CONCEPT OF PERCEPTION AND COORDINATION B.

LABORATORY / DIAGNOSTIC TEST

NERVOUS SYSTEM A. Lumbar puncture

- Measures CSF pressure (N: 60-150 mmH20)
- Obtain specimen for lab
analysis
- Check color of CSF ( N:
clear) and check for
blood
- Inject air, dye or drugs
into the subarachnoid
PART ON E
space at the level of L3-
L4
Anatomically CNS PNS
- Contraindication: clients with IICP, may lead to
Brain Cranial Nerves
Spinal Cord Spinal Nerves brain herniation

Functionally SNS ANS

(Voluntary Sympathetic B. X-ray of skull and spine
activities) Parasympathetic - Used to detect atrophy, erosion, or fractures of
(involuntary activities ) bones; calcifications

C. Computerized tomography (CT scan)

A. ANATOMY AND PHYSIOLOGY OF THE BRAIN
AND SPINAL CORD

A. CEREBRUM
B. CEREBRAL CORTEX
C. BASAL GANGLIA
D. DIENCEPHALON
E. BRAINSTEM
F. CEREBELLUM - Used to detect intracranial bleeding, space
G. SPINAL CORD occupying lesions, cerebral edema, infarction,
H. MENINGES hydrocephalus, cerebral atrophy and shifts of
I. CEREBROSPINAL FLUID brain structures
- May or may not require an injection of dye
- Is a clear and colorless fluid with sp gravity of - Check for shellfish / iodine allergy
1.007
- Assess disorientation
- Secreted in the ventricles and circulates - Contraindication: Obesity > 300 lbs
through the ventricles to the subarachnoid
Pregnancy
layer of the meninges where it is reabsorbed
Unstable vital signs
- Circulates in the subarachnoid space
Claustrophobia
- Choroid plexus – responsible for CSF production
- Normal pressure is 50-175 mmH20 D. Magnetic resonance imaging (MRI)
- Normal volume is 125-150 ml
- Acts as a protective cushion
- Aids in the exchange of nutrients and wastes
J. VENTRICLES
K. BLOOD SUPPLY
L. NEUROTRANSMITTERS
M. NEURONS
N. AXONS AND DENDRITES
O. SPINAL NERVES
P. AUTONOMIC NERVOUS SYSTEM - Used to identify types of tissues, tumors and
Characteristics of Normal CSF vascular abnormalities
Appearance clear and colorless - Similar to CT scan but provides more detailed
Pressure 9-14mmHg pictures and does not expose the client to
Red blood cells None ionizing radiation
White blood cells Occasional - Remove all metals
Protein 15-45 mg/dl
- C/I same with CT scan
Glucose 45-75 mg/dl
Sodium 140 mEq/liter
Potassium 3 mEq/liter E. Cerebral angiography
Specific gravity 1.007 - Injection of radiopaque substance into the
pH 7.32-7.35 cerebral circulation via carotid, vertebral,
Volume in the femoral or brachial artery ffd by x-ray
System at one time 125-150 ml
Volume formed in 24h 500-800 ml - Used to visualize cerebral vessels and detect
tumors, aneurysms, occlusions, hematomas,
abscesses
 - Pressure dressing / ice o Incomprehensible sounds -
- Report bleeding / swelling at the site 2
- Rest for 12-24 hrs after o None - 1

F. Electroencephalography (EEG) EYE OPENING ABILITY (E)

- Used to detect foci of seizure activity and to o Spontaneous - 4
quantitatively evaluate level of brain function o To voice / speech -
3
o To pain - 2
o None - 1

III.NEUROLOGICAL ASSESSMENT

A. Neurological examination
1. Mental status exam (cerebral function)
a. General appearance and behavior
b. Level of consciousness c. Intellectual function: memory (recent
i. Orientation to time, place and and remote) , attention span, cognitive
person skills
ii. Speech: clear, garbled d. Emotional status
iii. Ability to follow commands e. Thought content
iv. Abnormal posturing ( may f. Language / speech
occur spontaneously or in i. Expressive aphasia : inability to
response to stimulus) speak / frontal lobe problem
1. Decorticate posturing: Brocas area “motor speech
damage to cortex”
corticospinal tracts; aka BROCAS APHASIA
cerebral hemisphere ii. Receptive aphasia: inability to
2. Decebrate posturing: understand spoken words /
damage to upper temporal lobe problem
brainstem, midbrain or Sensory speech area
pons aka WERNICKE’S APHASIA
iii. Dysarthria: difficult speech due
to impairment of muscles
Glasgow Coma Scale involved with speech
production
Definition: Technique of objectifying a client’s level of 2. Cranial nerves
responses; client’s best response in each area is given 3. Cerebellar function : posture, gait, balance ,
a numerical value, and three values are totaled for a coordination
score ranging from 3-15. a. Romberg’s Test – stand with eyes
closed and feet together
A score of 15 indicates client is awake and oriented. A b. Heel-toe-walk in a straight line
score of 7 to 4 is considered coma . The lowest 4. Motor function : muscle size, tone, strength,
score is 3, client is considered in deep coma abnormal or involuntary movements
5. Sensory function : light touch, superficial pain,
MOTOR RESPONSE, UPPER LIMB (M) temperature, vibration and position
o Obeys commands - 6 6. Reflexes
o Localizes to pain - a. Deep tendon : grade from 0 (no
5 response) to 4 ( hyperactive); 2 is
o Flexor withdrawal - 4 normal
o Abnormal flexion (decorticate) 3 b. Pathologic: babinski’s reflex indicates
o Extension ( decebrate) - 2 damage to corticospinal tracts
o Flaccid - 1 Babinski (+) : dorsiflexion of great toe
& fanning of other toes
VERBAL RESPONSE (V)
o Oriented - 5 Neurologic Disorders
o Confused conversation - 4
o Inappropriate words - 3 A. INCREASED INTRACRANIAL PRESSURE
 - A condition in which the pressure of the CSF, o LATE SIGNS: HIGH, SHRILL CRY AND SEIZURE
blood or brain volume within the skull exceeds ACTIVITIES
the upper limits for normal pressure
- Can impede circulation to the brain, absorption
of CSF, affect the functioning nerve cells and Nursing Care
lead to brainstem compression and death • Teach the family about the management
- Etiology : trauma, hemorrhage, tumors, required for the disorder
hydrocephalus, edema or inflammation o Treatment is surgical by direct removal
of the obstruction and insertion of
shunts to provide primary drainage of
NURSING ASSESSMENT CSF to peritoneum
o Infants : bulging fontanel, high pitch cry, poor o Ventriculostomy is a new nonshunting
feeding, separated sutures procedure
o Older children and adults
o Progressive decreased LOC, Projectile • Provide pre-operative nursing care
vomiting , headache, changes in behavior, o Assess head circumference, fontanel’s,
seizures , ipsilateral pupillary dilatation, cranial sutures and LOC
contralateral hemiparesis o Firmly support head and neck when
o Initial signs among adults: change in LOC , holding the child
headache, lethargy, inc dizziness and o Provide skin care for the head to
bradypnea prevent breakdown
o LATE SIGNS IICP: widening pulse pressure, inc o Give small frequent feedings to
BP, slowed HR decrease the risk of vomiting
• Provide post operative nursing care
Nursing Care: Priority : Maintain patent airway
& ventilation o Assess for signs of inc ICP and check
• Prevent hypoxia and hypercarbia the ffg: head circumference, ant.
fontanel for size and fullness and
• Maintain fluid balance ( 1200-1500 ml/ day)
behavior
• Elevate HOB to 30-45 degrees & neck on o Administer prescribed medications:
neutral position antibiotics, analgesics
• Prevent further inc in ICP o Provide shunt care
• Quiet and comfortable environment  Monitor for shunt infection and
• No straining: give stool softeners malfunction which may be
• Prevent vomiting : antiemetic char. By a rapid onset of
• Prevent excessive coughing vomiting, severe headache,
irritability, lethargy, fever,
• Administer medications as ordered
redness along the shunt tract
o Hyperosmotic agents (mannitol) and fluid around the shunt
o Corticosteroids ( dexamthesaone) valve
o Diuretics ( furosemide)  Prevent infection
o Anticonvulsants ( phenytoin) • Teach home care
o Analgesics o Encourage parents to provide as
normal lifestyle as possible
B. HYDROCEPHALUS o Explain how to recognize s/sx of inc ICP
and shunt malfunction: headache and
- An imbalance of CSF absorption lack of appetite ( earliest common sign
or production, caused by of shunt malfunction)
malformations, tumors, o Explain importance of routine medical
hemorrhage, infections or trauma check ups
- Results in head enlargement
and increased ICP
C. HEAD INJURIES
- Most commonly due to vehicular accidents
- Concussion : severe blow on the head/ a jarring
of the brain within
the skull with
temporary loss of
consciousness
NURSING ASSESSMENT - Contusion: a
o Infant : increased head circumference, anterior bruising type of
fontanel tense(bulging), scalp veins dilated, injury to the brain, it
frontal bossing, sunset eyes may occur with
o Child : behavior changes such as irritability and subdural or
lethargy, headache upon awakening, nausea extradural
and vomiting, nystagmus collections of blood
 - Hemorrhage : 1. Epidural 2. Subdural 3. o Encourage nutrient – dense diet to compensate
Subarachnoid 4. Intracerebral for antibiotic impact on nutritional status
- Fracture : 1. Linear 2. Comminuted 3. o Provide care for the client requiring brain
Depressed 4. Basilar surgery
o Explain the need to complete prescribed
NURSING ASSESSMENT therapy of antibiotics and continue
anticonvulsant therapy
• Leakage of blood o Instruct client to seek prompt treatment for
or CSF from nose/ otitis media, sinusitis and dental and other
ears infections
• Battle’s sign
• Raccoon eyes Treatment
o Large doses of antibiotics
o In severe cases, a craniotomy may be
performed to allow removal of abscess
o Anticonvulsants to control seizures

Diagnosis : Skull X-ray, CT Scan, MRI E. INTRACRANIAL TUMORS

Nursing Care - Abnormal growths within the cranium

- Benign or malignant
o Maintain patent airway and adequate - Primary or secondary
ventilation
o Observe for CSF leakage
o (+) Testape or Dextostix Testt for glucose, NURSING ASSESSMENT
bloody spot encircled by watery pale ring
o Never clean the ears or nose, suction nose • Headache is the most common
unless ordered by doctor
o If SCF leak is present • Papilledema
o Never blow nose; HOB elevated 30
degrees as ordered • Nausea & vomiting, dizziness / vertigo
o Place cotton ball in the ear to absorb
otorrhea, replace frequently
o Gently place sterile gauze pad at the • Seizures, motor / sensory loss
bottom of the nose for rhinorrhea
Diagnosis: CT scan, MRI, Angiography
o Observe signs of meningitis and give
antibiotics as ordered
Nursing Care
o Prepare client for surgery as indicated
o Depressed skull fracture: removal or o Medications as ordered
elevation of splintered bone; o Psychological support
debridement and cleansing of area; o Preparation for surgery
repair of dural tear if present ;
o Craniotomy – surgical opening into the
cranioplasty ( if necessary for large
skull
cranial defect)
o Cranioplasty- repair of a cranial defect
o Epidural, subdural hematoma:
with a metal or plastic plate
evacuation of hematoma
o Craniectomy – excise portion of the
skull and removed permanently
D. BRAIN ABSCESS  Post Op: Check ABC
- Collection of free & encapsulated pus in the • Supratentorial incision :
brain , occurs when there is an infection in Semi fowlers
another region on the body that spreads to the • InFrantentorial Incision:
brain or after a penetrating head wound Flat
o No straining
NURSING ASSESSMENT o WOF seizures, decrease LOC, signs of IICP
• Headache o Rehabilitation for residual deficits
• Malaise and anorexia
• Fever
• Nausea and vomiting F. SPINAL CORD INJURY
• Weight loss
• Focal deficits based on site: vision loss, paresis,
seizures, personality changes

Nursing Care
 • Immobilize and maintain spinal alignment :
cervical tongs, cervical collar, spinal board or
halo traction
• Prevent pneumonia and atelectasis turn
q2hours; cough and DBE q1hr.
• Maintain fluid and electrolyte balance and
nutrition
- Par tial • Check bowel sounds before feeding (paralytic
or ileus) : clear liquids to RD
• Prevent complication of immobility
footboard/high topped sneakers to prevent
footdrop; splint for quadriplegic clients to
prevent wrist drop
• Maintain urinary catheterization; increase fluid
intake
• Maintain bowel elimination stool softeners,
suppositories to prevent fecal impaction

Surgery: decompression laminectomy & spinal fusion

complete disruption of nerve tracts and LEVEL OF FUNCTIONAL SELF-CARE
neurons resulting in paralysis , sensory loss, INJURY ABILITY CAPABILITY
altered reflex activity and autonomic nervous C5,c4,c3 and Inability to control Unable to care for
system dysfunction above muscles of self, life sustaining
- Etiology: MVA, falls, sporting and industrial breathing, no upper ventilator support
extremity muscle essential
accidents
functions
C6 Muscle functions in May self propel a
NURSING ASSESSMENT C5 level; partial light weight
• Spinal shock – absence of reflexes below the strength in wheelchair, may
lesion, flaccidity, hypotension, bradycardia, pectoralis major feed self with
retention devices, can write
and care for self,
can transfer from
Diagnosis : Spinal X-ray chair to bed
C7 Muscle function in Can dress lower
CLASSIFICATION OF CORD INVOLVEMENT C6 level, no finger extremities,
a. FUNCTIONAL DEFICIENCIES : muscle power minimal assistance
1. Quadriplegia (C1-C8) injury – paralysis of needed,
all four extremities; lesions above C6 independence in
causes respiratory depression wheelchair, can
drive car with hand
2. Paraplegia (T1-L4) injury – paralysis of the
controls
lower half of the body involving both legs C8 Muscle function in Same as C7; in
EXTENT OF INJURY C7 level, finger general, activities
a. Complete cord transaction muscle power easier
a. Loss of all voluntary movement and T1-T4 Good upper Some
sensation below the level of injury extremity muscle independence from
b. Reflex activity may return to normal strength wheelchair, long leg
after the spinal shock resolves and if braces for standing
blood supply to cord below injury is exercises
T5-L2 Balance difficulties Still requires
intact
wheelchair, limited
b. Incomplete lesions: varying degree or motor or ambulation with
sensory loss below the level of the lesion long leg braces and
depending on which neurologic tracts are crutches
damaged and which are spared. L3-L5 Trunk pelvis muscle May use crutches or
function intact canes for
Autonomic dysreflexia – occurs in clients with lesions ambulation
above T6, most often those with cervical injuries, after L5-S3 Waddling gait Ambulation
spinal shock has resolved
- Acute emergency – results in exaggerated
G. BELLS PALSY ( FACIAL PARALYSIS)
autonomic responses to stimuli ( most often
distended bladder or impacted rectum) – treat
immediately to prevent stroke - It is caused by a lower motor neuron lesion of
the seventh cranial nerve that may result from
infection, trauma, hemorrhage, meningitis or a
Nursing Care tumor
ACUTE CARE - It results in paralysis of one side of the face
• Assess ABC: suction, tracheostomy set; jaw - Recovery usually occurs in few weeks without
thrust maneuver residual effects
NURSING ASSESSMENT
-Episodes of abnormal
o Flaccid facial muscles motor, sensory or
o Inability to raise the eyebrows, frown, smile, autonomic due to abnormal
close the eyelids and puff out the cheeks discharge from brain cells.
o Upward movement -Epilepsy – chronic
of the eye when recurrent seizures
attempting to close - Etiology : infantile
the eyelid fever, head injury,
o Loss of taste hypertension, CNS infection, brain tumor or
metastasis, drug withdrawal, stroke
Nursing Care
Types of Seizure
• Encourage facial exercises to prevent the
loss of muscle tone ( a face sling may be 1. Generalized seizures(bilaterally symmetric;
prescribed) without local onset)
• Protect the eyes from dryness and prevent a. Major motor seizure (grand mal) : aura;
injury usually starts with tonic or stiffening
phase ffd by clonic or jerking phase;
• Promote frequent oral care
may have bowel/bladder incontinence;
• Instruct the client to chew on the unaffected
in posticatal phase, sleeps hard to
side
arouse
b. Absence seizure (petit mal) : sudden
H. TRIGEMINAL NEURALGIA onset, with twitching or rolling of eyes;
lasts a few seconds, brief lapse of
-It is a sensory disorder of the 5th cranial nerve consciousness
-It results in severe, recurrent, sharp, facial pain c. Myoclonic: a seizure that presents a
along the trigeminal nerve brief generalized jerking or stiffening of
extremities; the victim may fall to the
ground from the seizure
NURSING ASSESSMENT d. Atonic or Akinetic ( drop attacks): a
o Client has pain on the lips, gums, or nose or sudden momentary loss of muscle
across the cheeks tone; the victim may fall to ground as a
o Situations that stimulate the symptoms result of the seizure
o Cold e. Febrile seizure : common under 5 years
o Washing the of age; seizure occurs only when fever
face is rising. EEG is normal 2 weeks after a
o Chewing seizure
o Food or 2. Partial seizures (seizure beginning locally)
fluids of a. Psychomotor seizure : may follow
extreme trauma, hypoxia, drug use; purposeful
but inappropriate repetitive motor acts;
aura present, dreamlike state
b. Simple partial seizure : seizure
temperatures confided to one hemisphere of the
brain. NO LOSS OD CONSCIOUSNESS;
Nursing Care maybe motor , sensory or autonomic
symptoms
• Instruct the client to avoid hot or cold foods c. Complex partial seizure : begins in
and fluids focal area but spreads to both
• Provide small feedings of liquid and soft foods hemispheres; impairs consciousness;
maybe preceded by an aura
• Instruct the client to chew food on the
d. Jacksonian seizure: twitching begins at
unaffected side
distal end of extremity, eventually
• Administer medications as prescribed
involving entire extremity and possibly
o Elavil, tegretol, valium, dilantin, entire side of the body; no loss of
consciousness, not commonly seen in
Surgery children
• An alcohol injection along the affected portion 3. Status epilepticus : usually refers to grand mal
of the nerve to produce anesthesia of the seizures; prolonged (repeated seizures without
nerve may provide relief of pain for up to 16 regaining consciousness) and unresponsive to
hours treatment; can result in hypoxia and possible
• Janetta procedure surgically relocates the cardiac arrest
artery that is compressing the trigeminal nerve
NURSING ASSESSMENT (tonic-clonic seizure)
o Aura or warning sensation ( seeing spots or
I. SEIZURES feeling dizzy)
 o Loss of consciousness during seizure - Loss of brain functions caused by loss of blood
o Lethargy often follows return to consciousness circulation to areas of the brain. The specific
(postictal phase) neurologic deficits may vary depending on the
o Pupils become fixed and dilated location, extent of the damage, and cause of the
o Often the client cries out as seizure begins or disorder.
- CVA is a syndrome in which the cerebral
as air is exhaled forcefully
circulation is interrupted causing neurological
o Tonic clonic movement of the muscles
deficits. Cerebral anoxia lasting longer than 10
o Incontinence and abnormal EEG
minutes causes cerebral infarction with
irreversible change.
Nursing Care - Etiology : embolism, thrombosis , hemorrhage, TIA
During seizure activity Stages of Development
• Protect form injury;
prevent falls, support TIA Stroke in Evolution Completed Stroke
head, decrease <24 hrs hrs-days deficits for 2-3
external stimuli, do not days
restrain, do not use
tongue blade, loosen Manifestations of Right Brain and left Brain
clothing Stroke
• Keep airway open: side Right Brain Damage Left Brain Damage
lying position, suction ( stroke on right side of ( stroke on left side of
excess mucus the brain) the brain)
• Observe and record Paralyzed left side : Paralyzed right side:
seizure hemiplegia hemiplegia
Left – sided neglect Impaired speech /
o Note any pre-
Spatial –perceptual language aphasia
ictal phase:
deficits Impaired right / left
fear, anxiety,
Tends to deny or discrimination
hallucinations,
minimize problems Slow performance,
de javu
Rapid performance, cautions
symptoms
short attention span Aware of deficits:
o Note nature of Impulsive, safety depression, anxiety
the ictal phase: symmetry of problems Impaired comprehension
movement, response to stimuli, LOC, Impaired judgment related to language,
respiratory pattern Impaired time math
o Note post-ictal phase : amount of time concepts
it takes to orient to time and place ;
sleepiness
• Provide client teaching and discharge planning
• Need to drug therapy
• Wear a medic-alert identification bracelet or
carry ID
• Availability of support group and community
agencies

Drug Therapy (Anticonvulsants)

Neurological Assessment in CVA
• Phenytoin (Dilantin)- most commonly used can  Changes in LOC
only be administered within normal saline and  Signs of IICP
levels are monitored; therapeutic level is 10-20  Assessment of Cranial Nerves
mg / dl; side effects include gum hyperplasia, o V – difficulty with chewing
hirsutism, ataxia, gastric distress, nystagmus, o VII – facial paralysis or paresis
anemia and sedation o IX and X – dysphagia; absent
• Phenobarbital – reduce emotional stress gag reflex
• Carbamazepine ( Tegretol) is use in tonic-clonic o XII – impaired tongue
, complex partial seizure movement
• Diazepam (Valium) used for status epilepticus Order in which function may return : FACIAL-
SWALLOWING, LOWER LIMB, SPEECH AND ARM
Surgery
• To remove tumor, hematoma or epileptic focus
NURSING ASSESSMENT
J. CEREBROVASCULAR ACCIDENT (STROKE) o Decrease LOC, cognitive changes
o Weakness or paralysis
- Destruction / infarction of brain cells caused by o Speech deficits ( dysphonia, dysarthria,
reduction in cerebral blood flow & oxygen aphasia)
 o Urinary / bowel incontinence
o Agnosia
o Apraxia
o Hemianopsia
o Homonymous hemianopsia
o Neglect syndrome (unilateral negect0
o Proprioception alterations
Nursing Care
Priority: Patent airway and ventilation
• Proper positioning and body alignment
• Head of bed elevated at 30-45 degrees
• Position change q 2 hrs
• Passive ROM exercises q 4 hrs
• Promote nutrition
• Maintain adequate elimination
• Provide quiet and restful environment
• Prevent injury
• Establish means of communication with patient
• Promote self care activities
• Administer ,medications as ordered
Rehabilitation
• Hemiplegia
o Support paralyzed arm on pillow or use
sling
o Elevate extremities to prevent
dependent edema
o Provide active and passive ROM
regularly
o Institute safety measures at all times
• Homonymous Hemianopsia
o Approach client on UNAFFECTED side
o Place food, personal belonging on the
UNAFFECTED side
o Teach client to compensate by
SCANNING
• Receptive Aphasia
o Give simple, slow and clear directions
o Stand within 6 feet and face client
directly
o Give 1 command at a time, gradually
shift topics
o Use non-verbal techniques
o Talk without pressing a response
• Expressive Aphasia
o Listen and watch carefully when client
attempts to speak
o Anticipate client’s needs to decrease
frustration
o Allow sufficient time for the client to
answer
o Begin with simple words then progress
later
K. CEREBRAL ANEURYSM
- Cerebral aneurysm is dilation of the walls of
the weakened cerebral artery
- Aneurysm can lead to rupture
NURSING ASSESSMENT
o Headache
o Pain
o Diplopia
o Blurred vision
o Tinnitus
o Nausea
o Hemiparesis
o Nuchal rigidity
o Irritability
o Seizure
Nursing Care
• Maintain a patent airway
• Administer oxygen as prescribed
• Monitor vital signs and for hypertension or
dysrhythmias
• Avoid taking temperatures via the rectum
• Initiate aneurysm precautions
o Maintain bed rest in semi fowler or side
lying position
o Maintain a darkened room without
stimulation
o Limit visitors
o Maintain fluid restrictions
o Avoid stimulants in the diet
Figure 38-10 Types of aneurysms. (A) A berry
aneurysm is a small sac on a stem or stalk. (B) A
saccular aneurysm is formed from a distended small
portion of the vessel wall. (C) A fusiform aneurysm is
an enlarged area of the entire blood vessel. (D) A
dissecting aneurysm is formed when blood fills the
area between the tunica media and the tunica intima.
L. CNS INFECTIONS
- MENINGITIS: bacterial infection of pia, arachnoid &
CSF leading to inflammation of meninges
- ENCEPHALITIS: inflammation of the brain , caused
by a virus, may occur as a sequala of measles,
mumps, chickenpox
NURSING ASSESSMENT
o Headache – most common
o Fever & chills
 o Dizziness, vomiting, malaise autoimmune response or vital
infection.
- Precipitating factors include pregnancy,
fatigue, stress, infection and trauma.
- Electroencephalogram findings are
abnormal.
- A lumbar puncture indicates increased
gammaglobulin, but the serum globulin
o Photophobia, irritability level is normal.
o Signs of meningeal irritation
o Nuchal rigidity: stiff neck NURSING ASSESSMENT
o Opisthotonos: head and heels bent o Fatigue and weakness
backward and body o Ataxia and vertigo
arched forward o Tremors and spasticity of the lower
o Kernig’s sign: extremities
supine position, o Parasthesias
thigh and knee o Blurred vision and diplopia
flexed to right o Nystagmus
angle, .extension of o Dysphasia
leg causes spasm o Decreased perception to pain, touch
of hamstring, and temperature
resistance and pain o Bladder and bowel disturbances,
o Brudzinki’s sign: flexion of head causes including urgency, frequency, retention
flexion of both thighs at hips and knee and incontinence
flexion o Abnormal reflexes, including
hyperreflexia, absent reflexes and a
DIAGNOSIS : Lumbar puncture – measurement and positive Babinski’s reflex
analysis of CSF shows increased pressure, elevated o Emotional changes such as apathy,
WBC and protein, decrease glucose and culture euphoria, irritability and depression
positive for specific microorganism o Memory changes and confusion

Nursing Care
• Give large doses of antibiotics as ordered Nursing Care
• Isolation precaution for 24 hours after initiation • Provide bed rest during exacerbation.
of treatment • Protect the client from injury by
• Provide nursing care for increase ICP, seizures providing safety measures.
and hyperthermia • Place an eye patch on the eye for
• Bedrest in quiet and dark room diplopia.
• Dirt: high protein, high carbohydrates, small • Monitor for potential complications
frequent meals such as urinary tract infections
calculuses decubitus ulcers respiratory
• Administer medications as ordered tract infections and contractures.
• Maintain fluid and electrolyte balance • Promote regular elimination by bladder
• Prevent complications of immobility and bowel training.
• VS and neuro checks regularly • Encourage independence.
• Rehabilitation for residual deficits • Assist the client to establish a regular
exercise and rest program.
• Instruct the client to balance moderate
PART TWO activity with rest periods.
• Assess the need for and provide
A. MULTIPLE SCLEROSIS assistive devices.
- Multiple sclerosis is a chronic, • Initiate physical and speech therapy.
progressive, non-contagious, • Instruct the client to avoid fatigue,
degenerative disease stress, infection, overheating and
of the CNS chilling.
characterized by • Instruct the client to increase fluid
demyelinization of intake and eat a balanced diet,
the neurons. including low-fat, high-fiber foods and
- Multiple sclerosis foods high in potassium.
usually occurs • Instruct the client in safety measures
between the ages of related to sensory loss, such as
20 and 40 and regulating the temperature of bath
consists of periods of remissions and water and avoiding heating pads.
exacerbations. • Instruct the client in safety measures
- The causes are unknown, but the related to motor loss, such as avoiding
disease is thought to be a result of an
 the use of scatter rugs and using b. Pyridostigmine bromide
assistive devices. (Mestinon, Regonol)
• Instruct the client in the self- c. Edrophonium chloride
administration of prescribed (Tensilon)
medication 3. Side effects
a. Sweating
b. Salivation
c. Nausea
d. Diarrhea and abdominal
cramps
B. MYASTHENIA GRAVIS e. Bradycardia
f. Hypotension
- Myasthenia gravis is a neuromuscular
disease characterized by considerable
weakness and abnormal fatigue of the
voluntary muscles. 4. Interventions
- A defect in the transmission of nerve a. Administer medications on
impulses at the myoneural junction time.
occurs. b. Administer medication 30
minutes before meals with milk
- Causes include insufficient secretion of
and crackers to reduce
acetylcholine, excessive secretion of
gastrointestinal upset.
cholinesterase and unresponsiveness
c. Monitor and record muscle
of the muscle fibers to acetylcholine.
strength.
d. Note that excessive doses lead
NURSING ASSESSMENT
to cholinergic crisis.
o Weakness and fatigue
e. Have the antidote (atropine
o Difficulty chewing
sulfate) available.
o Dysphagia
o Ptosis Myasthenic crisis
o Diplopia 1. Description
o Weak, hoarse voice a. Myasthenic crisis is an acute
o Difficulty breathing exacerbation of the disease.
o Diminished breath sounds b. The crisis is caused by a rapid,
o Respiratory paralysis and failure unrecognized progression of
the disease, an inadequate
Nursing Care amount of medication,
• Monitor respiratory status and ability to infection, fatigue or stress.
cough and deep breathe adequately. 2. Assessment
• Monitor for respiratory failure. a. Increased pulse, respirations
• Maintain suctioning and emergency and blood pressure.
equipment at the bedside. b. Anorexia and cyanosis
• Monitor vital signs. c. Bowel and bladder
• Monitor speech and swallowing abilities incontinence
to prevent aspiration. d. Decreased urine output
• Encourage the client to sit up when e. Absent cough and swallow
eating. reflex
3. Interventions
• Assess muscle status.
a. Assess for signs of myasthenic
• Instruct the client to conserve strength. crisis.
• Plan short activities that coincide with b. Increase anticholinesterase
times of maximal muscle strength. medication.
• Monitor for myasthenic and cholinergic Cholinergic crisis
crises. 1. Description
• Administer anticholinesterase a. Cholinergic crisis results in
medications as prescribed. depolarization of the motor end
• Instruct the client to avoid stress, plates.
infection, fatigue and over the counter b. The crisis is caused by
medications. overmedication with
• Instruct the client to wear a Medic-Alert anticholinesterase.
bracelet. 2. Assessment
a. Abdominal cramps
Anticholinesterase medications b. Nausea, vomiting and diarrhea
1. Action: Increase levels of acetycholine c. Blurred vision
at the myoneural junction. d. Pallor
2. Medications e. Facial muscle twitching
a. Neostigmine bromide f. Hypotension
(Prostigmin) g. Pupillary miosis
 3. Interventions o Handwriting that becomes
a. Hold anticholinesterase progressively smaller
medication. o Tremors in hands and fingers at rest
b. Prepare to administer the (pill rolling)
antidote, atropine sulfate, if o Tremors increasing when fatigued and
prescribed. decreasing with purposeful activity or
sleep
Tensilon Test o Rigidity with jerky interrupted
1. Description: The Tensilon Test is
movements
performed to diagnose myasthenia
o Restlessness and pacing
gravis and to differentiate between
o Blank facial expression-mask –like
myasthenic crisis and cholinergic crisis.
2. To diagnose myasthenia gravis faces
a. Edrophonium (Tensilon) o Drooling
injection is administered to the o Difficulty swallowing and speaking
client. o Loss of coordination and balance
b. Positive for myasthenia gravis: o Shuffling steps, stooped position and
Client shows improvement in propulsive gait
muscle strength after the
administration of Tensilon.
c. Negative for myasthenia Nursing Care
gravis: Client shows no • Assess neurological status.
improvement in muscle • Assess ability to swallow and chew.
strength and strength may • Provide high-calorie, high-protein, high-
even deteriorate after injection fiber soft diet with small, frequent
of Tensilon. feedings.
3. To differentiate crisis: • Increase fluid intake to 2000 mL/day.
a. Myasthenic crisis: Tensilon is • Monitor for constipation.
administered, and if strength • Promote independence along with
improves, the client needs safety measures.
more medication. • Avoid rushing the client with activities.
b. Cholinergic crisis: Tensilon is • Assist with ambulation and provide
administered and if weakness assistive devices.
is more severe, the client is • Instruct the client to rock back and
overmedicated; administer forth to initiate movement.
atropine sulfate, the antidote • Instruct the client to wear low-heeled
as prescribed. shoes.
• Encourage the client to lift feet when
C. PARKINSON’S DISEASE
walking and to avoid prolonged sitting.
- Parkinson’s disease • Provide firm mattress and position the
is a degenerative client prone, without pillow to facilitate
disease caused by proper posture.
the depletion of • Instruct in proper posture by teaching
dopamine, which the client to hold the hands behind the
interferes with the back to keep the spine and neck erect.
inhibition of • Promote physical therapy and
excitatory rehabilitation.
impulses. • Administer anticholinergic medications
- Parkinson’s disease results in a as prescribed to treat tremors and
dysfunction of the extrapyramidal rigidity and to inhibit the action of
system. acetylcholine.
- Parkinson’s disease is a slow, • Administer antiparkinsonian
progressive disease that results in a medications to increase the level of
crippling disability. dopamine in the CNS.
- The debilitation can result in falls, self- • Instruct the client to avoid foods high in
care deficits, failure of body systems vitamin B6 because they block the
and depression. effects of antiparkinsonian
- Mental deterioration occurs late in the medications.
disease. • Instruct the client to avoid monoamine
oxidase inhibitors because they will
NURSING ASSESSMENT precipitate hypertensive crisis.
o Bradykinesia, abnormal slowness of
movement and sluggishness of
physical and mental responses D. GUILLAIN-BARRE SYNDROME
o Akinesia
o Monotonous speech
 - It is an acute infectious neuronitis of
the cranial and NURSING ASSESSMENT
peripheral nerves o Fatigue
- The immune o Fatigue while talking
system o Muscle weakness and atrophy
overreacts to the o Tongue atrophy
infection and o Dysphagia
destroys the o Weakness of the hands and arms
myelin sheath
o Fasciculation of the face
- The syndrome
o Nasal quality of voice
usually is
preceded by a o Dysarthria
mild upper
respiratory infection or gastroenteritis
- The recovery is a slow process and can Nursing Care
take years • Care is directed toward the
- The major concern is difficulty treatment of symptoms
breathing Monitor respiratory status
Provide respiratory treatments
NURSING ASSESSMENT Prepare to initiate respiratory support
o Paresthesias Assess for complications of immobility
o Weakness of lower extremities Provide the client and family with support
o Gradual progressive weakness of upper extremities
and facial muscles
o Possible progression to respiratory failure
o Cardiac dysrhythmias
o Cerebrospinal fluid that reveals an elevated protein
level
o Abnormal EEG Nursing Care
• Care is directed toward the treatment of
symptoms
• Monitor respiratory status
• Provide respiratory treatments
• Prepare to initiate respiratory support
• Monitor cardiac status
• Assess for complications of immobility
• Provide the client and family with support

E. AMYOTROPHIC LATERAL SCLEROSIS

- Also known as Lou Gehrig’s disease

- It is a progressive degenerative disease
involving the motor system
- The sensory
and autonomic
systems are
not involved
and mental
status
changes does
not result from
the disease
- Cause of the
disease is
related to increase glutamate, a
chemical responsible for relaying
messages between the motor neurons
- As the disease progresses, muscle
weakness and atrophy develop until a
flaccid quadriplegia develops
- Eventually the respiratory muscle
become affected leading to respiratory
compromise, pneumonia and death
- No cure is known and the treatment is
symptomatic