7115210 Neurological

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NEUROLOGICAL

I. Neurologic Anatomy and PhysiologyA. Central nervous system (CNS) - coordinates and controls body

functionsa. Brainb. cerebrum

i. hemispheres right and leftii. frontal lobe - higher intellectual

functions, social behavior, personalityiii. parietal lobe - interprets sensory inputiv. temporal lobe - hearing, taste and

smellv. occipital lobe - vision

c. cerebellum - provide equilibrium and musclecoordination

d. brain stem - midbrain, pons and medullaoblongata; controls basic body functions andrelays impulses to and from spinal cord

2. Spinal corda. descending tract - anterior portion of cord

carrying motor informationb. ascending tract

i. the posterior portion of cord, carryingsensory information

ii. 31 segments

eight cervical: neck and upperextremities

12 thoracic: thoracic andabdomen

five lumbar: lower extremities

five sacral: lower extremities,urine and bowel control

one coccygealB. Peripheral nervous system - carries information to and from

the CNS1. Motor nerves2. Sensory nerves

C. Autonomic nervous system - regulates body's internalenvironment

1. Sympathetic - prepares body for fight or flight; usedonly as needed

2. Parasympathetic - controls normal body functioning forday to day activities, e.g., increases muscle tone,maintains secretions; maintains heart rate withinnormal limits; maintains peristalsis

D. Cranial nerves

These nerves are the vital bridges between the brain and therest of the body.

To remember the cranial nerves, remember this sentence:

On Old Olympus Towering Top A Frenchman And GermanViewed Some Hops

OR Oscar Osmond Ought To Try To Find A Girl's Voice SingingHigh

E. Physiology - nervous system coordinates and controls allactivities of the body

1. Receives internal and external stimuli2. Processes information to determine appropriate

response3. Transmits information over varied motor pathways to

effector organsF. Findings for increased intracranial pressure (ICP)

1. Earlya. change in level of consicousness (LOC):

restlessness, disorientation, confusion,lethargy, stupor

b. pupils: dilated ipsilaterally, react slowly to light

c. abnormal motor activity: contralateralhemiparesis

d. abnormal reflexes - hyper or hypo reflexiae. vital signs within normal parameters
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2. Latea. LOC: semicomatose, comab. pupils: dilated bilaterally and fixed; no reaction

to light

c. motor function: decorticate posture thendecerebrate posture; flaccid muscles at endstage

d. vital signs - increased systolic pressure toresult in a widened pulse pressure, decreasedrespirations with bradycardia, temperatureinitially may rise then fall below mornal

parameters

Dont let the testing procedure overwhelm you. Take it one step at a time andremain focused.Say to yourself "I will make decisions about at least 75 clients with individualneeds," rather than "this is THE TEST!"

II. Degenerative DisordersA. Parkinson's disease

1. Definition: degenerative disorder of the dopaminehydrochloride - producing neurons

a. result: dopamine hydrochloride depletionb. usually occurs in older adults and males more

than femalesc. etiology unknown

2. Findings

a. resting tremors of the lips, jaw, tongue, andlimbs, especially a resting pill-rolling tremor ofone hand that is absent during sleep. This isdifferent from an essential or intention tremorin which the tremor is action related.

b. bradykinesiac. fatigued. stiffness and rigidity with movemente. signs first unilateral, then bilateralf. mask-like facial expressiong. slow, shuffling walk; gradually more difficulth. difficulty rising from sitting positioni. ultimately confined to a wheelchairj. mind stays intact unless other aggravating

conditions

k. echolalia in most cases3. Diagnostics

a. based on finding with historyb. EEGc. MRId. computerized tomogram (CT scan)

4. Managementa. outcomes: palliative; postpone dependenceb. pharmacologic

I. anticholinergics - minimizeextrapyramidal effects

I. benzotropine mesylate(Cogentin)

II. procyclidine (Kemadrin)II. dopamine hydrochloridergics:

Levodopa (L-Dopa)III. antiparkinsonian agent: amantadine

hcl (Symmetrel) reduces rigidity andtremor

IV. MAO inhibitors: selegiline (Eldepryl)

c. therapiesI. physicalII. occupationalIII. speech

d. surgery: stereotaxic thalamotomy to decreasetremor

5. Nursing interventionsa. maintain safety of clientb. prevent effects of immobilityc. foster independence in activities of daily living

(ADL)d. reinforce the use of assistive devices for

ambulation as indicated

e. maintain good nutritionI. small, frequent mealsII. soft foodsIII. roughage with sufficient fluids to

decrease constipationf. monitor effectiveness of administered

medicationsg. provide emotional support to client and family

membersh. teach client

I. when and what side effects of thedrugs to report

II. the benefits of daily exerciseB. Huntington's disease

1. Definitiona. progressive atrophy of basal ganglia and some

parts of cerebral cortexb. etiology - genetic disorder, autosomal

dominant2. Findings: increased involuntary movements,

progressive decline in cognitive, findings usually occurin middle age

a. motorI. impaired chewing and swallowing

II. chorea

III. dystonic posture

IV. gradually becomes bedriddenb. cognitive: less able to organize, plan and

sequence behavior
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c. mental: personality changes, depression, evenpsychosis

3. Diagnostics: history and physical exam4. Management

a. outcomes: postpone dependenceb. supportive care for findingsc. therapies: speech, physicald. genetic counseling

5. Nursing interventionsa. foster independence in ADL (activities of daily

living)

b. reinforce the use of assistive devices forambulation as needed

c. teach client to:I. maintain good nutritionII. get emotional support from support

groups, friends seek genetic counseling

1. Amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease)5. Definition

a. progressive atrophy of spinal muscle; bulbarpalsy

b. progressive degeneration of the motor neurons

of the anterior horn cells of the spinal cord,brainstem, and motor cortex

c. onset in later middle age; more in men than inwomen

d. clients with ALS usually die within two to sixyears

e. etiology unknown6. Findings

a. usually beginning in head and arms, distalportion first

b. mild clumsiness progressing to total incapacityc. muscle wasting, atrophy, spasticityd. speech disorders

e. no change in sensation or autonomic systemf. death most often from complications:

respiratory failure, urinary or pulmonaryinfections for stasis

g. mind usually intact7. Diagnostics: history and physical exam8. Management

a. outcome: keep functional independence asmuch as possible

b. no curec. management of findings

i. muscle relaxants for spasticityii. therapies:

1. speech2. physical3. respiratory

9. Nursing interventionsa. provide for respiratory care and referralsb. maintain a safe environment focused toward

infection preventionc. prevent complications of immobilityd. postpone dependencee. maintain nutritionf. provide emotional support and referrals to

support groups2. Dementia

5. Etiologya. characterized by irreversible, progressive

cerebral dysfunction

b. Alzheimer's disease - most common cause ofdementia

i. characterized by brain atrophyii. development of senile plaques and

neurofibrillary tangles in the cerebralhemispheres

iii. etiology unknown6. Findings

a. characterized by decreased intellectualfunctioning

b. Alzheimer's disease has three stagesi. early stage:

1. memory loss
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2. subtle personality changes3. difficulty with abstract thinking

ii. middle stage:1. impaired language2. difficulty with motor activity

and object recognition3. wandering4. inability to carry out ADLs5. impaired judgment

iii. final stage:1. complete loss of language

2. loss of bowel and bladdercontrol

c. prognosis - incurable7. Management - maintenance of functional capacity8. Nursing interventions

a. meet client's physical needsb. promote client's independencec. promote contact with realityd. establish a routinee. provide emotional support or caregiver support

with appropriate referrals2. Cerebrovascular Accident (CVA, Stroke

1. Definition: decreased blood supply to the brain

5. Risk factorsa. hypertension, uncontrolledb. smokingc. obesityd. increased blood cholesterol and triglyceridese. chronic atrial fibrillation

6. Five classes of stroke: by severitya. transient ischemic attack (TIA), "angina" of the

braini. TIA is warning sign of strokeii. localized ischemic eventiii. produces neurological deficits lasting

only minutes or hoursiv. full functional recovery within 24 to 48

hoursb. reversible ischemic neurological deficit (RIND)

i. similar to TIAii. findings last between 24 hours and

three weeksiii. usual full functional recovery within

three to four weeksc. partial, nonprogressing stroke: some

neurological deficit, but stabilizedd. progressing stroke (stroke in evolution)

i. deteriorating neurological status oftenwith grand mal seizure activity

ii. with residual neurological deficits

e. completed stroke7. Two types of stroke by cause

a. ischemic (also known as occlusive) stroke (clot)- slower onset

i. results from inadequate blood flowleading to a cerebral infarction

ii. caused by cerebral thrombosis orembolism within the cerebral bloodvessels

iii. most common cause: atherosclerosisb. hemorrhagic stroke (bleeding) - abrupt onset

i. intracerebral hemorrhagic stroke1. blood vessels rupture with a

bleed into the brain2. occurs most often in

hypertensive older adults3. may also result during

anticoagulant or thrombolytictherapy

ii. subarachnoid hemorrhage (SAH)

1. most often caused by ruptureof saccular intracranialaneurysms

2. more than 90% are congenitalaneurysms

iii. epidural bleeds

1. arterial is involved2. often loss of consciousness for

a short period or calledtransient

3. recall clue: associate that "e" inepidural and "a" in artery aretogether at the top of thealphabet

iv. subdural bleeds1. vein is involved2. may not be evident until

months after the initial trauma3. recall clue: associate that "s" in

subdural and "v" in vein aretogether at the bottom of thealphabet

2. Findings (depends on location of lesion)

C. Diagnostics1. History and physical exam2. Computerized tomogram (CT) scan3. Magnetic resenance imaging (MRI)4. Doppler echocardiography flow analysis5. Carotid artery duplex doppler ultrasonography

6. EEG - shows electrical activity

7. Lumbar puncture - shows if blood found in cerebralspinal fluid
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8. Cerebral angiography - shows blood flow

a. may be done with or withoutcontrast

b. Types of CVA

D. Management - to prevent or minimize the damaging effects ofstroke; dependent on the type of CVA

1. Expected outcomes:a. prevent or minimize the damaging effects of

stokeb. is dependent on type of type of CVA

2. Occlusive strokea. pharmacologic

1. thrombolytics2. anticoagulant therapy: heparin,

coumadin

3. antiplatelet therapy: aspirin,dipyridamole

1. platelet aggregation inhibitor:clopidogrel (plavix), ticlopidineHCL (ticlid)

4. steroids: dexamethasoneb. surgery - bypass

3. Hemorrhagic strokea. pharmacologic

1. antihypertensive agents2. systemic steroids: dexamethasone

(decadron)3. osmotic diuretics: mannitol

4. antifibrinolytic agents: aminocaproicacid (amicar)

5. vasodilators

6. alpha-blockers and beta-blockers7. anticonvulsants

b. surgical excision of aneurysm4. Common to both types of stroke

a. care based on findingsb. therapies:

1. occupational2. speech3. nutritional support

E. Nursing interventions1. In acute stage of stroke

a. maintain airway patency; if grand mal seizureactivity note time, length, behaviors

b. monitor neuro vital signsc. maintain adequate fluidsd. provide activity as orderede. perform passive and/or active range of motion

exercisesf. position with head of bed elevated 15 to 30

degrees with client turned or tilted tounaffected side

g. maintain proper body alignmenth. administer medications as orderedi. care for post op client as indicated

j. provide care for client with increasedintracranial pressure

2. Long-term care of client with strokea. monitor elimination patternsb. teach/evaluate the use of supportive devicesc. maintain a safe environmentd. prevent the effects of immobilitye. maintain adequate nutrition in light of feeding

and swallowing problemsf. assist with eating and ADL as indicatedg. provide emotional supporth. provide methods of communication for client

with aphasia

2. Infectious, Inflammatory Disorders1. Meningitis2. Definition/course

a. acute or chronic inflammation of the meningesb. average length of illness is four months

3. Typesa. bacterial: most commonly meningococcus,

haemophilus influenzae, pneumococcusb. viralc. fungald. parasitic

4. Findingsa. severe headacheb. fever

c. nuchal rigidity (stiff neck)d. altered LOC
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5. Diagnosticsa. history and physical examb. positive Kernig's sign: 90-degree flexion of hip

and knee with extension of knee causes painc. positive Brudzinski's sign: flexion of neck

causes flexion of hip and knee

d. lumbar puncture (illustration ) forcharacteristics of cerebral spinal fluid

6. Managementa. expected outcome: to cure the infection and

prevent complicationsb. pharmacologic

1. antibiotic therapy depends on type andpathogen

2. preventive therapy for people exposedto those with meningococcal and H flumeningitis: rifampin (rifadin)

3. H flu vaccinec. actions to minimize feverd. prevention of increased intracranial pressure or

seizures7. Nursing interventions

a. care of client with increased ICP

b. seizure precautionsc. administer drugs as orderedd. provide comfort measures for paine. reduce external stimuli

D. Parameningeal infections1. Definition

a. localized collection of exudate in brain or spinalcord

b. usually caused by bacteria2. Findings

a. similar to meningitisb. headache, fever, stiff neck, altered

consciousness3. Diagnostics

a. NO lumbar puncture; may cause herniationb. computerized tomogram (CT) scan

4. Managementa. surgical decompression of abscessb. symptomatic and preventive treatment as with

meningitisc. drugs: antibiotics

5. Nursing interventions: same as meningitisE. Encephalitis

1. Definitiona. acute inflammatory viral diseaseb. can occur as epidemics or sporadically

c. death rate ranges up to 70%d. most common pathogen for sporadicencephalitis is herpes simplex

e. may follow a systemic viral illness such aschicken pox

2. Findings

a. sudden feverb. headachec. seizuresd. stiff necke. altered LOC progressing to coma

3. Diagnosticsa. history and physical examb. computerized tomogram (CT) scan

c. brain biopsy4. Management

a. uncomplicated cases require supportive andpreventive care

b. bed or chair restc. maintain nutritiond. maintain fluid balancee. herpes simplex calls for antivirals: vidarabine

(viraA), acyclovir (zoviraz) (f. prevention of increased ICP

5. Nursing interventionsa. comfort measures for feverb. administer drugs as ordered

c. seizure precautions3. Bed rest with padded side rails 2.Suction machine at bedside 3.

Oxygen at bedside

d.care of the client with increased ICP

a. when needed, ensure isolation and airborne-droplet precautions

CARE OF CLIENT WITH INCREASED INTRACRANIAL PRESSURE

1. Monitor neuro vital signs as ordered2. Maintain fluid restriction as ordered3. Raise head of bed at 30-45 degrees; avoid 90 degrees since pressure

in hip area increases ICP4. Prevent any activities that increase ICP such as: straining at stool,

coughing, vomiting, any restrictive clothing around neck, neck rotation,flexion, extension, anxiety, pushing up in bed with heels, pulling onrails when turning

5. Observe for herniation syndrome6. Monitor for changes in intracranial pressure7. Administer oxygen as ordered8. Institute seizure precautions9. Provide for care of the unconscious client10. Autoimmune Disorders of Neurologic System

1. Multiple sclerosis1. Definition
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1. demyelination of white matter throughout brainand spinal cord

2. third most common cause of disability inclients aged 15 to 60

3. specific cause unknown4. increased incidence in temperate to cool

climates5. illness improves and worsens unpredictably

2. Findings depend on the location of the demyelination1. cranial nerve: blurred vision, dysphagia,

diplopia, facial weakness and/or numbness

2. motor: weakness, paralysis, spasticity, gaitdisturbances

3. sensory: paresthesias, decreasedproprioception

4. cerebellar: dysarthria, tremor, incoordination,ataxia, vertigo

5. cognitive: decreased short-term memory,difficulty with new information, word-findingdifficulty, short attention span

6. urinary retention or incontinence7. loss of bowel control8. sexual dysfunction9. fatigue

3. Diagnostics1. history and physical exam2. lumbar puncture3. magnetic resonance imagery (MRI)4. computerized tomogram (CT) scan5. evoked potentials or response - the EEG record

of electrical activity at one of several levels inthe CNS by stimulation of an area of thesensory nerve system

4. Management1. expected outcomes: to alleviate findings and

prevent complications2. pharmacologic: adrenocorticotropic hormone

(ACTH)3. therapies based on findings

1. physical2. occupational3. pharmacologic

5. Nursing interventions1. maintain functional independence in ADL2. determine effectiveness of administed

medications3. prevent complications of immobility4. prevent injury from difficulties walking5. provide emotional support6. provide counseling for sexual dysfunction7. teach client to:

1. avoid fatigue and stress2. conserve energy3. exercise regularly

4. know drugs and side effects5. use self-help devices6. maintain a diet that supports nutrition

and energy needs2. Guillain-Barre syndrome

1. Definition1. acquired inflammatory disease2. process: demyelinization of peripheral nerves3. precipitating factors include prior bacterial or

viral infection within one to two weeks2. Findings

1. muscle weakness: progressive, ascending,bilateral

2. leads to paralysis of voluntary muscles3. loss of superficial and deep tendon reflexes

4. bulbar weakness5. dysphagia6. dysarthria7. respiratory failure8. sensory findings: paresthesias, burning pain9. paralysis may vary from being total to partial

of only one-half way up the body3. Diagnostics

1. history and physical exam

2. lumbar puncture will show increased protein inCSF electromyography (EMG)

4. Management1. expected outcomes: to prevent complications

and maintain body functions until any reversal2. steroids in acute phase3. care as dictated by areas involved

5. Nursing interventions

1. maintain the care of client on ventilatorysupport

2. provide for care of the immobilized client3. have a safe environment to minimize infection

4. maintain nutrition and fluid balance5. refer families or client to support groups6. supply referrals to therapies such as speech,

physical, occupational and counseling3. Myasthenia gravis

1. Definition:1. antibodies destroy acetylcholine receptors

where nerves join muscles2. two age clusters: women in early adulthood

and men in late adulthood3. progressive with occurances of crises

2. Findings1. progressive fatigue of voluntary muscles, but

no muscular atrophy2. facial

1. ptosis (drooping eyelid) and reducedeye closure
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2. weak smile3. diplopia, blurred vision4. speech and swallowing disorders5. weakness of facial muscles

3. signs of restrictive lung disease4. sensation remains intact

3. Diagnostics1. history and physical exam2. edrophonium (tensilon) test: improved muscle

strength after tensilon injection indicates apositive test for MG

4. Management1. expected outcome to improve strength and

endurance2. pharmacologic

1. anticholinesterase agents:pyridostigmine (mestinon),neostigmine (prostigmin)

2. corticosteroid therapy3. immunosuppressants: azathioprine

(imuran)

3. thymectomy (4. plasma exchange5. myasthenic crisis management

1. crisis usually follows stressor or duringdosage changes

2. signs: sudden inability to swallow,speak, or maintain patent airway

3. cholinergic crisis may follow overdosage of medication

4. positive edrophonium (tensilon) testsignals myasthenia

5. if negative endophronium test, clienthas not myasthenic but cholinergiccrisis, so treat with atropine

6. ventilatory support as indicated5. Nursing interventions

1. identify aggravating factors, such as:1. infection2. stress3. changes in medication regime

2. if client is in crisis: provide care of the client onventilatory support

3. give medications as ordered and on time4. help with ADL and feeding as indicated5. provide

1. emotional support2. adequate rest periods3. care of the surgical client

6. teach client

1. energy conservation techniques2. medications, expectations and side

effects

3. signs of impending crisis, bothmyasthenic and cholinergic

4. to avoid stressors11. Seizure Disorders

1. Definition/etiology1. Sudden, transient alteration in brain function2. Disorderly transmission of electrical activity in the

brain3. Causes

1. cerebral lesions2. biochemical alteration

3. cerebral trauma4. idiopathic

2. A classification of seizure types: partial, simple, complex,generalized

SEIZURE CLASSIFICATIONS

A. Types of generalized seizures - one classification system1. Absence seizures (petit mal seizures)2. Myoclonic seizures (bilateral massive epileptic myoclonus)3. Generalized tonic-clonic seizures (grand mal seizures)

4. Akinetic seizureB. Proposed international classification of epilepsies and epilepticsyndromes

1. Idiopathic2. Benign childhood epilepsy3. Primary reading epilepsy4. Symptomatic5. Chronic progressive epilepsia partialis continua of childhood6. Syndromes characterized by seizures with specific triggers7. Cryptogenic8. Presumed to be symptomatic but etiology is unknown9. Differs from Symptomatic by lack of etiologic evidence

1. Partial seizures1. focal motor2. seizure activity only in specific parts of the

brain3. usually client remains conscious

2. Simple with findings associated with1. motor activity2. special sensory feelings3. autonomic activity4. psychic issues5. psychomotor actions6. no loss of consciousness

3. Complex1. impairment of consciousness2. secondarily generalized3. progressing to generalized tonic-clonic

4. Generalized seizures: eight types
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1. petit mal - called absence seizures2. myoclonic

1. sudden, uncontrollable jerkingmovements of one or more extremities

2. usually occurs in the morning3. clonic

1. characterized by violent musclemovements

2. hyperventilation3. face contortion4. excessive salivation

5. diaphoresis6. tachycardia

4. tonic1. first, client loses consciousness

suddenly and muscles contract

2. body stiffens in opisthotonos position

(illustration )3. jaws clenched4. may lose bladder control5. apnea with cyanosis6. pupils dilated and unresponsive7. usually lasts less than a minute

e. grand mal: most common typei. tonic-clonic movements

ii. may be preceded by prodromaliii. lasts two to three minutesiv. after clonic phase, client is

unresponsive for about five minutesv. arms, legs go limpvi. breathing returns to normalvii. possible disorientation or confusion for

sometime afterwardsviii. possible headache and fatigue

afterwards

f. atonic: sudden loss of postural muscle tonewith collapse

g. unclassified seizuresh. status epilepticus

i. rapid sequence of seizures withoutinterruption

ii. medical and nursing emergencyiii. client in postictal state when next

seizure beginsiv. sometimes occurs if a sudden stop of

maintenance doses of anticonvulsantsv. if cerebral anoxia occurs, brain damage

or death can follow

vi. risk for severe organ and musclehypoxia

6. Diagnostics

e. by the event itself - see abovef. history and physical examg. electroencephalogram (EEG)h. computerized tomogram (CT) scan

6. Managemente. expected outcomes: to control the seizure activity and preventcomplicationsf. correction of underlying problemg. medications

i. benzodiazepines, I.V. such as diazepam(valium), lorazepam (ativan) for active

seizuresii. hydantoin anticonvulsants such as

phenytoin (dilantin) - maintenanceiii. barbiturates such as phenobarbitol -

maintenanceiv. succinimides such as ethosuximide

(zarontin) - maintenance7. Nursing interventions

e. administer medications as ordered

f. seizure care

1. Do not leave the client who is seizing2. Attempt to prevent or break client's fall by assisting him/her to

horizontal position on the bed or the floor3. Loosen tight clothing around neck and chest4. Remove objects near the client5. Place a pillow under the client's head if possible and available6. Place the client's head in a lateral position if possible to maintain

airway7. Place nothing in the client's mouth8. Cover the client if possible9. Document

a. type of seizure - describe behavior rather than labelingb. durationc. activity during and if incontinenced. if any precipitating factorse. client's response - immediate, then at 15 minute intervals until

stability is established

g. seizure precautionsh. teach client

i. about medication effects, interactions,and side effects

ii. to learn when a seizure may betriggered

iii. techniques to reduce stress

iv. seizure care at home or at workv. to wear medic-alert jewelry
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vi. if in public area, after the tonic phaseturn client to side

VII. HeadacheA. Definition

1. Pain located in upper region of the head2. One of the most common neurologic complaints

B. Classifications1. Recurrent migraine headache

a. onset during adolescence or early adulthoodb. familialc. involves unilateral, throbbing paind. subtypes

i. classic migraineii. common migrainei ii. cluster headacheiv. hemiplegic headachev. ophthalmoplegic headache

2. Recurrent muscular-contraction headache (pressure,tension headache)

a. most common form of headacheb. may be direct result of stress, anxiety or

depression3. Nonrecurrent headaches

a. occur with systemic infections and are usuallyassociated with fever

b. occur as the result of a lesion, after an invasivespinal cord procedure such as a lumbarpuncture, or subarachnoid bleed

c. caused by increased intracranial pressureC. Findings

1. Vary by type of headache2. May include throbbing, nausea, vomiting, visual

disturbance, tenderness, neck stiffness, and focalneurological signs

D. Diagnostics1. History and physical exam2. Computing tomogram (CT) scan3. Magnetic resonance imaging (MRI)

E. Management of headaches1. Expected outcomes: to alleviate pain and treat

underlying cause2. Vasoconstriction by pressure or cold3. Management of migraine

a. nonnarcotic analgesics: aspirin, acetaminophen(tylenol), ibuprofen

b. narcotic analgesics: codeine, meperidine(demerol)

c. alpha-adrenergic blocking agentblocker:ergotamine tartrate (ergostat) without or withcaffeine

d. steroids: dexamethasone (decadron)e. prophylactic treatment with beta-adrenergic

blocking agents, serotonin antagonists,antidepressants, imipramine (tofranil)

f. avoid headache-precipitating foods such asMSG, tyramine, or milk products, or suddenstopping of caffeinated drinks

4. Management of tension headachesa. nonnarcotic analgesicsb. muscle relaxantsc. prophylactically: antidepressants and/or

doxepin (sinequan)5. Management of cluster headaches

a. narcotic analgesics: codeine sulfateb. alpha-adrenergic blocking agentblocker:

ergotamine tartrate (ergostat)c. prophylactically with serotonin antagonists

F. Nursing interventions1. Suggest a quiet, dark environment2. Manage pain by prompt medication administration or

other comfort measures3. Help client identify precipitating factors and actions for

prevention4. Keep NPO until nausea and vomiting subside

5. Teach clienta. expected medication actions and side effectsb. alternatives for pain relief including referrals

for alternative approachesc. to avoid or minimize trigger factorsd. to keep a headache diary

G. Head TraumaH. Classifications

1. Closed versus open injurya. closed is nonpenetrating; no break in integrity

of skullb. open injury: skill broken with brain exposed

2. Severitya. mild: only momentary loss of consciousness

with no neurological sequelaeb. moderate: momentary loss of consciousness

with a change in neurological function which isusually not permanent

c. severe: decreased LOC with seriousneurological impairment and sequelae

I. Types of skull fractures1. Linear: simple break in bone; no displacement of skull2. Depressed: part of skull is pushed in3. Basal: at base of skull; may extend into orbit or ear;

ear or nose may leak CSF; most difficult to verify by x-ray

4. Concussion: temporary loss of neurologic function but

complete recoveryJ. Types of bleeding

1. Epidural hematoma


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a. usually something lacerated the blood vesselsof the middle meninges

b. since this is arterial bleeding, the risk of deathis greatest

c. client commonly looses consciousness afterinjury then is lucid , then LOC drops quicklywith the next 24 hours

2. Subdural hematomaa. something has lacerated the blood vessels

crossing the subdural spaceb. acute: findings surface in 24 to 72 hours after

injury with rapid neurologic deteriorationc. subacute: findings surface 72 hours to two

weeks after injury with a slower progression ofdeterioration

d. chronic: gradual clot formation over time,possibly months with minimal deterioration

K. Progression of skull fracture injury1. Onset: contusions and lacerations of nerve cells2. Gradual demyelinization of affected nerve fibers results

in neuron death3. Scarring: meninges adheres to injured area of brain

L. Complications1. Edema

a. results in increased intracranial pressureb. results directly from cerebral ischemia, anoxia,and hypercapnia

2. Syndrome of inappropriate anitdiuretic hormone (ADH)(SIADH)

a. too much ADH is producedb. water is excessively retained - hemodilutionc. urinary output decreases; urine specific granity

increases effectd. more common in the chronic phase of care

after a head injury3. Diabetes insipidus (DI)

a. DI results from a decrease release of ADH andbody excretes too much fluid

b. the increase in urinary output results in a lowspecific gravity

c. more common in the acute phase of headinjury

4. Stress ulcera. head injuries activate both the sympathetic

and parasympathetic systemsb. stimulation of sympathetic system leads to

gastric ischemia from vasoconstrictionc. stimulation of parasympathetic system leads to

increased release of hydrochloric acid (HCL)into the stomach

d. steroid therapy may contribute to the

development of ulcers since steroids increaseHCL acid

5. Seizure disorders

6. Infection in brain, lungs, urinary system7. Hyperthermia or hypothermia

M. Findings of head trauma1. Degree of neurological damage varies with type and

location of injury2. Restlessness and irritability - initially3. Decreased LOC - lethargy, difficulty with arousal4. Headache5. Nausea and vomiting - projectile vomiting indicates

increased ICPN. Diagnostics

1. History and physical exam2. Computerized tomogram (CT) scan3. Magnetic resonance imaging (MRI)4. Electroencephalogram (EEG)

O. Management1. Expected outcomes: to reduce or minimize increases in

intracranial pressure and protect the nervous system2. Medications for increased ICP

a. osmotic diuretics; mannitol (osmitrol) - IV dripor push

b. steroids: dexamethasone (decadron) - IV pushc. barbiturate coma may be induced to treat

refractory increased intracranial pressure

3. Surgical correction of underlying cause4. Treatment for evident findings: seizures, fever,infection

5. Therapya. speechb. physicalc. occupationald. behavioral

P. Nursing interventions

1. Provide care of the client with increased intracranialpressure

CARE OF CLIENT WITH INCREASED INTRACRANIAL PRESSURE

1. Monitor neuro vital signs as ordered2. Maintain fluid restriction as ordered3. Raise head of bed at 30-45 degrees; avoid 90 degrees since pressure

in hip area increases ICP4. Prevent any activities that increase ICP such as: straining at stool,

coughing, vomiting, any restrictive clothing around neck, neck rotation,flexion, extension, anxiety, pushing up in bed with heels, pulling onrails when turning

5. Observe for herniation syndrome6. Monitor for changes in intracranial pressure7. Administer oxygen as ordered

8. Institute seizure precautions9. Provide for care of the unconscious client
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a. seizure precautions

b. seizure care

c. care of the client on ventilator

CARE OF THE CLIENT ON VENTILATORNutrition

1. Maintain adequate, balanced nutrition and fluid2. Administer IV fluids as ordered

3. Provide nasogastric feedings as ordered4. Evaluate if intake and output are balanced

Hygiene

1. Provide rigorous, scheduled mouth care - prevents ventilator acquiredpneumonia

2. Provide bed baths as necessary3. Provide eye care if client has decreased level of consciousness4. Provide perenial care to prevent yeast infections

5. Initiate a bowel regime with stool softeners with

expected bowel movement every three days

Skin and Muscle Integrity

1. Prevent effects of immobility by routine passive or active range ofmotion exercises or get client OOB as tolerated

2. Prevent decubitus ulcers by avoidance of rubbing or massagingreddened areas

3. Turn client every two hours

Safety

1. Apply splints as ordered to prevent footdrop and wristdrop2. Provide a safe environment - bed in low position, side rails up, call light

within reach3. Start seizure precautions if indicated

Sensory Stimulation

1. Provide appropriate stimulation for client; be away to preventoverstimulation

2. Talk to client before and during procedures, care and when in the room

3. Explain procedures before beginning them4. Encourage family to talk to client about usual family activities

d. care of the client undergoing surgery2. Maintain balanced nutrition and fluids3. Help with ADL as indicated4. Prevent complications of immobility5. Monitor neuro vital signs6. Give medications as ordered7. Provide emotional support with appropriate referrals8. Manage pain within guidelines

VIII. Brain TumorsA. Growth of tissue within skull

1. May be cancerous or benign

2. Classified according to tissue type3. May be primary or metastatic

B. Findings1. Depend on size and location of tumor

a. frontal lobe: personality changes - classic, focalseizures, visual disturbances, hemiparesis,aphasia

b. occipital lobe: visual hallucinations, focalseizures

c. temporal lobe: headache, seizuresd. parietal lobe: visual losses, seizurese. cerebellum: coordination or mobility difficulties

2. Increased intracranial pressure

C. Diagnostics1. History and physical exam

2. CT scan3. Magnetic resonance imaging

D. Management1. Expected outcomes: remove the tumor, and minimize

harm to the nervous system2. Depends on location and size of tumor3. Treatment for associated increased intracranial

pressurea. surgeryb. craniotomy to remove tumorc. stereotactic laser surgery

d. radiation therapy for malignancy4. Medications for malignant tumors: chemotherapyE. Nursing interventions

1. Provide:

a. care of the client with increased intracranialpressure

b. care of the client undergoingi. surgeryii. radiation therapyiii. chemotherapy

c. seizure precautions

d. seizure caree. balanced nutrition and fluid

2. Facilitate emotional support with referrals to supportgroups

IX. Peripheral Nerve and Cranial Nerve Disorders
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A. Trigeminal neuralgia (tic douloureux)1. Syndrome of paroxysmal facial pain

a. middle age and older adultsb. affects cranial nerve five (trigeminal nerve)c. etiology unknownd. involves one side onlye. triggered by harmless events such as a breeze,

hot or cold liquids2. Findings

a. intense facial pain lasting about one to twominutes along the nerve branches

b. extreme facial sensitivity3. Diagnostics: history and physical exam4. Management

a. expected outcome: to relieve painb. anticonvulsants: carbamazepine (tegretol),

phenytoin (dilantin)c. surgery

i. minorI. radio-frequency gangliolysis:

heat destroys trigeminalganglion

II. glycerol gangliolysis: glycerolinjected into subarachnoid

space around gasserianganglion

ii. major - microvascular compression:move arterial loop away from posteriortrigeminal root

5. Nursing interventionsa. help clients to name trigger points with

identification of triggering incidentsb. recommend restful environment with

scheduled restc. provide balaned nutritiond. care of the client undergoing surgerye. teach client

i. medications and side effectsii. to avoid triggering agentsiii. to chew on the opposite side of the

mouthiv. to avoid draftsv. to avoid very hot or cold foods

B. Facial nerve paralysis (bell's palsy)1. Definition/etiology

a. disorder of cranial nerve seven (facial nerve)b. involves one side only; unilateralc. etiology unknown

2. Findings often occur suddenly over ten to 30 minutes

a. ptosis

b. cannot close or blink eye with excessivetearingc. flat nasolabial fold

d. impaired tastee. lower face paralysisf. dif ficulty eating

3. Diagnostics: history and physical exam4. Management

a. expected outcome: to restore cranial nervefunction

b. medicationsi. prednisoneii. analgesics

c. local comfort measures: heat, massage and

electrical nerve stimulation for muscle toned. alternative actions: reiki, massage, imagery

5. Nursing interventionsa. provide balanced nutrition: soft dietb. administer drugs as orderedc. teach client

i. to chew on opposite sideii. how to use protective eye wear during

risk periodsiii. effects of steroidsiv. the use of eye drugs or ointment to

protect the eye from corneal irri tationv. that once findings disappear their

return may occur especially in times ofhigh stressX. In multiple sclerosis, early changes tend to be in vision and motor

sensation; late changes tend to be in cognition and bowel control.XI. Peripheral nerves can regenerate, but nerves in the spinal cord are

thought to not be able to regenerate.XII. During a seizure, do not force anything into the client's mouth.XIII. A major problem often associated with a left-sided CVA is an alteration

in communication.XIV. Clients with CVAs are at a greater risk for aspiration. Initially these

clients must be evaluated to determine if dysphagia is present.XV. The rate, rhythm and depth of a client's respirations are more sensitive

indicators of increases in intracranial pressure than blood pressure andpulse.

XVI. When caring for a comatose client, remember that the hearing is thelast sense to be lost.

XVII. After a CVA clients often have a loss of memory, emotional lability anda decreased attention span.

XVIII. Communication difficulties of a client with a CVA usually indicateinvolvement of the dominant hemisphere, usually left, and isassociated with right sided hemiplegia or hemiparesis.

XIX. The client with myasthenia gravis will have more severe muscleweakness in the evening due to the fact that muscles weaken withactivity - described as progressive muscle weakness - and regainstrength with rest.

Acalculia Agnosiaakinetic mutismaphasiaapraxia ataxia bruit comaconcussioncontusionCT scandecerebratedecorticate postureecholalia festination flaccid hemiparesishomonymous hemianopia
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myasthenianuchal rigidityprodromal period ptosisstupor transient ischemicattack

III. Disorders of the Eye

Overview: eye disorders from front to back of eye

Eye disorders from most common to least common

A. Disorders ofrefraction1. Myopia (near-sightedness) - blurred distance vision,

but clear close vision2. Hyperopia (far-sightedness) - blurred close vision, but

clear distant vision3. Presbyopia - in middle age, lens loses elasticity with

results of hyperopia

4. Astigmatism - lens refracts light rays to focus on twodifferent points of retina

B. Glaucoma - second most common cause of vision loss in theUSA); may be unilateral or bilateral

1. Most common type: chronic open-angle glaucoma(simple, adult primary, primary open-angle)

1. etiology/epidemiology1. hereditary link2. etiology unknown

3. aqueous humor does not drainadequately which leads to increasedintraocular pressure (IOP)

4. this pressure on optic nerve causesdestruction of nerve fibers in retina toresult in a vision loss

2. findings1. most clients are without findings until a

loss of vision

2. peripheral vision affected first3. three classic assessment findings

1. elevated IOP

2. visual field loss (peripheral)3. cupping of optic disk

3. management1. expected outcomes

1. reduction of IOP2. prevention of visual field

defects2. treatment of choice: pharmacotherapy

1. miotic eyedrops(parasympathomimetic agents)

2. carbonic anhydrase inhibitors -Diamox

3. beta-adrenergic blockingagents - Timoptic drops

4. epinephrine eyedrops(contraindicated in clients withcardiac conditions) - more inemergency care

3. trabeculectomy or lasertrabeculectomy

1. performed whenpharmacological agents noteffective

2. small piece of sclera containingthe trabecular network isremoved and an iridectomy isperformed

3. cycloplegic and steroids areinstilled

4. antibiotics may be ordered

4. a mydriatic is then used to prevent adhesions to the cornea

4. nursing interventions1. for pharmacotherapy management

1. compliance with medicaltreatment

2. teach client to instill eyedropsusually recommended beforebedtime

3. teach safety risks related toimpaired vision

2. for trabeculectomy by traditionalsurgery

1. monitor dressing for excessive

bleeding2. antiemetics, analgesics and

antibiotics as ordered
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3. mydriatics as ordered.4. assist client with activities of

daily living3. for trabeculectomy by laser surgery

1. vision may be blurred for firstday or two post-op

2. eye patch or sunglasses forphotophobia

3. analgesics as ordered4. education of client with glaucoma

1. avoid activities that increase

IOP - bending, stooping,straining, caughing, blowingnose

2. stress importance of routineeye examinations - usuallyyearly

2. Less common type of glaucoma: acute closed-angle(shallow, narrow-angle, primary, or congestedglaucoma) - iris bulges and blocks trabecular network.

1. etiology /epidemiology1. a medical and nursing emergency2. iris lies near drainage channel (canal of

Schlemm) and bulges forward againstcornea, blocking the trabecularnetwork and increasing IOP

3. affects more women; usually after age45

2. findings

1. sudden onset of blurred vision, halosor colored rings around white lights,frontal headache

2. sudden severe eye pain, reddening ofthe eye, nausea, vomiting

3. followed by progression of findings aspressure increases:

1. profuse lacrimation

2. mildly dilated, nonreactivepupil

3. nausea/vomiting4. cornea appears hazy

4. blindness may result in two to five daysif left untreated

3. management1. expected outcome: to prevent or

minimize the damaging effects of acuteclosed-angle glaucoma

2. emergency pharmacologic treatmentto decrease IOC

1. intravenous osmotic agents

2. miotic eye drops3. includes carbonic anhydrase

inhibitors

4. systemic analgesics3. surgery

1. iridotomy or iridectomy2. procedure is usually then

repeated on unaffected eye4. nursing interventions

1. monitor for effectiveness ofmedications as ordered

2. post-op eyepatch or sunglasses forphotophobia

3. tell client that vision will be blurred for

one to two days postsurgery4. stress importance of routine yearly or

more frequent eye examinations5. teach clients to avoid activities that

increase IOPC. Cataract - maybe unilateral or bilateral

1. Etiology/epidemiology1. clouding of lens - one of the most common eye

disorders2. first type: senile cataract - result of aging

process3. second type: traumatic

1. develops within months of eye trauma

2. painless but progressive loss of sight inone or both eyes

2. Expected outcome: correction of visual field defect3. Treatment: only surgical

1. cataract extraction: removal of cloudy lens1. most commonly done as outpatient

procedure2. usually done on one eye at a time3. types of cataract extraction

1. extracapsular cataractextraction (ECCE)

1. procedure of choice

2. removes lens contents,

leaving posteriorchamber intact

2. Phacoemulsification -ultrasound fragments the lenscontents

3. intracapsular cataractextraction (ICCE)

1. removes lens contentsand lens capsule

2. eye becomeshypermetropic

2. intraocular lens implant usually performed attime of extraction

3. peripheral iridectomy usually performed aspart of ECCE or ICCE

4. Potential complications of surgery
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1. hyphema (blood in anterior chamber of theeye)

1. may require bed rest and patching2. observe for increased IOP - complaints

of severe pain

3. may prescribe miotics or cycloplegics2. vitreous prolapse

1. allows vitreous humor to fall forwardinto wound

2. may result in pupil block

3. may lead to retinal detachment4. vitrectomy may be performed3. intraocular infection

1. complaints of throbbing or in eye pain,drainage from eye

2. antibiotics (ophthalmic and/orsystemic)

5. Nursing interventions1. teach client to avoid causes of IOP2. observe client's ability to instill eyedrops

correctly; provide referrals if unable to3. provide written list of complications for the

client to report4. inform clients that an expected feeling after

surgery is one that "sand" is in the eye for sixto eight weeks afterwards

D. Retinal detachment (illustration )1. Etiology/epidemiology

1. holes or breaks (tears) in retina2. fluid, blood or a mass separates the retina's

sensory layer from the pigmented epithelium(pigment cells)

3. common causes are inflammation, trauma,hemorrhage, and tumors

4. retinal detachment often begins in peripheryand spreads posteriorly

2. Findings1. a rapid separation gives feeling of a curtainbeing pulled over eye so that client has partialvision in affected eye

2. slow separation may be asymptomatic3. ophthalmic exam reveals detached area as

gray bulge, ripple or fold3. Management

1. expected outcome: correction of and/orprevention of further vision loss: 90% aresuccessfully repaired

2. laser surgery1. photocoagulation: laser beam is

directed through dilated pupil2. effect is to seal localized breaks or rips

in retina3. cryotherapy: extreme cold freezes rips in retina

4. diathermy: heat applied with ultrasonic probeto repair rips

5. scleral buckle6. pharmacotherapy:

1. adrenergic-mydriatic agents

2. cycloplegic agents3. antibiotics

4. Nursing interventions1. maintain bed or chair rest as ordered2. post-op eye patch to rest eye (or both eyes)

3. dark glasses for photophobia4. administer medications as ordered5. prevent increases in IOP

E. Eye trauma1. Foreign body:

1. use eversion procedure2. if foreign body has penetrated, do not remove3. irrigate eye with sterile normal saline eye

irrigant

2. Corneal abrasion1. disruption of the cells and loss of superficial

epithelium2. caused by trauma, chemical irritant, foreign

body, or lack of moisture3. findings: severe pain, blurred vision, halo

around lights, lacrimation, inability to open eye

4. diagnosis by fluorescein sodium dye5. abrasions heal usually within 48 hours, usually

with no scarring or visual deficit6. treatment includes short-acting analgesic

drops, eye rest

3. Corneal laceration1. same causes, findings as abrasions, but

lacerations are serious emergencies2. surgery is generally required3. follow care for client undergoing eye surgery

(see points to remember at the end of thissection)

4. Penetrating injury1. do not remove object2. do not apply pressure of any kind to the eye or

the object3. cover the injured eye to protect movement of

the object. may use a cup or eye patch4. cover uninjured eye with eye patch to avoid

sympathetic movement5. get client to emergency room immediately6. surgery will be required

5. Chemical irritants

1. flush eye with plenty of water or sterile normalsaline

2. get client to emergency room immediately
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3. alkaline substances penetrate the cornearapidly and must be removed quickly

Alkaline substances include lye, ammonia, some powdered detergents, draincleaner, oven cleaner, and battery fluid. To remember alkaline, remember therhyme:If the Ph is high, it's alkali.

6. Ultraviolet burnsa. occur from sun exposure or welding flashesb. irritate epithelium, which swells and scales off

(desquamation)7. Managementa. general pharmacotherapy for eye trauma

i. topical anestheticsii. antibioticsiii. mydriatic-cycloplegic agents: prevent

pupillary constriction8. General management of any eye trauma

a. irrigation of affected eyeb. bilateral dressings to rest eyes by decreased

movementc. tinted glasses for photophobia to reduce

discomfortd. assist client with activities of daily living as

indicated

The Ear

II. Ear DisordersA. External ear

1. Swimmer's ear

a. diffuse bacterial otitis externab. preventable by using 70% alcohol to cleanse

ears after swimming

2. Otitis externaB. Meniere's disease

1. Definition - inner ear disorder: endolymphatic systemdilates and volume ofendolymph expands

2. Etiology unknowna. usually develops between ages 40 and 60b. acute attack may require hospitalizationc. client may average two to three attacks per

year3. Findings

a. attacks intermittentb. three recurrent and progressive findings

i. vertigo with prostrating nausea andvomiting

ii. tinnitusiii. hearing loss (on involved side) persists

and progresses

4. Managementa. expected outcomes: prevent hearing loss and

control vertigob. medical

i. cholinergic blocking agents such asatropine

ii. antihistamines or decongestantsiii. during remission:

diuretics to decrease fluid

vasodilators such as histamine

vestibular suppressants suchas diazepam (valium)

adrenergic neuron-blockingagents such as epinephrine

low-salt dietc. surgical

i. decompression ofendolymphatic sac:insertion of endolymphaticsubarachnoid shunt

ii. labyrinthectomy: client will lose allhearing in affected ear

4. Nursing interventions during an acute attack ofMeniere's disease

a. bed rest in quiet, dark roomb. avoid unnecessary movement of client

especially the headc. give general care of clients with nausea and

vomitingd. restrict salt and water intake

e. have client avoid tobacco, caffeine, and hightriglycerides

f. institute precautions to prevent client fromfalling

2. Otosclerosis4. Formation of new bone in labyrinth fixes stapes to oval

window5. Hereditary degenerative disorder results in conduction

deafness6. Etiology unknown7. Assessment: findings

a. hearing lossb. tinnitusc. bone conducts more sound than air does

8. Managementa. expected outcome: improvement of hearing in

affected earb. medical: use of hearing aid

c. surgical: stapedectomy - replacement of stapeswith prosthesis

9. Postoperative care
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a. clients are to avoid anything that mightdisplace prosthesis, such as coughing, blowingnose, swimming

b. give antibiotics as orderedc. limit activity as ordered and tolerated

d. give pain medications and/or antiemetics asordered

e. post-operatively assess facial nerve functionfor asymmetry

f. keep ear dryg. instruct client not to fly for six months

Eye

Anything that dilates the pupil obstructs the canal of Schlemm andincreases intraocular pressure.

Color blindness is caused by a deficiency in one or more types of conesand is caused by a sex-linked recessive gene.

Destruction of either the right or left optic nerve tract results inblindness in the respective side ofboth eyes

When mydriatics are instilled, caution clients that vision will be blurredwith photophobia for up to two hours since the pupils have beendilated

After eye surgery teach client to avoid, for six weeks, activities thatcan increase IOP

Stooping

Bending from the waist

Heavy lifting

Excessive fluid intake

Emotional upsets

Constrictive clothing around neck

Straining with bowel movement (or straining at stool)

Sustained coughing or blowing of the nose

Teach client proper administration of eyedrops especially to wash

hands before installation Provide sunglasses for photophobia

Assist with activities of daily living as required

When clients wear one eye patch, they lose depth perception.Remember that this loss presents a safety risk.

Systemic disorders that can change ocular status include diabetesmellitus, atherosclerosis, Graves' disease (hyperthyroidism), AIDS,leukemia, lupus erythematosus, rheumatoid arthritis sickle celldisease.

Ear

Changes in barometric pressure will affect persons with ear disordersto cause increased findings or malfunctions

Hearing loss can

be partial or total

affect one or both ears

occur in low, medium or high frequencies

in elderly be more frequently high frequency so special smokedetectors may be needed

American Medical Association formula for hearing loss: hearing isimpaired 1.5% for every decibel that the pure tone average exceeds25 decibels (dB)

A hearing loss of 22.5% usually affects social functionality and requiresa hearing aid

Noise exposure is the major cause of hearing loss in the United Statesof America

Ask client how he/she communicates: lip-reading, sign language, bodygestures, or writing

To gain the client's attention, raise a hand or touch the client's arm

When talking with client, speak slowly and face him/her

Speak toward the client's good ear

If the client wears a hearing aid, allow him/her to show how it'sinserted

Speaking louder to a hearing impaired client does not increase his/herchances of hearing

Communicate the client's hearing loss to other staff members

Ototoxic drugs include:

Aminoglycosides

Antimyobacterials

Thiazides

Loop diuretics

Antineoplastics

Tell clients taking ototoxic drugs to report any signs of dizziness, lossof balance, tinnitus, or hearing loss

accommodation acoustic neuroma acuityametropia anisocoriaastigmatism audiometry blepharitiscanthus cataract cerumen chalazionconduction deafness conjunctivitis dacryocystitisdecibel ectropionentropionenucleation esotropia exotropia hyperopia hyphema keratitis keratoplastylabyrinthitis lacrimationmiosis mydriasismyopia myringoplasty nyctalopianystagmus photophobiapresbyopiapterygium ptosisretinopathy scotomasensorineural deafness trachoma uveitisNeurology
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7115210 Neurological

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