Medical Surgical Nursing – Nervous System

PENTAGON REVIEW / SIR VALDEZ

COVERAGE Spinal Nerves - 31 pairs

I. Structures a. Cervical – 8
a. Based on Anatomically b. Thoracic – 12
b. Based on Physiologically c. Lumbar – 5
II. Autonomic Nervous System d. Sacral – 5
a. Sympathetic Nervous System e. Coccygeal – 1
b. Parasympathetic Nervous –––
System 31 pairs
III. Different Neurologic Disorder
a. Myasthenia Gravis > Foramen Magnum – hole inside the spinal
IV. Demyelinating Disorders cord
a. Multiple Sclerosis > Lumbar Puncture – between L3-L4; no nerves
b. Guillain Barre Syndrome will be hit because nerves end at L1; no risk for
c. Parkinson’s Disease paralysis

I. STRUCTURES II. Autonomic Nervous System

A. Based on Anatomically A. Sympathetic Nervous System (SNS)
1. Central Nervous System - Involved in flight or fight response
o Brain – 3 lbs; 2% of total body weight - Activated during stress or emergency
(TBW) situation  release of adrenalines
 Cerebrum – largest - All body activities except GIT & GUT
 Cerebellum – smallest
 Medulla Oblongata During stress - Increased blood flow to:
o SpinaL Cord a. Brain – for increased cerebration
b. Heart – to propel the blood towards
2. Peripheral Nervous System systemic circulation
o Central Nerves c. Skeletal Muscles – for increased agility
o Spinal Nerves
Effects of SNS:
B. Based on Physiologically 1. Mydriasis – pupil dilation
1. Somatic Nervous System 2. Dry mouth
- Controls voluntary movement (skeletal 3. Increased BP
muscles) 4. Tachycardia
2. Autonomic Nervous System 5. Bronchodilation
o SNS 6. Constipation
o PNS 7. Urinary retention
- Also controls involuntary movement
a. Heart Sympathomimetic / Adrenergic /
b. Lungs Anticholinergic Agents
c. GIT 1. Epinephrine (Adrenaline)0
Indications:
a. Cardiac Arrest / Asystole
Cranial Nerves – 12 pairs b. Anaphylaxis
a. Trigeminal – largest c. Bronchospasm
2. Atropine SO4
b. Vagus – longest
Indications:
c. Trochlear – smallest
a. Sinus Bradycardia
d. Olfactory – shortest b. Pre – op meds

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o To prevent excessive secretion - Long acting cholinergic agents given to

resulting to aspiration; no pts with MG
danger for aspiration - Antidote: Atropine SO4
3. Norepinephrine (Levophed) - Antidote for Atropine SO4:
4. Dopamine (Intropin) Physostigmine Salicylate (Antilirium)
5. Antipsychotic Agents 3. Bethanicol Chloride (Urecholine)
o Thorazine - given to pt with non-obstructive urinary
o Stellazine retention / given SQ
o Prolixine 4. Miotics
o Clozapine - Constricts pupil
o Haloperidol - Given to pt with glaucoma (increase
6. Bronchodilators IOP)
o Salbutamol – the only - Normal IOP: 12-21 mmHg
bronchodilator that does not cause - Pathognomonic Sx for Glaucoma:
tachycardia o Tunnel-like vision; loss of
7. Mydriatics peripheral vision
o Mydrazyl – given pre-op for - Painful
cataract extraction - Ex. Pilocarpine Na, Carbuchol
8. Antiparkinsonian Agents /
Anticholinergic
o Benztropine (Cogentin) III. DIFFERENT NEUROLOGIC
o Artane DISORDERS
A. Myasthenia Gravis
B. Parasympathomimetic Nervous - Chronic neuromuscular disorder
System (PNS) characterized by a disturbance in the
- Rest and digest transmission of impulses from nerve to
- Release of acetylcholine muscle cells at the neuromuscular
- Decreases all bodily activities except junction leading to  Descending
GIT & GUT muscle weakness
- Characterized by remissions &
Effects of PNS: exacerbation
1. Meiosis – constriction of pupils
2. Moist mouth A. Incidence rate:
3. Hypotension o common among women 20-40 y/o
4. Bronchoconstriction (bradypnea)
5. Bradycardia B. Predisposing factors
6. Diarrhea 1. Idiopathic
7. Urinary frequency 2. Autoimmune (produce antibodies that
affects the voluntary muscles of the:
Cholinergic Agents o Eyes
1. Edrophonium HCL (Tensilon) o Face
- IV / Short acting o Throat
- Effects at 5-10 mins o Respiratory
- Confirmatory test for myasthenia o Including arms & legs
gravis
2. Mestinon (Pyridogstigmine)
- DOC for MG

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Medical Surgical Nursing – Nervous System
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Pathophysiology 4. Dysphagia
5. Hoarseness of voice / dysphonia – voice
impairment
6. Respiratory muscle weakness that may lead
to respiratory arrest

> Unable to: see, swallow, speak & breath

Nursing Diag/Priority
o Airway
o Aspiration
o Immobility

Nursing management
1. Maintain patent airway & adequate
ventilation by:
o Assisting in mechanical
Basic pathogenesis ventilation
1. Autoimmune o Spirometer – monitor
- the body is producing antibody that attacks pulmonary function test
the 2 receptors sites 2. Monitor VS, I&O, neuro check & motor
a. MSKR Descending muscle grading scale
b. NAR > Glasgow Coma Scale (GCS)
weakness
- the quick neuro check
2. Normally - the objective measurement of LOC
Produces an enzyme Motor – 6
Thymus gland Verbal – 5
> upper anterior of the chest called CHOLINESTERASE
Eye – 4
(between the lungs)
Destroys ACH
GCS Scoring
Produces matured T cells C – 15-14
Decreased ACH L – 13-11
Destroys cancerous cells
S – 10-8
Descending muscle C–7
weakness DC – 3

Myasthenia Gravis > Levels of Consciousness

1. Conscious – awake
Treatment 2. Lethargy – drowsy, sleepy 
1. Thymectomy obtunded
3. Stupor – (+) generalized body
- removal of thymus gland
2. Cholinergic / Anticholinesterase Agent malaise / weakness, decrease bodily
reflexes, & can only be awakened by
C. Signs & symptoms vigorous stimulation
1. Ptosis- drooping of upper eyelid 4. Coma
2. Diplopia – double vision a. Light Coma
3. Mask like facial expression o (+) or responsive to
painful stimulation

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

b. Deep Coma Myasthenic Crisis

o (-) or unresponsive to Causes:
painful stimulation o Undermedication
o Stress
o Infection
Forms of painful stimulation S/Sx:
1. Sternal rub o Unable to see, swallow, speak
2. Pleasure on great toes & breath
3. Corneal or blinking reflex Treatment:
 Conscious – wisp of cotton o Administer cholinergic agents:
 Unconscious – instill 1gtt or saline Mestinon, Neostigmine
solution
Cholinergic Crisis
3. Maintain padded rails Causes:
4. Institute NGT feeding via gastric garage to o Overmedication
prevent aspiration S/Sx:
5. Prevent complications of immobility by o PNS
turning client to side q 2hrs Treatment:
> Prevent bed ulcer & o Administer anticholinergic
hypostatic pneumonia agents: ATSO4
6. Administer meds:
1. Corticosteroids: C. Diagnostic Procedures:
 Dexamethasone – to suppress immune 1. Edrophonium HCL (Tensilon) Test
response o Short acting cholinergic agent
2. Cholinergic / Anti cholinesterase o IV, provide temporary relief for about
 Mestinon (Pyridostigmine) – best given 5-10 mins
30 mins – 1 hr before meals (peak) o Also used to differentiate myasthenic
 Neostigmine from cholinergic crisis
SE - PNS: 3. CSF Analysis
Too much intake of Mestinon o Reveals increase in cholinesterase
levels
Mestinon Toxicity  If all treatments failed or the pt
doesn’t respond to treatment,
Antidote: ATSO4 administer meds as ordered

If too much ATSO4 is given 4. Monoclonal Antibody

o Ex. Rituximab (rituxan),
Antidote: Physostigmine Salicylate Uculuzumab (Soliiris)
o Give IV but passes serious SE:
Blood Dyscrasias
Pantocytopenia (anemia,
7. Assist in surgical procedure: Thymectomy leukopenia, thrombocytopenia)
8. Assist in plasmapheresis (filtering of blood
to remove the antibodies that attacks the IV. DEMYELINATING DISORDERS
receptor sites) with IV immunoglobulins - Neurons / Nerve cells – basic living unit
9. Monitor two types of crisis: of the nervous system
> Myasthenic Crisis
> Cholinergic Crisis

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

A. Chracteristics / Properties of Neurons (occurs in more temperate climates)

1. Excitability – the ability of the neurons
to be affected by changes in the
external environment
2. Conductivity – the ability of the
neurons to transmit a wave of
excitation from one cell to another
3. Permanent cell – once destroyed, not
capable of regeneration
B. Predisposing Factors
1. Idiopathic
2. Slow growing viruses – Epsteinn-Barr
Virus
3. Autoimmune  produce IgG that
destroys oligodendrocytes  decrease
production of myelin sheath

c. Signs & symptoms

B. Parts 1. Visual disturbances (early signs)
o Blurring vision
o Diplopia
o Seeing scotomos or blind spot or
partial loss of vision (optic neutitis)
2. Impaired sensation to touch, pain,
pressure, heat & cold
o Tingling sensation
o Paresthesia
o Numbness
3. Untoff’s sign / phenomenon
o Heat worsens the signs &
symptoms of MG like hot bath / hot
meal / exercise
o Do not give hot packs to pt
with MS – because of
decreased heat sensitivity,
heat application can cause
burns
4. Mood swings
o Euphoria

5. Impaired motor activity

o Weakness
o Spasticity
A. Multiple Sclerosis
o Paralysis
- Disseminated Sclerosis or
Encephalomyelitis Disseminata
Phlegia  Paralysis
- Chronic, intermittent disorder of the
Paresis  weakness
CNS characterized by white patches of
1. Monophlegia
demyelination in the brain & spinal
o One limb
cord
2. Hemiphlegia
- Characterized by remission &
o Right / left side
exacerbation
3. Paraphlegia
- No cure
o Waist down  catheter
A. Incidence Rate 4. Quadri or Tetraphlegia
> common among women 15-35 y/o o Neck down

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

6. Impaired cerebellar function
o Scanning / staccato speech
o Intentional tremors
o Nystagmus with / without ataxia
(unsteady gait)
o Or known as Charcot’s Triad
7. Urinary retention
8. Constipation
9. Impaired cognition
10. Decreased in sexual capacity
11. (+) Lhermitte’s Sign / Barber Chaiir
Phenomenon – (+) feeling of electric shock
sensation upon flexion of the neck
D. Complications
1. Respiratory Dysfunction
2. Infections of the
o Bladder
o Respiratory: Hypostatic Pneumonia
o Sepsis
3. Immobility
> Decubitus Ulcer
o Stage I – erythema / redness
o Stage II – affected dermis (blister)
o Stage III – full thickness skin
breakdown (crater)
o Stage IV – bones, muscle deeper
underlying supporting structures
are affected (eschar – darkened
necrotic tissue)
4. Speech voice & language disorder
o Dysarthria – inability to articulate
words
E. Diagnostic Procedures
1. CSF Analysis
o Through lumbar puncture 
reveals increased IgG & protein
(Oligoclonal bonds – confirms
presence of MS)
2. Lumbar puncture / Spinal tap
o A hollow spinal needle is inserted
into the subarachnoid space
between L3-L4 or L4-L5 of cauda
equine or lumbar enlargement)
3. Apply brief pressure of the punctured site to
prevent bleeding
4. Place client on supine position for 12-24 hours
to prevent
o Spinal headache
o CSF leakage
4. Force fluids
5. Monitor / Assess / Check for the movement
and sensation extremeties
6. Magnetic Resonance Imaging (MRI)
o Reveals the site & extent of
demyelination
o Before MRI, remove metal clips &
hairpins
o Ask the client if he has fear or close
spaces (claustrophobias) if head or
cervical MRI
F. Nursing Management
1. Administer meds as ordered:
 Acute Exacerbation
o ACTH (Adrenocorticotropic
Hormone) or Corticosteroids
> To reduce edema or swelling
at the site of demyelination
thereby preventing paralysis
> Given for relapses of MS
symptoms
o Beta-interferons
> given to alter immune
response
> given to reduce relapses of
MS
> SE: decreases WBC
(leukopenia) prone to develop
infection
> Ex. Avonex, Rebif, Betaferon
(Interferons)
o For bladder:
o Bethanecol Chloride
(Urecholine)
> Given SQ
> SE: Bronchospasm &
Wheezing
> Monitor for breath
sounds s1 hr after SQ
administration
o Oxybutynin (Ditropan)
> Reduces muscle
spasms of the bladder

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o For fatigue: - No cure!

o Amantidine HCl
(Antiviral & A. Incidence Rate
antiparkinsonian) o Common among men 30
> CNS effect helps above
improve fatigue
o Modafinil (Provigil) B. Predisposing Factors
> CNS stimulant 1. Idiopathic
> Last for 10-12 hrs 2. Autoimmune  the body produces
> DOC for excessive antibodies IgG that attacks Schwann
sleepiness / narcolepsy cells that produces myelin sheath in the
o For muscle spasticity PNS
o Baclofen (Lioresal) or 3. Antecedent viral infection
Dantrolene Na o Ex. Upper & Lower resp tract
(Dantrene) infection
> acts as muscle o GIT infection caused by
relaxant campylobacter jejuni infection
o Diazepam (Valium) (40-60% among americans)
o For tremors: 4. HIV Infection
o Beta blockers 5. Epsteinn-barr virus
> Propanolol (Inderal) 6. Related to immunization
o INH (Isoniazid) or o Swine flu vaccine
Isinicotinic acid o Influenza vaccine
Hydrozide o J&J vaccine

C. Signs & Symptoms

2. Provide relaxation techniques such as
1. Clumsiness (early sign)
o DBE
2. Dysphagia
o Yoga
3. Ascending muscle paralysis
3. Maintain padded siderails
4. Decrease deep tendon reflex (DTR’s)
4. Prevent complications of immobility
5. Alternate hypotension to
5. Avoid heat application
hypertension & vice versa (could lead
6. Provide catheterization
to arrhythmia)
7. Encourage increase OFI, high fiber diet &
6. Autonomic changes
provide acid ash to acidify urine to prevent
o Increase salivation
bacterial multiplication
o Increase sweating
o Grapes
o Constipation
o Cranberry
o Prune D. Diagnostic Procedures
o Plum 1. CSF Analysis through lumbar puncture
o Reveals increased IgG &
B. Gullain Barre Syndrome protein (CHON)
- Disorder of PNS 2. Electromyelography & Nerve
- characterized by bilateral, symmetrical, conduction studies:
polyneuritis (inflammation of peripheral nerves o Assess for demyelination of
both cranial & spinal)  leading to Ascending nerves by determining the
muscle paralysis muscle ability to respond the
- also called as Infectious polyneuritis nerve stimulation
- G (gradual) B (block) S (sensation)

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

o Immunoglobulin Therapy
E. Nursing Priority / Diagnosis > IV immunoglobulin from fonor
1. Airway  ineffective breathing pattern given to the pt to stop the
2. Immobility antibodies that are damaging the
3. Safety nerves particularly the peripheral
4. Bladder & bowel problems nerves
5. Aspiration
6. Diet / Nutrition 6. Assist in plasmaphoresis
7. Prevent complications:
F. Nursing Management o Respiratory Arrest
1. Maintain patent airway & adequate  Prepare at bedside
ventilation by: either tracheostomy &
o Assist in mechanical ventilation endotracheal set
o Monitor pulmonary function o Arrhythmia
test by using incentive  Prepare at bedside
spirometer cardiac monitor / holter
2. Maintain padded rails ECG
3. Prevent complications of immobility o Thrombophlebitis / DVT
4. Institute NGT feeding via gastric  (+) Homan’s Sign
gavage to prevent aspiration > (+) pain at the calf of
5. Administer meds as orders: leg muscles upon
o Corticosteroids dorsiflexion of the foot
 “sone” to suppress immune > Complication of DVT
reponse  Pulmonary
o Anticholinergic Embolism; S/Sx:
 ATSO4 1. Chest pain
2. Dyspnea
o Antiarrhythmic agents 3. Tachypnea
 Lidocaine (Xylocaine) 4. Tachycardia
> blocks release of 5. Exertional Discomfort
norepinephrine
 Amiodarone Treatment: Pulmonary Embolism
 Bretylium 1. Administer Morphine SO4 as ordered
> blocks release of norepi 2. O2 – 100%
> SE: hypotension 3. Place client on semi to high fowlers
 Quinidines 4. Thrombolytics / Fibrinolytiv Agents
> Antimalaria agents o Streptokinase
o Urokinase
o Altepase  Tissue Plasminogen
Anti-malarial Agents Activating Factor (TPAF)
1. Chloroquine Malaria: “King” of
2. Primaquine o Decubitus ulcer
Tropical Areas
3. Quinidines o Hypostatic Pneumonia
o Anti arrthymic o Paralytic ileus – absence of
Property Antidote: “quine”
peristalsis

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

Autonomic Changes
C. Parkinson’s Disease 1. Increased lacrimation
- Shaking palsy 2. Increased sweating
- Hypokinetic rigid syndrome 3. Seborrhea  oily skin
- Paralysis Agitans 4. Constipation
- Disorder of CNS characterized by 5. Decreased sexual capacity
degeneration of dopamine producing 6. Mood / ability (depression)
cells in the substantia nigra of the
midbrain & basal ganglia C. Stages
- Irreversible – no cure! 1. Unilateral flexion of upper extremity
- Decrease dopamine – acetylcholine will 2. Shuffling gait
predominate, also with norepinephrine 3. Progressive difficulty in ambulating
loss thus the postural hypotension 4. Progressive weakness
5. Disability
A. Predisposing Factors
1. Idiopathic D. Nursing Priority / Diagnosis
2. Poisoning 1. Administer meds as ordered:
o Lead o Antiparkinsonian agents
o Carbon Monoxide 1. Carbidopa / Levodopa
3. Arteriosclerosis (Sinemet) – used as
4. Hypoxia disease progresses ;
5. Encephalitis “wearing off”
6. Frequent head injury (boxing) phenomenon
7. High doses of the ff: - MOA: Increased levels of
Anti
o Reserpine (Serpasil) hypertensives
dopamine
o Methyldopa (Aldomet) - Carbidopa prevents levodopa
o Haloperidol (Haldol)  antipsychotic from breaking down into blood
o Phenothiazine & turn this into dopamine
SE:
o GIT Irritation
o Orthostatic hypotension
B. Signs & symptoms o Confusion
1. Pill rolling tremors (early signs) o Hallucination
2. Tremors at rest (most common) hands, o Arrhythmia
arms, legs, lips & tounge Contraindicated:
3. Bradykinesia  slow movement o Glaucoma  could lead to
4. Rigidity (cogwheel type) increased IOP & clients taking
o Stooped pasture MAOI  could lead to stoke
o Shuffling & propulsive gait Nursing alert:
5. Over-fatigue o Best given with meals to lessen
6. Mask like facial expression with GIT irritation
decrease blinking of the eyes (flat o Inform client that his urine &
affect) stool may be darkened
7. Difficulty in rising from sitting position o Instruct the client to avoid
8. Monotone speech taking foods high in Vit B6
9. Drooling of saliva  due to the (Pyridoxine)  reverses the
decrease ability to swallow therapeutic effect of Levodopa

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Medical Surgical Nursing – Nervous System
PENTAGON REVIEW / SIR VALDEZ

Avoid:
o Corn
o Boxed cereals
o Organ liver meats
o Green leafy vegetables

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