NERVOUS SYSTEM PNS – Parasympathomimetic Agents: mimics PNS

CHOLINERGIC AGENTS
OVERVIEW OF THE FUNCTIONS & STRUCTURE OF THE ▪ Edrophonium HCL (tensilon)
NERVOUS SYSTEM ➢ Short acting cholinergic agents used to diagnose MG
I. BASED ON ANATOMICALLY ➢ Effects is within 5-10mins
a. Central Nervous System (CNS) ▪ Mestinon (Pyridostigmine)
▪ Brain – weighs 3lbs or 2% of the total body weight ➢ Long acting cholinergic agents given to patient with MG
➢ Cerebrum (largest) ➢ Mestinon toxicity – could lead to aspiration – antidote:
➢ Cerebellum (smallest) ATSO4
➢ Medulla Oblongata (lowest) – prone to hernia o Antidote for ATSO4 toxicity: Pyrostigmine Salicylate
▪ Spinal Cord – letter H shaped structure (antilirium)
b. Peripheral Nervous System (PNS) ▪ Bethanecol Chloride (Urecholine)
▪ Cranial nerves – 12 pairs ➢ This is given to pt. with retention Tunnel like vision or
➢ Given SQ loss of peripheral
▪ Miotics vision
➢ constrict the pupil vision
➢ given to pt with glaucoma (increase IOP)
➢ normal IOP: 12-21mmHg
➢ example: Pilocarpine Na, Carbachol

DIFFERENT NEUROLOGICAL DISORDER

1. Neuromuscular Disorder
a. MYASTHENIA GRAVIS (MG)
➢ Chronic neuromuscular disorder characterized by a
▪ Spinal Nerve – 31 pairs
disturbance in the transmission of impulses from nerve to
➢ Cervical – 8
muscle cells at the neuromuscular junction leading to
➢ Thoracic – 12
DESCENDING MUSCLE WEAKNESS
➢ Lumbar – 5
➢ Characterized by REMISSIONS AND EXACERBATION
➢ Sacral – 5
➢ Coccyx – 1 MYASTHENIA GRAVIS (MG)
▪ INCIDENCE RATE:
II. BASED ON PHYSIOLOGICALLY ➢ Common among women 20-40 y/o
a. Somatic Nervous System
➢ Controls voluntary muscle (skeletal muscle) ▪ PREDISPOSING FACTORS:
b. Autonomic Nervous System ➢ Idiopathic
➢ Controls involuntary movement ➢ Autoimmune (produce antibodies that affects the voluntary
1. Sympathetic Nervous System (SNS) muscles of the:
➢ Involves during fight or flight response o Eyes
(adrenergic response) o Face
➢ Stress response o Throat
➢ Release norepinephrine o Respiratory
➢ Increase bodily activities except o Including the arms and legs
GUT/GIT
❖ EFFECTS OF SNS ▪ PATHOPHYSIOLOGY
• Mydriasis (dilation of pupils)
• Dry mouth
• HPN
• Tachycardia
• Tachypnea
• Constipation
• Urine retention

ANTI-CHOLINERGIC DRUGS/ADRENERGIC
▪ Epinephrine (adrenaline) – given to pt. experiencing
anaphylactic shock
▪ Atropine sulfate
▪ Norepinephrine (levophed)
▪ Dopamine (intropin)

2. Parasympathetic Nervous System (PNS)

▪ SIGNS AND SYMPTOMS
➢ Involves in rest & digest
➢ Ptosis (drooping of upper eyelid)
➢ Release of acetylcholine
➢ Diplopia (double vision)
➢ Decreases all bodily activities except
➢ Mask like facial expression
GUT/GIT
➢ Dysphagia
❖ EFFECTS OF PNS
➢ Hoarseness of voice "dysphonia": voice impairment
• Meiosis (constriction of pupils)
➢ Respiratory muscle weakness that may lead to respiratory
• Moist mouth
arrest
• Hypotension
➢ Extreme muscle weakness
• Bronchoconstriction (Bradypnea)
Bradycardia ▪ NURSING PRIORITY/DIAGNOSIS
• Diarrhea ➢ Airway
• Urinary frequency ➢ Aspiration
➢ Immobility
➢ Safety
▪ NURSING MANAGEMENT DEMYELINATING DISORDERS
❖ Maintain patent airway and adequate ventilation by: ▪ NEURONS/NERVE CELLS – basic unit of the nervous system
➢ Assist in mechanical ventilation
Myelin sheath in the CNS - produced by
➢ Monitor pulmonary function test by using incentive
OLIGODENDROCYTES (Multiple
spirometer
COVERED BY Sclerosis)
❖ Monitor VS, IO, neuro check and motor grading scale
❖ Maintain padded rails MYELIN SHEATH –
acts as insulator thereby Myelin sheath in the PNS –
❖ Institute NGT feeding via gastric gavage to prevent aspiration
facilitating nerve impulse produced by SCHWANN CELLS
❖ Prevent complication of immobility by turning client to sides every
transmission (Gullain-Barre Syndrome)
2 hours.
❖ Administer meds as ordered: 1. MULTIPLE SCLEROSIS (Disseminated Sclerosis or
➢ Corticosteroids: Ex. Dexamethasone – to suppress immune Encephalomyelitis Disseminata)
response 2. GULLAIN-BARRE SYNDROME
➢ Cholinergic/anti-cholinesterase agents:
MULTIPLE SCLEROSIS (MS)
o Mestinon (pyridostigmine) – best given 30mins to 1 hr
❖ Chronic, intermittent disorder of the CNS characterized by white
before meals (peak)
patches of demyelination in the brain and spinal cord.
o Neostigmine (prostigmine)
❖ Characterized by REMISSION AND EXACERBATION.
o SE: PNS
❖ NO CURE!!!
o Too much intake of Mestinon → Mestinon Toxicity →
Antidote: ATSO4 → If too much ATSO4 is given →
A. INCIDENCE RATE
Antidote: Pysostigmine Salicylate
➢ Common among women 15-35 y/o (occurs in more temperate
o Assist in surgical procedure: THYMECTOMY
climates)
o Assists in Plasmapheresis (filtering of blood to remove
the antibodies that attacks the receptor sites) with IV
B. PREDISPOSING FACTORS
immunoglobulins
➢ Idiopathic
o Monitor 2 types of crisis:
➢ Slow growing viruses: EPSTEINN BARR VIRUS
• MYASTHENIC CRISIS ➢ Auto immune → produce IgG that destroys oligodendrocytes →
• CHOLINERGIC CRISIS decrease production of myelin sheath
MYASTHENIC CRISIS CHOLINERGIC CRISIS
SIGNS AND SYMPTOMS
➢ CAUSES: ➢ CAUSES:
▪ Undermedication ▪ Overmedication • Visual disturbances (early sign)
▪ Stress ➢ Blurring of vision
▪ Infection ➢ Diplopia
➢ SIGNS AND SYMPTOMS: ➢ SIGNS AND SYMPTOMS: ➢ Seeing scotomas or blind spot or partial loss of vision (optic
▪ Unable to see, swallow, ▪ PNS neuritis)
speak and breathe
• Impaired sensation to touch, pain, pressure, heat and cold
➢ TREATMENT ➢ TREATMENT
▪ Administer cholinergic ▪ Administer anti- ➢ Tingling sensation
agents: MESTINON, cholinergic agent: ➢ Paresthesia
NEOSTIGMINE ATSO4 ➢ Numbness
• UHTOFF'S SIGN/PHENOMENON
▪ DIAGNOSTIC PROCEDURE ➢ Heat worsens the signs and symptoms of MS like hot bath/hot
➢ Edrophonium HCL (tensilon) test meal/exercise
✓ Short acting cholinergic agent • Mood swings
✓ IV, provide temporary relief for about. 5-10mins ➢ euphoria
✓ Also used to differentiate myasthenic from cholinergic • Impaired motor activity
crisis ➢ Weakness
➢ CSF Analysis: reveals increase in cholinesterase levels ➢ Spasticity
if all treatments failed or the patient doesn't respond to ➢ paralysis
treatment, administer meds as ordered: • Impaired cerebellar function
▪ Monoclonal antibody ➢ Scanning/stacatto speech
o EX. Rituximab (rituxan), uculuzumab (soliris) ➢ Intentional tremors
o Given IV but poses serious ➢ Nystagmus with or without ataxia (unsteady gait)
o SE: BLOOD DYSCRASIAS: PANCYTOPENIA ➢ OR KNOWN AS CHARCOT'S TRIAD
(anemia/leukopenia/thrombocytopenia) • Urinary retention
• Constipation
• Impaired cognition
• Decreased in sexual capacity
• (+) LHERMITTE'S SIGNS/ BARBER CHAIR'S
PHENOMENON: (+) feeling of electrical shock sensation upon
flexion of the neck

C. COMPLICATIONS
• RESPIRATORY DYSFUNCTION
• INFECTIONS OF THE
➢ Bladder
➢ Respiratory: hypostatic pneumonia
➢ sepsis
• IMMOBILITY
➢ Decubitus ulcer
▪ Stage 1: erythema/redness
▪ Stage 2: affected dermis (blister)
▪ Stage 3: full thickness skin breakdown (crater)
▪ Stage 4: bones, muscles and deeper underlying
supporting structures are affected (eschar-darkened
necrotic tissue)
• SPEECH VOICE AND LANGUAGE DISORDER
➢ Dysarthria

D. DIAGNOSTIC PROCEDURES
• CSF analysis: through lumbar puncture – reveals increase IgG &
CHON (oligoclonal bands) → confirms presence of MS
➢ Lumbar puncture/Spinal tap: a hollow spinal needle is inserted
into the subarachnoid space between L3-L4 or L4-L5 (site of
cauda equina or lumbar enlargement)
➢ Apply brief pressure at the punctured site to prevent bleeding
 B. PREDISPOSING FACTORS
➢ Place client on supine position for 12-24 hours to prevent: • Idiopathic
o Spinal headache • Autoimmune → the body produces antibodies IgG that attacks
o CSF leakage Schwann cells that produces myelin sheath in the PNS
➢ Force fluids • Antecedent viral infection:
➢ Monitor/assess/check for the movement and sensation Ex. Upper and lower respiratory tract infection
extremities ➢ GIT infection caused by CAMPYLOBACTER
• Magnetic Resonance Imaging (MRI) JEJUNI infection (40-60% among americans)
➢ Reveals the site and extent of demyelination ➢ HIV infection
➢ Before MRI, remove metal clips and hairpins ➢ Epsteinn Barr Virus
➢ Ask the client is he has fear of close spaces (claustrophobia) if • IMMUNIZATION that can caused GBS
head or cervical MRI Usually takes 30 mins per site ➢ Swine flu vaccine
➢ Influenza vaccine
E. NURSING PRIORITY/DIAGNOSIS ➢ J&J
• Safety (vision/coordination/decrease perception)
• Bladder and bowel problems C. SIGNS AND SYMPTOMS
• RRMS prevention - remitting relapsing MS • Clumsiness (early sign)
• Dysphagia
F. NURSING MANAGEMENT • Ascending muscle paralysis
• Administer meds as ordered • Decrease deep tendon reflexes (DTR's)
➢ ACUTE EXACERBATION • Alternate hypotension to hypertension & vice versa (could
▪ ACTH (adrenocorticotropic hormone) or lead to arrhythmia)
Corticosteroids • Autonomic changes:
o To reduce edema or swelling at the site of ➢ Increase salivation
demyelination thereby preventing paralysis ➢ Increase sweating
o Given for relapses of MS symptoms ➢ constipation
▪ Beta-interferons
o Given to alter immune response D. DIAGNOSTIC PROCEDURE
o Given to reduce relapses of MS • CSF Analysis thru lumbar puncture
o SE: decrease WBC (leukopenia) prone to develop ➢ reveals increase IgG and protein (CHON)
infection
• Electromyelography & Nerve conduction studies: assess
o EX: Avonex, Rebif, Betaferon (interferons) for demyelination of nerves by determining the muscle ability
to respond to nerve stimulation
➢ FOR BLADDER
▪ Cholinergic agents:
E. NURSING PRIORITY/ DIAGNOSIS
o Bethanecol chloride (urecholine)
• Airway → ineffective breathing pattern
✓ Given SQ
• Immobility
✓ SE: bronchospasm and wheezing
• Safety
✓ Monitor for breath sounds 1 hr after SQ
• Bladder and bowel problems
administration
o Oxybutinin (Ditropan) • Aspiration
✓ Reduces muscle spams of the bladder • Diet/nutrition
• Maintain patent airway and adequate ventilation by:
➢ FOR FATIGUE/WEAKNESS ➢ Assist in mechanical ventilation
▪ Amantadine HCL (anti-viral & anti-parkinsonian) ➢ Monitor pulmonary function test by using incentive
o CNS effect helps improve fatigue spirometer
▪ Modafinil (Provigil) • Maintain padded rails
o CNS stimulant • Prevent complications of immobility
o Last for 10-12hours • Institute NGT feeding via gastric gavage to prevent aspiration
o Drug of choice for excessive sleepiness/narcolepsy • Administer meds as ordered:
➢ Corticosteroids: "SONE" to suppress immune response
➢ FOR MUSCLE SPASTICITY ➢ Anti-cholinergic: Atropine Sulfate
▪ Baclofen (lioresal) or Dantrolene Na (Dantrene) ➢ Anti-arrhythmic agents:
o Acts as muscle relaxant ▪ Lidocaine (xylocaine) – blocks release of
▪ Diazepam (valium) norepinephrine
▪ Amiodarone
➢ FOR TREMORS ▪ Bretylium – blocks release of norepinephrine SE:
▪ Beta-blockers HYPOTENSION
o Propanolol (Inderal) ▪ Quinidines – anti malarial agents
▪ INH (Isoniazid) or Isonicotinic acid hydrazide ➢ Immunoglobulin therapy: IV immunoglobulin from donor
• Provide relaxation techniques such as: given to the patient to stop the antibodies that are damaging
➢ DBE the nerves particularly the peripheral nerves.
➢ Yoga • Assist in plasmapheresis
• Maintain padded rails • Prevent complications
• Prevent complications of immobility ➢ Respiratory arrest
• Avoid heat application ▪ Prepare at bedside either tracheostomy and endotracheal
• Provide catheterization set
• Encourage increase oral fluid-intake, high fiber diet and provide ➢ Arrhythmia
acid ash to acidify urine to prevent bacterial multiplication ▪ Prepare at bedside cardiac monitor/holter ecg
➢ Ex: Grapes ➢ Thrombophlebitis/DVT
➢ Cranberry ➢ Decubitus ulcer
➢ Prune ➢ Hypostatic pneumonia
➢ Plum ➢ Paralytic ileus

GULLAIN BARRE SYNDROME (GBS) DEGENERATIVE DISORDER

▪ Disorder of PNS
▪ Characterized by bilateral, symmetrical polyneuritis PARKINSON'S DISEASE
(inflammation of peripheral nerves both cranial and spinal) leading ▪ Shaking palsy
to ascending muscle paralysis. ▪ Hypokinetic rigid synd rome
▪ Also called as INFECTIOUS POLYNEURITIS ▪ Paralysis agitans
▪ G (gradual) B (block) S (sensation) ▪ Disorder of the CNS characterized by DEGENERATION OF
▪ NO CURE!!! DOPAMINE producing cells in the substantia nigra of the midbrain
and basal ganglia
A. INCIDENCE RATE ▪ IRREVERSIBLE
• Common among men 30 above ▪ NO CURE!!
▪ Decrease Dopamine, Acetylcholine will predominate. Also with
Norepinephrine loss thus the postural hypotension
A. PREDISPOSING FACTORS o MOA: inhibits the action of ACH
• Idiopathic o SE: SNS > DRY MOUTH
• Poisoning ▪ MAO Inhibitors TYPE B-decreases the breakdown of
➢ Lead dopamine
➢ Carbon monoxide ➢ Indication: relieves tremors
• Arteriosclerosis ➢ Rasagiline (Azilect)/ Eldepryl
• Hypoxia ➢ NURSING CARE:
• Encephalitis o Instruct the client to avoid taking foods rich in
• Frequent head injury (boxing) tyramine such as
❖ Aged cheese, draft beer, fermented
• High doses of the ff. drugs:
➢ Reserpine (Serpasil) foods/cabbage, chocolate, red wine,
➢ Methyldopa (Aldomet) smoke/cured foods → could lead to
➢ Haloperidol (Haldol) hypertensive crisis/stroke
➢ Phenothiazines • Maintain padded rails
• Prevent complications of immobility
B. SIGNS AND SYMPTOMS • Diet → (may need soft or thickened foods)
▪ Pill rolling tremors (EARLY SIGN) ➢ Dietary Intake of low CHON in AM and high CHON in PM
▪ Tremors at rest (most common) hands, arms, legs, lip and to induce sleep (tryptophan-amino acid)
tongue ➢ Increase intake of magnesium (seafoods, salmon, sardines)
▪ Bradykinesia • Assist in ambulation
▪ Rigidity (COGWHEEL TYPE) • Provide safety precaution
➢ Stooped posture ➢ Low heels
➢ Shuffling and propulsive gait ➢ Grab bars
▪ Over fatigue ➢ Walker
▪ Mask like facial expression with decrease blinking of the • Encourage increase in oral fluid intake, high in the diet (add BRAN
eyes (FLAT AFFECT) and Psyllium)
▪ Difficulty in rising from sitting position ➢ Metamucil (Psyllium) – bulk forming laxative
▪ Monotone speech • Assist in surgical procedure
▪ Drooling of saliva – due to the decrease ability to swallow ➢ Stereotaxic thalamotomy – a portion of the thalamus is
excised to relieved tremors
C. SIGNS AND SYMPTOMS • Complications:
▪ Autonomic changes o S-subarachnoid hemorrhage
➢ Increase sweating and lacrimation o E-encephalitis
➢ Seborrhea (oily skin) Constipation o A-aneurysm
➢ Decreased sexual capacity
▪ Mood lability (depression) CEREBRAL PERFUSION PRESSURE (CPP)
• Normal = 60 – 100mmHg
D. STAGES • It is the pressure that pushes the blood to the brain hence the CPP is
• Unilateral flexion of the upper extremity influence by cerebral blood flow
• Shuffling gait • FINDINGS:
• Progressive difficulty in ambulating ➢ Hyperperfusion = >100mmHg
• Progressive weakness ➢ Hypoperfusion = 40-60mmHg
• Disability ➢ Brain death = 0-40mmHg
➢ If the CPP is <50mmHg → irreversible neurological deficit
E. NURSING PRIORITY/DIAGNOSIS
• Airway clearance (ineffective)
• Thought process (altered)
• Communication (impaired)
• Physical mobility (impaired)
• Safety
• Aspiration
• Nutrition and diet

F. NURSING MANAGEMENT
CPP COMPUTATION EXAMPLE:
• Administer meds as ordered:
▪ Anti-parkinsonian agents
➢ Carbidopa/levodopa (sinemet) – Used as disease
progresses "Wearing off" phenomemenon
o MOA: increases levels of dopamine
o Carbidopa prevents levodopa from breaking down into blood
and turn this into dopamine.
o SE: GIT irritation, orthostatic hypotension, confusion,
hallucination, arrhythmia
o CONTRAINDICATED: glaucoma → could lead to increase
lOP and clients taking MAOI → could lead to stroke
o NURSING ALERT: best given with meals to lessen GIT
irritation
INCREASE INTRACRANIAL PRESSURE
✓ inform client that his urine and stool may be darkened
▪ NORMAL ICP = 0-15mmHg
✓ instruct the client to avoid taking foods high in VIT. B6
▪ Composition of the Brain and Spinal Cord (CNS)
(pyridoxine)
➢ 80% - Brain mass → Head Injury
• Administer meds as ordered ➢ 10% - CSF → Hydrocephalus
▪ Dopamine agonist-mimics the actions of dopamine ➢ 10% - Blood → Stroke
➢ Bromocriptine HCL (parlodel)
➢ Requipp (Ropinerole)
o INDICATION: decrease tremors/rigidity and
bradykinesia ICP DEVICE IS
o SE: Drowsiness, respiratory depression, nausea, USUALY
hallucination, postural hypotension CONNECTED
▪ Anti-histamine EITHER IN THE
➢ Diphenhydramine HCL (Benadryl) LATERAL
INDICATION: relieves tremors VENTRICLES OR
SE: Adult – drowsiness, children – hyperactivity SUBACHNOID
▪ Anti-cholinergic agents SPACE
➢ Benztropine (Cogentin)
➢ Artane
o Indication: relieves tremors
MONROE-KELLIE HYPOTHESIS ➢ Abnormal doll's eye (oculocephalic reflex) – indicates damage to brain
▪ It states that the skull is a closed container therefore any alteration stem; tested or elicited among unconscious client
or increase in one of the intracranial components could lead to
increase ICP C. NURSING PRIORITY/DIAGNOSIS
• Cerebral perfusion
• Airway
• Safety
• Nutrition/metabolic needs

D. NURSING MANAGEMENT
• Maintain patent airway & adequate ventilation by:
➢ Prevention of hypoxia & hypercarbia
➢ Assists in mechanical ventilation → it promotes
constriction of cerebral veins thereby decreasing
ICP
➢ Before and after suctioning, hyperventilate the
client 100% of oxygen to "blow off" CO2(CO2
dilates the blood vessels). Suction patient 10-
15seconds
• Place client of semi-fowlers/elevate head of bed of client
30-45 degree angle with neck in neutral position unless
contraindicated to promote venous drainage
• Limit fluid intake (1200-1500ml/day)
• Monitor strictly vitals signs & neuro check
• Prevent complications of immobility
• Prevent further increase in ICP by the following
measures:
A. PREDISPOSING FACTORS
➢ Provide comfortable & quiet environment
• Head injury
➢ Avoid use of restraints
• Brain tumor → ASTROCYTOMA
➢ Maintain padded rails
• Brain abscess ➢ Instruct clients to avoid activities leading to
• Meningitis Valsalva maneuver
• Hydrocephalus o Avoid straining of stool
• Cerebral edema ✓ Administer laxative or stool softener as
• Hemorrhage (STROKE) ordered:
✓ Dulcolax/ duphalac
B. SIGNS AND SYMPTOMS o Avoid excessive coughing
• Early signs ✓ Administer antitussives as ordered
➢ Changes or alteration in LOC ✓ Dextrometorphan
o Confusion to restlessness ➢ Instruct clients to avoid activities leading to
o Irritability & agitation Valsalva maneuver
o Lethargy to stupor o Avoid excessive vomiting
o Disorientation to 3 spheres (time, place & ✓ Administer anti-emetics
person) ✓ Plasil/phenergan
o Does not respond to questions o Avoid lifting of heavy objects
• Late signs o Avoid stooping/bending
➢ Changes in vital signs: • Administer meds as ordered
o Hypertension (SBP rises while DBP remains the ➢ Osmotic diuretics: Mannitol (Osmitrol)
same) ➢ Loop diuretics: Furosemide (Lasix)
✓ Normal adult BP = 120/80mmHg, Pulse WMUM ➢ Corticosteroids: Dexamethasone (Decadron)
pressure=40mmHg ➢ Mild analgesics: Codeine SO4
✓ BP of the client with increase ICP = 140/80 → Widening of ➢ Anticonvulsant: Dilantin (Phenytoin)
pulse pressure
o Bradycardia CONVULSIVE DISORDERS
o Bradypnea (cheyne-stokes respiration) → hyperventilation with ▪ Disorder characterized by seizure with-or without loss of
apnea or slow, irregular respiration (CUSHING'S TRIAD OR consciousness, abnormal motor activity, alteration in sensation and
REFLEX OF INCREASE ICP) perception. and changes in behavior.
o Hyperthermia
❖ Headache A. PREDISPOSING FACTORS:
❖ Projectile vomiting • Head injury secondary to birth trauma
❖ Papilledema-edema of the optic disc that could lead to blindness if left • Brain tumor (astrocytoma)
untreated • CO poisoning
❖ Possible seizure • Nutritional & metabolic deficiencies
❖ Unilateral dilation of pupil (uncal herniation) • Genetics
❖ DECORTICATE – abnormal flexion (3) → indicates corticospinal
• ETOH withdrawal
damage (spinal cord)
• Stroke
❖ DECEREBRATE – abnormal extension (2) → indicates damage to brain
• Acid base imbalance
stem
• CNS infections
o Midbrain
• Cerebral hypoxia
o Pons
o Medulla oblongata B. STAGES
• PRODROMAL STAGE
➢ When symptoms start appear prior to the big event
➢ Characterized by depression, anger, unable to sleep
➢ Anxiety, GIT and urinary problems

• AURA
➢ Warning sign of an impending seizure attack
➢ Subjective in nature
➢ Characterized by altered vision, taste, hearing, feels
dizzy, sudden weird taste

• ICTUS/ICTAL
➢ Actual seizure usually lasts for 1-3 minutes
➢ Time the actual seizure because a seizure that lasts for
about 5 minutes or more indicates: STATUS
EPILEPTICUS or BACK TO BACK SEIZURE
 • POST ICTAL/ICTUS 2. Avoid precipitating stimulation such as:
➢ After the seizure/recovery, unresponsive, sleep • Trauma
characterized by: • Stress
o Very tired and wants to sleep • Overexertion
o (+) confused, body sores • Loss of sleep
• Visual stimulation (bright/glaring lights or noises)
C. CLASSIFICATION 3. Institute seizure and safety precautions, post seizure activity:
• GENERALIZED SEIZURE: affects the whole brain • Suction apparatus
➢ Grand mal/Tonic Clonic Seizure: • O2 inhalation
o Most common type 4. Monitor & document the ff:
o Characterized by: • Onset and duration
❖ With or without aura
• Type of seizure
❖ Epileptic cry
• Duration of post ictal sleep
• Fall 5. Administer meds-as ordered:
• Loss of consciousness for about 1-3 • Phenobarbital (luminal)
minutes
➢ Drug level: 15-40 mcg/ml
❖ Tonic → direct symmetrical extension of ➢ Indication: used for grand mal/focal seizures
extremities or stretching & status epilepticus
❖ Clonic → body stiffening ➢ MOA: it stimulates GABA receptors & this
❖ Post – ictal sleep → unresponsive sleep/can’t
helps inhibitor transmission
remember events that happened to him
➢ SE: ataxia, drowsiness, hypotension &
➢ Petit Mal/Absence Seizure: respiratory depression
o Common among children
• Anti-convulsants: Hydantoins
o Characterized by:
➢ Ex. Dilantin (Phenytoin)
❖ Blank stare
➢ Toxicity level = 20mg/100ml
❖ Twitching of the mouth
➢ Normal range = 10-19mg/100ml
❖ Lip smacking
➢ MOA: decreases hyperactivity of brain
❖ Loss of consciousness for 5-10 seconds
waves
➢ Atonic Seizure (DROP FALL)
➢ SIDE EFFECTS:
o Provide helmet
o Gingival hyperplasia (swollen gums)
provide oral care, use of soft bristled
• PARTIAL/LOCALIZED SEIZURE toothbrush
➢ Focal/Jacksonian Seizure
• Anti-convulsants: Hydantoins
o Characterized by jerky movement of the index
➢ SIDE EFFECTS:
finger & that spreads to the shoulder & to the other
o Gingival hyperplasia (swollen gums)
side of the body
provide oral care, use of soft bristled
➢ Psychomotor/Focal Motor Seizure: characterized by:
toothbrush
o Automatism: stereotyped, repetitive and non –
o Hairy tongue
purposive behavior (such as finger rubbing, lip
o Ataxia
smacking, chewing)
o Nystagmus
o Mild hallucinatory sensory experience
o Bone marrow depression
o Clouding of consciousness: the client is not in
o Nursing care:
contact with the environment
✓ It is only mix with plan
NSS/.9NaCl to prevent
• STATUS EPILEPTICUS development of crystals or
➢ Major cause: sudden withdrawal to anti-convulsants precipitate
➢ Continuous and uninterrupted seizure activity
✓ Given via "sandwich method"
➢ If left untreated could lead to hyperpyrexia → could lead
✓ Instruct the client to avoid taking
to COMA
alcohol because it could lead to
➢ Can also lead to hypoxia/hypotension/hypoglycemia, severe CNS depression
arrythmias & lactic acidosis. ✓ Monitor for presence of
bruises/rashes
➢ Drug of choice:
• Benzodiazepines
o BENZODIAZEPINES → rapid onset of action &
➢ Diazepam (valium)
long duration of action
➢ Lorazepam (Ativan)
✓ Diazepam (valium)
➢ Midazolam (Versed)
✓ Lorazepam (Ativan)
➢ Indications: used for Petit mal and grand mal
✓ Midazolam (versed)
seizure
o IV glucose: D50W
➢ Fast acting agent to treat status epilepticus
➢ SE:
D. NURSING PRIORITY/DIAGNOSIS
o Drowsiness
o Airway
o Hepatotoxic (liver impairment)
o Trauma/suffocation
antidote: flumazenil
o Safety
• Valproates
➢ Valproic acid
E. DIAGNOSTIC PROCEDURES
➢ Indication: all types of seizure
• CT Scan: reveals brain lesion
➢ SE: hepatotoxic, blood dyscrasias, GIT
• Electroencephalography (EEG): reveals hyperactivity of irritation
brain waves 6. Assists in surgical procedure
➢ Nursing care:
• Cortical resection: a portion of the cortex is
✓ Shampoo the hair of the client
excised to relieved seizure
✓ No NPO
• Vagus nerve stimulator
✓ Avoid caffeine because it could alter the
7. Ketogenic diet: used for pediatric client
result of EEG
• Whose seizure is not controlled by meds
• High fats & low carbs
F. NURSING MANAGEMENT
1. Maintain patent airway & promote safety, before seizure • Fats – 65%
activity • CHON – 30%
➢ Clear the site of blunt/sharp objects • CHO – 5%
➢ Loosen clothing of client
➢ Avoid use of restraints
➢ Maintain padded rails
➢ Turn clients head to side to prevent aspiration
➢ Place mouthpiece, tongue guard on the clients
mouth to prevent biting of the tongue.
 CEREBROVASCULAR ACCIDENT (CVA) • Agraphia
❖ A-poplexy • Issues on seeing on the right side only: UNILATERAL
❖ B-rain attack NEGLECT
❖ C-erebral thrombosis
❖ S-troke APHASIA/SPEECH DISTURBANCES:
➢ Partial or complete disruption in the brains blood supply ➢ Expressive/broca's aphasia: inability to speak
o Damage to frontal lobe > broca's area or motor speech center
A. INCIDENCE RATE o Use of picture board
▪ Common among men ➢ Receptive/ Wernicke's aphasia
▪ Increases as men ages o Inability to understand spoken words/cannot comprehend
▪ May be preventable if causes discovered early o (+) illogical or irrational thoughts
o Damage to temporal lobe → Wernicke's area or "language
B. TYPES center or knowing Gnostic Area"
1. Ischemic stroke: caused by blood clots or stenosis o Nursing care: Use of gestures & point (pantomime)
• Thrombosis: blood clot (attach) ➢ Global aphasia: cannot speak & comprehend
• Embolus: detach thrombus
2. Hemorrhagic stroke: caused by ruptured aneurysm,
D. SIGNS AND SYMPTOMS
uncontrollable hypertension, old age (vessels are not anymore
❖ Based on the stages of stroke:
resilient) → Caused by vascular disruptions e.g aneurysms,
1. Transient ischemic attack (TIA): also called as the "Silent
AVM-Arteriovenous Malformation
Stroke"
• Mini stroke (it only lasts for about 30minutes) to resolve
• Warning sign of an impending stroke attack
characterized by:
➢ Headache
➢ Dizziness/vertigo
➢ Numbness
➢ Tinnitus
➢ Speech & visual disturbances
➢ Possible increase in ICP
➢ Paresis/phlegia
2. Stroke in evolution:
• The progression of the S&S of stroke
3. Complete Stroke:
• Resolution phase characterized by:
➢ Headache
C. RISK FACTORS: "STROKES HAPPEN" ➢ Dizziness
• S – moking → nicotine is a potent vasoconstrictor → ➢ Cheyne-stokes respiration
Hypertension → STROKE ➢ Anorexia
• T – hinners (blood) ➢ Nausea & vomiting
• R – hythm → arrhythmia (atrial fibrillation) ➢ Dysphagia
• O – ral contraceptives ➢ (+) kernig's & brudzinski → indicates
➢ Macropill – contains large amount of estrogen hemorrhagic stroke
➢ Minipill – contains large amount of progesterone ➢ (+) focal neurological deficits:
• K – in (family history/predisposition) o Phlegia
• E – xcessive weight (obesity) o Aphasia
o Dysarthria
• S – enior citizen
o Agraphia
• H – ypertension
o Alexia
• A – therosclerosis
o Amaurosis fugax - temporary/transient
• P – hysical inactivity (sedentary lifestyle)
loss of vision in one eye (last only for
• P – revious TIA - transient ischemic attack
seconds to minutes) → ischemia to
• E – levated blood glucose (DM) carotid system
• aN – eurysm (brain) o (+) homonymous hemianopsia (loss
or blindness in one of half of the visual
field)
✓ Always scan the
environment
E. DIAGNOSTIC PROCEDURES:
▪ Baseline CT Scan: reveals brain lesion & MRI → even better
(want to ensure that the stroke is not hemorrhagic)
▪ Cerebral arteriography: reveals the site and extent of
malocclusion

F. NURSING PRIORITY/DIAGNOSIS:
▪ Cerebral perfusion (altered)
▪ Physical mobility
▪ Verbal communication (impaired)
▪ Sensory perception
▪ Safety/injury
▪ aspiration
❖ RIGHT BRAIN INJURY → LEFT SIDE AFFECTED
SIGNS AND SYMPTOMS G. NURSING MANAGEMENT
▪ Left side weakness (paresis) or paralysis (phlegia) • Maintain patent airway & adequate ventilation by:
▪ Loss of depth perception ➢ Assists in mechanical ventilation Or
▪ Confused on time, date and place ➢ Administer O2 inhalation
▪ Trouble staying on one topic • Restrict fluids to prevent cerebral edema
▪ Impaired creativity: arts and music
• Place client on semi-fowlers position/elevate head of the bed
▪ Cannot recognized faces of the person's name
30-45 degrees
• Prevent complications of immobility by:
❖ LEFT BRAIN INJURY → RIGHT SIDE AFFECTED
➢ Turning client to sides every 2hrs
SIGNS AND SYMPTOMS
➢ Provide "egg-crate" mattresses or water bed
• Right side weakness (paresis) or paralysis (phlegia)
➢ Provide sandbag & footboard to prevent foot drop
• Cannot recognize faces or the person's name
• Institute NGT feeding via gastric gavage to-prevent aspiration
• Memory is intact
• Impaired math skills
• Aware of their limits. Expression, depression, anger & frustration
• Trouble understanding written text
 • Assists in passive ROM exercises every 4hrs to prevent ⁃ o SEVERE MYOPIA: no. l cause of RETINAL
contractures or to promote proper body alignment or prevent DETACHMENT > medical emergency,it could lead to
disuse syndrome → deterioration or stiffening of muscles due permanent blindness
to prolonged inactivity
• Provide alternative means of communication: ➢ HYPEROPIA (farsightedness)
➢ Use of non-verbal cues o TREATMENT: biconvex lens (outward facing lens)
➢ Provide "magic-slate"
• If positive to hemianopsia, approach client to the unaffected ➢ ASTIGMATISM (distorted vision)
side o Irregular shape of the cornea (irregularly curved)
• Encourage client to scan the environment to prevent injury o TREATMENT: Cylindrical lens
• Monitor strictly VS, I&O and neuro check
• Maintain padded rails ➢ PRESBYOPIA (Old sight)
• Instruct client to avoid activities leading to Valsalva maneuver o Inelasticity of lens due to aging
o TREATMENT: Bifocal lens/Doble vista
or bearing down
• Administer meds as ordered: GERONTOLOGICAL VISION CHANGES
➢ Osmotic diuretics: Mannitol (Osmitrol) it • Decrease visual acuity
promotes cerebral diuresis
• Decrease accommodation of the eyes
➢ Corticosteroids: Dexamethasone (Decadron)
• Decrease peripheral vision
➢ Mild analgesics: Codeine SO4
• Increase sensitivity to glare
➢ Thrombolyticss/fibrinolytics agents:
• Presbyopia/cataract
o Streptokinase
o Urokinase
o Tissue plasminogen activator (tpa) (alteplase)
→ should be given 3 hours upon onset
➢ Anti-coagulants:
o heparin (short acting) given parenteral
(IV/SC)
✓ Monitor PTT (partial thromboplastin
time) 30-40 secs
✓ INR (international normalized ratio):
1.2-2.5x within normal (therapeutic)
but if around 60-80secs. Prone to
bleeding → administer antidote:
Protamine Sulfate
o Warfarin/Coumadin (long acting) 2-3 days
to effect, given orally
✓ Monitor for PT (prothrombin time)
✓ Normal = 10-12secs
✓ INR: 2-3x (normal/therapeutic) more
than 36secs prone to bleeding →
administer an antidote called Vit. K
(Aquamephyton)
➢ Anti-platelets:
o PASA (Para-amino salicylic Acid) - Aspirin
o Persantine ❖ 20 feet distance (6 to 7 m)
o Toclopidine (Ticlid) ❖ Normal Visual Acuity
➢ 20/20
➢ Anti-hypertensive agents ✓ Numerator - distance to the snellen's chart
o Calcium channel blockers ✓ Denominator - distance the person can see the letters
o Nifedipine (Procardia) ❖ Abnormal Visual Acuity
o Cardizem (diltiazem) ➢ 20/200
o Verapamil (isoptin) ✓ Blindness

➢ Peripheral vasodilators C.N. II – OPTIC

o Papavarine HCL (Pavabid) • Sensory – Vision
• Tests
➢ Stool softener ➢ Test of Visual Acuity/Central or Distance Vision
o Dulcolax (Duphalac) o Materials Used
o Findings
• Provide client health teaching and discharge planning concerning: ➢ Visual Fields/Peripheral vision
➢ Avoid modifiable risk factors: lifestyle/diet/exercise o Superiorly
➢ Prevent complications o Bitemporally
o Subarachnoid hemorrhage o Nasally
o Brain herniation o Inferiorly
o Hypostatic pneumonia
GLAUCOMA
o Deep vein thrombosis
• An increase in the intra-ocular pressure (lOP), if left untreated could
o Depression & mood changes
lead to atrophy of the optic discs resulting to blindness.
➢ Dietary modifications
o Provide a general liquid to soft diet that is low in PREDISPOSING FACTORS
saturated fats, sodium, avoid caffeine & gas forming
• High risk group 40 ABOVE (African-american/ Hispanic &
foods
Asian)
➢ Rehabilitation for local neurological deficits
• Hereditary
PHYSIOLOGY OF VISION • Secondary glaucoma r/t other pre-existing conditions (HPN, DM,
❖ In order for the vision to occur, 4 physiological processes are involved: Migraine syndrome and long term used of steroids)
➢ Refraction of light rays (bending of ight rays) cornea/lens • Related to recent eye trauma, surgery or inflammation
➢ Accommodation of the lens • Obesity
➢ Constriction and dilation of pupil • Wearing of contact lenses/reading in low light
➢ Convergence of the eyes
PARTS OF THE EYE
❖ NORMAL REFRACTIONNORMAL EYE 2. INTERNAL/INTRINSIC PART OF THE EYEBALL
➢ EMMETROPIA b. MIDDLEMOST LAYER - (Uveal/Nutritive coat)

❖ ERROR OF REFRACTION
➢ MYOPIA (nearsightedness)
o TREATMENT: Biconcave lens (curved inwards) = they are
at the thinnest at the center and thicker at the edge
VASCULAR TUNIC PUNCTAL OCCLUSION:
❖ CILIARY BODY ❖ After instilling each eye drop med, have the Patient refrain from blinking
➢ a thick tissue composed of ciliary processes and muscle but to keep the eye closed & perform PUNCTAL OCCLUSION → Use
➢ Continues with the choroid behind and the iris in front the index finger & gently place pressure at the side of the bridge the nose
➢ Produces aqueous humor (over the lacrimal punctum) for about 2-3 mins. →Thereby preventing the
o A fluid that gives shape to the eye anteriorly and medication from draining down into the nasolacrimal duct being absorbed
maintains the IOP N = 12-2ImmHg by the blood → which can cause massive signs & symptoms.
o INCREASE IOP = GLAUCOMA o [Link] blockers
o Ciliary body produces aqueous humor → Goes to o Cholinergics
the anterior and posterior chamber (nourishes and
gives oxygen to cornea and lens) → Travels to the
trabecular meshwork → Drains into the canal of
Schlemn

TYPES OF GLAUCOMA
❖ Chronic open angle glaucoma (COAG)
• Most common type of glaucoma characterized by obstruction
in the flow of aqueous humor at the trabecular meshwork of
the canal of schlemn
• GRADUAL IN ONSET, BILATERAL
• IOP = 30-50mmHg
NURSING MANAGEMENT:
• Administer meds as ordered:
❖ Acute close angle glaucoma (ACAG)
❖ Prostaglandin Analogs: “prost”: Ex. Bimatoprost
• MOST DANGEROUS of all types of glaucoma characterized
o It promotes drainage of aqueous humor but it doesn't
by forward displacement of the iris to the cornea
cause systemic effects
• Could lead to BLINDNESS
o Common side effects: Thicker eyelashes & change
• Sudden/acute onset, UNILATERAL color of iris to brown
• IOP 50-70mmHg
❖ Rho kinase Inhibitors: Ex. Netarsudil
❖ Chronic close angle glaucoma (CCAG) o It promotes drainage of aqueous humor
• Precipitated by ACAG but with longer duration o Common side effect Conjunctival hyperemia (red
eyes)
SIGNS AND SYMPTOMS
• Tunnel like vision
❖ Epinephrine eyedrops
• Loss of peripheral vision
o Decreases formation and secretion of aqueous humor
• Halos and rainbows around lights/blurring of vision o NOTE: DO NOT GIVE ATROPINE SO4 EYEDROPS IT
• Headache COULD LEAD TO INCREASE IOP
• Nausea and vomiting
• Steamy cornea ❖ Carbonic anhydrase inhibitor
• Eye pain/discomfort/Red eyes o Acetazolamide (Diamox)-Oral or by drops
• Dificulty in focusing o Promotes increase outlow of aqueous humor for
• Dificulty in adjusting the eyes in dark room drainage/diuretic that inhibits carbonic acid production
• If left untreated, could lead to BLINDNESS o Assess for a sulfonamide allergy

❖ Beta-blockers
o Timolol maleate (Timoptics)
o Decrease production of aqueous humor
o Systemic effects: Punctal occlusion

❖ Osmotic agents
o Decreases IOP
o Glycerin PO
o Mannitol IV FOR GLAUCOMA CRISIS ACAG

DIAGNOSTIC PROCEDURE ❖ Alpha Agonists: "idine" Ex. Brimonidine

• Tonometry (Schiotz Tonometer) o It decreases aqueous humor production ( Constricting ciliary
➢ Reveals increase IOP body) & promotes drainage of aqueous humor
➢ Painless procedure o Systemic effects: Punctal occlusion
• Perimetry
▪ Assists in surgical procedure
➢ Reveals decrease peripheral vision
➢ Invasive:
• Gonioscopy
✓ Trabeculectomy (EYE TREPHINING):
➢ Reveals obstruction in the anterior chamber
o Removal of trabecular meshwork of canal of
NURSING PRIORITY/DIAGNOSIS schlemn to promote drainage
• Visual sensory perception (disturbed) ✓ Peripheral Iridectomy
• Safety (Risk for Injury) o A portion of the iris is excised to promote drainage
• Anxiety ➢ Non-invasive
✓ Selective Laser Trabeculoplasty:
NURSING MANAGEMENT o It lowers IOP by using lasers to target certain parts
• Maintain a comfortable and quiet environment of the drainage angle tissue, thereby allowing extra
• Enforce complete bed rest fluid to drain out of the eye. lOP is lowered over
• Maintain padded rails several months but not permanent.
• Provide emetic basin ➢ POST-OP NURSING CARE:
o Place client on the un-operative side to prevent tension
• Administer medications as ordered:
on the suture line.
➢ Cholinergics: (Miotics)
o Avoid activities leading to VALSALYA MANEUYER
➢ Constrict the Pupil but contracts the ciliary muscle, to
o Monitor for signs of increase lOP and notify the
promote increase outflow of aqueous humor (Ex.
physician/HCP:
Pilocarpine/ Carbachol)
▪ Headache
➢ Cholinergic effects: Sweating, increase salivation,
bronchospasm, bradycardia, ▪ Eye discomfort/pain
▪ Nausea and vomiting
▪ Tachycardia
▪ Place eye patch on both eyes
➢ PRE: OP eye patch on stronger eye to force the weaker eye to
be stronger
 CATARACT ❖ Though rarely occurs, serious complication might
arise ff. lens extraction
o Retinal detachment
o Vision loss/blindness
o Retrobulbar hemorrhage
o Endopthalmitis > inflammation of the
vitreous humor/body

❖ Partial or complete opacity of the lens

A. PREDISPOSING FACTORS
▪ High risk group: 60 y/o above -- DEGENERATIVE OR SENILE
CATARACT
▪ CONGENITAL
▪ Secondary cataract: DM, prolonged use of steroids
▪ Prolonged exposure to UV rays and heat from smoking
▪ Eye trauma/injury

B. SIGNS AND SYMPTOMS

▪ Hazy vision
▪ Loss of central vision
▪ (+) milky white appearance at the center of the pupil
▪ Painless
▪ Decrease in color perception
▪ Better vision in dim light
▪ Difficulty in focusing
▪ Sensitivity to lights and glare
▪ Increase near-sightedness, requiring frequent changes of eye glasses
▪ Distortion or ghost images
▪ Can lead to BLINDNESS if left untreated

C. DIAGNOSTIC PROCEDURES
▪ Ophthalmoscopy
▪ Reveals opacity of the lens
▪ Slit lamp exam
▪ Reveals opacity of the lens
▪ Ultrasound

D. NURSING PRIORITY/DIAGNOSIS
1. Visual sensory perception (disturbed)
2. Safety (risk for injury)
3. Knowledge deficit

E. NURSING MANAGEMENT
• Re orient the client to environment
• Maintain padded rails
• Assists in surgical procedure
➢ ECCLE – Extra Capsular Cataract Lens Extraction
o Partial removal of cataract
➢ ICCLE – Intra-capsular cataract lens extraction
o Total removal of lens together with its surrounding
capsule
➢ Khelma Phaco Emulsification
o The use of high frequency sound waves to liquify the
contents of the lens → which can then be safely remove
from the eye using suction through a 3 mm incision

• PRE-OP NURSING CARE

✓ Possibly cut eyelashes
✓ Face scrub
✓ Administer pre op meds
➢ Mydriatics
o Dilates the pupil
o Mydriacyl
➢ Cyclopegics
o Paralyzes the ciliary muscle
o Cyclogyl

• POST OP NURSING CARE

✓ Wear metal or plastic shield at night. Glasses during the day
✓ Avoid rubbing or placing pressures in the eyes
✓ Avoid activities leading to Valsalva maneuver
✓ Notify physician for the ff:
➢ Severe persistent eye pain that is not relieved by meds
➢ Decrease or loss of vision
➢ Increase eye discharges
➢ Monitor signs of complications: