MEDSURG SF

NERVOUS SYSTEM
to node travel hundreds of times faster than signals traveling along the
FUNCTIONS OF NERVOUS SYSTEM surface of the axon. This allows your brain to communicate with your toes in
a few thousandths of a second.
• The functional unit of the Nervous system is the nerve cell or neuron.
• Control over voluntary and involuntary functions / actions.
• To control body movements, respiration, circulation, digestion, hormone
secretion, body temperature
• To receive stimuli from sense organs, perceive them and respond
accordingly
• Higher mental functions like memory, receptivity, perception & thinking.

3 BASIC FUNCTIONS:
1. Receive sensory input from internal and external environments
2. Integrate the input
3. Respond to stimuli DIVISIONS:
CNS PNS ANS
The NEURON is the functional unit of the nervous system. Brain Cranial Nerves Parasympathetic
Spinal cord Spinal Nerves Sympathetic

NEURONS
Humans have about 100 billion neurons in their brain alone.

3 PARTS:

1. DENDRITES receive information from another cell and transmit the CEREBRUM
message to the cell body.
2. The CELL BODY (GRAY MATTER) contains the nucleus, mitochondria and • The cerebrum consists of the right and left hemispheres.
other organelles typical of eukaryotic cells. • Each hemisphere receives sensory information from the opposite side of
3. The AXON, elongated process or fiber extending from the cell body; the body and controls the skeletal muscles of the opposite side.
transmits impulses (messages) away from the cell body to dendrites or • The cerebrum governs sensory and motor activity and thought and
directly to the cell bodies of other neurons, neuron usually has only one learning.
axon, • Biggest p art of brain, divided into two hemispheres
▪ AFFERENT (SENSORY • Contra lateral control
NEURONS) carries nerve • Outer surface is grey due to cells
impulses towards the • Internally white due to fibers
brain. • Surface is folded to increase the area
▪ EFFERENT (MOTOR
NEURONS) carry nerve CEREBRAL CORTEX
impulses away from the
brain. The cerebral cortex is the outer gray layer; it is divided into FIVE LOBES. It is
▪ GANGLIA are clusters of responsible for the conscious activities of the cerebrum.
nerve cells.
1. FRONTAL LOBE
SYNAPSE - junction between a nerve cell and another cell. − Broca's area for speech.
− Morals (personality), emotions(behavior), reasoning and judgment
SYNAPTIC CLEFT - space between two cells. (intellectual functioning), concentration, and abstraction
• To cross the synaptic cleft requires the actions of neurotransmitters. precentral gyrus: motor function
2. PARIETAL LOBE
NEUROTRANSMITTERS - chemical agents involved in the transmission of − postcentral gyrus (Interpretation of taste, pain, touch, temperature,
impulse across synapse and are stored in small synaptic vesicles clustered at and pressure)
the tip of the axon. − Spatial perception, integrates sensory information.
3. TEMPORAL LOBE
Neurotransmitters: Acetylcholine − Auditory center, taste and smell
Norepinephrine − Wernicke's area for sensory and speech (understanding/formulation
Dopamine of language)
Serotonin 4. OCCIPITAL LOBE
Amino acids − Visual area.
Polypeptides 5. LIMBIC LOBE
− Emotional and visceral patterns for survival.
MYELIN SHEATH - a wrapping of myelin (a whitish, fatty material) that − Learning and memory.
protects and insulates nerve fibers and enhances the speed of impulse
conduction.
BASAL GANGLIA: Cell bodies in
SCHWANN CELLS - serve as supportive, nutritive, and service facilities for white matter that help the cerebral
neurons. cortex produce smooth voluntary
❖ The Schwann cell sheath is called the neurolemma. movements, part of extrapyramidal
❖ Neurons do not reproduce after the neonatal period. system
❖ If an axon or dendrite is damaged, it will die and be replaced slowly
only if the neurolemma is intact and the cell body has not died. CORPUS CALLOSUM - large fiber
tract that connects the two cerebral
NODE OF RANVIER - The gap between Schwann cells, and serves as hemispheres.
points along the neuron for generating a signal. Signals jumping from node

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DIENCEPHALON - connecting part of the brain, between the cerebrum MOTOR TRACTS
and the brain stem,

CONTAINS:

1. THALAMUS
− Relays sensory
impulses to the
cortex.
− Provides a pain
gate.
− Part of the reticular
activating system.
controls primitive
emotional responses
e.g. fear

2. HYPOTHALAMUS
− Regulates autonomic responses of the sympathetic and
parasympathetic nervous systems.
− Regulates the vital function; stress response, sleep, appetite, body
temperature, fluid balance, and emotions.
− Responsible for the production of hormones secreted by the
pituitary gland and hypothalamus.
BRAINSTEM – contains the midbrain, pons and medulla oblongata
REFLEX ARC. reflex consists of an involuntary response to a stimulus
occurring over a neural pathway components:
a. sensory receptors, receives/reacts to a stimulus
b. afferent pathway; transmits impulses to spinal cord
c. interneuron; synapses with a motor neuron (anterior horn cell)
d. efferent pathway; transmits impulses from motor neuron to effector
e. Effector - muscle or organ that responds to stimulus

a. MIDBRAIN SUPPORTING STRUCTURES:

− Responsible for motor coordination
− Contains the visual reflex and auditory relay centers a. SKULL
b. PONS: Contains the respiratory centers and regulates breathing − rigid; numerous bones fused together
c. MEDULLA OBLONGATA − protects and supports the brain
− Contains all afferent and efferent tracts and cardiac, respiratory, b. SPINAL COLUMN
vomiting, and − consists of 7 cervical, 12 thoracic and 5 lumbar vertebrae, as well as
vasomotor centers sacrum and coccyx
− Controls heart rate, − supports the head and protects the spinal cord
respiration, blood c. MENINGES - membranes between the skull and brain and the vertebral
vessel diameter, column and spinal cord
sneezing, swallowing, a) DURA MATER is the outermost layer; tough and fibrous membrane.
vomiting, and b) ARACHNOID MEMBRANE middle layer; delicate membrane and
coughing contains subarachnoid fluid.
c) PIA MATER is the innermost layer; vascular membrane. Subarachnoid
CEREBELLUM: Coordinates space is formed by the arachnoid membrane and the pia mater.
smooth muscle movement,
posture, equilibrium, and
muscle tone.

SPINAL CORD
• Provides neuron and synapse networks to produce involuntary
responses to sensory stimulation
• Allows for control of the number of pain impulses that pass through the
spinal cord on their way to the brain
• Carries sensory information to and motor information from the brain
• Extends from the first cervical to the second lumbar vertebra
• Protected by the meninges, cerebrospinal fluid, and adipose tissue
• Horns
a. Inner column of gray
matter; contains two
anterior and two
posterior horns
b. Posterior horns
connect with afferent
(sensory) nerve fibers.
c. Anterior horns contain
efferent (motor) nerve
fibers.

NERVE TRACTS

a. WHITE MATTER contains the nerve tract.

b. ASCENDING TRACTS (sensory pathway)
− posterior columns, carry impulses concerned with touch, pressure,
vibration, and position sense.
− spinocerebellar, carry impulses concerned with muscle tension and
position sense to cerebellum
− lateral spinothalamic, carry impulses resulting to pain and temp.
sensations.
− anterior spinothalamic, carry impulses concerned with crude touch
and pressure.
c. DESCENDING TRACT (motor pathway)
− corticospinal (pyramidal, upper motor neuron), conduct motor
impulses from motor cortex to anterior horn cells (cross the medulla)
− extrapyramidal, help to maintain muscle tone and to control body
movements esp. gross automatic movements such as walking.

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CEREBROSPINAL FLUID Maintenance of body temperature
Maintenance of water balance
• Secreted in the ventricles; circulates in the subarachnoid space and
through the ventricles to the subarachnoid layer of the meninges, COMPONENTS:
where it is reabsorbed
• Acts as a protective cushion; aids in the exchange of nutrients and a. SYMPATHETIC NERVOUS SYSTEM - generally accelerates some body
wastes functions in response to stress (adrenergic) fibers dilate pupils, increase
• Normal pressure is 50 to 175 mm H2O. heart rate and rhythm, contract blood vessels, and relax smooth
• Normal volume is 125 to 150 mL. muscles of the bronchi.
b. PARASYMPATHETIC NERVOUS SYSTEM - controls normal body
VENTRICLES functioning (cholinergic) fibers produce the opposite effect.

• Four ventricles
• The ventricles communicate between the subarachnoid spaces and
produce and circulate cerebrospinal fluid.

BLOOD SUPPLY
• Right and left internal
carotid arteries.
• Right and left vertebral
arteries
• These arteries supply the
brain via an anastomosis
at the base of the brain
called the circle of Willis.

PERIPHERAL NERVOUS SYSTEM

• 12 PAIRS OF CRANIAL NERVES FROM BRAIN (CRANIAL NERVES)
• 31 PAIRS OF SPINAL NERVES FROM SPINAL CORD (SPINAL NERVES)

− Mixed nerve fibers are formed by the joining of the anterior motor
and posterior sensory roots.
− Posterior roots contain afferent (sensory) nerve fibers.
− Anterior roots contain efferent (motor) nerve fibers.
ACTIONS OF THE AUTONOMIC NERVOUS SYSTEM

EFFECTOR AUTONOMIC ACTION

ORGAN DIVISION
Eye: pupil sympathetic dilation of the pupil
parasympathetic constriction of the pupil
Heart sympathetic dilation of coronary arteries,
increased HR, increased force of
contraction
parasympathetic slows, heart rate, reduces contraction
and conduction, constricts coronary
arteries
Bronchi sympathetic dilation
parasympathetic constriction and mucous secretion
Stomach sympathetic inhibition of peristalsis and secretion
and parasympathetic peristalsis and secretion
Intestines
Bladder sympathetic relaxed; sphincter closed
parasympathetic contracted; sphincter open

Drug How it works Clinical use

ADRENERGIC
Adrenaline acts directly on both alpha Used in asthma and other
(Medihaler-Epi, and beta receptors allergic diseases it relaxes
Lignostab, Eppy, airways and reduces
Xylocaine) swelling.
Phenylephrine acts directly on alpha Used as a decongestant in
(Decohist, receptors constricting small rhinitis and colds
Novahistine) blood vessels in the lining of
Pseudoephedrine the nose thus relieving
(Dimotane Co) congestion
Amphetamines Causes accumulation of No longer used clinically
including MDMA noradrenaline at the except for treatment of
(Ecstasy) synapses narcolepsy
ANTI-ADRENERGIC
Reserpine blocks the synthesis and Used in the management of
(Direserpine) storage of noradrenaline some types of hypertension
Propanolol (Inderal) blocks beta receptors Used in hypertension,
angina, migraine,
headaches and mitral valve
prolapse
CHOLINERGIC
Pilocarpine (Isopto- acts directly on muscarinic used as eye drops in
carpine, Sno Pilo) receptors ophthalmology to constrict
the iris of the eye. Used in the
treatment of glaucoma
ANTICHOLINERGIC
Atropine (Lomotil, blocks the action of Used in the treatment of
Atrosept) acetylcholine on diarrhea (Lomotil) as it can
muscarinic receptors slow down peristalsis Used
as a pre-op as it can prohibit
the secretion of mucous and
fluids which could block the
AUTONOMIC NERVOUS SYSTEM airways.
(INVOLUNTARY NERVOUS SYSTEM) Scopolamine blocks the action of Used in small doses in the
(Buscopan, Joy- acetylcholine on alleviation of the symptoms
Rides, Kwells) muscarinic receptors of motion sickness. Can be
− IT HAS CONTROL OVER used to promote twilight
Digestion sleep (drowsiness with
Respiration amnesia) in labour
Circulation
Hormone secretion

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 NEUROLOGICAL ASSESSMENT SIX PORTIONS

REVIEW OF RELATED HISTORY MENTAL STATUS

CURRENT PROBLEMS − Review from General Assessment

− Also
− Seizures/convulsions • Pupil Size
• Character • Glasgow Coma Scale
• Aura?
• LOC o MEMORY CHANGES
• Frequency o Short attention span
• Associated manifestations o Personality and behavioral changes
• Timing o Assessment of Level of Alertness (Becomes increasingly invasive as the
o Duration client is less responsive):
o Time of day − Speak to the client.
o Activities − Lightly touch the client.
• Medications − Painful stimuli (sternal rub, supraorbital pressure, trapezius squeeze)
− Pain
− Gait coordination PUPIL SIZE
− Weakness or paresthesia
• Paresthesia: unusual sensation such as numbness, tingling, or • Normal range: 2 - 6 mm
burning − Drugs: pinpoint pupils
− Changes in mental status − Increased intracranial pressure: pupils begin to dilate
− Changes in the 5 senses • Dilated and fixed, poor prognosis
• Assessment of Pupils
PAST MEDICAL HISTORY − Size
− Equality
− Trauma − Reactions to light: Described as brisk, slow, or fixed
− CVA − Unusual eye movements
− Meningitis, encephalitis − Unilateral pupil dilation indicates compression of the third cranial
− Deformities nerve.
− Hypertension − Mid – position fixed pupil indicates midbrain injury.
− Neurologic disorder − Pinpoint fixed pupil indicates pontine damage.
− Brain surgery

FAMILY HISTORY

− Hereditary disorders GLASCOW COMA SCALE

• Tay-Sachs
• Huntington’s chorea • Score BEST response in each
• Muscular dystrophy category
• Neurofibromatosis • Highest score = 15 (normal)
− Alcoholism • Lowest score = 3 (deep coma)
− Mental Retardation
− Epilepsy or other seizure disorder
− Alzheimer disease
− Learning disorders CRANIAL NERVES
− Weakness or gait disorders
− Thyroid disease
Review from
− Diabetes
− Hypertension • Assessment of the Head and Neck
• Assessment of the Ears
PERSONAL AND SOCIAL HISTORY • Assessment of the Eyes

− Environmental or occupational hazards

ASSESSMENT OF THE CRANIAL NERVES:
− Hand, eye, foot dominance
− ADL
CRANIAL NERVE I (OLFACTORY): SENSORY, SMELL.
− Sleeping patterns
− Use of alcohol and tobacco
• Have the client close the eyes and occlude one nostril with finger.
− Use of mood-altering drugs
• Ask the client to identify nonirritating odors such as coffee, tea, cloves,
− Anxiety
toothpaste, orange, and peppermint.
• Repeat the test on the other nostril.
EQUIPMENT AND TECHNIQUES
CRANIAL NERVE II (OPTIC): SENSORY, VISION.
EQUIPMENT
• Assess visual acuity with a Snellen chart or newspaper, or ask the client
− Penlight to count how many fingers the examiner is holding up.
− Tongue blade • Check visual fields by confrontation.
− Tuning fork • Have the client sit directly in front of the examiner and stare at the
− Familiar objects (coin, key, paper clip) examiner's nose.
− Cotton wisp • Examiner slowly moves his or her finger from the periphery toward the
− Reflex hammer center until the client says it can be seen.
− Aromatic substances • Check color vision by asking the client to name the colors of several
− Flavored substances nearby objects.
− Test tubes of hot and cold water
− DDST CRANIAL NERVE III (OCULOMOTOR); CRANIAL NERVE IV
(TROCHLEAR); CRANIAL NERVE VI (ABDUCENS):
TECHNIQUES
• The motor functions of these nerves overlap; therefore, they need to be
− Inspection
tested together.
− Palpation
• First, inspect the eyelids for ptosis (drooping); then assess ocular
movements and note any eye deviation.
GENERAL COMMENTS • Test the eyes for size, regularity, equality, direct and consensual light
reflexes, and accommodation; May be documented as PERRLA (pupils
• The neurologic system can be examined almost constantly while the rest
equally round, reactive to light and accommodation).
of the body is explored.
• Test extraocular movements (EOMs) by the cardinal positions of gaze.
• In fact, we have already covered the bulk of the neurologic examination
• Test for nystagmus, by assessing downward and inward eye
as we examined other systems.
movements.
• There are 6 portions to complete neurologic assessment
CRANIAL NERVE V (TRIGEMINAL): SENSORY, MOTOR.

• Test assesses sensation to the cornea, nasal and oral mucosa, facial
skin, and mastication.

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 • To test motor function, ask the client to close the jaws tightly and then − Voluntary and involuntary movements
try to separate the clenched jaws. − Purposeful and non – purposeful movements
• If decreased level of consciousness is present, test the corneal reflex by
lightly touching the client's cornea with a cotton wisp. ASSESSMENT FOR POSTURING
• Check sensory function by asking the client to close the eyes; then
lightly touch the forehead, cheeks, and chin, noting whether the client − Posturing indicates a deterioration of the condition.
can feel the touch equally on both sides. − FLEXOR (DECORTICATE POSTURING):
o Client flexes one or both arms on the chest and may extend the
CRANIAL NERVE VII (FACIAL): SENSORY, MOTOR. legs stiffly.
o Flexor posturing indicates a nonfunctioning cortex.
• Test taste perception on the anterior two thirds of the tongue.
− EXTENSOR (DECEREBRATE POSTURING):
• Have the client show the teeth.
o Client stiffly extends one or both arms and possibly the legs.
• Attempt to close the client's eyes against resistance, and ask the client
o Extensor posturing indicates a brainstem lesion.
to puff out the cheeks.
− FLACCID POSTURING: Client displays no motor response in any
• Place sugar, salt, or vinegar on the front of the tongue, with an
extremity.
applicator, and have the client identify these substances by their tastes.
o MOTOR RESPONSE
o Hemiparesis, hemiplegia, and decreased muscle tone.
CRANIAL NERVE VIII (ACOUSTIC): SENSORY.
o Cranial nerve dysfunction, especially cranial nerves III, IV, VI, VII,
• The ability to hear tests the cochlear portion. and VIII
• The sense of equilibrium tests the vestibular portion.
• Check the client's ability to hear a watch ticking or a whisper. PROPRIOCEPTION/CEREBELLAR FUNCTION
• Observe the client's balance, and observe for swaying when walking or
standing.
PROPRIOCEPTION
CRANIAL NERVE IX (GLOSSOPHARYNGEAL): SENSORY, MOTOR.
− The sensation of position and muscular activity originating from within
• Test assesses swallowing ability. the body which provides awareness of posture, movement, and
• Test assesses sensation to the pharyngeal soft palate and tonsillar changes in equilibrium
mucosa, taste
• perception on the posterior third of the tongue, and salivation. TEST

CRANIAL NERVE X (VAGUS): SENSORY, MOTOR. − Coordination and Fine Motor Skills
− Balance
• Test assesses swallowing and phonation, sensation to the exterior ear's
posterior wall, and sensation behind the ear. COORDINATION AND FINE MOTOR SKILLS
• Test assesses sensation to the thoracic and abdominal viscera.
− RAPID RHYTHMIC ALTERNATING MOVEMENTS
CRANIAL NERVE IX (GLOSSOPHARYNGEAL); CRANIAL NERVE X o Have seated person alternately pronate and supinate hands,
(VAGUS): patting knees, and gradually increasing speed OR
o Have person touch thumb to each finger on the same hand
• Have the client identify a taste at the back of the tongue. sequentially from index to little finger and back, gradually
• Inspect the soft palate and observe for symmetrical elevation when the increasing speed
client says “aah.” o person should be able to do these movements smoothly,
• Touch the posterior pharyngeal wall with a tongue depressor to elicit a maintaining rhythm, with increasing speed
gag reflex. o Observe for slow, stiff, non-rhythmic, or jerky movements
− ACCURACY OF MOVEMENT
CRANIAL NERVE XI (SPINAL ACCESSORY): MOTOR. o Finger-to-finger test with person’s eyes open
 Movements should be rapid, smooth, and accurate
• Test assesses uvula and soft palate movement and sternocleidomastoid  Consistent past pointing may indicate cerebellar impairment
and trapezius muscles. o Finger to nose test with person’s eyes closed
• Test assesses upper portion of the trapezius muscle, which governs  Movement should be smooth, accurate, and rapid
shoulder movement and neck rotation. o Heel-to-shin with person supine, sitting, or standing
• Palpate and inspect the sternocleidomastoid muscle as the client  Should move heel from knee up and down the shin in a straight
pushes the chin against the examiner's hand. line, without irregular deviations to the side
• Palpate and inspect the trapezius muscle as the client shrugs the − BALANCE: EQUILIBRIUM
shoulders against the examiner's resistance.
o Romberg test
 Have person stand with arms at side and feet together
CRANIAL NERVE XII (HYPOGLOSSAL): MOTOR.
 Have person perform initially with eyes open and then with eyes
closed
• Test assesses tongue movements involved in swallowing and speech.
 Stand close to prevent falls
• Observe the tongue for asymmetry, atrophy, deviation to one side, and
 person should maintain position with eyes open or closed for 20
fasciculations.
seconds with only minimal swaying
• Ask the client to push the tongue against a tongue depressor and then
 If the Romberg is positive (i.e. there is significant swaying or the
have the client move the tongue rapidly in and out and from side to
person has to take a step to maintain/regain balance) DO NOT
side.
DO OTHER TESTS OF BALANCE
• Ask the client to say “light,” “tight,” and “dynamite” and observe
o Have person stand with feet slightly apart
whether the sounds of the letters l, t, d, and n are clear and distinct.
 Examiner pushes shoulders with enough effort to throw person
off balance
SUMMARY:  Recovery should be quick
o Ability to balance on one foot with eyes closed for at least 5
EVALUATION OF CRANIAL NERVES seconds
o Ability to hop in place on one foot for at least 5 seconds
I. OLFACTORY NERVE – identification of smells
− BALANCE: GAIT
II. OPTIC NERVE – eye
o Covered in Musculoskeletal Assessment
III. OCULOMOTOR – pupil of eye o Heel-toe walking will exaggerate any unexpected finding in gait
IV. TROCHLEAR – movement of eyes evaluation
V. TRIGEMINAL – ability to feel face
VI. ABDUCENS – movement of eyes
SENSORY FUNCTION
VII. FACIAL – tastes, smiling
VIII. ACOUSTIC – hearing
PRIMARY SENSORY FUNCTIONS
IX. GLOSSOPHARYNGEAL – taste
X. VAGUS – swallowing − ALWAYS WITH THE PERSON’S EYES CLOSED
XI. ACCESSORY – moving shoulders/neck − SITES
XII. HYPOGLOSSAL – movement of tongue o Vision, hearing, smell, taste and facial sensations
 Part of CN Assessment
MUSCLE TONE AND STRENGTH o Hands
o Lower arms
REVIEW FROM MUSCULOSKELETAL ASSESSMENT o Abdomen
o Feet
ASSESSMENT OF MOTOR FUNCTION o Lower legs
− SUPERFICIAL TOUCH
− Muscle tone, including strength and equality
o Use a cotton wisp

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 o Have the person point to the area touched  Response – contraction of the triceps muscle with extension
− SUPERFICIAL PAIN of elbow
o Sharp and dull sensations − PATELLAR
o Allow 2 seconds between each stimulus  “Knee jerk”
− TEMPERATURE AND DEEP PRESSURE  Slightly lift up the leg under the knee, and tap the patellar
o ONLY TESTED when superficial pain sensation is not intact tendon with a reflex hammer
− VIBRATION If performed in a sitting position, have the legs dangle
o Place stem of tuning fork against bony prominences over the edge of the chair or table
o Begin distally  Response – contraction of the quadriceps muscle with
o Sites extension of lower leg
 Sternum − ACHILLES
 Finger – wrist – elbow – shoulder  At level of ankle
 Toes – ankle – shin  Slightly externally rotate at the hip
− POSITION OF JOINTS (great toes, one finger on each hand)  Gently dorsiflex the foot
o Up  Tap the Achilles tendon with a reflex hammer
o Down  Response – contraction of the gastrocnemius muscle with
plantar flexion of foot
CORTICAL SENSORY FUNCTIONS − CLONUS
 Test if reflexes are hyperactive
− ALWAYS WITH THE PERSON’S EYES CLOSED  Sharply dorsiflex the foor and maintain in that position
 Clonus is when the foot continues to tap
− STEREOGNOSIS
Count beats
o Ability to identify a familiar object by touch and manipulation
 Sustained clonus may represent neoropathy or hyperreflexia
 Tactile agnosia: inability to recognize objects
− GRAPHESTHESIA
ASSESSMENT OF MENINGEAL IRRITATION:
o With a blunt pen, draw a letter or number on the palm
o Should be readily recognized
GENERAL FINDINGS
− POINT LOCATION
o Touch an area of the body and ask the person to point to where you Irritability
have touched Nuchal rigidity
 This is being tested the same time as superficial touch Severe, unrelenting headaches
− EXTINCTION PHENOMENON Generalized muscle aches and pains
o Simultaneously touch one or both sides of the body Nausea and vomiting
o Ask the person to point to where you have touched Fever and chills
− TWO-POINT DISCRIMINATION Tachycardia
o Use two pointed objects, alternate touching skin with one or two Pupil reaction and eye movements
points Photophobia
o Find the distance at which the person can no longer discriminate 2 Nystagmus
points Abnormal eye movement
 Fingertips 2 - 8 mm
 Toes 3 - 8 mm BRUDZINSKI'S SIGN
 Palms 8-12 mm
 Forearms 40 mm Flexion of the head causes flexion of both thighs at the hips and knee
 Upper arms and thighs 75 mm flexion.

KERNIG'S SIGN
REFLEXES
Flexion of the thigh and knee to right angles and when the limbs are
SUPERFICIAL REFLEXES extended, it causes spasm of the hamstring and pain.

− ABDOMINAL REFLEX: See Abdominal Assessment ASSESSMENT OF THE AUTONOMIC SYSTEM

− CREMASTERIC REFLEX: See Male Genitalia
− PLANTAR REFLEX • Sympathetic functions, adrenergic responses
o Stroke lateral side of foot from heel to the ball, then across to the • Increased pulse and blood pressure
medial side • Dilated pupils
 Normal response is a positive plantar reflex • Decreased peristalsis
» Plantar flexion of all toes • Increased perspiration
 Abnormal response is the Babinski sign in those 2 yoa • Parasympathetic function, cholinergic responses
» Dorsiflexion of the great toe with or without fanning of the • Decreased pulse and blood pressure
other toes • Constricted pupils
• Increased salivation
DEEP TENDON REFLEXES • Increased peristalsis
• Dilated blood vessels
− Have person relaxed • Bladder contraction
− Position limb with slight tension on the tendon to be tapped
− Grading SCREENING EXAMINATION
0 No response
1+ Sluggish or diminished
When the history and PE findings prior to the neuro exam have revealed no
2+ Active or expected response
potential neurological problem, a screening exam is all that is necessary
3+ More brisk than expected
4+ Hyperactive with or without clonus − CN II-XII (without smell and taste)
− When the reflexes are absent try eliciting it after re-enforcing Jendrassik − Proprioception and Cerebellar Function
maneuver), by asking the person to interlock and pull flexed fingers o One test in each area
− BICEPS − Sensory function
 Antecubital fossa o Superficial touch and pain at a distal point on each extremity
 With the arm gently flexed at the elbow, find the biceps o Vibration and position of great toes
tendon with your thumb. − Reflexes: DTRs (except plantar reflex and clonus)
» Strike your own thumb with the hammer
 Response – contraction of biceps muscle causing flexion of
the elbow DEVELOPMENTAL VARIATIONS
− BRACHIORADIALIS
 1-2 inches above the wrist NEONATES
 Support the relaxed arm either on the lap or semi-pronated
on your forearm − Primitive reflexes
 Strike above the styloid process a few centimeters above the Palmar grasp
wrist on the thumb side Plantar grasp
 Response – flexion and supination of the forearm Moro (“Startle”)
− TRICEPS Stepping
 Back of elbow Tonic neck (“Fencing”)
 With the elbow in flexion, tap the triceps tendon, just proximal − Muscle strength and tone especially important
to the elbow, with a reflex hammer.
 The arm could also be abducted at the shoulder for this
maneuver

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INFANTS
CEREBRAL ANGIOGRAPHY/ARTERIOGRAM
− Purposeful movement begins at about 2 months
− Transferring objects at about 7 months Intra-arterial injection of contrast medium with simultaneous
− Purposeful releasing at about 10 months radiographs of head & neck

• Consent
CHILDREN
• Assess Allergy
• Remove metallic clips from hair
− Denver
• May experience flushing sensation
− DTRs not usually tested in child who demonstrates appropriate
• NPO 4-6 hours
development
• IVF
− Positive Babinski sign normal through age 2

AFTER PROCEDURE
PREGNANCY
• Check puncture site for bleeding
− Paresthesias
• Check distal pulses
− Headaches
• Check Color and temperature
• Check Neurologic status
OLDER ADULTS • Bed rest 6-b hours elevate HOB
Femoral-extend & immobile for hours
− Medications can impair much of the neuro exam
− May have markedly diminished sense of taste and smell
− May have reduced ability to differentiate colors COMPUTED TOMOGRAPHY SCAN
− Tactile, position, and vibratory senses may be diminished
− Less brisk or absent DTRs • Brain scanning.
• Obtain an informed consent.
• Assess for allergies to iodine.
DIAGNOSTIC TESTS, STUDIES & PROCEDURES • Need to lie still.
• Claustrophobia.
INVASIVE TESTS: • Expect diuresis.
• Fluid replacement.
• Lumbar Puncture
• Myelography Use of narrow x-ray beams to scan the head in successive layers
• Cerebral Angiography
• Need for consent
NON- INVASIVE TESTS: • Position/instructions
• Phobia/dye assessment
• CT-Scan • Sound expectations
• MRI • Sedation-restless
• X-Rays of skull & spine
• EEG POST-PROCEDURE

• Fluids
LUMBAR PUNCTURE • Injection site

• Insertion of a needle into the lumbar subarachnoid space to withdraw COMPUTERIZED AXIAL TOMOGRAPHY (CAT SCAN)
CSF
• ICP assessment
• CSF pressure- 0-15 mmHg/75-180mmh20 Glucose-50-80mg/dl, Protein- 20-
50mg/dl

POSITRON EMISSION TOMOGRAPHY

Insertion of a needle between L3 and L4
Computer-based nuclear imaging
Secure informed consent
technique that produces images of
Empty bladder
actual organ functioning
Proper positioning
Maintain strict asepsis • Similarity and differences with CT
Maintain flat position after the scan
procedure • Radioactive substance
Monitor neurological status administration

POSITION DURING:

 FETAL
 SHRIMP
 SIDE-LYING, KNEE CHEST

MYELOGRAM *2hours
X-ray of the Spinal Subarachnoid Space after injection of a contrast agent
into the SSS thru a lumbar puncture

• Consent
• Position/instructions
• Meds/dye assessment MAGNETIC RESONANCE IMAGING *30-90minutes

POST-PROCEDURE Use of a powerful magnetic field to obtain images of different body areas

• Dye types and positions • Metal assessment

• Fluids • Main risks
• Pantopaque/Metrizamide • Phobia
• Observe Neurologic status • Sound expectations
Purpose - Detects vertebral disk disease, spinal cord tumors
Check for N/V, generalized seizure

7|RCJB
 Remove all metal objects from the client
Contraindicated to patients with: SKULL AND SPINAL RADIOGRAPHY
Pacemaker
Implanted defibrillator • Radiographs of the skull reveal the size and shape of the skull bones,
Hip prosthesis suture separation in infants, fractures or bony defects, erosion, and
Vascular clips calcification.
Claustrophobia • Spinal radiographs identify fractures, dislocation, compression, curvature,
erosion, narrowed spinal cord, and degenerative processes.

PRE-PROCEDURE INTERVENTIONS

Provide nursing support for the confused, combative, or ventilator-

dependent client.
Maintain immobilization of the neck if a spinal fracture is suspected.
Remove metal items from body parts.
If the client has thick and heavy hair, this should be documented,
because it could affect interpretation of the x-ray film.

POST-PROCEDURE INTERVENTION

Maintain immobilization until results are known.

ELECTROENCEPHALOGRAPHY

EEG represents a record of electrical brain activity

NEUROLOGIC DISORDERS

• Explain DISORDERS OF THE NERVOUS SYSTEM

• Pre-procedure
• Patient assurance Responses to Altered Neurologic Function
• Meds/diet/sleep
DISTURBANCES IN CEREBRAL FUNCTION:
POST-PROCEDURE: care-wash
1. Head Injury
ELECTROENCEPHALOGRAM 2. Cerebrovascular Accident (CVA)
3. Cerebral Aneurysm
• Graphic recording of the brain’s electrical
activity
• Shampoo the client’s hair
HEAD INJURY
• Electrodes are attached
• 24 to 48 hours prior to the procedure, withhold: Any trauma to the skull resulting in varying degrees of injury to the brain by
Stimulants compression, tension or shearing force
Antidepressants
An insult to the brain that is capable of producing physical, intellectual,
Tranquilizers
emotional, social and vocational changes
Anticonvulsants

EEG WAVES CAUSES:

- Motor vehicle accidents

- Assaults
- Falls
- Sports

RISK FACTORS
- Alcohol
- Driving without seat belt

CLASSIFICATIONS OF BRAIN INJURIES:

a. OPEN INJURY
• Scalp lacerations
• Fractures in the skull
• Interruption of the dura mater
b. CLOSED INJURY
• Concussions
• Contusions
• Fractures
• Immediate complications include cerebral bleeding, hematomas,
uncontrolled increased ICP, infections, and seizures.
• Changes in personality or behavior, cranial nerve deficits, and any
other residual deficits depend on the area of the brain damage
and the extent of the damage.

SPECIFIC TYPES OF INJURIES (PRIMARY INJURIES)

1. CONCUSSION is a jarring of the brain within the skull, with temporary

loss of consciousness
2. CONTUSION is a bruising type of injury to the brain
• Contusion may occur with subdural or extradural collections of
blood.
• SKULL FRACTURES
3. Laceration/Abrasion
4. Hemorrhage
Epidural Hematoma

CONCUSSION

• LOC for 5 min or less, transient

• Retrograde amnesia
• Post traumatic amnesia
• Headache, dizziness
• N/V
• Irritability, lethargy, IICP

8|RCJB
CONTUSION MANIFESTATIONS
• Cerebral contusion: • Aneurysm is usually asymptomatic until it ruptures:
Hemiparesis • Sudden, severe headache w/ vomiting.
• Brain Stem Contusion • LOC, confusion, lethargy
Unresponsiveness • Seizures
Coma • Motor weakness
Cranial nerve • Coma
dysfunction
NURSING MANAGEMENT
• Provide calm, quiet env’t
• Assess client’s response to family visits & adjust visiting schedules
accordingly.
• Avoid sedation w/c interferes w/ accurate neurological assessment.

MAINTAIN ANEURYSM PRECAUTIONS:

• elevate head of the bed 15-30 degrees
• Instruct client to avoid straining.
• placed needed items w/in easy reach
• Monitor BP

EPIDURAL HEMATOMA NURSING/MEDICAL MANGEMENT

The most serious type of hematoma, epidural hematoma forms rapidly and
results from arterial bleeding.
Epidural hematoma forms between the dura and skull from a tear in the
meningeal artery.
Epidural hematoma is a surgical emergency.
SUBDURAL HEMATOMA
Subdural hematoma forms slowly and results from a venous bleed.
• assist w/ position.change
• instruct client not to rotate or flex the neck
• instruct the client that no active exercises are permitted.
• instruct client on avoidance of Valsalva’s maneuver
• avoid rectal stimulation or straining at stool
• No enemas or rectal temperatures
• administer stool softener and mild laxatives as prescribed
• Antihypertensive drugs
HEMATOMA

Subdural hematoma occurs under the dura as a result of tears in the veins occur as a result of a subarachnoid hemorrhage or an intracerebral
crossing the subdural space. hemorrhage.

MANAGEMENT ASSESSMENT

maintain patent airway and adequate ventilation
observe for CSF leakage
(+) Testape or Dextostix test for glucose
bloody spot encircled by watery, pale ring
never clean the ears or nose, suction nose unless ordered by doctor
if CSF leak is present
never blow nose; HOB elevated 30 degrees as ordered
place cotton ball in the ear to absorb otorrhea, replace frequently
gently place sterile gauze pad at the bottom of the nose for rhinorrhea
observe signs of meningitis and give antibiotics as ordered
prepare client for surgery as indicated
depressed skull fracture: removal or elevation of splintered bone;
debridement and cleansing of area; repair of dural tear if present;
cranioplasty (if necessary for large cranial defect)
epidural, subdural hematoma: evacuation of hematoma
give large doses of antibiotics as ordered
enforce respiratory isolation after initiation antibiotic therapy for
some types of meningitis
give nsg. care for increased ICP, seizures, and hyperthermia
provide nsg. Care for delirious or unconscious client as needed
bed rest; keep room quiet & dark if photophobia or headache occurs
maintain fluid and electrolyte balance
prevent complications of immobility
monitor vital signs and neuro checks frequently
teach client concerning discharge plans:
maintain a good diet high in protein, high calories, with small
frequent feedings
rehabilitation program for residual deficits
ANEURYSM (INTRACRANIAL)
AND SUBARCHNOID HEMORRHAGE
Intracranial aneurysm is congenital.
Traumatic, arteriosclerotic, or septal
weakening or out-pouching in vessel
walls.
Aneurysm may weaken, leak or rupture
and cause bleeding into the
subarachnoid space called
Subarachnoid Hemorrhage (SAH).
SAH maybe caused by head trauma,
intracranial tumors, vascular anomalies or
CNS infn.
RISK FACTORS FOR SAH ARE:
• Head trauma, HPN, cocaine use.
• Assessment findings depend on the injury.
• Clinical manifestations usually result from increased ICP.
• Changing neurological signs in the client
• Changes in level of consciousness
• Airway and breathing pattern changes
• Vital signs changes reflecting increasing ICP
• Headache, nausea, and vomiting
• Visual disturbances, pupillary changes, and papilledema
• Nuchal rigidity (not tested until spinal cord injury is ruled out)
• CSF drainage from the ears or nose: When the drainage is placed on a
white, sterile background, such as a gauze pad, it can be distinguished
from other fluids by the presence of concentric rings (yellowish stain
surrounded by bloody fluid); also, CSF tests positive for glucose when
tested by a strip test.
• Weakness and paralysis
• Posturing
• Decreased sensation or absence of feeling
• Reflex activity changes
• Seizure activity
INTERVENTIONS
• Monitor respiratory status and maintain a patent airway because
increased CO2 levels increase cerebral edema.
• Monitor neurological status and vital signs, including temperature.
• Monitor for increased ICP.
• Maintain head elevation to reduce venous pressure.
• Prevent neck flexion.
• Initiate normothermia measures for increased temperature.
• Assess cranial nerve function, reflexes, and motor and sensory function.
• Initiate seizure precautions.
• Monitor for pain and restlessness.
• Morphine sulfate may be prescribed to decrease agitation and control
restlessness caused by pain for the head injured client on a ventilator;
administer with caution because it is a respiratory depressant and may
increase ICP.
• Monitor for drainage from the nose or ears because this fluid may be CSF.
• Do not attempt to clean the nose, suction, or allow the client to blow his
or her nose if drainage occurs.
• Do not clean the ear if drainage is noted, but apply a loose, dry sterile
dressing.
• Check drainage for the presence of CSF.
• Notify the physician if drainage from the ears or nose is noted and if the
drainage tests positive for CSF.
• Instruct the client to avoid coughing because this increases ICP.
• Monitor for signs of infection.
• Prevent complications of immobility

9|RCJB
 • DYSARTHRIA (ANARTHRIA) - is a condition that occurs when problems
CEREBROVASCULAR ACCIDENT with the muscles that help you talk make it difficult to pronounce words.

CVA or stroke is infarction(death) of a specific portion of the brain due to EMOTIONAL OR BEHAVIORAL RXN:
insufficient blood supply.
• Severe mood swing
STROKE MAY OCCUR AS: • Social withdrawal
• Inappropriate sexual behavior
• Thrombosis • Outburst of frustrations/anger
• Embolism
• Intracerebral hemorrhage ASSESSMENT FINDINGS IN A STROKE (BRAIN ATTACK):
• Cerebral Arterial Spasm
• Compression of cerebral vessel due to tumor, large blood clot, swollen AGNOSIA. Inability to use an object correctly
brain tissues
APRAXIA. Inability to carry out a purposeful activity

STROKE HEMIANOPSIA. Blindness in half the visual field

loss of brain functions caused by a loss of blood circulation to areas of the HOMONYMOUS HEMIANOPSIA. Blindness in the same visual field of both eyes
brain. The specific neurologic deficits may vary depending on the location,
extent of the damage, and cause of the disorder. NEGLECT SYNDROME (UNILATERAL NEGLECT). Client unaware of the
existence of his or her paralyzed side
CAUSES
PROPRIOCEPTION ALTERATIONS. Altered position sense that places the client
• Emboli at increased risk of injury
• Thrombus
Important Point: With visual problems, the client must turn the head to scan
• Hemorrhage
the complete range of vision.
SIGNS AND SYMPTOMS APHASIA
Expressive
decreased LOC, cognitive changes
weakness or paralysis of anybody area • Damage occurs in Broca's area of the frontal brain.
speech deficits (dysphonia, dysarthria, aphasia) • Client understands what is said but is unable to communicate verbally.
urinary/ bowel incontinence
dysphagia, chewing RECEPTIVE
personality changes
homonymous hemianopsia • Injury involves Wernicke's area in the temporoparietal area.
• Client is unable to understand the spoken and often the written word.
RISK FACTORS R/T STROKE:
GLOBAL OR MIXED: Language dysfunction occurs in expression and
Prior ischemic episodes reception.
Cardiac disease
DM INTERVENTIONS FOR APHASIA
atherosclerotic dse of intracranial and extracranial vessels.
• Provide repetitive directions.
HPN
• Break tasks down to one step at a time.
Hypercholesterolemia
• Repeat names of objects frequently used.
Smoking
• Allow time for the client to communicate.
Oral contraceptive use
• Use a picture board, communication board, or computer technology.
Emotional stress
Obesity
Family Hx of stroke MEDICATIONS
Age
• Anticoagulants, Thrombolytics
• Anti-platelet agents; Aspirin
• Analgesics
• Antihypertensives

SURGERY

• The goal of treatment is to prevent the spread (extension) of the stroke

and to maximize the ability of the person to function.
• anti-coagulants such as heparin and coumadin are used to prevent
recurrent strokes. Aspirin and other anti-platelet agents are used to
prevent strokes as well.
Analgesics may be needed to control severe headache.
Antihypertensive medication may be needed to control high blood
pressure.
MANIFESTATIONS: Nutrients and fluids may need to be supplemented, especially if
swallowing difficulties are present. This may include intravenous nutrients
Warning signs that may precede CVA: and fluids or feeding through a tube in the stomach (feeding tube or
gastrostomy tube
• Paresthesias involving one-half of the body • Carotid endarterectomy, removal of plaque from the carotid arteries,
• Transients’ loss of speech. may be indicated for some people to prevent new strokes from occurring.
• Hemiplegia • Positioning, range of motion exercises, speech therapy, occupational
• Severe Occipital or nuchal headaches therapy, physical therapy, and other interventions may be advised to
• Vertigo or Syncope prevent complications and promote maximum recovery of function.
• Motor or sensory disturbances
• Epistaxis MANAGEMENT OF CARE
• Retinal hemorrhage
• Vomiting • Maintaining peak physical health
• Seizures • Structuring the environment
• Fever • Promoting socialization
• APHASIA - is an impairment of language ability. This class of language • Promoting independent functioning
disorder ranges from having difficulty remembering words • Preserving the family unit
• APRAXIA - is a disorder of the brain and nervous system in which a
person is unable to perform tasks or movements when asked, even MANAGEMENT
though: The request or command is understood; They are willing to
perform the task; • Neurological assessment q1 GCS.
• Homonymous Hemianopsia • Monitor for changes in LOC and for s/s of IICP
• AGNOSIA - a loss of ability to recognize objects, people, sounds, shapes, • Prevent any increased in intracranial pressure:
or smells; that is, the inability to attach appropriate meaning Suction minimally
Keep head of the bed elevated

10|RCJB
 promote activity COMPLICATIONS OF IMMOBILITY
Prevent excessive coughing, straining with stool, vomiting, lifting, or
use of arms to change position. • Constipation
Administer laxatives or stool softeners • Atelectasis
Treat fever w/ antipyretics and cooling blanket • Muscle atrophy
Avoid restraints w/c may increase agitation. • Pneumonia
• Bed sores
INTERVENTIONS DURING THE ACUTE PHASE OF STROKE • Urinary retention
• Deep vein thrombosis
• Maintain a patent airway and administer oxygen as prescribed • Osteoporosis
• Monitor vital signs.
• Maintain a blood pressure of 150/100 mm Hg to maintain cerebral
perfusion. INCREASED INTRACRANIAL PRESSURE
• Suction secretions as prescribed, but never suction nasally or for longer
than 10 seconds to prevent increasing ICP. A condition in which the pressure of the CSF; blood or brain volume within
• Monitor for increasing ICP because the client is most at risk during the first the skull exceeds the upper limits for normal pressure
72 hours following the stroke.
• Position the client on the side, with the head of bed elevated 15 to 30 CAUSE: metabolic, toxic, traumatic, infectious, neoplastic and idiopathic
degrees as prescribed.
SYMPTOMS:

INFANTS:

• bulging fontanel, high pitch cry

• poor feeding, separated sutures

• Monitor level of consciousness, pupillary response, motor and sensory OLDER CHILDREN AND ADULTS:
response, cranial nerve function, and reflexes.
• Maintain a quiet environment, and carry out minimal handling of the • projectile vomiting, headache
client to prevent further bleeding. • changes in behavior, seizures
• Insert a Foley catheter as prescribed. • progressive decreased LOC, may become coma
• Administer intravenous fluids as prescribed. • ipsilateral pupillary dilatation
• Maintain fluid and electrolyte balance. • contralateral hemiparesis
• Prepare to administer anticoagulants, antiplatelets, diuretics, • widening pulse pressure
antihypertensives, and anticonvulsants as prescribed.
• Establish a form of communication. Note: Slow increases are tolerated fairly well in young children before they
become symptomatic. Adults tolerate increased ICP less well.
INTERVENTIONS IN THE POST – ACUTE PHASE OF A STROKE:
• Intracranial pressure is measured in millimeters of mercury (mm Hg) and
• Continue with interventions from the acute phase. the upper limits of normal are around 180 to 200 mm Hg. Intracranial
• Position the client 2 hours on the unaffected side and 20 minutes on the pressure may be measured during a spinal tap (lumbar puncture) or may
affected side. be measured directly by attaching a device referred to as a bolt to a
• Position the client in the prone position if prescribed, for 30 minutes three small hole in the skull
times daily. • Increased intracranial pressure is almost always indicative of severe
• Provide skin, mouth, and eye care. medical problems. The pressure itself can be responsible for further
• Perform passive range-of-motion exercises to prevent contractures. damage to the central nervous system by decreasing blood flow to the
• Place antiembolism stockings on the client. brain or by causing the brain to herniate (push through) the opening in
• Measure thighs and calves for an increase in size. the back of the skull where the spinal cord is attached. Sudden herniation
• Monitor gag reflex and ability to swallow. through the foramen magnum (back of the skull) is fatal
• Provide sips of fluids and slowly advance diet to foods that are easy to
chew and swallow. INCREASED ICP
• Provide soft and semisoft foods and flavored, cool or warm, thickened
fluids rather than thin liquids because the stroke client can tolerate these • Traumatic
types of food better; speech therapists may do swallow studies to • Inflammatory
recommend consistency of food and fluids. • Infectious
• When the client is eating, position the client sitting in a chair or sitting up in • Neoplastic
bed, with the head and neck positioned slightly forward and flexed. • Idiopathic
• Place food in the back of the mouth on the unaffected side to prevent
trapping of food in the affected cheek. MANAGEMENT

INTERVENTIONS IN THE CHRONIC PHASE OF STROKE • Maintain patent airway

• Maintain fluid balance
• Head of bed elevated 30° to 40°
• Prevent further increase in ICP, administer medications:
• Client is unaware of the existence of his or her paralyzed side (unilateral 23.4% Sodium chloride
neglect), which places the client at risk for injury. Corticosteroids
• Teach the client to touch and use both sides of the body. Diuretics
Anticonvulsants
Client has blindness in half the visual field. Analgesics & antipyretics

HOMONYMOUS HEMIANOPSIA is blindness in the same visual field of INTRACRANIAL SURGERY

both eyes.
• Encourage the client to turn the head to scan the complete range of
vision; otherwise, he or she does not see half of the visual field.
• Approach the client from the unaffected side.
• Place the client's personal objects within the visual field.
• Provide eye care for visual deficits.
• Place a patch over the affected eye if the client has diplopia.
• Increase mobility as tolerated.
• Encourage fluid intake and a high-fiber diet.
• Administer stool softeners as prescribed.
• Encourage the client to express feelings.
• Encourage independence in activities of daily living
• Assess the need for assistive devices such as a cane, walker, splint, or
braces.
• Teach transfer technique from bed to chair and from chair to bed.
• Provide gait training.
• Initiate physical and occupational therapy.
• Refer client to a speech and language pathologist as prescribed.
• Encourage the client and family to contact available community
resources.
CRANIOTOMY - surgical opening of skull, used to remove a tumor, evacuate
blood clot, control hemorrhage, relieve increased ICP
CRANIECTOMY - excision of a portion of the skull; sometimes used for
decompression
CRANIOPLASTY - repair of a cranial defect with a metal or plastic plate
PRE-OP CARE
• provide emotional support explain that the client’s head will be shaved, a
head is bandaged post-op, possible temporary swelling and discoloration
around the eye of the affected side, possible headache
• Shampoo and check for infection. Shave hair
• insert Foley catheter as ordered
• evaluate and record baseline vital signs and neuro checks
POST-OP CARE
• maintain patent airway and adequate ventilation
a. SUPRATENTORIAL INCISION - HOB elevated 15-45 degrees; position on
back (if intubated or unconscious) or on unaffected side; turn q2hrs to
facilitate breathing and venous return

11|RCJB
 b. INFRATENTORIAL INCISION - HOB flat or elevated 20-30 degrees; do BRUDZINSKI’S SIGN
not flex head on chest; turn to sides q2hrs using a turning sheet; check
for signs of respiratory depression Present if the client’s hips and knees flex when he is lying supine with his
c. Instruct conscious client to breathe deeply but not to cough; avoid head lifted towards his chest.
vigorous suctioning
• monitor fluid and electrolyte status
• accurate I & O; restrict fluids 1500ml/day to decrease cerebral edema
• infratentorial- maybe NPO for 24hrs due to possible impaired swallowing or
gag reflexes
• assess dressings frequently and report any abnormalities
• administer corticosteroids, anti-convulsant, stool softeners as ordered
• apply ice to swollen eyelids; lubricate lids and areas around eyes with
petrolatum jelly

SEIZURES

episodes of abnormal motor, sensory or autonomic due to abnormal

discharge from brain cells.

EPILEPSY - chronic recurrent seizures.

may be caused by infantile fever, head injury, hypertension, CNS infection,

brain tumor or metastasis, drug withdrawal, stroke

TYPES

GENERALIZED SEIZURES

• major motor seizure (grand mal)

FINDINGS FOR INCREASED INTRACRANIAL PRESSURE (ICP)
EARLY
• change in (LOC): restlessness, disorientation, confusion, lethargy, stupor
• pupils: dilated ipsilaterally
• abnormal motor activity: contralateral hemiparesis
• abnormal reflexes - hyper or hypo reflexia
• vital signs within normal parameters
LATE
• LOC
• pupils: dilated bilaterally and fixed; no reaction to light
• motor function: decorticate posture then decerebrate posture; flaccid
muscles at end stage
• vital signs - increased systolic pressure to result in a widened pulse
pressure, decreased respirations with bradycardia, temperature initially
may rise then fall below normal parameters
CNS INFECTIONS
aura; usually starts with tonic or stiffening phase, followed by clonic or
jerking phase; may have bowel/ bladder incontinence; in postictal
phase, sleeps, hard to arouse
• absence seizure (petit mal)
sudden onset, with twitching or rolling of eyes; lasts a few seconds
• febrile seizures
common under 5yrs. of age; seizure occurs only when fever is rising;
EEG is normal 2 weeks after a seizure
PARTIAL SEIZURES
• psychomotor seizure
may follow trauma, hypoxia, drug use; purposeful but inappropriate
repetitive motor acts; aura present, dreamlike state
• simple partial seizure
seizure confined to one hemisphere of the brain. no LOC; maybe
motor, sensory, or autonomic symptoms
• complex partial seizure
begins in focal area but spreads to both hemispheres; impairs
consciousness; maybe preceded by an aura
• jacksonian seizure
twitching begins at distal end of extremity, eventually involving entire
extremity and possibly entire side of the body; no LOC; not commonly
seen in children
• status epilepticus
usually refers to grand mal seizures; prolonged (repeated seizures
without regaining consciousness) and unresponsive to treatment; can
result in hypoxia and possible cardiac arrest

MENINGITIS - inflammation of the meninges of the brain and spinal cord,

TYPES OF SEIZURES
caused by bacteria, viruses, or other microorganisms.

TONIC – rigid muscle contraction

ENCEPHALITIS - inflammation of the brain, caused by a virus; may occur
CLONIC: alternate contraction/relaxation of muscles
as a sequela of measles, mumps, chickenpox.
TONIC-CLONIC/GRAND MAL: contraction followed by clonic activity
SIGNS AND SYMPTOMS: MYOCLONIC: sudden, brief, shock-like muscle contractions
ATONIC: sudden reduction in muscle tone
• headache, photophobia, irritability, chills, fever, vomiting INFANTILE: poor long-term prognosis
• possible seizures, decreasing LOC FEBRILE: tonic-clonic from high fever
• signs of meningeal irritation
− nuchal rigidity: stiff neck
MANAGEMENT
− opisthotonos: head and heels bent backward and body arched
forward
DURING SEIZURE ACTIVITY
− Kernig’s sign
− Brudzinki’s sign
• protect from injury: prevent falls, support head, decrease external stimuli,
do not restrain, do not use tongue blades (may add stimuli), loosen
TESTS:
clothing
• keep airway open: side lying position, suction excess mucous
LUMBAR PUNCTURE - measurement and analysis of CSF shows increased
• observe and record seizure
pressure, elevated WBC and protein, decrease glucose and culture positive
− note any preictal aura: fear, anxiety, hallucinations, “déjà vu”
for specific microorganism.
symptoms
− note nature of the ictal phase: symmetry of movement, response to
KERNIG’S SIGN stimuli, LOC, respiratory pattern
− note postictal response: amount of time it takes to orient to time and
Present if lower leg cannot extend due to pain and spasm when client is
place; sleepiness
lying supine with one leg bent over his abdomen.
PROVIDE CLIENT TEACHING
AND DISCHARGE POLANNING

• need to drug therapy

• wear a Medic-Alert identification
bracelet or carry ID
• availability of support groups
and community agencies

12|RCJB
DRUG THERAPY • aid the family in coping with the disorder
• surgery is usually done within 48 hours after birth to lower the risk of
(ANTICONVULSANTS) infection, swelling, and further damage.

• Phenytoin (Dilantin) - most commonly used can only be administered NEURAL TUBE DEFECTS
with in normal saline and levels are monitored to titrate dosage;
therapeutic level is 10-20 mg/dl; side effects include gum hyperplasia,
hirsutism, ataxia, gastric distress, nystagmus, anemia, sedation
• Phenobarbital a barbiturate and its main side effects are on the CNS
• Tegretol (Carbamazepine) is used when seizure have not responded to
other anticonvulsants

SURGERY
to remove the tumor, hematoma or epileptic focus

61 SPINA BIFIDA
A birth defect where the backbone and spinal canal do not close before
birth, which allows the spinal cord and the covering membranes to protrude
out of the child's back.

CAUSES: genetic, viral, radiation, intrauterine folic acid deficiency

TYPES
HYDROCEPHALUS
• SPINA BIFIDA OCCULTA
• SPINA BIFIDA CYSTICA A disorder associated with excessive fluid in the brain- putting pressure on
meningocele the brain forcing it against the skull and destroying the tissues.
meningomyelocele/ myelomeningocele (75% of cases)
EARLY SYMPTOMS -- INFANTS
SYMPTOMS
− enlargement of the head (increased head circumference)
− visible sac-like protrusion on the mid to lower back-- not translucent − bulging fontanelles, with or without enlargement of the head size
when a light is shone from behind the sac − sutures – separated
− irritability
Meningomyelocele: motor and sensory deficit below the lesion
LATE SYMPTOMS
Spina bifida occulta may be indicated by:
− a tuft of hair at the sacral area (back part of the pelvis) dimpling of − decreased mental function
the sacrum − delayed development
− slow or restricted movement
− difficulty feeding
− lethargy, excessive sleepiness
− urinary incontinence
− brief, shrill, high-pitched cry
− slow growth (child 0-5 years)

IN OLDER INFANTS AND CHILDREN

− headache
− vomiting
− vision changes (sunset eyes)
− crossed eyed
− uncontrolled eye movements
− loss of coordination
− poor gait (walking pattern)
− confusion or psychosis

TESTS
• CT scan
• Transillumination

TAY-SACHS DISEASE
an autosomal recessive disorder found predominantly in Jewish families,
which results in early death.

caused by a deficiency of hexosaminidase A, an enzyme that is important

in the metabolism of gangliosides- these fatty acids then accumulate in the
brain causing degenerative neurological deterioration

ONSET: 3 to 6 months old

SIGNS & SYMPTOMS

− loss of motor skills
− increased startle reaction
− decreased eye contact (blindness); deafness
− listlessness; irritability
− seizures; dementia
MANAGEMENT − paralysis; loss of muscle strength
− delayed mental and social skills
• prevent trauma to the sac − slow growth
cover with sterile dressing soaked with normal saline − enzyme analysis of blood/body tissue for hexosaminidase levels
position prone or side lying − eye exam reveals a cherry-red spot in the macula
keep area free from contamination by urine or feces
inspect for signs of infection
• provide adequate nutrition, high fiber diet
• provide sensory stimulation
• prevent complications

13|RCJB

REYE’S SYNDROME
A syndrome of encephalopathy, with associated liver degeneration.
Unknown cause, but can be associated with viral agents such as influenza
or varicella, toxins, aspirin and other salicylates, and metabolic defects
SYMPTOMS
overhydration (cord edema); check bowel sounds before feeding
(paralytic ileus); progress slowly from clear liquid to regular diet
• prevent complications of immobility
footboard/high topped sneakers to prevent footdrop; splint for
quadriplegic clients to prevent wrist drop
• maintain urinary elimination
catheterization; increase fluids to 3000ml/day; acid ash foods
• maintain bowel elimination
stool softeners, suppositories to prevent fecal impaction

STAGE I: sudden onset of persistent vomiting, fatigue

STAGE II: behavior changes, disorientation, confusion, hyperreflexia
STAGE III: coma, decorticate posturing
STAGE IV: deeper coma, decerebrate posturing
STAGE V: seizures, absent deep tendon and respiratory reflexes
flaccid paralysis

SIGNS
• elevated liver enzymes
• elevated serum ammonia test
• The illness has a rapid onset and symptoms may vary greatly. CHRONIC CARE
• Changes in mental status occur including coma.
• Typically, Reye syndrome follows an upper respiratory infection or • NEUROGENIC BLADDER. intermittent catheterization q4hrs & gradually
chickenpox by about a week. It frequently begins with vomiting which is progress to q6hrs regulate fluids to 1800-2000ml/day
persistent over many hours. The vomiting is rapidly followed by irritable a. reflex/ upper motor neuron bladder- unable to store urine very long
and combative behavior. As the and empties involuntarily.
condition progresses the child may bladder taps stimulating trigger points to cause reflex emptying
become semi-conscious or stuporous. b. nonreflexive/lower motor neuron bladder- urine retention with
• Ultimately seizures and coma develop overflow
follow shortly by death. a history of Crede’ or rectal stretch
preceding URI or chickenpox (about 1 • SPASTICITY
week previously) stretching exercises, warm tub baths, whirlpool
• nausea, vomiting antispasmodics: baclofen (Lioresal), dantrolene (Dantrium), diazepam
• lethargy, confusion (Valium)
• LOC, coma • AUTONOMIC DYSREFLEXIA - s/s: severe headache, HPN, bradycardia,
• Seizures sweating, goosebumps, nasal congestion, blurred vision, seizures
• decerebrate positioning − reflex response to stimulation of CNS; occurs above T6
• weakness, paralysis of the arms and legs − stimulus: over-distended bladder or bowel, chilling, decubitus ulcer
• speech and hearing difficulties, double raise to sitting position to decrease BP
vision check and remove source of stimulus (catheterize, digitally
• elevated liver enzymes remove impacted feces, reposition client)
• elevated serum ammonia test antihypertensives - hydralazine HCL(Apresoline)
• hypoglycemia
GLASGOW COMA SCALE
SPINAL CORD INJURIES
DEFINITION: technique of objectifying a client’s level of responses; client’s
best response in each area is given a numerical value, and the three values
hemorrhage and edema cause ischemia, leading to necrosis and
is totaled for a score ranging from 3 - 15.
destruction of the cord

cause maybe traumatic or non-traumatic EYE OPENING ABILITY

Spontaneous 4
SIGNS AND SYMPTOMS To voice / speech 3
To pain 2
• SPINAL SHOCK: no reflexes None 1
below the lesion, flaccid paralysis,
lack of temperature control in BEST MOTOR RESPONSE, UPPER LIMB
affected parts, hypotension, Obeys commands 6
retention of urine and feces Localizes to pain 5
level of injury Flexor withdrawal (decorticate posturing) 4
• QUADRIPLEGIA: (C1-C8) injury, Abnormal flexion (decerebrate posturing) 3
paralysis of all four extremities; Extension 2
lesions above C6- causes respi. Flaccid 1
Paralysis
• PARAPLEGIA: (T1-L4) injury, BEST VERBAL RESPONSE
paralysis of the lower half of the Oriented 5
body involving both legs Confused conversation 4
extent of injury Inappropriate words 3
Incomprehensible sounds 2
1. COMPLETE CORD TRANSECTION None 1
a. loss of all voluntary movement and sensation below the level of the
injury; reflex activity below the level of the lesion may return to normal A score of 15 indicates client is awake and oriented.
after the spinal shock resolves. A score of 7 to 4 is considered coma.
b. lesions in the conus medullaris or cauda equina results in permanent The lowest score is 3, client is considered in deep coma.
flaccid paralysis and areflexia.
2. INCOMPLETE LESIONS: varying degrees of motor or sensory loss below ORGANIC BRAIN SYNDROME
the level of the lesion depending on which neurologic tracts are
damaged and which are spared. A general term refers to physical disorders that cause a decrease in mental
function, usually not including psychiatric disorders
DIAGNOSTIC TEST = spinal X- rays
TYPES
NURSING MANAGEMENT
ACUTE
ACUTE CARE
− delirium
• asses ABC suction, tracheotomy set; jaw thrust maneuver − clouding of consciousness
• immobilize cervical collar, spinal board − temporary alteration of brain functioning
• prevent pneumonia and atelectasis − reversible
turn q2hrs; cough & DBE q1hr; incentive spirometry q2hrs
• maintain fluid and electrolyte balance and nutrition CHRONIC
NGT maybe inserted until bowel sounds return; IV therapy-avoid
− Dementia

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− Senility FURTHER ASSESSMENT:
− insidious onset
− irreversible • Rigidity of facial muscles:
• masklike facies
• Drooling
ALZHEIMER’S DISEASE
• Dysphagia
• Dysarthria: Rapid slurred speech
destruction of nerve cells which leads to a
• Echolalia: repetition
decrease and imbalance of
• PSYCHOSOCIAL
neurotransmitters
Emotionally labile
Delayed reaction time
EARLY ONSET (5-10% OF CASES)
symptoms first appear before age 60
MANAGEMENT
LATE ONSET (MOST COMMON)
• LEVODOPA + CARBIDOPA
develops in people 60 and older
• Priority is safety
• Promote independence
SIGNS AND SYMPTOMS • High calorie, high protein, high fiber, soft diet in small frequent meals
• Provide a firm mattress
EARLY STAGES
• Prone position when sleeping
• Hold the hands behind the back
− Repeating statements frequently
• Swing back and forth
− Frequently misplacing items
− Trouble finding names for familiar objects
Administer anticholinergic medications as prescribed to treat tremors
− Getting lost on familiar routes
and rigidity and to inhibit the action of acetylcholine.
Administer antiparkinsonian medications to increase the level of
LATE STAGE
dopamine in the CNS.
− A decrease in knowledge of recent events Instruct the client to avoid foods high in vitamin B6 because they
− Forgetting events in their life history, and of who they are block the effects of antiparkinsonian medications.
− Problems choosing proper clothing Instruct the client to avoid monoamine oxidase inhibitors because
− Hallucinations, delusions, agitation, depression they will precipitate hypertensive crisis.

MEDICATIONS NURSING DIAGNOSIS

• tacrine (Cognex) • Self-care deficit related to slowness of movement and muscle rigidity
• donepezil (Aricept) • Risk for injury related to postural instability and muscular rigidity
• rivostigmine (Exxelon) • Impaired verbal communication related to slowness of movement
• Altered nutrition related to poor muscle control
• Knowledge deficit related to complexity of and fluctuations in treatment
PARKINSON’S DISEASE regimen
• Ineffective coping related to progressive nature of illness
• 50-60 years
• Idiopathic IMPLEMENTATION
• Male > female
• progressive deterioration of the basal ganglia and the extrapyramidal • Establish routine for personal care
area; deficiency of dopamine • Safety in bathing, transferring, walking
• AROM, PROM
SIGNS AND SYMPTOMS: • Encourage pt to take a deep breath before initiating a conversation,
using gestures
− muscle (cogwheel) rigidity • Rigidity of facial expression hides pts true feelings
− shuffling walk • Meals thickened liquids, semisolids
− finger thumb rubbing (pill-rolling • Eat sitting up
tremor) • Suction
− “mask” appearance • Daily wgts
− voice/ speech changes • Increase fluids/day for constipation
− loss of fine motor skills • Drug flowsheet to document response to medications
− decline in intellectual function • Keep patient active as long as possible

DEFINED

Presence of motor dysfunction with 4

cardinal symptoms

• resting tremor
• akinesia (slowness of body
movement)
• rigidity
• Postural instability

NO PREVENTION, NO CURE
AGE RANGE: 40-70, PEAK 60
Michael J. Fox dx at age 30

PATHOPHYSIOLOGY

REDUCED AMOUNT OF DOPAMINE

• Result: inhibition effect lost

• Excitatory effect predominant

REDUCED NOREPINEPHRINE IN SYMPATHETIC NS OF THE HEART:

MULTIPLE SCLEROSIS; MANY SCARS;
• Orthostatic hypotension MOTOR SENSORY; MYELIN SHEATH
ASSESSMENT: DEFINED
• Initially: one limb involved with mild weakness and arm and hand • Demyelinating disease affecting nerve fibers of the brain and spinal cord
trembling • CAUSE unknown. Thought to be an autoimmune problem with a viral
• Progresses to both limbs involved, slow shuffling gait trigger
• Continues to worsen: gait disturbances (slow shuffling, short hesitant steps, • Lesions scattered through the white matter of the brain around the
propulsive gait ventricles; some in grey matter
• Severe involvement: akinesia, rigidity, CANNOT GET OOD • Inflammatory response triggers phagocytosis with myelin as the target
• Edema around lesions

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• Eventually a hard plaque forms • Impaired nerve impulse conduction because of degeneration of motor
• Characterized by exacerbations and remissions neurons
• Progressive from benign with few symptoms to chronic with complete
paralysis. SIGNS AND SYMPTOMS
• 70% of pts lead active productive lives with long periods of remission
− muscle weakness, progressing to atrophy and paralysis of upper and
lower extremities
MULTIPLE SCLEROSIS − impaired speech; hoarseness
− difficulty swallowing and breathing
• 20-40 years − muscle contractions; twitching
• Female > male − usually fatal 2-15years after onset
• Impaired nerve impulse
conduction because of MEDICATION = Antibiotics (for respiratory and urinary infections)
destruction of myelin sheath

CAUSE
SIGNS AND SYMPTOMS
• Excess of glutamate: chemical responsible for relaying messages between
− visual problems (nystagmus)
the motor neurons
− muscle spasticity
• As the motor neurons die the muscle cells they supply undergo atrophic
− poor coordination
changes leading to paralysis
− speech deficits
− intentional tremor
PROGRESSION OF DISEASE
− bowel/ bladder dysfunction
− exacerbations and remissions
• Muscle weakness and atrophy develop leading to flaccid quadriplegia
• Eventually respiratory muscles become affected leading to respiratory
DIAGNOSIS compromise, pneumonia and death
• No known cure, treatment symptomatic
• LUMBAR PUNCTURE: CSF shows increase protein, lymphocytes, IgG,
presence of oligoclonal bands and increased myelin basic protein WHAT DO YOU SEE?
• MRI: demonstrates white matter lesions (plaques) of brain, brainstem and
spinal cord • FATIGUE
• Fatigue while talking
SYMPTOMS • Muscle weakness/atrophy
• Tongue atrophy
• Blurred vision • Dysphagia (difficulty swallowing)
• Double vision • Weakness hands and arms
• Dysphagia • Fasciculations (twitching) of face
• Facial weakness • Nasal quality of speech
• Numbness • Dysarthria (difficulty speaking)
• Pain
• Weakness CARE
• Paralysis
• abnormal gait • Focus on symptoms
• tremor • Monitor respiratory status
• vertigo • Prepare to initiate respiratory support
• fecal and urinary incontinence • Assess complications of immobility
• decreased short term memory
• word finding trouble
• decreased concentration MYASTHENIA GRAVIS
• mood alteration
• decreased libido for women • 20-50 years
• ejaculatory dysfunction for men • Female>male
• overwhelming weakness • Impaired transmission of nerve impulse to muscle cells possibly because of
acetylcholine deficiency
MULTIPLE SCLEROSIS MEDICATIONS:
SIGNS AND SYMPTOMS
• Baclofen (Lioresal), Dantrolene (Dantrium), Diazepam (Valium):
Used to lessen muscle spasticity − vision changes
• Bethanechol: Used to prevent urinary retention − profound muscle weakness or paralysis that worsens with exertion later in
the day
• Carbamazepine (Tegretol): Used to treat paresthesia
− difficulty talking; dysphagia; frequent choking
• Corticosteroids: Used to reduce edema and the inflammatory response; − can progress to respiratory failure (myasthenia crisis)
used to decrease the length of time the client's symptoms are
exacerbated and to improve the degree of recovery
MEDICATIONS
• Immunosuppressive medications: Used to treat chronic progressive
multiple sclerosis to stabilize the disease process • Anticholinesterase (Neostigmine, Pyridostigmine)
• Oxybutynin chloride (Ditropan): Used to decrease bladder spasms • Prednisone
and control urge incontinence and frequency • Plasmapheresis
• Propranolol (Inderal), Clonazepam (Klonopin): Used to treat • Thymectomy
cerebellar ataxia
Myasthenia gravis is a neuromuscular disease characterized by
MANAGEMENT considerable weakness and abnormal fatigue of the voluntary muscles.

A defect in the transmission of nerve impulses at the myoneural junction

• Bed rest during exacerbation
occurs.
• Priority is safety
• Eye patch for diplopia
Causes include insufficient secretion of acetylcholine, excessive secretion of
• Instruct the client to avoid:
cholinesterase, and unresponsiveness of the muscle fibers to acetylcholine
Stress
Infection Involves fluctuating levels of weakness of commonly used muscles.
Fatigue
Overheating Weakness occurs when the nerve impulse does not adequately reach the
Chilling muscle cells; this is caused by blockage of the action of transmitters (the
chemicals that transmit signals from nerve cell to muscle cell). This is thought
AMYOTROPHIC LATERAL SCLEROSIS to be the result of an immune response of the body against itself (an
autoimmune response). High levels of antibodies block the action of specific
AMYOTROPHIC LATERAL SCLEROSIS OR LOU GEHRIG’S DISEASE chemicals that are used to transmit messages from the nerve cell to the
muscle cell (neurotransmitters).
• Progressive degenerative disease involving the motor system (motor
neurons) The cause of autoimmune disorders is unknown. In some cases, it may be
• Sensory and autonomic systems not involved associated with tumors of the thymus (a tissue of the immune system). It also
• No mental status changes may be associated with thyrotoxicosis, rheumatoid arthritis, systemic lupus
• 40-70 years erythematosus, and other immune system disorders. In many cases, no other
• Male > female disorder is identified.

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Vision changes: double vision, difficulty maintaining steady gaze, eyelid MYASTHENIC CRISIS
drooping, diplopia, ptosis
Myasthenic crisis is an acute exacerbation of the disease. The crisis is
Weakness or paralysis improves with rest: muscle function best after rest,
caused by a rapid, unrecognized progression of the disease, inadequate
muscle function worst at the end of the day
amount of medication, infection, fatigue, or stress.

INTERVENTIONS ASSESSMENT
• Monitor respiratory status and ability to cough and deep-breathe
• Increased pulse, respirations, and blood pressure
adequately.
• Anoxia and cyanosis
• Monitor for respiratory failure.
• Bowel and bladder incontinence
• Maintain suctioning and emergency equipment at the bedside.
• Decreased urine output
• Monitor vital signs.
• Absent cough and swallow reflex
• Monitor speech and swallowing abilities to prevent aspiration.
• Encourage the client to sit up when eating.
INTERVENTIONS
• Assess muscle status.
• Instruct the client to conserve strength.
• Assess for signs of myasthenic crisis.
• Plan short activities that coincide with times of maximal muscle strength.
• Increase anticholinesterase medication, as prescribed
• Monitor for myasthenic and cholinergic crises.
• Administer anticholinesterase medications as prescribed.
• Instruct the client to avoid stress, infection, fatigue, and over-the counter CHOLINERGIC CRISIS
medications.
Cholinergic crisis results in depolarization of the motor end plates. The crisis is
• Instruct the client to wear a Medic-Alert bracelet. Inform the client about
caused by overmedication with anticholinesterase.
services from the Myasthenia Gravis Foundation.

TENSILON TEST ASSESSMENT

• Abdominal cramps
Description: The Tensilon test is performed to diagnose myasthenia gravis
• Nausea, vomiting, and diarrhea
and to differentiate between myasthenic crisis and cholinergic crisis.
• Blurred vision
TO DIAGNOSE MYASTHENIA GRAVIS • Pallor
• Facial muscle twitching
• Edrophonium (Tensilon) injection is administered to the client. • Hypotension
• Positive for myasthenia gravis: Client shows improvement in muscle • Pupillary miosis
strength after the administration of Tensilon.
• Negative for myasthenia gravis: Client shows no improvement in muscle INTERVENTIONS
strength, and strength may even deteriorate after injection of Tensilon.
• Hold anticholinesterase medication.
TO DIFFERENTIATE CRISIS • Prepare to administer the antidote, atropine sulfate, if prescribed.

• Myasthenic crisis: Tensilon is administered and, if strength improves, the DIAGNOSIS = Edrophonium chloride (Tensilon)
client needs more medication.
• Cholinergic crisis: Tensilon is administered and, if weakness is more severe, COMPLICATION
the client is overmedicated; administer atropine sulfate, the antidote, as
prescribed. MYASTHENIA CRISIS

ANTICHOLINESTERASE MEDICATIONS − abrupt onset of severe, generalized muscle weakness with inability to
swallow, speak or maintain respirations
ACTION: Increase levels of acetylcholine at the myoneural junction − caused by undermedication, physical or emotional stress, infection
− symptoms will temporarily improve with Tensilon test
MEDICATIONS:
CHOLINERGIC CRISIS
• Neostigmine bromide (Prostigmin)
• Pyridostigmine bromide (Mestinon) − same symptoms to myasthenia crisis; side effects of anti- cholinesterase
• Edrophonium chloride (Tensilon) drugs (excessive sweating and salivation, abd. cramps, diarrhea,
fasciculations, N & V)
SIDE EFFECTS − caused by overmedication with the cholinergic (anticholinesterase) drugs
− symptoms worsen with Tensilon test; keep atropine sulfate and emergency
Sweating equipment on hand
Salivation
Nausea
Diarrhea and abdominal cramps CEREBRAL PALSY
Bradycardia
Hypotension occur during fetal development or near the time of birth, symptoms are
usually evident before age 2 and in severe cases may appear as early as
INTERVENTIONS three months.

Administer medications on time. ETIOLOGY: Prenatal- genetic, altered neurologic development, trauma,
Administer medication 30 minutes before meals with milk and anoxia to mother (toxemia, rubella, accidents); Perinatal- drugs, precipitate
crackers to reduce gastrointestinal upset. delivery, fetal distress, breech with delay; Postnatal- kernicterus, head
Monitor and record muscle strength. trauma
Note that excessive doses lead to cholinergic crisis.
Have the antidote (atropine sulfate) available.
TYPES
Prednisone or other medications that suppress the immune response may
− Spastic (50% of cases)
be used if symptoms are severe and there is inadequate response to other
− Dyskinetic (athetoid)
medications. Some medications (such as the aminoglycosides) may make
− Ataxic
symptoms worse and should be avoided.
− Mixed
Lifestyle adjustments may enable continuation of many activities.
SYMPTOMS
Activity should be planned to allow scheduled rest periods. An eye patch
may be recommended if double vision is bothersome. Stress should be • Spasticity
avoided, because it worsens symptoms. • athetosis, ataxia
• partial or full loss of movement
Plasmapheresis, a technique in which blood plasma containing antibodies • sensory abnormalities
against the body is removed from the body and replaced with fluids • hearing and visual defects
(donated antibody-free plasma or other intravenous fluids), may reduce • speech abnormalities
symptoms in some cases. • intellectual dysfunction
• seizures
Surgical removal of the thymus (thymectomy) results in permanent remission
for many people. CEREBRAL PALSY – AFFECTED SITES
• Hemiplegia – one side of body
• Paraplegia – lower extremities

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• Quadriplegia – all extremities
• Diplegia – all extremities BELL’S PALSY
• Monoplegia – one extremity
• Triplegia – three extremities Disorder of cranial Nerve # 7

CEREBRAL PALSY – TYPES RISK FACTORS: I H.A.V.E.E T.T

• Spastic: muscles contract when stretched Ischemia, Herpes, Autoimmune, Viral & Ear infections, Emotional stress,
• Athetoid: limbs flail Trauma, Tumor
• Ataxia: loss of coordination
• Mixed SYMPTOMS
NURSING CARE/ TEACHINGS • Ptosis
• cannot close or blink eye with excessive tearing
• local comfort measures: heat, massage and electrical nerve stimulation • flat nasolabial fold
for muscle tone • impaired taste
• alternative actions: massage, imagery • lower face paralysis
• teach client • difficulty eating
to chew on opposite side
how to use protective eye wear during risk periods MANAGEMENT
effects of steroids
the use of eye drugs or ointment • PREDNISONE
that once findings disappear their return may occur especially in • Apply heat to reduce pain
times of high stress • Massage face
• provide balanced nutrition: soft diet • Chew on unaffected side
• use of eye patch • Oral care after meals
• Physical Therapy • Eye patch or artificial tears
• administer drugs as ordered prednisone & analgesics

MANAGEMENT GUILLAIN- BARRE SYNDROME

• Supportive (occupational and physical therapy, braces, appropriate Acquired inflammatory disease
glasses and hearing aids)
• Mainstreaming Demyelination of peripheral nerves Pattern of paralysis
• Cerebral palsy - support group
• Medications (muscle relaxants, anticonvulsants) may occur at any age but is most common in people of both sexes
• Surgery between the ages 30 and 50.

acute inflammation damages portions of the nerve cell, resulting in muscle

DISTURBANCE IN PERIPHERAL NERVE FUNCTION weakness or paralysis; (demyelination and denervation)

unknown cause, usually follows a minor infection (usually respiratory or

CRANIAL NERVE DISORDERS:
gastrointestinal)
1. Trigeminal Neuralgia
2. Bell’s Palsy RISK FACTORS
3. Guillain Barre Syndrome
Ascending weakness/paralysis usually beginning in the lower extremities and
spreading, sometimes rapidly thru the trunk, upper extremities and face w/
TRIGEMINAL NEURALGIA (TIC DOULOREUX) maximal deficit by 4 weeks in 90% cases.

Sensory disorder of the 5th Cranial nerve SIGNS AND SYMPTOMS

Intense facial pain lasting about one minute − weakness begins in the feet and legs and may progress upward to the
to 2 mins. along nerve branches arms and cranial (head) nerves,
− may progress rapidly over 24 to 72 hours
• Characteristics of attacks − may begin in the arms and progress downward
• Aggravating factors − numbness, decreased sensation
• Medications − tenderness or muscle (may be a cramp-like pain)
• surgery: Alcohol injection of the nerve − drooling, difficulty swallowing and breathing
• Dietary Instructions − urinary dysfunction
• Alternative meds: B-P
− Weakness
CAUSES − Paresthesia of the limbs
− Loss of DTR
• CNS tumor − Deep, aching muscle pain in shoulder girdle & thighs
• Infections − RESPIRATORY COMPROMISE m
• Vascular abnormalities − Autonomic Dysfunction
• Chronic compression − Facial weakness, Dysphagia, diplopia.

MANIFESTATION MANAGEMENT. Mechanical ventilation; Corticosteroids; Plasmapheresis

Unilateral burning, knifelike pain triggered by vigorous head movements,
and eating hot or cold food
MANAGEMENT
• CARBAMAZEPINE (TEGRETOL)
• VITAMIN B COMPLEX
• Provide emotional support
• Small frequent meals at room temperature
SURGICAL INTERVENTIONS
• Microvascular decompression: Surgical relocation of the artery that
compresses the trigeminal nerve as it enters the pons may relieve pain
without compromising facial sensation
• Radiofrequency thermocoagulation: Creates a heat lesion that provides
relief of pain without compromising touch or motor function
• Percutaneous balloon microcompression: Compresses the ganglion and
nerve root to control pain
• Glycerol injection: Destroys the myelinated fibers of the trigeminal nerve
(may take up to 3 weeks for pain relief to occur)
• Monitor cardiac & respiratory status
• Monitor laboratory arterial blood gas results
• Monitor results of daily pulmonary fxn studies.
• Assure respiratory support equipment is maintained @ bedside
• Asses ability to perform self-care and provide assistance based on level of
client’s ability
• Collaborate w/ physical & occupational therapy for adaptive devices &
exercises.
• Monitor for signs of deep vein thrombosis or pulmonary embolism while on
bedrest
• Initiate appropriate safety measures
• Provide measures to prevent skin breakdown.
• Corticosteroid

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