Title: NURSING%20OF%20ADULTS%20111
1NURSING OF ADULTS 111
- Introduction to Neurological Nursing
2NERVOUS SYSTEM
- CENTRAL 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
3 CENTRAL NERVOUS SYSTEM
- 1. Spinal cord (automatic motor
responsespathways 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
4. 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--constricti
on of pupil, promotes digestion, slows heart rate -
5The Brain
- Centre of our thought
- Interpreter of our external environment
- Origin of control over conscious (voluntary) and
unconscious (involuntary) movement
6FUNCIONAL AREAS OF THE CEREBRAL CORTEX
Parietal Lobe
Frontal Lobe
Occipital Lobe
Temporal Lobe
Brain Stem
Cerebellum
7Functions of the cerebral cortex
- Frontal lobe personality also contains the
motor cortex controls voluntary motor activity. - Prefrontal areas controls
- 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
8Cerebral 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.
9Cerebral 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 Wernickes area causes the inability to
understand spoken or written language or
recognize music.
10Cognitive 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.
11WHAT 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.
12NEURONS
- 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.
13CEREBRAL CIRCULATION
- Receives 15 of cardiac output
- High 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.
14Brainstem - 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.
15Anatomy of the Autonomic Nervous System (Brunner
2000, p. 1618) What impact on body re SC injury?
16EFFECTS 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
17 Cognitive and Perceptual
Disorders
- Assessment of the Neurologic System
18Neurologic 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, Huntingtons
- Psychosocial History personality changes, sleep
patterns, stressors, exposure to chemicals,
pesticide (Agent Orange)
19Neurologic System Physical Exam
- Cervical spinal cord injury can exhibit dec. B/P,
P T (loss of sympathetic nervous system) - Vital Signs note changes
- Mental 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
20Neurologic System Physical Exam
- Head, Neck, and Back
- 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) - Palpation
- Nodules, boggy skull, nuchal rigidity
- Percussion
- Gentle percussion watch for pain response
- Auscultation
- Major neck vessels turbulent - ? High risk for
CVA
21Neurologic SystemPhysical 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
22Neurologic System Physical Exam
- 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.
23Neurologic System Physical Exam
- Sensory Function
- Superficial Sensations
- Touch and Pain
- Mechanical Sensations
- Vibration tuning fork
- Proprioception
- Discrimination stereognosis distinguish
objects, graphism trace letters on palm of hand
24Neurologic System Physical Exam
- Abnormal Reflexes
- Babinskis Reflex
- Jaw Reflex
- Palm-Chin Reflex
- Clonus
- Snout Reflex
- Rooting Reflex
- Sucking Reflex
- Grasp Reflex
- Chewing Reflex
25Posturing
- Abnormal flexion (decorticate) internal rotation
of the arms wrists - Abnormal extension (decerebrate) extension
external rotation of arms wrists more serious
than abnormal flexion - midbrain
26Neurologic System Physical Exam
- Normal Reflexes
- Superficial (cutaneous) Reflexes
- Abdominal Reflex
- Plantar Reflex
- Corneal Reflex
- Pharyngeal Reflex - gag
- Cremasteric Reflex
- Anal Reflex check with MVA
- Deep Tendon Reflexes
27Neurologic System Physical Exam
- Autonomic Nervous System
- Cannot be examined directly
- Clinical Manifestations
- Increase/Decrease Heart Rate
- Vasoconstriction/Dilatation Peripherally
- Bronchoconstriction/Dilatation
- Increase/Decrease Peristalsis
- Pupil Constriction/Dilatation
28Neurologic System Physical Exam
- Functional Assessment
- Clinical Applications
- Diagnostic Tests-Noninvasive
- Skull and Spinal X-Ray Studies
- Computed Tomography
- Magnetic Resonance Imaging
- Positron Emission Tomography
29Neurologic System Diagnostic Tests
- Invasive
- Lumbar Puncture
- Myelography
- Cisternal Puncture
- Cerebral Angiography
- Cerebral Perfusion Studies
30Neurologic SystemDiagnostic Tests
- Noninvasive Tests of Function
- Electroencephalogram
- Evoked Potential Studies
- Neuropsychological Testing
- Invasive Tests of Function
- Caloric Testing
- Peripheral Nerve Studies
- Muscle Biopsy
- Cellular Assessment
31CONSCIOUSNESS
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
Cerebral Cortex Function).
32 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.
33 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)
34 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
35- Why is it important to assess LOC?
- How do we do this?
36Stages of decreasing LOC
- ALERT
- CONFUSION
- DISORIENTATION
- LETHARGY
- OBTUNDATION
- STUPOR
- COMA
37 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)
38 BREATHING IN THE UNCONSCIOUS
CLIENT
- Respiration controlled by cerebrum, pons and
medulla - Airway obstruction and aspiration common
complications - Obstructed airways causes?CO2 retention?vasodilati
on?cerebral edema?increased ICP - Reduced O2 levels?less oxygen to brain?increased
ICP
39 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).
40 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
41MOTOR 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
42CHANGES 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
43 44The Glasgow Coma Scale
(GCS)
Universally used Measures eye, verbal, and
motor response Excellent scale to measure
Arousal.
Know the difference b/t content arousal
45 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
46(No Transcript)
47- 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
test for cognitive function.
48Any 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.