Chapter 11 cARE OF THE CLIENTS with NEUROLOGIC DisoRDERS (Alteration in Perception) Introduction The body's most organized and and complex system, the nervous system, profoundly affects both psychological and Physiologic functions. Even more fascinating is the knowledge of man’s abili feel as an individual organism. ility to comprehend, learn, act and ____ The onset of neurologic disorders may be sudden or insidious. These disorders can be frightening, even devastating, to the clients and their significant others — especially if the process is irreversible. Providing nursing care for the clients with neurologic disorders is challenging and demands extensive knowledge. Have you ever wondered how and why you are able to : Go to sleep during the night and awaken in the morning? See your beautiful/ handsome face in the mirror? Able to remember what day is today at what time your classes are on Wednesdays? . . Able to discriminate which pair of your shoes is for your right foot, and which pair is for your left foot? Locate your school and your classroom? Answer questions in your examinations? Text your friends? Sing a song? Dance gracefully? 649Fall in love? All of these and many other functions are made possible by the nervous system. is discussi it it i to plan appropri This discussion provides the information necessary i Priate nursing care for clients who experience neurologic problems in both acute and rehabilitative stages. Learning Outcomes At the end of this Chapter, the learner will be able to: 1. Assess the client for clinical manifestations of common nervous system disorders. | 2. Discuss the etiology, risk factors and basic pathophysiology of nervous system disorders. 3. Develop plans of care for the prevention, management, prevention of complications and rehabilitation of clients with: a. Loss of protective function (unconscious, increased intracranial pressure, seizures). b. Cerebral disorders. c. Degenerative neurologic disorders. d. Spinal cord, peripheral and cranial nerves disorders. 4. Implement nursing interventions that optimize the quality of life for clients with nervous system disorders. 5. Evaluate effectiveness of client outcomes based on criteria established in the nursing plan of care. Anatomy and Physiology of the Nervous System: ¢ The human nervous system is highly specialized system responsible for the control and integration of the body's many activities. e The nervous system carries out the following functions: Y Receives stimuli from the intemal and external environments through a varied afferent or sensory pathways. ¥ Communicates information between distant parts of the body (periphery) to the central nervous system. Y Processes the information received at vari conscious (higher brain existing situations. ious reflex (spinal cord) and ) levels to determine responses appropriate to 650its informati i ion rapidly over varied efferent or motor path ways y qransm! f rector organs for ic beff rg) body action control or modifications. neue single neuron is the 16 is the basi weous eystem. sic structural and functional unit of the y The neuron consists of a cell body (sor F 7 the neon transmits information esi and axon. — neurons. e cell body to adjacent y The dendrites receive informati a . called synapses. tion from axon terminals at special sites y They transmit information to the cell body. 7 The axon (large fiber) is covered by the myelin sheath Y The myelin ae Ms sterrupted by nodes of Ranvier at distances PPO pu mm. apart. At these uninsulated areas, impulses are Ce Z ae Howse to ee Therefore, conduction velocity along the a 7 use the “jumpin. effect” all izatic roceed quickly. ping allows depolarization to Neurons make functional contact with one another at specialized site called the synapses. v Transmission across a synapse is essentially a chemical process. synaptic transmission is both excitatory and inhibitory in nature. v Chemicals _allowing excitatory transinissions are acetylcholine, norepinephrine, dopamine and serotonin. While those that inhibit transmission are the gamma aminobutyric acid (GABA) in brain tissue and glycine in the spinal cord. Divisions of the Nervous System v The nervous system Is divided into two major parts: the central nervous system (CNS), the peripheral nervous system (PNS)- .d of the brain and the spinal cord. in parts: ivided into three mai medulla) a. The CNS is compose n, midbrain, pons, = The brain (encephalon) is d cerebrum, brain stem (diencephalo and cerebellum. = The cerebrum (outer layer is cerebral cortex) is composed of the : rontal lobes, two parietal lobes, two following lobes: [eo al temporal lobes, and two occipital lobes. is divided into two hemispheres (left and = The cerebral cortex right) by the falx cerebri. a = Each of the cerebral hemisphere is divided into lobes by folds in the cerebral cortex called fissures OF the respective sulci. 651ates the fronta, Rolando (central sulcus) 5 tal lobe e es the frontal !obe f" re separat The fissure of ‘om the temporal lobe from the pa! The Sylvian fissu! lobe. The parieto ~ occipital fissure the occipital lobe The cortex of the cerebl movement, separates the parietal lobe from um receives and analyzes ail impulses, stores knowledge of at and controls voluntary impulses recelv' / be has the following functions: entral gyTus Of motor The frontal lo! Controls voluntary motor activity (pre ability to speak clearty cortex) = expressive amotor) speech + {eroca’s) area). Damage to this area leaves the client ® early (expressive of Motor aphasia). unable to speal | areas control er time) The prefronta tion (attention ov 4. Concentral 2. Motivation 3. Ability to formulate oF select goals. 2. Ability to plan (e.g. future planning) 5. Ability to initiate, maintain or terminate actions 6. Ability to self — monitor. 7. Ability to use feedback (‘executive functions’) 8 Reasoning, problem — solving activities, emotional stability |. Development of personality 40. Sense of humor 41. Motor ability 42. Ability to write words The parietal lobe has the following functions: tion (tactile sensations like temperature. 4. Sensory percept touch, pain, pressure) — post central gyrus. ion 2. Concept formation and abstracti ness of size and shapes 3. oe orientation and awaret stereognosis) and body positis i ion) — night eeta love ly position (proprioception) ng! — left parietal lobe. 4. Right - left orientation and mathematics The temporal lobe has the followi n e jing functions: 1. Auditory receptive area — billy 0 hear 6522. Auditory associati Cernates fenties areas — ability to store spoken language language (music poral); sound memories that are not 3, Wornicko's ere oul sounds, other noises). Damage to! this se ecutates understanding language. aphasia. tesults to receptive or auditory Hida pe lobe has the following functions: - Viewal recov (ntepreinon area : 2. isual association areas — storage of contributes to the ability to visually understand the environment. 3. Vous speech center enables a person to read. D: is area leaves the client unable to read (Alexia). ss through The central (insula) lobe. Nerve fi e. e fibers for taste pa! the parietal lobe to the insular lobe. Many association fibers leading to other parts of the cerebral cortex pass through this lobe. Hippocampus. Is a part of the medial section of the temporal lobe. It plays a vital role in the process of memory. Three levels of memory have been identified: = Short — term (recent) memory is lost minutes. = Intermediate memory lasts days to weeks and eventually it is lost. = The hippocampus assists in the convel memory into the intermediate and long — thalamus. Basal ganglia. Is composet deep in the cerebral hemisphere: nucleus putamen, globus pallidus, s nucleus. . Diencephalon. Is composed of the thalamus and hypothalamu: |S. » The thalamus channel jate cortical cells. te to the appropt 7 = The hypothalamus regulates the au (ANS) functions such as heart rate, d pres al and electrolyte palance, stomach and intestinal motility, glandular activity, D temperature, hunger, body weight, and sleep ~ wakefulness. It also serves aS the master over f visual memories; recognize an lamage to t after seconds oF rsion of short-term term memory in the gray matter buried structures include subthalamic .d of layers of 5. These ubstantia nigra, the Is all sensory information except smell tonomic nervous system blood pressure, water 653= Limbic system. Is composed of the medial portion of the the pituitary gland by releasing factors that stim inhibit pituitary gland output. late gy frontay lobe, temporal lobe (hippocampus), thalamus, hypothais Mus and the basal ganglia. * It is the center for feelings and control of em, expression (fear, anger, pleasure and sorrow). ° = The temporal lobe component of the limbic system 5 essential role in the interpretation of smell. rain stem. Is composed of the midbrai ee posed of the midbrain, pons and meduia = The midbrain integrates visual and auditory reflexes. E.g, j a person sees a wasp fiying toward him, he ducks or twats away (visual reflex). Another example is turing the head (ear) to a sound (auditory reflex). The midbrain is also responsible for righting reflexes, those that keep the heaq upright and maintain balance or equilibrium, = The pons contains 2 respiratory centers that promote normal rhythm of breathing. The apneustic center prolongs inhalation; the pneumotaxic center contributes to exhalation. = The medulla oblongata contains cardiac centers that regulate heart rate; vasomotor centers that regulate blood pressure; respiratory centers that regulate breathing. It also Contains reflex centers for coughing, sneezing, swallowing and vomiting. tional Plays Speech is a function of the dominant hemisphere of the brain, which is for all right - handed people and most left- handed people is the left side. The two speech centers are The Broca's area is located in the left frontal (expressive) speech center — enables a pers and make gestures. The Wernicke's area i auditory speech center - enables a pel understand language. peech include an area The other areas that are also involved in sp r aye in the frontal lobe which governs the ability to write words Broca’s area and Wernicke’s area. lobe. It is the motor ‘on to speak clearly is located in the temporal lobe. It is the gon to receive an’ 654an area in the occipit pital lobe (vis i enables a person to understand See center) which IN CAPSULE brain stem structures and functions are as follows: Structures 7 Diencephalon a. Thalamus b. Epithalamus c. Subthalamus d. Hypothalamus [Functions ____— * Serves as end station for all sensory impulses. = All sensory fibers synap' relay station to appropriat sensory cortex. = Houses pain threshold. * Contains pineal body endocrine gland wh retards sexual development growth). = Receives fibers from globus pallidus, a part of afferent descending pathway. = Mediates mos' endocrine _ functions, responses. se for final 1 portion of (thought to be ose secretion and t autonomic functions, emotional 2. Midbrain | »_Onigrr pulses from cerebral cortex = Relays im subcortical structures above an below. Origin of righting and postural reflex. 3. Pons 4. Medulla ital centers of cardiac, pneumotaxic center — = Contains rhythmic quality of controls = Contains vi respiration, swallowing vasomotor control, and and hiccoughing, gag and Le eT et |__cough reflex, 655et, lation of key, . sists in the regul sf eles + Reiular formal toa reflexes. Wt also filers incoming a," movement an . cortex. . he Sea reticular formation, the nent a ‘eticy, . catvatng system (RAS) controls the sleep ~ wake ele ang consciousness. and white matter, mposed of gray . Peano bate (equilibrium) and posture, = Itcontrols voluntary (purposeful) motor activities ang POsit ody parts. . eae i fia acts in the cerebellum do not cross, Therefore ight cerebellar hemisphere predominantly affects, night (pater side of the body and vice versa, the ° Left and Right Brain Functions | * Dominant Hemisphere (Left) ~ Language and logical operations 1) Number skills 2) Written language 3) Reasoning 4) Spoken language 5) Scientific skills 6) Right - hand control "Right Hemisphere ~ Emotions, artistic and spatial skills 1) Insight €.g. How does a client recognize implications of illness? How would the client respond to given situation (eg. house on fire)? 2) Forms (3 dimensions) 3) Art awareness 4) Imagination 5) Music awareness 8) Left~hand contro! Protective and Nu tritional Str * Cranium an Petes id vertebral Column. ~The cranium ig com, i mew . Posed of eight bones that fuse in €2! Childhood. The fused junctions are called sutures. 656- The vertebral coly thoracic vertebrae. fused into a sacrun coccyx. Meninges. Consists Mie the spinal con ro, Membranes that envelope the brain he: . dura mater. Se are the pia mater, arachnoid and the mn consis B lumen of” cervical vertebrae, 12 crum, and 4 r vertebrae, 5 sacral vertebrae Coccygeal vertebrae fused into a - The pia mater i supports bioed ‘Sa Vascular layer of connective tissues. It brain and spinal cord. S passing through the tissues of the - The arachnoid i i speed peaeen a thin layer of connective tissues. The subarachnoid sp re peraelinoed and the pia mater is called through this space. . Cerebrospinal fluid (CSF) flows pete erent cura ites 9 fouan anon ststane vascular betw ie. The subdural space is the potential space etween the inner dura mater and the arachnoid. The epidural space is between the dura mater and the periosteum. Reflex mechanisms. Reflex responses are the conscious automatic responses to the internal and external stimuli, The reflex centers are the spinal cord (flexion and extension) and the brain stem (heart rate, breathing, blood pressure, swallowing, sneezing, coughing and vomiting). Cerebrospinal fluid and the ventricular system. - CSF is a clear, colorless fluid. Approximately 100 to 160 ml. in amount. = The CSF is primarily produced by the choroid plexu: lateral ventricles (2/3 of the CSF). - Approximately, 500 mi. of CSF is normally, it is absorbed in the bloo which it is formed. ; ae 7 = The ventricular system is a series of cavities within the brain. is of the produced per day, but d at the same rate at 657- CSF flow Lateral ventricles roramen of Monro Third senticle Py of Sylvius Fourth testi Foramina of Luschka Foramen of Magendie L Subarachnoid space (Cisterna Magna) behind medulla, below the cerebellum | — brain and spinal cord CSF circulates upward into the superior sagittal sinus Where it is absorbed across the arachnoid villi = Blood — brain barrier. Is a layer of least permeable capillaries that limit the free movement of substances from the blood to the brain tissues. The barrier is selective, allowing entry of fluid gases and small molecular substances while preventing the entry of toxic substances, plasma protein and large molecules. "The CSF has the following functions: 14. Cushions the brain and protects it from jarring against the skull 2. Nourishes the brain. 3. Removes metabolites from the brain. 4. Regulates the intracranial pressure. * The spinal cord has an H-shaped central gray matter surrounded by white matter. The white matter is divided into three columns or funiculi as follows: anterior/ventral, lateral and Posterior/dorsal columns. Each contains ascending afd descending tracts. ee S also the site of reflex pathways. A refex Of specific stereotyped motor response to 2° adequat , ; a forse Sensory stimulus. It does not require relay to the bre" 658» The meninges which coy, spinal cord help support spinal cord. The outermo fer the nervous tissue in the brain and Protect and nourish the brain and the er is th i st layer is the dura mater, the middle layer is the arachnoid and the innermost is the pia mater. » There are thre i richiatelas Gina Spaces associated with the meninges * epidural (external to the dura); subdural (between dura and arachnoid) : arachnoid and pia mater). hnoid); and subarachnoid (between « The Spinal Cord 7 Det nate cord is composed of ascending and descending b. ain pathways (afferent fibers) are sensory fibers. impulses to the brain. c. The descending pathways (efferent fibers) are motor fibers. They carry impulses away from the brain . The spinal cord is the center for reflex acts. e. Itis the origin of the ANS (Autonomic Nervous System). The craniosacral segment is the origin of the parasympathetic nervous system. The thoracolumbar segment is the origin of the sympathetic nervous system. g. Damage to the spinal cord causes paralysis and loss of reflexes below the area of the lesion. E.g. Cervical spinal cord injury results to quadriplegia (paralysis of the four extremities). moa 2. The Peripheral Nervous System (PNS) is composed of bundle of nerves that are either sensory, motor, or “mixed”. = The PNS is composed of the 12 pairs of cranial nerves and 31 pairs of spinal nerves. The cranial nerves carry impulses to and from the brain. They originate mainly in the brainstem except for the olfactory nerve that arises in the olfactory bulb. * Spinal nerves are composed of a dorsal and ventral root. They are as follows: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. From Ls to Sz, the spinal nerves branch out to form the cauda equina. . | that transmit information toward the CNS are * Peripheral nerves T te afferent or sensory in nature. While peripheral nerves that transmit information away from the CNS are efferent or motor in nature. ear F 2 " The peripheral nervous system is divided into somatic and autonomic nervous system. The somatic nervous system 659‘i uscles. A small cleft etal (strated) TY gynaptic cleft). At the oe and the m! Jes containing acetylcholing “Of ee! acetylcholine is release muscle contraction. The Musee tylcholinesterase, which is locates ir skel innervates between the nerve ey the nerve ee er impulses move a reaches the muscle ore contraction is stoppe' yy in the muscle. stem is divided into sympa thet a is sy’ 4 ic * The autonomic (oarenergi) and the parasympathetic Nervous nervous sys! system crete for the postganglionic synapse of 4,, + The ne i i hrine; ang "4 system is norepinep! the Se aT te postganglionic Synapse Of the pare mpathetic nervous system is acetylcho! me ‘i . The effects of Sympathetic and Parasympathetic Nervous s follows: a SFFECTS OF THE SYMPATHETIC AND PARASYMPATHETIC NERVOUS SYSTEM Sympathetic Nervous Parasympathetic Organ System ymp See ee ats Heart Increased heart rate Decreased heart rate Blood Vessels Constricts visceral anc Dilates visceral and brain vessels brain vessels Lungs Dilates bronchi, T RR eens bronchi, RR Gastrointestinal Decreases peristalsis Increases peristalsis Anal Sphincter Closes anal sphincter Opens anal sphincter Urinary Relaxes bladder, closes Contracts bladder, sphincter opens phincter _| Eye Dilates pupils Constricts pupils Accommodates far vision Accommodates near z vision 4 Skin and sweat “Goose flesh”, Pallor, diaphoresis Decreases gastric and Increases gastric and Salivary secretions Salivary secretions Stimulates glycogenoh ‘sis (elevates blood ghreoes levels) 660SULE: Di aminishes Secretion of Be ncreatic enzymes timulates production o pee pinephrine fomotes ejaculation fe Increases secretion of pancreatic enzymes _ Causes erection APs ison between th compat © Sympathetic Nervous System (SNS) and ’ go Parasympathetic Nervous Systom (PNS} | IS ; PNS origin iThoraco = lumbar| Sacral segment of the Released egment of spinal cord_| spinal cord Hommon Norepinephrine Acetylcholine Concepts Everything is HIGH| Everything is LOW and FAST but GI/GU are SLOW and SLOW but GI/GU are FAST Necessary for survival. DILATE CONTRICT = Pupils = Pupils = Bronchial Tree * Coronary blood vessels = Bronchial Tree = Coronary blood vessels CONSTRICT = Peripheral blood vessels DILATE = Peripheral blood vessels Applications in Anticholinergic Cholinergic Pharmacology Beta agonists: Beta blockers: ANTIHYPERTENSIVES BRONCHODILATORSking Exercises TIC OR PARASYNp, ATHED, IC Critical Thin! : SYMPATHE Classify the following effects: SY! High Impact Concepts: Sympathetic - “Everything is Hig! “Everything is Low and Slow, except Gl and gy, hand Fast, except GI and Gy» | Parasympathetic — 1. Restlessness 2. Constriction of the pupils 3. Elevated BP 4. Tachypnea 5. Bradycardia 6. Diarrhea —__ 7. Dilatation of the Pupils — 8. Diaphoresis 8 Hypoglycemia —______________ 10. Increased gastric acid secretion —_________11. Constipation ————___________ 12. Urinary frequency —____ 13. Hyperglycemia ——__________ 14. Increased salivation ——____________ 15. Hypotension ———_____ 16. Pallor ———_______ 17. Thirst, Dryness of mouth 18. Urinary Tetention 19. Decreased Salivation 20. Cold, clammy skin 662; sympathetic —anticholi fi olinergic; Parasympathetic — cholinergic) wor werd ; sympathetic og parasympathetic 4, sympathetic i ympathetic : parasympathetic é parasympathetic 1 sympathetic & sympathetic . parasympathetic 40.Parasympathetic 41.sympathetic 42,Parasympathetic 43.sympathetic 44,Parasympathetic 4§.Parasympathetic 46,sympathetic 47.sympathetic 48,Sympathetic 49,Sympathetic 20,Sympathetic | 663Physi 4. Loss of brain cells 2. 3. 4. 5. 6. i 8. |. Decrease in blood flow and increased reaction time and increaseg tir . Impairment in short-term memory. . Alteration of sleep - wakefulness ratio. Decreased ability to regulate body temperature because of chang 8 in i the Nervous system with Agin io changes er tual loss of brain weight. 9 jth at i ae Gyri of the brain surface atrophy, causing widening and deepen; spaces between the gyri. NG op required for decision making. Ability of the brain to autoregulate its blood supply lessens, the function of the hypothalamus. Sensory and motor conduction decreases in velocity of impulses. Sensory conduction decreasing faster than motor, Nerve in peripheral nerves. * Specialy 664i tic Tests rodiagnos wes FS ’ — ray visualizatior vx N of the Y Remove metallic items from {confirms skull fracture. spine Films air. y_ X- fay visualization of the Spine. v Remove metallic item from aroun Y pvoid flexion / rotation of spine wre eek / BOW. cAT Scan 'e when fracture is ‘suspected. v Computerized reconstructi ray beams. ction of body part by passage of multiple X — v Remove metallic obj - . Y Client must remain asecine hair. These may be mistaken as lesions. ‘ess for claustr utely still during the entire procedure. v Asses' ustrophobia (fear of enclosed s} The procedure is done in a tunnel- like device. pace). The procedu ¥ Sedation is done if the client is restless or i panes oris I. Yineo 4'to 6 hrs! it contract medians ot ee to remain stil ¥ Observe for allergic reaction to iodinated contrast material . Electroencephalography (EEG) Y Graphical recording of spontaneous eléctrical impulses of the brain from scalp electrodes. Explain procedure to the client. : v Hair shampoo before the procedure to remove oil / spray$. For better transmission of electrical impulses of the brain. ¥ Avoid caffeine and other stimulants, anticonvulsants for at least 24 hours before the procedure. These substances affect electrical activities of the brain. ¥ Wash hair after the procedure to remove EEG paste. Electromyography (EMG) and Nerve Conduction Velocity (NCV) Y EMG records electrical activities in muscles at rest, during voluntary contraction, and in response to electrical stimulation. Y NCV studies, record speed of conduction in motor and sensory fibers of peripheral nerves. . y F ' a Detects neuromuscular disorders, e.g. Myasthenia Gravis, Parkinson's di pease etc, all electrode needles will be Y Explain procedure to the client ; sm inserted into the muscles. “¥ May be with mild discomfort due to the needles, Y Time is approximately ‘45 minutes for one muscle. * Brain Scan 665< " lide (oral, IV, intra ~ a Involves administration of radionuclide ( terial, inhalation). lar diseases, Detects brain tumors, area ve negtigibl, Reassure client: radiation dure is painless. Time is about 45 minutes; proce eadure The client must lie still during the pro ° Cerebral Angiography (Asteriogrem) with simultaneous ~ Intra ~ arterial injection of contrast med intracranial and radiographs of head and neck to visualize in oxtracraniay vessels. Y Nursing Considerations * Before the Procedure ; © Explain procedure to the client. | a | © May experience hot, flushing sensation as dye is injected, © Contrast material injected into femoral, brachial or Carotid arteries. ’ | © Remove metallic clips from hair. © Check allergy to iodine or seafoods. © NPO4~-6 hours. © IV fluid to ensure adequate hydration. © Premedicate as ordered. After the Procedure © Observe arterial puncture site for bles pressure dressing or small sandbag Observe pulse distal to the Puncture Pulse may indicate impaired circulati vessel by thrombus or by hematom: © Observe affected limb for color and SSANN eding or hematoma; appl or ice pack to the area. site; diminished or absent ion due to blockage of a. to vagal irritation in Carotid artery. ° Observe for any changes in Neurological status; risk of stroke of ischemia following angiography secondary to embolus, thrombus or vasospasm, © Bed rest (may have head eleva Puncture, must keep leg exten ted) for 6 to 8 hrs.; if femoral hours to prevent dislodgi \ded and immobile for several Jement of clot.>» mbar Puncture (Lumba; ’ Vi Introduction of needle ine La, Le (CSF) int = Ls, bs = Sy, intone Spinal Subarachnoid space usually at Ls — ‘ebral space, to assess cerebrospinal fluid v_ Nursing Considerations » Before and Durin, ° ° ° = Aft ° ° ° ° * Not ° ° ° 9 the Procedure Encoura, ie a comfort. ge Client to void before the procedure. To promote Assist client to assume position with back arch widen intervertebral Spi spinal needle. Local anesthetic is used t Label the specimen collected (eget >, 3 Queckenstedt’s test may be performed to test for subarachnoid obstruction. The jugular veins are compressed for 10 secs., first on one side, and then on the other side: note for any change in pressure of spinal fluid. ler the Procedure Lie flat in bed for 6 — 8 hrs. (may turn to sides). To prevent spinal headache, which is due to leakage of CSF through the puncture hole. Encourage fluids if not contraindicated. Headache;may develop due to CSF leakage; treated with bedrest , analgesics and ice to head. Observe for changes in neurological status. mal Values of CSF Pressure > 75 to 180 mmH;0 or 0 to 15 mmHg. Elevated in increased ICP. Glucose —> 50 to 80 mg/dl. Decreased in infection. Protein —> 20 to 50 mg/dl. Elevated in infection or presence of tumor in the brain or spinal cord. “fetal position” (lateral recumbent led, head and knees flexed on chest) to ‘aces. This facilitates insertion of the 667. ore of a radiopaque solution, oil ~ based or water _ in as the spinal subarachnoid space with fluoroscopic and TAdiograppe observation. ic! My Y. Detects vertebral disk disease , spinal cord tumors. y Nu © Magnetic Reson: Y Us y¥ Nu sing Considerations Before the Procedure ‘ © Consent must be signed. © Requires lumbar rae Premedicate client as o1 a ° |nform client that time is approximately up to 2 hours, After the Procedure , se © For pantopaque myelogram (oil — based), Patient lies flat for 8b 24 hrs. to prevent spinal headache, Oil- based dye does, ot Combine with CSF. Itis possible to remove all of the dye after the procedure, Flat Position is maintained to Stabilize CSF Pressure, © For metrizamide myelogram (water — based), HOB bed) is elevated at 30 degrees for at least 8 hrs, to Meningeal irritation, Water- based dye (head of ° Encourage fluids to enhance excretion of dye, © Observe for any change in Neurologic status — Confusion, disorientation, Nausea and vomiting. © Observe for generalized seizures, © Avoid administration of phenothiazines (they lower seizure threshold). lance Imaging (MRI) eS a very strong magnet Combined with radiofrequency waves anda Computer to produce X-ray y-like ima irsing Considerations Obtain history of Metal implants including Cardiac pacemakers (clients with metal it implants are not eligible for MRI Scans). Procedure lasts from 30 to 90 Minutes, Reassure client that Procedure is, Painless, Assess for claustrophobia Inform client sounds, 9eS of body chemistry. that machine makes drum — like or knocking Request client to remove credit ¢; . ‘ards, watches which may be demagnetized ar any metal item, 668ye OM oencephalography ‘al contrast study of the ventricular and cistemal systems using air A contrast medium. if curate | izatic . . . its accurate localization of brain lesions by spinal or cisternal Pel ei 4 J yncture with X-ray examination, VN ing Considerations , Before the Procedure ° e000 o000 ° + Ventriculography ¥ Airis introduces openings Secure written consent. Sedative as ordered. General anesthesia may be used. Time is about 2 hours. i May experience discomfort, headache, nause: (contraindicated in increased ICP.) a and vomniting After the Procedure Flat in bed 24 to 48 hours. Monitor VS and do neurologic checks. Severe headache lasts 48 hrs. Observe seizure precaution. Observe for respiratory difficulty. d directly into the lateral ventricles through trephine (burr holes) into the skull, X-ray films are taken. ¥ Performed in OR (operating room). y¥ Nursing Considerations * Before the Procedure o Secure surgical permit. ° ° * After Procedure o Same as after pneumoence Positive ¥ Involves use of radioactive-sub: (positrons) while CT scanning is pe! Y Provides metabo! Prepare client as if for surgery. Inform client that general anesthesia will be used. phalography. PET Scan) bstances that emit positive electrons formed. lic profile by revealing the rai Emission Tomography ( ite at which tissues metabolize glucose. Evoked Potentials (Auditory, Visual) / Y Electrical measurements aturation of human nervous of physiologic m: - system. ts Aids in the diagnosis of multiple sclerosis. = 669logic Functioning: mal Nowe uires the follows + Basic Concepts in No! us system req lowing: Normal functioning of the requis 20% of the OxYEN in the bog, 3 isos Sy The brain requires 65 10 70% of the glucose gt 2. Glucose supply. ; a pe euppy, Te brain requires 1/8 ofthe cardiac output 4, ‘Acid — base balance. ilation and increases int 5 | suese cerebral vasodilatio racra | Acidosis causes corel CNS depressant and may lead to nial is also a ess 1 v Alkalosis (Ot bral vasceoneicet aa anes al is a stimulant intracranial pressure. It is also called and may i 5. Blood ~ brain barr Intact blood — brain barrier protects the brain fr tain drugs, chemicals and microorganisms. 1 6. csr Volume. CSF cushions the brain; it nourishes the brain, ang determines the ICP. ¢ Neurologic assessment 1. Mental status Y Assess orientation and memory. ¥ Orientation involves people, time and place. ¥ Memory includes short — term, recent and remote memory. 2. Level of consciousness (LOC): It is the single most sensitive indicator of changes in the neurologic status of a client. Y The levels of consciousness are as follows: a. Level |. Conscious, coherent, cognitive (3 C’s), b. Level Il. Confused, drowsy, lethargic, somnolent, obtunded. Somnolent or obtunded patient sleeps most of the time, but easily aroused by verbal stimuli, c. Level Mil. Stuporous; responds only to noxious, strong or intense stimuli, e.g. sternal Pressure, trapezius pinch, pressure at the base of the nail or Supraorbital area; very strong light or very loud sound. d. Level lv, * Light coma: response is only grimace or withdrawing limb from pain, primitive and disorgani: ainful stimuli. ganized response to pé * Deep coma: absence of Tes inful stimuli, ‘Sponse to even the most pal 670¥ Glascow Coma Scale Gi is i ‘ LOC. (GCS) is an objective measure to describe ee areas assessed j response and verbal a GCS are eye opening, motor a. Eye Opening nee * 4 Spontaneous = 3 On request * 2 To painful stimuli = 1No eye opening b. Best verbal Response : a onone to time, place, person a Words aoaker burearve, confused in content ut conversati i : 2 Groans aan rsation not sustained . lo response even on e\ c. Best Motor Response ae * 6 Obeys command » 5 Localizes painful stimuli * 4 Flexion withdrawal » 3 Decortication (abnotmal flexion) = 2 Decerebration (abnormal flexion) = 1 No response. 3, Sensory Function v Tests for sensory function assess the functioning of the parietal lobe. yes closed, €.9- placing cold ¥ The tests are done with the client's e' and warm fluid in test tubes over the skin; pricking skin with blunt objects; iving cinnamon to taste; coffee to smell. The eyes are closed during the test to avoid visual clues. | ¥ The’ examiner should avoid giving verbal cues such as, “Is this sharp?” ’ v The sensory stimulus should be applied in such patient does not iding rhythmic app! stimulus. : v In routine neurologic testing. Sean is sufficient. However, if a disturba skin is identified, the boundaries of that dys carefully delineated along the dermatomes ; innervated by the sensory fibers of 2 single dorsal roo! nerve). a way that the t expect it, avoi licaticn of the testing of the four extremities ice in sensory function of the function should be (areas of the skin t of a spinal 671. Light touch = The examiner gently strokes a cotton wis; P Over each extremities and asks the patient to indicate wig! ty stimulus is fell by saying “touch”, te . Pain and temperature 9 i kin with the Pain is tested by touching the st pin. This stimulus is irregularly altemated with . stimulus with the dull end of the pin to determing wether patient can distinguish between the two stimul Shh NAD eng A Simplg ta i Extinction or inhibition is assessed by g Stimulating opposite sides of the bod: either a pain or a touch stimulus, ot Normally, the simultaneous stimuli are both Perce (sensed); perception of only one may indicate Parietay lobe lesion. . The sensation of temperature is tested by applying tubes oy warm and cold water to the skin and asking the Patient 1, identify the stimuli with the eyes closed. \f pain sensation is intact, assessment of tempera Serisation may be omitted because both Sensations arg carried by the same ascending pathways, Vibration sense. Is assessed by applying a vibrating tuning fork to the fingernails and the bony prominences of the hands, legs and feet with the Patient's eyes closed, *" The examiner as} ks the patient if the vibration or IMultane, 'Y symmetricayy “YY Cally wth, . The examiner stops the vibratio hand as desired. Position sense. Is assessed by Placing the thumb and the forefinger or great toe and gently moving the finger or toe up and down. The patient with eyes closed, is asked to indicate the direction in which the digit is moved, Another test of position Change in the lower extremities is the Romberg test. The patient is asked to stand with the feet together and then close the eyes, * IF the patient is able to maintain balance with the eyes open but sways or falls with the eyes cleced (ie., a postive Romberg tests), vestibule-cochicar dysfunctions or disea 672v S88 in the posterio itis important eons of the spinal cord may be indicated. ah Cortical Sensory Fun aa patient safety during this test. « Cortical integrati ; parietal iebaaai of sensory perceptions occurs In the * Two — point discrimination i i ofe a cctimination is assessed by placing two points The minimum mMpass on the tips of the fingers and toes. fingertips and fecognizable separation is 4 to 5 mm-in the ae Ene greater degree if separation elsewhere. This cort portant in diagnosing diseases of the sensory ee aa Peripheral nervous system. a esthesia (ability to feel writing on s! aving the Patient identify numbers traced on hands while the eyes are closed. . See is ability to perceive the form and nature of objects. It is tested by having the patient identify the size and shape of easily recognizable objects (e.g., coin, keys, 4 safety pin) placed in the hands again, with the eyes closed. * Sensory extinction or inattention is evaluated by touching both sides of the body simultaneously. = An abnormal response occurs when the patient perceives the | stimulus only on one side. The other stimulus is “extinguished”. . = Agnosia is the inabil kin) is tested by the palm of the lity to perceive sensory stimuli. 4, Motor Function | lobe is affected, the client experiences inability to If the frontal perform motor activities. Apraxia is inability to perform fine motor activities (done by fingers) ‘Agraphia is inability to write. bellar function (sense of Romberg test is done to assess cerel equilibrium). The test is done by asking the client to stand with the feet together and the eyes closed or the client is asked to walk in an imaginary straight line. Normal result of Romberg test is that, the client should be able to stand erect. Slight swaying is normal. Or the client is able to walk coordinatedly in an imaginary straight line. if the client falls or experiences uncoordinated movement (ataxia), this is positive Romberg that indicates cerebellar function impairment. Ataxia is uncoordinated movement, characterized by wide — base stance and swaying manner of walking. 673- the foll ; v Assessing the motor function includes © following: a. General saan HA unpurposeful, and Uneoor : Healer asymmetry of the face, muscle Aystrophy ey b. Muscle power. Assess for = Weakness ("paresis") “= Paralysis (“plegia”) ¢. Muscle tone. Assess for = Flaccidity (hypotonicity) ® Rigidity (hypertonicity) d. Muscle volume. Assess for "Atrophy (loss of muscle volume) * Hypertrophy (increase in muscle volume) ©. Movement. Assess for " Bradykinesia (slow muscle movement weakness). Akinesia (absence of muscle mover weakness). f. Coordination. Assessed by = FTNT (finger-to-nose-test) * H-K-T (heel-to-knee-to-toe test) = Heel —to— shin test 9. Station and gait. Station is not aSSOciateq With ‘ment not Associated With Posture; gait is manner Of walking, Parkinson's disease is characterized by shuffling, festinating gait (tiptoe walking, Starting at slow Motion, the pace keeps on increasing until the client assumes Tunning Pace). 5. Reflex testing. Y Superficial Reflexes . Pupillary Reflexes ° Direct light Teflex is elicited by applying light stimulus, moved a Side into the Pupil; this results to Constriction of the Pupils. : oamenetel light reflex results to simultaneous constriction oth pupils even if light is applied to one pupil only. © Accommodation reflex resutts to constriction of pupils when gaze is shifted from a distant obj i S ect to a near object. © pupillary reflexes are fepresented by PERRLA (Pupiis Equal, Round, Reactive to light, Accommodation). 674A fixed i a Ce aetive nd dilated pupil in a client who has had previously pan hens Neurologic emergency. This may indicate aseeere at com; it " physician immediately. presses the brainstem. Notify the Caen 8 Clicited by touching the cornea with a wisp of cote OCCURS. This teoOXS toward opposite direction; blinking of the oes - This tests the sensory function of the trigeminal Abdominal reflex results to contracti i lbdomen stroked with blunt object. traction of the side of the a Cremasteric feflex is elicited by downward stroking of the inner thigh of the male; elevation of the scrotum on the same side occurs; this is done only among unconscious males. Babinski reflex is elicited by stroking the sole of the foot from the heel upwards; plantarflexion (negative Babinski) is the normal result among adults. Interpretation of Superficial Reflexes = 0O-— absent « + slightly present = +-— normally active Deep Tendon Reflexes (DTR’s) = In general, the biceps, triceps, brachioradialis, patellar and Achiles tendon reflexes are tested. * Tendons attached to skeletal muscles have receptors that are sensitive to stretch. A reflex contraction of the skeletal muscle occurs when the tendon is stretched. A simple muscle stretch reflex is initiated by briskly tapping the tendon of a stretched muscle, usually with a reflex hammer. = The response (muscle contraction of the corresponding muscle) is measured as follows: 0/5 absent 1/5 weak response 2/5 normal 3/5 exaggerated response 4/5 hyperreflexia with clonus. " Clonus, an abnormal response, is a continued rhythmic contraction of the muscle with continuous application of the ‘stimulus. - e " Biceps reflex is elicited by placing {the examiner's thumb over the biceps tendon in the antecubital space and striking the 675Oculocephalic Reflex or Doll's ey demonstrated by holding the pe head from side to side. Positive The patient should have the ay, jth a hammer. Ims up. The normal ren? thumb with a with the pal respon flexed at the ep at the elbow oF contraction of the re i fexion fe fan It by the Sree ettoseoer “se muscle thal ©; elicited by striking fon ab Triceps reflex ee WS flexed. The normal moe ty elbow while the P: ee i or visi 4 extension of fig reflex is elicited by striking the ragiy, ; ee @ the wrist while the patient's arm is telaxeg rem Gea is flexion and supination at the elbow contraction of the brachioradialis muse ri Patellar reflex (knee jerk) is elicited by stri ing the Patel, tendon just below the patella. The patient can be sitting o; bing as long as the leg being tested hangs freely. The noms response is extension of the leg with contraction of the quadriceps. i is elicit iking the Achilles Achilles tendon reflex is elicited by striking tendon while the patient's leg is flexed at the knee and the foot is dorsifiexed at the ankle. The normal response is plantar flexion at the ankle. atti y OF Visite Interpretation of DTRs +1 hypoactive +2 normal +3 brisk but not pathological +4 hyperactive, pathological Ankle jerk is produced by tapping the tendon of Achilles; plantar flexion of the foot occurs (Tendon of Achilles reflex). Knee jerk (patellar reflex) is produced by tapping the quadriceps femoris, just below the patella; it results to leg extension. Reflexes to assess meningeal irritation o Kernig’s sign. The client is placed in supine position. Flex the knee, attempt to extend the leg. Pain is experienced (positive result- abnormal). © Brudzinski's reflex. The client is placed in supine positon Passively flex the neck, spontaneous flexion of the his occurs (positive result- abnormal), This is more accuré? indicator of meningeal irritati ig’ ‘ye phenomenon. Thisis the son's eyelids open and rotating or normal dolls eye is 676 ble contraction of the triceps "St,v v demonstrated by i, opposite side, Dyseo uate Movement of the eyes towards the Paso aaa impaten ° movement of the eyes indicate irrigating the. a oF Caloric Ice Water Test. This is done by normally causes connie, canals of the ear with ice water. It eyes. This is an Perea Ber movement or nystagmus of the functioning. Dysco od of assessing brainstem ju : function impaimery 942 movement of the eyes indicate brainstem . Language and Speech. The speech centers are as follows: Broca’s i THe pares ° oa a outa lobe. This is the motor speech center. the Broca's area et speak and make gestures. Impairment of inabili lo expressive or motor aphasia which is inability to speak and make gestures. Wernicke’ 'S area in the temporal lobes. This is the auditory speech center. This enables a person to interpret sounds or language. Impairment of the Wemicke's area results to receptive or auditory aphasia, which is inability to understand sounds or language. Global aphasia inability to use and understand language. This occurs from impairment of both the Broca’s and Wernicke’s areas. Visual speech center in the occipital lobe. This enables a person to read or interpret symbols. Impairment of the visual speech center results to alexia, which is inability to read. . Bowel and Bladder Function ‘The sympathetic nervous system (SNS) which originates from the thoracolumbar segment of the spinal cord is the inhibitory impulse. Impairment of the SNS leads to bowel and bladder retention. The parasympathetic nervous system (PNS) which originates from the craniosacral segment of the spinal cord is the motor impulse. Impairment of the PNS leads to bowel and bladder incontenence. 6778. Cranial Nerve testing Cranial Nerves Olfactory (CN ) Smell a Vision Abnormal in of smell Neg Papilledemg: i vision; scotorm,. "8d - ma; blindness" mastication; sensations for the entire face and cornea Oculomotor | Pupil constriction, elevation | Anisucuria; ina (CN II) of the upper lid Pupils; fixed, dlofag Pupils Trochlear (CN IV) | Eye movement; controls Nystagmus (roling a ‘| superior oblique muscle the eyeballs) Trigeminal (CN V) | Controls muscles of Trigeminal Neuralgig (Tic dovloureux) Abducens (CNV) Eye movement; control the lateral rectus muscles Diplopia; ptosis of the eyelid Facial (CN VI) Controls muscles for facial expression; anterior 2/3 of the tongue. Bell's palsy; ‘ageusia (loss of sense of taste) on the anterior 2/3 of the tongue. Acoustic (CN Vill) Cochlear branch permits hearing; vestibular branch helps maintain equilibrium Tinnitus (cochlear branch); Vertigo (vestibular branch) Glossopharyngeal (CN IX) Vagus nerve (CNX) Controls muscles of the throat; taste of posterior 3 of the tongue. Controls muscles of the throat, Parasympathetic Nervous System stimulation of thoracic and abdominal organs. 678 Loss of gag reflex,” drooling of saliva, dysphagia, . dysphonia, posterior third ageusia "| Loss of gag reflex drooling of saliva. dysphagia, dysarthria, . bradycardia.increased HCI secretion Inabilily to rotate the spinal Accesolry = | Controls () ster 7 an rapes oman and | head and move the Aypogiossal Movement oes shoulders (cnx!) of the tongue. _| Protrusion of the tongue or deviation of the tongue to one side of the mouth CNs |, I! — originate from the cerebral CNs Ill, IV — originate from the midbrain, hed Ns V, VI, Vil, VIll — originate from the pons CNs IX, X, XI, Xl - originate from the medulla oblongata , cranial Nerve Testing Testing of each cranial nerve is an essential component of the neurologic examination. 4, Olfactory Nerve (CN I) ¢ After determining the both nostrils are patent, the olfactory nerve is tested by asking the patient to close one nostril, close both eyes, and sniff from a bottle containing coffee, spice, soap ‘or some other readily recognizable odor. The same is done for the other nostril. Y Generally, olfaction is not tested unless the patient has some disturbance with smell. Chronic thinitis, sinusitis and heavy smoking can often decrease the sense of smell. Y Disturbance in the ability to smell may be associated with a tumor involving the olfactory bulb, or it may be the result of a basilar skull fracture that has damaged the olfactory fibers as they pass through the delicate cribriform plate of the skull. 2. Optic Nerve (CNII) a | Y Visual fields and visual acuity are assessed to test the function of ic nerve. v Peril visual fields are assessed by confrontation. The examiner positioned directly opposite the patient, asks the patient to choose ‘one eye, look directly at the bridge of the examiner's nose, and indicate when an object (finger, pencil tip, head of pin) presented from the periphery of each of the four visual field quadrants is seen. The same test is repeated for the other eye. 679. Oc v v ise from lesions of the ,,,. defects may arise Optic Sree or tracts that extend through the temporay, em, ipital lobes. . Visual eld changes resulting from fain lesions arg us either a hemianopsia (loss of half of the visual fig ay quadrantanopsia (one fourth of the visual field is ay... 4 & monocular. . . Visual acuity is tested by asking the patient to reag 4 Stele chart from 20 feet away. als physical condition of the optic disc oe wes the retina and blood vesselg ate nerve atrophy and papilledema can be detected by this Methege ‘tulomotor (CN Ill), Trochlear (CN IV) and Abducens (cy vy These 3 cranial nerves all help move the eyes ang they are tested together. oy The patient is asked to follow the examiner's finger as it moveg horizontally and vertically (making a cross) and diagonal (making an X). If there is weakness or paralysis of one of the eye mi eyes do not move together, and the patient has dysco, gaze. The presence and direction of nystagmus (fi jerking movements of the eyes) are-observed at this time, even though this condition most often indicates vestibulocerebellar problems. Other functions of the oculomotor nerve are tested by checking for pupillary reflexes as follows: a. Direct light reflex — the normal re: Pupil in response to light. b. Consensual light reflex — the examiner shines a light into the Pupil of one eye and looks for ipsilateral constriction of the Same pupil and contralateral constriction of the opposite eye. ©. Convergence and accommodation — are tested by having the patient focus on the examiner's finger as it moves towad the patient's nose. (Convergence is observed as eft? turning inward and accommodation is observed as pusié constricting with near vision). The size and shape of the Pupils should also be noted. T™ normal resting size of the Pupils is 3 to Smm. is The normal pupillary responses should be PERRLA (pt?! equal round, reactive to light, accommodation). njugate Ine, rapid sponse is constriction of the 680y Another function of the ocu ora ae to the feces nerve is to keep the eyelids y p a " normalities and ine Cause ptosis (drooping eyelids), esting for pupillary reflex ‘ye muscle weakness. neurologic assessment of syndrome. Because t A he the brainstem at the sneer nerve exists at the top of by expandin torial notch, it can be easil sed result is a Beatie lesions in the cerebral hemispheres. The may become iia ee Not constrict in response to light; it acts unopposed. cause the sympathetic input to the pupil Anisucuria i pressure icon Pupils) ‘indicate incrdased intracranial the left cerebral hemig a ipsilateral dilation of the pupil (e.g., if ¥ Pinpoint ora’ Nemisphere is affected, the left pupil is dilated.) a point pupils indicate involvement of the pons. ixed, di ils i i Lt indi et lated pupils in an unconscious patient indicates uncal erniation. This is the sign of i it tl i jh : impending death. Compression of the brainstem affects the centers that regulate the respiration and cardiac functions. . Trigeminal Nerve (CN V) : | v The sensory component of the trigeminal nerve is tested by having the patient identify light touch (cotton) and pinprick in each | of the three divisions (ophthalmic, maxillary and mandibular) of the nerve on both sides of the face. v The patient's eyes should be closed during this part of the examination. Y The motor component is tested by asking the patient to clench tne teeth and palpate the masseter muscles just above the mandibular angle. / ¥ The corneal reflex test evaluates CN V_ and CN Vil simultaneously. This test is not normally done in patients who are awake and alert because other tests evaluate these two lying a cotton wisp strand to the cornea. nerves. It involves appl t n ; Y The sensory component ‘of this reflex (corneal sensation) is ision of CN V. i d by the ophthalmic division of v er Me ret (eye blink) is innervated by the facial nerve (CN VII). . v ie i creased level of consciousness, the corneal Roc peie wih = ion of the brainstem integrity at ides an evaluati Haleeady sie pond because the fibers of CN V and VII have connections in this area- 6815. ° . Glossopharyn: v Facial Nervo (CN Vl) the muscles of facial Y The facial nerve LE eel the patient to ie Sig Its function is tested by the lips, draw back th SYebraye close the eyes tight, Pu smile and frown. * "© Omen the mouth in an exaggerated smi mit g ¥ The examiner should note any ee y etry in the fas movements because they can indicate damage tg the tea v Although taste discrimination of salt and Sugar in the ante two thirds of the tongue is a function of this Nerve, it i a Toutinely tested unless a peripheral nerve lesion is Suspecy Bt Absence of sense of taste is called ageusia. Acoustic Nerve (CN VIII) ¥ Itis called vestibule-cochlear nerve. ¥ The cochlear portion of the acoustic nerve is t the patient close the eyes and indicate when a the rustling of the examiner's finger tips is heard as the stimulus is brought closer to the ear. Each ear is tested individually, and the distance from the patient's ear to the Sound source when first heard is recorded. This test identifies only gross defi precise test for hearing, the audiome' lested by hayi ticking watch or cits in hearing. For more ter is used, caloric testing may be done, geal (CN IX) and Vagus Nerve (CN X) The glossopharyngeal nerves and the vagus nerves are tested together because they both innervate the pharynx. The glossopharyngeal nerve is primarily sensory. In the gag reflex (bilateral contractioy v df ne or absent, ient is in danget aspirating food OF secretions, me Patent The strength and efficiency of i i to testi" 5 Icy of swallowing are important these patients for the same Teaser ee ree 682v Another test for th patient phonate symmetry of eley: indicate weakness or ian | Paralysi ¥ Swallowing is also assessed 1 ic iner' hands on either sig ‘ed by lightly holding the examiner's patient to swallow, na 7 the patient's throat and asking the a spinal ‘Accessory Nerve (enn is noted Is tested by it resistance Hiei the patient to shrug the shoulders against Vv There should be peslbeg head to either side against resistance. and traperuis raseot” Contraction of the sternocleidomastoid v Asymmet fenaeae atrophy or fasciculation of the muscles should also 9. Hyglossal Nerve (CN XIl) v Is tested by asking the patient to protrude thi Y Itshould protrude in the midline ae ¥ The patient should also be able to push the tongue to either side against the resistance of the tongue blade Y Any protrusion of the tongue or deviation of the tongue to one side of the mouth should be noted e a ; By stake Cooperative patient is to have the ation ie ‘ask” and to note the bilateral the soft palate. Any asymmetry can + The three common problems among clients with neurologic disorders are as follows: 4, Increased intracranial pressure. 2. Seizures 3. Altered level of consciousness (ALOC) Care of the Client with Increased Intracranial Pressure (ICP) Increased ICP occurs whenever there is increase in the bulk of the brain The bulk of the brain consists of the brain tissues, blood supply and CSF The disorders that increase the bulk of the brain tissues are called space — occupying lesions, e.g. cerebral tumor, abscess, edema (due to infection or trauma). : The factors that may increase the blood supply to the brain are cerebral hemorrhage, thrombosis, embolism, aneurysm, arteriovenous malformation (A-V mal). : The factors a increase the bulk of CSF are obstruction to the flow of CSF caused by brain tumor oF ventricular system defects (hydrocephalus); F overproduction of CSF caused by tumor in the choroid plexus. Increased ICP causes cerebral hypoxia. 683Kellie’s Theory on Increased Intracranial Pressure Monro — Kel Brain is enca: ion of the bulk of the brain "Fico supply and CSF volume) + ged ina body skull No room for é: (brain tissues, f any one of the three components, "he worth bulk of the brain increase + Compression of “ brain components Cerebral ischemia Cerebral Hypoxia — Cerebral Infarction oe Cerebral Edema en icp The clinical manifestations of increased ICP are as follows: Y Restlessness. Is the initial sign of increased ICP. ¥ Headache is due to traction on pain — sensitive brain structures and on cranial nerves, v Nausea and vomiting. Is due to Pressure at the medulla oblongata. Vomiting may be projectile. Y Diplopia (double vision). Is due to pressure on the cranial nerve VI (abducens), which controls the lateral tectus muscle of the eye. Cratid Nerve VI is the longest intracranial nerve. Therefore, it is very vulnerable to compression, Y Altered level of consciousness. Is due to affectation of ascending Feticular activating system (ARAS). 7 Y Vital sign changes. Are due to stimulation of the Cushing's reflexin response to cerebral hypoxia: The ing’s tri follows: a. Blood Pressure Cushing's triad are as , * Systolic pressure is elevated. This is due to increased fore? Cardiac contractility, the bod 's a increase cere! tissue perfusion and oxygenation mae 684X < « Diastolic pressure remains isk te ir " normal or decreased. This is due to longer time required for the heart to relax. + Widening of pulse pressure. itis more than 40 mmHg. (Pulse pressures the dference between systolic pressure and eo | pulse pressure is 30 to 40 mmbg, Ise pressure). Normal p! pb. Pulse rate. Bradycardia (slow bounding pulse) occurs. c. Respiratory rate. Is slow, due to i ‘odulla oblongata and pons. to involvement of the mé The other vital sign changes are as follows: a. Body temperature. Hyperthermia or hypothermia may occur due to the involvement of the hypothalamus. Pupillary Changes a. Anisucuria (unequal pupil). Is due to Cranial nerve I! (oculomotor) compression. There is ipsilateral (same side of brain affectation) pupil dilatation. . Pinpoint pupils indicate pons involvement. c. Fixed, dilated pupils. Indicates uncal/ brain herniation. This causes compression of the brainstem that results to cardiopulmonary arrest. (The uncus is the pointed part of the temporal lobe located immediately above the brainstem). Papilledema (choked disc). Is due to the compression of the optic nerve. Lateralizing Sign. This is contralateral (opposite side) loss of motor function due to decussation (crossing) of motor fibers at the level of medulla oblongata, e.g. left brain affectation leads to right hemiplegia (paralysis of the right lateral half of the body); right brain affectation leads to left hemiplegia (paralysis of the left lateral half of the body). Brainstem Function Impairment a. Doll's Eye sign. Dysconjugate movement of the eyes as the head is moved to one side. b. Decortication (flexion, adduction and internal rotation of upper extremities. Lower extremities are extended). This indicates involvement above the midbrain. ¢. Decerebration (extension, adduction, and internal rotation of the ams and extension of lower extremities). This indicates involvement of the brainstem. This indicates poor prognosis. The client may have cardiopulmonary arrest, anytime, d. Oculovestibular Test (Caloric Ice water test). Dysconjugate movement of the eyes occur in response to irrigation of the ear with cold water. os 685“4 rations in: | a soneahy Function tagnosia) b. Motor Function (seizures). one sph c. Language and Speech (expressive ap! ! ic i itinen« 6 wo ad bladder function (retention or incontinence) The collaborative management for the client with increased jcp e include the following: Nurse Alert: Increased ICP is an emergency. The cerebral cortex can tolerate hypoxia only for 4 to 6 minutes. The medulla oblongata can tolerate hypoxia only for 10 to 15 minutes, v lan i — Fowler's, lateral position. The HOB elevation is 15tp 50 degrees mex of 45 degree. To promote drainage of CSF fron the subarachnoid space of the brain to the spinal cord. This position also promotes maximum lung expansion and improves cerebral tissue oxygenation. Caution: do not elevate HOB at 90 degree. This may cause brain herniation. v Adequate oxygenation. Mechanical ventilation helps promote acid - base balance. Acidosis and alkalosis may increase ICP. Y Safety. Prevent falls that may result from altered level of consciousness and seizures. ¥ Rest. Physical and emotional stress may further increase the ICP. Y Avoid factors that increase ICP as follows: " Nausea and vomiting Valsalva maneuver, e.g. Straining at stool Over suctioning Restraints application Rectal examination Enema Bending or stooping ¥ If coughing and sneezing could not be avoided, follow — through with open mouth. ¥ Control hypertension. H ertension i fusion. Rec has mein a nc eee rea ese pti reduce CSF production, _ ° Y Pharmacotherapy * Mannitol, an osmotic diuretic. increasing ure crete 'treduces cerebral edema by 686o Check hourly urine outp ut. ; Coed SP ot Potential hypotension, Hig! iturates for reduction of cerebral metabolism. Lasix (Furosemide), a diureti increasing urine output, irolle. I reduces cerebral edema Py Smee nee a corticosteroid. It has anti- porticosteroid that cane I cerebral edema. This is the only Ss throt ~brai ic Anti iconvulsants to prevent ee the blood — brain barrier. o Dilantin (Phenytoin Sodium) o Phenobarbital (Sodium Luminal) ° at (Carbamazepine) Antacids to prevent G.I. irritation that Decadron (dexamethasone). at maybe Induced by Histamine — He feceptor antagonist, e.g. Zantac (Ranitidine) or Proton pump inhibitor e.g., Protonix (Pantaprazole) to prevent stress ulcer (Cushing's ulcer). Anticoagulants, to prevent thromboerabolism Dilantin (Phenytoin) o If given p.o. (per orem / by mouth) > give after meals to prevent Gl upset If given IV + prepare 10mls. NS (Normal Saline) to flush the IV line before and after Dilantin IV administration. Dilantin crystallizes in the veins. (5 mls NS — Dilantin +> 5 mis NS) © Side effects / adverse effects of Dilantin - Glupset - Sedation - Red urine - Gum hyperplasia (overgro' gums) - Ataxia - Nystagmus - Bone marrow depression — ap! ‘ions to prevent gum hyperplasia wth of gingival tissues / swelling of lastic anemia (monitor weekly cbc) © Nursing Interventi - Good oral care 687h Use soft bristled ne = Massage gums - Regular dental ¢! Critical to Remember: . contraindicated to the clig 5 datives are COT i Nt v Opie (es may cause respiratory depression that leagy increased ICP. to acidosis. . usually avoid ium, Ativan) are led in e9. Wall ‘ased ICP because of the hypotensi heck - UP Benzodiazepines (e.9- V4 management of patients with incre: effect. i it Disorder : ; Care of the Client with Seizure sive, disorderly electrical discharges of th, © Seizures are sudden, exces: neurons. ¢ The most common type e Grand mal seizure is chara impending seizure. It may be dizziness. . . Tonic — clonic phase (ictal phase) of grand mal seizure is accompanied by dyspnea, drooling of saliva, urinary incontinence. Tonic movements are characterized by contractions, while clonic movements are characterized by jerking movements. Post — ictal phase of grand mal seizure is when tonic- clonic movements stop. It is characterized by earaustion, headache, drowsiness, deep sleep of 1 to 2 hours, and when the patient awakens, disorientation may be present. e The other types of seizures are: petit mal, Jacksonian seizure psychomotor seizure, febrile seizure. » Petit Mal (“Absence Seizure” or “Little Sickness”) is not preceded b/ an aura. There is little or No tonic — clonic movements. There is sudden cessation of ongoing physical activities. It is characterized by blank faci expression and automatism like lip — chewing, cheek — smacking, kicki"d of legs. Regain of consciousness is as rapid as it was lost; lasts for 10" + dackeonten (ea ecu dutina childhood and adolescence. icksonian (Focal seizure). . 2 ic brait iesion ike frontal lobe tumor, Acre among cfents with gan crawling feeling. It is chara terized t iS present like numbness, Y tonic ~ cloni nts of 9 of muscles e.g. hands, foot or face, then it fa ee ea ci oe of seizure is grand mal seizure. terized by an aura. Aura is @ premonition of flashing lights, smells, spots before the eyes, 688sychomotor seizure. | pallucinations or ilusions) ao, a out of touch with the environment ‘aracterizey the time of loss of consgj ). The client Psychiatric Component. Aura is present i by mental clouding (being t! Fs clousness, appears intoxicated. During is mae PY confusion, amnesin se fe ongoing physical activities. It er ‘turing thi t antisocial acts, e.g a for sleep. The client may am : ee eli of loss of consciouss ing naked in public, running Febrile si - This is com less, when body temperature ig Mon among children under 5 years of age, i ising, Status epilepticus. A typ full consciousnes: urs a ma . A occur. The attack is my gloNge" during which time recurring seizures anticonvulsants, Collaborative management for 4. Stay with the client. 2. Protect the client from injury. ¥ Put up padded side — rails. v Ifthe client is sitting or standing, ease him up onto the floor. Protect head with small pillow or place the head onto the lap. Y¥ Do not apply restraints. v Do not insert tongue blade. 3. Promote patent airway. v Turn the client to the side. To drain secretions from the mouth and to prevent the tongue from falling back. Y Loosen constricting clothing especially around the neck. 4, Make relevant observation and documentation. 5. Pharmacotherapy: anticonvulsants. 1) Anticonvulsants = Hydantoins Barbiturates Succinimides soph fo Oxazolidones / Oxazolidinedione Benzodiazepines Iminostilbenes * Valproates e abnormal electric impulses from Anticonvulsant drugs suppress ‘areas, thus preventing the the seizure focus to othe preve' seizure but not eliminating the cause of the sei seizure disorder include the following: 2 689Ui: Isants are classified as central nervous system, (CNg) 3) Anticonvul depressants. toins: 4 Y Serial (Dilantin) ; Mephenytoin (Mesantoin) Ethotoin hese convulsants have least toxic effect, small ef fener sedation and nonaddicting. fect on The therapeutic serum level of phenytoin is 10 to 20 meg,/ml. Intravenous infusion of phenytoin should Be admini direct injection into a large vein. It should be dilute, normal saline solution. Dextrose solution should not of drug precipitation. inamessuar iu) injection of phenytoin irritates tis May cause damage, therefore this route is discou Continuous IV infusion of phenytoin should not be because hypotension or cardiac dysthythmias mi Mephenytoin is more toxic than phenytoin. This for severe grand mal or psychomotor seizures tl respond to phenytoin or other anticonvulsant th Ethotoin produces similar re: shorter half - life of 3 to 6 hou istered with t be Useg, SSues ang raged, e used, lay Occur. drug is useq hat do not erapy, sponses as phenytoin, has a rs; therefore, the chance of Cumulative drug effect decreases. ° ° ° Nursing Interventions in Phenytoin nausea and vomiting, Initially, avoid driving and Performing hazardous activities Uniil the client ada Pts to drug dosage; drowsiness is apt to occur. Avoid alcohol and CNS depressants. These lower Seizure threshold To prevent gum hyperplasia, advise client to: — Have good oral care, Massage the gums. - Hee, Soft ~ bristled toothbrush, ~ Have preventive dental = Monitor serum gl seer: jin inhibits ingulin Car -oS° Eels of diabetic client. Pheny™ inhibits insulin felease, Causing hyperglycemia. 690 | |(com, Cause bone CoMPlete blood count). Phenytoin may Client sh Ould rey and Nosebleeds Symptoms of sore throat, bruising © Instruct clie n every day with ge the anticonvulsant at the same time © Phenytoin ig con ils to prevent G.I. irritation. raindicated in pregriancy. It may cause fetal anom ali i. palate. ls such as cardiac defects, cleft lip and cleft = The side effec follows: © Gingival h reddened ae {overgrowth of gum tissues — o Neurolosi leed easily) nyst oie an bsychiatric eects such as ataxia , sedation, sI hlepeean lurred speech, confusion and © Bone marrow depression - anemia, leukopenia, thrombocytopenia Hyperglycemia ~ the drug inhibits release of insulin. o Gastrointestinal effects: anorexia, nausea, vomiting, constipation o Drowsiness, headaches, alopecia, hirsutism. Phenytoin causes pinkish red or reddish — brown discoloration of urine. This is a harmless side effect Withdraw the drug gradually to prevent status epilepticus. ts i and adverse reactions to hydantoins are as ° ° 2) Barbiturates and their indications « Amobarbital (Amytal) — status epilepticus « Mephobarbital (Mebaral) — grand mal, petit mal = Phenobarbital (Luminal) grand mal, petit mal, status ilepticus | ns Primidone (Mysoline) — grand mal, psychomotor seizure * Phenobarbital is used to treat grand mal seizures and acute episodes of status epilepticus seizures. It causes general ic rug tolerance. | sedation phenobarbital gradually to avoid recurrence of seizures. ccinimides ; » = Ethosuximide (Zarontin) 2 Methsuximide (Celontin) 691 ee IE TE To |4 5) . imide (Milontin) Used to raat eer or petit mal foes : Etnosuximide is the drug of choice in this group of anticonvulsants. Seen * Gastric irritation is common; it she with foog Oxazolidones / Oxazolidinedione = Paramethadione (Paradione) * Trimethadione (Tridione) * Prescribed to treat petit mal seizures. ; "= Withdraw drug gradually to prevent rebound seizures, Benzodiazepines . "The benzodiazepines that have anticonvulsant effects ate as follows: o Clonazepam (Klonopin) © Clorazepate dipotassium (Tranxene) o Diazepam (Valium) o Lorazepam (Ativan) "Clonazepam is effective in controlling petit mal (absence) seizures, myoclonus and status epilepticus. " Chlorazepate dipotassium is administered for treating partial seizures. * Diazepam is prescribed to treat acute status epilepticus. It must be administered IV to achieve the desired response. * Lorazepam is used to control Status epilepticus. Infusion rate should not exceed 2mg/min. 6) Iminostilbenes " Carbamazepine (Tegretol) " Oxcarbazepine (Trileptal) * Carbamazepine is effective in treatin i; ; ig refractory seizure disorders that have not fesponded to other anticonvulsant therapies. It is used to cont i seizures. rol grand mal and partial " Carbamazepine is also used for psychiatric disorders (€9: bipolar disease), trigemi y BGS alcohol withdrawal "2! Neuralgia (as an analgesic). 692