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Tuesday, September 18, 2007

Neurological Handouts

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Neurological Handouts Slideshow Transcript

Slide 1: NEUROLOGICAL MODULE

Slide 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.

Slide 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

Slide 4: THE NEUROLOGICAL SYSTEM Your knowledge of neuroanatomy and physiology and methods of assessing these, will improve your patient care and outcomes

Slide 5: THE NEUROLOGICAL SYSTEM The neurological system is divided into three parts 1. Central nervous system (CNS) 2. Peripheral nervous system (PNS) 3. Autonomic nervous system (ANS)

Slide 6: THE NEUROLOGICAL SYSTEM All physical, intellectual, and emotional activities are coordinated thru complex interactions of these systems

Slide 7: THE CENTRAL NERVOUS SYSTEM (CNS) The brain The spinal cord

Slide 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

Slide 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.

Slide 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.

Slide 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.

Slide 12: CEREBRAL FUNCTIONS Sensory cortex-body sensation. Motor cortex- body movement Cerebellum-controls balance and coordination

Slide 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.

Slide 14: THE SUB-CORTEX The hypothalamus- regulatory functions of temperature, pituitary hormone production, water balance, appetite, normal body temperature, and helps control reproductive functions.

Slide 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)

Slide 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

Slide 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.

Slide 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.

Slide 19: CLINICALLY IMPORTANT REFLEXES Knee jerk (patellar) Babinski Corneal Cough

Slide 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

Slide 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. 6. Olfactory 11. Hypoglossal 7. Optic 12. Accessory 8. Oculomotor 9. Trochlear 10. Abducent 11. Trigeminal 12. Facial 13. Auditory 14. Glosspharyngeal 15. Vagus

Slide 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.

Slide 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.

Slide 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.

Slide 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

Slide 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.

Slide 27: NEUROLOGICAL EXAM Examination begins with the highest level of neurological function and works down to the lowest.

Slide 28: NEUROLOGICAL EXAM Mental status and speech Cranial nerve function Sensory function Motor function reflexes

Slide 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.

Slide 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…?

Slide 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.

Slide 32: GLASGOW COMA SCALE Response eyes open Spontaneous 4 To speech 3 To pain 2 Absent 1

Slide 33: GLASGOW COMA SCALE verbal Converses/oriented 5 Converses/disoriented 4 Inappropriate 3 Incomprehensible 2 Absent 1

Slide 34: GLASGOW COMA SCALE Motor Obeys 6 Localizes pain 5 Withdraws (flexion) 4 Decorticate (flexion) rigidity 3 Decerebrate (extension) rigidity 2 Absent 1

Slide 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

Slide 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.

Slide 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.

Slide 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

Slide 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

Slide 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

Slide 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

Slide 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.

Slide 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

Slide 44: SENSORY TESTING Usually performed by neurologist Checking for light touch, pain, vibration, position, and discrimination

Slide 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

Slide 46: ABNORMAL GAITS Hemiparesis is seen in stroke. Ataxic gait is seen in cerebellar lesions Steppage gait is seen in lower motor neuron damage.

Slide 47: ASSESSING REFLEXES Deep tendon reflexes Superficial reflexes Primitive reflexes

Slide 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

Slide 49: SUPERFICIAL REFLEXES Babinski – “feet tickling” abnormal when toe turns up instead of down in an adult Cremastic Tummy tickle

Slide 50: PRIMITIVE REFLEXES These are reflexes that are abnormal if seen in an adult The include: grasp, snout, sucking, bite, and glabella.

Slide 51: NEUROPSYCHOLOGICAL ASPECTS OF BRAIN DAMAGE STROKE

Slide 52: FACT Stroke is the 3rd leading cause of death in the U.S.A., behind heart disease and cancer.

Slide 53: FACT Every year 400,000 to 600,000 Americans suffer a stroke

Slide 54: FACT Stroke claims about 145,000 lives a year

Slide 55: FACT Stroke is the leading cause of disability among adults.

Slide 56: FACT The estimated cost to treat stroke ranges from $15.6 to $30 billion

Slide 57: FACT Currently, more than 3 million people are living with the effects of strok 10% if those in long term care facilities

Slide 58: FACT The death rate from stroke has decreased significantly since 1972

Slide 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

Slide 60: TYPES OF STROKE 1. Cerebral thrombosis 2. Cerebral embolism 3. Subarachnoid hemorrhage 4. Cerebral hemorrhage

Slide 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

Slide 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

Slide 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

Slide 64: CEREBRAL HEMORRHAGE A defective artery in the brain bursts, flooding brain tissue with blood 10% of all strokes

Slide 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)

Slide 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

Slide 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

Slide 68: UNTREATABLE RISK FACTORS Age Sex Race Family hx of stroke/TIA Previous stroke/TIA Diabetes Asymptomatic carotid bruit

Slide 69: OTHER RISK FACTORS Geographic area Season and climate Socioeconomic factors Certain kinds of drug abuse Physical inactivity

Slide 70: MOST COMMON RISK FACTORS High blood pressure Elevated blood cholesterol Abnormal glucose tolerance Left ventricular hypertrophy Cigarette smoking

Slide 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

Slide 72: MEDICAL INTERVENTION Lab studies Radiology Tx of symptoms Anti-Coagulation Anti-platelet therapy

Slide 73: CLOT BUSTING THERAPY • Within 3 hours of initial onset. (only for embolic strokes)

Slide 74: SURGICAL INTERVENTIONS • Carotid Endarterectomy

Slide 75: HOW STROKE AFFECTS BEHAVIOR Left Brain Injury -Paralyzed right side -Speech-language deficits -Slow, cautious behavioral style -Memory deficits

Slide 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

Slide 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

Slide 78: HOW STROKE AFFECTS BEHAVIOR One side neglect Stroke in General

Slide 79: NEGLECT •Neglect is both a problem with the tactile sensation and proprioception •And may include a visual neglect

Slide 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)

Slide 81: STROKE REHABILITATION •Acute care: -Diagnose the stroke -Monitor for other medical problems -Prevent or treat complications -Prevent another stroke

Slide 82: REHABILITATION • TYPES: -Hospital programs -Nursing home programs -Outpatient programs -Home based programs

Slide 83: GOALS OF REHABILITATION •Functional mobility •Self care •Adaptations for former activities and life style •Education •Team philosophy •Focus on discharge planning

Slide 84: RETURN TO COMMUNITY •Making appropriate plans and arrangements •Return to previous lifestyle

Slide 85: COMMUNITY RESOURCES •Stroke information •Support groups •Home health services •Daycare •Meal delivery •Transportation

Slide 86: COMMUNITY RESOURCES •Companion services •Housing options •Other

Slide 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

Slide 88: STROKE SURVIVAL Call 911





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