neuro Flashcards
structures of the nervous system
central nervous system
peripheral nervous system
what is part of the central nervous system
brain
spinal cord
cranial nerves 1 and 2
what is part of the peripheral nervous system
cranial nerves 3-12
the spinal system (autonomic nervous system)
-parasympathetic nervous system
-sympathetic nervous system
what does each lobe of the brain control
Frontal lobe = consciousness Parietal lobe = movement and stimulus perception Occipital lobe = vision Cerebellum = movement coordination Brain stem (midbrain, pons, medulla) = basic vital functions Temporal lobe = speech recognition
what does each part of the peripheral nervous system control
Autonomic = subconscious, control systems -Parasympathetic = rest and digest -Sympathetic = fight or flight Somatic = voluntary, muscle movement
location and function of motor areas of brain
primary = precentral gyrus, facilitates motor control and movement on the opposite side of the body supplemental = anterior to precentral gyrus, facilitates proximal muscle activity, including activity for stance and gait, spontaneous movement and coordination
location and function of sensory areas of brain
somatic = postcentral gyrus, processes sensory response from the opposite side of body
visual = occipital lobe, registers visual images
auditory = superior temporal gyrus, registers auditory inputs
association areas = parietal lobe, integrates somatic and sensory inputs
association areas = posterior temporal lobe, integrates visual and auditory inputs for language comprehension
association areas = anterior temporal lobe, integrates past experiences
association areas = anterior frontal lobe = controls higher-order process (judgment, insight, reasoning, problem solving, planning)
location and function of language parts of the brain
comprehension = Wernicke's area, integrates auditory language (understanding of spoken words) expression = broca's area, regulates verbal expression
other locations and functions of the brain
basal ganglia = near lateral ventricles of both cerebral hemispheres, control and facilitate learned and automatic movements
thalamus = below basal ganglia, relays sensory and motor inputs to cortex and other parts of cerebrum
hypothalamus = below thalamus, regulates endocrine and autonomic functions (feeding, sleeping, emotional and sexual responses)
limbic system = lateral to hypothalamus, influences affective (emotional) behavior and basic drives such as feeding and sexual behavior
neuro assessment step 1
Begin with conversation if pt is awake
Introduce yourself, watch pt reaction
- “what is your last name?” - “where are you today?” - “what is the date today?”
If pt is unconscious or not able to speak, go straight to #2.
neuro assessment step 2
Do full set of vital signs including Blood Pressure, Heart Rate, Respirations, & Temp
neuro assessment step 3
Start Neuro signs (NVS)
Eye Opening Best verbal response Best motor response Pupil response Limb response
eye opening
Spontaneously – opens eyes without prompt, or has them open
To speech – opens eyes to command, or once nurse speaks
To pain – if pain stimulus is required to open eyes
none
best verbal response
Oriented x3 – answers questions correctly (Person, place and time)
Confused – Orient x3 but speaks/behaves inappropriately, or does not know any orientation questions
Inappropriate words – speaks nonsense
Incomprehensible sounds – moans or makes noises only
None – trached or no verbal response
best motor response
Obeys command – squeeze hand bilaterally to command
Localizes pain – attempts to remove pain stimulus
Flexion withdrawal – arm/leg flexes to pain
Flexion abnormal – arm flexes in abnormal posture to pain
Extension abnormal – abnormal extension of limbs to pain
No response – nil response after ++ pain stimulus
pupil response
Mark +, -, or c, or sl (sluggish)
Estimate size according to chart
limb response
Normal - good motor strength
Weak – weak motor strength
Spontaneous – pt moves limb but doesn’t follow command
Withdraws – pt pulls limb away from stimulus, must see flexion of limb
Abnormal posturing – abnormal response to pain, limb goes into extension
No response – nil response to pain stimulus
decorticate posturing/rigidity
upper extremity flexion, lower extremity extension
Slowly developing flexion of arm, wrist, and fingers with adduction in the upper extremity and extension, internal rotation, and plantar flexion of lower extremity
Hemispheric damage above midbrain releasing medullary and pontine reticulospinal systems
decerebrate posturing/rigidity
upper and lower extremity extensor responses
Opisthotonos (hyperextension of vertebral column) with clenching of teeth; extension, abduction, and hyperpronation of arms; and extension of lower extremities
Associated with severe damage involving midbrain or upper pons
In acute brain injury, shivering and hyperpnea may accompany unelicited recurrent decerebrate spasms
Acute brain injury often causes limb extension regardless of location
extensor responses in upper extremities accompanied by flexion in lower extremities
location of injury = pons
flaccid state with little or no motor response to stimuli
location of injury = lower pons and upper medulla
NVS/CNS
LOC (GCS)
Mental status: speech, conversation, cognitive, emotion, memory, behavior
Pupils: size, shape equal, reactive (PERL)
Lightheadedness, dizzy
Pain (location, type, scale 1-10)
Sedation/analgesic/sleep
Intra Cranial Pressure, external ventricular drain, Cerebro-Spinal drainage (drain level, color, amount), C-spine traction/braces
Halo sign, otorrhea, battle sign
confusion
loss of ability to think rapidly and clearly, impaired judgment and decision making
disorientation
beginning loss of consciousness, disorientation to time followed by disorientation to place and impaired memory, lost last is recognition of self
lethargy
limited spontaneous movement or speech, easy arousal with normal speech or touch, may or may not be oriented to time, place or person
obtundation
mild to moderate reduction in arousal (awakeness) with limited responses to environment, falls asleep unless stimulated verbally or tactilely, answers questions with minimal response
stupor
condition of deep sleep or unresponsiveness from which person may be aroused or caused to open eyes only by vigorous and repeated stimulation, response is often withdrawal or grabbing at stimulus
coma
no verbal response to external environment or to any stimuli, noxious stimuli such as deep pain or suctioning do not yield motor movement
associated with nonpurposeful movement only on stimulation
light coma
associated with purposeful movement on stimulation
deep coma
associated with unresponsiveness or no response to any stimulus
hemispheric breathing patters: normal
description = After a period of hyperventilation that lowers partial pressure of carbon dioxide in arterial blood (PaCO2), the individual continues to breathe regularly but with reduced depth.
location of injury = Response of nervous system to an external stressor—not associated with injury to central nervous system (CNS)
hemispheric breathing patterns: posthyperventilation apnea
description = Respirations stop after hyperventilation has lowered partial pressure of carbon dioxide (PCO2) level below normal.
Rhythmic breathing returns when PCO2 level returns to normal.
location of injury = Associated with diffuse bilateral metabolic or structural disease of cerebrum
hemispheric breathing patterns: cheyne-stokes respirations
description = Breathing pattern has a smooth increase (crescendo) in rate and depth of breathing (hyperpnea), which peaks and is followed by a gradual smooth decrease (decrescendo) in rate and depth of breathing to the point of apnea, when the cycle repeats itself. The hyperpneic phase lasts longer than the apneic phase.
location of injury = Bilateral dysfunction of deep cerebral or diencephalic structures; seen with supratentorial injury and metabolically induced coma states
brainstem breathing patterns: central neurogenic hyperventilation
description = A sustained, deep, rapid, but regular pattern (hyperpnea) occurs, with a decreased PaCO2 and a corresponding increase in pH and PO2.
location of injury = May result from CNS damage or disease that involves midbrain and upper pons; seen after increased intracranial pressure and blunt head trauma
brainstem breathing patterns: apneusis
description = A prolonged inspiratory cramp (a pause at full inspiration) occurs; a common variant of this is a brief end-inspiratory pause of 2 or 3 seconds, often alternating with an end-expiratory pause.
location of injury = Indicates damage to respiratory control mechanism located at pontine level; most commonly associated with pontine infarction but documented with hypoglycemia, anoxia, and meningitis
brainstem breathing patterns: cluster breathing
description = A cluster of breaths has a disordered sequence with irregular pauses between breaths.
location of injury = Dysfunction in lower pontine and high medullary areas
brainstem breathing patterns: ataxic breathing
description = Completely irregular breathing occurs, with random shallow and deep breaths and irregular pauses. The rate is often slow.
location of injury = Originates from a primary dysfunction of medullary neurons controlling breathing
brainstem breathing patterns: gasping breathing pattern (agonal gasps)
description = A pattern of deep “all-or-none” breaths is accompanied by a slow respiratory rate
location of injury = Indicative of a failing medullary respiratory centre
mechanisms in the lower brainstem
Vomiting, yawning, hiccups
Vomiting/nausea = direct involvement of central neural mechanism
Projectile vomiting = pressure on medulla oblongata
alterations in cerebral hemodynamics
Brain reacts to an injury through alterations in cerebral blood flow, intracranial pressure and oxygen delivery
^ these will change your clinical manifestations
changes in cerebral blood flow due to
Inadequate cerebral perfusion
Normal cerebral perfusion
Elevated intracranial pressure
patho for increased intracranial pressure
Intracranial Pressure (ICP) is the pressure exerted due to the combined total volume of the three components of the brain tissue, blood and Cerebrospinal fluid (CSF) If the pressure is able to be displaced to a cranial vault, then the pressure is unchanged If the pressure is unable to be displaced to another area within the brain, there is elevated ICP
increased intracranial pressure occurs when
Increased in intracranial content -> tumor
Edema
Excess CSF
Intracranial hematomas of Hemorrhage
Metabolic and physiological factors-> C02, 02, fever, pain
Vascular anomalies-> Arteriovenous malformations
anytime you increase metabolic demand
you increase intracranial pressure
stage 1 of intracranial hypertension
Vasoconstriction and external compression of the venous system to decrease the intracranial pressure
May have effective compensatory mechanisms in place so little change in ICP
No clinical manifestations except through ICP monitoring
stage 2 of intracranial hypertension
Increased pressure within the brain
Changes in oxygenation, and systemic arterial vasoconstriction occurs to elevate the systemic blood pressure to overcome the IICP
Clinical Manifestations include: confusion, restlessness, drowsiness, slight pupillary and breathing changes
stage 3 of intracranial hypertension
Brain tissues experience hypoxia and hypercapnia
Patient’s condition starts to changes dramatically
Clinical manifestations include: changes in arousal or central neurogenic hyperventilation, widened pulse pressure, bradycardia, and small, sluggish pupils
stage 4 of intracranial pressure
Brain shifts and herniates from the compartment
Blood supply is compromised leading to further ischemia and hypoxia
Increased pressure leads to small hemorrhages within the brain tissue
Obstructive hydrocephalus
widened pulse pressure
large difference between systolic and diastolic pressure
cerebral edema
Vasogenic cerebral edema (most important)
Cytotoxic cerebral edema
Interstitial cerebral edema
clinical manifestations of increased intracranial pressure
Changes in LOC Changes in Vital Signs Cushing’s Triad (widening pulse pressure, bradycardia, irregular respirations Ocular Signs Decrease in Motor Function Abnormal posturing Headache Vomiting
nursing assessment of increased intracranial pressure
I-PAP
Pupils, Vital Signs, Gait, Movement, Posturing, Headache
early signs of increased intracranial pressure
altered level of consciousness (confusion, restlessness) = unilateral pupil change in size, equality, and/or reactivity, altered respiratory pattern (bradypnea or irregular pattern), unilateral hemiparesis
variable signs = focal findings (speech difficulty, visual disturbances), papilledema, vomiting, headache, seizures
late signs of increased intracranial pressure
decreased level of consciousness (stupor) = unilateral or bilateral pupillary changes: size, equality, and/or reactivity, ineffective breathing pattern (cheyne-strokes), abnormal motor response (decorticate or decerebrate posturing)
variable signs = hypertension with widened pulse pressure, bradycardia, hyperthermia
terminal signs of increased intracranial pressure
coma = bilaterally fixed and dilated pupils, respiratory arrest, absence of motor response (flaccid)
variable signs = hypertension with widened pulse pressure, bradycardia, hyperthermia
nursing assessment for intracranial pressure: neuro
LOC and monitoring for deterioration to worst case, coma and unresponsive, pupillary changes unilaterally and bilaterally, equal, abnormal in shape, size, reactivity, does the patient follow commands, MP weak/strong, equal upper/lower; abnormal posturing, flaccid, headache, changes in vision;
