Lecture Notes on Neurologic NursingPrepared By: RONEL E. JAPONDecreased HR and BPDecresead RRDiarrheaUrinary FrequencySeizuresMEDICAL-SURGICAL NURSINGNeurologic Nursing ________________________________________________________OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE NERVOUS SYSTEMI.Divisionsa. CNS brain and spinal cordb. PNS 12 pairs of cranial nerves and 31 pairs of spinal nerves 1. Spinal nerves: Cervical 8 Thoracic 12 Lumbar 5 Sacral 5 Coccygeal - 1c. ANS sympathetic and parasympathetic systemsII. SNS a. Adrenergic Agents 1. Epinephrine (Adrenaline) 2. Note: Side Effects (SE) normal drug expectancies b. Beta-Adrenergic Agents (Beta-Blockers) 1. Propanolol, metoprolol, atenolol 2. Bronchospasm, Elicits decreased cardiac contractions, Treats HPN, AV conduction slows down (BETA) 3. Anti-HPN Management Beta-blockers -olol ACE inhibitors -pril Ca-Antagonist nifedipine Transient headache and dizziness Orthostatic hypotension Q Assist in ambulation Q Pt. to rise slowly from sitting position 4. BP = CO x PR 5. CO = HR x SV 6. (N) HR = 60-100 bpm 7. (N) SV = 60-70 ml of H2OTOXIC SUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARIER: (BLACK) Bilirubin yellow pigment Lead Antidote: Ca+ EDTA Ammonia cerebral toxin; present in hepatic encephalopathy (liver cirrhosis) Carbon Monoxide in Parkinsons and Epilepsy Ketones cerebral depressantIII. CNSa.Sympathetic flight or aggression response release ofnorepinephrine increase in all bodily activity except GI(constipation); adrenergic; parasympatholytic response.REMEMBER: GIT is the least important area during stress decreased blood flow in the area; Increased blood flow in the brain,heart and skeletal muscles Mydriasis (dilat-ation) Dry mouth Increase in HR and BP Tachypnea Constipation Urinary retentionParasympathetic flight or withdrawal response release ofAcetylcholine decrease in all bodily activity except GI (diarrhea);chonlinergic/ vagal/ sympatholytic response Meiosis Increased salivationMSb.Cells1. Neurons Excitability Conductivity Permanence2. 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) Ependymal cells produces chemoattractants which concentrates bacteriaComposition1. 80% brain mass CEREBRUM divided into two hemispheres, the left and right and is bridged by the corpus callosum Motor, sensory, integrative function Lobes: Q Frontal controls higher cortical thinking, personality development, motor activity, contains BROCAs are or the motor-speech center. (Expressive Aphasia) Q Occipital vision Q Parietal appreciation and discrimination of sensory impulses (pain, touch, pressure, heat and cold)Abejo1

Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical InstructorQQQTemporal hearing, short term memory,contains the general interpretative areaWernickes aphasiaInsula (Island of Reil) visceral function(internal area)Limbic System (Rhinencephalon) senseof smell, libido or sexual urge control, longterm memoryCI Atlas; C2 AxisCSF shock absorber, cushions brain altered when there isobstruction in CSF drainageHYDROCEPHALUS posteriorly growth of the head d/t earlyclosure of fontanelsTypes of Cells:Labile (regenerative) Epidermal, GIT, Respiratory, GUTStable regenerative but limited survival period: liver, pancreas, salivary glands, kidneysPermanent cardiac, neurons, osteocytes, retinalNEUROLOGIC ASSESSMENTI.COMPREHENSIVE NEUROLOGIC EXAMA. Purpose 1. To know exact neuro deficit 2. To localize lesion 3. For rehabilitation 4. For guidance in nursing careB. Survey of Mental Status 1. LOC Conscious awake Lethargy sleepy/drowsy/obtunded Stupor only awakened by vigorous stimulation General body weakness Decreased body defenses Coma Light (+) to all painful stimuli Deep (-) to all painful stimuli PAINFUL STIMULATION Deep Sternal Stimulation/Pressure Orbital Pressure Pressure on Great Toes Nail bed pressure Corneal/Blinking Reflex Q Conscious wisp of cotton Q Unconscious institute/drop of saline solution (coma if positive reaction, deep coma if negative) 2. Test of memory (consider educational background) Short term memory (ask what the pt ate for breakfast) (+) anterograde amnesia temporal lobe damage Long term memory (ask birthday) (+) retrograde amnesia damage to Rhinencephalon (Limbic system)C. Levels of Orientation (time, person and place)D. CN AssessmentE. Motor AssessmentBASAL GANGLIA areas of gray matterlocated deep within each cerebral hemisphere;involved in the extrapyramidal tract; producesDOPAMINE (controls gross voluntary movement)MIDBRAIN (Mesencephalon) acts as a relaystation for sight and hearing particularly helps insize and reaction of pupils and hearing acuity N hearing acuity : 30-40dB N pupil constriction: 2-3 mm N pupil finding: PERRLA Isocoria vs. AnisocoriaDIENCEPHALON (Interbrain) Thalamus acts as a relay station for sensation Hypothalamus controls temperature, BP, sleep and wakefulness, thirst, appetite (satiety), some emotional responses like fear, anxiety and excitement, controls pituitary functionsBRAIN STEM Pons (Pneumotaxic center) controls rate, rhythm and depth of respiration Medulla Oblongata lowest part; damage: most life threatening; controls respiration, HR,swallowing,vomiting,hiccups, vasomotor centerCEREBELLUM smallest part; lesser brain;balance, equilibrium, gait and posture.F.2.3.10 % CSF10% BloodMONROE KELLY HYPOTHESIS the skull is a closedvault, any increase in one component will bring about increasesin ICPNORMAL ICP IS 0-15 MMHG; NORMAL CSF: 120-250CC/DAYNORMAL CSF OPENING PRESSURE: 60-150 MMHGNORMAL CSF CONTENTS: GLUCOSE, PROTEINS, WBCSFORAMEN MAGNUM - The large opening in the basal part ofthe occipital bone through which the spinal cord becomescontinuous with the medulla oblongata.2Sensory Assessment1. PAIN - Gingerbread test 100% very painful 75% tolerable pain 25% moderate pain 0% no pain2. TOUCH Stereognosis Identifying familiar object placed on clients hands Astereognosis if patient cannot identify object; damage in parietal lobe3. PRESSURE AND TOUCH Graphesthesia Identify numbers or letters written on clients palm Agraphesthesia if (-), damage to parietal lobeG.Cerebellar TestAbejoMS

Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical InstructorH.I. Rombergs Test Instruct patient to close eyes, assume a normal anatomical position for 5-15 minutes; two nurses at right and left side Normal is (-) If (+) ataxia2. Finger-to-nose Test3. Alternate Pronation and Supination Dysmetria inability of a client to stop a movement at a desired pointDTRsAutonomics1.2.3.Dysosmia distorted sense of smellAnosmia absence of smellII. 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 = 3II. OPTIC A. Sensory Vision B. Tests 1. Test of Visual Acuity/Central or Distance Vision Materials Snellens Chart Q Alphabet literate Q E chart illiterate Q 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 Nasally InferiorlySensorySensoryMotorMotorSensory,motorMotorSensory,motorSensorySensory,motorSensory,motorMotorMotorSomeSayMarryMoneyButMyBrotherSaysBadBusinessMarryMoneyC.COMMON VISUAL DISORDERS1. Glaucoma 40 yo, obese hereditary Loss of peripheral vision tunnel vision Increased IOP (N = 12-21 mm Hg) Signs and symptoms: Headache Nausea and vomiting Halos around lights Steamy cornea Acute angle closure glaucoma most dangerous, may lead to blindness Diagnostics: Tonometry increased IOP Gonioscopy obstruction in anterior chamber Perimetry decreased visual fields Drugs (for lifetime) Timolol maleate Pilocarpine drug of choice (miotic) Epinephrine decrease in aqueous humor CarbonicAnhydraseDiamox (Acetazolamide) Q Decrease in aqueous humor (maintains IOP); promotes drainage Q Monitor I/OAbejoCRANIAL NERVE ASSESSMENTI.II.III.IV.V.VI.VII.VIII.IX.X.XI.XII.I.OlfactoryOpticOculomotorTrochlear (smallest) (down)Trigeminal(largest)(triCHEWminal)Abducens (at the sides)FacialAcoustic (Vestibulocochlear)GlossopharyngealVagus (longest) (mavagal)Accessory (shoulders)HypoglossalOLFACTORYA. Sensory smellB. Use coffee, bar soap, vinegar, cigarette tarC. Abnormal findings Indication of: Head trauma damaging the cribriform plate of ethmoid bone where olfactory cells are located Sinusitis give antibiotics to prevent meningitis 1. Hyposmia decreased sensitivity to smell3MS

Lecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor NO ATROPINE: may lead to increased IOPSurgery Trabeculectomy Peripheral iridectomy Q Uveitis inflammation of the iris Q Keratitis inflammation of the cornea TraumaNasolabial folds most evident sign of facialsymmetryI.2.3.CataractLoss of central vision Glaring or hazy visionOpacity of lens, milky white appearance of cornea, decreased perception to colorsDue to agingProlonged UV rays exposureCongenital disorder very rareDMDx: Ophthalmoscopic examinationTx: Mydriatics, cycloplegics (cyclogil) paralyzes ciliary musclesSurgery: lens extraction ECLE partial removal of cataract ICLE capsule included, total removal of cataractRetinal Detachment most common complicationfollowing lens extractionCurtain veil like visionLeads to blindnessSevere myopia common cause Emetropia normal refraction of eyes Presbyopia loss of lens elasticity due to aging(+) floaters d/t seepage of RBCsSurgery: Scleral Buckling, Diathermy (heat application), Cryosurgery (cold application)Macular degeneration degeneration of macula lutea(yellowish spots in center of retina)Black spotsYellowish spots in center of retina or the macula luteaIt innervates movt of EOMsACOUSIC/VESTIBULOCOCHLEARA. Controls balance or kinesthesia (position sense/ movement and correlation of body in space) 1. Organ of corti (true sense organ for hearing) for hearing 2. Cochlea snail-shaped organ in middle earB. Disorders 1. Conductive hearing loss 2. Otitis Media 3. Menieres diseaseArchimedes Principle buoyancy (pregnancyfetus)Daltons Law of Partial PressureInertia - Kinesthesia II.III.IV.V.GLOSSOPHARYNGEAL taste; posterior 1/3 tongueVAGUS gag reflex, decreased vital signs, eyes constrict, mouthmoist PNSSPINAL/ACCESSORY controls 2 muscles:A. Sternocleidomastoid (neck)B. Trapezius (Shoulder)HYPOGLOSSAL tongue movement; frenulum linguae anchors tongue (tongue tied short frenulum)DEMYELINATING DISEASESI.ALZHEIMERS DISEASE - atrophy of the brain tissuecharacterized by:a. Amnesiab. Agnosia (-) sense of smellc. Apraxia (-) purposive movementsd. Aphasia 1. Expressive/Brocas problem in speaking 2. Receptive/Wernickes problem in understanding; USUAL FOR ALZHEIMERS 3. Brocas area motor speech center; frontal 4. Wernickes area general interpretative area; temporale. ARICEPT drug of choice, given at HS COGNEX also given4.III. OCULOMOTORIV. TROCHLEARV. ABDUCENSSR(Abducens) LR IRIO (trochlear) MRSOA.B.C.Normal response PEBRTLA/ PERRLA (isocoria)Anisocoria unequal pupilsNystagmus Rhythmical oscillation of the eyeballs, eitherpendular 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 chewing, dysphagia 1. avoid foods with extreme temperature 2. DOC: carbamazepine (Tegretol)VII. FACIALA. Sensory anterior 2/3 of tongue; identify taste without swallowingB. Motor facial expression control 1. instruct patient to smile, frown or raise eyebrows Bells palsy or (temporary) facial paralysis damage to facial nerve caused by: Forceps delivery - #1 cause Autoimmune Stress4PICKS Disease: a form of dementia wherein there is damage in thefrontoparietal areaII. MULTIPLE SCLEROSIS chronic, intermittent disorder of the CNS characterized by white patches of demyelination of the brain and spinal cord. IDIOPATHIC, AUTOIMMUNEA.B.INCIDENCE RATE: 15-35 yo, femalesPREDISPOSING FACTOR1. Slow growing virus2. Autoimmune body produces antibodies which attacks normal cells3. REVIEW: ANTIBODIES IgG passes placenta (gestational) IgA found in bodily secretions, colostrumsAbejoMSLecture Notes on Neurologic NursingPrepared By: Mark Fredderick R Abejo R.N, MAN Clinical InstructorIgM acute infections (mabilis)IgE allergic reactionsIgD Chronic infections (dalas)Brought about by increase in the three intracranial componentsA.PREDISPOSING FACTORSa. Head injuryb. Tumorc. Localized abscessesd. Cerebral edemae. Hydrocephalusf. Hemorrhageg. Inflammatory conditions 1. Meningitis 2. EncephalitisSIGNS AND SYMPTOMSa. Early signs 1. Decreased or change in LOC 2. Restlessness to confusion 3. Disorientation 4. Lethargy to stupor 5. Stupor to comab. Late signs 1. Changes in the vital signs Elevated BP (SBP rising, DBP constant) N Pulse Pressure: 40 mmHG HR decreased RR decreased (Cheyne-Stokes respiration: normal rhythmic respiration followed by periods of apnea) Elevated temperature 2. Headache, papilledema, projectile vomiting 3. Abnormal posturing- decorticate (flexion) damage to corticospinal tract (spinal cord and cerebral cortex) remember: deCORDThreecate OR decerebrate (extension): upper brain stem damage pons, midbrain, cerebellum 4. Unilateral dilation of pupil (ANISOCORIA) indicates uncal brain herniation; if bilateral dilatation: tentorial herniation 5. possible seizures 6. Cushings reflex (hypertension with bradycardia)ooC.SHOCK inadequate tissue perfusionHYPOXIA inadequate tissue oxygenationB.C.CLINICAL MANIFESTATION1. Visual disturbances Blurring of vision Diplopia Scotoma (blind spot)2. Impaired sensation to touch, pain, pressure, heat and cold Tingling sensation Paresthesia Numbness3. Mood swings Euphoria sense of well-being4. Impaired motor activity Weakness Spasticity Paralysis5. Impaired cerebellar function CHARCOTS TRIAD: ataxia (unsteady gait), nystagmus, intentional tremors Scanning speech6. Urinary retention or incontinence7. Constipation8. Decrease in sexual capacityDIAGNOSTIC PROCEDURE1. CSF Analysis LT: reveals increased CHON and IgG2. MRI site and extent of demyelinationNURSING MANAGEMENT: Palliative1. Administer medications as ordered Acute Exacerbation ACTH (Adrenocorticotropic hormone) reduces edema at site of demyelination thereby preventing paralysis; compression of spinal cord will lead to paralysis Baclofen (Lioresal), Dantrolene Na to reduce muscle spasticity Interferons Immunosuppressives Diuretics PROPHANTHELENE BROMIDE (PRO-BANTHENE) anti-cholinergic for urinary incontinence2. Provide for Relaxation DBE, biofeedback, yoga3. Retain side rails4. Prevent complications of immobility TTS Q2h, Q1 h for elderly, 20 minutes only on affected side5. Increase OFI, high fiber diet (for constipation), acid- ash in diet to acidify urine to prevent bacterial multiplication (cranberry juice, prunes, grape juice, vitamin c, plums, orange and pineapple juice.)6. Provide catheterization for urinary retentionD.F.NURSING MANAGEMENT 1. maintain patent airway and adequate ventilation by: prevention of hypoxia ( cerebral edema increased ICP) and hypercarbia (CO2 retention) cerebral vasodilation increased ICP decreased tissue perfusion possible shock Early signs of hypoxia Restlessness Agitation Tachycardia Late signs of hypoxia Bradycardia Extreme restlessness Dyspnea Cyanosis Increased CO2 most potent respiratory stimulant in the normal person (irritates medulla oblongata) Decreased O2 stimulates respiration in CRDS Suctioning should only last for 10 -15 seconds and application of suction should be done upon withdrawal of catheter in a circular fashion.2.3.Assist in mechanical ventilationElevate head of bed 30-45 degrees with neck in neutralposition when contraindicated to promote venousdrainageLimit fluid intake to 1.2-1.5 l per day (Forced fluids =2-3 L/day)Monitor VS, NVS, I/O strictlyPrevent complications of immobilityPrevent further increase in ICPProvide comfortable environmentAvoid use of restraints fracturesKeep side rails upAbejo4.5.6.7.INCREASED INTRACRANIAL PRESSUREMS58.