Nervous System

Function of the Nervous System

Controls all motor, sensory, autonomic, cognitive, and
behavioral activities
Basic functional unit: neuron

Nerve Impulses
Nerve Impulses
Neuron = nerve cell
Electrical signals travel along the neuron
Myelin sheaths increase the speed of
transmission
 Anatomy Of the Nervous System

CNS PNS
Brain & Spinal Cord Cranial nerves/Spinal Nerves
Somatic system (voluntary)
Autonomic Nervous System-
Functions to regulates
activities of internal organs
and to maintain and restore
internal homeostasis
Sympathetic- fight or
flight; norepinephrine
Parasympathetic-
conservation, restorative
system ; acetylcholine
Central Nervous System -
The Brain
Three major divisions
Cerebrum
Cerebellum
Brain stem

Surrounded and protected by cranium, meninges

and CSF/Cerebrospinal fluid
- serves as a shock absorber to protect brain
and spinal cord
Brain
Topography of the Cortex as
It Relates to Function
Cerebral blood supply

Circle of Willis
Ensures blood supply
is not compromised
Blood Supply
Brain only uses glucose for energy
In Cerebral Circulation (brain):
1. Veins and arteries are thinner
2.Veins do not have valves (this is different than circulatory
pathways in the body).
Blood Brain Barrier- particles must enter by active transport
Permeable to H2O, CO2, other gasses, lipid soluble
compounds; altered with trauma, cerebral edema
Protective structures
Meninges
Skull
Spinal cord
CSF-immune/metabolic functions
Cerebrum-largest and highest brain
Frontal lobe
section Temporal lobe
Voluntary motor Hearing
function Smell
Conscious thought
Speech Occipital lobe
Reasoning Vision

Parietal lobe
Sensory input
Cerebellum
Balance and coordination
Involuntary motor function
Athletes have a cerebellum that functions at
optimal level
Brainstem

Controls - Level of Consciousness or LOC

Involuntary motor functions, ex. diaphragm
Basic life functions:
EX: breathing
Brainstem cont
Three parts:
1.Midbrain-conducts impulse between brain parts
& certain eye and hearing reflexes

2.Pons- controls reflexes such as chewing, tasting;

assists with respirations
3.Medulla Oblongata- connects to spinal cord
regulates heart rate, breathing,
swallowing, blood pressure
Central Nervous System cont.
Spinal Cord
Protected by vertebrae and meninges
Exits skull through foramen magnum
Ends at ~L2- second Lumbar Vertebrae
Starts at brainstem = Medulla Oblongata
Functions
Transmit nerve impulses between body and brain
Reflex actions
Efferent nerves/Afferent nerves
Spinal Cord
Continues from
medulla
Connection between
brain and periphery
Meninges surround
Cervical, Thoracic
Lumbar, Sacral
Coccygeal
CT scan of spinal cord
Anterior Horn- Voluntary and Reflexes activity

Posterior Horn Relay station in the sensory/

reflex pathway
Meninges and Related Structures
 Peripheral Nervous System
1. 12 pairs cranial nerves
2. 31 pairs spinal nerves

Autonomic Nervous System

1. Sympathetic-Fight or Flight
2. Parasympathetic-Counteracts Fight or Flight
Types of nerves
Afferent:
1.Carries sensory messages
2.Carry messages from the body part receptors to
brain and spinal cord (CNS)
3.Somatic and visceral sensory nerve fibers

Somatic motor

voluntary
Types of nerves
Efferent:
1.Carry messages from brain/spinal cord to areas
of the body-muscles/glands
2.Carries motor messages
3.Email sent out
 Parasympathetic vs. Sympathetic
Responses

Cholinergic
SLUD

Adrenergic

ACTION
Function of Neurotransmitters

http://
www.search-results.com/search?q=video+on+ne
urotransmitters&o=APN10198&l=dis&tpr=2&ctyp
e=videos
 neurotransmitters
Communicate messages from one neuron to another or to a
specific target tissue

Neurotransmitters can potentiate, terminate, or modulate a

specific action or can excite or inhibit a target cell

Many neurologic disorders are due to imbalance in

neurotransmitters PARKINSONS (dopamine); mood
disorder (serotonin SSRIs medication)

http://www.bing.com/videos/search?q=ssri+video&F
ORM=VIRE4#view=detail&mid=35525F960C528D93A1AD35
525F960C528D93A1AD
 Synapses
Junction between two
neurons
Neurotransmitters
Chemical messengers
Carry impulse across the
synapse
Neurological AssessmentHealth
Pain History
Seizures
Dizziness (abnormal sensation of imbalance
or movement)
Vertigo (illusion of movement, usually
rotation)
Visual disturbances
Motor movements
Cerebellar- movement and coordination
Weakness
Abnormal sensations
 Neurological Assessment
Cerebral function: mental status, intellectual function,
thought content, emotional status, perception, motor
ability, and language ability
***Assess impact of any neurologic impairment on
lifestyle and patient abilities and limitations

Cranial Nerves Assess I-XII

Motor system (discriminate right/left): posture, gait,

muscle tone and strength, coordination and balance, and
Romberg test

Sensory system(discriminate right/left): tactile sensation;

superficial pain, vibration, and position sense,
graphesthesia- draw # in hand, stereognosis- id object
Neurological Assessment
Deep Tendon Reflex: Plantar (Babinski), Biceps,
Triceps, Brachioradialis, Patellar, Achilles

Speech- clear, dysarthria- ineffective

articulation, Aphasia-Expressive (Brocas),
Receptive (Wernickes);Global (mixed)

Cerebellar: finger to nose; heel to shin; pronator

drift; rapid movement hands/feet.
Neuro Assessment Contd

Meningitis
Kernig s sign
Brudzinkis sign
GCS Scenario- what is the GCS
MS Sykes

Willameena Sykes is a 46-year Caucasian female, who was in her usual

state of health, when during an intense verbose discussion with her 17-
year old daughter, had a sudden onset of intense headache pain behind
her right eye. She also reportedly complained of dizziness and nausea.
Her daughter called 911 who came quickly and transported her to
TWUMC, (Texas Womans University Medical Center), a highly
respected teaching hospital in the Texas Medical Center, Houston, Texas.

The EMS Technicians obtained the first set of vital signs: BP 226/138,
HR 114, Respirations 18, Temp 37.4C, SpO2 96% on room air. She was
agitated but responsive and cooperative; She opened her eyes
spontaneously, was oriented to person, place and time, and followed
requests to move her extremities when asked.
 Diagnostic Tests
Computed tomography (CT): with or without contrast dye
Magnetic resonance imaging (MRI): with or without contrast
Cerebral angiography: X-ray of cerebral circulation with contrast
Myelography: X-ray of spinal subarachnoid space with contrast
Noninvasive carotid flow studies: Ultrasound to assess arterial flow

Transcranial Doppler: Record blood flow thru intracranial vessels

Electroencephalography (EEG): Electrons measure brain waves

Electromyography (EMG): Needle measures muscle activity

Nerve conduction studies, evoked potential studies: visual, brain,

somatosensory lesion or defects

Lumbar puncture, and analysis of cerebrospinal fluid: Meningitis

CT vs MRI
 Gerontological Considerations
Important to distinguish normal aging changes from
abnormal changes
Determine previous mental status for comparison;
assess mental status carefully to distinguish delirium
from dementia
Mental confusion or delirium in elderly may be due
to disease state, dehydration, medication or infection
Mental status change is NOT normal part of aging
Gerontological cont..
Normal changes may include:
Losses in strength and agility; changes in gait,
posture and balance; slowed reaction times and
decreased reflexes; visual and hearing alterations;
deceased sense of taste and smell; dulling of
tactile sensations; changes in the perception of
pain; and decreased thermoregulatory ability
Nurse should assess environmental adaptation
ex: Falls Assessment high/low
Nervous System
 Kernigs sign
Brudzinkis sign

This sign is indicative of

meningitis. This sign occurs when
the patients knee/hips are flexed
and the neck also will flex.
Which aphasia involves expressive
speech?
Wernickes
Brocas
Neurotransmitter deficit in the
body that leads to Parkinsons
Acetylcholine
Norepinephrine
Dopamine
Serotonin
Brain food is
Protein
Sugar
Fats
GCS for comatose patient
13
10
7
Dementia is normal aging process
True
False
Delirium can be caused by
Drugs
Infection
Disease process
All of the above
Test performed to determine
infectious process such as
meningitis in the CSF.
Electroencephalogram
Lumbar Puncture
Transcranial Doppler
How do you test Pronator Drift?
Patient stands on one foot for a period of time
and balance is observed
Patient closes eyes and identifies object placed in
palm of hand
Patient holds arms out, palms up, for 20- 30
seconds with eyes closed and arm placement
observed.
Stroke-CVA
Decreased oxygen to the brain caused by a blood
clot or bleeding
Risk Factors: HTN; sickle cell disease, drug abuse;
diabetes; atherosclerosis; heart arrhythmia
Signs and symptoms:
One-sided weakness
Aphasia
Loss of consciousness
Visual changes
Gradual or sudden
Stroke 4 Types
1) TIA- brief period of deficits resolve in 24 hours

2)Thrombotic CVA--blood clot within a blood vessel in

the brain or neck. Thrombus occurs quickly deficits
progress slowly

3)Embolic CVA- blood clot originates elsewhere in body.

Sudden onset w/ immediate symptoms. If not absorbed
may be persistent

4)Hemorrhagic CVA- intracranial hemorrhage> ICP.

Most often fatal. Symptoms appear suddenly with loss of
consciousness in of cases. Ex. AVmalformations
Stroke: Signs/symptoms
Blood pressure may be severely elevated due to
increased intracranial pressure.

Patient may experience sudden, severe, headache

with nausea and vomiting.

Meets criteria in the NIH Stroke Scale

Patient may remain comatose for hours, days, or

even weeks, and then recover. Longer coma-poor
prognosis

ICP is a frequent complication resulting from

hemorrhage or ischemia and subsequent cerebral
edema.
 CVA Signs and Symptoms
Highly dependent upon size and site of lesion.

1) Internal Carotid

2) Middle Cerebral

3) Anterior Cerebral

4)Vertebral Artery
Medical and Nursing Management during the Acute
Phase of CVA

1) Antiplatelet agents to treat TIAs and treat previous

CVA clients (non hemorrhagic)

2) Acute phase thrombotic and embolic CVA-

thrombolytic therapy using tPA- tissue plasminogen
activator. Can only be administered within first 3
hours to dissolve clot

3) Anticoagulant therapy IV Heparin initially followed

by oral anticoagulant Coumadin or Lovenox.

4) Cerebral edema- hyperosmolar solutions- Manitol or

diuretics Lasix

5) Seizures- anticonvulsants- Dilantin, barbiturates-

Valium/ Ativan
Medical and Nursing Management during the Acute
Phase of CVA cont..
1) Do not disrupt a clot that has formed after hemorrhagic
stroke

2) Endovascular for aneurysm to clip/coiling

3) Interventional Radiology may be used to remove clot for

thrombotic/embolic

4) Carotid Endarterectomy -surgical prevention for TIA or

mild stroke

5) Carotid Artery stenting high risk patients

6) Monitor INR in hemorrhagic-correct with plasm or Vitamin

K
 Medical and Nursing Management during the
Acute /Discharge home phase of CVA
1) Rehab is crucial- PT/OT/Speech

2) Passive/Active ROM-affected & unaffected side

3) Turn & Repositioning Q2-painful affected side

4) Monitor extremities for Thrombophlebitis

5) Encourage participation in ADLs; Clothe affected side first

6) Thickened liquids; aspiration precautions

6) Alternate communication methods; supportive environment

7) Teach client to turn head side to side to fully scan visual field if
homonymous hemianopia is present
 Bells Palsy
Cranial nerve disorder characterized by
unilateral facial paralysis.

Unilateral inflammation of 7th cranial

nerve (facial nerve) produces weakness
or paralysis of the facial muscles.

Unknown cause, but may be due to

viral, autoimmune or vascular ischemia

80% recover completely in weeks to

months.
Bells Palsy Signs, Symptoms & TX
SIGNS & SYMPTOMS
TX
Facial distortion- Corticosteroids for
paralysis on one side swelling
Inability to close eyelid Analgesics for pain
Increase lacrimation Warm compresses
Painful face Electrical stimulation to
prevent muscle atrophy of
Facial Swelling
face
Corneal irritation Surgery in rare case to r/o
Loss of taste; speech malignancy or tumor
impairment Eye patch and drops
Multiple Sclerosis

Progressive degeneration of the myelin sheath in

the CNS with unknown cause
Etiology possibilities: infection by slow virus in
childhood; auto immune cause; and genetic
factors.
Occurs primarily in ages 20-40
Types: Relapsing-remitting
Primary Progressive
 MS signs and symptoms
1) Weakness; Muscle spasms; Ataxia.
2) Visual disturbances (nystagmus, blurred
vision, blindness).
3) Slurred, hesitating speech.
4) Intention tremor.
5) Abnormal reflexes (absent or hyperactive).
6) Paraplegia later stages or in progressive
early on
7) Urinary and bowel
incontinence/retention/UTIs.
8) Emotional- labile (depressed, euphoric).
MS: DX & TX
No cure-education
CT/MRI- multiple Supportive care-ADLs &
plaques in CNS lifestyle management
Lumbar puncture reveals Manage symptoms
clonal IGg EX: Bladder/bowel
Evoked potential studies- dysfunction; ataxia
assess progression Steroids
Urodynamic studies Anti-spasmotics
Neuropsychological Disease Therapy Drugs
-cognitive (decrease relapses):
Interferon; Copaxone;
Avonex
GUILLAIN-BARRE SYNDROME
Disorder of the nervous system that affects
peripheral nerves and spinal nerve roots
resulting in demyelination.
It is also called infectious polyneuritis.
Occurs most commonly between ages of 30-
50.
Guillain Barre-Signs & Symptoms
5. Cardiac involvement due to
1. Symmetrical motor
weakness to extremities; autonomic dysfunction
from Vagus nerve:
often first symptoms is
to lower extremities Hypotension, Hypertension,
2. Progresses (ascends), to Tachycardia, Bowel/Bladder
total paralysis requiring dysfunction
ventilator support.
3. Paresthesia's- 6. Cognition and LOC
numbness, and tingling. unchanged
4. Cranial nerve 7. Duration of symptoms
involvement resulting in varies- may be 2 weeks.
difficulty chewing,
talking, and speaking
Guillain-Barre Syndrome
Causes
The exact cause is unknown.
Thought to have an
autoimmune component.
Many patients have a history
of a recent viral infection,
immunization, surgery, injury.
HIV
H.influenzae
Epstein-Barr
CMV-Cytomegalovirus
Incidence
Male-16-25 yrs. or 45-60 yrs.
1 to 2 cases per 100,000
60-75% of cases recover
completely
20-25% have residual signs
after recovery
Death in 5% -respiratory
failure, sepsis, emboli
Nursing Management of patient
with Guillain-Barre Syndrome
TX MANAGEMENT
Treatment is nonspecific Supportive nursing care
and symptomatic. measures indicated by the
Monitor respiratory patient's degree of
status paralysis.
Plasmaphoresis & IVIG- PT or OT: Rehabilitation
used to decrease Assess residual effects
peripheral nerve myelin such as flaccid paralysis
antibody level. may lead to muscle
Continuous EKG atrophy
monitoring DVT prevention
Nutritional status: PEG
tube; Speech evaluation
Parkinsons Disease
http://www.bing.com/videos/search?q=Ear
ly+Symptoms+Parkinson+Disease&Form=VQFR
VP#view=detail&mid=BC1EBB518F5976D0E7F3
BC1EBB518F5976D0E7F3
Parkinsons Disease
A progressive degenerative neurological disease
characterized by bradykinesia, muscle rigidity,
and nonintentional tremor.
Due to decreased Dopamine levels
Commonly affects older adults (diagnosed
between 50-60)
Unknown cause
Possible causes: Genetic factors, viruses, chemical
toxicity, encephalitis, and cerebrovascular disease.
 Tremor-at rest
Rigidity of muscles
Bradykinesia-slow
movements (common)
Postural instability-shuffling
gait
Dementia,Depression,
Delirium
Hypokinesia diminished 2.Rigidity
movement
Micrographia-small writing
Dysphonia-soft slurring of
speech.
Parkinsons
Signs/Symptoms
Diagnosis is made
clinically by patient
History and having
4 cardinal signs:
1.Tremor
3.Postural changes
4.Bradykinesia
Parkinsons Disease -Nursing Management
1) Goal= Optimizing function

2) AROM 2x /day> PROM 2x/day

3) Encourage ambulate 4x/day

4) Assistive devices (Velcro vs buttons & slip on shoes)

5) Assess communication skills

6) Speech pathologist if needed, swallow evaluation

7) Assess nutritional status and feeding ability

8) Nutrition- high fiber and fluids

1) Education
3) Malnutrition, constipation, skin breakdown, incontinence, contractures
4) Falls assessment
 Parkinsons Disease
TX TX
No cure -goal is to control MAO inhibitors stop
symptoms Dopamine
Levodopa converts to breakdown
Dopamine Surgical options:
Anticholingeric 1. Thalamotomy
tremosr,rigidity 2. Pallidotomy
Antidepressants Deep Brain Stimulation
Dopamine agonist early Neuro Transplantation
disease of when Levodopa 1. Use of fetal brain, or stem cells
ineffective
2. Porcine neuronal cells
Antivirals-rigidity
Meningitis
Inflammation of the meninges (lining of the
brain and spinal cord)
May be bacterial or viral
Signs and Symptoms:
High fever, stiff neck, headache,
seizures, coma, death (untreated)
 Meningitis Signs & Symptoms
+ Kernig & Brudzinskis sign
Headache (often severe)with
Photophobia.
Nausea, vomiting.
Nuchal rigidity (stiffness of the
neck).
S/S of ICP
Opisthotonos (extreme
hyperextension of the head
and arching of the back due
to irritation of the meninges).
Altered level of
consciousness
(LOC);Seizures
Multiple petechiae on the
body (meningococcal).
Rash with Neisseria
meningitidis
Fever, Chills
Meningitis Causes
Infectious
microorganisms travel to COMMON MICROORGANISMS
meninges via bloodstream
EX: otitis media (ear Meningococcus.
infection) *college dorm living:
Menactra
Exposure to secretions or
aerosal contamination
Streptococcus.
EX: Neisseria meningitis
Microorganisms travel to
Staphylococcus.
meninges from traumatic
injury to facial bones or
from invasive procedure Pneumococcus
EX: Lumbar puncture; Haemophilus influenza B
shunt, head injury. * common in children*
Meningitis-predisposing conditions
Dense community living military; college dorm
Tobacco use
Upper respiratory infection
Otitis media or Mastoiditis
Alter immune system
Ex: AIDS; Cancer patients
Meningitis- DX and TX
DX TX

ABX (Vancomycin &

MRI/CT- check for brain cepholosporin)
shift Steroids: Decadron IV
Lumbar puncture: CSF; Dilantin; Seizure
gram stain culture + for Precautions
organisim Monitor ICP if needed
Blood cultures Fluids
Patient assessment Assess LOC
GCS; VS; Nuchal rigidity,
O2 if needed; airway
etc
Dim lights; calm
Antipyretics
Meningitis
***Bacterial Meningitis is a medical emergency
untreated can be fatal in hours-days***
Treatment to all exposed- vital!-Rifampin IM
Droplet Isolation -24-48 hours
Increased Intracranial Pressure -ICP
Rapid or prolonged increase in intracranial pressure
> 15 mmHg measured in lateral ventricles

Coughing, sneezing, straining, and bending forward

all cause temporary ICP.

Increased pressure may result from edema,

bleeding, trauma, or space-occupying lesions

Exceeding pressure will lead to brain herniation

(foramen magnum). Irreversible damage
ICP- Signs & Symptoms
Early- blurred vision Increase SBP-
unchanged DBP
Decreased visual acuity,

Diplopia Widening Pulse

pressure
headaches
Reflex Bradycardia
Vomiting
due to Carotid body
Change in LOC most stimulation
significant sign.
ICP Diagnostics
1) CT/ MRI
2) No LP due to risk of herniation
3) Monitoring
ICP-Therapeutic Management
Medical emergency
Restoring normal pressure accomplished by meds,
surgery, and drainage of CSF from ventricles
Assess neuro status q 1-2 hours
1) LOC, behavior, motor/ sensory function, pupil
size and response, vital signs, temp
Maintain airway
Assess bladder distension and bowel constipation
Quiet environment
Fluid restrictions
Meds
1) Osmotic diuretics- Mannitol
2) Loop diuretics- Lasix
3) Corticosteroids
 Intracranial hemorrhage:
Diagnostic studies
EEG
X-ray
CT scan
LP w/ CSF analysis
Blood studies
ECG
Intracranial Hemorrhage

Hematomas are a result of bleeding within the

closed compartment of the skull. They may cause
compression of brain tissue.
Three common locations:
1.Epidural
2.Subdural
3.Intercranial
1. Epidural Hematoma
Caused by bleeding between
the skull and the dura.
Arterial bleed.
Medical emergency.
s/s- Headache
LOC: lucidness to rapid
deterioration
Drowsiness to coma with
fixed/ dilated pupils on affected side
and hemiparesis, hemiplegia, seizures.
2. Subdural Hematoma
Bleeding between the dura and the arachnoid-
pia mater.
Slow progression may be mistaken for dementia
in elderly, slow thinking, lethargy, confusion,
drowsiness,
Ipsilateral pupil dilation
Sluggishness,
Seizures.
3. Intracranial Hematoma
bleeding into brain.
S/S vary depending on location.
Headache
decreased LOC
hemiplegia,
ipsilateral pupil dilation
possible herniation
resulting in coup and contrecoup injury.
Contusion- bruised brain
Blunt trauma coup- counter coup.
Severe jarring of the brain causes bruising of the
brain.
Loss of consciousness
Bruising is the result of blood vessel rupture.
Permanent damage may result.
Risk of brain herniation and hemorrhage
Concussion
Results from violent jarring of the brain against
the interior of the skull.
The patient may experiences a brief loss of
consciousness
Confusion, headache, and irritability may follow.
Complete recovery is usual.
Grade 1-AMS < 15 min, Grade 2 AMS > 15 min,
Grade 3 LOC worst)
Seizure Disorder
A period of abnormal electrical disturbance in
one or more areas of the brain. Manifested by
disturbances of skeletal motor activity,
sensation, autonomic dysfunction of viscera,
behavior or consciousness
Partial begin in an area of the brain
Generalized involve electrical discharge in the
entire brain
Seizures- Causes & DX
CAUSES DX
Head injury EEG
Brain tumor X-ray
Allergies
CT scan/MRI
CNS infections
Cardiovascular disease- LP w/ CSF analysis
EX: HTN Blood studies
Fever children ECG
Drug/ETOH withdraw SPECT imaging
Metabolic/toxic conditions Patient signs & symptoms
EX: Renal Failure Patient PMHX
Seizures- Types
Tonic-clonic seizures- grand mal most common type
Aura maybe
Loss of consciousness, sharp muscle contractions
Client falls to floor & bowel/bladder incontinence
Tonic Phase- extension)breathing ceases during tonic
phase; 15-60 sec
Clonic Phase- (flexion) hyperventilation, eyes roll back in
head; 0-90 sec.
Post-ictal phase- quiet, calm unconscious, confusion and
disorientation after waking, complaints of aches and
fatigue
Seizure- Types cont
Simple partial seizures
limited to 1 hemisphere
alterations in motor function, sensory signs,
autonomic or psychic symptoms

Complex partial seizures

originate in temporal lobe
may have aura; impaired LOC
non-purposeful movement- lip smacking,
blinking , aimless walking; amnesia is common
Seizures- Types cont
Generalized partial seizure
partial but spreads to both hemispheres

Absence seizure
generalized lasts 5-30 seconds
blank stare
absence of motor activity
may be accompanied by eyelid fluttering or lip
smacking.
Seizure Types cont
Status epilepticus- Valium, Ativan IV drug of
choice
o life-threatening cycles of tonic clonic phases

o patient may become hypoxic,

o hypoglycemic,

o hyperthermia,

o exhausted
Seizures: Nursing Management
1) Maintain airway
2. Reduce risk of injury
3) Provide support- vocational
4) Medications
1. Antiepileptics:
Dilantin, Depakote,
Depakene, Tegretol,
Neurontin, Lamictal
1) Patient Teaching:
lifestyle management
2) Medic Alert
3) Driving
4) ETOH- Sleep
5) Discuss treatment
options-
Surgical Interventions
6) Implanted devices to
reduce seizure activity
(connect to Vagus nerve)
Spinal Cord Injuries
Causes:
1.Automobile accidents.
2.Athletic injuries (diving, hard-contact sports).
3.Falls.
4.Gunshot wounds, stab wounds.
5.Industrial accidents

Diagnostic: MAINTAIN C-SPINE PRECAUTIONS

1.X-ray
2.CT/ MRI
Spinal Cord Injuries
Spinal shock Paraplegia
temporary loss of reflex Paralysis of lower extremeties;
function. caused by injury thoracic spine or
lower
bradycardia; hypotension;
flaccid paralysis of skeletal
muscles Tetraplegia
loss of pain, touch, formerly quadraplegia; paralysis
temperature, pressure, visceral of arms, trunk, legs, and pelvis;
injury of cervical spine
and somatic sensations; bowel
and bladder dysfunction
no perspiration
Spinal Cord Injuries:
Autonomic Dysreflexia
o Exaggerated sympathetic o Vasodilation above injury;
response that occurs in clients
with T6 injuries or higher; o Bradycardia;
response
o Systolic hypertension
o After spinal shock-stimuli
cannot ascend cord; stimuli o Widening pulse pressure.
such as urge to void or
abdominal pain

o Vasoconstriction below injury

Spinal Cord Injury:
Therapeutic Management
Immobilize injury C-Spine Precautions
Monitor respiratory function (injury C6 or above may
require ventilator support)
Treat autonomic dysreflexia immediately-life
threatening
Elevate HOB
Remove anti-embolism stockings
Assess BP Q 2-3 minutes while assessing for trigger
Remove stimulus when found-full bladder
Contact physician and administer anti-hypertensives

Bowel and bladder training

Halo Vest- teach raises center of gravity risk for falls, no
driving
Myasthenia Gravis
Chronic, progressive autoimmune disorder
affecting the neuromuscular transmission of
impulses in the voluntary muscles of the
peripheral nervous system.

Transmission of impulses from the nerve to the

motor end plate of the muscle is hindered by
decreasing numbers of receptors for
acetylcholine.
Myasthenia Gravis
NORMAL PROCESS
Acetylcholine is released at
the nerve ending and moves
to the muscle end plate,
causing muscle contraction.
Acetylcholine is then broken
down into acetate and
choline by the substance
cholinesterase.
MYASTHENIA GRAVIS
Too much cholinesterase
present, and acetylcholine is
destroyed too quickly.
Inadequate depolarization of
motor muscle motor end plate
movement due to lack of
acetylcholine
Antibiodies against acetycholine
impair impulses across myoneural
junction
Myasthenia Gravis- Signs/Symptoms
1) Diplopia (double vision).
2) Ptosis
3) Abnormal muscle weakness;
characteristically worse after
effort and improved by rest.
4) Bowel and bladder
incontinence.
5) Myasthenia crisis: sudden
motor weakness, risk of
respiratory failure,
aspiration, cause- infection &
missed dose of medication
6) Cholinergic crisis: severe
muscle weakness, cramps,
diarrhea, bradycardia,
bronchial spasm, and
pulmonary secretions caused
by over medication
7) Diagnosis:
Tensillon test for diagnosis-
administered IV symptoms
go away temporarily with
administration
Myasthenia Gravis: Patient Care

Anticholinesterase drugs: Nutrition- medicate 30-45

enhance the action of minutes prior to meals for
acetylcholine at the increased strength
myoneural junction Eye care- patch for double
vision, drops for dryness,
PT/OT sunglasses
Teaching
1) Rest
2) Avoid stress and meds that will
Maintain respiratory function exacerbate symptoms (alcohol,
Chin tilt with eating/ drinking sedatives, local anesthetics)
Avoid exposure to respiratory 3) Signs of crisis
illnesses 4) Medic Alert bracelet
Coughing/ I/S/ chest PT/ 5) Communication methods
suction
(1) Always assume that the patient can
hear, even though he makes no
response.
(2) Always address the patient by name
and tell him what you are going to do.
(3) Refrain from any conversation
about the patient's condition while in
the patient's presence.

Nursing Considerations
1) Change in alertness or cognition
often first sign of neurological
change
2) The most common causes of
prolonged unconsciousness
(Coma) include:
Cerebrovascular accident (CVA).
Head injury.
Brain tumor.
Drug overdose.

Nursing Considerations: Altered

Level of Consciousness
 Brain function deterioration follows a predictable
pattern, except brain stem injury
Higher functions to primitive
1.Confusion, forgetfulness, disorientation to time, then
person, then place, agitation, poor problem-solving,
change in behavior
2.Lethargy, obtundation,stupor
3.Purposeful movement to decorticate posturing, small
reactive pupils, to dolls eyes
4.Decerebrate posturing, fixed pupils

Nursing Considerations: Assessment

(1) Always take a rectal temperature.

(2) Observe for changes in vital signs

(3) Note changes in response to stimuli.

(4) Note the return of protective reflexes such as

blinking the eyelids or swallowing saliva.

(5) Keep the patient's room at a comfortable

temperature.

(6) Patient's skin temperature by feeling the

extremities for warmth or coolness.

Nursing Care
Maintain a patent airway by proper positioning of the
patient. Position the patient on his side with the chin
extended. This prevents the tongue from obstructing the
airway.
This lateral recumbent position is often referred to as
the "coma position."
It is the safest position for a patient who is left
unattended.
Suction the mouth, pharynx, and trachea as often as
necessary to prevent aspiration of secretions.
Reposition the patient from side-to-side to prevent
pooling of mucous and secretions in the lungs.
Administer oxygen as ordered.
Always have suction available to prevent aspiration of
vomitus.
Nursing care- Airway/Breathing
The bowel should be evacuated regularly to prevent
impaction of stool.
(1) Keep accurate record of bowel movements. Note
time, amount, color, and consistency.
(2) A liquid stool softener may be ordered by the
physician to prevent constipation or impaction. It is
generally administered once per day.

(3) Assess for fecal impaction.

Small, frequent, loose stools may be the first signs of
an impaction as the irritated bowel forces liquid.
stools around the retained feces
(4) If enemas are ordered, use proper technique to
ensure effective administration and effective return
of feces and solution

Nursing care: Patient Elimination - Bowel

The bladder should be emptied regularly to
prevent infection or stone formation.
(1) Adequate fluids should be given to prevent
dehydration.
(2) Keep accurate intake and output records.
(3) Report low urine output to professional
nurse.
(4) Provide catheter care at least once per shift to
prevent infection in catheterized patients

Nursing Care: Elimination- Urine

Maintain proper body alignment. The
unconscious patient cannot tell you that he is
uncomfortable or is experiencing pressure on a
body part.

(1) Limbs must be supported in a position of function.

Do not allow flaccid limbs to rest unsupported.
(2) When turning the patient, maintain alignment and
do not allow the arms to be caught under the torso.
(4) Utilize a foot board at the end of the bed to
decrease the possibility of foot drop.

Nursing Care : Positioning 1

1) When joints are not exercised in their full range of motion each day,
the muscles will gradually shrink, forming what is known as a
contracture. Passive exercises must be provided for the unconscious
patient to prevent contractures.
2) Exercises with a range of motion (ROM) are performed under the
direction of the physical therapist.
3) It is a nursing care responsibility to maintain the patient's range of
motion.
4) Precautions must be taken to prevent the development of pressure
sores.
5) Utilize a protective mattress such as a flotation mattress, alternating
pressure mattress, or eggcrate mattress.
6) Change the patient's position at least every two hours.
7) Unless contraindicated, get the patient out of bed and into a
cushioned, supportive chair.

Nursing Care: Positioning 2

A patient who is unconscious is normally fed and
medicated by gavage. (G-Tube or PEG)
Always observe the patient carefully when administering
anything by gavage.
Do not leave the patient unattended while gavage feeding.
Keep accurate records of all intake. (Feeding formula, water,
liquid medications.)
When gavage feeding an unconscious patient, it is best to
place the patient in a sitting position (Fowler's or semi-
Fowlers) and support with pillows.
This permits gravity to help move the feeding or medication.
The chance of aspiration of feeding into the airway is reduced.

IV fluids
Strict I& O

Nursing Care: Nutritional Needs

The unconscious patient should be given a complete bath
every other day. (This prevents drying of the skin.) The
patient's face and perineal area should be bathed daily.
(1) The skin should be lubricated with moisturizing
lotion after bathing.
(2) The nails should be kept short, as many patients will
scratch themselves
Provide oral hygiene at least twice per shift. Include the
tongue, all tooth surfaces, and all soft tissue areas. The
unconscious patient is often a mouth breather. This
causes saliva to dry and adhere to the mouth and tooth
surfaces.
(1) Always have suction apparatus immediately available when
giving mouth care to the unconscious patient.
(2) Apply lubricant to the lips to prevent drying.

Nursing Care: Skin Care 1

 Keep the nostrils free of crusted secretions. Prevent
drying with a light coat of lotion, petrolatum, or water-
soluble lubricant.

Artificial Tear to prevent eye irritation or infection due

to dryness and decrease lacrimation's.

If the patient is incontinent, the perineal area must be

washed and dried thoroughly after each incident. If
Foley in place, do pericare daily and prn to prevent
UTIs

Nursing Care: Skin Care 2