Module 11 - Neurological System Portion Flashcards
The nervous system is like the ___ of the body
Switchboard operator of the body (it processes, filters, and automatically/voluntarily routes messages)
3 Major Functioning Units of the Nervous System
- Spinal Cord Level
- Brain Stem and Subcortical Level
- Cortical Level
What is the spinal cord level
the lowest functional level of NS
controls automatic motor responses (reflexes)
What is the brain stem and subcortical level
controls BP, respiration, equilibrium, and primitive emotions
What is the cortical level
Responsible for cognition
Central nervous system
brain and spinal cord
network of coordination and control of the body
Peripheral nervous system
cranial nerves, spinal nerves, ANS (SNS+PNS)
motor and sensory nerves and ganglia outside the CNS which carries information to and from the CNS
How many pairs of cranial nerves are there
12
How many pairs of spinal nerves are there
31
Spinal nerves are ___ nerves
somatic (they innervate voluntary muscles)
Why do we avoid palpating or taking carotid pulse in non-emergency situations?
to not trigger baroreceptors in the brain
How much blood supply does the brain get
15 to 20% of the total cardiac output goes to the brain
What brings blood to the brain
The Basilar Artery
It is made from the 2 internal carotid arteries and 2 vertebral arteries joining together
3 Major Units of the Brain
Cerebrum
Cerebellum
Brainstem
Cerebrum
2 Hemispheres divided into lobes
Gray Matter of the Cerebrum
Outer layer (of the cerebral cortex)
made up of cell bodies
Controls higher mental function, general movement, visceral functions, perception, behavior, and integrates these functions
White Matter of the Cerebrum
Nerve fibers and myelin (heavily myelinated)
Bulk of it is in the inside of the cerebrum
Disorders associated with White Matter
Multiple Sclerosis
CMV
Encephalitis
Folate or Vit-B12 Deficiency
Vasculitis
PKU (Phenylketoneuria)
Frontal Lobe
Lobe of cerebrum
Responsible as a motor cortex, and for voluntary skeletal movement and fine repetitive motor movements and eye movements
Has impact on intellect and emotion and higher order processing
Brocas Area and Motor Cortex in this lobe
Parietal Lobe
Lobe of cerebrum for processing sensory data
Assists in interpretation of tactile, visual, olfactory, gustatory, and auditory sensations; recognition of body parts and position; and acts as a communicator between sensory and motor areas of the brain
Somatosensory cortex here
Occipital Lobe
Primary vision center lobe of the cerebrum
provides interpretation of visual data and gives the ability to read and understand
Visual cortex here
Temporal lobe
Perception and interpretation of sounds along with determination of source, integration of taste/smell/balance/reception/interpretation of speech
Wernickes Area and Auditory cortex here
Works with the cerebellum to control balance
Broca’s Area
Area of frontal lobe responsible as the motor area of speech
If broca’s aphasia occurs here they cannot speak correctly
Wernicke’s Area
Area of the temporal lobe responsible for reception and comprehension of language/speech
If there is damage here the person can speak, but speaks nonsensically
Cerebellum
- Works with motor cortex for integration of voluntary movement
- processes sensory info from eyes, ears, touch receptors
- Works with vestibular system for reflexive control of muscle tone, equilibrium, and posture to produce steady and precise movements (BALANCE)
The cerebellums main functions are ___ and ___
balance and coordination
Potential Causes of Cerebellum Disorders and Symptoms?
Causes: Congenital issues, hereditary ataxia, acquired conditions
Symptoms: vary but typically include ataxia
Ataxia
impaired muscle coordination
Brainstem
pathway between spine and brain
controls many involuntary movements (like cardiac and resp)
Nuclei here have 12 cranial nerves
Has a reticular formation running through it, and is mostly made of 3 main parts
3 Main Parts of the Brainstem
Midbrain
Pons
Medulla Oblongata
What does the reticular formation do
Contains a network of fibers for muscle stimulation
Main functions of the brainstem
Counteract gravitational forces
Regulate cardiac and resp systems
Maintain consciousness
Medulla Oblongata
Contains CN IX -XII
Controls respiration, circulation, vasomotor activities, houses the respiratory center.
Controls reflexes like: swallowing, coughing, vomiting, sneezing, hiccupping
Pons
Contains CN V-VIII
Regulates respiration, houses a portion of the respiratory center, controls voluntary muscle action
Midbrain
Contains CN III and IV
Reflex center for eye and head movement
Auditory Relay pathway
Diencephalon
Includes the hypothalamus, thalamus, and pituitary glands
Contains CN I and II
It relays info between the cerebrum, cerebellum, pons, and medulla (all sensory impulses except olfactory)
Also responsible for consciousness, perception of sensation, and abstract feelings
What sense does the thalamus/Diencephalon NOT relay?
Olfactory (scent)
Purpose of the Thalamus
perception of pain
temperature control
Purpose of Epithalamus
A pineal body for sexual development and behavior
Purpose of Hypothalamus
Major processing center of stimuli for the ANS
Maintains TEMPERATURE control, H2O metabolism, body fluid osmolarity, feeding behavior, neuroendocrine activity
Purpose of Pituitary Gland
HORMONAL GROWTH CONTROL
lactation
VASOCONCSTRICTION
metabolism
Severe Brainstem injuries can lead to …
Decerebrate and Decorticate Posturing
Decerebrate Posture
arms and legs extended
toes pointed downward
head and neck arched backwards
muscles rigid
Usually indicates severe brainstem damage
Decorticate Posture
arms flexed
clenched fists
extended legs held straight out
Arms bent inward toward the body with wrists and fingers bent and held to chest
muscles rigid
What is more ominous, decerebrate or decorticate posturing?
Both are dangerous, but Decerebrate is more ominous (since its association with brainstem injury)
Spinal Cord Length
40 to 50 cm
What constitutes the spinal cord?
Fibers grouped into 2 tracts that run carrying sensory (afferent), motor (efferent), and automatic impulses between brain and body
there are 31 spinal nerves covered in myelinated white matter making ascending and descending tracts with gray matter nerve cell bodies
How are the gray matter cell bodies organized in the spinal cord?
In a butterfly shape for the anterior and posterior horns
Ascending Tract
carries SENSORY (Afferent) data to the brain
mediates and facilitates sensation like complex discrimination to touch, pressure, vibration, joint positions, and two point discrimination
Descending Tract
Carries MOTOR (Efferent) impulses from the brain to the body
Impulses conveyed to various muscle groups by inhibiting or exciting spinal activity
Sympathetic System is ___ or ___
Fight or Flight
Parasympathetic System is ___,___,___
Feed breed rest
ANS
Autonomic NS which controls body functions not directly monitored
Somatic NS
Deliberate actions / voluntary muscle movement
CN I
Olfactory Nerve
Sense of Smell
CN II
Optic Nerve (NOT Peripheral NS!)
Vision
CN III
Oculomotor Nerve
Upward, downward, medial eye movement, lid elevation, pupil constriction
CN IV
Trochlear Nerve
Eye movements downward and medial
CN V
Trigeminal Nerve
Somatic Sensation of face, mouth, cornea
Muscles of Mastication
CN VI
Abducens Nerve
Eye movements laterally
CN VII
Facial Nerve
Controls facial expression muscles and anterior taste of tongue
Salivation, scalp, facial movement, lacrimation
CN VIII
Acoustic Nerve
Cochlear hearing (and balance)
CN IX
Glosso-pharyngeal nerve
External ear, taste posterior 1/3, carotid reflexes, sinus, baro and chemoreceptors
Gag reflex, swallow reflex, salivation
CN X
Vagus Nerve
external ear, pharynx, swallow, pronation, bronchoconstriction, gastric secretion, peristalsis
CN XI
Accessory Nerve
Swallow, pharyngeal muscles, head turn, shoulders rise
CN XII
Hypoglossal nerve
tongue movements
What type of nerve is CN I
S
What type of nerve is CN II
S
What type of nerve is CN III
M
What type of nerve is CN IV
M
What type of nerve is CN V
S and M
What type of nerve is CN VI
M
What type of nerve is CN VII
S and M
What type of nerve is CN VIII
S
What type of nerve is CN IX
S and M
What type of nerve is CN X
S and M
What type of nerve is CN XI
M
What type of nerve is CN XII
M
The weber and rinne tests are important for which cranial nerve
CN VIII
The 5 Sense are controlled by which Cranial Nerves
I - olfactory
II - Optic
III - Oculomotor
IV - Trochlear
VI - Abducens
All responsible for smell, vision, pupillary constriction, extraocular movement
What cranial nerves control taste?
VII - Facial
IX - Glossopharyngeal
What cranial nerve controls hearing?
VIII - Acoustic
What cranial nerve controls sensory innervation to face, teeth, tongue, eyes?
V - Trigeminal
What things does the neurologic assessment accomplish?
- Level of functioning, emotional, mental capacity, and functioning are determined
- Monitors/Detects changes and to assess nervous system dysfunctions
- Evaluates motor, sensory, autonomic, cognitive, and behavioral elements
The most complex nursing assessment of the physical examination is the …
neurologic assessment
Any abnormal neurologic symptoms should be assessed using …
COLDSPA
during neurologic and musculoskeletal exams there is a stress on …
safety!
Pertinent Symptoms and information that need further assessment in the neurologic health history?
Dizziness
Numbness and tingling
loss of feeling
changes in sensation
mood changes
surgeries
difficulty or changes in speech/swallowing
hearing
memory
balance and coordination
head, back, neck injuries and accidents
seizure history
headaches
syncope
drug and ETOH use
chemical exposures
changes in sleep schedules
activity level
medications
changes in ADLS
Sequence of techniques in neurologic exam?
Inspection –> Palpation
Auscultation and Percussion not necessarily needed
When performing a neurologic physical exam, it is important to go ___ and ___
cephalocaudally and bilaterally
The neurologic exam does not look only at motor, but also ___
sensory
What things should be looked for during inspection via general survey and approach for a neurologic exam?
General appearance - is it appropriate, gait, posture, awareness, manner of grooming and dress
Get patients perception of things
Are they comfortable
Allow older patients longer response times
Patient Perceptions in the physical neurologic assessment is considered ___ data
objective
Spastic Hemiparesis
Gait where affected leg is stiff and extended
foot drags and toes scrape
Affected arm is flexed and adducted with no swing
Ataxia
uncoordinated uncontrolled falling occurs in gait
Parkinsonian Gait
stooped, rigid, short shuffling steps with difficulty starting and stopping
Glasgow Coma Scale
gold standard scale for Level of consciousness
has 4 levels but does not assess verbal response
4 Levels of the Glasgow Coma Scale
- Awake and Alert - Follows commands
- Lethargic - drowsy/tap awake
- Stuporous - Shake or shout to wake
- comatose - does not respond to verbal cues or pain stimuli
What aspects of mental status are important to look at during a neurologic examination?
Behavior/Mood/Affect
Emotional state
does their mood change
non verbal cues they give
speech characteristics
thought processes and cognitive function
assessment of orientation, attention, and memory
their use of language
Orientation Status
Test of awareness of person, place, and time for a patient
EX: *individualize to the specific person
Person - what is your name? address? who is examiner?
Place - tell me where you are?
Time - what day, month, year, season, president, etc
How should you go about assessing memory?
Put it into the general conversation, do not just quiz them usually
Memory is part of ___ function
cerebral
If recollection of past is easier than present what tests should be done?
Immediate Memory Tests:
- Repeat numbers backward and forward
- Recent Memory - Dietary recall
- Remote Memory - past occupations and birth place
What is intellectual functioning?
Ability to define proverbs, learn a new item, perform computation, possess the ability to read, and have insight and judgment into situations
What plays a large roll in intellectual functioning?
Age and Culture
What is the Mini Mental Status Exam for Elders?
A judgment of mental status that assesses: (ORRAcL)
1.Orientation
2.Registration
3.Attention and Calculation
4.Recall
5..Language
What can mental status changes indicate?
Early indications of change to neurological status which could be difficult or subtle to detect:
May begin slowly with forgetfulness, memory loss, inability to concentrate or process info quickly
Could rapidly proceed to unconsciousness
Causes for Mental Status Changes?
Neurological Issues
Fluid and Electrolyte Imbalance
Hypoxia
Poor perfusion
Nutritional Deficiencies
Infections
Renal and Liver Disease
Hyper/Hypothermia
Trauma
Medications/Toxins
Drug/ETOH Abuse
What is the order of information to go by when doing the neurologic exam?
Patient Perceptions > What you see > What family says is occurring
Proprioception
Ability to maintain posture, balance, and coordination
Done via the posterior columns of the spinal cord carrying stimuli and fibers for touch and integrating with the cerebellum
Functions of the Cerebellum
Works with vestibular sense to correct movement
Balance and coordination
Integrates muscle contractions for posture
If some non-neuro condition can cause motor issues..
do not assume the problem is from an issue of cerebellar function
Ways to Test Cerebellar Function
Finger to nose (helps display upper extremity movement)
Finger Nose and Finger Movements
Rapidly Alternative Movements: Thumb to 4 fingers as rapidly as possible, or slapping thighs with palms alternating with the back of hands (note speed and accuracy)
Heel to Shin Standing
Romberg Test
Tandem/Tip Toe Walking
How to test somatic sensation function?
- Sensation (Dermatomes, Major Peripheral nerves, forehead, cheek, hand, foot)
- Light Touch (wisp of cotton on diff. areas)
- Pain and Temp (sharp, dull, hot, cold)
- Vibration (tuning fork on bone prominence - ask localization stop and start)
*** always check bilaterally
Anesthesia
Lack of sensation
Hyperthesia
Very sensitive
Hypothesia
decreased sensation/ dull sensation
Paresthesia
Tingling sensation
Dermatomes
Sensory areas of the body where peripheral nerves are
It is a relationship between spinal nerves and skin sensation and each of the roots provides sensation to a predictable area of the skin (but there is a lot of overlap)
With sensory function it is important to also check for ___ sensitivity and ___ discrimination
position sensitivity and tactile discrimination
Stereognosis
Can they make out the form/what is in their hand when eyes are closed
Graphesthesia
If you write something with your finger on their palm or back can they tell what you wrote
Two Point Discrimination
What is the point that they can discriminate two different sensations
Deep Tendon Reflexes (DTR)
Reflexes that reroute info to cause the movement from the spinal level while also sending info to the brain
What are the main DTR?
Biceps
Brachioradialis
Achilles
Triceps
Patellar
Plantar
How is DTR rated?
on a scale of 0 to 4 with +2 being normal
The strength is then also rated on 0 to 5 with 5 being normal strength
Important Primitive Reflexes that should only be seen in newborns and infants
Sucking
Rooting
Moro (Startle)
Babinski
Blabellar
Palmar/Grasp
Plantar
Tonic Neck
Rooting Reflex
baby will auto turn toward stimulus and make sucking/rooting motions when mouth or cheek is touched
Sucking Reflex
when top of mouth is touched the baby will auto start sucking
Moro reflex
Startle Reflex
In a response to sudden loss of support the baby will spread out their arms then pull them in and likely begin to cry
Babinski Reflex
sole of foot being firmly stroked on an infant will cause the toes to fan out
Glabellar Reflex
Tap patient on forehead, and if extinction does not occur and they continue to blink after a while that is an abnormal response
Palmar/Grasp Reflex
put finger in babies hand, they should grasp around it
Plantar Reflex
In adults, the stroking of the foot should cause this flexion inward of toes rather than a babinski response
Tonic Neck
Fencing Reflex
When head is turned to one side, babies arm on ipsilateral side will extend while contralateral arm will bend at elbow
Important Superficial reflexes
Abdominal
Anal
Corneal
Cremasteric
Abdominal reflex
4 Strokes toward the umbilicus should elicit abdominal contraction
Anal Reflex
Anal Wink
Reflexive anal contraction to stimulus to the skin around the anus
Corneal Reflex
Reflexive blinking from stimulation of the cornea (by touch or foreign body)
Touch the cornea with cotton in a coma patient usually
Cremasteric Reflex
Only in males
if inner thigh is stroked, the cremaster muscle will pull up on the ipsilateral testicle
When a patient states they have headaches what should you analyze?
COLDSPA (pain)
Acute or chronic
localized or generalized
90% of headaches are …
benign, caused by muscle contraction and or vascular issue (migraine or cluster)
10% of headaches are…
a serious medical issue
Dizziness
a “fainting sensation”
Vertigo
Sensation that everything is “spinning”
can be accompanied with nausea, vomiting, nystagmus
Syncope
temporary loss of consciousness
“black out” / “had a spell”
Paresthesia
Numbness or tingling
Symptoms of dizziness, vertigo, syncope, or paresthesia can be …
benign OR serious (like in an impending CVA) so investigate thoroughly
Possible causes for dizziness, paresthesia, syncope, and vertigo?
diabetes
neurological issues
metabolic issues
cardiovascular issues
renal issues
inflammatory diseases
toxins
Disorders of the CNS
Multiple Sclerosis
Generalized Seizure Disorder
Meningitis
Lyme Disease
Space occupying lesions
Cerebral palsy
Normal pressure hydrocephalus
Spina bifida
Amyotrophic lateral sclerosis
Disorders of PNS (peripheral)
Myasthenia Gravis
Trigeminal neuralgia (tic douloureux)
Bells Palsy
Gullain barre Syndrome (GBS)
Peripheral Neuropathy
Multiple Sclerosis
immune destruction of myelin sheathing
Generalized Seizure Disorder
Systemic disease, head trauma, toxins, stroke, or hypoxic syndromes cause this
S/S: disturbances in consciousness, behavior, sensation, autonomic functioning, urinary and fecal incontinence
Meningitis
Inflammation, bacterial or viral, of the fluid and membranes surrounding the brain and spinal cord (can cause stiff neck and headache)
Kernig and brudzinski signs indicate this
Lyme Disease
caused by ticks
Has 3 Stages:
- bulls Eye rash
- Neuro and cardio symptoms (facial palsy, swollen knees, etc)
- Arthritis and worsening neuro s/s
What can help cure lyme disease?
Antibiotics
Space Occupying Lesion
Primary or metastatic
S/S depend on the location
Cerebral palsy
non progressive issue with anoxia or hypoxia
permanent movement disorders starting in childhood
Normal Pressure Hydrocephalus
Corrected by V-P Shunt
liquid gathering in skull/brain
Spina Bifida
Neural tube defect (incomplete dev of brain, spinal cord, or protective coverings) causing spinal parts to come out of the back
Amyotrophic Lateral Sclerosis
Form of muscular dystrophy
Weakness muscles and is progressive
ALS/Lou Gehrigs Disease
CVA
Cerebrovascular Accident
Brain attack or stroke - sudden focal neurologic deficit resulting from impaired circulation to/within the brain
Causes of CVA
associated with cario disease
thrombosis
embolism
hemorrhaging causing circulation impairment
Most common site of CVA?
distribution of the anterior circulation of the brain
Warning Signs of Stroke
Sudden weakness, numbness, facial/arms/leg paralysis (especially on one side)
Sudden vision trouble in one or both eyes, diplopia, monocular blindness
Sudden confusion, dysarthria, aphasia
Sudden severe headache without apparent reason
Sudden trouble walking, dizziness, loss of balance, or falling without reason, loss of coordination
Dysarthria
difficulty speaking
Aphasia
Difficulty understanding speech
F.A.S.T
Acronym for stroke risk - stands for:
Face (have them smile, does one side droop)
Arms (raise both arms, is their drifting downward of one)
Speech (can they repeat simple phrase without strangeness or slurring)
Time (if you see a sign call 911 immediately)
Parkinson’s Disease
Slowly progressing degenerative disorder of dopamine NTs in the brain resulting in poor communication in the neuronal system
Causes of Parkinson’s Disease
questionable genetic links
environmental components
can be viral, vascular, or toxic in origin
S/S of Parkinson’s Disease
Tremors at rest
fatigue
masked facial expression
parkinson’s shuffling gait / propulsive gait
muscle rigidity
“pill rolling” - like something is between their fingers
behavioral changes and dementia
commonly causes stiffness or slowing of movement
coordination, movement, and balance issues
Alzheimer’s disease
destruction of brain cells progressively leading to decline in memory and mental functions
Insidious and Neurologic
Most common cause of demetia is …
alzheimers disease
What are causes for Alzheimer’s disease?
combo of genetics lifestyle, and environment alongside the major risk of increasing age
BUT this is not a normal aging process
Alzheimer’s Onset?
Late more common than early onset
Early onset occurs between 30-60 with less than 10% of all alzheimers being early and usually due to genetics
Myasthenia Gravis
Peripheral NS disorder
chronic, autoimmune disorder involving lower motor neurons and muscle fibers
Immune system attacks synaptic junctions between nerve and muscle fibers
Tic Douloureux
Trigeminal Neuralgia
Damage to 5th cranial nerve (could even be from surgery) that is chronic and due to compression by a small artery that wears away CN V’s myelin
It may be associated with MS, tumors, AVM, injuries (sinus, oral, CVA, facial trauma)
PNS disorder
Treatment for Tic Douyloureux
Meds, Injection, surgery
Bells Palsy
Temporary facial paralysis from damage/trauma to facial nerve (CN VII) from swelling, inflammation, or compression
Could potentially be viral and can be treated with antibiotics or prednison
risk for aspiration and low self esteem is possible
TEMPORARY and can affect anyone (can recover in 2 weeks to several months)
PNS disorder
GBS
Gullain barre syndrome (PNS disorder)
Autoimmune disorder that is an acute inflammatory demyelination of peripheral nerves
It is rapidly progressive and may be bacterial or vial in origin or links to immunizations or Epstein barr syndrome - We truly do not know the cause
Treatment is more supportive as it is progressive
Peripheral Neuropathy
PNS issue
motor and sensory issues seen in hands and feet
caused by diabetes, toxins, vit b 12 deficiency, autoimmune issues, neurologic conditions
s/s: numbness, tingling, burning, cramping
Depression
May accompany anxiety and has many causes
can affect all ages, races, genders
NEED TO ASSESS - asking will not cause a suicide attempt and they need assistance
BE ATTUNED TO THE POTENTIAL
At risk populations for depression?
chronic disease patients
LGBTQ
“devastating” acute condition patients
Neurologic Nursing Diagnoses
risk for injury
risk for activity intolerance / activity intolerance
ineffective airway clearance
anxiety
risk for aspiration
disturbed body image
imbalanced body temp
bowel incontinence
powerlessness
risk for infection
impaired verbal communication
caregiver role strain
unilateral neglect
impaired urinary elimination
impaired walking
wandering
compromised family coping
