PERIPHERAL NERVOUS SYSTEM Nerves and ganglia Connection to brain and spinal cord No protective covering Somatic nervous

system (voluntary control) Autonomic nervous system ( involuntary control) Guillain-Barre Syndrome Guillain-Barre syndrome is a disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms. Ascending paralysis no known cure PATHOPHYSIOLGY IMMUNE RESPONSE TARGETS HOST ATTACKS GANGLIOSIDES INFLAMMATION OF THE MYELIN SHEATH CONDUCTION IS BLOCKED Triggering factors: Most commonly, infection with campylobacter, a type of bacteria often found in undercooked food, especially poultry Mycoplasma pneumonia Surgery Epstein-Barr virus Influenza virus Hodgkin's disease Mononucleosis HIV, the virus that causes AIDS Diagnostic and Laboratory exam Spinal tap (lumbar puncture) Nerve function test - Electromyography -Nerve conduction studies TREATMENT Plasmapheresis blood purification procedure Intravenous immunoglobulin-Immunoglobulin contains healthy antibodies from blood donors. High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barresyndrome. NSG. CONSIDERATIONS Maintain respiratory function

Evaluate rate and progress of paralysis Frequent evaluation of swallowing reflexes Psychological support Vital signs and physical assessment Tic Douloureux Also called trigeminal neuralgia, this is a neurologic condition of the trigeminal nerve, characterized by paroxysms (sudden outburst) of flashing, stabbing pain radiating along the course of a branch of the nerve from the angle of the jaw. Electric-shock-like pain Trigeminal nerve Risk factor: 20-40 yo ; increase frequency with aging ASSESSMENT tearing, darting that occurs on one the face facial twitching Pain initiated with cutaneousstimulation Pain for a tooth Diagnostic exam Based on symptoms Treatment phenytoin (Dilantin) carbamazepine Baclofen may also be helpful Surgical intervention: - Local nerve block Non-invasive treatment: Gamma radiotherapy radiofrequency rhizotomy Nursing Considerations Offer soft diet prepare food that are not too cold or hot offer Soft bristle tooth brush Umbrella or wide brim hat when going out on daylight Wear sun block Assist patient when walking Advise patient to see EENT Bells Palsy a sudden weakness or paralysis of one side of the face. This may happen when the nerve that controls your face muscles (facial nerve) becomes swollen or irritated. Bell's palsy symptoms may range from mild to severe usually goes away on its own Herpes simplex virus, other viruses Assessment Weakness or paralysis on one side of the face. Drooping of one side of the face. Trouble closing your eye on the affected side of the face. More sensitive hearing on the affected side. Numbness or pain in the ear, tongue, or face. Unable to taste with the tip of your tongue. Food may not taste the same because of this. Problems with chewing foods or whistling.

Physical examination MRI or CT scan EMG - determines electrical potential of the muscle Treatment Medicine Antiviral medicine Anti-inflammatory medicine Pain medicine Physical therapy Surgical treatment: decompression surgery Nursing consideration Eye care Lubrication of the eye Encourage facialexcercises Instruct client to chew on unaffected side Place from a quiet, well ventilated and lighted room 2. Migraine unilateral (affecting one half of the head) and pulsating in nature and lasting from 4 to 72 hours -Numerous theories -Usually with aura -Prodrome, aura, pain, post drome -Photophobia -Phonophobia -hemianopsia Theories of migraine Depolarization theory cortical depression release of inflammatory mediators irritation of cranial nerve pain Vascular theory bld. vessels contracts arterial spasm constriction continues Multiple Sclerosis

Disease characterized by multiple areas demyelination of the neurons in the CNS chronic Remission and exacerbation Pathophysiology: Loss of myelin sheath causes decreased impulse, conduction destruction of the nerve axon and blockage of impulse conduction Assessment Etiology: genetic ; environmental; infectious Most common in women Lhermittes symptom electric shock like symptom Charcot triad ( nystagmus, intention tremor, scanning speech) Motor dysfunction weakness of the eye or spasticity of extremities paresthesia Sensory blurred vision, vertigo, tinnitus Bowel and bladder dysfunction Impotence Psychosocial Treatment Immunomodulator - Glatiramiracetate Interferons Immunosuppresant Herbal medicines Rehabilitation Management Diagnostic Exam EMG Serial MRI Lumbar tap Maintain homeostasis and prevent complication Prevent complications of immobility Teach medical regimen and side effects of medication AMYOTROPIC LATERAL SCLEROSIS Involves a progressive degeneration of nerves involving the motor system; mental and sensory not involved Lou Gehrigs Disease Upper motor neuron and lower motor neuron dies Pathophysiology subsequent shrinkage of musculature and muscle fibers fiber atrophy

loss of nerve fibers Causes Mutation of a gene Exotoxic injury = excitatoxicity of glutamate Assessment Common to men than women 2-5 years survival rate Intellect is intact muscle weakness Muscle atrophy Fatigue Fasciculation of the face dysarthia Diagnostic Exam EMG Muscle biopsy Treatment Riluzole Neuroprotectants Nursing Consideration Provide comfort measures Assist with ADL Monitor respiratory status Assess any complication of immobility MYASTHENIA GRAVIS A neuromuscular disorder charac. by decrease in acetylcholine at the receptor sites in the neuromuscular junction ; disturbance in the transmission of nerve impulses Assessment Risk factor: autoimmune ; 20-30 yo(peak) Muscular fatigue (increase with activity) Muscle contraction Ptosis Impairment of facial mobility and expression Impairment of chewing and swallowing Dysarthia Poor bladder and bowel control Weakness of proximal to distal Exacerbation and remission Physiology release acetylcholine transmission of impluses at the neuromuscular junction acetlycholine binds receptor at the end plate muscle fiber surface

muscle contracts remaining acetylcholine split by the enzyme acetylcholinestrase splits into choline and acetic acid choline is reuse Pathophysiology release acetylcholine transmission of impluses at the neuromuscular junction interruption of acetlycholine due to loss acetylcholine receptor in binding site CRISIS MYASTHENIC CRISIS Acute exacerbation preceded from some infection -Decrease or absent cough reflex -Increase in pulse or blood pressure Treatment Anticholinesterase medication or Cholinergic medication Neostigmine bromides (prostigmin) Pyridostigmine bromide (mestinon) -intensify transmission of impulsesthrougout the CNS Edrophonium chloride ( tensilon)

-diagnostic purposes Plasma electrophoresis Immunosuppressive therapy CHOLINERGIC - toxic response to an anticholinesterase medications Surgical procedure : Thymectomy Nursing consideration To maintain respiratory function Distinguish what type of crisis Give medication in corresponds to diagnosis Avoid use 0f sedatives andtranquilers Psychological support Parkinsons Disease (paralysisagitants) A progressive neurological disorder causing degenerative destruction of nerve cells in the basal ganglia , damaging the extrapyramidalsystem which resulting to difficulty in control and regulation of movement Decrease dopamine release / increase acetylcholine release Assessment Risk Factor: onset 50 yo bilateral tremors affects the arms and hand

Pill rolling tremor Cog-wheel rigidity Bradykinesia loss of ability to swallow, difficulty initiating movement, loss of normal arm swing when movement Shuffling propulsive gait Mental deterioration similar to Alzheimers Onset gradual Pathophysiology Decrease dopamine release Progressive destruction ofnigrostriatal pathway diencephalon subthalamic nucleus substancia nigra are affected Diagnosis Physical examination CT scan PET scan Treatment Dopaminergic carbidopa,levodopa Restores normal transmission of nerve impulses Anticholinergic medication - cogentin, artane ( decrease synaptic transmission in the CNS) Nursing consideration To maintain muscle function Maintain nutrition Set realistic goal Provide pleasant atmosphere during mealtime Anticholinergic side effects Alzheimers Disease Alzheimer's is the most common form of dementia, a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Alzheimer's disease accounts for 50 to 80 percent of dementia cases. although the greatest known risk factor is increasing age, and the majority of people with Alzheimer's are 65 and older. But Alzheimer's is not just a disease of old age. Up to 5 percent of people with the disease have early-onset Alzheimer's (also known as younger-onset), which often appears when someone is in their 40s or 50s. Assessment

Memory Disorientation and misinterpreting spatial relationships Speaking and writing Thinking and reasoning Making judgments and decisions Planning and performing familiar tasks Changes in personality and behavior Plaques. beta-amyloid may damage and destroy brain cells in several ways, including interfering with cell-to-cell communication. abnormal processing of beta-amyloidis a prime suspect. Tangles a protein called tau. In Alzheimer's, threads of tau protein twist into abnormal tangles, leading to failure of the transport system. This failure is also strongly implicated in the decline and death of brain cells. Diagnostic Exam Computerized tomography (CT) Magnetic resonance imaging (MRI) Positron emission tomography (PET) Blood exam (thyroid and Vitamin deficiency) Mini-mental test examination VDRL National Institute of Neurological and Communicative Disorders and Stroke(NINCDS) and Alzheimer's Disease and Related Disorders Association(ADRDA) Treatment Anticholinesterase inhibitors- improve cognitive function Chemicals that inhibit thecholinesterase enzyme from breaking down acetylcholine Tacrine (cognex) Donepezil (aricept) Revastigmine (Exelon) Nursing considerations Always remind patient of place, time and day Place pts. picture at the door of assigned room Watch out for RR Used caution with clients with peptic ulcer, bradycardia, urinary obstruction and lung disease Monitor liver function HUNTINGTONS CHOREA Huntington's disease is an inherited disease that causes the progressive breakdown of nerve cells in the brain. movement, thinking (cognitive) and psychiatric disorders. Disease develop signs and symptoms in their 40s or 50s Disease onset begins before age 20, the condition is called juvenile Huntington's disease. Assessement Involuntary jerking or writhing movements (chorea) Muscle rigidity Impaired gait, posture and balance

Difficulty Difficulty Difficulty Difficulty

planning, organizing and prioritizing tasks focusing on a task for long periods in learning new information swallowing

NEUROLOGICAL FUNCTION CENTRAL NERVOUS SYSTEM PERIPHERAL NERVOUS SYSTEM CENTRAL NERVOUS SYSTEM BRAIN SPINAL CORD PERIPHERAL NERVOUS SYSTEM 12 PAIRS OF CRANIAL NERVE 31 PAIRS OF SPINAL NERVE SNS ANS AXON carry impulses away from the body NEURON functional unit of NS GLIAL CELLS protective cells in the CNS CHEMICAL NEUROTRANSMITTERS potentiate, terminate and modulate specific action and can excite or inhibit the target cells activity MENINGES: PIA blood brain barrier Arachnoid water proof membrane beneath CSF flows Dura tough, responsible for enclosing CSF Component of CNS Grey matter - outer portion neurons White matter inner portion nerve fibers and supported tissues PARTS OF THE BRAIN AND ITS FUNCTIONS CEREBRUM - FRONTAL LOBE - PIMS THALAMUS RELAY STATION PONS DREAM (REM), RESPIRATION, VOMITING SWALLOWING MEDULLA OBLONGATA HR, RP, BP, cardiac, respiratory, vomiting AMYGDALA SIT OF EMOTIONS CEREBELLUM BALANCE, MOVEMENT AND TONE HYPOTHALAMUS BP, SLEEP, TEMPERATURE HUNGER, THIRST CEREBRAL CORTEX MOTOR CORTEX ; MOTOR ACTIVITY BASAL GANGLIA MAINTAINS POSTURE OCCIPITAL LOBE EYES TEMPORAL WERNICKES AREA, SMELL, HEARING

PARIETAL GENRAL SENSORY ASSESSMENT OF CRANIAL NERVES CRANIAL NERVE 1 (OLFACTORY)- odor CRANIAL NERVE II(OPTIC) snellen chart CRANIAL NERVE III ( OCUMLOMOTOR)- pupillarycontriction ; eye movement CRANIAL NERVE IV (TROCHLEAR) - downward/inward movement CRANIAL NERVE V (TRIGEMINAL) - sensory/motor; mastication, touching of face; sensation to cornea CRANIAL NERVE VI (ABDUCENS)- lateral movement of the eye CRANIAL NERVE VII (FACIAL)- showing of tee CRANIAL NERVE VIII (ACOUSTIC)- hearing CRANIAL NERVE IX (GLOSSOPHARYENGEAL )- swallowing CRANIAL NERVE X (VAGUS)- elicit gag; assist in swallowing CRANIAL NERVE XI (SPINAL ACCESSORY) assess uvula, soft palate movement,sternocleiodomastoid muscle CRANIAL NERVE XII (HYPOGLOSSAL)- tongue movement; speech CEREBROVASCULAR ACCIDENT Disruption of blood supply to an area of the brain resulting to tissue necrosis and sudden loss of body function Atherosclerosis Types of stroke: 1. Thrombosis formation of clot ; narrowing of vessel lumen 2. embolism- total occlusion of cerebral artery 3. Cerebral hemorrhage- rupture of cerebral artery 4. Transient Ischemic Attack brief episode of neurological dysfunction PATHOPHYSIOLOGY HIGH CHOLESTEROL IN THE BLOOD ATHEROSCLEROSIS BLOCKING OF NORMAL FLOW IN THE BV POOR OXYGENATION ISCHEMIA OF CEREBRAL TISSUE EDEMA AND CONGESTION VASCULAR DAMAGE / CELLULAR INJURY STROKE Risk factors Smoking Obesity Sedentary lifestyle Increased stress Oral contraceptives Sex Age Hereditary predisposition Risk factors

Smoking Obesity Sedentary lifestyle Increased stress Oral contraceptives Sex Age Hereditary predisposition ASSESSMENT Visual defects Transient hemiparesis Slurred speech Facial asymmetry Confusion Nose bleeding Hemiplegia - paralysis Aphasia impairment in comprehension and using of words, writing and reading Agnosia- loss 0of ability to rec0ognize Increase intracranial pressure Cranial nerve impairment Pupillary response Caloric testing / caloric reflex test Glascow coma scale Decorticate Decerebrate FAST MNEMONIC Agnosia- loss 0of ability to rec0ognize Increase intracranial pressure Cranial nerve impairment Pupillary response Caloric testing / caloric reflex test Glascow coma scale Decorticate Decerebrate FAST MNEMONIC Neurological assessment - eye opening, motor, verbal response EYE OPENING Spontaneous -4 To sound -3 To pain -2 Never -1 MOTOR RESPONSE Obeys command 6 Localizes pain - 5 Normal flexion withdrawal 4 Abnormal flexion posturing - 3 Extension posturing -2 None -1 VERBAL RESPONSE Oriented -5

Confused conversation - 4 Inappropriate words -3 Incomprehensible sound -2 No word -1 PUPILLARY RESPONSE 1.Ipsilateral pupillary changesoccuring at the same side 2.Contralateral - opposite side of the lesion 3.Unilateral dilatation of the pupils Dolls phenomenon (oculocephalic reflex) head move from side to side, eyes side to side (positive), eyes remain fixed midline position (negative) PUPILLARY RESPONSE 1.Ipsilateral pupillary changesoccuring at the same side 2.Contralateral - opposite side of the lesion 3.Unilateral dilatation of the pupils Dolls phenomenon (oculocephalic reflex) head move from side to side, eyes side to side (positive), eyes remain fixed midline position (negative) PERRLA pupil equal round reactive to light andacoomodation Unilateral pupil dilation compression of cranial nerve III Pinpoint pupil pons damage Decorticate- midbrain, thalamus Decerebrate- lesions to cerebellum ; brain stem damage Babinski dorsal flexion of the foot and large toe with fanning of the other toe Decorticate position Midbrain and thalamus posturing, with elbows, wrists and fingers flexed, and legs extended and rotated inward Decerebrate position Midbrain, cerebellum damage Brain stem damage abnormal extensor posturing. Decerebrate position Midbrain, cerebellum damage Brain stem damage abnormal extensor posturing. Other assessment Babinski reflex dorsiflexion; fanning of the other toe Spasticity Upper motor neuron Flaccidity and atrophy Lower motor neuron Walks with their heels and their toes with feet wide apart pts with polyneuropathy Rombergs test Analgesia, hypalgesia,hypergesia lesions in the thalamus and peripheral nerves Anesthesia, hypesthesia,paresthesia, dysesthesia lesions of peripheral nerves, brainstem of spinal cord injury Graphesthesia sensory cortex ; tactual ability to recognize writing on the skin Sterognosis and astereognosis parietal lobe recognize object inability to recognize by touch object by touch

DIAGNOSTIC EXAM CLINICAL MANIFESTATION Cerebral angiogram Lumbar tap CT MRI and brain scan Cerebral angiography Hemispheric ishemia Homonymous Hemianopsia MEDICATIONS FOR CEREBROVASCULAR ACCIDENTS CITICHOLINE (SOMAZINE/ NICHOLIN)- CNS stimulant CORTICOSTEROIDS LAXATIVES stimulates peristalsis; decrease surface tension allowing water to penetrate feces; promote peristalsis of the large intestine;nonabsorbable agents that pulls fluid into the bowel. ANTIEMETICS depresses chemoreceptor triggering zone and vomiting center Hypertensive and aspirins- prophylaxis T-plasminogen activator is a protein involved in the breakdown of blood clots Most effective for ischemic stroke Myocardial infarction Pulmonary embolism Cerebral infarction SURGICAL MANAGEMENT Surgical carotidendarterectomy - trephanation Mechanical thrombectomy direct removal of clot blood from the cerebral circulation NURSING CONSIDERATIONS Maintain patent airway and adequate cerebral oxygenation Assess and implement measures to decrease intracranial pressure Maintain adequate nutrition Preserve function of the musculoskeletal system ALLERGY TO SHELLFISH AND IODINE Sand bag on femoral site Watch out for hematoma formation Inform patient of having warm face and metallic taste during the procedure No metal Right sided damaged= leftaffedted Hemorrhagic storke Ischemic stroke CEREBRAL ANEURYSM A dilatation of the wall of the cerebral artery often arises from an arterial junction in the circle ofwillis. pressure in the cerebral walls bulging of the walls

exerts pressure on brain tissues rupture of bulged wall aneurysm ASSESSMENT

Severe headache Intermittent nausea Rupture frequently occurs without warning Severe headache Seizures Nuchal rigidity Hemiparesis Syncope Increase intracranial pressure

Diagnostic exam LP Cerebral angiogram CAT scan

Treatment 1.Osmotic diuretics 2.Antihypertensive drugs 3.Thrombolytics 4.Surgical interventions- clippings of the aneurysm THROMBOLYTIC MEDICATIONS Activates plasminogento plasmin Anteplase; reteplase; streptokinase Nursing Consideration Prevent ICP Elevate head of bed 30 to 45 degrees / 60 degress Administer analgesic cautiously No hot, cold beverages or food HEADS MNEMONIC MANAGEMENT FOR ICP BRAIN INJURY Highest incident of traumatic brain injury is motor cycle accidents Primary - traumatic brain injury Secondary results of TBI Primary can be classified as open or closed injuries Open - break in the skull Closed - no fracture but unrestrained force cause the brain to get damaged Levels of severity 1.Mild 2.Moderate 3.Severe Contracoup injuries brain strikes rough object opposite the site of direct injury

Indirect injury from a direct blow Contusion brain is bruised Concussion jarring of the brain Hematoma bleeding in an area of the brain PATHOPHYSIOLGY INJURED BLOOD VESSEL Disrupt neuron/axon Disrupt cell bodied bleeding Interruption of synaptic depletion of energy damaged brain action stores tissue Interruption to nerve decreased tissue ICP impulses perfusion incoordination of body function cellular anoxia ASSESSMENT Location of the trauma Physical Cognitive Behavior Determine patients consciousness Glasgow coma scale PERRLA Rancho Los Amigos scale patients progress RACOON OR BATTLE SIGN Pupillary response PERRLA- pupil equal reactive responsive to light and accommodation

Diagnostic exam Neurological exam CT scan fMRI blood flow CBC ABG Treatment Antianxiety drugs Antidepressant Anticonvulsant Anti emetics Surgical procedure : Nursing Consideration

Craniotomy Trephanation

Watch out for RR Orient patient from time to time when fully awake Maintain homeostasis Oxygenation Watch out for increase ICP decrease LOC, increase BP management : HEADS Nursing Consideration Watch out for RR Orient patient from time to time when fully awake Maintain homeostasis Oxygenation Watch out for increase ICP decrease LOC, increase BP management : HEADS BRAIN TUMOR More than 50% are malignant May be benign, malignant of metastatic Types of brain tumor Most common tumor glioma (CH) CNS lymphoma- lymphocytes Meningiomas covering of the brain Adenomas pituitary tumor Schwannos nerve fibers Hemangioblastoma most common vascular tumor Supratentorial anterior two-thirds of the brain; ocular, motor and repiratory Cerebrum Infratentorial - posterior third ; loss of consciousness, cardiac and repiratory Cerebellum Regardless of the origin, site or presence of malignancy Assessment Risk Factor 55-70 yo / lung and breast Vomiting Ataxia, staggering gait Hypotonia Nystagmus, diplopia , decrease visual acuity Behavioral changes Decrease muscle strength Seizures Papillaedema Dizziness and vertigo Headache more severe in the morning Children persistent, irritated crying and head rolling Diagnostic Exam S/Sx EEG CT scan MRI extension of tissue invasion Treatment Dexamethasone Anticonvulsant Radiation and Chemotherapy Surgical procedure: craniotomy craniectomy Complication

Brain stem herniation diabetes insipidus - pituitary hormone SIADH water intoxication Nursing Consideration Provide appropriate increase intracranial pressure Neuro checks Maintain pulmonary function Prevent aspiration Discourage vigorous coughing Careful evaluation of LOC Evaluate dressing Position post operatively Maintain fluid regulation Evaluate changes in temperature Provide appropriate pain reliever Prevent complications of immobility NURSING DIAGNOSIS ALTERED TISSUE PERFUSION: CREBERAL RELATED TO INADEQUATE BLOOD SUPPLY TO THE BRAIN INEEFECTIVE AIRWAY CLEARANCE RELATED TO STASIS OF REPISRATORY MUCOUS SECONDARY TO BEDRIDDEN sample A two-year old child who experienced a head trauma and receiving mechanical ventilation suddenly develops increased intracranial pressure. Which of the following actions would a nurse take first? A. suction endotraheal tube B. position the child intrendelenberg position C. increase the oxygen concentration D. hyperventilate the child While taking care of a child on mechanical ventilation, the best way of nursing intervention during suction is: A. suction then hypeventilate B. hyperventilate then suction C. high back rest, suction then hyperventilate D. hyperventilate suction then hyperventilate once again While taking care of an ICU patient with a diagnosis of aneurysm, the nurse can offer: A. soft diet made of hot chicken soup B. soft diet made of warm oatmeal C. soft diet made of warm beef stew D. hot balanced-diet MUSCLE PARALYSIS PERIPHERAL NERVOUS SYTEM DYSFUNCTION

PERIPHERAL NERVOUS SYSTEM Nerves and ganglia Connection to brain and spinal cord No protective covering Somatic nervous system (voluntary control) Autonomic nervous system ( involuntary control) Guillain-Barre Syndrome Guillain-Barre syndrome is a disorder in which your body's immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms. Ascending paralysis no known cure PATHOPHYSIOLGY IMMUNE RESPONSE TARGETS HOST ATTACKS GANGLIOSIDES INFLAMMATION OF THE MYELIN SHEATH

CONDUCTION IS BLOCKED During routine treatment of CVA, the ER physician orders to increase mannitol to Q8 hrs from q12 hrs, the nurse should expect : A. edema of the face B. slight elevation in urine output C. poor skin turgor D. papilledema A patient diagnosed withastrocytomas is admitted in your area, your most important nursing consideration is: A. introduce self to the patient more often B. side rails up and let mother stay with client C. give soft diet to the patient D. monitor BP of the patient q30