NURSING OF ADULTS 111

Introduction to Neurological Nursing

NERVOUS SYSTEM
lCENTRAL NERVOUS SYSTEM
q q

BRAIN SPINAL CORD

lPERIPHERAL NERVOUS SYSTEM

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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

l 1. Spinal cord (automatic motor responsespathways for messages to and from the brain) l 2. Lower brain (control of B.P., resp, equilibrium, muscular movements, primitive emotions) -basal ganglia, thalamus, hypothalamus, midbrain, pons, medulla & cerebellum l 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
l Centre of our thought l Interpreter of our external environment l Origin of control over conscious (voluntary) and unconscious (involuntary) movement

FUNCIONAL AREAS OF THE CEREBRAL CORTEX

Motor cortex Written speech

Sensory area (pain, touch, etc.)

Visual interpretation area

Frontal Lobe

Parietal Lobe

Motor speech

Occipital Lobe Temporal Lobe Brain Stem Cerebellum

Visual receiving area

Auditory receiving area

Auditory interpretation area

Functions of the cerebral cortex:

l Frontal lobe personality also contains the motor cortex controls voluntary motor activity. l Prefrontal areas controls
1. 2. 3. 4. 5. 6. 7.

Concentration Motivation Ability to formulate or select goals Ability to plan Ability to initiate or terminate actions Ability to self monitor 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)

l 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 q Animal sounds, train whistles, automobile horn etc. l Damage to Wernickes area causes the inability to understand spoken or written language or recognize music.

Cognitive Function
Each 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?

l SKULL q 8 bones encase the brain protecting it (frontal, temporal, parietal, occipital) fuse in childhood in junctions called sutures. l MENINGES q Fibrous connective tissue covering the brain the spinal cord providing protection, support, and nourishment Dura Mater, Arachnoid, Pia Mater l CSF q 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. q Cushions and Shock Absorber l BLOOD-BRAIN BARRIER q Blocks macromolecules and many compounds from dyes and medications from reaching the neurons. q Helps keep a stable env. for neurons by regulating ion movement.

NEURONS

l Neurons (specialized cells), make complex connections with one another to send and receive messages in the brain and spinal cord. l The brain and spinal cord is like a computer, the neurons are like the switches and circuitry that make it work.

CEREBRAL CIRCULATION
l Receives 15% of cardiac output l High metabolic demand and does not store nutrients can be critical with diabetics (glucose) feel shaky, foggy, confused. l Flows against gravity (arteries fill from below and veins drain from above) l 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. Neurological functions located in the brainstem include those necessary for survival (breathing, digestion, heart rate, blood pressure) and for arousal (being awake and alert). Most of the cranial nerves come from the brainstem. The brainstem is the pathway for all 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
l Loss of nerve cells therefore slower to receive and send messages l Learning , memory and reasoning decline
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Memory loss for recent events No change in intelligence but it takes longer to learn

l Takes longer to process thoughts and put them into action

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l Decreased ability to hear, see certain colors, decreased peripheral vision, sense of smell l Reduced taste buds and sense of touch in fingers and toes

Cognitive and Perceptual Disorders

lAssessment of the Neurologic System

Neurologic System: History

l Biographical and Demographic Data (is the data reliable) l Current Health (what brought them to seek care) l Past Health History q Childhood & Infectious Diseases meningitis, herpes q Major Illnesses & Hospitalizations diabetis, CVA, liver failure q Medications prescribed, OTC, herbal q Growth and Development duration of problem l Family Health History- ALS, MD, Huntingtons l Psychosocial History personality changes, sleep patterns, stressors, exposure to chemicals, pesticide (Agent Orange)

Neurologic System:
Physical Exam
l Cervical spinal cord injury can exhibit dec. B/P, P & T (loss of sympathetic nervous system) l Vital Signs note changes l Mental Status note changes
q q q q q q q

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

Neurologic System:
Physical Exam
l Head, Neck, and Back
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Inspection raccoons eyes basal skull fx (look for CSF from nares)

Battles sign middle basal skull fx bruising over mastoid process (look for CSF from ears)
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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
l Cranial Nerves
q q q q q q q q q

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

Neurologic System:
Physical Exam
l Motor System
q q q q q q q

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.

Neurologic System:
Physical Exam
l Sensory Function
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Superficial Sensations
Touch and Pain

Mechanical Sensations
Vibration tuning fork Proprioception

Discrimination stereognosis distinguish objects, graphism trace letters on palm of hand

Neurologic System:
Physical Exam
l Abnormal Reflexes
q q q q q q

Rooting Reflex Sucking Reflex Grasp Reflex Chewing Reflex

Babinskis Reflex Jaw Reflex Palm-Chin Reflex Clonus Snout Reflex

Posturing
l Abnormal flexion (decorticate) internal rotation of the arms & wrists l Abnormal extension (decerebrate) extension & external rotation of arms & wrists more serious than abnormal flexion - midbrain

Neurologic System:
Physical Exam
l Normal Reflexes
q q q q q q q q

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

Neurologic System:
Physical Exam
l Autonomic Nervous System
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Cannot be examined directly Clinical Manifestations

Increase/Decrease Heart Rate Vasoconstriction/Dilatation Peripherally Bronchoconstriction/Dilatation Increase/Decrease Peristalsis Pupil Constriction/Dilatation

Neurologic System:
Physical Exam
l Functional Assessment l Clinical Applications l Diagnostic Tests-Noninvasive
q q q q

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

Neurologic System:
Diagnostic Tests lInvasive
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Lumbar Puncture Myelography Cisternal Puncture Cerebral Angiography Cerebral Perfusion Studies

Neurologic System:Diagnostic Tests

l Noninvasive Tests of Function
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Electroencephalogram Evoked Potential Studies Neuropsychological Testing Caloric Testing Peripheral Nerve Studies Muscle Biopsy Cellular Assessment

l Invasive Tests of Function

q q q q

CONSCIOUSNESS

is a state of general awareness of oneself and environment.

Consciousness has two components: 1. Arousal (wakefulness): concerned with the persons 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

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

l Disruption of the ascending reticular activating system (extending from the length of the brain stem into the thalamus) l Disruption in the function of one or both cerebral hemispheres l Metabolic depression of the brain (i.e.-----as with drug overdose)

DISORDERS PRODUCING UNCONSCIOUSNESS

l Structural lesions in the brain placing pressure on the brain stem or other structures
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Brain tumors Head trauma Cerebral hemorrhage Hypoxia/Ischemia Liver, lung and kidney disorders Toxins, hypoglycemia, fever, infections, fluid/electrolyte imbalance, acid-base imbalance Catatonia and Hysteria

l Metabolic disorders and diffuse lesions

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l Psychogenic causes
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l Why is it important to assess LOC? l How do we do this?

Stages of decreasing LOC

l ALERT l CONFUSION l DISORIENTATION l LETHARGY l OBTUNDATION l STUPOR l COMA

SUSTAINED UNCONSIOUSNESS
l COMA
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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

l Respiration controlled by cerebrum, pons and medulla l Airway obstruction and aspiration common complications
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Obstructed airways causesCO2 retention vasodilationcerebral edemaincreased ICP Reduced O2 levelsless oxygen to brain increased ICP

UNCONSCIOUS CLIENT
l CN responsible for eye movement exit thru the brain stem. If compressed eye movement is impaired. l Normally gaze straight ahead and track together l 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

l Nuclei of CN11 and 111 located below cerebrum and in mid-brain l Assessed for size, equality, reaction, responsive l Fixed and dilated late signs of herniation and severe hypoxia l Other causes
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Hypothermia, Medications, Lesions

MOTOR RESPONSES SEEN IN UNCONSCIOUSNESS

l POSTURING
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Decorticate Decerebrate Flaccidity (Unilateral or Bilateral) Primitive sucking or snout reflexes Strong reflexive hand grasps Restlessness Resistance to passive movements Hemiplegia Hemiparesis Seizures

l OTHER MOTOR SIGNS

q q q q q q q

CHANGES IN VITAL SIGNS

l Wide variations may be seen with various levels of consciousness and some changes directly related to the cause of the unconsciouness l Cushings (Triad) may develop with increased ICP
q q

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 Know the difference b/t Arousal.
content & arousal

Eyes

GLASGOW COMA SCALE SCORE (GCS) 1 Closed at all times 2 Opens to pain 3 Opens to voice command 4 Open spontaneously 1 No response A score of 10 or less 2 Extension (decerebrate rigidity) indicates a need for 3 Flexion posturing emergency attention 4 Flexion withdrawal 15 (top score) 5 Localizes painful stimulus 6 Obeys commands A score less than 7 is interpreted as coma

Motor

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

CONTENT Besides 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

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.