NCMB316 FINALS REVIEWER Romberg’s test

• Gait =ATAXIA =wide base gait

Nervous system Basal ganglia
• CNS • Fine motor movement and coordination
• Brain Involuntary movement
• Spinal cord • Ballismus(both sides of the body )
• PNS – spinal nerve and CN hemiballismus Movement
• Somatic nervous system • Tremors disorder
• Autonomic nervous system • Chorea
o SNS Brain stem
o PNS • vital center of the brain
Brain Midbrain
• Frontal lobe - larger lobe • Pons – respiratory center
o Executive functions, thinking, planning organizing • Medulla – respiratory center/ cardiovascular center
and problem solving, emotions and behavioural Origin of CN
control, personality • Midbrain = CN III, IV
• Parietal lobe • Pons = CN V, VI, VII, VIII
o Perception, making sense of the world, arithmetic, • Medulla= CN IX ,X,XI, XII
spelling • CN I – olfactory bulb (nose)
• Temporal lobe • CN II – eyes
o Memory, understanding, language Thalamic nuclei
• Occipital lobe • Thalamus
o Vision • Subthalamus
• Motor cortex • Epithalamus
o Movement • Hypothalamus
Muscle weakness Supratentorial
• paresis/hemiparesis • Above the tentorium cerebelli
Paralysis • Cerebrum
• plegia (complete paralysis) Infratentorial
• hemiplegia (paralysis on one side of the body) • Below the tentorium cerebelli
Speech area • cerebellum
• Frontal lobe Protective covering of the brain
o brocas’s area • Dura mater extension
o expressive speech
o Falx cerebri
o broca’s aphasia
o Tentorium cerebelli
• Temporal lobe o Falx cerebelli
o wernicke’s area Protective structures of the CNS
o receptive speech • skull – bony protection / vertebrae
o wernicke’s aphasia
• meninges- membranes covering the barin
• global aphasia
o dura mater – toughest, outermost covering
o ineffective verbal communication - To use sign o arachnoid- weblike
language/ picture boards o pia mater – inner most
dysarthria
• CSF- cushion
• dysfunction in articulation
o 500ml/day
o Ex. Defect in the CN XII- tongue o 150 ml
limbic lobe – limbic system o 75 ml brain and 75 ml Spinal cord
• frontal lobe • Ventricles of the brain
• temporal lobe = overall emotion and behavior of the person
o Caivities inside the brain that contains CSF
• hypothalamus o Hydrocephalus
kluver – bucy syndrome o CSF-located in the ventricles of the brain
• anti social • Blood brain barrier (BBB)
• loss of fear Spinal cord functions
• sexually pervert • passageway of tracts : SAME
• voracious eater o a. sensory/ afferent/ ascending- 6 sensory
Cerebelllum – balance o b. motor /efferent/descending – 8 motor
• Ipsilateral (same side ) • center of reflex
 o Reflex- an involuntary response to a stimulus • CN IX- glossopharyngeal nerve – medulla → sensory (
withdrawal reflex taste )/ motor (ms of swallowing )
• origin of spinal nerves (31 pairs) • CN X vagus nerve -medulla → sensory and motor → 75
• make up the ANS % of PNS
Tract • CN XI- spinal accessory → motor – ms of the shoulder
• motor tract and neck
o efferent/descending • CN XII- hypoglossal → motor – ms of the tongue
o 8 tract Spinal cord
• sensory • Center of reflex
o afferent/ ascending • Reflex – involuntary response to a stimulus
o 6 tract • Withdrawal reflex
• Origin of ANS

PNS
• Somatic NS →spinal nerves
Plexus
• Autonomic NS→spinal nerve
• – network of nerves → branches →different parts
• and cranial nerves
C1- upper c5
Nerve cells
• cervical plexus nerve branches → head and neckC3 and
• Neurons – functional unit – conductivity
c4
• neuroglia – Glial cells- supporting cells
• phrenic nerve → diaphragm
Brachial plexus o astrocyptes – support the nerve fibers
o ependymal cells – line ventricles of the brain
• lower C5 – T1 upper extremeties
o oligodendrocytes – producing myelin sheath in the
o Median nerve
CNS
o ulnar nerve
o Schwann cells- producing myelin sheath in the PNS
o radial nerve
o Microglia – macrophages
o axiliary nerve
Trigeminal neuralgia
o musculocutaneos
• CN V
• Lumbo sacral plexus
Pain areas
• L2-S4 - lower extremeties and pelvis
• Ophthalmic branch
o Sciatic nerve
• Maxillary branch
o femoral nerve
o obturator nerve • Mandibular branch
cranial nerve Etiology
• CN I – olfactory → olfactory bulb (nose) → temporal • Idiopathic
lobe (smelling) Risk factor
• CN II – optic → eyes→ occipital lobe (seeing) • Autoimmune
• CN III –oculomotor –midbrain • Viral infection
• CN IV – trochlear – midrain • Vascular ischemia
• CN VI– abducens – pons S/SX
• Unilateral (one side)
• CN III, IV, VI → extracular muscles (eye movement) all
EOMs are supplied by CN III except LaSOt • Ipsilateral facial pain
• L – lateral rectus – abducens • Effect of facial pain
• SO – superior obliques – trochlear o Nutritonal problem
o Oral infection
• CN V – trigeminal –pons→sensory (face) → motor (ms
Diagnostic test
of mastication)
• MRI
• CN VII – facial nerve – pons → sensory (taste) → motor
• NERVE CONDUCTION TEST
(ms of the face)
• CN VIII – auditory – pons → ears → temporal lobe • EMG
Goal in mgt
(hearing )
• Prevent the pain - avoid precipitating factors for pain
 • Manage the pain • Increased intracranial pressure
o Pain – neuropathic Diagnostic test
o Drug choice • ECG
▪ ANTI SEIZURE DRUG – Cabamazepine • MRI
(Tegretol) • CT scan
▪ PAIN RELIEVER – narcotics • Lumbar puncture
▪ NON- NARCOTICS – NSAID’s S/SX
• Manage complication • Motor symptoms – convulsion
o Nutritional problem – soft diet (complete nutrition ) • Atonic seizure
o Oral care – gargle with water based mouth wash • Sensory
o Anxiety • Psychomotor
Bell’s palsy – facial paralysis (unilateral)
• Blank staring
• Inflammation of cn vii
• Reversible! (3 months)
Etiology
• Idiopathic
Risk factor
• Viral infection
• Autoimmune
• Trauma
• Vascular ischemia
S/SX - unilateral
• Facial asymmetry
• Inability to close eyes
• Drooling of the saliva
Goal in the management:
• To prevent muscle atrophy
Management goals
• Facial muscle exercise
• Facial massage
• TENS – Transcutaneous Electrical nerve stimulation
• Steroids – anti – inflammatory effect
• Vit B complex
Diagnostic test
• MRI
• CT scan
• Complete physical examination
• History
Seizure
• condition characterized by abnormal and excessive
impulse transmitting in the brain
Primary seizure
• idiopathic
primary seizure disorder
• epilepsy
o Status epilepticus- a medical emergency associated
with significant morbidity and mortality. SE is
defined as a continuous seizure lasting more than 30 Pre ictal phase
min, or two or more seizures without full recovery of • “AURA “before seizure
consciousness between any of them Ictal phase
Secondary seizure - known causes • sz
• CVA Post ictal phase
• TBI • after the seizure
• Brain tumor o Adult – confused – reorient
• Brain infection o Pedia – asleep- assess the breathing pattern
• Fever
Management Autonomic dysreflexia/ autonomic hypreflexia
• Drug therapy – hallmark • Exaggerated autonomic response to stimulus
• Safety Stimulus
• Airway • any noxious stimulus ( painful ), discomfort , bladder or
Antiseizure drugs bowel distention
• Barbiturates- Phenobarbital
• Benzodiazepine – diazepam
• Hydantoin – phenytoin
• Carbamazepine
• Lamptrigine
• Topiramate
• Best to give a drug is BEDTIME
Spinal cord injury
• Causes : Management
o Trauma (most common) • Prevention
o Non traumatic – tumor , infection • Empty the bladder
Complete • Place the client in a high fowler’s position (90 degrees)
• complete transaction of the cord • Antihypertensive drugs
Incomplete Nursing management
• partial resection of the cord • Immobilization
descending tract (motor) • Paralysis – impaired physical mobility
• lateral corticospinal tract (motor) • Use of assistive devices
• ventral corticospinal tract (motor) • Prevent disuse syndrome (ms atrophy, bes sores, DVT)
ascending tracts (sensory) • Sensory deficits
• doral columns (fine touch, proprioception, vibration • Provide safety measures
• lateral spinothalamic tract (pain, temperature) • Bladder and bowel training
• ventral spinothalamic tract ( light touch) • Teach the couples about exploring other ways to express
Management sexual desires
• Call for help! Incomplete lesion of the spinal cord
• Immobilize • Central cord syndrome -spine in hyperextension
• Massive dooses of steroids - metylpredisolone o injury to the central region of the spinal cord (central
• Vasopressors → inc BP corticospinal tracts and decussating fibers of the
• Anticholinergic drug – antropine sulfate lateral spinothalamic tract)
• Surgery laminectomy o Diagnostics
• Log rolling technique - moving the patient after surgery ▪ CT
(as one unit) ▪ MRI to determine location, cause, and extent of
• Rehabilitation therapy neurological damage
Complete SCI – complete transection of the cord o Clinical manifestation
• C4 – from the neck → below (high tetraplegia/high ▪ Due to hyperextention of C- spine
quadriplegia ▪ Disproportional greater UL weakness
• C6 – from the chest → below (low tetraplegia/low ▪ Sensory loss is usually minimal
quadriplegia ▪ Some control over the bowel & bladder
• T6 – from waist → below (high paraplegia) ▪ Recovery is possible
• L1- from the hips → below (low paraplegia) • Anterior cord syndrome –
o Damage to the anterior two-thirds of the spinal cord,
• Bladder and bowel dysfunction sexual dysfunction
usually as a result of reduced blood flow or
occlusion to the anterior spinal artery (ASA) →
anterior spinal artery syndrome (∼ 95% of cases)
o Diagnostics
▪ Spinal MRI (best confirmatory test)
▪ Excludes soft-tissue lesions (e.g., tumors,
hematomas) and bone lesions
▪ Detects spinal cord parenchyma abnormalities
(e.g., infarction) in the anterior part of the spinal
cord: Dorsal columns and Lissauer tract, which
 are located in the posterior part of the spinal CPP = 93- 10
cord, are intact. CPP= 83 NORMAL
• posterior cord syndrome
o injury of the posterior spinal cord affecting the CPP = MAP – ICP
posterior column (fine touch, vibration, pressure, and CPP = 93 -30
proprioception) CPP = 63
o Diagnostics
▪ MRI showing infarction of the dorsal columns in
the case of posterior spinal artery occlusion
▪ VDRL or RPR if syphilis suspected
• Brown Sequard syndrome
o hemisection of the spinal cord (often in the cervical
cord)
o diagnostic
▪ CT if trauma has occurred or an MRI if a tumor
is suspected.

Early s/sx
• Altered level of conscious
• Restless, confused , slurred speech , irritable
• Headache
• Dizziness
• Vomiting
• Papilledema
INTRACRANIAL PRESSURE (ICP ) ASSESSMENT
• Pressure extended by the cranial contents against the skull • GCS – scoring system = 3-15 -a score of 8 and below –
Patient risk brain injury
• brain tumor, brain swelling • S- sensorium
• blood- bleeding • P- Papillary response
o Venous blood
• E- extraocular muscles – Doll’s eye maneuver
o Arterial blood
• R- Respiration
• CSF – 150 ml ; 75 ml in the spinal cord – hypocephalus
• M-motor function
normal ICP 10 - - 20 mgmHg , 5-15mmHg , 0-15 mmHg
not more than 20mmHg
CVA – Cerebrovascular accident/stroke
• Brain tumor
• Brain infection
• traumatic brain injury
• hydrocephalus/ obstruction to the flow of CSF
Roles of nurses in increased ICP
• To identify patients at risk for increased ICP
• To identify s/sx of increased ICP
• Patient risk
ICP – Intracranial pressure
MAP – mean arterial pressure
CPP – cerebral perfusion [ressure
MAP = SP + 2 (DP)
3
BP = 120/ 80
MAP = 93 NORMAL 60- 100mmHg
CPP = normal 70-100 mmHg

CPP= MAP – ICP

 Blood supply of the brain
• Internal carotid arteries
o Anterior cerebral artery supplies the medical
portion/surface
o Middle cerebral artery dorso lateral surface of the
brain
• Vertebral arteries
o Part cerebral artery base & occipital lobe of the brain
o Cerebellar artery supplies cerebellum
• Circle of willis - Once affected death is nearly possible
MONRO – KELLIE HYPOTHESIS o Union of anterior cerebral middle cerebral post
• Displacement CSF cerebral and cerebellar arteries
o spinal cord Brain 50 ml , spinal cord 100 ml CVA
• Dec blood in the brain • CVA - Cerebro vascular accident - Stroke - Brain attack
o Venous – increase venous return to the heart • Ischemic - obstruction to the flow of blood to the brain
o Position HOB 30- 40 degrees ( low fowler’s position) o Thrombotic - obstruction develops inside the blood
to promote venous return head and neck aligned vessel
o Arterial – decrease oxygenated blood to the brain o Embolic - dislodge thrombus from other vessels
Nsg Dx - INEFFECTIVE CEREBRAL TISSUE PERFUSION (embolus) --> block the cerebral vessels
• Brain herniation • Hemorrhagic - rupture of the blood vessels ( bleeding )
o protrusion of the brain tissue Thrombotic Stroke
Cushing’s TRIAD INCREAS ICP – LATE S/SX • Etio: - Idiopathic
• Increasing systolic pressure (widening of pulse pressure • RF --> atherosclerosis
• Dec HR • TIA - transient ischemic attack - neurologic deficits that
• Dec RR resolve within 24 hours
CPP = MAP – ICP • RIND - Reversible ischemic neurlogic disorder -
BP = 120/ 80 neurologic deficits resolve beyond 24 hours
MAP = 93 • Modifiable RF: high cholesterol diet, alcohol, smoking,
CPP = 93-30 obesity,DM, hypertension, stress
CPP = 63 Embolic Stroke
• Thrombus from other part of the body that has dislodge
If systolic pressure is high = pulse pressure is widen
and block the blood su[pply of the brain
BP= 120/ 80 BP = 140/ 80 MAP = 100
• Most commonly from the left side of the heart - RF:
microthrombi from the left heart ( endocarditis or atrial
CPP = MAP – ICP
fibrillation)
CPP = 100- 30
Diagnostic tests
CP = 70
• CT scan
MANAGEMENT
• MRI
• Position – low fowlers, head and neck aligned – to
S/sx
promotes
• Diffused - increased ICP
• Cerebral oxygenation
• Focal - specific areas of the brain is affected
• Mannitol as orded
• hemiparesis/hemiplegia
• Steroids- hydrocortisone as orders
• paresthesia
• Reduce brain metabolism
• aphasia - expressive/receptive
o Manage fever
o CNS depressant, rapid or short acting • dysarthria
• Transient hypenventilation • ataxia
o An dec pC02 because in pC02 can inc ICP : normal • agnosia
pC02 – 30-40mmHG • apraxia
o It causes vasoconstriction • movement disorders
• Manage the cause • visual disturbances
Stroke – brain attack o hemianopsia
CVA – cerebro – vascular accident o blindness
• Ischemic stroke • amnesia
• Thrombotic stroke • unilateral neglect
• Embolic stroke
Hemorrhagic stroke – rupture of blood vessel
 Concussion
• after tbi- neurologic s/sx but no significant findings in the
skull S-rays, CT scans or MRI
• hematoma in the brain tissue
head injury – types
• open head injury – there is penetration to the skull
• closed head injury - there is no penetration to the skull
• basilar skull fracture – leaking of the CSF
• nose – rhinorrhea
• ear – otorrhea
nursing action – collect the fluid and teast for glucose (+) =
Hemorrhagic stroke
CSF
• Bleeding in the brain
blood with CSF – linen = halo sign
• Rupture of blood vessel
Epidural hemorrhage
• Etiology:
• rupture of middle meningeal artery
• 1. Cerebral aneurysm - abnormal dilatation and sac
• "LUCID interval"
formation in the wall of an artery
• 2. AV malformation
• normal artery --> aretriole --> capillaries --> venules -->
vein
Subdural hemorrhage
• RF: uncontrolled hypetension
• acute - sudden onset
S/SX
• Diffused symptoms – inc ICP • subacute - 2 -3 up to weeks
• Bleeding subsides – focal symptoms • chronic - > 2 weeks
Diagnostic tests
• Skull xray
• CT scan
• MRI
Mgt:
• Manage increased ICP
• Craniotomy
• Prevent complications
• Rehabilitation
AUTOIMMUNE DISORDERS OF THE NERVOUS
Mgt: Ischemic stroke SYSTEM
• Thrombotic • Myasthenia gravis
o Manage increased ICP
• Multiple scelerosis
o 2. Thrombolytic therapy - dissolve the thrombus
• Gullian barre syndrome
▪ U - Urokinase
Myasthenia gravis
▪ S - Streptokinase
• NMJ - neuromuscular junction
▪ A - Alteplase
• Etio: Thymoma
• INR - international normalized ratio, PT, PTT
o Antithrombotic drugs • Idiopathic
▪ a. antiplatelet drugs • RF: Viral infection
▪ Clopidogrel, Aspirin • destroy the Acetylcholine receptors at the NMJ
▪ b. Anticoagulant • slow impulse transmission from the nerve to the muscles
• Low molecular weight heparin, warfarin initial -> Ptosis
o Manage risk factor diagnostic test
o Rehabilitation therapy • EMG
Mgt: Hemorrhagic stroke • NCT
• Manage increased ICP • Tensilon test – most definitive
• Craniotomy o Endrophonium HCI
o to stop bleeding o Drug – anticholinesterease drug – cholinesterase
o to remove clot inhibitors
• Manage risk factors o Short acting drug -diagnostic drug
• Rehabilitation therapy o Long acting anticholinesterase drug onset 20-30min –
Traumatic brain injury (TBI) – traumatic 4 to 6 hours
o Neostigmine
 o Physostigmine • Schwann cells are not destroyed --> reversible – recovery
o pyridostigmine within 2 years
• overdose – inc Ach in the junction (cholinergic crisis) – • first --> lower exrtremity - ascending paralysis, loss of
enchance PNS effect reflexes, paresthesia
• s/sx – dec HR, hypotension, diarrhea, incontinence diagnostic test
underdose – dec Ach in the junction (myasthenic crisis) - • MRI
dec PNS effect • CT scan
• s/sx inc HR, hypertension, constipation, retention, • CSF analysis – identifying lg present in the CSF
• tensilon – there is temporary worsening of muscle • EMG
weakness- cholinergic crisis • Nerve conduction test
• antidote- anticholinergic drug Management
• tensilon – temporary improvement in ms function – • Support respiratory function – mech ventilator
myasthenic crisis • Improve physical mobility
• antidote – anticholinesterase drug • Prevent complication from immobilization
• (+) tensilon test – myasthenia gravis – temporary • Provide safety
improvement in muscle function • Plasmapheresis
management • IV – lg (intravenous immunoglobulins)
• support respiratory function Parkinson’s dse
• improve physical mobility • Degeneration of substantia nigra
• prevent complication for immobilization • Dopamine producing cells in the midbrain
• prevent aspiration Etiology ?
• promote good nutrition RF:,
• provide safety • age
• anticholinesterase drug • family
• plasmapheresis – separating the antibodies from the • Hx
plasma • Exposure to chemicals dec dopamine production
• thymoma – thymectomy • Basal gangliadec dopamine inhibitory inc acetylcholine –
Multiple Sclerosis excitatory
• CNS - brain and spinal cord Alzheimer’s dse
• Etio: idiopathic • Degeneration of the cells in the cerebral cortex
• RF: Viral infection Etiology ?
• demyelination of the CNS RF:
• impaired impulse transmission in the CNS • Age
• Oligodendrocytes are also destroyed • Family
• irreversible and progressive • HX
• first nerve affected - optic nerve - visual disturbances • Stress
4 patterns • Destruction of Ach receptors in the CNS
• relapsing remitting • Precipitation of abnormal protein called amyloid
• primary progressive Huntington’s dse
• secondary progressive • Degeneration of cells in the cerebral cortex and the basal
• progressive relapsing ganglia
management etiology
• improve physical mobility • Hereditary
• regular exercise • Gene – huntingtin gene autosomal dominant
• prevent complications • Onset of s/sx – middle adult years 35-45 y/o
• provide safety Amyotropic lateral sclerosis (ASL)/ lou Gehrig’s dse
• communicate therapeutically • Degeneration of all motor
• plasmapheresis • Neurons- upper motor
• palliative relief of s/sx • Neurons – lower motor
Guillain Barre Syndrome • Neurons – CN with motor function
• PNS - peripheral nervous system = motor and sensory Etiology?
• Etio: idiopathic RF
• RF: EBV, CMV, Campylobacter jejuni • males
• demyelination of the PNS • family
• impaired impulse transmission in the PNS • history
 • over excitation of NT called glutamate (excitatory)
parkinson’s disease
• movement disorders
• cardinal signs
o tremors
o rigidity
o bradykinesias
alzheimer’s disease
• cardinal signs
o memory loss – dementia
o cognitive dysfunction
o emotional dusturbances
• stage 1 - initial stage – lucid
• stage 2 – confusion stage
• stage 3 – terminal stage
huntington’s dse
• cardinal signs
o cognitive dysfuntion
o emotional dysfuntion
o chorea
ASL
• cardinal sign
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