NEURO                                                      3.   Parietal- sensory: pain, temperature, touch               ...
o ANS (fight/flight)                                 4. MRI- Gadolinium (magnetic) is administered in            o Sleep-w...
3. Myelography- Xray of entirovertebral canal with     -    Language test      radioiplaque dye on air                    ...
o Anal                                        Akinteic mutism- a state of unresponsiveness to the         o Bulbocavernous...
Inc ICP                                                         -   HOB elevationCranial Vault:                           ...
o    Helps reduce edema surrounding brain          -   Patient becomes volume overloaded and has                 tumors wh...
o    Can be triggered by menstrual cycles,          -    Addtl drug therapy includes the use of                 bright lig...
o   Reassure pt that the headache is not          -   Intense rigidity of the entire body followed by                 due ...
- Push aside any furniture that may injure the pt              -   Also associated with brain tumors, abscesses,      duri...
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NCM notes: Neuro

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NCM notes: Neuro

  1. 1. NEURO 3. Parietal- sensory: pain, temperature, touch - Interprets size, shapeM. Guimalan- January 15, 2012 - Lobe of non-dominant hand 4. Temporal- hearing - Language: Wernicke’s AreaANA-PHYIOSOLOGY - MemoriesNeuron: Cerebellum- little brain - Axon- efferent - 2 hemispheres joined by Vermis - Dendrites- afferent; branches - Cerebellon perduncles connects to brainstem - Walnut shapedSynapse- neurotransmitters - Position, proprioception, balance, motor  Pre-synaptic- sender - Coordinates sensory input from inner ear and  Post synaptic- receiver muscles  Electrical- direct open fluid channels Brainstem- connects forebrain and the spinal cord o Our body has negative charges except for the olfactory nerve  Chemical- excitable neurotransmitters - Breathing and blood pressureBasic Function a. Midbrain 1. Sensory- by afferent - Cranial nerve 3 & 4 2. Integrative- appropriate response - Auditory, visual, reflex 3. Motor- efferent b. Pons - CN 5-8Nervous System Organizational structure - Respiratory center - Pneuomotoxic and apneustic- breathing A. Central Nervous system - Sleep and arousal a. Brain and spinal cord c. Medulla oblangata B. Peripheral Nervous system - CN 9-13 a. Cranial and Spinal Nerves, ANS - Consciousness and arousalBrain- encephalon - Respiratory center - Vasomotor - Has 2 layers: - Cardiovascular o Cerebral Cortex- grey matter (unmyelinated) PRIMITIVE STRUCTURES  Outer, 7in thick, 16ft 1. Limbic- within temporal lobe  2 folds and grooves - Emotional brain- drives (hunger, aggression,  Sulci fissures sexual, emotional arousal, fear, anger, pleasure) o Corpus Callosum- joins the hemisphere - If damaged, memories and recent events will beCerebral lobes: forgotten 2. Diencephalon 1. Frontal- judgement and planning a. Thalamus- cognition - Abstract reasoning, visual b. Hypothalamus- homeostasis - Speech center- Broca’s Area o Body temp, appetite, water balance, - Emotions and social behaviour pituitary secretion (hormones) - Motor (movement) o Emotions (with limbic) 2. Occipital- visual processing
  2. 2. o ANS (fight/flight) 4. MRI- Gadolinium (magnetic) is administered in o Sleep-wake cycle (Circadian rhythm) vein 3. Reticular activating system - Takes 50-90mins - Excitable neurons - Ix: multiple sclerosis, brain tumor - Sleep-wake cycle stimulator 5. EEG- graphic recording of brain’s electrical 4. Spinal cord activity - 31 pairs - Determines brain death - Fora magnum- joins brain - Interfering factors: fasting, caffeine, body and - Information integration eye mov’t, sedatives, anticonvulsants 5. PNS- provides sensory (afferent) information to - Hair care CNS and carries motor (efferent) commands out - Hyperventilate for 30mins to body’s tissue - Takes 1hr or more - Dermatome- area of skin that picks stimulation - Sleeping is shortened night before the test: 6. ANS- internal organs adults: 4-5hrs, children: 5-7hrs - Visceral efeferent nerves 6. Carotid ultrasound (artery duplex scanning)  Sympathetic NS- thoracolumbar - Ix: headache, neurologic symptoms o Exits the spinal cord between levels of - UTZ- Doppler and grayscale image TL & L2 2nd - Extracranial carotid artery - Pupillary dilation, inc RR, HR, BP and contractility, diaphoresis, inhibits GI secretion, Invasive: inc glucose secretion and blood clotting, inc 1. Cerebral angiography- radiographic visualization mental alertness and metabolic rate, dec urine of the cerebral vascular symptoms output, adrenergic activity - Ix: cerebral patency  PNS- craniosacral - Sites: carotid system, vertebral artery - Go so slow - Determines aneurysms, occlusions, stenosis, - Pupillary and bronchiole constriction, dec HR, AVM RR, BP - If on GA, put on NPO 6hrs prior - Inform 2-3hrs hot feeling when dyes is injected,NEURODX TESTS metallic tasteNon-invasive: - POST: bed rest overnight o Pedal pulse may be diminished 1. X-ray- skull 2. Lumbar puncture- measures pressure 2. CT Scan- 3d view - Administration of anesthetics - Indication: - Pressure greater than 20cm H2O is considered o Intracranial bleeding, lesion, (not) normal and indicative of increased hydrocephalus, cysts, head trauma, intracranial pressure cerebrovascular disturbances, CBF - Apply digital pressure on prone position with - Takes 30-50minutes pillow under abdomen - NPO 4hrs before - Increase fluid with straw - Drink fluids after - Reclining position for 1hr - Determine allergies to contrast - Normal: 50-100mm H2O 3. Positron Emission Tomography- determines - Takes 15mins cerebral blood flow - During: side lying, kneels and neck flexed - Inhale stable stenon gas 26 - Tube1: glucose, protein, electrophoresis - Normal: 55m per 100g/minute - Tube2: gram stain bacterial and viral culture - Brain death if CBF=0 - Tube3: cell count & differential; tube 4
  3. 3. 3. Myelography- Xray of entirovertebral canal with - Language test radioiplaque dye on air - Construction- shapes - Ix: SI, meningocele & metastatic tumor, herniated intravertebral disks, lesions, obstruction 2. Cranial nerves- perfume, alcohol - Contrast mediums: o Oil-based- pantopaque (preferred) o Water-based- Amipaque 3. Motor- to evaluate cerebellum, cerebral cortex - 15mL dye injected - Compare left and right, proximal and distal - During: prone position, head tilted down, lights - Absence of gait and posture off  Muscle tone (@rest): flaccid (dec); rigid/spastic - POST: if oil based, flat on bed for 6-24hrs (inc strength) o If water- HOB elevated 30-60deg at all - Hyper/hypotonia times for 8-24hrs 4. Electromyography- electrical activity - To detect primary muscular disorders - CIx: anticoagulant, anticholinergics, 4. Coordination and gait anticonvulsants, tea, coffee, alcohol, cigarettes  Rapid altering movements: arms, fingers, tandem- gait, heel-to-toe walkingNEURO AX - Heel-shin - Romberg test- balance, eyes open and closedMaterials: while standing - Reflex hammer, tuning fork, Snellen chart or Rosenbaun chart, penlight/otoscope, wooden handed cotton swabs, paperclips, 5. Sensory opthalmoscope  Pain  Temp7categories:  Light touch- cotton swab 1.Mental status- changing of position  Response to vibration- tuning fork  Level of consciousness: awake/fully conscious  Extinction - Drowsy/confusion  Sense of position - Stupurous- painful stimuli  Graphesthesia - Lethargy- somnolent, responsive to verbal and  Sterognosis point localization tactile stimulus but goes back to sleep - Comatose- unarousable - Deep coma/vegetative- absence of brain stem 6. Reflexes reflexes, corneal, pupillary, and tendon reflexes  Deep tendon reflexes:  Glasgow coma scale (15pts) o Biceps (C5, C6) - Best eye opening, verbal, motor response o Elbow, - Coma: <7 o Patellar - Lowest: 3 o Achilles (S1, S2)  Mini-MSE o Brachioradial - Orientation- name of hospital  Superficial - Registration- 3 objects and repeat o Pharyngeal/gag - Attention & calculatioin o Abdominal - Recall o Cream asteric reflex
  4. 4. o Anal Akinteic mutism- a state of unresponsiveness to the o Bulbocavernous environment in which the patient makes no movement o Corneal or sound but sometimes opens or closes his eyes  Pathologic superficial: Persistent vegetative stage- a condition in which the o Grasp o Sucking unresponsive patient resumes sleep-wake cycles after o Snout- puckering coma but is devoid of cognitive or affective mental o Babinski function Causes: - Neurologic (head injury, stroke) 7. Special tests  Vital signs - Toxicology (drug overdose, alcohol intoxication) - Temperature- hypothalamus or brainstem - Metabolic (hepatic or renal failure, DKA) involvement  Leads to disruption in the cells of the nervous - Pulse rate- ANS controls PR and rhythm by system, neurotransmitters, or brain anatomy pressure on brain stem & CN: hypoglossal and  Results to faulty impulse transmission, vagus impeding communication within the brain or o Low pulse rate- Spinal Cord injury from the brain to other parts of the body - BP- pressor receptors in medulla- carotid sinus Medical Mgt: and aortic sinus - Respiration- medulla and pons - Obtain and maintain patent airway  Assessing unconscious brain stem o Orally or nasally intubated; - Oculocephalic (Doll’s eye) tracheostomoy; mechanical ventilation o If positive, brain stem is intact o Relaxation of muscles- tongue falls back o Don’t perform procedure if you suspect ward- obstruction SCI or inc ICP o Elevate head, positioning, side-lying, o Normal- eyes turn to side opposite from suction where head is facing, opposite from - Maintain fluid balance status brain stem- damage at pons or - Nutritional support- feeding tube, gastrostomy midbrain - Monitoring of circulatory status - Oculovestibular (Caloric Ice water test) o Blood pressure and heart rate- changes o Assess for intact tympanic membrane are signs of inc ICP, esp bounding pulse and clear external ear canal o Monitor ABG, O2 in tank, provide oral o Irrigation with 20-200mL of cold or ice care water, done by MD Complications: o Normal response- conjugate eye movement or eyes deviate toward - Respiratory distress or failure stimulated ear in comatose patients o Supportive care is given with intact brainstem- 10mL: nausea - Pneumonia- pts who are receiving mechanical o Abnormal- dysconjugate movement ventilation o Absent- no eye movement o Passive ROM exercises - Pressure ulcers- pts unable to move or turn - Aspiration of gastric contents- may precipitateMGT OF PATIENTS WITH NEUROLOGICAL pneumonia or airway occlusionDYSFUNCTION: o CPT
  5. 5. Inc ICP - HOB elevationCranial Vault: Secondary effects of inc ICP:Brain- 1,400 grams - May be caused by a variety of conditions: brain tumors, subarachnoid hemorrhage, toxic andBlood- 75cc CSF viral encephalopathiesBlood volume- 75cc Changes in vital signs- caused by pressure on brain stem. 1st sign of inc ICP. Assess for:Monro-kellie hypothesis- because of the limited space - Rising BP or widening pulse pressure. This mayfor expansion within the skull, an inc in any of the be followed by hypotension, labile vital signs,components cause a change in the volume of the others indicating further brain stem compromise - Grave signs of ICP- Cushing Triad: Bradypnea,Brain compensates by bradycardia, hypertension - Pulse changes with bradycardia changing to - displacing or shifting CSF tachycardia as ICP rises - Reduction of cerebral blood volume -> hypoxia - - Respi irregularities  inc icp - Hyperthermia followed by hypothermia - Displacement of brain tissue- volume increases ischemia Decortication- internal rotation and flexion of upperCauses: extremities and plantar flexion of the lower extremities 1. Cerebral blood flow - Occurs with the damage to the cerebralCerebral blood flow/edema  inc ICP  reduction of hemispherescerebral blood flow ischemia Decerebration- extension and outward rotation of theFactors that affect CBF: upper extremities and plantar flexion of the lower extremities - Concentration of CO2 in the blood and brain tissues - Represents damage to the midbrain or pons o PACO2 causes cerebral vessels to dilate Flaccidity- extremities become flaccid and reflexes are leading to inc CBF and inc ICP absent o Dec PaCO2 causes vasoconstriction causing a dec venous outflow limiting - Rag doll appearance: jaw sags and the tongue blood flow to the brain; inc cerebral becomes flaccid blood volume causing an inc ICP - Airway obstruction and inadequate respiratory 2. Cerebral edema- occurs when there is an inc in change the water content of the CNS - Certain brain tumors are associated with the Management: excessive production of anti-diuretic hormone 1. Decreasing cerebral edema resulting in fluid retention - Osmotic diuretics: Mannitol, Glycerol - Dec ATP- for sodium-potassium pump o Draw water across intact membranesTx of inc ICP: o Indwelling urinary catheter is usually inserted - PaCO2- 25-30mmHg - Corticosteroids: dexamethasone - Provide loop and osmotic diuretics
  6. 6. o Helps reduce edema surrounding brain - Patient becomes volume overloaded and has tumors when it is the cause of an inc dec UO ICP - Serum sodium concentration becomes dilute - Limit fluid intake - Tx: fluid restriction, administration of phenytoin to dec ADH release HEADACHE- cephalgia 2. Controlling fever- elevated temp increases cerebral metabolism and the rate at which - Vasodilation of blood vessels, releases cerebral edema forms chemicals that wraps around the arteries - Shivering causes an inc ICP (avoid) by increasing stimulates nerve fibers to vasoconstrict vasoconstriction, catecholamines and oxygen - One of the most common of all physical consumption, metabolism complaints - Provide TSB, paracetamol, cooling blankets - A symptom rather than a dse entity - May indicate organic dse, a stress response, vasodilation, skeletal muscles tension, or a 3. Reducing metabolic demands combination of factors - Administer barbiturates - Can occur 1-8times in a day - Sedation and analgesia should also be provided Primary headache- is one for which no organic cause because the paralyzing agents do not provide can be identified: migraine, tension-type, cluster either headache - Do not test for GCS - Improves oxygenation/circulation, reduces Secondary headache- is a sx associated with an organic metabolic demand, didribam cause: brain tumor, aneurysm - pts receiving these meds are cared for in the ICU and require cardiovascular monitoring, Divisions: endotracheal intubation, mechanical 1. Sinus- usually behind the forehead and/or ventilation, ICP monitoring and arterial pressure cheekbones, caused by blowing of nose monitoring 2. Cluster- pain is in and around one eye - normal ICP: 0-10mmHg, up to 15 3. Tension- pain is like a band squeezing the head 4. Migraine- pain, nausea and visual changes areComplications of inc ICP: typical of classic form 1. Brain stem herniation - Exercise, sleep - when the pressure builds in the cranial vault, the brain tissue presses down on the brain Migraine- a symptom complex characterized by periodic stem increase pressure on the brain stem and recurrent attacks of severe headache cessation of blood flow in the brain - Often considered to be a vascular headache irreversible brain anoxia brain death with vasospasm and ischemia of intracranial 2. Diabetes insipidus- result of dec secretion of vessels being the cause of pain anti-diuretic hormone - Lasts up to 3days - Has excessive urine output - Has aura, sensitive to light and noise - Therapy consist of: administration of fluids, - Usually starts at puberty; occurs commonly in electrolyte replacement women and has strong familial tendencies - 20L or urine, 150cc/hr - Headache is unilateral; throbbing and pulsatile 3. Syndrome of inappropriate anti-diuretic - Factors: hormone- result of inc secretion of ADH
  7. 7. o Can be triggered by menstrual cycles, - Addtl drug therapy includes the use of bright lights, stress, depression, sleep antidepressants, barbiturates and tranquilizers deprivation, fatigue, overuse of certain medications, exercise Cluster headache o Food such as aged cheese, chocolate, - Up until 8 attacks citrus fruits, coffee, pork, dairy - Classified as a form of migraine products, nitrites, and many processed - The attacks come in cluster groups with foods can trigger headache excruciating pain localized in the eye and orbit o Oral contraceptives may inc frequency and radiating to the facial and temporal region and severity of attacks in some women - Lasts up to 4weeks - Teach the pt to avoid triggers that may lead to - Pain is accompanied with watering of the eye headaches and nasal congestion; deep, boring, intense - Pts may be sensitive to odours from cigarette or pain cigar smoke, paint, gasoline, perfume, or - Attacks last from 15mins to 2hrs aftershave lotion - Seen most frequently in men - He or she may be able to limit pain by resting in - Swelling of temporal area a darkened room - Tx of choice: Lithium (cannot be used for - Behaviour therapy such as biofeedback, migraine) exercise therapy and relaxation techniques - Explore with the pt some techniques for stress Cranial arteritis- vasculitis reduction and adequate rest - Inflammation of the cranial arteries - Lifestyle and diet mgt - Characterized by a severe headache localized in - Find out what triggers your headache the region of the temporal arteries - If menstruation and ovulation are triggers, - 50 yrs and above consult physician - CxMx: fatigue, malaise, weight loss, fever, - Alcohol may trigger migraines inflammation - Low food intake may lead to low blood glucose. - If not treated, can lead to blindness or stroke Eat small, frequent feedings to dec the risk. No - Tx: corticosteroid drug to prevent the fasting. possibility of loss of vision due to vascular - Stress mgt is essential occlusion or rupture of the involved artery - Medication: Propanolol (not for cluster) o Analgesics for comfortMgt of acute attaks:  Abrupt withdrawal of medication may cause relapse - Ergotamine titrates act on smooth muscle, causing prolonged constriction of the cranial Tension headache- muscle tension headache blood vessels - Is characterized by steady, constant feeling of - Cafergot (combination of ergotamine and pressure that usually begins in the forehead, in caffeine) can arrest or reduce the severity of the temple, or at the back of the neck the headache - Often described as a “weight on top of the - Propanolol (Inderal) control the dilation of the head” ; tight band-like discomfort that is blood vessels unrelenting - Methysergide (sansert) is an effective - No aura unlike migraine profilactic agent in preventing frequent and - Mgt: symptomatic relief may be obtained by severe migraine attacks local heat, massage, analgesics, antidepressants - Anti-emetics for symptomatic tx and muscle relaxant
  8. 8. o Reassure pt that the headache is not - Intense rigidity of the entire body followed by due to brain tumor jerky alterations of muscle relaxation and contractionSEIZURE- sudden, abnormal electrical discharges from - Simultaneous contraction of the diaphragm andthe brain that results in changes in sensation, behavior, the chest muscles may produce epileptic crymovements, perception or consciousness - Often the tongue is chewed and the pt is - A part or all of the brain may be involved incontinent of urine and stool - Pt. May be at risk of hypoxia, vomiting, and - Types: pulmonary aspiration or persistent metabolic o Absence- more in children, change in abnormalities LOC, blank stare, light movements that usually last for 10secondsCauses: o Myoclonic- involuntary jerking movements which may be rhythmic 1. Idiopathic- genetic, developmental defects o Clonic- relaxation and contraction: 2. Acquired- hypoxemia, vascular insufficiency, arching of back, abducted elbow fever, head injury, hypertension, CNS, infection, o Tonic- stiffness and extension metabolic and toxic condition, brain tumor, o Tonic-clonic (Grand-mal seizure)- drug withdrawal and allergy relaxation-contraction cycle deepInternational Classification of seizure: sleep o Atonic 1. Partial seizure- begin in one part of the brain a. Simple- consciousness remains intact Assessment findings: - Only a finger or hand may shake or the mouth - Aura, LOC, dyspnea, fixed and dilated pupil, may jerk uncontrollably incontinence - The person may talk unintelligibly and may be dizzy Mgt: - May experience unusual or unpleasant sights, sounds, odors, or tastes but without loss of - Nsg goal is to prevent injury to the pt which consciousness include physical support but psychological support as well - Care for pt. During seizure: o Provide privacy and protect pt from b. Complex- consciousness is impaired- curious onlookers associated with amnesia o Ease the pt to the floor, if possible, - Either remains motionless or moves support head with pillow automatically but inappropriately for time and - If an aura precedes the seizure, put padded place tongue depressor prior to seizure to prevent - May experience excessive emotions, of fear, tongue or cheek being bitten anger, elation or irritability - Do not attempt to pry open the jaws that are - Does not remember the episode when it’s over clenched in a spasm to insert anything - Do not restrain - If possible place the pt on one side with head 2. Generalized- two brain hemispheres; involve flexed forward. If suction is available, use it if electrical discharges in the whole brain necessary to clear secretions. - Leads to a loss of consciousness - Protect head with a pad to prevent injury  Grand mal seizure - Loosen constrictive clothing
  9. 9. - Push aside any furniture that may injure the pt - Also associated with brain tumors, abscesses, during the seizure and congenital malformations - If the pt is in bed remove pillows - Oxygen: 6-10L/min, face mask Dx:  After the seizure: - CT scan - Keep the pt on one side to prevent aspiration. - EEG Make sure the airway is patent - There is usually a period of confusion after a Mgt: grand mal seizure - Pharmacotherapy- controls rather than cure - A short apneic period may occur during or seizures immediately after a generalized seizure - Sudden withdrawal of anticonvulsant drugs may - The pt on awakening should be reoriented to cause seizure to occur with greater frequency the environment or can precipitate the development of status - If the pt experiences severe excitement after a epilepticus (hypoxia) seizure, try to handle the situation with calm persuasion and gentle restraint Side effects of drugs:Patient education: - Idiosyncratic or allergy - Acute toxicity - Take meds at regular basis (Phenytoin) - Chronic toxicity - Avoid alcohol, this lowers seizure threshold - Adequate rest Surgery- for pt whose epilepsy results from intracranial - Well-balanced diet tumors, abscess, cysts, or vascular anomalies - Avoid driving, operating machines, swimming until seizure are well controlled - Lead an active lifeEpilepsies - A chronic disorder or recurrent seizure o An isolated, single seizure does not constitute epilepsy - Problem is thought to be the electrical disturbance in the nerve cells in one section of the brain - May be associated with loss of consciousness, excess movement or loss of muscle tone or movement, and disturbance of behaviour, mood, sensation, and perceptionCauses: - Often follow birth trauma, asphyxia, neonatorum, head injuries, some infectious se, toxicity, circulatory problems, fever, metabolic and nutritional disorders, and drug and alcohol intoxication

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