Neurological Handouts
- 2. THE NEUROLOGICAL SYSTEM The neurological system controls body functions and is inter-related to other body systems i.e. a patient with dieabetes may suffer a stroke.
- 3. THE NEUROLOGICAL SYSTEM Because the nervous system is complex, evaluation may be a bit daunting but many of the tests may be routine to any daily nursing assessment When talking to a patient, you are assessing orientation, LOC, and ability to comprehend and express speech and language
- 4. THE NEUROLOGICAL SYSTEM Your knowledge of neuroanatomy and physiology and methods of assessing these, will improve your patient care and outcomes
- 5. THE NEUROLOGICAL SYSTEM The neurological system is divided into three parts Central nervous system (CNS) Peripheral nervous system (PNS) Autonomic nervous system (ANS)
- 6. THE NEUROLOGICAL SYSTEM All physical, intellectual, and emotional activities are coordinated thru complex interactions of these systems
- 7. THE CENTRAL NERVOUS SYSTEM (CNS) The brain The spinal cord
- 8. THE BRAIN The cerebrum or cerebral cortex including the 4 lobes of the brain. The brainstem including the midbrain, pons, and medulla The cerebellum
- 9. THE BRAIN Contains nerve cells, glial cells, blood vessels, and nerve fiber tracts. Contains over 10 billion cells. Receives 20% of cardiac output. Consumes 25% of the total oxygen.
- 10. THE BRAIN Responsible for all higher mental functions, such as thinking, speaking, and mathematical calculation, etc. Controls motor and sensory functions of the body. It is encased in the skull, and is covered by 3 membranes. 1. Dura mater 2. Arachnoid 3. Pia mater NOTE: If blood or fluid builds up in the skull or between the membranes, brain function is compromised.
- 11. LOBES AND THEIR FUNCTIONS Parietal lobe- sensations, awareness of body shape. Occipital lobe- visual stimuli Temporal lobe - hearing, language comprehension, memory Storage, and recall. Frontal lobe - personality, judgment, abstract reasoning, social behavior, language expression, and movement.
- 12. CEREBRAL FUNCTIONS Sensory cortex-body sensation. Motor cortex- body movement Cerebellum-controls balance and coordination
- 13. THE SUB-CORTEX The diencephalon contains: The thalamus - a relay station for sensory and motor impulses including touch, pain, temperature,and plays a role in consciousness, alertness, and attention.
- 14. THE SUB-CORTEX The hypothalamus- regulatory functions of temperature, pituitary hormone production, water balance, appetite, normal body temperature, and helps control reproductive functions.
- 15. THE BRAINSTEM Midbrain-sensory projection tracts and pupillary reflexes and eye movement (CN III & CN IV) Pons-projection tracts and centers for CN V, VI, VIII. Medulla oblongata- upper portion of the spinal tract containing centers for heartbeat, blood pressure, respirations, swallowing and coughing, sneezing, vomiting, and hiccoughing. (CN IX, X, XI, XII)
- 16. CEREBELLUM Newest and most posterior portion of the brain. Facilitates smooth, coordinated movements of the muscles Helps maintain equilibrium and posture. Aids swallowing coordination
- 17. SPINAL CORD Primary pathway for the conduction of impulses from the Peripheral areas of the body, to the brain. Mediates the reflex arch-a protective response that happens Automatically with no mediation by the brain.
- 18. REFLEX ARC A sensory or afferent neuron detects the stimulus, carries the impulses along the axon to the dorsal root where it enters the spinal column. A motor or efferent neuron carries the response along its axon back to the muscle. The response is involuntary.
- 19. CLINICALLY IMPORTANT REFLEXES Knee jerk (patellar) Babinski Corneal Cough
- 20. THE PERIPHERAL NERVOUS SYSTEM (PNS) Includes peripheral and cranial nerves Peripheral afferent nerves transmit stimuli to the dorsal horn of the spinal column. They come from the skin, muscles, sensory organs, and viscera
- 21. THE PERIPHERAL NERVOUS SYSTEM (PNS) The upper motor neurons of the brain and the lower motor Neurons of the cell bodies in spinal cord carry efferent impulses that affect movement. The 12 pairs of cranial nerves are the primary motor and sensory pathways between the brain, head, and neck. Olfactory 11. Hypoglossal Optic 12. Accessory Oculomotor Trochlear Abducent Trigeminal Facial Auditory Glosspharyngeal Vagus
- 22. THE AUTONOMIC NERVOUS SYSTEM Contains motor neurons to regulate the activities of the visceral organs and affect smooth and cardiac muscles and glands. Sympathetic (fight or flight) reaction Parasympathetic- which maintains baseline body functions.
- 23. ASSESSMENT Record patient complaints. Most common are headache, dizziness, confusion, gait disturbances, weakness on one or both sides of the body. Record onset, frequency, what precipitates or exacerbates the problem, previous treatment for the condition. Record past health and family history.
- 24. OTHER QUESTIONS Does light bother your eyes? Do you experience numbness, tingling, tremors, or seizures? Do you have trouble walking, talking, or understanding? Do you have difficulty swallowing, reading, writing, thinking, or remembering.
- 25. AGE VARIABLES Some neurological changes are age related. Diminished reflexes. Diminished vision, hearing, tasting, or agility. Check for medications especially new ones. Check for asymmetry of symptoms
- 26. HEALTH AND FAMILY HISTORY Chronic disease Major illness Injuries or accidents Surgical procedures Allergies Genetic diseases If a patient has a family member that has had a stroke they are 3 times more likely to have a stroke.
- 27. NEUROLOGICAL EXAM Examination begins with the highest level of neurological function and works down to the lowest.
- 28. NEUROLOGICAL EXAM Mental status and speech Cranial nerve function Sensory function Motor function reflexes
- 29. MENTAL STATUS AND SPEECH Remember, you have already received information from your history taking such as how well the patient talks , remembers, and how well they are oriented. Ask questions that require more than a yes or no answer.
- 30. QUESTIONS Name, Mother’s name, date, year. Where are you, where were you born, & how old are you? Why are you here? What did you have for breakfast? Who is the president? Can you count backwards from 20 to 1? Can you spell “world” Can you repeat 2,7,11,14,20…?
- 31. LEVEL OF CONSCIOUSNESS (LOC) * This is the earliest and most sensitive indicator of mental status change. * Terms include: alert, lethargic, stuperous, somnolent, comatose, etc. The Glasgow Coma Scale is a more objective measure of LOC.
- 32. GLASGOW COMA SCALE Response eyes open Spontaneous 4 To speech 3 To pain 2 Absent 1
- 33. GLASGOW COMA SCALE Converses/oriented 5 Converses/disoriented 4 Inappropriate 3 Incomprehensible 2 Absent 1 verbal
- 34. GLASGOW COMA SCALE Motor Obeys 6 Localizes pain 5 Withdraws (flexion) 4 Decorticate (flexion) rigidity 3 Decerebrate (extension) rigidity 2 Absent 1
- 35. GLASGOW COMA SCALE The sum obtained in this scale is used to assess coma and impaired consciousness. Mild is 13-15 points Moderate is 9-12 points Severe is 3-8 points Patients with scores less than 8 are in a coma
- 36. OBSERVATION Observe how the patient is dressed and groomed. Ask family if this is normal. Note how well the patient understands you and your directions. Note if conversation is cogent & sequenced. Note the patient’s judgment and emotional stability.
- 37. CRANIAL NERVE I- OLFACTORY Indicates a disease of the olfactory tract, tumor, hemorrhage, or facial bone fracture. Have pt identify 2 smells such as coffee or cinnamon.
- 38. CRANIAL NERVES II, III, IV, VI, OPTIC, OCULOMOTOR, TROCLEAR, ABDUCENS Visual field defects, tumors, or infarcts. i.e. stroke Pupillary changes-damage to the optic nerve Ptosis
- 39. CRANIAL NERVE V-TRIGEMINAL Look for sensory loss to the face or jaw. Check light touch on cheeks With eyes closed see if pt can identify whip of cotton on forehead, cheek, and jaw. Assess pain at same sites. Have pt clench jaw while you palpate the temporal and masseter muscles
- 40. CRANIAL NERVER VII-FACIAL Look for facial weakness or flattening of nasal labio fold. ie STROKE Have pt identify taste such as sweet/sour; have pt smile, frown, and raise eyebrows
- 41. CRANIAL NEVERS IX & X Glossopharyngeal and vagus Dysphagia or difficulty swallowing from stroke or lesion Listen to pt’s voice, observe for symmetry of palate as at say’s “ah” and assess gag carefully, by touching pharyngeal wall with tongue depressor
- 42. CRANIAL NERVE XI-SPINAL ACCESSORY With hand on cheek have patient turn against your resistance and with hands on shoulders have patient shrug against your resistance.
- 43. CRANIAL NERVE XII Hypoglossal Listen to speech/dysarthria Have pt extend tongue and note deviation Observe for fasiculations and tremors Observe for strength by having pt push tongue against inside of cheek
- 44. SENSORY TESTING Usually performed by neurologist Checking for light touch, pain, vibration, position, and discrimination
- 45. MOTOR TESTING This involves observing the muscles, testing tone and strength, and abnormal movements. Looking for weakness, tics, tremors or fasiculations. Assess pt’s standing, walking, turning, balance, endurance, and any falling. Tics and tremors indicate neurological damage. “ Pill rolling” is seen in parkinson’s “ intention tremors” are seen in cerebellar disease
- 46. ABNORMAL GAITS Hemiparesis is seen in stroke. Ataxic gait is seen in cerebellar lesions Steppage gait is seen in lower motor neuron damage.
- 47. ASSESSING REFLEXES Deep tendon reflexes Superficial reflexes Primitive reflexes
- 48. DEEP TENDON REFLEXES Evaluated when patient is relaxed. Tested from head to toe. Includes: biceps, triceps, patellar, brachioradialis, and achilles Scale: Absent 0 Diminished +1 Normal +2 Increased +3 Hyperactive +4
- 49. SUPERFICIAL REFLEXES Babinski – “feet tickling” abnormal when toe turns up instead of down in an adult Cremastic Tummy tickle
- 50. PRIMITIVE REFLEXES These are reflexes that are abnormal if seen in an adult The include: grasp, snout, sucking, bite, and glabella.
- 51. NEUROPSYCHOLOGICAL ASPECTS OF BRAIN DAMAGE STROKE
- 52. FACT Stroke is the 3 rd leading cause of death in the U.S.A., behind heart disease and cancer.
- 53. FACT Every year 400,000 to 600,000 Americans suffer a stroke
- 54. FACT Stroke claims about 145,000 lives a year
- 55. FACT Stroke is the leading cause of disability among adults.
- 56. FACT The estimated cost to treat stroke ranges from $15.6 to $30 billion
- 57. FACT Currently, more than 3 million people are living with the effects of stroke; 10% if those in long term care facilities
- 58. FACT The death rate from stroke has decreased significantly since 1972
- 59. FACT Modern stroke care can prevent long term disability. Early recognition of risk, symptoms, and fast action if symptoms occur may prevent a serious stroke
- 60. TYPES OF STROKE Cerebral thrombosis Cerebral embolism Subarachnoid hemorrhage Cerebral hemorrhage
- 61. CEREBRAL THROMBOSIS Most common Occurs when a blood clot (thrombus) forms and blocks blood flow in an artery that supplies some part of the brain. 70% to 80% of all strokes
- 62. CEREBRAL EMBOLISM Wondering clot ( an embolus) or some other particle is carried by the blood stream until it lodges in an artery in the brain, blocking flood flow 5%-14% of all strokes
- 63. SUBARACHNIOD HEMORRHAGE Blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and skull 7% of all strokes
- 64. CEREBRAL HEMORRHAGE A defective artery in the brain bursts, flooding brain tissue with blood 10% of all strokes
- 65. DIAGNOSIS OF STROKE Past medical hx Hx of recent events Current physical and neurological condition Imaging tests (CAT scan, MRI, etc.) EEG Blood flow tests (Doppler, DSA)
- 66. SYMPTOMS/WARNING SIGNS Sudden weakness or numbness of face, arm, or leg on one side of body. Sudden dimness or loss of vision Loss of speech, trouble talking, or understanding speech. Unexplained dizziness, unsteadiness or sudden falls. Loss of coordination Confusion (person, place or time) LOC About 10% of strokes are preceded by TIA’s with symptoms lasting less than 5 seconds
- 67. TREATABLE RISK FACTORS high blood pressure Heart disease Cigarette smoking High red blood cell count High cholesterol level Excess alcohol use Obesity Use of oral contraceptives
- 68. UNTREATABLE RISK FACTORS Age Sex Race Family hx of stroke/TIA Previous stroke/TIA Diabetes Asymptomatic carotid bruit
- 69. OTHER RISK FACTORS Geographic area Season and climate Socioeconomic factors Certain kinds of drug abuse Physical inactivity
- 70. MOST COMMON RISK FACTORS High blood pressure Elevated blood cholesterol Abnormal glucose tolerance Left ventricular hypertrophy Cigarette smoking
- 71. ACTIONS TO TAKE FOR STROKE SURVIVAL Get to a hospital immediately by calling 911 Promt medical attention could prevent a fatal or disabling stroke from occurring
- 72. MEDICAL INTERVENTION Lab studies Radiology Tx of symptoms Anti-Coagulation Anti-platelet therapy
- 73. CLOT BUSTING THERAPY Within 3 hours of initial onset. (only for embolic strokes)
- 74. SURGICAL INTERVENTIONS Carotid Endarterectomy
- 75. HOW STROKE AFFECTS BEHAVIOR Left Brain Injury Paralyzed right side Speech-language deficits Slow, cautious behavioral style Memory deficits
- 76. HOW STROKE AFFECTS BEHAVIOR Right Brain Injury Paralyzed left side Spatial-perceptual deficits Quick, impulsive behavioral style Memory deficits Denial of symptoms Attention disturbances Difficulty understanding and using non verbal communication Impaired judgment, sequencing, problem solving, organization, abstract reasoning
- 77. SUB-CORTICAL STROKES Thalamus- difficulty relaying information Amygdala -fear, anxiety, emotional problems Hippocampus -short term memory Hypothalamus -body, temperature, libido, hunger, pleasure, and pain Gasal ganglia - equilibrium, control, body movements Cerebellum - balance
- 78. HOW STROKE AFFECTS BEHAVIOR One side neglect Stroke in General
- 79. NEGLECT Neglect is both a problem with the tactile sensation and proprioception And may include a visual neglect
- 80. STROKE IN GENERAL Paralysis Quality control. General memory deficits Retention span Old vs. new learning Generalization Emotional lability (if redirected pt will stop crying) Depression (a pt does not stop crying when redirected)
- 81. STROKE REHABILITATION Acute care: -Diagnose the stroke -Monitor for other medical problems -Prevent or treat complications -Prevent another stroke
- 82. REHABILITATION TYPES: Hospital programs Nursing home programs Outpatient programs Home based programs
- 83. GOALS OF REHABILITATION Functional mobility Self care Adaptations for former activities and life style Education Team philosophy Focus on discharge planning
- 84. RETURN TO COMMUNITY Making appropriate plans and arrangements Return to previous lifestyle
- 85. COMMUNITY RESOURCES Stroke information Support groups Home health services Daycare Meal delivery Transportation
- 86. COMMUNITY RESOURCES Companion services Housing options Other
- 87. REVIEW * Stroke is a life threatening event in which the brain’s vital supply of oxygen is disrupted. 4 types of strokes – thrombosis, embolism, subarachnoid, and cerebral hemorhages How the diagnosis is made. Hx, physical, and testing which includes CAT Scan, MRI, etc
- 88. STROKE SURVIVAL Call 911