• Gross anatomy

• The nervous system is divided into the central and

peripheral nervous system
• The Central nervous system consists of the BRAIN
and the Spinal Cord
• The peripheral nervous system consists of the
Spinal nerves and the cranial nerves
The nervous system is the master controller of the body. Each thought,
each emotion, each action—all result from the activity of this system.
It then processes that information and decides how the body should
respond, if at all.

Finally, if a response is needed, the system sends out electrical signals

that spur the body into immediate action.

The central nervous system is made up of the brain and spinal cord. The
brain functions to receive nerve impulses from the spinal cord and cranial
nerves.

The spinal cord contains the nerves that carry messages between the brain
and the body.

The brain
The human brain is a soft, shiny, grayish white, mushroom-shaped
structure encased within the skull.

Although brain size varies considerably among humans, there is no

correlation or link between brain size and intelligence.

The brain is composed of lobes-

• Frontal lobe- personality, memory and motor function
• Parietal lobe- sensory function
• Temporal lobe- hearing and olfaction and emotion by the
limbic system
• Occipital lobe- vision

The left cerebral hemisphere controls movement of the right side of
the body. Depending on the severity, a stroke affecting the left
cerebral hemisphere may result in functional loss or motor skill
impairment of the right side of the body, and may also cause loss of
speech.
The right cerebral hemisphere controls movement of the left side of
the body. Depending on the severity, a stroke affecting the right
cerebral hemisphere may result in functional loss or motor skill
impairment of the left side of the body. In addition, there may be
impairment of the normal attention to the left side of the body and its
surroundings.
The thalamus is an important relay station for sensory information
coming to the cerebral cortex from other parts of the brain.
The thalamus also interprets sensations of pain, pressure, temperature,
and touch, and is concerned with some of our emotions and memory.
Cerebellum- Is both excitatory and inhibitory actions and responsible for
coordination of movement. It controls also fine movements, balance,
position sense or proprioception and integration of sensory input.
• The cerebellum is involved in coordination and equilibrium
• The diencephalon consists of the :
• Thalamus- the relay center of all sensory input
• Hypothalamus- center for endocrine regulation,
sleep, temperature, thirst, sexual arousal, hunger,
satiety
The cerebellum processes input from other areas of the brain,
providing precise timing for coordinated, smooth movements of the
skeletal muscular system.
A stroke affecting the cerebellum may cause dizziness, nausea,
balance and coordination problems.
• Test for balance- heel to toe
• Test for coordination- rapid alternating movements and finger
to nose test
• ROMBERG test
• BALANCE TESTS:
B. ROMBERG TEST
- Ask the person to stand up with feet together and arms at
the side.
- Ask the client to close the eyes and to hold the position for
about 20 seconds.
Normally, a person can maintain posture and balance even with the
visual orienting information blocked, although slight swaying may
occur.
Positive Romberg sign (loss of balance that occurs when closing the
eyes) occurs with cerebellar ataxia, loss of proprioception and loss of
vestibular function.
• BALANCE TESTS:
A. TANDEM WALKING
- Ask the person to walk a straight line in a “heel-to-toe”
fashion.
Tandem walking decreases the base of support and accentuates
problem with coordination.
Normally, the person can walk straight and stay balanced.
Inability to tandem walk may indicate upper motor neuron lesion
such as in multiple sclerosis.
• COORDINATION TESTS:
A. RAPID ALTERNATING MOVEMENTS (RAM)
- Ask the person to pat the knees with both hands, patting
alternately with the dorsum and palmar surfaces of the
hands.
- Start slowly then ask the client to do it faster.
- Ask the person to touch the thumb to each finger on the
same hand, starting with the index finger then reverse
direction.
STEREOGNOSIS – test the person’s ability to recognize objects by
feeling their forms, sizes and weights.
- Ask the client to close his eyes and identify an object that is
placed in his hand.
- Test a different object in each hand.
Normally, a person will explore the object with the fingers and
correctly name it.
Testing the left hand assesses right parietal lobe functioning.
ASTEREOGNOSIS occurs in sensory cortex lesions.
GRAPHESTESIA – ability to read a number by having it trace on
the skin.
- With the client’s eyes closed, use a blunt instrument to
trace a number or a letter on the palm.
 Can't remember the names of the cranial nerves? Here is a handy-
- Ask the person to tell you what the number or letter is. dandy mnemonic for you:

- The brainstem is composed of the:

- MIDBRAIN- for visual and auditory
reflexes CRANIAL NERVES FUNCTIONS ABNORMAL FINDINGS
- Pons- respiratory apneustic center,
nucleus of cranial nerves- 5,6,7,8
- Medulla oblongata- respiratory and
cardiovascular centers, nucleus of I. Olfactory Smell Anosmia (absence of smell)
cranial nerves 9,10,11,12

The Brain stem is the stalk of the brain and is a

continuation of the spinal cord. II. Optic Vision blurred vision; blindness

It consists of the medulla oblongata, pons, and

midbrain.
III. Oculomotor Pupil constriction, elevation of the upper fixed, dilated pupils
The medulla oblongata is actually a portion of
lid.
the spinal cord that extends into the brain.

All messages that are transmitted between the IV. Trochlear Eye movement; controls superior Nystagmus
brain and spinal cord pass through the medulla. oblique muscle.
Nerves on the right side of the medulla cross to
the left side of the brain, and those on the left
cross to the right. V. Trigeminal Controls of muscles of mastication; Trigeminal Neuralgia (tic douloureux)
sensations for the entire face.
The result of this arrangement is that each side
of the brain controls the opposite side of the
body.
VI. Abducens Eye movement; controls the lateral Diplopia; ptosis of the eyelid.
Three vital centers in the medulla control rectus muscle.
heartbeat, rate of breathing, and diameter of the
blood vessels.

Centers that help coordinate swallowing, VII. Facial Controls muscles for facial expression; Bell’s palsy; ageusia (loss of sense of
vomiting, hiccuping, coughing, sneezing, and anterior 2/3 of the tongue. taste) of the anterior 2/3 of the tongue.
other basic functions of life are also located in
the medulla.
VIII. Acoustic Cochlear branch permits hearing; Tinnitus; vertigo
• Pons bridge between the two halves of vestibular branch helps maintain
the cerebellum and between medulla equilibrium.
cerebrum.
IX. Glossopharyngeal Controls muscles of the throat; taste of Loss of the gag reflex, drooling of the
• It also controls the heart, respiration, the posterior 1/3 of the tongue. saliva, dysphagia, dysphagia, dysphonia,
blood pressure. posterior third ageusia.
• CN V, VIII connects in the brain in
the pons. X. Vagus nerve Controls muscles of the throat, PNS Loss of gag reflex, drooling of the
stimulation of thoracic and abdominal saliva, dysphagia, dysarthia,
Test for the Oculocephalic reflex- doll’s eye organs. bradycardia, increased HCl secretion.
• Normal response- eyes appear to
move opposite to the movement of the head
• Abnormal- eyes move in the same direction
Sen
What is the spinal cord? Sen
The spinal cord is part of the nervous system and is about 45 cm long in Mo
men and 43 cm long in women. Mo
Mi
The length of the spinal cord is much shorter than the length of the bony Mo
spinal column. It runs the length of the back, extending from the base of Mi
the brain to about the waist. Sen
Mi
The area within the vertebral column beyond the end of the spinal cord is Mi
called the cauda equina. Mo
Mo
The nervous system is made up of nerve cells or neurons.

Neurons have a limited ability to repair themselves. Unlike other body

tissues, nerve cells cannot also be repaired if damaged due to injury or
disease.
XI. Spinal Accessory Controls sternocleidomastoid and
trapezius muscles. EYE OPENING E
Spontaneous 4
To speech 3
To pain 2
XII. Hypoglossal Movements of the tongue. No response 1
BEST MOTOR RESPONSE M
To Verbal Command:
Obeys 6
To Painful Stimulus:
Localizes pain 5
PHYSICAL EXAMINATION Flexion-withdrawal 4
• 5 categories:
• 1. Cerebral function- LOC, mental status Flexion-abnormal 3
• 2. Cranial nerves Extension 2
• 3. Motor function
No response 1
• 4. Sensory function
• 5. Reflexes BEST VERBAL RESPONSE V
Oriented and converse 5
CATEGORIES OF CONSCIOUSNESS
• NORMAL Spontaneous eye opening Disoriented 4
& aware of self &
environment. Inappropriate words 3
Incomprehensible sounds 2
• LETHARGIC State of drowsiness or
inaction which pt. needs an No response 1
increase stimulus. To be awaken.
Glasgow Coma Score
8 and Below= severe head injury!
• OBTUNDED Duller indifferences to
external stimuli & Assessing the sensory function
response is minimally maintained. • Evaluate symmetric areas of the body
• Ask the patient to close the eyes while testing
• STUPOR Marked reduction in mental &
• Use of test tubes with cold and warm water
physical activity, vigorous &
continuous stimuli needed. Shows • Use blunt and sharp objects
some spontaneous movement. • Use wisp of cotton
• Ask to identify objects placed on the hands
• COMA Does not respond to any stimuli, no • Test for sense of position
voluntary movement.
Reflexes maybe intact or absent. • C5 – The deltoid muscle (abduction of the arm at the
shoulder).
• GLASCOW COMA SCALE to assess these simple three • C6 – The biceps (flexion of the arm at the elbow).
(3) parameters: • C7 – The triceps (extension of the arm at the elbow).
• C8 – The small muscles of the hand.
1. THE OPENING OF THE EYES;
•
2. THE USE OF VOICE;
3. and, THE BEST MOVEMENT ( Motor Response). • L4 – The quadriceps (extension of the leg at the knee).
• L5 – The tibialis anterior (upward flexion of the foot at the
The GCS assigned a score to its function: ankle).
• S1 – The gastrocnemius muscle (downward flexion of the foot
I - As the lowest number ( absence of function ) at the ankle).
I5 – As the highest score • FOUR POINT SCALE FOR GRADING REFLEXES
8 OR LESS – defines coma ( which indicates less brain function and 4+ - very brisk, hyperactive with clonus, indicative
suggest a higher degree of injury ). of disease.

Coma represents the last and lowest level of function of the brain 3+ - brisker than average, may indicate disease.
prior to death. As a general rule: IF A PATIENT IN COMA
SURVIVES FIRST 7 to 10 days following THE INJURY OF THE 2+ - average, normal.
BRAIN, THEN LONG TERM SURVIVAL CAN BE EXPECTED,
HOWEVER THE QUALITY OF THE SURVIVAL REMAINS A 1+ - diminished, low normal.
SUBJECT OF DEBATE.
0 - no response
 • Surgical complications
Deep tendon reflex • Subarachnoid hemorrhages
• 0- absent • Viral infection
• + present but diminished
• ++ normal Pathophysiology
• +++ increased • The cranium only contains the brain substance, the CSF and
• ++++ hyperactive or clonic the blood/blood vessels
Superficial reflex • MONRO-KELLIE hypothesis- an increase in any one of the
• 0 absent components causes a change in the volume of the other
• +present • Any increase or alteration in these structures will cause
increased ICP
• EEG • In response Pathologic conditions alter the relationship
• Withhold medications that may interfere with the intracranial volume and ICP
results- anticonvulsants, sedatives and stimulants • 2. reduction of oxygen will lead to brain damage will lead to
• Wash hair thoroughly after the procedure edema of the brain and shifting of fluids from the dura and
• Definition increase ICP.
• 1. Measurement and recording of electrical activity of the • 3. Increase PaCO2 lead to increase ICP
brain in the form of waves
Nursing interventions:
• 2. Provides information about seizure disorders, local
Maintain patent airway
tumors,infections of the central nervous system, and chemical
toxicity • 1. Elevate the head of the bed 30 degrees- to promote venous
drainage
CT scan
• With radiation risk • 2. assists in administering 100% oxygen or controlled
• If contrast medium will be used- ensure consent, assess for hyperventilation- to reduce the CO2 blood levels◊constricts
allergies to dyes and iodine or seafood, flushing and metallic blood vessels◊reduces edema
taste are expected as the dye is injected • 3. Administer prescribed medications- usually
• Cross-sectional visualization of the brain determined by • Mannitol- to produce negative fluid balance
computer analysis of relative tissue density as an x-ray beam • corticosteroid- to reduce edema
passes through; also known as computerized axial tomography • anticonvulsants- to prevent seizures
(CAT) scan • 4. Reduce environmental stimuli
• 5. Avoid activities that can increase ICP like valsalva,
PET scan
coughing, shivering, and vigorous suctioning, flexion of the
• Definition
head**
• 1. This test registers glucose metabolism in a cross-section of
the brain; glucose metabolism increases in areas of the brain • 6. Keep head on a neutral position. AVOID- extreme flexion,
that are active valsalva
• 2. Utilized to diagnose Alzheimer's disease, depression, • 7. monitor for secondary complications
dementia,and brain tumors
• Diabetes insipidus
MRI • SIADH
 Uses magnetic waves
Altered level of consciousness
 Patients with pacemakers, orthopedic metal prosthesis and
implanted metal devices cannot undergo this procedure • It is a manifestation of multiple pathophysiologic phenomena
This procedure utilizes magnetism and radio waves to produce images of • Causes: head injury, toxicity and metabolic derangement
cross-sections of the body • Disruption in the neuronal transmission results to improper
function
Cerebral arteriography / angiography Assessment
 Note allergies to dyes, iodine and seafood • Orientation to time, place and person
 Ensure consent • Motor function
 Keep patient at rest after procedure • Decerebrate
 Maintain pressure dressing or sandbag over punctured site • Decorticate
• Sensory function
Lumbar puncture / Spinal tap
 Ensure consent, determine ability to lie still • COMA= clinical state of unconsciousness where patient is
 Contraindicated in patients with increased ICP*** NOT aware of self and environment
 Keep flat on bed after procedure**
 Increase fluid intake after procedure • Etiologic Factors
1. Head injury
Increased Intracranial pressure 2. Stroke
Brunner= Normal intracranial pressure 10-20 mmHg 3. Drug overdose
Causes: 4. Alcoholic intoxication
• Head injury 5. Diabetic ketoacidosis
• Stroke 6. Hepatic failure
• Inflammatory lesions • ASSESSMENT
• Brain tumor 1. Behavioral changes initially
 2. Pupils are slowly reactive Definition/etiology
3. Then , patient becomes unresponsive and pupils become fixed disorder of cranial nerve seven (facial nerve)
dilated involves one side only; unilateral
Glasgow Coma Scale is utilized etiology unknown

Nursing Intervention Findings often occur suddenly over ten to 30 minutes

1. Maintain patent airway ptosis
• Elevate the head of the bed to 30 degrees cannot close or blink eye with excessive tearing
• Suctioning flat nasolabial fold
2. Protect the patient impaired taste
• Pad side rails lower face paralysis
difficulty eating
• Prevent injury from equipments, restraints and etc.
Diagnostics: history and physical exam
3. Maintain fluid and nutritional balance
Management
• Input and output monitoring – expected outcome: to restore cranial nerve function
• IVF therapy – medications
• Feeding through NGT » prednisone
4. Provide mouth care » analgesics
• Cleansing and rinsing of mouth – local comfort measures: heat, massage and electrical nerve
• Petrolatum on the lips stimulation for muscle tone
5. Maintain skin integrity – alternative actions: massage, imagery
• Regular turning every 2 hours
• 30 degrees bed elevation – administer drugs as ordered
– teach client
• Maintain correct body alignment by using trochanter rolls, » to chew on opposite side
foot board » how to use protective eye wear during risk periods
6. Preserve corneal integrity » effects of steroids
• Use of artificial tears every 2 hours » the use of eye drugs or ointment to protect the eye from
7. Achieve thermoregulation corneal irritation
• Minimum amount of beddings » that once findings disappear their return may occur
• Rectal or tympanic temperature especially in times of high stress
• Administer acetaminophen as prescribed – provide balanced nutrition: soft diet
8. Prevent urinary retention » use of eye patch
• Use of intermittent catheterization** » Physical Therapy
9. Promote bowel function
• High fiber diet Traumatic brain injury
• AN INJURY TO THE BRAIN OR SCALP AS A RESULT OF
• Stool softeners and suppository
TRAUMA.
10. Provide sensory stimulation
• Occurs when a mechanical force comes in contact with a
• Touch and communication**
portion of the brain. (generally the frontal or temporal lobes)
• Frequent reorientation
directly or indirectly
Autonomic Dysreflexia/hyperreflexia Most common causes
• Seen commonly in spinal cord injury above T6 • Vehicle accidents compounded by drugs or alcohol use
• An exaggerated response by the autonomic system resulting • Acts of violence
from various stimuli most commonly distended bladder, • Falls
impacted feces, pain, skin irritation*** • Sports –related injury
Trigeminal neuralgia (tic douloureux)
• Findings • Occurs most in males between 10-39 yrs old
– intense facial pain lasting about one to two minutes along the • Types:
nerve branches a. Minor
– extreme facial sensitivity 1. Laceration of the scalp-tearing of the vessels of the scalp that
• Diagnostics: history and physical exam may cause bleeding
• Management 2. Contusion- brief loss of consciousness;may also experience
– expected outcome: to relieve pain amnesia and headaches.
– anticonvulsants: phenytoin (dilantin) • Major:
– help clients to name trigger points with identification of 1. Fractures – comminuted, linear , or depressed
triggering incidents Clinical manifestations:
– recommend restful environment with scheduled rest Battle’s sign (post-auricular ecchymosis)
– provide balanced nutrition Racoon’s eye (periorbital edema)
teach client Rrhinorrhea (leakage of CSF from nose)
• medications and side effects Otorrhea – fluid from ear
• to avoid triggering agents 2. Epidural hematoma – arterial bleed result of temporal bone.
• to chew on the opposite side of the mouth 3. Subdural hematoma- venous bleed generally result of a laceration of
• to avoid very hot or cold foods brain tissue.

Findings of head trauma

Facial nerve paralysis (bell's palsy) • Degree of neurological damage varies with type and location of
injury
 • Restlessness and irritability - initially • The real danger lies in possible spinal cord damage. Spinal
• Decreased LOC - lethargy, difficulty with arousal,amnesia fractures most commonly occur in the 5th, 6th, and 7th
• Nausea and vomiting - projectile vomiting indicates increased cervical, 12th thoracic, and 1st lumbar vertebrae.
ICP Complications:
• Cushing’s reflex- severe hypertension and wide pressure is a late • Spinal shock-occurs immediately following the injury.
sign. • Characterized by:
• Hypovolemic shock • - decreased reflexes
• Behavioral changes • Loss of sensation
• Weakness • Flaccid paralysis below the site of injury
• Ataxia
• Decreased muscle tone Neurogenic shock- loss of vasomotor tone results from the injury
characterized by:
hypotension,
1. CONCUSSION bradycardia.
- Occurs with cervical or high thoracic injury
• Involves jarring of head without tissue injury
• Temporary loss of neurologic function lasting for a few
• Types of injury:
minutes to hours
a. Incomplete
2. CONTUSION
1. Central cord syndrome- occurs in older adults in the cervical
• Involves structural damage cord area
• The patient becomes unconscious for hours 2. Anterior cord syndrome- results from flexion injury with
3. Intracranial hemorrhage motor paralysis and loss of pain and temperature below the
Epidural Hematoma- blood collects in the epidural space between skull site of injury
and dura mater. Usually due to laceration of the middle meningeal 3. Posterior cord syndrome-rare;loss of proprioception
artery*** 4. Brown-sequard syndrome-loss of motor function ipsilateral and
Symptoms develop rapidly** contralateral pain and temperature remains intact below the level of
MANIFESTATIONS injury.
• 1. Altered LOC 5. Conus medullaris and cauda equina- lower limb paralysis,bowel and
• 2. CSF otorrhea bladder dysfxn. In th elumbar and sacral area.
• 3. CSF rhinorrhea
• 4. Racoon eyes and Battle sign • AUTONOMIC HYPERREFLEXIA /DYSREFLEXIA-
Autonomic dysreflexia (hyperflexion)
NURSING MANAGEMENT - Occurs in injury at T6 or above.
1. Monitor for declining LOC- use of Glasgow - Most common cause is overdistended bladder or bowel
2. Maintain patent airway - Characterized by hypertension (systolic greater than
• Elevate bed, suction prn, monitor ABG 300mmHg),bradycardia,diaphoresis and piloerection( body
• Logroll the client hair erection.), nausea and nasal congestion
NURSING INTERVENTIONS
3. Monitor for rhinorhea or otorrhea
4. Administer good skin care • 1. Elevate the head of the bed immediately
5. Monitor for increase intracranial pressure • 2. Check for bladder distention and empty bladder with
6. Provide adequate nutrition urinary catheter
7. Prevent injury • 3. Check for Fecal impaction and other triggering factors like
• Use padded side rails skin irritation, pressure ulcer
• Avoid extreme flexion or extension of the neck • 4. Administer antihypertensive medications- usually
8.Elevate the head of the bed to 30 degrees hydralazine
9.Provide warm or coldcompress to the eyes to dec. periorbital Spinal Shock
edema Pathophysiology
10.. Maintain skin integrity • The sudden depression of reflex activity in the spinal cord
• Prolonged immobility will likely cause skin breakdown below the level of injury
• Turn patient every 2 hours • The muscles below the lesion are flaccid, the skin without
• Provide skin care every 4 hours sensation and the reflexes are absent including bowel and
• Avoid friction and shear forces bladder functions
• Prevent complications of immobility
7. Monitor potential complications
• Spinal shock: A rare condition that can occur after spinal cord
• Increased ICP injury and involves a period of absent reflexes which may be
permanent or last for hours to weeks. This period may be
• Meningitis** followed by a period of excessive reflexes.
• Post-traumatic seizures
• Impaired ventilation • Signs and symptoms of spinal shock
Surgical management: • Absence of reflex
Craniotomy:performed to decrease ICP to remove ischemic tissues • Paraplegia
• Atonic paralysis
Spinal Cord Injury
• Injury to the spinal cord as a result of an incomplete or • Sensory loss
complete loss of sensory and motor function.
Nursing Interventions
• Caused by MVA, sports injuries or violence and falls.
• The greatest at risk is the 16 to 30 yr.old category.
The primary treatment after a spinal injury is immediate immobilization
to stabilize the spine and prevent cord damage; other measures are Major risk factors
supportive. » Coronary artery dse.
Cervical injuries require immobilization, using a type of cervical » Hypertension
immobilization device (CID) on both sides of the patient’s head, a hard » Age
cervical collar, or skeletal traction » DM
» Previous TIA
• Treatment of stable lumbar and dorsal fractures consists of bed » transient ischemic attack (TIA), "angina" of the brain
rest on firm support (such as a bed board) » TIA is warning sign of stroke
» localized ischemic event
• Later measures include exercises to strengthen the back » produces neurological deficits lasting only minutes or hours
muscles and use of a back brace or other device to provide » full functional recovery within 24 to 48 hours
support while walking. » reversible ischemic neurological deficit (RIND)
• Reorient the patient by calling his name frequently » similar to TIA
• Provide background information as to date, time, place,
Two types of stroke by cause
environment
– ischemic (also known as occlusive) stroke (clot) - slower
3. Use large signs as visual cues
onset
4. Post patient's photo on the door
» results from inadequate blood flow leading to a cerebral
5. Encourage family members to bring personal articles and place them in
infarction
the same area
» caused by cerebral thrombosis or embolism within the
• Establish a regular pattern for bowel care cerebral blood vessels
• Place the patient on potty every other day » most common cause: atherosclerosis
• Use of stool softeners – There is disruption of the cerebral blood flow due to
• Maintain a dietary intake. Avoid foods that can cause obstruction by embolus or thrombus
excessive gas production CLINICAL MANIFESTATIONS
• Elevate the head of the bed 90 degrees during meals and 30 • 1. Numbness or weakness
minutes after • 2. confusion or change of LOC
• Serve foods that are soft and small sized • 3. motor and speech difficulties
• Keep suction equipment on bedside • 4. Visual disturbance
• Consult with rehabilitation team as to assistive devices that • 5. Severe headache
can be utilized
– hemorrhagic stroke (bleeding) - abrupt onset ; TYPES
Clinical manifestations » blood vessels rupture with a bleed into the brain
• 1. Paraplegia » occurs most often in hypertensive older adults
• 2. quadriplegia » may also result during anticoagulant or thrombolytic
• 3. diplegia therapy
• EMERGENCY MANAGEMENT » most often caused by rupture of saccular intracranial
aneurysms
• A-B-C
The Circle of Willis is the joining area of several arteries at the
• Immobilization bottom (inferior) side of the brain.
• Immediate transfer to tertiary facility
NURSING INTERVENTION At the Circle of Willis, the internal carotid arteries branch into
• 1. Promote adequate breathing and airway clearance smaller arteries that supply oxygenated blood to over 80% of the
• 2. Improve mobility and proper body alignment*** cerebrum.
• 3. Promote adaptation to sensory and perceptual alterations
• 4. Maintain skin integrity Middle cerebral artery:
• Aphasia – inability to communicate
• 5. Maintain urinary elimination • Dysphagia
• 6. Improve bowel function • HEMIPARESIS on the OPPOSITE side- more severe on the
• 7. Provide Comfort measures face and arm than on the legs (weakness)
Anterior cerebral artery:
• 8. Monitor and manage complications
• Weakness
• Thrombophlebitis
• Numbness on the opposite side
• Orthostatic hypotension
• Personality changes
• Spinal shock
• Impaired motor and sensory function
• Autonomic dysreflexia
Posterior cerebral artery:
CEREBROVASCULAR ACCIDENTS
• Visual field defects
• An umbrella term that refers to any functional
• Sensory impairment
abnormality of the CNS related to disrupted blood supply
• Coma
• Definition: decreased blood supply to the brain
• Less likely paralysis
• Risk factors
• hypertension, uncontrolled
RISKS FACTORS
• smoking Non-modifiable
• obesity • Advanced age
• increased blood cholesterol and triglycerides • Gender
• chronic atrial fibrillation
 • race • Give one instruction at a time
8. Maintain skin integrity
Modifiable • Use of specialty bed
• Hypertension • Regular turning and positioning
• Cardio disease • Keep skin dry and massage NON-reddened areas
• Obesity • Provide adequate nutrition
• Smoking 9. Promote continuing care
• Diabetes mellitus • Referral to other health care providers
• hypercholesterolemia 10. Improve family coping
Motor Loss 11. Help patient cope with sexual dysfunction
• Hemiplegia – paralysis of one side of the body after a stroke
• Hemiparesis - weakness Multiple sclerosis
Communication loss Definition
demyelination of white matter throughout brain and spinal cord
• Dysarthria= difficulty in speaking
– third most common cause of disability in clients aged 15 to 60
• Aphasia= Loss of speech – specific cause unknown
• Apraxia= inability to perform a previously learned action – increased incidence in temperate to cool climates
Perceptual disturbances – illness improves and worsens unpredictably
• Hemianopsia – defective vision or blindness in half of the
visual field of one or both eyes. Findings depend on the location of the demyelination
Sensory loss – cranial nerve: blurred vision, dysphagia, diplopia, facial
• Paresthesia – any abnormal touch sensation as numbness or weakness and/or numbness
tingling in the absence of stimuli – motor: weakness, paralysis, spasticity, gait disturbances
NURSING INTERVENTIONS: ACUTE – sensory: paresthesias, decreased proprioception
1. Ensure patent airway – cerebellar: dysarthria, tremor, incoordination, ataxia, vertigo
2. Elevate head
3. Monitor VS and GCS, pupil size – cognitive: decreased short-term memory, difficulty with new
4. IVF is ordered but given with caution as not to increase ICP information, word-finding difficulty, short attention span
5. NGT inserted – urinary retention or incontinence
6. Medications: Heparin, Enoxaparin, t-PA, ASA, Steroids, – loss of bowel control
Mannitol (to decrease edema), Diazepam – sexual dysfunction
NURSING INTERVENTIONS: Hospital – fatigue
1. Improve Mobility and prevent joint deformities
• Correctly position patient to prevent contractures » avoid fatigue and stress
• Place pillow under axilla » conserve energy
• Hand is placed in slight supination- “C” » exercise regularly
» know drugs and side effects
• Change position every 2 hours » use self-help devices
2. Enhance self-care » maintain a diet that supports nutrition and energy
• Carry out activities on the unaffected side needs
• Prevent unilateral neglect- place some items on the affected
side!!!
• Keep environment organized
• Use large mirror • Guillain Barre Syndrome
• Definition
– acquired inflammatory disease
3. Manage sensory-perceptual difficulties – process: demyelinization of peripheral nerves
• Approach patient on the Unaffected side – precipitating factors include prior bacterial or viral infection
• Encourage to turn the head to the affected side to compensate within one to two weeks
for visual loss – muscle weakness: progressive, ascending, bilateral
– leads to paralysis of voluntary muscles
4. Manage dysphagia – loss of superficial and deep tendon reflexes
• Place food on the UNAFFECTED side – bulbar weakness
• Provide smaller bolus of food – dysphagia
• Manage tube feedings if prescribed – dysarthria
– respiratory failure
5. Help patient attain bowel and bladder control – sensory findings: paresthesias, burning pain
• Intermittent catheterization is done in the acute stage – paralysis may vary from being total to partial of only one-half
• Offer bedpan on a regular schedule way up the body
• High fiber diet and prescribed fluid intake
– expected outcomes: to prevent complications and maintain body
6. Improve thought processes
functions until any reversal
• Support patient and capitalize on the remaining strengths
– steroids in acute phase
7. Improve communication – care as dictated by areas involved
• Anticipate the needs of the patient
• Offer support Nursing interventions
• Provide time to complete the sentence – maintain the care of client on ventilatory support
• Provide a written copy of scheduled activities – provide for care of the immobilized client
 – have a safe environment to minimize infection » energy conservation techniques
– maintain nutrition and fluid balance » medications, expectations and side effects
– refer families or client to support groups » signs of impending crisis, both myasthenic and
– supply referrals to therapies such as speech, physical, cholinergic
occupational and counseling » to avoid stressors
Parkinson's disease
Definition: degenerative disorder of the dopamine hydrochloride - producing neurons (substantia nigra
• Myasthenia Gravis
• Definition: – result: dopamine hydrochloride depletion
– antibodies destroy acetylcholine receptors where nerves join – usually occurs in older adults and males more than females
muscles – etiology unknown
– two age clusters: women in early adulthood and men in late
adulthood – resting tremors of the lips, jaw, tongue, and limbs, especially a
– progressive with occurrence of crises resting pill-rolling tremor of one hand that is absent during sleep.
This is different from an essential or intention tremor in which
– progressive fatigue of voluntary muscles, but no muscular the tremor is action related.
atrophy – bradykinesia / akinesia
– facial – fatigue
» ptosis (drooping eyelid) and reduced eye closure – stiffness and cogwheel rigidity with movement
» weak smile – signs first unilateral, then bilateral
» diplopia, blurred vision – mask-like facial expression
» speech and swallowing disorders – slow, shuffling walk; gradually more difficult
» weakness of facial muscles – Drooling of saliva
– signs of restrictive lung disease – Dysphagia
– sensation remains intact – Trunk bent forward
– Microphonia
– Micrographia
– difficulty rising from sitting position
– history and physical exam – No intellectual impairment
– edrophonium (tensilon) test: improved muscle strength after – No true paralysis
tensilon injection indicates a positive test for MG – No loss of sensation
• Management
– expected outcome to improve strength and endurance DIET: Inc. caloriec, soft diet
– pharmacologic Position to prevent contractures:
» anticholinesterase agents: pyridostigmine firm beds, no pillows
(mestinon),
neostigmine (prostigmin) Prone position when lying in bed
» corticosteroid therapy – pharmacologic
» immunosuppressants: azathioprine (imuran) » anticholinergics - minimize extrapyramidal effects

» dopamine hydrochloridergics-improve muscle

– myasthenic crisis management flexibility: Levodopa (L-Dopa)
» crisis usually follows stressor or during dosage » antiparkinsonian agent: amantadine hcl (Symmetrel)
changes reduces rigidity and tremor
» signs: sudden inability to swallow, speak,Avoid the following foods rich in Vit. B6 when on Levodopa therapy;may block the effects of
or maintain
patent airway
» cholinergic crisis may follow over dosage of
medication
» positive edrophonium (tensilon) test signals
myasthenia
» Avoidhas
if negative endophronium test, client tyramine
not rich foods (may cause hepertensive crisis)
myasthenic but cholinergic crisis, so treat with chocolate
atropine coffee
» ventilatory support as indicated

Seizure
– identify aggravating factors, such as: Definition/etiology
» infection
• Sudden, transient alteration in brain function
» stress
» changes in medication regime • Disorderly transmission of electrical activity in the brain
• Causes
– if client is in crisis: provide care of the client on ventilatory – cerebral lesions
support – biochemical alteration
– give medications as ordered and on time – cerebral trauma
– help with ADL and feeding as indicated – idiopathic
– provide Types of generalized seizures - one classification system
» emotional support
Absence seizures (petit mal seizures)
» adequate rest periods
» care of the surgical client Myoclonic seizures (bilateral massive epileptic myoclonus)
– teach client Generalized tonic-clonic seizures (grand mal seizures)
 Akinetic seizure » techniques to reduce stress
• petit mal - called absence seizures » seizure care at home or at work
• myoclonic » to wear medic-alert jewelry
» if in public area, after the tonic phase turn client to
• sudden, uncontrollable jerking movements of one or
side
more extremities
• usually occurs in the morning
• clonic In multiple sclerosis, early changes tend to be in vision and motor sensation; late changes tend to
• characterized by violent muscle movements be in cognition and bowel control.
• hyperventilation Peripheral nerves can regenerate, but nerves in the spinal cord are thought to not be able to
• face contortion
• excessive salivation During a seizure, do not force anything into the client's mouth.
• tonic A major problem often associated with a left-sided CVA is an alteration in communication.
• first, client loses consciousness suddenlyClients
and muscles
with CVAs are at a greater risk for aspiration. Initially these clients must be evaluated to
contract determine if dysphagia is present.
• body stiffens in opisthotonos position
• jaws clenched The rate, rhythm and depth of a client's respirations are more sensitive indicators of increases in
• may lose bladder control intracranial pressure than blood pressure and pulse.
• apnea with cyanosis When caring for a comatose client, remember that the hearing is the last sense to be lost.
• pupils dilated and unresponsive After a CVA clients often have a loss of memory, emotional lability and a decreased attention span.
• usually lasts less than a minute Communication difficulties of a client with a CVA usually indicate involvement of the dominant
hemisphere, usually left, and is associated with right sided hemiplegia or hemiparesis.
– grand mal: most common type The client with myasthenia gravis will have more severe muscle weakness in the evening due to
» tonic-clonic movements the fact that muscles weaken with activity - described as progressive muscle weakness - and regain
» lasts two to three minutes strength with rest.
» client is unresponsive for about five minutes
» arms, legs go limp
» breathing returns to normal
» possible disorientation or confusion for sometime
afterwards

– atonic: sudden loss of postural muscle tone with collapse

– status epilepticus
» rapid sequence of seizures without interruption
» medical and nursing emergency
» sometimes occurs if a sudden stop of maintenance
doses of anticonvulsants
» if cerebral anoxia occurs, brain damage or death can
follow

e harmful objects from the patient’s surrounding

he client to the floor
t the head with a pad
ve and note for the duration, parts of body affected, behaviors before and after the

ave the client who is seizing

to prevent or break client's fall by assisting him/her to horizontal position on the bed or the

ght clothing around neck and chest

objects near the client
illow under the client's head if possible and available
client's head in a lateral position if possible to maintain airway
hing in the client's mouth

type of seizure - describe behavior rather than labeling

duration
activity during and if incontinence
if any precipitating factors
client's response - immediate, then at 15 minute intervals until stability is established

client
» about medication effects, interactions, and side effects
» to learn when a seizure may be triggered