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NEUROLOGY

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Stanley C. Luces, M.D

Topic Outline
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Brief review of Anatomy and Physiology Application of the Nursing process in the approach of neurologic problems:
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ASSESSMENT relevant techniques and lab procedures DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Topic Outline
Trauma and related accidents
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Traumatic brain injury Spinal cord injury

Cerebrovascular Accidents

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Degenerative disorders- demyelinating


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Multiple sclerosis Guillain-Barre syndrome

Degenerative disordersNON- demyelinating


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Alzheimers disease Parkinsons disease

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Motor dysfunction- CNS


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Epilepsy Bells palsy Trigeminal neuralgia Myasthenia gravis

Motor dysfunction- cranial nerve


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Motor dysfunction- peripheral


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Infectious Disease
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Meningitis Brain abscess Encephalitis

Neoplastic disease

IMPLEMENTATION PHASE
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Increased Intracranial pressure Altered level of consciousness Seizures Autonomic dysreflexia/hyperreflexia Spinal shock Cognitive impairment Bowel incontinence

IMPLEMENTATION PHASE
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Impaired physical mobility Impaired swallowing Disturbed sensory perception

THE NERVOUS SYSTEM

Anatomy and Physiology


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Gross anatomy
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The nervous system is divided into the central and peripheral nervous system The Central nervous system consists of the BRAIN and the Spinal Cord The peripheral nervous system consists of the Spinal nerves and the cranial nerves

Anatomy and Physiology


The brain is composed of lobesn Frontal lobe- personality, memory and motor function n Parietal lobe- sensory function n Temporal lobe- hearing and olfaction and emotion by the limbic system n Occipital lobe- vision

Major Lobes of the Brain

Anatomy and Physiology


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The Cerebellum is involved in coordination and equilibrium The Diencephalon consists of the :
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Thalamus- the relay center of all sensory input Hypothalamus- center for endocrine regulation, sleep, temperature, thirst, sexual arousal and emotional response

Anatomy and Physiology


The Brainstem is composed of the: n Midbrain- for visual and auditory reflexes n Pons- respiratory apneustic center, nucleus of cranial nerves- 5,6,7,8 n Medulla Oblongata- respiratory and cardiovascular centers, nucleus of cranial nerves 9,10,11,12

ASSESSMENT OF THE NEUROLOGIC SYSTEM


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HISTORY A confused client becomes an unreliable source of history

ASSESSMENT OF THE NEUROLOGIC SYSTEM


PHYSICAL EXAMINATION
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5 categories:

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1. 2. 3. 4. 5.

Cerebral function- LOC, mental status Cranial nerves Motor function Sensory function Reflexes

ASSESSMENT OF THE NEUROLOGIC SYSTEM


Neuro Check n Level of consciousness n Pupillary size and response n Verbal responsiveness n Motor responsiveness n Vital signs

Level Of Consciousness(Arousal): Techniques and Patient Response


Technique Level Alertness Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and respond fully and appropriately to stimuli (arousal is intact) Abnormal Response

Lethargy

Speak to the patient in a Appears drowsy but opens loud voice. e.g., call the the eye and looks at you, patients name or ask How responds to questions, and are you? then falls asleep.

Level Of Consciousness(Arousal): Techniques and Patient Response


Obtundation Shake the patient gently as if awakening Patients open the eyes and a sleeper. looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. Stupor Apply a painful stimulus. For example, Patient arouses from sleep pinch a tendon, rub the sternum, or only after a painful roll a pencil across a nail bed. ( No stimuli. Verbal response stronger stimuli needed) are slow or even absent. There is minimal awareness of self or the environment.

Level Of Consciousness(Arousal): Techniques and Patient Response


Coma Apply repeated painful stimuli. Remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.

CEREBRAL FUCTION
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Assess the degree of wakefulness/alertness Note the intensity of stimulus to cause a response Apply a painful stimulus over the nailbeds with a blunt instrument Ask questions to assess orientation to person, place and time

Cerebral function
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Utilize the Glasgow Coma Scale An easy method of describing mental status and abnormality detection Tests 3 areas- eye opening, verbal response and motor response Scores are evaluated- range from 3-15 No ZERO score

Glasgow Coma Scale

Glasgow Coma Score n Eye Opening (E) n Verbal Response (V) n Motor Response (M)

Glasgow Coma Scale

Glasgow Coma Score 7 and Below= COMA!

Glasgow Coma Scale


Glasgow Coma Score n Eye Opening (E) 4=Spontaneous 3=To voice (when told to) 2=To pain 1=None (No response)

Glasgow Coma Scale


Glasgow Coma Score n Verbal Response (V) 5=Normal/oriented 4=Disoriented/CONFUSED 3=Words, but incoherent/ inappropriate 2=Incomprehensible/mumbled words 1=None

Glasgow Coma Scale


Glasgow Coma Score n Motor Response (M) 6=Normal- obeys command 5=Localizes pain 4=Withdraws to pain (Flexion) 3=Decorticate posture 2=Decerebrate posture 1=None (flaccid)

Cranial Nerve Function: Cranial Nerve 1- Olfactory


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Check first for the patency of the nose Instruct to close the eyes Occlude one nostrils at a time Hold familiar substance and asks for the identification Repeat with the other nostrils PROBLEM- ANOSMIA- loss of smell

Cranial Nerve Function: Cranial Nerve 1- Olfactory

Cranial Nerve Function: Cranial Nerve 2- Optic


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Check the Visual Acuity with the use of the Snellen chart Check for Visual Field by confrontation test Check for Pupillary Reflex- direct and consensual Fundoscopy to check for papilledema

Cranial Nerve Function: Cranial Nerve 2- Optic

Snellens Chart

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Cranial Nerve Function: Cranial Nerve 2- Optic

Confrontation test

Cranial Nerve Function: Cranial Nerve 2- Optic

Pupillary light Reflex

Cranial Nerve Function: Cranial Nerve 2- Optic

Fundoscopy

Cranial Nerve Function: Cranial Nerve 3, 4 and 6


Assess simultaneously the movement of the extra-ocular muscles Deviations: n Opthalmoplegia- inability to move the eye in a direction n Diplopia- complaint of double vision
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Cranial Nerve Function: Cranial Nerve 3, 4 and 6

Cranial Nerve Function: Cranial Nerve 5 -trigeminal


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Sensory portion- assess for sensation of the facial skin Motor portion- assess the muscles of mastication Assess Corneal Reflex

Cranial Nerve Function: Cranial Nerve 5 -trigeminal

Cranial Nerve Function: Cranial Nerve 5 -trigeminal

Cranial Nerve Function: Cranial Nerve 5 -trigeminal

Cranial Nerve Function: Cranial Nerve 7 -facial


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Sensory portion- prepare salt, sugar, vinegar and quinine. Place each substance in the anterior two thirds of the tongue, rinsing the mouth with water Motor portion- ask the client to make facial expressions, ask to forcefully close the eyelids

Cranial Nerve Function: Cranial Nerve 7 -facial

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory


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Test patients hearing acuity Observe for nystagmus and disturbed balance

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory

Cranial Nerve Function: Cranial Nerve 8- vestibulo-auditory

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal


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Together with Cranial nerve 10 vagus Assess for gag reflex Watch the soft palate rising after instructing the client to say AH n The soft palate should rise symmetrically, the uvula should remain midline and the pharynx should constrict medially like a curtain. The posterior one-third of the tongue is supplied by the glossopharyngeal nerve

Cranial Nerve Function: Cranial Nerve 9- glossopharyngeal

Cranial Nerve Function: Cranial Nerve 11- accessory


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Press down the patients shoulder while he attempts to shrug against resistance

Cranial Nerve Function: Cranial Nerve 11- accessory

Cranial Nerve Function: Cranial Nerve 12- hypoglossal


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Ask patient to protrude the tongue and note for symmetry

Cranial Nerve Function: Cranial Nerve 12- hypoglossal

ASSESS Motor function


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Assess muscle tone and strength by asking patient to flex or extend the extremities while the examiner places resistance

Grading of muscle strength


0 No muscle contraction is detected 1 A trace contraction is noted in the muscle by palpating the muscle while the patient attempts to contract it. 2 The patient is able to actively move the muscle when gravity is eliminated. 3 The patient may move the muscle against gravity but not against resistance from the examiner. 4 The patient may move the muscle group against some resistance from the examiner. 5 The patient moves the muscle group and overcomes the resistance of the examiner. This is normal muscle strength.

Assessing the motor function of the cerebellum


Test for balance- heel to toe (tandem walking)/(-) upper motor weakness n Test for coordination- rapid alternating movements and finger to nose test *Dysdiadochokinesis- inability to follow alternating movements n ROMBERGs is actually a test for the posterior spinothalamic tract
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Assessing the motor function of the brainstem


Test for the Oculocephalic reflex- Dolls eye n Normal response- eyes appear to move opposite to the movement of the head n Abnormal- eyes move in the same direction

Assessing the motor function of the brainstem


Test for the Oculovestibular reflex n Slowly irrigate the ear with cold water and warm water n Normal response- cOld- OppOsite, wArM- sAMe

Nystagmus

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Assessing the sensory function


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Evaluate symmetric areas of the body Ask the patient to close the eyes while testing Use of test tubes with cold and warm water Use blunt and sharp objects Use wisp of cotton Ask to identify objects placed on the hands Test for sense of position

Assessing the reflexes


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Deep tendon reflexes


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Biceps Triceps Brachioradialis Patellar Assessing the sensory function Achilles

Assessing the reflexes


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Superficial reflexes
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Abdominal Cremasteric Anal Babinski- stroke the lateral aspect of the soles doing an inverted J

Pathologic reflex
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(+)- DORSIFLEXION of the Big toe with fanning out of the little toes

A positive Babinski's sign is indicative of an upper motor neuron lesion affecting the lower extremity in question.

Grading of reflexes
Deep tendon reflex n 0- absent n + present but diminished n ++ normal n +++ increased n ++++ hyperactive or clonic Superficial reflex n 0 absent n +present

DIAGNOSTIC TESTS:
Electroencephalography - graphic recording of electrical activity of the brain by several small electrodes placed on the scalp. n evaluate level of brain function
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Electroencephalography

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Interventions:
Pretest Care: n Patient should be deprived of sleep before EEG n Withhold sedatives, tranquilizers, stimulants for 24 to 48 hrs of EEG n Coffee, tea, and cola drinks are omitted in the meal n Assure the client that the procedure is safe Postest Care:
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remove electrode paste with acetone and shampoo hair

Computed Tomography Scanning


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makes use of a narrow x-ray beam to scan the head in successive layers lesions in the brain are seen as variations in tissue density differing from the surrounding normal tissue

interventions:
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Preparation for the procedure and patient monitoring teaching the patient to lie quietly Relaxation technique for claustrophobic patient Detect for allergies for iodine based dye

DIAGNOSTIC TESTS
CT scan n With radiation risk n If contrast medium will be used- ensure consent, assess for allergies to dyes and iodine or seafood, flushing and metallic taste are expected as the dye is injected

Magnetic Resonance Imaging (MRI)


- uses powerful magnetic field to obtain images of different areas of the body.
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Interventions:
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non-invasive technique that detects presence of tumors, slipped discs

Patient preparation ( relaxation technique ) All metal objects and credit cards are removed. Careful history taking: ( presence of aneurysm clips, orthopedic hardware etc.)

Cerebral arteriography
dye injected into the artery n vascular system of the brain is visualized Interventions:
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q q q q

Note allergies to dyes, iodine and seafood Ensure consent Keep patient at rest after procedure Maintain pressure dressing or sandbag over punctured site

LUMBAR PUNCTURE (Spinal tap)


inserting a needle into the lumbar subarachnoid space to withdraw CSF site of needle insertion: Newborn L4-L5 level of iliac spine Older child/adult L3-L4 level of iliac crest
performed to:
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To To To To To

obtain CSF for examination measure and reduce CSF pressure( N 60-150 mm H20 ) determine the presence or absence of blood in the CSF detect spinal subarachnoid block administer antibiotics intrathecally

Contraindications: n Infection at site of puncture n Coagulopathies n Increased intracranial pressure n Cervical cord lesion n Suspected or known intracranial mass n Severe cardiovascular compromise

Complications of Lumbar Puncture: n Spinal headache n Iatrogenic infection n Bleeding n Backpain n Herniation

Pretest Have client empty bladder Position client in lateral recumbent position with head and neck flexed on to the chest and knees pulled up. Explain the need to remain still diring the procedure

Posttest Ensure labeling of CSF specimens in proper sequence. Keep client flat for 12-24 hours as ordered. Check puncture site for bleeding, leakage of CSF. Assess sensation and movement in lower extremities. Monitor Vital signs Administer analgesics for headache as ordered.

Increased Intracranial pressure


Intracranial pressure more than 15 mmHg Brunner= Normal intracranial pressure 10-20 mmHg Causes: n Head injury n Stroke n Inflammatory lesions n Brain tumor n Surgical complications

Increased Intracranial pressure


Pathophysiology n The cranium only contains the brain substance, the CSF and the blood/blood vessels n MONRO-KELLIE hypothesis- an increase in any one of the components causes a change in the volume of the other n Any increase or alteration in these structures will cause increased ICP

Increased Intracranial pressure


Pathophysiology n Compensatory mechanisms: n 1. Increased CSF absorption n 2. Blood shunting n 3. Decreased CSF production

Increased Intracranial pressure


Pathophysiology Decompensatory mechanisms: n 1. Decreased cerebral perfusion n 2. Decreased PO2 leading to brain hypoxia n 3. Cerebral edema n 4. Brain herniation

Decreased cerebral blood flow


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Vasomotor reflexes are stimulated initially slow bounding pulses Increased concentration of carbon dioxide will cause VASODILATION increased flow increased ICP

Cerebral Edema
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Abnormal accumulation of fluid in the intracellular space, extracellular space or both.

Herniation
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Results from an excessive increase in ICP when the pressure builds up and the brain tissue presses down on the brain stem

Cerebral response to increased ICP


1. 2.
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Steady perfusion up to 40 mmHg Cushings response


Vasomotor center triggers rise in BP to increase ICP Sympathetic response is increased BP but the heart rate is SLOW Respiration becomes SLOW

Increased Intracranial pressure


CLINICAL MANIFESTATIONS Early manifestations: n Changes in the LOC- usually the earliest n Pupillary changes- fixed, slowed response n Headache n vomiting

Increased Intracranial pressure


CLINICAL MANIFESTATIONS late manifestations : n Cushing reflex- systolic hypertension , bradycardia and wide pulse pressure n bradypnea n Hyperthermia n Abnormal posturing

Increased Intracranial pressure


Interventions: Maintain patent airway n 1. Elevate the head of the bed 15-30 degrees- to promote venous drainage n 2. assists in administering 100% oxygen or controlled hyperventilation- to reduce the CO2 blood levelsconstricts blood vesselsreduces edema

Increased Intracranial pressure


interventions n 3. Administer prescribed medicationsusually
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Mannitol- to produce negative fluid balance corticosteroid- to reduce edema anticonvulsants- to prevent seizures

Increased Intracranial pressure


interventions n 4. Reduce environmental stimuli n 5. Avoid activities that can increase ICP like valsalva, coughing, shivering, and vigorous suctioning

Increased Intracranial pressure


interventions n 6. Keep head on a neutral position. AVOID- extreme flexion, valsalva n 7. monitor for secondary complications
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Diabetes insipidus- output of >200 mL/hr Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)

Altered level of consciousness


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It is a function and symptom of multiple pathophysiologic phenomena Causes: head injury, toxicity and metabolic derangement Disruption in the neuronal transmission results to improper function

Altered Level of Consciousness


Assessment n Orientation to time, place and person n Motor function
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Decerebrate Decorticate

Sensory function

Altered level of consciousness


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Patient is not oriented Patient does not follow command Patient needs persistent stimuli to be awake COMA= clinical state of unconsciousness where patient is NOT aware of self and environment

Altered level of consciousness


n 1. 2. 3. 4. 5. 6.

Etiologic Factors Head injury Stroke Drug overdose Alcoholic intoxication Diabetic ketoacidosis Hepatic failure

Altered level of consciousness


ASSESSMENT 1. Behavioral changes initially 2. Pupils are slowly reactive 3. Then , patient becomes unresponsive and pupils become fixed dilated Glasgow Coma Scale is utilized
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Altered level of consciousness


Intervention 1. Maintain patent airway n Elevate the head of the bed to 30 degrees n Suctioning 2. Protect the patient n Pad side rails n Prevent injury from equipments, restraints and etc.

Altered level of consciousness


Intervention 3. Maintain fluid and nutritional balance n Input an output monitoring n IVF therapy n Feeding through NGT 4. Provide mouth care n Cleansing and rinsing of mouth n Petrolatum on the lips

Altered level of consciousness


Intervention 5. Maintain skin integrity n Regular turning every 2 hours n 30 degrees bed elevation n Maintain correct body alignment by using trochanter rolls, foot board 6. Preserve corneal integrity n Use of artificial tears every 2 hours

Altered level of consciousness


Intervention 7. Achieve thermoregulation n Minimum amount of beddings n Rectal or tympanic temperature n Administer acetaminophen as prescribed 8. Prevent urinary retention n Use of intermittent catheterization

Altered level of consciousness


Intervention 9. Promote bowel function n High fiber diet n Stool softeners and suppository 10. Provide sensory stimulation n Touch and communication n Frequent reorientation

SEIZURES
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Episodes of abnormal motor, sensory, autonomic activity resulting from sudden excessive discharge from cerebral neurons A part or all of the brain may be involved

SEIZURES
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PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively

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SEIZURES
n 1. 2. 3. 4. 5.

ETIOLOGIC FACTORS Idiopathic- BFC Fever Head injury CNS infection Metabolic and toxic conditions
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SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure
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SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

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SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen 4/23/12

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EPILEPSY
A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins
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EPILEPSY
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Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms
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GENERALIZED SEIZURES
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1. General Tonic-Clonic seizure- ( Grand mal ) characterized by loss of consciousness and alternating movements of the extremities 2. Absence Seizure ( Petit mal )- common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares
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GENERALIZED SEIZURES
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3. Myoclonic seizure- characterized by brief, involuntary muscular jerks of body extremities 4. Akinetic seizure- general loss of postural tone and a temporary loss of consciousness- a drop attack

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PARTIAL SEIZURES
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1. Simple partial seizure- typically limited to one cerebral hemisphere 2. Complex partial seizure- begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements

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Epilepsy
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DIAGNOSTIC TESTS 1. EEG 2. CT 3. MRI 4. LP 5. Angiography


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Epilepsy
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Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery

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Epilepsy
Intervention n 1. Care of patients during seizure n 2. care of patients after seizures n 3. patient teaching

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SEIZURES
n n

PATHOPHYSIOLOGY An electrical disturbance in the nerve cells in one brain section EMITS ELECTRICAL IMPULSES excessively

SEIZURES
n 1. 2. 3. 4. 5.

ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions

SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen

Tonic Clonic Seizures

Stages in a Grand Mal Seizure


1.

1.

Prodromal period - from hours to days - drowsiness, dizziness, lack of coordination Aura warning before the seizure Reflects the portion of the brain which might be affected Smelling unpleasent odors ( temporal lobe)

- Flashing of lights ( occipital lobe) - Numbness of extremities ( parietal lobe ) - Cheshire cat grin ( Frontal lobe) 3. Tonic Stage all muscles of the body contract and the person falls to the ground - Body stiffens, face distorts - Lasts for 20 seconds - Contraction of throat muscles and muscles for respiration - Biting of the tongue

4. Clonic stage contraction and relaxation of muscles


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Blowing bubbles or saliva Incontinent of stool ad urine Lasts about 20 seconds 5. post ictal period coma

May be unresponsive for 1-4 hours then will be arousable to pain Awakens with severe headache and no memory of the seizure
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Absence Seizures

Myoclonic Seizure

Atonic/Akinetic Seizures

Simple Partial Seizures

Complex Partial Seizures

Status Epilepticus

EEG of Patient in Status Epilepticus

Recovery Position

HEADACHE
n n n n

Cephalgia Primary headache- no organic cause Secondary headache- with organic cause Migraine headache- periodic attacks of headache due to vascular disturbance Tension headache- the most common typedue to muscle tension

HEADACHE
n 1. 2. 3. 4.

Migraine Prodrome stage Aura phase Headache Recovery phase

HEADACHE
Interventions n 1. Avoid precipitating factors n 2. modify lifestyle n 3. relieve pain by pharmacologic measures
n n

Beta-blockers Serotonin antagonists- triptan"

Autonomic Dysreflexia/hyperreflexia
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Seen commonly in spinal cord injury above T6 An exaggerated response by the autonomic system resulting from various stimuli most commonly distended bladder, impacted feces, pain, skin irritation

Autonomic Dysreflexia/hyperreflexia
n n n n n n

Clinical MANIFESTATIONS 1. Hypertension 2. Bradycardia 3. severe pounding headache 4. diaphoresis 5. nausea and nasal congestion

Autonomic Dysreflexia/hyperreflexia
INTERVENTIONS n 1. Elevate the head of the bed immediately n 2. Check for bladder distention and empty bladder with urinary catheter n 3. Check for Fecal impaction and other triggering factors like skin irritation, pressure ulcer n 4. Administer antihypertensive medicationsusually hydralazine

Spinal Shock
Pathophysiology n The sudden depression of reflex activity in the spinal cord below the level of injury n The muscles below the lesion are flaccid, the skin without sensation and the reflexes are absent including bowel and bladder functions

Spinal Shock
Interventions n 1. Assist in chest physical therapy n 2. Manage potential complication- DVT

Cognitive Impairment
Interventions 1. Assist or encourage the patient to use eyeglass, hearing aid or assistive devices 2. Reorient the patient by calling his name frequently 3. Provide background information as to date, time, place, environment

Cognitive Impairment
Interventions 4. Use large signs as visual cues 5. Post patient's photo on the door 6. Encourage family members to bring personal articles and place them in the same area

Bowel and Bladder incontinence


n

Establish a regular pattern for bowel care


n n

Place the patient on potty every other day Use of stool softeners

Maintain a dietary intake. Avoid foods that can cause excessive gas production

Impaired Swallowing
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n n

Elevate the head of the be 90 degrees during meals and 30 minutes after Serve foods that are soft and small sized Keep suction equipment on bedside Consult with rehabilitation team as to assistive devices that can be utilized

NEUROLOGICAL DISORDERS

CONGENITAL DISORDERS: Hydrocephalus


n

n n

Excessive CSF accumulation in the brains ventricular system In infants, head enlarges In children and adults- brain compression

CONGENITAL DISORDERS: Hydrocephalus


n

Non-communicating hydrocephalus results from CSF outflow obstruction Communicating hydrocephalus results from faulty absorption or increased CSF production

CONGENITAL DISORDERS: Hydrocephalus


n n n n

Assessment 1. irritability 2. change in LOC 3. infants- enlargement of the head, thin scalp skin 4. sunset eyes

CONGENITAL DISORDERS: Hydrocephalus


n n n

DIAGNOSTIC TESTS 1. Skull x-ray 2. ventriculography

CONGENITAL DISORDERS: Hydrocephalus


Intervention n 1. monitor neurologic status n 2. teach parents to watch for signs of shunt malfunction, and periodic surgery to lengthen the shunt as child grows

Neural Tube Defects


Anencephaly n The absence of cerebral hemisphere Microcephaly n Characterized by slow brain growth which falls more than three standard deviations below normal on growth charts n Results in mental retardation because of the lack of functioning brain tissue.

CONGENITAL DISORDERSpinal cord defects


n

1. Spina bifida occulta- incomplete closure of one or more vertebrae without protrusion of the spinal cord or meninges 2. Spina bifida with meningocele- a sac contains meninges and CSF 3. Spina bifida with meningomyelocele- a sac contains spinal cord substance, meninges and CSF

Spina Bifida Occulta


n n

Incomplete fusion of spinal cord Usually occurs in the lubosacral area (L5 and S1) There is positive tuft of hair or dimple over the affected area May result to progressive disturbance of gait with weak foot or bowel and bladder disturbances

Meningocele
n

Hernial protrusion of a saclike cyst of meninges filled with spinal fluid Positive cystic swelling beneath the skin which contains CSF

Meningomyelocele
n

Hernial protrusion of a saclike cyst containing meninges, spinal fluid and a portion of the spinal cord May result to either positive or negative neurologic deficits Usually seen with hydrocephalus and Arnold Chiari malformation

Encephalocele
n

Cranial meningocele or myelomeningocele Occurs most often in the occipital area of the skull

CONGENITAL DISORDER: Spinal cord defects


n n n n

Causes 1. environmental factors 2. radiation 3. folic acid deficiency in a pregnant woman 4. possibly genetic

CONGENITAL DISORDER: Spinal cord defects


n n

n n n n

ASSESSMENT 1. a dimple or tuft of hair in the vertebral area 2. external sac DIAGNOSIS 1. Spinal x-ray 2. myelography

CONGENITAL DISORDER: Spinal cord defects


INTERVENTION n 1. cover the defect with sterile dressing moistened with sterile saline n 2. position the patient on prone or side to protect the fragile sac n 3. place a diaper under the infant and change it often

CONGENITAL DISORDER: Spinal cord defects


INTERVENTION n 4. avoid the use of lotion n 5. avoid frequent handling n 6. Measure the childs head circumference daily n 7. check anal reflex n 8. support family members n 9. prepare the parents for the possible outcome of the defect

CONGENITAL DISORDER: Spinal cord defects


INTERVENTION n 10. Post-operative care n Position on abdomen n Check post-operative dressings n Place infants hips in abduction and feet in neutral position n Monitor intake and output n Check for urine retention n Assess infant frequently as he recovers from the surgery

Traumatic brain injury


1. CONCUSSION n Involves jarring of head without tissue injury n Temporary loss of neurologic function lasting fore a few minutes to hours

Traumatic brain injury


2. CONTUSION n Involves structural damage n The patient becomes unconscious for hours

Traumatic brain injury


3. Diffuse Axonal injury n Involves widespread damage to the neurons n Patient has decerebrate and decorticate posture

Traumatic brain injury


4. Intracranial hemorrhage Epidural Hematoma- blood collects in the epidural space between skull and dura mater. Usually due to laceration of the middle meningeal artery Symptoms develop rapidly

Traumatic brain injury


4. Intracranial hemorrhage Subdural hematoma- a collection of blood between the dura and the arachnoid mater caused by trauma. This is usually due to tear of dural sinuses or dural venous vessels Symptoms usually develop slowly

Traumatic brain injury


4. Intracranial hemorrhage Intracerebral Hemorrhage and hematomableeding into the substance of the brain resulting from trauma, hypertensive rupture of aneurysm, coagulopahties, vascular abnormalities Symptoms develop insidiously, beginning with severe headache and neurologic deficits

Traumatic brain injury


MANIFESTATIONS n 1. Altered LOC n 2. CSF otorrhea n 3. CSF rhinorrhea n 4. Racoon eyes and battle sign
n

HALO SIGN- blood stain surrounded by a yellowish stain

Traumatic brain injury


MANAGEMENT 1. Monitor for declining LOC- use of Glasgow 2. Maintain patent airway n Elevate bed, suction prn, monitor ABG

Traumatic brain injury


MANAGEMENT 3. Monitor Fluid and Electrolyte balance n Daily weights n IVF therapy n Monitor possible development of DI and SIADH

Traumatic brain injury


4. Provide adequate nutrition 5. Prevent injury n Use padded side rails n Minimize environmental stimuli n Assess bladder n Consider the use of intermittent catheter

Traumatic brain injury


6. Maintain skin integrity n Prolonged immobility will likely cause skin breakdown n Turn patient every 2 hours n Provide skin care every 4 hours n Avoid friction and shear forces

Traumatic brain injury


7. Monitor potential complications n Increased ICP n Post-traumatic seizures n Impaired ventilation

Spinal cord injury


n

n n n n

The most frequent vertebrae C5-C7, T12 and L1 Concussion Contusion Compression Transection

Spinal cord injury


Clinical manifestations n 1. Paraplegia n 2. quadriplegia n 3. spinal shock

Spinal cord injury


n n n n

DIAGNOSTIC TEST Spinal x-ray CT scan MRI

Spinal cord injury


EMERGENCY MANAGEMENT n A-B-C n Immobilization n Immediate transfer to tertiary facility

Spinal cord injury


INTERVENTION n 1. Promote adequate breathing and airway clearance n 2. Improve mobility and proper body alignment n 3. Promote adaptation to sensory and perceptual alterations n 4. Maintain skin integrity

Spinal cord injury


n n n n

5. Maintain urinary elimination 6. Improve bowel function 7. Provide Comfort measures 8. Monitor and manage complications
n n n n

Thromboplebhitis Orthostaic hypotension Spinal shock Autonomic dysreflexia

Spinal cord injury


n

9. Assists with surgical reduction and stabilization of cervical vertebral column

Spinal Cord Injury


n

Causes
n n n

Falls Diving VA Paralysis Loss of reflexes, sensory and motor function Autonomic dysfunction

Effects
n n

Cervical SCI
n n n n

Above C4 fatal Quadriplegia Respiratory muscle paralysis Bowel/bladder retention Paraplegia Poor control of upper trunk Bowel/bladder retention

Thoracic SCI
n n n

Lumbar SCI
n n

Paraplegia flaccid Bowel/bladder retention Above S2 with erection, no ejaculation S2-S4 no erection with ejaculation Paraplegia Bowel / bladder INCONTINENCE

Sacral SCI
n n n n

COLLABORATIVE MANAGEMENT
n

n n

n n n

Respiratory function is the first priority especially in cervical SCI Immobilize in a flat, firm surface Cervical collar if cervical injury is suspected Transport patient as a unit Do not attempt to realign body parts Traction , cast, surgery

Complications of SCI
n

Spinal Shock/Neural Shock/Areflexia


n

Period of flaccid paralysis and a complete loss of all reflexes occurs Assessment
n

n n n

Absence of sweating below the level of the lesion Bowel and bladder retention Hypotention Bradycardia

If the lumbosacral segments are undamaged, spinal shock wears off in 2-3 weeks
n

n n

First sign of wearing off is contraction of the quadriceps (hamstrings) and flexion and extention of toes on plantar flexion Bladder empties reflexively as in the infants Reflex defecation and sweating returns

Autonomic Dysreflexia
n

Occurs with lesions above T6; most often in cervical injuries Causes
n

Visceral distention (distended bladder,impacted rectum)

Assessment
n n n n n n

Bradycardia Hypertension CVA, blindness Sweating above the lesion goose flesh Severe headache Nasal stuffiness

Collaborative Management
n n

Sitting position to decrease BP Check bladder distention, fecal impaction Ganglionic blocking agent (hexamethonium chloride) Vasodilators (Nitroprusside)

CEREBROVASCULAR ACCIDENTS (CVA)


n

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

Cerebro-vascular Accident
n n n

Disruption of blood supply to the brain The MCA most commonly affected Internal carotid artery second most frequently affected

Causes
n

Thrombosis
n n

Most frequent cause of CVA Most common cause of cerebral thrombosis is atherosclerosis ; usually affecting elderly persons Occurs during sleep or soon after rising

Embolism
n n n

Second most common cause of CVA Affecting younger people Cause by RHD and MI

Hemorrhage
n

Due to HPN, subarachnoid, hemorrhage or rupture of aneurysm, AV malformation

Transient Ischemic Attack (TIA)


n n

Temporary episodes of neurologic dysfunction Manifestations include contralateral weakness of the lower portion of the face, fingers, hands, arms and legs, sensory impairment Signs resolve within 24 hours

Reversible Ischemic Neurologic Disease (RIND)


n

Manifestations resolve within 7 days

Blood Supply to the Brain

CEREBROVASCULAR ACCIDENTS
Can be divided into two major categories n 1. Ischemic stroke- caused by thrombus and embolus n 2. Hemorrhagic stroke- caused commonly by hypertensive bleeding

CEREBROVASCULAR ACCIDENTS
The stroke continuum n 1. TIA- transient ischemic attack, temporary neurologic loss less than 24 hours duration n 2. Reversible Neurologic deficits n 3. Stroke in evolution n 4. Completed stroke

General manifestations

Localization
Middle Cerebral Artery: n Aphasia n Dysphagia n HEMIPARESIS on the OPPOSITE sidemore severe on the face and arm than on the legs

Localization
Anterior Cerebral Artery: n Weakness n Numbness on the opposite side n Personality changes n Impaired motor and sensory function

Localization
Posterior Cerebral Artery: n Visual field defects n Sensory impairment n Coma n Less likely paralysis

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


n

There is disruption of the cerebral blood flow due to obstruction by embolus or thrombus

RISKS FACTORS
Non-modifiable n Advanced age n Gender n race Modifiable n Hypertension n Cardio disease n Obesity n Smoking n Diabetes mellitus n hypercholesterolemia

Pathophysiology of ischemic stroke


n n n

Disruption of blood supply Anaerobic metabolism ensues Decreased ATP production leads to impaired membrane function Cellular injury and death can occur

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


n n n n

DIAGNOSTIC test 1. CT scan 2. MRI 3. Angiography

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


CLINICAL MANIFESTATIONS n 1. Numbness or weakness n 2. confusion or change of LOC n 3. motor and speech difficulties n 4. Visual disturbance n 5. Severe headache

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


Motor Loss n Hemiplegia n Hemiparesis

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


Communication loss n Dysarthria= difficulty in speaking n Aphasia= Loss of speech n Apraxia= inability to perform a previously learned action

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


Perceptual disturbances n Hemianopsia Sensory loss n paresthesia

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS: ACUTE 1. Ensure patent airway 2. Keep patient on LATERAL position 3. Monitor VS and GCS, pupil size 4. IVF is ordered but given with caution as not to increase ICP 5. NGT inserted 6. Medications: Steroids, Mannitol (to decrease edema), Diazepam

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS: Hospital 1. Improve Mobility and prevent joint deformities n Correctly position patient to prevent contractures
n n n

Place pillow under axilla Hand is placed in slight supination- C Change position every 2 hours

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 2. Enhance self-care n Carry out activities on the unaffected side n Prevent unilateral neglect- place some items on the affected side!!! n Keep environment organized n Use large mirror

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 3. Manage sensory-perceptual difficulties n Approach patient on the Unaffected side n Encourage to turn the head to the affected side to compensate for visual loss

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 4. Manage dysphagia n Place food on the UNAFFECTED side n Provide smaller bolus of food n Manage tube feedings if prescribed

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 5. Help patient attain bowel and bladder control n Intermittent catheterization is done in the acute stage n Offer bedpan on a regular schedule n High fiber diet and prescribed fluid intake

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 6. Improve thought processes n Support patient and capitalize on the remaining strengths

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 7. Improve communication n Anticipate the needs of the patient n Offer support n Provide time to complete the sentence n Provide a written copy of scheduled activities n Use of communication board n Give one instruction at a time

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 8. Maintain skin integrity n Use of specialty bed n Regular turning and positioning n Keep skin dry and massage NONreddened areas n Provide adequate nutrition

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 9. Promote continuing care n Referral to other health care providers

CEREBROVASCULAR ACCIDENTS: Ischemic Stroke


INTERVENTIONS 10. Improve family coping 11. Help patient cope with sexual dysfunction

CEREBROVASCULAR ACCIDENTS: Stroke


MEDICAL MANAGEMENT 1. Pharmacologic:
n n n n n n

Aspirin Diazepam to prevent seizures Thrombolytics Stool softeners Antihypertensives Analgesics, Muscle relaxants, STEROIDS

CVA: Hemorrhagic Stroke


n

Normal brain metabolism is impaired by interruption of blood supply, compression and increased ICP Usually due to rupture of intracranial aneurysm, AV malformation, Subarachnoid hemorrhage

CVA: Hemorrhagic Stroke


n n

n n n

Sudden and severe headache Same neurologic deficits as ischemic stroke Loss of consciousness Meningeal irritation Visual disturbances

CVA: Hemorrhagic Stroke


n n n n

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. Lumbar puncture (only if with no increased ICP)

CVA: Hemorrhagic Stroke


INTERVENTIONS n 1. Optimize cerebral tissue perfusion n 2. relieve Sensory deprivation and anxiety n 3. Monitor and manage potential complications

Collaborative Management
n

Emergency Care
n

Care of the patient with increased ICP TPN, NGT feeding, gastrostomy feeding Turn every hour, ROM exercises, prevent contractures I and O; Start urinary and bowel program

Promote nutrition
n

Promote activity
n

Promote elimination
n

Promote communication
n

Care of the client with Aphasia


n n n n n

Say one word at a time Identify one object at a time Give simple commands Anticipate needs Allow to verbalize no matter how long it takes him Speech therapy

n n

Compensate for Perceptual Difficulties Provide emotional support


n

Care of the client with Hemianopsia


n n n

Approach from the unaffecte side Place articles on the unaffected side Teach scanning techniques. Turn head from side to side to see entire visual field

Rehabilitation Care
n

Rehabilitation
n

Learning to live to ones maximum potential with a chronic impairment and its resultant disability Promotes reintegration into the clients family and community Influenced by the client and clients motivation

Goals of Rehab
n n n

Prevent complications Correction of deformities Restoration of function to achieve maximum independence Limitation of disability

DEMYELINATING DISEASES
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Topic Outline
n n n n n n n

Multiple Sclerosis Guillian-Barre syndrome Alzheimers Disease Parkinsons Disease Epilepsy Bells palsy Trigeminal Neuralgia

n n n n n

Myasthenia Gravis Meningitis Brain Abscess Encephalitis Neoplasia

MULTIPLE SCLEROSIS
n

An auto-immune mediated progressive demyelinating disease of the Central Nervous System (CNS) The myelin sheath is destroyed and replaced by sclerotic tissue (sclerosis)

MULTIPLE SCLEROSIS
n n

CAUSE- unknown Multiple factors- viral infection, environmental factors, geographic location and genetic predisposition Common in WOMEN ages 20-40

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY n Sensitized T cells will enter the brain and promote antibody production that damages the myelin sheath n Plaques of sclerotic tissues appear on the demyelinated axons interrupting the neuronal transmission

MULTIPLE SCLEROSIS
PATHOPHYSIOLOGY n The most common areas affected are
n n n n

Optic nerves and chiasm Cerebrum Cerebellum Spinal cord

MULTIPLE SCLEROSIS
CLINICAL MANIFESTATIONS n 1. visual problems such as diplopia, blurred vision and nystagmus n 2. motor dysfunction- mono/qudradiplegia n 3. Fatigue, sensory impairment n 4. Mental changes like mood swings, depression n 5. spasticity, ataxia

MULTIPLE SCLEROSIS
DIAGNOSTIC TESTS n 1. MRI- primary diagnostic study n 2. CSF Immunoglobulin G

MULTIPLE SCLEROSIS
NTERVENTIONS 1. Promote physical mobility n Exercise n Schedule activity and rest periods n Warm packs over the spastic area n Swimming and cycling are very useful

MULTIPLE SCLEROSIS
INTERVENTIONS 2. Prevent injuries n Wide stance walking n Use of walking aids n Wheelchair

MULTIPLE SCLEROSIS
3. Enhance bladder and bowel control n Set a voiding schedule n Intermittent bladder catheterization n Use of condom catheter n Adequate fluids, dietary fibers and bowel training program

MULTIPLE SCLEROSIS
4. Manage speech and swallowing difficulties n Careful feeding, proper positioning, suction machine availability n Speech therapist

MULTIPLE SCLEROSIS
5. Improve Sensory and Cognitive function n Vision- use eye patch for diplopia n Obtain large printed reading materials n Offer emotional support n Involve the family in the care

MULTIPLE SCLEROSIS
6. Strengthen coping mechanism n Alleviate the stress n Referral to the appropriate agencies

MULTIPLE SCLEROSIS
7. improve self-care abilities n Modify activities according to physical strength n Provide assistive devices

MULTIPLE SCLEROSIS
8. promote sexual functioning n Refer to sexual counselor

MULTIPLE SCLEROSIS
MEDICAL MANAGEMENT Pharmacotherapy
n n n n n n

Interferons Immunomodulators Corticosteroids BACLOFEN for muscle spasms NSAIDS for pain Antidepressants

Guillian-Barre Syndrome
n

An auto-immune attack of the Peripheral Nervous System (PNS) Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves POTENTIALLY FATAL!

Guillian-Barre Syndrome
n

CAUSE: post-infectious polyneuritis of unknown origin commonly follows viral infection

Guillian-Barre Syndrome
n

PATHOPHYSIOLOGY
n

Cell-mediated immune attack to the myelin sheath of the peripheral nerves (PNS) Infectious agent may elicit antibody production that can also destroy the myelin sheath of the PERIPHERAL NERVES!!

GBS
n

Because this syndrome causes inflammation and degenerative changes in the posterior and anterior nerve roots, MOTOR and SENSORY losses occur SIMULTANEOUSLY!

Guillian-Barre Syndrome
CLINICAL MANIFESTATIONS n 1. Ascending Weakness and Paralysis: Leg affected first n 2. diminished reflexes of the lower extremities n 3. paresthesia n 4. potential respiratory failure

Guillian-Barre Syndrome
LABORATORY EXAMINATION 1. CSF Protein level is INCREASED but the WBC remains normal in the CSF 2. EMG and nerve conduction velocity studies

Guillian-Barre Syndrome
INTERVENTIONS 1. Maintain respiratory function n. Chest physiotherapy and incentive spirometry n. Mechanical ventilator

Guillian-Barre Syndrome
INTERVENTIONS n 2. Enhance physical mobility
n n n n

Support paralyzed extremities Provide passive range of motion exercise Prevent DVT and pulmonary embolism Padding over bony prominences

Guillian-Barre Syndrome
INTERVENTIONS n 3. Provide adequate nutrition
n n n

IVF Parenteral nutrition Assess frequently return of gag reflex

Guillian-Barre Syndrome
INTERVENTIONS n 4. Improve communication
n

Use other means of communication

Guillian-Barre Syndrome
INTERVENTIONS n 5. Decrease fear and anxiety
n n n

Provide Referrals Answer questions Provide diversional activities DVT, Urinary retention, pulmonary embolism, respiratory failure

6. Monitor and manage complications


n

Guillian-Barre Syndrome
MEDICAL MANAGEMENT n ICU admission n Mechanical Ventilation n TPN and IVF n PLASMAPHERESIS n IV IMMUNOGLOBULIN

ALZHEIMERS disease
n

A Progressive Neurologic Disorder that affects the brain resulting in Cognitive Impairments

ALZHEIMERS disease
CAUSES: n Unknown n Potential factors- Amyloid plaques in the brain, Oxidative stress, neurochemical deficiencies

ALZHEIMERS disease
CLINCAL MANIFESTATIONS n 1. Forgetfulness n 2. Recent memory loss n 3. Difficulty learning n 4. Deterioration in personal hygiene n 5. Inability to concentrate

ALZHEIMERS disease
LATE CLINICAL MANIFESTATIONS n 1. Difficulty in abstract thinking n 2. Difficulty communicating n 3. Severe deterioration in memory, language and motor function n 4. repetitive action- perseveration n 5. personality changes

ALZHEIMERS disease
DIAGNOSTIC TEST n Neurologic examination n PET scan n EEG, CT and MRI n Other tests to rule out Vit B deficiencies and hypothyroidism n Autopsy is the most definitive

ALZHEIMERS disease
Drug therapy n 1. drugs to treat behavioral symptoms- antipsychotics n 2. anxiolytics n 3. Donepezil n 4. Tacrine

ALZHEIMERS disease
Interventions n 1. Support patients abilities n 2. Provide emotional support

ALZHEIMERS disease
Interventions 3. Establish an effective communication system with the patient and family n Use short simple sentences, words and gestures n Maintain a calm and consistent approach n Attempt to analyze behavior for meaning

ALZHEIMERS disease
4. protect the patient from injury n Provide a safe and structured environment n Requests a family member to accompany client if he wanders around n Keep bed in low position n Provide adequate lightning n Assign consistent caregivers

ALZHEIMERS disease
5. Encourage exercise to maintain mobility

PARKINSONs Disease
n

A slowly progressing Neurologic Movement Disorder The degenerative idiopathic form is the most common form

PARKINSONs Disease
CAUSATIVE FACTORS: unknown n Potential factors: genetics, atherosclerosis, free radical stress, viral infection, head trauma and environmental factors

PARKINSONs Disease
Pathophysiology n Decreased levels of Dopamine due to destruction of pigmented neuronal cells in the Substantia Nigra in the basal ganglia n Clinical symptoms do not appear until 60% of the neurons have disappeared

PARKINSONs Disease
CLINICAL MANIFESTATIONS 1.Tremor: resting(Tremor at rest),pill-rolling" 2. Rigidity: Cog-wheel rigidity, Lead-pipe rigidity 3. Bradykinesia- abnormally slow movement 4. Dementia, depression, sleep disturbances and hallucinations 5. excessive sweating, paroxysmal flushing, orthostatic hypotension

PARKINSONs Disease
Medical management n 1. Anti-parkinsonian drugs- Levodopa, Carbidopa n 2. Anti-cholinergic therapy n 3. Antiviral therapy- Amantadine n 4. Dopamine Agonists- bromocriptine and Pergolide, Ropirinole anmd Pramipexole

PARKINSONs Disease
n n n n

Medical management 5. MAOI 6. Anti-depressants 7. Antihistamine

PARKINSONs Disease
INTERVENTIONS n 1. Improve mobility n 2. Enhance Self- care activities n 3. Improve bowel elimination n 4. Improve nutrition n 5. Enhance swallowing n 6. Encourage the use of assistive devices

PARKINSONs Disease
INTERVENTIONS n 7. improve communication n 8. Support coping abilities

Myasthenia gravis
n

A Sporadic, but Progressive Weakness and abnormal fatigability of striated muscles which are exacerbated by exercise and repetitive movements

Myasthenia gravis
ETIOLOGY n Autoimmune disease n Thymoma Women suffer at an earlier age and are more affected

Myasthenia gravis
Pathophysiology: n 1. Acetylcholine receptor antibodies interfere with impulse transmission n 2. Follows an unpredictable course of periodic exacerbations and remissions

Myasthenia gravis
CAUSE: autoimmune disorder that impairs transmission of nerve impulses ASSESSMENT FINDINGS 1. Gradually progressive skeletal muscle weakness and fatigue 2. Weakness that worsens during the day 3. Ptosis, diplopia and weak eye closure 4. Blank, mask-like facies 5. Difficulty chewing and swallowing 6. Respiratory difficulty
n

Myasthenia gravis
DIAGNOSTIC TESTS n 1. EMG n 2. TENSILON TEST (Edrophonium) n 3. CT scan n 4. Serum anti-AchReceptor antibodies

Myasthenia gravis
MEDICAL THERAPY n Anticholinesterase drugspyridostigmine and neostigmine n Corticosteroids n Immunosuppresants n Plasmapheresis n Thymectomy

Myasthenia gravis
INTERVENTIONS n 1. Administer prescribed medication as scheduled n 2. Prevent problems with chewing and swallowing n 3. Promote respiratory function n 4. Encourage adjustments in lifestyle to prevent fatigue n 5.maximize functional abilities

Myasthenia gravis
n

n n

6. Prepare for complications like myasthenic crisis and cholinergic crisis 7. prevent problems associated with impaired vision resulting from ptosis of eyelids 8. provide client teaching 9. promote client and family coping

EPILEPSY
A group of syndromes characterized by recurring seizures CAUSES 1. idiopathic 6. brain tumors 2. Birth trauma 7. head Injury 3. perinatal infection 8. metabolic disorders 4. infectious disease 9. CVA 5. ingestion of toxins
n

EPILEPSY
n

Recurring seizures may be classified as GENERALIZED or PARTIAL SEIZURES Generalized Seizures- cause a generalized electrical abnormality within the brain Partial seizures- these seizures arise from a localized part of the brain and cause specific symptoms

SEIZURES
n 1. 2. 3. 4. 5.

ETIOLOGIC FACTORS Idiopathic Fever Head injury CNS infection Metabolic and toxic conditions

GENERALIZED SEIZURES
n

1. General Tonic-Clonic seizure- ( Grand mal )


n

characterized by loss of consciousness and alternating movements of the extremities common in children, begins with a brief change in the LOC, indicated by blinking, rolling of eyes and blank stares

2. Absence Seizure ( Petit mal )n

GENERALIZED SEIZURES
n

3. Myoclonic seizuren

characterized by brief, involuntary muscular jerks of body extremities

4. Akinetic seizuren

general loss of postural tone and a temporary loss of consciousness- a drop attack

PARTIAL SEIZURES
n

1. Simple partial seizuren

typically limited to one cerebral hemisphere

2. Complex partial seizuren

begins with an aura, then with impaired consciousness, with purposeless behaviors like lip-smacking, chewing movements

Epilepsy
n n n n n n

DIAGNOSTIC TESTS 1. EEG 2. CT 3. MRI 4. LP 5. Angiography

SEIZURES
Interventions During seizure n 1. remove harmful objects from the patients surrounding n 2. ease the client to the floor n 3. protect the head with pillows n 4. Observe and note for the duration, parts of body affected, behaviors before and after the seizure

SEIZURES
Interventions During seizure n 5. loosen constrictive clothing n 6. DO NOT restrain, or attempt to place tongue blade or insert oral airway

SEIZURES
Interventions POST seizure n 1. place patient to the side to drain secretions and prevent aspiration n 2. help re-orient the patient if confused n 3. provide care if patient became incontinent during the seizure attack n 4. stress importance of medication regimen

Epilepsy
n n

Medical treatment 1. Anticonvulsants- most commonly phenytoin, phenobarbital and carbamazepine Ethosuximide and valproic acid for absence seizure 2. surgery

Epilepsy
Intervention n 1. Care of patients during seizure n 2. care of patients after seizures n 3. patient teaching

BELLS PALSY
Dysfunction of the facial nerve (CN 7)
n

BELLS PALSY
Causes n 1. infection n 2. hemorrhage n 3. tumor n 4. local traumatic injury n 5. Idiopathic

BELLS PALSY
MANIFESTATIONS 1 . Unilateral Facial Weakness 2. Mouth drooping 3. Distorted taste perception 4. Smooth forehead 5. Inability to close eyelid on the affected side 6. Incomplete eye closure 7. excessive tearing when attempting to close the eyes 8. Inability to raise eyebrows, puff out the

BELLS palsy
Diagnostic tests n EMG

BELLS palsy
Medical management n 1. Prednisone n 2. Artificial tears

BELLS palsy
Interventions n 1. Apply moist heat to reduce pain n 2. Massage the face to maintain muscle tone n 3. Give frequent mouth care n 4. Protect the eye with an eye patch. Eyelid can be taped at night n 5. instruct to chew on unaffected side

Trigeminal neuralgia
n n

Also called "Tic Douloureux Painful disorder that affects one or more branches of the fifth cranial nerve (Trigeminal nerve) CAUSES: repetitive pulsation of an artery as it exits the pons is the usual cause

Trigemial neuralgia
n

Nearly all cases of typical TN are caused by blood vessels compressing the trigeminal nerve root as it enters the brain stem. This neurovascular or microvascular compression at the trigeminal nerve root entry zone may be caused by arteries of veins, large or small, that may simply contact or indent the trigeminal nerve.

Trigeminal neuralgia
ASSESSMENT n 1. Pain history n 2. Searing or burning jabs of pain lasting from 1-15 minutes in an area innervated by the trigeminal nerve n DIAGNOSTIC TESTS Skull x-ray or CT scan

Trigeminal neuralgia
INTERVENTIONS n 1. provide emotional support n 2. encourage to express feelings n 3. provide adequate nutrition in small frequent meals at room temperature

Brain Abscess
n

A free or encapsulated collection of pus in the brain parenchyma Causes: usually secondary to another infection like- sinusitis, meningitis, dental abscess, mastoiditis, bacteremia and trauma

Encephalitis
n

Intense inflammation of the brain tisssue with lymphocytic infiltration, cerebral edema, degeneration of brain cells and diffuse nerve cell destruction

CNS infections
n n n n n n n

ASSESSMENT FINDINGS Meningitis 1. fever, headache, vomiting 2. positive meningeal sings Brain abscess 1. headache, N/V, seizures, changes in LOC 2. Focal neurologic deficits

CNS infections
n n n n n n n n

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. EEG MEDICAL TREAMENT 1. Antibiotics 2. Surgical drainage 3. Drugs to reduce increased ICP

CNS infections
INTERVENTIONS n 1. Frequent monitoring of neurologic status n 2. Monitor intake and output n 3. Administer antibiotics n 4. Administer mild laxative to prevent constipation n 5. maintain quiet environment

Neoplastic diseases
n

A brain tumor is a localized intracranial lesion that occupies space within the skull Primary brain tumors originate from cells and structures within the brain.

Neoplastic disease
n n

The cause of brain tumors is unknown The only risk factor accepted is radiation exposure to ionization rays

Neoplastic disease
n n

CLINICAL MANIFESTATIONS 1. increased ICP


n n n n

Vomiting Headache. Especially early in the morning Vomiting Visual disturbances

Neoplastic disease
n n n n

2. Localized symptoms Hemiparesis Seizures Mental status changes

Neoplastic disease
n n n n n

DIAGNOSTIC TESTS 1. CT scan 2. MRI 3. PET 4. EEG

Neoplastic disease
n n n n

MEDICAL MANAGEMENT Surgery Chemotherapy Radiotherapy

Neoplastic disease
INTERVENTIONS n 1. promote self-care independence n 2. improve nutrition n 3. relieve anxiety n 4. enhance family processes n 5. provide pre-operative and post-operative care n 6. manage pain

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