NURSING OF ADULTS 111

1. NURSING OF ADULTS 111 Introduction to Neurological Nursing

2. 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

3. CENTRAL NERVOUS SYSTEM • 1. Spinal cord (automatic motor responses—pathways 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--constriction of pupil, promotes digestion, slows heart rate

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

6. Motor cortex Sensory area (pain, touch, etc.) Written speech Visual interpretation area Motor speech Visual receiving area Auditory receiving area Auditory interpretation area FUNCIONAL AREAS OF THE CEREBRAL CORTEX Parietal Lobe Frontal Lobe Occipital Lobe Temporal Lobe Brain Stem Cerebellum

7. 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

8. 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.

9. 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 Wernicke’s area causes the inability to understand spoken or written language or recognize music.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

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

16. 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

17. Cognitive and Perceptual Disorders • Assessment of the Neurologic System

18. 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, Huntington’s • Psychosocial History – personality changes, sleep patterns, stressors, exposure to chemicals, pesticide (Agent Orange)

19. 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

20. Neurologic System: Physical Exam • Head, Neck, and Back • Inspection – • raccoon’s eyes – basal skull fx (look for CSF from nares) • Battle’s 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

21. Neurologic System:Physical 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

22. 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.

23. 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

24. Abnormal Reflexes Babinski’s Reflex Jaw Reflex Palm-Chin Reflex Clonus Snout Reflex Rooting Reflex Sucking Reflex Grasp Reflex Chewing Reflex Neurologic System: Physical Exam

25. 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

26. 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

27. 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

28. 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

29. Neurologic System: Diagnostic Tests • Invasive • Lumbar Puncture • Myelography • Cisternal Puncture • Cerebral Angiography • Cerebral Perfusion Studies

30. Neurologic System:Diagnostic Tests • Noninvasive Tests of Function • Electroencephalogram • Evoked Potential Studies • Neuropsychological Testing • Invasive Tests of Function • Caloric Testing • Peripheral Nerve Studies • Muscle Biopsy • Cellular Assessment

31. CONSCIOUSNESS • … is a state of general awareness of oneself and environment. • Consciousness has two components: • 1. Arousal (wakefulness): concerned with the person’s 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?

36. Stages 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vasodilation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

41. 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

42. 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

43. ASSESSING CONSCIOUSNESS

44. 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

45. GLASGOW COMA SCALE SCORE (GCS) Eyes1 Closed at all times 2 Opens to pain 3 Opens to voice command 4 Open spontaneously Motor1 No response 2 Extension (decerebrate rigidity) 3 Flexion posturing 4 Flexion withdrawal 5 Localizes painful stimulus 6 Obeys commands Verbal1 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

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.

48. 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.