1. Management of clients with nervous diseases

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

3. Stroke morbidity in different countries 1:3,6 1:7 Hemorrhagic stroke Ischemic stroke per 100 OOO of population per 100 OOO of population

4. Stroke morbidity per 100 000 of population

5. Stroke mortality in different countries per 100 000 of population

6. Mortality from different types of stroke in Ukraine per 100 000 of population

7. Nowadays

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

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

10. Classification Strokes: Haemorrhage Haemorrhage subdural, epidural subdural, epidural intracerebral haemorrhage intracerebral haemorrhage ventricular hemorrage ventricular hemorrage mixed mixed Ischemic Ischemic Atherothrombotic Atherothrombotic Cardioembolic Cardioembolic Hemodynamic Hemodynamic Rheologic Rheologic Lacuna Lacuna

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

13. Peculiarities of hemorrhage Sudden onset (during day – time, after physical or emotional stress, while activity) Sudden onset (during day – time, after physical or emotional stress, while activity) In young people (age 40 – 45) In young people (age 40 – 45) Precursors are very rare (headache, dizziness) Precursors are very rare (headache, dizziness) It is associated with severe headache It is associated with severe headache Vomiting with blood portion can be observed Vomiting with blood portion can be observed Consciousness disorders, psychomotor agitation Consciousness disorders, psychomotor agitation Facial hyperemia, tachycardia, tachypnoe, increased BP – autonomic changes Facial hyperemia, tachycardia, tachypnoe, increased BP – autonomic changes

14. Peculiarities of hemorrhage There are two groups of symptoms – general cerebral and focal There are two groups of symptoms – general cerebral and focal General cerebral are well expressed at hemorrhage and dominate over focal ones General cerebral are well expressed at hemorrhage and dominate over focal ones While hemorrhage in right hemisphere involuntary movements of non – paralyzed extremities (parakinesis) or syndrome of automatic gesticulation can be observed While hemorrhage in right hemisphere involuntary movements of non – paralyzed extremities (parakinesis) or syndrome of automatic gesticulation can be observed State of patients with hemorrhage is very severe State of patients with hemorrhage is very severe

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

16. C o m a response to stimuli is absent response 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 anizokoria, cross – eyes, sometimes gaze paresis can be observed) pupils are changed (there can be anizokoria, cross – eyes, sometimes gaze paresis can be observed) mouth angle is a little bit lower mouth angle is a little bit lower

18. Brain infarction

19. Clinical features Precursors - transient ischemic attacks in the same region where brain infarction is developed. Gradually during several hours focal neurologic symptoms are developed. Precursors - transient ischemic attacks in the same region where brain infarction is developed. Gradually during several hours focal neurologic symptoms are developed. The prevalence of focal symptoms over the general cerebral ones. The prevalence of focal symptoms over the general cerebral ones. General cerebral symptoms manifest as: General cerebral symptoms manifest as: - Headache - Vomiting - Consciousness disorders Focal symptoms depend on localization of the infarction, damaged vessel and state of collateral blood circulation.

20. Clinical features Atherothrombotic stroke Occur at older age Occur at older age Developed during some ours and days Developed during some ours and days TIA present in anamnesis TIA present in anamnesis Developed at night or in the morning time Developed at night or in the morning time Stenosis and occlusion of MAH at ultrasound examination Stenosis and occlusion of MAH at ultrasound examination Decreased of Internal Carotid artery pulsation on the neck Decreased of Internal Carotid artery pulsation on the neck

21. Ischemic stroke Lacunar Extensive

23. Smoking Risk of recurring stroke in smokers increases in 1.5 times Risk of recurring stroke in smokers increases in 1.5 times

24. Weight For all over weighted people is recommended to keep weight index between 18,5 and 24,9 kg/m2 and size of waist not more than 88 sm in women and not more than 102 sm in men (Northern Manhattan Study) For all over weighted people is recommended to keep weight index between 18,5 and 24,9 kg/m2 and size of waist not more than 88 sm in women and not more than 102 sm in men (Northern Manhattan Study)

25. Physical activity For patients are recommended physical exercises not less than 30min per day For patients are recommended physical exercises not less than 30min per day

26. Definition Spinal osteochondrosis – is a degenerative lesion of cartilage - between vertebral disc associated with reactive changes in neighboring vertebras, between vertebral joints and connecting apparatus Spinal osteochondrosis – is a degenerative lesion of cartilage - between vertebral disc associated with reactive changes in neighboring vertebras, between vertebral joints and connecting apparatus

27. Vertebrogenous syndrome Limitation of movements in lumbar – sacral part of spinal cord (bending forward, backward) Limitation of movements in lumbar – sacral part of spinal cord (bending forward, backward) Increasing of pain while movements, coughing and laughing Increasing of pain while movements, coughing and laughing Protective straining of long back muscles Protective straining of long back muscles Extension of lumbar lordosis, cyphosis in lumbar – sacral division Extension of lumbar lordosis, cyphosis in lumbar – sacral division Scoliosis, sometimes with rotation Scoliosis, sometimes with rotation Painful paravertebral points and vertebral processes Painful paravertebral points and vertebral processes

28. Vertebrogenous syndrome Discharge – postures and symptoms Discharge – postures and symptoms –Knee – elbow position –While standing the patient keeps his leg aside in order to make the load less on his leg –While lying in the bed he bends his leg in all joints. The symptoms of spinal cord instability (it is difficult for the patient to stand, to wash himself, but it is much more easier to walk) The symptoms of spinal cord instability (it is difficult for the patient to stand, to wash himself, but it is much more easier to walk)

30. The points of pain: Pain along the crista iliaca Pain along the crista iliaca The point of iliosacral joint The point of iliosacral joint The point of m. gluteus minimus (just under the crista iliaca) The point of m. gluteus minimus (just under the crista iliaca) The point of m. gluteus medius (1 sm lower) The point of m. gluteus medius (1 sm lower) The point under the backside fold The point under the backside fold Trochanter os iliaca Trochanter os iliaca Along the ischiadic nerve (the posterior surface of hip and fossa subpoplitea) Along the ischiadic nerve (the posterior surface of hip and fossa subpoplitea)

31. The symptoms of strain Lasegue’s symptom – in case of straining and lifting the leg the low back pain appears Lasegue’s symptom – in case of straining and lifting the leg the low back pain appears Neri symptom – there is pain in leg at bending head forward Neri symptom – there is pain in leg at bending head forward Matskevych symptom – there is pain in the anterior surface of the leg at knee bending while lying on abdomen Matskevych symptom – there is pain in the anterior surface of the leg at knee bending while lying on abdomen Wasserman symptom – the same clinical picture at lifting the leg Wasserman symptom – the same clinical picture at lifting the leg

32. The symptoms of strain Sequar symptom – there is pain on posterior surface of leg at foot flexing Sequar symptom – there is pain on posterior surface of leg at foot flexing Turin symptom – the same clinical picture at toe’s flexing Turin symptom – the same clinical picture at toe’s flexing Bechterev’s symptom – there is pain at knee – flexed leg extension Bechterev’s symptom – there is pain at knee – flexed leg extension Dejerine’s symptom - there is pain in posterior surface of the leg at coughing, sneezing Dejerine’s symptom - there is pain in posterior surface of the leg at coughing, sneezing

34. Prevention –Hypokinesia prevention –Moderate physical activity –Treatment of chronic diseases

35. Epilepsy and convulsion syndromes

36. Epilepsy is a chronic disorder, which is characterized by the presence of: Epileptic focus Epileptic focus Recurrent attacks with various clinical signs Recurrent attacks with various clinical signs Personality disorders between attacks Personality disorders between attacks Some specific paraclinical signs Some specific paraclinical signs

39. Clinical features A. General seizures. Epileptic general tonic – clonic attack (grandmal) usually begins with short initial stage that lasts several seconds. The last can manifest as: Epileptic general tonic – clonic attack (grandmal) usually begins with short initial stage that lasts several seconds. The last can manifest as: –Bilateral general muscle jerks –Loss of consciousness –Autonomic changes –Enlargement of pupils

40. Clonic epileptic attacks general typical clonic attacks are often observed in newborn babies. general typical clonic attacks are often observed in newborn babies. loss of consciousness loss of consciousness autonomic disorders autonomic disorders rhythmic clonic seizures rhythmic clonic seizures between the attacks of clonic muscles jerks there is muscle hypotonia between the attacks of clonic muscles jerks there is muscle hypotonia If the attacks last 1–2 min the consciousness recovers quickly. But these attacks can last 4–5 min and even more. Then after the attack coma can be developed. If the attacks last 1–2 min the consciousness recovers quickly. But these attacks can last 4–5 min and even more. Then after the attack coma can be developed.

41. Treatment of patients with epileptic status

42. Measures Time, min Treatment 0-5 Definition of state of living functions. Oxigenotherapy. 6-10 Intravenous infusion of physiological solution. Checking of tempeature, BP, biochemical blood analysis. Intravenous injection of Tiaminum 100 mg, then 50 ml 40 % glucose.

43. Time, min Treatment 11-15 Intravenous injection of Diazepam 0,2 mg per kg (speed 5 mg per min). Injection is repeated every 5 min. General dose is not more then 20 mg 16-45 Intravenous injection by drops of Fenitoin in dose 20 mg per kg (speed 50 mg per min). While injection ECG is made, BP is checked. At changes on ECG or BP injection is stopped. If attacks continue we can add 5 – 10 mg per kg of Fenitoin.

44. Time, min Treatment 46-59 If attacks continue we make endotracheal intubation, then use Fenobarbitalum in dose 20 mg per kg (speed 100 mg per min) 60-90 If attacks continue we introduce patient in barbiturate coma. It is recommended to start usage of Fenobarbital in dose 5 mg per kg up to stopping of epileptic activity on EEG.Then continue usage of 0,5-3,0 mg per kg per hour to stop recurring attacks. From time to time we decrease speed to prove ourselves that the attacks are absent. While infusion we check EEG, ECG, BP and breathing functions.