BASIC

TOPOGRAPHY OF THE
BRAIN
 The Brain
•  Composed of 100 billion neurons
•  Parts of CNS
–  Brain and spinal cord
•  CNS contains – neurons or neuroglia (protect
and support neurons
–  Oligodendrocytes – insulate neurons
–  Astrocytes – maintain the blood brain barrier
–  Microglia – phagocytosis
–  Ependymal cells – CSF production



BRAIN
q It is the control center
q It receives information through our five
senses: sight, smell, touch, taste, and hearing,
often many at one time.
q It assembles the messages in a way that has
meaning to us
q It can store information in our memory.


q It controls our thoughts, memory and speech,

movement of the arms and legs, and the function
of many organs within our body.
q It also determines how we respond to stressful
situations (such as taking a test, losing a job, or
suffering an illness) by regulating our heart and
breathing rate.

 Superficial Brain Structure
•  Grey cell bodies VS
white matter deeper/myelin sheets
•  Convolution – wrinkles
•  Gyrus – buldge
•  Sulcus – shallow groove
•  Fissure deep groove
•  crebral cortex
– outer few mm of the cerebrum
The brain consists of four main structures:

•  Cerebrum
•  Cerebellum
•  Pons
•  Medulla
 The Cerebrum
•  higher brain
•  2 hemispheres
–  Left and right hemispheres
–  Connected by corpus callosum
•  Divided in lobes
–  Frontal , Parietal, Temporal,
Occipital lobe
 Frontal Lobe
•  Cognition
•  Intelligent thought, planning, sense of
consequence and rationalization
•  Prefrontal cortex – Intelligent stuffs
•  Primary Motor cortex (precentral gyrus)
–  Muscle control (moving of arms legs etc.)
•  Broca s Area
–  Speech function
clearly speaking
 Parietal Lobe
•  Sensing
•  Primary somatosensory cortex
–  (postcentral gyrus) Touch and sensing
•  Wernicke s Area (slightly in temporal lobe)
–  General interpretive area or comprehension of
speech
•  Imagination and dreaming
•  Sense of where your body in space

 Temporal lobe
•  Hearing
•  Auditory cortex
•  Auditory association area
•  Olfactory cortex deep connection to
memory
 Occipital Lobe
•  Vision
•  Visual Cortex – enables you to see
•  Visual association Area – make sense of what
you see
 Corpus Callosum

•  Strip of white matter that connects the

hemispheres of the cerebrum
 Limbic system
•  Establish emotion, linking higher and lower
brain function and memoy storage and
retrieval
Four parts of the Limbic system
•  Amygdala – interprets taste; fight or flight;
alerting areas for fear, anger and sadness
•  Hypothalamus – registers and controls
temperature, libido, hunger, aggression, and
endocrine and autonomic systems, circadian
rythms
•  Thalamus – modulates levels of awareness
and attention; relay organ for sensory cortex
•  Hippocampus – lays down memories; storage
of memories as it connects to cortex

Basal ganglia
- Coordination of learned
movements (maintaining rather
than intiating)
- Precise movements
- Inhibited by dopamine
5 parts
• Caudate – control of eye movements, behavior
and memory
• Putamen- motor control
• Globus pallidus- motor control
• Subthalamic nucleus- motor control
• Substantia nigra- where dopamine is produced
 Ventricles
–  Cavities deep within the cerebrum
–  Generates the CSF to protect the CNS
 Brainstem
•  3 parts
–  Midbrain
–  Pons
–  Medulla

 Midbrain
•  also called the mesencephalon
•  It is a small region of the brain that serves as a
relay center for visual, auditory, and motor
system information
•  Maintaining of consiousness
 Pons
•  Links cerebellum with the other parts of the
brain and spinal cord
•  Message station
•  Significant role in dreaming
 Medulla oblongata
•  Inferior portion of the brainstem
•  which is responsible for controlling such
autonomic functions as breathing, heart rate,
and digestion.
 CEREBELLUM
•  Littel brain
•  Inferior to the occipital lobe and posterior to
pons and medulla
•  Coordination and blance
 Meninges
•  Membranes that wrap around the superficial
portion
•  Insulate the central nervous system and
regulate blood flow
 Blood supply of the Brain
•  The Brain is one of the most highly perfused
organs in the body.
•  It is therefore not surprising that the arterial
blood supply to the human brain consists of
two pairs of large arteries
Ø  Right and left internal carotid
Ø  Right and left vertebral arteries

 Brian disorders
•  Seizures
•  Concussions
•  Meningitis
•  Stroke (CVA)
•  Hemorrhage
•  Aphasia
•  Dyslexia
•  Hydrocephalus
•  Parkinson s Disease
•  Alzheimers disease
•  Myasthenia Gravis
•  Guillain-barre syndrome
 Monro-Kellie Doctrine
•  More than two centuries ago, Alexander Monro applied some
of the principles of physics to the cranial cavity and for the
first time hypothesized that the blood circulating in the
cranium was of constant volume at all times. This hypothesis
was supported by experiments by Kellie. What finally came to
be known as the Monro–Kellie doctrine, or hypothesis, is that
the sum of volumes of brain, CSF, and intracranial blood is
constant. An increase in one should cause a decrease in one
or both of the remaining two. Specifically, a bleed into the
brain which occupies space and increases intracranial
pressure (ICP), must cause a displacement of some of the
substance in the brain such as CSF or blood.
 NURSING THE
CRITICALLY-ILL
NEUROLOGIC PATIENT
 NERVOUS SYSTEM
Nervous System - is made up of the brain,
the spinal cord and nerves

➔ The brain is a mass of nerve cells located

in the head.
➔ Extending from the brain is the spinal cord

➔ Nerves extend from the brain and spinal

cord to the different parts of the body

PARTS OF THE BRAIN
MAJOR PARTS OF THE BRAIN
CEREBRUM – longest structure in the
brain divided into halves (hemisphere)
Four Lobes
• Frontal lobes
– Which influences:
• Personality
• Judgment
• Abstract reasoning
• Language expression
• Movement (in the motor
portion)- motor control of
voluntary muscle
 MAJOR PARTS OF THE BRAIN
(Four Lobes)

Temporal Lobe
Hearing and smell
Language comprehension
Storage and recall of memories
Parietal Lobe
Interprets and integrates
sensation - pain, temperature,
touch
Interprets size, shape, distance
and texture
taste
 MAJOR PARTS OF THE BRAIN
(Four Lobes)

Occipital Lobe
Interprets visual
stimuli (sight)
 MAJOR PARTS OF THE BRAIN
(Four Lobes)

CEREBELLUM
Controls the movement
of muscles for
balance
 MAJOR PARTS OF THE BRAIN
(Four Lobes)

MEDULLA OBLONGATA
Is at the base of the
brain
It controls the basic life
function, heartbeats
and breathing
It takes care of reflex
actions such as
blinking, coughing and
knee jerk
 Nervous System

SPINAL CORD
•extension of the brain
•It runs down from the base
of the brain to lower part of
the back bone
•Is just as thick as a finger
•It is made up of gray matter
which contains the bodies
of nerve cells and white
matter which contains the
nerve fibers
The Nerve Cell
The basic unit in
the nervous
system
Sensory – brain and
spinal cord receives
messages from the
different parts of the body
Motor Nerve - brain or
spinal cord may send
messages to body tissue
and organs, instructs
them to take the proper
action.
Connector Nerve – link
up the sensory nerves
and motor nerves
MONROE KELLIE HYPOTHESIS

3 components within the cranial vault

 MONROE KELLIE HYPOTHESIS

The cranial vault is non-distensible (bone)

Components of the vault are essentially
non-compressible
An increase in one component will
reciprocate a decrease in either one or
both of other components
 NEUROLOGICAL ASSESSMENT

To establish baseline neurologic assessment to

note deviations and trends
To detect changes in the neurologic status of
patients
Minimize further loss of function from neurologic
deficits
Determine effects of neurologic dysfunction on ADL
Compare data to previous assessments to
determine change, trends and needed intervention
 NEUROLOGICAL ASSESSMENT
Nursing History
1. Statistical Data, Name, Age
2. Presenting complaint
3. History of Present Illness
Analysis of symptoms according to the following criteria:
a). Character of symptoms (intensity)
b). Date of first occurrence
c). Mode of onset
d). Usual time of onset
e). Precipitating factors
f) . Factors that alleviates or increase of complaint
g). Duration of symptom
h). Progression or regression of symptom
 NEUROLOGICAL ASSESSMENT

Vital signs
1. Blood Pressure
2. Pulse
3.Respiration
4.Temperature
 LEVELS OF CONSCIOUSNESS

Alert - if he responds
appropriately to
stimuli
- oriented to
person, place and
time
 LEVELS OF CONSCIOUSNESS

• Lethargic – if he
sleeps a lot, arouses
easily and responds
appropriately after he
is awakened.
 LEVELS OF CONSCIOUSNESS

Obtunded – if (before
he responds
appropriately) he
needs to be aroused
by shaking him or
shouting his name.
After responding, he
will return to sleep
 LEVELS OF CONSCIOUSNESS

Stuporous - if he
withdraws his
finger or attempts
to push your
hand away. In
most cases, he is
never completely
awake during
stimulation
 LEVELS OF CONSCIOUSNESS
• Semi-comatose - if
he performs a reflex
movement, such as
decorticate (flexing
one or both arms to
his chest) or
decerebrate (stiffly
extending one or both
arms with palms
facing outward
posturing).
 LEVELS OF CONSCIOUSNESS

• Comatose – if he has
no response, no
reflexes and flaccid
muscle tone in his
extremities.
 LEVELS OF CONSCIOUSNESS

Note:
Be sure to document your patient's LOC in your
nurse's notes (DAR). Also include the
Date/Time of your observation and the stimulus
used.
 Pupillary Assessment
Size
– Normal, constricted or dilated usually 2 to 5 mm.
– Constriction may suggest narcotics or if pinpoint could be
a pontine stroke or long lasting analgesia or short acting
opioid analgesic.
Equality
– May be normal to have equal pupils
– Could be a neurological event (decreased LOC)
Reaction
– Brisk, sluggish and fixed
– Source of light is important
– Environmental light
– (no reaction from a blind or false eye)
 MOTOR SYSTEM
EXAMINATION
Evaluation of
• Muscle size
• Muscle tone
• Muscle strength
• Gait/posture
• Involuntary
movements
Muscle size
Inspect symmetric
muscles for both side
and contour. Note for
muscle wasting,
atrophy or
hypertrophy
 Motor system

Muscle Tone
– Tone is the normal state of
muscle tension.
– Muscle is palpated while at rest
and during passive stretching
– Spasticity – increased
resistance to passive
movements.
– Flaccidity – decreased muscle
tone or hypotonia. Muscle is
weak, soft and flabby.
 Motor Strength Scale

• 5/5 – Normal movement against gravity and

resistance
• 4/5 – full range of motion against moderate resistance
and gravity
• 3/5 – full range of motion against gravity only, not
against resistance
• 2/5 – extremity can move, but not against gravity - can
roll but not lift.
• 1/5- muscle contracts but extremity cannot move
• 0/5 – no visible or palpable muscle contraction or
movement of extremity
GAIT

ØNatural
ØOn toes
ØOn heels
ØTandem along straight
line
POSTURE
CRANIAL NERVE ASSESSMENT

1. I - Olfactory - smell
2. II - Optic - vision
3. III - Oculomotor – extraocular
movement of the eyes
4. IV - Trochlear – eye movement
down and inward
5. V - Trigeminal - chewing
6. VI - Abducens – eye - outward
7. VII - Facial – taste (anterior 2/3)
8. VIII - Auditory – hearing/balance
9. IX - Glossopharyngeal –
gag/cough
10. X – Vagus – swallowing
11. XI - Accessory - turns head
12. XII – Hypoglassa – moves tongue
 Cerebellar Examination
Finger-to-Nose Test
• Patient is asked to touch
his/her own nose with their
index finger and then to
touch the examiner's
finger
• Dysmetria – inability to
perform point-to-point
movements due to over or
under projecting one’s
fingers
 Cerebellar Examination

Heel-to-Shin Test

Ø Ask patient to
repeatedly run the heel
down the shin to the big
toe
Ø Look for jerky or
wobbling movements or
note if the heel
constantly falls off to the
side
 Cerebellar Examination
Romberg’s Test
Ø Ask the patient to
remain still and close
her eyes

Ø (+) Romberg test

if a patient loses
balance after standing
still with their eyes
closed
 CONSCIOUS LEVEL CHART

The first section of the conscious level

chart (Coma Scale) is adapted from the
Glasgow Coma Scale (GCS) developed
in 1974 at the University of Glasgow by
Drs. Jennet and Teasdale as an
objective tool to quantitatively designate
the severity of head injury.
 Conscious Level Chart
contains 4 Basic Elements
1. Coma Scale
2. Vital Signs
3. Pupils
4. Limb Movement
 Eye Opening

Spontaneously – eyes open without any

stimulation. If they are open, this is recorded
as spontaneous eye opening.
Speech - responds to any speech or shout
- not necessarily to command
- if eyes are closed, first speak and then if
necessary shout
-Use a name he is used to.
 Verbal Response (Awareness)

Oriented - to person, place and time

- allow for some minor mistakes
Confused – attention can be held
- responsive to questions in a
conversational manner
- answers given does not answer the
question that was asked
- Do not repeat the same questions to all
the patients, as they are capable of memorizing
the questions and answers.
 Verbal Response

Inappropriate - no conversational exchange

- more words than sentences
- replies may need to be obtained by physical
stimulation

Incomprehensible Sounds
- moaning, groaning, screaming
- sounds are spontaneous or to painful stimulus

None - self-explanatory
 Best Motor Response
Localizes Pain
• The patient moves a limb in such a way as to
locate the painful stimulus in an attempt to
remove it
• The movement was purposeful

Flex or Withdrawal
• Withdraws from pain
• Bending the elbows and withdrawing the hand
 Best Motor Response

Abnormal Flexion (decorticate)

• Flexion of the arms
• Flexion of legs and feet (consider spinal injury)
Extension (decerebrate)
• Extension of arms, legs, feet
• Occasional internal rotation of the shoulders,
hands
• Can be spontaneous
None
• Flaccid (rule out spinal injury)
 Limb Movement: (comparison of
degree of strength L+R)
• Normal Power – limb power are appropriate for the
patient
• Mild weakness – when one limb is tested to show
normal power but is less strong than the opposite limb.
• Severe Weakness – if the difference between the
normal limb and the opposite is very marked
• Spastic flexion – same as abnormal flexion
• Extension – same as extension under Best Motor
response
• No response – self- explanatory
SPECIAL NEUROLOGIC NURSING
CONSIDERATIONS
 Clinical Problems

There are two major

threats to the
unconscious
patient:
1. The disease or
trauma that
produced
unconsciousness
2. The threat of the
unconscious state
 Objectives of Treatment and
Nursing Management
NURSING GOAL:
to assume the
protective reflexes
for the patient until
he is aware of
himself and can
function in his
environment
 Objectives of Treatment & Nursing
Management

A. Establish &
maintain an
adequate airway.
1. Place the patient in
a three fourth prone
or semiprone
position.

2. Oral airway
 Objectives of Treatment & Nursing
Management

3. Endotracheal tube
4. Utilize humidified
oxygen
5. Keep the airway free
of secretions with
efficient suctioning
6. Carry out periodic
determinations of
arterial PO2 and PCO2
to determine adequacy
of treatment.
 Objectives of Treatment & Nursing
Management

B. To assess the level of responsiveness

1. Carry out neurologic exam
C. To evaluate the progression of vital signs
D. To maintain fluid and electrolyte and nutritional
balance
1. Hyperalimentation feeding
2. Initiate nasogastric feedings
- aspirate stomach before each feeding
- elevate patient’s head and thorax
- give 2000- 2500 ml. of fluid (according to
patient’s condition)
 Objectives of Treatment
& Nursing Management

E. To give nursing support as the patient’s changing

conditions indicates

1. Be aware of the varying phases of restlessness

- have adequate lighting in the room to prevent
hallucinations as the patients regains consciousness.
- Pad side rails; may apply mitts or boxing gloves on hands,
or use other devices to protect patients.
- avoid over-sedating the patient
- avoid restraints if at all possible
- speak softly to the patient, calling him by name
- touch him as gently as possible
 Objectives of Treatment
& Nursing Management

2. Keep the skin clean and dry and free of pressure

3. Put all extremities through range of motion exercises 4
times daily.
4. Turn the patient from side to side at regular intervals.
5. Observe the patient for indication of an overdistended
bladder.
6. Carry out oral care
7. Protect the eyes from corneal irritation
8. Be alert for the development of complications
9. Be aware that the patient will feel uneasy concerning his
period of unconsciousness.
 Nursing Management of the Patient with
Increasing Intracranial Pressure

• Intracranial pressure is the pressure within the

ventriculosubarachnoid space.
CAUSES:
- Head injury/hematoma
- Cerebral edema; cerebrovascular accident
- Abscess, infection
- Hemorrhage
- Brain tumor
- Cranial surgery
Nursing Management of the Patient with
Increasing Intracranial Pressure

NURSING ALERT!!!
As Intracranial pressure
increases, the brain
substance is compressed.
A sudden increase may
produce an emergency
situation in a few minutes.
This condition may lead
rapidly to death or result in
a vegetative existence for
the patient.
 Treatment and Nursing
Management

1. Provide continuing
assessment of patient.
- Response to commands
2. Administer
pharmacologic agents
- Hyperosmotic agents
3. Monitor patient’s
temperature
 Treatment and Nursing
Management
1. Employ passive
hyperventilation
2. Avoid certain
positions and
activities that produce
a rise in intracranial
pressure
3. Prepare for surgical
intervention if
patient’s condition
warrants it
 Nursing Care of the Patient With IIP

• Elevate HOB • Restrict fluids

• Neck in neutral • Foley
position • Suctioning
• Avoid flexion of • O2
hips, waist and • Hypothermia
neck
blanket
• Avoid isometric
activity or
Valsalva
 Seizures: Nursing Care

• Protect
– Lower to the floor; pad side rails; pillow
under head; don’t restrain
– No bite block or padded tongue blade
– Allow for post-ictal rest
• Prevent aspiration (airway)
– Turn side; loosen clothing around neck
• Document everything
• Get the duration
 Emotional Support
• After CVA, a patient may:
– Behave erratically
– Becoming angry
– Swearing
– Acting in many ways that baffle family members.
• To help them cope, explain that patient’s stroke
caused both physical and emotional deficits.
Retraining neurologic pathways will probably help
him return to normal. Encourage your patient, too.
He needs to know his effort are worthwhile.
 Emotional Support
Base your evaluation on the patient’s expected
outcome. Ask yourself these questions:
1. Does he communicate his needs to the staff and
his family?
2. How does he express his needs?
3. Is he becoming frustrated?
* The answers to this questions will help you
evaluate your patients status and the
effectiveness of his care. Keep in mind that these
questions stem from the sample care plan. Your
questions may differ.
 REMEMBER!!!
1. Don’t shout at the patient; his
hearing’s fine.
2. Face the patient, and speak slowly
and distinctly.
3. Be patient; give him time to express
himself.
4. Use nonverbal communication,
touch him, squeeze his hand, SMILE.
5. Help the patient repeat words and
encourage practice to help establish
new impulse pathways in the brain.
6. Simplify directions.
7. Help the family by explaining the
causes of aphasia, the goals of
therapy, and ways they can support
the patient.
Are you a right brain
person or a left brain
person?