NERVOUS SYSTEM

CNS
Brain
Spinal

PNS
Cranial Nerves
Spinal Nerves

ANS
Parasympathetic
Sympathetic

CN I II

DYSFUNCTION Decreased sense of smell Decreased visual acuity and visual fields

INTERVENTIONS Is often accompanied by impaired taste and weight loss Frequent reorientation to environment. Position objects around client in deference to visual impairment Intermittent eye patching Lubricate eyes to protect against corneal abrasions Caution in shaving and mouth care. Choose easy to chew foods with high caloric content. Protect corneas from abrasion by using lubricant Oral hygiene. Account for decreased food intake. Cosmetic approach to hiding facial weakness. SAFETY! Move slowly to prevent nausea and emesis. Assist ambulation Maintain airway. Prevent aspiration. Swallow therapy Mobility aids. Physical therapy Maintain airway. Prevent aspiration. Swallow therapy

III Double vision (diplopia) IV,VI V Decreased facial sensation Inability to chew Decreased corneal reflexes Facial weakness and decreased taste(ant. tongue) Hearing loss, imbalance, vertigo, tinnitus Dysarthria, Dysphagia, cardiac and respiratory instability Inability to turn shoulders or turn head from side to side Dysarthria, dysphagia

VII VIII IX X XI XII

Actions of the Autonomic Nervous System

EFFECTOR ORGAN AUTONOMIC ACTION DIVISION

Eye : pupil
Heart

sympathetic dilation of the pupil parasympathetic constriction of the pupil

sympathetic dilation of coronary arteries, increased HR, increased force of contraction parasympathetic slows, heart rate, reduces contraction and conduction, constricts coronary arteries sympathetic dilation parasympathetic constriction and mucous secretion sympathetic inhibition of peristalsis and secretion parasympathetic peristalsis and secretion sympathetic relaxed; sphincter closed parasympathetic contracted; sphincter open

Bronchi Stomach and Intestines Bladder

Drug ADRENERGIC Adrenaline ( Medihaler-Epi, Lignostab, Eppy, Xylocaine) Phenylephrine (Decohist, Novahistine) Pseudoephedrine (Dimotane Co)

How it works

Clinical use

acts directly on both alpha and beta receptors acts directly on alpha receptors constricting small blood vessels in the lining of the nose thus relieving congestion causes accumulation of noradrenaline at the synapses

Used in asthma and other allergic diseases it relaxes airways and reduces swelling. Used as a decongestant in rhinitis and colds

Amphetamines including MDMA (Ecstasy)

No longer used clinically except for treatment of narcolepsy

Drug ANTIADRENERGIC Reserpine (Direserpine)

How it works

Clinical use

blocks the synthesis and storage of noradrenaline blocks beta receptors

Used in the management of some types of hypertension Used in hypertension, angina, migraine, headaches and mitral valve prolapse

Propanolol (Inderal)

CHOLINERGIC Pilocarpine (Isoptocarpine, Sno Pilo)

acts directly on muscarinic receptors

used as eye drops in ophthalmology to constrict the iris of the eye. Used in the treatment of glaucoma
Used in the treatment of diarrhea (Lomotil) as it can slow down peristalsis. Used as a pre-op as it can prohibit the secretion of mucous and fluids which could block the airways. Used in small doses in the alleviation of the symptoms of motion sickness. Can be used to promote twilight sleep (drowsiness with amnesia) in labour

ANTICHOLINERGIC Atropine (Lomotil, Atrosept)

blocks the action of acetylcholine on muscarinic receptors

Scopolamine (Buscopan, Joy-Rides, Kwells)

blocks the action of acetylcholine on muscarinic receptors

NEUROLOGIC

DISORDERS

INCREASED INTRACRANIAL PRESSURE

A condition in which the pressure of the CSF; blood or brain volume within the skull exceeds the upper limits for normal pressure cause: metabolic, toxic, traumatic, infectious, neoplastic and idiopathic Symptoms: Infants: bulging fontanel, high pitch cry poor feeding, separated sutures Older children and adults: projectile vomiting, headache changes in behavior, seizures progressive decreased LOC, may become coma ipsilateral pupillary dilatation contralateral hemiparesis widening pulse pressure Note: Slow increases are tolerated fairly well in young children before they become symptomatic. Adults tolerate increased ICP less well.

MANAGEMENT
maintain patent airway maintain fluid balance (1200-1500ml/day) position HOB elevated, 30-40 degrees prevent further increase in ICP administer medications: Hyperosmotic agents (Mannitol [Osmitrol]) Corticosteroids (dexamethasone[Decadron]) Diuretics (furosemide[Lasix]) Anticonvulsants (phenytoin[Dilantin]) Analgesics (small doses of codeine, stronger opiates are C/I )

CEREBRAL PALSY
occur during fetal development or near the time of birth, symptoms are usually
evident before age 2 and in severe cases may appear as early as three months. etiology: Prenatal- genetic, altered neurologic development, trauma, anoxia to mother (toxemia, rubella, accidents); Perinatal- drugs,precipitate delivery, fetal distress, breech with delay; Postnatal- kernicterus, head trauma Types - Spastic (50% of cases) - Dyskinetic (athetoid) - Ataxic - Mixed Symptoms spasticity athetosis, ataxia partial or full loss of movement sensory abnormalities hearing and visual defects speech abnormalities intellectual dysfunction seizures

MANAGEMENT
Supportive (occupational and physical therapy, braces, appropriate glasses and hearing aids) Mainstreaming Cerebral palsy- support group Medications (muscle relaxants, anticonvulsants) Surgery

SEIZURES
episodes of abnormal motor, sensory or autonomic due to abnormal
discharge from brain cells. Epilepsy- chronic recurrent seizures. may be caused by infantile fever, head injury, hypertension, CNS infection, brain tumor or metastasis, drug withdrawal, stroke TYPES Generalized seizures major motor seizure (grand mal) - aura; usually starts with tonic or stiffening phase, followed by clonic or jerking phase; may have bowel/ bladder incontinence; in postictal phase, sleeps, hard to arouse absence seizure(petit mal) - sudden onset, with twitching or rolling of eyes; lasts a few seconds febrile seizures - common under 5yrs. of age; seizure occurs only when fever is rising; EEG is normal 2 weeks after a seizure

Partial seizures psychomotor seizure - may follow trauma, hypoxia, drug use; purposeful but inappropriate repetitive motor acts; aura present, dreamlike state simple partial seizure - seizure confined to one hemisphere of the brain. no LOC; maybe motor, sensory, or autonomic symptoms complex partial seizure - begins in focal area but spreads to both hemispheres; impairs consciousness; maybe preceded by an aura jacksonian seizure - twitching begins at distal end of extremity, eventually involving entire extremity and possibly entire side of the body; no LOC; not commonly seen in children status epilepticus - usually refers to grand mal seizures; prolonged ( repeated seizures without regaining consciousness) and unresponsive to treatment; can result in hypoxia and possible cardiac arrest

MANAGEMENT
During seizure activity protect from injury: prevent falls, support head, decrease external stimuli, do not restrain, do not use tongue blades(may add stimuli), loosen clothing keep airway open: side lying position, suction excess mucous observe and record seizure - note any preictal aura: fear, anxiety, hallucinations, dj vu symptoms - note nature of the ictal phase: symmetry of movement, response to stimuli, LOC, respiratory pattern - note postictal response: amount of time it takes to orient to time and place; sleepiness Provide client teaching and discharge polanning need to drug therapy wear a Medic-Alert identification bracelet or carry ID availability of support groups and community agencies

Drug therapy (Anticonvulsants)

Phenytoin (Dilantin)- most commonly used can only be administered with in normal saline and levels are monitored to titrate dosage; therapeutic level is 10-20 mg/dl; side effects include gum hyperplasia, hirsutism, ataxia, gastric distress, nystagmus, anemia, sedation Phenobarbital a barbiturate and its main side effects are on the CNS Tegretol (Carbamazepine) is used when seizure have not responded to other anticonvulsants Surgery to remove the tumor, hematoma or epileptic focus

SPINA BIFIDA
A birth defect where the backbone and spinal canal do not close before birth, which allows the spinal cord and the covering membranes to protrude out of the child's back. causes: genetic, viral, radiation, intrauterine folic acid deficiency Types * spina bifida occulta * spina bifida cystica - meningocele - meningomyelocele/ myelomeningocele (75% of cases) Symptoms - visible sac-like protrusion on the mid to lower back-not translucent when a light is shone from behind the sac Meningomyelocele: motor and sensory deficit below the lesion Spina bifida occulta may be indicated by: - a tuft of hair at the sacral area (back part of the pelvis) dimpling of the sacrum

MANAGEMENT
prevent trauma to the sac - cover with sterile dressing soaked with normal saline - position prone or side lying - keep area free from contamination by urine or feces - inspect for signs of infection provide adequate nutrition, high fiber diet provide sensory stimulation prevent complications aid the family in coping with the disorder surgery is usually done within 48 hours after birth to lower the risk of infection, swelling, and further damage.

HYDROCEPHALUS
A disorder associated with excessive fluid in the brain- putting pressure on the brain forcing it against the skull and destroying the tissues. EARLY SYMPTOMS-- INFANTS - enlargement of the head (increased head circumference) - bulging fontanelles, with or without enlargement of the head size - sutures - separated - irritability LATE SYMPTOMS - decreased mental function - delayed development - slow or restricted movement - difficulty feeding - lethargy, excessive sleepiness - urinary incontinence - brief, shrill, high-pitched cry - slow growth (child 0-5 years)

IN OLDER INFANTS AND CHILDREN

- headache - vomiting - vision changes ( sunset eyes) - crossed eyed - uncontrolled eye movements - loss of coordination - poor gait(walking pattern) - confusion or psychosis

TESTS CT scan Transillumination

TAY-SACHS DISEASE
an autosomal recessive disorder found predominantly in Jewish families, which results in early death. caused by a deficiency of hexosaminidase A, an enzyme that is important in the metabolism of gangliosides- these fatty acids then accumulate in the brain causing degenerative neurological deterioration onset: 3 to 6 months old Signs & Symptoms loss of motor skills increased startle reaction decreased eye contact (blindness); deafness listlessness; irritability seizures; dementia paralysis; loss of muscle strength delayed mental and social skills slow growth enzyme analysis of blood/body tissue for hexosaminidase levels eye exam reveals a cherry-red spot in the macula

REYES SYNDROME
A syndrome of encephalopathy, with associated liver degeneration. Unknown cause, but can be associated with viral agents such as influenza or varicella, toxins, aspirin and other salicylates, and metabolic defects Symptoms stage I: sudden onset of persistent vomiting, fatigue stage II: behavior changes, disorientation, confusion, hyperreflexia stage III: coma, decorticate posturing stage IV: deeper coma, decerebrate posturing stage V: seizures, absent deep tendon and respiratory reflexes flaccid paralysis

Signs elevated liver enzymes elevated serum ammonia test

OBS
A general term refers to physical disorders that cause a decrease in mental function, usually not including psychiatric disorders Types Acute - delirium - clouding of consciousness - temporary alteration of brain functioning - reversible Chronic - dementia - senility - insidious onset - irreversible

 destruction of nerve cells which leads to a decrease and imbalance of neurotransmitters early onset (5-10% of cases) -symptoms first appear before age 60 late onset (most common) -develops in people 60 and older Signs and symptoms early stages - Repeating statements frequently - Frequently misplacing items - Trouble finding names for familiar objects - Getting lost on familiar routes late stage - A decrease in knowledge of recent events - Forgetting events in their life history, and of who they are - Problems choosing proper clothing - Hallucinations, delusions, agitation, depression

Medications tacrine (Cognex) donepezil (Aricept) rivostigmine (Exxelon)

 50-60 years Male> female progressive deterioration of the basal ganglia and the extrapyramidal area; defiency of dopamine Signs and symptoms: - muscle (cogwheel) rigidity - shuffling walk - finger thumb rubbing (pill-rolling tremor) - mask appearance - voice/ speech changes - loss of fine motor skills - decline in intellectual function

Medications Deprenyl Amantadine Levodopa; Carbidopa

 20-40 years Female>male Impaired nerve impulse conduction because of destruction of myelin sheath Signs and symptoms - visual problems (nystagmus) - muscle spasticity - poor coordination - speech deficits - intentional tremor - bowel/ bladder dysfunction - exacerbations and remissions

Medications Muscle relaxants (Baclofen, dantrolene, diazepam) Cholinergic medications Corticosteroids or ACTH Amantadine; Antidepressant

 40-70 years Male>female Impaired nerve impulse conduction because of degeneration of motor neurons Signs and symptoms - muscle weakness, progressing to atrophy and paralysis of upper and lower extremities - impaired speech; hoarseness - difficulty swallowing and breathing - muscle contractions; twitching - usually fatal 2-15years after onset Medication Antibiotics( for respiratory and urinary infections)

 20-50 years Female>male Impaired transmission of nerve impulse to muscle cells possibly because of acetylcholine deficiency Signs and symptoms - vision changes - profound muscle weakness or paralysis that worsens with exertion later in the day - difficulty talking; dysphagia; frequent choking - can progress to respiratory failure(myasthenia crisis)
Medications Anticholinesterase (Neostigmine, Pyridostigmine) Prednisone Plasmapheresis Thymectomy

Diagnosis Edrophonium chloride (Tensilon) Complication Myasthenia crisis - abrupt onset of severe, generalized muscle weakness with inability to swallow, speak or maintain respirations - caused by undermedication, physical or emotional stress, infection - symptoms will temporarily improve with Tensilon test Cholinergic crisis - same symptoms to myasthenia crisis; side effects of anticholinesterase drugs(excessive sweating and salivation, abd. cramps, diarrhea, fasciculations, N & V) - caused by overmedicaiton with the cholinergic (anticholinesterase) drugs - symptoms worsen with Tensilon test; keep atropine sulfate and emergency equipment on hand

 may occur at any age but is most common in people of both sexes between the ages 30 and 50. acute inflammation damages portions of the nerve cell, resulting in muscle weakness or paralysis; (demyelination and denervation) unknown cause, usually follows a minor infection (usually respiratory or gastrointestinal) Signs and symptoms - weakness begins in the feet and legs and may progress upward to the arms and cranial (head) nerves, - may progress rapidly over 24 to 72 hours - may begin in the arms and progress downward - numbness, decreased sensation - tenderness or muscle (may be a cramp-like pain) - drooling, difficulty swallowing and breathing - urinary dysfunction Management Mechanical ventillation; Corticosteroids; Plasmapheresis

 loss of brain functions caused by a loss of blood circulation to areas of the brain. The specific neurologic deficits may vary depending on the location, extent of the damage, and cause of the disorder. Causes emboli thrombus hemorrhage Signs and symptoms - decreased LOC, cognitive changes - weakness or paralysis of any body area - speech deficits ( dysphonia, dysrthria, aphasia) - urinary/ bowel incontinence -dysphagia, chewing - personality changes - homonymous hemianopsia

Medications Anticoagulants, Thrombolytics Anti-platelet agents; Aspirin Analgesics Antihypertensives Surgery Carotid endarterectomy

MANAGEMENT OF CARE
Maintaining peak physical health Structuring the environment Promoting socialization Promoting independent functioning Preserving the family unit

SPINAL CORD INJURIES

hemorrhage and edema cause ischemia, leading to necrosis and destruction of the cord cause maybe traumatic or non traumatic Signs and symptoms - spinal shock: no reflexes below the lesion, flaccid paralysis, lack of temperature control in affected parts, hypotension, retention of urine and feces - level of injury quadriplegia: (C1-C8) injury, paralysis of all four extremities; lesions above C6- causes respi. paralysis paraplegia: (T1-L4) injury, paralysis of the lower half of the body involving both legs

- extent of injury 1. complete cord transection a. loss of all voluntary movement and sensation below the level of the injury; reflex activity below the level of the lesion may return to normal after the spinal shock resolves. b. lesions in the conus medullaris or cauda equina results in permanent flaccid paralysis and areflexia. 2. incomplete lesions: varying degrees of motor or sensory loss below the level of the lesion depending on which neurologic tracts are damaged and which are spared.

Diagnostic test spinal X- rays

NURSING MANAGEMENT
ACUTE CARE
asses ABC suction, trachoestomy set; jaw thrust maneuver immobilize cervical collar, spinal board prevent pneumonia and atelectasis turn q2hrs; cough & DBE q1hr; incentive spirometry q2hrs maintain fluid and electrolyte balance and nutrition NGT maybe inserted until bowel sounds return; IV therapy-avoid overhydration(cord edema); check bowel sounds before feeding (paralytic ileus);progress slowly from clear liquid to regular diet prevent complications of immobility footboard/high topped sneakers to prevent footdrop; splint for quadriplegic clients to prevent wrist drop maintain urinary elimination catheterization; increase fluids to 3000ml/day; acid ash foods maintain bowel elimination stool softeners, suppositories to prevent fecal impaction

CHRONIC CARE neurogenic bladder

intermittent catheterization q4hrs & gradually progress to q6hrs regulate fluids to 1800-2000ml/day a. reflex/ upper motor neuron bladder- unable to store urine very long and empties involuntarily. bladder taps stimulating trigger points to cause reflex emptying b. nonreflexive/lower motor neuron bladder- urine retention with overflow Crede or rectal stretch spasciticy stretching exercises, warm tub baths, whirlpool; antispasmodics: baclofen(Lioresal), dantrolene(Dantrium), diazepam(Valium) autonomic dysreflexia- s/s: severe headache, HPN, bradycardia, sweating, goosebumps, nasal congestion, blurred vision, seizures - reflex response to stimulation of CNS; occurs above T6 - stimulus: overdidtended bladder or bowel, chilling, decubitus ulcer * raise to sitting position to decrease BP * check and remove source of stimulus (catheterize, digitally remove impacted feces, reposition client) * antihypertensives- hydralazine HCL(Apresoline)

BRAIN INJURY
concussion contusion epidural hemorrhage subdural hemorrhage subarachnoid hemorrhage intracerebral hemorrhage

MANAGEMENT maintain patent airway and adequate ventilation

observe for CSF leakage - (+) Testape or Dextostix test for glucose bloody spot encircled by watery, pale ring - never clean the ears or nose, suction nose unless ordered by doctor if CSF leak is present - never blow nose; HOB elevated 30 degrees as ordered - place cotton ball in the ear to absorb otorrhea, replace frequently - gently place sterile gauze pad at the bottom of the nose for rhinorrhea - observe signs of meningitis and give antibiotics as ordered prepare client for surgery as indicated - depressed skull fracture: removal or elevation of splintered bone; debridement and cleansing of area; repair of dural tear if present; cranioplasty ( if necessary for large cranial defect) - epidural, subdural hematoma: evacuation of hematoma

INTRACRANIAL SURGERY
Craniotomy- surgical opening of skull, used to remove a tumor, evacuate blood clot, control hemorrhage, relieve increased ICP Craniectomy- excision of a portion of the skull; sometimes used for decompression Cranioplasty- repair of a cranial defect with a metal or plastic plate Pre-op care provide emotional support explain that the clients head will be shaved, a head is bandaged post-op, possible temporary swelling and discoloration around the eye of the affected side, possible headache Shampoo and check for infection. Shave hair insert Foley catheter as odered evaluate and record baseline vital signs and neuro checks

Post-op care

- maintain patent airway and adequate ventilation

a. Supratentorial incision- HOB elevated 15-45 degrees; position on back (if intubated or unconscious) or on unaffected side; turn q2hrs to facilitate breathing and venous return b. Infratentorial incision- HOB flat or elevated 20-30 degrees; do not flex head on chest; turn to sides q2hrs using a turning sheet; check for signs of respiratory depression c. Instruct conscious client to breathe deeply but not to cough; avoid vigorous suctioning

- monitor fluid and electrolyte status

- accurate I & O; restrict fluids 1500ml/day to decrease cerebral edema - infratentorial- maybe NPO for 24hrs due to possible impaired swallowing or gag reflexes

- assess dressings frequently and report any abnormalities - administer corticosteroids, anti-convulsants, stool softeners as ordered - apply ice to swollen eyelids; lubricate lids and areas around eyes with
petrolatum jelly

CNS INFECTIONS
Meningitis- inflammation of the meninges of the brain and spinal cord, caused by bacteria, viruses, or other microorganisms. Encephalitis- inflammation of the brain, caused by a virus; may occur as a sequela of measles, mumps, chickenpox. Signs and symptoms: headache, photophobia, irritability, chills, fever, vomiting possible seizures,decreasing LOC signs of meningeal irritation - nuchal rigidity: stiff neck - opisthotonos: head and heels bent backward and body arched forward - Kernigs sign - Brudzinkis sign Tests: Lumbar puncture- measurement and analysis of CSF shows increased pressure, elevated WBC and protein, decrease glucose and culture positive for specific microorganism.

KERNIGS SIGN Present if lower leg cannot extend due to pain and spasm when client is lying supine with one leg bent over his abdomen.

BRUDZINSKIS SIGN Present if the clients hips and knees flex when he is lying supine with his head lifted towards his chest.

MANAGEMENT
give large doses of antibiotics as ordered enforce respiratory isolation after initiation antibiotic therapy for some types of meningitis give nsg. care for increased ICP, seizures, and hyperthermia provide nsg. Care for delirious or unconscious client as needed bed rest; keep room quiet & dark if photophobia or headache occurs maintain fluid and electrolyte balance prevent complications of immobility monitor vital signs and neuro checks frequently teach client concerning discharge plans: - maintain a good diet high in protein, high calories, with small frequent feedings - rehabilitation program for residual deficits

DEFINITION:technique of objectifying a clients level of responses;clients best response in each area is given a numerical value,and the three values is totaled for a score ranging from 3 - 15. EYE OPENING ABILITY: Spontaneous----------------------------------------------------------------(4) To voice / speech----------------------------------------------------------(3) To pain-------------------------------------------------------------------------(2) None----------------------------------------------------------------------------(1) BEST MOTOR RESPONSE,UPPER LIMB: Obeys commands---------------------------------------------------------(6) Localizes to pain-----------------------------------------------------------(5) Flexor withdrawal(decorticate posturing) ------------------------(4) Abnormal flexion(decerebrate posturing) ------------------------(3) Extension --------------------------------------------------------------------(2) Flaccid ------------------------------------------------------------------------(1)

BEST VERBAL RESPONSE: Oriented ----------------------------------------------------------------------------(5) Confused conversation -------------------------------------------------------(4) Inappropriate words ----------------------------------------------------------- (3) Incomprehensible sounds --------------------------------------------------- (2) None --------------------------------------------------------------------------------- (1) A score of 15 indicates client is awake and oriented. A score of 7 to 4 is considered coma. The lowest score is 3,client is considered in deep coma.

A 50 year old male client with CVA, can open his eyes in response to auditory stimuli; can respond with incomprehensible sounds; and can move his hands in and up, toward the cortex. The nurse performing neurological assessment determines the clients Glasgow coma scale as:

a. 11 b. 8 c. 14 d. 5