Management of Management of clients with clients with nervous diseasesnervous diseases

StrokeStrokeis acute disorders of cerebral blood is acute disorders of cerebral blood circulation, rapidly developing clinical circulation, rapidly developing clinical signs of focal (at times global) signs of focal (at times global) disturbance of cerebral function, lasting disturbance of cerebral function, lasting more than 24 hours or leading to death more than 24 hours or leading to death with no apparent cause other then that with no apparent cause other then that of vascular originof vascular origin

Stroke morbidity in Stroke morbidity in different countriesdifferent countries

269,8

200

0

50

100

150

200

250

300

Ukraine Europe

1:3,61:7

Hemorrhagic Hemorrhagic stroke stroke

Ischemic Ischemic strokestroke

per

per

10

0

10

0 O

OO

OO

O o

f p

op

ula

tion

of

pop

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Stroke morbidity Stroke morbidity

266,3

253,9

247,2

260,7

256,6

269,8

235

240

245

250

255

260

265

270

2000 2001 2002 2003 2004 2005

per

100

000

of

po

pu

lati

on

Stroke mortality in different Stroke mortality in different countries countries

72,4

0

10

20

30

40

50

60

70

80

Ukraine Developed countries

per

100

000

of p

opul

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n

Mortality from different types Mortality from different types of stroke in Ukraineof stroke in Ukraine

19,7

39,8

30,7

3,2

0 20 40 60

SH

IH

IS

nonspecified

per 100 000 of population

Nowadays Nowadays

... ... Every fifth Ukrainian resident will die Every fifth Ukrainian resident will die of strokeof stroke ... ...

Every fifth one will finish his life as Every fifth one will finish his life as depending from others disabled person depending from others disabled person

ClassificationClassification

Strokes:Strokes: Haemorrhage Haemorrhage • subdural, epiduralsubdural, epidural• intracerebral haemorrhageintracerebral haemorrhage• ventricular hemorrageventricular hemorrage• mixedmixed IschemicIschemic• Atherothrombotic Atherothrombotic • CardioembolicCardioembolic• Hemodynamic Hemodynamic • Rheologic Rheologic • LacunaLacuna

Combined hemorrhagesCombined hemorrhages (they (they take the whole region of basal nuclei: subcortical take the whole region of basal nuclei: subcortical nuclei, thalamus, internal capsule)nuclei, thalamus, internal capsule)

Peculiarities of hemorrhagePeculiarities of hemorrhage• Sudden onset (during day – time, after Sudden onset (during day – time, after

physical or emotional stress, while activity)physical or emotional stress, while activity)

• In young people (age 40 – 45)In young people (age 40 – 45)

• Precursors are very rare (headache, Precursors are very rare (headache, dizziness)dizziness)

• It is associated with severe headacheIt is associated with severe headache

• Vomiting with blood portion can be Vomiting with blood portion can be observedobserved

• Consciousness disorders, psychomotor Consciousness disorders, psychomotor agitationagitation

• Facial hyperemia, tachycardia, tachypnoe, Facial hyperemia, tachycardia, tachypnoe, increased BP – autonomic changes increased BP – autonomic changes

Peculiarities of hemorrhagePeculiarities of hemorrhage• There are two groups of symptoms – There are two groups of symptoms –

general cerebral and focalgeneral cerebral and focal• General cerebral are well expressed at General cerebral are well expressed at

hemorrhage and dominate over focal ones hemorrhage and dominate over focal ones • While hemorrhage in right hemisphere While hemorrhage in right hemisphere

involuntary movements of non – paralyzed involuntary movements of non – paralyzed extremities (parakinesis) or syndrome of extremities (parakinesis) or syndrome of automatic gesticulation can be observed automatic gesticulation can be observed

• State of patients with hemorrhage is very State of patients with hemorrhage is very severesevere

ComaComais characterized by deep is characterized by deep consciousness disorder, consciousness disorder, disturbance of breathing disturbance of breathing and heart activity. The and heart activity. The patient doesn’t respond patient doesn’t respond to stimuli.to stimuli.

C o m aC o m a• response to stimuli is absentresponse to stimuli is absent• eyes are closed, mouth is opened eyes are closed, mouth is opened • face is red, lips are cyanotic, skin is cold, face is red, lips are cyanotic, skin is cold, • neck vessels are pulsing neck vessels are pulsing • there is breathing disturbance there is breathing disturbance • pulse is strained and slow pulse is strained and slow • blood pressure is increased blood pressure is increased • temperature increases in 24 hours temperature increases in 24 hours • patient is lying on his back patient is lying on his back • all muscles are relaxed all muscles are relaxed • pupils are changed (there can be pupils are changed (there can be

anizokoria, cross – eyes, sometimes gaze anizokoria, cross – eyes, sometimes gaze paresis can be observed)paresis can be observed)

• mouth angle is a little bit lower mouth angle is a little bit lower

Brain Brain infarctioninfarction

Clinical featuresClinical features• PrecursorsPrecursors - - transient ischemic attacks in transient ischemic attacks in

the same region where brain infarction is the same region where brain infarction is developed.developed. GraduallyGradually during several hours during several hours focal neurologic symptoms are developed.focal neurologic symptoms are developed.

• The prevalence of focal symptoms over the The prevalence of focal symptoms over the general cerebral ones.general cerebral ones.

• General cerebral symptomsGeneral cerebral symptoms manifest as:manifest as:- HeadacheHeadache- VomitingVomiting- Consciousness disordersConsciousness disordersFocal symptomsFocal symptoms depend on localization of depend on localization of

the infarction, damaged vessel and state the infarction, damaged vessel and state of collateral blood circulation.of collateral blood circulation.

Clinical features Clinical features AtherothromboticAtherothrombotic stroke stroke

• Occur at older ageOccur at older age

• Developed during some ours and daysDeveloped during some ours and days

• TIA present in anamnesisTIA present in anamnesis

• Developed at night or in the morning timeDeveloped at night or in the morning time

• Stenosis and occlusion of MAH at Stenosis and occlusion of MAH at ultrasound examinationultrasound examination

• Decreased of Internal Carotid artery Decreased of Internal Carotid artery pulsation on the neck pulsation on the neck

Ischemic strokeIschemic stroke

Lacunar

Extensive

SmokingSmoking

• Risk of recurring stroke in smokers Risk of recurring stroke in smokers increases in increases in 1.5 1.5 timestimes

WeightWeight

• For all over weighted people is For all over weighted people is recommended to keep weight index recommended to keep weight index between between 18,5 18,5 andand 24,9 24,9 kgkg//mm2 2 and size of and size of waistwaist not more than not more than 88 88 sm sm in women and in women and not more than not more than 102102 sm sm in menin men ((Northern Northern Manhattan Study)Manhattan Study)

Physical activityPhysical activity

• For patients are recommended For patients are recommended physical exercises not less than physical exercises not less than 3030min min per dayper day

DefinitionDefinition

Spinal osteochondrosis – is a Spinal osteochondrosis – is a degenerative lesion of cartilage degenerative lesion of cartilage

- between vertebral disc - between vertebral disc associated with reactive associated with reactive changes in neighboring changes in neighboring

vertebras, between vertebral vertebras, between vertebral joints and connecting apparatusjoints and connecting apparatus

Vertebrogenous syndromeVertebrogenous syndrome

• Limitation of movements in lumbar – Limitation of movements in lumbar – sacral part of spinal cord (bending sacral part of spinal cord (bending forward, backward) forward, backward)

• Increasing of pain while movements, Increasing of pain while movements, coughing and laughingcoughing and laughing

• Protective straining of long back musclesProtective straining of long back muscles

• Extension of lumbar lordosis, cyphosis in Extension of lumbar lordosis, cyphosis in lumbar – sacral divisionlumbar – sacral division

• Scoliosis, sometimes with rotationScoliosis, sometimes with rotation

• Painful paravertebral points and Painful paravertebral points and vertebral processes vertebral processes

Vertebrogenous Vertebrogenous syndromesyndrome• Discharge – postures and symptomsDischarge – postures and symptoms

– Knee – elbow positionKnee – elbow position– While standing the patient keeps his While standing the patient keeps his

leg aside in order to make the load leg aside in order to make the load less on his legless on his leg

– While lying in the bed he bends his While lying in the bed he bends his leg in all joints.leg in all joints.

• The symptoms of spinal cord The symptoms of spinal cord instability (it is difficult for the patient instability (it is difficult for the patient to stand, to wash himself, but it is to stand, to wash himself, but it is much more easier to walk)much more easier to walk)

The points of pain:The points of pain:• Pain along the crista iliaca Pain along the crista iliaca • The point of iliosacral jointThe point of iliosacral joint• The point of m. gluteus minimus (just The point of m. gluteus minimus (just

under the crista iliaca)under the crista iliaca)• The point of m. gluteus medius (1 sm The point of m. gluteus medius (1 sm

lower)lower)• The point under the backside foldThe point under the backside fold• Trochanter os iliacaTrochanter os iliaca• Along the ischiadic nerve (the posterior Along the ischiadic nerve (the posterior

surface of hip and fossa subpoplitea)surface of hip and fossa subpoplitea)

The symptoms of The symptoms of strainstrain • Lasegue’s symptom – in case of straining Lasegue’s symptom – in case of straining and lifting the leg the low back pain and lifting the leg the low back pain appearsappears

• Neri symptom – there is pain in leg at Neri symptom – there is pain in leg at bending head forwardbending head forward

• Matskevych symptom – there is pain in Matskevych symptom – there is pain in the anterior surface of the leg at knee the anterior surface of the leg at knee bending while lying on abdomen bending while lying on abdomen

• Wasserman symptom – the same clinical Wasserman symptom – the same clinical picture at lifting the legpicture at lifting the leg

The symptoms of The symptoms of strainstrain•Sequar symptom – there is pain on Sequar symptom – there is pain on

posterior surface of leg at foot flexingposterior surface of leg at foot flexing•Turin symptom – the same clinical Turin symptom – the same clinical

picture at toe’s flexingpicture at toe’s flexing•Bechterev’s symptom – there is pain Bechterev’s symptom – there is pain

at knee – flexed leg extensionat knee – flexed leg extension•Dejerine’s symptom - there is pain in Dejerine’s symptom - there is pain in

posterior surface of the leg at posterior surface of the leg at coughing, sneezingcoughing, sneezing

PreventionPrevention

–Hypokinesia preventionHypokinesia prevention–Moderate physical Moderate physical activityactivity

–Treatment of chronic Treatment of chronic diseasesdiseases

Epilepsy Epilepsy and convulsion and convulsion

syndromessyndromes

EpilepsyEpilepsy

is a chronic disorder, which is is a chronic disorder, which is characterized by the presence of:characterized by the presence of:

• Epileptic focusEpileptic focus

• Recurrent attacks with various clinical Recurrent attacks with various clinical signssigns

• Personality disorders between attacksPersonality disorders between attacks

• Some specific paraclinical signsSome specific paraclinical signs

Clinical featuresClinical featuresA. General seizures.A. General seizures.

• Epileptic general tonic – clonic Epileptic general tonic – clonic attack (grandmal) usually begins attack (grandmal) usually begins with short initial stage that lasts with short initial stage that lasts several seconds. The last can several seconds. The last can manifest as:manifest as:

– Bilateral general muscle jerksBilateral general muscle jerks– Loss of consciousnessLoss of consciousness– Autonomic changesAutonomic changes– Enlargement of pupilsEnlargement of pupils

Clonic epileptic attacksClonic epileptic attacks

• ggeneral typical clonic attacks are often observed eneral typical clonic attacks are often observed in newborn babies. in newborn babies.

• loss of consciousnessloss of consciousness• autonomic disordersautonomic disorders• rhythmic clonic seizuresrhythmic clonic seizures• bbetween the attacks of clonic muscles jerks there etween the attacks of clonic muscles jerks there

is muscle hypotoniais muscle hypotonia• If the attacks last 1–2 min the consciousness If the attacks last 1–2 min the consciousness

recovers quickly. But these attacks can last 4–5 recovers quickly. But these attacks can last 4–5 min and even more. Then after the attack coma min and even more. Then after the attack coma can be developed.can be developed.

Treatment Treatment of patients with epileptic of patients with epileptic

status status

MeasuresMeasures

Time, Time, minmin

Treatment Treatment

0-50-5 Definition of state of living functions. Definition of state of living functions. Oxigenotherapy.Oxigenotherapy.

6-106-10 Intravenous infusion of physiological solution. Intravenous infusion of physiological solution. Checking of tempeature, BP, biochemical blood Checking of tempeature, BP, biochemical blood analysis.analysis.Intravenous injection of Tiaminum 100 mg, then Intravenous injection of Tiaminum 100 mg, then 50 ml 40 % glucose. 50 ml 40 % glucose.

Time, Time, minmin

Treatment Treatment

11-1511-15 Intravenous injection of Diazepam 0,2 mg per kg Intravenous injection of Diazepam 0,2 mg per kg (speed 5 mg per min)(speed 5 mg per min). . Injection is repeated every Injection is repeated every 5 min. General dose is not more then 20 mg5 min. General dose is not more then 20 mg

16-4516-45 Intravenous injection by drops of Fenitoin in dose Intravenous injection by drops of Fenitoin in dose 20 mg per kg (speed 50 mg per min).20 mg per kg (speed 50 mg per min).While injection ECG is made, BP is checked. At While injection ECG is made, BP is checked. At changes on ECG or BP injection is stopped. If changes on ECG or BP injection is stopped. If attacks continue we can add 5 – 10 mg per kg of attacks continue we can add 5 – 10 mg per kg of Fenitoin. Fenitoin.

Time, Time, minmin

Treatment Treatment

46-5946-59 If attacks continue we make endotracheal If attacks continue we make endotracheal intubation, then use Fenobarbitalum in dose 20 intubation, then use Fenobarbitalum in dose 20 mg per kg (speed 100 mg per min)mg per kg (speed 100 mg per min)

60-9060-90 If attacks continue we introduce patient in If attacks continue we introduce patient in barbiturate coma. It is recommended to start barbiturate coma. It is recommended to start usage of Fenobarbital in dose 5 mg per kg up to usage of Fenobarbital in dose 5 mg per kg up to stopping of epileptic activity on EEG.Then stopping of epileptic activity on EEG.Then continue usage of continue usage of 0,5-3,0 0,5-3,0 mg per kg per hour to mg per kg per hour to stop recurring attacks. From time to time we stop recurring attacks. From time to time we decrease speed to prove ourselves that the decrease speed to prove ourselves that the attacks are absent.attacks are absent. While infusion we check EEG, While infusion we check EEG, ECG, BP and breathing functions. ECG, BP and breathing functions.