Intracranial Regulation student (1).pdf

Intracranial Dysregulation Parkinson’s disease, Huntington’s What is the Brain? The brain is the command center of the body, like a supercomputer controlling everything we do, think, and feel. It's made up of billions of tiny cells called neurons that communicate with each signals. other using elect...

Intracranial Dysregulation Parkinson’s disease, Huntington’s What is the Brain? The brain is the command center of the body, like a supercomputer controlling everything we do, think, and feel. It's made up of billions of tiny cells called neurons that communicate with each signals. other using electrical The brain is responsible for who we are, how we think, wand what we feel The different parts of the brain? Different parts of the brain have specific jobs, allowing us to think, move, feel emotions, and take care of vital functions such as respiratory control, pulse control, as well as control of movement, emotions, speech, etc. https://www.brainfacts.org/3dbrain#intro=false&focus=Brain&zoo m=false Prefrontal Cortex Amygdala Hippocampus Alterations in Consciousness We have discussed brain function in different sections of the course, if there is damage to a particular site in the brain, there will be difficulty with function in the area of the body that section of the brain is responsible for. ⚬ For example, if you have a left sided stroke, the right side of your body will be affected. What is consciousness? ⚬ Argued most recently with advent of AI ⚬ State of awareness of oneself and the environment ⚬ Arousal - state of alertness ⚬ Awareness - Encompasses all cognitive functions How would you discuss someone’s cognitive status in a nursing note? What sorts of words could you use to describe someone awake? Someone who isn’t? Alterations in Arousal Divided according to the location of the pathological condition: Supratentorial ⚬ Upper region of the brain, cerebrum ￭ Neoplasm, closed-head trauma, subdural bleeding, infarcts, emboli, tumours Infratentorial ⚬ Lower region of the brain, cerebellum ￭ Direct destruction, accumulation of infection, neoplasm, brainstem disorders, infarcts Metabolic ⚬ hypoxia, electrolyte disturbances, hypoglycemia Psychogenic ⚬ Neuro exam N, psychiatric disorder-related how do we evaluate? LOC A+O x3; GCS (3-15) Pattern of Breathing Regular? apnea? Pupillary Reaction PERRLA Oculomotor Responses Able to follow an object, fixed gaze Motor Responses Unilateral weakness, hiccup, vomiting, yawning Reassess Often! These also are indexes for evaluating changes in CNS function. A patient has a structural problem within the brain tissue that decreases the level of consciousness. Which term best describes this location? A.Subdural B.Infratentorial C.Intracerebral D.Extracerebral A patient has a structural problem within the brain tissue that decreases the level of consciousness. Which term best describes this location? A.Subdural B.Infratentorial C.Intracerebral D.Extracerebral BRAIN DEATH Failure of the brain to maintain homeostasis Must meet very specific criteria: Etiology capable of causing neurological death, absence of reversible conditions Unresponsive coma with bilateral absence of motor responses (excludes spinal reflexes) Apnea (no spontaneous resps) No brainstem functions No confounding factors BRAINSTEM FUNCTIONS Breathing Consciousness Respirations Blood Pressure Sleep Heart Rate Oculovestibular Function (PERRLA, Doll’s Eye, Caloric Ice Water) Primitive Reflexes (grasping, sucking, snut, palmomental, babinski) all N in newborn but disappear in infancy. Decorticate Decerebrate ↓ POSTURING↓ ↓ POSTURING↓ l a r b e r e C h t a e D Cerebral death (irreversible coma) is death of the cerebral hemispheres exclusive of the brainstem and cerebellum No behavioural or environmental responses The brain can continue to maintain internal homeostasis Cerebral Death Survivors of cerebral death: ⚬ Remain in coma ⚬ Emerge into a persistent vegetative state ⚬ Progress into a minimally conscious state ⚬ Locked-in syndrome Alterations in Awareness Awareness is considered our “thought content.” This includes awareness of self, environment, mood. Part of executive functioning: Attention, memory, reasoning, decision making, judgment, selfcontrol Alterations in Awareness Selective Attention (orienting) is part of awareness referring to the ability to pick specific information to be processed from available (and often competing) stimuli. To be able to focus on a task without becoming distracted. Can be visual or auditory. Some selective deficits can include seizures, tumours, contusions, strokes, Alzheimer’s, dementia, and psychotic disorders Alterations in Awareness Common in stroke, selective attention deficits may include extinction and neglect Extinction occurs when someone only recognizes unilateral stimuli when presented bilaterally Neglect occurs when an individual does not recognize their own body parts on one side. Alterations in Awareness Memory is the recording, retention, and retrieval of information. Amnesia is the loss of memory and is a ranged disorder, from mild to severe. Two types: ⚬ Retrograde Amnesia ⚬ Anterograde Amnesia Can be temporary (after seizures), or permanent (head injury, Alzheimer’s) Often associated with other cognitive deficits as well Alterations in Awareness Pathophysiology of awareness changes include: ⚬ Direct destruction (Ischemic changes stroke) ⚬ Indirect destruction (compression) ⚬ Metabolic, toxic, or chemical effects (drugs) Data-Processing Deficits Agnosia - failure to recognize form and nature of objects. can be tactile, visual, or auditory, but generally only one of these is affected. ⚬ May not be able to see an object and recognize what it is, but can identify with touch (i.e. safety pin) Typically caused by stroke, or something that affects a particular part of the brain. Data-Processing Deficits Dysphasia: Impairment with comprehension or production of language. Aphasia is inability to communicate using language. Often both used interchangeably. Often a result of stroke or injury to specific part of the brain in the left hemisphere broca area (inferior frontal) and wernicke area (superior temporal) Many types: Expressive Transcortical Receptive Global Conductive Anomic aphasia Acute Confusional States Transient disorders of awareness (acute) that result from cerebral dysfunction. Can be secondary to drug use, metabolic disorders, conditions that acutely affect the brain (hyponatremia) Delirium can also occur with nervous system over (hyperactive delirium) or underactivity (hypoactive). Agitation, confusion, sweating, aggression. Can be result of drugs, hypoxia, hypoglycemia, thyroid, liver and kidney disorders Dementia Progressive failure of many cerebral functions including impairment of intellectual processes Can include deficits in one, some, or all of the following: Orientation, memory, language, judgement, and decision making Causes: Neuron degeneration, brain compression, atherosclerosis, trauma, or genetics. Alzheimer’s Disease Leading cause of severe cognitive dysfunction in older adults. Three types: Nonhereditary or late-onset (70-80%) Early-onset familial Early-onset (very rare) Causes: Exact cause unknown. Linked with gene mutations on chromosomes 19 and 21, as well with changes in amyloid proteins within the brain. Alzheimer’s Disease Pathophysiological changes occur slowly and can happen decades before the appearance of symptoms: Progressive, from mild short-term deficits to total loss of cognitive and executive functioning. Forgetfulness, Emotional upset, Disorientation, Confusion, Lack of concentration, Decline in abstraction, problem solving, and judgement Investigations: MMSE, Lab test (r/o metabolic cause), CT/MRI brain (brain atrophy - widening sulci loss of gyri) Cerebrovascular Accident (CVA) - Stroke In Canada, cerebrovascular disease is third highest cause of death. HTN and DM2 have 4x more likelihood of stroke, and 8x more likely to die from same. Other risk factors include atrial fibrillation (clotting disorders), dyslipidemia (atherosclerosis), smoking (2x), hypercoaguability, cancer Cerebrovascular Accident (CVA) - Stroke Two major types and a third special type: Ischemic (most common) Hemorrhagic Hypoperfusion* TIAs are transient episodes of neuro dysfunction lasting no more than 1 hour, resulting from focal cerebral ischemia (think angina of the brain). ~12% of TIA progress to stroke. If stroke occurs on left side, right side is affected, and vice versa. Recognition of which area of the brain is affected can help guide treatment and expectations. Cerebrovascular Accident (CVA) - Stroke Rapid recognition of symptoms is most important thing we can do as healthcare professionals - Time is brain! Must have CT immediately - determine whether ischemic or hemorrhagic. If Ischemic can give TPA/TNK within 4 hours, if embolic can go for thrombectomy within 24 hours. Other investigations include carotid dopplers/CTA, echocardiogram, bloodwork, MRI Once stroke is discovered must control HTN, likely will start antiplatelet therapy for life Once brain is ischemic, will never fully regain function, likely will need rehabilitation services and interdisciplinary care. Cerebrovascular Accident (CVA) - Stroke Monitoring includes assessments for intracranial regulation including: ⚬ Changs in mental or motor functions (weakness, sensory changes, confusion) ⚬ Change in Glasgow Coma Scale (GCS) ⚬ National Institute of Health Stroke Scale (NIHSS) ⚬ Cranial Nerve Testing ⚬ Mental Status Testing ⚬ Vitals testing (bradycardia, widening pulse pressure, hyperthermia) Cerebral Edema An increase in the fluid content of brain tissue It occurs as a result of: Electrolyte imbalance (hyponatremia), brain insult from trauma, infection, hemorrhage, tumour, ischemia, infarction, or hypoxia. The harmful effects of cerebral edema are caused by distortion of blood vessels, displacement of brain tissues, increase in Intracranial Pressure (ICP), and eventual herniation of brain tissue to a different brain compartment (shift; mass effect). Cerebral Edema Intracranial Pressure (ICP) Stage 1 through Stage 4, results from increase in intracranial contents (tumour growth, edema, excessive CSF, hemorrhage) Clinical Manifestations: Adults: headache, change in consciousness; Peds: irritability, lethargy, poor feeding, bulging fontanelle Brain herniation can result if untreated: 1, uncal (transtentorial); 2, central; 3, cingulate; 4, transcalvarial (external herniation through an opening in the skull). Infratentorial: 5, upward herniation of cerebellum; 6, cerebellar tonsillar move down through foramen magnum. Hydrocephalus Hydro – Water; Cephalus - Head Excessive accumulation of fluid in the cerebral ventricles, subarachnoid space, or both. Clinical Manifestations = Increased ICP, declining cognitive function Occurs because of intereference with flow of CSF (cerebrospinal fluid). Overproduction, or obstruction of ventricles, or defective reabsorption. Congenital - ventricular enlargement before birth. Communicating - faulty reabsorption (adults) Non-communicating - ventricle obstruction (peds) FIG. 50.8, Page 1371 Hydrocephalus: a block in flow of cerebrospinal fluid. A: Patent cerebrospinal fluid circulation. B: Enlarged lateral and third ventricles caused by obstruction of circulation—stenosis of aqueduct of Sylvius. Low, L.K.C.S.C.O.S.P.M.H. D. (2022). Perry's Maternal Child Nursing Care in Canada (3rd ed.). Elsevier Health Sciences (US). Brain Tumours Can be benign or malignant AKA “gliomas” Fast growing or slow growing Primary brain tumours are idiopathic, only known environmental risk is ionizing radiation. Can cause a myriad of symptoms, depending on the area of the brain that is affected - Seizures (interruptions in electrical conduction), increased ICP, swelling, dysfunction of the functional portion of the brain that is compressed. Brain Tumours WHO grades brain tumours into 4 categories: Grades I and II are benign or slow growing Grades III and IV are malignant tumours. I: Common in children and youth, people with neurofibromitosis, least malignant, well differentiated, slow-growing, non-infiltrative ⚬ pilocytic astrocytoma II: Common in young adults, slow growing, infiltrates to adjacent tissue, may recur at higher grade ⚬ oligodenroglioma, low-grade astrocytoma III: Common in young adults, malignant, rapid cell division, infiltrates adjacent tissue, frequently recurs at higher grade ⚬ malignant (anaplastic) astrocytoma IV: Common in older people, poorly differentiated, bizarre appearance, wildly infiltrative, vascular, necrotic tissue ⚬ glioblastoma; glioblastoma multiforme FIGURE 16.15 Common Sites of Intracranial Tumours. p. 405 Alterations in Neuromuscular Function Movements are complex patterns of activity controlled by the cerebral cortex, the pyramidal system, the extrapyramidal system, and the motor units. Dysfunction in any of these areas can cause motor dysfunction. General neuromotor dysfunctions are associated with changes in muscle tone, movement, and complex motor performance. Hypotonia - very little resistance with passive movement, floppy Flaccidity - limp, atrophied muscles, paralysis (nerve impulses are lost) Hypertonia - increased muscle resistance to passive movement Spasticity - increased resistance then a clasp-knife movement, inc. DTR, clonus (spread of reflexes) Paratonia - Resistance to passive movement which varies in proportion to force applied Dystonia - sustained, involuntary muscle contrraction with twisting movemement Rigidity - resistance to passive movement that is uniform in flexion and extension Alterations in Movement Hyperkinesia Excessive, purposeless movement Include tremors Paroxysmal dyskinesias ⚬ Abnormal, involuntary movements that occur as spasms Tardive dyskinesia ⚬ Involuntary movement of the face, lip, tongue, trunk, and extremities ⚬ Usually occurs as a side effect of prolonged antipsychotic medication therapy Alterations in Movement Many types of hyperkinesia and tremors: Chorea - associated with Huntington’s Disease, a non-repetitive muscular contraction (extremity or face), random pattern of irregular and involuntary contractions of muscles. Disappears with sleep, increases with stress and voluntary movement Akathisia - Compulsion to move (especially legs), can be mild or frenzied, may be partially voluntarily suppressed but carrying out movement brings sense of relief Parkinsonian Tremor - Rhythmic, oscillating movement affecting one or more body parts (Parkinson’s Disease) Essential Tremor - Tremor of hands, fingers, absent at rest but accentuated by extensino or prolonged activity and stress Table 15.17 P 371 Group Activity Create a chart identifying similarities and differences between parkinson’s disease and huntington’s disease Include clinical manifestations, investigations, evaluations, and interventions Huntington’s Disease Also known as chorea Autosomal dominant hereditary degenerative disorder Severe degeneration of the basal ganglia (caudate nucleus) and cerebral cortex Depletion of gamma-aminobutyric acid (GABA) https://www.youtube.com/watch?v=7c2BrsTIfFY Parkinson’s Disease Severe degeneration of the basal ganglia (corpus striatum) involving the dopaminergic nigrostriatal pathway ⚬ Parkinsonian tremor, rigidity, bradykinesia ⚬ Masked face ⚬ Pill rolling ⚬ Cogwheeling ⚬ Gait shuffling ⚬ Postural disturbances ⚬ Autonomic and neuroendocrine symptoms ⚬ Cognitive-affective symptoms https://www.youtube.com/watch?v=I2SE9dsyIk0 References Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier, Inc. Low, L.K.C.S.C.O.S.P.M.H. D. (2022). Perry's Maternal Child Nursing Care in Canada (3rd ed.). Elsevier Health Sciences (US). Power-Kean, K., Zettel, S., El-Hussein, M., Huether, S. E., & McCance, K. L. (2023). Huether and McCance’s Understanding Pathophysiology. Elsevier Canada.