NEUROLOGICAL SYSTEM

Lecturer: MS. Louradel M. Ulbata, RN

PHYSIOLOGY OF THE NEUROLOGIC SYSTEM
Ora!"#at"o! o$ t%e Ner&ou' S('te)
A. Ce!tral !er&ou' '('te) *CNS+.
1. Brain
2. Spinal Cord
,. Per"-%eral !er&ou' '('te) *PNS+.
1. Twelve pairs of cranial nerves
2. Thirty-one pairs of spinal nerves
,... Auto!o)"c !er&ou' '('te)
a. Sympathetic system
b. Parasympathetic system.
,./. SOMATIC NER0OUS SYSTEM
a. Afferent Nerves
b. fferent Nerves
CELLS OF THE NER0OUS SYSTEM
A. Neuro!-the f!nctional cell of the nervo!s system.
1. Co))o! c%aracter"'t"c'.
a. "esponds or reacts to stim!li
b. Cond!cts imp!lses
c. #nfl!ences other ne!rons.
/. Structure
a. Cell bod(-contains the cell n!cle!s which controls
cell!lar activity.
b. A1o!-cond!cts imp!lses away from the cell body
c. 2e!dr"te'-receive incomin$ stim!li and transmit
them to the a%on of another ne!ron.
&. Fu!ct"o!3cla''"$"cat"o!.
a. A$$ere!t !euro!' *'e!'or(' transmit information
away from the CNS.
b. E$$ere!t !euro!' *)otor+ transmit information
away from the CNS.
"((B") SAME
Se!'or( = A$$ere!t; Motor = E$$ere!t
c. So)at"c '('te)
1'. Afferent are sensory ne!rons that transmit
imp!lses from the s*eletal m!scles and s*in to the
CNS.
2'. fferent are motor ne!rons that transmit imp!lses
that lead to contraction and control of s*eletal
m!scle.
d. 0"'ceral '('te).
1'. Afferent are sensory ne!rons that transmit
imp!lses from smooth m!scle and cardiac m!scle to
the CNS.
2' fferent are motor ne!rons that transmit imp!lses
to the $lands+ cardiac m!scle+ and smooth m!scle.
e. Synapse or synaptic terminals are areas of
chemical transmission of an imp!lse from the a%on of
one ne!ron to the dendrites of another ne!ron.
Fu!ct"o!al Pro-ert"e' o$ Neuro!'
#rritability , ability to respond to stim!li
Cond!ctivity , ability to transmit an imp!lse
NER0E FUNCTION "' NER0E
CON2UCTION
ACTION POTENTIAL
Ner&e Cell u!deroe':
1. "estin$ (embrane Potential
2. Action Potential - .epolari/ation
&. "epolari/ation - "estabili/ation
1. RESTING MEM,RANE POTENTIAL
Sodi!m predominates o!tside the cell+
potassi!m inside the cell.
#nside of the cell is relatively ne$ative with the
presence of potassi!m and lar$e amo!nts of
ne$ative ions.
2. Act"o! Pote!t"al 3 2e-olar"#at"o!
0hen a cell is stim!lated+ cell membranes
become permeable to sodi!m ions.
Sodi!m moves inside the cell and potassi!m
moves o!t.
#nside of the cell becomes positively char$ed.
S!dden chan$e in the char$e of the cell from
ne$ative to positive is called action potential.
&. REPOLARI4ATION
The sodi!m-potassi!m p!mp restores the
ori$inal confi$!ration
This action re1!ires ATP
Sodi!m is p!mped o!t of the cell and
potassi!m bac* into the cell.
,. S!pportin$ cells provide s!pport+ no!rishment+
and protection to the ne!ron.
1. Neur"le))a , protective cells which
s!rro!nd the a%ons in the PNS.
a. Provide for effective re$eneration of PNS
nerve fibers.
b. 2orm the myelin sheath in the PNS.
c. No ne!rilemma present in the CNS.
2. Glial cells protective cells in the CNS3
responsible for the formation of the myelin.
3. Myelin sheath.
a. .ense membrane or ins!lator aro!nd the
a%on.
b. 2acilitates f!nction of the ne!ron+
c. Contrib!tes to the blood-brain barrier to
protect the central nervo!s system a$ainst
harmf!l molec!les.
4. !ode' o$ Ra!&"er
- #ntermittent $aps between the
myelin sheath that allow
comm!nication between nerve
fibers.
- Si$nals 5!mpin$ from node to node
travel h!ndreds of times faster than
si$nals travelin$ alon$ the s!rface of
the a%on.
2. I)-ul'e co!duct"o!.
SALTATORY CON2UCTION
An action potential e%cites one section of the
nerve membrane and electrical imp!lse then
6S7#PS8 from one node to the ne%t
$eneratin$ an action potential.
These node-to-node mode of cond!ction is
termed 6 SA9TAT:"; :" 9AP#N<
T"ANS(#SS#:N8
A20ANTAGES OF SALTATORY O$ LEAPING
TRANSMISSION
1
(embranes are formin$ fewer action potentials
so)
1. The speed of cond!ction is m!ch faster
2. The nerve is protected from e%ha!stion or
!sin$ !p ener$y to form m!ltiple action
potentials
S(!a-t"c tra!')"''"o!:
TRANSMISSION OF ELECTRICAL IMPULSES
FROM ONE NEURON TO ANOTHER
a. A chemical synapse maintains a one-way
comm!nication lin* between ne!rons
'(!a-'e 5 5!nction between two ne!rons.
N"= S;NAPS #S (A. >P :2)
1. -re'(!a-t"c nerve -ends B2:"
specific synapse
2. '(!a-t"c cle$t -separates synapse by a
tiny $ap ?less than one-millionth
of an inch'
&. Po't '(!a-t"c Ner&e - be$ins A2T"
synapse
b. C%e)"cal !eurotra!')"tter' *!euro5
)ed"ator'' facilitate the transmission of the
imp!lse across the synapse.
1'. Acetylcholine.
2'. Norepinephrine.
&'. .opamine.
4'. @istamine.
c. #mp!lses pass in only one direction.
#mp!lses are able to cross the synapse to
another nerve
Ne!rotransmitter is released from a
nerveAs a%on terminal
The dendrite of the ne%t ne!ron has
receptors that are stim!lated by the
ne!rotransmitter
An action potential is started in the
dendrite
To retur! t%e e$$ector to a re't"! 'tate 'o t%at
"t ca! be 't")ulated aa"!, t%e act"o!' o$
t%e'e !eurotra!')"tter )u't be 'to--ed b(
o!e or )ore o$ t%e'e -roce''e':
1. "e!pta*e by the presynaptic nerve
- ne!rotransmitters are reabsorbed by the
presynaptic nerve to re!se-recycle
2. #nactivation by an en/yme
&. Bro*en down by en/ymes in the area
4. .iff!sion o!t of the synaptic cleft and removal
by the vasc!lar system
d. Ner&e ree!erat"o! , entire ne!ron is !nable to
!nder$o complete re$eneration.
1. The a%ons of the PNS may re$enerate via the
connective tiss!e ne!rilemma+ providin$ the cell body
of the ne!ron remains viable.
2. Ne!ron re$eneration in the CNS is very limited+
possibly d!e to the lac* of ne!rilemma.
&. Scar tiss!e is a ma5or deterrent to s!ccessf!l
cell!lar re$eneration.
CENTRAL NER0OUS SYSTEM
The brain and the spinal cord within the
vertebral col!mn ma*e !p the central nervous
system.
A. The brain and the spinal col!mn are
protected by the ri$id bony str!ct!re
of the s*!ll and the vertebral col!mn.
,. Me!"!e' ,protective membranes
that cover the brain and are
contin!o!s with those of the spinal
cord. (DAP)
1. 2!ra mater-a to!$h membrane
immediately o!tside the arachnoid3
provides protection to the brain and
spinal cord.
2. Arachnoid-a delicate nonvasc!lar+
waterproof membrane that encases
the entire CNS3 the s!barachnoid
space contains the cerebral spinal
fl!id.
&. Pia mater-a delicate vasc!lar
connective tiss!e layer that covers
the s!rfaces of the brain barrier.
C. Cerebral '-"!al $lu"d *CSF+.
1. Serves to c!shion and protect the
brain and spinal cord3 brain literally
floats in CS2.
2. CS2 is clear+ colorless+ watery fl!id3
appro%imately 1BB to 2BB cc total
vol!me+ with a normal fl!id press!re
of CB to 1DB mm of water Eavera$e-
12D cm water press!re'.
&. 2ormation and circ!lation of CS2.
a. 2l!id is secreted by the choroids
ple%!s located in the ventricles of the
brain.
b. CS2 flows thro!$h the lateral
ventricles into the third ventricle+
flows thro!$h the A1!ed!ct of
Sylvi!s into the fo!rth ventricle where
the central of the spinal col!mn
opens.
c. 2rom the fo!rth ventricle+ there are
openin$s into the cranial
s!barachnoid space3 CS2 flows
aro!nd the spinal cord ad brain.
d. Since CS2 is formed contin!o!sly+ it
is reabsorbed at a comparable rate
by the arachnoid villi.
2. ,ra"!.
I. FORE,RAIN
Pro'e!ce-%alo! 5 "Pro Die & ell
2"e!ce-%alo! 67 T%ala)u',
H(-ot%ala)u'
Tele!ce-%alo! 67 Cerebru)
1. Cerebru) , seat of conscio!sness
- convol!tions or $yri F $rooves) s!lci
or fiss!res which e%pands or
increases the s!rface area of the
brain
- is divided into left and ri$ht
hemispheres connected to each
other by the corp!s callos!m
- the cerebral corte% is the s!rface
layer of each hemisphere.
A. Ma8or lobe' o$ t%e ce!tral
corte1.
2
a. Fro!tal.
1'. Coordination of vol!ntary s*eletal
m!scle movement.
2'. Abstract thin*in$+ morals+ 5!d$ment.
&'. Speech area+ motor speech area
?BrocaAs area' located in only one
hemisphere.
b. Par"etal.
1. #nterprets sensory nerve imp!lses
?pain+ temperat!re+ to!ch'.
2. (aintains proprioception.
&. "eco$nition of si/e+ te%t!re+ and shape
of ob5ects.
c. Te)-oral.
1. A!ditory area- interprets meanin$ of
certain so!nds.
2. 0ernic*eAs area- comprehension and
form!lation of speech.
d.Occ"-"tal area-interprets vision and
controls ability to !nderstand written
words.
e. The l")b"c lobe is tho!$ht
to be a lin* bet emotional F co$nitive
?tho!$ht' mechanisms.
f. The ce!tral lobe *"!'ula+
is tho!$ht to be involved in both
a!tonomic F somatic activities.
2. T%ala)u'.
1. relay station for all sensory
information
2. Activities related to conscio!sness.
&. . H(-ot%ala)u'.
1. "e$!lation of visceral activities-
body temperat!re+ motility and
secretions of the <# tract+ arterial blood
press!re.
2. Nerve connections with the
thalam!s and the cerebral corte%
ma*e it possible for o!r emotions to
infl!ence visceral activity.
&. "e$!lation of endocrine $lands via
infl!ence on the pit!itary $land.
4. Ne!rosecretion of antidi!retic
hormone ?A.@' which is stored in the
pit!itary
&. Motor area' o$ t%e cerebral corte1.
a. Primary f!nction is coordination and
control of s*eletal m!scle activity.
b. Cort"co'-"!al tract' *-(ra)"dal
tract'+.
1. .escendin$ tract from the motor
area of the cerebral corte% to the
spinal cord.
2. (a5ority of nerves cross in the
med!lla to the opposite side
before descendin$ into the
spinal cord.
&. These pathways do not cross over.
c. Brain cells and the nerve fibers in the
descendin$ tracts of the central nervo!s
system are called u--er )otor
!euro!'.
II. MI2,RAIN *MESENCEPHALON+
5 Consists of 4 ro!nded bodies+ the corpora
1!adri$emina)
Paired !pper bodies) serve as vis!al
refle% centers for head F eyeball
movements
Paired lower bodies) serve as relay
centers for a!ditory information
III. HIN2,RAIN *RHOM,ENCEPHALON+
,ra"!'te)
Po!'
Medulla oblo!ata
Cerebellu)
A.. Po!'- respiratory apne!stic center+
n!cle!s of cranial nerves- D+G+C+H
B. Medulla oblo!ata-a contin!ation of the
spinal cord as it enters into the cranial va!lt
in the brain.
- respiratory and cardiovasc!lar centers+
n!cle!s of cranial nerves E+1B+11+12
1. Cond!ction center and crossin$ center
for the !pper motor ne!rons.
2. (aintains control of cardiac rate.
&. =asomotor center for constriction and
dilation of vessels.
4. "espiratory center for chan$es in rate
and depth of breathin$.
D. =omitin$ refle% center.
G. Swallowin$ refle% center.
C. T%e Cerebellu)
2nd lar$est part of the brain w-c consists of 2
hemispheres F a connectin$ portion+ the
vermis
responsible for coordination of m!scle
movements
f!nctions)
1. helps ma*e m!sc!lar movement
smooth instead of 5er*y F tremblin$
2. helps maintain m!scle tone F
post!re
&. imp!lses from the vestib!lar
apparat!s are contin!o!sly delivered
to the cerebell!m to help maintain
e1!ilibri!m
RETICULAR FORMATION
Nerve fibers arisin$ from the central core of
the med!lla and lower pons
Reticular Activating System
- arises from retic!lar formation.
- essential for aro!sin$ from sleep
and remainin$ alert.
- #n5!ry to "AS can ca!se anesthesia
and coma
,a'al a!l"a *cerebral !ucle"+
, re$!late and pro$ram m!scle activity
comin$ from the cerebral corte%.
Mo&e)e!t "' co!trolled b(:
a. Cerebral corte1 , vol!ntary initiation
of motor activity.
b. ,a'al a!l"a-assist to maintain
post!re.
c. Cerebellu)-coordinates m!scle
movement.
CERE,RAL CIRCULATION
a. The internal carotid arteries enter the cranial
va!lt at the temporal area
b. Vertebral arteries arise from the s!bclavian
artery and enter the brain at the foramen
ma$n!m.
3
c. The Circle of Willis is an arterial anastomosis
at the base of the brain. The circle
ens!res contin!ed circ!lation if one of the
main vessels is disr!pted.
THE SPINAL COR2
1. The spinal cord is contin!o!s with the
med!lla and e%tends down the vertebral
col!mns to the level of the first and second
l!mbar vertebra.
2. ach col!mn is divided into f!nctional $ro!ps
of nerve fibers.
a. A'ce!d"! tract' , transmit imp!lses to the
brain ?sensory pathway'.
b. 2e'ce!d"! tract' , transmit imp!lses from
the brain to the vario!s levels of the spinal cord
?motor pathways'.
&. Structure.
a. Closely appro%imately vertebrae provide
protection from the spinal cord and nerve
roots.
b. Intervertebral discs lie between each
vertebra to provide fle%ibility to the spinal
col!mn.
c. Nucleus pulposus is a $elatin s!bstance in
the vertebral disc.
D. Upper motor neurons-ori$inate in the brain+
transmit imp!lses to the m!scles and
or$ans.
G. Loer motor neurons , ori$inate in the
spinal cord+ transmit imp!lses to the
m!scles and or$ans.
9. Re$le1 act"&"t(.
a. The refle% arch m!st be intact+ the spinal
cord serves as the connection between the
afferent pathway ?sensory'+ and the efferent
pathway ?motor'.
b. By testin$ the refle% arc ?deep tendon
refle%es'+ the lower motor ne!ron and the
sensory-motor fibers from the spinal col!mn
can be eval!ated.
Re$le1 arc
a. Re$le1 are is the f!nctional !nit which
provides pathways over which nerve
imp!lses travel.
b. Passa$e of imp!lses over a refle% arc is
called a refle% act or a refle%.
c. Re$le1 arc , The afferent ne!ron carries
the stim!l!s to the spine3 inte$rates it into
and thro!$h the spine ?CNS' to the efferent
ne!ron3 crosses the synapse with the
messa$e from the CNS to the or$an or
m!scle which responds to the stim!li. This
is the se1!ence of events when testin$
the deep tendon refle%es.
PERIPHERAL NER0OUS SYSTEM
*PNS+
Cranial nerves
1. Twelve pairs of
cranial nerves.
2. :ri$inate from
!nder the s!rface of the brain.
A. S-"!al !er&e'.
1. ach pair of nerves is
n!mbered accordin$ to the
level of the spinal cord from
which it ori$inates.
2. ach spinal nerve is
connected to the cord by two roots.
A. 2ORSAL
*PoSter"or+ root- receives
SNS:"; inp!t from sensory
receptors thro!$ho!t the body.
B. 0e!tral *a!ter"or root' , a
motor nerve carryin$ ne!ron
messa$es to $lands and to the
peripheral area.
REMEM,ER:
.:"SA9 "::T- P:ST"#:"
ISNS:";
=NT"A9 "::T- ANT"#:" I
(:T:"
&. The roots f!se at the e%it
from the vertebra to form a mi%ed
spinal nerve.
9. SPINAL NER0E PLE;USES
- networ* of interwoven spinal nerves
MA<OR PLE;USES:
A. CER0ICAL PLE;USES
a. sends motor imp!lses to the NC7
m!scles
b. Sends o!t P@"N#C nerve+ activatin$
the diaphra$m
c. "eceives sensory imp!lses from nec*
snd bac* of the head
,. ,RACHIAL PLE;USES
- #nnervates sho!lder+ arm+ forearm+
wrist and hand
c. LUM,OSACRAL PLE;US
- #nnervates the lower e%tremities.
- Sends o!t the lar$e SC#AT#C
N"=
C. So)at"c !er&ou' '('te) , associated with the
vol!ntary control of body movements via s*eletal
m!scles+ and with sensory reception of e%ternal
stim!li ?e.$.+ to!ch+ hearin$+ and si$ht
.. auto!o)"c !er&ou' '('te) , re$!lates
invol!ntary activity ?cardiovasc!lar+ respiratory+
metabolic+ body temperat!re+ etc.'
1. Consists of two divisions that have
anta$onistic activity.
2. !arasympathetic division , maintains
normal body f!nctions.
- "ST F .#<ST
&. Sympathetic division-prepares the body to
meet a challen$e or an emer$ency
?preparation for "fight#flight8'.
SYMPATHETIC 0S PARASYMPATHETIC

Para'()-at%et"c: Para'()-at%et"c:
!ES A"D !ES A"D
D#GES D#GES
S()-at%et"c: S()-at%et"c:
$#G% & $&#G% $#G% & $&#G%
Fu!ct"o!: Fu!ct"o!: 67 'lo=' 'tu$$ 67 'lo=' 'tu$$
do=! do=!
67 '-eed 'tu$$ 67 '-eed 'tu$$
u- u-
Co!trol Co!trol Cra!"o'acral: Cra!"o'acral:
bra"! > belo= t%e bra"! > belo= t%e
T%oracolu)bar: T%oracolu)bar:
abo&e t%e belt abo&e t%e belt
4
belt belt
Neurotra!')"tt Neurotra!')"tt
er er
ACETYLCHOLIN ACETYLCHOLIN
E E
EPINEPHRINE ? EPINEPHRINE ?
NE NE

$%U&''(LS$) $%U&''(LS$)
2 2iarrhea iarrhea
U Urination rination
M Miosis iosis $constrict$ $constrict$
, ,radycardia radycardia
, ,ronchoconstrict ronchoconstrict
E Erection rection $point$ $point$
L Lacrimation acrimation
S Salivation alivation
*pposite of *pposite of
!arasympathetics !arasympathetics
) )
Constipation Constipation
>rinary retention >rinary retention
(ydriasis (ydriasis $eyes $eyes
ide ith fright$ ide ith fright$
Tachycardia Tachycardia
Bronchodilate Bronchodilate
5ac!lation 5ac!lation
$shoot$ $shoot$
Jerophthalmia Jerophthalmia
?dry eyes' ?dry eyes'
Jerostomia ?dry Jerostomia ?dry
mo!th' mo!th'
CRANIAL NER0ES
are nerves which start directly from the
brainstem instead of the spinal cord.
:nly the first and the second pair emer$e
from the cerebr!m3 the remainin$ 1B pairs
emer$e from the brainstem.
N>(B" NA( 2>NCT#:N
#.
##.
###.
#=.
=.
=#.
=##.
:lfactory
:ptic
:c!lomotor
Trochlear
Tri$eminal)
:pthalmic
(acillary
(andib!lar
Abd!cens
2acial
Sense of smell
=ision-cond!cts
information from the
retina
.own and o!tward
movement of the eye
P!pillary constriction
and accommodation
(!scle of the !pper
eyelid ?ability to *eep
the eye open'
(ovement of the eye
Corneal refle%
Sensory fibers of the
face
(otor nerves for
chewin$ and
swallowin$
#nward movement of
the eye
2acial e%pression
Sense of taste on
anterior ton$!e
(!scle of the eyelid
?ability to close the
eye'
=###.
#J.
J.
J#.
J##.
Aco!stic
<lossopharyn$eal
=a$!s nerve
Accessory ?Spinal'
@ypo$lossal
"eception of hearin$
and maintenance of
e1!ilibri!m
Sense of taste on
posterior ton$!e
Salivation
Swallowin$ or $a$
refle%
Assists in
swallowin$ action
(otor fibers to
laryn% for speech
#nnervation of
or$ans in thora% and
abdomen
#mportant in
respiratory+ cardiac+
and circ!latory
refle%es
Ability to rotate the
head and raise the
sho!lder
(!scles of the
ton$!e
Neurolo"cal E1a)"!at"o!
NEUROLOGICAL ASSESSMENT:
Three Components)
.. I!ter&"e=
- psychosocial assessment
- e%tensive ne!rolo$ic history
2. P%('"cal a''e'')e!t
- ne!rolo$ic e%amination
&. Ge!eral a!d S-ec"al Neurolo"c d"a!o't"c
'tud"e'
S('te) A''e'')e!t
A. H"'tor(.
.. Neurolo"c %"'tor(.
a. Avoid s!$$estin$ symptoms to the
client.
b. The manner in which the problems
be$an and the overall co!rse of the
illness are very important.
c. (ental stat!s m!st be assessed
before ass!min$ the history data
from the client is acc!rate.
2. Med"cal %"'tor(.
a. Chronic+ conc!rrent medical
problems.
b. (edications ?especially tran1!ili/ers+
sedatives+ narcotics+ etc'.
c. Pre$nancy and delivery history of
infants and yo!n$ children.
d. Se1!ence of $rowth and
development.
@. Fa)"l( %"'tor(5-re'e!ce o$
%ered"tar( or co!e!"tal -roble)'.
9. Per'o!al %"'tor(5act"&"t"e' o$ da"l(
l"&"!, a!( c%a!e "! rout"!e.
A. H"'tor( a!d '()-to)' o$ curre!t
-roble).
a. Paralysis or paresthesia.
b. Syncope+ di//iness
c. @eadache.
d. Speech problems.
e. =is!al problems
f. Chan$es in personality.
$. (emory loss.
h. Na!sea+ vomitin$.
B. P%('"cal A''e'')e!t.
1. <eneral observation of client.
a. Post!re+ $ait..
b. Position of rest for the infant or yo!n$ child.
c. Personal hy$iene+ $roomin$.
d. val!ate speech and ability to comm!nicate.
5
1. Pace of speech-rapid+ slow+ haltin$.
2. Clarity , sl!rred or distinct.
&. Tone , hi$h pitched+ ro!$h.
4. =ocab!lary , appropriate choice of words.
e. 2acial feat!res may s!$$est specific syndromes in
children.
2. mental stat!s m!st ta*e into consideration the
clientAs c!lt!re and ed!cational bac*$ro!nd'.
a. <eneral appearance and behavior.
b. 9evel of conscio!sness.
1. :riented to time+ person+ place.
2. Appropriate response to verbal
and tactile stim!li.
&. (emory+ problem-solvin$ abilities.
c. (ood.
d. Tho!$ht content and intellect!al capacity.
&. Assess papillary stat!s and eye movements.
a. Si/e of p!pils sho!ld be e1!al.
b. "eaction of p!pils.
1. Accommodation, papillary constriction to
accommodate near visions.
2. .irect li$ht refle% , constriction of p!pil
when li$ht is shown directly into eye.
&. Consens!al refle% , constriction of the
opposite eye for the direct li$ht refle%.
c. val!ate ability to move eye.
1. Note nysta$m!s-fine+ 5er*in$ eye
movement.
2. Ability of eyes to move to$ether.
&. "estin$ position sho!ld be at mid position
of the eye soc*et.
d. P""9A , indicates that p!pils are e1!al+
ro!nd+ reactive to li$ht and accommodation is
present.
4. val!ate motor f!nction.
a. Assess face and !pper e%tremities
for e1!ality of movement and sensation.
b. val!ate appropriateness of motor
movement+ spontaneo!s and
on command.
c. (ovement of e%tremities sho!ld
always be eval!ated bilaterally+
comparin$ tone+ stren$th+ and m!scle
movement of each side.
d. Presence of inappropriate+ non-
p!rposef!l movement+ i.e.+ post!rin$.
e. Ability of an infant to s!c* and to
swallow.
f. Asymmetrical contraction of facial
m!scles.
D. val!ate refle%es.
a. <a$ or co!$h refle%.
b. Swallow refle%.
c. Corneal refle%.
d. Babins*i refle%, normal is ne$ative
in ad!lts and children over one year+
positive si$n is dorsal fle%ion of the foot and
lar$e toe with fannin$ of the other toes.
e. deep tendon refle%es ?simple
stretch refle%'.
G. Assess vital si$ns and correlate with other data3
chan$es often occ!r slowly and the overall trend
needs to be eval!ated.
a. Blood press!re and p!lse-intracranial problems
precipitate chan$es+ blood press!re
may increase and p!lse rate may decrease.
b. "espirations , rate+ depth+ and rhythm are
sensitive indicators of intracranial problems.
1. Cheyne Sto+es , periodic breathin$ in
which hyperpnea alternates with apnea+ rapid+ deep
hyperpnea.
2. Neurogenic hyperventilation-re$!lar+ rapid+
deep hyperpnea.
&. Ata,ic , completely irre$!lar pattern with
random deep and shallow respirations.
c. Temperat!re , eval!ate chan$es in temperat!re as
related to a ne!rolo$ical control vers!s infection.
KN!rsin$ AlertL Bedside ne!ro chec*s-eval!ate level
of conscio!sness3 respiratory patterns3 papillary
si$ns3 eye movements3 motor responses3 vital si$ns.
C. Neuro c%ecB' , parameters for fre1!ent n!rsin$
eval!ation of ne!rolo$ical symptoms.
1. Assess level of conscio!sness ?9:C'.
a. =erbal and motor response to command.
b. Appropriate conversation and speech.
c. Presence of delayed response to stim!li+
from lethar$ic to !nresponsive.
d. Appropriate behavior in infants and yo!n$
children.
e. Be e%plicit in describin$ 9:C3 may !tili/e a
specific coma scale ?<las$ow'.
2. "espiratory patterns , eval!ate c!rrent respiratory
pattern and assess for chan$es in pattern.
&. P!pillary response.
a. 1!ality of p!pils.
b. Presence of consens!al+ direct+ and
accommodation refle%es.
c. Position of p!pils at rest.
4. (otor f!nction.
a. Ability to move all e%tremities with e1!al
stren$th.
b. Presence of post!rin$.
c. Presence of sei/!re activity.
d. Presence of $a$ and co!$h refle%.
D. =ital si$ns.
a. Correlate blood press!re and p!lse
chan$es.
b. Assess respiratory pattern.
c. Assess temperat!re in re$ard to overall
condition.
G. Assess for presence of pain+ headache.
C. Presence of pro5ective vomitin$ not associated with
na!sea.
H. #nfants-assess fontanel and s!t!re lines.
a. Si/e of fontanel for $rowth and development level.
b. 2ontanel sho!ld be soft to to!ch with sli$ht
p!lsations.
c. Normal appro%imation of cranial s!t!re lines.
ASSESSMENT OF LE0EL OF CONSCIOUSNESS
Conscio!sness is defined as the state of
bein$ aware of physical events or mental
concepts.
2irst and most important observation made in
people with ne!ro d-o.
Le&el' o$ Co!'c"ou'!e'':
Alert a!d Or"e!ted
2"'or"e!ted
Let%ar"c 5 'l"%t reduct"o! "! alert!e''

Obtu!ded
.rowsy-somnolent
Clo!ded conscio!sness
Slow tho!$ht+ movement+ and
speech
Stu-orou'
(ar*ed red!ction in mental and
physical activity
6
=i$oro!s stim!li needed to provo*e a
response
Co)ato'e
Completely !nconscio!s
Cannot be aro!sed by painf!l stim!li
Absence of vol!ntary movement
M-- refle%es
GLASGOC COMA SCALE *GCS+
a ne!rolo$ical scale that aims to $ive a
reliable+ ob5ective way of recordin$ the
conscio!s state of a person
Tests & areas- eye openin$+ verbal response
and motor response
Scores are eval!ated- ran$e from &-1D
No -(R* score
patients with scores of &-H are !s!ally said to
be in a coma.
Tests & areas)
E(e O-e!"! *E+ D 9 -o"!t'
0erbal Re'-o!'e *0+ D A -o"!t'
Motor Re'-o!'e *M+5 E -o"!t'
ASSESSMENT OF SPEECH AN2 LANGUAGE
.ysarthria
- diffic!lty in artic!lation
- lesions of ton$!e F palate
.ysphonia
- diffic!lty in phonation
- lesions of palate F vocal cords
A$nosia
- inability to reco$ni/e ob5ects or symbols
by means of senses
A'hasia
- inability !se and !nderstand written and
spo*en words
TYPES:
1. E('ressi)e (*otor+ non,l-ent+ or .roca/s)
a'hasia0
- The ability to create words is
impaired+ b!t comprehension and ability to
concept!ali/e are relatively preserved.
. - #t often ca!ses a1ra'hia ?loss of the ability
to write' and impairs oral readin$.
2. !ece'ti)e (sensory+ ,l-ent+ or 2ernic3e/s)
a'hasia0
4 Patients cannot comprehend words or
reco$ni/e a!ditory+ vis!al+ or tactile symbols.
- :ften, ale(ia ?loss of the ability to read
words' is also present.
!EMEM.E!0
,ECARE)
,rocaNs area) E%pressive dysphasia.
Cernic*eNs Area) REceptive dysphasia
CRANIAL NER0E ASSESSMENT
I. Cra!"al Ner&e .5 Ol$actor(
Chec* first for the patency of the nose
P":B9() ANOSMIA5 6loss of smell8
II. Cra!"al Ner&e /5 O-t"c
Pa-"llede)a
- optic disc swellin$ that is ca!sed by
increased intracranial press!re.
He)"a!o-'"a
- is loss of vision in one-half of the normal
vis!al field ?!s!ally the ri$ht or left half' of one or
both eyes.
.+ I-'"lateral bl"!d!e'': :ptic nerve lesion
/+ ,"te)-oral He)"a!o-'"a: :ptic chiasm lesion
@+ Ho)o!()ou' He)"a!o-'"a *R"%t or Le$t+:
:ptic tract lesion
III. CRANIAL NER0E III, I0,0I
CN ### , p!pil constriction F elevation of
eyelid
- assess p!pil ?P""9A'
- assess for ptosis
CN ###+ #=+ =# , control eye movement
- S56 + &! 7 I CN 4 controls the
s!perior obli1!e m!scle and CN G
controls the lateral rect!s m!scle
- Assess sim!ltaneo!sly the
movement
%eviations)
:pthalmople$ia- inability to move the eye in a
direction
.iplopia- complaint of do!ble vision
!upil Abnormalities)
Asymmetry of p!pil si/e of K1mm s!$$ests
CN ### compression
,"lateral d"lat"o!
ano%ia
dr!$ ffect
U!"lateral co!'tr"ct"o!
sympathetic dysf!nction ?@orner
syndrome'
carotid artery dissection
,"lateral co!'tr"ct"o!
PinPoint , oPiods F Pontine d-o
Ar(ll Robert'o! -u-"l
- bilateral small p!pils that constrict when the
patient foc!ses on a near ob5ect ?they
7
6accommodate8'+ b!t do not constrict
when e%posed to bri$ht li$ht ?they do not
6react8 to li$ht'.
- formerly *nown as OProstit!teNs P!pilsO
beca!se of their association with tertiary
syphilis
- Prostit!teNs P!pils ) "!rostitutes
accommodate but do not react.
A!"'ocor"a
K2mm difference in si/e
Ad"eF' *To!"c+ -u-"l
sl!$$ish response
I0. Cra!"al Ner&e A 5tr"e)"!al
Sensory portion- assess for sensation of the
facial s*in
(otor portion- assess the m!scles of
mastication
Assess corneal refle%
0. CRANIAL NER0E G D Fac"al
Sensory portion- prepare salt+ s!$ar+ vine$ar
and 1!inine. Place each s!bstance in the
anterior two thirds of the ton$!e+ rinsin$ the
mo!th with water
(otor portion- as* the client to ma*e facial
e%pressions+ as* to forcef!lly close the
eyelids
/acial nerve 0CN VII1 palsy) 'ell2s !alsy
0I. Cra!"al Ner&e H 0e't"bulococ%lear !er&e
Test patientAs hearin$ ac!ity
:bserve for nysta$m!s and dist!rbed
balance
0II. Cra!"al Ner&e I5 lo''o-%ar(!eal
To$ether with Cranial nerve 1B ,va$!s
Assess for $a$ refle%
0atch the soft palate risin$ after instr!ctin$
the client to say 6A@8
The posterior one-third of the ton$!e is
s!pplied by the $lossopharyn$eal nerve
0III. Cra!"al Ner&e ..5 acce''or(
Press down the patientAs sho!lder while he
attempts to shr!$ a$ainst resistance
I;. Cra!"al Ner&e ./5 %(-olo''al
- As* patient to protr!de the ton$!e
and note for symmetry
- >nilateral cortical lesions ca!ses the
protr!ded ton$!e to deviate toward
the affected side
SENSORY ASSESSMENT
1. 2ISCRIMINATION
- Tests the inte$rative f!nctions of sensation
and memory in the brainAs parietal lobe
- #ncl!des)
a. STEREOGNOSIS
- discernment of the form or
confi$!ration of ob5ects felt
b. GRAPESTHESIA
- reco$nition of the form of written
symbol
/. SENSATION A,NORMALITIES
a. 2YSESTHESIAS
- well locali/ed irritatin$ sensations 3 warmth+ cold+
itchin$+ tic*lin$
b. PARESTHESIAS
- distortion of sensory stim!li 3 li$ht to!ch may
be interpreted as b!rnin$ or painf!l sensation
c. ANESTHESIA
- absence of sense of to!ch
d. HYPERESTHESIA
5 patholo$ic over perception of to!ch
e. HYPALGESIA
5 red!ced sensation to pai
$. HYPERALGESIA
- increased sensation to pain
. ANALGESIA
5 absence of pain sensation
%. ASTEREOGNOSIS
- loss of sense of three dimensional
discrimination
MOTOR SYSTEM ASSESSMENT
Pra%is I ability to perform a motor activity
Apra%ia I inability to perform vol!ntary
movement in the absence of deficits
.yspra%ia I diffic!lty performin$ an activity
A. Coord"!at"o!:
Cerebellar d"'ea'e
incoordination is worse with eyes
closed
d(')etr"a
point-to-point movements are
cl!msy+ !nsteady+
inappropriately varyin$ in
speed+ force+ F direction
,. GAIT
.. Ata1"c
- sta$$erin$ and !nsteady
/. SPASTIC GAIT
- stiff+ short steps+ toes catch and dra$+ le$s
are held to$ether and hips and *ness are
fle%ed
@. SCISSORS GAIT
- le$s cross while wal*in$ with short+ slow
steps
9. STEPPAGE GAIT
- foot and toes lifted hi$h+ heels come down
heavily
A. CA22LING GAIT
- a broad-based $ait with a d!c*-li*e waddle
to the swin$ phase
E. $e't"!at"! a"t
5 a $ait in which the patient invol!ntarily
moves with short+ acceleratin$ steps+
often on tiptoe+ as in par*insonism.
C. A,NORMAL MO0EMENTS
.. AJINESIA
- red!ced body movement in the absence of
wea*ness or paralysis
/. ATHETOSIS
- $ross+ writhin$+ worm-li*e movement of
body+ face or e%tremities
@. ,RA2YJINESIA
- slow movement
2. POSTURING
.. 2E85!ICATE RIGI2ITY
Abnormal fle%or response
Characteri/ed by ri$idity+ fle%ion of the arms+
clenched fists+ and e%tended le$s
the arms are bent inward toward the
body with the wrists and fin$ers bent
and held on the chest
8
.estr!ctive lesion of 8orticospinal tracts
2. 2ECERE,RATE RIGI2ITY
Abnormal E%tensor "esponse
Characteri/ed by ri$id e%tension of the arms
and le$s+ downward pointin$ of the toes+ and
bac*ward archin$ of the head
Typicall ca!sed by deterioration of the
str!ct!res of the nervo!s system+ partic!larly
the !pper brain stem
lesion in diencephalon+ midbrain+
pons
metabolic disorders
A''e''"! t%e )otor $u!ct"o! o$ t%e bra"!'te)
1. Test for the Oculoce-%al"c re$le15 dollF' e(e
- head is moved rapidly from side to side
Normal response- eyes appear to move
opposite to the movement of the head
Abnormal- eyes move in the same direction
with s!spected cervical spine in5!ry
NOTE:
.o not !se the .ollAs eye test on people with
s!spected cervical spine in5!ry.
2. Test for the Oculo&e't"bular re$le1
Slowly irri$ate the ear with cold water and
warm water
Normal response- COCS
Cold I Opposite ) Carm I Same
N('ta)u' 5 #nvol!ntary eye movements
!s!ally tri$$ered by inner ear stim!lation
REFLE;ES ASSESSMENT
TCO */+ REFLE;ES:
1. SUPERFICIAL *CUTANEOUS'
- elicited by s!perficial or c!taneo!s
stim!lation
- stim!l!s is prod!ced by stro*in$ a sensory
/one with an ob5ect that will not ca!se
dama$e
2. 2EEP TEN2ON REFLE; *MUSCLE STRETCH+
- refle% m!scle contraction res!lts from
rapidly stretchin$ the m!scle
- prod!ced rapidly by stri*in$ a m!scleAs
tendon of insertion sharply with a
s!dden+ brief blow !sin$ a refle%
hammer
SUPERFICIAL *CUTANEOUS+ REFLE;ES
.. A,2OMINAL REFLE;
- scratchin$ the s*in on an abdominal
1!adrant normally contracts the abdominal
m!scle in that 1!adrant.
2. CORNEAL REFLE;
- $entle stro*in$ of cornea with a wisp of
cotton ca!ses refle% blin*in$
&. PHARYNGEAL 3 GAG REFLE;
- $entle stim!lation with a ton$!e blade at
the bac* of the throat and pharyn%
normally prod!ce $a$$in$.
4. CREMASTERIC REFLE;
- stro*in$ the inner thi$h of a male
normally elevates the ipsilateral testicle.
2EEP TEN2ON REFLE; *MUSCLE STRETCH+
1. AN79 P"7 ?plantar fle%ion of the foot'
- prod!ced by tappin$ the Achilles tendon
2. 7N P"7 ?le$ e%tension'
- prod!ced by tappin$ the 1!adriceps femoris
tendon 5!st below the patella
&. B#CPS P"7 ?forearm fle%ion'
- prod!ced by tappin$ the biceps brachii
tendon
4. T"#CPS P"7 ?forearm e%tension'
- is prod!ced by tappin$ the triceps brachii
tendon at the elbow
2ee- Te!do! Re$le1e': Grad"!
Grade 2TR Re'-o!'e
4M =ery bris*+ hyperactive+ with
clon!s
& Bris*er than avera$e+ sli$htly
hyperrefle%ic
2 Avera$e+ e%pected response3
normal
1 Somewhat diminished+ low
normal
B No response+ absent
PATHOLOGICAL REFLE;ES
- do not normally occ!r
- presence indicates ne!rolo$ic d-o
.. CLONUS
- "hythmic :scillation
2. ,A,INSJI REFLE;
- stro*e the lateral aspect of the soles doin$
an inverted
?M'-.:"S#29J#:N of the Bi$ toe with
fannin$ o!t of the little toes
2IAGNOSTIC E;AMINATION
1. LUM,AR PUNCTURE
- N.9 #S #NS"T. BT0N 94-9D
- B9:0 T@ 9=9 :2 T@ SP#NA9
C:".
" L3 4 L5 ill +eep the spinal cord alive.
Co)-l"cat"o!':
@A.AC@
@;P:TNS#:N
(N#N<#T#S
S>BA"AC@N:#. @(AT:(A
NORMAL CSF CHARACTERISTICS)
P"SS>" ) G-1& mm@$
APPA"ANC ) clear F colorless
"BC ) none
0BC ) B-D cells-mm
Protein) very little
<l!cose) 4B-HB m$ -dl
Chlorides) C2B-CDB m$-dl
NURSING CARE FOR CLIENTS CITH
NEUROLOGICAL 2ISOR2ER
Cl"e!t ="t% Headac%e
@eadaches may be d!e to beni$n or patholo$ical
condition
Pat%o-%('"olo() m!ltiple pain sensitive str!ct!res
within cranial va!lt+ face+ and scalp are stim!lated
and ca!se pain perception
9
T(-e':
Te!'"o!-characteri/ed by sensation of ti$htness
aro!nd head and may have specific locali/ed painf!l
areas3 areas ca!sed by s!stained contraction of
m!scles and head and nec*3 precipitated by stress
and an%iety
M"ra"!e *)ore co))o! "! =o)e!+
-rec!rrin$ vasc!lar headache often initiated by
tri$$erin$ event and accompanied by ne!rolo$ic
dysf!nction3 or increase release of sensory
s!bstances ?e.$. serotonin'3 tri$$ers incl!de stress+
fl!ct!atin$ $l!cose levels+ fati$!e+ hormones+ bri$ht
li$hts
Clu'ter *co))o! "! )e!+
-typically awa*ens client with !nilateral pain aro!nd
eye accompanied by rhinorrhea+ lacrimation+ fl!shin$3
attac*s occ!r in cl!sters of 1-H days for wee*s
HEA2ACHE
1. Tension headache-EBQ3 noise+ stressRs!stained
contraction of m!scles
2. Sin!s @eadache
=ir!s+ aller$en+ bacteria+ temp
S
Nerves in sin!ses swell
S
@eadache
e.$. brain free/e d!e to swallowin$ of cold
s!bstances rapidly
&. @an$-over headache
Alcohol bloc*s hormonal mechanisms
S
.ehydration
4. 0ine headache
#ncreases histamine-tyramine
S
.ilate blood vessels
S
Press!re on nerves
D. (i$raine headache) 1)4 ho!sehold
T0omen &% more than men) &days a wee*
T(ay be ca!sed by)
9i$ht
Noise
#rre$!lar eatin$ and sleep
Chocolate
Stron$ smell
Pean!t b!tter
S
lectrical imp!lse altered and tri$$ers tri$eminal
nerve
S
Tri$eminal nerveIvasodilation and nerve irritation
G. Cl!ster @eadache
T%cr!ciatin$ pain
TG % more in men+ &B min to 2 ho!rs
Nerves irritated
S
Pain si$nals
S
Tension @eadache
Ma!ae)e!t:
Pharmacolo$ical
1. Aspirin6 Ibuprofen-s!ppress prosta$landin that
dilates and sensiti/es nerve fibers
2. Acetaminophen-tension headache3 wor*s in CNS
to red!ce pain witho!t effect on prosta$landin ?safe
for $astritis'
&. 7riptans-anti-mi$raine3 activates serotonin
receptors decreasin$ inflammation of blood vessels
4. 'oto, ?p!rified bot!lin!m bacteria'
-small dosa$es allow it to be locali/ed3 paralyses
m!scles locally and is not absorbed into the blood
stream ?may ca!se nerve paralysis if $iven in lar$e
doses'
D. #ndomethacin-for cl!ster headaches3 with pain
*illers
Nonpharmacolo$ical)
1. Biofeedbac*
2. Ac!p!nct!re
&. (assa$e
4. ;o$a
D. @erbal remedies
SYNCOPE3FAINTING
T"ANS#NT 9:SS :2 C:NSC#:>SNSS
#NA.U>AT B"A#N P"2>S#:N
MANAGEMENT:
.AN<9 2T 2:" &B SC B2:"
STAN.#N<
SP#"#TS :2 A((:N#A
0ERTIGO
SNSAT#:N :2)
":TAT#N< S>"":>N.#N<S
C9#NT #S ":TAT#N<
SN #N)
N>": .S
:T:9:<#C .S
CA".#:=ASC .S
NEUROLOGIC PAIN
A"#S 2":( N>":9:<#C 9S#:NS
C:NC"N#N< PA#N SNSAT#:N
S>"<";)
NEURECTOMY , DT@ N"=
"SCT:N #N T"#<(#NA9
N>"A9<#A
RHI4OTOMY- "SCT#:N :2 T@
P:ST"#:" N"= "::T
I!crea'ed I C P
T#ncreased blood vol!me+ increased brain vol!me+
increased CS2 vol!me
TNormal press!re) G-1&mm@$+ with press!re
transd!cer with head elevated &BV3
GB-1HB cm@2B+ water manometer with client lateral
rec!mbent
@ e''e!t"al co)-o!e!t' o$ 'Bull:
1. Brain tiss!e-CHQ
2. Blood -12 Q
&. CS2-1BQ
10
Mo!roe5Jell"e H(-ot%e'"':
7he s+ull is a CL*S(% C*N7AIN(R
and contains a fi,ed volume8
An increase in any one of the
components causes a change in
the volume of the other
Nor)al Co)-e!'ator( Ada-tat"o!':
#nitial)
o #ncreased CS2 absorption
o .isplacement of CS2 into the spinal
s!barachnoid spaceRspace between
arachnoid and pia mater'
o Collapse of the cerebral veins and d!ral
sin!ses
:ther mechanisms)
o .istensibility of the d!ra
o #ncreased veno!s o!tflow
o .ecreased CS2 prod!ction
o Constriction and vasodilation
o Sli$ht compression of brain tiss!e
TSu'ta"!ed "!crea'e' a''oc"ated ="t%:
a. Cerebral edema
b. @ead tra!ma
c.T!mors
d. Abscesses
e. Stro*e
f. #nflammation
$. @emorrha$e
TFactor' t%at I!crea'e ICP
W@ypercapnea+ hypo%emia
WCerebral vasodilatin$ a$ents
W=alsalva mane!ver3 co!$hin$ or snee/in$
WBody positionin$
?prone+ nec* fle%ion+ e%treme hip fle%ion'
W#sometric m!scle contraction
Wmotional !pset3 no%io!s stim!li
WAro!sal from sleep
WCl!sterin$ of activities
WPain and a$itation
A. Cerebral edema.
1. =aso$enic edema occ!rs when there is an
increase in the vol!me of brain tiss!e ca!sed
by increase in the permeability of the walls of
the cerebral vessels. Protein-rich fl!id lea*s
into the e%tra cell!lar space. (ost often the
ca!se of ##CP in ad!lts.
2. Cytoto%ic ?cell!lar' edema occ!rs as a res!lt of
hypo%ia. This res!lts in abnormal acc!m!lation of
fl!id within the cell ?intracell!lar' and a decrease
of e%tra cell!lar fl!id.
B. Cerebral arteries dilate with a decrease in the
delivery of o%y$enated blood.
1. #ncrease in PC:2 and acc!m!lation of lactic acid
precipitates an acidotic state.
2. An acidotic state increases cerebral vasc!lar
dilatation which+ in t!rn+ increases cerebral
vasc!lar blood flow and increases intracranial
press!re.
C. "e$ardless of the ca!se+ ##CP will res!lt in
pro$ressive ne!ro deterioration3 the specific
deficiencies seen are determined by the area of
compression of brain tiss!e.
.. #n infants where the cranial s!t!re lines are open+
increased #CP will ca!se f!rther separation of the
s!t!re lines and increased the circ!mference of
the head.
Sc%e)at"c 2"ara)
Cranial ins!lt
S
Tiss!e edema
S
#ncreased #CP
S
Compression of blood vessels
S
.ecreased cerebral blood flow
S
.ecreased o%y$en with brain cell death
S
dema aro!nd necrotic tiss!e
S
#ncreased #CP with brainstem and respiratory center
compression
S
Carbon dio%ide acc!m!lation
S
=asodilation
S
#ncreased #CP
S
.AT@
Pat%o-%('"olo(:
press!re res!lts to lac* of o%y$en and blood s!pply
MANIFESTATIONS:
.. HEA2ACHE
- TNS#:N :N #NT"AC"AN#A9
=SS9S
NURSIN9 CAR()
7P @:B 9=AT.
P:ST) N: T"N.9NB"<
ASP#"#N AS :".".
N: NA"C:T#CS
? P>P#99A"; C@AN<S'
/. 0OMITING
- >N"9AT. T: (A9S
:" NA>SA
P":PCT#9
P"SS>" ST#(>9AT#:N :2
(.>99A :B9:N<ATA
NURSIN9 CAR()
# F :
0#T@@:9. :"A9 29>#.S
S>CT#:N #2 N..
@. CI2ENING PULSE PRESSURE
- "29J 22CT :2
C"B"A9 AN:J#A
NURSIN9 CAR()
(:N#T:" =S @:>"9;
"P:"T 0#.N#N< :2
P>9S P"SS>"
9. SLOCING OF RESPIRATION
- P"SS>" F AN:J#A
:2 (.>99A
11
- >NCA9 @"N#AT#:N
NURSIN9 CAR()
(:N#T:" =S @:>"9;
"" #N 1 2>99 (#N
A. FALLING PULSE RATE
- "29J 22CT :2 "#S#N< BP
NURSIN9 CAR()
(:N#T:" =S @:>"9;
P>9S #N 1 2>99 (#N
E. PAPILLE2EMA
- d!e to the compression of optic disc
- >NCA9 @"N#AT#:N
NURSIN9 CAR()
P>P#99A"; C@C7S ) U>A9#T;
F "ACT#:N T: 9#<@T
G. LOSS OF MOTOR FUNCTION
- .C:"T#CAT
- .C"B"AT
- P"SS>" :N (:T:"
CNT"S
NURSIN9 CAR()
"C:". @(#PA"S#S
CN CJS
C@C7 "29JS
H. SEI4URE
- #NT"AC"AN#A9
- ST#(>9AT#:N T: B"A#N
NURSIN9 CAR()
CA"";:>T S#X>"
P"CA>T#:N
I. LOSS OF SPHINCTER CONTROL
- C"B"A9 P"SS>"
- #NT"2" 0#T@ SP@#NCT"
#N@#B#T:"; C:NT":9
NURSIN9 CAR()
"C:". # F :
C@C7 .#STNT#:N-
#NC:NT#NNC
CAT@T"#X
.K. TEMPERATURE 0ARIATIONS
- .A(A< T: @;P:T@A9A(>S
- (TAB:9#C C@AN<S
- .=9:P(NT :f (N#N<#T#S
NURSIN9 CAR()
ANT#P;"T#CS
#C BA<
"(:= JCSS#= C9:T@#N<
P"=NT C@#99S
... CHANGES IN LOC
- 9T@A"<; , A"9#ST S#<N
:2 #NC"AS. #CP
- P"SS>" :N C"B"A9
C:"TJ F "AS
NURSIN9 CAR()
N:T "ST9SSNSS
=A9>AT C:NSC#:>SNSS
"C:". .#S:"#NTAT#:N
F @A99>C#NAT#:NS
./. ,ULGING OF FONTANELS
- (C@AN#CA9 P"SS>"
NURSIN9 CAR()
"P:"T CS2 9A7A<
"#N2:"C 0#T@ ."SS#N<S

CUSHINGFS TRIA2: ":;!(R'RA%;'RA%;.

@ypertension
Bradycardia
Bradypnea
Late '"!')
coma
apnea
!nilateral p!pil chan$es
TREATMENT:
85"SE!9A#9E)
1. @;P"BA""#C :2 - @;P"=NT#9AT#:N,
2. 9=AT @:B
&. (.#CAT#:NS
Med"cat"o!' $or I!crea'ed ICP:
WO')ot"c d"uret"c' increases osmolarity of blood
and draw fl!id from edemato!s brain and tiss!e
into vasc!lar bed
- (annitol
WLoo- d"uret"c' s!ch as f!rosemide
L STEROI2S- .CA.":N , :N9; ST":#.
T@AT CAN C":SS T@ BBB
WA!t"-(ret"c' or %(-ot%er)"a bla!Bet) !sed to
control increases in cerebral metabolic rate
WA!t"co!&ul'a!t' to mana$e sei/!re activity
WH"'ta)"!e H/ rece-tor' to decrease ris* of stress
!lcers
W,arb"turate') may be $iven as contin!o!s inf!sion
to ind!ce coma and decrease metabolic
demands of in5!red brain
W0a'oact"&e )ed"c"!e may be $iven to maintain
blood press!re to cerebral perf!sion
4. 29>#. "ST"#CT#:N
AGG!ESS#9E treat*ent) (C@AN#CA9
.C:(P"SS#:N
1. C"AN#:T:(;
- B"A#N T#SS> JPANS#:N
- S!r$ery incl!des removal of brain t!mors+
b!rr holes
2. =NT"#C>9A" ."A#NA<
- insertion of draina$e catheter or sh!nt to
drain e%cessive CS2

ICP )o!"tor"!
WContin!o!s intracranial press!re monitor is !sed for
contin!al assessment of #CP and to monitor effects of
medical therapy and n!rsin$ interventions
W"is* of infection e%ists with invasive proced!re
Nur'"! 2"a!o'e'
1. #neffective Tiss!e perf!sion
2. "is* for infection) open head wo!nds and
intracranial monitor device re1!ires metic!lo!s
aseptic techni1!e
&. An%iety ?family'
NURSING INTER0ENTION
<oal) to identify and decrease problem
of ##CP.
1. Ne!ro chec*s as indicated by client
stat!s.
2. maintain semi-2owlerAs position to
promote veno!s draina$e and
respiratory f!nction.
12
NURSING ALERT 7 I$ t%e cl"e!t ="t% IICP
de&elo-' %(-o&ole)"c '%ocB, do !ot -lace
cl"e!t "! Tre!dele!burF' -o'"t"o!, ele&ate t%e
lo=er e1tre)"t"e' to e!%a!ce &e!ou' retur!.
&. Chan$e clientAs position slowly and
$ently3 avoid 5er*y movements.
4. (aintain fl!id restriction.
D. val!ate inta*e and o!tp!t.
a. #n response to di!retics.
b. As correlated with chan$es in daily
wei$ht.
c. 2or complications of diabetes insipid!s.
G. (aintain inta*e evenly over twenty-fo!r
ho!r time period.
C. Sedatives and narcotics can depress
respiration and mas* symptoms
indicatin$ increasin$ #CP.
H. Client sho!ld avoid stren!o!s co!$hin$+
=alsalvaAs mane!ver+ and isometric
m!scle e%ercises.
E. #n infants+ meas!re frontal occipital
circ!mference to eval!ate increase in
si/e of the head.
1B. Control hyperthermia as indicated.
<oal) to maintain respiratory
f!nction.
NURSING PRIORITY 7 A"r=a( "' o!e o$ t%e
)o't co))o! -roble)' "! t%e u!co!'c"ou'
cl"e!t, -o'"t"o! t%e) to )a"!ta"! -ate!t a"r=a(
or u'e a"r=a( ad8u!ct'.
1. Prevent respiratory problems of immobility.
2. val!ate patency of airway fre1!ently3 as
level of conscio!sness decreases+ client is at
an increased ris* for respiratory obstr!ction
by the ton$!e and acc!m!latin$ secretions.
&. 7eep PC:2 levels within normal to low
ran$e.
4. S!ction as necessary+ b!t in short d!ration
with rest periods.
D. Client may re1!ire int!bation and control on a
vol!me ventilator.
<oal) to protect from in5!ry.
1. Ta*e sei/!re preca!tions.
2. "estrain client only if absol!tely necessary3
str!$$lin$ a$ainst restraints will increase #CP.
&. .o not clean the ears or nasal passa$es of a
head in5!ry+ or ne!ro s!r$ery client. #f
bleedin$ or draina$e occ!rs from these
areas+ eval!ate caref!lly as it may be
cerebral spinal fl!id.
4. Aspiration is a ma5or problem in the
!nconscio!s client. Caref!lly assess the
swallow refle% in clients who are not f!lly
conscio!s3 position the client in Semi-
2owlerAs for t!be feedin$.
D. (aintain 1!iet+ nonstim!latin$ environment if
condition is !nstable.
G. #nspect eyes and prevent corneal !lceration.
a. Protective closin$ of eyes if the eyes remain
open.
b. Normal saline irri$ation or methylcell!lose
drops to restore moist!re.
<oal) to maintain psycholo$ical
e1!ilibri!m.
1. Ne!ro chec*s are a contin!o!s reminder of
potential problem.
2. nco!ra$e verbali/ation of fears re$ardin$
condition.
&. <ive simple e%planation of proced!res to client
and family.
4. Altered states of conscio!sness will ca!se
increased an%iety and conf!sion3 maintain
reality orientation.
D. #f client is !nconscio!s+ contin!e to tal* to
him-her+ describe proced!res and treatments3
always ass!me that client can hear.
G. Assist parents and family to wor* thro!$h
feelin$s of $!ilt and an$er.
<oal) to prevent complications of
immobility.
<oal) to maintain elimination.
1. >rinary incontinence , may !se condom
catheter or indwellin$ bladder catheter.
2. 7eep perineal area free from e%coriation.
&. (onitor bowel f!nction3 eval!ate for fecal
impaction.
COMPLICATION OF INCREASE2 ICP: ,RAIN
HERNIATION
A,NORMAL ,O2Y TEMPERATURE
@;P"T@"(#A- @;P"P;"J#A
K or I 41o C or 1BG o 2
The temperat!re-re$!latory center in the
hypothalam!s can be dist!rbed by)
C"B"A9 .(A
C"B":=ASC>9A" .#SAS
#NT"AC"AN#A9 S>"<";
@A. #NP>";
B"A#N T>(:"S
"5E0
(AC: *C */ RIS( IN 7(&! < => ? INCR(AS( IN
*@ R(AIR(&(N7*/ '*%; 7ISSU(SB'RAIN
7ISSU( IS :I9:L; SUSC(!7I'L( 7* :;!*CIA
NURSING MANAGEMENT:
(A#NTA#N "::( T(P
#NC"AS 29>#.S &BBB (9-.A;
ANT#P;"T#CS
C:(2:"T (AS>"S
(:N#T:" =S
#C BA<S T: <":#N+ AJ#99A
APHASIA OR 2YSPHASIA
N>"S#N< CA")
"@AB G-12 07S A2T" ST":7
2:"(A9 SPC@ T@"AP;
="BA9 ST#(>9AT#:N
TA97 S9:09; F #N A NAT>"A9 T:N
S#(P9 0:".S F P@"ASS
>S CA".S+ P#CT>"S+ S9AT B:A".S
SEI4URES
Se"#ure'
-alteration in conscio!sness+ sensory and motor
WParo%ysmal motor+ sensory+ or co$nitive
manifestations of spontaneo!s abnormal dischar$es
from ne!rons in cerebral corte%
W(ay involve all or part of brain conscio!sness+
a!tonomic f!nction+ motor f!nction and sensation
E-"le-'(
13
) any disorder characteri/ed by rec!rrent sei/!res
T#:9:<#C 2ACT:"S
1. #diopathic
2. 2ever
&. @ead in5!ry
4. CNS infection
D. (etabolic and to%ic conditions
Cateor"#at"o! o$ 'e"#ure':
Partial sei/!res) activation of part of one cerebral
hemisphere
a8 Simple partial seiDure) no altered conscio!sness+
rec!rrent m!scle contraction3 motor portion of corte%
affected
b8 Comple, partial seiDure) impaired conscio!sness3
may en$a$e in a!tomatisms ?repetitive nonp!rposef!l
activity s!ch as lip smac*in$+ preceded by a!ra+
ori$inates in the temporal lobe'
<enerali/ed sei/!res)
T#nvolves both brain hemispheres3 conscio!sness
always impaired
TAbsence seiDures 0petit mal1) characteri/ed by
s!dden brief cessation of all motor activity+ blan*
stare and !nresponsiveness often with eyes fl!tterin$
(;:C9:N#C S#X>"
S>..N #N=:9>NTA"; C:NT"ACT#:N
:2 A S#N<9 :" S(A99 <":>PS :2
(>SC9
(A; :CC>" .>"#N< PT#T (A9
Tonic-clonic sei/!res
TPreceded by a!ra+ s!dden loss of conscio!sness
T7onic phase) ri$id m!scles+ incontinence ?as
m!scle contracts+ bladder rela%'
TClonic phase) altered contraction+ rela%ation+ eyes
roll bac*+ froths at mo!th
T!ostEictal phase) !nconscio!s and !nresponsive to
stim!li
Statu' E-"le-t"cu'
1. Contin!o!s sei/!re activity+ $enerally tonic-clonic
type
2. Client at ris* to develop hypo%ia+ acidosis+
hypo$lycemia+ hyperthermia+ e%ha!stion
&. 9ife threatenin$ medical emer$ency re1!irin$
immediate treatment)
a. stablish and maintain airway
b. .ia/epam ?=ali!m' and 9ora/epam ?Ativan'
intraveno!sly at
c.DBQ .e%trose #=
d. Phenytoin ?.ilantin' #=-increase sei/!re
threshold
e. Pentobarbital-lessen nervo!s irritation
Med"cat"o!':
a. (ana$e b!t do not c!re sei/!res
b. "aise sei/!re threshold
c. Carbame/epine F 9amotri$ine
- associated with Stevens-Pohnson
syndrome ?SPS' or to%ic epidermal
necrolysis ?TN'.
- very dan$ero!s s*in reactions
- These problems start o!t as s*in
rashes b!t can pro$ress to permanent
disfi$!rement or even loss of life.
d.Phenytoin
- most common S is <#N<#=A9
@;P"9AS#A
NS< Care) :"A9 @;<#N
e. =alproic acid
Je( I!ter&e!t"o!':
1. Protect client from in5!ry and maintain airway
2. .o not force anythin$ into the clientAs mo!th
&. 9oosen clothin$ aro!nd nec*
Nur'"! 2"a!o'e':
1. "is* for #neffective airway clearance
2. An%iety
I!ter&e!t"o!':
1. Assess for si$ns and symptoms of sei/!re activity
s!ch as report of a!ra or twitchin$ of m!scle $ro!ps
2. @ave an oral airway o%y$en and s!ction readily
available
&. Stay with client to protect him from in5!ry and
observe sei/!re activity. #f he is in bed+ remove
pillows+ raise side rails+ and p!t bed on flat position.
9oosen any restrictive clothin$
4. After sei/!re+ assess respiration and p!lse. #f they
present and he is !nresponsive t!rn him onto his side
to *eep his airway patent
D. Cover him with a blan*et for warmth and privacy
G. :bserve and doc!ment characteristics of the
sei/!re
THE UNCONSCIOUS CLIENT
Co)a
Irre&er'"ble co)a - ve$etative state
WPermanent condition of complete !nawareness of
self and environment+ death of cerebral hemispheres
with contin!ed f!nction of brain stem and cerebell!m
WClient does not respond meanin$f!lly to environment
b!t has sleep-wa*e cycles and retains ability to chew+
swallow and co!$h
Wyes may wander b!t cannot trac* ob5ects
W(inimally conscio!s state) client aware of
environment+ can follow simple commands+ indicates
yes-no responses3 ma*e meanin$f!l movements
?blin*+ smile'
W:ften res!lts from severe head in5!ry or $lobal
ano%ia
LocBed5"! '(!dro)e
1. Client is alert and f!lly aware of environment3 intact
co$nitive abilities b!t !nable to comm!nicate thro!$h
speech or movement beca!se of bloc*ed efferent
pathways from brain
2. (otor paralysis b!t cranial nerves may be intact
allowin$ client to comm!nicate thro!$h eye
movement and blin*in$
&. :cc!rs with hemorrha$e or infarction of pons+
disorders of lower motor ne!rons or m!scles
,ra"! 2eat%
1. Cessation and irreversibility of all brain f!nctions
2. <eneral criteria)
a. Absent motor and refle% movements
b. Apnea
c. 2i%ed and dilated p!pils
d. No oc!lar responses to head t!rnin$ and caloric
stim!lation
e. 2lat <
NURSING 2IAGNOSES
14
W#neffective airway clearance) limit s!ctionin$ to L1B-
1D seconds+ hypero%y$enate
W"is* for aspiration
W"is* for impaired s*in inte$rity) preventive meas!res+
contin!al inspection
W#mpaired physical mobility) maintain f!nctionality of
5oints+ physical therapy
W"is* for #mbalanced N!trition) 9ess than body
re1!irements
WAn%iety ?of family'
NEUROLOGICAL 2ISOR2ERS
=8 %(9(N(RA7IV( %IS(AS(S
- P"(AT>" SNSCNC :2 C99S
- Par*insonAs disease
- @!ntin$tonAs Chorea
- A9S
- Al/heimers
@8 AU7*I&&UN( %IS(AS(
- (!ltiple Sclerosis
- (<
- <BS
>8 C(R('R*VASCULAR %IS(AS(S
- A"T"#:SC9":S#S
- AN>";S(+ @(:""@A<
- #N2A"CT#:N
- C=A
38 7RAU&A7IC INFURI(S
- @A. #NP>";
- SP#NA9 #NP>";
58 N(UR*!A7:I(S
- T"#<(#NA9 N>"A9<#A
- B99AS PA9S;
G8 N(*!LAS&S
-
2EGENERATI0E 2ISEASES
I. PARJINSONFS 2ISEASE
.e$eneration of dopamine-providin$ cells in the
s!bstantia ni$ra+ which leads to de$eneration of
ne!rons in the basal $an$lia3 !s!ally develops
after GB a$e
Associated with decreased levels of dopamine
d!e to destr!ction of pi$mented ne!ronal cells in
the s!bstantia ni$ra in the basal $an$lia of the
brain ?Smelt/er F Bare+ 2BB4+ p. 1ECE'
#mbalance between dopamine and acetylcholine
T%ree card"!al $eature':
.. Tre)or' at re't
We.$. rhythmic+ slow t!rnin$ motion ?pronation-
s!pination' of the forearm and the hand and a motion
of the th!mb a$ainst the fin$ers as if rollin$ a pill
Wtremor is present while at rest+ increases when the
patient is wal*in$+ concentratin$+ feelin$ an%io!s
?Smelt/er F Bare+ 2BB4+ p. 1EHB'.
2. R""d"t(-resistance to passive limb movement
&. ,rad(B"!e'"a-most common feat!res3 patients
ta*e lon$er to complete most
activities and have diffic!lty initiatin$ movement
Cl"!"cal Ma!"$e'tat"o!':
W<enerali/ed feelin$s of stiffness
W(ild+ diff!se m!sc!lar pain
W@and tremor at rest ?pill rollin$'
WA*inesia
W<ait chan$es ,sh!fflin$ $ait
WCharacteristic stance-stooped post!re
W(as*li*e-facial e%pression
WSpeech pattern-slow+ low vol!me monotono!s in
tone with poor artic!lation
W#nvol!ntary droolin$
W.ecreased lacrimation3 constipation+ incontinence
W@eat intolerance3 e%cessive perspiration
W9ac* of spontaneo!s swallowin$
Med"cal Ma!ae)e!t
W9evodopa-Carbidopa T-synthetic prec!rsor of
dopamine for basal $an$lia ?Sinemet'
WAnticholiner$ic-to control symptoms ?Co$entin+
Artane+ Symmetrel'3 anticholiner$ic dr!$s act at
central sites to inhibit cerebral motor imp!lses that
ca!se ri$idity of the m!sc!lat!re
W(A:#-Bomcriptine3 inhibit brea*down of dopamine
WPhysiotherapy-red!ces ri$idity of m!scles and
prevents contract!res
Sur"cal "!ter&e!t"o!-to destroy $lob!s pallid!s ?to
relieve ri$idity' and-or thalam!s ?relieve tremors'
Nur'"! Ma!ae)e!t
WProvide safe environment
WN!trition
TSmall bite pieces of food to prevent cho*in$
TSmall fre1!ent meals for easy mastication
TAde1!ate inta*e of ro!$ha$e to prevent
constipation
Tnco!ra$e diet rich in n!trient-dense foods
s!ch as fr!its+ ve$etables+ whole $rains
WPositionin$ and activity
T9imit post!ral activities
T(aintain $ait as normal as possible) may !tili/e
cane or wheel chair
Tnco!ra$e daily physical therapy to limit ri$idity
and prevent contractions
T(edication compliance3 report side effects
WAvoid r!shin$ client as he is !nable to wor* !nder
press!re
WAssist client in settin$ achievable $oals to improve
self-esteem
WTotal body f!nction s!pport in advanced sta$es
?respiratory elimination'
II. AMYOTROPIC LATERAL SCLEROSIS *ALS+
is a pro$ressive+fatal+ ne!rode$enerative
disease ca!sed by the de$eneration of motor
ne!rons+ the nerve cells in the central
nervo!s system that control vol!ntary m!scle
movement
Pro$ressive+ de$enerative ne!rolo$ic disease
characteri/ed by wea*ness and wastin$ of
m!scles ="t%out 'e!'or( or co!"t"&e
c%a!e'
onset is !s!ally between a$e of 9K D EK
hi$her incidence in )ale' at earlier a$es b!t
e1!ally post menopa!se
.eath !s!ally occ!rs in 2 , D years d!e to
respiratory fail!re
Cl"!"cal Ma!"$e'tat"o!' :
depends on the location of the affected motor
ne!rons
Chief symptoms)
fati$!e
pro$ressive m!scle wea*ness
cramps
fascic!lation ?twitchin$'
incoordination
.iffic!lty liftin$ the front part of the foot and
toes ?footdrop'
0ea*ness in the le$+ feet or an*les
@and wea*ness or cl!msiness
Sl!rrin$ of speech or tro!ble swallowin$
15
Med"cal Ma!ae)e!t
no specific treatment for A9S
Su--ort"&e a!d Re%ab"l"tat"&e Mea'ure'
,aclo$e!, da!trole! 'od"u), or
d"a#e-a) for spasticity
Mu"!"!e for m!scle cramps
R"lu#ole a $l!tamate anta$onist+ to
slow m!scle de$eneration
E!teral Feed"!' *perc!taneo!s
endoscopic $astrotomy YP<Z+ for
patients with aspiration or swallowin$
diffic!lties
Nur'"! 2"a!o'e'
"is* for .is!se Syndrome
#neffective Breathin$ Pattern) may re1!ire
mechanical ventilation and tracheostomy
Nur'"! Ma!ae)e!t:
.. #mprovin$ "espiratory 2!nction
/. Preventin$ Aspiration
- assess for droolin$+ re$!r$itation thro!$h
the nose and cho*in$ while attemptin$ to
swallow
- provide standby s!ction
- enco!ra$e rest before meals3 place patient
in an !pri$ht position to facilitate swallowin$
- provide soft foods that are easily swallowed
@. #ncreasin$ Physical (obility
- emphasi/e importance of ta*in$
medications on time to improve stren$th and
end!rance
4. #mprovin$ Comm!nication
III. HUNTINGTONFS 2ISEASE
is a ne!rode$enerative $enetic disorder that
affects m!scle coordination and leads to
co$nitive decline and dementia
Ca!se !n*nown
A!tosomal dominant $enetic disorder
- each children of a parent with @!ntin$tonAs
disease has a DBQ ris* of inheritin$ the
disorder
No c!re
>s!ally asymptomatic !ntil a$e of &B , 4B
a si$nificant red!ction ?vol!me and activity' of
acetylcholine and nerve cell de$eneration
Cl"!"cal )a!"$e'tat"o!':
:. Mo)e*ent
Chorea , abnormal invol!ntary
movements
Cl!msiness
Paw clenchin$ ?br!%ism'
9oss of coordination and balance
Sl!rred speech
Swallowin$ and-or eatin$ diffic!lty
>ncontrolled contin!al m!sc!lar
contractions ?dystonia'
0al*in$ diffic!lty+ st!mblin$+ fallin$
/. Co!"t"&e:
Co$nitive f!nction is !s!ally affected with
dementia !s!ally occ!rrin$.
#mpaired 5!d$ment and memory
Slowin$ of tho!$ht processes to control
m!scle.
@. P'(c%"atr"c S()-to)'
A. .epression
b. Psychotic symptoms
- .el!sions
- @all!cinations
- Paranoia
Ma!ae)e!t::
NNO treat)e!t t%at %alt' or re&er'e'8
Med"cat"o!' to reduced c%orea:
a' 2o-a)"!e rece-tor blocBer'
- improve the chorea in many
patients
- Thiothi%ene @ydrochloride ?Navane'
- @aloperidol .ecanoate ?@aldol'
b' R"lu#ole *R"luteB+
- showed to red!ce chorea
c.' A!t"de-re''a!t'
- for patients with emotional
dist!rbances+ partic!larly depression.
d.' A!t"-'(c%ot"c )ed"cat"o!'
E 0in lo doses1 for patients with
psychotic symptoms.
Nur'"! 2"a!o'e' :
"is* for in5!ry
"is* for Aspiration
#mbalanced N!trition) 9ess than body
re1!irements
#mpaired S*in #nte$rity
#mpaired =erbal Comm!nication
.ist!rbed tho!$ht processes
Nur'"! Care :
Focu' o!:
1. (obility
2. Personal hy$iene
&. Comm!nication
4. N!trition
D. limination
G. Ge!et"c cou!'el"!
I0. AL4HEIMERFS d"'ea'e
A pro$ressive ne!rolo$ic disorder that affects
the brain res!ltin$ in co$nitive impairments
CAUSES:
>n*nown
Potential factors- Amyloid pla1!es in the
brain+ :%idative stress+ ne!rochemical
deficiencies
=ery common3 ris* increases with a$e
Brain chan$es)
pla1!es
tan$led ne!rons
blood vessel de$eneration
chemical chan$es
A-to'sy is the *ost ;e,initi)e
Te! =ar!"! '"!' o$ Al#%e")erO' d"'ea'e
(emory loss
.iffic!lty performin$ familiar tas*s
Problems with lan$!a$e
.isorientation to time and place
Poor or decreased 5!d$ment
Problems with abstract thin*in$
(isplacin$ thin$s
Chan$es in mood or behavior
Chan$es in personality
9oss of initiative
16
9 STAGES OF Al#%e")erO' 2ISEASE
Stae P .
K2or$etf!lness
K(ild memory lapses
KShort attention span
K.ecrease interest in personal affairs
Ks!btle behavior chan$es
Stae P /
Kshort term memory 9apses
Khesitant speech
Kco!$abulat"o! to hide memory problems
Kmisplace item
Krepetitive behavior
Stae P@
K.isoriented to person+place+time
K=a!der'
KApra%ia-impairment in the ability to perform
p!rposef!l acts or to manip!late ob5ects
Stae P 9
KTerminal Sta$e
Ksevere physical and mental deterioriation
KNo reco$nition of self-others
Kcompletely dependent
Kincontinent
KAphasia
K.yspha$ia
Med"cal Ma!ae)e!t
(edication to treat symptoms
(emory)Co!e1, Ar"ce-t
A$itation) (ellaril+ @aldol
S!pplements
2olic Acid F =itamin B12
9ow fat diet
NSA#.S
Nur'"! 2"a!o'"'
A9T". T@:><@T P":CSS
NURSING INTER0ENTIONS:
1. S!pport patientAs abilities
2. Provide emotional s!pport
&. stablish an effective comm!nication system with
the patient and family
>se short simple sentences6 ords
and gestures
(aintain a calm and consistent
approach
Attempt to analy/e behavior for
meanin$
4. protect the patient from in5!ry
Provide a safe and str!ct!red
environment
"e1!ests a family member to
accompany client if he wanders
aro!nd
7eep bed in low position
Provide ade1!ate li$htnin$
Assign consistent caregivers

/ Be( -o"!t' $or all care:

Prevent overstim!lation
Provide str!ct!red+ orderly
environment
9 CF' "! Al#%e")erF'
>se of)
1. Calendar
2. Cloc*
&. Colors
4. Consistency of care$ivers
Creut#$eldt5<aBob d"'ea'e
- "apid pro$ressive de$enerative ne!rolo$ic disease
ca!sin$ brain de$eneration witho!t inflammation
Transmissible and pro$ressively fatal
=ariant form of CP. is 6mad cow disease8)
believed transmitted by cons!mption of beef
contaminated with bovine form of disease
Pathophysiolo$y) spon$iform de$eneration of
$ray matter of brain
No definitive treatment. :!tcome is fatal.
Ma!"$e'tat"o!':
Personality chan$es
An%iety
.epression
(emory loss
#mpaired thin*in$
Bl!rred vision
#nsomnia
.iffic!lty spea*in$
.iffic!lty swallowin$
S!dden 5er*y movements
Ter)"!al 'tate') clients are comatose with
decorticate and decerebrate post!rin$
Nur'"! Care )
>se of standard preca!tions with blood and
body fl!ids
S!pport and assistance to client and family
AUTOIMMUNE 2ISEASES
I. MULTIPLE SCLEROSIS
An a!to-imm!ne mediated pro$ressive
de)(el"!at"! d"'ea'e o$ t%e CNS
The myelin sheath is destroyed and replaced
by sclerotic tiss!e ?sclerosis'
Periods of e1acerbat"o!' a!d re)"''"o!'
CA>S- !n*nown
(!ltiple factors- viral infection+ environmental
factors+$eo$raphic location and 1enetic
're;is'osition
#ncidence is hi$hest in (ou! adult' */K D
9K+Q onset between 2B , DB
Affects $e)ale' more than males ?&S
feminine title1
(ore common in te)-erate cl")ate'
PATHOPHYSIOLOGY
Sensiti/ed T cells will enter the brain and
promote antibody prod!ction that dama$es
the myelin sheath
Pla1!es of sclerotic tiss!es appear on the
demyelinated a%ons interr!ptin$ the ne!ronal
transmission
Ma!"$e'tat"o!'
1. 2ati$!e- initial manifestation
2. O-t"c !er&e "!&ol&e)e!t) bl!rred vision+ ha/iness
&. ,ra"! 'te) "!&ol&e)e!t) nysta$m!s+ dysarthria
?scannin$ speech'3 co$nitive dysf!nction+ verti$o+
deafness
4. 0ea*ness+ n!mbness in le$s+ spastic paresis+
bladder and bowel dysf!nction
17
D. Cerebellar "!&ol&e)e!t) nysta$m!s+ ata%ia+
hypotonia
G. Blindness
CHARCOTFS TRIA2 57 NYSTAGMUS
INTENTIONAL TREMOR
SCANNING SPEECH
TREATMENT:
1. No c!re3 medical treatment is
directed toward treatment of the
disease process and symptoms.
2. (edications to decrease edema and
inflammation of the nerve site.
a. Anti-inflammatory.
b. Antispasmodic.
c. #mm!nos!ppressive.
d. Anticholiner$ic and choliner$ic.
e. #nterferons.
Nur'"! I!ter&e!t"o!:
<oal) to maintain homeostasis and prevent
complications in an ac!te e%acerbation of
disease symptoms.
1. (aintain ade1!ate respiratory f!nction.
a. Prevent respiratory infection.
b. <ood p!lmonary hy$iene.
c. Prevent aspiration3 sittin$ position for
eatin$.
d. val!ate ade1!acy of co!$h refle%.
2. (aintain !rinary tract f!nction.
a. Prevent !rinary tract infection.
b. #ncrease fl!id inta*e.
c. val!ate voidin$-assess for retention
and incontinence.
d. Provide $ood perineal care.
&. (aintain n!trition.
a. val!ate co!$hin$ and swallowin$
refle%.
b. Provide food that is easy to chew.
c. #f client is e%periencin$ diffic!lty
swallowin$+ observe closely with
fl!id inta*e.
4. Prevent complications of immobility.
1. 2oc!s on remainin$ capabilities.
2. nco!ra$e independence and assist
client to $ain control over
environment.
&. #f impotence is a problem+ initiate
se%!al co!nselin$.
4. Assist client to wor* thro!$h the
$rievin$ process.
D. #dentify comm!nity reso!rces
available.
D. Assist client to !nderstand implications of the
disease process and meas!res to maintain health.
1. (edical re$imen and side effects of
the medications.
2. Physical therapy to maintain m!scle
f!nction and decrease spasticity.
A. 0ater e%ercises.
B. Stretchin$ e%ercises.
C. <ait trainin$ and devices to maintain
amb!lation.
G. (eas!res to maintain voidin$.
a. Participation in bladder retrainin$.
b. Cr[de method of voidin$
c. #ntermittent self-catheteri/ation as
indicated-resid!al !rine sho!ld be
less than 1DB cc.
C. Safety meas!res d!e to decreased sensation.
a. Chec* bath water temperat!re.
b. 0ear protective clothin$ in the
winter.
c. Avoid heatin$ pads and clothin$ that
is constrictive.
d. Client sho!ld !nderstand that
relapses are fre1!ently associated
with an increase in physiolo$ical and
psycholo$ical stress.
II. MYASTHENIA GRA0IS
A ne!rom!sc!lar disease characteri/ed
by a decrease in acetylcholine at the
receptor sites in the ne!rom!sc!lar
5!nction3 precipitates a dist!rbance in the
transmission of nerve imp!lses.
A''e'')e!t
1. "is* factors-etiolo$y.
a' Condition has been associated
with dysf!nction of the thym!s
$land.
b' A!toimm!ne in ori$in.
c' (ore common in women.
d' Pea* incidence between 2B and
&B.
2. Clinical manifestations.
a. Primary problem is s*eletal m!scle
fati$!e3 symptoms are predominantly
bilateral.
1' (!sc!lar fati$!e increases
with activity.
2' Ptosis?droopin$ of the
eyelids' and diplopia ?do!ble
vision' are fre1!ently the first
symptoms.
&' #mpairment of facial mobility
and e%pression.
4' #mpairment of chewin$ and
swallowin$.
D' Speech impairment
?dysarthria'.
G' No sensory deficit+ loss of
refle%es+ or m!sc!lar
atrophy.
b. Co!rse is variable.
1' (ay be pro$ressive.
2' (ay stabili/e.
&' (ay be characteri/ed by short
remissions and e%acerbations
a. M(a't%e!"c cr"'"'-an ac!te
e%acerbation of symptoms of the
condition characteri/ed by wea*ness
of the m!scles controllin$ swallowin$
and breathin$ ?dyspha$ia+
dysarthria+ dyspnea'. :cc!rs as a
res!lt of ins!fficientacetylcholine
?anticholinesterase'or e%acerbation
of disease state.
b. C%ol"!er"c cr"'"' is a to%ic
response to the anticholinesterase
medications.
c. The symptoms of a myasthenic crisis
and a choliner$ic crisis are
essentially the same.
1. .iffic!lty breathin$+ swallowin$+
chewin$+ or spea*in$.
18
2. #ncreased secretions ?saliva+
bronchial'.
&. "estlessness and apprehension.
4. Tensilon test to differentiate crisis.
&. 2"a!o't"c'.
a. Clinical manifestations.
b. lectromyo$raphy-shows a decreasin$
response of m!scles to stim!li.
c. TENSILON te't- edrophoni!m
chloride ?Tensilon' administered and
client with myasthenia will show
si$nificant improvement lastin$ D
min!tes
Treat)e!t:
1. Anticholinesterase ?choliner$ic'
medications
a. to improve imp!lse
transmission ?(estinon'
2. Steroids
a. to s!ppress imm!ne system
?steroids+ Cyto%an'
&. Plasmapheresis
a. >sed to remove antibodies
4. #mm!nos!ppressive therapy.
D. S!r$ical removal of the thym!s
?thymectomy'.
Nur'"! I!ter&e!t"o!:
? Client $enerally hospitali/ed for ac!te
myasthenic crisis or for respiratory
infection'.
<oal) to maintain respiratory f!nction.
1. Assess for increasin$ problems of
diffic!lt breathin$.
2. .etermine clientAs medication
sched!le3 when was medication last
ta*en\
&. Assess ability to swallow3 prevent
problems of aspiration.
4. val!ate effectiveness of co!$h
refle%.
D. @ave emer$ency tracheotomy set
available.
Nur'"! Pr"or"t(: 2o !ot "&e t%e cl"e!t
"! )(a't%e!"c cr"'"' a!(t%"! to eat
or dr"!B, t%ere "' '"!"$"ca!t "!crea'ed
r"'B $or a'-"rat"! dur"! t%"' t")e.
<oal) to distin$!ish between myasthenic
crisis and choliner$ic crisis.
1. (aintain ade1!ate ventilatory
s!pport d!rin$ crisis.
2. Assist in administration of TNS#9:N
to differentiate crisis
a' (yasthenic crisis-clientAs
condition will improve.
b' Choliner$ic crisis-clientAs
condition will improve.
&. #f myasthenic crisis+ neosti$mine may
be administered.
4. #f choliner$ic crisis+ atropine may be
administered and all choliner$ic
medications discontin!ed.
D. Avoid !se of sedatives and
tran1!ili/ers which ca!se respiratory
depression.
G. Provide psycholo$ical s!pport d!rin$
crisis.
<oal) to assist client to !nderstand
implications of disease process and
meas!res to maintain health.
1. #mportance of ta*in$
medication on a re$!lar
basis3 pea* effect of the
medication sho!ld coincide
with mealtimes.
2. #f ptosis becomes severe+
client may need to wear an
eye patch to protect cornea
?alternate eye patches if
problem is bilateral'.
&. motional !pset+ severe
fati$!e+ infections+ and
e%pos!re to e%treme
temperat!res may precipitate
myasthenic crisis.
III. GUILLAIN5,ARRR SYN2ROME
This condition involves se$mental de)(el"!at"o!
o$ !er&e root "! t%e PNS. .emyelination occ!rs+
leadin$ to inflammation+ edema and nerve root
compression which ca!ses decreased nerve
cond!ction and rapidly ascendin$ paralysis. Both
sensory and motor impairment+ also called
polyradic!litis.
A''e'')e!t
1. "is* factors-etiolo$y.
a' Possibly a!toimm!ne in ori$in.
b' (ay effect any a$e $ro!p+ more
common in a$es 2B to DB.
c' (ay be associated with swine fl!
imm!ni/ations.
d' 2re1!ently preceded by mild
respiratory of intestinal infection.
2. Cl"!"cal )a!"$e'tat"o!'.
a' Be$ins in the lower e%tremities
and ascends bilaterally
1. 0ea*ness.
2. Ata%ia.
&. Bilateral paresthesia pro$ressin$
to complete paralysis.
b'. -aral('"' a'ce!d' t%e bod(
symmetrically and prod!ces
problems of the lower brain stem.
1' Paralysis of respiratory
m!scles.
2' .iffic!lty tal*in$ and
swallowin$.
&' Cranial nerve
involvement.
c'. 9oss of sensation and f!nction of
bowel and bladder.
d'. (anifestations may pro$ress
rapidly or occ!r over two to three
wee*s.
e'. (!scle atrophy is minim!m.
Nur'"! Pr"or"t(: O$ t%e
!euro)u'cular d"'order', Gu"lla"!5
,arre "' t%e )o't ra-"dl( de&elo-"!
a!d -rore''"&e co!d"t"o!. It "'
-ote!t"all( $atal "$ u!reco!"#ed.
&. .ia$nostics , based primarily on the
clinical manifestations.
Treat)e!t:
?S!pportive'.
1. Corticosteroids.
19
2. (aintain respiratory
f!nction3 may re1!ire
mechanical ventilation.
Nur'"! I!ter&e!t"o!:
<oal) to eval!ate pro$ress of paralysis
and initiate actions to prevent
complications.
1. val!ate rate of pro$ress of
paralysis3 caref!l assessment of
chan$es in respiratory pattern.
2. 2re1!ent eval!ation of co!$h and
swallow refle%.
a' "emain with client while
eatin$3 have s!ction
e1!ipment available.
b' NP: if refle%es are involved.
&. #f paralysis is rapid+ prepare for T
int!bation and respiratory assistance.
4. Prevent complications of immobility
d!rin$ period of paralysis.
<oal) To prevent complications of
hypo%ia if respiratory m!scles become
involved.
<oal) to maintain psycholo$ical
homeostasis.
1. Simple e%planation of
proced!res.
2. <enerally complete
recovery is anticipated3
resid!al problems are
not common.
&. provide psycholo$ical
s!pport d!rin$ period of
assisted ventilation.
4. 7eep client and family
aware of pro$ress of
disease.
Cerebral 0a'cular Acc"de!t *C0A+
Also *nown as a stro*e+ C=A is the disr!ption of the
blood s!pply to an area of the brain res!ltin$ in tiss!e
necrosis and s!dden loss of brain f!nction.
,RAIN:
2Q of the bodyNs wei$ht
2BQ of the o%y$en s!pply
$ets 2BQ of the blood flow.
Cons!mes CBQ of the $l!cose in the body
#f brain cells do not $et o%y$en for & to D
min!tes+ they be$in to die.
C"B"A9 AN:J#A)
4-G (in!tes , "="S#B9
K 1B (in!tes , #""="S#B9
A. Atherosclerosis , res!ltin$ in cerebral
vasc!lar disease+ fre1!ently precedes the
development of a C=A.
B. Types of stro*e.
1. T%ro)bo'"'-formation of a clot which res!lts
in the narrowin$ of a vessel l!men and
event!al occl!sion.
a. Associated with hypertension and
diabetes ?i.e.+ conditions which accelerate
atherosclerotic process'.
b. Associated with atherosclerotic
disease of the carotid+ s!bclavian+ and
vertebral arteries.
c. <enerally a condition of the elderly.
2. E)bol"') , occl!sion of a cerebral artery by
an embol!s.
a. common site of ori$in is the endocardi!m.
b. (ay effect any a$e $ro!p3 fre1!ently
associated with rhe!matic heart disease and
atrial fibrillation.
@. Cerebral %e)orr%ae.
a. "!pt!re of a cerebral artery secondary to
hypertension+ tra!ma+ or ane!rysm.
b. Blood lea*s into the brain tiss!e and the
s!barachnoid space3 creates a mass that
displaces the brain.
C. The area of edema res!ltin$ from tiss!e
dama$e may precipitate more dama$e than
the vasc!lar dama$e itself.
Tra!'"e!t "'c%e)"c attacB *TIA+.
1. Brief episode of ne!rolo$ical dysf!nction.
2. 2re1!ently indicative of advanced
atherosclerotic disease of the cerebral
vessels.
&. Sho!ld be considered a warnin$ symptom of
an impendin$ C=A.
4. Ne!rolo$ic dysf!nction is present for min!tes
to ho!rs+ b!t no permanent ne!rolo$ical
deficit remains.
RISJ FACTORS ASSOCIATE2 CITH
CERE,RAL 0ASCULAR ACCI2ENT
"eversible)
Smo*in$
:besity
#ncreased salt inta*e
Sedentary life style
:ral contraceptives
Partially "eversible)
@ypertension
Cardiac valve disease
.ysrhythmias
.iabetes mellit!s
@ypercholesterolemia
Nonreversible)
Se% ?increased incidence in men'
A$e
#ncreased incidence in the blac*
@ereditary predisposition
1. .ama$e to the left side of the brain will res!lt
in paralysis of the ri$ht side of the body
?hemiple$ia-paralysis of one side of the
body'.
2. Both !pper and lower e%tremities of the
involved side are affected.
A''e'')e!t:
1. "is* factors-tiolo$y) ?see previo!s table'
2. Clinical (anifestations)
a. T#A
1. Temporary loss of vision in one eye
2. Transient hemiparesis
&. Tinnit!s
4. =erti$o
D. Conf!sion
G. Nosebleeds?epista%is'
b. Completed C=A ?occ!rs s!ddenly with an
embolism more $rad!ally in
hemorrha$e or thrombosis'
20
1. He)"-le"a , loss of vol!ntary movement+
dama$e to the ri$ht side of the brain will
res!lt in left-sided wea*ness and paralysis
2. A-%a'"a , defect in !sin$ and interpretin$ the
symbols of lan$!a$e+ may incl!de written+
printed or spo*en words+ may be partial or
complete.
&. Problem of ne!rom!sc!lar control of
respiration.
4. Problem of ne!rom!sc!lar control over
swallowin$ and co!$h refle%.
D. #nitially may be incontinent.
G. A!o'"a- a percept!al defect that ca!ses a
dist!rbance in interpretin$ sensory
information+ client may not be able to
reco$ni/e previo!sly familiar ob5ects.
C. motional lability.
H. #mpairment of 5!d$ment and memory.
E. @ypotonia ?flaccidity' for days to wee*s
followed by hypertonia ?spasticity'.
1B. =is!al defects homonymo!s hemianopsia+ the
loss of vision in one half of the vis!al field.
11. Percept!al defects.
12. Apra%ia inability to carry o!t learned
movements.
Nur'"! 2"a!o'"':
- #neffective Airway Clearance related to
ne!rolo$ical deficits inability to co!$h.
- Altered Tiss!e Perf!sion related to interr!pted
cerebral vasc!lar blood s!pply.
- #mpaired =erbal Comm!nications related to
vis!al and speech impairment.
- Potential for #n5!ry related to sei/!res and
ne!rolo$ical deficits.
- Alteration #n N!trition)
9ess Than Body "e1!irements related
diffic!lty in swallowin$ and potential for
aspiration.
- #mpaired Physical (obility related to severe
wea*ness and paralysis.
- 7nowled$e .eficit related to pro$nosis.
@. 2"a!o't"c'
a. Clinical manifestations elicited in the
ne!rolo$ical e%am.
b. Cerebral arterio$ram.
c. 9!mbar p!nct!re
d. CAT and brain scan.
Treat)e!t
=8 !rophylactic8
a. Aspirin.
b. Persantine
c. Antihypertensives.
@8 &edical
a. (edications to decrease cerebral edema.
1. :smotic di!retics
2. Corticosteroids ?de%amethasone'.
b. (edical meas!rements to maintain
homeostasis.
>8 Surgical8
a. Carotid endarterectomy.
b. Cerebral revasc!lari/ation.
U!"lateral Nelect3 Nelect S(!dro)e ,
- ne!ropsycholo$ical condition in which+ after
dama$e to one hemisphere of the brain+ a
deficit in attention to and awareness of one
side of space is observed.
- is very commonly seen contralateral to the
dama$ed hemisphere
Nur'"! I!ter&e!t"o!
<oal) to prevent C=A thro!$h client ed!cation.
1. #dentification of individ!als with reversible ris*
factors and meas!res to red!ce them.
2. Appropriate medical attention for control of
chronic conditions cond!cive to the
development of C=A ?Partial reversible ris*
factors'.
<oal) to maintain patent airway and ade1!ate
cerebral o%y$enation.
1. Position side-lyin$ with head elevated.
2. Assess for symptoms of hypo%ia3 T
int!bation and mechanical ventilation may be
necessary.
&. (aintain patent airway3 !se oropharyn$eal
airway to prevent airway obstr!ction by the
ton$!e.
4. Client is prone to obstr!cted airway and
p!lmonary infection3 have-her co!$h and
deep breathe as indicated.
<oal) to assess for and implement meas!res to
decrease intracranial press!re
<oal) to maintain ade1!ate n!tritional inta*e.
1. Administer P: feedin$s with ca!tion3 chec*
presence of $a$ refle% and swallowin$ before
feedin$.
2. Place food on the !naffected side of the
mo!th.
&. Select foods that are easy to control in the
mo!th and swallow3 li1!ids often promote
co!$hin$ as client is !nable to control them.
4. (aintain hi$h 2owlerAs position for feedin$.
D. (aintain privacy and !nr!shed atmosphere.
G. #f client is !nable to tolerate P: inta*e+ t!be
feedin$s may be initiated.
<oal) to preserve f!nction of the m!sc!los*eletal
system to prevent 5oint contraction and m!scle
atrophy.
1. Passive ":( on affected side.
2. Active ":( on !naffected side.
&. >tili/e footboard to *eep at ri$ht an$les and
prevent foot drop.
4. 9e$s sho!ld be maintained in a ne!tral
position3 prevent e%ternal rotation of affected
hip by placin$ a trochanter roll or sandba$ at
the thi$h.
D. Position every two ho!rs b!t limit the period
of time spent on the affected side.
G. Assess for add!ction and internal rotation of
the affected arm3 maintain arm in a ne!tral
?sli$htly fle%ed' position with each 5oint
sli$htly hi$her than the precedin$ one.
C. "estraints sho!ld be avoided+ they often
increase a$itation.
H. (aintain 5oints in position of normal f!nction
to prevent fle%ion contract!res.
<oal) to maintain homeostasis thro!$h contin!ed
n!rsin$ assessment and appropriate n!rsin$
intervention.
1. val!ate ade1!acy of cardiac o!tp!t.
2. (onitor hydration stat!s-prevent fl!id
overload.
a. Caref!lly re$!late #= inta*e.
b. val!ate response to di!retics.
c. Assess for the development of
peripheral edema.
21
d. "estrict fl!id inta*e as indicated.
e. Assess respiratory parameters
indicative of fl!id overload ?rales+
dyspnea+ etc.'
&. (aintain and promote normal
elimination.
a. Avoid !rinary catheter if possible3 if
catheter is necessary+ remove as
soon as possible.
b. :ffer bedpan or !rinal every two
ho!rs3 help establish a sched!le.
c. Prevent constipation- increase b!l* in
the diet+ stool softeners+ etc.
d. Provide privacy and decrease
emotional tra!ma related to
incontinence.
4. Prevent problems of s*in brea*down
thro!$h proper positionin$ and $ood
s*in hy$iene.
D. (aintain psycholo$ical homeostasis
a. Client is very an%io!s d!e to the flac*
of !nderstandin$ of what has
happened to him-her and the inability
to comm!nicate.
b. Spea* slowly+ clearly+ and e%plain
what has happened.
c. Assess clientAs comm!nication
abilities and identify methods to
promote comm!nication.
<oal) to assist client to become
independent in activities of daily livin$ as
rehabilitation phase pro$resses.
1. nco!ra$e self-feedin$
2. Provide clothin$ easy to $et in and
o!t of.
&. Active participation in ":(3 do
his-her own ":( on affected side.
4. Physical therapy for retrainin$ of lost
f!nction.
D. 0hen in the sittin$ position+ assist
client to maintain sense of balance3
client will fre1!ently fall to the
affected side.
G. nco!ra$e participation in carryin$
o!t daily personal hy$iene.
C. Assist-teach client safe transfer from
bed to wheelchair.
H. (aintain bowel and bladder trainin$
pro$ram.
E. Promote !rinary continence.
1B. nco!ra$e social interaction.
a. Speech therapy
b. 2re1!ent and meanin$f!l verbal
stim!li.
c. Allow client plenty of time to respond.
d. Spea* slowly and clearly3 do not $ive
too many directions at one time.
e. .o not 6tal* down to8 or treats as a
child.
f. (ental stat!s may be normal3 do not
ass!me it is impaired.
NIH STROJE SCALE
Standardi/ed stro*e severity scale to
describe ne!rolo$ical deficits in ac!te stro*e
patients
Allows to)
U!antify o!r clinical e%am
.etermine if the patientsA
ne!rolo$ical stat!s is improvin$ or
deterioratin$
Provide for standardi/ation
Comm!nicate patient stat!s
11 item scorin$ system
#nte$rates components of ne!rolo$ical e%am
#ncl!des testin$ of 9:C+ select cranial
nerves+ motor+ sensory+ cerebellar f!nction+
lan$!a$e+ inattention ?ne$lect'
(a%im!m score) 42+ minim!m score) B
NIHSS te't' t%e $ollo="! "te)':
9:C
Best $a/e
=is!al field testin$
2acial paresis
Arm F le$ motor f!nction
9imb ata%ia
Sensory
Best lan$!a$e
.ysarthria
%tinction F inattention
NIHSS a!d Pat"e!t Outco)e'
Total scores ran$e from B-42 with hi$her
val!es representin$ more severe infarcts
K2D =ery severe ne!rolo$ical
impairment
1D-24 Severe impairment
D-14 (oderately severe
impairment
LD (ild impairment
A 2-point ?or $reater' increase on the N#@SS
administered serially indicates stro*e
pro$ression. #t is advisable to report this
increase.
C%e! to Co))u!"cate NIHSS Re'ult'
Ne!rolo$ical decline
New focal deficit
Advancin$ ne!rolo$ical deficit
:ther concern
CERE,RAL ANEURYSM, SU,ARACHNOI2
HEMORRHAGE
A dilation of the wall of a cerebral artery ?Berry
ane!rysm' most often arises from an arterial 5!nction
in the Circle of 0illis.
a. An ane!rysm fre1!ently r!pt!res and bleeds into
the s!barachnoid space.
b. Symptoms occ!r when ane!rysm enlar$es and
e%erts press!re on the brain tiss!e+ or when it
r!pt!res.
c. 2re1!ently the vasopasm that accompanies the
r!pt!re ca!ses a si$nificant increase in the area of
dama$e.
A''e'')e!t
22
1. Ris+ factors#etiology.
a. Con$enital deformities of the
vessel.
b. Atherosclerosis res!ltin$ in
wea*ness of the vessel wall.
c. @ypertension3 head tra!ma
may enhance the problem.
d. (ost often occ!rs in middle
life.
2. Clinical manifestations.
a. A "!pt!re may be preceded by)
a. Severe headache.
b. #ntermittent na!sea.
c. "!pt!re fre1!ently occ!rs witho!t
warnin$.
1. Severe headache.
2. Sei/!res.
&. N!chal ri$idity
4. @emiparesis.
D. 9oss of conscio!sness.
G. :verall symptoms depends on the
site and amo!nt of bleedin$3 overall
pro$nosis is poor.
>8 %iagnostics8
a. 9!mbar p!nct!re+ revealin$
blood in the spinal fl!id.
b. Cerebral an$io$ram.
c. CAT scan.
Treat)e!t
1. :smotic di!retics.
2. Antihypertensive medications.
&. S!r$ical intervention-li$ation or 6clippin$8 of
the ane!rysm.
Nur'"! I!ter&e!t"o!
<oal) to prevent f!rther increase in intracranial
press!re and possible r!pt!re.
1. #mmediate+ strict bed rest.
2. Prevent =alsalvaAs mane!ver.
&. Client sho!ld avoid strainin$+ snee/in$+
p!llin$ !p in bed+ ac!te fle%ion of the nec*+
ci$arette smo*in$.
4. levate head of the bed 1DV to &BV.
D. U!iet+ dim+ nonstim!latin$ environment.
G. Constant monitorin$ of condition to identify
occ!rrence of bleedin$ as evidenced by
symptoms of increasin$ intracranial press!re.
C. Administer anal$esics ca!tio!sly+ the client
sho!ld contin!e to be easily aro!sed in order
to perform ne!ro chec*s.
Nur'"! Pr"or"t(: I$ t%e cl"e!t 'ur&"&e' t%e
ru-ture o$ t%e a!eur('), "t "' )o't l"Bel( to
rebleed ="t%"! t%e !e1t /9 to 9H %our'.
<oal) to assess for and implement n!rsin$
meas!res to decrease intracranial press!re.
<oal) to provide appropriate preoperative n!rsin$
intervention.
<oal) to maintain homeostasis and monitor
chan$es in intracranial press!re postoperative
craniotomy.
TRAUMATIC IN<URIES
Head I!8ur(
9aceration
@ematoma
Cont!sion
Bleedin$
Source':
1. Scalp in5!ry
2. S*!ll fract!re
&. Brain in5!ry
R"'B $actor':
a. (otor vehicle accidents
b. levated blood alcohol levels
c. <reatest ris*) male a$ed 1D-&B and those over CD
Mec%a!"') o$ trau)a:
1. Accelerat"o! "!8ur() head str!c* by movin$ ob5ect
2. 2ecelerat"o! "!8ur() head hits stationary ob5ect
&. Accelerat"o!5decelerat"o! ?co!p-co!nterco!p
phenomena' head hits ob5ects and brain rebo!nds
within s*!ll
2"$$u'e a1o!al "!8ur(-most severe form of brain
in5!ry also called shearin$ in5!ry
T(-e' o$ bra"! I!8ur(:
a. :pen head in5!ries ?d!ra'
b. Closed head in5!ries ,bl!nt tra!ma
c. Conc!ssions ,ca!sed by s!dden blow to the head
or rapid acceleration-deceleration
res!lts in retro$rade amnesia and loss of
conscio!sness for D min!tes
No brea* in s*!ll or d!ra
(ay have headache+ na!sea or vomitin$
d. Cont!sions-ca!se more dama$e+ dama$e to brain
itself involve cortical br!isin$ and laceration of
vessels and brain tiss!es
Co)-l"cat"o!' o$ ,ra"! I!8ur(
A. Post conc!ssion syndrome)
(anifestations)
T@eadache+ di//iness
TNervo!sness+ irritability
TChan$es in intelli$ence+ poor concentratin$+
poor memory
T2ati$ability
T#nsomnia
Tra!matic Brain #n5!ry
pid!ral
S!bd!ral
#ntracerebral
B. @ematoma 2ormation)
=8 Subdural hematoma ?slower pro$ression'-veins+
poor pro$nosis d!e to late dia$nosis3 occ!rs within
24-4H ho!rs of in5!ry in ac!te+ 2-14 days in s!bac!te3
can occ!r !p to several months in chronic
Ma!"$e'tat"o!':
Ac!te
WPro$ressive and mar*ed depression of
conscio!sness
W@eadache+ drowsiness+ a$itation and
conf!sion
WP!pillary and motor chan$es
Chronic
W#ncreasin$ severe headache
WSlow cerebration and drowsiness
WPapilledema and ipsilateral p!pil dilatation
Systemic-Bilateral
@8 (pidural 0e,tradural1 :ematoma
W#mmediate loss of conscio!sness+ l!cid interval
lastin$ for few min!tes or ho!rs3 lapse into
!nconscio!sness
23
WSevere+ headache+ sei/!res+ vomitin$+ hemiparesis+
fi%ed+ dilated ipsilateral p!pils
>8 Intracerebral :ematoma
WContained well-defined blood clot3 !s!ally at frontal
and temporal lobes
Cou-5Co!trecou- "!8ur(-dama$e to the site of
impact ?co!p' and dama$e on the opposite side of
the in5!ry ?contreco!p'.
Ma!ae)e!t) Craniotomy
C. Cerebral edema and #ncreased #CP
SBull $racture
Wbrea* in contin!ity of s*!ll !s!ally res!ltin$ in brain
tra!ma
a. L"!ear) d!ra remains intact3 s!bd!ral or epid!ral
hematoma may occ!r !nderneath
b. Co))"!uted a!d de-re''ed 'Bull $racture':
increase ris* for direct in5!ry to brain tiss!e from
cont!sion ?br!ise' and bone fra$ment) ris* for
infection
c. ,a'"lar) involves base of s*!ll ?softer' and !s!ally
involves e%tension of ad5acent fract!res
A''e'')e!t:
WR%"!orr%ea) thro!$h nose
WOtorr%ea) thro!$h
W(ay appear on %-ray
WHe)ot()-a!u)) blood behind tympanic membrane
?p!rple or dar* color'
Normal) pearly $ray
W,attleF' '"!) blood over mastoid process
WRaccoo! e(e') bilateral periorbital ecchymosis
W<l!cose rea$ent strip) #f positive indicates CS2
I!ter&e!t"o!':
a. 7eep nasopharyn% and e%ternal ear clean
b. No blowin$ nose+ co!$hin$ or hard snee/in$
c. Prophylactic antibiotic
Nur'"! Ma!ae)e!t $or %ead "!8ur"e':
#mmediately followin$ s!r$ery)
W#mmobili/e head and nec* !ntil cervical in5!ry is
r!led o!t
WAvoid fle%ion) hypere%tension and rotation of the
nec*
WPaw thr!st mane!ver
-Patent airway and s!pport ventilatory f!nction
-.oc!ment baseline ne!rolo$ical assessment
After initial stabili/ation)
W(onitor ne!rolo$ical stat!s every ho!r !ntil stable
-9:C+ responsiveness
-P!pillary si/e+ position+ direct and consens!al
response
-Assess e%traoc!lar movements
-Note verbal and motor chan$es
W(onitor for complications
-@ematoma formation
-#nfection
-Ac!te hydrocephal!s
-A".S
W(onitor temperat!re and maintain normothermia
?decrease metabolism'
W"eport hi$h !rine o!tp!t ?over 2BB ml-hr for 2
consec!tive ho!rs'
W(onitor osmolality and ser!m electrolytes
WCBC
W":( e%ercises
Wye-ear care
WN!trition-N<T ?hi$h $l!cose-brain f!nctionin$3
protein-tiss!e repair'
Wlimination-la%atives+ increase fiber
Cra!"oto)(-s!r$ical openin$ of the s*!ll
Cra!"ecto)( ,permanent removal of the crani!m to
relieve press!re on the brain by providin$ space for
e%pansion
Nur'"! )a!ae)e!t
Preoperative
WParenteral corticosteroids
WScalp preparation
WAntiembolism stoc*in$s
Postoperative
1. Ne!rolo$ical assessment
2. @ead dressin$s) monitor for CS2 lea*s
&. Control #CP
WAssess for si$ns of increasin$ #CP
WPositionin$ to prevent increase in #CP
- Supratentorial surgery-elevate head of
bed &B de$rees
- Infratentorial-*eep flat+ t!rn every 2 ho!rs+
b!t never onto the bac* ?to prevent brain
hernation'
- !osterior fossa surgery-either side b!t
never on the bac*
- 'one flap-on the !noperated side
S-"!al Cord I!8ur(
<enerally occ!rs as a res!lt of direct tra!ma to the
head or nec* area.
A. #nitially after the in5!ry+ the nerve fibers swell and
circ!lation to the spinal cord is decreased3
hemorrha$e and edema occ!r ca!sin$ an increase in
the ischemic process which pro$resses to necrotic
destr!ction of the spinal cord.
Nur'"! Pr"or"t(: Within tentyEfour hours of the
inHury6 edema secondary to the inflammatory process
results in compression of the cordI the edema
e,tends above and belo the area of inHury and
increases the area of ischemic damage.
B. Conse1!ences of cord in5!ry depend on the e%tent
of dama$e as well as the level of cord in5!ry.
Mec%a!"')' o$ '-"!al cord "!8ur(.
?a' Fle1"o!5e1te!'"o!) whiplash+ seen with
rapid deceleration in5!ries.
?b' Sublu1at"o!) incomplete or partial
dislocation.
?c' Tor'"o!) twistin$ of the spinal cord.
?d+ Co)-re''"o!
1. The hi$her the lesion+ the more severe the
se1!ela.
2. Complete transaction ?complete cord dissol!tion+
complete lesion'-paralysis below the level of in5!ry3
minim!m+ if any+ ret!rn of f!nction.
a. 9oss of sensory f!nction.
b. 9oss of vol!ntary motor activity
c. 9oss of sense of position ?proprioception'.
d. (inim!m+ if any ret!rn of f!nction.
24
&. #ncomplete.
a. Central cord syndrome-center of cord is
dama$ed+ res!lts primarily in impairment
in !pper e%tremities.
b. %amage to one side of the cord 0'ronE
SeJuard syndrome'-motor f!nction and
position sense may be present on one side+
temperat!re and sensation may be lost
on the opposite side.
c. Anterior cord damage-disr!ption of blood
flow res!lts in a mi%ed loss of sensory and
motor f!nction below the level of in5!ry.
C. S-"!al Cord S%ocB *are$le1"a'-occ!rs
predominantly in complete cord lesions. Beca!se of
the loss of comm!nication with the hi$her centers of
control+ the m!scles below the level of in5!ry will
become flaccid and all f!nctional control will cease.
1. Spinal cord in5!ry interr!pts the sympathetic nerve
imp!lse transmission+ the parasympathetic imp!lses
are not co!nter chec*ed and vasodilation occ!rs3 this
res!lts in hypovolemia and hypotension.
2. There is loss of the hypothalam!s to control body
temperat!re by vasoconstriction and dilation.
&. Condition may persist for several wee*s and
reverse spontaneo!sly+ resol!tion of spinal shoc* will
be evident by the ret!rn of refle%es.
4. Spasticity will occ!r as recovery pro$resses.
Spastic movements may be precipitated by emotion
and c!taneo!s stim!lation.
2. Neuroe!"c '%ocB.
1. .ominance of the parasympathetic nervo!s
system res!lts in loss in vasomotor tone and
increased va$al tone leadin$ to hypotension and
bradycardia.
2. s*in stays warm and dry d!e to loss of sympathetic
response of vasoconstriction.
&. Condition may mas* symptoms of hemorrha$e in
the tra!ma client.
E. Auto!o)"c d('re$le1"a *A2+ occ!rs in clients with
an in5!ry at T-G or hi$her.
1. A no%io!s stim!li below the level of in5!ry tri$$ers
the sympathetic nervo!s system which ca!ses a
release of catecholamines res!ltin$ in bnypertension.
2. Spinal in5!ry bloc*s the normal transmission of
sensory imp!lses and the imp!lses cannot reach the
brain+ b!t they rebo!nd and stim!late the sympathetic
nervo!s system.
&. there is an e%a$$erated response to the sensory
stim!li+ most common stim!li ca!sin$ the response
are a f!ll bladder+ fecal impaction+ and s*in
stim!lation.
4. Severe hypertension+ po!ndin$ headache+
bradycardia+ restlessness+ s*in fl!shed and warm are
not !ncommon body responses.
D. Treatment is directed identifyin$ and removin$
no%io!s stim!li.
2. Bladder dysf!nction will occ!r as a res!lt of the
in5!ry. Normal bladder control is dependent on both
the sensory and motor pathways+ and the lower
motor ne!rons bein$ intact.
1. Re$le1 !euroe!"c bladder ?spastic+
a!tonomo!s'occ!rs in clients with cord lesions above
the level of lower l!mbar and ca!dal area of the
spine. The lower motor ne!ron pathway remains
intact below the level of the in5!ry.
a.There is loss of vol!ntary m!scle control+
and dependin$ on the level of the in5!ry+
there is loss or decreased sensation.
b. Bladder will retain a vol!me of !rine+ then
refle%ive invol!ntary voidin$ will occ!r.
c. Bladder empties a!tonomically in response
to stretchin$ of the detr!sor m!scles.
2. No!re$le1"c !euroe!"c bladder *$lacc"d+ occ!rs
in clients will cord lesions at the lower l!mbar and
ca!dal area of the spine. The lower motor ne!rons
are dama$ed.
a. The sensory f!nction may remain
!nimpaired+ there is loss of bladder tone
and vol!ntary control.
b. Bladder retains a vol!me of !rine+
becomes distended and overflows.
c. There is no bladder m!scle contraction or
forcef!l emptyin$.
<. 9on$-term rehabilitation potential depends on the
amo!nt of dama$e done to the cord which may not
be evident for several wee*s after the in5!ry.
A''e'')e!t
1. "is* factors-etiolo$y-accidents.
2. Clinical manifestations-depend on
level of cord in5!ry.
a. C1-C&-!s!ally fatal at the scene of
the accident d!e to respiratory
arrest.
b. 2laccid paralysis and sensory loss
below the level of in5!ry.
c. S-"!al '%ocB.
1' <enerally occ!rs within
seventy-two ho!rs and may
last for several wee*s.
2' 2laccid paralysis.
&' 9oss of sensation and
absence of refle%es.
4' Bowel and bladder
dysf!nction.
D' @ypotension and
bradycardia.
G' After spinal shoc*+ refle%es+
and a!tonomic activity
ret!rn as evidenced by
development of spasticity.
d. Neuroe!"c '%ocB
1' @ypotension from vasodilation.
2' Bradycardia from increased
va$al tone.
&' S*in remains warm and dry.
4' (ay re1!ire vasoactive
medications ?dopamine and
dob!tamine' for hypotension
and bradycardia.
e. Auto!o)"c d('re$le1"a in clients
with in5!ries at TG or hi$her.
1' Severe hypertension.
2' Severe bradycardia.
&' Complaints of headache.
4' 2l!shin$ and diaphoresin$
above level of in5!ry.
Nur'"! 2"a!o'"':
Spinal Cord InHury
- Potential for Aspiration related to
inability to co!$h.
25
- Alteration in limination+ bowel and
Bladder related to level of in5!ry.
- #mpaired Physical (obility related to
level of in5!ry.
- .ist!rbance in Body #ma$e related to
dependency on others and
chan$e in body f!nction.
- Self Care .eficit related to anticipated
losses.
- <rievin$ related to anticipated losses.
- Altered 2amily Process related to
ad5!stment of family member to
permanent disability.
@. 2"a!o't"c'
a. @istory of accident
b. clinical manifestations.
c. J-rays to determine level of dama$e.
d. ("#.
e. CT scan.
Treat)e!t
1. #mmobili/ation of the vertebral col!mn
in cervical fract!re.
a. Stry*er frame.
b. Circ!lar electric bed.
c. Cervical ton$s ?Cr!tchfield' for
cervical immobility.
2. "espiratory s!pport as indicated.
&. #mmobili/ation of spinal col!mn by bed
rest in l!mbar fract!re.
4. Stabili/ation of spinal col!mn by
s!r$ical proced!res.
D. Corticosteroids to decrease cord e
dema.
Nur'"! I!ter&e!t"o!:
Goal: to )a"!ta"!' 'tab"l"t( o$ t%e &ertebral
colu)! a!d -re&e!t $urt%er cord
da)ae.
1. mer$ency care and treatment.
a. S!spect spinal cord in5!ry if there is
any evidence of direct tra!ma to the head
or nec* area ?contact sports+ divin$
accidents+ (=A'.
b. #mmobili/e and place on spinal board
with the head and nec* in a ne!tral
position3 do not allow the nec* to fle%.
Nur'"! Pr"or"t(0 %o not hypere,tend the nec+
in the client ith a suspected cervical
inHury8 Airays should be opened by the
Ha lift method8 Improper handling of the
client at the scene of the accident often
results in e,tension of the damaged
area8
a. (aintain in e%tended position with no
twistin$ or t!rnin$3 do not remove from
the spinal board !ntil area of in5!ry is
identified.
b. (aintain patent airway d!rin$
transportation.
2. (aintain stability of the vertebral col!mn as
indicated by the level of in5!ry.
a' Bed rest on firm mattress with s!pportive
devices ?sandba$s+s*in traction+ etc.'3
maintain ali$nment in the s!pine position3
lo$roll witho!t any fle%ion or twistin$.
b' (aintain cervical traction-ton$s are
inserted into the s*!ll with traction and
wei$hts applied3 do not remove wei$hts3
lo$roll to maintain spinal immobility.
c' Stry*er frame or circle bed permit chan$e
of position from prone to s!pine3
fre1!ently !tili/ed in con5!nction with
cervical traction3 maintain safety
preca!tions when t!rnin$.
d' (aintain e%tremities in ne!tral+ f!nctional
position.
&. Appropriate n!rsin$ intervention when s!r$ery
is indicated for stability of the in5!ry.
Goal: to )a"!ta"! o!o"! a''e'')e!t to
"de!t"$( le&el o$ da)ae a!d c%a!e' "!
!eurolo"cal 'tatu'.
1. (otor and sensory eval!ation.
a. Ability to move all e%tremities3 stren$th of
e%tremities.
b. Sensory e%amination incl!din$ to!ch and
pain.
c. Presence of deep tendon refle%es.
2. :n$oin$ assessment and stat!s of)
a' Bladder f!nction.
b' <astric f!nction.
c' "espiratory and cardiovasc!lar systems.
d' Bowel f!nction.
e' Psycholo$ical ad5!stment to the in5!ry.
Goal: to )a"!ta"! re'-"rator( $u!ct"o!.
1. 2re1!ent assessment of respiratory f!nction
d!rin$ first forty-ei$ht ho!rs.
a' val!ate for chan$es in breathin$
pattern.
b' val!ate clientAs complaints of increasin$
diffic!lty in breathin$3 !tili/ation of
sternocleidomastoid and intercostals
m!scles for respiration.
c' val!ate AB<.
d' val!ate for presence of increasin$
hypo%ia.
2. (aintain ade1!ate respiratory f!nction as
indicated.
a' Chest physiotherapy.
b' #ncentive spirometry.
c' Chan$in$ position within limits of in5!ry.
d' Assess for complications of atelectasis+
p!lmonary emboli+ and pne!monia
e' Nasopharyn$eal or endotracheal
s!ctionin$ s!ctionin$ as indicated.
Goal: to )a"!ta"! card"o&a'cular 'tab"l"t(.
1. Ne!ro$enic shoc*.
a' (onitor vital si$ns closely for first 24
ho!rs post in5!ry.
b' Caref!lly titrate #= fl!ids as client is at
hi$h ris* for fl!id overload.
c' Assess other client parameters for
evidence of hemorrha$e and other
in5!ries.
1' Abdominal m!scles will remain
flaccid in presence of abdominal
in5!ries.
2' 0ith the loss of vasc!lar tone the
symptoms of hemorrha$e will be
mas*ed.
2. Spinal shoc*.
a' (onitor vital si$ns and
eval!ate chan$es with
26
re$ard to development
of ne!ro$enic shoc*
and hemorrha$e.
b' =a$al stim!lation+
hypothermia+ and
hypo%ia may
precipitate spinal
shoc*.
c' .evelopment of
spasticity of m!scles
below the level of
in5!ry indicates
resol!tion of spinal
shoc*.
&. Assess for developmental of a!tonomic
dysrefle%ia+ if it occ!rs)
a' levate the head of the bed ?if possible'.
b' Assess for so!rces of stim!li-distended
bladder+ fecal impaction+ or constipation.
c' "elieve the stim!li and fre1!ently
dysrefle%ia will s!bside.
d' (aintain cardiovasc!lar s!pport d!rin$
period of hypertension.
4. val!ate cardiovasc!lar responses when or
s!ctionin$.
D. #f t!rnin$ on a circ!lar electric bed+ eval!ate for
post!ral hypotension.
G. Antiembolism stoc*in$s or elastic wraps to the
le$s to facilitate veno!s ret!rn. ?9ac* of m!scle
tone and loss of sympathetic tone in the
peripheral vessels res!lts in a decrease in
veno!s tone and in veno!s ret!rn predisposin$
the client to the development of deep vein
thrombosis'.
Goal: to )a"!ta"! adeSuate $lu"d a!d
!utr"t"o!al 'tatu'.
1. .!rin$ the first forty-ei$ht ho!rs+
eval!ate <# f!nction fre1!ently3
decrease in f!nction may necessitate
!tili/ation of a naso$astric t!be to
decrease distention.
2. Prevent complications of na!sea and
vomitin$.
&. val!ate bowel so!nds and clientAs
ability to tolerate P: fl!ids.
4. #ncrease protein and calories in diet3
may need to decrease calci!m
inta*e.
D. val!ate for presence of paralytic
ile!s.
G. #ncrease ro!$ha$e in diet to promote
bowel f!nction.
Goal: to -re&e!t co)-l"cat"o!' o$ "))ob"l"t(.
Goal: to -ro)ote bo=el a!d bladder $u!ct"o!
1. >rine is retained d!e to the loss of
a!tonomic and refle%ive control of the
bladder.
d. #ntermittent catheteri/ation or
indwellin$ catheter initially to prevent
bladder distention.
e. N!rsin$ intervention to prevent
!rinary tract infection.
2. .etermine type of bladder
dysf!nction and assist client to
determine appropriate method of
bladder emptyin$.
&. Assess clientAs awareness of bladder
f!nction.
4. #nitiate meas!res to instit!te bladder
control.
a. stablish a sched!le for voidin$3
have client attempt voidin$ every two
ho!rs.
b. >tili/e the Cr[de method for man!al
e%pression of !rine.
c. (ay be necessary to teach client
self-catheteri/ation.
d. "ecord o!tp!t and eval!ate for
resid!al !rine.
D.val!ate bowel f!nctionin$.
a. #ncontinence and paralytic ile!s
fre1!ently occ!r with spinal shoc*.
b. #ncontinence and impaction are
common later.
G. #nitiate meas!res to promote bowel
control ?after spinal shoc* is resolved'.
a' #dentify clientAs bowel habits prior
to in5!ry.
b' (aintain s!fficient fl!id inta*e
and ade1!ate b!l* in the diet.
c' stablish specific time each day
for bowel evac!ation.
d' Assess clientAs awareness of
need to defecate.
e' Teach client effective !tili/ation
of the =alsalva mane!ver to
ind!ce defecation.
f' #nd!ce defecation by di$ital
stim!lation+ s!ppository or as a
last resort+ enema.
Goal: To )a"!ta"! -'(c%olo"cal eSu"l"br"u).
1. Simple e%planation of all proced!res.
2. Anticipate o!tb!rst of an$er and
hostility as client be$ins to wor*
thro!$h the $rievin$ process and
ad5!stments in body ima$e.
&. Anticipate and accept periods of
depression in client.
4. nco!ra$e independence whenever
possible3 allow client to participate in
decisions re$ardin$ care and to $ain
control over environment.
D. nco!ra$e family involvement in
identifyin$ appropriate diversional
activities.
G. Avoid sympathy and emphasi/e
clientAs potential.
C. #nitiate fran*+ open disc!ssion
re$ardin$ se%!al f!nctionin$.
H. Assist client family to identify
comm!nity reso!rces.
E. Assist client to set realistic short-term
$oals.
Med"cal Ma!ae)e!t
T#mmobili/ationR<ardner ,well ton$s+ halo e%ternal
fi%ation
T(aintenance of heart rate ?Atropine' and BP
?dopamine' vasopressors
T(ethylprednisolone therapy
T#nsertion of N<T
T#nt!bation+ if needed
T#ndwellin$ !rinary catheter
TStress !lcer prophyla%is ?Proton-p!mp inhibitos+ @2
bloc*ers'
TPhysical therapy
CLIENTS IN TRACTIONS
CER0ICAL TRACTIONS:
.. S*!ll Ton$s- Cr!tchfield Ton$
N' Mt: PETAM
27
- Provide pin care.
- ns!re wt is han$in$ freely.
- T!rn to sides 12@
- Assess insertion site for infection.
- (assa$e the occip!t.
2. @alo Traction
A. Avoid p!ttin$ powder inside the vest.
B. T!rn the pt as a !nit+ do not !se the halo
vest to lift the pt.
C. Assess for ti$htness of the vest by
ens!rin$ that 1 fin$er can be placed !nder the
5ac*et.
.. @ave the correct-si/e wrench available at
all times for emer$ency.
. Provide pin care.
CNS INFECTIONS
I. Me!"!"t"'
W#nflammation of pia matter+ arachnoid and
s!barachnoid space
WSpreads rapidly thro!$h CNS beca!se of circ!lation
of CS2 aro!nd brain and spinal cord
W(ay be bacterial+ viral+ f!n$al+ parasitic in ori$in
W#nfection enters CNS tho!$h invasive proced!re or
thro!$h bloodstream+ secondary to another infection
in body
,acter"al Me!"!"t"'
Ca!sative or$anism)
Neisseria menin$itides+ Streptococc!s pne!monia+
@aemophil!s infl!en/a+ scherichia coli
Ma!"$e'tat"o!'
a. 2ever+ chills
b. @eadache+ bac* and abdominal pain
c. Na!sea and vomitin$
d. Me!"!eal "rr"tat"o!:
TN!chal ri$idity ?stiff nec*'-early si$n
] :pisthotonos
TPositive 7erni$As si$n
TPositive Br!d/ins*iAs si$n-when the patientAs
nec* is fle%ed+ fle%ion of the *nees and hips is
prod!ced
TPhotophobia ,e%treme sensitivity to li$ht
e. Me!"!ococcal )e!"!"t"') rapidly spreadin$
petechial rash of s*in and m!co!s membrane
f. I!crea'ed ICP) decreased 9:C+ papilledema ,
edema of optic disc d!e to increased #CP
0"ral Me!"!"t"'
W9ess severe+ beni$n co!rse with short d!ration+
intense headache with malaise+ na!sea+ vomitin$+
lethar$y+ si$ns of menin$eal irritation
E!ce-%al"t"'
1. Ac!te inflammation of parenchyma of brain or
spinal cord
2. >s!ally ca!sed by vir!s
Med"cat"o!'
1. (enin$itis) immediate treatment of effective
antibodies for C-21 days accordin$ to c!lt!re res!lts3
de%amethasone to s!ppress inflammation
.ilantinR#ncrease sei/!re threshold
Healt% Pro)ot"o!
1. =accinations for menin$ococcal+ pne!mococcal+
haemophil!s menin$itis
2. Prophylactic rifampins for persons e%posed to
menin$ococcal menin$itis
&. (os1!ito control
4. Prompt dia$nosis
D. Asepsis care for clients with open head in5!ry or
ne!ros!r$ery
NEUROPATHIES
I. Tr"e)"!al Neural"a
A Cranial nerve disorder affectin$ the sensory
branches of the tri$eminal ?cranial nerve ='.
A''e'')e!t
1. "is* factors-etiolo$y.
a. :nset $enerally between 2B and 4B years of
a$e.
b. #ncreasin$ fre1!ency with a$in$.
2. Clinical manifestations.
a. Abr!pt onset of paro%ysmal pain in the lower and
!pper 5aw+ chee*+ and lips.
1' Tearin$ of the eyes and fre1!ent blin*in$.
2' 2acial twitchin$ and $rimacin$.
&' Pain !s!ally brief3 ends as abr!ptly as it
be$ins.
b. "ec!rrence of pain is !npredictable.
c. Pain is initiated by c!taneo!s stim!lation of the
affected nerve area.
1' Chewin$.
2' 0ashin$ the face.
&' %tremes of temperat!re-either on the face or
in food.
4' Br!shin$ teeth.
&. .ia$nostics.
a. clinical manifestations.
b. Test to r!le o!t other ne!rolo$ic dysf!nctions.
Treat)e!t
1. (edical mana$ement of pain.
a. .#9ANT#N.
b. T<"T:9.
2. S!r$ical intervention.
a. 9ocal nerve bloc*.
b. S!r$ical intervention to interr!pt nerve imp!lse
transmission.
Nur'"! I!ter&e!t"o!
<oal) to control pain.
1. Assess the nat!re of a painf!l attac*.
2. #dentify tri$$erin$ factors3 ad5!st environment
to decrease factors.
a. 7eep room at an even+ comfortable
temperat!re.
b. Avoid to!chin$ client.
c. Avoid 5arrin$ the bed.
d. Allow client to carry o!t own A.9 as
necessary.
&. Administer anal$esics to decrease pain.
Nur'"! 2"a!o'"')
Tri$eminal Ne!ral$ia
Alteration #n Comfort) Ac!te Pain related to
condition.
7nowled$e .eficit related to inade1!ate
*nowled$e re$ardin$ condition+ precipitatin$
factors+ and treatment.
28
Potential for Self @arm related to inability to cope
with pain.
"-rsin1 Priority0 D-e to the se)ere 'ain o, the
con;ition+ clients are s-sce'ti<le to se)ere
;e'ression an; s-ici;e.
<oal) to maintain n!trition.
1. 2re1!ently client does not eat d!e to
rel!ctance to stim!late the pain.
2. Provide l!*ewarm food which is
easily chewed.
&. #ncrease protein and calories.
<oal) to eval!ate resid!al effects and prevent
complications postoperative s!r$ical intervention.
1. #dentify presence of corneal refle%3 provide
protective eye care if refle% is absent.
2. #f there is loss of sensation to the side of the
face client sho!ld)
a. Chew on the !naffected side.
b. Avoid temperat!re e%tremes in foods.
c. Chec* the mo!th after eatin$ to remove
remainin$ particles of food.
d. (aintain metic!lo!s oral hy$iene.
e. @ave fre1!ent dental chec*!ps.
II. ,ELLFS PALSY
A cranial nerve disorder affectin$ the facial nerve
?cranial nerve =##'+characteri/ed by a disr!ption
of the motor branches on one side of the face.
The disr!ption of the motor branches res!lts in
m!scle flaccidity of the affected side of the face.
A''e'')e!t
1. "is* factors-etiolo$y.
a. Can affect any a$e $ro!p3 increased
incidence between a$es 2B and 4B.
b. C!rrent theories s!$$est the inflammation
and demyelini/ation of the nerve is
precipitated by a viral a$ent+ possibly herpes
simple%.
2. Clinical manifestations.
a. 9a$ or inability to close eyelid on affected
side.
b. .roopin$ of the mo!th.
c. .ecreased taste sensation.
d. (ay e%perience pain behind the ear of the
affected side.
&. .ia$nostics-no specific dia$nostic test.
Treat)e!t
1. Corticosteroids.
2. =asodilators.
Nur'"! I!ter&e!t"o!
<oal) to assess nerve f!nction and prevent
complications.
1. Anal$esics to decrease pain.
2. val!ate ability of client to eat.
&. (etic!lo!s oral hy$iene.
4. Prevent dryin$ of the cornea on the
affected side.
a. #nstill methylcell!lose drops
fre1!ently d!rin$ the day.
b. :phthalmic ointment and eye
patches may be re1!ired at ni$ht.
D. As f!nction ret!rns+ active facial
e%ercises.
<oal) to assist client to maintain a positive self-
ima$e.
1. Chan$es in physical appearance may be
dramatic.
2. .isc!ss with client that the condition is
!s!ally self-limitin$ with minim!m+ #f any+
resid!al effects.
&. Client may re1!ire co!nselin$ if facial
appearance is permanent.
Nur'"! 2"a!o'"':
BellAs Palsy
.ist!rbance in Body #ma$e related to facial
deficits.
Potential for #n5!ry) ye related to loss of normal
blin* refle%.
Potential for alteration in N!trition) 9ess Than
Normal Body "e1!irements related to diffic!lty
eatin$.
NEOPLASMS
I. ,RAIN TUMORS
A. Classification of t!mors.
1. T!mors arisin$ from the protective coverin$
of the brain-i.e.+ d!ral menin$iomas.
2. T!mors developin$ # or aro!nd cranial
nerves-i.e.+ aco!stic ne!romas.
&. T!mors ori$inatin$ in the brain tiss!e-i.e.+
$liomas.
4. (etastatic t!mors ori$inatin$ elsewhere in
the body3 fre1!ently+ metastasis is from the
l!n$ or the breast.
B. <liomas are the most common t!mors3
fre1!ently are mali$nant.
C. Brain t!mors may be beni$n+ mali$nant+ or
metastatic3 mali$nant brain t!mors rarely
metastasi/e o!tside the CNS.
.. S!pratentorial , t!mors occ!rrin$ within the
anterior two-thirds of the brain+ primarily the
cerebr!m.
. #nfratentorial , t!mors occ!rrin$ in the
posterior third of the brain ?or below the
tentori!m'3 primarily in the cerebell!m or the
brain stem.
2. "e$ardless of the ori$in+ site+ or presence of
mali$nancy+ problems of increased
intracranial press!re occ!r beca!se of the
limited area in the intracranial contents.
A''e'')e!t
1. "is* factors-etiolo$y.
a. Ad!lts-hi$hest incidence between DD and CB
years of a$e.
b. Pro$nosis is $enerally poorer in the infant
than in older children.
c. Presence of metastatic cancer of the l!n$ or
breast.
2. Clinical manifestations , symptoms correlate
with the area of the brain initially involved.
a. @eadache.
1'. "ec!rrent.
2'. Pro$ressive.
&'. (ore severe in the mornin$.
4'. Affected by position.
D'. @eadache in infant may be identified by
persistent+ irritated cryin$ and head rollin$.
b. =omitin$ , initially with or witho!t na!sea3
pro$ressively becomes pro5ectile.
c. Coordination dist!rbances ?ata%ia+ sta$$erin$
$ait'.
d. @ypotonia+ hyporefle%ia.
e. =is!al chan$es d!e to locali/in$ effects.
29
1. Nysta$m!s.
2. .iplopia.
&. .ecrease in vis!al ac!ity.
4. =is!al field deficits.
f. @ead tilt- child may tilt the head d!e to
dama$e to e%tra oc!lar m!scles3 may be first
indication of a decrease in vis!al ac!ity.
$. Behavioral chan$es.
1' :bvio!s personality chan$es.
2' .ecreasin$ level of conscio!sness.
&' .ecreasin$ activity+ increased sleep
periods in the infant.
h. .ecrease in m!scle stren$th or loss of
specific areas of movement.
i. Chan$es in vital si$ns indicative of increasin$
#CP.
5. Sei/!res ?focal or $enerali/ed'.
*. Cranial enlar$ement in the infant !nder
ei$hteen months old.
l. Papilledema ?edema of the optic disc'.
m. .i//iness and verti$o.
NURSING 2IAGNOSES: Brain T!mor
#n5!ry) @i$h "is* related to $ait disorders+ verti$o+
vis!al dist!rbances+ or
compression-displacement of brain tiss!e.
An%iety related to implications of condition and
!ncertain f!t!re.
Self-care .eficit related to inability to perform
A.9As secondary to sensory-motor impairment.
Altered 2amily Processes related to the nat!re of
the condition+ role dist!rbances+ and !ncertain
f!t!re.
&. .ia$nostics.
a. Clinical manifestations e%hibited in the
ne!rolo$ical e%am.
b. <.
c. CAT scan.
d. Brain scan.
e. Cerebral an$io$ram.
Treatment
1. (edical.
a. .e%amethasone
b. Anticonv!lsants
c. "adiation and chemotherapy if mali$nant.
2. S!r$ical e%cision-craniotomy.
Complications
(enin$itis+ respiratory aspiration+ brain stem
herniation3 diabetes insipid!s+ inappropriate A.@
secretion.
N!rsin$ #ntervention
See N!rsin$ .ia$nosis for #ncreased
#ntracranial Press!re.
Preoperative mana$ement , see n!rsin$
$oals for increased intracranial press!re.
<oal) to provide appropriate preoperative
n!rsin$ intervention.
1. <eneral preoperative care with e%ceptions as
noted.
2. Shave the head+ save the hair and ret!rn it to
the family+ or dispose of its indicated by
instit!tional policy.
&. #f there is increased #CP+ $enerally do not
administer an enema.
4. Prepare client+ family+ and parents for
appearance of the client postoperatively.
D. nco!ra$e verbali/ation re$ardin$ concerns of
s!r$ery.
<oal) to maintain homeostasis and
monitor chan$es increased intracranial
press!re postoperative craniotomy.
1. Ne!ro chec*s as necessary.
2. (aintain p!lmonary f!nction and hy$iene.
a. Patent airway.
b. Prevent aspiration.
c. #ncrease respiratory e%c!rsion by deep
breathin$.
d. Antiemetics to decrease vomitin$ and
possibility of aspiration.
e. .isco!ra$e vi$oro!s co!$hin$.
&. Caref!l eval!ation of the level of
conscio!sness3 re$ression to more lethar$ic or
irritable state may be indicative of increasin$
#CP.
4. val!ate dressin$.
a. 9ocation and amo!nt of draina$e.
b. val!ate for CS2 lea* thro!$h the incision.
c. .o not chan$e dressin$ initially+ b!t reinforce it.
D. Position in low to semi-2owlerAs if there is a
spinal fl!id lea* from ears or nose.
G. Position postoperatively for infratentorial
s!r$ery.
a. Bed sho!ld be flat.
b. Position client on either side3 *eep off bac*.
c. (aintain head and nec* in midline and sli$htly
e%tended.
C. Position postoperatively for s!pratentorial
s!r$ery-semi to low 2owlerAs.
H. Trendelenb!r$ position is contraindicated in
both types of s!r$ery.
E. (aintain fl!id re$!lation.
a. Be$in clear li1!ids P: after swallow and $a$
refle%es ret!rn and client is awa*e.
b. (aintain #= fl!id !ntil client tolerates fl!ids.
c. Closely monitor inta*e and o!tp!t.
d. Client may be on fl!id restriction.
1B. val!ate ne!ro stat!s in response to fl!id
balance and di!retics.
11. Caref!lly eval!ate chan$es in temperat!re-may
be d!e to respiratory complications or to
alteration in the f!nction of the hypothalam!s.
12. Provide appropriate pain relief.
a. Avoid narcotic anal$esics.
b. Aspirin or T;9N:9 is fre1!ently !sed.
c. (aintain 1!iet+ dim atmosphere.
d. Avoid s!dden movements.
1&. Prevent complications of immobility.
14. (aintain sei/!re preca!tions.
CERE,RAL PALSY *CP+
A non pro$ressive abnormality in the pyramidal
system ?motor corte%+ basal $an$lia+ and cerebell!m'
res!ltin$ in impairment of m!scle control. (ay be
classified accordin$ to the specific area of brain
involvement and to the res!ltin$ clinical
manifestations.
Assessment
1. "is* factors-etiolo$y.
a. Associated with cerebral ano%ia d!rin$
pre$nancy or perinatal period.
b. Prenatal.
1' (aternal anemia+ metabolic
dist!rbances.
2' #ntra!terine infection.
&' Blood incapatabilities.
4' To%emia.
30
c. Perinatal.
1' Premat!rity.
2' Tra!ma d!rin$ delivery.
&' @yperbilir!binemia.
d. Postnatal.
1' Cerebral tra!ma.
2' C=A
&' #nfection.
2. Clinical manifestations.
a' .elayed achievement of
developmental milestones.
b' Ne!romotor dysf!nction in
motor performances.
c' #ncreased or decreased
resistance to passive
movement.
d' Abnormal post!re.
e' Presence of infantile refle%es
?tonic nec* refle%+ e%a$$erated
moro'.
f' Associated disabilities incl!de)
1. (ental retardation3
appro%imately 1-& of the
children affected are of
normal or s!perior
intelli$ence.
2. Sei/!res
&. Attention-deficit problems.
4. =ision and hearin$
sensory impairments
&. .ia$nostics.
a. Ne!rolo$ical
e%amination and
contrib!tin$ history.
b. .ia$nostics tests to
r!le o!t other
ne!rolo$ical
dysf!nction.
c. 2re1!ently diffic!lt to
dia$nose in early
months3 condition
may not be evident
!ntil child attempts to
wal*.
Treatment
?<enerally s!pportive'.
1. (aintain and promote mobility wit
orthopedic devices and physical
therapy.
2. S*eletal m!scle rela%ant.
&. Anticonv!lsant as indicated.
N!rsin$ #ntervention)
?Child is fre1!ently cared for a home and
on an o!tpatient basis !nless complications
occ!r.'
<oal) to assist child to become as
independent and self s!fficient as possible.
a' Physical therapy pro$ram desi$ned
to assist individ!al child to $ain
ma%im!m f!nction.
b' Assist child to pro$ress accordin$
to developmental level and
f!nctional abilities3 enco!ra$e
crawlin$+ sittin$ and balancin$
appropriate to developmental+
level.
c' Assist child to carry o!t activities of
daily livin$ as a$e and capacities
permit ?feedin$+ dressin$ and
personal hy$iene'.
d' Speech therapy is indicated.
e' nco!ra$e play appropriate for
a$e.
f' nco!ra$e appropriate ed!cational
activities.
$' Bowel and bladder trainin$ may be
diffic!lt d!e to poor control.
<oal) to maintain physiolo$ical
homeostasis.
a' (aintain ade1!ate n!trition
1. may e%perience diffic!lty
eatin$ d!e to spasticity3
may drool e%cessively.
2. enco!ra$e independence in
eatin$3 !tili/e self help
devices
&. provide a balanced diet
with increased caloric
inta*e to meet e%tra ener$y
demands.
b' (aintain safety and preca!tions to
prevent in5!ry.
c' #ncreased s!sceptibility to infections+
especially respiratory infectioBns
d!e to poor control of intercostals
m!scle and diaphra$m.
d' #ncreased incidence of dental
problems3 fre1!ent dental chec* !p.
<oal) to promote a positive self- ima$e # the
child and provide s!pport to the
family.
a' >se positive reinforcement
b' Assist parents to set realistic $oals.
c' nco!ra$e recreation and
ed!cational activities+ especially
those involvin$ other cerebral palsy
children.
d' nco!ra$e child to e%press feelin$s
re$ardin$ his-her disorder.
e' .o not 6tal* down8 to child3
comm!nicate at appropriate mental
level..
f' Assists parents in problem solvin$
in home environment.
$' #dentify comm!nity reso!rces
available.
H(droce-%alu'
W#ncrease in vol!me of CS2 within ventric!lar system+
which becomes dilated
Co))o! Cau'e':
1. No!co))u!"cat"!) obstr!ction in CS2 draina$e
from ventric!lar system
2. Co))u!"cat"!) CS2 is not effectively
reabsorbed thro!$h arachnoid villi
&. Nor)al -re''ure %(droce-%alu') occ!rs in
personsKGB in which ventricles enlar$e ca!sin$
cerebral tiss!e compression
Ma!"$e'tat"o!'
depend on rate of onset)
pro$ressive co$nitive dysf!nction
$ait disr!ptions
!rinary incontinence
W=is!al chan$es
W#ncrease in head si/e
W#ncrease #CP
31
Treat)e!t3Ma!ae)e!t
1. .i!retics
2. S!r$ery
&. Protect from in5!ry from altered 9:C and
immobility
SPINA ,IFI2A
Spina Bifida , refers to a malformation of the spine in
which the posterior portion of the laminae of the
vertebrae fails to close. #tAs the most common
developmental defect of the Central Nervo!s System.
(:ST C:((:N T;PS
1. SP#NA B#2#.A :CC>9TA+ in which the
defect is only in the vertebrae. The spinal
cord and menin$es are normal.
2. (N#N<:C9+ in which the menin$es
protr!de thro!$h the openin$ in the spinal
canal+ formin$ a cyst filled with Cerebro
Spinal 2l!id and covered with s*in.
&. (N#N<:(;9:C9 :"
(;9:(N#N<:C9 ,- in which both the
spinal cord and cord membranes protr!de
thro!$h the defect in the laminae of the spinal
canal. (enin$omyeloceles are covered by a
thin membrane.
"achischisis ne!ral t!be defect e%tends the
len$th of the spine which is always fatal.
Spina bifida cystica is also another term
!sed to describe (enin$omyelocele.
T#:9:<;)
1. !n*nown+ b!t $enerally tho!$ht to res!lt from
$enetic predisposition tri$$ered by somethin$
in the environment.
2. #t involves an arrest in the orderly formation
of the vertebral arches and spinal cord that
occ!rred between the 4
th
and G
th
wee* of
embryo$enesis.
T@:"#S CA>SAT#:N)
A'. There is incomplete clos!re of the ne!ral t!be
d!rin$ the 4
th
wee* of embryonic life.
B'. The ne!ral t!be forms ade1!ately b!t then
r!pt!res.
#NC#.NC)
1. <eo$raphical distrib!tion and incidence vary
widely.
2. Condition occ!rs in appro%imately 1 per
1+BBB live births in the >.S.
&. most common developmental defect of -
CNS.
4. more common in Ca!casians than in non
white pop!lation specially those of celtic
ancestry and those livin$ in So!th astern
>.S.
D. condition may have other con$enital
anomalies associated with it.
G. 0omen who have spina bifida and parents
who have one affected child have an
increased ris* of prod!cin$ children with
ne!ral t!be defects.
A9T". P@;S#:9:<; AN. C9#N#CA9
(AN#2STAT#:NS)
A. SP#NA B#2#.A :CC>9TA
1. (ost common type+ may occ!r in as many as
2DQ of otherwise normal children.
2. The bony defect may ran$e from a very thin
slit separatin$ one lamina from the spino!s
process to a complete absence of spine and
laminae.
&. A thin+ fibro!s membrane sometimes covers
the defect.
4. The spinal cord and its menin$es may be
connected with a fist!lo!s tract e%tendin$ to
and openin$ onto the s!rface of the s*in.
D. (ost patients have no symptoms)
a. They may have a dimple on the s*in or a
$rowth of hair over the malformed vertebra.
b. There is no e%ternally visible sac.
c. 0ith $rowth+ the child may develop foot
wea*ness or bowel and bladder sphincter
dist!rbances.
,. MENINGOCELE
1. An e%ternal cystic defect can be seen in the
spinal cord+ !s!ally in the center line.
a. The sac is composed only of menin$es and is
filled with CS2.
b. The cord and nerve roots are !s!ally normal.
2. The defect may occ!r anywhere in the cord.
@i$her defect ?from the thora% and !p' are
!s!ally menin$oceles.
&. There is seldom evidence of wea*ness of the
le$s or lac* of sphincter control.
4. S!r$ical correction is necessary to prevent
r!pt!re of the sac and s!bse1!ent infection.
D. @ydrocephal!s may be an associated
findin$s and may be a$$ravated after s!r$ery
for a menin$ocele.
a. :cc!rs in abo!t EQ of patients
b. >s!ally not associated with the Arnold-Chiari
malformation
G. Pro$nosis is $ood with s!r$ical correction.
C. MENINGOMYELOCELE
* MYELOMENINGOCELE+
1. most common type of open spinal defect ,
occ!rs 4-D times more fre1!ently than
menin$ocele.
2. A ro!nd+ raised+ and poorly epitheliali/ed
area may be noted at any level of the spinal
col!mn. @owever+ the hi$hest incidence of
the lesion occ!rs in the l!mbosacral area.
&. The lesion contains both the spinal cord and
cord membranes. A bl!ish area may be
evident on the top beca!se of e%posed ne!ral
tiss!e.
4. The sac may lea* in !tero and may r!pt!re
after birth allowin$ free draina$e of CS2. This
renders the child hi$hly s!sceptible to
menin$itis.
D. Pro$nosis.
a. #nfl!enced by the site of the lesion and the
presence and de$ree of associated
hydrocephal!s. <enerally+ the hi$her the
defect+ the $reater the e%tent of ne!rolo$ic
deficit and the $reater the li*elihood of
hydrocephal!s.
b. #n the absence of treatment+ most infants with
menin$omyelocele die early in infancy.
c. S!r$ical intervention is most effective if itAs
done early in the neonatal period+ preferably
within the 1
st
few days of life.
d. ven with s!r$ical intervention+ infants can
be e%pected to manifest associated
ne!ros!r$ical+ orthopedic and or !rolo$ic
problems.
e. New techni1!es of treatment+ intensive
research and improved services have
increased life e%pectancy and have $reatly
32
enhanced the 1!ality of life for most children
who received treatment for the defect.
CLINICAL PRO,LEMS COMMONLY
ASSOCIATE2 CITH MENINGOMYELOCELE
A. Neurolo"c Proble)'.
1. Arnold-Chiari malformation
a'. associated malformation involvin$ the
brain stem and cerebell!m
b'. ca!ses bloc*-flow-CS2 thr! the ventricles
and leads to fail!re n the reabsorption
mechanism of CS2
c'. Prod!ces si$nificant hydrocephal!s in
appro%imately 2-& of children wit
menin$omyelocele
2. 9oss of motor control and sensation below the
level of the lesion.
,. Mob"l"t( a!d Ort%o-ed"c Proble)'
1. Contract!res
2. Cl!bfeet
&. Scoliosis
4. Amb!lation and ability to be !pri$ht.
C. Urolo"c Proble)' - sacral nerves innervate the
bladder.
2. ,o=el Proble)' , poor innervation of the anal
sphincter and bowel m!sc!lat!re.
E.SB"! Proble)' , areas of decreased sensation
have a tendency to brea* down.
F. 2"etar( Proble)' , children become overwei$ht
beca!se of activity limitations.
.ietary control to prevent obesity.
G. 2e&elo-)e!tal Proble)' , avera$e intellect!al
ability despite hydrocephal!s.
2IAGNOSTICS , prenatal screenin$ for ne!ral t!be
defects. A blood test may reveal hi$h levels of
maternal A2P , ser!m alphafetoprotein indicatin$ a
brea* in the ne!ral t!be that is allowin$ too m!ch of
this protein to seep into amniotic fl!id and
s!bse1!ently into the motherAs blood. The res!lts
m!st be confirmed by !ltraso!nd and amniocentesis+
altho!$h these tests canAt determine the severity of
the defect.
TREATMENT AN2 NURSING INTER0ENTIONS)
- .epends on the e%tent of the ne!rolo$ic deficit+
level of the lesion+ and any complication she may
have , most commonly hydrocephal!s and >T#.
5 I! car"! $or a !e=bor! o$ '-"!a b"$"da, t%e
!ur'eF' )a8or co!cer! "' -re&e!t"! "!$ect"o!.
a. Scree!"! - indentation or t!ft of hair may be the
only visible si$n of mild forms of spina bifida.
#n more severe cases - the defect is obvio!s) a
portion of the spinal cord protr!des from the infantAs
bac*. Tiss!es and nerves are either completely
e%posed or covered by a thin membrane of s*in.
Co&er t%e -rotrud"! 'ac , whether open or closed
, ri$ht away with a non adherent+ sterile $a!/e
dressin$ soa*ed with sterile saline. 7eepin$ it moist
will help prevent infection before referrin$ her to a
ne!ros!r$eon. S!r$ery to repair the sac with intact
tiss!e and s*in $rafts within the ne%t 4H to C2 hrs.
?others within 24 hrs.'
,e$ore 'urer() N!rses do complete physical
e%amination - Since m!sc!los*eletal problems s!ch
as dislocated hips and cl!bfeet fre1!ently accompany
myelomenin$ocele , pay partic!lar attention to the
lower e%tremities.
To Bee- t%e '-"!e al"!ed a!d to a&o"d -re''ure
o! t%e bab(F' bacB+ place her on her abdomen on
an elevated wooden bo% covered with sheeps*in. The
baby stays in this position d!rin$ feedin$s. .o ran$e
of motion e%ercises $ently every ho!r to prevent
press!re sores.
Ur"!e a!d $ece' - that remain for any len$th of time
in the babyAs diaper increase the ris* of infection. So
instead of diaperin$ simply place one !nderneath her.
A foley cathether is inserted before s!r$ery.
To $urt%er -rotect aa"!'t "!$ect"o! , start a
contin!o!s #= inf!sion of <entamycin ?<aramycin' or
Ampicillin ? Polycillin , N' as per .octorAs order.
C%a!e t%e au#e dre''"! at least once a shift and
ri$ht before s!r$ery.
POST OPERATI0E CARE)
Ta*e vital si$ns and monitor the infantAs
ability to feed. #n addition to a flat diaper !nder the
infant+ p!t a piece of sterile plastic above the an!s to
deflect feces away from the s!r$ical site.
0atch for fever+ si$ns of infection
0atch for lea*a$e of CS2 at the clos!re site+
and evidence of hydrocephal!s.
.o a complete orthopedic and !rinary
assessment.
bonne chance.
Lmulbata@2011

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