NURSING%20OF%20ADULTS%20111

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NURSING OF ADULTS 111

• Introduction to Neurological Nursing

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NERVOUS 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

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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

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. 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

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The Brain

• Centre of our thought
• Interpreter of our external environment
• Origin of control over conscious (voluntary) and
  unconscious (involuntary) movement

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FUNCIONAL AREAS OF THE CEREBRAL CORTEX
Parietal Lobe
Frontal Lobe
Occipital Lobe
Temporal Lobe
Brain Stem
Cerebellum
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Functions 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

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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.

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Cerebral 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.

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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.

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WHAT 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.

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NEURONS

• 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.

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CEREBRAL 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.

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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.
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Anatomy of the Autonomic Nervous System (Brunner
2000, p. 1618) What impact on body re SC injury?
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EFFECTS 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

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Cognitive and Perceptual
Disorders

• Assessment of the Neurologic System

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Neurologic 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)

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Neurologic 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

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Neurologic 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

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Neurologic 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

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Neurologic 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.

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Neurologic 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

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Neurologic System Physical Exam

• Abnormal Reflexes
• Babinskis Reflex
• Jaw Reflex
• Palm-Chin Reflex
• Clonus
• Snout Reflex

• Rooting Reflex
• Sucking Reflex
• Grasp Reflex
• Chewing Reflex

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Posturing

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

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Neurologic 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

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Neurologic 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

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Neurologic System Physical Exam

• Functional Assessment
• Clinical Applications
• Diagnostic Tests-Noninvasive
• Skull and Spinal X-Ray Studies
• Computed Tomography
• Magnetic Resonance Imaging
• Positron Emission Tomography

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Neurologic System Diagnostic Tests

• Invasive
• Lumbar Puncture
• Myelography
• Cisternal Puncture
• Cerebral Angiography
• Cerebral Perfusion Studies

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Neurologic 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

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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
Cerebral Cortex Function).
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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.
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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)

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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

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• Why is it important to assess LOC?
• How do we do this?

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Stages of decreasing LOC

• ALERT
• CONFUSION
• DISORIENTATION
• LETHARGY
• OBTUNDATION
• STUPOR
• COMA

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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)

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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

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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).

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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

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MOTOR 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

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CHANGES 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

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• ASSESSING CONSCIOUSNESS

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The Glasgow Coma Scale
(GCS)
Universally used Measures eye, verbal, and
motor response Excellent scale to measure
Arousal.
Know the difference b/t content arousal
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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
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(No Transcript)
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• 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.

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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.