Neurological Study Guide.

Neurotransmitters:
1. Chemicals that cross synaptic cleft
a. dopamine
b. serotonin
c. norepinephrine
d. GABA
e. Enkephalin, endorphin
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Anatomy of Brain:
1. Cerebrum: higher thought, two hemispheres
a. Corpus callosum: nerve fibers that connect the two hemispheres
b. four lobes:
Frontal: concentration, abstract thought, motor function
Parietal: sensory, pain, touch, temperature
Temporal: auditory, sensory and speech
Occipital: visual
2. Brain Stem:
a. midbrain: relay station
b. pons: respirations
c. medulla: HR, respirations, blood vessel diameter, sneezing, swallowing, vomiting
3. cerebellum: motor function, balance
4. basal ganglia,: asssits cerbral cortex in smooth voluntary movement
5. thalamus: emotions, relay station to other areas of body
6. hypothalamus: regulations of body temp, sleep wake- cycles ect, considered master gland

Spinal cord: carries messages from brain to rest of body, 1st cervical to 2nd lumbar vertebra
Afferent fibers: sensory
Efferent: motor

Structures protecting the brain:

1. Skull
2. Meninges
3. Cerebrospinal fluid: normal pressure is 60 to 180 mmH2O

Cerebral circulation:
1. Arteries: 2 internal carotid, 2 vertebral
2. Veins: do not have valves

Autonomic Nervous system

1. cardiac, smooth muscle
2. involuntary functions
3. parasympathetic and sympathetic nervous system
sympathetic: fight or flight
parasympathetic: visceral function, maintains homeostasis

Diagnostic Tests:
Skull and spinal x ray: bone information such as fractures, dislocation, compressions ect.
a. maintaining immobilzation is important when dealing with these injuries!!
CT: can be with or without dye,
a. detects intracranial bleeding, cerebral edema, infarctions, hydrocephalus, shifts of brain
structures
b. pre procedure: need informed consent if using dye!
c. monitor for allergies for shellfish, iodine (if using dye)
d. hold metformin (if using dye) to limit renal damage, need current BUN and creatinine
MRI: Ids tumors and vascular abnormalities, similar to CT but does not need dye
a. no metal
b. no MRIs on pacemakers ect.
c. claustrophobia an issue
Lumbar puncture:
a. insertion through L3 - L4
b. used to take sample of CSF
c. contraindicated with clients with increased intracranial pressure
d. empty bladder before
e. knee chest position during procedure
f. complication is headache due to loss of CSF, must call physician
Meylogram: injection of dye or air into subarachnoid space to detect abnormalities of spinal cord and
vertebrae, (not used as much due to the use of CT and MRI) ..true dat.
a. #1 complication is headache due to loss of CSF similar to lumbar puncture
Cerebral Angiography: perfusion study, such as aneurisms
EEG: graphic recording of electrical activity
a. need to hold stimulants, anticonvulsants, antidepressants ect before procedure

Neurological Assessment:
1. Subjective data: loss of consciousness, dizziness, fainting, numbness, ect., H/A, convulsions
2. mental status
a. observation of patient
b. asking questions
c. objective data: posture, gait, motor movements, dress, hygiene, facial expressions
d. mood, thought process, level of consciousness
e. length of concentration
f. memory
g. abstract reasoning, sound judgments ect.
3. Cranial Nerves:
I Olfactory: hold scent under nostril
II Optic: eye chart
III Oculomotor: follow finger, eye movement
IV Trochlear: eye movement
V Trigeminal: sensory function, light versus sharp touch
VI Abducens: eye movement
VII Facial: sensory and motor function of face,
VIII Acoustic: whisper test
IX Glossopharyngeal: say ah
X Vagus
XI Spinal acessory: shrug shoulders
XII Hypoglossal: protude tongue.
4. Cerebellar function
5. Motor assessment: muscle size, tone, movement ect.
6. reflexes

Decorticate: flexion in response to pain

Decerebrate: extension in response to pain

Glasgow coma: score between 1 - 15. score of 8 coma is present (probably needs intubation)
a. eye opening
b. verbal
c. best motor response

Respirations:
Cheyne-Stokes: periods of apnea
Neurogenic hyperventilation: rapid and deep sustaining respirations, dysfunction of midbrain and middle
pons
Apneustic: irregular respirations with pauses at end of inspiration and expiration
Ataxic: irregular

Altered Level of consciousness

1. Signs and symptoms:
a. decreased alertness, decreased consciousness, change in pupils/eye opening, subtle behavior
changes
b. early sign and symptoms: restlessness and anxiety.
2. complications:
a. respiratory failure
b. pneumonia
c. pressure ulcers
d. aspiration
3. medical management:
a. airway
b. breathing
c. circulation
d. nutrition
4. 1859! risk for injury is one of the most common nursing diagnosis with altered level of consciousness

Increased intracranial pressure

Caused: Head injury, brain tumors, toxic and viral encephalopathies, subarachnoid hemorrhage
earliest sign of ICP is change in LOC

Patho:
1. increased ICP leads to decreased cerebral perfusion
2. leads to ischemia and cell death which stimulates further edema
3. shifting of brain tissue
4. herniation
5. death. this is bad.

complications:
1. brain stem herniation
a. cushings triad: rise in BP with widening pulse pressure, bradycardia, decrease respirations
2. diabetes insipidus: from pressure on the pituitary gland, lack of antidiuretic hormone.
3. syndrome of inappropriate antidiuretic hormone: too much antidiuretic hormone, sodium goes down to
due hemodilution

Normal CPP is 70 to 100 mmHG, intracranial pressure 0-10 mmHG

CPP: MAP - ICP, (cerebral profusion pressure: mean arterial pressure minus ICP)
MAP: systolic BP + (2 x diastolic BP)/3

Management of ICP:
1. osmotic diuretics (mannitol)
2. corticosteroids (dexamethasone)
3. fluid restriction
4. hypothermia
5. reduce CSF and intracranial blood volume
a. ventriculostomy drain
b. hyperventilation will result in vasoconstriction (this reduces ICP)
6. Control temperature
a. antipyretic meds
b. cooling blanket
c. a shivering patient will have increased ICP
7. reduce metabolic demands
a. barbiturates: pentobarbital
b. paralyzing agents: pavulon
c. sedation: diprivan
d. analgesia: fentanyl

Intracranial surgery:
1. craniotomy: surgical opening of the skull
a. to relieve ICP
b. evacuate blood clot
c. control hemorrhage
d. remove a tumor
2. transphenoidal: mouth and nasal sinus to gain access to pituitary glands
3. Burr holes; exploration or diagnosing, evacuate hematoma or abscess
4. craniectomy: removal of portion of skull
5. cranioplasty: repair of cranial defect

Preoperative management:
1. antiseizure meds: dilantin, cerebx
2. Corticosteroids
3. fluid restrictions mannitol
4. antibiotics:
5. anxiolytic

Head, Brain, and Spinal cord injuries

1. Primary Injury: injury done to brain from a traumatic event ( initial damage to brain)
2. Secondary injury: damage that evolves, hours to days, that is primarily due to brain swelling or ongoing
bleeding. example: ICP

Types of Head injuries:

1. Scalp: highly vascular. Abrasion, contusion, laceration, hemotoma
2. Skull Fracture:
a. linear: along the fissure
b. communiuted: bone fragment, shattering
c. Depressed: caved in
d. Basilar: base of skull around the ears
Signs and symptoms of basilar fracture:
Hemorrhage
Battles sign: bleeding over mastoid bone, indicative of basilar fracture
CSF otorrhea: blood coming out of ear
CSF rhinorrhea: blood coming out of nose
Halo sign: stain on the pillow from CSF leakage
3. Diagnostic test: CT, MRI, Cerebral angiography
4. S/S of head injury in general:
a. altered LOC
b. pupil abnormalities
c. absent gag reflex
d. changes in vital signs
5. Medical management:
a. close observation
b. surgery

Brain Injury:
1. Closed (blunt) brain injury: head accelerates and rapidly decelerates and collides with another object
2. Open brain injury: objects penetrates the skull, and damages the soft brain tissue
Types of brain injury:
1. Concussion: temporary loss of function with no apparent structural change
a. if frontal lobe is affected: bizarre behavior
b. temporal: amnesia
2. Contusion
a. unconscious for more than a few seconds or minutes
b. involuntary evacuation of bowels and bladder
c. shallow respirations, cool pale skin
d. B/P and temp subnormal
e. abnormal eye movement
f. body functions will eventually return to normal
g. full recovery days to months
h. vertigo, seizures, residual h/a are common
3. Diffuse axon injury
a. widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem
b. mild to sever head trauma: axonal swelling and disconnection
c. severe, no lucid intervals and experiences immediate coma, decorticate and decerebrate
posturing, global cerebral edema
d. diagnosis: clinical signs plus CT or MRI
e. recovery depends on the severity of the axonal injury
4. Intracranial Hemorrhage: collection of blood, most serious brain injury
a. epidural: arterial blood between skull and dura, S/S: loss of consciousness, an apparent
recovery, then sudden signs of compression
b. Subdural; collection of blood between dura and the brain, can be acute and chronic, elderly and
alcoholics more susceptible, number one symptom: change in LOC
c. Intracerebral: bleeding into the substance of the brain: force is exerted to the head over a small
area (bullet wound), systemic HTN, saccular aneruysm, vascular anomalies. Management if
mostly dealing with ICP and supportive care.
5. Management of brain injuries
a. all treatment is towars preserving brain homeostasis and preventing secondary injury
b. cerebral edema, B/P, respirations, electrolyte imbalance, anti-hypertensives, head of bed 30-45
degrees, diuretics

Spinal Cord Injury

Facts:
1. 4x more in males
2. 16 - 30
3. African American more than caucasians
4. 35% MVA, 30% violence, 19% falls

Patho:
1. Transient concussion: usually 100 percent recovery
2. Contusion
3. Laceration
4. Compression
5. Transection: complete cutting of cord

Catagories:
1. Primary: initial trauma
2. Secondary: contusion or tear injury after the initial injury

Emergency Management:
1. rapid assessment
2. Immobilization
3. extrication (from vehicle if possible)
4. Stabilization
5. Transportation to close location

Management of acute phase:

1. Goal is prevent secondary injury
2. high dose of coritcosteroids ASAP
3. O2 therapy, keeps sats high to oxygenate cord
4. Blood transfusions
5. Respiratory therapy:
a. dont bend neck to intubate
6. Skeletal fracture reduction and traction

Complications: pg 1938
1. Spinal shock and neurogenic shock: develops due to loss of autonomic innervations below area of injury
a. the higher the injury on the spinal cord results in more areas that are affected
2. Respirations: especially the higher spinal cord injuries
a. decreased vital capacity
b. retention of secretions
c. increased CO2 levels
d. decreased O2 levels
e. respiratory failure
f. pulmonary edema
3. DVTs: increased risk for blood clots
4. Autonomic dysflexia
a. S/S: headache, profound sweating, nasal congestion, bradycardia, HTN, urinary retention
b. considered acute emergency from exaggerated autonomic responses to normal stimuli
c. occurs after spinal shock is resolved
d. triggered by: distended bladder, bowel distention, distention or contraction of visceral organs,
simulation of skin (break in skin, rash ect.)
e. need to remove triggering stimulus to avoid serious complications (check bladder first)
f. put in high fowlers to lower BP

Oncologic disorders of the brain:

1. Primary Brain tumors
a. localized lesion that occupies space with the skull
b. Shape; spherical mass and grow diffusely and infiltrate tissue
c. pathphysiological events
d. Origination: often unknown, ionizing radiation, increased ICP
2. Types:
a. Gliomas: most common type, can infiltrate any portion of brain, spreads by infiltrating into
surrounding neural connective tissue, most deadly, cannot be completely removed
b. Angiomas: 83% occur in cerebellum, masses composed largely of abnormal blood vessels,
increased risk for CVA,
c. Meningiomas: on cover of brain, benign encapsulatd on meninges, can be removed
d. Acoustic neuromas: on cranial nerves, grow very slowly, often balance problems,
e. Pituitary adenomas: on pituitary, can have pressure effects such as vision or headaches and
hormonal effects form the gland itself.
Clinical Manifestations:
1. Increased ICP reflect symptoms
a. headache
b. vomiting
c. visual disturbances
d. hemiparesis
e. seizures
f. mental status changes
g. personality changes
2. the symptoms you may if the tumor is in the:
a. occipital lobe: loss of vision on opposite side of tumor
b. cerebellum: dizziness, ataxia, staggering, gait, muscle incoordination
d. frontal lobe: higher level thinkingyou may think you have one right now for example after
reading 7 pages of this

Diagnostics: CT, MRI, PET, EEG, CSF (MRI the most helpful)

Medical management:
1. chemo
2. radiation
3. brachytherapy: inplanted radiation into system
4. bone marrow transplant
5. corticosteroids

Cerebral Aneurysm:
1. def: Dilation of the walls of the cerebral artery, often resulting from a weakness in arterial wall.
a. usually occurs around circle of willis
2. cause:
a. atherosclerosis
b. congential defect of vessel wall
c. hypertensive vascular disease
d. head trauma
e. age
f. multiple cerebral aneurysms are not uncommon
3. S/S:
a. sudden, severe headache, loss of consciousness (if aneurysm ruptures)
b. pain and rigidity in back of neck and spine
c. visual disturbance
d. tinnitus, dizziness, hemiparesis
e. coma and death.
4. Management:
a. prevent rupturing of aneurysm
b. aneurysm can be reinforced or ligated (clipped off) in surgery
c. extracranial-intracranial arterial bypass
d. bed rest
e. analgesics
f. elastic compression stockings to prevent DVT while on bed rest.