Neurology

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ladynesh
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160057
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Neurology
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2012-06-25 22:00:25
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Neurology Final
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  1. Nervous System
    • Peripheral Nervous System (PNS)
    • somatic & autonomic (sympathetic & parasympathetic)

    • Central Nervous System (CNS)
    • brain
    • spinal cord     
  2. Peripheral Nervous System
    • Cranial Nerves
    • 12 pairs from lower surface of brain
    • 3 sensory (1,2,8)
    • 5 motor (3,4,6,11,12)
    • 4 mixed (5,7,9,10)    
  3. Cranial Nerves
    Oh Oh Oh To Touch And Feel A Girls Vagina Such Heaven

    Sensory-Motor-Both
    Some Say Money Matters But My Brother Says Big Boobs Matter More    
    • Olfactory - Smell
    • Optic - Sight
    • Oculomotor -Controls eye muscles
    • Trochlear - Supplies one eye muscle
    • Trigeminal - Deals with pain, touch, & temp. of the face, supplies muscles for chewing
    • Abducens - Supplies one eye muscle
    • Facial - Deals with facial expression tast, salivary & lacrimal glands
    • Auditory or Vestibulocochlear - Hearing & Balance   
    • Glossopharyngeal - Supplies tongue, parotid gland & muscles for swallowing
    • Vagus - Supplies thoracic & abdominal organs, digestive glands *when stimulated can drop HR*
    • Spinal Accessory - Supplies muscles of neck & back
    • Hypoglossal - Allows for tongue movement         
  4. Parasympathetic Nervous System
    • Homeostasis
    • Restores/conserves energy
    • Found in the cranial & sacral areas
    • Involuntary*   
  5. Sympathetic Nervous System
    • Stress response (fight or flight)
    • Inhibits processes nnot essential for fight or flight
    • Expends energy
    • Found in thoracic region to 2nd lumbar spinal nerve   
  6. Functions of the Autonomic Nervous System
    • Sympathetic responses are caused by the release of neurotransmitters
    • epinephrine & nor-epinephrine
    • medications that cause the same effects are called adrenergic
    • from old term adrenaline
    • Parasympathetic responses are caused by the release of neurotransmitter Acetylcholine
    • medications that cause the same effects are called Cholinergic     
  7. Brain
    • Largest mass of neural tissue in the body
    • Cerebrum
    • Cerebellum
    • Brain stem
    • Hypthalamus
    • Thalamus
    • Basal ganglia
    • Cranial nerves    
  8. Frontal Lobe
    Cerebrum  
    • concentration & abstract thought
    • memory
    • motor function
    • broca's area
    • personality & judgement   
  9. Parietal Lobe
    Cerebrum
    • sensory information analyzed (pain, temp. touch)
    • awareness of body in space
    • spatial relationships
    • understanding speech
    • using speech to express thoughts    
  10. Temporal Lobe
    Cerebrum
    • auditory & smell receptive information
    • interpretive area that integrates visual & auditory
    • most dominant role in thinking  
  11. Occipital Lobe
    Cerebrum
    • visual interpretation
    • combines visual images 
  12. Thalamus
    • relay station for all sensation except smell
    • all memory, sensation, & pain impulses pass through
    • Composed of:
    • basal ganglia
    • anterior, medial, lateral, & ventral nuclei
  13. Hypothalamus
    • regulates temperature
    • regulates water metabolism & thirst
    • regulates appetite
    • sleep-wake cycle
    • primitive emotions (fear, pleasure, aggression)
    • center for mind-over-matter phenomenon
    • cough, vomit, & swallowing centers
  14. Hippocampus
    • "Librarian"
    • finds info from short & long term memory
    • applies to info from thalamus  
  15. Brain Circulation
    • 15% of cardiac output
    • high metabolic demand
    • flows against gravity
    • poor collateral blood flow   
  16. Brain Circulation
    Arteries
    • 2 internal carotid
    • 2 vertebral
    • basilar
    • circle of willis  
  17. Brain Circulation
    Veins
    • flow into internal jugular vein
    • empty into dural sinuses
    • no valves to prevent back flow  
  18. Blood-Brain Barrier
    • protective function
    • enothelial cells of brain capillaries form continous tight junctions
    • creates barrier to large molecules & many compounds  
  19. Brain Stem
    Pons
    • bridge between 2 halves of cerebellum
    • portions regulate breathing, heart, & BP
    • reflex center for head movement in response to visual & auditory stimuli
    • contains sensory & motor pathways   
  20. Brain Stem
    Medulla Oblongata 
    • relay center
    • regulates breathing
    • sensitive to increase O2, decrease CO2, & changes in pH
    • regulates cardiac rate & force
    • regulates BP by contracting or dilating blood vessels    
  21. Cerebellum
    • aids in coordination of voluntary fine muscles & muscle tone
    • integrates information received from Frontal lobe
    • helps maintains balance with information from inner ear (proprioception)  
  22. Cells of the CNS
    Known as neuroglia 
    • ependymal cells
    • oligodendrocytes
    • astrocytes
    • microglia
    • neurons
  23. Cells of the CNS
    Ependymal cells 
    • line the ventricles & central canal in the brain
    • assist in producing, circulating & monitoring CSF 
  24. Cells of the CNS
    Oligodendrocyte cells   
    • cells that myelinate CNS axons
    • provide structural framework 
  25. Cells of the CNS
    Astrocyte cells 
    • maintain the blood-brain barrier
    • provide structural support
    • regulate ion, nutrient & dissolved gas concentrations
    • absorb & recycle neurotransmitters & form scar tissue after injury   
  26. Cells of the CNS
    Microglia cells 
    • remove cell debris, waste, & pathogens
    • process known as phagocytosis 
  27. Cells of the CNS
    Neuron Cells 
    • functional unit of the NS
    • consists of cell body, axon, & a synapse
    • classified as sensory & motor
    • unable to divide   
  28. Neuron
    • Dendrites:
    • conducts impulses toward the cell body
    • Cell body:
    • contains the nucleus
    • Axon:
    • conducts impulses away from the cell body     
  29. Neurotransmitters
    • Epinephrine & Nor-epinephrine:
    • produced by the Adrenal Medulla
    • Acetylcholine:
    • released at the neuromuscular junction
    • Dopamine:
    • found only in the brain, helps regulate body movement & facial expression
    • Others:
    • Serotonin, GABA, Histamine, Endorphins, Prostaglandin, Glutamate       
  30. Spinal Cord
    • Spinal Roots:
    • Each spinal nerve attached to cord by 2 roots located in the gray matter
    • Dorsal root carries sensory signals
    • Ventral root carries motor signals   
  31. DTR Measurements
    •   0 = absent impulses
    • +1 = diminished impulses
    • +2 = normal impulses
    • +3 = 
    • +4 = 
    •       
  32. Common Therapeutic Measures
    Surgery
    • Craniotomy:
    • surgical opening of the skull
    • Craniectomy:
    • excision of a segment of the skull
    • Cranioplasty:
    • any procedure done to repair a skull defect     
  33. Head Injury
    Altered Level of Consciousness (ALOC) 
    • not a disease but the result of multiple pathologic phenomena
    • underlying cause -->disruption in neurons, brain anatomy (esp. RAS) or neurotransmitters
    • May start out as subtle behavior changes  
  34. Glascow Coma Scale
    • Primary use for LOC
    • The overall score can be indicate the severity of the head injury as:
    • Less than 8: severe head injury
    • Score 9-12: moderate head injury
    • Score 13-15: mild head injury    
  35. Increased Intracranial Pressure (IICP)
    • Volume & pressure of brain tissue, blood, CSF
    • meased in lateral ventricles
    • normal pressure 10-20 mmHg
    • Pathophysiolgy:
    • head trauma
    • tumor
    • subarachnoid hemorrhage
    • toxic/viral encephalitis
    • Clinical Manifestations:
    • Increase Temp & BP
    • Decrease HR & Resp          
  36. Complications of IICP
    • Brain stem herniation:
    • brainstem pushed out by pressure
    • Diabetes Insipidus:
    • nothing to do with blood sugar
    • Syndrome of inappropriate ADH (SIADH):
    • Anti-diabetic hormone     
  37. Intracranial Surgery
    • Craniotomy: open skull surgically to determine degree of increased ICP, evacuate hematoma or abscess, or decompress the ventricles
    • Supratentorial: above the tentorium
    • Infratentorial: below the tentorium
    • Transsphenoidal: through nasal passages

    Slight increase temp. early sign of dehydration     
  38. Seizure Disorder: Classification
    • Partial seizures:
    • Simple:
    • part of one cerebral hemisphere; consciousness not impaired
    • Complex:
    • consciousness impaired, may exhibit bizarre behavior   
    • Generalized seizures:
    • involve the entire brain from the onset
    • consciousness lost during the ictal (seizure) period
    • types: tonic-clonic, absence, myoclonic, and atonic
    • Status epilepticus:
    • medical emergency; continous seizures or repeated seizures in rapid succession for 30 minutes or more
    • Aura:
    • dizziness, numbness, visual or hearing disturbance, noting an offensive odor, or pain may precede a seizure
    • Medical treatment:
    • resolution of the underlying condition
    • antivonvulsant drug therapy            
  39. Seizure Disorder: Nursing Care
    • Assessment:
    • describe the seizure episode, including the postictal period (following the seizure), and document drug therapy 
  40. Head Injury: Types
    • Skull fractures:
    • simple comminuted
    • depressed
    • basilar (base of spine)
    • Open or closed (closed-intact dura)    
  41. Head Injury
    Clinical Manifestations 
    Halo sign is highly suggestive of CSF leak
  42. Brain Injury
    Concussion
    • temporary loss of neurologice function w/no apparent structural damage
    • Observe for:
    • HA, dizziness, lethargy, irritability, anxiety
    • Signs & Symptoms requiring immediate attention:
    • difficulty awakening
    • difficulty speaking
    • confusion
    • severe HA
    • vomiting
    • weakness on one side of the body  

    Most Serious Brain Injury is Intracranial Hemorrhage        
  43. Brain Death
    • 3 cardinal signs of brain death:
    • 1. coma
    • 2. absence of brain stem
    • 3. apnea
    • All three have to be present    
  44. Spinal Cord
    • Gray matter: (inside)
    • consists of the bodies of nerve cells that control motor and sensory activities 
    • White matter: (outside)
    • myelinated (surrounded by a sheath): consists of bundles of fibers
    • convey information between the brain & the spinal cord
    • tracts may be ascending or descending     
  45. Spinal Cord
    • Blood Supply:
    • major arterial supply to the spinal cord; consists of the vertebral arteries posteriorly and the anterior spinal artery
    • Reflexive activity:
    • the sensory stimulus is received, and a response is initiated at the level of the spinal cord
    • Information conveyed to brain and spinal cord via PNS    
  46. Types of Spinal Cord Injuries
    • Location: (most common)
    • Cervical (C5-7), thoracic(T12), or lumbar(L1)
    • Open or closed:
    • Closed: trauma in which the skin and meningeal covering that surround the spinal cord remain intact
    • Open: damage to the protective skin and Meninges
  47. Spinal Shock
    • An immediate, transcient response to injury in which reflex activity below the level of the injury temporarily ceases due to loss of autonomic function below the level of the lesion.
    • Have to lose DTRs to get this....when DTRs return your spinal shock dissolved 
  48. Autonomic Dysreflexia
    • True Medical Emergency
    • Exaggerated response of autonomic nervous system to noxious (painful) stimuli
    • With injury at or above the level of T6

    Can only occur after spinal shock is resolved   
  49. Autonomic Dysreflexia
    They sympathetic nervous system is stimulated, but an appropriate parasympathetic modulation response can't be elicited b/c of the spinal cord injury that separates the two divisions of the autonomic nervous system.

    Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes.

    Change pt's slow & steady is the Key
  50. Preventing Further Cord Injury
    Move them in 1 piece, Log Roll
  51. Nursing Care of the Laminectomy Patient
    • Preoperatively:
    • assess pt's VS & neurologic status to establish baselines
    • pt's understanding of surgical routines
    • tell pt what to expect in the immediate postop period
    • ongoing assessment of neurologic status and on promoting healing at the operative site    
  52. Nursing Care of the Laminectomy Patient
    • Assessment:
    • VS, neurologic status, & breath sounds
    • frequently assess movement, strength, ROM, & ability to localize sensory sstimulus
    • fluid intake & output
    • abdomen for bowel sounds; palpate bladder
    • inspect the surgical dressing for bleeding, clear CSF drainage, and foul drainage
    • if the pt has pain, obtain a complete description      
  53. Common Terms Associated with Stroke & TIA
    • agnosia: the inability to recognize an object by sight, touch or hearing
    • anosognosia: the apparent denial or unawareness of one's own neurological deficts
    • aphasia: the absence or impairment of the ability to communicate through speech, reading or writing because of brain dysfunction
    • apraxia: the inability to perform purposeful movements despite the absence of sensory or motor impairment
    • ataxia: impairment of muscular coordination especially with attempted movement of voluntary muscles
    • broca's aphasia: loss of 'motor' speech called expressive aphasia
    • contra-lateral: opposite side
    • dysarthria: speech difficulty due to dysfunction that affects oral lingual or pharyngeal muscles
    • dysphagia: difficulty or inability to swallow
    • hemi-anesthesia: loss of sensation to half of the body
    • hemi-anopsia: loss of sight in one half of the visual field
    • hemi-paresis: hemi-plegia
    • hemi-plegia: paralysis of one side of the body
    • Lacunar Stroke: a focal loss of brain tissue due to stroke involving  a small penetrating artery in the brain
    • Proprioception: the awareness of posture, movement and changes in equilibrium and the knowledge of position, weight and resistance of objects in relation to the body
    • Wernicke's Aphasia: loss of speech due to an injury in Wernicke's area on the dominant side of the brain, wich results in an inability to understand spoken or written words. Also called receptive aphasia
    • TIA: A neurologice deficit, vascular in origin that produces stroke symptoms that usually resolve in 24 hrs
  54. Major Blood Supply to the Brain
    Blood is supplied to the brain, face, and scalp via two major sets of vessels; the right and left common carotid arteries and the right and left vertebral arteries
  55. Stroke in the Anterior Communicating Artery
    • Motor deficits of the foot and leg
    • Contra-lateral weakness of upper extremities
    • Urinary incontinence
    • Loss of proprioception
    • Contra-lateral grasp & sucking reflex
    • Apraxia     
  56. Blood Supply to the Brain: MCA
    • The middle cerebral artery is the largest branch of the internal carotid artery
    • The artery supplies a portion of the frontal lobe and the lateral surface of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm and in the dominant hemisphere, the areas for speech
    • The MCA is the artery most often occluded in stroke or CVA  
  57. Stroke in the Middle Cerebral Artery
    • Contra-lateral hemi-paresis or paralysis
    • Loss of contra-lateral proprioception, fine touch and localization
    • Aphasia if dominant cerebral hemisphere is affected
    • Neglect of opposite side if non dominant hemisphere is affected
    • Homonymous hemianopsia    
  58. Blood Supply to the Brain: PCA
    • The posterior cerebral arteries stem from the basilar artery
    • The posterior cerebral arteries supply the temporal and occipital lobes of the left and right hemispheres
    • When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from the heart

    Think vision Think PCA 
  59. Two Major Types of Stroke
    • Ischemic Stroke (Thrombotic Stroke)
    • counts for about 80% of all strokes 
    • occurs when plaque forms in the lumen of an artery, called atherosclerosis, in the brain
    • as the lumen of the artery becomes more narrow, arterial flow is diminished or completely occluded
    • platelets aggregate at plaque sites and can lead to total occlusion
    • Hemorrhagic Stroke
    • account for 20% of strokes
    • is caused by a rupture of one of the arteries in the CNS
    • onset of symptoms with hemorrhagic stroke are much swifter as there is usally a rapid accumulation of blood (clot) within the brain
  60. Alzheimer's: Nursing Care
    • Health promotion
    • Impaired memory
    • Risk for imapired safety
    • Risk for anziety
    • Risk for confusion
    • Risk for hopelessness     
  61. Multiple Sclerosis
    • Chronic, progressive degenerative disease
    • attacks protective myelin sheath around axons & disrupts conduction of impulses thru CNS
    • Exact cause is unknown; viral infections & autoimmune processes have been implicated  
  62. Multiple Sclerosis Etiology
    • Relapsing-progressive: most common clinical course/exacerbations with full or partial recovery
    • Primary progressive: steady worsening from onset with occas. minor recovery
    • Secondary progressive: begins with relapsing-remitting but steadily becomes worse
    • Progressive-relapsing: rare-continues to progress from onset but also has exacerbations   
  63. Multiple Sclerosis Medical Treatment
    • Corticosteroids (ACTH, prensione, methylpredisolone)
    • Immuno-modulators: Interferon B 1b (Betaseron) and interferon 1a (Avonex) glatiramer acetate (Copaxone)
    • Immuno-suppressants: azathioprine (Imuran)
    • Muscle relaxants
    • Urinary retention treated with cholinergic, such as bethanechol (Urecholine) or neostigmine (Prostigmine)    
  64. Parkinson's
    • Progressive, degenerative
    • decreased levels of dopamine
    • - more excitatory than inhibitory neurotransmitters
    • - leads to imbalance in voluntary movement
    • - gradual onset
    • Cardinal Signs
    • tremor
    • rigidity
    • bradykinesia
    • postural instability      
    • Pharmacology Therapy
    • Dopaminergics (Levadopa)
    • Anticholinergic (Cogentin)
    • Antiviral (Symmetrel)
    • Dopamine Agonist (Parlodel)
    • MAO inhibitors
    • Antidepressants
    • Antihistamines           
  65. Parkinson's Nursing Interventions
    • impaired mobility
    • self-care deficit
    • altered bowel function
    • altered nutritional status
    • risk for impaired swallowing
    • risk for impaired communication
    • altered sleep pattern
    • Parkinson's Shuffle is the Gait Name       
  66. Huntington's Disease
    • Chronic, progressive, hereditary
    • Premature cell death in Basal Ganglia that control movement
    • Cell death in cortex & cerebellum
    • Onset usually 35-45 yrs
    • Prognosis 10-20 yrs     
    • Signs & Symptoms
    • Chorea (abnormal involuntary movements)
    • Intellectual decline
    • Emotional disurbance  
  67. Myasthenia Gravia
    • may have autoimmune basis
    • more women than men
    • women develop earlier (20-40)
    • men develop later (60-70)
    • Insufficient receptor sites at the junction of the motor nerve with muscle
    • Medical Treatment
    • Anticholinesterase drugs
    • * Neostigmine & pyridostigmine (Mestinon)
    • Corticosteroids
    • Cytotoxic therapies
    • Thymectomy
    • Plasmapheresis          
  68. Guillain-Barre Syndrome
    • Cause unknown, believed to be autoimmune
    • Initial phase:
    • symmetric muscle weakness; begins in LE; ascends to trunk & UE
    • visual and hearing disturbances; difficulty swallowing, and lack of facial expression
    • mild paresthesias or anesthesia in feet and hands in a glove or stocking distrubution patter
    • hypertension, orthostative hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention
    • Plateau phase (stabilizing):
    • remains essentially unchanged
    • no further neurologic deterioration, but no improvement
    • Recovery phase:
    • re-myelinization; muscle strength returns in a proximal-to-distal pattern (heads to toes)          
  69. Cranial Nerve Disorders

    Trigeminal Neuralgia 
    • 5th cranial nerve (has 3 branches)
    • spasm of pain in area of any of the 3 branches
    • pain stops as abruptly as it starts
    • involuntary contraction of facial muscles
    • called 'tic dougoureux'
    • unilateral pain
    • pathology: unknown
    • suspect vascular compression & pressure
    • possible de-myelination of trigeminal root
    • happens more in MS patients         
  70. Cranial Nerve Disorders Trigeminal Neuralgia 
    Medical Management:
    • Pharmacologic:
    • anti-seizure medication
    • *take with meals, toxicity risk, hyperplasgia of the gums*
    • Surgical:
    • microvascular decompression
    • radiofrequency thermal coagulation
    • percutaneous balloonn microcompression      
  71. Cranial Nerve Disorders Trigeminal Neuralgia
    Nursing Care 
    • preventing pain
    • prevention strategies
    • chronic pain interventions

    • Post-op care
    • neuro assessments     
  72. Cranial Nerve Disorders Bell's Palsy
    • 7th cranial nerve
    • unilateral inflammation
    • weakness of paralysis of facial muscles
    • Pathology: unknown
    • suspect vascular ischemia
    • possible: viral, autoimmune, combination of all
    • Symptoms:
    • face distortion
    • lacrimation (tears)
    • painful sensations
    • speech difficulties
    • unable to eat on affected side           
  73. Cranial Nerve Disorders Bell's Palsy
    Medical Management 
    • Corticosteroids
    • Analgesics (for inflammation not pain)
    • Heat
    • Electrical stimulation
    • Surgery if tumor suspected
    • Nursing management:
    • protect eye from injury
    • massage after pain decreases
    • facial exercises
    • avoild cold & drafts         
  74. Meningitis
    inflammation of the meningeal coverings of the brain & spinal cord caused by either viruses or bacteria

    Usually enters through head wounds, blood, eyes, or inner ear 
  75. Meningitis
    Signs & Symptoms 
    • headache
    • nuchal rigidity (stiffness of the back of the neck)
    • irritability (sensory included)
    • diminished LoC
    • photophobia (sensitivity to light)    
    • hypersensitivity
    • seizure activity
    • positive kernig's sign
    • positive brudzinski's sign   

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