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Neuro Nursing

Neuro Nursing

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Published by: heiyu on Sep 04, 2010
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11/29/2012

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NEUROLOGICAL SYSTEM
Physiology of the Neurologic SystemSpace Occupying LesionsInterruption of Cerebral circulationInflammatory ProblemsSpinal Cord InjuryNeuromuscular DisordersPeripheral Nerve DisordersThe neurologic or nervous system is composed of two primaryareas; the central nervous system which includes the brain and thespinal cord, and the peripheral nervous system which includes allthe network of nerves extending from the central system. In order to enhance the understanding of a very complex system, commondisorders and conditions are categorized according to thephysiological origin of the problem, as well as to similaritiesinvolved in nursing care. The concept of increased intracranialpressure is presented, followed by a discussion of commonconditions involved. Neuromuscular degenerative diseases,inflammatory conditions, spinal cord injuries and problems of cerebral circulation are broad categories under which specificconditions are addressed.
PHYSIOLOGY OF THE NEUROLOGIC SYSTEM
Organization of the Nervous System
A
. Central nervous system (CNS).1. Brain2. Spinal Cord
B
. Peripheral nervous system (PNS).1. Twelve pairs of cranial nerves2. Thirty-one pairs of spinal nerves3. Autonomic nervous systema. Sympathetic systemb. Parasympathetic system.CELLS OF THE NERVOUS SYSTEM
A
. Neuron-the functional cell of the nervous system.1. Common characteristics.a. Responds or reacts to stimulib. Conducts impulsesc. Influences other neurons.2. Structure.a. Cell body-contains the cell nucleus which controls cellular activity.b. Axon-conducts impulses away from the cell bodyc. Dendrites-receive incoming stimuli and transmit them to theaxon of another neuron.3. Function/classification.a. Afferent neurons (sensory) transmit information away from theCNS.b. Efferent neurons (motor) transmit information away from theCNS.c. Somatic system1). Afferent are sensory neurons that transmit impulses from theskeletal muscles and skin to the CNS.2). Efferent are motor neurons that transmit impulses that lead tocontraction and control of skeletal muscle.d. Visceral system.1). Afferent are sensory neurons that transmit impulses fromsmooth muscle and cardiac muscle to the CNS.2) Efferent are motor neurons that transmit impulses to the glands,cardiac muscle, and smooth muscle.e. Synapse or synaptic terminals are areas of chemicaltransmission of an impulse from the axon of one neuron to thedendrites of another neuron.
B.
Supporting cells provide support, nourishment, and protection tothe neuron.1.Neurilemma – protective cells which surround the axonsin the PNS.a.Provide for effective regeneration of PNS nerve fibers.b.From the myelin sheath in the PNS.c.No neurilemma present in the CNS.2.Glial cells – protective cells in the CNS; responsible fothe formation of the myelin.3.Myelin sheath.a.Dense membrane or insulator around the axon.b.Facilitates function of the neuron,c.Contributes to the blood-brain barrier to protect thecentral nervous system against harmful molecules.
C.
Nerve regeneration entire neuron is unable to undergocomplete regeneration.1. The axons of the PNS may regenerate via the connective tissueneurilemma, providing the cell body of the neuron remains viable.2. Neuron regeneration in the CNS is very limited, possibly due tothe lack of neurilemma.3. Scar tissue is a major deterrent to successful cellular regeneration.
D
. Impulse conduction.1. Reflex arc.a. Reflex are is the functional unit which provides pathways over which nerve impulses travel.b. Passage of impulses over a reflex arc is called a reflex act or areflex.c. Reflex arc – The afferent neuron carries the stimulus to thespine; integrates it into and through the spine (CNS) to the efferentneuron; crosses the synapse with the message from the CNS tothe organ or muscle which responds to the stimuli. This is thesequence of events when testing the deep tendon reflexes.2. Synaptic transmission.a. A chemical synapse maintains a one-way communication linkbetween neurons.b. Chemical neurotransmitters (neuro-mediators) facilitate thetransmission of the impulse across the synapse.1). Acetylcholine.2). Norepinephrine.3). Dopamine.4). Histamine.c. Impulses pass in only one direction.CENTRAL NERVOUS SYSTEMThe brain and the spinal cord within the vertebral columnmake up the
central nervous system
.
A.
The brain and the spinal column are protectedby the rigid bony structure of the skull and thevertebral column.
B.
Meninges –protective membranes that cover the brain and are continuous with those of thespinal cord.1.Pia mater-a delicate vascular connectivetissue layer that covers the surfaces of thebrain barrier.2.Arachnoid-a delicate nonvascular, waterproof membrane that encases the entire CNS; thesubarachnoid space contains the cerebralspinal fluid.3.Dura mater-a tough membrane immediatelyoutside the arachnoid; provides protection tothe brain and spinal cord.
C.
Cerebral spinal fluid (CSF).1.Serves to cushion and protect the brain andspinal cord; brain literally floats in CSF.2.CSF is clear, colorless, watery fluid;approximately 100 to 200 cc total volume, witha normal fluid pressure of 70 to 150 mm of water 9average-125 cm water pressure).3.Formation and circulation of CSF.a.Fluid is secreted by the choroids plexuslocated in the ventricles of the brain.b.CSF flows through the lateral ventricles intothe third ventricle, flows through the Aqueductof Sylvius into the fourth ventricle where thecentral of the spinal column opens.c.From the fourth ventricle, there are openingsinto the cranial subarachnoid space; CSFflows around the spinal cord ad brain.
1
 
d.Since CSF is formed continuously, it isreabsorbed at a comparable rate by thearachnoid villi.
D.
Brain.1.Cerebrum – the largest portion of the brain isseparated into hemispheres; the cerebralcortex is the surface layer of each hemisphere.2.Major lobes of the central cortex.a.Frontal.1). Coordination of voluntary skeletal musclemovement.2). Abstract thinking, morals, judgment.3). Speech area, motor speech area (Broca’s area)located in only one hemisphere.b. Parietal.1. Interprets sensory nerve impulses (pain,temperature, touch).2. Maintains proprioception.3. Recognition of size, texture, and shape of objects.c. Temporal.1. Auditory area- interprets meaning of certainsounds.2. Wernicke’s area- comprehension and formulationof speech.d.Occipital area-interprets vision and controls abilityto understand written words.3. Motor areas of the cerebral cortex.a. Primary function is coordination and control of skeletal muscle activity.b. Corticospinal tracts (pyramidal tracts).1. Descending tract from the motor area of thecerebral cortex to the spinal cord.2. Majority of nerves cross in the medulla tothe opposite side before descending into the spinalcord.3. These pathways do not cross over.c. Brain cells and the nerve fibers in the descendingtracts of the central nervous system are calledupper motor neurons.d. Basal ganglia (cerebral nuclei) – regulate andprogram muscle activity coming from the cerebralcortex.4. Movements is controlled by:a. Cerebral cortex – voluntary initiation of motoactivity.b. Basal ganglia-assist to maintain posture.c. Cerebellum-coordinates muscle movement.5. Cerebellum-attached to the medulla and thepons.a. Primarily concerned with coordination of muscular activity and maintenance of equilibrium.b. Nerve fibers spread upward to the cerebrum anddownward to the pons, medulla, and spinal cord.1). Visual reflexes-pupillary constriction andmovement of the eyeball.2). Auditory reflexes-turning of the head towardsound.6. Brain stem consists of the pons and themedulla.a. Pons-contains the reticular formation, which isresponsible for alertness.b. Medulla oblongata-a continuation of the spinalcord as it enters into the cranial vault in the brain.1. Conduction center and crossing center for theupper motor neurons.2. Maintains control of cardiac rate.3. Vasomotor center for constriction and dilation of vessels.4. Respiratory center for changes in rate and depthof breathing.5. Vomiting reflex center.6. Swallowing reflex center.c. Thalamus.1. Organization and distribution of incomingsensory impulses.2. Activities related to consciousness.d. Hypothalamus.1. Regulation of visceral activities-bodytemperature, motility and secretions of the GI tract,arterial blood pressure.2. Nerve connections with the thalamus andthe cerebral cortex make it possible for ouemotions to influence visceral activity.3. Regulation of endocrine glands via influenceon the pituitary gland.4. Neurosecretion of antidiuretic hormone(ADH) which is stored in the pituitary.7. Cerebral circulation.a. The internal carotid arteries enter the cranialvault at the temporal area; the main branches are:b. Vertebral arteries arise from the subclavian arteryand enter the brain at the foramen magnum.c. The Circle of Willis is an arterial anastomosis atthe base of the brain. The circle ensures continuedcirculation if one of the main vessels is disrupted.E. Spinal Cord.1. The spinal cord is continuous with the medullaand extends down the vertebral columns to thelevel of the first and second lumbar vertebra.2. Each column is divided into functional groups of nerve fibers.a. Ascending tracts – transmit impulses to the brain(sensory pathway).b. Descending tracts – transmit impulses from thebrain to the various levels of the spinal cord (motor pathways).4. Structure.a. Closely approximately vertebrae provideprotection from the spinal cord and nerve roots.b. Intervertebral discs lie between each vertebra toprovide flexibility to the spinal column.c. Nucleus pulposus is a gelatin substance in thevertebral disc.5. Upper motor neurons-originate in the brain,transmit impulses to the muscles and organs.These neurons from the reflex arc.6. Lower motor neurons – originate in the spinalcord, transmit impulses to the muscles and organs.These neurons form the reflex arc:7. Reflex activity.a. The reflex arch must be intact, the spinal cordserves as the connection between the afferentpathway (sensory), and the efferent pathway(motor).b. By testing the reflex arc (deep tendon reflexes),the lower motor neuron and the sensory/motor fibers from the spinal column can be evaluated.For example, if the biceps reflex is normal, then thelower motor neurons and the nerve fibers at C5 andC6 are intact.c. Babinski reflex- normal up to one year, shouldnot be positive in clients over one year of age.
PERIPHERAL NERVOUS SYSTEM (PNS)
The cranial and spinal nerves which connectthe CNS with the body parts continue the PNS. Theperipheral nervous system is further divided intosubdivisions based on the destination of the nerves
2
 
which compromise the cranial and spinal nerves.The autonomic nervous system is part of thesubdivision.A.Cranial nerves1.Twelve pairs of cranialnerves.2.Originate from undethe surface of the brain.B.Spinal nerves.1.Each pair of nerves is numberedaccording to the level of the spinalcord from which it originates.2.Each spinal nerve is connected tothe cord by two roots.a.Dorsal (posterior root)-a sensory nervecarrying messages tothe CNS.b.Ventral (anterior root) –a motor nerve carryingneuron messages toglands and to theperipheral area.3.The roots fuse at the exit from the vertebra toform a mixed spinal nerve.C. Somatic nervous system – fibers which connectthe CNS with the structures of the body wall.D. autonomic nervous system regulatesinvoluntary activity (cardiovascular, respiratory,metabolic, body temperature, etc.)1. Consists of two divisions that have antagonisticactivity.2. Parasympathetic division maintains normalbody functions.3. Sympathetic division-prepares the body to meeta challenge or an emergency (preparation for “fight/flight”).4. Most of the organs of the body receiveinnervation from both the Parasympathetic and thesympathetic divisions. The divisions are usuallyantagonistic, the other relaxes.5. Chemical mediators – facilitate transmission of impulses in the autonomic nervous system.a. Acetylcholine is released by the fibers in bothdivisions of the autonomic nervous system.1. Cholinergic fibers those fibers releasingacetylcholine.2. Acetylcholine is destroyed by the enzymecholinesterase.CRANIAL NERVESNUMBERNAMEFUNCTIONI.II.III.IV.V.VI.VII.OlfactoryOpticOculomotor Trochlear Trigeminal:OpthalmicMacillaryMandibular AbducensFacialSense of smellVision-conducts informationfrom the retinaDown and outwardmovement of the eyePupillary constriction andaccommodationMuscle of the upper eyelid(ability to keep the eyeopen)Movement of the eyeCorneal reflexSensory fibers of the faceMotor nerves for chewingand swallowingInward movement of the eyeFacial expressionSense of taste on anterior tongueMuscle of the eyelid (abilityto close the eye)VIII.IX.X.XI.XII.AcousticGlossopharyngealVagus nerveAccessory (Spinal)HypoglossalReception of hearing andmaintenance of equilibriumSense of taste on posterior tongueSalivationSwallowing or gag reflexAssists in swallowingactionMotor fibers to larynx for speechInnervation of organs inthorax and abdomenImportant in respiratory,cardiac, and circulatoryreflexesAbility to rotate the headand raise the shoulder Muscles of the tongueb.Norepinephrine released primarily by thesympathetic division.1.Adrenergic fibers those fibers releasingnorepinephrine.2.Effects are widespread and augmented bysecretions from the adrenal medulla.3.Norepinephrine is inactivated by monoamineoxidase (MAO) medications.System AssessmentA.History.1.Neurologic history.a.Avoid suggesting symptoms to the client.b.The manner in which the problems began andthe overall course of the illness are veryimportant.c.Mental status must be assessed beforeassuming the history data from the client isaccurate.2.Medical history.a.Chronic, concurrent medical problems.b.Medications (especially tranquilizers,sedatives, narcotics, etc).c.Pregnancy and delivery history of infants andyoung children.d.Sequence of growth and development.3.Family history-presence of hereditary or congenital problems.4.Personal history-activities of daily living, anychange in routine.5.History and symptoms of current problem.a.Paralysis or paresthesia.b.Syncope, dizzinessc.Headache.d.Speech problems.e.Visual problems.f.Changes in personality.g.Memory loss.h.Nausea, vomiting.AUTONOMIC NERVOUS SYSTEMArea AffectedSympatheticParasympatheticPupilBronchiHeartGastrointestinalDilatesDilatesIncreases rateInhibits peristalsisConstrictsConstrictsDecreases rateStimulates peristalsis
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