THE NERVOUS SYSTEM receptors in the postsynaptic cell
membrane
 The function of the nervous system is to
control all motor, sensory, autonomic,
cognitive, and behavioral activities.
 CNS
 Brain and spinal cord
 PNS
 Cranial nerve and spinal nerve
 Spinal Nerves 31 pairs
 Cranial Nerves 12
 ANS
 Sympathetic and parasympathetic
 THE NEURON
 functional unit
 dendrites
 receive neural messages & transmit
towards cell body
 axon
 transmits neural messages
 away from cell body myelin & cellular
sheath produced by Schwann cells
 Types of Neurons
 Sensory neurons
- Typically have a long dendrite and short
axon carry messages from sensory
receptors  central nervous system.
 Motor neurons
- Have a long axon and short dendrites;
transmit messages from central nervous
system muscles (or to glands)
 Interneuron
- are found only in the central nervous
system where they connect neuron to
neuron
 Afferent neurons
- From tissues and organs into the CNS
(sensory neurons.)
 Efferent neurons
- From CNS to the effector cells (motor
neurons)
 NEUROTRANSMITTERS
 Neurotransmitters communicate messages
from one neuron to another or from a
neuron to a specific target tissue
 Neurotransmitters are manufactured and
stored in synaptic vesicles. They enable
conduction of impulses across the synaptic
cleft.
 When released, the neurotransmitter
crosses the synaptic cleft and binds to
 The action of a neurotransmitter is to
potentiate, terminate, or modulate a specific
action and can either excite or inhibit the
target cell’s activity
 Acetycholine
 Dopamine
 Epinephrine and Norepinephrine
 GABA
 Serotonin (↓ depression, ↑ manic)
 Glutamine (excitatory)
 CEREBRUM
 Frontal
 Occipital
 Parietal
 Temporal
 CENTRAL LOBE
 controls visceral function
 CEREBELLUM
 Sensory perception and motor output
 Disorder = in fine movement, equilibrium,
posture and motor learning
 Coordinates smooth muscle movement
 Coordinates, posture, equilibrium and
muscle tone
 It controls fine movements, balance, and
position sense. (awareness of where each
part of the body is)
 CENTRAL NERVOUS SYSTEM
 Thalamus
 Afferent neurons coming from all
sense organs (except olfactory) & motor
neurons synapse with nuclei found within
the thalamus  cerebrum
 The thalamus also helps one
associate feelings of pleasantness or
unpleasantness with sensory impulses
 Relays sensory impulses to the cortex
 Provides a pain gate
 Hypothalamus
 located anterior and inferior to the
thalamus
 hypothalamus lies immediately
beneath and lateral to the lower portion of
the wall of the third ventricle
 includes the optic chiasm (the point at
which the two optic tracts cross) and the
mamillary bodies.
 The hypothalamus plays an important  CEREBRAL FUNCTION
role in the endocrine system because it  Assess the degree of wakefulness/alertness
regulates the pituitary secretion of  Note the intensity of stimulus to cause a
hormones that influence metabolism, response
reproduction, stress response, and urine  Apply a painful stimulus over the nailbeds
production. with a blunt instrument
 It works with the pituitary to maintain  Ask questions to assess orientation to
fluid balance and maintains temperature person, place and time
regulation by promoting vasoconstriction or  Glasgow Coma Scale
vasodilatation.  An easy method of describing mental
status and abnormality detection
 BRAINSTEM  Tests 3 areas- eye opening, verbal
 Midbrain response and motor response
 Motor coordination  Scores are evaluated- range from 3-15
 Visual reflex and auditory relay center  No ZERO score
 Pons  EYE OPENING (E)
 Regulates breathing- resp. center - 4=Spontaneous
 Medulla oblongata - 3=To voice (when told to)
 Contains efferent/afferent fibers - 2=To pain
 Cardiac, respiratory, vomiting and - 1= No response
vasomotor center( bld. vessel diameter)  VERBAL RESPONSE (V)
 Vital reflex centers within the medulla: - 5=Normal/oriented
- Cardiac centers – control heart rate - 4=Disoriented/confused
- Vasomotor centers – control blood - 3=Words, but incoherent/ inappropriate
pressure
- Respiratory centers – regulate breathing - 2=Incomprehensible/ mumbled words
- Centers for vomiting, sneezing, - 1=None
coughing, & swallowing  MOTOR RESPONSE (M)
- Centers for reflexes mediated by CNs IX- - 6=Normal- obeys command
XII - 5=Localizes pain
- 4=Withdraws to pain (Flexion)
 MENINGES - 3=Decorticate posture
 Dura Mater - 2=Decerebrate posture
 Outermost tough, white fibrous - 1=None (flaccid)
connective tissue
 Subdural space = potential space
 Arachnoid
 Middle
 Thin, delicate, cobweb-like membrane
 Subarachnoid space
- Filled with CSF & blood vessels
 Pia Mater
 Innermost
 Thin, vascular membrane tightly bound
to the brain

 ASSESSMENT OF THE
NEUROLOGIC SYSTEM
 5 Categories Physical Examination
 Cerebral function- LOC, mental status
 Cranial nerves
 Motor function
 Sensory function
 Reflexes
 CRANIAL NERVE 1- OLFACTORY
 Check first for the patency of the nose
 Instruct to close the eyes
 Occlude one nostril at a time
 Hold familiar substance and asks for the
identification
 Repeat with the other nostrils
 Problem: ANOSMIA- “loss of smell”
 CRANIAL NERVE 2- OPTIC
 Check the visual acuity with the use of the
Snellen chart
 Check for visual field by confrontation test
 Check for pupillary reflex- direct and
consensual
 Snellen chart
 CRANIAL NERVE 3, 4 AND 6
 Assess simultaneously the movement of the
extra-ocular muscles
 Deviations:
 Opthalmoplegia
- inability to move the eye in a direction
 Diplopia
- complaint of double vision
 CRANIAL NERVE 5 -TRIGEMINAL
 Sensory portion
 assess for sensation of the facial skin
(touch cotton to forehead, chick & jaw)
 Motor portion
 assess the muscles of mastication
( ask to clench and move jaw side to side)
 Assess corneal reflex ( wisp of cotton on
temporal surface of cornea)
 CRANIAL NERVE 7 -FACIAL
 Sensory portion
 prepare salt, sugar, vinegar and
quinine. Place each substance in the
anterior two thirds of the tongue, rinsing the
mouth with water
 Motor portion
 ask the client to make facial
expressions, ask to forcefully close the
eyelids
 CRANIAL NERVE 8- VESTIBULO-
AUDITORY
 Test patient’s hearing acuity
 Observe for nystagmus and disturbed
balance
 Test for lateralization (Weber)
 Test for air and bone conduction (Rinne)
 CRANIAL NERVE 9-
GLOSSOPHARYNGEAL
 Together with Cranial nerve 10 –vagus
 Assess for gag reflex
 Watch the soft palate rising after instructing
the client to say “AH”
 The posterior one-third of the tongue is
supplied by the glossopharyngeal nerve
 CRANIAL NERVE 11- ACCESSORY
 Press down the patient’s shoulder while he
attempts to shrug against resistance
 CRANIAL NERVE 12-
HYPOGLOSSAL
 Ask patient to protrude the tongue and note
for symmetry
 ASSESSING THE MOTOR
FUNCTION OF THE CEREBELLUM
 Test for balance- heel to toe
 Test for coordination- rapid alternating
movements and finger to nose test
 Romberg’s is actually a test for the
posterior spinothalamic tract
 ABNORMAL REFLEXES
 Positive Brudzinski’s sign
 (pain, resistance, flexion of hips and
knees when head flexed to chest with client
supine) indicates meningeal irritation
 Positive Kernig’s sign
 (excessive pain and/or resistance
when examiner attempts to straighten
knees with client supine and knees and hips
flexed) indicates meningeal irritation
 Positive Babinski reflex
 (dorsiflexion of big toe with fanning of
other toes): UMN diseases of pyramidal
tract
 Decorticate posturing
 (upper arms close to sides, elbows,
wrists and fingers flexes, legs extended with
internal rotation, feet are flexed: body parts
pulled into core of body): lesions of
corticospinal tracts
 Decerebrate posturing
 (neck extended with jaw clenched,
arms pronated, extended, close to sides,
legs are extended straight out and feet
plantar flexed): lesions of midbrain, pons,
diencephalon
  DIAGNOSTIC TEST
 Skull and spinal x-ray
 identify fractures dislocation.
Compression, spinal cord problem
 Nursing Care
- provide nursing support for the confused or
combative patient
- No to pregnant (CBQ)
- maintain immobilization
- remove metal items
 CT Scan
 Skull/ spinal cord are scanned in
successive layers by a narrow beam of X-
rays. A computer uses information obtained
to construct a picture of the internal
structure of the brain
 Detect intracranial bleeding, space
occupying lesion, cerebral edema.
Hydrocephalus, infarction
 Nursing Care
- Assess for allergies
- Instruct to lie still and flat
- Inform pt that there may be hot, flushed
sensation and metallic taste in the mouth
- Treat allergic reaction
- Remove hairpins etc
 Magnetic Resonance Imaging
 Computer-drawn, detailed pictures of
structures of the body through use of large
magnet, radio waves
 Used to detect intracranial and spinal
abnormalities associated with disorders
such as CVA, tumors, abscesses, cerebral
edema, hydrocephalus, multiple sclerosis
 Nursing Interventions
- Instruct client to remove jewelry, hairpins,
glasses, wigs,( with metal clips), and other
metallic objects-CBQ
- Patients with orthopedic hardware,
intrauterine devices, pacemaker, internal
surgical clips or other fixed metallic objects
in the body cannot undergo the procedure-
CBQ
- Inform client to remain still during the
procedure ( last 45-60 mins)
- Teach relaxation techniques to assist client
& help prevent claustrophobia
- Warn the client of normal audible humming
and thumping noises from the scanner
during test
- Have client void before test
- Sedate client if ordered
 Electroencephalography
 graphic recording of electrical activity
of the brain by several small electrodes
placed on the scalp.
 Nursing Interventions
- Withhold medications that may interfere
with the results- anticonvulsants, sedatives
and stimulants
- Wash hair thoroughly before procedure
- Instruct adult client to sleep no more than 5
hrs the night before.
- Instruct child client to sleep no more than 5-
7 hrs the night before
 Lumbar Tap
 Insertion of spinal needle through the
L3 and L4 into the subarachnoid space
 Purposes
- Measures CSF pressure (normal opening
pressure 60-150mmH2O)
- Obtain specimens for lab analysis (protein
normally not present), sugar (normally
present), cytology, C&S
- Check color of CSF (normally clear) and
check for blood
- Inject air, dye, or drugs into the spinal canal
 Nursing Care Pre-Test
- Have client empty bladder
- Position client in a lateral recumbent
position with head and neck flexed onto the
chest and knees pulled up.
- Explain the need to remain still during the
procedure
- NURSING CARE POST-TEST
- Ensure labeling of CSF specimens in
proper sequence
- Keep client flat for 12-24 hours as ordered
- Force fluids
- Check puncture site for bleeding, leakage of
CSF
- Assess sensation and movement in lower
extremities
- Monitor vital signs
- Administer analgesics for headache as
ordered
 Contraindication To Lumbar Tap
- increased icp
- coagulopathy & decreased platelets
- spinal deformities (scoliosis, kyphosis)
 Cerebral Angiography
 Injection of radiopaque substance into
the cerebral circulation via carotid,
vertebral, femoral , or brachial artery
followed by x-rays
 Used to visualize cerebral vessels and
detect tumors, aneurysm, occlusion,
hematomas, or abscesses
 Nursing Care Pre-Test
- Check allergy to iodine
- Keep NPO after midnight or offer clear
liquid breakfast only
- Explain that the client may have warm,
flushed feeling and salty taste in mouth
during procedure
- Take baseline vital signs and neuro check
- Administer sedation if ordered
 Nursing Care Post-Test
- Maintain pressure dressing over site if
femoral or brachial artery used; apply ice as
ordered
- Maintain bed rest until next morning as
ordered
- Monitor vital signs, neuro checks frequently;
report any changes immediately
- Check site frequently for bleeding or
hematoma; if carotid artery used; assess for
swelling of neck, difficulty swallowing or
breathing
- Check pulse, color, and temperature of
extremity distal to site used.
- Keep extremity extended and avoid flexion
 NEUROLOGICAL DISODERS
 HEADACHE
 Headache is pain affecting the front, top, or
sides of the head. Often occurring in the
middle of the day, the pain may have these
characteristics:
 Mild to moderate.
 Constant.
 Assessment S/Sx.
 Pressure pain, & tight feeling in the
temporal area
 Pain
 Nausea
 Headache with sensitivity to light
 Diagnostics
 Health history
 Physical examination
 CT scan
 MRI
 Treatments
 Depends on the type of headache and
whether it is acute or chronic
 Quiet, dark room especially for
migraines.
 Antiemetics such as Phenergan if
vomiting.
 Opiate analgesics
 Medications like Sumatriptan (SSRI)
can be given to abort the headache but the
cardiovascular risk must be weighed
against the benefit. These are reserved for
clients who are having two or more
migraines per month
 Ergot derivatives (Bromocriptine)
stimulate dopamine receptors; are also
given to abort the headache but can also
cause spontaneous abortion (miscarriage)
 Chronic migraines may be treated
prophylactically with Propranolol (beta-
blocker), Amitriptyline, clonidine,
Verapamil (calcium-channel blocker),
Cyproheptadine (Periactin), as well as
various antidepressants.
 Opioid analgesics such as Demerol
mixed with phenergan for severe attacks.
 Nonsteroidal antiinflammatory drugs
(NSAIDs) PO or IM such as Toradol,
Decadron
 INCREASE INTRACRANIAL
PRESSURE
 An increase in intracranial bulk due to
increase in any of the major intracranial
components: brain tissue, CSF, or Blood
 Causes
 Brain abscesses, hemorrhage, edema,
hydrocephalus, inflammation
 If left in treated it can lead to brain
herniation
 Clinical Manifestations
 Early manifestations
- Changes in the LOC- usually the earliest
- Pupillary changes- fixed, slowed response
- Headache
- vomiting
- Increased Intracranial pressure
 Late manifestations
- CUSHING TRIAD
 systolic hypertension
 bradycardia
 wide pulse pressure
- bradypnea
- Hypothermia
- Abnormal posturing
 Nursing interventions
 Maintain patent airway
 Elevate the head of the bed 15-30
degrees- to promote venous drainage
 assists in administering 100% oxygen
or controlled hyperventilation- to reduce the
 CO2 blood levelsconstricts blood
vesselsreduces edema
 Administer prescribed medications
- Mannitol- to produce negative fluid balance
- Corticosteroid- to reduce edema
- Anticonvulsants- to prevent seizures
 Reduce environmental stimuli
 Avoid activities that can increase ICP
like valsalva, coughing, shivering, and
vigorous suctioning
 CEREBROVASCULAR ACCIDENTS
 An umbrella term that refers to any
functional abnormality of the CNS related to
disrupted blood supply
 Can be divided into two major categories
 Ischemic stroke
- caused by thrombus and embolus
 Hemorrhagic stroke
- caused commonly by hypertensive bleeding
 The Stroke Continuum
 TIA
- transient ischemic attack, temporary
neurologic loss less than 24 hours duration
 Reversible Neurologic deficits
 Stroke in evolution
 Completed stroke
 Ischemic Stroke
 Diagnostic Test
- CT scan
- MRI
- Angiography
 Clinical Manifestations
- Numbness or weakness
- confusion or change of LOC
- Motor and speech difficulties
- Visual disturbance
- Severe headache
- Motor Loss
 Hemiplegia
 Hemiparesis
- Communication loss
 Dysarthria= difficulty in speaking
 Aphasia= Loss of speech
 Apraxia= inability to perform a previously
learned action
- Perceptual disturbances
 Hemianopsia
- Sensory loss
 Paresthesia
 Nursing Interventions: Acute
 Ensure patent airway
 Give 100% oxygen to the patient to
decrease ICP
 Keep patient on LATERAL position
( initially)
 Then if stable position low fowlers with
neck aligned
 Monitor VS and GCS, pupil size
 IVF is ordered but given with caution
as not to increase ICP
 NGT inserted
 Medications: Steroids, Mannitol (to
decrease edema), Diazepam,
Thrombolytics
 Nursing Intervention- Rehab
Care For Hemiplegia
 Turn every 2 hours
 Use proper positioning and
repositioning to prevent deformities
 Support paralyzed arm on pillow or
use sling while out of bed to prevent
subluxation of shoulder
 Elevate extremities to prevent
dependent edema
 Provide active and passive ROM
exercises every 4 hours
 SAFETY
- Keep side rails up at all times
- Institute safety measures
- Inspect body parts frequently for signs of
injury
 DYSPHAGIA
- Check gag reflex before feeding client
- Maintain calm unhurried approach
- Place client upright position
- Place food in unaffected side of mouth
- Offer soft foods
- 6.)Give mouth care before and after meals
 HOMONYMOUS HEMIANOPSIA
- Approach client on unaffected side
- Place personal belongings, food, etc. on
unaffected side
- Teach scanning techniques
 EMOTIONAL LABILITY: MOOD
SWINGS
- Create a quiet, restful environment with a
reduction in excessive sensory stimuli
- Maintain a calm , non threatening manner
- Explain to family that the client’s behavior is
not purposeful
 RECEPTIVE APHASIA
- Give simple, slow directions
- Give one command at a time ; gradually
shift topics
- Use non verbal techniques in
communication (pantomime) -CBQ
 EXPRESSIVE APHASIA
- Listen & watch carefully when the client
attempts to speak
- Anticipate the clients needs to decrease
frustrations
- Give magic slate- CBQ
 APRAXIA
- loss of ability to perform purposeful skilled
acts
- Guide the client through intended
movement
- Keep repeating the movement
 MENINGITIS
 Inflammation of the meninges of the brain
and spinal cord
 Causes
 Bacteria
 Viruses
 Other Microorganisms
 May reach the brain via
 Blood, CSF
 By direct extension from adjacent
cranial structures (nasal sinuses, mastoid
bone, ear, skull fracture)
 By oral or nasopharyngeal route
 Assessment Findings
 Headache, photophobia, malaise,
irritability
 Fever and chills
 Signs of meningeal irritation
- Nuchal rigidity: stiff neck
- Kernig’s sign: contraction or pain in the
hamstring muscle when attempting to
extend the leg when hip is flexed
- Opisthotonus: head and heals bent
backward and body arched forward
- Brudzinski’s sign: flexion at the hip and
knee in response to forward flexion of the
neck
 Vomiting
 Possible seizures and decreasing LOC
 Diagnostic Test: Lumbar Puncture
 CSF shows: elevated WBC, protein,
decreased glucose and culture positive for
specific microorganisms
 Nursing Interventions
 Administer large doses of antibiotics IV
as ordered
 Enforce respiratory isolation for 24
hours after initiation of antibiotic therapy
 Provide bed rest; keep room dark and
quiet
 Administer analgesics for headache as
ordered
 Maintain fluid and electrolyte balance
 Monitor vital signs and neuro checks
frequently
 High calorie, high protein, small
frequent feeding
 Refer to Audiologist
 ENCEPHALITIS
 Inflammation of the brain caused by a virus,
 E.g. herpes simplex or arbovirus
( transmitted by mosquito or tick)
 May occur as a sequela of other diseases
such as measles, mumps, chickenpox
 Assessment
 Headache
 Fever, chills, vomiting
 Signs of meningeal irritation
 Possibly seizures
 Alteration in LOC
 Nursing Interventions
 Monitor vital signs and neurological VS
frequently
 Provide nursing measures for
increased ICP
 Provide nursing care for confused or
unconscious client as needed
 CEREBRAL ANEURYSM
 Dilation of the walls of a cerebral artery
resulting in a sac-like out pouching of the
vessel
 Causes
 Congenital weakness in the vessel
 Trauma
 Arteriosclerosis
 Hypertension
 Pathophysilogy
 Aneurysms compress nearby cranial
nerves or brain substance, producing
dysfunction
 Aneurysms may rupture, causing
intracerebral hemorrhage
 Assessment
 Severe headache, and pain in the
eyes
 Diplopia, tinnitus, dizziness
 Nuchal rigidity, ptosis, decreasing
LOC, hemiparesis, seizures
 Nursing Interventions
 Maintain a patent airway and adequate
ventilation
- instruct client to take deep breaths but to
avoid coughing
- suction only with a specific order
 Monitor vital signs and neurological VS
and observe signs of vasospasm, increased
 ICP, hypertension, seizures, and
hyperthermia
 Institute seizure precaution
 Enforce bed rest and provide complete
care
 Keep head of bed flat or elevated to
20-30 degrees as ordered
 Maintain a quiet and darkened
environment
 Avoid taking rectal temperature, avoid
sneezing, coughing, and straining at stool
 Enforce fluid restriction as ordered;
maintain accurate I&O
 Give medications
- Antihypertension
- Corticosteriods
- Anticonvulsant
- Stool softeners
 SEIZURES
 Episodes of abnormal motor, sensory,
autonomic activity resulting from sudden
excessive discharge from cerebral neurons
 A part or all of the brain may be involved
 EPILEPSY
 Neurologic disorder in which the patient
experiences recurrent seizures consisting of
transient disturbances of cerebral function
due to paroxysmal neuronal discharge
 Pathophysiology
 An electrical disturbance in the nerve
cells in one brain section EMITS
ELECTRICAL IMPULSES excessively
 Etiologic Factors
 Often idiopathic
 Cerebral trauma, infection, vascular
disease, neoplasms, degenerative disease
(Alzheimer)
 Drugs, chemical poisons
 Metabolic disorders
 Children, high fever
 Others: lack of sleep, alcohol
 Classification Of Seizures
 SIMPLE PARTIAL
- symptoms confined to one hemisphere,
may have motor (change in posture),
sensory (hallucinations), or autonomic
(flushing, tachycardia) symptoms ; no loss
of consciousness
 COMPLEX PARTIAL
- begins in one focal area but spreads to both
hemispheres (more common in adults),
there is loss of consciousness; aura of
visual disturbances, post-ictal symptoms
 GENERALIZED
- entire cerebral cortex is involved
 ABSENCE (petit mal)
- sudden onset, lat 5-10 seconds; can have
100 daily, precipitated by stress,
hypoglycemia, fatigue, hyperventilation ,
there is loss of responsiveness but
continued ability to maintain posture control
and not fall, twitching of the eyelids, lip
smacking , no post-ictal symptoms
 TONIC-CLONIC(grand mal)
- victim becomes rigid, cries out, loses
consciousness, falls & stops breathing
(tonic phase); muscular jerking, may bite
tongue or lips, may be incontinent (clonic
phase); after awakening, subject is drowsy
& amnesic
 CYCLONIC
- repeated shock like, often violent
contractions in one or more muscle groups
 STATUS EPILEPTICUS
- one or a series of grand mal seizures
lasting more than 30 minutes w/o waking
intervals
 Diagnostics
 EEG shows focal abnormalities in the
rate, rhythm or relative intensity of cerebral
cortical rhythms
 CT scan
 MRI
 Nursing Interventions
 During seizure
- remove harmful objects from the patient’s
surrounding
- ease the client to the floor
- protect the head with pillows
- Observe and note for the duration, parts of
body affected, behaviors before and after
the seizure
- loosen constrictive clothing
- DO NOT restrain, or attempt to place
tongue blade or insert oral airway
 Pharmacology
 Dilantin
- used to prevent seizure.
- causes brownish urine
- never abruptly stop (can cause rebound
seizure)
- can cause gingival hyperplasia (massage
gums)
 Benzodiazepine
- Major indications: Anxiety, insomnia, and
seizure (skeletal muscle relaxation
- Should be started on low dosage and
gradually increased to achieved desired
clinical response.
- No to pregnant mother
- Monitor client for drowsiness,
lightheadedness, and dizziness periodically
during treatment, these usually disappear
as therapy progresses
- Restrict amount of drug available or the
client. May cause physical dependence if
prolonged therapy.
 TRIGEMINAL NEURALGIA
(TIC DOULOUREUX)
 Is an intensely painful neurologic condition
affecting the 5th CN (trigeminal)
 Patient may experience lancinating or
electric shock-like facial pain
 Pain can be triggered when talking,
shaving, eating, touching the face, brushing
teeth, or when exposed to cold and wind.
 Avoid too hot or too cold food or liquids
 Room temp for food and water for bathing
 Chewing on the unaffected side is
recommended
 No massage
 Provide water jet device for mouth care
 Tegretol for pain
 Phenol Injection in the Gasserian ganglia
(loss of temporary facial sensation)
 Rhizotomy (surgical intervention)
 Percutaneous radio-frequency trigeminal
gangliolysis
 BELL’S PALSY
 Affects the 7th cranial nerve (facial)
 Produces unilateral facial weakness, or
paralysis
 Onset is rapid
 Occurs in persons under age 60
 Named after Scottish anatomist Charles
Bell
 Acute peripheral facial paralysis of the 7th
CN (facial)
 Self-limiting that usually improves in 4-6
months.
 Cause is unknown
 Inflammation
 Vascular ischemia
 Autoimmune demyelination
 Assessment
 Inability to close eye completely on the
affected side
 Pain around the jaw or ear
 Ringing in the ear
 Taste distortion on the anterior portion
of the tongue on the affected side
 Unilateral facial weakness
 Eye roll upward and tears excessively
when the patient attempts to close it
 Artificial tears is recommended and
dark glasses (CBQ)
 Apply warm packs to the affected
 Inadequate eyelid closure
 Exercise (grimacing, wrinkling,
whistling, puffing the cheeks, blowing out
air)
 Provide soft diet (CBQ)
 Instruct to chew on unaffected side,
avoid hot fluids/ food (CBQ)
 MULTIPLE SCLEROSIS
 Degenerative disease
 Demyelination of the (myelin sheath) nerve
fibers (brain and spinal cord)
 Hypofunction of oligodendroglial cells and
Schwann cells(responsible for reproduction
of the myelin sheath)
 Chronic slowly progressive
 Characterized by remission and
exacerbation
 Maybe triggered by
 Pregnancy
 Fatigue
 Stress
infection and trauma
 May worsen in extreme temperatures
 Lesions are scattered
 Common among women
 Causes
 Unknown
 Autoimmune (post viral infection)
 Diagnostic test
 CT scan
 MRI
 CSF (IgG)
 EEG
 Manifestations
 Eye problem (early manifestation)
- vision is impaired, blurring, diplopia,
scotoma (patch blindness), nystagmus, total
blindness
 Disruption of sensory nerve
- Paresthesia and pain
 Frontal lobe problem
- memory loss,  concentration, poor abstract
reasoning
 Cerebellum and basal ganglia
involvement
- Ataxia (uncoordinated muscle movement)
- Tremor
- Weakness of muscle in throat and face
 Sacral cord problem
- Impotence, bowel and bladder dysfunction
 Charcot’s triad
- Nystagmus
- Tremors
- Scanning speech
 Diagnostic Test
 CSF- IgG in CSF
 Management
 Avoid fatigue, stress and infection
 Promote safety and rest
 Visual disturbance (scanning vision)
eye patch for diplopia
 Sensory problem (caution for cuts and
burns), avoid hot tubs ( heat increases
weakness)
 Motor problem (fall and slip)
 Bowel and bladder program
 Steroids, Immunosuppressive,
Antibiotics, baclofen, Plasmapheresis,
Thymectomy
 Respiratory Distress precautions
 GUILLIAN-BARRE SYNDROME
 An auto-immune attack of the peripheral
nerve myelin
 Acute, rapid segmental demyelination of
peripheral nerves and some cranial nerves
 Neuromuscular disease
 Ascending paralysis
 (Schwann cells) Demyelinating
polyneuropathy of motor and sensory
nerves
 Causes
 Unknown
 Autoimmune (post viral infection)
 Diagnostic test
 EMG
 CSF
 ECG
 Manifestations
 Clumsiness (initial symptom)
 Muscle weakness or paralysis of the
feet or legs that goes upward
 Hyporeflexia
 Distention to incontinence
 Paralysis of the diaphragm
 Dysphagia and drooling
 Respiratory depression
 Blurred vision (CN II)
 Nursing Intervention
 mostly supportive
 Maintain adequate ventilation
 Check individual muscle groups every
2 hours in acute phase to check
progression of weakness
 Check cranial nerve function, assess
gag reflex and swallowing ability, give
pureed foods.
 Monitor vital signs
 Administer corticosteroids to suppress
immune function
 MYASTHENIA GRAVIS
 Marked weakness and fatigue of voluntary
muscles
 acetylcholine or – communication of nerve
cells
 acetylcholinesterase – inactive form
 sensitivity to acetylcholine by the receptor
site
 Defect in transmission of nerve impulse at
the myoneural junction
 Causes
 Unknown
 Autoimmune (post viral infection)
 Diagnostic Test
 Tensilon Test (Edrophonium)
- Short acting cholinergic is administered
- Increased muscle strength is observe
(+Tensilon)
 EMG
 Manifestations
 Ptosis, diplopia and eye squint (early
sign)
 May start from ocular to
oropharyngeal, facial and to respiratory
muscle paralysis
 Muscle weakness more pronounce in
the evening
 3 D’s dysphagia, dysphonia, dysarthria
 Drooping faces
 Respiratory paralysis (cause of death)
 Nursing Interventions
 Supportive
 Assess gag reflex before feeding
 Administer meds 20-30 mins. Before
meals to prevent aspiration
 Administer meds at precise time to
prevent respiratory distress which may
cause death
 Protect from falls due to weakness
 Start meal with cold beverages to
improve ability to swallow
 Avoid exposure to infection
 Adequate rest and activity  Artane
 Plasmapharesis- involves removal of  Akineton
antibodies from the plasma to inhibit  SIDE EFFECT
immune response  Blurring of vision
 Myasthenic crisis – caused by  Dryness of mouth/throat
undermedication  Constipation
 Cholinergic crisis – caused by  Urinary retention
overmedication  Dysarthria
 Medications  Mental disturbance
 Neostigmine - Antiparkinsonian Drugs
 Pyridostegmine  Levodopa
 MEDICATIONS TO AVOID (increases  Carbidopa
muscle weakness) - Antiviral
 Muscle relaxant  Amantadine
 Barbiturates  Bromocriptine
 Morphine sulfate - Antispasmodics
 Tranquilizers  Procyclidine
 Neomycin - Antihistamine
 Benadryl- to decrease tremors and anxiety
 PARKINSON’S DISEASE  Avoid The Following Drugs When On
 Degeneration of the substantia nigra Levodopa Therapy
 Older people greatly affected - Phenothiazines, reserpine, pyridoxine (vit
B6) these blocks the effects of levodopa.
 Depletion of dopamine
 Foods To Avoid
 Causes
- Tuna
 Unknown
- Pork
 CVA
- Dried Beans
 Post encephalitic, arteriosclerotic
- Salmon
 Drug Induced
- Beef Liver
- Methyldopa
 Blocks effect of Levodopa (CBQ)
- Haldol
 Side effect of Levodopa
- Phenothiazine
- Nausea and vomiting
 Manifestations - Orthostatic hypotension
 Triad - Insomnia
- Bradykinesia - Agitation
- Resting tremors - Mental confusion
- Rigidity (Cogwheel) - Renal damage
 Pill rolling (fingers)
 Stooped posture  AMYOTROPHIC LATERAL
 Masklike face SCLEROSIS
 Monotone speech
 Progressive, debilitating, degenerative and
 Drooling of saliva
eventually fatal neurologic disease involving
 Festinating gait
degeneration of motor neurons in the
 Nursing Interventions anterior horn of the spinal cord and the
 Supportive motor nuclei of the lower brainstem
 Aspiration precaution
 Characterized by weakness and muscle
 Increase fluid intake to prevent
wasting without sensory or cognitive
constipation
changes
 Position the patient to prevent
 Maybe caused by an excess of
contractures
GLUTAMATE, a chemical responsible for
- Firm bed, no pillows
relaying messages between the motor
- Hold hands folded at the back when walking
neurons.
 Give meds as ordered
- Anticholinergic  Causes
 To reduce tremors  Unknown
 Cogentin  5-10% GENETICS
 Onset basal ganglia causes chronic progressive
 Age of 40 – 60 chorea (involuntary & irregular movements)
 Males > females and cognitive deterioration, ending in
years due to respiratory failure dementia
 Etiology  Huntington’s disease usually strikes people
 DEGENERATION OF MOTOR between ages 25-55
NEURON  Death usually results 10-15 years after
 Familial onset of from suicide, heart failure, or
 Heavy metal intoxication pneumonia
 Tumors  Causes
 Onset - midlife  Autosomal dominant genetic
 Manifestations transmission
 Fatigue  Assessment
 Muscle Weakness & Wasting  CHOREIC MOVEMENTS
 Incoordination - rapid, often violent and purposeless that
 Dysarthria becomes progressively severe and may
 Respiratory Difficulty (Brainstem include:
Involvement)  Fidgeting
 Unilateral Disability Of Upper And  Tongue smacking
Lower Extremities  Dysarthria
 Fasciculations  Indistinct speech
 Diagnostic Test  Athetoid movements
 Testing to rule - out hyperthyroidism,  Slow sinuous writhing movements,
compression of spinal cord, infections, especially the hands
neoplasms  Torticollis
 EMG - differentiates neuropathy from  twisting of the neck
myopathy,  DEMENTIA
 Muscle biopsy - atrophy and loss of - mild at first but eventually disrupts the
muscle fiber patients personality
 Serum creatine kinase - elevated (non- - Gradual loss of musculoskeletal control,
specific) eventually leading to total dependence
 Pulmonary function tests – determine - Personality changes, carelessness,
degree of respiratory involvement untidiness, moodiness, apathy, loss of
 Nursing Management memory and paranoia
 Maximize functional abilities  Diagnostics
- Prevent complications of immobility  POSITRON EMISSION
- Promote self-care TOMOGRAPHY (PET)
- Maximize effective communication - Detects the disease
 Ensure adequate nutrition  DEOXYRIBONUCLEIC ACID
 Prevent respiratory complications ANALYSIS
- promote measures to maintain adequate - Detects the disease
airway  CT SCAN
- promote measures to enhance gas - reveals brain atrophy
exchange – O2 therapy & ventilatory  MRI
assistance - reveals brain atrophy
- promote measures to prevent respiratory  Treatments
infection  Disease has no cure. Treatment is
 Help client and family deal with current supportive, protective, and aimed at
health problems relieving symptoms
 Plan for future needs including inability  Drug Therapy
to communicate - ANTIPSYCHOTICS
 Chlorpromazine (thorazine)
 HUNTINGTON’S CHOREA  Haloperidol (Haldol)
 Is a hereditary disease in which  To help control choreic movements
degeneration in the cerebral cortex and - ANTIDEPRESSANT
 Imipramine (Tofranil)  Management
 To help control choreic movements)  Respiratory function is the first priority
 Nursing Interventions especially in cervical SCI
 Provide physical support by attending  Immobilize in a flat, firm surface
to patient’s needs (hygiene, skin care,  Cervical collar if cervical injury is
bowel & bladder care) etc. suspected
 Stay alert for possible suicide  Transport client as a unit
 Pad the side rails of the bed but avoid  Do not attempt to realign body parts
restraints  Traction
 Provide emotional support  Cast
 Assist in designing behavioral plan  Surgery
that deals with disruptive and aggressive
behavior and impulse control problem  AUTONOMIC DYSREFLEXIA
 Reflex response to stimulation of the
 SPINAL CORD INJURY sympathetic nervous system
 Occurs most commonly in young adult  Rise in blood pressure, sometimes to fatal
males between ages 15-25 level due to over distended bladder and
 Causes bowel
 Motor vehicle accidents  Occurs in clients with cord lesion above T6
 Diving in a shallow water and most commonly in clients with cervical
 Falls injuries
 Sports injuries  Assessment
 Effects  Bradycardia
 Paralysis  Hypertension—CVA, blindness
 Loss of reflexes  Sweating above lesion
 Loss of sensory function  Severe headache
 Loss of motor function  Blurring of vision
 Autonomic dysfunction  Nasal stuffiness
 Cervical SCI  Management
 Above C4 is fatal  Position the patient in a sitting position
 Quadriplegia ( paralysis of all four to decrease BP
extremities)  Check bladder distention, fecal
 Respiratory muscle paralysis impaction
 Bowel/ bladder retention  Remove offending stimulus
 Thoracic SCI ( catheterize)
 Paraplegia  Monitor blood pressure
 Poor control of upper trunk  Administer antihypertensive
 Bowel/bladder retention
 Lumbar SCI  ALZHEIMER’S DISEASE
 Paraplegia(flaccid)  Form of dementia characterized by
 Bowel/ bladder retention progressive, irreversible deterioration of
 Sacral SCI general neurological functioning begins
 Above S2 insidiously
 With erection  Characterized by gradual losses of
 No ejaculation cognitive function and disturbances in
 S2-S4 behavior and affect
- No erection  Pathophysiology
- No ejaculation  Characterized by cortical atrophy and
- Bowel and bladder incontinence loss of neurons, particularly in the parietal
 Diagnostic Test and temporal lobes. With significant
 Spinal x-ray atrophy, there is ventricular enlargement
 CT scan (i.e., hydrocephalus) from the loss of brain
 MRI tissue.
 There is presence of amyloid-  apraxia
containing neuritic plaques and  astereognosis
neurofibrillary tangles  inability to write
 These plaques are found in areas of  frustration and depression
the cerebral cortex that are linked to  Stage III
intellectual function. - Increasing dependence
 Neurochemically, Alzheimer’s disease - Inability to communicate & loss of
has been associated with a decrease in the continence
level of acetylcholine transferase activity in - Progressive loss of cognitive abilities
the cortex and hippocampus - Delusion, hostility, paranoid reaction,
 Warning signs combativeness
 Memory loss affecting ability to - Prone to falls
function in job  Diagnostic Tests
 Difficulty with familiar tasks  EEG
 Problems with language, abstract - slow pattern in later stages of disease
thinking  MRI
 Disorientation, changes in mood and  CT scan
personality  Positron emission tomography (PET)
 Assessment  Folstein Mini-Mental Status
 Subtle recent memory loss  Cerebral Biopsy
- progressive - confirms the diagnosis
 Death usually due to malnutrition and  Medications
secondary infection  Acetylcholinesterase inhibitors
 Duration 8-10 yrs. - mild to moderate dementia
 Clinical Manifestations - enhances Acetylcholine uptake in the brain
 Stage I  Tacrine hydrochloride (Cognex)
- Appears healthy and alert  Donezepil hydrochloride (Aricept)
- Cognitive deficits are undetected  Rivastigmine (Exelon)
- Subtle memory lapses and forgetfulness  Antidepressants
- Personality changes - depression  Tranquilizers
- Seems restless and uncoordinated - for severe agitation
 Stage II - Thioridazine (Mellaril)
- Memory deficits - Haloperidol (Haldol)
 more apparent  Antioxidants
 may lose ability to recognize familiar places, - Vitamin E
faces and objects  Anti-inflammatory agent
 may get lost in a familiar environment  Estrogen replacement therapy in
 conversation becomes difficult women
 word-finding difficulties  Nursing Management
- ability to formulate concepts and to think  Support cognitive function
abstractly disappears – concrete thinking - Provide a calm, predictable environment
predominates - Speak in a quiet and pleasant manner
- Impulsive behavior - Use memory aids and cues
- Less able to behave spontaneously - Gives a sense of security
- Wandering behavior - Color-code the doorway
- Changes in sleeping patterns - Encourage active participation
- Agitation and stress  Promote physical safety
- Trouble with simple decisions - Remove all obvious hazards
- Sundowning: increased agitation, - Monitor patient’s intake of food and
wandering, disorientation in afternoon and medications
evening hours - Wandering behavior – use gentle
- Language problems persuasion or distracting the patient
 Echolalia - Avoid restraints – increases agitation
 scanning speech - Secure doors leading from the house
 total aphasia at times
- Supervise all activities outside the home –
let patient wear identification bracelet or
neck chain
 Reduce anxiety and agitation
- provide constant emotional support
- keep the environment uncluttered, familiar
and noise-free
- structure activities
- familiarize oneself with the patient’s
predicted responses to certain stressors
 Improve communication
- Nurse uses clear, easy-to-understand
sentences
- List simple written instructions – serve as
reminders
- Patient may use nonverbal communication
- Tactile stimuli – hug or hand pat – signs of
affection, concern & security
 Promote independence in self-care
activities
- Simplify daily activities
- Collaborate with occupational therapist
- Direct patient supervision
- Encourage patient to make decisions
 Provide for socialization and intimacy
needs
- Encourage socialization
- Encourage patient to enjoy simple
recreational activities
 Walking
 Exercising
 Socializing
- Encourage px to care for a pet – provides
an outlet for energy
 Promote adequate nutrition
- Keep mealtime simple and calm
- One dish is offered at a time
- Cut food into small pieces
- Hot food and beverages are served warm
- Provide familiar foods that look appetizing
and tastes good
- Provide adaptive equipment if necessary

Reference:
- Smelter,Smelter C. and Bare, Brenda G. 2003.
Brunner and Suddarths’s Textbook of Medical-Surgical
Nursing 10th edition