C - 8 T - 12 L - 5 S – 5 C - 1
MEDICAL SURGICAL
OVERVIEW OF THE STRUCTURES & FUNCTIONS OF THE NERVOUS SYSTEM 3 PARTS OF THE NERVOUS SYSTEM
1. Central NS 2. Peripheral NS 3. Autonomic NS
Brain & Spinal cord 31 Spinal & Cranial Sympathetic NS & Parasympathetic NS
Somatic NS I. Autonomic Nervous System
A. Sympathetic NS (SNS)
1. Fight or Aggression Response
2.
Release of Norepinephrine (adrenaline – cathecolamine) = Adrenal Medulla (potent vasoconstrictor) 3. All body activities increased except GIT (GIT decreased motility)Bodily Effects of SNS
a.
Mydriasis = Dilated pupil , to be aware of surroundings b. Dry mouthVS = Increase c. BP & HR c. RR d. Constipation e. Urinary Retention
f. Increased BF to heart, brain, skeletal muscles 4. Adrenergic or Parasympatholitic Response
Adrenergic Agents a. Epinephrine (Adrenaline) S/E : SNS Effects b. Anti-Psychotics ex. Haldol (Haloperidol) S/E : SNS Effects B. Parasympathetic NS
1. Flight or Withdrawal Response
2.
Release of Acetylcholine (ACTH) 3. All bodily activities decreased except GIT Bodily Effects of PNSa.
Meiosis = constriction of pupils b. Increased salivationVS:decreased c. BP & HR
d. RR =bronchoconstriction e. Diarrhea =Increased Motility f. Urinary Frequency
4. Cholinergic or Vagal or Sympatholitic Response
a. Beta-Adrenergic Blocking Agents (Beta-Blockers) (all end in –‘lol’) Ex. Propanolol, Metopanolol
- Blocks release of norepinephrine, Decrease body activities except GIT (diarrhea) S/E:
B – broncho spasm (bronchoconstriction) E – elicits a decrease in myocardial contraction T – treats HPN
A – AV conduction slows down Given To/As: a. Angina Pectoris
b. MI – beta-blockers to rest heart c. Anti HPN agents: -Beta blockers (-lol)
- Ace inhibitors (-pril) ex ENALAPRIL, CAPTOPRIL - Calcium antagonist ex. CALCIBLOC or NEFEDIPINE
d. Anti-arrhythmic agents (arrhythmia= irregular contraction of the heart) b. Cholinergic agents Ex. Mestinon (prostigmine) given to MG to increase ACTH
S/E = PNS
II. CNS (Brain & Spinal Cord) Part 1 : Parts:
A. Cells – neurons = Basic living units Properties and Characteristics
a. Excitability – ability of neuron to be affected by changes in the external environment b. Conductivity – ability of neuron to transmit a wave of excitation from one cell to another c. Permanent cells – once destroyed, can not regenerate (ex. heart, retina, brain, osteocytes)
3 Types of Cells According To Its Regenerative Capacity:
1. Labile – once destroyed, can regenerate: Epidermal, GIT, lung cells, GUT cells 2. Stable – capable of regeneration BUT limited survival time: salivary gland, pancreas,
liver, kidney cells
3. Permanent – cannot regenerate: retina, brain, heart, osteocytes & myocardial cells B. Neuroglia : can cause brain tumors
Functions & its 4 Types:
1. Astrocyte = maintain integrity of blood brain barrier (semi-permeable/selective) 2. Microglia = stationary cells
3. Ependymal Cells 4. Oligodendrocytes
1.
Astrocytes:•
# 1 type of brain tumor= Astrocytoma ( 90 – 95%)• Toxic substance that destroys astrocyte & passes the Blood Brain Barrier
a.
Ammonia = a cerebral toxin , product of protein catabolismHepatic encephalopathy (liver cirrhosis) = death of liver d/t necrosis Primary Cause : Malnutrition
Major Cause : Alcoholism
Early Sign : Asterixis (Flapping hand tremors)
Late Sign : Headache, Restlessness, Fetor Hepaticus (ammonia-like breath) Hepatic Coma ---N.P. Airway
b. Bilirubin = yellow pigment --- jaundice (Icteric Sclerae) others: Bilivedrin = green pigment
Hemosiderin = golden-brown pigment Hepatitis Hemoglobin = red cell pigment
* Carotenemia = yellowish discoloration of the skin *Sign of Tumor in the Pituitary Gland * Kernicterus (Hyperbilirubinemia)
- Increased bilirubin in the brain, irreversible brain damage
b.
Carbon Monoxide :Tx for Carbon monoxide poisoning = Hyperbaric Oxygenation (100%) Parkinson’s Disease SeizureEarly Sign: Pill-Rolling Tremors
d. Lead = Antidote for lead poisoning --- Calcium EDTA e. Ketones - acids, CNS depressant
Ketones in Blood
DKA ---- Type 1 DM d/t increase fat catabolism free fatty acids
Cholesterol Ketones --- DKA : Early Signs = Weakness/ Weight Loss Leads to: Atherosclerosis Late Signs = Acetone Breath & Kussmaul’s Breathing
Leads to Coma HPN ==MI or Stroke --Death
2. Microglia = Stationary Cells --- Phagocytosis Organ Macrophage
• Brain --- Microglia
• Blood --- Monocytes
• Kidney/Liver --- Kupffer Cells
• Lungs --- Alveolar Macrophages
• SC Tissues --- Histiocytes
3. Ependymal Cells = acts as a defense in the CNS along with microglia secretes a glue --- Chemoattractants
4. Oligodendrocytes = produces myelin sheath: acts as a cover for neurons
acts as an insulator w/c facilitates rapid nerve impulse transmission No myelin sheath – degenerates neuron
DEMYELINATING DISEASE 1.
ALZHEIMER’S DISEASE – atrophy of brain tissue due to a deficiency of acetylcholine - Degenerative disorder
- A type of Dementia
Predisposing Factors: 1. Aging 2. Aluminum Accumulation S&Sx:
A – amnesia – loss of memory *Short-Term -- Anterograde Amnesia *Long-Term Retrograde Amnesia A – apraxia – unable to determine purpose of object thru movement
A – agnosia – unable to recognize familiar object A – aphasia – 2 types:
1. Expressive – Brocca’s aphasia – inability to speak ex. (+) nodding TX: use of picture-boards
- damage to frontal lobe
- Brocca’s ---- motor speech center in the frontal lobe
2. Receptive – Wernicke’s aphasia – unable to understand spoken words ex. (+) illogical thoughts - damage to Temporal lobe
- Wernicke’s Area --- general interpretative area - Common to Alzheimer – Receptive Aphasia
- Drug of choice – ARICEPT or COGNEX --- best given : at bedtime
2. MULTIPLE SCLEROSIS (MS) -Chronic intermittent disorder of CNS
Characterized by white patches of demyelenation in brain & spinal cord. Remission & exacerbation
Common – women, 15 – 35 y/o Predisposing factor:
1. Idiopathic
2. Slow growing virus
3. Autoimmune – (supportive & palliative treatment only) self-killing immunity
Normal Resident Antibodies: 5 types
IgG – can pass placenta – passive immunity, temporary IgA – body secretions – saliva, tears, colostrum IgM – acute inflammation
IgE – allergic reactions IgD – chronic inflammation S & Sx of MS:
1. Visual disturbances : a. *Blurring of vision = Initial sign b. Diplopia/ double vision c. Scotomas (blind spots)
2. Impaired sensation to touch, pain, pressure, heat, cold: a. Numbness b. Tingling c. Paresthesia 3. Mood swings – common : EUPHORIA (sense of elation )
4. Impaired motor function: a. Weakness
b. Spasticity –“ tigas” c. Paralysis
5. Impaired cerebellar function Triad Sx of MS (INA)
I – intentional tremors
N – nystagmus CHARCOT’S TRIAD (INA) A – Ataxia - unsteady gait
6. Scanning of Speech
7. Urinary retention or incontinence 8. Constipation
9. Decrease sexual ability Dx:
1. CSF analysis thru lumbar puncture : bet. L3 & L4 : Reveals CHON & IgG 2. MRI – reveals site & extent of demyelination
3. Lhermitte’s Sign : confirmatory Dx of MS
- continuous contraction & pain of the SC following laminectomy ( removal portion of lamina) Nsg Mgt:
- Supportive mgt
1.) Administer Meds as ordered
a. ACTH ( adrenocorticotropic hormone) : Acute exacerbation
– to reduce edema at the site of demyelination to prevent paralysis - compression of spinal nerves b. Baclopen (Lioresol) or Dantrolene Na (Dantrene) : To muscle spasticity
c. Interferons – to alter immune response d. Immunosuppressant
e. Diuretics
f. Bethanecol Chloride ( Urecholine) : N.M.
Administer only SC
Monitor S/E : wheezing, bronchospasm Monitor breath sounds 1 hr. after SC admin. h. Anti-spasmodic (Prophanthelene Bromide) Pro-banthene & anti-cholinergic
2. Maintain side rails
3. Assist passive ROM exercises – promote proper body alignment 4. Prevent complications of immobility (q 2 hr. elderly q 1 hr.)
5. Encourage fluid intake & increase fiber diet – to prevent constipation 6. Provide catheterization d/t urinary retention
7. Avoid heat application 8.. Give diuretics
9. Increase fiber & provide acid-ash diet – to acidify urine & prevent bacteria multiplication Ex. Grape, Plums, Cranberry, Orange juice, Prune juice, pineapple juice,Vit C
*3 Causes of UTI In Women
Shorter Urethra F= 1-2.5 inches (3-5 cm.) M= 5-6-8 inches (16-20 cm) Poor Perineal Care
Moist Vaginal Area PART II: Compositions of Cord & Spinal cord
80% - brain mass 10% - CSF 10% - blood 1 : Brain massst
A. CEREBRUM– Largest Part - Connects Right & Left cerebral hemisphere - Corpus collusum
Function: 1. Sensory 2. Motor 3. Integrative Compose of 6 Lobes:
1.) Frontal (garbled speech) a. Controls motor activity
b. Controls personality development c. Where primitive reflexes are inhibited
e. Control higher cortical thinking f. Brocca’s area – speech center
Damage - expressive aphasia 2.) Temporal –
a. Hearing
b. Short term memory
c. Wernicke's area – gen. interpretative Damage – receptive aphasia
3.) Parietal lobe – appreciation & discrimination of sensory impulses - Pain, touch, pressure, heat & cold
4.) Occipital – vision
5.) Insula/island of reil/ Central lobe- controls visceral fx Function: - activities of internal organ
6.) Rhinencephalon/ Limbic
- Smell, libido, long-term memory *Anosmia- absence of smell Basal Ganglia – areas of gray matter located deep within a cerebral hemisphere
Extra pyramidal tract
Releases dopamine- a neurotransmitter Controls gross voluntary unit
Dopamine :Parkinson’s or Huntington’s Dopamine : Schizophrenia Acetylcholine :Myasthenia Gravis & Alzheimer’s Acetylcholine : Bipolar Disorder B. MID BRAIN/ MESENCEPHALON
relay station for sight & hearing
Controls size & reaction of pupil ( Normal: 2 – 3 mm)
Controls hearing acuity ( Normal Hearing Acuity : 30-40 decibels) *PERRLA= Pupil dilated round & reactive to light & accommodation :Normal * Isocoria – normal size (equal) *Anisocoria – uneven size – damage to mid brain C. DIENCEPHALON ---between brain
2 Parts:
1.Thalamus – acts as a relay station for sensation
2. Hypothalamus – Thermo-regulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center
Controls some emotional responses like fear, anxiety Controls pituitary function.
D. BRAIN STEM
a. PONS – Pneumotaxic center – controls rate & depth of respiration Cranial 5 – 8 CNS
b. MEDULLA OBLONGATA- lowest portion of the brain
-controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus -Vasomotor center
- Site of Spinal Decuissation Termination, CN 9, 10, 11, 12 E. CEREBELLUM – smallest part of the brain
- Controls posture, gait, balance, equilibrium Cerebellar Tests:
a.) R – Romberg’s test- needs 2 RNs to assist
- Pt. in Normal anatomical position 5 – 10 min
(+) Romberg’s test is (+) ataxia or unsteady gait/drunken movement w/ loss of balance --seen in MS. b.) Finger to nose test –
(+) To FTNT – seen in Dymetria – inability to stop a movement at a desired point c.) Alternate pronation & supination
– seen in Dymetria 2 : CerebroSpinal Fluid (CSF)nd
10% Blood
10% Compose of lipids
Normal amount produced: 125-250 ml /day Produced at the Choroid Plexus
Composition: Clear, colorless, odorless: (+) glucose, protein,WBC but not RBC Fx: cushions the brain
Alters if there is obstruction in the flow of CSF = Increase ICP
Enlargement of the skull posteriorly d/t early closure of the posterior fontanel----Hydrocephalus 3 : Bloodrd
Stroke: partial/total obstruction in brain blood supply : 2 Commonly Affected artery:
1. ICA or Internal Carotid Artery 2. MCA or Middle Cerebral Artery *Composition of brain - based on Monroe Kellie Hypothesis
o Skull is a closed container. Any alteration in 1 of 3 intracranial components = increase in ICP *Normal ICP – 0 – 15 mmHg
Foramen Magnum = the hole in the skull where spinal cord enters C1 – atlas : carrying the entire skull
C2 – axis ---After C1 is the location of the medulla oblongata
Brain Herniation = when the medulla forced thru in the foramen : Observe for signs of ICP (+) Projectile vomiting , irregular respiration & HR
Observe for 24 hrs. before MRI DISORDER:
1.
INCREASED ICP – increase IC bulk is due to increase in 1 of the IC components A. Predisposing factors: 1.) Head injury
2.) Tumor
3.) Localized abscess 4.) Hemorrhage (stroke) 5.) Cerebral edema 6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis B. S&Sx
Earliest Sx:
a.) Change or decrease LOC – Restlessness to confusion (conscious, lethargy, stupor, coma) - Disorientation to lethargy *conscious = awake - Stupor to coma
Late Sx: a. Change in V/S : always a late sx
1. BP (systolic increase, diastole- same) Normal adult BP 120/80 : 40 (normal PP) 2. Widening pulse pressure Ex. Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide) 3. RR : Cheyne-Stokes =rapid respiration w/ periods of apnea
4. Temperature increase
DIFFERENCE BET. SHOCK : & INCREASE ICP: Decrease BP Increase BP
Increase HR Decrease HR CUSHING’S EFFECT Increase RR Decrease RR
Decrease Temp Increase temp Narrowing PP Widening PP b.) Headache
c.) Projectile vomiting
d.) Papilledima (edema of optic disk – outer surface of retina) e.) Abnormal Posturing
1. Decorticate = abnormal flexion of arms = damage to cortico spinal tract 2. Decerebrate = abnormal extension of arms
= damage to upper brainstem, cerebrum, midbrain & pons Except: Flaccid = loss of muscle tone, damage to the lower brain, medulla
f. Uncal herniation – unilateral dilation of pupil g. Possible seizure
Nursing Management:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia =decrease tissue oxygenation & hypercarbia =increase in CO2 retention Hypoxia – cerebral edema - increase ICP
Early Sx: R – restlessness Late Sx: B – bradycardia
A- agitation “RAT” E – extreme restlessness “BEDC”
T- tachycardia D – dyspnea
C – cyanosis =late
* Powerful respiratory stimulant : CO2 ---an CO2 retention/ hypercarbia ---stimulate medulla O.
stimulate lungs to Hyperventilate 2. Before & after suctioning, hyperventilate 100% - decrease CO2 – excrete CO2
Suctioning – 10-15 seconds, max 15 seconds Ambu bag – pump upon inspiration 3. Assist in mechanical ventilation
4. Monitor VS & I&O, neuro check
5. Positioning -- Elevate head of bed 30- 45 degrees angle neck in neutral position unless C/I to promote venous drainage
4. Limit fluid intake 1,200 – 1,500 ml/day
(FORCE FLUID means: Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP. 5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment b. Avoid use of restraints – lead to fractures c. Maintain side rails up
d. Instruct patient to avoid activities leading to:Valsalva maneuver or bearing down -Avoid straining of stool(give laxatives/ stool softener Dulcolax/ Duphalac) - Excessive cough – antitussive (Dextrometorpham)
-Excessive vomiting – anti emetic (plasil)
- Avoid Lifting of heavy objects, Bending & stooping - Avoid clustering of nursing activities
7. Administer meds as ordered:
1.) Osmotic diuretic – Mannitol/Osmitrol: promotes cerebral diuresis by decompressing brain tissue
Nursing considerations: Mannitol
1. Monitor BP – S/E: hypotension
2. Monitor I&O every hr. report if < 30cc out put 3. Administer via side drip
4. Regulate fast drip – to prevent formation of crystals/precipitate 5. Inform client, will feel flushing sensation as drug is introduced 2.) Loop diuretic - Lasix (Furosemide) in ampule
Nursing Mgt: Lasix
Same as Mannitol except
- Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15
Action of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm) S/E of LASIX
1. Hypokalemia (Normal K-3.5 – 5.5 meg/L)
S&Sx : Compared to Hyperkalemia:
1. Weakness & fatigue 1. Irritability & Agitation 2. Constipation 2. Diarrhea, abdominal cramps 3. (+) “U” wave in ECG tracing 3. Peaked T-wave
both will lead to arrhythmia Nursing Mgt: 1. Administer K supplements – ex. Kalium Durule, Oral Kcl
Potassium Rich food: ABC’s of K
Vegetables Fruits A - asparagus A – apple
C – carrots C – cantaloupe/ melon O – orange (increase) Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa Iron – raisins,
*Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions, no grapes – may choke S/E of Lasix:
2. Hypocalcemia or Tetany: life-threatening (Normal level Ca = 8.5 – 11mg/100ml) S&Sx : Weakness
Paresthesia
(+) Trousseau sign or carpo-pedal spasm – pathognomonic (+) Chvostek’s sign
Complications: Arrhythmia Laryngospasm N. M. - Administer – Ca gluconate – IV slowly Ca gluconate toxicity: Sx : seizure – administer Mg SO4
Mg SO4 toxicity– administer Ca gluconate : “BURP” B – BP decrease
U – urine output decrease R – RR decrease
P – patellar reflexes absent 3. Hyponatremia (Normal Na level = 135 – 145 meg/L)
S/Sx: Hypotension
Signs of Dehydration
Early signs – thirst and agitation for adults ---children: tachycardia, dry mucous m. Mgt: force fluid 2-3 L/day
Administer isotonic fluid sol
4. Hyperglycemia – Increase blood sugar level P – polyuria
P – polyphagia 3 P’s of Hyperglycemia P – polydipsia
Nsg Mgt:
a. Monitor FBS (Normal =80 – 120 mg/dl)
*Lasix can be given to DM but strict FBS monitoring 5. Hyperurecemia – increase serum uric acid = by product of purine metabolism
Gouty arthritis kidney stones- renal colic (pain) Cool moist skin
Sx joint pain & swelling ----great toe affected ----gouty arthritis Nsg Mgt of Gouty Arthritis
a.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO) b.) Force fluid
c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout: Colchicene – acute gout drug of choice ---promotes excretion of uric acid
Kidney stones – renal colic (pain). Cool moist skin Mgt:
1.) Force fluid
2.) Meds – narcotic analgesic Morphine SO4
3.) Strain all urine using gauze pads S/E of Morphine SO4 toxicity
Respiratory depression (check RR 1st)
Antidote for morphine SO4 toxicity –Narcan (NALOXONE) Naloxone toxicity – tremors
Cont. Increase ICP meds
3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone) *Steroids best given: 2/3 dose am &
1/3 dose pm - to mimic normal diurnal rhythm 4.) Mild analgesic – codeine SO
5.) Anti consultants – Dilantin (Phenytoin)
Increase ICP what is the immediate nsg action? Administer Mannitol as ordered
Elevate head 30 – 75 degrees Restrict fluid
Avoid use of restraints *Nsg Priority – ABC & safety Pt. suffering from epiglotitis. What is nsg priority?
a. Administer steroids – least priority b. Assist in ET – temp, a/w
c. Assist in tracheotomy – permanent (Answer) d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET can’t pass. Need tracheostomy only-
Magic 2’s of Drug Monitoring Toxicity Level: “DLADA”
Drug Normal Range Toxicity Classification Indication D – digoxin .5 – 1.5 meq/L 2 Cardiac glycosides CHF L - lithium .6 – 1.2 meq/L 2 Antimanic Bipolar Disorder
A – aminophylline 10 – 19 mg/100ml 20 Bronchodilator COPD
D – Dilantin 10 -19 mg/100 ml 20 Anticonvulsant Seizures
A – acetaminophen 10 – 30 mg/100ml 200 Narcotic analgesic Osteoarthritis
D- Digitalis (Digoxin) – increase cardiac contraction = increase CO Cardiac Glycosides Nursing Mgt:
1. Check PR, HR (if HR below 60bpm, don’t giveDigoxin) Increase force of cardiac contraction Digitalis toxicity – antidote - Digibind
a. Anorexia increase cardiac output
b. n/v GIT c. Diarrhea
d. Confusion e. Photophobia
f.
Changes in color perception – yellow spots---Xantopsia L – lithium (lithane) decrease levels of norepinephrine, serotonin, and acetylcholineAnti-manic agent Lithium toxicity
S/Sx - a. Anorexia *N.M. 1. Force Fluid
b. n/s 2. Increase intake in diet 4-10g/d
c. Diarrhea
d. Dehydration – force fluid, maintain Na intake 4 – 10g daily e. Hypothyroidism
f. Fine Tremors
CRETINISM– the only endocrine disorder that can lead to mental retardation
A – aminophyline (Theophylline) ---dilates the bronchial tree *Seizure= 1st attack
*Febrile seizure= normal 5 y/o S/Sx : Aminophylline toxicity: * Epilepsy = succeeding attacks
2. Hyperactivity – restlessness, agitation, tremors (CNS excitability) N.M. ---Avoid giving food with Aminophylline
a.Cheese/butter– food rich in tyramine, avoided only if pt is given MAOI b. Beer/ wine –
c. Hot chocolate & tea – caffeine – CNS stimulant tachycardia d. Organ meat/ box cereals – anti parkinsonian
MAOI – antidepressant m AR plan
n AR dilcan lead to CVA or hypertension crisis p AR nate
3 – 4 weeks - before will take effect
Anti Parkinsonian agents – Vit B6 Pyridoxine reverses effect of Levodopa D – dilatin (Phenytoin) – anti convulsant/seizure
Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate o Do sandwich method
o Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol – bec. alcohol + dilantin can lead to severe CNS depression Dilantin toxicity: “ GHAN ” *Osteoarthritis: Sign –Heberdens nodes
S/Sx:
G – gingival hyperplasia – swollen gums
i. Oral hygiene – soft toothbrush ii. Massage gums H – hairy tongue
A - ataxia
N – nystagmus – abnormal movement of eyeballs
A – acetaminophen/ Tylenol – non-opoid analgesic & antipyretic – febrile pts a. Acetaminophen toxicity :
1. Hepato toxicity : Monitor liver enzyme
SGPT (ALT) – Serum Glutamic Pyruvate Transaminase SGOT- Serum Glutamic Oxaloacetic Transaminase 2. Monitor BUN (10 – 20)
*Creatinine (.8-1)most reliable, indicative for kidney clearance b. Acetaminophen toxicity can lead to hypoglycemia :” TIRED”
T – tremors / Tachycardia I – irritability R – restlessness E – extreme fatigue D – depression Diaphoresis/Nightmares *Antidote for acetaminophen toxicity – Acetylcesteine ---- Prepare suctioning apparatus Exercise: The following are symptoms of hypoglycemia except:
PARKINSONS DISEASE (Parkinsonism)
-
Chronic, progressive disease of CNS characterized by degeneration of dopamine producing cells in substancia nigra at mid brain & basal ganglia (produces dopamine)Mngt: Palliative & Supportive Only Predisposing Factors:
1. Poisoning (lead & carbon monoxide) 2. Hypoxia
3. Arteriosclerosis 4. Encephalitis 5. Drug Overdose
High doses of the ff:
a. Reserpine (serpasil)---than only anti-HPN with S/E of depression ---suicidal --- only HPN known to be link to breast cancer --- promote safety
b. Methyldopa (aldomet)---Anti-HPN c. Haloperidol (Haldol) - anti psychotic
d. Phenothiazine - anti psychotic S/E of anti-psychotic drugs – Extra Pyramidal Symptom Over medication of anti psychotic drugs
– neuroleptic malignant syndrome characterized by tremors (severe) S/Sx: Parkinsonism:
1.
Pill-rolling tremors of extremities – 1st Sign2.
Bradykinesia – slow movement---2nd Sign3. Over fatigue
4. Rigidity (cogwheel type) --- a. Stooped posture b. *Shuffling c.Propulsive gait 5. Mask like facial expression with decrease blinking of the eyelids 6. Monotone speech
7. Difficulty rising from sitting position
8.
Mood labilety – Depression– suicide Nsg priority: Promote safety 9. Increase salivation – drooling type10. Autonomic signs:
Increase sweating Increase lacrimation
Seborrhea (increase sebaceous gland) Constipation
Decrease sexual activity Nsg. Mgt.
1.) Administer Meds:Anti-parkinsonian agents
- Levodopa (L-Dopa)---short-acting
- Carbidopa (Sinemet), Amantadine Hcl (Symmetrel)----long-acting Mechanism of action: Increase levels of dopa – relieving tremors & bradykinesia S/E of anti-parkinsonian Anorexia n/v Confusion *Orthostatic hypotension Hallucination
Arrhythmia, GIT irritation ( administer with meals) Contraindication:
1. Pt. with glaucoma----because L-dopa intra-ocular pressure (N: 12-21 mmHg) 2. Pt. taking MAOI (Parnate, Marplan, Nardil)
= Takes effect : 2-6 wks.
=If on MAOI avoid: Tyramine, tryptophan rich foods
ex. aged cheese, liver, beer, alcohol----leads to hypertensive crisis—stroke
Nsg. Mgt. when giving anti-parkinsonian
a. Take with meals – to decrease GIT irritation b. Inform pt – urine/ stool may be darkened
c. *Instruct pt. not to take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg Because Vit. B6 reverses therapeutic effects of levodopa
Only increase intake of Vit. B6 in taking INH (isoniazid, anti-TB) Isonicotinic Acid Hydrazide---effect---peripheral neuritis 2.) Anti- cholinergic agents – relieves tremors
*Artane mechanism – inhibits acetylcholine *Cogentin action ---S/E - SNS
3.) Antihistamine – Diphenhydramine Hcl (Benadryl) – take at bedtime---relieves tremors S/E: adult– drowsiness – avoid driving & operating heavy equipment. Child – Hyperactivity (CNS excitability)
4.) Dopamine agonist:
Bromocriptine Hcl (Parlodel)---relieves rigidity, bradykinesia S/E: CNS depression, Check RR Nsg. Mgt.
1.) Maintain siderails to prevent falls 2.) Prevent complications of immobility
- Turn pt every 2h
- Turn pt every 1 h – elderly
-Turn affected extremity every 30 minutes 3.) Assist in passive ROM exercises to prevent contractures 4.) Maintain good nutrition: Protein
CHON – in am
CHON – in pm – to induce sleep – d/t Tryptopan ex. milk 5.) Increase fluid in take, high fiber diet to prevent constipation 6.) Assist in surgery – Stereotaxic Thalamotomy
Common complications: a. Subarachnoid hemorrhage b. Encephalitis c. Aneurysm 7.) Assist in ambulation
MYASTHENIA GRAVIS (MG)
–A neuromuscular disorder characterized by a disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction leading to descending muscle weakness. Predisposing Factors:
Common in Women, 20 – 40 y/o, Unknown cause or idiopathic
Autoimmune – release of cholenesterase (enzyme that destroys acetylcholine) Pathophysiology: Cholinesterase destroys ACTH
ACTH Descending muscle weakness M.G. S/ Sx:
1.) Ptosis – drooping of upper lid ( initial sign)
Palpebral fissure – normal opening of upper & lower lids 2.) Diplopia (double vision)
3.) Mask-like facial expression 4.) Dysphagia
5.) Weakening of laryngeal muscles – hoarseness of voice
6.) *Respiratory muscle weakness – lead respiratory arrest. Prepare at bedside tracheostomy set 7.) Extreme muscle weakness during activity especially in the morning.
Priority: to watch out for: a. A/W
b. Aspiration
c. Physical immobility Dx. Test:
1.
Tensilon test (Edrophonium Hcl) – an anti-cholinesterase/cholinergic agent----short-acting only) Administer to pt. for temporary relief for 5 – 10 mins. (+) for M.G.2. CSF analysis- reveals cholinesterase Nsg Mgt.
1. Maintain patent a/w & adequate ventilator by:
a.) Assist in mechanical ventilator – attach to ventilator b.) Monitor pulmonary function test using spirometer
2. Monitor VS, I&O neuro check, muscle strength or motor grading scale (4/5, O/S, etc) 3. Siderails up
4. Prevent complications of immobility 5. NGT feeding to prevent complications 6. Administer medication as ordered
a. Cholinergics or anticholinesterase agents
Mestinon (Pyridostinine) Action: Increases ACTH Neostignine (prostigmin) S/E : PNS
b. Steroids, Corticosteroids – to suppress immune response Decadron (dexamethasone)
Monitor for 2 types of Crisis:
Myastinic crisis Cholinergic crisis
Cause: 1. Under medication 2. Stress 3. Infection
S&Sx: 1. Unable to see – Ptosis & diplopia 2. Dysphagia
3. Unable to breath
Mgt.: Administer cholinergic agents: Mestinon
Cause: Over medication S/Sx - PNS
Mgt.
Administer anti-cholinergic 1. Atropine SO4
S/E: SNS – dry mouth 7. Assist in surgical procedure – Thymectomy (removal of thymus)
8. Assist in plasmapheresis – filtering of blood
GBS – GUILLIAN BARRER SYNDROME
A disorder of the CNS characterized by bilateral symmetrical polyneuritis leading to ascending paralysis Polyneuritis --- inflammation of the peripheral nerves Can leadto slow but complete recovery
Predisposing Factors:
1. Cause – unknown, idiopathic 2. Auto immune
3. *R/t antecedent viral infection (from LRTI) 4. Immunizations
S&Sx
1. Clumsiness --- Initial sign of GBS
2. Ascending muscle weakness – lead to paralysis 3. Dysphagia
4.
Decrease or diminished DTR (deep tendon reflexes) --- Paralysis 5. *Alternate HPN to hypotension – complication: Can lead to arrhythmia 6. Autonomic changes: a. Increase sweating b. Increase lacrimation c. Increase salivation d. Constipation Dx:Most important: CSF analysis thru lumbar puncture reveals increase in : IgG & CHON---same with MS Nsg Mgt.
1. Maintain patent a/w & adequate vent a. Assist in mechanical vent b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia 3. Siderails
4. Prevent complicarions – immobility 5. Assist in passive ROM exercises 6. Institute NGT feeding
7. Administer medications as ordered:
1. Anti-cholinergic – Atropine SO4
2. Corticosteroids – to suppress immune response 3. Anti arrhythmic agents:
a.) Lidocaine /Xylocaine—S/E: confusion & agitation b.) Bretyllium---blocks release of norepinephrine
c.) Quinidines/Quinitine – anti malarial agent & anti-arrythmic > Toxic effect – Cinchonism
Quinidine toxicity: S/E – anorexia, n/v, headache, vertigo, visual disturbances
*Malaria ---king of tropical disease----antidote----Queen (Quinidine) 8. Assist in plasmapheresis
INFLAMMATORY CONDITIONS OF THE BRAIN Anatomy:
Meninges –a 3-fold membrane that covers the brain & spinal cord Fx:
1. Protection & support 2. Nourishment 3. Blood supply
3 layers:
1. Duramater (outermost in bet. is sub dural space 2. Arachmoid matter (middle)
3. Pia matter (outermost) sub arachnoid space where CSF flows L3 & L4
1. MENINGITIS
– An inflammation of the meninges of the brain & spinal cord Etiology: a. Meningococcus---most dangerous type
b. Pneumococcus
c. Hemophilous influenza – common to children d. Streptococcus –a type of adult meningitis MOT: Direct transmission via droplet nuclei (airborne) S&Sx
Stiff neck or Nuchal Rigidity ---Initial Sign of meningeal irritation Headache Projectile vomiting Photophobia
Fever chills, anorexia General body malaise Weight loss
Decorticate/decerebration – abnormal posture Possible seizure
Opisthotonus (arching of the back)---2nd intital sign*Pathognomonic Sign: (+) Kernig’s & Brudzinski sign
Leg pain Neck pain
Dx:
1. Lumbar Puncture: lumbar/ spinal tap – use of hallow spinal needle Aspiration in the sub arachnoid space between L3 & L4 or L4 & L5.
Nsg Mgt . For Lumbar Puncture--- invasive
1. Consent / explain procedure to pt
RN – will explain if laboratory exams MD – will explain if operation procedure 2. Empty bladder, bowel – promote comfort
Nsg Mgt. Post Lumbar:
1. *Flat on bed – 12 – 24 h to prevent spinal headache & leak of CSF 2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue, discomfort 4. Assess for movement & sensation of extremities
Result:
1. CSF analysis: a. Increase CHON & WBC b. Decrease glucose
Confirms Meningitis c. Increase CSF opening pressure (Normal: 50 – 160 mmHg) d. (+) Culture microorganism
2. Complete blood count CBC – reveals increase WBC (Leukocytosis) Mgt:
1. Adm meds
a.) Broad-spectrum antibiotic: Penicillin S/E :
1. GIT irritation – take with food 2. Hepatotoxicity, nephrotoxcicity 3. Allergic reaction
4.* Super infection – alteration in normal bacterial flora Normal flora: throat – streptococcus Normal flora : intestine –E. Coli Sx: of superinfection of penicillin Diarrhea
b.) Antipyretic
c.) Mild analgesic for headache
2. Strict respiratory isolation 24 hrs. after start of antibiotic therapy 3. Comfy & dark room – due to photophobia & seizure
4. Prevent complications of immobility 5. Maintain F & E balance
6. Monitor VS, I&O , neuro check
7. Provide client health teaching & discharge plan
a. Nutrition – Increase CHON & CHO but Small freq feeding b. *Prevent complication of Hydrocephalus & Nerve Deafness 8. Institute measures to prevent Increase ICP & seizures
9. Rehabilitation for residual deficit ( mental retardation & delayed psychomotor development) Exercise: Where to bring 2 y/o post meningitis ?
Audiologist due to damage to post repair myelomeningoceleREVIEW:
3 Types of ISOLATION: 1. Strict Isolation
2. Reverse Isolation 3. Enteric
Ex. Pt. with -Cushing’s syndrome – reverse isolation
-Aplastic anemia – reverse isolation--- bone marrow depletion----pancytopenia -Cancer any type – reverse isolation
-Post-Liver transplant – reverse isolation -Prolonged use steroids – reverse isolation -Meningitis – strict isolation
-Asthma – not to be isolated - Hepatitis A - Enteric - Measles – Strict - Mumps – Strict - Pneumonia – Strict - PTB -Strict REVIEW:
*Thrombosis & Stroke leads to atherosclerosis Initial sign: Headache
Late sign: Pruritus ---
* Anemia : Initial sign: Weakness & Fatifue Blood:
Leukopenia WBC Leukocytosis
Anemia RBC Polycythemia
CEREBRO VASCULAR ACCIDENT :
Or Stroke, Brain Attack or Cerebral Thrombosis, Apoplexy A partial or complete disruption in the brains blood supply 2 largest & common artery in stroke :
a. Middle cerebral artery b. Internal carotid artery Common to male – 2 – 3x high risk, increases as you grow older Predisposing factor:
1. Thrombosis – clot (attached)---No. 1 cause of Stroke 2. Hemorrhage
3.
Embolism – dislodged clot – pulmo embolism---2nd causeS/Sx: P ulmonary Embolism 1. Sudden sharp chest pain 2. Unexplained dyspnea, SOB
3. Tachycardia, palpitations, diaphoresis & mild restlessness S/Sx: Cerebral Embolism
1. Headache, disorientation, confusion & decrease in LOC----lead to coma
4.
*Compartment Syndrome – compression of nerves/ arteries Test Analysis:*Femur Fracture
Fx. Complications:> Fat embolism – most feared complication w/in 24hrs >Hemorrhage
*Yellow bone marrow – produces fat cells at medullary cavity of long bone *Red bone marrow – provides WBC, platelets, RBC found at epiphysis Risk factors of CVA:
a. HPN b. DM c. MI
d. Artherosclerosis e. Valvular heart disease
f.
Post cardiac surgery---*Mitral valve replacement g. Lifestyle:1. Smoking – nicotine – potent vasoconstrictor 2. Sedentary lifestyle
3. Hyperlipidemia –genetic-genes that easily binds to cholesterol h. Obesity ---20% of BW
Overweight ---10% of BW i. Prolonged use of oral contraceptives
2 types: - Macro pill – has large amount of estrogen - Mini pill – has large amount of progestin Mini-pill---- Promote lipolysis – artherosclerosis – HPN – stroke j. Type A personality
a. Deadline driven person b. 2 – 5 things at the same time c. Guilty when not dong anything k. Diet – increase saturated fats ---ex. whole milk l. Emotional & physical stress
S & Sx:
1. Transient Ischemic Attack ( TIA) - 1 st sign of Impending stroke attacks
-o Headache – initial sing of TIA
o Dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or phlegia (monoplegia – 1 extreme) (Paraplegia—lower extremeties)
o
Increase ICP, *Temporary memory loss 2. Stroke in evolution – progression of S & Sx of stroke 3. Complete stroke – resolution of strokea.) Headache
b.) *Cheyne-Stokes Resp c.) Anorexia, n/v
d.) Dysphagia e.) Increase BP
f.) (+) Kernig’s & Brudzinski – Sx of Hemorrhage Stroke g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria – inability to vocalize 3. Aphasia
4. Agraphia – difficulty in writing 5. Alexia – difficulty in reading
6. Homonymous Hemianopsia – loss of half of field of vision Left sided hemianopsia – approach Right side of pt – the unaffected side
Nsng. Dx. = Unilateral Neglect Dx.
1. Computerized Tomography Scan – reveals brain lesion 2. Cerebral Arteriography – rveals site & extent of mal-occlusion
Invasive procedure due to inject dye Allergy test
*All Dx ending in graphy/gram are invasive: injection of a dye, ask if allergic to seafoods Post-CT Scan
1.) Force fluid – to excrete dye because it is nephrotoxic---check BUN & Creatinine 2.) Check peripheral pulse
3.) Check Fluid imbalance----dye is an osmotic diuretic Nsg. Mgt.
1. Maintain patent a/w & adequate vent - Assist mechanical ventilation - Administer O2 inhalation 2. Restrict fluids – prevent cerebral edema 3. Instruct client to avoid valsalva maneuver 4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by: a. Turn client q2h Elderly q1h
- To prevent decubitus ulcer/ bed sores
-
To prevent Hypostatic pneumonia –type of pneumonia r/t long immobility b. Egg crate mattress or H2O bed6. NGT feeding – if pt can’t swallow
7. *Passive ROM exercise q4h to prevent contractures & to promote proper body alignment 8. Alternative means of communication
- Use Non-verbal cues - Magic slate
- (+) To hemianopsia – approach on unaffected side 9. Position pt.: elevate heat 30 degrees angle/ semi-fowlers 10. Maintain siderails
11.Meds
a. Osmotic diuretics – Mannitol ( Osmitrol) ---Side-drip—fast drip ----S/E: decrease BP b. Loop diuretics – Lasix/ Furosemide---IV push
3. Corticosteroids – Dextamethazone (ends in one)
4. Mild analgesic---codeine Sulfate---S/E: Respiratory Depression 5. Thrombolytic/ fibrolitic agents – tunaw clot
Ex. Streptokinase---S/E: Allergic Reaction Urokinase---S/E: Hypertension
Tissue Plasminogen Activating Factor ( TPAF)----S/E: Chest Pain *Monitor bleeding time
6. Anti-coagulants – Heparin & Coumadin----” sabay”
Why : Coumadin will take effect after 3 days---long-acting Anti-Coagulants
Heparin Coumadin or Warfarin
(Short-Acting) (Long-Acting)
Monitor: PTT (Partial Thromboplastin Time) PT (Prothrombin Time) If prolonged, indicates bleeding if prolonged, indicates bleeding Antidote: Protamine Sulfate Vitamin K (Aquamephyton)
7. Anti-platelet (PASA) – aspirin paraanemo aspirin -the only NSAID that has anti-platelet property - Do not give to pts. With Dengue, Ulcer & Headache - Aspirin--- No. 1 ulceronegenic agent
S/E: Tinnitus, Anemia, Heartburn & Dyspepsia
*EPISTAXIS/ nose bleeding--- parameter that indicates effectiveness of thrombolytic therapy Health Teachings:
1. Avoidance of modifiable lifestyle - Diet, smoking
2. Dietary modification
- Avoid caffeine, decrease Na & decrease saturated fats 3. Prevent Complications:
*Subarachnoid hemorrhage 4. Rehab for focal neurological deficit
1. Mental retardation
CONVULSIVE Disorder (CONVULSIONS)
o
A disorder of the CNS characterized by paroxysmal seizures with or w/o loss of consciousness, abnormal motor activity, alteration in sensation & perception & changes in behavior.Exercise: Can you outgrow febrile seizure? Febrile seizure Normal if < 5 y/o Pathologic if > 5 y/o
Predisposing Factor:
a. Head injury d/t birth trauma--- No .1 cause of convulsions b. Toxicity of carbon monoxide
c. Brain tumor d. Genetics
e. Nutritional & metabolic deficit f. Physical stress
g. Sudden withdrawal to anticonvulsants---No .1 of status epilepticus Status epilepticus – Drug of Choice: Diazepam & glucos
S & Sx. Of Epilepsy dependent upon stages: I. Generalized Seizure –
1.) Grand mal / tonic clonic seizures---most common type of seizure - With or w/o Aura – warning symptoms of impending seizure attack Epigastric pain ---1st sign of aura
This is associated with olfactory, tactile, visual, auditory sensory experience Epileptic cry – fall
*Loss of consciousness 3 – 5 minutes Tonic-clonic contractions
Tonic - Direct symmetrical extension of extremities Clonic - contractions
Post ictal (state of lethargy or drowsiness) sleep- unresponding sleep after tonic clonic 2.) Petit mal seizure – (same as daydreaming!)
- Blank stare
- Decrease blinking eye - Twitching of mouth
- *Loss of consciousness – 5 – 10 seconds (quick & short) - *Common to children
II. Localized/partial seizure
1. Jacksonian seizure or Focal seizure
– tingling/jerky movement of index finger/thumb &
spreads to shoulder & 1 side of the body with janksonian march 2. Psychomotor/ Focal-motorseizure
-*Automatism – stereotype repetitive & non-purposive behavior - Clouding of consciousness – not in contact with environment - Mild hallucinatory sensory experience
3 Types of HALLUCINATION:
1. Auditory – schitzophrenia – paranoid type 2. Visual – Korsakoffs psychosis – chronic alcoholism 3. Tactile – addict – substance abuse
III. Status Epilecticus
– Continuous, uninterrupted seizure activity leading to hyperpyrexia – coma – death Drug of Choice : Diazepam & Glucose
Pathophysiology: Status Epilepticus
Increase electrical firing in the brain: if left untreated Increase Heat production ---hyperpyrexia
Increase metabolism using glucose & O2 ---need for glucose therapy Coma---Death
Dx: For All Types:
1. CT scan – revealsbrain lesion
2. EEG electroencephalography --revealsHyperactivity brain waves 3. ECT therapy
Nsg. Mgt.
Priority – Airway & Safety *If with seizure: S/E is PNS 1. Maintain patent a/w & promote safety Before seizure:
1. Remove blunt/sharp objects 2. Loosen clothing of pt.
3. Avoid restraints----can lead to fracture 4. Maintain siderails
5. Turn head to side to prevent aspiration
6. Tongue guard or mouth piece to prevent biting of tongue (emergency—clean piece of cloth) 7. Avoid precipitating stimulus – bright glaring lights & noises, drafts
8. Administer meds
a. Dilantin (Phenytoin) –( toxicity level – 20 ) S/E: Gingival hyperplasia H-hairy tongue A-ataxia N-nystagmus
b. Acetaminophen- febrile pt
Mix only with NSS, sandwich method - Don’t give alcohol – lead to CNS depression c. (Tegretol) Carbamazepine
d. Phenobarbital (Luminal) ---common S/E: hallucination & mild arrythmia e. Diazepam
2. Institute seizure & safety precaution
By Post seizure: Administer O2 inhalation. Suction apparatus ready at bedside 3. Monitor onset & duration of
- Duration of post ictal sleep----the longer the duration, the danger of status epilepticus 4. Assist in surgical procedure
- Cortical resectio n
Exercise: 1 y/o grand mal – immediate nursing action = a/w & safety a. Mouthpiece – 1 yr old – little teeth only
b. Adm o2 inhalation – post! c. Give pillow – safety d. Prepare suction Neurological Assessment:
4 Objectives of Neurological Assessment: 1. To know the exact neurological deficit 2. To localized lesion
3. For rehabilitation 4. Guidance in nursing care 2 Types of N.A.
1.
Glasgow Coma Scale (GCS)– objective measurement of LOC or quick neuro check 3 components of ECS (“MVE”)M – motor 6 V – verbal response 5 E – eye opening 4 15---- highest score Scaling: 15 – 14 – Conscious 13 – 11 – Lethargy 10 – 8 – Stupor 7 – Coma
3 – Deep coma – lowest score ( no 0 score on any response, lowest is only 1)
2. Comprehensive Neuro Exam
A. Survey of Mental status & speech (Comprehensice Neuro Exam) 1.) LOC & Test of memory
2.) Levels of orientation 3.) Cranial Nerve assessment 4.) Motor assessment 5.) Sensory assessment
6.) Cerebral test – Romhberg, finger to nose 7.) DTR
8.) Autonomics
1. a. Levels of consciousness (LOC)
1.
Conscious (conscious) – awake – levels of wakefulness2.
Lethargy (lethargic) – drowsy, sleepy, obtunded3. Stupor (stuporous) – awakened by vigorous stimulation Pt. has general body weakness, decrease bodily reflex 4. Coma (Comatose) Light – (+) all forms of painful stimulations
Deep – (-) to painful stimulation *Watch out for the rise & fall of the chest
b. Different types of pain stimulation o Don’t prick
1. Deep sternal pressure/stimulation: 3x– fist knuckle With response – light coma Without response – deep coma 2. Pressure on great toe – 3x
3. Orbital pressure – pressure on orbits only – below eye 4. Corneal reflex/ blinking reflex
*Wisp of cotton – used to illicit blinking reflex among conscious patients *Instill 1-drop saline solution – unconscious pt if (-) response pt is in deep coma
c. Test of memory – consider educational background a. Short term memory –
What did you eat for breakfast?
Damage to temporal lobe – (+) antero grade amnesia b. Long term memory
(+) Retrograde amnesia – damage to limbic system (rhinencephalon) 2. Levels of orientation:
1st: Time 2nd:: Person 3rd: Place
Exercise: Describe a conscious pt ?
a. Alert – not all pt are alert & oriented to time & place b. Coherent
c. Awake d. Aware
3. Cranial Nerve Assessment: 12 pairs of cranial nerves
I – Olfactory Old s Some
II – Optic Opie s Say
III – Oculomotor Occasionaly m Marry
IV – Trocheal Tries m smallest CN Money
V – Trigeminal Trigonometry b largest CN But
VI – Abducens And m My
VII – Facial Feels b Brother
VIII – Acoustic/auditory (V) Very s Says
IX – Glossopharyngeal Gloomy b Bad
X – Vagus Vague b longest CN Business
XI– Spinal accessory And m Marry
XII – Hypoglossal Hypoactive m Money
I. Olfactory – don’t use ammonia, alcohol, cologne irritating to mucosa – use coffee granules, vinegar * Hyposmia – decrease sensitivity to smell
*Diposmia – distorted sense of smell *Anosmia – absence of sense of smell
*Either of 3 might indicate head injury – damage to cribriform plate of ethmoid bone where olfactory cells are located or indicate inflammation condition – sinusitis
II Optic (Sensory or Vision)
1. Test of visual acuity or central or distance vision (test of near vision) Use Snellens Chart:
a. Snellen’s Alphabet ---used for literate client b. Snellen’s E chart ---used for illiterate c. Animal Chart ---used for children Normal: 20/20 vision
20 numerator is constant: 20 ft (6-7 m) distance from the chart 20 denomenator ---vision distance the person can see the letters OD – Rt eye 20/20 =20/200 – blindness – can’t read E – biggest
OS – left eye 20/20
OU – both eye 20/20
2. Test of Peripheral Vision/ visual field: facing the client a. Superiorily
c. Inferiorly d. Nasally Common Disorders
1. Glaucoma – (Normal 12 – 21 mmHg intra-ocular pressure)
- Increase IOP - Loss of peripheral vision – “tunnel vision” 2. Cataract – opacity of lens - Loss of central vision, “Blurring or hazy vision” 3. Retinal detachment – curtain veil – like vision & floaters
4. Macular degeneration – black spots III Oculomotor, IV (Throclear), VI (Abducens)
– Tested simultaneously because it controls or innervates the movement of extrinsic ocular muscle *6 Cardinal Gaze Extrinsic Ocular Movement
Rt eye N left eye
IO SO O S
LR MR E
SR
Throclear – controls superior oblique (1) Abducens - lateral rectus (1)
9. Oculomotor- controls the size & response of pupil (Pupil size 2 -3 cm or 1.5 – 2 mm) - controls opening of the eyelids
- controls the 4 gaze V – Trigeminal
– Largest nerve – consists of - ophthalmic, maxillary & mandibular branch 1. Sensory – controls sensation of the face, mucus membrane; teeth & corneal reflex
Unconscious – instill drop of saline solution 2. Motor – controls muscles of chewing/ muscles of mastication
*Trigeminal neuralgia – difficulty in chewing & swallowing - damage to the trigeminal nerve - Drug of Choice: Tegritol
-Extreme food temperatire is not recommended -Avoid hot or cold preparation
Exercise: Trigeminal neuralgia, RN should give a. Hot milk, butter, raisins b. Cereals
c. Gelatin, toast, potato – all correct but d. Potato, salad, gelatin – salad easier to chew VI Facial:
a. Sensory – controls taste – anterior 2/3 of tongue: Test cotton applicator with sugar. -Put applicator with sugar to tip to tongue.
-Start of taste insensitivity: Age group – 40 yrs old
b. Motor- controls muscles of facial expression, smile frown, raise eyebrow if Damage causes ---Bells palsy or facial paralysis
Cause of Bells palsy in children---No 1 cause : R/T forcep delivery Temporary only, resolve w/in 4-6 months
*Most evident clinical sign of facial symmetry: Nasolabial folds VIII Acoustic/ Vestibulocochlear
b. Vestibule---controls balance (kinesthesia /position sense) ---Movement & orientation of body in space
---located in the inner ear—if it moves—the head moves too--kinesthesia
*Meniere’s Disease----only disease of the inner ear----loss of balance---Nsg. Priority: Safety Parts of Ears:
Outer – tympanic membrane, pinna, oricle (impacted cerumen), cerumen Middle – hammer, anvil, stirrup or melleus, incus, staples. Mid otitis media
• Eustachean ear
Inner ear- meniere ear, sensory hearing loss
Remove vestibule – meniere’s dse – disease inner ear
*Archimedes law --Bouyancy
*Daltons law – Partial pressure of gases (Diffusion) *Inertia – law of motion (dizziness, vertigo) Exercise:
1.) Pt. with multiple stab wound in the chest
- Movement of air in & out of lungs is carried by what principle? - Diffusion – Dalton’s law
2.) Pregnant – check up – ultrasound reveals fetus is carried by amniotic fluid - Archimedes
3.) Severe vertigo d/t Inertia
Test for acoustic nerve: ---Repeat words uttered
IX – Glossopharyngeal – controls taste – the posterior portion 1/3 of the tongue X – Vagus – controls gag reflex
Test 9 – 10
Pt say ah – check uvula (in the middle tonsils) – should be midline
If there is deviation from L to R ----Damage to cerebral hemisphere Gag reflex – place tongue depression post part of tongue
Don’t touch uvula
Gag reflex----vagal stimulation ---PNS Effect XI – Spinal Accessory - controls sternocleidomastoid (neck) & trapezius
• Shrug shoulders, put pressure. Pt should resist pressure. Paresis or phlegia XII – Hypoglossal - movement of tongue – say “ah”
If L or R deviation---damage to the cerebral hemisphere - Push tongue against cheek. Normal= tongue in midline,
EYES
A. External Parts:1.
Orbital cavity – made up of connective tissue, protects eye from trauma.2.
EOM (Extrinsic Ocular Muscles ) – involuntary muscles of eye, needed for gazing movement.3.
Eyelashes/ eyebrows – aesthetic purposes4.
Eyelids – palpebral fissure – opening upper & lower lid. Protects eye from direct sunlight Meibomean gland – secrets a lubricating fluid inside eyelida.) Stye/ sty or Hordeolum- inflamed Meibomean gland 5. Conjunctiva
6. Lacrimal apparatus – tears
B. Intrinsic Coat
I. Sclerotic coat – outer most
a.) Sclera – white. Occupies ¾ posterior of eye. Refracts light rays b.) Canal of sclera – site of aqueous humor drainage
c.) Cornea – transparent structure of eye II. Uveal Tract – provides nutritive care
Uveitis – inflammation of the uveal tract Consist of:
a.) Iris – colored muscular ring of the eye 2 Muscles of Iris:
1. Circular smooth muscle fiber - Constricts the pupil 2.radial smooth muscle fiber - Dilates the pupil 2 Chambers of the Eye:
1. Anterior
a.) Vitereous Humor – maintains spherical shape of the eye b.) Aqueous Humor – maintains intrinsic ocular pressure
(Normal IOP= 12-21 mmHg) II. Retina (innermost layer)
a. Optic discs or blind spot – nerve fibers only No auto receptors
Cones (daylight/ colored vision) Rods – night, twilight vision
Phototopic vision “Scotopic vision” = Vit. A deficiency – rods insufficient b. Maculla lutea – yellow spot center of retina
c. Fovea centralis – area with highest visual acuity oracute vision Physiology of Vision:
4 Physiological Processes for Vision to occur:
1. Refraction of light rays – bending of light rays 2. Accommodation of lens
4. Convergence of eyes *Unit of measurements of refraction – Diopters
*Normal eye refraction – Emmetropia *PERRLA ---Normal Reaction
ERROR of Refraction:
1. Myopia - near sightedness – Tx: biconcave lens 2. Hyperopia - farsightedness – Tx: biconvex lens 3. Astigmatisim -distorted vision – Tx: cylindrical
4. Presbyopia - “old slight” – inelasticity of lens d/t aging – Tx: bifocal lens or double vista *Accommodation of lenses – based on Thelmholtz Theory of accommodation
Near vision: Far vision:
-Ciliary muscle contracts - Ciliary muscle dilates / relaxes
-Lens bulges -Lens is flat
Convergence of the Eye: Error:
1. Exotropia – 1 eye normal
2.
Esophoria – corrected by corrective eye surgery3.
Strabismus- squint eye 4. Amblyopia – prolong squinting1. GLAUCOMA
–An increase Intra Ocular Pressure – if untreated, atrophy of optic nerve disc – blindness - Preventable but not curable
Predisposing Factors:
1. High risk group – 40 y/o & above 2. HPN
3. Hereditary 4. Obesity
5. Recent eye surgery, trauma, inflammation Type:
1. Chronic --- (open angle G.) – *most common type
Obstruct in flow of aqueous humor at trabecular meshwork of canal of schlema 2. Acute --- (close angle G.) – *Most dangerous type
Forward displacement of iris to cornea leading to blindness. 3. Chronic--- (closed – angle) - Precipitated by acute attack
S/Sx:
1. *Loss of Peripheral Vision – a Tunnel-like vision 2. *Halos/Rainbows around lights
3. Headache & Dizziness 4. n/v
5. Steamy cornea 6. Eye discomfort 7. *Ocular Pain
7. If untreated – gradual loss of central vision – blindness Diagnosis:
1. *Tonometry –reveals increase IOP >12- 21 mmHg 2. Perimetry – reveals decrease peripheral visual field 3. *Gonioscopy – reveals abstruction in anterior chamber Nursing mgt:
1. Enforce CBR 2. Maintain siderails 3. Administer meds
Ex. Pilocarpine Na (Carbachol)
b.) Epinephrine eye drops ---decrease formation & production of aqaueous humor
c.) Carbonic anhydrase inhibitors. --- Promotes increase out flow of aquaeous humor(drainage) Ex. Acetazolamide (Diamox)
d.) Timoptics (Timolol maleate)- Increase outflow of aquaous humor (drainage) 2. Surgery:
Invasive:
a.) Trabeculectomy --- eye-trephining
– removal of trabelar meshwork of canal or schlera to drain aqueous humor b.) *Peripheral Iridectomy – portion of iris is excised to drain aqueous humor
Non-invasive:
a. Trabeculotomy (eye laser surgery) Nursing Mgt.: Pre –operative for all types of surgery:
1. Apply eye patch on unaffected eye to force weaker eye to become stronger. Nursing Mgt. Post-operative – all types of surgery
1. Position unaffected/ unoperated side - to prevent tension on suture line. 2. Avoid valsalva maneuver
3.
Monitor symptoms of IOP a.) Headache b.) n/vc.) Eye discomfort d.) Tachycardia
2. Eye patch – for both eyes – post-operatively
2. CATARACT
–A partial/ complete opacity of lens, can lead to blindness Predisposing Factor:
1. Aging : 90-95% (degenerative/ senile cataract)---60 y/o & above 2. Congenital (very rare)
3. Prolonged exposure to UV rays 4. DM
S/Sx:
1.
*Loss of Central Vision - “Hazy or blurring of vision” 2. Painless3. Milky white appearance at center of pupil
4.
*Decrease perception of colors *Elderly can only see Red & Green Dx:1. Opthalmoscopic exam – reveals (+) opacity of lens Nsg Mgt:
1. Reorient pt. to environment – due opacity 2. Siderails
3. Medications a.) *Mydriatics – dilate pupil – not lifetime Ex. Mydriacyl b. ) Cycloplegics – paralyzes ciliary muscle. Ex. Cyclogyl c.) Atrophine
4. Surgery a. E – extra
C - capsular
C – cataract Partial removal of lens L - lens
E – extraction b. I - intra
C - capsular
C – cataract Total removal of lens & surrounding capsules L - lens
E – extraction
Retinal Detachment Endopthalmitis Nursing Mgt:
1.Position unaffected/ unoperated side - to prevent tension on suture line. 2.Avoid valsalva maneuver
3.Monitor symptoms of IOP
a.) Headache b.) n/v
c.) Eye discomfort d.) Tachycardia 4.Eye patch – both eyes - post op
3. RETINAL DETACHMENT
- The separation of 2 layers of retina, can lead to blindness Predisposing factors:
1. *Severe myopia – near sightedness 2. Diabetic Retinopathy
3. Trauma
4. *Following lens extraction 5. HPN
S/Sx:
1. *“Curtain –veil” like vision 2. Flashes of lights
3. *Floaters d/t seepage of blood (Photopsia) 4. Gradual decrease in central vision
Dx: Opthaloscopic exam Drug of Choice: Cycloplegics Nursing Mgt:
1. Siderails (all visual disease) 2. Surgery:
a.) Cryosurgery (cold application) b.) *Scleral buckling
c.) Diathermy ---heat application
4. MACULAR DEGENERATION
PATHOGNOMONIC SIGNS
Addison’s Disease Bronze-Like Skin
Angina Pectoris Levine’s Sign
Appendicitis Rebound Tenderness
Asthma Wheezing On Expiration
Bulimia Nervosa Chipmunk Face
Cataract (loss of central vision) Hazy Vision
Cholecyctitis (+) Murphy’s Sign
Cholera Rice-Watery Stool
Cushing’s Disease Moon Face Appearance
Dengue Petechiae
Diptheria Pseudomembrane
Down Syndrome Protrusion Of Tongue
Down Syndrome Simean Creases on Palms
Emphysema Barrel Chest
Glaucoma (peripheral vision) Tunnel-like Vision Grave’s Disease (Hyperthyroidism) Exopthalmus
Hepatitis Jaundice
Hyperpituitarism ( Acromegaly) Carotenemia ( yellowish skin)
Kawasaki Disease Strawberry Tongue
Leprosy Leioning Face
Liver Cirrhosis Spider Angioma
Malaria Chills
Measles Koplik’s spot
Meningitis (+) Kernig’s & Brudzinski’s Sign
Myasthenia Gravis Ptosis
Pancreatitis( Ectopic Pregnancy) (+) Cullen’s Sign (ecchymosis of umbilicus) (+) Grey-Turner’s (ecchymosis of flank) Parkinson’s Disease Pill-Rolling Tremors
Patent ductus Arteriosus Machine-like Murmur
Pernicious Anemia Beefy Red Tongue
Pneumonia Rusty Sputum
PTB Low-Grade Fever
Pyloric Stenosis Olive Shape Mass
Retinal Detachment Curtain Veil-Like Vision Systemic Lupus Erythematosus Butterfly rash
Tetanus Risus Sardonicus
Tetany (+) Trousseau & (+) Chvostek Sign
Tetralogy Of Fallot Clubbing of Fingers
Thombophlebitis (+) Homan’s Sign
RELATED DISORDERS:
1. COPD = # 1 cause: Smoking --- 4 Types: ---- all needs bronchodilators
BRONCHITIS ASTHMA BRONCHOIECTASIS EMPHYSEMA
Blue bloaters Wheezing on Expiration Hemoptysis Barrel Chest Dyspnea on Exertion Cause by allergens Undergo Pneumonectomy Pink Puffers Lead to cor pulmonale Hereditary Bronchoscopy Dyspnea at Rest
Reversible Lead to Cor Pulmonale
Cause by Allergens Hereditary
CO2 narcosis Purse Lip Breathing Irreversible
To Prevent STD Local – practice monogamous relationship CGFNS/NCLEX – condom
ENDOCRINE SYSTEM
The endocrine system integrates body functions by the synthesis & release of hormones. Hypothalamus: link between the nervous system & the endocrine system.
ENDOCRINE GLANDS:
Secrete their products directly into the bloodstream Different from exocrine glands
Exocrine glands: secrete through ducts unto epithelial surfaces or into the GIT Parts:
Pituitary Gland Adrenal Glands Pancreas Thyroid Glands
GH
hH
Parathyroid GlandsGonads
HORMONES:
- Are chemical substances that are secreted by the endocrine glands.
- Can travel moderate to long distances or very short distances.
- Acts only on cells or tissues that have receptors for the specific hormone. - Target Organ: The cell or tissue that responds to a particular hormone - Regulation of Hormones: Negative Feedback Mechanism
When the hormone concentration rises, further production of that hormone is inhibited. When the hormone concentration falls, the rate of production of that hormone increases.
2 BASIC PATHOPHYSIOLOGICAL DISORDER OF THE ENDOCRINE
A. Hyposecretion/ Hypoactivity B. Hypersecretion / Hyperactivity
D/T D/T
1. Congenital absence of glands 1. Tumor w/n or outside the gland
Ex. No pancreas Ex. Tumor in adrenal gland
2. Surgical removal of glands Ex. Total Thyroidectomy
Primary” Disease Problem in target gland; autonomous “Secondary” disease problem outside the target gland; Most often d/t a problem in pituitary gland
Parts:
I. PINEAL GLAND
Function: Secretes Melatonin
–
Inhibits leutenizing hormone (LH) secretion– Regulates body clock, sleeping pattern or circadian rhythm II. PITUITARY GLAND (Hypophysis Cerebri)
The main gland located at base of the brain at Sella Turcica
Fx: Master gland of body/ Master clock of body---it controls all the metabolic activity of the body 2 Divisions:
Anterior Pituitary Gland – Adenohypophysis Posterior Pituitary Gland – Neurohypophysis
A. ANTERIOR PITUITARY GLAND Function:
1. Responsible for Growth Hormone (GH) (Somatotropic Hormone) Function: For elongation of long bones
*Puberty age: 9 y/o – 21 y/o & the Epiphysial plate closes at 21 y/o DISORDER: Hypopituitarism Hyperpituitarism
*Dwarfism -- Children Acromegaly -- Adult
-Dwarf w/ obesity - If s/s appear before closure of epiphyseal plate - Mentally retarded - rapid growth of long bones
- Loss of reproductive ability d/t genital atrophy
2. Simmond’s Disorder/ Pituitary Cachexia 2. Acromegaly
- Appearance of a “wizened old man” - If s/s appear after closure of epiphyseal plate - Premature senility, Skin dry & wrinkled - Hyperthrophy of soft tissue & bone thickness - Mental retardation - Disproportional growth
- Male: Absence of spermatogenesis
- Female: Amenorrhea Enlargement of cartilage ( nose & ears) Enlargement of larynx (deep voice) Progmatism: Protrusion of jaw
Dx: Square face & jaw
- X-ray, MRI or CT scan: pituitary tumor Macroglossia Obstructive Sleep Apnea - Plasma hormone levels: decreased
Tx:
Drug of Choice in acromegaly:
Octreotide (Sandostatin) --S/E: Seizure & GIT irritation Somatostatin Hormone - antagonizes the release of GH
2. Melanocytes Stimulating Hormone (MSH) Function: For skin pigmentation DISORDER:
*Albinism ---hyposecretion of MSH *Vitiligo ---hypersecretion of MSH ----prone to develop skin cancer & blindness
3. Prolactin/ Lactogenic Hormone
Initiates milk let-down reflex with help of oxytocin Promotes development of mammary gland/breast tissue Disorder: Prolactin Deficiency : Failure to lactate 4. Adrenocorticotropic Hormone – ACTH Development & maturation of adrenal cortex S & Sx in Deficiency:
- Results in diminished cortisol secretion.
- Weakness, fatigue, weight loss, and hypotension. 5. LH ---Progesterone
6. FSH----Estrogen
B. POSTERIOR PITUITARY GLAND: secretes----1.) Oxytocin
a. Promotes uterine contractions---preventing bleeding/ hemorrhage.
- Best time to administer Oxytocin: after placental delivery to prevent uterine atony. b. Initiates the Milk let-down reflex with help of prolactin.
2.) Anti-Diuretic Hormones (ADH) /ADH-replacement ---Vasopressin or Pitressin Function: Prevents urination – conserve H2O
Regulates water metabolism
Released during stress or in response to an increase in plasma osmolality to stimulate reabsorption of water & decreased urine output
DISORDERS OF THE POSTERIOR PITUARY GLAND
1. DIABETIS INSIPIDUS (DI)
– The hyposecretion of ADH
Disorder w/ massive polyuria d/t either lack of ADH or kidney’s insensitivity to it Cause: Idiopathic/ unknown
Predisposing factor: “PITT”