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Neuro Nursing Document Transcript

  • 1. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  Decreased HR and BP  Decresead RR  Diarrhea  Urinary Frequency  Seizures II. SNS a. Adrenergic Agents 1. Epinephrine (Adrenaline) 2. Note: Side Effects (SE) – normal drug expectancies b. Beta-Adrenergic Agents (Beta-Blockers) MEDICAL-SURGICAL NURSING 1. Propanolol, metoprolol, atenolol 2. Bronchospasm, Elicits decreased cardiac contractions, Treats HPN, AV conduction slows down (BETA) Neurologic Nursing 3. Anti-HPN Management  Beta-blockers – ―-olol‖ Lecturer: Mark Fredderick Abejo RN, MAN  ACE inhibitors – ―-pril‖________________________________________________________  Ca-Antagonist – nifedipine  Transient headache and dizzinessOVERVIEW OF THE STRUCTURE AND FUNCTION OF THE  Orthostatic hypotension NERVOUS SYSTEM  Assist in ambulation  Pt. to rise slowly from sitting positionI. Divisions 4. BP = CO x PR a. CNS – brain and spinal cord 5. CO = HR x SV b. PNS – 12 pairs of cranial nerves and 31 pairs of spinal 6. (N) HR = 60-100 bpm nerves 7. (N) SV = 60-70 ml of H2O 1. Spinal nerves: TOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN  Cervical – 8 BARIER: (BLACK)  Thoracic – 12  Bilirubin – yellow pigment  Lumbar – 5  Lead – Antidote: Ca+ EDTA  Sacral – 5  Ammonia – cerebral toxin; present in hepatic encephalopathy  Coccygeal - 1 (liver cirrhosis) c. ANS – sympathetic and parasympathetic systems  Carbon Monoxide – in Parkinson’s and Epilepsy  Ketones – cerebral depressant III. CNS a. Cells 1. Neurons  Excitability  Conductivity  Permanence 2. Neuroglia – majority of tumors arise from here; about 40% from astrocytes  Astrocytes – maintains integrity of BBB  Oligodendrocytes – production of myelin  Myelin sheath – insulates axons; for rapid impulse transmission  Microglia – STATIONARY cells which carry on phagocytosis (cell eating)Sympathetic – flight or aggression response  release of  Ependymal cells – produces chemoattractantsnorepinephrine  increase in all bodily activity except GI which concentrates bacteria(constipation); adrenergic; parasympatholytic response. b. Composition 1. 80% brain massREMEMBER: GIT is the least important area during stress   CEREBRUM – divided into two hemispheres, thedecreased blood flow in the area; Increased blood flow in the brain, left and right and is bridged by the corpusheart and skeletal muscles callosum  Mydriasis (―dilat‖-ation)  Motor, sensory, integrative function  Dry mouth  Lobes:  Increase in HR and BP  Frontal – controls higher cortical thinking,  Tachypnea personality development, motor activity,  Constipation contains BROCA’s are or the motor-speech  Urinary retention center. (Expressive Aphasia)Parasympathetic – flight or withdrawal response  release of  Occipital – visionAcetylcholine  decrease in all bodily activity except GI (diarrhea);  Parietal – appreciation and discriminationchonlinergic/ vagal/ sympatholytic response of sensory impulses (pain, touch, pressure,  Meiosis heat and cold)  Increased salivationMS 1 Abejo
  • 2. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  Temporal – hearing, short term memory,  CI – Atlas; C2 – Axis contains the general interpretative area—  CSF – shock absorber, cushions brain  altered when there is Wernicke’s aphasia obstruction in CSF drainage  Insula (Island of Reil) – visceral function  HYDROCEPHALUS – posteriorly growth of the head d/t early (internal area) closure of fontanels  Limbic System (Rhinencephalon) – sense of smell, libido or sexual urge control, long Types of Cells: term memory  Labile (regenerative) – Epidermal, GIT, Respiratory, GUT  Stable – regenerative but limited survival period: liver, pancreas, salivary glands, kidneys  Permanent – cardiac, neurons, osteocytes, retinal NEUROLOGIC ASSESSMENT I. COMPREHENSIVE NEUROLOGIC EXAM A. Purpose 1. To know exact neuro deficit 2. To localize lesion 3. For rehabilitation 4. For guidance in nursing care B. Survey of Mental Status 1. LOC  Conscious – awake  Lethargy – sleepy/drowsy/obtunded  Stupor – only awakened by vigorous stimulation  BASAL GANGLIA – areas of gray matter  General body weakness located deep within each cerebral hemisphere;  Decreased body defenses involved in the extrapyramidal tract; produces  Coma DOPAMINE (controls gross voluntary movement)  Light – (+) to all painful stimuli  MIDBRAIN (Mesencephalon) – acts as a relay  Deep – (-) to all painful stimuli station for sight and hearing particularly helps in  PAINFUL STIMULATION size and reaction of pupils and hearing acuity  Deep Sternal Stimulation/Pressure  N hearing acuity : 30-40dB  Orbital Pressure  N pupil constriction: 2-3 mm  Pressure on Great Toes  N pupil finding: PERRLA  Nail bed pressure  Isocoria vs. Anisocoria  Corneal/Blinking Reflex  DIENCEPHALON (Interbrain)  Conscious – wisp of cotton  Thalamus – acts as a relay station for sensation  Unconscious – institute/drop of saline  Hypothalamus – controls temperature, BP, solution (coma if positive reaction, deep sleep and wakefulness, thirst, appetite coma if negative) (satiety), some emotional responses like fear, 2. Test of memory (consider educational background) anxiety and excitement, controls pituitary  Short term memory (ask what the pt ate for functions breakfast)  BRAIN STEM  (+) anterograde amnesia  temporal lobe  Pons (Pneumotaxic center) – controls rate, damage rhythm and depth of respiration  Long term memory (ask birthday)  Medulla Oblongata – lowest part; damage:  (+) retrograde amnesia  damage to most life threatening; controls respiration, Rhinencephalon (Limbic system) HR, swallowing, vomiting, hiccups, C. Levels of Orientation (time, person and place) vasomotor center D. CN Assessment  CEREBELLUM – smallest part; ―lesser brain‖; E. Motor Assessment balance, equilibrium, gait and posture. F. Sensory Assessment 1. PAIN - Gingerbread test  100% very painful  75% tolerable pain  25% moderate pain  0% no pain 2. 10 % CSF 2. TOUCH – Stereognosis 3. 10% Blood  Identifying familiar object placed on clients hands  Astereognosis – if patient cannot identify object; MONROE KELLY HYPOTHESIS – the skull is a closed damage in parietal lobe vault, any increase in one component will bring about increases 3. PRESSURE AND TOUCH – Graphesthesia in ICP  Identify numbers or letters written on client’s NORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAY palm NORMAL CSF OPENING PRESSURE: 60-150 MMHG  Agraphesthesia if (-), damage to parietal lobe NORMAL CSF CONTENTS: GLUCOSE, PROTEINS, WBCS FORAMEN MAGNUM - The large opening in the basal part of the occipital bone through which the spinal cord becomes continuous with the medulla oblongata. G. Cerebellar TestMS 2 Abejo
  • 3. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor 1. Romberg’s Test 2. Dysosmia – distorted sense of smell  Instruct patient to close eyes, assume a normal 3. Anosmia – absence of smell anatomical position for 5-15 minutes; two nurses at right and left side  Normal is (-)  If (+)  ataxia 2. Finger-to-nose Test 3. Alternate Pronation and Supination  Dysmetria – inability of a client to stop a movement at a desired point H. DTRs I. AutonomicsII. Glasgow Coma Scale A. objective measurement of LOC; B. quick neuro check 1. Motor – 6 2. Verbal – 5 3. Eye Opening – 4 C. Normal: 14-15 – conscious 1. lethargy 13-11 2. Stupor 10-8 3. Coma = 7 4. deep coma = 3 II. OPTIC A. Sensory – Vision B. Tests 1. Test of Visual Acuity/Central or Distance Vision  Materials  Snellen’s Chart  Alphabet – literate  E chart – illiterate  Animal chart – pedia, since shorter attention span  20 feet distance (67 cm) 20 feet/6-7 m; constant  normal 20/20  numerator – distance to snellen chart  denominator – distance the person can see the letters  Abnormal findings  20/200 blindness  OD: oculus dexter  OS: oculus sinister  OU: oculus uritas 2. Visual Fields/Peripheral vision  Superiorly  Bitemporally  NasallyCRANIAL NERVE ASSESSMENT  Inferiorly I. Olfactory Sensory Some C. COMMON VISUAL DISORDERS 1. Glaucoma II. Optic Sensory Say  40 yo, obese III. Oculomotor Motor Marry  hereditary IV. Trochlear (smallest) (―down‖) Motor Money  Loss of peripheral vision  tunnel vision V. Trigeminal (largest) Sensory, But  Increased IOP (N = 12-21 mm Hg) (―triCHEWminal‖) motor  Signs and symptoms: VI. Abducens (―at the sides‖) Motor My  Headache VII. Facial Sensory, Brother  Nausea and vomiting motor  Halos around lights  Steamy cornea VIII. Acoustic (Vestibulocochlear) Sensory Says  Acute angle closure glaucoma – most IX. Glossopharyngeal Sensory, Bad dangerous, may lead to blindness motor  Diagnostics: X. Vagus (longest) (―mavagal‖) Sensory, Business  Tonometry – increased IOP motor  Gonioscopy – obstruction in anterior XI. Accessory (―shoulders‖) Motor Marry chamber XII. Hypoglossal Motor Money  Perimetry – decreased visual fields  Drugs (for lifetime)I. OLFACTORY  Timolol maleate A. Sensory – smell  Pilocarpine – drug of choice (miotic) B. Use coffee, bar soap, vinegar, cigarette tar  Epinephrine – decrease in aqueous humor C. Abnormal findings  Carbonic Anhydrase  Diamox  Indication of: (Acetazolamide)  Head trauma damaging the cribriform plate of  Decrease in aqueous humor (maintains ethmoid bone where olfactory cells are located IOP); promotes drainage  Sinusitis – give antibiotics to prevent meningitis  Monitor I/O 1. Hyposmia – decreased sensitivity to smellMS 3 Abejo
  • 4. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  NO ATROPINE: may lead to increased IOP  Trauma  Surgery  Nasolabial folds – most evident sign of facial  Trabeculectomy symmetry  Peripheral iridectomy  Uveitis – inflammation of the iris I. ACOUSIC/VESTIBULOCOCHLEAR  Keratitis – inflammation of the cornea A. Controls balance or kinesthesia (position sense/ movement and correlation of body in space) 2. Cataract 1. Organ of corti (true sense organ for hearing)  for  Loss of central vision  Glaring or hazy vision hearing  Opacity of lens, milky white appearance of cornea, 2. Cochlea – snail-shaped organ in middle ear decreased perception to colors B. Disorders  Due to aging 1. Conductive hearing loss  Prolonged UV rays exposure 2. Otitis Media  Congenital disorder – very rare 3. Meniere’s disease  DM  Dx: Ophthalmoscopic examination Archimedes Principle – buoyancy (pregnancyfetus)  Tx: Mydriatics, cycloplegics (cyclogil) – paralyzes Dalton’s – Law of Partial Pressure ciliary muscles Inertia - Kinesthesia  Surgery: lens extraction  ECLE – partial removal of cataract II. GLOSSOPHARYNGEAL – taste; posterior 1/3 tongue  ICLE – capsule included, total removal of III. VAGUS – gag reflex, decreased vital signs, eyes constrict, mouth cataract moist  PNS 3. Retinal Detachment – most common complication IV. SPINAL/ACCESSORY controls 2 muscles: following lens extraction A. Sternocleidomastoid (neck)  Curtain veil like vision B. Trapezius (Shoulder)  Leads to blindness V. HYPOGLOSSAL – tongue movement; frenulum linguae –  Severe myopia – common cause anchors tongue (tongue tied – short frenulum)  Emetropia – normal refraction of eyes  Presbyopia – loss of lens elasticity due to aging DEMYELINATING DISEASES  (+) floaters – d/t seepage of RBCs  Surgery: Scleral Buckling, Diathermy (heat I. ALZHEIMER’S DISEASE - atrophy of the brain tissue application), Cryosurgery (cold application) characterized by: a. Amnesia 4. Macular degeneration – degeneration of macula lutea b. Agnosia – (-) sense of smell (yellowish spots in center of retina) c. Apraxia – (-) purposive movements  Black spots d. Aphasia  Yellowish spots in center of retina or the macula 1. Expressive/Broca’s – problem in speaking lutea 2. Receptive/Wernickes – problem in understanding; USUAL FOR ALZHEIMER’SIII. OCULOMOTOR 3. Broca’s area – motor speech center; frontalIV. TROCHLEAR It innervates mov’t of EOMs 4. Wernickes’ area – general interpretative area;V. ABDUCENS temporal e. ARICEPT – drug of choice, given at HS  COGNEX also given SR IO (trochlear) (Abducens) LR MR IR SO A. Normal response – PEBRTLA/ PERRLA (isocoria) B. Anisocoria – unequal pupils C. Nystagmus – Rhythmical oscillation of the eyeballs, either pendular or jerky; can be seen in MS, dilantin toxicity.VI. TRIGEMINAL – largest cranial nerve with 3 branches; sensory and motor. A. Ophthalmic branch B. Maxillary branch C. Mandibular branch D. Sensory – controls sensation of face and teeth, mucous membrane and corneal reflex E. Motor – Mastication or chewing F. Trigeminal Neuralgia – characterized by severe pain upon PICK’S Disease: a form of dementia wherein there is damage in the chewing, dysphagia frontoparietal area 1. avoid foods with extreme temperature 2. DOC: carbamazepine (Tegretol) II. MULTIPLE SCLEROSIS – chronic, intermittent disorder of the CNS characterized by white patches of demyelination of theVII. FACIAL brain and spinal cord. IDIOPATHIC, AUTOIMMUNE A. Sensory – anterior 2/3 of tongue; identify taste without swallowing A. INCIDENCE RATE: 15-35 yo, females B. Motor – facial expression control B. PREDISPOSING FACTOR 1. instruct patient to smile, frown or raise eyebrows 1. Slow growing virus  Bell’s palsy or (temporary) facial paralysis – 2. Autoimmune – body produces antibodies which attacks damage to facial nerve caused by: normal cells  Forceps delivery - #1 cause 3. REVIEW: ANTIBODIES  Autoimmune  IgG – passes placenta (gestational)  Stress  IgA – found in bodily secretions, colostrumsMS 4 Abejo
  • 5. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  IgM – acute infections (mabilis) Brought about by increase in the three intracranial components  IgE – allergic reactions  IgD – Chronic infections (dalas) A. PREDISPOSING FACTORS a. Head injury b. Tumor c. Localized abscesses d. Cerebral edema e. Hydrocephalus f. Hemorrhage g. Inflammatory conditions 1. Meningitis 2. Encephalitis B. SIGNS AND SYMPTOMS a. Early signs 1. Decreased or change in LOC 2. Restlessness to confusion 3. Disorientation 4. Lethargy to stupor 5. Stupor to coma b. Late signs C. CLINICAL MANIFESTATION 1. Changes in the vital signs 1. Visual disturbances  Elevated BP (SBP rising, DBP constant)  Blurring of vision  N Pulse Pressure: 40 mmHG  Diplopia  HR decreased  Scotoma (blind spot)  RR decreased (Cheyne-Stokes respiration: normal 2. Impaired sensation to touch, pain, pressure, heat and rhythmic respiration followed by periods of apnea) cold  Elevated temperature  Tingling sensation 2. Headache, papilledema, projectile vomiting  Paresthesia 3. Abnormal posturing- decorticate (flexion) – damage to  Numbness corticospinal tract (spinal cord and cerebral cortex) 3. Mood swings remember: deCORDThreecate OR decerebrate  Euphoria – sense of well-being (extension): upper brain stem damage – pons, midbrain, 4. Impaired motor activity cerebellum  Weakness 4. Unilateral dilation of pupil (ANISOCORIA) –  Spasticity indicates uncal brain herniation; if bilateral dilatation:  Paralysis tentorial herniation 5. Impaired cerebellar function 5. possible seizures  CHARCOT’S TRIAD: ataxia (unsteady gait), 6. Cushing’s reflex (hypertension with bradycardia) nystagmus, intentional tremors  Scanning speech o SHOCK – inadequate tissue perfusion 6. Urinary retention or incontinence o HYPOXIA – inadequate tissue oxygenation 7. Constipation 8. Decrease in sexual capacity C. NURSING MANAGEMENT 1. maintain patent airway and adequate ventilation by: D. DIAGNOSTIC PROCEDURE  prevention of hypoxia ( cerebral edema  1. CSF Analysis  LT: reveals increased CHON and IgG increased ICP) and hypercarbia (CO2 retention) 2. MRI – site and extent of demyelination  cerebral vasodilation  increased ICP  decreased tissue perfusion  possible shock F. NURSING MANAGEMENT: Palliative  Early signs of hypoxia 1. Administer medications as ordered  Restlessness  Acute Exacerbation  Agitation  ACTH (Adrenocorticotropic hormone) –  Tachycardia reduces edema at site of demyelination  Late signs of hypoxia thereby preventing paralysis; compression of  Bradycardia spinal cord will lead to paralysis  Extreme restlessness  Baclofen (Lioresal), Dantrolene Na – to reduce  Dyspnea muscle spasticity  Cyanosis  Interferons  Increased CO2 – most potent respiratory  Immunosuppressives stimulant in the normal person (irritates medulla  Diuretics oblongata)  PROPHANTHELENE BROMIDE (PRO-BANTHENE) –  Decreased O2 – stimulates respiration in CRDS anti-cholinergic for urinary incontinence  Suctioning should only last for 10 -15 seconds and 2. Provide for Relaxation application of suction should be done upon  DBE, biofeedback, yoga withdrawal of catheter in a circular fashion. 3. Retain side rails 4. Prevent complications of immobility – TTS Q2h, Q1 h 2. Assist in mechanical ventilation for elderly, 20 minutes only on affected side 3. Elevate head of bed 30-45 degrees with neck in neutral 5. Increase OFI, high fiber diet (for constipation), acid- position when contraindicated to promote venous ash in diet to acidify urine to prevent bacterial drainage multiplication (cranberry juice, prunes, grape juice, 4. Limit fluid intake to 1.2-1.5 l per day (Forced fluids = vitamin c, plums, orange and pineapple juice.) 2-3 L/day) 6. Provide catheterization for urinary retention 5. Monitor VS, NVS, I/O strictly 6. Prevent complications of immobility 7. Prevent further increase in ICP  Provide comfortable environment  Avoid use of restraints  fractures INCREASED INTRACRANIAL PRESSURE 8. Keep side rails upMS 5 Abejo
  • 6. Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor 9. Avoid valsalva maneuver  SE: major depression  suicidal ideation  Straining of stools (give laxatives/stool softeners)  Linked to Breast Ca development  Excessive vomiting (give Metoclopramide (plasil)  SBE is done 7 days after menstruation – anti-emetic)  Breast Ca - #1 Ca in women  Lifting of heavy objects  Cervical Ca - #2 Ca in women  Bending or stooping 1. multiple sex partners 10. Administer medications as ordered 2. early pregnancy  Osmotic Diuretics – Mannitol (Osmitol) –  Ovarian Ca - #3 Ca in women cerebral diuresis  Monitor VS especially BP (SE: Hypotension  mammography lasts for 10-20 minutes resulting from hypovolemia)  Methyldopa (Aldomet) – has anti HPN properties  Monitor I/O qH  Haloperidol (Haldol) – anti-psychotic  Given via side drip, fast drip to avoid  NEUROLEPTIC MALIGNANT SYNDROME precipitate formation (NMS)  Instruct client that a flushing sensation will  Tremors, tachycardia, tachypnea, fever be felt as drug is introduced  Phenothiazides – anti-psychotic  Loop Diuretics via IV push – Furosemide  PHENERGAN – only anti-psychotic with anti-  BP emetic properties  Monitor 1/0 q1, notify if <30cc/hr  IV push Lasix  effect in 10-15 minutes, B. CLINICAL MANIFESTATION max 6 hours; best given in AM to prevent 1. PILL ROLLING TREMORS of the extremities – first sx sleep interruption 2. Bradykinesia – second sx  Corticosteroids 3. Rigidity (―cogwheel type‖) – third sx  Dexamethasone (decadron) 4. Stooped posture, SHUFFLING GAIT, propulsive gait  Steroids administered 2/3 in AM to 5. Overfatigue mimic diurnal rhythm 6. Mask-like facial expression, decreased blinking of the  Hydorcortisone eyelids  Prednisone 7. Difficulty in rising from sitting position  Mild Analgesic 8. Quiet monotone speech  Codeine sulfate 9. Mood lability  depression  suicide  Anti-Convulsant 10. Increased salivation, drooling type  Pheytoin (Dilantin) 11. Autonomic changes  Increased sweating and lacrimation  Seborrhea Benadryl is given at HS because it causes drowsiness  Constipation Levothyroxine is given in AM to prevent insomnia  Decreased sexual capacityIII. PARKINSON’S DISEASE – (degenerative disease) chronic progressive disorder of the CNS characterized by degeneration of the dopamine producing cells in the substantia nigra of the midbrain and basal ganglia (areas of gray matter in both hemispheres which is involved in the extrapyramidal tract) IRREVERSIBLE, IDIOPATHIC C. NURSING MANAGEMENT (palliative) 1. Administer medications as ordered  Anti-Parkinsonian Agents  increase dopamine  relieves rigidity (CAPABLES!)  Levodopa (L-dopa) – short acting A. PREDISPOSING FACTORS dopaminergic 1. Poisoning  Amantadine HCl (Symmetrel) – long acting  Lead (ANTIDOTE: Ca EDTA – heavy metal dopaminergic antagonist)  Carbidopa (Sinemet) – long acting  Carbon Monoxide  decreased capacity of dopaminergic hemoglobin to carry oxygen  cherry red skin  SE: (GIT) anorexia, nausea and vomiting, color orthostatic hypotension, hallucination, 2. Arteriosclerosis arrhythmia 3. Hypoxia – inadequate tissue perfusion 4. Encephalitis  Contraindications: narrow angle closure 5. Drugs glaucoma  loss of peripheral vision   Reserpine (Serpasil) tunnel vision  halos in light; normal IOP =  Has anti HPN properties 12-21 mmHg  Promote safety when giving this drug MS 6 Abejo
  • 7. Lecture Notes on Neurologic Nursing Prepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  Also contraindicated in patient’s taking C. CLINICAL MANIFESATION MAOI’s (Avoid tryptophan and tyramine in 1. PTOSIS – INITIAL SIGN pts taking MAOI’s)  Check palpebral fissure  drooping of upper  Administer with food or snack to lessen GIT eyelids irritation 2. Double vision  Inform client that stools/urine maybe 3. Mask like facial expression darkened 4. Weakened laryngeal muscles  dysphagia (difficulty  INSTRUCT CLIENT TO AVOID FOODS RICH IN of swallowing, without food); odynophagia ang with VITAMIN B6--PYRIDOXINE (Cereals, organ food meat, green leafy vegetables) – reverses 5. Hoarseness of voice therapeutic effect of levodopa 6. Respiratory muscle weakness  respiratory arrest;  Anti-cholinergics – relieves tremors prepare trache set at bedside  Relieves tremors 7. Extreme muscle weakness especially during activity or  Artane and Cogentin exertion in AM  Mode of action: increases dopamine  SE: SNS D. DIAGNOSTICS  Antihistamine – relieves tremors 1. TENSILON TEST (EDROPHONIUM HCL)  Diphenhydramine HCl (Benadryl)  Temporary relief of symptoms  SE:  Strengthens muscles temporarily  Drowsiness – adult  Pt, temporarily can open eyelids, increased muscle  CNS excitement and hyperactivity – children strength 5-10 minutes after admin  Dopamine Agonists – relieves tremors and rigidity  Bromocriptine HCl (Parlodel) E. NURSING MANAGEMENT  Airway  SE: CNS Depression  Aspiration  No OCP’s  decreased effect  Immobility 2. Maintain side rails to prevent injuries related to falls 1. Maintain patent airway and adequate ventilation 3. Prevent complications of immobility  Assist in mechanical ventilation 4. Maintain good nutrition. Provide dietary intake that is  Assess PFT (decreased Vital Lung Capacity) low in protein in AM and high protein at night to 2. Monitor Strictly VS, IO, NVS, motor grading scale induce sleep (muscle strength)  TRYPTOPHAN – induces sleep 3. Maintain side rails 5. Assists in passive ROM exercises to prevent 4. institute NGT feeding to prevent aspiration contractures. Q4h for proper body alignment. 5. prevent complications of immobility – q2 turning, q1 6. Increased OFI is encouraged and increased Fiber in the for elderly diet for constipation 6. Administer meds as ordered 7. Ambulate with assistance  Corticosteroids – for immunosuppression 8. Assist in STEROTAXIC THALAMOTOMY  Cholinergic/Anticholinergic agents  COMPLICATIONS: SUBARACHNOID HEMORRHAGE,  Mestinol (Pyridostigmine) ENCEPHALITIS, CEREBRAL ANEURYSM  Neostigmine (Prostigmin)  Monitor for the two types of crisisIV. MYASTHENIA GRAVIS (MG) – neuromuscular disorder characterized by a disturbance in the transmission of impulses Myasthenic Crisis Cholinergic Crisis from nerve to muscle cells at the neuromuscular junction (or motor end plate – site of exchange of neurotransmitters) Causes: undermedication, stress, Cause: overmedication infection IDIOPATHIC; DECENDING MUSCLE WEAKNESS S/sx: (-) seeing, swallowing, speaking, S/sx: PNS, increased breathing salivation  aspiration Tx: admin cholinergic agents as ordered Tx: anticholinergic agents, atropine sulfate Monitor for BRITTLE CRISIS: characterized by severe respiratory muscle weakness and exertioal discomfort. Prepare trache set. 7. Assist in  THYMECTOMY – removal of thymus which is believed to produce autoimmunity  Plasmaparesis – filtering of blood; removal of autoimmune antibodies in the blood 8. Prevent complications  respiratory arrest 9. Prepare trache set in pts with MG V. MENINGITIS – inflammation of the meninges of the brain and spinal cord  Meninges – 3fold membrane that covers the brain and spinal cord For support and protection For blood supply A. INCIDENCE RATE For nourishment 1. Women aged 20-40 years old  Dura mater - outermost  Subdural space – between dura and arachnoid B. PREDISPOSING FACTORS  Arachnoid mater - middlemost 1. Autoimmune  Subarachnoid space  where CSF circulates; location  Involves release of CHOLINESTERASE an where aspirate is taken during LT (puncture either bet l3-l4 enzyme which destroys Ach  descending muscle or l4-l5 because it is above these areas where the spinal cord weakness terminates)  Pia mater – ―gentle mater‖ MS 7 Abejo
  • 8. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor VI. CEREBROVASCULAR ACCIDENTS (Stroke, brain attack, A. ETIOLOGIC AGENTS cerebral thrombosis, apoplexy) – partial or total disruption in the 1. MENINGOCOCCUS – MOST DANGEROUS blood supply of the brain, usually in the MCA or ICA (2 largest 2. Pneumococcus cerebral arteries) 3. Streptococcus – adult 4. Hemophilus influenzae – pedia A. INCIDENCE RATE – 2-3x higher in males than in females B. MODE OF TRANSMISSION – airborne transmission via B. PREDISPOSING FACTORS droplet infection 1. Thrombosis – attached clot, #1 cause of stroke C. CLINICAL MANIFESTATION 2. Emboli – detached/wandering thrombosis 1. Headache, photophobia, projectile vomiting  Pulmonary embolism 2. Fever, chills, anorexia, generalized body malaise,  Sudden sharp chest pain weight loss  Unexplained dyspnea 3. decorticate (deCORDthreecate) and or decerebrate  Tachycardia 4. Possible seizure and increased ICP  Palpitation 5. Signs of meningeal irritation  Diaphoresis  Nucchal rigidity  Cerebral embolism  Opisthotonus – rigid arching of the head  Headache  (+) kernig’s sign – leg pain  Dizziness  (+) brudzinksi’s sign – neck pain  Disorientation  Change in LOC that may lead to coma D. DIAGNOSTICS 3. Hemorrhage 1. Lumbar puncture (lumbar or spinal tap)  Nursing management for before LT  Obtain informed consent  Explain procedure to client  Empty bowel and bladder for comfort  Encourage client to arch back to clearly visualize spinal columns  Nursing management post LT  Flat on bed for 12-24 hours to prevent spinal headaches and CSF leakage  Forced fluids  Check puncture site for any discoloration, drainage and leakage to tissues  ASSESS FOR MOVEMENT AND SENSATION OF EXTREMITIES (MOST IMPORTANT)  CSF analysis will reveal  Increased CHON and WBC  Decreased Glucose C. RISK FACTORS  Increased CSF opening pressure 1. HPN  N = 50-160 mmHg 2. DM  (+) cultured microorganisms 3. Atherosclerosis  MI  These confirm presence of meningitis 4. Valvular heart disease, Mitral/post-cardiac 2. CBC Reveals surgery/mitral valve replacement  mlt CVA  Increased WBC 5. Lifestyle  Smoking E. NURSING MANAGEMENT  Sedentary lifestyle 1. Complete bed rest  Obesity (more than 20% ideal body weight) 2. Administer medications as ordered  Diet rich in saturated fats  Broad Spectrum Antibiotics  Hyperlipidemia – genetic; (+) genes that easily  Penicillin  alteration in the N flora of the binds to cholesterol GI superinfection  diarrhea  Type A personality  Analgesics  Deadline driven person  Antipyretics  Does several things at the same time 3. Institute strict respiratory isolation after initiation of  Feels guilty when not doing anything antibiotic therapy  Prolonged use of oral contraceptives 4. Institute ICP monitoring  Macropil  estrogen 5. Dim environment  d/t photophobia  Minipil  progestin 6. Monitor strictly VS, IO and NVS  Increases lipolysis  breakdown of lipids  7. Maintain F and E balance atherosclerosis  HPN  CVA 8. Prevent complications of immobility: turn to sides q2 9. Health Teaching and D/C planning D. CLINICAL MANIFESTATION  Dietary intake increased in calories with small 1. TRANSIENT ISCHEMIC ATTACK – initial sign of CVA frequent feedings (increase carbohydrates)  Headache, dizziness, tinnitus, visual and speech  Prevent complications disturbances, paresis to plegia, increase in ICP  HYDROCEPHALUS possible, cheyne-stokes respirations  HEARING LOSS (NERVE DEAFNESS) 2. Stroke in evolution – progression of S/sx  Visit audiologist for audiometric screening 3. Complete Stroke – resolution phase characterized by after resolution of meningitis still dizziness and headache  Rehabilitation for residual deficits  Cheyne-stokes respirations  Mental retardation or delay and psychomotor  Anorexia development  Nausea and vomiting  Singit lang to: pag post repair ng  Dysphagia myelomeningocoele  checkup with  (+) Kernigs and Brudzinksi’s urologist baka na-hit ung bladder  Focal Neurological Deficits  Plegia  AphasiaMS 8 Abejo
  • 9. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor  Dysarthria – speaking difficulty VII. GUILLAINE-BARRE SYNDROME (GBS) – CNS disorder  Alexia – reading difficulty characterized by bilateral, symmetrical, polyneuritis leading to  Agraphia – writing difficulty ascending muscle weakness/paralysis.  Homonymous hemianopsia –loss of ½ vision field A. Cause – IDIOPATHIC  Unilateral neglect B. PREDISPOSING FACTORS 1. Autoimmune E. DIAGNOSTICS 2. antecedent viral infection 1. CAT scan 3. immunizations such as your flu vaccine 2. Cerebral Arteriography – reveals site of lesion  Informed consent C. CLINICAL MANIFESTATION  Allergies to seafood 1. CLUMSINESS – INITIAL SIGN  Post-dx: forced fluids and check for presence of 2. Dysphagia hematoma 3. Ascending muscle weakness  paralysis 4. Decreased DTRs F. NURSING MANAGEMENT 5. Alternate hypertension and hypotension; MOST FEARED 1. Maintain patent airway and adequate ventilation COMPLICATION: ARRHYTHMIAS  Assist in mechanical ventilation 6. Autonomic changes  Administer oxygen as ordered  Increased sweating and lacrimation 2. Restrict Fluids  Increased salivation 3. Elevate head of bed, 30-40 degrees to promote venous  Constipation drainage 4. Avoid activities that cause valsalva maneuver D. DIAGNOSTICS 5. Prevent complications of immobility 1. CSF Analysis : reveals elevated CHON and IgG  Prevent bed sores and hypostatic pneumonia  CSF is produced in the choroid plexus  TTS q2  Use of egg crate mattress or water bed E. NURSING MANAGEMENT  Sand bag/foot board to prevent foot lag 1. Maintain patent airway and ventilation 6. Institute NGT feeding  Assist in mechanical ventilation 7. ROM exercises q4h to prevent contractures and 2. Maintain side rails (paralysis) promote proper body alignment 3. prevent complications of immobility 8. Alternative means of communication 4. institute NGT feeding  Non verbal cues 5. Administer medications as ordered  Magic slate or picture board  Anticholinergics – Atropine Sulfate 9. If positive for hemianopsia, approach client on  Corticosteroids – to suppress immune response unaffected side  Anti-arrhythmic agents 10. Administer meds as ordered  Lidocaine (Xylocaine)  Osmotic diuretics  Bretyllium – Blocks norepinephrine  Mannitol (Osmitrol)  Quinidines – anti-arrhythmic, anti-malarial  Corticosteroids (Malaria –king of tropical diseases kaya ang  Dexamethasone (Decadron) meds ay queen = quinines) Common SE:  Mild Analgesics QUINCHONISM :  Codeine Sulfate  Female anopheles – malaria, night biting, lay  Thrombolytics eggs in the morning  Streptokinase  Female aegis egyptis – dengue, day biting,  Urokinase lay eggs at night, 4 o’clock habit  Tissue Plasminogen Activity Factor (TPAF)  Plasmodium falciparum – most dangerous  Monitor for bleeding form of malaria  hemorrhage  Anti-coagulants as ordered. 6. Assist in plasmaparesis  Heparin  check PTT – if prolonged, 7. Prevent complications indicates bleeding  give protamine sulfate  ARRHYTHMIAS when overdosed  RESPIRATORY ARREST  Coumadin  check PT – if prolonged, indicates bleeding  vitamin K VIII. CONVULSIVE DISORDERS (aquamephyton) as antidote  A disorder of the CNS characterized by paroxysmal  Given together because coumadin will take seizures with or without loss of consciousness, alternation in effect after 3 days still sensation and perception, abnormal motor activity and  Loop-diuretics changes in behavior; IDIOPATIHIC  Lasix (okay to administer in DM pts but  Febrile seizures are normal for children below 5 years only; monitor CBG) can be outgrown  Anti-platelets  Febrile seizures in children >5 yo = abnormal  ASA – anti-thrombotic  SEIZURE – first convulsive attack  Contraindicated in dengue, ulcers and  EPILEPSY – series of seizure activity unknown cause of headache  potentiates bleeding 11. Health Teaching  Avoid modifiable risk factors  Avoid / prevent complications: Sub-arachnoid hemorrhage  Diet modification: low saturated fat, sodium and caffeine  Rehabilitation for focal neurologic weakness  Importance of ffup care and strict compliance to medicationsMS 9 Abejo
  • 10. Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor A. PREDISPOSING FACTORS  Diazepam (Valium) – for status epilepticus 1. Head injury secondary to birth trauma  Carbamazepine (Tegretol) 2. Lead poisoning  Also used for Trigeminal neuralgia (Tic 3. Genetics Dolor) 4. Brain tumor  Phenobarbitals (Luminal) 5. Nutritional and metabolic deficiencies 4. Institute seizure and safety precautions 6. Sudden withdrawal of anti-convulsive drugs  Post-seizure:  Causes STATUS EPILEPTICUS  O2 inhalation  DOC: diazepam, glucose  Suction apparatus 7. Physical and emotional stress 5. Monitor and document the following  Onset and duration B. TYPES OF SEIZURES  Type of seizure 1. Generalized  Duration of post-ictal sleep  increased length of  Grand Mal (Tonic-Clonic) sleep can lead to status epilepticus  With or without an aura 6. Assist in CORTICAL RESECTION  Epigastric pain – initial sign of an aura (aura is an initial sign of seizures) For a one year old client suffering grand mal seizures:  Visual  auditory  olfactory  tactile  NOT Mouthpiece Eh onte lang teeth ng one year sensory experience old eh  Epileptic cry  Give pillows  support for the head (For banging of  Fall head during seizure activity)  Loss of consciousness for 3-5 minutes  Tonic-clonic contractions  Direct symmetrical extension of extremities  Shaking/convulsive activity  Post-ictal sleep (unresponsive sleep)  Petit Mal (Absence Seizure)  S/sx:  Blank stare  Decreased blinking of the eyes  Twitching of the mouth and loss of consciousness for 5-10 seconds 2. Partial Seizures  Jacksonian seizure (focal seizures) – characterized by tingling and jerky movements of index finger and thumb  spreads to shoulders  Psychomotor seizure (focal-motor seizures) – characterized by:  Automatism – stereotype, non-repetitive and non-purposive behavior  Clouding of consciousness – not in contact with reality  Mild hallucinating sensory experience 3. Status Epilepticus – continuous uninterrupted seizure activity that if left untreated may lead to hyperpyrexia  coma  death  Increased electrical activity in brain  increased metabolism  increased glucose and oxygen use, increased temperature  coma  death  DOC: Valium, Glucose C. DIAGNOSTICS 1. CT-SCAN – brain lesion d/t head trauma 2. EEG – hyperactivity of brain waves (all elevated)  Alpha, beta, delta, theta waves D. NURSING MANAGEMENT 1. Maintain patent airway and promote safety before seizure activity  Clear the site of sharps, harmful objects  Loosen clothing of the patient  Avoid use of restraints  fractures  Maintain side rails  Turn head to side to prevent aspiration  Tongue guard is between mouth and teeth to prevent biting of the tongue 2. Avoid precipitating stimulus  Bright/glaring lights  Noise 3. Administer medications as ordered  Phenytoin (Dilantin)  Gingival Hyperplasia  Use soft-bristled toothbrush  Ataxia  Nystagmus  HirsutismMS 10 Abejo