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FLOW OF CEREBRAL SPINAL FLUID .

By
Professor Maxwell mwamba

Cerebrospinal fluid (CSF) is a clear fluid found within the ventricles (cavities) of the brain, central canal of spinal cord and beneath the cranial and spinal meninges in the subarachnoid space. It protects and nourishes the brain and spinal. The meninges (dura mater, arachnoid mater, and pia mater) are the three membranes that envelop the brain and spinal cord. Cerebrospinal fluid is located in the subarachnoid space between the arachnoid mater and the pia mater. The primary function of the meninges is to protect the central nervous system.

The whole process begins when cerebral spinal fluid (CSF) is produced by the choroid plexus in the lateral ventricles. Cerebrospinal fluid will flow through an opening called the foramen of monro to enter the third ventricle. From the third ventricle, the cerebral spinal fluid continues to flow downward into the fourth ventricle passing through a passageway called cerebral aqueduct/aqueduct of silvius. In the fourth ventricle, the cerebrospinal fluid will continue the journey flowing download into the spinal cord. Nevertheless, some fluid will pass through the foramina in the roof of the fourth ventricle called foramen of lushka also called foramen of mangendie to enter the subarachnoid space.
The cerebral spinal fluid will circulate through the brain and spinal cord in this space (subarachnoid space) and passes back or be absorbed into the blood through tiny diverticular of arachnoid mater called the villi which project into the venous sinuses.

Balance between production and absorption of cerebrospinal fluid is critical. Because cerebrospinal fluid is made continuously, medical conditions that block it normal flow or absorption results in over accumulation of cerebrospinal fluid. This results in pressure against the brain tissue causing hydrocephalus.
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MANAGEMENT OF INCOMPLETE ABORTION*

AIMS
1. To resuscitate the woman (mrs mwape).
2. To assess complications and patient's condition.
3. To remove or evacuate the returned products in the uterus.
4. To educate the woman on her condition and plan of treatment.
5. To prevent infections.

*QUICK ASSESSMENT*
- I will do a quick assessment to see the condition of the woman so that I can plan for her treatment.
- I will check for the level of couscous of the woman.
- I will check for the breathing of the woman if she is breathing by checking for the raise and fall of the baby.
- I will check for the bleeding from the va**na if it's minimal or excessive.
- I will check for the signs of shock.
- I will check for the blood pressure to rule out shock.
- I will check for the pulse rate to rule of signs of shock or cardiac arrest.
- I will get blood for FBC.
- I will collect blood for grouping and cross match of which if the HB is low I will do a blood transfusion.
- I will check for bed time clotting.

*RESUSCITATION*
AIRWAY
- I will check the airway for any secretions if there are there I will suction them.
I will check for the back falling of the tongue if present I will place in a wooden spatula to prevent airway obstruction or I will put in a airway tube to help preventing airway obstruction.

BREATHING
- I will check for the raise and fall of the chest to check for the breathing pattern.
- I will monitor the respiration rates of which the normal is 16 to 24 breaths.
- I will check for the oxygen saturation of which if it's below 93% I will commence oxygen.

CIRCULATION
- I will check for the blood pressure to rule out signs of shock of which if it's low it's a sign of shock.
- I will check for the pulse of it's fast and weak it's a sign of shock.
- I will cannulate the woman with 2 large cannulars on both hands.
- I will commence fluids normal saline and ringer's lactate to prevent hypovolemic shock.
- I will commence blood or do blood transfusion if needs be.
- I will put a catheter to monitor fluids output.

DRUGS
- I will administrator oxygen if the saturation is less than 93%.
- I will administrator atrazemic acid to prevent bleeding.
- I will administrator oxytocin 0.5mls to help in contacting the uterus and stop the bleeding.

EVALUATION
- I will evaluate the patient's condition to see if my resuscitative measures where successful if not I will repeat the process again but if successful I will now go on to treat the abortion.

*ENVIRONMENT*
- I will nurse the patient in a gynaecological ward.
- I will nurse the patient from the acute bay for close monitoring and observation.
- I will make sure the room is warm to prevent hypothermia.
- I will make sure that all the resuscitative equipments are near by and are working.

INVESTIGATION
- I will do an assessment to confirm the diagnosis so that I can start the treatment.

HISTORY TAKING
- I will ask about the woman's lmp
- I will ask when the bleeding started.
- I will ask if anything products of conception had come out.
- I will ask about the pain if it's incomplete abortion pain is one of the symptoms.

PHYSICAL EXAMINATION
- I will do a quick physical examination to rule out abnormalities.
- on the abdomen it's smaller than the gestation age.
- I will check for signs of shock.
- I will check for Pallor
- I will check for the cold skin

PELVIC EXAMINATION
- I will check for the per va**nal bleeding.
- I will check for the os if it's open.
- I will check for products of conception if they are felt on the cervix or in the uterus.

LABORATORY INVESTIGATION
- I will collect blood for full blood count.
- I will collect blood for grouping and cross match incase of need of blood transfusion.
- I will collect blood for bed time clotting.
- I will collect blood for rhesus factor checking to rule out if it's the cause.
- I will do a syphilis test to rule out if it's the cause.
- I will do a malaria test.
- I will do an ultrasound scan.

PAIN MANAGEMENT
- I will administrator analgesia to the patient to help in the pain such as brufen or diclofenac.

PSYCHOLOGICAL CARE
- I will explain the condition to the patient to alley anxiety and because the patient has the rights to know there condition.
- I will explain the patient's condition to the husband or relative the patient came with.
- I will ask the patient to ask questions so that I can answer them.
- I will assure the patient that I will keep her condition confidential and private.
- I will explain to the patient that there is need to remove the remaining products of conception manually since she had an incomplete abortion.
- I will ask the patient to sign a consent because her condition may need surgical operation if needs be.
- if patient is unable to give consent the relative will be asked on behalf of the patient.
- I will explain the complications of the condition of not treated or managed.
- I will build provider-patient relationship.

UTERINE EVACUATION
- I will assess for retained products if present the uterus will not contract and bleeding won't stop.
- I will do a manual vacuum aspiration to remove the retained products.
- I will administrator an analgesia for the pain before the procedure.
- I will explain the procedure to the patient to gain there cooperation.
- I will monitor the patients condition during the procedure to prevent complications and shock.
- after the procedure I will assure the patient that she will be well.
- I will do an ultrasound scan to check if the products of conception are completely removed.
- if products of conception are completely removed the bleeding will stop.
- if they are removed completely the uterus will contract.
- I will administrator oxytocin 0.5mls.

OBSERVATIONS
- I will monitor the blood pressure
- I will monitor the respiration
- I will monitor the temperature
- I will monitor the pulse.
- I will monitor for signs of shock.
- I will monitor for signs of infections.
- I will monitor for the va**nal bleeding.
- I will monitor for the patient's general condition.

MEDICATIONS
- I will administrator prescribed antibiotics to prevent infections.
- I will administrator prescribed analgesia for the pain.
PREVENTION OF INFECTIONS
- I will use sterile equipment during the manual vacuum aspiration procedure.
- I will maintain aseptic technics.
- I will administrator antibiotics after the procedure.
- I will be monitoring the patient's temperature for signs of infection.

FAMILY PLANNING
- I will advise and counsel the patient's on the important of family planning and make sure she starts.

HEALTH EDUCATION
- I will teach the patient on the importance of family planning.
- I will explain to the patient that she may get pregnant just after her me**es start and that she needs to rest.
- I will advise her on the dangers if she gets pregnant right away.
- I will explain to her and her husband what they went through and the cause so that they can prevent such from happening again.

By NURSES HALL ACADEMY.
MAXWELL MWAMBA
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FLOW OF CEREBRAL SPINAL FLUID .

By Maxwell mwamba.

Cerebrospinal fluid (CSF) is a clear fluid found within the ventricles (cavities) of the brain, central canal of spinal cord and beneath the cranial and spinal meninges in the subarachnoid space. It protects and nourishes the brain and spinal. The meninges (dura mater, arachnoid mater, and pia mater) are the three membranes that envelop the brain and spinal cord. Cerebrospinal fluid is located in the subarachnoid space between the arachnoid mater and the pia mater. The primary function of the meninges is to protect the central nervous system.

The whole process begins when cerebral spinal fluid (CSF) is produced by the choroid plexus in the lateral ventricles. Cerebrospinal fluid will flow through an opening called the foramen of monro to enter the third ventricle. From the third ventricle, the cerebral spinal fluid continues to flow downward into the fourth ventricle passing through a passageway called cerebral aqueduct/aqueduct of silvius. In the fourth ventricle, the cerebrospinal fluid will continue the journey flowing download into the spinal cord. Nevertheless, some fluid will pass through the foramina in the roof of the fourth ventricle called foramen of lushka also called foramen of mangendie to enter the subarachnoid space.
The cerebral spinal fluid will circulate through the brain and spinal cord in this space (subarachnoid space) and passes back or be absorbed into the blood through tiny diverticular of arachnoid mater called the villi which project into the venous sinuses.

Balance between production and absorption of cerebrospinal fluid is critical. Because cerebrospinal fluid is made continuously, medical conditions that block it normal flow or absorption results in over accumulation of cerebrospinal fluid. This results in pressure against the brain tissue causing hydrocephalus.
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POLIOMYELITIS
(By maxwell mwamba )

Definition
✓This is an acute contagious viral infection caused by the polio virus and is charecterised by fever, difficulty breathing and swallowing with or without paralysis.

MODE OF TRANSMISSION
1.Through ingestion.
2.Through inhalation
✓This means that it affects even the respiratory system and the digestive system initially.

RISK FACTORS
1.OVERCROWDED PLACES
✓This is a condulsive place for polio as itt is also transmitted through inhalation.
2.POOR WASTE DISPOSAL
✓The virus is also found in stool hence transmitted via ingestion of food or water contaminated with the polio virus.
3.MALNUTRITION
✓This lowers the immunity predisposing a child to poliomyelitis,
4.UNIMMUNIZED CHILDREN
✓Prophylaxis against polio is through vaccination against the polio virus.Unimmunized children are at risk.
5.POOR HOUSING
✓There is poor ventilation that put an individual at risk of poliomyelitis.

CLASSIFICATIONS OF POLIOMYELITIS
✓poliomyelitis is classified in to three;
1.Abortive poliomyelitis.
2.Non-paralytic poliomyelitis and
3.Paralytic poliomyelitis.

1. ABORTIVE POLIOMYELITIS
✓This type of poliomyelitis affects the GIT,clinical features include;
✓diarrhea due to a disturbance in the GIT mortility.
✓Abdominal pains related to inflammation.
✓Anorexia related to abdominal discomfort.
✓Vomiting related to a disturbance in the relaxations and contractions of the GIT.
✓Abdominal tenderness related to inflammation.
✓Fever related to infections.

2.NON PARALYTIC POLIOMYELITIS
✓During this type of poliomyelitis,the virus goes to the central nervous system and cause an antigen antibody reaction leading to inflammation.
✓paralysis at the stage has not yet occured.
✓This then causes symptoms such as...
✓Headache related to increased intra cranial pressure..
✓Confusion related to severe cerebral altered tissue perfusion.
✓Fever related to infections.
✓vomitind related to a disturbance in the centres regulating vomiting.
✓convulsions related to cerebral hypoxia.

3..
PARALYTIC POLIOMYELITIS
✓Duing this type,there is severe damage to some nerves and cerebral parts causing paralysis.
✓This type has 4 sub divisions...
1.Spinal paralytic poliomyelitis.
2.Bulbar paralytic poliomyelitis.
3.Bulbo paralytic poliomyelitis.
4.Encephalitic paralytic poliomyelitis.

IMPORTANT NOTE
✓The three(3) classifications should be when stating the clinical manifestations of poliomyelitis according to stages.
✓Abortive Poliomyelitis in this regard will be called Prodromal stage

TYPES OF POLIOMYELITIS

1. SPINAL PARALYTIC POLIOMYELITIS
✓There is flaccid or specific paralysis.
✓There is paralysis of the limbs due to damage to nerves supplying the limbs.

2. BULBAR POLIOMYELITIS
✓Therre is damage to the 9th,10th and 11th cranial nerves causing paralysis of the respiratory system and the palate.
✓This then causes difficultiesin swallowing and inabilities to breath.

3. BULBO PARALYTIC POLIOMYELITIS
✓There paralysis of the limbs,respiratory tract and palate.
✓combination of spinal and bulbar.

4. ENCEPHALITIC PARALYTIC POLIOMYELITIS
✓There is inflammation to the brain cells causing symptoms like fever,headache,confusions,photophobia,hallucination etc.

PATHOPHYSIOLOGY
✓Poliomyelitis is a acute viral contagious Infection that affects the digestive system, respiratory system, and the central nervous system.
✓The polio virus enters the body through inhalation of the infectious droplets containing the polio virus and through ingestion of food and water contaminated with the polio virus.
✓Following ingestion of food or water contaminated with the plio virus.The virus goes to the stomach and gains access into the intestines where it causes Inflammation leading to symptoms such as diarrheoa, fever, abdominal pains, vomiting, and abdominal tenderness .
✓The poliovirus will then transverse the wall of the intestines and get into the blos stream.
✓In the Blood stream,it is taken to the central nervous system where it causes inflammation to the brain cells(encephalitis) and inflammation to the meninges(meningitis)
✓There is eventually damage to the cranial nerves following prolonged Inflammation and effects of the virus on the nerves causing paralysis of the palate,the limbs and the respiratory system causing inabilities to breath, difficulties in swallowing and chewing. There is also paralysis of the lower limbs that causes immobility.

MGT
INVESTIGATIONS
1.HISTORY TAKING
✓This will reveal signs and symptoms like paralysis of limbs, breathing and swallowing difficulties.
2.PHYSICAL EXAM
✓This will be done to reveal Clinical features such as difficulties in swallowing, paralysis of the palate, lower limbs paralysis Etc
3.THROAT SWAB
✓This is done to for m/c/s to isolate the causative organism.
4.BLOOD/STOOL/URINE FOR PCR
✓This is done to show presence and location of the virus.
5.LUMBAR PUNCTURE
✓This is done to rule out meningitis.
6.FULL BLOOD COUNT
✓The white blood cells will be raised due to presence of infection in blood

TREATMENT
✓This is a viral infection. It has no specific treatment.
✓Treat it symptomatically

1. ISOLATION
✓Isolate the patient from others to prevent spread of the Infection to others.

2.ANTIBIOTICS
✓X-Pen 50,000iu/kg iv 6hourly for 5days. With
✓Gentamycin 3.5-7mg/kg 12hourly iv for 5days.

3.ANTI PYRETICS
✓Paracetamol 15mg/kg 8hourly orally for 3days.

4.IV FLUIDS
✓1/2SD in 10%Dextrose
✓Norma saline
✓Ringer's lactate
✓ dextrose.

5.O2 Therapy 1-2litre/min to increase on the tissue perfusion.

6. ANTI-INFLAMMATORY DRUGS
✓ Dexamethasone 0.15mg/kg 6hourly Intravenously.

7.NG TUBING
✓This is done for feeding when patient can't swallow and retain oral feeds by mouth.

COMPLICATIONS
1.RESPIRATORY PARALYSIS
✓This occurs due to paralysis of the cranial nerves that supply the respiratory system.
2.ENCEPHALITIS
✓This is inflammation of the brain cells due to a viral infections.
3.MENINGITIS
✓This is due to antigen antibody reaction to the meninges that cause inflammation.
4.SEPTICEAMIA
✓This is due a rise in the viral load.infection in blood mulitplies.
5.PNEUMONIA
✓Poliomyelitis is also transmitted via inhalation hence it affects the respiratory tract and may descend to the lungs causing viral pneumonia.

NURSING CARE PLAN
1.ALTERED BODY TEMPERATURE related to a viral infection evidenced by a raised body temperature of 38.

2.ALTERED NUTRITION STATUS related to inabilities to swallow evidenced by weight loss.

3.IMPAIRED PHYSICAL MOBILITY related to paralysis of lower limbs evidenced by patient confined to bed.

4.RISK FOR IMPAIRED SKIN INTEGRITY related to immobility.
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