INCREASED INTRACRANIAL PRESSURE ● It is the pressure that pushed the

(Cerebral Perfusion Pressure) blood to the brain. Hence, influences

the cerebral blood flow (CBF)
DEFINITION:
● Pressure in the skull increases Normal CPP is 60-100 mmHg
○ It is a medical emergency ● When CPP falls too low the brain is
PHYSIOLOGY: not perfused and brain tissue DIE
● Intracranial pressure is created by
the following CPP CALCULATIONS:
○ Brain Tissue
○ Cerebrospinal Fluid (CSF) ● CPP=MAP (Mean Arterial pressure)
○ Blood - ICP (intracranial pressure)
● Normal ICP ● MAP [(Diastolic x 2) + Systolic
○ 5-15 mmHg (RN.com) pressure] / 3
○ 0-15 mmHg (Book) Example
● Emergency! ● BP: 90/42, ICP: 19
○ >20 mmHg ● MAP: [(42 x 2 = 84) + 90] / 3
○ Need immediate treatment ○ MAP=58
3 Structure that can alter Intracranial ● CPP(39)=58-19 - It’s very very bad
Pressure: (meaning that it’s Fatal)
● Brain CAUSE:
● CSF ● Traumatic Brain Injury (Trauma)
● Blood ● High amount/volume CSF (A
Monro-Kellie Hypothesis: condition)
● How ICP is affected by CSF brain’s ● Bleeding (hemorrhage)
blood & tissue to maintain cerebral ● Hematoma
perfusion pressure (CPP) ● Hydrocephalus
○ So if there is an increased ● Tumor
volume in any of those ● Encephalitis/Meningitis
structures (Brain tissue, CSF, FACTOR:
and blood) the other ● Body Temperature
structure will try to ● Oxygenation status, especially CO2
compensate by decreasing and O2 Level
its volume to help alleviate it ○ Hypoxic
■ Moving structure in ○ CARBON can dilate the
the spinal cords blood vessel and increase
■ The cerebral artery Blood pressure
will be compressed ● Body position
and constrict and ○ Keeping neck midline not flex
decrease its blood ○ Keeping in 30-45 degrees
flow- the tissue will ● Arterial and Venous pressure
be deprived of blood ● Anything that increases intra-
Cerebral Perfusion Pressure abdominal/thoracic pressure
(vomiting and bearing down)
PATHOPHYSIOLOGY: “M-I-N-D C-R-U-S-H”
● The human skull is very hard and
has limited space within its cavity M MENTAL STATUS CHANGES
○ Limits expansion of the brain ● Earliest: Restless, confused,
whenever there’s a responding to question NLE Tips
swelling/increase in I IRREGULAR BREATHING:
intracranial pressure ● Cheyne-StokesNLE Tips
○ Hyperventilation then Apnea
Increase ICP= Ischemia due to decrease (Late)
CPP ○ Occurs when the PONS is
| compressed or displaced
Its gonna cut of the Blood supply of the N NERVE CHANGES TO OPTIC &
Brain (Decrease CBF leads to the limitation OCULOMOTORNLE Tips
of nutrient to the brain) ● Double vision
| ● Swelling of Optic Nerve
The body will try to compensate for it by “Papilledema”NLE Tips
increasing the systolic blood pressure- and ● Unequal Pupils
it will push more blood there because the ● Abnormal Doll’s eyes
body thinks that the brain is not receiving ○ “Oculocephalic reflex”NLE
enough blood Tips
*But pressure still continuously increases ○ Indicates that there is
| damage in the brainstem
The Increase Systolic Blood pressure will ■ Side to side of they
add up with the existing pressure and will move in the opposite
lead to: side
● Swelling/Edema ■ If not (DANGEROUS)
● Arteries dilate due to the increase in D DECEREBRATE AND DECORTICATE
CO2 POSTURING OR FLACCID
○ Limitation of venous floor ● Decerebrate is the worstNLE Tips
○ Draining of CSF will be ○ Extension type of posturing
stagnant/obstructed ○ There will be adduction of the
■ Increase more arm and Extension of the
swelling arms with pronation
| ○ The feel will be just flexed
Displacement of Brain ○ A lot of E meaning a lot of
Compression of Brainstem, medulla Extensions
oblongata, and Pons ● DecorticateNLE Tips
| ○ Arms adducted to the body
Respiratory depression, Alteration of and Leg internally with feet
Cardiac system and Neuro alteration flex
| ○ Look at that arm and see if
Death it’s close to the core of the
SIGNS AND SYMPTOMS body
○ Core in the body where are
 P POSITION HOB (Head Over Bed)
C CUSHING’S TRIAD (LATE) ● 30-34 degrees
● Increase Systolic Pressure ● Head Mid Line
○ Widening of Pulse Pressure ● No Flexion of Neck and Hips
○ Increase SBP and decrease ○ Can impede blood flow and
DBP obliterate the venous
● Decrease Heart Rate, Decrease return/draining of blood
Respiratory Rate (Abnormal) ○ Can also increase intra-
Normal: 40 mmHg abdominal pressure
*If High meaning widening
R REFLEX (Late) R RESPIRATORY:
● (+) Babinski Reflex (Toes Fanout) ● Prevent Hypoxia (low oxygen level)
● Baroreceptor Reflex and Hypercapnia (too high CO2)
○ The parasympathetic has Normal Values:
been stimulated because of ○ CO2 (35-43)
that high Systolic blood ○ Too much can cause
pressure Vasodilation= Increase ICP
■ To decrease that SBP O2 Saturation
down ○ 95-100%
U UNCONSCIOUS (Late) ○ Monitor ABGs
S SEIZURE ○ Suction PRN (no more than
H HEADACHE 15 sec)
E EMESIS (Vomiting) w/out nausea ■ Because suctioning
● Projectile Vomiting itself can increase
D DETERIORATION ICP
● Hemiplegia ■ Hyperventilate them
○ Motor Deteriation before and after
○ One side paralysis ○ Mechanical Ventilation
DIAGNOSTIC PROCEDURE: ■ The PaCO2 Level
● There is a device that will measure must be kept (30-35)
the Intracranial pressure because f we keep it
○ Lateral ventricle low to prevent
○ Subarachnoid space vasodilation
MEDICATION: ■ Keep PEEP low
● Barbituates & Anticonvulsants because if this too
● For Supportive Meds: Anti-emetic high it can increase
and Laxatives intrathoracic pressure
NURSING INTERVENTION that can lead to
increased ICP
Goal: PReventing Progressive increase of
ICP and Monitoring of ICP & PROVIDING E ELEVATED TEMPERATURE PREVENT!
routine care for the unconscious ● Increased ICP can also increase
metabolic needs
“P-R-E-S-S-U-R-E” ● Monitor temperature
 ○ If Unconscious (Rectally, Ventriculostomy
tympanic, temporal)
○ Avoid oral and axillary route
● Antipyretics, Tepid Sponge bath/cool
bath, remove extra blankets,
decrease room temperature and
cool blanket
● The reason for that increased in
temperature
○ Is due to damage to the
hypothalamus, infection
dehydration and etc
.

S SYSTEMS TO MONITOR
● Round the clock assess NeuroVitals,
Glasgow Coma Scale ● A.k. A External Ventricular Drain
● It monitors the ICP and has a
catheter inserted in the area of the
Behavior Response
lateral ventricle and drains the CSF
4- Spontaneously during increase pressure reading
3- To Speech ○ >20 mmHg call M.D
2- To pain REMEMBER THEY ARE NOT GOOD
1- No response CANDIDATES FOR LUMBAR PUNCTURE
Verbal Response 5- Oriented to time,
person, and place S STRAINING ACTIVITIES AVOIDED
4- Confused ● Vomiting
3- Inappropriate ○ antiemetic may be prescribed
words ● Sneezing
2- ● Valsalva maneuver
Incomprehensible
sounds ○ Laxative
1- No response ● Kepp environment calm anf avoid
restraint
Motor Response 6- Obeys command U UNCONSCIOUS PATIENT CARE
5- Moves to ● Avoid over sedating
localized pain ○ It can mask the early S&S of
4- Flex to withdraw
from pain increase intracranial
3- Abnormal flexion pressure
2- Abnormal ● Assess Lung sound
Extension ○ They can have pooling of
1- No response secretions
● Best Score: 15 ○ Move them every 2 hours
● Comatose: Less than 8 ○ Suction as needed (not more
● Unresponsive: 3 than 15 sec)
 ● Skincare for immobile Loop Diuretics and Corticosteroids
● GI Tube (protein starts leaking in a breakdown on
○ Check residual the Blood-Brain Barriers, and corticosteroids
● The risk for renal stone development can help with that)
○ Foley catheter
● Contractures
1. Select the main structures below that play a role with altering
● Eyes Care
intracranial pressure:
● Constipation A. Brain
B. Neurons
● Blood Blots (PT and INR) C. Cerebrospinal Fluid
● Treat them as a conscious patient D. Blood
E. Periosteum
Rx/MEDICATION F. Dura mater
● Barbiturates The answers are A, C, and D. Inside the skull are three structures
that can alter intracranial pressure. They are the brain, cerebrospinal
○ Decrease Brain metabolism fluid (CSF), and blood.
and Decrease BP and ICP
○ Vasopressor/IVF if they have 2. The Monro-Kellie hypothesis explains the compensatory
relationship among the structures in the skull that play a role with
too much Mannitol intracranial pressure. Which of the following are NOT compensatory
● Antihypertensive medication mechanisms performed by the body to decrease intracranial pressure
naturally? Select all that apply:
○ To decrease MAP (SBP) A. Shifting cerebrospinal fluid to other areas of the brain and spinal
● Mannitol cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
E EDEMA MANAGEMENT: D. Leaking proteins into the brain barrier
The answers are B and D. These are NOT compensatory
● Hyperosmotic Drugs mechanisms, but actions that will actually increase intracranial
pressure. Vasoconstriction (not dilation) decreases blood flow and
○ Dehydrating brain helps lower ICP. Leaking of protein actually leads to more swelling of
○ Done very carefully and the brain tissue. Remember water is attracted to protein (oncotic
pressure).
○ Monitor BP and renal
Functions
3. A patient is being treated for increased intracranial pressure.
Mannitol Which activities below should the patient avoid performing?
● Concentrated sugar A. Coughing
B. Sneezing
● Draws water that is pooling in the C. Talking
D. Valsalva maneuver
brain into the blood E. Vomiting
● Filtered through Glomerulus and Not F. Keeping the head of the bed between 30- 35 degrees
The answers are A, B, D, and E. These activities can increase ICP.
reabsorbed by the renal tubules
○ Water remove = Na+
4. A patient is experiencing hyperventilation and has a PaCO2 level
+Chloride of 52. The patient has an ICP of 20 mmHg. As the nurse you know
● The risk for Fluid Volume Overload that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
○ The risk for Heart Failure B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
○ The risk for Pulmonary D. cause vasodilation and decrease the ICP
Edema The answer is C. An elevated carbon dioxide level in the blood will
cause vasodilation (NOT constriction), which will increase ICP
● The risk for Fluid Depletion (normal ICP 5 to 15 mmHg). Therefore, many patients with severe
○ S&S: Thirst and dry ICP may need to be mechanical ventilated so PaCO2 levels can be
lowered (30-35), which will lead to vasoconstriction and decrease ICP
○ Dehydration (with constriction there is less blood volume and flow going to the
○ Monitor Renal Function, brain and this helps decrease pressure)....remember Monro-Kellie
hypothesis.
○ UOP (urinary output),
○ Electrolytes
5. You're providing education to a group of nursing students about The answer is A. LPs are avoided in patients with ICP because they
ICP. You explain that when cerebral perfusion pressure falls too low can lead to possible brain herniation.
the brain is not properly perfused and brain tissue dies. A student
asks, "What is a normal cerebral perfusion pressure level?" Your
response is: 11. You're collecting vital signs on a patient with ICP. The patient has
A. 5-15 mmHg a Glascoma Scale rating of 4. How will you assess the patient's
B. 60-100 mmHg temperature?
C. 30-45 mmHg A. Rectal
D. >160 mmHg B. Oral
The answer is B. This is a normal CPP. Option A represents a normal C. Axillary
intracranial pressure. The answer is A. This GCS rating demonstrates the patient is
unconscious. If a patient is unconscious the nurse should take the
patient’s temperature either via the rectal, tympanic, or temporal
6. Which patient below is at MOST risk for increased intracranial method. Oral and axillary are not reliable.
pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury. 12. A patient who experienced a cerebral hemorrhage is at risk for
C. A patient who recently experienced a myocardial infarction. developing increased ICP. Which sign and symptom below is the
D. A patient post-op from eye surgery. EARLIEST indicator the patient is having this complication?
The answer is B. Remember head trauma, cerebral hemorrhage, A. Bradycardia
hematoma, hydrocephalus, tumor, encephalitis etc. can all increase B. Decerebrate posturing
ICP. C. Restlessness
D. Unequal pupil size
The answer is C. Mental status changes are the earliest indicator a
7. A patient with increased ICP has the following vital signs: blood patient is experiencing increased ICP. All the other signs and
pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, symptoms listed happen later.
oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these
findings you would?
A. Administered PRN dose of a vasopressor 13. Select all the signs and symptoms that occur with increased ICP:
B. Administer 2 L of oxygen A. Decorticate posturing
C. Remove extra blankets and give the patient a cool bath B. Tachycardia
D. Perform suctioning C. Decrease in pulse pressure
The answer is C. It is important to monitor the patient for D. Cheyne-stokes
hyperthermia (a fever). A fever increases ICP and cerebral blood E. Hemiplegia
volume, and metabolic needs of the patient. The nurse can F. Decerebrate posturing
administer antipyretics per MD order, remove extra blankets, The answers are A, D, E, and F. Option B is wrong because
decrease room temperature, give a cool bath or use a cooling bradycardia (not tachycardia) happens in the late stage along with an
system. Remember it is important to prevent shivering (this also INCREASE (not decrease) in pulse pressure.
increases metabolic needs and ICP).

14. You're maintaining an external ventricular drain. The ICP

8. A patient has a ventriculostomy. Which finding would you readings should be?
immediately report to the doctor? A. 5 to 15 mmHg
A. Temperature 98.4 'F B. 20 to 35 mmHg
B. CPP 70 mmHg C. 60 to 100 mmHg
C. ICP 24 mmHg D. 5 to 25 mmHg
D. PaCO2 35 The answer is A. Normal ICP should be 5 to 15 mmHg.
The answer is C. A ventriculostomy is a catheter inserted in the area
of the lateral ventricle to assess ICP. It will help drain CSF during
increase pressure readings and measure ICP. The nurse must 15. Which patient below with ICP is experiencing Cushing's Triad? A
monitor for ICP levels greater than 20 mmHg and report it to the patient with the following:
doctor. A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
9. External ventricular drains monitor ICP and are inserted where? D. BP 80/40, HR 49, RR 12
A. Subarachnoid space The answer is C. These vital signs represent Cushing's triad. There is
B. Lateral Ventricle an increase in the systolic pressure, widening pulse pressure of 140
C. Epidural space (200-60=140), bradycardia, and bradypnea.
D. Right Ventricle
The answer is B. External ventricular drains (also called
ventriculostomy) are inserted in the lateral ventricle. 16. The patient has a blood pressure of 130/88 and ICP reading of
12. What is the patient's cerebral perfusion pressure, and how do you
interpret this as the nurse?
10. Which of the following is contraindicated in a patient with A. 90 mmHg, normal
increased ICP? B. 62 mmHg, abnormal
A. Lumbar puncture C. 36 mmHg, abnormal
B. Midline position of the head D. 56 mmHg, normal
C. Hyperosmotic diuretics The answer is A. CPP is calculated by the following formula:
D. Barbiturates medications CPP=MAP-ICP. The patient’s CPP is 90 and this is normal. A normal
CPP is 60-100 mmHg.
 Option A is a normal ICP reading and shows the mannitol is being
effective. BP is within normal limits, and dry mouth/thirst will occur
17. According to question 16, the patient's blood pressure is 130/88. with this medication because remember we are trying to dehydrate
What is the patient's mean arterial pressure (MAP)? the brain to keep edema and intracranial pressure decreased.
A. 42
B. 74
C. 102
D. 88
The answer is C. MAP is calculated by taking the DBP (88) and
multiplying it by 2. This equals 176. Then take this number and add
the SBP (130). This equals 306. Then take this number and divide by
3, which equal 102.

18. During the assessment of a patient with increased ICP, you note
that the patient's arms are extended straight out and toes pointed
downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing
The answer is B.

19. While positioning a patient in bed with increased ICP, it important

to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips
The answer is D. Avoid flexing the hips because this can increase
intra-abdominal/thoracic pressure, which will increase ICP.

20. During the eye assessment of a patient with increased ICP, you
need to assess the oculocephalic reflex. If the patient has brain stem
damage what response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved
side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved
side to side.
The answer is D. This is known as a negative doll's eye and
represents brain stem damage. It is a very bad sign.

21. A patient is receiving Mannitol for increased ICP. Which

statement is INCORRECT about this medication?
A. Mannitol will remove water from the brain and place it in the blood
to be removed from the body.
B. Mannitol will cause water and electrolyte reabsorption in the renal
tubules.
C. When a patient receives Mannitol the nurse must monitor the
patient for both fluid volume overload and depletion.
D. Mannitol is not for patients who are experiencing anuria.
The answer is B. All the other options are correct. Mannitol will
PREVENT (not cause) water and electrolytes (specifically sodium
and chloride) from being reabsorbed....hence it will leave the body as
urine.

22. What assessment finding requires immediate intervention if found

while a patient is receiving Mannitol?
A. An ICP of 10 mmHg
B. Crackles throughout lung fields
C. BP 110/72
D. Patient complains of dry mouth and thirst
The answer is B. Mannitol can cause fluid volume overload that leads
to heart failure and pulmonary edema. Crackles in the lung fields
represent pulmonary edema and require immediate intervention.
STROKE (CEREBROVASCULAR ■ Memory Recall
ACCIDENTS) ■ Music/Art Awareness
■ Control the left side
DEFINITION: of the body
● Blood rich in oxygen can not reach ○ Left (Logic)
brain cells and cells begin to die ■ Logical
○ Blockage or Bleeding ■ Reading Writing and
● Types of Strokes: speaking
○ Ischemic Stroke ■ Speaking
○ Hemorrhagic Stroke ■ writing
○ Transient Ischemic Attack ■ Reading
■ Math skills
ANATOMY AND PHYSIOLOGY: ■ Analyzing info
● Blood Supply: ■ Planning
○ Carotid and Vertebral
Arteries
Right Side of the Left Side of the
■ Each areas of the Brain Brain
brain has specific
function - Attention - Speaking
● Brains cells are super sensitive span - Writing
○ They cannot go without a - Showing - Reading
Emotions - Math skills
minutes without blood rich
- Ability to - Analyzing
oxygen solve info
○ Cells affected within 5 everyday - Planning
minutes problems by - Controls the
■ The longer it goes the making left side of
more cell death can decisions/pl the body
occur an
- Reasoning
● Hemisphere of the Brain
{understandi
○ Right ng jokes,
■ Creativity reading in
■ Music and Arts between the
■ Attention Span lines}
■ Showing emotions - Memory
Recall
■ Ability to solve
- Music/Art
everyday problems by awareness
making - Controls the
decision/plans left side of
■ Reasoning the body
(understanding
jokes… read in ● Parts of the brain and function:
between the line) ○ Frontal:
■ Making judgement ■ Decision making
calls ■ Thinking
 ■ Speaking or atrial fibrillation) nd
■ Memory travelled to the brain,
■ Movement which stops blood
■ Broca’s Area flow
○ Parietal Lobe ■ Thrombosis: Clot
■ Language form within the
■ Touch arterial wall within the
○ Temporal Lobe: neck or rain
■ Hearing ● Seen in
■ Learning patient with
■ Feeling Hyperlipidem
■ Weicken’s Area ia and
○ Occipital atherosclero
■ Vision Acuity sis
■ Color perception ● Hemorrhagic Stroke:
○ Cerebellum ○ Happen due to
■ Ballance ■ Bleeding in the
■ Coordination Brain due to a break
○ Brain Stem in blood vessel
■ Breathing ■ Leads to no blood to
■ Heart Rate perfuse the brain cells
■ Temperature and excessive blood
CAUSE in the brain
● Blockage: ■ Cause: a brain
○ Atherosclerosis aneurysm bursts.
○ Clots Uncontrolled
○ Embolism hypertension, old age
○ Thrombi (vessels are not as
● Bleeding resilient)
○ AMD ○ Can cause excessive
○ Cerebral Aneurysm swelling and increase
PATHOPHYSIOLOGY intracranial pressure
● Ischemic Stroke ● Transient Ischemic Attack:
○ Blockage of Blood Vessel/ ○ This is an ischemia type of
Stenosis or artery stroke on its origin
■ Not be able to feed ■ There is some type of
the brain tissue blockage on that
○ Results to a lack of blood vein/arteries that
flow in affected area prevents blood from
○ Can Happen due to coming in
■ Embolism: A clot has ■ It’s a mini type of
left a part of the body stroke
(example the heart: ■ It’s not a full blown
heart valve problem stroke yet
 ■ Usually its a sign that ● Apraxia: Can’t perform voluntary
something’s big is movement even though muscles
about to happen function is normal
○ Signs and Symptoms last ● Agraphia: loss the ability to write
few minutes to hours and ● Alexia: loss the ability to read {does
will resolve not understand or see the words
○ It's a Warning signs ● Agnosia: doesn’t understand
○ Bloodakege of of the vessel sensations or recognize known
○ Mini type stroke NOT A objects or people
FULL BLOWN STROKE ○ They can’t call pencil a pencil
● Dysphagia: issue swallowing
SIGNS AND SYMPTOMS ○ Major risk for pneumonia
● Physical Examination reveals ● Hemianopia: limited vision in half of
○ Happen suddenly the visual fields
■ Need to act FAST to ● Learn to recognize the Signs of a
save brain cells Stroke
○ Call rapid response of 911 ○ Act “FAST”
○ NOTE the time ■ F for Face
■ tPA might be ● Drooping of
administered before 3 the face
hours of onset stoke ● Uneven smile
● Aphasia- unable to speak and ■ A for Arms
comprehension it or producing ● Arm
○ Types numbness or
■ Receptive- unable to weakness
comprehend speech ● Ask the
{wernicke’s area at person to
the temporal lobe raise their
■ Expressive arms
comprehends speech {however it
but can’t respond the arms still
back with speech drops down
{Broca’s area at the and isn’t
frontal lobe ready}
■ Mixed: both ■ A for speech
combination of two difficulty
■ Global: complete ● Ask the
inability to understand person to
speech or produce it repeat
● Dysarthria: unable to speak clearly something
due to weak muscle {hard to ● Slurred
understand} speech
■ T for tome
 ● Act fast if
going to think
someone is things through-
experiencing very impulsive
stroke - Poor ability to
symptoms make decisions
and assessing
Right Brain Injury Left Brain Injury spatial
elements...sha
pes
- Denial about
their
limitations
- Not able to
interpret
nonverbal
language or
understand the
Findings: Findings: hidden meaning
- Left side ● Right side of things
weakness: Hemiplegia - Very short
Hemiparesis ● Aphasia attention span
and {trouble
Hemiplegia formulating
- Impairment in words and RISK FACTOR:
creativity: Arts comprehendin ● “S.T.R.O.K.E.S H.A.P.P.E.N”
and music g them} ○ S-moking
- Confused on ● Aware of their ○ T-hinners {anticoagulant}
date, time, limits {they ■ When blood gets too
place often thin the pressure
- Cannot experience
increases which will
recognize depression,
faces or the anger, lead to bursting of
person’s name frustration} fragile vessel
- Loss of depth ○ They ○ R-hythm Changes {Atrial
perception know what Fibrillation}
- Trouble they feel ■ Clot can form and
staying on ● Trouble
lead to TIA or stoke
topic understanding
- Can’t see written text ○ O-ral Contraceptives
things on left issues with ■ Estrogen
side: writing ○ K-in
- LEFT SIDE {agraphia} ■ Family
NEGLECT: ● Memory intact ○ E-xcessive weight
Ignores left side ● Issues with ■ Risk for developing
of the body seeing on the
atherosclerosis
- Trouble with right side
maintaining ■ Hyperlipidemia
proper ○ S-enior Citizens
grooming ○ H-ypertension
- Emotionally: not ○ A-therosclerosis
 ○ P-hysical Inactivity ○ Hasn’t received any blood
○ P-revious TIA thinners and other
○ E-levated glucose anticoagulants like heparin
■ Diabetes Mellitus TREATMENT
■ The sugarry blood ● tPA
can irritate the blood NURSING INTERVENTION
vessel and stick to ● NURSING INTERVENTION FOR
vessel and form a tPA
thrombi and ○ Check for bleeding
eventually leads to ○ Neuro checks around the
emboli and stoke clock
○ a-N-eurysm brain ■ NIH stroke scale
■ Outpouching of ● Assess 11
vessel level areas of
DIAGNOSTIC AND LABORATORY TEST their body
● Remember prompt diagnosis is the ● Scores ranges
key from 0-42
● CT scan and MRI ● 0: no stroke
○ They want to rule out if there ● Worst score
is bleeding or stroke 21-42
○ Because if they do, they are
not candidate for t-PA tissue ○ Blood pressure medication if
plasminogen activator needed for hypertension
■ A medication ○ VItal signs
indicated only for ○ Labs
Ischemic Stroke and ■ INR
not Hemorrhagic ○ Monitor Glucose
○ tPA dissolved the clot by ○ Prevent injury
activating the protein that ■ Promote bed rest
causes fibrinolysis ■ Fall can increase
■ Given within 3 hours ecchymosis and
from onset signs and bleeding
symptoms ○ Avoid unnecessary
■ 3-4.5 hours if meets venipunctures
the criteria ○ Avoid IM injection
● Criteria for tPA ○ Most patient will go to ICU to
○ CT scan negative be monitored
○ Labs within normal limit ■ During 1st 14 hours
■ Glucose after administration of
■ INR the medication
■ Platelets
○ BP is controlled
■ <180/110
 ○ V/S: Increase BP, Decrease
HR, and Decrease RR
■ Because they are
high at risk of
developing increased
intracranial pressure
especially for
Hemorrhagic Stroke
■ Increase
ICP=Nauseas and
vomiting, decrease
Level of
Consciousness
■ No pupil response
○ Airway: issue swallowing
■ Suction at bedside
can provided
○ Cranial Nerves: pupil.
Swallowing, facial gaze, gag
reflex and etc
○ Bladder and Bowel Function
■ Bedpan
■ Foley - bladder scan
● For urine
retention
○ Maintain Skin and Limb
integrity
■ Reposition them
every 2 hours
■ Maintain proper body
alignment
■ Perform passive
motion technique
■ Watch out for
Neglect Syndrome/
Unilateral neglect
● Right side
injury and
ignore the left
side
● Teach patient
to always do a
conscious
● Monitor: effort to touch
 and feel the ■ Short phrases and
left side of the simple details
body ■ Use gestures and
■ Always scan the point
environment and ■ Be patient
surrounding to ■ Remove distractions
prevent injury of the ■ Repeat and repeat
affected side and rephrase
○ Hemianopia: Half od the ○ Expressive Aphasia: They
visual field is gone can comprehend but trouble
■ Increase risk for injury responding
■ Prevent injury by ■ Be patient and let
● Always turn them speak
head side to ● Don't rush and
side to see all fill out what
vision fields they say
○ Diet: Evaluated by SLP ■ Ask one question at a
■ Problems like time and let those
difficulty swallowing question be direct
occurs ■ Use communication
■ Thickened Liquid, board
crushed meds with
applesauce, our Grade: C
mechanical soft foods Percentage of What you Got Right: 71
○ Always assist patient with
eating Go Here for More Quizzes
■ Assess Pouching
food in cheeks can Your Answers & what you got Right &
increase risk for Wrong:
aspiration
■ Always assess risk 1. A patient is admitted with uncontrolled
for Aspiration atrial fibrillation. The patient’s medication
■ To prevent aspiration history includes vitamin D supplements and
TUCK IN CHIN TO calcium. What type of stroke is this patient
CHEST WHILE at MOST risk for?
SWALLOWING A. Ischemic thrombosis
● Communication: Aphasia B. Ischemic embolism
○ Always note that they don’t C. Hemorrhagic
have mental deficits D. Ischemic stenosis
○ They just can’t properly The answer is B. If a patient is in
communicate like they used uncontrolled a-fib they are at risk for clot
to be formation within the heart chambers. This
○ For Receptive aphasia: clot can leave the heart and travel to the
brain. Hence, an ischemic embolism type
stroke can occur. An ischemic thrombosis
type stroke is where a clot forms within the
artery wall of the neck or brain. 4. A patient who suffered a stroke one
month ago is experiencing hearing
problems along with issues learning and
2. Which patient below is at most risk for a showing emotion. On the MRI what lobe in
hemorrhagic stroke? the brain do you expect to be affected?
A. A 65 year old male patient with carotid A. Frontal lobe
stenosis. B. Occipital lobe
B. A 89 year old female with C. Parietal lobe
atherosclerosis. D. Temporal
C. A 88 year old male with uncontrolled The answer is D. The temporal lobe is
hypertension and a history of brain responsible for hearing, learning, and
aneurysm repair 2 years ago. feelings/emotions.
D. A 55 year old female with atrial flutter.
The answer is C. A hemorrhagic stroke
occurs when bleeding in the brain happens 5. A patient's MRI imaging shows damage
due to a break in a blood vessel. Risk to the cerebellum a week after the patient
factors for a hemorrhagic stroke is suffered a stroke. What assessment
uncontrolled hypertension, history of brain findings would correlate with this MRI
aneurysm, old age (due to aging blood finding?
vessels.) All the other options are at risk for A. Vision problems
an ischemic type of stroke. B. Balance impairment
C. Language difficulty
D. Impaired short-term memory
3. You're educating a patient about transient The answer is B. The cerebellum is
ischemic attacks (TIAs). Select all the important for coordination and balance.
options that are incorrect about this
condition:
A. TIAs are caused by a temporary 6. A patient is demonstrating signs and
decrease in blood flow to the brain. symptoms of stroke. The patient reports
B. TIAs produce signs and symptoms that loss of vision. What area of the brain do you
can last for several weeks to months. suspect is affected based on this finding?
C. A TIAs is a warning sign that an A. Brain stem
impending stroke may occur. B. Hippocampus
D. TIAs don't require medical treatment. C. Parietal lobe
The answers are B and D. Options A and C D. Occipital lobe
are CORRECT statements about TIAs. The answer is D. The occipital lobe is
However, option B is wrong because TIAs responsible for vision and color perception.
produce signs and symptoms that can last a
few minutes to hours and resolve (NOT
several weeks to months). Option D is 7. A patient has right side brain damage
wrong be TIAs do require medical from a stroke. Select all the signs and
treatment.
symptoms that occur with this type of 9. During discharge teaching for a patient
stroke: who experienced a mild stroke, you are
A. Right side hemiplegia providing details on how to eliminate risk
B. Confusion on date, time, and place factors for experiencing another stroke.
C. Aphasia Which risk factors below for stroke are
D. Unilateral neglect modifiable?
E. Aware of limitations A. Smoking
F. Impulsive B. Family history
G. Short attention span C. Advanced age
H. Agraphia D. Obesity
The answers are B, D, F, and G. Patients E. Sedentary lifestyle
who have right side brain damage will have The answers are A, D, and E. These risk
LEFT side hemiplegia (opposite side), factors are modifiable in that the patient can
confused on date, time, and place, unilateral attempt to change them to prevent another
neglect (left side neglect), DENIAL about stroke in the future. The other risk factors
limitations, be impulsive, and have a short are NOT modifiable.
attention span. Agraphia, right side
hemiplegia, aware of limitations, and
aphasia occur in a LEFT SIDE brain injury. 10. Your patient who had a stroke has
issues with understanding speech. What
type of aphasia is this patient experiencing
8. You're educating a group of nursing and what area of the brain is affected?
students about left side brain damage. A. Expressive; Wernicke's area
Select all the signs and symptoms noted B. Receptive, Broca's area
with this type of stroke: C. Expressive; hippocampus
A. Aphasia D. Receptive; Wernicke's area
B. Denial about limitations The answer is D.
C. Impaired math skills
D. Issues with seeing on the right side
E. Disoriented 11. Your patient has expressive aphasia.
F. Depression and anger Select all the ways to effectively
G. Impulsive communicate with this patient?
H. Agraphia A. Fill in the words for the patient they can't
The answers are A, C, D, F, and H. Patients say.
who have left side brain damage will have B. Don't repeat questions.
aphasia, be AWARE of their limitations, C. Ask questions that require a simple
impaired math skills, issues with seeing on response.
the right side, no deficit in memory, D. Use a communication board.
depression/anger, cautious, and agraphia. E. Discourage the patient from using words.
All the other options are found in right side The answers are C and D. Patients with
brain injury. expressive aphasia can understand spoken
words but can't respond back effectively or
at all. Therefore be patient, let them speak,
be direct and ask simple questions that
require a simple response, and 15. You're assessing your patient's pupil
communicate with a dry erase board etc. size and vision after a stroke. The patient
says they can only see half of the objects in
the room. You document this finding as:
12. While conversing with a patient who had A. Hemianopia
a stroke six months ago, you note their B. Opticopsia
speech is hard to understand and slurred. C. Alexia
This is known as: D. Dysoptic
A. Dysarthria The answer is A.
B. Apraxia
C. Alexia
D. Dysphagia 16. A patient who has hemianopia is at risk
The answer is A. for injury. What can you educate the patient
to perform regularly to prevent injury?
A. Wearing anti-embolism stockings daily
13. You're reading the physician’s history B. Consume soft foods and tuck in chin
and physical assessment report. You note while swallowing
the physician wrote that the patient has C. Scanning the room from side to side
apraxia. What assessment finding in your frequently
morning assessment correlates with this D. Muscle training
condition? The answer is C. Hemianopia is limited
A. The patient is unable to read. vision in half of the visual field. The patient
B. The patient has limited vision in half of needs to scan the room from side to side to
the visual field. prevent injury.
C. The patient is unable to wink or move his
arm to scratch his skin.
D. The patient doesn't recognize a pencil or 17. You receive a patient who is suspected
television. of experiencing a stroke from EMS. You
The answer is C. conduct a stroke assessment with the NIH
Stroke Scale. The patient scores a 40.
According to the scale, the result is:
14. You need to obtain informed consent A. No stroke symptoms
from a patient for a procedure. The patient B. Severe stroke symptoms
experienced a stroke three months ago. The C. Mild stroke symptoms
patient is unable to sign the consent form D. Moderate stroke symptoms
because he can't write. This is known as The answer is B. Scores on the NIH stroke
what: scale range from 0 to 42, with 0 (no stroke
A. Agraphia symptoms) and 21-42 (severe stroke
B. Alexia symptoms).
C. Hemianopia
D. Apraxia
The answer is A. 18. In order for tissue plasminogen activator
(tPA) to be most effective in the treatment of
stroke, it must be administered?
A. 6 hours after the onset of stroke D. Have the patient extend the neck upward
symptoms away from the chest while eating.
B. 3 hours before the onset of stroke The answer is B. Because the patient has
symptoms weakness on the right side and dysphagia
C. 3 hours after the onset of stroke the nurse should regularly check for
symptoms pouching of food in the right cheek.
D. 12 hours before the onset of stroke Pouching of food in the cheek can lead to
symptoms aspiration or choking. The HOB should be
The answer is C. tPA dissolves the clot >30', liquids thickened per MD order, and
causing the blockage in stroke by activating the patient should tuck in the chin to the
the protein that causes fibrinolysis. It should chest while swallowing.
be given within 3 hours after the onset of
stroke symptoms. It can be given 3 to 4.5
hours after onset IF the patient meets strict 21. A patient has experienced right side
criteria. It is used for acute ischemia stroke, brain damage. You note the patient is
NOT hemorrhagic!! experiencing neglect syndrome. What
nursing intervention will you include in the
patient's plan of care?
19. Which patients are NOT a candidate for A. Remind the patient to use and touch both
tissue plasminogen activator (tPA) for the sides of the body daily.
treatment of stroke? B. Offer the patient a soft mechanical diet
A. A patient with a CT scan that is negative. with honey thick liquids.
B. A patient whose blood pressure is C. Ask direct questions that require one
200/110. word responses.
C. A patient who is showing signs and D. Offer the bedpan and bedside commode
symptoms of ischemic stroke. every 2 hours.
D. A patient who received Heparin 24 hours The answer is A. It is important to watch for
ago. neglect syndrome. This tends to happen in
The answers are B and D. Patients who are right side brain damage. The patient ignores
experiencing signs and symptoms of a the left side of the body in this condition.
hemorrhagic stroke, who have a BP for The nurse needs to remind the patient to
>185/110, and has received heparin or any use and touch both sides of the body daily
other anticoagulants etc. are NOT a and that the patient must make a conscious
candidate for tPA. tPA is only for an effort to do so.
ischemic stroke.

20. You're assisting a patient who has right

side hemiparesis and dysphagia with eating.
It is very important to:
A. Keep the head of bed less than 30'.
B. Check for pouching of food in the right
cheek.
C. Prevent aspiration by thinning the liquids.
EPILEPSY (SEIZURES) ○ CNS infection
○ Hypoglycemia
DEFINITION: ○ EtOH withdrawal
● Abnormal electrical signals in the ○ Acid-base imbalances
brain being fired from neurons: ○ Hypoxia
Two Category: ○ Brain tumor
○ Generalize (both side of the ● But some patient Epilepsy frequent
brain) seizures activity due to Chronic
○ Focal (partial seizure and condition
only target specific parts of ○ Traumatic brain injury (TBI)
the brain) ○ congenital birth defect
PHYSIOLOGY ○ Massive Stroke
● Neurons ○ Idiopathic
○ Their task is handling and ○ Effects of an illness
transmitting information and STAGES OF A SEIZURE:
impulses
2 Types of Neuron PRODROMAL
● Excitatory ● When symptoms start to appear
○ Whenever they are prior to the big event (hence the
stimulated they will cause a seizure)
response ○ Depression
○ They will release a ○ Anger
neurotransmitter glutamate ○ Issue sleeping
● Inhibitory ○ Anxiety
○ They will inhibit a response ○ GI and Urinary issue
they will decrease it ● Can start days before a seizure
○ They will release a happens
neurotransmitter GABA ● Intervention: Pro;ong betablockes &
There is an equilibrium for a patient who calcium blocker can e utilize to
does not have a seizure prepare themselves for the seizure
AURA
Problem: Damage in inhibitory neuron will ● It does NOT happen with all type
be damage then there won’t be an inhibiting ○ Focal seizures or tonic-clonic
excessive excitatory neurotransmitter types
release by the excitatory muscle-- ● Happens at the very beginning of a
overstimulation of the brain seizure (Serve as a warning signs) a
● For example, the Barbituates- will bigger seizure is expected
stimulate the GABA receptors that ○ Altered vision or hearing
will decrease the excitatory ○ Anxiety or dread
○ Deja Vu
CAUSE ○ Sudden weird taste or smell
● Affects Anyone due to an acute ○ Dizziness
illness ○ Inability to speak
○ Hugh fever
 ● Happens within hour, second or their side to prevent
minute aspiration on their
● Intervention: They can immediately own tongue and to
render care by administering facilitate secretions
phenobarbital and etc to prevent out the mouth, put
seizure pillows as well to
ICTUS/THE SEIZURE prevent injury to the
● The actual seizure head)
● It last about 1-3 minutes ○ Lost of Consciousness: They
○ Nursing Responsibility TIME are risk for Injury
THE SEIZURE |
● Greater than 5 minutes or starts to ○ Tonic: Body stiffened
have seizures back to back: ■ Groan/crying
○ May indicate Status (respiratory muscles
Epilepticus are stiffened)
○ Caused by medication, brain ■ Bite Tongue
trauma etc. ■ Foaming apnea
○ They may need intermediate ■ Cyanosis
medical treatment to make |
seizure stops ○ Clonic: Recurrent Jerking of
POST-ICTUS extremities relax-spas-relax
● After the seizure ■ Experience
● Recovery Incontinence (Urinary
● Time for the brain to recover and Bowel)
● Takes hours to days (tonic-clonic) or ○ Time the Seizure:
Immediate (absence) ■ N: 1-3 mis
○ Very tired that they want to ■ >5 mins (Status
sleep Epilepticus)
○ Confused ○ Post Ictus:
○ Headache ■ Sore from the
○ Injury (tongue, cheek, body) stiffening of the body
● Allow them to rest ■ Sleepy
TYPES ■ Headache
■ Can’t remember the
Generalized:Whole Brain event
○ Tonic-clonic (grand mal) Types of Generalized Seizures:
○ Most common type ● Tonic: Body stiffened
○ Usually 1-3 minutes ○ Groan/crying (respiratory
■ If >5 mins treat muscles are stiffened)
immediately ○ Bite Tongue
(EMERGENCY) ○ Foaming apnea
○ Has Aura ○ Cyanosis
■ Warning signs (Ask ● Clonic: Recurrent Jerking of
on that: Lie them on extremities relax-spas-relax
 ○ Experience Incontinence ○ Symptoms vary (location and
(Urinary and Bowel) dependent
● Absence Seizure (Petit-mal) ○ Small area of the lobe
○ Most common in Pediatrics ■ (Occipital: Changes in
○ Hallmark: Staring (Appear Vision)
to be daydreaming) ○ Patient is Aware ( Also refer
■ May Go unnoticed as to the Aura because they
■ Won’t response to are Short <2 mins)
you ● Focal Impaired Awareness
■ They will stop doing ○ Complex Partial
their current activity ○ Unaware
and just stare ■ Motor Symptoms
○ Very short (Seconds) ■ Automatisms
○ Post-Ictus ● Its the activity
■ Immediate that they’re
■ They won’t remember doing without
event them noticing
○ Atonic (Drop Attacks) that they’re
■ Without Muscle tone doing it
■ Goes limps falls ● Lips smacking
(when their standing) ■ Normally align with
● Risk for the temporal lobe
Cerebral injury CAUSE (SEIZURE TRIGGERS)
because our ● “S-T-O-P--S-E-I-Z-U-R-E”
head is heavy) S Stress
● Wear helmet T Trauma (cerebral)
for children O Overexertion
■ Sumps Over (sitting) P Period, Pregnancy
● Helmet may ● Hormone Shift and Ovulation
be advised
■ Not aware during the S Sleep Loss
event E Electrolyte & Metabolic imbalance/Issue
■ Post-Ictus: ● Hypoglycemia
● Immediate ● Hypernatremia
● They can ● Acidosis
regain ● Dehydration
consciousnes I Illness (Meningitis, Encephalopathy)
s VisualiZation disturbances, Sounds or
Focal: Partial/Specific Area smells
U Undermedicated
Two types R Recreational Drug
● Focal Onset Aware E ETOH
○ Simple partial DIAGNOSTIC AND LABORATORY TEST
EEG
 ● Painless Procedures ● Steven
● No caffeine prior to the test Johnson
● Hold Seizure medications and other syndrome
stimulants ● Refer to the
● Can eat before the test doctor
● Wash and Dry hair ■ Don’t give with milk or
○ Oily hair will slip the antacids
electrodes ● It can alter the
● Sleep absorption
○ It depends on the technicians ■ Drug Level:
● Breathing, Light ● 10-20 mcg/mL
● Benzodiazepines:
MEDICATION ○ Used for absence, tonic-
● Barbiturates: Phenobarbital clonic or focal seizures
○ Used for tonic clonic or focal ○ For Status Epilepticus
seizures and status ■ Diazepam and
epilepticus Lorazepam
○ Mechanism of Action: ■ Fast Acting for Status
Stimulate GABA receptors & Epilepticus
this helps inhibitory ○ Side Effect:
neurotransmission of ■ Very drowsy
Glutamate ■ Tolerance (not as
○ Side effects: Drowsiness, effective)
Ataxia ■ Impairment of liver
○ Monitor: ○ Antidote: Flumazenil
■ Respiratory ● Valproates: Valproic Acids
depression & ○ Used for all types
hypotension ○ Side Effects:
● Hydantoins (Phenytoin) ■ Monitor Liver, WBCs,
○ Used for Tonic clonic or focal Platelets and GI
seizures issues
○ Side Effects TREATMENTS:
■ Monitor Gums (It can ● Surgery:
cause gingival ○ To removes an area of the
hyperplasia) brain that is causing the
Enlargement and seizure
bleeding of gums ■ Example: Focal
■ Bone marrow Seizure (Removal of
suppression (Risk for Temporal lobe)
Fractures) Temporal Lobectomy
● Watch ● Vagus Nerve Stimulator
platelets and ○ Electrical device that sends
WBC electrical signals to the vagus
■ Monitor Rash nerve
 ● For Pediatric Patient (KETOGENIC ○ Blood in the mouth?
DIET) ○ Incontinence
○ Used in pediatric patient ● Before and During
whose epilepsy is not Characteristics/Signs and Symptoms
controlled by medication ● Be calm and reassure patient
■ High in Fats and
Protein After the Seizures
■ Low in Carbs ● Vital signs and Neurological
■ 5% Carbs assignment
■ 30% Protein ● How is your patient behaving
■ 65% Fats ● Drawing blood, Medication, EEG
NURSING INTERVENTION (assess brain activity)
EEG
Assess Risk Factors: ● Painless Procedures
● Seizures precautions ● No caffeine prior to the test
● O2 and suction (not more than 15 ● Hold Seizure medications and other
seconds) stimulants
● IV access panned bed rails ● Can eat before the test
● Bed (Lowest position) ● Wash and Dry hair
● Pillow ○ Oily hair will slip the
● No restrictive clothing electrodes
Assess Seizure History ● Sleep
● Prodromal? ○ It depends on the technicians
● Signs and Symptoms of Aura ● Breathing, Light
○ How fast?
● How long do they last? Your Answers & what you got Right &
○ Is it Drugs Illicit? Wrong:
○ When they take their Drug
Level? 1. Neurons in the brain are tasked with
During the Seizure handling and transmitting information. There
● Put Patient on their side are different types of neurons, such as
○ Standing or sitting lay down excitatory and inhibitory. Excitatory neurons
with pillow underneath the release the neurotransmitter
head _____________, while inhibitory neurons
● Do not restrain/Try to open their release the neurotransmitter
mouth ________________.
● Do not insert anything in their mouth A. GABA, glutamate
● Remove restrictive items or glasses B. Norepinephrine, GABA
● Time seizures C. Glutamate, GABA
○ Status Epilepticus D. Dopamine, glutamate
● Note Characteristics: The answer is C. Excitatory neurons release
○ Cry out? glutamate and inhibitory neurons release
○ Stiffening? GABA.
○ Jerking?
 statement requires you to re-educate the
2. You’re assessing your patient load for the patient about the triggers?
patients who are at MOST risk for seizures. A. “I’m at risk for seizure activity during my
Select all the patients below that are at risk: menstrual cycle.”
A. A 32-year-old with a blood glucose of 20 B. “I will limit my alcohol intake to 2 glasses
mg/dL. of wine per day.”
B. A 63-year-old whose CT scan shows an C. “It’s important I get plenty of sleep.”
ischemic stroke. D. “I will be sure to stay hydrated, especially
C. A 72-year-old who is post opt day 5 from during hot weather.”
open heart surgery. The answer is B. The patient should avoid
D. A 16-year-old with bacterial meningitis. all alcohol because it can lead to a seizure.
E. A 58-year-old experiencing ETOH Hormone shifts (menstrual cycle, ovulation,
withdrawal. pregnancy) sleep deprivation, and
The answers are A, B, D, and E. All the dehydration can lead to a seizure.
patients are at risk except option C.
Remember all the risk factors: illness
(especially CNS types like bacterial 5. True or False: A patient who is
meningitis), fever, electrolyte/metabolic experiencing a tonic-clonic seizure is
issues (low blood sugar, acidosis etc), experiencing a focal (partial) seizure.
ETOH (alcohol) withdraw, brain injury, True
STROKE, congenital brain defects, tumors False
etc. Answer FALSE: A patient who is
experiencing a tonic-clonic seizure is
experiencing a GENERLAIZED seizure.
3. A patient with a history of epilepsy is This type of seizure affects both sides of the
taking Phenytoin. The patient’s morning brain.
labs are back, and the patient’s Phenytoin
level is 7 mcg/mL. Based on this finding, the
nurse will? 6. A 7-year-old male patient is being
A. Assess the patient for a rash evaluated for seizures. While in the child’s
B. Initiate seizure precautions room talking with the child’s parents, you
C. Hold the next dose of Phenytoin notice that the child appears to be
D. Continue to monitor the patient daydreaming. You time this event to be 10
The answer is B. A normal Phenytoin level seconds. After 10 seconds, the child
is 10 to 20 mcg/mL. The patient’s level is appropriately responds and doesn’t recall
low; therefore, the patient is at risk for the event. This is known as what type of
seizures. The nurse should initiate seizure seizure?
precautions. Remember a patient being A. Focal Impaired Awareness (complex
under medicated is a trigger for developing partial)
a seizure. B. Atonic
C. Tonic-clonic
D. Absence
4. You’re educating a 25-year-old female The answer is D. This is an absence seizure
about possible triggers for seizures. Which and is most common in children. The
hallmark of it is staring that appears to be seizure….this is known as status
like a daydreaming state. It is very short and epilepticus.
the post ictus stage of this type of seizure is
immediate.
9. Your patient has entered the post ictus
stage for seizures. The patient’s seizure
7. Your patient has a history of epilepsy. presented with an aura followed by body
While helping the patient to the restroom, stiffening and then recurrent jerking. The
the patient reports having this feeling of déjà patient had incontinence and bleeding in the
vu and seeing spots in their visual field. mouth from injury to the tongue. What is an
Your next nursing action is to? expected finding in this stage based on the
A. Continue assisting the patient to the type of seizure this patient experienced?
restroom and let them sit down. A. Crying and anxiety
B. Initiate the emergency response system. B. Immediate return to baseline behavior
C. Lay the patient down on their side with a C. Sleepy, headache, and soreness
pillow underneath the head. D. Unconsciousness
D. Assess the patient’s medication history. The answer is C. Based on the findings
The answer is C. The patient is reporting during the seizure the patient experienced a
signs and symptoms of an aura (this is a tonic-clonic seizure. In the post ictus stage
warning sign before a seizure event). Lay (after the seizure) the patient is expected to
the patient down on their side with a pillow be sleepy (very tired), have soreness, and a
underneath the head and remove any headache. The nurse should let the patient
restrictive clothing. Also, time the seizure. If sleep.
the seizure lasts more than 5 minutes or if
the patient starts to have seizures back-to-
back activate the emergency response 10. You’re developing discharge instructions
system. to the parents of a child who experiences
atonic seizures. What information below is
important to include in the teaching?
8. Keeping the previous question in mind, A. “This type of seizure is hard to detect
the patient is now experiencing because the child may appear like he or she
characteristics of a tonic-clonic seizure. The is daydreaming.”
seizure started at 1402 and it is now 1408, B. “Be sure your child wears a helmet daily.”
and the patient is still experiencing a C. “It is common for the child to feel
seizure. The nurse should? extremely tired after experiencing this type
A. Continue to monitor the patient of seizure.”
B. Suction the patient D. “Avoid high fat and low carbohydrate
C. Initiate the emergency response system diets.”
D. Restrain the patient to prevent further The answer is B. This type of seizure leads
injury to a sudden loss of muscle tone. The patient
The answer is C. Tonic-clonic seizures will go limp and fall, which when this
should last about 1-3 minutes. If the seizure happens the head is usually the first part of
lasts MORE than 5 minutes, the patient the body to hit the floor or an object nearby.
needs medical treatment FAST to stop the It is important the child wears a helmet daily
to protect their head from injury. Option A is A. Oxygen and suction at bedside
a characteristic of an absence seizure. B. Bed in highest position
Option C is a characteristic of a tonic-clonic C. Remove all pillows from the patient’s
seizure during the post ictus stage. And head
option D is wrong because some patients D. Have restraints on stand-by
benefit from this type of diet known as the E. Padded bed rails
ketogenic diet. F. Remove restrictive objects or clothing
from patient’s body
G. IV access
11. You’re assessing a patient who recently The answers are A, E, F, and G. The bed
experienced a focal type seizure (partial needs to be in the LOWEST position
seizure). As the nurse, you know that which possible, a pillow should be underneath the
statement by the patient indicates the patient’s head to protect it from injury,
patient may have experienced a focal AVOID using restraints (this can cause
impaired awareness (complex partial) musculoskeletal damage).
seizure?
A. “My friend reported that during the
seizure I was staring off and rubbing my 13. You’re patient is scheduled for an EEG
hands together, but I don’t remember doing (electroencephalogram). As the nurse you
this.” will:
B. “I remember having vision changes, but it A. Keep the patient nothing by mouth.
didn’t last long.” B. Hold seizure medications until after the
C. “I woke up on the floor with my mouth test.
bleeding.” C. Allow the patient to have coffee, milk,
D. “After the seizure I was very sleepy, and I and juice only.
had a headache for several hours.” D. Wash the patient’s hair prior to the test.
The answer is A. The patient will experience E. Administer a sedative prior to the test.
an alternation in consciousness (hence the The answers are B and D. An EEG is a
name focal IMPAIRED awareness) AND will painless procedure that will assess the
perform an action without knowing they are patient’s brain activity (if a seizure occurs
doing it called automatism like lip-smacking, during the test this can allow the physician
rubbing the hands together etc. With a focal to determine what type of seizure it is).
onset AWARE seizure (also called partial Therefore, the nurse would hold seizure
simple seizure) the patient is aware and will medications (this can affect the test) and
remember what happens (like vision would NOT allow the patient to have
changes etc.). caffeine like coffee or stimulant drugs (the
patient can eat prior to the test just NO
caffeine). The patient’s hair should be
12. You have a patient who has a brain cleaned prior to the test so the technician
tumor and is at risk for seizures. In the can apply the electrodes and get them to
patient’s plan of care you incorporate stick to the scalp easily. A sedative is not
seizure precautions. Select below all the needed before this test.
proper steps to take in initiating seizure
precautions:
14. A patient is taking Phenytoin for lead to respiratory depression and
treatment of seizures. Which statement by hypotension, therefore, it is very important
the patient requires you to re-educate the the nurse monitors the patient for this.
patient about this medication?
A. “Every morning I take this medication
with a full glass of milk with my breakfast.” 17. An 8-year-old child, who is not
B. “I know it is important to have my drug responding to anti-seizure medications, is
levels checked regularly.” prescribed to start a ketogenic diet. This diet
C. “I will report a skin rash immediately to will include:
my doctor.” A. High carbohydrates and high fat
D. “This medication can lower my body’s B. Low fat, high salt, and high
ability to clot and fight infection.” carbohydrates
The answer is A. This medication should C. High fat and low carbohydrates
NOT be taken with milk products or antacids D. High glucose, high fat, and low
because it affects absorption. All the other carbohydrates
options are correct. The answer is C. This is a type of diet used
in the pediatric population with epilepsy
whose seizures cannot be controlled by
15. The nurse is ordered to administer medication. It is a high fat and low carb diet.
Lorazepam to a patient experiencing status
epilepticus. As a precautionary measure,
the nurse will also have what reversal agent
on standby?
A. Narcan
B. Flumazenil
C. Calcium Chloride
D. Idarucizumab
The answer is B. Flumazenil is the reversal
agent for Lorazepam, which is a
benzodiazepine.

16. A patient who is having a tonic-clonic

seizure is prescribed Phenobarbital. During
administration of this drug, it is important the
nurse monitors for:
A. Respiratory depression
B. Hypertension
C. Disseminated intravascular clotting
D. Hypotension
E. Fever
The answers are A and D. This medication
stimulates the GABA receptors and helps
with inhibitory neurotransmission. It can
HEADACHE ■ Its the most common
reason why OTC
DEFINITION: analgesia are
● Headache can be Divided into TWO purchased
MAIN TYPES ○ Location:
● Cephalalgia ■ Bilateral
PRIMARY: ○ CHaracteristics:
● Main and common type of ■ Pressure or tightened
headaches which waxes and
○ Unilateral Headache wanes
(Migraine) ○ Duration:
○ Tightness of the Head ■ Variable
Headache (Tension type ○ Associated Symptoms:
Headache) ■ None
○ Orbit area headaches ● Cluster Headache
(Cluster Headache) ○ Group of Idiopathic
○ Sinus Headache headache that is associated
○ Hormonal Headache with trigeminal neuralgia
SECONDARY: ○ Location:
● Pretty Bad Headaches ■ Always unilateral
● These are the Red Flag Headaches (around the eyes)
PRIMARY HEADACHE ○ Characteristics:
PATHOPHYSIOLOGY ■ Pain begins quickly
● Migraine: ■ Deep continuous pain
○ Disorder of recurrent attacks ■ Excruciating and
○ Location: Unilateral (70%) explosive in quality
○ Characteristics: ○ Durations:
■ Gradual Onset ■ 1o mins to 1 hour
■ Crescendo Pattern ○ Associated Symptoms:
■ Moderate to severe ■ Horner's Symptoms
intensity ● Ptosis
○ Duration: ● Miosis
■ 4-72 hours ● Pain
○ Associated Symptoms: ■ Lacrimation
■ Nausea ■ Nasal Discharge
■ Vomiting ○ Function of Trigeminal
■ Photophobia Nerve:
■ Phenophobia ■ Important for the
■ Aura sensation around
● Tension Headache your forehead which
○ More muscular is supplied by the
■ Most ambiguous ophthalmic branch of
headache headache the trigeminal (V1)
■ Maxillary Branch (V2)
 ■ Mandibular Branch ○ O Other associated condition
(V3) or features
● Sinus Headache: ○ P Precious Headache History
○ Associated with Sinusitis with headache progression
● Hormonal Headache: or change in attack character
○ Associated with Low *The Head is very abnormal, it indicates a
estrogen concentration very serious problem
■ Beginning of
menstrual cycle Intracranial Hemorrhage
■ Withdrawal of ● Subdural
Hormone Therapy ● Epidural
TREATMENT ● Subarachnoid
● Migraine:
○ NSAIDs/ Aspirin + Antiemetic
○ Hydration
● Tension Headache:
○ OTC paracetamol
● Cluster Headache:
○ Subcutaneously
Sumatroptophan or Oxygen
○ Triptants are
Contraindicated in patient
with CAD, PVD, or
Cerebrovascular Disease
● Sinusitis Headache:
● Supportive Therapy
○ Analgesic/Anti
Inflammatory
○ Antibiotics

SECONDARY HEADACHE
PATHOPHYSIOLOGY
● It is a result of an underlying
disease/conditions
● Warning signs and symptoms
○ S Systemic Symptoms
(Illness or conditions like
cancer)
○ N Neurological symptoms or
abnormal signs
○ O Onset is new (Age >40) or
sudden (Thunderclaps)
Stroke
 ○ CNS infection
○ Hypoglycemia
DEFINITION: ○ EtOH withdrawal
● Abnormal electrical signals in the ○ Acid-base imbalances
brain being fired from neurons: ○ Hypoxia
Two Category: ○ Brain tumor
○ Generalize (both side of the ● But some patient Epilepsy frequent
brain) seizures activity due to Chronic
○ Focal (partial seizure and condition
only target specific parts of ○ Traumatic brain injury (TBI)
the brain) ○ congenital birth defect
PHYSIOLOGY ○ Massive Stroke
● Neurons ○ Idiopathic
○ Their task is handling and ○ Effects of an illness
transmitting information and
impulses
2 Types of Neuron
● Excitatory
○ Whenever they are
stimulated they will cause a
response
○ They will release a
neurotransmitter glutamate
● Inhibitory
○ They will inhibit a response
they will decrease it
○ They will release a
neurotransmitter GABA
There is an equilibrium for a patient who
does not have a seizure

Problem: Damage in inhibitory neuron will

be damage then there won’t be an inhibiting
excessive excitatory neurotransmitter
release by the excitatory muscle--
overstimulation of the brain
● For example, the Barbituates- will
stimulate the GABA receptors that
will decrease the excitatory

CAUSE
● Affects Anyone due to an acute
illness
○ Hugh fever
GUILLAIN-BARRE SYNDROME ○ Then allows it to reach to the
axon terminal
DEFINITION: PATHOPHYSIOLOGY
● Autoimmune condition ● If a defect was found in the Nerve
● The immune system attacks nerves ○ Sensory and Nerve function
in the body specifically in will not be effective
○ Peripheral Nervous system ○ Can lead to Respiratory
■ Nerves located Failure as the disease
outside the spinal ● There is an existing condition that
cords triggers this condition
○ Cranial Nerves ○ May ask the patient’s history
● Immune system attacking extensively
○ Myelin Sheath ● GBS can affect anyone at any age,
○ Demyelination is occurring any gender and any race
● If the GBS is severe enough it can ● There is no cure to this disease
extends to the autonomic nervous If illness does exist
system ● The immune system usually fights
● GBS=Gradual block the illness but somewhere along the
RISK FACTOR: way it got confuse and attacked the
Myelin sheath
ANATOMY AND PHYSIOLOGY: ● Gradual Block of Sensation
● Peripheral Nervous System:
○ Somatic: control voluntary Different Type of Guillain Barre
functions Syndrome
○ Autonomic: Controls ❏ Miller Fisher Syndrome:
involuntary functions ❏ MFS originates in the eyes,
● Purpose of Nerve: adversely affecting the
○ It receives and transmit manner in which the
signals so some type of individual walks. It is more
action can occur prevalent in Asia compared
○ For sensory and motor to North America.
■ The nerve receives ❏ Acute Motor Axonal Neuropathy
impulses at the (AMAN)/Acute Motor-Sensory
dendrites Axonal Neuropathy (AMSAN):
■ Then to the stoma AMSAN and AMAN
■ And go through the ❏ affect more people in Asian
Axon with Myelin countries in comparison to
sheaths the USA.
● Purpose of Myelin Sheath ❏ Acute Inflammatory
○ It serves as an insulator that Demyelinating
can allow smooth passage of Polyradiculoneuropathy (AIDP):
signals without being ❏ It is the most widespread
interrupted form of GBS, characterized
by muscular weakness and
 numbness that develops ● Lower extremities they felt
from the lower extremity and numbness and tingling and they
shoots upward. Majority of have trouble walking
affected Americans are ○ They reported that they have
diagnosed with the AIDP severe GI illness caused by
WHAT HAPPENS: Campylobacter Jejuni
● .It tends to start in the feet ● Peripheral nerves starts
○ Feeling of paresthesia demyelination downwards then
{tingling, numbness ascends
● It migrates upward/ ascends ● .After 2 weeks
○ It is symmetrical ○ Work signs and symptoms
● This can lead to paralysation of the occur
body ● After the worst scenario
● The myelin sheath is destroyed and ○ Remyelination occurs
won’t get any signal ○ The symptoms starts
WHY? subsiding
● Report illness ○ They start to get better
○ 1-3 weeks of upper ● After 1 to 2 years
respiratory disease or an ○ The symptoms will reoccur
Gastrointestinal Disease
■ Caused by a Worst case scenario
Campylobacter ● Cranial: Migrates to brain stem
Jejuni ○ Face paralysis
○ “As many as 40 percent of ○ Difficulty Swallowing
GBS cases in the United ○ Difficulty Speaking
stated are thought to be ○ Vissium issue
triggered by Campylobacter ● Severe Pain at the cramps of muscle
infection” + ○ Odd paradox
○ Also link with patient with ● Involvement of Autonomic nervous
Epstein Barr Virus {EBV} system
○ Also link with HIV and AIDS ○ Heart:
○ Also link with recent ■ Dysrhythmias
vaccination ■ Orthostatic
■ Swine flu Hypotension
■ Influenza ■ Paroxysmal
Hypertension
PATHOPHYSIOLOGY ● GI system:
● If a defect was found in the Nerve ○ Constipation
○ Sensory and Nerve function ■ Feeding tube and
will not be effective always be alerted that
○ Can lead to Respiratory if bowel sound is
Failure as the disease present- paralytic
ileus
 ■ Always check ○ Assess the demyelination of
Residuals the nerves by determining
■ muscle’s ability to response
○ Renal to nerve stimulation
■ Urinary Retention ● Lumbar Puncture:
● As disease progresses and ascends ○ Elevated Protein without
in the chest elevated white blood cell
○ Muscle wall responsible for ■ Before: Empty
drawing air in and out will Bladder
start to paralyze ■ During: Position
■ And patient will start lateral recumbent with
experiencing Difficulty knee up to abdomen
breathing and bend chin to
○ chest
SIGNS AND SYMPTOMS ■ After: Lie flat needs
● Paresthesia at the lower extremities to consume a lot of
● Migration upward/ Ascending fluids to prevent
Numbness and tingling headache and to
symmetrically replace loss CSF
● Paralysis on the waist down TREATMENT
● Absent Reflexes ● TReatment can not CURE
● Loss Muscle Time ● They can only decrease recovery
● Patient will complain difficulty time and Improves Signs and
breathing Symptoms
○ Ineffective cough ○ Decrease signs and
○ So Always prepare Airway symptoms
management kit at the ● They have to be administered 2
bedside weeks from the onset of symptoms
● Difficult swallowing MEDICATION
○ They can aspirate and can ● Immunoglobulin Therapy:
develop pneumonia ○ IV immunoglobulin from a
○ Always assess swallowing donor given to the patient to
activity stop the antibodies that are
● They can’t speak and articulate damaging the nerves
words ● Plasmapheresis
○ Always provide a ○ Machine that will filter the
communication boards blood to remove the
○ Always provide they antibodies from the plasma
assurance that this is that are attacking the myelin
temporary and they can sheth
regain their sensation back NURSING INTERVENTION
DIAGNOSTIC AND LABORATORY TEST ● Immobility and Paralysis can lead to
● electromyography and Nerve Increase risk for infection, blood
Conduction Studies
 clots, pressure injuries UTIs, Weight C. signs and symptoms that are
loss asymmetrical and ascending that start in the
○ They can be Intubated upper extremities
○ Anticoagulants and monitor D. signs and symptoms that are
SCDs symmetrical and ascending that start in the
○ Turning them frequently lower extremities
○ Physical therapy and The answer is D. GBS signs and symptoms
p[reventing contractures will most likely start in the lower extremities
○ Maintain muscle Integrity (ex: feet), be symmetrical, and will gradually
○ Monitor Weights daily spread upward (ascending) to the head.
Your Grade: B There are various forms of Guillain-Barré
Percentage of What you Got Right: 82 Syndrome. Acute inflammatory
demyelinating polyradiculoneuropathy
Go Here for More Quizzes (AIDP) is the most common type in the U.S.
and this is how this syndrome tends to
Your Answers & what you got Right & present.
Wrong:

1. True or False: Guillain-Barré Syndrome 3. You're assessing a patient's health

occurs when the body's immune system history for risk factors associated with
attacks the myelin sheath on the nerves in developing Guillain-Barré Syndrome. Select
the central nervous system. all the risk factors below:
True A. Recent upper respiratory infection
False B. Patient's age: 3 years old
FALSE: Guillain-Barré Syndrome is an C. Positive stool culture Campylobacter
autoimmune neuro condition where the Jejuni
immune system attacks the nerves (myelin D. Hyperthermia
sheath) in the PERIPHERAL NERVOUS E. Epstein-Barr
SYSTEM and cranial nerves. This condition F. Diabetes
does NOT occur in the central nervous G. Myasthenia Gravis
system (CNS). The answers are: A, C, and E. Risk factors
for developing Guillain-Barré Syndrome
include: experiencing upper respiratory
2. During nursing report you learn that the infection, GI infection (especially from
patient you will be caring for has Guillain- Campylobacter Jejuni), Epstein-Barr
Barré Syndrome. As the nurse you know infection, HIV/AIDS, vaccination (flu or
that this disease tends to present with: swine flu) etc.
A. signs and symptoms that are unilateral
and descending that start in the lower
extremities 4. A 25 year-old presents to the ER with
B. signs and symptoms that are symmetrical unexplained paralysis from the hips
and ascending that start in the upper downward. The patient explains that a few
extremities days ago her feet were feeling weird and
she had trouble walking and now she is
unable to move her lower extremities. The The answers are A and C. Some patients
patient reports suffering an illness about 2 who experience GBS will need a feeding
weeks ago, but has no other health history. tube because they are no longer able to
The physician suspects Guillain-Barré swallow safely due to paralysis of the
Syndrome and orders some diagnostic cranial nerves that help with swallowing.
tests. Which finding below during your GBS can lead to a decrease in gastric
assessment requires immediate nursing motility and paralytic ileus. Therefore,
action? before starting a scheduled feeding the
A. The patient reports a headache. nurse should always assess for bowel
B. The patient has a weak cough. sounds and check gastric residual.
C. The patient has absent reflexes in the
lower extremities.
D. The patient reports paresthesia in the 6. You’re educating a patient about
upper extremities. treatment options for Guillain-Barré
The answer is B. The patient’s signs and Syndrome. Which statement by the patient
symptoms in this scenario are typical with requires you to re-educate the patient about
Guillain-Barré Syndrome. The syndrome treatment?
tends to start in the lower extremities (with A. "Treatments available for this syndrome
paresthesia that will progress to paralysis) do not cure the condition but helps speed
and migrate upward. The respiratory system up recovery time."
can be affected leading to respiratory B. "Plasmapheresis or immunoglobin
failure. Therefore, the nurse should assess therapies are treatment options available for
for any signs and symptoms that the this syndrome but are most effective when
respiratory system may be compromised given within 4 weeks of the onset of
(ex: weak cough, shortness of breath, symptoms."
dyspnea...patient says it is hard to breath C. "When I start plasmapheresis treatment
etc.). The nurse should immediately report a machine will filter my blood to remove the
this to the MD because the patient may antibodies from my plasma that are
need mechanical ventilation. Absent attacking the myelin sheath."
reflexes is common in GBS and paresthesia D. "Immunoglobulin therapy is where IV
can extend to the upper extremities as the immunoglobulin from a donor is given to a
syndrome progresses. A headache is not patient to stop the antibodies that are
common. damaging the nerves.
The answer is B. This statement is
incorrect. Plasmapheresis and
5. A patient with Guillain-Barré Syndrome immunoglobin therapies are treatment
has a feeding tube for nutrition. Before options available for GBS, BUT they are
starting the scheduled feeding, it is essential only really effective when given within 2
the nurse? Select all that apply: weeks from the onset of symptoms (not 4
A. Assesses for bowel sounds weeks).
B. Keeps the head of bed less than 30'
degrees
C. Checks for gastric residual
D. Weighs the patient
7. Which tests below can be ordered to help the bladder becoming punctured during the
the physician diagnose Guillain-Barré procedure.
Syndrome? Select all that apply:
A. Edrophonium Test
B. Sweat Test 10. Your patient is back from having a
C. Lumbar puncture lumbar puncture. Select all the correct
D. Electromyography nursing interventions for this patient?
E. Nerve Conduction Studies A. Place the patient in lateral recumbent
The answers are C, D, and E. These are the position.
tests that can be ordered to help the MD B. Keep the patient flat.
determine if the patient is experiencing C. Remind the patient to refrain from eating
GBS. or drinking for 4 hours.
D. Encourage the patient to consume liquids
regularly.
8. You're teaching a group of nursing The answers are B and D. The patient will
students about Guillain-Barré Syndrome need to stay flat after the procedure for a
and how it can affect the autonomic nervous prescribed amount of time to prevent a
system. Which signs and symptoms headache, and the nurse will need to
verbalized by the students demonstrate they encourage the patient to drink fluids
understood the autonomic involvement of regularly to help replace the fluid lost during
this syndrome? Select all that apply: the lumbar puncture.
A. Altered body temperature regulation
B. Inability to move facial muscles
C. Cardiac dysrhythmias 11. The patient's lumbar puncture results
D. Orthostatic hypotension are back. Which finding below correlates
E. Bladder distension with Guillain-Barré Syndrome?
The answers are A, C, D, and E. All these A. high glucose with normal white blood
are some signs and symptoms that can cells
present in severe cases of GBS when the B. high protein with normal white blood cells
autonomic nervous system is involved. C. high protein with low white blood cells
D. low protein with high white blood cells
The answer is B.
9. You're about to send a patient for a
lumbar puncture to help rule out Guillain-
Barré Syndrome. Before sending the patient
you will have the patient?
A. Clean the back with antiseptic
B. Drink contrast dye
C. Void
D. Wash their hair
The answer is C. The patient will need to
void and empty the bladder before going for
a LP. This will help decrease the chances of
MULTIPLE SCLEROSIS ○ Myelin sheath
■ What protect the
DEFINITION Axon
● Autoimmune disease that affects the ■ What allows easy
Myelin sheath of the neuron on passage of the
the CNS signals
● MS=Myelin Sheath=Multiple ■ Serves as an
sclerosis insulator
○ Neuron can become inflamed ■ They are made up of
and scar Schwann Cells: fats
○ It decreases the nerve signal and proteins
transmission ● There is good synapse- nerve
○ Lead in many motor sensory signal is passed
problem ○ Because the myelin sheath
QUICK FACTS facilitates the impulses for it
● This disease is immune related to restructure that permits a
● Symptoms Vary neuron (or nerve cell) to pass
○ Because it can affect an electrical or chemical
different parts of the neurons signal to another neuron or to
and lobes in the brain the target effector cells the
○ Example Cerebellar: tremor, Axon terminal
dysarthria, ataxia, cognition ○
○ Occipital Lobe: Eye problems pATHOPHYSIOLOGY
● Women 20-40 years old ● Demyelination in progress
● Cause is unknown ○ Damage of the myelin
● No cure sheaths
○ Lifestyle change and ● When an impulse/signal is
medication are needed to transferred down to this neuron
improve signs and symptoms ○ Not gonna happen correctly
● Appear and Disappear ○ Not strong enough
○ Relapsing remitting MS ● There won’t have stimulation of the
ANATOMY muscle/organ that it supplies
● Dendrites: ● They is no synapse/ signal
○ They receives to create stimulation
some types of action ○ The signal received in the
● Soma/Body: axon terminal is not enough
○ Helps pass the signal receive ○ There is none signal received
on the Dendrites and help it ● Multiple sclerosis Concept:
pass to the rest of the bodies ○ We are talking of the nerve cells
● Axon Hillock in the CNS
○ Axon connect ■ Brain and spinal cord
● Axon: ○ Sensory problems and motor
problems
○ It takes impulses away from
■ Touch and vision
the neuron
 ■ Emotional and cognitive ○ Can lead to injury
position ● Numbness*
■ Coordination an bladder ○ Tingling on the face and
symptoms extremities
● Dizziness/vertigo*
● Coordination*
● + Romberg signs
○ Patient stand with their eyes
close and feet together
○ + they have lesion on
cerebellar area
■ Proprioceptors
■ Loss of balance and
sway
● + Lhermitte’s signs
○ It is where the patient
whenever they move their
RISK FACTORS
head in various motion they
● SDASASD
can experience electric
SIGNS AND SYMPTOMS
shock down in their body
● Remember that symptoms may vary
■ Electric shock
depending on the lobe and structure
sensation
it will affects
■ L-Lighting shock
● And * can indicated early
VISION
symptoms
● Nystagmus
Emotions and Cognitive
● Optic Neuritis*
● Drained/fatigues*
● It is where the optic nerve that
○ Even though they didn’t do
supplies the eyes gets inflamed and
anything
scarred because of the
● Depressed
demyelination of myelin sheaths
● Speech issues *
○ Double vision
○ Dysarthria-Cerebellar lesions
○ Blurry
○ Swallowing problem*
○ Dull/gray vision
■ Dysphagia
○ Pain moving eyes
● Mood swings
○ Dark spot vision
● Trouble thinking -cerebellar problem
ELIMINATION*
○ Focus
● Can’t hold urine:
○ Problem solving problem
○ Nocturia-peeing alot at night
○ Thinking problem
○ overactive bladder
Sensation issues:
● Problems with contracting to coid
● Remors
○ Urinary retention .
● Spasms*
○ At risk for
○ Can be very painful
■ UTIs and renal stones
● Clumsiness*
● Bowel:
○ They may feel drunk
 ○ constipation ○ Drug Names: ANOVEX
○ Diarrhea {Interferon beta 1a}, Rebif,
○ Can’t hold stool Betaferon
UHTHOFF’s SIGN ● Corticosteroids:
● Heat makes signs and symptoms ○ For those who’s already
worst having relapse of MS
DIAGNOSTIC PROCEDURE ○ Ordered to decrease the
● It really takes time inflammation and to
● Neurologist assess various things: decrease that immune
○ There is no single test to rule response
out MS ○ Drug Names:
● Patient’s signs and symptoms: Methylprednisolone,
○ They must be assessed prednisone
thoroughly because the S For Bladder issue: Medication includes
and S may mimic other ● OXYBUTYNIN
disease ○ Anticholinergic
● MRI ○ It helps with overactive
○ In the brain and Spinal cord bladder by relaxing the
○ This allows viewing of the bladder muscle to prevent
Inflammation of the brain and contraction
spinal cord ● BETHANECHOL:
● Lumbar puncture: ○ Cholinergic
○ CSF oligoclonal bands ○ Helps with emptying the
○ High amount of proteins and bladder by helping with
Oligoclonal bands bladder contraction
● Evoked potential studies Medication for Fatigue:
○ They will evoked an electrical ● Amantadine
signet to the CNS to create a ○ Antiviral and antiparkinsonian
response ○ It has CNS effects that helps
TREATMENT improve fatigue in patient
● SDASASD with MS
MEDICATION ● Modafinil
● Beta Interferon: ○ CNS stimulant
○ Decreases the number of Spasms:
relapses of symptoms by ● Baclofen:
decreasing inflammation and ○ Skeletal muscle relaxants
the immune response that acts centrally
towards the Myelin sheath ● Diazepam
■ Can be High risk for Tremors:
infection ● Propranolol
■ It can decrease ○ Beta Blockers
WBCs ○ Warn the patient with DM
that if they take this
medication
 ■ They when they go ● Scan the environment before they
Hypo can cause get up
tremors
● Isoniazid: Speech language pathology
○ Antibiotic used for infection ● Speech problem
○ Especially with TB ○ For Dysarthria patient
○ Helps with certain tremors in ● Swallowing problems
MS ○ Dysphagia
NURSING INTERVENTION ○ Aspiration
● Safety {Vision, coordination, ■ Assess lung sound
decrease reception pain,
bowel/bladder issue, Remitting Physical therapist
Relapse MS RRMS prevention, ● Exercise and regimens
Medication} ● Help them us assistive devices
Preventing the increase ef Signs and
Symptoms: Support groups
● Stress. ● Support to one another
○ Provide and nice,
comfortable, and non Bower Problems
stressful environment ● Constipation
○ Provide stress relief ○ Increase fiber
techniques ○ Stool softer
● Infection ● Incontinent stool
○ Avoid infection ○ Skin care
● Overexertion Bladder Problems
○ Exercise is needed to ● Overactive bladder
improve tolerance ○ Always assure easy access ti
○ BUT DONT DO IT OVERLY the comfort room that are
■ Relax clutter free
○ Swimming exercise is good ● Incontinence:
■ Because water is cool ○ Foley catheter
● Remember UHTHOFF's Sign ○ Assess for skin break down
○ Avoid Heat ○ Provide clean pads
■ No heating pads, ○ Self Catheter
warming blankets, ● Skin problem:
keeping room and ○ Provide skin care
temp hot ○ 1-2 fluids a day to prevent
ASSISTIVE DEVICES: concentration
● Showering is difficult and standing is our Grade: D
a problem Percentage of What you Got Right: 67
○ Provide shower chair
○ Railing Go Here for More Quizzes
● Creating a clutter free room
○ Eyes problem
Your Answers & what you got Right & present at different locations in the
Wrong: CENTRAL NERVOUS SYSTEM....hence
the brain and spinal cord (not the peripheral
1. Select all the TRUE statements about the nervous system).
pathophysiology of multiple sclerosis:
A. "The dendrites on the neuron are
overstimulated leading to the destruction of 4. A patient is suspected of having multiple
the axon." sclerosis. The neurologist orders various
B. "The myelin sheath, which is made up of test. The patient's MRI results are back and
Schwann cells, is damaged along the axon." show lesions on the cerebellum and optic
C. "This disease affects the insulating nerve. What signs and symptoms below
structure found on the neuron in the central would correlate with this MRI finding in a
nervous system." patient with multiple sclerosis?
D. "The dopaminergic neurons in the part of A. Blurry vision
the brain called substantia nigra have B. Pain when moving eyes
started to die." C. Dysarthria
The answers are B and C. In multiple D. Balance and coordination issues
sclerosis the myelin sheath (which is the E. "Pill rolling" of fingers and hands
insulating and protective structure made up G. Heat intolerance
of Schwann cells that protects the axon) is H. Dark spots in vision
damaged. MS affects the CNS (central I. Ptosis
nervous system) and when the myelin The answers are A, B C, D, and H. If lesions
sheath becomes damaged it leads to a are present on the optic nerves, optic
decrease in nerve transmission. neuritis can occurs which can lead to blurry
vision, pain when moving the eyes, and
dark spots in the vision. If cerebellar lesions
2. True or False: Multiple Sclerosis tends to are found, this can affect movement,
affect men more than women and occurs speech, and some cognitive abilities. This
during the ages of 50-70 years. would present as dysarthria (issues
True articulating words), and
False balance/coordination issues. "Pill rolling" of
False: MS affects WOMEN more than men the fingers and hands is found in
and shows up during the ages of 20-40 Parkinson's disease. Ptosis is common in
years. myasthenia gravis, and heat intolerance in
thyroid issues.

3. True or False: Patients with multiple

sclerosis have different signs and symptoms 5. You're performing a head-to-toe
because this disease can affect various assessment on a patient with multiple
areas of the peripheral nervous system. sclerosis. When you ask the patient to move
True the head and neck downward the patient
False reports an "electric shock" sensation that
False: Yes, patients with MS have different travels down the body. You would report
signs and symptoms because lesions can
your finding to the doctor that the patient is the CNS and is a common finding in
experiencing: multiple sclerosis.
A. Romberg's Sign
B. Lhermitte's Sign
C. Uhthoff's Sign 8. You're developing a plan of care for a
D. Homan's Sign patient with multiple sclerosis who presents
The answer is B. This finding is known as with Uhthoff's Sign. What interventions will
Lhermitte's Sign. you include in the patient's plan of care?
Select all that apply:
A. Avoid movements of the head and neck
6. Which finding below represents a positive downward
Romberg Sign in a patient with multiple B. Keep room temperature cool
sclerosis? C. Encourage patient to use warm packs
A. The patient report dark spots in the visual and heating pads for symptoms
fields during the confrontation visual field D. Educate the patient on three ways to
test. avoid overheating during exercise
B. When the patient closes the eyes and The answers are B and D. Uhthoff's Sign is
stands with their feet together they start to where when the patient experiences too
lose their balance and sway back and forth. much heat their symptoms increase and get
C. The patient's sign and symptoms worst. Therefore, it is important the patient
increase when expose to hot temperatures. stays cool and doesn't overheat
D. The patient reports an electric shock (overheating can come from outside
feeling when the head and neck are moved temperatures, exercise, emotional events
downward. etc.). The room should be cool and the
The answer is B. This is an example of a patient should be encouraged to exercise
positive Romberg's Sign. but to avoid overheating.

7. Your patient is scheduled for a lumbar 9. During your discharge teaching to a

puncture to help diagnose multiple patient with multiple sclerosis, you educate
sclerosis. The patient wants clarification the patient on how to avoid increasing
about what will be found in the symptoms and relapses. You tell the patient
cerebrospinal fluid during the lumbar to avoid:
puncture to confirm the diagnosis of MS. A. Cold temperatures
You explain that ____________ will be B. Infection
present in the fluid if MS is present. C. Overexertion
A. high amounts of IgM D. Salt
B. oligoclonal bands F. Stress
C. low amounts of WBC The answer is B, C, and F. The patient
D. oblong red blood cells and glucose should also avoid extreme heat, which can
The answer is B. These specific proteins, increase symptoms.
oligoclonal bands, which are
immunoglobulins will be found in the CSF.
This demonstrates there is inflammation in
10. A patient with multiple sclerosis has
issues with completely emptying the
bladder. The physician orders the patient to
take ___________, which will help with
bladder emptying.
A. Bethanechol
B. Oxybutynin
C. Avonex
D. Amantadine
The answer is A. This medication is a
cholinergic medication that will help with
bladder emptying.

11. A patient is receiving Interferon Beta for

treatment of multiple sclerosis. As the nurse
you will stress the importance of?
A. Physical exercise to improve fatigue
B. Low fat diet
C. Hand hygiene and avoiding infection
D. Reporting ideation of suicide
The answer is C. Interferon Beta decreases
the number of relapses of symptoms in MS
patients by decreasing the immune system
response, but it lowers the white blood cells
count. Hence, there is a risk of infection. It is
very important the nurse stresses the
importance of hand hygiene and avoiding
infection.

12. Which medications below can help treat

muscle spasms in a patient with multiple
sclerosis? Select all that apply:
A. Propranolol
B. Isoniazid
C. Baclofen
D. Diazepam
E. Modafinil
The answers are C and D. These
medications treat muscle spasms in patients
with MS.
MYASTHENIA GRAVIS ● Key player:
○ Neuromuscular Junction
DEFINITION ■ Nicotinic
● Autoimmune Condition Acetylcholine
● Body attacks the muscle receptors Receptors
that controls the voluntary muscles ■ Function of Muscle
Can lead to : Specific Kinase
● Muscle weakness ■ Acetylcholine
Organs Involves: ■ Immune system
● Voluntary Muscles: ● Produces
○ Eyes: Most likely 1st signs antibodies
■ Drooping of the eyes against
■ Diplopia/Lazy eyes receptors
■ Strabismus ● Thymus gland
○ Throat: Another common ● A neuromuscular junction (or
signs myoneural junction) is a chemical
■ Weakens muscle on synapse between a motor neuron
throat and a muscle fiber.
■ Dysphasia ○ Cholinergic fibers initiates the
■ Hoarseness of voice release of acetylcholine
■ Chewing is an effort ○ And they bind with
○ Arms and Legs Nicotinic Acetylcholine
○ Respiratory receptors {nAChRs}
■ Severe case ○ Acetylcholinesterase
QUICK FACTS {AChE}
● This disease is immune related ■ Enzymes that Break
● Symptoms Vary Down acetylcholine
○ Because it can affect into two pieces
different ● It allows the motor neuron to
RISK FACTORS transmit a signal to the muscle fiber,
● This disease is immune related causing muscle contraction.
● Symptoms Var ● Muscles require innervation to
ANATOMY function—and even just to maintain
muscle tone, avoiding atrophy. In the
neuromuscular system nerves from
the central nervous system and the
peripheral nervous system are linked
and work together with muscles.
PATHOPHYSIOLOGY
● Key player:
○ Neuromuscular Junction
■ Nicotinic
Acetylcholine
Receptors
 ■ Function of Muscle ■ By puberty the
Specific Kinase thymus gland has
■ Acetylcholine usually produce a
■ Immune system lifelong supply of t
● Produces cells that we are
antibodies going to need
against ○ ABut as person ages usually
receptors in the older age the thymus
● Thymus gland gland will actually turn into
● The Immune system build up an fatty tissue
antibody that destroys the Nicotinic ● People with Myasthenia Gravis the
Acetylcholine receptors {nAChRs} thymus gland is still enlarge
● Alot of them won’t be available and ○ They are not small like they
working meaning that they are not should be
functioning well ○ They have tumors
○ They won’t be able to receive ○ A Lot of immune cell has
the Acetylcholine congregate together
○ Muscle fibers won’t be ○ The thymus is actually
contracting like they erroneously creating this
should antibodies to attracts the
■ WEAKNESS receptor site of
● Antiacetylcholinesterase are neuromuscular junction
administer ○ Making acetylcholine not
○ Like Pyridosestigmy reaching the tissue site
○ To prevent breakdown ■ To create voluntary
○ So more acetylcholine can contraction
be made available to these SIGNS AND SYMPTOMS
limited receptors ● ****Hallmark:
○ To increase muscle strength ○ Muscle weakness gets worse
● Thymus Gland with activity
○ Location: Anterior at the ■ Especially repetitive
upper part of the body activity
■ Behind the sternum ■ Because the
and between the receptors are very
lungs limited and remaining
○ Provides a very important acetylcholine is very
role on our immune system abundant but can be
and health destroyed later on
○ Creator or T cells when enzyme breaks
■ Fighting against them down
viruses and bacteria ○ But will improve after resting
and cell the muscle
○ This tends to be enlarge at ● “W.E.A.K.N.E.S.S”
children than an adult
 ○
Weakness of the neck, face, for the
arms and legs “hemiplegia” receptors
○ Eyelid drooping “Ptosis” ■ Muscle can’t contract
○ Appearance mask like ○ Severe muscle weakness
■ Very sleepy and respiratory failure
expression ■ Need for intubation
○ Keep on choking/gagging and mechanical
when eating ventilator
■ Risk for aspiration ○ Cause?
○ No Energy ■ Not enough
■ Do it in the morning Anticholinesterase
when they have Medication
enough rest ■ Stress
■ When patient has ■ Respiratory infection
more energy to do ● Frequent use
stuff of muscle
○ Extraocular Muscle ■ Surgery
Involvement ● Cholinergic Crisis:
■ Strabismus ○ Too much medication
■ Diplopia ■ Where a lot a
○ Slurred speech acetylcholine will
○ Shortness of breath continuously bombard
COMPLICATION the receptors and
● Myasthenic Crisis wear them out
○ Disease can go to remission ■ This will result a
{no signs and decrease in the
symptoms1]BUT can number of nicotinic
experience acute Acetylcholine
exacerbation receptors available
■ THIS occurs because ■ They can be tolerant
they are not receiving ○ Severe muscle weakness
acetylcholine like they and respiratory depression
should ○ Making Acetylcholine
● Because abundant in the synapses
Cholinesteras LABORATORY AND DIAGNOSTIC
e an enzyme PROCEDURE
will ● Tensilon Test
continuously ○ A medication Edrophonium
breakdown is given
acetylcholine ○ Used to diagnose and
● Making differentiate myasthenic and
acetylcholine cholinergic crisis in
not available myasthenia gravis
○ It’s an anticholinesterase:
 ■ Prevents breakdown ○ To decrease inflammatory
acetylcholine more response
available at ● IV immunoglobulins
neuromuscular ● Plasmapheresis
junction and makes it ○ Dialysis
more available to the ○ Blood is filtered and removes
site antibodies
Result: ● Thymectomy
● Myasthenia gravis or crisis: ○ Improves signs and
○ They will get better symptoms
○ Strength is improved NURSING INTERVENTION
● Cholinergic Crisis ● Note improvement, cardiac monitor,
○ Strength becomes worst make atropine available, have the
○ Weaker crash cart at the bedside
○ Provide antidote: ● Monitor respiratory status:
■ Physostigmine ○ Effort of breathing
■ Atropine ○ Respiratory rate
{anticholinergic} ○ Suction must be provided to
TREATMENT and MEDICATION prevent aspiration
● NO CURE ● Neuromuscular functions
● Anticholinesterase ○ Assess cranial nerves
“Pyridostigmine” ○ Vision, sound of voice
○ Take 30 minutes to 1 hours ○ Speech, facial appearance
before meal-peak ○ Strength of arms and legs
● Complication: Myasthenic Crisis ● Determine swallowing function
{inadequate medication} and ○ Before eating and
● Complication: Cholinergic Crisis administration of PO
{Too much medication} medication
○ Signs and Symptom: Similar ● Speech Langage pathologist must
to over stimulation of the be referred to patient
parasympathetic system ● Always secure safety
“Rest and digest” ○ Always assess any risk for
■ Bradycardia fall
■ Pupil constriction ■ Weak arms and leg
■ Bronchospasm ■ Low rr-they might
■ Increase salivation pass out
and Mucous ■ Vission problem
■ GI: cramping and ● Aspiration
diarrhea ○ Speech Pathologist
■ Bladder incontinence ○ Evaluate swallowing
■ Muscle weakness ○ During feeding the head over
and respiratory failure bed mus be raised at >30
● Corticosteroid: degree
● Educating of Eating:
 ○ Larger meals in the morning leads to the neurotransmitter acetylcholine
because they have energy to from being able to communicate with the
chew muscle fiber to make it contract.
■ Then small meal later
in day
○ Schedule medication 30 mins 2. You're educating a patient about the
to 1 hour after taking pathophysiology of myasthenia gravis.
anticholinesterase While explaining the involvement of the
■ It is the peak time of thymus gland, the patient asks you where
the medication the thymus gland is located. You state it is
○ Thicken liquid located?
○ Small bites, soft foods A. behind the thyroid gland
○ Perform most activities in the B. within the adrenal glands
morning C. behind the sternum in between the lungs
■ Ambulating D. anterior to the hypothalamus
■ Leg rolling The answer is C. The thymus is located
■ And other procedure anteriorly in the upper part of the chest
behind the sternum in between the lungs.
Your Grade: A
Percentage of What you Got Right: 90
3. A patient with myasthenia gravis will be
Go Here for More Quizzes eating lunch at 1200. It is now 1000 and the
patient is scheduled to take Pyridostigmine.
Your Answers & what you got Right & At what time should you administer this
Wrong: medication so the patient will have the
maximum benefit of this medication?
1. Myasthenia gravis occurs when A. As soon as possible
antibodies attack the __________ receptors B. 1 hour after the patient has eaten (at
at the neuromuscular junction leading to 1300)
____________. C. 1 hour before the patient eats (at 1100)
A. metabotropic; muscle weakness D. at 1200 right before the patient eats
B. nicotinic acetylcholine; muscle weakness The answer is C. Pyridostigmine is an
C. dopaminergic adrenergic; muscle anticholinesterase medication that will help
contraction improve muscle strength. It is important the
D. nicotinic adrenergic; muscle contraction patient has maximum muscle strength while
The answer is B. In myasthenia gravis, eating for the chewing and swallowing
either the nicotinic acetylcholine receptors process. Therefore, the medication should
are attacked by antibodies created by the be given 1 hour before the patient eats
immune system (hence why this disease is because this medication peaks (has the
considered autoimmune) or antibodies are maximum effect) at approximately 1 hour
inhibiting the function of muscle-specific after administration. How does the
kinase (which is a receptor tyrosine kinase medication improve muscle strength? It
that helps with maintaining and building the does this by preventing the breakdown of
neuromuscular junction). Either way this acetylcholine. Remember the nicotinic
acetylcholine receptors are damaged and The answer is A. Atropine will help reverse
the patient needs as much acetylcholine as the effects of the drug given during a
possible to prevent muscle weakness. Tensilon test, which is Edrophonium, in
Therefore, this medication will allow more case an emergency arises. Edrophonium is
acetylcholine to be used...hence improving a short-acting cholinergic drug, while
muscle strength. atropine is an anticholinergic.

4. The neurologist is conducting a Tensilon 6. Which patient below is MOST at risk for
test (Edrophonium) at the bedside of a developing a cholinergic crisis?
patient who is experiencing unexplained A. A patient with myasthenia gravis is who
muscle weakness, double vision, difficulty is not receiving sufficient amounts of their
breathing, and ptosis. Which findings after anticholinesterase medication.
the administration of Edrophonium would B. A patient with myasthenia gravis who
represent the patient has myasthenia reports not taking the medication
gravis? Pyridostigmine for 2 weeks.
A. The patient experiences worsening of the C. A patient with myasthenia gravis who is
muscle weakness. experiencing a respiratory infection and
B. The patient experiences wheezing along recently had left hip surgery.
with facial flushing. D. A patient with myasthenia gravis who
C. The patient reports a tingling sensation in reports taking too much of their
the eyelids and sudden ringing in the ears. anticholinesterase medication.
D. The patient experiences improved The answer is D. Remember patients who
muscle strength. experience a cholinergic crisis are most
The answer is D. During a Tensilon test likely to because they’ve received too much
Edrophonium is administered. This of their anticholinesterase medications
medication prevents the breakdown of (example Pyridostigmine). However, on the
acetylcholine, which will allow more of the other hand, patients who have received
neurotransmitter acetylcholine to be present insufficient amount of their
at the neuromuscular junction....hence anticholinesterase medication or have
IMPROVING muscle strength IF myasthenia experienced an illness/stress/surgery are
gravis is present. Therefore, if a patient with most likely to experience a myasthenia
MG is given this medication they will have crisis. Both conditions will lead to muscle
improved muscle strength. weakness and respiratory failure but from
different causes, which is why a Tensilon
test is used to help differentiate between the
5. You're preparing to help the neurologist two conditions.
with conducting a Tensilon test. Which
antidote will you have on hand in case of an
emergency? 7. Which meal option would be the most
A. Atropine appropriate for a patient with myasthenia
B. Protamine sulfate gravis?
C. Narcan A. Roasted potatoes and cubed steak
D. Leucovorin B. Hamburger with baked fries
C. Clam chowder with mashed potatoes 10. You're a home health nurse providing
D. Fresh veggie tray with sliced cheese care to a patient with myasthenia gravis.
cubes Today you plan on helping the patient with
The answer is C. Patients with MG have bathing and exercising. When would be the
weak muscles and this can include the best time to visit the patient to help these
muscles that are used for chewing and tasks?
swallowing. The patient should choose meal A. Mid-afternoon
options that require the least amount of B. Morning
chewing and that are easy to swallow. C. Evening
Option C is a thick type of soup and the D. Before bedtime
mashed potatoes are soft....both are very The answer is B. Patients with MG tend to
easy to eat and swallow compared to the have the best muscle strength in the
other options. morning after sleeping or resting rather than
at the end of the day....the muscles are tired
from being used and the muscle become
8. Select all the signs and symptoms below weaker as the day progresses etc.
that can present in myasthenia gravis: Therefore any rigorous activities are best
A. Respiratory failure performed in the morning or after the patient
B. Increased salivation has rested.
C. Diplopia
D. Ptosis
E. Slurred speech
F. Restlessness
G. Mask-like appearance of looking sleepy
H. Difficulty swallowing
The answers are A, C, D, E, F (restlessness
from hypoxia, which is experienced with
respiratory failure), G, and H.

9. You're providing teaching to a group of

patients with myasthenia gravis. Which of
the following is not a treatment option for
this condition?
A. Plasmapheresis
B. Cholinesterase medications
C. Thymectomy
D. Corticosteroids
The answer is B. These medications are not
used to treat MG, but ANTIcholinesterase
medications (like Pyridostigmine) are used
to treat this condition.
Cholinergic Crisis vs Myasthenic Crisis
Signs and Symptoms: Signs and
Symptoms:
● Key player: ● Dilated pupils
○ Neuromuscular Junction ● Increased Similar to “Rest
■ Nicotinic Heart rate and and digest”
Acetylcholine BP
Receptors ● No cough and ● GI:
gag vomiting,
■ Function of Muscle
● aspiration / no diarrhea,
Specific Kinase swallowing cramping
■ Acetylcholine reflex ● Pupil
■ Immune system ● Incontinence constriction
● Produces bowel and ● Increase
antibodies bladder salivation
against and tears
● Increase
receptors respiratory
● Thymus gland secretions
● Muscle
fasciculatio
Myasthenic Crisis Cholinergic Crisis
n
Happens due to low to Happens due to “twitching”
no stimulation at the excessive due to
neuromuscular stimulation at the constantly
junction by ACh neuromuscular stimulation
{acetylcholine} junction by ACh ● Decrease
{acetylcholine} HR and BP

Can lead to severe Overdrive in Tensilon test: Tensilon Test:

muscle weakness and cholinergic
respiratory failure response, severe ● Medication ● Medication
muscle weakness Edrophonium= Edrophoniu
and respiratory Anticholinester m=Anticholi
failure ase nesterase
Medication Medication
Cause: Cause: Adds More ACh at the Adding more ACh
junction at the junction-
Insufficiency Too much
anticholinesterase anticholinesterase Improvement of Worsening of
medication or medication signs and symptoms signs and
respiratory infection, symptoms
stress and acute It stops the Positive test result
exacerbation breakdown of ACh Negative test
mare at the Treatment per MD result
junction Order
Anticholinesterase Treatment:
Great for MG Antidote Atropine
treat,emt but too hold further dose
much cholinergic
our Grade: D
Percentage of What you Got Right: 67 with the availability of acetylcholine, but
because there is TOO MUCH of it at the
Go Here for More Quizzes receptor site. Therefore, during this test the
patient would experience worsening of
Your Answers & what you got Right & symptoms NOT improvement.
Wrong:

1. __________________ happens due to 4. You're examining a patient’s health

excessive stimulation of the receptors at the history and find that the patient experienced
neuromuscular junction by acetylcholine, a cholinergic crisis last year. As the nurse
which eventually leads to muscle weakness you know that the most common cause of a
and respiratory failure. cholinergic crisis is?
A. Myasthenic crisis A. Over usage of adrenergic blocker
B. Cholinergic crisis medications
The answer is B. B. Stress
C. Respiratory infections
D. Overmedication of an anticholinesterase
2. _________________ happens due to medication
minimal to no stimulation of the receptors at The answer is D. The most common cause
the neuromuscular junction site by of a cholinergic crisis is overmedication of
acetylcholine because there is damage to an anticholinesterase medication. However,
the receptor sites, which leads to muscle on the other hand, the cause of a
weakness and respiratory failure. myasthenic crisis is NOT enough of an
A. Myasthenic crisis anticholinesterase medication or having a
B. Cholinergic crisis respiratory infection or experiencing stress
The answer is A. of some type.

3. A patient is experiencing unexplained 5. While assisting with a Tensilon test you

muscle weakness and respiratory failure. will have what antidote on hand?
The neurologist conducts a Tensilon test to A. Narcan
differentiate between myasthenic crisis or B. Atropine
cholinergic crisis. During the test the patient C. Flumazenil
experiences improved muscle strength. D. Glucagon
Based on this finding the patient has: The answer is B. Atropine is the antidote for
A. Myasthenic Crisis Edrophonium, which is given during a
B. Cholinergic Crisis Tensilon test.
C. Neither
The answer is A. During a Tensilon test the
medication Edrophonium is given, which is 6. Select all the signs and symptoms
an cholinesterase medication. This will associated with a myasthenic crisis:
increase the availability of acetylcholine at A. Pupil dilation
the neuromuscular junction. If the patient B. Muscle fasciculation
had a cholinergic crisis the problem is not C. Miosis
D. Bowel and bladder incontinence 9. You're patient is recovering from a
E. Negative gag or cough reflex myasthenic crisis and you are providing
F. Respiratory failure education to the patient about the causes of
G. Bradycardia this condition. Which statement by the
The answers are A, D, E, and F. patient demonstrates they understood the
teaching about how to prevent this
condition?
7. During a Tensilon test the patient has A. "I will make sure I don't take too much of
worsening of muscle weakness. The nurse my anticholinesterase medication because it
anticipates that the physician will give the can lead to this condition."
following order? B. "I will avoid milk products while taking
A. Administer Atropine along with an Pyridostigmine because it increases the
anticholinesterase medication. chances of toxicity."
B. Administer Atropine and hold any further C. "I will avoid taking over-the-counter
doses of Pyridostigmine. supplements that contain aconite."
C. Administer Pyridostigmine and hold D. "I will avoid people who are sick with
Atropine. respiratory infections and be sure not to
D. Administer Edrophonium along with miss my scheduled doses of
Atropine. Pyridostigmine."
The answer is B. If a patient experiences The answer is D. Myasthenic crisis is
worsening of muscle weakness during a caused by not enough anticholinesterase
Tensilon test the patient has cholinergic medication (pyridostigmine) or respiratory
crisis. Therefore, the nurse could anticipate infection/stress etc. The other options are
that the physician will order Atropine (to NOT causes of this condition.
reverse the signs and symptoms...because
remember this drug is the antidote for
Edrophonium which is given during the test)
and to HOLD any further doses of
Pyridostigmine (this is an anticholinesterase
drug).

8. Select all the signs and symptoms

associated with cholinergic crisis:
A. Miosis
B. Dry mouth
C. Blurred vision
D. Constipation
E. Muscle fasciculation
F. Diarrhea and abdominal cramping
G. Respiratory failure
The answers are A, C, E, F, and G.
PARKINSON'S DISEASED SYMPTOMS

DEFINITION:
● Its is a neurological disease that
affects the movement
● Dopaminergic Neurons DIE in
substantia nigra
○ Location of Substantia Nigra
○ This area is part of the Basal
ganglia which is a part of part RISK FACTORS
of the MidBrain that overall ● Tends of Affects Older adults 60+
plays a huge role in our ● Cause is Unknown
movement ANATOMY
● The substantia Nigra is black ● Dopamine provides us an
accuracy with
○ Dopaminergic Neurons is the ● MOVEMENTBalance Between
part of the brain called ○ ACh {Excitatory}
Substantia Nigra has started ■ This causes
to die cholinergic activity
■ They release ○ Dopamine {Inhibitory}
Dopamine What Happen when Dopamine is Less
{neurotransmitter} ● There is an imbalances between
● Leading to: Less Dopamine ACh and Dopamine
○ Dopamine provides us an ○ Causing Overstimulation of
accuracy with MOVEMENT neurons ACh to produce a
● The receptors are find and waiting cholinergic action:
for the Dopamine to come Tremors, Rigidity, etc
Medication involves:
● Administration of Anticholinergic
Medication
○ Younger people are
common users of this
medication
PATHOPHYSIOLOGY
●
SIGNS AND SYMPTOMS:
● Subtle at 1st but it may VARY
● But as time goes on
○ May worsen-they will realize
the problems in movement
○ It may affect one side of the
extremities and progresses
● Tremors at Rest:
○ Most common
 ○ It involves Hands, legs, lips, ○ Chewing issue
tongue ○ Speech is slowed and
○ *Pill-Rolling*-tremors of the slurred
finger and hand ● Compensation for that
■ Improves with ○ Coordination problems-
purposeful movement steap to compensate
● Stiffness of the extremities ● Non Motor
○ Arms Don’t swing with gait ○ Loss of smell
● Akinesia ○ Constipation
○ Lose the ability to do ○ Depression
movement voluntarily
○ Example when they’re
walking they tend to freeze
up
○ No voluntary movement of
Muscle
■ Freeze up
● Shuffling of gait
○ They won’t be able to pick up
their feel very well
● Posture
○ Forward bent LABORATORY AND DIAGNOSTIC
● Cogwheel Rigidity TESTING:
○ muscular rigidity in which ●
passive movement of the TREATMENT
limbs (as during a physical ● There is NO CURE
examination) elicits ratchet- ● But medication can be given to
like start-and stop decrease the signs and symptoms
movements through the MEDICATION
range of motion of a joint (as ● Carbidopa with Levodopa
of the elbow) and that occurs “sinemet”
especially in individuals ○ Adds more dopamine to
affected with Parkinson's brain
disease The third major sign, ○ Carbidopa: prevents
rigidity (sometimes called levodopa from breaking
"cogwheel" rigidity ), is down in the blood more
peculiar to Parkinson's enters in the brain and turn
○ The hands will just jerk back into dopamine
as you move them ○ Side Effects
● Bradykinesia: ■ Nausea and
○ Movement is Slow involuntary movement
○ Swallowing issue: drooling ○ Patient education:
○ Expressionless face “mask
like”
 ■ Take up to 3 weeks to ○ They will experience Dry
notice decrease signs mouth
and symptoms ● MAO inhibitors Type B
■ Body fluids turn dark ● Rasagiline “Azilect”
color ● Increase dopamine by
■ Long term use “weak stopping MAO activity
off” before next dose ● NO FOODS with Tyramine
● COMT ○ Aged cheese
inhibitors: ○ Smoked/cured meats
Entacapone ○ Fermented food
“Comtan” ○ Beers
■ Entacopanoe
● Not be taken ● COMT “Catechol-O-
with MAOIs methyltransferase”
■ NO High vitamin B6 ○ Used with Sinemet
can decrease the ○ It can decrease wearing off
effects phase
■ Not taking food with ○ Block COMT enzyme that will
HIGH protein breakdown Levodopa in the
● They compete blood to make it last longer
in the small NURSING INTERVENTION
intestine Areas of Intervention:
● Ropinirole “Requip” ● Safety
○ Stimulates dopamine ○ Cogwheel
receptors to increase ○ Freeze Up
improvement ● Psychosocial
○ Side Effects: ○ Depression
■ Drowsiness ○ Loss of Self Care
○ They might abruptly sleep ○ Loss of autonomy
● Amantadine: ● Medication side effects
○ Antiviral in treatment of ○ Mediation
influenza A ● Digestion and nutrition
○ Stimulates dopamine in CNS ○ Constipation
● Anticholinergic ● Education
○ Benztropine “Cogentin”
○ Blocks ACh Safety:
■ Decrease rigidity ● Assistive Devices
■ Decrease salivation ○ Hand rail
■ Decrease signs and ○ Cane, walkers,
symptoms ○ Keeping rubs off the floor
○ Not for glaucoma patient ○ Pets must be trained
○ Don't Abruptly quit ● Balance: More slowly with position
○ NO ETOH changes
 ○ They can use Rubber tip ○ This can increase Signs and
cane single point symptoms and might
● Shoes ware: Low heel shoes without exacerbate symptoms
rubber sole Digestion/Nutrition
○ The rubber sole can stick to ● Soft easy to chew foods
the floor and end up tripping ● Speech language Pathologist
● High fiber foods and 2 liter of water
Education: Freeze up ● Stool softer
● When they are normally walking ● Always assess digestion
and suddenly their foot is stuck ● Watch protein rich foods with
on the ground, can lead to medication
increase risk for fall ○ They will compete with the
○ Change Direction of medications
movement
■ As you move forward Parkinson's Disease
you’re foot suddenly
stops NCLEX Questions
■ Try to move to the
side This quiz will test your knowledge on
○ Laser patient cane or walker Parkinson's Disease in preparation for
○ Ass they walk and Freeze up the NCLEX exam.
happen
■ They must
consciously make an 1. As the nurse you know that
effort to Lift legs off Parkinson's Disease tends to
the floor walking like affect the _____________ of the
their marching midbrain, which leads to the
○ Don’t try to push through it depletion of the
Psychosocial Part neurotransmitter
● Autonomy problem ________________.*
○ A. red nucleus, acetylcholine
○ Make sure that you allow
them to take care of ○ B. leminisci, norepinephrine
themselves-like feeding, ○ C. substantia nigra, dopamine
dressing and etc ○ D. tectum nigra, dopamine
● Special cookware and utensils 2. True or False: Parkinson's
● Dressings: Shirt without buttons and Disease most commonly
zipper affects patients in young
○ Velcros adulthood, and there is
● Shoes without tie currently no cure for the
○ Velcros shoes disease.*
● Support groups ○ A. True
● Exercise ○ B. False
● Don’t try to stress them up 3. You're caring for a patient with
○ Hurrying them and etc Parkinson's Disease that has
 tremors. Select the option that patient could experience with
is INCORRECT about tremors this disease:*
experienced in this disease:* ○ A. Increased Salivation
○ A. The tremors are most likely ○ B. Loss of smell
to occur with purposeful ○ C. Constipation
movements.
○ D. Tremors with purposeful
○ B. A common term used to movement
describe the tremors in the
○ E. Shuffling of gait
hands and fingers is called
"pill-rolling".
○ F. Freezing of extremities
○ C. Tremors are one of the ○ G. Euphoria
most common signs and ○ H. Coordination issues
symptoms in Parkinson's 7. You're providing diet education
Disease. to a patient with Parkinson's
○ D. Tremors in this disease can Disease. Which statement
occur in the hands, fingers,
below demonstrates the
patient understood your
arms, legs and even the lips
teaching? Select all that
and tongue.
apply:*
4. While assessing a patient with ○ A. "I will limit foods high in
Parkinson's Disease, you note fiber like fruits and vegetables
the patient's arms slightly jerk
in my diet."
as you passively move them
toward the patient's body. This ○ B. "I will be sure to drink 2
is known as:* Liter of fluid per day."
○ A. Lead Pipe Rigidity ○ C. "It is very common for me
○ B. Cogwheel Rigidity to experience diarrhea with
this disease."
○ C. Pronate Rigidity
○ D. "I will avoid taking
○ D. Flexor Rigidity
Carbidopa/Levodopa with a
5. A patient with Parkinson's
protein rich meal."
Disease has slow movements
that affects their swallowing, 8. A patient with Parkinson
facial expressions, and ability Disease is experiencing weight
to coordinate movements. As loss due to difficulty chewing
the nurse you will document and swallowing. Which meal
the patient has:* option below is the best for
○ A. Akinesia this patient?*
○ A. Scrambled eggs with a side
○ B. "Freeze up" tremors
of cottage cheese
○ C. Bradykinesia
○ B. Grilled cheese with apple
○ D. Pill-rolling slices
6. You're providing free education ○ C. Baked chicken with bacon
to a local community group slices
about the signs and symptoms
○ D. Tacos with refried beans
of Parkinson's Disease. Select
all the signs and symptoms a
9. As the home health nurse you ○ B. Body fluids can turn a dark
are helping a patient with color and stain clothes.
Parkinson's Disease get ○ C. This medication is most
dressed. What item gathered commonly prescribed with a
by the patient to wear should vitamin B6 supplement.
NOT be worn?*
○ D. Carbidopa helps to prevent
○ A. Velcro pants
Levodopa from being broken
○ B. Pull over sweatshirt down in the blood before it
○ C. Non-slip socks enters the brain. Hence,
○ D. Rubber sole shoes levodopa is able to enter the
10. A spouse of a husband who brain.
has Parkinson's Disease 12. You're patient with Parkinson's
explains to you that her Disease has been taking
husband experiences episodes Carbidopa/Levodopa for
while walking where he freezes several years. The patient
and can't move. She asks what reports that his signs and
can be done to help with these symptoms actually become
types of episodes to prevent worse before the next dose of
injury. Select all the options medication is due. As the
that are correct:* nurse, you know what
○ A. Have the husband try to medication can be prescribed
change direction of movement with this medication to help
by moving in the opposite decrease this for happening?*
direction when the freeze ups ○ A. Anticholinergic
occur. (Benztropine)
○ B. Use a cane with a laser ○ B. Dopamine agonists
point while walking. (Ropinirole)
○ C. Have the husband try to ○ C. COMT Inhibitor
push through the freeze ups. (Entacapone)
○ D. Encourage the husband to ○ D: Beta blockers (Metoprolol)
consciously lift the legs while 13. While providing discharge
walking (as with marching). teaching to a patient
11. A patient is prescribed to take prescribed Ropinirole (Requip),
Carbidopa/Levodopa you make it priority to teach
(Sinemet). As the nurse you the patient about what side
know that which statement is effect?*
incorrect about this ○ A. Drowsiness
medication:* ○ B. Dry mouth
○ A. It can take up to 3 weeks ○ C. Coughing
for the patient to notice a
○ D. Dark sweat or saliva
decrease in signs and
14. A physician orders a patient to
symptoms when beginning
take Benztropine (Cogentin).
treatment with this medication.
The patient has never taken
this medication before and is
 due to take the first dose at
1000. What statement by the
patient requires you to hold the
dose and notify the physician?
*
○ A. "I forgot to tell the doctor I
take eye drops for my
glaucoma."
○ B. "I had a PET scan last
week."
○ C. "I take aspirin once day."
○ D. "My hands are experiencing
tremors at rest."
15. A patient is taking Rasagiline
"Azilect" for treatment of
Parkinson's Disease. What
foods do the patient want to
limit in their diet? Select all
that apply:*
○ A. Liver
○ B. Aged Cheese
○ C. Sweetbread
○ D. Beer
○ E. Fermented foods
○ F. Shellfish
AUTONOMIC DYSREFLEXIA CAUSE:
{HYPERREFLEXIA}

● All patient that has a spinal cord

DEFINITION: injury are high risk of developing
Autonomic Dysreflexia
○ All injury T6 high
● Exaggerated reflex response by the ● They recieve that irritating stimulus
autonomic nervous system due to they can trigger that reflex response
an irritating stimulus BELOW the site by the sympathetic nervous response
of spinal injury.
○ It affects the SYMPATHETIC
NERVOUS SYSTEM “Fight or 3 BIG B’S
Flight” system
○ Result of SEVERE
HYPERTENSION
● If this is uncontrolled ● BLADDER* {MOST COMMON}
○ It can lead to STROKE, ○ Urinary retention
SEIZURE AND CAN BE ○ Full and distended bladder
FATAL ● BOWEL
● IT IS A MEDICAL EMERGENCY ○ Harden stool
○ Preventing AD ○ Impaction
○ Detecting AD ● BREAKDOWN OF SKIN
○ ACTon AD appropriately ○ Pressure injury
○ Ingrown toenail

RISK FACTOR

● All patient that has a spinal cord

injury are high risk of developing
Autonomic Dysreflexia
○ All injury T6 high

ANATOMY
Role of AUTONOMIC NERVOUS SYSTEM: it b. Causing our nerves to send an
controls the Sympathetic and impulse that something is
Parasympathetic Nervous system wrong
c. However since we have an
injured Spinal Cord T6 and
Higher the stimulus can be
blong creating no response
2. It will create Exaggerated
Sympathetic Parasympathetic Sympathetic Reflex Response
Nervous System Nervous System a. This is excessive and
“Fight or Flight” “Rest and Digest” Exaggerated
3. Vasoconstriction
● Vasoconstriction ● Vasodilation
a. Vasoconstriction and
● Sweat glands ● Decrease HR
stimulation ● Salivation narrowing of vessel BELOW
● Bronchodilation ● Bronchoconstricti THE INJURED SPINE
● Increase HR on b. Increase blood pressure
● Dilates Pupils ● Constrict Pupils c. It's going to cause a veryPale
cool clammy
i. Because we are
* These system works beautifully together but constricting vessel to
they oppose each other to check balance the non-vital organs
between each other BUT NUMBER ONE 4. The body will sense it specifically
REQUIREMENT: They must have a good Baroreceptors Sense
spinal cord structure and functioning a. It doesn't know what’s going
on Or if there is an existing
issue below T6
b. So the Increase BP will cause
PATHOPHYSIOLOGY the Baroreceptors to Stimulate
PARASYMPATHETIC
ACTIVITY
● What is that requirement? i. VASODILATION {
○ They must have that irritating ii. Flushing
stimulus and destroyed or iii. Decrease HR less than
injured T6 and above spinal 60
cord iv. Bradycardia
c. However these Baroreceptor
response really can’t bring
IRRITATING STIMULUS change the BP below T6
i. Instead it will cause
Vasodilation Up there
and vasoconstriction
1. Irritating Bladder Down there
a. Its ascending irritating stimulus 5. The compensatory mechanism is NOT
to our body effective due to vasoconstriction
Goal: Remove the irritating response and treat MEDICAL
patient appropriately MANAGEMENTS/SURGERY/MEDICATION

Medication to help treat AD

SIGNS AND SYMPTOMS:
● Nitropaste: Topical
administration
○ Do not administer if a patient
has taken
phosphodiesterase
inhibitors in the past 24
hours….. Sildenafil or
Tadalafil
○ Other medications:
Nifedipine {CCBs}

● Throbbing Headache
○ Due to increase blood NURSING INTERVENTION
pressure
● Hypertension
○ Systolic 20-40 mmHg higher ● P-prevention
than BASELINE ○ Think of the 3 Big B’s
○ Example 106/78 to 149/92 ■ Bladder
■ Bowel
● Flushing ■ Breakdown of Skin
○ Above T6 or Above injury ○ Irritating response must be
○ Vasodilation above the injury eliminated
● Pale, cool, clammy
○ Below the T6 or sight of Injury
○ Vasoconstriction below the
injury
● Bradycardia Bladder {most common cause}
○ Below 60
● Sweating
● Dilated pupils ● Keep Bladder EMPTY
● Stuffy nose ● Assess I and O’s
● Anxiety ● Routine Bladder Scans
● Goosebumps ● Prevent UTIs
● Foley draining
 ■ Assess for signs and
○ Determine if its kink or
symptoms of AD
blocked
■ What to do if signs and
● Use anesthetic jelly if need
symptoms present?
catheterized
● A-action

It is a MEDICAL EMERGENCY
● Call a rapid response and get
help

Bowel ● Position the patient at 90 degrees

with legs lowered
● Check for impaction ○ This will allow gravity to pool
● down on those leg and
● Assess bowel sounds decrease the blood pressure
● Palpate for distention ● Assess BP every 2-5 minutes
● Assess last Bowel movement ● Removed Binding devices or
● For impacted always use clothing
○ Use anesthetic jelly, prior to ● Investigate 3 Big B’s and correct it
stool removal ● Start w/ bladder, then proceed to
bowel, and the skin

LAST RESORT

Breakdown of the skin

Medication to help treat AD
● Remove binding devices
● Reposition every Hours ● Nitropaste: Topical
● Asses skin regularly administration
● Protect from injury ○ Do not administer if a patient
has taken
phosphodiesterase
inhibitors in the past 24
hours….. Sildenafil or
Tadalafil
○ Other medications:
Nifedipine {CCBs}
● D-detection and A-action
○ Patient w/ T6 Or higher are at
the HIGHEST
○ Always assess blood
pressure and monitor for: Your Grade: A
■ Any elevation of a
systolic pressure 20-
40 mmHg more than
baseline Percentage of What you Got Right: 91
■ If patient reports
HEADACHE, always
check BP immediately
Go Here for More Quizzes

Your Answers & what you got Right & 2. Your patient, who has a spinal cord
Wrong: injury at T3, states they are experiencing a
throbbing headache. What is your NEXT
nursing action?

A. Perform a bladder scan

1. Which patient below is at MOST risk for
developing a condition called autonomic
dysreflexia? B. Perform a rectal digital examination

A. A 24-year-old male patient with a C. Assess the patient's blood pressure

traumatic brain injury.

D. Administer a PRN medication to

B. A 15-year-old female patient with a alleviate pain and provide a dark, calm
spinal cord injury at C7. environment.

C. A 35-year-old male patient with a spinal The answer is C. This is the nurse's NEXT
cord injury at L6. action. The patient is at risk for developing
autonomic dysreflexia because of their
spinal cord injury at T3 (remember patients
D. A 42-year-old male patient recovering who have a SCI at T6 or higher are at
from a hemorrhagic stroke. MOST risk). If a patient with this type of
injury states they have a headache, the
nurse should NEXT assess the patient's
blood pressure. If it is elevated, the nurse
The answer is B. Patients who are at MOST would take measures to check the bladder
risk for developing autonomic dysreflexia (a bladder issue is the most common
are patients who've experienced a spinal cause of AD), bowel, and skin for
cord injury at T6 or higher...this includes breakdown.
C7. L6 is below T6, and traumatic brain
injury and hemorrhagic stroke does not
increase a patient risk of AD.
 try to find the cause of the autonomic
dysreflexia, which could be a full bladder,
impacted bowel, or skin break down.
3. You're performing a head-to-toe
assessment on a patient with a spinal cord
injury at T6. The patient is restless,
sweaty, and extremely flushed. You assess
the patient's blood pressure and heart rate.
The patient’s blood pressure is 140/98 and
heart rate is 52. You look at the patient's
chart and find that their baseline blood
pressure is 106/76 and heart rate is 72.
What action should the nurse take FIRST? 4. You’re providing an in-service to a
group of new nurse graduates on the
causes of autonomic dysreflexia. Select all
the most common causes you will discuss
A. Reassess the patient’s blood pressure. during the in-service:

B. Check the patient's blood glucose. A. Hypoglycemia

C. Position the patient at 90 degrees and B. Distended bladder

lower the legs.

C. Sacral pressure injury

D. Provide cooling blankets for the patient.

D. Fecal impaction
The answer is C. Based on the patient
findings and how the patient has a spinal
cord injury at T6, they are experiencing
autonomic dysreflexia. Patients with this E. Urinary tract infection
condition may have a blood pressure that
is 20-40 mmHg higher than their baseline
and may experience bradycardia (heart The answers are B, C, D, and E. Anything
rate less than 60). The FIRST action the that can cause an irritating stimulus below
nurse should take when AD is suspected is the site of the spinal injury (T6 or higher)
to position the patient at 90 degree (high can lead to autonomic dysreflexia, which
Fowler's) and lower the legs. This will causes an exaggerated sympathetic reflex
allow gravity to cause the blood to pool in response and the parasympathetic system
the lower extremities and help decrease is unable to oppose it. This will lead to
the blood pressure. Then the nurse should severe hypertension. The most common
cause of AD is a bladder issue
(full/distended bladder, urinary tract
infection etc). Other common causes are
due to a bowel issue like fecal impaction or 6. The physician orders Nitropaste for a
skin break down (pressure injury/ulcer, patient who has developed autonomic
cut, infection etc.). dysreflexia. Which finding would require
the nurse to hold the ordered dose of
Nitropaste and notify the physician?

A. The patient’s blood pressure is 130/80.

B. The patient reports a throbbing

5. After taking all the necessary steps for a headache.
patient who has developed autonomic
dysreflexia, what should the nurse assess
FIRST as a possible cause of this C. The patient’s lower extremities are pale
condition? and cool.

A. Skin break down D. The patient states they took Sildenafil

12 hours ago.

B. Blood glucose
The answer is D. A patient should not
receive a dose of Nitropaste if they have
C. Possible bladder irritant taken a phosphodiesterase inhibitor within
the past 24 hours (Sildenafil or Tadalafil).
This will cause major vasodilation and
D. Last bowel movement severe hypotension that will not respond
to medication. Another medication should
be used. All the other findings are
expected with autonomic dysreflexia.
The answer is C. A bladder issue is usually
the most common cause of AD. If this isn’t
the issue the nurse should assess the
bowel and then the skin for break down.
7. A patient is receiving treatment for a occurring below the site of injury for the
complete spinal cord injury at T4. As the sympathetic response reflex.
nurse you know to educate the patient on
the signs and symptoms of autonomic
dysreflexia What signs and symptoms will
you educate the patient about? Select all
that apply:

A. Headache

8. What is the BEST position for a patient

experiencing autonomic dysreflexia?
B. Low blood glucose

A. High Fowler's with legs lowered

C. Sweating

B. Low Fowler's with legs lowered

D. Flushed below site of injury

C. Semi-Fowler's with legs at heart level

E. Pale and cool above site of injury

D. Prone
F. Hypertension

The answer is A. The patient should be in

G. Slow heart rate high Fowler's (90 degrees) with the legs
lowered. This will allow gravity to cause
blood to pool in the lower extremities and
H. Stuffy nose help decrease blood pressure.

The answers are A, C, F, G and H. All of

these are signs and symptoms of
autonomic dysreflexia. The patient will
have flushing above site of injury due to
vasodilation from parasympathetic
activity, BUT will be pale and cool below
site of injury due to vasoconstriction
9. In autonomic dysreflexia, the nurse A. "Autonomic dysreflexia is an
would expect what finding below the site exaggerated reflex response by the
of the spinal cord injury? parasympathetic nervous system that
results in severe hypertension due to a
spinal cord injury."
A. Flushed lower body

B. "Autonomic dysreflexia causes a slow

B. Pale and cool lower extremities heart rate and severe hypertension."

C. Low blood pressure C. "Autonomic dysreflexia is less likely to

occur in a patient who has experienced a
lumbar injury."

D. Absent reflexes

D. "The first-line of treatment for

autonomic dysreflexia is an
The answer is B. The lower extremities antihypertensive medication."
would be cool and pale due to
vasconstriction caused by the exaggerated
reflex response of the sympathetic
nervous system from an irritating stimulus. The answers are B and C. Option A is
The sympathetic reflex can NOT be false, it should say: Autonomic dysreflexia
unopposed by the parasympathetic is an exaggerated reflex response by the
nervous system due to the spinal injury, SYMPATHETIC (NOT parasympathetic)
which is blocking the nerve impulse. The nervous system that results in severe
areas found ABOVE the site of injury hypertension due to a spinal cord injury.
would be flushed due to vasodilation from Option D is false because medications are
parasympathetic stimulation. used only if the blood pressure is not
decreasing or the cause cannot be
determined.

10. Which statements are TRUE about

autonomic dysreflexia? Select all that
apply: 11. The nurse is about to assess for bowel
impaction in a patient who has developed
autonomic dysreflexia. The nurse makes it
priority to?

A. Avoid using lubricants

B. Stimulate the bowel with rectal

manipulation

C. Slowly administer a saline solution prior

to assessment

D. Instill an anesthetic jelly prior to

assessment

The answer is D. To avoid increasing

autonomic dysreflexia symptoms by
increasing the sympathetic reflex due to
an irritating stimulus, the nurse should
instill an anesthetic jelly before assessing
the rectum for hardened stool. This is also
important prior to catheterization to check
the bladder for urine.
ANATOMY OF CRANIAL NERVES: ○ III, IV, VI, XI, XII {3,4,6,11,12}
● MIXED
○ V, VII, IX, X {5,7,9,10}.
MID BRAIN ORIGIN

FACTS:
I. OLFACTORY NERVE {SENSORY}
II. OPTIC NERVE {sENSORY}
III. OCULOMOTOR {MOTOR} ● Smallest Cranial Nerve
IV. TROCHLEAR {MOTOR} ○ 4th cranial nerve i.e. trochlear
nerve
● Shortest Cranial nerve
PONS ORIGIN ○ 1st cranial nerve i.e. Olfactory
nerve
● Largest Cranial nerve
○ 5th Trigeminal Nerve
V. TRIGEMINAL {MIX} ● Longest Cranial Nerve
VI. ABDUCENS {MOTOR} ○ 10th vagus nerve
VII. FACIAL {MIX} ● Highest number of branches
VIII. AUDITORY/ACOUSTIC/ ○ 10th Vagus nerve
VESTIBULOCOCHLEAR ● Dentist Nerve
{SENSORY} ○ Trigeminal {mandibular}
● Cranial Nerve Arise/Insertion
○ From brain to stem
MEDULLA OBLONGATA ● Only Nerve that arise from Dorsal
aspect of brain stem is
○ Trochlear Cranial nerve
● Most commonly cranial nerves
IX. GLOSSOPHARYNGEAL {MIX}
involved/affected in diabetes {Diabetic
X. VAGUS {MIX}
Neuropathy}
XI. ACCESSORY SPINAL {MOTOR}
○ 3th- Most affected
XII. HYPOGLOSSAL {MOTOR}.
○ 4th
○ 6th
● Most commonly cranial nerve
12 PAIR CRANIAL NERVE FOUND IN involved/affected in shingles {caused
HUMAN BRAIN by Herpes Zosters}
○ 5th
○ 7th
● SENSORY ○ 9th
○ I, II, VIII {1,2,8 ○ 10th
● MOTOR ○ 7th
 ○ Affected mostly {called as
Ramsay Hunt disease} Nuclei of
○ Most Common SIgns of thalamus to
Occipital
Shingles area of
■ Tingling Brain
■ Pain
■ Rashes Function Vision
■ Numbness
III-
Oculomotor
Nature Motor
Nerves
{efferent}

Origin Midbrain

Insertion Muscles of the

● Herpes Zosters most commonly {56 eyeball
percent} affecting thoracic spinal {superior
nerve ganglia rectus, Medial
rectus, inferior
rectus, inferior
oblique}

Function * Eyeball
movement
* Pupil
Cranial Information Movement
Nerve {iris}
*{compression
I-Olfactory of III nerve
Nerves causes
Nature Sensory
Nerve unilateral pupil
{afferent} dilation}
*Upper eyelid
Origin Nasal- Movement
Mucosa {levator
palpebrae}
Insertion Midbrain to
temporal IV-Trochlear
Nerve
Function Smell Nature Motor {efferent}

Origin Midbrain
II- Optic
Nerves Insertion Muscle of
Nature Sensory
Nerve eyeball
{Afferent} {superior
oblique
Origin Retina muscle}

Insertion Lateral Function * Eyeball

Geniculate Movement
 Nerves
* Outward Nature Motor
downward {efferent}
movement
Origin PONS
V-Trigeminal Insertion Muscle of
Nerves eyeballs
Nature Mix
a. Ophthalmic {Lateral rectus
Largest muscles}
{S}
Nerve
b.Maxillary {S}
C. Mandibular Function * Eyeball
{M} movement
* Outward
Origin PONS movement

Insertion Around the VII- Facial

eyes, facem Nerves
nose, lips, Nature Mix
maxilla, a. Sensory
mandible Facial
B. Motor Facial
Function * Sense from
upper eye lid, Origin PONS
eye brow,
forehead, Insertion Face skin and
anterior part Facial Muscle
of scalp
* Sense from Function * Anterior 2/3rd
upper lip, of tongue
upper jaw, {taste}
gums, teeth, * Touch,
hard and soft temperature of
palate, nose, facial area
skin, oral * Facial
mucosa. Expression
* Muscle of
mastication Paralysis of
and sense of 7th cranial
lower jaw, nerves
lower lips, causes
chin, teeth, BELL’S
hums FACIAL
PALSY

VIII-
VESTIBULO
Nature Sensory Nerve
COCHLEAR
{afferent}
NERVE
a. Vestibular
branch-sensory
balance
b. Cochlear
VI-Abducens
 branch-sensory Digestive tract
hearing {Parasympathe
tic branch}
Origin Inner ear
Function * Pain
Insertio PONS sensation from
n visceral organs
{Heart,
Functio * Vestibular digestive,
n Branch-sensory respiratory,
balance kidney}
* Cochlear
branch- sensory *
hearing Parasympathet
ic supply to
IX- visceral organs
GLOSSOPH
Nature Mix
ARYNGEAL Vagal Maneuver:
a. Sensory GP
NERVES ● Is an act that used to
B. Motor GP
slow down the heart
Origin Medulla rate {Sinus
Oblongata tachycardia} by
stimulating the
Insertion Posterior ⅓ Vagus nerves
part of the ○ Straining
tongue {taste} ○ Bearing
down
Muscle of
swallowing
XI-
Function a. Sensory GP- ACCESSOR
Nature Motor
taste Y SPINAL
{efferent}
B. Motor GP- NERVES
movement of Origin Medulla
muscle of Oblingate
swallowing
Insertion Accessory
X- VAGUS Muscle of
NERVE Respiration
Nature Mix {Sternocleido
Longest mastoid SCM,
a. Sensory scalene,
nerve
Vagus trapezius}
B. Motor Vagus
Has many
branching Function Neck
Origin Medulla movement
nerve Oblongata

XII-
Insertion Trachea, Hypoglossal
Nature Motor
Heart, Nerves
{efferent}
 ● Also called “
Origin Medulla ○ Tic Douloureux”,
Oblongata ○ “Prosoplagia” or
○ “Forthergill’s disease”
Insertion Muscles of ● It involve 5th cranial Nerve
tongue compression that causes sharp
intense, pin-like pain on face
Function Tongue {EPISODIC PAIN}
movement ● It is sudden, severe facial pain
during chewing ● It is a sharp shooting pain or like
and speech having an electric shock in the jaw,
teeth, or gums
● It usually last from a few seconds to
about 2 minutes
● The attacks stop as suddenly as they
LINK REFLEX {CORNEAL REFLEX} start

● Loss of blink indicate dysfunction of Sleep can provide some relief from the pain
Naso-cillary branch of OPTHALMIC so patient sleep most of the time
BRANCH OF TRIGEMINAL NERVE
{levator palpebrae muscle}
● It can be tested by cotton wisp if TWO MAIN TYPES:
patient is conscious or by a sterile
drop if patient is unconscious
○ Sterile drops of NS is safest ● Typical Trigeminal Neuralgia
method ○ Episodes of severe sudden,
shock-like pain in one side of
the face
○ Last for seconds to a few
CRANIAL NERVE THAT SUPPLY TO minutes
EYEBALL MUSCLES ○ Groups of these episodes can
occur over a few hours
● Atypical trigeminal neuralgia
○ It is a constant burning pain
that is less severe
○ Episodes may be triggered by
any touch to the face

CAUSES:

● Main Cause of trigeminal Neuralgia:

Blood vessel Compressing on the root
of the trigeminal nerve
● Pressure on the Trigeminal Nerve may
be cause vy
○ Tumor
 ○ Multiple sclerosis ● Paralysis/weakness of one side
○ Trauma face
○ Stroke ○ Caused by damage of lower
motor neuron of 7th cranial
nerve {Facial nerve}
○ Bell’s palsy usually resolves
Management: on its own within six months
○ Physiotherapy can help
prevent muscle permanently
contracting
● Carbamazepines {Drug of choice}
○ Reduce transmission of
impulses
● Oxcarbazepine
● Nerve Blocks {local anesthetics}
● Radiofrequency/Rhizotomy
○ Resection of nerve roots
● Glycerol injection Characterized by:
○ Demyelinating nerve, effective
for 3 weeks
● Avoid Cold/Hold food and fluids
○ Muscles weakness that
causes one half of the face to
droop

Cause:
BELL’S PALSY

● Unknown

Risk Factors:

● Diabetes
● Upper respiratory tract infection
● Some viruses
○ Varicella zoster
○ Epstein Barr Virus
○ Herpes zoster
● Familial Inheritance

SYMPTOMS:

● FLACCID FACIAL MUSCLES and

numbness
 ○ Drooling and Dry eyes
● Drooping {ptosis} MS=Myelin Sheath
○ On affected side SPECIFIC SIGNS AND SYMPTOMS OF
○ Loss of ability to taste
MS:
● Numbness
● Cramping
Treatment: ● Muscle weakness

Parkinson’s Disease: decrease of amount

● Facial exercise of DOPE in the PARK
○ It is a self limiting disease ● Less Dopamine
○ It starts to improve generally in
14 days and recovers in 6-15 ● Dopamine Helps Regulates
week ○ BP {when patient gets to a
● Eye Moisturizer CODE or HYPOTENSION-
○ Prevent eye dryness DOPE release to
● Mouth care and eye care Vasoconstriction}
○ Priority of Nursing care
● Corticosteroid ○ CNS and Ability to Move
○ prednisone ■ They Move slowly
■ Shuffling Gait
● Someone barely learning how to
park a car
○ They walk so slowly, they
shuffling the feet
Neurological Disorders: Parkinson's, MS, ○ Pill Rolling
MG, ALS

PATHOPHYSIOLOGY OF CNS DISEASE:

NEURO
PNS
● They are more on motor function
CNS PNS
M.G= Disney Waltz Movie Show white
{Sleepy} was dedicated for his friend that
Multiple Parkinso Myasthe Amyotro has Myasthenia Gravis
sclerosis n’s nia phic ● A disease that inhibits you from a
Disease Gravis Lateral producing a chemical called
Sclerosi
Acetylcholine
s (ALS)
○ Acetylcholine- help body and
neuron to contract at the
Myoneural Junction
○ If lacking it can cause severe
PATHOPHYSIOLOGY OF CNS DISEASE:
muscle weakness
● You have
CNS IS OUR CMP {Central Nervous
○ Ptosis “drooping eyes”
System, Multiple Sclerosis, Parkinons}
 ○ Extremely fatigue ○ Because even the lung
○ Severe muscle weakness muscles that helps your lung
■ Dysphagia “fail to breath starts to fail
swallow perfectly ○ Mech vent is need
■ Aspiration
Precaution, Airway
issue and
diaphragm issue
■ Not a progressive
disease
● Myasthenia Gravis: Gravity
○ Gravity pulling down your
eyelid
○ Making you very sleepy and
TIIIIIIIRRREDDD

‘
ALS: Amyotrophic Lateral Sclerosis
(ALS).
● This is by far the worst neurological
disease you can get
○ Incurable
○ No remission
○ Can get you dead within 5
years
● Motor Neurons will get Sclerotic
and can get Stiff
○ Motor Neurons: Grip, Push,
Pull, contract and still
○ You get a prisoner of the
body
■ Not dementia
■ No Loss of Sensation
■ No Irrationality
○ You’re just in bed but you
can’t just move
■ Very sad
● 3 D’s of ALS
○ Dysarthria- difficulty moving
○ Dysphagia-Difficulty
Swallowing
○ Drooling
● Can get you killed with a pneumatic
disease