NEUROLOGIC
DISORDERS
Lecturer:
Christian John B. Timogan, RN, USRN
ANATOMY AND
PHYSIOLOGY
NERVOUS SYSTEM
CENTRAL NERVOUS PERIPHERAL NERVOUS
SYSTEM (CNS) SYSTEM (PNS)
Ø Brain & Spinal Cord
SOMATIC NERVOUS AUTONOMIC NERVOUS
SYSTEM (SNS) SYSTEM (ANS)
Ø Voluntary Movements Ø Sympathetic
Ø Parasympathetic
NEURONS - Basic functional unit of The Nervous System
AXON
NEURONS - Basic functional unit of The Nervous System
DENDRITE
NUCLEUS
AXON
MYELIN SHEATH
AXON TERMINAL
NODE OF RANVIER
SYNAPSE
NEURONS - Basic functional unit of The Nervous System
DENDRITE
Ø Extension that carry the
impulses toward the
cell body.
NEURONS - Basic functional unit of The Nervous System
AXON
Ø Transmits impulses
away from the cell
body
NEURONS - Basic functional unit of The Nervous System
MYELIN SHEATH
Ø Allows impulse to
transmit
TYPES OF NEURONS
Ø SENSORY NEURONS
- Transports impulse from receptors
to the CNS
Ø MOTOR NEURONS
- Transports impulse from CNS to
the receptors
CRANIAL NERVES
I - OLFACTORY
Ø Sense of Smell
Ø Sensory
II - OPTIC
Ø Sense of Sight / Vision
Ø Sensory
III – OCULOMOTOR
Ø Pupillary constriction & dilation
Ø Motor
CRANIAL NERVES
IV - TROCHLEAR
Ø 6 Cardinal Gaze movement
Ø Motor
V - TRIGEMINAL
Ø TriCHEWminal – For chewing
Ø Facial SENSATION
Ø Both
VI – ABDUCENS
Ø Eye movement side-to-side (AbduSIDE-TO-SIDE)
Ø Motor
CRANIAL NERVES
VII - FACIAL
Ø Facial MOVEMENT
Ø Anterior 2/3 of tongue sensation
Ø Both
VIII - VESTIBULOCOCHLEAR
Ø Sense of hearing, balance, and coordination
Ø Sensory
IX – GLOSSOPHARYNGEAL
Ø Gag Reflex Activation
Ø Posterior 1/3 of the tongue sensation
Ø Both
CRANIAL NERVES
X - VAGUS
Ø Movement of Uvula
Ø Parasympathetic sensation
Ø Both
XI - ACCESSORY
Ø Neck movement
Ø Motor
XII - HYPOGLOSSAL
Ø Tongue movement
Ø Motor
31 PAIRS SPINAL NERVES
CERVICAL – C1 – C8
THORACIC – T1 – T12 T – Twelve
LUMBAR – L1 – L5 L – Lima
SACRAL – S1 – S5 S - Sinko
COCYX - 1
31 PAIRS SPINAL NERVES
C1 – C4 – Diaphragm
C5 – T1 – Arms
T2 – T6 – Chest
T7 – T12 – Abdomen
L1 – L5 – Legs
S1 – S2 – GI & GU
S3 – S5 – Genitals (Sex Organs)
DEMYELINATION
DISORDERS
Ø Autoimmune diseases that damages
the myelin sheath and would lead into
delayed impulse transmission
MULTIPLE SCLEROSIS
Ø Demyelination of CNS nerves
Ø Has remission and exacerbation
Ø Common cause: Autoimmune
Ø Common in: 20-40 years old (female)
MULTIPLE SCLEROSIS
Ø Signs and Symptoms:
• Visual Disturbances
- Scotoma – White patches in vision
- Earliest sign
- Diplopia
- Blurred vision
• Dysphagia
• Respiratory depression
• Decrease GI and GU movement
• Ataxia
MULTIPLE SCLEROSIS
• Numbness and Spasticity
• Lhermitte’s Sign
MULTIPLE SCLEROSIS
• Numbness and Spasticity
• Lhermitte’s Sign
• CHARCOAT’S TRIAD – Due to impaired cerebellar
function
Intentional Tremors
SIN
Stoccato Speech Nystagmus
MULTIPLE SCLEROSIS
Ø Management:
1. Corticosteroids
2. Muscle Relaxants – Dantrolene Sodium (Baclofen)
3. Oxygen and Mechanical ventilation
4. Assistive devices
5. Promote regular elimination:
- Increase fluid and fiber intake
- Stool softener
6. Priority: SAFETY
7. Unilateral eye patch
GUILLAIN – BARRE SYNDROME
Ø Demyelination of PNS nerves
Ø Cause: Autoimmune
History of GI or Respi Infxn (Campylobacter Jejuni)
Ø Signs and Symptoms:
• Ascending Paralysis
• Dyskinesia (Leg weakness / Clumsiness ) – Early Sign
• Respiratory Depression
• Dec. GIT and GUT function
• Numbness & Spasticity
GUILLAIN – BARRE SYNDROME
Ø Management:
1. Corticosteroids
2. Muscle Relaxants – Dantrolene Sodium (Baclofen)
3. O2 and mech vent
4. Assistive devices
5. No to hot baths
6. Priority: Safety
7. Promote regular elimination
- Increase fluid and fiber intake
- Stool softener
NEUROTRANSMITTER
DISORDERS
MYASTHENIA GRAVIS
Ø Cause: Autoimmune that will attack acetylcholine receptors
Antibody will bind to acetylcholine receptors
Acetylcholine can’t bind anymore
Acetylcholine accumulates in the synapse
Acetylcholinesterase will kill acetylcholine in the synapse
POOR MUSCLE MOVEMENT
MYASTHENIA GRAVIS
Ø Diagnostics:
• TENSILON TEST (Confirmatory)
- Cholinesterase inhibitor (Endrophonium) is injected
- (+) MG = Temporary improve in muscle movement
- Prepare Atropine Sulfate (Symphatomemitics) for
possible side effects.
Ø Signs and Symptoms:
• Descending Paralysis
• Muscle weakness in the afternoon
MYASTHENIA GRAVIS
Ø Management:
1. Priority: Airway
2. NGT feeding
3. Plasmapheresis to remove excess antibody
4. Mechanical Ventilator Stand-by
5. Tracheostomy Set at Bed Side
6. Medications:
• Neostigmine (Prestigmine)
Anticholinesterase
• Pyrastigmine (Mestonin)
• Steroids
MYASTHENIA GRAVIS
Ø Complications:
CHOLINERGIC CRISIS MYASTHENIC CRISIS
Ø Overmedication Ø Undermedication
Ø Tensilon Test: Muscle weakness Ø Tensilon Test: Temp. Relief
Ø Parasympathetic effects Ø Sympathetic effects
Ø Prepare: Atropine Sulfate Ø Prepare: Cholinergics
PARKINSON’S DISEASE
Ø Problem in Dopamine regulation (Decrease Dopamine Level)
CHOLINERGICS DOPAMINE
PARKINSON’S DISEASE
Ø Problem in Dopamine regulation (Decrease Dopamine Level)
CHOLINERGICS
DOPAMINE
PARKINSON’S DISEASE
Ø Signs and Symptoms:
• Cog-wheel rigidity (Jerky movement in the limb)
• Stooped posture (Osteoporosis like)
• Bradykinesia (Dec. Muscle Movement)
• Shuffling gait (Short, rapid steps)
• Mask – Like Appearance
• Dysphagia
• Resting Tremors
• Decrease GIT and GUT function
• Respiratory depression
PARKINSON’S DISEASE
Ø Management:
1. Activity: Anything that involves fingers
2. Priority: Safety
3. Mobility: Marching walk ; if they freeze, move to
opposite side
4. Diet: Puree diet because of dysphagia
5. Anti-parkinsonian drugs: Anticholinergics
SEIZURE – RELATED
DISORDERS
SEIZURE
Ø Abnormal transmission of impulse at motor complex of
the brain.
Ø Cause:
• Information overload
• Infection
• Trauma (Brain)
• Autoimmune
• Heredity
• Vegan diet – Vitamin B12 deficiency
SEIZURE
Ø Types of Seizure:
• Petit Mal - Absence seizure
- Blank facial expression
- “Blank Stare”
- Common in pedia
• Grand Mal - Tonic – Clonic Seizure (Preceded with Aura)
- TONIC – Stiffening
- CLONIC – Involuntary muscle jerking
SEIZURE
• Myoclonic - Brief, involuntary muscle jerking of the body
• Akinetic - Drop attack seizure
- Sudden loss of postural tone & consciousness
• Symptomatic - Benign seizure
- Temporary until the cause will be addressed
- ex: Febrile (convulsion)
SEIZURE
• Pre - Ictal Phase
- Watch out for aura:
• Flashing lights
• Smells somethings burning
• Spots before the eyes
• Dizziness
• Metallic taste
- Priority: Safety
• Slide to the wall (if pt is standing)
SEIZURE
• Pre - Ictal Phase
- Loss of consciousness:
1. Protect the head and neck
2. Turn to sides
3. Loosen constrictive clothing
4. Clear the area
SEIZURE
• Ictal Phase
- Actual seizure movement
- Observe the patient, take note of the duration
- Maintain side lying position
- DO NOT PUT ANYTHING IN THE MOUTH
• Post - Ictal Phase
- Patient is recovering and regains consciousness
- Priority: Securing the airway
- Reorient the patient after securing the airway
SEIZURE
Ø Management:
1. Turn patient to side (Left lateral side lying)
2. Remove objects that may harm the patient
3. Loosen restrictive clothing
4. Raise 2-3 side rails
5. Do not put anything inside the patient’s mouth
6. Remove pillow if seizure on bed; Put pillow if happens on the floor
7. Suction machine at bedside
8. Medications: Anticonvulsants
INCREASE INTRACRANIAL
PRESSURE
Monro – Kellie Hypothesis:
“Skull is incompressible”
Brain – 80%
CSF - 10%
Blood - 10%
BRAIN CSF BLOOD
INCREASED ICP
Ø Normal: 0-15 mmHg
Ø Initial Sign: Altered Level of Consciousness
- Restlessness
- Confusion
- Disorientation
- GCS alteration
Ø Late Sign: - Decrease Level of Consciousness (Lethargy)
- Seizure
- Projectile Vomiting - Indicates medulla oblongata
damage
INCREASED ICP
- Cheyne – Stoke Respiration – Indicates pons damage
- Decerebrate Posture
- Cushing’s Triad – Indicates brain stem damage
- High - pitched cry (newborn)
- Bulging fontanels (newborn)
INCREASED ICP
Ø Management:
1. Maintain patent airway
2. Position: Semi-fowlers with head and neck at midline
3. Adequate oxygenation to neutralize acidity of the brain
- DON’T HYPEROXYGENATE = Brain alkalosis = Seizure
4. Loose, comfortable clothes
5. Quite, Calm, Non – stimulating environment
6. Seizure and Aspiration precaution
7. Stool softeners; NO ENEMA AND SUPPOSITORY
8. Surgery: Ventriculostomy – To monitor ICP
INCREASED ICP
9. Medications:
• IV mannitol - For cerebral edema
- Check BP before administration
- Check urine output during therapy
• Dexamethasone - Steroids for cerebral inflammation
10. DON’TS:
• Valsalva Maneuver
• Routine suctions
• Lumbar puncture
• Coughing / Sneezing
CEREBROVASCULAR
ACCIDENT
CEREBROVASCULAR ACCIDENT
Ø Disruption of blood supply to the brain
Ø Causes:
• Thrombus Formation
• Hypertension
• Atherosclerosis
• Diabetes Mellitus
• Aneurysm
CEREBROVASCULAR ACCIDENT
Ø Risk Factors:
• Age: 45 years old and above
• Obesity
• Estrogen Therapy – Increases clotting ability
• Hereditary
• Sedentary lifestyle
• Smoking
• Alcoholism
Ø 2 Types:
• Ischemic
• Hemorrhagic
CEREBROVASCULAR ACCIDENT
Ø What to assess:
• Facial drooping
• Arm defect
• Slurred speech
• Time – To measure the severity of brain damage and for
the drug administration
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Aphasia:
- BROCHA’S APHASIA – Unable to speak fluently
- WERNICKE’S APHASIA – Unable to comprehend
- GLOBAL APHASIA – Combined
- Management:
1. Short, one at a time task
2. Independence promotion
3. Make simple direction
4. Alternative communication style
5. Provide time to verbalize concerns
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
2. Slipping tub bath
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
2. Slipping tub bath
3. Electric wheel chair
4. Avoid – Roller Walker
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Foot drop (Plantar Flexion)
- Management:
1. High topped sneakers
2. Foot board
• Neglect Syndrome (Unilateral Neglect)
- Inability to identify for weak side
- Management:
1. Instruct the patient to touch the weak side
2. Offer a mirror
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Homonymous Hemianopia (Half Vision)
CEREBROVASCULAR ACCIDENT
Ø Signs and Symptoms:
• Homonymous Hemianopia (Half Vision)
- Management:
1. Scan the environment
2. Move side-to-side
3. Initially; Approach from unaffected side
4. Latter; Approach from affected side
Ø Drug Management:
• Striptokinase – Thrombolytics
- Ideally given within 12 hours
• Antihypertensives
TRAUMATIC
BRAIN INJURY
TRAUMATIC BRAIN INJURY
Ø 2 Types:
• CLOSED
- CONCUSSION – Jarring of the brain
- CONTUSION – Bruising of the brain
• Coup – Same side to the site of injury
• Counter – Coup – Opposite side to the site
• Coup – Counter – Coup – Bouncing back
TRAUMATIC BRAIN INJURY
TRAUMATIC BRAIN INJURY
Ø 2 Types:
• OPEN (Skull Fracture)
- LINEAR – Fine line on the skull
- Most common
- DEPRESSED – Skull is driven inward
- COMMINUTED – Skull is fragmented
- BASAL – SKULL
Ø Signs & Symptoms:
• Racoon’s Eye – Periorbital Edema
• Battle Sign – Ecchymosis of Mastoid Bone
• CSF leakage – Do DEXTROSTIK TEST
TRAUMATIC BRAIN INJURY
SPINAL CORD
INJURY
SPINAL CORD INJURY
Ø Injury to the spinal cord which characterized by a decrease
or loss of sensory and motor functions below the level of
injury
Ø Causes:
• Motor vehicle accidents
• Gunshot injuries
• Falls
• Sports injuries
• Whiplash injury – Neck
• Transection – Due to sharp objects
• Hyper rotation
SPINAL CORD INJURY
Ø Risk factors:
• Young age
• Alcohol and drug abuse
• Male
Ø Types of Spinal Cord Injury
CERVICAL SCI THORACOLUMBAR SCI
PARALYSIS - Quadriphlagia - Paraphlagia (Lower body)
PRIORITY - Respiratory - Elimination
SPINAL CORD INJURY
Ø Management
1. Stabilize the airway (Jaw Thrust Maneuver)
2. Immobilization (Flat, firm surface)
3. Cervical collar
4. Transport client as a unit
5. Do not attempt to realign body parts
6. Suctioning may be indicated, but with caution
7. Position change q 2 hours
8. Intermittent catheterization for bladder distention
9. Anticoagulants
10. Anti-embolic stockings
SPINAL CORD INJURY
Ø Complication: AUTONOMIC DYSREFLEXIA
- Life threatening condition that occurs in patients with SCI
above T6 level.
- Impairs the normal equilibrium between sympathetic and
parasympathetic divisions
Ø Causes:
• Bladder distention (Most common)
• Bowel impaction
• UTI
• Pressure ulcers
SPINAL CORD INJURY
Ø Pathophysiology:
Lower body irritation (Distended bladder)
Stretched bladder sends nervous impulse to the spinal cord
When the impulse reaches T6, it would lead into
Norepinephrine release
Vasoconstriction
Increase Blood Pressure
SPINAL CORD INJURY
Increase Blood Pressure to the brain
Brain will interpret that the cause of Inc. Pressure is fluid
overload from distended bladder
However, taman ra sa
T6 ang impulse
Brain will send signal to the bladder to urinate it
SPINAL CORD INJURY
Ø Manifestations:
• Hypertension
• Throbbing / Pounding headache
• Diaphoresis
• Piloerection
• Bradycardia
• Blurring of vision
• Warm and flushed – Above the level of injury
• Cold and Pale – Below the level of injury
SPINAL CORD INJURY
Ø Management:
1. Position the patient in sitting position to decrease BP
2. Catheterization
3. Check for fecal impaction
4. Monitor blood pressure
5. Antihypertensive medication: HYDRALAZINE
THANKS!
Do you have any questions?
christiantimogan@gmail.com
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