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The function of the nervous system is to control all motor, sensory & autonomic functions of the body. Divided into: Central Nervous System (CNS) Consisting of the brain and spinal cord. Peripheral Nervous System (PNS) Cranial nerves (12) and spinal nerves (31) Autonomic Nervous System Sympathetic Division: fight or flight response Parasympathetic Division:
CNS:The Brain
The brain controls, initiates and integrates all body functions.
Composed of both gray matter and white matter. Protective Mechanisms:
Skull (cranium): Bony container surrounding the brain Meninges: Three additional layers of protection Dura mater, arachnoid mater & pia mater
Head Injuries
Head Injury
Broad term to classify sudden trauma to head, which includes injuries sustained to the scalp, skull or brain. Most common causes:
MVA: motor vehicle collisions (50%) Falls (21%) Violence (12%) Sports related-injuries (10%)
The most serious type of head injury is traumatic brain injury (TBI)
TBI: Pathophysiology
Primary Injury
Initial damage to the brain that results from the traumatic event.
Secondary Injury
Additional damage to the brain tissue occurring minutes to hours after the initial traumatic event. As a result of the cellular changes that occur with cerebral edema, ischemia and hemorrhage.
Scalp Injury
Very vascular Can distract from more serious injury What about brain and neck???? Bleeding usually NOT enough to cause hypovolemic shock. Exceptions: Children, arterial
Cerebral Concussion
Head injury with temporary loss of neurological function with no structural damage.
Cause: jarring of the brain results in temporary disruption of synaptic activity; often occurs with acceleration-deceleration injuries.
Clinical Manifestations:
Loss of consciousness; usually brief Amnesia regarding events immediately prior to injury
Postconcussion Syndrome
Usually occurs within 24 to 48 hours after injury and may present up to several months later, but will subside in time. S/Sx: HA, lethargy, irritability, memory deficits, dizziness & insomnia
Cerebral Contusion
Bruising of the brain tissue; actual structural damage visible on diagnostic testing (i.e. CT scan).
Often caused by deformation or acceleration-deceleration injuries (often two focal areas of bruising)
Clinical Manifestations
Loss of consciousness (more than brief) Vary depending on the location & size of contusion
Secondary injury is possible (i.e. hemorrhage or cerebral edema) the client must be monitored closely for increased ICP.
Clinical Manifestations:
+ LOC after initial trauma; usually at the location of injury Lucid interval (30-50% experience) Rapid deterioration in neurologic status; S/Sx of ICP
Management
Medical emergency requiring immediate medical and surgical intervention (i.e. craniotomy).
Interacerebral Bleeding
Cushings Triad:
Systolic HTN (widening pulse pressure) Bradypnea Bradycardia (bounding, slow pulse)
Small pupils (< 3mm); sluggish responses to light Vomiting (maybe projectile)
bilateral)
Ataxic Respirations
Stage V (Death)
Brain Death
Complete, irreversible cessation of function of the entire brain and brain stem.
Brain Tumors
Space-occupying intracranial lesions
Benign or malignant.
Clinical manifestations differ according to area of lesion and rate of growth Common Signs / Symptoms:
Alterations in consciousness Neurologic deficits
Motor & Visual Disturbances
Reflex Arc
Interneurons connecting sensory & motor fibers.
Dermatomes
Sensory depiction of the corresponding spinal nerves
Cranial Nerves
The neurological exam performs many tests at the head of the patient. These are to test if Cranial Nerve function is intact. The exam tests the twelve Cranial Nerves:
I - Olfactory / Smell II - Optic / Vision III - Oculomotor / Eye Movement & Pupil Size IV - Trochlear / Eye Movement V - Trigeminal / Facial Sensation VI - Abducens / Eye Movement VII - Facial / Facial Motor - Expressions VIII - Acoustic / Hearing - Balance IX - Glossopharyngeal / Swallowing X - Vagus / Swallowing - Heart Rate XI - Spinal Accessory / Shoulder & Neck Movement XII - Hypoglossal / Tongue Movement
Cranial Nerves
PNS Injuries
Spinal Injuries
Spinal Nerves
Quad
Para
Neurological Assessment
Health History General Signs & Symptoms Physical Examination Considerations
Level of Consciousness Motor Function Pupillary Function / Eye Movements Vital Signs
Respiratory Patterns
Consciousness:
Composed of Two Components:
Arousal (Alertness) Awareness (Content)
Assessment: Orientation vs. Disorientation Person, Place & Time Varying sequence of questions is important !!
Categories of Consciousness
Alert:
Responds immediately to minimal external (visual, tactile or auditory) stimuli.
Lethargic:
A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish.
Obtunded:
Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting) ; verbal responses include one or two words, but will drift back to sleep without stimulation.
Categories of Consciousness
Stuporous:
Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning).
Comatose:
Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful (light coma) or non-purposeful or absent (deep coma).
Assessing LOC
Glasgow Coma Scale (GCS)
Three Categories:
Eye opening Best motor response Best verbal response
Scoring
Highest or best possible score 15 A score of < 8 indicates coma Lowest or worst possible score 3
Pupillary Examination
The pupillary examination can be quickly and easily performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBIs may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patient's condition and administer or advocate for immediate interventions.
Check pupil size in lighted room, and reactivity to light in a darkened room.
Rapid interventions are needed to prevent death or permanent brain damage TBIs can progress rapidly!
CN IV Trochlear:
moves eyes down and in..
EOMs:
(extraoccular movement)
CN V Trigeminal:
3 branches; sensation to the face, cornea and scalp; opens jaw against resistance
CN VII Facial:
moves the face; taste.
CN VII paralysis
CN VIII Acoustic: 2 branches, acoustic (hearing) and vestibular (balance) CN IX Glossopharyngeal: moves the pharynx (swallow, speech & gag) CN X Vagus: voice quality
CN XI Spinal Accessory:
turns head and elevates shoulders
CN XII Hypoglossal:
moves tongue
Shoulder Shrug
Assessment Tip:
Test CN IX, X, XII all at once: Test gag, swallow and speech together..
CN Tips:
observe for nystagmus with EOMs (2-3 beats normal with lateral gaze). diplopia (double vision): cover one eye, should clear if sixth nerve palsy (offer eye patch over good eye).
Motor Examination
Motor Exam: use the motor grading scale to maintain objectivity and eliminate confusion 5/5: strong against resistance 4/5: weak against resistance 3/5: overcomes gravity; offers no resistance 2/5: cannot overcome gravity; moves with gravity eliminated 1/5: contracts muscle to stimulus 0/5: no muscle movement Assess hand grips for strength and equality.
Drift Assessment
Drift Assessment: test for motor weakness
Arm: hold arms out with palms up; eyes closed Pronator drift: hands pronate (roll over); Motor drift: arm drifts downward Cerebellar drift: arm drifts back toward head or out to side
Movement Assessment
Movements are purposeful or non-purposeful
purposeful: picking at tubings or bed linens, scratching nose localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortex withdrawal: pulling away from pain; occurs in the hypothalamus non-purposeful: do not cross the midline abnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem abnormal extension: (decerebrate) Decorticate rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. Decerebrate
Trapezius Pinch
Abmornal Reflexes
Abnormal Reflexes:
Babinski: initial inflection of great toe in response stroking of sole; upgoing toe is abnormal Grasp: involuntary grasp in response to stimulation of palm; abnormal in an adult Dolls eyes: impairment of eye movement to opposite side when head is turned = damage to brainstem; no movement = loss of brainstem
Speech Patterns
Note: speech patterns, fluency, word usage ability to follow 1 or 2 step commands (must cross the midline) ability to name common objects and their use. Aphasia: a disorder in processing Language: Apraxia of speech: disorder in programming of speech (dominant hemisphere) Dysarthria: disorder in mechanics of speech (cranial nerve weakness)
Brain Teaser
Brain Teaser
a) b) c) d) a) b) c) d)
a) b) c) d)
a) b) c) d)
a) b)
c) d)
spine and spinal cord most likely will result in the following condition: Hemiplegia Quadraplegia Paraplegia Contralateral paralysis 8. Any suspected head, neck or spine injured victim should immediately be given spinal immobilization precautions, except: When the victim complains of pain only upon turning his head to one side. When the victim refuses to allow spinal immobilization even after listening carefully to multiple attempts to explain the dangers and risk involved. When the victim is intoxicated on alcohol and cannot speak clearly. When the victim was never unconscious and denies any pain.
a)
b)
c)
d)
9. When assessing a patient with altered LOC, you feel his state of awareness/arousal is best described as Obtunded, this means: Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting); verbal responses include one or two words, but will drift back to sleep without stimulation. A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish. Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning). Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful
a) b) c) d) a) b) c) d) a) b) c) d)
10. The Glasgow Coma scale tests for three kinds of responses, they are: Eye Opening Motor Response Verbal Response Auditory Response 11. The best and worst possible score on the GCS is: 15 and 0 13 and 3 15 and 3 18 and 5 12. When assessing pupillary response, you are looking for the following conditions except: Coordinated eye movement and bilateral blinking. Reactivity to and accommodation to light. Symmetry of pupils and accommodation to light. Abnormal pupil shape.
a) b) c) d) e) a) b) c) d)
a) b) c) d)
13. A constricted pin point pupil indicates: (best answer) Brain Stem herniation Cardiac Arrest Cerebral Infarction of the parietal lobe Cerebral Infarction of the occipital lobe A wide variety of conditions, some being extremely life threatening. 14. What Cranial nerve(s) controls the movement of the eyes down and in? CN VI Abducens CN III Oculomotor CN IV Trochlear CN II Optic 15. The Motor strength scale goes from 0/5 to 5/5, 0 being no strength at all and 5 being normal strength. A person with a motor strength of 4/5 would be: overcomes gravity; offers no resistance strong against resistance weak against resistance no muscle movement
16. Match the following postures with its definition: Decerebrate_____________ Decorticate______________
a) Abnormal flexion: rigidly flexed arms and wrists; fisted hands; occurs in upper brainstem b) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists and fisted hands; occurs in midbrain or pons. 17. The Babinski reflex is the initial inflection (extension) of great toe in response stroking of the sole of the foot, select the correct answer: a) An upgoing great toe is abnormal. b) An upgoing great toe is normal. c) An upgoing great toe is abnornal in adults. d) An upgoing great toe is normal in infants.