NEUROLOGIC SYSTEM

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Review of Systems

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 Neurologic System
■ Communication network • Cognitive
■ It processes
1.◆Reception
from the outside world 1. Judgment
◆ coordinates and organizes the2. Insight
2. Response
functions of all the other body 3.
systems
Memory
3. Executive functioning

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 A. Brain

Substantia Nigra

Dopamine
Cholinesterase Acetylcholine

GABA

B. Arm 4
NEUROLOGICAL
DISORDERS

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1

3 8
ACUTE DISORDERS

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SEIZURE DISORDERS
(EPILEPSY)

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• Seizure - an unconditioned discharge of
neurons

May be:
• as a blank stare, lasting a second,
• as long as a tonic-clonic seizure,
lasting several minutes

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• Possible causes:
–Strong firing of
impulse
–Insufficient
neurotransmitters

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• Epilepsy - recurrent seizures
– a sign of CNS disorder
–Classified as:
•Partial
•Generalized
•Unclassified

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 Type
Type of
of seizure
seizure Length
Length

Partial
Partial Petit mal < 5 mins.
> 5 mins.
Generalized Tonic clonic
< 20 mins.

Unclassified Lack of data

• > 20 mins
Status epilepticus
• Life-threatening
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 Assessment
• Aura
• Irregular breathing
• Disorientation
• Loss of coordination
• Altered LOC

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 Diagnostic Evaluation

• EEG
• CT Scan / MRI

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 Nursing Interventions

• Before seizure
–PRIORITY: Safety!

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During seizure
• Safety
• DON’T RESTRAIN!
• If client is standing, lower him to a flat surface
• Respiratory support
– Maintain a patent airway
– Turn the client’s head to one side
– Administer oxygen
– Suction as needed
• Note: date, time of onset, and length
• Provide a calm environment
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After seizure
• Assess
–VS and neurologic status - LOC
• Allow verbalization of
feelings.

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• Preventive
–Administer medications, as
ordered.

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• Acute attacks (2-3/ week): Valium (diazepam)
• S/E: Sedation

• Preventive: Dilantin (Phenytoin HCl)

• S/E:
• Red-orange urine
• GI distress
• Gingival hyperplasia
• Bone marrow depression
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 TRAUMATIC
HEAD INJURY

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• Results from a trauma to the head,
leading to
• brain injury
• bleeding within the brain

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• Classified by brain injury type:

• A. Fractures
•Depressed
•Comminuted
•Linear

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B. Hemorrhages
•Epidural
•Subdural
•Intracerebral

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 Possible Causes

• Fall
• Automobile accident
• Assault

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Assessment Findings
• S/sx of increase in ICP
(N: 0-15 mmHg)
• ALOC
• Paresthesia
• Paralysis
• Dementia
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 Nursing Interventions
• Safety
– Seizure precautions
– CSF leak
• Airway & breathing
– Monitor
• VS
• LOC
• Pulse oximeter / ABG
• Reflexes
• Fluids and Electrolytes
• Medications, as ordered 28
• Medications:

–For pain Codeine SO4

–Swelling / Inflammation Steroids

–Edema Mannitol

–Bleeding Vasopressin

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• Surgeries:

–Epidural / subdural: Craniotomy

–Intracerebral:Open brain surgery

• Barbiturates
• 6-12 months
• To induce coma
• To reverse coma
• Methamphetamine HCl
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SPINAL CORD INJURY

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CLASSIFICATIONS

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A. Type of injury

1.Contusion
2.Laceration
3.Transaction

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B. Level of injury

•Cervical: quadriplegia
•Thoracic & Lumbar: paraplegia

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C. Force / Mechanism

Compression Hyperextension Hyperflexion

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 Diagnostic Evaluation

• Spinal X-rays
• CT scan or MRI
• Myelography

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 Possible Causes
• Trauma
–Fall
–Vehicular accident
–Diving
• Congenital anomalies
• Tumors
 Assessment Findings

• Loss of muscular or sensory function

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– Voluntary motor movement
– Pain
– Problems on light touch, temperature,
pressure, and proprioception
– Reflex activity
– Autonomic activity
– Bowel and bladder dysfunction
– Respiratory distress
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 Nursing Interventions

• Assess VS and
neurologic status.
• Immobilize, reduce
and align

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• Safety
–Bed rest on a firm surface
• Airway and Breathing
–Oxygen
–DBCT
• Assess for Autonomic Dysreflexia

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• Autonomic
Dysreflexia
–an exaggerated
sympathetic
response to a
noxious stimulus
–SCI above T7
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– Signs and symptoms:
• Hypertension
• Pounding headache
• Flushing
• Diaphoresis
• Blurred vision
• Bradycardi

Treatment: remove the noxious

stimulus
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a
CEREBROVASCULAR
ACCIDENT

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• AKA stroke or brain attack
• Sudden disruption in cerebral circulation.
• Types
• Obstructive
• Thrombus - atherosclerosis
• Embolus
• Hemorrhage
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Assessment Findings

• Altered LOC
• Headache
• Nuchal rigidity
• Signs of increased ICP

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 Diagnostic Evaluation

• CSF analysis
• CTS / MRI
• Cerebral angiogram
• EEG

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 Nursing Interventions
• Safety: Seizure precautions
• Promote respiratory support
–Oxygen, as ordered
–DBCT
–Pulse oximetry and ABG
–Reflexes
–NPO and NGT
• CBR
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• Diet:
–Low-sodium
–Low-cholesterol
–Low-fat

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• Administer medications as ordered:
• Hemorrhagic
• Antihypertensive

• Obstructive
• Anticholesterol
• Anticoagulants
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CHRONIC DISORDERS

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Format:
• Disorder / other name
• Involvement
• Pathophysiologic Basis
• Assessment
• Diagnostic
• Management
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Disorder
/ Pathophysiologic
Involvement
basis Asssessment Diagnostic Management
Other
name

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ALZHEIMER’S DISEASE
“Senile Dementia”

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 a. Judgment
Involvement: Cognitive b. Insight
c. Memory

Predisposing Factors:
1. Age (65 and above)
2. Substances a. Lead
b. Arsenic
c. Nicotine
d. Aluminum 60
Pathophysiologic Basis:
Presence of neurofibrillary plaques and
tangles

Cell death

Decreased acetylcholine

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 Assessment:
Hallmark: DEMENTIA
Manifestations:
Agnosia - inability to recognize people or
objects
Aphasia - inability to speak
Apraxia - inability to perform purposeful
movements
Executive dysfunction - inability to learn new
information 62
 Stages:
Forgetfulness • 1-3 years
• Difficulty remembering
appointments
• 4-8 years
• Difficulty remembering past but not the
Advanced recent events
• Sundown syndrome
• Best time to give medications

Terminal • 9 years and up

• Death occurs in 1 year
• Causes: dehydration and starvation
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ALZHEIMER’S DISEASE

Diagnostic:

• CT Scan
• MRI

Confirmatory: Autopsy
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 Management: 2S6C
Safety • Favorable - warm
Security • Red
Clock • • Activities
Yellow
For • reorientation
• •Aricept (Donepezil)
Orange
Personnel
Calendar •• Cognex (Tacrine)
Avoid - cool
Consistency
• Blue
Color • Violet
Cholinesterase Inhibitors
• Green
Custodial Care 65
MYASTHENIA GRAVIS

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MY Muscles

ASTHENIA Weakness

GRAVIS Severe

Severe muscle weakness

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MYASTHENIA GRAVIS

Involvement: Motor
Predisposing Factor/s: Autoimmune
Thymus gland - abnormal antibodies
Pathophysiologic Basis:
Destruction of acetylcholine
receptor sites
 A. Brain

Substantia Nigra

Dopamine
Cholinesterase Acetylcholine

GABA

B. Arm 69
MYASTHENIA GRAVIS

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MYASTHENIA GRAVIS

Assessment:
Earliest symptom: Ptosis

Hallmark: Muscle weakness

Strong in the morning, weak in the

afternoon
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MYASTHENIA GRAVIS

Diagnostic:
1. CTS
Thymoma
2. MRI
3. Blood test (+) Ab
4. Tensilon (edrophonium) Test

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 Tensilon Test
- best done: PM
- Routes:
a. IV b. IM
- Ideal - history of cholinergic crisis
- Onset: STAT - Onset: 3-5 minutes
- Half-life: 1-3 minutes - Half-life: 1-3 minutes

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Tensilon Test
1. ⬆muscle strength - (+) Myasthenia gravis
- DOC:
- Neostigmine
- Pyridostigmine
2. ⬇muscle strength - (+) Cholinergic crisis
- Antidote:
- Atropine Sulfate (IV)
3. ❌ effect - (+) Brittle crisis
- Steroids
- Plasmapheresis
- Thymectomy 74
Management: 1. Equipment:
- Suction App
A Airway - Oxygen
2. Side-lying
3. Diet: Thickened
B Breathing Mechanical ventilator

A Assist with ADL

P Pharmacologic treatment 75
AMYOTROPHIC LATERAL
SCLEROSIS
Other name: Lou Gehrig’s Disease

F3:M1

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ALS
Involvement: Motor and cognitive

Predisposing Factors:

G enetics
U nnecessary radiation exposure
N utrition - lack of vitamin B complex
- too much MSG
S low-acting virus- rhabdo
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ALS
Pathophysiologic Basis:
Local demyelination

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ALS

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ALS
Assessment:
First sign: Fasciculations
Hallmark: Muscle atrophy
- peripheral to central

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ALS
Diagnostics:
CTS
MRI
CSF analysis - elevated total protein
Elevated CK-MM
EMG

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Management: 1. Equipment:
- Suction App
A Airway - Oxygen
- Pulse oximeter
2. Side-lying
3. Diet: Thickened
B Breathing Mechanical ventilator

A Assist with ADL

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 MULTIPLE SCLEROSIS

• 20 - 40 years old
• With remissions and exacerbations

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 Involvement: Motor
Cognitive
Sensory

Predisposing Factors:
G enetics
U nnecessary radiation exposure
N utrition - lack of vitamin B complex
- too much MSG
S low-acting virus- rhabdo
Multiple Sclerosis

Assessment:
Earliest symptom: Diplopia
Hallmark: Charcot’s Triad
S canning of speech

Intentional tremors

Nystagmus 86
 Diagnostics:
CTS
MRI
CSF analysis - elevated total protein

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Multiple Sclerosis Management:
S afety - patch 1 eye

A irway Physical stress

- Extreme temperatures
B reathing - Pregnancy
- Lack of sleep
A ssist with ADL

Prevent exacerbation 89
90
Guillain - Barre Syndrome
• AKA: Idiopathic polyneuritis

• Prognosis: 80-90%
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GBS

Involvement: Motor and sensory

Predisposing Factor/s:
Legio debilitans
Post-viral exposure Epstein-Barr
Zika
* Autoimmune

Pathophysiologic Basis: Polyneuritis

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GBS

Assessment:
a. Paresthesia Ascending

b. Paralysis } Bilateral
Consummated

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GBS
Diagnostic:
1. CTS
2. MRI
3. ⬆ ESR - Normal: 0-20 mm/hr
- Moderate to severe inflammation

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Management:
S Safety - complete bed rest

B Breathing - mechanical ventilator

1. Equipment:
- Suction App

A Airway
- Oxygen
- Pulse oximeter
2. Side-lying
3. Diet: Thickened

P Pharmacology - DOC: Steroids

Parkinson’s Disease
Paralysis Agitans
Shaking Palsy

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 A. Brain

Substantia Nigra

Dopamine
Cholinesterase Acetylcholine

GABA

B. Arm 97
Parkinson’s Disease

Involvement: Motor

Predisposing Factor/s: Trauma

a. Damage to the substantia nigra Infection /
b. Medications Antipsychotics inflammation
Tumor
Pathophysiologic Basis:
Low DOPAMINE level High ACETYLCHOLINE

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High ACETYLCHOLINE Stooped
posture
Low DOPAMINE Mask-like face
Muscle rigidity Cogwheel
rigidity
EARLY: CN # 7
CN # 11 Pill-rolling
tremors

LATE: CN # 9 - swallowing
CN # 12 - gag Shuffling /
propulsive gait
Risk: ASPIRATION
Parkinson’s Disease
Diagnostic:

1. CTS
2. MRI
} Damage to the
substancia nigra

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 Management:
walker
S Safety - assistive walking device
cane
A Airway

P Pharmacology Sinemet (Levodopa-Carbidopa)

1.Dopaminergics / Dopamine agonists

• avoid vitamin B6
• taken before meals
• may cause postural hypotension
2. Anticholinergics
Cogentin • May cause:
Akineton • Dry mouth
Benadryl • Dry eyes 101
Artane
Huntington’s Disease
Huntington’s Chorea
Hereditary Chorea

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Involvement: Motor & cognitive

Predisposing Factor/s:
Heredity : JEWS
Age: 25 - 55

Pathophysiologic Basis:
Lesion
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Huntington’s Disease

Assessment:
• Dementia
• Chorea (hallmark)
• Fatigue
• Depression

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Huntington’s Disease

Diagnostic:
1. EEG
2. CTS
3. MRI

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Management:
a. Suicide
S Safety
b. Injury

A Assist with ADL

a. Major tranquilizers
P Pharmacology b. Anti-depressants
- SRRI
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CRANIAL NERVE
DISORDERS

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 Bell’s Palsy Trigeminal Neuralgia
(Tic Doloreux)
Cause Unknown
Cranial Nerve
7 (Facial) 5 (Trigeminal)
Predisposing factor
Trauma, infection / inflammation, tumor
Diagnostics
CTS / MRI CTS / MRI
EMG X-ray
Symptoms
Paralysis / paresthesia Pain

Treatment

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 Management

• Prednisone therapy (14

days)
• Electrotherapy
• Moist heat

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 Nursing Interventions
• Massage affected face
• Privacy at mealtimes
• Oral care
• Psychological support

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 Management

• Nerve blocks
• Surgery

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 Nursing Interventions
• Nutrition
–SFF at room temperature
–Use unaffected side when
chewing
• Oral hygiene
• Avoid stimulation

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B BP & temp = increased
R RR & HR = decreased
A Altered LOC
I Irritability / agitation
N N/V
S Seizures 115
 Level of Consciousness
LOC DESCRIPTION

ALERT Conscious and coherent

LETHARGY Slight alert reduction, less aware, thinks slowly

OBTUNDED Moderate alert reduction; clouding of consciousness;

STUPOR Sleep-like state; arousal is brief with vigorous

stimulation
LIGHT COMA Complete unresponsiveness, (+) re exes

DEEP COMA Complete unresponsiveness, (-) re exes

DEATH (-) Brain waves

fl
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 AVPU SCALE /
GLASGOW COMA SCALE
AVPU Scale
A Alert

V Verbally responsive

P Pain responsive

U Unresponsive
The AVPU scale is a system by which a
health care professional can measure
and record a patient’s LOC. It is mostly
used in emergency medicine protocols,
and within rst aid.
fi
Glasgow Coma Scale
The GCS provides a practical
method for assessment of
impairment of LOC in response to a
de ned stimuli.
fi
GCS-P Scale
The GCS-P is used:
• As an index of “overall” brain damage
• In distinguishing head injuries of
differing severities
• Monitoring their progress and
prognosis
 The GCS Total Scores....
15 Minor injury
9-12 Moderate injury
3-8 Severe injury
 The GCS Total Scores....
15 Best response
8 or less Comatose
3 Unresponsive
Score Motor Response Verbal Response Eye Opening

1 None None None

2 Extension Sounds To pressure

3 Abnormal Flexion Words To speech

4 Withdrawal Confused Spontaneous

5 Localizing Oriented

6 Obeying Commands
 Pupil Reactivity Score
(Pupils UNREACTIVE to light)

2 Both

1 One Pupil

0 Neither Pupil
 For total GCS, subtract pupil
reactivity score from calculated
GCS.
Example: A 37-year-old patient with a traumatic
head injury is admitted to the ER. The admission
assessment are as follows:
She does not open her eyes, she moans, and
displays abnormal exion in her limbs to pain. On
examination of her pupils, they are both xed and
dilated.
fl
fi
 Parameters Assessment Score

Motor Response Abnormal exion

Verbal Response She moans (sound)

Eye Opening Does not open her eyes

Total calculated GCS

Both are xed and
Pupil reactivity
dilated
GCS-P SCORE
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SPECIALTY BEDS

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• Non-Modifiable Risk Factors
–Age
–Gender African Americans
–Family History / Heredity Native Americans
Hispanics

• Modifiable Risk Factors

–Smoking
–Hypertension
–Obesity
–Elevated cholesterol
–Stress