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** Nervous System Cells: Neurons and Glial
primary functional units with three characteristics: Excitability (ability to generate nerve impulse), conductivity (ability to transmit impulse), influence (to influence other neurons, muscle cells, glandular cells by ramsmitting nerve impulses to them)-Consists of : cell body,*nucleaus, cytoplasm) multiple dendrites ( short processes extending from cell body that receive impulses from the axons of other neurons and conduct impulses toward cell body), axon ( carries nerve impulses to other neurons or to end organs), axons covered in myelin sheath as insulator.
=> Nerve regernation:
- => Glial cells: provide support, nourishment and protection to neurons. AMake up half of the brain/spinal cord mass. Divided into microglia (specialized macrophaages capable of phagocytosis, protect neurons, mobile and multiply when brain is damanged) and macroglial (astrocytes-most abundant), oligodendrocytes, and ependymal cells).
- -Astrocytes: found in gray matter, strucutural support, processes from the blood brain barrier. Play role in synapitc transmission.
- -oligodendrocytes: produce myelin sheath of nerve fibers, white matter of CNS (schwann cells myelinate nerves in periphery)
- -Ependymal cells: line brain ventricles and aid in the secretion of cerobrospinal fluid.
Damaged nerve cells sprout branches from damaged end of their axons, CNS are less successful than peripheral axons. Injured nerve fibers in the PNS can regenerate by growing within the protective myelin sheath of the supporting Schwann cells if the cell body is intact.
=> Nerve impulses:
-Purpose of neurons: intitiate, receive, and process messages about events both within and outside the body.
Initiation of a neuronal message (nerve impulse) involves actional potiential -> along axon-> across synapse (through transmittal of neurotrasmitters). Node of ranvier-gaps let AP travel by hopping faster (saltatory) conduction.
-Neurotransmitters: chemicals that affect transmission of impulses across synaptic cleft. Excitatory: activate postynaptic receptors that increase AP generation. Inhibitory neurotrasmitters: activate posynaptic receptors taht inhibit AP genearation. Neurotransmitters affected by drugs taht can modify fn or block their attachment to receptor sites on post synaptic memebrane.
** Central Nervous System: Cerebrum, brainstem, cerebellum and spinal cord.
-Spinal cord: white matter vs gray, ascending vs descending, LMN Lesions? Reflex Arc
- => Spinal cord: Continuous with brainstem, exits cranial cavity through foramen mangnum.
- -Cross section: "H" in middle (white matter), sourrounded y gray matter (voluntary motor neurons, preganglionic autonomic motor neurons and associated nurons. White matter: axons of the ascending sensory and the descending motor fibbers. white because myeline covered.
- -Ascending tracts: carry specific sensory info to HIGHER levesls of CNS (touch, pressure, postion, kenestheisia-weight appreciation). Spinocerebellar tracts: Muscle tensions and body positon to cerebellum. Spinothalamic: pain and temp sensation.
- -Descending tracts: carry impulses for muscle movmement. Pyramidal tract: carry voluntary impulses from cerebtal contrex. Motor output exits the spinal cord by way of the VENTRAL roots of spinal nerves.
- -Lower motor neurons: final common pathway through with descending motor tracts influence skeletal muscle. Located in anterior horn. LMN lesions: cause weakness or paralysis, dnervation atrophy, hyporeflexia or areflexia dn flaccidity.
- -Upper motor nerurons: orignal in cerbal cotrext, project downward. Influence skeletal muscle movement. Lesions: weakness of pralysis, disuse atrophy, hyperreflexia and Spasticity.
- -Reflex Arc: involuntary response to stiuli, maintains muscle tone in spinal cord--essential for body posture. Monosynapti reflex: receptor organ, afferent neuron, effector neuron and effector organ (muscle). Afferent neuron synapses with efferent neuron in GRAY matter. COmplex reflex arcs have interneurons.
- => Brain: Cerebrum, brainstem, cerebellum- BRAIN: Frontal: higher cognitive function, memory retnetion, voluntary eye movements, voluntary motor movment and speech in Broca's area.
- -Temporal: integrates somatic, visual and auditory data, contains wernecke's speech area.
- -Parietal lobe: interprets spatial info and contains the sensory cortex.
- -Occipital: processing of sight takes place in the occipital lobe. -contains: basal ganglia (group of structures: initiation, execution, and completion of vluntary movements, learning, emotional response and autonomatic movements associated with skeletal muscle activity), thalamus ( above brainstem, major relayy center for afferent inputs), hypotlhamus (below thalamus, regulates the ANS and the endocrine system) and limbic system (located near innner surfaces of hemispheres: oncerened with emotion, aggression, feeding, behavior and sexual response)=> Brainstem: midbrain, pons, and medulla. where ascending and descending fibers pass through from cerebrum and cerebellum. Nuclei of crainal nerves 3-12 are in brainstem. Vital centers: respiratory, vasomotor, and cardiac function located in medulla.-reticular formation: diffusely arranged group of neurons and their axons that extends from the medulla to the thalamus and hypothalamus. Functions of: relaying sensory info, influencing excitatory and ihibiory control or spinal motor neurons and controlling vasomotor and respiratory activity. -Reticular Activating system: complex system that requires communication among the brainstem, reticular formation and cerbral conrtex. RAS: responsible for regulating arousal and sleep wake transitions. Brainstem also contains centers for sneezing, coughing, hiccupping, vommiting, sucking and swallowing. => Cerebellum: Inferior to the occiptital lobe, coordinates voluntary movment and maintains truck stability and equilibrium; receives info from the cerebral cortex, muscles, joints and inner ear.
=> Brain: Cerebrum, brainstem, cerebellum
Cerebrum, brainstem, cerebellum
- - BRAIN: Frontal: higher cognitive function, memory retnetion, voluntary eye movements, voluntary motor movment and speech in Broca's area.
- -Temporal: integrates somatic, visual and auditory data, contains wernecke's speech area.-Parietal lobe: interprets spatial info and contains the sensory cortex.
- -Occipital: processing of sight takes place in the occipital lobe.
- -contains: basal ganglia (group of structures: initiation, execution, and completion of voluntary movements, learning, emotional response and autonomatic movements associated with skeletal muscle activity),
- thalamus ( above brainstem, major relayy center for afferent inputs)
- hypotlhamus (below thalamus, regulates the ANS and the endocrine system) and limbic system (located near innner surfaces of hemispheres: concerned with emotion, aggression, feeding, behavior and sexual response)
- => Brainstem: midbrain, pons, and medulla. where ascending and descending fibers pass through from cerebrum and cerebellum. Nuclei of crainal nerves 3-12 are in brainstem.
- Vital centers: respiratory, vasomotor, and cardiac function located in medulla.
- -reticular formation: diffusely arranged group of neurons and their axons that extends from the medulla to the thalamus and hypothalamus.
- Functions of: relaying sensory info, influencing excitatory and inhibiory control or spinal motor neurons and controlling vasomotor and respiratory activity.
- -Reticular Activating system: complex system that requires communication among the brainstem, reticular formation and cerbral conrtex. RAS: responsible for regulating arousal and sleep wake transitions. Brainstem also contains centers for sneezing, coughing, hiccupping, vommiting, sucking and swallowing.
Inferior to the occiptital lobe, coordinates voluntary movment and maintains truck stability and equilibrium; receives info from the cerebral cortex, muscles, joints and inner ear.
**Cerebrospinal Fluid (CSF):
- Circulates within subarachnoid space taht surrounds brain, brainstem and spinal cord. Provides cushioning for the brain and spinal cord, allows fluid shifts from the cranial cavity fo the spinal caviity, and carries nutrients.
- -Formed in choroid plexus in ventricles from both passive diffusion and active transport of substances.
- -Resembles ultrafiltrate of blood; absorbed through arachnoid villi into the intradula venous sinuouses and eventually into venous system
- -Excessive build up of CSF: "hydrocephalus"
- -CSF compositon: gives info about certain NS diseases, pressure measuresd in patient's with intracranial injury suspected. CSF pressure
- => Intracranial pressure -> downward herniation of brain and brainstem.
**PERIPHERAL NERVOUS SYSTEM:
-Cranial vs spinal nerves?
- Spinal and cranial Nervves with associated Ganglia (grouping of cell bodies)**
- **Spinal Nerves:
- -Each pair contains dorsal (afferent sensor) and ventral (efferentt motor) fibers which innervate specific body regions.
- -Cell bodies of autonomic (involuntary ) motor system located in anterolateral portion of spinal cord gray matter. Sensory fibers located in dorsal root angial.
- -Dermatome: area of skin innervated by the SENSORY fibers of a single dorsal root of a spinal nerve. Myotome: muscle group innervated by primary motor neurons of a single ventral root.
- **Cranial Nerves: -12 paired nerves composed of cell bodies with fibers tat exit from cranial cavity. CNS can be mixed with both motor and sensory.
- Mnemonic for the Cranial Nerves: Oh, Oh, Oh. To Touch A Female's Ass Gave Victor Sucha Hard-on.
Oh, Oh, Oh. To Touch A Female's Ass Gave Victor Sucha Hard-on.
CN 1 Olfactory: Sensory -Smell
CN 2 Optic: Sensory: vision
CN 3 Oculomotor: Motor: eye movment muscles,
CN 4 Trochlear: Motor: One eye movment muscle (superior oblique muslce)
CN 5 Trigeminal: Sensory: Forehead, side of face, below face
CN 6 Abducens: Motor: Lateral movment of eye
CN 7 Facial: mixed: Motor (facial muscles, close eyes, labial speech, close mouth) Sensory (taste)
CN 8 Acoustic: Sensory: Hearing and equilibrium
CN 9 Glosso-pharyngeal: Mixed. Motor (pharynx-phonation and swallowing), sensory (taste on posterior one third of tongue, pharynx -gag reflex
CN 10 Vagal: Mixed: Motor (pharynx and larynx-talking and swallowing) Sensory (general sensatioin from carotid body, carotid sinus) Parasympathetic (carotid reflex)
CN 11 Spinal Accessory: Motor: movement of trapezius and sternomastoid muscles
CN 12 Hypoglossal: Motor: Movement of tongue.
**Autonomic Nervous System:
-Sym and Parsym
-Cerebral Circulation: Blood Brain Barrier, Meninges (protective structures)
- - Divied into sym and parasymph systems. Governs involuntary functions through both efferent and afferent pathways.
- -Pregagnllionic cell bodies of SNS are located in spinal segments T1-L2. Norepinephrine released.
- -In parasympathetic: located in brainstem and sacaral spinal segments. Acetylcholine is neurtorasmitter released.
- -SNS: fight or flight vs PNS: conservsd energy (parachute-slows down)
=> Protective structures:
- **Cerbral Ciirculation: -brain's blood supply arises form internal carotid arterias and bertebral arteries.
- -Circle of willis-
- Venous blood drains from the brain trhough dural sinuses that drain into the two jugular veins.
- => Blood brain barrier: physiologic barrier b/w blood caps and brain tissues. Protect brain from harmful agents, allows nutrients and gases to enter. Lipid soluble compounds enter bhrain easily but water soluble and ionized drugs enter slowly.
three protective membranes that surround brain and spinal cord: dura mater, arachnoid and pia mater.
- Arachnoid mater: delicate membrane that lies between dura mater and pia mater (delcicate innermost layer of meninges); filled with CSF.
- -Skull: protect from external trauma.
- -Vertebral column: protect spinal cord
**NEURO: GERONTOLOGIC CONSIDERATIONS**
=> CNS Brain
=> Functional: Motor & Sensory
=> CNS Brain:
Decrease in Cerebral Blood flow/metabbolism (alternation in mental functioning), decreased efficiency of temp regulation (impaired ability to adapt to environmental temp), Decreased neurotramsmitters, loss of neurons (conduction of nerve impulses slowed, response slowed, changes in gain and ambulation, Diminished kenesthetic sense) Decreased Oxygen supply (alterened balance, vertigo, syncope, increased postural hypotension. Cerebral tissue atrophy and increased size of ventricles (propioception decreased and sensory input)
=> PNS: Cranial/spinal Nerves:
Loss of myselin, donduction time, (Decreased rxn time in specific nerves), cellular degneration, death of neuron (decreased speed and intesity of neuronal reflexes)
=> Regular formation/RAS:
- => Functional Divisions:
- -Motor: Decreased muslce bulk: diminisehd strenght and agility
- -Sensory: Decreasesd sensory resptors, electrical activity (slowing in sensory receptioon), atrophy of taste buds (malnutrition, weight loss) Degenernation and loss of fibers in olfactory bulb (diminished snes of smell. Denegrate changes in nerve cells in inner ear, cerebellum and propioceptive pahtways (poor ability to maintain balance, widened gait), decreased deep tendon reflexes (below average reflex score) and decreased sensory conduction velocity (sluggish reflexes, slowing of reaction time)
Modificiation of hypothalimic function, decreased stage 4 sleep -> disturbances in sleep
=> ANS: Symp/PS:
Morphologic features of ganglia, slowing of ANS responses -> Orthostatic hypotension, systolic hypertension.
**Purpose & Function of Neuro System
- Important in considering how you're going to test for these nerves. Provide the functions of:
- Sensation: Ability to receive and process stimuli received through the sensory organs.
- Perception: Ability to experience, recognize, organize, and interpret sensory stimuli.Cognition: Intellectual ability to think, which includes memory, judgment, and orientation.
- **Function of Neuro system-Receiving info from internal and external environment via sensory afferent nerves
- -Communicating info between periphery with CNS: perception
- -Process info from reflex (spinal) with conscious (brain) for response
- -Transmit info via motor (efferent) nerve for body movement
**Structural Protection for the Central Nervous System-
Subdural hematoma, subarachanoid bleeding. Talking about lining in brains, when there's bleeds in those layers, causes pressure on brain which permanently or temporarily damages the brain.
-from stroke or external blow depending on location of injury, be familiar with how that person is going to show that/manifest that.
**Spinal Nerves(31 Pairs)
- -Cervical (8 pairs)
- -Thoracic (12)
- -Lumbar (5)
- -Sacral (5)
- -Coccygeal nerve (1)
-cranial nerves-spinal nerves comes from spinal nerve that innervate different parts of your body.
T-6: thoracic area, concerned about breathing/diaphgram
C-5ish: Difficulty/poor sensation of arms
==> Neurological Assessment (Subj)
-Past Med History
- **Past Medical History
- -Diagnostic evaluation or hospitalization for a neurologic disorder: Lay people=sensory deficit
- -Cranial or spinal column surgery
- -Head or spinal cord trauma
- -Birth trauma
- -Cardiovascular disorder
- -Psychiatric counseling
- **Health History:
- =>Past healthy history: -First avoid suggesting symptoms or asking leading questions. Second the mode of onset and the course of the illness are especially imporaant aspect of the history. Birth injuries included.
- -Medications: sedatives, opioids, tranquilizers, mood elevating drugs-Surgery
- =>Functional Health Pattern: -Patient health practices: substance abuse, smoking, adequate nutrition, blood pressure control, safe partipication in physical recreational activities, seat belts
- -Nutrition: problem related to chewing, muslc cooratation, facial nerve paralysis, cobalamin deficiency
- -Elimination pattern: incontinece associated with neurological issues
- -Activity/exercise: affect pt mobility strenght, cooordiation
- -Sleep: hallucination, dementia, drugs?
- -Cognitive: memory, language, calculation ability, problem solving, insight, judgement, Delirium (acute and trasient disorder of cognition that can be seen at any time), understand language?
- -Self perception: physical apprearnce and emotional control altered by neurological disases
- -Role Relationship: weakness / paralysis can alter or limit participation
- -Sexuality: cerebal lesion: inhibit desire phase or the reflex response of the excitement phase. Brainstem and spinal cord lesion: interrupt desire or ability to have intercouse
- -Value/Belief pattern
- **Family History
- Neurologic disorders Epilepsy Neurofibromatosis Muscular dystrophy Multiple sclerosisAmyotrophic lateral sclerosis Huntington chorea Alzheimer’s disease Mental retardation
- Psychiatric disorders: schizophrenia, bipolar, major depression, generalized anxiety disorder, personality disorders
- **Psychosocial History -Environmental and occupational hazards: exposed to things that would damage the nerve system like "nerve gas" from factories, radiation, work places where you can sustain a fall, includes carpel tunnel (secretaries, long term student)
- Emotional status
- Intellectual level: cognitive deficits
- Alcohol use: damages your brain, bathed in liquid, binge drinks -> neurological deficit
- Recreational drug use: marijuana, wide-spread=> cognitive deficits.
NEURO: OBJECTIVE DATA:
1. Mental Status.2. Cranial Nerves3. Motor System4. Sensory System5. Reflexes
- 1. Mental Status.
- 2. Cranial Nerves
- 3. Motor System
- 4. Sensory System
- 5. Reflexes
- =>Mental Status
- A. LOC: Level of Consciousness
- B. Orientation: person, place, time, situation: why are you here today?
- C. Mood and behavior: is it congruent to their behavior, crying in happy day.
- D. Knowledge: tests for cognitive abilities. Something that they know and that YOU know the answer to.
- E. Vocab: should be culturally sensitive, "picnic" baskets.
- F. Memory: Reasonably expect them to know
=> Cranial Nerve function
=>Language and speech: head trauma, woke up speaking another language. Or spoke back to native tongue, are they using language you expect them to use? are responses appropriate?
- => Meningeal signs: lay flat and tilt chin down, irritation with menigeal linking b/c your stretching the irritated membrane which causes pain
- =>Sensory status: touch (numb areas, diabetes pts-signs of neuropathy), pain, proprioception (knowing where you are in space), Temp
- => Motor status:
- a. gait. Steady? ataxic?
- b. muscle strength, tone-symmetrical
- c. coordination, muscle stretch reflex-wack
**Mental Status Screening Questions
- What is your name?-Orientation to person
- What is today’s date?-Orientation to time
- What year is it?-Orientation to time
- Where are you now?- Orientation to place
- How old are you?-Memory
- Where were you born?- Remote memory
- What did you have for breakfast?- Recent memory
- Who is the U.S. president? -General knowledge
- Can you count backwards from 20 to 1? Attention and calculation skills
- Why are you here?-Judgment
** Let’s check our cranial nerves
1. Smell with eyes closed
2. Snellen, vision
3,4,6 together. H, PERRL
5. Sensation to nasal, oral, chewing
7. Smile, show teeth, puff out cheek, raise and lower eyebrows, ID sugar, salt, lemon,
8. Hearing, balance. Whisper “can you hear me”, audiology. Stand on 1 foot
9,10,12 together. Tongue blade say “Ah”, check epiglottis symetrical elevation, tongue movement, check for gag reflex
11. Push chin against your hand, shrug shoulder against your resistance
12. Stuck out your tongue at nurse
**Glasgow Coma Scale
KNOW THAT <7=Coma
=>Eyes open: spontaneously 4, speech 3, pain 2, No Response 1
=>Verbal: Oriented/converese: 5, Disoriented/convereses 4, Inappropriate words 3, Garbled sounds 2, No response 1
=> Motor: Reacts to command 6, Localizes painful stimuli 5, Flexes and withdraw from pain-in unconscious (4), Flexor posture with pain-everything flexes, not just the body pain (3), Extensor posture pain-rub chest and whole body stiffens 2, No response 1
**Neurological Changes in the Elderly
-Decrease in number of cerebral neurons by 1% a year beginning at 50 y.o.
-Decrease velocity of nerve impulse conduction by 10% between 30-90 y.o.
-Decrease in sensory perceptions of touch and pain
-Decrease in problem solving skills
-Remote memory better than recent memory: married vs dinner
-Decrease in synthesis and metabolism of neurotransmitters so increase risk of delirium during physiologic stress: UTI causes physiological stress so neurotransmitters don't work well as their supposed to causing change in LOC or behaviors.
-Hearing loss, vision deficit, or anosmia (alteration of smell)
**Nursing Diagnoses associated with the neuro system
- Acute/chronic confusion
- Altered sensory/perceptions
- Altered thought processes
- Decreased adaptive capacity, intracranial
- Impaired communication
- Impaired environmental interpretation syndrome
- Impaired memory
- Risk for disuse syndrome
- Risk for injury
- Risk for neurovascular dysfunction
- Unilateral neglect: neglecting just one part of yourself, not cleaning one part of their side. Could also be body image disturbance.
1. Assess if pt. had an aura (change in light perception, something heard, a smell) or cried out prior to collapse/posturing
2. Note time of onset. What time did it start and note duration?
3. Note site of initial body movement Whole body seizure, try to find where it started on body
4. Assess skin color, airway (maintain it, have them on their side), incontinent, duration.
5. Post Ictal: after the seizure, Check airway, check for physical injury, reorient them, neuro check
6. seizure precautions: pad siderails, bed in low position
7. Per orders, give medication, check epilepsy medication blood levels. You can give antiseizures through IV line (ativan) to change threshold and bring them out of long lasting seizures.
**Early detection of s/s head injury or stroke
**Prevent Neuro Problems
- -see if they're having a brain bleeding
- Altered LOC
- Headache especially worse in AM
- Clumsiness, numbness, tingling
- Nausea, Vomtting
- Personality changes
- -Stroke signs: speech clarity, stick out arms level, and facial
Wear seat belt
- Don’t drink and drive
- Wear helmet
- Supervise children swimming
- Stay healthy, prevent HTN, DM
NEURO ASSESSMENT: MENTAL STATUS
- Mental Status: Cerebral function; determines complex and high level cerebral functions or cerebral cortex.
- Much of mental status assessed through interaction of patient (language, significant past events) Consider cultural and educational background when evaluating mental status
- General appearance/Behavior: LOC and speech pattern
- Cognition: Orientation. “How much money is a dime and nickel?” Any factors of cognitive impairment? Hallucinations, delusions, dementia.
- Mood and affect: Take appropriateness into account.
- Recognize odors.
- Chronic Rhinitis sinusitis, heavy smoking may decrease smell sense. Disturbance associated with tumor in olfactory bulb or basilar skull fracture that damaged olfactory fibers as they pass through delicate cribriform plate of the skull.
Optic Nerve (CN 2):
- Tell pt. to look at your nose and move finger into periphery. Visual field defects: from lesions of optic nerve, chiasm or tracts that extend through temporal, parietal or occipital lobes.
- Hemianopsia: visual field changes resulting from brain lesion vs. Quadrantanopsia (1/4th) or monocular.
- Snellen TEST
Oculomotor (CN3), trochlear (CN4) and Abducens (CN 6):
Nerves help move the eye, tested together. Move focus of eyes around the shape of “H”.
- Disconjugate gaze: eyes do not move together due to weakness or paralysis
- Nystagmus: fine rapid jerking movement of the eyes indicates vestibulo-cerbellar problems
- Accommodating (occulomotor): pupils constrict at near vision
- Ipsilateral contraction: shine light into pupil of one eye and Contralateral (consensual) constriction of other eye. Checks intactness of optic nerve.
- Dilated pupils mean compressed oculomotor nerve by expanding lesions causing sympathetic input to the pupil and remains dilated, early sign of central hernia.
- PERRL: Pupils are Equal, Round and Reactive to Light. Accomodating: moving finger towards person nose
- Oculomotor: keeps eyelids open
- Ptosis: drooping eyelid due to muscle weakness
Trigeminal Nerve (CN 5):
Close eyes and sense light touch and pin prink in each of the three divisions (ophthalmic, maxillary and mandibular) on both sides of face.
Clench teeth and palpate masseter muscle just abouve mandibular angle
Corneal reflex: Evaluates CN 5 and CN 7 simultaneous: blink to threat (eyedrop); innervated by ophthalmic division of CN 5. Motor component (blink) innervated by facial nerve 7.
Facial Nerve CN 7:
- Raise eyebrows, close eyes tight, smile, puff cheeks.
- Asymmetry: indicate damage to nerve
- Taste discrimination of salt and sugar in anterior two thirds of tongue is a function of facial nerve -> peripheral nerve lesion.
Vestibulocochlear/Acoustic Nerve (CN 8):
- Close eyes and do webber/Rinne tests.
- Complaints of dizziness, vertigo or unsteadiness
- Oculocephalic reflex: movement of the eyes when the head is briskly turned to the side (in coma)
Glossopharyngeal (CN 9) and Vagus Nerve (CN 10):
Both innervate pharynx. Glosso: sensory and Vagus: motor
Test gag reflex: bilateral contraction of palatal muscles by touching sides of posterior pharynx or solf palate with tongue blade.
Decreased gag reflex => decreased LOC, brainstem lesion, throat musculature disease. Weak or absent => aspiration risk
Say, “ahh” and note bilateral symmetry of elevation of soft palate
Endotracheally intubated: cough reflex (suction cath touches carina)
Accessory Nerve (CN 11):
Shrug shoulders and turn head against resistance. Note symmetry, atrophy or fasciculation of muscle
Hypoglossal (CN 12) :
stick tongue out, note symmetry.
NEURO ASSESSMENT: MOTOR SYSTEM:
- Assess strength, tone, coordination and symmetry of muscle groups
- Push/pull against resistance of arm
- Resistance of shoulders/knees, hips
- Pronator drift: Milk weakness of arm is demonstrated by downward drifting of the arm or pronation of palm
- Muscle tone: move limbs passively through their ROM Should be a slight resistance.
- o Hypotonia: flaccid vs. Hypertonia: Spasticity
- o Tremors or tics?
- o Myoclonus: spasm of msucleso Athetosis: slow, writhing, involuntary movements of extermieties
- o Chorea: involuntary, purposeless, rapid motionso Dystonia: impairment of muscle tone
- Balance and coordination: Gait, Balance
- o Finger to nose
- o Heel to shin
- o Pronate/supinate hands
NEURO ASSESSMENT: SENSORY SYSTEM:
- Touch, pain, and Temperatureo Cotton whisp or light pin prick on four extermities.
- o Sharp vs dull
- o “extinction: simultaneously touching both sides of the body symmetrically. Abnormal if only one side is felt.
- o Temp: only when deep pain isn’t felt
- Vibration Sense: tuning form to bony prominences, pt. lets you know when buzz isn’t felt
- Position Sense: “Proprioception”” place thumb & forefinger and move great toe up or down and indicate direction.
- o Romberg test: stand with feet together and close eyes. Positive: faling when eyes closed. => indicates vestibulocochlear dysfunction or posterior column disease in spinal cord
- Cortical Sensory Function:
- o Two point discrimination: place two points on tips of fingers and toes. 4-5 mm sepearation is recognizable.
- o Graphesthesia: ability to feel writing on skin
- o Stereogenesis: ability to perceive the form and nature of objects
- Reflexes: Tendon receptors sensitive to stretch leading to reflex contraction.
- o Biceps, triceps, brachiolradialis, patellar, Achilles. o 0/5 : absent 2/5=normal, 3 (exaggerated), 4 (hyperrefflexia with clonus-abnormal continued rhythmic contraction of muscle with continuous application of stimulus).
=> Altered Consciousness:
stuporous, mute, diminished response to verbal cutes or pain -> Intracranial lesions, metabolic disorder, psychiatric disorders.
Inability to recognize bodily defect or disease. -> Lesions in right parietal cortex
=> Aphasia or Dysphasia:
Loss of or impaired language faculty (comprehension, expression, or both) -> Left cerebral cortex lesion
Lack of coordination in articulating speech -> Cerebellar or cranial nerve lesion. Antiseizure drugs, sedatives, hypnotic drug toxicity (including alcohol)
Inequality of pupil size -> Opitic Nerve injury
Double vision -> Lesions affecting nerves of extraocular muscles, cerebellar damage
Loss of vision in one side of visual field -> Lesions in the contralateral occiptial lobe
Difficulty in swallowing -> lesions involving motor pathways of CNS 9 and 10 (including lower brainstem)
Paralysis of eye muscles -> Lesions in brainstem
"Choked disc", swelling of optic nerve head -> Increase in intracrania pressure.
Inability to perform learned movements despite having desire and physical ability to perform them -> cerebral cortex lesion
Lack of coordination of movement -> Lesions of sensory or motor pathways, cerebellum. Antiseizure drugs, sedatives, hypnotic drug toxicity (including alcohol)
Impairement of voluntary movment, resulting in framentary or incomplete movements. -> Disorders of basal ganglia, idiosyncratic reaction of psychotropic drugs.
paralysis on one side -> Stroke and other lesions involving motor cortex
Jerking or bobbing of eyes as they track moving objects -> Lesions in cerebellum, brainstem, vestiibular system. Antiseizure drgus, sedatives, hypnotic toxicity (including alchohol)
Loss of pain sensation -> Lesion in spinothalamic tract or thalamus,s peciic medicatin
Absence of sensation -> Lesions in spinal cord, thalamus, sensory cortex, or peripheral sensory nerve. Specific meds also.
Alteration in sensation => Lesions in the posterior column or sensory cortex
Inability to recognize form of obeject by touuch. -> Lesions in parietal cortex.
=> Extensor Plantar Response:
Upgoing toes with plantar stimulation -> Suprasegmental or upper motor neuron lesion
=> Deep tendon reflexes:
Diminished or absent motor response -> Lower motor neuron lesions
=> Bladder dysfunction:
-atonic/autonomous: Absence of muscle tone and contractility, enlargment of capacity, no sensation of discomforot, overflow with large residual, inability to voluntarily empty -> early stage of spinal cord injury
-Hypotonic: More ability than atonic bladder but less than normal -> interruption of afferent pathways from bladder
-Hypertonic: Increase in muscle tone, diminshed capacity, reflex emptying, dribbling, incontinence -> Lesions in pyramidal tracts (efferent pathways)
paralysis of lower extermieties -> Spinal cord transection or mass lession (thoracolumbar region)
=> Tetraplegia/Quadriplegia: Paralysis of all extermities -> Spinal cord transection or mass lesion (cervical region)
=> Cerebrospinal Fluid Analysis:
-Normal: clear, colorless, odorless, and free of RBCs and contains little protein.
-Can be obtained through lumbar puncture or ventriculostomy
- -> Lumbar Puncture: Most common method to sample CSF, contraindicated in the presence of increased intracranial pressure or infection at the site of puncture.
- Before procedure, have patient void. Commonly: patient is side lying but seated position may also be used. Uses sterile needle passed between two lumbar verebrae, he or she may feel temp pain radiating down the leg. Manometer attached to the needle to obtain a CSF pressure.
- -Monitor for headache intensity, meningeal irritation *nuchal rigidity) or s/s or local trauma (hematoma/pain)
- ->CSF aspirated by needle insertion in L 3-4 or L 4-5
Ensure that patient does not have signs of incrased ICP because of the risk of downward erniation from CSF removal. Patient assumes and maintains lateral recumbent position. Use strict aspeptic technique. Ensure labeling of CSF speciments in proper sequence. Encourage Fluids. Monitor neurologic signs and VS. Adminsiter analgesia as needed.
=> Skull /Spine x rays:
Simple xray of skull and spinal column is done to detect fractures, bone erosion, calcifications, abormal vascularity -> Explain that procedure is noninvasive. Explain positions to be assumed.
=> Computed Tomography:
Scans provide a rapid means of obtaining radiographic images of the brain; provide a 3D representation of the intracranial contents, Dense appears white and fluid/air appear dark or blak. Can be completed both with or without contrast media. Detect problems such as hemmorrhage, tumor, cyst, edema, infarction, brain atrophy and other abonrmalities.
->NR: Assess for contraindications to contrast media, including allergy to shellfish, iodine or dye. Explain appearance of scanner. Instruct pt to remain still during procedure.
=> Magnetic Resonance Imaging:
- MRI provides greater detail than CT; improved resolution of intracranial structure. BUT takes longer and not appropriate in life-threatning emergiencies. Imaging of brain, spinal cord, and spinal canal by means of magnetic energy. used to detect strokes, MS, tumors, Trauma, herniation and sizures. No invasive procedures requires. Contrast media may be used to enhance visualization. Has greater contrast in images of soft iissue and structurs than CT scan
- -NR: Screen pt for metal parts and pacemaker in body, instruct pt to lie STILL for up to one hour. Sedation may be necesssary if pt is claustrophobic.
- => Magnetic Resonance Angiography (MRA): Uses differential signal characteristics of floowing blood to evaluate extracranial and intracranial blood vessels. Provide both anatomic and hemodynamic info. Can be used in conjuction with contrast media.
- -NR: Screen pt for metal parts and pacemaker in body, instruct pt to lie STILL for up to one hour. Sedation may be necesssary if pt is claustrophobic.
=> Cerebral Angiography:
Serial xray visualization of intracranial and extracranial blood vessels performed to detect vascular lesions and tumors of brain. Contrast medium used.
** Nursing Resp:
ssess pt for stroke risk before procedure since thrmobi may be disloged during procedue. Withhold preceding meal. Explain that pt will have hot flush of head/neck when contrast medium injected. adminster premedication and explain they must be STILL.
- --Post Procedure: Monitor neurologic signs and vitals every 15-30 min for first 2 hours, every hour for next 6 hrs, then every 2 hr for 24 hr. Maintain bed rest until patient is alert and stable vitals. Report any neurologic status changes.
- -Indicated when vascular lesions or tumors are suspected. Cath inserted into the femoral artery and passed throught he aortic arch and into base of a carotid or vertebral artery for injection of contrast media. Timed sequence radiographic images obtained as contrast flows through arteries, smaller vessels and veins.
- -Identify and localize abscesses, aneurysms, hematomas, arteriovenous malformations, arterial spasm and certain tumors.
- -Invasive: allergic/anaphylactic reaction to the contrast medium. After: observe for bleeding at the cath puncture site (usually groin)
=> Positron Emission Tomography (PET):
Measures metabolic activities of brain to assess cell death or damage. Uses radioactive material that shows up as a birght spot on the image. Used for patients with stroke, alzheimer's desease, seizure disorders, Parkinson's and tumors.
NR. explain procedure, two IV lines will be sierted. Instruct pt not to take sedatives or tranquilizers. Have pt empty bladder before procedure. Pt may be asked to perform different activities during test.
=> Single Photom emission computed tomograplhy (SPECT):
A method of scanning similar to PET, but it uses more stable substances and different detectors. Radiolabeled compounds are injected and their photom emissions can be detected. Images made are accumulation lf labeled compound. Used to visualized blood flow or oxygend or glucose metabolism in brain. Useful in diagnosing strokes, brain tumors and seizures disorders.
-> NR: explain procedure, two IV lines will be sierted. Instruct pt not to take sedatives or tranquilizers. Have pt empty bladder before procedure. Pt may be asked to perform different activities during test.
x ray of spinal cord and vertebral column after injection of contrast medium into subarachooid space. Used to detect spinal lesions (herniated or ruptured disc, spinal tumor)
- -> NR:
- Preprocedure: administere sedative, empty bladder, ptatient on tilting table that moves during test.
- POST: Pt lies flat for few hours, encourage fluid, monitor neurlogic/vital signs, . Headache, nauseea and vomitting may occur.
- records electrical activity of the surface cortical neurons of the brain by elecrodes placed on specific areas of the scalp.
- -Done to evlauate not only cerebral disease but also CNS effects of many metabolic and ssystemic diseases.
- -Seizure disorders, sleep disorders, cerebrovascular lesiiions and brain injury-non invasive. No risk of electrick shock.
Inform pt that procedure is nonivasive, no danger of electric shock, determine whether any meds (tranquilizer, snatiseizures) should be withheld. Resume meds and instruct pt to wash elecrode paste out of hair after test.
Uses biomanetometere to detect magnetic fields generated by neural activity. Can accuratively pinpoint part of brain involed in a stroke, seizure of other disorder or injury. Measures extracranial magnetic fields and scalp electric field (EEG).
-> NR: a passive sensor, no physical contact with pt.
=> Electromyography and Nerve Conduction Studies
-EMG records electrical activy associated with innervation of skeletal muscle. Needle electrodes inserted into the muscle to record speciic motor units because recording from the skin is not sufficient. Normal muscle at rest shows no electrical activity, only shows as muscle contracts.
- -Diseases alter muslce and innervation (segmental/peripheral neuropathic conditions).
- -Nerve conduction studies: applying a brief electrical stimulus to a distal portion of a sensory or mixed nerve and recording the resulting wave or depolarizatiioin at some point proximal to stimulus. The time between the stimulus onset and initial wave of depolarization at the recording. electrode is measuresed. This is known as "nerve conduction velocity". Damaged nerves have slower conduction velocities.
-> NR: Inform pt that pain associated with needle insertion
=> Evoked potential :
recordings of electrical activity associated with nerve conditon along sensory pathways. Electrical activty generated by specific sensory stimulus related to type of study (click sound for auditory vs milky electrical pulses for somatosensory evoked potentials).
-Electrodes are placed on specific areas of the skin and the scalp. Increases in normal time from stimulus onset to a given peak (latency) indicate slowed nerve conduction or nerve damage.
-Diagnose abnormalities of visual/auditory systems because it reveals whether a sensory impulse is reaching the appropriate part of the brain. Indications for these tests include evaluation of consciousness, MS (optic neuritis) and acoustic neuroma.
-> NR: just explain the procedure.
=> Ultrasound: Cartoid duplex studies:
- Cartoid duplex studies: combines ultrasound and pulsed doppler technology. Proble placed over carotid artery and slowly moved along course of commorn carotid artery. Frequency of reflected ultrasound signal corresponds to the blood velocity. Increased blood flow velocity can indicate stenosis of a vessel.
- -> NR: Explain procedure to pt. Duplex scanning s a non invasive study that evaluates the degree of stenosis of the cartoid and vertebral arteries
=> Transcranial Doppler (Ultra):
same tech as carotid duplix but evaluates blood flow velocities of intracranial bvs. Probs placed on skin at various "windows (areas in the skull that have only a thin bony covering to regiester velocities of BVs).
-> NR: Noninvasive, used to assess vasospasm associated suth subarachnoid hemmorrhage, altered intracranial blood flow, dynamics associated with occlusive vascular disease, prescence of emboli and cerbral autoregulation
** Normal CSF values:
- -Spec gracity: 1.007
- pH: 7.35
- Clear, colorless, no RBC's, 0-5 WBCs.
- Lumbar (25-45 mg/dL);
- Cisternal (15-25)
- Ventricular (5-15)
- Glucose: 40-70 mg/dL
- NO microorganism
60-150 mm H20 Pressure
Pain Defn, Dimensions
Pain is whatever the person experiencing the pain says it is, existing whenever the person says it does-Margo McCaffrey
=> Definition of Pain: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage
- **Dimensions of Pain:
- Sensory: sensation
- Affective: how it affects behavior
- Cognitive: how are they thinking about it, feeling about it?
- => pain untreated: causes physical and emotional suffering, depression, anxiety, impaired immune function, reduced healing. Depression and anxiety have chronic pain tolerance.
**Chemicals that activate PAIN
Prostaglandins, veterans/car trauma
release K+, histamines, bradykinins, activate platelets serotonin activate PAN, substance P, dilate blood vessels, edema, more histamines (Inflammation and injury that causes the pain)
=> Fear, anxiety, anger activates ANS:
Releases norepinephrine, prostaglandins, activates on contact, pain impulse to brain. Pain is amplified by emotional state. animals are frightened because they experience pain.
- -99% of hospitalized patient will have pain
- -Opioid is the best pain relief: they don't always work the same for each person
- -1% will have respiratory depression from opiod (decreased respiratory rate or very shallow breathing, don't overdose them)
- -Treat the underlying cause or assist in other ways to avoid any respiratory depression
- -Be creative: distraction
- => Nursing Role“ RN provides direct and indirect patient care serves that insure the …comfort of patients”
- Nursing practice Act, section 2725. We are patient advocates, we are in charge of the patient's pain. If orders we have are not enough, it's up to us to collaborate with physicans to try to get their pain managed better. Nurse Practice Act. Proper management of patient’s pain is incorporated in the RN’s role as a patient advocate Section 1443.5
**Types of Pain & Quality
- Referred: some place else
- Radiating: starts in one spot and leaches off to another
- Ischemic: Pain comes from poor blood flow
- Neuropathic: Neurological
- Psychogenic: In your mind. Not a real injury but brain tells you that there is pain so to the person, it IS very real. Ex. Phantom pain.
- Quality of Pain: "what is it like? stabbing or just throbbing?"
- Cutaneous: localized, sharp
- Somatic: localized aching, throbbing
- Visceral: diffuse,squeezing, crampingNeuropathic: burning, electric
**Classification of Pain: Acute vs. Chronic
Chronic: (Intractable-hard to manage and keep away) >3 months
- Acute: < 3 months or until tissue heals. It is expected to resolve because it's coming from an issue. You're waiting for a bone or tissue to heal.
- -post operative pain, labor, pain from trauma (lacerations, fracture), pain from infection or acute ischemia.
- -treatment: analgesic, postherapic neuraligia: development into a chronic pain.
- -course of pain: decreases over time and goes away as recovery occurs
- -Typical Physical behavior: Manifestiations vary but reflect sympathetic nervous system activation: increased HR, Resp, BP, Diaphoresis, pallor, anxiety, agitation, confusion, urine retention.
- -Goal: Pain control with eventual elimination.
- Severity and functional impact of chrnoic pain often are disproportionate to objective findings because of changes in NS
- -accompanied by anxiety and depression
- Malignant Pain: pathology
- Non-malignant Pain: some tension, but nothing is falling apart or being damaged inside your body.
- -Predominantly behavioral manifestations: Flat affect, decreased physical activity, fatigue, withdrawal from social interaction.
- -Goal: pain control to the extend possible. Focus on enhancing function and quality of life.
=> Pain Intensity
- **Pain Intensity:
- pain meds are ordered by pain intensity, for how bad a pain to the prescriber.
- 0 No pain
- 1,2,3 Mild
- 4,5 Moderate
- 6,7 Severe
- 8,9 Very severe
- 10 Worst Possibe
- **Pain Assessment-0-10 scale
- -Behavior Scales: F/ACC,
- -restlessness, grimacing
- -body tension
- -vocalization changes
- -resistance to ventilation: biting(assess q contact, med,when turn)
- Pain Assessment - PQRST
- P = Precipitating factors: what brought the pain on
- Q = Quality of pain: descriptive words. Feels "heavy, tight, hot"
- R = radiation: where is pain going to
- S = Severity: number, how bad
- T = Timing: How long does it last.
Nursing Managment of Pain
-Barriers to Pain Managment
=> Reducing Barriers to pain managment:
- -Effective communication: pts need to feel confident that their reporting of pain wiell be believed and will not be perceived as complaning.
- =>Challenges to effective pain managment:
- -tolerance (opiodis) charactarized by the need for an increased opioid dose to maintain the same degree of analgesia. Opioid rotation considered, though increased opioid levels can increase pain levels (hyperalgesia)
- -physical dependence: withdrawal symptoms (anxiety, diaphoresis, shaking, dilated pupils, tremors, restlessness, fever, tacycardia, insomnia). Tapering schedule should be used with careful monitoring. Calculate 24 hour dose divide by 2, of this amount, 25% given evenry 6 hours..
- -pseudoaddiction: Inadequate treatment of pain--> pt exhibts wanting more drugs; occurs in a mistrust b/w patient and prvidder.
- -Addiction: complex neurobiologic condition characterized by aberrant behavior. Hallmarks: compulsive use, loss of control of use, continued use despite ris of harm
-Fear of addiction, tolerance, concern about side effects, fear of injections, Desire to be "good" patient, to be stoic, forgetting to take analgesic, concern taht pain indicates disease progression, sense of fatalism, ineffective medication.
- => Pain managment (teaching guide)
- -Self managment technqiues, realistic goals for pain control, negative consequences of unrelieved pain, need to maintain a record of pain level and effectiveness of treamtne, pain should be treated with drugs before it becomes severe, meds may stop working after it is taken for a period of time so dosages must be readjusted, potential side effects/complications associated with pain therapy, need to report when pain is NOT relieved to tolerable levels.
Pain => Gerontological Considerations:
- -persistent pain associated with physical disability/psychosocial problems
- - chronic pain is prevalent: musculoskeletal condtions
- -osteroarthritis, low back pain. Results in depression, sleep distrubance, decreased mobility, increased health care utilization and physical/social role dysfunction.
- -barrier to pain assessment: providers think pain is normal part of aging
- may not repot pain for fear of being a "burden" or a "complainer", use "aching, soreness, discomfort" rather than pain. Carry out assessment in an unhurried manner. they have increased prevalance of cognitive, sensorty perceptual and motor problems that interfere with a person's ability to process info and to communicate.
- Ex: demential, delirium, postroke, aphasia and other communication barriers. Use other assessment tools: large print pain intensity scale.
-Assess depression and functional impairments.
older adults metabolize drugs more slowly than younger people and are at greater risk for higher blood levels and adverse effects. "start low and go slow". Second
: use of NSAIDs is associated wtih high frequency GI bleeding. Third
, older adults often are taking many drugs for one or more chronic conditions. Dangerous drug interactions. Fourth
: cognitive impairment and ataxia are exacerabated by analgesics such as opioids, antidepressants, and antizeizures.
- Informed consent: Diagnostics, IV line meds
- Assess and evaluate response: evaluate the pain med, know onset of medication and how long it's been so you know when it's supposed to kick in and if it's working. Some meds don't work on a few people.
- Cultural sensitive: mom and son having pain, secret?
- Est. therapeutic relationship: your patient knowing that you care about them helps them deal with it more
- Use distraction
- Relaxation techniques
- Breathing, imagery, music
- Massage: as long as you don't damage anything.
- Transcutaneous stimulation: chronic pain, tens unit, neurostimulaton around the area that hurts to distract the nerves.
- Exercise: chronic back piain
- Administer Medications
1.Describe the origins of pain
=> Nociceptive Pain:
=> Neuropathic Pain
- -Normal processing of stimulus that damages normal tissue or has the potential to do so if prolonged.
- -Treatment: usuall responsive to nonopioid and or opioid drugs
- ->Types: Superficial somatic pain, Deep somatic pain, visceral pain
- 1. Superficial Somatic: pain arising from skin, mucous membranes, subcutaneous tissue. Tends to be well localized. Examples: Sunburn, skin contusions.
- 2. Deep Somatic Pain: Arseing from muscles, fasciae, bones, tendons. Localized or diffuse and radiating. Examples: arthritis, tendonititis, myofascial pain
- 3. Visceral pain: activation of nociceptors in interal organts, respond to inflmmation, streching and ischemia. Distension produces cramping pain. Pain arising from visceral organs, such as GI tract and bladder. Well or poorly localized. Often referred to cutaneous sites. Ex: appendicitis, pancreatitis, cancer affecting internal organs, irritable bowel and bladder syndromes.
**Complex Regional Pain Syndrom:
- => Neuropathic Pain: Abnormal processing of sensory input by the peripheral or central nervous system. Typically described as numbing, hot, burning, shototing, stabbing, sharp, or electric shock like pain. Intense, short lived or lingering.
- -Treatment: usually includes adjuvant analegesics
- => Types: Central, Peripheral nerupathies, Deafferentation pain, Sympathetically maintained pain.
- 1. Central : Caused by primary lesion or dysfunction in the CNS. Ex: Poststroke pain, pain associated with multiple sclerosis.
- 2. Peripheral Neruopathies: pain felt along the distribution of one or many peripheral nerves caused by damage to the nerve. Ex Diagetic neruopathy, alchohol nutritional neuropathy, trigeminal nerualigia, postherpetic neuraliga
- 3. Deaffernetation pain: resutls from a loss of afferent input. Ex: Phantom limb pain, postmastectomy pain, spinal cord injury pain. 4. Sympathetically Maintained Pain: associated with dysregulation of the autonomic ns and central pain is caused by CNS lesions or dysfunctions. persists secondary to sympathetic nervous system activity. Ex: phantom limb pain, complex regional pain syndrome.
debilitating type of neuropathic pain, dramtic changes in color and temp of skin over the affectedd limb or body part accompanied by insense purning pain, skin sensitivity, sweating and swelling. Trigged by tissue injur, surgery or vascular event such as stroke. Or peripheral nerve lesion (type 2)
=> Core Principles of Pain Assessment and Nursing Implications:
- 1. Patients have the right to appropriate assessment and managment of pain (assess in all patients)
- 2. Pain is subjective (pt's self report of pain the the single most reliable indicator of pain.)
- 3. Physiologic and behavioral signs of pain (tachycardia, grimacing) are not reliable or specific for pain (don't rely primary on onservations and objective signs unless pt can't tell you)
- 4. Pain is unpleasant sensory and emotial experience (address both physical and spychological aspects when assessing)
- 5. assessment appropatches, including tools must be appropriate for the pt population (special considerations are needed for assessing pain in patient's with difficulty communication, included family members when appropriate)
- 6. Pain can exist without a physical cause (don't attribute pain that doesn't have an identifiable cause to psychological causes)
- 7.Diff pts experience diff levels of pain in comparable stiuli (no uniform threshold for pain exists)
- 8. Pt with chronic pain may be more snesitive to pain and other stimuli (pain tolderance varies)
- 9. Unrelieved pain has adverse consequences. Acute pain that is not adequately controlled can result in physiologic changes that increase the likelihood of developing persisten pain (encourage pt to report pain and follow through with pain meds.)
=> Goals of Nursing pain assessment:
diescribe pt pain experience in order to identifiy and implement appropriate pain management techniques and identify the pt's goal for therapy and resources for self management.
- is a state in which an individual lacks conscious awarness of environmental surroundings but can be eassily aroused.
- -Sleep disturbance: used to indicate conditions of poor sleep quality
- -Sleep disorders are abnormalities unique to sleep. Dyssomnias or parasomnias.
- Dysomnia is a term used to describe problems associated with initiating or maintaing sleep.
- Parasomnia: a group of sleep disorders that involve unwanted events or experiences that occur while you are falling asleep, sleeping or waking up. Parasomnias may include abnormal movements, behaviors, emotions, perceptions or dreams.
=> Sleep cycle
- Regulated by brainstem, hypothalamus, and thalamus.
- -Reticular Activating system: clusster of neuronal structures in middle of brainstem. Associated with generalized cortical activation and behavioral arousal. Various transmitters promote wake cycle: glutamate, acetylcholine, norepinephrine, dopamine, histamine, seoronin
- -Alzheimers: loss of cholinergic nerurons --> sleep disturbances
- -Parkinsons: degeneration of dopamine -> excessive daytime sleepiness.
- -Narcolepsy: decreased levels of orexin or it's receptors lead to difficulties staying awake.
- -melatonin: endogenous hormone produced by the pineal gland in beain, tied to light/dark cycle
- -Suprachiasmatic nucleaus in the hypothalamus is the master clock.
- ** Sleep Cycle:
- -A sleep cycle lasts beteween 70-90 minutes. -Pass through 4-6 sleep cycles for 7-8 hours of sleep.
- -As sleep progress need less NREM stage 3 & 4 and more REM sleep.
- -Stages of Sleep: NREM and REM
** Four stages of NREM sleep:
Transitional stage betweeen wakefulness and sleep. Relaxed but still sort of aware of surrounding. Easily aware.
Person falls asleep but still aroused relatively easy, encompasses most of the night's sleep.
Deeper sleep and arousal becomes increasingly difficult.
- -Stage 4: Greatest depth of sleep called delta sleep, slow brain waves recorded on
- EEG:Electroencephalographic wave forms , Decrease vital signs, relaxed muscles.
- => Stage 3 & 4 needed for physical recovery and healing. The following occur during stage 3 &4 of sleep:
- -Somnambulism: sleep walking
- -Somniloquy: talking in your sleep
- -Bruxism: grind teeth
- -Enuresis: wetting bed
- -Night Terrors: usually in children, not seeing you, still living it.
**Stages of Sleep:
- -Rapid Eye Movement Sleep (REM):-active brain waves on EEG.
- -Eyes dart quickly back and forth
- -Facial muscle twitching
- -Large muscle lose tone and flaccid.
- -Vs fast or irregular-Increased gastric secretions: "great for GERD"?
- -Increased Metabolism
- -Required for mental and emotional equilibrium
- -Required for learning, memory and adaptation --> Problem when taking sleep aides, not enough quality sleep
- -Dreams and nightmares occur during REM
- -When deprived of REM sleep spend more time in REM sleep the following nights.
**Sleep in the Elderly:
- -Require a longer time to fall asleep
- -wake up earlier and more frequently during the night
- -Tend to nap during the day so sleeps less during the night; limit naps less than one to three hours; hospital shifts sleep pattern
- -Less able to cope with changes in their usual sleep pattern
**Alterations in Sleep Patterns:
Insomnia, Hypersomnia, Narcolepsy, Sleep Apnea, Somnambulism, Somniloquy, Enuresis, Bruxism
- -insomnia-difficulty falling asleep
- -Hypersomnia: sleeping too much
- -Narcolepsy: Uncontrollable desire to sleep
- -Sleep Apnea: periods of no breathnig during sleep; obstructive due to pallete and then regular.
- -Somnambulism: sleep walking
- -Somniloquy: sleep talking
- -Enuresis: bed wetting
- -Bruxism: Teeth grinding
- characterized by difficulty falling/remaining asleep, waking up too early or comomplaints of waking up feeling unfrefreshed.
- -acute: difficulties falling/remaining asleep at least 3 nights per week for less than a month
- -Chronic: one month or longer, increases with age up to 65.
- -Exacerbated by drinking alchol, smoking close to bedtime, taking long naps in afternoon, exercising near bed time, having jet lag-comorbid insomnia
- => Clinical manifestations: difficulty fallling asleep (long sleep latency), Fragmented sleep (frequent wakening), prlonged nightime awakening, feeling unrefreshed (non restorative sleep)
- => Diagnositic Studies:
- -Self Report: subjective complaints
- -Actigraphy: relatively non invased method of monitoring rest/activity cycle, wron on ritest to measure gross motor acivity.
- -Polysomnography: clinical PSG study done only if there are symptoms or signs of another sleep disorder. Electrodes siultaneously record physiological measures that define main stages of sleep and wakefulness: muscle tone recorded using electromyogram, eye movements recorded with electrooculogram, and brain activity recorded through EEG. Airflow measured, non invased oxygen saturation
- => collaborative care:
- -Sleep hygiene: variety of different practices taht are imporant to have normal quality nightime sleep: Don't go to bed unless sleep, if you aren't asleep after 20 mins get out of bed, adopt a regular bedtime pattern, make bedroom quiet, dark and bit cool, don't read, write,eat,watch tv, talk on phone in bed..avoid caffeine, nictoine, alcohol 4-6 hrs before bed, don't go to bed hungry, avoid strenous exercise within 6 hours of bedtime, avoid sleeping pills, practing relaxation tecniiques.
- -Behavioral strategies for Insomnia: limit amount of time individual can stay in bed, maintain a scheduled time to get up in the morning, go to bed only when an individual feels sleepy and geot out of bed when unable to sleep.
- => Drug therapy: Rebound insomnia is common with abrupt withdrawal of some hypnoitic meds
- -benzodiazepenes: activate gaba receptors to promote sleep (valium)Melatonin Receptor Agonist: don't cause tolerance
- -Antidepressants: sedative properties
- -Antihistamines:; tolerances develops quickly
=> Nursing assessment Sleep:
-Sleep disturbances in hospital
- - sleep assessment: self report and objective data; ask about sleep aides
- -sleep diary for two weeks
- -Patient's med history (benign prostatic hyperplasia), psychiatric problems, work schedules
- => Nursing Diagnosis: insomnia, sleep deprivation, distrubed sleep pattern, readiness for enhanced sleep.
**Sleep disturbances in the hospital:
- => Nursing Implementation:
- - reducing dietary intake of subtances containing caffeine, reduce light and noise levels, teach pts about sleep meds
-Decreased REM sleep, patients with sleep apnea should use continuous positive airway pressure (CPAP)
- -chronic neurologic disorder caused by the brain's inability to regulate sleep wake cycles normally. Pts often go direcetly into REM from wakefulness, experience fragmented and disturbed nightime sleep.
- Two categoroies, one includes "Cataplexy": brief and sudden loss of skeletal muscle tone or muscle weakness. Manifest as a breat eposode of muscle weakness or complete postural collapse and faling. Triggered by anger, suprprise and laughter.
- -associated with deficiency of orexin-neuropeptide linked to waking, suspected autoimmune disorder
Sleep parlysis: temporary paralysis of skeletal muscles that occur in the transition from REM to waking
=> Nursing Managment: E
ncourage 3 15 minute naps during day.
modanafil, serotoinin reuptake inhibitors.-Safety precautions: driving
**Circadian rhythm disorders: dilation of cerbal blood vessels, irritability
**Sleep disordered breathing:
Jet lag disorder and shift work sleep disorder. Melatonin is effective as a sleep aide to help synchronize body's rhythm
**Sleep disordered breathing: indicates abnormal respiratory patterns associated with sleep: snoring, apnea, hypopnea ( shallow respirations; by 30-50 % reduction in airflow) due to narrowing of air passages with muscle relatxation, tongue and soft palate fall backward. Hypoxemia and hypercapnia experienced.
=> clinical manifestations: frequent arousals during sleep, insomina, excessive daytime sleepiness, morning headaches (hyperccapnia or increased blood pressure that causes vasod
** SLEEP: Gerontologic Considerations**
- -> Decreased amount of deep sleep, increase in arousal and awakenings
- -more difficult maintaining sleep, overall shorter sleep time, decreased sleep efficiency, more awakening
- -Even healthy older adults often have fragmented sleep, norcturnal wakefullness, use sleep assessment for them
- -Factors affecting sleep quality: depression, heart disease, body pain and cognitive problems.
- -awakening and getting out of bed at night to use bathroom increase the risks for fall.
- -chronic condidtions more common in elderly (COPD, diabetes, demential, chrnic pain)
- -"PM": Diphenhydramine: siedating with anticholnergic effects, should be used cautiously; more sensitive to sedative drugs; metabolism of most hypnotic drugs decreases
- -Those who take benzodiazepines are at increased risk of daytime sedation, falls, and cognitive and psychomotor impairment
- undesirable behavior that occur while falling asleep: sleep walking, sleep terrors- sudden awakening rom sleep along with a loud cry and signs of panic. Increased heart rate and respiration and diaphoresis. (during NREM). Nightmares: recurrent awakening with recall of a frightful or distrubed dream (tinal stage of REM)
**Dx: Sleep pattern disturbance, Fatigue, Activity Intolerance
=> Interventions to promote Sleep
Sleep pattern disturbance, Fatigue, Activity Intolerance
- => Interventions to promote Sleep
- -Sunshine, exercise, melatonin
- -Provide a quiet environment
- -Initiate relaxation techniques
- -Avoid Caffeine After 3 pm
- -Minimize disruptions of sleep time