1st Session

2nd Session

Home

3rd Session

4th Session

Hydrocephalus

Characterized by an increased in the amount of CSF within the ventricle of the brain.

Types Communicating Noncommunicating

Characterized by an increased in the amount of CSF within the ventricle of the brain.

Types Communicating Noncommunicating

Types
Communicating Also known as non-obstructive or Extraventricular Impaired absorption of CSF in subarachnoid space Non-communicating Also known as obstructive or Intraventricular Obstruction to the flow of CSF within the ventricle

Predisposing Factors Genetics Age Precipitating Factors Prematurity Hemorrhage Idiopathic Infection Tumor
Increase intraventricular Pressure dilatation of pathways proximal to the site of obstruction

CSF forms in the Choroid plexus of the lateral ventricle

Obstruction in the aqueduct of Sylvius

Dilatation of the 3rd and lateral ventricles

Obstruction of CSF flow through the ventricular system

Ventricles enlarge and disrupts the ventricular lining and the underlying white mater

Increase water content

Edematous parenchyma become spongy

Enlaged head, bulging fontanelle, shiny scalp, dilated scalp veins

Interhemispheric fissure become elongated and thinned out

Axonal and myelin destruction

Expansion of the skull and thinning and atrophy

Irritability, lethargy, sleepiness, reduced activity and drowsiness

Alteration in cerebral circulation

Signs and Symptoms

Increase head circumference Cranial suture separation

Downward rotation of eyes

Increased ICP

Increased ICP may occur with an increased in the CSF volume, blood entering the CSF, cerebral edema, or space occupying lesions such as tumors. ICP normally ranges from 1-10 mmHg. A level greater than 15 mmHg is considered abnormal. ICP monitoring can be used to estimate cerebral perfusion pressure (CPP) or cerebral blood flow. Normal CPP is at least 50 mmHg. Cerebral circulation ceases if ICP ever exceeds

CPP is calculated by subtracting the mean intracranial pressure (MICP) from the mean arterial pressure (MAP) MAP-MICP = CPP Mean arterial pressure is determined by subtracting the diastolic B/P (DBP) from (SBP) reading, dividing the result by 3, then adding the sum to 80. MAP=(SBP-DBP)/3+80

Follow this example:

A child has a blood pressure of 100/70 mmHg and an ICP of 10 mmHg. Using the formula, calculate the MAP.

3 incompressible elements : - Brain tissue -CSF - Blood

Expansion of any one of these incompressible elements must be balanced by proportional constriction of one or both or there will be an increase in ICP.

Diagnostics Tests
Serial Transilluminations
CT Scan

Management
Shunting (Ventriculoperitoneal & Ventriculoatrial) Insertion of a flexible tube into the lateral ventricle of the brain (peritoneum or right atrium)

Medications
Acetazolamide (Diamox)

Isosorbide osmotic diuretics

Furosemide (Lasix) Mannitol (Osmotril) Corticosteroids Dexamethasone (Decadron)

Anticonvulsants Phenytoin (Dilantin)

Analgesics

Nursing Responsibility
1. Pre-op care 2. Check neuro status 3. Post-op care
DO NOT flex neck on the side where the shunt is placed Observe for signs of infection Observe for signs of ICP

4. Parental teaching

H-ead of bed (not more than 30 ) E-valuate A-irway D-rainage S-afety

Prognosis
If treated Learning Disabilities Memory Deficits Psychological Deficits Motor Skill Disabilities Hearing Difficulties Vision Problem Seizure Hormonal Imbalance

If not treated Decrease cerebral perfusion Decrease PO2 leading to hypoxia Brain damage DEATH

Neural Tube Defects

Abnormalities that are derived from the embryonic neural tube Constitute the largest group of congenital anomalies that is consistent with multifactorial inheritance Prevention
Intake of 0.4mg of folic acid in women of childbearing age will prevent 50%-70% of all cases of neural tube defects

Encephalocele

is a neural tube defect characterized by sac-like protrusions of the brain and the membranes that cover it through openings in the skull.

Folic Acid Deficit

Unformed Occipital area of the skull, nasal or nasopharyngeal

Protrusion of brain and meninges covered fully by skin, & dura

No motor and no sphincter

Continuous voiding and defecation

Incidence Frequently associated with other cranial (head, skull, or brain) and/or facial abnormalities. Approximately 1-4 per 10,000 live births. Only half survive to birth.

Commonly in females than males.

Cause is unknown

Diagnostic Tests

Ultrasound
The alpha-fetoprotein levels are not typically elevated with this defect because the defect is covered by skin Thorough examination Fetal MRI by perinatologists

Management
Surgery
Done between birth to 4 months of age. Done more quickly if there is no skin covering over the defect or if there is hemorrhage, airway obstruction or impairment of vision. When surgical correction is not urgent, the baby is evaluated for other problems before surgery.

Management
Palliative Care Support the baby with food, comfort and oxygen as needed, but no surgical procedures are done and the baby's life is not extended with any type of life support machinery. These babies can even go home with hospice support if that is desired.
if large and with other anomalies

Spina Bifida

is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube.

Spina bifida may also be nearly inconsequential, or may be reparable through surgery

is a developmental congenital disorder caused by the incomplete closing of the embryonic neural tube.

Types

Spina bifida occulta Hidden

Spina bifida cystica Vissible

Spina bifida occulta

Occurs very frequently and is usually found accidentally in x-rays or in an examination of the back.

Normal Newborn Vertebra

Spina bifida occulta

Spina bifida occulta In some cases may cause: Chronic back pain Enuresis Cold feet Lateness in learning to walk

Spina bifida cystica

Besides fissures of the osseous structures, one also finds abnormalities of the meninges and/or of the spinal cord itself. The membranous covering can be present or absent.

Spina bifida cystica

Subdivided into 3 types

Meningocele Myelomeningocele *(with or without cysts) Myeloschisis

The mildest form is the meningocele where merely the meninges protrude under the skin through the cleft in the malformed vertebral arch.

Normal Newborn Vertebra

Meningocele

Myelomeningocele meninges as well as the spinal cord (myelon) are found outside of the vertebral arch. They are visible as a protrusion under the skin.

Normal Newborn Vertebra

Myelomeningocele

In addition, the central canal is bloated and forms a cyst. In this case one speaks of a myelocystomeningocele

Normal Newborn Vertebra

Myelomeningocele

Myeloschisis (rachischisis) is the severest form of the spina bifida cystica. The nerve tissue is here fully bare and a dermal or meningeal covering is absent.

Normal Newborn Vertebra

Myeloschisis

Folic Acid Deficiency

Unformed vertebrae

Lack of sphincter

Protrusion of meninges and spinal cord

Lost of bladder and bowel movement

Damage lower motor and sensory neuron

Continuous dibbling of Urine and stool

Flaccid lax infant legs

Lack of Sensation

Diagnostic Tests
1. Prenatal Ultrasound Amniocentesis 2. Postpartal X-ray CT Scan of skull Myelogram Encephalogram U/A culture & sensitivity BUN Creatinine clearance

Medical Management
Surgery
Closure of the sac Shunt procedure Orthopedic procedures

Drug therapy
Antibiotics Anticholinergic *

Immobilization (casts, brace, traction)

Nursing Interventions
Preventing trauma to the sac
Cover with sterile dressing soaked with normal saline Prone or side-lying position Protective barrier drape Signs of infection Antibiotics

Nursing Interventions
Prevent complications
Signs of hydrocephalus, meningitis, joint deformities Intermittent urinary catheter Medications PROM

Nursing Interventions
Nutrition Sensory stimulation

Emotional support for parents/family Client teaching & discharge planning

Wound care, PT, complications, meds, feeding, diapering, positioning, support/community

Adjust objects according to position Stimulate other senses.

End Here

Cerebral Palsy

a group of non-progressive, noncontagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement.
T y p e s

spastic (stiff and difficult movement) ataxic (disturbed sense of balance and depth perception) athetoid (involuntary and

PRENATAL - Genetics - Altered neurologic development - Trauma or anoxia to mother (TORCH)

PERINATAL - Drugs at delivery - Precipitate delivery - Fetal distress - Breech deliveries with delay

POSTNATAL - Kernicterus - Head trauma (falls/accidents)

DAMAGE TO THE CELLULAR STRUCTURES OF THE UPPER MOTOR NEURON Weak or absent voluntary movt with increased muscle tone SPASTIC TYPE TYPE Muscles become Too tight CEREBELLUM Hypotonia or Atonia BASAL GANGLIA Difficulty initiating movement (Bradykinesia) ATHETOID TYPE = MIXED

ATAXIC TYPE Low muscle tone and poor coordination

Smooth and coordinated movements and Body posture is altered Choreiform movts Ballism Rigidity Dystonia Involuntary grimacing Tongue thrusting Drooling and speech problems

Limb deformities Contractures Hyperreflexia Stiff and jerky movements (limited movt) Have a hard time moving from one position to another. Have a hard time holding and letting go of objects.

Intentional/ terminal tremor Nystagmus Dysdiadochokineasia Dysarthria Unsteady and shaky even when handling small objects Accomploshes tasks slower Wide-based gait

Diagnostic Tests

X-RAY or Sonogram Cerebral assymetry EEG spikes

Nursing Interventions

1. Obtain pregnancy, birth, and childhood history. 2. Observe childs behavior in various situations. 3. Assist with ADL (including feeding) Careful teaching and demonstration. 4. Safety environment. (Pad the crib and wear helmet) 5. Physical therapy prevent contractures and assist in mobility (braces) 6. Discharge and Teaching plan
Nature of the disease Care of orthopaedic devices Need for continued physical, occupational and speech therapy Provision for childs return to school Availability of support group

Reyes Syndrome

An acute encephalopathy with fatty degeneration of the liver Potentially fatal disease that causes numerous detrimental effects to many organs, especially the brain and liver, as well as causing a lower than usual level of blood sugar (hypoglycemia).

The exact cause is unknown, and while it has been associated with aspirin consumption by children with viral illness, it also occurs in the absence of aspirin use.

Cause: UNKNOWN Predisposing factors: or varicella) Genetics Use of SALICYLATES in viral-induced fever and flu (Influenza A & B

FEVER

VOMITING

LOSS OF APPETITE

LISTLESSNESS

Exhaustion of Glycogen HYPOGLYCEMIA ACCUMULATION Signs and symptoms of hypoglycemia Brain Edema CNS Symptoms MOBILIZATION OF FATTY ACID LACTIC ACID

Interfering with mitochondrial function Accumulation of fats In tiny intercellular Vesicles of: HEART KIDNEYS SKELETAL MUSCLES

ACIDOSIS

Liver dysfunction Increased Ammonia Increased bilirubin Increased liver enzymes

Other tissues

Stage 1

Rash on palms of hands and feet Persistent, heavy vomiting that is not relieved by not eating

Generalized lethargy
Confusion Nightmares High fever

Headaches

Stage 2

Stupor caused by encephalitis Hyperventilation

Fatty liver (found by biopsy)

Hyperactive reflexes

Stage 3

Continuation of Stage I and II symptoms Possible coma

Possible cerebral oedema

Rarely, respiratory arrest

Stage 4

Deepening coma Dilated pupils with minimal response to light Minimal but still present hepatic dysfunction

Stage 5

Very rapid onset following stage IV Deep coma

Seizures
Multiple organ failure Flaccidity Hyperammonemia (above 300 mg/dL of blood)

Death

Nursing Management
Stage 1 Assess Hydration Status (Skin turgor, mucous membrane, urine SG) IV Therapy

I&O

Nursing Management
Stage 2 - 5 Assess respiratory status: Note rate, pattern, restlessness, agitation, cyanosis Assess circulatory status: V/S, neck vein distention, skin color and temperature, heart sounds Support child and family: Explain treatment, procedures and conferences Parental and community education

Nursing Management
Stage 1 - 5
Assess neurological status, LOC, pupils, motor coordination, extremity movement, orientation, posturing, seizure activity

Meningitis

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively The inflammation as the meninges

may be caused by infection with viruses, bacteria, or other microorganisms, and less commonly by certain drugs

Meningitis can be life-threatening because of the inflammation's proximity to the brain and spinal cord; therefore the condition is classified as a medical emergency

Cause: Bacteria or Virus Meningococcus (Nissera meningitides) Pneumococcus (Stretococcus pneumoniae) (Haemophilus influenzae) Streptococcus (E coli & Group B Strep)

Predisposing factors: - Hematogenous spread from an URTI, otitis media, or pneumonia - Established infection - Neurosurgical procedure

By way of the predisposing factors, the microorganisms travels through the blood, CSF, and lymphs into the CNS Fever and Chills Increased WBC Causative agent multiplies and sets in infection Activation of inflammatory process CSF Changes

Meningeal inflammation Meningeal irritation Signs and Symptoms 1. Nuchal rigidity 2. (+) Brudzinskis sign 3. (+) Kernigs sign 4. Opisthotonos 5. Photophobia 6. Seizures 7. Vomiting 8. Headache

Veins and arteries traveling in the subarachnoid space become inflamed

1. (+) for the causative agent 2. Increased CHON and Decreased glucose 3. Cloudy CSF 4. Increased CSF Pressure

Vasculitis and endothelial damage causing necrosis of vessel walls and thrombosis Cellular debris and fibrin can block CSF outflow

WATERHOUSEFRIDERICHSEN SYNDROME

HYDROCEPHALUS

INCREASED ICP

CEREBRAL INFARCTION

Assessment Findings Malaise Chills Fever Headache Stiff neck and back Photophobia

Assessment Findings Vomiting Exaggerated deep tendon reflexes Visual alterations (diplopiatwo images of a single object) Confusion Delirium Deep stupor Coma Increase ICP Irritability

Assessment Findings Petechial, purpuric, or ecchymotic rash on the lower part of the body (meningococcal meningitis) Seizures Twitching

Assessment Findings Positive Brudzinkis sign (client flexes hips or knees when the nurse places her hands behind his neck and bends it forward)

Assessment Findings Positive Kernigsign (pain or resistance when the clients leg is flexed at the hip or knee while hes in a supine position)

Assessment Findings Opisthotonos (a spasm in which the back and the extremities arch backward so that the body rests on the head and heels)

Diagnostic Evaluation CSF analysis reveal: WBC count reveals leukocytosis

Elevated pressure
cloudy or milky white high protein level

positive Gram stain and culture

depressed CSF glucose concentration

Nursing Diagnoses
Decreased intracranial adaptive capacity

Hyperthermia
Risk for injury

Collaborative Management

Bed rest Hypothermia I.V. fluid administration O2 therapy, possibly with ET intubation and mechanical ventilation Medications

Antibiotics depending on the isolated microorganism Diuretic: mannitol (Osmitrol) Anticonvulsant: phenytoin (Dilantin), Phenobarbital (Luminal) Analgesic or antipyretic: acetaminophen (Tylenol)

Nursing Interventions Assess neurologic function. Evaluate for an increasing ICP

Watch for deterioration in the clients condition, which may signal an impending crisis
Monitor fluid balance. Maintain adequate fluid intake. Monitor CVP Administer antibiotics, as ordered

Nursing Interventions Watch for adverse reactions to I.V. antibiotics. Position the client carefully to prevent joint stiffness and neck pain Assist with ROM exercises to prevent contracture Implement increased ICP precautions Reassure the family behavioral changes usually disappear to allay anxiety. Follow strict aseptic technique.

Preventive Measures Vaccination meningococcal conjugate vaccine Prophylactic antibiotics

Respiratory isolation

Myasthenia gravis

An autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction, inhibiting the stimulative effect of the neurotransmitter acetylcholine.

Normal

Myasthenia gravis

Assessment

Muscle weakness
Dyspnea/dysphagia / activity Fatigue

Ptosis
Diplopia Impaired speech Strabismus Mask-like facial expression Drooling

Drooping of the eyelid is called ptosis. Ptosis may result from damage to the nerve that controls the muscles of the eyelid, problems with the muscle strength, or from swelling of the lid.

Diagnostic Test

Tensilon Test (Edrophonium)

EMG MRI Serum anti-acetylcholine receptor antibodies

Collaborative Management Assess swallowing / gag reflex Administer meds. 20 30 mins. a.c. Administer meds. at precise time Protect from falls Aspiration precaution Start meal with cold beverage

Adequate ventilation X exposure to infection Adequate rest with activity Plasmapheresis Surgery :Thymectomy Intravenous immune globulin

Collaborative Management

Collaborative Management Pharmacotherapy Cholinergics (Anticholinesterase) Neostigmine (Prostigmin)

Pyridostigmine (Mestinon)
Ambenomium (Mytelase) Glucocorticoids Cytotoxic medication Azathioprine Cyclosporine Cyclophosphamide Antacids

Nursing Management
Myasthenic Crisis
Under medication Respiratory distress

Cholinegic Crisis
Over medication Diaphoresis

Bowel/bladder incontinence

Diarrhea Abdominal cramps Excessive salivation Blurred vision Facial muscle twitching Sudden decrease in BP Bradycardia
Atropine sulfate

Neostigmine

Survival Guide (MG)

Reschedule daily task

Secure handicapped parking sticker Frequent rest periods

Take medications on time (alarm clock)

Eye patch, if with diplopia Start meal with cold beverage X very hot / cold weather X aerosol, pesticides/ cleaners X alcohol, tonic water, cigarette smoke

Multiple Sclerosis

an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms.

women; 30 40 years old Chronic; with remissions/ exacerbations Causes

Unknown Viral Infections Autoimmune Dis.

Multiple foci of demyelination in the white matter (brainstem, SC, optic nerves, cerebrum) then later gray matter

Destruction of myelin sheath (SCHWANNs CELLS)

Interruption / distortion of impulse (slowed / blocked)

Assessment

Diplopia
Scotoma Blindness

Muscle Spasm
Weakness / Numbness Fatigue susceptibility to URTI Emotional Instability Bowel / Bladder Problems

Assessment

Charcots Triad
Scanning speech Intention tremors

Nystagmus
Lhermittes Sign Dysphagia Ataxic Gait

Diagnostic Test CSF - IgG

Clinical Pattern

Clinical Pattern

Collaborative Management Diet Speech Therapy

Plasmapheresis
Muscle Relaxants Baclofen (Lioresal) Physical Therapy Force Fluids Glucocorticoids Prednisone Dexamethasone Corticotropin

Medication

Avonex

Betasero n
Copaxone Rebif

Decrease T-cell Proliferation Decrease number of new lesions

Inhibits antigen specific T-cell activation

End Here

Trigeminal Neuralgia

also called Tic Douloureux Is a painful disorder of one or more branches of the fifth cranial (trigeminal) nerve that produces paroxysmal attacks including facial pain. Incidence:
above 40 more common in women

Can subside spontaneously, with remissions lasting from several months to years.

Possible Causes Unknown Trigeminal nerve compression secondary to tumor Occasionally, it can be a manifestation of multiple sclerosis or herpes zoster

Assessment Findings Searing pain in the facial area Triggers: Light touch to a sensitive area of the face (trigger zone)

Exposure to hot or cold

Eating, smiling, or talking Drinking hot or cold beverages

temperature

Diagnostic Evaluation Skull X-rays, tomography, and CT scan rule out sinus or tooth infections, and tumors

Nursing Diagnoses
Acute pain Powerlessness Anxiety

Collaborative Management
Anticonvusant drugs Carbamazepine (Tegretol) Phenytoin (Dilantin)

Collaborative Management

Nerve block
injection of alcohol or phenol into one or more branches of the nerve. (temporary effect last: 6-18 months)

Collaborative Management

Surgery
Microvascular decompression Radio-frequency Thermal Coagulation (RFTC) Percutaneous Balloon Microcompression

Nursing Interventions Observe and record the characteristics of each attack. Provide adequate nutrition in small frequent meals at room temperature. (Temperature extremes may cause an attack) Place food in the unaffected side of his mouth when chewing.

Health teachings on good oral hygiene.

Reinforce natural avoidance of stimulation.

Bells Palsy

Also known as idiopathic facial paralysis, is a form of facial paralysis resulting from dysfunction cranial nerve VII (the facial nerve) that results in the inability to control facial muscles on the affected side.

Assessment Findings Inability to close eye completely on the affected side Pain around the jaw or ear Unilateral facial weakness Eye rolls upward and tears excessively when the client attempts to close it

Ringing in the ears

Taste distortion on the affected anterior portion of the tongue

Nursing Diagnoses Acute pain Disturbed sensory perception Disturbed body image

Collaborative Management Electrotherapy after the 14th day of prednisone therapy to help prevent facial muscle atrophy

Moist heat
Medications: Corticosteroid: prednisone (Deltasone) to reduce facial nerve edema and improve nerve conduction and blood flow

Nursing Interventions During treatment with prednisone, watch for adverse reactions: GI distress (usually relieved with an antacid) Fluid retention. Immunosuppression

Hyperglycemia (diabetics must be monitored)

Apply moist heat to the affected side of the face, taking care not to burn the skin to reduce pain.

Nursing Interventions Massage the clients face with a gentle upward motion two to three times daily for 5 to 10 minutes. Arrange for privacy at mealtimes to reduce embarrassment Oral care (as residue is common) Psychological support. Give reassurance that recovery is likely within 1 to 8 weeks to allay the clients anxiety.

Cerebrovascular Disease

A group of brain dysfunctions related to disease of the blood vessels supplying the brain. Hypertension is the most important cause; it damages the blood vessel lining, endothelium, exposing the underlying collagen where platelets aggregate to initiate a repairing process which is not always complete and perfect.

Sustained hypertension permanently changes the architecture of the blood vessels making them narrow, stiff, deformed, uneven and more vulnerable to fluctuations in blood pressure.

occurs when there is ischemia(distrupted blood supply) to a part of the brain or hemorrhage into the brain that results in the death of the brain cells.Functions such as movements,sensations or emotions that are controlled by the particular part is affected.

-It occurs due to vascular occlusion and severe hypoperfusion.

-It occurs due to extravasation of blood into the brain and subarachnoid space.

Ischemic Stroke

Hemorrhagic stroke

Causes
Thrombosis Is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system A thrombus starts with damage the endothelial lining of the vessel Atherosclerosis is the primary culprit Atherosclerosis causes fatty materials to deposit and form plaque on vessel walls Thrombotic stroke is the most common type of stroke in people with diabetes

Causes
Embolism Occlusion of a cerebral artery by an embolus An embolus forms outside the brain, detaches and travesls through the cerebral cerculation until it lodges in and occludes a cerebral artery

Causes
Hemorrhage

Result from rupture of a cerebral vessel, which causes bleeding to the brain tissue
Is often secondary to hypertension and most common after 50 years of age Produce extensive residual function lose and have the slowest recovery of all the stroke

Causes
TIA Occurs when the blood supply to a part of the brain is interrupted or totally occluded Ultimate survival of ischemic brain tissue depends on the length of time it is deprived plus the degree of altered brain metabolism Last for few seconds or minute but not more than 24hr.

Causes
TIA Occurs when the blood supply to a part of the brain is interrupted or totally occluded Ultimate survival of ischemic brain tissue depends on the length of time it is deprived plus the degree of altered brain metabolism Last for few seconds or minute but not more than 24hr.

Risk Factors
Hypertension Cardiovascular disease Atrial fibrillation Diabetes mellitus Carotid stenosis hx of TIA

Risk Factors Hyperlipidemia Cigarette smoking

Excessive alcohol consumption

Cocaine use Obesity

Increase dose of estrogen oral contraceptive

Assessment
Sign and symptoms of increase ICP

Perceptual defects
Aphasia Hemianopsia

Collaborative Management
Emergency care

Promote nutrition
Promote activity Promote elimination

Promote communication

Emergency Care

Elevate head but neck should not be flexed

Maintain patent airway

Promote drainage of saliva from the airway

Emergency Care
Restore Cerebral blood flow Using thrombolytic agent Anticiagulant ASA Coumadin Heparin Antiplatelet Thrombolytic therapy Streptokinase (x if > 3 hours)

Contraindication to thrombolytic therapy

More than 3 hours of onset Intercranial hemmorhage of CT scan Intercranial surgery or head trauma Uncontrolled hypertension

Emergency Care
Prevent Complication Bleeding
Cerebral edema Mannitol

Dexamethasone
Non-steroidal anti-inflammatory

Emergency Care
Other complications Coma Hyperthermia

Specific Deficits after Stroke Hemiparesis and Hemiphgia Aphasia Wernickes (Sensory or receptive) aphasia Brocas (Motor or expressive) aphasia Global Aphasia Dysarthria Dysphagia

Specific Deficits after Stroke Visual Changes

Homonymous hemianopsia Binasal hemianopsia

Bitemporal hemianopsia

Specific Deficits after Stroke Horners syndrome Ptosis Anhidrosis Myosis Enophalmia Loss ciliospinal reflex A lag on dilation Agnosia

Specific Deficits after Stroke Unilateral neglects

Failure to attend to one side of the body

Failure to respond to stimuli on one side of the body

Failure to use one extremity

Failure to orient the head and eyes to one side

Collaborative Management Care of the client with aphasia Say one word at a time Identify one object at a time Give simple commands Anticipate needs Allow to verbalize Reinforce success in speech Assist in speech therapy

Collaborative Management

Compensate for Perceptual Difficulties

Care of the client with hemianopsia Approach from the unaffected side

Place articles at the unaffected side

Teach scanning techniques Provide emotional support Provide patient teaching

Rehabilitation Care Physical therapy Occupational therapy Speech therapy

Primary Prevention of Stroke

Maintaining an ideal body weight

Maintaining safe cholesterol levels

Smoking cessation Use of low dose estrogen contraceptives

Reduce alcohol consumption

Eliminate illicit drug use

Secondary Prevention of Stroke Adequate BP control Care of DM Treatment of CVD, TIA and atrial fibrillation

Parkinsons Disease

A degenerative disorder of the central nervous system. It results from the death of dopaminecontaining cells in the substantia nigra, a region of the midbrain; the cause of cell-death is unknown.

Males / Females; 50 60 years Degenerative disease EPS Dopamine (EPS posture, balance, locomotion) Causes:

Unknown Viral Infections Drugs :

phenothiazines reserpine haloperidol methyldopa

Dopamine< acetylcholine Encephalitis Arteriosclerosis CO poisoning

Depigmentation of the substantia nigra of the BASAL GANGLIA Loss of neurons DOPAMINE (loss of inhibitory influence; excitatory Mechanisms are unopposed

Tremors

Pillrolling tremors Resting tremors

Cogwheel rigidity Absence of arm swing Mask -like appearance Drooling Dysphagia

3 Cardinal Signs

Rigidity

Dyskinesia Akinesia Bradykinesia Shuffling gait

Microphonia
Monotomous low voice with poor articulation

Festinating gait

Assessment Moist, oily skin Emotional instability Fatigue Microphonia Micrographia intellectual impairment loss of sensation true paralysis

Diagnostic Test CT SCAN, EEG

Collaborative Management
Diet

residue, Caloric, Soft

Position

to prevent contractures

Firm bed, X pillows Prone position Hold hands folded at the back when walking

Aspiration

precaution fluid intake

Collaborative Management
Anticholinergics

Cogentin (Benztropine Mesylate) Artane ( Trihexyphenidyl) Akineton (Biperidine) s.e. : blurring of vision dryness of mouth / throat constipation urinary retention dysarthria mental disturbance

Collaborative Management
Drugs

Anti Parkinsonian Agents (Dopaminergics)

Levodopa Carbidopa

with Levodopa (Sinemet)

Antiviral / Dopamine Agonists

Amantadine

HCl (Symmetrel) Bromocriptine (Parlodel)

Antispasmodics
Procyclidine

HCl (kemadrin)

Collaborative Management

Avoid the following drugs: (Levodopa)

Phenothiazines, Reserpine, Pyridoxine(Vit. B6) MAOI (Parnate, Marplan, Nardil)

Enhances NE activity Hypertensive crisis Potentiate effect of LEVODOPA)

Methyldopa

Block desired action of Levodopa

Avoid the following foods

B6 rich foods:tuna, pork, dried beans, salmon, beef liver Tyramine rich foods

Collaborative Management

Cheese Cream Yogurt Coffee Chocolate Bananas Raisins Italian green beans Liver Pickled herring sausage

Tyramine-rich foods

Soy sauce Yeast Beer Red wine

Alzheimers Disease

A progressive neurologic disease of the brain leading to the irreversible loss of neurons and the loss of intellectual abilities, including memory and reasoning, which become severe enough to impede social or occupational functioning.

Alzheimer's disease is also known as simply Alzheimer's, and Senile Dementia of the Alzheimer Type (SDAT) .

Memory Loss
Stage
Stage

1
II

Mild memory lapses Obvious short term memory lapses

Stage
Stage

III
IV

Disintegration of personality Terminal stage physical and mental deterioration

Vascular dementia (abnormalities in the vessels that carry blood to the brain) Lewy bodies variant (LBV), also called dementia with Lewy bodies Parkinson's disease Frontotemporal dementia

Diagnostic Test CT Scan Neuropsycho Testing: change in ability to think to test

Collaborative Management
Protect

from injury. Promote activity. Promote sleep. Avoid agitation / violence Avoid fatigue

Change of routine Excessive demands Overwhelming situation Physical stressors

Escalate behavioral dysfunction

Collaborative Management
Avoid

scolding / embarrassing Avoid arguing / reasoning Address by name

Huntingtons Disease

A neurodegenerative genetic disorder that affects muscle coordination and leads to cognitive decline and dementia.

Huntingtons Disease

Normal Brain

Assessment Findings

Loss of musculoskeletal control

Dementia Choreic movements - rapid, usually violent and purposeless; accompanied by Dysarhria (indistinct speech) Athetoid movements (slow, sinuous, writhing movements, especially of hands)

torticollis (twisting of the neck)

Personality change

Diagnostic Test

Family History & S/Sx

CT Scan & MRI Recombinant DNA technology

Management
Neuro check Medications Thiothixene HCl (Navane) & Haloperidol Duanate (Haldol) Reserpine Tetrabenazine Antiparkinsonism drugs (Levodopa) Antidepressants Antipsychotics

Management
Psychotherapy
Surgical implantation of fetal neural allografts Health teaching Medications manage chorea, swallowing problems, limitation in ambulation & losing bowel & bladder function Speech therapy Genetic counseling

Head and Spinal cord Injury

TYPE OF INJURY
Concussion

DESCRIPTION
A blow to the head causes the brain to strike the skull

SYMPTOMS
Headache, transient loss of consciousness, amnesia, nausea

Contusion

A blow to the head causes a bruise to the brain Blood accumulates in the head; can be anywhere Skull is cracked or broken

Decreased level of consciousness, aphasia, hemiplegia Depends on the area affected Headache at site, cerebrospinal fluid leakage from nose or ear.

Hemorrhage

Fracture

Type of injury Acute injury

Description Spinal Shock

Symptoms Absence of reflexes Flaccid paralysis Urine retention Hypotension Bradycardia Temperature lability Traction as indicated -Gardner-Wells (Cervical tongs) - Halo device

Nursing Interventions -ABC - Immobilization -Prevent complications of immobility

Chronic injury

Sensory and motor dysfunction may be partial or complete, based on level of spinal cord injury

-ABC - Prevent complications of immobility -Meticulous pin site care

Care of the Client with SCI

Causes
Falls Diving

Vehicular accident

Care of the Client with SCI

Effects
Paralysis Loss of reflexes

Loss of sensory function

Loss of motor function Autonomic dysfunction

Care of the Client with SCI

Cervical SCI

C4 fatal
Quadriplegia Resp. muscle paralysis

Bowel / bladder retention

Care of the Client with SCI

Thoracic SCI Paraplegia Poor control of upper trunk Bowel / bladder retention Lumbar SCI Paraplegia (flaccid) Bowel / bladder retention

Care of the Client with SCI

Sacral SCI S2 erection

X ejaculation
S2 S4 X erection X ejaculation lesion - probability to perform sexually lesion - probability to perform sexually

Care of the Client with SCI

Paraplegia
Bowel / bladder INCONTENENCE

Collaborative Management
Respiratory function
Immobilize in a flat, firm surface Cervical collar Transport as a unit X attempt to realign body parts Traction Cast

Surgery

(Complications of SCI :SPINAL SHOCK, AUTONOMIC DYSREFLEXIA )

End Here

Brain Tumor

An abnormal mass found in the brain resulting from unregulated cell growth and division. Can cause compression of blood vessels, ischemia, edema, and increased ICP.

Can be primary (originating in the brain tissue) or secondary (metastasizing from another area of the body). Classified according to the tissue or origin
Gliomas - neurological cells Meningiomas meninges

Astrocytomas

Management
Etiology Idiopathic Risk Factors Primary Environmental factors Genetics Viral Theory Immunologic factors Alteration in the regulatory control mechanism of normal cells of brain. (NEOPLASIA) Secondary Benign (meningiomas) Malignant ( Gliomas)

Pathophysiology
Growth of Tumor _______________________________________________

Obstruction of CSF flow nerve Hydrocephalus fxns

Osteoclast stimulation

Focal brain damage

compression of brain & cranial

skull thinning

various alterations of CNS

Increased ICP Altered CNS fxns

Assessment Findings
A

tumor in any area of the brain may lead to:

deficits in cerebral function headache

In the frontal lobe, tumor may lead to: aphasia seizures In the parietal lobe, tumor may lead

to:

motor seizures sensory impairment

Assessment Findings
In

the occipital lobe tumor may lead to:

homonymous hemianopsia (defective vision or blindness affecting the right halves or the left halves of the visual field of the two eyes) visual hallucinations visual impairment

In the cerebellum, tumor impaired coordination impaired

may lead to:

equilibrium

Diagnostic Evaluation
CT scan and MRI shows location and size of tumor

Nursing Diagnoses
Disturbed sensory perception (kinesthetic) Anxiety Risk for injury

Collaborative Management
Craniotomy Radiation

therapy Medications:
anticonvulsant Antineoplastic: vincristine (oncovin), lomustine (CeeNu), carmustine (BiCNU) Diuretic decrease ICP

Glucocorticoid:

dexamethasone (Decadron) relieve inflammation

Nursing Interventions
Assess

status Assess pain. Assess for increased ICP. Monitor V/S, I/O Monitor for signs and symptoms of SIADH Turn and reposition client every 2 hours to maintain skin integrity Maintain the clients diet to promote healing

neurologic and respiratory

Nursing Interventions
Encourage

the client to drink fluids to maintain hydration Administer I.V. fluids to maintain hydration if client cant drink adequate amounts Administer oxygen to prevent ischemia Administer enteral nutrition or total parenteral nutritioun (TPN), as indicated, to meet nutritional needs

Nursing Interventions
Implement

increased ICP precautions Encourage the client to verbalization of feelings. Maintain seizure precautions.

Seizure Disorder

Sudden excessive disorderly electrical discharges of the neurons.

Effects of the Seizures

Mental status LOC Sensory and Special senses

Motor function
Autonomic function

Care of the Client with Seizure Disorder Types of Seizures Partial Generalized

Grand mal
Tonic/clonic Focal Absence Status Epilepticus

(SE) is a life-threatening condition in which the brain is in a state of persistent seizure. Definitions vary, but traditionally it is defined as one continuous unremitting seizure lasting longer than 5 minutes,[1] or recurrent seizures without regaining consciousness between seizures for greater than 5 minutes. It is always considered a medical emergency.

Care of the Client with Seizure Disorder

Care of the Client with Seizure Disorder Collaborative Management

Do not leave alone Protect from injury

Loosen constricting clothings

Turn to sides Do not apply restraints Do not insert tongue blade during tonic clonic movements Pad side rails Make relevant observation and documentation

Care of the Client with Seizure Disorder

Collaborative Management
Patient Education Take medication at regular basis Avoid alcohol Adequate rest

Well balanced diet

Avoid driving, operating machines, swimming Lead an active life

Head Ache

Diffuse pain in the different parts of the head

Management
Assess details of headache. Provide, quiet, dark environment. Medications Symptomatic Non-narcotic analgesics Fiorinal Midrin Sumatriptan (inutrix) Ergotamine tartrate (gynergen) or ergotamine with caffeine (cafergot) Prophylactic to prevent migraine attacks Methysergide maleate (sansert) Propanolol (inderal) & amytriptyline (Elavil)

Management
Intervention for pain Discharge & teaching plan Identification of factors that precipitate attacks ( include diet) Examination of lifestyle, stressor, coping behaviors Daily exercise & relaxation Use & S/E of medications

Encephalitis

Is a severe inflammation and swelling of the brain. Transmission vectors or through ingestion of infected goats milk and accidental injection or inhalation of the virus. Eastern equine encephalitis may produce permanent neurologic damage and is commonly fatal.

Possible Causes
Exposure to virus

Pathophysiology
Intense lymphocytic infiltration of brain tissues and the meninges Cerebral edema Degeneration of the brains ganglion cells, and diffuse nerve cell destruction Signs and symptoms

Assessment Findings
Sudden onset of fever
Headache Meningeal irritation (stiff neck and back) and neuronal damage (drowsiness, coma, paralysis, seizures, ataxia, organic psychoses) Vomiting Coma (following the acute phase of illness)

Sensory alterations

Diagnostic Evaluation
Blood CSF analysis studies identify the virus and confirm diagnosis.
EEG reveals abnormalities such as generalized slowing of waveforms CT scan may be ordered to rule out cerebral hematoma

Nursing Diagnoses
Disturbed thought processes
Hyperthermia Impaired physical mobility

Collaborative Management
Medications: Antiviral: acyclovir (Zovirax) (effective only against herpes encephalitis; effective only if administered before the onset of coma) Analgestic and antipyretic: asprin or acetaminophen (Tylenol) (relieves headache and reduces fever)

Diuretic: furosemide (Lasix) or mannitold (Osmitrol) (reduces cerebral swelling)

Laxative: bisacodyl (Dulcolax) Sedative: lorazepam (Ativan) for restlessness

Nursing Interventions
Assess neurologic function often
Maintain adequate fluid intake but avoid fluid overload Measure I/O.

Administer medications, as ordered.

Careful handling of the patient. Assist with ROM exercises to maintain joint mobility

Maintain adequate nutrition.

Nursing Interventions
Give a stool softener or mild laxative (prevent straining) Provide good oral care Maintain a quiet environment. Darkening the room may decrease photophobia and headache. Provide emotional support.

Reassure the client and his family that behavioral changes caused by encephalitis usually disappear to decrease anxiety.

Herpes Simple Virus Encephalitis

Infection of buccal mucosa Spread along the trigeminal nerve

Fungal Encephalitis
Related to geographic area and compromised immune system Enters the body via inhalation

Arthropod-Borne Virus Encephalitis Common vector is mosquito Vectors transmit several type of viruses: 4 types La Crosse Encephalitis

St. Louis Encephalitis

Western Equine Encephalitis Eastern Equine Encephalitis

Guillain-Barre Syndrome

An acute inflammatory demyelinating polyneuropathy (AIDP), a disorder affecting the peripheral nervous system. The disease causes motor weakness symmetrically and in an ascending fashion. The clients airway is compromised when the disease reaches the diaphragm

Pathophysiology

Assessment Findings Muscle weakness (ascending from the legs to arms)

Dysphagia (difficulty swallowing) or dysarthia (poor speech caused by impaired muscular control)
Facial diplegia (affecting like parts on both sides of the face; possibly accompanied by opthalmoplegia [ocular paralysis])

Assessment Findings Hypertonia (excessive muscle tone) and areflexia (absence of reflexes)

Paresthesia
Stiffness and pain in the form of a severe charley horse Weakness of the muscles supplied by cranial nerve XI, the spinal accessory nerve, this is a less common finding; these muscles affect shoulder movement and head rotation

Diagnostic Test 1. CSF studies (increase CHON) 2. EMG: slowed nerve conduction Medical Management 1. Mechanical ventilation 2. Plasmapheresis 3. ECG 4. Propanolol 5. AtSO4

Nursing Management Adequate ventilation Check muscle groups q 2 hrs to check for progression of muscle weakness CN function V/S, observe for signs of autonomic dysfunction fluctuating with hypotension, tachycardia, arrhythmia Corticosteroids

Nursing Management Anti- arrhythmias Prevent complications of immobility Promote comfort Optimum nutrition Psychologic support Rehabilitation

End Here

Unit 1 - Common Health Problems of the Neonate and Infant

Hydrocephalus
Encephalocele Spina Bifida

Unit 2 - Common Health Problems of the Child and Adolescent

Cerebral palsy
Reyes Syndrome Meningitis

Unit 3 - Common Health Problems of the Young Adult

Myasthenia gravis

Multiple Sclerosis

Unit 3 - Common Health Problems of the Middle Aged Adult

Myasthenia gravis Multiple Sclerosis

3 incompressible elements :
Brain tissues Blood supply CSF Expansion of any one of these incompressible elements must be balanced by proportional constriction of one or both or there will be an increase in ICP

Unit 2 - Common Health Problems of the Child and Adolescent

Hydrocephalus Encephacele

Amyotrophic Lateral Sclerosis

A form of motor neuron disease caused by the degeneration of neurons located in the ventral horn of the spinal cord and the cortical neurons that provide their afferent input.

Pathophysiology

Assessment
Dysphagia Fatigue Awkwardness

(1st sign) of fine finger

movement Muscle wasting Muscle weakness Atrophy Fasciculations Dysarthria

Assessment Jaw clonus Respiratory difficulty Spasticity of flexor muscles Unilateral disability of UE & LE Death 5 to 10 years (resp./ bulbar paralysis) Diagnostic Test EMG (No definite test) CPK-MM - elevated

Collaborative Management: Symptomatic

Gastrostomy feeding Assist with ADL Prosthesis to support weakened muscle Promote effective AW clearance

Emotional support (Complete dependency as disease progresses) Drug: Riluzole ( Rilutele)- neuroprotective effect

X ASPIRATION SUCTION TUCKED chin pos. when eating / drinking

Brain

vasodilatation

Cerebral Edema

Bony Skull

Cerebral Hypoxia

Increase in Intracranial Pressure

No Room For Expansion

Cerebral Ischemia

Monros Theory

Increase in the Bulk of the Brain

Compression of Brain Structures and Blood Supply