Medical Surgical Reviewer

A. Central NS: Brain and Spinal Cord B. Peripheral NS a. Autonomic NS SYMPATHETIC -involved in fight or fly response -Adrenergic - releases Norepinephrine **everything goes up except GIT and GUT Mydriasis (pupils dilate) Dry mouth BP, HR, RR increased Constipation Urinary retention Muscle Contract Eg. atropine sulfate PARASYMPATHETIC -involved in rest and digest response -Cholinergic - releases ACh (acetylcholine) **everything goes down except GIT and GUT Meiosis (contraction of pupils) Increase salivation BP,HR, RR decreased Diarrhea Urinary frequency Muscle Stimulant Eg: Mestinon- drug for Myasthenia Gravis HPN drugs: Propanolol,Nifedipine,Captopril

b. Somatic NS - associated with the voluntary control of body movements via skeletal muscles i) Spinal Nerves: -They are peripheral nerves that carry sensory information into the spinal cord and motor commands. -31pairs ii) Cranial Nerves: -They are the nerve fibers which carry information into and out of the brain stem. They include smell, vision, eye, eye muscles, mouth, vision,. Taste, ear, neck, shoulders and tongue. -12pairs

I II III IV V VI VII VIII IX X XI XII

Olfactory Optic Occulomotor Trochlear Trigeminal Abducens Facial Accoustic(vestibulocochlear) Glossopharyngeal Vagus Spinal Hypoglossal

smell vision Raising of eyelid, control pupil size, superior,medial,inferior RectuS muscle ,inferior Oblique muscle Superior Oblique muscle Face Sensation Mastication Lateral Rectus muscle Facial Expression Anterior 2/3 of tongue(taste) Hearing,balance,equilibrium Posterior 1/3 tongue(taste) Motor innervations of stylopharyngeus muscle Swallowing(laryngeal pharyngeal muscles) , speaking Special sense of taste frm epiglottis Shrugging & head movement Muscle of tongue (swallowing, speech articulation)

S S M M B M B S B B M M

Neurons -Properties and Characteristics: 1. Excitability- ability of neuron to be affected in external environment 2. Conductivity ability of neuron to transmit a wave of excitation frm one cell to another 3. Permanent Cells once destroyed cannot regenerate -Regenerative Capacity: 1. Labile once destroyed cannot regenerate Ex: epidermal cells, GIT cells, lung cells, GUT cells 2. Stable capable of regeneration but limited time only Ex: salivary gland, pancreas cells, Liver cells and kidney 3. Permanent Cells- once destroyed cannot regenerate Ex. Retina, brain , osteocytes Neuroglia attached to Neurons. Support neurons. Where brain tumors are found. Types: 1. astrocyte 2.olygodendria *90-95% of brain found in astrocyte. Called astrocytoma. *astrocyte maintains BBB (Blood-Brain Barrier) Toxins that can pass BBB

1. Ammonia (liver cirrhosis) 2. Carbon Monoxide (seizure&parkinsons) 3. Bilirubin (jaundice, kernicterus, hyperbilirubinemia) 4. Ketones (DM) Oligodendria-produces MYELIN SHEATH Wraps around neuron and act as insulator facilitating rapid nerve impulse Transmission. Damage to myelin sheath causes demyellinating d/o (ALZHEIMERs) Microglia- stationary cell that engulfs bacteria and cellular debris -Composition of Brain and spinal cord 80% brain mass 10% CSF 10% blood -Mon Roe Kelly Hypothesis the skull is a closed vault. Any increase in one component will increase ICP. **Normal ICP: 0-15 mmHg Parts of the Brain: I.CEREBRUM largest part of brain - connects right and left cerebral hemisphere - Corpus Calosum connects the 2 hemispheres Fxn: sensory, motor, integrative FRONTAL TEMPORAL PARIETAL -Controls motor activity -Controls personality development -Where primitive reflexes are inhibited -Site of development of sense of humor -Broccas area speech center **damage : expressive aphasia -Hearing Short term memory -Wernickes areainterpretative **damage: receptive aphasia -Appreciation &discrimination of sensory impulse -Pain, touch, pressure, heat and cold

OCCIPITAL -vision

CENTRAL/ISLAND of REIL -Controls visceral fxn/activities of internal organ

RHINENCEPHALON/LIMBIC -Smell -Libido -Long term memory

Basal Ganglia areas of gray matter located w/in cerebral hemisphere -extra pyramidal tract -rlse dopamine -controls gross voluntary unit **decrease dopamineParkinsons (pin rolling of extremities) & Huntingtons dse **increase ACTH Myasthenia Gravis & Alzheimers Psyche: ** increased dopa- schizo **increased ACTH bipolar

II. CEREBELLUM lesser brain -controls posture, gait, balance & equilibrium III. LIMBIC SYSTEM - found buried within the cerebrum - Consist of thalamus, hypothalamus, amygdala&hypocampus a. Thalamus-acts as relay station for sensation b. Hypothalamus-thermo regulating center of temp, sleep, wakefulness, thirst, appetite, emotional responses. Controls pituitary fxn IV. BRAIN STEM - responsible for basic vital life functions such as breathing, heartbeat, and blood pressure - made of the midbrain, pons, and medulla a. Mid Brain relay station for sight and hearing Controls size and rxn of pupil 2-3 mm Controls hearing acuity CN 3&4 *Isocoria-normal size *Aniscoria-uneven sizemeans damage to mid brain *PERRLA b. PONS- a pneumotaxic center that controls respi *Cranial Nerve 5-8 c. Medulla Oblongata- controls heart rate, swallowing, vomiting, hiccups/singutus, vasomotor center, and spinal decuissation center CN 9,10,11,12 *Foramen Magnum - large opening in the occipital bone of the cranium C1 atlas C2 - axis Segments of the Spinal Cord

8 Cervical 12 Thoracic 5 Lumbar 5 Sacral 1Coccygeal Note:

Composition of Brain-based on Monroe-Kelly Hypothesis--Skull is a closed container. Any alteration in 1-3 intracranial components= Increase ICP (+) projectile vomiting= increase ICP -- Observe for 24-48hrs CSF cushions the brain, shock absorber Obstruction of flow of CSF= increase ICP Hydrocephalus posteriorly due to closure of posterior fontanel CVA- partial/total obstruction of blood supply

ALZHEIMERS DISEASE -atrophy of brain tissue due to deficiency of ACTH S/sx:

*Expressive /Broccas Aphasia unable to speak * Receptive/Wernickes Aphasia unable to understand spoken words (common to Alzheimers) Drug of Choice: ARICEPT (taken at bedtime) or COGNEX Mgt: 1. Remove Hazardous items or potential obstacles frm cx enviro 2. Provide verbal and non verbal communication that is CONSISTENT and STRUCTURED 3. Increase social interaction 4. Encourage use of Community resources INCREASE ICP - due to increase of 1 of the intracranial components (brain mass, CSF, blood) Predisposing Factors: 1. Head injury 2. Tumor 3. Localized abscess 4. Hemorrhage(stroke) 5. Cerebral edema 6. Hydrocephalus 7. Inflamatory conditions(meningitis,encephalitis) S/Sx: 1. Change or decrease LOC (earliest sx) -restlessness to confusion Disorientation to lethargy Stupor to coma 2. Head ache Projectile vomiting Papilledema (edema of optic disk-outer surface of retina) Decorticate (abn flexion) =damage to cortico spinal tract Decerebrate(abn extension)=damage to upper brain stempons 3. Uncal herniation- unilateral dilation of pupil **bilateral dilation of pupiltentorial herniation 4. Change in VS (late sx) o Increase BP o Decrease HR o Decrease RR o Increase Temp o Widening of Pulse Pressure 4. Possible seizure Management: 1. Maintain patent a/w -prevent hypoxia and hypercapnia Hypoxiacerebral edemaincrease ICP Hypercapniacerebral vasodilation increase ICP Early sx of hypoxia: -restlessness, Agitation, Tachycardia (body trying to compensate) Late sx of hypoxia: -bradycardia, extreme restless, dyspnea, cyanosis (everything is deteriorating so VS doing down) 2. Monitor VS and I&O 3. Elevate HOB 30-45degrees angle neck in neutral position unless contraindicated to promote venous drainage 4. Limit fluid intake 1,200-1,500 ml per day 5. Prevent complications of immobility 6. Prevent increase ICP by: Maintain quiet environment Avoid use of restraintsmay lead to fracture

Side rails up Instruct pt to avoid the ff: o Valsava maneuver(give laxatives or stool softener) o Excessive cough (give antitissive*dextrometotphan) o Excessive vomiting (give antiemetic *Phenergan) o Lifting heavy objects o Bending and stooping 7. Administer meds as ordered: a. Osmotic Diuretic Mannitol (promotes cerebral dieresis by decompressing brain tissue) Nx consideration: 1.Monitor BPSE: hypotension 2. Monitor I&O q1 and report if <30cc output 3. Administer via side drip 4. Regulate fast drip to prevent formation of crystals b. Loop Diuretic Lasix(Furosemide) Nx Consideration: 1.same as mannitol except Lasix is given IV push (expect urine after 10-15 mins) shld be in the morning. Immediate effect w/in 15 mins max effect 6hrs due 2. WOF s/e of Lasix (Hypo K, Hypercalcemia, Hyponatremia, Hyperglycemia, Hyperuricemia) NOTE:

c. Corticosteroids dexamethasone(decreases cerebral edema) d. Mild Analgesics Codeine sulfate (for head ache) e. anti convulsant dilantin(phenytoin)

Magic 2s of Drug Monitoring Drug D - Digoxin L - Lithium A - Aminophyline D - Dilantin A -Acetaminophen Indication CHF Bipolar COPD seizures osteoarthritis Classification Cardiac glycoside Anti manic Bronchodilator Anticonvulsant Narcotic Analgesic N Range .5 -1.5 meq/L .6-1.2 meq/L 10-19 mg/100 ml 10-19 mg/100 ml 10-30 mg/100 ml Toxicity 2 2 20 20 200

Digitalis increase cardiac contraction = increase CO Nx mgt: 1. Check PR, HR (if HR below 60bpm, DO NOT GIVE DIGOXIN) 2. WOF digitalis toxicity: antidote- Digivine Anorexia N/V Diarrhea Confusion Photophobia Change in coloror perception(yellow spots) Ok to give in patients with renal failure since metabolized in liver not kidney. Lithium decrease level of NE, serotonin and ACTH Antimanic agent Nx Mgt: 1. WOF sx of lithium toxicity: Anorexia N/V

Diarrhea DHN force fluid. Maintain Na intake to 4-0g daily Hypothyroidism Cretinism- only endocrine d/o that can lead to mental retardation

Aminophyline dilates bronchioles Nx Mgt: 1. Take BP before giving aminophyline 2. WOF aminophyline toxicity: Tachycardia Hyperactivity (restless,agitation, tremors 4. Mgt for toxicity: activated charcoal NOTE:

Dilantin(phenytoin) anticonvulsant/anti seizure Nx Mgt: 1. Mix w/ plan NSS or .9 NaCl to prevent formation of crystals or precipitate - Do sandwich method -give NSS, then dilantin , then NSS 2. Instruct pt to avoid alcohol. Alcohol+dilantin = CNS depression 3 WOF sx of dilantin toxicity Gingival hyper plasia **oral hygiene, massage gums Hairy Tongue Ataxia Nystagmus Acetaminophen/Tylenol non opoid analgesic& antipyretic febrile patients 4. Mgt for toxicity: activated charcoal Acetaminophen - narcotic Analgesic Nx Mgt: 1. Hepatotoxic -Monitor liver enzymes *SGPT&SGOT -Monitor BUN (10-20) and Crea (.8-1) 2. Acetaminophen toxicity may lead to HYPOglycemia T Tremors, tachycardia I - irritability R -restlessness E Extreme fatigue D Depression (nightmares), diaphoresis 3. Antidote: Acetylcysteine = causes outpouring of secretions. Prepare suctioning apparatus.

PARKINSONS DSE -chronic progressive disease of CNS characterized by degeneration of dopamine producing cells in substancia nigra at midbrain and basal ganglia. -fxn of dopamine is to control gross voluntary movement Predisposing factors: 1. Poisoning (lead, carbon monoxide) antidote for lead: Calcium EDTA 2. Hypoxia 3. Arteriosclerosis 4. Encephalitis 5. Drug induced effect High doses of the ff drugs: 1.reserpine-anti HPN SE: depression (suicidal), breast Ca 2. Methyldopa (aldomet) 3. Haloperidol - antipsychotic 4. Phenothiazide - antipsychotic S/Sx: pill rolling tremors, tremors at rest early sx bradykinesia slow movement rigidity(cogwheel type) o stooped posture o shuffling(most common) o propulsive gait mask like facial expression w/ decrease blinking eyes monotone speech difficulty rising frm sitting position mood labile=always depressed(suicidal)

increase salivation/drooling autonomic signs: increase sweating increase lacrimation seborrhea constipation decrease sexual activity

Nx Mgt: 1. MEDS: a. Anti parkinsonian agents: -Levodopa, Carbidopa, Amantadine Hcl -MOA: increase level of Dopa ---relieving tremors and bradykinesia -S/E of Anti-parkinsonian: anorexia confusion hallucination N/V orthostatic hypotension arrhythmia -Mgt when giving anti parkinsonian: 1. Take w/ meals(to decrease GIT irritation) 2. Inform pt urine/stool may be darkened 3. Instruct pt DO NOT take food w/ vit B6(pyridoxine) like cereals,organ meats,green leafy veg <vit B6 reverses therapeutic effects of levodopa> NOTE: VIT B6 (pyridoxine is given to patients taking isoniazid(INH) to prevent peripheral neuritis b.. Anti-cholinergic agents -Artane, Cogentin -inhibits acetylcholine hence reduce tremors c. Antihistamine -Diphenhydramine -taken at bedtime -S/E adult: drowsiness child: hyperactivity/CNS excitement d. Dopamine agonist -Bromotriptine HCl -S/E: respiratory depression. Monitor RR 2. Maintain siderails 3. Prevent complications of immobility -Turn pt q2 -Turn elderly pt q1 4. Assist passive ROM to prevent contractures 5. Maintain good nutrition Decrease CHON in AM Increase CHON in PM -due to tryptopan(amino acid) 6. Increase fluid intake,high fiber diet to prevent constipation 7. Assist in surgery (Sterotaxic Thalamotomy) Complications: 1) subarachnoid hemorrhage 2) aneurysm 3) encephalitis

MULTIPLE SCLEROSIS
-chronic intermittent d/o of CNS (white patches of demyelination in brain and spinal cord) -remission and exacerbation -common in women 15-35y/o S/Sx : (everything down) Visual disturbance o Blurring of vision o Diplopia o Scotoma (blind spots) initial sx Impaired sensation to touch, pain, pressure, heat, cold o Numbness o Tingling o Paresthesia Mood swings Impaired motor function o Weakness o Spasticity (tigas) o Paralysis Impaired cerebral fxn o Intentional tremors o Nystagmus o Ataxia Urinary retention or incontinence Constipation Decrease sexual ability Dx Procedures: 1. CNS analysis thru lumbar puncture -reveals increase CHON and IgG 2. MRI -reveals site and extent of demyelination

3. Lhermittes response (+) -Introduce electricity at the back. There is spasm and paralysis at spinal cord Mgt: 1. Meds a. Acute exacerbation a. Adenocorticotrophic Hormone(ACTH) b. Steroids reduce edema at site of demyelination to prevent paralysis. 2. Maintain side rails 3. Assist passive ROM exercise to promote proper body alignment 4. Prevent complications of immobility 5. Encourage inc fluid intake and high fiber diet to prevent constipation 6. Provide catheterization for urinary retention 7. Give diuretics **for urinary incontinence give Propantheline Bromide (antispasmodic, anticholinergic) 8. Give stress reducing activity. 9. Provide ACID ASH diet to cidify urine and prevent bacteria multiplication **grape, cranberry, orange juice, vit C AMYOTROPIC LATERAL SCLEROSIS (Lou Gehrigs Dse) -progressive degenerative disorder that leads to decrease motor fxn in upper and lower motor neuron system Cause: idiopathic, possibly slow acting virus S/Sx: Atrophy of tongue Awkwardness of fine finger movement Dysphagia Fatigue Muscle Weakness oh hands and feet Increased Creatinine Kinase level Mgt: 1. Mgt of Sx 2. Neuroprotective Agent: Riluzole

MYASTHENIA GRAVIS
-disturbance in transmission of impulse frm nerve to uscle cells at neuro muscular jxn -common in women 20-40y/o -autoimmune : rlse of enzyme cholinesterasecholineterase destroys ACHdecrease ACHDESCENDING MUSCLE WEAKNESS S/Sx: Ptosis drooping of upper lid(initial sx) **check palpebral fissure-opening of upper & lower lid = to know if (+) MG Diplopia Mask like Facial expression Dysphagia Weakening of Laryngeal muscle Resp musce weakness lead to respiratory arrest prepare bedside tracheotomy Extreme muscle weakness during activity especially in the morning Dx Procedures: Tensilon Test(Edrophonium HCl) ---temporarily strengthens muscle for 5-10 mins Mgt: 1. Maintain patent a/w w/ adeq ventilation 2. Monitor VS, I&O, neuro check, muscle strength/motor grading scale 3. Side rails up 4. Prevent complications of immobility **adult- q2 **elderly q1 5. NGT feeding 6. Meds Cholinergic or anti-cholinesterase agents: *Mestino(PYRIDOSTIGMENE) *Neostigmine (PROSTIGMIN) long term Increase acetylcholine SE: PNS Corticosteroids **Decadron(DEXAMETHASONE)

MYASTINIC CRISIS
Cause: under medication,stress, infxn S/Sx: unable to see(Ptosis & diplopia) Dysphagia Unable to breathe Mgt: administer cholinergic agent PYRIDOSTIGMENE) *Neostigmine (PROSTIGMIN) 7. 8. 9.

CHOLINERGIC CRISIS
Cause: Overmeds S/Sx: PNS dec RR,HR and BP, inc salivation, diarrhea

Mgt: administer anticholinergics **Atropine SO4 ** dry mouth

Assist in surgical procedure thymectomy(removal of thymus gland w/c secrete auto immune antibody Assist plasmaparesis(filter blood) Prevent complication: respiratory arrest prepare bedside tracheostomy set

GUILLAIN BARRE SYNDROME

-bilateral symmetrical polyneuritis -ASCENDING PARALYSIS -cause: unknown,idiopathic, autoimmune:r/t antecedent viral infxn(immunization) S/Sx:

 Clumsiness Ascending muscle weakness (lead to paralysis) Dysphagia Decreased DTR Alternate HYPERtension to HYPOtension (lead to arrhythmiacomplication) Autonomic Changes (increase sweating,increase salivation, increase lacrimation,constipation) Dx most Important: CSF analysis thru lumbar puncture reveals increase in IgG & CHON (same with MS) Mgt: Maintain patent a/w and adeq vent Monitor VS,I&O,neurocheck,ECG tracing due to arrhythmia Siderails up Prevent complication of immobility Assist in passive ROM exercises Institute NGT feeding due to dysphagia MEDS: Anticholinergics : atropine SO Corticosteroid to suppress immune response Anti-arrythmic agents : o Lidocaine S/E: confusion=VTach o Bretyllium o Quinines/Quinidine anti malarial agent. Give with meals Toxic effect: cinchonism S/E: anorexia,N/V,head ache,vertigo,visual disturbance Assist in plasmaperesis Prevent Complication (arrhythmia,respiratory arrest. Prepare tracheostomy set @ bedside.

HUNTINGTONs DSE
-Hereditary (Autosomal dominant) dse in which degeneration in the cerebral cortex and basal ganglia causes chronic preogressive chorea(involuntary&irregular movement) and cognitive deterioration ..ending in dementia. S/Sx: Choreic MOvemnet Dysarthria Torticollis (twisting of neck) Dementia Gradual Loss of Musculo-Skeletal Control Mgt: supportive and protective mgt sins not curable. Meninges- 3 fold membrane w/c covers brain and SC FXN:1) protection&support 2) nourishment 3)blood supply 3Layers: 1. Duramater 2. Arachnoid Mater 3. Piamater sub arachnoid space where CSF flows L3 and L4site of LUMBAR PUNCTURE

MENINGITIS
-inflammation of meninges & SC -Etiology: 1.Meningococcus 2. Pneumonococcus 3.H.Influenza(child) 4.Streptococcus(adult) MOT: direct transmission via droplet nuclei S/Sx: o Stiff neck or nuchal rigidity(initial sx) o Head ache o Projectile vomiting (due to increase ICP) o Photophobia o Fever,chills,anorexia o Gen body malaise o Wt loss o Decorticate/decerebrate o Possible seizure **Sx of meningeal irritation: nuchal rigidity opisthotonus(rigid arching of back) **Pathognomonic Sign: (+) Kernigs sign <leg pain> and (+)Brudzinski sign<neck pain> Dx: 1.LUMBAR PUNCTURElumbar /spinal tap -use of hallow spinal needle subarachnoid space b/w L3&L4 OR L4&L5 Nx Mgt for Lumbar Puncture: i. Consent ii. Empty bladder, bowel to promote comfort iii. Arch Back to clearly visualize L3&L4 Nx Mgt POST lumbar Puncture: i. Flat on Bed 12-24 hrs to prevent Spinal head ache and leak of CSF ii. Force Fluid iii. Check puncture sites for drainage, discoloration and leakage to tissue iv. Assess for movement & sensation of extremities **Result: 1. CSF Analysis: increase CHON and WBC 2. Decrease Glucose 3. Increase CSF opening pressure (N=50-160 mmHg)

2. COMPLETE BLOOD COUNT reveals increase WBC Mgt: I. MEDS 1.:Broad Spectrum Antibiotic Penicillin S/E: GIT Irritation SuperInfxn: (alteration in normal bacterial flora) Hepatotoxicity/nephrotoxicity N flora throat: streptococcus N Flora intestine: E. Colli Allergic Rxn S/Sx superinfxn: diarrhea 2. Antipyretic 3. Mild Analgesic II.Strict Respiratory isolation (Safe AFTER 24h of antibiotic therapy) Nice to Know: Cushings Syndrome Aplastic Anemia Cancer of any type Post Liver Transplant Prolonged use of steroids MENINGITIS Asthma

Reverse Isolation Reverse Isolation Reverse Isolation Reverse Isolation Reverse Isolation Strict Respiratory Isolation NOT to be isolated

Due to increased corticosteroid in body Due to bone marrow depression immunocompromised Takes steroid lifetime Safe AFTER 24h of antibiotic therapy

Isolation pt can infect others. Room is at negative pressure. Visitors wear mask etc Reverse Isolation others can infect pt. Room is at Positive pressure. Pt wears mask etc III. Comfy and dark room due to photophobia and seizure IV. Prevent complications of immobility V. Maintain F&E balance VI. Monitor VS, I&O, neurocheck VII. Provide client Health Teaching & discharge plan a. Nutrition: increase Calcium, CHO,CHON(for tissue repair. Small freq feeding b. Prevent complications: hydrocephalus, hearing loss or nerve deafness **Where to bring 2y/o post meningitis: Audiologist due to damage to hearing Urologist damage to sacral areaspina bifidacontrols urination VIII. Prevent seizure IX .Rehab for neurological deficit. Can lead to mental retardation or delay in psychomotor development

CEREBRO VASCULAR ACCIDENT

-stroke, cerebral thrombosis, brain attack, apoplexy -partial or complete disruption in brains blood supply -2 largest and common artery in stroke: 1) Middle Cerebral Artery 2) Internal Carotid Artery -common to male 2-3xhigh risk Predisposing Factor: I. Thrombosis- clot (attached) II. Embolism dislodged clot *PULMO embolism *Cerebral Embolism S/Sx: sudden, sharp chest pain S/Sx: head ache Unexplained dyspnea, SOB disorientation Tachycardia, palpitations confusion Diaphoresis, mild restlessness decrease in LOC ***Femur Fracture: complication: Fat embolism (most feared complication within 24hrs) III. Hemorrhage IV. Compartment Syndrome compression of nerves and arteries Risk Factors: HPN, DM, MI, ARtherosclerosis, valvular heart dse ,post heart surgery(mitral valve replacement), Lifestyle: 1.Smoking **nicotine potent vasoconstrictor 2. Sedentary lifestyle 3. Hyperipidemia (genetic) 4. Prolonged use of OCP promote lipolysis(breakdown of lipidsartherosclerosisHPNstroke Macropill has large amnt of Estrogen Minipill has large amnt of Progestin 5. Type A personality a.dead line driven person b. 2-5 things at the same time c. guilty when not doing anything 6. Increase saturated fats 7. Emotional and Physical stress 8. Obesity S/Sx: I. TIA warning signs of impending stroke attack Headache (initial sx) dizziness vertigo numbness tinnitus speech disturbance Paresis(wekness) or plegia(paralysis) (monoplegia- 1extremity) II. Stroke in evolution progression of S/Sx of stroke III. Complete stroke resolution of stroke a) head ache b) cheyne - stokes respiration

c )anorexia, N/V d) dysphagia e) Increase BP f) (+) Kernigs and Brudzinski sx of hemorrhagis stroke g) focal and Neurological deficit 1. Plegia 2. Dysarthria inability to vocalize, articulate words 3. Aphasia 4. Agraphia difficulty writing 5. Alesia difficulty writing 6. Homonimous Hemianopsia loss of half of field of vision **Left Sided Hemianopsia approach right side of pt the unaffected side DX: CT Scan reveals brain lesion Cerebral Arteriography site and extent of malocclusion *invasive procedure due to dye injection: ALLERGY TEST *Post: force fluid then check peripheral pulses ALL graphy invasive due to Iodine Dye

Mgt: 1. 2. 3. 4. 5. 6. Maintain patent a/w and adeq vent Restrict fulids prevent cerebral edema Elevate HOB 30-45 degrees angle Avoid valsava maneuver Monitor I&O,VS, Neurocheck Prevent complication of immobility a. Turn cx q2 adult q1- elderly *to prevent decubitus ulcer *to prevent hypostatic pneumonia b. Egg crate mattress or H2O bed c. Sand bag or foot board to prevent foot drop 7. NGT if pt cannot swallow 8. Passive ROM q4 9. Alternate means of communication a. Nonverbal cues b. Magic slate. no pen and paper. Tiring to pt c. For hemianopsia approach unaffected side 10. MEDS Osmotic diuretic: Mannitol Loop Diuretic: Lasix/Furo Corticosteroids: Dexamethasone Mild Analgesic Thrombolytic/Fibrinolytic Agents: Streptokinase, Urokinase (tunaw Clot) S/E: urticaria,pruritus Anticoagulant : Heparin and Coumadin (given sabay) **Coumadin will take effect after 3days **Heparin: Monitor PTT if prolonged bleeding give Protamine sulfate **Coumadin: Monitor PT if prolonged bleeding give Vit K (Aquamephyton) Antiplatelet: aspirin **do not give to dengue, ulcer, and unknown head ache

Spinal Cord Injury

S/Sx: loss of bowel and Bladder control Paresthesia/Paralysis below level of injury Mgt. 1. Flat Position. Immobilize neck (cervical collar) and maintain alignment (Halo vest, Skull Tongs) 2. Assess for spinal Shock loss of sensation accompanied by motor paralysisw/ initial loss but gradual recovery of reflexes 3. WOF Autonomic Dysreflexia sudden extreme rise in BP , cx injured T6 or higher S/Sx: increase BP(systolic: >200) Intense H/A Profuse Sweating Facial Erythema Feeling of doom / Apprehension Blurred Vison Mgt: Anti HPN Vasodilators : Nitrates Straight Cath

CONVULSIVE DISORDER
-d/o of CNS char by paroxysmal seizures w/ or w/o loss of consciousness , abn motor activity, alteration in sensation ,perception and change in behavior Predisposing Factor: 1. Head injury due to birth trauma 2. Toxicity to carbon monoxide 3. Brain tumor 4. Genetics 5. Nutritional and metab deficit 6. Physical stress 7. Sudden withdrawal to anticonvulsant will bring abt STATUS EPILEPTICUS DOC: diazepam + glucose

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S/Sx: 1) Localized/Partial Seizure a)Psychomotor/Focal Motor Seizure -automatism stereotype repetitive&non purposive behavior -Clouding of Consciousness not in control w/ environment -Mild Hallucinatory sensory experience **Note: Auditory Hallucination- schizo - paranoid type Visual Hallucination Korsakoffs Psychosis chronic alcoholism Tactile addict substance abuse b) Jacksonian/Focal Seizure -tingling jerky movement of thumb/index finger,spread to shldr then 1 side of body w/ jacksonian march 2) Generalized Seizure a)Petimal Seizure(same as day dreaming) or absent seizure -blank stare -decrease blinking eye -twitching mouth -loss of consciousness 5-10 sec (quick and short) b) Grand Mal /Tonic Clonic Seizures -with or w/o aura **Warning sx of impending seizure attack: epigastric pain -epileptic cry fall -Loss of consciousness 3-5mins -Tonic-Clonic Contractions -Direct symmetrical extension of extremities (TONIC) Contractions (CLONIC) -Post ictal sleepstate of lethargy or drowsinessunresponsive sleep after tonic-clonic 3.Status Epilepticus - Continuous, uninterrupted seizure activity, IF untreated will lead to hyperprexiacoma DEATH -Seizure: increase electrical firing in brain increase metab activity in brain brain using glucose and O2decrease glucose, decrease O2 - DOC: diazepam + glucose Dx: get health hx CT scan: brain lesion EEG Hyperactivity brain waves Mgt: **Priority: AIRWAY& safety 1. Maintain patent a/w and promote safety Remove blunt/sharp objects Loosen clothing Avoid restraints Maintain siderails Turn head to side to prevent aspiration Avoid precipitating stimulus bright/glaring lights and noises 2. Administer meds 1. Dilantin (Phenytoin) **toxicity level: 20 a. S/E: i. Gingival hyper plasia **oral hygiene, massage gums ii. Hairy Tongue iii. Ataxia iv. Nystagmus b. **Mix w/NSS. Dont give w/alcohollead to CNS depression 2. Tegretol(CArbamasene) -- S/E arrhythmia **given also to Trigeminal Neuralgia 3. Phenobarbital -- S/E hallucination 2. Institute seizure and safety precauition post seizure: o Administer O2 o Suction apparatus ready at bedside 3. Monitor onset and duration o Type of seizure o Duration of post ictal phase ( the longer the post ictal phase the higher chance of having status epilepticus 4. Assist in surgical procedure. Cortical resection

ENCEPHALITIS
-inflammation of Brain usually caused by mosquito or tick borne virus S/Sx: Meningeal irritation Neuro damage (drowsiness, coma, seizure,psychosis) Sudden onset of fever H/A Vommiting Mgt: 1. Antiviral: Acyclovir effective only before coma Slow IV to avoid kidney damage 2. Maintain quiet and darken room to prevent increase ICP

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CATARACT:
-occurs when normally transparent crystalline lens in eye becomes opaque S/Sx: Diminished or blurred vision Better vision in dim light with pupil dilated Yellow,gray or white pupil Mgt: ECE Intracapsular Lens Implant always place items on unaffected side

GLAUCOMA
-increase IOP causes damage to optic nerve a. Open Angle Glaucoma overproduction/obstructed outflow of aqueous humor b. Angle Closure Glaucoma obstructed outflow of aqueous humordue to anatomically narrow angles S/Sx: Acute ocular PAIN Blurred vision Dilated pupil Halo Vision Mgt: 1. Chronic OAG: * Alpha Adrenergic Agonist: Brimonidine *Beta Adrenergic Antagonist: Timolol 2. Acute ACG: * Cholinergic Agent: Pilocarpine * Laser Iridectomy

Retinal Detachment
-Separation of retina frm choroid S/Sx: PAINLESS Change in vision Photopsia(recurrent flashes of light) Veil Curtain or Cobweb Mgt: 1. BedRest to prevent further detachment 2. Cryopexy hole 3. Scleral Buckling reattach Post Op: lie on back/unaffected side to avoid increase IOP

MENIERES DSE
-a dysfxn in the labyrinth 1. Temporary constriction of BV supplying the inner ear 2. Overproduction/decrease absorption of endolymph that produces severe vertigo,sensorineural hearing loss and tinnitus S/Sx. Vertigo Sensorineural hearing loss and tinnitus Mgt: 1. Restrict NA to >2g/day 2. Surgery to destroy labyrinth causes irreversible hearing loss 3. Atropine: stop attack in 20-30 mins

OTOSCLEROSIS
-overgrowth of the ears spongy bone around oval window and stapespreventing sound frm being transmitted to cochlea conductive hearing Loss S/Sx Progressive hearing Loss Tinnitus Mgt: 1. Hearing Aid 2. Stapedectomy and insertion of prosthesis

---------------------------------------------------------------------------------------------------------------------------------------------------------------i. References: Medical-Surgical Nursing Review : dnos, Lippincotts NCLEX-RN Review

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