Neurological System Chapter 38

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Neurological SystemChapter 38

• White
• Christensen
• Kockrow
• Adam
• Leslie Lehmkuhl, RN 2008

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Key Terms

• Affect
• Agnosia
• AneurysmAphasia
• Areflexia
• Apraxia
• Ataxia
• Aura
• Automatism
• Autonomic nervous system

• Bradykinesia
• Stroke
• Central nervous system
• Diplopia

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Terms

• Cephalgia
• Chorea
• Copralalia
• Dysarthria
• Dysphagia
• Emotional lability
• Encephalitis

• Decorticate posturing of arms and legs rigid
  plantar flexion
• Decerebrate rigid extension of arms and legs
  with wrists turned outward

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Terms

• Fasciculation
• Flaccid
• Glascow coma scale
• Global cognitive dysfunction
• Graphesthesia
• Hemanopia
• Hemiplegia

• Hemiparesis
• Hyperreflexia
• Meningitis
• Mentation
• Nystagmus
• Neuralgia
• Neurogenic shock
• Orientation
• Paraplegia

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Terms

• Postictal period
• Proprioception
• Quadrspelegia
• Sclerotic
• Spastic
• Spinal shock
• Status epilepticus
• Sterognosis
• Unilateral neglect

• Vertigo

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Introduction

• The nervous system is the bodys communication
  network.
• It coordinates and organizes the functions of
  all other body systems.
• A highly complex and coordinates and controls all
  motor, sensory and autonomic functions.

• This intricate network has 2 main divisions
• Central Nervous System
• Peripheral Nervous System

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Nervous System Division

• Central nervous system (CNS)
• Brain and spinal cord
• (bodys control center)

• Peripheral nervous system
• (PNS)
• Contains cranial and spinal nerves that connect
  to CNS to remote body parts which relay and
  transmit messages
• Somatic nervous system
• Sends messages from the CNS to the skeletal
  muscles voluntary
• Autonomic nervous system
• Sends messages from the CNS to the smooth muscle,
  cardiac muscle and certain glands involuntary.
  Includes the sympathetic and parasympathetic
• note a i are vowels

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CNS

• Brain is composed of gray and white matter.
• Gray matter is the outside which contains
  billions of neurons.
• The white matter make up the inner structure of
  the brain contains pathways that transmit nerve
  impulses to different areas of the brain.

• The brain and spinal cord are protected by the
  bony skull and vertebre, CSF and three membranes
• Dura mater
• Pia mater
• Arachnoid mater

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Dura mater,Pia mater, Arachnoid mater

• Dura mater a tough fibrous, leatherlike tissue
  composed of two layers.
• Inner lining/ layer of the skull
• Thick layer which covers the brain and provides
  support and protection

• Pia mater- connective tissue that covers and
  contours the spinal tissue and brain.
• Arachnoid mater- thin, fibrous membrane that
  hugs the brain and spinal cord, though not as
  preciously as the pia mater.

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The Spaces Between

• Between the dura mater and arachnoid membrane is
  the subdural space
• Between the pia matter and the arachnoid membrane
  is the subarachnoid space.

• Within the subarachnoid space and the brains
  four ventricles is CSF, a liquid composed of
  water, and traces of organic material (protein,
  glucose, and minerals.
• The fluid protects the brain and special tissue
  from jolts and blows

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CNS

• Cells of the nervous system
• Neuron (fundamental unit of the nervous system)
• Delicate threadlike nerve fibers called axons and
  dendrites that extend from the cell body

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CELLS OF THE NERVOUS SYSTEM

• Neurons (Nerve Cell)
• Consist of three main partsdendrites cell body
  of neuron and axon
• Dendrites conduct impulses to cell body of neuron
• Axons conduct impulses away from cell body of
  neuron

• Most neurons have multiple dendrites but only one
  axon.
• Gap between each neuron is a synapse and
  neurotransmitters conduct impulses through the
  gap
• Neurotransmitters acetycholine, norepinephrine,
  dopamine, serotonin

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Nerve Cell
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Myelin and Nerve Structure
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Brain Hemispheres

• The cerebrum is divided into right and left
  hemispheres
• The right side controls the left side of the body
• The left side controls the right side of the body

Right Controls the Left, and the Left Controls
the Right
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Brain Hemispheres

• Right Hemisphere-
• perception, physical environment, art, music,
  spiritual, non-verbal communication

• Left Hemisphere-
• Analysis, interpretation,
• calculation, problem solving, writing, and reading

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Spinal Cord

• 17 to 18 inches long is a 2 way conductor pathway
  between the brain and peripheral nervous system.
• Spinal cord conducts impulses to and from the
  brain, serves as a center for reflex action

• 31 pairs of spinal nerves originate from the
  spinal cord to the body
• The spinal cord has an H shaped appearance called
  horns. (gray mater)
• These horns contain the cell bodies of neurons
  needed for voluntary reflex action

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Gray mater cell bodies
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CSF

• 500 milliliters are produced daily
• CSF absorbs shock and bathes the brain
• The nutrients (protein, glucose, Naurea) are
  delivered to the CNS cells

• Toxic and waste products are removed.

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NERVES AND TRACTS

• Nervebundle of peripheral axons
• Tractbundle of central axons
• White mattertissue composed primarily of
  myelinated axons (nerves or tracts). Transmits
  nerve impulses to different areas of the brain.
• Gray mattertissue composed primarily of cell
  bodies and unmyelinated fibers

• Nerve coveringsfibrous connective tissue
• Endoneuriumsurrounds individual fibers within a
  nerve
• Perineuriumsurrounds a group (fascicle) of nerve
  fibers
• Epineuriumsurrounds the entire nervea

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CENTRAL NERVOUS SYSTEM

• Divisions of the brain Brainstem
• Consists of three parts of brain named in
  ascending order the medulla oblongata, pons, and
  midbrain
• Structurewhite matter with bits of gray matter
  scattered through it

• Functiongray matter in the brainstem functions
  as reflex centers (e.g., for heartbeat,
  respirations, and blood vessel diameter)
• Sensory tracts in the brainstem conduct impulses
  to the higher parts of the brain
• Motor tracts conduct from the higher parts of the
  brain to the spinal cord

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Peripheral Nervous System

• Somatic Nervous
• System
• Connects CNS to skin and skeletal muscles
• Conscious activities (walking, exercise)

• Autonomic Nervous
• System
• Connects CNS to visceral organs (e.g. heart,
  stomach, GI, and other viseral organs)
• Unconscious activities (breathing)

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ANS

• Sympathetic System

• Parasympathetic System

See pg 1064 Table 38-2
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ANS

• Sympathetic nervous system increases heart rate,
  blood pressure, dry mouth
• Fight or flight system

• Parasympathetic slows the system for normal
  function
• Decreases heart rate, decreases blood pressure..

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NEUROLOGICAL ASSESSMENT

• History
• Cerebral function
• Cranial nerve function
• Motor function
• Sensory function
• Reflexes

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Nursing assessment

• History of incident or accident headaches,
  changes of vision, seizure activity,numbness or
  tingling in an extremity, mood changes,
  personality changes, fatigue,

• pupil size and reaction, level of consciousness,
  perception, speech, lethargy, motor coordination,
  proprioception

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Cerebral Function Assessment

• Level of consciousness (responsiveness and
  orientation), most important indicator of change
  in LOC..
• Call pt by name
• If no response touch pt gently or shaking
  shoulder
• If no response. use strong stimulation (e.g.
  nail bed pressure)

• To document use Glasgow Coma Scale or document
  pts state of arousal
• Alert
• Disorientation
• Lethargic
• Obtunded
• Stuporous
• Semiconcious
• Comatose

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Glasgow Coma Scale

• Scale of responses to eye opening, motor response
  and verbal response with a number for each
• Eyes open 4- spontaneous 3- to speech 2- to
  pain 1- none
• Best verbal response 5- obeys commands 4-
  confused 3- inappropriate 2- incomprehensible
• 1- none
• Best motor response 5- obeys commands 4-
  localizes pain 3- flexion to pain 2- extension
  to pain 1- none

• Total 3 to 15
• lt7 is considered a comatose state
• It is important to monitor any downward trend in
  the patients score. If this happens, the nurse
  must act quickly, call MD and assist with
  measures to prevent or reduce ICP and prevent
  further brain damage..

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Cerebral Function Assessment

• Mental status (e.g., Mood, behavior, facial
  expressions, gestures)
• Intellectual function (e.g., concentration and
  recall)
• repeating numbers-recall
• adding small numbers -calculation
• last meal eaten

• Short term memoryrepeating 3 numbers stating
  what was eaten for last meal
• Long term memoryschool attended time served in
  the military
• concentration
• general knowledge repeating recent news
  information

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Cerebral Function Assessment

• Emotional status (affect).
• Pupillary reaction (size and equality)

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Cerebral Function Assessment

• PERRLA
• Pupils
• Equal
• Round
• Reactive
• Brisk
• Sluggish
• Non-reactive
• consensual

• Accommodation normal findings
• Distance dilation
• Close up constriction

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Cerebral Function Assessment

• Oral and written communication.
• Vocabulary used-
• Aphasia no speech
• Sensory aphasia Receptive aphasia inability to
  comprehend the spoken or written word

• Motor aphasica Expressive aphasia inability to
  use words or symbols
• Global aphasia inability to understand the
  written word or to speak
• Anomia inability to name objects
• Dysarthria difficult speech

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Cranial Nerve Function Assessment

• a reflection of brain stem activity, is usually
  assessed by a physician or advanced practice
  nurse.

• See Understanding Cranial Nerves handout
  provided.

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Motor Function Assessment

• Muscle size and symmetry
• Compare bilaterally
• Muscle tone
• Normal, flaccid (hypotonic), rigid (constant stae
  of spacicity), spastic (rigid, may have tremors)

• Muscle strength
• 0 to 5 (see next slide)
• Push against resistance
• Coordination
• Cerebellum functioning
• finger to nose (38-6)
• run heel of foot down opposite shin (38-7)
• Ataxia is the inability to perform voluntary
  muscle function

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Muscle Strength

• 5/5 strong
• 4/5 fair to moderate strength
• 3/5 just able to overcome gravity
• 2/5 can move but not overcome gravity
• 1/5 minimal power strength
• 0/5 no movement

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Finger to nose with eyes closed
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Coordination using heel slide
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Motor Function Assessment

• Posturing
• Decorticate posturing of arms and legs rigid
  plantar flexion
• Decerebrate rigid extension of arms and legs
  with wrists turned outward
• Flaccid weak, lack muscle tone
• Spastic sudden involuntary movement

• Balance
• Romberg test
• Eyes closed
• Feet together
• Arms extended in front
• Slight swaying is normal use safety precautions
  (stand in front of pt)and prevent falls

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Sensory Function Assessment

• Tactile Sensation use cotton ball on arms,
  hands, feet, legs bilat.
• Pain and temperature transmit on same pathway.
  Use safety pin dull sharp
• Vibration tuning fork feel vibrations on wrists
  and ankles

• Proprioception space position in regard sto
  joints. Passively move pt fingers or extremities
  and ask direction moved to pt.
• Unilateral neglect individual ignores one side
  of body
• Hemianopia defect in vision blind in ½ vision
  field

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Vibration
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Sensory Function Assessment

• Sterognosia recognition of objects comb, pen,
  pencil, coin, keys. with eyes closed
  (sensation a function of brain not pathways)
• Graphesthesia recognize letters drawn on the
  palm of the hand with eyes closed

• Integration of sensation two point
  discrimination touching 2 points on opposite
  sides of the body at one time with a distance
  between the points.
• Have pt give of times touched

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Stereognosis
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Graphesthesia
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Reflex Assessment

• Deep tendon reflexes are usually assessed by a
  physician or advanced practice nurse.
• Superficial- on the skin as the plantar reflex
  or Babinski negative in adults can use reflex
  hammer handle, finger, pen

• Deep tendon reflexes patellar or knee jerk
  reflex normally intact stretching near the
  insertion site of the muscle not present
  indicates motor or sensory dysfuynction
• The abscemce of DTRs is considered abnormal

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Babinski

• A fanning of toes and dorsoflex of big toe
• Indicates a corticospinaldiseaes and is the most
  important abnormal superficial reflex

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Babinski Reflex Possible Causes

• Generalized tonic-clonic seizure (there may be a
  temporary Babinski's reflex for a short time
  after a seizure)
• Amyotrophic lateral sclerosis
• Brain tumor (if it occurs in the corticospinal
  tract or the cerebellum)
• Familial periodic paralysis
• Friedreich's ataxia
• Head injury

• Hepatic encephalopathy
• Meningitis
• Multiple sclerosis
• Pernicious anemia
• Poliomyelitis (some forms)
• Rabies
• Spinal cord injury
• Spinal cord tumor
• Stroke
• Syringomyelia
• Tuberculosis (when it affects the spine)

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Aging/Prevention of Problems

• Slower reflexes
• Tremors that increase with fatigue
• Decreased sense of touch, fine motor coordination
  decreases
• Takes longer to learn.. Chronic diseases cause
  chronic pain and interfers with movement

• Reduce factors as high blood pressure, smoking,
  obesity, stress, lack of exercise, control heart
  disease
• History assess headaches, loss of function,
  visual changes, seizure activity, numbness or
  tingling in extremity, pain, change of
  personality

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Tests

• Arterial blood gas (o2 content Guillain-barre)
• Urinalysis (Diabetes Insipidus)
• Cerebral spinal fluid (infection lower glucose in
  infection blood)
• CT (with or without contrast takes 20-30 min to
  an hour person must lie still and have no allergy
  to iodine invasive procedure and consent
  required)

• Brain scan (detect brain abnormalities)
• mri
• Angiography(Angiogram for vascular abnormalities
  dye injected and takes 2-3 hours bedrest for 4-6
  hours post test vital signs q 15 min post test
  and neurological check )

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Tests

• Carotid doppler (technology usually of carotid
  artery to detect carotid blockage)
• Electromylogram( for nerve conduction as in
  Myasthenia gravis)

• Echoencephlogram (for intracranial brain
  structure detect intracranial structureshave pt
  brain-shampoo hair to remove gel
• MRI magnetic resonance imaging (use of a magnetic
  force)

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Mini Neuro Assessment

• Speech, squeeze hands equally, raise forearms
  against resistance, pupil size and reaction to
  light, push against nurses hands equally with
  feet,raise feet against resistance orientation to
  person, place, time and environment and notate
  response.
• MR F COP

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Prevention of Disorders

• Avoid drugs and alcohol, wear seat belts, safe
  swimming practice, treatment for iv drug abuse to
  prevent hiv transmission prompt treatment of ear
  and sinus infection to prevent brain infections

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Head Injury

• Scalp injuries bleed profusely to blood vessels
  in the scalp wound is cleaned and irrigated,
  object removed if present and scalp is sutured
• Skull Injuries fractures are common

• Open- dura matter is torn
• Closed- dura matter is not torn Symptom of
  fracture is pain

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Head Injury Skull Fx

• TYPES
• Linear a line fracture
• Comminuted the bone is broken into multiple
  fragments
• Depressed when bone depressed into the tissue or
  intracranial cavity

• BasilarBasa the bones at the base of the
  skulldura matter may be torn with cerebral
  spinal fluid leaking from ears or nose. The
  internal carotid and cranial nerves may also be
  damaged

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Battle's Sign - Behind the Ear

• Skull fractures are common in children and
  result from accidents (the majority are
  automobile or auto/bike accidents) or abuse.
  Battle's sign is seen several days following a
  basilar skull fracture. There may have been
  bloody drainage from the ear immediately after
  the fracture occurred.
• Basilar fractures are concerning secondary to
  proximity of the fragile sinus bones and adhesion
  of the dura mater to this area..

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Skull Fracture

• Although the skull is tough, resilient, and
  provides excellent protection for the brain, a
  severe impact or blow can result in fracture of
  the skull and may be accompanied by injury to the
  brain. Some of the different types of skull
  fracture include

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Indications of Head Injury

• Head injury can be classified as either closed or
  penetrating. In closed head injury, the head
  sustains a blunt force by striking against an
  object. In penetrating head injuries, a high
  velocity object breaks through the skull and
  enters the brain. The signs and symptoms of a
  head injury may occur immediately or develop
  slowly over several hours.

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Open Brain Injury

• Injury as skull fracture can hemorrhage from
  the nose, pharynx, ears, or ecchymosis over the
  mastoid area
• Battles sign or blood in conjunctiva cerebral
  spinal fluid can leak from the nose or ears CT
  or MRI done to determine extent of injury
•  

• Deficits depend on area and extent of injury

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Closed Brain Injury

• Caused by blunt force to the head
• Concussion transient deficits caused by shaking
  the brain
• Coup impact of head against an object
• Countercoup impact of brain against the opposite
  side of the head

• Contusion surface bruises of brain often
  unconscious for longer period than concussion, or
  drift back and forth from conscious to
  unconscious Laceration tearing of cortical
  tissue manifestations deep coma from time of
  impact, extension posturing, autonomic
  dysfunction, nonreactive pupils,.

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Concussion

• A concussion may result when the head strikes
  against an object or is struck by an object.
  Concussions may produce unconsciousness or
  bleeding in or around the brain, momentary loss
  of reflexes, resp arrest for several seconds,
  amnesia before and after the event

Concussion
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Hemorrhage

• Epidural hematoma
• Decreased in Neuro status, HAs, seizures,
  hemparesis
• Stop the bleeding and evacuate the clot

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Subdural Hematoma

• Bleeding in subdural space
• May be acute, subacute, or chronic
• Manifestations headache, drowsiness, confusion
• Small hematoma may be absorbed
• Large hematoma needs surgical removal

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Subarrachnoid

• Below the arrachnoid
• Manifestations nuchal rigidity, stiffness,
  inability to bend neck, blood in subarrachnoid
  space
• --Increased intracranial pressure
• Intracranial hematoma with contusion in temporal
  or frontal lobes
• DecreasedLOC, pupil change, VS change

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Intracranial Pressure

• Etiology bleeding trauma
• Causing increasing pressure and pressure on the
  brain stem
• Movement of pressure is supratentorial and can
  result in brain herniation --pressing down on
  brain stem

• Manifestations equal pupils are no longer equal
  one is larger or dilated or blown (fully
  dilated), decreasing heart rate, widening pulse
  pressure and dilating pupil/s, decreasing level
  of consciousness
• Report to MD immediately),

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Abnormal Posturing

• Decerebrate rigid extention of arms and legs
  with wrists turned outwardhas worse prognosis as
  deeper levels of the brain are involved..
• Decorticate flexion of arms and rigid legs

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Brain Injury

• Management
• Reduce intracranial pressure
• Stabilize VS
• Keep temperature stable.
• Oxygen
• IV fluids- osmotic diuretics (Mannitol) to
  rapidly reduce fluid in brain tissue

• Corticosteroids (Decadron) to reduce cerebral
  edema
• Neuro checks
• Foley
• Suctioning may be necessary but is never done in
  the nose on a head injury because it could
  possibly be CSF leakage..

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Intracranial Pressure Catheter
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BRAIN TUMOR

• Space-occupying intracranial lesions, either
  benign or malignant.
• Symptoms differ according to area of lesion and
  rate of growth.
• Manifestations are relative to the functions of
  areas involved (e.g. visual problems resulting
  from occipital lobe tumors)

• Management is based on tumor type, growth rate,
  and assessment of client.
• Also radiation, surgery, chemotherapy

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CEREBROVASCULAR ACCIDENT (CVA)

• A brain attack.
• Can be caused by ischemia from a thrombus,
  embolus, severe vasospasm, or cerebral
  hemorrhage.
• Causes neurological deficits of sensation,
  movement, thought, memory, or speech.
• Loss of function temporary or permanent.

• Transient ischemic attacks (TIAs) are mini
  strokes
• Caused by temporary impairment of blood flow to
  the brain..
• Loss of motor or sensory function may last from a
  few seconds to minutes to 24 hours..

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Stroke
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CVA/TIA

• Documenting clinical manifestations
• Hemiparesis weakness of one side of the body
• Dysarthria difficulty in speaking
• Emotional lability unstable fluctuating
• Homonymous Hemianopia defect or blindness in
  half of the visual field

• Agnosia total or partial loss of ability to
  recognize familiar objects or people
• Unilateral neglect unaware of one side of body
• Teach modification of risk factors
• Have B/P checked annually

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CVA/TIA Management

• Airway maintenance and supportive therapy during
  the first 24 to 48 hours.
• Depending on the location of the CVA and the
  extent of neurologic deficit, collaboration with
  physical, occupational, and speech therapists for
  client to reach the optimal functional level of
  recovery.

• Ca Channel blockers help to dilate blood vessels
  and increaese cerbral perfusion
• B/P meds to control
• Anticoagulents to prevent bllod clots
• Thrombolytics to dissolve clots

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CVA/TIA Management (cont)

• Fluids may be restricted
• IV fluids or tube feedings given (gag reflex
  needs to be checked before po foods are given)
• If embolic or thrombolic stroke HOB is kept flat
  to increase cerebral perfustion

• If hemorrhagic stroke HOB is elevated to decrease
  cerebral perfusion (reduces swelling)
• Footboard
• PROM to affected side