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BRAIN STEM
The brain stem consists of the midbrain, pons and medulla
oblongata:
MIDBRAIN- connects the pons and cerebellum with the
cerebral hemispheres, it contains sensory and motor pathways
and serves as the center for auditory and visual reflexes.
Cranial nerves III and IV originate in the midbrain.
PONS is situated in front of the cerebellum between the
midbrain and the medulla and between medulla and the
midbrain. Cranial nerves V through XIII originate in the pons.
Portion of pons help regulate respiratory system
Medulla-control cardiac rate, BP, respirators and swallowing
CEREBELLUM
Has two hemispheres
Coordination of skeletal muscle activity, maintenance of balance,
posture and control of voluntary movements
CEREBROSPINAL FLUID
- Is a clear and colorless fluid that is produced in the choroid plexus of
the ventricles and circulates around the surface of the brain and
spinal cord.
- It is important in immune and metabolic functions in the brain. It is
produced at a rate of about 500ml/day.
- The CSF may also be tested for immunoglobulins or presence of
bacteria.
CRANIAL NERVES
- It innervate the head, the neck and special structures. There are 12
pairs of cranial nerves emerge from the lower surface of the brain
and pass through openings in the base of the skull
Cranial Nerves
I. Olfactory
II. Optic
III. Oculomotor
TYPE
Sensory
Sensory
Motor
IV. trochlear
V. trigeminal
Motor
Mixed
VI. abducens
VII. facial
Motor
Mixed
VIII. acoustic
IX.
glossopharyngeal
Sensory
Mixed
X. Vagus
Mixed
XI. Spinal
accessory
XII. hypoglosal
Motor
Motor
FUNCTION
Sense of smell
Visual acuity and visual fields
Muscles that move the eye and
lid, papillary constriction, lens
and accommodation
Muscle that move the eye
Facial sensation, corneal reflex,
mastication
Muscles that move the eye
Facial expression and muscle
movement, salivation and tearing,
taste, senasation in the ear
Hearing and equilibrium
Taste sensation in the pharynx
and tongue and pharyngeal
muscles, swallowing
Muscles of the pharynx, larynx
and soft palate, sensation in
external ear, pharynx, larynx,
thoracic and abdominal viscera,
parasympathetic innervations of
thoracic and abdominal organs
Sternocleidomastoid and
trapezius muscles
Movement of the tongue
Parasympathetic
Effects
Constricted
Sympathetic
Effects
Dilated
Decreased
Increased
constricted
No direct effect
No direct effect
Dilated
dilated
Constricted
Decreased
Increased
constricted
Decreased
Dilated
Increased
Increased
Decreased
Relaxed
Contracted
No direct effect
Increased
Contracted
Relaxed
Relaxed, variable
Relaxed
Contracted
Contracted
under
No direct effect
some conditions;
varies
with
menstrual
cycle
and pregnancy
No direct effect
Increased
Contracted
(goose-flesh)
Secretion
of
epinephrine
and
norepinephrine
Effect organ
Sympathetic
Parasympathetic
Heart
Lungs
Relaxation
Contraction
Decreased Contraction
Increased
GIT
Motility
Tone sphincters
Relaxation
Urinary bladder
Bladder muscle
Sphincter
Liver
Relaxation
Contraction
Contraction
Relaxation
Glycogenolysis
None
Neurodiagnostic
Examination
Skull Films
x -ray visualization of the skull. It confirms skull fracture
remove metallic items from hair
Spine Films
X-ray visualization of the spine
Avoid flexion/rotation of spine when fracture is suspected
CT scan
Electroencephalography
Graphical recording of spontaneous electrical impulses of the
brain from scalp electrodes
Hair shampoo to remove oil/sprays- for better transmission of
electrical impulses of the brain
Avoid caffeine and other stimulants, anticonvulsants for at
least 24 hours. These substances affect electrical activities of
the heart
Wash hair after the procedure to remove EEG paste
Electricomyography (EMG) and Nerve conduction velocity
Emg records electrical activities in muscles at rest, during
voluntary contraction and in response to electrical stimulation
May be with mild discomfort due to the needles
Brain scan
Involves administration of radionuclide
Cerebral angiography
Intrarterial injection of contrast medium with simultaneous
radiographs of head and neck to visualize intracranial and
extracranial vessels
May experience hot. Flushing sensation as dye is injected
Remove metallic clips from hair
Check allergy to iodine or seafoods
Observe arterial puncture site for bleeding or hematoma.
Observe for any for any change in neurological status: due to
embolus, thrombus or vasospasm may at risk of ischemia
Bed rest may have head elevated for 6 to 8 hours. If femoral
puncture, must keep leg extended and immobile for several
hours to prevent dislodgement of clot
NEUROLOGIC ASSESSMENT
I. Comprehensive History Taking
Demographic Data
Current health
Past health history
Medication history
Growth and development
Family health history
Psychosocial history
II. V/S
III.Mental Status Assessment
LOC
Orientation
Memory
Mood/affect
Intellectual performance
Judgment/Insight
Language/communication
Steppage gait (client drags or lifts foot high, then slaps foot onto
floor; inability to walk on heels; disease of LMN
Sensory ataxia (client walks on heels before bringing down toes and
feet are held wide apart; gait worsens with eyes closed
Parkinsonian gait (stooped over position while walking with
shuffling gait with arms held close to the side)
Rombergs test (Positive)- With feet approximated, the patient
stands with eyes open and then closed; if closing the eyes
increases the unsteadiness, a loss of proprioceptive control is
indicated
REFLEX
Hyperactive: reflexes
Decreased reflexes
Clonus of foot (Hyperactive, rhythmic dorsiflexion and plantar
flexion of foot)
Superficial reflexes (such as abdominal) and cremasteric reflex
Positive Babinski reflex (dorsiflexion of big toe)
Special Neurologic Assessment
Increased ICP
Stroke, hematoma, intracranial hemorrhage
Tumors
Infections
Demyelinating disorders
Hypoglycemia
F/E imbalance
Accumulated waste products from liver or renal failure
Drugs affecting CNS: alcohol, analgesics, anesthetics
Seizure activity: exhausts energy metabolites
Level of Consciousness
Alert
Lethargic-very sleepy
Obtunded
Stuporous
Coma
Death
Oriented
Confused
Utters inappropriate words
Incomprehensible words
None
Obeys command
Localizes pain
Withdraws with painful stimuli
Flexion (Decorticate posturing)
Extension (Decerebrate posturing
None
3-15
14 no impairment
3 compatible with brain death
7 state of coma
COMA
NURSING DIAGNOSIS
Ineffective airway clearance: limit suctioning to <10-15
seconds, hyperoxygenate
Risk for aspiration
Risk for impaired skin integrity: preventive measures, continual
inspection
Impaired physical mobility: maintain functionality of joints,
physical therapy
Risk for Imbalanced Nutrition: Less than body requirements
Anxiety (of family)
Inability to move
Objectivity
A. Early symptoms of spinal shock
Absence of reflexes below level of lesion
Flaccid paralysis below level of injury
Hypotonia results in bowel and bladder distention
Inability to perspire in affected parts
Hypotension
B. Later symptoms of spinal cord injury
Reflex hyperexcitability
State of diminished reflex hyperexcitability below site in all
instances of cord damage following hyperreflexia
In total cord damage-loss of motor and sensory function is
permanent
Sacral region-atonic bladder and bowel with impairment of
sphincter control
Lumbar region- spastic bladder and loss of bladder and anal
sphincter control
Thoracic-trunk below the diaphragm
Cervical-from neck down, if above C4 respirations and depressed
In partial cord damage, depends on the type of neurons affected
(spastic vs. flaccid)
Clinical manifestations:
Paralysis of muscles of respiration
Bradycardia
Hypotension
Urinary retention
Hypomotility
Muscle atrophy
Poikilothermia-abnormality in sensing change in temperature
The type of injury refers to the extent of injury to the spinal cord
itself.
Muscle Functioning
remaining
Cervical, above
C4
None
C5
C6-C7
Thoracic
Lumbo-sacral
Legs
Laminectomy
Autonomic dysreflexia (after spinal shock resolves)
Exaggerated autonomic response to stimuli: such as distended
bladder or bowel (e.g. pain)
Severe hypertension
Headache
Flushed skin
Diaphoresis
Nasal Congestion
Management:
emergency management: any patient who is involved in a motor
vehicle crash, a diving orcontact sports injury, a fall,or any direct
trauma to the head and neck must be considered to have SCI. Initial
Medical Management
ImmoblizationGardner well tongs, halo external fixation
Maintenance of heart rate (Atropine) and BP (dopamine)
vasopressors
Methylprednisolone therapy
Insertion of NGT
Intubation, if needed
Indwelling urinary catheter
Stress ulcer prophylaxis (Proton-pump inhibitos, H2 blockers)
Physical therapy
Cerebral embolus-moving
Cerebral thrombus
Cerebral hemorrhage
Risk Factors
Prior ischemic episodes
Cardiac disease
DM
Atherosclerotic diseasae
Hypertension, hypercholesterolemia
Polycythemia
Smoking
Oral contraceptives
Emotional stress
Obesity
Family history of stroke
Age
Warning signs that may precede CVA
Paresthesia
Transient loss of speech
Hemiplegia
Severe occipital or nuchal headaches
Vertigo or syncope
Motor or sensory disturbances (tingling transient paralysis)
Epistaxis
CLINICAL MANIFESTATIONS
Numbness or weakness of the face, arm, or leg especially on one
side of the body
Confusion or change in mental status
Trouble speaking or understanding speech
Visual disturbance
Difficulty walking, dizziness or loss of balance or coordination
Sudden severe headache
******** motor, sensory, cranial nerve, cognitive and other functions may
be disrupted
SPECIFIC DEFICITS
Dependent upon area damaged
Hemiplegia
Aphasia
- sensory/receptive-Wernicks aphasia
- motor/expressive-Brocas aphasia (able to understand the
stimuli but cannot express
Global aphasia
- Agnosia
- Dysarthria
- Incontinence
- Horners syndrome-decrease lacrimation
- Unilateral neglect
Medical management
Decreased ICP
BP management
Fluid volume management
Tissue plasminogen activator-must be given within 3 hours of onset
of manifestations and will dissolve clot; recombinant altephase
(Activase rt-pa)
Antithrombotic (aspirin, clipyridamole)-prevent platelet aggregation
Anticoagulant (heparin, clexane)
Steroids or osmotic, diuretics
Antihypertensive and diuretics
Nursing management
Prevention of injury
- eyes-normal saline, artificial tears, eye patch
- side rails up
- decubitus ulcer prevention/management
- Oral mucosa care
Nutrition/prevention of aspiration
- Communication
- Others:
Reorientation
Minimize environmental stimuli
Emotional support
Rehabilitative
Discharge care
Medications:
a. Manage but do not cure seizures- suppresses the abnormal
electric impulses from the seizure focus to toher cortical areas,
thus preventing the seizure but not eliminating the cause of
the seizure
Ex. Hydantoins- dialntin
Barbiturates- phenobarbital
Benzodiazepines- diazepines
Iminostilnes- carbamazepine
Key Interventions:
1. Stay with the client
2. Protect client from injury
Put padded side rails
If the client sitting or standing, ease him upto onto the floor.
Protect head with small pillow or place the head onto the lap
Do not apply restraints
emotional
Collaborative management:
patch the eye alternately for diplopia
provide- well balanced diet, high in fiber to prevent constipation
Myasthenia
Gravis
Disturbance in the transmission of impulses at the myoneural
junction resulting in profound weakness (muscle of the eyes, eyelid,
chewing, swallowing, speaking and breathing)
Believed to be due to reduced acetylcholine receptors due to
destruction and blockage attributed to autoimmune process
An autoimmune disorder, characterized by varying degrees of
weakness of the voluntary muscles (Smeltzer & Bare, 2004, p. 1956)
Highest in young adult females.
Manifestations
Extreme muscle weakness, worsens as the muscle is used but
disappears with rest
Dysphagia, drooling
Diplopia (double vision)
Dysarthria
Ptosis of the eyelid (both eyes), strabismus
Myasthenia smile (nasal smile)snarl smile, mask like facial
expression
Impaired speech
Respiratory difficulty
Note:
Myasthenia gravis is purely a motor disorder with NO effect on
sensation or coordination
Diagnostic Test
Cholinergic Crisis
Caused by Overdosage of anticholinergic drugs
May mimic the symptoms of exacerbation
Interventions- discontinue all cholinergic drugs until cholinergic
effects decrease, adequate ventilation, 1mg atropine sulphate
Note:
TRIGEMINAL NEURALGIA
Tic Doulorex
Is a sensory disorder of the 5th cranial nerve
It is manifested by excruciating, recurrent paroxysms of sharp,
stabbing facial pain along the trigeminal nerve (lips,gums, nose,
cheeks)
Pain aggrevated by cold, washing th efface, chewing, hot or cold
foods and fluids, touch of wind on the face
Collaborative management for the client with trigeminal neuralgia
are as follows:
Instruct the client to avoid hot or cold foods and beverages
Provide liquidsand soft foods
Instruct client to chew food on the unaffected side
Pharmacotherapy:
a) Elavil (amitriptyline)
b) Lioresal (baclofen)
c) Tegretol (Carbazepine)
d) Valium (diazepam)
e) Dilantin (phenytoin)
Surgery- alcohol injection of the nerve
Neurectomy
ICP
Increased blood volume, increased brain volume, increased CSF
volume
Normal pressure: 5-15 mmHg, with pressure tranducer with head
elevated 30; 60-180 cmH20, water manometer with client
lateral recumbent
Sustained increases associated with:
a. Cerebral edema
b. Head trauma
c. Tumors
d. Abscesses
e. Stroke
f.
Inflammation
g. Hemorrhage
Factors that Increases ICP
Hypercapnea, hypoxemia
Cerebral vasodilating agents
Valsalva maneuver; coughing or sneezing
Body positioning (prone, neck flexion, extreme hip flexion)
Isometric muscle contraction
ICP
Cranial insult
Tissue edema
Increased ICP
Increased ICP
DEATH
Manifestations:
Restleness- initial sign of increased ICP