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MEDICAL SURGICAL REVIEWER

Nervous System
Central NS
Brain & spinal cord

C- 8
T- 12
L- 5
S- 5
C- 1

Peripheral NS
31 spinal

Autonomic NS
sympathetic NS
Parasympathatic NS

Somatic NS
ex. Breakfast 8am diaphragm, chest wall muscles, shoulders & arms
ex. Lunch 12nn upper body, GI functions
ex. Dinner 5pm (napaa aga haha) lower body, bladder, bowel
ex. Dinner ulit kasi matakaw
ex. Midnight snack 1am

SNS (involved in fight or aggression response / LABAN)


Release of norepinephrine (adrenaline
cathecolamine)
Adrenal medulla (potent vasoconstrictor)
Increases body activities
Except GIT decrease GIT motility
Why GIT is not increased = GIT is not important!
Increase blood flow to skeletal muscles, brain &
heart.

Effects of SNS (anti-cholinergic/adrenergic)


1. Dilate pupil to aware of surroundings
medriasis
2. Dry mouth
3. BP & HR= increased
bronchioles dilated to take more oxygen
4. RR increased
5. Constipation & urinary retention

I. Adrenergic Agents Epinephrine (adrenaline)


SE: SNS effect
II. PNS: Beta adrenergic blocking agents (opposite of adrenergic agents) (all end in lol)
Blocks release of norepinephrine.
Decrease body activities except GIT (diarrhea)
Ex. Propanolol, Metopanolol
Sie effects:
B broncho spasm (bronchoconstriction)
E elicits a decrease in myocardial contraction
T treats HPN
A AV conduction slows down
- Given to angina & MI beta-blockers to rest heart
Anti HPN agents:
1. Beta blockers (-lol)
S/E- of Anti-HPN drugs:
2. Ace inhibitors (-pril)
1. orthostatic hpn
Ex. ENALAPRIL, CAPTOPRIL
2. transient headache & dizziness.
3. Calcium antagonist
Mgt. Rise slowly. Assist in ambulation.
Ex. CALCIBLOC or NEFEDIPINE
Parasympathetic Nervous System: (Cholinergic / BAWI)
Involved in fly or withdrawal response
Release of acetylcholine (ACTH)
Decrease all bodily activities except GIT (diarrhea)
I. Cholinergic agents
Ex. Mestinon
Antidote anti cholinergic agents Atropine Sulfate S/E SNS

Effect of PNS: (cholinergic/ opposite ng SNS)


1. Meiosis contraction of pupils
2. Increase salivation
3. BP & HR decreased
4. RR decrease broncho constriction
5. Diarrhea increased GI motility
6. Urinary frequency

CENTRAL NS (brain & spinal cord)

I. Cells A. Neurons 10 billion


o Properties and characteristics
a. Excitability ability of neuron to be affected in external environment.
b. Conductivity ability of neuron to transmit a wave of excitation from one cell to another
c. Permanent cells once destroyed, cant regenerate (ex. heart, retina, brain, osteocytes)
Regenerative capacity
Labile once destroyed cant regenerate
Epidermal cells, GIT cells, resp (lung cells). GUT
Stable capable of regeneration BUT limited time only ex salivary gland, pancreas cells cell of liver, kidney cells
Permanent cells retina, brain, heart, osteocytes cant regenerate.
*Neuroglia attached to neurons.
o Supports neurons. Where brain tumors are found.
Types:
1. Astrocyte
2. Oligodendria
Astrocytoma 90 95% brain tumor from astrocyte. Most brain tumors are found at astrocyte, most common.
*Astrocyte maintains integrity of blood brain barrier (BBB).
BBB semi permeable / selective
Toxins that can pass in BBB:
1. Ammonia - liver cirrhosis.
2. Carbon Monoxide seizure & parkinsons.
3. Bilirubin - jaundice, hepatitis, kernicterus/hyperbilirubenia.
4. Ketones DM.
*OLIGODENDRIA Produces myelin sheath wraps around a neuron acts as insulator facilitates rapid nerve impulse transmission.
No myelin sheath degenerates neurons
Damage to myelin sheath demyellenating disorders
**DEMYELLENATING DISEASES
1. ALZHEIMERS DISEASE atrophy of brain tissue due to a deficiency of acetylcholine.
S/S: FOUR As
A amnesia loss of memory
A apraxia unable to determine function & purpose of object
A agnosia unable to recognize familiar object
A aphasia
o Expressive broccas aphasia unable to speak
o Receptive wernickes aphasia unable to understand spoken words
Common to Alzheimer receptive aphasia
Drug of choice ARICEPT (taken at bedtime) & COGNEX.
Mgt: Supportive & palliative.
*MICROGLIA stationary cells, engulfs bacteria, engulfs cellular debris.

II. Compositions of Cord & Spinal cord


80% - brain mass
10% - CSF
10% - blood
*MONROE KELLY HYPOTHESIS: The skull is a closed vault. Any increase in one component will increase ICP.
Normal ICP: 0-15mmHg

BRAIN MASS

1. Cerebrum largest part


Corpus collusum - connects R & L cerebral hemisphere.
Function:
1. S - Sensory
2. I - Integrative
3. M Motor
4.
**LOBES
1.) Frontal
a. Controls motor activity
b. Controls personality development
c. Where primitive reflexes are inhibited
d. Site of development of sense of umor
e. Broccas area speech center
Damage - expressive aphasia
2.) Temporal
a. Hearing
b. Short term memory
c. Wernickes area gen interpretative or knowing Gnostic area
Damage receptive aphasia
3.) Parietal lobe appreciation & discrimation of sensory imp
- Pain, touch, pressure, heat & cold
4.) Occipital - vision
6.) Rhinencephalon/ Limbec
- Smell, libido, long-term memory
2. BASAL GANGLIA areas of gray matteR located deep within a cerebral hemisphere
Extra pyramidal tract
Releases dopamine
Controls gross voluntary unit
**TRIVIA
Decrease dopamine (Parkinsons) pin rolling of extremities & Huntingtons Dse.
Decrease acetylcholine Myasthenia Gravis &
Alzheimers
Increased neurotransmitter = psychiatric disorder
Increase dopamine schizo
Increase acetylcholine bipolar
3. MID BRAIN relay station for sight & hearing
Controls size & reaction of pupil 2 3 mm
Controls hearing acuity
CN 3 4
Isocoria normal size (equal)
Anisocoria uneven size damage to mid brain
PERRLA normal reaction
4. DIENCEPHALON - between brain
Thalamus acts as a relay station for sensation
Hypothalamus (thermoregulating center of temp, sleep & wakefulness, thirst, appetite/ satiety center, emotional
responses, controls pituitary function.
5. BRAIN STEM
a. Pons or pneumotaxic center controls respiration
Cranial 5 8 CNS
b. Medulla Oblangata - controls heart rate, respiratory rate, swallowing, vomiting, hiccups/ singutus
Vasomotor center, spinal decuissation termination, CN 9, 10, 11, 12
6. CEREBELLUM lesser brain

- Controls posture, gait, balance, equilibrium


**Cerebellar Tests:
a.) R Rombergs test- needs 2 RNs to assist
- Normal anatomical position 5 10 min
(+) Rombergs test (+) ataxia or unsteady gait or drunken like movement with loss of balance.
b.) Finger to nose test
(+) To FTNT dymetria inability to stop a movement at a desired point
c.) Alternate pronation & supination
Palm up & down . (+) To alternate pronation & supination or damage to cerebellum dymentrium
**Composition of brain - based on Monroe Kellie Hypothesis
Skull is a closed container.
Any alteration in 1 of 3 intracranial components = increase in ICP
o Normal ICP 0 15 mmHg
o CSF cushions the brain, shock absorber
o Foramen Magnum
o Obstruction of flow of CSF = increase ICP
o C1 atlas
o Hydrocephalus posteriorly due to closure of
o C2 axis
posterior fontanel
o (+) Projectile vomiting = increase ICP
o CVA partial/ total obstruction of blood supply
o Observe for 24 - 48 hrs
--------------------------------------------------------------------------------------------------------------------------------------------------------------INCREASED ICP increase ICP is due to increase in 1 of the Intra Cranial components.
Predisposing factors:
1.) Head injury
2.) Tumor
3.) Localized abscess
4.) Hemorrhage (stroke)
5.) Cerebral edema
6.) Hydrocephalus
7.) Inflammatory conditions - Meningitis, encephalitis
S&Sx
**change in VS = always LATE symptoms
**Earliest Sx: (vision changes, change in LOC, headache)
a.) Change or decrease LOC Restlessness to confusion
Wide pulse pressure: Increased ICP
- Disorientation to lethargy
Narrow pp: Cardiac disorder, shock
- Stupor to coma
Late sign change in V/S
1. BP increase (systolic increase, diastole- same)
2. Widening pulse pressure
Normal adult BP 120/80 120 80 = 40 (normal pulse pressure)
Increase ICP = BP 140/80 = 140 80= 60 PP (wide)
3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea)
4. Temp increase
Increased ICP: Increase BP
Shock decrease BP
Decrease HR
Increase HR
CUSHINGS TRIAD (opposite ng inceased ICP)
Decrease RR
Increase RR
b.) Headache
Projectile vomiting
Papilledima (edema of optic disk outer surface of retina)
Decorticate (abnormal flexion) = Damage to cortico spinal tract /
Decerebrate (abnormal extension) = Damage to upper brain stem-pons/
c.) Uncal herniation unilateral dilation of pupil. (**kapag Bilateral dilation of pupil = tentorial herniation.)
d.) Possible seizure.

Nursing priority:
1.) Maintain patent a/w & adequate ventilation
a. Prevention of hypoxia (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention).
o Hypoxia cerebral edema - increase ICP
o Hypoxia inadequate tissue oxygenation
Late symptoms of hypoxia ----------- B bradycardia
E extreme restlessness
D dyspnea
C cyanosis
**Early symptoms --------- R restlessness
A agitation
T tachycardia

Increase CO2 retention/ hypercarbia cerebral vasodilatation = increase ICP


Most powerful respiratory stimulant increase in CO2 ----- remember this!
Hyperventilate decrease CO2 it excretes CO2 kaya nga dapat i-brown bag to retain CO2

Respiratory Distress Syndrome (RDS) decrease Oxygen


*Suctioning 10-15 seconds, max 15 seconds.
o Suction upon withdrawal
*Ambu bag pump upon inspiration
**Assist in mechanical ventilation
1. Maintain patent airway
2. Monitor VS & I&O
3. Elevate head of bed 30 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage
4. Limit fluid intake 1,200 1,500 ml/day
(side note: FORCE FLUID means = Increase fluid intake/day 2,000 3,000 ml/day) - not for inc ICP.
5. Prevent complications of immobility
6. Prevent increase ICP by:
a. Maintain quiet & comfy environment
b. Avoid use of restraints lead to fractures
c. Siderails up
d. Instruct patient to avoid the ff:
* Avoid valsalva maneuver or bearing down, avoid straining of stool
(give laxatives/ stool softener Dulcolax/ Duphalac)
* Avoid Excessive cough antitussive
Ex. Dextrometorpham
* Avoid Excessive vomiting anti emetic (Plasil brand name sa pinas) / Phenergan
* Avoid Lifting of heavy objects
* Avoid Bending & stooping
* Avoid clustering of nursing activities
7. Administer MEDS as ordered:
1.) Osmotic diuretic Mannitol./Osmitrol - promotes cerebral diuresis by decompressing brain tissue
Nursing considerations:
o Monitor BP SE of hypotension
o Monitor I&O every hr. report if < 30cc out put
o Administer via side drip
o Regulate fast drip to prevent formation of crystals or precipitate
2.) Loop diuretic - Lasix (Furosemide)
Nursing Mgt:
o Same as Mannitol except
o Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15
o Immediate effect of Lasix within 15 minutes. Max effect 6 hrs due (7am 1pm)
**S/E of Lasix

1. Hypokalemia (normal K-3.5 5.5 meg/L)


S&Sx
Weakness & fatigue
Constipation
(+) U wave in ECG tracing
Nursing Mgt:
o Administer K supplements ex Kalium Durule, K chloride
o Potassium Rich food:
ABCs of K
Vegetables
Fruits
A - asparagus
A apple
B broccoli (highest)
B banana green
C carrots
C cantalope/ melon
O orange (highest) for digitalis toxicity also.
o
o
o
o

Vit A squash, carrots yellow vegetables & fruits, spinach, chesa


Iron raisins
Food appropriate for toddler spaghetti! Not milk increase bronchial secretions
Dont give grapes may choke

2. Hypocalcemia (Normal level Ca = 8.5 11mg/100ml) or Tetany:


S&Sx
weakness
Paresthesia
(+) Trousseau sign pathognomonic or carpopedal spasm. [Put bp cuff on arm = hand spasm.]
(+) Chevosteks sign - nerve hyperexcitability (tetany) [FACE will contract or twitch kapag haplusin mo]
Arrhythmia
Laryngospasm
Administer Ca gluconate IV slowly
*Ca gluconate toxicity: Sx seizure administer Mg SO4
*Mg SO4 toxcicity administer Ca gluconate
B BP decrease
U urine output decrease
R RR decrease
P patellar reflexes absent
3. Hyponatremia (Normal Na level = 135 145 meg/L)
S/Sx
Hypotension
Signs of Dehydration: dry skin, poor skin turgor, gen body malaise.
Early signs Adult: thirst and agitation / Child: tachycardia
Mgt: force fluid
Administer isotonic fluid solution
4. Hyperglycemia increase blood sugar level
P polyuria
P polyphagia
P polydipsia
Nsg Mgt:
Monitor FBS (N=80 120 mg/dl)

5.) Hyperurecemia increase serum uric acid.

Tophi- urate crystals in joint.


kidney stones- renal colic (pain), cool moist skin
Gouty arthritis - Sx: joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis


a.) Cheese - dairy products may lower your risk. (Not good if pt taking MAOI tyramine may lead to HTN crisis)
b.) Force fluid
c.) Administer meds Allopurinol/ Zyloprim inhibits synthesis of uric acid drug of choice for gout
Colchicene excretes uric acid. Acute gout drug of choice.
d.) Avoid sardines, anchovies, organ meat
**Kidney stones renal colic (pain). Cool moist skin
Mgt:
o Force fluid
o Meds narcotic analgesic
o Morphine SO4
SE of Morphine SO4 toxicity
st
o Respiratory depression (check RR 1 )
o Antidote for morphine SO4 toxicity Narcan (NALOXONE)
o Naloxone toxicity tremors
**BALIK TAYO INCREASE ICP -----------------------------------------------------------------------------------------------------------------Increase ICP meds:
3.) Corticosteroids - Dexamethsone decrease cerebral edema (Decadrone)
4.) Mild analgesic codeine SO4. For headache.
5.) Anti consultants Dilantin (Phenytoin)
Question: Increase ICP what is the immediate nsg action?
Administer Mannitol as ordered --- mannitol kagad basta ordered
Elevate head 30 45 degrees
Restrict fluid
Avoid use of restraints
Question: Pt suffering from epiglotitis. What is nsg priority?
a. Administer steroids least priority
b. Assist in ET n/a
c. Assist in tracheotomy permanent (Answer)
d. Apply warm moist pack? Least priority
Rationale: Wont need to pass larynx due to larynx is inflamed. ET cant pass. Need tracheostomy only
----------------------------------------------------------------------------------------------------------------------------------------------------------Drug Monitoring
Drug
D digoxin
L - lithium
A aminophylline
D Dilantin
A acetaminophen

N range
0.5 1.5 meq/L
0.6 1.2 meq/L
10 19 mg/100ml
10 -19 mg/100 ml
10 30 mg/100ml

Toxicity
2
2
20
20
200

Classification
cardiac glycosides
antimanic
bronchodilator
anticonvulsant
analgesic

Indication
CHF
bipolar
COPD
seizures
osteoarthritis

Digitalis increase cardiac contraction = increase CO // Digitalis toxicity antidote - Digivine


Nursing Mgt
1. Check PR, HR (if HR below 60bpm, dont giveDigoxin)
a.

Anorexia

-initial sx. GIT

b.
c.
d.
e.
f.

nausea/vomiting
Diarrhea
Confusion
Photophobia
Changes in color perception yellow spots
(Ok to give to pts with renal failure. Digoxin is metabolized in liver not in kidney.)

L lithium (lithane) - decrease levels of norepinephrine, serotonine, acetylcholine


a.)
b.)
c.)
d.)

Antimanic agent
S/Sx Anorexia
Diarrhea
Dehydration force fluid, maintain Na intake 4 10g daily
Hypothyroidism
(CRETINISM the only endocrine disorder that can lead to mental retardation)

A Aminophyline (theophylline) dilates bronchioles.


Take bp before giving aminophylline.
S/Sx : Aminophylline toxicity:
1. Tachycardia
2. Hyperactivity restlessness, agitation, tremors

a.
b.

c.

Question: Avoid giving food with Aminophylline


Cheese/butter food rich in tyramine, avoided only if pt is given MAOI
Beer/ wine Hot chocolate & tea caffeine CNS stimulant, can cause tachycardia
Organ meat/ box cereals anti parkinsonian

**MAOI antidepressant // 3 4 weeks - before MAOI will take effect


m AR plan
n AR dil
Avoid tyramine rich foods, can lead to CVA or hypertensive crisis
p AR nate
Anti Parkinsonian agents Vit B6 Pyridoxine reverses effect of Levodopa

D dilatin (Phenytoin) anti convulsant/seizure


Nursing Mgt:
1. Mixed with plain NSS or .9 NaCl to prevent formation of crystals or precipitate
Do sandwich method
Give NSS then Dilantin, then NSS!
2. Instruct the pt to avoid alcohol bec alcohol + dilantin can lead to severe CNS depression
Dilantin toxicity:
S/Sx:
G gingival hyperplasia swollen gums
Oral hygiene soft toothbrush
Massage gums
H hairy tongue
A - ataxia
N nystagmus abnormal movement of eyeballs
A acetaminophen/ Tylenol non-opoid analgesic & antipyretic febrile pts
Acetaminophen toxicity :
Hepato toxicity
Monitor liver enzymes
**SGPT (ALT) Serum Glutamic Piruvate Tyranase

**SGOT- Serum Glutamic Acetate Tyranase


Monitor BUN (10 20)
Creatinine (.8-1)

Acetaminophen toxicity can lead to hypoglycemia


T tremors, Tachycardia
I irritability
R restlessness
E extreme fatigue

D depression (nightmares) , Diaphoresis


Antidote for acetaminophen toxicity Acetylcesteine =
causes outporing of secretions. Suction.
Prepare suctioning apparatus.

------------------------------------------------------------------------------------------------------------------------------PARKINSONS (parkinsonism)

chronic, progressive disease of CNS char by degeneration of dopamine producing cells in substancia nigra at mid brain &
basal ganglia
Function of dopamine: controls gross voluntary motors.
Predisposing Factors:
o Poisoning (lead & carbon monoxide). Antidote for lead = Calcium EDTA
o Hypoxia
o Arteriosclerosis
o Encephalitis
o High doses of the ff:
a. Reserpine (serpasil)
anti HPN, Side Effect 1.) depression 2.) breast cancer
b. Methyldopa (aldomet)
c. Haloperidol (Haldol)- anti psychotic
d. Phenothiazide - anti psychotic
**SE of anti psychotic drugs Extra Pyramidal Symptom
Over meds of anti psychotic drugs neuroleptic malignant syndrome char by tremors (severe)
S/Sx: Parkinsonism
1. Pill rolling tremors of extremities early sign
2. Bradykinesia slow movement
3. Over fatigue
4. Rigidity (cogwheel type)
a. Stooped posture
b. Shuffling most common
c. Propulsive gait
5. Mask like facial expression with decrease blinking eyes
6. Monotone speech
7. Difficulty rising from sitting position
8. Mood labilety always depressed suicide
Nsg priority: Promote safety
9. Increase salivation drooling type
10. Autonomic signs:
Increase sweating
Increase lacrimation iyakin!
Seborrhea (increase sebaceous gland) oily!
Constipation
Decrease sexual activity
**Nsg Mgt:
1. Anti parkinsonian agents
Levodopa (L-Dopa) short acting
Carbidopa (Sinemet) long acting
Amantadine Hcl (Symmetrel) eto hindi ko alam haha
Mechanism of action
Increase levels of dopa relieving tremors & bradykinesia
*S/E of anti parkinsonian
o Anorexia
o n/v
*Contraindication:
o Narrow angled closure glaucoma

o
o

Confusion
Orthostatic hypotension
o

o
o

Hallucination
Arrhythmia

Pt taking MAOI (Parnate, Marplan, Nardil)

*Nsg Mgt when giving anti-parkinsonian:


Take with meals to decrease GIT irritation
Inform pt urine/ stool may be darkened
Instruct pt- dont take food Vit B6 (Pyridoxine) cereals, organ meats, green leafy veg
Cause B6 reverses therapeutic effects of levodopa
Give INH (Isoniazide-Isonicotene acid hydrazide.) SE-Peripheral neuritis.
2. Anti cholinergic agents relieves tremors
o Artane
o Cogentin
3. Antihistamine Diphenhydramine Hcl (Benadryl)
S/E:
Adult drowsiness, avoid driving & operating heavy equipt. Take at bedtime.
Child hyperactivity CNS excitement for kids.
4. Dopamine agonist
Bromotriptine Hcl (Parlodel) respiratory depression. Monitor RR.
**Nsg Mgt Parkinson
1.)
Maintain siderails
2.)
Prevent complications of immobility
o Turn pt every 2h
o Turn pt every 1 h elderly
3.)
Assist in passive ROM exercises to prevent contractures
4.)
Maintain good nutrition
CHON (protein) in am
CHON (protein) in pm to induce sleep due Tryptopan Amino Acid
5.)
Increase fluid in take, high fiber diet to prevent constipation
6.)
Assist in surgery Sterotaxic Thalamotomy
Complications in sterotaxic thalmotomy- 1.) Subarachnoid hemorrhage 2.) aneurism 3.) encephalitis
----------------------------------------------------------------------------------------------------------------------------------------------------------------

MULTIPLE SCLEROSIS (MS) - myelin sheath


Chronic intermittent disorder of CNS white patches of demyelenation in brain & spinal cord.
Remission & exacerbation
Common women, 15 35 yo
cause unknown
Predisposing factor:
1. Slow growing virus
2. Autoimmune (supportive & palliative treatment only)
*Normal Resident Antibodies:
Ig G can pass placenta passive immunity. Short acting.
Ig A body secretions saliva, tears, colostrums, sweat
Ig M acute inflammation
Ig E allergic reactions
IgD chronic inflammation
**S & Sx of MS: (everything down)
1. Visual disturbances
a. Blurring of vision
b. Diplopia/ double vision
c. Scotomas (blind spots) initial sx
2. Impaired sensation to touch, pain, pressure, heat, cold
a. Numbness
c. Paresthesia tingling sensation
3. Mood swings euphoria (sense of elation )
4. Impaired motor function:

a. Weakness
b. Spasiticity tigas
c. Paralysis major problem
5. Impaired cerebellar function
Triad Sx of MS aka (Charcots triad)
I intentional tremors
N nystagmus abnormal rotation of eyes
A Ataxia & Scanning speech
6. Urinary retention or incontinence
7. Constipation

10

8. Decrease sexual ability


**Dx MS
1. CSF analysis thru lumbar puncture
- Reveals increase CHON & IgG
2. MRI reveals site & extent of demyelination
3. Lhermittes response is (+). Introduce electricity at the back. Theres spasm & paralysis at spinal cord.
Nsg Mgt MS
Supportive mgt
1.) Meds
a. Acute exacerbation
ACTH adenocorticotopic
Steroids to reduce edema at the site of demyelination to prevent paralysis
2. Maintain siderails
3. Assist passive ROMexercises promote proper body alignment
4. Prevent complications of immobility
5. Encourage fluid intake & increase fiber diet to prevent constipation
6. Provide catheterization die urinary retention
7. Give diuretics
Urinary incontinence give Prophantheline bromide (probanthene)
Antispasmodic anti cholinergic
8. Give stress reducing activity. Deep breathing exercises, biofeedback, yoga techniques.
9. Provide acid-ash diet to acidify urine & prevent bacteria multiplication
Ex. Grape, Cranberry, Orange juice, Vit C
-------------------------------------------------------------------------------------------------------------------------------------------------------------------

MYASTHENIA GRAVIS (MG)


disturbance in transmission of impulses from nerve to muscle cell at neuro muscular junction.
Common in Women, 20 40 yo, unknown cause or idiopathic
Autoimmune release of cholenesterase enzyme [REMEMBER! Lumabas sa boards yan.]
Cholinesterase destroys ACH (acetylcholine) = Decrease acetylcholine
Descending muscle weakness
Nsg priority:
o a/w
o aspiration
o immobility
S/ Sx:

Ptosis drooping of upper lid of the eye ( initial sign)


Check Palpebral fissure opening of upper & lower lids = to know if (+) of MG.
Diplopia double vision
Mask like facial expression
Dysphagia risk for aspiration!!!
Weakening of laryngeal muscles hoarseness of voice
Resp muscle weakness leads to respiratory arrest. [Prepare at bedside tracheostomy set]
Extreme muscle weakness during activity especially in the morning.

Dx test
Tensilon test (Edrophonium Hcl) temporarily strengthens muscles for 5 10 mins. Short term- cholinergic. PNS effect.
o Remember ung aso sa video dati, ung biglang lumakas meaning nun (+) sya for MG
Nsg Mgt
1. Maintain patent a/w & adequate vent by:
3. Siderails
*Assist in mechanical vent attach to ventilator
4. Prevent complications of immobility.
*Monitor pulmonary function test.
Adult - every 2 hrs.
//
Elderly - every 1 hr.
= kasi decreased vital lung capacity ung pt.
5. NGT feeding
2. Monitor VS, I&O neuro check, muscle strength or motor
grading scale (4/5, 5/5, etc)

11

**Administer meds
Cholinergics or anticholinesterase agents
Mestinon (Pyridostigmine)
Neostignine (prostigmin) Long term
Increase acetylcholine
Corticosteroids to suppress immune response
o Ex. Decadron (dexamethasone)
**Monitor for 2 types of Crisis:
Myastinic Crisis
Cause 1. Under medication
2. Stress
3. Infection
S/S
1. Unable to see Ptosis & diplopia
2. Dysphagia- unable to swallow.
3. Unable to breath

Cholinergic crisis
Cause: 1 over meds
S/Sx - PNS

Mgt. - adm anti-cholinergic


Atropine SO4

Mgt administer cholinergic agents


7. Assist in surgical proc thymectomy - Removal of thymus gland. [Thymus secretes auto immune antibody.]
8. Assist in plasmaparesis filter blood
9. Prevent complication respiratory arrest [Prepare tracheostomy set at bedside.]

-----------------------------------------------------------------------------------------------------------------------------------------------GBS Guillain Barre Syndrome aka Acute inflammatory demyelinating polyneuropathy (AIDP)
Disorder of CNS
Bilateral symmetrical polyneuritis
Ascending paralysis
Cause unknown, idiopathic
Auto immune
r/t antecedent viral infection
Immunizations
**S&Sx
Initial :
1.
2.
3.
4.
5.
6.

Clumsiness
Ascending muscle weakness lead to paralysis
Dysphagia
Decrease or diminished DTR (deep tendon reflexes)
Paralysis
Alternate HPN to hypotension lead to arrhythmia - complication
Autonomic changes
increase sweating, increase salivation.
Increase lacrimation

Dx most important: CSF analysis - thru lumbar puncture reveals increase in : IgG & CHON (same with MS)
Nsg Mgt
1. Maintain patent a/w & adequate vent
a. Assist in mechanical vent
b. Monitor pulmonary function test
2. Monitor vs., I&O neuro check, ECG tracing due to arrhythmia
3. Siderails
4. Prevent compl immobility
5. Assist in passive ROM exercises
6. Institute NGT feeding due dysphagia

12

7. Adm meds (GBS) as ordered:


Anti cholinergic atropine SO4
Corticosteroids to suppress immune response
Anti arrhythmic agents
o Lidocaine /Xylocaine SE confusion = VTach
o Bretyllium
o Quinines/Quinidine anti malarial agent. Give with meals. // Toxic effect cinchonism
8. Assist in plasmaparesis (MG. GBS)
9. Prevent comp arrhythmias, respiratory arrest [Prepare tracheostomy set at bedside.]
------------------------------------------------------------------------------------------------------------------------------------------------------------------Meninges 3-fold membrane cover brain & spinal cord
Functions:
Protection & support
Nourishment
Blood supply
**3 layers:
1. Duramater
sub dural space
2. Arachmoid matter
3. Pia matter
sub arachnoid space
where CSF flows L3 & L4. [Site for lumbar puncture.]

MENINGITIS inflammation of meningitis & spinal cord


Etiology Meningococcus
Pneumococcus
Hemophilous influenza child
Streptococcus adult meningitis
Transmission direct transmission via droplet nuclei
S/S:
Stiff neck or nuchal rigidity (initial sign)
Headache
Projectile vomiting due to increase ICP
Photophobia
Fever chills, anorexia
Gen body malaise
Wt loss
Decorticate/decerebration abnormal posturing
Possible seizure
**Signs of meningeal irritation nuchal rigidity or stiffness
Opisthotonus- rigid arching of back
Pathognomonic sign (+) Kernigs [leg pain] & Brudzinski sign [neck pain]
Dx:
1. Lumbar puncture lumbar/ spinal tap use of hallow spinal needle sub arachnoid space L3 & L4 or L4 & L5
**Nsg Mgt for lumbar puncture invasive
1. Consent / explain procedure to pt
o RN diagnostic procedure (lab)
o MD operation procedure
2. Empty bladder, bowel promote comfort
3. Arch back to clearly visualize L3, L4 *sims, shrimp position+
**Nsg Ngt post lumbar
1. Flat on bed 12 24 h to prevent spinal headache & leak of CSF
2. Force fluid
3. Check punctured site for drainage, discoloration & leakage to tissue

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4.

Assess for movement & sensation of extremeties

Result
1. CSF analysis:

a. increase CHON & WBC


b. Decrease glucose
Confirms meningitis c. increase CSF opening pressure
N 50 160 mmHg
d. (+) Culture microorganism
2. Complete blood count CBC reveals increase WBC

Content of CSF: CHON, WBC, Glucose

Management:
1. Adm meds
a.) Broad-spectrum antibiotic penicillin
**Side effects:
1. GIT irritation take with food
2. Hepatotoxicity, nephrotoxcicity
3. Allergic reaction
4. Super infection alteration in normal bacterial flora
Normal flora sa throat streptococcus
Normal flora sa intestine e coli
**Sign of superinfection of penicillin = diarrhea
b.) Antipyretic
c.) Mild analgesic
2. Strict respiratory isolation 24h after start of antibiotic therapy
**Side note:
A Cushings synd reverse isolation - due to increased corticosteroid in body.
B Aplastic anemia reverse isolation - due to bone marrow depression.
C Cancer any type reverse isolation immunocompromised.
D Post liver transplant reverse isolation takes steroids lifetime.
E Prolonged use steroids reverse isolation
F Meningitis strict respiratory isolation safe after 24h of antibiotic therapy
G Asthma not to be isolated
3.
4.
5.
6.
7.

Comfy & dark room due to photophobia & seizure


Prevent complications of immobility
Maintain F & E balance
Monitor vs, I&O, neuro check
Provide client health teaching & discharge plan
a. Nutrition increase cal & CHO, CHON-for tissue repair. Small freq feeding
b. Prevent complication hydrocephalus, hearing loss or nerve deafness.
8. Prevent seizure.
Where to bring 2 y/o post meningitis
Audiologist - due to damage to hearing- post repair myelomeningocele
Urologist -Damage to sacral area spina bifida controls urination
9. Rehab for neurological deficit. [Can lead to mental retardation or a delay in psychomotor development.]
-------------------------------------------------------------------------------------------------------------------------------------------------------------------

CEREBRO VASCULAR ACCIDENT stroke, brain attack or cerebral thrombosis, apoplexy


Partial or complete disruption in the brains blood supply
2 largest & common artery in stroke
Middle cerebral artery
Internal carotid artery
Common to male 2 3x high risk

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Predisposing factor:
1. Thrombosis clot (attached) [stationary]
2. Embolism dislodged clot pulmo embolism [circulating]
S/Sx: pulmo embolism
Sudden sharp chest pain
Unexplained dyspnea, SOB
Tachycardia, palpitations, diaphoresis & mild restlessness
S/Sx: cerebral embolism
Headache, disorientation, confusion & decrease in LOC
[Femur fracture complications: fat embolism most feared complication w/in 24hrs]
Yellow bone marrow produces fat cells at meduallary cavity of long bone
Red bone marrow provides WBC, platelets, RBC found at epiphisis
3.) Hemorrhage
4.) Compartment syndrome compression of nerves/ arteries
**Risk factors of CVA:
HPN
DM
MI
artherosclerosis
**Lifestyle:

valvular heart dse


Post heart surgery
mitral valve replacement

1. Smoking nicotine potent vasoconstrictor


2. Sedentary lifestyle
3. Hyperlipidemia genetic
4. Prolonged use of oral contraceptives
- Macro pill has large amount of estrogen
- Mini pill has large amt of progestin
- Promote lipolysis (breakdown of lipids/fats) artherosclerosis HPN - stroke
5. Type A personality [punong Abala! gusto laging busy]
a. Deadline driven person
b. 2 5 things at the same time
c. Guilty when not dong anything
6. Diet increase saturated fats
7. Emotional & physical stress
8. Obesity

S /S:
1. TIA- [Transient inschemic attack] - warning signs of impending stroke attacks
Headache (initial sx)
dizziness/ vertigo, numbness, tinnitus, visual & speech disturbances, paresis or plegia (monoplegia 1 extreme)
Increase ICP
2. Stroke in evolution progression of S & Sx of stroke
3. Complete stroke resolution of stroke
a.) Headache
b.) Cheyne-Stokes Resp - progressively deeper and sometimes faster breathing, followed by a gradual decrease**
c.) Anorexia, n/v
d.) Dysphagia
e.) Increase BP
f.) (+) Kernigs & Brudzinski sx of hemorrhagic stroke
g.) Focal & neurological deficit
1. Phlegia
2. Dysarthria inability to vocalize, articulate words hirap magsalita! D:
3. Aphasia
4. Agraphia difficulty writing
5. Alesia difficulty reading
6. Homoninous hemianopsia loss of half of field of vision half bulag! ._o
**Ex. Left sided hemianopsia approach Right side of pt the unaffected side - [always approach unaffected side]

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Dx:
1.
2.

CT Scan reveals brain lesion


Cerebral arteriography site & extent of mal occlusion
Invasive procedure due to inject dye
Allergy test
**REMEMBER!!! -- All graphy = invasive due to iodine dye- [lahat ng GRAPHY = invasive!]
**Post [after]
1.) Force fluid to excrete dye is nephrotoxic
2.) Check peripheral pulses - distal
**Nsg Mgt:
1. Maintain patent a/w & adequate vent
- Assist mechanical ventilation
- Administer O2
2. Restrict fluids prevent cerebral edema
3. Elevate head of bed 30-45 degrees angle. Avoid valsalva maneuver.
4. Monitor vs., I&O, neuro check
5. Prevent compl of immobility by:
a. Turn client q2h
Elderly q1h
To prevent decubitus ulcer
To prevent hypostatic pneumonia after prolonged immobility.
b. Egg crate mattress or H2O bed
c. Sand bag or foot board- prevent foot drop
6. NGT feeding if pt cant swallow
7. Passive ROM exercise q4h
8. Alternative means of communication
- Non-verbal cues
- Magic slate. Not paper and pen. Tiring for pt.
- (+) To hemianopsia approach on unaffected side
9. Meds
o Osmotic diuretics Mannitol
o Loop diuretics Lasix/ Furosemide
o Corticosteroids dextamethazone
o Mild analgesic
o Thrombolytic/ fibrolitic agents tunaw clot. SE-Urticaria, pruritus-caused by foreign subs.
Streptokinase
Urokinase
Tissue plasminogen activating
o Monitor bleeding time
o Anticoagulants Heparin & Coumadin sabay
Coumadin will take effect after 3 days
o Heparin monitor PTT partial thromboplastin time if prolonged bleeding give Protamine SO4- antidote.
o Coumadin Long term. monitor PT prothrombin time if prolonged- bleeding give Vit K Aquamephyton- antidote.
o Antiplatelet PASA aspirin paraanemo aspirin, dont give to dengue, ulcer, and unknown headache.
Health Teaching
1. Avoidance modifiable lifestyle - Diet, smoking
2. Dietary modification - Avoid caffeine, decrease Na & saturated fats
Complications:
Subarachnoid hemorrhage
Rehab for focal neurological deficit physical therapy
1. Mental retardation
2. Delay in psychomotor development

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