Nursing Management of Neurological Disorders PDF

**[UNIT III -NURSING MANAGEMENT OF PATIENT WITH NEUROLOGICAL DISORDERS]** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Marks | **Questio | **Total | | | | | distribut | n | Marks** | | | | | ion** | Distribut | | | | | | | ion\*** | ** ** | | | | +===========+===========+===========+===========+===========+===========+ | **Must | **Desirab | **Long | **Short | **Short | | | Know** | le | Essay** | Essay** | Answer** | | | | to Know** | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | 12 | 2 | 1 | | 2 | 14 | +-----------+-----------+-----------+-----------+-----------+-----------+ **[LONG ESSAYS (MK):10 Marks each]** 1. **Mr.X, 30 year old male has met with RTA and has sustained head injury. He had transient loss of consciousness and is confused and complaints of severe headache and has projectile vomiting-Answer the following:** a. **Define head injuries.** - Head injuries also called traumatic brain injury. - Traumatic brain injury can be defined as an insult to the brain that is capable of producing physical, emotional, social and vocational changes. - Traumatic brain injury is a non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. b. **Briefly explain the major types of head injuries?** - Scalp blood vessels constrict poorly hence the scalp bleeds profusely when injured. - Scalp injuries can cause laceration, hematoma, contusion, and abrasion to the skin. - Application of pressure, suturing, antibiotics. - It is a break in the continuity of the skull caused by forceful trauma. - It may occur with or without damage to the brain. - Fracture of the vault of the skull -- 3 types - Linear fracture - MOST COMMON- 80%, Simple clean break in the skull, caused by compression. - Risk of infection or CSF leakage is minimal. - Subdural and epidural hematomas-ICP - Skull distortion - Continue to the base of the skull causing fracture of the anterior cranial fossa or middle cranial fossa or posterior cranial fossa. - Simple and comminuted fracture - Common type, bone is crushed into small fragments. - It impact injuries, acceleration or deceleration injury. - It can lead to intracranial hemorrhages - Depressed fracture - Two types- closed and open - Treatment of depressed fracture -Assess-fracture is open or closed - The whole head- shaved and careful assessment - Laceration- wound debridement - A bure- hole is made and treatment for Dural tear - Bulged and plum colored- subdural hemorrhage - The incision should be made on dura and to have to look inside to stop the bleeding - Hemorrhage from the Dural vessels- diathermy. - Fracture of the base of the skull - Fracture of the anterior cranial fossa - Hemorrhage from the nose - Escape of C.S.F and even brain matter through the nose - Fracture of the middle cranial fossa - Otorrhoea, epitasis, facial palsy, deafness, internal strabismus - Fracture of the posterior cranial fossa - Extravasations of blood- sub occipital region - The most important consideration in any head injury is whether the brain is injured. - The brain cannot store oxygen or glucose to any significant degree. - The cerebral cells need an uninterrupted blood supply to obtain these nutrients; irreversible brain damage and cell death occur if the blood supply is interrupted for even a few minutes. - Injuries to the brain can be focal or diffuse - Focal injuries include contusions and several types of hematomas. - Epidural hematoma - Subdural hematoma - Concussions and diffuse axonal injuries are the major diffuse injuries. **C. Write a nursing care plan for Mr. X based on his clinical presentation.** 1. Ineffective tissue (cerebral) perfusion related to increased ICP associated, with cerebral hemorrhage, hematoma as manifested by signs and symptoms of increased ICP - Monitor ICP - Monitor patent airway - Monitor cerebral oxygenation - Provide oxygen - Monitor LOC, cranial nerve function, motor and sensory function 2. Ineffective airway clearance related to accumulation of secretion and unconsciousness secondary to head injury as manifested by decreased respiratory rate - Assess the condition - Monitor GCS - Clear and oropharynx and mouth - Suctioning - Monitor ABG, administer oxygen 3. Hyperthermia related to infection, loss of cerebral integrative function secondary to possible hypothalamic injury as manifested by rise of mercury level - Monitor patient temperature for every 2-4 hours - Control temperature by using acetaminophen and cooling blankets. 4. Deficient fluid volume related to deceased LOC and hormonal dysfunction. - Monitoring of serum electrolyte levels especially in patients receiving osmotic diuretics. - Serial studies of blood and urine electrolytes and osmolality re carried out because head injuries may be accompanied by disorders of sodium regulation. - Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values and intake and output. - Urine is tested regularly for acetone - Record of daily weights is maintained 5. Imbalanced nutrition less than body requirements related to increased metabolic demands, fluid restriction and inadequate intake. - Head injury results in metabolic changes that increase calorie consumption and nitrogen excretion. Protein demand increases. - Parenteral nutrition via a central line or enteral feedings administered via a NG tube feeding should be considered. 6. Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, immobility or restlessness. - Assess all body surfaces and documenting skin integrity every 8 hours - Turning and repositioning the patient every 2 hours - Providing skin care every 4 hours - Assisting the patient to get out of bed to a chair 3 times a day. Suresh K. Sharma, Brunner and Suddarth's Textbook of Medical-Surgical Nursing, volume 2, page no: 1736-1750. **2. Mrs.Y, 40 years old female slipped in the staircase and sustained spinal injury. She is not able to move any of her extremities- Answer the following:** **a. Explain the mechanism of spinal injuries.** [Hyperflexion] Usually result from blows to the back of the head or forceful decelerations as might occur in motor vehicle accidents. They are usually stable and rarely associated with neurological injury. [Hyperflexion-rotation] Disruption of the posterior ligamentous complex occurs and although cervical nerve root injury is common the spine is stable and not usually associated with spinal cord damage. [Vertical compression or axial loading] Depending on the magnitude of the compression forces, the resulting injury ranges from loss of vertebral body height with relatively intact margins, to complete disruption of the vertebral body. Posterior displacement of comminuted fragments may result producing cord injury. Despite cord injury the spine is usually stable. [Hyperextension] Usually result from a blow to the anterior part of the head or from a whiplash injury. Twice as common as flexion injuries and more often associated with cord damage. Violent hyperextension with fracture of the pedicles of C2 and forward movement of C2 on C3 produces the "Hangman's fracture". [Lateral flexion] Often associated with extension and flexion injuries. - The mechanism of injury of the thoracolumbar spinal cord is similar. - The spinal canal is narrower in the thoracic segment relative to the width of the cord, so that when vertebral displacement occurs it is more likely to damage the cord. Until age 10 the spine has increased physiological mobility due to lax ligaments that affords some protection against acute spinal cord injury. - In contrast, elderly patients are at an increased risk due to osteophytes and narrowing of spinal canal. **b. Classify and differentiate plegias.** [Monoplegia] - Paralysis of one limb. Or - Monoplegia is a paralysis of a single limb, usually an arm. - Causes: Cerebral palsy, epilepsy, head or spinal trauma, hereditary brachial neuritis, central nervous mass lesion including tumor, hematoma or abscess. - Signs and symptoms: weakness, numbness and pain in the affected limb. [Diplegia ] - Paralysis of both upper and lower limbs. Or - It refers to the paralysis affecting symmetrical parts of the body. - Causes: Cerebral palsy, vascular disorders that limit blood flow to the area, infectious and toxic agents that damage nerves or muscles in the affected area, spinal cord and brain injuries. - Signs and symptoms: Delayed motor or movement milestones i.e. rolling over, sitting, and standing. Walking on toes, flexed knees, strabismus, and seizures. [Paraplegia] - Paralysis of both lower limbs. Or - Impairment in motor or sensory function of the lower extremities. - Causes: Strokes, genetic disorders such as hereditary spastic paraplegia, autoimmune disorders. - Signs and symptoms: Weakness of upper and lower limbs, mental retardation, seizures, spasticity, muscle atrophy. [Hemiplegia] - Paralysis of upper limb, torso and lower leg on one side of the body. Or - Hemiplegia refers to the paralysis of the muscles of the lower face, arm and left on one side of the body. - Causes: Stroke, trauma such as spinal cord injury, brain tumors and brain infections. - Signs and symptoms: Muscle stiffness or weakness on one half of the body, difficulty balancing and walking, lack of fine motor skills, developmental delays. [Quadriplegia] - Paralysis of all four limbs. Or - Tetraplegia also known as quadriplegia is a paralysis caused by illness or injury that results in the partial or total loss of use of all four limbs or torso. - Causes: Trauma, congenital disorders such as muscular dystrophy, disease such as transverse myelitis, Guillain barre syndrome, multiple sclerosis. - Signs and symptoms: Impairment of the limbs, loss or impairment of in controlling bowel and bladder, spasticity. **c. Write a nursing care plan for Mrs. Y based on her clinical presentation.** 1\. Impaired skin integrity related to immobility and poor tissue perfusion as evidenced by reddened skin over bony prominences. - Monitor skin for areas of redness and breakdown - Provide back care - Frequent change of positioning to relieve pressure without disrupting traction - Monitor patients nutritional status to maintain healthy skin 2\. Constipation related to neurogenic bowel and immobility as evidenced by lack of bowel movement for more than 2 days. - Monitor bowel movements including frequency, consistency, shape, volume and color to establish baseline function - Monitor bowel sounds to determine if peristalsis is present - Instruct patient on foods high in fiber - Initiate a bowel training program to establish a bowel routine as quickly as possible. 3. Impaired urinary elimination related to spinal injury and limited fluid intake as evidenced by urinary retention, bladder distention, involuntary emptying of bladder. - Monitor intake and output to evaluate fluid balance - Monitor degree of bladder distention by palpation and percussion - Insert urinary catheter to relieve urinary retention in spinal shock - Refer to urinary continence specialists to establish long term bladder management program. 4. Ineffective protection related to spinal cord injury, vertebral cord instability or forced immobilization by traction as evidenced by inability to move purposefully, limited muscle strength. - Place on an appropriate therapeutic mattress / bed to allow for frequent turning without disrupting cervical traction and spinal alignment - Apply appliances to prevent foot drop. 5\. Risk for autonomic dysreflexia related to reflex stimulation of sympathetic nervous system after spinal shock resolves. - Identify and minimize stimuli that may precipitate dysreflexia: bladder distention, renal calculi, infection, fecal impaction, skin breakdown, constrictive clothing or bed linen and other examinations. Suresh K. Sharma, Brunner and Suddarth's Textbook of Medical-Surgical Nursing, volume 2, page no: 1750-1760. **3. MRS. X, 36 years old female has presented with severe prolonged headache and intermittent vomiting since one month and has been diagnosed as having Glioma-Answer the following:** **a) What is Glioma?** Ans. A type of tumor that occurs in the brain and spinal cord. Gliomas can occur in the brain and various locations in the nervous system, including the brain stem and spinal column. **b) List the measures for treating Glioma?** Ans. Treatment for brain gliomas depends on the location, the cell type, and the grade of malignancy. ***Medical Management:*** 1. Chemotherapy : Temozolomide is a chemotherapy drug which can be administered easily and is able to cross blood brain barrier effectively. 2. Immunotherapy 3. Stereotactic radiation therapy 4. Meta-analysis compared radiotherapy with radiotherapy and chemotherapy ***Surgical Management:*** 1. Craniotomy **c) Write a nursing care plan for MRS.X based on 3 prioritized nursing diagnosis** ***Pre-operative nursing diagnosis:*** 1. Acute pain related to disease process as evidenced by increased pain score reading. ***Nursing Interventions:*** I. Assess the pain score of the patient II. Provide diversional therapy III. Provide psychological support IV. Apply a cool compress on the head for low to moderate pain. V. Administer analgesics as per doctors order 2\. Anxiety related to health status as evidenced by verbalization. ***Nursing Interventions:*** I. Assess the anxiety level of the patient II. Clarify all the doubts of the patient III. Provide psychological support to the patient IV. Explain the procedure to the patient V. Administer medications as per doctor's order. 3\. Risk for infection related to side effects of chemotherapy. ***Nursing Interventions:*** I. Assess the general condition of the patient II. Carry out all the procedures in an aseptic manner III. Administer medications as per doctors order ***Post-operative nursing diagnosis:*** 1. Acute pain related to surgical procedure as evidenced by increased pain score reading ***Nursing Interventions:*** I. Assess the pain score of the patient II. Provide comfortable position III. Provide psychological support IV. Administer medications as per doctors order 2\. Anxiety related to health status as evidenced by verbalization ***Nursing Interventions:*** I. Assess the level of anxiety of the patient II. Provide psychological support III. Clarify all the doubts of the patient IV. Administer medications as per doctors order 3\. Risk for infection related to presence of surgical wound ***Nursing Interventions:*** I. Assess the surgical site for any signs of infection II. Provide sterile dressing III. Administer medications as per doctors order **4. Mrs.Y, 35 years old female presented with complaints of weakness in lower limb since 15 days and pain in lumbar region radiating to lower extremity. She has been diagnosed as having herniation of intervertebral disc at L2 level-Answer the following:** **a) Explain the pathophysiology of Lumbar disc herniation?** Ans. The intervertebral disc consists of an inner nucleus pulposus and an outer annulus fibrosus.The central nucleus pulposus is a site of collagen secretion and contains numerous proteoglycans which facilitate water retention creating hydrostatic pressure to resist axial compression of the spine. The nucleus pulposus is primarily composed of type 2 collagen, which accounts for 20% of its overall dry weight. In contrast, the annulus fibrosus functions to maintain the nucleus pulposus within the center of the disc with low amount of proteoglycans. In LDH, narrowing of the space available for the thecal sac can be due to protrusion of disc through an intact annulus fibrosus, extrusion of the nucleus pulposus through the annulus fibrosus though still maintaining continuity with the disc space or complete loss of continuity with the disc space and sequestration of a free fragment. Several changes in the biology of the intervertebral disc are thought to contribute to lumbar disc herniation. **b) Write a nursing care plan for Mrs.Y based on her clinical presentation?** 1. Acute pain related to disease process as evidenced by increased pain score reading. ***Nursing Interventions:*** 1\. Assess the pain score of the patient 2\. Provide comfortable position to the patient 3\. Provide hot or cold compress for low to moderate pain 4\. Administer medications as per doctor's order 2. Impaired physical mobility related to weakness of lower limb as evidenced by confinement to bed ***Nursing Interventions:*** 1. Assess the general condition of the patient 2. Provide comfortable position to the patient 3. Provide assistive devices 4. Advice the patient to carry out simple range of motion exercises 3. Anxiety related to health status as evidenced by verbalization ***Nursing Interventions:*** 1. Assess the anxiety level of patient 2. Provide psychological support 3. Clarify all the doubts of the patient 4. Explain everything before doing any procedure 4\. Risk for injury related to weakness of the lower limbs ***Nursing Interventions:*** 1. Assess the risk for injury 2. Provide assistive devices 3. Advice the patient to ask for assistance if needed 4. Provide bedside commode **5. Mrs. Z 48 year's old female is admitted in the neurological ward with the diagnosis of seizures-Answer the following:** **Ans (a):** The risk factors are: - Falling: If you fall during seizures, you can injure your head or break a bone. - Drowning: If you have a seizure while swimming or bathing, you're at risk of accidental drowning. - Car accidents: A seizure that causes either loss of awareness or control can be dangerous if you're driving a car or operating other equipment. - Pregnancy complication. - Emotional health issues. **Ans (b):** The type of seizures: - Absence seizures (formerly known as petit mal) - Tonic-clonic or convulsive seizures (formerly known as grand mal) - Atonic seizures (also known as drop attacks) - Clonic seizures. - Tonic seizures. - Myoclonic seizures. **Ans (c):** Medical management: - Stop the seizures as quickly as possible, - Ensure adequate cerebral oxygenation, and - Maintain the patient in a seizure-free state. - An airway and adequate oxygenation are established. - - Pharmacological therapy : - Intravenous diazepam, lorazepam, or fosphenytoin is administered slowly in an attempt to halt the seizure. - To maintain seizure Free State, other anticonvulsant medications (carbazepine, primidone, phenytoin, phenobarbital, ethosuximide and valproate) are prescribed after the initial seizure is treated. **Ans (d):** Nursing care plan. +-----------+-----------+-----------+-----------+-----------+-----------+ | Assessmen | Nursing | Objective | Plan of | Implement | | | t. | diagnosis | | action | ation | | +===========+===========+===========+===========+===========+===========+ | Subjectiv | Risk for | Patient | - Asses | - Asses | | | e | trauma | will be | the | sed | | | data: | related | free from | gener | the | | | | to | trauma. | al | gener | | | | seizures. | | condi | al | | | | | | tion | condi | | | | | | of | tion | | | | | | the | of | | | | | | patie | the | | | | | | nt. | patie | | | | | | | nt. | | | | | | - Provi | | | | | | | de | - Provi | | | | | | safet | ded | | | | | | y | the | | | | | | aid. | safet | | | | | | | y | | | | | | - Provi | aid. | | | | | | de | | | | | | | safet | - Provi | | | | | | y | ded | | | | | | envir | safet | | | | | | onment. | y | | | | | | | envir | | | | | | | onment. | | +-----------+-----------+-----------+-----------+-----------+-----------+ | Subjectiv | Risk for | Patient | - Asses | - Asses | | | e | ineffecti | will | the | sed | | | data: | ve | maintain | gener | the | | | | airway | her | al | gener | | | | clearance | airway. | condi | al | | | | related | | tion | condi | | | | to | | of | tion | | | | seizures. | | the | of | | | | | | patie | the | | | | | | nt. | patie | | | | | | | nt. | | | | | | - Monit | | | | | | | or | - Monit | | | | | | the | ored | | | | | | vital | the | | | | | | sign. | vital | | | | | | | sign. | | | | | | - Monit | | | | | | | or | - Monit | | | | | | the | ored | | | | | | respi | the | | | | | | ratory | respi | | | | | | statu | ratory | | | | | | s. | statu | | | | | | | s. | | +-----------+-----------+-----------+-----------+-----------+-----------+ - **https://www.epilepsyontario.org** - **https://www.slideshare.com** - [**https://www.nurseslabs.com**](https://www.nurseslabs.com) **6. Mr Z, a 65 years old male is admitted in the emergency department in unconscious stage and is diagnosed as having cerebrovascular accident (CVA) and right sided hemiplegic-Answer the following:** a. **Explain the pathophysiology of CVA.** b. **List the medical management for CVA.** c. **Write a nursing care plan for Mr Z for first 48 hours.** **Ans (a):** Pathophysiology: - Atherosclerosis: major cause of CVA. - Thrombus formation and emboli development. - Abnormal filtration of lipids in the intimal layer of the arterial wall. - Plaque develops and location of increased turbulence of blood-bifurcations. - Increased turbulence of blood or a tortuous area. - Calcified plaques rupture or fissure. - Platelets and fibrin adhere to the plaque. - Narrowing or blockage of an artery by thrombus or emboli. - Cerebral infraction: blocked artery with blood supply cut off beyond the blockage. - Ischemic cascade. - Series of metabolic events. - Inadequate ATP adenosine triphosphate production. - Loss of ion homeostasis. - Release of excitatory amino acids -- glumate. - Free radical formation. - Cell death. - Border zone: reversible area that surrounds the core ischemic area in which there is reduced blood flow but which can be restored. **Ans (b)**: Medical management: - Platelet-inhibiting medication: Aspirin, dipyridamole (persantine), clopidogrel (Plavix), and ticlopidine (ticlid). Currently the most cost-effective antiplatelet regimen is aspirin 50mg/d and dipyridamole 400mg/d. - Thrombolytic therapy: Recombinant t-PA, a thrombolytic substance made naturally by the body. The minimum dose is 0.9mg/kg; the maximum dose is 90mg. - Anticoagulation agents. - Management of increased intracranial pressure (ICP): osmotic diuretics elevate the head of bed to promote venous drainage and to lower increased ICP. **Ans (c):** +---------+---------+---------+---------+---------+---------+---------+ | | Nursing | Objecti | Plan of | Impleme | | | | | diagnos | ve | action | ntation | | | | | is | | | | | | +=========+=========+=========+=========+=========+=========+=========+ | Subject | Ineffec | Patient | - Ass | - Ass | | | | ive | tive | will | es | essed | | | | data: | tissue | increas | the | the | | | | | perfusi | ed | pat | gen | | | | | on | blood | ient | eral | | | | | related | flow. | gen | con | | | | | to | | eral | dition | | | | | decreas | | con | of | | | | | ed | | dition. | the | | | | | cerebro | | | pat | | | | | vascula | | - Mon | ient. | | | | | r | | itor | | | | | | blood | | vit | - Mon | | | | | flow. | | al | itored | | | | | | | sig | the | | | | | | | n. | vit | | | | | | | | al | | | | | | | - Mon | sig | | | | | | | itor | n. | | | | | | | neu | | | | | | | | rologic | - Mon | | | | | | | sta | itored | | | | | | | tus. | the | | | | | | | | neu | | | | | | | - Mon | rologic | | | | | | | itor | sta | | | | | | | res | tus. | | | | | | | pirator | | | | | | | | y | - Mon | | | | | | | sta | itored | | | | | | | tus. | the | | | | | | | | res | | | | | | | | pirator | | | | | | | | y | | | | | | | | sta | | | | | | | | tus. | | | +---------+---------+---------+---------+---------+---------+---------+ | Subject | Ineffec | Patient | - Ass | - Ass | | | | ive | tive | will | es | essed | | | | data: | airway | maintai | the | the | | | | | clearan | n | gen | gen | | | | | ce | airway. | eral | eral | | | | | related | | con | con | | | | | to | | dition | dition | | | | | inabili | | of | of | | | | | ty | | the | the | | | | | to | | pat | pat | | | | | raise | | ient. | ient. | | | | | secreti | | | | | | | | ons | | - Aus | - Aus | | | | | as | | cultate | cultate | | | | | evidenc | | the | d | | | | | ed | | bre | the | | | | | by | | ath | bre | | | | | diminis | | sou | ath | | | | | hed | | nd. | sou | | | | | breath | | | nd. | | | | | sound. | | - Rem | | | | | | | | ove | - Rem | | | | | | | the | oved | | | | | | | sec | the | | | | | | | retion | sec | | | | | | | by | retion. | | | | | | | suc | | | | | | | | tioning | - Ass | | | | | | | to | isted | | | | | | | cle | the | | | | | | | ar | pat | | | | | | | the | ient | | | | | | | air | in | | | | | | | way. | sit | | | | | | | | ting | | | | | | | - Ass | pos | | | | | | | ist | ition. | | | | | | | the | | | | | | | | pat | - | | | | | | | ient | | | | | | | | in | | | | | | | | sit | | | | | | | | ting | | | | | | | | pos | | | | | | | | ition. | | | | +---------+---------+---------+---------+---------+---------+---------+ | Subject | Impaire | Patient | - Ass | - Ass | | | | ive | d | will | es | essed | | | | data: | physica | maintai | the | the | | | | | l | n | gen | gen | | | | | mobilit | his | eral | eral | | | | | y | range | con | con | | | | | related | of | dition | dition | | | | | to | motion. | of | of | | | | | neuromu | | the | the | | | | | scular | | pat | pat | | | | | and | | ient. | ient. | | | | | cogniti | | | | | | | | ve | | - Det | - Det | | | | | impairm | | ermine | ermined | | | | | ent | | pat | pat | | | | | as | | ient | ient | | | | | evidenc | | rea | rea | | | | | ed | | diness | diness | | | | | by | | to | to | | | | | limited | | eng | eng | | | | | range | | age | age | | | | | of | | in | in | | | | | motion. | | act | act | | | | | | | ivity. | ivity. | | | | | | | | | | | | | | | - Enc | - Enc | | | | | | | ourage | ouraged | | | | | | | pat | pat | | | | | | | ient | ient | | | | | | | to | to | | | | | | | pra | pra | | | | | | | ctice | ctice | | | | | | | exe | exe | | | | | | | rcises | rcises | | | | | | | ind | ind | | | | | | | ependen | ependen | | | | | | | tly. | tly. | | | +---------+---------+---------+---------+---------+---------+---------+ - **https://www.slideshare.com** **7. Mrs. X, 9 year old female admitted to the neurology ward with complaints of ascending weakness and diagnosed to have GB Syndrome-Answer the following: \[2+2+6=10\]** **a. Enumerate the causes of GB syndrome.** - Unknown - Viral infection of GI and Respiratory tract - Cytomegalovirus(CMV) - Epstein-Barrn virus (EBV) - Mycoplasma pneumonia, which is an atypical pneumonia caused by bacteria like organism - Surgery - In rare cases people can develop the disorder after receiving a vaccination. https://www.healthline.com/health/guillain-barre-syndrome **b. List the medical management of GB Syndrome.** - Intravenous immunoglobulin (IVIG), administered for 2,3 or 5 days - Plasmapheresis to decrease circulating antibodies - EKG monitoring for automatic dysfunction - Hormonal therapy - Physical therapy to increase muscle flexibility and strength - Respiratory support - Corticosteroids - ACTH, proponolol, atropine. **c. Write a nursing care plan for Mrs. X based on her clinical presentation & the probable risk diagnosis.** 1\. Ineffective breathing pattern and impaired gas exchange related to rapidly progressive weakness and impeding respiratory failure. Goal: client will maintain normal respiratory function Nursing intervention: - Respiratory function can be maximized with incentive spirometry and chest physiotherapy - Monitoring for changes in vital capacity and negative respiratory force - Provide mechanical ventilation: client may require mechanical ventilation for a long period of time - Suctioning is needed to maintain a clear airway - Nurse should assess the blood pressure and heart rate frequently to identify autonomic dysfunction - Medications are administered or a temporary pacemaker placed for clinically significant bradycardia. 2\. Impaired bed and physical mobility related to paralysis Goal: client will increase mobility Nursing intervention: - To enhance physical mobility and prevent the complications of immobility - Perform passive range of motion exercises - Place the client in a comfortable position. Provide frequent position changes as tolerated - Padding should place over bony prominences such as elbows and heels to reduce risk of pressure ulcers - Nurse should evaluate laboratory test results it may indicate dehydration of which increase the risk of pressure ulcer and decrease mobility - Nurse should collaborate with physician and dietitian to develop a plan to meet the client's nutritional and hydration needs. 3\. Imbalance nutrition less than body requirements related to inability to swallow Goal: client will improve nutritional status Nursing intervention: - Nurse should administer IV fluids and parenteral nutrition - Monitor for the return of bowel sounds - If the patient cannot swallow because of immobility of muscles a gastrostomy tube may be placed to administer nutrients - Nurse should assess the return of gag reflex and bowel sounds before resuming oral nutrition. Brunner & Suddarths textbook of Medical Surgical Nursing 13^th^ edition pg.no.2043-2046. **8. Mr. Y, 48 year old male presented with muscle weakness, difficulty in breathing & diplopia. He is diagnosed as having Myasthenia Gravis-Answer the following: \[2+2+6\]** **a. Enumerate the causes of Myasthenia Gravis.** - Idiopathic - Autoimmune process - Genetic predisposition factors(congenital MG) - Familial causes (5-7%) - Environmental factor - Thyroid gland abnormality in 80%clients - Thymic tumor - Hyperthyroidism / thyrotoxicosis - Rheumatoid arthritis - Systemic Lupus Erythematosus - Myasthenic crisis-emotional upset, upper RTI,surgery,trauma,ACTH therapy - Antibodies induced accelerated degradation as well as the functional blockage of the AChR with depression of immune complex at NMJ. Brunner & Suddarths textbook of Medical Surgical Nursing 13^th^ edition **b. Explain the Pathophysiology of Myasthenia Gravis.** Due to autoimmune process Antibodies against Ach is produced Decrease in the number of AChR on the post synaptic membrane of NMJ Antibodies attack the AChR sites on the NMJ This prevents Ach molecules from attaching and stimulating muscle contraction. Voluntary muscle weakness Brunner & Suddarths textbook of Medical Surgical Nursing 13^th^ edition **c. Write a nursing care plan for Mr. Y based on three prioritized nursing diagnosis.** 1\. Ineffective breathing pattern related to respiratory muscle weakness Goal: Client will maintain effective breathing pattern as evidence by relaxed breathing at normal rate Nursing intervention: - Assess and record respiratory rate depth at least every hours - Assess ABG level - Monitor for diaphragmatic muscle fatigue or weakness - Assess the position that the client assumes for breathing - Utilize pulse oximetry to check oxygen saturation and pulse rate. 2\. Self-care deficit related to muscle weakness, general fatigue Goal: Client will perform his daily routine activities Nursing intervention: - Assess the patient strength - Encourage the patient to give passive exercise - Consider the patient's needs for assistive devices - Evaluate gag reflex - Allow the patient to feed himself as soon as possible - Provide comfortable position - Establish regular activities. 3\. Risk for aspiration related to weakness of bulbar muscle Goal: Client is free of signs of aspiration and the risk of aspiration is decreased Nursing intervention: - Assess the level of consciousness - Monitor respiratory rate, depth and effort - Not for any signs of aspiration such as dyspnea , cough, wheezing - Auscultate bowel sounds to assess for gastrointestinal mobility - Assess pulmonary status for clinical evidence of aspiration. - Keep suction machine available when feeding high risk patient. If aspiration occur suction immediately - Keep head of bed elevated when feeding. **9. Mr.Y, 75 years old male has been diagnosed to have Parkinson's disease. He is giving the history of tremors, rigidity, postural changes and difficulty in swallowing- Answer the following questions:** a. **.What is the causes of Parkinson's disease?** - [Genetic] - Gene play a role in the development of Parkinson's.Someone with a close relative is at an increased risk of developing the disease. - Gene mutation is another cause for the disease. - Exposure to chemicals like pesticides such as insecticides, herbicides, and fungicides. - Drinking well water and consuming manganese. - These are abnormal clumps of proteins found in the brain stem of people With Parkinson's disease.These proteins are unable to break. Cluster of Lewy bodies cause the brain to degenerate affecting the motor coordination in people with Parkinson's. - Dopamine is a neurotransmitter chemical that aids in passing messages between different sections of the brain.The cells that produce dopamine are damaged in people with Parkinson's disease. Without an adequate blood supply of dopamine the brain is unable to properly send and receive messages.This affects the body's ability to coordinate the movement. - As age increase brain and dopamine functions begin to decline. - Men are more susceptible than women - Peoples who have jobs in welding, agriculture, and industrial work. This is because individuals in these occupations are exposed to toxic Chemicals. **b) List the medical measures for measuring Parkinson's disease?** - [Anticholinergic agents] - Trihexyphenidyl hydrochloride- control tremors. - Benztropinemesylate --counteract the action of acetylcholine. - [Antiviral Agents] Amantadine hydrochloride -- Reduce rigidity, tremors, bradykinesis, And postural changes. - [Dopamine Agonist] Bromocriptinemesylate- secondary drug therapy. - [Mono amine oxidase inhibitors] Selegiline -- inhibit dopamine breakdown. - [Levodopa therapy] Levodopa is converted to dopamine in the basal ganglia producing symptomatic relief. - Carbidopa is often added to levodopa to avoid early metabolism before It reaching the site. **c).Describe the components of home care management for Mr. Y.** It includes family understands -- - How PDand its treatment impact physiological functioning, ADLs,IADLs , Roles, relationships, spirituality. - The importance of adhering to the prescribed medication regimen ; including knowing the purpose , dose , route , schedule , side effects, And precautions. - How and when to contact all members of the treatment team. - Specific type of environmental and safety changes or support that will Allow optimum functioning in the home. - The risks of falls / injury and how to implement fall precautions and Adaptive measures in the home. The life style changes that are necessary to promote self-care and independence include -; - [Maintain a healthy diet] Ensuring nutritional needs, including dietary restrictions, managing dysphagia, and preventing aspiration. Consuming antioxidants can fight oxidative stress.foods rich in Antioxidants are dried fruits and beans, grape juice or red wine Blue berries, avocado etc. - [Speech] Promoting speech and communication skills; speech exercise, communication techniques, breathing exercises. - [Fight Constipation] Managing constipation: fluid intake and bowel routine. Raw fruits And vegetables are preferred more than high fiber rich foods as it cause Intestinal gas and cramping. - [Managing urinary problems] Functional incontinence, retention, indwelling urinary catheter care and Suprapubic catheter care. - [Skin care] Avoiding the effects of immobility and promoting the advantages of preventive care: frequent turning, pressure release, skin care (Skin Breakdown). Pneumonia --deep breathing movement. Contractures -- range of motion exercise. - [Exercise] Ensure safe waking and balancing. Use appropriate coping mechanisms and diversional activities. - [Fall prevention] Modify the home environment to make things easier and safer to prevent a fall. Customize seating, toilets, bathtubs, and showers by installing grab bars.Remove tables with pointed edges that could injure. ### Suresh K. Sharma, S.Madhavi Brunner and Suddarth's "Text book of ### Medical Surgical'' Nursing, vol-2, South Asian Edition, 2018, ### Page no. 1805-1811. **10. Mrs. X, 32yrs old female has been admitted to neuro ward with** **Diagnosis of Multiple Sclerosis. Answer the following:** a. **Explain the pathophysiology of Multiple Sclerosis?** Activation of immune response in the body due to etiological factors like autoimmune activity , genetic factors ,smoking , lack of exposure to vitamin D, and exposure to Epstein --Barr virus. Sensitized T and B lymphocytes cross the blood brain barrier.. Sensitized T cells remain in the CNS and promote the infiltration of other Agents that damage the immune system. [.]Inflammatory response in the CNS destroys the myelin layer and oligodendroglia cells.. Interruption into the flow of nerve impulse b. **Write a care plan for Mrs. X based on three prioritized nursing diagnosis.** i. **Impaired physical mobility** related to muscle weakness or paralysis and muscle spasticity as manifested by inability to ambulate, intermittent muscle spasms, pain associated with muscle spasms. - Use assistive as indicated to decrease fatigue and enhance independence, comfort and safety. - Do active ranges of motion exercise at least 2 times per day to prevent contractures and minimize muscle atrophy? - Encourage and assist with ambulation and transfer as indicated to maintain mobility, promote independence, and provide safety. - Change position of patient (bedridden) at least q2hr to prevent circulatory problems and pressure ulcers. - Perform stretching exercises every 6 to 8 hours to relieve spasms and contracted muscles. - Assess self -- care problems to plan appropriate interventions to meet care needs - Promote use of appropriate assistive devices so that patient can maximally participate in self -- care activities with minimum fatigue. - Perform or assist with ADLs only as indicated to promote patients independence. - Administer cholinergic drugs as ordered to improve the muscle tone of bladder and facilitate bladder emptying. - Follow intermittent catheterization protocol to prevent distention or dribbling. - Use Credemaneuver or reflex stimulation as an alternative method of empting the bladder. - Maintain fluid intake of 3000ml per day to dilute urine and reduce risk of urinary tract infection. - Teach patient signs and symptoms of urinary tract infection to ensure early identification and treatment. - Initiate bladder training program to help restore adequate bladder function. ### Suresh K. Sharma, S.Madhavi Brunner and Suddarth's "Text book of ### Medical Surgical'' Nursing, vol-2, South Asian Edition, 2018, ### Page no1775-1776. **11. Define stroke. List down the various types of stroke. Explain in detail the rehabilitation of the patient with hemiplegia?** A stroke appears when a blood supply to part of brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. [Definition]\..... Stroke is defined as sudden death of brain cells due to lack of oxygen, caused by blockade of blood flow or rupture of an artery to the brain which is characterized by sudden loss of speech, weakness, or paralysis of one side of body. [Types of Stroke]\...\... 1. [Ischemic Stroke]: Occurs when a blood vessel supplying blood to the brain is obstructed 2. [Hemorrhagic stroke]: Occurs when a weakened blood vessel ruptures. The leaked blood puts too much pressure on brain cells, which damages them. There are two types of hemorrhagic strokes: \# Intracranial Hemorrhage: Is the most common type of hemorrhagic stroke. It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood. \# Subarachnoid Hemorrhage: Is a less common type of hemorrhagic stroke. It refers to bleeding in the area between the brain and thin tissue that cover it. 3. [Transient Ischemic Attack (TIA)]: A transient ischemic attack is sometimes called a mini stroke. It is different from the major types of stroke because blood flow to the brain is blocked for only a short time, usually no more than 5 minutes. [Rehabilitation of Patient with Hemiplegia] For rehabilitation of patients with hemiplegia, placing 1 or 2 pillows under the affected arm can prevent dislocation of the shoulder. If the arm is flaccid, a well-constructed sling can prevent the weight of the arm and hand from overstretching the deltoid muscle and subluxating the shoulder. A posterior foot splint applied with the ankle in a 90° position can prevent equines deformity (talipes equinus) and foot drop. Resistive exercise for hemiplegic extremities may increase spasticity and thus is controversial. However, re-education and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 wk. Active and active-assistive range-of-motion exercises are started shortly afterward to maintain range of motion. Active exercise of the unaffected extremities must be encouraged, as long as it does not cause fatigue. Various activities of daily living (e.g., moving in bed, turning, changing position, sitting up) should be practiced. For hemiplegic patients, the most important muscle for ambulation is the unaffected quadriceps. If weak, this muscle must be strengthened to assist the hemiplegic side. A gait abnormality in hemiplegic patients is caused by many factors (e.g., muscle weakness, spasticity, and distorted body image) and is thus difficult to correct. Also, attempts to correct gait often increase spasticity, may result in muscle fatigue, and may increase the already high risk of falls, which often result in a hip fracture; functional prognosis of hemiplegic patients with a hip fracture is very poor. Consequently, as long as hemiplegic patients can walk safely and comfortably, gait correction should not be tried. Additional treatments for hemiplegia may include the following: - - - - - YAMSHON LJ, MACHEK O, COVALT DA. The tonic neck reflex in the hemiplegic; an objective study of its therapeutic implication. *Arch Phys Med Rehabil. *1949 Nov;30(11):706--711 **12. Mr. Ram 48 year's old male is admitted to the emergency department with a history of fall from height. He is diagnosed to have spinal cord injury at C4 level.** **a) List down the clinical features of cervical injury.** **b) Discuss the emergency Management of Mr. Ram.** **c) Prepare a nursing care plan for Mr. Ram.** **a) Generally the direct result of trauma that causes** - **Cord compression** - **Ischemia** - **Edema** - **And possible cord transection** - **The patient with an incomplete lesion may demonstrate a mixture of symptoms.** - **The higher the injury the more serious sequel because of the proximity of the cervical cord to the medulla and brainstem.** - **Movement and rehabilitation potential related to specific location.** **AMERICAN CERVICAL INJURY ASSOCIATION (ACIA) IMPAIRMENT SCALE** A. **Complete:** **No Motor or sensory function is preserved in the Sacral segments S4-S5.** B. **Incomplete:** **Sensory but not motor function is preserved below neurological level and includes. The Sacral segments.S4-S5.** C. **Incomplete:** **Motor function is preserved below the neurological level and more than half of key muscles below the neurological level have a muscle grade less than 3.** D. **Incomplete:** **Motor function is preserved below the neurological level and at least half of key muscles below the neurological level have a muscle grade of3 or more** E. **Normal:** **Motor and sensory functions are normal.** **b) Discuss the emergency Management of Mr. Ram.** **Initial:** - **Ensure patent Airway.** - **Stabilize cervical spine.** - **Administer oxygen via nasal cannula or nonrebreather mask.** - **Establish IV access with two large bore catheters to infuse normal saline or lactated Ringers solution as appropriate.** - **Assess for other injuries.** - **Control external bleeding obtains cervical spine X-rays, CT scan, or MRI.** - **Prepare for stabilization with cranial tongs and traction.** - **Administer high dose methylprednisolone if ordered.** **Ongoing Monitoring:** - **Monitor vital signs, level of consciousness, oxygen saturation ,cardiac rhythms, urine output** - **Keep warm.** - **Monitor for urinary retention and hypertension.** - **Anticipate need for intubation if gag reflex absent** **Drug Therapy:** - **The methylprednisolone is to be given within 8 hours of injury, when the loading dose of 30mg/kg is given within 3 hours of injury.** - **This is followed by 24 hours of 5.4mg/kg/hr. IV drip.** - **If this loading dose is given between 3 and 8 hours post injury the IV drip is maintained for 48 hours.** - **Vasopressor agents such as dopamine used in acute phase of adjuvant to treatment.** **Diagnostic:** - **History and PE including complete neurological examination.** - **ABGs** - **Serial bedside PFTs** - **Electrolytes, glucose level, coagulation profile, hemoglobin and hematocrit levels.** - **Urinalysis** - **Anteroposterior, lateral, and odontoid spinal X-rays.** - **CT scan ,MRI** - **X-rays of spine** - **Myelography** - **EMG to measure evoked potentials** - **Venous duplex studies.** **Collaborative Therapy:** - **Immobilization of vertebral column by skeletal traction.** - **Maintenance of heart rate and BP.** - **Methylprednisolone high dose therapy** - **Insertion of NG tube and attachment to suction** - **Intubation ( if indicated ABGs and PFTs)** - **Oxygen by high humidity mask** - **Administration of IV fluids** - **Indwelling urinary catheter** - **Stress ulcer prophylaxis** - **DVT prophylaxis** - **Bowel and bladder training.** **Rehabilitation and home care:** **Physical therapy** - **ROM exercises** - **Mobility training** - **Muscle strengthening** **Occupational therapy** - **Splints, activities of daily living training)** - **Bowel and bladder training** - **Autonomic dysreflexia prevention** **Recreational therapy** - **Patient and family education.** **C) Prepare a nursing care plan for Mr. Ram.** **1)Impaired gas exchange related to intercostal muscle and diaphragmatic fatigue or paralysis and retained secretions as evidenced by decreased paO2, decreased tidal volume, diminished breath sounds.** **Goals:** **2) Demonstrates no signs of respiratory distress.** **Intervention and rationale:** **Respiratory monitoring** - **Monitor rate, rhythm, depth and effort of respirations to note baseline and changes in status.** - **Monitor for diaphragmatic muscle fatigue** - **Auscultate breath sounds.** - **Monitor PFT values like vital capacity. Maximal inspiratory force and forced expiratory volume.** **Airway management:** - **Identify patient potential airway insertion to ensure timely intervention.** - **Perform ET suctioning to stimulate coughing and to clear respiratory secretions.** **2)Impaired skin integrity related to skull long placement immobility and poor tissue perfusion as evidenced by reddened skin over bony prominences and open long sites.** **Goals:** 1. **Demonstrates no signs of infection at skull long sites.** 2. **Maintain intact skin over bony prominences.** - **Infection protection** **-Inspect condition of any surgical incision/ wound to detect early signs of infection.** - **Infection control:** **-Ensure appropriate wound care techniques to prevent bacterial colonization at long sites.** - **Pressure management:** **-Monitor skin for areas of redness and breakdown so that intervention can be initiated promptly if a problem develops.** **-Facilitate small shifts of body weight to relieve pressure without disrupting traction.** **-Monitor the patient's nutritional status to maintain healthy skin resistant to breakdown.** **3)Ineffective coping related to loss of control over bodily functions and altered lifestyle secondary to paralysis as evidenced by verbalization of inability to cope, expression of anger or other negative feeling related to disrupt changes in function and participate in social contacts.** **GOALS** **1) Reports ability to cope with effects of spinal cord injury.** **2) Expresses feelings of grief in adapting to losses related to chronic condition.** **INTERVENTIONS AND RATIONALES** - **Appraise patient's adjustment to changes in body image** - **Appraise impact of patient's life situation on roles and relationships** - **Provide an atmosphere of acceptance** - **Encourage verbalization of feelings, perceptions, and fears to aid patient's in clarify feelings** - **Provide factual information concerning diagnosis, treatment and prognosis** - **Provide patient with realistic choices about certain aspects of care** - **Support use of appropriate defense mechanism** - **Assist patient to identify positive strategies to deal with limitations and changes in lifestyle or role changes to prevent patients from practicing ineffective behaviors such as smoking, drinking.** - **Encourage family involvement to enhance patient's sense of worth and value at a person** **4) Constipation related to neurogenic bowel, inadequate fluid intake as evidenced by lack of bowel movement for more than 2 days, decreased bowel sounds or stool incontinence** **GOALS** **1) Establishes a bowel management program based on neurologic function and personal preference** **2) Maintains a bowel movement every other day** **INTERVENTIONS AND RATIONALES** - **Monitor bowel movements, including frequency, consistency, shape, volume, and color to establish baseline function** - **Monitor bowel sounds** - **Instruct patient on foods high in fiber bulk and fiber are necessary** - **Initiate a bowel training program to establish a bowel routine as quickly as possible** **Lewis,Heitkemper,Dirksen,O'Brien and Bucher, Medical Surgical Nursing, 7^th^ edition.** **13. Mr. Ashok 45 years old is admitted with history of double vision and giddiness and is diagnosed with brain tumors:** **a) List the types of brain tumors.** Mainly there are 2 types ▪ Primary: can be benign or malignant ▪ Metastatic: malignant Benign tumors are: Chordomas Craniopharyngiomas Gangliocytomas Glomus jugulare Meningiomas Pineocytomas Pituitary adenomas Schwannomas Malignant tumors are: Gliomas o Astrocytomas o Ependymomas o Glioblastoma multiform(GBM) o Medulloblastomas o Oligodendroglia Other types of brain tumors Hemangioblastomas Rhomboid tumors https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Brain-Tumors **b) Enumerate the clinical manifestation of brain Tumor that will be seen in Ashok.** General symptoms include: Headache, which may be severe and worsen with the activity or in the early morning. Seizures: the different types of seizures are listed below Myoclonic o Single or multiple muscle twitches, jerks, spasms Tonic clonic o Loss of consciousness and body tone, o Loss of body functions, such as loss of bladder control o May be short period of no breathing, and a person skin may turn a shade of blue, purple, gray, white or green Sensory o A changes in the sensation ,vision, smell and/or hearing without losing consciousness Complex partial o May cause a loss of awareness or a partial or total loss of consciousness o May be associated with repetitive, unintentional movements such as twitching Personality or memory changes Nausea or vomiting Fatigue Drowsiness Sleep problems Memory problems Changes in ability to walk or perform daily activities Some specific symptoms are: Pressure or headache near the tumor Loss of balance and difficulty with fine motor skills is linked with a tumor in the cerebellum Changes in judgement, including loss of initiative, sluggishness, and muscle weakness or paralysis is associated with a tumor in the Frontal lobe of the cerebrum. Partial or complete loss of vision is caused by a tumor in the occipital lobe or temporal lobe of the cerebrum Changes in speech, hearing, memory, or emotional state, such as aggressiveness and problems understanding or retrieving words can Develop from a tumor in the frontal and temporal lobe of cerebrum. Altered perception of touch or pressure, arm or leg weakness on 1 side of the body, or confusion with left sides of the body are linked to a tumor in the frontal or parietal lobe of cerebrum. Inability to look upwards can be caused by a pineal gland tumor. Lactation, which is the secretion of breast milk, and altered menstrual periods in women, and growth in hands and feet in adults are Linked with a pituitary tumor. Difficulty swallowing, facial weakness or numbness or double vision is a symptom of a tumor in the brain stem. Vision changes, including loss of part of the vision or double vision can be from a tumor in the temporal lobe, occipital lobe or brain Stem. https://www.google.nl/search?ie=UTF-8&source=android- Browser&q=Enumerate%2Bthe%2Bclinical%2Bmanifestation%2Bo&client=ms-android-oppo-rev1 **c) Explain the post-operative management of Ashok after Craniotomy** General instructions are: In general, the length of hospital stay varies between 3-7days and full recovery may take 6-12 weeks so have patience. A post-operative CT/MRI will be ordered and reviewed the day after surgery like it will take your body time to recover from this Procedure so make sure goes get plenty of rest. Avoiding keeping head of the bed flat.use extra pillows while sleeping. no sofas or recliners for the first 2 weeks post operatively. No lifting, it will increase the intracranial pressure and can cause complications. Absolutely no alcoholic beverages. These will make to develop seizures. 1st week o Take lots of sleep, o No lifting or straining o Use skin sensitive shampoo like "baby shampoo" until incision is well healed. o No driving. o Early ambulation is encouraged to decrease the risk of increased risk of blood clots and pneumonia. Staff off with 1-2 blocks a day And increase as tolerated. o No sexual activity. 2nd week. o Make sure to attend post-operative visit for suture/staple removal and evaluation. o Increase ambulation daily as tolerated. o No driving, but may ride as passengers. o May climb stairs with assistance and not symptomatic. o Try to ween narcotic medication and replace with non-narcotic pain medication. o No sexual activity. 3rd week o Continued to increase activity and are allowed to perform basic tasks. o May resume sexual activity if not symptomatic 4th week o Increase.activity as tolerated. o May return to work if OK with doctor. o OK to drive when directed by doctor. **14. Classify spinal cord tumors. Explain the management of spinal cord tumors.** Answer: ^5^ https://www.slideshare.net/mobile/dodulmondal/spinal-cord-tumor **[Management]** - Medical management - Surgical management [Medical Therapy]: - High dose intravenous corticosteroids (prolonged use of steroids can be associated with gastric ulceration, hyperglycemia and immunosuppression with cushingoid features) Chemotherapy and Radiation therapy particularly for intramedullary tumors and metastatic lesions. ^6^ https://www.slideshare.net/mobile/AmitAgrawal35/spinal-tumors-approach-and-management [Surgical management: ] Two surgical approaches may be used to manage spinal cord tumors: 1. Anterior decompression: is typically indicated because most spinal tumors are anterior. 2. The posterolateral: approach may be used for excision of thoracic tumors [Nursing management] Providing preoperative care: - The objective of preoperative care include recognition of neurologic changes through ongoing assessments, pain control, and management of altered activities of daily living due to sensory and motor deficits and bowel and bladder dysfunctions. - The nurse assesses for weakness, muscle wasting, spasticity, sensory changes, bowel and bladder dysfunction and potential respiratory problems, especially if a cervical tumor is present. - The patient is also evaluated for coagulation deficiencies. A history of aspirin intake is obtained and reported because the use of aspirin may impede hemostasis post operatively. - Breathing exercise is taught and demonstrated pre operatively. Postoperative pain management strategies are discussed with the patient before surgery. Postoperative care: - The patient is monitored for deterioration in neurologic status. - A sudden onset of neurologic deficit is an ominous sign and may be due to vertebral collapse associated with spinal cord infraction. - Frequent neurologic checks are carried out with emphasis on movement, strength and sensation of the upper and lower extremities and GSC. - Assessment of sensory function involves pinching the skin of the arms, legs and trunk to determine if there is loss of feeling and, if so, determining at what level. Vital signs are monitored at regular intervals. - Assess the pain using scale and provide the medications prescribed by the physician in adequate amount and at appropriate intervals to relieve pain. - The nurse monitors the patient for symmetric chest movement, abdominal breathing and abdominal breath sounds. - Demonstrate to patient to perform breathing exercise. [Nursing Diagnosis:] 1. Pain related to nerve compression 2. Impaired urinary elimination related to spinal cord compression 3. Risk for injury related to surgery 4. Risk for peripheral neuromuscular dysfunction related to nerve compression. 5. Anxiety related to diagnosis of spinal tumor, surgery and outcome. ^7^ **15. Ms. Seema 15years old is admitted to Neuro ward with bacterial meningitis. Answer the following** a. **Define meningitis** b. **List down the etiological factors and clinical features of meningitis** c. **Describe the collaborative management for the patient** Ans : a) [Definition of Meningitis] Meningitis's an acute inflammation of the protective membranes covering the brain and spinal cord, collectively known as the meninges. Meningitis can be life-threatening because of the inflammation\'s proximity to the brain and spinal cord. b\) [Etiological factors of Meningitis] Viral infections are the most common cause of meningitis, followed by bacterial infections and, rarely, fungal infections. Because bacterial infections can be life-threatening, identifying the cause is essential. **INFECTIOUS CAUSES** Bacterial meningitis: Bacteria that enter the bloodstream and travel to the brain and spinal cord cause acute bacterial meningitis. But it can also occur when bacteria directly invade the meninges. This may be caused by an ear or sinus infection, a skull fracture, or rarely after some surgeries. Several strains of bacteria can cause acute bacterial meningitis, most commonly: - Streptococcus pneumoniae (pneumococcus). This bacterium is the most common cause of bacterial meningitis in infants, young children and adults. It\'s more common causes are pneumonia, ear or sinus infections. A vaccine can help prevent this infection. - Neisseria meningitis (meningococcus). This bacterium is another leading cause of bacterial meningitis. These bacteria commonly cause an upper respiratory infection but can cause meningococcal meningitis when they enter the bloodstream. This is a highly contagious infection that affects mainly teenagers and young adults. A vaccine can help prevent infection. - Haemophilus influenza (haemophilus) and Haemophilus influenza type b (Hib) bacteria was once the leading cause of bacterial meningitis in children. But new Hib vaccines have greatly reduced the number of cases of this type of meningitis. - Listeria monocytogenes (listeria). These bacteria can be found in unpasteurized cheeses, hot dogs and lunchmeats. Pregnant women, newborns, older adults and people with weakened immune systems are most susceptible. Listeria can cross the placental barrier, and infections in late pregnancy may be fatal to the baby. Viral meningitis Viral meningitis is usually mild and often clears on its own. Most cases are caused by a group of viruses known as enteroviruses, which are most common in late summer and early fall. Viruses such as herpes simplex virus, HIV, mumps, West Nile virus and others also can cause viral meningitis. Fungal meningitis Fungal meningitis is relatively uncommon and causes chronic meningitis. It may mimic acute bacterial meningitis. Fungal meningitis isn\'t contagious from person to person. Cryptococcal meningitis is a common fungal form of the disease that affects people with immune deficiencies, such as AIDS. It\'s life-threatening if not treated with an antifungal medication. **NON INFECTIOUS CAUSES** Meningitis can also result from noninfectious causes, such as chemical reactions, drug allergies, some types of cancer and inflammatory diseases such as sarcoidosis. [Clinical features of meningitis] Early meningitis symptoms may mimic the flu (influenza). Symptoms may develop over several hours or over a few days. Possible signs and symptoms include: - Sudden high fever - Stiff neck - Severe headache that seems different than normal - Nausea or vomiting - Confusion or difficulty concentrating - Seizures - Sleepiness or difficulty waking - Sensitivity to light - No appetite or thirst - Skin rash (sometimes, such as in meningococcal meningitis) C\) [Collaborative management for Meningitis:] Diagnostic measures, 1. History and physical examination. 2. Analysis of CSF for protein, glucose, WBC, gramstain and culture. 3. CBC, platelet counts, coagulation profile and electrolyte level. 4. Blood culture 5. CT scan, MRI and PET scan 6. Skull X-Ray studies Collaborative Therapy, - Rest - IV fluids - Hypothermia Drug therapy, IV antibiotics Ampicillin, Penicillin Cephalosporin (e.g.; cefotaxime, ceftriaxone) Codeine for headache Acetaminophen or Aspirin for temperature \> 100.4 °F Phenytoin IV Mannitol IV for diuresis Mayo clinic, patient care & health information\>diseases and conditions, Meningitis. Available from: https[[://www.mayoclinic.org/diseases-conditions/meningitis/symptoms-causes/syc-20350508]](https://www.mayoclinic.org/diseases-conditions/meningitis/symptoms-causes/syc-20350508) \[accessed Jan 8 2019\] Suzanne C Smeltzer G Barre, Janice L Hinkle, Kerry H Cheever. Brunner and Suddharth\'s textbook medical surgical nursing. Eleventh edition volume II. Page no 1440 **[SHORT ANSWERS (MK):2 Marks each]** 1. **List cranial nerves.** - Olfactory Nerve: Sense of smell - Optic Nerve: Vision - Oculomotor Nerve: Eyeball and eyelid movement - Trochlear Nerve: Eye movement - Trigeminal Nerve: This is the largest cranial nerve and is divided into three branches consisting of the ophthalmic, maxillary and mandibular nerve. Functions controlled include facial sensation and chewing. - Abducens Nerve: Eye movement - Facial Nerve: Facial expressions and sense of taste - Vestibulocochlear Nerve: Equilibrium and hearing - Glossopharyngeal Nerve: Swallowing, sense of taste and saliva secretion - Vagus Nerve: Smooth muscle sensory and motor control in throat lungs, heart and digestive system - Accessory Nerve: Movement of neck and shoulders - Hypoglossal Nerve: Movement of tongue, swallowing, and speech https:www.health.com\>health 2. **Differentiate primary and secondary headache**. - [Primary headache] A primary headache is a headache that is due to the headache condition itself and not due to another cause. Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems. For example, migraine is a type of primary headache. - [Secondary headache] A secondary headache is a headache that is present because of another condition such as a sinus headache from sinusitis. Secondary headaches are caused by an underlying disease like an infection, head injury, vascular disorders, rain bleed or tumors. 3. **List major types of head injuries.** [Brain injury] What Causes Non-Penetrating Traumatic Brain Injuries? - The most important consideration is any head injury is whether the brain is injured. - The brain cannot store oxygen or glucose to any significant degree because the cerebral cells need an uninterrupted blood supply to obtain these nutrients, irreversible brain damage and cell death occur if the blood supply is interrupted for even a few minutes. Suresh K. Sharma, Brunner and Suddarth's Textbook of Medical-Surgical Nursing, volume 2, page no: 1736-1740. 4. **Differentiate between Paraplegia, Quadriplegia, and Hemiplegia?** Paraplegia is the paralysis that affects all or part of the torso, legs and pelvic organs. Quadriplegia is the paralysis of all four limbs and torso. Hemiplegia is the paralysis on one side of the body that can affect the arms, legs and facial muscles. https://www.appolohospitals.com ![Types of Paralysis. \#Hemiplegia \| \#Paraplegia \| \#Quadriplegia \...](media/image4.jpeg) 5. **Define herniation of intervertebral disc?** Intervertebral disc herniation is an injury to the cushioning and connective tissue between vertebrae, usually caused by excessive strain or trauma to the spine. http://www.wikipedia.com Intervertebral Disc Herniation\|Types\|Symptoms\|Treatment\|Diagnosis \... ![Understanding Intervertebral Disc Herniation - Aguirre Legal Nurse \...](media/image6.jpeg) 6. **Define gliomas?** A type of tumor that occurs in the brain and spinal cord. Gliomas can occur in the brain and various locations in the nervous system, including the brain stem and spinal column. Treatment for brain gliomas depends on the location, the cell type, and the grade of malignancy. Medical Management: 5. Chemotherapy : Temozolomide is a chemotherapy drug which can be administered easily and is able to cross blood brain barrier effectively. 6. Immunotherapy 7. Stereotactic radiation therapy 8. Meta-analysis compared radiotherapy with radiotherapy and chemotherapy Surgical Management***:*** 2. Craniotomy Glioma - Symptoms and causes - Mayo Clinic https://www.appolohospitals.com 7. **List four warning signs of aneurysms?** The warning signs are: a. Sudden, extremely severe headache. b. Nausea and vomiting. c. Stiff neck. d. Blurred or double vision. e. Sensitivity to light. f. Loss of consciousness. **BLIBLIOGRAPHY:** - [**https://www.mayoclinic.com**](https://www.mayoclinic.com) **8. List the changes occur in CSF in bacterial meningitis** ![Results CSF Analysis At different types of Meningitis \| Nursing \...](media/image8.jpeg) The changes occur are: a. CSF glucose to blood glucose ratio of 0.4 or lower. b. CSF WBC count increased. c. CSF lactate level increased. - **https://www.medscape.com** 9. **Define chorea?** A movement disorder marked by involuntary spasmodic movements especially to the limbs and facial muscles and typically symptomatic of neurological dysfunction. \_by Merriam Webster. Ceaseless rapid complex body movements that look well-coordinated and purposeful but are, in fact, involuntary. \_ From Medicine net. Rapid, jerky, involuntary, purposeless movement of the extremities or facial muscles, including facial grimacing. \_From Brunner and suddarth's. - **https://www.merriam-webster.com** - **https://www.medicinenet.com** - **Brunner and Suddarth's textbook of medical-surgical nursing 13 edition volume 2.wolters Kluwer.pg(2052).** **10. State the triad of Parkinson's syndrome.** Parkinson's disease is a chronic progressive neurodegenerative disease that is clinically manifested by a triad of cranial motor symptoms-rigidity, bradykinesia and tremor-due to loss of dopaminergic neurons. The motor symptoms of Parkinson's disease become progressively worse as the disease advances. [https://www.google.com/search?q=triad-of-Parkinson's-syndrome](https://www.google.com/search?q=triad-of-Parkinson's-syndrome) **11. List the stages of Seizures.** 1\. Generalized seizures: - Tonic-clonic seizures - Typical absence seizures - Atypical absence seizures - Myoclonic seizures - Atonic seizures - Tonic seizures 2\. Partial seizures: - Simple partial seizures - Complex partial seizures https://www.slideshare.net/mobile/sajjadhussainraja/classification-of-seizures **12. Write the constituent of CSF.** - Glucose 50-80mg/dl - Protein 15-45mg/dl - Uric acid 0.5-3.0mg/dl - Urea 6.0-16mg/dl - Creatinine 0.6-1.2mg/dl - Cholesterol 0.2-0.6mg/dl - Ammonia 10-35mg/dl - Sodium 135-150mg/dl - Potassium 2.6-3.0mg/dl - Chloride 115-130mg/dl - Magnesium 2.4-3.0mg/dl - Cells(WBC) 0-5 Lymph/µL 13. **List FOUR clinical features of increased intracranial pressure?** - Earliest sign is change in LOC. Agitation, slowing of speech, delay in response to verbal suggestions. - Restlessness, confusion and drowsiness. - Patient becomes stuporous, reacting only to painful or loud d stimuli. - The patient becomes comatose and exhibits abnormal motor responses in the - Headache - Nausea/vomiting - Blurred vision - Papilledema - Somnolence alter level of consciousness - Pupillary dilatation - Cushing triad - Bradycardia - Hypertension - Irregular respiration ### **Suresh K. Sharma, S.Madhavi Brunner and Suddarth's "Text book of** **Medical Surgical'' Nursing, vol-2, South Asian Edition, 2018,** Page no.1684. 14. **What is Bell's palsy?** Bell palsy (facial palsy) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the affected side. OR Bell palsy is a type pressure paralysis. The inflamed, edematous nerve becomes compressed to the point of damage, or its blood supply is occluded producing Ischemic necrosis of the nerve. - Vascular ischemia, viral diseases (herpes simplex, herpes zoster), autoimmune disease. - Painful sensation in the face , behind the ear ,and in the eye ,speech difficulty, and Unable to eat on the affected side. ### Suresh K. Sharma, S.Madhavi Brunner and Suddarth's "Text book of ### Medical Surgical'' Nursing, vol-2, South Asian Edition, 2018, ### Page no.1792. 15. **What is Trigeminal Neuralgia?** Trigeminal Neuralgia is a condition of the fifth cranial nerve that is characterized by paroxysms of sudden pain in the area innervated by any of the three branches of the nerve. **[CLINICAL FEATURES]** - Pain described as a unilateral shooting and stabbing or burning sensation. - Involuntary contractions of the facial muscles causing sudden closing of Eye or twitching of the mouth. ### Suresh K. Sharma, S.Madhavi Brunner and Suddarth's "Text book of ### Medical Surgical'' Nursing, vol-2, South Asian Edition, 2018, ### Page no1789. 16. **What is cerebral aneurism?** A cerebral aneurism also called an intracranial aneurism or brain aneurism is a bulging, weakened area in the wall of an artery in the brain, resulting in an abnormal widening, ballooning, or bleb. Because there is a weakened spot in the aneurism wall, there is a risk for rupture of the aneurism OR A **cerebral or intracranial aneurism** is an abnormal focal dilation of an artery in the brain that results from a weakening of the inner muscular layer (the intima) of a blood vessel wall. The vessel develops a \"blister-like\" dilation that can become thin and rupture without warning. The resultant bleeding into the space around the brain is called a **subarachnoid hemorrhage** (SAH). This kind of hemorrhage can lead to a stroke, coma and/or death. Cerebral Aneurysm \| Department of Neurology Raps EC, Rogers JD, Galetta SL, Solomon RA, Lennihan L, Klebanoff LM, Fink ME: The clinical spectrum of un ruptured intracranial aneurysms. Arch Neurol 50:265--268, 1993. **17.** **List classical symptoms of Parkinsonism?** \* Tremor or shaking usually begins in a limb, often your hands or fingers \* Slowed movement (bradykinesia) \* Rigid muscles \* Impaired posture and balance etc. are the classical signs Other symptoms include\...\... \* Loss of automatic movements \* Speech changes \* Writing changes Tobottom BJ, Weiner WJ, Shulman LM (2009-09-28). \"Chapter 42: Parkinsonism\". In Lisak RP, Truong DD, Carroll W, Bhidayasiri R (eds.). *International Neurology: A Clinical Approach*. Blackwell Publishing Ltd. pp. 152--58 **18.** **Define Aphasia?** Aphasia is inability to understand or produce speech, as a result of brain damage. OR Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to brain most commonly from a stroke, particularly in older individuals. OR Aphasia is an ability to comprehend or formulate language because of damage to specific brain regions. The major causes are a cerebral vascular accident, or head trauma, but aphasia can also be the result of brain tumors, brain infections, or neurodegenerative disease such as dementia. Hunting-Pompon R, Kendall D, Bacon Moore A (June 2011). \"Examining attention and cognitive processing in participants with self-reported mild anomia\". *Aphasiology*. **25** (6--7): 800--812. **19. Classify Aphasia?** **Based on characteristics of verbal expression.** **There are two types:** **1) Nonfluent** **2) Fluent** **1) Nonfluent:** **Speech production is halting and effortful. Grammar is impaired; content words may be preserved.** **Language comprehension relatively intact:** **a) Boca's Aphasia:** **-Repition of words/ phrases poor.** **b) Transcortical Motor Aphasia:** **- Strong repetition skills; may have difficulty spontaneously answering question** **Language comprehension impaired** **a) Global Aphasia:** **-Severe expressive and receptive language impairment may be able to communicate using facial expressions, intonation gestures.** **2) Fluent:** **Person is able to produce connected speech sentences structure is relatively intact but lacks meaning** **Language comprehension relatively intact:** **a) Conduction Aphasia:** **Word finding difficulties, difficulty repeating phrases.** **b) Anomic Aphasia:** **Repetition of words/phrases good, word finding difficulties uses generic fillers** **E.g.: "Thing" or circumlocution.** **Language comprehension impaired:** **1) WERNICKE'S APHASIA:-Repetition of words/phrases.** **2) TRANSCORTICAL SENSORY APHASIA:-Repetition of words/phrases good: may repeat questions rather than answering them.** **Lewis, Heitkemper, Dirksen, O'Brien and Bucher, Medical Surgical Nursing, 7^th^ edition.** **20. Define spinal shock?** **Spinal shock is defined as the immediate failure of all spinal cord functions at the time of injury below the level of cord damage resulting in flaccid paralysis, loss of reflexes, and loss of sympathetic innervation.** **Spinal shock is characterized by** - **Decreased reflexes** - **Loss of sensation** - **Flaccid paralysis below the level of injury** **This syndrome lasts days to months and may mask post injury neurologic function.** **Lewis, Heitkemper, Dirksen, O'Brien and Bucher, Medical Surgical Nursing, 7^th^ edition.** **21. Differentiate between Concussion and Contusion** ![What is concussion? - Queensland Brain Institute - University of \...](media/image10.jpeg) Concussion CEREBRAL CONTUSION Cerebral contusion,\... - Nepal Chikitsha.Com \...Contusion +-----------------------------------+-----------------------------------+ | [Contusion] | [Concussion] | +===================================+===================================+ | - The bruising of the brain | - A sudden transient mechanical | | tissue within a focal area | head injury, such as a blow | | without alerting the | or explosion, with disruption | | integrity of the piameter and | of neural activity and a | | subarachnoid layers. | change in the level of | | | consciousness. | | - Usually associated with a | | | closed head injury and severe | - Associated with minor head | | trauma. | injury. | | | | | - Hemorrhage, infarction, | - Typical signs of concussion | | necrosis and edema and | include a brief disruption in | | frequently occurs at a | loss of consciousness, | | fracture site phenomena of | amnesia regarding the event | | countercoup injury is often | retrograde amnesia and | | noted. | headache. | | | | | - Contusion is a major head | - Concussion is a minor head | | trauma. | trauma. | +-----------------------------------+-----------------------------------+ **Lewis, Heitkemper, Dirksen, O'Brien and Bucher, Medical Surgical Nursing, 7^th^ edition.** **22. What is chorea?** Chorea is a movement disorder that causes involuntary, unpredictable body movements. Chorea symptoms can range from minor movements, such as fidgeting; to severe uncontrolled arm and leg movements. It can be interfere with: Speech swallowing Posture Gait **23. Coup and counter coup injury** Coup and counter coup (pronounce coo and contra coo) refer to a type of head injury (traumatic brain injury) and reference where the injury Occurred relative to the point of impact. A coup injury occurs on the brain directly under the point of impact. A countercoup injury occurs on the Opposite side of the brain from where the impact occurred. Coup and countercoup injuries are a type of traumatic brain injury that results in the Bruising of the brain. **24. List out uses of Glasgow coma scale** Doctors use it to evaluate less serious altered levels of consciousness in post-traumatic situations. They also use it for things like the depth and duration of a coma. The patient's score on the scale helps us understand the severity of the injury. The Glasgow coma scale gives providers precision and certainty. Experts use it for other traumatic and non-traumatic pathologies. Professionals in diverse fields use it for emergency situations. Consequently, it's very useful in the early stages of treatment. https://www.google.nl/amp/s/exploringyourmind.com/glasgow-coma-scale-definition-use-advantages/amp/ **25. List out the components of Glasgow coma scale?** +-----------------------+-----------------------+-----------------------+ | BEHAVIOR | RESPONSE | SCORE | +=======================+=======================+=======================+ | Eye opening response | Spontaneously | 4 | | | | | | | To speech | 3 | | | | | | | To pain | 2 | | | | | | | No response | 1 | +-----------------------+-----------------------+-----------------------+ | Best verbal response | Oriented to time, | 5 | | | place & person | | | | | 4 | | | Confused | | | | | 3 | | | Inappropriate words | | | | | 2 | | | Incomprehensible | | | | sounds | 1 | | | | | | | No response | | +-----------------------+-----------------------+-----------------------+ | Best motor response | Obeys commands | 6 | | | | | | | Moves to localized | 5 | | | pain | | | | | 4 | | | Flexion withdrawal | | | | from pain | 3 | | | | | | | Abnormal flexion | 2 | | | | | | | Abnormal extension | 1 | | | | | | | No response | | +-----------------------+-----------------------+-----------------------+ **Minor brai9n injury:** 13-15 points; **Moderate brain injury**: 9-12 points; **severe brain injury**: 3-8 points^1^ **26. What is agnosia?** The inability to recognize people or objects even when basic sensory modalities are intact. There are three types of agnosia: a. Visual agnosia: Person has difficulty recognizing objects, faces and words. b. Auditory agnosia: inability to define/ recognize sounds. c. Somatosensory agnosia: the person has difficulty perceiving objects through tactile stimulation.^2^ **27. What is dementia?** Dementia is a syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment and reasoning. Personality changes and behavioral problems such as agitation, delusion and hallucinations may occur. Ultimately these problems result in alterations in the individual\'s ability to work, fulfill social and family responsibilities and perform activities of daily living. Dementia is often diagnosed when two or more brain functions such as memory loss or language skills are significantly impaired. Lewis, Dirksen Heitkemper, Bucher. Lewis medical surgical nursing: assessment and management of clinical problems. Second South Asia edition vol II. Page no 1501 **28. What is Romberg Test?** Romberg Test is for cerebellar dysfunction requiring patient to stand with feet together, eyes closed and arms extended. Inability to maintain the position, with either significant stagger or sway is a positive test. Suzanne C Smeltzer, Brenda G Barre, Janice L Hinkle, Kerry H Cheever. Brunner and Suddhartha's textbook medical surgical nursing. Eleventh edition volume II. Page no 2129 ![Romberg Test: Technique & Assessment » How To Relief](media/image12.png) **[SHORT ANSWERS (DK):2 Marks each]** **1. Define neurocysticercosis.** - It is the most common parasitic disease of nervous system and it is the main cause of acquired epilepsy in developing countries. - Neurocysticercosis can be acquired via fecal-oral contact with carries adult tape worm taenia solium. - This usually indicates the presence of tape worm carrier in immediate environment or by accidental ingestion of contaminated food. - Neurocysticercosis is the condition in which results from encystment of the larva of taenia sodium, the pork tapeworm in the tissue of the brain. **2. List signs and symptoms of neurocysticercosis?** - Epilepsy - Headache - Dizziness - Stroke - Neuropsychiatric dysfunction - Dysarthria **3. Enumerate medical and surgical management of neurocysticercosis?** Medical management: a. Analgesics. b. Antiepileptic drugs. c. Anti-inflammatory drugs. d. Anti-parasitic treatment.e.g. albendazole Surgical management: a. Neuroendoscopy. [**https://www.ncbi.nlm.nih.gov**](https://www.ncbi.nlm.nih.gov) **4. Define Hydrocephalus.** Hydrocephalus is defined as abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles and subarachnoid spaces. It is often associated with dilatation of the ventricular system and increased intracranial pressure (ICP). Hydrocephalus is an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles and cavities of brain. This causes increased intracranial pressure inside the skull and may cause progressive enlargement of head. Hydrocephalus is defined as an imbalance between the production and absorption of cerebrospinal fluid. **5. Define syringomyelia?** Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms Within the spinal cord. This, cyst called a syrinx, can expand and elongate over time, destroying the spinal cord. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. OR Syringomyelia is a rare disorder in which a fluid filled cyst forms within your spinal cord. This cyst is referred to as a syrinx. As the syrinx expands and lengthens over time, it compresses and damages part of your spinal cord from its center outward. OR Syrigomyelia is a disease of the spinal cord in which the nerve tissue is replaced by a cavity filled with fluid. ### National Institute of Neurological Disorders and Stroke, Syringomyelia Fact Sheet ### Last update March 17, 2020. Available at: ### Accessed March 28, 2020 6\. **Classify spina bifida?** \* OCCULTA: Mildest and commonest form in which one or more vertebrae are malformed. \* CLOSED NEURAL TUBE DEFECT: This form consist of a diverse group of defect in which is marked by malformation of fat, bone and meninges. \* MYELOMENINGOCELE: Most severe and occurs when spinal cord are exposed through the opening in the spine, resulting in partial or complete paralysis of body. \* MENINGOCELE: Spinal fluid and meninges protrude through an abnormal vertebral opening. *Kancherla, Vijaya; Wagh, Kaustubh; Johnson, Quentin; Oakley, Godfrey P. (15 August 2018). \"A 2017 global update on folic acid-preventable spina bifida and anencephaly\". Birth Defects Research. **110** (14): 1139--1147.* **7. List clinical manifestation of chairi malformation?** - **Severe headache and neck pain.** - **Spasticity** - **Dizziness** - **Balance problem** - **Double or blurred vision** - **Hypersensitivity to bright lights** - **Sleep apnea** - **Loss of pain temp sensation of upper torso and arms.** - **Loss of muscle strength in and arms.** **.** **8. What are the normal values of Proteins and Glucose in Cerebrospinal fluid?** Protein: 20-40mg/dL Normal CSF Proteins concentration in children's: o Up to 6 days of age: 70 mg/dL o Up to 4 years of age: 24mg/dL Glucose: 45-80mg/dL **9. Where is the cerebrospinal fluid produced?** Answer: Cerebrospinal fluid is a clear, colorless body fluid found in the brain and spinal cord. It is produced by specialized ependymal cells in the choroid plexuses of the ventricles of the brain, and absorbed in the arachnoid granulations. There is about 125ml of CSF at any one time, and about 500ml is generated every day. A sample of CSF can be taken via lumbar puncture.^3^ **10. List three major functions of Nervous system?** Answer: The three major functions are: a. Sensory function: Nervous system uses its millions of sensory receptors to monitor changes occurring both inside and outside of the body. Those changes are called STIMULI and the gathered information is called sensory input. b. Integrative function: The nervous system process and interprets the sensory input and makes decisions about what should be done at each moment- a process is called integration. c. Motor function: The nervous system then sends information to muscles, glands and organs so they can respond correctly, such as muscular contraction or glandular secretions.^4^ **11. List the symptoms of Guillian - Barre Syndrome?** Ans: Guillain-Barre syndrome is a rare disorder in which your body\'s immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form Guillain-Barre syndrome is a medical emergency. Most people with the condition must be hospitalized to

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