NERVOUS SYSTEM

DEFINITION OF TERMS:

Thrombosis is the formation of a blood clot (thrombus) inside a blood

vessel, obstructing the flow of blood through the circulatory system.
embolism (plural embolismsoccurs when an object and causes a
blockage (occlusion) of a blood vessel in another part of the body

Aphasia
is an acquired language disorder in which there is an impairment of any
language modality. This may include difficulty in producing or
comprehending spoken or written language.

Hemianopsia is the loss of half of a field of vision.

Tremor is an involuntary, somewhat rhythmic, muscle movement

involving to-and-fro movements (oscillations) of one or more body parts.
It is the most common of all involuntary movements and can affect the
hands, arms, head, face, vocal cords, trunk, and legs.
bradykinesia denotes "slow movement" It is a feature of a number of
diseases, most notably Parkinson's disease and other disorders of the basal
ganglia.

Akinesia is the inability to initiate movement due to difficulty selecting and/or

activating motor programs in the central nervous system. Common in severe
cases of Parkinson's disease, akinesia is a result of severely diminished
dopaminergic cell activity in the direct pathway of movement.
Dysphagia is the medical term for the symptom of difficulty in
swallowing.

Microphonia Weakness of voice.

Diplopia, commonly known as double vision, is the simultaneous

perception of two images of a single object. These images may be
displaced horizontally, vertically, or diagonally (i.e. both vertically and
horizontally) in relation to each other.

A scotoma is an area or island of loss or impairment of visual acuity

surrounded by a field of normal or relatively well-preserved vision.
Charcot's neurologic triad is the combination of nystagmus, intention
tremor, and scanning or staccato speech. This triad is associated with
multiple sclerosis, where it was first described; however, it is not
considered pathognomonic for it. It is named for Jean-Martin Charcot.

Lhermitte's Sign, sometimes called the Barber Chair phenomenon, is

an electrical sensation that runs down the back and into the limbs from
involvement of the posterior columns, and is produced by bending the
neck forward or backward.

Plasmapheresis is the removal, treatment, and return of (components

of) blood plasma from blood circulation.

Ptosis is an abnormally low position (drooping) of the upper eyelid.

Strabismus squint-eyed. Eyes are not properly aligned with each other.[
 Basic Concept in Normal
Neurologic Function
Oxygen Supply: The brain requires 20% of the oxygen in
the body

Glucose supply: The brain requires 65 to 70 % of the

glucose in the body

Blood supply: The brain requires 1/3 of the cardiac output

Acid—Base Balance

>Acidosis
-Cerebral vasodilation
-CNS depressant—Coma
>Alkalosis
-Cerebral vasoconstriction
-CNS stimulant—seizure
Blood Brain Barrier. Protects the brain from
certain drug, chemicals and microorganism. It is a
layer of semi-permeable membrane

CSF volume. CSF cushions the brain; it nourishes

the brain and determines the ICP. The choroids
plexus in the lateral ventricles primarily produced
CSF. The normal CSF volume is 100 to 150 ml at a
time, an average of 120 ml.

CSF CIRCULATION
 Cranial Function Abnormal
Nerve Findings
I. Olfactory Smell Anosmia (absence of
smell)
II. Optic Vision Papilledema; blurred
vision; scotoma;
blindness
III. Oculomotor Pupil constriction, Anisucuria; pinpoint
elevation of the pupils; fixed, dilated
upper lid pupils
IV. Trochlear Eye movement; Nystagmus
controls superior
oblique muscle
V. Trigeminal Controls muscles of Trigeminal Neuralgia
mastication; (Tic douloureux)
sensations of the
entire face
 Cranial Function Abnormal
Nerve Findings
VI. Abducens Eye movement; Diplopia; ptosis of the
controls the lateral eyelid
rectus muscle
VII. Facial Controls muscle for Bell’s palsy; ageusia
facial expression; (loss of sense of taste),
anterior 2/3 of the the anterior 2/3 of the
tongue tongue
VIII. Acoustic Cochlear branch Tinnitus; vertigo
permits hearing;
vestibular branch helps
maintain equilibrium

IX. Controls muscle of the Loss of gag reflex,

Glossopharyngethroat; taste of drooling of saliva,
al posterior 1/3 of the dysphagia, dysphonia,
tongue posterior third ageusia
 Cranial Function Abnormal
Nerve Findings
X. Vagus Nerve Controls muscle of the Loss of gag reflex,
throat, PNS stimulation drooling of saliva,
of thoracic and dysphagia, dysathia,
abdominal organs bradycardia, increased
KCl secretion
XI. Spinal Controls Inability to rotate the
Accessory sternocleidomastoid head and move the
and trapezius muscles shoulders
XII. Hypoglossal Movement of the Protrusion of the tongue
tongue deviation of the tongue
to one side of the mouth
Glasgow Coma Scale
Eye Opening
4—Spontaneous
3—On request
2—To painful stimuli
1—No opening

Best Verbal response

5—Oriented to time, place, person
4—engage in conversation, confused in content
3—Words spoken but conversation not sustained
2—Groans on evoked pain
1—No response

Best Motor Response

6—Obeys Command
5—Localizes painful stimuli
4—Flexion withdrawal
3—Decorticate (Abnormal Flexion)
2—Decerebrate (Abnormal Extension)
1—No response
Increased Intracranial Pressure

Brain Tissues (space—occupying lesions) e.g.

tumor, abscess, edema

Blood Supply, e.g. thrombosis, embolism,

aneurysm, A-V malformation

CSF, e.g. obstruction to the flow caused by a

brain tumor; overproduction of CSF due to tumor
in the choroids plexus
Monroe's Theory
Brain
↓
Bony Skull
↓
No room for expansion
↓
Increase in bulk of the brain
↓

Compression of Brain structure and blood supply

↓
Cerebral Ischemia
↓
Cerebral Hypoxia → Necrosis (Cerebral Infarction)
↓
Inflammation
↓
Cerebral Edema
↓
Increased Intracranial Pressure
Box Theory
An increase in any one of the content of the
cranium usually is accompanied by a reciprocal
change in volume of one of the other.

Assessment:

Restlessness is the initial sign of increased ICP

Headache, Nausea and vomiting, diplopia
Decreased LOC
Vital sign changes (widening pulse pressure)
Pupillary Changes—anisucuria
Papilledema. Also known as “choked disc”
Lateralizing sign
Collaborative Management:

Position patient in semi-fowlers

Adequate Oxygenation
Safety
Rest
Avoid factors that increase ICP—Nausea and vomiting,
sneezing, coughing, Valsalva maneuver, over suctioning,
restraining, rectal examination
Control HTN
Restrict fluid intake
Pharmacotherapy
Mannitol
Furosemide (Lasix)
Anticonvulsan (Diazepam, Dilantin, Penobarbital)
Antacid
Histamin receptor antagonist
Anticougulant
Seizure
Sudden, excessive, disorderly
electrical discharge of the neurons

Effects of Seizure

Mental Status
LOC
Sensory and Special senses
Motor Function
Types of Seizure

1. Grand Mal —most common type

The phases are as follows:

Aura
↓
Shout/Cry
↓
Fall
↓
Tonic—Clonic Phase
↓
Post—ictal phase
2. Petit mal (Absence Seizure or Little
Sickness)

Not preceded by an aura

Little or no tonic-clonic movement

Chracterized by blank facial expression,

automatism like lip-chewing, cheek-smacking

Usually occurring during childhood and

adolescence
3. Jacksonia/Focal Seizure

Common among client with brain

organic lesion like frontal lobe tumor

Aura is present

Characteerized by tonic-clonic
movement of group of muscles e.g.
hands, foot or face, then it proceeds to
grand mal seizure
4. Psychomotor Seizure

Has psychiatric component

Aura is present
Characterized by mental clouding (being touch
with the environment)
Characterized by ongoing physical activity
during the time of loss of consciousness
Appears intoxicated
Manifested by confusion, amnesia, need for
sleep
The client may commit violent or antisocial acts
5. Febrile Seizure
This is common among children under 5 years of age, when
temperature is rising

6. Status Epilepticus
A type of seizure occurring in rapid succession and full
consciousness is not regained between seizure
Brain damage may occur secondary to prolonged hypoxia
and exhaustion
The client is often in Coma for 12 to 24 hours or longer,
during which time recurring seizure
The attack is usually related to failure to take prescribed
anticonvulsant.
Collaborative Management:

Do not leave the client alone

Protect from injury
Loosen constricting clothing
Turn sides
Do not apply restraints
Do not insert tongue blade during tonic-clonic movement
Pad side-rails
Patient Education
Take medication at regular basis
Avoid alcohol
Adequate rest
Well-balanced diet
Avoid driving
Headache

Causes:

Expanding masses
Intracranial bleeding
Inflammation of meninges
Infections of the brain and spinal cord
Dilation of cerebral vessels
Head trauma
Cerebral hypoxia
Stress
Eye, ear or sinus diseases
TYPES OF HEADACHE

1. Migraine headache

 Strongly hereditary
 More common in women
 Tend to occur with stress of life crisis
 Lasts for hours to days
 One side of the head is more affected that the other
 Caused by dilation of blood vessels
 Aura of acute attack includes visual field defects,
confusion, paresthesia, paralysis in extreme cases
 Associated symptoms: nausea and vomiting, chills,
fatigue, irritability, sweating, edema
 Treatment: Ergotamine Tartrate, Propranolol,
NSAID’s, Relaxation technique
 Avoid nuts, chocolate, onions and food seasoning
2. Cluster headache

More common in older men

Precipitated by alcohol intake or
nitrate
Intense, throbbing, deep, often
unilateral pain, begin in infraoebital
region and spread to head and neck
Associated symptoms: flushing,
tearing of eyes, nasal stuffiness,
sweating, swelling of temporal vessels
Treatment: Narcotic Analgegecis IM
during acute phase
3. Tension Headache (Muscle
Contraction)

Related to tension
Episodic, vary with stress
Usually bilateral, involves neck
and shoulders
Associated symptoms: sustained
contraction of head and neck
muscle
Treatment: Nannarcotic
Analgesics (acetaminophen),
Relaxation Technique,
Amitriptyline
 Cerebrovascular Accident

Disruption of the Blood Supply of the Brain

↓
Neurologic Deficit

Middle Cerebral Atrery (MCA) is most

commonly affected
The second most frequently affected is the
internal carotid artery
Causes:

1. Thrombosis

 The most common frequent cause of

CVA
 The most common cause of cerebral
thrombosis is atherosclerosis usually
affecting elderly persons
 Tends to occur during sleep or soon
after rising
 Characterized by gradual deterioration
of the client’s condition
 This may also occur among clients with
diabetes mellitus, hypertension.
2. Embolism

The second most common cause of CVA

Most commonly affecting younger people
Most frequently caused by rheumatic hearth
disease and myocardial infarction
Symptoms occur at any time and progress
rapidly
 3. Hemorrhage

May be due to hypertension, subarachnoid

hemorrhage, rupture of aneurysm, A—V
malformation, hypocoagulation

4. Transient Ischemic Attack (TIA)

Refers to transient cerebral ischemia with temporary

episodes of neurologic dysfunction
Manifestations include collateral weakness of the lower
portion of the face, fingers, hands, arms and legs;
transient dysphagia; sensory impairment
Stroke in evolution refers to development of a
neurologic deficit over several hours
Complete stroke refers to a permanent neurologic
deficit
Assessment:

Signs and symptoms of increased ICP

Perceptual Deficit
Aphasia
Hemianopsia (loss of half of the visual field)
Collaborative Management:

Emergency Care
-Care of the client with increased ICP

Promote Nutrition
-TPN, NGT feeding, gastrostomy feeding

Promote Activity
-Turn frequently
-Perform ROM exercise
-Prevent contracture

Promote Elimination
-Monitor I and O to check for urinary retention
-Start urinary and bowel program
Promote Communication
-Say one word at a time
-Identify one object at a time
-Give simple command
-Anticipate needs
-Allow client to verbalized, no matter how long it takes him
-Reinforce success in speech
-Assist in speech therapy
Compensate for Perceptual Difficulties
-Care of client with Hemianopsia
-Approach from the unaffected side
-Place articles on the unaffected side
-Teach scanning technique. Turn head from side to side to
see the entire visual field
Provide Emotional Support
Provide Patient Teaching
Rehabilitation Care:

Rehabilitation
-The process of learning to live to one’s
maximum potential with a chronic impairment and
its resultant disability
-Promotes reintegration into the client’s family
and community through a team approach
-Primarily influenced by the client and the
client’s motivation
Goal of Rehabilitation
-Prevention of Complications
-Correcting of Deformities
-Restoration of function to achieve maximum
independence
-Limitation of disability
 Parkinson’s Disease (Paralysis Agitans)

Male / Female; 50-60 Years

Degenerative disease
↓
EPS
↓
↓ Dopamine (EPS—posture, balance, locomotion)
Causes:

Unknown Methyldopa
Viral Infection Dopamine—Acetylcoline
Phenothiazines
disequilibrium
Reserpine Encephalitis
Haloperidol Arteriosclerosis
Carbon Monoxide Poisoning

Depigmentation of the substansia

nigra of the Basal Ganglia
↓
Loss of Neurons
↓
↓ Dopamine
(loss of inhibition influence;
excitatory mechanism are
unopposed)
Assessment:

Pillrolling tremors of the

finger
Resting tremors (non- Trunk bent forward
Moist, oily skin
intentional tremors)
Rigidity, with muscle Defect in judgment
Emotional instability
weakness
Bradykinesia / Fatigue
Misccrophonia, slow
AkinesiaCogwheel rigidity
Absence of arm swing in monotonous voice
Micrographia (small
normal rhythmic gait
Masklike appearance of the handwriting)
No intellectual impairment
face
Drooling of saliva, causing No true paralysis
No loss of Sensation
skin irritation
Dysphagia
Shuffling Gait
PATIENT WITH PARKINSON’S
DISEASE
Collaborative Management:

Diet
-↑ Residue, ↑ Caloric, Soft diet (well-balanced
diet)
Position to prevent Contracture
-Firm bed, no pillows
-Prone position when lying in bed
-Hold hands folded at the back when walking
Aspiration Precaution
-↑ fluid intake to prevent constipation
Anticholinergic to reduce tremors
-Cogentin (Benztropine Mesylate)
-Artane (Trihexyphenidyl)
-Akineton (Biperiden)
-Side Effect: blurring of vision
-Dryness of mouth / throat
-Constipation
-Urinary retention
-Dysarthria
-Mental disturbance
Anti-parkinsonian Agents (Dopaminergic). It improves
muscle flexibility

-Levodopa
-Carbidopa with Levodopa (Sinemeet).
Carbidopa reduce destruction of levodopa at
the periphery

Antiviral / Dopamine Agonists

-Amantadine HCl (Symmetrel)

-Bromocriptine (Parlodel)

Antispasmodias

-Procyclidine HCl (kemadrin)

Antihistamines

-Benadryl (Diphenhydramine) to reduce tremor

and anxiety
Avoid the following drugs when on Levodopa
therapy:

Phenothiazines, Resserpine, Pyridoxine (Vit.

B6). These block the effects of Levodopa

MAOI (Pernate, Marplan, Nardil)

-Enhance norepinephrine activity

-Hypernsive crisis may occur
-Methyldopa—potentiates the effect of
Levodopa
Avoid the following foods when on Levodopa thera

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

Thyramine rich foods (may cause hypertensive crisis)

Cheese Italian green beans

Cream Liver
Yogurt Pickled herring
Coffee Sausage
Chocolate Soy sauce
Bananas Yeast
Raisins Beer
Red wine
Side Effect of Levodopa:

Nausea and Vomiting

Orthostatic Hypotension
Insomnia
Agitation
Mental Confusion
Renal damage

Patient Teaching:

Gradual change of position, wear elastic stockings

to prevent postural hypotention

Reddish brown urine is harmless

Multiple Sclerosis
↑ in women; 30-40 years old
Chronic; with
remissions/exacerbations
Pathophysiology Causes
Unknown
Viral infection
Autoimmune Disease
↓
Multiple foci of demyelination in the white matter
↓
Destruction of myelin sheath
(schwann’s cells)
↓
Interruption / distortion of impulse
(slowed / blocked)
Assessment:

Diplopia (double vision)

Scotoma (spots before the eyes)
Blindness
Muscle Spasm
Weakness / Numbness
Fatigue
↑ susceptibility to URTI
Emotional Instability; euphoria during remissions
Bowel / Bladder Problems
Charcoat’s Triad
Scanning speech
Intention tremors
Nystagmus
Lhermitte’s Sign (sudden “electrical shock”,
sensation experienced on passive flexion of the
neck)
Dysphagia
Ataxic Gait
Collaborative Management:

Eye patch for diplopia

Diet: well-balanced diet, high in fiber to prevent constipation
Physical Therapy
Forced Fluids
Avoid hot baths. Heat increases weakness
Speech Therapy
Plasmapheresis
Muscle Relaxant
-Baclofen (Lioresal)
Glucocorticoid
-Prednisone
-Dexamethasone
-Corticotropin
Myasthenia Gravis

↑ in women; young adult

25% with thymoma
Neuromascular disorder that result in the failure to
transmit nerve impulse xat the myoneural junction

Causes:

↓ Acethycholine secretion by the motor end plate

↑ cholinesterase at the nerve ending
Autoimmune diseases
Assessment:

Muscle weakness
-Dyspnea / dysphagia / decreased physical activity
Fatigue
Ptosis
Diplopia
Impaired Speech
Strabismus
“Snarl Smile” (smile slowly)
Masklike facial expression
Drooling
Respiratory Difficulty
Collaborative Management:

Assess swallowing / gag reflex before feeding

Administer medication 20-30 mins a.c. to prevent
aspiration
Administer medication at precise time. To prevent
respiratory distress
which cause death
Protect from fall. Falls are due to muscle weakness
Aspiration precaution
Start meal with cold beverages. To improve ability to
swallow
Adequate ventilation. To relieve respiratory difficulty
Avoid exposure to infection. Exacerbations of the
disease may be triggered
Adequate rest period
Plasmaparesis. This involves removal of antibodies
from the plasma to inhibits autoimmune response
Pharmacotherapy
-Cholinergics (Anti-cholinesterase)
Neostigmine (Prostigmin)
Pyridostigmine (Mestinon)
Ambernomium (Mystelase)
-Glucocorticoid. Fro Anti-inflammatory effects
-Antacid. To prevent gastrointestinal upset due
to glucocorticoid
Surgery: Thymectomy
-To achieve remission for 5-10 days
Drugs to be avoided by the client
with Myasthenia Gravis

Muscle relaxant
Barbiturates
Morphine Sulfate
Tranquilizer
Neomycin
Survival Guide (MG)

Reschedule daily task

Secure “handicapped” parking sticker
Frequent rest period
Take medications on time (alarm clock should be available)
Eye patch, if with diplopia
Start meal with cold beverages
Avoid very hot / cold weather
Avoid aerosol, pesticide / cleaner
Avoid alcohol, tonic water, cigarette smoke
Myasthenic Crisis

Caused by under medication

Manifested by extreme weakness
Tensilon test relieves symptoms
Managed by cholinergic

Cholinergic Crisis

Caused by over medication

Manifested by weakness
Symptoms worsen with Tensilon test
Managed by anti-cholinergic, e.g. Atrophine sulfate
Alzheimer’s Disease

A degenerative disorder of the brain cells (cerebral cortex) resulting to

Most common cause of dimentai
Incidence: Men=Women; over 60 years of age

Cause:

Unknown
Autoimmune
Heredity
Stages:

Stage I—mild memory lapses

Stage II—Obvious short-term memory lapses
Stage III—Disintegration of personality
Stage IV—Terminal stage; physical and mental deterioration
Collaborative Management:

Protection from injury

Promote activity
Promote sleep
Avoid agitation / violence
Avoid Fatigue
Avoid scolding / embarrassing
Avoid arguing / reasoning
Address by name
Guillain-Barre Syndrome (Infectious
Polyneuritis)

Relatively rare disease affecting the peripheral and cranial

nerves
Usually follows a viral infection; may be auto-immune; may
follow swine flu immunization

Manifestation:

Ascending or Descending paralysis which may progress to

respiratory muscle paralysis
Paralysis ascend and stays at maximum level 2-3 weeks and
then slowly descends
Abnormal sensation of tingling and numbness
Management:

No specific therapy; symptomatic,

supportive care of paralyzed, immobilized
patient

-ROM
-Skin care
-Respiratory Care

Full recovery often occurs if good supportive

care during illness is adequately
implemented
Trigeminal Neuralgia (Tic Douloreux)

Neurologic disorder affecting the 5th cranial nerve

Manifested By excruciating, recurrent paroxysmal of sharp,
stabbing facial pain along trigeminal nerve

Management:

Antiepileptic drugs (Tegretol and Dilantin)

Alcohol injection of the nerve
Surgery (neurectomy)
Avoid Extremes of heat and cold
Protect eye if surgery is done
Bell’s Palsy

Lower motor neuron lesions of the 7th cranial nerve,

resulting in paralysis of one side of the face
Usually self limiting to few weeks

Manifestations:

Facial paralysis involving the eye (Ptosis)

Tearing of eye
Painful sensations in the face
Sagging of one side of mouth; drooling
Management:

Steroid and analgesics

Protect involved eye
Active facial exercise
 NEURODIAGNOSTIC TESTS

CT Scan

Computerized reconstruction of body part by passage of

multiple X-ray beams

Remove metallic objects from hair

Must remain absolutely still

Time is approximately 20 minutes if without contrast

medium; 60 minutes if with contrast medium

Sedation if unable to remain still

NPO 4-6 hours if contrast medium is used

Observe for allergic reaction to iodinated contrast material

 Electroencephalography (EEG)
Graphical recording of spontaneous electrical impulses
of the brain from scalp electrodes

Explain procedure to client

Hair shampoo to remove oil/sprays

No caffeine and other stimulants, anticonvulsants for at

least 24 hours

Wash hair after the procedure to remove EEG paste

Cerebral Angiography

Intra- arterial injection of contrast medium with simultaneous

radiographs of head and neck to visualize intracranial and
extracranial vesssels.
Nursing Responsibilities

Before the procedure:

Explain procedure to client

May experience hot, flushing sensation as dye
is injected
Contrast material injected into femoral, brachial
or carotid arteries
Remove metallin clips from hair
Check for allergy to iodine/ seafoods
NPO 4-6 hours
IVF to ensure adequate hydration
Premedicate as ordered
After Procedure:
Observe arterial puncture site for bleeding or hematoma;

apply pressure dressing or ice pack to the area

Observe pulse distal to the puncture site; diminished or

absent pulse may indicate blockage of vessel by thrombus or by
hematoma

Observe affected limb for color and temperature

Observe for bradycardia and hypotension which may occur due

to vagal irritation in carotid artery

Observe for any change in neurological status; risk of stroke or

ischemia following angiography secondary to embolus, thrombus
or vasospasm

Bed rest (may have head elevated) for 12 to 24 hours; if femoral

puncture, must keep leg extended and immobile for several house
Magnetic Resonance Imaging (MRI)

Uses a very strong magnet combined with radio frequency

waves and a computer to produce X-ray like images of body
chemistry
Nursing Considerations
Obtain hx of metal implants (clients
with metal implants are not eligible for
MRI scan)

Procedure lasts from 30-90 minutes

Reassure client that procedure is

painless

Assess for claustrophobia

Inform client that machine makes

drum- like sounds

Request client to remove credit cards,

watches which may be demagnetized or