Neuro disorder part 1

Frontal Lobe Functions

• Written speech, or the ability to write, is governed by the frontal lobe.
• Motor speech, encompassing the muscles required for speaking, is also controlled by the frontal lobe, specifically Broca's area.
• Individuals who experience a stroke affecting Broca's area may develop expressive aphasia, which is difficulty in speaking and expressing oneself.
• Motor ability, referring to body movements, is another function of the frontal lobe.
• The left brain controls the right side of the body, while the right brain controls the left side.
• Analysis and intellectualization, involving the ability to form concepts, are also attributed to the frontal lobe.
• The frontal lobe is responsible for personality, emotions, behavior, and judgment formation.
• Movement is a key function associated with the frontal lobe.

Parietal Lobe Functions

• The parietal lobe primarily processes sensory information, including touch, pain, and temperature.
• It is responsible for the recognition of body parts and spatial awareness.
• The parietal lobe enables the determination of left from right, as well as the perception of shapes, sizes, and distances.

Temporal Lobe Functions

• Wernicke's area, located in the temporal lobe, is crucial for language comprehension.
• It integrates auditory stimuli, enabling understanding of spoken words.
• Damage to Wernicke's area can result in receptive aphasia, characterized by the inability to comprehend spoken or written language.

Occipital Lobe Function

• The occipital lobe is dedicated to processing visual impulses.

Neurological History Assessment

• A thorough neurological history is essential in assessing patients for neurological disorders.
• Key aspects of the history include headaches, new onset of clumsiness or loss of function, changes in visual acuity, new or worsening seizure activity, and paresthesias (numbness and tingling).
• Assessment also includes pain in an extremity or other body part, especially neuropathic pain resulting from neurological damage.
• Personality changes, mood swings, and extreme fatigue or tiredness are also important factors to consider.
• A neurological history aids in identifying clues and anticipating potential issues, which helps to guide clinical judgment and patient care.
• History includes symptoms, signs and patient perceptions
• When taking history about headaches, take special note if the onset is after middle age and if there are changes in the type of headaches experienced.

Mental Status Assessment

• Mental status assessment is a critical component of neurological evaluation.
• Orientation is assessed to determine if the patient knows who they are, where they are, what time it is, and the purpose of their visit.
• Mood and behavior are evaluated to identify any changes or abnormalities.
• General knowledge is tested to assess cognitive function and awareness of current events.
• Short-term and long-term memory are assessed using techniques such as recalling a set of words or recalling past events.
• Concentration and attention span are evaluated to identify any deficits in cognitive function.

Level of Consciousness

• Changes in the level of consciousness are early and sensitive indicators of neurological changes.
• A decrease in the level of consciousness may be an early sign of increased intracranial pressure.
• Impaired cerebral blood flow or decreased oxygenation can contribute to changes in consciousness.

Arousal vs. Awareness

• Arousal refers to wakefulness and the ability to open the eyes spontaneously, in response to voice or pain.
• Arousal indicates that the brainstem is functioning.
• Awareness involves the ability to interact with and interpret the environment, including tracking individuals and responding to commands.
• A person can be awake but not alert, meaning they can have their eyes open but not respond to the environment.
• Alertness demonstrates a patient's responsiveness to the surrounding environment

Defining Levels of Consciousness

• Alert: Responds appropriately to auditory, tactile, and visual stimuli.
• Disorientation: Unable to follow simple commands, slowed thinking, inattentive, or flat affect.
• Stupor: Responds to verbal commands with moaning or groaning, appears unaware of surroundings.
• Semi-comatose: Impaired state of consciousness, can be aroused only by energetic stimulation.
• Comatose: Unable to respond to painful stimuli; absent corneal or pupillary reflexes; cannot swallow or cough; incontinent of urine and feces; decreased or absent EEG activity.

Awareness Components

• Awareness has four components: orientation, memory, attention span and knowledge.
• Orientation: Assessed by asking person, place, time, and purpose questions.
• Memory: Assessed for both short-term and long-term recall, avoiding yes/no questions.
• Assessment of knowledge: Local and national news is assessed

Glasgow Coma Scale (GCS)

• Is a tool used to assess the degree of Consciousness impairment in critically ill patients
• The Glasgow Coma Scale is a standardized system for assessing the degree of consciousness impairment and predicting outcomes, especially in head injuries.
• It evaluates eye-opening, best verbal response, and best motor response.
• Each category is scored, and the scores are added together.
• The highest possible score is 15, indicating no neurological impairment.
• A score of 8 or less indicates a coma.
• The lowest possible score is 3.

Four Coma Scale

• A newer coma scale specifically designed for patients with neurological conditions that affect cognition, such as stroke, craniotomy, or traumatic brain injury (TBI).
• It assesses eye response, motor response, brain stem reflexes, and respiration pattern.
• Each component is graded on a scale of 0 to 4.
• Scores are not totaled; instead, each component is assessed individually.

Language and Speech Assessment

• Speech function is controlled by the dominant hemisphere, which is typically the left side of the brain.
• Aphasia: Language function is defective or absent due to injury to the cerebral cortex.
• Broca's area (frontal lobe) and Wernicke's area (temporal lobe) are commonly involved in aphasia.
• Sensory aphasia (receptive aphasia): Inability to comprehend spoken or written words.
• Motor aphasia (expressive aphasia): Inability to speak or write.
• Global aphasia: Inability to comprehend or speak.
• Anomic aphasia: Inability to name objects.
• Dysarthria: Difficult or poorly articulated speech resulting from interference in the control of speech muscles.

Cranial Nerve Assessment

• Olfactory (I): Identifies common odors.
• Optic (II): Tests visual acuity and visual fields.
• Oculomotor (III): Tests movement of the eyes together in all directions and pupillary response.
• Trochlear (IV): Tested along with oculomotor to assess eye movement.
• Trigeminal (V): Tests jaw strength, sensation of the face, and corneal reflex.
• Abducens (VI): Tested with oculomotor to assess eye movements.
• Facial (VII): Assesses symmetry of facial movements and identification of tastes.
• Acoustic or Vestibulocochlear (VIII): Tests hearing and equilibrium/balance.
• Glossopharyngeal (IX): Identifies tastes and assesses gag reflex.
• Vagus (X): Controls movement of the uvula and soft palate, and can cause significant vital sign issues when stimulated.
• Spinal Accessory (XI): Assesses shoulder and neck movement.
• Hypoglossal (XII): Tests tongue motion.

Motor Function Assessment

• Evaluates gate, stance, posture, muscle tone, coordination, and involuntary movements.
• Assessment includes observation for paralysis (loss of function) or paresis (lesser degree of movement).
• Flaccid: there is literally no muscle tone.
• Terms to know include:
  • Tremors: are an involuntary sudden movement or muscle contraction.
  • Fasciculations: Small, localized, spontaneous, involuntary contractions
  • Clonus: An alternating contraction and partial relaxation of a muscle and it's initiated by muscle stretch

Sensory and Perceptual Status Assessment

• Assesses pain, touch, temperature, and proprioception (awareness of body position and muscle activity).
• Unilateral neglect: Individual is perceptually unaware or inattentive to one side of the body.
• Hemianopsia: Defective vision or blindness in half of the visual field.

Diagnostic Tests for Neurological Disorders

• Lumbar puncture: Insertion of a needle into the subarachnoid space to collect cerebrospinal fluid for testing contraindicated in patients with increased intracranial pressure due to risk of brain herniation, patients must lay flat for several hours, a blood patch may be administered if the patient has a headache.
• CT scan: With or without contrast; assesses for allergies to iodine or shellfish if contrast is used; evaluate BUN and creatinine levels; patients should be NPO for 4-6 hours prior.
• Brain scan: Radio isotopes are injected.
• MRI/MRA: Uses magnetic fields; assess for metal inside the patient; patient can expect loud sounds.
• PET scan: Radioactive fluorine injected to cancerous areas.
• EEG (electroencephalogram): Assesses brain activity.
• Myelogram: Dye is injected through a lumber puncture
• Angiogram: Dye injected into the blood to see the brain and blood vessels. Patient must remain on bedrest for 4 - 6 hours. Reinforce pressure dressing but never remove it. Assess distal circulation. Assess puncture site and vital signs every 15 minutes.
• Carotid Doppler/Duplex: Ultrasound to assess blood flow in carotid arteries.
• EMG (electromyogram): Evaluates muscle response to electrical stimulation.
• Urine culture: To rule out any potential infection.

Initial Patient Assessment

• Check orientation
• Level of Consciousness
• Bilateral Muscle Strength
• Speech ability
• Ability to follow commands
• Abnormal posturing

Headache Types and Causes

• Primary: Not caused by another physiological disorder.
• Vascular: Includes migraines, cluster headaches, and hypertensive headaches.
• Tension: Arises from stress or medical problems like cervical arthritis.
• Secondary: Caused by an underlying health disorder, like hypertension.

Migraine Headaches

• Throbbing, pounding pain, often worse on one side of the head.
• Exact cause often unknown, involves genetics and environmental factors.
• More common in women, with onset in teens and peak in the 30s.
• Prodrome symptoms: Constipation, fluid retention, mood changes days before onset.
• Aura: Visual defects, unusual smells or sounds, disorientation, paresthesias occurring minutes to hours before the headache.
• Other symptoms: Nausea, vomiting, photophobia, chills, fatigue, irritability, diaphoresis, edema, autonomic dysfunction.

Migraine Assessment

• Assess subjective and objective signs and symptoms.
• Ask questions to assess patient's understanding, triggers and what factors release the pain.
• Evaluate the location, frequency, duration, character, and pattern of the pain.
• Determine if an aura or prodrome symptoms are present.

Migraine Triggers

• Excess wine
• caffeine
• Sleep Changes
• Processed foods
• Food additives
• Stress
• Birth control

Migraine Interventions

• Rule out other causes of headache with diagnostic testing.
• Counsel to avoid foods with tyramine, nitrates, glutamates, vinegar, chocolate, yogurt, alcohol, fermented foods, and caffeine.
• Consider psychotherapy and relaxation techniques.
• Medications: Aspirin, acetaminophen, ibuprofen, triptans (e.g., eletriptan), ergotamine derivatives, topiramate, beta-blockers, tricyclic antidepressants, calcium channel blockers, thiazide diuretics, antihypertensives, anti-seizure medicines, antiemetics.
• Botox injections may help.

Cluster Headaches

• Daily occurrences for a time, subside, and return regularly.
• More common in men, especially adolescents and middle-aged men.
• Pain is usually one-sided, described as burning, sharp, or steady.
• Sudden onset, often at the same time of day.
• May be accompanied by a teary eye and nasal stuffiness.
• Possible triggers are the same for migraine headaches
• Triggers: Exertion, heat, and high altitudes may also trigger cluster headaches.
• Horner syndrome: Small pupil or drooping eyelid only during an attack.
• Treatment may require opioids for severe pain (IM), Imitrex, prednisone, or DHE (dihydroergotamine).

Other Interventions for Headaches

• Rest and relaxation.
• Biofeedback.
• Avoid alcohol.
• Regular exercise.
• Identify and avoid triggers.
• Regular sleep patterns.
• Quiet, dark environment.
• Cool cloths on the face and back of the skull.
• Follow-up care.

Neuropathic Pain

• Originates from the peripheral or central nervous system due to stimulation of myelinated nervous tissue.
• Reported as burning or tingling in areas of sensory loss.
• Causes: Postherpetic neuralgia (shingles), diabetes, trigeminal neuralgia, phantom limb pain.
• Treatment: TENS unit, acupuncture, nerve blocks, medications like gabapentin (Neurontin), carbamazepine (Tegretol), pregabalin (Lyrica).
• Promote rest and relaxation and avoid straining with bowel movements.

Increased Intracranial Pressure

• An abnormal increase in the pressure inside the skull. Normal is 10 - 15.
• Causes: Head injuries, brain tumors, hemorrhage, anoxic brain injury, toxic or viral encephalopathies, and cerebrospinal problems.### Intracranial Pressure (ICP)
• Normal ICP ranges from 10 to 15 millimeters of mercury.
• The cranial vault's rigidity means that an increase in one content (brain tissue, blood, CSF) must be compensated by a decrease in another to maintain normal pressure.
• Increased ICP occurs when compensation fails.
• Signs and symptoms of increased ICP may develop over hours or days.
• Decreased cerebral blood flow occurs due to increased ICP, leading to decreased brain oxygenation and perfusion.
• If increased ICP occurs rapidly, surgery may be required to relieve pressure and prevent death; however it can be a slow process too.
• Initial compensation involves venous compression in the brain and displacement of cerebrospinal fluid (CSF).

Physiological Changes and Late Signs of Increased ICP

• Increased CO2 (hypercapnia) and decreased O2 (hypoxia) lead to decreased pH (acidosis), causing vasodilation and cerebral edema.
• Changes in level of consciousness are the earliest signs of increased ICP.
• Late signs include changes in blood pressure, pulse, respiration, and temperature.
• Widening pulse pressure (rising systolic and falling diastolic) is observed.
• Bradycardia (slow heart rate) and abnormal respirations occur.

Brain Herniation

• Supratentorial shift: Brain herniates when compensatory mechanisms fail.
• Herniation involves the brain stem being compressed at the base of the skull.
• Brain stem compression affects vital signs and other critical functions, leading to death.

Early Indicators and Symptoms

• Change in level of consciousness is the earliest sign.
• Diplopia (double vision).
• Changes in personality and cognitive abilities such as increased irritability.
• Headache, and nausea.
• Headache intensified by coughing, straining, or stooping

Pupil Changes

• Sluggish pupillary response is an early warning sign.
• Pupil dilation and slowed reaction to light indicates impending brain herniation.
• Ipsilateral pupil: Pupil changes occur on the same side as the brain lesion.
• Fixed and dilated pupils are an ominous sign, potentially indicating herniation.
• Context is important, as certain eye surgeries may cause similar pupil changes.

Cushing's Response

• Cushing's response: Severe hypertension, widening pulse pressure, bradycardia, and abnormal respirations.
• Cushing's response is a late-stage sign of brain herniation that requires immediate reporting.
• A sonorous (noisy) breathing pattern may indicate increasing cranial pressure
• Breathing patterns may include Cheyne-Stokes or ataxic/irregular breathing, indicating damage to the medulla.
• Ataxic breathing progresses to respiratory arrest as intracranial pressure rises.

Thermoregulation and Motor Function

• Hyperthermia (elevated temperature) often accompanies neurological issues due to hypothalamic damage.
• Decreased motor function, abnormal reflexes (Babinski's), hyperreflexia, muscle rigidity, seizures, and posturing are observed.
• Projectile vomiting, and singultus (hiccups).
• Drainage from the ear or nose may indicate CSF leakage.
• Papilledema (swelling of the optic disc) is a sign of increased ICP, leading to a blind spot.

Posturing

• Decorticate posturing (flexor): Arms flexed towards the core, indicating cervical spinal tract or cerebral hemisphere problems.
• Decerebrate posturing (extensor): Arms extended outwards, indicating a more severe brain injury.
• Doll's eyes: Eyes remain fixed forward despite head movement, indicating severe brain damage.

Diagnosis of Increased ICP

• CT scans and MRIs are primary diagnostic tools.
• Intracranial pressure monitoring involves inserting a hollow screw into the skull to measure pressure.
• EEG, angiogram, carotid Doppler, and PET scans may also be used.
• Lumbar punctures are avoided.

Treatment Strategies

• Adequate oxygenation, often requiring intubation.
• Mechanical decompression via craniotomy or craniectomy.
• Subarachnoid bolt or ventricular catheter use for ICP monitoring.
• Arterial blood gases (ABGs) to guide ventilation strategies.

Medications

• Osmotic diuretics (Mannitol) to reduce cerebral edema.
• Corticosteroids to decrease inflammation.
• Anticonvulsants to prevent seizures.
• Loop diuretics to remove additional fluid.
• Antacids, H2-receptor blockers, or proton pump inhibitors to prevent GI ulcers/bleeding.
• Opioids are avoided unless the patient is intubated due to respiratory depression risks.
• Neuromuscular blockers and sedatives (Versed) may be used to reduce patient resistance and improve oxygenation.

Mannitol

• Mannitol draws water from edematous brain tissue, acting within 15 minutes and lasting up to six hours.
• Corticosteroids like dexamethasone are used cautiously, as they can significantly increase glucose levels.

Additional Treatments and Nursing Interventions

• Glasgow Coma Scale (GCS) scores of 8 or less indicate a coma.
• CSF drainage from ventricles or removal of subdural hematomas.
• Dark room with limited visitors to reduce brain stimulation.
• Elevate the head of the bed 30-45 degrees to promote venous return.
• Maintain a neutral neck position to facilitate drainage.
• Avoid flexion of hips, waist, or neck and rotation of the head.
• Restrict fluid intake, as ordered.
• Stool softeners are preferred over enemas or laxatives to prevent straining.
• Foley catheter for urinary drainage.
• Suction only when necessary, limited to 10 seconds, with pre- and post-hyperoxygenation.
• Cooling blankets to manage hyperthermia.

Factors Increasing ICP

• Hypercarbia (elevated CO2 levels) lead to cerebral vasodilation.
• Endotracheal/oral tracheal suctioning.
• Coughing, forceful nose blowing.
• Extreme neck or hip flexion/extension.
• Head of the bed should be less than 30 degrees.
• Restrictive clothing.
• Straining.

Muscle Tone Disturbances

• Flaccidity: Weak, soft, flabby muscles lacking tone.
• Hyperreflexia/spasticity: Increased muscle tone and involuntary movements.
• Muscle relaxants (baclofen, dantrolene, diazepam) may be used to decrease muscle tone.
• Hemiplegia: Partial paralysis on one side of the body.
• Foot drop: Toes point downwards due to paralysis; prevented with footboards or high-top shoes.
• Assess for coordination, muscle strength, tone, and atrophy.
• Barium swallow test to diagnose dysphagia.

Dysphagia

• Patients with dysphagia are at risk of aspiration.
• Position patients at a 90-degree angle with chin tucked during meals.
• Tip the head toward the unaffected side to improve swallowing.
• Avoid using straws, as they increase choking risk.
• Assistive devices (plate guards, weighted utensils) and thickening agents in liquids are helpful.
• Avoid foods causing choking.
• Check for food accumulation in the mouth.
• Ensure good oral hygiene and denture use.

General Care and Safety

• Side rails should be raised to prevent falls.
• Restraints may be needed to maintain body position, with proper documentation.
• Frequent skin inspections, especially over bony prominences.
• Turn patients every two hours to prevent pressure ulcers.
• Active and passive range of motion exercises.
• Address psychological needs and provide good nutrition.

Sensory and Perceptual Disturbances

• Irrigating eyes with normal saline may need to wear an eye patch or a Um a shield which is a hard Shield.
• Unilateral neglect: Lack of awareness of one side of the body; teach protective measures.
• Agnosia: Inability to recognize familiar objects through sensory stimuli.
• Anomia: Inability to name familiar objects- subtype of agnosia
• Compensate for sensory deficits by using other senses (e.g., lip reading for hearing loss).

Seizure Activity and Epilepsy

• Seizures result from abnormal electrical activity in the brain.
• Epilepsy: Neurological disorder with recurrent episodes of seizures.
• Causes of Seizures: Hyperthermia, drug use, alcohol/barbiturate withdrawal, hypoglycemia, electrolyte imbalances, brain tumors/infections, water intoxication, and epilepsy.
• The three phases of seizures are Aura, Seizure, and post-itcial stay
• Status epilepticus: Recurring generalized seizures without regaining full consciousness between episodes; requires medical emergency intervention

Seizure Observation and Documentation

• Nature of movements (tonic-clonic).
• Duration of the seizure.
• Incontinence, noises during the seizure.
• Alertness, preceding factors, and time of occurrence.
• Characteristics of each phase: aura, seizure, and postictal state.

Types of Seizures

• Tonic-clonic (grand mal): Aura, loss of consciousness, muscle rigidity and jerking, postictal state.
• Absence (petit mal): Brief staring spells, no aura or postictal state.
• Psychomotor (psycho): Aura (hallucinations/illusions), intoxicated appearance, antisocial acts, but are all seizure related.
• Jacksonian: Shaking starts locally (hand, foot, face) and progresses to tonic-clonic activity.
• Myoclonic: Sudden, excessive jerks of the body or extremities, no loss of consciousness.
• Akinetic: Loss of muscle tone, sudden fall to the ground, unconsciousness for a minute or two.

Seizure Treatment and Nursing Care

• Maximize seizure control with minimal toxic effects from anticonvulsants.
• Promote safety precautions and avoid other CNS depressants.
• Monitor blood levels of anticonvulsants to ensure therapeutic range.
• Protect from injury during a seizure, and protect their head.
• Maintain a patent airway, typically positioning on the side.
• Loosen restrictive clothing and never restrain or put anything in the patient's mouth!

Explore the functions of the brain's frontal and parietal lobes. The frontal lobe controls speech, motor skills, personality, and judgment. The Parietal lobe processes sensory information.