Shalom H. Jaco BSN MEDICAL SURGICAL Overview of the Structures & Functions of Nervous System Central NS PNS ANS Brain & spinal cord 31 spinal & cranial sympathetic NS Parasypathatic NS Somatic NS C- 8 T- 12 L- 5 S- 5 C- 1 ANS (or adrenergic of parasympatholitic response) SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic) 1. Dilate pupil – to aware of surroundings Release of norepinephrine (adrenaline – cathecolamine) - medriasis Adrenal medulla (potent vasoconstrictor) 2. Dry mouth Increases body activities VS = Increase 3. BP & HR= increased Except GIT – decrease GITmotility bronchioles dilated to take more oxygen 4. RR increased * Why GIT is not increased = GIT is not important! 5. Constipation & urinary retention Increase blood flow to skeletal muscles, brain & heart. I. Adrenergic Agents – Epinephrine (adrenaline) SE: SNS effect II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’) - Blocks release of norepinephrine. - Decrease body activities except GIT (diarrhea) Ex. Propanolol, Metopanolol SE: B – broncho spasm (bronchoconstriction) E – elicits a decrease in myocardial contraction T – treats HPN A – AV conduction slows down Given to angina & MI – beta-blockers to rest heart Anti HPN agents: 1. Beta blockers (-lol) 2. Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL 3. Calcium antagonist ex CALCIBLOC or NEFEDIPINE Peripheral nervous system: cholinergic/ vagal or sympatholitic response Effect of PNS: (cholinergic) - Involved in fly or withdrawal response 1. Meiosis – contraction of pupils
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Shalom H. Jaco BSN MEDICAL SURGICAL
Overview of the Structures & Functions of Nervous SystemCentral NS PNS ANSBrain & spinal cord 31 spinal & cranial sympathetic NS
Parasypathatic NS
Somatic NSC- 8T- 12L- 5S- 5C- 1
ANS (or adrenergic of parasympatholitic response)
SNS involved in fight or aggression response Effects of SNS (anti-cholinergic/adrenergic)1. Dilate pupil – to aware of surroundings
Release of norepinephrine (adrenaline – cathecolamine) - medriasisAdrenal medulla (potent vasoconstrictor) 2. Dry mouthIncreases body activities VS = Increase 3. BP & HR= increasedExcept GIT – decrease GITmotility bronchioles dilated to take more oxygen
4. RR increased* Why GIT is not increased = GIT is not important! 5. Constipation & urinary retentionIncrease blood flow to skeletal muscles, brain & heart.
I. Adrenergic Agents – Epinephrine (adrenaline)SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in –‘lol’)- Blocks release of norepinephrine.- Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol
SE: B – broncho spasm (bronchoconstriction)E – elicits a decrease in myocardial contractionT – treats HPNA – AV conduction slows down
Given to angina & MI – beta-blockers to rest heart Anti HPN agents:
-Mgt. Rise slowly. Assist in ambulation.CNS (brain & spinal cord)I. Cells – A. neurons
Properties and characteristicsa. Excitability – ability of neuron to be affected in external environment. b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells – once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)Regenerative capacityA. Labile – once destroyed cant regenerate
- Epidermal cells, GIT cells, resp (lung cells). GUTB. Stable – capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cellsC. Permanent cells – retina, brain, heart, osteocytes can’t regenerate.
3.) Neuroglia – attached to neurons. Supports neurons. Where brain tumors are found.Types:
1. Astrocyte2. Oligodendria
Astrocytoma – 90 – 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte.Astrocyte – maintains integrity of blood brain barrier (BBB).BBB – semi permeable / selective-Toxic substance that destroys astrocyte & destroy BBB.Toxins that can pass in BBB:
OLIGODENDRIA – Produces myelin sheath – wraps around a neuron – acts as insulator facilitates rapid nerve impulse transmission.No myelin sheath – degenerates neurons
Damage to myelin sheath – demyellenating disorders
DEMYELLENATING DSE 1.)ALZHEIMER’S DISEASE– atrophy of brain tissue due to a deficiency of acetylcholine.
S&Sx:A – amnesia – loss of memoryA – apraxia – unable to determine function & purpose of objectA – agnosia – unable to recognize familiar objectA – aphasia –
- Expressive – brocca’s aphasia – unable to speak - Receptive – wernickes aphasia – unable to understand spoken words
Common to Alzheimer – receptive aphasiaDrug of choice – ARICEPT (taken at bedtime) & COGNEX. Mgt: Supportive & palliative.
- Pain, touch, pressure, heat & cold4.) Occipital - vision5.) Insula/island of reil/ Central lobe- controls visceral fx
Function: - activities of internal organ6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory
Basal Ganglia – areas of gray matte located deep within a cerebral hemisphere- Extra pyramidal tract- Releases dopamine- - Controls gross voluntary unit
MID BRAIN – relay station for sight & hearingControls size & reaction of pupil 2 – 3 mm Controls hearing acuityCN 3 – 4Isocoria – normal size (equal)Anisocoria – uneven size – damage to mid brain PERRLA – normal reaction
DIENCEPHALON- between brain Thalamus – acts as a relay station for sensationHypothalamus – (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional responses, controls pituitary function.
BRAIN STEM- a. Pons – or pneumotaxic center – controls respirationCranial 5 – 8 CNS
Cerebellar Tests:a.) R – Romberg’s test- needs 2 RNs to assist
- Normal anatomical position 5 – 10 min(+) Romberg’s test – (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test –(+) To FTNT – dymetria – inability to stop a movement at a desired point
c.) Alternate pronation & supinationPalm up & down . (+) To alternate pronation & supination or damage to cerebellum – dymentrium
Composition of brain - based on Monroe Kellie Hypothesis- Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP
Normal ICP – 0 – 15 mmHgForamen Magnum C1 – atlasC2 – axis
(+) Projectile vomiting = increase ICPObserve for 24 - 48 hrsCSF – cushions the brain, shock absorber Obstruction of flow of CSF = increase ICPHydrocephalus – posteriorly due to closure of posterior fontanelCVA – partial/ total obstruction of blood supply
INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components.Predisposing factors:
B. S&Sx change in VS = always late symptomsEarliest Sx:a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP
- Disorientation to lethargy Narrow pp: Cardiac disorder, shock - Stupor to coma
Late sign – change in V/S 1. BP increase (systolic increase, diastole- same)2. Widening pulse pressure
Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure)Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)4. Temp increaseIncreased ICP: Increase BP Shock – decrease BP –
b.) HeadacheProjectile vomitingPapilledima (edema of optic disk – outer surface of retina)Decorticate (abnormal flexion) = Damage to cortico spinal tract /Decerebrate (abnormal extension) = Damage to upper brain stem-pons/
c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.)d.) Possible seizure.
Nursing priority:1.) Maintain patent a/w & adequate ventilationa. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
Hypoxia – cerebral edema - increase ICPHypoxia – inadequate tissue oxygenationLate symptoms of hypoxia – B – bradycardia
E – extreme restlessness D – dyspnea C – cyanosis
Early symptoms – R – restlessness A – agitation T – tachycardia
Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICPMost powerful respiratory stimulant increase in CO2Hyperventilate decrease CO2 – excrete CO2
Respiratory Distress Syndrome (RDS) – decrease OxygenSuctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap.Ambu bag – pump upon inspiration
c. Assist in mechanical ventilation1. Maintain patent a/w 2. Monitor VS & I&O3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage4. Limit fluid intake 1,200 – 1,500 ml/day (FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP.5. Prevent complications of immobility6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints – lead to fracturesc. Siderails upd. Instruct patient to avoid the ff: -Valsalva maneuver or bearing down, avoid straining of stool (give laxatives/ stool softener Dulcolax/ Duphalac)- Excessive cough – antitussive
Dextrometorpham -Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan
- Lifting of heavy objects- Bending & stooping
e. Avoid clustering of nursing activities7. Administer meds as ordered:
Nursing considerations: Mannitol1. Monitor BP – SE of hypotension2. Monitor I&O every hr. report if < 30cc out put3. Administer via side drip 4. Regulate fast drip – to prevent formation of crystals or precipitate
Nursing Mgt:1.) Administer K supplements – ex Kalium Durule, K chloride
Potassium Rich food:ABC’s of K
Vegetables FruitsA - asparagus A – apple B – broccoli (highest) B – banana – greenC – carrots C – cantalope/ melon
O – orange (highest) –for digitalis toxicity also.Vit A – squash, carrots yellow vegetables & fruits, spinach, chesaIron – raisins, Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretionsDon’t give grapes – may choke
S/E of Lasix:1.) Hypokalemia2.) Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany:
S&Sx weaknessParesthesia(+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm.(+) Chevostek’s signArrhythmiaLaryngospasm
Administer – Ca gluconate – IV slowly
Ca gluconate toxicity: Sx – seizure – administer Mg SO4Mg SO4 toxcicity– administer Ca gluconate
B – BP decreaseU – urine output decreaseR – RR decreaseP – patellar reflexes absent
3.) Hyponatremia – Normal Na level = 135 – 145 meg/L S/Sx – Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise. Early signs – Adult: thirst and agitation / Child: tachycardiaMgt: force fluidAdminister isotonic fluid sol
Nsg Mgt of Gouty Arthritisa.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO)b.) Force fluidc.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout
Colchicene – excretes uric acid. Acute gout drug of choice.Kidney stones – renal colic (pain). Cool moist skinMgt:
1.) Force fluid2.) Meds – narcotic analgesic
Morphine SO4
SE of Morphine SO4 toxicityRespiratory depression (check RR 1st)Antidote for morphine SO4 toxicity –Narcan (NALOXONE)Naloxone toxicity – tremors
Question: Increase ICP what is the immediate nsg action?a. Administer Mannitol as orderedb. Elevate head 30 – 45 degreesc. Restrict fluidd. Avoid use of restraints
Nsg Priority – ABC & safety
Pt suffering from epiglotitis. What is nsg priority?a. Administer steroids – least priorityb. Assist in ET – temp, a/wc. Assist in tracheotomy – permanent (Answer)d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only-
Question: Avoid giving food with Aminophyllinea. Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI b. Beer/ wine - c. Hot chocolate & tea – caffeine – CNS stimulant tachycardiad. Organ meat/ box cereals – anti parkinsonian
MAOI – antidepressantm AR plann AR dil can lead to CVA or hypertensive crisisp AR nate
3 – 4 weeks - before MAOI will take effect Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa
D – dilatin (Phenytoin) – anti convulsant/seizureNursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate- Do sandwich method - Give NSS then Dilantin, then NSS! 2. Instruct the pt to avoid alcohol – bec alcohol + dilantin can lead to severe CNS depression
Dilantin toxicity: S/Sx:
G – gingival hyperplasia – swollen gums i. Oral hygiene – soft toothbrush
ii. Massage gums H – hairy tongue A - ataxia N – nystagmus – abnormal movement of eyeballs
Antidote for acetaminophen toxicity – Acetylcesteine = causes outporing of secretions. Suction.Prepare suctioning apparatus.
Question: The following are symptoms of hypoglycemia except:a. Nightmaresb. Extreme thirst – hyperglycemia symptomsc. Weakness d. Diaphoresis
PARKINSONS DSE (parkinsonism) - chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia
- Palliative, SupportiveFunction of dopamine: controls gross voluntary motors.
Predisposing Factors:1. Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA2. Hypoxia3. Arteriosclerosis4. Encephalitis
High doses of the ff:a. Reserpine (serpasil) anti HPN, SE – 1.) depression - suicidal 2.) breast cancerb. Methyldopa (aldomet) - promote safetyc. Haloperidol (Haldol)- anti psychoticd. Phenothiazide - anti psychotic
SE of anti psychotic drugs – Extra Pyramidal Symptom Over meds of anti psychotic drugs – neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism – 1. Pill rolling tremors of extremities – early sign2. Bradykinesia – slow movement3. Over fatigue4. Rigidity (cogwheel type)
a. Stooped postureb. Shuffling – most commonc. Propulsive gait
5. Mask like facial expression with decrease blinking eyes6. Monotone speech7. Difficulty rising from sitting position8. Mood labilety – always depressed – suicide
Nsg Mgt when giving anti-parkinsonian1. Take with meals – to decrease GIT irritation2. Inform pt – urine/ stool may be darkened3. Instruct pt- don’t take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg- Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.2.) Anti cholinergic agents – relieves tremors
Normal Resident Antibodies:Ig G – can pass placenta – passive immunity. Short acting.Ig A – body secretions – saliva, tears, colostrums, sweatIg M – acute inflammationIg E – allergic reactionsIgD – chronic inflammation
S & Sx of MS: (everything down)1. Visual disturbances
a. Blurring of visionb. Diplopia/ double visionc. Scotomas (blind spots) – initial sx
3. Mood swings – euphoria (sense of elation )4. Impaired motor function:
a. Weaknessb. Spasiticity –“ tigas”c. Paralysis –major problem
5. Impaired cerebellar functionTriad Sx of MS
I – intentional tremors N – nystagmus – abnormal rotation of eyes Charcots triadA – Ataxia & Scanning speech
6. Urinary retention or incontinence7. Constipation8. Decrease sexual ability
Dx – MS1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG2. MRI – reveals site & extent of demyelination3. Lhermitte’s response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS- Supportive mgt
1.) Meds
a. Acute exacerbationACTH – adenocorticotopicSteroids – to reduce edema at the site of demyelination to prevent paralysis
Spinal Cord InjuryAdminister drug to prevent paralysis due to edema a. Give ACTH – steroids
b. Baclopen (Lioresol) or Dantrolene Na (Dantrene)To decrease muscle spasticity
c. Interferone – to alter immune responsed. Immunosuppresants
2. Maintain siderails3. Assist passive ROMexercises – promote proper body alignment4. Prevent complications of immobility5. Encourage fluid intake & increase fiber diet – to prevent constipation6. Provide catheterization die urinary retention7. Give diuretics Urinary incontinence – give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.9. Provide acid-ash diet – to acidify urine & prevent bacteria multiplication
Grape, Cranberry, Orange juice, Vit C
MYASTHENIA GRAVIS (MG) – disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction.
Common in Women, 20 – 40 yo, unknown cause or idiopathic Autoimmune – release of cholenesterase – enzymeCholinesterase destroys ACH (acetylcholine) = Decrease acetylcholineDescending muscle weakness(Ascending muscle weakness – Guillain Barre Syndrome)
Nsg priority: 1) a/w 2) aspiration 3) immobility
S/ Sx: 1.) Ptosis – drooping of upper lid ( initial sign)
Check Palpebral fissure – opening of upper & lower lids = to know if (+) of MG.2.) Diplopia – double vision3.) Mask like facial expression4.) Dysphagia – risk for aspiration!5.) Weakening of laryngeal muscles – hoarseness of voice6.) Resp muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set7.) Extreme muscle weakness during activity especially in the morning.
Dx test1. Tensilon test (Edrophonium Hcl) – temporarily strengthens muscles for 5 – 10 mins. Short term- cholinergic. PNS effect.
Nsg Mgt1. Maintain patent a/w & adequate vent by:
a.) Assist in mechanical vent – attach to ventilatorb.) Monitor pulmonary function test. Decrease vital lung capacity.
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, 5/5, etc)3. Siderails4. Prevent complications of immobility. Adult-every 2 hrs. Elderly- every 1 hr.5. NGT feeding Administer meds –
a.) Cholinergics or anticholinesterase agentsMestinon (Pyridostigmine)Neostignine (prostigmin) – Long term- Increase acetylcholines/e – PNS
b.) Corticosteroids – to suppress immune resp Decadron (dexamethasone)
Monitor for 2 types of Crisis: Myastinic crisis Cholinergic crisisA cause – 1. Under medication 2. Stress 3. InfectionB S&Sx 1. Unable to see – Ptosis & diplopia
Cause: 1 over medsS/Sx - PNS
2. Dysphagia- unable to swallow. 3. Unable to breath C Mgt – adm cholinergic agents Mgt. adm anti-cholinergic
- Atropine SO4- SNS – dry mouth
7. Assist in surgical proc – thymectomy. Removal of thymus gland. Thymus secretes auto immune antibody.8. Assist in plasmaparesis – filter blood9. Prevent complication – respiratory arrest
1. Clumsiness2. Ascending muscle weakness – lead to paralysis3. Dysphagia4. Decrease or diminished DTR (deep tendon reflexes)- Paralysis5. Alternate HPN to hypotension – lead to arrhythmia - complication6. Autonomic changes – increase sweating, increase salivation.
Increase lacrimationConstipationDx most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt1. Maintain patent a/w & adequate vent
a. Assist in mechanical ventb. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia3. Siderails4. Prevent compl – immobility5. Assist in passive ROM exercises6. Institute NGT feeding – due dysphagia
7. Adm meds (GBS) as ordered: – 1. Anti cholinergic – atropine SO4 2. Corticosteroids – to suppress immune response 3. Anti arrhythmic agents
a.) Lidocaine /Xylocaine –SE confusion = VTachb.) Bretylliumc.) Quinines/Quinidine – anti malarial agent. Give with meals.
Nsg Ngt post lumbar1. Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF2. Force fluid3. Check punctured site for drainage, discoloration & leakage to tissue4. Assess for movement & sensation of extremeties
Result 1. CSF analysis: a. increase CHON & WBC Content of CSF: Chon, wbc, glucose
b. Decrease glucose Confirms meningitis c. increase CSF opening pressure
1. GIT irritation – take with food2. Hepatotoxicity, nephrotoxcicity3. Allergic reaction4. Super infection – alteration in normal bacterial flora- N flora throat – streptococcus- N flora intestine – e coli
Sx of superinfection of penicillin = diarrheab.) Antipyretic c.) Mild analgesic
2. Strict resp isolation 24h after start of antibiotic therapyA – Cushing’s synd – reverse isolation - due to increased corticosteroid in body.B – Aplastic anemia – reverse isolation - due to bone marrow depression.C – Cancer anytype – reverse isolation – immunocompromised.D – Post liver transplant – reverse isolation – takes steroids lifetime.
E – Prolonged use steroids – reverse isolationF – Meningitis – strict respiratory isolation – safe after 24h of antibiotic therapyG – Asthma – not to be isolated
3. Comfy & dark room – due to photophobia & seizure 4. Prevent complications of immobility 5. Maintain F & E balance6. Monitor vs, I&O , neuro check7. Provide client health teaching & discharge plan
a. Nutrition – increase cal & CHO, CHON-for tissue repair. Small freq feedingb. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.Where to bring 2 yo post meningitis- Audiologist due to damage to hearing- post repair myelomeningocele - Urologist - Damage to sacral area – spina bifida – controls urination
9. Rehab for neurological deficit. Can lead to mental retardation or a delay in psychomotor development.
CEREBRO VASCULAR ACCIDENT – stroke, brain attack or cerebral thrombosis, apoplexy - Partial or complete disruption in the brains blood supply- 2 largest & common artery in stroke
S/Sx: cerebral embolismHeadache, disorientation, confusion & decrease in LOC
Femur fracture – complications: fat embolism – most feared complication w/in 24hrsYellow bone marrow – produces fat cells at meduallary cavity of long boneRed bone marrow – provides WBC, platelets, RBC found at epiphisis
2.) Hemorrhage3.) Compartment syndrome – compression of nerves/ arteries
Risk factors of CVA: HPN, DM, MI, artherosclerosis, valvular heart dse - Post heart surgery – mitral valve replacement
Lifestyle: 1. Smoking – nicotine – potent vasoconstrictor2. Sedentary lifestyle3. Hyperlipidemia – genetic 4. Prolonged use of oral contraceptives
- Macro pill – has large amt estrogen- Mini pill – has large amt of progestin- Promote lipolysis (breakdown of lipids/fats) – artherosclerosis – HPN - stroke
5. Type A personalitya. Deadline driven personb. 2 – 5 things at the same timec. Guilty when not dong anything
1. Phlegia2. Dysarthria – inability to vocalize, articulate words 3. Aphasia4. Agraphia diff writing5. Alesia – diff reading6. Homoninous hemianopsia – loss of half of field of vision
Left sided hemianopsia – approach Right side of pt – the unaffected side
Dx 1. CT Scan – reveals brain lesion2. Cerebral arteriography – site & extent of mal occlusion- Invasive procedure due to inject dye - Allergy testAll – graphy – invasive due to iodine dyePost 1.) Force fluid – to excrete dye is nephrotoxic2.) Check peripheral pulses - distal
Nsg Mgt 1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation- Administer O2
2. Restrict fluids – prevent cerebral edema3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.4. Monitor vs., I&O, neuro check5. Prevent compl of immobility by:
a. Turn client q2h Elderly q1h
- To prevent decubitus ulcer- To prevent hypostatic pneumonia – after prolonged immobility.
b. Egg crate mattress or H2O bedc. Sand bag or foot board- prevent foot drop
6. NGT feeding – if pt can’t swallow7. Passive ROM exercise q4h8. Alternative means of communication
- Non-verbal cues- Magic slate. Not paper and pen. Tiring for pt.- (+) To hemianopsia – approach on unaffected side
Coumadin will take effect after 3 daysHeparin – monitor PTT partial thromboplastin time if prolonged – bleeding give Protamine SO4- antidote.Coumadin –Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K – Aquamephyton- antidote.Antiplatelet – PASA – aspirin paraanemo aspirin, don’t give to dengue, ulcer, and unknown headache.
Health Teaching1. Avoidance modifiable lifestyle
- Diet, smoking2. Dietary modification
- Avoid caffeine, decrease Na & saturated fatsComplications:
Subarachnoid hemorrhageRehab for focal neurological deficit – physical therapy
1. Mental retardation2. Delay in psychomotor development
CONVULSIVE Disorder (CONVULSIONS)- disorder of the CNS char. by paroxysmal seizures with or without loss of consciousness, abnormal motor activity, alteration in sensation & perception & change in behavior.
Can you outgrow febrile seizure? Difference between: Seizure- 1st convulsive attackFebrile seizure Normal if < 5 yo Epilepsy – 2nd and with history of seizurePathologic if > 5 yo
Predisposing FactorHead injury due birth traumaToxicity of carbon monoxideBrain tumorGeneticsNutritional & metabolic deficitPhysical stressSudden withdrawal to anticonvulsants will bring about status epilepticusStatus epilepticus – drug of choice: Diazepam & glucose
S & Sx I. Generalized Seizure –
a.) Grand mal / tonic clonic seizuresWith or without aura – warning symptoms of impending seizure attack- Epigastric pain- associated with olfactory, tactile, visual, auditory sensory experience
- Epileptic cry – fall- Loss of consciousness 3 – 5 min- Tonic clonic contractions- Direct symmetrical extension of extremities-TONIC. Contractions-CLONIC - Post ictal sleep -state of lethargy or drowsiness - unresponding sleep after tonic clonic
b.) Petimal seizure – (same as daydreaming!) or absent seizure.- Blank stare- Decrease blinking eye- Twitching of mouth- Loss of consciousness – 5 – 10 secs (quick & short)
II. Localized/partial seizurea.) Jacksonian seizure or focal seizure – tingling/jerky movement of index finger/thumb & spreads to shoulder & 1
sideof the body with janksonian marchb.) Psychomotor/ focal motor - seizure
-Automatism – stereotype repetitive & non-purposive behavior- Clouding of consciousness – not in control with environment- Mild hallucinatory sensory experience
III. Status epilecticus – continuous, uninterrupted seizure activity, if untreated, lead to hyperprexia – coma – deathSeizure: inc electrical firing in brain=increased metabolic activity in brain=brain using glucose and O2=dec glucose, dec O2.
Tx:Diazepam (drug of choice), glucoseDx-Convulsion- get health history!
1. Remove blunt/sharp objects2. Loosen clothing3. Avoid restraints4. Maintain siderails5. Turn head to side to prevent aspiration6. Tongue guard or mouth piece to prevent biting of tongue-BEFORE SEIZURE ONLY! Can use spoon at home.7. Avoid precipitating stimulus – bright glaring lights & noises8. Administer medsa. Dilantin (Phenytoin) –( toxicity level – 20 )
SE Ginguial hyperplasia H-hairy tongue A-ataxia N-nystagmus
A-acetaminophen- febrile ptMix with NSS- Don’t give alcohol – lead to CNS depression
b. (Tegretol) Carbamasene- given also to Trigeminal Neuralgia. SE: arrythmiac. Phenobarbital (Luminal)- SE: hallucinations
2. Institute seizure & safety precaution. Post seizure: Administer O2. Suction apparatus ready at bedside3. Monitor onset & duration
- Type of seizure - Duration of post ictal sleep. The longer the duration of post ictal sleep, the higher chance of having status epilepticus!
4. Assist in surgical procedure. Cortical resection 5. Complications: Subarachnoid hemorrhage and encephalitis
Question: 1 yo grand mal – immediate nursing action = a/w & safetya. Mouthpiece – 1 yr old – little teeth onlyb. Adm o2 inhalation – post!c. Give pillow – safety (answer)d. Prepare suction
Neurological assessment:1. Comprehensive neuro exam2. GCS - Glasgow coma scale – obj measurement of LOC or quick neuro check
3 components of ECSM – motor 6V – verbal resp 5E – eye opening 4
15
15 – 14 – conscious13 – 11 – lethargy10 – 8 – stupor 7 – coma 3 – deep coma – lowest score
Survey of mental status & speech (Comprehensice Neuro Exam)1.) LOC & test of memory2.) Levels of orientation3.) CN assessment4.) Motor assessment5.) Sensory assessment6.) Cerebral test – Romhberg, finger to nose7.) DTR8.) Autonomics
Levels of consciousness (LOC) – 1. Conscious (conscious) – awake – levels of wakefulness2. Lethargy (lethargic) – drowsy, sleepy, obtunded3. Stupor (stuporous) – awakened by vigorous stimulation
Pt has gen body weakness, decrease body reflex4. Coma (Comatose) light – (+) all forms of painful stimulations
Deep – (-) to painful stimulationQuestion: Describe a conscious pt ?a. Alert – not all pt are alert & oriented to time & placeb. Coherentc. Awake- answerd. Aware
Different types of pain stimulation- Don’t prick1. Deep sternal stimulation/ pressure 3x– fist knuckle
With response – light comaWithout response – deep coma
2. Pressure on great toe – 3x3. Orbital pressure – pressure on orbits only – below eye4. Corneal reflex/ blinking reflex
Wisp of cotton – used to illicit blinking reflex among conscious patientsInstill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma
5. Test of memory – considered educational backgrounda.) Short term memory – - What did you eat for breakfast?
Damage to temporal lobe – (+) antero grade amnesiab.) Long term memory(+) Retrograde amnesia – damage to limbic system
6. Levels of orientationTime Place Person
Graphesthesia- can identify numbers or letters written on palm with a blunt object.Agraphesthesia – cant identify numbers or letters written on palm with a blunt object.
CN assessment:I – Olfactory sII – Optic sIII – Oculomotor mIV – Trocheal m smallest CNV – Trigeminal b largest CNVI – Abducens mVII – Facial bVIII – Acustic/auditory sIX – Glassopharyngeal bX – Vagus b longest CNXI– Spinal accessory mXII – Hypoglossal m
I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee, bar soap, vinegar, cigarette tar- Hyposmia – decrease sensitivity to smell- Diposmia – distorted sense of smell- Anosmia – absence of sense of smellEither of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition – sinusitis
II optic- test of visual acuity – Snellens chart – central or distance visionSnellens E chart – used for illiterate chartN 20/20 vision distance by w/c person can see letters- 20 ft Numerator – distance to snellens chartDenominator – distance the person can see the lettersOD – Rt eye 20/20 20/200 – blindness – cant read E – biggestOS – left eye 20/20OU – both eye 20/20
2. Test of peripheral vision/ visual fielda. Superiorityb. Bitemporallyc. Inferiorlyd. Nasally
Common Disorders – see page 85-87 for more info on glaucoma, etc.1. Glaucoma – Normal 12 – 21 mmHg pressure
- Increase IOP - Loss of peripheral vision – “tunnel vision” 2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision”3. Retinal detachment – curtain veil – like vision & floaters4. Macular degeneration – black spots
III, IV, VI – tested simultaneously - Innervates the movementt of extrinsic ocular muscle
V – Trigeminal – Largest – consists of - ophthalmic, maxillary, mandibular Sensory – controls sensation of the face, mucus membrane; teeth & cornea reflex
Unconscious – instill drop of saline solutionMotor – controls muscles of chewing/ muscles of masticationTrigeminal neuralgia – diff chewing & swallowing – extreme food temp is not recommended
Question: Trigeminal neuralgia, RN should givea. Hot milk, butter, raisinsb. Cereals c. Gelatin, toast, potato – all correct butd. Potato, salad, gelatin – salad easier to chew
VI Facial: Sensory – controls taste – ant 2/3 of tongue test cotton applicator put sugar. -Put applicator with sugar to tip to tongue. -Start of taste insensitivity: Age group – 40 yrs old
Cause – bells palsy pedia – R/T forcep deliveryTemporary only
Most evident clinical sign of facial symmetry: Nasolabial folds
VIII Acoustic/ vestibule cochlear (controls hearing) – controls balance (kenesthesia or position sense) - Movement & orientation of body in space- Organ of Corti – for hearing – true sense organ of hearing
Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumenMiddle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
Archimedes law – buoyancy (pregnancy – fetus)Daltons law – partial pressure of gases Inertia – law of motion (dizziness, vertigo)
1.) Pt with multiple stab wound - chest- Movement of air in & out of lungs is carried by what principle?- Diffusion – Dalton’s law
2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid- Archimedes
3.) Severe vertigo due- Inertia
Test for acoustic nerve:- Repeat words uttered
IX – Glossopharyngeal – controls taste – posterior 1/3 of tongueX – Vagus – controls gag reflex
Test 9 – 10Pt say ah – check uvula – should be midline Damage cerebral hemisphere is L or R Gag reflex – place tongue depression post part of tongue
Don’t touch uvula
XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius (shoulders and back)- Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia
XII – Hypoglossal – controls movement of tongue – say “ah”. Assess tongue position=midlineL or R deviation
- Push tongue against cheek- Short frenulum lingue – Tongue tied – “bulol”