NURSING OF ADULTS 111 Introduction to Neurological Nursing.

NURSING OF ADULTS 111

Introduction to Neurological Nursing

NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM

BRAIN SPINAL CORD

PERIPHERAL NERVOUS SYSTEM CRANIAL NERVES---12 pairs

SPINAL NERVES---31 pairs• 8 CERVICAL• 12 THORACIC• 5 LUMBAR• 5 SACRAL• 1 COCCYGEAL

AUTONOMIC NS• SYMPATHETIC• PARASYMPATHETIC

CENTRAL NERVOUS

SYSTEM 1. Spinal cord (automatic motor

responses—pathways for messages to and from the brain)

2. Lower brain (control of B.P., resp, equilibrium, muscular movements, primitive emotions) -basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla & cerebellum

3. Higher brain (cortical function –memory, reasoning, speech, vision, hearing, sensation, abstraction & patterns of responses, ) cerebral cortex

.

1. Central Nervous System = Brain & Spinal Cord

2. Peripheral Nervous System = 12 Cranial & 31 Spinal Nerves

3. Autonomic Nervous System = Hypothalamus (part of CNS)

Sympathetic Nervous System – important in emergency situations –”fight or flight” response--increase in heart rate, dilatation of bronchioles, dilatation of pupils, vasoconstriction of skin & skeletal muscles, slowing peristalsis, secretion of nor/epinephrine

Parasympathetic nervous system – brings about responses assc. With restful activites--constriction of pupil, promotes digestion, slows heart rate

The Brain

Centre of our thought Interpreter of our

external environmentOrigin of control over

conscious (voluntary) and unconscious (involuntary) movement

Written speech

Motor speech

Auditory receiving area

Auditory interpretation area

Motor cortex

Sensory area (pain, touch, etc.)

Visual interpretationarea

Visual receiving area

Frontal Lobe

Parietal Lobe

Temporal Lobe

Brain Stem

Occipital Lobe

Cerebellum

FUNCIONAL AREAS OF THE CEREBRAL CORTEX

Functions of the cerebral cortex:

Frontal lobe – “personality” also contains the motor cortex – controls voluntary motor activity.

Prefrontal areas controls1. Concentration2. Motivation3. Ability to formulate or select goals4. Ability to plan5. Ability to initiate or terminate actions6. Ability to self monitor7. Ability to use feedback

Cerebral Cortex (cont.)

Parietal lobes – have primary receptive areas for tactile sensations i.e. temperature, touch, pressure. Also has association areas – spatial orientation and awareness of size & shape & body position (proprioception).

Occipital lobe – visual receptive & association area. Visual memories are stored in this lobe – helps visually recognize & understand our environment.

Cerebral Cortex (cont)

Temporal lobes – auditory receptive area & secondary auditory association area. Language memories are stored on the left side. On the right side all other sound memories that are not memories

Animal sounds, train whistles, automobile horn etc.

Damage to Wernicke’s area causes the inability to understand spoken or written language or recognize music.

Cognitive FunctionEach area of the brain

controls particular activities. Generally the outer and forward areas share more advanced function; the inner structures determine basic metabolic processes. Each side of the brain receives the sensory impressions and activates the muscles of the opposite side of the body.

WHAT PROTECTS THE BRAIN?

SKULL 8 bones encase the brain protecting it (frontal, temporal, parietal, occipital) fuse in

childhood in junctions called sutures. MENINGES

Fibrous connective tissue covering the brain the spinal cord providing protection, support, and nourishment

• Dura Mater, Arachnoid, Pia Mater CSF

Clear, colorless fluid 100-160 mls circulate b/w the subarachnoid spaces & the ventricles. Approx. 500 mls produced per day, most is reabsorbed by the bld. Consider pressure on the brain, if not reabsorbed.

Cushions and Shock Absorber BLOOD-BRAIN BARRIER

Blocks macromolecules and many compounds from dyes and medications from reaching the neurons.

Helps keep a stable env. for neurons by regulating ion movement.

NEURONS

Neurons (specialized cells), make complex connections with one another to send and receive messages in the brain and spinal cord.

The brain and spinal cord is like a computer, the neurons are like the switches and circuitry that make it work.

CEREBRAL CIRCULATION

Receives 15% of cardiac outputHigh metabolic demand and does not store

nutrients – can be critical with diabetics (glucose) feel shaky, foggy, confused.

Flows against gravity (arteries fill from below and veins drain from above)

Cannot tolerate a decrease in blood flow b/c there is no collateral circulation.

Brainstem - The lower extension of the brain where it connects to the spinal cord. Neurologicalfunctions located in the brainstem include those necessary for survival (breathing, digestion, heartrate, blood pressure) and for arousal (being awake and alert).

Most of the cranial nerves come from the brainstem. The brainstem is the pathway forall fiber tracts passing up and down from peripheral nerves and spinal cord to the highest parts of the brain.

Anatomy of the Autonomic Nervous System

(Brunner 2000, p. 1618)

What impact on body re SC injury?

EFFECTS ON AGING

Loss of nerve cells therefore slower to receive and send messages

Learning , memory and reasoning decline Memory loss for recent events

Takes longer to process thoughts and put them into action No change in intelligence but it takes longer to learn

Decreased ability to hear, see certain colors, decreased peripheral vision, sense of smell

Reduced taste buds and sense of touch in fingers and toes

Cognitive and Perceptual Disorders

Assessment of the Neurologic System

Neurologic System: History

Biographical and Demographic Data (is the data reliable) Current Health (what brought them to seek care) Past Health History

Childhood & Infectious Diseases – meningitis, herpes Major Illnesses & Hospitalizations –diabetis, CVA, liver failure Medications – prescribed, OTC, herbal Growth and Development – duration of problem

Family Health History- ALS, MD, Huntington’s Psychosocial History – personality changes, sleep patterns, stressors,

exposure to chemicals, pesticide (Agent Orange)

Neurologic System: Physical Exam

Cervical spinal cord injury can exhibit dec. B/P, P & T – (loss of sympathetic nervous system)

Vital Signs – note changesMental Status – note changes

Level of Consciousness Orientation Memory – long & short term Mood and Affect- aggression & euphoria Intellectual Performance – knowledge/calculation Judgment and Insight – assess reasoning Language and Communication – fluent & appropriate


Head, Neck, and Back Inspection –

– raccoon’s eyes – basal skull fx (look for CSF from nares)

– Battle’s sign – middle basal skull fx – bruising over mastoid process (look for CSF from

ears)

Palpation

– Nodules, boggy skull, nuchal rigidity

Percussion

– Gentle percussion – watch for pain response

Auscultation

– Major neck vessels – turbulent - ? High risk for CVA

Neurologic System:Physical Exam

Cranial Nerves Olfactory Nerve (CNI): Smell

Optic Nerve (CN II): Vision

Oculomotor (CNIII),Trochlear (CNIV), Abdocens (CNVI): Eye control

Trigeminal Nerve (CNV): Sensations of the face, movement of the mouth

Facial Nerve (CNVII): Facial muscles

Acoustic Nerve (CNVIII): Hearing

Glossopharyngeal (CNIX), Vagus (CNX) Nerves: Palate, Uvula

Spinal Accessory Nerve (CNXI): Muscles of the Shoulders and Neck

Hypoglossal Nerve (CN XII): Tongue


Motor System Muscle Size- symmetrical Muscle Strength - symmetrical Muscle Tone – rigid/flaccid/normal Muscle Coordination – repetitive movement Gait and Station- proprioception Movement – fine & gross motor Motor Testing of Unconscious Patients – to test

response to pain – sternal rub, pressure on nail bed, orbit of the eye.


Sensory Function Superficial Sensations

• Touch and Pain

Mechanical Sensations

• Vibration – tuning fork

• Proprioception

Discrimination – stereognosis – distinguish objects,

graphism – trace letters on palm of hand


Abnormal Reflexes Babinski’s Reflex

Jaw Reflex

Palm-Chin Reflex

Clonus

Snout Reflex

Rooting Reflex

Sucking Reflex

Grasp Reflex

Chewing Reflex

Posturing

Abnormal flexion (decorticate) internal rotation of the arms & wrists

Abnormal extension (decerebrate) extension & external rotation of arms & wrists – more serious than abnormal flexion - midbrain


Normal Reflexes Superficial (cutaneous) Reflexes Abdominal Reflex Plantar Reflex Corneal Reflex Pharyngeal Reflex - gag Cremasteric Reflex Anal Reflex – check with MVA Deep Tendon Reflexes


Autonomic Nervous System Cannot be examined directly Clinical Manifestations

• Increase/Decrease Heart Rate

• Vasoconstriction/Dilatation Peripherally

• Bronchoconstriction/Dilatation

• Increase/Decrease Peristalsis

• Pupil Constriction/Dilatation


Functional AssessmentClinical ApplicationsDiagnostic Tests-Noninvasive

Skull and Spinal X-Ray Studies Computed Tomography Magnetic Resonance Imaging Positron Emission Tomography

Neurologic System: Diagnostic Tests

Invasive Lumbar Puncture

Myelography

Cisternal Puncture

Cerebral Angiography

Cerebral Perfusion Studies

Neurologic System:Diagnostic Tests

Noninvasive Tests of Function Electroencephalogram Evoked Potential Studies Neuropsychological Testing

Invasive Tests of Function Caloric Testing Peripheral Nerve Studies Muscle Biopsy Cellular Assessment

CONSCIOUSNESS… is a state of general awareness of oneself

and environment.

Consciousness has two components:

1. Arousal (wakefulness): concerned with the person’s wakefulness (Controlled by Cerebral Cortex Function + Upper Brain Stem)

2. Content/cognition/awareness (cognitive + affective function or awareness of self): the sum of cerebral mental functions (Controlled by Cerebral Cortex Function).

AROUSAL

The mediator of arousal and sensory stimulation is the RETICULAR ACTIVATING SYSTEM (RAS). The RAS is located in the Brain Stem and contains projections between the Thalamus and the Cortex. A network of neurons in the RAS monitors ascending and descending stimuli.

Nerve cells run through the medulla, pons, midbrain, thalamus, and hypothalamus. RAS maintains muscle tone, keeps the higher brain in a state of alert wakefulness, and filters incoming messages.

HOW UNCONSIOUSNESS OCCURS

Disruption of the ascending reticular activating system (extending from the length of the brain stem into the thalamus)

Disruption in the function of one or both cerebral hemispheres

Metabolic depression of the brain (i.e.-----as with drug overdose)

DISORDERS PRODUCING UNCONSCIOUSNESS

Structural lesions in the brain placing pressure on the brain stem or other structures

Brain tumors Head trauma Cerebral hemorrhage

Metabolic disorders and diffuse lesions Hypoxia/Ischemia Liver, lung and kidney disorders Toxins, hypoglycemia, fever, infections, fluid/electrolyte

imbalance, acid-base imbalance Psychogenic causes

Catatonia and Hysteria

Why is it important to assess LOC?

How do we do this?

Stages of decreasing LOC

ALERTCONFUSIONDISORIENTATIONLETHARGYOBTUNDATIONSTUPORCOMA

SUSTAINED UNCONSIOUSNESS

COMA A STATE OF SUSTAINED UNCONSIOUSNESS IN

WHICH THE PATIENT DOES NOT RESPOND TO VERBAL STIMULI, MAY HAVE VARYING RESPONSES TO PAINFUL STIMULI, DOES NOT MOVE VOLUNTARILY, MAY HAVE ALTERED RESPIRATORY PATTERNS, MAY HAVE ALTERED PUPILLARY RESPONSES TO LIGHT, AND DOES NOT BLINK. (Black, 5th edition)

BREATHING IN THE UNCONSCIOUS CLIENT

Respiration controlled by cerebrum, pons and medulla

Airway obstruction and aspiration common complications Obstructed airways causesCO2

retentionvasodilationcerebral edemaincreased ICP

Reduced O2 levelsless oxygen to brainincreased ICP

EYE MOVEMENTS IN THE UNCONSCIOUS CLIENT

CN responsible for eye movement exit thru the brain stem. If compressed eye movement is impaired.

Normally gaze straight ahead and track together In comatose client they are uncoordinated, and

pupillary response is abnormal. (Eyes movements can be dysconjugate, ocular bobbing, roving, nystagmus).

PUPILLARY CHANGES IN THE UNCONSCIOUS CLIENT

Nuclei of CN11 and 111 located below cerebrum and in mid-brain

Assessed for size, equality, reaction, responsive

Fixed and dilated late signs of herniation and severe hypoxia

Other causes Hypothermia, Medications, Lesions

MOTOR RESPONSES SEEN IN UNCONSCIOUSNESS

POSTURING Decorticate Decerebrate Flaccidity (Unilateral or Bilateral)

OTHER MOTOR SIGNS Primitive sucking or snout reflexes Strong reflexive hand grasps Restlessness Resistance to passive movements Hemiplegia Hemiparesis Seizures

CHANGES IN VITAL SIGNS

Wide variations may be seen with various levels of consciousness and some changes directly related to the cause of the unconsciouness

Cushings (Triad) may develop with increased ICP Decreased pulse Increased systolic BP with same or slightly higher

diastolic resulting in a widened Pulse Pressure Slow respirations

ASSESSING CONSCIOUSNESS

The Glasgow Coma Scale (GCS)

Universally used

Measures eye, verbal, and motor response

Excellent scale to measure Arousal. Know the difference b/t

content & arousal

GLASGOW COMA SCALE SCORE (GCS)Eyes 1 Closed at all times 2 Opens to pain 3 Opens to voice command 4 Open spontaneously

Motor 1 No response 2 Extension (decerebrate rigidity) 3 Flexion posturing 4 Flexion withdrawal 5 Localizes painful stimulus 6 Obeys commands

Verbal 1 No response 2 Incomprehensible sounds 3 Inappropriate words 4 Disoriented and converses 5 Oriented and converses

15 (top score)

A score of 10 or less indicates a need for emergency attention

A score less than 7 is interpreted as coma

CONTENTBesides orientation to time, place and person the following cognitive abilities should also be

assessed:

•Attention and vigilance•Memory – short, intermediate, long term•Language – understanding of spoken and

written word•General fund of information

•Construction ability•Sequencing activities

•Problem solving•Abstraction

•Insight and judgement

The Mini Mental Status Exam is an example of a test for cognitive function.

Any process that results in ↑ICP will produce impairment of content and arousal.

***Remember restless and other changes in behavior frequently precede changes in vital signs,However, changes in LOC will occur first.

NURSING OF ADULTS 111 Introduction to Neurological Nursing.

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