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NERVOUS SYSTEM Overview of structures and functions: Central Nervous System Brain Spinal Cord Peripheral Nervous System

Cranial Nerves Spinal Nerves Autonomic Nervous System Sympathetic nervous system Parasympathetic nervous system Sympathetic Nervous System(ADRENERGIC) -nvolved in fight or aggression response.Release of Norepinephrine (cathecolamines)from adrenal glands and causes vasoconstriction. - Increase all bodily activity except GIT EFFECTS OF SNS - Dilation of pupils(mydriasis) in order to be aware.- Dry mouth (thickened saliva).Increase BP and Heart Rate.- Bronchodilation, Increase RR- Constipation.- Urinary Retention.- Increase blood supply to brain,heart and skeletalmuscles - SNS .1 Adrenergic Agents - Give Epinephrine.Signs and Symptoms: - SNS Contraindication: - Contraindicated to patients suffering from COPD(Broncholitis, Bronchoectasis, Emphysema, Asthma). II. Beta-adrenergic Blocking Agents - Also called Beta-blockers .- All ending with lol-Propranolol ,Atenelol ,Metoprolol. Effects of Beta-blockers B roncho spasm E licits a decrease in myocardial contraction. T reats hypertension. A -V conduction slows down. -Should be given to patients with Angina Pectoris Parasympathetic Nervous System(CHOLINERGIC, VAGAL, SYMPATHOLYTIC) Involved in fight or withdrawal response.- Release of Acetylcholine.- Decreases all bodily activities except GIT. EFFECTS OF PNS - Constriction of pupils (meiosis). - Increase salivation.- Decrease BP and Heart Rate.Bronchoconstriction, Decrease RR.- Diarrhea- Urinary frequency. I. Cholinergic Agents -Mestinon , Neostigmine. Side Effects - PNS II. Anti-cholinergic AgentsTo counter cholinergic agents.- Atropine Sulfate Side Effects - SNS

, Myocardial Infarction , Hypertension . ANTI- HYPERTENSIVE AGENTS 1. Beta-blockers lol 2. Ace Inhibitors Angiotensin, pril (Captopril,Enalapril)3. Calcium Antagonist Nifedipine (Calcibloc) -In chronic cases of arrhythmia give Lidocaine (Xylocaine) CENTRAL NERVOUS SYSTEM -Brain and Spinal Cord. I. CELLSA. NEURONS - Basic cells for nerve impulse and conduction. PROPERTIESExcitability ability of neuron to be affected by changes in external environment. Conductivity ability of neuron to transmit a wave of excitation from one cell to another. Permanent Cell once destroyed not capable of regeneration. TYPES OF CELLS BASED ON REGENERATIVE CAPACITY 1. Labile -Capable of regeneration. -Epidermal cells, GIT cells, GUT cells, cells of lungs. 2. Stable -Capable of regeneration with limited time, survival period. -Kidney cells, Liver cells, Salivary cells, pancreas. 3. Permanent -Not capable of regeneration. -Myocardial cells, Neurons, Bone cells, Osteocytes, Retinal Cells. B. NEUROGLIA -Support and protection of neurons. TYPES 1. Astrocytes -maintains blood brain barrier semi-permeable. -Majority of brain tumors (90%) arises from calledastrocytoma. 2. Oligodendria 3. Microglia 4. EpindymalSUBSTANCES THAT CAN PASS THE BLOOD-BRAIN BARRIER 1. Ammonia -Cerebral toxin -Hepatic Encephalopathy (Liver Cirrhosis) -Ascites -Esophageal Varices Early Signs of Hepatic Encephalopathy -asterixis (flapping hand tremors).

Late Signs of Hepatic Encephalopathy -Headache -Dizziness -Confusion -Fetor hepaticus (ammonia like breath) -Decrease LOC PATHOGNOMONIC SIGNS 1. PTB low-grade afternoon fever. 2. PNEUMONIA rusty sputum. 3. ASTHMA wheezing on expiration. 4. EMPHYSEMA barrel chest. 5. KAWASAKI SYNDROME strawberry tongue. 6. PERNICIOUS ANEMIA red beefy tongue. 7. DOWN SYNDROME protruding tongue. 8. CHOLERA rice watery stool. 9. MALARIA stepladder like fever with chills. 10. TYPHOID rose spots in abdomen. 11. DIPTHERIA pseudo membrane formation 12. MEASLES kopliks spots. 13. SLE butterfly rashes. 14. LIVER CIRRHOSIS spider like varices. 15. LEPROSY lioning face. 16. BULIMIA chipmunk face. 17. APPENDICITIS rebound tenderness. 18. DENGUE petechiae or (+) Hermans sign. 19. MENINGITIS Kernigs sign (leg pain), Brudzinski sign (neck pain). 20. TETANY HYPOCALCEMIA (+) Trousseaus sign/carpopedal spasm; Chvostek sign(facial spasm). 21. TETANUS risus sardonicus. 22. PANCREATITIS Cullens sign (ecchymosis of umbilicus); (+) Grey turners spots. 23. PYLORIC STENOSIS olive like mass. 24. PDA machine like murmur. 25. ADDISONS DISEASE bronze like skin pigmentation. 26. CUSHINGS SYNDROME moon face appearance and buffalo hump. 27. HYPERTHYROIDISM/GRAVES DISEASE exopthalmus. 28. INTUSSUSCEPTION sausage shaped mass 2. Carbon Monoxide and Lead Poisoning -Can lead to -Parkinsons Disease. -Epilepsy Treat with ANTIDOTE :Calcium EDTA. 3. Type 1 DM (IDDM) -Causes diabetic ketoacidosis. -And increases breakdown of fats. -And free fatty acids -Resulting to cholesterol and (+) to Ketones (CNS depressant). -Resulting to acetone breath odor/fruity odor. -KUSSMAULS respiration, -a rapid shallow respiration. Which may lead to diabetic coma. 4. Hepatitis -Signs of jaundice (icteric sclerae). -Caused by bilirubin (yellow pigment) 5. Bilirubin -Increase bilirubin in brain (Kernicterus). -Causing irreversible brain damage. Astrocites -Maintains integrity of blood brain barrier. Oligodendria Produces myelin sheath in CNS - Act as insulator and facilitates rapid nerve impulse transmission.

1. ALZHEIMERS DISEASE -Atrophy of brain tissues. Sign and Symptoms 4 As of Alzheimer a.Amnesia loss of memory. b.Agnosia no recognition of inanimate objects. c.Apraxia no recognition of objects function. d.Aphasia no speech (nodding). *Expressive aphasia - motor speech center -Brocas Aphasia *Receptive aphasia -inability to understand spoken words. -Wernickes Aphasia -General Knowing Gnostic Area or General Interpretative Area. DRUG OF CHOICE: ARICEPT ( taken at bedtime) and COGNEX. 2. MULTIPLE SCLEROSIS -Chronic intermittent disorder of CNS characterized by white patches of demyelination in brain andspinal cord. -Characterized by remission and exacerbation. -Women ages 15-35 are prone -Unknown Cause -Slow growing virus -Autoimmune disorders -Pernicious anemia -Myasthenia gravis -Lupus -Hypothyroidism -GBS Ig G only antibody that pass placental circulation causing passive immunity.- short term protection.- Immediate action. Ig A present in all bodily secretions (tears, saliva, colostrums). Ig M acute in inflammation. Ig E for allergic reaction. Ig D for chronic inflammation. * Give palliative or supportive care. Signs and Symptoms1. Visual disturbances -blurring of vision (primary) -diplopia (double vision) scotomas(blind spots) 2. Impaired sensation -to touch, pain, pressure, heat and cold. -tingling sensation -paresthesia -numbness 3. Mood swings -euphoria (sense of well being) 4. Impaired motor function -weakness -spasticity -paralysis 5. Impaired cerebral function -scanning speech

TRIAD SIGNS OF MS Ataxia (Unsteady gait, (+) Rombergs test ) Intentional tremors Nystagmus 6. Urinary retention/incontinence 7. Constipation 8. Decrease sexual capacity DIAGNOSTIC PROCEDURE -CSF analysis (increase in IgG and Protein). -MRI (reveals site and extent of demyelination). -(+) Lhermittes sign a continuous and increase contraction of spinal column. NURSING MANAGEMENT1. Administer medications as ordered a.ACTH (Adreno Corticotropic Hormone)/ Steroids -for acute exacerbation to reduce edema at siteof demyelination to prevent paralysis. b.Baclofen (Dioresal)/ Dantrolene Sodium (Dantrene) muscle relaxants. c.Interferons alter immune response.d. Immunosupresants 2.Maintain side rails to prevent injury related to falls. 3.Institute stress management techniques. a.Deep breathing exercises b. Yoga 4.Increase fluid intake and increase fiber to prevent constipation. 5.Catheterization to prevent retention. a.Diuretics b.Bethanicol Chloride (Urecholine)Nursing Management -Only given subcutaneous. -Monitor side effects bronchospasm and wheezing. -Monitor breath sounds 1 hour after subcutaneous administration. c.For Urinary IncontinenceAnti spasmodic agent a.Prophantheline Bromide (Promanthene) -Acid ash diet like cranberry juice, plums, prunes, pineapple, vitamin C and orange. -To acidify urine and prevent bacterial multiplication. COMMON CAUSE OF UTIFemale -5 cm, 1-1 inches)

Nursing Management

Male

MICROGLIA stationary cells that carry on phagocytosis (engulfing of bacteria or cellular debris, eating),pinocytosis (cell drinking). M A C R O P H A G E Microglia Monocytes Kupffers cells Histiocytes O R G A N Brain Blood Kidney Skin

Alveolar Macrophage EPINDYMAL CELLS

Lung

chemo attractants that concentrate the bacteria. COMPOSITION OF BRAIN

I. Brain MassPARTS OF THE BRAIN1. CEREBRUM Functions of Cerebrum

Lobes of Cerebrum1. Frontal

when damaged results to garbled speech. 2. Temporal 3. Parietal pressure, heat, cold, numbness. 4. Occipita balance, equilibrium, posture and gait. INTRA CRANIAL PRESSURE Monroe Kellie Hypothesis Skull is a closed container Any alteration or increase in one of the intracranial components Increase intra-cranial pressure(normal ICP is 0 15 mmHg) Cervical 1 also known as ATLAS. Cervical 2 also known as AXIS. Foramen Magnum Medulla Oblongata Brain Herniation Increase intra cranial pressure * Alternate hot and cold compress to prevent HEMATOMA enlargement of skull posteriorly called hydrocephalus. skull in hydrocephalus. NEUROLOGIC DISORDERS INCREASE INTRACRANIAL PRESSURE increase in intra-cranial bulk brought about by an increase in oneof the 3 major intra cranial components. Causes:

Signs and Symptoms (Early)

Signs and Symptoms (Late) systolic blood pressure increases but diastolic remains the same). neurologic in nature (if narrow cardiac in nature).

papilledema (edema of optic disc) decorticate posturing (damage to cortex and spinal cord). decerebrate posturing (damage to upper brain stem that includes pons, cerebellum and midbrain). unilateral dilation of pupils calleduncal herniation bilateral dilation of pupils called tentorial herniation Nursing Management 1. Maintain patent and adequate ventilation by: a. Prevention of hypoxia and hypercarbia Early signs of hypoxia

Late signs of hypoxia Bradycardia Extreme restlessness Dyspnea Cyanosis HYPERCARBIA decrease O2 stimulates respiration. b. Before and after suctioning hyper oxygenate client 100% and done 10 15 seconds only. c. Assist in mechanical ventilation 2. Elevate bed of client 30 35o angle with neck in neutral position unless contraindicated to promote venous drainage. 3. Limit fluid intake to 1200 1500 ml/day (in force fluids 2000 3000 ml/day).4. Monitor strictly input and output and neuro check 5. Prevent complications of 6. Prevent further increase ICP by: a. provide an comfortable and quite environment. b. avoid use of restraints. c. maintain side rails. d. instruct client to avoid forms of valsalva maneuver like: tussive like dextromethorphan) ng activity together. 7. Administer medications like: a.Osmotic diuretic (Mannitol) Nursing Management monitor vital signs especially BP (hypotension). 1 hour notify physician if output is less 30 cc/hr.

crystal formation. b.Loop diuretic (Lasix, Furosemide) Drug of choice for CHF (pulmonary edema) Nursing Management BP (hypotension). 1 hour notify physician if output is less 30 cc/hr. immediate effect of 10 15 minutes. c.Corticosteroids ne (Decadron)

*CONGESTIVE HEART FAILURE Signs and Symptoms orthopnea

pulsus alternans displaced laterally (ventricular gallop) Valve

TREATMENT Morphine Sulfate Aminophelline Digoxin Diuretics Oxygen Gases, blood monitor RIGHT CONGESTIVE HEART FAILURE (Venous congestion)Signs and Symptoms jugular vein distention (neck)

jaundice

Signs and Symptoms of Lasix in terms of electrolyte imbalances 1. Hypokalemia potassium level normal valueis3.4 5.5 meq/LSign and Symptoms ECG tracing Nursing Management Kalium Durule, Oral Potassium Chloride) F R U I T S VEGETABLES

Apple Banana Cantalope Oranges 2. Hypocalcemia/ Tetany calcium level normal valueis 8.5 11 mg/100 mlSigns and Symptoms

Asparagus Brocolli Carrots Spinach

(+) Trousseaus sign/ Carpopedal spasm (+) Chvosteks signComplications Nursing Management * Calcium Gluconate toxicity results to SEIZURE Magnesium Sulfate Magnesium Sulfate toxicity S/S BP Urine output DECREASE Respiratory rate Patellar relfex absent 3. Hyponatremia sodium level normal value is135 145 meq/LSigns and Symptoms THIRST, in infant TACHYCARDIA) membrane Nursing Management isotonic fluid solutionas ordered 4. Hyperglycemia normal FBS is 80 100 mg/dlSigns and Symptoms

Nursing Management FBS 5. Hyperuricemia *Increase in tophi deposit leads to Gouty arthritis.Signs and Symptoms joint pain (great toes) Nursing Management a. Allopurinol (Zyloprim) Drug of choice for gout. Mechanism of action : inhibits synthesis of uric acid. b. Colchecine Mechanism of action: promotes excretion of uric acid. * KIDNEY STONES Signs and Symptoms renal colic

Nursing Management

ANTIDOTE: Naloxone (Narcan)toxicity leads to tremors.b. Allopurinol (Zyloprim) Side Effects PARKINSONS DISEASE/ PARKINSONISM dopamine producingcells in the SUBSTANCIA NIGRA of the midbrain and basal ganglia. Predisposing Factors 1. Poisoning (lead and carbon monoxide) 2. Arteriosclerosis 3. Hypoxia 4. Encephalitis 5. Increase dosage of the following drugs: a. Reserpine(Serpasil) b. Methyldopa(Aldomet) AntihypertensiveS c. Haloperidol(Haldol) d. Phenothiazine AntipsychoticS SIDE EFFECTS RESERPINE to suicide - Alones - Loss of spouse - Loss of job

priority Signs and Symptoms for Parkinsons

mask like facial expression with decrease blinking of the eyes. Monotone type speech depression) drooling type) capacity Nursing Management 1. Administer medications as ordered Anti Parkinsonian agents -dopa) short acting

Mechanism of Action Side Effects be taken with meals

Contraindications thiamine)

Vitamin B6 (Pyridoxine) reverses the therapeutic effects of Levodopa * Increase Vitamin B when taking INH (Isoniazid), Isonicotinic Acid HydrazideAnti Cholinergic Agents (ARTANE and COGENTIN) -to relieve tremorsMechanism of Action Side Effects Anti Histamine (Dipenhydramine Hydrochloride) Side Effects Adult: drowsinessChildren: CNS excitement (hyperactivity) because blood brain barrier is not yet fully developed. Dopamine Agonist - relieves tremor rigidityBromocriptene Hydrochloride (Parlodel)Side Effects 2. Maintain side rails to prevent injury 3. Prevent complications of immobility 4. Decrease protein in morning and increase protein in afternoon to induce sleep 5. Encourage increase fluid intake and fiber. 6. Assist/supervise in ambulation 7. Assist in Stereotaxic Thalamotomy DRUG Normal range Toxicity Level Indication Digoxin/ Lanoxin .5 -1.5 meq 2 CHF (Increase force of cardiac output) Lithium/ Lithane (Decrease level of Ach/NE/Serotonin) Aminophylline (Dilates bronchial tree) Dilantin/ Phenytoin Acetaminophen/tylenol .5 -1.5 meq 10- 19mg /100 ml 10- 19mg /100 ml 10- 30mg /100 ml 2 20 20 200 Bipolar COPD Seizures Osteoarthritis

Classification Cardiac glycoside

Anti Manic agent Bronchodilator Anti convulsant Non Narcotic/ Analgesic

1. Digitalis ToxicitySigns and Symptoms -nausea and vomiting

Antidote: Digibind 2. Lithium Toxicity Signs and Symptoms

Nursing Management 10 g% daily 3. Aminophylline ToxicitySigns and Symptoms

Nursing Management 0.9 NaCl to prevent development of crystals or precipitate. n lead to severe CNS depression 4. Dilantin ToxicitySigns and Symptoms

nystagmusNursing Management 5. Acetaminophen ToxicitySigns and Symptoms atotoxicity (monitor for liver enzymes) SGPT/ALT (Serum Glutamic Pyruvate Transaminace) SGOT/AST (Serum Glutamic Oxalo-Acetil Transaminace) 20) and Creatinine (.8 1) Tremors, tachycardia Irritability Restlessness Extreme fatigue Diaphoresis, depression Antidote: Acetylcisteine (mucomyst) prepare suction apparatus as bedside MYASTHENIA GRAVIS to muscle cells at the neuromuscular junction leading to descending muscle weakness. Incidence rate: women 20 40 years old Predisposing factors enzyme that destroys Ach. Signs and Symptoms initial sign is Ptosis a clinical parameter to determine ptosis is palpebral fissure.

to respiratory arrest especially during exertion and morning Diagnostic Procedure Tensilon test (Edrophonium Hydrochloride) provides temporary relief of signs and symptomsfor about 5 10 minutes and a maximum of 15 minutes. obe and midbrain and is negative for M.G. Nursing Management 1. airway 2. aspiration maintain patent airway and adequate ventilation 3. mmobility* assist in mechanical ventilation and monitor pulmonary function test* monitor strictly vital signs, input and output and neuro check* monitor strength or motor grading scale 4. maintain side rails to prevent injury related to falls 5. institute NGT feeding 6. administer medications as ordered a. Cholinergic (Mestinon) b. Anti Cholenisterase (Neostegmin) Mechanism of Action Side Effects Cortocosteroids suppress immune response Myasthenic crisis Causes: - under medication- stress- infection Signs and Symptoms - The client is unable to see, swallow, speak,breathe Treatment Cholinergic crisis Cause: - over medication Signs and Symptoms - PNS Treatment

- administer cholinergic agents as ordered

- Administer anti cholinergic agents(Atropine Sulfate)

7. Assist in surgical procedure known as thymectomy because it is believed that the t h y m u s g l a n d i s responsible for M.G. 8. Assist in plasma paresis and removing auto immune anti bodies9. Prevent complications INFLAMMATORY CONDITIONS OF THE BRAIN MENINGITIS Meninges

LAYERS OF THE MENINGES 1.Dura matter outer layer 2. Arachnoid middle layer 3. Pia matter inner layer A. Etiology 1. Meningococcus most dangerous 2. Pneumococcus 3. Streptococcus - causes adult meningitis 4. Hemophilus Influenzae causes pediatric meningitis B. Mode of transmission C. Signs and Symptoms

irritation a. Nuchal rigidity or stiff neck b. Opisthotonus (arching of back) c. (+) Kernigs sign (leg pain) d. (+) Brudzinski sign (neck pain) D. Diagnostic Procedures L4 to L5. Nursing Management for LPBefore Lumbar Puncture 1. Secure informed consent and explain procedure 2. Empty bladder and bowel to promote comfort 3. Encourage to arch back to clearly visualize L3-L4. Post Lumbar Puncture 1. Place flat on bed 12 24 o 2. Force fluids3. Check punctured site for any discoloration, drainage and leakage to tissues.4. Assess for movement and sensation of extremities. CSF analysis reveals 1. Increase CHON and WBC 2. Decrease glucose 3. Increase CSF opening pressure (normal pressure is 50 100 mmHg) 4. (+) cultured microorganism (confirms meningitis) CBC reveals 1. Increase wbc E. Nursing Management 1. Enforce complete bed rest 2. Administer medications as ordered a. Broad spectrum antibiotics (Penicillin, Tetracycline)

b. Mild analgesicsc. Anti pyretics3. Institute strict respiratory isolation 24 hours after initiation of anti biotic therapy 4. Elevate head 30-45o 5. Monitor strictly V/S, input and output and neuro check 6. Institute measures to prevent increase ICP and seizure. 7. Provide a comfortable and darkened environment. 8. Maintain fluid and electrolyte balance. 9. Provide client health care and discharge planning concerning: a. Maintain good diet of increase CHO, CHON, calories with small frequent feedings. b. Prevent complications feared is hydrocephalus hearing loss/nerve deafness is second complication audiologist c. Rehabilitation for neurological deficit CVA (STROKE/BRAIN ATTACK/ ADOPLEXY/ CEREBRAL THROMBOSIS) the brains blood supply. artery affected by strokea. Mid Cerebral Arteryb. Internal Cerebral Artery the 2 largest artery A. Incidence Rate -3 times high risk B. Predisposing Factors e m b o l u s ( d e t a c h e d a n d m o s t d a n g e r o u s b e c a u s e i t c a n g o t o t h e lungs a n d c a u s e pulmonary embolism or the brain and cause cerebral embolism. Signs and Symptoms of Pulmonary Embolism Tachycardia

Signs and Symptoms of Cerebral Embolism

feared complications after femur fracture. produced from the medullary cavity of the long bones and produces fat cells. ture there is hemorrhage and there would be escape of the fat cells in the circulation.

C. Risk Factors 1. Hypertension, Diabetes Mellitus, Myocardial Infarction, Atherosclerosis, Valvular Heart Disease, PostCardiac Surgery (mitral valve replacement) 2. Lifestyle (smoking), sedentary lifestyle 3. Obesity (increase 20% ideal body weight) 4. Hyperlipidemia more on genetics/genes that binds to cholesterol 5. Type A personalitya. deadline drivenb. can do multiple tasksc. usually fells guilty when not doing anything 6. Related to diet: increase intake of saturated fats like whole milk 7. Related stress physical and emotional 8. Prolong use of oral contraceptives promotes lypolysis (breakdown of lipids) leading to atherosclerosis thatwill lead to hypertension and eventually CVA. D. Signs and Symptoms 1. TIA Signs and Symptoms

2. Stroke in evolution 3. Complete stroke Signs and Symptoms Cheyne Stokes Respiration which may lead to hemorrhagic stroke reading)e. agraphia (difficulty writing)f. homonymous hemianopsia (loss of half of visual field) E. Diagnostic Procedure 1.CT Scan reveals brain lesions2. Cerebral Arteriography of dye are iodine based (femoral) F. Nursing Management 1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. administrate O2 inhalation 2. Restrict fluids to prevent cerebral edema that might increase ICP 3. Elevate head 30 45 o 4. Monitor strictly vitals signs, I & O and neuro check 5. Prevent complications of immobility by:a. turn client to sideb. provide egg crate mattresses or water bedc. provide sand bag or food board. 6. Assist in passive ROM exercise every 4 hours to promote proper bodily alignment and prevent contractures 7. Institute NGT feeding 8. Provide alternative means of communicationa. non verbal cuesb. magic slate 9. If positive to hemianopsia approach client on unaffected side 10. Administer medications as ordered a. Osmotic Diuretics (Mannitol) b. Loop Diuretics (Lasix, Furosemide) c. Cortecosteroids d. Mild Analgesicse. Thrombolytic/Fibrinolytic Agents dissolves thrombus Streptokinase Urokinase Tissue Plasminogen Activating Factor Side Effect: Chest Painf. Anti Coagulants Heparin (short acting) Comadin/ Warfarin (long acting) days a risk for bleeding PASA (Aspirin) Contraindicated for dengue, ulcer and unknown cause of headache because it maypotentiate bleeding11. Provide client health teachings and discharge planning concerninga. avoidance of modifiable risk factors (diet, exercise, smoking)b. prevent complication (subarachnoid hemorrhage is the most feared complication)c. dietary modification (decrease salt, saturated fats and caffeine)d. importance of follow up care GUILLAIN BARRE SYNDROME A. Predisposing Factors 1. Autoimmune 2. Antecedent viral infections such as LRT infections B. Signs and Symptoms 1.Clumsiness (initial sign) 2. Dysphagia 3. Ascending muscle weakness leading to paralysis

4. Decreased of diminished deep tendon reflex 5. Alternate hypotension to hypertension ** ARRYTHMIA (most feared complication) 6. Autonomic symptoms that includes a. increase salivation b. increase sweating c. constipation C. Diagnostic Procedures 1. CSF analysis reveals increase in IgG and protein D. Nursing Management 1. Maintain patent airway and adequate ventilation by:a. assist in mechanical ventilationb. monitor pulmonary function test 2. Monitor strictly the followinga. vital signsb. intake and outputc. neuro checkd. ECG 3. Maintain side rails to prevent injury related to fall 4. Prevent complications of immobility by turning the client every 2 hours 5. Institute NGT feeding to prevent aspiration 6. Assist in passive ROM exercise 7. Administer medications as ordereda. Corticosteroids suppress immune responseb. Anti Cholinergic Agents Atrophine Sulfatec. Anti Arrythmic Agents blocks release of norepinephrine to prevent increase of BP 8. Assist in plasma pharesis (filtering of blood to remove autoimmune anti-bodies) 9. Prevent complicationsa. Arrythmiab. Paralysis or respiratory muscles/Respiratory arrest * Sengstaken Blakemore Tube air in the balloon prevent air embolism CONVULSIVE DISORDER/ CONVULSION activity alternation in sensation and perception and changes in behavior. Seizure first convulsive attack Epilepsy second or series of attacks Febrile seizure normal in children age below 5 years A. Predisposing Factors 1. Head injury due to birth trauma 2. Genetics 3. Presence of brain tumor 4. Toxicity froma. leadb carbon monoxide 5. Nutritional and Metabolic deficiencies 6. Physical and emotional stress 7. Sudden withdrawal to anti convulsant drug is predisposing factor for status epilepticus (drug of choice isDiazepam, Valium) B. Signs and Symptoms I. Generalized Seizure 1.Grand mal Seizure (tonic-clonic seizure) a. Signs or aura with auditory, olfactory, visual, tactile, sensory experience b. Epileptic cry is characterized by fall and loss of consciousness for 3 5 minutes c. Tonic contractions - direct symmetrical extension of extremities Clonic contractions - contraction of extremitiesd. Post ictal sleep unresponsive sleep 2.Petit mal Seizure absence of seizure common among pediatric clients characterized bya. blank stareb. decrease blinking of eyesc. twitching of mouthd. loss of consciousness (5 10 seconds) II. Partial or Localized Seizure 1.Jacksonian Seizure(focal seizure) Characterized by tingling and jerky movement of index finger and thumb that spreads to the shoulder and other side of the body 2.Psychomotor Seizure(focal motor seizure)a. automatism stereotype repetitive and non propulsive behavior b. clouding of consciousness not in contact with environmentc. mild hallucinatory sensory experience III. Status Epilepticus pted seizure activity, if left untreated can lead to hyperpyrexia and leadto coma and eventually death. Drug of choice : Diazepam, Valium and Glucose

C. Diagnostic Procedures 1. CT Scan reveals brain lesions2 . EEG reveals hyper activity of electrical brain waves D. Nursing Management 1. Maintain patent airway and promote safety before seizure activitya. clear the site of blunt or sharp objectsb. loosen clothing of clientc. maintain side railsd. avoid use of restrainse. turn clients head to side to prevent aspirationf. place mouth piece of tongue guard to prevent biting or tongue 2. Avoid precipitating stimulus such as bright/glaring lights and noise 3. Administer medications as ordereda. Anti convulsants (Dilantin, Phenytoin)b. Diazepam, Valiumc. Carbamazepine (Tegretol) Trigeminal neuralgiad. Phenobarbital, Luminal 4. Institute seizure and safety precaution post seizure attacka. administer O2 inhalationb. provide suction apparatus 5. Document and monitor the followinga. onset and durationb. types of seizuresc. duration of post ictal sleep may lead to status epilepticusd. assist in surgical procedure cortical resection COMPREHENSIVE NEURO EXAMGLASGOW COMA SCALE Components 1. Motor response2. Verbal response3. Eye opening Conscious 15 14 Lethargy 13 11 Stupor 10 8 Coma 7 Deep Coma 3 COMPREHENSIVE NEURO EXAMGLASGOW COMA SCALE Components 1. Motor response2. Verbal response3. Eye opening b. Test of memory

a, Rombergs test 2 nurses, positive for ataxia b. Finger to nose test positive result mean dimetria(inability of body to stop movement at desired point) c. Alternate supination and pronation positive result mean dimetria I. LEVEL OF CONSCIOUSNESS 1. Conscious - awake2. Lethargy lethargic (drowsy, sleepy, obtunded)3. Stupor 4. Coma to all forms of painful stimulus) DIFFERENT PAINFUL STIMULATION 1. Deep sternal stimulation/ deep sternal pressure2. Orbital pressure3. Pressure on great toes4. Corneal or blinking reflex rop of saline solution II. TEST OF MEMORY 1. Short term memory

de amnesia and damage to limbic system III. LEVELS OF ORIENTATION 1. Time first asked2. Person second asked3. Place third asked CRANIAL NERVES Cranial nerves

Function

1.olfactory 2.optic 3. occulomotor 4.tronchlear 5.trigeminal 6.abducense 7.facial 8.acoustic 9.glossopharyngeal 10.vagus 11.spinal accessory 12.hypoglossal CRANIAL NERVE I: OLFACTORY Material Used

S S M M SMALLEST B LARGEST M B S B B LONGEST M M

ammonia, perfume because it is irritating and highly diffusible Procedure Abnormal Findings 1. Hyposnia decrease sensitivity to smell 2. Dysosmia distorted sense of smell 3. Anosmia absence of smell Indicative of 1. head injury damaging the cribriform plate of ethmoid bone where olfactory cells are located 2. may indicate inflammatory conditions (sinusitis) CRANIAL NERVE II: OPTIC ction for vision or sight Functions 1. Test visual acuity or central vision or distance Snellens Chart clients illiterate clients for pediatric clients visual acuity 20/20 7 m, 20 feet) client is able to read letters above the red line. 2. Test of visual field or peripheral vision a. Superiorly b. Bitemporaly c. Nasally d. Inferiorly COMMON VISUAL DISORDERS1. Glaucoma 12 21 mmHg A. Predisposing Factors

B. Signs and Symptoms 1. Loss of peripheral vision tunnel vision 2. Headache, nausea, vomiting, eye pain ( halos around light) cornea C. Diagnostic Procedures 1. Tonometry2. Perimetry3. Gonioscopy D. Treatment 1.Miotics constricts pupila. Pilocarpine Sodium ,Carbachol 2.Epinephrine eyedrops

decrease formation of aqueous humor 3.Carbonic Anhydrase Inhibitors a.Acetazolamide (Diamox) promotes increase outflow of aqueous humor or drainage 4.Timoptics ( Timolol Maleate ) E. Surgical Procedures 1.TRABECULECTOMY (Peripheral Indectomy) drain aqueous humor 2. Cataract A. Predisposing Factor 1. Aging 65 years and above 2. Related to congenital 3. Diabetes Mellitus 4. Prolonged exposure to UV rays B. Signs and Symptoms 1. Loss of central vision C. Pathognomonic Signs 1. Blurring or hazy vision2. Milky white appearance at center of pupils3. Decrease perception to colors D. Diagnostic Procedure 1. Opthalmoscopic exam E. Treatment 1.Mydriatics (Mydriacyl) constricts pupils2. Cyclopegics (Cyclogyl) paralyses cilliary muscle F. Surgical ProcedurE Extra Intra Capsular Capsular Cataract Cataract Lens Lens Extraction Extraction- P a r t i a l r e m o v a l T o t a l r e m o v a l o f c a t a r a c t w i t h i t s s u r r o u n d i n g c a p s u l e s Most feared complication post op is RETINAL DETACHMENT3. Retinal Detachment epithelial surface of retina A. Predisposing Factors . Post Lens Extraction2. Myopia (near sightedness) B. Signs and Symptoms 1. Curtain veil like vision2. Floaters C. Surgical Procedures 1.Scleral Buckling 2.Cryosurgery cold application 3.Diathermy heat application 4. Macular Degeneration macula lutea (yellowish spot at the center of retina) A. Signs and Symptoms 1. Black Spots CRANIAL NERVE III, IV, VI: OCULOMOTOR, TROCHLEAR, ABDUCENS of extrinsic ocular muscle (EOM) 6musclesS u p e r i o r R e c t u s S u p e r i o r O b l i q u e L a t e r a l R e c t u s M e d i a l R e c t u s I n f e r i o r O b l i q u e I n f e r i o r R e c t u s

Oculomotor

3 mm pupil: Anisocoria CRANIAL NERVE V: TRIGEMINAL ophthalmic, maxillary, mandibular membrane, teeth, soft palate and corneal reflex mastication or chewing leads to trigeminal neuralgia/thickdolorum medication: Carbamezapine(Tegretol) CRANIAL NERVE VII: FACIAL tongue cial paralysis or Bells Palsyand the primary cause is forcep delivery. CRANIAL NERVE VIII: ACOUSTIC/VESTIBULOCOCHLEAR Controls balance particularly kinesthesiao r p o s i t i o n s e n s e , r e f e r s t o m o v e m e n t a n d orient ation of the body in space. Parts of the Ear 1.Outer Ear 2.Middle Ear Hammer Malleus Anvil Incus Stirrup Stapes 3.Inner Ear Vestibule: Meineres Disease

COCHLEA : controls hearing, contains the Organ of Corti (the true organ of hearing) CRANIAL NERVE IX, X: GLOSOPHARYNGEAL, VAGUS NERVE gag reflex o cerebral hemisphere CRANIAL NERVE XI: SPINAL ACCESSORY CRANIAL NERVE XII: HYPOGLOSSAL hemisphere and/or has short frenulum. ENDOCRINE SYSTEM Overview of the structures and functions1. Pituitary Gland (Hypophysis Cerebri) oLocated at base of brain particularly at sella turcica oMaster gland or master clock oControls all metabolic function of body PARTS OF THE PITUITARY GLAND 1.Anterior Pituitary Gland ocalled as adenohypophysis2. Posterior Pituitary Gland ocalled as neurohypophysis osecretes hormones oxytocin -promotes uterine contractions preventing bleeding/ hemorrhage oadministrate oxytocin immediately after delivery to prevent uterine atony. o initiates milk let down reflex with help of hormone prolactin

2. Antidiuretic Hormone oPitressin (Vasopressin) oFunction: prevents urination thereby conserving water oDiabetes Insipidus/ Syndrome of Inappropriate Anti Diuretic Hormone DIABETES INSIPIDUS oDecrease production of anti diuretic hormone A. Predisposing Factor oRelated to pituitary surgery oTrauma oInflammation oPresence of tumor B. Signs and Symptoms 1. Polyuria 2. Signs of dehydration a. Adult: thirst b. Agitation c. Poor Skin turgor d. Dry mucous membrane 3. Weakness and fatigue 4. Hypotension 5. Weight loss 6. If left untreated results to hypovolemic shock (sign is anuria) C. Diagnostic Procedures 1. Urine Specific Gravity oNormal value: 1.015 1.030 oPh 4 82. Serum Sodium oIncrease resulting to hypernatremia D. Nursing Management 1. Force fluids 2. Monitor strictly vital signs and intake and output 3. Administer medications as ordereda. Pitressin (Vasopresin Tannate) administered IM Z-tract4. Prevent complilcations HYPOVOLEMIC SHOCK is the most feared complication SIADH O hypersecretion of anti diuretic hormone A. Predisposing Factors 1. Head injury2. Related to presence of bronchogenic cancer o initial sign of lung cancer is non productive cough o non invasive procedure is chest x-ray3. Related to hyperplasia (increase size of organ br ought about by increase of number of cells) of pituitary gland. B. Signs and Symptoms 1. Fluid retentiona. Hypertensionb. Edemac. Weight gain2. Water intoxication may lead to cerebral edema and lead to increase ICP may lead to seizure activity C. Diagnostic Procedure 1. Urine specific gravity is increased 2. Serum Sodium is decreased D. Nursing Management 1. Restrict fluid2. Administer medications as ordereda. Loop diuretics (Lasix)b. Osmotic diuretics (Mannitol)3. Monitor strictly vital signs, intake and output and neuro check4. Weigh patient daily and assess for pitting edema5. Provide meticulous skin care6. Prevent complications ANTERIOR PITUITARY GLAND o also called ADENOHYPOPHYSIS secretes 1. Growth hormones (somatotropic hormone) o Promotes elongation of long bones o Hyposecretion of GH among children results to Dwarfism

o Hypersecretion of GH results to Gigantism o Hypersecretion of GH among adults results to Acromegaly (square face) o Drug of choice : Ocreotide (Sandostatin)2. Melanocyte Stimulating hormone o for skin pigmentation o Hyposecretion of MSH results to Albinism o Most feared complications of albinisma. Lead to blindness due to severe photophobiab. Prone to skin cancer o Hypersecretion of MSH results to Vitiligo3. Adrenochorticotropic hormone (ACTH) o promotes development of adrenal cortex4. Lactogenic homone ( Prolactin ) o promotes development of mammary gland with help of oxytocin it initiates milk let down reflex5. Leutinizing hormone o secretes estrogen6. Follicle stimulating hormone o secretes progesterone PINEAL GLAND o secretes melatonin o inhibits LH secretion o it controls/regulates circadian rhythm (body clock) THYROID GLAND o located anterior to the neck 3 Hormones secreted 1. T3 ( Tri iodothyronine ) - 3 molecules of iodine (more potent)2. T4 (

tetra iodothyronine , Thyroxine) o T3 and T4 are metabolic or calorigenic hormone o promotes cerebration (thinking)3. Thyrocalcitonin antagonizes the effects of parathormone to promote calcium resorption. HYPOTHYROIDISM o all are decrease except weight and menstruation o memory impairment Signs and Symptoms o there is loss of appetite but there is weight gain o menorrhagia o cold intolerance o constipation HYPERTHYROIDISM o all are increase except weight and menstruationSigns and Symptoms o increase appetite but there is weight loss o amenorrhea o exophthalmos THYROID DISORDERSSIMPLE GOITER o enlargement of thyroid gland due to iodine deficiency A. Predisposing Factors 1. Goiter belt areaa. places far from seab. Mountainous regions2. Increase intake of goitrogenic foods o contains pro-goitrin an anti thyroid agent that has no iodine. o cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts o soil erosion washes away iodine o goitrogenic drugsa. Anti Thyroid Agent Prophylthiuracil (PTU)b. Lithium Carbonate c. PASA (Aspirin)d. Cobalte. Phenylbutazones (NSAIDs)- if goiter is caused by B. Signs and Symptoms 1. Enlarged thyroid gland2. Mild dysphagia3. Mild restlessness C. Diagnostic Procedures 1. Serum T3 and T4 reveals normal or below normal2. Thyroid Scan reveals enlarged thyroid gland.3. Serum Thyroid Stimulating Hormone (TSH) is increased (confirmatory diagnostic test) D. Nursing Management 1. Enforce complete bed rest2. Administer medications as ordereda. Lugols Solution/SSKI

( Saturated Solution of Potassium Iodine) o color purple or violet and administered via straw to prevent staining of teeth. o 4 Medications to be taken via straw: Lugols, Iron, Tetracycline, Nitrofurantoin (drug of choicefor pyelonephritis)b. Thyroid Hormones o Levothyroxine (Synthroid) o Liothyronine (Cytomel) o Thyroid Extracts Nursing Management when giving Thyroid Hormones 1. Instruct client to take in the morning to prevent insomnia2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations3. Monitor side effects o insomnia o tachycardia and palpitations o hypertension o heat intolerance4. Increase dietary intake of foods rich in iodine o seaweeds o seafoo ds like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine. o iodized salt, best taken raw because it it is easily destroyed by heat5. Assist in surgical procedure of subtotal thyroidectomyHYPOTHYROIDISM o hyposecretion of thyroid hormone o adults : MYXEDEMA non pitting edema o children : CRETINISM the only endocrine disorder that can lead to mental retardationA. Predisposing Factors 1. Iatrogenic Cause disease caused by medical intervention such as surgery2. Related to atrophy of thyroid gland due to trauma , presence of tumor , inflammation 3. Iodine deficiency4. Autoimmune ( Hashimotos Disease ) B. Signs and Symptoms(Early Signs) 1. Weakness and fatigue2. Loss of appetite but with weight gain which promotes lipolysis leading to atherosclerosis and MI3. Dry skin4. Cold intolerance5. Constipation (Late Signs) 1. Brittleness of hair and nails2. Non pitting edema (Myxedema)3. Hoarseness of voice4. Decrease libido5. Decrease in all vital signs hypotension, bradycardia, bradypnea, hypothermia6. CNS changes o lethargy o memory impairment

o psychosis o menorrhagia C. Diagnostic Procedures 1. Serum T3 and T4 is decreased2. Serum Cholesterol is increased3. RAIU (Radio Active Iodine Uptake) is decreased D. Nursing Management 1. Monitor strictly vital signs and intake and output to determine presence of o Myxedema coma is a complication of hypothyroidism and an emergency case o a s e v e r e f o r m o f h y p o t h y r o i d i s m i s c h a r a c t e r i z e d b y s e v e r e h y p o t e n s i o n , b r a d y c a r d i a , bra dypnea, hypoventilation, hyponatremia, hypoglycemia, hypothermia leading to pregressivestupor and coma. Nursing Management for Myxedema Coma Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids2. Force fluids3. Administer isotonic fluid solution as ordered4. Administer medications as orderedThyroid Hormonesa. Levothyroxineb. Leothyroninec. Thyroid Extracts5. Provide dietary intake that is low in calories6. Provide comfortable and warm environment7. Provide meticulous skin care8. Provide client health teaching and discharge planning concerninga. Avoid precipitating factors leading to myxedema coma o stress o infection o cold intolerance o use of anesthetics, narcotics, and sedatives o prevent complications (myxedema coma, hypovolemic shock

o hormonal replacement therapy for lifetime o importance of follow up care HYPERTHYROIDISM o increase in T3 and T4 o Graves Disease or Thyrotoxicosis o developed by Robert GraveA. Predisposing Factors 1. Autoimmune it involves release of long acting thyroid stimulator causing exopthalmus (protrusionof eyeballs) enopthalmus (late sign of dehydration among infants)2. Excessive iodine intake3. Related to hyperplasia (increase size) B. Signs and Symptoms 1. Increase appetite (hyperphagia) but there is weight loss2. Moist skin3. Heat intolerance4. Diarrhea5. All vital signs are increased6. CNS involvementa. Irritability and agitationb. Restlessnessc. Tremorsd. Insomniae. Hallucinations7. Goiter 8. Exopthalmus9. Amenorrhea C. Diagnostic Procedures 1. Serum T3 and T4 is increased2. RAIU (Radio Active Iodine Uptake) is increased3. Thyroid Scan- reveals an enlarged thyroid gland D. Nursing Management 1. Monitor strictly vital signs and intake and output2. Administer medications as orderedAnti Thyroid Agenta. Prophythioracill (PTU)b. Methymazole (Tapazole)

Side Effects of Agranulocytosis o increase lymphocytes and monocytes o fever and chills o sore throat (throat swab/culture) o leukocytosis (CBC)3. Provide dietary intake that is increased in calories .4. Provide meticulous skin care5. Comfortable and cold environment6. Maintain side rails7. Provide bilateral eye patch to prevent drying of the eyes.8. Assist in surgical procedures known as subtotal thyroidectomy** Before thyroidectomy administer Lugols Solution (SSKI) to decrease vascularity of the thyroidgland to prevent bleeding and hemorr hage. POST OPERATIVELY,1. Watch out for signs of thyroid storm/ thyrotoxicosis AgitationH y p e r t h e r m i a T a c h y c a r d i a o administer medications as ordereda. Anti Pyreticsb. Beta-blockers o monitor strictly vital signs, input and output and neuro check. o maintain side rails o offer TSB 2. Watch out for accidental removal of parathyroid gland that may lead toHypocalcemia (tetany)Signs and Symptoms o (+) trousseaus sign o (+) chvostek sign o Watch out for arrhythmia, seizure give Calcium Gluconate IV slowly as ordered 3. Watch out for accidental Laryngeal damage which may lead to hoarseness of voice Nursing Management o encourage client to talk/speak immediately after operation and notify physician 4. Signs of bleeding (feeling of fullness at incisional site) Nursing Management o Check the soiled dressings at the back or nape area. 5. Hormonal replacement therapy for lifetime6. Importance of follow up carePARATHYROID GLAND o A pair of small nodules behind the thyroid gland o Secretes parathormone o Promotes calcium reabsorption o Hypoparathyroidism o Hyperparathyroidism HYPOPARATHYROIDISM o Decrease secretion of parathormone leading to hypocalcemia o Resulting to hyperphospatemia A. Predisposing Factors 1. Following subtotal thyroidectomy2. Atrophy of parathyroid gland due to: a. inflammationb. tumor c. trauma B. Signs and Symptoms

1. Acute tetanya. tingling sensationb. paresthesiac. numbnessd. dysphagiae. positive trousseus sign/carpopedal spasmf. positive chvostek signg. laryngospasm/broncospasmh . s e i z u r e f e a r e d c o m p l i c a t i o n s i. arrhythmia2. Chronic tetanya. photophobia and cataract formationb. loss of tooth enamelc. anorexia, nausea and vomitingd. agitation and memory impairment C. Diagnostic Procedures 1. Serum Calcium is decreased (normal value: 8.5 11 mg/100 ml)2. Serum Phosphate is decreased (normal value: 2.5 4.5 mg/100 ml)3. X-ray of long bones reveals a decrease in bone density4. CT Scan reveals degeneration of basal ganglia D. Nursing Management1. Administer medications as ordered such as: a. Acute Tetany Calcium Gluconate IV slowlyb. Chronic Tetany Oral Calcium supplements Calcium Gluconate Calcium Lactate Calcium Carbonatec. Vitamin D (Cholecalciferol) for absorption of calcium CHOLECALCIFEROL ARE DERIVED FROM D r u g D e t ( Calcidiol ) S u n l i ( Calcitriol )d. Phosphate binder Aluminum Hydroxide Gel ( Ampogel ) Side effect: constipation ANTACIDA . A . C M A D A l u m i n u m C o n t a i n n e s i u m C o n t a i n i n g A n t a c A n t a c i d s AluminumHydroxide

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Gel S i d e E f f e c t : C o n s t i p a t i o n S i d e E f f e c t : D i a r r h e a 2. Avoid precipitating stimulus such as glaring lights and noise3. Encourage increase intake of foods rich in calcium a. anchoviesb. salmonc. green turnips 4. Institute seizure and safety precaution5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result.6. Prepare trache set at bedside for presence of laryngo spasm7. Prevent complications8. Hormonal replacement therapy for lifetime9. Importance of follow up care.HYPERTHYROIDISM o Decrease parathormone

o Hypercalcemia: bone demineralization leading to bone fracture (calcium is stored 99% in bone and 1%blood) o Kidney stones A. Predisposing Factors 1. Hyperplasia of parathyroid gland2. Over compensation of parathyroid gland due to vitamin D deficiencya. Children: Rickettsb. Adults: Osteomalacia B. Signs and Symptoms 1. Bone pain especially at back (bone fracture)2. Kidney stonesa. renal cholicb. cool moist skin3. Anorexia, nausea and vomiting4. Agitation and memory impairment C. Diagnostic Procedures 1. Serum Calcium is increased2. Serum Phosphate is decreased3. X-ray of long bones reveals bone demineralization D. Nursing Management 1. Force fluids to prevent kidney stones2. Strain all the urine using gauze pad for stone analysis3. Provide warm sitz bath4. Administer medications as ordereda. Morphine Sulfate (Demerol)5. Encourage increase intake of foods rich in phosphate but decrease in calcium6. Provide acid ash in the diet to acidify urine and prevent bacterial growth7. Assist/supervise in ambulation8. Maintain side rails9. Prevent complications (seizure and arrhythmia)10. Assist in surgical procedure known as parathyroidectomy 11. Hormonal replacement therapy for lifetime12. Importance of follow up care