Disturbances in Perception and Coordination Nervous system Divided into 2 groups 1.

. Central nervous system Brain Spinal cord 2. Peripheral nervous system Spinal nerves All other nerves in your system Neurons: cells which receive and send impulses. Neurons are myelinated and unmyelinated. Myelin sheath and Schwann cells faster transmission of impulses 1. Dendrite afferent; can regenerate 2. Cell body - cant regenerate 3. Axon efferent; can regenerate If axons or dendrites are destroyed, it can regenerate. But the cell body cannot Myelin sheath/ Schwann cells for faster transmission, coated fibers Cell types 1. Neurons Grey matter cell bodies and dendrites White matter myelinated fibers 2. Neuroglia protect and nourish neurons Tumor formations starts here and not in nerve cells Action potentials Impulses occur when stimulus reaches a point great enough to generate change in the electrical charge across cell membrane of neuron Chief regulators of membrane potential: sodium (+ ion in extracellular fluid) and potassium (+ion in intracellular fluid) Myelinated fibers - faster Unmyelinated fibers Neurotransmitters 1. Gamma aminobutyric acid (GABA) inhibits CNS function; increased if depressed 2. Dopamine inhibitory or excitatory and controls fine movement and emotions; psychotics have too much dopamine, parkinsonian disease has less dopamine; lack dopamine means rigid, slow and uncoordinated movement regulates acetylcholine 3. Serotonin usually inhibitory; controls sleep, hunger, behaviour, affects consciousness o Enzyme: mono amine oxydase; acetyl cholinesterase (enzymes responsible of reuptake of neurotransmitters) Cholinergics 4. Acetylcholine excitatory; found in the brain and mostly in neuromuscular junctions; degraded by enzyme acetylcholinesterase; affected in myesthinia gravis 5. Epinephrine excitatory of inhibitory Receptors found in viscera, skeletal muscles and medulla Adrenergic 6. Norepinephrine to: Alpha-adrenergic Beta adrenergic CNS STRUCTURES Cerebrospinal fluid (CSF) o Clear, colorless liquid o Cushions brain o Nourishes brain o Removes waste of metabolism o Made at the choroid plexus in lateral ventricles o 150 mL of CSF is produced and constantly replaced / eliminated in the arachnoid space through the arachnoid villi. o Problems in CSF may happen which is commonly seen in congenital types of Hydrocephalus. Aside from this, acute hydrocephalus can happen to a person who had a head trauma, surgery and growth of tumor. This trauma is same as the communicating type of hydrocephalus in which the problem is in the absorption while the tumor is same as the non-communicating type in which there is obstruction in the flow of the CSF o Clear, colorless liquid formed by choroid plexus o FLOW: Lateral, third ventricle, midbrain, fourth ventricle, spinal cord, subarachnoid space, arachnoid villi, veins o Perform lumbar tap to measure and collect CSF sample. Normal pressure: 30 drops/ minute. Spinomanometer can also be used instead of counting the number of drops.

Responsibility during the examination let the patient signal you when he wants to move so that accidental puncture of the spinal cord will not occur o C-position in getting a sample. But in measuring the ICP, straighten body especially the legs since Cposition can increase the ICP. o L3 and L4 in adults. At a lower level in children because they have a longer spinal cord. o In taking a CSF sample, it is important to replace fluid by allowing the person to drink through a straw since the person cannot and should not elevate his head after the procedure. o After the procedure, assess and ask the client to elevate his legs to assess any paralysis at the lower extremities Normal values: o ICP = 60-150 mm H20 or 0-15mmHg o Total protein = 15-45 mg/dL increase means infection or tumor o Glucose = 50-75 mg/dL (20 mg/dL less than serum) decrease in infection o Protein = 15- 45 mg/dL o Albumin = 29.5mgdL o IgG - < 14% of total proteins increased in infection o Oligoclonal cells absent Meninges 1. Dura mater nearest skull, hardest part; most affected in fractures 2. Arachnoid middle layer, most blood vessels are located, subarachnoid villi found which is connected to the veins where resorption and absorption occurs 3. Pia nearest brain; usual layer affected in meningitis Cerebral circulation o Circle of willis the center; usual area where aneurysm of the brain will grow o Cerebral circulation during increased or decreased ICP, will always compensate transitorily depending on what the brain needs. o Remove the cause of the disruption because the cerebral circulation cannot withstand it for a long time Venous circulation o Venous circulation drains excess fluids from the brain. Generally, in increased ICP, elevated head 30-45 degrees. But in cases (infratentorial surgery) where head elevation is not possible, put the patients bed flat ensuring that the neck would be straight. This means that the jugular vein is straight, ensuring venous drainage. o Brain receives 750 mL of blood per minute o 20% of bodys total oxygen uptake o 25% of bodys glucose brains sole source of energy o Liver will do glycogenolysis (saving organ for glucose supply in the brain) in case glucose is not sufficient for the brain. o Patient with hypoglycaemia may lead to coma. o During stroke, emboli and hemorrhage, if hypoglycaemia occurs, the patient can die o During a hypoglycaemic attack, if there is no plasma in your brain, your brain will be comatosed Mean Arterial Pressure o Mean arterial pressure at which autoregualtion is effective (70-105 mmHg) o Upper limit is 150 mmHg o MAP = [SBP + 2(DBP)] / 3 Cerebral Perfusion Pressure o Cerebral perfusion pressure needed to ensure blood flow to the brain o CPP = MAP ICP o As CPP decreases, autoregualtion fails and CBF diminishes - 30 mmHg is incompatible with life Blood brain barrier o Capillaries of brain have low permeability o ALLOWS lipids, glucose, some amino acids, water, carbon dioxide, oxygen to pass through o Usually BLOCKS urea, creatinine, some toxins, proteins, most antibiotics. o When urea, ammonia and proteins increased (things that are usually blocked) can force itself through the blood-brain-barrier into the brain. o Overdose of drugs can also result to brain malfunction. o Higher doses, longer duration, more potent antibiotics, and sometimes through intrathecal administration (putting it directly into the ventricles) are needed in order to allow this antibiotics inside the brain and treat brain infection Brain o Brain is comprised of: Cerebrum 2 hemispheres Right - motor function; proprioception; nonverbal perceptual Left language function; aphasic problems; damage in the left side, manifestation at the left If one hemisphere is affected, you may not necessarily lose consciousness If both hemispheres, you will lose consciousness Corpus collusum connects the 2 hemispheres Diencephalon comprised of

thalamus - relaying center, sorting, processing, and relaying station for inputs into cortical region hypothalamus - control temperature, water metabolism, appetite, emotional expression, part of sleep-wake cycle, thirst. If thalamus is cut, the hypothalamus cannot detect temperature or regulate it below to where the cord is cut called as poikylothermia epithalamus includes the pineal body part of endocrine system affecting growth and development; near pituitary gland Brain stem controls most of the vital function; Midbrain center for auditory and visual reflexes, where most of cranial nerves are attached, nerve pathway between cerebral hemispheres and lower brain; assessed by looking at the functioning of cranial nerves; reflexes assessment also applied; if midbrain is cut, the person becomes comatosed. pons contains nuclei that control respiration; *areas in the brain controlling involuntary respiration: pons and medulla* voluntary respiration: cerebral cortex*; if oxygen decreases, the pons will make you breathe NO MATTER WHAT medulla oblongata plays role in controlling heart rate, blood pressure, respiration, swallowing; hypogloassal, vagal nerve is located *injuries above C4 will have very poor prognosis. Cerebellum controls and regulates movement for coordination of skeletal muscle activity, maintenance of balance, control of fine movements; if damaged can lead to ataxic gait Limbic system tissue in medial side Basal ganglia fails to regulate in parkinsons disease Substantia negra affected in parkinsons disease; problems in regulation in movement caused by damage in here (basta kay nay mubaba diri) Cortex Frontal Parietal - somatosensory Temporal Occipital important for lesion Wernickes area at the back of temporal; if damaged, you can talk but you cannot understand Brocas area if affected, problem in motor, speech mechanism Reticular formation RAS (reticular activating system) stimulating system for cerebral cortex, keeping it alert and responsive to stimuli o Sleep center o Area that maintains motor tone and coordinated movements o Vasomotor and cardiovascular regulatory centers o Poor prognosis: below 8 o Basilar part of the skull base of the skull, basically softer than the top of the skull Spinal column and nerve divisions o T11-T12, L1-L2 Most movable area of the spinal column o C4 C5 neck area; where most of the spinal cord injuries usually happens o Spinal nerves arising out of the spinal cord innervate certain parts of the brain. Intercostal muscle is affected by thoracic area of the cord. o Injury above Cervical area may also affect breathing if damage is transverse at the same time affecting the bowel and extremities. o Lumbar 1 affected anterior part and back part affected o Lumbar 2 affected back part and front part of the leg 8 cervical 12 thoracic 5 lumbar 5 sacral Coccyx nd o Extends form medulla to level of 2 lumber vertebra o Conducting message to and from brain, reflex center o Spinal nerves Anterior motor damage causes flaccid paralysis Posterior sensory damage causes loss of sensation o Messages to and from brain travel via pathways: Ascending tract (sensory) spinothalamic; from bottom to top; from spine to thalamus Carry sensations for pain, temperature, crude touch Descending tract (pyramidal and extrapyramidal tracts) mediate purposeful movement, stimulate and inhibit certain msucel actions and muscle tone Extrapyramidal tracts maintain muscle tone and gross body movement Cranial nerves from brain stem o Olfactory sensory anosmia (inability to smell) o Optic sensory blindness in one eye;

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Acoustic Glossopharyngeal Vagus Spinal accessory

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homonymous hemianopia (impaired vision/blindness in one side of the eyes) Impaired vision eyes movement Nystagmus Constricted pupils ptosis Nystagmus Constricted pupils ptosis decreased sensation to face and cornea Nystagmus Constricted pupils ptosis swallowing Movement of face, taste, and tongue Loss ability to taste Decreased movement of facial muscles Inability to close eyes, nasolabial fold flat, paralysis of lower face, inability to wrinkle forrhead Eyelid weakness, paralysis of lower face Pain, paralysis, sagging of facial muscles decreased hearing or deafness (side effect of drug, too much noise exposure, or problem) dysphagia Unilateral loss of gag reflex dysphagia Unilateral loss of gag reflex head erect Weakness of neck muscles Contralateral hemiparesis tongue movement Atrophy Fascicualtions Tongue deviation toward involved body side

Special neurologic assessment iwht abnormal findings Positive brudzinskis sign o Pain, resistance, flexion of hips and knees when head flexed to chest with client supine o Indicates meningeal irritation Positive Kernigs sign o excessive pain and resistance when examiners attempts to straighten knees Decorticate o upper arms close to sides, elbows, wrists and fingers flexes, legs extended with internal rotation, feet flexed: body parts pulled into the core of body o Lesions of corticospinal tracts Decerebrate o neck extended with jay clenched, arms pronated, extended, close to sides, legs are pronated, extended, close to sides, legs are extended straight out and feet plantar flexed; o lesions of midbrain

RESEARCH GLASGOW COMA

Highest 15; lowest 3 Types of paralysis o Quadriplegia tetraplegia o Hemiplegia half of body (longitudinal) o Paraplegia half of body transversely Paresis weakness Neurologic system: Diagnostic tests o Noninvasive tests of function Electroencephalogram electrodes are directly applied to the scalp of patient; electrodes can be attached to areas with hair Preparation Stop sedative and tranquilizers, muscle relaxants before the test Do not drink or eat foods that have caffeine (such as coffee, tea, cola, and chocolates) for 8 hours before the test It is important that your hair be clean and free of sprays, oils, creams, and lotions Shampoo only your hair and rinse with water sleep less (about 4 or 5 hours) night before Lessen taking naps just before the test

MRI a narrow table moves the patient through a tube Preparation Guidelines about eating and drinking before an MRI exam vary with the specific exam and also with the facility Some MRI examination may require the pateitn to swallow contrast material (gadolinium) or receive an injection of contrast into the bloodstream requirement functioning kidneys Pregnancy is contraindicated because the baby will be in strong magnetic field unless necessary Claustrophobia, chidren, and infants mild sedative given Jewelry, watches, credit cards, and hearing aids can be damaged in MRI Pins, hairpins, metal zippers and similar metallic items, which can distort MRI images Removable dental work, pens, pocket knives, eyeglasses, body piercing In most cases, an MRI exam is safe for patient with metal implants except for: o Internal (implanted) defibrillator or pacemaker o Cochlear (ear) implant o Clips used in brain aneurysms o Artificial heart valves o Metal objects used in orthopaedic surgery like titanium may pose no risk. However, a recently placed artificial joint may require another imaging procedure o Sharpnels, bullets, or dyes used in tattoos may contain iron and could heat up during MRI but this is rarely a problem o Tooth filling o Earplugs to reduce the noise of the MRI. Use music (45 minutes) o If not sedated, may resume you usual activities and normal diet immediately after the exam o Gadolinium is safe but if mothers may abstain from breastfeeding for 24 hours with active expression and discarding breast milk from both breasts during that periods. Evoked potential studies Neuropsychological testing Transcranial dopler determines the status of circulation in the brain Measures the velocity of blood flow through the brains blood vessels Used to help in the diagnosis of emboli, stenosis, vasospasm form subarachnoid hemorrhage Often ysed in conjunction with other tests such as MRI, MRA, carotid duplex UTZ and CT scans Insonation windows PET measures important bodyfunctions, blood flow, oxygen use, sugar metab, to help doctors evaluate how well organs and tissues are functioning Uses amount of radioactive material radiotracers Nuclear medicine imaging Preparation: o If breastfeeding, collect milk first by pump o Information about any medications including vitamin and herbal supplements, allergies to sea food and about recent illness o Diabetic patients will receive special instructions to prepare for this exam o If breastfeeding, collect first milk by pump o Metal objects including jewelry, eyeglasses, dentures hearing aids and hairpins may affect the CT images o NPO prior eating may alter the distribution of the PET tracer suboptimal scan. Electromyography Myelography looking at your spinal column. Contrast medium needed and is injected around spinal cord and will then be asked to undergo X-ray examination. Preparation: o Assess any allergies, especially barium o Stop intake of meds one or 2 days before exam. These include certain antipsychotic meds, antidepressants, blood thinners, metformin, antiseizures. o Usually patients are advised to increase their fluid intake the day before the scheduled myelogram. Solid foods should be avoided for several hours before the exam o Remove jewelry, dentures, eye glasses and any metal objects or clothing that might interfere with the Chest x-ray images o At the conclusion of the myelogram, the patient usually remains in an observation area with head elevated at 30-40 degrees angle for 4 hours o Vital signs and general patient conditions are observed for 1-2 hours o o Contraindicated for pregnant

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Encourage to take fluids to help eliminate the contrast material from you body and prevent headache o Following the procedure, refrain from strenuous activity and bending over for 1-2 days after the exam. You should notify your health professional: o Fever o Severe headache for more than 24 hours (spinal headache duration: only about 6-12 hours) o Neck stiffness or numbness in legs o Problems urinating or moving legs (indicative of injured spinal cord) Lumbar puncture L3- L4 Cerebral angiography insertion of dye through a catheter Place dye directly into the common carotid artery (no leg elevation needed) or femoral (needs leg elevation so that the catheter can go into the femoral artery) Digital subtraction angiography For problems in blood vessels Cerebral angiography head is positioned and held still using a strap, tape or sandbags to prevent movement ECG leads attached to monitor heart activity during the test Mild sedative for relaxation Groin is cleaned, anesthetized. A catheter is placed through femoral artery and carefully moved up into IVC through moving x-ray images A special dye (contrast material) is injected into catheter After x-rays are taken the needle and catheter are withdrawn Pressure is immediately applied on the leg at the site of insertion for 10-15 minutes to stop bleeding A tight bandage is applied to the leg and kept straight for 12 hours after the procedure How to Prepare Consent form indicating the procedure and risks Routine blood tests and examination of the nervous system, bleeding tendencies Assess allergies to shellfish or iodine substances Contraindicated to pregnant mother NPO 4-8 hours before the test alter dye distribution You must remove all jewelry (for Xray) can alter images

Neulogic disorders Processes that affect LOC Increased ICP Stroke, hematoma, Intracranial hemorrhage Tumors Infections Demyelinating disorders Systemic conditions affecting the brain Hypoglycemia F/e imbalances (usually sodium and potassium) Accumulated waste products from liver or renal failure (ammonia, urea) Drugs affecting CNS: alcohol, analgesics, anesthetics Seizure activity: exhausts energy metabolites; unconscious due to consumption of glucose and oxygen after seizure Assessment with decreasing LOC Increased stimulation required to elicit response from client More difficult to rouse client agitated and confused when awakened Orientation changes loses orientation to time first, then place; then finally person Continuous stimulation required to maintain wakefulness Client has no response, even to painful stimuli *deep coma client does not respond even to painful stimuli Types of respirations and brain involvement Diencephalon Cheyne -Stokes respirations Midbrain neurogenic hyperventilation may exceed 40/minute Pons apneustic respirations (sighing on mid inspiration or prolonged inhalation and exhalation) Medulla ataxic or apneic respirations (totally uncoordinated and irregular) most dangerous Respiratory patterns of pupil associated with lesions Dead dilated, fixed pupil together with lack of breathing Pupillary and oculomotor responses

Localized lesion effects ipsilateral pupil (same side as lesion) Generalized or systemic processes pupils affected equally o Compression of cranial nerve III o Pupils become oval and eccentric o Progress to become fixed (no response to light) o Progress to dilation

Loss of simultaneous eye movement and reflex brain stem not functioning Dolls eye movements normal: eyes move in opposite side or stay inline Oculocephalic reflex normal: eye will move down if head is moved up Oculovestibular response normal: cold on the ear, elicits papillary movement Motor function assessment Movements are more generalized and less purposeful (withdrawal, grimacing) Reflexive motor responses Flaccid with little or no motor response may be due to very weak muscles; decreasing level of consciousness 2 types of coma Irreversible type o Permanent condition of complete unawareness of self and environment; death of cerebral hemispheres with continued function of brain stem and cerebellum o Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow (nonpurposeful), and cough; movements are reflexive o Permanent condition of complete unawareness of self and environment; death of cerebral hemispheres with continued function of brain stem and cerebellum o Cortical death o A lot of these movements are reflexive in nature. Locked-in type o Client is alert and fully aware of the environment, intact cognitive abilities but unable to communicate through speech or movement o Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking o Occurs with hemorrhage or infarction of pons, disorders of lower motor neurons or muscles Brain death Cessation and irreversibility of all brain functions General criteria o Absent motor and reflex movements o Apnea o Fixed and dilated pupils o No ocular responses to head turning and caloric stimulation o Flat EEG Increased Intracranial Pressure Normal: 5-15 mmHg with pressure transducer with head elevated 30 degrees Transient increases occur with normal activities, coughing, sneezing, straining, bending forward Sustained increases associated with disease conditions Increased (highest) in the morning upon waking up. Every time theres a change in ICP, theres compensation in the brain Stages of Increasing ICP Stage 1 increased perfusion Stage 2 MAP compensates Stage 3 Decompensation, increased ICP Stage 4 CPP<30 mmHg, necrosis, respiratory arrest from compression of brain stem Manifestations of Increased ICP Changes in LOC Initially hemiparesis, progresses to decorticate and decerebrate positioning Altered vision Headache on rising Papilledema (edema of optic disc) noted on fundoscopic exam Projectile vomiting CNS ischemic response, increased MAP, increased pulse pressure, bradycardia Changes in respiratory pattern and dramatic rise in temperature Medications for ICP Osmotic diuretics decrease CSF in the brain Loop diuretics such as furosemide decrease CSF in the brain

Antipyretics or hypothermia blanket fever may be caused by infection in the brain Anticonvulsants to manage seizure activity problems in head may lead to neuronal firings Histamine H2 receptors to decrease risk of stress ulcers for cushings ulcer in head injuries; decreased blood supply in the GI to increase circulation to the brain and hypervagal nerve stimulation (increased acid production) cause stress ulcer Barbiturates Vasoactive (vasopressor) medications to support cerebral perfusion

Monroe Kelley Hypothesis, Increased pressure inside the vault, you need to displace pressure to reduce this. But this cannot be done in adults since they have fixed skulls. Thus, surgery is needed to relieve the pressure (Burr holing, craniectomy) Prevent infection best method: hand washing Surgery include removal of brain tumors, burr holes, insertion of drainage catheter (Jackson Pratt) or shunt to drain excessive CSF; ventriculoperitoneal shunt; ventriculoatrial shunt (right atrium) Craniectomy ICP monitoring Nursing diagnosis Ineffective tissue perfusion: cerebral Risk for infection: open head wounds and intracranial monitoring device require meticulous aseptic technique Anxiety (family): need for teaching Client with a Headache May be due to benign or pathological condition o Pathophysiology: multiple pain-sensitive structures within cranial vault, face and scalp are stimulated and cause pain perception. o Benign: quality, initially painful and gradually decreases o Pathologic: quality, sudden onset of acute pain; increasing in quality and not stopping Types of Benign Headache 1. Tension sensation of tightness, around head; caused by sustained contraction of muscles of head and neck; precipitated by stress and anxiety; treated with aspirin and acetaminophen 2. Migraine recurring vascular headache often initiated by triggering event and accompanied by neurologic dysfunction; or increase release of sensory substances (e.g. serotonin); triggers include stress, fluctuating glucose levels, fatigue, hormones, bright lights; common in women due to hormonal changes; has an aura of its occurrence. Require prophylactic therapy including serotonin antagonist or beta blocker 3. Cluster typically awakens client with unilateral pain around eye accompanied by rhinorrhea, lacrimation, flushing. Attacks occur in clusters of 1-8 days for weeks; cannot be anticipated Common in males Treated with same medications as migraines Medication according to type 1. Migraine may require prophylacitic 2. Cluster headaches are often treated with same meds as migraines 3. Tension headaches are treated with aspirin and acetaminophen Nursing diagnosis Pain Client with Seizure disorder Seizures paroxysmal motor, sensory or cognitive manifestations of spontaneous abnormal discharges from neurons in cerebral cortex; neurons are hypersensitive Epilepsy any disorder characterized by recurrent seizures Categories of seizure Partial seizures o Activation of part of one cerebral hemispheres Generalized: seizure involve both brain hemispheres; consciousness always impaired o E.g. absence seizures (petit mal): characterized by sudden brief cessation of all motor activity, blank stare and unresponsiveness often with eye fluttering o Grand-mal/tonic clonic seizures Tonic clonic seizure: preceded by aura, sudden loss of consciousness Tonic phase: rigid muscles, incontinence Clonic phase: altered contraction, relaxation; eyes rolls back, froths at mouth

Post ictal phase: unconscious and unresponsive to stimuli Petit Mal/ Absence seizures Characterized by sudden brief cessation of all motor activity, blank stare and unresponsiveness often with eye fluttering Status epilepticus Continuous seizure activity, generally tonic clonic type Client at risk to develop hypoxia, acidosis, hypoglycaemia, hyperthermia, exhaustion Life threatening medical emergency requiring immediate treatment Establish and maintain airway Diazepam and lorazepam IV at 10 min interval 50% dextrose IV Phenytoin IV Possibly phenobarbital Medication Manage but do not cure seizure Raise seizure threshold o Carbamazepine (tegetrol) o Phenyyoitn (dilantin) o Valproic acid o Tiagabine Care of client during seizure protect client from injury raise side rails Maintain airway Do not force anything into clients mouth Loosen clothing around neck After the seizure: side lying position O2 inhalation and administration of glucose solutions Nursing Dx Risk for ineffective airway clearance Anxiety

TRAUMATIC BRAIN INJURY Includes having fractures, contusions, injuries, hemorrhage inside your brain Main manifestation: altered LOC and increasing ICP Any type of brain injury is an emergency condition: Risk factors o Motor vehicular accident o Mechanisms of trauma o Acceleration injury hit by moving object o Deceleration injury head stopped by steady object o A-D injury opposite sites of the injury in the head (coup counter coup) A responsibility in brain injury is to ensure that there is no spinal injury Skull fracture o The more open it is, the more dangerous o Break in the continuity of skull usually resulting in brain trauma o Linear dura remains intact; subdural or epidural hematoma may occur underneath o Comminuted and depressed skull fractures fracture and damage going down to brain tissue; increase risk for direct injury to the brain tissue o Basilar involves base of the skull and usually involve extension of adjacent fractures o Assessment: Rhinorrhea through nose Otorrhea ear May appear on x-ray Hemotympanum blood behind tympanic membrane (normal: pearly gray); bulging in this membrane losing its shiny cluster becoming dark or reddish in color Battles sign blood over mastoid process Raccoon eyes bilateral periorbital ecchymosis (bruising) Unequal pupils o Diagnosis Glucose reagent strip if positive indicates CSF halo test - for rhinorrhea and otorrhea o interventions keep nasopharynx and external ear clean no blowing of nose, coughing hard and sneezing cause it may cause escape of CSF and increase ICP prophylactic antibiotic even if patient is not manifesting infection; CSF leaking is enough.

Specific types of brain injuries o Concussion caused by a sudden blow to the head or rapid acceleration or deceleration Retrograde amnesia and loss of consciousness for 5 minutes No break in the skull or dura May have headache, nausea and vomiting o Contusion bruise of cortex of brain Manifestations and degree of impairment depend on size and location of injury; slow recovery of consciousness May have laceration of vessels and brain tissues o Epidural hematoma Blood collects in potential space between the dura and the skull Occur with skull fracture from torn artery, tend to occur rapidly (rapid bleeding also) May have brief lucid period after injury and then rapid decline form drowsiness to coma o Subdural hematoma Localized mass of blood collects between dura mater and arachnoid mater More common than epidural Acute subdural hematomas develop within 48 hours of injury Chronic subdural develops over weeks to months s/s: severe headache, seizures, vomiting, hemiparesis, fixed, dilated and ipsilateral pupil on the area where the injury is located. If arterial, faster manifestation; if venous, slower In the arachnoid, there is subarachnoid villi to reabsorb CSF; but during injury here, clot formation occur here, disallowing CSF to be reabsorb causing increased ICP leading to acute type of hydrocephalus which is noncommunicating type (absorption problem) o Diffuse axonal injury Most sever of all brain injuries; shearing injury o Intracerebral hematoma Clot formation in the brain itself Blood is drained from the brain to apply the Monroe Kelly hypothesis of compensation in the brain. Types of intracranial herniation o Supratentorial o Intratentorial Tonsilar herniation is the most dangerous because if the brain stem will go down to the foramen magnum can cause great damage to the body and cause constriction of the brain stem Meningitis o Inflammation of the pia mater, arachnoid and subarachnoid space o Spreads rapidly through CNS because of circulation of CSF around brain and spinal cord o May be bacterial, viral, fungal, parasitic in origin o Infection enters CNS through invasive procedure or through bloodstream, secondary to another infection in the body o CSF cloudy, increased protein, decrease glucose o Usual precursor infection is upper respiratory tract infection o Bacterial meningitis Cause; N. meningitides, meningococcus, streptococcus pneumonia, H. influenzae, E. coli Manifestations: Fever, chills Headache, back and abdominal pain common in children because of sustrained constriction of the back and abdomen especially that they are usually in an opisthotonus position (arched back all the time) Nausea and vomiting Meningeal irritation nuchal rigidity, photophobia, positive Kernig and Brudzinski Waterhouse Friferichsen syndrome o Petechiae o Disseminated vascular coagulation o Adrenal hemorrhage indicates damage in the adrenal gland o Meningococcal meningitis rapidly spreading petechial rash of skin and mucous membrane o Increased ICP decreased LOC, papilledema Viral meningitis less severe, self limiting Encephalitis o Brain parenchyma affected or spinal cord o Usually caused by a virus o Occurring with manifestations similar to meningitis o LOC deteriorates and clients may become comatose Brain abscess o Infection inside the brain with pus formation usually in the cerebrum o Usually because of open trauma and neurosurgery, infection of the ears and sinuses o Medications:

Antibiotics for 7-21; usually prolonged because it needs to cross BBB; according to culture results Dexamethasone inflammation Anti-viral meds May include intraventricular administration Anticonvulsants Antipyretics o Health promotion Vaccination for meningococcal, pneumococcal, haemophilic meningitis Prophylactic Rifampin for person exposed to meningococcal meningitis Mosquito control Prompt diagnosis and treatment Client with Stroke (CVA) o Stroke condition in which neurologic deficits result from decreased blood flow to localized area of brain. Categorized as: Ischemic: thrombus or embolus reduced blood flow Hemorrhagic o Neurologic deficits determined by the area of brain involved, size of affected area, length of time blood flow is decreased or stopped. o Risk factors DM (faster clot formation due to sluggish flow) HPN increasing flow cause rupture of blood vessels in areas where there is increase in pressure: arteriovenous malformation of your brain (a weak area), circle of Willis Sickle cell disease clumping of RBC causing obstruction Substance abuse including alcohol, nicotine, heroin, amphetamines, cocaine Atherosclerosis Obesity, sedentary life-style, hyperlipidemia, atrial fibrillation, cardiac disease, cigarette smoking, previous transient ischemic attacks Women oral contraceptive use, pregnancy, menopause pills increases hypercoagulability of the blood o Pathophysiology Characterized by gradual, rapid onset of neurologic deficits due to compromised cerebral blood flow Blood flow and oxygenation of cerebral neurons decreased or interrupted; changes occur in 4-5 minutes; >10 minutes, irreversible Cells swell and cerebral blood vessels swell decreasing blood flow; vasospasm and increased blood viscosity (due to sluggish blood movement) further impede blood flow causing destruction of blood cells called penumbra Penumbra central core of dead or dying cells surrounded by band of minimally perfused cells; these cells may survive Transient Ischemic attack (TIA) o Brief period of localized cerebral ischemia causing neurologic deficits lasting < 24 hours usually 1-2 hours o Common occurring deficits Contralateral numbness or weakness of hand, forearm, corner of mouth (middle cerebral artery) Aphasia (due to ischemia of left hemisphere) Visual disturbances such as blurring o Ischemic stroke with obstruction Thrombotic CVA common in older persons Occlusion of a large cerebral vessel by thrombus; resting or sleeping when BP is lower Lacunar strokes thrombotic strokes affecting smaller cerebral vessels; leaving small cavity or lake Stroke in evolution occurs rapidly, progresses slowly, begins as TIA and worsens over 1-2 days Completed stroke when max neurologic deficit has been reached (3 days); Embolic CVA Common in young, awake and active person and during atrial fibrillation Blood clot or clump of matter travelling through cerebral blood vessels lodges in vessel From thrombus in left chambers in the heart Carotid artery, atherosclerotic plaque, bacterial endocarditis, recent MI, RHD, ventricular aneurysm o Hemorrhagic stroke Rupture of the blood vessels Most often in person with sustained increase in MAP (150 mmHg) Patho: rupture of BV, blood enters brain and ventricles, brain tissue Compresses adjacent tissues causing blood vessel spasm and cerebral edema Impaired absorption of CSF o CUSHINGS TRIAD Increasing systolic pressure Widened pulse pressure (normal: 30 -50 mmHg Bradycardia (final compensatory mechanism to maintain CS)

Assessment ACT fast Face asymmetry including tongue and smile (tongue moved to the affected side) Arms raise - weakness Speech slurred speech if one part of face is paralyzed Time Stages of motor deificits Motor Flaccidity Muscle spasticity 6-8 weeks; prevented by resting splints (a thing that will follow the normal alignment of the extremity) o Adduction of shoulder o Pronation of forearm o Flexion of fingers o Extension of hip and knee o Foot drop, outward rotation of leg Synergy flexion of broader muscle groups; may resolve to normal or usually residual weakness Sensory perceptual Hemianopia blindness in one side; half of the eyes blind Agnosia cant identify familiar object Apraxia inability to perform familiar actions Neglect syndrome neglect in one side of the body (always face the mirror) Elimination disorders Partial loss of sensation that triggers bladder elimination: urinary frequency, urgency incontinence Communication Aphasia inability to use or understand language o Expressive brocas aphasia o Receptive aphasia wenickes aphasia o Mixed or global aphasia Dysarthria any disturbance in muscular control of speech; caused by CN damage; deep voice, slurred speech Cognitive and behavioural changes Emotional lability laughing or crying inappropriately Loss of self control Nursing diagnoses Ineffective tissue perfusion: cerebral (for the first 3 days) Impaired physical mobility Self-care deficit Impaired verbal communication Impaired urinary elimination and risk for constipation Impaired swallowing Medications Anticoagulant therapy Ordered for thrombotic strike during stroke in evolution Prevent further extension of clit: heparin, warfarin Contra in complete and hemorrhagic stroke Thrombolytic therapy Must be given within 3 hours of onset of manifestations and will dissolve clot Antithrombotic Maintenance therapy Inhibit platelet phase of clot formation; contraindication with hemorrhagic stroke (aspirin, dipyrimadole) Calcium channel blockers Corticosteroids Diuretics Anticonvulsants Endarterectomy: removal of clot or thrombus from the artery Only carotid artery Carotid angioplasty and stenting

Spinal cord injury Cervical 1-6 (neck) Thoracic 11- lumbar 2 (waist) Usually younger age, 16-30 yo (MVA) Violence, falls and sports injury (diving) Pathophysiology o Primary injury causes microscopic haemorrhages in gray matter of cord and edema of white matter of cord

o Mucrocirculation of cord is impaired by edema and hemorrhage; further impaired by vasospasm o Necrosis of gray and white matter occurs and function of nerves through injured area is lost Manifestaions o Loss of sympathetic impulse (t1-L1) manifested as bradycardia, hypotension, venous stasis o Loss of hypothalamic control o Cord edema leading to compression of blood vessel and spinal cord tissue o With cell damage potassium escapes into extracellular space Classification o Complete: total loss of motor and sensory function below level of injury o Incomplete: variable loss of function below level of injury function below level of injury Brown-Sequards syndrome(spastic paralysis and loss of proprioception and injured side and loss of pain and heat sensation on the other side) Level of injury o L1 injury: paraplegia o T6 injury: paraplegia o C6 injury: tetraplegia o C4 injury: tetraplegia Care at the scene o Reduce injury, preserve function o Rapid assessment ABC o Immobilize and stabilize head and neck o Care with all transfers not to complicate original injury o Fractures C1 to C4 levels result in respiratory paralysis, will require ventilator assistance o Address other injuries that may necessitate immediate care Spinal shock o Temporary loss of reflex function below level of injury beginning immediately after complete transaction of spinal cord-ends in reflexive activity o Manifestation Bradycardia and hypotension Flaccid paralysis of skeletal muscles distal to injury Loss of all sensation distal to injury Absence of visceral and somatic sensation Bladder and bowel dysfunction Loss of ability to perspire o Autonomicic dysreflexia Unopposed stimulation of sympathetic nerves after reoliution of spnal shock with cord injurues at T6 or higher Client develops bradycardia and severe HPT, flushed, warm skin with profuse sweating above the lesion and dry skin below; anxiety If sustained could result in stroke, myocardial infarction or seizure Responsibility: avoid the trigger of AD o Abnormal discomfort: full bladder o Stimulation of pain receptors: pressure ulcers o Visceral contractions: fecal impaction If hypertensive: elevate head: blood will rush to leg reducing intracranial HPN o Elevate clients head and remove any support base: this will immediately decrease the blood pressure since client has orthostatic hypotension o Monitor blood pressure; assess and relive causative factor o Notification of physician and administration of medicine to lower blood pressure Nursing dx Impaired physical mobility o Intervention to maintain joint mobility, prevent contractures o Maintain skin integrity, use of special beds o Prevention of DVT Impaired gas exchange o Ventilator support often indicated in cervical injuries o Assist client to cough by splinting lower chest region Ineffective breathing pattern Dysreflexia Altered urinary elimination and constipation o Intermittent catheterization procedure o Use of stool softeners and bowel training program Sexual dysfunction o Males have different abilities to have erection o Females usually do not have sensation Low self esteem o A client has sustained threat to body image, self esteem, role performance o Promotion of self care, independent decision making Medications

 Corticosteroids Vasopressors to treat bradycardia and hypotension Histamine antagonist to prevent stress ulcers Anticoagulation if not contraindicated Treatments Surgeries include decompression laminectory, spinal fusion, insertion or metal rods Stabilization and immobilization o Application of traction (Gardner-wells tongs) o External fixation (halo external fixation device): allows for greater mobility, self care, participation in rehabilitation program problem is skin care because it is restrictive causing skin irritation Client with Alzheimers disease (AD) From of dementia characterized by progressive, irreversible deterioration od general intellectual functioning Begins with subtle memory loss Deteriorating cognition and judgment Eventual physical decline and total inability to perform ADL Risk factors include older age, female, family history Exact cause is inkown, theoris include loss of transmitter stimulation, genetic defect, viral and autoimmune Changes in brain Loss of nerve cells and presence of neurofibrillary tangles and amyloid plaques o Instead of normal amyloid, there is beta amyloid propagating the production of neurifibriliary tangles causing destruction of brain tissues Progressive brain atrophy Stage 1 Stage 2

Appears healthy and alert Cognitive deficits are undetected Subtle memory lapses, personality changes Seems restless, forgetful, uncoordinated Memory deficits more apparent Less ability to behave spontaneously Wandering behaviour, deterioration in orientation to time and place o Commonly in afternoon and night sundowning Changes in sleeping patterns, agitation, stress Trouble with simple decisions Sundowning: increased agitation, wandering, disorientation in afternoon and evening hours Echolalia, scanning speech, total aphasia at times, apraxia, asteerognosis, inability to write Becomes frustrated and depressed

Stage 3 Increasing dependence with inability to communicate, loss of continence Progressive loss of cognitive abilities, falls, delusions, paranoid reactions Average life expectancy is 7 years from diagnosis to death, often from pneumonia, secondary to aspiration Nursing diagnosis Impaired memory Chronic confusion Anxiety Hopelessness Caregove role strain Home care Education regarding disease Anticipation of needs Use of memory cues Support groups and peer counselling Medications Cholinesterase inhibitors used to treat mild to moderate dementia o Tacrine HCL (Cognex) o Donepezil HCL (Aricept) o RIvastigmine (Exelon) Medications to treat depressions Tranquilizers for severe agitation o Thioridazine Mellaril o Haloperidol(Haldol) antioxidantsL vitamin E, anti inflammatory agents, estrogen replacement therapy in women Client with parkinsons disasese

progressive, degenerative neurological disease cahracterised by tremor at rest, muscle rigidity and akinesia (poor movement): cause UNK mean age 60 with males more often than females Parkinson-like syndrome can occur with some medications, encephalitis, toxin these are usually reversible Damaged: Basal ganglia-Dopaminergic site Pathophysiology Neurons in cerebral cortex atrophy and dopamine receptors in basal ganglia decrease by 80% Decrease in dopamine for motor function Disturbance between balance of dopamine and Ach Progressive loss of coordinated movement and increase muscle tension and tremors Manifestations Tremors at rest with pill rolling motion of thumb and fingers o Lessens with purposeful movements o Worsens with stress and anxiety o Progressive impairment affecting ability to write and eat Rigidity o Involuntary contraction of skeletal muscles o Cogwheel rigidity: jerky motion Akinesia o Slowed or delayed movement that affects chewing, speaking, eating o May freeze: loss of voluntary movement o Bradykinesia: slowed movement Posture abnormality o Involuntary flexion of head and shoulders, stooped leaning forward position o Equilibrium problems causing falls, and short, accelerated steps o Parkinsonian gait Autonomic nervous system o Constipation and urinary hesitation or frequency o Otho hypo, dizziness with position change o Exzema, seborrhoea Depression and dementia; confusion, diorentation, memory loss, slowed thinking Inability to change position while sleeping Medication o Anticholinergic selegline (Carbex), amantadine (symmetrel) inhibit cerebral motor impulses that causes rigidity of the muscles o Combination carbidopa-levodopa (sinemet) o MAOI bromocriptine ( Parlodel, Pergolide (Permax) inhibit dopamine breakdown o COMT cathecol o methyl transferase inhibitor inhibit reuptake of dopa CI: alcohol antagonist o Vit b6 increase conversion in liver o Protein inhibit absorption of levodopa Treatments o Electrical stimulation for tremor suppression o Physiotherapy reduces rigidity of muscles and prevents contractures o Deep brain stimulation with pacemaker to upper chest o Surgery has sometimes been done Pallidotomy destruction of involved tissue (ablation) Sterotaxic thalamotomy Autologous transplant of brain cells Nurse management o Provide safe environment o Nutrition Small bite pieces of food to prevent choking Small frequent meals for easy mastication Adequate intake of roughage to prevent constipation Encourage diet rich in nutrient dense foods Allow time to eat o Positioning and activities Limit postural activities Maintain gait as normal as possible Encourage daily physical therapy Elevate back legs of seats 2 inches Practice walking Avoid rushing client Assist client in setting achievable goals to improve self esteem Total body function support in advanced stages (respiratory, elimination altered) Multiple Sclerosis Chronic demyelinating disease of CNS associated with abnormal immune response to environmental factor

Progression of disease with increasing loss of function Only one that affects the optic nerve Young adults (20-40);onset 20-50 Affects females more than males More common in temperate climates Occurs mainly in Caucasians In demyelination, there is poorer conduction. Affected nerve cells include spinal cord, brain stem, cerebrum, cerebellum Pathophysiology o Believed to be autoimmune response to prior viral infection breaching the BBB o Inflammation destroys myelin leading to axon dysfunction; neurons in spinal cord, brain stem, cerebrum, cerebellum, and optic nerve affected o Recurrent demylination and plaque formation result in scarring of glia and degeneration of acons o Disease follows different courses, most common is the relapsing remitting type Manifestations o Fatigue o Optic nerve involvement: blurred vision, haziness, blindness o Brain stem involvement: nystagmus, dysarthria (scanning speech), cognitive dysfunctions, vertigo, deafness o Weakness, numbness in legs, spastic paresis, bladder and bowel dysfunction o Cerebellar: nystagmus, ataxia, hyptonia

Amytrophic lateral Sclerosis (ALS) Progressive, degenerative neurologic disease characterized by weakness and wasting of muscles without sensory or cognitive changes Age of 40-60; higher incidence in males at earlier ages but equally post menopause Physiologic problems involve swallowing, managing secretions, communication, respiratory muscle dysfunction Death usually occurs in 2-5 years due to respiratory failure No cognitive and sensory involvement Pathophysiology o Degeneration and demyelination of upper and lower motor neurons in anterior horn of spinal cord, brain stem and cerebral cortex muscle weaknes o Cerebral cortex and brain stem -- hyperactive reflexes, jaw clonus, tongue fasciculations, babinski reflex o Reinnervation occurs in the early course of disease, but fails as disease progresses Manifestations o Initial o Atrophy of tongie and facial muscles result in dysphagia and dysarthria; emotional lability and loss of control occur o Descending type of paralysis o 50% of clients will die within 2-5 years after diagnosis, often from respiratory failure or aspiration pneumonia Nursing diagnosis o Risk for disuse syndrome o Ineffective breathing pattern: may require mechanical ventilator and tracheostomy Medications o Rilutek (Riluzole) antiglutamate Prescribed to slow down muscle degeneration Hepatotoxic - requires monitoring of liver function, blood count, chemistries and alkaline phosphatase Myesthenia Gravis Chronic neuromuscular disorder characterized by fatigue and severe weakness of skeletal muscles Believed to be autoimmune in origin Pathophysiology o Antibodies destroy or block neuromuscular junction receptor sites, resulting in decreased number of AcH receptors o Causes decrease in muscles ability to contract, despite sufficient AcH o Majority of clients have hyperplasia of thymus gland (in an adult, this gland atrophies; in children, part of immune system) which is usually inactive after puberty Manifestations o Ptosis (drooping of eyelids); diplopia (double vision) o Weakness in the mouth muscles resulting in dysarthria and dysplagia o Weak voice; smile appears as snarl o Head juts forward o Muscles are weak but DTRs are normal o Weakness and fatigue exacerbated by stress, fever, overexertion, exposure to heat; improved with rest (most weak probably late in the afternoon) Complications o Pneumonia o Myasthenic crisis evidence of lack of acetylcholine

Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration Manifestations: tachycardia, tachypnea, respiratory distress, dysphasia o Cholinergic crisis Occurs with overdosage of medications (anticholinesterase drugs) used to treat MG Develops GI symptoms, severe muscle weakness, vertigo, and respiratory distress Differentiation by administration of Edrophonium chloride (Tensilon), which will improve the muscle weakness in Myesthenic crisis and be ineffective with cholinergic crisis Medications o Anticholinesterase medications most commonly used is Pyridostigmine (Mestinon) o Immunosuppression medications including glucocorticoids o Cyclosporineor azathioprine (Imuran) to weaken the immune system o Surgery: Thymectomy is recommended in clients <60 Remission occurs in 40% clients but may take several years to occur o Plasmapheresis Used to remove antibodies Often done Nursing diagnosis o Ineffective airway clearance o Impaired swallowing: plan to take medication to assist with chewing activity

Guillain Barre Syndrome Acute inflammatory demyelinating disorder of peripheral nervous system characterized by acute onset of motor paralysis (usually ascheding) Cause is unknown but precipitating events include GI or respiratory infection prior , surgery, or viral immunizations Characterized by progressive ascending flaccid paralysis of extremities with paresthesia and numbness Pathophysiology o Destruction of myelin sheath covering peripheral nerves as result of immunologic response o Demyelination causes sudden muscle weakness and loss of reflexes Manifestations o Most client have symmetric weakness, beginning in lower extremities o Ascends body to include upper extremities, torso and cranial nerves o Severe pain o Sensory involvement causes severe pain, paresthesia and numbness o Client cannot close eyes o Paralysis of intercostals and diaphragmatic muscle can result in respiratory failure o Autonomic nervous system involvement: blood pressure fluctuations, cardiac dysrhythmias, paralytic ileus, urinary retention o Weakness usually plateaus or starts to improve in the fourth week with slow return of muscle strength Medications supportive and prophylactic care o Antibiotic for infections o Morphine for pain control o Anticoagulation to prevent thromboembolic complications (usually develops in lower extremities) o Vasopressors as needed for orthostatic hypotension o Surgery -May need tracheostomy, if prolonged ventilator support o Plasmapharesis may be helpful, if used early in the course of disease Dietary management usually requires enteral feeding or total parenteral nutrition Nursing diagnoses o Acute pain o Risk for impaired skin integrity o Impaired communication Home care o Client and family will need support groups o Physical and occupational therapy usually require long-term rehabilitation to regain maximum muscle strength Bells Palsy Disorder of CN VII and causes unilateral facial paralysis Occurs between age of 20-60 equally in males and females Cause unknown, but thought to be related to herpes virus (CNS VII) Manifestations o Numbness, stiffness noticed first o Later face appears asymmetric: side of face droops, unable to close eye, wrinkle forehead and pucker lips on one side o Lower facial muscles are pulled to one side; appears as if stroke Collaborative care o Corticosteroids are prescribed in some cases but use has been questioned o Treatment is supportive Nursing care

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Teaching client self care prevent injury and maintain nutrition Use of artificial tears, wearing eye patch or taping eye shut at night, wearing sunglasses Soft diet that can be chewed easily, small frequent meals

Hydrocephalus Increase in volume of CSF within ventricular system which becomes dilated. Common types o Noncommunicating obstruction o Communicating CSF not reabsorbed QUESTIONS 1. A patient with CVA is showing slightly dilated pupils. This can be explained by non-conduction of a. CNS III 2. Intact, functioning cranial nerves give information about the a. Brain stem where CN orginates 3. The client is comatose following brain surgery, which of the following actions would be contraindicated in his care: a. Raising the head of his bed to decrease ICP b. Pharyngeal suctioning stimulate gag reflex, increases ICP c. Nasal suctioning d. Tooth brushing must be done; primary responsibility: prevent aspiration 4. The patient is admitted to the hospital with right-sided hemiplegia as a result of a stroke. The nurse should position the client: a. On her right side as much as possible prone to injury because right side cant detect pressure b. On her left side with brief periods on her back and right side c. Upright as long as tolerated d. Supine with pillow under her knees 5. The nurse notes that the client with head trauma has clear fluid draining form his nose. Which of the following actions by the nurse is most appropriate initially? a. Notify the physician immediately b. Test the fluid for glucose c. Send a specimen of the fluid for culture d. Encourage the client to blow his nose often to promote drainage 6. The nurse notes that the client with head trauma has clear fluid draining from his nose. Which of the following si the best test to confirm CSF drainage? a. Halo test b. Glucose strip test c. Culture and sensitivity d. CBC 7. The nurse understands that the Dolls eye reflex is present if the patients eyes a. Move in the same direction in which his head is turned b. Move in the direction opposite to which his head is turned c. Not move when the head is turned d. Move to the medical aspect of the orbit when head is turned 8. What should the nurse include in the plan of care for a newly admitted client with an infratentorial craniotomy due to a brain tumor? a. Keep HOB elevated 30-45 degrees and a large pillow under the clients head and shoulder b. Keep the head of bed flat and the clients head turned to either side c. Assess vital signs and pupils every four hours d. Flex neck every 2 hours to prevent stiffness 9. The nurse has explained the use of neostigmine methylsulfate (prostigmine) to a client with myasthenia gravis. Which comment by the client indicates the need for further instructions? a. I need to take the medication regularly even when I feel strong b. I should take the medication once daily after bedtime c. If I take too much medication, I can become weak and have breathing probralms d. I may have difficulty swallowing my saliva if I take too much medication 10. A 36 year old female reports double vision, visual loss, weakness, numbness of the hands, fatigue, tremors, and incontinence. On assessment, the nurse notes nystagmus, scanning speech, ataxia and muscular weakness. Based on these findings, the nurse suspects the client has: a. Parkinsons disease b. Myesthenic gravis c. Amytropic lateral sclerosis d. Multiple sclerosis 11. Mr. F. is comatose following auto accident. Which of the following will provide the most accurate information of the cause of his decreased level of his decreased level of consciousness? a. Detailed history of the accident b. CT scan c. Skull x-ray d. Physical examination 12. Knowing that for a comatose patient hearing is the last sense to be lost, as the nurse, what should you do? a. Tell her family that probably she cant hear them

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b. Talk loudly so that the patient can hear you c. Tell her family who are in the room not to talk d. Speak softly the hold her hands gently Which among the following interventions should you consider as the highest priority, when caring or June who has hemiparesis secondary to stroke? a. Place June on an upright lateral position b. Perform range of motion exercises c. Apply antiembolic stockings d. Use hand rolls or pillows for support Which among the following interventions should you consider as the highest priority, when caring for June who has hemiparesis secondary to stroke a. Narrowing of pulse pressure, cheynes stroke respirations, tachycardia b. Widening pulse pressure, irregular respiration, bradycardia c. Hypertension, Kussmauls respiration, Tachycardia d. Hypotension, irregular respiration bradycardia In a client with a Cheyne strokes respiration, which of the following is the most appropriate nursing diagnosis? a. Ineffective airway clearance b. Ineffective breathing pattern c. Impaired gas exchange d. Activity tolerance You are caring for a patient with a tumor causing increased ICP. Which plan of care should you include to reduce the ICP? a. Administer bowel softener b. Position client with head turned toward the side of the tumor c. Provide sensory stimulation d. Encourage coughing and deep breathing exercise Keeping this patients head and neck alignment results in: a. Increased intrathoracic pressure b. Increased venous outflow c. Decreased venous outflow d. Increased intra-abdominal pressure After you assess that a patient has an increase in ICP, your most appropriate respiratory goal is: a. Maintain PaO2 above 80 mmHg to prevent too much vasodilation b. Lower aterial pH reflective of metabolic c. Keep bicarbonates at a low level reflective of metabolic d. Promote CO2 elimination through breathing For the past 10 years Ana, 42 years old has had Multiple sclerosis. As part of her rehabilitation plan, the nurse suggested therapies to help her: a. Strengthen muscle coordination b. Establish daily routine c. Develop perseverance and motivation rehabilitation for psychiatric patient d. Establish good health habits prevention Patient has myasthenia gravis and is having difficulty in speaking. What communication strategy should the nurse avoid when interacting with the patient? a. Repeating what the client says for better understanding b. Using paper and pencil in communicating with the client stated in a way where the nurse will be the one to use the paper and pencil c. Encouraging the client to speak slowly d. Encouraging the client to speak quickly On patient Bs second day of admission, he was unable to stand and was having difficulty in swallowing and talking. Which of the following is a priority? a. To prevent bladder distention b. To prevent contractures c. To prevent decubitus ulcer d. To prevent aspiration pneumonia The wife of a 72 year old with Alzheimers disease says I cannot understand my husband anymore. Your most appropriate response would be: a. The staff will make sure you husband is safe in this institution b. This has been difficult for you. Lets go for a walk so we can talk c. He wil recover soon d. Do not worry. We are doing the best we can. The patient with CVA manifested hemiplegia, dysphagia, and increase ICP. Which of the following independent nursing citons is not suited for her? a. Oropharyngeal suction every 15 minutes to prevent aspiration b. Keep head of bed elevated 30-35 degrees c. Maintain head in straight alignment and prevent hip flexion d. Prevent constipation and increase in intraabdominal pressure The patient underwent lumbar puncture. After the procedure the priority of the nurse should be: a. Logroll the client with the help of another nurse b. Inform the client that he should be in supine position

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c. Assess for sensory loss in the legs d. Instruct the patient to move from side to side The patient sustained an injury to the spine. Because of this he has to wear a back brace. Which position is recommended when the brace is applied? a. Sitting position b. Standing position c. Lying on his side d. Supine position The cardinal symptoms of Alzheimer disease: a. Inability to transform thoughts into action b. Problems expressing speech or understanding sounds c. Significant forgetfulness d. Inability to recognize objects Carlo, 66 years old, is admitted in Medical City with a diagnosis of organic brain syndrome. The nurse noticed personality changes and judgment impairment. Which of the following lobes is affected? a. Temporal lobe b. Parietal c. Frontal d. Occipital Charlene was rushed to the Philippine Heart Center. The admitting diagnosis is CVA. As a nurse, what will be your priority goal? a. Promote urinary elimination by inserting a foley catheter b. Obtain BP and application of pulse oximetry c. Complete cognitive assessment d. Maintain a patent airway Mr. Tony Perez has been prescribed to receive an antiparkinsons drug. Which of the following is not given: a. Bromocriptine b. Carbidopa-dopamine c. Thorazine d. Amantadine Dong is complaining of pain. Which site in the central nervous system is for the conduction in the sensation? a. Ascending pathway Marvin, 70, is admitted in the orthopaedic hospital due to SCI. He has severe respiratory failure. Which of his spinal nerves has been involved? a. Sacral 1-5 b. Thoracic 2-12 c. Cervical 1-4 d. Lumbar 1-5

Eye and Ear Disorders Eyes disorders problems of the ducts, external or internal parts of the eyes Anatomy Eyelids protection (OBVIOUS) Lacrimal glands tears Pupil central circle; simply a hole, what makes it dilate and constrict is the movement of the iris due to the contraction and relaxation of the muscles that will pull it Sclera covered by bulbar conjunctiva (colorless) Palpebral conjunctiva pinkish Lens- located at the back of the iris; pulled by some portion of the ciliary muscles to bend and accommodate light Iris attached to ciliary muscles Ciliary body produces aqueous humour, lubricating lens and anterior chamber of eyes. In increase pressure, anterior chamber increases causing increased pressure at the back of the eye Retina where rods and cones are located for day and night time vision Rods night time and colors Macula area a the back that is circular; allow central vision focusing Choroid supplies retina with blood, glucose and oxygen Optic nerve transmit visual impulses for interpretation in the brain Astigmatism corneal irregularities Myopia nearsightedness, eyeball is very long Hyperopia - farsightedness Presbyopia common among elderly due to hardening of the lens due to aging process causing inability of the lens to bend Eyelid conditions Marginal blepharitis inflammation of glands and lash follicles on eyelid margins Seborrheic, usually associated with dandruff Staphylococcal infections hordeolum (Sty) Chalazion inflammation of meibomian gland

Conjunctivitis o Most common eye disease o Transmission direct contact (hands, tissues, towels); allergens, chemical irritants, exposure to radiant energy o Acute conjunctivitis Trachoma Chlamydia trachomatis

Refractory errors Myopia (nearsightedness) eyeball is elongated and image focuses in front of retina instead of on it Hyperopia farsightedness eyeball is short and image focuses behind the retina Presbyopia due to age, elasticity of lens decreases and leads to loss of accommodation, client cannot see close objects without reading glasses Astigmatism develops with abnormal curvature of cornea or eyeball and causes image to focus at multiple points on retina Treatment o Nonsurgical correction of refraction errors with eyeglasses or contact lenses o Surgical reshaping cornea through series of radial incisions Cataract Opacification (clouding) of lens of eye which interfere with light transmission to retina and ability to perceive images clearly Pathophysiology o With normal aging process, fibers and proteins change and degenerate, begins at periphery and involve central portion o May happen as a complication of disease (DM) Doctor will only remove the lens until the whole lens is destroyed Risk factors: for senile cataract (aging) o Long term exposure to sunlight (UV-B rays) o Cigarette smoking - vasoconstriction problems, less oxygen and blood supply o Heavy alcohol consumption Acquired cataract o Eye trauma o DM especially with controlled glucose levels formation of sorbitol and glycosylated end products o Use of meds: corticosteroids, chlorpromazine Manifestations o Tend to occur bilaterally but development is usually not symmetric o Decreased vision acuity, both close and distance vision, related to glare; difficulty adjusting between light and dark environments o Difficulty distinguishing between color hues o Cloudiness or opacities seen in the eye upon examination with light o Color of pupils is white or gray not black no longer transparent, can no longer reflect what is inside Surgical approaches Intracapsular o Lens and entire capsule removed o You cannot place a new lens at the back and is placed in front of the iris at the anterior chamber Extracapsular o Lens and anterior capsule removed o Posterior lens capsule remains o Lens placed at the back of the iris at the posterior chamber o Most common Preoperative surgical care o Stop anticoagulants if medically appropriate 5-7 days before until a prothrombin time of 1.5 is reached (to prevent retrobulbar hemorrhage after retrobulbar injection) o Papillary dilation with mydriatics every 10 minutes x 4 doses at least 1 hour before surgery o Prophylactic antibiotics, corticosteroid and NSAID drops to prevent post operative infection and inflammation. Post operative care o Explain minimal discomfort which can be relieved by mild analgesic o Antibiotic, anti-inflammatory, corticosteroid drops are continued o Wear protective eye patch for 24 hours, then replace with protective glasses for 1-4 weeks o Eye shields are used at night and sunglasses for sun exposure o Clean damp cloth may be used for slight morning eye discharge o Report for floaters, flashes of light, pain, redness, and decrease in vision indicative of glaucoma and other retinal problems Prognosis o Blurring of vision may be experience form several days to weeks due to corneal sutures o Temporary astigmatism o As healing occurs, fast visual improvement is observed than those who ware aphakic glasses o Vision stabilizes upon complete healing in 6-12 weeks healing depends on the nutritional status, existing disease condition

Glaucoma Characterized by increased intraocular pressure of eye and a gradual loss of vision; thief in the night Causes blindness, pain, redness/edema or cornea Primary glaucoma exist s without identified precipitating cause (open angle); secondarily as result of infection, cataract, tumor hemorrhage, eye trauma (close angle) Primary without any cause, increase pressure, genetic predisposition After eye operation, can cause glaucoma Pathophysiology o Aqueous humor is fluid within the eye, maintains a normal intraocular pressure of 15-20 mmHg o Glaucoma increase in intraocular pressure due to decrease in absorption of fluid, which usually causes ischemia of neurons within the eye and degeneration of optic nerve o Tonometer can be used to measure intraocular pressure Forms of primary glaucoma o Open angle (chronic simple) flow through orbicular meshwork is obstructed, increasing amount of aqueous humor and intraocular pressure problem is not the angle but rather in the meshwork Usually affects both eyes although not symmetrically Manifestations Vague and client is unaware of loss of peripheral vision Mild headache, difficulty adapting to darkness, seeing halos around lights, and having difficulty focusing on near objects Peripheral vision is reduced tunnel vision Field of vision is narrows to such a degree that one cannot see clearly. The angle is open but drainage is defective (clogged) o Angle closure Anterior chamber angle narrows due to corneal flattening or bulging of iris into anterior chamber Abrupt increase in intraocular pressure damages neurons of retina and optic nerve Rapid, permanent loss of vision without prompt treatment Manifestations Episodes usually involve one eye, but other eye is at increased risk for angle-closure in future Episodes occur in association with factors that cause pupil dilation: darkness, emotional upset, etc Severe eye and face pain Nausea and vomiting Seeing colored halos around light Conjunctiva of affected eye is reddened and cornea clouded with corneal edema Pupil fixed at midpoint Pathophysiology Aqueous humor is fluid within the eye, maintains a normal intraocular pressure of 1520 mmHg. Tonometer- measures intracocular pressure Glaucoma increase in intraocular pressure due to decrease in absorption of fluid, which usually causes ischemia of neurons within the eye and degeneration of optic nerve Medications: client controls pressure and preserve vision indefinitely with drug therapy Cholinergics (miotics) facilitate outflow of aqueous humor, papillary constriction (pilocarpine) Prostaglandin analogs (lantanoprost [Xalatan]) Adrenergics (mydriatics) decrease production of aqueous humor (ephinephrine, dipivefrin) Beta-adrenergics blocking agents decrease production of aqueous Carbonic anhydrase inhibitors dorzolamide (Trusopt); systemic drug: acetazolamide (Diamox) Surgical Laser trabeculoplasty opening of trabecular meshwork Trabeculotomy creation of fistula Treatment for acute angle-closure (usually done in both eyes) Gonioplasty scarring of iris Laser iridotomy multiple perforations of iris Peripheral iridectomy small segment of iris removed surgically Nursing care: Patient on unaffected side No straining: no heavy lifting, no coughing Head elevated Retinal detachment Disruption of retinal layer of eye by trauma or disease, results in blindness; separation of retina from choroid

Pathophysiology o Shrinkage of vitreous humor may pull retina away from choroids o Break or tear in retina allows fluid from vitreous cavity to enter defect Manifestations o Seeing floaters or spots, lines, flashes of light in visual field o Sensation of curtain drawn across vision o No pain, eye appears normal to visual inspection Interventions o Purpose: resume contact of retina and choroids to re-establish blood and nutrient supply to retina o Cryotherapy or laser photocoagulation o Sclera buckling- put a buckle around the eye to make it stick to the choroids Enucleation o Surgical removal of eyes is sometimes necessary due to trauma, infection, glaucoma, intractable pain, or malignancy o Temporary prosthesis (conformer) is fitted within a week o Permanent prosthesis is fitted one 2 months post surgery o Nursing care involves monitoring for complications of hemorrhage and infection, teaching and psychological support o Artificial eye will not move o Do not sleep on the affected site, no pressure

Blind

Visual acuity no greater than 20/200 in the better eye with optimal correction or visual field less than 20 degrees (normal=180 degrees) In practical terms, person with visual deficits require assistive devices or aid Nursing care: o Focus on helping client cope with loss and deal effectively with societal attitudes that encourage feelings of inferiority, helplessness, and inadequacy o Foster inadequacy in the hospitalized client by Adequate orientation to environment physically and verbally Verbalize about activities occurring around the client Provide additional sensory stimuli (radio, TV) Assist with meals and describe the position of foods according to face of clock Assist with ambulation by allowing client to hold onto nurses arm, describe environment Refer to available community resources for mobility training, self-care activities, education, rehabilitation as the client needs EAR PROBLEMS Anatomy of the Ear (Cochlear cells) organ of corti - Major organ for hearing If one part of the ear is irritated, pain in all tract will be experienced. Pinna outer part of the ear; very instrumental in catching sound waves Malleus, incus, stapes Cranial nerve VIII Middle ear connected to Eustachian tube which is connected to your nose and sinus area. When there is backflow in the oropharynx area, it may also go into your ear through this tube. In a mongoloid, they have a low set ear. The middle ear is usually higher in level than the inner ear. Thus they usually develop infections like otitis media. Outer and Middle ear involved conductive hearing loss Inner ear involved sensorineural hearing loss Ear is adjacent to your mastoid process, which is also adjacent to the brain causing meningitis and encephalitis as a complication of untreated infections Endolymph maintain sense of equilibrium Tympanic membrane pearly gray, code of light reflected from your otoscope. When there is inflammation at the back of the membrane, this bulges forward and lose contact with the incuse thus no light will be reflected and the color will turn to orange and pinkish in an attempt to increase in vascularity by growing new blood vessels. Perforated tympanic membrane heals spontaneously if due to accidental perforation. Perforation due to infection may need myringoplasty to repair the ear drum. External otitis Causative organism commonly Pseudomonas aeruginosa, may be fungal or due to mechanical trauma or local hypersensitivity Common inflammation of ear canal, swimmers ear, persons wearing hearing aids or ear plugs which hold moisture in ear canal. If insect goes inside your ear, you can use oil. Once the oil goes inside, the insect can no longer move anymore, allowing easy drainage of the insect out of the ear Manifestations o Feeling of fullness in ear o Ear pain increased by manipulation of the auricle

o o

Odourless watery or purulent drainage Ear canal appears inflamed and edematous

Otitis Media Inflammation or infection of middle ear associated with URI and auditory (Eustachian) tube dysfunction which occurs with allergies. Primary forms o Serous otitis media o Acute or suppurative otitis media typically URI; Streptococcus pneumoniae and pyogenes, and Haemophilus Influenzae, leads to pus formation Pus in the ear can cause conduction problems Manifestations o Mild to severe pain in affected ear o Temperature elevation o Diminished hearing, dizziness, vertigo, tinnitus o Otoscopic exam: tympanic membrane appears red, inflamed or dull and bulging o Too much pus can lead to spontaneous rupture of membrane releases purulent drainage Barotitis media Middle ear cannot just adjust rapid changes in barometric pressure (as with air travel or underwater diving) Acute pain, hemorrhage into middle ear, rupture of tympanic membrane Fluid moves from intravascular space to middle ear Manifestations o Decreased hearing in affected ear o Snapping or popping in ear o Tympanic membrane demonstrates decreased mobility, and may appear retracted or bulging due to accumulation of fluid inside or at the back of the membrane Nursing diagnoses o Altered sensory perception disturbances in sound conduction o Pain due to bulging o Risk for injury risk for rupture of tympanic membrane o Risk for infection may proceed to a bacterial infection in and outside the ear o Altered thermoregulation Treatments o Ear irrigation to promote healing contraindicated for perforated eardrum Use of boric acid (cleanser) and alcohol content (drying effect) May use a wick to help in the introduction of medicine into the air. Nursing responsibility tilt head to allow entrance of medicine, straighten ear canal, irrigation/ medication must be in body temperature o Local and systemic antibiotics local (drops); systemic (parenteral, oral) o Analgesics pain subsides with swelling in 24-48 hours Surgical management o Myringoplasty closure of perforation o Tympanoplasty surgical correction of a perforated ear drum o Ossiculoplasty ossicular construction o Myringotomy perforation of tympanic membrane for drainage Acute mastoiditis Extension of otitis media, happen when otitis media is untreated Rare due to advent of antibiotic therapy Inflammation of the mastoid bone at the back of the ear Manifestations occurs 2-3 weeks after an episode of acute otitis media o Recurrent earache persistent and throbbing pain o Hearing loss on affected side o Tenderness, redness and inflammation over mastoid process behind the ear o Fever tinnitus, headache, profuse drainage from ear may be present Surgical management o Matsoidectomy removal of the contents of the mastoid bone to control infection Close or canal wall up performed in conjunction with tympanoplasty and ossiculoplasty to retain or regain hearing Open or canal wall down radical, modified mastoidectomy Preoperative care for ear surgeries o Assess patients hearing acuity o Explain what to expect during the procedure because local anesthesia with sedation is often used o Give immediate postoperative instructions Postoperative o Mild analgesics for pain o Protect from falling due to vertigo and light headedness o Only a small amount of drainage which is serosanguinous

o Lien on the un-operated side o If necessary, blow nose gently one side at a time to prevent suture from loosening o Sneeze and cough with mouth open to equalize pressure o Participation in water sports or activities prohibited o If operation is outside, be careful not to wet the area. If inside, it would be ok, it will not go in. Client expectations o Initial decrease in hearing in the operated ear form surgical packing o Noises in ear such as cracking or popping o Minor ear ache due to inflammatory process and discomfort in cheek and jaw o Ear swelling o With continuous fever, headache, expect additional complications such as meningitis and infection

Otosclerosis Common cause of conductive hearing loss Hardening of the structures inside ear Abnormal bone formation in osseous labyrinth of temporal bone causes footplate of stapes to become fixed or immobile in oval window Hereditary disorder with an autosomal dominant pattern, occurring commonly in Caucasians and females; begins in adolescence and is accelerated by pregnancy Positive Rinne test increased bone conduction than air conduction; normal webbers test (abnormal webbers test is due to sensorineural problems) Fixation of footplate otosclerosis is a deposit of new bone that prevents the moving of the footplate of stapes Manifestations o Both ears are affected but rate of hearing loss is asymmetric, bone conduction of sound is retained o Tympanic membranes appears reddish or pinkish-orange due to increased vascularity Treatment o Hearing aid - must be clean or else otitis externa will develop Nursing care o Hygiene especially the hearing aid to prevent otitis externa, volume adjustment o Every time you remove the hearing aid, put it off. So that when the patient puts it back, the patient can adjust the volume to prevent a lot of abnormal vibrations that may irritate the patients ear Menieres Disease (endolymphatic hydrops) Chronic disorder characterized by recurrent attacks of vertigo, tinnitus, and progressive unilateral hearing loss Affects males and females equalle, ages 35-60, familial history for increased risk, at risk: hormonal imbalance Due to over accumulation of endolymph on membranous labyrinth of inner ear due to water retention, salt retention and hormonal imbalance Episodes are linked to increased sodium intake, stress, allergies, premenstrual fluid retention Progressive hearing loss and severe vertigo causing nausea, vomiting, and immobility Sensorineural hearing loss Disorders affecting inner ear, auditory nerve or auditory pathways of brain; damage in the temporal lobe Significant cause is damage to hair cells of organ of Corti related to noise exposure; causes include o Exposure to high level of noise (rock concert) Normal conversation = 50-65 dB Amplified rock music = 120 dB Nearby jetplane = about 140 dB *Noise levels above 85 dB can damage the organ of Corti o Ototoxic medications such as aspirin, furosemide (Lasix), aminoglycoside antibiotics, anti-malarial drugs, and some chemotherapy o Prenatal exposure to rubella, viral infections, meningitis, trauma, Menieres disease, aging (last thing to be destroyed in the elderly) o Webers test and Rinnes abnormal Nursing diagnosis o Altered growth and development o Low self-esteem Questions: 1. The patient has glaucoma. The nurse identified a problem of disturbed sensory perception, visual impairment characterized by: a. Loss of night vision retinal problems b. Loss of peripheral vision c. Loss of central vision cataract, macular degeneration d. Loss of eyesight 2. The appropriate method for instilling eye drops is: isntill into an opened eye, with the head held back and with the eye looking: a. Sideward to the left gives more space b. Downward c. Upward

3.

4.

Straight *ointment applied in the inner to outer canthus under the palpebral conjunctiva *normal feeling of patient after eye instillation: blurring of visions, clears up as it is absorbed When performing a neurologic assessment on a client, you find that his pupils are fixed and dilated. This indicated that: a. Is going to be blind because of trauma b. Probably has meningitis c. Has a significant brain injury fixation due to eye problem does not cause d. Is permanently paralyzed The most common cause of adult blindness a. Diabetic therapy b. Retinal detachment c. Glaucoma d. Cataract

d.

5. A nurse is admitting a client who reports vision loss; to determine if a client has a glaucoma or a detached retina, the nurse check for what to determine that the client indeed has a detached retina?
a. Seeing of floating spots b. Eye pain c. Seeing flashes of lights A client reads Snellens chart. The nurse determines level of visual acquity if more than how many letters are read correctly in the line? a. 50% b. 60% c. 80% d. 90% The nurse observes client at the Senoir Citizen center. Which among the elderly would probably have a hearing impairment? a. Those who speak softly to each other b. One who is pleasant in asking questions c. One who smiles and engages in conversation d. One who repeatedly turns his head to one side For the prevention of open-angle glaucoma, the nurses health teaching will include a. Regular optic nerve and tonometry tests with eye examinations to know if eye is starting to show increase in pressure b. Wearing of protective eye gear prevention of cataract, ptyridium c. Well balanced diet with adequate Vitamin A prevention of retinal problems d. Avoiding head blows and extreme temperatures *primary glaucoma no cause The nurse taking care of a patient with primary glaucoma should be concerned about which statement from the patient? a. I take aspirin everyday to prevent clotting good for glaucoma, even used for maintenance b. I drink 8-10 glasses of water a day normal c. I take decongestants on a regular basis cause vasoconstriction d. I love to eat hot and spicy food does not increase eye pressure a. Central blindness b. Peripheral blindness c. Flaucoma d. Color blindness The patient form a recent eye surgery is ready to sleep and should be positioned: a. Flat corneal and sclera laceration; so that there wont be any escape of the fluids b. On the affected side c. With head of bed elevated facilitate venous drainage ; ideally on the unaffected side if turned to side d. In any position of comfort Jim works in a factory area where noise level is 7-85 Db. The company nurse should instruct him to: a. Look for another job b. Use ear plugs c. Assess the source of noise d. Lower down the noise levels The nurse performs RInne test and informs the client that results are negative. This implies: a. Conductive hearing loss b. Sensorineural hearing loss c. High frequency hearing loss d. Normal hearing Mr. Dumbledore , 80 y/o is admitted to the ward. Which hearing disorder is associated with the aging

6.

7.

8.

9.

10. A call center agent develops macular degeneration. The nurse understands that he is at greatest risk for:

11.

12.

13.

14.

process?
a. b. c. d. Amblyopia no cure; eye disease Otalgia ear pain Presbycusis Tinnitus ringing

15. The school nurse attends to the athletes and gives health teachings to the swimmers. The earliest sign of otitis externa is:
a. b. c. d. a. b. c. d. A popping sensation in the ear - barotitis Pain when the pinna is manipulated Low-grade fever - infection Humming or buzzing noises heard Keeping the clients head upright Using solution at body temperature Spraying an antiseptic solution to the ear Occluding the ear completely with the syringe

16. The nurse assists the doctor to irrigate the clients ear. Nursing intervention propority should focus on:

17. The patient is treated for perforation of the ear drum. The nurse shares that correction of this Insertion of an implantable hearing device otosclerosis, sensorineural problems a. Bed rest b. Myringoplasty - otosclerosis c. Stapedectomy 18. The nurse teaches the patient which of the following in the care of hearing aids: a. Turn the device off b. Clean the c. Wave the ear mold to remove water droplets d. Wrap the hearing aid in tissue paper when not in use 19. 4-6 weeks following ear surgery, a patient is instructed to avoid: a. Doing any activity to general b. Blowing the nose can be done one at a time with mouth opened c. Getting the ear wet d. Flying in an air craft not really necessary; this can only be caused by barotitis 20. The nurse would recommend that the client with Menieres disease avoid which of the following food? a. Cucumber b. Cheese c. Potato chips d. Yogurt MUSCULLOSKELETAL disorders Anatomy

Bones Joints Ligaments: Tendons Bursae: cartilaginous sac Muscle Form structures and provide support for soft tissues Protect vital organs from injury Serve to move body parts by providing points of attachment for muscles Store mineral Serve as site for hematopoeisis Bone resorption and bone deposit occur at all periosteal and endosteal surfaces Bones ins use (subjected to stress) 0 increase osteoblastic activity Inactive bones undergo increased osteoclast activity and bone resorption Hormonal stimulus regulates blood calcium levels Bone remodelling regulated by gravitational pull and mechanical stress from pull of muscles Bones that undergo increased stress are heavier and larger

Functions of bones

Constusions, Strain, Sprain Contusion bleeding into soft tissue resulting from blunt force Hematoma contusion with a large amount of bleeding Strain stretching injury to a muscle or muscle-tendon unit caused by mechanical overloading o Most common sites: lower back and cervical region of spine o Manifestations: pain increasing with isometric contraction, swelling and stiffness Sprain injury to ligament surrounding a joint, overstretch and/or tear Treatments for soft tissue injuries o Rest, immobilization, ice for first 24-48 hours post injury to allow local vasoconstriction o Compression dressing, elevation above heart level to promote drainage o More severe injuries may require surgery, physical therapy

Fracture Any break in continuity of bone Occurs when bone is subjected to more kinetic energy than the bone can absorb Manifestations may be obvious deformity May be accompanied by soft tissues injuries involving muscles, arteries, veins, nerves, skin Advantagious when elderly is heavy or obese. Muscle wounds, tear, muscular injuries, hemotoma Arteries especially in the hips, massive bleeding, the patient can die of shock, especially at the epiphyseal areas Nerves pain or paresthesia; if peripheral nerve and spinal cord connection is cut, poikylothermia may be observed Types o Greenstick common among children; second to linear in the rate of healing o Longitudinal along the vertical axis o Transverse o Comminuted crushed o Impacted one bone goes into another bone o Oblique o Spiral o Stellate o Linear heals very fast Clinical manifestations o Deformity o Swelling o Bruising o Muscle o Bruising o Muscle spasm o Tenderness o Pain o Impaired sensation o Loss of normal function o Crepitus o Abnormal mobility of affected part o Hypovolemic shock when we have fractures in epiphyseal margins or where there is abundance in bone marrow Healing of fracture influenced by o Age and physical condition of client o Type of fracture Time of healing o Uncomplicated fracture of arm or foot heals in 6-8 weeks o Fractured hip heals in 12-16 weeks o More complicated fractures may take many months or years for remodelling Stages of fracture healing Inflammatory phase o Hematoma formation first 2 days; inflammatory phase Reparative phase o Granulation tissue hematoma changes into new blood vessels, fibroblasts, osteoblasts (osteoid) 3-14 days, temporary splint o Callus formation deposition of minerals into osteoids within 2-3 weeks; hardened granulation tissue; the bone will not be straight during the healing process o Ossification 3 weeks to 4 months o Consolidation closing of distance between bone fragments; this will make it harder and denser as compared to other tissues Remodelling phase o 1 year or over a year; excess bone cells are reabsorbed; facilitated by stress and weight bearing; rehabilitation needed for stronger bones and faster remodelling; pull of gravity is important in bone remodelling Emergency care of fractures o Immobilization Immobilize above and below the deformity. (clean wraps can be used to bind the splint) Splint to maintain normal anatomical alignment and prevent further dislocation or damage If already bended, do not attempt to straighten it. This may cause more damage to the bone. Immobilize it in that position o Maintenance of tissue perfusion Control obvious bleeding with pressure dressing Assessment of (distal) pulses, movement, sensation checking for neurovascular status, nerve status and blood supply Prevention of infection: cover open wounds with sterile dressing this is to prevent bone infection because this type of infection is very hard to heal due to poor blood supply, not well oxygenated

Medication o Pain relief according to degree of injury and clients assessment of pain (may require narcotics) o NSAIDS for anti-inflammaotry affect as well as analgesia o Anti-ulcers o Stool softeners to prevent constipation due to decreased mobility o Antibiotics especially with open fractures o Anticoagulants, if client considered at risk for deep vein thrombosis ROM can be done to a fractured patient to the joint that is not affected. Example: fracture is on the knee, ROM on the ankle and hips can be done. Treatments o External fixation rods outside the skin o Internal fixation rods inside the skin o Traction to maintain or return fractured bones in normal alignment; prevent muscle spasms Countertraction body weight Composed of foot plate and line of pull The heavier the patient, the heavier the weight of traction Balanced Suspension traction with Pearson attachment Skeletal traction Prevent ulcer to patients with traction through pressure relief; depressing every area of the mattress one at a time to promote circulation, done every 30 minutes ideally. Egg crate mattress can be used instead in relieving pressure. o Casting to immobilize bones and promote healing Whole cast Bi-valve cast Cast with windows windows for fractures with wounds; if massive wound, it wont be window, it would be bi valve in which half would be removed. o Electrical bone stimulation: to treat fractures that are not healing properly Complications of fractures o Compartment syndrome excess pressure in limited space, constricting structures within and reducing circulation to muscles and nerves; normal pressure is 10-20 mmHg Within first 48 hours of injury Manifestations: progressive pain distal to injury not responsive to analgesia, decreased sensation, loss of movement; pulses may remain normal o In applying a cast, there should be a space (a finger is enough) to allow room for the swelling o Fat emobolism occurs with long bone fracture Manifestations characterized by neurologic dysfunction, pulmonary insufficiency, petechial rash on chest, axilla, and upper arms within few hours or weeks after injury Prevention: early stabilization of long bone fractures o Deep vein thrombosis Blood clot forms in lining of large vein; can lead to pulmonary embolism Prevention: early immobilization of fracture and early ambulation Prophylactic anticoagulation, antiembolism stocking (if fracture is above the legs) and compression boots. o Infection any complication decreasing blood supply increases risk; may result from contamination at time of injury or during surgery Organisms include pseudomonas, staphylococcus, or clostridium (anaerobic) May lead to osteomyelitis, infection within the bone o Delayed union prolonged healing of bones beyond usual time period Risk factors include Poor nutrition Inadequate immobilization Prolonged reduction time did not allow bone to fuse together, poor bone healing Infection, necrosis, age Immunosuppression - prone to getting infection Severe bone trauma the more complicated the fracture, the more difficult to heal o Non-union persistent pain and movement at fracture site Treatments Surgery: internal fixation, bone grafting Debridement if infection present Electrical stimulation

Amputation Partial or total removal of body part resulting from traumatic event or chronic condition Goals o Alleviate symptoms o Maintain healthy tissue o Increase functional outcome Types of amputation o Open (guillotine) performed when infection is present and remains open to drain

Closed (flap) wound is closed with flap of skin sutured in place over stump; common during accidents, avulsion Amputation sites o Arm o Legs Nursing diagnoses o Acute pain o Risk for peripheral neurovascular dysfunction o Risk for infection o Impaired physical mobility o Risk for disturbed sensory perception Complications o Infection, delayed healing o Chronic stump pain o Phantom limb pain sensations such as tingling, numbness, cramping or itching in the phantom foot or hand, often self-limited o Contracture prevented by Lying prone for periods throughout day (intermittent, maybe 8-12 hours per day) Active and passive range of motion Avoid prolonged sitting when you sit, you are actually raising your leg Stump dressing o Every time you apply a stump dressing, follow the contour. Tighter at the distal because blood supply must be pushed up towards the heart.

Carpal tunnel syndrome Compression of median nerve as result of inflammation and swelling of synovial lining of tendon sheaths Manifestations o Numbness and tingling of thumb, index finger, lateral ventral surface of middle finger o Pain interfering with sleep and reliever by massage and shaking of hands and fingers o Weakness and inability to hold items or perform precise activity Bursitis Inflammation of bursa enclosed sac found between muscles, tendons, bony prominences especially in shoulder, hip and elbow Epicondylitis Inflammation of tendons at point of origin into the bone Tennis elbow, golfers elbow with point tenderness and pain radiating down the dorsal surface of forearm Osteoporosis Characterized by loss of bone mass, increased bone fragility, increased risk for fractures Imbalance of processes that influence bone growth and maintenance; associated with aging Risk factors o Umodifiable Age Female Race Genetic Endocrine disorders o Modifiable Calcium deficiency Estrogen deficiency Smoking High alcohol intake Sedentary lifestyle Medications Meds o Estrogen replacement therapy o Raloxifene (Evista) o Biphosphonates potent inhibitors of bone resorption o Calcitonin (Micalccin) available as nasal spray or parenteral o Sodium fluoride stimulates osteoblast activity Health promotion o Calcium intake Optimal intake before age 30-35 increases peak bone mass Foods high in calcium Supplementation: calcium carbonate o Exercise (weight bearing) Waking 20 minutes, 4 times per week Gout

Syndrome occurs from inflammatory response to production or excretion of uric acid Primary gout Secondary gout hyperuricemia occurs as a result of other disease and treatments (cancer, chemotherapy) Big toe first, starts with one toe only Rheumatoid arthritis symmetrical manifestations Urate crystals or tophus or tophi in the joint area Pathophysiology o UA product of purine metabolism is normally excreted only through urine and feces o Levels >7 mg/dL (normal 2.4-7 mg/dL Manifestations o Hyperuricemia Uric acid average 9-10mg/dL Recurrent attacks of inflammation at the joint o Acute gouty arthritis Affecting single joint May be Affected joint is red, hot, swollen, very painful, and tender; often first metatarsophalangeal joint (great toe) Accompanied by fever, elevated WBC o Topahceous )chronic gout Occers Tophi Skin over tophi may ulcerate exude chalky material and urate crystals Medications o NSAIDS o Colchicines o Uricosuric drugs o Steroids o Analgesia including narcotics o Clients who produce excessive amounts of uric acids are treated with allopurinol (Zyloprim) which lowers serum uric acid levels Dietary management o If low purine diet recommended, client must avoid all meats, seafoods, yeast, beans, oatmeal, spinach, mushrooms o Lose weight, but fasting not advised o Avoid alcohol o Avoid slimy foods (okra) Other o Liberal fluid intake (2000mL) to increase urate excretion; urinary alkalinizing agents

Osteoarthritis Most common Loss of articular cartilage in articulating joints Risk factors o Age, but may be inherited as autosomal recessive trait o Pain exacerbated by work, relieved by rest o Excessive weight Cartilage lining joint degenerates, and loses tensile strength, Heberdens terminal interphalangeal joints Bouchards proximal interphalangeal joints Medications o Aspirin, acetaminophen. NSAIDS o Capsaicin cream topically to reduce joint pain and tenderness o NSAID COX-2 inhibitors with fewer GI and renal side effects Surgery o Change the joint o Reconstruction or total joint replacement o Arthoplasty o Arthrotomy changing the shape, reshaping Nursing care o Promote comfort o Maintain mobility Osteomyelitis BASA MOG LIBRO UI!haha Antibiotics mandatory to prevent acute case from becoming chronic Continued at least 4-6 weeks; may be given intravenously or intraosseously 1. Grating sound on hips in arthritis

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

18. 19.

a. Joint destruction Medical history related to hip joint condition of elderly a. High school soccer sport injury Potassium depleting diuretics a. Muscular weakness Right knee swollen, evaluate first a. Compare it to the left knee Fractures from osteoporosis, medication a. Estrogen Preparation of myelogram (most important) a. NPO hours prior to the procedure Arthrocentesis, interventions after procedure: a. Maintain compression bandage Total hip replacement, most serious complication a. Deep vein thrombosis Degenerative bone changes, include in diet a. Calcium fortified orange juice Decrease osteoporosis, encourage a. Walking Osteoporosis, important discharge health teaching a. Elimination of home safety hazards Acute osteomyelitis treatment a. IV followed by oral antiubiotics for 6-8 weeks Osteoarthritis a. Degeneration of atricular cartilage in synovial joints Complete fracture, the bone is a. Fractured through the entire bone structure First 72 hours after a bone fracture a. Hematoma formation Sustained a knee fracture and swollen. First action a. Elevate and apply ice pack Cast application should wait for how long for the cast to completely set and tolerate weight bearing before going home a. 1-2 hours In bivalve hours, careful to do the following a. Be sure not to pinch the skin between the two halves Cast is completely dry a. Odourless (cracked sound)