INCREASED INTRACRANIAL PRESSURE ● It is the pressure that pushed the

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

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

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

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

8. A patient has a ventriculostomy. Which finding would you readings should be?
immediately report to the doctor? A. 5 to 15 mmHg
A. Temperature 98.4 'F B. 20 to 35 mmHg
B. CPP 70 mmHg C. 60 to 100 mmHg
C. ICP 24 mmHg D. 5 to 25 mmHg
D. PaCO2 35 The answer is A. Normal ICP should be 5 to 15 mmHg.
The answer is C. A ventriculostomy is a catheter inserted in the area
of the lateral ventricle to assess ICP. It will help drain CSF during
increase pressure readings and measure ICP. The nurse must 15. Which patient below with ICP is experiencing Cushing's Triad? A
monitor for ICP levels greater than 20 mmHg and report it to the patient with the following:
doctor. A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
9. External ventricular drains monitor ICP and are inserted where? D. BP 80/40, HR 49, RR 12
A. Subarachnoid space The answer is C. These vital signs represent Cushing's triad. There is
B. Lateral Ventricle an increase in the systolic pressure, widening pulse pressure of 140
C. Epidural space (200-60=140), bradycardia, and bradypnea.
D. Right Ventricle
The answer is B. External ventricular drains (also called
ventriculostomy) are inserted in the lateral ventricle. 16. The patient has a blood pressure of 130/88 and ICP reading of
12. What is the patient's cerebral perfusion pressure, and how do you
interpret this as the nurse?
10. Which of the following is contraindicated in a patient with A. 90 mmHg, normal
increased ICP? B. 62 mmHg, abnormal
A. Lumbar puncture C. 36 mmHg, abnormal
B. Midline position of the head D. 56 mmHg, normal
C. Hyperosmotic diuretics The answer is A. CPP is calculated by the following formula:
D. Barbiturates medications CPP=MAP-ICP. The patient’s CPP is 90 and this is normal. A normal
CPP is 60-100 mmHg.
 C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved
17. According to question 16, the patient's blood pressure is 130/88. side to side.
What is the patient's mean arterial pressure (MAP)? The answer is D. This is known as a negative doll's eye and
A. 42 represents brain stem damage. It is a very bad sign.
B. 74
C. 102
D. 88 21. A patient is receiving Mannitol for increased ICP. Which
The answer is C. MAP is calculated by taking the DBP (88) and statement is INCORRECT about this medication?
multiplying it by 2. This equals 176. Then take this number and add A. Mannitol will remove water from the brain and place it in the blood
the SBP (130). This equals 306. Then take this number and divide by to be removed from the body.
3, which equal 102. B. Mannitol will cause water and electrolyte reabsorption in the renal
tubules.
C. When a patient receives Mannitol the nurse must monitor the
18. During the assessment of a patient with increased ICP, you note patient for both fluid volume overload and depletion.
that the patient's arms are extended straight out and toes pointed D. Mannitol is not for patients who are experiencing anuria.
downward. You will document this as: The answer is B. All the other options are correct. Mannitol will
A. Decorticate posturing PREVENT (not cause) water and electrolytes (specifically sodium
B. Decerebrate posturing and chloride) from being reabsorbed....hence it will leave the body as
C. Flaccid posturing urine.
The answer is B.

22. What assessment finding requires immediate intervention if found

19. While positioning a patient in bed with increased ICP, it important while a patient is receiving Mannitol?
to avoid? A. An ICP of 10 mmHg
A. Midline positioning of the head B. Crackles throughout lung fields
B. Placing the HOB at 30-35 degrees C. BP 110/72
C. Preventing flexion of the neck D. Patient complains of dry mouth and thirst
D. Flexion of the hips The answer is B. Mannitol can cause fluid volume overload that leads
The answer is D. Avoid flexing the hips because this can increase to heart failure and pulmonary edema. Crackles in the lung fields
intra-abdominal/thoracic pressure, which will increase ICP. represent pulmonary edema and require immediate intervention.
Option A is a normal ICP reading and shows the mannitol is being
effective. BP is within normal limits, and dry mouth/thirst will occur
20. During the eye assessment of a patient with increased ICP, you with this medication because remember we are trying to dehydrate
need to assess the oculocephalic reflex. If the patient has brain stem the brain to keep edema and intracranial pressure decreased.
damage what response will you find?
A. The eyes will roll down as the head is moved side to side.
B. The eyes will move in the opposite direction as the head is moved
side to side.
STROKE (CEREBROVASCULAR ● Brains cells are super sensitive
ACCIDENTS) ○ They cannot go without a
minutes without blood rich
DEFINITION: oxygen
● Blood rich in oxygen can not reach ○ Cells affected within 5
brain cells and cells begin to die minutes
○ Blockage or Bleeding ■ The longer it goes the
● Types of Strokes: more cell death can
○ Ischemic Stroke occur
○ Hemorrhagic Stroke ● Hemisphere of the Brain
○ Transient Ischemic Attack ○ Right
■ Creativity
ANATOMY AND PHYSIOLOGY: ■ Music and Arts
● Blood Supply: ■ Attention Span
○ Carotid and Vertebral ■ Showing emotions
Arteries ■ Ability to solve
■ Each areas of the everyday problems by
brain has specific making
function decision/plans
 ■ Reasoning
the body
(understanding
jokes… read in
between the line) ● Parts of the brain and function:
■ Making judgement ○ Frontal:
calls ■ Decision making
■ Memory Recall ■ Thinking
■ Music/Art Awareness ■ Speaking
■ Control the left side ■ Memory
of the body ■ Movement
○ Left (Logic) ■ Broca’s Area
■ Logical ○ Parietal Lobe
■ Reading Writing and ■ Language
speaking ■ Touch
■ Speaking ○ Temporal Lobe:
■ writing ■ Hearing
■ Reading ■ Learning
■ Math skills ■ Feeling
■ Analyzing info ■ Weicken’s Area
■ Planning ○ Occipital
■ Vision Acuity
■ Color perception
Right Side of the Left Side of the ○ Cerebellum
Brain Brain
■ Ballance
- Attention - Speaking ■ Coordination
span - Writing ○ Brain Stem
- Showing - Reading ■ Breathing
Emotions - Math skills ■ Heart Rate
- Ability to - Analyzing ■ Temperature
solve info
CAUSE
everyday - Planning
problems by - Controls the ● Blockage:
making left side of ○ Atherosclerosis
decisions/pl the body ○ Clots
an ○ Embolism
- Reasoning ○ Thrombi
{understandi ● Bleeding
ng jokes,
○ AMD
reading in
between the ○ Cerebral Aneurysm
lines} PATHOPHYSIOLOGY
- Memory ● Ischemic Stroke
Recall ○ Blockage of Blood Vessel/
- Music/Art Stenosis or artery
awareness ■ Not be able to feed
- Controls the
the brain tissue
left side of
 ○ Results to a lack of blood vein/arteries that
flow in affected area prevents blood from
○ Can Happen due to coming in
■ Embolism: A clot has ■ It’s a mini type of
left a part of the body stroke
(example the heart: ■ It’s not a full blown
heart valve problem stroke yet
or atrial fibrillation) nd ■ Usually its a sign that
travelled to the brain, something’s big is
which stops blood about to happen
flow ○ Signs and Symptoms last
■ Thrombosis: Clot few minutes to hours and
form within the will resolve
arterial wall within the ○ It's a Warning signs
neck or rain ○ Bloodakege of of the vessel
● Seen in ○ Mini type stroke NOT A
patient with FULL BLOWN STROKE
Hyperlipidem
ia and SIGNS AND SYMPTOMS
atherosclero ● Physical Examination reveals
sis ○ Happen suddenly
● Hemorrhagic Stroke: ■ Need to act FAST to
○ Happen due to save brain cells
■ Bleeding in the ○ Call rapid response of 911
Brain due to a break ○ NOTE the time
in blood vessel ■ tPA might be
■ Leads to no blood to administered before 3
perfuse the brain cells hours of onset stoke
and excessive blood ● Aphasia- unable to speak and
in the brain comprehension it or producing
■ Cause: a brain ○ Types
aneurysm bursts. ■ Receptive- unable to
Uncontrolled comprehend speech
hypertension, old age {wernicke’s area at
(vessels are not as the temporal lobe
resilient) ■ Expressive
○ Can cause excessive comprehends speech
swelling and increase but can’t respond
intracranial pressure back with speech
● Transient Ischemic Attack: {Broca’s area at the
○ This is an ischemia type of frontal lobe
stroke on its origin ■ Mixed: both
■ There is some type of combination of two
blockage on that
 ■ Global: complete repeat
inability to understand something
speech or produce it ● Slurred
● Dysarthria: unable to speak clearly speech
due to weak muscle {hard to ■ T for tome
understand} ● Act fast if
● Apraxia: Can’t perform voluntary someone is
movement even though muscles experiencing
function is normal stroke
● Agraphia: loss the ability to write symptoms
● Alexia: loss the ability to read {does
Right Brain Injury Left Brain Injury
not understand or see the words
● Agnosia: doesn’t understand
sensations or recognize known
objects or people
○ They can’t call pencil a pencil
● Dysphagia: issue swallowing
○ Major risk for pneumonia
● Hemianopia: limited vision in half of
the visual fields
● Learn to recognize the Signs of a Findings: Findings:
Stroke - Left side ● Right side
○ Act “FAST” weakness: Hemiplegia
■ F for Face Hemiparesis ● Aphasia
● Drooping of and {trouble
Hemiplegia formulating
the face
- Impairment in words and
● Uneven smile creativity: Arts comprehendin
■ A for Arms and music g them}
● Arm - Confused on ● Aware of their
numbness or date, time, limits {they
weakness place often
● Ask the - Cannot experience
recognize depression,
person to
faces or the anger,
raise their person’s name frustration}
arms - Loss of depth ○ They
{however it perception know what
the arms still - Trouble they feel
drops down staying on ● Trouble
and isn’t topic understanding
- Can’t see written text
ready} things on left issues with
■ A for speech side: writing
difficulty - LEFT SIDE {agraphia}
● Ask the NEGLECT: ● Memory intact
person to Ignores left side ● Issues with
 ■ Risk for developing
of the body seeing on the
- Trouble with right side atherosclerosis
maintaining ■ Hyperlipidemia
proper ○ S-enior Citizens
grooming ○ H-ypertension
- Emotionally: not ○ A-therosclerosis
going to think ○ P-hysical Inactivity
things through-
○ P-revious TIA
very impulsive
- Poor ability to ○ E-levated glucose
make decisions ■ Diabetes Mellitus
and assessing ■ The sugarry blood
spatial can irritate the blood
elements...sha vessel and stick to
pes vessel and form a
- Denial about
their thrombi and
limitations eventually leads to
- Not able to emboli and stoke
interpret ○ a-N-eurysm brain
nonverbal ■ Outpouching of
language or vessel
understand the
DIAGNOSTIC AND LABORATORY TEST
hidden meaning
of things ● Remember prompt diagnosis is the
- Very short key
attention span ● CT scan and MRI
○ They want to rule out if there
is bleeding or stroke
RISK FACTOR:
○ Because if they do, they are
● “S.T.R.O.K.E.S H.A.P.P.E.N”
not candidate for t-PA tissue
○ S-moking
plasminogen activator
○ T-hinners {anticoagulant}
■ A medication
■ When blood gets too
indicated only for
thin the pressure
Ischemic Stroke and
increases which will
not Hemorrhagic
lead to bursting of
○ tPA dissolved the clot by
fragile vessel
activating the protein that
○ R-hythm Changes {Atrial
causes fibrinolysis
Fibrillation}
■ Given within 3 hours
■ Clot can form and
from onset signs and
lead to TIA or stoke
symptoms
○ O-ral Contraceptives
■ 3-4.5 hours if meets
■ Estrogen
the criteria
○ K-in
● Criteria for tPA
■ Family
○ CT scan negative
○ E-xcessive weight
○ Labs within normal limit
 ■ Glucose ■ During 1st 14 hours
■ INR after administration of
■ Platelets the medication
○ BP is controlled
■ <180/110
○ Hasn’t received any blood
thinners and other
anticoagulants like heparin
TREATMENT
● tPA
NURSING INTERVENTION
● NURSING INTERVENTION FOR
tPA
○ Check for bleeding
○ Neuro checks around the
clock
■ NIH stroke scale
● Assess 11
level areas of
their body
● Scores ranges
from 0-42
● 0: no stroke
● Worst score
21-42

○ Blood pressure medication if

needed for hypertension
○ VItal signs
○ Labs
■ INR
○ Monitor Glucose
○ Prevent injury
■ Promote bed rest
■ Fall can increase
ecchymosis and
bleeding
○ Avoid unnecessary
venipunctures
○ Avoid IM injection
○ Most patient will go to ICU to
be monitored
 ○ V/S: Increase BP, Decrease
HR, and Decrease RR
■ Because they are
high at risk of
developing increased
intracranial pressure
especially for
Hemorrhagic Stroke
■ Increase
ICP=Nauseas and
vomiting, decrease
Level of
Consciousness
■ No pupil response
○ Airway: issue swallowing
■ Suction at bedside
can provided
○ Cranial Nerves: pupil.
Swallowing, facial gaze, gag
reflex and etc
○ Bladder and Bowel Function
■ Bedpan
■ Foley - bladder scan
● For urine
retention
○ Maintain Skin and Limb
integrity
■ Reposition them
every 2 hours
■ Maintain proper body
alignment
■ Perform passive
motion technique
■ Watch out for
Neglect Syndrome/
Unilateral neglect
● Right side
injury and
ignore the left
side
● Teach patient
to always do a
conscious
● Monitor: effort to touch
 and feel the ■ Short phrases and
left side of the simple details
body ■ Use gestures and
■ Always scan the point
environment and ■ Be patient
surrounding to ■ Remove distractions
prevent injury of the ■ Repeat and repeat
affected side and rephrase
○ Hemianopia: Half od the ○ Expressive Aphasia: They
visual field is gone can comprehend but trouble
■ Increase risk for injury responding
■ Prevent injury by ■ Be patient and let
● Always turn them speak
head side to ● Don't rush and
side to see all fill out what
vision fields they say
○ Diet: Evaluated by SLP ■ Ask one question at a
■ Problems like time and let those
difficulty swallowing question be direct
occurs ■ Use communication
■ Thickened Liquid, board
crushed meds with
applesauce, our Grade: C
mechanical soft foods Percentage of What you Got Right: 71
○ Always assist patient with
eating Go Here for More Quizzes
■ Assess Pouching
food in cheeks can Your Answers & what you got Right &
increase risk for Wrong:
aspiration
■ Always assess risk 1. A patient is admitted with uncontrolled
for Aspiration atrial fibrillation. The patient’s medication
■ To prevent aspiration history includes vitamin D supplements and
TUCK IN CHIN TO calcium. What type of stroke is this patient
CHEST WHILE at MOST risk for?
SWALLOWING A. Ischemic thrombosis
● Communication: Aphasia B. Ischemic embolism
○ Always note that they don’t C. Hemorrhagic
have mental deficits D. Ischemic stenosis
○ They just can’t properly The answer is B. If a patient is in
communicate like they used uncontrolled a-fib they are at risk for clot
to be formation within the heart chambers. This
○ For Receptive aphasia: clot can leave the heart and travel to the
brain. Hence, an ischemic embolism type
stroke can occur. An ischemic thrombosis
type stroke is where a clot forms within the
artery wall of the neck or brain. 4. A patient who suffered a stroke one
month ago is experiencing hearing
problems along with issues learning and
2. Which patient below is at most risk for a showing emotion. On the MRI what lobe in
hemorrhagic stroke? the brain do you expect to be affected?
A. A 65 year old male patient with carotid A. Frontal lobe
stenosis. B. Occipital lobe
B. A 89 year old female with C. Parietal lobe
atherosclerosis. D. Temporal
C. A 88 year old male with uncontrolled The answer is D. The temporal lobe is
hypertension and a history of brain responsible for hearing, learning, and
aneurysm repair 2 years ago. feelings/emotions.
D. A 55 year old female with atrial flutter.
The answer is C. A hemorrhagic stroke
occurs when bleeding in the brain happens 5. A patient's MRI imaging shows damage
due to a break in a blood vessel. Risk to the cerebellum a week after the patient
factors for a hemorrhagic stroke is suffered a stroke. What assessment
uncontrolled hypertension, history of brain findings would correlate with this MRI
aneurysm, old age (due to aging blood finding?
vessels.) All the other options are at risk for A. Vision problems
an ischemic type of stroke. B. Balance impairment
C. Language difficulty
D. Impaired short-term memory
3. You're educating a patient about transient The answer is B. The cerebellum is
ischemic attacks (TIAs). Select all the important for coordination and balance.
options that are incorrect about this
condition:
A. TIAs are caused by a temporary 6. A patient is demonstrating signs and
decrease in blood flow to the brain. symptoms of stroke. The patient reports
B. TIAs produce signs and symptoms that loss of vision. What area of the brain do you
can last for several weeks to months. suspect is affected based on this finding?
C. A TIAs is a warning sign that an A. Brain stem
impending stroke may occur. B. Hippocampus
D. TIAs don't require medical treatment. C. Parietal lobe
The answers are B and D. Options A and C D. Occipital lobe
are CORRECT statements about TIAs. The answer is D. The occipital lobe is
However, option B is wrong because TIAs responsible for vision and color perception.
produce signs and symptoms that can last a
few minutes to hours and resolve (NOT
several weeks to months). Option D is 7. A patient has right side brain damage
wrong be TIAs do require medical from a stroke. Select all the signs and
treatment.
symptoms that occur with this type of 9. During discharge teaching for a patient
stroke: who experienced a mild stroke, you are
A. Right side hemiplegia providing details on how to eliminate risk
B. Confusion on date, time, and place factors for experiencing another stroke.
C. Aphasia Which risk factors below for stroke are
D. Unilateral neglect modifiable?
E. Aware of limitations A. Smoking
F. Impulsive B. Family history
G. Short attention span C. Advanced age
H. Agraphia D. Obesity
The answers are B, D, F, and G. Patients E. Sedentary lifestyle
who have right side brain damage will have The answers are A, D, and E. These risk
LEFT side hemiplegia (opposite side), factors are modifiable in that the patient can
confused on date, time, and place, unilateral attempt to change them to prevent another
neglect (left side neglect), DENIAL about stroke in the future. The other risk factors
limitations, be impulsive, and have a short are NOT modifiable.
attention span. Agraphia, right side
hemiplegia, aware of limitations, and
aphasia occur in a LEFT SIDE brain injury. 10. Your patient who had a stroke has
issues with understanding speech. What
type of aphasia is this patient experiencing
8. You're educating a group of nursing and what area of the brain is affected?
students about left side brain damage. A. Expressive; Wernicke's area
Select all the signs and symptoms noted B. Receptive, Broca's area
with this type of stroke: C. Expressive; hippocampus
A. Aphasia D. Receptive; Wernicke's area
B. Denial about limitations The answer is D.
C. Impaired math skills
D. Issues with seeing on the right side
E. Disoriented 11. Your patient has expressive aphasia.
F. Depression and anger Select all the ways to effectively
G. Impulsive communicate with this patient?
H. Agraphia A. Fill in the words for the patient they can't
The answers are A, C, D, F, and H. Patients say.
who have left side brain damage will have B. Don't repeat questions.
aphasia, be AWARE of their limitations, C. Ask questions that require a simple
impaired math skills, issues with seeing on response.
the right side, no deficit in memory, D. Use a communication board.
depression/anger, cautious, and agraphia. E. Discourage the patient from using words.
All the other options are found in right side The answers are C and D. Patients with
brain injury. expressive aphasia can understand spoken
words but can't respond back effectively or
at all. Therefore be patient, let them speak,
be direct and ask simple questions that
require a simple response, and 15. You're assessing your patient's pupil
communicate with a dry erase board etc. size and vision after a stroke. The patient
says they can only see half of the objects in
the room. You document this finding as:
12. While conversing with a patient who had A. Hemianopia
a stroke six months ago, you note their B. Opticopsia
speech is hard to understand and slurred. C. Alexia
This is known as: D. Dysoptic
A. Dysarthria The answer is A.
B. Apraxia
C. Alexia
D. Dysphagia 16. A patient who has hemianopia is at risk
The answer is A. for injury. What can you educate the patient
to perform regularly to prevent injury?
A. Wearing anti-embolism stockings daily
13. You're reading the physician’s history B. Consume soft foods and tuck in chin
and physical assessment report. You note while swallowing
the physician wrote that the patient has C. Scanning the room from side to side
apraxia. What assessment finding in your frequently
morning assessment correlates with this D. Muscle training
condition? The answer is C. Hemianopia is limited
A. The patient is unable to read. vision in half of the visual field. The patient
B. The patient has limited vision in half of needs to scan the room from side to side to
the visual field. prevent injury.
C. The patient is unable to wink or move his
arm to scratch his skin.
D. The patient doesn't recognize a pencil or 17. You receive a patient who is suspected
television. of experiencing a stroke from EMS. You
The answer is C. conduct a stroke assessment with the NIH
Stroke Scale. The patient scores a 40.
According to the scale, the result is:
14. You need to obtain informed consent A. No stroke symptoms
from a patient for a procedure. The patient B. Severe stroke symptoms
experienced a stroke three months ago. The C. Mild stroke symptoms
patient is unable to sign the consent form D. Moderate stroke symptoms
because he can't write. This is known as The answer is B. Scores on the NIH stroke
what: scale range from 0 to 42, with 0 (no stroke
A. Agraphia symptoms) and 21-42 (severe stroke
B. Alexia symptoms).
C. Hemianopia
D. Apraxia
The answer is A. 18. In order for tissue plasminogen activator
(tPA) to be most effective in the treatment of
stroke, it must be administered?
A. 6 hours after the onset of stroke D. Have the patient extend the neck upward
symptoms away from the chest while eating.
B. 3 hours before the onset of stroke The answer is B. Because the patient has
symptoms weakness on the right side and dysphagia
C. 3 hours after the onset of stroke the nurse should regularly check for
symptoms pouching of food in the right cheek.
D. 12 hours before the onset of stroke Pouching of food in the cheek can lead to
symptoms aspiration or choking. The HOB should be
The answer is C. tPA dissolves the clot >30', liquids thickened per MD order, and
causing the blockage in stroke by activating the patient should tuck in the chin to the
the protein that causes fibrinolysis. It should chest while swallowing.
be given within 3 hours after the onset of
stroke symptoms. It can be given 3 to 4.5
hours after onset IF the patient meets strict 21. A patient has experienced right side
criteria. It is used for acute ischemia stroke, brain damage. You note the patient is
NOT hemorrhagic!! experiencing neglect syndrome. What
nursing intervention will you include in the
patient's plan of care?
19. Which patients are NOT a candidate for A. Remind the patient to use and touch both
tissue plasminogen activator (tPA) for the sides of the body daily.
treatment of stroke? B. Offer the patient a soft mechanical diet
A. A patient with a CT scan that is negative. with honey thick liquids.
B. A patient whose blood pressure is C. Ask direct questions that require one
200/110. word responses.
C. A patient who is showing signs and D. Offer the bedpan and bedside commode
symptoms of ischemic stroke. every 2 hours.
D. A patient who received Heparin 24 hours The answer is A. It is important to watch for
ago. neglect syndrome. This tends to happen in
The answers are B and D. Patients who are right side brain damage. The patient ignores
experiencing signs and symptoms of a the left side of the body in this condition.
hemorrhagic stroke, who have a BP for The nurse needs to remind the patient to
>185/110, and has received heparin or any use and touch both sides of the body daily
other anticoagulants etc. are NOT a and that the patient must make a conscious
candidate for tPA. tPA is only for an effort to do so.
ischemic stroke.

20. You're assisting a patient who has right

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

16. A patient who is having a tonic-clonic

seizure is prescribed Phenobarbital. During
administration of this drug, it is important the
nurse monitors for:
HEADACHE ● Headache can be Divided into TWO
MAIN TYPES
DEFINITION: ● Cephalalgia
PRIMARY:
 ● Main and common type of ■ Pressure or tightened
headaches which waxes and
○ Unilateral Headache wanes
(Migraine) ○ Duration:
○ Tightness of the Head ■ Variable
Headache (Tension type ○ Associated Symptoms:
Headache) ■ None
○ Orbit area headaches ● Cluster Headache
(Cluster Headache) ○ Group of Idiopathic
○ Sinus Headache headache that is associated
○ Hormonal Headache with trigeminal neuralgia
SECONDARY: ○ Location:
● Pretty Bad Headaches ■ Always unilateral
● These are the Red Flag Headaches (around the eyes)
PRIMARY HEADACHE ○ Characteristics:
PATHOPHYSIOLOGY ■ Pain begins quickly
● Migraine: ■ Deep continuous pain
○ Disorder of recurrent attacks ■ Excruciating and
○ Location: Unilateral (70%) explosive in quality
○ Characteristics: ○ Durations:
■ Gradual Onset ■ 1o mins to 1 hour
■ Crescendo Pattern ○ Associated Symptoms:
■ Moderate to severe ■ Horner's Symptoms
intensity ● Ptosis
○ Duration: ● Miosis
■ 4-72 hours ● Pain
○ Associated Symptoms: ■ Lacrimation
■ Nausea ■ Nasal Discharge
■ Vomiting ○ Function of Trigeminal
■ Photophobia Nerve:
■ Phenophobia ■ Important for the
■ Aura sensation around
● Tension Headache your forehead which
○ More muscular is supplied by the
■ Most ambiguous ophthalmic branch of
headache headache the trigeminal (V1)
■ Its the most common ■ Maxillary Branch (V2)
reason why OTC ■ Mandibular Branch
analgesia are (V3)
purchased ● Sinus Headache:
○ Location: ○ Associated with Sinusitis
■ Bilateral ● Hormonal Headache:
○ CHaracteristics: ○ Associated with Low
estrogen concentration
 ■ Beginning of ○ N Neurological symptoms or
menstrual cycle abnormal signs
■ Withdrawal of ○ O Onset is new (Age >40) or
Hormone Therapy sudden (Thunderclaps)
TREATMENT Stroke
● Migraine: ○ O Other associated condition
○ NSAIDs/ Aspirin + Antiemetic or features
○ Hydration ○ P Precious Headache History
● Tension Headache: with headache progression
○ OTC paracetamol or change in attack character
● Cluster Headache: *The Head is very abnormal, it indicates a
○ Subcutaneously very serious problem
Sumatroptophan or Oxygen
○ Triptants are Intracranial Hemorrhage
Contraindicated in patient ● Subdural
with CAD, PVD, or ● Epidural
Cerebrovascular Disease ● Subarachnoid
● Sinusitis Headache:
● Supportive Therapy
○ Analgesic/Anti
Inflammatory
○ Antibiotics

SECONDARY HEADACHE
PATHOPHYSIOLOGY
● It is a result of an underlying
disease/conditions
● Warning signs and symptoms
○ S Systemic Symptoms
(Illness or conditions like
cancer)
○ Their task is handling and
transmitting information and
DEFINITION: impulses
● Abnormal electrical signals in the 2 Types of Neuron
brain being fired from neurons: ● Excitatory
Two Category: ○ Whenever they are
○ Generalize (both side of the stimulated they will cause a
brain) response
○ Focal (partial seizure and ○ They will release a
only target specific parts of neurotransmitter glutamate
the brain) ● Inhibitory
PHYSIOLOGY ○ They will inhibit a response
● Neurons they will decrease it
 ○ They will release a ○ Hugh fever
neurotransmitter GABA ○ CNS infection
There is an equilibrium for a patient who ○ Hypoglycemia
does not have a seizure ○ EtOH withdrawal
○ Acid-base imbalances
Problem: Damage in inhibitory neuron will ○ Hypoxia
be damage then there won’t be an inhibiting ○ Brain tumor
excessive excitatory neurotransmitter ● But some patient Epilepsy frequent
release by the excitatory muscle-- seizures activity due to Chronic
overstimulation of the brain condition
● For example, the Barbituates- will ○ Traumatic brain injury (TBI)
stimulate the GABA receptors that ○ congenital birth defect
will decrease the excitatory ○ Massive Stroke
○ Idiopathic
CAUSE ○ Effects of an illness
● Affects Anyone due to an acute
illness
GUILLAIN-BARRE SYNDROME ○ It receives and transmit
signals so some type of
DEFINITION: action can occur
● Autoimmune condition ○ For sensory and motor
● The immune system attacks nerves ■ The nerve receives
in the body specifically in impulses at the
○ Peripheral Nervous system dendrites
■ Nerves located ■ Then to the stoma
outside the spinal ■ And go through the
cords Axon with Myelin
○ Cranial Nerves sheaths
● Immune system attacking ● Purpose of Myelin Sheath
○ Myelin Sheath ○ It serves as an insulator that
○ Demyelination is occurring can allow smooth passage of
● If the GBS is severe enough it can signals without being
extends to the autonomic nervous interrupted
system ○ Then allows it to reach to the
● GBS=Gradual block axon terminal
RISK FACTOR: PATHOPHYSIOLOGY
● If a defect was found in the Nerve
ANATOMY AND PHYSIOLOGY: ○ Sensory and Nerve function
● Peripheral Nervous System: will not be effective
○ Somatic: control voluntary ○ Can lead to Respiratory
functions Failure as the disease
○ Autonomic: Controls ● There is an existing condition that
involuntary functions triggers this condition
● Purpose of Nerve:
 ○ May ask the patient’s history ○ It is symmetrical
extensively ● This can lead to paralysation of the
● GBS can affect anyone at any age, body
any gender and any race ● The myelin sheath is destroyed and
● There is no cure to this disease won’t get any signal
If illness does exist WHY?
● The immune system usually fights ● Report illness
the illness but somewhere along the ○ 1-3 weeks of upper
way it got confuse and attacked the respiratory disease or an
Myelin sheath Gastrointestinal Disease
● Gradual Block of Sensation ■ Caused by a
Campylobacter
Different Type of Guillain Barre Jejuni
Syndrome ○ “As many as 40 percent of
❏ Miller Fisher Syndrome: GBS cases in the United
❏ MFS originates in the eyes, stated are thought to be
adversely affecting the triggered by Campylobacter
manner in which the infection” +
individual walks. It is more ○ Also link with patient with
prevalent in Asia compared Epstein Barr Virus {EBV}
to North America. ○ Also link with HIV and AIDS
❏ Acute Motor Axonal Neuropathy ○ Also link with recent
(AMAN)/Acute Motor-Sensory vaccination
Axonal Neuropathy (AMSAN): ■ Swine flu
AMSAN and AMAN ■ Influenza
❏ affect more people in Asian
countries in comparison to PATHOPHYSIOLOGY
the USA. ● If a defect was found in the Nerve
❏ Acute Inflammatory ○ Sensory and Nerve function
Demyelinating will not be effective
Polyradiculoneuropathy (AIDP): ○ Can lead to Respiratory
❏ It is the most widespread Failure as the disease
form of GBS, characterized
by muscular weakness and ● Lower extremities they felt
numbness that develops numbness and tingling and they
from the lower extremity and have trouble walking
shoots upward. Majority of ○ They reported that they have
affected Americans are severe GI illness caused by
diagnosed with the AIDP Campylobacter Jejuni
WHAT HAPPENS: ● Peripheral nerves starts
● .It tends to start in the feet demyelination downwards then
○ Feeling of paresthesia ascends
{tingling, numbness ● .After 2 weeks
● It migrates upward/ ascends
 ○ Work signs and symptoms ■ And patient will start
occur experiencing Difficulty
● After the worst scenario breathing
○ Remyelination occurs ○
○ The symptoms starts SIGNS AND SYMPTOMS
subsiding ● Paresthesia at the lower extremities
○ They start to get better ● Migration upward/ Ascending
● After 1 to 2 years Numbness and tingling
○ The symptoms will reoccur symmetrically
● Paralysis on the waist down
Worst case scenario ● Absent Reflexes
● Cranial: Migrates to brain stem ● Loss Muscle Time
○ Face paralysis ● Patient will complain difficulty
○ Difficulty Swallowing breathing
○ Difficulty Speaking ○ Ineffective cough
○ Vissium issue ○ So Always prepare Airway
● Severe Pain at the cramps of muscle management kit at the
○ Odd paradox bedside
● Involvement of Autonomic nervous ● Difficult swallowing
system ○ They can aspirate and can
○ Heart: develop pneumonia
■ Dysrhythmias ○ Always assess swallowing
■ Orthostatic activity
Hypotension ● They can’t speak and articulate
■ Paroxysmal words
Hypertension ○ Always provide a
● GI system: communication boards
○ Constipation ○ Always provide they
■ Feeding tube and assurance that this is
always be alerted that temporary and they can
if bowel sound is regain their sensation back
present- paralytic DIAGNOSTIC AND LABORATORY TEST
ileus ● electromyography and Nerve
■ Always check Conduction Studies
Residuals ○ Assess the demyelination of
■ the nerves by determining
○ Renal muscle’s ability to response
■ Urinary Retention to nerve stimulation
● As disease progresses and ascends ● Lumbar Puncture:
in the chest ○ Elevated Protein without
○ Muscle wall responsible for elevated white blood cell
drawing air in and out will ■ Before: Empty
start to paralyze Bladder
 ■ During: Position Your Grade: B
lateral recumbent with Percentage of What you Got Right: 82
knee up to abdomen
and bend chin to Go Here for More Quizzes
chest
■ After: Lie flat needs Your Answers & what you got Right &
to consume a lot of Wrong:
fluids to prevent
headache and to 1. True or False: Guillain-Barré Syndrome
replace loss CSF occurs when the body's immune system
TREATMENT attacks the myelin sheath on the nerves in
● TReatment can not CURE the central nervous system.
● They can only decrease recovery True
time and Improves Signs and False
Symptoms FALSE: Guillain-Barré Syndrome is an
○ Decrease signs and autoimmune neuro condition where the
symptoms immune system attacks the nerves (myelin
● They have to be administered 2 sheath) in the PERIPHERAL NERVOUS
weeks from the onset of symptoms SYSTEM and cranial nerves. This condition
MEDICATION does NOT occur in the central nervous
● Immunoglobulin Therapy: system (CNS).
○ IV immunoglobulin from a
donor given to the patient to
stop the antibodies that are 2. During nursing report you learn that the
damaging the nerves patient you will be caring for has Guillain-
● Plasmapheresis Barré Syndrome. As the nurse you know
○ Machine that will filter the that this disease tends to present with:
blood to remove the A. signs and symptoms that are unilateral
antibodies from the plasma and descending that start in the lower
that are attacking the myelin extremities
sheth B. signs and symptoms that are symmetrical
NURSING INTERVENTION and ascending that start in the upper
● Immobility and Paralysis can lead to extremities
Increase risk for infection, blood C. signs and symptoms that are
clots, pressure injuries UTIs, Weight asymmetrical and ascending that start in the
loss upper extremities
○ They can be Intubated D. signs and symptoms that are
○ Anticoagulants and monitor symmetrical and ascending that start in the
SCDs lower extremities
○ Turning them frequently The answer is D. GBS signs and symptoms
○ Physical therapy and will most likely start in the lower extremities
p[reventing contractures (ex: feet), be symmetrical, and will gradually
○ Maintain muscle Integrity spread upward (ascending) to the head.
○ Monitor Weights daily There are various forms of Guillain-Barré
Syndrome. Acute inflammatory C. The patient has absent reflexes in the
demyelinating polyradiculoneuropathy lower extremities.
(AIDP) is the most common type in the U.S. D. The patient reports paresthesia in the
and this is how this syndrome tends to upper extremities.
present. The answer is B. The patient’s signs and
symptoms in this scenario are typical with
Guillain-Barré Syndrome. The syndrome
3. You're assessing a patient's health tends to start in the lower extremities (with
history for risk factors associated with paresthesia that will progress to paralysis)
developing Guillain-Barré Syndrome. Select and migrate upward. The respiratory system
all the risk factors below: can be affected leading to respiratory
A. Recent upper respiratory infection failure. Therefore, the nurse should assess
B. Patient's age: 3 years old for any signs and symptoms that the
C. Positive stool culture Campylobacter respiratory system may be compromised
Jejuni (ex: weak cough, shortness of breath,
D. Hyperthermia dyspnea...patient says it is hard to breath
E. Epstein-Barr etc.). The nurse should immediately report
F. Diabetes this to the MD because the patient may
G. Myasthenia Gravis need mechanical ventilation. Absent
The answers are: A, C, and E. Risk factors reflexes is common in GBS and paresthesia
for developing Guillain-Barré Syndrome can extend to the upper extremities as the
include: experiencing upper respiratory syndrome progresses. A headache is not
infection, GI infection (especially from common.
Campylobacter Jejuni), Epstein-Barr
infection, HIV/AIDS, vaccination (flu or
swine flu) etc. 5. A patient with Guillain-Barré Syndrome
has a feeding tube for nutrition. Before
starting the scheduled feeding, it is essential
4. A 25 year-old presents to the ER with the nurse? Select all that apply:
unexplained paralysis from the hips A. Assesses for bowel sounds
downward. The patient explains that a few B. Keeps the head of bed less than 30'
days ago her feet were feeling weird and degrees
she had trouble walking and now she is C. Checks for gastric residual
unable to move her lower extremities. The D. Weighs the patient
patient reports suffering an illness about 2 The answers are A and C. Some patients
weeks ago, but has no other health history. who experience GBS will need a feeding
The physician suspects Guillain-Barré tube because they are no longer able to
Syndrome and orders some diagnostic swallow safely due to paralysis of the
tests. Which finding below during your cranial nerves that help with swallowing.
assessment requires immediate nursing GBS can lead to a decrease in gastric
action? motility and paralytic ileus. Therefore,
A. The patient reports a headache. before starting a scheduled feeding the
B. The patient has a weak cough. nurse should always assess for bowel
sounds and check gastric residual.
6. You’re educating a patient about 8. You're teaching a group of nursing
treatment options for Guillain-Barré students about Guillain-Barré Syndrome
Syndrome. Which statement by the patient and how it can affect the autonomic nervous
requires you to re-educate the patient about system. Which signs and symptoms
treatment? verbalized by the students demonstrate they
A. "Treatments available for this syndrome understood the autonomic involvement of
do not cure the condition but helps speed this syndrome? Select all that apply:
up recovery time." A. Altered body temperature regulation
B. "Plasmapheresis or immunoglobin B. Inability to move facial muscles
therapies are treatment options available for C. Cardiac dysrhythmias
this syndrome but are most effective when D. Orthostatic hypotension
given within 4 weeks of the onset of E. Bladder distension
symptoms." The answers are A, C, D, and E. All these
C. "When I start plasmapheresis treatment are some signs and symptoms that can
a machine will filter my blood to remove the present in severe cases of GBS when the
antibodies from my plasma that are autonomic nervous system is involved.
attacking the myelin sheath."
D. "Immunoglobulin therapy is where IV
immunoglobulin from a donor is given to a 9. You're about to send a patient for a
patient to stop the antibodies that are lumbar puncture to help rule out Guillain-
damaging the nerves. Barré Syndrome. Before sending the patient
The answer is B. This statement is you will have the patient?
incorrect. Plasmapheresis and A. Clean the back with antiseptic
immunoglobin therapies are treatment B. Drink contrast dye
options available for GBS, BUT they are C. Void
only really effective when given within 2 D. Wash their hair
weeks from the onset of symptoms (not 4 The answer is C. The patient will need to
weeks). void and empty the bladder before going for
a LP. This will help decrease the chances of
the bladder becoming punctured during the
7. Which tests below can be ordered to help procedure.
the physician diagnose Guillain-Barré
Syndrome? Select all that apply:
A. Edrophonium Test 10. Your patient is back from having a
B. Sweat Test lumbar puncture. Select all the correct
C. Lumbar puncture nursing interventions for this patient?
D. Electromyography A. Place the patient in lateral recumbent
E. Nerve Conduction Studies position.
The answers are C, D, and E. These are the B. Keep the patient flat.
tests that can be ordered to help the MD C. Remind the patient to refrain from eating
determine if the patient is experiencing or drinking for 4 hours.
GBS.
D. Encourage the patient to consume liquids 11. The patient's lumbar puncture results
regularly. are back. Which finding below correlates
The answers are B and D. The patient will with Guillain-Barré Syndrome?
need to stay flat after the procedure for a A. high glucose with normal white blood
prescribed amount of time to prevent a cells
headache, and the nurse will need to B. high protein with normal white blood cells
encourage the patient to drink fluids C. high protein with low white blood cells
regularly to help replace the fluid lost during D. low protein with high white blood cells
the lumbar puncture. The answer is B.

MULTIPLE SCLEROSIS ○ They receives to create

some types of action
DEFINITION ● Soma/Body:
● Autoimmune disease that affects the ○ Helps pass the signal receive
Myelin sheath of the neuron on on the Dendrites and help it
the CNS pass to the rest of the bodies
● MS=Myelin Sheath=Multiple ● Axon Hillock
sclerosis ○ Axon connect
○ Neuron can become inflamed ● Axon:
and scar ○ It takes impulses away from
○ It decreases the nerve signal the neuron
transmission ○ Myelin sheath
○ Lead in many motor sensory ■ What protect the
problem Axon
QUICK FACTS ■ What allows easy
● This disease is immune related passage of the
● Symptoms Vary signals
○ Because it can affect ■ Serves as an
different parts of the neurons insulator
and lobes in the brain ■ They are made up of
○ Example Cerebellar: tremor, Schwann Cells: fats
dysarthria, ataxia, cognition and proteins
○ Occipital Lobe: Eye problems ● There is good synapse- nerve
● Women 20-40 years old signal is passed
● Cause is unknown ○ Because the myelin sheath
● No cure facilitates the impulses for it
○ Lifestyle change and to restructure that permits a
medication are needed to neuron (or nerve cell) to pass
improve signs and symptoms an electrical or chemical
● Appear and Disappear signal to another neuron or to
○ Relapsing remitting MS the target effector cells the
ANATOMY Axon terminal
● Dendrites: ○
pATHOPHYSIOLOGY ● Remember that symptoms may vary
● Demyelination in progress depending on the lobe and structure
○ Damage of the myelin it will affects
sheaths ● And * can indicated early
● When an impulse/signal is symptoms
transferred down to this neuron Emotions and Cognitive
○ Not gonna happen correctly ● Drained/fatigues*
○ Not strong enough ○ Even though they didn’t do
● There won’t have stimulation of the anything
muscle/organ that it supplies ● Depressed
● They is no synapse/ signal ● Speech issues *
stimulation ○ Dysarthria-Cerebellar lesions
○ The signal received in the ○ Swallowing problem*
axon terminal is not enough ■ Dysphagia
○ There is none signal received ● Mood swings
● Multiple sclerosis Concept: ● Trouble thinking -cerebellar problem
○ We are talking of the nerve cells ○ Focus
in the CNS ○ Problem solving problem
■ Brain and spinal cord ○ Thinking problem
○ Sensory problems and motor
Sensation issues:
● Remors
problems
● Spasms*
■ Touch and vision
○ Can be very painful
■ Emotional and cognitive
● Clumsiness*
position
○ They may feel drunk
■ Coordination an bladder
○ Can lead to injury
symptoms
● Numbness*
○ Tingling on the face and
extremities
● Dizziness/vertigo*
● Coordination*
● + Romberg signs
○ Patient stand with their eyes
close and feet together
○ + they have lesion on
cerebellar area
■ Proprioceptors
■ Loss of balance and
sway
● + Lhermitte’s signs
RISK FACTORS
○ It is where the patient
● SDASASD
whenever they move their
SIGNS AND SYMPTOMS
head in various motion they
 can experience electric ○ This allows viewing of the
shock down in their body Inflammation of the brain and
■ Electric shock spinal cord
sensation ● Lumbar puncture:
■ L-Lighting shock ○ CSF oligoclonal bands
VISION ○ High amount of proteins and
● Nystagmus Oligoclonal bands
● Optic Neuritis* ● Evoked potential studies
● It is where the optic nerve that ○ They will evoked an electrical
supplies the eyes gets inflamed and signet to the CNS to create a
scarred because of the response
demyelination of myelin sheaths TREATMENT
○ Double vision ● SDASASD
○ Blurry MEDICATION
○ Dull/gray vision ● Beta Interferon:
○ Pain moving eyes ○ Decreases the number of
○ Dark spot vision relapses of symptoms by
ELIMINATION* decreasing inflammation and
● Can’t hold urine: the immune response
○ Nocturia-peeing alot at night towards the Myelin sheath
○ overactive bladder ■ Can be High risk for
● Problems with contracting to coid infection
○ Urinary retention . ■ It can decrease
○ At risk for WBCs
■ UTIs and renal stones ○ Drug Names: ANOVEX
● Bowel: {Interferon beta 1a}, Rebif,
○ constipation Betaferon
○ Diarrhea ● Corticosteroids:
○ Can’t hold stool ○ For those who’s already
UHTHOFF’s SIGN having relapse of MS
● Heat makes signs and symptoms ○ Ordered to decrease the
worst
inflammation and to
DIAGNOSTIC PROCEDURE
decrease that immune
● It really takes time
response
● Neurologist assess various things:
○ Drug Names:
○ There is no single test to rule
Methylprednisolone,
out MS
prednisone
● Patient’s signs and symptoms:
For Bladder issue: Medication includes
○ They must be assessed
● OXYBUTYNIN
thoroughly because the S ○ Anticholinergic
and S may mimic other ○ It helps with overactive
disease bladder by relaxing the
● MRI bladder muscle to prevent
○ In the brain and Spinal cord contraction
 ● BETHANECHOL: ○ Provide stress relief
○ Cholinergic techniques
○ Helps with emptying the ● Infection
bladder by helping with ○ Avoid infection
bladder contraction ● Overexertion
Medication for Fatigue: ○ Exercise is needed to
● Amantadine improve tolerance
○ Antiviral and antiparkinsonian ○ BUT DONT DO IT OVERLY
○ It has CNS effects that helps ■ Relax
improve fatigue in patient ○ Swimming exercise is good
with MS ■ Because water is cool
● Modafinil ● Remember UHTHOFF's Sign
○ CNS stimulant ○ Avoid Heat
Spasms: ■ No heating pads,
● Baclofen: warming blankets,
○ Skeletal muscle relaxants keeping room and
that acts centrally temp hot
● Diazepam ASSISTIVE DEVICES:
Tremors: ● Showering is difficult and standing is
● Propranolol a problem
○ Beta Blockers ○ Provide shower chair
○ Warn the patient with DM ○ Railing
that if they take this ● Creating a clutter free room
medication ○ Eyes problem
■ They when they go ● Scan the environment before they
Hypo can cause get up
tremors
● Isoniazid: Speech language pathology
○ Antibiotic used for infection ● Speech problem
○ Especially with TB ○ For Dysarthria patient
○ Helps with certain tremors in ● Swallowing problems
MS ○ Dysphagia
NURSING INTERVENTION ○ Aspiration
● Safety {Vision, coordination, ■ Assess lung sound
decrease reception pain,
bowel/bladder issue, Remitting Physical therapist
Relapse MS RRMS prevention, ● Exercise and regimens
Medication} ● Help them us assistive devices
Preventing the increase ef Signs and
Symptoms: Support groups
● Stress. ● Support to one another
○ Provide and nice,
comfortable, and non Bower Problems
stressful environment ● Constipation
 ○ Increase fiber nervous system) and when the myelin
○ Stool softer sheath becomes damaged it leads to a
● Incontinent stool decrease in nerve transmission.
○ Skin care
Bladder Problems
● Overactive bladder 2. True or False: Multiple Sclerosis tends to
○ Always assure easy access ti affect men more than women and occurs
the comfort room that are during the ages of 50-70 years.
clutter free True
● Incontinence: False
○ Foley catheter False: MS affects WOMEN more than men
○ Assess for skin break down and shows up during the ages of 20-40
○ Provide clean pads years.
○ Self Catheter
● Skin problem:
○ Provide skin care 3. True or False: Patients with multiple
○ 1-2 fluids a day to prevent sclerosis have different signs and symptoms
concentration because this disease can affect various
our Grade: D areas of the peripheral nervous system.
Percentage of What you Got Right: 67 True
False
Go Here for More Quizzes False: Yes, patients with MS have different
signs and symptoms because lesions can
Your Answers & what you got Right & present at different locations in the
Wrong: CENTRAL NERVOUS SYSTEM....hence
the brain and spinal cord (not the peripheral
1. Select all the TRUE statements about the nervous system).
pathophysiology of multiple sclerosis:
A. "The dendrites on the neuron are
overstimulated leading to the destruction of 4. A patient is suspected of having multiple
the axon." sclerosis. The neurologist orders various
B. "The myelin sheath, which is made up of test. The patient's MRI results are back and
Schwann cells, is damaged along the axon." show lesions on the cerebellum and optic
C. "This disease affects the insulating nerve. What signs and symptoms below
structure found on the neuron in the central would correlate with this MRI finding in a
nervous system." patient with multiple sclerosis?
D. "The dopaminergic neurons in the part of A. Blurry vision
the brain called substantia nigra have B. Pain when moving eyes
started to die." C. Dysarthria
The answers are B and C. In multiple D. Balance and coordination issues
sclerosis the myelin sheath (which is the E. "Pill rolling" of fingers and hands
insulating and protective structure made up G. Heat intolerance
of Schwann cells that protects the axon) is H. Dark spots in vision
damaged. MS affects the CNS (central I. Ptosis
The answers are A, B C, D, and H. If lesions D. The patient reports an electric shock
are present on the optic nerves, optic feeling when the head and neck are moved
neuritis can occurs which can lead to blurry downward.
vision, pain when moving the eyes, and The answer is B. This is an example of a
dark spots in the vision. If cerebellar lesions positive Romberg's Sign.
are found, this can affect movement,
speech, and some cognitive abilities. This
would present as dysarthria (issues 7. Your patient is scheduled for a lumbar
articulating words), and puncture to help diagnose multiple
balance/coordination issues. "Pill rolling" of sclerosis. The patient wants clarification
the fingers and hands is found in about what will be found in the
Parkinson's disease. Ptosis is common in cerebrospinal fluid during the lumbar
myasthenia gravis, and heat intolerance in puncture to confirm the diagnosis of MS.
thyroid issues. You explain that ____________ will be
present in the fluid if MS is present.
A. high amounts of IgM
5. You're performing a head-to-toe B. oligoclonal bands
assessment on a patient with multiple C. low amounts of WBC
sclerosis. When you ask the patient to move D. oblong red blood cells and glucose
the head and neck downward the patient The answer is B. These specific proteins,
reports an "electric shock" sensation that oligoclonal bands, which are
travels down the body. You would report immunoglobulins will be found in the CSF.
your finding to the doctor that the patient is This demonstrates there is inflammation in
experiencing: the CNS and is a common finding in
A. Romberg's Sign multiple sclerosis.
B. Lhermitte's Sign
C. Uhthoff's Sign
D. Homan's Sign 8. You're developing a plan of care for a
The answer is B. This finding is known as patient with multiple sclerosis who presents
Lhermitte's Sign. with Uhthoff's Sign. What interventions will
you include in the patient's plan of care?
Select all that apply:
6. Which finding below represents a positive A. Avoid movements of the head and neck
Romberg Sign in a patient with multiple downward
sclerosis? B. Keep room temperature cool
A. The patient report dark spots in the visual C. Encourage patient to use warm packs
fields during the confrontation visual field and heating pads for symptoms
test. D. Educate the patient on three ways to
B. When the patient closes the eyes and avoid overheating during exercise
stands with their feet together they start to The answers are B and D. Uhthoff's Sign is
lose their balance and sway back and forth. where when the patient experiences too
C. The patient's sign and symptoms much heat their symptoms increase and get
increase when expose to hot temperatures. worst. Therefore, it is important the patient
stays cool and doesn't overheat
(overheating can come from outside The answer is A. This medication is a
temperatures, exercise, emotional events cholinergic medication that will help with
etc.). The room should be cool and the bladder emptying.
patient should be encouraged to exercise
but to avoid overheating.
11. A patient is receiving Interferon Beta for
treatment of multiple sclerosis. As the nurse
9. During your discharge teaching to a you will stress the importance of?
patient with multiple sclerosis, you educate A. Physical exercise to improve fatigue
the patient on how to avoid increasing B. Low fat diet
symptoms and relapses. You tell the patient C. Hand hygiene and avoiding infection
to avoid: D. Reporting ideation of suicide
A. Cold temperatures The answer is C. Interferon Beta decreases
B. Infection the number of relapses of symptoms in MS
C. Overexertion patients by decreasing the immune system
D. Salt response, but it lowers the white blood cells
F. Stress count. Hence, there is a risk of infection. It is
The answer is B, C, and F. The patient very important the nurse stresses the
should also avoid extreme heat, which can importance of hand hygiene and avoiding
increase symptoms. infection.

10. A patient with multiple sclerosis has 12. Which medications below can help treat
issues with completely emptying the muscle spasms in a patient with multiple
bladder. The physician orders the patient to sclerosis? Select all that apply:
take ___________, which will help with A. Propranolol
bladder emptying. B. Isoniazid
A. Bethanechol C. Baclofen
B. Oxybutynin D. Diazepam
C. Avonex E. Modafinil
D. Amantadine The answers are C and D. These
medications treat muscle spasms in patients
with MS.
MYASTHENIA GRAVIS ■ Drooping of the eyes
■ Diplopia/Lazy eyes
DEFINITION ■ Strabismus
● Autoimmune Condition ○ Throat: Another common
● Body attacks the muscle receptors signs
that controls the voluntary muscles ■ Weakens muscle on
Can lead to : throat
● Muscle weakness ■ Dysphasia
Organs Involves: ■ Hoarseness of voice
● Voluntary Muscles: ■ Chewing is an effort
○ Eyes: Most likely 1st signs ○ Arms and Legs
 ○ Respiratory ○ And they bind with
■ Severe case Nicotinic Acetylcholine
QUICK FACTS receptors {nAChRs}
● This disease is immune related ○ Acetylcholinesterase
● Symptoms Vary {AChE}
○ Because it can affect ■ Enzymes that Break
different Down acetylcholine
RISK FACTORS into two pieces
● This disease is immune related ● It allows the motor neuron to
● Symptoms Var transmit a signal to the muscle fiber,
ANATOMY causing muscle contraction.
● Muscles require innervation to
function—and even just to maintain
muscle tone, avoiding atrophy. In the
neuromuscular system nerves from
the central nervous system and the
peripheral nervous system are linked
and work together with muscles.
PATHOPHYSIOLOGY
● Key player:
○ Neuromuscular Junction
■ Nicotinic
● Key player: Acetylcholine
○ Neuromuscular Junction Receptors
■ Nicotinic ■ Function of Muscle
Acetylcholine Specific Kinase
Receptors ■ Acetylcholine
■ Function of Muscle ■ Immune system
Specific Kinase ● Produces
■ Acetylcholine antibodies
■ Immune system against
● Produces receptors
antibodies ● Thymus gland
against ● The Immune system build up an
receptors antibody that destroys the Nicotinic
● Thymus gland Acetylcholine receptors {nAChRs}
● A neuromuscular junction (or ● Alot of them won’t be available and
myoneural junction) is a chemical working meaning that they are not
synapse between a motor neuron functioning well
and a muscle fiber. ○ They won’t be able to receive
○ Cholinergic fibers initiates the the Acetylcholine
release of acetylcholine ○ Muscle fibers won’t be
contracting like they
should
 ■ WEAKNESS receptor site of
● Antiacetylcholinesterase are neuromuscular junction
administer ○ Making acetylcholine not
○ Like Pyridosestigmy reaching the tissue site
○ To prevent breakdown ■ To create voluntary
○ So more acetylcholine can contraction
be made available to these SIGNS AND SYMPTOMS
limited receptors ● ****Hallmark:
○ To increase muscle strength ○ Muscle weakness gets worse
● Thymus Gland with activity
○ Location: Anterior at the ■ Especially repetitive
upper part of the body activity
■ Behind the sternum ■ Because the
and between the receptors are very
lungs limited and remaining
○ Provides a very important acetylcholine is very
role on our immune system abundant but can be
and health destroyed later on
○ Creator or T cells when enzyme breaks
■ Fighting against them down
viruses and bacteria ○ But will improve after resting
and cell the muscle
○ This tends to be enlarge at ● “W.E.A.K.N.E.S.S”
children than an adult ○ Weakness of the neck, face,
■ By puberty the arms and legs “hemiplegia”
thymus gland has ○ Eyelid drooping “Ptosis”
usually produce a ○ Appearance mask like
lifelong supply of t ■ Very sleepy
cells that we are expression
going to need ○ Keep on choking/gagging
○ ABut as person ages usually when eating
in the older age the thymus ■ Risk for aspiration
gland will actually turn into ○ No Energy
fatty tissue ■ Do it in the morning
● People with Myasthenia Gravis the when they have
thymus gland is still enlarge enough rest
○ They are not small like they ■ When patient has
should be more energy to do
○ They have tumors stuff
○ A Lot of immune cell has ○ Extraocular Muscle
congregate together Involvement
○ The thymus is actually ■ Strabismus
erroneously creating this ■ Diplopia
antibodies to attracts the ○ Slurred speech
 Shortness of breath
○ the receptors and
COMPLICATION wear them out
● Myasthenic Crisis ■ This will result a
○ Disease can go to remission decrease in the
{no signs and number of nicotinic
symptoms1]BUT can Acetylcholine
experience acute receptors available
exacerbation ■ They can be tolerant
■ THIS occurs because ○ Severe muscle weakness
they are not receiving and respiratory depression
acetylcholine like they ○ Making Acetylcholine
should abundant in the synapses
● Because LABORATORY AND DIAGNOSTIC
Cholinesteras PROCEDURE
e an enzyme ● Tensilon Test
will ○ A medication Edrophonium
continuously is given
breakdown ○ Used to diagnose and
acetylcholine differentiate myasthenic and
● Making cholinergic crisis in
acetylcholine myasthenia gravis
not available ○ It’s an anticholinesterase:
for the ■ Prevents breakdown
receptors acetylcholine more
■ Muscle can’t contract available at
○ Severe muscle weakness neuromuscular
and respiratory failure junction and makes it
■ Need for intubation more available to the
and mechanical site
ventilator Result:
○ Cause? ● Myasthenia gravis or crisis:
■ Not enough ○ They will get better
Anticholinesterase ○ Strength is improved
Medication ● Cholinergic Crisis
■ Stress ○ Strength becomes worst
■ Respiratory infection ○ Weaker
● Frequent use ○ Provide antidote:
of muscle ■ Physostigmine
■ Surgery ■ Atropine
● Cholinergic Crisis: {anticholinergic}
○ Too much medication TREATMENT and MEDICATION
■ Where a lot a ● NO CURE
acetylcholine will ● Anticholinesterase
continuously bombard “Pyridostigmine”
 ○Take 30 minutes to 1 hours ○ Strength of arms and legs
before meal-peak ● Determine swallowing function
● Complication: Myasthenic Crisis ○ Before eating and
{inadequate medication} and administration of PO
● Complication: Cholinergic Crisis medication
{Too much medication} ● Speech Langage pathologist must
○ Signs and Symptom: Similar be referred to patient
to over stimulation of the ● Always secure safety
parasympathetic system ○ Always assess any risk for
“Rest and digest” fall
■ Bradycardia ■ Weak arms and leg
■ Pupil constriction ■ Low rr-they might
■ Bronchospasm pass out
■ Increase salivation ■ Vission problem
and Mucous ● Aspiration
■ GI: cramping and ○ Speech Pathologist
diarrhea ○ Evaluate swallowing
■ Bladder incontinence ○ During feeding the head over
■ Muscle weakness bed mus be raised at >30
and respiratory failure degree
● Corticosteroid: ● Educating of Eating:
○ To decrease inflammatory ○ Larger meals in the morning
response because they have energy to
● IV immunoglobulins chew
● Plasmapheresis ■ Then small meal later
○ Dialysis in day
○ Blood is filtered and removes ○ Schedule medication 30 mins
antibodies to 1 hour after taking
● Thymectomy anticholinesterase
○ Improves signs and ■ It is the peak time of
symptoms the medication
NURSING INTERVENTION ○ Thicken liquid
● Note improvement, cardiac monitor, ○ Small bites, soft foods
make atropine available, have the ○ Perform most activities in the
crash cart at the bedside morning
● Monitor respiratory status: ■ Ambulating
○ Effort of breathing ■ Leg rolling
○ Respiratory rate ■ And other procedure
○ Suction must be provided to
prevent aspiration Your Grade: A
● Neuromuscular functions Percentage of What you Got Right: 90
○ Assess cranial nerves
○ Vision, sound of voice Go Here for More Quizzes
○ Speech, facial appearance
Your Answers & what you got Right & At what time should you administer this
Wrong: medication so the patient will have the
maximum benefit of this medication?
1. Myasthenia gravis occurs when A. As soon as possible
antibodies attack the __________ receptors B. 1 hour after the patient has eaten (at
at the neuromuscular junction leading to 1300)
____________. C. 1 hour before the patient eats (at 1100)
A. metabotropic; muscle weakness D. at 1200 right before the patient eats
B. nicotinic acetylcholine; muscle weakness The answer is C. Pyridostigmine is an
C. dopaminergic adrenergic; muscle anticholinesterase medication that will help
contraction improve muscle strength. It is important the
D. nicotinic adrenergic; muscle contraction patient has maximum muscle strength while
The answer is B. In myasthenia gravis, eating for the chewing and swallowing
either the nicotinic acetylcholine receptors process. Therefore, the medication should
are attacked by antibodies created by the be given 1 hour before the patient eats
immune system (hence why this disease is because this medication peaks (has the
considered autoimmune) or antibodies are maximum effect) at approximately 1 hour
inhibiting the function of muscle-specific after administration. How does the
kinase (which is a receptor tyrosine kinase medication improve muscle strength? It
that helps with maintaining and building the does this by preventing the breakdown of
neuromuscular junction). Either way this acetylcholine. Remember the nicotinic
leads to the neurotransmitter acetylcholine acetylcholine receptors are damaged and
from being able to communicate with the the patient needs as much acetylcholine as
muscle fiber to make it contract. possible to prevent muscle weakness.
Therefore, this medication will allow more
acetylcholine to be used...hence improving
2. You're educating a patient about the muscle strength.
pathophysiology of myasthenia gravis.
While explaining the involvement of the
thymus gland, the patient asks you where 4. The neurologist is conducting a Tensilon
the thymus gland is located. You state it is test (Edrophonium) at the bedside of a
located? patient who is experiencing unexplained
A. behind the thyroid gland muscle weakness, double vision, difficulty
B. within the adrenal glands breathing, and ptosis. Which findings after
C. behind the sternum in between the lungs the administration of Edrophonium would
D. anterior to the hypothalamus represent the patient has myasthenia
The answer is C. The thymus is located gravis?
anteriorly in the upper part of the chest A. The patient experiences worsening of the
behind the sternum in between the lungs. muscle weakness.
B. The patient experiences wheezing along
with facial flushing.
3. A patient with myasthenia gravis will be C. The patient reports a tingling sensation in
eating lunch at 1200. It is now 1000 and the the eyelids and sudden ringing in the ears.
patient is scheduled to take Pyridostigmine.
D. The patient experiences improved The answer is D. Remember patients who
muscle strength. experience a cholinergic crisis are most
The answer is D. During a Tensilon test likely to because they’ve received too much
Edrophonium is administered. This of their anticholinesterase medications
medication prevents the breakdown of (example Pyridostigmine). However, on the
acetylcholine, which will allow more of the other hand, patients who have received
neurotransmitter acetylcholine to be present insufficient amount of their
at the neuromuscular junction....hence anticholinesterase medication or have
IMPROVING muscle strength IF myasthenia experienced an illness/stress/surgery are
gravis is present. Therefore, if a patient with most likely to experience a myasthenia
MG is given this medication they will have crisis. Both conditions will lead to muscle
improved muscle strength. weakness and respiratory failure but from
different causes, which is why a Tensilon
test is used to help differentiate between the
5. You're preparing to help the neurologist two conditions.
with conducting a Tensilon test. Which
antidote will you have on hand in case of an
emergency? 7. Which meal option would be the most
A. Atropine appropriate for a patient with myasthenia
B. Protamine sulfate gravis?
C. Narcan A. Roasted potatoes and cubed steak
D. Leucovorin B. Hamburger with baked fries
The answer is A. Atropine will help reverse C. Clam chowder with mashed potatoes
the effects of the drug given during a D. Fresh veggie tray with sliced cheese
Tensilon test, which is Edrophonium, in cubes
case an emergency arises. Edrophonium is The answer is C. Patients with MG have
a short-acting cholinergic drug, while weak muscles and this can include the
atropine is an anticholinergic. muscles that are used for chewing and
swallowing. The patient should choose meal
options that require the least amount of
6. Which patient below is MOST at risk for chewing and that are easy to swallow.
developing a cholinergic crisis? Option C is a thick type of soup and the
A. A patient with myasthenia gravis is who mashed potatoes are soft....both are very
is not receiving sufficient amounts of their easy to eat and swallow compared to the
anticholinesterase medication. other options.
B. A patient with myasthenia gravis who
reports not taking the medication
Pyridostigmine for 2 weeks. 8. Select all the signs and symptoms below
C. A patient with myasthenia gravis who is that can present in myasthenia gravis:
experiencing a respiratory infection and A. Respiratory failure
recently had left hip surgery. B. Increased salivation
D. A patient with myasthenia gravis who C. Diplopia
reports taking too much of their D. Ptosis
anticholinesterase medication. E. Slurred speech
F. Restlessness
G. Mask-like appearance of looking sleepy 10. You're a home health nurse providing
H. Difficulty swallowing care to a patient with myasthenia gravis.
The answers are A, C, D, E, F (restlessness Today you plan on helping the patient with
from hypoxia, which is experienced with bathing and exercising. When would be the
respiratory failure), G, and H. best time to visit the patient to help these
tasks?
A. Mid-afternoon
9. You're providing teaching to a group of B. Morning
patients with myasthenia gravis. Which of C. Evening
the following is not a treatment option for D. Before bedtime
this condition? The answer is B. Patients with MG tend to
A. Plasmapheresis have the best muscle strength in the
B. Cholinesterase medications morning after sleeping or resting rather than
C. Thymectomy at the end of the day....the muscles are tired
D. Corticosteroids from being used and the muscle become
The answer is B. These medications are not weaker as the day progresses etc.
used to treat MG, but ANTIcholinesterase Therefore any rigorous activities are best
medications (like Pyridostigmine) are used performed in the morning or after the patient
to treat this condition. has rested.

Cholinergic Crisis vs Myasthenic Crisis

{acetylcholine} junction by ACh
{acetylcholine}
● Key player:
○ Neuromuscular Junction Can lead to severe Overdrive in
■ Nicotinic muscle weakness and cholinergic
respiratory failure response, severe
Acetylcholine
muscle weakness
Receptors and respiratory
■ Function of Muscle failure
Specific Kinase
■ Acetylcholine Cause: Cause:
■ Immune system
Insufficiency Too much
● Produces anticholinesterase anticholinesterase
antibodies medication or medication
against respiratory infection,
receptors stress and acute It stops the
● Thymus gland exacerbation breakdown of ACh
mare at the
junction
Myasthenic Crisis Cholinergic Crisis
Great for MG
Happens due to low to Happens due to treat,emt but too
no stimulation at the excessive much cholinergic
neuromuscular stimulation at the
junction by ACh neuromuscular Signs and Symptoms: Signs and
 Symptoms:
● Dilated pupils Go Here for More Quizzes
● Increased Similar to “Rest
Heart rate and and digest” Your Answers & what you got Right &
BP Wrong:
● No cough and ● GI:
gag vomiting, 1. __________________ happens due to
● aspiration / no diarrhea,
excessive stimulation of the receptors at the
swallowing cramping
reflex ● Pupil neuromuscular junction by acetylcholine,
● Incontinence constriction which eventually leads to muscle weakness
bowel and ● Increase and respiratory failure.
bladder salivation A. Myasthenic crisis
and tears B. Cholinergic crisis
● Increase The answer is B.
respiratory
secretions
● Muscle
fasciculatio 2. _________________ happens due to
n minimal to no stimulation of the receptors at
“twitching” the neuromuscular junction site by
due to acetylcholine because there is damage to
constantly
the receptor sites, which leads to muscle
stimulation
● Decrease weakness and respiratory failure.
HR and BP A. Myasthenic crisis
B. Cholinergic crisis
Tensilon test: Tensilon Test: The answer is A.

● Medication ● Medication
Edrophonium= Edrophoniu
Anticholinester m=Anticholi 3. A patient is experiencing unexplained
ase nesterase muscle weakness and respiratory failure.
Medication Medication The neurologist conducts a Tensilon test to
Adds More ACh at the Adding more ACh differentiate between myasthenic crisis or
junction at the junction- cholinergic crisis. During the test the patient
experiences improved muscle strength.
Improvement of Worsening of
Based on this finding the patient has:
signs and symptoms signs and
symptoms A. Myasthenic Crisis
Positive test result B. Cholinergic Crisis
Negative test C. Neither
Treatment per MD result The answer is A. During a Tensilon test the
Order medication Edrophonium is given, which is
Anticholinesterase Treatment: an cholinesterase medication. This will
Antidote Atropine
increase the availability of acetylcholine at
hold further dose
the neuromuscular junction. If the patient
had a cholinergic crisis the problem is not
our Grade: D with the availability of acetylcholine, but
Percentage of What you Got Right: 67
because there is TOO MUCH of it at the E. Negative gag or cough reflex
receptor site. Therefore, during this test the F. Respiratory failure
patient would experience worsening of G. Bradycardia
symptoms NOT improvement. The answers are A, D, E, and F.

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

AUTONOMIC DYSREFLEXIA ● Exaggerated reflex response by the

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

RISK FACTOR

● All patient that has a spinal cord

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

ANATOMY

Role of AUTONOMIC NERVOUS SYSTEM: it

controls the Sympathetic and
Parasympathetic Nervous system

CAUSE:

● All patient that has a spinal cord

injury are high risk of developing Sympathetic Parasympathetic
Autonomic Dysreflexia Nervous System Nervous System
○ All injury T6 high “Fight or Flight” “Rest and Digest”
● They recieve that irritating stimulus ● Vasoconstriction ● Vasodilation
they can trigger that reflex response ● Sweat glands ● Decrease HR
by the sympathetic nervous response stimulation ● Salivation
● Bronchodilation ● Bronchoconstricti
● Increase HR on
● Dilates Pupils ● Constrict Pupils
* These system works beautifully together but i. Because we are
they oppose each other to check balance constricting vessel to
between each other BUT NUMBER ONE the non-vital organs
REQUIREMENT: They must have a good 4. The body will sense it specifically
spinal cord structure and functioning Baroreceptors Sense
a. It doesn't know what’s going
on Or if there is an existing
PATHOPHYSIOLOGY issue below T6
b. So the Increase BP will cause
the Baroreceptors to Stimulate
PARASYMPATHETIC
● What is that requirement? ACTIVITY
○ They must have that irritating i. VASODILATION {
stimulus and destroyed or ii. Flushing
injured T6 and above spinal iii. Decrease HR less than
cord 60
iv. Bradycardia
c. However these Baroreceptor
IRRITATING STIMULUS response really can’t bring
change the BP below T6
i. Instead it will cause
Vasodilation Up there
1. Irritating Bladder
and vasoconstriction
a. Its ascending irritating stimulus
Down there
to our body
5. The compensatory mechanism is NOT
b. Causing our nerves to send an
effective due to vasoconstriction
impulse that something is
wrong
c. However since we have an
injured Spinal Cord T6 and Goal: Remove the irritating response and treat
Higher the stimulus can be patient appropriately
blong creating no response
2. It will create Exaggerated
Sympathetic Reflex Response
a. This is excessive and
Exaggerated
3. Vasoconstriction
a. Vasoconstriction and SIGNS AND SYMPTOMS:
narrowing of vessel BELOW
THE INJURED SPINE
b. Increase blood pressure
c. It's going to cause a veryPale
cool clammy
 ● Nitropaste: Topical
administration
○ Do not administer if a patient
has taken
phosphodiesterase
inhibitors in the past 24
hours….. Sildenafil or
Tadalafil
○ Other medications:
Nifedipine {CCBs}

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

Medication to help treat AD

Bowel ● Position the patient at 90 degrees
with legs lowered
● Check for impaction ○ This will allow gravity to pool
● down on those leg and
● Assess bowel sounds decrease the blood pressure
● Palpate for distention ● Assess BP every 2-5 minutes
● Assess last Bowel movement ● Removed Binding devices or
● For impacted always use clothing
○ Use anesthetic jelly, prior to ● Investigate 3 Big B’s and correct it
stool removal ● Start w/ bladder, then proceed to
bowel, and the skin

LAST RESORT

Breakdown of the skin

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

It is a MEDICAL EMERGENCY
● Call a rapid response and get
help
Your Answers & what you got Right & 2. Your patient, who has a spinal cord
Wrong: injury at T3, states they are experiencing a
throbbing headache. What is your NEXT
nursing action?

A. Perform a bladder scan

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

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

traumatic brain injury.

D. Administer a PRN medication to

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

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

A. Reassess the patient’s blood pressure.

A. Hypoglycemia

B. Check the patient's blood glucose.

B. Distended bladder

C. Position the patient at 90 degrees and

lower the legs.
C. Sacral pressure injury

D. Provide cooling blankets for the patient.

D. Fecal impaction

The answer is C. Based on the patient

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

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

5. After taking all the necessary steps for a

patient who has developed autonomic B. The patient reports a throbbing
dysreflexia, what should the nurse assess headache.
FIRST as a possible cause of this
condition?
C. The patient’s lower extremities are pale
and cool.
A. Skin break down

D. The patient states they took Sildenafil

B. Blood glucose 12 hours ago.

C. Possible bladder irritant The answer is D. A patient should not

receive a dose of Nitropaste if they have
taken a phosphodiesterase inhibitor within
D. Last bowel movement the past 24 hours (Sildenafil or Tadalafil).
This will cause major vasodilation and
severe hypotension that will not respond
to medication. Another medication should
The answer is C. A bladder issue is usually be used. All the other findings are
the most common cause of AD. If this isn’t expected with autonomic dysreflexia.
the issue the nurse should assess the
bowel and then the skin for break down.

7. A patient is receiving treatment for a

complete spinal cord injury at T4. As the
6. The physician orders Nitropaste for a nurse you know to educate the patient on
patient who has developed autonomic the signs and symptoms of autonomic
dysreflexia. Which finding would require dysreflexia What signs and symptoms will
you educate the patient about? Select all
that apply:

8. What is the BEST position for a patient

A. Headache experiencing autonomic dysreflexia?

B. Low blood glucose A. High Fowler's with legs lowered

C. Sweating B. Low Fowler's with legs lowered

D. Flushed below site of injury C. Semi-Fowler's with legs at heart level

E. Pale and cool above site of injury D. Prone

F. Hypertension The answer is A. The patient should be in

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

H. Stuffy nose

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

these are signs and symptoms of
autonomic dysreflexia. The patient will
have flushing above site of injury due to
vasodilation from parasympathetic 9. In autonomic dysreflexia, the nurse
activity, BUT will be pale and cool below would expect what finding below the site
site of injury due to vasoconstriction of the spinal cord injury?
occurring below the site of injury for the
sympathetic response reflex.
A. Flushed lower body

B. Pale and cool lower extremities

C. Low blood pressure C. "Autonomic dysreflexia is less likely to
occur in a patient who has experienced a
lumbar injury."
D. Absent reflexes

D. "The first-line of treatment for

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

10. Which statements are TRUE about

autonomic dysreflexia? Select all that
apply: 11. The nurse is about to assess for bowel
impaction in a patient who has developed
autonomic dysreflexia. The nurse makes it
A. "Autonomic dysreflexia is an priority to?
exaggerated reflex response by the
parasympathetic nervous system that
results in severe hypertension due to a A. Avoid using lubricants
spinal cord injury."

B. Stimulate the bowel with rectal

B. "Autonomic dysreflexia causes a slow manipulation
heart rate and severe hypertension."
C. Slowly administer a saline solution prior The answer is D. To avoid increasing
to assessment autonomic dysreflexia symptoms by
increasing the sympathetic reflex due to an
irritating stimulus, the nurse should instill
D. Instill an anesthetic jelly prior to an anesthetic jelly before assessing the
assessment rectum for hardened stool. This is also
important prior to catheterization to check
the bladder for urine.

ANATOMY OF CRANIAL NERVES: 12 PAIR CRANIAL NERVE FOUND IN

HUMAN BRAIN

MID BRAIN ORIGIN

● SENSORY
○ I, II, VIII {1,2,8
I. OLFACTORY NERVE {SENSORY} ● MOTOR
II. OPTIC NERVE {sENSORY} ○ III, IV, VI, XI, XII {3,4,6,11,12}
III. OCULOMOTOR {MOTOR} ● MIXED
IV. TROCHLEAR {MOTOR} ○ V, VII, IX, X {5,7,9,10}.

PONS ORIGIN FACTS:

V. TRIGEMINAL {MIX} ● Smallest Cranial Nerve

VI. ABDUCENS {MOTOR} ○ 4th cranial nerve i.e. trochlear
VII. FACIAL {MIX} nerve
VIII. AUDITORY/ACOUSTIC/VESTIBULO ● Shortest Cranial nerve
COCHLEAR {SENSORY} ○ 1st cranial nerve i.e. Olfactory
nerve
● Largest Cranial nerve
○ 5th Trigeminal Nerve
MEDULLA OBLONGATA ● Longest Cranial Nerve
○ 10th vagus nerve
● Highest number of branches
IX. GLOSSOPHARYNGEAL {MIX} ○ 10th Vagus nerve
X. VAGUS {MIX} ● Dentist Nerve
XI. ACCESSORY SPINAL {MOTOR} ○ Trigeminal {mandibular}
XII. HYPOGLOSSAL {MOTOR}. ● Cranial Nerve Arise/Insertion
○ From brain to stem
● Only Nerve that arise from Dorsal
aspect of brain stem is
 ○ Trochlear Cranial nerve
● Most commonly cranial nerves Origin Nasal-
involved/affected in diabetes {Diabetic Mucosa
Neuropathy} Insertion Midbrain to
○ 3th- Most affected temporal
○ 4th
○ 6th Function Smell
● Most commonly cranial nerve
involved/affected in shingles {caused II- Optic
Nerves
by Herpes Zosters} Nature Sensory
○ 5th Nerve
{Afferent}
○ 7th
○ 9th Origin Retina
○ 10th
○ 7th Insertion Lateral
Geniculate
○ Affected mostly {called as
Nuclei of
Ramsay Hunt disease} thalamus to
○ Most Common SIgns of Occipital
Shingles area of
■ Tingling Brain
■ Pain
Function Vision
■ Rashes
■ Numbness
III-
Oculomotor
Nature Motor
Nerves
{efferent}

Origin Midbrain

Insertion Muscles of the

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

Function * Eyeball
movement
* Pupil
Cranial Information Movement
Nerve {iris}
*{compression
I-Olfactory of III nerve
Nerves causes
Nature Sensory unilateral pupil
Nerve dilation}
{afferent} *Upper eyelid
 Movement mucosa.
{levator * Muscle of
palpebrae} mastication
and sense of
IV-Trochlear lower jaw,
Nerve lower lips,
Nature Motor {efferent} chin, teeth,
hums
Origin Midbrain

Insertion Muscle of
eyeball
{superior
oblique
muscle}

Function * Eyeball
Movement
* Outward VI-Abducens
downward Nerves
Nature Motor
movement {efferent}

V-Trigeminal Origin PONS

Nerves
Nature Mix Insertion Muscle of
a. Ophthalmic eyeballs
Largest
{S} {Lateral rectus
Nerve
b.Maxillary {S} muscles}
C. Mandibular
{M} Function * Eyeball
movement
Origin PONS * Outward
movement
Insertion Around the
eyes, facem
nose, lips, VII- Facial
maxilla, Nerves
Nature Mix
mandible a. Sensory
Facial
Function * Sense from B. Motor Facial
upper eye lid,
eye brow, Origin PONS
forehead,
anterior part Insertion Face skin and
of scalp Facial Muscle
* Sense from
upper lip, Function * Anterior 2/3rd
upper jaw, of tongue
gums, teeth, {taste}
hard and soft * Touch,
palate, nose, temperature of
skin, oral facial area
 * Facial B. Motor GP-
Expression movement of
muscle of
Paralysis of swallowing
7th cranial
nerves X- VAGUS
causes NERVE
BELL’S Nature Mix
FACIAL Longest
PALSY a. Sensory
nerve
Vagus
B. Motor Vagus
VIII- Has many
VESTIBULO branching Origin Medulla
Nature Sensory Nerve
COCHLEAR nerve Oblongata
{afferent}
NERVE
a. Vestibular
branch-sensory
balance Insertion Trachea,
b. Cochlear Heart,
branch-sensory Digestive tract
hearing {Parasympathe
tic branch}
Origin Inner ear
Function * Pain
Insertio PONS sensation from
n visceral organs
{Heart,
Functio * Vestibular digestive,
n Branch-sensory respiratory,
balance kidney}
* Cochlear
branch- sensory *
hearing Parasympathet
ic supply to
IX- visceral organs
GLOSSOPH
Nature Mix
ARYNGEAL Vagal Maneuver:
a. Sensory GP
NERVES ● Is an act that used to
B. Motor GP
slow down the heart
Origin Medulla rate {Sinus
Oblongata tachycardia} by
stimulating the
Insertion Posterior ⅓ Vagus nerves
part of the ○ Straining
tongue {taste} ○ Bearing
down
Muscle of
swallowing
XI-
Function a. Sensory GP- ACCESSOR
Nature Motor
taste Y SPINAL
{efferent}
NERVES
 Origin Medulla
Oblingate

Insertion Accessory
Muscle of
Respiration
{Sternocleido
mastoid SCM,
scalene,
trapezius}

Function Neck
movement

XII- ● Also called “

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

LINK REFLEX {CORNEAL REFLEX}

Sleep can provide some relief from the pain
so patient sleep most of the time

● Loss of blink indicate dysfunction of

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

CAUSES:

● Main Cause of trigeminal Neuralgia:

Blood vessel Compressing on the root
of the trigeminal nerve
● Pressure on the Trigeminal Nerve may
be cause vy
○ Tumor
○ Multiple sclerosis
○ Trauma
○ Stroke

Management:
● Paralysis/weakness of one side
face
○ Caused by damage of lower
● Carbamazepines {Drug of choice} motor neuron of 7th cranial
○ Reduce transmission of nerve {Facial nerve}
impulses ○ Bell’s palsy usually resolves
● Oxcarbazepine on its own within six months
● Nerve Blocks {local anesthetics} ○ Physiotherapy can help
● Radiofrequency/Rhizotomy prevent muscle permanently
○ Resection of nerve roots contracting
● Glycerol injection
○ Demyelinating nerve, effective
for 3 weeks
● Avoid Cold/Hold food and fluids

Characterized by:

BELL’S PALSY ○ Muscles weakness that

causes one half of the face to
droop

Cause:
 ● Unknown

NEURO
Risk Factors:

CNS PNS
● Diabetes
● Upper respiratory tract infection
● Some viruses Multiple Parkinso Myasthe Amyotro
○ Varicella zoster sclerosis n’s nia phic
○ Epstein Barr Virus Disease Gravis Lateral
○ Herpes zoster
Sclerosi
● Familial Inheritance
s (ALS)

SYMPTOMS:
PATHOPHYSIOLOGY OF CNS DISEASE:

● FLACCID FACIAL MUSCLES and CNS IS OUR CMP {Central Nervous

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

● Facial exercise
Parkinson’s Disease: decrease of amount
○ It is a self limiting disease of DOPE in the PARK
○ It starts to improve generally in ● Less Dopamine
14 days and recovers in 6-15 ● Dopamine Helps Regulates
week ○ BP {when patient gets to a
● Eye Moisturizer
○ Prevent eye dryness
CODE or HYPOTENSION-
● Mouth care and eye care DOPE release to
○ Priority of Nursing care Vasoconstriction}
● Corticosteroid ○ CNS and Ability to Move
○ prednisone ■ They Move slowly
■ Shuffling Gait
● Someone barely learning how to
park a car
○ They walk so slowly, they
Neurological Disorders: Parkinson's, MS, shuffling the feet
MG, ALS ○ Pill Rolling
 ○ Can get you dead within 5
years
PATHOPHYSIOLOGY OF CNS DISEASE: ● Motor Neurons will get Sclerotic
and can get Stiff
PNS ○ Motor Neurons: Grip, Push,
● They are more on motor function Pull, contract and still
○ You get a prisoner of the
M.G= Disney Waltz Movie Show white body
{Sleepy} was dedicated for his friend that ■ Not dementia
has Myasthenia Gravis ■ No Loss of Sensation
● A disease that inhibits you from a ■ No Irrationality
producing a chemical called ○ You’re just in bed but you
Acetylcholine can’t just move
○ Acetylcholine- help body and ■ Very sad
neuron to contract at the ● 3 D’s of ALS
Myoneural Junction ○ Dysarthria- difficulty moving
○ If lacking it can cause severe ○ Dysphagia-Difficulty
muscle weakness Swallowing
● You have ○ Drooling
○ Ptosis “drooping eyes” ● Can get you killed with a pneumatic
○ Extremely fatigue disease
○ Severe muscle weakness ○ Because even the lung
■ Dysphagia “fail to muscles that helps your lung
swallow perfectly breath starts to fail
■ Aspiration ○ Mech vent is need
Precaution, Airway
issue and
diaphragm issue
■ Not a progressive
disease
● Myasthenia Gravis: Gravity
○ Gravity pulling down your
eyelid
○ Making you very sleepy and
TIIIIIIIRRREDDD

‘
ALS: Amyotrophic Lateral Sclerosis
(ALS).
● This is by far the worst neurological
disease you can get
○ Incurable
○ No remission