CONGENITAL ANOMALIES & TRAUMATIC CONDITIONS

Hydrocephalus

• Normal CSF amount: 150 mL
• Normal CSF pressure (ICP): 10-15 mmHg
• CSF has no red blood cells
• CSF is produced by the choroid plexus, travels around the ventricular system and is reabsorbed by the subarachnoid villi
• Causes and Associated Factors:
• prematurity - ventricular system may be underdeveloped
• gram (-) meningitis - causes inflammation and subsequent edema
• aqueductal stenosis - a blockage in the Aqueduct of Sylvius, the passageway from the third to the fourth ventricle
• head injury - may cause inflammation on the brain post-trauma
• intracranial tumor - may impede flow of CSF depending on the area blocked
• Arnold-Chiari malformation - congenital herniation of the cerebellar tonsils leading to a blockage of flow of CSF from the brain to the spinal cord
• Dandy-Walker Syndrome - congenital absence of the the cerebellar vermis and an increased size of the fourth ventricle, increasing pressure on the brain
• myelomeningocele - neural tube defect which forms a sac on an unclosed area of the spine causing increased pressure of CSF
• Types
• Communicating - caused by decreased absorption of the subarachnoid villi
• Non-communicating - impediment of CSF flow within the brain's ventricular system
• Signs and Symptoms
• increased head circumference
• bulging fontanels
• dilated scalp veins
• separated skull sutures
• MacEwen's Sign (crackpot sound upon percussion)
• sluggish pupillary reflexes
• increased ICP
• change in level of consciousness
• setting sun sign - also called sunset eyes; a downward deviation of the eye, such that you can see the sclera in between the iris and the upper eyelid
• high pitched cry
• Diagnostic Tests
• CT scan - to check for bones and other hard tissue (e.g. tumors) blocking the ventricular system
• MRI - to check for soft tissue deformities (e.g. cysts, stenosis)
• daily measurement of head circumference
• Treatment
• removal of tumor
• shunting - diversion of flow of CSF to another body area where it is reabsorbed
• ventriculoperitoneal - from a ventricle to the peritoneum
• ventriculoatrial - from a ventricle to the heart's atrium
• lumboperitoneal - from the lumbar area of the spine to the peritoneum
• ventircular pleural - from a ventricle to the pleural space
• ventricular bypass - from one ventricle to another
• Complications:
• infection
• malfunction - obstruction or dislodged shunting catheter
• PreOp
• avoid increasing ICP
• AVOID sneezing, coughing, straining, Valsalva reflex
• DO NOT occluding the carotid artery
• hips slightly flexed and legs abducted
• support the neck muscles
• fluid restrictions
• administer stool softeners
• place sheep skin or lamb's wool under head for support
• change positions q2h
• small frequent feedings up until NPO
• PostOp
• avoid increasing ICP (see above)
• frequent neurologic assessment
• pain relievers as ordered
• antibiotics as ordered
• emotional support
• position on the unoperated side
• monitor for changes

Spina Bifida

• the higher the deformity, the more neurologic deficits presented
• Types
• Spina Bifida Occulta - not visible externally
• manifests with a skin dimple, port-wine nevi (wine-colored strained skin), tufts of hair, of subcutaneous lipoma (fat despoit)
• Spina Bifida Cystica - with an external sac-like protrusion
• Meningocele - protrusion of the meninges and CSF; (+) transillumination
• Myelomeningocele - protrusion of the meninges, CSF, and nerves; (-) transillumination
• Diagnostic Tests
• fetal ultrasound
• increased alpha-fetoprotein (16-18 weeks)
• chorionic villi sampling (9 weeks)
• MRI, CT, myelography (visualization of the flow of CSF in the spine)
• transillumination
• Treatment
• surgical closure within 1st 72 hours of life
• open fetal surgery
• PREVENTION: FOLIC ACID (0.4-4 mg/day during pregnancy)
• shunting
• prone position at rest
• side-lying position when feeding
• apply sterile dressing with NSS on area
• avoid increased ICP (see above)

Neurogenic Bladder Syndrome

• dysfunction of the urinary bladder due to spinal cord disease, injuries, and defects (e.g. spina bifida)
• Signs and Symptoms
• difficulty or complete inability to urinate
• Treatment
• intermittent catheterization
• vesicostomy - stoma creation on the abdominal wall and urinary bladder to provide for drainage
• urinary diversion - construction of a new urinary bladder from bowel/stomach
• oxybutynin (Ditropan) - improves bladder control and storage
• augmentation enterocystoplasty - improves bladder capacity

Cerebral Palsy

• Types
• Spastic - most common; hypertonicity of muscles, impaired motor skills
• Dyskinetic/Athetoid - may be caused by kernicterus (high unconjugated bilirubin at birth leading to brain damage); athetoid movements (slow, writhing, wormlike movements), drooling, dysarthria (poor articulation of words, "bolol-bolol"), poor motor skills
• Ataxic - may be caused by damage to cerebellum; poor motor skills, wide based gait, tremors
• Mixed/Dystonic - a mix of spastic and athetoid
• Causes
• cord coil
• intrauterine hypoxia
• birth trauma
• intrauterine infection, radiation exposure
• multiple births
• Treatment
• foot orthoses/braces - remedies fait problems
• rhizotomy - surgical release of nerves causing spasticity
• baclofen & botox injections - relieves spasticity
• stretching exercises
• seizure precautions
• promote safety
• use sturdy, padded furniture
• side rails up
• wear helmets
• use safety restraints as needed
• avoid polished floors
• talk slowly
• encourage participation during self care
• encourage activities that improve manual dexterity - drawing, writing
• PATIENCE
  

Skull Fractures

• Types
• Linear Skull Fracture - linear crack on the skull
• Comminuted/Depressed Skull Fracture - fractured area of skull breaks into pieces and are displaced inward; usually occurs from blunt force trauma e.g. rock to head, baseball bat to head, hammer to head
• Basillar Skull Fracture - fracture of the bones at the base of the skull
• Signs and Symptoms
• halo sign - blood stain surrounded by yellowish stain (indicative of CSF leakage)
• raccoon eyes - periorbital ecchymosis
• Battle's Sign - bruising behind the ear (for basillar skull fracture)
• blood in the sinuses
• bleeding from the ears or nose
• Injury Types
• Coup Injury - at point of impact (hits forehead on wheel after MVA)
• Contracoup Injury - at opposite side of impact (hits back of head to headrest after MVA)
• Primary Injury - impact damage (bruising on forehead)
• Secondary Injury - delayed events that follow injury (edema, infection, hypoxia)
• Emergency Management
• log rolling technique
• jaw thrust maneuver
• immobilize head and neck (e.g. cervical collar)
• decrease stimuli

Traumatic Brain Injury

• Concussion - reversible; may have temporary change of level of consciousness, headache, and nausea and vomiting
• Contusion - irreversible; actual damage to the brain
• Closed - force from object damages brain but doesn't penetrate skull
• Open - object penetrated the skull and into the brain
• Signs and Symptoms:
• altered levels of consciousness
• loss of reflexes
• pupillary abnormalities
• neurologic deficits
• change in vital signs
• sensory dysfunction
• headache
• vertigo
• seizures
• Management
• evacuation of clots
• mannitol - to reduce ICP
• phenytoin - for seizures
• analgesics
• monitor neurologic vital signs
• quiet environment
• wound care
• fluid regulation
• ventilatory support
• Complications:
• Intracranial Hemorrhage
• Epidural - blood collecting in between the dura and the skull
• Subdural - blood collecting in between the dura and the brain
• Intracerebral - blood collecting within the brain
• Diffuse Axonal Injury - disconnection of axons within the brain; patient immediately after the injury becomes comatose, decorticate, or decerebrate

Spinal Cord Injuries

•  Types
• Incomplete - only part of the spinal cord is damaged
• Complete - damage to an entire area of the spinal cord; may results in paraplegia (paralysis of lower extremities) or quadriplegia (paralysis of all extremities)
• Effects of Injuries
• Central Cord Syndrome
• motor deficits, bowel and bladder dysfunction
• injury to the central area of the spinal cord
• Anterior Cord Syndrome
• motor deficits, loss of sensation
• injury to the anterior area of the spinal cord or blockage of the anterior spinal artery
• Lateral Cord Syndrome (Brown-Sequard Syndrome)
• ipsilateral loss of sensation and paralysis (left side injured, right side manifestations)
• damage to half of the spinal cord transversely
• Autonomic Dysreflexia
• overstimulation of the ANS after injury
• BP > 200mmHG, diaphoresis, bradycardia, restlessness, bowel and blader distention, facial flushing, cognitive impairment
• Carpal Tunnel Syndrome - compression of the median nerve of the wrist from inflammation of the carpal tunnel; caused by repetitive movements of the wrist; symptoms include numbness and pain of the hand affected, muscle atrophy, and loss of grip strength
• Sciatica - injury to the sciatic nerve resulting in pain to the lower extremity
• Management
• emergency care
• immobilization
• spinal/back board
• patient must always be in an extended position
• patient must be twisted or flexed
• methylprednisolone - improves sensory and motor deficits
• surgery

INFLAMMATORY DISTURBANCE IN PERCEPTION & COORDINATION

Brain Abscess

• accumulation of pus within the brain tissue from local/systemic infection
• Causes:
• EENT infections
• brain trauma/surgery
• bacterial endocarditis
• pulmonary infection
• causes of brain abscess from sites far away from the brain are caused by bacteria traveling through the circulatory system via the carotid artery and into the cerebral arteries
  
• Common bacterial causes:
• Streptococci
• Staphylococci
• Signs and Symptoms
• Affected Area: Frontal Lobe
• hemiparesis
• aphasia - impairment of language
• seizure
• frontal headache
• Affected Area: Temporal Lobe
• aphasia
• vision changes
• facial weakness
• localized headache
• Affected Area: Cerebellum
• ataxia - lack of coordinated muscle movements
• nystagmus
• occipital headache
• Diagnostic Tests
• CT & MRI
• Treatment
• antibiotics - helps kill bacteria
• corticosteroids - reduces inflammation
• surgical drainage of abscess via craniotomy (hole made into skull) or craniectomy (part of skull is temporarily removed then placed back)
• Nursing Management
• paper and pen communication
• non-stimulating environment
• complete bed rest
• assess neurologic vital signs

Viral Encephalitis

• Types
• Epidemic
• caused by Arboviruses (ARthropod-BOrne Viruses; e.g. ticks, mosquitoes)
• headache, fever, nausea and vomiting, nuchal rigidity, coma
• Non-epidemic 
• dormant viruses in the nerves reawaken and attack the brain
• herpes simplex, mumps, measles, varicella
• fever, seizures, headache, nausea and vomiting
• may lead to brain herniation, brain swelling, coma, death
• Treatment and Management
• ACYCLOVIR 
• provide safety
• assess neurologic vital signs
• avoid increasing ICP
• elevate head of bed
• anticonvulsants
• steroids

Meningitis

• primarily affect the subarachnoid space
• Mode of Transmission: head injury, droplet transmission, bloodstream
• Types
• Aseptic - no bacteria, meninges may be irritated by lymphoma, leukemia, or brain abscess
• Septic - Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae
• Tuberculous - Mycobacterium tuberculosis
• Signs and Symptoms
• headache
• fever
• nuchal rigidity
• photophobia
• seizures
• increased ICP
• neurologic impairment
• Kernig's sign - thigh and hip flexion, leg can't be extended
• Brudzinski's sign - flex the neck, knees and hips flex too
• Diagnostic Test
• increased WBC count
• CSF analysis - increased protein, decreased glucose
• Treatment
• RIFAMPICIN
• phenytoin - for seizures
• cephalosporin - to augment rifampicin's anti-infective capabilities
• mannitol - to decrease ICP
• dexamethasone - for inflammation
• codeine - for pain and coughing
• pyritinol - for altered levels of consciousness
• Management
• non-stimulating environment
• respiratory isolation
• raise side rails
• small frequent feedings
• assess neurologic vital signs
• complete bed rest
• increase protein and caloric intake
• elevate head of bed
• seizure precautions

Viral Meningitis

• Causative Agent: 
• Mumps virus
• Human Immunodeficiency Virus
• Herpes Simplex Virus
• Cytomegalovirus
• Epstein-Barr Virus
• Signs and Symptoms: same as bacterial meningitis
• Diagnostic Test
• decreased WBC count
• CSF analysis
• polymerase chain reaction test
• Treatment
• antivirals - stops proliferation of virus but doesn't treat disease
• anticonvulsants
• complete bed rest
• symptomatic management

Cryptococcosis / Torulosis

• Causative Agent: Cryptococcus neoformans
• Signs and Symptoms:
• chest pain
• fatigue
• confusion
• fever
• headache
• Diagnostic Test: CSF analysis
• Treatment: AMPHOTERICIN B

Mucormycosis / Phycomycosis

• Causative Agent: Mucorales and Phycomycetes spores
• Signs and Symptoms
• one-sided headache
• facial pain
• black nasal discharges
• sinusitis
• Diagnostic Test: CSF analysis
• Treatment: AMPHOTERICIN B

Diphtheria / Kleb-Loeffler's Disease

• Causative Agent: Corynebacterium diphtheriae
• Affects respiratory tract, larynx, and pharynx
• Reservoir: humans
• Mode of Transmission: direct contact, droplet
• Incubation Period: 2-5 days
• Types:
• Respiratory
• bull neck appearance
• serosanguinous secretions
• pseudomembranes - thick patchy grayish-green membranes over larynx, pharynx, and tonsils
• Cutaneous
• small ulcers often seen on the legs
• Diagnostic Test
• Schick Testing - tests susceptibility to diphtheria
• throat culture
• Treatment
• ERYTHROMYCIN
• Nursing Management
• soft diet
• strict isolation
• complete bed rest
• small frequent feedings
• Complications
• Diphtheritic Neuropathy - the toxin of C. diphtheria causes chronic demyelination of nerves damaging the autonomic nervous system

Tetanus

• Causative Agent: Clostridium tetani
• C. tetani toxins block the neurotransmitter acetylcholine rendering muscles unable to properly function
• Reservoir: soil and animal feces
• Mode of Transmission: dental infections, open fractures, animal bites, open wounds
• Incubation Period: 3-21 days
• Signs and Symptoms
• RISUS SARDONICUS
• trismus
• opisthotonus
• respiratory spasm (late)
• Diagnostic Test: clinical only (based on observation of symptoms)
• Treatment
• TIg - tetanus immunoglobulin to provide passive immunity
• TT - tetanus toxoid to provide active immunity
• Management
• maintain patent airway
• do not restrain
• soft diet
• avoid unnecessary stimulation

Botulism

• Causative Agent: Clostridium botulinum
• Reservoir: soil, contaminated food
• Mode of Transmission: ingestion of toxins or spores
• Incubation Period: 18-36 hours
• Types
• Infant - colonization of GI tract through ingestion of spores
• Wound - contamination of wound by the bacteria
• Foodborne - ingestion of toxins from contaminated food
• Signs and Symptoms
• nausea and vomiting
• diarrhea
• dysphagia - difficulty swallowing
• dystonia - sustained twitching and repetitive movements
• dry mouth
• ptosis - drooping of eyelids
• diplopia - double vision
• dysarthria - motor speech disorder; poor articulation; ("bolol-bolol")
• descending paralysis
• Diagnostic Test: serum analysis and gastric lavage
• Treatment
• BOTULINUM ANTITOXIN
• GASTRIC LAVAGE of wound
• DEBRIDEMENT
• mechanical ventilation if descending paralysis has set in
• AVOID
• cracked jars
• dented/inflated cans
• forcefully expelled food from cans (foods oozing out or explode upon opening)
• "off" odor in foods
• loose/dented lids

Syphilis and Neurosyphilis

• Causative Agent: Treponema pallidum
• Reservoir: humans
• Mode of Transmission: sexual contact, contact with infected lesions, sharing of needles
• Incubation Period: 10-90 days
• Stages
• Primary - appearance of painless chancres (ulcerations) at site of infection
• Secondary - chancres appear at trunk and extremities, transmission can occur, lymphadenopathy, meningitis, hair loss, weight loss, fever, malaise
• Latency - no signs and symptoms
• Tertiary - appearance of gummas (soft, tumor-like balls of inflammation)
• Neurosyphilis
• Neurosyphilis Types
• Asymptomatic - present in CSF upon test but no signs and symptoms
• Meningovascular
• affects CNS and damages blood vessels
• presents with cranial nerve palsies
• may present as STROKE SYNDROME, damage and subsequent occlusion of the middle cerebral artery
• Parenchymatous / General Paresis
• present with dementia
• Argyll-Robertson pupil - unreactive to light
• Tabes Dorsalis
• areflexia - absence of deep tendon reflexes
• loss of proprioception of feet (doesn't know where foot is placed)
• irregular intense stabbing pain
• Diagnostic Test: 
• FTA-Abs (Fluorescent Treponema Antibody Absorption)
• TPHA (Treponema Pallidum Particle Hemagglutination)
• Treatment: PENICILLIN
• Jarisch-Herxheimer Reaction - reaction caused by sudden death of millions of bacteria; manifested by fever, muscle pains, headache

PERCEPTION AND COORDINATION

NERVOUS SYSTEM ANATOMY & PHYSIOLOGY

Functions

• receives information
• communicates information
• processes information
• transmits information

Neurons - basic unit of the nervous system

• Cell Body (soma) - primary component of the grey matter of the CNS
• Cell Membrane - encloses outer boundary of soma; receives multiple synapses
• Axon - transmits information away from the soma
• Dendrites - conduct impulses toward the soma
• Myelin Sheath - insulator of axons and makes up the white matter of the CNS
• Synapse - specialized site where neurons make functional contact with each other

Characteristics of Neurons

• Irritability/Excitability - ability of the neuron to respond to stimulus
• Conductivity - ability to transmit nerve impulses to effector organs

resting potential --> depolarization (sodium ions rush into soma) --> action potential (a nerve impulse is generated and transmitted) --> repolarization (potassium ions rush out of cell; no other impulses can be made) --> ion concentration is restored by sodium potassium pump

CLUE: PISO (Potassium Inside, Sodium Outside) --> applicable to all cells

Cerebrum Parts and Functions

• Frontal Lobe - smell, thinking, abstraction, conceptualization
• Parietal Lobe - taste, perception, interpretation, recognition of body parts
• Temporal Lobe - hearing, memory
• Occipital Lobe - sight, understanding written material
• Broca's Area - language expression
• Wernicke's Area - language comprehension

CLUE: brOca --> O for Out, language going OUT of the brain or being expressed

CLUE: wernIcke --> I for In, language going IN the brain or being understood/comprehended

Diencephalon Parts and Functions

• Thalamus - relay station of impulses; sends and receives all sensory impulses
• Epithalamus - sleep wake cycle
• Subthalamus - pathway for efferent impulses from the brain
• Hypothalamus - temperature regulation, hormones, fluid & electrolyte regulation

Brainstem Parts and Functions

• Midbrain - reflex center, pathway for efferent impulses
• Pons - rhythm of breathing; from inspiration to expiration and again
• Medulla - swallowing, cardiac & respiratory control
• Cerebellum - orientation to time and space, voluntary movements
  

PERCEPTION AND COORDINATION

Perception - awareness of stimuli from the environment through the senses

Coordination

• occurs in the CEREBELLUM
• process of synchronizing or integrating contraction of muscles in relation to each other for movement
• harmonizing the functioning of parts for a response

Sight

• sensory cells: RODS (black) AND CONES (color)

light enters cornea --> aqueous humor --> lens --> vitreous humor --> retina --> rods and cones --> axons of optic nerve --> impulses carried by nerve fibers --> at optic chiasm, fibers cross over to opposite side (decussation) --> nerve fibers are now called optic tracts --> optic tracts connect to the thalamus --> axons form the optic radiation which run all the way to the occipital lobe --> visual interpretation

Taste

• sensory cells: TASTE BUDS

food and saliva mix --> chemicals in food dissolve in saliva --> chemicals touch the tongue's papillae --> taste buds --> gustatory cells transmit impulses via facial, glossopharyngeal, and vagus nerves --> impulses run toward medulla oblongata --> fibers connect to thalamus and connect to parietal lobe --> taste interpretation

Smell

• sensory cells: OLFACTORY HAIRS

air enters nose --> chemicals in air touch olfactory hairs --> nasal epithelium --> olfactory bulb --> olfactory tract --> olfactory nerve --> impulses run toward hypothalamus --> fibers connect to frontal lobe --> smell interpretation

Hearing

• sensory cells: HAIR CELLS

sound waves enter ears --> external auditory canal --> tympanic membrane (eardrum) vibrates --> vibrations travel to ossicles and oval window --> vibrations pass the basillar membrane and on to the round window --> hair cells move in relation to vibration in the cochlea at the Organ of Corti --> impulses travel via the vestibulocochlear nerve --> impulses pass through thalamus and transmitted to temporal lobes --> sound interpretation

Touch

• sensory cells:
• thermoreceptors - heat and cold
• nociceptors - pain
• free nerve endings - touch, pressure, stretch
• Meissner's corpuscle - changes in texture, slow vibrations
• Pacinian corpuscle - rapid vibrations
• hair end organ - initial touch, movement changes in hair
• Ruffini's end organ - tension deep in skin
• Merkel's disc - sustained touch and pressure

stimulus on skin --> cutaneous receptors receive stimuli --> impulses generated --> impulses travel along ascending tract up to the CNS --> impulses pass through the medulla then through the thalamus --> impulses sent to the somatosensory cortex at the topmost area of the parietal lobe