Chapter 21 The Neurological System Complete PDF

The Neurological System Objectives Theory- Define the vocabulary particular to problems of the nervous system. Examine the differences in the action of sympathetic and parasympathetic nervous systems. Identify four specific ways in which a nurse can contribute to prev...

The Neurological System Objectives Theory- Define the vocabulary particular to problems of the nervous system. Examine the differences in the action of sympathetic and parasympathetic nervous systems. Identify four specific ways in which a nurse can contribute to preventing neurologic disorders Provide rational for the appropriate preparation and post-procedure care for patients undergoing lumbar puncture (spinal tap), electroencephalogram (EEG), and radiologic studies of the brain and cerebral vessels Demonstrate techniques used for assessment of the nervous system Compare and contrast the various signs and symptoms of the common problems experienced by patients with nervous system disorders Clinical Practice- Gather a pertinent history for a patient with a nervous system problem Demonstrate a “neuro check” Score the neurologic status of a patient with a nervous system disorder according to the Glasgow Coma Scale Definitions of Key Terms Accommodation: adjustment specifically the ability of the ocular lens to see objects in the distance Afferent: carries impulses to the CNS Aphasia: the loss of the power of expression by speech, writing, or signs or the comprehension of spoken or written language Babinski Reflex: a reflex action elicited by stimulating the sole of the foot and characterized by dorsiflexion of the great toe and flaring of the smaller toes. A positive Babinski Reflex indicates an abnormality in the motor control pathways of the nervous system Calculi: an abnormal concretion, usually of mineral salts, occurring mainly in hollow organs or their passages (renal calculus, kidney stone) Caloric testing: testing the oculovestibular reflex. A patient’s eye movements are observed while the external ear canal is irrigated with cold water. Absence of eye movement indicates a brainstem lesion Clonus: abnormal neuromuscular activity characterized by rapidly alternating involuntary contraction and relaxation of skeletal muscle; occurs with epileptic seizures Decerebrate posturing: extensor posturing; the arms are stiffly extended and held close to the body while the wrists are flexed outward. Indicates damage to the midbrain or brainstem Definitions of Key Terms Delirium: an altered state of consciousness that is usually acute and of short duration Dysphagia: difficulty swallowing Efferent: carries impulses away from the CNS Extensor posturing: position of the body in which the arms are stiffly extended and held close to the body, the wrists are flexed outward, and eh legs are stiff with toes pointed downward (plantar flexion); indicates damage to the midbrain or brainstem Flexor posturing: the extension and stiffening of the legs with plantar flexion, adduction of the arms with the forearms bent upward, and wrists and fingers flexed on the chest; indicates damage to the cortex Hemiparesis: weakness affecting only one side of the body Hemiplegia: paralysis of ½ or one side of the body Nystagmus: involuntary rapid rhythmic movement of the eyeball Quadriplegia: paralysis of all 4 extremities Synapse: a junction between two nerve cells, consisting of a minute gap across which impulses pass by diffusion of a neurotransmitter Tetraplegia: another term for paralysis of all 4 extremities The Neurologic System The Nervous System is composed of the Central Nervous System (CNS) and the Peripheral Nervous System (PNS) Central and Peripheral Nervous System Sensory organs cranial nerves (12) spinal nerves (31 pairs) ganglia Anatomy and Physiology of the CNS The brain is divided into the Cerebrum Diencephalon Cerebellum Brainstem The brainstem consists of the Midbrain Pons Medulla Each division performs specific functions See Figure 21.1 and Table 21.2 page 485 Anatomy and Physiology of the CNS Cerebrum Center of intellect and Cerebr consciousness um Receives and interprets sensory information Controls voluntary movements and certain involuntary movements Responsible for thinking, learning, language capability, judgment, personality Stores memories Anatomy and Physiology of the CNS Cerebellum Responsible for coordination of movement, posture, and muscle tone used for balance Anatomy and Physiology of the CNS Diencephalon Thalamus: relay center for sensory and motor signals between the spinal cord and cerebrum Regulates consciousness, sleep, alertness Hypothalamus: controls body temperature, appetite, and water balance Links nervous and endocrine systems Anatomy and Physiology of the CNS Brainstem Midbrain Visual movement Visual and Auditory processing Controls cranial nerves III and IV Pons Relays messages to link parts of the brain Helps regulate respiration Medulla Oblongata Regulates heartbeat, respiration, blood pressure Controls swallowing, coughing, sneezing, vomiting Anatomy and Physiology of the CNS Spinal Cord Extends from the medulla to the level of the 1st lumbar vertebra Serves as a conduction pathway for sensory and motor impulses to and from the brain a reflex center for nerve impulse transmission Sensory impulses travel the “ascending” pathways pathways that carry sensory impulses (information) to the brain Motor impulses travel “descending” pathways pathways that carry impulses (instructions) away from the brain to the body Pyramidal tracts: conduction pathways that begin in the cerebral cortex and end in the spinal cord; controls voluntary skeletal muscle movement (works with the Somatic Nervous System [SNS]) Extrapyramidal tracts: all other conduction pathways outside the pyramidal tract pathways that carry impulses responsible for Anatomy and Physiology Peripheral Nervous System includes Sensory organs (eyes, ears, taste buds, olfactory receptors, touch receptors) Cranial nerves (12 pairs) Spinal nerves (31 pairs) Ganglia collections of nerve cell bodies outside the CNS that link the sensory organs, muscles, and other parts of the body to the brain and spinal cord Nucleus collections of nerve cell bodies inside the CNS that link the sensory organs, muscles inside the brain Dermatomes (pathways of spinal nerves) Conduction of an impulse Neuron A specialized nerve cell that transmits nerve impulses Referred to as “The functional unit of the nervous system” Neurons have a cell body, dendrite, and axon The dendrite is a short extension from the cell’s body to the synapse. Its function is to ‘pick up’ impulses at the synapse from other cells and deliver it to the cell body Axon A long threadlike extension from a cell body to a synapse that conducts impulses from the cell body to other cells React to stimuli Conduct impulses Influence other neurons Dendrite A short-branched extension of a nerve cell, along which impulses received from other cells at synapses are transmitted to the cell body Anatomy and Physiology of a Neuron Conduction of an impulse The cells of a neuron are polarized (“the ready state”) which means the inside of the cell has a negative charge and the outside of the cell has a positive charge The neuron cells are ready to be excited “stimulated” A physical, chemical, or electrical stimulus changes the permeability of the cell membrane and allow passing of ions into and out of cell causing the charge inside the cell to become positive creating an impulse that is then sent along the axon pathways At the end of the pathways are synapses (gap between the axon and dendrite) which requires a neurotransmitter to “carry” the impulse across the gap to continue to its destination. Neurotransmitters are secreted by the neuron and released into the synapse and bind with the impulse to carry it across the gap to a specific receptor on the next neuron Central Nervous System neurotransmittersPeripheral Nervous System neurotransmitters Norepinephrine Acetylcholine Epinephrine Norepinephrine Serotonin Epinephrine Dopamine Dopamine https://www.youtube.com/watch?v=b2ctE Endorphins sGEpe0 Enkephalins https://www.youtube.com/watch?v=HYLyh XRp298 Conduction Impulses travel in one of the following ways to be interpreted: Reflex Arc A pathway in which a sensory neuron travels to a receptor site in the spinal cord and is sent directly back to a motor neuron at an effector site for a “reflex” response (maintaining upright position, pain)- see Figure 21.5 page 489 https://www.youtube.com/watch?v=Nn2RHLWST-k Sensory impulses travel the afferent or “ascending” pathways pathways that go up toward the brain that carry sensory information Motor impulses travel efferent or “descending” pathways that carry impulses from the brain to the body Pyramidal tracts: carry impulses responsible for voluntary control of muscles of the body and face Extrapyramidal tracts: carry impulses responsible for involuntary control of muscles that control balance and posture Once the impulse is interpreted a response is generated and sent to the appropriate site to produce an action Neurotransmitters Table 21.3 page 489 CNS Function Comments neurotransmitters Acetylcholine Generally excitatory Synapses of Diencephalon Inhibitory to some visceral (thalamus, hypothalamus), medulla, effectors basal forebrain to control endocrine and REM sleep Norepinephrine The receptor it acts on Synapses of the Pons to control determines whether it is attentiveness, sleep, dreaming, excitatory or inhibitory emotions, and learning Epinephrine The receptor it acts on Synapses of the Hypothalamus, determines whether it is pituitary gland to control behavior excitatory or inhibitory and mood Dopamine Excitatory Synapses of the Hypothalamus to control movement and reward motivated behavior Serotonin Inhibitory Synapses of the Pons to regulate mood, social behavior, sexual function/desire Endorphins/Enkephalins Inhibitory Synapses of the Pituitary gland to control pain and stress Neurotransmitters Table 21.3 page 489 PNS Function Comments neurotransmitters Acetylcholine Generally excitatory Skeletal neuromuscular junction Inhibitory to some synapses visceral effectors Many synapses outside the CNS Norepinephrine The receptor it acts on Cardiac and visceral neuromuscular determines whether it junction synapses is excitatory or inhibitory Epinephrine The receptor it acts on Pathways for fight or flight response determines whether it is excitatory or inhibitory Dopamine Excitatory Pathways that control coordination and movement The Nervous System Somatic Nervous System “voluntary system” Controls voluntary body movement resulting in skeletal muscle movement May be conscious and voluntary movement or a reflex-type movement that is not of a conscious and voluntary decision The Autonomic Nervous System “involuntary system” Controls involuntary body movement such as heartbeat, respirations, and gland secretions to maintain homeostasis Located in both the CNS and PNS 2 subcategories: Sympathetic nervous system mobilizes energy to initiate changes (the gas) Parasympathetic nervous system conserves and restores energy (the brake) The sympathetic and parasympathetic nervous systems have the opposite effect on organs-see Figure 21.6 and Table 21.4 page Protection Myelin sheath protects the axon by acting as an insulator and speeds up the conduction of the impulse. If missing or damaged the impulse will be delayed or stopped impulses, for example multiple sclerosis The skull and vertebral column bones provide a protective barrier for the brain and spinal cord The 3 meninges layers are protective membranes for the brain and spinal cord Pia mater covers the brain directly Arachnoid encases the entire CNS Dura mater is a tough protective membrane covering the brain and spinal cord Cerebrospinal Fluid (CSF) lies in the subarachnoid space located between the pia mater and arachnoid (Figure 21.7 page 492) Continuously circulates to filter Cushions and protects the brain and spinal cord Is produced (choroid plexus) and reabsorbed (arachnoid villi) at the same rate to maintain a constant volume and pressure NORMAL CSF pressure is 100 - 180 cmH2O during lumbar puncture and 200- Anatomy and Physiology The Circle of Willis is a Blood Flow to the CNS common site for aneurysm Neurons die within 4-6 minutes without O2, so the brain requires a continuous supply Arterial blood flow is supplied anteriorly by the right and left carotid arteries and posteriorly by the right and left vertebral arteries- all 4 vessels empty into the Circle of Willis at the base of the brain to help maintain a constant blood flow even when a blockage or narrowing develops- see Figure 21.8 page 492 Blood is drained from the brain via the jugular veins Intracranial Pressure (ICP) Normal pressure in the skull is 5-15 mmHg Volume of brain tissue, CSF, and cerebral blood flow determine ICP examples: swelling of brain tissue, increased CSF, increased blood flow, decreased venous drainage increase ICP ICP >20 requires treatment and prolonged elevation can cause brain injury or death Special Characteristics Some nerves cells in the PNS can regenerate the outer membrane (neurolemma or “Schwann sheath”) but NO nerve cells in the brain can regenerate…once these cells are damaged or destroyed, they cannot be replaced, but other brain cells may pick up Age Related Changes Loss of neurons with aging but doesn’t seem to affect intellectual functioning After age 70 the brain’s weight “drops considerably” but doesn’t seem to affect intellectual functioning Slower reaction time due to decreased number of dendrites causing slower impulse transmission Blood flow to the brain is decreased increasing their risk of damage with blood flow is reduced further Loss of neurons and slower nerve conduction reduces efficiency of autonomic nervous system In late adulthood decreased sensation tremors without rigidity hypoactive reflexes Death related to exposure to heat or cold Slower adaptation to physiologic stress with incomplete recovery Poor short-term memory while distant memory is intact Age Related Changes Diminished abstract reasoning Altered perception Decreased secretion of neurotransmitters (especially dopamine and norepinephrine) Increased monoamine oxidase which affects function, gait, balance Pupils decrease in size allowing for less light rays to enter the eye, more room light will be required Reduced number of posterior root fibers and sympathetic nerve fibers in the spinal cord affect autonomic nervous system functioning Myelin sheath degenerate reducing reflexes Slower movement, response time, decreased sensation Tremors Hypoactive tendon reflexes Adaptation to physiologic stress such as heat or cold is slowed Causative Factors Many factors can affect neurologic functioning- see Box 21.1 page 493 “Classification of Common Neurologic Disorders” Genetics/Acquired developmental disorders Cerebral palsy, muscular dystrophy, Huntington's disease Trauma Head injury, penetrating brain injury, spinal cord injury, ruptured intervertebral disk Infection and Inflammation Meningitis, encephalitis, brain abscess, poliomyelitis, Guillain-Barre syndrome Tumors Brain or spine Vascular degeneration Cerebrovascular accident, ruptured aneurysm, arteriovenous malformation, migraine, cluster headache Neuromuscular disorders Multiple Sclerosis, myasthenia gravis, amyotrophic lateral sclerosis Causative Factors Degenerative Disorders Parkinson’s disease, Alzheimer’s disease Cranial Nerve disorders Bells Palsy, Trigeminal neuralgia Metabolic disorders Endocrine disorders Chemicals Diagnostic Studies Table 21-6 page 497-500 Diagnostic Tests for Neurologic Disorders Assessment A complete neurologic exam measures the ability of the body to perform motor and sensory function and is an extensive, long process that is usually performed for hospitalized clients and clients suspected of having a neurological disorder or deficit Components of the exam are performed for every patient, (cranial nerve, coordination and balance, muscle strength, and reflexes are standard for every patient) Cognitive changes may the first sign of hypoxia, drug reaction, or other condition History and Physical- see page 494 Focused Assessment “Data Collection for the Neurologic System” genetic, familial, or personal neurological conditions Comorbid medical conditions such as CVA, trauma, infection, seizures Includes the following 7 categories: 1. Mental status 2. Cranial nerves 3. Motor system 4. Reflexes 5. Sensory system 6. Coordination Assessment Vital Signs We all know the importance of taking vital signs and what they indicate for our patient’s health. Indicators of a problem with the neurological system include An elevated temperature can indicate infection or damage to the temperature control mechanisms from increasing ICP An increase in systolic blood pressure and a widening pulse pressure can indicate an increase in ICP. A prolonged elevation will produce a slow bounding pulse, labored irregular respirations See Clinical Cues page 494 See Assignment Consideration “Reporting Observations” page 494 Remember when documenting physical assessment use terms that are measurable— everyone that reads the assessment should be able to use the same tool to measure and get the same or comparable results Mental Function and Level of Consciousness LOC is best measured using the Glasgow Coma Scale (GCS) or FOUR Score Scale-see page 495 Table 21.5 GCS scores in 3 categories Eye opening Assessment Mental Function and Level of Consciousness A number is assigned to each response The score is totaled from each category The score ranges from 3-15. A score of 15 = fully alert patient 8 or less = coma level 3 = totally comatose patient FOUR Score Scale (Full Outline of UnResponsiveness) Becoming the preferred scale to assess comatose patients or intubated patients who cannot speak 4 categories are assessed Eye response Motor response Brain stem reflexes Respiration A score of 0-4 is assigned to each category and totalled 0 = no function Assessment---START HERE ON REWORKING GCS and FOUR scale Nonpurposeful responses occur in 2 ways either unilateral or bilateral: Decorticate (flexor) posturing: extension of the legs with internal rotation and adduction of the arms with the elbows bent upward—indicates damage to the cortex Decerebrate (extensor) posturing: extended stiff arms held close to the body, wrists are flexed outward—indicates damage to the midbrain or brainstem—a very serious injury **Flexor and Extensor posturing can be unilateral, bilateral, or both may be present at the same time** Assess mental function of alert patients by asking questions to determine orientation to person, place, time Assess memory lapses by asking questions of orientation to address, current events/holidays, or giving them 3 simple terms to remember Assess thinking by giving them 3 simple numbers to add, count by 2’s or 3’s A simple puzzle to solve (allow pencil and paper to be used) A card with simple instructions, such as walk to the sink or turn on the light Judgement can be assessed by asking them questions to determine if they have been making rational decisions in their life or giving them a scenario and asking Assessment Mental Function and Level of Consciousness Level of consciousness (alert, lethargic, nonresponsive) 1st use a loud voice if no answer 2nd gently shake Apply a painful stimuli x 20 – 30 seconds by: 3rd pinch the trapezius muscle at the angle of the shoulder and neck and twist the fingers slightly and increase pressure for 10-20 seconds 4th apply gentle pressure above the eye by placing a thumb under the midbrow and push upward if no response to the “trapezius twist” 5th apply pressure to the angle of the mandible with the index and middle fingers 6th apply pressure to the nail bed near the cuticle with a pen or pencil Sternal rub with the knuckles in the form of a fist in a twisting motion—NO longer recommended due to injury and bruising Level of responses to pain Purposeful withdrawal from the stimulus or an attempt to push it away Nonpurposeful response—frown, moving an arm or leg in a random fashion Posturing Failure to respond at all—bilateral flaccidity Assessment Neurologic and Neuromuscular status Much information can be gained thru observation of ADLs and interaction with the patient. Cranial nerves and motor function can be assessed during these activities. For example, Is the face symmetrical in movement when talking or smiling Is speech clear and sensible Are they having trouble swallowing Is movement of extremities smooth, without difficulty, and symmetrical Is gait steady or ataxic Can the patient hear you when their back is turned Are they having any trouble with balance Assess extraocular movements (peripheral vision, extraocular muscle function test) Do the eyes move conjugate (together) or deviate (note direction of deviation) Is nystagmus present? (can indicate MS, adverse medication reaction [Dilantin]) Assess hearing (whisper test) Assessment Neurologic and Neuromuscular status Assess PERRLA Document PERRLA when normal responses and means “pupils equal, round, and reactive to light with accommodation” Measure pupil size-do not estimate (pupil size varies)-see page 496 Equal pupil size is considered normal; however, some patients have different pupil sizes termed Anisocoria and affects 20% of the population; in others it indicates nerve damage or disease- see Table 21.8 page 502 Examine in room with low light, bring beam from lateral to middle eye, observe for constriction in that eye (direct reflex) and then observe for constriction in the opposite eye (consensual reflex), repeat with opposite eye Pupils that remain dilated and fixed in the presence of bright light indicates brain damage One pupil fixed and dilated indicates increased ICP Both pupils remaining constricted indicates damage to the pons Alcohol and certain drugs can affect pupil size and reaction scolpamine and atropine can dilate pupils Opiates, miotics, street drugs can cause constriction Assessment Neuromuscular Assessment Assess motor pathways and strength by having the patient follow verbal commands involving movement (touch your right elbow with your left hand, raise your right arm, raise your left leg) Assess strength by using resistance (have patient bend arm at the elbow and have them lift against your hand that is applying light pressure, have them push against your hand with leg, have them push against your hand with their hand or squeeze your finger, push against your hand with their feet) Coordination and Balance Romberg Test Observe patient walk across room and assess gait Stand in front of patient and hold up your finger have them touch your finger then their nose. Move your finger to a different location in front of the patient. Tests the ability to follow directions as well as coordination Posture Arm swing Toe heel walking: dorsiflexion weakness with heel walking, plantar flexion weakness with toe walking Assessment Reflexes In an unconscious person the oculocephalic or “dolls eye” test tests the brainstem Gently hold the patient’s eyes open while rotating the head to one side. In a normal (positive) response the eyes will appear to roll to the opposite side (example if the head is rotated to the left, then the eyes move the right). In a negative (abnormal) finding the eyes do not move Oculovestibular reflex or “caloric testing” in an unconscious patient Knee Jerk or patellar reflex: tap patellar tendon just below the patella to cause the leg to “jerk” due to contraction of the quadriceps muscle of thigh to test the 2 nd thru 4th lumbar nerves Biceps reflex: place thumb on bicep tendon and strike with tendon reflex hammer to test the 5th and 6th cervical nerves Triceps reflex: hold the patients arm bent at a 90* angle and tap the triceps tendon to test the 7th and 8th cervical nerves Brachioradialis reflex: rest the patients arm and strike the brachioradialis tendon 3 inches above the wrist to test the 5th and 6th cervical nerves Achilles Tendon reflex: tap the Achilles tendon to illicit plantar flexion to test the 1st and 2nd sacral nerves Babinski reflex: scrape an object along the sole of the foot to test the motor Assessment Grading of Reflexes 0/5= absent 1/5= weak response 2/5= normal response 3/5= exaggerated response 4/5= hyperreflexia with clonus Clonus: continued rhythmic contraction of the muscle while being stimulated Sensory Testing Pain and temperature, light touch and pressure, vibration, proprioception (a sense or perception of the person’s body movements and position independent of vision) Pain: touch each of the 4 extremities with a pointed object with the patient's eyes closed while comparing side to side and distal to proximal—results should feel the same to the patient Temperature: touch areas of the face and body with warm/cool temperatures— compare side to side Proprioception: closed eyes have the patient extend arm and touch the end of their nose Vibration: tuning fork on digit joints and count seconds until the patient can’t feel it— compare sides Assessment Neurological / Neuromuscular Function Cranial nerve assessment Test cardinal positions of gaze (are eyes conjugate or does one deviate and if so which direction, nystagmus present at end points of each direction) PERRLA Hand grip strength Arm and leg movement (raise arms to arms length, raise knees separately while sitting, raise legs separately, bend knee / elbow, touch elbow with opposite hand) Arm, hand, leg, foot strength against resistance Have patient rub heel from knee down shin—should be able to this fairly rapidly Finger tapping- tap each finger to the thumb and should be able to do without problem bilaterally Toe tapping- tap toes as rapidly as possible for 10 seconds and count number— should be able to this easily bilaterally Assessment “Neuro Checks” Completed for those: At risk for increased ICP Expected change in level of consciousness High risk for neurological damage Examples of when neuro checks may be ordered Traumatic head injury Drug or chemical overdose Actual or suspected CVA Loss of consciousness 4 areas assessed Vital signs LOC Pupil reaction Motor function Set schedule Varies per facility policy, patient condition, but may be ordered every 15 minutes to intervals up to 2 or 8 hours Anatomy and Physiology Cranial Nerves Mnemonic: On Old Olympus’s Towering Top, A Finn Very Gladly Viewed A Hop Cranial Nerves Sensory Nerves Cranial Name Function Nerve CN I Olfactory smell CN II Optic Visual acuity, field of vision, pupillary response CN VIII Acoustic Hearing, sense of balance CN X Vagus Sensations of posterior tongue, throat, larynx; impulses from the heart, lungs, bronchi, GI tract Motor Nerves Cranial Name Function Nerve CN III Oculomot Eyelid elevation, extraocular (outside of eyeball) eye or movement, pupil size, convergence (moving eyes inward toward each other), pupillary constriction CN IV Trochlear Extraocular eye movement (inferior and lateral) CN VI Abducens Extraocular eye movement (lateral) CN XI Spinal Shoulder movement and head rotation Accessory Cranial Nerves Both Sensory and Motor Nerves Cranial Name Function Nerve CN V Trigeminal Sensory: corneal reflex (blink reflex with cornea stimulation) Motor: facial sensation, chewing, biting, lateral jaw movement CN VII Facial Sensory: taste Motor: facial muscle movement including expression, lacrimal gland and salivary gland control CN IX Glossopharyng Sensory: sensations of the throat, taste (posterior tongue) eal Motor: gagging and swallowing movements Assessment of Cranial Nerves Table 21.7 Page 501 Cranial Nerve Quick Testing Method Olfactory CN 1 Have the patient smell coffee, perfume, pickle juice one nare at a time—occlude the opposite nare—do not use ammonia, peppermint, menthol due to stimulation of the trigeminal nerve Optic CN II Test acuity with a Snellen Eye Chart Test visual field by having patient hold head still and report # of fingers you are holding up in the periphery of the visual fields Oculomotor CN III Assess pupil size—average pupil size is 3-4mm, Miosis (too Trochlear CN IV constricted) equal or 5mm, Abducens CN VI Anisocoria= asymmetrical pupils, reaction to light (consensual constriction), accommodation (hold pen 10cm from face and alternate looking away from and at pen), smooth pursuits (ability to follow an object) Trigeminal CN V Motor: Have patient clamp jaw shut and try to open against resistance, open mouth wide, move jaw from side to side, chewing motions Sensory: touch areas of the face with a warm or cool item and have the patient identify temperature (warm or cool), corneal reflex test: touch cornea with cotton Q-tip Assessment of Cranial Nerves Table 21.7 Page 501 Cranial Nerve Quick Testing Method Acoustic CN VII Rub fingers at arms length or whisper from varying distances and locations behind the patient and have them repeat, Romburg test: ask patient to stand with feet slightly apart and eyes closed. Observe for swaying of the body—steady posture will be maintained without severe swaying from side to side Glossopharyngeal Ask patient to say Ah and place tongue depressor on the 1st third of CN IX the tongue and flatten it and observe movement of the uvula and Vagus CN X palate—should raise evenly at midline Assess gag reflex by touching the sides of the pharynx—a brisk response Have patient swallow some water Spinal Accessory XI Ask patient to elevate the shoulders with and without resistance, turn head side to side, resist pulling chin back to the midline, push head forward against resistance Hypoglossal CN XII Have patient stick out tongue and move rapidly from side to side then in and out—watch for deviation from midline Apply pressure to cheek and patient to push tongue against hand to Prevention and Nursing Implications Education is key for safety Wear helmets when riding motorcycles or bicycles and when participating in sports with high risk for head injury Wear helmets in the workplace where head injury may occur Observe swimming and diving precautions—never dive in water of unknown depth to prevent spinal cord injury Fasten seat belts prior to putting car in gear Fasten children in appropriate car seats Wear protective clothing, gloves, and face masks when exposed to chemicals and wash immediately afterwards Refrain from using recreational drugs since they increase risk of stroke and injury Drink alcohol responsibly to reduce injury and prevent the damaging effect on brain cells Obtain vaccinations to prevent infectious diseases Control blood pressure and cholesterol See page 493 Health Learn the symptoms of stroke for fast treatment to reduce damagePromotion “Protecting the Nervous System Nursing Implications Choosing a nursing diagnosis will depend on Phase Acute Recovery Rehabilitation Severity of symptoms and damage Is damage temporary or permanent If damage is permanent the goal is for the patient to reach the highest level of functioning See Table 21-9 pages 504-506 for the most commonly used NANDAs, STG, LTGs, expected outcomes, and nursing interventions Interventions and education geared toward the nursing diagnosis is pertinent and key to healing Healing time may be lengthy—keep LTGs appropriate and realistic Evaluation and revision of goals is critical Care will take more time due to weakness, paralysis, decreased sensation, confusion, disorientation, aphasia, etc. It is best to partner with a coworker to provide care and plan for extra time spent with patients Nursing Implications Altered breathing pattern If no spinal cord or brain injury elevate HOB 30 degrees to displace diaphragm downward to allow for lung expansion Monitor adequacy of respiratory effort Promote a patent airway and chest expansion For unconscious patients place on side to prevent tongue from falling back and blocking airway Encourage and assist with deep breathing and incentive spirometer use Skin Integrity Promote skin integrity Use special bed, mattress, or protective cover/pad Inspect for pressure-especially pressure points Keep skin clean and dry Nursing Implications Altered mobility Work with patient and physical therapist for continuity of care Assist patient to cope with weakness or paralysis and loss of independence Provide ROM as needed to prevent contractions and muscle atrophy Maintain proper alignment of joints and limbs Educate on proper use of assistive devices and assist with use as needed Teach the patient to become aware of limbs to prevent injury in cases of decreased sensation and paralysis Teach proper transfer especially patients with decreased sensation and paralysis Provide adequate pain relief and treatment of muscle spasms Monitor for and implement measures to prevent edema Provide skin care and turn every 2 hours Change linens and briefs frequently Nursing Implications Altered self-care ability Assist or provide ADLs including oral hygiene especially if the patient is unconscious Lubricate and cleanse lips and mouth- mouth breathing makes lips and mouth dry Moisten oral mucosa with swabs and sponges Brush teeth twice daily with fluoride toothpaste and soft bristled brush To clean mouth may use a gauze moistened with 50-50% solution of mouthwash and water or a solution of water with a small amount of hydrogen peroxide and sodium bicarbonate; turn patient on side and use an irrigation syringe and oral suction especially if the client has a poor gag reflex Assist patient to cope with loss of independence Eye care for client’s who cannot close eyes—cleanse with warm sterile water or normal saline every few hours and instill artificial tears or lubricants If the corneal reflex is absent use an eye shield or eye patch—close eyes before applying and assess eyes at least daily Assist with nutrition and work with OT to help client learn to use assistive devices for meals Provide encouragement when appropriate Space activities due to fatigue and weakness and to prevent failure and frustration when too tired to meet goal for the activity Nursing Implications Dysphagia Ensure swallowing reflex has been assessed and follow recommendations/orders Nurses can perform a bedside swallow screening prior to administering any medications-give the patient a teaspoon of water while sitting upright in bed and observe swallowing and for choking, gurgly voice, or dribbling water; if the patient tolerates the spoonful well then give 60 cc of water (do NOT use a straw) and if tolerated well they are considered to have passed the bedside test Assess periodically for swallowing saliva Patients should always attempt to drink small amounts of water successfully prior to eating food Assist with nutrition and hydration Place in high Fowler’s position to eat and for at least 30 minutes afterward Reduce distractions during mealtime because stress makes dysphagia worse If patient is receiving tube feedings provide as ordered Nursing Implications Incontinence / Bladder Training Program Keep the patient clean and dry Initiate a bladder training program, and provide a positive attitude with even small successes for the program to be successful Purpose to prevent urinary infections, complications such as stones, promote skin health, and promote independence 2-hour toileting Drink 2000-3000mL by 6 pm (avoid caffeine and alcohol products after dinner due to diuretic effect) Evaluate effectiveness in 6 weeks Drugs may be used to assist Neurogenic bladder patients will need to be taught measures to promote voiding Crede maneuver- used by those with nerve damage and paralysis L2 or below to empty the bladder; an open hand presses over the bladder and directed toward the suprapubic area **controversial** Straight or self catheterization Artificial sphincter of the bladder is new Nursing Implications Bowel Training Program Monitor with a diary x 2-3 days to identify incontinence Identify patient's bowel habits before the injury (enema/laxative use, frequent constipation) Identify the patient's former bowel pattern Do they have an urge to defecate Start a high fiber diet and adequate liquid intake Toilet 30 minutes prior to identified incontinence times and insert a suppository to help evacuation and prevent incontinence Start a stool softener if needed Provide comfort and “normal” positioning and equipment when possible Provide privacy Nursing Implications Pain Assess pain and manage appropriately and as ordered—narcotics may be contraindicated since it masks increasing ICP Loss of sleep often accompanies pain- assess, refer Depression often accompanies pain- assess, refer Confusion/Deficit in memory, Intellect, Reasoning, Judgement May be acute and short term or chronic and long term, mild or severe, and accompanied with anxiety, agitation, and refusal to cooperate Patient cannot reason or rationalize and may experience hallucinations, delusions, and severe agitation Support and Protect the patient Provide a stable quiet environment Teach family safety Provide a consistent and dependable schedule for activities Provide written activities for those with memory loss Hand the patient an object to calm Nursing Implications Aphasia Receptive, Expressive, or Global Work with other disciplines to plan the most effective form of communication Goal is to stimulate communication without frustration and stress Teaching techniques to communicate Avoid talking to patient like they are mentally incompetent—speak to not about the patient and understand if they cannot speak it does not mean they cannot hear or understand Use slow distinct speech using a normal voice Use body language and sign language if it helps the patient to understand Ask one question at a time and give them time to respond Use the exact same words when repeating statements Provide a quiet and orderly environment Encourage when appropriate Support the patient emotionally Do not correct pronunciation Be patient See Focused Assessment “Determining the Type of Aphasia Problem” page 510 Nursing Implications Aphasia Use self-talk: stating what you are doing while performing a task so the client can associate the words with the action Parallel-talk: explain what the patient is doing while performing a task so the client can associate the words with the action Expansion: the person communicating with the patient completes the patient’s sentences when he or she cannot Modeling: the patients' sentences are completed, and new information is added Provide technology as appropriate Do not use any form of communication in a condescending manner Always treat the patient respectfully Provide / assist with oral hygiene since this makes it easier for a patient to form words Nursing Implications Sexual Dysfunction Allow expression of feelings, concerns, beliefs Arrange sexual counseling Psychosocial Concerns Allow the patient to express feelings, concerns, beliefs Support the patient emotionally Assist the patient to cope Provide encouragement and develop realistic goals Work with social worker Arrange community resources especially for job retraining if needed Assist to plan for social contact to be reinstated Ineffective Family Coping Provide education to the family Refer to social work, community resources, and counseling