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NCM 116 LEC
REVIEWER / SECOND SEMESTER
NEUROLOGIC SYSTEM
DEFINITION
Controls motor, sensor, autonomic, cognitive, and behavioral activities
THREE DIVISIONS
CNS Brain & spinal cord PNS Cranial nerves, spinal nerves, and autonomic nervous system ANS Involuntary activities (smooth and cardiac muscles functions)
2 TYPES OF ANS
SYMPATHETIC NERVOUS SYSTEM
❑ Those neurological ganglia nerves, plexuses which innervate the involuntary motor/ sensory receptions. ❑ Releases NOREPINEPHRINE ❑ Fight and flight response. PARASYMPATHETIC NERVOUS SYSTEM ❑ Dominates during relaxed, non- stressful situations. ❑ Releases ACETYLCHOLINE SNS PNS Fight or Flight Rest and Digest Increased HR Decreased HR Increased RR Decreased RR Increased BP Decreased BP Decreased GIT Increased GIT Decreased GUT Increased GUT
NEURON
Basic function unit Composed of the following: Dendrites Extension that carries impulses toward the cell body. Axon Transmits impulses away from the cell body
TYPES OF NEURONS
SPINAL CORD
Center for reflex acts. Sensory and Motor neurons. SENSORY NEURONS Also known as Afferent Neurons Transmit impulses from receptors to the CNS. MOTOR NEURONS Also termed as Efferent Neurons Transmit impulses from the central nervous system to the effectors (muscles, glands) INTERNEURONS Found entirely within the central nervous system. Specialized in transmitting sensory/ motor impulses. NEUROTRANSMITTERS
Communicate message from one neuron to another or from a neuron to a specific target tissue. Potentiate, terminate or module a specific action and can either excite or inhabit the target cell activity. Dopamine Excitatory Control complex movements, motivation, cognition. Regulates emotion response. Norepinephrin e Excitatory Causes changes in attention, learning and memory, sleep and wakefulness, mood Epinephrine Excitatory Controls fight-or- flight response Serotonin Inhibitory Controls fluid intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, regulation of emotion. Acetylcholine Excitatory/inhibitory Controls sleep and wakefulness cycle. Signals muscles to become alert Gamma- aminobutyric acid (GABA) Inhibitory Modulates other neurotransmitters Glutamine Excitatory Results in neurotoxicity if levels are too high. CNS CEREBRUM ❑ 2 sections called CEREBRAL HEMISPHERE (R & L HEM.) ❑ Outermost layer: CEREBRAL CORTEX ❑ Right Brain: controls the left part of the body. ❑ Left Brain: controls the right part of the body. GYRI Small humps; raised convolution SULCI Shallow grooves (divided into several lobes) FISSURES Deep furrows PARTS OF THE SULCI Frontal lobe (PIMS) Personality Intelligence Mot activ. Speech Largest lobe Major functions: concentration, abstract thought, information storage and memory function. Contains Broca’s area-motor control of speech (complication: EXPRESSIVE APHASIA) Generates the impulses that bring about voluntary movement. Parietal lobe (Tactile Sensation) Sensory function: Touch, taste, temperature This is where sensations are felt. Grading:
Assessed whether through RHOMBERG’s TEST , HEEL-TOE TEST, FINGER-NOSE TEST. PNS
- Spinal Nerves : Composed of 31 pairs Cervical 8 Thoracic 12 Lumbar 5 Sacral 5 Coccygeal **1
- Cranial nerves:** I (OLFACTORY) - SENSORY Sense of smell II (OPTIC) - SENSORY Visual acuity III (OCULOMOTOR) - MOTOR Muscles that move the eye and lid, pupillary constriction, lens accommodation IV (TROCHLEAR) - MOTOR Muscles that move the eye V (TRIGEMINAL) - MIXED Facial sensation, corneal reflex, mastication VI (ABDUCENS) - MOTOR Muscles that move the eye VII (FACIAL) MIXED Facial expression and muscle movement, salivation and tearing, taste, sensation in the ear. VIII (VESTIBULOCOCHLEAR) - SENSORY Hearing and balance/equilibrium IX (GLOSSOPHARYNGEAL) - MIXED Taste, sensation in pharynx and tongue, pharyngeal muscles. X (VAGUS) - MIXED Muscles of pharynx, larynx, and soft palate; sensation in external ear, pharynx, larynx, thoracic and abdominal viscera; parasympathetic innervation of thoracic and abdominal organs XI (SPINAL ACCESSORY) - MOTOR Sternocleidomastoid and trapezius muscles XII (HYPOGLOSSAL) - MOTOR Movement of the tongue ASSESSMENT CRANIAL NERVES I (OLFACTORY) ❑ With eyes closed, the patient is asked to identify familiar odors (cinnamon, coffee). ❑ Each nose is tested separately. Problem: anosmia = loss of sense of smell CRANIAL NERVES II (OPTIC) ❑ Assess vision using a Snellen eye chart. ❑ Assess visual fields.
❑ Perform ophthalmoscopic examination. Problem: hemianopia (loss of one-haft of the visual field, either unilateral or bilateral); decreased visual acuity/blindness CRANIAL NERVES III (OCULOMOTOR) ❑ Test the eye movement towards the nose. ❑ Inspect for conjugate movements and nystagmus. ❑ Evaluate papillary size and test for papillary reactive to light. ❑ Inspect ability to open eyelids. Problem: Dysconjugate gaze; Double vision; Dilated pupil; with or without impaired papillary reaction to light CRANIAL NERVES IV (TROCHLEAR) ❑ Test for upward eye movement. ❑ Inspect for conjugate movements and nystagmus. Problem: Dysconjugate gaze; gaze weakness or paralysis; double vision CRANIAL NERVES V (TRIGEMINAL) ❑ Instruct client to close his/her eyes. ❑ Ask the patient to identify touch on different parts of the face. ❑ Ophthalmic, maxillary & mandibular ❑ While the patient looks up, light touches a wisp of cotton against the temporal surface of each cornea. ❑ A blink reflex and tearing are normal responses. ❑ Have the client clench and move the jaw from side to side. Palpate the masseter and temporal muscles, noting strength and equality. Problem: impaired or absent corneal reflex, facial numbness, and jaw weakness CRANIAL NERVES VI (ABDUCENS) ❑ Test for Bilateral eye movement. ❑ Inspect for conjugate movement. Problem: dysconjugate gaze; gaze weakness or paralysis; double vision CRANIAL NERVES VII (FACIAL) ❑ Ask the patient to frown, smile, and wrinkle forehead. ❑ Check for symmetry. Problem: facial weakness, inability to completely close the eyelids & impaired taste CRANIAL NERVES VIII (VESTIBULOCOCHLEAR) ❑ Performing whisper/ watch-tick test ❑ Test for lateralization (Weber test) ❑ Test for air & bone condition (Rinne test) ❑ Assess standing balance with eyes closed ( Romberg test) Problem: decreased hearing/ deafness & impaired balance CRANIAL NERVES IX (GLOSSOPHARYNGEAL) ❑ Assess patient’s ability to swallow. ❑ Assess ability to discriminate between sugar & salt on posterior third of the tongue. Problem: dysphagia & impairs taste CRANIAL NERVES X (VAGUS)
❑ Start meal with cold beverages to improve ability to swallow ❑ Avoid exposure to infection Provide adequate rest and activity MYASTHENIC CRISIS ❑ Caused by undermedication ❑ Increase BP & HR ❑ Increase Secretions ❑ Intervention: Give Neostigmine CHOLINERGIC CRISIS ❑ Caused by overmedication ❑ Weakness with difficulty of swallowing ❑ Intervention: Discontinue all cholinergic drugs MULTIPLE SCLEROSIS ❑ Degenerative disease ❑ Demyelination of the nerve fibers ❑ Chronic, slowly progressive ❑ Characterized by periods of remission and Exacerbation. CAUSES ❑ Unknown ❑ Post viral infection DIAGNOSTIC TESTS ❑ MRI ❑ Electrophoresis (CSF) ❑ EEG CLINICAL MANIFESTATIONS
1. CHARCOT'S TRIAD ❑ Scanning speech ❑ Intentional tremors ❑ **Nystagmus
- VISUAL DISTURBANCES** ❑ Blurring of vision ❑ Diplopia ❑ Patchy blindness ❑ Total blindness 3. SENSORY NERVE DISTURBANCES ❑ Paresthesia ❑ Proprioception loss ❑ Pain 4. COGNITIVE DISTURBANCE ❑ Memory loss ❑ Decreased concentration ❑ Dementia ❑ Poor abstract reasoning 5. CEREBELLUM / BASAL GANGLIA INVOLVEMENT ❑ Ataxia ❑ Tremors ❑ Weakness of muscle in throat and face 6. OTHERS: ❑ Bowel & Bladder dysfunction ❑ Importance ❑ Muscle hypertonicity MANAGEMENT PHARMACOLOGIC THERAPY ❑ Interferon beta ❑ Methylprednisolone ❑ Baclofen (medication of choice for spasticity) ❑ Steroids NURSING MANAGEMENT PROMOTING PHYSICAL MOBILITY ❑ Walking
❑ Use of assistive devices OTHERS ❑ Warm packs (minimizes spasticity of contractures) ❑ Avoid hot baths (increases risk for burn injury) ❑ Swimming & stationary bicycling are useful in treating muscle spasticity. ❑ Strenuous exercises are to be avoided (this may exacerbate symptoms) ❑ Instruct client to prevent cuts and burns. ❑ Eye patch for diplopia ❑ Respiratory distress precautions ❑ Bowel and bladder program GUILLAIN — BARRE SYNDROME ❑ An autoimmune attack of the peripheral nerve myelin ❑ Acute, rapid segmental demyelination of peripheral nerves and some cranial nerves ❑ Neuromuscular disease ❑ More frequent in males CAUSES ❑ Unknown ❑ Post viral infection DIAGNOSTIC TESTS ❑ EMG ❑ CSF ❑ ECG CLINICAL MANIFESTATIONS ❑ Diminished reflexes and muscle weakness that goes upward. ❑ Clumsiness (initial symptom) ❑ Paralysis of the diaphragm ❑ Dysphagia ❑ Respiratory depression ❑ Paresthesia ❑ Paralysis of the ocular muscles ❑ Ataxia COMPLICATIONS ❑ Respiratory failure ❑ Cardiac dysrhythmias ❑ Transient hypertension ❑ Orthostatic hypotension ❑ Pulmonary embolism MEDICAL MANAGEMENT ❑ Plasmapheresis ❑ Corticosteroids NURSING MANAGEMENT ❑ Mostly supportive ❑ Maintain adequate ventilation ❑ Incentive spirometry ❑ Chest physiotherapy ❑ Perform range-of-motion ❑ Assess gag reflex before starting the feeding ❑ Monitor vital signs ❑ Check cranial nerve function ❑ Administer corticosteroids to suppress immune function PARKINSON'S DISEASE ❑ It is a slowly progressing neurologic movement disorder that eventually leads to disability. ❑ Associated with decreased levels of dopamine CAUSES ❑ Idiopathic ❑ Degenerative ❑ Viral infection
THALAMOTOMY
Most common complications: ❑ Ataxia and Hemiparesis PALLIDOTOMY ❑ Involves destroying part of the ventral aspect of the medial globus pallidus through electrical stimulation in patients with advanced disease. PACEMAKER-LIKE BRAIN IMPLANTS NURSING MANAGEMENT ❑ Improve client's mobility. o Walking o Riding stationary bicycle o Swimming o Gardening o Provide warm baths and massage ❑ Increase fluid intake to prevent constipation ❑ Aspiration Precaution ❑ Provide semi-solid diet and thick fluids ❑ Use of small electronic amplifier may lessen client's hearing deficit HEALTH TEACHING (LEVODOPA THERAPY) SIDE EFFECTS OF LEVODOPA ❑ Nausea & vomiting ❑ Orthostatic hypotension ❑ Insomnia ❑ Agitation ❑ Mental confusion ❑ Renal damage
DRUGS THAT BLOCK THE EFFECT OF
LEVODOPA
❑ Phenothiazines ❑ Reserpine ❑ Pyridoxine (Vitamin B6) FOODS TO AVOID ❑ Tuna ❑ Pork ❑ Dried beans ❑ Salmon ❑ Beef liver BELL’S PALSY ❑ Unilateral inflammation of the seventh cranial nerve ❑ Produces unilateral facial weakness and paralysis ❑ Rapid onset ❑ May equally happen to both sexes ❑ Adults (< 45 y/o) CAUSE ❑ Unknown ❑ Autoimmune ❑ Viral (Herpes Simplex / Herpes Zoster) ❑ Bacterial infection PATHOPHYSIOLOGY
- Inflamed and edematous facial nerve
- Compression
- Facial nerve damages
- Occlusion of blood supply
- Ischemic necrosis of the facial nerve CLINICAL MANIFESTATIONS
❑ Inability to close eye completely on the affected side ❑ Ptosis ❑ Pain around the jaw or ear ❑ Unilateral facial weakness ❑ Ringing in the ear ❑ Eating difficulty ❑ Taste distortion on the anterior portion of the tongue (affected side) ❑ Flat nasolabial fold DIAGNOSTIC TESTS ❑ History and Physical Exam ❑ EMG MANAGEMENT MEDICATIONS ❑ Prednisone (7 to 10 days) ❑ Analgesics (pain control) ❑ Antiviral drugs COMFORT MEASURES ❑ Heat application on the involved side ❑ Gentle massage ❑ Electrical nerve stimulation NURSING MANAGEMENT ❑ Nutrition: Soft diet ❑ Instruct to chew on the unaffected side ❑ Avoid hot fluids/food ❑ Administer drugs as ordered ❑ Artificial tears is recommended (prevents corneal irritation) ❑ Facial exercise (grimacing; wrinkling, whistling, puffing of the cheeks, blowing out air) TRIGEMINAL NEURALGIA ❑ Other Term: TIC DOULOUREUX ❑ It is a condition of the fifth cranial nerve characterized by paroxysms of pain in the area innervated by any of the ❑ three branches ❑ Second and third branches of the trigeminal nerve (most common) ❑ 400 times more common in patients with Multiple Sclerosis (MS) ❑ Men with MS > Women with MS CAUSES ❑ Chronic compression or irritation of trigeminal nerve ❑ Degenerative changes in the Gasserian ganglion ❑ Vascular pressure from structural abnormalities encroaching on the trigeminal nerve, Gasserian ganglion or root entry zone CLINICAL MANIFESTATIONS ❑ Intense recurring episodes of pain (sudden, jabbing, burning or knifelike) ❑ Episodes of pain begin and end suddenly, lasting for a few seconds to minutes. ❑ Unilateral pain DIAGNOSTIC TESTS
