medical

1. Neurological disorders
Nursing management of patients with
common Neurological problems
Lecture for year III Nursing students
by
Amir A
January,2020
Rift Valley university
Amirahmed39@gmail.com
05/02/2023
By Amir A
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2. Objective
Describe over view of A/P of Nervous system
Describe over view of assessment of Nervous
system.
Mention diagnostic studies of Nervous system.
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3. Objective
Describe the causes, pathophysiology, clinical
manifestations, medical ,surgical and nursing
management of :
 Increased intracranial pressure (ICP)
 Seizures/Epilepsy
 Headache(cephalgia)
 Cerebrovascular Disorder(stroke)
 Head injury, Spinal cord injury ,
 Bell’s palsy(Facial paralysis), Parkinson’s diseases
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4. OVER VEIW OF A/P NERVEOUS SYSTEM
A network of billions of nerve cells linked together in a
highly organized fashion to form the rapid control
center of the body
The Nervous system consists of two divisions:
 The central Nervous system (CNS)
 The Brain and Spinal cord.
 The peripheral nervous system, made up of
The Cranial and Spinal nerves.
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5. OVER VEIW OF A/P NERVEOUS SYSTEM cont’d
The peripheral Nervous system divided into
 The Somatic, or Voluntary, Nervous system,
 The Autonomic, or Involuntary, Nervous
system,which includes
 Para sympathetic (Rest and Digest) and
sympathetic (Fight or Flight)Nervous system
 The function of the Nervous system is to
control all motor, sensory, autonomic,
cognitive, and behavioral activities.
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6. OVER VEIW OF A/P CONT.d
Cells of the Nervous System
The basic functional unit of the brain is the
Neuron .It is composed of a cell body, a
dendrite, and an axon. ).
Neuroglial cells, another type of nerve cell,
support, protect, and nourish neurons.
Most of brain tumors rises from Glia
cells(45%)
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7. OVER VEIW OF A/P CONT’d….
 The brain is divided into three major areas:
 The cerebrum, The brain stem, and The cerebellum.
 The cerebrum is composed of two hemispheres,
 the Thalamus, the Hypothalamus, and the
Basal ganglia.
 Additionally, connections for the olfactory
(cranial nerve I) and optic (cranial nerve II)
nerves are found in the cerebrum.
The brain stem includes the Midbrain, Pons,
Medulla, and connections for cranial nerves III and
IV through XII.
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8. OVER VEIW OF A/P CONT’D
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9. Brain Area & Function…
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10. OVER VEIW OF A/P CONT’D
The cerebellum is located under the cerebrum
and behind the brain stem
 The brain accounts for approximately 2% of the
total body weight;
It weighs approximately 1,400 g in an verage
young adult .
 In the elderly, the average brain weighs
approximately 1,200 g.
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11. OVER VEIW OF A/P CONT’d
The Hypothalamus is located anterior and
inferior to the thalamus.
 Hypothalamus plays an important role in the
endocrine system because it regulates the
pituitary secretion of hormones that influence
metabolism, reproduction, stress response, and
urine production.
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12. OVER VEIW OF A/P CONT’d
The hypothalamus is the site of the hunger center
and is involved in appetite control.
 It contains centers that regulate the sleep–wake
cycle, blood pressure, aggressive and sexual
behavior,and emotional responses
 The hypothalamus also controls and regulates
the autonomic nervous system
Secretes two important hormones Antidiuratic
hormone (ADH) and Oxytocin
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13. Hemispheric Lateralization
 Functional differences between left and right
hemispheres
 In most people (90%), left brain (dominant
hemisphere) controls:
 reading, writing, and math
 decision-making
 speech and language
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 Right cerebral hemisphere relates to:
 senses (touch, smell, sight, taste, feel)
 recognition (faces, voice inflections)
 Unclear dominance may lead to dyslexia (Impaired
ability to learn to read)

15. OVER VEIW OF A/P CONT’d
The brain is contained in the rigid skull, which
protects it from injury.
 The meninges
It covers the brain and spinal cord
provide protection, support, and nourishment to
the brain and spinal cord.
The layers of the meninges are the Dura,
Arachnoid, and Pia mater.
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16. OVER VEIW OF A/P CONT’d
 CEREBROSPINAL FLUID
 CSF, a clear and colorless fluid with a specific
gravity of 1.007,
Is produced in the ventricles and circulates
around the brain and the spinal cord through
the ventricular system.
ventricles: the right and left lateral, and the
third and fourth ventricles.
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17. OVER VEIW OF A/P CONT’d
CEREBRAL CIRCULATION
 The cerebral circulation receives 15% of the
cardiac output, or 750 mL per minute.
 The brain does not store nutrients and has a high
metabolic demand that requires the high blood
flow.
 The brain’s blood pathway is unique because it
flows against gravity;
 Its arteries fill from below and the veins drain
from above
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18. OVER VEIW OF A/P CONT’d
The spinal cord
 It servs as the connection between the brain and the
periphery.
Approximately 45 cm (18 in) long and about the
thickness of a finger
 It extends from the foramen magnum at the base of the
skull to the lower border of the first lumbar vertebra,
 The spinal cord is an H-shaped structure with
nerve cell bodies (gray matter) surrounded by
ascending and descending tracts
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19. 05/02/2023
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20. OVER VEIW OF A/P CONT’d
SPINAL NERVES
The spinal cord is composed of
31 pairs of spinal nerves: 8 cervical,12 thoracic,
5 lumbar, 5 sacral, and 1 coccygeal.
 Each spinal nerve has a ventral root and a dorsal
root
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21. The Neurologic Examination cont’d
PHYSICAL EXAMINATION
The brain and spinal cord cannot be examined as
directly as other systems of the body.
 Much of the neurologic examination is an indirect
evaluation that assesses the function of the specific
body part or parts controlled or innervated by the
nervous system.
A neurologic assessment is divided into five
components:
cerebral function, cranial nerves, motor system,
sensory system, and reflexes
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22. The Neurologic Examination cont’d
Assessing Cerebral Function
 MENTAL STATUS
An assessment of mental status begins by observing the
patient’s
appearance and behavior, noting dress, grooming, and
personal hygiene.
 Posture, gestures, movements, facial expressions.
The patient’s manner of speech and level of
consciousness
Assessing orientation to time, place, and person .
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23. 05/02/2023
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24. Increased Intracranial Pressure
Intra cranial pressure(ICP)
 is the pressure exerted in the cranium by its
contents
 The brain ,Blood, and cerebrospinal fluid(CSF)
 The pressure is measured via the CSF, the normal
pressure of CSF IS 5-15mmHg or 60-
180mmH2O,presssure over 250mmH2O is called
increased ICP,
 Is a symptom of serious underlying disorder.
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25. Increased Intracranial Pressure cont’
 The rigid cranial vault contains brain tissue
(1,400 g), blood(75 mL), and CSF (75 mL) . The
volume and pressure of these three components
are usually in a state of equilibrium and produce
the ICP.
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26. Increased Intracranial Pressure cont
The Monro-Kellie hypothesis states that because of
the limited space for expansion within the skull, an
increase in any one of the components causes a
change in the volume of the others.
Because brain tissue has limited space to change,
compensation typically is accomplished by
displacing or shifting CSF, increasing the absorption
of CSF, or decreasing cerebral blood volume.
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27. Increased Intracranial Pressure cont
 ICP will begin to rise under normal
circumstances in the following conditions
 Minor changes in blood volume and CSF
volume occur constantly due to alterations in
intrathoracic pressure.
 coughing,sneezing, straining, posture, blood
pressure, and systemic oxygen and carbon
dioxide levels.
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28. Increased Intracranial Pressure cont
 Common causes of increased ICP
 Head trauma(injury )
 Intracranial hemorrhage,
 Hematoma, cerebral edema
 Brain tumors.(increasing tissue volume)
 CNS infection e.g.: meningitis
 Brain abscess
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29. Increased Intracranial Pressure cont
Increased ICP due to increased CSF volume,
 can result from increased CSF production,
 impaired reabsorption ,
 blocked flow
Increased ICP caused by increased blood volume results
from Vasodilatation
The rise in CO2 cause cerebral vasodilatation which
further contribution to a rise in ICP
 Risk factors include any injury or disease to the brain
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30. Clinical Manifestations
 change LOC (Early sign )
 Restlessness, confusion, or increasing drowsiness
 Headache that is constant, increasing in intensity, and
aggravated by movement or straining.
 Vomiting , papille edema
 Double vision (diplopia)
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31. Clinical Manifestations
Vital sign changes are a late indication of Increased
ICP. Cushing’s response is a classic late sign of
increased ICP.
Cushing’s response (or Cushing’s triad) is
Characterized by bradycardia, bradypnea, and arterial
hypertension(increasing systolic blood pressure while
diastolic blood pressure remains the same),
 Widening pulse pressure.
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32. Clinical Manifestations cont’d
 Detecting Later Signs of Increased ICP
 LOC continues to deteriorate until the patient is comatose.
 Altered respiratory patterns develop, including Cheyne-Stokes
breathing
 Projectile vomiting may occur with increased pressure on the
reflex center in the medulla.
 Hemiplegia, paralysis of one side of the body ( when
pressure on the brain stem increases)
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33. Diagnostic Findings
History and physical examination
computed tomography (CT)scanning
Magnetic resonance imaging (MRI)
cerebral angiography
Skull x ray
 Lumbar puncture is avoided in patients with increased
ICP because the sudden release of pressure can cause
the brain to herniation
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34. Management
DECREASING CEREBRAL EDEMA
1,Osmotic diuretics (mannitol) -may be given to
dehydrate the brain tissue and reduce cerebral edema.
They act by drawing water across intact membranes,
thereby reducing the volume of brain and extracellular
fluid.
An indwelling urinary catheter is usually inserted to
monitor urinary out.
2,Corticosteroids (eg, dexamethasone)- help reduce the
edema surrounding brain tumors.
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35. Management cont’d
3,Other method for decreasing cerebral edema is fluid
restriction
 Limiting over all fluid intake leads to dehydration and
hemoconcentration
 Hyperventilation of the patient
 Elevating the patient’s head to optimize venous
drainage
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36. management cont’d
4.Preventing a Temperature elevation (because fever
increases cerebral metabolism)
Strategies to reduce temperature
Include administration of antipyretic medications, , and
use of a cooling blanket.
5. MAINTAINING OXYGENATION
Arterial blood gases must be monitored to ensure that
systemic oxygenation remains optimal
Hyperventilation is recommended
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37. Management cont’d
6. MAINTAINING A PATENT AIRWAY
 Secretions that obstructing the airway must be
suctioned with care
Hypoxia caused by poor oxygenation leads to cerebral
ischemia and edema.
 Coughing is discouraged because coughing and
straining also increase ICP.
 Elevating the head of the bed
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38. Proper positioning helps to reduce ICP,The head is kept in
a neutral (midline) position,
 Extreme rotation and flexion of the neck should be
avoided
 Extreme hip flexion is also avoided because this position
causes an increase in intra-abdominal and intrathoracic
pressures
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Management cont’d

39. Management cont’d
Stool softeners may be prescribed.
 Abdominal distention, which increases intra-
abdominal and intrathoracic pressure and ICP,
should be noted.
Emotional stress and frequent arousal from sleep
are avoided.
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40. Management cont’d
Surgical Management
I, REDUCING CSF AND INTRACRANIAL BLOOD
VOLUME
CSF drainage is frequently performed BY
1 An intraventricular catheter (ventriculostomy),
When a ventriculostomy or Ventricular catheter
monitoring device is used for monitoring ICP,
 A fine-bore catheter is inserted into a lateral ventricle of
the brain .
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41. Management cont’d
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42. Complications of increased intracranial pressure
1, Brain herniation(is a shifting of brain contents from a
compartment of greater pressure to one of lower pressure
2, Diabetes insipidus,
 is the result of decreased secretion of antidiuretic hormone.
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43. LEARNING OBJECTIVES
 Define Seizure and epilepsy
 Describe the international classification of Seizure.
 List the etiologies or risk factors for Seizure
disorder
 To identify the clinical manifestation of different
types of Seizure disorders
 To understand the diagnostic approaches & patient
management
 To aware the complication of eizure/epilepsy:status
epilepticus
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44. SEIZURE DISORDERS
 A seizure is a brief, temporary disturbance in the electrical
activity of the brain
 Episodes of abnormal:
 Motor
 Sensory
 Autonomic
 Psychic activity
that result from sudden excessive discharge from cerebral neurons.
 A part or all of the brain may be involved.
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or a combination

45. SEIZURE…
Most seizures are sudden and transient
Seizures can develop at any time during a
person’s life.
A seizure may be a symptom of epilepsy or
other neurological disorders such as a brain
tumor or meningitis.
Epilepsy is a chronic neurological disorder
characterized by recurrent seizure activity
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46. SEIZURE…
Etiology of seizure or risk factors:
 Idiopathic or cryptogenic (70%)
 Genetic factor (Family History) ,
 Developmental defects
 Acquired hypoxemia of any causes, Fever (child
hood),
 vascular insufficiency , Hypertension, stroke
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47. SEIZURE…
 CNS infections,
 Metabolic and toxic condition (Hypoglycemia,
Hypocalcaemia, Hypernatremia, Renal failure,
Pesticides)
 Head trauma, Neoplasms,
 allergies
 Drugs, Alcohol & others
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48. SEIZURE…
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SEIZURE
Partial Generalized Unclassified
Seizures beginning
Locally(focal seizure)
Involve electrical
discharges in
the whole brain
i. Neonatal seizures
ii. Infantile spasm
Classification of seizures based on the international
Seizure classification society.

49. SEIZURE…
1. Partial Seizures (focal seizures)
A. Simple partial seizure
B. Complex partial seizure
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50. SEIZURE…
Clinical features
A. Simple Partial Seizures
Consciousness is not impaired
Convulsion of a single limb or a group of muscles.
 Motor, sensory, autonomic or psychiatric.
 Motor manifestation focal clonic or tonic movement of :
 Angle of mouth may jerky
 Only Finger or hand may shake
 Person s may experience unusual or unpleasant
sights,sounds,odors or tastes
 This seizure activity may spread over one side of the body.
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51. SEIZURE…C/F
B. Complex partial seizure
 Impaired consciousness
 Attack of confusion, bizarre behavior when consciousness impaired.
 Unable to respond appropriately to visual or verbal commands
during the seizure.
 Begins with an aura.(warning sign)
 Start of the ictal phase is often a sudden behavioral arrest or
motionless stare.
Ictal means(seizure)
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52. SEIZURE…C/F
PARTIAL SEIZURES. Repetitive, purposeless behaviors,
called automatisms, are the classic symptom of partial
seizures.
 Chewing
 lip smacking
 picking movement of the hands
 Staring
 display of emotions.
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53. SEIZURE…C/F
 Patients may be labeled as mentally ill, particularly if
automatisms include unacceptable social behaviors such
as spitting or fondling themselves
 The patient appears to be in a dreamlike state while
picking at his or her clothing, chewing, or smacking his or
her lips
 Patients are not aware of their behavior or that it is
inappropriate.
 Have also post-ictal confusion and transition to full
recovery may take minutes to hours.
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54. SEIZURE…
2.Generalized Seizures (convulsive or nonconvulsive,bilaterally
symmetric, without local onset),
Generalized seizures that involve electrical discharges in the whole brain.
Generalized seizures
i. Absence seizures ( petit mal )
ii. Tonic – clonic seizures ( grand mal )
iii. Myoclonic seizures
iv. Clonic seizures
v. Tonic Seizures
vi. Atonic seizures
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55. SEIZURE…C/F
Generalized Seizures
i. Absence seizure (petit mal)
Common in children
 Sudden and brief lapses of consciousness without
loss of postural control.
 Lasts for only few seconds.
 Subtle motor manifestations:
 blinking of the eyes
 chewing movements.
 Slight muscle twitching may occur
 There is no post-ictal confusion.
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56. SEIZURE…C/F
ii. Generalized tonic clonic seizure(Grand mal)
The most common seizure type(60%)
 Ictal phase begins with tonic contraction of muscles
throughout the body:
 Which is responsible for loud moan or cry (due tonic
contraction of the muscles respiration and the larynx)
Tonic posturing
Respiration is impaired
The patient falls to the ground
there may be tongue biting due to tonic contraction of
the jaw muscles.
 Phase of Grand Mal:Aura, epileptic cry ,tonic
,clonic,post ictal
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57. SEIZURE…C/F
 After 10 – 20sec tonic phase evolves to clonic phase
 Clonic phase lasts for another 1 minute
 Characterized by bilateral jerking clonic movement
involving the whole body.
 Contraction with relaxation of major muscles
 The patient is incontinent of urine and stool
 Biting the lips or tongue may cause bleeding.
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58. SEIZURE…C/F
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59. 05/02/2023
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60. SEIZURE…C/F
iii. Myoclonic seizure
 Sudden and brief muscle contraction/relaxation
 Involve one part of the body or the entire.
 Can be physiologic or pathologic.
 Is most commonly seen with metabolic disorders,
degenerative diseases of the CNS or anoxic brain
injury.
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61. SEIZURE…C/F
iv. Atonic Seizures
 Sudden loss of postural muscle tone, lasting 1 to 2
Seconds.
 Consciousness is briefly impaired
 Usually manifest as a head drop or nodding
movement
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62. Assessment & Diagnosis
DX is aimed at the types of seizure, their
frequency and severity
Pt’s Hx & P/E.
 History of events
 History of suggesting cause and risk factors
 Eg: factors that precipitate seizure
 Events of pregnancy and child birth
 Mode of delivery ,instrumental delivery ,like vacuum,or forceps
delivery
 History of head injury ,CNS infection
 Neurologic evaluations
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63. Assessment & Diagnosis
EEG (Electroencephalography)
Aids in classifying the types of seizure and the
treatment
Neuroimaging preferably :MRI,CT scan
Used to detect lesions in the brain
Other routine laboratory assessment
 CBC.
 Urinalysis
 Serum glucose(FBS,RBS)
 Liver function test
 RFT
 Electrolytes test
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64. Assessment & Diagnosis
EEG
A graphic recording of the electrical activity of the
superficial layers of the cerebral cortex.
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EEG

65. EPILEPSY
Definition:
 It is a group of syndromes characterized by
unprovoked, recurring seizures.
 The most common syndromes being those with
generalized seizures and those with partial-
onset seizures.
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Epilepsy
Primary Secondary
Idiopathic Symptom of another
underlying condition.

66. THE EPILEPSIES
is a group of syndromes characterized by recurring
seizures.
Types of epilepsies are differentiated by how the seizure
activity manifests and EEG feature.
the most common syndromes being those with
generalized seizures and those with partial-onset
seizures.
Epilepsy can be primary (idiopathic) or secondary,
when the cause is known (the epilepsy is a symptom of
another underlying condition such as a brain tumor ).
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67. Pathophysiology
Messages from the body are carried by the neurons
(nerve cells) of the brain by means of discharges of
electrochemical energy that sweep along them.
These impulses occur in bursts whenever a nerve cell
has a task to perform.
Sometimes, these cells or groups of cells continue
firing after a task is finished.
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68. Etiology
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69. Management
Treatment of underlying condition
Avoidance of precipitating factor
Suppression or control of recurrent seizure
 Antiepileptic drug therapy (AEDT)
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70. Management
PHARMACOLOGIC THERAPY
Many medications are available to control seizures,
although the mechanisms of their actions are still
unknown .
The objective is to achieve seizure control with minimal
side effects.
 Medication therapy controls rather than cures seizures.
Medications are selected on the basis of the type of
seizure being treated and the effectiveness and safety of
the medications .
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71. Management…
Medical Management
 To prevent subsequent seizure using a single agent , in
order to limit side effects.
 The drugs should be administered in progressive dose
until seizure control.
 If monotherpay fails, a second drug added to the pt’s
regimen.
 If control is achieved, first agent might be carefully
withdrawn.
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72. Management…
A. Phenobarbitone
In developing countries,
 is the drug of choice for the control of partial and GTC seizures,
due to the wide availability and cheaper cost of the drug
Dosage forms: 15, 30, 60 and 100 mg tabs.
 Starting dose for adults is 60mg PO daily.
 If seizure is not controlled the dosage may be increased
gradually.
 If Rx fails or poor control with maximum , tolerable doses, a
2nd AEDS is often added.
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73. Management…
B. Phenytoin:
Usual prescribed as a 2nd line drug in
resource limited settings.
Dosage:
100 mg PO BID or TID , which may be gradually
increased to a max of 200 mg PO TID.
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Side effects:
• Gingival hyperplasia
• Coarsening of facial feature
• Toxic hepatitis

74. Management…
Primary GTCS Partial Absence Atypical absence
myoclonic,
Atonic.
First line Valproic acid
Lamotrigine
Carbamazepine
Phenytoin
Valproic acid
Valproic acid
Ethusuximide
Valproic acid.
Second line Phenytoin
Carbamazepine
Phenobarbitone
Topiramate
Phenobarbitone.
Lamotrigin
Clonazepam
Lamotrigin.
Clonazepam.
Topiramate.
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75. Management…
Surgical methods
For patients whose epilepsy results from:
 Intracranial tumors
 Abscesses
 Cysts or
 Vascular anomalies.
 Patient’s who are refractory to medical ,control benefit from
surgery. (intractable seizure disorders that do not respond to
medication
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76. Management…
 Surgical removal of epileptogenic region
 Cutting corpus callosum to prevent spread of seizures b/n
hemispheres
 Temporal lobe resection
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77. STATUS EPILEPTICUS
Definition:
 A condition characterized by continuous or repetitive seizure
with impairment of consciousness during interictal period,
which lasts for more than 30 minutes.
 Acute prolonged seizure activity
 Generalized seizures that occurs with out full recovery of
consciousness between attacks
 It is a medical emergency.
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78. CLINICAL FEATURE
Patient is having over convulsion
After 30-35 min of uninterrupted seizure, the signs may
become increasingly subtle.
EEG
History of epilepsy /seizure ,withdrawal of the drugs
Blood tests
Glucose, Electrolytes, LFT, RFT .
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DIAGNOSTIC FINDINGS

79. Complications
Hypoxia
Metabolic acidosis
Hypotension
Hyperthermia
Irreversible neuronal injury
Hypoglycemia
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80. MANAGEMENT
Goals of treatment:
To stop the seizures as quickly as possible.
To ensure adequate cerebral oxygenation
To maintain the patient in a seizure-free state.
1.Emergency supportive measures:
 Keep Airway patent and maintain breathing
 Secure IV line and take blood for lab Invn.
 Give glucose IV with Thiamine
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81. MANAGEMENT
2. Control the seizure with anticonvulsant.
Diazepam IV 5-10mgIV.
Phenoytoin 20 mg/min if seizure continues.
General anesthesia with phentobarbitol, if
seizure becomes refractory.
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82. NURSING M.g. of seizure/epilepsy
Areas of the body involved
Type of movements in the part of the body involved
Whether the eyes or head turned to one side
Presence or absence of automatisms
Incontinence of urine or stool
Duration of each phase of the seizure
Unconsciousness, if present, and its duration
Confused or not confused after the seizure
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83. NURSING M.g.
Description of seizure should include:
 Events preceding seizure: What was happening before the
seizure ?
 Does patient recognize onset of seizure by a smell, visual
disturbance, sound or odd feeling ?
 Events during the seizure: What are the initial events ? Is
consciousness lost or altered ? What kind of body
movements occurred ? How long did the seizure last ? Did
the person urinate or bite his/her tongue ?
Events after the seizure (i.e. postictal period). Is the patient
alert, drowsy, or confused ?
 Was there any numbness or weakness ?
84
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84. Nursing Management After a Seizure
 the nurse’s role is to document the events leading
to and occurring during the seizure.
prevent complications (eg, aspiration, injury).
To prevent complications,the patient is placed in
the side-lying position .
 if needed to maintain a patent airway.
The bed is placed in a low position with side rails
up and padded if necessary to prevent patient
injury.
05/02/2023
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85. NURSING M.g.t…
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86. Epilepsy…
First aid measures
 Protect the person from injury - (remove harmful objects from
nearby)
 Cushion their head
 Look for an epilepsy identity card or identity jewelery.
 Aid breathing by gently placing them in the recovery position once
the seizure has finished.
 Stay with the person until recovery is complete
 Be calmly reassuring
By Amir A
87
05/02/2023

87. Epilepsy…
Do not do…
 Restrain the person’s movements
 Put anything in the person’s mouth
 Try to move them unless they are in danger
 Give them anything to eat or drink until they are fully
recovered
 Attempt to bring them round
By Amir A
88
05/02/2023

88. Cerbrovascular accident
(Stroke)
05/02/2023
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89. Cerebrovascular disorders (stroke)
Cerebrovascular disorders (stroke)- term that
refers to any functional abnormality of the
central nervous system (CNS) that occurs when
the normal blood supply to the brain is disrupted.
A stroke, or CVA, occurs when blood supply
to part of the brain is disrupted, causing
brain cells to die
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90. Epidemiology
 Stroke is prevalent all over the World wide.
 It is third commonest cause of death in
developed world .
 Following Coronary heart diseases and cancer.
 It is a leading cause of disability.
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91. 05/02/2023
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 The brain represents only 2% of the body's weight. But,
 It uses about 25 % of the body's oxygen supply and 70 % of the
glucose.
 Unlike muscles, the brain cannot store nutrients.
 If the blood supply is interrupted for:
 30 seconds-unconsciousness and
 4 minutes- Permanent brain damage result in.
When brain cells die, they are not replaced

92. Stroke…
 Large artery thrombosis
 Small penetrating artery
thrombosis
 Cardiogenic embolic
 Accounts  80% - 85%
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 Intracerebral hemorrhage
 Subarachnoid hemorrhage
• Cerebral aneurysm
• Arteriovenous malformation
 Accounts  15% - 20%
Etiologic classification
Ischemic Hemorrhagic
CAUSES

93. Etiologic classification
can be divided into two major categories:
A, ischemic stroke -(85%); in which vascular
occlusion and significant hypoperfusion occur.
it is termed “brain attack”
is a sudden loss of function resulting from
disruption of the blood supply to a part of the
brain.
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Classification Stroke

94. Ischemic Stroke…
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Types
Thrombotic
Embolic
 Blood clot travels to
the brain
Blood flow is blocked
to the brain

95. Ischemic Stroke
Are subdivided in to different types
according to their cause:
A,THROMBOTIC(61%)
 large artery thrombosis : resulting from
narrowing of cerebral arteries due to
atherosclerosis.
 small penetrating artery thrombosis
Also called lacunar strokes b/c cavity
created.
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96. Ischemic Stroke…
B, cardiogenic embolic stroke
 Are associated with cardiac
dysrhythmias,usually atrial fibrillation.
 Emboli originate from the heart and circulate
to the cerebral vasculature.
 Most commonly the left middle cerebral artery.
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97. Ischemic Stroke…
C,Cryptogenic and others
 strokes, which have no known cause.
D, Other strokes, can be from drugs - cocaine use,
coagulopathies,
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98. Ischemic Stroke…
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Classification Coverage
1 Small penetrating artery
thrombosis
25%
2 Large artery thrombosis 20%
3 Cardiogenic embolic stroke 20%
4 Cryptogenic 30%
5 Other 5%

99. Ischemic Stroke
Ischemic Stroke…
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100. Hemorrhagic Stroke
B,Hemorrhagic (15%), in which there is extravasation of
blood into the brain.
 caused by an intracranial hemorrhage
Mainly associated with unrecognized or poorly
controlled hypertention.
 subarachnoid hemorrhage.
from ruptured intracranial aneurysm, or certain
medications (eg, anticoagulants and amphetamine)
 Patients generally have more severe deficits and a longer
recovery time compared to those with ischemic stroke .
 is a much common cause of stroke in developing countries
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101. Pathophysiology…
A. Ischemic stroke occurs because of a loss of blood supply
to part of the brain, initiating the ischemic cascade.
There are three reasons why ischemic stroke might occur:
 Thrombosis (obstruction of a blood vessel by a blood clot
forming locally)
 Embolism (obstruction due to an embolus from elsewhere
in the body,
 Systemic hypo perfusion ( blood supply, e.g. shock)
05/02/2023
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102. Pathophysiology…
Atherosclerosis may disrupt the blood supply by :
Narrowing the lumen of blood vessels or
formation of blood clots within the vessel, or
Releasing showers of small emboli  reduction of blood
flow
05/02/2023
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103. Pathophysiology…
Embolic infarction occurs as a consequence of atrial
fibrillation, or occlude the cerebral circulation.
Then the brain becomes low in energy  anaerobic
respiration which produces less ATP to fuel depolarization
and releases a by-product called lactic acid.
Lactic acid is an irritant acid which disrupts acid-base
balance in the brain  destroy brain cells
05/02/2023
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104. Pathophysiology…
B. Hemorrhagic Stroke
Intracranial hemorrhage is the accumulation of blood
anywhere within the skull vault.
 Epidural hematoma
 Subdural hematoma
 Subarachnoid hemorrhage
By Amir A
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05/02/2023

105. Pathophysiology…
Hemorrhagic strokes result in tissue injury by causing
compression of tissue from an expanding hematomas.
The pressure leads to a loss of blood supply to affected
tissue with resulting infarction, and
The blood released to brain also have direct toxic effects
on brain tissue
05/02/2023
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106

106. Warning Signs for Stroke
Warning Signs
 All patients should be taught to recognize warning signs of a
stroke, and to call 911 immediately if they occur.
 Warning signs include:
 Sudden numbness or weakness of face, arm, or leg(especially
on one side of the body)
 Sudden confusion, trouble speaking, or understanding
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance,or
coordination
 Sudden severe headache with no known cause
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107. Clinical Manifestations of stroke
Symptoms are varied and depend on the area of the brain
affected.
Common symptoms include
visual disturbances,
language disturbances,
 weakness or paralysis on one side of the body
 difficulty swallowing (dysphagia).
 In addition, the patient with a hemorrhagic stroke may
experience rapid deterioration, drowsiness, and a
severe headache, often described as “the worst headache of my
life
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108. Language Disturbances
Aphasia refers to the absence of language;
Dysphasia refers to difficulty with speech .
Aphasia may be expressive, in which the patient
knows what he wants to say but cannot speak or
make sense,
Aphasia may be receptive, with an inability to
understand spoken and/or written words.
Global aphasia occurs when both expressive and
receptive aphasia are present.
05/02/2023
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Clinical Manifestations of stroke

109.  Dysarthria is Slurred or indistinct speech and abnormal
pronunciation of words and articulation because of a motor
problem
(difficulty in speaking caused by paralysis of the muscles
responsible for producing speech)
 Apraxia (inability to perform a previously learned action)
Motor, sensory, cranial nerve, cognitive, and other functions may
be disrupted.
 MOTOR LOSS
 The most common motor dysfunction is Hemiplegia (paralysis
of one side of the body) due to a lesion of the opposite side of
the brain.
 Hemiparesis,or weakness of one side of the body.
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Clinical Manifestations…

110. Clinical Manifestations…
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Strokes occur in the brain and
affect the opposite side of the body

111. Clinical Manifestations…
 The patient's head turns away from the affected side of
his body, and he tends to neglect that side and the space
on that side.
 In such instances, the patient is unable to see food on
half of the tray, and only half of the room is visible.
The patient may not be able to dress himself because of
his inability to match his clothing to his body parts.
05/02/2023
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112

112. Clinical Manifestations…
Bladder Dysfunction.
After a stroke the patient may have transient
urinary incontinence
due to confusion, inability to communicate his
needs, and inability to use the urinal/bedpan
because of impaired motor and postural controls.
Occasionally after a stroke the bladder becomes
atonic with impaired sensation in response to
bladder filling.
05/02/2023
By Amir A
113

113. Clinical Manifestations…
COGNITIVE IMPAIRMENT AND PSYCHOLOGICAL
EFFECTS
If damage has occurred to the frontal lobe
learning capacity,memory, or other higher cortical
intellectual functions may be impaired.
manifested by emotional lability, hostility, frustration,
and lack of cooperation.
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114

114. Clinical Manifestations…
Cognitive Deficits
 Short- and long-term memory loss
 Decreased attention span
 Impaired ability to concentrate
 Altered judgment
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115

115. Diagnosis
History and physical examination important
Important historical Information includes:
Mode of onset and pattern of progression.
Embolisms usually occur suddenly when the patient is
awake, most often early in the morning, giving maximum
deficit onset.
Hemorrhagic stokes also occur suddenly while the patient
is awake and may be physically active or straining and
progressive with minutes to hours.
05/02/2023
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116. Diagnosis
History and physical examination
Thrombosis often occurs during sleep hour or
present upon arising from bed progressing in
stepwise fashion.
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117. Diagnosis
Angiography-“gold standard” identifies occlusion or
stenosis of large and small vessels
CT scans
MRI
 Doppler ultrasound, and
Arteriography
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118. Diagnosis…
Physical examination
A neurological examination
A medical history of the symptoms and
A neurological status, helps giving an evaluation of the
location and severity of a stroke.
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119. Diagnostic…MRI
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120. Assessment and Diagnostic…CT scan
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121. Diagnostic…
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122. Diagnostic…
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123. Assessment and Diagnostic…
Echocardiogram – detects if any thrombus (blood
clot) within the heart chambers
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124. MANAGEMET OF STROKE
Goal of treatment:
Interruption of further brain damage.
Managemet of complication.
General Measures(ABC)
 Admit the patients where close follow up can be given.
continue follow up and maintenance of vital functions.
 Airway and ventilation.
Controlling of blood pressure.
Controlling body temperature.
Fluid administration/hydration
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125. MANAGEMET OF STROKE
If the patient is comatose or has impaired mental status
changing the patients position every 2 hrs and avoid the
occurrence of bed sores.
 bladder and bowel care: if the patient has incontinence-
Inserting catheter.
Infections such as aspiration pneumonia should be treated
with antibiotics.
05/02/2023
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126

126. Treatment
Treatment of ischemic stroke
Definitive therapy is aimed at removing the blockage:
 thrombolysis, or
 thrombectomy
The more rapidly blood flow is restored to the brain, the
fewer brain cells die.
05/02/2023
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127

127. Treatment…
Treatment of ischemic stroke…
 Antiplatelet agents
 ASA50-300 mg: ↓ risk by 20-25%.
 Dipyridamole 200mg BID alone: ↓ risk by 15%.
 Plavix 75 mg po qid : ↓ 0.5% absolute annual risk reduction when
compared to ASA.
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128

128. Treatment….
Treatment of hemorrhagic stroke
Neurosurgical evaluation: Intracerebral hemorrhage
require to detect and treat the cause of the bleeding
Anticoagulants and antithrombotic: cannot be used in
intracerebral hemorrhage
 monitoring level of consciousness, and B/P, blood sugar,
and oxygenation are kept at optimum levels.
Surgery to repair the aneurysm may be done.
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129. 05/02/2023
By Amir A 130
Prevention of another stroke
 Control The Risk Factors For Stroke, Such As:
 High blood pressure,
 Atrial fibrillation,
 High cholesterol, and
 Diabetes
Changes in lifestyle will be an important to reduce risks:
 Limit alcohol, Avoid smoking or 2nd hand smokers
 At least 30 minutes of exercise Walking is a good choice.
 Stay at a healthy weight, Eat a balanced diet that is low in cholesterol,
saturated fats, and salt.

130. HEAD INJURIES
Head injury is a broad classification that includes
injury to the scalp,skull, or brain .
Traumatic brain injury is the most serious form
of head injury.
The most common causes of traumatic brain
injury are motor vehicle crashes, violence, and
falls.
05/02/2023
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131

131. Pathophysiology
Damage to the brain from traumatic injury takes two
forms: primary injury and secondary injury.
 Primary injury is the initial damage to the brain that
results from the traumatic event.
This may include contusions, lacerations, and torn blood
vessels from impact, acceleration/deceleration, or foreign
object penetration
 Secondary injury evolves over the ensuing hours and
days after the initial injury and is due primarily to brain
swelling or ongoing bleeding.
05/02/2023
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132. Pathophysiology
An injured brain is different from other injured body areas
due to its unique characteristics.
 It resides within the skull, which is rigid, closed
compartment .
Thus, any bleeding or swelling within the skull increases
the volume of contents within a container of fixed size
and so can cause increased intracranial pressure (ICP).
05/02/2023
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133. Pathophysiology
 If the increased pressure is high enough, it can cause a
downward or lateral displacement of the brain through or
against the rigid structures of the skull.
 This causes restriction of blood flow to the brain,
decreasing oxygen delivery and waste removal.
Cells within the brain become anoxic and cannot
metabolize properly, producing ischemia, infarction,
irreversible brain damage, and eventually brain death.
05/02/2023
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134

134. HEAD INJURIES cont’d
SCALP INJURY
Isolated scalp trauma is generally classified as a minor
head injury.
Because its many blood vessels constrict poorly, the scalp
bleeds aprofusely when injured.
Trauma may result in an abrasion , contusion, laceration,
or hematoma beneath the layers of tissue of the scalp
(subgaleal hematoma).
05/02/2023
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135

135. HEAD INJURIES cont’d
Diagnosis
 P/E--inspection, and palpation.
 Scalp wounds are potential portals of entry of organisms that
cause intracranial infections.
 Therefore, the area is irrigated before the laceration is sutured
 To remove foreign material and to reduce the risk for infection.
 Wound dressing
 Oral antibiotic drug
 Subgaleal hematomas (hematomas below the outer covering
of the skull) usually absorb on their own and do not require
any specific treatment.
05/02/2023
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136

136. HEAD INJURIES cont’d
SKULL FRACTURES
A skull fracture is a break in the continuity of the skull
caused by forceful trauma.
 It may occur with or without damage to the brain.
Skull fractures are classified as linear, depressed,and
basilar.
A fracture may be open, indicating a scalp laceration or
tear in the dura .
 closed, in which the dura is intact .
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137. SKULL FRACTURES
05/02/2023
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138. HEAD INJURIES cont’d
Simple linear fracture-this is aline of fracture which
usually marks of severe forces of injury.
Constitute about 80% of all fractures of the skull
Can be left as such if they are closed
No specific neurological management is required.
Depressed skull fructure
This types of fracture is usually as result of blunt trauma.
It could be open or closed.
50|% occurs in frontal area
05/02/2023
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139. HEAD INJURIES cont’d
The open type of fracturẹ/compound depressed
fracture/has a high risk of infection so that it should be
handled as emergency.
The depressed fragments may lacerate the dura and brain
tissue.
In infants: ping-pong fracture, skull deformed but
not broken and should be elevated
Treatment
Debride and irrigate contaminated wounds
Full course of interavenouse antibiotics.
Elevation if indicated 05/02/2023
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140. HEAD INJURIES cont’d
 Fractures of the base of the skull
Tend to traverse the paranasal sinus of the frontal bone or
the middle ear located in the temporal bone; thus, they
frequently produce
Hemorrhage from the nose, the pharynx, or the ears,
Blood may appear under the conjunctivae.
An area of ecchymosis. or bruising, may be seen over the
mastoid (Battle's sign).
The escape of CSF from the ears (CSF otorrhea) and the
nose (CSF rhinorrhea) suggests basal skull fracture.
05/02/2023
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141. HEAD INJURIES cont’d
A halo sign (a blood stain surrounded by a yellowish
stain) may be seen on bed linens or the head dressing and
is highly suggestive of a CSF leak.
Drainage of CSF is a serious problem because meningeal
infection can occur if organisms gain access to the cranial
contents through the nose, ear, or sinus through a tear in
the dura.
 Bloody CSF suggests a brain laceration or contusion.
05/02/2023
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142

142. Assessment and Diagnostic Findings
History and physical examination
 A computed tomography (CT) scan
 Skull x-rays.
Magnetic resonance imaging (MRI)
Cerebral angiography
05/02/2023
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143

143. Treatment of basal skull fracture
 The nasopharynx and the external ear should be kept clean.
 Usually a piece of sterile cotton is placed loosely in the ear, or
a sterile cotton pad may be taped loosely under the nose or
against the ear to collect the draining fluid.
 The patient who is conscious is cautioned against sneezing or
blowing the nose.
 The head is elevated 30 degrees to reduce ICP and promote
spontaneous closure of the leak .
 Persistent CSF rhinorrhea or otorrhea usually requires surgical
intervention.
 IV Antibiotic to prevent infection
05/02/2023
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144

144. HEAD INJURIES cont’d
Brain Injury
The most important consideration in any head injury is
whether or not the brain is injured.
The brain cannot store oxygen and glucose to any
significant degree.
 Because the cerebral cells need an uninterrupted blood
supply to obtain these nutrients, irreversible brain damage
and cell death occur when the blood supply is interrupted
for even a few minutes.
05/02/2023
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145

145. HEAD INJURIES cont’d
Concussion
 A cerebral concussion after head injury is a temporary loss
of neurologic function with no apparent structural damage.
 A concussion generally involves a period of
unconsciousness lasting from a few seconds to a few
minutes.
 The jarring of the brain may be so slight as to cause only
dizziness and spots before the eyes , or it may be severe
enough to cause complete loss of consciousness for a time.
 If the brain tissue in the frontal lobe is affected, the patient
may exhibit bizarre irrational behavior.
05/02/2023
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146

146. HEAD INJURIES cont’d
The patient may be hospitalized overnight for observation
or discharged from the hospital in a relatively short time
after a concussion.
Treatment
 involves observing the patient for headache,dizziness,
lethargy, irritability, and anxiety.
The occurrence of these symptoms after injury is referred
to as postconcussion syndrome.
Giving the patient information, explanations, and
encouragement may reduce some of the problems of
postconcussion syndrome.
05/02/2023
By Amir A
147

147. HEAD INJURIES cont’d
Contusion
Cerebral contusion is a more severe injury in which the brain
is bruised, with possible surface hemorrhage.
The patient is unconscious for more than a few seconds or
minutes.
 Clinical signs and symptoms
 depend on the size of the contusion and the amount of
associated cerebral edema.
 The patient may lie motionless,with a faint pulse, shallow
respirations, and cool, pale skin.
 Often there is involuntary evacuation of the bowels and the
bladder.
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148

148. HEAD INJURIES cont’d
 The blood pressure and the temperature are subnormal,
similar to that of shock.
In general, patients with severe brain injury who have
abnormal motor function, abnormal eye movements, and
elevated ICP have poor outcomes
Reading assignment
Admission criteria for head injury
Classification of severity of head injury based
Glasgow coma scale(GCS)
05/02/2023
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149

149. HEAD INJURIES cont’d
Intracranial Hemorrhage
Hematomas (collections of blood) that develop within the
cranial vault are the most serious brain injuries.
A hematoma may be epidural (above the dura), subdural
(below the dura), or intracerebral (within the brain) .
05/02/2023
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150

150. HEAD INJURIES cont’d
Epidural Hematoma /Extradural Hematoma
 After a head injury, blood may collect in the epidural
(extradural) space between the skull and the dura.
This often results from fractures of the skull that cause
rupture or laceration of the middle meningeal artery,
which runs between the dura and the skull located just
inferior to a thin portion of temporal bone; hemorrhage
from this artery causes pressure on the brain.
05/02/2023
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151

151. HEAD INJURIES cont’d
The symptoms are caused by the expanding
hematoma.
There is usually a momentary loss of consciousness at
the time of injury
Followed by an interval of apparent recovery (lucid
interval).
During the lucid interval, compensation for the
expanding hematoma takes place by rapid
absorption of CSF and decreased intravascular
volume,.
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152

152. HEAD INJURIES cont’d
 signs of compression appear
 Usually deterioration of consciousness
 Focal neurologic deficits such as
 Dilation and fixation of a pupil
 Paralysis of an extremity, and the patient
deteriorates rapidly.
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153

153. HEAD INJURIES cont’d
 Management.
An epidura! hematoma is considered an extreme
emergency, as marked neurologic deficit or even
cessation of breathing may occur within minutes.
 The treatment consists of making openings through the
skull (burr holes), removing the clot, and controlling
the bleeding point.
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154

154. HEAD INJURIES cont’d
Subdural Hematoma
 A subdural hematoma is a collection of blood between the dura and the
underlying brain.
 The most common cause is trauma, but it may also occur in case aneurysms.
 A subdural hematoma may be acute, subacute, or chronic, depending on the size
of the involved vessel and the amount of bleeding present.
 Acute subdural hematoma :with in 48 hours after injury
 Sub acute subdural hematoma with in 2 to 14 days injury
 Chronic subdural hematoma: greater than 14 days
 Acute subdural hematomas are associated with major head injury involving
contusion or laceration.
 Usually the patient is comatose, and the clinical signs are similar to those of
epidural hematoma.
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155

155. HEAD INJURIES cont’d
A rising blood pressure with slowing of pulse and
respirations indicates a rapidly increasing hematoma.
The mortality rate for patients with acute subdural
hematomas is high, because frequently there is associated
brain damage.
If the patient can be transported rapidly to the hospital, an
immediate craniotomy is performed to open the dura,
allowing for the solid subdural clot to be evacuated.
 Successful outcome also depends on the control of ICP
and careful monitoring of respiratory
05/02/2023
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156

156. HEAD INJURIES cont’d
 patient's clinical signs and symptoms fluctuate.
There may be severe headache, which tends to come and
go.
Alternating focal neurologic signs
Personality changes
Mental deterioration
Focal seizures. Unfortunately, the patient may be labeled
neurotic or psychotic if the cause of the symptoms is
overlooked.
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157

157. HEAD INJURIES cont’d
The treatment of a chronic subdural hematoma
consists of surgically evacuating the clot by
suctioning or irrigating the area.
The procedure may be carried out through multiple
burr holes.
 craniotomy may be performed for a sizable subdural
mass lesion that cannot be drained through burr holes.
05/02/2023
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158

158. HEAD INJURIES cont’d
 Intracerebral Hemorrhage/Hematoma
Intracerebral hemorrhage is bleeding into the
substance of the brain.
It is commonly seen in head injuries in which force is
exerted to the head over a small area ( bullet wounds;
stab injury).
These hemorrhages within the brain may also result
from systemic hypertension,
 from rupture of a saccular aneurysm;
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159

159. HEAD INJURIES cont’d
from vascular anomalies;
 from intracranial tumors;
from systemic causes, including bleeding
disorders such as leukemia, hemophilia, and
thrombocytopenia;
 from complications of anticoagulant therapy.
Medical therapy involves
Careful administration of fluids and electrolytes,
Antihypertensive medications
Control of ICP, and supportive care.
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160

160. HEAD INJURIES cont’d
Surgical intervention by craniotomy or
craniectomy permits removal of the blood clot
and provides opportunity for control of the sites
of hemorrhage .
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161

161. Bell’s palsy (facial paralysis)
 Is a paralysis of the facial nerve (cranial nerve VII)
Is due to unilateral inflammation of the seventh cranial
nerve, which results in weakness or paralysis of the facial
muscles on the affected side .
The cause is unknown
 Possible causes may include
vascular ischemia,(stroke,hypertension)
viral disease ( HIV/AIDS .Herpes simplex, Herpes
zoster),
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162
Facial Paralysis(Bell’s palsy)

162.  Autoimmune disease, or a combination of all of these
factors.
Loss of motor control generally occurs on one side of the
face;
Bilateral facial palsy occurs in less than 1% of cases.
Contracture of facial muscles may occur if recovery is
slow.
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163
Facial Paralysis(Bell’s palsy)

163. Prevalence
Men and women are affected equally.
Bell’s palsy is more common in the third trimester of
pregnancy,
in individuals with immune disorders such as HIV
infection, and individuals with diabetes. Hypertension
 It occurs in all ages (including children) and at all times
of the year.
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164
Facial Paralysis(Bell’s palsy)

164. Facial Paralysis(Bell’s palsy)
Signs and Symptoms
Onset of symptoms may be sudden or may progress over a
2- to 5-days period.
The severity of the paralysis usually peaks within several
days of onset of symptoms.
Pain behind the ear may precede the onset of facial
paralysis.
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165

165. Facial Paralysis(Bell’s palsy)
The patient may be unable to close the eyelid,
Un able to wrinkle the forehead, smile, raise the eyebrow,
or close the lips effectively.
The mouth is pulled toward the unaffected side
 Other vague initial symptoms are dry eye or tingling
around the lips with progression to the more recognizable
symptoms .
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166

166. Drooling of saliva occurs, and the affected eye has
constant tearing.
Sense of taste is lost over the anterior two-thirds of the
tongue.
Speech difficulties are present.
Fifty percent of these patients will have complete
recovery in a short period of time.
 Thirty five percent will have full recovery in less than 1
year
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167
Facial Paralysis(Bell’s palsy)

167. 05/02/2023
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168
Facial Paralysis(Bell’s palsy)

168. Diagnostic Tests
History of the onset of symptoms is used to diagnose
Bell’s palsy.
Observation of the patient confirms the diagnosis.
The possibility of a stroke must be ruled out.
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169
Facial Paralysis(Bell’s palsy)

169. Therapeutic Interventions
Prevention of complications is the goal of treatment.
Prednisone may be given over 7 to 10 days to decrease
edema.
Analgesics are given for pain control.
Antiviral medication may be prescribed
05/02/2023
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170
Facial Paralysis(Bell’s palsy)

170. Moist heat with gentle massage to the face and ear also
eases pain.
To reduce pain and prevent muscle atrophy.
Provide warm, moist compresses prn.
Massage face.
Assist with facial exercises several times a day.
Provide frequent mouth care
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171
Facial Paralysis(Bell’s palsy)

171. Complications associated with Bell's palsy
include
 facial weakness
 facial spasm with contracture,
 corneal ulceration,
blindness
05/02/2023
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172
Facial Paralysis(Bell’s palsy)

172. Parkinson’s Disease
Parkinson’s disease is a chronic degenerative movement
disorder that arises in the basal ganglia in the cerebrum.
It usually begins in the fourth or fifth decade of life, with
symptoms becoming progressively worse as the patient
ages.
The disease is characterized by tremors, changes in
posture and gait, rigidity, and slowness of movements.
Approximately 1% of people over 65 have a diagnosis of
Parkinson’s disease.
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173

173. Parkinson’s Disease
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174

174. Parkinson’s Disease
Pathophysiology
The substantia nigra is a group of cells located within the
basal ganglia, which is situated deep within the brain.
These cells are responsible for the production of
dopamine, an inhibitory neurotransmitter.
 Dopamine facilitates the transmission of impulses from
one neuron to another.
Parkinson’s disease is caused by destruction of the cells of
the substantia nigra, resulting in decreased dopamine
production.
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175

175. Parkinson’s Disease
 Loss of dopamine function results in impairment of
semiautomatic movements.
 Parkinson’s disease is sometimes referred to as an
extrapyramidal disorder because the extrapyramidal tracts that
contain motor neurons are affected.
 Acetylcholine, an excitatory neurotransmitter, is secreted
normally in individuals with Parkinson’s disease.
 The normal balance of acetylcholine and dopamine is
interrupted in these patients, causing a relative excess of
acetylcholine,
 which results in the tremor, muscle rigidity, and bradyakinesia
and loss of muscle movement) characteristic of Parkinson’s
disease.
05/02/2023
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176

176. Parkinson’s Disease
Clinical Manifestations
 has a gradual onset and symptoms progress slowly .
The three cardinal signs are tremor, rigidity, and
bradykinesia(abnormally slow movements).
Other features include hypokinesia, gait disturbances, and
postural instability
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177

177. Parkinson’s Disease
TREMOR
 resting tremor is present in 70% of patients at the time of
diagnosis.
Resting tremor characteristically disappears with
purposeful movement but is evident when the extremities
are motionless.
The tremor may present as a rhythmic, slow turning
motion of the forearm and the hand and a motion of the
thumb against the fingers as if rolling a pill.
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178

178. Parkinson’s Disease
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179

179. Parkinson’s Disease
Tremor is present while the patient is at rest; it increases
when the patient is walking, concentrating, or feeling
anxious.
RIGIDITY
Resistance to passive limb movement characterizes
muscle rigidity.
Passive movement of an extremity may cause the limb to
move in jerky increments referred to as cog wheeling.
Stiffness of the neck, trunk, and shoulders is common.
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180

180. Parkinson’s Disease
BRADYKINESIA
One of the most common features of Parkinson’s disease
is bradykinesia.
Patients take longer to complete most activities and have
difficulty initiating movement, such as rising from a
sitting position or turning in bed.
Hypokinesia (abnormally diminished movement) is also
common and may appear after the tremor.
 the patient tends to shuffle and exhibits a decreased arm
swing.
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181

181. Parkinson’s Disease
the patient develops dysphagia, begins to drool, and is at
risk for choking and aspiration.
The patient commonly develops postural and gait
problems.
There is a loss of postural reflexes, and the patient stands
with the head bent forward and walks with a propulsive
gait. The posture
is caused by the forward flexion of the neck, hips, knees,
and elbows. The patient may walk faster and faster, trying
to move the shuffling gait
05/02/2023
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182

182. Parkinson’s Disease
Assessment and Diagnostic Findings
History and neurologic examination
Laboratory tests and imaging studies are not helpful in the
diagnosis of Parkinson’s disease,
 Evaluating levodopa (precursor of dopamine) uptake and
conversion to dopamine in the corpus striatum
05/02/2023
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183

183. Parkinson’s Disease
 Treatment is directed at controlling symptoms
 maintaining functional independence because
there are no medical or surgical approaches that
prevent disease progression.
 Care is individualized for each patient based on
presenting symptoms and social,occupational,
and emotional needs.
05/02/2023
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184

184. Parkinson’s Disease
Therapeutic Interventions
 There is no cure for Parkinson’s disease. Treatment is aimed
 at controlling symptoms and maximizing the patient’s
functional level.
 Anticholinergic Blocks the action of acetyl-choline to
control tremor and salivation
 Dopamine Agonists Convert into dopamine in the brain
 Levodopa/carbidopa combination .
 Carbidopa prevents peripheral breakdown of levodopa so more
is available in the CNS
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185

185. Parkinson’s Disease
Complications
The most typical acute complications of Parkinson’s
disease
 patients are very prone to falls, which may result in
injuries
Constipation is common because of decreased activity,
diminished ability to take in food and fluids, and side
effects of anticholinergic medications.
Patients are encouraged to increase fiber and fluids in
their diet.
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186

186. Parkinson’s Disease
Treatment is based on a combination of the following:
(a) Drug therapy.
(b) Physical therapy.
(c) Rehabilitation techniques.
(d) Patient and family education.
(2) Encourage patient to participate in physical therapy
and an exercise program to improve coordination and
dexterity.
(a) Emphasize importance of a daily exercise program.
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187

187. Parkinson’s Disease
 b) Instruct patient in postural exercises and walking techniques to
offset shuffling gait and tendency to lean forward.
 (c) Encourage warm baths and showers to help relax muscles and
relieve spasms.
 (3) Instruct patient to establish a regular bowel routine with a
high fiber diet and plenty of fluids.
 Constipation is a problem due to muscle weakness, lack of
exercise, and drug effects.
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188

188. Parkinson’s Disease
Eat a well-balanced diet. Nutritional problems develop
from difficulty chewing and swallowing and dry mouth
from medications.
Encourage patient to be an active participant in his/her
therapy and in social and recreational events, as
Parkinsonism tends to lead to withdrawal and depression
05/02/2023
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189

189. Spinal cord injuries
Excessive force exerted on the spinal column can result in
extreme flexion, hyperextension, compression or rotation.
Etiology
Motor vehicle accidents(which account for 35% of the
injuries)
 Falls(19%)
 Acts of violence(30%)
Sports injuries(8%)
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190
Spinal Cord Injury

190. The predominant risk factors for Spinal cord injury
include
Age, gender, and alcohol and drug use.
Individuals at risk for spinal cord injury injuries
Young adults b/n 15 – 30 yrs of age
Motor cyclists
Sky dive
Foot ball players
Police & military personnel
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191
Spinal Cord Injury

191. The vertebrae most frequently involved in Spinal
cord injury are the 5th, 6th, and 7th cervical (neck),
the 12th thoracic, and the 1st lumbar vertebrae
 There is a greater range of mobility in the vertebral
column in these areas
Spinal cord injury can be due to cord compression
by bone displacement, interruption of blood supply
to the cord or traction resulting from pulling on the
cord.
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192
Spinal Cord Injury

192.  Pathophysiology
Damage to the spinal cord ranges from transient
concussion (from which the patient fully recovers) to
contusion, laceration, and compression of the cord
substance (either alone or in combination)
 Spinal cord injury is can be separated into two categories:
primary injuries and secondary injuries.
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193
Spinal Cord Injury

193. Primary injuries are the result of the initial insult or
trauma and are usually permanent.
Secondary injuries are usually the result of a contusion or
tear injury ,in which the nerve fibers begin to swell and
disintegrate.
A secondary chain of events produces ischemia, hypoxia,
edema, and hemorrhagic lesions, which in turn result in
destruction of myelin and axons, thought to be reversible
4 to 6 hours after injury.
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194
Spinal Cord Injury

194. Classification
Spinal cord injuries are classified by
 Degree of injury
 Level of injury
 Mechanism of injury
 Neurologic level refers to the lowest level at
which sensory and motor functions are normal.
 Below the neurologic level, there is total
sensory and motor paralysis
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195
Spinal Cord Injury

195. The degree of spinal cord injury
 A complete spinal cord injury means that there is no motor
or sensory function below the level of the injury.
 Both Sides equally affected
 Can Result in quadriplegia or paraplegia
 An incomplete lesion
 Some function and/or sensation below injury site.
 classified according to the area of spinal cord damage:
central, lateral, anterior, or peripheral
 One side may be more affected than other
 Some patients find that having areas where sensation is intact
may be more painful than useful.
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196
Spinal Cord Injury

196. 05/02/2023
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197
Spinal Cord Injury

197. 05/02/2023
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198
Spinal Cord Injury

198. 05/02/2023
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199
Spinal Cord Injury

199. The level of injury may be
Cervical - thoracic or lumbar level
The cervical and lumbar portions of the spine are
injured more often than the thoracic or sacral segments.
 This is because the cervical and lumbar areas are the
most mobile portions of the spine
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200
Spinal Cord Injury

200. 05/02/2023
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201

201. the major mechanisms of injury are
 Hyperextension injury
 Hyper flexion injury
 Compression
 Excessive rotation
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202
Spinal Cord Injury

202. Signs and Symptoms
Cervical Injuries
 Signs and symptoms depend on the level of cord that is
damaged
 Cervical cord injuries can affect all four extremities,
causing paralysis and paresthesias
 Impaired respiration, and loss of bowel and bladder
control.
05/02/2023
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203
Spinal Cord Injury

203. Paralysis of all four extremities is called quadriplegia;
weakness of all extremities is called quadriparesis
Injury of the spinal cord at the cervical level results in
quadriplegia(tetraplagia)
Is the most dangerous and usually results in respiratory
muscle paralysis
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204
Spinal Cord Injury

204. If the injury is at C3 or above, the injury is usually fatal
because muscles used for breathing are paralyzed
 An injury at the fourth or fifth cervical vertebra affects
breathing and may necessitate some type of ventilatory
support.
Narcotic should not be given as analgesic for patients with
high cervical injury
These patients typically need long-term assistance with
activities of daily living
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205
Spinal Cord Injury

205. Thoracic and Lumbar Injuries
 Thoracic and lumbar injuries affect the legs, bowel, and
bladder.
 Paralysis of the legs is called paraplegia;
 weakness of the legs is called paraparesis.
 Injury of the spinal cord at the thoracic and lumbar vertebral
level can cause paraplegia
 Sacral injuries affect bowel and bladder continence and may
affect foot function.
 Individuals with thoracic, lumbar, and sacral injuries can
usually learn to perform activities of daily living
independently.
05/02/2023
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206
Spinal Cord Injury

206. Spinal Shock(neurogenic shock )
Spinal cord injury has a profound effect on the autonomic
nervous system.
 Immediately following injury, the cord below the injury
stops functioning completely.
This causes a disruption of sympathetic nervous system
function, resulting in vasodilation, hypotension, and
bradycardia ,paralytic ileus(occasionally),flaccid paralysis
,loss of reflex
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207
Spinal Cord Injury

207.  Dilation of the blood vessels allows more blood flow just
under the skin.
 This blood cools and is circulated throughout the body,
causing hypothermia.
 Keep the patient covered as much as possible but avoid
overheating.
In addition, all reflexes below the level of the injury are
lost, and retention of urine and feces occurs.
Spinal shock can last from a week to many weeks in some
patients.
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208
Spinal Cord Injury

208. Diagnostic test
 History and Complete neurological exam
Assessment of motor system.
Motor examination: Check for weakness of muscle power
and tendon reflexes
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209
Spinal Cord Injury

209. Assessment of sensory system.
Assessment of Sensory Examination includes:
Pain and temperature (by spinothalamic tract).
Position and vibration (by posterior column tract)
Light touch.
Two-point discrimination
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210
Spinal Cord Injury

210. Assessment of the reflexes.
Hematology - electrolyte, glucose, Hgb levels
X – ray of the Spinal cord – in different positions
U/A
CT scan, MRI.
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211
Spinal Cord Injury

211.  Therapeutic mg’t
 Emergency mg’t
 The initial goals are to sustain life & prevent cord damage
 Secure the airway, breathing and circulation (ABC rule of
trauma management
 Monitor air way have airway equipment available.
 IV resuscitation should be started in patients with spinal shock
 Patients with injuries above C4–5 have some degree of
respiratory impairment.
 The patient may require a tracheotomy and continuous
mechanical ventilation
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212
Spinal Cord Injury

212. Some patients are able to breathe by using a phrenic nerve
stimulator
 Immobilization of vertebral column by skeletal traction.
 Administration of 02
Maintenance of heart rate ( eg. Atropine ) and B/P (e.g.
Dopamine )
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213
Spinal Cord Injury

213. Steroid( prednisone) therapy to reduce edema
Assess for other injuries and control external bleeding
Indwelling urinary catheter insertion
Moderate fluid restriction for the 1st 72 hrs
Monitor V/S, level of consciousness, 02 saturation,
cardiac rhythm(ECG)
Mgt & attachment to suction intubation
keep warm.
 Giving Enema
 insertion of Nasogastric tube
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214
Spinal Cord Injury

214.  Bed sore prevention by bed care and frequent position
change
 Neurologic damage is prevented by suitable reduction
and immobilization any fracture
 Cervical spine malalignment –traction using skull tongs
or a hole apparatus
 Open reduction if traction fails
 Thoracic and lumbar spine –usually require a plastic body
jacket or plastic cast for three months
05/02/2023
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215
Spinal Cord Injury

215. 05/02/2023
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216
Spinal Cord Injury

216. 05/02/2023
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217
Spinal Cord Injury

217.  Surgery: If there is deterioration of neurological function
after initial assessment
 In ability to reduce the fracture or dislocation
Chronic pt Mg’t
Stress ulcer prophylaxis
Physical therapy ( range of motion exercise) occupational
therapy ( splints, activities of daily living training )
Rehabilitation is directed to wards self care and
vocational readjustment
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218
Spinal Cord Injury

218. Complications
 Infection
Impaired respiratory effort, decreased cough, mechanical
ventilation, immobility all predispose the cervical cord
injured patient to pneumonia.
Catheterization, whether indwelling or intermittent, places
patients at risk for urinary tract infection.
05/02/2023
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219
Spinal Cord Injury

219. Orthostatic Hypotension
Most spinal cord injured patients no longer have muscular
function in their legs to promote venous return to the
heart.
They also have impaired vasoconstriction.
This leads to pooling of the blood in the legs when the
patient moves from a supine to a sitting position.
If the movement is sudden, the patient may become dizzy
or faint.
05/02/2023
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220
Spinal Cord Injury

220. Skin Breakdown
Development of pressure ulcers can lead to infection and
loss of skin, muscle, or bone. Treatment of
pressure ulcers is time consuming and expensive
 Renal Complications
Urinary tract infections are an ongoing concern to spinal
cord–injured patients.
Both urinary reflux and untreated urinary tract infections
can cause permanent damage to the kidneys.
05/02/2023
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221
Spinal Cord Injury

221.  Deep Vein Thrombosis
Lack of movement in the legs inhibits normal blood
circulation.
Depression and Substance Abuse
Patients with spinal cord injury have a higher than average
incidence of depression and substance abuse
05/02/2023
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222
Spinal Cord Injury

222. Head Aches(Cephalgia)
 is one of the most common of all human physical complaints.
 Head ache is actually a symptom rather than a disease entity
 It is a symptom of underlying disease
As many as 90% of individuals have at least one episode of
headache per year.
 Most headaches are transient events and do not indicate a serious
pathological condition.
 If headaches are recurrent, persistent, or increasing in severity,
the patient should undergo a neurological evaluation.
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223

223. There are two types of head ache
 A primary headache is one for which no organic cause can
be identified.
These types of headache include Migraine, Tension type,
and Cluster headaches, Cranial arthritis
 A secondary headache is a symptom associated with an
organic cause, such as a brain tumor or an aneurysm.
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224
Head Aches(Cephalgia)

224. Headache assessment
 Headache characteristics – time of onset, location, frequency,
duration, quality , intensity ,paths of radiation etc
 Presence of localized tenderness
 Presence of an aura
 Associated symptoms occurring before, during or after a
headache
 precipitating factors
 Activities of daily living patterns
 Drug history
 Any family history
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225
Head Aches(Cephalgia)

225. Tension or Muscle Contraction Headaches
The most common type of head ache
Clinical feature
Tension headache is characterized by mild or moderate,
bilateral pain.
 Headache is a constant, tight, pressing or band like may
be described as “a weight on top of my head.
 Pain sensation in the frontal, temporal, parietal area or
Occipital
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226. precipitating factors that may cause tension headache
Including.
Stress – usually occurs in the afternoon after long stressful
work hours
 Over work
Sleep disturbance
Uncomfortable stressful position and/or bad posture
Hunger (Irregular meal time)
Eye strain resulting from continuous TV watching,
working on computer screen for a long time.
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227.  Tension head ache Usually lasts less than 24 hrs but can
persist for days or weeks.
 Prodromal symptoms are absent, some patients have neck, jaw
discomfort.( there is no nausea and vomiting)
 Pharmacotherapy
 Non narcotic analgesics(NSAIDS)
Diclofenac , ASA, Ibuprofen, and paracetamol
 supportive treatment:
 Include the use of relaxation techniques,, rest, localized heat
application, appropriate counseling ,massage of the affected
muscles
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228. Migraine Headache
Migraine headache is a benign and episodic disease,
characterized by
headache, nausea, vomiting and/ or other symptoms of
neurological dysfunction.
It is the most common cause of vascular headache.
 It approximately affects 15% of women and 6% men.
It usually begins in childhood or young adult life.
Family history can be found in 65% of the patient
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229. PATHOPHYSIOLGY
A migraine headache is believed to be caused by cerebral
vasoconstriction followed by vasodilatation.
 The vasoconstriction may be due to a response triggered
by the trigeminal nerve, which stimulates release of
substance P, a pain transmitter, into the vessels or by the
release of amines such as serotonin, norepinephrine, and
epinephrine.
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230.  A migraine may or may not begin with an aura (visual
phenomena, such as a flashing light that precedes an
attack
 Commonly used descriptors of migraine pain include
throbbing, boring and pounding
 It is usually on one side of the head(unilateral )
 Noise and light tend to exacerbate the headache
 leading the patient to rest in a dark, quiet environment.
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231.  the cause of migraine is often unknown, common precipitants
 Family history of migraine present in nearly 2/3 of patients.
 Environmental, dietary and psychological factors.
 Emotional stress , depression
 Altered sleep pattern
 Oral contraceptives
 menstrual cycle
 Alcohol intake especially red wine
 Caffeine withdrawal
 Various food staffs ( e.g. chocolates, cheese , meals
containing nitrates
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232. There are two types of migraine headaches:
classic migraine and common migraine.
 The classic migraine has a preheadache (prodromal)
phase in which the patient may experience
visual disturbances, difficulty with speaking, and/or
numbness or tingling, depression ,restlessness, irritable
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233.  The headache that follows is often accompanied by
nausea and sometimes vomiting, and may last for hours to
days.
A common migraine does not have the preheadache phase,
but the patient experiences an immediate onset of a
throbbing headache
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234.  Prophylactic Treatment: includes drug regimens and changes
in patients behavior
 Prophylactic treatment is indicated if the patient has three or
more attacks per month.
 Drugs used for this purpose include β-blockers (propranolol),
Calcium channel blockers (Verapamil ,Tricyclic
antidepressants (amitriptyline)
 Dietary restrictions may be helpful if precipitating foods or
beverages can be identified.
 Biofeedback therapy
 It is simple and cost effective. by helping patients deal more
effectively with stress
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235. Acute attack
 NSAIDS (Nonsteroidal antinflamatory agents): such as
ASA, paracetamol, Ibuprofen, Diclofenac
Reduce the severity and duration of migraine attack. for
mild to moderate attacks
Are most effective when taken early.
Ergot preparations: Ergotamine and dihydro-ergotamine)
Can be given oral, sublingual, rectal, nasal and parentral
preparation.
Dose: 1 – 2 mg oral
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236. Cluster Headaches
 Vascular disturbance, stress, anxiety, and emotional
distress are all proposed causes of cluster headaches.
 As indicated by the name, these headaches tend to occur
in clusters during a time span of several days to weeks.
 Alcohol consumption may worsen the episodes.
 The patient may state that the headache begins suddenly,
typically at the same time of night. Throbbing and
excruciating pain .
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237.  The headache tends to be unilateral, affecting the nose,
eye, and forehead. A bloodshot, teary appearance of the
affected eye is common, nasal stiffness
 During attack patients often have associated nasal
stiffness, lacrimation and redness of the eye ipsilateral to
the headache.
 Alcohol provokes attacks in about 70% of patients
 Because of the brief nature of cluster headaches, treatment
is difficult.
 A quiet, dark environment and cold compresses may
decrease the intensity of the pain.
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238. Treatment
Acute attack (Treatment)
 NSAID
 Inhalation of 100% oxygen and
 ergotamine .
 Sumatriptan
Preventions/prophylactic therapy:
Prednisolone , Lithium, Methysergide, Ergotamine,
Sodium valproate and verapamil
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240. References
 Suzanne C. O’Connell Smeltzer, & Brenda G. Bare. (2004). Brunner
and Suddarth’s Text Book of Medical-Surgical Nursing. 10th
Edition.
 Lewis,M.S.,Heitkemper,M.M.,and Dirksen,.R..S.(2000).Medical
Surgical Nursing :Assessment And Management Of Clinical
Problems .5th Ed.
 Kasper L, Braunwald E.(2005). Harrison’s princeples of internal
medicine,16th Edition.
 Porth C.(1989). Pathopysiology concepts of alterd health states. 4th
Ed
 Myers R.Allen,(2003) .National medical series for independent
study (NMS)3 th Edition.
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241. References
 Barbara B.(1995) A Guide to physical
examination and history taking,6 th Edition.
 http://www.medicinenet.com/seizure.
 Teklehaymanot R (1986) prevalence of active
epilepsy in Addis Ababa.
 Beare,G.P. &Myers,J.(1990).Principles And
Practice Of Adult Health Nursing.
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Thank
you!
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