Track (Motor) - ADM

2. Descending Track (Sensory) – PAS

Descending Tracts:
1. Pyramidal Tract
 the motor area under conscious control
2. Extrapyramidal Tract PERIPHERAL NERVOUS SYSTEM (PNS)
 the motor area under unconscious control
1. SPINAL NERVES (31 PAIRS)
2. CRANIAL NERVES (12 PAIRS)
SPINAL NERVES (31 pairs) Thirty-one pairs of spinal nerves emerge from
 Cervical - 8 pairs various segments of the spinal cord. Each
 Thoracic - 12 pairs spinal nerve has a dorsal root and a ventral
 Lumbar - 5 pairs root. The dorsal root contains afferent
(sensory) fibers that transmit information to the
 Sacral - 5 pairs spinal cord from the sensory receptors. The
 Coccygeal - 1 pair ventral root contains efferent (motor) fibers
that carry messages from the spinal cord to
PLEXUS the effectors. Cell bodies of the efferent fibers
reside in the spinal cord gray matter. These
 Interlacing of the spinal nerves at the anterior portion of the
roots become nerves that innervate (transmit
spinal cord nerve impulses to) muscles and organs
throughout the body.
1. Cervical Plexus
 the Phrenic nerve located between C3 and C4, innervates the muscle for respiration ---
the diaphragm
 If there is damage at the level of C6 (a transection of nerve at C6 – naputol) your
phrenic nerve can no longer enervate your diaphragm – respiration is impossible.

2. Brachial Plexus
 Innervates your upper extremities

 Improper use of crutches may damage your brachial plexus, which means
that the upper extremities may be paralyzed.
 Crutches should be at least 1 to 2 inches from the axilla

 Radial Plexus
 enervates posterior arm and triceps
 damage to this nerve may cause wrist drop

 Ulnar Plexus
 enervates anterior forearm and 4th and 5th finger – Pope’s hand

 Median Plexus
 enervates anterolateral arm and rest of the fingers
  Mucocutaneous Nerve
 Enervates biceps.

 There are no thoracic plexus, where visceral organs are located

 These are already enervated by your autonomic nervous system

3. Lumbar Plexus
* innervates the abdominal region, groin and genitalia and upper thigh

a. Femoral Nerve – responsible for leg extension (abduction – outwards)

b. Obturator Nerve – responsible for leg adduction (towards)

4. Sacral Plexus
 innervates the lower thigh and lower extremities

 Sciatic Nerve
 Peroneal Nerve – damage
to this nerve may cause
Foot Drop X

5. Pudendal Plexus
ii. Saddle Block – significance is in childbirth anesthesia

AUTONOMIC NERVOUS SYSTEM (ANS)

It is under the Motor (efferent pathway of the peripheral nervous system (PNS)
Involuntary
Which provides and gives innervation to the visceral organs (thoracic or abdominal organs)
There are 2 Divisions:
Sympathetic Parasympathetic
 all systems up except GIT and  all systems up except GIT and
Urinary/bladder control Urinary/bladder control
 activated during stressful situtations  activated during rest and relaxation

HEART HEART
 BP =  BP = or Normal
 HR = Because you  HR = or Normal
need more
 RR = blood supply  RR = or Normal

EYES EYES
 will have mydriasis (dilation of the  will have miosis (contraction of the
pupil) pupil)
 ―mag siga ang mata‖  ―mag gamay ang mata‖

GIT (gastrointestinal tract) GIT (gastrointestinal tract)

 all down  all up or Normal
 Dry mouth  Watery saliva (lami i-kaon)
 Peristalsis movement is leading  Peristalsis movement is leading
to constipation to diarrhea
 Urine is (to stop urinating)  Urine is
 Anal Sphincter is also (to stop  Anal Sphincter is also or relaxed
defecating)

Neurotransmitters Neurotransmitters
 HEAD INJURIES IN GENERAL

4 TYPES:
1. CONCUSSION 2. CONTUSION 3. HEMORRHAGE 4. FRACTURE

1. CONCUSSION  It is important to watch out for CSF

 Jarring & jostling of the brain (cerebrospinal fluid) leak (esp in fracture)
 Temporary neuro deficits o Rhinorrhea – CSF leak from the
nose
2. CONTUSION  Nsg. Mgt. = put mustache gauze
 Bruising of the brain  Send specimen to lab
 In its most severe form there are residual effects o Otorrhea – CSF leak from the ears
(nausea for example)  Nsg. Mgt = put cotton balls
 Send specimen to lab
3. HEMORRHAGE  **SIGNS OF FRACTURE:
 Extravasation of blood in the brain due to damage of  1. Sx for CSF leak – Halo Sx found on the
blood vessels pillows

4. FRACTURE  Do not suction your CSF

 Linear – resembling a line  How do you know it’s CSF? Laboratory
results will show + glucose in the fluid,
 Depressed - inward (glucose is the main nutrient of the
displacement of a brain)because it’s the food of the CSF.
part of the cal
varium

 Comminuted –
fragmentation of
the bone

Other Sx of
 Compound – or open Fracture:
skull fracture - with  2.Battle Sx
laceration of overlying o Hematoma at the
scalp and/or mucous back of the ear
membrane  3.Raccoon’s Eyes
o Hematoma
Remedies for Fractures: around the eyes
 Intracranial Surgeries
1. Craniotomy = opening of the skull ―buslot‖
2. Craniectomy = Excision of a portion of the skull, without replacement of the bone
3. Cranioplasty = repairs of the cranium
Nsg Mgt.: POST OP POSITIONS: (BOARD
QUESTION)
 3 approaches of craniotomy
 Head of the bed should be flat to avoid pressure
1. Infratentorial – front/side approach
on the suture line (FOR INFRATENTORIAL)
 ABCs
o Airway
 Should be open, no clogs
 No laryngeal edema
 Prepare intubation or tracheostomy set
o Breathing
 2. Supratentorial – at the back
of the head

3. Transsphenoidal – at the
Base of the nose or gingiva
(ex: hypophysectomy
-removal of pituitary gland)

Post op teaching: Never disturb the suture line.

Pre-Op: Shave hair, Pre-op steroids (↓ inflamm.); avoid enemas (↑ ICP)

DRUGS FOR HEAD INJURY

 During injury, the inflammatory process is activated, thus, there will be cerebral edema.
 Drugs needed are:

1. Osmotic Diuretic – to drain out the excess fluid brought about by inflammation
 Mannitol ( BOARD QUESTION)

2. Steroids -
 Dexamethasone
 Prednisone

(BOARD QUESTION-HEPARIN & COUMADIN)

 Prevent clot formation
i. Heparin – for short-term use While on anticoagulants, patients
 Test for clotting time regularly: will be prone to bleeding, thus,
 PTT (partial thromboplastin time) we need antidotes: (BOARD
QUESTION)
ii. Warfarin (Coumadin) – for long-term use  heparin
 Test for clotting time regularly o HEP (Protamine SO4)
 PT (prothrombin time)  Coumadin
 o CouK (Vitamin K)

4.Fibrinolytics – adverse effect is also bleeding

 Used when a clot is already present  Fibrin, means
 Need to dissolve the clot ―clot‖,‖thrombus‖
 MOA: clot dissolution  Lytic from the root word
 ANTIDOTE: AMINO CAPROIC ACID ―lysis‖, meaning ―erase‖
 (AMICAR)

iii. Urokinase
iv. Streptokinase
v. TPA (tissue, plasminogen activator)
 The plasmin will dissolve the clot

5. Analgesics
 For headaches

Nursing Management (HEAD INJURIES)

  Provide with a quiet environment – to prevent seizure if nervous system is highly stimulated
 Provide with a safe environment
 Provide a stress-free environment
 Restrict Visitors
 No Loud noises
 Dim lights
 Schedule your routines and visits
 Maintain nutrition/diet – if there is a problem with swallowing give thickened soups, bite size food
 Turn patient every 2 hours
 Offer bed pan every 4 hours
 Take vital signs

SPINAL CORD INJURIES (SCI)

 will depend on the ―level‖ of injury

o C1 to C8 Injury - quadriplegia (paralysis of all 4 limbs)

o C6 - phrenic nerve (innervation of diaphragm-
respiratory distress)
o T1 toL4 - paraplegia (paralysis of lower extremities)

 Signs and Symptoms of spinal cord injury will depend on the area damaged.
o Anterior /ventral= refers to motor
o Posterior/dorsal = refers to sensory

 Brown-Sequard syndrome
o One part of your body can move but cannot feel any
sensation
o While the other part of your body can feel sensation
but cannot move

3 STAGES OF NURSING REPONSIBILITY

FOR SPINAL CORD INJURIES

I. EMERGENCY PHASE
 at the scene of the accident always suspect an SCI
 perform ABCs
 2 ways to open for airway: (BOARD QUESTION)
o Chin lift – do not use if you suspect an SCI coz you
cannot hyperextended the neck in px w SCI
o Jaw thrust – use this if you suspect an SCI
 Immobilization of patient
o Only move the patient in the presence of company
o Move only the patient as a unit
 Neutral Position- Neck is in midline, neither
hyperextended nor flexed.
o No flexion and extension
o Use a cervical collar if necessary – to immobilize the spinal cord, neck is in neutral position
o Transport using a spinal board
o Do not remove your spinal board even during X-ray procedures. (x-rays to rule out spinal
transection- putol) Only time to remove collar and board is when confirmed that there is no SCI
II. ACUTE PHASE (first 24 to 48 hours)
o The goal of treatment is to prevent
further injury to the spinal cord.
o Perform ABCs.
o Pharma - ↑ dose of Corticosteroids –
to improve motor & sensory functions
o O2 administration – to prevent
hypoxemia that would worsen the
neuro deficits. (mechanical ventilators
if O2 is not effective anymore)
o
o Fractures – Goal is to immobilize &
reduce dislocations; restoration of Normal positions; stabilization of vertebral column
a.Cervical Tongs: Crutchfield, Gardner-Wells, Vinke
- inserted thru burr holes
- traction; rope with pulley & weights –promote alignment,reduce dislocation
- applied asap after surgery or injury
b.Halo Vest
- applied before discharge
- attached to the skull with 4 pins
- halo attached to plastic vest
- cannot drive,coz limited peripheral vision due to the halo vest
- carry screwdriver or wrench (NCLEX QUESTION) To tighten loose screws
- Nsg care: pinsite care; clean with antiseptic solution

Surgery: Laminectomy – involves the removal of the lamina or spinous process in the spinal column to
repair the spinal cord.
After laminectomy, the Nursing Mgt. in the hospital would be:
o Keep alignment (impt. In any spinal surgery) of the spinal
column using tractions or cervical tongs
o Follow the principle of traction:
o The rope should not have any knots
o The weight is determined by the physician
o The weight should hang freely, it should not touch the floor

o Before discharge, the Nursing Mgt. would be:

o To provide a halo vest
o Patient Teachings:
o Do not remove halo vest
o Do not drive a car because Halo Vest will hamper your vision

**COMPLICATIONS**: (of SCI)

A.♣ Neurogenic/Spinal Shock

1.Neurogenic Shock – loss of autonomic NS function below the level of injury; vital organs are affected (↓BP,
HR, no perspiration on paralyzed area)
2.Spinal Shock – sudden depression of reflex activities below the level of injury; bladder & bowel function is
affected

B.♣ Deep Vein Thrombosis (DVT)/ THROMBOPHLEBITIS

- Caused by immobility (blood pools)
- ↑ risk of pulmonary embolism –pulmonary artery is clogged by the embolus (dislodged
thrombus) – Priority mgt: O2

- SX: chest pain, SOB, anxiety

- Mgt(DVT):
- 1. thigh & calf measurement (usually inflamed);
- 2. compression stockings (anti-embolic stocking)-to promote venous return;
- 3. ROM exercises
III. CHRONIC CARE

♣ NEUROGENIC BLADDER (cannot control)

- bladder unable to store urine very long, empties involuntarily
- urine retention with outflow
- Mgt.:
- intermittent catheterization(straight cat) q4°;
- regulate fluids to 1800 to 2000ml/day

♣SPASTICITY (tigas) spasm

- Drug: Baclofen (Lioresal)-muscle relaxant; Dantroline (Dantrium); Diazepam (Valium)
- Physical Therapy:
- stretching exercises,
- warm tub baths,
- whirlpool

♣ AUTONOMIC DYSREFLEXIA (BOARD QUESTION)-

Abnormal reflexes to certain stimuli
- exaggerated autonomic response to stimuli that are harmless in normal people
- occurs with patients with lesion above T6(-T8) after spinal shock has subsided
- Triggers: distended bladder (most common); constipation & fecal impaction, rough edges
- Stimulation of skin (tactile, pain, thermal, pressure ulcers)

- SX&SY:
- severe headache,
- hypertension (elevated BP) (BOARD QUESTION),
- bradycardia,
- sweating & goose bumps,
- blurred vision & convulsions

- Mgt:
- 1. pt on sitting position (high fowler’s) to ↓ BP;
- 2. remove triggers,
- 3. DOC: Hydralazine (Apresoline) antihypertensive as ordered

INCREASING INTRACRANIAL PRESSURE

The normal ICP (intracranial pressure ) = 0 to 15 mmHg

 During sneezing and coughing or when you do Valsalva maneuver the ICP can reach up to 15 mmHg,
this is still normal
> 15 mmHg = ICP, based on Monro-Kellie Doctrine -The Monroe-Kellie Doctrine
Monro-Kelly Theory – Box Theory simply states that in a non-expandable, non-contractable,
that cranium cannot be expanded. freely communicating space, the pressure of the fluid
contents and the brain itself, must be directly
porportional to eachother in order to maintain a constant
pressure. If one of these pressures increases, another
must decrease in order to compensate.

 The danger of ICP is brain herniation (protrusion), the excess fluids will go downward to the base of
your skull --- foreamen magnum --- the first will be affected is your (brain stem)pons which contains
your Vital Centers - responsible for respiration, blood pressure, heart rate, vomiting centers and reflexes
such as gag and swallowing reflex

SIGNS/ SX OF INC. ICP:

Earliest Signs of ICP:
Altered level of consciousness (BOARD QUESTION) Papilledema = swelling of your optic
disc, but cannot be seen by the naked
eye. You need an ophthalmoscope to
determine it.
 Triad Signs: (HPP) (BOARD
QUESTION)
Headache,
Projectile vomiting
Papilledema
Pulse Pressure = the difference between your
Vital Signs or Late Signs: Cushing’s Triad (BOARD) systolic and diastolic. In ICP
S = 90 --- continually increases
1. *increased BP (widening pulse pressure)
D = 60 --- will remain the same
2. *decreased RR (Cheyne Stokes Respiration) ---------
Pulse Pressure = 30 --- pulse pressure
3. *decreased HR (Bradycardia)
4. increased Temperature (Normal sometimes) –sometimes asked in addition to cushing’s triad

Mgt: (INC. ICP)

1. Airway –
a. HYPERVENTILATION
b. -position HOB 30°; neck in neutral position Cheyne Stokes = the waxing/shallow and
c. suction secretions but hyperoxygenate 1st 100%O2 waning of your breathing with periods
of apnea (absence of breathing)
2.Drugs (same with head injuies):

1. Osmotic Diuretic – Mannitol; monitor urine output; indicates that the drug is working
2. Steroids (to lower cerebral edema)
 Dexamethasone
 Prednisone
3. Analgesics – for headache

3. NSG. INTERVENTION/ PREVENTION of ICP

- quiet environment
- avoid Valsalva maneuver
- avoid sneezing
- avoid coughing (antitussive)
- sked activities

SEIZURES

Abnormal firing of electrical impulses in the cerebral cortex (short circuit in electrical wiring)
Affecting the oxygenation in the brain. (more than 5 minutes can mean irreversible damage to brain)
Thus, impairing movement, balance, cognition and consciousness

Causes:
1. Tumor
2. Clots

TYPES OF SEIZURES:

1. Grandmal Seizure (BOARD QUESTION)

PHASES OF GRANDMAL SEIZURE
Aura phase
 Like a premonition and the only person who can explain it is the patient. It is a state where the
patient sees or smells something.
Tonic phase (tigas) The board exam usually asks:
 The patient stiffens, pupils dilate & roll up, the  When does stiffening occur? Tonic
glottis closes and a ―cry‖ will occur, loss of Phase
consciousness; lasts 20-40 seconds  When does the cry occur? Tonic Phase
Clonic phase (―kisay-kisay‖) 1 minute
 Uncontrolled movements, drooling of saliva
 Postictal phase
 State of calm
 Patient feels dizzy, sleepy, exhaustion, drowsiness

2. Absence (petit mal) seizure

Very brief and sometimes unnoticeable; similar to daydreaming
May be in the form of eye blinks or laughing only

3. Myoclonic seizure
Jacksonian (like Michael Jackson)
Only certain group of muscles will twitch

4. Febrile Seizure (convulsion)

Increased Temperature
This is supposed to subside after 6 years old in children. The theory here is that the blood-brain-
barrier is not fully developed below six years old. If it persists after 6 years old it is already
epilepsy.

DRUGS: (SEIZURE)

1. Dilantin (Phenytoin) BOARD QUESTION FAVORITE (anti-seizure drug)

 Nsg. Intervention: do meticulous oral care; use only very soft toothbrush bristles
 SIDE EFFECT: Urine color is usually Pink
 Should not be stopped abruptly (may lead to status epilipticus-epilepsy that can’t be treated
with medications)

 ADVERSE EFFECTs:
 1.Gingival Hyperplasia (―maga ang gums‖)
 2.Blood dyscrasias -
 Abnormalities in WBC, RBC or platelets Values.

2.) Phenobarbital – addicting (CNS DEPRESSANTS)

3.) Diazepam (CNS DEPRESSANT)

Both drugs are CNS depressant (anti-anxiety)

Side effects:
Nausea,
dizziness,
groggy

Nursing Mgt. (SEIZURE)

1. Safety should be the priority. Thus, put up side rails, assist ambulation, night light on, call
bells at bedside
2. Do not use tongue blades
3. No restraints, put a pillow under the head or use your hand
4. Do not transfer patient on a bed or anywhere else.
5. Loosen up tight clothing.
6. If patient is drooling, turn him towards the left to prevent risk of aspiration
7. Watch out for ―aura‖. Ask the patient if he saw or smelled something before the episode
8. Take note of the time and duration of the seizure. (to monitor oxygen supply to the brain)

3 minutes without oxygen in the brain = reversible

5 minutes or more without O2 in the brain = irreversible

CEREBRAL VASCULAR ACCIDENT (CVA)

 Brain Attack,/ Stroke/, Apoplexy

 CAUSE: Vascular damage to the brain due to thrombus, embolus, or hemorrhage
 Damage depends on area affected (usually the eyes, body parts affected are opposite the area of stroke,
eg. If right brain has tumor, left eyes and limbs are affected, except facial expression-same side.)

 Types:

 ISCHEMIC –
- No blood flow to the brain
 Thrombotic or Embolic
 Disruption of blood flow due to an obstruction
 HEMORRHAGIC
 Extravasation of blood to the brain, due to rupture of arteries.
 Aneurysm – outpouching of the arteries, due to increased pressure, common cause of
hemorrhagic stroke

 Stages of Development
 1. TIA – Transient Ischemic Attack – signs and sx will stay for only 24 hrs
 Precursor to CVA (warning sign already that a more severe stroke will follow)
 Resolves withing 24°
 2. STROKE IN EVOLUTION
 Progressive deterioration of neuro function after 24° to days
 3. COMPLETED STROKE
 Neuro deficits remain unchanged for 2-3 days

 Neuro Deficits
 VISUAL
 1. Homonymous Hemianopsia – loss of ½ of visual field
 Nsg Mgt: put things on the unaffected side, and teach px to scan his area
 Nsg. Dx: Unilateral Neglect- approach the px on the affected side as the nsg intervention as
a therapeutic intervention. But if without Unilateral neglect- put things on the unaffected
side.

 2. Loss of peripheral vision
 (Nsg. Mgt: No driving)

 3. Diplopia
 (Nsg. Mgt: eye patch)

 MOTOR
 1. Hemiplegia, Hemiparesis (paresis-weakness) damage in the brain is opposite the
weakened limbs. (plegia-paralysis)
 Nsg mgt: ROM exercises (for hemiplegia)
 Nsg. Mgt: put things on the unaffected side.(for hemiparesis)

 2. Ataxia – staggering unstable gait. Problem is SAFETY. So assist px, and provide
assistive devices.

 3. Dysphagia-diff. swallowing.
 Nsg. Mgt: Feed on the unaffected side.

 4. Dysarthria – difficulty speaking/articulation.
 Nsg. Mgt: Provide alternative communication, eg. Magic slate,flash cards

 SENSORY
 Paresthesia-numbness or tingling of extremity.

 VERBAL
 Aphasia –inability to communicate

  COGNITIVE
 Loss of memory, orientation
 AGNOSIA- inability to recognize objects and persons.
 APRAXIA – inability to perform tasks you’ve already learned.
 Eg: using the toothbrush to brush the hair

Table 62-2 • Neurologic Deficits of Stroke: Manifestations and Nursing Implications

NEUROLOGIC DEFICIT MANIFESTATION NURSING IMPLICATIONS/PATIENT TEACHING APPLICATIONS
Visual Field Deficits
Homonymous (same
• Unaware of persons or objects on Place objects within intact field of vision.
side) hemianopsia (BQ)
(loss of half of the visual side of visual loss Approach the patient from side of intact field of vision.
field) affected eyes are Neglect of one side of the body Instruct/remind the patient to turn head in the direction of visual
opposite affected brain • loss
area.
• Difficulty judging distances to compensate for loss of visual field.
Encourage the use of eyeglasses if available.
When teaching the patient, do so within patient’s intact visual field.
Loss of peripheral vision • Difficulty seeing at night Avoid night driving or other risky activities in the darkness.
(side vision) Unaware of objects or the Place objects in center of patient’s intact visual field.
•
borders
of objects Encourage the use of a cane or other object to identify objects in the
periphery of the visual field.
Diplopia • Double vision Explain to the patient the location of an object when placing it near
the patient.
Consistently place patient care items in the same location.
Motor Deficits
Weakness of the face, arm, and
Hemiparesis • Place objects within the patient’s reach on the nonaffected side.
leg
on the same side (due to a lesion Instruct the patient to exercise and increase the strength on the un-
in the opposite hemisphere) affected side.
Hemiplegia • Paralysis of the face, arm, and leg Encourage the patient to provide range-of-motion exercises to the
on the same side (due to a lesion affected side.
in the opposite hemisphere) Provide immobilization as needed to the affected side. Maintain
body alignment in functional position.
Exercise unaffected limb to increase mobility, strength, and use.
Ataxia • Staggering, unsteady gait Support patient during the initial ambulation phase.
• Unable to keep feet together; Provide supportive device for ambulation (walker, cane).
needs a broad base to stand Instruct the patient not to walk without assistance or supportive
device.
Dysarthria • Difficulty in forming words Provide the patient with alternative methods of communicating.
Allow the patient sufficient time to respond to verbal
communication.
Support patient and family to alleviate frustration related to difficulty
in communicating.
Dysphagia • Difficulty in swallowing Test the patient’s pharyngeal reflexes before offering food or fluids.
Assist the patient with meals.
Place food on the unaffected side of the mouth.
Allow ample time to eat.
Sensory Deficits
Paresthesia (occurs on Numbness and tingling of Instruct the patient to avoid using this extremity as the dominant
•
the limb
side opposite the lesion) extremity due to altered sensation.
Difficulty with proprioception Provide range of motion to affected areas and apply corrective
•
devices
as needed.
Verbal Deficits
Expressive aphasia • Unable to form words that are Encourage patient to repeat sounds of the alphabet.
understandable; may be able to
speak in single-word responses
Receptive aphasia Unable to comprehend the Speak slowly and clearly to assist the patient in forming the sounds.
•
spoken
word; can speak but may not Use alternative communication methods.
make sense
Speak clearly and in simple sentences; use gestures or pictures when
Global (mixed) aphasia • Combination of both receptive
able.
and expressive aphasia Establish alternative means of communication.
Cognitive Deficits
 Short- and long-term memory Reorient patient to time, place, and situation frequently.
•
loss
• Decreased attention span Use verbal and auditory cues to orient patient.
• Impaired ability to concentrate Provide familiar objects (family photographs, favorite objects).
• Poor abstract reasoning Use noncomplicated language.
Altered judgment Match visual tasks with a verbal cue; holding a toothbrush, simulate
•
brush-
ing of teeth while saying, “I would like you to brush your teeth
now.”
Minimize distracting noises and views when teaching the patient.
Repeat and reinforce instructions frequently.
Emotional Deficits • Loss of self-control Support patient during uncontrollable outbursts.
Emotional lability - unstable Discuss with the patient and family that the outbursts are due to the
•
disease process
• Decreased tolerance to stressful
situations Encourage patient to participate in group activity.
• Depression Provide stimulation for the patient.
• Withdrawal Control stressful situations, if possible.
• Fear, hostility, and anger Provide a safe environment.
Feelings of isolation Encourage patient to express feelings and frustrations related to
•
disease
process.

 Nursing Intervention/Care: (CVA)


 1. ACUTE PHASE ( 1st 24-48°); Goal – to keep patient alive
 a. Maintain patent airway
 b. Neuro Check/Assessment
 1. GCS – Glasgow Coma Scale
 3 factors: Eye Opening, Best Verbal Response, Best Motor Response ( EVM)
 Perfect Score – 15;
 below 7 – comatose ;
 3 – brain dead

 2. Vital Signs

 3. Pupillary Response
 PERRLA – Pupil Equally Round & Reacting to Light & Accomodation)
 Fixed & Dilated (Dead)
 Normal Pupil Size: 2-3mm

 c. Motor & Sensory Function
 d. Check Reflexes (percussion/reflex hammer)
 1. Biceps, Triceps, Patellar (knee-jerk); Ankle
 4+ hyperactive;
 3+ briskier than N;
 maybe N; 2+ N;
 1+ hypoactive or diminished response; 0 no response

 2. Clonus – if reflexes are hyperactive, dorsiflex foot then release; will continue to
beat 2-3x before it settles in a position. If cva px, usually non stop beating.

 3. Babinski Reflex – to see if CNS is intact; toes fan out (ABN)
 +babinski reflex newborn- normal. +babinski in adult- abnormal, damage in brain,
toes should only curl, not fan out.

 4. Blink Reflex – corneal reflex

 5. Doll’s Eyes Reflex (oculocephalic reflex) – to see if intact brain stem; N – eyes
deviate to opposite direction

  e. Check Posture
 Decerebrate – back arched, hands extended
 Decorticate – towards the core, flexed arms, extended legs

 C. Bedrest – restful environment, restrict visitors, dim lights, ↓ noise

 D. Maintain F&E balance – IV & NGT

 E. Maintain Body Position

 HOB – 30-45° (↓ICP) SEMI FOWLER’S
 Reposition q2° side to side (1 hour on unaffected side & 20 minutes on the affected
side)
 ROM exercises q4° to prevent contractures (tigas ang joints)
 We want extension/ abduction/ supination instead of adduction/flexion/pronation; in
order to maintain the normal anatomical position.
 Skin care – no powder, alcohol; instead put lotion to prevent dryness

 F. Promote adequate elimination

 Catheterize – if bedrest
 Offer bedpan q2°-4°
 Stool softener (Colace) BOARD QUESTION – immobility causes constipation

 G. Drugs
 Corticosteroids (Dexamethasone) - ↓ cerebral edema
 Anticonvulsants (Phenobarbital/Dilantin) – to prevent seizures
 Thrombolytics (Fibrinolytics) – to dissolve clots; should be given within 2° after the
episode; and monitor BLOOD PRESSURE
 (Antidote for fibrinolytics) – Amino Caproic Acid (AMICAR)
THROMBOLYTICS/ FIBRINOLYTICS:
 Tissue Plasminogen Activator
 Streptokinase
 Urokinase

 Anticoagulants
 Heparin (short-term use); Antidote – Protamine Sulfate
 Warfarin (long-term use); Antidote – Vitamin K
 Aspirin, Dipyridamole (Persantine) - DRUG OF CHOICE FOR TIA (transient
ischemic attack).

 Osmotic Diuretics – Mannitol

 Antihypertensive Drugs – Hydralazine (Apresoline)

 2. REHABILITATION PHASE (after 48°)

 HEMIPLEGIA
 Turn q2° to Prevent contractures (can do log rolling, can lift the px, or ask px to help lift
himself up by the use of trapeze) EXCEPT SLIDING THE PX
 PREVENT HAZARDS – side rails up
 DYSPHAGIA – thickened food, upright position, check gag reflex, feed on unaffected side
 HOMONYMOUS HEMIANOPSIA – approach on unaffected side; belongings on unaffected
side; teach scanning; (Unilateral Neglect – approach affected side)
 APHASIA
 Receptive – simple, slow directions; one command at a time, use NV techniques
 Expressive – anticipate pt needs; allow enough time to express; listen & watch carefully,
don’t finish the sentence for pt
 ATAXIA – loss of ability to perform purposeful movement; guide & keep repeating the
intended movement

CNS INFECTIONS
 - Common in children because blood-brain barrier is not fully developed (↓8yo)

- Common Signs:
- fever,
- headache,
- vomiting,
- altered LOC,
- seizures

 A. MENINGITIS (highly communicable)

 Infection of the meninges. Highly communicable disease, and thus needs ISOLATION.
 Causative Agents: Bacteria, Virus

 Mode of Transmission: blood, CSF, Lymph Nodes

 Hallmark Signs: “KNOB”

 Kernig’s Sign- flex knees with pain
 Nuchal Rigidity –neck rigidity
 Opisthotonos - is a condition in which the body is held in an abnormal posture. It usually involves
rigidity and severe arching of the back, with the head thrown backward. If a person with
opisthotonos lays on his or her back, only the back of the head and the heels would touch the
supporting surface
 Brudzinski Sign – flex neck and knees will also flex

 Labs: ↑CSF; ↑WBC

 Mgt:
 Antibiotics (bacteria)
 Acyclovir (virus)
 Analgesics for fever, headache
 Aspiration precautions
 Safety precautions

 MENINGES – covering of the brain beneath the cranial bones

 Layers: DAP – Dura, Arachnoid, Pia
 Epidural: Meningeal Arteries
 Subdural: Meningeal Veins
 SubArachnoid: CSF circulation

 CEREBRO SPINAL FLUID – clear fluid that provides protection (cushion) & allows exchange
of nutrients & wastes; produced by the BV of the Choroid Plexus found in the ventricles;
 Normal Volume of CSF – 100-150ml

 R&L Lateral Ventricles

 Foramen of Monro
 3rd Ventricles
 Aqueduct of Sylvius
 4th Ventricles
 SubArachnoid Space via Foramen of Magendi & Luschka
 Returns to Arachnoid Villi
 Cranial Nerve Sinuses

 B. ENCEPHALITIS
 Inflammation of the brain (Aka ―Sleeping Sickness‖)

 Common Causes:
 Herpes Simplex II virus;
 Arbo Virus (caused by mosquito bites or ticks);
 Nile River Fever

 Drug: Acyclovir
  Labs & Mgt: Same as Meningitis

 C. POLIOMYELITIS
 Infection of the Anterior Horn of the SC (anterior-motor), resulting to weakness of the muscles;
eventually atrophies

 Caused by Polio Virus

 Drug: Anti-Polio Vaccine

 Lab: Pandy’s Test (↑amount of protein in the CSF)

 LUMBAR PUNCTURE
 Introduction of a needle in the subarachnoid space on the spinal canal at the level bet. L4-L5
 Purposes:
 Reading of the CSF Pressure: N- 60-150mmH2O

 Specimen for Lab Analysis (For C&S & for + protein or blood) – needs 3 specimens
 For therapeutic purposes – introduction of medication (intrathecal route); introduction of dye
as a contrast media; remove extra CSF

LUMBAR PUNCTURE (PRE-TEST AND POST-TEST)

 Pretest:
 Let patient void
 Position: Lateral recumbent, then fetal/shrimp position
 Instruction: Remain still
 Post-test:
 Pt lie flat for 12-24° (to prevent leakage of CSF)
 Side Effect: Headache (give paracetamol/analgesics)
 Check puncture site (CSF leak, bleeding)
 Assess sensation & movement of lower extremities

CNS AUTOIMMUNE DISEASES

- Antibodies attacking your own system

- Characterized by remissions & exacerbations
- Usual remedy: Plasmapheresis
Plasmapheresis is a process involving the following steps:

Whole blood is withdrawn from the person.

The liquid portion or plasma is removed from the blood and replaced.
The blood, with all its red and white blood cells, is transfused back into the person.
This process is a successful method for treating autoimmune diseases such as multiple sclerosis, myasthenia
gravis and Guillain-Barré syndrome, because it removes the circulating antibodies that are thought to be
responsible for these diseases.

It is not clear whether plasmapheresis is of benefit in the short- or long-term treatment of MS, and its use in MS
remains controversial.-

- Because MS may also involve an autoimmune process—where the body is attacked by its own
immune system—and because demyelinating factors have been found in plasma from MS
patients, plasmapheresis has been tried as a treatment for MS.

 A. MYASTHENIA GRAVIS (MG)

 Disturbance in the transmission of impulse from the nerve to the muscle at the neuromuscular junction
 Antibodies destroy acetylcholine receptor sites at the neuromuscular junction..
  Voluntary muscles are affected especially those innervated by the Cranial Nerves
 Descending paralysis; motor defect with no effect on sensation & coordination

 Theory: persistence of the Thymus Gland after 18yo; Thymus gland develop T-cells before they mature
to the lymph nodes & spleen; found at the mediastinum; thought to involved in the production of
antibodies against acetylcholine

 SX&SY:
 Diplopia
 Ptosis ( lid lag) – early sign
 Mask-like facial expressions
 Weak, hoarse voice
 Dysphagia
 Respiratory Failure – weakness of intercostals muscles

 LAB/DIAG:
 “TENSILON TEST‖
 Edrophonium Chloride (Tensilon) injected IV 2mg at a time to a total of 10 mg.
 After 30 seconds, facial weakness & ptosis will resolve;
 Improvement means + MG

 WOF S/E: bradycardia/tachycardia, sweating, cramping

 Antidote: Atropine Sulfate

 MGT:
 Use eyepatch daily (alternate) for diplopia
 Check for gag reflex
 Enough rest, sked activities
 In hospital setting, never leave while pt is eating; have suction equipment ready

 MEDS: ANTICHOLINESTERASE DRUGS (coz acetylcholine is destroyed by antibodies)

 Neostigmine (Prostigmin)
 Pyridostigmine (Mestinon)
 Take in AM; 30 minutes before meals
 Take with milk

 SURGERY: Thymectomy – removal of the thymus gland

 COMPLICATIONS:

 1. MYATHENIC CRISIS
 Exacerbation of symptoms especially generalized muscle & respiratory weakness which could lead
to respiratory failure (can’t swallow, can’t talk, can’t breathe)

 Causes: under medication, physical & emotional stress, infection, ↑ temp, surgery & pregnancy

 Mgt: ↑ Anticholinesterase Drug

 2. CHOLINERGIC CRISIS
 Symptoms mimic exacerbation
 To differentiate, do the Tensilon Test; if improve – myasthenic crisis; if not – cholinergic crisis

 Cause: over medication

 Mgt: discontinue medication

 3. BRITTLE CRISIS – the patient has developed tolerance for the drug

 B. MULTIPLE SCLEROSIS (MS) = NST

 Demyelination of sheaths in the CNS (brain, spinal cord)
 SIGNS/ SYMPTOMS:
 Signs & symptoms will depend on what area the demyelination is found
 There is impairment in sensation & coordination (touch, pain, temp, paresthesia, ataxia, numbness,
tingling)

 First Sign: Visual Disturbance (Diplopia, Blurred Vision)

 CHARCOT’S TRIAD:
 (NST) –
 NYSTAGMUS
 SCANNING SPEECH
 TREMORS

 LABS:↑ IgG & ↑ Proteins

 MEDS:
 Steroids (Prednisone)
 Baclofen (Lioresal) – muscle relaxant (FOR TREMORS)
 Carbamazepine (Tegretol) – paresthesia
 Diazepam – anxiolytics

 C. GUILLAIN BARRE SYNDROME (GBS)

 Inflammation & demyelination of sheaths in the PNS (spinal & cranial nerves)
 Ascending paralysis
 Muscles don’t atrophy
 Usually preceded by a GI or respiratory infection 2 weeks before

SIGNS AND SYMPTOMS:

 Early Manifestation: Clumsiness

 Mgt: No meds; condition is self-limiting; supportive care

 Emergency Care: mech ventilation, O2 administration (IN CASES OF RESPIRATORY INFECTIONS)

 Risk: Respiratory failure, heart dysrhythmia

- Often leads to depression & dementia

CNS DEGENERATIVE DISEASES – will lead to DEMENTIA

And usually no cure ( coz degenerative)

 A. PARKINSON’S DISEASE
 ↓ levels of DOPAMINE in substantia nigra at the basal ganglia (affected)

 CARDINAL SIGNS:
 ―BRaT‖ – Bradykinesia; Rigidity (Cogwheel – doing things in increments); Tremors (resting; pill
rolling)
 Other Signs:
 Stooped posture
 Shuffling gait
 Micrographia
 Masklike face
 Drooling of saliva
 Slow, monotonous speech

 Cause: UNKNOWN
  The substantia nigra of the basal ganglia, projects neuronal pathway at the corpus striatum
 At corpus striatum, balance of acetylcholine (excitatory) & dopamine (inhibitory)
 Relays to a higher motor center to refine & control movements

 Nursing Care:
 Provide safe environment (side rails up, handle bars, toilet/bathtub/hallway railings, no area rugs)
 Hard back or spring-boarded chairs for getting up (easier)
 ↑ Mobility – stretching exercises, passive ROM, assistive devices; if patient freezes, suggest walking
on something
 Encourage independence in ADLs – Velcro – opening in front; don’t rush
 Maintain adequate nutrition – cut food in bite sizes; allow sufficient time to eat; SFF

 Meds:
 ANTIPARKINSONIAN AGENTS
 ↑ Dopamine
 1. Levodopa – has many adverse effects (nausea, vomiting, postural hypotension,
dyskinesias); do not give Vitamin B6 (Pyridoxine) interferes with absorption; taken with
food/snack to ↓ GI irritation;
 SIDE EFFECTS: urine/sweat turns dark

 2. Carbidopa – given to ↑ effects of Levodopa & prevents its breakdown outside the brain;
for fewer side effects
 ANTICHOLINERGIC THERAPY – to control tremors & rigidity (Biperiden, Benztropine
Mesylate)
 DOPAMINE AGONISTS – stimulates release of dopamine; added to regimen if Levodopa &
Carbidopa loses effectiveness (Bromocriptine Mesylate; Pergolide)
 ANTIVIRAL AGENTS – Amantadine (Symmetrel) used in combination with Levodopa to ↓
BRAT (bradykinesia, rigidity, tremor)
 ANTIDEPRESSANTS (TCAs, SSRIs) Elavil, Tofranil, Luvox, Prozac

 B. ALZHEIMER’S DISEASE
 Chronic, progressive brain disorder affecting the frontal & parietal lobe that affects memory, cognition
& affect
 May exhibit ―Sundown Phenomenon‖ – client becomes disoriented when it starts to get dark
 Cerebral neurons atrophies (shrinks); brain atrophies; tangled mass of non-functioning neurons (plaques)
 No cure – just control the symptoms

 Cause is unknown; could be familial & trauma

 DOC: TACRINE HYDROCHLORIDE (COGNEX) (board question) - ↑ brain function & memory by ↑
acetylcholine uptake; adverse effect – hepatotoxic

 Nursing Mgt:
 Supporting Cognitive Function
 calm & predictable environment – don’t change their furnitures
 regular routine
 simple & clear explanations – no complex sentences
 use memory aids – color coding (coz they even get lost in their own room)
 calendars, clocks
 Safety – hazards removed, activities supervised, coz they can’t feel anything anymore.
 Reducing Anxiety & Agitation
 Environment – uncluttered & familiar
 Remaining calm
 Listening to music, stroking, rocking – to provide distraction. (If px is throwing tantrums.)
 Structured activities
 No loud noises
 Communication – unhurried, clear, easy to understand, make simple lists of instructions to
serve as reminders; use NV communication – hug, pat to show affection
 Socialization & Intimacy – encourage visits-nsg homes (brief & unstressful); provide
recreation – hobbies, exercise, pets
 Adequate Nutrition – food offered one dish at a time; familiar foods; cut into bite-sized pieces
 C. HUNTINGTON’S DISEASE (HUNTINGTON’S CHOREA)
 A hereditary disorder (defect in Chromosome 4) wherein there is premature death of cells at the corpus
striatum at the basal ganglia; collection of glutamine – building block of protein
 APOPTOSIS- time of death for every cell

 Cell destruction leads to lack of GABA & acetylcholine which helps inhibit nerve action
 Results to Chorea, Choreiform actions/movements or St. Vitus dance – affecting all body
musculature; abnormal involuntary movements Choreiform mov’t -(writhing, twisting, facial tics &
grimaces); purposeless movements
 No coordinated movements
 Leads to intellectual decline & mental disturbance, esp DEMENTIA

 Nsg Care is similar to Parkinsons & Alzheimers

 Meds: Antipsychotic (Haloperidol) to control behavior of patients, and dementia; TCA & MAOIs

 Prognosis: 10-20 years after onset of disease due to heart failure, pneumonia & infection

 D. AMYOTROPHIC LATERAL SCLEROSIS (ALS)

 Aka ―Lou Gehrig’s Disease (friend of Babe Ruth)
 Progressive death of the motor neuron in the anterior horn of the Spinal Cord

 Cause: unknown

 Theory: overexcitation of the nerve cells by NT glutamate (neurotransmitter) causing cell injury &
neuronal degeneration

 SX&SY: depends on the affected area

 General Signs: MYO- muscles; SCLEROSIS-hardening
 Fatigue
 Progressive muscle weakness
 Cramping
 Twitching
 Overactive reflexes
 Difficulty talking, swallowing, breathing (end point)

 Mgt: No known treatment but given supportive care such as Mech Vent, Enteral feedings, Meds –
Baclofen & Diazepam
 Prognosis: 6mos – 2y after onset of the disease

DIAGNOSTIC TEST FOR THE NERVOUS SYSTEM

IMPT: PRE-OP MGT AND POST-OP MGT

 COMPUTED TOMOGRAPHY (CT) SCAN (graphy-with a dye,usually iodine based)

 Uses Xray beams (contraindicated to pregnant women)-may cause teratogenic effect
 IF px is claustrophobic, dr. can give sedative
 Skull or spinal cord are scanned in successive layers so computer can construct a picture of the internal
structure of the brain
 Takes pictures of internal structure of the brain
 Detects lesions & tumors
 May use contract medium or not

 Nsg. Mgt.
 Explain appearance of scanner– tunnel-like (ask if claustrophobic; if yes, give sedatives)
 Instruct pt to keep still for the whole duration of scan – 20-30 mins
 Remove hairpins, glasses, hearing aids – contains metals that may obstructs view
 If with contrast medium – check allergy to iodine (seafood) if contrast media is used,if px is allergic
to iodine, physician can give antihistamine first.
 MAGNETIC RESONANCE IMAGING (MRI)
 Uses large magnets, radiowaves
 Detects intracranial & spinal abnormalities
 Nsg Care:
 Have client void first.
 May ask if px is claustrophobic
 Remove jewelry, hairpins, glasses,pacemakers,dentures, wigs with metal clips & other metallic
objects
 Contraindicated to those with orthopedic hardware, IUD, pacemaker, internal surgical clips, braces,
toothbridges or other fixed metallic objects in the body
 Remain still – 45 to 60 minutes duration of mri
 Tunnel like (claustrophobia) – sedate client if ordered
 Warn client of normal audible humming & thumping noises from the scanner during the test

 BRAIN SCAN (SCAN)- ENTAILS INJCECTION OF RADIOACTIVE ISOTOPE

 Injection of radioactive isotope (tracer dose not a therapeutic dose), followed by a scanning of the head,
that’s why it’s not under radiation precaution . But if THERAPEUTIC DOSE IS USED-radiation
precaution is needed.
 Radioactive isotope can emit radiation which can kill cells inside the body.
 Radiation precaution (time, distance,shielding with lead-lined apron) is needed for pxs who have radium
implants like cervical cancer pxs
 Isotope will accumulate in the abnormal lesion & will be recorded by a the scanner
  Nsg. Care: check for allergy to iodine

 MYELOGRAPHY MYELO-SPINAL CORD

 Lumbar puncture (L3-L5) used to withdraw a small amount of CSF, which is replaced with a
radioopaque dye; used to detect tumors or herniated intervertebral discs.

 Nursing care: Pretest

 Keep NPO after liquid breakfast.
 Check for iodine allergy.
 Confirm the signed consent.

 Nursing care: Posttest (BOARD QUESTION)

 (Same with lumbar puncture)
 If oil-based dye (iophendylate; Pantopaque), was used, keep client flat for 12 hours. (like lumbar
puncture)
 If water-based dye (Metrizamide; Amipaque) was used, elevate head of bed 30-45° to prevent
upward displacement of the dye, which may cause meningeal irritation and possibly seizures.
 Institute seizure precautions (for water based) so provide calm,dark environment to prevent
seizures.

 CEREBRAL ANGIOGRAPHY (ANGIO-ARTERY)

 Injection of the radiopaque substance into the cerebral circulation via carotid, vertebral, femoral or
brachial artery – followed by Xrays

 Visualizes cerebral vessels & detect tumors, aneurysms, occlusions, hematomas or abscesses

 Pretest Nsg. Care:

 Explain that client may have warm, flushed feeling & salty or metallic taste in mouth during
procedure (caused by the dye)
 Check for allergy to iodine
 Keep NPO after midnight or offer clear liquid breakfast only
 Administer sedation if ordered

 Posttest Nsg. Care:

 Maintain pressure dressing over site; apply ice (vasoconstriction) as ordered (to prevent bleeding)
 Maintain bed rest until the next morning as ordered
 Check site for bleeding or hematoma; if carotid artery is used, assess swelling of neck, difficulty of
swallowing & breathing (check patency of airway)
 If femoral artery is used, check for the distal pulses (popliteal and dorsalis pedis), check for
movement, sensation. Since femoral artery supplies the lower extremities.
 Check pulse, color, temperature of extremity distal to the site used
 Keep extremity extended & avoid flexion in order to prevent bleeding

 ELECTROENCEPHALOGRAM (EEG)/ ELECTROENCEPHALOGRAPHY

 ELECTRO – NO DYES, JUST ELECTRICAL ACTIVITY/ELECTRODES
 Graphic recording of the electrical activity of the brain (like the ECG of the heart)
 Detects abnormal electrical discharges
 To diagnose seizures, epileptic disorder, head injury, encephalopathy, determine brain death
 Procedure:
 17-21 electrodes are placed on the scalp; filled with conductive jelly
 Connected to a machine
 Time – 45-60 minutes to several hours
 Mimic a seizure activity (Activation Phase) – flashing lights, hyperventilation, sleep deprivation the
night before the test
 Nsg. Care:
  Tranquilizers (Sedatives)-CNS DEPRESSANTS, Antiseizures, Stimulants (caffeine, ↑ sugar, tea) –
withhold 2-3 days prior to the test; they will alter the EEG waves/results
 Meals are not omitted but it should be ↓ glucose bec it alters electrical activity pattern
 Patient teaching – it will not cause electrical shock; will not treat seizures – only a test
 Shampoo hair after test to remove electrode paste (BOARD QUESTION)

 ELECTROMYOGRAM (EMG)
 Test that records electrical activity associated with muscle contraction

 Px teaching:
 Tell px it Involves some discomfort bec. needle electrodes are placed into the muscle to be examined
 No complications